Cardiotoxic Effects Produced by Omeprazole and Methylene Blue in an Animal Model of Cardiac Ischemia and Reperfusion and Potential Implications for the Pharmacological Strategy for Vasoplegic Syndrome.

Defined as systemic hypotension caused by intense vasodilation due to the loss of systemic vascular resistance, vasoplegic syndrome (VS) is associated with elevated morbidity and mortality in humans. Although vasopressors such as norepinephrine and vasopressin are the first-choice drugs for VS treatment, several other drugs such as methylene blue (MB) can be used as adjuvant therapy including rescue therapy. To develop new pharmacological strategies to reduce the risk of VS, we investigated the effects of treatments with MB (2 mg/kg/IV), omeprazole (OME, 10 mg/kg/IV), and their combination in an animal model of cardiac ischemia-reperfusion (CIR). The ventricular arrhythmia (VA), atrioventricular block (AVB), and lethality (LET) incidence rates caused by CIR (evaluated via ECG) and serum levels of the cardiac lesion biomarkers creatine kinase-MB (CK-MB) and troponin I (TnI) in adult rats pretreated with saline solution 0.9% and submitted to CIR (SS + CIR group) were compared to those pretreated with MB (MB + CIR group), OME (OME + CIR group), or the MB + OME combination (MB + OME + CIR group). The AVB and LET incidence rates in the MB + CIR (100%), OME + CIR (100%), and MB + OME + CIR (100%) groups were significantly higher compared to the SS + CIR group (60%). The serum level of CK-MB in these groups were also significantly higher compared to the SS + CIR group, demonstrating that the treatments before CIR with MB, OME, and MB + OME produced similar effects in relation to cardiac function and the occurrence of lesions. These results demonstrate that the treatment of animals subjected to the CIR protocol with OME produced the same effects promoted by the treatment with MB, which may suggest the possibility of using OME alone or in combination with MB in medical clinics in treatment of VS.

Pharmacological Modulation of the Ca2+/cAMP/Adenosine Signaling in Cardiac Cells as a New Cardioprotective Strategy to Reduce Severe Arrhythmias in Myocardial Infarction.

Acute myocardial infarction (AMI) is the main cause of morbidity and mortality worldwide and is characterized by severe and fatal arrhythmias induced by cardiac ischemia/reperfusion (CIR). However, the molecular mechanisms involved in these arrhythmias are still little understood. To investigate the cardioprotective role of the cardiac Ca2+/cAMP/adenosine signaling pathway in AMI, L-type Ca2+ channels (LTCC) were blocked with either nifedipine (NIF) or verapamil (VER), with or without A1-adenosine (ADO), receptors (A1R), antagonist (DPCPX), or cAMP efflux blocker probenecid (PROB), and the incidence of ventricular arrhythmias (VA), atrioventricular block (AVB), and lethality (LET) induced by CIR in rats was evaluated. VA, AVB and LET incidences were evaluated by ECG analysis and compared between control (CIR group) and intravenously treated 5 min before CIR with NIF 1, 10, and 30 mg/kg and VER 1 mg/kg in the presence or absence of PROB 100 mg/kg or DPCPX 100 µg/kg. The serum levels of cardiac injury biomarkers total creatine kinase (CK) and CK-MB were quantified. Both NIF and VER treatment were able to attenuate cardiac arrhythmias caused by CIR; however, these antiarrhythmic effects were abolished by pretreatment with PROB and DPCPX. The total serum CK and CK-MB were similar in all groups. These results indicate that the pharmacological modulation of Ca2+/cAMP/ADO in cardiac cells by means of attenuation of Ca2+ influx via LTCC and the activation of A1R by endogenous ADO could be a promising therapeutic strategy to reduce the incidence of severe and fatal arrhythmias caused by AMI in humans.

Effects of Calendula officinalis extract on liver histopathology, lipid profile, and oxidative stress in rats submitted to a diet rich in cholesterol and carbohydrates.

