Indicadores hospitalares de acesso e efetividade e crise econômica: análise baseada nos dados do Sistema Único de Saúde, Brasil e estados da região Sudeste, 2009-2018 / Access and effectiveness inpatient care indicators and economic crisis: analysis based on the Brazilian Unified Health System data, Brazil and Southern Brazil states, 2009-2018

Resumo No contexto de crise e restrições de recursos é razoável supor o agravamento de fragilidades do Sistema Único de Saúde (SUS), como desigualdades regionais, subfinanciamento e problemas na qualidade do cuidado. Este estudo explorou a aplicação de indicadores de acesso e efetividade, facilmente compreensíveis e calculados, passíveis de refletir a crise na rede hospitalar. Cinco indicadores extraídos do Sistema de Informações Hospitalares, relativos ao Brasil e a estados da Região Sudeste, foram analisados no período de 2009-2018: internações resultantes em morte; internações cirúrgicas resultantes em morte; cirurgias eletivas no total das internações cirúrgicas; próteses de quadril na população de idosos; e angioplastias na população de 20 anos ou mais. Utilizaram-se gráficos de controle estatístico para a comparação dos indicadores entre estados, antes e a partir de 2014. No Brasil, as mortes hospitalares tiveram um leve crescimento enquanto que as mortes cirúrgicas uma queda; as cirurgias eletivas e próteses de quadril também diminuíram. No Sudeste, o Rio de Janeiro apresentou os piores resultados, em especial a queda de cirurgias eletivas. Os resultados ilustram o potencial dos indicadores para monitorar efeitos da crise sobre o cuidado hospitalar.

Abstract In the context of crisis and resource constraints, it is reasonable to assume the deteriorated weaknesses of the Unified Health System (SUS), such as regional inequalities, underfinancing, and care quality issues. This study explored the application of easily comprehensible and calculated access and effectiveness indicators that could reflect the hospital network crisis. Five indicators extracted from the Hospital Information System, related to Brazil and states of the Southeastern region, were analyzed in the 2009-2018 period: hospitalizations resulting in death; surgical hospitalizations resulting in death; elective surgeries in the total of surgical hospitalizations; hip prostheses in the senior population; and angioplasties in the population aged 20 years and over. Statistical control charts were used to compare indicators between states, before and from 2014. In Brazil, overall hospital deaths had a slight increase while surgical deaths declined; elective surgeries and hipprosthesis also decreased. In Southeastern Brazil, Rio de Janeiro was the worst performer, especially the decrease of the elective surgeries. The results illustrate the potential of indicators to monitor crisis effects on hospital care.

Endovascular Neurosurgery in the Northern Macro-Region of Rio Grande do Sul: Part I

Introduction The city of Passo Fundo, in the north of the Rio Grande do Sul state, has been standing out in the health care field for many years. The state has become a reference in endovascular interventional neuroradiology. We will cover 10 years of experience in this area and divide our observations in 3 parts: cerebral angiograms (part I), carotid angioplasties (part II) and intracranial aneurysms (part III). The goal of part I is to statistically assess the cerebral angiograms, their indications, risks and complications, as well as to do a technical review. Materials and Methods A retrospective study from 2005 to 2015 with a total of 5,567 interventional neuroradiology procedures performed. A total of 4,114 angiograms, 639 embolizations of intracranial aneurysms, 414 carotid angioplasties, 143 embolizations of cerebral arteriovenous malformations, 32 embolizations of dural arteriovenous fistulas, 102 cerebral vasospasm treatments, 21 treatments of epistaxis, 36 embolizations of craniocervical tumor, 25 thrombolysis of ischemic stroke, 18 vertebroplasties and 13 embolizations of arteriovenous malformations of the face. Results A total of 4,084 procedures performed, 21,811 vessels studied, average vase 7.62/2.82 vessel and patient/procedure. Of these, 2,536 were diagnostic procedures and 1,548 angiographic controls. Of the total, 1,188 patients received only an angiogram, 27.14% of which were therapeutic procedures. We obtained a total of 3.89% complications: 2.33% reflection vasovagal, 0.56% allergic skin reaction, anaphylactic shock 0.07%, 0.27% femoral hematoma, 0.26% transient neurological deficit, 0.12% permanent neurological deficit and no case of death. Conclusion Cerebral angiography in adults, children and infants is a safe procedure with low risk of permanent neurological complications.

