Crisis adrenal neonatal secundaria a hipoplasia hipofisaria / Neonatal Adrenal Crisis Secondary to Pituitary Hypoplasia

Introducción: La insuficiencia adrenal hipotálamo hipofisaria usualmente se manifiesta secundaria a tumores y, cuando resulta congénita se asocia, con frecuencia, con otras deficiencias hormonales. La crisis adrenal suele presentarse en su debut y puede resultar potencialmente mortal. Objetivo: Examinar el caso de una paciente con insuficiencia adrenal central que debutó con una crisis adrenal congénita. Presentación del caso: Recién nacida a término, padres no consanguíneos, hospitalizada a los 9 días de vida por clínica de una semana con múltiples episodios eméticos y apnea. Ingresó con deshidratación severa, hipotensa y estuporosa. Además, se encontró acidosis metabólica severa, hipoglucemia persistente, hiponatremia e insuficiencia prerrenal. Ante la no mejoría de su estado hemodinámico, a pesar del uso de cristaloides y vasopresores, finalmente mejoró con la administración de dosis altas de hidrocortisona. El diagnóstico de deficiencia de cortisol de origen central se realizó con un test dinámico de insulina y la resonancia magnética nuclear hipofisaria. Conclusiones: La crisis adrenal se debe tener presente como diagnóstico diferencial en episodios agudos con inestabilidad hemodinámica persistente e hipoglucemia de difícil manejo. Adicionalmente, hay que considerar que existen otras causas menos comunes de insuficiencia adrenal en neonatos como la hipoplasia hipofisaria(AU)

Introduction: Hypothalamic-pituitary adrenal insufficiency usually manifests secondary to tumors and, when congenital, is often associated with other hormonal deficiencies. Adrenal crisis usually occurs at its onset and can be life threatening. Objective: To review the case of a patient with central adrenal insufficiency who had an onset with a congenital adrenal crisis. Case presentation: Term newborn, non-consanguineous parents, hospitalized at 9 days of life for a week-long clinical presentation with multiple emetic episodes and apnea. She was admitted with severe dehydration, hypotensive and stuporous. In addition, severe metabolic acidosis, persistent hypoglycemia, hyponatremia and prerenal failure were found. Given the lack of improvement of her hemodynamic status, despite the use of crystalloids and vasopressors, she finally improved with the administration of high doses of hydrocortisone. The diagnosis of cortisol deficiency of central origin was made with a dynamic insulin test and pituitary nuclear magnetic resonance imaging. Conclusions: Adrenal crisis should be kept in mind as a differential diagnosis in acute episodes with persistent hemodynamic instability and difficult-to-manage hypoglycemia. Additionally, other less common causes of adrenal insufficiency in neonates, such as pituitary hypoplasia, should be considered(AU)

A randomized clinical trial on inhaled ciclesonide for managing acute asthma in the emergency room

ABSTRACT BACKGROUND: Use of inhaled corticosteroids for managing acute asthma exacerbations has been tested since the 1990s. OBJECTIVE: To compare high doses of inhaled ciclesonide with systemic hydrocortisone for managing acute asthma exacerbations in the emergency department. DESIGN AND SETTING: Double-blind, randomized clinical trial in the public healthcare system of the city of São Paulo. METHODS: Fifty-eight patients with moderate or severe asthma with peak flow < 50% of predicted were randomized into two groups. Over the course of four hours, one group received 1440 mcg of inhaled ciclesonide plus hydrocortisone-identical placebo (ciclesonide + placebo), while the other received 500 mg of intravenous hydrocortisone plus ciclesonide-identical placebo (hydrocortisone + placebo). Both groups received short-acting bronchodilators (fenoterol hydrobromide and ipratropium bromide). The research protocol included spirometry, clinical evaluation, vital signs and electrocardiogram monitoring. Data were obtained at 30 (baseline), 60, 90, 120, 180, and 240 minutes. We compared data from baseline to hour 4, between and within groups. RESULTS: Overall, 31 patients received ciclesonide + placebo and 27 received hydrocortisone + placebo. Inhaled ciclesonide was as effective as intravenous hydrocortisone for improving clinical parameters (Borg-scored dyspnea, P = 0.95; sternocleidomastoid muscle use, P = 0.55; wheezing, P = 0.55; respiratory effort, P = 0.95); and spirometric parameters (forced vital capacity, P = 0.50; forced expiratory volume in the first second, P = 0.83; peak expiratory flow, P = 0.51). CONCLUSIONS: Inhaled ciclesonide was not inferior to systemic hydrocortisone for managing acute asthma exacerbations, and it improved both clinical and spirometric parameters. TRIAL REGISTRATION: RBR-6XWC26 - Registro Brasileiro de Ensaios Clínicos (http://www.ensaiosclinicos.gov.br/rg/RBR-6xwc26/).

Crisis suprarrenal: prevención, corticoterapia y elección del fármaco, revisión de la evidencia actual y recomendaciones / Adrenal crisis: prevention, corticotherapy and choice of the drug, review of current evidence and recommendations

INTRODUCCIÓN. La crisis suprarrenal se refiere a la insuficiencia suprarrenal aguda; la cual es un trastorno en el que la corteza adrenal no produce suficientes hormonas esteroides (en especial cortisol) para satisfacer las demandas del cuerpo, de acuerdo al mecanismo fisiopatológico se la puede clasificar como primaria, secundaria y terciaria, siendo más común en pacientes con insuficiencia suprarrenal primaria. Es una emergencia potencialmente mortal que requiere tratamiento inmediato. OBJETIVO. Establecer una estrategia de prevención y tratamiento de la crisis suprarrenal, así como la farmacoterapia ideal y sus alternativas válidas. MATERIAL Y MÉTODOS. Se realizó una revisión bibliográfica en varias revistas virtuales de alto carácter científico como Cochrane Library, Cochrane Systematic Reviews Database, MEDLINE a través de PubMed y ClinicalTrial.gov. Se seleccionaron revisiones sistemáticas con o sin metaanálisis, ensayos clínicos y recomendaciones de expertos relacionados con prevención y tratamiento de crisis suprarrenal en general. RESULTADOS. Se obtuvieron 1819 resultados, de los cuales se seleccionaron 20 artículos con mayor validez y replicabilidad en el medio para establecer un protocolo unificado de actuación. CONCLUSIÓN. El objetivo de la terapia es el tratamiento de la hipotensión y reversión de las anomalías electrolíticas y de la deficiencia de cortisol. Se deben infundir por vía intravenosa grandes volúmenes (1 a 3 litros) de solución salina al 0,9% o dextrosa al 5% en solución salina al 0,9% y la administración de hidrocortisona (bolo de 100 mg), seguido de 50 mg cada 6 horas (o 200 mg / 24 horas como infusión continua durante las primeras 24 horas). Si no se dispone de hidrocortisona, las alternativas incluyen prednisolona, prednisona y dexametasona.

