Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: Border II Trial.

OBJECTIVE: Critically ill patients are at high risk of developing pressure ulcers (PU), with the sacrum and heels being highly susceptible to pressure injuries. The objective of our study was to evaluate the clinical effectiveness of a new multi-layer, self-adhesive soft silicone foam heel dressing to prevent PU development in trauma and critically ill patients in the intensive care unit (ICU). METHOD: A cohort of critically ill patients were enrolled at the Royal Melbourne Hospital. Each patient had the multi-layer soft silicone foam dressing applied to each heel on admission to the emergency department. The dressings were retained with a tubular bandage for the duration of the patients' stay in the ICU. The skin under the dressings was examined daily and the dressings were replaced every three days. The comparator for our cohort study was the control group from the recently completed Border Trial. RESULTS: Of the 191 patients in the initial cohort, excluding deaths, loss to follow-up and transfers to another ward, 150 patients were included in the final analysis. There was no difference in key demographic or physiological variables between the cohorts, apart from a longer ICU length of stay for our current cohort. No PUs developed in any of our intervention cohort patients compared with 14 patients in the control cohort (n=152; p<0.001) who developed a total of 19 heel PUs. CONCLUSION: We conclude, based on our results, that the multi-layer soft silicone foam dressing under investigation was clinically effective in reducing ICU-acquired heel PUs. The findings also support previous research on the clinical effectiveness of multi-layer soft silicone foam dressings for PU prevention in the ICU.

Liver melanomacrophage centres as indicators of Atlantic bluefin tuna, Thunnus thynnus L. well-being.

Melanomacrophage centres (MMCs), located in different organs of non-mammalian vertebrates, play a role in the destruction, detoxification or recycling of endogenous and exogenous materials. Cytochrome P450 monoxygenase 1A (CYP1A) is involved in xenobiotics biotransformation, and its liver expression is considered as a biomarker for detecting exposure to environmental pollutants. Atlantic bluefin tuna (ABFT), Thunnus thynnus L., liver samples were collected from: wild animals caught in the eastern Atlantic; juveniles reared in the central Adriatic; juveniles reared in the northern Adriatic; adults reared in the western Mediterranean. The samples were processed for basic histology, histochemistry and for CYP1A immunodetection. An unexpected high density of MMCs, containing ferric iron and lipofuscin-ceroids, was detected in the juveniles sampled in the northern Adriatic Sea. These individuals showed also a strong anti-CYP1A immunopositivity in hepatocytes and in the epithelium of bile ducts. This study supports the utility of MMCs as biomarkers of fish 'health status' and gives concern for a potential contaminant accumulation in ABFT.

An estimate of the potential budget impact of using prophylactic dressings to prevent hospital-acquired PUs in Australia.

OBJECTIVE: To estimate the potential cost saving to the Australian health-care system of introducing the use of prophylactic dressings to prevent hospital-acquired pressure ulcers (PUs) for patients with a high-risk developing a PU. METHOD: We estimated the costs of pressure ulceration based on conservative estimates of an incidence rate of 13% within 10% of the total admitted Australian patient population. RESULTS from a recent large randomised control trial of prophylactic dressing used to prevent PUs in high-risk patients were then extrapolated to this population to derive a potential national cost/benefit calculation. RESULTS: Our estimate revealed that within the high-risk population of acute hospitals, more than 71,000 patients could be expected to develop a PU annually costing AU$77,800,000 (£43,000,000). Whereas by implementing a national PU prevention initiative based on the use of prophylactic multilayer silicone foam dressings for high-risk patients, an annual saving of AU$34,800,000 (£19,700,000) could be achieved, which represents a cost benefit of 55% to the Australian health-care system. CONCLUSION: Our estimate of the potential cost benefit of implementing the use of prophylactic dressings to prevent hospital acquired PUs in high-risk patients uses conservative estimates of both the incidence rates of ulceration and of treatment costs. However, this is also based on one of the largest reported randomised control trials of this technique to prevent PUs. We believe that our modelling is robust yet requires replication in other countries with different health-care systems and costing structures.

[Natural history of mucopolysaccharidosis type III in a series of Colombian patients]. / Historia natural de la mucopolisacaridosis III en una serie de pacientes colombianos.

