Internações por condições sensíveis à atenção primária em crianças, Rondônia, Brasil, 2008-2019 / Hospitalizations for ambulatory care-sensitive conditions in children, Rondônia, Brazil, 2008-2019

Resumo Objetivou-se caracterizar o perfil de internações de crianças na rede pública dos 52 municípios do estado de Rondônia, Brasil, no período de 2008 a 2019. Trata-se de um estudo de série temporal do tipo ecológico, com dados secundários do Sistema de Informações Hospitalares. A tendência anual das internações foi apresentada por faixa etária e regional de saúde. Foi realizada regressão linear aplicando a técnica de Prais-Winsten no pacote estatístico Stata, versão 11.0. As internações por doenças gastrointestinais tiveram declínio em todas as faixas etárias, assim como pelas doenças previníveis por imunizantes entre 1 a 9 anos. As internações por doenças de pele e tecido subcutâneo foram crescentes em todas as idades, as epilepsias em idades de 1 a 9 anos e pelas doenças relacionadas ao parto e puerpério foi crescente. As regiões de saúde apresentaram perfil de internações variável, com tendência estável nas regiões Cone Sul, Madeira-Mamoré, Café, Vale do Guaporé, Vale do Jamari; e em declínio nas regiões Central e Zona da Mata. As elevadas taxas de internações por condições sensíveis à atenção primária em crianças refletem a pouca efetividade das estratégias e dos investimentos na esfera da atenção primária no estado.

Abstract This study aimed to define the profile of hospitalizations of children in public hospitals of 52 municipalities of the state of Rondônia, Brazil. We performed an ecological time series study using secondary data provided by the Hospital Information System. The annual trend of Hospitalizations was presented by age group and health region. Linear regression was performed using the Prais-Winsten technique of the statistical package Stata, version 11.0. Hospitalizations for gastrointestinal diseases were found to be decreasing in all age groups, just as those for vaccine-preventable diseases in children aged between 1 and 9 years. Hospitalizations for skin and subcutaneous tissue diseases were increasing in all ages, as well as those caused by epilepsies in children aged 1 to 9 and those caused by diseases related to childbirth and puerperium. Health regions showed a varied hospitalization profile. A stable trend was found in the Cone Sul, Madeira-Mamoré, Café, Vale do Guaporé, and Vale do Jamari regions, whereas a declining trend was found in the Central and Zona da Mata regions. The high rates of hospitalizations for ambulatory care-sensitive conditions in children show how inefficient strategies and investments in primary care have been in the state of Acre, Brazil.

Resumen ejecutivo: Enfermedad por hígado graso no alcohólico en sujetos con diabetes mellitus tipo 2: Postura conjunta de la Asociación Chilena de Hepatología (ACHHEP) y la Sociedad Chilena de Diabetología (SOCHIDIAB) / Non-alcoholic fatty liver disease in type 2 diabetes: a joint statement of the Chilean Hepatology and Diabetology Societies

Non-alcoholic fatty liver disease (NAFLD) has a high prevalence and risk of progression to cirrhosis and other complications in patients with type 2 diabetes mellitus (T2DM). Likewise, the presence of NAFLD implies a high risk of developing T2DM, determining a bidirectional relationship between them. The diabetology and hepatology societies, developed a joint initiative aiming to unify criteria, reviewing the definitions, diagnostic criteria, risk stratification, treatment, and follow-up of patients with NAFLD and T2DM. The key questions to be discussed were defined by a panel of specialists in diabetology and hepatology. The Delphi methodology was used to reach consensus on the respective recommendations. Based on the discussion generated among the experts, diagnostic and treatment algorithms were proposed, as well as an indication for referral and the role of the different specialists involved in the management of these patients. Strengthening multidisciplinary work with patients with NAFLD and T2DM will allow the early recognition of the disease, the prevention of the progression to cirrhosis, and reducing the associated complications.

Análisis del sistema de alistamiento y priorización para trasplante hepático de adultos en Chile

