Use of etomidate in endotracheal intubations in the emergency room during the COVID-19 pandemic: a randomized clinical trial.

PURPOSE: Shock, cardiovascular problems, and respiratory failure constitute the main causes of death in patients cared in medical emergency rooms. Patients commonly require orotracheal intubation (OTI), a fact that has been intensified by diseases that generate important and fatal hemodynamic and respiratory problems in the affected patient. METHODS: Although etomidate (ETO) is a highly used anesthetic for OTI, its use remains controversial in several scenarios. Some studies refer to an increase in mortality with its use in critically patients, while others do not refer to a difference. Therefore, we evaluated the mortality of patients submitted to OTI in the public hospital of a public federal university, with the use of ETO and other sedative-hypnotic drugs used in the induction of the performance of OTI, with the in-hospital mortality of patients cared in hospital. RESULTS: The results demonstrate that the use of ETO as a hypnotic for OTI in the emergency room is not associated with a significant difference in morbidity or early mortality, within 30 days of hospitalization, compared with other hypnotics. CONCLUSIONS: There was no difference in mortality between patients intubated in the emergency department who used ETO and those who used non-ETO hypnotic within 72 hours and 30 days.

Forty years of a Postgraduate Program in Cardiology at a Brazilian public university: indicators of its graduates.

PURPOSE: To evaluate the profile of graduates of the Postgraduate Program (PGP) in Cardiology of a public federal university, according to sociodemographic factors and professional trajectory. METHODS: The variables were collected from databases from the observed institution and digital platforms. The analysis of differences between the various levels of degrees was carried out in three cohorts: the entire historical series (graduates from 1978-2021), the first 20 years (1978-1997) and the second 20 years (1998-2018). RESULTS: The results demonstrated that most students from the PGP completed a PhD and are men over 30 years old, they came from public universities and the Southeast region. In the first 20 years, significant differences were observed in the distribution of masters and doctors working professionally at the institution analyzed, as well as in the age of the students. In the 20 years of the second half, there were differences between masters and PhD working professionally in the institution itself, as they came from private universities, they are women and PhD. CONCLUSIONS: The changes in the profile of masters and PhD that graduated from this PGP in cardiology reflect transformations that occurred in the job market and academy over the decades.

Cardiotoxic Effects Produced by Omeprazole and Methylene Blue in an Animal Model of Cardiac Ischemia and Reperfusion and Potential Implications for the Pharmacological Strategy for Vasoplegic Syndrome.

Defined as systemic hypotension caused by intense vasodilation due to the loss of systemic vascular resistance, vasoplegic syndrome (VS) is associated with elevated morbidity and mortality in humans. Although vasopressors such as norepinephrine and vasopressin are the first-choice drugs for VS treatment, several other drugs such as methylene blue (MB) can be used as adjuvant therapy including rescue therapy. To develop new pharmacological strategies to reduce the risk of VS, we investigated the effects of treatments with MB (2 mg/kg/IV), omeprazole (OME, 10 mg/kg/IV), and their combination in an animal model of cardiac ischemia-reperfusion (CIR). The ventricular arrhythmia (VA), atrioventricular block (AVB), and lethality (LET) incidence rates caused by CIR (evaluated via ECG) and serum levels of the cardiac lesion biomarkers creatine kinase-MB (CK-MB) and troponin I (TnI) in adult rats pretreated with saline solution 0.9% and submitted to CIR (SS + CIR group) were compared to those pretreated with MB (MB + CIR group), OME (OME + CIR group), or the MB + OME combination (MB + OME + CIR group). The AVB and LET incidence rates in the MB + CIR (100%), OME + CIR (100%), and MB + OME + CIR (100%) groups were significantly higher compared to the SS + CIR group (60%). The serum level of CK-MB in these groups were also significantly higher compared to the SS + CIR group, demonstrating that the treatments before CIR with MB, OME, and MB + OME produced similar effects in relation to cardiac function and the occurrence of lesions. These results demonstrate that the treatment of animals subjected to the CIR protocol with OME produced the same effects promoted by the treatment with MB, which may suggest the possibility of using OME alone or in combination with MB in medical clinics in treatment of VS.

