Staphylococcus lugdunensis Endocarditis Presenting with Brain Abscesses and Temporal Vision Deficits.

Staphylococcus lugdunensis is a coagulase-negative staphylococcal bacterium (CoNS) that colonizes the skin. While infectious endocarditis (IE) caused by S. lugdunensis is rare, it is noteworthy because it has been associated with an aggressive clinical course. In this report, we present a case of culture-negative IE complicated by brain abscesses, vision deficits, and progressive heart failure that ultimately required mitral valve replacement. The causative agent was eventually identified as S. lugdunensis through molecular testing of valvular tissue.

A case of cryptococcoma in an immunocompetent man with polysubstance use.

Cryptococcus most commonly affects the pulmonary and central nervous systems in patients who are immunocompromised. It is most likely to present as meningitis. However, it can affect immunocompetent patients in the cerebral parenchyma. Here we describe a rare case of cryptococcoma in an immunocompetent male patient who originally presented with headache and possible seizure-like activity and had IV drug use as a risk factor. Cryptococcomas are a rare manifestation of the disease, and can present due to Cryptococcus gatti. Definite diagnosis is dependent on culture of the organism and treatment includes a long course of anti-fungals.

Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors.

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

Progression of chronic rhinosinusitis to invasive cerebro-orbital aspergillosis following steroid treatment: A case of induced immunosuppression.

Invasive aspergillosis is a classic fungal infection of immunocompromised hosts which rarely manifests in immunocompetent patients. In this report, we present a case of invasive aspergillosis which resulted from induced immunosuppression through corticosteroid treatment of chronic rhinosinusitis. Further investigation is necessary into the epidemiology of mixed fungal rhinosinusitis and providers should be wary of invasive disease in those receiving chronic steroids.

Clinical Impact of Staphylococcus aureus Skin and Soft Tissue Infections.

The pathogenic bacterium Staphylococcus aureus is the most common pathogen isolated in skin-and-soft-tissue infections (SSTIs) in the United States. Most S. aureus SSTIs are caused by the epidemic clone USA300 in the USA. These infections can be serious; in 2019, SSTIs with S. aureus were associated with an all-cause, age-standardized mortality rate of 0.5 globally. Clinical presentations of S. aureus SSTIs vary from superficial infections with local symptoms to monomicrobial necrotizing fasciitis, which can cause systemic manifestations and may lead to serious complications or death. In order to cause skin infections, S. aureus employs a host of virulence factors including cytolytic proteins, superantigenic factors, cell wall-anchored proteins, and molecules used for immune evasion. The immune response to S. aureus SSTIs involves initial responders such as keratinocytes and neutrophils, which are supported by dendritic cells and T-lymphocytes later during infection. Treatment for S. aureus SSTIs is usually oral therapy, with parenteral therapy reserved for severe presentations; it ranges from cephalosporins and penicillin agents such as oxacillin, which is generally used for methicillin-sensitive S. aureus (MSSA), to vancomycin for methicillin-resistant S. aureus (MRSA). Treatment challenges include adverse effects, risk for Clostridioides difficile infection, and potential for antibiotic resistance.

Capnocytophaga sepsis causing purpura fulminans in a 50-year-old man with chronic opioid use.

We present a case of polymicrobial sepsis with Capnocytophaga spp. complicated by purpura fulminans following a dog-bite in a 50-year-old-man with an extensive history of opioid use disorder. Generally, severe Capnocytophaga cases are thought to occur in patients with underlying immune deficiencies. However, this case highlights the importance of maintaining clinical suspicion for Capnocytophaga infection in immunocompetent patients, and we discuss the role of chronic opioid-use in severe infection.

An unusual case of Lemierre syndrome - One pathogen or two?

Lemierre syndrome, or septic thrombophlebitis of the internal jugular vein, is a rare disease that affects healthy young adults following an episode of pharyngitis or other upper respiratory disease. It most commonly involves the anaerobe Fusobacterium necrophorum, a component of normal oral flora. In this report, we present an unusual case of polymicrobial Lemierre syndrome involving both F. necrophorum and Group C streptococcus following an episode of pharyngitis and streptococcal toxic shock syndrome. Providers should consider the possibility of polymicrobial infection when there are imaging findings suggestive of Lemierre Syndrome and adjust antibiotic regimens accordingly.

Association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19.

