Characterization of a cohort of patients with hypercalcemia in a tertiary pediatric hospital. / Caracterización de una cohorte de pacientes con hipercalcemia en un centro pediátrico de tercer nivel.

Introduction. Hypercalcemia is infrequent in pediatrics, of diverse etiology, and with multiorgan morbidity. Objective. Describe the etiology, biochemistry, clinical, and treatment in pediatric patients with hypercalcemia. Population and methods. Retrospective and descriptive study of a cohort of patients with hypercalcemia between 2008 and 2022. They were classified into three groups (G): hypercalcemia of iatrogenic cause (G1), parathyroid hormone (PTH) independent (G2), or PTH-dependent (G3). Results. One hundred forty-seven patients were included; 57% were male, with a median age of 3.7 years, median calcemia of 11.8 mg/dl, and mean phosphatemia of 4.9 mg/dl. Symptoms were present in 29% of patients, and 28.6% required additional treatments to those of the first line. In G1, 76 patients (51.7%) were included; in G2, 58 (39.4%), and in G3, 13 (8.8%). Median calcemia was lower in G1 vs. G2 and G3 (11.6 mg/dl, 12.6 mg/dl, and 12.3 mg/dl), and mean phosphatemia was lower in G3 vs. G1 and G2 (3.7 mg/dl, 5.3 mg/dl, and 4.9 mg/dl). Most of the patients with hypercalcemia were asymptomatic and did not require additional treatments. The percentage of symptomatic patients and the percentage requiring additional treatment were lower in G1 than in the other two groups. Conclusions. Iatrogenesis was the most frequent cause, presenting lower calcemia, while PTH-dependent causes presented the lowest phosphatemia. PTH-independent causes represented a diagnostic and therapeutic challenge due to lacking a characteristic biochemical profile.

Introducción. La hipercalcemia es infrecuente en pediatría, de etiología diversa y con morbilidad multiorgánica. Objetivo. Describir etiología, bioquímica, clínica y tratamiento en pacientes pediátricos con hipercalcemia. Población y métodos. Estudio retrospectivo y descriptivo de una cohorte de pacientes con hipercalcemia entre 2008 y 2022. Se clasificaron en tres grupos (G): hipercalcemia de causa iatrogénica (G1), paratohormona (PTH) independiente (G2) o PTH dependiente (G3). Resultados. Se incluyeron 147 pacientes; el 57 % eran varones, edad mediana de 3,7 años, calcemia mediana 11,8 mg/dl y fosfatemia media 4,9 mg/dl. El 29,9 % de los pacientes fueron sintomáticos y el 28,6 % requirió tratamientos adicionales a los de la primera línea. En G1 se incluyeron 76 pacientes (51,7 %); en G2, 58 (39,4 %), y en G3, 13 (8,8 %). La calcemia mediana fue menor en G1 vs. G2 y G3 (11,6 mg/dl, 12,6 mg/dl y 12,3 mg/dl). La fosfatemia media fue menor en G3 vs. G1 y G2 (3,7 mg/dl, 5,3 mg/dl y 4,9 mg/dl). La mayoría de los pacientes con hipercalcemia fueron asintomáticos sin requerimientos de tratamientos adicionales. El porcentaje de pacientes sintomáticos y el de requerimiento de tratamientos adicionales fue menor en G1 que en los otros dos grupos. Conclusiones. La iatrogenia fue la causa más frecuente, y se presentó con calcemias más bajas; mientras que las causas PTH dependientes presentaron las fosfatemias más bajas. Las causas PTH independientes representaron un desafío diagnóstico y terapéutico por la falta de un perfil bioquímico característico.

Umbilical Cord Blood as an Alternative to Neonatal Blood for Complete Blood Count: A Comparison Study.

OBJECTIVE: To assess concordance between umbilical cord blood (UCB) and neonatal blood (NB) laboratory test results at birth. STUDY DESIGN: This retrospective study considered very preterm neonates (<32 weeks' gestational age) admitted to a tertiary neonatal intensive care unit from 2012 to 2023. Inclusion criteria required neonates with a complete blood count measured in both UCB and NB drawn within 2 hours after birth. Median hemoglobin (Hb) and hematocrit (Hct) concentrations were compared between UCB (venous samples) and NB (venous, arterial, or capillary samples). RESULTS: A total of 432 neonates with paired UCB and NB values were included in the study. Hb concentration in UCB was 14.7 g/dL (IQR 13.5-16.1 g/dL) compared with 14.8 g/dL (IQR 12.6-19.3 g/dL) in venous NB samples, 13.9 g/dL (IQR 12.9-15.3 g/dL) in arterial NB and 18.7 g/dL (IQR 16.6-20.8 g/dL) in capillary NB. The regression equation showed a correction factor of 1.08 for converting Hb values from UCB to venous NB. Median Hct concentration in UCB was 0.45 L/L (IQR: 0.41-0.49 L/L) compared with 0.48 L/L (IQR 0.43-0.54 L/L) in venous NB, 0.42 L/L (IQR 0.38-0.45 L/L) in arterial NB and 0.57 L/L, (IQR 0.51-0.63 L/L) in capillary NB. CONCLUSIONS: Hb and Hct concentrations measured in UCB are similar to those measured in venous blood in very preterm infants and are valid alternatives for NB tests at birth. Hb and Hct concentrations in arterial and capillary NB are respectively lower and higher compared with UCB measurements.

