Training in healthcare during and after COVID-19: proposal for simulation training

SUMMARY INTRODUCTION: The challenge of facing COVID-19 falls under all health care structures, and without specific training to health care professionals they are probably the professionals with the highest level of exposure. Regardless of the level of health care, the training of professionals aims to optimize resources and attend patients while assuring quality and security. POINT OF VIEW: This report proposes simulation training for health care professionals to update professionals for attending patients during the pandemic. This training was built with five simulated stations, considering different stages of a patient with COVID-19. This report takes advantage of different simulation techniques, such as skills training, standardized patient, medium- and high-fidelity simulator, rapid cycle of deliberate practice, and in situ simulation. DISCUSSION: Medical procedures for COVID-19 patients offer additional risk for health care professionals, especially considering exposure to procedures that generate aerosols, such as compression, mask ventilation, and orotracheal intubation. Thus, finding educational strategies that allow training is essential to simulate the evolution of COVID-19 patients in a safe manner. CONCLUSION: Simulation has proven to be a useful and effective form of training around the world for training health teams on the front lines for patient care in COVID-19.

Penile enlargement with methacrylate injection: is it safe? / Aumento peniano com injeção de metacrilato: isto é seguro?

Penis size is a great concern for men in many cultures. Despite the great variety of methods for penile augmentation, none has gained unanimous acceptance among experts in the field. However, in this era of minimally invasive procedure, injection therapy for penile augmentation has become more popular. Here we report a case of methacrylate injection in the penis that evolved with penile deformity and sexual dysfunction. This work also reviews the investigation and management of this pathological condition.

A 36-year-old male sought medical care with a complaint of penile deformity and sexual dysfunction after methacrylate injection. The treatment administered was surgical removal. Satisfactory cosmetic and functional results were reached after two months.

There is a need for better structured scientific research to evaluate the outcomes and complication rates from all penile augmentation procedures. .

O tamanho peniano é uma grande preocupação para homens em diversas culturas. Apesar da grande variedade de possíveis métodos para o aumento peniano, nenhum ganhou aceitação unânime por especialistas no assunto. Mas na era dos procedimentos minimamente invasivos, a terapia de injeção para aumento peniano tem se tornado mais popular. Aqui relatamos um caso de injeção de metacrilato no pênis que evoluiu com deformidade peniana e disfunção sexual. Este trabalho também revisa a investigação e gerenciamento desta afecção.

Um homem de 36 anos procurou atendimento médico com queixa de deformidade peniana e disfunção sexual após injeção de metacrilato. Remoção cirúrgica foi realizada como tratamento. Após dois meses, satisfatórios resultados cosmético e funcional foram alcançados.

Trabalhos científicos mais bem estruturados para avaliar as taxas de complicação e resultados de todos os procedimentos para aumento peniano são necessários. .

Robotic-assisted laparoscopic partial nephrectomy: initial experience in Brazil and a review of the literature

CONTEXT AND PURPOSE: Partial nephrectomy has become the standard of care for renal tumors less than 4 cm in diameter. Controversy still exists, however, regarding the best surgical approach, especially when minimally invasive techniques are taken into account. Robotic-assisted laparoscopic partial nephrectomy (RALPN) has emerged as a promising technique that helps surgeons achieve the standards of open partial nephrectomy care while offering a minimally invasive approach. The objective of the present study was to describe our initial experience with robotic-assisted laparoscopic partial nephrectomy and extensively review the pertinent literature. MATERIALS AND METHODS: Between August 2009 and February 2010, eight consecutive selected patients with contrast enhancing renal masses observed by CT were submitted to RALPN in a private institution. In addition, we collected information on the patients' demographics, preoperative tumor characteristics and detailed operative, postoperative and pathological data. In addition, a PubMed search was performed to provide an extensive review of the robotic-assisted laparoscopic partial nephrectomy literature. RESULTS: Seven patients had RALPN on the left or right sides with no intraoperative complications. One patient was electively converted to a robotic-assisted radical nephrectomy. The operative time ranged from 120 to 300 min, estimated blood loss (EBL) ranged from 75 to 400 mL and, in five cases, the warm ischemia time (WIT) ranged from 18 to 32 min. Two patients did not require any clamping. Overall, no transfusions were necessary, and there were no intraoperative complications or adverse postoperative clinical events. All margins were negative, and all patients were disease-free at the 6-month follow-up. CONCLUSIONS: Robotic-assisted laparoscopic partial nephrectomy is a feasible and safe approach to small renal cortical masses.Further prospective studies are needed to compare open partial nephrectomy with its minimally invasive counterparts.