Forty years of a Postgraduate Program in Cardiology at a Brazilian public university: indicators of its graduates

ABSTRACT Purpose: To evaluate the profile of graduates of the Postgraduate Program (PGP) in Cardiology of a public federal university, according to sociodemographic factors and professional trajectory. Methods: The variables were collected from databases from the observed institution and digital platforms. The analysis of differences between the various levels of degrees was carried out in three cohorts: the entire historical series (graduates from 1978-2021), the first 20 years (1978-1997) and the second 20 years (1998-2018). Results: The results demonstrated that most students from the PGP completed a PhD and are men over 30 years old, they came from public universities and the Southeast region. In the first 20 years, significant differences were observed in the distribution of masters and doctors working professionally at the institution analyzed, as well as in the age of the students. In the 20 years of the second half, there were differences between masters and PhD working professionally in the institution itself, as they came from private universities, they are women and PhD. Conclusions: The changes in the profile of masters and PhD that graduated from this PGP in cardiology reflect transformations that occurred in the job market and academy over the decades.

Effects of Calendula officinalis extract on liver histopathology, lipid profile, and oxidative stress in rats submitted to a diet rich in cholesterol and carbohydrates.

PURPOSE: To evaluate the modulatory properties of Calendula officinalis L. (Asteraceae) (C. officinalis) extract on cafeteria diet-fed rats. METHODS: A cafeteria diet was administered ad libitum for 45 days to induce dyslipidemia. Then, the rats were treated with the formulations containing C. officinalis in the doses of 50, 100, and 150 mg/kg or only with the vehicle formulation; the control group received a commercial ration. RESULTS: The cafeteria diet decreased glutathione S-transferase activity and high-density lipoprotein plasmatic levels and damaged the hepatic architecture. The C. officinalis extract was able to reduce lipid infiltration in liver tissue and to modulate oxidative stress and lipid profile markers. CONCLUSIONS: The correlations between the variables suggest a pathological connection between oxidative stress markers and serum lipid profile.

Pharmacological Modulation of the Ca2+/cAMP/Adenosine Signaling in Cardiac Cells as a New Cardioprotective Strategy to Reduce Severe Arrhythmias in Myocardial Infarction.

Acute myocardial infarction (AMI) is the main cause of morbidity and mortality worldwide and is characterized by severe and fatal arrhythmias induced by cardiac ischemia/reperfusion (CIR). However, the molecular mechanisms involved in these arrhythmias are still little understood. To investigate the cardioprotective role of the cardiac Ca2+/cAMP/adenosine signaling pathway in AMI, L-type Ca2+ channels (LTCC) were blocked with either nifedipine (NIF) or verapamil (VER), with or without A1-adenosine (ADO), receptors (A1R), antagonist (DPCPX), or cAMP efflux blocker probenecid (PROB), and the incidence of ventricular arrhythmias (VA), atrioventricular block (AVB), and lethality (LET) induced by CIR in rats was evaluated. VA, AVB and LET incidences were evaluated by ECG analysis and compared between control (CIR group) and intravenously treated 5 min before CIR with NIF 1, 10, and 30 mg/kg and VER 1 mg/kg in the presence or absence of PROB 100 mg/kg or DPCPX 100 µg/kg. The serum levels of cardiac injury biomarkers total creatine kinase (CK) and CK-MB were quantified. Both NIF and VER treatment were able to attenuate cardiac arrhythmias caused by CIR; however, these antiarrhythmic effects were abolished by pretreatment with PROB and DPCPX. The total serum CK and CK-MB were similar in all groups. These results indicate that the pharmacological modulation of Ca2+/cAMP/ADO in cardiac cells by means of attenuation of Ca2+ influx via LTCC and the activation of A1R by endogenous ADO could be a promising therapeutic strategy to reduce the incidence of severe and fatal arrhythmias caused by AMI in humans.

