Fibroma mole gigante vulvar: relato de caso / Giant soft vulvar fibroma: case report

Fibroma mole, ou pólipo fibroepitelial, é uma lesão de proporções geralmente reduzidas, de cor hiperpigmentada ou igual à da pele, localizando-se frequentemente na face, pescoço, tronco e regiões intertriginosas. É um tumor classificado como benigno e pode acometer tanto homens quanto mulheres em idade reprodutiva e depois da quarta década de vida. Ocorre principalmente em obesos, diabéticos e durante a gestação. Com menor frequência, podem alcançar dimensões que excedem 5 cm. Seu crescimento pode ser lento ou rápido e comumente são assintomáticos, mas podem promover sangramentos por conta de ulcerações decorrentes de traumas repetidos. Apresentamos neste relato um fibroma mole, gigante, de localização vulvar, com 11 cm de comprimento, 11 cm de largura e 5 cm de espessura, pesando 500 g.

Giant soft vulvar fibroma is a fibroepithelial polyp lesion with generally reduced proportions, with a hyperpigmented color or similar to that of the skin, frequently located on the face, neck, trunk and intertriginous regions. It is a tumor classified as benign, can affect both men and women, of reproductive age and after the fourth decade, mainly obese, diabetic and during pregnancy. However, less frequently, they can reach dimensions that exceed 5 cm, may have a slow or accelerated evolution. They are commonly asymptomatic, but bleeding may be present due to ulcerations resulting from repeated trauma. In the current study, we describe a giant soft fibroma with a vulvar location measuring 11 cm in length, 11 cm in width, 5 cm in thickness and weighing 500 grams.

Potencial quimiopreventivo de lipídios estruturados obtidos da Tributirina e Tricaprilina na fase de promoção da hepatocarcinogênese experimental / Chemopreventive potential of structured lipids obtained from Tributyrin and Tricaprylin in the promotion phase of experimental hepatocarcinogenesis

A quimioprevenção do câncer refere-se ao uso de compostos naturais ou sintéticos para prevenir o desenvolvimento das neoplasias antes do estabelecimento da malignidade. O ácido butirico (AB) atua como um potente quimiopreventivo na hepatocarcinogênese, reduzindo o número e o tamanho de lesões pré neoplásicas persistentes (pLPN), induzindo a apoptose e modulando mecanismos epigenéticos. Já o ácido caprílico (AC), além da sua atuação como potencializador de absorção, vem sendo investigado na área da prevenção do câncer. Neste cenário, o objetivo do trabalho visa avaliar a atividade quimiopreventiva de lipídios estruturados (EST) obtidos por interesterificação enzimática da tributirina com a tricaprilina, na fase de promoção da hepatocarcinogênese experimental. Após o processo de interesterificação, o produto final apresentou novos triacilgliceróis com composição de duas moléculas de ácido butírico para uma de ácido caprilíco. Ratos machos isogênicos da linhagem Fischer 344 foram submetidos ao modelo do hepatócito resistente, sendo distribuídos em dois grupos e tratados diariamente por via intragástrica com lipídios estruturados (EST) ou com o seu controle isocalórico, a maltodextrina (MD), durante a fase de promoção. Como esperado, não houve diferença estatística (p>0,05) em relação ao peso inicial e final dos animais dos grupos MD e EST, o que indica ausência de toxicidade dos compostos administrados. Na análise macroscópica do fígado, foi observada uma redução de 33,3% no grupo EST em relação ao número médio de nódulos macroscópicos em comparação ao grupo MD, porém essa redução não atingiu diferença estatística (p>0,05). Para a avaliação das lesões pré neoplásicas (LPN) foi utilizada a marcação imunoistoquímica para glutationa-S-transferase (GST-P). O grupo EST apresentou uma redução no número de lesões em remodelação e total GSTP-P+, quando comparado com o grupo MD (p<0,05). Quando avaliada a % de corpúsculos apoptóticos e índice de proliferação celular, não houve diferença estatística entre os grupos (p>0,05). Animais tratados com lipídios estruturados apresentaram maiores (p<0,05) concentrações de AC e AB por grama de tecido hepático em relação ao tratamento com maltodextrina. Em relação aos danos no DNA, o grupo EST resultou em cometas de comprimentos menores (p<0,05), menores níveis de γ-H2AX (p<0,05) e maiores concentrações de p53 nuclear, quando comparados aos animais que receberam maltodextrina, sugerindo uma proteção contra danos no DNA no grupo tratado com EST. Os resultados mostraram que o tratamento com EST resultou em ações efetivas na fase de promoção da hepatocarcinogênese experimental

