Non-occlusive Mesenteric Ischaemia and Acute Kidney Injury: A Case Report of Severe Idiopathic Systemic Capillary Leak Syndrome.

Systemic capillary leak syndrome is a rare, underdiagnosed and life-threatening disease characterized by periodic episodes of hypovolaemic shock due to leakage of plasma from the intravascular to the extravascular space. It is associated with haemoconcentration, hypoalbuminaemia and generalized oedema. We report the case of a patient with a history of emergent extensive small and large bowel resection and several episodes of hypovolaemic shock with acute renal injury, who presented with abdominal pain, headache and generalized oedema. Severe systemic capillary leak syndrome was diagnosed after a complex diagnostic approach. This case report describes the acute and prophylactic treatment administered to the patient and the 4-year follow-up. We highlight the importance of timely recognition and prompt treatment, as well as the need for new investigations to prevent the serious and unusual complications seen in this case. LEARNING POINTS: Idiopathic systemic capillary leak syndrome (ISCLS) should be suspected in the presence of the triad of hypotension, haemoconcentration and hypoalbuminaemia; the diagnostic work-up is challenging and requires exclusion of several causes of hypotension and shock of uncertain aetiology.Acute mesenteric ischaemia leading to extensive and emergent bowel resection is an irreversible but atypical complication of ISCLS; other complications include myocardial oedema and deep vein thrombosis.ISCLS is characterized by three phases; supportive as well as prophylactic treatment adapted to each phase is crucial for prognosis and to avoid end-organ damage.

Azathioprine-induced interstitial nephritis in an anti-neutrophil cytoplasmic antibody (ANCA) myeloperoxidase (MPO) vasculitis patient.

Azathioprine (AZA) is used in a wide array of autoimmune diseases, still corresponding to the mainstay maintenance therapy in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides. Although generally well-tolerated, several side effects are recognized. We report the case of a 50-year-old Caucasian man with kidney-limited ANCA myeloperoxidase (MPO) vasculitis who presented with general malaise, fever, worsening renal function, and elevated inflammatory markers 2 weeks after the initiation of therapy with oral AZA. Although a disease relapse was suspected, renal biopsy revealed an eosinophilic infiltrate, suggestive of acute interstitial nephritis. After suspension of AZA, a sustained improvement of renal function and normalization of inflammatory markers was observed. A diagnosis of allergic interstitial nephritis secondary to AZA was established, corresponding to the first biopsy-proven case described in an ANCA MPO vasculitis patient. Although rare, renal toxicity of AZA must be present in the clinician's mind, avoiding the straightforward assumption of disease relapse in the case of worsening renal function.

Vivenciando a Rede: Caminhos para a Formação do Médico no Contexto do SUS / Experiencing the Network: Paths for Medical Training in the Context of the SUS

RESUMO Os cursos de educação médica têm implementado disciplinas e módulos que aproximem os discentes da realidade da saúde nacional, a fim de se adequarem às crescentes necessidades de reorganização da formação médica. O presente artigo relata uma experiência de acadêmicos de Medicina da Universidade Estadual de Santa Cruz (UESC) com as atividades e ações incluídas no módulo de Gestão e Rede de Atenção à Saúde, parte da Prática de Integração Ensino-Serviço-Comunidade (PIESC), como proposta de reorientação do currículo na aquisição de habilidades de liderança e gerenciamento de recursos físicos e humanos em saúde. A proposta foi inserir os discentes em diferentes níveis de complexidade tecnológica do SUS a fim de contextualizar o estudo da Rede de Atenção à Saúde (RAS) por meio de vivências e pesquisa-ação em serviços de saúde situados nos diferentes níveis de atenção. Para isso, foram realizadas entrevistas semiestruturadas com profissionais e usuários em cada ambiente visitado. Tais vivências ampliaram a visão dos acadêmicos sobre os serviços de saúde, possibilitando um melhor entendimento da estruturação da RAS, bem como um dimensionamento dos entraves encontrados nos diferentes cenários e proporcionando uma experiência in loco das críticas e dificuldades apresentadas e vividas por usuários e profissionais. Percebeu-se que não há resolutividade dos problemas de saúde dos usuários nos serviços, bem como existe uma falta de entendimento destes acerca de seus direitos e da continuidade da atenção à saúde nos diferentes níveis de atenção. Explicitou-se que as instâncias primárias de atenção não funcionam como porta de entrada adequada, o que culmina com a desestruturação da RAS observada. A experiência relatada neste artigo demonstrou um modo dinâmico de abordar a temática da Gestão e Rede de Atenção à Saúde, além de contribuir para a formação do estudante de Medicina, já que possibilitou um melhor entendimento da rede quanto às práticas em saúde e às dimensões do processo saúde-doença implicados na gestão do SUS.