Effects of Calendula officinalis extract on liver histopathology, lipid profile, and oxidative stress in rats submitted to a diet rich in cholesterol and carbohydrates

Purpose: To evaluate the modulatory properties of Calendula officinalis L. (Asteraceae) (C. officinalis) extract on cafeteria diet-fed rats. Methods: A cafeteria diet was administered ad libitum for 45 days to induce dyslipidemia. Then, the rats were treated with the formulations containing C. officinalis in the doses of 50, 100, and 150 mg/kg or only with the vehicle formulation; the control group received a commercial ration. Results: The cafeteria diet decreased glutathione S-transferase activity and high-density lipoprotein plasmatic levels and damaged the hepatic architecture. The C. officinalis extract was able to reduce lipid infiltration in liver tissue and to modulate oxidative stress and lipid profile markers. Conclusions: The correlations between the variables suggest a pathological connection between oxidative stress markers and serum lipid profile.

Comparison of three methods for teaching mechanical ventilation in an emergency setting to sixth-year medical students: a randomized trial.

OBJECTIVE: To determine if there are significant differences between the tutorial, simulation, or clinical-case-based discussion teaching methods regarding the transmission of medical knowledge on mechanical ventilation. METHODS: A randomized, multicenter, open-label controlled trial was carried out using 3 teaching methods on mechanical ventilation: clinical-case-based discussion, simulation, and online tutorial. Voluntary students of the sixth year of medical school from 11 medical colleges answered a validated questionnaire on knowledge about mechanical ventilation for medical students before, immediately after, and 6 months after in-person training consisting of 20 multiple-choice questions, and 5 questions about the participants' demographic profile. RESULTS: Immediately after the test there was no difference between the scores in the simulation and clinical case groups,[15,06 vs 14,63] whereas, after some time, there was a significant difference in retention between the case-based and simulation groups, with the score in the simulation group 1.46 [1.31; 1.64] times higher than the score of the case group (p-value < 0.001). In the multivariate analysis, an individual who had received more than 4 hours of information showed an increase of 20.0% [09.0%; 33.0%] in the score (p-value = 0.001). CONCLUSIONS: Our results indicate that, in comparison with other forms of training, simulation in mechanical ventilation provides long-lasting knowledge in the medium term. Further studies are needed to improve the designing and evaluation of training that provides minimal mechanical ventilation skills.

Comparison of three methods for teaching mechanical ventilation in an emergency setting to sixth-year medical students: a randomized trial

SUMMARY OBJECTIVE: To determine if there are significant differences between the tutorial, simulation, or clinical-case-based discussion teaching methods regarding the transmission of medical knowledge on mechanical ventilation. METHODS: A randomized, multicenter, open-label controlled trial was carried out using 3 teaching methods on mechanical ventilation: clinical-case-based discussion, simulation, and online tutorial. Voluntary students of the sixth year of medical school from 11 medical colleges answered a validated questionnaire on knowledge about mechanical ventilation for medical students before, immediately after, and 6 months after in-person training consisting of 20 multiple-choice questions, and 5 questions about the participants' demographic profile. RESULTS: Immediately after the test there was no difference between the scores in the simulation and clinical case groups,[15,06 vs 14,63] whereas, after some time, there was a significant difference in retention between the case-based and simulation groups, with the score in the simulation group 1.46 [1.31; 1.64] times higher than the score of the case group (p-value < 0.001). In the multivariate analysis, an individual who had received more than 4 hours of information showed an increase of 20.0% [09.0%; 33.0%] in the score (p-value = 0.001). CONCLUSIONS: Our results indicate that, in comparison with other forms of training, simulation in mechanical ventilation provides long-lasting knowledge in the medium term. Further studies are needed to improve the designing and evaluation of training that provides minimal mechanical ventilation skills.

