Deep Vein Thrombosis and the Neurosurgical Patient

@#Background: Neurosurgical patients are varied, encompassing cranial and spinal diseases and trauma, and are admitted under both elective and emergency settings. In all settings, neurosurgery patients are at risk of deep vein thrombosis. D-dimer and ultrasound Doppler have long been good screening and confirmatory tools for the diagnosis of deep vein thrombosis (DVT). We conducted a study to identify the factors associated with DVT among neurosurgical patients, and the overall rate of occurrence at our centre. We aimed to also compare our results to the incidence in similar studies elsewhere in which more judicious use of pharmacological prophylaxis was undertaken. We also included the Well’s score to validate its usefulness in screening for DVT in our local setting. Methods: All patients admitted into our centre were screened for eligibility and those who underwent surgery from September 2016 to September 2017 had a D-dimer screening after surgery, followed by an ultrasound Doppler if the former was positive. The choice of anticoagulant therapy was not influenced by this study, and observation of the use was in keeping with usual practices in our centre was done. Results: A total number of 331 patients were recruited in this study, however, after the inclusion and exclusion criteria had been met, 320 patients remained eligible, i.e. suitable for analysis. The mean age of our patients was 46 years, with 66% being male patients. A majority of the cases in this study were cranial related, with only 5% being spine surgeries. On the multivariate analysis, the Well’s score and the number of days in bed remained statistically significant, after adjusting for age group, gender, ethnicity, type of central venous access and type of DVT prophylaxis with an adjusted odd’s ratio, and a confidence interval of 95%, and P < 0.05 for each. Conclusion: Well’s scoring and number of days in bed were independent factors affecting the rate of DVT in patients undergoing neurosurgical procedures in our centre.

Item analysis of the basic clinical skills assessment / Монголын Анагаах Ухаан

Introduction@#The clinical skills training at medical schools provides the opportunity for future medical doctors to deal with the client with proper care, diagnosis of the disease, first aid, treatment, nursing, treatment, counseling to address the complexity of the problem solving and the ethical attitude of the doctor. To achieve this objective, it is necessary to assess the level of knowledge, skills and attitudes students have acquired.@*Goal@#To analyze assignment of basic clinical skills assessment and to identify the level of кknowledge and skills students who have graduated second year medical program at “Ach” Medical University during 2016- 2017 academic year.@*Materials and Methods@#The study was used as a descriptive model to measure the reliability of the assignment, the difficulty factor of tasks, and the Hoffsten’s scores based on the tasks and performance of each station and compared with the indicators.@*Results@#Based on Hoffsten’s study on the success rate of examiners at the 5 stations, the Hoffsten’s score level of clinical examination was 68 percent, the physical examination station was 64 percent, the station’s diagnostic level was 71 percent, the laboratory was 70 percent and the nursing station was 70 percent.@*Conclusion@#At each clinical trial, the differential diagnosis of each individual clinical trial, clinical interview, nursing station and visual diagnostic station (DF> 95), at the laboratory and at the physical examination station, assess the student with a higher grade of difficulty factor (DF> 80) to the Hoffsten’s score of the basic clinical skills exam is set to be 70 percent.

Item analysis on graduate exam performance / Монголын Анагаах Ухаан

Introduction@#One of the quality assurance measurements for medical schools is the achievement of students who have graduated in the assessment of the knowledge, skills and attitudes they are trained in.@*Goal@#To analyze assignment of theoretical and practical exam and to identify the level of кknowledge students who have graduate at “Ach” Medical University during 2015-2016 academic year.@*Materials and Methods@#The study was conducted on a cross sectional and descriptive study through the based on the task of analyzing the 261 graduate students theoretical and practical exam performance of the bachelor degree in Medicine, Dentistry, Traditional Medicine and Nursing of Ach Medical University of Mongolia /AMU/ and was assessed and to identify a reliability coefficient, difficulty factor, discrimination index, Hoffsten’s score. @*Results@#The reliabiliy coefficient of graduate exam meets requirement when it’s 0.94-0.96. According to the analysis of the 300 test of the each classroom of graduates was 70 percent (n=202) with weak dicrimination index, difficallty factor was more than 50 percent too easy, The Hoffsten’s score to which exam was passed of Medical graduates is 70 percent, traditional medicine is 87 percent, dentistry is 79 percent, the nursing is a Hoffsten’s score was 80 percent.@*Conclusions @#The reliability coefficient the theoretical exam of the graduates’ knowledge is convenient for all occupations, and whole field examines the weak difficulty index (DI≤0) for all field examinations. The Hoffsten’s score is 70% above the medical field. Graduate assignments can not discriminate graduates’ knowledge and skills levels and the difficulty factor graduate examination was very easy.