Cancer chemoprevention refers to the use of natural or synthetic compounds to prevent the development of neoplasms before the establishment of malignancy. Butyric acid (AB) acts as a potent chemopreventive in hepatocarcinogenesis, reducing the number and size of persistent preneoplastic lesions (pLPN), inducing apoptosis and modulating epigenetic mechanisms. Caprylic acid (CA), in addition to its role as an absorption enhancer, has been investigated in the area of cancer prevention. In this scenario, the objective of this work was to evaluate the chemopreventive activity of structured lipids (EST) obtained by enzymatic interesterification of tributyrin with tricaprylin, in the phase of promotion experimental hepatocarcinogenesis. After the interesterification process, the final product presented new triacylglycerols with a composition of two molecules of butyric acid to one of caprylic acid. Isogenic male Fischer 344 rats were submitted to the resistant hepatocyte model, divided into two groups and treated daily intragastrically with structured lipids (EST) or with its isocaloric control, maltodextrin (MD), during the promotion phase. As expected, there was no statistical difference (p>0.05) in relation to the initial and final weight of the animals in the MD and EST groups, which indicates the absence of toxicity of the administered compounds. In the macroscopic analysis of the liver, a reduction of 33.3% was observed in the EST group in relation to the mean number of macroscopic nodules compared to the MD group, but this reduction did not reach a statistical difference (p>0.05). For the evaluation of pre-neoplastic lesions (PNL) immunohistochemical staining for glutathione-Stransferase (GST-P) was used. The EST group showed a reduction in the number of remodeling lesions and total GSTP-P+, when compared to the MD group (p<0.05). Animals treated with structured lipids had higher (p<0.05) concentrations of AC and AB per gram of liver tissue compared to treatment with maltodextrin. Regarding DNA damage, the EST group resulted in comets of shorter lengths (p<0.05), lower levels of γ-H2AX (p<0.05) and high concentration of nuclear p53, when compared to animals that received maltodextrin, suggesting protection against DNA damage in the EST treated group. The results showed that EST treatment resulted in effective actions in the promotion phase of experimental hepatocarcinogenesis

Protection of intestinal immune barrier against ischemia/reperfusion injury in a swine model using anisodamine hydrobromide

Abstract Intestinal ischemia/reperfusion (I/R) causes barrier impairment and bacterial influx. This study explored the protective effects of anisodamine hydrobromide (AH) on intestinal I/R injury caused by cardiopulmonary resuscitation (CPR) after cardiac arrest (CA). After successful CPR, minipigs were randomly divided into two groups (n = 8): saline and AH (4 mg/kg), and then treated with saline or AH via central venous injection, respectively. The same procedures without ventricular fibrillation initiation were conducted in the Sham group (n = 8). Levels of interferon gamma (IFN-γ) and interleukin 4 (IL-4) were measured at different time points (0, 0.5, 1, 2, 4, and 6 h) in serum and 6 h in gut associated lymphoid tissues (GALTs) after the return of spontaneous circulation (ROSC) to evaluate changes in the proportion of T-helper type 1 (Th1) and T-helper type 2 (Th2). Moreover, the positive culture rates of GALTs were examined to evaluate bacterial translocation. AH treatment markedly alleviated aberrant arterial blood gas and hemodynamics as well as intestinal macroscopic and morphological changes after CPR. Moreover, AH treatment significantly increased IFN-γ and decreased IL-4 in both serum and GALTs. Furthermore, AH treatment dramatically decreased positive bacterial growth in GALTs. AH treatment mitigated immunosuppression caused by intestinal I/R and protected the intestinal immune barrier against bacterial translocation, thereby reducing the risk of secondary intestinal infection