PURPOSE: To evaluate the modulatory properties of Calendula officinalis L. (Asteraceae) (C. officinalis) extract on cafeteria diet-fed rats. METHODS: A cafeteria diet was administered ad libitum for 45 days to induce dyslipidemia. Then, the rats were treated with the formulations containing C. officinalis in the doses of 50, 100, and 150 mg/kg or only with the vehicle formulation; the control group received a commercial ration. RESULTS: The cafeteria diet decreased glutathione S-transferase activity and high-density lipoprotein plasmatic levels and damaged the hepatic architecture. The C. officinalis extract was able to reduce lipid infiltration in liver tissue and to modulate oxidative stress and lipid profile markers. CONCLUSIONS: The correlations between the variables suggest a pathological connection between oxidative stress markers and serum lipid profile.

Effects of Calendula officinalis extract on liver histopathology, lipid profile, and oxidative stress in rats submitted to a diet rich in cholesterol and carbohydrates

ABSTRACT Purpose: To evaluate the modulatory properties of Calendula officinalis L. (Asteraceae) (C. officinalis) extract on cafeteria diet-fed rats. Methods: A cafeteria diet was administered ad libitum for 45 days to induce dyslipidemia. Then, the rats were treated with the formulations containing C. officinalis in the doses of 50, 100, and 150 mg/kg or only with the vehicle formulation; the control group received a commercial ration. Results: The cafeteria diet decreased glutathione S-transferase activity and high-density lipoprotein plasmatic levels and damaged the hepatic architecture. The C. officinalis extract was able to reduce lipid infiltration in liver tissue and to modulate oxidative stress and lipid profile markers. Conclusions: The correlations between the variables suggest a pathological connection between oxidative stress markers and serum lipid profile.

Comparison of three methods for teaching mechanical ventilation in an emergency setting to sixth-year medical students: a randomized trial.

OBJECTIVE: To determine if there are significant differences between the tutorial, simulation, or clinical-case-based discussion teaching methods regarding the transmission of medical knowledge on mechanical ventilation. METHODS: A randomized, multicenter, open-label controlled trial was carried out using 3 teaching methods on mechanical ventilation: clinical-case-based discussion, simulation, and online tutorial. Voluntary students of the sixth year of medical school from 11 medical colleges answered a validated questionnaire on knowledge about mechanical ventilation for medical students before, immediately after, and 6 months after in-person training consisting of 20 multiple-choice questions, and 5 questions about the participants' demographic profile. RESULTS: Immediately after the test there was no difference between the scores in the simulation and clinical case groups,[15,06 vs 14,63] whereas, after some time, there was a significant difference in retention between the case-based and simulation groups, with the score in the simulation group 1.46 [1.31; 1.64] times higher than the score of the case group (p-value < 0.001). In the multivariate analysis, an individual who had received more than 4 hours of information showed an increase of 20.0% [09.0%; 33.0%] in the score (p-value = 0.001). CONCLUSIONS: Our results indicate that, in comparison with other forms of training, simulation in mechanical ventilation provides long-lasting knowledge in the medium term. Further studies are needed to improve the designing and evaluation of training that provides minimal mechanical ventilation skills.

Comparison of three methods for teaching mechanical ventilation in an emergency setting to sixth-year medical students: a randomized trial

SUMMARY OBJECTIVE: To determine if there are significant differences between the tutorial, simulation, or clinical-case-based discussion teaching methods regarding the transmission of medical knowledge on mechanical ventilation. METHODS: A randomized, multicenter, open-label controlled trial was carried out using 3 teaching methods on mechanical ventilation: clinical-case-based discussion, simulation, and online tutorial. Voluntary students of the sixth year of medical school from 11 medical colleges answered a validated questionnaire on knowledge about mechanical ventilation for medical students before, immediately after, and 6 months after in-person training consisting of 20 multiple-choice questions, and 5 questions about the participants' demographic profile. RESULTS: Immediately after the test there was no difference between the scores in the simulation and clinical case groups,[15,06 vs 14,63] whereas, after some time, there was a significant difference in retention between the case-based and simulation groups, with the score in the simulation group 1.46 [1.31; 1.64] times higher than the score of the case group (p-value < 0.001). In the multivariate analysis, an individual who had received more than 4 hours of information showed an increase of 20.0% [09.0%; 33.0%] in the score (p-value = 0.001). CONCLUSIONS: Our results indicate that, in comparison with other forms of training, simulation in mechanical ventilation provides long-lasting knowledge in the medium term. Further studies are needed to improve the designing and evaluation of training that provides minimal mechanical ventilation skills.