Penile prosthesis implantation in an academic institution in Latin America

PURPOSE: We performed a retrospective study to analyze the effectiveness of implantable penile prostheses in the treatment of erectile dysfunction. MATERIALS AND METHODS: This study included 249 patients who received implants between 2001 and 2008. A total of 139 patients who underwent penile prosthesis implantation were interviewed. RESULTS: Approximately half of patients had previously used oral drugs before implantation of the prosthesis. About 45 percent had diabetes, 25.9 percent had previously undergone radical prostatectomy (RP), and 64 percent had hypertension. Exchange was performed in 5.7 percent for fracture, inadequate size, or extrusion. A total of 24.5 percent of men had immediate postoperative pain, 7.9 percent had local infection, and 8.6 percent had other complications. Patients who had previously undergone RP were 3.2 times more likely to experience a postoperative complication than patients who had not (p = 0.061). Eighty-nine (64 percent) patients returned to having sex as they had before being diagnosed with ED. Ninety-two of the men (66.2 percent) had sexual intercourse one to two times per week. One hundred twenty patients (86.3 percent) rated their level of satisfaction as good, excellent or very good, which was similar to the percentage of partners. The mean follow-up was 40 months. CONCLUSION: Higher rates of postoperative infections and mechanical problems with the implant were found in this study as compared to other studies, which was probably associated with the relative lack of experience of the trainees who were performing the surgeries. Patients with a history of RP or diabetes mellitus prior to implantation were at higher risk of postoperative complications.

Escroto agudo / Acute scrotum

O escroto agudo, caracterizado pela presença de dor local intensa, edema e alteração da consistência das estruturas da bolsa testicular, constitui uma urgência urológica e corresponde a 0,5% dos atendimentos nos serviços de emergência. As causas mais frequentes de escroto agudo são os processos inflamatórios locais...

Acute scrotum always represents a clinical emergency and is seen in 0,5% of patients attending acute care units. The main cause of acute scrotum are inflammatory conditions of the testis or epididymis and testicular torsion. Based on clinical evaluation the diferential diagnosis between these two conditions can be...

Histopathological characterization of a syngeneic orthotopic murine bladder cancer model

PURPOSE: We developed and characterized by histopathology and immunohistochemistry a syngeneic murine bladder tumor model derived from the MB49 tumor cell line. MATERIALS AND METHODS: Bladder tumor implantation was achieved by intravesical instillation of 5 x 10(5) MB49 tumor cells in C57BL/6 mice. A chemical lesion of the bladder was performed in order to promote intravesical tumor implantation. The bladder wall lesion was accomplished by transurethral instillation of silver nitrate (AgNO3). After 15 days, the animals were sacrificed, examined macroscopically for intravesical tumor and bladder weight. Histology and immunohistochemistry were performed using cytokeratin 7 (CK7), carcinoembrionic antigen (Dako-CEA), p53 and c-erbB2 oncoprotein (Her2/neu). RESULTS: Twenty-nine out of 30 animals (96.7 percent) developed intravesical tumors in a 15-day period. Macroscopically, the mean bladder weight was 0.196g (0.069-0.538g), 10 to 15 times the normal bladder weight. The immunohistochemical analysis showed significant membrane expression of CEA and CK7: a similar finding for human urothelial cancer. We also characterized absence of expression of p53 and anti-Her2/neu in the murine model. CONCLUSIONS: High tumor take rates were achieved by using the chemical induction of the bladder tumor. Although electric cauterization is widely described in the literature for syngeneic orthotopic animal models, the technique described in this study represents an alternative for intravesical bladder tumor implantation. Moreover, the histopathology and immunohistochemical analysis of the murine bladder tumor model derived from the MB49 cell line showed a resemblance to human infiltrating urothelial carcinoma, allowing clinical inference from experimental immunotherapy testing.

