RESUMO
BACKGROUND: The abdominal wall can be considered comprised of two compartments: an anterior and a posterior compartment. The anterior compartment includes the anterior rectus sheath and the rectus muscle. The posterior compartment comprises the posterior rectus sheath, the transversalis fascia, and the peritoneum. When a large defect in the anterior compartment has to be corrected, for example, a rectus diastasis or large incisional hernia, an action on the anterior compartment is necessary; therefore, an anterior component separation has to be considered. If a loss of substance is present in the posterior compartment, a trasversus abdominis release should be accomplished. METHODS: We propose an original anterior compartment mobilisation, by a posterior approach. Dissection of the posterior rectus sheet proceeds until the linea semilunaris is reached. Incision of the anterior rectus sheath permits a mobilisation of the anterior compartment by a posterior approach. A mesh is placed in a sublay position. If the abdominal wall presents a loss of substance of the posterior compartment, a transversus abdominis release (TAR) can be performed in the same time. RESULTS: No hernia recurrences, no wound infection, and no mesh infection have been reported. CONCLUSIONS: The anterior compartment mobilization permits mobilization towards the midline of rectus muscle and restoration of anterior compartment, with low morbidity rate; it can be easily associated to a large sublay mesh placement, it allows the preservation of the neurovascular bundles and rectus muscle trophism, and it can be associated with a concomitant TAR procedure for the restoration of the PC, if necessary.
Assuntos
Músculos Abdominais/cirurgia , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Hérnia Incisional/cirurgia , Telas Cirúrgicas , Músculos Abdominais/anatomia & histologia , Parede Abdominal/anatomia & histologia , Parede Abdominal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Dissecação , Fáscia , Humanos , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/métodosRESUMO
RESULTS Of the 1619 included patients,1029 (63.6%) weremale,1327(82.0%) had coronary artery disease (843[52.1%] with prioracutemyo cardial infarction),355(21.9%)had priorischemicstroke ortransientischemicattack,and197 (12.2%) had peripheral vascular disease,andthemean( SD) age was 65.6 (10.5) years. Among randomized clusters, 30 (75%) were cardiology sites, 6 (15%) were primary careunits,and 26 (65%) were teaching institutions.Amonge ligible patients,thosein intervention clusters were more like ly to receive aprescription of evidence-based therapies thant hose in control clusters (73.5%[515of701] vs58.7% [493of840];oddsratio,2.30;95%CI,1.14-4.65). There were no differences between the intervention and control group swithregard storisk factor control(ie,hyperlipidemia,hypertension,ordiabetes).Ratesofeducationforsmokingcessationwere higher among current smokers in the intervention group thanin the control group (51.9%[364of701] vs18.2%[153of840];oddsratio,11.24;95%CI,2.20-57.43).Therateofcardiovascularmortality,acute myocardial infarction,andstrokewas2.6%for patients from intervention cluster sand 3.4%forthose in the control group (hazardratio, 0.76;95%CI,0.43-1.34). (AU)
Assuntos
Humanos , Doenças Cardiovasculares/tratamento farmacológico , Medicina Baseada em Evidências/métodos , Prevenção de DoençasAssuntos
Hipertensão/complicações , Albuminúria/complicações , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Brasil , Doença da Artéria Coronariana/complicações , Complicações do Diabetes , Diabetes Mellitus , Medicina Baseada em Evidências , Humanos , Hipertensão/tratamento farmacológico , Síndrome Metabólica/complicações , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controleAssuntos
Aquaporina 4/imunologia , Encefalopatias/diagnóstico por imagem , Tronco Encefálico/diagnóstico por imagem , Doenças Desmielinizantes , Imunoglobulina G/sangue , Imageamento por Ressonância Magnética , Neuromielite Óptica , Doenças Desmielinizantes/sangue , Doenças Desmielinizantes/complicações , Doenças Desmielinizantes/diagnóstico por imagem , Feminino , Humanos , Pessoa de Meia-Idade , Neuromielite Óptica/sangue , Neuromielite Óptica/complicações , Neuromielite Óptica/diagnóstico por imagemRESUMO
Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial (hypopnea) or complete interruption (apnea) in breathing during sleep due to airway collapse in the pharyngeal region. OSA and its cardiovascular consequences have been widely explored in observational and prospective studies. Most evidence verifies the positive relationship between OSA and hypertension, coronary artery disease, atrial fibrillation, stroke and heart failure. However, more studies are needed to better assess the impact of OSA, and possible benefit of treatment with continuous positive airway pressure (CPAP) on dyslipidemia, type 2 diabetes, insulin resistance and cardiovascular mortality. The leading pathophysiological mechanisms involved in the changes triggered by OSA, include intermittent hypoxemia and re-oxygenation, arousals and changes in intrathoracic pressure. Hypertension is strongly related with activation of the sympathetic nervous system, stimulation of the renin-angiotensin-aldosterone system and impairment of endothelial function. The high prevalence of OSA in the general population, hypertensive patients and especially obese individuals and patients resistant to antihypertensive therapy, highlights the need for effective screening, diagnosis and treatment of OSA to decrease cardiovascular risk.
