Síndrome de Hedinger secundario a Tumor neuroendocrino bronquial. Presentación de un caso

El síndrome carcinoide es un síndrome paraneoplásico que se presenta en tumores neuroendocrinos. Aunque es una entidad infrecuente suele ser la primera manifestación de la enfermedad. La baja incidencia junto a la presentación inespecífica genera retrasos diagnósticos importantes. Se presenta el caso de una paciente con síntomas digestivos y tuforadas que posteriormente agrega insuficiencia cardíaca, logrando mediante un ecocardiograma típico y marcadores analíticos el diagnóstico de síndrome carcinoide. Posteriormente se evidencia que su origen en un tumor neuroendocrino bronquial. Conocer las características de este síndrome es fundamental para mantener una alta sospecha clínica en pacientes con síntomas sugestivos logrando un diagnóstico precoz y adecuado.

Carcinoid syndrome is a paraneoplastic syndrome that occurs in neuroendocrine tumors. Although It is an uncommon entity, it is usually the first manifestation of the disease. The low incidence besides the non-specific presentation generates important diagnostic delays. We present the case of a patient presenting digestive symptoms and flushing that subsequently adds heart failure, achieving though a typical echocardiogram and analytical markers the diagnosis of carcinoid syndrome. Later it is discovered its origin in a bronchial neuroendocrine tumor. Knowing the characteristics of this syndrome is essential to maintain a high clinical suspicion in patients with suggestive symptoms, in order to achieve an early and adequate diagnosis.

El síndrome carcinoide é um síndrome paraneoplásico que ocorre em tumores neuroendócrinos. Embora seja uma entidade rara, geralmente é a primeira manifestação da doença. A baixa incidência, juntamente com a apresentação inespecífica, resulta em atrasos importantes no diagnóstico. Apresentamos o caso de uma paciente com sintomas digestivos e ruborização cutânea, que posteriormente desenvolve insuficiência cardíaca. O diagnóstico de síndrome carcinoide foi estabelecido por meio de um ecocardiograma característico e marcadores analíticos. Posteriormente, foi evidenciada a origem em um tumor neuroendócrino brônquico. Conhecer as características deste síndrome é fundamental para manter uma alta suspeita clínica em pacientes com sintomas sugestivos, permitindo um diagnóstico precoce e adequado.

Utilização das boas práticas no parto e experiência e satisfação materna / Using good delivery practices and maternal experience and satisfaction

Objetivo: Descrever a utilização das boas práticas de atenção ao parto e nascimento e o grau de satisfação e experiência de puérperas com o parto. Métodos: Estudo transversal, realizado no período de julho de 2017 a janeiro de 2018, em uma maternidade de referência em Fortaleza, Ceará. Para coleta de dados utilizou-se o Questionário de Experiência e Satisfação com o Parto e questionário para avaliação dos dados sociodemográficos e obstétricos. Os dados foram analisados no softwareStatistical Package for the Social Science. O estudo foi aprovado pelo Comitê de Ética em Pesquisa. Resultados: Participaram 237 puérperas com média de idade de 26 anos. 168 (70,9%) mulheres estiveram bastante satisfeitas com a estrutura da instituição, 119 (50,2%) com os cuidados profissionais prestados e 160 (67,5%) com o trabalho de parto e parto. Dentre os fatores que estiveram associados à experiência positiva com o parto, destaca-se a realização do contato pele a pele, o estímulo ao aleitamento materno e a utilização dos métodos não farmacológicos de alívio da dor. Conclusão: Para uma experiência mais positiva de parto, ressalta-se a importância de abordagens mais humanizadas que incentivem práticas como contato pele a pele e início precoce do aleitamento materno, além de garantir que profissionais de saúde forneçam cuidados holísticos. Descritores: Satisfação do Paciente; Enfermagem Obstétrica; Trabalho de Parto; PartoNormal; PartoHumanizado.

Objective:To describe the use of good practices in delivery and childbirth care and the satisfaction levels and experiences of puerperal women with their deliveries.Methods:A cross-sectional study conducted from July 2017 to January 2018 in a reference maternity hospital from Fortaleza, Ceará. The Childbirth Experience and Satisfaction Questionnaire and another one to assess the sociodemographic and obstetric data were used for data collection. The data were analyzed in the Statistical Package for the Social Science. The study was approved by the Research Ethics Committee. Results:The participants were 237 puerperal women with a mean age of 26 years old. 168 (70.9%) women were quite satisfied with the institution's structure, 119 (50.2%) with the professional care provided, and 160 (67.5%) with labor and delivery. Among the factors that were associated with positive experiences with delivery, the most important are skin-to-skin contact, stimulating breastfeeding, and using non-pharmacological pain relief methods. Conclusion: For a more positive experience with delivery, it is worth emphasizing the importance of more humanized approaches that encourage practices such as skin-to-skin contact and early breastfeeding initiation, as well as ensuring that health professionals provide holistic care. Descriptors:Patient Satisfaction; Obstetric Nursing; Labor. Normal Delivery; Humanized Delivery.

