Submitted by LENIZE DA SILVA RODRIGUES (nize_silva@hotmail.com) on 2017-09-27T19:16:54Z No. of bitstreams: 1 DISSERTACAO DE MESTRADO PESQUISA CLINICA - LENIZE DA SILVA RODRIGUES.pdf: 2672614 bytes, checksum: 59d7f6f68213dfaccdca11f5c0b0f7bf (MD5) / Approved for entry into archive by Monique Sasaki (sayumi_sasaki@hotmail.com) on 2017-09-28T14:36:32Z (GMT) No. of bitstreams: 1 rodrigues_ls_me_bot.pdf: 2672614 bytes, checksum: 59d7f6f68213dfaccdca11f5c0b0f7bf (MD5) / Made available in DSpace on 2017-09-28T14:36:32Z (GMT). No. of bitstreams: 1 rodrigues_ls_me_bot.pdf: 2672614 bytes, checksum: 59d7f6f68213dfaccdca11f5c0b0f7bf (MD5) Previous issue date: 2017-09-01 / A Síndrome de Cockett (SC) se deve a uma compressão extrínseca da veia ilíaca comum esquerda (VICE) pela artéria ilíaca comum direita (AICD). Em consequência há o desenvolvimento de lesões intraluminais. Este cruzamento entre a artéria e a veia é considerada uma condição anatômica usual, porém em cerca de 29% da população ela pode torna-se sintomática. Os sintomas causados pela SC são: edema, dor, claudicação venosa, hiperemia, varizes e úlceras, podendo evoluir também com complicações como trombose venosa, embolia pulmonar, e mais raramente com Flegmasia Cerúlea Dolens. Até hoje não existe consenso sobre a melhor forma de tratar pacientes com SC na presença ou ausência de trombose da VICE, dividindo as opiniões se deve ser feito o tratamento clínico e/ou endovascular. Preferencialmente alguns autores optam pelas técnicas endovasculares em todos os casos e sugerem que a mesma seja realizada, na tentativa de melhorar a fluxo venoso evitando as complicações tardias. Á curto prazo, os resultados do tratamento endovascular com stents, tem mostrado excelente perviedade, embora estejam alguns deles associados ao uso de antiagregantes, anticoagulantes e ao tratamento clinico convencional com a meia elástica. Objetivo: O presente estudo teve a finalidade de comparar os resultados de perviedade e a taxa de complicações ocorridas em pacientes portadores da SC, tratados com angioplastia e stent, na presença e ausência de trombose da VICE, utilizando a Revisão Sistemática e Meta-análise de estudos observacionais. Método: Foram utilizadas as recomendações do manual Cochrane Handbook for Intervention Reviews produzido pela Cochrane que orienta a produção de revisões sistemáticas utilizando como referência para a escolha do método. A produção desta dissertação e manuscrito foi baseada no MOOSE statement para garantir que todas as etapas do estudo sejam reportadas claramente. As bases de dados utilizadas foram: Medline, EMBASE, LILACS, Scopus, Scielo, Pubmed e, Web of Science. A data da última busca foi 06 de abril de 2017. Esta pesquisa incluiu estudo de 2 grupos principais, tratados com angioplastia e stent: no G1: foram incluídos pacientes com a SC ausência trombose VICE e no G2 foram incluídos pacientes com SC presença de trombose da VICE. Resultados: De 250 artigos foram selecionados 3 estudos comparativos observacionais, sendo o número total de pacientes avaliados igual a 243. Nestes trabalhos selecionados foram associados ao tratamento endovascular o uso de antiagregantes plaquetários, anticoagulantes durante o período 3 a 12 meses e o uso da meia elástica. A patência primária, respectivamente, no G1 e G2 foi de e 93,4% e 89,2% (OR 0.55, 95% IC [0.15, 2.06], P= 0.37; I2=29%, P=0.24). E a patência secundária, respectivamente, de G1 e G2 foi de 93.5% e 82.06% (OR 0.50, 95% IC [0.05, 4.72], P= 0.54; I2=69%, P=0.04). Embora não estatisticamente significante, observa-se uma tendência em ocorrer maior patência nos pacientes do G1. Em relação ás complicações no total, houve tendência maior no G2 em relação ao G1. Conclusão: Os resultados obtidos neste estudo de revisão sistemática, mostraram que o tratamento endovascular é eficaz em ambos os grupos à curto prazo e longo prazo, mas, sugere que no grupo 1 a perviedade é discretamente melhor que no grupo 2, com menores complicações. / The Cockett Syndrome (CS) is due to an extrinsic compression of the common left iliac vein (CLIV) by the common right iliac artery (CRIA). Consequently, there is a development of intraluminal lesions. This crossing between the artery and the vein is considered a usual anatomic condition; however, in about 29% of the population it may become symptomatic. The symptoms caused by the CS are: edema, pain, venous claudication, hyperemia, varicose veins e ulcers, being possible also to evolve with complications such as venous thrombosis, pulmonary emboli and more rarely with Flegmasia Cerúlea Dolens. Until today there´s no consensus about the best way to treat patients with CS in either the presence or the absence of CLIV thrombosis, it has been dividing opinions whether the clinical or the endovascular treatment should be done. Preferably, some authors choose the endovascular techniques in all cases and suggest that it be performed, in the attempt of improving the venous flow thus avoiding later complications. In short term the results of the endovascular treatment with stents, have shown excellent patency, although some of them are associated to the use of antiplatelet, anticoagulants and to the