RESUMO OBJETIVO: Determinar se existem diferenças significativas entre os métodos de ensino tutorial, simulação ou discussão de casos clínicos relativos à transmissão de conhecimentos médicos sobre ventilação mecânica. MÉTODOS: Um ensaio clínico randomizado, multicêntrico, aberto e controlado foi realizado usando três métodos de ensino em ventilação mecânica: discussão baseada em casos clínicos, simulação e tutorial on-line. Alunos voluntários do sexto ano de medicina de 11 faculdades responderam a um questionário validado abordando o conhecimento sobre ventilação mecânica para estudantes de medicina antes, imediatamente após e seis meses depois do treinamento presencial, composto por 20 questões de múltipla escolha e cinco questões sobre perfil demográfico dos participantes. RESULTADOS: Imediatamente após o teste, não houve diferença entre as pontuações nos grupos de simulação e caso clínico [15,06 vs 14,63], ao passo que, após algum tempo, houve uma diferença significativa na retenção entre o baseado em caso e a simulação grupos, com a pontuação no grupo simulação 1,46 [1,31; 1,64] vez maior que a pontuação do grupo caso (p-valor <0,001). Na análise multivariada, um indivíduo que recebeu mais de quatro horas de informação apresentou aumento de 20,0% [09,0%; 33,0%] no escore (p-valor=0,001). CONCLUSÕES: Nossos resultados indicam que, em comparação com outras formas de treinamento, a simulação em ventilação mecânica proporciona um conhecimento duradouro a médio prazo. Mais estudos são necessários para melhorar o desenho e a avaliação do treinamento que forneça habilidades mínimas de ventilação mecânica.

Development and validation of a questionnaire to assess the knowledge of mechanical ventilation in urgent care among students in their last-year medical course in Brazil.

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.

Development and validation of a questionnaire to assess the knowledge of mechanical ventilation in urgent care among students in their last-year medical course in Brazil

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.

Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians.

OBJECTIVE:: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS:: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire's self-assessment items for knowledge were transformed into scores. RESULTS:: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION:: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil.

Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians

OBJECTIVE: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire’s self-assessment items for knowledge were transformed into scores. RESULTS: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil.

Doenças císticas das vias biliares / Cystic diseases of the bile ducts

JUSTIFICATIVA E OBJETIVOS: Os ductos biliares podemapresentar dilatações congênitas ou adquiridas. As lesões congênitaspodem ser hipoplásticas (atresias) e císticas. O primeiroestudo descrito na literatura foi realizado por Vater and Ezler in1723. Os cistos biliares são isolados ou múltiplos, e aparecemem qualquer idade, mas 75% deles são antes dos 20 anos. Elespodem ocorrer em toda árvore biliar, sendo, as intra-hepáticasrestritas, conhecida como doença de Caroli. O objetivo desseestudo foi fazer uma revisão sobre as Doenças císticas das viasbiliares. CONTEÚDO: As dilatações císticas extra-hepáticaatingem diversos tamanhos e são classificadas segundo sua formae localização. São elas: fusiforme, divertículos e dilataçõessaculares. Háuma incidência variada dessas lesões com câncer,entre 2,5% e 17,5%. O quadro clínico mais comum éa colestaseneonatal, correspondendo a 80% dos pacientes. Na idadeadulta, podem ser assintomáticos ou apresentar apenas sintomasinespecíficos como náuseas,vômitos. A dificuldade de drenagemda colestase obstrutiva pode lavar a cirrose biliar secundária.CONCLUSÃO: O ultrassom de abdome pode confirmar odiagnóstico. No tocante ao laboratório, observa-se uma hiperbilirrubinemiae elevação de enzimas canaliculares. A terapêuticaempregada na maioria dos casos écirúrgica, com excisão do cistoe reconstrução da drenagem biliar, devendo-se evitar a drenagemisolada, pois tais pacientes tendem a evoluir com complicaçõescomo fístulas, estenose, colangite e carcinoma.(AU)