RESUMO OBJETIVO: Determinar se existem diferenças significativas entre os métodos de ensino tutorial, simulação ou discussão de casos clínicos relativos à transmissão de conhecimentos médicos sobre ventilação mecânica. MÉTODOS: Um ensaio clínico randomizado, multicêntrico, aberto e controlado foi realizado usando três métodos de ensino em ventilação mecânica: discussão baseada em casos clínicos, simulação e tutorial on-line. Alunos voluntários do sexto ano de medicina de 11 faculdades responderam a um questionário validado abordando o conhecimento sobre ventilação mecânica para estudantes de medicina antes, imediatamente após e seis meses depois do treinamento presencial, composto por 20 questões de múltipla escolha e cinco questões sobre perfil demográfico dos participantes. RESULTADOS: Imediatamente após o teste, não houve diferença entre as pontuações nos grupos de simulação e caso clínico [15,06 vs 14,63], ao passo que, após algum tempo, houve uma diferença significativa na retenção entre o baseado em caso e a simulação grupos, com a pontuação no grupo simulação 1,46 [1,31; 1,64] vez maior que a pontuação do grupo caso (p-valor <0,001). Na análise multivariada, um indivíduo que recebeu mais de quatro horas de informação apresentou aumento de 20,0% [09,0%; 33,0%] no escore (p-valor=0,001). CONCLUSÕES: Nossos resultados indicam que, em comparação com outras formas de treinamento, a simulação em ventilação mecânica proporciona um conhecimento duradouro a médio prazo. Mais estudos são necessários para melhorar o desenho e a avaliação do treinamento que forneça habilidades mínimas de ventilação mecânica.

Development and validation of a questionnaire to assess the knowledge of mechanical ventilation in urgent care among students in their last-year medical course in Brazil.

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.

Development and validation of a questionnaire to assess the knowledge of mechanical ventilation in urgent care among students in their last-year medical course in Brazil

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.

Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians.

OBJECTIVE:: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS:: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire's self-assessment items for knowledge were transformed into scores. RESULTS:: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION:: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil.

Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians

OBJECTIVE: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire’s self-assessment items for knowledge were transformed into scores. RESULTS: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil.

Doenças císticas das vias biliares / Cystic diseases of the bile ducts

JUSTIFICATIVA E OBJETIVOS: Os ductos biliares podemapresentar dilatações congênitas ou adquiridas. As lesões congênitaspodem ser hipoplásticas (atresias) e císticas. O primeiroestudo descrito na literatura foi realizado por Vater and Ezler in1723. Os cistos biliares são isolados ou múltiplos, e aparecemem qualquer idade, mas 75% deles são antes dos 20 anos. Elespodem ocorrer em toda árvore biliar, sendo, as intra-hepáticasrestritas, conhecida como doença de Caroli. O objetivo desseestudo foi fazer uma revisão sobre as Doenças císticas das viasbiliares. CONTEÚDO: As dilatações císticas extra-hepáticaatingem diversos tamanhos e são classificadas segundo sua formae localização. São elas: fusiforme, divertículos e dilataçõessaculares. Háuma incidência variada dessas lesões com câncer,entre 2,5% e 17,5%. O quadro clínico mais comum éa colestaseneonatal, correspondendo a 80% dos pacientes. Na idadeadulta, podem ser assintomáticos ou apresentar apenas sintomasinespecíficos como náuseas,vômitos. A dificuldade de drenagemda colestase obstrutiva pode lavar a cirrose biliar secundária.CONCLUSÃO: O ultrassom de abdome pode confirmar odiagnóstico. No tocante ao laboratório, observa-se uma hiperbilirrubinemiae elevação de enzimas canaliculares. A terapêuticaempregada na maioria dos casos écirúrgica, com excisão do cistoe reconstrução da drenagem biliar, devendo-se evitar a drenagemisolada, pois tais pacientes tendem a evoluir com complicaçõescomo fístulas, estenose, colangite e carcinoma.(AU)

BACKGROUND AND OBJECTIVES: The bile duct dilatationmay have congenital or acquired. Congenital lesions can behipoplásticas (atresia) and cystic. The first study described in theliterature was performed by Vater and Ezler in 1723. Biliary cystsare isolated or multiple and appear at any age, but 75% of themare before age 20. They can occur throughout the biliary tree,and the intrahepatic restricted, known as Caroli disease. Theaim of this study was to review about the cystic biliary diseases.CONTENTS: Dilated cystic extrahepatic reach various sizesand are classified according to their shape and location. Theyare: fusiform, saccular dilatation and diverticula. There is anincidence of these lesions with cancer varied between 2.5% and17.5%. The most common symptom is a neonatal cholestasis,corresponding to 80% of patients. In adulthood, may beasymptomatic or show only nonspecific symptoms such as nausea,vomiting. The difficulty of draining obstructive cholestasis canwash the secondary biliary cirrhosis. CONCLUSION: Theabdominal ultrasound can confirm the diagnosis. Regarding thelaboratory, there is a hyperbilirubinemia and elevated GGT. Thetherapy used in most cases is surgical excision of the cyst andreconstruction of biliary drainage, should be avoided drainagealone because these patients tend to develop complications suchas fistula, stricture, cholangitis and carcinoma.(AU)

An evaluation of the professional, social and demographic profile and quality of life of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil.