Importance: Therapies that improve survival in critically ill patients with coronavirus disease 2019 (COVID-19) are needed. Tocilizumab, a monoclonal antibody against the interleukin 6 receptor, may counteract the inflammatory cytokine release syndrome in patients with severe COVID-19 illness. Objective: To test whether tocilizumab decreases mortality in this population. Design, Setting, and Participants: The data for this study were derived from a multicenter cohort study of 4485 adults with COVID-19 admitted to participating intensive care units (ICUs) at 68 hospitals across the US from March 4 to May 10, 2020. Critically ill adults with COVID-19 were categorized according to whether they received or did not receive tocilizumab in the first 2 days of admission to the ICU. Data were collected retrospectively until June 12, 2020. A Cox regression model with inverse probability weighting was used to adjust for confounding. Exposures: Treatment with tocilizumab in the first 2 days of ICU admission. Main Outcomes and Measures: Time to death, compared via hazard ratios (HRs), and 30-day mortality, compared via risk differences. Results: Among the 3924 patients included in the analysis (2464 male [62.8%]; median age, 62 [interquartile range {IQR}, 52-71] years), 433 (11.0%) received tocilizumab in the first 2 days of ICU admission. Patients treated with tocilizumab were younger (median age, 58 [IQR, 48-65] vs 63 [IQR, 52-72] years) and had a higher prevalence of hypoxemia on ICU admission (205 of 433 [47.3%] vs 1322 of 3491 [37.9%] with mechanical ventilation and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of <200 mm Hg) than patients not treated with tocilizumab. After applying inverse probability weighting, baseline and severity-of-illness characteristics were well balanced between groups. A total of 1544 patients (39.3%) died, including 125 (28.9%) treated with tocilizumab and 1419 (40.6%) not treated with tocilizumab. In the primary analysis, during a median follow-up of 27 (IQR, 14-37) days, patients treated with tocilizumab had a lower risk of death compared with those not treated with tocilizumab (HR, 0.71; 95% CI, 0.56-0.92). The estimated 30-day mortality was 27.5% (95% CI, 21.2%-33.8%) in the tocilizumab-treated patients and 37.1% (95% CI, 35.5%-38.7%) in the non-tocilizumab-treated patients (risk difference, 9.6%; 95% CI, 3.1%-16.0%). Conclusions and Relevance: Among critically ill patients with COVID-19 in this cohort study, the risk of in-hospital mortality in this study was lower in patients treated with tocilizumab in the first 2 days of ICU admission compared with patients whose treatment did not include early use of tocilizumab. However, the findings may be susceptible to unmeasured confounding, and further research from randomized clinical trials is needed.

Marked Sinus Bradycardia Associated With Remdesivir in COVID-19: A Case and Literature Review.

Remdesivir has seen extensive use during the coronavirus disease-2019 pandemic given its clinically proven efficacy against severe acute respiratory syndrome coronavirus type 2. There has been little cited regarding adverse effects. Here we present the case of a patient with marked sinus bradycardia that began acutely on initiation of remdesivir and resolved almost immediately on cessation of the drug. (Level of Difficulty: Beginner.).

Las revisiones sistemáticas y los metaanálisis en anestesiología: se publican pocos: 1ª parte / Systematic reviews and meta-analyses in anesthesiology: are too few published: 1st. part

En esta primera entrega se desarrolla una comunicación acerca de los conceptos básicos sobre las revisiones sistemáticas (RS) y los metaanálisis (MA) como diseños de investigación de mayor evidencia en el campo de las ciencias de la salud. Particularmente en nuestra especialidad, son relativamente pocos y controversiales las revisiones sistemáticas y los metaanálisis publicados en comparación con otras disciplinas, principalmente la clínica médica, la cardiología, la pediatría y la epidemiología. En este artículo se enumeran las características más relevantes de estos tipos de diseños, su metodología, sus ventajas y desventajas, los problemas que surgen en su construcción como en su interpretación y, por último, el papel que desempeña la Colaboración Cochrane en el terreno de los MA y las RS en cuanto a su desarrollo y análisis crítico. En una segunda entrega, se llevará a cabo una revisión sistemática de RS y MA en el campo de la anestesiología a los efectos de ponderar cuali y cuantitativamente el papel que cumplen estos diseños en nuestra disciplina.