Erectile dysfunction in patients with chronic renal failure

OBJECTIVE: Determine the prevalence of erectile dysfunction in patients undergoing hemodialysis MATERIALS AND METHODS: This cross-sectional study was carried out to determine the prevalence of erectile dysfunction in a population of 58 patients in hemodialysis program. Erectile dysfunction was assessed by using the International Index of Erectile Function (IIEF). Information on demographic data, renal failure, comorbidities, laboratory tests and search for medical treatment for erectile dysfunction by means of interviews and researches in medical charts was obtained. Student t test was utilized to compare the laboratory results between group of patients with and without erectile dysfunction. The chi-square test was utilized to compare the comorbidities and the characteristics of the population studied between the groups of patients with and without erectile dysfunction. The significance level considered was 5 percent RESULTS: Mean patient age was 50.2 ± 14.6 years and the time of hemodialysis was 30.4 ± 28.4 months. The prevalence of erectile dysfunction was 60.3 percent. A progressive increase respecting the age was reported. In patients younger than 50 years, this prevalence reached 31.4 percent and in patients older than 50 years, this prevalence reached 68.6 percent. With respect to the comorbidities, hypertensive patients prevailed with 94.8 percent of the total, whilst diabetic patients represented 24.9 percent. However only the association between diabetes and erectile dysfunction was significant. Patients with erectile dysfunction presented significantly lower values for serum creatinine and Kt/V. There was no variation between the groups with reference to calcium, potassium, phosphorus, hematocrit, hemoglobin, pre- and post-dialysis urea values. There was no correlation between erectile dysfunction and time of dialysis. Amongst patients with erectile dysfunction, 8.6 percent sought medical care CONCLUSIONS: The...

Development of a urinary lithiasis localizer mechanism to couple ultrasound and extracorporeal lithotripsy equipment in canine model

INTRODUCTION: Due to the evolution of extracorporeal lithotripsy equipment (ESWL) and presently, the fact that most part of the equipment does not present ultrasound to localize urinary calculi, a system that allows adapting ultrasound equipment to ESWL equipment was developed, disposing only of fluoroscopy. Thus, this equipment was developed and was tested in urinary stones in canine models, to check its precision in relation to fluoroscopy. METHOD: Seven male dogs were utilized with the introduction, in the bladder through the ureteral route, of chalkstones, with initial localization by fluoroscopy, with a further ultrasound coincidence check localization of the vesical stones, being submitted to ESWL with a 3-hour, 21 days and 60 days follow-up after the procedure. RESULTS: Success of localization in all animals was verified presenting elimination of stones in the first micturitions, after ESWL. No complications were verified in those animals for 60 days. CONCLUSION: We verified that this equipment can lead to an update of the equipment that use only fluoroscopy, increasing in this way, their technical capacity in the treatment of urinary calculi, mainly in cases of non-radiopaque stones.

Histomorphometry of penile smooth muscle fiber in severe erectile dysfunction

CONTEXTO E OBJETIVO: A fibra muscular lisa apresenta fundamental importância no mecanismo de ereção e alterações em sua função ou em sua quantidade podem estar associadas à disfunção erétil. O objetivo do estudo é analisar a proporção de fibras musculares lisas em pacientes com disfunção erétil grave. TIPO DE ESTUDO E LOCAL: Estudo clínico, realizado no Grupo de Disfunção Erétil da Universidade Federal de São Paulo (Unifesp) e no Laboratório de Anatomia e Urologia da Universidade Estadual do Rio de Janeiro (UERJ). MÉTODOS: 20 pacientes com disfunção erétil grave de acordo com o Indice Internacional de Função Erétil e Teste de Ereção Fármaco-Induzida divididos em dois grupos de 10 pacientes, sendo um com fluxo arterial normal (44 a 78 anos, média @ 63 anos) e o outro com fluxo arterial alterado (38 a 67 anos, média @ 56,2 anos) ao duplex ultra-som. Os resultados são comparados com um grupo formado por 10 cadáveres de 18 a 25 anos (média @ 21,6 anos) presumidamente potentes. A quantificação das fibras musculares lisas foi realizada a partir de estudo imunoistoquímico com anticorpo anti-actina e análise computadorizada da imagem pelo sistema HSL (matiz, saturação e luminosidade). RESULTADOS: A proporção de fibras musculares lisas encontradas foi de 41,15 por cento para o grupo controle. Os pacientes com disfunção erétil apresentaram 27,24 por cento de fibras musculares lisas para o grupo com fluxo arterial normal e 25,74 por cento para o grupo com fluxo arterial insuficiente. Com exceção de apenas um paciente (do grupo com fluxo arterial normal), 19 pacientes apresentavam ao menos uma doença crônica ou fator de risco para disfunção erétil, destacando-se diabetes mellitus, hipertensão arterial sistêmica e tabagismo, nesta ordem. CONCLUSAO: Nos pacientes com disfunção erétil grave, o fluxo arterial isoladamente não apresenta interferência na proporção de fibras musculares lisas, pois os resultados foram semelhantes. Nestes pacientes com disfunção grave, a diminuição das fibras musculares lisas em relação ao grupo controle pode decorrer das doenças crônicas e de seu potencial aterosclerótico.