INTRODUCTION: Mucopolysaccharidosis type III (MPS III), also known as Sanfilippo syndrome, is a lysosomal storage disease with progressive neurodegenerative features, predominantly affecting the central nervous system. Diagnosis is based on clinical features, with neurodevelopmental and neuropsychiatric alterations taking precedence, including over phenotype alterations. The disease is confirmed by biochemical analysis to identify the type of glycosaminoglycans present, enzyme assay and molecular genetic studies. CASE REPORTS: A clinical description was performed for eight patients diagnosed with MPS III in Colombia. Their initial symptoms were related to developmental delay and behavioural disorders presenting between 3 and 8 years of age, associated in all cases with coarse facial features, thick eyebrows, hepatomegaly and progressive hearing loss. One of the patients presented cardiac anomalies; two presented focal epilepsy; and one presented optic atrophy. They all presented neuroimaging alterations, with evidence of parenchymal volume loss, corpus callosum atrophy and cortical thinning; the diagnosis was performed by biochemical glycosaminoglycan chromatography studies, and all patients have a confirmatory genetic study. CONCLUSIONS: MPS III is a challenge for diagnosis, particularly in its early stages and in patients in which the course of the disease is attenuated. This is due to its variable course, non-specific early neuropsychiatric symptoms, and the absence of obvious somatic features compared to other types of MPS. After a definitive diagnosis has been made, interdisciplinary care must be provided for the patient and their family, and support given for the treatment of physical symptoms, ensuring the best possible care and quality of life for the patient and their family, as the condition is neurodegenerative.

TITLE: Historia natural de la mucopolisacaridosis III en una serie de pacientes colombianos.Introducción. La mucopolisacaridosis de tipo III (MPS III), o síndrome de Sanfilippo, es un trastorno de almacenamiento lisosómico con características neurodegenerativas progresivas, predominante del sistema nervioso central. Su diagnóstico se basa en el cuadro clínico, y priman alteraciones en el neurodesarrollo y neuropsiquiátricas, incluso antes de la presencia de alteraciones fenotípicas. El análisis bioquímico para identificar el tipo de glucosaminoglucanos presente, la determinación enzimática y el estudio de genética molecular confirman la enfermedad. Casos clínicos. Se realiza la descripción clínica de ocho pacientes con diagnóstico de MPS III en Colombia, con síntomas iniciales en relación con retraso del desarrollo y trastornos comportamentales evidenciados entre los 3 y 8 años, asociado a facies toscas, cejas pobladas, hepatomegalia y pérdida auditiva progresiva en todos los casos. Uno de los pacientes presentó anomalías cardíacas; dos de ellos, epilepsia focal; y en uno se evidenció atrofia óptica. Todos presentaron alteraciones en las neuroimágenes con evidencia de pérdida del volumen parenquimatoso, atrofia del cuerpo calloso y adelgazamiento cortical; el diagnostico se realizó a través de estudios bioquímicos de cromatografía de glucosaminoglucanos y todos cuentan con un estudio genético confirmatorio. Conclusiones. La MPS III es un desafío diagnóstico, particularmente en pacientes con un curso atenuado de la enfermedad, debido al curso variable, síntomas neuropsiquiátricos tempranos inespecíficos y falta de características somáticas evidentes en comparación con otros tipos de MPS. Cuando se tiene el diagnóstico definitivo, es fundamental brindar atención interdisciplinaria para el paciente y la familia, y apoyar el tratamiento de los síntomas físicos, garantizando ofrecer el mejor cuidado posible y la mejor calidad de vida para el paciente y su familia, al tratarse de una condición neurodegenerativa.

A comparison of the efficacy of trastuzumab deruxtecan in advanced HER2-positive breast cancer: active brain metastasis versus progressive extracranial disease alone.

