Primary splenic angiosarcoma: a rare entity often associated with rupture and hemoperitoneum.

Primary splenic angiosarcoma (PSA) is a rare neoplasm of vascular origin associated with aggressive behavior and poor prognosis. The clinical presentation is usually non-specific and is mostly characterized by a wasting disease with anemia and splenomegaly, mimicking a wide range of entities. The authors present the case of an 80-year-old woman with cardiovascular comorbidities with a 6-month history of weight loss, fatigue, weakness, pallor, and abdominal pain. The physical examination showed massive splenomegaly and pallor. After a thorough evaluation that ruled out lymphoproliferative diseases, the working diagnosis was a myelodysplastic disorder. A few days after discharge, she returned to the emergency room with severe abdominal pain, worsening fatigue, and a remarkable pallor. Point-of-care ultrasound showed free intraperitoneal fluid. Spleen rupture was confirmed by abdominal computed tomography (CT) scan, and an emergency laparotomy with splenectomy was performed. The postoperative period was uneventful, and the patient recovered in a few days. The histopathology confirmed the diagnosis of PSA and the patient was referred to an oncological center. Two months later staging CT demonstrated liver and peritoneal metastases, and despite the chemotherapy she died 6 months after the diagnosis.

Algorithms for monitoring warfarin use: Results from Delphi Method.

Warfarin stands as the most prescribed oral anticoagulant. New oral anticoagulants have been approved recently; however, their use is limited and the reversibility techniques of the anticoagulation effect are little known. Thus, our study's purpose was to develop algorithms for therapeutic monitoring of patients taking warfarin based on the opinion of physicians who prescribe this medicine in their clinical practice. The development of the algorithm was performed in two stages, namely: (i) literature review and (ii) algorithm evaluation by physicians using a Delphi Method. Based on the articles analyzed, two algorithms were developed: "Recommendations for the use of warfarin in anticoagulation therapy" and "Recommendations for the use of warfarin in anticoagulation therapy: dose adjustment and bleeding control." Later, these algorithms were analyzed by 19 medical doctors that responded to the invitation and agreed to participate in the study. Of these, 16 responded to the first round, 11 to the second and eight to the third round. A 70% consensus or higher was reached for most issues and at least 50% for six questions. We were able to develop algorithms to monitor the use of warfarin by physicians using a Delphi Method. The proposed method is inexpensive and involves the participation of specialists, and it has proved adequate for the intended purpose. Further studies are needed to validate these algorithms, enabling them to be used in clinical practice.

Algorithms for monitoring warfarin use: Results from Delphi Method / Algoritmos para monitorar o uso de varfarina: resultados do método Delphi

Summary Warfarin stands as the most prescribed oral anticoagulant. New oral anticoagulants have been approved recently; however, their use is limited and the reversibility techniques of the anticoagulation effect are little known. Thus, our study's purpose was to develop algorithms for therapeutic monitoring of patients taking warfarin based on the opinion of physicians who prescribe this medicine in their clinical practice. The development of the algorithm was performed in two stages, namely: (i) literature review and (ii) algorithm evaluation by physicians using a Delphi Method. Based on the articles analyzed, two algorithms were developed: "Recommendations for the use of warfarin in anticoagulation therapy" and "Recommendations for the use of warfarin in anticoagulation therapy: dose adjustment and bleeding control." Later, these algorithms were analyzed by 19 medical doctors that responded to the invitation and agreed to participate in the study. Of these, 16 responded to the first round, 11 to the second and eight to the third round. A 70% consensus or higher was reached for most issues and at least 50% for six questions. We were able to develop algorithms to monitor the use of warfarin by physicians using a Delphi Method. The proposed method is inexpensive and involves the participation of specialists, and it has proved adequate for the intended purpose. Further studies are needed to validate these algorithms, enabling them to be used in clinical practice.