conventional clinical treatment with compression stocking. Objective: the present study had as goal to compare the results of the patency and the complication rate occurred in patients bearing the CS, treated with angioplasty and stent, in the presence and absence of the CLIV thrombosis, using the Systematic Review and Meta-Analysis in the observational studies. Method: It has been used the recommendations of the manual Cochrane Handbook for Intervention Reviews which orients the production of systematic reviews using as reference for the choice of the method. The production if this dissertation and manuscript has been based on the MOOSE statement to assure that all phases of the study be reported with clarity. The data bases used were: Medline, EMBASE, LILACS, Scopus, Scielo, Pubmed and, Web of Science. The date of the last search was April 6th 2017. This research includes the study of two main groups, both treated with angioplasty and stent: in the G1: it has been included patients with CS without CLIV thrombosis and in the G2: it has been included patients showing CS without CLIV thrombosis. Results: From 250 articles, it has been selected three comparative observational studies, being the total number of analyzed patients equal to 243. In these selected works it has been associated the use of antiplatelet, anticoagulants during the period from 3 to 12 months and the use of the compression stocking. The primary patency, respectively, in G1 and G2 has been of 93.4% and 89.2% (OR 0.55 (95% IC [0.15, 2.06], P= 0.374; I2=29%, P=0.24). And the secondary patency, respectively, in G1 and G2 has been of 93.5% and 82.06% (OR 0.50, 95% IC [0.05, 4.72], P= 0.54; I2=69%, P=0.04). Even though statistically not relevant in both patencies, it can be observed a tendency in the occurrence of a greater patency in patients from G1. In relation to the complications in the total, there has been difference being greater G2 in relation to the G1. Conclusion: The results obtained in the study of systematic review, have shown that the endovascular treatment is effective in short and long terms, but it suggests that in group 1 the patency is discreetly greater than in group 2, with less complications.

Introdução – Pouco se publicou na literatura médica a respeito de projeções angiográficas dedicadas às anatomias especiais. Neste cenário, propomos uma projeção angiográfica para a exposição da bifurcação do tronco da artéria coronária esquerda (TCE) quando o conjunto de projeções rotineiras previamente utilizadas foi ineficaz para exibir com clareza essa região. Pacientes e Métodos – 84 pacientes foram submetidos à projeção Lateral Direita (90-120°) associada a Cranial (30-40°). Estudo de reprodutibilidade, realizado com a participação de dois observadores independentes, julgou a eficácia da projeção proposta. O índice kappa, ajustado para a prevalência e viés (PABAK) com IC de 95%, foi utilizado para demonstrar a intensidade da concordância inter e intraobservador: ≤ 0,20 = ruim, 0,21 – 0,40 = fraca, 0,41 – 0,60 = moderada, 0,61 – 0,80 = substancial e 0,81 – 1,0 = quase perfeita. Resultados – A projeção proposta foi eficaz em 79% dos angiografias com concordância de 0,76 (0,6 – 0,9; P ≤ 0,001). A origem e o segmento proximal da artéria coronária descendente anterior foram expostos em 89% com concordância de 0,86 (0,7 – 1,0; P ≤ 0,001), a origem e o segmento proximal da artéria circunflexa foram expostos em 83% com concordância de 0,72 (0,5 – 1,0; p ≤ 0,001) e a origem e o segmento proximal do ramo intermediário, quando presente, foram expostos em 89% com concordância de 0,79 (0,6 – 1,0; p ≤ 0,001). Conclusão – A projeção proposta é eficaz, segura e reproduzível. Em situações especiais, onde projeções rotineiras falham, essa poderá exibir detalhes importantes da anatomia da bifurcação do TCE à cinecoronariografia ou ser a projeção de trabalho durante a intervenção coronariana percutânea. / Objectives – We propose a 90 – 120° right lateral with 30-40° cranial angiographic view to expose the bifurcation of the left main coronary artery (LMCA) when previously used routine projections were inefficient at clearly showing this region. Background – Little has been published in the medical literature regarding angiographic projections dedicated to special anatomies. Methods – A total of 84 patients were subjected to the proposed projections. A reproducibility study, conducted with the participation of two independent observers, judged the effectiveness of the proposed projection. The Prevalence and Bias Adjusted Kappa (PABAK) index, with a 95% confidence interval (CI), was used to demonstrate the intensity of intra- and inter-observer agreement: ≤ 0.20 = poor, 0.21 – 0.40 = slight, 0.41 – 0.60 = moderate, 0.61 – 0.80 = substantial and 0.81 – 1.0 = almost perfect. Results – The proposed projection was efficient in 79% of the angiograms, with agreement of 0.76 (0.6 – 0.9; P ≤ 0.001). The origin and the proximal segment of the anterior descending coronary artery were exposed in 89% of the angiograms, with agreement of 0.86 (0.7 – 1.0; P ≤ 0.001); the origin and the proximal segment of the circumflex artery were exposed in 83% of the angiograms, with agreement of 0.72 (0.5 – 1.0; P ≤ 0.001); and the origin and the proximal segment of the intermediate branch, when present, were exposed in 89% of the angiograms, with agreement of 0.79 (0.6 – 1.0; P ≤ 0.001). Conclusion – The proposed projection is effective, safe and reproducible. In special situations where routine projections fail, this proposed projection can reveal important details of the anatomy of the bifurcation of the LMCA during conventional / Tese (Doutorado)