Síndrome de Edwards: desde el diagnóstico prenatal hasta el neonatólogo

RESUMEN El síndrome de Edwards o síndrome de trisomía 18 es un trastorno cromosómico autosómico que se caracteriza por la presencia de un cromosoma 18 extra, con rasgos clínicos distintivos. Se presenta un caso con diagnóstico prenatal basados en la ecografía morfológica obstétrica que condujeron a la realización ecocardiografía fetal donde resalta la displasia de la válvula pulmonar con doble lesión y la comunicación interventricular. Posteriormente se realiza cordocentesis para realización del cariotipo y asesoramiento genético.

ABSTRACT Edwards' syndrome, or trisomy 18 syndrome, is an autosomal chromosomal disorder characterized by the presence of an extra chromosome 18, with distinctive clinical features. We present a case with a prenatal diagnosis based on obstetrical morphological ultrasound that led to the performance of a fetal echocardiography with findings of a pulmonary valve dysplasia with double injury and interventricular communication. Subsequently, cordocentesis is performed for karyotyping and genetic counseling.

Profile of women affected with premature childbirth and neonatal outcomes / Perfil de mulheres acometidas por parto prematuro e desfechos neonatais

Abstract Objectives: to describe the profile of women affected with premature childbirth and neonatal outcomes at a referral maternity in the city of Fortaleza-CE, Brazil. Methods: descriptive and retrospective documentary type study, with a quantitative approach, carried out from January to December, 2017, with 253 medical records of women who had premature childbirth in a referral maternity. Results: the average age was 28, with the prevalence of women living in a stable union, graduated from high school and without formal work. The gestational mean average was three pregnancies, gestational age of 34 weeks and three days, and six prenatal consultations, starting in the first trimester. The major intercurrence was pre-eclampsia. In relation to the neonatal data, there was a prevalence of male newborns, with an average of 2.251 kg and a score of seven on the 1-minute Apgar and eight on the 5-minute Apgar. Newborns in going to a hospital accommodation after childbirth and in room air, spending an average of 12.71 days in the hospital. Conclusion: in this case of this research, knowing the woman's profile and the outcomes in premature newborns is useful to encourage public policies and reduce the sequelae on mother and baby

Resumo Objetivos: descrever o perfil de mulheres acometidas por parto prematuro e os desfechos neonatais em maternidade de referência, na cidade de Fortaleza-CE, Brasil. Métodos: estudo do tipo documental, descritivo, retrospectivo, com abordagem quantitativa, realizadode janeiro a dezembro de 2017, com 253 prontuários de mulheres que tiveram parto prematuro em maternidade de referência. Resultados: média de idade de 28 anos, com prevalência de mulheres vivendo em união estável, ensino médio completo, sem trabalho formal. A média gestacional foi de três gravidezes, idade gestacional de 34 semanas e trêsdias e seis consultas de pré-natal, iniciando no primeiro trimestre. A maior intercorrência foi a pré-eclâmpsia. Relacionado aos dados neonatais, houve prevalência de recém-nascidos do sexo masculino, com média de 2,251 quilos e escore sete no Apgar do 1º minuto e oito, no Apgar do 5º minuto. Recémnascidos indo para alojamento conjunto após o parto e em ar ambiente, tendo passado, em média, 12,71 dias internados. Conclusões: no caso da pesquisa, conhecer o perfil dessa mulher e os desfechos do recém-nascido prematuro é útil para estimular as políticas públicas e diminuir as sequelas para mãe e bebê.

Retinopatía del prematuro: resultados de un programa de prevención, detección y tratamiento

RESUMEN Introducción: La Retinopatía del Prematuro (ROP) es una de las principales causas de ceguera prevenibles en la infancia. La Fundación Visión implementa; el Programa de Prevención, Detección y Tratamiento en el año 2015. Objetivos: Describir los resultados de implementación y los resultados alcanzados por un programa de ROP en su accesibilidad, efectividad y calidad de atención. Materiales y Métodos: Estudio descriptivo, ambispectivo, de casos consecutivos de recién nacidos prematuros con criterios de evaluación; de una población evaluada en el año 2009 y del 2015 al 2019. Resultados: Las unidades neonatales incluidas aumentaron de 3 a 7; cubriendo Asunción, área Central, Caaguazú y Alto Paraná. De los registros se constato que la cobertura aumento de 36% en el año 2009 a 97% en el 2019. Desde que se instaló el programa; en el primer año la proporción del número de evaluaciones aumento entre el 28 y el 216%; y los resultados globales de julio 2015 a diciembre 2019 fueron: número totales de pacientes con criterio: 2397 pacientes; número totales de pacientes evaluados: 2080 (86,8%), número de pacientes con ROP: 416/2080 pacientes (20%), número de pacientes con ROP que requirieron tratamiento: 76/416 pacientes (18,2%), proporción global de ROP grave con tratamiento: 76/2080 pacientes (3,4%). Conclusiones: El programa a través de un equipo multidisplinario y la inovación con telemedicina logró aumentar la proporción de cobertura y la disminución de los casos graves que requirieron tratamiento.