Características de idosos traumatizados hospitalizados em uma unidade de terapia intensiva / Characteristics of traumatized elderly people hospitalized in an intensive care unit

Introdução: o trauma é uma doença significativa em perda de anos de vida, contribuindo para alta morbidade e mortalidade. Seu evento em idosos pode ocasionar desfechos indesejáveis devido às condições fisiológicas do idoso. Objetivo: analisar as características e associação com o óbito de idosos traumatizados hospitalizados em uma unidade de terapia intensiva. Material e métodos: estudo transversal, com dados de prontuários de idosos hospitalizados por trauma em uma unidade de terapia intensiva geral. Foram incluídos pacientes com 60 anos ou mais de idade e admitidos por lesões. As variáveis coletadas relacionam-se às características sociodemográficas, da internação, de saúde, do trauma e do tratamento intensivo. Para identificação das principais características foi realizada análise descritiva, e para associação com o óbito foi realizado o teste de associação qui-quadrado. Resultados: observou-se predominância masculina (62,5%); idosos entre 60 e 79 anos (70,2%); com comorbidades (60,4%); politraumatizados (58,3%); trauma contuso (95,8%) tendo como principal causa externa as quedas (56,3%). A região do corpo mais afetada foi cabeça e pescoço (39,6%); e a gravidade do trauma foi leve (52,1%). Foram associados ao óbito a disfunção pulmonar (p=0,005), uso de nutrição enteral (p=0,027), drogas vasoativas (p=0,003) e ventilação mecânica (p<0,001). Conclusão: as informações sobre idosos hospitalizados por trauma em tratamento intensivo, sobretudo a observação de fatores associados ao óbito, são úteis para a composição de um perfil clínico capaz de direcionar para a assistência intensiva capaz de prevenir esse e demais desfechos indesejados durante a hospitalização.(AU)

Introduction: trauma is a significant disease in terms of loss of years of life, contributing to high morbidity and mortality. Its occurrence in the elderly can cause undesirable outcomes due to the physiological conditions of such a population. Objective: to analyze the characteristics and association with the death of traumatized elderly people hospitalized in an intensive care unit. Material and methods: cross-sectional study, with data collected from medical records of elderly hospitalized for trauma in a general intensive care unit. Patients aged 60 years' old and over, having been admitted for injuries, were included. The variables collected are related to sociodemographic, hospitalization, health, trauma, and intensive care characteristics. In order to identify the main characteristics, a descriptive analysis was performed. The chi-square association test was applied for the association with death. Results: the study presented predominance of male patients (62.5%); age ranging between 60 and 79 years' old (70.2%); with comorbidities (60.4%); polytrauma (58.3%); blunt trauma (95.8%) with falls being considered the main external cause (56.3%). The head and neck were the regions most frequently affected (39.6%), and the severity of the trauma being mild (52.1%). Lung dysfunction (p = 0.005), use of enteral nutrition (p = 0.027), vasoactive drugs (p = 0.003), and mechanical ventilation (p <0.001) were associated with death. Conclusion: information on elderly hospitalized for trauma in intensive care, especially the observation of factors associated with death, are useful for the composition of a clinical profile capable of guiding the patient to intensive care capable of preventing this and other undesirable outcomes during hospitalization.(AU)

Epidemiologia, complicações e fatores associados à doença crítica crônica em pacientes hospitalizados por trauma em unidade de terapia intensiva / Epidemiology, complications, and factors associated with chronic critical illness in patients hospitalized by trauma in an intensive care unit

