Descriptive study of goat external and middle ear through computed tomography and endoscopic evaluation, compared with the human ear.

OBJECTIVE: To describe the external and middle ear of goats, using computed tomography and endoscopic dissection, comparing them with the anatomy of the human ear, aiming to evaluate the viability of this animal model for training in otological endoscopic surgery. METHODS: Images of the external and middle ear of goats were produced by computed tomography in the coronal and axial planes and analyzed. The radiological anatomy of the external and middle goat and human ear are described. Some measures of surgical interest were described, such as the length of the external auditory canal, external and internal cross-sectional area of the external auditory canal, middle ear depth, vertical angle of the external auditory canal, length of malleus and incus. After the tomographic study, we analyzed the importance of evaluations through the endoscopic dissection of the goat ear. RESULTS: The bony canal is extremely tortuous and shows a bony prominence with significant elevation near the lower edge of the tympanic membrane. The middle ear has a large tympanic bulla in the hypotympanum region. The malleus is shaped similarly to that of the human, but its handle is located anterior to its head. The mastoid is not pneumatized. Compared to the human mastoid, there was a statistically significant difference in the external and internal cross-sectional area, at the depth of the middle ear, in the vertical angle of the canal and in the length of the incus. CONCLUSION: Goat morphometric anatomy showed that this model is suitable for surgical simulation in the initial training for endoscopic otological surgery. It is an important contribution to the development of skills to accelerate the subsequent endoscopic otological surgical training in humans, despite some differences found.

Descriptive study of goat external and middle ear through computed tomography and endoscopic evaluation, compared with the human ear

Abstract Objective: To describe the external and middle ear of goats, using computed tomography and endoscopic dissection, comparing them with the anatomy of the human ear, aiming to evaluate the viability of this animal model for training in otological endoscopic surgery. Methods: Images of the external and middle ear of goats were produced by computed tomography in the coronal and axial planes and analyzed. The radiological anatomy of the external and middle goat and human ear are described. Some measures of surgical interest were described, such as the length of the external auditory canal, external and internal cross-sectional area of the external auditory canal, middle ear depth, vertical angle of the external auditory canal, length of malleus and incus. After the tomographic study, we analyzed the importance of evaluations through the endoscopic dissection of the goat ear. Results: The bony canal is extremely tortuous and shows a bony prominence with significant elevation near the lower edge of the tympanic membrane. The middle ear has a large tympanic bulla in the hypotympanum region. The malleus is shaped similarly to that of the human, but its handle is located anterior to its head. The mastoid is not pneumatized. Compared to the human mastoid, there was a statistically significant difference in the external and internal cross-sectional area, at the depth of the middle ear, in the vertical angle of the canal and in the length of the incus. Conclusion: Goat morphometric anatomy showed that this model is suitable for surgical simulation in the initial training for endoscopic otological surgery. It is an important contribution to the development of skills to accelerate the subsequent endoscopic otological surgical training in humans, despite some differences found.

INFLUENCE OF MINIMALLY INVASIVE LAPAROSCOPIC EXPERIENCE SKILLS ON ROBOTIC SURGERY DEXTERITY.

BACKGROUND: It is unclear if there is a natural transition from laparoscopic to robotic surgery with transfer of abilities. AIM: To measure the performance and learning of basic robotic tasks in a simulator of individuals with different surgical background. METHODS: Three groups were tested for robotic dexterity: a) experts in laparoscopic surgery (n=6); b) experts in open surgery (n=6); and c) non-medical subjects (n=4). All individuals were aged between 40-50 years. Five repetitions of four different simulated tasks were performed: spatial vision, bimanual coordination, hand-foot-eye coordination and motor skill. RESULTS: Experts in laparoscopic surgery performed similar to non-medical individuals and better than experts in open surgery in three out of four tasks. All groups improved performance with repetition. CONCLUSION: Experts in laparoscopic surgery performed better than other groups but almost equally to non-medical individuals. Experts in open surgery had worst results. All groups improved performance with repetition.

Uterine Fibroids and Pregnancy: How Do They Affect Each Other?