ABSTRACT Introduction: Retinopathy of Prematurity (ROP) is one of the main preventable causes of blindness in childhood. The Vision Foundation implemented the Prevention, Detection and Treatment Program in 2015. Objective: To describe the implementation results and the outcomes achieved by a ROP program regarding its accessibility, effectiveness and quality of care. Materials and Methods: This was a descriptive and ambispective study of consecutive cases of premature newborns with criteria for evaluation, of a population evaluated in the year 2009 and from 2015 to 2019. Results: The participating neonatal units increased from 3 to 7; covering Asunción, the Central, Caaguazú and Alto Paraná Departments. From the records, it was found that program coverage increased from 36% in 2009 to 97% in 2019. Since the beginning of the program, during the first year the proportion of the number of evaluations increased between 28 and 218%; the global results from July 2015 to December 2019 were: total number of patients with criteria: 2397 patients; total number of patients evaluated: 2,080 (88%), number of patients with ROP: 416/2080 patients (20 %), number of patients with ROP requiring treatment: 76/416 patients (18.3%), overall proportion of severe ROP with treatment: 76/2080 patients (3.4%). Conclusions: The program, using a multidisciplinary team and the innovation of telemedicine, managed to increase the proportion of coverage and the reduction of serious cases that require treatment.

Variablilidad de la presión arterial, hipertensión arterial nocturna y su asociación con tabaquismo / Blood pressure variability, nocturnal hypertension and its association with smoking / Variabilidade da pressão arterial, hipertensão arterial noturna e sua associação com o tabagismo

Resumen: Introducción: La hipertensión arterial y el tabaquismo son factores de riesgo independientes para el desarrollo de eventos cardiovasculares. El consumo de tabaco determina una elevación aguda de la presión arterial por acción del sistema simpático. Sin embargo los efectos a largo plazo son contradictorios. El aumento de la variabilidad de la presión arterial y la presencia de hipertensión arterial nocturna se asocia con eventos cardiovasculares adversos independientemente de los niveles de presión arterial. Objetivos: Evaluar la asociación entre tabaquismo e hipertensión arterial diurna, nocturna y variabilidad. Material y Métodos: Estudio analítico, observacional, transversal, multicéntrico, que incluye pacientes hipertensos mayores de 18 años con monitoreo ambulatorio de la presión arterial (MAPA). Resultados: Se incluyeron 391 pacientes, siendo 14.6% fumadores. Se encontraron cifras de presión arterial diurna sistólica y diastólica más elevadas en pacientes tabaquistas (p=0.204, p=0.087, respectivamente). Se observó una asociación significativa entre la hipertensión arterial nocturna y la presencia de diabetes mellitus e índice de masa corporal aumentado. No se encontró asociación entre el consumo de tabaco y los distintos patrones de variabilidad, así como tampoco con la hipertensión arterial nocturna. Conclusiones: El grupo de pacientes fumadores presentó una tendencia a cifras de presión arterial media diurna sistólica y diastólica más elevadas que los no fumadores, lo que podría sugerir que el tabaquismo incide en el control de cifras de presión arterial.

Abstract: Introduction: Hypertension and smoking are independent risk factors for the development of cardiovascular events. Tobacco use causes an acute elevation of blood pressure due to the action of the sympathetic system. However, the long-term effects are contradictory. Increased variability in blood pressure and the presence of nocturnal arterial hypertension are associated with adverse cardiovascular events regardless of blood pressure levels. Objectives: To evaluate the association between smoking and daytime and nighttime arterial hypertension and variability. Material and Methods: Analytical, observational, cross-sectional, multicenter study, which includes hypertensive patients over 18 years of age with ambulatory blood pressure monitoring (ABPM). Results: 391 patients were included, being 14.6% smokers. Higher levels of systolic and diastolic daytime blood pressure were found in smoking patients (p = 0.204, p = 0.087, respectively). A significant association was observed between nocturnal arterial hypertension and the presence of diabetes mellitus and increased body mass index. No association was found between tobacco consumption and the different patterns of variability, as well as with nocturnal arterial hypertension. Conclusions: The group of smoking patients showed a trend towards higher mean daytime systolic and diastolic blood pressure figures than non-smokers, which could suggest that smoking affects the control of blood pressure numbers.