Late post-arthroscopy hip instability. Diagnosis, treatment, and 5-year follow-up: A case report.

INTRODUCTION: Hip instability following arthroscopy is a rare complication with a clinical spectrum ranging from gross dislocation (macro-instability) to micro-instability, characterized by pain and limitation for daily activities. Therefore, it should be considered as a potential differential diagnosis in patients experiencing persistent pain after hip arthroscopy. CASE PRESENTATION: A 41-year-old male presented with a history of anterior hip dislocation and macro-instability symptoms three years post-hip arthroscopy. Magnetic resonance imaging (MRI) revealed a disruption of the anterior hip capsule. The patient initiated physiotherapy and resumed activities, but ten months later, experienced another anterior dislocation. Pain and apprehension during external hip rotation were evident. Three-dimensional computed tomography (CT) indicated irregularities in the anterior and superior margin of the acetabulum, while MRI arthrogram showed a rupture of the anterior capsule and deficiency in the anterior hip ligaments. Open reconstruction of the anterior capsule was performed, resulting in favorable progression over the 5-year follow-up. DISCUSSION: This case highlights post-arthroscopy hip instability with a delayed presentation, possibly linked to chronic anterior capsule deficiency and inadequate acetabular coverage. Primary capsule repair after hip arthroscopy has proven effective in reducing the occurrence of instability symptoms and reoperations. CONCLUSIONS: Post-arthroscopic hip instability may manifest immediately after surgery or several years later. Open reconstruction of the anterior capsule emerges as a successful strategy for addressing this complication, demonstrating satisfactory outcomes in a 5-year follow-up.

Edema pulmonar por reexpansión. Reporte de Caso / Pulmonary edema due to re-expansion. Case Report

Introducción. El edema pulmonar por reexpansión es una complicación poco frecuente, secundaria a una rápida reexpansión pulmonar posterior al drenaje por toracentesis o toracostomía cerrada. Al día de hoy, se ha descrito una incidencia menor al 1 % tras toracostomía cerrada, con mayor prevalencia en la segunda y tercera década de la vida. Su mecanismo fisiopatológico exacto es desconocido; se ha planteado un proceso multifactorial de daño intersticial pulmonar asociado con un desequilibrio de las fuerzas hidrostáticas. Caso clínico. Presentamos el caso de un paciente que desarrolló edema pulmonar por reexpansión posterior a toracostomía cerrada. Se hizo una revisión de la literatura sobre esta complicación. Resultados. Aunque la clínica sugiere el diagnóstico, la secuencia de imágenes desempeña un papel fundamental. En la mayoría de los casos suele ser autolimitado, por lo que su manejo es principalmente de soporte; sin embargo, se han reportado tasas de mortalidad que alcanzan hasta el 20 %, por tanto, es importante conocer los factores de riesgo y las medidas preventivas. Conclusión. El edema pulmonar de reexpansión posterior a toracostomía es una complicación rara en los casos con neumotórax, aunque es una complicación que se puede presentar en la práctica diaria, por lo cual debe tenerse en mente para poder hacer el diagnóstico y un manejo adecuado.

Introduction. Re-expansion pulmonary edema is a rare complication secondary to rapid pulmonary re-expansion after drainage by thoracentesis and/or closed thoracostomy. As of today, an incidence of less than 1% has been described after closed thoracostomy, with a higher prevalence in the second and third decades of life. Its exact pathophysiological mechanism is unknown; a multifactorial process of lung interstitial damage associated with an imbalance of hydrostatic forces has been proposed. Clinical case. We present the case of a patient who developed pulmonary edema due to re-expansion after closed thoracostomy, conducting a review of the literature on this complication. Results. Although the clinic suggests the diagnosis, the sequence of images plays a fundamental role. In most cases, it tends to be a self-limited disease, so its management is mainly supportive. However, mortality rates of up to 20% have been recorded. Therefore, it is important to identify patients with major risk factors and initiate preventive measures in these patients. Conclusions. Re-expansion pulmonary edema after thoracostomy is a rare complication in cases with pneumothorax; however, it is a complication that can occur in daily practice. Therefore, it must be kept in mind to be able to make the diagnosis and an adequate management.

