Remote ischemic preconditioning in patients with intermittent claudication

OBJECTIVE: Remote ischemic preconditioning (RIPC) is a phenomenon in which a short period of sub-lethal ischemia in one organ protects against subsequent bouts of ischemia in another organ. We hypothesized that RIPC in patients with intermittent claudication would increase muscle tissue resistance to ischemia, thereby resulting in an increased ability to walk. METHODS: In a claudication clinic, 52 ambulatory patients who presented with complaints of intermittent claudication in the lower limbs associated with an absent or reduced arterial pulse in the symptomatic limb and/or an ankle-brachial index <0.90 were recruited for this study. The patients were randomly divided into three groups (A, B and C). All of the patients underwent two tests on a treadmill according to the Gardener protocol. Group A was tested first without RIPC. Group A was subjected to RIPC prior to the second treadmill test. Group B was subjected to RIPC prior to the first treadmill test and then was subjected to a treadmill test without RIPC. In Group C (control group), both treadmill tests were performed without RIPC. The first and second tests were conducted seven days apart. Brazilian Clinical Trials: RBR-7TF6TM. RESULTS: Group A showed a significant increase in the initial claudication distance in the second test compared to the first test. CONCLUSION: RIPC increased the initial claudication distance in patients with intermittent claudication; however, RIPC did not affect the total walking distance of the patients

Filtros de veia cava inferior em pacientes com câncer: experiência em 50 casos

OBJECTIVE: To study the immediate and late results obtained from the implantation of vena cava filters in cancer patients with deep vein thrombosis concomitant with neoplasia. METHODS: This was a retrospective evaluation of 50 patients with an association of cancer and deep venous thrombosis who underwent interruption of the inferior vena cava and the insertion of permanent vena cava filters. The indications for the procedure, filter implantation technique, early and late complications related to the operation, and the clinical evolution were evaluated. RESULTS: The most frequent indication for filter implantation was the contraindication for full anticoagulant treatment (80%). The femoral vein was the preferred access route (86% of the patients). There were no complications related to the surgical procedure. During the follow-up, the following complications were observed: 1 episode of nonfatal pulmonary thromboembolism, 2 cases of occlusion of the inferior vena cava, and 1 case of thrombus retained in the device. Twenty patients (40%) died due to progression of the neoplasm. CONCLUSIONS: Interruption of the inferior cava vein using an endoluminal filter is a procedure with a low rate of complications. It is a safe and efficient measure for preventing pulmonary embolism in cancer patients who have deep vein thrombosis of the lower limbs.OBJETIVO: Estudar os resultados imediatos e tardios obtidos com a implantação de filtros de veia cava inferior em pacientes com trombose venosa profunda concomitante a neoplasia. MÉTODOS: Avaliamos retrospectivamente 50 pacientes com câncer e trombose venosa profunda associada submetidos a interrupção de veia cava inferior com filtros intraluminais definitivos. Foram estudados aspectos referentes à indicação do procedimento, à técnica de implante dos dispositivos, complicações precoces e tardias relacionadas à operação e à evolução dos pacientes. RESULTADOS: A indicação mais freqüente para o procedimento foi a impossibilidade de anticoagulação plena (80% ) e a via de acesso preferencial foi a punção da veia femoral, realizada em 86% dos pacientes. Não houve complicações relativas ao implante dos filtros. Durante a evolução ocorreram: um episódio de tromboembolia pulmonar não fatal e dois casos de oclusão da veia cava inferior; em um paciente foi demonstrada a presença de coágulo retido no dispositivo. Vinte pacientes (40%) faleceram devido à neoplasia. CONCLUSÃO: A interrupção da veia cava inferior com filtro endoluminal é um procedimento com baixo índice de complicações e eficaz na prevenção da embolia pulmonar nos pacientes com tromobose venosa profunda de membros inferiores portadores de câncer

Técnicas endovasculares para colocação de cateteres de longa permanência para quimioterapia