INTRODUCTION. Adrenal crisis refers to acute adrenal insufficiency; which is a disorder in which the adrenal cortex does not produce enough steroid hormones (especially cortisol) to meet the body's demands, according to the pathophysiological mechanism it can be classified as primary, secondary and tertiary, being more common in patients with primary adrenal insufficiency. It is a life-threatening emergency that requires immediate treatment. OBJECTIVE. To establish a strategy for the prevention and treatment of adrenal crisis, as well as the ideal pharmacotherapy and its valid alternatives. MATERIAL AND METHODS. A literature review was performed in several highly scientific virtual journals such as Cochrane Library, Cochrane Systematic Reviews Database, MEDLINE through PubMed and ClinicalTrial.gov. Systematic reviews with or without meta-analysis, clinical trials and expert recommendations related to prevention and treatment of adrenal crisis in general were selected. RESULTS. A total of 1819 results were obtained, from which 20 articles with greater validity and replicability in the setting were selected to establish a unified protocol for action. CONCLUSIONS. The aim of therapy is the treatment of hypotension and reversal of electrolyte abnormalities and cortisol deficiency. Large volumes (1 to 3 liters) of 0.9% saline or 5% dextrose in 0.9% saline and administration of hydrocortisone (100 mg bolus), followed by 50 mg every 6 hours (or 200 mg / 24 hours as a continuous infusion for the first 24 hours) should be infused intravenously. If hydrocortisone is not available, alternatives include prednisolone, prednisone, and dexamethasone.

Análisis bibliométrico y mapeo de publicaciones internacionales sobre cortisol salival (1960-2019) / Bibliometric analysis and mapping of international publications about salivary cortisol (1960-2019)

El objetivo del presente estudio fue evaluar la actividad científica sobre el cortisol salival. Se aplicó un método bibliométrico utilizando MEDLINE y LILACS. El período estudiado fue de 1960 a 2019. Los datos fueron analizados por los programas VOSviewer y Publish or Perish. La búsqueda localizó 6063 documentos en MEDLINE y 47 en LILCAS. El crecimiento de las publicaciones mostró un aumento notorio en el período 2010-2019. En MEDLINE, Estados Unidos lideró la producción científica con el 21 por ciento de los documentos y en LILACS, Brasil, con el 70,2 por ciento. Los autores con índice de productividad igual o mayor que 1 (grandes productores) alcanzaron el 0,93 por ciento en MEDLINE y en LILACS, 0 por ciento. El número medio de autores por publicación fue de 5,12 en MEDLINE y 4,70 en LILACS. Hubo seis temas principales de investigación relacionada con cortisol salival: 1) estrés; 2) eje hipotalámico-pituitario-suprarrenal; 3) ritmo circadiano; 4) emociones, ansiedad, depresión; 5) vigilia-sueño; 6) factores determinantes. El número de estudios sobre cortisol salival va en aumento y la multiautoría, como expresión de la colaboración entre los autores, también. La investigación futura debe centrarse en las diferencias interindividuales y la variabilidad intraindividual de la concentración del cortisol salival(AU)

The purpose of the study was to evaluate the scientific activity about salivary cortisol. A bibliometric method was applied using MEDLINE and LILACS. The study period extended from 1960 to 2019. The data presented in the study were analyzed with the software VOSviewer and Publish or Perish. The search retrieved 6063 documents from MEDLINE and 47 from LILACS. Increase in the number of publications was notable in the period 2010-2019. The United States had the largest scientific production in MEDLINE with 21percent of the documents, whereas Brazil was at the top of the list in LILACS with 70.2percent. Authors with a productivity index equal to or greater than 1 (prolific producers) represented 0.93percent in MEDLINE and 0percent in LILACS. Mean number of authors per publication was 5.12 in MEDLINE and 4.70 in LILACS. Six main research topics were found to be related to salivary cortisol: 1) stress 2) hypothalamic-pituitary-adrenal axis; 3) circadian rhythm; 4) emotions, anxiety, depression; 5) sleep-wake; 6) determining factors. Research on salivary cortisol is on the increase, with gradual improvement in multiauthorship as an expression of collaboration between authors. Future research should focus on interindividual differences and intraindividual variability of salivary cortisol concentration(AU)

Pituitary immune-related adverse events induced by programmed cell death protein 1 inhibitors in advanced lung cancer patients: A report of 3 cases / 北京大学学报(医学版)

Pituitary immune-related adverse events induced by programmed cell death protein 1 inhibitors in advanced lung cancer patients: A report of 3 cases SUMMARY Programmed cell death protein 1 (PD-1) and its ligand 1 (PD-L1) have been widely used in lung cancer treatment, but their immune-related adverse events (irAEs) require intensive attention. Pituitary irAEs, including hypophysitis and hypopituitarism, are commonly induced by cytotoxic T lymphocyte antigen 4 inhibitors, but rarely by PD-1/PD-L1 inhibitors. Isolated adrenocorticotropic hormone(ACTH) deficiency (IAD) is a special subtype of pituitary irAEs, without any other pituitary hormone dysfunction, and with no enlargement of pituitary gland, either. Here, we described three patients with advanced lung cancer who developed IAD and other irAEs, after PD-1 inhibitor treatment. Case 1 was a 68-year-old male diagnosed with metastatic lung adenocarcinoma with high expression of PD-L1. He was treated with pembrolizumab monotherapy, and developed immune-related hepatitis, which was cured by high-dose methylprednisolone [0.5-1.0 mg/(kg·d)]. Eleven months later, the patient was diagnosed with primary gastric adenocarcinoma, and was treated with apatinib, in addition to pembrolizumab. After 17 doses of pembrolizumab, he developed severe nausea and asthenia, when methylprednisolone had been stopped for 10 months. His blood tests showed severe hyponatremia (121 mmol/L, reference 137-147 mmol/L, the same below), low levels of 8:00 a.m. cortisol (< 1 μg/dL, reference 5-25 μg/dL, the same below) and ACTH (2.2 ng/L, reference 7.2-63.3 ng/L, the same below), and normal thyroid function, sex hormone and prolactin. Meanwhile, both his lung cancer and gastric cancer remained under good control. Case 2 was a 66-year-old male with metastatic lung adenocarcinoma, who was treated with a new PD-1 inhibitor, HX008, combined with chemotherapy (clinical trial number: CTR20202387). After 5 months of treatment (7 doses in total), his cancer exhibited partial response, but his nausea and vomiting suddenly exacerbated, with mild dyspnea and weakness in his lower limbs. His blood tests showed mild hyponatremia (135 mmol/L), low levels of 8:00 a.m. cortisol (4.3 μg/dL) and ACTH (1.5 ng/L), and normal thyroid function. His thoracic computed tomography revealed moderate immune-related pneumonitis simultaneously. Case 3 was a 63-year-old male with locally advanced squamous cell carcinoma. He was treated with first-line sintilimab combined with chemotherapy, which resulted in partial response, with mild immune-related rash. His cancer progressed after 5 cycles of treatment, and sintilimab was discontinued. Six months later, he developed asymptomatic hypoadrenocorticism, with low level of cortisol (1.5 μg/dL) at 8:00 a.m. and unresponsive ACTH (8.0 ng/L). After being rechallenged with another PD-1 inhibitor, teslelizumab, combined with chemotherapy, he had pulmonary infection, persistent low-grade fever, moderate asthenia, and severe hyponatremia (116 mmol/L). Meanwhile, his blood levels of 8:00 a.m. cortisol and ACTH were 3.1 μg/dL and 7.2 ng/L, respectively, with normal thyroid function, sex hormone and prolactin. All of the three patients had no headache or visual disturbance. Their pituitary magnetic resonance image showed no pituitary enlargement or stalk thickening, and no dynamic changes. They were all on hormone replacement therapy (HRT) with prednisone (2.5-5.0 mg/d), and resumed the PD-1 inhibitor treatment when symptoms relieved. In particular, Case 2 started with high-dose prednisone [1 mg/(kg·d)] because of simultaneous immune-related pneumonitis, and then tapered it to the HRT dose. His cortisol and ACTH levels returned to and stayed normal. However, the other two patients' hypopituitarism did not recover. In summary, these cases demonstrated that the pituitary irAEs induced by PD-1 inhibitors could present as IAD, with a large time span of onset, non-specific clinical presentation, and different recovery patterns. Clinicians should monitor patients' pituitary hormone regularly, during and at least 6 months after PD-1 inhibitor treatment, especially in patients with good oncological response to the treatment.