BACKGROUND: Trastuzumab deruxtecan (T-DXd) has demonstrated efficacy in patients with brain metastasis (BM), a group historically with poor outcomes. The prevalence of BMs in patients commencing T-DXd is currently unknown. No direct comparisons have been made of the activity of T-DXd in patients with active BM versus those with extracranial progression alone. This real-world study explored the prevalence of BMs in patients commencing T-DXd, the efficacy of T-DXd in active BM versus extracranial progression alone and the safety of T-DXd. PATIENTS AND METHODS: Patients with human epidermal growth factor receptor 2-positive advanced breast cancer treated with T-DXd between June 2021 and February 2023 at our specialist cancer hospital were identified and notes reviewed. Clinicopathological information, prior treatment, the presence or absence of central nervous system (CNS) disease, outcomes and treatment-emergent adverse events (TEAEs) were recorded. RESULTS: Twenty-nine female patients, with a median age of 52 years (interquartile range 44-62 years), were identified; the prevalence of BM was 41%. Median number of lines of prior therapy was 2 (range 2-6). At a median follow-up of 13.8 months, median progression-free survival (PFS) for the overall population was 13.9 months [95% confidence interval (CI) 12.4 months-not estimable (NE)], 16.1 months (95% CI 15.1 months-NE) for active BMs and 12.4 months (95% CI 8.3 months-NE) for progressive extracranial disease alone. The 12-month overall survival (OS) rate was 74% (95% CI 59% to 95%) in the overall population, and 83% (95% CI 58% to 100%) and 66% (95% CI 45% to 96%) for active BMs and extracranial disease only, respectively. Most common TEAEs were fatigue, alopecia, and constipation. In nine patients (31%, including two deaths), pneumonitis occurred. CONCLUSION: In this real-world population, we demonstrate T-DXd to be effective in patients with active BMs and those with progressive extracranial disease alone. PFS and OS were numerically longer in those with active BMs. These data demonstrate that patients with active BM treated with T-DXd have at least comparable outcomes to those with extracranial disease alone. The high rate of pneumonitis warrants further consideration.

Evidence that severe acute stress and starvation induce rapid atresia of ovarian vitellogenic follicles in Atlantic bluefin tuna, Thunnus thynnus (L.) (Osteichthyes: Scombridae).

The effects of different stressors on the atretic degeneration of ovarian vitellogenic follicles, as well as on the ovarian mass, were examined in female Atlantic bluefin tuna, Thunnus thynnus (L.), from the Mediterranean Sea. The stressors taken into consideration were short-term starvation (up to 14 days), long-term cage rearing (1 year) and crowding-induced severe panic frenzy. Wild-caught individuals were used as a control group. Fish subjected to either severe panic frenzy or starvation exhibited a decrease in gonad mass and had significantly higher intensity of α atresia in the vitellogenic follicles (means: 78% and 58%, respectively; range: 36-100%) than either wild or long-term caged individuals (means: 32% and 30%, respectively; range: 19-44%). The extensive atresia in fish stressed by severe panic frenzy was observed as early as 24 h after the stressing event. The present study represents the first evidence of the extreme susceptibility of Atlantic bluefin tuna to severe acute stress during vitellogenesis; it also shows that starvation is associated with progressive reabsorption of vitellogenic oocytes.

Predicting concordance with multilayer compression bandaging.

OBJECTIVE: To examine the relationship between concordance with multilayer compression bandaging and a number of client and wound characteristics, including wound severity, health status and client independence with respect to activities of daily living. METHOD: Using data gathered for a randomised controlled trial that compared two types of antimicrobial dressings on infected or critically colonised lower leg ulcers, we explored the level of concordance with compression therapy by patients with wounds that had an ankle brachial pressure index of between 0.8 and 1.2. RESULTS: A logistic regression analysis found that increased pain and wound size, older age and shallow wound depth were all significant predictors of non-concordance with multilayer compression bandaging. CONCLUSION: Although the results suggest that pain, wound size, age and wound depth are all significant predictors of non-concordance with multilayer bandaging, the generalisability of these results is limited, given that data were gathered in the context of a RCT. Further studies are required to explore the relative contribution of predictors of concordance with compression therapy, in order to help inform strategies that promote it and, thereby, optimise healing. CONFLICT OF INTEREST: None.

A histological investigation of the occurrence of non-reproductive female bluefin tuna Thunnus thynnus in the Mediterranean Sea.