PURPOSE: To analyze the results from using endovascular techniques to place long-term chemotherapy catheters when advancing the catheter using the external jugular vein is difficult due to obstructions or kinking. METHODS: Between July 1997 and August 2000, 320 long-term chemotherapy catheters were placed, and in 220 cases the external jugular vein was used as the primary venous approach. In 18 of these patients, correct positioning was not achieved and several endovascular techniques were then utilized to overcome these obstacles, including manipulation of a J-wire with a moveable core, venography, and the exchange wire technique. RESULTS: In 94.5% of the patients with difficulties in obtaining the correct positioning, we were able to advance the long-term catheter to the desired position with the assistance of endovascular techniques. CONCLUSIONS: Venography and endovascular guidance techniques are useful for the placement of long-term catheters in the external jugular vein.OBJETIVO: Analisar os resultados da utilização de técnicas endovasculares na colocação de cateteres de longa permanência para quimioterapia quando a progressão do cateter através da veia jugular externa é dificultada devido a obstruções ou tortuosidades. MÉTODOS: Entre Junho de 1997 e Agosto de 2000, foram colocados 320 cateteres de longa permanência para quimioterapia, e, em 220 casos a veia jugular externa foi utilizada como acesso venoso primário. Em 18 desses pacientes, o correto posicionamento não foi conseguido sendo então utilizadas várias técnicas endovasculares para superar os obstáculos incluindo o uso de fio guia com ponta em J, flebografia e troca de cateteres. RESULTADOS: Em 94,5% dos pacientes com dificuldades para obtermos o correto posicionamento, foi conseguida a progressão do cateter de longa permanência até o posicionamento desejado com a assistência de técnicas endovasculares. CONCLUSÃO: A Flebografia e a técnica endovascular são úteis para a colocação de cateteres de longa permanência através da veia jugular extern

Comparação entre ultrassonografia, tomografia computadorizada e ressonância nuclear magnética com medidas intra-operatórias na avaliação dos aneurismas de aorta abdominal