Ovarian adrenal rest tumor in congenital adrenal hyperplasia: Is medical treatment the first line option?

SUMMARY Ovarian adrenal rest tumors (OARTs) are very rare. We describe a case of a young woman with uncontrolled classical congenital adrenal hyperplasia (CCAH), presenting with bilateral OARTs, successfully treated with steroid replacement. A 20-year-old woman, known to have 21OH-CCAH, presented with severe abdominal pain, vomiting, diarrhea, and fever. As a result of poor compliance, 6 months before her admission hirsutism worsened and amenorrhea, hyperpigmentation, and weakness developed. ACTH levels were 278 < pmol/L and 17OHP 91.3 nmol/L. She was admitted for parenteral antibiotics and high-dose hydrocortisone treatment. CT revealed bilateral juxta-ovarian masses (6.2 x 3.6 x 7.4 cm left and 5 x 2.2 x 3.2 cm right) that on MRI were iso-intense in T1 and hypointense in T2, with early enhancement and rapid washout. One week of high-dose hydrocortisone resulted in significant clinical and laboratory improvement and the patient was discharged with 2 mg dexamethasone/day. One month later US revealed shrinkage of the masses and dexamethasone dose was decreased. At three months from discharge, she has resumed regular menses, and a repeated MRI revealed the para-ovarian masses have shrunk. One year after the diagnosis, the para-ovarian masses have shrunk more to 2.8 x 1.9 x 4.3 on the left and 2.1 x 0.9 x 1.2 on the right with less contrast enhancement in comparison to previous test possibly due to fibrotic changes of the tissue. OARTs are rare tumors with a poorly known natural history, and surgery has been the first option in the few reported cases. We demonstrate that medical treatment is a good alternative, leading to significant tumor shrinkage over a short period.

Masa ósea y tratamiento esteroideo en pacientes con hiperplasia suprarrenal congénita / Bone mass and steroid treatment in patients with congenital adrenal hyperplasia

Introducción: La terapia de reemplazo con glucocorticoides sigue siendo el paradigma de tratamiento en las formas clásicas de la hiperplasia suprarrenal congénita. Sus efectos sobre la mineralización ósea no están totalmente claros. Objetivo: Describir las variables relacionadas con la masa ósea en pacientes con HSC que reciben tratamiento esteroideo sustitutivo. Método: Se realizó un estudio descriptivo transversal que exploró variables clínicas, bioquímicas, hormonales y de mineralización óseaen 25 pacientes con hiperplasia suprarrenal congénita por déficit de 21OHasa y tratamiento esteroideo. Resultados: 21 (84,0 por ciento) femeninas, el mayor grupo correspondió a los adolescentes entre 10 y 19 años (52 por ciento). Predominaron las formas clásicas con 22 pacientes (88,0 por ciento), de ellas 13 (52 por ciento) fueron perdedoras de sal, 9 virilizantes simples (36,0 por ciento) y solo 3 (12,0 por ciento) formas no clásicas. El esteroide más utilizado fue la hidrocortisona en 16 pacientes (64 por ciento), a una dosis media de 22,10±12,00 mg diarios, correspondiendo con 17,09±5,71 mg/m2sc/día y como promedio llevaban 14,02±6,57 años de terapéutica sustitutiva. No se detectaron alteraciones del metabolismo fosfocálcico. La densidad y el contenido mineral óseo en columna y en fémur mostraron valores superiores en las formas no clásicas de la enfermedad, seguidos de la virilizante simple y finalmente los pacientes perdedores de sal, en ninguno de los casos con significación estadística. Conclusiones: Los pacientes con hiperplasia suprarrenal congénita del presente estudio mostraron en su mayoría una masa ósea conservada(AU)

Introduction: Glucocorticoid replacement therapy is still the treatment´s paradigm in the classic forms of congenital adrenal hyperplasia. Its effects on bone mineralization are not entirely clear. Objective: Describe bone mass-related variables in congenital adrenal hyperplasia patients receiving substitute steroid treatment. Method: A cross-sectional descriptive study was conducted exploring clinical, biochemical, hormonal and bone mineralization variables in 25 patients with congenital adrenal hyperplasia caused by 21OHase deficiency and steroid treatments. Results: 21 women (84.0 percent); the largest group was of adolescents between the age of 10 and 19 years (52 percent).Classical forms predominated with 22 patients (88.0 percent), including 13 of them (52 percent) that were salt losers, 9 simple virilizers (36.0 percent) and only 3 (12.0 percent) of non-classical forms. The most commonly used steroid was hydrocortisone in 16 patients (64 percent), at an average dose of 22.10±12.00 mg daily, corresponding to 17.09±5.71 mg/m2sc/day and on average carried 14.02±6.57 years of substitute therapy. No alterations in the phosphocalcic metabolism were detected. Density and bone mineral content in the spinal column and femur showed higher values in non-classical forms of the disease, followed by simple virilizing and finally the salt loser patients, in none of the cases with statistical significance. Conclusions: Patients with congenital adrenal hyperplasia in this study showed mostly preserved bone mass(AU)