Effect of sildenafil in cavernous arteries of patients with erectile dysfunction

INTRODUCTION: Sildenafil citrate is a type 5 phosphodiesterase inhibitor, which has demonstrated excellent results in the treatment of erectile dysfunction. The effect of sildenafil citrate in the cavernous arteries of patients with erectile dysfunction has not been established yet. The objective of this study was to assess the effect of sildenafil citrate in the cavernous arteries of patients with erectile dysfunction, following an intracavernous injection of alprostadil. MATERIALS AND METHODS: 29 male patients, with mean age of 53.8 years (32 to 75 years), were prospectively evaluated. The mean time with complaint of erectile dysfunction was 50.5 months (6 to 168 months). Each patient was his own control. Patients underwent a measurement of peak systolic velocity before and after use of sildenafil citrate associated with 5 micrograms of alprostadil, through ultrasonic velocitometry Knoll/MIDUS® system. In the interval between measurements, approximately 15 days, patients used 3 tablets of sildenafil at home with their partners. RESULTS: Using only 5 mcg of alprostadil, average peak systolic velocity was 23.9 cm/s, and when associated to 50 mg of sildenafil it was 24.8 cm/s. Despite the increase in the flow rate caused by sildenafil, the difference was not statistically significant, Zcalculated = - 0.695 NS (Wilcoxon test). Twenty one of the 29 patients (72.4 percent) showed global improvement in sexual performance with the use of sildenafil citrate at home. There was not a statistically significant correlation between the global response to sildenafil citrate and the increase in the peak systolic velocity. CONCLUSION: We concluded that, even though the use of 50 mg of sildenafil citrate associated with 5 mcg of alprostadil provides an increase in the peak systolic velocity of the cavernous arteries, there was no statistic difference in relation to alprostadil alone. There was no correlation between the global response to sildenafil and the increase in the peak systolic velocity.

Apoptose renal induzida por ondas de choque de alta energia / Renal apoptosis induced by high energy shock waves

Desde a sua introduçäo, em 1980, a litotrcia extracorpórea por ondas de choque se tornou a primeira opçäo no tratamento de 85 porcento dos casos de litíase urinária. Apesar da sua rápida aceitaçäo, a melhor compreensäo do mecanismo de açäo das ondas de choque de alta energia e vários estudos clínicos demonstraram que essa nova forma de energia causa lesäo celular. Simultaneamente, vários estudos demonstraram que a apoptose tem um papel marcante no aparecimento e desenvolvimento de vários tipos de doenças benignas e malignas.Para verificar o efeito das ondas de choque de alta energia na apoptose, visando o desenvolvimento de uma terapia näo invasiva do câncer renal, desenvolvemos o presente estudo. O experimento foi realizado em dez ratos Wistar, machos com 30 dias de vida, expostos a 1000 ondas de choque de 16 Kv. A escolha dessa metodologia tornou possível a realizaçäo do experimento durante a fase de intensa multiplicaçäo celular desses animais, bem como verificar seus efeitos cronicamente. Näo houve nenhuma alteraçäo macroscópica dos rins dos animais. Por outro lado, encontramos apoptose nesses animais. Assim, podemos concluir que as ondas de choque de alta energia causam apoptose em células renais normais, em crescimento(au)