Abstract In the Czech Republic there is no doubt about the tendency of gradual increase in median life expectancy, which is significantly affected by the fact that mortality from cardiovascular diseases, especially from acute coronary syndromes, has been decreasing. Besides the provable effect of a healthy lifestyle, diet and, by all means, a quality and effective pharmacotherapy, a significant development in the field of interventional cardiology contributes to this accomplishment. The number of coronographies, coronary angioplasties and implanted stents have multiplied, and today the invasive coronarographic diagnostics and percutaneous myocardial revascularization belong to the the most common diagnostic and therapeutic methods in treatment of acute forms of ischemic heart diseases. An obvious prerequisite for such a rapid development in the field of intervention coronary angiography was the establishment of a sufficiently dense network of catheter laboratories and specialized facilities, which provide a highly professional and intensive care for patients. This thesis is focused on three basic objectives: ? To survey and characterize differences in nursing care concerning various complications in patients after SKG / PCI ? To survey bio / psycho / social impacts of complications after SKG / PCI on a patient ? To identify and summarize personal and material prerequisites and requirements to ensure quality nursing care for these complicated conditions The research was conducted by using a qualitative methodology. The methods used were observation, non-standardized interviews and medical and nursing records analyses. The research survey samples on which the investigation was focused were patients with the acute coronary syndrome hospitalized in the coronary care unit in the Cardio Center in České Budějovice, their family members and also the nursing staff providing the comprehensive nursing care. The outcomes of this survey were eleven descriptive case reports characterizing the occurrence of the most frequent complications in patients with ACS after SKG / PCI. To ensure clarity, each case study is complemented by a thought map with an account of the most important nursing interventions in the management of specific acute conditions. The paper also contains a framework analysis of bio / psycho / social impacts of complicated situations on patients. It is interesting to compare this matter from the perspective of nurses and patients, which is seen in correlation graphs. The section describing the organizational and personnel provision is introduced with the characteristics of the medical process and it also contains the list of medical personnel with their qualifications and the length of experience in the Coronary care unit in České Budějovice. Summarization of the instrumental medical equipment is also based on the analysis of previous cases and is accompanied by photographs of the equipment typical and indispensable for the care of patients in the Coronary care unit, which primarily has an informative and complementary character to get an integrated view of the Coronary care unit running and the nursing staff work.

INTRODUÇÃO: Poucas são as estratégias testadas para reduzir o volume de contraste durante angioplastia coronária. Levantamos a hipótese de que o ultrassom intravascular teria o potencial de substituir muitas informações fornecidas pela angiografia, reduzindo, dessa forma, o volume total de contraste utilizado durante a angioplastia coronária. MÉTODOS: No total, 83 pacientes foram randomizados para realização de angioplastia guiada pela angiografia isolada ou angioplastia guiada pelo ultrassom intravascular. Ambos os grupos foram tratados com estratégias rigorosas para redução de contraste, tendo como objetivo primário o volume final de contraste utilizado na angioplastia coronária. Os pacientes foram acompanhados por um período médio de 4 meses. RESULTADOS: A mediana do volume total de contraste foi de 64,5 ml (intervalo interquartil [ITQ], 42,8-97 ml; mínimo de 19 ml e máximo de 170 ml) no grupo angioplastia guiada pela angiografia isolada vs. 20 ml (ITQ, 12,5-30 ml; mínimo de 3 ml e máximo de 54 ml) no grupo angioplastia guiada pelo ultrassom intravascular (P < 0,001). De forma semelhante, a mediana da razão entre o volume de contraste e o clearance de creatinina foi significantemente menor entre os pacientes submetidos a angioplastia guiada pelo ultrassom intravascular, quando comparados aos pacientes do grupo angioplastia guiada pela angiografia isolada (1 [ITQ, 0,6-1,9] vs. 0,4 [ITQ, 0,2- 0,5], respectivamente; P < 0,001). Os desfechos intra-hospitalares e aos 4 meses de acompanhamento não foram diferentes entre os pacientes