Background: In Chile, organ allocation for liver transplantation (LT) in adults is prioritized according to the MELD-Na score. Exceptions such as Hepatocellular Carcinoma (HCC) and other non-HCC exceptions receive a score called Operational MELD score. Aim: To evaluate the effectiveness of the MELD-Na score and the operational MELD score as a prioritization system for LT in Chile. Material and Methods: Retrospective analysis of the waiting list (WL) of adult candidates (≥ 15 years) for elective LT in Chile from 2011 to 2017. The probability of leaving the WL, defined by death or contraindication for LT was compared in three groups: 1) Cirrhotic patients prioritized according to their real MELD-Na score (CPM), 2) HCC and 3) other non-HCC exceptions. Results: We analyzed 730 candidates for LT, with a median age of 57 years, 431 (56%) were men. In the study period, 352 LT were performed (48%). The annual exit rate was significantly higher in the CPM group (45.5%) compared to HCC (33.1%) and non-HCC (29.3%), (p < 0.001). Post LT survival was 86% at 1 year and 85% at 5 years, without significant differences between groups. In the CPM group, post-transplant survival was significantly lower (p < 0.05) in patients with MELD-Na ≥ 30 at transplant (81% per year) compared to patients with patients with MELD-Na < 30 (91% per year). Conclusions: MELD-Na score can discriminate very well patients who have a higher risk of death in the short and medium term. However, the assignment of operational scores for situations of exception produces inequities in the allocation of organs for LT and must therefore be carefully adjusted.

Unidad de ACV en el Hospital de Clínicas: comportamiento clínico-epidemiológico de los pacientes con ACV (2007-2012) / Stroke Unit at the Hospital de Clínicas: clinical-epidemiological behavior in patients with stroke (2007-2012)

Introducción: El ataque cerebrovascular (ACV) es una importante causa de mortalidad, discapacidad y demencia en el mundo y en nuestro país. Provoca un gran impacto económico ya sea por gastos directos o indirectos. Objetivos: Describir aspectos clínicos, factores de riesgo e indicadores que permiten un adecuado manejo del ACV en su tratamiento agudo. Material y Métodos: Se realizó un estudio descriptivo y prospectivo de los ACV ingresados en el Hospital de Clínicas, entre 2007 y 2012 aplicando un protocolo con escalas clínicas, etiopatogénicas y funcionales, con test estadísticos adecuados. Resultados: Se protocolizaron 784 pacientes: 75% infartos, 16% hemorragias y 9% AIT. La HTA fue el factor de riesgo más frecuente. Un tercio llegó a puerta antes de las 4,5 h. En infartos y AIT se disminuyeron los días de internación y se mejoró la funcionalidad a 6 meses. Conclusiones: La formación de equipos entrenados en el diagnóstico y tratamiento del ACV disminuyeron el tiempo de internación y mejoraron la funcionalidad de estos pacientes.

Introduction: The cerebrospinal fluid (CSF) fistula is defined as the abnormal leak of fluid from the skull to outside the body through an osteomeningeal gap, which allows the passage of organisms to the intra-cranial space, with the risk of infection, potentially life-threatening. Divided as traumatic and non-traumatic, the condition is relatively common, and poses great challenges to neurosurgeons. Objective: to present the first case of post-traumatic CSF fistula in Uruguay, assessed with cistern MRI with diagnostic purposes. Case report: the case described is that of a patient that received treatment at the University Hospital (Hospital de Clínicas). The case is used to illustrate the condition and review the latest controversial issues involved in the algorithms for the diagnosis and therapy of the condition. Discussion: the main controversial issues found included the following: when to start prophylactic antibiotic (ATB) therapy following diagnosis; imaging tests requested for diagnosis, and type of therapy prescribed. Conclusions: The review of literature leads us to conclude that a correct diagnosis requires the routine use of CT and MRI; if doubts persist, cistern MRI, endoscopy, or cistern CT are indicated. With regards the therapeutic algorithm, we conclude that therapy should be conservative, applying medical therapy for two to four weeks; surgery will be prescribed if the fistula persists after that. Antibiotic therapy is an option and not a recommendation.

Ataque cerebrovascular isquémico en Uruguay: comunicación de los primeros 34 casos trombolizados en el Hospital de Clínicas / Ischemic stroke in Uruguay. First 34 cases of thrombolized patients at the Clinicas Hospital