Corticoides sistémicos en COVID-19 / Systemic corticosteroids in COVID-19

CONTEXTO CLÍNICO: La Enfermedad por el Coronavirus 2019 (COVID­19, por su sigla en inglés Coronavirus Disease 2019) es una enfermedad respiratoria de humanos producida por un nuevo coronavirus identificado con la sigla SARS-CoV-2. El 11 de marzo de 2020 la Organización Mundial de la Salud (OMS) declaro la COVID-19 como una pandemia. Desde ese momento hasta el 15 de junio su circulación se ha reportado en 205 países reportándose más de 7.800.000 casos y la muerte 430.000 personas. El período de incubación de la infección es de 2 a 14 días. La mayor parte de los contagios se producen persona a persona, siendo altamente transmisible.(3) La clínica varía desde casos asintomáticos a cuadros febriles con tos y dificultad respiratoria, neumonía y distrés respiratorio. También puede acompañarse de alteraciones gastrointestinales. En los casos con mal pronóstico, el paciente presenta un importante deterioro respiratorio en 4-8 días. Las imágenes radiológicas muestran generalmente neumonía focal o generalizada semejante al síndrome de distress respiratorio agudo. (3) La mayoría de los casos graves requieren ingreso hospitalario, siendo mayoritariamente casos primarios en pacientes de edad avanzada y con comorbilidades (diabetes, enfermedad crónica renal, hipertensión, enfermedad cardiaca y enfermedad pulmonar crónica). La tasa media de letalidad de los pacientes ingresados a UTI es cercana al 49%, siendo los valores más elevados en pacientes masculinos de más de 50 años con comorbilidades múltiples. Actualmente el tratamiento de la COVID­19 es sintomático y de sostén no existiendo hasta el momento tratamiento farmacológico específico curativo. Debido a la evidencia que sugiere que el daño pulmonar agudo observado en la infección por SARS-CoV-2 estaría asociada a la activación de las células inmunes circulantes, incluyendo células T y las citoquinas que conducen a un síndrome de liberación de citoquinas (similar al síndrome de activación macrofágica y hemofagocítico) por lo que se plantea que el uso de corticoides sistémicos podría disminuir la mortalidad y/o necesidad de soporte ventilatorio invasivo. TECNOLOGÍA: Los glucocorticoides (GCS) son una familia de medicamentos antiinflamatorios e inmunomoduladores que se utilizan en el tratamiento de diversas patologías cuyo principal componente etiopatogénico es la inflamación. Dentro de los mecanismos de acción propuestos se encuentran: inhibición de citoquinas inflamatorias (IL-1 y IL-2), inhibición de la migración de leucocitaria, inhibición de la desgranulación de mastocitos, depleción linfocitaria (principalmente linfocitos T), incremento de citoquinas anti-inflamatorias (IL-10). Dentro de las alternativas para la administración sistémica se pueden mencionar a la hidrocortisona, dexametasona, betametasona, prednisona, prednisolona, metilprednisolona y deflazacort. Todos ellos difieren principalmente en el grado de actividad mineralocorticorticoide y vida media. OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso de corticoides sistémicos en COVID­19. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas, en buscadores genéricos de internet, y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS), evaluaciones económicas, guías de práctica clínica (GPC) y recomendaciones de diferentes organizaciones de salud. RESULTADOS: Se incluyeron un ECA, una RS, dos estudios observacionales, un documento de evaluación de tecnología sanitaria, 12 guías de práctica clínica, recomendaciones de organismos gubernamentales o sociedades científicas acerca del uso de corticoides sistémicos en pacientes con diagnóstico de COVID­19. CONCLUSIONES: Evidencia de alta calidad proveniente de los resultados de un ensayo clínico aleatorizado aún no publicado sugiere que el uso de corticoides sistémicos se asocia a una disminución en el riesgo de mortalidad principalmente en pacientes con requerimientos de oxigeno suplementario o asistencia mecánica invasiva. Evidencia de muy baja calidad también sugiere que podría tener el mismo beneficio en aquellos pacientes con COVID-19 que presentan síndrome de distrés respiratorio agudo. Múltiples ensayos clínicos aleatorizados en pacientes con cuadros moderados o severos se encuentran en curso. Las guías de práctica clínica de diferentes sociedades internacionales y organismos gubernamentales que lo recomiendan indican su utilización para el tratamiento de pacientes con criterios de síndrome de distrés respiratorio agudo. Si bien no se encontraron estudios de costo-efectividad en Latinoamérica, el costo total del tratamiento al igual que su impacto presupuestario sería muy bajo.

Informe diário de evidências COVID-19: busca realizada entre 24 e 26 de abril de 2020 / COVID-19 daily evidence report: search conducted between April 24 and 26, 2020

Essa é uma produção do Departamento de Ciência e Tecnologia (Decit) da Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde (SCTIE) do Ministério da Saúde (Decit/SCTIE/MS), que tem como missão promover a ciência e tecnologia e o uso de evidências científicas para a tomada de decisão do SUS, tendo como principal atribuição o incentivo ao desenvolvimento de pesquisas em saúde no Brasil, de modo a direcionar os investimentos realizados em pesquisa pelo Governo Federal às necessidades de saúde pública. Informar sobre as principais evidências científicas descritas na literatura internacional sobre tratamento farmacológico para a COVID-19. Além de resumir cada estudo identificado, o informe apresenta também uma avaliação da qualidade metodológica e a quantidade de artigos publicados, de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, entre outros). Foram encontrados 25 artigos e 47 protocolos.

Effect of Recreational Intervention on the Approach of Pediatric Patients in Dental Treatment: Analysis of Salivary Cortisol

Abstract Objective: To verify whether recreational interaction with pediatric patient before dental care influences cortisol levels and anxiety. Material and Methods: Twelve children were selected and divided into two groups: 6 children who had not previously received recreational intervention (Group I) and 6 children who received recreational intervention before dental care (Group II). Saliva was collected with Salivettes™ kits before and soon after dental care for the measurement of cortisol. Wilcoxon test was applied to verify the difference in salivary cortisol levels before and after the dental visit in the whole sample, and the Mann-Whitney U test was used to analyze the difference between groups I and II. A significance level of 0.05 was considered. Results: Among patients from Group I, 3 had their cortisol levels increased after dental care, 2 had their cortisol levels decreased, and the other 1 patient remained constant. All participants from Group II had no significant difference in cortisol levels pre- and post-procedure. Mean salivary cortisol level was higher in Group I, pre- and post-procedure, compared to Group II. Conclusion: Pediatric patients who participated in an interactive activity prior to dental care have a lower level of anxiety according to the salivary cortisol levels obtained, compared to patients who did not participate in recreation. The techniques for the dentist to approach the child control the anxiety of the patient and make the procedure calmer and less stressful for both of them.