Resumo: Introdução: Hipertensão e tabagismo são fatores de risco independentes para o desenvolvimento de eventos cardiovasculares. O uso do tabaco provoca elevação aguda da pressão arterial devido à ação do sistema simpático. No entanto, os efeitos de longo prazo são contraditórios. O aumento da variabilidade da pressão arterial e a presença de hipertensão arterial noturna estão associados a eventos cardiovasculares adversos, independentemente dos níveis de pressão arterial. Objetivos: Avaliar a associação entre tabagismo e hipertensão arterial diurna e noturna e variabilidade. Materiai e Métodos: Estudo analítico, observacional, transversal, multicêntrico, que inclui hipertensos maiores de 18 anos com monitorização ambulatorial da pressão arterial (MAPA). Resultados: Foram incluídos 391 pacientes, sendo 14,6% tabagistas. Níveis mais elevados de pressão arterial diurna sistólica e diastólica foram encontrados em pacientes fumantes (p = 0,204, p = 0,087, respectivamente). Foi observada associação significativa entre hipertensão arterial noturna e presença de diabetes mellitus e aumento do índice de massa corporal. Não foi encontrada associação entre o consumo de tabaco e os diferentes padrões de variabilidade, bem como com a hipertensão arterial noturna. Conclusões: O grupo de pacientes fumantes apresentou tendência a valores médios de pressão arterial sistólica e diastólica mais elevados do que os não fumantes, o que pode sugerir que o tabagismo afeta o controle dos valores da pressão arterial.

Desfechos neonatais associados às intervenções obstétricas realizadas no trabalho de parto em nulíparas / Neonatal outcomes associated with obstetric interventions performed during labor in nulliparous women

RESUMO Objetivo analisar os desfechos neonatais associados às intervenções obstétricas realizadas no trabalho de parto em nulíparas de baixo risco. Métodos estudo observacional de corte transversal, realizado com 534 nulíparas de baixo risco. Resultados a interrupção do contato pele a pele após o parto se mostrou associado às intervenções obstétricas como cardiotocografia na admissão, ocitocina no trabalho de parto, amniotomia e episiotomia. A necessidade de ventilação por pressão positiva e oxigenoterapia tiveram associação ao incentivo à manobra de Valsalva; a realização desta manobra está associada, também às intervenções amniotomia, episiotomia e puxo dirigido. Conclusão o estudo evidenciou que a utilização das intervenções obstétricas durante o trabalho de parto de mulheres de baixo risco está associada aos desfechos neonatais desfavoráveis que acarretam a necessidade de mais intervenções após o parto.

ABSTRACT Objective to analyze neonatal outcomes associated with obstetric interventions performed during labor in low-risk nulliparous women. Methods a cross-sectional observational study of 534 low-risk nulliparous women. Results interruption of skin-to-skin contact after delivery was shown to be associated with obstetric interventions such as cardiotocography at admission, oxytocin in labor, amniotomy, and episiotomy. The need for positive pressure ventilation and oxygen therapy was associated with the encouragement of the Valsalva maneuver; the performance of this maneuver was also associated with interventions such as amniotomy, episiotomy and directed pulling. Conclusion the study showed that the use of obstetric interventions during labor in low-risk women is associated with unfavorable neonatal outcomes that lead to the need for further interventions after delivery.

Use of Agro-Industrial Wastes for the Production of a Wild Yeast Enzyme with Disintegration Activity on Plant Tissues

Abstract The objective of the present study was to develop a cost-effective medium, using agro-industrial wastes for the production of a polygalacturonase by Wickerhanomyces anomalus of interest in cassava starch industries. The effect of several raw agro-industrial wastes and others nutrients on polygalacturonase production by W. anomalus, were evaluated, in a reference fermentation medium, using statistical designs, by batch culture. The ability of the cell-free supernatant to extract cassava starch was evaluated. Lemon peel was the best inducer for the production of PGase. Statistical analysis of the data showed that lemon peel, Mg+2 and PO4HK2 had significant effect on PGase production, and the others variables (yeast extract, Ca+2, Fe+2, amino acid and trace element solution) were no significant. PGase synthesis reached ~31 EUmL-1, in the OFM (glucose, lemon peel, urea, vitamins, KH2PO4 and MgSO4), after 12 h of culture, at a lab scale bioreactor. PGase of W. anomalus, was able to disintegrate cassava tuber tissue, and the starch granules contained within the cells were released into the reaction medium. Lemon peel can be used as inducer for PGase production by W. anomalus, in a low cost culture medium, appropriate for the production of the enzyme at large scale.

