[Advantages of a cohort study on cardiac arrest conducted by nurses]. / Vantagens do estudo de coorte realizado por enfermeiros em parada cardiorrespiratória.

OBJECTIVE: Identifying factors associated to survival after cardiac arrest. METHOD: An experience report of a cohort study conducted in a university hospital, with a consecutive sample comprised of 285 patients. Data were collected for a year by trained nurses. The training strategy was conducted through an expository dialogue lecture. Collection monitoring was carried out by nurses via telephone calls, visits to the emergency room and by medical record searches. The neurological status of survivors was evaluated at discharge, after six months and one year. RESULTS: Of the 285 patients, 16 survived until hospital discharge, and 13 remained alive after one year, making possible to identify factors associated with survival. There were no losses in the process. CONCLUSION: Cohort studies help identify risks and disease outcomes. Considering cardiac arrest, they can subsidize public policies, encourage future studies and training programs for CPR, thereby improving the prognosis of patients.

Trend in the incidence rates of accidents with venomous animals in children and adolescents in Brazil (2007-2019).

OBJECTIVE: To estimate the temporal trend of the incidence rates of accidents with venomous animals in children and adolescents in Brazil. METHODS: An ecological time-series study was carried out between 2007 and 2019. Data were obtained from the Brazilian Information System on Diseases of Compulsory Declaration (Sistema de Informação de Agravos de Notificação - SINAN). The time series of incidence rates of accidents with venomous animals were stratified by age group (children aged 0 to 9 years and adolescents aged 10 to 19 years), Brazilian macro-regions (North, Northeast, Midwest, Southeast, and South), and type of accident (snake, scorpion, spider, and caterpillar). For trend analysis, the Prais-Winsten model and the Annual Percent Change (APC) were used. RESULTS: The time series of the incidence rate of accidents with venomous animals in children and adolescents from the North, Northeast, Midwest, and Southeast macro-regions and in children from the South region showed an upward trend. The average annual incidence rates were higher in the age group of 10 to 19 years, except for the South macro-region. Accidents with scorpions, snakes, and spiders, in this order, were the most frequent; the trends in the time series stratified by type of animal varied according to the geographic macro-region. CONCLUSIONS: There was an upward trend in the incidence rate of accidents with venomous animals in children and adolescents in Brazil, except for adolescents in the South macro-region of the country.

Construction and validation of an in-hospital transport simulation scenario.

OBJECTIVE: To build and validate the content of a clinical simulation scenario for teaching in-hospital transport of critically ill patients. METHODS: A descriptive study of construction and validation of a clinical simulation scenario for teaching in-hospital transport. A scenario based on the literature was built, followed by validation, using the Delphi technique, by five specialists, with an agreement of 80%. The experts were selected through snowball sampling. An instrument was developed containing 26 topics to be assessed for relevance, clarity, objectivity, feasibility, current content, vocabulary, and a field for observations. RESULTS: Two rounds were carried out by the specialists to reach a consensus of 80%. According to the experts´ recommendation, the initial scenario was written more clearly and objectively, and divided into two parts: patient preparation and patient transport. CONCLUSION: In this study, the construction and validation of the scenario for teaching in-hospital transport were successfully performed. It may be applied in several services to evaluate the training of nursing undergraduate students, as well as for the professional improvement of those who work in the in-hospital transport service.

Incidence, characteristics and long-term outcomes of patients with diabetic ketoacidosis: a prospective prognosis cohort study in an emergency department.

BACKGROUND: Diabetic ketoacidosis is the most frequent hyperglycemic complication in the evolution of diabetes mellitus. Common precipitating factors include newly diagnosed diabetes mellitus, noncompliance with therapy and infections. However, few studies have been conducted in Brazil and none were prospective in design. OBJECTIVE: To describe the incidence, clinical and laboratory characteristics and precipitating factors of diabetic ketoacidosis among emergency department patients in a tertiary-level teaching hospital in Brazil. We also aimed to identify immediate and long-term mortality within two years. DESIGN AND SETTING: Prospective prognosis cohort study conduct at a tertiary-level teaching hospital in São Paulo, Brazil. METHODS: All patients > 12 years old presenting diabetic ketoacidosis who were admitted to the emergency department from June 2015 to May 2016 were invited to participate. RESULTS: The incidence of diabetic ketoacidosis per 1,000 admissions was 8.7. Treatment noncompliance and infection were the most common causes of diabetic ketoacidosis. The immediate mortality rate was 5.8%, while the six-month, one-year and two-year mortality rates were 9.6%, 13.5% and 19.2%, respectively. Death occurring within two years was associated with age, type 2 diabetes, hypoalbuminemia, infection at presentation and higher sequential organ failure assessment (SOFA) score at admission. CONCLUSIONS: Diabetic ketoacidosis among patients presenting to the emergency department was relatively frequent in our hospital. Treatment noncompliance and infection were major precipitating factors and presence of diabetic ketoacidosis was associated with immediate and long-term risk of death.

