Prehospital emergency services in Catalonia: the SEPHCAT analysis. / Estudio SEPHCAT: análisis de los servicios de emergencias prehospitalarios en Cataluña.

OBJECTIVES: To describe the main characteristics of all prehospital emergency services (SEPHs, the Catalan acronym) in Catalonia (the SEPHCAT study). MATERIAL AND METHODS: A professional survey researcher interviewed the medical directors of all services in Catalonia, using a questionnaire prepared by the authors. Questions covered aspects related to organization, professional staffing and employment conditions, as well as the staff's training, instructional activity and research. Only closed answers were collected. The survey reflected the situation in 2015. RESULTS: We identified 13 SEPHs (11 in the public health service and 2 private companies). Together they received 2 482 627 calls (16.4% to private services) and attended 943 849 emergencies (11.8% attended by private companies). Three hundred thirty-six basic life support units and 73 advanced life support units were reported. They were mostly considered to be of sufficient size and quality. The SEPHs contracted 1374845 person-hours/y (753995 physician-hours and 620 850 nurse-hours; 23.4% in private companies). These figures correspond to 815 full-time staff positions (447 for physicians and 368 for nurses). The numbers of physicians and nurses working were relatively stable during the morning, afternoon and evening shifts but decreased during the midnight-to-early-morning shift (physicians, by 31%; nurses, by 9%). A majority of the physicians employed were trained in family and community medicine (56.8%), but 21.3% had no specialized training; 6.5% had PhD degrees. SEPH physicians (61.5%) and nurses (46.2%) also taught undergraduate medical students; 46.2% of physicians and 84.6% of nurses taught postgraduate medical courses. Both undergraduate medical and nursing students were received in the same measure for practical training by 15.4% of the SEPHs; 69.2% also offered practical training for physicians at the postgraduate level and 76.9% trained postgraduate nurses. CONCLUSION: SEPHs in Catalonia are very active, and private companies account for nearly 12% of the activity. Together the public and private sectors employ a large number of physicians and nurses. Staff members are involved in training others but are less involved in research.

OBJETIVO: Describir las principales características de todos los servicios de emergencias prehospitalarios (SEPH) existentes en Cataluña. METODO: Una encuestadora profesional entrevistó a los responsables clínicos de todos los SEPH de Cataluña. La encuesta fue preparada por los autores, y abordaba diversos aspectos organizativos, profesionales, laborales, formativos, docentes y de investigación. Las preguntas contenidas en la encuesta solo permitían respuestas cerradas, y hacían referencia a la situación en 2015. RESULTADOS: Se identificaron 13 SEPH (11 públicos, 2 privados), que recibieron 2.482.627 consultas (16,4% a SEPH privados) y realizaron 943.849 atenciones (11,8% por SEPH privados). Había 336 bases de soporte vital básico y 73 de avanzado, con instalaciones mayoritariamente consideradas de tamaño suficiente y calidad buena. Se contrataron 1.374.845 horas anuales (753.995 de médico y 620.850 de enfermero), el 23,4% de ellas por SEPH privados, que globalmente corresponderían a 815 puestos de trabajo a jornada completa (447 de médico, 368 de enfermero). La dotación de médicos/enfermeros era relativamente estable durante el día, pero decaía un 31%/9% de madrugada. La especialidad médica mayoritaria era medicina familiar y comunitaria (56,8%), el 21,3% no tenía formación especializada, y el 6,5% tenía título de doctor. Había médicos/enfermeros profesores universitarios de grado en el 61,5%/46,2% de los SEPH; y de postgrado en el 46,2%/84,6%. Recibían estudiantes de medicina/enfermería en prácticas de grado el 15,4%/15,4% de los SEPH, y de postgrado el 69,2%/76,9%. CONCLUSIONES: La actividad de los SEPH en Cataluña es elevada; un 12% la desarrollan SEPH privados, y globalmente implica a un número alto de médicos y enfermeros, los cuales además desarrollan un rol docente y, en menor medida, investigador.

SUHCAT study, part 5: Comparison of staff and chiefs' perceptions of emergency department quality in Catalonia. / Estudio SUHCAT-5: comparación de la percepción de la calidad de los servicios de urgencias de Cataluña entre los profesionales sanitarios y sus responsables.

OBJECTIVES: To study the perceptions of Catalan Society of Emergency Medicine (SoCMUE) members who staff hospital emergency departments regarding measures taken to cope with overcrowding, staff rest areas, and staff size. MATERIAL AND METHODS: Descriptive cross-sectional analysis of a survey sent to SoCMUE members. We compared opinions expressed by physicians and nurses in this survey and also compared them to opinions expressed by heads of departments in prior SUHCAT studies. RESULTS: Responses were received from 363 members who worked in hospital departments. More nurses than physicians expressed the opinion that ambulance unloading was habitually blocked (P=.045), patients were being redirected (P<.001), and staffing was inadequate (P=.007). When the results of our SoCMUE survey were compared to those of the earlier SUHCAT surveys of department chiefs, we found that more SoCMUE members believed that measures to cope with overcrowding are frequently applied, quality in rest areas is poorer, and staffing is inadequate. CONCLUSION: Physicians and nurses who are members of SoCMUE and work in hospital emergency departments have different views on measures taken to cope with overcrowding, quality of rest areas, and staff size. In addition, the SoCMUE members' opinions differed from those of respondents in prior SUHCAT studies.