Estudio observacional, prospectivo, abierto, multicéntrico, post-comercialización, para evaluar la efectividad y seguridad de ácido fenofíbrico 105 mg comprimidos en pacientes con hipertrigliceridemia y/o dislipidemias mixtas / Prospective, open-label, multicenter, post-marketing observational study to evaluate the effectiveness and safety of 105 mg fenofibric acid tablets in patients with hypertriglyceridemia and/or mixed dyslipidemia

Introducción: Estudio observacional, prospectivo, abierto, multicéntrico. Se evaluaron 117 pacientes reclutados en 16 centros. Se incluyeron pacientes mayores de 18 años, con hipertrigliceridemia mayor a 200 mg/dl (asociado o no a dislipidemia mixta) que ya estén recibiendo ácido fenofíbrico 105 mg/día desde hace por lo menos 8 y no más de 12 semanas. El cronograma de visitas consistió en una visita inicial (entre 8 a 12 semanas de iniciado el tratamiento con ácido fenofíbrico) y una visita final (8 semanas después de la visita inicial). Resultados: La efectividad fue evaluada a partir de valores de laboratorio y su respuesta al tratamiento, (descenso de niveles séricos de triglicéridos principalmente y descenso de niveles séricos de LDL, y ascenso de niveles séricos de HDL), comparando valores basales y controles de laboratorio en la visita inicial y final. Efectividad: 106 pacientes evaluables. Triglicéridos: Basal: 368,44 ± 165,39 mg/dl; Día 60: 246,30 ± 171,43 mg/dl; Día 120: 180,92 ± 130,59 mg/dl. Anova: p<0,05. LDL: Basal: 144,24 ± 42,33 mg/dl; Día 60: 121,73 ± 38,24 mg/dl; Día 120: 116,08 ±39,81 mg/dl. Anova: p < 0,05. HDL: Basal 41,58 ± 14,09 mg/dl; Día 60: 43,74 ±13,78 mg/dl; Día 120: 46,43 ± 16,09 mg/dl. Anova: p: <0,05. Seguridad: 117 pacientes evaluables. Eventos adversos: 9 pacientes (7,69%) Conclusiones: En nuestro grupo de pacientes evaluados, la administración de 105 mg de Acido Fenofíbrico al día resultó efectiva para disminuir los valores séricos de Triglicéridos y LDL, además de aumentar el HDL. El perfil de seguridad fue aceptable (AU)

Introduction: Observational, prospective, open, multicenter clinical study. One hundred and seventeen (117) patients were recruited from 16 sites. Inclusion criteria: both sexes patients elder than 18 years old with bypertriglyceridemia values higher than 200 mg/dl (related or not to mixed dylipidemia), who had to be taking 105 mg/day of fenofibric acid sinde - at least - 8 weeks and no more than 12 weeks. Study schedule: Baseline visit between 8 and 12 weeks after fenofibric acid strting tretment. Last clinical trial visit: 8 weeks after the baseline one. Results: Effectiveness was evaluated considering laboratory clinical values achieved after treatment. It means: as primary outome it was considerd lower triglycerides serum levels and, as a secondary one, lower LDL and higher HDL serum levels. Laboratory values were compared between the ones from baseline visit and the ones from last visit. Effectiveness: 106 evaluable patients. Triglycerides: Baseline: 368,44 ± 165,39 mg/dl: Day 60: 246,30 ±171,43 mg/dl. Day 120: 180,92 ± 130,59 mg/dl. Anova: p< 0.05. LDL: Baseline: 144,24 ± 42,33 mg/dl: Day 60: 121,73 ± 38,24 mg/dl; Day 120: 116,08 ± 39,81 mg/dl. Anova: p<0,05. HDL: Baseline: 41,58 ± 14,09 mg/dl: Day 60: 43,74 ± 13,78 mg/dl. Day 120: 46,43 ± 16.09 mg/dl. Anova: p<0.05. Safety: 117 evaluable patients: Adverse Events: 9 patients (7,69%). Conclusion: The administration of 105 mg/day of fenofibric acid to the evaluable patients recruited for this clinical study, showed to be effective not only to decrease triglycerides and LDL serum levels, but also to increase HDL, cholesterol values. Patient safety was acceptaable (AU)

Competências e atividades profissionais confiáveis: novos paradigmas na elaboração de uma matriz curricular para residência em medicina de família e comunidade / Competencies and entrustable professional activities: new models for elaboration of a curriculum framework for family and community medicine residency / Competencias y actividades profesionales confiables: nuevos paradigmas en la elaboración de una matriz curricular para residencia en medicina de familia y comunidad