Clinical simulation strategies for knowledge integration relating to initial critical recognition and management of COVID-19 for use within continuing education and health-related academia in Brazil: a descriptive study.

BACKGROUND: The COVID-19 pandemic has led to an immense need to develop training on case recognition and management, with a focus on patients' and health professionals' safety at several levels of healthcare settings in Brazil. Different simulation strategies can be included in the diverse clinical care phases for these patients. OBJECTIVE: To suggest a complete simulation-based training program for Brazilian hospitals and/or academic institutions at this moment of the pandemic. DESIGN AND SETTING: Descriptive analysis on possible simulated clinical cases using different methodologies, thereby supporting suspected or confirmed COVID-19 patients. METHODS: This was a reflective theoretical descriptive study on an educational program based on clinical simulation, with four practical phases at different performance and complexity levels. Wearing, handling and adequately disposing of personal protective equipment, along with specific respiratory procedures in different healthcare settings up to intensive care for seriously infected patients were addressed. RESULTS: This program was designed for application at different Brazilian healthcare levels through different clinical simulation strategies. Summaries of expected performance were suggested in order to standardize technical capacity within these simulation settings, so as to serve these levels. CONCLUSIONS: Developing training programs for situations such as the current COVID-19 pandemic promotes safety not only for patients but also for healthcare workers. In the present context, clear definition of which patients need hospital outpatient or inpatient care will avoid collapse of the Brazilian healthcare system. Institutions that do not have simulated environments can, through the examples described, adopt procedures to promote didactic information in order to help healthcare professionals during this time.

Medical faculty's perception of students' mental health: a qualitative survey study / Percepción de los profesores de medicina sobre la salud mental de los estudiantes: un estudio cualitativo / Percepção dos docentes de medicina sobre a saúde mental dos estudantes: um estudo qualitativo

This study sought to explore the perspective of medical faculty on the mental health of their students. This qualitative study based on a focus group is part of a longitudinal research that studied the mental health of Brazilian students. One group was conducted with faculty employed at a medical school. Topics discussed covered the concept of mental health and medical education. Six professors participated in one group. The mental health of medical students is a construct that encompasses emotional aspects, ability to solve problems and multiple facets of a human being, according to the participants. Artistic practices, moments of socialization and leisure were perceived as stimulating students' good mental health. Excessive demands generate competitiveness and the teacher's expectation of the student's good performance based on their own experience can harm the student's mental health. Participants also highlighted that a pedagogical reformulation that makes sense for the student's learning process is necessary to update traditional curricula. Medical students' mental health is influenced by experiences and exchanges during the medical school, mainly between professor and student, understood as necessary and inherent to the process of becoming physician. The findings of this study show the need for curriculum changes in the medical education process and updating teacher training for good practices that reinforce good mental health.

Este estudio buscó explorar la perspectiva de los profesores de medicina sobre la salud mental de sus estudiantes. Este estudio cualitativo basado en un grupo focal es parte de una investigación longitudinal que estudió la salud mental de estudiantes brasileños. Un grupo se llevó a cabo con profesores empleados en una escuela de medicina. Los temas tratados abarcaron el concepto de salud mental y educación médica. Seis docentes participaron en un grupo. La salud mental de los estudiantes de medicina es un constructo que abarca aspectos emocionales, capacidad de resolución de problemas y múltiples facetas del ser humano, según los participantes. Las prácticas artísticas, los momentos de socialización y el ocio fueron percibidos como estimulantes de la buena salud mental de los estudiantes. Las exigencias excesivas generan competitividad y la expectativa del docente sobre el buen desempeño del estudiante basándose en su propia experiencia puede perjudicar la salud mental del estudiante. Los participantes también resaltaron que es necesaria una reformulación pedagógica que tenga sentido para el proceso de aprendizaje del estudiante para actualizar los currículos tradicionales. La salud mental de los estudiantes de medicina está influenciada por las experiencias y los intercambios durante la carrera de medicina, principalmente entre profesor y estudiante, entendidos como necesarios e inherentes al proceso de convertirse en médico. Los hallazgos de este estudio muestran la necesidad de cambios curriculares en el proceso de formación médica y de actualización de la formación docente hacia buenas prácticas que refuercen la buena salud mental.