OBJETIVO: Conocer la percepción de los socios de la Societat Catalana de Medicina d'Urgències i Emergències (SoCMUE) con actividad laboral en servicios de urgencias hospitalarios (SUH) respecto a las medidas frente al colapso, las áreas de descanso y la dimensión de la plantilla, y compararla con la de sus responsables. METODO: Estudio descriptivo transversal mediante encuesta enviada a los socios de SoCMUE. Se compararon las respuestas dadas entre el estamento médico y enfermero, y con los resultados de los estudios SUHCAT 1 y 2. RESULTADOS: Participaron 363 socios. Los enfermeros opinan más frecuentemente que los médicos que es habitual impedir la descarga de ambulancias (p = 0,045), redireccionar pacientes (p < 0,001) y que sus plantillas son insuficientes (p = 0,007). Los socios de SoCMUE perciben mayor frecuencia en la puesta en marcha de todas las medidas para hacer frente al colapso, peor calidad de las áreas de descanso y una plantilla insuficiente en comparación con la opinión de los responsables de los SUH. CONCLUSIONES: Los médicos y enfermeros socios de la SoCMUE que trabajan en los SUH tienen una percepción diferente en aspectos relacionados con las medidas frente al colapso, áreas de descanso y dimensión de la plantilla, que difiere también de la opinión de sus responsables.

[Occupational aspects of emergency medicine practice in Catalonia: the OPENCAT opinion survey]. / Opinión de los profesionales acerca de diversos aspectos laborales de los servicios de urgencias y emergencias de Cataluña: Estudio OPENCAT.

OBJECTIVES: To gather information on the contracting and training of members of the Catalan Society of Emergency Medicine (SoCMUE) who work in emergency medicine and services in Catalonia. To survey their opinions on certain aspects of resource availability and working conditions. MATERIAL AND METHODS: Cross-sectional descriptive study based on a survey sent to SoCMUE members. We studied the opinions of 5 types of respondent: hospital physicians, out-of-hospital physicians, hospital nurses, out-of-hospital nurses, and emergency medical technicians. Responses were grouped to compare the opinions of physicians and nurses and workers in hospital and prehospital settings. RESULTS: We received 616 responses from 1273 members (48.4% response rate). More physicians than nurses come from outside Catalonia and have contracts specifically linked to emergency care; in addition, physicians have done less postgraduate training in emergency medicine. More hospital staff than prehospital staff have permanent contracts linked to the department where they work. More hospital physicians are specialized in internal medicine than in family and community medicine. The opinion that emergency services are inadequately staffed was widespread. Most respondents believed that patient transport is good or adequate. However, respondents working in prehospital services expressed a lower opinion of transport. Great difficulty in combining work with family (life achieving work-life balance) was expressed by 13.5% overall, and more often by hospital staff. Some type of aggression was experienced by 88.2%; 60% reported the event to superiors. Nurses reported aggression more often than physicians. A police report was filed by 10.1%. CONCLUSION: Emergency medicine working conditions can be improved in Catalonia according to members of SoCMUE. Relations between groups of professionals are not optimum in some aspects.

OBJETIVO: Investigar las condiciones contractuales y formativas de los socios de la Societat Catalana de Medicina d'Urgències i Emergéncies (SoCMUE) que trabajan en el ámbito de la Medicina de Urgencias y Emergencias (MUE) en Cataluña, y su percepción acerca de algunos recursos disponibles y aspectos de su práctica laboral. METODO: Estudio descriptivo transversal mediante encuesta enviada a los socios de SoCMUE. Se distinguieron médicos hospitalarios y extrahospitalarios, enfermeros hospitalarios y extrahospitalarios, y técnicos en emergencia sanitaria (TES). Se realizaron agrupaciones de médico/enfermero y hospitalario/extrahospitalario. RESULTADOS: Respondieron 616 de 1.273 socios (48,4%). Respecto a los enfermeros, los médicos tienen mayor porcentaje de profesionales no comunitarios, contratos más vinculados a urgencias/emergencias, y han realizado menos formación de postgrado en MUE. Los profesionales hospitalarios, respecto a los extrahospitalarios, tienen mayor proporción de contratos fijos y vinculados al propio servicio, han realizado menos formación de postgrado, y la proporción de especialistas en medicina interna es mayor y en medicina familiar y comunitaria menor. Existe la percepción generalizada de plantillas insuficientes. La transferencia de pacientes es considerada mayoritariamente buena o correcta, pero es peor percibida por extrahospitalaria. El 13,5% refiere una conciliación familiar imposible, más frecuentemente en el ámbito hospitalario. El 88,2% ha sufrido algún tipo de agresión, el 60% lo comunicó a sus superiores (enfermeros más que médicos) y el 10,1% lo denunció judicialmente. CONCLUSIONES: Para los socios de la SoCMUE, en la práctica de la MUE en Cataluña, existen algunas condiciones laborales mejorables y la relación entre colectivos de profesionales es poco óptima en algunos aspectos.

