RESUMO
BACKGROUND: The Global Initiative for Children's Surgery (GICS) group produced the Optimal Resources for Children's Surgery (OReCS) document in 2019, listing standards of children's surgical care by level of healthcare facilities within low resource settings. We have previously created and piloted an audit tool based on the OReCS criteria in a high-income setting. In this study, we aimed to validate its use in identifying gaps in children's surgery provision worldwide. METHODS: Our OReCS audit tool was implemented in 10 hospitals providing children's surgery across eight countries. Collaborators were recruited via the Oxford Paediatrics Linking Our Research with Electives (OxPLORE) international network of medical students and trainees. The audit tool measured a hospital's current capacity for children's surgery. Data were analysed firstly to express the percentage of 'essential' criteria met for each specialty. Secondly, the 'OxPLORE method' was used to allocate each hospital specialty a level based on procedures performed and resources available. A User Evaluation Tool (UET) was developed to obtain feedback on the ease of use of the tool. RESULTS: The percentage of essential criteria met within each category varied widely between hospitals. The level given to hospitals for subspecialties based on OReCS criteria often did not reflect their self-defined level. The UET indicated the audit tool was practicable across multiple settings. CONCLUSIONS: We recommend the use of the OReCS criteria to identify areas for local hospital improvement and inform national children's surgical plans. We have made informed suggestions to increase usability of the OReCS audit tool.
Assuntos
Cirurgia Geral , Acessibilidade aos Serviços de Saúde , Criança , Estudos Transversais , HumanosRESUMO
Cough may be associated with complications such as syncope, urinary incontinence, pneumothorax, and less frequently, pulmonary hernia and costal fractures. Chronic cough is a cause of rib fractures and when they occur it is likely to affect more than one rib. We report a 53 year-old obese male in treatment with enalapril 10 mg for hypertension with a dry cough lasting five months. He consulted for bilateral chest pain and a Chest X ray examination showed symmetrical fractures in the seventh left and right ribs. Enalapril was discontinued, cough and pain subsided in two weeks.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Tosse/induzido quimicamente , Enalapril/efeitos adversos , Fraturas das Costelas/etiologia , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Doença Crônica , Tosse/complicações , Enalapril/uso terapêutico , Humanos , Hipertensão/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Fraturas das Costelas/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
Angioedema induced by angiotensin converting enzyme inhibitors is a rare entity characterized by skin and mucosal edema, due to increased vascular permeability caused by inhibition of the converting enzyme and subsequent increase in bradykinin. It frequently presents with facial and mucosal involvement, being uncommon the intestinal or airway compromise. Intestinal angioedema may be associated with facial or isolated angioedema, the latter being exceptional. It is associated with recurrent episodes of pain, abdominal distention and watery diarrhea which complete recovery in two or three days. Although it is a rare entity, the fact that it is associated with frequently used drugs makes us include it in the differential diagnosis of recurrent abdominal pain. We report a case of isolated intestinal angioedema associated with the use of enalapril.
Assuntos
Angioedema/induzido quimicamente , Anti-Hipertensivos/efeitos adversos , Enalapril/efeitos adversos , Enteropatias/induzido quimicamente , Idoso , Angioedema/diagnóstico por imagem , Feminino , Humanos , Hipertensão/tratamento farmacológico , Enteropatias/diagnóstico por imagem , Intestino Delgado/diagnóstico por imagemRESUMO
Vertigo is defined as an abnormal sensation of body motion or of its surrounding objects. It is a common chief complaint in emergency departments comprising 2 to 3% of these consultations worldwide. Vertigo is classified as peripheral or central, according to its origin, and can also be occasionally mixed, the most common cause of peripheral involvement being benign paroxysmal positional vertigo. The initial findings on clinical evaluation of patients are the clues for making a correct diagnosis. The differentiation between central and peripheral vertigo can be optimized by analysing nystagmus, by using the skew test and the head impulse test (HINTS), as also by performing the appropriate tests to evaluate the integrity of the vestibular-cerebellar pathway. In addition, tonal threshold audiometry could raise the diagnostic sensibility from 71 to 89% on initial approach. Appropriate diagnosis is the principal key for managing this clinical condition.
