Social determinants of hospitalizations for ambulatory care sensitive conditions in Guarulhos, São Paulo / Los determinantes sociales de las hospitalizaciones por condiciones sensibles a la atención primaria en guarulhos, são paulo / Determinantes sociais das Internações por Condições Sensíveis à Atenção Primária em Guarulhos, São Paulo

The study goals present an overview of Hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) in Guarulhos, SP, from 2008 to 2012. This is an ecological study based on secondary data obtained from the Brazilian Hospital Information System, and supported by the Praxical Theory of Intervention of Collective Health Nursing. Applied descriptive statistics for analysis. It was observed that Guarulhos shows an upward trend in hospitalizations by ACSC (20% increase), the most frequent causes of heart failure (11.8%), cerebrovascular disease (10.6%) and angina (9.7%), most frequently in the age group ≥ 65years old, for both sexes. The results are similar to other Brazilian studies, but their analysis should extrapolate the biological limits and the supply of healthcare resources, focusing on the social determinants of the health-disease process.


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El estudio tuvo como objetivo proporcionar una visión general de las Hospitalizaciones por Condiciones Sensibles a la Atención Primaria (ICSAP) en Guarulhos, SP, en el período 2008-2012. Se trata de un estudio ecológico a partir de datos secundarios obtenidos a través del Sistema de Información Hospitalaria, y apoyado por la Teoría de Intervención Práxica de la Enfermería en Salud Colectiva. Se aplicó la estadística descriptiva para el análisis. Se observó que Guarulhos muestra una tendencia al alza en las hospitalizaciones por ICSAP (aumento del 20%), las causas más frecuentes de insuficiencia cardiaca (11,8%), enfermedad cerebrovascular (10,6%) y la angina (9,7% ), con mayor frecuencia en el grupo de edad ≥ 65 años para ambos sexos. Los resultados son similares a otros estudios brasileños, pero su análisis debe extrapolar los límites biológicos y el suministro de los recursos sanitarios, centrándose en los determinantes sociales del proceso salud-enfermedad.
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Objetivo Apresentar o panorama das Internações por Condições Sensíveis à Atenção Primária (ICSAP) no município de Guarulhos, SP, no período de 2008 a 2012. Método Estudo ecológico, com dados secundários obtidos via Sistema de Informações Hospitalares, sustentado pela Teoria de Intervenção Práxica da Enfermagem em Saúde Coletiva. Empregou-se estatística descritiva para análise. Resultados Observou-se que Guarulhos apresenta trajetória crescente nas internações por ICSAP (aumento de 20%), sendo as causas mais frequentes a insuficiência cardíaca (11,8%), as doenças cerebrovasculares (10,6%) e a angina (9,7%), com maior frequência na faixa etária ≥ 65 anos, para ambos os sexos. Conclusão Os resultados encontrados assemelham-se a outros estudos brasileiros, porém sua análise deve extrapolar os limites biológicos e a oferta de recursos assistenciais, atentando para as determinações sociais do processo saúde-doença. .

Hipertensão porta na esquistossomose mansônica: repercussões do tratamento cirúrgico no perfil histomorfométrico da mucosa gástrica / Portal hypertension in mansonic schistosomiasis: profile of the gastric mucosa

Investigou-se, através da análise digital de imagens, as repercussões do tratamento cirúrgico para controle da hipertensão porta e seus efeitos na vasculatura gástrica de pacientes jovens portadores de esquistossomose mansônica. Foram incluídos no estudo pacientes no pré-operatório (n=5) e grupos de pacientes submetidos à intervenção cirúrgica, em diferentes períodos (0-2 anos, n=04; 2-6 anos, n=13; acima de 6 anos, n=10). Foram obtidas biópsias endoscópicas da mucosa do antro e corpo gástrico, submetidas à rotina histológica e montadas em blocos de parafina. Confeccionaram-se lâminas histológicas que foram usadas para a análise histomorfométrica dos seguintes parâmetros: número médio de vasos por campo, diâmetro médio e espessura da parede dos vasos. Os resultados obtidos evidenciaram uma diminuição significativa da densidade e do diâmetro dos vasos a partir dos dois anos de pós-operatório até o período superior a 6 anos. Os dados dão suporte ao conceito de que a técnica cirúrgica ministrada ameniza, em longo prazo, as alterações histopatológicas específicas, como a hemorragia e a ectasia.