Factors associated to potential drug interactions in one Intensive Care Unit: a cross-sectional study / Factores asociados a interacciones medicamentosas potenciales en un Centro de Terapia Intensiva: estudio transversal / Fatores associados a interações medicamentosas potenciais em um Centro de Terapia Intensiva: estudo transversal

ABSTRACT Objective: to identify the factors associated to Potential Drug Interactions with High Alert Medications in the Intensive Care Unit of a Sentinel Hospital. Methods: a cross-sectional, retrospective study using a quantitative approach carried out at a Sentinel Hospital in Rio de Janeiro. The research was based on the analysis of the prescriptions of patients hospitalized in the Intensive Care Unit of the Hospital, in a period of one year, in order to identify the drug interactions related to high alert medications in these prescriptions. Results: Of the 60 prescriptions analyzed, 244 were selected. In these prescriptions, 846 potential drug interactions related to high alert medications and 33 high alert medications were identified. Of the 112 types of potential drug interactions identified, some were more recurrent: tramadol e ondansetron, midazolam and omeprazole, regular insulin and hydrocortisone, fentanyl and midazolam, and regular insulin and noradrenaline. The variables polypharmacy, length of hospital stay, and some specific medications were associated with drug interactions with high alert medications. Conclusion and Implications for practice: It is important to strengthen strategies to reduce adverse drug events. Therefore, the relevance of studies that investigate the origin of these events is highlighted. Drug interactions can represent medication errors. It's indispensable to work with strategies to better manage the medication system.

RESUMEN Objetivo: identificar los puntos asociados a las Interacciones Medicamentos Potenciales con Medicamentos de alta vigilancia en un Centro de Cuidados Intensivos de un Hospital de Guardia. Métodos: estudio transversal, retrospectivo, de abordaje cuantitativo, realizado en un hospital de guardia en Rio de Janeiro. Esta investigación se basó en el análisis de las prescripciones medicamentosas de pacientes internados en un Centro de Cuidados Intensivos de un hospital, en un período de 1 año, con el objetivo de identificar las interacciones medicamentosas relacionadas con Medicamentos de alta Vigilancia recurrentes en las mismas. Resultados: de los informes analizados, se seleccionaron 244 prescripciones medicamentosas. En las 244 prescripciones de medicamentos, se pudieron identificar 846 Interacciones de Medicamentos Potenciales (IMP) relacionados a Medicamentos de Alta Vigilancia y 33 Medicamentos de Alta Vigilancia. De los 112 tipos de interacciones de medicamentos potenciales identificados, algunos han sido más recurrentes; a saber: tramadol y ondansetrón, midazolam y omeprazol, insulina regular e hidrocortisona, fentanilo y midazolam, insulina regular y noradrenalina. Las variables polifarmacia, tiempo de internación y algunos medicamentos específicos se asociaron a las interacciones medicamentosas potenciales con Medicamentos de Alta Vigilancia. Conclusión e Implicaciones para la práctica: es importante fortalecer las estrategias para reducir los eventos adversos relacionados con medicamentos. Por lo tanto, se destaca la relevancia de los estudios que plantean la naturaleza de estos eventos. Las interacciones medicamentosas pueden provocar errores de medicación. Es imprescindible trabajar con estrategias para administrar mejor el sistema de medicación.

RESUMO Objetivo: Identificar os fatores associados às Interações Medicamentosas Potenciais com Medicamentos de alta vigilância em Centro de Terapia Intensiva de um Hospital Sentinela. Métodos: Estudo transversal, retrospectivo, de abordagem quantitativa, realizado em um hospital sentinela no Rio de Janeiro. A pesquisa apoiou-se na análise das prescrições de pacientes internados no setor, com recorte temporal de 1 ano, a fim de identificar as interações medicamentosas relacionadas a medicamentos de alta vigilância recorrentes nas mesmas. Resultados: Dos 60 prontuários analisados, selecionaram-se 244 prescrições. Nelas identificaram-se 846 interações medicamentosas potenciais, relacionadas aos medicamentos de alta vigilância e 33 medicamentos de alta vigilância. Dos 112 pares de interações identificadas, foram mais recorrentes: tramadol e ondansetrona, midazolam e omeprazol, insulina regular e hidrocortisona, fentanil e midazolam, e insulina regular e noradrenalina. As variáveis polifarmácia, tempo de internação e alguns medicamentos específicos foram associadas às interações com medicamentos de alta vigilância. Conclusão e Implicações para a prática: É importante fortalecer as estratégias para reduzir os eventos adversos relacionados a medicamentos. Portanto, destaca-se a relevância de estudos que levantem a natureza desses eventos. As interações medicamentosas podem configurar erros de medicação. Portanto, é indispensável que se trabalhe com estratégias para melhor manejar o sistema de medicação.

Antivenom therapy: efficacy of premedication for the prevention of adverse reactions

Antivenoms or antitoxins have been effectively used for more than a century. During this time, these products have always proven to be highly effective in the treatment of infections and envenomations. However, antivenoms did not exhibit good safety results in their initial applications. After many improvements, antivenoms have substantially better safety profiles but still have some side effects. Due to the occurrence of adverse reactions, the practice of using premedication with the intent to decrease side effects has become accepted or mandatory in many countries. The drugs used for premedication belong to the histamine H1 antagonist, glucocorticoid and catecholamine groups. Currently, this practice is being questioned due to low or controversial efficacies in clinical assays. In this article, we discuss the causes of adverse reactions, the mechanisms of drugs that block the undesired effects and the results obtained in clinical trials. Although these three families of drugs could have positive effects on reducing adverse reactions, only adrenaline has demonstrated positive results in clinical assays.

Antivenom therapy: efficacy of premedication for the prevention of adverse reactions

Antivenoms or antitoxins have been effectively used for more than a century. During this time, these products have always proven to be highly effective in the treatment of infections and envenomations. However, antivenoms did not exhibit good safety results in their initial applications. After many improvements, antivenoms have substantially better safety profiles but still have some side effects. Due to the occurrence of adverse reactions, the practice of using premedication with the intent to decrease side effects has become accepted or mandatory in many countries. The drugs used for premedication belong to the histamine H1 antagonist, glucocorticoid and catecholamine groups. Currently, this practice is being questioned due to low or controversial efficacies in clinical assays. In this article, we discuss the causes of adverse reactions, the mechanisms of drugs that block the undesired effects and the results obtained in clinical trials. Although these three families of drugs could have positive effects on reducing adverse reactions, only adrenaline has demonstrated positive results in clinical assays.(AU)

Edema agudo hemorrágico de la infancia: Lesiones alarmantes de un cuadro benigno. Reporte de caso / Acute hemorrhagic edema of infancy: alarming lesions of a benign condition. Case report

Se reporta un caso de edema agudo hemorrágico de la infancia, en un lactante de 18 meses, después de un episodio de otitis media. El cuadro comenzó con máculas eritematosas en los muslos, seguidas de lesiones purpúricas en los brazos, las piernas y edema en los tobillos. Se interpretó, inicialmente, como urticaria, por lo que recibió esteroides. Sin embargo, las características clínicas fueron de edema agudo hemorrágico de la infancia, una vasculitis leucocitoclástica benigna que se presenta en niños de entre 4 y 24 meses y que se caracteriza por fiebre, máculas y lesiones purpúricas. Estas se ubican, principalmente, en la cara, los lóbulos de las orejas y las extremidades, y se asocian, muchas veces, a edema. Los diagnósticos diferenciales son eritema multiforme, urticaria, vasculitis inducida por droga, enfermedad de Kawasaki, eccema infectado, meningococcemia y maltrato infantil, algunas de ellas, con riesgo de mortalidad. El manejo es conservador, sin embargo, los esteroides podrían ser una opción terapéutica.