ABSTRACT Medical courses in Brazil have implemented subjects and modules that aim to bring students closer to actual national health concerns, as one way of adapting to the growing needs for medical training reorganization. Thus, this article reports on the experience of medical students at the Universidade Estadual de Santa Cruz (UESC) [State University of Santa Cruz] with activities and actions included in the Health Care Network and Management module, part of the Teaching-Service-Community Intergration Practice (PIESC), as a proposal for the reorientation of the curriculum and acquisition of leadership skills and management of physical and human resources in health. The proposal was to insert the students at different levels of technological complexity of the Unified Health System (SUS) in order to contextualize the study of the Health Care Network (RAS) through experiences and action research in health services located at different care levels. Semi-structured interviews with professionals and users were therefore performed in each visited environment. These experiences served to broaden the students' vision of health care networks, enabling a better understanding of how the services are structured, as well as of the magnitude of the obstacles found in different scenarios, providing an in loco experience of the criticisms and difficulties faced by users and professionals. It was noticed that user health problems are often not resolved within the health care services, and the users lack understanding of their health rights. A lack of continuity of the health care was also observed through the various health care levels. Thus, it is concluded that the instances of primary care fail to offer adequate gateway services, culminating in the breakdown of the observed network. The experiment reported in this article demonstrated a dynamic way to approach the issue of Health Care Network Management, contributing to medical student training, as it enabled a better understanding of the network in terms of the health practices and the dimensions of the health-disease process involved in the management of the SUS.

“Além da Mama”: o Cenário do Outubro Rosa no Aprendizado da Formação Médica / “Beyond the Breast”: the Pink October Scenario among Medical Students

RESUMO O câncer de mama pode ser considerado, atualmente, um problema de saúde pública devido a sua crescente incidência e índices de letalidade. Diante disso, o movimento Outubro Rosa visa chamar a atenção da população a respeito dessas neoplasia em mulheres de todo o mundo, de modo que suas ações têm por objetivo comum realizar o diagnóstico precoce no intuito de diminuir a mortalidade em decorrência dessa neoplasia. Dessa forma, o presente artigo objetiva relatar a experiência de acadêmicos do curso de Medicina da Universidade Estadual de Santa Cruz, no Módulo de Práticas de Integração Ensino, Serviço e Comunidade III (Piesc III), numa ação conjunta com a Equipe de Saúde da Família (ESF) de Iguape, em Ilhéus (BA), no contexto do movimento Outubro Rosa, objetivando também compartilhar considerações sobre a formação médica levantadas pelo grupo acerca da vivência descrita. No período, realizou-se abordagem inicial na sala de espera, anamnese dirigida e foi feito o exame físico das mamas das pacientes que compareceram à Unidade de Saúde da Família. A experiência não consistiu apenas em identificar pacientes com suspeita de câncer de mama e quantificar os dados, mas numa oportunidade de exercício da Educação e Comunicação em Saúde e de desenvolvimento da relação médico-paciente. Ainda permitiu aos acadêmicos reconhecer e entender melhor as dificuldades das usuárias em relação à prevenção e promoção da saúde das mamas, sendo que se observou que diversas mulheres não estavam familiarizadas com os temas abordados. O estudante de Medicina precisa compreender que o conhecimento teórico-prático se reconstrói em cada paciente com contexto histórico específico e com diferentes visões e interpretações dos conceitos de saúde e doença. Além disso, o profissional médico deve exercitar, desde a graduação, habilidades que extrapolam o ortodoxo trabalho médico, assumindo também uma postura de multiplicador de cidadania, um agente propagador de direitos e deveres.