This first part is a communication about the basic concepts regarding systematic reviews (SR) and meta-analyses (MA) as research reviews with the best evidence in the field of health sciences. In our specialty in particular, there are relative few and rather controversial systematic reviews and meta-analyses published, as compared to other disciplines, mainly clinical medicine, cardiology, pediatrics and epidemiology. This article enumerates the most salient features of these types of design, their methodology, pros and cons, the problems that arise during their construction as well as their interpretations and lastly, the role of the Cochrane Cooperation in the field of MAs and RSs in regard to their development and critical analysis. A second paper will contain a systematic review of RSs and MSs in the field of anesthesiology in order to weigh the role of these designs in our discipline, both he qualitatively and quantitatively.

Nesta primeira entrega, são abordados os conceitos básicos sobre as revisões sistemáticas (RS) e meta-análises (MA) como desenhos de pesquisa de máxima evidência no campo das ciências da saúde. Particularmente em nossa especialidade, são relativamente poucos e controvertidos as revisões sistemáticas e meta-análises publicadas em comparação com outras disciplinas, principalmente clínica médica, cardiologia, pediatria e epidemiologia. Neste artigo, são enumeradas as características mais relevantes desses tipos de desenhos, sua metodologia, suas vantagens e desvantagens, os problemas que surgem em sua construção e interpretação e, por último, o papel que desempenha a Colaboração Cochrane no terreno dos MA e as RS no que diz respeito ao seu desenvolvimento e análise crítica. Em uma segunda entrega, será feita uma revisão sistemática das RS e MA na área da anestesiologia, com a finalidade de ponderar qualitativamente e quantitativamente o papel desses desenhos em nossa disciplina.

Abordaje diagnóstico y terapéutico de la cefalea en racimos (cluster headache): aplicación de un modelo de análisis de decisión / Diagnostic and therapeutic approach to cluster headache: application of a decision-making analysis model

Introducción: Las ciencias de la decisión conforman el conjunto de técnicas y teorías surgido del método cuantitativo y matemático dirigido al auxilio de una toma de decisiones con criterio aplicable a varias disciplinas y en los más variados contextos, donde la multicausalidad y la influencia de múltiples factores hace difícil la elección de una decisión unívoca, dado que la incertidumbre es el patrón común situacional. Se presenta a continuación el caso concreto de un paciente de 50 años portador de una cefalea en racimos, en el que se aplica el análisis de decisión de abordaje diagnóstico-terapéutico, y se elige la conducta a seguir basándose en esta metodología. Objetivos: Aplicar este modelo de análisis de la decisión a un problema clínico individual: un paciente de 50 años, portador de una cefalea en racimos o acuminada. Demostrar que en este caso clínico puntual, ante varias opciones diagnósticas y terapéuticas, el intervencionismo antálgico es una de las herramientas más efectivas y elegidas por los pacientes, teniendo en cuenta aspectos tales como la evidencia científica de respaldo de cada alternativa, la calidad de vida de los pacientes con dolor crónico no oncológico de tipo invalidante y el uso de una metodología concreta para la toma de decisión. Material y métodos: Aplicación de un análisis de decisión diagnóstico (terapéutico concreto), presentando un caso clínico real de cefalea en racimos. Búsqueda bibliográfica en Medline y OVID. Para la formulación de los valores umbrales, el análisis de sensibilidad y la graficación del árbol de decisión se utilizó el paquete estadístico STATA - DATA TREE AGE 3.5. Como outcome principal se determinó la expectativa de vida ajustada por calidad (medida en QALYs)...

Introduction: The science of decision-making is a set of techniques and theories arising from the quantitative and mathematic method, aimed at assisting in decision-making with criterion, applicable to many disciplines and numerous different contexts in which multi-causality and the influence of multiple factors make the choice of an unequivocal decision difficult, as uncertainty is the common pattern of the situation. Following is the case history of a 50-year-old patient suffering from cluster headaches; the analysis of decision-making as to the diagnostic-therapeutic approach is applied and the choice of conduct is based on this methodology. Objectives: To apply this decision-making analysis model to a clinical problem: a 50-year-old patient with cluster or acuminate headaches. To prove that in this specific clinical case, faced with different diagnostic and therapeutic options, antalgic interventionism is one of the most effective tools and is chosen by patients, taking into account aspects such as scientific backing proof of each alternative, quality of life of patients with chronic non-oncology invalidating pain and the use of a specific methodology for making the decision. Material and methods: Application of a diagnostic decision analysis, with a real clinical case of cluster headaches. Bibliographic research in Medline and OVID. To formulate threshold values, the sensitivity analysis and graphing the decision tree, the STATA - DATA TREE AGE 3.5 was used. As main outcome, the life expectancy adjusted by quality (measured in QALYs) was determined. Results: Once the sequence of the analysis was developed, the model firmly showed that the best diagnosis prognosis decision is to make a best diagnosis-prognosis block with local anesthetics and, should it be positive, to proceed to denervate the sphenoid-palatine ganglion by radiofrequency...