Diferenças regionais no acesso a cirurgia cardiovascular no Brasil, 2002 -2010 / Regional differences in access to coronary bypass surgery in Brazil, 2002-2010

As taxas internação por angioplastia e cirurgia de revascularização vêm sendo usadas como proxies de acesso a serviços de alta complexidade. O objetivo é analisar sua evolução e discutir quais seriam as possíveis causas associadas às desigualdades regionais. Foram calculadas as taxas padronizadas de realização de angioplastia e cirurgia de revascularização por sexo e idade por 100 mil habitantes de 20 anos e mais, no período 2002 a 2010. A comparação com os dados internacionais mostra que o Brasil tem taxas menores que as observadas nos países da OECD. No Brasil, as taxas padronizadas de internação por angioplastia na população de 20 anos ou mais apresentaram uma tendência de crescimento, passando de 27,5 por 100 mil habitantes em 2002 para 39 por 100 mil em 2010. Na comparação das taxas padronizadas por idade e sexo entre as grandes regiões do Brasil, além das diferenças marcantes no eixo Norte - Sul, o que chama atenção é que mantenham um padrão estável e também as diferenças regionais. A constituição de redes assistenciais regionais hierarquizadas para cirurgias cardíacas constitui uma estratégia importante para: garantir a qualidade do cuidado, a optimização dos custos operacionais e reduzir as desigualdades no acesso entre as regiões brasileiras.

The hospitalization rates for angioplasty and coronary bypass surgery have been used as proxies for access to highly specialized services. The scope of this study is to analyze the evolution of these rates and discuss what are the possible causes associated with regional inequalities. Standardized rates of angioplasty and coronary bypass surgery by age and sex per 100,000 inhabitants aged 20 and over, in the period from 2002 to 2010 were calculated. Comparison with international data shows that Brazil has lower rates than those observed in OECD countries. In Brazil, the standardized rates of hospitalization for angioplasty in the population aged 20 and over showed an upward trend, rising from 27.5 per 100,000 in 2002 to 39 in 2010. When mortality rates by age and sex from different geographical regions were compared, besides the marked differences in the north - south axis, what is notable is the maintenance of a stable pattern of these rates and regional differences over the period analyzed. The definition of regional health care networks for cardiac surgery is an important strategy to ensure the quality of care, optimization of operating costs and reduction of inequalities in access to healthcare between Brazilian regions.

Role of N-Acetyl Cysteine to prevent nephrotoxicityin Patients with Impaired Renal Functionundergoing angioplasty