The present narrative review is aimed to rekindle discussion regarding whether and how uterine leiomyoma and pregnancy may impact each other. Although fibroids are hormone-dependent lesions, their growth during pregnancy seems to have a nonlinear trend. Besides placental estrogens and progesterone, an array of endocrine and paracrine factors affect fibroid blood supply, growth rate, and risk of degeneration along the gestational and puerperal periods. According to current evidence, the presence of leiomyomas might increase the risk of some adverse pregnancy outcomes. Although a causative relation between fibroids and spontaneous abortion is questionable, the presence of multiple submucosal lesions in certain populations, such as infertile women, may increase the risk of pregnancy loss. Slightly increased risks of placenta previa, placental abruption and fetal malpresentation may occur, mainly due to the mechanical influence of multiple and large fibroids. Cesarean section and preterm birth rates are also probably increased in the presence of fibroids. The risk associations are based on meta-analyses of cohort studies (level of evidence 2a), retrospective cohort studies (2b), case-control (3a), and cross-sectional studies (3b), but with a predominantly low risk of bias. For evaluating the growth pattern of leiomyomas and their real influence on obstetric outcomes, future studies should enroll women with fibroids diagnosed prior to pregnancy and follow them prospectively throughout the gestation and puerperium.

Perfil epidemiológico e assistência clínica a mulheres com endometriose em um hospital universitário público brasileiro / Epidemiological profile and clinical assistance of women with endometriosis in a Brazilian public university hospital

Objetivo: Analisar o perfil epidemiológico e clínico e a assistência médica fornecida às pacientes acompanhadas no ambulatório específico para endometriose em um hospital universitário público brasileiro. Métodos: Trata-se de um estudo transversal retrospectivo. Foram incluídos os prontuários médicos de 153 pacientes com endometriose acompanhadas em nosso ambulatório desde sua criação, em fevereiro de 2017, até abril de 2020. Os dados coletados foram utilizados para estabelecer os sintomas mais prevalentes, os métodos diagnósticos utilizados, os locais acometidos com maior frequência, o tratamento clínico estabelecido e as características epidemiológicas da população estudada. Resultados: A idade média das pacientes foi de 35,2 ± 7,23 anos. Os sintomas mais prevalentes foram dismenorreia (88,2%), dispareunia (65,4%) e infertilidade (52,9%). O ovário foi o local mais acometido (60,1%). A coexistência de doenças autoimunes foi identificada em 7,2% das pacientes. Cerca de 47,7% das pacientes foram diagnosticadas com ressonância magnética pélvica e 45% foram tratadas com dienogeste. Conclusão: O reconhecimento da epidemiologia da endometriose, os sintomas mais frequentes e as comorbidades associadas à doença podem permitir aos profissionais de saúde melhorar sua capacidade diagnóstica e realizar uma assistência clínica individualizada e eficiente.(AU)

Objective: To analyze the epidemiological and clinical profile and the medical assistance provided to patients followed up in the specific outpatient clinic of endometriosis in a Brazilian public university hospital. Methods: It was a cross-sectional retrospective study. Medical records of 153 patients with endometriosis followed up in our specific outpatient clinic, since its creation, in February 2017, until April 2020 were included. Data collected was used to establish the most prevalent symptoms, diagnostic methods used, most frequent sites of involvement, clinical treatment and epidemiological characteristics of the study population. Results: The mean age of patients was 35.2 ± 7.23 years old. The most prevalent symptoms were dysmenorrhea (88.2%), dyspareunia (65.4%) and infertility (52.9%). Ovary was the most affected site (60.1%). The coexistence of autoimmune disease was identified in 7.2% patients. About 47.7% were diagnosed by pelvic magnetic resonance imaging (MRI) and 45% were treated with dienogest. Conclusion: The recognition of endometriosis epidemiology, the most frequent symptoms and the comorbidities associated with the disease may enable health care professionals to improve the diagnostic capacity and to perform an individualized and efficient clinical assistance.(AU)

Prospective evaluation of clarithromycin in recurrent chronic rhinosinusitis with nasal polyps.