Shoeshine maneuver for cystic duct dissection: a simple technique to make Calot-triangle dissection smooth

ABSTRACT Purpose: Laparoscopic cholecystectomy, introduced in 1985 by Prof. Dr. Erich Mühe, has become the gold standard for treating chronic symptomatic calculous cholecystopathy and acute cholecystitis, with an estimated 750,000 procedures performed annually in the United States of America. The risk of iatrogenic bile duct injury persists, ranging from 0.2 to 1.3%. Risk factors include male gender, obesity, acute cholecystitis, previous hepatobiliary surgery, and anatomical variations in Calot's triangle. Strategies to mitigate bile duct injury include the Critical View of Safety and fundus-first dissection, along with intraoperative cholangiography and alternative approaches like subtotal cholecystectomy. Methods: This paper introduces the shoeshine technique, a maneuver designed to achieve atraumatic exposure of anatomical structures, local hemostatic control, and ease of infundibulum mobilization. This technique involves the use of a blunt dissection tool and gauze to create traction and enhance visibility in Calot's triangle, particularly beneficial in cases of severe inflammation. Steps include using the critical view of safety and Rouviere's sulcus line for orientation, followed by careful dissection and traction with gauze to maintain stability and reduce the risk of instrument slippage. Results: The technique, routinely used by the authors in over 2000 cases, has shown to enhance patient safety and reduce bile duct injury risks. Conclusion: The shoeshine technique represents a simple and easy way to apply maneuver that can help surgeon during laparoscopic cholecystectomies exposing the hepatocystic area and promote blunt dissection.

Marco legal para la prevención de procedimientos estéticos con sustancias modelantes / Legal framework for preventing aesthetic procedures with modeling substances i:en

En la actualidad, la alogenosis iatrogénica es una condición reconocida en todo el orbe, especialmente en Latinoamérica, donde es evidente la ausencia de control en la administración de sustancias no reguladas con fines estéticos, lo que ha devenido un problema emergente por la magnitud de las complicaciones, ya que algunos productos, como aceites minerales, hidrocarburos, silicona industrial, generan graves consecuencias, tanto locales como sistémicas, en el organismo. Muchos países aún no han regulado la prohibición de esta práctica, aunque cada día son más las campañas para prevenirla; sin embargo, al mismo tiempo aumenta la incidencia de la enfermedad en todo el mundo por el incremento de estos procedimientos estéticos. Al respecto, en Cuba, el creciente número de afectados por esta causa evidencia vulnerabilidad en el cumplimiento de lo establecido hasta la fecha, por lo que se impone instaurar un marco legal de estricto cumplimiento que regule la inyección de sustancias modelantes con fines estéticos.

Currently, iatrogenic allogenosis is a condition recognized throughout the world, especially in Latin America, where the absence of control in the administration of unregulated substances for aesthetic purposes is evident, which has become an emerging problem due to the magnitude of complications, since some products, such as mineral oils, hydrocarbons, industrial silicone, generate serious consequences, both local and systemic, in the body. Many countries have not yet regulated the prohibition of this practice, although every day there are more campaigns to prevent it. However, at the same time the incidence of the disease increases worldwide due to the increase in these aesthetic procedures. In this regard, in Cuba, the growing number of people affected by this cause shows vulnerability in compliance with what has been established to date, that is why it is necessary to establish a legal framework of strict compliance that regulates the injection of modeling substances for aesthetic purposes.

Algoritmo diagnóstico y terapéutico de las lesiones esplácnicas provocadas durante la inserción de sondas pleurales / Diagnostic and Therapeutic Algorithm for Splanchnic Injuries Caused during Chest Tube Insertions

Introducción: La colocación de sondas pleurales es un procedimiento quirúrgico frecuente que puede tener graves complicaciones, las cuales dependen en la mayoría de los casos de la experiencia del operador, el tamaño del tubo y el uso de imágenes para guiar la inserción. Objetivo: Describir las principales lesiones esplácnicas provocadas durante la inserción de sondas pleurales y presentar algoritmos para el diagnóstico precoz y el tratamiento oportuno de estas iatrogenias. Métodos: Se realizó una revisión descriptiva narrativa durante el primer trimestre del año 2023. Se utilizaron las bases de datos electrónicas PubMed, LILACS, EBSCO y Cochrane. Se revisaron artículos publicados desde 1984 hasta el 2022. Se procuró que la mayoría de la información se enmarcara en un período no mayor de 10 años de antigüedad. Desarrollo: De las lesiones esplácnicas de la cavidad torácica, la de pulmón es la más frecuente y puede conducir a sangrado o fuga aérea persistente. Las lesiones vasculares son graves y pueden provocar la muerte si no se toman las medidas pertinentes. Se han descrito lesiones de órganos huecos de la cavidad abdominal que suelen ser parte de una hernia diafragmática. Dentro de las lesiones esplácnicas en el abdomen más frecuentes están la hepática y la esplénica. Conclusiones: Estas lesiones son prevenibles y se debe tener en cuenta su mecanismo de producción para evitarlas. Para este fin recomendamos una selección cuidadosa del sitio de inserción, realizar una confirmación adecuada de la posición de la sonda, manipularla cuidadosamente y monitorear constantemente al paciente(AU)