Este estudo buscou explorar a perspectiva dos docentes de medicina sobre a saúde mental de seus alunos. Este estudo qualitativo baseado em grupo focal faz parte de uma pesquisa longitudinal que estudou a saúde mental de estudantes brasileiros. Um grupo foi conduzido com professores empregados em uma faculdade de medicina. Os temas discutidos abrangeram o conceito de saúde mental e educação médica. Seis professores participaram de um grupo. A saúde mental dos estudantes de medicina é um construto que engloba aspectos emocionais, capacidade de resolução de problemas e múltiplas facetas do ser humano, segundo os participantes. As práticas artísticas, os momentos de socialização e de lazer foram percebidos como estimuladores da boa saúde mental dos estudantes. Exigências excessivas geram competitividade e a expectativa do professor pelo bom desempenho do aluno com base na própria experiência pode prejudicar a saúde mental do aluno. Os participantes destacaram também que é necessária uma reformulação pedagógica que faça sentido para o processo de aprendizagem do aluno para atualizar os currículos tradicionais. A saúde mental dos estudantes de medicina é influenciada pelas experiências e trocas durante o curso de medicina, principalmente entre professor e aluno, entendidas como necessárias e inerentes ao processo de tornar-se médico. Os achados deste estudo mostram a necessidade de mudanças curriculares no processo de formação médica e de atualização da formação docente para boas práticas que reforcem a boa saúde mental.

What do Cochrane systematic reviews say about the management of irritable bowel syndrome?

BACKGROUND: Irritable bowel syndrome (IBS) is a clinical disorder associated with high socioeconomic burden. Despite its importance, management of IBS remains difficult and several interventions have been hypothesized as beneficial for this condition. This study identified and summarized all Cochrane systematic reviews (SRs) about the effects of interventions for managing IBS patients. DESIGN AND SETTING: Review of systematic reviews, carried out in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). METHODS: Review of Cochrane SRs addressing interventions for IBS. RESULTS: We included six SRs assessing acupuncture, bulking agents, antispasmodics, antidepressants, herbal medicines, homeopathy, hypnotherapy and psychological therapy for IBS. The certainty of evidence ranged from unknown to moderate, mainly due to imprecision in the estimates and high risk of bias from the primary studies included. There was moderate certainty of evidence that acupuncture had no important benefit regarding improvement of symptoms and quality of life, compared with sham acupuncture. There was also very low certainty of evidence that homeopathic asafoetida, used alone or in association with nux, was better than placebo regarding self-reported overall improvement. CONCLUSION: There was moderate certainty of evidence that acupuncture had no important benefit regarding improvement of symptoms and quality of life. Further well-designed and well-conducted randomized clinical trials are needed in order to reduce the uncertainties regarding the most commonly used interventions for patients with IBS.

What do Cochrane systematic reviews say about cardiac arrest management?

CONTEXT AND OBJECTIVE: Cardiac arrest is associated with high morbidity and mortality and imposes a significant burden on the healthcare system. Management of cardiac arrest patients is complex and involves approaches with multiple interventions. Here, we aimed to summarize the available evidence regarding the interventions used in cardiac arrest cases. DESIGN AND SETTING: Review of systematic reviews (SRs), conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A systematic search was conducted to identify all Cochrane SRs that fulfilled the inclusion criteria. Titles and abstracts were screened by two authors. RESULTS: We included nine Cochrane SRs assessing compression techniques or devices (three SRs), defibrillation (two SRs) and other interventions (two SRs on hypothermia interventions, one on airway management and one on pharmacological intervention). The reviews included found qualities of evidence ranging from unknown to high, regarding the benefits of these interventions. CONCLUSION: This review included nine Cochrane systematic reviews that provided a diverse range of qualities of evidence (unknown to high) regarding interventions that are used in management of cardiac arrest. High-quality evidence was found by two systematic reviews as follows: (a) increased survival until hospital discharge with continuous compression, compared with interrupted chest compression, both administered by an untrained person and (b) no difference regarding the return of spontaneous circulation, comparing aminophylline and placebo, for bradyasystolic patients under cardiac arrest. Further studies are needed in order to reach solid conclusions.