INTRODUCTION: The antiinflammatory effects of macrolides, especially clarithromycin, have been described in patients with chronic rhinosinusitis without polyps and also other chronic inflammatory airway diseases. There is no consensus in the literature regarding the effectiveness of clarithromycin in patients with chronic rhinosinusitis with sinonasal polyposis and the national literature does not report any prospective studies on the efficacy of clarithromycin in chronic rhinosinusitis in our population. OBJECTIVE: To evaluate the effect of clarithromycin in the adjunctive treatment of recurrent chronic rhinosinusitis with sinonasal polyposis refractory to clinical and surgical treatment. METHODS: Open prospective study with 52 patients with chronic rhinosinusitis and recurrent sinonasal polyposis. All subjects received nasal lavage with 20 mL 0.9% SS and fluticasone nasal spray, 200 mcg / day, 12/12 h for 12 weeks; and clarithromycin 250 mg 8/8 h for 2 weeks and, thereafter, 12/12 h for 10 weeks. The patients were assessed by SNOT 20, NOSE and Lund-Kennedy scales before, immediately after treatment and 12 weeks after treatment. The patients were also evaluated before treatment with paranasal cavity computed tomography (Lund-Mackay) and serum IgG, IgM, IgA, IgE and eosinophil levels. The outcomes evaluated were: SNOT-20, NOSE and Lund-Kennedy. RESULTS: Most patients were women, aged 47 (15) years (median / interquartile range), and 61.5% (32/52) had asthma. All patients completed the follow-up after 12 weeks and 42.3% (22/52) after 24 weeks. Treatment resulted in a quantitative decrease in the SNOT-20 [2.3 (1.6) vs. 1.4 (1.6); Δ = -0.9 (1.1); p < 0.01]; NOSE [65 (64) vs. 20 (63); Δ = -28 (38), p < 0.01] and Lund-Kennedy [11 (05) vs. 07 (05); Δ = -2 (05); p < 0.01] scores. SNOT-20 showed a qualitative improvement (>0.8) in 54% (28/52, p < 0.04) of patients, a group that showed lower IgE level [108 (147) vs. 289 (355), p < 0.01]. The group of patients who completed follow-up 12 weeks after the end of treatment (n = 22) showed no worsening of outcomes. CONCLUSION: Long-term adjuvant use of low-dose clarithromycin for chronic rhinosinusitis patients with recurrent sinonasal polyposis refractory to clinical and surgical treatment has resulted in improved quality of life and nasal endoscopy findings, especially in patients with normal IgE levels. This improvement persisted in the patient group evaluated 12 weeks after the end of the treatment.

Sulfato de magnésio: principais utilizações na obstetrícia contemporânea / Magnesium sulphate: main uses in contemporary obstetrics

O sulfato de magnésio tem sido utilizado em obstetrícia por décadas e milhares de mulheres já foram incluídas em ensaios clínicos que estudaram sua eficácia em uma variedade de condições gestacionais. Os principais usos do medicamento na atual prática obstétrica incluem prevenção e tratamento de convulsões eclâmpticas, prolongamento da gravidez para administração antenatal de corticosteroides e neuroproteção fetal na iminência de interrupção prematura da gravidez. Em função da alta qualidade e da consistência dos resultados de importantes ensaios clínicos, a indicação do sulfato de magnésio para profilaxia e terapia das convulsões eclâmpticas está bem estabelecida. Entretanto, tal unanimidade não ocorre com relação ao seu emprego como tocolítico, tanto pela discussão sobre sua efetividade quanto pelas doses mais altas usualmente utilizadas para esse fim. Em relação à importância do sulfato de magnésio como agente neuroprotetor fetal, a paralisia cerebral é a causa mais comum de deficiência motora na infância e tem como fator de risco mais importante a prematuridade, cuja incidência tem aumentado significativamente. Diretrizes nacionais e internacionais mais recentes, baseadas em resultados de ensaios clínicos randomizados e metanálises de boa qualidade, mostraram que a administração antenatal de sulfato de magnésio na iminência de parto pré-termo precoce é uma intervenção eficiente, viável, segura, com boa relação custo-benefício e pode contribuir para a melhoria dos desfechos neurológicos neonatais.