BACKGROUND AND OBJECTIVES: The bile duct dilatationmay have congenital or acquired. Congenital lesions can behipoplásticas (atresia) and cystic. The first study described in theliterature was performed by Vater and Ezler in 1723. Biliary cystsare isolated or multiple and appear at any age, but 75% of themare before age 20. They can occur throughout the biliary tree,and the intrahepatic restricted, known as Caroli disease. Theaim of this study was to review about the cystic biliary diseases.CONTENTS: Dilated cystic extrahepatic reach various sizesand are classified according to their shape and location. Theyare: fusiform, saccular dilatation and diverticula. There is anincidence of these lesions with cancer varied between 2.5% and17.5%. The most common symptom is a neonatal cholestasis,corresponding to 80% of patients. In adulthood, may beasymptomatic or show only nonspecific symptoms such as nausea,vomiting. The difficulty of draining obstructive cholestasis canwash the secondary biliary cirrhosis. CONCLUSION: Theabdominal ultrasound can confirm the diagnosis. Regarding thelaboratory, there is a hyperbilirubinemia and elevated GGT. Thetherapy used in most cases is surgical excision of the cyst andreconstruction of biliary drainage, should be avoided drainagealone because these patients tend to develop complications suchas fistula, stricture, cholangitis and carcinoma.(AU)

An evaluation of the professional, social and demographic profile and quality of life of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil.

OBJECTIVE: To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life. METHODS: Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil. RESULTS: Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p<0.01), worked exclusively in prehospital care (18.0 vs 7.7%; p<0.001), with workloads >48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU. CONCLUSIONS: The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies were mostly found in pediatrics and psychiatry, with specific deficiencies in the handling of essential equipment and in the skills necessary to adequately attend to prehospital emergencies. A disrespectful labor scenario was also found; the evaluation of quality of life showed a notable presence of pain on the SF-36 among physicians at SAMU and especially among doctors who had worked for a longer length of time at SAMU.

An evaluation of the professional, social and demographic profile and quality of life of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil

OBJECTIVE: To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life. METHODS: Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil. RESULTS: Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p<0.01), worked exclusively in prehospital care (18.0 vs 7.7%; p<0.001), with workloads >48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams* (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU. CONCLUSIONS: The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies ...

Desmame da ventilação mecânica: abordagem para o clínico / Weaning from mechanical ventilation: approach for the internist

Weaning from mechanical ventilation is a challenge. Its prolongation is related to increased mortality. Studies have demonstrated that traditional objective criteria used are notable to shorten this time for discontinuation of mechanical ventilation. The aim of this study is to review the strategies that have been proposed and that can be used by the internist to shorten the weaning process. The judicious and systematized clinical judgment in the weaning process seems to be critical to decrease the time of weaning from mechanical ventilation. A cause of failure in weaning process should be systematically reviewed by the internist (airway and respiratory tract dysfunction, cardiac, neurological, endocrine and metabolic dysfunction). A protocol for weaning and sedation also seems crucial to shorten weaning. For the weaning process, bedside clinical follow-up by a multidisciplinary team is essential, taking various aspects into account, not only traditional objective criteria. With this approach strategy it is possible to reduce the duration of mechanical ventilation.

O desmame da ventilação mecânica é um desafio. O seu prolongamento está relacionado ao aumento da mortalidade. Estudos têm demonstrado que os critérios objetivos tradicionais utilizados não são capazes de reduzir este tempo para interrupção da ventilação mecânica. O objetivo deste estudo é analisar as estratégias que têm sido propostas e que podem ser usadas pelo clínico para encurtar o processo de desmame. O julgamento clínico criterioso e sistematizado no processo de desmame parece ser fundamental para diminuir o tempo de desmame da ventilação mecânica. A causa da falha no processo de desmame deve ser sistematicamente revista pelo clínico (disfunções do trato respiratório, da via aérea, cardiológicas, neurológicas, endocrinológicas e disfunções metabólicas). Um protocolo para o desmame e sedação também parece crucial para reduzir o desmame. Para o processo de desmame, um acompanhamento clínico a beira do leito por uma equipe multidisciplinar é essencial, levando em consideração vários aspectos, não apenas critérios objetivos tradicionais. Com esta estratégia de abordagem é possível reduzir a duração da ventilação mecânica.