Introduction: Chest tube insertion is a frequent surgical procedure that can have serious complications, which depend mostly on the practitioner's experience, the tube's size and the use of imaging to guide the insertion. Objective: To describe the main splanchnic injuries caused during chest tube insertion, as well as to present algorithms for early diagnosis and timely treatment of these types of iatrogeny. Methods: A descriptive narrative review was performed during the first quarter of the year 2023. The electronic databases PubMed, LILACS, EBSCO and Cochrane were used. Articles published from 1984 to 2022 were reviewed. Most of the information was secured to be framed within a period of no more than 10 years. Development: Among the splanchnic injuries within the thoracic cavity, lung injury is the most frequent and may lead to bleeding or persistent air leak. Vascular injuries are severe and can lead to death if appropriate measures are not taken. Injuries to hollow organs of the abdominal cavity have been described to be usually part of a diaphragmatic hernia. Among the most frequent splanchnic lesions within the abdomen are the hepatic and splenic injuries. Conclusions: These lesions are preventable and their mechanism of production should be taken into account in order to avoid them. To achieve this, we recommend that the insertion site be carefully selected and that the tube's position be adequately confirmed, as well as the careful handling of the tube and the constant monitoring of the patient(AU)

Review of surgical treatment of iatrogenic iliofemoral artery injury in the pediatric population after catheterization.

Trauma is the leading cause of death in the pediatric population. Although vascular trauma has an incidence of 6% in civilian population, iatrogenic injuries are the leading cause, and the most frequent injured vessel is the iliofemoral sector. However, little information is available and there are no guidelines about its treatment. Therefore, this review aimed to describe the information available concerning pediatric iatrogenic arterial trauma, focusing on the iliofemoral segment and present 3 cases. We described 11 articles with 171 patients, of whom 61% underwent surgery to treat iatrogenic trauma. Mean age was 3.28 years (standard deviation of 3.5 years), and 54% were female. Most iliofemoral injuries occurred after arterial catheterization for hemodynamic monitorization and therapeutic or diagnostic cardiac catheterization (due to congenital heart diseases, including septal defects, tetralogy of Fallot, aortic coarctation, and patent ductus arteriosus). For acute complications, arterial thrombosis was the leading injury, followed by pseudoaneurysm, hematoma, dissection, transection, avulsion, eversion, and combined lesions.

How to avoid iatrogenic injuries of the biliary tract in urgent surgery? The use of indocianine green is an alternative.

Iatrogenic bile duct injury is a rare complication, although feared due to its morbidity and mortality. In urgent surgeries, its incidence can be doubled, so in selected cases we must assess the use of resources such as indocyanine green to minimize the risk of biliary or arterial lesions by allowing the correct identification of the structures. We present the case of a 57-year-old patient with acute cholecystitis who underwent laparoscopic cholecystectomy. Given the difficulty in differentiating structures in Calot's triangle, the decision was made to use indocyanine green, which identifies a very short cystic duct, thus avoiding iatrogenic bile duct injury.

La lesión iatrogénica de vía biliar es una complicación infrecuente, aunque temida por su morbimortalidad. En cirugías urgentes, su incidencia puede duplicarse, por lo que en casos seleccionados debemos valorar la utilización de recursos como el verde de indocianina para minimizar el riesgo de lesiones biliares o arteriales, al permitir una correcta identificación de las estructuras. Presentamos el caso de una paciente de 57 años con colecistitis aguda a la que realizamos colecistectomía laparoscópica. Ante la dificultad en la diferenciación de estructuras en el triángulo de Calot, se decidió utilizar verde de indocianina, que identificó un conducto cístico muy corto, evitando así una lesión iatrogénica de vía biliar.

Revisitando Whitaker: psicofármacos e cuidado em Saúde Mental na Atenção Primária à Saúde / Revisiting Whitaker: psychotropic drugs and Mental Health care in Primary Health Care

RESUMO Os Problemas de Saúde Mental (SM) e o uso indiscriminado de psicofármacos são problemas de grande relevância para a Atenção Primária à Saúde (APS) e a saúde pública. O objetivo deste ensaio é apresentar uma fundamentação atualizada da tese de Robert Whitaker, desenvolvida no livro 'Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental'. É apresentada uma síntese do livro, acrescida de comentários sobre determinados temas, visando à melhor ancoragem científica dos argumentos. A tese defendida é que se deve evitar prescrever o uso de psicofármacos; e, caso seja iniciado o uso, que seja como sintomático agudo pelo menor tempo possível. Os argumentos giram em torno de que há evidências favoráveis apenas para redução de sintomas, para algumas dessas drogas e para curtos períodos de uso. Com seu uso crônico, há piora em longo prazo quanto à estabilidade, autonomia e funcionalidade social, com problemas graves de abstinência. Especialmente na APS (e também nos serviços especializados em SM), os profissionais deveriam ter uma abordagem mais crítica dos psicotrópicos e investir em outras abordagens terapêuticas, para fazerem algo melhor, menos iatrogênico e tão ou mais eficaz para os pacientes com problemas de SM no longo prazo.