Introdução: As ciências da decisão conformam um conjunto de técnicas e teorias surgido do método quantitativo e matemático direcionado ao auxílio de uma tomada de decisão criteriosa, aplicável a diversas disciplinas e nos mais variados contextos, onde a multicausalidade e a influencia de múltiplos fatores torna difícil a escolha de uma decisão unívoca, já que a incerteza é o padrão situacional genérico. Apresenta-se o caso de um paciente de 50 anos, portador de cefaléia em cacho, em que foi aplicado o processo de análise de decisão de abordagem diagnóstica-terapêutica, sendo escolhida a conduta a seguir tomando como base esta metodologia. Objetivos: Aplicar este modelo de análise de decisão a um problema clínico individual: um paciente de 50 anos, portador de uma cefaléia em cacho ou acuminada. Provar que neste caso clínico particular, a intervenção antálgica, diante de várias opções diagnósticas e terapêuticas, é uma das ferramentas mais eficazes e escolhidas pelos pacientes, considerando aspectos tais como a evidência científica de apoio a cada alternativa, a qualidade de vida dos pacientes com dor crônica não oncológica incapacitante e o uso de uma metodologia concreta para a tomada de decisão. Material e métodos: Aplicação de uma análise de decisão diagnóstica (terapêutica concreta), apresentando um caso clínico real de cefaléia em cacho. Busca bibliográfica na Medline e na OVID. Para a formulação dos valores limiares, a análise de sensibilidade e a representação gráfica da árvore de decisão, foi utilizado o pacote estatístico STATA - DATA TREE AGE 3.5. Como outcome principal, determinou-se a expectativa de vida ajustada à qualidade (medida em QALYs). Resultados: Desenvolvida a seqüência da análise, o modelo mostra, de forma contundente, que a melhor decisão diagnóstica-terapêutica é o bloqueio diagnóstico-prognóstico com anestésicos locais, e caso esse bloqueio seja satisfatório, fazer a denervação por radiofreqüência do ganglio esfenopalatino...

Abordaje diagnóstico y terapéutico de la cefalea en racimos (cluster headache): aplicación de un modelo de análisis de decisión / Diagnostic and therapeutic approach to cluster headache: application of a decision-making analysis model

Introducción: Las ciencias de la decisión conforman el conjunto de técnicas y teorías surgido del método cuantitativo y matemático dirigido al auxilio de una toma de decisiones con criterio aplicable a varias disciplinas y en los más variados contextos, donde la multicausalidad y la influencia de múltiples factores hace difícil la elección de una decisión unívoca, dado que la incertidumbre es el patrón común situacional. Se presenta a continuación el caso concreto de un paciente de 50 años portador de una cefalea en racimos, en el que se aplica el análisis de decisión de abordaje diagnóstico-terapéutico, y se elige la conducta a seguir basándose en esta metodología. Objetivos: Aplicar este modelo de análisis de la decisión a un problema clínico individual: un paciente de 50 años, portador de una cefalea en racimos o acuminada. Demostrar que en este caso clínico puntual, ante varias opciones diagnósticas y terapéuticas, el intervencionismo antálgico es una de las herramientas más efectivas y elegidas por los pacientes, teniendo en cuenta aspectos tales como la evidencia científica de respaldo de cada alternativa, la calidad de vida de los pacientes con dolor crónico no oncológico de tipo invalidante y el uso de una metodología concreta para la toma de decisión. Material y métodos: Aplicación de un análisis de decisión diagnóstico (terapéutico concreto), presentando un caso clínico real de cefalea en racimos. Búsqueda bibliográfica en Medline y OVID. Para la formulación de los valores umbrales, el análisis de sensibilidad y la graficación del árbol de decisión se utilizó el paquete estadístico STATA - DATA TREE AGE 3.5. Como outcome principal se determinó la expectativa de vida ajustada por calidad (medida en QALYs)...(AU)

