Enterite mesentérica como complicação rara do lúpus eritematoso sistêmico / Mesenteric enteritis as a rare complication of systemic lupus erythematosus

A dor abdominal no paciente com lúpus eritematoso sistêmico tem amplo espectro clínico, variando desde condições inespecí- ficas, como diarreia e vômitos, até eventos de importante morbi- mortalidade, como o abdome agudo inflamatório e/ou perfura- tivo. A seguir, descreve-se um caso de paciente do sexo feminino, de 23 anos, internada por dor abdominal associada a vômitos e à diarreia crônica e progressiva. Foi diagnosticada com lúpus eritematoso sistêmico há 2 anos. Durante a internação, evoluiu com quadro de abdome agudo, e foi realizada tomografia compu- tadorizada de abdome, revelando importante edema de parede intestinal difuso. Isso, somado a alterações clínico-laboratoriais, permitiu o diagnóstico de enterite lúpica. Foi realizado tratamen- to conservador, com corticoterapia e terapia de suporte com correção de distúrbios eletrolíticos severos, sendo iniciado ciclo- fosfamida, com resolução dos sintomas gastrintestinais.

Abdominal pain in patients with systemic lupus erythematosus has a broad clinical spectrum, ranging from nonspecific symp- toms, such as diarrhea and vomiting, to events of significant morbidity and mortality, such as acute inflammatory and/or per- forating abdomen. This article describes a case of a 23-year-old female patient hospitalized for abdominal pain, associated with vomiting and progressive chronic diarrhea. She was diagnosed with systemic lupus erythematosus 2 years ago. During hospita- lization, the patient progressed with acute abdomen, and an ab- dominal computed tomography scan was performed, revealing major diffuse intestinal wall edema. This, added to clinical and laboratories alterations, allowed the diagnosis of lupus enteritis. A conservative treatment with corticotherapy and supportive therapy with correction of severe electrolyte disturbances were initiated, as well as the prescription of cyclophosphamide, with resolution of gastrointestinal symptoms.

Prevalência de hiperglicemia de estresse em uma unidade de terapia intensiva / Prevalence of stress hyperglycemia in an intensive care unit

Objetivo: Avaliar a prevalência e o manejo da hiperglicemia de estresse em pacientes internados em uma unidade de terapia intensiva. Métodos: Estudo retrospectivo, realizado de janeiro a junho de 2018. Os dados foram obtidos a partir de 582 prontuá- rios eletrônicos, considerando os valores glicêmicos durante a hospitalização, história prévia ou não de diabetes mellitus, causas do internamento, tempo de permanência na unidade de terapia intensiva, presença de complicações durante o internamento e conduta utilizada em caso de hiperglicemia de estresse. Resulta- dos: Dos 582 pacientes internados na unidade de terapia intensi- va, 579 tiveram sua glicemia indicada nos prontuários analisados; 341 (58,9%) apresentaram hiperglicemia em algum momento da internação, sendo a hiperglicemia de estresse caracterizada em 200 pacientes (35%). A duração média de internamento desses pacientes foi de 8,39±10,9 dias, e a causa mais frequente de inter- namento foi devido a pós-operatório por diversas causas, somando 148 indivíduos (74%). Dentro os pacientes, 72 (36%) apresenta- ram alguma complicação. Além disso, 13 casos (6,5%) evoluíram para óbito. Conclusão: Estudos disponíveis sobre alvos de gli- cose em pacientes críticos das unidades de terapia intensiva apresentam difícil interpretação devido às diferenças subs- tanciais no grupo de populações e aos protocolos de gestão de pacientes utilizados em vários centros. Todavia, a prevalência da hiperglicemia de estresse encontrada nesta amostra é se- melhante à de outras casuísticas estudadas. O índice eleva- do de complicações enfatiza a necessidade de padronização nos critérios para diagnóstico e tratamento da hiperglicemia de estresse objetivando melhor prognóstico desses pacientes independentemente da causa do internamento.

Objective: To evaluate the prevalence and management of stress hyperglycemia in patients hospitalized in anintensive care unit. Methods: Retrospective study, carried out from January to June 2018. Data were obtained from 582 electronic medical records, considering glycemic values during hospitalization, existence of previous history of Diabetes Mellitus, causes of hospitalization, length of stay in the intensive care unit, presence of complications during hospitalization, and behavior used in case of stress hyper- glycemia. Results: Of the 582 patients admitted in the ICU, 579 had their glycemia indicated in the charts analyzed: 341 (58,9%) had hyperglycemia in a certain moment of hospitalization, with stress hyperglycemia being present in 200 patients (35%). The average duration of hospitalization of these patients was 8,39 ± 10,9 days, and the most frequent cause of hospitalization was postoperative for various causes, totaling 148 individuals (74%). Of the patients, 72 (36%) presented some type of complication and 13 patients (6,5%) died. Conclusion: Available studies on glucose targets in critical intensive care unit patients are difficult to be interpre- ted because of substantial differences in the study populations and of patient management protocols used at various centers. However, the prevalence of stress hyperglycemia found in this sample is similar to that of other study groups. The high com- plication rate emphasizes the need for standardization of the criteria for diagnosis and treatment of stress hyperglycemia aiming at a better prognosis of these patients regardless of the cause of hospitalization.