Introducción: el ataque cerebrovascular (ACV) constituye un problema de salud en Uruguay y en el mundo. Se ha comprobado que la trombolisis intravenosa disminuye la morbimortalidad y las secuelas en los pacientes con ACV isquémicos agudos (nivel de evidencia IA). Objetivos: analizar los casos de ACV isquémico trombolizados en el Hospital de Clínicas y valorar la utilidad de un score de predicción de sangrado intracraneano sintomático en esta población. Material y método: estudio descriptivo, observacional y prospectivo. Población: pacientes trombolizados en el Hospital de Clínicas en el período 2010-2013. Se aplicó score predictivo de hemorragia sintomática a toda la población de trombolizados. Tests estadísticos: test de chi cuadrado, test de student, test de Wilcoxon, se consideraron diferencias estadísticamente significativas aquellas con una p < 0,05. Resultados: treinta y cuatro pacientes trombolizados, promedio de edad 67 años, mayoría mujeres, alto porcentaje de ACV graves, National Institute of Health Stroke Scale (NIHSS) promedio al ingreso: 11, con mejoría estadísticamente significativa al alta. Etiología principal: cardioembolia. Tiempo síntoma aguja promedio: 170 minutos. Hemorragia intracraneana: ocho pacientes (23,5%), fallecieron cuatro de ellos. El puntaje del score de sangrado no predijo el sangrado intracraneano. Conclusiones: en el Hospital de Clínicas, desde la inauguración de la Unidad de ACV, el porcentaje de infartos cerebrales trombolizados ha ido en aumento, siendo actualmente comparable a cifras internacionales. El tiempo síntoma-aguja es menor que en otros estudios. La trombolisis generó un beneficio estadísticamente significativo en la escala de NIHSS. El porcentaje de sangrados fue similar al descrito en la literatura...

Neumatosis intestinal y gas porto-mesentérico: hallazgos radiológicos y significado clínico en un caso de catástrofe abdominal / Pneumatosis intestinalis and portall venus gas: radiological findings and clinical significance in a case of abdominal catastrophe

Presentamos el caso de una mujer de 56 años de edad, con dolor abdominal de cinco días de duración asociado a manifestaciones inespecíficas y sin etiología clara del dolor. Se realizaron estudios en busca del origen del dolor con los que se documentó neumatosis intestinal grave, que posteriormente se agravó a pesar del manejo medico. Debido al mal estado hemodinámico y el rápido deterioro clínico luego de la evaluación médica no pudo ser llevada a cirugía y la paciente fallece.

We report a 56-year-old woman with abdominal pain 5 days duration associated with nonspecific manifestations without etiology of pain. We conducted studies in search of the source of pain between these severe intestinal pneumatosis that progress despite medical management and could not be taken to surgery due to hemodynamic state to a rapid deterioration after medical evaluation and documented patient dies. Finally, we review this case and the most frequent finding of portomesenteric venous gas.

Síndrome de arteria mesentérica superior secundario a quemadura severa / Superior mesenteric artery syndrome caused by severe burn

El síndrome de la arteria mesentérica superior (síndrome de Wilkie) es una causa poco frecuente de obstrucción duodenal. El síndrome resulta por la compresión de la tercera porción del duodeno, que cruza por debajo de la arteria mesentérica superior. Se asocia con situaciones que disminuyen el ángulo entre la arteria mesentérica superior y la aorta (compás aorto-mesentérico), secundarias a pérdida de grasa retroperitoneal (descenso brusco de peso o caquexia). Describimos el caso de un paciente masculino de 17 años con quemaduras de segundo grado y compromiso del 28 % de la superficie corporal total, quien posteriormente presentó vómito, distención abdominal e intolerancia a la vía oral y en quien, luego de múltiples estudios, se confirma el diagnóstico de síndrome de Wilkie.

Superior mesenteric artery syndrome is an uncommon cause of upper gastrointestinal tract obstruction. The syndrome results from compression of the third portion of duodenum as it crosses underneath the superior mesenteric artery. It is associated with conditions that decrease the angle between the superior mesenteric artery and the aorta (aorto-mesenteric compass) secondary to loss of retroperitoneal fat (sudden decrease in weight or cachexia). In this article, we describe a male patient of 17 years old with deep second degree burns, 28% of the total body surface, who later started to vomit associated with abdominal distension and intolerance to food and after multiple studies confirmed the diagnosis of Wilkie's syndrome.

Disgenesia gonadal pura XX: relato de caso / Pure gonadal dysgenesis XX: case report

Objetivo: relatar um caso de Disgenesia Gonadal Pura XX (DGP XX), acompanhado naFundação Santa Casa de Misericórdia do Pará (FSCMPA). Relato do caso: paciente do sexofeminino, 22 anos, com queixa de amenorreia primária e ausência de desenvolvimento mamário.O diagnóstico de DGP XX foi confirmado através de dosagens hormonais, que apontaram umhipogonadismo hipergonadotrófico; ultrassonografia pélvica e cariotipagem. Consideraçõesfinais: a DGP é uma nosologia rara, porém, deve ser lembrada em pacientes com amenorreiaprimária, sendo fundamental a realização de cariotipagem para o diagnóstico final. É necessáriauma adequada assistência médica a tais pacientes em virtude das possíveis complicaçõespsicossociais e médicas que podem decorrer de tal quadro.