The presence of non-reproductive Atlantic bluefin tuna Thunnus thynnus females in the Mediterranean Sea was investigated through histological analysis of the gonads. Three hundred and twenty-six ovary samples were collected from adults captured at different locations in the Mediterranean Sea during the reproductive seasons between 1998 and 2008. Only three specimens were considered to be in a non-reproductive state: two of them were in a reabsorbing state showing ovaries with early vitellogenic oocytes and extensive alpha and beta atresia of vitellogenic follicles; the third showed gonads with perinucleolar oocytes and was considered to be in a resting state. The low occurrence of non-reproductive individuals found in this study makes it unlikely that non-reproductive individuals aggregate with reproductive ones during their migration towards spawning grounds. Further research is suggested in order to investigate the potential presence of non-reproductive individuals on non-spawning grounds during the reproductive season.

Historia natural de la mucopolisacaridosis III en una serie de pacientes colombianos / Natural history of mucopolysaccharidosis type III in a series of Colombian patients

Introducción: La mucopolisacaridosis de tipo III (MPS III), o síndrome de Sanfilippo, es un trastorno de almacenamiento lisosómico con características neurodegenerativas progresivas, predominante del sistema nervioso central. Su diagnóstico se basa en el cuadro clínico, y priman alteraciones en el neurodesarrollo y neuropsiquiátricas, incluso antes de la presencia de alteraciones fenotípicas. El análisis bioquímico para identificar el tipo de glucosaminoglucanos presente, la determinación enzimática y el estudio de genética molecular confirman la enfermedad. Casos clínicos: Se realiza la descripción clínica de ocho pacientes con diagnóstico de MPS III en Colombia, con síntomas iniciales en relación con retraso del desarrollo y trastornos comportamentales evidenciados entre los 3 y 8 años, asociado a facies toscas, cejas pobladas, hepatomegalia y pérdida auditiva progresiva en todos los casos. Uno de los pacientes presentó anomalías cardíacas; dos de ellos, epilepsia focal; y en uno se evidenció atrofia óptica. Todos presentaron alteraciones en las neuroimágenes con evidencia de pérdida del volumen parenquimatoso, atrofia del cuerpo calloso y adelgazamiento cortical; el diagnostico se realizó a través de estudios bioquímicos de cromatografía de glucosaminoglucanos y todos cuentan con un estudio genético confirmatorio. Conclusiones: La MPS III es un desafío diagnóstico, particularmente en pacientes con un curso atenuado de la enfermedad, debido al curso variable, síntomas neuropsiquiátricos tempranos inespecíficos y falta de características somáticas evidentes en comparación con otros tipos de MPS. Cuando se tiene el diagnóstico definitivo, es fundamental brindar atención interdisciplinaria para el paciente y la familia, y apoyar el tratamiento de los síntomas físicos, garantizando ofrecer el mejor cuidado posible y la mejor calidad de vida para el paciente y su familia, al tratarse de una condición neurodegenerativa.(AU)

Introduction: Mucopolysaccharidosis type III (MPS III), also known as Sanfilippo syndrome, is a lysosomal storage disease with progressive neurodegenerative features, predominantly affecting the central nervous system. Diagnosis is based on clinical features, with neurodevelopmental and neuropsychiatric alterations taking precedence, including over phenotype alterations. The disease is confirmed by biochemical analysis to identify the type of glycosaminoglycans present, enzyme assay and molecular genetic studies. Case reports: A clinical description was performed for eight patients diagnosed with MPS III in Colombia. Their initial symptoms were related to developmental delay and behavioural disorders presenting between 3 and 8 years of age, associated in all cases with coarse facial features, thick eyebrows, hepatomegaly and progressive hearing loss. One of the patients presented cardiac anomalies; two presented focal epilepsy; and one presented optic atrophy. They all presented neuroimaging alterations, with evidence of parenchymal volume loss, corpus callosum atrophy and cortical thinning; the diagnosis was performed by biochemical glycosaminoglycan chromatography studies, and all patients have a confirmatory genetic study. Conclusions: MPS III is a challenge for diagnosis, particularly in its early stages and in patients in which the course of the disease is attenuated. This is due to its variable course, non-specific early neuropsychiatric symptoms, and the absence of obvious somatic features compared to other types of MPS. After a definitive diagnosis has been made, interdisciplinary care must be provided for the patient and their family, and support given for the treatment of physical symptoms, ensuring the best possible care and quality of life for the patient and their family, as the condition is neurodegenerative.(AU)

Testosterone is related to GABA+ levels in the posterior-cingulate in unmedicated depressed women during reproductive life.