Magnesium sulfate has been used in obstetrics for decades and thousands of women have already been included in clinical trials that have studied its effectiveness in a variety of gestational conditions. The main uses of the drug in current obstetrical practice include prevention and treatment of eclamptic seizures, prolongation of pregnancy for antenatal administration of corticosteroids, and fetal neuroprotection in the imminence of premature termination of pregnancy. Because of the high quality and consistency of the results of important clinical trials, the indication of magnesium sulfate for prophylaxis and therapy of eclamptic seizures is well established. However, such unanimity does not occur regarding its use as tocolytic, either by the discussion of its effectiveness or by the higher doses usually used for this purpose. Regarding the importance of magnesium sulfate as a fetal neuroprotective agent, cerebral palsy is the most common cause of motor deficits in childhood and has a significantly higher incidence of prematurity as a major risk factor. More recent national and international guidelines, based on results from randomized controlled trials and good quality meta-analyzes, have shown that the antenatal administration of magnesium sulfate at the imminence of early preterm delivery is a cost-effective, viable, efficient intervention and safe and can contribute to the improvement of neonatal neurological outcomes.

Influence of minimally invasive laparoscopic experience skills on robotic surgery dexterity / Influência da experiência da cirurgia laparoscópica na destreza da cirurgia robótica

ABSTRACT Background: It is unclear if there is a natural transition from laparoscopic to robotic surgery with transfer of abilities. Aim: To measure the performance and learning of basic robotic tasks in a simulator of individuals with different surgical background. Methods: Three groups were tested for robotic dexterity: a) experts in laparoscopic surgery (n=6); b) experts in open surgery (n=6); and c) non-medical subjects (n=4). All individuals were aged between 40-50 years. Five repetitions of four different simulated tasks were performed: spatial vision, bimanual coordination, hand-foot-eye coordination and motor skill. Results: Experts in laparoscopic surgery performed similar to non-medical individuals and better than experts in open surgery in three out of four tasks. All groups improved performance with repetition. Conclusion: Experts in laparoscopic surgery performed better than other groups but almost equally to non-medical individuals. Experts in open surgery had worst results. All groups improved performance with repetition.

RESUMO Racional: É incerto se há transferência natural de habilidades da cirurgia laparoscópica para a robótica. Objetivo: Avaliar o desempenho e aprendizado de tarefas em plataforma robótica simulada em indivíduos com diferentes conhecimentos em cirurgia. Método: Três grupos de indivíduos foram testados quanto à habilidade robótica: a) especialistas em cirurgia laparoscópica (n=6); b) especialista em cirurgia convencional (n=6); e c) indivíduos não médicos. A idade variou em todo grupo entre 40-50 anos. Cinco repetições de quatro tarefas simuladas foram realizadas: visão espacial, coordenação bimanual, coordenação mão-pé-olho e destreza manual. Resultados: Especialistas em cirurgia laparoscópica tiveram desempenho semelhante aos indivíduos não médicos e melhor que os especialistas em cirurgia convencional em três das quatro tarefas. Todos os grupos melhoraram desempenho com repetições . Conclusão: Especialistas em cirurgia laparoscópica desempenharam melhor que os outros grupos, mas quase igualitariamente aos indivíduos não médicos. Especialista em cirurgia convencional apresentaram os piores resultados. Todos os grupos melhoraram com as repetições.

Progesterone receptor ligands for the treatment of endometriosis: the mechanisms behind therapeutic success and failure.