Resumo A varfarina é o anticoagulante oral mais prescrito. Novos anticoagulantes orais foram recentemente aprovados; porém, o uso é restrito e as técnicas de reversibilidade do efeito anticoagulante ainda são pouco conhecidas. Assim, este estudo propõe o desenvolvimento de um algoritmo para o monitoramento terapêutico de pacientes em uso de varfarina, com base na opinião de médicos que utilizam esse fármaco na prática clínica. O desenvolvimento do algoritmo foi realizado em dois estágios: (i) revisão da literatura e (ii) avaliação do algoritmo por médicos, segundo o método Delphi. Com base na análise dos artigos, dois algoritmos foram desenvolvidos: "Recomendações para o uso de varfarina na terapia anticoagulante" e "Recomendações para o uso de varfarina na terapia anticoagulante: ajuste de dose e controle de sangramento". Posteriormente, os algoritmos foram analisados por 19 médicos que responderam ao convite e aceitaram participar da pesquisa. Desses, 16 responderam a primeira rodada, 11, a segunda e oito, a terceira. Houve um consenso de 70% ou mais na maioria das questões e 50% para seis questões. Assim, foi possível desenvolver algoritmos para o monitoramento do uso de varfarina por médicos, utilizando o método Delphi. O método proposto é de baixo custo e envolve a participação de médicos especialistas, revelando-se adequado para o fim pretendido. Mais estudos são necessários para validar esses algoritmos, permitindo que eles sejam usados na prática clínica.

Identificação da demanda da populaçãoidosa assistida em hospital de ensino / Identification of population demand Elderly assisted in teaching hospital

Objetivo - Partindo da premissa que o envelhecimento da população brasileira acarreta aumento da demanda nos hospitais,este estudo objetivou analisar indicadores que retratem a demanda de idosos atendidos em instituição hospitalar. Método: Estudoquantitativo, transversal, retrospectivo e analítico desenvolvido em um hospital de ensino do município de São Paulo. Resultados: Onúmero total de atendimentos foi 268.757, sendo que esses foram prestados a 67.608 idosos no período de janeiro de 2004 a agosto de2014. A média de idade é de 71,6 anos. A especialidade de clínica médica foi a mais procurada. Os diagnósticos mais frequentes foramdor da região lombar baixa, infecções de trato urinário e hipertensão essencial. A maioria das altas foi para residência com permanênciahospitalar entre menos de uma hora a 91 dias. Conclusão: Esses resultados induzem a refletir sobre a necessidade de implementar novosmodelos assistências que vão além de suprir os aspectos biomédicos.

Estudo dos óbitos no pronto-socorro de um hospital de ensino: humanização, prognóstico e gastos / Study of deaths in the emergency department of a teaching hospital: humanization, prognostics and expenses

Prontos-socorros convivem com o problema dos pacientes terminais. A busca de leitos hospitalares para adultos em hospitais de qualidade, como os hospitais de ensino, gerauma demanda maior que a capacidade instalada dos mesmos. Para maior conhecimento da dimensão do problema que envolve pacientes fora de possibilidade terapêutica e danecessidade de sistematização para os cuidados paliativos e terminalidade, estudamos os óbitos ocorridos no Pronto-Socorro do Hospital Universitário da USP no período de janeiro a julho de 2009. Os objetivos do estudo foram identificar e analisar os óbitos de idosos que ocorreram no pronto-socorro e levantar a necessidade de implantação de unidade de cuidados de terminalidade. O estudo utiliza in icadores como suporte ao processo decisório e a gestão hospitalar (gestão das informações). No caso estudado, os indicadores são óbitos em pronto-socorro e recursos diagnósticos utilizados. A utilização de sériehistórica desses indicadores aponta tendências. Estudar pacientes que evoluíram para óbito após período maior que 48 horas no pronto atendimento ajudará na elaboração deestratégia para abordar este problema.

Emergency rooms deal with the problem of terminality. The search for hospital rooms for adults in high quality hospitals, like school hospitals, for example, generates a demand higher than the capacity of the hospitals. For better understanding of the problem which involves patients with no therapeutical possibility and the need of a systematization for palliative care and terminality, we studied the deaths that occurred in the emergency roomof Hospital Universitário from Universidade de São Paulo from January to July of 2009.The objectives of this study were to identify and analyze the deaths of elderly people thatoccurred in the emergency room and understand the need to create units of terminal care. The study uses indicators to support the process of decision making and the managing of the hospital (information management). In this case, the indicators are the number of deaths in the emergency room and diagnostic resources used. The history of these indicators shows a tendency. Studying patients that ended up dying after a period longer than 48 hours after emergency care will help in the elaboration of the strategy to approach this problem.