Contrast-induced nephrotoxicity [CIN],is an important cause of acute renal failure. The incidence of CIN has risen as the number of diagnostic and interventional procedures using contrast media increased in recent years. Only intravenous and intra-arterial administration of contrast media is associated with CIN. Oral contrast agents, such as Gastro grafin, do not cause CIN. CIN is now the third leading cause of new onset acute renal failure in hospitalized patients. Sequelae of CIN may include prolonged hospital stay, need for temporary or permanent dialysis [about 5% of cases], or death. This study was to evaluate the role of N-Acetyl Cysteine [NAS] oral administration in patients with impaired renal function undergoing angioplasty. Forty- eight consecutive patients undergoing to Percutaneous coronary angioplasty [PCI]. 33 patients with impaired renal function Serum createnine level [>1.5mg/dl] .And 15 patients without impaired renal function referred to International Hospital center at Ahmad Helmy Street Cairo one day before PCI. The PCI was done at Cardiovascular-Cath .lab Centre [CCC] Eldoki . Cairo at the period between May 2008 and March 2009. All patients were subjected to the following ,Full history taking ,clinical examinations ,12 lead resting ECG, blood samples for serum Urea, Creatinine and k one day before and 24 hours after PCI ,hepatitis B and C virus ,600 mg orally twice daily for four doses starting on the day prior to the procedure. Bothgroups of patients were hydrated with 0.9% normal saline at 1 ml/ kg/hour for 12 hours prior to and 12 hours following PCI . All patients underwent the same procedure for PCI. RESULTS ;There was highly statistically significant value improvement in renal function [serum creatinine and urea] in both groups before and after PCI .Also highly statistically significant improvement in serum K level in Group I with [P value 0.000] but no significant in Group II with [P value 0.082]. One out of 33patients Group I developed Acute renal failure and need renal dialysis [contrast induced nephropathy].- CONCLUSION; We conclude that prophylactic administration. Of N-Acetyl Cysteine along with hydration diminishes the incidence of deterioration of renal function induced by contrast agents in patients with renal insufficiency during coronary angioplasty procedures

Angioplastia infrapatelar en la isquemia de miembros inferiores / Bellow-the-Knee angioplasty for inferior limb claudication

Analizar la evolución hospitalaria y alejada de los pacientes (ptes.) que recibieron una angioplastia periférica infrapatelar (ATP-IFP) por claudicación de miembros inferiores...

To analyze in-hospital and long term evolution of patients who underwent bellow-the knee (BTK) Angioplaty for inferior limb claudication...

Resultados de las angioplastias del sector femoropoplíteo en isquemia crítica / Femoropopliteal angioplasty for the treatment of critical limb ischemia

Introducción: La isquemia critica de las extremidades inferiores (EEII) es una condición que afecta a pacientes que presentan grave patología ateromatosa en múltiples territorios y por ende tienen mal pronostico vital. La terapia endovascular validada en algunos sectores, en éste no ha logrado posicionarse. Objetivo: Evaluar la evolución de los pacientes sometidos a Angioplastia Endoluminal Percutánea (AGP) del territorio femoropoplíteo por isquemia critica. Material y Método: Estudio retrospectivo que incluye 58 extremidades en 54 pacientes con isquemia critica de las EE.II por patología femoropoplítea, sometidos a angioplastia entre Julio del 2001 a Diciembre del 2004 y seguidos en su evolución hasta Abril del 2006. Resultados: Fueron realizadas 58 AGP (54 pacientes): masculinos 54 por ciento, femeninos 46 por ciento, y 74 por ciento diabéticos. Edad promedio 70,6 años. El grupo incluye lesiones TASC A, B, C y D. El 24 por ciento de las extremidades no tenía run off. Éxito técnico inicial se obtuvo en el 84 por ciento. La permeabilidad primaria 43,3 por ciento a 1 año (ES 6,52), 32,7 por ciento a 2 años (ES 7,44) y 16,9 por ciento a 3 años (ES 6,31). Durante el periodo, 4 pacientes fueron sometidos a nuevas angioplastias del mismo territorio y 7 pacientes a by pass. Mortalidad a 30 días 1,7 por ciento. Existieron 4 complicaciones mayores (8 por ciento). Al término del seguimiento hay 20 amputaciones mayores (34 por ciento), cuatro de ellas por compromiso local, las restantes por isquemia irreversible. La mortalidad al final del seguimiento fue de 29,6 por ciento. Conclusión: La angioplastia infrainguinal en la isquemia crítica es posible, segura y de baja morbimortalidad, no excluyendo revascularizar mediante by pass si fracasa.