Infecção fulminante por Clostridium septicum: relato de caso / Fulminant Clostridium septicum infection: case report

As infecções de tecidos moles causadas por espécies de Clostridium têm sido descritos na literatura por centenas de anos. A gangrena gasosa por Clostridium continua sendo uma importante causa de morbidade e mortalidade no mundo. O objetivo deste estudo foi relatar um caso de paciente com diagnóstico de síndrome mielodisplásica, submetida à curetagem uterina e evoluindo com gangrena gasosa espontânea, 10 horas após a cirurgia.Paciente do sexo feminino, 26 anos, com história de dor em terço distal de membros inferiores, irradiando para região de fossa poplítea, com piora à palpação e movimentação dos membros, acompanhada de aumento da temperatura e volume local. Negava febre, hiperemia ou trauma local, evoluindo para choque séptico. Angiotomografia das extremidades e pelve revelou a presença de gás permeando os feixes musculares da coxa e da perna, bilateralmente. A combinação da história e exame clínico,ao estudo radiológico confirmou o diagnóstico sindrômico de gangrena gasosa espontânea. Apesar de elevado índice de suspeição melhorar os resultados clínicos, tais infecções progridem tão rapidamente que o óbito pode preceder o diagnóstico,não obstante, o reconhecimento precoce e tratamento agressivo,incluindo drenagem aberta ou percutânea. Antibióticos parenterais contra Clostrídios devem ser prontamente iniciados, bem como medidas de suporte clínico.

The soft tissue infections caused by Clostridium species have been described in the literature for hundreds of years. The gas gangrene due to Clostridium remains an important cause of morbidity and mortality worldwide. The aim of this study was to report a patient diagnosed with myelodysplastic syndrome who underwent curettage, evolving with spontaneous gas gangrene, 10 hours after surgery. Female patient, 26 years, with pain in the distal third of the lower limbs, radiating to the popliteal fossa region, which worsened on palpation and movement of limbs, and accompanied by an increase in temperature and local volume. She denied fever, redness or local trauma, and progressed to septic shock. Angiotomography of the extremities and pelvis revealed the presence of gas permeating the muscle bundles of the thigh and leg bilaterally. The combination of history and clinical examination and radiological examination confirmed the syndromic diagnosis of Spontaneous Gas Gangrene. Although a high index of suspicion may improve clinical outcomes, such infections progress so rapidly that death usually precedes the diagnosis. However, early recognition and aggressive treatment, including open or percutaneous drainage and parenteral antibiotics against Clostridia should be promptly initiated, along with clinical support.

Síndrome da lise tumoral: uma revisão para o clínico / Tumor lysis syndrome: a review for the clinician

JUSTIFICATIVA E OBJETIVOS: As possibilidades terapêuticas para o câncer cresceram muito nos últimos anos. A possibilidade de urgências relacionadas aos pacientes sobreviventes em tratamento do câncer vem crescendo muito. A síndrome da lise tumoral (SLT) é uma emergência oncológica metabólica que exige do médico emergencista uma abordagem específica e adequada. O objetivo deste estudo foi rever o assunto e trazer aspectos atuais de seu tratamento.CONTEÚDO: A SLT é uma emergência oncológica que nos últimos anos vem sendo associada com um número cada vez maior de tipos de câncer. Avaliar seus fatores de risco e promover adequada profilaxia pode diminuir sua incidência. As consequências da SLT são um conjunto de anormalidades metabólicas: hiperfosfatemia,hipocalcemia, hiperuricemia, hipercalemia, além de lesão renal aguda, insuficiência cardíaca, retenção volêmica e efeitos neuromusculares,neurológicos e gastrointestinais que devem ser prontamente diagnosticados e tratados pelo médico emergencista. CONCLUSÃO: A SLT é uma emergência que pode levar a morte ou prejudicar muito a possibilidade do paciente receber a terapia citotóxica. Dessa forma é fundamental o rápido alívio dos sintomas e a rápida correção das suas alterações metabólicas.

BACKGROUND AND OBJECTIVES: The therapeutic possibilities for cancer increased greatly in recent years. The possibility of emergencies related to patients surviving cancer treatment has been increasing. The tumor lysis syndrome (TLS) is a metabolic oncologic emergency that requires the emergency physician to have a specific and adequate approach. This study aimed at reviewing the theme and bringing current aspects for its treatment. CONTENTS: TLS is an oncologic emergency that in recent years has been associated with an increasing number of cancer types. Assessing its risk factors and promoting appropriate prophylaxis can decrease its incidence. The consequences of TLS are a set of metabolic abnormalities: hyperphosphatemia, hypocalcemia, hyperuricemia, hyperkalemia, and acute kidney injury, heart failure, volume retention, replacement, and neuromuscular, neurological and gastrointestinal effects that should be promptly diagnosed and treated by the emergency physician. CONCLUSION: Clinical TLS is an emergency that can lead to death or can severely impair the possibility of patients receiving an adequate cytotoxic therapy. Thus, rapid relief of symptoms and prompt correction of all metabolic alterations related to TLS are mandatory.