Assuntos
Hipertensão/etiologia , Apneia Obstrutiva do Sono/complicações , Humanos , Hipertensão/epidemiologia , Respiração com Pressão Positiva , Apneia Obstrutiva do Sono/epidemiologia , Apneia Obstrutiva do Sono/terapiaRESUMO
BACKGROUND: It has been hypothesized that epicardial adipose tissue (EAT) exerts pathogenic effects on cardiac structures. We analysed the associations between EAT and both cardiovascular (CV) disease risk factors and CV events in patients with chronic kidney disease (CKD). PATIENTS AND METHODS: We included 277 nondialysed patients [median age 61, interquartile range (IQR) 53-68 years; 63% men] with stages 3-5 CKD in this cross-sectional evaluation. EAT and abdominal visceral adipose tissue (VAT) were assessed by computed tomography. Patients were followed for median 32 (IQR 20-39) months, and the composite of fatal and nonfatal CV events was recorded. RESULTS: With increasing EAT quartiles, patients were older, had higher glomerular filtration rate, body mass index, waist, VAT and coronary calcification, higher levels of haemoglobin, triglycerides, albumin, C-reactive protein and leptin and higher prevalence of left ventricular hypertrophy and myocardial ischaemia; total and high-density lipoprotein cholesterol, 25-hydroxy-vitamin D and 1, 25-dihydroxy-vitamin D progressively decreased. Associations between EAT and cardiac alterations were not independent of VAT. During follow-up, 58 CV events occurred. A 1-SD higher EAT volume was associated with an increased risk of CV events in crude [hazard ratio (HR) 1.41, 95% confidence interval (CI) (1.12-1.78) and adjusted (HR 1.55, 95% CI 1.21-1.99) Cox models. However, adding EAT to a standard CV disease risk prediction model did not result in a clinically relevant improvement in prediction. CONCLUSION: Epicardial adipose tissue accumulation in patients with CKD increases the risk of CV events independent of general adiposity. This is consistent with the notion of a local pathogenic effect of EAT on the heart or heart vessels, or both. However, EAT adds negligible explanatory power to standard CV disease risk factors.
Assuntos
Tecido Adiposo/metabolismo , Doenças Cardiovasculares/etiologia , Pericárdio/metabolismo , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/metabolismo , Gordura Abdominal/metabolismo , Adiposidade , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
Cordeiro AC, Amparo FC, Oliveira MAC,Amodeo C, Smanio P, Pinto IMF, Lindholm B,Stenvinkel P, Carrero JJ (Karolinska Institutet,Stockholm, Sweden; Dante Pazzanese Institute ofCardiology, S~ao Paulo; Dante Pazzanese Institute ofCardiology, S~ao Paulo; Dante Pazzanese Instituteof Cardiology, S~ao Paulo; Dante Pazzanese Instituteof Cardiology, S~ao Paulo, Brazil). Epicardialfat accumulation, cardiometabolic profile andcardiovascular events in patients with stages35 chronic kidney disease.