OBJECTIVE: To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life. METHODS: Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil. RESULTS: Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p<0.01), worked exclusively in prehospital care (18.0 vs 7.7%; p<0.001), with workloads >48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU. CONCLUSIONS: The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies were mostly found in pediatrics and psychiatry, with specific deficiencies in the handling of essential equipment and in the skills necessary to adequately attend to prehospital emergencies. A disrespectful labor scenario was also found; the evaluation of quality of life showed a notable presence of pain on the SF-36 among physicians at SAMU and especially among doctors who had worked for a longer length of time at SAMU.

An evaluation of the professional, social and demographic profile and quality of life of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil

OBJECTIVE: To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life. METHODS: Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil. RESULTS: Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p<0.01), worked exclusively in prehospital care (18.0 vs 7.7%; p<0.001), with workloads >48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams* (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU. CONCLUSIONS: The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies ...

Desmame da ventilação mecânica: abordagem para o clínico / Weaning from mechanical ventilation: approach for the internist

Weaning from mechanical ventilation is a challenge. Its prolongation is related to increased mortality. Studies have demonstrated that traditional objective criteria used are notable to shorten this time for discontinuation of mechanical ventilation. The aim of this study is to review the strategies that have been proposed and that can be used by the internist to shorten the weaning process. The judicious and systematized clinical judgment in the weaning process seems to be critical to decrease the time of weaning from mechanical ventilation. A cause of failure in weaning process should be systematically reviewed by the internist (airway and respiratory tract dysfunction, cardiac, neurological, endocrine and metabolic dysfunction). A protocol for weaning and sedation also seems crucial to shorten weaning. For the weaning process, bedside clinical follow-up by a multidisciplinary team is essential, taking various aspects into account, not only traditional objective criteria. With this approach strategy it is possible to reduce the duration of mechanical ventilation.

O desmame da ventilação mecânica é um desafio. O seu prolongamento está relacionado ao aumento da mortalidade. Estudos têm demonstrado que os critérios objetivos tradicionais utilizados não são capazes de reduzir este tempo para interrupção da ventilação mecânica. O objetivo deste estudo é analisar as estratégias que têm sido propostas e que podem ser usadas pelo clínico para encurtar o processo de desmame. O julgamento clínico criterioso e sistematizado no processo de desmame parece ser fundamental para diminuir o tempo de desmame da ventilação mecânica. A causa da falha no processo de desmame deve ser sistematicamente revista pelo clínico (disfunções do trato respiratório, da via aérea, cardiológicas, neurológicas, endocrinológicas e disfunções metabólicas). Um protocolo para o desmame e sedação também parece crucial para reduzir o desmame. Para o processo de desmame, um acompanhamento clínico a beira do leito por uma equipe multidisciplinar é essencial, levando em consideração vários aspectos, não apenas critérios objetivos tradicionais. Com esta estratégia de abordagem é possível reduzir a duração da ventilação mecânica.

Infecção fulminante por Clostridium septicum: relato de caso / Fulminant Clostridium septicum infection: case report

As infecções de tecidos moles causadas por espécies de Clostridium têm sido descritos na literatura por centenas de anos. A gangrena gasosa por Clostridium continua sendo uma importante causa de morbidade e mortalidade no mundo. O objetivo deste estudo foi relatar um caso de paciente com diagnóstico de síndrome mielodisplásica, submetida à curetagem uterina e evoluindo com gangrena gasosa espontânea, 10 horas após a cirurgia.Paciente do sexo feminino, 26 anos, com história de dor em terço distal de membros inferiores, irradiando para região de fossa poplítea, com piora à palpação e movimentação dos membros, acompanhada de aumento da temperatura e volume local. Negava febre, hiperemia ou trauma local, evoluindo para choque séptico. Angiotomografia das extremidades e pelve revelou a presença de gás permeando os feixes musculares da coxa e da perna, bilateralmente. A combinação da história e exame clínico,ao estudo radiológico confirmou o diagnóstico sindrômico de gangrena gasosa espontânea. Apesar de elevado índice de suspeição melhorar os resultados clínicos, tais infecções progridem tão rapidamente que o óbito pode preceder o diagnóstico,não obstante, o reconhecimento precoce e tratamento agressivo,incluindo drenagem aberta ou percutânea. Antibióticos parenterais contra Clostrídios devem ser prontamente iniciados, bem como medidas de suporte clínico.