[Catalan hospital emergency department heads' opinions on the creation of a residency program for specializing in emergency medicine]. / Opinión de los responsables de los servicios de urgencias hospitalarios de Cataluña acerca de la creación de la especialidad de Medicina de Urgencias y Emergencias.

OBJECTIVES: To understand the opinions of emergency department (ED) heads in Catalonia on their support for a residency program for specializing in emergency medicine (EM) and on their beliefs about the impact such a program would have. MATERIAL AND METHODS: Heads of ED were asked if there would be support (from them, their staff, and their hospital) for a residency program to train specialists in EM. They were also asked their opinion on the impact that specialization would have on quality of care and costs in their department. Responses were compared by type of hospital and ED and by affiliation or not with the Spanish Society of Emergency Medicine (SEMES). RESULTS: Responses were received from 79 of the 82 heads of hospital EDs in Catalonia (96%). They reported that favorable opinions toward creation of an EM specialization were held by them personally (93.7%; 95% CI, 85.8%-97.9%), by their in their departments (88.6%; 95% CI, 79.4%-94.7%), and by staff in their hospitals (48.7%; 95% CI, 36.7%-59.6%). A majority thought that the impact of specialization would be good in the short term (82.0%; 95% CI, 71.7%-89.8%) and in the medium and long term (94.8%; 95% CI, 87.2%-98.6%). The respondents were neutral about whether there would be an impact on costs (60.3%; 95% CI, 48.6%-71.2%). More heads in mid-sized hospitals, private hospitals, and nonmembers of SEMES thought that creating a specialty would raise ED costs (p<0,05). CONCLUSION: The heads of Catalan ED, their staff, and their hospitals' staffs hold favorable opinions of the proposal to create a residency program allowing specialization in EM. They foresee short-, medium-, and long-term benefits for the EDs and scarce impact on costs.

OBJETIVO: Conocer la opinión de los responsables de los servicios de urgencias hospitalarios (SUH) de Cataluña respecto al soporte e impacto que tendría la creación de la especialidad primaria de Medicina de Urgencias y Emergencias (MUE). METODO: Se solicitó la opinión a los responsables de SUH respecto al respaldo a una futura especialidad primaria de MUE (personal, en su servicio y en su hospital) y la estimación del impacto (cualitativo y económico) que tendría en su SUH. Se compararon las respuestas en función del tipo de hospital y SUH y de su afiliación a la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). RESULTADOS: Contestaron 79 de los 82 responsables de los SUH de Cataluña (96%), que percibieron una posición favorable a la creación de la especialidad, tanto ellos personalmente (93,7%; IC 95%: 85,8-97,9) como en sus SUH (88,6%; 79,4- 94,7) y hospitales (48,7%; 36,7-59,6). El 82,0% (71,7-89,8) opinó que la especialidad tendría un efecto positivo a corto plazo y el 94,8% (87,2-98,6) que también lo tendría a medio-largo plazo, y respecto al impacto económico, la opinión mayoritaria fue que sería neutro (60,3%; 48,6-71,2). Los responsables de SUH con actividad media, de hospitales privados y no afiliados a SEMES consideraron más frecuentemente que la creación de la especialidad encarecería el SUH (p < 0,05). CONCLUSIONES: Los responsables de los SUH catalanes tienen una opinión favorable y también la perciben en su servicio y su hospital respecto a la creación de la especialidad primaria de MUE y consideran que tendría efectos beneficiosos a corto, medio y largo plazo para el SUH, con un escaso impacto económico.

Carga imediata com prótese fixa provisória e cirurgia sem retalho gengival / Immediate loaded with provisional prosthesis and flapless surgery

O artigo descreve a técnica de cirurgia guiada sem retalho gengival com carga imediata provisória e subsequente avaliação do posicionamento dos implantes instalados. Material e Métodos: Paciente de 54 anos com maxila e dentula com enxerto bilateral dos seios maxilares. O planejamento cirúrgico foi realizado em software a partir dos dados da Tomografia Computadorizada Conebeam (TCCB). Estes dados foram editados para geração da guia cirúrgica virtual e com a tecnologia de prototipagem rápida foram produzidos dois protótipos. O primeiro da maxila com o arco dental para produção da estrutura da prótese fixa provisória e o segundo da guia cirúrgica, que orientou a fresagem e a colocação de seis implantes. Ao final da cirurgia a prótese provisória foi instalada. As imagens da TCCB pós-operatória foram sobrepostas às imagens do planejamento para mensuração das discrepâncias entre as posições dos implantes pré e pós-operatórios. Resultados: Em 2,5 horas seis implantes e a prótese fixa provisória foram instalados com sucesso. Os desvios médios foram: 0,64mm (OP ± 0,32mm) na região coronal; 1,22mm (OP ± 0,63) na região apical e 4,83 graus (OP ± 1,77) no desvio angular. Conclusão: Neste caso clínico. a técnica proporcionou, com sucesso, a reabilitação com implantes e prótese fixa provisória em carga imediata em 2,5 horas. Os desvios no posicionamento dos implantes estão dentro da variação encontrada na literatura.