BACKGROUND: Despite intense research, it remains intriguing why hormonal therapies in general and progestins in particular sometimes fail in endometriosis. OBJECTIVE AND RATIONALE: We review here the action mechanisms of progesterone receptor ligands in endometriosis, identify critical differences between the effects of progestins on normal endometrium and endometriosis and envisage pathways to escape drug resistance and improve the therapeutic response of endometriotic lesions to such treatments. SEARCH METHODS: We performed a systematic Pubmed search covering articles published since 1958 about the use of progestins, estro-progestins and selective progesterone receptor modulators, to treat endometriosis and its related symptoms. Two reviewers screened the titles and abstracts to select articles for full-text assessment. OUTCOMES: Progesterone receptor signalling leads to down-regulation of estrogen receptors and restrains local estradiol production through interference with aromatase and 17 beta-hydroxysteroid dehydrogenase type 1. Progestins inhibit cell proliferation, inflammation, neovascularisation and neurogenesis in endometriosis. However, progesterone receptor expression is reduced and disrupted in endometriotic lesions, with predominance of the less active isoform (PRA) over the full-length, active isoform (PRB), due to epigenetic abnormalities affecting the PGR gene transcription. Oxidative stress is another mechanism involved in progesterone resistance in endometriosis. Among the molecular targets of progesterone in the normal endometrium that resist progestin action in endometriotic cells are the nuclear transcription factor FOXO1, matrix metalloproteinases, the transmembrane gap junction protein connexin 43 and paracrine regulators of estradiol metabolism. Compared to other phenotypes, deep endometriosis appears to be more resistant to size regression upon medical treatments. Individual genetic characteristics can affect the bioavailability and pharmacodynamics of hormonal drugs used to treat endometriosis and, hence, explain part of the variability in the therapeutic response. WIDER IMPLICATIONS: Medical treatment of endometriosis needs urgent innovation, which should start by deeper understanding of the disease core features and diverse phenotypes and idiosyncrasies, while moving from pure hormonal treatments to drug combinations or novel molecules capable of restoring the various homeostatic mechanisms disrupted by endometriotic lesions.

Is Stress a Cause or a Consequence of Endometriosis?

Clinical studies clearly indicate that endometriosis is a condition associated with high levels of chronic stress. The stress intensity correlates with pain severity and disease extension. However, it is unknown whether chronic stress represents a primary cause of endometriosis and, therefore, if avoiding or treating chronic stress may reduce the risk of developing endometriosis. Repeated, uncontrolled stress either before or after experimental endometriosis induction promotes disease mechanisms and accelerates lesion growth in rodents. Furthermore, patients with endometriosis have a heightened risk of other inflammatory and immune-related diseases, many of which have also been associated with stress. Here, we review the latest evidences regarding the relationship between chronic stress and endometriosis and discuss the potential bidirectional aspect of such association. Further research may clarify if endometriosis is a cause and/or a consequence of stress and whether stress-reducing therapies are effective to mitigate symptoms and slow down the development of endometriotic lesions.

Surgical treatment of endometriosis: prognostic factors for better quality of life.

The present study investigated the effect of surgical treatment of endometriosis on physical and mental health. We undertook a prospective survey including 153 premenopausal women with histological diagnosis of endometriosis. The Short Form 12 (SF-12) questionnaire comprising physical and mental component scales was used. Two groups of patients were distinguished: Group A (n = 42) with SF-12 scores above the median in both physical and mental scales; Group B (n = 111) with SF-12 scores below the median in either physical or mental scale. Group A was diagnosed and operated for endometriosis for the first time at an older age (30 vs. 26 years), had undergone more frequently a single surgical intervention (64% vs. 46%), was less affected by symptom or lesion recurrence and had reported less intense current pain symptoms than Group B. Having the first endometriosis surgery at a later age was an independent predictor of better health status (adjusted odds ratio 1.146 per year, 95% confidence interval 1.058-1.242) after accounting for the potential confounding effects of reoperation, pelvic pain and time elapsed since the first surgery. In conclusion, patients with endometriosis who had a single surgery at an older age have good symptom control and better quality of life (QoL).

New biomarkers in endometriosis.

Endometriosis is a benign gynecological disorder which presents significant challenges in terms of diagnosis and management. Despite decades of research, there are no sufficiently sensitive and specific signs and symptoms nor blood tests for the clinical confirmation of endometriosis, which hampers prompt diagnosis and treatment. The huge majority of potential biomarkers has been discarded in research stage and very few have been translated to clinical practice. Serum CA-125 is the most studied and used one, but studies have shown its poor diagnostic performance. Several factors involved in the chronic inflammatory process of endometriosis, such as hormones, cytokines, chemokines, angiogenic factors, oxidative stress markers and others, have been implicated in the disease's pathogenesis and have been extensively studied, but not a single one has successfully been able to accurately identify the disease. MicroRNAs have emerged more recently but their utility to detect endometriosis remains uncertain. The search for a biomarker or a set of biomarkers is still open and may benefit from novel molecular biology and bioinformatics approaches to mine and uncover molecular signatures specifically associated with the disease.