Introduction: The critical ischemia of the lower extremities is a condition that affects patients who present serious atheromatous pathology in multiple territories and, consequently, have bad live prognosis. Endovascular therapy, valid in some sectors, has not been able to find a position in this one yet. Objectives: to evaluate the gradual development of patients who were subjected to angioplasty of the femoropopliteal territory because of critical ischemia. Material and method: retrospective study, which includes 58 extremities in 54 patients with critical ischemia of the interior extremities due to femoropopliteal pathology who were subjected to angioplasty between July 2001 and December 2004, and whose development was studied until April 2006. Results: 58 AGP were performed in 54 patients: 54 percent male, 46 percent female, and 74 percent diabetics. The average age was 70.6 years old. The group includes TASC A, B, C, and D lesions. 24 percent of the extremities did not have run off. The initial technical success was obtained in 84 percent of the cases. The primary permeability 43,3 percent after a year (ES 6,52), 32,7 percent after 2 years (ES 7,44) and 16,9 percent after 3 years (ES 6,31). 4 patients were subjected to further angioplasty of the same territory and 7 patients were subjected to bypass during this period. The 30-day mortality was 1,7 percent. There were 4 major complications (8 percent). By the end of the monitoring, there are 20 major amputations (34 percent), 4 of these due to local compromise, and the rest of them due to irreversible ischemia. The mortality at the end of the monitoring was 29,6 percent. Conclusion: infrainguinal angioplasty on critical ischemia is possible, safe and presents a low morbimortality, not excluding revascu-larization through bypass in case of failure.

Grado de satisfacción del cuidado de enfermería en pacientes sometidos a angioplastia coronaria transluminal percutanea (ACTP) con stent / Satisfaction level in nursing care among patients with the experience of percutaneous transluminal Coronary Angioplasty (ACTP) with Stent

El objetivo del presente estudio fue valorar la evolución en el logro de resultados, medir el grado de logro de los mismos y determinar el grado de satisfacción con el cuidado de enfermería en personas que viven la experiencia de angioplastia coronaria. El diseño del estudio fue descriptivo, de casos. La muestra la constituyeron 18 pacientes programados para angioplastia, por enfermedad coronaria, hospitalizados en el Hospital Militar Central de Bogotá durante los meses de octubre-diciembre de 2003 y enero-abril de 2004. De los resultados preliminares se concluye que existe un grado medio, con tendencia a alto, de resultados positivos del cuidado de enfermería ofrecido a los pacientes sometidos al procedimiento de angioplastia coronaria con Stent. Cuidados planifica dos según diagnósticos de enfermería evidencian que las enfermeras poseen los conocimientos técnico-científicos y las habilidades de cuidadoras de pacientes con angioplastia coronaria. El grado de satisfacción con el cuidado varió entre poco y medianamente satisfecho; posiblemente hay algún problema en la comunicación enfermera/paciente, tal vez por la cantidad de tareas que debe cumplir la enfermera en estos servicios.

The purpose of the pre sent study was to evaluate the evolution in achieving results, measuring the achievement level as such and to determine the level of satisfaction in nursing care, among people living with the experience of Coronary Angioplastia. The design of the study was descriptive, on a case by cases basis. The sample was composed by 18 patients programmed for angioplastia, due to coronary illness, hospitalized in the Hospital Militar Central of Bogotá, between October - December 2003, and January - April 2004. From preliminary results we concluded that there is tendency from mid to high level of positive results regarding the nursing care offered to the patients who underwent the procedure of coronary angioplastia with Stent. Care planned according to the Nursing Diagnos...

Combined iliac artery angioplasty and infrainguinal reconstruction in multilevel atherosclerotic disease

Patients with limb ischemia and diffuse aortoiliac or combined aortoiliac and femoropopliteal disease present as a difficult problem for surgeons. Is to present our early experience with the combined use of iliac artery angioplasty and infrainguinal surgical revascularization for the treatment of multilevel artherosclerotic disease. Thirteen patients with iliac artery stenosis and femoropopliteal occlusive disease were treated with fem-pop grafting and iliac balloon angioplasty [IBA] which was performed percutaneously within 1-2 days before surgery. Stenting was performed for suboptimal IBA. Graft patency was evaluated by clinical examination, duplex scanning/ankle-brachial index [[ABI] at 1, 3, 6, and 12 months. indications for surgery were limb salvage [46%], rest pain [23%], and claudication [31%]. IBA alone was successful in 10 patients. Stenting was needed in the remaining 3 patients. Distal bypass grafting was performed with an autogenous vein conduit in 10 patients. PTFE placed in the above-knee popliteal segment was used in 3 patients. The primary patency of combined procedures at 1year was 81.8%. There was only one amputation with an overall limb salvage rate of 90.9%. Iliac angioplasy can successfully be used as a prelude to distal arterial bypass in patients with multilevel atherosclerotic disease