Assuntos
Vertigem/diagnóstico , Vertigem/fisiopatologia , Vertigem Posicional Paroxística Benigna/diagnóstico , Vertigem Posicional Paroxística Benigna/fisiopatologia , Vertigem Posicional Paroxística Benigna/terapia , Tontura/diagnóstico , Tontura/fisiopatologia , Tontura/terapia , Humanos , Doença de Meniere/diagnóstico , Doença de Meniere/fisiopatologia , Doença de Meniere/terapia , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/fisiopatologia , Transtornos de Enxaqueca/terapia , Nistagmo Patológico/diagnóstico , Nistagmo Patológico/fisiopatologia , Nistagmo Patológico/terapia , Vertigem/terapia , Neuronite Vestibular/diagnóstico , Neuronite Vestibular/fisiopatologia , Neuronite Vestibular/terapiaRESUMO
Deep vein thrombosis (DVT) of the upper limb is a rare entity, estimated to account for 10% of all cases of DVT. Classically, they are classified into primary (idiopathic, due to subclavian vein compression or exercise related) and secondary (cancer, thrombophilia, trauma, shoulder surgery, associated to venous catheters or due to hormonal causes). The Paget- Schrötter syndrome is a primary thrombosis of the subclavian vein in the subclavian-axillary junction, related either to repetitive movements or to exercise; leading to microtrauma in the endothelium with consequent activation of the coagulation cascade. Clinically, it presents abruptly with pain, edema and feeling of heaviness in the affected limb. The treatment varies from thrombolytics and anticoagulation to surgical intervention, depending on the time of evolution. We present four cases of exercise-related subclavian vein thrombosis.
Assuntos
Veia Axilar/patologia , Veia Subclávia/patologia , Trombose Venosa Profunda de Membros Superiores/patologia , Adolescente , Adulto , Anticoagulantes/uso terapêutico , Veia Axilar/diagnóstico por imagem , Edema , Feminino , Humanos , Masculino , Flebografia , Veia Subclávia/diagnóstico por imagem , Ultrassonografia Doppler , Trombose Venosa Profunda de Membros Superiores/diagnóstico , Trombose Venosa Profunda de Membros Superiores/tratamento farmacológicoRESUMO
In the political and social context of World War periods and unstoppable technological advances, health professionals in the early twentieth century tried to orientate the practice of medicine towards a modern anthropological concept close to the biomedical perspective, which defends the dignity of a person. Threatened by the risks represented by collectivism and the meanness of the prevailing repressive governments, a personal struggle for the defense of life aroused, which was socially expressed by the advent of bioethics, psychoanalytic theories and the concept that environment has an important role in peoples health and welfare. And above all, the appearance of a paradoxical claim of religious ideals as support of science in times of overall crisis.
Assuntos
Altruísmo , Religião e Medicina , Santos/história , II Guerra Mundial , I Guerra Mundial , Feminino , História do Século XIX , História do Século XX , Humanos , MasculinoRESUMO
Intravascular lymphoma is a rare subtype of extranodal diffuse large B-cell lymphoma characterized by clonal proliferation of lymphocytes inside of small and medium caliber vessels. Its incidence is estimated at one case per million. The clinical picture is very variable, but frequently has skin and central nervous system involvement. It is diagnosed by demonstrating pathological blood vessel infiltration by lymphoma cells. We report a 44 years old male presenting with fever, malaise and erythematous lesions in the abdominal wall. An abdominal wall biopsy showed dilated vascular vessels with atypical cells in their lumen, compatible with large B-cell intravascular lymphoma. He was treated with rituximab, cyclophosphamide, adriamycin, vincristine and prednisone and an autologous hematopoietic stem cell transplantation, achieving a complete remission that has lasted two years.
Assuntos
Linfoma Difuso de Grandes Células B/patologia , Neoplasias Vasculares/patologia , Parede Abdominal/irrigação sanguínea , Adulto , Biópsia , Eritema/complicações , Transplante de Células-Tronco Hematopoéticas , Humanos , Linfoma Difuso de Grandes Células B/terapia , Masculino , Indução de Remissão , Neoplasias Vasculares/terapiaRESUMO
The Hughes-Stovin syndrome is a rare entity characterized by deep vein thrombosis and pulmonary artery aneurysms of unknown etiology and pathogenesis. Some authors considered a variant of Behcet's disease. Its natural course is usually fatal. The symptoms are cough, dyspnea, hemoptysis, chest pain and fever. The treatment goes from steroids and cytotoxic agents to surgery. We present the case of a 41 year old man who shows dyspnea, hemoptysis, and chest pain leading to the diagnosis of deep venous thrombosis of the right leg, lung thromboembolism and pulmonary artery aneurysms. He was treated with high-dose corticosteroids and 6 cyclophosphamide pulses of 1 gram each per 6 months with complete regression of aneurysms and symptomatology.