Disfunçäo erétil / Erectile dysfunction

Na introduçäo, os autores apresentam dados epidemiológicos da disfunçäo erétil (DE) e, em seguida, o diagnóstico clínico da DE de origem orgânica e psicogênica, bem como o diagnóstico laboratorial. O tratamento é subdividido em informaçöes gerais, medicamentos por via oral (sildenafil e análogos, ioimbina e fentolamina, apomorfina, trazodone e L-arginina), medicamentos por via uretral (alprostadil), farmacoterapia intracavernosa, bombas de vácuo e próteses penianas. Os autores concluem que existiu uma grande evoluçäo da fisiopatologia e do tratamento da DE e que esta doença é bastante comum, existindo soluçöes para restabelecer o bem-estar do paciente.(au)

Infecçöes do trato urinário nos homens / Men's urinary tract infections

A ITU é um dos problemas mais freqüêntes na prática médica, sendo responsável por morbidez e custos consideráveis. A maioria das ITU em homens é considerada complicada, visto que grande parte delas ocorre nos recém-natos, lactentes ou idosos, e estäo associadas a anormalidades urológicas. Em homens idosos as infecçöes säo mais freqüêntes devido ao aumento do volume prostático, que leve a uma obstruçäo infravesical.(au)

Intracavernous injection in the treatment of erectile dysfunction after radical prostatectomy: an observational study

CONTEXT: Despite the recent improvements in performing radical retropubic prostatectomy that have led to a considerable decrease in the complication rate, erectile dysfunction still represents a major problem. Moreover, less invasive treatment options that are emerging for erectile dysfunction have not shown satisfactory results in managing these patients. OBJECTIVE: To study the efficacy and side effects of self-injection therapy in the treatment of men who had become impotent after undergoing radical prostatectomy due to prostate cancer, over a study period of 96 months. DESIGN: Observational study. SETTING: University Referral Center. PARTICIPANTS: 168 patients with erectile dysfunction, aged 43 to 78 years old, who underwent radical retropubic prostatectomy due to localized prostate cancer. PROCEDURES: The patients were treated with self-injection therapy using papaverine, phentolamine and prostaglandin E1, at home. RESULTS: This study showed an acceptable 94.6 percent success rate, with no life-threatening complications. In addition to this, our series presented a 13.1 percent cure rate with this therapy. CONCLUSION: Self-injection therapy with papaverine, phentolamine and prostaglandin E1 is effective and safe in the treatment of erectile dysfunction after radical prostatectomy

Validade dos escores clinicos / Validation of voiding sympton index

Embora os escores clinicos tenham contribuido na avaliaçao clinica dos pacientes, nao foi demonstrada especificidade em relaçao a HPB. Outro aspecto importante e saber se existe diferença quando sao auto-aplicaveis, como e o indicado, ou quando ministrados aos pacientes pelos medicos. Aleatoria e consecutivamente, foram estudados 104 pacientes que procuraram o Serviço de Urologia do Hospital Beneficencia Portuguesa de Sao Paulo ou a clinica privada (NRNJ), com idades variando entre 40 a 94 anos, media 67 anos. A razao da consulta nem sempre deveu-se a queixas de prostatismo, podendo haver sido por causas urologicas diversas. Denominamos grupo "P" quando o teste era auto-aplicavel, ou seja, o paciente respondia ao questionario sem a ajuda medica e "M" quando as perguntas eram feitas pelos medicos. O primeiro estudo comparou os escores do grupo "P" versus grupo "M". A seguir foram alocados em 2 sub-grupos, de acordo com o nivel de escolaridade dos pacientes. O grupo A era constituido por 40 pacientes com instruçao primaria e o B por 64 pacientes com educaçao secundaria ou superior. Outra questao estudada foi criada com a divisao do sub-grupos A e B em 2 outros de acordo com a idade dos pacientes ser igual ou menor 65 anos ou maior que 65 anos (Tabela). Os resultados mostraram que nao houve diferença, ou seja, os pacientes compreenderam perfeitamente bem o questionario, nao havendo necessidade de maiores esclarecimentos pelo medico. A relaçao entre a escolaridade e os escores nao mostrou diferença significante quando o metodo foi auto-aplicado ou ajudado pelo medico, tanto no grupo com educaçao primaria quanto no de nivel cultural mais elevado (p > 0,01). O fator idade poderia ter influencia determinando diferenças entre as respostas ao I-PSS. A analise dessas correlaçoes mostrou concordancia significante, variando de 75 a 96,8//. Dessa maneira conclui-se que nem a faixa etaria nem o nivel de escolaridade comprometem a aplicaçao dos escores clinicos. Os escores clinicos, representados pelo I-PSS, representam um importante avanço no estudo da HPB, que contudo devem ser interpretados a luz dos conhecimentos aqui discutidos