Functional iron deficiency in patients on hemodialysis: prevalence, nutritional assessment, and biomarkers of oxidative stress and inflammation / Deficiência funcional de ferro em pacientes em hemodiálise: prevalência, avaliação nutricional e de biomarcadores de estresse oxidativo e de inflamação

Abstract Introduction: Anemic patients with chronic kidney disease (CKD) can be divided into anemic patients without or with functional iron deficiency (FID). The increase in the number of cases of hemosiderosis in patients on hemodialysis (HD) attributed to excessive intravenous iron replacement has called for the investigation of the factors involved in the genesis of FID. Objectives: This study aimed to describe the prevalence of FID in patients with CKD on HD, characterize the included individuals in terms of clinical and workup parameters, and assess their nutritional, oxidative stress, and inflammation statuses. This cross-sectional study assembled a convenience sample of 183 patients with CKD on HD treated in Southern Brazil. Patients meeting the inclusion and exclusion criteria were divided into two groups, one with anemic subjects with FID and one with anemic patients without FID. Participants answered a questionnaire probing into socio-epidemiological factors, underwent anthropometric measurements, and were tested for markers of anemia, oxidative stress, inflammation, and nutrition. Statistical analysis: The date sets were treated on software package GraphPad InStat version 3.1. Variables were tested with the Kolmogorov-Smirnov, chi-square, Student's t, and Mann-Whitney tests. Statistical significance was attributed to differences with a p < 0.05. Results: Markers of inflammation were not statistically different between the two groups. Markers of anemia and nutrition were significantly lower in patients with FID. Patients with FID were prescribed higher doses of parenteral iron (p < 0,05). Discussion: FID was associated with lower nutritional marker levels, but not to increased levels of markers of inflammation or oxidative stress, as reported in the literature. Additional studies on the subject are needed.

Resumo Introdução: A anemia na DRC pode ser dividida em anemia sem deficiência funcional de ferro e com deficiência funcional de ferro (ADFF). Diante do aumento dos casos de hemossiderose em pacientes em hemodiálise, atribuídos à reposição excessiva de ferro endovenoso, maiores conhecimentos sobre os fatores envolvidos na gênese da ADFF são importantes. Objetivos: documentar a prevalência de ADFF em renais crônicos em hemodiálise. Caracterizar clínica e laboratorialmente os portadores de ADFF em HD e avaliar o estado nutricional, estresse oxidativo e inflamatório. Estudo transversal, amostra de conveniência, envolvendo 183 renais crônicos em hemodiálise no sul do Brasil. Após aplicação dos critérios de exclusão, os pacientes foram separados em dois grupos: portadores de anemia com e sem deficiência funcional de ferro. Foram submetidos a questionário socioepidemiológico, à análise antropométrica e análise laboratorial dos marcadores de anemia, estresse oxidativo, inflamatórios e nutricionais. Análise estatística: programa GraphPad InStat versão 3.1. Foram aplicados os testes: Kolmogorov-Smirnov, qui-quadrado, t de Student e Mann-Whitney. Nível de significância adotado de 5%. Resultados: não houve diferença significativa nos marcadores inflamatórios entre os dois grupos. Houve diferença significativa nos marcadores de anemia e nutrição, significativamente menores nos pacientes com ADFF. Pacientes com ADFF receberam doses mais elevadas de ferro parenteral (p < 0,05). Discussão: ADFF esteve associada a menores valores de marcadores nutricionais, mas não esteve associada a marcadores inflamatórios ou de estresse oxidativo aumentados, como relatado na literatura. Estudos adicionais sobre o tema são necessários.

Antioxidant effect of endothelin-1 receptor antagonist protects the rat kidney against chronic injury induced by hypertension and hyperglycemia / Efeito antioxidante de antagonista dos receptores de endotelina-1 protege ratos contra lesão renal crônica induzida por hipertensão e hiperglicemia