The article describes the technique of flapless surgery with immediate load. Methods: The subject was a 54 year-old female patient with edentulous maxilla. Eight months before the surgerya sinus lifting was done with autogenous bone. The surgical planning was made in sof- tware using cone beam computerized tomography (CBCT) data.lt was edited to create two rapid prototype models, one for the maxilla with the dental arc and the other was the surgical guide. The first model was used to produce the temporary prosthesis, and the surgical template guided the drilling and placement of six implants. At the end of the surgery the prosthesis was fixed. The postoperative image was fused with the planning one to measure the linear and angular differences. Results: In two and half hours the implants and the fixed temporary prosthesis were successfully installed. The mean deviations were : 0,64mm (50 ± 0,32mm) in coronal position and 1,22mm (50 ± 0,63) in apex position, and the angular deviations was 4,83 degress (OP ± 1,77). Conclusion: Within a limited sample, this technique ma de the oral rehabilitation in two and hours possible. The deviations found are within the one in the literature.

Use of the plasma CTX for assessing the bone activity of the mandible among osteopenic and osteoporotic patients.

The aim of this study was to determine whether the plasma CTX bone remodeling marker is useful for indicating the bone metabolic activity level of the mandible. Thirty-six patients were selected; all were postmenopausal and aged 50 years or over. In accordance with the WHO criteria for osteoporosis, a control group was set up (n = 10) in which the T-score was greater than -1 and a diseased group with T-score less than -1. Using MDP-(99m)Tc samples, the radioisotope uptake in the femoral neck (R(2)) and mandibular body (R(1)) was analyzed. A third examination was performed using the plasma CTX biochemical bone-modeling marker. The inferential results for the diseased group showed that Ln(R(1)) presented a statistically significant linear relationship with Ln(CTx) (p = 0.067) and with the T-score (p = 0.018). The plasma CTX bone remodeling marker is useful for monitoring the bone metabolic activity of the mandible.

Use of the plasma CTX for assessing the bone activity of the mandible among osteopenic and osteoporotic patients

The aim of this study was to determine whether the plasma CTX bone remodeling marker is useful for indicating the bone metabolic activity level of the mandible. Thirty-six patients were selected; all were postmenopausal and aged 50 years or over. In accordance with the WHO criteria for osteoporosis, a control group was set up (n = 10) in which the T-score was greater than -1 and a diseased group with T-score less than -1. Using MDP-99mTc samples, the radioisotope uptake in the femoral neck (R2) and mandibular body (R1) was analyzed. A third examination was performed using the plasma CTX biochemical bone-modeling marker. The inferential results for the diseased group showed that Ln(R1) presented a statistically significant linear relationship with Ln(CTx) (p = 0.067) and with the T-score (p = 0.018). The plasma CTX bone remodeling marker is useful for monitoring the bone metabolic activity of the mandible.

[The emergency department short stay unit and the hospital at home as alternatives to standard inpatient hospitalisation]. / La unidad de corta estancia de urgencias y la hospitalización a domicilio como alternativas a la hospitalización convencional.

The emergency short stay unit (ESSU) is a support unit for the accident and emergency services and a clear alternative to the conventional hospitalisation of patients needing urgent care, who are affected by the re-aggravation of certain chronic diseases (whether seasonal o not) or by moderate short-evolution pathologies. Hospitalisation at home is one alternative making it possible to undertake the care and treatment characteristic of a hospital in the home of the patient, with greater comfort and intimacy. The origin of the patient might be the conventional hospital, the emergency service or ESSU. A suitable selection of patients is essential in both alternatives to conventional hospitalisation, using strict criteria that are both clinical and socio-family in nature. Their correct use assures a significant saving in stays in conventional hospital units, a reduction of the average stay in hospital medical and surgical services and less pressure on the accident and emergency service, since they increase the availability of beds both for programmed admission and for urgent admission in conventional hospitalisation and thus improve patient outflow in the accident and emergency service.

O papel da vitamina D3 e da osteocalcina no metabolismo ósseo: uma análise necessária para se otimizar a osseointegração / The role of vitamin D3 and osteocalcin in the bone metabolism: a necessary analysis to optimize the osteointegration

A necessidade de uma melhor compreensão do metabolismo ósseo tornou-se crescente na Odontologia. O advento da implantodontia demandou a busca por boas condições de tecido ósseo visando à colocação de implantes osseointegráveis e também pela necessidade de preparo prévio de leitos receptores em áreas que necessitam de enxerto ósseo até as grandes reconstruções no campo da cirurgia buco-maxilo-facial que buscam reconstruir estruturas ósseas perdidas decorrentes de trauma ou de destruição tumoral tendo como área doadora a região ilíaca. A osteocalcina, produto da ação osteoblástica, intimamente relacionada à mineralização da matriz óssea tem sua ação estimulada pela vitamina D3 e é imprescindível para o processo de mineralização do tecido ósseo. Neste trabalho procurou-se fazer uma revisão dos aspectos mais importantes relacionados à atuação destas duas substâncias no metabolismo ósseo.

