[Fungal endocarditis with central and peripheral embolization: case report]. / Endocardite fúngica corn embolização central e periférica: um caso clínico.

A 50-year-old man with a history of drug addiction was admitted to the cardiology department for aortic valve fungal endocarditis complicated by severe aortic regurgitation, cerebral infarcts and right common iliac artery pseudoaneurysm. While awaiting transfer to the cardiothoracic surgery department, the patient presented acute arterial ischemia of the left leg, and distal left patellofemoral embolectomy was successfully performed. The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve. After fourteen days he was referred for vascular surgery, where the four-month hospitalization was complicated by left leg amputation. Four months after discharge, the patient was admitted to the emergency department for recurrent fungal endocarditis complicated by multiple renal and splenic infarcts and celiac trunk embolization. He was transferred to the cardiothoracic surgery department, but suffered cardiac arrest before surgical intervention.

Association between red blood cell distribution width and outcomes at six months in patients with acute coronary syndromes.

BACKGROUND: Higher values of red ceildistribution width (RDW) may be associated with adverse outcomes in patients with heart failure and in those with stable coronary artery disease. We assessed the hypothesis that higher RDW values are associated with adverse cardiovascular outcomes in patients with acute coronary syndromes (ACS). METHODS: We studied 1796 patients with ACS admitted to a coronary care unit. We analyzed clinical and laboratory characteristics, management, and outcomes of patients according to tertiles of baseline RDW. The primary outcome was death or myocardial infarction (MI) during six-month follow-up. RESULTS: Patients with higher RDW values tended to be older, were more likely to be female and have a history of MI, and more often had renal dysfunction, anemia, and Killip class >I on admission (p < 0.05). Higher RDW values were associated with increased 6-month mortality (tertile 1: 8.2%; tertile 2: 10.9%; tertile 3: 15.5%; p = 0.001 for trend) and increased 6-month death/MI rates (tertile 1, 13.0%; tertile 2, 17.2%; tertile 3, 22.9%; p < 0.0001 for trend). An association between higher RDW and increased 6-month death/MI rates was found in patients with non-ST-elevation ACS (10.5% vs. 15.3% vs. 22.7%; p < 0.001 for trend), with a tendency in patients admitted with ST-elevation MI (15.1% vs. 19.1% vs. 23.1%; p = 0.053 for trend). After adjustment for baseline characteristics and treatment, higher RDW values remained independently associated with the study's primary composite outcome but not with all-cause death. Using the first tertile of RDW as reference, the adjusted odds ratio (OR) for 6-month death/MI among patients in the highest RDW tertile was 1.43 (95% confidence interval [CI], 1.00-2.05; p = 0.049). Using RDW as a continuous variable, the adjusted OR for 6-month death/MI was 1.16 (95% CI, 1.03-1.30; p = 0.017) per 1% increase in RDW. CONCLUSIONS: RDW is an easily determined predictor of outcome after ACS. We found a graded independent association between higher RDW values and adverse outcomes in patients with ACS.

Coexistence of coronary cameral fistulae and cor triatriatum sinister in an elderly patient.

Coronary cameral fistulae are unusual congenital or acquired anomalous communications between an epicardial coronary artery and a cardiac chamber. There are no reported cases of the association of coronary cameral fistulae and cor triatriatum, a rare congenital cardiac anomaly in which a fibromuscular membrane divides the left atrium into two chambers. We report the case of an 82-year-old man presenting with recurrent anterior chest pain. Echocardiographic examination identified non-obstructive cor triatriatum, mitral valve prolapse resulting in significant mitral regurgitation, dilated coronary arteries, and established the entry site of coronary artery fistulae at the apex of the left ventricle (Figure 1). Coronary angiography confirmed the existence of a plexiform fistula between the left anterior descending coronary artery and the left ventricle. Tetrofosmine scintigraphy revealed the presence of stress-induced ischaemia in the apex. To our knowledge, we report the oldest person with coronary cameral fistulae presenting with angina only at this stage, and the interesting case of the coexistence of two, although unconnected, congenital conditions in an elderly patient. In addition, this report highlights the important role of transthoracic and transoesophageal echocardiography to the characterization of these unusual anomalies, and the complementary information offered by three-dimensional transthoracic echocardiography.