Como proceder frente a un síndrome coronario agudo (SCA) / How to proceed in acute coronary syndrome (ACS)

Bajo la denominación de síndrome coronario agudo se incluyen el infarto con y sin onda Q y el angor inestable, cuadros cuya mortalidad oscila entre 5 y 10 por ciento tanto durante como en el curso del primer mes de evolución. En el artículo se describen las medidas que forman parte del manejo de las emergencias coronarias. Entre ellas se incluyen administración inmediata de aspirina y de nitroglicerina, toma de electrocardiograma que es un importante predictor de riesgo; inicio de trombolisis o realización de angioplastía con colocación de stent, terapia anticoagulante. Se discuten las ventajas relativas de la terapia invasiva precoz comparada con la invasora

Revascularização percutânea no paciente diabético / Percutaneous revascularizarion in diabetic patients

O diabete melito é um dos mais importantes fatores derisco para o desnvolvimento da aterosclerose coronária e está freqüentemente associado a outras co-morbidades, como a hipertensäo arterial, as dislipidemias e as alterações do sistema de coagulaçäo. Os diabéticostêm aterosclerose coronária mais extensa e grave, apresentam particularidades tanto na fisiopatologia comonas manisfetações clínicas da doença, e cursam com maior evoluçäo clínica a longo prazo, particularmente naqueles portadores de doença multiarterial e disfunçäo ventricular esquerda. A angioplastia coronária com o baläo apresentam muitas vantagens no tratamento desses pacientes (altas taxas de sucesso hospitalar, baixo índice de complicações maiores, além de tratar-se de procedimento menos agressivos, de menor custo e reabilitaçäo rápida), porém associa-se a taxas mais altas de reestenose, menor capacidade de revascularizaçäo completa e necessidade de procedimentos adicionais de revascularizaçäo. Os "stents" representam a possibilidade de superaçäo dessas limitações no tratamento dos diabéticos, pois promovem taxas mais altas de sucesso primário, permitem a abordagem de lesões mias complexas, ao mesmo tempo que reduzem as complicações maiores e podem atuar favoravelmente quanto às taxas de reestenose e necessidade de novos procedimentos de revascularizaçäo.

Angioplastia primaria en el tratamiento del infarto agudo del miocardio / Primary angioplasty in the treatment of acute myocardial infarction

Un total de 11 pacientes con infarto agudo del miocardio fue tratado mediante angioplastia primaria como única forma de terapia. El tiempo promedio transcurrido entre la aparición del dolor de pecho y la reperfusión coronaria fue de 4 ñ 2 horas. El porcentaje de recanalización fue del 100 por ciento, independientemente de la arteria obstruida. La mortalidad hospitalaria fue del 9 por ciento. La fracción de expulsión ventricular promedio global aumentó de 49 por ciento (preangioplastia) a 55 por ciento (postangioplastia). Las complicaciones observadas fueron: hemorragia y hematoma femoral (9 por ciento), reoclusión temprana de la arteria responsable del infarto (9 por ciento) y reestenosis tardía (18 por ciento). Se implantaron siete mallas intracoronarias postangioplastia por estenosis residual del 50 por ciento. Después del procedimiento, en todos los casos se obtuvo un flujo coronario TIMI grado 3. Se concluye que la angioplastia primaria y la inserción de mallas intracoronarias son la mejor opción para recanalizar la arteria responsable del infarto y disminuir la incidencia de reoclusión o reestenosis tempranas