ABSTRACT Hypertension and Diabetes mellitus are the two main causes of chronic kidney disease that culminate in the final stage of kidney disease. Since these two risk factors are common and can overlap, new approaches to prevent or treat them are needed. Macitentan (MAC) is a new non-selective antagonist of the endothelin-1 (ET-1) receptor. This study aimed to evaluate the effect of chronic blockade of ET-1 receptor with MAC on the alteration of renal function observed in hypertensive and hyperglycemic animals. Genetically hypertensive rats were divided into control hypertensive (HT-CTL) group, hypertensive and hyperglycemic (HT+DIAB) group, and hypertensive and hyperglycemic group that received 25 mg/kg macitentan (HT-DIAB+MAC25) via gavage for 60 days. Kidney function and parameters associated with oxidative and nitrosative stress were evaluated. Immunohistochemistry for neutrophil gelatinase-associated lipocalin (NGAL), ET-1, and catalase in the renal cortex was performed. The HT+DIAB group showed a decrease in kidney function and an increase in NGAL expression in the renal cortex, as well as an increase in oxidative stress. MAC treatment was associated with attenuated ET-1 and NGAL production and increases in antioxidant defense (catalase expression) and nitric oxide production. In addition, MAC prevented an increase in oxidant injury (as measured by urinary hydroperoxide and lipid peroxidation), thus improving renal function. Our results suggest that the antioxidant effect of the ET-1 receptor antagonist MAC is involved in the improvement of kidney function observed in hypertensive and hyperglycemic rats.

RESUMO Hipertensão e Diabetes Mellitus figuram como as duas principais causas de doença renal crônica que culmina em doença renal terminal. Uma vez que os dois fatores de risco são comuns e podem se sobrepor, novas abordagens preventivas e terapêuticas se fazem necessárias. O macitentan (MAC) é um novo antagonista não-seletivo dos receptores da endotelina-1 (ET-1). O presente estudo teve como objetivo avaliar os efeitos do bloqueio crônico dos receptores da ET-1 com MAC sobre a alteração da função renal em animais hipertensos e hiperglicêmicos. Ratos geneticamente hipertensos foram divididos em grupos com animais hipertensos de controle (HT-CTL), hipertensos e hiperglicêmicos (HT+DIAB) e hipertensos e hiperglicêmicos tratados com 25 mg/kg de macitentan (HT-DIAB+MAC25) via gavagem por 60 dias. Foram avaliados função renal e parâmetros associados ao estresse oxidativo e nitrosativo. Exames de imunoistoquímica foram realizados para lipocalina associada à gelatinase neutrofílica (NGAL), ET-1 e catalase no córtex renal. O grupo HT+DIAB exibiu diminuição da função renal e aumento na expressão de NGAL no córtex renal, bem como estresse oxidativo aumentado. O tratamento com MAC foi associado a atenuação da produção de ET-1 e NGAL e maior ativação das defesas antioxidantes (expressão de catalase) e elevação da produção de óxido nítrico. Além disso, o MAC evitou exacerbação da lesão oxidante (medida por hidroperóxidos urinários e peroxidação lipídica), melhorando assim a função renal. Nossos resultados sugerem que o efeito antioxidante do antagonista dos receptores da ET-1 MAC esteja imbricado no aprimoramento da função renal observada em ratos hipertensos e hiperglicêmicos.

The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.

Sodium thiosulfate and pamidronate for treatment of calciphylaxis: case report / Tiosulfato de sodio y pamidronato para el tratamiento de calcifilaxis: reporte de caso

Abstract Introduction: Calciphylaxis is an infrequent disease that almost exclusively affects patients with chronic kidney disease, although cases have been observed in patients without renal function impairment. The diagnosis is mainly made by clinical manifestations and subsequently confirmed by radiological and histological study. The optimal treatment is not known, although there is a consensus that a multifactorial approach is required. Clinical Case: A 68-year-old woman on hemodialysis for 2 years, who presented a painful nodular lesion in the left thigh, a skin biopsy was performed resulting in a diagnosis of calciphylaxis. Treatment and Outcome: Treatment was started with intravenous sodium thiosulfate. Pamidronate is added intravenously, three months later, due to an unfavorable evolution. After 6 months of treatment, improvement in nodular lesions and healing of the ulcerated lesion was observed to be generally well tolerated treatment. Conclusion: The combined treatment of sodium thiosulfate, pamidronate and calcitomimetics has been effectiveand safe for the treatment of calciphylaxis, inducing complete remission.

Resumen: Introducción: La calcifilaxis es una enfermedad infrecuente que afecta casi exclusivamente a pacientes con insuficiencia renal, aunque se han observado casos en pacientes sin deterioro de la función renal. El diagnóstico es clínico confirmándose con estudio radiológico e histológico. No se conoce con exactitud el tratamiento óptimo, aunque hay consenso en que se requiere un abordaje multifactorial. Caso Clínico: Mujer de 68 años en hemodiálisis desde hace 2 años, que presenta una lesión nodular dolorosa en muslo izquierdo, resultando un diagnostico compatible con calcifilaxis, tras biopsia cutánea. Tratamiento y resultado: Inicia tratamiento con tiosulfato de sodio vía venosa. Tres meses más tarde y ante la evolución desfavorable, se añade al tratamiento pamidronato vía intravenosa. Tras 6 meses de tratamiento se observa mejoría de las lesiones nodulares y cicatrización de la lesión ulcerada, habiéndose experimentado buena tolerancia. Conclusión: El tratamiento combinado de tiosulfato de sodio, pamidronato y calcimiméticos ha resultado efectivo y seguro para el tratamiento de la calcifilaxis, induciendo su remisión completa.