ABSTRACT Mental Health (MH) issues and the indiscriminate use of psychotropic drugs are a great deal of a problem for the Primary Health Care (PHC) and public health. The aim of this article is to show an updated basis from Robert Whitaker theses in his book 'Anatomy of an epidemic: magic bullets, psychiatric drugs and the astonishing rise of mental illness'. It is presented a synthesis of the book, with specific comments about some topics, aiming for better scientific base of the arguments. The thesis endorses that prescribing psychotropic drugs must be avoided; and, if required, it must be as an acute symptomatic scenario for the least time as possible. The study has positive evidence that a few of these drugs only reduces symptoms, for a short period of time. If chronic used, in a long-term scenario, it seems to actually reduce stability, autonomy and social functionality, leaving the user with serious abstinence from the drug. Specially in PHC (and also in MH specialized services), professionals should have a mindful and discerning approach to psychotropic drugs, and invest in other therapeutic strategies, in order to do something better, less iatrogenic and as effective or more for the mental health patients in the long term.

Manejo das irregularidades menstruais secundárias ao uso de contraceptivos ­ análise das recomendações atuais / Management of menstrual irregularities secondary to contraceptive use ­ analysis of current recommendations

As irregularidades menstruais representam uma série de desordens na quantida- de, duração, frequência ou regularidade do sangramento uterino. Entre suas cau- sas destaca-se o sangramento secundário ao uso de anticoncepcionais, uma razão frequente de descontinuidade dos contraceptivos, podendo aumentar as taxas de gestações não planejadas. Boa parte dos contraceptivos pode levar a mudanças no padrão de sangramento uterino, e a abordagem inicial do sangramentos irregula- res inclui a avaliação de outras possíveis causas, o reforço do uso correto da medi- cação, a tranquilização da paciente quanto à benignidade do quadro e à tendência a melhora com a continuidade do uso. Os anti-inflamatórios podem ser usados como estratégia inicial, e, não havendo resposta satisfatória, há alternativas espe- cíficas para cada método. Este trabalho visa identificar as recomendações atuais sobre o manejo do sangramento anormal decorrente de contraceptivos, por meio de revisão narrativa de estudos publicados sobre o tema nos últimos vinte anos.

Abnormal uterine bleeding represents a series of disorders in the amount, du- ration, frequency and or regularity of uterine bleeding. Among its causes, uterine bleeding secondary to the use of contraceptives stands out as a frequent reason for contraceptive discontinuity, which could lead to unplanned pregnancies. Most contraceptives can cause changes in the pattern of uterine bleeding, and the ini- tial approach of the abnormal bleeding includes assessing other possible cau- ses, reinforcing the correct use of medication, and reassuring the patient about the benignity of the condition and the tendency to improve with the continuity of the treatment. Anti-inflammatory drugs can be used as an initial strategy, and, if there is no satisfactory answer, there are specific alternatives for each contracep- tive method. This work aims to identify them current recommendations on the management of abnormal bleeding resulting from contraceptives use, through a narrative review of studies published on the subject in the last twenty years.

Pediatric Medical Traumatic Stress and Trauma-Informed Care in Pediatric Chronic Illness: A Healthcare Provider Survey.

OBJECTIVE: To inform approaches to pediatric medical traumatic stress (PMTS) by exploring providers' (1) perception of the impact of PMTS on the medical care of patients with pediatric-onset chronic illnesses, (2) self-reported competencies and practices of PMTS prevention, treatment, and counseling, and (3) perception of the barriers influencing the adoption of these practices. STUDY DESIGN: A convenience sample of multidisciplinary healthcare providers was recruited through a multimodal recruitment strategy to participate in an electronic survey adapted from the Trauma-Informed Care Provider Survey. RESULTS: Among participants (n = 304), 99% agreed that PMTS impacts patient health. Participants report altering medical care plans due to PMTS, including deferring or stopping treatments (n = 98 [32%]) and changing medication regimens (n = 88 [29%]). Sixty-eight percent (n = 208) report negative impact of PMTS on patient implementation of medical care plans, including medication nonadherence (n = 153 [50%]) and missed appointments (n = 119 [39%]). Although participants agreed it is their job to decrease patient stress (n = 292 [96%]) and perform PMTS assessments (n = 268 [88%]), few practiced PMTS-focused trauma informed care. Systems-level barriers to practice included insufficient training, absent clinical workflows, and lack of access to mental health experts. CONCLUSIONS: Our findings have helped inform a conceptual framework for understanding the relationship between PMTS and health outcomes. Systems-level opportunities to optimize PMTS-focused trauma-informed care include (1) dissemination of provider training, (2) integrated workflows for PMTS mitigation, and (3) enhanced accessibility to mental health providers. Further work is required to determine if these interventions can improve health outcomes in patients with pediatric-onset chronic illnesses.