The repercussions from surgical treatment for controlling portal hypertension and its effects on the gastric vasculature of young patients with mansonic schistosomiasis were investigated by digital image analysis. The study included five patients at the preoperative stage and 27 patients who had undergone surgical intervention at different times in the past: 0-2 years ago, n=4; 2-6 years ago, n=13, and more than 6 years ago, n=10. Endoscopic biopsies were taken from the mucosa of the gastric antrum and body endoscopic mucosa and the samples underwent routine histological tests after embedding in paraffin blocks. Histological thin sections were used for histomorphometric analysis of the following parameters: mean number of vessels per field, and mean diameter and thickness of the vessel walls. The results showed that, between the patients whose operation was not more than two years ago and those whose operation was more than six years ago, there was a significant decrease in the density and diameter of the vessels. These findings give support to the concept that the surgical treatment administered decreases specific histological alterations like hemorrhage and ectasia, over the long term.

Low hematocrit impairs gastric mucosal CO2 removal during experimental severe normovolemic hemodilution

OBJECTIVE: The net effects of acute normovolemic hemodilution with different hemoglobin levels on splanchnic perfusion have not been elucidated. The hypothesis that during moderate and severe normovolemic hemodilution, systemic and splanchnic hemodynamic parameters, oxygen-derived variables, and biochemical markers of anaerobic metabolism do not reflect the adequacy of gastric mucosa, was tested in this study. METHODS: Twenty one anesthetized mongrel dogs (16 ± 1 kg) were randomized to controls (CT, n = 7, no hemodilution), moderate hemodilution (hematocrit 2 5 percent ± 3 percent, n = 7) or severe hemodilution (severe hemodilution, hematocrit 15 percent ± 3 percent, n = 7), through an isovolemic exchange of whole blood and 6 percent hydroxyethyl starch, at a 20 mL/min rate, to the target hematocrit. The animals were followed for 120 min after hemodilution. Cardiac output (CO, L/min), portal vein blood flow (PVF, mL/min), portal vein-arterial and gastric mucosa-arterial CO2 gradients (PV-artCO2 and PCO2 gap, mm Hg, respectively) were measured throughout the experiment. RESULTS: Exchange blood volumes were 33.9 ± 3.3 and 61.5 ± 5.8 mL/kg for moderate hemodilution and severe hemodilution, respectively. Arterial pressure and systemic and regional lactate levels remained stable in all groups. There were initial increases in cardiac output and portal vein blood flow in both moderate hemodilution and severe hemodilution; systemic and regional oxygen consumption remained stable largely due to increases in oxygen extraction rate. There was a significant increase in the PCO2-gap value only in severe hemodilution animals. CONCLUSION: Global and regional hemodynamic stability were maintained after moderate and severe hemodilution. However, a very low hematocrit induced gastric mucosal acidosis, suggesting that gastric mucosal CO2 monitoring may be useful during major surgery or following trauma.