Tratamiento con radioyodo endovenoso y estimulación con TSH recombinante humana en paciente con cáncer de tiroides extenso: caso clínico / Intravenous radioiodine and recombinant human TSH in a patient with extensive thyroid cáncer: report of one case

Abstract: We report a 72-years-old male patient with extensive differentiated thyroid cancer (DTC), who required a tracheostomy and gastrostomy. Considering his clinical condition, risk of aspiration and management of the ostomies, radioiodine (131I) was administered intravenously, using recombinant human thyrotropin (rhTSH) and levothyroxine. The procedure was successful, both clinically and in terms of radioprotection.

The serum homocysteine level in patients with acute ischemic stroke (AIS) after thrombolysis and its relationship with clinical outcomes

SUMMARY OBJECTIVE The present study aims to investigate whether hyperhomocysteinemia (HHcy) affects the outcomes of the thrombolytic treatment for patients with AIS. METHODS A sample of 120 AIS patients were recruited and grouped according to their serum homocysteine (Hcy) levels. The National Institute of Health Stroke Scale (NIHSS) was obtained before treatment and 7 days after it to evaluate neurological outcomes; modified Rankin Scale (mRS) was obtained 12 weeks later to assess functional outcomes. Receiver operating characteristic curve (ROC) was used to demonstrate the relationship between serum Hcy level and the outcomes after tPA treatment. RESULTS The serum Hcy level of 120 patients was of 27.57±20.17μmol/L. The NIHSS scores of the patients in the low Hcy level group were remarkably lower compared to those in the high-level group (p<0.05), after 7 days of treatment. In addition, the mRS scores of the patients in the low Hcy level group, after 12 weeks, were remarkably lower compared to those in the high-level group (p<0.01). ROC demonstrated that the serum Hcy level is related to the clinical outcomes of thrombolytic treatment with moderate specificity (80.3%) and sensitivity (58.2%). CONCLUSION In conclusion, higher serum Hcy levels can indicate poorer clinical outcomes of thrombolytic treatment in patients with AIS.

RESUMO OBJETIVO O presente estudo tem por objetivo investigar se a hiperhomocisteinemia (HHcy) afeta os resultados do tratamento trombolítico em pacientes com AVCI agudo. METODOLOGIA Uma amostra de 120 pacientes AVCI agudo foi recrutada e agrupada de acordo com os níveis séricos de homocisteína (Hcy). Uma avaliação nos padrões do National Institute of Health Stroke Scale (NIHSS) foi obtida antes do tratamento e 7 dias após ele para avaliar desfechos neurológicos e a escala de Rankin modificada foi utilizada 12 semanas depois para avaliar os desfechos funcionais. A curva ROC (Receiver Operating Caracteristic) foi utilizada para demonstrar a relação entre os níveis séricos de Hcy e os desfechos após tratamento com t-PA. RESULTADOS Os níveis séricos de Hcy de 120 pacientes foi de 27,57±20,17μmol/L. Os escores NIHSS dos pacientes no grupo de baixo nível de Hcy foram notavelmente mais baixos em comparação àqueles do grupo de nível mais alto (p<0,05), após 7 dias de tratamento. Além disso, os escores mRS dos pacientes no grupo de baixo nível de Hcy, após 12 semanas, foram consideravelmente mais baixos em comparação com os do grupo de alto nível (p<0,01). A curva ROC demonstrou que o nível sérico de Hcy tem relação com os desfechos clínicos do tratamento trombolítico com especificidade moderada (80,3%) e sensibilidade (58,2%). CONCLUSÃO Podemos concluir então que níveis séricos mais altos de Hcy podem prever desfechos clínicos piores para o tratamento trombolítico em pacientes com AVCI agudo.

Use of pamidronate for osteoporosis treatment in public health care in Brazil / Uso de pamidronato para o tratamento da osteoporose no sistema público de saúde no Brasil