Objetive: to report a case of XX pure gonadal dysgenesis, assisted in the Santa Casa deMisericordia do Pará (FSCMPA). Case report: a female patient, 22 years, complaining ofprimary amenorrhea and absence of breast development. The diagnosis of pure gonadaldysgenesis XX (PGD XX) was confirmed by hormonal measurements, which showed ahypergonadotropic hypogonadism, pelvic ultrasound and karyotyping. Final considerations:the pure gonadal dysgenesis is a rare condition, but should be considered in patients withprimary amenorrhea. It is fundamental to perform karyotyping for the final diagnosis. Thispatients need a proper medical care because of possible psychosocial and medical complicationsthat may arise from this condition.

Gastritis colágena: presentación de un caso clínico y revisión de la literatura / Collagenous gastritis: presentation of a clinical case and review of the literature

Collagenous gastritis (CG) is an exceptional disease characterized by the deposition of subepithelial collagen band thicker than 10 tm in association with increased inflammatory cell infiltrate of the lamina propria. These histological features seem to overlap with other "collagenous enterocolitides". The pathogenesis and prognosis of CG still remains unclear. CG presentation is seen completely different in two major subsets of patients, children and adults. We report a 38 year-old man with abdominal pain and chronic diarrhea. The upper endoscopy showed a severe gastritis with biopsies that revealed CG, and the colonoscopy was normal with biopsies indicative of collagenous colitis. This characteristic form of clinical presentation in adult patients suggests that subepithelial collagen deposition may be a generalized disease affecting different areas of the gastrointestinal tract. The patient was treated with proton-pump-inhibitors and budesonide, with clinical improvement.

La gastritis colágena (GC) es una enfermedad poco frecuente caracterizada por el depósito subepitelial de colágeno de grosor mayor de 10 um asociado a infiltrado inflamatorio en la lámina propia. Estos hallazgos histológicos son similares a los encontrados en la enterocolitis colágena. La patogénesis y pronóstico de la GC permanece aún desconocida. La presentación clínica de la GC se observa de manera diferente en dos subgrupos de pacientes, niños y adultos. Se presenta el caso de un hombre de 38 años con dolor abdominal y diarrea crónica. La endoscopia digestiva alta mostró una gastritis severa con biopsias que revelaron la presencia de GC y la colonoscopia fue normal con biopsias que mostraron una colitis colágena. Esta forma de presentación clínica en el paciente adulto sugiere que el depósito de colágena subepitelial corresponde a una enfermedad generalizada que puede afectar a diferentes áreas del tracto gastrointestinal. El paciente fue tratado con inhibidores de la bomba de protones y budesonida con mejoría clínica.

Fenómeno de acomodación inmunológica: Trasplante hepático ABO incompatible. Caso clínico / Accomodation process: ABO-incompatible liver transplantation. Report of one case

We report a 33 year-old female with a diagnosis of halothane-induce fulminant hepatic failure who was subjected to a liver transplant with an ABO-incompatible graft. The patient received a therapeutic protocol that included total plasma exchange, splenectomy and quadruple immunosuppression. After 5 years, the patient remains asymptomatic and with normal liver enzymes, while she has been treated with low dose of immunosuppressive drugs. This case demonstrates an example of how the immunological process of accomodation opens the possibility of using ABO-incompatible organs as a definitive grafts.

"Síndrome pequeño para su tamaño", (small-for-size), como complicación de un trasplante hepático con donante vivo adulto relacionado / Small-for-size syndrome: report of one case

Although the use of cadaveric split or living donor liver transplantation is a valid option for liver transplants, they have several complications, being the "small-for-size syndrome" one of the most frequent. This entity is mainly due to the incapacity that the graft has to meet the blood drainage demands. We report a 61 year-old patient with sub-acute liver failure, transplanted with a partial liver graft that developed hyperbilirubinemia, ascites and liver function deterioration. A meso-caval shunt was performed, after which the ascites resolved, serum bilirubin normalized and the synthetic function of the liver improved. After one month, a follow-up CT seen showed the absence of blood flow in the shunt, possible due to the reduction of the hyper-perfusion of the liver. The clinical and biochemical condition of the patient continued improving despite the lack of flow through the shunt.