Utilidad del índice de Rockall en pacientes con episodios de hemorragia digestiva alta no variceal / Utility of Rockall index in patients with upper non-variceal gastrointestinal bleeding episodes

INTRODUCCIÓN: por la alta mortalidad de pacientes con hemorragia digestiva alta, es necesario la utilización de sistemas pronósticos para el adecuado manejo de aquellos con alto riesgo de resangrar. OBJETIVO: evaluar la capacidad del índice de Rockall para predecir el riesgo de resangrado y mortalidad en el paciente con episodio de hemorragia digestiva alta de origen no variceal. MÉTODOS: estudio longitudinal, descriptivo y prospectivo entre diciembre de 2011 y junio de 2012. Se incluyeron 89 pacientes admitidos en el cuerpo de guardia del Hospital Militar Central "Dr. Carlos J. Finlay", con evidencia clínica de hemorragia digestiva alta, a quienes se les realizó una endoscopia dentro de las 24 h posteriores al ingreso. Se evaluaron parámetros demográficos (edad, género) y endoscópicos (hallazgos, terapéutica). Se aplicó el índice de Rockall y se evolucionó al paciente las 72 h siguientes al ingreso. Se realizó un análisis por curva de COR. RESULTADOS: hubo un predominio del sexo masculino (64/89; 71,9 %); la edad promedio fue de 63,6 años. El 26,0 % de los casos (n= 23) presentó un índice de Rockall alto, con una capacidad predictiva sobre la mortalidad (área bajo la curva de COR de 0,875) y el resangrado (área bajo la curva de COR de 0,757; p= 0,020). CONCLUSIONES: se confirma la utilidad del índice de Rockall para identificar a los pacientes con alto riesgo de fallecer y resangrar, lo que puede ser utilizado para el manejo del paciente con hemorragia digestiva no variceal.

INTRODUCTION: the use of prognostic systems is necessary for the proper management of those at high risk of bleeding again. OBJECTIVE: to evaluate the ability of the Rockall index for predicting the risk of rebleeding and mortality in patients with upper gastrointestinal bleeding episode of non-variceal origin. METHODS: a longitudinal, descriptive, prospective study was conducted in 89 patients who arrived with clinical evidence of upper gastrointestinal bleeding at ER of "Dr. Carlos J. Finlay" Central Military Hospital from December 2011 to June 2012. They underwent an endoscopy within 24 h after admission. Demographic parameters (age, gender) and endoscopic (findings, therapeutic) were evaluated. Rockall index was applied and patients were followed up 72 h after admission. COR curve Analysis was performed. RESULTS: there was a predominance of males (64/89, 71.91 %); the average age was 63.58 years. 26 % of cases (n= 23) had a higher rate of Rockall, with a predictive capacity for mortality (area under the ROC curve = 0.875) and rebleeding (area under the ROC curve = 0.757, p= 0.020). CONCLUSIONS: Rockall index utility is confirmed to identify patients at high risk of death and reindent, which can be used for the management of patients with non-variceal gastrointestinal bleeding.

Effectiveness of magnesium sulfate as initial treatment of acute severe asthma in children, conducted in a tertiary-level university hospital: A randomized, controlled trial / Eficacia del sulfato de magnesio como tratamiento inicial del asma aguda grave pediátrica: Estudio aleatorizado y controlado

Introduction. Magnesium sulfate is a calcium antagonist that inhibits bronchial smooth muscle contraction promoting bronchodilation. It is used for the management of acute severe asthma in children; however most of the studies have been performed in adults. Objective. To evaluate the effectiveness of intravenous magnesium sulfate for the treatment of pediatric patients with acute severe asthma exacerbations. Population and Methods. A clinical, randomized, controlled trial was conducted between March 2006 and March 2011 at Hospital Universitario Austral. Children with acute severe asthma admitted to the emergency department were randomized into two groups. Group A (control group): standard protocol for the initial treatment of acute asthma exacerbation. Group B: treatment protocol with magnesium sulphate for acute severe asthma exacerbation. The primary outcome was the requirement of invasive or non invasive mechanical ventilation support. Results. One hundred and forty three patients randomized into 2 groups were analyzed. The treatment group included 76 patients receiving magnesium sulfate within the first hour of the initiation of rescue treatment at the hospital, and the control group included 67 patients not treated with magnesium sulphate. Among the patients in the control group, 33% (n= 22) required mechanical ventilation support, compared to only 5% (n= 4) of the patients in the treatment group (p = 0.001). Conclusions. Intravenous infusion of magnesium sulfate during the first hour of hospitalization in patients with acute severe asthma significantly reduced the percentage of children who required mechanical ventilation support.