BACKGROUND: The role of testosterone (T) in the pathophysiology of affective disorders and anxiety is broadly supported. Evidence suggests that T has anxiolytic and antidepressant properties. One proposed route for the central effects of T is its interaction with the gamma-aminobutyric acid (GABA) system. We explored the relationship between T levels and GABA+ levels in anterior-cingulate (ACC) and the posterior-cingulate (PCC) regions in depressed women, using magnetic resonance spectroscopy (1H-MRS). METHODS: Twenty-one depressed patients with regularly cycling who were not taking hormonal or psychotropic drugs were recruited. We assessed severity of depression using the Hamilton Depression Rating Scale (HDRS). Blood samples were taken for quantification of free (FT) and total testosterone (TT) on the day of the magnetic resonance (MR) scan. We evaluated GABA+ levels in the PCC and ACC, using the Hadamard Encoding and Reconstruction of MEGA-Edited Spectroscopy (HERMES) sequence. Pearson correlations were used to evaluate the association between FT, TT, GABA+ concentrations, and HDRS scores. RESULTS: TT and FT levels were positively correlated with GABA+ levels in the PCC. No correlation was observed between T levels and GABA+ levels in the ACC. The HDRS total scores correlated negatively with FT levels. LIMITATIONS: Limitations include the cross-sectional evaluation and the lack of a comparative healthy group. CONCLUSIONS: Our findings suggest that the potential anxiolytic and antidepressant properties of T are related to increased GABA+ levels in the PCC. This observation may contribute to increased understanding of the role of T in depressive and anxiety symptoms in women.

[Fournier gangrene: evaluation of prognostic factors in 90 patients]. / Gangrena de Fournier: estudio de los factores pronósticos en 90 pacientes.

INTRODUCTION: This study evaluates the risk factors and prognostic variables that affect survival of patients with gangrene of Fournier. MATERIAL AND METHODS: The study retrospectively analyzed 90 consecutive patients with gangrene of Fournier treated in our institution between 1975 and 2008. We evaluated the average age, associated systemic diseases, and the source, time of evolution and extent of necrotizing fasciitis. The outcomes were assessed according to whether the patient survived or died. All patients had aggressive surgical debridement, and received parenteral antibiotic therapy. RESULTS: The mortality rate was 34.4%. The mean age was 63.0 years (range 33-95), a statistically significant difference was found between the age of the survivors (median age, 59.84 years) and those who died (median age, 70.20 years) (p = 0.001). Medical comorbidities were identified in 51 patients; the death rate was higher in patients who had any medical disease, especially those who suffered from cancer. Although diabetes mellitus was the most common associated pathology, it was not related to a statistically significant worst prognosis. The source of the infection was identified in 62 patients, who showed a higher mortality (p = 0.015), the mortality rate when a urological source is identified was 50%. Moreover, patients suffering from a more extensive necrotizing infection showed a worst prognosis. CONCLUSIONS: The gangrene of Fournier has a high mortality rate. Large series are required to study prognostic variables of this disease. The patient age, the presence of systemic risk factors, especially cancer, a urological source of infection and the extent of the disease have impact on the prognosis of Fournier's gangrene.

Rearing in captivity affects spermatogenesis and sperm quality in greater amberjack, Seriola dumerili (Risso, 1810).

The greater amberjack, (Risso, 1810), is a promising candidate for the diversification of European aquaculture production, but inconsistent reproduction in captivity prevents commercial production. Recent studies showed that greater amberjack confined in sea cages exhibited scarce gonad development and early interruption of gametogenic activity during the reproductive season. The aim of the present study was to improve our understanding of the observed impairment of spermatogenesis. Adult wild and captive-reared males were sampled during 3 different phases of the reproductive cycle: early gametogenesis (EARLY; late April to early May), advanced gametogenesis (ADVANCED; late May to early June), and spawning (SPAWNING; late June to July). Spermatogonial stem cells and proliferating germ cells were identified through the immunohistochemical localization of and proliferating cell nuclear antigen, respectively. Apoptotic germ cells were identified throughout the terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate nick end labeling method. Sperm quality of captive-reared fish was evaluated using computer-assisted sperm analysis. Captive-reared males exhibited seminiferous lobules of a smaller diameter, a precocious and progressive decrease of spermatogonial mitosis, and a high level of apoptosis at the beginning of the reproductive season, concomitant with a many-fold higher 17ß-estradiol plasma concentration. The motile spermatozoa percentage of captive greater amberjack was lower than in other teleosts, and a drastic decrease of spermatozoa motility duration, velocity, and ATP content occurred along the reproductive season. An abnormal increase of sperm concentration as well as an increase of dead spermatozoa occurred during the SPAWNING phase, probably because of lack of sperm hydration and ejaculation and consequent sperm ageing. The present study demonstrates the extreme susceptibility of greater amberjack to rearing stress and underscores the need for improvement of the rearing and handling procedures to ameliorate gametogenesis dysfunctions in commercial aquaculture production.