Parada cardiorrespiratória após infarto agudo do miocárdio por vasoespasmo coronariano. Relato de caso e revisão da literatura / Cardiorespiratory arrest after acute myocardial infarction due to coronary vasospasm. Case report and literature review

A angina vasoespástica é uma causa incomum de parada cardíaca e arritmias ventriculares. No entanto, os sobreviventes dessas complicações têm um risco aumentado de recorrência, apesar da função ventricular normal e do tratamento médico otimizado. Descrevemos o caso de uma ex-tabagista de 50 anos que teve parada cardiorrespiratória secundária a vasoespasmo coronariano grave.

Vasospastic angina is an uncommon cause of cardiac arrest and ventricular arrhythmias. However, survivors of these complications are at an increased risk of recurrence, despite normal ventricular function and optimized medical therapy. We describe a case of a 50-year-old former smoker who developed cardiorespiratory arrest secondary to severe coronary vasospasm.

Trend in the incidence rates of accidents with venomous animals in children and adolescents in Brazil (2007-2019) / Tendência das taxas de incidência de acidentes com animais peçonhentos em crianças e adolescentes no Brasil (2007-2019)

ABSTRACT Objective: To estimate the temporal trend of the incidence rates of accidents with venomous animals in children and adolescents in Brazil. Methods: An ecological time-series study was carried out between 2007 and 2019. Data were obtained from the Brazilian Information System on Diseases of Compulsory Declaration (Sistema de Informação de Agravos de Notificação - SINAN). The time series of incidence rates of accidents with venomous animals were stratified by age group (children aged 0 to 9 years and adolescents aged 10 to 19 years), Brazilian macro-regions (North, Northeast, Midwest, Southeast, and South), and type of accident (snake, scorpion, spider, and caterpillar). For trend analysis, the Prais-Winsten model and the Annual Percent Change (APC) were used. Results: The time series of the incidence rate of accidents with venomous animals in children and adolescents from the North, Northeast, Midwest, and Southeast macro-regions and in children from the South region showed an upward trend. The average annual incidence rates were higher in the age group of 10 to 19 years, except for the South macro-region. Accidents with scorpions, snakes, and spiders, in this order, were the most frequent; the trends in the time series stratified by type of animal varied according to the geographic macro-region. Conclusions: There was an upward trend in the incidence rate of accidents with venomous animals in children and adolescents in Brazil, except for adolescents in the South macro-region of the country.

RESUMO Objetivo: Estimar a tendência temporal das taxas de incidência de acidentes com animais peçonhentos em crianças e adolescentes no Brasil. Métodos: Foi realizado um estudo ecológico de séries temporais, entre 2007 e 2019. Os dados foram obtidos do Sistema de Informação de Agravos de Notificação (SINAN). As séries temporais das taxas de incidência com animais peçonhentos foram estratificadas por faixa etária (crianças de 0 a 9 anos e adolescentes de 10 a 19 anos), macrorregiões brasileiras (Norte, Nordeste, Centro-Oeste, Sudeste e Sul) e tipo de acidente (serpente, escorpião, aranha e lagarta). Para análise de tendência, foi utilizado o modelo de Prais-Winsten e calculada a variação percentual anual das taxas (Annual Percentage Change — APC). Resultados: As séries históricas da taxa de incidência de acidentes com animais peçonhentos em crianças e adolescentes das macrorregiões Norte, Nordeste, Centro-Oeste e Sudeste e em crianças da macrorregião Sul apresentaram tendência ascendente. As taxas de incidências anuais médias foram maiores na faixa etária de 10 a 19 anos, exceto na macrorregião Sul. Os acidentes com escorpiões, serpentes e aranhas, nesta ordem, foram os mais frequentes; as tendências das séries históricas estratificadas por tipo de animal variaram conforme a macrorregião. Conclusões: Houve tendência ascendente na taxa de incidência de acidentes com animais peçonhentos em crianças e adolescentes no Brasil, exceto nos adolescentes da macrorregião Sul do país.

