Investigation Route of the Coronary Patient in the Public Health System in Curitiba, São Paulo and in Incor - IMPACT Study / Itinerário de Investigação do Paciente Coronariano do SUS em Curitiba, São Paulo e Incor - Estudo IMPACT

Background: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. Objective: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. Methods: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. Results: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. Conclusion: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS. .

Fundamento: A investigação da doença arterial coronariana (DAC) estável e seu tratamento dependem da estratificação de risco para a decisão sobre a necessidade de cateterismo cardíaco e revascularização. Objetivo: Analisar os procedimentos utilizados no diagnóstico e tratamento invasivo dos pacientes com DAC do Sistema Único de Saúde (SUS) nos municípios de Curitiba, São Paulo e no IIncor- FMUSP. Métodos: Estudo retrospectivo, descritivo, observacional dos itinerários diagnósticos e terapêuticos dos pacientes do SUS, entre os grupos submetidos ou não a testes não invasivos prévios ao cateterismo cardíaco invasivo. Foram quantificados os procedimentos de teste ergométrico, ecocardiograma de estresse, cintilografia de perfusão, cateterismo e tratamento com revascularização percutânea ou cirúrgica e o impacto econômico destas estratégias utilizadas. Resultados: Existem diferenças importantes na avaliação do paciente com DAC suspeita ou conhecida nos três cenários. Apesar dos testes funcionais serem os procedimentos mais frequentemente utilizados, os custos diretos referentes a esses procedimentos diferem significativamente (6,1% em Curitiba, 20% em São Paulo e 27% no Incor-FMUSP). Os custos relacionados aos procedimentos e tratamentos invasivos representam 59,7% dos custos diretos do SUS em São Paulo e 87,2% em Curitiba. No Incor-FMUSP, apenas 24,3% dos pacientes com DAC estável submetidos à revascularização foram submetidos a um teste não invasivo antes do procedimento. Conclusão: Apesar dos testes funcionais não invasivos serem os exames mais frequentemente solicitados na avaliação de pacientes com DAC suspeita ou conhecida, a maior parte dos custos está relacionada a procedimento/tratamento ...

Lymphoscintigraphic evaluation of chronic lower limb oedema

Ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), venography, lymphoscinti-graphy (LS) and contrast lymphography are frequently utilized in the evaluation of lower limb oedema but no clinical data from the Caribbean have been published on the role of LS despite its well-recognized clinical application. The successful clinical application of CT, colour doppler sonography and MRI in differentiating the various causes of lower limb oedema is well understood. Lymphoscintigraphy has found less acceptability especially in the Caribbean where nuclear imaging techniques are only now currently being developed. This paper describes the initial experience with this technique in 15 patients over a five-year period and discusses its value when lower limb lymphoedema is suspected. Scintigrams were analyzed for visualization of lymph vessels and lymph nodes, dilatation of lymphatic vessels, collaterals and dermal back flow. Lymphoscintigrams were classified as normal (n = 5) or consistent with lymphoedema (n = 10). Failure to visualize lymphatic vessels occurred in two cases of suspected primary lymphoedema. In the remaining eight cases of secondary lymphoedema, a positive study based on altered lymphatic flow and anatomy was recorded. An alternative explanation was offered in three out of five cases in which a normal lymphoscintigram was obtained

Nasopharyngeal carcinoma: value of bone and liver scintigraphy in the pre-treatment and follow-up period.

Nasopharyngeal carcinoma (NPC) is a disease with a high potential of distant metastasis, especially to bone and liver. To evaluate the routine use of bone and liver scintigraphy in the evaluation of metastatic disease during the pre-treatment and follow-up period, 112 new cases of NPC were enrolled. The pre-treatment scintigraphs were performed at the time of staging evaluation, while the follow-up ones were performed once a year and whenever clinically indicated. At the pre-treatment period, 3/112 cases showed a true positive result, all at bony sites. At the 3 years follow-up, 10/83 and 8/83 cases respectively showed a true positive result in the bone and liver. All of the positive cases had definite symptoms and signs of metastases, which correlated well with the scintigraphic findings. All without clinical evidence showed a negative finding. Therefore, we conclude that, without clinical indication, routine bone and liver scintigraphy are of limited value.