[Interest in disinterestedness in the epidemiology of health systems and services]. / El interés del desinterés en la epidemiología de servicios y sistemas de salud.

This article intends to critique of the cultural authority of the medical sciences, opening up a discussion on its publicization from a political standpoint. At the same time, from a more technical standpoint, it proposes the implementation of an epidemiology of health systems and services. Based on Pierre Bourdieu's concept of interest in disinterestedness and Joseph Gusfield's notion of the cultural authority of public problems, it analyzes why epidemiological information is so rarely used in the evaluation and monitoring of clinical, population, institutional, and territorial practices. That is, why does the dominant culture of decision making eschew epidemiological information? Within this conceptual framework, a body of documental evidence is analyzed that sheds light on the weak scientific basis that upholds or that has underpinned certain practices in the health field at different historical moments. The discussion is organized around three major themes: assistentialist professional practice, medication, and biomedical technologies.

Este trabajo se propone problematizar, discutir y publicizar la autoridad cultural de la medicina científica, desde una dimensión política, y la implementación de la epidemiología de los servicios y sistemas de salud, desde una dimensión técnica. A partir de los conceptos de interés del desinterés, de Pierre Bourdieu, y de autoridad cultural de los problemas públicos de Joseph Gusfield se analiza ¿por qué la información epidemiológica es tan poco utilizada para la evaluación y monitoreo de las prácticas clínicas, poblacionales, institucionales y territoriales?, ¿por qué domina una cultura de toma de decisiones sin información epidemiológica? Desde este marco conceptual, se aborda un cuerpo documental que permite recuperar la débil cientificidad que sustentaron o sustentan algunas prácticas del campo de la salud en diferentes momentos históricos, organizado en tres ejes temáticos: la práctica profesional asistencial, los medicamentos y las tecnologías biomédicas.

Drugs as Possible Triggers of Takotsubo Cardiomyopathy- Update 2022: Systematic Review.

BACKGROUND: A list of drugs that can induce takotsubo cardiomyopathy (TCM) was published in 2011 and 2016. The aim of the present review was to update this list. METHODS: Similar to the 2011 and 2016 reviews, from April 2015 to May 2022 case reports of druginduced TCM were identified by a comprehensive search in Medline/PubMed database. The search terms were: takotsubo cardiomyopathy, tako-tsubo cardiomyopathy, stress cardiomyopathy, transientleft- ventricular ballooning syndrome, apical ballooning syndrome, ampulla cardiomyopathy OR broken heart syndrome; together with "iatrogenic", "induced by" OR "drug-induced". Registers published in English or Spanish, in humans, and with full texts were retrieved. Articles that recognized any drug associated with the development of TCM were selected. RESULTS: Overall, 184 manuscripts were identified by the search. A total of 39 articles were included after an exhaustive revision. Eighteen drugs as possible triggers of TCM were identified in the current update. Of them, 3 (16.7%) have been previously identified, and 15 (83.3%) are different from the previous reports. Thus, the list of drugs as possible triggers of TCM updated in 2022 includes 72 drugs. CONCLUSION: There are new case reports that link drugs with the development of TCM. The current list is principally made up of drugs that generate sympathetic overstimulation. However, some of the listed drugs do not have a clear link with sympathetic activation.

Construção e evidência de validade do Instrumento de Avaliação do Conhecimento sobre Prevenção Quaternária / Construction and evidence of validity of the knowledge assessment instrument on quaternary prevention / Construcción y pruebas de validez del instrumento de evaluación de los conocimientos sobre prevención cuaternaria

