[Shock and Coma after Ingestion of Morels]. / Morchelvergiftung mit Schock und Koma.

Shock and Coma after Ingestion of Morels Abstract. We present the case report of a previously healthy, 42-year-old woman who suffered from a hypovolemic shock, hypoglycemic coma, NSTEMI and temporary dependency on dialysis following the ingestion of morels. Alas there is little public knowledge about the toxicity of morels and the importance of their appropriate preparation so that intoxications can be prevented.

[Record-Breaking Acidosis]. / Rekordverdächtig sauer.

Record-Breaking Acidosis Abstract. To maintain a stable cellular metabolism, tight regulation of blood pH within a normal range (pH 7,35-7,45) is essential. Even small aberrations can have detrimental effects, and pH values <6,8 or pH >7,8 are considered - based on current medical and physiological knowledge - incompatible with life [9-19].

[Necrotizing esophagitis by stress-cardiomyopathy with right ventricular insufficiency]. / Nekrotisierende Ösophagitis bei Stresskardiomyopathie mit Rechtsherzversagen.

Acute necrotizing esophagitis ("black esophagus") is defined as complete necrosis of the esophageal mucosa, which typically affects the entire circumference. We report a case of a healthy 62-year-old woman, who became hemodynamically unstable due to stress cardiomyopathy with acute right heart failure. Transfusion-dependent anemia occurred 24 h later and an upper gastrointestinal endoscopy revealed a black discoloured mucosa of the distal esophagus. After hemodynamic stabilization and treatment with proton pump inhibitors and sucralfate, complete healing of the esophageal mucosa was achieved.

[Red Flags and Shock Symptoms]. / «Red Flags¼ und Schocksymptome.

Red Flags and Shock Symptoms Abstract. The term 'red flags' is often used in emergency medicine. However, there is no clear medical definition in German for 'red flag'. In most cases, 'red flags' are warning symptoms that indicate a potentially harmful threat to a patient's health. This article wants to explain and define the term 'red flags'. Red flags are explained in emergency medicine and especially in shock in the context of their basic pathophysiological causes. The aim is to improve the understanding of the timely recognition and the exact interpretation of these warning symptoms in the preclinical environment, in order to immediately start a sufficient therapy.

[Death within Hours]. / Tod innerhalb von Stunden.

Death within Hours Abstract. The clinical picture of invasive meningococcal disease is broad, it mostly manifests as meningitis and/or sepsis. The severity ranges from a simple bacteremia associated with mild, unspecific symptoms to fulminant sepsis with multiorgan failure and death, which happens in 10-15 % of cases. Sometimes purely local infections (e.g. septic arthritis or conjunctivitis) or rarely a chronic course (prolonged, intermittent fever, rash, arthritis and headache) are the only clinical manifestation - which can also lead to a disseminated fulminant disease. Our case illustrates the tragic progression of a fulminant meningococcal sepsis with rapid death.

[One Case for Two]. / Ein Fall für zwei.

One Case for Two Abstract. We report on a 59-year-old patient with a rash, hypotension and chest pain after eating tuna fish. A diagnosis of scombroid fish poisoning was made. It is a syndrome resembling an allergic reaction that occurs after eating fish of the Scombridae family contaminated with high levels of histamine. The authorities responsible for food safety should be immediately informed in order to investigate the event from their perspective, i.e. inspect selling premises, sample and test implicated food, as well as to take appropriate measures. Anaphylaxis rarely manifests as a vasospastic acute coronary syndrome, called Kounis syndrome.

Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality.

BACKGROUND: While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality. METHODS: The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003-2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: 'early presenters' versus 'late presenters'); and for (b) onset of pain-to-FMC (min) as a continuous variable. RESULTS: After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013-1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001-1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368-0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex ( p=0.003), anterior infarction ( p=0.004) and diabetes mellitus ( p=0.035) were independently associated with longer delay, while hyperlipidaemia ( p=0.002) and cardiogenic shock ( p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% ( p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999-1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676-1.573; p=0.886). CONCLUSION: In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.

Use of tranexamic acid in trauma patients: an analysis of cost-effectiveness for use in Brazil / Uso de ácido tranexâmico no trauma: uma análise de custo-efetividade para o uso no Brasil

ABSTRACT Introduction: Use of tranexamic acid (TXA) in trauma has been the subject of growing interest by researchers and health professionals. However, there are still several open questions regarding its use. In some aspects medical literature is controversial. The points of disagreement among experts include questions such as: Which patients should receive TXA in trauma? Should treatment be performed in the pre-hospital environment? Is there any need for laboratory parameters before starting TXA treatment? What is the drug safety profile? The main issue on which there is still no basis in literature is: What is the indication for treatment within massive transfusion protocols? Objective: Answer the questions proposed based on critical evaluation of the evidence gathered so far and carry out a study of cost-effectiveness of TXA use in trauma adapted to the Brazilian reality. Methods: A literature review was performed through searching Pubmed.com, Embase and Cab Abstract by headings "tranexamic AND trauma", in all languages, yielding 426 articles. Manuscripts reporting on TXA utilization for elective procedures were excluded, remaining 79 articles. Fifty-five articles were selected, and critically evaluated in order to answer study questions. The evaluation of cost effectiveness was performed using CRASH-2 trial data and Brazilian official population data. Results: TXA is effective and efficient, and should be administered to a wide range of patients, including those with indication evaluated in research protocols and current indication criteria for TXA should be expanded. As for the cost-effectiveness, the TXA proved to be cost-effective with an average cost of R$ 61.35 (currently US$16) per year of life saved. Conclusion: The use of TXA in trauma setting seems to be effective, efficient and cost-effective in the various groups of polytrauma patients. Its use in massive transfusion protocols should be the subject of further investigations.