Covid-19 pandemic for Emergency Medicine residents: an observational study on mental health and medical practice / Pandemia Covid-19 para residentes Medicina de Emergência: estudo observacional em saúde mental e prática médica

Abstract: Introduction: Emergency medicine is a relatively new medical specialty in Brazil, approved just in 2016. Residency training programs have been implemented ever since. The emergency environment is known to represent a death-and-life tension on the professional team, culminating with high rates of mental illness in this population. The Covid-19 pandemic seems to be affecting these rates of depression, anxiety, and burnout in health professionals. Objective: To assess the symptoms of burnout, depression, and anxiety in Brazilian medical residents of Emergency Medicine during the Covid-19 pandemic and compare the residents' beliefs regarding clinical practice related to Covid-19 patients. Methods: A quantitative study was conducted with a convenience sample of volunteer medical residents from an anonymous online survey, available during April 2020. This investigation collected sociodemographic information and used the Oldenburg Burnout Inventory (OLBI) to measure burnout; the Patient Health Questionnaire (PHQ-9) to measure depression; and the General Anxiety Disorders (GAD-7) to measure generalized anxiety disorder. This study also developed a Covid-19 Impact Questionnaire (CIQ-19) to assess the residents' beliefs and clinical practices related to Covid-19 patients. Results: The survey consisted of 63 respondents, about 26,35% of emergency medicine residents in Brazil. Only 39.6% residents felt safe while working with Covid-19 patients. Mild depressive symptoms were found in 68.2% of the residents, followed by anxiety symptoms in 50.7% and burnout in 54.0% overall. About 12% of the residents do nothing about their mental health status, while some prefer to talk with family or friends (36.1%) and discuss with their team support (24.3%) when they need mental health care. Conclusion: Emergency medicine residents have high rates of mental illness and it could get worse when submitted to stressful and unknown situations, such as the Covid-19 pandemic. Initiatives should be made to improve these physicians' mental health status. It is proposed that health institutions pay medical supervisors a closer and more unique look at physicians in training. A mentoring program proposal is an opportunity to reflect on technical and personal improvements for medical residents.

Resumo: Introdução: Medicina de emergência é uma especialidade relativamente nova no Brasil, aprovada apenas em 2016, e programas de treinamento em residência têm sido instituídos desde então. O ambiente da emergência é conhecido por representar uma tensão entre vida e morte nos profissionais, o que culmina em altos índices de adoecimento mental nessa população. A pandemia da Covid-19 aparenta estar influenciando nas taxas de depressão, ansiedade e burnout de profissionais de saúde. Objetivo: Este estudo teve como objetivos avaliar os sintomas de burnout, depressão e ansiedade em residentes de medicina de emergência brasileiros durante a pandemia da Covid-19 e comparar as crenças deles sobre a prática clínica relacionada aos pacientes com a doença. Método: Um estudo quantitativo foi realizado com uma amostra conveniente de médicos residentes voluntários, por meio de uma pesquisa on-line anônima disponível durante o mês de abril de 2020. Esta investigação coletou informações sociodemográficas e utilizou as seguintes escalas: Oldenburg Burnout Inventory (OLBI) para mensurar burnout, Patient Health Questionnaire (PHQ-9) para mensurar depressão e General Anxiety Disorders (GAD-7) para mensurar transtorno de ansiedade generalizada. Neste estudo, também foi desenvolvido um Questionário sobre o Impacto da Covid-19 (CIQ-19) para acessar as crenças e práticas clínicas relacionadas aos pacientes com Covid-19. Resultado: A pesquisa foi composta de 63 voluntários, aproximadamente 26,35% dos residentes em medicina de emergência no Brasil. Apenas 39,6% dos residentes se sentiram seguros enquanto trabalhavam com pacientes com Covid-19. Encontraram-se sintomas leves de depressão em 68,2%, seguidos de sintomas de ansiedade em 50,7% e burnout em 54,0%. Aproximadamente 12% dos residentes não fazem nada relação à própria saúde mental, alguns preferem conversar com familiares e amigos (36,1%), e outros discutem com a equipe de suporte (24,3%) quando precisam de atendimento. Conclusão: Os residentes de medicina de emergência possuem altos índices de adoecimento mental, e isso pode piorar quando submetidos a situações estressantes e desconhecidas, como a pandemia da Covid-19. Iniciativas devem ser tomadas para melhorar a saúde mental desses médicos. Propõe-se que as instituições de saúde ofereçam aos supervisores médicos uma visão mais próxima e exclusiva sobre os médicos em treinamento. A proposta de um programa de mentoria é uma oportunidade de refletir sobre melhorias técnicas e pessoais para médicos residentes.

Do not attempt resuscitation orders at the emergency department of a teaching hospital.