We report a case of acute hemorrhagic edema of infancy in an 18-month-old boy after an episode of otitis media. The clinical presentation begins with skin erythematous macules on the thighs, followed by purpuric lesions in arms, legs, and ankle edema. It was initially interpreted as urticaria, whereby steroids were indicated. However, the clinical feature was acute hemorrhagic edema of infancy, a benign leukocytoclastic vasculitis that occurs in children between 4 and 24 months of age and is characterized by fever, large purpuric palpable target-like skin lesions affecting the face, lobes of the ears, limbs and frequently associated with edema. Differential diagnosis includes erythema multiforme, hemorrhagic urticaria, drug-induced vasculitis, Kawasaki disease, infected eczema, sepsis (either meningococcal or non-meningococcal) and child abuse. Some of them have risk of mortality. Management is conservative, however, steroids may be a therapeutic option.

Allergic reaction to patent blue dye in breast surgery - case report / Reação alérgica ao corante azul patente em cirurgia de mama - relato de caso

Abstract We present a case of allergic reaction to patent blue in a patient who underwent excision of sentinel lymph node associated with segmental breast resection. About 20 min after the dye injection, the patient developed hypotension (BP = 70 × 30 mmHg) associated with increased heart frequency. The patient was treated successfully with decreased inspired fraction of inhaled anesthetic and fluid replacement. At the end of the procedure, she presented with bluish urticarial-like plaques on the head, neck, upper limbs, and trunk; hydrocortisone was then used. The patient recovered uneventfully and was discharged from the PACU 2 h after the end of surgery without skin changes, and was discharged from hospital on the morning after surgery. The incidence of allergic reactions with the use of patent blue is far superior to the hypersensitivity reactions seen with anesthetic and adjuvant drugs. Therefore, the anesthesiologist must be aware of cardiovascular instability associated with skin changes during the use of patent blue, for early diagnosis and appropriate treatment of this hypersensitivity reaction to this dye.

Resumo Os autores apresentam um caso de reação alérgica ao azul patente em uma paciente submetida à exérese de linfonodo em sentinela associada a uma ressecção segmentar de mama. Paciente apresentou aproximadamente pós 20 minutos da injeção do corante hipotensão (PA = 70 × 30 mmHg) associada a aumento da frequência cardíaca. Foi tratada satisfatoriamente com diminuição da fração inspirada do anestésico inalatório e reposição volêmica. No fim do procedimento apresentava placas urticariformes azuladas em cabeça, pescoço, membros superiores e tronco e foi usada hidrocortisona. Evoluiu, sem intercorrências, na sala de recuperação pós-anestésica e teve alta duas horas após o término do procedimento cirúrgico sem a presença das alterações cutâneas. Alta hospitalar na manhã seguinte à cirurgia. A incidência de reações alérgicas com o emprego do azul patente é muito superior às reações de hipersensibilidade observadas com drogas anestésicas e adjuvantes. Portanto, o anestesiologista deve ficar atento à instabilidade cardiovascular associada a alterações cutâneas quando do uso do azul patente para o diagnóstico precoce e tratamento adequado dessa reação de hipersensibilidade com o emprego do corante.

Análise de fatores clínico-demográficos, psicológicos, hormonais e genéticos na síndrome da ardência bucal e ardor bucal secundário / Analysis of clinical and demographic factors, psychological, hormonal and genetic in burning mouth syndrome and secondary burning mouth

A síndrome da ardência bucal (SAB) é uma condição clínica pouco esclarecida caracterizada por sensação espontânea de ardência, dor ou prurido na mucosa oral, sem alterações locais ou sistêmicas identificáveis. Sua etiopatogenia é incerta, não havendo até o momento uma padronização dos critérios utilizados para o seu diagnóstico. O presente estudo objetivou verificar a associação de fatores psicológicos, hormonais e genéticos com a SAB no sentido de propor uma melhor caracterização de sua natureza. Além de uma análise descritiva da amostra estudada, os aspectos analisados foram especificamente os níveis de estresse e sua fase, depressão, e ansiedade, compondo os fatores psicológicos; mensuração dos níveis séricos de cortisol e desidroepiandrosterona (DHEA); bem como a verificação sobre a ocorrência de polimorfismos no gene da Interleucina-6 (IL6). Foram realizadas análises comparativas entre um grupo de pacientes com SAB e um grupo composto por indivíduos com ardor bucal secundário (AB). Os resultados revelaram diferenças estatisticamente significativas entre os dois grupos com relação aos seguintes aspectos: xerostomia (p=0,01) e hipossalivação em repouso (p<0,001), que foram mais prevalentes no grupo SAB; sintomas de depressão (p=0,033), também mais presentes no grupo SAB; e dosagem de DHEA, que apresentou níveis mais reduzidos no grupo SAB (p=0,003).

A dosagem desse hormônio mostrou-se amplamente sensível e específica para o diagnóstico da síndrome em estudo, sendo verificado que níveis séricos de DHEA abaixo de 0,37µg/mL para mulheres, utilizando-se os procedimentos propostos na pesquisa, possuem um Odds Ratio de 4,0 [95%IC (0,37 a 2,71)]. Foi verificado ainda que o alelo C do polimorfismo rs2069849 da IL-6 pode representar um alelo de risco para a ocorrência de ardor bucal em ambos os grupos, no entanto, não se pode garantir sua real implicação nos processos inflamatórios da SAB. Os presentes resultados sugerem uma provável influência da depressão, bem como de níveis diminuídos do hormônio DHEA na SAB. (AU)

The burning mouth syndrome (BMS) is a clinical condition characterized by spontaneous burning sensation, pain or itching in the oral mucosa without identifiable local or systemic changes. Its pathogenesis is uncertain, with no observable standardization in previous literature of the criteria used for its diagnosis. The present study aimed to determine demographic, psychological, hormonal and genetic factors in patients with BMS and secondary burning mouth to propose a better characterization of the nature and classification of this condition. Besides a descriptive analysis of the sample of 163 individuals, were analyzed the levels of stress and its phase, depression and anxiety; measurement of serum levels of cortisol and dehydroepiandrosterone (DHEA), as well as checking on the occurrence of polymorphisms in the gene of interleukin-6 (IL6). Comparative analysis between a group of patients with BMS and a group of individuals with secondary burning mouth (BM) were performed. The results revealed statistically significant differences between the two groups with respect to the following aspects: xerostomia (p=0.01) and hyposalivation at rest (p<0.001), which were more prevalent in the BMS group; symptoms of depression (p=0.033), more present in the BMS group, and dosage of DHEA, which showed lower levels in BMS patients (p=0.003). The dosage of this hormone was largely specific and sensitive for the diagnosis of the studied syndrome, and was verified that serum levels of DHEA below 0.37 µg/mL in women, using the procedures proposed in this research, have an Odds Ratio of 4.0 [95 % CI (0.37 to 2.71)]. These results suggest a possible influence of depression and decreased levels of the hormone DHEA in the pathogenesis of BMS. (AU)