Abstract Purpose: The use of bisphosphonates for osteoporosis is effective in reducing the risk of fractures. However, oral formulations are sometimes not well tolerated or are contraindicated. Due to its availability in Brazilian public health system, pamidronate is frequently prescribed for osteoporosis, despite the lack of studies demonstrating its anti-fracture efficacy and the absence of FDA or EMEA approval for this purpose. The aim of this study was to evaluate the bone mineral density (BMD) response to pamidronate in a group of women with osteoporosis in a tertiary care hospital. Patients and methods: The medical records of women with osteoporosis who received pamidronate for up to two years of treatment were reviewed. Patients were stratified at high or intermediate risk of fracture. Results: A total of 70 women were in treatment with pamidronate. Among them, 74% were at high risk of fracture. A significant gain in spine BMD after 24 months of treatment was observed (p = 0.012). There was no difference between the groups of high and not high risk of fracture. At the femur, no significant increase in BMD was present, though, a strong negative correlation with high PTH levels (r = −0.61; p = 0.003) was seen. In the multivariate analysis BMI at 12 months had impact in the response to the treatment. Conclusion The intravenous pamidronate in a group of postmenopausal women with predominant high risk of fracture promoted an isolated gain in the spine BMD, even though, clinical randomized trials are needed to confirm its anti-fracture efficacy.

Resumo Justificativa: O uso de bisfosfonatos para a osteoporose é eficaz na redução do risco de fraturas. No entanto, as formulações orais às vezes não são bem toleradas ou são contraindicadas. Em razão da sua disponibilidade no sistema público de saúde brasileiro, o pamidronato é frequentemente prescrito para a osteoporose, apesar da falta de estudos que demonstrem a sua eficácia antifratura e da ausência de aprovação da Food and Drug Administration (FDA) ou da European Medicine Agency (Emea) para essa finalidade. O objetivo deste estudo foi avaliar a resposta da densidade mineral óssea (DMO) ao pamidronato em um grupo de mulheres com osteoporose em um hospital terciário. Pacientes e métodos: Revisaram-se os prontuários médicos de mulheres com osteoporose que receberam pamidronato por até dois anos de tratamento. As pacientes foram estratificadas em risco alto ou intermediário de fratura. Resultados: Estavam em tratamento com pamidronato 70 mulheres. Entre elas, 74% tinham alto risco de fratura. Observou-se um ganho significativo na DMO da coluna vertebral após 24 meses de tratamento (p = 0,012). Não houve diferença entre os grupos de risco de fratura alto e não alto. No fêmur, não foi encontrado aumento significativo na massa óssea; contudo, observou-se uma forte correlação negativa com altos níveis de PTH (r = −0,61; p = 0,003). Na análise multivariada, o IMC aos 12 meses tinha impacto na resposta ao tratamento. Conclusão O pamidronato intravenoso em um grupo de mulheres na pós-menopausa predominantemente com alto risco de fratura promoveu um ganho isolado na DMO da coluna vertebral, embora sejam necessários ensaios clínicos randomizados para confirmar sua eficácia antifratura.

Evolución del protocolo de trombolisis endovenosa en ataque cerebrovascular isquémico agudo / Intravenous thrombolysis for acute ischemic stroke. A four years' experience in a Chilean public hospital

Background: Intravenous thrombolysis (IVT) with alteplase (tissue plasminogen activator) is the standard pharmacological treatment in acute ischemic stroke (AIS), reducing disability in patients. Aim: To report the results a thrombolysis protocol during four years in a regional public hospital. Material and Methods: Data from 106 consecutive patients aged 68 ± 13 years (57% men) who were treated with IVT, from May 2012 until April 2016, was analyzed. Results: The median door-to-needle time was 80 minutes (interquartile range = 57-113). The median National Institute of Health Stroke Scale (NIHSS) scores on admission and at discharge were was 11.5 and 5 points respectively. At discharge, 27% of hospitalized patients had a favorable outcome (n = 99), defined as having 0 to 1 points in the modified Rankin scale. Symptomatic intracerebral hemorrhage and mortality rates were 5.7 and 13.1%, respectively. The thrombolysis rate rose from 0.7% in 2012 to 6% in 2016. Conclusions: The implementation of 24/7 neurology shifts in the Emergency Department allowed us to increase the amount and quality of IVT in our hospital, as measured by the rate of thrombolysis and by process indicators such as door-to-needle time.

Simple prediction model for unfavorable outcome in ischemic stroke after intravenous thrombolytic therapy / Modelo simples de predição de desfecho desfavorável em acidente vascular cerebral isquêmico tratado após terapia trombolítica intravenosa

ABSTRACT Objective We aimed to develop a model to predict unfavorable outcome in patients with acute ischemic stroke treated with intravenous thrombolytic therapy (IVT), based on simple variables present on admission. Methods Retrospective analysis of acute ischemic stroke patients treated with IVT in a hospital in Rio de Janeiro. Clinical and radiographic variables were selected for analysis. Multivariate logistic regression was used to develop a predictive model. Results We analyzed a total of 82 patients. Median National Institutes of Health Stroke Scale (NIHSS) on admission was 9 (3–22), 40.2% presented with a hyperdense artery sign (HAS), 62% had identifiable early parenchymal changes and 61.6% experienced a favorable outcome. An NIHSS score of > 12 on arrival, age > 70 and the presence of HAS were associated with the outcome, even after correction in a logistic regression model. Conclusion An NIHSS > 12 on arrival, presence of HAS and age > 70 years were predictors of unfavorable outcome at three months in patients with acute ischemic stroke treated with IVT.