The need of a better understanding of the bone metabolism became growing in Dentistry. The coming of the implantology demanded the search for good conditions of bone tissue seeking to the placement of implants and also for the need of previous preparation in order to receive bone grafts in areas that need bone to great reconstructions in the of maxillofacial surgery which looks upon to rebuild bone structures lost by trauma or tumoral damages, which tends as donor area, the iliac bone. The osteocalcin, product of the osteoblastic action, intimately related to the mineralization of the bone matrix, keeps its action stimulated by the vitamin D3 and is indispensable for the process of the bone tissue mineralization. This paper intend to a revision of the most important aspects related to the performance of these two substances in the bone metabolism.

Biological factors and overestimation of left ventricular ejection fraction by gated SPECT.

BACKGROUND: Some patients present an overestimated left ventricular ejection fraction (LVEF) on electrocardiogram-gated myocardial scintigraphy (gated SPECT). OBJECTIVE: To establish the relationship between biological factors and overestimated LVEF. METHODS: We selected 3838 patients who underwent gated SPECT between May 20, 2000 and September 16, 2005 with normal perfusion images and LVEF > or =50%. The following variables were analyzed: gender (29.4% females and 70.6% males), age (from 20 to 94 years - mean: 56 years), weight (from 33.5 to 150 kg - mean: 79.6 kg), height (from 138 to 220 cm - mean: 171 cm) and BMI (from 13.9 to 54 - mean: 27.2). In a subgroup of 1002 patients who underwent echocardiogram, the diastolic diameter (from 36 to 68 mm - mean 47.5 mm) and systolic diameter (from 22 to 41 mm - mean 29.8 mm) variables were included. The patients were divided into two groups: normal LVEF (< or =80%) and overestimated LVEF (>80%). The odds ratio (OR) for presenting an overestimated LVEF was calculated for each variable using logistic regression. RESULTS: The following odds ratios were found (p < 0.005): female gender OR = 3.585 (95%CI: 2.745 to 4.683), age in years OR = 1.020 (95%CI: 1.011 to 1.029) and height in cm OR = 0.893 (95%CI: 0.829 to 0.962). Weight and BMI were not significantly associated with LVEF (p>0.2). In the subgroup of 1002 patients, a statistically significant influence was found in overestimated LVEF values for the systolic diameter, gender and height variables. CONCLUSION: Although systolic diameter influences the overestimation of LVEF, the gender and height variables have an independent influence on LVEF overestimation by gated SPECT.

Fatores biológicos e superestimação da fração de ejeção do ventrículo esquerdo no gated SPECT / Biological factors and overestimation of left ventricular ejection fraction by gated SPECT

FUNDAMENTO: Alguns pacientes apresentam fração de ejeção do ventrículo esquerdo (FEVE) superestimada na cintilografia miocárdica com sincronização eletrocardiográfica (gated SPECT). OBJETIVO: Estabelecer a relação entre fatores biológicos e FEVE superestimada. MÉTODOS: Selecionamos 3.838 pacientes que realizaram gated SPECT entre 20/5/2000 e 16/9/2005, com imagens normais de perfusão e FEVE >50 por cento. Analisamos as variáveis: sexo (29,4 por cento feminino e 70,6 por cento masculino), idade (de 20 a 94 anos - média: 56 anos), peso (de 33,5 a 150 kg - média: 79,6 kg), altura (de 138 a 220 cm - média: 171 cm) e IMC (de 13,9 a 54 - média: 27,2). Em um subgrupo de 1.002 pacientes que realizaram ecocardiograma, incluímos as variáveis diâmetros diastólico (de 36 a 68 mm - média 47,5 mm) e sistólico (de 22 a 41 mm - média 29,8 mm). Dividimos os pacientes em dois grupos: FEVE normal (<80 por cento) e superestimada (>80 por cento). A Razão de Chances (RC) para apresentar FEVE superestimada foi calculada para cada variável por regressão logística. RESULTADOS: Encontramos as seguintes Razões de Chances (p < 0,005): sexo feminino RC = 3,585 (IC95 por cento: 2,745 a 4,683), idade em anos RC = 1,020 (IC95 por cento: 1,011 a 1,029) e altura em cm RC = 0,893 (IC95 por cento: 0,829 a 0,962). O peso e o IMC não se associaram a FEVE significativamente (p>0,2). No subgrupo de 1.002 pacientes, encontramos influência estatisticamente significativa na obtenção da FEVE superestimada para as variáveis diâmetro sistólico, sexo e altura. CONCLUSÃO: Apesar de o diâmetro sistólico influenciar na obtenção da FEVE superestimada, as variáveis sexo e altura apresentam influência independente na superestimação da FEVE pelo gated SPECT.