randomizados para o grupo angioplastia guiada pela angiografia isolada e aqueles do grupo angioplastia guiada pelo ultrassom intravascular. CONCLUSÕES: A utilização racional do ultrassom intravascular como método de imagem para guiar a angioplastia foi segura e reduziu de forma significativa o volume de contraste, comparativamente à angioplastia guiada pela angiografia isolada. O uso do ultrassom intravascular para esse propósito deve ser considerado para pacientes de elevado risco para o desenvolvimento de nefropatia induzida pelo contraste ou sobrecarga de volume e que serão submetidos a angioplastia coronária / BACKGROUND: To date, few approaches have been described to reduce the final dose of contrast agent in percutaneous coronary intervention. We hypothesized that intravascular ultrasound might serve as an alternative imaging tool to angiography in many steps during percutaneous coronary intervention, thereby reducing the use of iodine contrast. METHODS: A total of 83 patients were randomized to angiography alone-guided percutaneous coronary intervention or intravascular ultrasound-guided percutaneous coronary intervention. Both groups were treated according to a pre-defined meticulous procedural strategy, and the primary endpoint was the total volume contrast agent used during percutaneous coronary intervention. Patients were followed clinically for an average of 4 months. RESULTS: The median total volume of contrast was 64.5 mL (interquartile range [IQR], 42.8 to 97 mL; minimum, 19 mL; maximum, 170 mL) in the angiography alone-guided group vs. 20 mL (IQR, 12.5 to 30 mL; minimum, 3 mL; maximum, 54 mL) in the intravascular ultrasound-guided group (P < 0.001). Similarly, the median volume of contrast/creatinine clearance ratio was significantly lower among patients treated with intravascular ultrasound-guided percutaneous coronary intervention when compared with patients treated with angiography alone-guided percutaneous coronary intervention (1 [IQR, 0.6 to 1.9] vs. 0.4 [IQR, 0.2 to 0.6], respectively; P < 0.001). In-hospital and 4-month outcomes were not different between patients randomized to angiography alone-guided and intravascular ultrasound-guided percutaneous coronary intervention. CONCLUSIONS: Thoughtful and extensive use of intravascular ultrasound as the primary imaging tool to guide percutaneous coronary intervention was safe and markedly reduced the volume of iodine contrast compared with angiographyalone guidance. The use of intravascular ultrasound should be considered for patients at high risk of contrast-induced acute kidney injury or volume overload undergoing coronary angioplasty

Introdução: A liberação de biomarcadores de necrose miocárdica após a intervenção coronária percutânea (ICP) ocorre frequentemente. No entanto, a correlação entre a liberação dos biomarcadores e o diagnóstico do infarto agudo do miocárdio (IAM) tipo 4a tem gerado controvérsia, especialmente com o aumento da sensibilidade nos ensaios de troponina (Tn). Neste estudo, objetivamos quantificar a liberação dos biomarcadores cardíacos em pacientes submetidos à ICP eletiva sem o surgimento de novo realce tardio pelo gadolínio (RTG) na ressonância magnética cardíaca (RMC) após o procedimento. Métodos: Foram incluídos pacientes consecutivos com doença arterial coronária estável e função ventricular preservada, com indicação eletiva para ICP em pelo menos duas artérias epicárdicas. RMC com RTG foi realizada em todos os pacientes antes e depois das intervenções. Medidas seriadas de Tn e creatinoquinase fração MB (CK-MB) foram realizadas imediatamente antes do procedimento até 48 horas após. Pacientes com novo RTG na RMC após o procedimento foram excluídos. Resultados: 71 pacientes foram referenciados para a realização eletiva da ICP sendo que 15 (21,1%) foram excluídos, 10 (14,1%) por causa do surgimento de um novo RTG na RMC após a ICP. Nos 56 pacientes sem a evidência de IAM tipo 4a pela RMC predominava o gênero masculino 37 (66,1%) com idade média de 61,7 (± 8,4) anos e escore de SYNTAX médio de 16,6 (± 7,7). Após a ICP, 48 (85,1%) pacientes apresentaram um pico de elevação de Tn acima do percentil 99 sendo que em 32 (57,1%) a elevação foi superior a 5 vezes esse limite, enquanto que apenas 2 (3,6%) apresentaram um pico de CK-MB maior do que 5 vezes o percentil 99. A mediana do pico de liberação da Tn foi de 0,290 (0,061 - 1,09) ng/mL, valor 7,25 vezes superior ao percentil 99. Conclusão: Diferentemente da CK-MB, a liberação da troponina I ocorre com frequência após procedimento de ICP mesmo na ausência de realce tardio pelo gadolínio na ressonância magnética cardíaca / Background: The release of myocardial necrosis biomarkers after percutaneous coronary intervention (PCI) frequently occurs. However, the correlation between biomarker release and the diagnosis of procedurerelated myocardial infarction (MI) (type 4a) has been controversial. This study aims to evaluate the amount and pattern of cardiac biomarker release after elective PCI in patients without the image of a new MI after the procedure assessed by cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE). Methods: Patients with normal baseline cardiac biomarkers