Objetivo: Realizar uma revisão na literatura sobre Currículo Baseado em Competências que possa subsidiar a elaboração de uma Matriz para Programa de Residência em Medicina de Família e Comunidade de Fortaleza, Ceará. Métodos: Foi realizada revisão de literatura sobre o referencial teórico do ensino baseado em competências, selecionando artigos, diretrizes, documentos e modelos de currículos de escolas médicas e entidades nacionais e internacionais envolvidas com o ensino médico. Resultados: A revisão de literatura evidenciou dois principais modelos de currículo repetidamente citados nas referências consultadas: ACGME (Accreditation Council for Graduate Medical Education) Milestones e CanMEDS (Canadian Medical Education Directions for Specialists) Framework. O Currículo Baseado em Competências enfatiza o ensino centrado no aluno e utiliza abordagem baseada em resultados para a criação, implementação e avaliação de programas de educação médica, usando uma estrutura organizacional de competências mapeadas com atividades profissionais confiáveis, na forma de uma matriz. A avaliação é feita por meio de desempenho e resultados graduados em marcos de desenvolvimento. Para fins de elaboração de Matriz curricular própria, optou-se como modelo e referência a proposta do CanMEDS 2015 por este ser aprovado por 12 organizações médicas canadenses e atualmente usado como base curricular em dezenas de países, sendo o modelo mais amplamente aplicado no mundo. Conclusão: Espera-se que esta revisão sirva de ferramenta para que também outras Instituições de Ensino e seus respectivos Programas de Residência possam desenvolver seus próprios Currículos Baseados em Competências.(AU)

Objective: The purpose is to carry out a literature review on Competency Based Curriculum that could support the elaboration of a matrix for the Residency Program in Family and Community Medicine of Fortaleza, Ceará. Methods: A literature review was made on the theoretical reference of competency-based education, selecting articles, guidelines, documents and curricula models of medical schools and national and international entities involved with medical education. Results: The literature review evidenced two main curriculum models repeatedly mentioned in the references: ACGME (Accreditation Council for Graduate Medical Education) Milestones and CanMEDS (Canadian Medical Education Directions for Specialists) Framework. Competency-Based Curriculum emphasizes student-centered teaching and uses a results-based approach to the design, implementation, and evaluation of medical education programs. It is organized as a framework of competencies mapped to entrustable professional activities in the form of a matrix. The evaluation is based on performance through milestones. For creating its own curricular Matrix, the CanMEDS 2015 was adopted as a model because it was approved by 12 Canadian medical organizations and it is currently used as reference in dozens of countries, being the most widely applied model in the world. Conclusion: We expect that this review would serve as a tool for other Medical Schools and their Residency Programs to develop their own Competency-Based Curricula.(AU)

Objetivo: El objetivo es realizar una revisión en la literatura sobre Currículo Basado en Competencias que pueda subsidiar la elaboración de una Matriz para Programa de Residencia en Medicina de Familia y Comunidad de Fortaleza, Ceará. Métodos: Se realizó una revisión de literatura sobre la referencia teórica de la educación basada en competencias, seleccionando artículos, directrices, documentos y modelos de currículos de escuelas médicas y entidades nacionales e internacionales involucradas en la enseñanza médica. Resultados: La revisión de la literatura evidenció dos modelos principales de currículo citados repetidamente en las referencias: ACGME (Accreditation Council for Graduate Medical Education) Milestones y CanMEDS (Canadian Medical Education Directions for Specialists) Framework. El Currículo Basado en Competencias enfatiza la enseñanza centrada en el alumno y utiliza un enfoque basado en resultados para la creación, implementación y evaluación de programas de educación médica, usando una estructura organizacional de competencias asignadas con actividades profesionales confiables, en forma de una matriz. La evaluación se hace a través del desempeño y resultados graduados en marcos de desarrollo. Para crear su propia matriz curricular, CanMEDS 2015 se adoptó como modelo porque fue aprobado por 12 organizaciones médicas canadienses y actualmente se utiliza como referencia en docenas de países, siendo el modelo más ampliamente aplicado en el mundo. Conclusión: Esperamos que esta revisión sirva de herramienta para que también otras Escuelas Médicas y sus respectivos Programas de Residencia puedan desarrollar sus propios Currículos Basados en Competencias.(AU)

Consumo de marihuana en estudiantes de medicina en Uruguay y su asociación con tabaquismo / Marijuana Use among Medical Students in Uruguay and its Association with Smoking

Objetivos: Evaluar la prevalencia de consumo de tabaco y cannabis entre estudiantes de medicina, asociación entre ambos consumos y conocimiento del abordaje de los mismos. Materiales y métodos: Se realizó un estudio descriptivo y analítico. Los estudiantes respondieron un cuestionario anónimo de autorreporte. Las variables fueron edad, sexo, consumo de tabaco, marihuana, frecuencia de consumo, instrucción en el abordaje de consumo de tabaco y THC y si consideran nocivo el consumo. Resultados: Consumieron tabaco en los últimos 12 meses el 29.6% y alguna vez en la vida 63.5%.Consumieron marihuana en los últimos 12 meses el 30.8% y alguna vez en la vida el 50%. Existió una asociación estadísticamente significativa entre consumo de tabaco y marihuana. Se encontró una relación estadísticamente significativa entre formación en marihuana y tabaco, y el consumo alguna vez en la vida. No se encontró relación entre formación y consumo en los últimos 12 meses, de marihuana ni tampoco de tabaco. No existió asociación estadísticamente significativa entre concepto de nocividad y consumo alguna vez. Conclusiones: A pesar del concepto de nocividad del consumo de marihuana en estudiantes de medicina es relativamente común. El consumo de tabaco podría predisponer al consumo de marihuana. Debemos insistir en la formación de los estudiantes de medicina en abordaje y manejo de los pacientes consumidores de marihuana.