Clinical and biomechanical perspectives on pressure injury prevention research: The case of prophylactic dressings.

In this perspective paper, we discuss clinical and biomechanical viewpoints on pressure injury (or pressure ulcer) prevention research. We have selected to focus on the case of prophylactic dressings for pressure injury prevention, and the background of the historical context of pressure injury research, as an exemplar to illuminate some of the good and not so good in current biomechanical and clinical research in the wound prevention and care arena. Investigators who are conducting medical or clinical research in academia, in medical settings or in industry to determine the efficacy of wound prevention and care products could benefit from applying some basic principles that are detailed in this paper, and that should leverage the research outcomes, thereby contributing to setting higher standards in the field.

Artéria circunflexa com origem anômala em seio de valsalva direito em paciente idoso: relato de caso / Circumflex artery with anomalous origin in the right sinus of valsalva in an elderly patient: case report

INTRODUÇÃO: As anomalias coronárias congênitas são raras na população geral, com uma prevalência de 0,2 a 2,3%. Nos pacientes adultos a variante anatômica mais frequente é a artéria circunflexa (CX) anômala, tendo como possíveis origens o óstio separado dentro do seio coronário direito ou ramo proximal da arteria coronária direita (CD), sendo este último bastante incomum. O diagnóstico na maioria dos casos é realizado como um achado incidental durante uma cinecoronariografia. RELATO DE CASO: Paciente masculino, 71 anos, portador de hipertensão arterial sistêmica, diabetes mellitus, dislipidemia, hipotireoidismo, doença pulmonar obstrutiva crónica e ex-tabagista, com história de Doença Arterial Coronária Crónica (DAC) com revascularização miocárdica cirúrgica há sete anos, encaminhado ao nosso serviço por queixa de dispneia classe funcional NYHA II. Negava angina. Eletrocardiograma apresentava alteração inespecífica da repolarização ventricular e o ecocardiograma transtorácico revelou função ventricular preservada. Realizou prova funcional com evidência de isquemia em parede inferior e inferolateral (carga isquêmica 10-14%). Desta forma, foi submetido a cateterismo cardíaco que evidenciou Artéria Coronária Direita ocluída em terço proximal, descendente anterior (DA) com lesão de 95% no terço proximal enchendo retrogradamente por ponte de artéria mamaria interna esquerda pérvia, ponte safena para primeiro ramo diagonal ocluída e pontes safena para descendente posterior e primeiro ramo marginal pérvios. Evidenciada CX originando-se do seio coronário direito, achado não relatado previamente a despeito dos antecedentes do paciente. O caso foi discutido em HEART TEAM e optado por manutenção de tratamento clínico otimizado. DISCUSSÃO: A investigaçãoda doença aterosclerótica coronaria leva, por vezes, à necessidade de cinecoronarografia, o que pode levar ao diagnóstico de anomalias congênitas, sendo a origem de CX a partir do seio de valsalva direito um achado raro. Nos pacientes adultos que apresentam essas variantes anatómicas, a isquemia miocárdica pode ocorrer devido à aterosclerose precoce e mais agressiva quando comparada a uma artéria coronária normal, sendo descrito na literatura uma maior incidencia de estenoses em artérias com origem anômala do seio coronario direito. CONCLUSÃO: Trata-se de caso pouco frequente de um paciente com DAC e origem anômalada CX. Na literatura varios autores já sugerem esta associação, porém o prognóstico desses pacientes ainda é incerto e tratamento permanece um Figura 1. A - ECG com critérios clássico para HVE e alterações da repolarização ventricular, RNM de coração desafio.