OBJECTIVE: To identify factors associated with not attempting resuscitation. METHODS: A cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05). RESULTS: No cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole. CONCLUSION: Advanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

Malignant catatonia responsive to low doses of lorazepam: case report.

CONTEXT: Catatonia can be divided into non-malignant or malignant. The latter is characterized by autonomic instability, exhibiting high fever, tachycardia and hypertension, and is regarded as a fulminant and rapidly progressive subtype. CASE REPORT: This article reports a case of malignant catatonia in a 43-year-old patient who had been presenting psychiatric disorders for the last three years. The patient was stable, maintaining mutism, immobility and autonomic abnormalities. Oral lorazepam (1 mg every eight hours) was introduced and, in a few hours, the patient became afebrile. Two days later, the patient was already responding to verbal commands. CONCLUSIONS: Early intervention with lorazepam reduced the evolution of this patient to a fatal complication. Therefore, this case report sought to show that early diagnosis and intervention reduced the occurrence of serious and irreversible clinical outcomes.

The use of a metronome during cardiopulmonary resuscitation in the emergency room of a university hospital.

Objective: to compare the rate of return of spontaneous circulation (ROSC) and death after cardiac arrest, with and without the use of a metronome during cardiopulmonary resuscitation (CPR). Method: case-control study nested in a cohort study including 285 adults who experienced cardiac arrest and received CPR in an emergency service. Data were collected using In-hospital Utstein Style. The control group (n=60) was selected by matching patients considering their neurological condition before cardiac arrest, the immediate cause, initial arrest rhythm, whether epinephrine was used, and the duration of CPR. The case group (n=51) received conventional CPR guided by a metronome set at 110 beats/min. Chi-square and likelihood ratio were used to compare ROSC rates considering p≤0.05. Results: ROSC occurred in 57.7% of the cases, though 92.8% of these patients died in the following 24 hours. No statistically significant difference was found between groups in regard to ROSC (p=0.2017) or the occurrence of death (p=0.8112). Conclusion: the outcomes of patients after cardiac arrest with and without the use of a metronome during CPR were similar and no differences were found between groups in regard to survival rates and ROSC.

Statins for aortic valve stenosis.

BACKGROUND:: Aortic valve stenosis is the most common type of valvular heart disease in the USA and Europe. Aortic valve stenosis is considered similar to atherosclerotic disease. Some studies have evaluated statins for aortic valve stenosis. OBJECTIVES:: To evaluate the effectiveness and safety of statins in aortic valve stenosis. METHODS:: Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS - IBECS, Web of Science and CINAHL Plus. These databases were searched from their inception to 24 November 2015. We also searched trials in registers for ongoing trials. We used no language restrictions.Selection criteria: Randomized controlled clinical trials (RCTs) comparing statins alone or in association with other systemic drugs to reduce cholesterol levels versus placebo or usual care. Data collection and analysis: Primary outcomes were severity of aortic valve stenosis (evaluated by echocardiographic criteria: mean pressure gradient, valve area and aortic jet velocity), freedom from valve replacement and death from cardiovascular cause. Secondary outcomes were hospitalization for any reason, overall mortality, adverse events and patient quality of life.Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The GRADE methodology was employed to assess the quality of result findings and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 to create a 'Summary of findings' table. MAIN RESULTS:: We included four RCTs with 2360 participants comparing statins (1185 participants) with placebo (1175 participants). We found low-quality evidence for our primary outcome of severity of aortic valve stenosis, evaluated by mean pressure gradient (mean difference (MD) -0.54, 95% confidence interval (CI) -1.88 to 0.80; participants = 1935; studies = 2), valve area (MD -0.07, 95% CI -0.28 to 0.14; participants = 127; studies = 2), and aortic jet velocity (MD -0.06, 95% CI -0.26 to 0.14; participants = 155; study = 1). Moderate-quality evidence showed no effect on freedom from valve replacement with statins (risk ratio (RR) 0.93, 95% CI 0.81 to 1.06; participants = 2360; studies = 4), and no effect on muscle pain as an adverse event (RR 0.91, 95% CI 0.75 to 1.09; participants = 2204; studies = 3; moderate-quality evidence). Low- and very low-quality evidence showed uncertainty around the effect of statins on death from cardiovascular cause (RR 0.80, 95% CI 0.56 to 1.15; participants = 2297; studies = 3; low-quality evidence) and hospitalization for any reason (RR 0.84, 95% CI 0.39 to 1.84; participants = 155; study = 1; very low-quality evidence). None of the four included studies reported on overall mortality and patient quality of life. AUTHORS CONCLUSIONS:: Result findings showed uncertainty surrounding the effect of statins for aortic valve stenosis. The quality of evidence from the reported outcomes ranged from moderate to very low. These results give support to European and USA guidelines (2012 and 2014, respectively) that so far there is no clinical treatment option for aortic valve stenosis.