Vinte anos de hipertensão arterial refratária sem diagnóstico: relato de caso / Twenty years of refractory hypertension without diagnosis: case report

JUSTIFICATIVA E OBJETIVOS: A grande maioria dos pacientes portadores de hipertensão arterial sistêmica (HAS) apresenta a forma primária. O diagnóstico de hipertensão arterial (HA) secundário sempre deve ser considerado, correspondendo à prevalência de até 5% dos pacientes hipertensos.O objetivo deste estudo foi ressaltar a importância do reconhecimento clínico precoce da HA secundária, através de anamnese, observação clínica e exame físico minudentes, no exame médico habitual.RELATO DO CASO: Paciente do sexo feminino, 49 anos, portadora de HA refratária a todos os tratamentos farmacológicos instituídos, com diagnóstico tardio de HA secundária. Como sintomas, apresentava cefaleia e precordialgia associada aos esforços. Foi tratada por quase toda vida como HA primária.CONCLUSÃO: Diagnosticar uma causa específica de HA secundária, embora pouco frequente, apenas com um exame físico e anamnese adequados, pode ser necessário para realizar um tratamento definitivo, resolvendo a hipertensão de difícil controle.Ressalta-se também a importância de uma propedêutica qualificada no pré-operatório para evitar complicações cirúrgicas, pós-cirúrgicas e causas secundárias que necessitem correções.

BACKGROUND AND OBJECTIVES: Although the vast majority of patients with secondary systemic blood pressure (SBP) have the primary form, the diagnosis of secondary hypertension should always be evaluated, corresponding to 5% of hypertensive patients. The aim of this study is to highlight the importance of early clinical recognition of secondary hypertension by accurate history, physical examination and clinical observations in theu sual medical examination.CASE REPORT: Female, 49 year-old patient, with hypertension refractory to all drug treatments, with late diagnosis of secondary hypertension. The symptoms were headache and exercise-related chest pain. She has been treated for primary hypertension almost all her life long.CONCLUSION: Making the diagnosis of a specific cause of secondary hypertension, only with physical examination and history, although uncommon, may be necessary in order to givea definitive treatment, solving difficult-to-control hypertension.We also emphasize the importance of a qualified preoperative workup to prevent surgical, post-surgical complications and secondary causes that require corrections.

Ventilação mecânica invasiva na sala de emergência: uma revisão para o clínico / Invasive mechanical ventilation in the emergency room: a review for clinicians

JUSTIFICATIVA E OBJETIVOS: Muitos pacientes permanecem na sala de emergência em ventilação mecânica (VM). No Brasil há falta de leitos disponíveis suficientes em terapia intensiva. Nesse cenário, o conhecimento do médico emergencista dos princípios básicos da VM é de fundamental importância. O objetivo deste estudo foi apresentar os princípios básicos de inicio e manutenção do paciente em VM na emergência e orientar as condutas diante das principais complicações. CONTEÚDO: Os princípios da sedação e a analgesia devem ser de conhecimento do emergencista para acessar a via aérea com segurança e manter o paciente em VM. A configuração inicial do ventilador conforme situação clínica deve ser então iniciada. Geralmente nas modalidades convencionais: volume assisto-controlado (VCV), pressão assisto-controlado (PCV) ou pressão de suporte (PS). Após o inicio da VM invasiva algumas complicações associadas (barotraumas, instabilidade hemodinâmica, hiperinsuflação dinâmica, obstruções da viaaérea) à ela devem ser diagnosticadas e manipuladas pelo médicoe mergencista. CONCLUSÃO: O conhecimento das recomendações na abordagem inicial, manutenção e conduta nas complicações da VM invasiva são essenciais para o médico emergencista.