Introduction: The science of decision-making is a set of techniques and theories arising from the quantitative and mathematic method, aimed at assisting in decision-making with criterion, applicable to many disciplines and numerous different contexts in which multi-causality and the influence of multiple factors make the choice of an unequivocal decision difficult, as uncertainty is the common pattern of the situation. Following is the case history of a 50-year-old patient suffering from cluster headaches; the analysis of decision-making as to the diagnostic-therapeutic approach is applied and the choice of conduct is based on this methodology. Objectives: To apply this decision-making analysis model to a clinical problem: a 50-year-old patient with cluster or acuminate headaches. To prove that in this specific clinical case, faced with different diagnostic and therapeutic options, antalgic interventionism is one of the most effective tools and is chosen by patients, taking into account aspects such as scientific backing proof of each alternative, quality of life of patients with chronic non-oncology invalidating pain and the use of a specific methodology for making the decision. Material and methods: Application of a diagnostic decision analysis, with a real clinical case of cluster headaches. Bibliographic research in Medline and OVID. To formulate threshold values, the sensitivity analysis and graphing the decision tree, the STATA - DATA TREE AGE 3.5 was used. As main outcome, the life expectancy adjusted by quality (measured in QALYs) was determined. Results: Once the sequence of the analysis was developed, the model firmly showed that the best diagnosis prognosis decision is to make a best diagnosis-prognosis block with local anesthetics and, should it be positive, to proceed to denervate the sphenoid-palatine ganglion by radiofrequency...(AU)

IntroduþÒo: As ciÛncias da decisÒo conformam um conjunto de técnicas e teorias surgido do método quantitativo e matemático direcionado ao auxílio de uma tomada de decisÒo criteriosa, aplicável a diversas disciplinas e nos mais variados contextos, onde a multicausalidade e a influencia de múltiplos fatores torna difícil a escolha de uma decisÒo unívoca, já que a incerteza é o padrÒo situacional genérico. Apresenta-se o caso de um paciente de 50 anos, portador de cefaléia em cacho, em que foi aplicado o processo de análise de decisÒo de abordagem diagnóstica-terapÛutica, sendo escolhida a conduta a seguir tomando como base esta metodologia. Objetivos: Aplicar este modelo de análise de decisÒo a um problema clínico individual: um paciente de 50 anos, portador de uma cefaléia em cacho ou acuminada. Provar que neste caso clínico particular, a intervenþÒo antálgica, diante de várias opþ§es diagnósticas e terapÛuticas, é uma das ferramentas mais eficazes e escolhidas pelos pacientes, considerando aspectos tais como a evidÛncia científica de apoio a cada alternativa, a qualidade de vida dos pacientes com dor cr¶nica nÒo oncológica incapacitante e o uso de uma metodologia concreta para a tomada de decisÒo. Material e métodos: AplicaþÒo de uma análise de decisÒo diagnóstica (terapÛutica concreta), apresentando um caso clínico real de cefaléia em cacho. Busca bibliográfica na Medline e na OVID. Para a formulaþÒo dos valores limiares, a análise de sensibilidade e a representaþÒo gráfica da árvore de decisÒo, foi utilizado o pacote estatístico STATA - DATA TREE AGE 3.5. Como outcome principal, determinou-se a expectativa de vida ajustada O qualidade (medida em QALYs). Resultados: Desenvolvida a seq³Ûncia da análise, o modelo mostra, de forma contundente, que a melhor decisÒo diagnóstica-terapÛutica é o bloqueio diagnóstico-prognóstico com anestésicos locais, e caso esse bloqueio seja satisfatório, fazer a denervaþÒo por radiofreq³Ûncia do ganglio esfenopalatino...(AU)

Paciente geronte programada para cirugía no cardíaca portadora de una estenosis aórtica severa, ¿se requiere el tratamiento quirúrgico de su valvulopatía previamente a la cirugía programada en cuestión? / Elderly patient with severe aorta stenosis programmed for non-cardiac surgery. of surgical treatment of her valvulopathy required prior to the programmed surgery?