Manejo de zona donante de injertos cutáneos con polvo de quemados / Handling of donor zone of skin grafts treated with powder for burn victims

Tipo de estudio: Prospectivo longitudinal. Propósito: difundir los resultados obtenidos en el manejo de zonas donantes de injertos de piel parcial tratados con polvo de quemados (PQ). Objetivos: Determinar el tiempo de reepitelización de zonas donantes de injertos de piel parcial tratados con PQ. Cuantificar el grado de dolor referidos por pacientes en que se empleó PQ en las zonas donantes. Metodología: se incluyeron 30 pacientes de la Unidad de Quemados del Hospital Luís Vernaza entre enero y marzo del 2004, con edades entre 18 y 50 años y que presentaron quemaduras que requirieron injertos de piel parcial, y en cuyas zonas donantes se empleó PQ. Se evaluó el tiempo de reepitelización en días y el nivel de dolor referido por el paciente a las 48 horas de post operatorio determinado por la escala de intensidad del dolor. Resultados: el promedio de reepitelización fue de 12.86 días y el del dolor referido a las 48h del postoperatorio fue de 4.13 sobre 10. No se presentaron complicaciones. Conclusiones: el PQ es un producto efectivo en el manejo de zonas donantes de injertos cutáneos, produciendo una rápida reepitelización, dolor tolerable y evitando complicaciones.

Study type: Prospective longitudinal. Purpose: To present the results obtained in handling donor zonesof skin grafts treated with powder for burn victims (PBV). Objectives: To set the re-epithelization of donor zones of partial skin grafts treated with PBV. Assess the pain level showed by patients treated with PBV in donor zones. Methodology: thirty patients of the Burnt Unit of the “Luis Vernaza” hospital were included between January and March/2004, age: between 18 and 50 years old, presenting burns requiring partial skin grafts and with donor zones treated with PBV. Time for re-epithelization was assessed in days as well as the level of pain mentioned by the patient 48 hours after post-operative period, set by the pain intensity scale. Results: average time for re-epithelization : 12.86 days and the pain showed 48 hours after post-operative period was 4.13 /10. There were no complications. Conclusions: PB is an effective product for handling donor zones in skin grafts, it produces a fast re-epithelization, makes pain bearable, and avoids complications.

Teratoma quístico de ovario bilateral / Bilateral ovarian cystic teratoma (benign dermoyd cyst)

Los teratomas son tumores, que presentan en su estructura tejidos derivados de las tres capas germinales (ectodermo, endodermo y mesodermo); como pelos, tejido cerebral, uñas, etc. Pueden ser benignos o malignos. El teratoma quístico maduro, es el tumor de células germinales más frecuente, y afecta principalmente a mujeres jóvenes. El caso reportado es el de una mujer de 21 años, que fue diagnosticada de teratoma quístico maduro en ambos ovarios. Para la extirpación se prefirió cirugía abierta por sobre la laparoscópica, por el tamaño de las masas.

Teratomas are tumors that present in their structure, derived tissues from the three germinal layers (Ectoderm, Mesoderm, and Endoderm); as hair, cerebral tissue, nails, etc. They can be benign or malignant. Mature cystic teratoma (benign dermoyd cyst), is the most frequent germ cells tumor which principally affects young woman. The case reported is of a 21 years old woman who was diagnosed of mature cystic teratoma in both ovaries. For extirpation, open surgery was preferred over laparoscopic by the size of the mass.

Enfermedad por descompresión en el buceo: análisis de casos ocurridos en Costa Rica, 1980-1987 / Diseases by decompression in the diving: analysis of cases happened in Costa Rica, 1980-1987

Dentro de los riegos de buceo, la enfermedad por descompresión constituye un trastorno multisistémico que resulta de la liberación de gas inerte (por lo común, nitrógeno) en solución con la consecuente formación de burbujas de gas en la sangre y los tejidos, cuando desciende abruptamente la presión ambiental. Este trabajo se refiere al estudio clínico de nueve casos que ocurrieron en Costa Rica entre enero de 1980 y octubre de 1987. Se analizaron las características generales de buzos, y del buceo en el momento del informtunio, las manifestaciones clínicas, los datos de laboratorio y de radiología, la evolución y la anatomía patológica. Tres de los buzos fallecieron. En estos se registraron los siguientes promedios en su buceo: número de inmersiones 1,66, profundidad 41,6 metros, duración de lainmersión 1,75 hora, y tiempo de ascenso de 9 minutos. En los sobrevivientes los por medios fueron: número de inmersiones 1,5, profundidad de inmersión 34,3 duración de la inmersión 3,4 horas y tiempo de ascenso de 10,2 minutos. Entre las manifestaciones clínicas más relevantes: alteración de la conciencia que varió entre el estado comatoso e hiperexcitabilidad; parálisis, dolores abdominales, náuseas, sensación de quemadura en piel o en músculos. La sescuela más frecuentemente fue el déficit motor en miembros inferiores. En los tres casos fatales, la muerte se atribuyó a: enfisema pulmonar intersticial, hemorragia cerebral y embolismo pulmonar masivo, respectivamente.