OBJETIVO: Os efeitos da hemodiluição normovolêmica com diferentes níveis de hemoglobina na perfusão esplâncnica são pouco conhecidos. Testamos a hipótese que durante a hemodiluição moderada e acentuada, os parâmetros hemodinâmicos sistêmicos e regionais e as variáveis relacionadas ao metabolismo de oxigênio não refletem a adequação da perfusão da mucosa gástrica. MÉTODOS: Vinte e um cães anestesiados com fentanil e vecurônio (16±1 kg) foram randomizados como controles (CT, n=7, sem hemodiluição normovolêmica), hemodiluição normovolêmica moderada (Ht 25±3 por cento, n=7) ou hemodiluição normovolêmica acentuada (Ht 15±3 por cento, n=7), pela troca isovolêmica entre o sangue total e hidroxietil amido a 6 por cento, 20 mL/min até o hematócrito pré-estabelecido para cada grupo. Os animais foram acompanhados por 120 min após a hemodiluição normovolêmica. Durante todo o experimento foram medidos o débito cardíaco (CO, L/min), o fluxo de veia porta (PVF, mL/min), e os gradientes de CO2 veia porta-arterial e mucosa gástrica-arterial (PV-artCO2 and PCO2-gap, mmHg, respectivamente). RESULTADOS: O volume de sangue trocado foi de 33,9±3,3 mL/kg para hemodiluição normovolêmica moderada e de 61,5±5,8 mL/kg para a hemodiluição normovolêmica acentuada. A pressão arterial e os níveis de lactato sistêmico e regional permaneceram estáveis em todos os grupos. Houve aumentos iniciais de débito cardíaco e de fluxo de veia porta, tanto na hemodiluição normovolêmica moderada quanto na hemodiluição normovolêmica acentuada; o consumo de oxigênio sistêmico e regional permaneceram estáveis, principalmente por conta de aumentos na taxa de extração de oxigênio. O PCO2-gap apresentou aumento significativo apenas nos animais submetidos a hemodiluição normovolêmica acentuada. CONCLUSÃO: Ocorre estabilidade hemodinâmica global e regional tanto na hemodiluição normovolêmica moderada quanto na acentuada. Entretanto, o hematócrito de 15 por cento induziu acidose moderada de mucosa gástrica, o que pode ser relevante em procedimentos cirúrgicos de grande porte ou no trauma.

Comparative gastrointestinal toxicity of selective cyclooxygenase (COX-2) inhibitors.

Cyclooxygenase (COX-2) inhibitors were developed with the hope that they will cause fewer gastrointestinal adverse effects. Ability of selective as well as nonselective COX inhibitors to alter ischemia-reperfusion induced damage of gastric mucosa and hapten-induced colitis in rats has been compared. Celecoxib (10, 20 and 40 mg/kg(-l)) was significantly more potent at aggravating ischemia-reperfusion injury as compared to nimesulide. Similarly, celecoxib was found to maximally potentiate TNBS-induced colitis, followed by nimesulide and indomethacin. Celecoxib at its highest dose produced maximum deep histological injury. This paradoxic ulcer and colitis aggravating effect of selective COX-2 inhibitors may be explained by suppression of protective prostaglandins generated as a consequence of COX-2 induction in inflammatory states.

Band ligation of Dieulafoy lesions.

Various endoscopic methods have been used successfully to treat Dieulafoy lesions. We describe our experience at one center of successful band ligation of Dieulafoy lesions in 7 patients.

Dieulafoy disease of the stomach presenting as mass lesion--a case report.

Dieulafoy disease is a rare cause of severe gastrointestinal haemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. We describe a 55 year old patient of severe upper gastrointestinal bleeding caused by a gastric Dieulafoy disease, presenting as a mass lesion in the stomach, diagnosed clinically and radiologically as gastrointestinal stromal tumour. Increased awareness and early endoscopy are important for accurate diagnosis.

Angiodysplasia of cardia of stomach--a case report.

Angiodysplasia of gastrointestinal tract is still thought to be an entity of unknown aetiology. This lesion is most commonly observed in elderly patients presenting with severe and persistent iron deficiency anaemia, following occult blood loss or acute episodes of haematemesis. In the stomach antral vascular ectasia is the most common presentation. We report an autopsy case of vascular ectasia in the cardia of stomach in a young patient with clinical symptoms of anaemia as the presentation and an associated secondary hemosiderosis of liver.

Assessment of portal hemodynamics by ultrasound color Doppler and laser Doppler velocimetry in liver cirrhosis.

BACKGROUND: Color Doppler is a noninvasive method for assessing portal hemodynamics. Laser Doppler velocimetry is useful in assessment of microcirculatory abnormalities in portal hypertensive gastropathy (PHG). AIMS: To study portal hemodynamics by color Doppler and gastric mucosal blood flow (GMBF) by laser Doppler velocimetry in patients with cirrhosis. METHODS: Twenty-eight patients with cirrhosis of liver (24 men) and 10 healthy subjects (7 men) were studied. Portal venous blood flow (PVBF) and portal flow velocity (PFV) were assessed by color Doppler at the level where the hepatic artery crosses the portal vein, and GMBF was measured by laser Doppler velocimetry. RESULTS: PVBF (379.5 [102.9] mL/min), PFV (5.3 [1.1] cm/sec) and GMBF (3.5 [0.8] volts) were significantly lower in patients with cirrhosis than in controls. PVBF and PFV were significantly lower in patients in Child class B and C than those in class A. Patients with ascites had significantly lower PVBF, PFV and GMBF than those without; values were also lower in patients with PHG than in those without. History of bleeding had no relation with PVBF and PFV. GMBF showed good correlation with PVBF (r=0.58, p<0.001) and with PFV (r=0.48, p<0.01). CONCLUSIONS: In cirrhosis of liver, PVBF, PFV and GMBF are significantly lower, and the changes increase with increasing severity of liver disease.