PURPOSE: To study the imaging exams more commonly used for abdominal aortic aneurysms evaluation - ultrasonography, conventional computerized tomography, helical computerized tomography and nuclear magnetic angioresonance - comparing the preoperative measurements reached by those radiological methods with the measurements made during the surgical procedures. METHODS: Patients who had indication of elective transperitoneal surgical treatment for their abdominal aortic aneurysms were included in the study. The initial diagnosis of the aortic dilatation was made by ultrasonography and, after the surgical treatment was indicated, the patient was submitted to another imaging method. Sixty patients were divided into 3 groups according to the complementary imaging method (conventional computerised tomography, helical computerized tomography, nuclear magnetic angioresonance). The ultrasonography of the first 20 patients were joined in a fourth group. There were considered in the study the measurements of the transversal diameter of the proximal neck, maximum transversal diameter of the aneurysm, straight-line length and transversal diameter of the common iliac arteries given by the imaging methods. The same measurements were made by using a caliper during the surgical procedure, and then compared to the values obtained from the radiological exams. RESULTS: The maximum transverse diameter had a range measurement variation of 4.5 to 13.6 cm in the intraoperative, with no statistically significant differences when compared with all the imaging tests. The ultrasonography, however, overestimated the measurements of the proximal neck and the common iliac arteries, in comparison with intraoperative measures. The length of the aorta aneurysm obtained by the conventional computerized tomography was significantly lower if compared to the measures done with the calliper during the operation. The helical computerized tomography and the nuclear magnetic angioresonance provided measurements with no significant differences in the statistic view when compared to the intraoperative measures. CONCLUSIONS: Ultrasonography is a reliable method for the diagnosis and follow-up of the aorta abdominal aneurysms, but insufficient for endovascular surgery planning. The conventional computed tomography can provoke distortion in the length measurements of the aorta dilatation. Helical computed tomography and nuclear magnetic angioresonance provided precise measurements of all the studied parameters, being of great utility for surgical planning.OBJETIVO: Estudar os métodos mais freqüentemente empregados na avaliação dos aneurismas de aorta abdominal - ultrassonografia, tomografia computadorizada convencional, tomografia computadorizada helicoidal e angio-ressonância nuclear magnética - comparando as medidas fornecidas por estes exames radiológicos no pré-operatório com medidas realizadas durante a operação. MÉTODO: Foram incluídos no estudo pacientes portadores de aneurisma da aorta abdominal com indicação de tratamento cirúrgico eletivo por via transperitoneal. O diagnóstico inicial da dilatação aórtica foi feito com ultra-sonografia e, uma vez indicado o tratamento cirúrgico, era então solicitado um outro exame radiológico complementar, já que não é nossa rotina operar esses pacientes com base apenas na ultra-sonografia. Sessenta pacientes foram divididos em 3 grupos de acordo com o exame complementar realizado (tomografia computadorizada convencional, tomografia computadorizada helicoidal ou angio-ressonância nuclear magnética). As ultra-sonografias dos 20 primeiros pacientes foram incluídas em um 4&deg; grupo. Analisamos neste estudo as medidas do colo proximal da aorta, o diâmetro transverso máximo e o comprimento do aneurisma, além do diâmetro transverso das artérias ilíacas comuns conseguidos a partir dos exames radiológicos. As mesmas medidas eram realizadas por ocasião da operação com o auxílio de um paquímetro e , então, comparadas aos valores indicados pelos exames de imagem. RESULTADOS: As medidas do diâmetro transverso máximo do aneurisma variaram de 4.5 a 13.6 cm no intra-operatório, não apresentando diferença estatisticamente significativa em relação a nenhum dos exames radiológicos estudados. A ultra-sonografia, entretanto, superestimou as medidas do colo proximal da aorta e dos diâmetros transversos das artérias ilíacas, em comparação com os valores auferidos durante o tratamento cirúrgico. O comprimento dos aneurismas medidos pela tomografia computadorizada convencional era menor em relação às medições feitas com o paquímetro de maneira estatisticamente significativa. Tanto a tomografia computadorizada helicoidal quanto a angio-ressonância nuclear magnética proporcionaram medidas sem diferença significante do ponto de vista estatístico para todos os parâmetros estudados, quando confrontados com os valores obtidos no intra-operatório. CONCLUSÕES: A ultra-sonografia consiste em método valioso para o diagnóstico e seguimento clínico de pacientes com aneurisma de aorta abdominal, sendo, porém, insuficiente para o planejamento de tratamento por técnica endovascular. A tomografia computadorizada convencional pode induzir a erro na estimativa da extensão crânio-caudal do aneurisma. A tomografia computadorizada helicoidal e a angio-ressonância nuclear magnética geraram medidas precisas de todos os parâmetros estudados, sendo ambos de grande importância para a programação operatória

Oxidized low-density lipoprotein and ankle-brachial pressure index in patients with clinically evident peripheral arterial disease

OBJECTIVES: To investigate whether oxidized low-density lipoprotein is a suitable predictor of peripheral arterial disease severity. The role of oxidized low-density lipoprotein in the pathogenesis of atherosclerosis has already been investigated. Its relevance as a predictor of the appearance and worsening of coronary arterial disease is also well known. However, the same is not true regarding peripheral arterial disease. METHOD: Eighty-five consecutive patients with an ankle-brachial pressure index (ABPI) < 0.9 and the presence of either intermittent claudication or critical lower leg ischemia were included. The plasma level of IgG autoantibodies against oxidized low-density lipoprotein was evaluated through an enzyme-linked immunosorbent assay. The results were categorized into quartiles according to the ankle-brachial pressure index (a marker of peripheral arterial disease severity), and significant differences were investigated with the Kruskal-Wallis test. RESULTS: There was no significant difference between the quartiles for this population (p = 0.33). No correlation was found between the ankle-brachial pressure index and oxidized low-density lipoprotein levels in subjects with clinically evident peripheral arterial disease with a wide range of clinical manifestations. CONCLUSIONS: Oxidized low-density lipoprotein is not a good predictor of peripheral arterial disease severity