Introducción: Uno de los mayores desafíos en el quehacer asistencial actual del anestesiólogo es poder aplicar los avances diagnóstico-terapéuticos crecientes y aggiornarse en la utilización de Guías de Práctica Clínica cuya evidencia científica respaldatoria ayuda a protocolizar y homogeneizar la práctica y evitar la variabilidad inadecuada. En este contexto cambiante, el anestesiólogo se ve obligado a contrastar la habitualidad de su praxis con nuevos paradigmas y adaptar su toma de decisiones acorde a las nuevas evidencias disponibles. La Evidencia Orientada al Paciente o al Problema (E.O.P.) surgió frente a la necesidad de información útil, sencilla de obtener, relevante y válida en la práctica clínica diaria. Fue diseñada para contestar preguntas originadas en el ejercicio profesional cotidiano, con el potencial de modificar la conducta médica, optimizando el mecanismo de búsqueda bibliográfica. Se utilizan como referencia sólo las investigaciones originales, los metaanálisis, las revisiones sistemáticas y los ensayos clínicos controlados y aleatorizados. En algunas oportunidades, de no contar con diseños más robustos, pueden ser de utilidad estudios de cohortes o Casos y Controles, según el objetivo del problema clínico. Objetivo: Presentar un caso clínico de E.O.P. dentro del campo de la anestesiología, acerca del siguiente problema: "¿cirugía no cardíaca programada en una paciente geronte portadora de una estenosis aórtica severa... ¿es necesario el tratamiento quirúrgico de la valvulopatía antes de la cirugía programada en cuestión?" Diseño: aplicación de un ejercicio de E.O.P. en un caso clínico concreto.

Introduction: One of the major challenges that anesthesiologists currently face is applying the growing diagnostic-therapeutic advances and keeping up to date in the use of clinical practice guidelines whose scientific backing evidence helps to prepare protocols and homogenize the practice and to avoid inadequate variability. In this ever-changing context, the anesthesiologist is forced to weigh the regular habits of his praxis against new paradigms and to adapt his decision-making according to the new available evidence. Patient (or Problem) Oriented Evidence (P.O.E) arose from the need to have useful, easily obtainable, relevant and valid information in the daily clinical practice. It was designed to answer questions that came up daily, with the potential of changing medical conduct, optimizing the mechanics of researching bibliography. Only original research, meta-analyses, systematic revisions and controlled and randomized clinical tests are used as a reference. In some cases, lacking stronger designs, cohorts or cases and control studies may be useful, according to the objective of the clinical problem1. Objective: Presentation of a clinical P.O.E case in the field of anesthesiology, concerning the following problem: "non cardiac programmed surgery in an elderly patient with severe aortic stenosis ... is surgical treatment of the valvulopathy necessary before the programmed surgery?" Design: Applying an exercise of P.O.E to a real clinical case.

Introdução: Um dos maiores desafios atuais no trabalho assistencial do anestesiologista é aplicar os crescentes avanços diagnóstico-terapêuticos e manter-se atualizado na utilização de guias de prática clínica cuja evidencia científica ajuda a protocolizar e homogeneizar a prática e evitar uma variabilidade inadequada. Neste contexto cambiante, o anestesiologista se ve obrigado a contrastar a habitualidade de sua praxe com novos paradigmas e adaptar sua tomada de decis6es as novas evidencias disponíveis. A evidencia orientada ao paciente ou ao problema (EOPP) surgiu perante a necessidade de contar com informação útil, simples de se obter, relevante e válida na prática clínica diária. Foi desenhada para responder perguntas originadas no exercício profissional cotidiano, com potencial para modificar a conduta médica, otimizando o mecanismo de busca bibliográfica. Sao utilizadas, como referencia, apenas as investigações originais, os meta-análise, as revisões sistemáticas e os ensaios clínicos controlados e aleatorizados. Em algumas oportunidades, quando nao se dispoe de desenhos más robustos, podem ser úteis os estudos de coortes ou casos e controles, conforme o objetivo do problema clínico. Objetivo: Apresentar um caso clínico de EOPP em anestesiologia sobre o seguinte problema: "cirurgia nao cardíaca programada em paciente idosa portadora de una estenose aórtica severa... é necessário o tratamento cirúrgico da valvulopatia antes da cirurgia programada em questao?" Desenho: Aplicação de um exercício de EOPP em um caso clínico concreto.

Paciente geronte programada para cirugía no cardíaca portadora de una estenosis aórtica severa, ¿se requiere el tratamiento quirúrgico de su valvulopatía previamente a la cirugía programada en cuestión? / Elderly patient with severe aorta stenosis programmed for non-cardiac surgery. of surgical treatment of her valvulopathy required prior to the programmed surgery?

