Role of Computed Tomography Angiography in the Short-Term Follow-up of Aortic Coarctation Repair.

INTRODUCTION: Coarctation of the aorta (CoA) is a narrowing of the thoracic aorta that often manifests as discrete stenosis but may be tortuous or in long segment. The study aimed to evaluate pre and post-surgical aspects of pediatric patients submitted to CoA surgical correction and to identify possible predisposing factors for aortic recoarctation. METHODS: Twenty-five patients were divided into groups according to presence (N=8) or absence (N=17) of recoarctation after surgical correction of CoA and evaluated according to clinical-demographic profile, vascular characteristics via computed angiotomography (CAT), and other pathological conditions. RESULTS: Majority of males (64%), ≥ 15 days old (76%), ≥ 2.5 kg (80%). There was similarity between groups with and without recoarctation regarding sex (male: 87% vs. 53%; P=0.277), age (≥ 15 days: 62.5 vs. 82%; P=0.505), and weight (≥ 2.5 kg: 87.5 vs. 76.5; P=0,492). Altered values of aortic root/Valsalva diameter, proximal transverse arch, and distal isthmus, and normal values for aorta prevailed in preoperative CAT. Normal values for the aortic root/Valsalva sinus diameter were observed with and without recoarctation, the same for both groups regarding ascending and descending aorta in postoperative CAT. No significant difference for altered values of proximal transverse arch and alteration in distal isthmus was observed. CONCLUSION: No predictive risk for recoarctation was observed. CTA proved to be important in CoA diagnosis and management, since CoA is mainly related with altered diameter of aortic root/sinus of Valsalva and proximal and distal aortic arch/isthmus, however, it failed to show predictive risk for recoarctation.

Role of Computed Tomography Angiography in the Short-Term Follow-up of Aortic Coarctation Repair

ABSTRACT Introduction: Coarctation of the aorta (CoA) is a narrowing of the thoracic aorta that often manifests as discrete stenosis but may be tortuous or in long segment. The study aimed to evaluate pre and post-surgical aspects of pediatric patients submitted to CoA surgical correction and to identify possible predisposing factors for aortic recoarctation. Methods: Twenty-five patients were divided into groups according to presence (N=8) or absence (N=17) of recoarctation after surgical correction of CoA and evaluated according to clinical-demographic profile, vascular characteristics via computed angiotomography (CAT), and other pathological conditions. Results: Majority of males (64%), ≥ 15 days old (76%), ≥ 2.5 kg (80%). There was similarity between groups with and without recoarctation regarding sex (male: 87% vs. 53%; P=0.277), age (≥ 15 days: 62.5 vs. 82%; P=0.505), and weight (≥ 2.5 kg: 87.5 vs. 76.5; P=0,492). Altered values of aortic root/Valsalva diameter, proximal transverse arch, and distal isthmus, and normal values for aorta prevailed in preoperative CAT. Normal values for the aortic root/Valsalva sinus diameter were observed with and without recoarctation, the same for both groups regarding ascending and descending aorta in postoperative CAT. No significant difference for altered values of proximal transverse arch and alteration in distal isthmus was observed. Conclusion: No predictive risk for recoarctation was observed. CTA proved to be important in CoA diagnosis and management, since CoA is mainly related with altered diameter of aortic root/sinus of Valsalva and proximal and distal aortic arch/isthmus, however, it failed to show predictive risk for recoarctation.

Abernethy Malformation: Possible Diagnosis for Patients with Congenital Heart Disease and Persistent Cyanosis.

CLINICAL DATA: Infant, nine months of age, female, diagnosed with congenital heart disease, with signs of heart failure associated with cyanosis and difficulty in gaining weight. CHEST RADIOGRAPHY: Cardiomegaly with prevalence of pulmonary vascular network. ELECTROCARDIOGRAM: Ectopic atrial rhythm with right ventricular overload and left anterosuperior divisional block. ECHOCARDIOGRAM: Single atrium with absent interatrial septum, atrioventricular connection with a single valve and two orifices, with increased pulmonary pressure and high Qp/Qs. COMPUTED TOMOGRAPHY: Absence of portal vein and intrahepatic segment of the inferior vena cava. Infrahepatic portion continuing with the azygos system at the level of the thoracic cavity, presence of mesenteric-caval communication associated with signs suggestive of hepatic peribiliary fibrosis. DIAGNOSIS: Abernethy malformation is a rare condition and represents an extrahepatic portosystemic shunt that develops between the mesenteric-portal vasculature and the systemic veins. It may be associated with cardiac malformations and advance with pulmonary hypertension and even the need for liver transplantation. Persistent cyanosis after corrective surgery led to a deeper investigation and correct diagnosis of this malformation. OPERATION: Sternotomy with 68 minutes of cardiopulmonary bypass and nine minutes of total circulatory arrest. In the postoperative period, persistence of cyanosis was evident, even though there were no immediate complications. Patient was discharged on the 10th postoperative day. An abdominal computed tomography angiography confirmed the diagnosis of Abernethy type I malformation, and the patient was transferred for liver transplantation after congenital heart disease treatment.