Tratamento farmacologico nao hormonal e nao alfa-bloqueador / Non-hormonal non-alpha-blocker pharmacological treatment

Atualmente com a longevidade alcançada pela populaçao masculina, os problemas prostaticos estao cada vez mais em evidencia. Do ponto de vista microscopico, apos os 50 anos de idade, 50 por cento dos homens apresentarao alteraçoes hiperplasicas e 25 por cento necessitarao de algum procedimento cirurgico para a regressao da sintomatologia prostatica. Com o advento da endoscopia, a ressecçao transuretral da prostata passou a ser o tratamento indicado para os pacientes com sintomas exacerbados. Entretanto, nos casos de sintomatologia moderada, o tratamento clinico e de grande interesse, podendo evitar a cirurgia. Ha varios seculos sao utilizadas drogas de varias origens na tentativa de melhorar a sintomatologia prostatica; fazemos uma revisao dos agentes, nao hormonais e nao alfa-bloqueadores, que fazem parte do arsenal urologico

Relaçao entre sintomatologia, peso prostatico e fluxo urinario / Relationship of symptoms prostatic weight and urinary from of benign prostatic hyperplasia

Restropectivamente foram estudados consecutivamente 106 pacientes com o diagnostico de Hiperplasia Benigna da Prostata (HBP) tratados por Termoterapia Transuretral por Microondas (TUMT). O protocolo baseava-se na anamnese, exame fisico (em particular o toque retal), avaliaçao laboratorial em especial a determinaçao do antigeno especifico prostatico (PSA), ultra-sonografia prostatica transretal e fluxometria. Nos 106 pacientes estudados comparou-se os sintomas irritativos (SI) com os sintomas obstrutivos (SO). O valor medio de SI (6,59), comparado com o valor medio de SO (4,94), mostrou que os sintomas irritativos sao mais frequentes que os sintomas obstrutivos (p < 0,01). Em 86 doentes comparou-se o fluxo urinario e o peso prostatico. O fluxo urinario maximo variou de 0 a 23, media 9,02 ml/s e o peso prostatico de 15 a 150 g, media 48,42 g. A analise estatistica nao mostrou diferença significante entre estes parametros (p > 0,01). Os pacientes foram distribuidos em 2 grupos de acordo com o peso da prostata. O grupo 1 era formado por 69 doentes cujas prostatas pesavam de 15 a 45 g, media 37,46 g. No grupo 2 foram avaliados 37 homens com prostatas variando entre 54 e 190 g. A analise estatistica demonstrou nao haver diferença entre os sintomas irritativos e obstrutivos tanto nos grupos de prostatas menores quanto nas mariores que 50 g (p > 0,01). Analisando 49 pacientes, cujos fluxos eram iguais ou menores a 10 ml/s, verificou-se que os sintomas irritativos variavam de 0 a 11, media 6,65 e os sintomas obstrutivos variavam de 0 a 11, media 5,08. A analise estatistica mostrou que os sintomas irritativos eram mais frequentes que os obstrutivos (p < 0,01). A seguir foram estudados 39 pacientes cujos fluxos maximos eram superiores a 10 ml/s. Os sintomas irritativos variavam de 1 a 10. ,media 6,26 e os sintomas obstrutivos variavam de 0 a 11, media 4,74. O estudo estatistico demonstrou a predominancia dos sintomas irritativos sobre os obstrutivos (p < 0,01). Portanto, os sintomas irritativos foram mais frequentes que os obstrutivos, independentemente do valor do fluxo urinario maximo. Em conclusao, nao se conseguiu estabelecer a correlaçao entre o peso prostatico, fluxo urinario maximo e escores clinicos