referred for elective PCI were prospectively included. CMR with LGE was performed in all of the patients before and after the interventions. Measurements of troponin I (TnI) and creatinekinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with a new LGE on the post-procedure CMR were excluded. Results: Of the 56 patients without the evidence of a procedure-related MI assessed by the CMR after PCI, 48 (85.1%) exhibited a TnI elevation peak above the 99th percentile. In 32 (57.1%), the peak was greater than 5 times this limit. On the other hand, 17 (30.4%) had a CK-MB peak above the limit of the 99th percentile, and this peak was greater than 5 times the 99th percentile in only 2 patients (3.6%). The median peak release of TnI was 0.290 (0.061 to 1.09) ng/ml, which is 7.25-fold higher than the 99th percentile. Conclusions: In contrast to CK-MB, TnI release often occurs after an elective PCI procedure, despite the absence of a new LGE on CMR

Intervenção nutricional educativa em pacientes submetidos à angioplastia transluminal coronária: ensaio clínico randomizado [Tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2016. INTRODUÇÃO: Mudanças no estilo de vida são estimuladas na prevenção primária e secundária da doença arterial coronária. A educação para promoção de saúde requer uma atividade capaz de problematizar a realidade do indivíduo e capacitá-lo para escolhas conscientes. Considerando os aspectos pluridimensionais da alimentação e a dificuldade de mudanças no comportamento alimentar, o objetivo deste estudo foi analisar a efetividade de uma intervenção nutricional educativa em pacientes submetidos à angioplastia transluminal coronária (ATC) quanto à mortalidade e recorrência de eventos como infarto agudo do miocárdio (IAM), revascularização cirúrgica do miocárdio (RM) ou nova ATC em até um ano de acompanhamento. Os objetivos secundários incluíram consumo alimentar; medidas antropométricas e bioquímicas; estágios de mudança do comportamento alimentar e a ocorrência de eventos cardiovasculares em até quatro anos de seguimento, além de uma análise qualitativa dos fatores socioculturais e atitudinais que influenciaram as práticas alimentares dessa população. MÉTODOS: Foi realizado um ensaio clínico controlado, randomizado e pragmático, com duração de um ano, relativo aos cuidados clínico-nutricionais nos grupos controle e intervenção, sendo neste adicionadas oficinas educativas de nutrição com abordagem construtivista. O ensaio foi complementado com um estudo de coorte para observar eventos cardiovasculares em até quatro anos. Foram alocados 200 pacientes, sendo 101 no grupo intervenção. Ao final do primeiro ano e depois de quatro anos, foram calculadas a redução do risco absoluto e o risco relativo como medidas de incidência cumulativa, respectivamente. RESULTADOS: Ao final de um ano de seguimento, nos grupos intervenção e controle, respectivamente, houve cinco e sete óbitos (p = 0,53); cinco e seis IAM (p = 0,73); quatro e seis re-ATC (p = 0,50); e quatro e quatro RMs (p = 0,98). Após quatro anos, os RR entre os grupos de intervenção e controle foram 0,75 (IC95% 0,35-1,58) para óbito; 0,89 (IC95% 0,34-2,28) para IAM; 0,86 (IC95% 0,40-1,84) para re-ATC e 1,14 (IC95% 0,38-3,40) para RM. Quanto à ingestão alimentar, observou-se redução de gordura saturada (p=0,04) e aumento de fibras (p=0,03) e potássio (p=0,01) no grupo intervenção comparado ao controle. As medidas antropométricas e bioquímicas não apresentaram diferença entre os grupos. A análise estratificada mostrou um efeito protetor para a circunferência da cintura nos subgrupos de idosos [-2.6 cm (IC95% -4,7; -0.6)] e até quatro anos de estudo [-2.5 cm (IC95% -4,9; -0,1)], com interação entre eles (p=0,02). Quanto à mudança de comportamento, houve um aumento no número de indivíduos nos estágios de ação/manutenção de 2,2 vezes (IC95%1,0;5,2) no grupo intervenção, porém sem diferença entre os grupos. Foram identificados fatores socioculturais relacionados ao prazer, hábito, cultura e medo, bem como fatores atitudinais como mudanças declaradas, ambivalência e resistência que permearam as práticas alimentares independente do estágio de mudança, além do conhecimento adquirido, explícito ou ausente. CONCLUSÕES: A intervenção educativa pareceu vantajosa, embora a amostra não tenha sido suficiente para ser conclusiva quanto à ocorrência de eventos cardiovasculares. Houve redução de gordura saturada e aumento no consumo de fibras e potássio, porém sem melhora nas medidas antropométricas e bioquímicas, exceto um menor acúmulo de gordura abdominal em idosos e sujeitos com baixa escolaridade. Há de se fortalecer o debate dos aspectos culturais que constituem o espaço social alimentar e repensar a orientação valorizando as mudanças positivas e escolhas alimentares dentro de um contexto de padrão alimentar saudável / INTRODUCTION: Changes in lifestyle are encouraged in primary and secondary prevention of coronary artery disease. The education for health promotion requires an activity capable of problematizing the individual\'s reality and enabling him to make conscious choices. Considering the multidimensional aspects of feeding and the difficulty of changes in