Purple urine bag syndrome: case report for Streptoccocus agalactiae and literature review.

We report a case of purple urine bag syndrome, associated to Streptococcus agalactiae urinary tract infection, progressing to septic shock and death. We present a review of the literature on the subject and take the opportunity to attend readers about increasing incidence with population aging and its potential bad outcome.

Construction and validation of an in-hospital transport simulation scenario / Construção e validação de cenário de simulação de transporte intra-hospitalar

ABSTRACT Objective To build and validate the content of a clinical simulation scenario for teaching in-hospital transport of critically ill patients. Methods A descriptive study of construction and validation of a clinical simulation scenario for teaching in-hospital transport. A scenario based on the literature was built, followed by validation, using the Delphi technique, by five specialists, with an agreement of 80%. The experts were selected through snowball sampling. An instrument was developed containing 26 topics to be assessed for relevance, clarity, objectivity, feasibility, current content, vocabulary, and a field for observations. Results Two rounds were carried out by the specialists to reach a consensus of 80%. According to the experts´ recommendation, the initial scenario was written more clearly and objectively, and divided into two parts: patient preparation and patient transport. Conclusion In this study, the construction and validation of the scenario for teaching in-hospital transport were successfully performed. It may be applied in several services to evaluate the training of nursing undergraduate students, as well as for the professional improvement of those who work in the in-hospital transport service.

RESUMO Objetivo Construir e validar o conteúdo de um cenário de simulação clínica para ensino do transporte intra-hospitalar de pacientes críticos. Métodos Estudo descritivo de construção e validação de um cenário de simulação clínica para o ensino de transporte intra-hospitalar. Foi construído um cenário fundamentado na literatura seguido da validação, por meio da técnica Delphi, por cinco especialistas, com nível de concordância de 80%. Os especialistas foram selecionados por meio da amostragem do tipo bola de neve. Foi desenvolvido um instrumento contendo 26 tópicos, para serem avaliados quanto a pertinência, clareza, objetividade, exequibilidade, conteúdo atual e vocabulário. Havia ainda um campo para observações. Resultados Foram realizadas duas rodadas pelos especialistas para a obtenção de consenso de 80%. De acordo com a recomendação dos especialistas, o cenário inicial foi escrito de forma mais clara e objetiva, e divido em duas partes: preparo do paciente e transporte do paciente. Conclusão Neste estudo, foram realizadas, com êxito, a construção e a validação do cenário para ensino do transporte intra-hospitalar. Ele poderá ser aplicado em diversos serviços para avaliação da formação dos graduandos de enfermagem, assim como para aprimoramento profissional daqueles que atuam no serviço de transporte intra-hospitalar.

Mentoria virtual durante a pandemia de Covid-19: percepções de mentorandos e mentores / Virtual mentoring during the Covid-19 pandemic: perceptions of mentees and mentors

Resumo: Introdução: A pandemia de Covid-19 impôs à educação médica novas modalidades de ensino a distância. Com isso, os programas de mentoria, prática do processo de formação em Medicina, precisaram se adequar à nova situação com a implementação da mentoria virtual destinada aos alunos. Relato de experiência: O grupo de mentoria reforçou a importância desse processo para a formação profissional, principalmente diante dos anseios e das inseguranças causados pela pandemia. A mudança para os encontros virtuais foi bem recebida pelos mentores e mentorandos. Por fim, o processo de mentoria virtual permitiu a discussão de temas mais leves, conversas com menos timidez sobre assuntos difíceis e reforçando a identidade do grupo. Discussão: Os programas de mentoria precisam investir em melhores treinamentos para os mentores, como forma de promover a qualidade do processo grupal, sem contar com os benefícios que isso traria ao mentor que passou a atuar de modo remoto com seus mentorandos. A pandemia acirrou as divergências entre gerações e os domínios das ferramentas virtuais por parte dos grupos de mentores e mentorandos. Os mentores e docentes do processo de formação médica precisam atentar para o sofrimento mental e as fragilidades dos alunos, na tentativa de minimizar esses problemas por meio da mentoria, das narrativas e do compartilhamento de experiências que permitem a suspensão do automatismo cotidiano. Conclusão: Não se observou nenhum tipo de prejuízo acerca da mentoria virtual, e não existe empecilho para que ela continue na modalidade remota, após a pandemia de Covid-19.