Comparación de variables derivadas de tonometría gástrica y cateter de Swan-Ganz en pacientes con shock séptico / Comparison of variables derived from gastric tonometry and Swan Ganz catheter in patients with septic shock

El déficit de O2 se asocia con falla orgánica múltiple y muerte. A pesar de presentar valores normales de perfusión sistémica, los pacientes críticos pueden tener valores anormales de perfusión tisular regional y de metabolismo. Los índices sistémicos de perfusión, como el gasto cardíaco o la saturación venosa mixta de O2 son valores globales y frecuentemente malos predictores de la evolución del paciente. La tonometría gástrica se ha descrito como una herramienta de monitoreo de hipoxia regional o isquemia tisular. La sepsis es una situación clínica donde una perfusión sistémica aparentemente normal se asocia a veces con perfusión esplácnica anormal. Objetivo: comparar pH intramucoso gástrico y tonometría gástica con variables hemodinámicas obtenidas mediante catéter de Swan Ganz en la sepsis y el shock séptico. Material y método: se incluyeron 21 pacientes con sepsis, desde setiembre de 1996 a marzo de 1998. Lugar: Centro de Tratamiento Intensivo, Hospital de Clínicas. Medidas: se colocó sonda de tonometría y catéter de Swan Ganz en todos los pacientes ingresados al CTI. Los pacientes recibieron ventilación mecánica y fueron sedados. Los requerimientos de inotrópicos, fármacos vasoactivos, antibióticos y fluidos se determinaron por el médico actuante. Resultados: el pH intramucoso gástrico y la presión parcial de CO2 (PgCO2) en la mucosa gástrica fueron mejores predictores de muerte y estadía en CTI que las variables derivadas del cateter de Swan Ganz, el pH arterial y el bicarbonato arterial (RR 3 y RR 2,5 respectivamente). La tasa de mortalidad fue 52 por ciento (11/21). No bubo diferencias estadísticamente significativas en los valores iniciales y finales cuando se compararon el pHi, el gradiente arterial de pCO2 y las variables derivadas del Swan Ganz. Los valores de pHi y PgCO2 fueron significativamente diferentes entre sobrevivientes y no sobrevivientes (7,17 ñ 0,14 versus 7,32 ñ 0,10 y 55,20 ñ 16,40 versus 39,13 ñ 7,64 respectivamente). VO2, DO2 y EO2 no se asociaron con muerte o estadía prolongada en el CTI. La correlación entre pHi y pH arterial y HCO3 fue 0,59 y 0,57, p=0,0001 respetivamente. La DPCO2 se relacionó significativamente con PAMP, RVS y PCP. Ni los sobrevivientes ni los fallecidos mostraron diferencias significativas entre valores iniciales y finales...

A case of bleeding from the Dieulafoy lesion of the jejunum

Dieulafoy lesion is an uncommon cause of gastrointestinal bleeding, reported to be only 2% of acute or chronic upper gastrointestinal bleeding episodes. Bleeding occurs from a small mucosal erosion involving an unusually large submucosal artery in an otherwise normal mucosa. It is associated with massive, life threatening hemorrhage and is difficult to diagnosis. In most cases the lesion is encountered in the proximal stomach, antrum, duodenum, colon and rectum. In particular, extragastric Dieulafoy lesion is an extremely rare source of intestinal bleeding. In Korea, no case of bleeding from a Dieulafoy lesion of the small intestine has been previously reported. We experienced one case of bleeding from a jejunal Dieulafoy lesion, which was confirmed by the pathologic examination of the resected specimen, and report here.