eating behavior, the objective of this study was to analyze the effectiveness of a nutrition education intervention program on mortality and recurrence of events as acute myocardial infarction (AMI), revascularization with re-percutaneous coronary intervention (re-PCI), or coronary artery bypass graft (CABG) surgery after one year of follow-up in patients who previously underwent elective PCI. The secondary objectives included food consumption, anthropometric and biochemical parameters, stages of dietary change, and recurrence of cardiovascular events after four years of follow-up, besides a qualitative analysis of the cultural and attitudinal factors that influenced the dietary practices of this population. METHODS: A controlled, randomized, and pragmatic clinical trial was performed during one-year, related to the clinical and nutritional care in the control and intervention groups, and nutrition education workshops that adopted a constructivist approach were additionally applied to the intervention group. The trial was complemented with a cohort study to observe cardiovascular events up to four years of follow-up. Two hundred patients were allocated, 101 in the intervention group. The absolute risk reduction and the risk ratio were calculated as measures of the cumulative incidence after one and four years, respectively. RESULTS: After one year of follow-up, in the intervention and control groups, respectively, there were five and seven deaths (p=0,53); five and six AMIs (p=0,73); four and six re-PCIs (p=0,50); and four and four CABGs (p=0,98). After four years, the risk ratios between intervention and control groups were 0,75 (95%CI 0,35-1,58) for death, 0.89 (95%CI 0,34-2,28) for AMI, 0,86 (95%CI 0,40-1,84) for re-PCI, and 1,14 (95%CI 0,38-3,40) for CABG. Regarding food consumption, a decrease in saturated fat (p = 0.04) and increase in fiber (p = 0.03) and potassium (p = 0.01) intakes were observed in the intervention group compared to the control group. Anthropometric and biochemical measurements did not show any difference between groups. The stratified analysis showed a protective effect for waist circumference in the elderly [-2.6 cm (95%CI-4,7; -0,6)] and individuals up to four years of study [-2.5 cm (95%CI -4,9 ;-0,1)] subgroups, with interaction between them (p = 0,02). Regarding the change in dietary behaviour, there was an increase in the number of individuals in the action/maintenance stages of 2.2 times (95%CI 1,0; 5,2) in the intervention group, but with no difference between the groups. Factors related to pleasure, habit, culture and fear were identified, as well as attitudinal factors such as stated changes, ambivalence and resistance that permeated eating practices regardless of the stage of change, as well as acquired, explicit or absent knowledge. CONCLUSION: The educational intervention seemed advantageous, although the sample was not enough to be conclusive about the occurrence of cardiovascular events. There was a reduction in saturated fat and an increase in fiber and potassium consumption, but there was no improvement in anthropometric and biochemical measurements, except for a lower accumulation of abdominal fat in the elderly and subjects with low schooling. There is a need to strengthen the debate on the cultural aspects that constitute the food social space and rethink the orientation by valuing positive changes and food choices within a healthy eating pattern

Introdução: Análise da custo-efetividade no tratamento da doença multiarterial coronária têm ganhado importância nos ensaios clínicos, uma vez que as principais opções terapêuticas: cirurgia de revascularização miocárdica (CRM), intervenção coronária percutânea (ICP) e tratamento medicamentoso (TM) apresentam eficácia similar em determinados subgrupos de pacientes. Atualmente os interesses direcionados à análise econômica têm crescido, uma vez que os gastos na saúde aumentaram com o desenvolvimento de novas tecnologias, porém os recursos disponíveis são finitos e merecem ser administrados. Objetivo: Analisar, prospectivamente, o custo comparativo das três formas terapêuticas da doença multiarterial coronária estável, durante dez anos de seguimento. Métodos: Foi computado o custo terapêutico global de 611 pacientes do ensaio clínico The Second Medicine, Angioplasty, or Surgery Study (MASS II), baseado na remuneração fornecida pelo sistema de saúde suplementar do Instituto do Coração do HC/FMUSP, utilizando valores em dólares. Posteriormente, a análise de custoefetividade foi realizada corrigindo o custo cumulativo obtido em cada grupo para o \"tempo livre de eventos clínicos\" e também para a combinação de \"tempo livre de eventos\" acrescido de \"tempo livre de angina\". Resultados: O TM apresentou um custo cumulativo ao final de dez anos de US$6.183; o ICP apresentou um custo de US$14.292; e o grupo CRM apresentou um custo de US$12.316. Os custos corrigidos para sobrevida livre de eventos foram, US$11.136 para TM; US$26.912 para ICP e US$17.883 para CRM. Houve diferença estatisticamente significativa entre os 3 grupos (p < 0,0001) e a análise pareada, mostrou um menor custo para o grupo tratamento clínico tanto comparado com