A doença crítica crônica (DCC) descreve pacientes que sobreviveram ao episódio inicial de doença crítica, mas que permanecem dependentes da unidade de terapia intensiva (UTI) por períodos prolongados ou pelo resto de suas vidas. O presente estudo objetivou caracterizar pacientes traumatizados e hospitalizados na Unidade de Terapia Intensiva com Doença Crítica Crônica. Foram coletados dados de internações por trauma UTI no interior do Paraná de 2013 a 2016, dessa maneira, foi traçado o perfil epidemiológico e realizado associações e comparação dos grupos analisados (total de pacientes traumatizados hospitalizados em UTI em comparação com os pacientes traumatizados que desenvolveram DCC). Notou-se que dos 417 indivíduos traumatizados investigados, 41 (9,8%) foram classificados com DCC. Além disso, o sexo masculino, menor índice de comorbidades, maior gravidade do trauma e ferimentos contusos estiveram relacionados ao desenvolvimento da DCC. Os pacientes com DCC apresentaram complicações cirúrgicas (87,8%), e 41,5% evoluíram a óbito. Portanto, os pacientes com DCC permanecem por longo período na UTI (com uma média de 19,88 dias), os quais necessitam de cuidados intensivos de enfermagem e da equipe multiprofissional.(AU)

Chronic critical illness (CCI) describes patients who survived the initial episode of critical illness, but who remain dependent of the intensive care unit (ICU) for extended periods or for the rest of their lives. This study aimed at characterizing traumatized patients hospitalized in the Intensive Care Unit with Chronic Critical Illness. Data from ICU trauma hospitalizations in the interior of the state of Paraná were collected from 2013 to 2016, and with them, the epidemiological profile was drawn up, associations were made, and the analyzed groups were compared (total traumatized patients hospitalized in the ICU compared to traumatized patients who developed CCI). It was observed that from the 417 traumatized individuals investigated, 41 (9.8%) were classified as having CCI. In addition, it was observed that gender (male), a lower rate of comorbidities, greater severity of trauma, and blunt injuries were related to the development of CCI. Patients with CCI had surgical complications (87.8%), and 41.5% died. Therefore, CCI remain in the ICU for a long period (with an average of 19.88 days), which require intensive nursing care and the use of a multidisciplinary team.(AU)

Comportamiento del lesionado en el Hospital Universitario "General Calixto García" / Conduct of Injured Patients in General Calixto Garcia University Hospital

Introducción: En el mundo moderno, el traumatismo es la primera causa de mortalidad y discapacidad en menores de 35 años. Múltiples son los esfuerzos para tratar de definir su pronóstico desde el momento en que se produce. Con el decurso de los años se han creado varias escalas, para describir la gravedad de las lesiones, las alteraciones fisiológicas que se producen, así como para evaluar los sistemas de atención. Objetivo: Describir el comportamiento de los lesionados en el Hospital "Calixto García" según variables. Métodos: Se realizó un estudio observacional descriptivo, prospectivo y longitudinal en 1582 lesionados atendidos en el servicio de Cirugía General. Resultados: El intervalo trauma/ingreso superó los 60 minutos en un número elevado y la mitad de ellos presentó parámetros clínicos de inestabilidad hemodinámica en la recepción; se logró su compensación en la primera hora de admitidos en 7 de cada 10 lesionados. Más de la mitad desarrolló alguna complicación y predominó la estadía hospitalaria entre 15 y 21 días. Conclusiones: Algunas de las variables estudiadas se comportaron similar a la literatura consultada. Los resultados sugieren la necesidad de implementar un programa de atención prehospitalaria al lesionado más efectivo para mejorar la atención y el índice de sobrevida en los mismos(AU)

Introduction: In the modern world, trauma is the leading cause of death and disability in people under 35 years of age. Multiple efforts are made to define its prognosis from the moment it occurs. Over the years, several scales have been created to describe the severity of injuries, the physiological changes that occur, as well as to assess care systems. Objective: To describe the behavior of injured patients in Calixto García Hospital according to variables. Methods: A observational, descriptive, prospective and longitudinal study was carried out with 1582 injured patients treated in the general surgery service. Results: The trauma/admission interval exceeded sixty minutes in a high number of cases. Half of them presented clinical parameters of hemodynamic instability at admission. Compensation was achieved at the first hour of admission in seven out of ten injured patients. More than half the patients developed some complication. There was a predomination of hospital stay between 15 and 21 days. Conclusions: Some of the variables studied behaved similarly to the way described in the consulted literature. The results suggest the need to implement a more effective prehospital care program for the injured patients to improve care and survival rate(AU)