BACKGROUND: Some patients present an overestimated left ventricular ejection fraction (LVEF) on electrocardiogram-gated myocardial scintigraphy (gated SPECT). OBJECTIVE: To establish the relationship between biological factors and overestimated LVEF. METHODS: We selected 3838 patients who underwent gated SPECT between May 20, 2000 and September 16, 2005 with normal perfusion images and LVEF >50 percent. The following variables were analyzed: gender (29.4 percent females and 70.6 percent males), age (from 20 to 94 years - mean: 56 years), weight (from 33.5 to 150 kg - mean: 79.6 kg), height (from 138 to 220 cm - mean: 171 cm) and BMI (from 13.9 to 54 - mean: 27.2). In a subgroup of 1002 patients who underwent echocardiogram, the diastolic diameter (from 36 to 68 mm - mean 47.5 mm) and systolic diameter (from 22 to 41 mm - mean 29.8 mm) variables were included. The patients were divided into two groups: normal LVEF (<80 percent) and overestimated LVEF (>80 percent). The odds ratio (OR) for presenting an overestimated LVEF was calculated for each variable using logistic regression. RESULTS: The following odds ratios were found (p < 0.005): female gender OR = 3.585 (95 percentCI: 2.745 to 4.683), age in years OR = 1.020 (95 percentCI: 1.011 to 1.029) and height in cm OR = 0.893 (95 percentCI: 0.829 to 0.962). Weight and BMI were not significantly associated with LVEF (p>0.2). In the subgroup of 1002 patients, a statistically significant influence was found in overestimated LVEF values for the systolic diameter, gender and height variables. CONCLUSION: Although systolic diameter influences the overestimation of LVEF, the gender and height variables have an independent influence on LVEF overestimation by gated SPECT.

Cirurgia Assistida por Computador - Relato de caso clínico / Computer-Assisted Surgery - A clinical report

O sucesso das reabilitações orais suportadas por implantes requer um planejamento protético e cirúrgico cuidadoso. Recentemente sistemas computacionais associados à tecnologia de prototipagem rápida são utilizados como uma importante ferramenta otimizando os resultados e reduzindo o tempo cirúrgico. Neste processo primeiramente confecciona-se uma guia radiográfica com objetivo de transferir as informações protéticas e do contorno gengival para a tomografia computadorizada (TC). Os dados da TC são abertos em software de planejamento cirúrgico onde podemos visualizar tridimensionalmente as coroas nos espaços protéticos. Conciliando esta informação com a imagem do relevo ósseo instalam-se virtualmente os implantes. Baseado neste projeto confecciona-se a guia cirúrgica pela técnica de prototipagem rápida (PR) adequada a cirurgia sem retalho gengival. Este artefato direciona as fresas cirúrgicas durante as perfurações dos tecidos. Relataremos um caso clínico com a instalação de três implantes utilizando cirurgia sem retalho gengival, software de planejamento cirúrgico e guia cirúrgica em prototipagem rápida.

Association between risk factors for coronary artery disease and coronary disease in patients undergoing myocardial perfusion scintigraphy.

OBJECTIVES: To establish the degree of association between cardiovascular risk factors and the presence of coronary artery disease (CAD) in a group of patients undergoing myocardial perfusion scintigraphy (MPS). METHODS: The study included 7183 patients who had undergone MPS. Using logistic regression analysis the odds ratios for the following risk factors were evaluated: age, gender, family history, body mass index, smoking, dyslipidemia, diabetes mellitus (DM) and systemic hypertension. Indicators for the presence of CAD were defined as: myocardial infarction, revascularization, angioplasty or an altered MPS. Analysis was based on the whole the group as well as on male and female subgroups. The impact of the risk factors in relation to age was also analyzed. RESULTS: A statistically significant association was observed between patient age and gender and the presence of CAD. For females, it was demonstrated that DM is the main modifiable risk factor for CAD. For males various modifiable risk factors were associated with the presence of CAD, particularly DM and dyslipidemia. In the analysis by age groups some risk factors showed a more expressive association. CONCLUSION: The main risk factors for CAD were aging and male gender. In relation to modifiable risk factors and the presence of CAD, the greatest associations for males were DM and dyslipidemia and for females DM. The most relevant factors for specific age groups were smoking for young men and DM and smoking for women between the ages of 40 and 50.

Associação entre fatores de risco para doença arterial coronariana e coronariopatia em pacientes submetidos a cintilografia de perfusão do miocárdio / Association between risk factors for coronary artery disease and coronary disease in patients undergoing myocardial perfusion scintigraphy

OBJETIVOS: Estabelecer o grau de associação entre fatores de risco cardiovascular e a presença de doença arterial coronária (DAC) em um grupo de pacientes submetidos a cintilografia de perfusão do miocárdio (CPM). MÉTODOS: Foram estudados 7.183 pacientes submetidos a CPM. Utilizando análise de regressão logística, avaliou-se a razão de chances dos seguintes fatores de risco: idade, sexo, antecedentes familiares, índice de massa corpórea, tabagismo, dislipidemia, diabetes melito (DM) e hipertensão arterial sistêmica. Definiram-se como indicativas da presença de DAC as seguintes condições: infarto, revascularização, angioplastia ou alteração na CPM. Analisou-se a amostra global de pacientes bem como os indivíduos masculinos e femininos separadamente. Caracterizou-se também a importância dos fatores de risco por faixas etárias. RESULTADOS: Observou-se associação estatisticamente significativa entre a idade e o sexo dos pacientes e a presença de DAC. Para o sexo feminino, o DM apareceu como o principal fator de risco controlável para DAC. Para o masculino, vários fatores de risco controláveis foram associados à presença de DAC, destacando-se o DM e a dislipidemia. Na análise por faixas etárias alguns fatores de risco passaram a apresentar associação mais expressiva. CONCLUSÃO: Os principais fatores de risco para DAC foram o envelhecimento e o sexo masculino. Dos fatores de risco passíveis de serem controlados, os que apresentaram maior associação com a presença de DAC foram o DM e a dislipidemia no homem e o DM na mulher. Para faixas etárias específicas destacaram-se o tabagismo para homens jovens, o DM e o tabagismo para mulheres entre 40 e 50 anos.