BACKGROUND AND OBJECTIVES: Many patients remain in the emergency room on mechanical ventilation (MV). In Brazil, there are not sufficient beds available in intensive care units. In this scenario, the emergency physician's knowledge of the basic principles of MV is crucial. The objective of this study was to present the basic principles for starting and maintaining the patient on MV in an emergency setting, and to guide procedures in face of major medical complications. CONTENTS: The emergency doctor should know the principles of sedation and analgesia to access the airway safely and maintain the patient on MV. The initial settings of the ventilator according to the clinical situation should then be initiated. Generally conventional modalities: volume-controlled ventilation (VCV), pressure-controlled ventilation (PCV) or pressure support ventilation (PS). After start of invasive MV, some associated complications (barotrauma, hemodynamic instability, dynamic hyperinflation,airway obstruction) must be diagnosed and handled by the emergency physician. CONCLUSION: Knowledge of the recommendations for the initial approach, maintenance and management of complications in invasive MV is essential for the emergency physician.

Doença de Chagas congênita com manifestações pleomórficas: relato de caso / Congenital Chagas disease in adolescent with pleomorphic manifestations: case report

JUSTIFICATIVA E OBJETIVOS: A doença de Chagas é uma infecção parasitária, endêmica, em várias regiões do Brasil. Nas últimas décadas, a via de transmissão predominante foi modificada de vetorial para congênita, devido ao êxodo rural e aos métodos mais eficazes de combate aos vetores. Alguns pacientes jovens apresentam manifestações crônicas e intensas, consequentes da transmissão congênita. O objetivo deste estudo foi relatar um caso de uma paciente com doença de Chagas de transmissão vertical com manifestações variadas da doença. Ressalta-se a importância de se conhecer diversas formas de transmissão e, ademais, enfatiza-se a importância de realizar adequado pré-natal em áreas endêmicas para possível diagnóstico, tratamento precoce e acompanhamento clínico. RELATO DO CASO: Paciente do sexo feminino, 20 anos, solteira, apresentando há 8 meses dispneia aos mínimos esforços, precordialgia, epigastralgia e tosse seca, evoluindo com disfagia, confirmando-se o diagnóstico de insuficiência cardíaca com exames complementares. A investigação prosseguiu com provas sorológicas, eletrocardiograma, radiografia do coração e vasos da base (RCVB), Ecodopplercardiograma, confirmando-se: IgG positivo para Chagas em dois testes sorológicos (hemaglutinação indireta e imunofluorescência para T. Cruzi), alterações eletrocardiográficas difusas, megaesôfago grau II, cardiomegalia grau III. Foi realizado tratamento etiológico com benzonidazol (Rochagan®) para doença de Chagas crônica de início recente. Apesar da dificuldade na obtenção dos exames complementares,objetivando maior acurácia no diagnóstico e melhor acompanhamento do tratamento, concluiu-se que era um caso de doença de Chagas congênita, uma vez que a história familiar era positiva e a paciente não teve contato com triatomídeos (morou sempre na área urbana) e a transmissão vetorial está diminuindo devido às campanhas de erradicação dos vetores...

BACKGROUND AND OBJECTIVES: Chagas disease is a parasitic infection, endemic in several regions of Brazil. In recent decades the predominant route of transmission changed from vectorial to congenital, due to rural exodus and more effective methods for fighting the vectors. Some young patients have chronic and severe manifestations due to congenital transmission. The aim of this study was to report a case of a young adult patient with Chagas disease vertical transmission, with varied clinical manifestations of the disease. The importance of knowing the various forms of transmission was emphasized and also of the importance of prenatal assistance in endemic areas for possible early diagnosis, treatment and clinical follow up. CASE REPORT: Female patient, 20 years old, single, has presented experiencing, for the previous 8 months, dyspnea on exertion, constrictive chest pain, epigastric pain, and dry cough associated with progressive dysphagia; the diagnosis of heart failure was confirmed by complementary tests. The investigation progressed with serological tests, electrocardiogram, chest teleradiograph, echodopplercardiogram, confirming: IgG positive for Chagas disease, in two different serological tests (indirect hemagglutination assay and immunofluorescence for T cruzi), diffuse electrocardiographic changes, grade II megaesophagus, grade III cardiomegaly. Etiological treatment was conducted with benzonidazol (Rochagan®) for chronic Chagas disease of recent onset. Despite the difficulty in obtaining additional tests, aiming greater accuracy in the diagnosis and better monitoring of the treatment, it was concluded that it was a case of congenital Chagas disease, since family history is positive and the patient denied having contact with triatomids (hematophagus bugs) as she has always lived in urban areas, and because vectorial transmission is declining due to campaigns for eradication of the vectors...