Objetivo: desenvolver e estimar a evidência de validade de um instrumento para avaliar a percepção dos acadêmicos de medicina sobre a prevenção quaternária. Método: Trata-se de um estudo metodológico desenvolvido em três etapas: 1) construção do instrumento para avaliação do conhecimento sobre Prevenção Quaternária a partir de referenciais teóricos; 2) evidência de validade baseada no conteúdo, realizada por 13 juízes; 3) evidência de validade baseada na estrutura interna, realizada por 180 acadêmicos de medicina. Análises fatoriais foram realizadas para verificar a estrutura hierárquica do modelo a partir das duas dimensões inicialmente construídas: Domínio Conhecimento e Domínio Prático. Resultados: O coeficiente de evidência de validade de conteúdo da escala total (CVCt) foi de 0,98, demonstrando uma alta concordância entre os avaliadores com a conceituação teórica subjacente. Quanto à precisão do instrumento, todos os itens apresentaram valores de Alfa de Cronbach acima de 0,7, indicando boa precisão. Verificou-se bons indicadores de precisão para a escala com dois fatores (Domínio Conhecimento e Domínio Prático) ƛ2= 109.746, gl= 103; p<0,001; ƛ2/gl= 0,30; CFI= 0,98 e RMSEA 0,019. Conclusão: o instrumento IP4-15 apresentou as evidências de validade de conteúdo, estrutura interna, precisão e propriedades dos itens adequadas para avaliar o conhecimento e a prática da prevenção quaternária de acadêmicos do curso de medicina. Serão necessários estudos futuros para investigar a aplicabilidade do IP4-15 para outras populações.(AU)

Objective: to develop and estimate the evidence of validity of an instrument to assess the perception of medical students about Quaternary Prevention. Method: this is a methodological study carried out in three steps: 1) construction of the instrument to assess knowledge about Quaternary Prevention based on theoretical references; 2) content-based evidence of validity, performed by 13 judges; 3) internal structure-based evidence of validity, performed by 180 medical students. Factor analyzes were performed to verify the hierarchical structure of the model based on the two dimensions initially constructed: Knowledge Domain and Practical Domain. Results: The total scale content validity evidence coefficient (CVCt) was 0.98, demonstrating a high inter-rater agreement with the underlying theoretical conceptualization. As for instrument precision, all items had Cronbach's Alpha values above 0.7, indicating good precision. Good precision indicators were found for the scale with two factors (Knowledge Domain and Practical Domain) ƛ2= 109,746, gl= 103; p<0.001; ƛ2/gl=0.30; CFI=0.98 and RMSEA 0.019. Conclusion: the IP4-15 instrument presented adequate evidence of content validity, internal structure, precision, and properties of the items to assess the knowledge and practice of Quaternary Prevention of medical students. Future studies will be needed to investigate the applicability of IP4-15 to other populations.(AU)

la percepción de los estudiantes de medicina sobre la Prevención Cuaternaria. Método:se trata de un estudio metodológico desarrollado en tres etapas: 1) construcción de un instrumento para evaluar el conocimiento sobre Prevención Cuaternaria basado en referencias teóricas; 2) prueba de validez basada en el contenido, realizada por 13 jueces; 3) prueba de validez basada en la estructura interna, realizada por 180 estudiantes de Medicina. Se realizaron análisis factoriales para verificar la estructura jerárquica del modelo a partir de las dos dimensiones construidas inicialmente: Dominio del conocimiento y dominio práctico. Resultados: el coeficiente de evidencia de validez de contenido de la escala total (CVCt) fue de 0,98, lo que demuestra...(AU)

An occult iatrogenic pneumothorax as a cosmetic procedure complication.

A pneumothorax is the abnormal gas accumulation within the pleural space. We present a case of a patient with an occult iatrogenic pneumothorax who presented with symptomatic anemia that substantially improved after a transfusion, diverting the clinical suspicion. As a result, she developed acute respiratory distress, initially considered secondary to a possible pulmonary embolism vs. fat embolism. After computed tomography confirmed the diagnosis, a chest tube was inserted. This case emphasizes the importance of suspecting pneumothorax secondary to cosmetic procedures and using computed tomography as the first diagnostic tool in complex cases since chest x-rays can miss pneumothorax.

Post-thoracotomy paraplegia after oxidized cellulose spinal compression

ABSTRACT Post-thoracotomy paraplegia after non-aortic surgery is an extremely uncommon complication. A 56-year-old woman presented with a 1-year history of progressive shortness of breath. Computed tomography revealed a locally advanced posterior mediastinal mass involving the ribs and the left neural foramina. Tumor excision with a left pneumonectomy was performed. Post-resection, bleeding was noted in the vicinity of the T4-T5 vertebral body, and the bleeding point was packed with oxidized cellulose gauze (Surgicel®). Postoperatively, the patient complained of bilateral leg numbness extending up to the T5 level, with bilateral paraplegia. An urgent laminectomy was performed, and we noted that the spinal cord was compressed by two masses of Surgicel® with blood clots measuring 1.5 × 1.5cm at T4 and T5 levels. The paraplegia did not improve despite the removal of the mass, sufficient decompression, and aggressive postoperative physiotherapy. Surgeons operating in fields close to the intervertebral foramen should be aware of the possible threat to the adjacent spinal canal as helpful hemostatic agents can become a preventable threat.