CRM (p < 0,0001) quanto comparado com ICP (p < 0,0001). O tratamento CRM contra ICP, também mostrou menor custo (p < 0,0001). Os custos corrigidos para sobrevida livre de eventos e angina foram, US$25.690 para TM; US$45.989 para ICP e US$27.920 para CRM; com expressiva diferença entre os 3 grupos (p < 0,0001). Na comparação dos grupos, observou-se um menor custo no grupo tratamento clínico comparado com ICP (p < 0,0001), o grupo angioplastia também teve um maior custo quando comparado com o grupo cirúrgico (p < 0,001). Contudo entre o grupo tratamento medicamentoso e tratamento cirúrgico não houve diferença significativa (p=0,5613). Conclusão: A análise econômica comparativa de longa data, revelou que ICP foi o tratamento menos custo-efetivo. O tratamento medicamentoso foi o mais custo-efetivo na prevenção de eventos, porém na prevenção de eventos e angina, teve custo-efetividade semelhante ao tratamento cirúrgico / Introduction: The cost-effectiveness analysis in multivessel coronary artery disease treatment have gained importance in clinical trials, since the main treatment options: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) and medical treatment (MT) have similar efficacy in certain subgroups of patient. Currently, the concernment in economic analysis have grown, since Medical Treatment costs have increased with the constant development of new technologies, but the available budget are finite and should be administered. Objective: prospectively analyze the comparative cost of the three medical treatments for stable multivessel coronary artery disease, during ten years follow-up. Methods: It was calculated the overall therapeutic cost of 611 patients in the clinical trial \"The Second Medicine, Angioplasty, or Surgery Study (MASS II) \", considering the remuneration provided by the health insurance system of the Heart Institute of HC/FMUSP converted to dollar currency. Afterward, the costeffectiveness analysis was conducted by adjusting the cumulative cost obtained at each group for the \"time free of clinical events\" and also for the combination of \"time free of events\" and \"time free of angina\". Results: The MT had a cumulative cost, at the end of ten years, of US$ 6,183.00; PCI had a cost of US$ 14,292.00; and the CABG group had a cumulative cost of US$ 12,316.00. The costs adjusted for \"events-free survival\" were US$ 11,136.00 for MT; US$ 26,912.00 for PCI and US$ 17,883.00 for CABG. There was a statistically significant difference between the 3 groups (p < 0.0001) and paired analysis showed lower cost for the medical treatment group compared with CABG (p < 0.0001) and PCI (p < 0.0001). The CABG compared with PCI also showed lower cost (p < 0.0001). The adjusted costs for \"survival free of clinical events and angina\" were US$25,690.00 for MT; US$45,989.00 for PCI and US$27,920.00 for CABG; with a significant difference between the 3 groups (p < 0.0001). Comparing the groups, it can be seen a lower cost in the medical treatment group, compared with CABG (p < 0.0001), and also in comparison with PCI (p < 0.0001). However, the comparison between the medical treatment group and surgical treatment group showed no significant difference (p=0.5613). Conclusion: The long-term comparative economic analysis revealed that PCI showed up to be the least cost-effective treatment. The medical treatment was the most cost-effective in \"events prevention\", but considering \"events and angina prevention\", it had a cost-effectiveness similar to surgical treatment

Estudo comparativo entre os custos dos tratamentos clínico, cirúrgico ou percutâneo em portadores de doença multiarterial coronária estável - 5 anos de seguimento [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo, 2013. INTRODUÇÃO: As principais opções terapêuticas para a doença multiarterial coronária incluem cirurgia de revascularização miocárdica (CRM), intervenção coronária percutânea (ICP) e tratamento clínico (TC). Essas três estratégias terapêuticas apresentam eficácia similar em determinados subgrupos de pacientes. No presente momento, estudos direcionados à análise econômica são escassos, e contemplam, principalmente, os custos comparativos entre as intervenções cirúrgica e percutânea. OBJETIVOS: Analisar, prospectivamente, o custo comparativo das três formas terapêuticas da doença multiarterial coronária estável, durante cinco anos de seguimento. MÉTODOS: Foi computado o custo terapêutico global de 611 pacientes do ensaio clínico The Second Medicine, Angioplasty, or Surgery Study (MASS II), baseado na remuneração provida pelo sistema de saúde suplementar do Instituto do Coração do HC/FMUSP, tomando-se os valores em moeda nacional corrente. Realizou-se, posteriormente, análise de custo-efetividade para o tempo livre de eventos clínicos e o tempo livre de eventos acrescido de tempo livre de angina. RESULTADOS: O TC apresentou 3.79 e 2.07 QALY (quality-adjusted lifeyears); o ICP apresentou 3.59 e 2.77 QALY; e o CRM apresentou 4.4 e 2.81 QALY, respectivamente, para sobrevida livre de eventos e sobrevida livre de eventos e angina. Os custos para sobrevida livre de eventos foram R$ 16.327,80 para TC, R$ 35.940,60 para ICP e R$ 32.873,40 