Effect of a short course of indomethacin on gastric mucosal blood flow using endoscopic laser-Doppler velocimetry.

OBJECTIVE: To assess the effect of a short course of indomethacin on gastric mucosal blood flow (GMBF). METHODS: Patients with musculo-skeletal pain of recent origin and were prescribed a short course of therapy with indomethacin (25 mg tid for 7 days) were studied Baseline measurements of GMBF were carried out using endoscopic laser-Doppler velocimetry prior to starting indomethacin. At sites on the antrum, incisura, lesser and greater curvatures, and fundus. GMBF measurements were repeated after indomethacin therapy, as above and also on sites of erosions, it any. RESULTS: Baseline GMBF at sites on the antrum, incisura, greater and lesser curvatures, and fundus were (mean) 8.6, 7.9, 8.8, 8.5 and 8.7 volts, respectively. Post-therapy values did not differ from the corresponding baseline values (8.7, 8.5, 8.6, 8.6 and 8.3 volts, respectively). However, ten of the 16 patients developed gastric mucosal erosions and the mean GMBF on these sites of erosion was significantly reduced (6.6 +/- 1.3 volts, p < 0.05). CONCLUSIONS: A short course of indomethacin therapy produces a patchy decrease in blood flow in the gastric mucosa and erosions were seen in these areas.

Comparison of gastric mucosal blood flow in normal subjects and in patients with portal hypertension using endoscopic laser-Doppler velocimetry.

OBJECTIVE: To compare gastric mucosal blood flow (GMBF) in normal subjects with that in patients with portal hypertension with or without portal hypertensive gastropathy (PHG). METHODS: GMBF was measured by endoscopic laser-Doppler velocimetry in 20 gastroscopically normal subjects and 30 patients with portal hypertension with or without PHG. The effects of breath-holding (vasomotor reflex), submucosal epinephrine and sublingual isosorbide dinitrate were also studied. RESULTS: In normal subjects, GMBF on the greater curvature was (mean +/- SD) 9.5 +/- 1.3 V and on the lesser curvature, 9.1 +/- 1.9 V. Breath-holding caused a reduction in GMBF by 57.1 +/- 13.7%, submucosal epinephrine reduced it by 41.5 +/- 21.5% and sublingual isosorbide caused a rise of 25.8 +/- 15.2%. The GMBF on the greater and lesser curvature respectively in patients with mild PHG (7.7 +/- 1.2 V and 7.7 +/- 0.8 V) and those with severe PHG (6.5 +/- 3.5 V and 6.3 +/- 2.2 V), was significantly less than that in normal subjects (p < 0.05 and p < 0.001 respectively). Vasomotor reflex was blunted in patients with mild and severe PHG (23.3% +/- 20.3 and 23.1% +/- 17.7 respectively, p < 0.001). Responses to submucosal epinephrine and sublingual isosorbide were similar to those recorded in normal subjects. CONCLUSIONS: Patients with portal hypertension have significantly reduced GMBF and significantly attenuated vasomotor reflex in the gastric vascular bed as compared to normal subjects.

Gastropatia da hipertensäo porta: uma revisäo / Portal hypertensive gastropathy: a review

Os autores revisam os principais aspectos de patogenia da gastropatia da hipertensäo porta (GHP), enfatizando a importância do fluxo sanguíneo gástrico aumentado, o papel desempenhado por substâncias vasoativas, especialmente o óxido nítrico, e finalmente um possível papel exercido pelo Helicobacter pylori.

A new method to asses gastric mucosa rewarming time in patients with portal hypertension