Neuroproteção fetal: uma utilização contemporânea do sulfato de magnésio / Fetal neuroprotection: a contemporary use of magnesium sulfate

Os principais usos contemporâneos do sulfato de magnésio na prática obstétrica incluem a prevenção e o tratamento de convulsões em portadoras de pré-eclâmpsia e eclâmpsia, o prolongamento da gravidez para administração antenatal de corticosteroides e a neuroproteção fetal na iminência de interrupção prematura da gestação, uma indicação mais recente. A paralisia cerebral é a causa mais comum de deficiência motora na infância e apresenta como fator de risco mais importante o nascimento pré-termo, cuja incidência tem aumentado significativamente. Como consequência, a ocorrência da paralisia cerebral também tem aumentado, a despeito da melhoria da sobrevida dos fetos pré-termos. No atual contexto de procura por estratégias que se mostrem efetivas na redução da paralisia cerebral nos recém-nascidos prematuros e que deveriam ser implementadas com o objetivo de diminuir os seus efeitos danosos nos indivíduos e suas famílias, nos serviços de saúde e na sociedade como um todo, o sulfato de magnésio tem se mostrado como o mais promissor agente neuroprotetor fetal. Desde a década de 1990, estudos resultantes das suas indicações para a prevenção das convulsões eclâmpticas ou para tocólise têm evidenciado redução nas taxas de paralisia cerebral e leucomalácia periventricular em prematuros. Diretrizes nacionais e internacionais mais recentes, baseando-se em resultados de ensaios randomizados controlados e metanálises de boa qualidade, têm avançado na recomendação sobre os regimes terapêuticos e na construção de algoritmos para utilização do sulfato de magnésio na neuroproteção fetal.(AU)

The main contemporary uses of magnesium sulfate in obstetric practice include the prevention and treatment of seizures in patients with preeclampsia and eclampsia, prolongation of pregnancy for antenatal administration of corticosteroids and fetal neuroprotection at the imminence of premature termination of pregnancy, a more recent indication. Cerebral palsy is the most common cause of motor deficits in childhood and has a significant increase in preterm birth as a major risk factor. As a result, the occurrence of cerebral palsy has also increased, despite the improvement in the survival of preterm fetuses. In the current context of search for strategies that are effective in reducing cerebral palsy in preterm newborns and that should be implemented with the aim of reducing their harmful effects on individuals and their families, health services and society as a whole, magnesium sulfate has been shown to be the most promising fetal neuroprotective agent. Since the 1990s, studies arising from its indications for prevention of eclamptic seizures or tocolysis have shown a reduction in the rates of cerebral palsy and periventricular leukomalacia in preterm infants. More recent national and international guidelines, based on results from randomized controlled trials and good quality meta-analyzes, have advanced the recommendation on therapeutic regimens and the construction of algorithms for the use of magnesium sulphate in fetal neuroprotection.(AU)

Apoptosis modulation by activin A and follistatin in human endometrial stromal cells.

Activin A is a growth factor that stimulates decidualization and is abundantly expressed in endometrial proliferative disorders. Nevertheless, whether it directly affects endometrial cell survival is still unknown. This study investigated the effects of activin A on total death and apoptosis rates and on tumor necrosis factor (TNF) release by human endometrial stromal cells (HESC). We performed a controlled prospective in vitro study using primary HESC cultures obtained from healthy reproductive age women (n = 11). Cells were treated with medium alone (control) or activin A (25 ng/mL) or activin A (25 ng/mL) and its antagonist follistatin (250 ng/mL). Apoptosis and total cell death were measured by flow cytometry, while TNF concentrations in culture media were quantified by ELISA. Activin A decreased the percentage of apoptotic/dead cells from 31% to 22% (p < 0.05, paired t-test) and reduced TNF levels in culture medium by 14%, but there was no linear correlation between TNF release and apoptotic rates. Both effects of activin A were reversed by follistatin. These findings indicate that activin A promotes HESC survival, possibly by a TNF-independent pathway. This mechanism may be critical to the actions of activin A upon stromal cell growth and differentiation in physiology and disease.

