Computed tomography changes diagnosis, management and surgical planning of ankle fractures.

PURPOSE: To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation. MATERIALS AND METHODS: A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning. RESULTS: The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75). CONCLUSIONS: The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care. LEVEL OF EVIDENCE III: Retrospective Comparative Study.

Psoas abscess: diagnostic and therapeutic considerations in six patients.

Psoas abscess (PA) is an infrequent clinical entity and presents diagnostic and therapeutic challenges. Six cases are reported concerning diagnostic and therapeutic considerations. Clinical diagnosis is difficult because of non-specific symptoms. The primary psoas abscess has no definite etiology and is spread by hematogeneous route from a distant occult site. The PA can also be secondary to gastrointestinal pathology through direct infection of adjacent structures. The most common causes are Crohn's disease, appendicitis, diverticulitis and carcinoma. Routine laboratory evaluation is seldom useful for localizing the disease process. Conventional radiological techniques are often unhelpful. Modern imaging diagnosis techniques such as ultrasound and computerized tomography have allowed for a refinement in both the etiologic diagnosis and the treatment by means of CT-guided or ultrasound-guided percutaneous drainage of the abscess, thus avoiding surgical drainage in many cases. Immediately on diagnosis of PA prompt treatment is necessary. Percutaneous drainage should be performed whenever possible and in case of failure, surgical drainage should be practiced as well as intestinal resection, whenever indicated.

Large intestine obstruction complicated with perforation: a rare manifestation of Schistosoma mansoni infection.

The authors report a case of a 25 year old Brazilian man with a history of crampy abdominal pain in the left iliac fossa for 2 weeks, abdominal distention, mucous diarrhea and anorexia. The patient presented signs of hemodynamic instability and a hard mass palpated in the left iliac fossa presented peritoneal irritation. At laparotomy, fecal peritonitis and a punched-out perforation of the midsigmoid colon were found. A left hemicolectomy was performed with terminal colostomy. Specimen examination revealed a thickened rectosigmoid wall, narrow lumen and multiple mucosal polyps. Microscopically, chronic granulomatous colitis with Schistosoma mansoni eggs confirmed the etiology. To the authors' knowledge, this is the first case of obstruction complicated with perforation due to mansoni schistosomiasis reported in the literature.

[Late results of Heller operation and fundoplication for the treatment of the megaesophagus: analysis of 83 cases]. / Resultados tardios da operação de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos.

BACKGROUND: Retrospective study of the late results of the Heller's cardiomyotomy and fundoplication for the treatment of the megaesophagus. MATERIAL AND METHODS: Were studied 83 patients with a follow-up from one to 186 months (average 40.0 +/- 47.4 months). The fundoplications used were in three plans in 15.7% and posterior in 83.1%. The main pre-operatory complain was dysphagia followed by regurgitation and loss of weight. Chagas, Disease as the etiology was confirmed in 72.3% of the patients. RESULTS: In the follow-up 55.4% of the patients were assymptomatic, 34.9% complained of sporadic dysphagia, 14.4% of heartburn, 8.4% of regurgitation and 2.4% did not changed the dysphagia, these being re-operated and had improvement the symptoms. Gastro-esophageal reflux was noted in 8.4% of the patients. Other late complications were par-esophageal hernia, sliping of the fundoplication, Barrett esophagus and cancer. CONCLUSIONS: The necessity of a long-term clinical and endoscopical follow-up, even after surgery, owing to the possibility of late complications, especially cancer was emphasized. The late results are good in relation to the dysphagia. Myotomy is proposed as an alternative to patients with advanced megaesophagus with bad clinical conditions who can not be submitted to an esophagectomy.

Resultados tardios da operaçäo de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos / Late results of Heller operation and fundoaplication for the treatment of the megaesophagus: analysis of 83 cases

Objetivo. Estudo retrospectivo dos resultados tardios dos pacientes submetidos a miotomia e fundoplicatura para o tratamento do megaesôfago. Casuística e Métodos. Foram estudados 83 pacientes com seguimento de um a 186 meses (média de 40,0 + 47,4 meses). A fundoplicatura em três planos, proposta por Pinotti, foi realizada em 15,7 por cento dos doentes e a fundoplicatura parcial posterior em 83,1 por cento. A queixa pré-operatória principal foi disfagia, seguida de regurgitação e perda ponderal. A etiologia chagásica pode ser comprovada em 72,3 por cento dos doentes, através de teste sorológico. Resultados. No seguimento, 55,4 por cento dos doentes estavam assintomáticos, 34,9 por cento queixavam-se de disfagia esporádica, 14,4 por cento de pirose, 8,4 por cento de regurgitação e 2,4 por cento de disfagia igual pré-operatória, sendo esses últimos pré-operados, com melhora da sintomatologia. Refluxo gastro-esofágico foi constatado em 8,4 por cento dos doentes. Outras complicações tardias foram: hérnia paraesofágica, deslizamento da fundoplicatura, esôfago de Barrett e neoplasia do esôfago. Conlcusões. Os autores salientaram a necessidade de acompanhamento clínico e endoscópico perene dos doentes, mesmo operados, devido à possibilidade de complicações tardias, em especial o câncer. Concluem por bons resultados tardios em relação à disfagia. Propõem, como alternativa à esofagectomia, a operação de Heller em pacientes portadores de megaesôfago para grau IV com más condições clínicas, que não suportariam uma cirurgia de maior porte.

Desenvolvimento e validação de instrumento para avaliação de desempenho por competências alinhado ao planejamento estratégico institucional / Development and validation of employee performance appraisal evaluation by competences alignment to institutional strategic planning

A avaliação de desempenho passou a ser empregada nas empresas com o objetivo de alcançar um desenvolvimento maior do homem, das relações humanas e do trabalho desenvolvido. É uma técnica utilizada para obter informações sobre o comportamento profissional do funcionário. Clientes e usuários estão cada vez mais exigentes com os produtos e serviços de que dispõem, e a questão da qualidade tem apresentado crescente preocupação em todo o mundo. A nova consciência de qualidade dos produtos e serviços concede mais valorização aos esforços do indivíduo, considerando-se que as pessoas envolvidaS são fundamentais, pois a qualidade depende do trabalho individual ou em grupo. A preocupação dos hospitais, atualmente, pela busca da qualidade dos serviços vem exigindo de seus profissionais e colaboradores uma nova postura...