Objectives: To assess the prevalence of tobacco and cannabis consumption among medical students, the association between tobacco/ cannabis use and the students' instruction in the management of tobacco/cannabis use. Materials and Methods: We conducted a descriptive, analytical study. The students answered an anonymous self-report questionnaire. The variables were: age, gender, tobacco and marijuana consumption, frequency of consumption, instruction in the management of tobacco and THC (tetrahydrocannabinol) use and whether they consider such consumption as harmful. Results: 29.6% of students consumed tobacco in the last 12 months, and 63.5% at least once in their lives. 30.8% consumed marijuana in the last 12 months, and 50% at least once in their lives. There was a statistically significant association between tobacco and marijuana consumption. We found a statistically significant relationship between the students' instruction in marijuana and tobacco and marijuana/tobacco consumption at least once in their lives. We didn't find any relationship between their instruction in marijuana and tobacco and marijuana/tobacco consumption in the last 12 months. There wasn't a statistically significant association between the concept of harmfulness and use of marijuana/tobacco at least once in their lives. Conclusions: Despite the concept of harmfulness related to the use of marijuana, it is relatively common among medical students. The use of tobacco could predispose the individual to use marijuana. We must insist on instructing medical students in how to approach and manage patients who consume marijuana.

Marijuana Use among Medical Students in Uruguay and its Association with Smoking

Objectives: To assess the prevalence of tobacco and cannabis consumption among medical students, the association between tobacco/ cannabis use and the students' instruction in the management of tobacco/cannabis use. Materials and Methods: We conducted a descriptive, analytical study. The students answered an anonymous self-report questionnaire. The variables were: age, gender, tobacco and marijuana consumption, frequency of consumption, instruction in the management of tobacco and THC (tetrahydrocannabinol) use and whether they consider such consumption as harmful. Results: 29.6% of students consumed tobacco in the last 12 months, and 63.5% at least once in their lives. 30.8% consumed marijuana in the last 12 months, and 50% at least once in their lives. There was a statistically significant association between tobacco and marijuana consumption. We found a statistically significant relationship between the students' instruction in marijuana and tobacco and marijuana/tobacco consumption at least once in their lives. We didn't find any relationship between their instruction in marijuana and tobacco and marijuana/tobacco consumption in the last 12 months. There wasn't a statistically significant association between the concept of harmfulness and use of marijuana/tobacco at least once in their lives. Conclusions: Despite the concept of harmfulness related to the use of marijuana, it is relatively common among medical students. The use of tobacco could predispose the individual to use marijuana. We must insist on instructing medical students in how to approach and manage patients who consume marijuana.

Síndrome neuroléptico maligno like

RESUMEN El síndrome neuroléptico maligno like o crisis acinética es una rara y potencialmente letal complicación del abandono de medicación de los pacientes con enfermedad de Parkinson. Se presenta el caso clínico de un paciente de sexo masculino de 52 años de edad, con antecedente de enfermedad de Parkinson de 10 años de evolución que se encuentra en tratamiento con levodopa-carbidopa. Acude a consultar por disminución del estado de conciencia y rigidez muscular generalizada, relacionado con el abandono de medicación 7 días antes del inicio de los síntomas.

ABSTRACT Neuroleptic malignant-like syndrome or akinetic crisis is a rare and potentially lethal complication of the withdrawal of medication of patients with Parkinson's disease. We present the clinical case of 52-year man with 10-year history of Parkinson's disease who is being treated with levodopa-carbidopa. He consults for decreased level of consciousness and general muscular rigidity, related to the withdrawal of the medication 7 days before the onset of symptoms.