Retrospective study of polytrauma patients's medical records that presented abdominal trauma, comperad to abdominal trauma and extra-abdominal injuries

This study sought to retrospectively assess the relationship between intra and extra-abdominal injuries in polytrauma patients undergoing laparotomy at the Regional University Hospital of Maringá between 2017 and 2018.This study was based on 111 electronic medical records from the Brazilian public health system "SUS", admitted to the hospital due to trauma and undergoing laparotomy, comparing two groups: abdominal injury without extra-abdominal injury (WoEI) and abdominal injury with extra-abdominal injury (WiEI).A total of 111 medical records were analyzed, 57 from 2017 and 54 from 2018. Of these 111records, 43 (39%) were trauma victims with only abdominal injuries and 68 (61%) trauma victims with abdominal and extra-abdominalinjuries. Most patients were male (85%), with an average age of 33 years, ranging from 14 to 87 years. In statistical analysis, according to the T-test, there was significance (p > 0.05) between the WoEI and WiEI groups for data collected regarding death rates and hospitalization days. As for the morbidity rate and difference between genders (male and female), there was no statistical significance (p < 0.05).Polytraumapatients are exposed to greater kinetic energy, with more severe conditions and therefore required more in-hospital care.

Coagulopatía asociada al trauma en la Unidad de Cuidados Intensivos / Trauma associated coagulopathy in the Intensive Care Unit / Coagulopatia associada a trauma em Unidade de Terapia Intensiva

Resumen: Introducción: la enfermedad traumática es un problema de salud mundial. La coagulopatía asociada al trauma (CAT) constituye una complicación grave, multifactorial y de diagnóstico controversial. Objetivos: valorar la incidencia de CAT, los factores asociados a su desarrollo y su asociación con el pronóstico, en una serie de pacientes traumatizados ingresados a la Unidad de Cuidados Intensivos de nuestro hospital. Pacientes y métodos: estudio prospectivo de todos los pacientes ingresados con diagnóstico de trauma grave a la UCI. Se definió CAT en base a los parámetros clásicos de laboratorio, por la presencia de al menos uno de: INR mayor a 1,3, plaquetopenia menor a 100.000/mm3, y/o aPTT mayor a 38 segundos. Las variables continuas se expresaron como la media ± desvío estándar. Se realizó análisis de chi cuadrado, test exacto de Fisher y regresión logística binaria para estudiar la asociación entre las variables. Se consideró significativo un valor p < 0,05. Resultados: se analizaron 103 pacientes, con media de edad de 33 años y predominio de sexo masculino. Se encontró CAT en 42 pacientes (40,8%), presentándose al ingreso hospitalario en la mayoría de los casos. Los factores de riesgo asociados a CAT fueron: gravedad al ingreso, shock, hipoperfusión, acidosis, transfusión masiva, sangrado significativo (estudio univariado), así como trauma penetrante y disfunción multiorgánica (estudio multivariado). No se encontró asociación significativa entre CAT y mortalidad. Conclusiones: presentamos el primer reporte de este tema en nuestro medio. En nuestra población la CAT es frecuente y se presenta ya al ingreso hospitalario. Se relaciona con la gravedad y el tipo de trauma. Su diagnóstico precoz es clave en el manejo de los pacientes con trauma grave.

Abstract: Introduction: trauma is a global health problem. Trauma-associated coagulopathy constitutes a severe and multifactorial complication whose diagnosis is controversial. Objectives: to assess the incidence of trauma-associated coagulopathy, the factors associated to the development of this condition and their impact on prognosis in a series of trauma patients admitted into the intensive care unit of our hospital. Method: prospective study of all patients admitted to the ICU with a diagnosis of acute trauma. Trauma-associated coagulopathy was defined according to classical laboratory parameters, when it complies with one of the following: International normalized ratio (INR) greater than 1.3, thrombocytopenia smaller than 100000/mm3, and/or aPTT greater than 38 seconds. Continuous variables were expressed as the average ± standard deviation. The chi square analysis, Fisher exact test and binary logistic regression were performed, p < 0,05 being considered significant. Results: 103 patients were analysed, average age was 33 years old and they were mostly male. Trauma-associated coagulopathy was found in 42 patients (40.8 %), and it was seen in most patients at the time they were hospitalized. Risk factors of trauma-associated coagulopathy were the following: severity upon hospitalization, shock, hypoperfusion, acidosis, massive transfusion, significant bleeding (univariate analysis); penetrating trauma and multi-organ dysfunction (multivariate analysis). No significant association between trauma- associated coagulopathy and mortality was found. Conclusions: the study presents the first report on this topic in our country. Trauma associated coagulopathy is rather common in our population and it is seen upon hospitalization. This condition is related to severity and the kind of trauma. Early diagnosis is essential in the handling of patients with severe trauma.