Assuntos
Aneurisma Roto/diagnóstico , Artéria Pulmonar , Embolia Pulmonar/diagnóstico , Trombose Venosa/diagnóstico , Adulto , Síndrome de Behçet/diagnóstico , Hemoptise/etiologia , Humanos , Masculino , SíndromeRESUMO
Sensory neuronopathies or ganglionopathies, or dorsal root ganglion disorders, represent a subgroup of peripheral nervous system diseases, frequently associated with dysinmune or neoplastic disorders and with toxic agents. A degeneration of both central and peripheral sensory proyections is present. Patients typically show early ataxia, loss of deep tendon reflexes and positive sensory symptoms present both in proximal and distal sites of the body. We retrospectively studied 10 cases with a final diagnosis of sensory neuronopathy. Sensory neuropathy was the presenting symptom and the course was subacute in all cases. Paresthesias in upper limbs were a predominant manifestation (100%). Other manifestations included: hypoesthesia (10/10), gait ataxia (8/10), autonomic symptoms (3/10) and perioral paresthesias (3/10). Electrophysiology showed sensory axonal neuronal pattern, with normal motor responses. Final diagnosis was acquired sensory neuronopathy in all patients, associated with Sjögren's syndrome in 2, with lupus erythematosus in 1, with rheumatoid arthritis in 1, with a cancer in 2 (paraneoplastic) and idiopathic in 4. In paraneoplastic cases, the tumor was small cell lung cancer in 1 (with positive anti-Hu antibodies), and epidermoid lung cancer in the other. Eight patients were treated with immunotherapy, high dose intravenous methylprednisolone and/or intravenous immunoglobulin; with poor response in 4 cases, neurologic improvement in 5, and without any change in 1 patient. The present work shows the typical clinical and electrophysiological pattern of subacute sensory neuronopathy, and the relevance of early treatment.
Assuntos
Ataxia/diagnóstico , Ataxia/tratamento farmacológico , Carcinoma de Células Escamosas/complicações , Neoplasias Pulmonares/complicações , Carcinoma de Pequenas Células do Pulmão/complicações , Tempo para o Tratamento , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios/uso terapêutico , Artrite Reumatoide/complicações , Ataxia/complicações , Evolução Fatal , Feminino , Marcha Atáxica/diagnóstico , Marcha Atáxica/tratamento farmacológico , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Fatores Imunológicos/uso terapêutico , Lúpus Eritematoso Sistêmico/complicações , Masculino , Metilprednisolona/uso terapêutico , Pessoa de Meia-Idade , Parestesia/diagnóstico , Parestesia/tratamento farmacológico , Estudos Retrospectivos , Síndrome de Sjogren/complicaçõesRESUMO
Appendicitis is a common cause of acute abdominal pain. It is caused by the obstruction of the cecal lumen and can evolve to perforation and peritonitis. This article reviews the initial description and history of appendicitis and describes the signs and symptoms used for diagnosis. In today's medicine, where technology plays an important role, the value of anamnesis and physical examination should be stressed as useful tools.
Assuntos
Apendicite/história , Doença Aguda , História do Século XV , História do Século XVI , História do Século XVII , História do Século XVIII , História do Século XIX , História do Século XX , HumanosRESUMO
The discovery of the renin-angiotensin-aldosterone system (RAS) was one of the important findings in physiology. Two research groups, in both North and South America, independently discovered that renin released a novel vasopressor agent. The Argentine group named it hypertensin, and called hypertensinogen to its plasma protein substrate. The group from the United States named it angiotonin. In 1958, Braun Menendez and Irvine Page suggested that the peptide's name should be angiotensin. Development of angiotensin converting enzyme (ACE) inhibitors proved that the RAS is effective in controlling hypertension and heart failure, and in preventing vascular injury in chronic diseases. Both teams, showing that beyond being great investigators they were remarkable persons, shared the merit of the discovery.