Efecto de la reperfusión no inmediata sobre los potenciales tardíos luego de Angioplastía de la Arteria responsable del infarto ocluída / Effect of delayed recanalization of occluded acutemyocardial infarction-related artery using coronary angioplasty on late potentials

Evidencias recientes sugieren que la reperfusión tardía de una arteria responsable del infarto (ARI) ocluída luego del infarto agudo del miocardio (IAM), puede reducir la frecuencia de eventos arrítmicos subsecuentes y muerte súbita. La reperfusión mecánica de una ARI ocluída, por medio de angioplastía coronaria transluminal percútanea (ACTP) de 48 horas a dos semanas después de del IAM tiene una alta tasa de éxito y poca reestenosis sintomática. Se identificaron 20 pacientes (19 hombres y una mujer, con edades entre 32 y 77 años, con un primer IAM, electrocardiograma de alta resolución (ECG-AR) y una ARI ocluída). 14 pacientes presentaban potenciales tardíos (PT) positivos después del IAM. En 18 pacientes se realizó una ACTP exitosa de la arteria ocluida, de 6 a 32 días después del IAM. Se realizó ECG-AR de seguimiento de 1 a 8 días después. En el subgrupo de 12 pacientes con reperfusión exitosa y un ECG-AR anormal antes de la ACTP, 7(58,3 por ciento) mostraron resolución de los PT en el seguimiento, la duración del QRS filtrado mostró una reducción significativa (112,1 mas, menos 14,2 mseg a 96,7 mas, menos 12,6 mseg, p=0,02), y hubó una tendencia a incrementar el voltaje y la duración de las señales de baja amplitud. En contraste 2 pacientes con PT positivos antes de la ACTP y reperfusión no exitosa, no presentaron cambios significativos en el ECG-AR en algunos pacientes con un primer IAM, queda por demostrar si esto mejoraría la supervivencia a largo plazo, por lo que deberá investigarse en un estudio más amplio.

Seguimiento a largo plazo de 400 pacientes con angioplastía coronaria / Long-term follow up 400 patients who underwent coronary angioplasty

Entre octubre de 1985 y mayo de 1992 se practicaron 518 angioplastías coronarias en un total de 400 pacientes, con 92 por ciento de éxito. El promedio de estenosis se redujo de 88 a 15 por ciento. Se presentaron 25 complicaciones mayores (6 por ciento): 8 cirugías de revascularización de urgencia, 5 decesos y 12 infartos de miocardio. De los 367 pacientes con angioplastía exitosa, fue posible obtener el seguimiento en 329 (90 po ciento), con un tiempo promedio de 44 meses. De los 113 sujetos a quienes se practicó una angiografía por considerarlos con recidiva clínica, 73 mostraron restenosis, 18 progresión de la enfermedad y 22 (19 por ciento) ausencia de restenosis. En 44, se procedio a una segunda angioplastía con 93 por ciento de éxito, 22 fueron enviados a cirugía de revascularización y a 7 se dio tratamiento médico. Además 18 enfermos fueron operados por presentar progresión de al enfermedad coronaria. Durante el seguimiento 25 por ciento de los enfermos requirieron otra angioplastía o cirugía de revascularización. Además de los 73 (22 por ciento) con evidencia angiográfica de restenosis, 42 (13 por ciento) se presentaron como una recidiva clínica: doce por angina, 15 infarto del miocario y 15 muerte de origen cardiovascular. Al combinar estos grupos, un total de 115 pacientes (35 por ciento) se presentaron clínica o angiográficamente con restenosis. Al final del seguimiento, 259 sujetos (79 por ciento) se encontraban libres de infarto del micardio, cirugía de revascularización y muerte de origen cardiovascular. La tasa de sobrevida a la cardiopatía isquémica a 3.7 años fue de 94.5 por ciento. En conclusión, la angioplstía coronaria fue efectiva y segura con muy buena evolución a largo plazo.