Compromiso respiratorio en fumadores de marihuana / Respiratory commitment in marijuana smokers

RESUMEN La marihuana es la droga ilegal más consumida en el mundo. El objetivo de esta revisión es describir las consecuencias a nivel respiratorio de fumar marihuana, basado en estudios publicados recientemente. Los efectos de fumar cannabis sobre la mucosa respiratoria comprenden inflamación de la mucosa bronquial con mayor prevalencia de bronquitis aguda y crónica; alteración de las defensas antifúngicas y bacterianas de los macrófagos alveolares con predisposición a infecciones respiratorias. Los efectos sobre la función pulmonar y el cáncer broncopulmonar son discordantes. Los estudios concluyen que el consumo inhalado regular es perjudicial para la salud respiratoria y debería desaconsejarse

ABSTRACT Marijuana is the most commonly used illegal drug in the world. The aim of this review is to describe the respiratory-related consequences of smoking marijuana, based on recently published studies. The effects of cannabis smoking on the respiratory mucosa include inflammation of the bronchial mucosa with a higher prevalence of acute and chronic bronchitis; Alteration of the antifungal and bacterial defenses of the alveolar macrophages with predisposition to respiratory infections. The effects on lung function and bronchopulmonary cancer are discordant. Studies conclude that regular inhaled consumption is detrimental to respiratory health and should be discouraged.

De la teoría a la práctica en el manejo de las enfermedades intersticiales / From theory to practice in handling of interstitial diseases

Las EPID conforman un grupo de enfermedades muy diversas y de maravillosa complejidad, incluso para los expertos en dichas afecciones. Las doctoras Varela, Tabaj y colaboradores describen en el artículo "Manejo de las enfermedades intersticiales en Argentina: Una encuesta a neumonólogos" una encuesta a neumonólogos argentinos con el fin de evaluar la aceptabilidad y las dificultades de implementación de las guías y consensos propuestos para el diagnóstico y manejo de las enfermedades pulmonares intersticiales difusas (EPID). Los autores comparan también los resultados del trabajo con los obtenidos de una encuesta similar realizada en el año 2011 a propósito del consenso publicado el mismo año

Un caso excepcional de paracoccidioidomicosis e histoplasmosis pulmonares de presentación concomitante / Concomitant pulmonary paracoccidioidomycosis and pulmonary histoplasmosis: a rare case

La incidencia de las micosis pulmonares en Uruguay es muy baja, y estas usualmente aparecen en pacientes inmunocomprometidos. Se discute el caso de un paciente inmunocompetente proveniente de área rural, que presenta tos, disnea y fiebre de dos meses de evolución. La imagenología mostró una neumonitis extensa y fibrosis pulmonar. Los test micológicos directos, cultivo y serológicos muestran histoplasmosis y paraccocidioidomicosis en forma concomitante. El paciente presentó hipotensión arterial diagnosticándose una insuficiencia suprarrenal. A pesar de que la extensa fibrosis pulmonar y la neumonitis no fueron reversibles, el paciente mejoró clínicamente con el tratamiento antifúngico. Se trata de un caso excepcional de dos micosis pulmonares en un mismo paciente.

The incidence of pulmonary fungal infections is very low in Uruguay, and such infections typically affect immunocompromised patients. We report the case of an immunocompetent patient presenting with a two-month history of cough, dyspnea, and fever. The patient resided in a rural area. Imaging tests revealed extensive pneumonitis and pulmonary fibrosis. On the basis of direct mycological examination, culture, and serological testing, we made a diagnosis of concomitant histoplasmosis and paracoccidioidomycosis. The patient presented arterial hypotension that was diagnostic of adrenocortical insufficiency. Although the pulmonary fibrosis and pneumonia were irreversible, the clinical condition of the patient improved after antifungal treatment. This was an exceptional case of two pulmonary fungal infections occurring simultaneously in the same patient.

Tromboendarterectomía en hipertensión pulmonar tromboembólica crónica: reporte del primer caso clínico en Uruguay / Thromboendarterectomy in chronic thromboembolic pulmonary hypertension of the first clinical case report in Uruguay

La hipertensión pulmonar tromboembólica crónica (HPTEC) es una entidad subdiagnosticada y de alta morbimortalidad si no se accede a un tratamiento adecuado.El centellograma V/Q confirma la naturaleza tromboembólica de la hipertensión pulmonar (HP), pero es la arteriografía convencional el estudio que valora la topografía de los trombos y su accesibilidad a cirugía. El cateterismo cardíacoderecho confirma la HP, su severidad, y brinda parámetros de gran valor pronóstico. La HPTEC es la única etiología de hipertensión pulmonar con posibilidad de un tratamiento quirúrgico potencialmente curativo a través de la tromboendarterectomía pulmonar (TEE).Se reporta el primer caso de nuestro país de HPTEC tratada con TEE y evolución exitosa.

Chronic thromboembolic pulmonary hypertension ( CTEPH) is a delayed diagnosed disease with high morbidity and mortality, especially when untreated. Ventilation/perfusion lung scan confirms the thromboembolic etiology, but pulmonary angiography is still the gold standard diagnostic procedure for defining the extension and location of the disease and surgical indication. Right heart catheterization provides accurate prognostic and disease severity information. Pulmonary endarterectomy represents a potentially curative option in eligible patients.