Acolhimento na Atenção Primária à Saúde: revisão integrativa / Reception in Primary Health Care: an integrative review

O presente estudo tem por objetivo analisar o conhecimento produzido sobre o acolhimento na Atenção Primária à Saúde, nos últimos oito anos. Trata-se de uma revisão integrativa, relacionada também ao acolhimento no âmbito da Estratégia Saúde da Família. Pode-se afirmar que o processo de acolhimento ainda não está totalmente sistematizado nos modelos de atenção à saúde, podendo ser esta uma justificativa para as dificuldades apresentadas tanto por profissionais quanto por usuários. São necessários estudos com novas abordagens ou estratégias para a sistematização do acolhimento nas unidades de Atenção Primária à Saúde, e verificar se estas têm realmente impacto na qualidade dos serviços e na satisfação dos usuários.

The present study aims to analyze the knowledge produced about the reception in the Primary Health Care, in the last eight years. It is about an integrative review, also related to the reception within the Family Health Strategy. It can be stated that the reception process is not yet fully systematized in the models of health care, and this may be a justification for the difficulties presented by both professionals and users. There are necessary studies with new approaches or strategies for the systematizing of the reception in units of Primary Health Care, and verify if these actually have an impact on the quality of services and in the users satisfaction.

Catatonia due to systemic lupus erythematosus / Catatonia secundária a lúpus eritematoso sistêmico

Objectives Discuss neuropsychiatric aspects and differential diagnosis of catatonic syndrome secondary to systemic lupus erythematosus (SLE) in a pediatric patient. Methods Single case report. Result A 13-year-old male, after two months diagnosed with SLE, started to present psychotic symptoms (behavioral changes, hallucinations and delusions) that evolved into intense catatonia. During hospitalization, neuroimaging, biochemical and serological tests for differential diagnosis with metabolic encephalopathy, neurological tumors and neuroinfections, among other tests, were performed. The possibility of neuroleptic malignant syndrome, steroid-induced psychosis and catatonia was also evaluated. A complete reversal of catatonia was achieved after using benzodiazepines in high doses, associated with immunosuppressive therapy for lupus, which speaks in favor of catatonia secondary to autoimmune encephalitis due to lupus. Conclusion Although catatonia rarely is the initial clinical presentation of SLE, the delay in recognizing the syndrome can be risky, having a negative impact on prognosis. Benzodiazepines have an important role in the catatonia resolution, especially when associated with parallel specific organic base cause treatment. The use of neuroleptics should be avoided for the duration of the catatonic syndrome as it may cause clinical deterioration. .

Objetivos Discutir aspectos neuropsiquiátricos e o diagnóstico diferencial da síndrome catatônica secundária a lúpus eritematoso sistêmico (LES) em paciente pediátrico. Métodos Relato de caso individual. Resultado Adolescente do sexo masculino com 13 anos de idade iniciou, após dois meses de diagnosticado com LES, quadro psicótico (alterações comportamentais, alucinações e delírios) que evoluiu para franca catatonia. Durante internação hospitalar foram realizados, entre outros, exames de neuroimagem, bioquímicos e sorologias para diagnóstico diferencial com encefalopatia metabólica, tumores neurológicos e neuroinfecções. Foi avaliada também a possibilidade de síndrome neuroléptica maligna, psicose e catatonia induzida por corticoides. Houve reversão completa da catatonia após o uso de benzodiazepínico em altas doses associado à terapia imunossupressora para o lúpus, o que fala a favor de uma catatonia secundária a uma encefalite autoimune de base lúpica. Conclusão Apesar de a catatonia ser raramente apresentação clínica inicial do LES, o atraso no reconhecimento da síndrome pode ser arriscado, tendo impacto negativo no prognóstico. Os benzodiazepínicos têm papel importante na resolução da catatonia, principalmente quando associada ao tratamento específico em paralelo para a causa orgânica de base. O uso de neurolépticos deve ser evitado durante a vigência da síndrome catatônica, podendo agravar o quadro clínico. .