OBJECTIVES: To establish the degree of association between cardiovascular risk factors and the presence of coronary artery disease (CAD) in a group of patients undergoing myocardial perfusion scintigraphy (MPS). METHODS: The study included 7183 patients who had undergone MPS. Using logistic regression analysis the odds ratios for the following risk factors were evaluated: age, gender, family history, body mass index, smoking, dyslipidemia, diabetes mellitus (DM) and systemic hypertension. Indicators for the presence of CAD were defined as: myocardial infarction, revascularization, angioplasty or an altered MPS. Analysis was based on the whole the group as well as on male and female subgroups. The impact of the risk factors in relation to age was also analyzed. RESULTS: A statistically significant association was observed between patient age and gender and the presence of CAD. For females, it was demonstrated that DM is the main modifiable risk factor for CAD. For males various modifiable risk factors were associated with the presence of CAD, particularly DM and dyslipidemia. In the analysis by age groups some risk factors showed a more expressive association. CONCLUSION: The main risk factors for CAD were aging and male gender. In relation to modifiable risk factors and the presence of CAD, the greatest associations for males were DM and dyslipidemia and for females DM. The most relevant factors for specific age groups were smoking for young men and DM and smoking for women between the ages of 40 and 50.

Relação entre os níveis séricos de cálcio e paratormônio e a positividade da cintilografia das paratiróides com sestamibi: análise de 194 pacientes / The relation between serum levels of calcium and PTH and the positivity of parathyroid scintigraphy with sestamibi: analysis of 194 patients

Com o objetivo de correlacionar os níveis séricos de cálcio e PTH com a porcentagem de resultados positivos na cintilografia das paratiróides (CP), analisamos retrospectivamente 194 pacientes submetidos à CP. Avaliou-se visualmente a distribuição dos resultados das CP em um diagrama de dispersão cujos eixos eram os níveis de cálcio (eixo Y) e PTH (eixo X) séricos. Foram definidos 6 grupos de pacientes: 1) cálcio > 12mg/dL; 2) 11mg/dL < cálcio < 12mg/dL; 3) 9,9mg/dL < cálcio < 11mg/dL com PTH > 120pg/mL; 4) 9,9mg/dL < cálcio < 11mg/dL com 65pg/mL < PTH < 120pg/mL; 5) 9,9mg/dL < cálcio < 11mg/dL com PTH < 65pg/mL; e 6) cálcio < 9,9mg/dL. A porcentagem de exames positivos nestes 6 grupos foram respectivamente: 10/10 (100 por cento), 18/29 (62 por cento), 7/9 (78 por cento), 18/45 (40 por cento), 2/21 (10 por cento) e 1/80 (1 por cento). Em conclusão, nos pacientes com suspeita de hiperparatiroidismo primário, as CPs realizadas antes da cirurgia de paratiroidectomia naqueles com níveis de cálcio acima de 11mg/dL são, na maioria das vezes, positivas. Para pacientes com níveis de cálcio sérico entre 9,9mg/dL e 11mg/dL, a pertinência da realização da cintilografia vai depender dos níveis de PTH sérico, sendo esta pertinência alta para pacientes com níveis de PTH acima de 120pg/mL e muito baixa para pacientes com PTH abaixo de 65pg/mL. Pacientes com cálcio sérico abaixo de 9,9mg/dL raramente apresentam cintilografia das paratiróides positivas.

Padronização de valores de captação tiroidiana com 123I / Reference values for thyroid 24 hours 123I uptake

Com o objetivo de padronizar valores de referência para captação tiroidiana (CAPTIR) com 123I, analisamos 475 pacientes que realizaram dosagens de T4 livre e TSH e exames de CAPTIR 24h após a administração de 123I. Separamos os pacientes em 3 grupos: hipertiróideo, normal e hipotiróideo, de acordo com os resultados do T4 livre e TSH. Calculamos as médias e os desvios-padrão (DP) dos valores de captação, realizamos testes t não-pareados e calculamos curvas ROC para definir os melhores valores de CAPTIR para separar os grupos. As médias e DP dos valores de captação foram: hipertiróideo (36,5 por cento ± 16,5 por cento), normal (14,4 por cento ± 5,48 por cento) e hipotiróideo (13,7 por cento ± 7,5 por cento). O teste t não-pareado mostrou diferença significativa entre os grupos hipertiróideo e normal (p< 0,01), sem diferença significativa entre os grupos normal e hipotiróideo (p= 0,55). O valor de captação 23 por cento apresentou melhor relação sensibilidade (80 por cento) / especificidade (93 por cento) para separar o grupo normal do hipertiróideo. A curva ROC não mostrou bons resultados para a separação do grupo normal do hipotiróideo. Em conclusão, o limite superior da normalidade para CAPTIR pode ser estabelecido em 23 por cento. Não foi possível estabelecer limite inferior de normalidade, devido à grande sobreposição dos valores de captação dos grupos hipotiróideo e normal.

