Utility of Combining High-Sensitive Cardiac Troponin I and PESI Score for Risk Management in Patients with Pulmonary Embolism in the Emergency Department.

BACKGROUND AND OBJECTIVES: Pulmonary embolism (PE) has a major burden of morbidity and mortality, consequently the need for a prompt risk stratification for these subjects is crucial. In order to evaluate the risk management and final disposition of patients with PE in the Emergency Department (ED), we conducted a study that was divided in two phases: Phase I retrospective study (RS), Phase II prospective study (PS). MATERIALS AND METHODS: In Phase I, 291 patients were enrolled while in Phase II, 83 subjects were evaluated. In both study phases, the enrolled subjects were analyzed for final disposition in ED using PESI score, right ventricle (RV) imaging, and high-sensitive cardiac troponin I (hs-cTnI) data. The RS patients were divided into low risk and high risk according to the sPESI score, while PS patients were grouped in low, intermediate, and high risk classes according to PESI score. In both study phases, all the studied patients were further divided into negative (hs-cTnI-) or positive (hs-cTnI+) groups according to hs-cTnI levels within normal or above cutoff values, respectively. For all enrolled subjects, CT pulmonary angiography was analyzed to assess the RV/LV diameter and volume ratio as an indicator of RV involvement. RESULTS: In both RS and PS phases, hs-cTnI+ group showed a higher PESI score. Nevertheless, a significant percentage of hs-cTnI+ patients resulted to be in the low-risk PESI class. Patients with a positive RV/LV ratio were more likely to have a hs-cTnI+ (p < 0.01), while among those with a negative ratio, 24 to 32% showed as hs-cTnI+. In the hs-cTnI+ group from both study phases, patients were more likely to be admitted in an ICU (RR 3.7, IC: 2.1-6.5). CONCLUSIONS: In conclusion, in patients with PE in the ED compared PESI score alone, the combination of hs-cTnI and PESI seems to be of greater utility in improving risk stratification and final disposition decision-making.

Diagnóstico de áreas contaminadas pela disposição final de resíduos sólidos no município de Paço do Lumiar (MA) / Diagnosis of contaminated areas by final disposal of solid waste in the municipality of Paço do Lumiar (MA), Brazil

RESUMO A disposição final de resíduos sólidos é considerada uma fonte potencial de contaminação e tem merecido destaque em função dos problemas ambientais e socioeconômicos que pode gerar. O município de Paço do Lumiar, no Maranhão, utiliza um lixão como forma de disposição de resíduos sólidos urbanos mesmo após ter cessado o prazo para o fim dos lixões no Brasil conforme a Política Nacional de Resíduos Sólidos, Lei Federal nº 12.305, de 2 de agosto de 2010. Em virtude disso, este estudo teve como objetivo detectar áreas contaminadas pela disposição de resíduos sólidos em Paço do Lumiar com base na metodologia do Manual de Gerenciamento de Áreas Contaminadas do projeto CETESB/GTZ (1999), utilizando os compartimentos ambientais solo e água superficial como objetos de análise. Assim, verificou-se que o lixão tem contribuído para a contaminação do solo com metais pesados no local de disposição e a 200 m a sua jusante, o que pode significar contaminação potencial da água subterrânea em virtude de a geologia local e o solo arenoso serem facilitadores no processo de transporte de contaminantes. Já a análise da água superficial revelou que a disposição de resíduos sólidos pode estar contribuindo menos que outras fontes de contaminação, destacando-se, nesse contexto, os efluentes gerados pelas comunidades que ocupam a bacia. Portanto, como a contaminação verificada compromete alguns usos da terra (residencial e agrícola), estudos posteriores poderão contemplar o processo de remediação de áreas contaminadas conforme material da CETESB/GTZ (1999) para que medidas corretivas minimizem os impactos ambientais na região.

ABSTRACT The final disposal of solid waste is considered a potential source of contamination and has been highlighted due to the environmental problems and socioeconomic factors that it can generate. The municipality of Paço do Lumiar, Maranhão, uses a garbage dump as a way of disposing urban solid waste, even after the deadline for the end of dumps in Brazil, as established by the National Solid Waste Policy, Federal Law No. 12,305, dated August 2, 2010. As a result, the objective of this study was to detect areas contaminated by disposal of solid waste in Paço do Lumiar, based on the Workshop Management of Contaminated Areas' methodology, a part of the project CETESB/GTZ (1999), using the environmental compartments soil and surface water as objects of analysis. Thus, it was found that the garbage dump has contributed to the contamination of soil with heavy metals in the place of provision and 200m to its downstream, which can mean potential contamination of ground water due to the local geology and the fact that sandy soil facilitates the process of transporting contaminants. The analysis of the surface water revealed that the disposal of solid waste can contribute less than other sources of contamination, highlighting in this context those generated by the communities that occupy the basin. Therefore, as the verified contamination compromises some land uses (residential and agricultural), further studies may contemplate the remediation process of these contaminated areas according to the CTESB/GTZ (1999) material for stablishing measures to minimize this region's environmental impacts.

The moral unacceptability of abandoning human embryos.

The focus of this paper is on the ethics of the act of wilfully "abandoning" human embryos. I offer a critique of this unique behaviour, which draws on empirical data about who wilfully abandons their surplus embryos and why. I argue that wilful embryo abandonment is in all cases avoidable. Given this, I make three observations which speak to the moral unacceptability of embryo abandonment. The first has to do with the abandoner's unfair treatment of the clinic storing their abandoned embryos, and the second the abandoner's apparent lack of sympathy for the plight of other people like them, who require assistance (e.g. donated embryos) in pursuing their family-building goals. The third observation has to do with the abandoner's failure to meet their responsibility for directing the handling of their embryos, and what their reaction to that responsibility (through abandonment) says about their moral character in certain respects. There is good reason to conclude that wilful embryo abandonment is morally unacceptable. One implication of this normative conclusion is that clinics have reasonable grounds for justifying the design of their policies and practices so as to make wilful embryo abandonment impossible.