Assuntos
Angiotensinas/história , Sistema Renina-Angiotensina , Pesquisadores/história , Argentina , História do Século XIX , História do Século XX , Humanos , Estados UnidosRESUMO
Armand Trousseau (1801-1867) was born in Tours, France on October 14, 1801. He graduated as a physician in the same city under the direction of Pierre Bretonneau and received his doctorate in 1825 in Paris. He was the first physician to practice tracheotomy in diphtheria and perform thoracenteses to remove air or fluid from the pleural space. He recommended tracheal intubation in different scenarios. He described the first cases of laryngeal tuberculosis and the presence of carpopedal spasm in hypocalcemia, a sign that has his name. He also described the association between migratory thrombophlebitis and neoplasia, which is known as Trousseau's syndrome. Ironically, on January 1, 1867 he diagnosed in himself a deep vein thrombosis of the left upper limb and told one of his disciples "I am lost; I have no doubt about the nature of my disease". He died of gastric cancer at the age of 66 years on June 23, 1867. He carried out an educational and medical work. He instructed his students about the rather instantaneous thought process in clinical medicine. He always conducted his clinical work with the certainty of a sound scientific background. Contemporary physicians should take advantage of the example and lessons of Armand Trousseau.
Assuntos
Medicina Clínica/história , Hipocalcemia/história , França , História do Século XIXRESUMO
Frédéric Chopin - a great Polish composer and pianist-suffered from a chronic disease. Both during his life and after his death, physicians disagreed on Chopin's diagnosis. His contemporaries accepted the diagnosis of tuberculosis, a common disease in the 18th century. Description of new clinical entities provoked new dilemmas in the 21th century. Although other alternative diagnoses to tuberculosis have emerged, such as cystic fibrosis or alpha-1 antitrypsin deficiency, we still sustain that the first diagnosis is the most probable. In this paper we report F. Chopin's case history and discuss cons and pros for different diseases as the cause of F. Chopin's suffering and death.
Assuntos
Pessoas Famosas , Música/história , Fibrose Cística/história , História do Século XVIII , História do Século XIX , Tuberculose Pulmonar/história , Deficiência de alfa 1-Antitripsina/históriaRESUMO
Granulomatosis with polyangiitis (GPA) or Wegener's disease is characterized by a granulomatous vasculitis of the upper and lower airways and kidney. It involves the lower respiratory tract causing subglottic tracheal stenosis, which occurs in approximately 22% of patients. We report two females aged 40 and 52 years, admitted to the hospital with a subglottic tracheal stenosis. Their symptoms and management are reviewed. The first patient responded to rituximab. The second patient required a tracheostomy.
Assuntos
Granulomatose com Poliangiite/complicações , Estenose Traqueal/etiologia , Adulto , Anticorpos Monoclonais Murinos/uso terapêutico , Feminino , Humanos , Pessoa de Meia-Idade , Rituximab , Estenose Traqueal/terapia , TraqueostomiaRESUMO
Hiccup is a spasmodic involuntary contraction of the diaphragm which triggers a sudden inspiration and an abrupt closure of the glottis with a characteristic sound. Regarding its duration, it is classified as hiccup attack, persistent hiccup or rebellious or intractable hiccup. We present the case of a 75 old male with rebellious hiccup which prevented him to fall asleep by day or by night, associated with belches lasting for three years, refractory to chlorpromazine. An extensive evaluation led to the diagnosis of right ethmoid sinus tumor. The tumor resection was performed and after subsequent local radiotherapy the hiccup disappeared. We consider this a rare cause of rebellious hiccup that generated a diagnostic and therapeutic challenge.
Assuntos
Carcinoma de Células Escamosas/complicações , Seio Etmoidal , Soluço/etiologia , Neoplasias dos Seios Paranasais/complicações , Idoso , Humanos , MasculinoRESUMO
INTRODUCTION: The COVID-19 vaccine became an effective instrument to prevent severe SARS-CoV-2 infections. However, 5% of vaccinated patients will have moderate or severe disease. OBJECTIVE: to compare mortality and days between the symptom onset to the peak disease severity, in vaccinated vs. unvaccinated COVID-19 hospitalized patients. METHODS: Retrospective observational study in 36 hospitals in Argentina. COVID-19 adults admitted to general wards between January 1, 2021, and May 31, 2022 were included. Days between symptoms onset to peak of severity were compared between vaccinated vs. unvaccinated patients with Cox regression, adjusted by Propensity Score Matching (PSM). Results in patients with one and two doses were also compared. RESULTS: A total of 3663 patients were included (3001 [81.9%] unvaccinated and 662 [18%] vaccinated). Time from symptom onset to peak severity was 7 days (IQR 4-12) vs. 7 days (IQR 4-11) in unvaccinated and vaccinated. In crude Cox regression analysis and matched population, no significant differences were observed. Regarding mortality, a Risk Ratio (RR) of 1.51 (IC95% 1.29-1.77) was observed in vaccinated patients, but in the PSM cohort, the RR was 0.73 (IC95% 0.60-0.88). RR in patients with one COVID-19 vaccine dose in PSM adjusted population was 0.7 (IC95% 0.45-1.03), and with two doses 0.6 (IC95% 0.46-0.79). DISCUSSION: The time elapsed between the onset of COVID-19 symptoms to the highest severity was similar in vaccinated and unvaccinated patients. However, hospitalized vaccinated patients had a lower risk of mortality than unvaccinated patients.