Assistência pré-natal às usuárias de drogas ilícitas / Prenatal care of illicit drugs users

O uso de drogas ilícitas na gravidez é um problema complexo de cunho social e de saúde pública. Com ocorrência crescente na população mundial, resulta no aumento significativo da morbiletalidade materno-fetal, com maiores taxas da exposição às drogas e da síndrome de abstinência neonatal, além de prejuízos no desenvolvimento subsequente das crianças expostas a tais substâncias. Em virtude da variedade de fatores sociais, psicossociais, comportamentais e biomédicos que estão implicados nos resultados neonatais adversos, as usuárias devem receber orientações acerca dos riscos periconcepcionais, anteparto e pósparto causados pelas drogas de abuso. Idealmente, a assistência pré-natal deve ser realizada por uma equipe multidisciplinar. Os tocoginecologistas têm a obrigação ética de aprender e utilizar protocolos para rastreio universal do uso das substâncias ilegais, empreender intervenções iniciais e encaminhar as usuárias e seus familiares para tratamento médico especializado. A construção de uma relação médico-paciente desprovida de preconceitos e baseada em confiança recíproca é também pré-requisito fundamental. A frequência das consultas pré-natais e a avaliação da vitalidade fetal devem ser pautadas pela análise constante e individualizada dos riscos, segundo as diretrizes de assistência às gestações de alto risco. Após o parto, o seguimento das mães, dos recém-nascidos e de suas famílias deve prosseguir em serviços devidamente capacitados.(AU)

Illicit drugs use in pregnancy is a complex social and public health issue. As a growing problem worldwide, it results in significant increase of maternal and fetal morbidity and mortality, with higher rates of drug exposure and neonatal abstinence syndrome, besides loss in the subsequent development of children exposed to such substances. Due to the variety of social, psychosocial, behavioral and biomedical factors that are implicated in adverse neonatal outcomes, users should receive guidance regarding conception, antepartum and postpartum risks caused by illicit drugs. Ideally, prenatal care should be performed by a multidisciplinary team. Obstetricians and gynecologists have an ethical obligation to learn and utilize universal screening protocols for the use of illegal substances, undertake initial interventions and refer users and their families for specialized medical treatment. The construction of a non-judgemental physician-patient relationship based on reciprocal trust is also a fundamental prerequisite. The frequency of antenatal visits and assessment of fetal well-being must be guided by constant and individualized analysis of risks, according to the guidelines of care for high-risk pregnancies. After birth, the follow-up of mothers, newborns and their families should continue in properly prepared health care services.(AU)

Gravidez ectópica em cicatriz de cesárea: uma complicação emergente / Cesarean scar ectopic pregnancy: an emerging complication

Entre as complicações de longo prazo da operação cesariana, destacam-se o acretismo placentário (placenta acreta, increta e percreta) e, mais recentemente, a implantação embrionária na cicatriz uterina de cesárea prévia. A denominada gravidez ectópica em cicatriz de cesárea persiste como um evento pouco divulgado em função da sua raridade; porém, apresenta incidência crescente devido principalmente ao aumento global das taxas de cesariana. Os atrasos no diagnóstico e no tratamento podem resultar em ruptura uterina, hemorragia grave, necessidade de histerectomia e elevada mortalidade materna. Dessa forma, os objetivos principais na condução dos casos de gravidez ectópica em cicatriz de cesárea devem incluir o diagnóstico ultrassonográfico precoce e acurado e a prevenção de hemorragias graves, além da preservação da fertilidade. Entretanto, devido à sua raridade, ainda não há consenso acerca da melhor forma de tratamento dessa complicação.(AU)

Among the long-term complications of cesarean section stand out the pathologically adherent placenta (accreta, increta and percreta) and, more recently, the embryonic implantation in the uterine scar from previous cesarean. The so-called cesarean scar ectopic pregnancy remains a little known event due to its rarity. But it shows increasing incidence due mainly to the overall increase in cesarean rates. The delay in diagnosis and treatment can result in uterine rupture, severe hemorrhage, need for hysterectomy and high maternal mortality. Thus, the main objectives in the management of cesarean scar ectopic pregnancy should include early and accurate ultrasound diagnosis and prevention of severe blood loss, and the preservation of fertility. However, due to its rarity, there is no consensus about the best treatment for this complication.(AU)