The soft tissue infections caused by Clostridium species have been described in the literature for hundreds of years. The gas gangrene due to Clostridium remains an important cause of morbidity and mortality worldwide. The aim of this study was to report a patient diagnosed with myelodysplastic syndrome who underwent curettage, evolving with spontaneous gas gangrene, 10 hours after surgery. Female patient, 26 years, with pain in the distal third of the lower limbs, radiating to the popliteal fossa region, which worsened on palpation and movement of limbs, and accompanied by an increase in temperature and local volume. She denied fever, redness or local trauma, and progressed to septic shock. Angiotomography of the extremities and pelvis revealed the presence of gas permeating the muscle bundles of the thigh and leg bilaterally. The combination of history and clinical examination and radiological examination confirmed the syndromic diagnosis of Spontaneous Gas Gangrene. Although a high index of suspicion may improve clinical outcomes, such infections progress so rapidly that death usually precedes the diagnosis. However, early recognition and aggressive treatment, including open or percutaneous drainage and parenteral antibiotics against Clostridia should be promptly initiated, along with clinical support.

Síndrome da lise tumoral: uma revisão para o clínico / Tumor lysis syndrome: a review for the clinician

JUSTIFICATIVA E OBJETIVOS: As possibilidades terapêuticas para o câncer cresceram muito nos últimos anos. A possibilidade de urgências relacionadas aos pacientes sobreviventes em tratamento do câncer vem crescendo muito. A síndrome da lise tumoral (SLT) é uma emergência oncológica metabólica que exige do médico emergencista uma abordagem específica e adequada. O objetivo deste estudo foi rever o assunto e trazer aspectos atuais de seu tratamento.CONTEÚDO: A SLT é uma emergência oncológica que nos últimos anos vem sendo associada com um número cada vez maior de tipos de câncer. Avaliar seus fatores de risco e promover adequada profilaxia pode diminuir sua incidência. As consequências da SLT são um conjunto de anormalidades metabólicas: hiperfosfatemia,hipocalcemia, hiperuricemia, hipercalemia, além de lesão renal aguda, insuficiência cardíaca, retenção volêmica e efeitos neuromusculares,neurológicos e gastrointestinais que devem ser prontamente diagnosticados e tratados pelo médico emergencista. CONCLUSÃO: A SLT é uma emergência que pode levar a morte ou prejudicar muito a possibilidade do paciente receber a terapia citotóxica. Dessa forma é fundamental o rápido alívio dos sintomas e a rápida correção das suas alterações metabólicas.

BACKGROUND AND OBJECTIVES: The therapeutic possibilities for cancer increased greatly in recent years. The possibility of emergencies related to patients surviving cancer treatment has been increasing. The tumor lysis syndrome (TLS) is a metabolic oncologic emergency that requires the emergency physician to have a specific and adequate approach. This study aimed at reviewing the theme and bringing current aspects for its treatment. CONTENTS: TLS is an oncologic emergency that in recent years has been associated with an increasing number of cancer types. Assessing its risk factors and promoting appropriate prophylaxis can decrease its incidence. The consequences of TLS are a set of metabolic abnormalities: hyperphosphatemia, hypocalcemia, hyperuricemia, hyperkalemia, and acute kidney injury, heart failure, volume retention, replacement, and neuromuscular, neurological and gastrointestinal effects that should be promptly diagnosed and treated by the emergency physician. CONCLUSION: Clinical TLS is an emergency that can lead to death or can severely impair the possibility of patients receiving an adequate cytotoxic therapy. Thus, rapid relief of symptoms and prompt correction of all metabolic alterations related to TLS are mandatory.