Introducción: A pesar de la eficacia de la vacuna contra el COVID-19 el 5% de los pacientes vacunados presentaran una enfermedad moderada o grave. El objetivo del presente estudio fue comparar los días entre el inicio de los síntomas y la gravedad máxima de la enfermedad, en pacientes con COVID-19 vacunados vs. no vacunados. Métodos: Estudio observacional retrospectivo en 36 hospitales de Argentina. Se incluyeron adultos con COVID-19 hospitalizados entre el 1/01/2021 y 31/5/2022. Se recolectaron datos demográficos, comorbilidades y progresión clínica de la enfermedad. Se compararon los días entre el inicio de los síntomas y el pico de gravedad entre vacunados y no vacunados mediante regresión de Cox, ajustada por emparejamiento por Propensity Score Matching (PSM). En un análisis de subgrupos, se compararon los resultados en pacientes con una y dos dosis de vacuna. Resultados: Se incluyeron 3663 pacientes (3001 [81.9%] no vacunados y 662 [18%] vacunados). El tiempo transcurrido desde el inicio de los síntomas hasta el pico de gravedad fue de 7 días (IQR 4 - 12) en no vacunados, y de 7 días (IQR 4-11) en vacunados. Tanto en el análisis de regresión de Cox crudo como en el ajustado, no se observaron diferencias significativas entre ambos grupos (HR ajustado 1.08 [IC 95% 0.82-1.4; p = 0.56]). En cuanto a la mortalidad, el Riesgo Relativo (RR) fue 1.51 (IC95% 1.29-1.77) en los pacientes vacunados, pero en la cohorte ajustada por Propensity Score, el RR fue de 0.73 (IC95% 0.60-0.88). El RR en el grupo con una dosis de vacuna COVID-19 en el análisis PSM fue 0.7 (IC95% 0.45-1.03), y con dos dosis 0.6 (IC95% 0.46-0.79). Discusión: El tiempo entre el inicio de los síntomas de COVID-19 y el pico de severidad fue igual en vacunados y no vacunados. Sin embargo, los pacientes vacunados hospitalizados presentaron menor mortalidad tras el ajuste por confundidores.
Assuntos
COVID-19 , Adulto , Humanos , COVID-19/prevenção & controle , Vacinas contra COVID-19 , SARS-CoV-2 , Sistema de Registros , VacinaçãoRESUMO
BACKGROUND AND AIM: Hughes-Stovin syndrome (HSS) is a rare systemic vasculitis with widespread venous/arterial thrombosis and pulmonary vasculitis. Distinguishing between pulmonary embolism (PE) and in-situ thrombosis in the early stages of HSS is challenging. The aim of the study is to compare clinical, laboratory, and computed tomography pulmonary angiography (CTPA) characteristics in patients diagnosed with PE versus those with HSS. METHODS: This retrospective study included 40 HSS patients with complete CTPA studies available, previously published by the HSS study group, and 50 patients diagnosed with PE from a single center. Demographics, clinical and laboratory findings, vascular thrombotic events, were compared between both groups. The CTPA findings were reviewed, with emphasis on the distribution, adherence to the mural wall, pulmonary infarction, ground glass opacification, and intra-alveolar hemorrhage. Pulmonary artery aneurysms (PAAs) in HSS were assessed and classified. RESULTS: The mean age of HSS patients was 35 ± 12.3 years, in PE 58.4 ± 17 (p < 0.0001). Among PE 39(78 %) had co-morbidities, among HSS none. In contrast to PE, in HSS both major venous and arterial thrombotic events are seen.. Various patterns of PAAs were observed in the HSS group, which were entirely absent in PE. Parenchymal hemorrhage was also more frequent in HSS compared to PE (P < 0.001). CONCLUSION: Major vascular thrombosis with arterial aneurysms formation are characteristic of HSS. PE typically appear loosely-adherent and mobile whereas "in-situ thrombosis" seen in HSS is tightly-adherent to the mural wall. Mural wall enhancement and PAAs are distinctive pulmonary findings in HSS. The latter findings have significant therapeutic ramifications.