Reconstruções arteriais associadas à ressecção de tumores malignos

OBJECTIVE: When trunk arteries are affected by malignant neoplasia, and surgical treatment involving tumor and arterial resection is used, the vascular reconstruction must be performed immediately to avoid ischemia in the brain and large tissue masses. The objective of this study was to analyze the results obtained with the treatment of patients with malignant neoplasia who underwent tumor and vascular resection associated with arterial reconstruction. The primary patency of reconstructions, the occurrence arterial complications, and patient survival were assessed. METHODS: Thirty-six patients with cervical, abdominal, or lower limb neoplasias were followed up. These patients underwent elective operations at Hospital do Câncer A.C. Camargo, São Paulo, between September 1997 and September 2004. They were divided into 3 groups according to tumor location: Cervical (14), lower limbs (13), and Abdomen (9). Thirty-eight arterial reconstructions were performed in these 36 patients. RESULTS: There were 5 arterial complications: 2 early- and 3 late-stage. The early complications consisted of 1 symptomatic carotid occlusion with sequelae and 1 femoral graft rupture without sequelae. The late-stage complications consisted of 1 symptomatic carotid occlusion, 1 occlusion of an axillary-carotid graft, and 1 occlusion of a branch of the aortobifemoral graft, all without sequelae. There was no difference between the primary arterial patency rates. All the deaths (22) resulted from progression of neoplasic disease. CONCLUSIONS: Arterial reconstructions associated with resection of malignant neoplasia in cervical, abdominal, or lower limbs can be carried out with low rates of morbidity and mortality. There was no difference in the primary arterial patency rates among the groups studied.OBJETIVO: Quando há acometimento de artérias tronculares por neoplasias malignas e o tratamento cirúrgico é empregado para realização de ressecções tumoral e arterial, a reconstrução vascular deve ser imediata, para evitar a isquemia de tecidos nobres. O objetivo desse trabalho é analisar os resultados do tratamento de pacientes portadores de neoplasias malignas submetidos a ressecções tumoral e vascular associada à reconstrução arterial, avaliando a perviedade primária das reconstruções, as complicações arteriais e a sobrevida dos pacientes. MÉTODOS: Foram acompanhados 36 pacientes com neoplasias em regiões cervical, abdominal ou extremidades inferiores, operados eletivamente no período de setembro de 1997 a setembro de 2004 no Hospital do Câncer A.C.Camargo em São Paulo. Os pacientes foram divididos em três grupos de acordo com a localização das neoplasias: Cervical (14), Extremidade (13) e Abdome (9). Foram realizadas 38 reconstruções arteriais nos 36 pacientes. RESULTADOS: Houve cinco complicações arteriais, sendo duas precoces e três tardias. Entre as precoces, houve uma oclusão carotídea sintomática com seqüelas e uma rotura de enxerto femoral sem seqüelas. Entre as tardias, houve uma oclusão carotídea sintomática, uma oclusão de enxerto carotídeo-axilar e uma oclusão de ramo de enxerto aorto-bifemoral, todas sem sequelas. Não houve diferença entre os índices de perviedade arterial primária . Todos os óbitos (22) ocorreram devido à evolução da doença neoplásica. CONCLUSÕES: As reconstruções arteriais associadas à ressecção de neoplasias malignas em segmentos cervical, abdominal ou extremidades inferiores podem ser realizadas com baixos índices de morbi-mortalidade. Não houve diferença entre os índices de perviedade primária das reconstruções

Relationship between gait speed and physical function in patients with symptomatic peripheral artery disease