RESUMO Introdução: O uso do ácido tranexâmico (TXA) no trauma tem sido alvo de interesse crescente por parte de pesquisadores e profissionais de saúde. No entanto, seus benefícios ainda não foram completamente definidos. Os pontos de divergência entre especialistas incluem questões como: quais pacientes devem receber TXA no trauma? O tratamento deve ser realizado em ambiente pré-hospitalar? Há necessidade de exames laboratoriais para indicar o tratamento? Qual o perfil de segurança da droga? A principal questão para a qual ainda não existe qualquer embasamento na literatura é: qual a indicação do tratamento dentro de protocolos de transfusão maciça? Objetivo: Responder às questões propostas, com base em avaliação crítica da evidência reunida até o momento e realizar estudo de custo-efetividade do uso do TXA no trauma adaptado à realidade brasileira. Métodos: Foi realizada revisão da literatura através de estratégia de busca: PubMed.com, Embase e no Cab Abstract pelos descritores "tranexamic AND trauma", em todos idiomas, resultando em 426 artigos. Foram excluídos aqueles relativos às operações eletivas, restando 79 artigos. Cinquenta e cinco foram selecionados e avaliados criticamente com vistas a responder às questões em estudo. A avaliação de custo-efetividade foi realizada utilizando dados do estudo CRASH-2 e populacionais oficiais brasileiros. Resultados: Através da análise da evidência disponível chegou-se à conclusão de que o ácido tranexâmico é tratamento eficaz e efetivo, devendo ser administrado à ampla gama de pacientes, incluindo todos aqueles com indicação já avaliada nos protocolos de pesquisa publicados e provavelmente devam-se expandir os critérios de indicação. Quanto à avaliação de custo-efetividade, o TXA mostrou-se bastante custo-eficaz com gasto médio de R$ 61,35 por ano de vida salvo. Conclusão: O uso do ácido tranexâmico no trauma parece ser eficaz, efetivo e custo-eficaz nos diversos grupos de pacientes politraumatizados. Seu uso em protocolos de transfusão maciça ainda deve ser objeto de futuras investigações.

Expression of heat shock protein 27, 60 and 90 in gastric cancer and its clinical value / 中国免疫学杂志

Objective: To investigate the expression of HSP-27,-60 and -90 in gastric cancer and its clinical significance. Methods:66 cases of gastric carcinoma was detected by immunohistochemistry HSP-27,60 and 90 of the expression and clinical significance of combined with clinical and pathological characteristics, tumor cell proliferation and survival analysis of three kinds of heat shock protein expression. Results: HSP-27,-60 and -90 were highly expressed in gastric cancer tissues. HSP-27 expression and tumor size (pT,P=0. 026),organ metastasis (pM,P=0. 046) and pathological staging (P=0. 041),HSP-27 staining intensity and lymph node status were significantly correlated ( pN, P=0. 042 ) . HSP-60 expression was associated with gender ( P=0. 011),and HSP-60 staining intensity was associated with age (P=0. 027) and tumor grade (P=0. 031). There was no correlation between HSP-90 expression and the clinical pathological parameters of this study; however, the intensity of HSP-90 staining was significantly correlated with tumor size (P=0. 020,pT). Single factor analysis showed that HSP-90 was significantly associated with longer survival (P=0. 033). Multivariate analysis demonstrated that HSP-90 was highly expressed as an independent prognostic factor for gastric cancer (P=0. 026). Conclusion: the HSP-27,-60 and -90 and some clinical pathological parameters. These parameters is very important for the treatment of patients with gastric cancer. The high expression of HSP-90 in patients with gastric cancer were inde-pendent prognostic indicators.

Fluid therapy for septic shock resuscitation: which fluid should be used? / Fluidoterapia para a ressuscitação no choque séptico: qual tipo de fluido deve ser utilizado?

Early resuscitation of septic shock patients reduces the sepsis-related morbidity and mortality. The main goals of septic shock resuscitation include volemic expansion, maintenance of adequate tissue perfusion and oxygen delivery, guided by central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation and arterial lactate levels. An aggressive fluid resuscitation, possibly in association with vasopressors, inotropes and red blood cell concentrate transfusion may be necessary to achieve those hemodynamic goals. Nonetheless, even though fluid administration is one of the most common interventions offered to critically ill patients, the most appropriate type of fluid to be used remains controversial. According to recently published clinical trials, crystalloid solutions seem to be the most appropriate type of fluids for initial resuscitation of septic shock patients. Balanced crystalloids have theoretical advantages over the classic solutions, but there is not enough evidence to indicate it as first-line treatment. Additionally, when large amounts of fluids are necessary to restore the hemodynamic stability, albumin solutions may be a safe and effective alternative. Hydroxyethyl starches solutions must be avoided in septic patients due to the increased risk of acute renal failure, increased need for renal replacement therapy and increased mortality. Our objective was to present a narrative review of the literature regarding the major types of fluids and their main drawbacks in the initial resuscitation of the septic shock patients.