Introducción. El sulfato de magnesio es un antagonista del calcio que inhibe la contracción del músculo liso bronquial y favorece la broncodilatación. Se utiliza en el manejo del asma aguda grave en pediatría no obstante haber sido la mayoría de los estudios desarrollados en adultos. Objetivo. Evaluar la eficacia del sulfato de magnesio endovenoso para exacerbaciones graves de pacientes asmáticos pediátricos. Población y métodos. Se realizó un estudio clínico, controlado y aleatorizado, entre marzo de 2006 y marzo de 2011 en el Hospital Universitario Austral. Los pacientes con asma aguda grave admitidos en Emergencias se aleatorizaron en dos grupos. Grupo A: protocolo inicial estándar de exacerbación asmática aguda grave. Grupo B: protocolo de intervención con sulfato de magnesio de exacerbación asmática aguda grave. La variable principal de resultado fue la necesidad de soporte invasivo o no invasivo ventilatorio mecánico. Resultados. Se analizaron 143 pacientes aleatorizados en 2 grupos. El grupo de intervención de 76 pacientes que recibieron tratamiento con sulfato de magnesio dentro de la primera hora de iniciado el tratamiento de rescate en el hospital, y el grupo control testigo de 67 pacientes que no recibieron tratamiento con sulfato de magnesio. El 33% (n= 22) de los pacientes del grupo control requirió asistencia ventilatoria mecánica, en comparación con solo 4 (5%) de los pacientes del grupo intervención (p= 0,001). Conclusiones. El uso de sulfato de magnesio en infusión endovenosa en la primera hora de ingreso del paciente con asma aguda grave redujo significativamente el porcentaje de niños que requirieron asistencia ventilatoria mecánica.

Associação entre o escore de Sheldon e o teste de inclinação no diagnóstico de síncope vasovagal / Association between Sheldon?s score and tilt test in the diagnosis of vasovagal syncope

Introdução: Síncope é uma situação comum. Há diversas etiologias. A mais prevalente é a vasovagal (SVV). O teste de inclinação (TI) é o exame de maior acurácia no diagnóstico da SVV, mas de difícil realização. O escore de Sheldon (ES) é um questionário composto por variáveis clínicas que, através do escore de pontos, identifica pacientes com SVV. O ES é de fácil aplicação e tem alta sensibilidade e especificidade.Objetivo: Avaliar a associação entre o ES e o TI no diagnóstico de SVV.Material e métodos: Estudo transversal com pacientes consecutivos com um ou mais episódios de síncope, encaminhados para o TI. Responderam a um questionário padrão, ao ES e realizaram o TI. Considerou-se o TI como o padrão-áureo para o diagnóstico de SVV. Associou-se o resultado do TI com as diferentes pontuações do ES (positivo para =-2).Resultados: Estudamos 147 pacientes, sendo que 61 (61,8%) eram do sexo feminino e a média de idade foi de 42,3 anos (DP=22,4). Obteve-se 55 (37,4%) resultados positivos para o TI e ES. Dos TI negativo, 31,5% tiveram ES negativo. A probabilidade do ES em identificar TI positivo não foi significativa para =-2 (p=0,434). Quando o ES era positivo para =0; 62,2% dos pacientes com TI positivo tiveram ES positivo; dos pacientes com TI negativo, 64,4% tiveram ES negativo, tornando-se significativo (p=0,002, sensibilidade de 62,2%, especificidade de 64,4%).Conclusão: O ES é de fácil aplicação, de razoável sensibilidade e deve ser usado com o TI para identificação de pacientes com suspeita de SVV.

Risco cardiovascular pré e pós-terapia antirretroviral potente nospacientes com síndrome da imunodeficiência adquirida / Cardiovascular risk before and after highly active antiretroviral therapy in acquired immunodeficiency syndrome

JUSTIFICATIVA E OBJETIVOS: A terapia antirretroviral potente (HAART) nos pacientes com síndrome da imunodeficiência adquirida (SIDA), está associada à alterações metabólicas como dislipidemia, resistência insulínica, diabetes e obesidade visceral, fatores de risco relacionados à aterosclerose precoce. O objetivo deste estudo foi avaliar o incremento do risco cardiovascular estimado pelo escore de Framingham pré e pós-HAART, assim como a influência do tempo de tratamento, da idade, do sexo, da raça e da presença de lipodistrofia. MÉTODO: Foram avaliados 359 pacientes, através de dados secundários dos prontuários do Hospital Universitário da Universidade Federal de Mato Grosso do Sul (UFMS) e do Centro de Doenças Infecciosas e Parasitárias do município de Campo Grande - MS, referentes às variáveis sócio-demográficas, esquema terapêutico, tempo de tratamento e exames realizados. Para comparar as diferentes classes de antirretrovirais os pacientes foram distribuídos em quatro grupos: Grupo I igual zidovudina, lamivudinae inibidor da protease; Grupo II igual zidovudina, lamivudina e efavirenz ou nevirapina; Grupo III igual estavudina, lamivudina e efavirenz ou nevirapina e Grupo IV igual estavudina, lamivudina e inibidor da protease. RESULTADOS: Os achados deste estudo mostraram uma elevação de 1,85% no escore de Framingham. Doença arterial coronária foi diagnosticada em 13 pacientes. O risco foi mais significativo nos pacientes com idade entre 60 e 74 anos, no sexo masculino e nos pacientes com lipodistrofia. Diferença estatisticamente significativa não foi observada em relação ao tempo de exposição à medicação e à raça. O grupo IV apresentou maior incremento no risco cardiovascular quando comparado ao grupo II. CONCLUSÃO: A utilização da terapia antirretroviral nos pacientes com SIDA está associada ao aumento do risco para doença aterosclerótica coronária.