Abstract: Introduction: The Covid-19 pandemic imposed new forms of distance learning on medical education. Thus, mentoring programs, a practice in the medical education process, needed to adapt to the new situation with the implementation of virtual mentoring for students. Experience report: The mentoring group reinforced the importance of this process for professional training, especially in view of the anxieties and insecurities caused by the pandemic. The move to virtual meetings was well received by mentors and mentees. Finally, the virtual mentoring process allowed lighter topics to be discussed, more open conversations about difficult issues and reinforced the identity of that group. Discussion: Mentoring programs need to invest in better training for mentors, as a way to promote the quality of the group process, not to mention the benefits that this would bring to the mentor who started to work remotely with their mentors. The pandemic increased the discrepancies between generations and the mastering of virtual tools by mentors and mentees. Mentors and teachers in the medical education process need to pay attention to the mental suffering and weaknesses of students, in an attempt to minimize these problems through mentoring according to the narratives and the sharing of experiences that help break the automatized daily routine. Conclusion: No damage was observed about virtual mentoring, and there would be no obstacle for it to remain in remote mode after the Covid-19 pandemic.

Incidence, characteristics and long-term outcomes of patients with diabetic ketoacidosis: a prospective prognosis cohort study in an emergency department

ABSTRACT BACKGROUND: Diabetic ketoacidosis is the most frequent hyperglycemic complication in the evolution of diabetes mellitus. Common precipitating factors include newly diagnosed diabetes mellitus, noncompliance with therapy and infections. However, few studies have been conducted in Brazil and none were prospective in design. OBJECTIVE: To describe the incidence, clinical and laboratory characteristics and precipitating factors of diabetic ketoacidosis among emergency department patients in a tertiary-level teaching hospital in Brazil. We also aimed to identify immediate and long-term mortality within two years. DESIGN AND SETTING: Prospective prognosis cohort study conduct at a tertiary-level teaching hospital in São Paulo, Brazil. METHODS: All patients > 12 years old presenting diabetic ketoacidosis who were admitted to the emergency department from June 2015 to May 2016 were invited to participate. RESULTS: The incidence of diabetic ketoacidosis per 1,000 admissions was 8.7. Treatment noncompliance and infection were the most common causes of diabetic ketoacidosis. The immediate mortality rate was 5.8%, while the six-month, one-year and two-year mortality rates were 9.6%, 13.5% and 19.2%, respectively. Death occurring within two years was associated with age, type 2 diabetes, hypoalbuminemia, infection at presentation and higher sequential organ failure assessment (SOFA) score at admission. CONCLUSIONS: Diabetic ketoacidosis among patients presenting to the emergency department was relatively frequent in our hospital. Treatment noncompliance and infection were major precipitating factors and presence of diabetic ketoacidosis was associated with immediate and long-term risk of death.

Cohort study on the factors associated with survival post-cardiac arrest.

CONTEXT AND OBJECTIVE: Cardiac arrest is a common occurrence, and even with efficient emergency treatment, it is associated with a poor prognosis. Identification of predictors of survival after cardiopulmonary resuscitation may provide important information for the healthcare team and family. The aim of this study was to identify factors associated with the survival of patients treated for cardiac arrest, after a one-year follow-up period. DESIGN AND SETTING: Prospective cohort study conducted in the emergency department of a Brazilian university hospital. METHODS: The inclusion criterion was that the patients presented cardiac arrest that was treated in the emergency department (n = 285). Data were collected using the In-hospital Utstein Style template. Cox regression was used to determine which variables were associated with the survival rate (with 95% significance level). RESULTS: After one year, the survival rate was low. Among the patients treated, 39.6% experienced a return of spontaneous circulation; 18.6% survived for 24 hours and of these, 5.6% were discharged and 4.5% were alive after one year of follow-up. Patients with pulseless electrical activity were half as likely to survive as patients with ventricular fibrillation. For patients with asystole, the survival rate was 3.5 times lower than that of patients with pulseless electrical activity. CONCLUSIONS: The initial cardiac rhythm was the best predictor of patient survival. Compared with ventricular fibrillation, pulseless electrical activity was associated with shorter survival times. In turn, compared with pulseless electrical activity, asystole was associated with an even lower survival rate.