RESUMO Objetivo Desenvolver um modelo para predizer desfecho desfavorável em pacientes com acidente vascular cerebral isquêmico (AVCi) agudo tratados com terapia trombolítica intravenosa (TTI), baseado em variáveis simples presentes à admissão. Métodos Análise retrospectiva de casos de AVCi tratados com TTI em um hospital no Rio de Janeiro. Variáveis clínicas e radiográficas foram selecionadas para análise. Foi utilizada regressão logística para desenvolver modelo preditivo. Resultados 82 casos foram analisados. A mediana de escore de National Institutes of Health Stroke Scale (NIHSS) na admissão foi 9 (3–22), 40,2% se apresentaram com sinal da artéria hiperdensa (SAH), 62% possuíam alterações parenquimatosas precoces e 61,6% obtiveram um desfecho favorável. NIHSS > 12, idade > 70 e a presença de SAH foram associados com o desfecho, mesmo após correção em modelo de regressão logística. Conclusão NIHSS > 12, a presença de SAH e idade maior que 70 anos foram preditores de desfecho desfavorável em 3 meses em pacientes com AVCi tratados com TTI.

Assessment of an intervention aimed at early discontinuation of intravenous antimicrobial therapy in a Brazilian University hospital

Abstract Many interventions demonstrate success in adapting the duration of intravenous antibiotic therapy, but few studies have been conducted in developing countries. The aim of this study was to evaluate the effectiveness of an intervention in the induction of early discontinuation of intravenous antimicrobial therapy and/or its switch to oral therapy. The study employed a before–after intervention design that consisted of displaying a message in the computerized prescription on the third day and suspension of the prescription on the fifth day of intravenous antimicrobial therapy. A total of 465 patients were followed during the control period (CP) and 440 in the intervention period (IP). The intravenous therapy was switched to oral therapy for 11 (2.4%) patients during the CP and 25 (5.7%) in the IP (p = 0.011), and was discontinued for 82 (17.6%) patients during the CP and 106 (24.1%) in the IP (p = 0.017). During the IP there was a significant increase of patients who had their antimicrobial treatment discontinued before the seventh day of intravenous treatment, 37.40% (49/131) in the IP and 16.13% (15/93) in the CP (p = 0.0005). The duration of intravenous antimicrobial therapy decreased by one day, but it was not significant (p = 0.136). It is concluded that the proposed intervention is effective in promoting the early discontinuation of antimicrobial treatment and/or switch to oral therapy. As long as a computerized system for prescription already exists, it is easy and inexpensive to be implemented, especially in hospitals in developing countries.

Evaluation of the efficacy of sodium valproate in convulsive status epilepticus following to ıschemic stroke / Avaliação da eficácia do valproato de sódio no status epilepticus convulsivo devido ao acidente vascular cerebral isquêmico

Objective : Convulsive status epilepticus (CSE) is very rarely observed after ischaemic stroke. Sodium valproate (SV) is one of the agents used in the treatment of CSE, but its role still controversial, and its degree of efficacy in treating CSE that develops following stroke is unclear. Method : We evaluated 19 patients who were treated with intravenous (IV) SV (20 mg/kg, 2 mg/kg/h-12h) after diazepam. Patients’ modified Rankin scores (mRS), SE types, and changes in biochemical parameters after treatment were assessed. Results : CSE was successfully treated in 12 (63.15%) patients. Side effects such as hypotension and allergic reactions were observed in two patients. Refractory SE development was observed in 5 (29.4%) patients with high mRS (˃ 3). No significant deterioration in patients’ laboratory evaluations, conducted before and after status, was observed. Conclusion : SV may be safe and effective in the treatment of CSE observed after ischaemic stroke, especially in patients with low mRS. .

Objetivo : Status epilepticus convulsivo (SEC) é muito raramente observado após acidente vascular cerebral isquêmico. Valproato de sódio (VS) é um dos agentes utilizados no tratamento do SEC, mas seu papel ainda é controverso e seu grau de eficácia não é claro no SEC pós acidente vascular. Método Avaliamos 19 pacientes que foram tratados com AV endovenoso (EV) (20 mg/kg, 2 mg/kg/h-12h) após diazepam. Valores da escala modificada de Rankin (mRS) dos pacientes, tipos de SE e mudanças nos parâmetros bioquímicos foram avaliados. Resultados SEC foi tratado com sucesso em 12 pacientes (63,15%). Efeitos colaterais como hipotensão e reações alérgicas foram observados em dois pacientes. Desenvolvimento de SE refratário foi observado em cinco pacientes (29,4%) com altos valores de mRS (˃ 3). Não houve deterioração significativa nas avaliações laboratoriais dos pacientes feitas antes ou depois do status. Conclusão AV pode ser eficaz no tratamento do SEC observado após acidente vascular cerebral isquêmico, especialmente nos pacientes com baixo mRS. .