Identificación de signos y síntomas para el diagnóstico del dolor discal: revisión de mapeo / Identification of signs and symptoms for the diagnosis of discogenic low back pain: mapping review

OBJETIVO: El dolor lumbar constituye una de las patologías con mayor prevalencia en la población adulta. Su carga económica para el servicio de salud e impacto en la calidad de vida y funcionalidad de los pacientes lo convierte en un tema de suma relevancia. En la mayoría de los casos es posible atribuir el dolor a una de las estructuras de la columna lumbar; sin embargo, no existe una escala diagnóstica que permita diferenciar el dolor lumbar de origen discogénico (DLD). La revisión de los signos y síntomas del DLD más frecuentes en la literatura permite un mejor abordaje al paciente con dolor lumbar, y a la vez una aproximación a la creación de una escala diagnóstica piloto para definir DLD. MATERIALES Y MÉTODOS: Se realizó una búsqueda sistemática de la literatura de los últimos 20 años en MEDLINE y BIREME, a partir de la cual se realizó una revisión de mapeo del reporte de los signos y síntomas comúnmente utilizados para sospechar DLD. Se revisaron un total de 1010 artículos, de los cuales se seleccionaron 103 para analizar la frecuencia de reporte de signos y síntomas incluidos en el diagnóstico. RESULTADOS: En la revisión de mapeo el síntoma más frecuente fue el dolor lumbar axial, seguido por la ausencia de dolor radicular. Se observó menor frecuencia de descripción en la literatura en torno a los signos asociados al dolor discal, encontrando mención solamente en el 12 % de los artículos de movimientos bifásicos al pasar de sedestación a bipedestación. La centralización del dolor al examen físico, el test de vibración y la ausencia de mejoría con bloqueo facetario y sacroiliaco fueron otros de los signos encontrados en la revisión. En cuanto a las imágenes diagnósticas, la escala de Pfirrmann tuvo la mayor frecuencia de aparición, seguida de los cambios HIZ (High intensity zone) y Modic. CONCLUSIÓN: El dolor lumbar es una patología compleja en su tratamiento y en sus consecuencias en la vida de los pacientes. El diagnóstico del DLD puede mejorar el enfoque del paciente. Los síntomas y signos clínicos y radiológicos tienen mayor impacto diagnóstico cuando se usan en conjunto. Se seleccionaron las características con mayor frecuencia de aparición en la literatura para generar una escala piloto, que debe ser comparada con el patrón de oro en DLD, la discografía

OBJECTIVE: Low back pain is one of the most common pathologies in adult population. Its economic burden to the health system and its impact on quality of life and function, makes it a relevant theme. In most of the cases the etiology of pain can be delimitated but a diagnostic scale for discogenic low back pain (DLBP) is not available. Reviewing the most frequent signs and symptoms of DLBP in literature may improve the approach to the patient with pain. Additionally, it may aid the creation of a pilot diagnostic scale for DLBP. MATERIALS AND METHODS: A systematic review of literature was done over the last 20 years in MEDLINE and BIREME. A mapping review of the most frequent symptoms and signs (clinical and imaging) used to suspect DLBP was conducted. A total of 1010 articles were reviewed, 103 of which were selected to analyze the frequency of reporting signs and symptoms included in the diagnosis. RESULTS: In the mapping review, the most frequent symptom was axial low back pain, followed by the absence of radicular pain. A lower frequency of description was observed in the literature regarding the signs associated with disc pain, finding mention only in 12 % of the articles of biphasic movements when passing from sitting to standing. The centralization of pain to the physical examination, a positive vibration test and the absence of improvement with facet and sacroiliac infiltration, were other signs found in the review. As for the diagnostic images, the Pfirrmann scale had the highest frequency of appearance, followed by the HIZ (High intensity zone) and Modic changes. CONCLUSIONS: Low back pain is a complex pathology in its treatment and its consequences in the lives of patients. Diagnosing DLD can improve how we manage patients. Symptoms and clinical and radiological signs have a greater diagnostic impact when used together. The characteristics with the highest frequency of appearance in the literature were selected to generate a pilot scale, which should be compared to the gold standard in DLD, discography

Organizaçöes públicas brasileiras: a busca da eficiência, da eficácia ou da efetividade? / Brazilian public organizations: searching for efficiency, efficacy or effectiveness?

Defende que mais que a eficiência (relacionada ao "fazer as coisas bem"), a eficácia (relacionada ao "fazer as coisas certas") é a efetividade (referente ao que pode ser visto e sentido pelo cliente) a meta que deve ser buscada pelas organizaçöes públicas. A efetividade é a manifestaçäo, fora da organizaçäo, do processo e do produto gerados dentro dela (AMSB)