Abernethy Malformation: Possible Diagnosis for Patients with Congenital Heart Disease and Persistent Cyanosis

ABSTRACT Clinical data: Infant, nine months of age, female, diagnosed with congenital heart disease, with signs of heart failure associated with cyanosis and difficulty in gaining weight. Chest radiography: Cardiomegaly with prevalence of pulmonary vascular network. Electrocardiogram: Ectopic atrial rhythm with right ventricular overload and left anterosuperior divisional block. Echocardiogram: Single atrium with absent interatrial septum, atrioventricular connection with a single valve and two orifices, with increased pulmonary pressure and high Qp/Qs. Computed tomography: Absence of portal vein and intrahepatic segment of the inferior vena cava. Infrahepatic portion continuing with the azygos system at the level of the thoracic cavity, presence of mesenteric-caval communication associated with signs suggestive of hepatic peribiliary fibrosis. Diagnosis: Abernethy malformation is a rare condition and represents an extrahepatic portosystemic shunt that develops between the mesenteric-portal vasculature and the systemic veins. It may be associated with cardiac malformations and advance with pulmonary hypertension and even the need for liver transplantation. Persistent cyanosis after corrective surgery led to a deeper investigation and correct diagnosis of this malformation. Operation: Sternotomy with 68 minutes of cardiopulmonary bypass and nine minutes of total circulatory arrest. In the postoperative period, persistence of cyanosis was evident, even though there were no immediate complications. Patient was discharged on the 10th postoperative day. An abdominal computed tomography angiography confirmed the diagnosis of Abernethy type I malformation, and the patient was transferred for liver transplantation after congenital heart disease treatment.

Capacidade funcional de pacientes com indicação de cuidados paliativos na atenção primária / Functional capacity of patients indicated for palliative care in primary care

INTRODUÇÃO: Pacientes com indicação de cuidados paliativos podem ter perda da capacidade funcional e da qualidade de vida, mas há pouca informação sobre essas condições na atenção primária à saúde. OBJETIVO: Caracterizar os aspectos funcionais e sintomáticos dos indivíduos com indicação de cuidados paliativos na atenção primária. MÉTODOS: Estudo transversal e descritivo com seis equipes de saúde da família de três unidades básicas de saúde de Londrina, Paraná, que indicaram pacientes com necessidade de cuidados paliativos. Os pacientes foram avaliados pela Escala de Performance de Karnofsky (EPK), pela Escala de Avaliação de Sintomas de Edmonton (ESAS) e por questionário sociodemográfico e clínico. RESULTADOS: 73 pacientes (30 homens e 43 mulheres) foram incluídos, com idade média de 77,2 ± 12,1 anos. Demências e doenças cerebrovasculares foram as condições mais frequentes com 20 (27%) e 19 (26%) pacientes, respectivamente. A média na EPK foi de 47,9 ± 13,9 pontos, sendo 44 ± 11,3 pontos para homens e 51 ± 11,3 para mulheres, com diferença significativa entre os sexos (p = 0,023). Pacientes com câncer tiveram um melhor grau de funcionalidade em comparação àqueles com doenças neurológicas. A ESAS indicou que os sintomas mais frequentes foram o comprometimento do bem-estar, dor, cansaço e sonolência, todos com escore médio abaixo de 3 pontos (intensidade leve). Pacientes sem cuidadores tiveram melhor status funcional, mas apresentaram maior intensidade para dor e cansaço. CONCLUSÃO: Todos os pacientes tinham alguma limitação da funcionalidade, sendo aqueles com doença neurológica os mais acometidos. Os sintomas tiveram, no geral, uma intensidade leve. A presença de cuidadores pode ter influência num melhor controle dos sintomas.