BACKGROUND AND OBJECTIVES: The highly active antiretroviral therapy (HAART) in patients with acquired immunodeficiency syndrome (AIDS) is associated with metabolic disorders such as dyslipidemia, insulin resistance, visceral obesity and diabetes, risk factors related to early atherosclerosis. The objective of this study was to evaluate the increase of the cardiac risk estimated to the Framingham's score before and after HAART, as well as the influence of the time of treatment, age, sex, race and presence of lipodystropy. METHOD: 359 patients were evaluated through the secondary data of handbooks of the University Hospital of Federal University of Mato Grosso do Sul (UFMS) and Center of Infectious and Parasitic Diseases of the city of Campo Grande - MS, concerning to the socio-demographic variables, treatment schedule, duration of treatment and examinations. To compare the different antiretroviral classes the patients had been distributed in four groups: Group I equal zidovudine, lamivudine and protease inhibitor; Group II equal zidovudine, lamivudine and efavirenz or nevirapine; Group III equal stavudine, lamivudine and efavirenz or nevirapine; and Group IV equal stavudine, lamivudine and protease inhibitor. RESULTS: The findings of this study had shown increase of 1.85% in Framingham's score, coronary artery disease was diagnosed in 13 patients. The risk was more significant in the age group from 60 to 74 years, in men and in patients with lipodistrophy. No statistically significant difference was observed in the time of exposure to medication and the race. Group IV presented higher increase in cardiovascular risk when compared to the Group II. CONCLUSION: The use of antiretroviral therapy in AIDS patients is associated with increased risk for coronary atherosclerotic disease.

Role of Clinical Stage, PSA and Gleason`s Score in Predicting Pathologic Outcome in Prostate Cancer / 대한비뇨기과학회지

Preoperative clinical staging in the prostate cancer does not always accurately predict the surgical-pathological outcome. We evaluated how the clinical staging, and other clinical parameters including preoperative PSA and Gleason`s score could reflect on the surgicopathological findings in 30 patients with prostate cancer, who underwent radical prostatectomy. Twelve of 24 patients with clinical T1 or T2 disease were understaged by clinical staging determined by digital rectal examination, bone scan, and radiologic studies including CT and MRI with endorectal coil. MRI with endorectal coil accurately reflected the extracapsular disease only in 59.1% of 22 patients studied. At the same time, it also showed low sensitivity (50%) with high specificity (100%) in detecting lymph node metastasis. Preoperative levels of PSA in patients with P2, P3, and N+ disease were 17.8 +/- 4.5, 47.9 +/- 11.3, 93.5 +/- 20.5ng/ml, respectively. The level of PSA was less than 20ng/ml in 9 of 12 patients with P2 disease, while they were greater than 20ng/ml in 9 of 12 patients with P3 disease. PSA may have a role to rule out lymph node metastasis when its level is less than 10ng/ml, although it did not reach the statistical significance because of small sample size. Gleason`s scores in patients with P2 disease were quite similar to those in patients with P3 disease (5.92 +/- 0.69 vs 5.67 +/- 0.56), whereas Gleason`s scores in all 6 patients with N+ disease were 9 or greater. Neoadjuvant hormonal therapy with LH-RH analogue and androgen receptor blocker for 1.5 to 3 months had no impact on the reduction of margin positivity or downstaging in 10 patients. PSA failure rate in patients with P2 and P3 disease was 25% at 1 year after operation. PSA is a good marker for differentiating between P2 and P3 disease (,p=0.0214) and can safely rule out N+ disease if its level is below 10ng/ml, while Gleason`s score may reflect the lymph node metastasis when it is 9 or greater (p=0.0012). Among the candidates for radical prostatectomy, selection of the patients on the basis of PSA and Gleason`s score might improve the surgical-pathological outcome.