para CRM. A análise pareada dos custos para sobrevida livre de eventos mostrou que houve diferença significante favorecendo TC contra ICP (P < 0,01), e em comparação com CRM (P < 0,01); e CRM versus ICP (P = 0,01). Os custos para sobrevida livre de eventos e angina foram R$ 29.795,40, R$ 46.495,80 e R$ 44.305,20, respectivamente. A comparação pareada dos custos livres de eventos mais livres de angina demonstrou que houve diferença significante favorecendo TC contra ICP (P = 0,04), e em comparação com CRM (P < 0,001). Não houve diferença entre CRM e ICP (P > 0,05). CONCLUSÃO: A análise comparativa entre as diferentes opções terapêuticas desta amostra revelou que TC foi mais custo-efetivo que CRM, e esta, por sua vez, mais custo-efetivo que ICP / BACKGROUND: The therapeutic options for multivessel coronary artery disease are coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), or medical treatment alone (MT). These three therapeutic strategies present similar efficacy for specific subgroups. At the present moment, economic outcome trials are scant, and contemplate comparative cost between surgical or percutaneous intervention. OBJECTIVE: To analyze, prospectively, the comparative cost from three therapeutic strategies in multivessel coronary artery disease, at 5-year of follow-up. METHODS: We analyzed cumulative costs of 611 patients from clinical trial The Second Medicine, Angioplasty, or Surgery Study (MASS II). The economic analysis is based on remuneration provided by the supplementary health system of the Heart Institute of the Clinical Hospital of FMUSP, expressing these values in Brazilian currency. It was compared to the cumulative costs of each therapeutic strategy in the 5-year follow-up period. A cost-effectiveness analysis was then conducted for event-free survival and event plus angina-free survival. Cost-effectiveness analysis was performed by quality-adjusted life- year (QALY) analysis. RESULTS: Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years (QALY) and 2.07 QALY; PCI presented 3.59 and 2.77 QALY; and CABG demonstrated 4.4 and 2.81 QALY. The event-free costs were R$ 16327.80 for MT; R$ 35940.60 for PCI; and R$ 32873.40 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P < 0.01) and versus CABG (P < 0.01) and CABG versus PCI (P =0.01). The event-free plus angina-free costs were R$ 29795.40, R$ 46495.80 e R$ 44305.20, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P =0.04), and versus CABG (P < 0.001); there was no difference between CABG and PCI (P > 0.05). CONCLUSION: The comparative analysis among the different therapeutic strategies demonstrated that MT was more cost-effective than CABG, and this than PCI

We reviewed 13 cases of ultrasound-guided thrombin injection of femoral pseudoaneurysms. All cases occurred within a 17-month period from January 1998 through May 1999 and were complications of femoral artery puncture. Immediate total thrombosis occurred in nine of 13 patients. Twenty-four-hour follow-up ultrasound in seven patients revealed no recurrence of pseudoaneurysm. Two of 13 patients required operative repair. One pseudoaneurysm thrombosed with 15 minutes of compression after injection and one case required a second injection. No cases of arterial thrombosis were noted. Ultrasound-guided thrombin injection for femoral artery pseudoaneurysm represents a safe and effective alternative to operative repair.

No / The purpose of this article is to investigate characteristics of cine phase contrast-calculated cerebrospinal fluid (CSF) flow and velocity measures in patients with relapsing-remitting (RR) multiple sclerosis (MS) receiving standard medical treatment who had been diagnosed with chronic cerebrospinal venous insufficiency (CCSVI) and underwent percutaneous transluminal angioplasty (PTA). This case-controlled, magnetic resonance (MR) imaging-blinded study included 15 patients with RR MS who presented with significant stenoses (>/=50% lumen reduction on catheter venography) in the azygous or internal jugular veins. Eight patients underwent PTA in addition to medical therapy immediately following baseline assessments (case group) and seven had delayed PTA after 6 months of medical therapy alone (control group). CSF flow and velocity measures were quantified over 32 phases of the cardiac cycle by a semiautomated method. Outcomes were compared between groups at baseline and at 6 and 12 months of the study by mixed-effect model analysis. At baseline, no significant differences in CSF flow or velocity measures were detected between groups. At month 6, significant improvement in flow (P<.001) and velocity (P = .013) outcomes were detected in the immediate versus the delayed group, and persisted to month 12 (P = .001 and P = .021, respectively). Within-group flow comparisons from baseline to follow-up showed a significant increase in the immediate group (P = .033) but a decrease in the delayed group (P = .024). Altered CSF flow and velocity measures were associated with worsening of clinical and MR outcomes in the delayed group. PTA in patients with MS with CCSVI increased CSF flow and decreased CSF velocity, which are indicative of improved venous parenchyma drainage.