Resumo: Introdução: as doenças traumáticas são um problema de saúde global. A coagulopatia associada a trauma (TAC) é uma complicação diagnóstica séria, multifatorial e controversa. Objetivos: avaliar a incidência de TAC, os fatores associados ao seu desenvolvimento e sua associação com o prognóstico, em uma série de pacientes com trauma internados na Unidade de Terapia Intensiva do Hospital Maciel em Montevidéu, Uruguai. Pacientes e métodos: estudo prospectivo de todos os pacientes admitidos na UTI com diagnóstico de trauma grave. A TAC foi definida com base nos parâmetros laboratoriais clássicos, pela presença de pelo menos um dos seguintes: coeficiente internacional normalizado - INR maior que 1,3, trombocitopenia menor que 100.000 / mm3 e / ou PTTa maior que 38 segundos. As variáveis contínuas foram expressas como média ± desvio padrão. A análise do qui-quadrado, o teste exato de Fisher e a regressão logística binária foram realizados para estudar a associação entre as variáveis. Um valor de p <0,05 foi considerado significativo. Resultados: foram analisados 103 pacientes, com média de idade de 33 anos e predomínio do sexo masculino. A TAC foi encontrada em 42 pacientes (40,8%), apresentando-se na admissão hospitalar na maioria dos casos. Os fatores de risco associados à TAC foram: gravidade na admissão, choque, hipoperfusão, acidose, transfusão massiva, sangramento significativo (estudo univariado); bem como trauma penetrante e disfunção de múltiplos órgãos (estudo multivariado). Nenhuma associação significativa foi encontrada entre CAT e mortalidade. Conclusões: apresentamos o primeiro relatório sobre o tema em nosso meio. Em nossa população, a TAC é frequente e já está presente na admissão hospitalar. Está relacionado à gravidade e ao tipo de trauma. Seu diagnóstico precoce é fundamental no manejo de pacientes com traumas graves.

Reporte de caso. Uso de toxina botulínica tipo A para la reparación de hernia ventral gigante planeada / Surgical treatment of diabetic foot based on Wagner classification, Case report

Introducción: La incidencia de eventración post quirúrgica es del 2-20%, se da mayormente en pacientes con factores de riesgo durante los primeros tres años posteriores a la cirugía inicial. La mayoría de las hernias de la pared abdominal pueden ser reparadas fácilmente, sin embargo, las hernias gigantes (>10cm de diámetro) o aquellas con pérdida de domicilio requieren métodos de expansión gradual de la pared abdominal pre y/o transoperatoriamente. Se ha descrito que posterior a la aplicación de toxina botulínica serotipo A (TBA) de forma bilateral en la pared abdominal, los defectos disminuyen clínica y tomográficamente hasta 5.25cm, por su efecto selectivo en terminaciones nerviosas periféricas colinérgicas, provocando atrofia muscular sin fibrosis. El efecto máximo ocurre al mes de la aplicación y dura 28 semanas. Esta técnica permite planear preoperatoriamente la magnitud de la cirugía. Nuestro caso, paciente masculino de 33 años. Quien ingresa por politrauma. Se realiza procedimiento quirúrgico abdominal y posteriormente se eviscera en múltiples ocasiones. Se cierra herida y posteriormente desarrolla hernia ventral gigante con la que egresa. Se realiza TC abdominal evidenciando defecto herniario de 15.9cm, con este resultado se aplica toxina botulínica serotipo A en la pared abdominal bilateral (50 unidades en cada lado) guiado por ultrasonido. 25 días después se realiza TC abdominal control que evidencia defecto herniario de 14.7cm y se decide ingreso para cirugía electiva. Se decide llevar a sala de operaciones donde se realiza hernioplastía con liberación de componentes anteriores mas colocación de malla de polietileno (cuatro semanas posteriores a la aplicación de la toxina), quedando defecto totalmente cerrado y sin tensión. Paciente con adecuada evolución posterior a intervención por lo que egresa. Actualmente sin defecto herniario recurrente. Conclusión: El uso de toxina botulínica serotipo A es un nuevo recurso prequirúrgico para la preparación de pacientes con hernias ventrales gigantes, ya que permite el cierre sin tensión en la mayoría de los casos. Además, ayuda a que transoperatoriamente la separación de componentes se realice de una mejor manera, ya que se da mejor manipulación al momento de desplazar las estructuras musculares. Idealmente se debe de realizar la intervención quirúrgica cuatro semanas posteriores a su aplicación. (AU)