Assuntos
Insuficiência Renal Crônica , Obesidade , UremiaRESUMO
Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial (hypopnea) or complete interruption (apnea) in breathing during sleep due to airway collapse in the pharyngeal region. OSA and its cardiovascular consequences have been widely explored in observational and prospective studies. Most evidence verifies the positive relationship between OSA and hypertension, coronary artery disease, atrial fibrillation, stroke and heart failure. However, more studies are needed to better assess the impact of OSA, and possible benefit of treatment with continuous positive airway pressure (CPAP) on dyslipidemia, type 2 diabetes, insulin resistance and cardiovascular mortality. The leading pathophysiological mechanisms involved in the changes triggered by OSA, include intermittent hypoxemia and re-oxygenation, arousals and changes in intrathoracic pressure. Hypertension is strongly related with activation of the sympathetic nervous system, stimulation of the reninangiotensinaldosterone system and impairment of endothelial function. The high prevalence of OSA in the general population, hypertensive patients and especially obese individuals and patients resistant to antihypertensive therapy, highlights the need for effective screening, diagnosis and treatment of OSA to decrease cardiovascular risk.
Assuntos
Apneia Obstrutiva do Sono , Doença da Artéria Coronariana , Doença das Coronárias , HipertensãoRESUMO
BACKGROUND:In chronic kidney disease (CKD), multiple metabolic and nutritional abnormalities contribute to the impairment of skeletal muscle mass and function thus predisposing patients to the condition of sarcopenia. Herein, we investigated the prevalence and mortality predictive power of sarcopenia, defined by three different methods, in non-dialysis-dependent (NDD) CKD patients.METHODS:We evaluated 287 NDD-CKD patients in stages 3-5 [59.9 ± 10.5 years; 62% men; 49% diabetics; glomerular filtration rate (GFR) 25.0 ± 15.8 mL/min/1.73 m(2)]. Sarcopenia was defined as reduced muscle function assessed by handgrip strength (HGS <30th percentile of a population-based reference adjusted for sex and age) plus diminished muscle mass assessed by three different methods: (i) midarm muscle circumference (MAMC) <90% of reference value (A), (ii) muscle wasting by subjective global assessment (B) and (iii) reduced skeletal muscle mass index (<10.76 kg/m² men; <6.76 kg/m² women) estimated by bioelectrical impedance analysis (BIA) (C). Patients were followed for up to 40 months for all-cause mortality, and there was no loss of follow-up.RESULTS:The prevalence of sarcopenia was 9.8% (A), 9.4% (B) and 5.9% (C). The kappa agreement between the methods were 0.69 (A versus B), 0.49 (A versus C) and 0.46 (B versus C). During follow-up, 51 patients (18%) died, and the frequency of sarcopenia was significantly higher among non-survivors. In crude Cox analysis, sarcopenia diagnosed by the three methods was associated with a higher hazard for mortality; however, only sarcopenia diagnosed by method C remained as a predictor of mortality after multivariate adjustment...
Assuntos
Insuficiência Renal Crônica , Mortalidade , SarcopeniaAssuntos
Doenças Cardiovasculares/prevenção & controle , Promoção da Saúde , Aspirina/uso terapêutico , Brasil , Medicina Baseada em Evidências , Feminino , Humanos , Hipertensão/prevenção & controle , Metanálise como Assunto , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Resultado do TratamentoAssuntos
Feminino , Humanos , Doenças Cardiovasculares/prevenção & controle , Promoção da Saúde , Aspirina/uso terapêutico , Brasil , Medicina Baseada em Evidências , Hipertensão/prevenção & controle , Metanálise como Assunto , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation. METHODS: We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable. RESULTS: Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035). CONCLUSIONS: Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.
Assuntos
Transplante de Rim , Obesidade/fisiopatologia , Resultado do Tratamento , Adulto , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
Thyroid cancer is the most common endocrine malignancy with the highest mortality, so it has generated considerable debate and voluminous literature by endocrinologists, surgeons, and nuclear physicians. If total thyroidectomy is the primary treatment for patients with differentiated thyroid cancers (DTC) and it has proven to be effective and safe, the extent of lymph nodes dissection remains controversial among experts in the field. This controversy persists largely due to the lack of a prospective randomized controlled trial to define whether the addition of central lymph node dissection (CLND) to total thyroidectomy for papillary thyroid cancer (PTC) confers an increased risk of permanent hypoparathyroidism and permanent nerve injury. According to the Consensus Conference of the UEC's Club therapeutic modified radical neck dissection (MRND) should be performed only in the patients with evidence of neoplastic multiple lymph node involvement. Although central lymph node dissection may increase the risk of hypoparathyroidism and nerve injury when compared with total thyroidectomy without CLND, it may decrease recurrence of PTC and likely improves disease specific survival and offers a sufficient alternative to routine prophylactic modified radical neck dissection. Selective central lymph node dissection should be performed, under the care of experienced surgeons, in high risk patients (50 years or older aged, large tumor expansion within the thyroid, or with extrathyroid extension), with the extension to the station II-III-IV in case of single lymph node involvement.