INTRODUCTION: Patients indicated for palliative care may have losses in functional capacity and quality of life, but there is little information about these conditions in primary health care. OBJECTIVE: To characterize the functional and symptomatic aspects of individuals indicated for palliative care in primary care. METHODS: This cross-sectional descriptive study involved six family health teams from three basic health units in Londrina, Paraná, Brazil that indicated patients with palliative care needs. The patients were assessed with the Karnofsky Performance Scale (KPS), the Edmonton Symptom Assessment Scale (ESAS) and a sociodemographic and clinical questionnaire. RESULTS: 73 patients (30 men and 43 women) whose mean age was 77.2 ± 12.1 years were included. Dementia and cerebrovascular diseases were the most frequent conditions, with 20 (27%) and 19 (26%) patients, respectively. The mean KPS score was 47.9 ± 13.9 points (44 ± 11.3 points for men and 51 ± 11.3 for women), with a significant difference between the sexes (p = 0.023). Cancer patients had better functionality than those with neurological diseases. The ESAS, whose mean score was below 3 points (mild intensity), indicated that the most frequent symptoms were impaired well-being, pain, fatigue and drowsiness. Patients without caregivers had better functional status, but greater pain and fatigue intensity. CONCLUSION: All patients had some functional limitations, and those with neurological diseases were the most affected. The symptoms were generally mild. The presence of caregivers may positively influence symptom control.

Identification and characteristics of patients with palliative care needs in Brazilian primary care.

BACKGROUND: The Brazilian healthcare system offers universal coverage but lacks information about how patients with PC needs are serviced by its primary care program, Estratégia Saúde da Família (ESF). METHODS: Cross-sectional study in community settings. Patients in ESF program were screened using a Palliative Care Screening Tool (PCST). Included patients were assessed with Karnofsky Performance Scale (KPS), Edmonton Symptom Assessment System (ESAS) and Palliative Care Outcome Scale (POS). RESULTS: Patients with PC needs are accessing the ESF program regardless of there being no specific PC support provided. From 238 patients identified, 73 (43 women, 30 men) were identified as having a need for PC, and the mean age was 77.18 (95 % Confidence Interval = ±2,78) years, with non-malignant neurologic conditions, such as dementia and cerebrovascular diseases, being the most common (53 % of all patients). Chronic conditions (2 or more years) were found in 70 % of these patients, with 71 % scoring 50 or less points in the KPS. Overall symptom intensity was low, with the exception of some cases with moderate and high score, and POS average score was 14.16 points (minimum = 4; maximum = 28). Most patients received medication and professional support through the primary care units, but limitations of services were identified, including lack of home visits and limited multi-professional approaches. CONCLUSION: Patients with PC needs were identified in ESF program. Basic health care support is provided but there is a lack of attention to some specific needs. PC policies and professional training should be implemented to improve this area.

Identificação de pacientes com indicação de Cuidados Paliativos na Estratégia Saúde da Família: estudo exploratório / Identification of patients referred to Palliative Care in the Brazilian Family Health Strategy: an exploratory study

Resumo Introdução Os Cuidados Paliativos (CP) buscam oferecer uma melhor qualidade de vida para pacientes com doenças em fase avançada. No entanto, há poucos dados sobre sua aplicação e demanda na atenção primária. Assim, buscou-se explorar um método de triagem para identificar pacientes com indicação de CP na Estratégia Saúde da Família (ESF), quantificar o número desses pacientes no território de uma Unidade Básica de Saúde (UBS) e descrever suas características clínicas e sociodemográficas. Métodos Pacientes cadastrados na ESF foram triados por meio da Palliative Care Screnning Tool para identificar aqueles com necessidade de CP, e foi aplicado um questionário para a obtenção das informações. Resultados Após a triagem, 24 pacientes foram incluídos (0,73% da população cadastrada), com idade média de 76 anos. Condições crônicas foram as mais frequentes, principalmente devido às doenças cerebrovasculares, cânceres e demências. A maioria requeria assistência nas atividades cotidianas, e os serviços mais utilizados na UBS foram a obtenção de medicamentos e a orientação técnica. Identificaram-se limitações no suporte oferecido pela UBS. Conclusões Não há iniciativas específicas para a oferta de CP na ESF, apesar de haver pacientes com essas demandas, com alto grau de incapacidade funcional. As políticas para a aplicação de CP são limitadas na atenção primária.

Abstract Background Palliative Care (PC) aims to offer a better quality of life to patients with advanced stage diseases but there is few data about its application and requirements in the primary care. Thus, a screening method was performed to identify patients with need for PC in the Brazilian Family Health Strategy (ESF), to quantify how the number of patients in a Basic Health Unit (UBS) and to describe their clinical and sociodemographic characteristics. Methods ESF patients were screened by Palliative Care Screening Tool to identify the need for PC and a questionnaire was applied to obtain data. Results Screening method resulted in 24 patients included (0.73% of the ESF registered population), with average age of 76 years old. Chronic conditions were most frequent, especially due to stroke, cancer and dementia. Most patients required considerable assistance in daily activities, and the most usual support offered by UBS was drugs and technical orientation. We identified limitations in the received support from UBS. Conclusion There is no specific initiative to offer PC in the ESF despite some patients’ needs, with high level of functional incapacity. The specific polices to support the PC application in primary care are limited.