Introducción: Uno de los mayores desafíos en el quehacer asistencial actual del anestesiólogo es poder aplicar los avances diagnóstico-terapéuticos crecientes y aggiornarse en la utilización de Guías de Práctica Clínica cuya evidencia científica respaldatoria ayuda a protocolizar y homogeneizar la práctica y evitar la variabilidad inadecuada. En este contexto cambiante, el anestesiólogo se ve obligado a contrastar la habitualidad de su praxis con nuevos paradigmas y adaptar su toma de decisiones acorde a las nuevas evidencias disponibles. La Evidencia Orientada al Paciente o al Problema (E.O.P.) surgió frente a la necesidad de información útil, sencilla de obtener, relevante y válida en la práctica clínica diaria. Fue diseñada para contestar preguntas originadas en el ejercicio profesional cotidiano, con el potencial de modificar la conducta médica, optimizando el mecanismo de búsqueda bibliográfica. Se utilizan como referencia sólo las investigaciones originales, los metaanálisis, las revisiones sistemáticas y los ensayos clínicos controlados y aleatorizados. En algunas oportunidades, de no contar con diseños más robustos, pueden ser de utilidad estudios de cohortes o Casos y Controles, según el objetivo del problema clínico. Objetivo: Presentar un caso clínico de E.O.P. dentro del campo de la anestesiología, acerca del siguiente problema: "¿cirugía no cardíaca programada en una paciente geronte portadora de una estenosis aórtica severa... ¿es necesario el tratamiento quirúrgico de la valvulopatía antes de la cirugía programada en cuestión?" Diseño: aplicación de un ejercicio de E.O.P. en un caso clínico concreto. (AU)

Introduction: One of the major challenges that anesthesiologists currently face is applying the growing diagnostic-therapeutic advances and keeping up to date in the use of clinical practice guidelines whose scientific backing evidence helps to prepare protocols and homogenize the practice and to avoid inadequate variability. In this ever-changing context, the anesthesiologist is forced to weigh the regular habits of his praxis against new paradigms and to adapt his decision-making according to the new available evidence. Patient (or Problem) Oriented Evidence (P.O.E) arose from the need to have useful, easily obtainable, relevant and valid information in the daily clinical practice. It was designed to answer questions that came up daily, with the potential of changing medical conduct, optimizing the mechanics of researching bibliography. Only original research, meta-analyses, systematic revisions and controlled and randomized clinical tests are used as a reference. In some cases, lacking stronger designs, cohorts or cases and control studies may be useful, according to the objective of the clinical problem1. Objective: Presentation of a clinical P.O.E case in the field of anesthesiology, concerning the following problem: "non cardiac programmed surgery in an elderly patient with severe aortic stenosis ... is surgical treatment of the valvulopathy necessary before the programmed surgery?" Design: Applying an exercise of P.O.E to a real clinical case. (AU)

IntroduþÒo: Um dos maiores desafios atuais no trabalho assistencial do anestesiologista é aplicar os crescentes avanþos diagnóstico-terapÛuticos e manter-se atualizado na utilizaþÒo de guias de prática clínica cuja evidencia científica ajuda a protocolizar e homogeneizar a prática e evitar uma variabilidade inadequada. Neste contexto cambiante, o anestesiologista se ve obrigado a contrastar a habitualidade de sua praxe com novos paradigmas e adaptar sua tomada de decis6es as novas evidencias disponíveis. A evidencia orientada ao paciente ou ao problema (EOPP) surgiu perante a necessidade de contar com informaþÒo útil, simples de se obter, relevante e válida na prática clínica diária. Foi desenhada para responder perguntas originadas no exercício profissional cotidiano, com potencial para modificar a conduta médica, otimizando o mecanismo de busca bibliográfica. Sao utilizadas, como referencia, apenas as investigaþ§es originais, os meta-análise, as revis§es sistemáticas e os ensaios clínicos controlados e aleatorizados. Em algumas oportunidades, quando nao se dispoe de desenhos más robustos, podem ser úteis os estudos de coortes ou casos e controles, conforme o objetivo do problema clínico. Objetivo: Apresentar um caso clínico de EOPP em anestesiologia sobre o seguinte problema: "cirurgia nao cardíaca programada em paciente idosa portadora de una estenose aórtica severa... é necessário o tratamento cirúrgico da valvulopatia antes da cirurgia programada em questao?" Desenho: AplicaþÒo de um exercício de EOPP em um caso clínico concreto. (AU)