Assuntos
Carcinoma Papilar/patologia , Carcinoma Papilar/cirurgia , Excisão de Linfonodo , Recidiva Local de Neoplasia/prevenção & controle , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Adenocarcinoma Folicular/patologia , Adenocarcinoma Folicular/cirurgia , Humanos , Metástase Linfática , Esvaziamento Cervical/métodos , Estadiamento de Neoplasias , Fatores de Risco , Tireoidectomia/efeitos adversos , Resultado do TratamentoAssuntos
Humanos , Masculino , Adulto , Feocromocitoma/diagnóstico , Feocromocitoma/etiologia , Hipertensão , Sinais e SintomasRESUMO
Abdominal wall neoplasms represent more or less 1% of human neoplasms in the adult. The authors reports their own experience based on 9 cases during over 20 years. The prognosis of these tumors is almost influenced from a lot of factors such as: histology, localization, staging, grading, sex, surgical margins, number of local recurrences. Abdominal wall neoplasm are less aggressive for compartmentalization of muscle layer and with a better prognosis because of their localization, and surgical opportunities of extensive resection (not less of 2 cm from tumor's macroscopic limits) allowed by modern prosthetic reconstruction techniques. Polipropilene seems to be the ideal material for such kind of reconstruction even if also mersilene, PTFEe and others were employed. PTFEe and Dual-meshes could be useful in those malignant tumors in which peritoneum resection is necessary.
Assuntos
Neoplasias Abdominais/cirurgia , Parede Abdominal/cirurgia , Fibromatose Agressiva/cirurgia , Fibrossarcoma/cirurgia , Humanos , Leiomioma/cirurgia , Leiomiossarcoma/cirurgia , Estudos Retrospectivos , Telas Cirúrgicas , Resultado do TratamentoRESUMO
BACKGROUND: This retrospective study was undertaken to evaluate if a high resectability rate could improve the long-term outcome of patients with proximal bile duct cancer. METHODS: Between 1985 and 2001, 50 patients (34 males and 16 females) with proximal bile duct cancer were treated. The tumor site were classified according to Bismuth-Corlette's classification: 9 lesions (18%) were Bismuth type I, 23 lesions (46%) type II, 12 lesions (24%) Type IIIa, 5 lesions (10%) type IIIb and only 1 resected tumor (2%) was type IV. Thirty-six patients (72%) were considered suitable for surgery, while 14 underwent non surgical palliative procedures. Twenty patients had bile duct resection only. Ten patients had Roux-enY cholangiojejunostomy with two or three divided segmental hepatic ducts; in ten, the cholangiojejunostomy was performed with 4 or 5 divided segmental hepatic ducts. Thirteen patients had bile duct resection plus hepatectomy. Despite the curative intention of the operation, only in 19 (52.7%) patients did the histopathological examination reveal tumor-free margins. RESULTS: There was no operative mortality. Overall 1-year, 3-year and 5-year survival of the entire surgical group was 61%, 22.5% and 9% respectively. In the 19 patients treated with curative intent the survival at 1,3, and 5 years was 66%, 30% and 15%, respectively, while in the palliative group it was 45%, 15% and 0%, respectively. CONCLUSION: Only margins free from tumor may guarantee an improvement in long-term outcome. Increasing resectability improves survival and could offer a chance of better 5-year survival.
Assuntos
Carcinoma/cirurgia , Tumor de Klatskin/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose em-Y de Roux , Ductos Biliares/cirurgia , Carcinoma/classificação , Carcinoma/mortalidade , Drenagem , Feminino , Hepatectomia , Humanos , Jejunostomia , Tumor de Klatskin/classificação , Tumor de Klatskin/mortalidade , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos , Complicações Pós-Operatórias , Estudos Retrospectivos , Análise de Sobrevida , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Bilateral breast cancer has a cumulative incidence of 3-13% in patients with primary breast cancer, and the majority of these lesions are metachronous. The synchronous and metachronous bilateral breast cancer have at greater risk for distant metastasis than unilateral breast cancer. There was no difference in overall survival when comparing metachronous and synchronous bilateral patients to those with unilateral disease.