Caso incomum de infarto agudo do miocárdio: embolia distal por grande aneurisma de tronco de coronária esquerda / Unusual case of acute myocardial infarction: distal embolism due to large aneurysm of the left main coronary artery

INTRODUÇÃO: Os aneurismas de artéria coronária (AAC) são definidos por uma dilatação focal de mais de uma vez e meia o segmento normal da artéria. São raros, sendo o aneurisma de tronco de coronária esquerda (TCE), ainda mais raro com incidência estimada em 0,1% dentre os pacientes submetidos a angiografia coronariana. Os aneurismas podem apresentar-se apenas como achado de exame em pacientes assintomáticos em sua maioria, porém podem também evoluir com trombose local, compressão extrínseca ou ruptura aneurismática. RELATO DE CASO: Homem de 42 anos, sem comorbidades, foi atendido no pronto socorro com dor torácica típica, sendo diagnosticado com infarto agudo de miocardio (IAM) anterior extenso e submetido a trombólise com critérios reperfusão. No ecocardiograma transtorácico apresentava acinesia do segmento médio e apical da parede anterior e anterolateral com fração de ejeção 45%. Realizada cineangiocoronariografia (CATE) que não evidenciou lesões obstrutivas significativas, porém identificou a presença de um aneurisma de 9 mm no TCE com imagem negativa sugestiva de alta carga trombótica. (Figura 1). Após uma semana de anticoagulação plena o CATE foi repetido e já não se observavam mais os trombos no TCE. (Figura 2) Realizada triagem para trombofilias, doenças do tecido conjuntivo e infecciosas sendo todas negativas. Paciente é mantido em tripla terapia por um ano. Atualmente estável sem novos eventos trombóticos. DISCUSSÃO: Apresentamos um caso raro de aneurisma de TCE com trombos no seu interior cuja manifestação inicial foi um IAM. O aneurisma de TCE, embora muito raro, pode ser causa de IAM. O AAC, na maioria das vezes, possui etiologia aterosclerótica, seguido por doença de Kawasaki, do tecido conjuntivo, autoimune, infecciosa e idiopática. A maioria dos AAC são assintomáticos, outros apresentam uma clínica variável. O baixo fluxo no segmento aneurismático pode levar a formação de trombo com consequente embolização distal podendo ocasionar um IAM. O CATE continua sendo o padrão ouro para o diagnóstico. O tratamento inclui a ligação cirúrgica, angioplastia com stent recoberto ou tratamento clínico mediante anticoagulação associada ou não a antiagregação plaquetária. A cirurgia é o tratamento de eleição em casos de doença aterosclerótica obstrutiva grave associada ou aneurismas gigantes com risco de ruptura. Os pacientes necessitam de acompanhamento clínico e de imagem periodicamente. Aneurismas pequenos tem um prognóstico favorável com baixo risco de eventos isquêmicos diferentemente dos aneurismas gigantes.

Morte súbita abortada secundária à trombose coronariana em paciente jovem: relato de caso / Aborted sudden death secondary to coronary thrombosis in a young patient: case report