Pseudohipoaldosteronismo y aparente exceso de mineralocorticoides: cara y ceca en dos pacientes pediátricos / Pseudohypoaldosteronism and apparent mineralocorticoid excess: two faces, two pediatric patients

Los síndromes endocrinológicos con hipofunción o hiperfunción con niveles paradójicos de dosajes hormonales han sido bien caracterizados en los últimos años del siglo XX, a partir del desarrollo de técnicas genéticas y moleculares. Presentamos dos pacientes con pseudohipoaldosteronismo y aparente exceso de mineralocorticoides como síndromes en espejo, con la intención de alertar al médico clínico respecto de su consideración como entidad diagnóstica en niños con alteraciones hidroelectrolíticas. (AU)

Endocrinological syndromes with underactive or overactive hormonal levels with paradoxical dosages have been well characterized over the years of the twentieth century, from the development of genetic and molecular techniques. We present two patients with pseudohypoaldosteronism and apparent mineralocorticoid excess as mirror syndromes, with the aim to alert the clinician regarding their consideration as a diagnostic entity in children with fluid and electrolyte disturbances. (AU)

Meloxicam associado ou não ao tramadol no controle da dor após ovário-histerectomia videoassistida em cadelas / Meloxican with or without tramadol for control of pain undergoing laparoscopic-assisted ovariohysterectomy in bitches

O objetivo deste estudo foi avaliar a eficácia do meloxicam associado ou não ao tramadol, no controle da dor após ovário-histerectomia (OVH) laparoscópica com dois portais. Foram selecionadas 14 cadelas hígidas. Os animais foram separados de forma aleatória, em dois grupos. O grupo M (GM) recebeu meloxicam (0,2mg kg-1, s.i.d.), enquanto os animais do grupo MT (GMT) receberam a associação de meloxicam (0,2mg kg-1, s.i.d.) e tramadol (4mg kg-1, t.i.d.), ambos durante dois dias de pós-operatório. Para avaliação da dor pós-cirúrgica, foram utilizadas as escalas de Melbourne e escala visual analógica (EVA), além de mensurações de glicemia e cortisol sérico. Não houve diferença ao se avaliarem os grupos GM e GMT pela escala de Melbourne nem pela EVA. As mensurações de cortisol não atingiram valores superiores aos de referência para a espécie, enquanto os valores de glicemia não apresentaram variação significativa ao longo do tempo de avaliação nem entre grupos. Com os resultados deste estudo, foi possível concluir que a utilização de meloxicam associado ou não ao tramadol, nas doses e posologias propostas, é eficaz para controlar a dor pós-operatória de cadelas submetidas à OVH laparoscópica com dois portais.

The aim of this study was to evaluate the efficacy of meloxicam with or without tramadol for pain control after laparoscopic-assisted ovariohysterectomy (OVH) by two-portal access. Were selected 14 healthy dogs to perform video-assisted OVHs. The animals were divided randomly into two groups (GM and GMT). The GM group received meloxicam (0.2mg kg-1, s.i.d), whereas the GMT group received the combination of meloxicam (0.2mg kg-1, s.i.d) and tramadol (4mg kg-1, tid), both for two days after surgery. To evaluate the post-surgical pain Melbourne and EVA scales were used, and blood glucose and serum cortisol were measured. There was no statistical difference when evaluating GM and GMT groups and the Melbourne scale or the visual analogue scale VAS. Cortisol measurements did not reach values higher than the reference for the species, while blood glucose levels did not present significant statistical variation throughout the evaluation time or between groups. With these results, we concluded that the use of meloxicam with or without the tramadol at the doses and dosage schedules proposed, is effective to control postoperative pain in bitches that had undergone video-assisted OVH with two-portal access.

Dor em urgência odontológica: uso de anti-inflamatórios, corticoides e analgésicos em casos de pulpite aguda irreversível / Pain in dental emergency: anti inflammatory use, steroids and painkillers in cases of irreversible acute pulpitis

O objetivo deste estudo foi avaliar o uso do cetorolaco de trometamina 10mg sublingual 30 minutos antes do procedimento de biopulpectomia em pacientes com pulpite irreversível com relação à dor antes do procedimento e nas 48 horas subsequentes, a quantidade de medicação consumida no pós-operatório e tempo esperado para sua utilização. Também foi avaliada a influência da anestesia intrapulpar, o uso da automedicação analgésica antes da procura pelo atendimento e diferença entre gêneros sobre os níveis de dor pré e pós-operatória. Propôs-se avaliar também a necessidade da presença do antibiótico na medicação intracanal, comparando o Otosporin® com hidrocortisona. Participaram da pesquisa 608 pacientes que procuraram o Setor de Urgência Odontológica da Faculdade de Odontologia de Bauru ou o Setor Odontológico do Pronto Socorro Central da Prefeitura Municipal de Bauru, sendo que 34 completaram de forma adequada o protocolo previsto. Foram divididos em 4 grupos que receberam cetorolaco ou placebo como medicação pré-operatória e Otosporin® ou hidrocortisona como medicação intracanal. Foram anotados os valores de intensidade de dor, em uma escala visual analógica, antes da medicação pré-operatória, antes do atendimento, após o atendimento, 1, 2, 4, 12, 24, 48 horas após e quando houve necessidade de medicação pós-operatória para alívio da dor. Também foi anotado se o paciente havia se automedicado e qual a droga utilizada, se houve necessidade de anestesia intrapulpar, a quantidade de medicação consumida pelo paciente no pós-operatório e o tempo esperado para seu consumo. Dos resultados observou-se que os pacientes que receberam cetorolaco como medicação pré-operatória tiveram uma redução significativa da dor em 30 minutos, quando comparado ao placebo. Foi observado que o tempo necessário para a ingestão de medicamentos pós-operatórios não demonstrou diferença significativa entre os grupos, assim como na quantidade de medicação ingerida. O tempo decorrido entre a primeira e a última dose de medicação pós-operatória também não demonstrou diferença estatística. Com relação a anestesia intrapulpar, 78% dos pacientes necessitaram desta técnica, mas devido ao pequeno tamanho da amostra obtida, não foi possível correlacionar o seu uso com a utilização da medicação pós-operatória. Para os pacientes que se automedicaram previamente, não houve diferença significativa em relação à dor inicial. Quando os gêneros foram comparados, não foi possível observar uma diferença estatística significante entre eles com relação aos parâmetros estudados. Também foram descritos no trabalho os motivos de não inclusão dos 574 pacientes que foram abordados durante a realização deste estudo. Com base nos resultados, conclui-se que o cetorolaco diminuiu expressivamente o nível de dor durante a espera pelo atendimento, porém com relação ao tempo esperado pelo paciente para tomar a primeira dose de medicação pós-operatória, a última dose, a quantidade de comprimidos e a frequência de ingestão não demonstrou a mesma diferença. Também não houve diferença no nível de dor inicial entre os pacientes que se automedicaram e os que não fizeram uso dessa prática. Devido ao pequeno número da amostra, não foi possível encontrar uma correlação entre o uso da técnica anestésica intrapulpar e medicação pós-operatória, sugerindo mais estudos futuros.(AU)