Es posible que el daño mucoso en la gastropatía congestiva de la hipertensión portal puede tener una base de isquemia, desde el tiempo de recalentamiento en otros sitios se correlacione con el flujo sanguíneo local se diseñó un método con el flujo sanguíneo local se diseñó un método para apreciar la capacidad de la mucosa gástrica de volver a calentarse, después de haberla enfriando, como índice de isquemia. Once sujetos control y 15 pacientes con hipertensión portal (10 tratados por escleroterapia) fueron estudiados con un circuito integrado de un transductor de temperatura conectado con una ventana digital. Un balón que contenía al transductor de temperatura fue fijado en forma reversible 10 cm más arriba del extremo de un panendoscopio. Una vez completada la endoscopia se perfundió al balón ubicado en el antro, con agua fría (2§C) se midió a través de un tubo de polietileno. El tiempo transcurrido para que el agua se recalentara desde 20§C hasta 25§C, de 25§C hasta 30§C y desde 20§C hasta 30§C (fue medido), la reproducibilidad de las mediciones repetidas dio un coeficiente de variación de 6 por ciento. El tiempo total de recalentamiento fue (-X ñ SD) 178 ñ 51,3 segundo, significativamente mayor en los pacientes con hipertensión portal si se lo compara con 114 ñ 34,7 segundos en los controles (95 por ciento de intervalo de confianza:-X 63,4 segundos C1 45,2 a 81,78). Hubo 60 por ciento de sensibilidad y 100 por ciento de especificidad. El recalentamiento más lento en pacientes con hipertensión portal puede ser resultado de la isquemia de la mucosa, pero el edema y la infiltración celular pueden afectar también el flujo sanguíneo

Hemorragia digestiva alta causada pela doença de Dieulafoy / Gastrointestinal bleeding caused by Dieulafoy's disease

No período compreendido entre março de 1979 a julho de 1991, cinco pacientes (quatro do sexo masculino e um do feminino) portadores de hemorragia digestiva alta (HDA) por doença de Dieulafoy (DL) foram atendidos em nosso serviço. A idade dos enfermos variou de 31 a 75 anos (média de 56 anos). Clinicamente, a DL caracterizou-se por HDA maciça, recorrente (dois a três episódios de sangramento por enfermo), COM repercussao hemodinâmica e necessidade de transfusao sanguínea (mínimo de duas, máximo de seis unidades de papa de hemácias por enfermo; média de três unidades/paciente). Realizaram-se de duas a quatro endoscopias por doente (média de 2,8 endoscopias/paciente), até a definiÇao diagnostica. Em todos os casos, a lesao foi definida como coto vascular visível sobre erosao diminuta, em fundo ou corpo gástrico. Um dos pacientes foi submetido a ressecçao em cunha da área sangrante, pois naquela época (l979) a hemostasia endoscópica nao era preconizada. O anatomopatológico confirmou a presença de artéria submucosa, anormalmente calibrosa, com ponto de rotura, o que define DL. Os demais quatro enfermos foram submetidos a hemostasia endoscópica com injeçao de soluçao hipertônica de glicose e adrenalina, seguida de álcool absoluto. Houve interrupçao definitiva do sangramento em todos os casos. A análise da literatura mundial e da casuística aqui apresentada permite afirmar que a endoscopia digestiva alta mudou a história natural da DL, contribuindo de maneira fundamental para seu diagnóstico e terapêutica.

Malformaçäo vascular gastrointestinal / Gastrointestinal vascular malformation

A doença de Dieulafoy é representada por dilataçäo arterial na submucosa gástrica cuja mucosa suprajacente mostra-se ulcerada e, algumas vezes, pode ser responsável por severa hemorragia gastrointestinal. O diagnóstico endoscópico nem sempre pode ser realizado, tendo em vista a natureza intermitente do sangramento. Säo relatadas e tecidas consideraçöes etipatogênicas sobre dois casos: um no estômago e outro no jejuno

Involvement of prostaglandins in chilli-induced early gastric vascular damage in adult Wistar rat.

OBJECTIVE: To explore the role of prostaglandins in protecting against chilli-induced early gastric vascular damage. METHODS: Early gastric vascular damage was induced in rats by oral administration of 8 mg/Kg chilli extract. The damage was assessed by estimating spectrophotometrically the amount of Evan's blue leaking into gastric tissue and luminal contents 10 min after exposure to chilli. Further groups of rats were pretreated with misoprostol (10, 25 or 50 micrograms/Kg) or dazmegrel (1, 5 or 25 mg) to evaluate their protective effects. RESULTS: Both misoprostol and dazmegrel were able to reduce gastric vascular damage induced by chilli in a dose-dependent fashion. CONCLUSION: Prostaglandins may play a role in protecting against chilli-induced early gastric vascular damage.