OBJECTIVE: The aim of the study was to analyze the relationship between gait speed and measurements of physical function in patients with symptomatic peripheral artery disease (PAD). METHODS: One hundred sixty-nine patients (age 66.6±9.4 years) with symptomatic PAD were recruited. Usual and fast gait speeds were assessed with a 4-meter walk test. Objective (balance, sit-to-stand, handrip strength, and six-minute walk test) and subjective (WIQ – Walking Impairment Questionnaire and WELCH – Walking Estimated-Limitation Calculated by History) measurements of physical function were obtained. Crude and adjusted linear regression analyses were used to confirm significant associations. RESULTS: Usual and fast gait speeds were significantly correlated with all objective and subjective physical function variables examined (ro0.55, po0.05). In the multivariate model, usual gait speed was associated with six-minute walking distance (b=0.001, po0.001), sit-to-stand test score (b=-0.005, p=0.012), and WIQ stairs score (b=0.002, p=0.006) adjusted by age, ankle brachial index, body mass index, and gender. Fast gait speed was associated with six-minute walking distance (b=0.002, po0.001), WIQ stairs score (b=0.003, p=0.010), and WELCH total score (b=0.004, p=0.026) adjusted by age, ankle brachial index, body mass index, and gender. CONCLUSION: Usual and fast gait speeds assessed with the 4-meter test were moderately associated with objective and subjective measurements of physical function in symptomatic PAD patients

Cross-cultural adaptation of the dysfunctional voiding score symptom (DVSS) questionnaire for Brazilian children

PURPOSE: To translate and culturally adapt the Dysfunctional Voiding Symptom Score (DVSS), questionnaire into Brazilian Portuguese. MATERIALS AND METHODS: The 10-item Dysfunctional Voiding Symptom Score (DVSS) was translated into Brazilian Portuguese according to a standard methodology: translation, synthesis, back-translation, Expert Committee, and pre-testing. After the translation process the final version was pre-tested and patient responses were analyzed to identify necessary modifications. Reliability was evaluated using the test-retest method, and internal consistency was assessed using Cronbach’s alpha. RESULTS: The Cronbach’s alpha coefficient was calculated in the test and retest phases. Internal consistency was found to be satisfactory, as confirmed by a Cronbach’s alpha coefficient of 0.76 for the test and 0.77 for the retest. A high degree of stability was found in the test/retest, with an intraclass correlation coefficient (ICC) of 0.960 (p < 0.001; 95% CI: 0.943-0.972). CONCLUSION: The cross-cultural adaptation process of the Dysfunctional Voiding Symptom Score questionnaire to be used on Brazilian children was successfully completed following internationally accepted methodologies.Pernambuco State University Division of Pediatric UrologyFederal University of Bahia Division of Pediatric UrologyFederal University of Juiz de Fora Division of Pediatric UrologyUrology and Nephrology Institute Division of Pediatric UrologyFederal University of São Paulo Division of Pediatric UrologyHospital for Sick Children Division of Pediatric UrologyUNIFESP, Division of Pediatric UrologySciEL

Relationship between gait speed and physical function in patients with symptomatic peripheral artery disease

OBJECTIVE: The aim of the study was to analyze the relationship between gait speed and measurements of physical function in patients with symptomatic peripheral artery disease (PAD). METHODS: One hundred sixty-nine patients (age 66.6±9.4 years) with symptomatic PAD were recruited. Usual and fast gait speeds were assessed with a 4-meter walk test. Objective (balance, sit-to-stand, handrip strength, and six-minute walk test) and subjective (WIQ – Walking Impairment Questionnaire and WELCH – Walking Estimated-Limitation Calculated by History) measurements of physical function were obtained. Crude and adjusted linear regression analyses were used to confirm significant associations. RESULTS: Usual and fast gait speeds were significantly correlated with all objective and subjective physical function variables examined (ro0.55, po0.05). In the multivariate model, usual gait speed was associated with six-minute walking distance (b=0.001, po0.001), sit-to-stand test score (b=-0.005, p=0.012), and WIQ stairs score (b=0.002, p=0.006) adjusted by age, ankle brachial index, body mass index, and gender. Fast gait speed was associated with six-minute walking distance (b=0.002, po0.001), WIQ stairs score (b=0.003, p=0.010), and WELCH total score (b=0.004, p=0.026) adjusted by age, ankle brachial index, body mass index, and gender. CONCLUSION: Usual and fast gait speeds assessed with the 4-meter test were moderately associated with objective and subjective measurements of physical function in symptomatic PAD patients