A ressuscitação precoce de pacientes com choque séptico tem o potencial de reduzir sua morbidade e mortalidade. Os objetivos principais da ressuscitação no choque séptico incluem expansão volêmica, manutenção da perfusão tecidual e da oferta de oxigênio para os tecidos, guiados pela pressão venosa central, pressão arterial média, saturação venosa mista ou central de oxigênio e lactato arterial. Uma ressuscitação agressiva com fluidos, possivelmente em associação com vasopressores, inotrópicos e transfusão de concentrado de hemácias, pode ser necessária para atingir estes objetivos hemodinâmicos. Todavia, embora a administração de fluidos seja uma das intervenções mais comumente realizada em pacientes graves, o tipo de fluido mais apropriado para ser utilizado permanece controverso e incerto. De acordo com os estudos clínicos mais recentes, os cristaloides são os fluidos de escolha para serem utilizados na ressuscitação inicial de pacientes com choque séptico. As soluções cristaloides balanceadas possuem vantagens teóricas em relação as não balanceadas, porém ainda não há evidências suficientes para indicá-las como tratamento de primeira escolha. Além disso, albumina humana parece ser uma alternativa segura e efetiva quando grandes quantidades de fluidos são necessárias para o restabelecimento da estabilidade hemodinâmica. O uso de soluções de hidroxetilamido deve ser evitado em pacientes sépticos, devido ao maior risco de desenvolvimento de insuficiência renal aguda, necessidade de terapia de substituição renal e aumento de mortalidade. O objetivo deste estudo foi apresentar uma revisão narrativa da literatura sobre os principais tipos de fluidos e os problemas mais importantes na ressuscitação inicial de pacientes com choque séptico.

[Fatal agranulocytosis after metamizole reexposure]. / Fatale Agranulozytose nach Metamizol-Reexposition.

We present the case of a 63 year old man who died of severe septic shock in the setting of agranulocytosis induced by dipyrone (metamizole). The patient had previously developed agranulocytosis after dipyrone exposure 18 months prior to this. The case illustrates the seriousness of dipyrone-induced agranulocytosis, highlights the risks associated with re-exposure and underlines the need for excellent communication between treating physicians and their patients. The possible underlying mechanisms, epidemiology and management of dipyrone-induced agranulocytosis are discussed.

Abdome agudo por apendicite com apresentação atípica levando a choque em paciente obeso e hepatopata crônico / Acute abdomen due appendicitis with atypical presentation leading to shock in an obese patient and with chronic liver disease

Objetivos: Expor um caso de abdome agudo por apendicite cujo diagnóstico apresentou-se difícil e complicado devido ao perfil do paciente e suas comorbidades.Descrição do Caso: Paciente masculino, 52 anos, superobeso, tabagista e hepatopata crônico, com queixa de dor abdominal aguda em hipocôndrio direito, vômitos e baixa diurese. Inicialmente sem sinais de irritação peritoneal, foi manejado clinicamente, mas apresentou piora do quadro, evoluindo para choque e parada cardiorrespiratória. Em investigação por laparotomia exploratória constatou-se apendicite aguda, circulação colateral e cirrose hepática.Conclusões: O quadro de abdome agudo tem grande incidência nas unidades de pronto atendimento e, uma vez que compreende inúmeras situações clínicas, faz-se imprescindível conhecer e suspeitar de suas principais causas e de suas apresentações atípicas, de difícil...

Aims: To expose a case of acute abdomen due to appendicitis whose diagnosis was difficult and complicated because of the patient?s profileand his comorbidities.Case Description: Male patient, 52 years old, superobese, smoker and with chronic liver disease, complaining of acute abdominal pain inthe right hypochondrium, vomiting and low diuresis. Initially with no signs of peritoneal irritation, the patient was medically managed, butpresented worsening of clinical status, progressing to shock and cardiac arrest. The investigation by laparotomy found acute appendicitis,collateral circulation and liver cirrhosis.Conclusions: Acute abdomen has great impact on emergency care and, since it comprises several clinical situations, knowing and suspectingits main causes and its atypical presentations becomes essential, mainly in cases of difficult diagnosis...

Septicemia fatal causada por Vibrio cholerae no-O1, no-O139 hemolítico en Chile: Caso clínico / Non-toxigenic hemolytic Vibrio cholerae non-O1non-O139 fatal septicemia: Report of one case

We report a 70-year-old woman, who had recently consumed shellfish, that was admitted to the intensive care unit with septic shock and died 19 hours later due to a multi-organic failure. Microbiological, serological and molecular assays confirmed a hemolytic tdh+ Vibrio cholerae non-01, non 0139 as the etiologic agent (Rev Méd Chile 2009; 137: 1193-6).