Prevenção quaternária e suas implicações para a prática clínica: uma revisão sistemática / Quaternary prevention and its implications for the clinical practice: a systematic review

A crescente produção de iatrogenias justifica a discussão acerca da incorporação da prevenção quaternária na prática médica cotidiana. Este estudo identificou e sistematizou a produção de conhecimento sobre prevenção qua-ternária e sua implicação para a prática clínica. Trata-se de revisão sistemática descritiva apoiada na pergunta nor-teadora: "Quais são as evidências produzidas sobre prevenção quaternária e sua implicação para a prática clínica?" Realizou-se o levantamento bibliográfico entre agosto e setembro de 2020, utilizando-se o descritor "prevenção quaternária", nos idiomas inglês, português e espanhol. A análise dos 30 artigos produziu evidências sobre inter-venções médicas potencialmente danosas que justificariam a adoção da prevenção quaternária. O estudo provoca a comunidade médica a refletir sobre a incorporação da prevenção quaternária, visando uma prática assistencial menos iatrogênica, valorizando a medicina centrada na pessoa e os atributos da atenção primária à saúde. (AU)

The growing production regarding iatrogenesis justifies the discussion about the incorporation of quaternary pre-vention in the daily medical practice. This study identified and systematized the production of knowledge about quaternary prevention and its implications for the clinical practice. This is a systematic descriptive review supported by the guiding question: What evidence has been produced regarding quaternary prevention and its impact on the clinical practice? A bibliographic survey was carried out between August and September 2020 using the descriptor "quaternary prevention" in English, Portuguese and Spanish. The analysis of 30 articles produced evidence on po-tentially harmful medical interventions that would justify the adoption of quaternary prevention. The study invites the medical community to reflect on the incorporation of quaternary prevention, aiming for a less iatrogenic care practice, valuing person-centered medicine and the attributes of primary health care. (AU)

El error en la práctica médica / Error in Medical Practice

Introducción: El error está presente en cualquier actividad humana y la práctica de la medicina no es una excepción. Debido al aumento de los conocimientos sobre la salud y las enfermedades, la posibilidad de error, relacionada con la atención de estas últimas, disminuye, pero no se ha eliminado en su totalidad. Objetivo: Exponer las experiencias de los autores acerca del error en la práctica médica. Métodos: Revisión bibliográfica entre los años 2000 y 2020. Se localizaron y consultaron fuentes bibliográficas validadas en: Medline, PubMed y SciELO, a las que se accedió a través de la biblioteca virtual de salud. Se utilizaron para la búsqueda las palabras clave error médico, iatrogenia, responsabilidad penal del médico, método clínico. Se revisaron también tres bibliografías anteriores que se consideraron de utilidad para el artículo y tres capítulos de libros con temas afines, además de las resoluciones del Ministerio de Salud Pública de Cuba que tratan acerca del error médico. Al final se seleccionaron 21 bibliografías en idiomas español e inglés. Conclusiones: Existen grandes posibilidades de errores en el proceso del diagnóstico y tratamiento de los enfermos. El desarrollo de la tecnología y la mejoría en la construcción de guías y protocolos disminuyen las probabilidades de equivocaciones, pero no las eliminan. El perfeccionamiento en la formación de recursos humanos, unido al uso correcto del método clínico es una estrategia eficaz para disminuir los errores en la práctica médica(AU)

(AU)ntroduction: Error is present in any human activity; the medical practice is not an exception. Due to an increase in knowledge about health and diseases, error possibility related to disease management is decreasing, but has not been totally eliminated. Objective: To expose the authors' experiences regarding error in medical practice. Methods: A bibliographic review was carried out, covering the years between 2000 and 2020. Validated bibliographic sources were located and consulted in Medline, PubMed and SciELO, accessed through the Virtual Health Library. The following keywords were used for the search: error médico [medical error], iatrogenia [iatrogenic error], responsabilidad penal del médico [physician criminal liability] and método clínico [clinical method]. Three previous bibliographies considered useful for the article and three book chapters with related topics were also reviewed, in addition to the resolutions of the Ministry of Public Health of Cuba dealing with the topic of medical error. Finally, 21 bibliographies in Spanish and English were selected. Conclusions: There are great possibilities of errors in the process of patient diagnosis and management. The development of technology, as well as the improvement in the construction of guides and protocols, decreases the probabilities of errors, but do not eliminate them. The improvement in the training of human resources, together with the correct use of the clinical method, is an effective strategy to reduce errors in medical practice(AU)

Management of Iatrogenic Aortic Dissections During Percutaneous Right Coronary Artery Interventions.

Iatrogenic acute aortic dissections during percutaneous coronary interventions are an extremely rare but potentially life-threatening complication, occurring in less than 0.02% of transcatheter procedures. We report three patients with different characteristics suffering from iatrogenic aortic dissection during percutaneous coronary intervention successfully treated with an emergency open-heart surgery. A conservative strategy should be pursuit only in small, localized lesions.