Evaluation of clinical and laboratory variables associated with anemia in pediatric patients on hemodialysis / Avaliação de variáveis clínicas e laboratoriais associadas à anemia em pacientes pediátricos em hemodiálise

OBJECTIVE: To identify the occurrence of anemia in pediatric patients on hemodialysis and the association between hemoglobin levels and anemia in CKD-related variables. METHODS: This was a retrospective study. Patients aged up to 18 years with chronic kidney disease undergoing hemodialysis at this service between January of 2009 and December of 2010 were selected. Clinical and laboratory data were obtained from medical records. Statistical analysis was performed with chi-squared test, Student's t-test and general estimating equations (GEE) using SPSS 20.0, assuming a significance level of 5%. RESULTS: A total of 357 medical records depicting the monthly evolution of 29 patients were analyzed. The most common etiology for chronic kidney disease was malformations of the genitourinary tract (28%). Hemoglobin showed a mean (standard deviation) value of 9.20 (1.8) g/dL, with the occurrence of anemia in 65.3% of cases. Anemia was associated with hospitalization; antibiotic use; transfusion; use of intravenous iron hydroxide; low values of creatinine, hematocrit, and albumin; and high values of ferritin, aluminum, and equilibrated Kt/V (p < 0.05). The odds ratio for anemia with the use of intravenous iron hydroxide was 0.36 (95% CI: 0.25 to 0.89), i.e., a 2.78-fold higher chance of developing anemia without the use of this medication. CONCLUSIONS: Anemia predominated in children and adolescents with chronic kidney disease; intravenous iron hydroxide use was a protective factor. .

OBJETIVO: Identificar a ocorrência de anemia entre pacientes pediátricos em hemodiálise e a associação entre os valores de hemoglobina e variáveis relacionadas à anemia na DRC. MÉTODOS: Estudo retrospectivo. Selecionados pacientes até 18 anos com doença renal crônica em hemodiálise no serviço entre janeiro de 2009 e dezembro de 2010. Verificados prontuários para coleta de dados clínicos e laboratoriais. Análise estatística com testes de qui-quadrado, t de Student e General Estimating Equations (GEE) em programa Statistical Package for the Social Sciences 20.0, assumindo-se nível de significância de 5%. RESULTADOS: Analisadas 357 fichas de evolução médica mensal de 29 pacientes. A etiologia mais frequente para a doença renal crônica foram as malformações do trato genito-urinário (28%). Hemoglobina apresentou valor médio (desvio padrão) de 9,20 (1,8) g/dL, com ocorrência de anemia em 65,3% das consultas. Anemia associou-se a internação, uso de antibiótico, transfusão, uso de hidróxido de ferro endovenoso, valores baixos de creatinina, hematócrito e albumina e valores altos de ferritina, alumínio e Kt/V equilibrado (p < 0,05). A odds ratio para anemia com uso de hidróxido de ferro endovenoso foi 0,36 (95% IC 0,25-0,89), ou seja, uma chance 2,78 vezes maior de desenvolver anemia sem o uso dessa medicação. CONCLUSÕES: A anemia predominou em crianças e adolescentes com doença renal crônica, tendo como fator protetor o uso de hidróxido de ferro endovenoso. .

Colistina parenteral no tratamento de infeccoes graves: experiencia em centro unico / Parenteral colistin for the treatment of severe infections: a single center experience

Objetivo: Descrever a experiência de um único centro com o uso de colistina para tratar infecções hospitalares causadas por bactérias Gram-negativas resistentes a múltiplos fármacos e identificar fatores associados com lesão renal aguda e mortalidade. Métodos: Estudo longitudinal retrospectivo que avaliou pacientes gravemente enfermos, com infecções causadas por bactérias Gram-negativas resistentes a múltiplos fármacos. Foram considerados elegíveis para este estudo, durante o período compreendido entre janeiro e dezembro de 2008, todos os pacientes adultos com necessidade de tratamento com colistina endovenosa (colistimetato de sódio). As informações coletadas incluem dados demográficos, diagnóstico, duração do tratamento, presença de lesão renal aguda e mortalidade em 30 dias. Resultados: A colistina foi utilizada para tratar uma infecção em 109 de 789 pacientes (13,8%) admitidos à unidade de terapia intensiva. A mortalidade em 30 dias observada nestes pacientes foi de 71,6%. Vinte e nove pacientes (26,6%) tinham lesão renal prévia ao tratamento com colistina, sendo que seis deles conseguiram recuperar a função renal, mesmo durante o tratamento com colistina. Vinte e um pacientes (19,2%) desenvolveram lesão renal aguda durante o tratamento com colistina, sendo que 11 destes pacientes necessitaram ser submetidos à diálise. A variável independentemente associada com a presença de lesão renal aguda foi a pontuação segundo o sistema Sequential Organ Failure Assessment no início do tratamento com colistina (OR=1,46; IC95%=1,20-1,79; p<0,001). Idade (OR=1,03; IC95%=1,00-1,05; p=0,02) e uso de vasopressores (OR=12,48; IC95%=4,49-34,70; p<0,001) foram fatores associados a óbito, segundo um modelo de regressão logística. ...