INTRODUÇÃO: A trombose coronaria (TC) é definida como a presença de um trombo no interior de uma artéria epicárdica podendo causar infarto agudo do miocardio (IAM) e até morte súbita. A TC sem aterosclerose é rara e pode ser uma complicação das trombofilias e distúrbios mieloproliferativos como Policitemia Vera (PV), entidade também rara com incidência de 2,8%. Os critérios diagnósticos são: Critérios Maiores: 1) hemoglobina≥16,5mg/dl e hematócrito≥49% no sexo masculino, 2) biopsia medular com hipercelularidade, 3) mutação JAK2. Critério Menor: eritropoietina baixa. O diagnóstico e feito com os três critérios maiores ou dois maiores e um menor. RELATO DE CASO: G.M masculino, 27 anos, sem comorbidades. Deu entrada no pronto socorro devido a dor torácica intensa, evoluindo subitamente com parada cardiorrespiratória em fibrilação ventricular, foi reanimado conforme ACLS retornando a circulação espontânea após dois minutos. O eletrocardiograma mostrou uma elevação do segmento ST em parede anterior extensa, sendo submetido a cinecoronariografia que evidenciou imagem de trombo no terço proximal e médio da artéria descendente anterior, fluxo TIMI 1, foi realizada tromboaspiração, sem melhora do fluxo. Optou­se por implante de stent farmacológico com resultado final fluxo TIMI 3. Ao ecocardiograma apresentou fração de ejeção de 25% com hipocinesia anterior e apical. Na investigação foi evidenciada hemoglobina de 21mg/dl com hematócrito de 59% associado a eritropoietina baixa, a mutação para JAK2 foi negativa e até o momento aguardamos o resultado da biópsia medular. Demais pesquisas foram negativas para deficiência de proteína C e S, Anti-Cardiolipina IgG e IgM, Beta 2 Microglobulina, FAN, Anti-Trombina III, Fator V de Leiden, Fator VIII. Após cinco dias o paciente foi submetido a um segundo cateterismo, evidenciando novo trombo intra-stent porém sem repercussão hemodinâmica. Iniciou-se triple terapia com o paciente assintomático. DISCUSSÃO: Relatamos aqui um caso de um paciente jovem com morte súbita abortada secundária a IAM por trombose coronária. A TC quando não associada a ruptura de placa, pode ser secundária a doenças mieloproliferativas como PV ou trombofilias sendo o diagnóstico diferencial um verdadeiro desafio para o clínico em pacientes sem fatores de risco clássicos e não usuários de drogas. CONCLUSÃO: A estratégia terapêutica nesses pacientes com obstrução sustentada ainda é controversa uma vez que o implante de stent pode significar um risco maior de oclusão, novos estudos são fundamentais para um manejo adequado e oportuno para este grupo de doenças.

Cleaning up. The development of the Alfred/Medseed Wound Imaging System.

This paper describes the rationale, development, functions and applications of a new digital wound imaging system developed at The Alfred Hospital in Melbourne. The system known as The Alfred/Medseed Wound Imaging System (AMWIS) comprises a software package that quantitatively analyses a digital wound photograph and tracks the healing of the wound as a function of the wound care treatment used. The system is designed to enable the wound images and assessment data to be securely transmitted via the internet for review or consultation to any site equipped with the wound imaging system. The AMWIS is capable of being operated at a single site such as a hospital, at remote locations or as a mobile system. We believe that this is the first system of this kind developed in Australia that incorporates sophisticated analytical functions yet retains the flexibility to be used in inpatient, ambulatory or remote settings.

Stress in perioperative nursing: sources, frequency and correlations to personality factors.

Psychological stress in perioperative nursing is a complex phenomenon that is often reported in the literature as having potentially detrimental consequences. However, little specific research has been conducted into the causes and possible mediating processes involved in the stress response. The aims of this pilot study were firstly, to identify the range of stressors encountered by a group of perioperative nurses (n = 47) and secondly, to investigate the relationship of the reported interpersonal stressors to the personality construct of lifestyle proposed by individual Psychology (IP). The results of the study indicate that the major stressors experienced by this group of perioperative nurses are related to interpersonal conflict, organisational issues, equipment availability and workload. Interpersonal conflict was the leading stressor and the construct of lifestyle was significantly correlated with nurses' psychological stress in specific difficult interpersonal conflict situations. The implications of the findings include the possibility of developing interventions based on IP that may assist nurses to better deal with interpersonal conflict in the perioperative setting and to possibly reduce their stress responses in frequently encountered difficult interpersonal situations.

Drug calculation competencies of graduate nurses.

This study describes the analysis of the mathematical ability of 220 registered nurses (RNs) from six Victorian universities who applied for a graduate year program at St Vincent's Hospital, Melbourne. Each applicant completed a drug calculation competency test (DCCT) which required them to calculate 11 drug dosages commonly performed by RNs in clinical practice. The results revealed that 58 percent (n = 127) of the 220 applicants were not able to accurately calculate all 11 drug dosages. The results also demonstrated significant differences between applicants from respective universities. The findings suggest that there are fundamental problems with the mathematical competencies of this group of newly graduated nurses. The results may also support the assertion that the educational preparation of these nurses at the undergraduate level could be enhanced in some universities and does not appear to adequately prepare nurses to perform basic drug calculations which are frequently required in the acute setting.