The aim of this study was to evaluate the use of ketorolac tromethamine (10mg sublingual taken 30 minutes before pulpectomy in patients with irreversible pulpitis) in pain reduction immediately before the procedure and the 48 subsequent hours, postoperative consumption of analgesic drugs and time for its use. The influence of intrapulpal anesthesia, the use of analgesic self-medication prior to the demand for care and gender difference on the levels of pre- and postoperative pain was also evaluated. It was also proposed assess the need for antibiotic presence in the intracanal medicament, comparing Otosporin® with hydrocortisone. A total of 608 patients who presented to Dental Urgency Sector from Dental School of Bauru (USP) or Emergency Dental Sector from Bauru City Hall were invited to participate, and 34 completed properly planned protocol. They were distributed in 4 groups that received either ketorolac or placebo as preoperative medication and Otosporin® or hydrocortisone as intracanal medication. The rates of pain intensity were recorded by means of a visual analogue scale before pretreatment medication, immediately before the appointment, 1, 2, 4, 12, 24, 48 hours after the appointment, and when there was taken post medication for postoperative pain relief. It was also recorded if the patient had self medicated and which the drug used and, if there was need intrapulpal anesthesia, amount of ketorolac and rescue medication (paracetamol 750mg) consumed by the patient postoperative time and the waitng time for consumption. The results showed that patients receiving Ketorolac as preoperative medication had a significant reduction of pain in 30 minutes compared to placebo. It was observed that the time required for the intake of postoperative drug showed no significant difference between groups, as well as the amount of medication intake. The time elapsed between the first and last dose of postoperative medication also showed no statistical difference. Concerning intrapulpal anesthesia, 78% of patients required for this technique, but because of the small sample size obtained it was impossible to correlate their use with the use of postoperative medication. For patients who practiced self medication previously, there was no significant difference with respect to initial pain. When genders were compared, it was not possible to observe a statistically significant difference between them regarding the parameters studied. Were also described in the study the reasons of non-inclusion of 574 patients that were addressed during this study. Based on the results, it is concluded that ketorolac significantly decreased the level of pain during the waiting time, but with respect to the time length for the patient to take the first dose of postoperative medication, the last dose, the number of tablets and taken frequency did not show the same difference. There was no difference in the initial level of pain among patients who practiced self medication and those who did not use this practice. Due to the small sample size, it was not possible to find a correlation between the use of the anesthetic technique intrapulpal and postoperative medication, suggesting more future studies.(AU)

Hydrocortisone supresses inflammatory activity of metalloproteinase - 8 in carotid plaque / Hidrocortisona suprime a atividade inflamatória da metaloproteinase - 8 presente na placa carotídea

AbstractObjective:Matrix metalloproteinases are inflammatory biomarkers involved in carotid plaque instability. Our objective was to analyze the inflammatory activity of plasma and carotid plaque MMP-8 and MMP-9 after intravenous administration of hydrocortisone.Methods:The study included 22 patients with stenosis ≥ 70% in the carotid artery (11 symptomatic and 11 asymptomatic) who underwent carotid endarterectomy. The patients were divided into two groups: Control Group - hydrocortisone was not administered, and Group 1 - 500 mg intravenous hydrocortisone was administered during anesthetic induction. Plasma levels of MMP-8 and MMP-9 were measured preoperatively (24 hours before carotid endarterectomy) and at 1 hour, 6 hours and 24 hours after carotid endarterectomy. In carotid plaque, tissue levels of MMP-8 and MMP-9 were measured.Results:Group 1 showed increased serum levels of MMP- 8 (994.28 pg/ml and 408.54 pg/ml, respectively; P=0.045) and MMP-9 (106,656.34 and 42,807.69 respectively; P=0.014) at 1 hour after carotid endarterectomy compared to the control group. Symptomatic patients in Group 1 exhibited lower tissue concentration of MMP-8 in comparison to the control group (143.89 pg/ml and 1317.36 respectively; P=0.003). There was a correlation between preoperative MMP-9 levels and tissue concentrations of MMP-8 (P=0.042) and MMP-9 (P=0.019) between symptomatic patients in the control group.Conclusion:Hydrocortisone reduces the concentration of MMP- 8 in carotid plaque, especially in symptomatic patients. There was an association between systemic and tissue inflammation.

ResumoObjetivo:As metaloproteinases são biomarcadores inflamatórios envolvidos na instabilidade da placa carotídea. O objetivo deste estudo foi analisar a atividade inflamatória da MMP-8 e MMP-9 plasmática e presente na placa carotídea, após administração intravenosa de hidrocortisona.Métodos:Participaram do estudo 22 pacientes portadores de estenose ≥ 70% em artéria carótida (11 sintomáticos e 11 assintomáticos), submetidos à endarterectomia de artéria carótida. Os pacientes foram divididos em dois grupos: Grupo Controle - não foi administrado hidrocortisona e Grupo 1 - foi administrado 500 mg intravenoso de hidrocortisona durante a indução anestésica. As dosagens plasmáticas de MMP-8 e MMP-9 foram efetuadas no pré-operatório (24 horas antes da endarterectomia de artéria carótida) e em 1 hora, 6 horas e 24 horas após endarterectomia de artéria carótida. Na placa carotídea foram mensurados os níveis teciduais de MMP-8 e MMP-9.Resultados:O grupo 1 exibiu elevação dos níveis séricos da MMP-8 (994,28 pg/ml e 408,54 pg/ml, respectivamente; P=0.045) e MMP-9 (106.656,34 e 42.807,69, respectivamente; P=0.014) em 1 hora após a endarterectomia de artéria carótida, em relação ao grupo controle. Os pacientes sintomáticos do grupo 1 exibiram menor concentração tecidual de MMP-8, em relação ao grupo controle (143,89 pg/ml e 1317,36, respectivamente; P=0.003). Houve correlação entre os níveis pré-operatórios de MMP-9 e as concentrações teciduais de MMP-8 (P=0.042) e MMP-9 (P=0.019) entre os pacientes sintomáticos do grupo controle.Conclusão:A hidrocortisona reduz a concentração de MMP-8 na placa carotídea, em especial nos pacientes sintomáticos. Houve associação entre a inflamação sistêmica e a tecidual.