Objective: To describe a single center experience involving the administration of colistin to treat nosocomial infections caused by multidrug-resistant Gram-negative bacteria and identify factors associated with acute kidney injury and mortality. Methods: This retrospective longitudinal study evaluates critically ill patients with infections caused by multidrug-resistant Gram-negative bacteria. All adult patients who required treatment with intravenous colistin (colistimethate sodium) from January to December 2008 were considered eligible for the study. Data include demographics, diagnosis, duration of treatment, presence of acute kidney injury and 30-day mortality. Results: Colistin was used to treat an infection in 109 (13.8%) of the 789 patients admitted to the intensive care unit. The 30-day mortality observed in these patients was 71.6%. Twenty-nine patients (26.6%) presented kidney injury prior to colistin treatment, and six of these patients were able to recover kidney function even during colistin treatment. Twenty-one patients (19.2%) developed acute kidney injury while taking colistin, and 11 of these patients required dialysis. The variable independently associated with the presence of acute kidney injury was the Sequential Organ Failure Assessment at the beginning of colistin treatment (OR 1.46; 95%CI 1.20-1.79; p<0.001). The factors age (OR 1.03; 95%CI 1.00-1.05; p=0.02) and vasopressor use (OR 12.48; 95%CI 4.49-34.70; p<0.001) were associated with death in the logistic-regression model. Conclusions: Organ dysfunction at the beginning of colistin treatment was associated with acute kidney injury. In a small group of patients, we were able to observe an improvement of kidney function during colistin treatment. Age and vasopressor use were associated with death. .

Terapia intravenosa. Trabajo en equipo para evitar complicaciones por catéteres venosos / Intravenous therapy: team work to avoid complications due to venous catheters

La práctica de la medicina actual está relacionada con la administración frecuente de medicamentos y líquidos por vía parenteral, por lo cual se requiere una vía intravascular permeable. Desde hace algunos años se ha observado la tendencia al manejo extrahospitalario de pacientes con problemas crónicos que necesitan tratamiento farmacológico intravenoso. Estos procedimientos con mucha frecuencia son prolongados, y en algunas ocasiones por el resto de la vida del paciente, lo cual implica el riesgo de complicaciones, entre las que sobresalen las de origen infeccioso. El objetivo de esta comunicación es proponer una guía general para la creación y desarrollo de un servicio especializado en el manejo de dispositivos intravasculares, con la finalidad de brindar una atención de calidad. La integración de un servicio con estas características requiere de un equipo multidisciplinario en el que participe el médico, la enfermera y el químico clínico, previa elaboración de los criterios y rutinas que integrarán los procedimientos de manejo. Un manual de procedimientos señalará las técnicas de aplicación y retiro de dispositivos intravasculares, los cuidados de enfermería, estrategias de permeabilización de catéteres y toma de muestras, administración de líquidos y medicamentos. Es importante que queden señalados los criterios para definir la presencia de una complicación, ya sea infecciosa o de otra índole, y establecer los principios generales de su manejo. El cumplimiento de los procedimientos establecidos permitirá garantizar una atención médica de calidad a los pacientes que en su domicilio reciben los servicios y requieren de la aplicación parenteral de medicamentos por tiempo prolongado.

The contemporary practice of medicine is related with the parenteral administration of many drugs. It is necessary to maintain a patent vascular line that permissive the drugs and fluids administration in therapeutics for many diseases. Since many years ago, there is a tendentious to the extrahospitalary management to the patients with chronic diseases and whose need intravenous drugs administration. The treatments are the most of the times for longer periods and many times for ever. There is a risk for complications in this situation, and one of the most important is infection. The purpose of this paper is to show a general guide from a specialized service in the management of intravascular devices to patients who need the parenteral administration of drugs with the fewer risk of complications. The specialized service needs a physician, a nurse and a clinical chemistry, all of them working around de same purpose: a medical service with quality. They need to establish the proceedings of general management and the specials protocols that are require on a specific situation like the infectious or the obstruction complication. The strategies for the vascular cannulation, cure, technics for flu ids and drugs administration are very important. The accomplish of the proceedings will let the evaluation and backwards to obtain and guarantee a medical service with quality to the chronic patients the needs service at home.