ABSTRACT The breast cancer can now be considered a public health problem due to its increasing incidence and lethality rates. In view of this, the October Rosa mobilization aims at drawing the population’s attention regarding this neoplasm in women from all over the world, so that their common objective is to perform the early diagnosis in order to reduce mortality due to this neoplasm. Thus, the following article describes the experiences of undergraduate medical students at the Universidade Estadual de Santa Cruz (Uesc) regarding the practice module on Integrated Teaching with Community Health and Service, as part of a joint initiative with a Family Health Team in the outskirts of Ilhéus, Bahia, Brazil, within the context of the “Pink October” movement, also aiming to share thoughts on the medical degree raised by the group on the experience described. As part of the Pink October initiative, the students were given the opportunity to take a clinical approach in the waiting room, collecting information and performing physical examinations on patients who appear at the Family Health Unit. This experience was not only intended to identify patients with suspected cancer and measure the data collected, but was also designed to provide the students the opportunity to put their health education and communication skills into practice, developing the doctor-patient relationship. It also allows academics to better recognize and understand users’ difficulties in preventing and promoting breast health. In this context, it was observed that several women were not familiar with the recommended techniques for the breast self-exam (???). Medical students must understand that practical and theoretical knowledge is reconstructed with every single patient according to their specific historical context and varying viewpoints and interpretations of the concepts of health and disease. In addition, the medical professional must exercise, from the undergraduate, skills that extrapolate the orthodox medical work, also assuming a position of multiplier of citizenship, a propagating agent of rights and duties.

[Thymus surgery in a general surgery department]. / Cirurgia do timo num serviço de Cirurgia Geral.

AIMS: Evaluation of thymectomy cases between 1990-2003, in a General Surgery Department. Evaluation of the therapeutic efficacy in Miastenia Gravis patients. PATIENTS AND METHODS: Retrospective study based on evaluation of data from Serviço de Cirurgia, Neurologia and Consult de Neurology processes, between 1990-2003, of 15 patients submitted to total thymectomy. RESULTS: 15 patients, aged 17 to 72, 11 female and 4 male. Miastenia Gravis was the main indication for surgery, for uncontrollable symptoms or suspicion of thymoma. In patients with myasthenia, surgery was accomplish after compensation of symptoms. There weren't post-surgery complications. Pathology were divided in thymic hyperplasia and thymoma. Miastenia patients have there symptoms diminished or stable with reduction or cessation of medical therapy. CONCLUSIONS: Miastenia was the most frequent indication for thymectomy. Surgery was good results, with low morbimortality, as long as the protocols are respected.

[Length of hospital stay, mortality and destination after discharge of stroke patients]. / Acidente vascular cerebral. Hospitalização, mortalidade e prognóstico.

Stroke remains an important cause of death, hospitalisation and chronic disability in developed populations. This study aimed to evaluate patients characteristics at admission that relate to length of hospital stay, mortality and destination of stroke patients. We studied 255 consecutive stroke patients admitted to internal medicine wards of Hospital São João, Porto. In-hospital mortality was 5.5%. In a multivariate analysis, we found male sex, paralysis in affected limb and intracerebral haemorrhage as significantly associated with longer hospitalisation. None of the studied characteristics was found to be independently associated with mortality. Previously living at an institution was significantly associated with discharge to an institution. This study showed that admission characteristics may provide relevant information to assess short term prognosis and to identify patients with special difficulties and needs.