[Reference values for thyroid 24 hours 123I uptake]. / Padronização de valores de captação tiroidiana com 123I.

To establish references for thyroid 24 h 123I uptake value (TUV), we reviewed 475 patients who had free T4 and TSH dosages, and TUV measured 24h after the administration of 123I. The patients were separated in 3 groups: hyperthyroid, euthyroid and hypothyroid, according to thyroid hormone results. The mean and standard deviation (SD) of the TUVs were calculated for each group. We used the unpaired T test to compare the means and ROC curves to evaluate the best TUV to separate the groups. The mean and SD of TUVs for the groups were: hyperthyroid (36.5% +/- 16.5%), euthyroid (14.4% +/- 5.48%) and hypothyroid (13.7% +/- 7.5%). The unpaired T test showed statistically significant difference between hyperthyroid and euthyroid groups (p < 0.01). There was no significative difference between hypothyroid and euthyroid groups (p = 0.55). The 23% TUV has the best sensitivity (80%)/specificity (93%) ratio to separate hyperthyroid from euthyroid groups. There was not a good TUV to separate euthyroid form hypothyroid groups. In conclusion, it can be established 23% as the optimal superior limit for the normal uptake values. However, it was not possible to establish a suitable inferior limit, due to the expressive overlay of TUVs of hypothyroid and euthyroid groups.

[The relation between serum levels of calcium and PTH and the positivity of parathyroid scintigraphy with sestamibi--analysis of 194 patients]. / Relação entre os níveis séricos de cálcio e paratormônio e a positividade da cintilografia das paratiróides com sestamibi--análise de 194 pacientes.

To correlate PTH and calcium serum levels with the percentages of positive results on the parathyroid scintigraphy, we retrospectively analyzed 194 patients who performed parathyroid scintigraphy. The distribution of the parathyroid scintigraphy results was visually analyzed in a scatter plot, being calcium (Y axis) and PTH (X axis) serum levels the axes. Six groups of patients were defined: 1) calcium > or = 12 mg/dL; 2) 11 mg/dL calcium < 12 mg/dL; 3) 9.9 mg/dL < or = calcium < 11 mg/dL with PTH > 120 pg/mL; 4) 9.9 mg/dL < or = calcium < 11 mg/dL with 65 pg/mL < PTH < or = 120 pg/mL; 5) 9.9 mg/dL < or = calcium < 11 mg/dL with PTH < or = 65 pg/mL; and 6) calcium < 9.9 mg/dL. The percentage of positive scintigraphy in these groups were respectively: 10/10 (100%), 18/29 (62%), 7/9 (78%), 18/45 (40%), 2/21 (10%) and 1/80 (1%). We conclude that in patients with suspected primary hyperparathyroidism, parathyroid scintigraphies performed before surgery on those with calcium level above 11 mg/dL are frequently positive. In patients with calcium levels between 9.9 mg/dL and 11 mg/dL the pertinence of performing the scintigraphy will depend on the PTH levels, and it will be high for patients with PTH serum level above 120 pg/mL and very low for patients with PTH level below 65 pg/mL. Patients with calcium level below 9.9 mg/dL rarely present positive results on parathyroid scintigraphies.

Relação dos níveis séricos de cálcio e paratormônio com a positividade da cintiligrafia das paratiróides / Relation of serum calcium and parathormone levels and positivity of parathyroid scintigraphy

O hiperparatiroidismo primário (HPP) é caracterizado pelo aumento da secreção de PTH, com conseqüente aumento da concentração sérica de cálcio. O diagnóstico é realizado pela dosagem de cálcio e PTH. A cintilografia das paratiróides é solicitada, classicamente, em pacientes com recorrência de HPP após paratiroidectomia, na tentativa de detectar glândulas patológicas ectópicas ou remanescentes. Algumas vezes este exame tem sido solicitado antes do primeiro ato cirúrgico, na tentativa de localizar as glândulas comprometidas e abreviar a duração da cirurgia; na nossa casuística, no entanto, a maioria dos exames solicitados com esta indicação resulta negativa. Comparamos os níveis séricos de cálcio e PTH nos pacientes com cintilografia das paratiróides positiva, com aqueles dos pacientes com cintilografia negativa, a fim de tentar definir níveis com índice maior de positividade na cintilografia. Foram estudados retrospectivamente 74 pacientes consecutivos submetidos à cintilografia das paratiróides. Avaliou-se a utilização dos valores mais baixos de PTH (79pg/mL) e cálcio (l0mg/dL) registrados no grupo com cintilografia positiva como referência para a indicação do exame. No grupo total de pacientes, 17 (23 por cento) apresentaram cintilografia positiva. No subgrupo com valores de PTH >79pg/mL e de cálcio >_10 mg/dL a porcentagem de exames positivos foi de 49 por cento. Concluímos que cintilografias das paratiróides realizadas antes da cirurgia de paratiroidectomia em pacientes com níveis de cálcio sérico abaixo do limite superior da normalidade ou níveis de PTH pouco aumentados são, na maioria das vezes, negativas.