ntroduction: The incidence of post-surgical eventration is 2-20%, it occurs mostly in patients with risk factors during the first three years after the initial surgery. Most abdominal wall hernias can be easily repaired, however, giant hernias (>10cm of diameter) or those with the loss of domain require methods of gradual expansion of the abdominal wall pre or intraoperatively. It has been described that after the application of botulinum toxin A bilaterally in the abdominal wall, the defect can decrease clinically and tomographically up to 5.25cm, due to its selective effect on cholinergic peripheral nerve endings, that cause muscle atrophy without fibrosis. The maximum effect occurs one month after the application and lasts 28 weeks. This technique allows to plan preoperatively the magnitude of the surgery. Description of case: A 33 year old male patient, who entered the emergency room due to polytrauma. Abdominal surgical procedure was performed and later he eviscerates on multiple occasions. The wound was closed and later he develops a giant ventral hernia with which it is discharged. An abdominal CT was performed, showing a hernia defect of 15.9cm. With this result botulinum toxin A was applied guided by ultrasound bilaterally in the abdominal wall (50 U on each side). A control abdominal CT was performed after 25 days, which it revealed a hernia defect of 14.7 cms, so admission was decided for elective surgery. The patient was taken to the operating room where a hernioplasty with anterior components separation plus the placement of a polyethylene mesh was performed (four weeks after the application of the botulinum toxin A), the hernia defect was completely close without tension. The patient had an adequate post-surgical evolution for which it was discharge. Currently without a recurrent hernia defect. Conclusion: The use of botulinum toxin A is a new pre-surgical resource for the preparation of patients with giant ventral hernias, since it allows the closure without tension in most cases. In addition, it helps transoperatively with the components separation, since there is a better manipulation at the time of displacing the muscular structures. Ideally, the surgical intervention should be performed four weeks after its application. (AU)

Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! / Control de Daños Prehospitalario: ¡Para Los Cristaloides, Para La Hipotermia Y…! ¡Para El Sangrado!

Abstract Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

Resumen La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.

Whole blood for blood loss: hemostatic resuscitation in damage control / Sangre total: la nueva alternativa en la resucitación hemostática

Abstract Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

Resumen El choque hemorrágico y sus complicaciones son la principal causa de muerte en los pacientes con trauma. La resucitación en control de daños ha demostrado una disminución en la mortalidad y mejoría en el manejo del paciente. La resucitación hemostática consiste en la recuperación del volumen con hemoderivados como glóbulos rojos, plasma, crioprecipitado y plaquetas, en proporciones de 1:1:1:1. Sin embargo, esta demanda de hemo componentes podría no aplicarse para toda Latinoamérica u otros países de medianos y bajos ingresos. Las principales barreras para la implementación de esta estrategia serían la escasa disponibilidad de bancos de sangre y de hemoderivados insuficientes para contar con un protocolo de transfusión masiva. Una propuesta para superar estas barreras es el uso de sangre total fresca fría para la resucitación hemostática de los pacientes exsanguinados. Ecuador ha sido pionero en la implementación de esta estrategia con una experiencia ya de seis años, en que han demostrado que la sangre total tiene ventajas sobre la terapia de hemo componentes incluyendo, pero no limitando, la trasfusión de sangre con una razón fisiológica de componentes, fácil transporte y transfusión, menor volumen de anticoagulantes y aditivos trasfundidos al paciente, y menor exposición a donantes. La sangre total es una herramienta con un potencial reemergente que puede ser implementado en centros de trauma civil con óptimos resultados y menor demanda técnica.

Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient / La Tomografía Computarizada Corporal Total es una herramienta segura, efectiva y eficiente en el paciente politraumatizado con inestabilidad hemodinámica

Abstract Trauma is a complex pathology that requires an experienced multidisciplinary team with an inherent quick decision-making capacity, given that a few minutes could represent a matter of life or death. These management decisions not only need to be quick but also accurate to be able to prioritize and to efficiently control the injuries that may be causing impending hemodynamic collapse. In essence, this is the cornerstone of the concept of damage control trauma care. With current technological advances, physicians have at their disposition multiple diagnostic imaging tools that can aid in this prompt decision-making algorithm. This manuscript aims to perform a literature review on this subject and to share the experience on the use of whole body computed tomography as a potentially safe, effective and efficient diagnostic tool in cases of severely injured trauma patients regardless of their hemodynamic status. Our general recommendation is that, when feasible, perform a whole body computed tomography without interrupting ongoing hemostatic resuscitation in cases of severely injured trauma patients with or without signs of hemodynamic instability. The use of this technology will aid in the decision-making of the best surgical approach for these patients without incurring any delay in definitive management and/or increasing significantly their radiation exposure.

Resumen El trauma es una compleja patología que requiere un equipo experimentado y multidisciplinario con una capacidad para la toma de decisiones Oportuna ya que en unos pocos minutos pueden representar la diferencia entre la vida y la muerte. Estas decisiones deben ser precisas para ser capaces de priorizar y controlar eficientemente las lesiones que puedan estar causando el compromiso hemodinámico. En esencia, este es el punto clave del concepto de control de daños en la atención del trauma. Con los nuevos avances tecnológicos, el equipo médico tiene a disposición múltiples herramientas imagenológicas de diagnóstico. Este artículo presenta una revisión de la literatura y descripción de la experiencia local con el uso de la tomografía corporal total como una herramienta diagnostica potencialmente segura, efectiva y eficiente en casos de pacientes con trauma severo sin importar su estado hemodinámico. La recomendación general, cuando sea posible, es que se debe realizar una tomografía corporal total sin interrumpir las maniobras de resucitación hemostática en casos de pacientes severamente traumatizados con o sin signos de inestabilidad hemodinámica. El uso de esta tecnología tiene como objetivo tomar decisiones pertinentes y definir el mejor abordaje quirúrgico para el paciente sin incurrir en tardanzas en el manejo definitivo o incrementar el tiempo de exposición a la radiación.

REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients / El REBOA como nuevo actor en el control de daños del paciente hemodinámicamente inestable con hemorragia no compresible del torso

Abstract Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.

Resumen La hemorragia no compresible del torso es una de las principales causas de muerte prevenibles alrededor del mundo. Una evaluación eficiente y apropiada del paciente traumatizado con hemorragia activa es la esencia para evitar el desarrollo del rombo de la muerte (hipotermia, coagulopatía, hipocalcemia y acidosis). Actualmente, las estrategias de manejo inicial incluyen hipotensión permisiva, resucitación hemostática y cirugía de control de daños. Sin embargo, los recientes avances tecnológicos han abierto las puertas a una amplia variedad de técnicas endovasculares que logran esos objetivos con una morbilidad mínima y un acceso limitado. Un ejemplo de estos avances ha sido la introducción del balón de resucitación de oclusión aortica; REBOA ( Resuscitative Endovascular Balloon Occlusion of the Aorta , por sus sigla en inglés ), el cual, ha tenido gran provecho entre los cirujanos de trauma alrededor del mundo debido a su potencial y versatilidad en áreas como trauma, ginecología y obstetricia, y gastroenterología. El objetivo de este artículo es describir la experiencia lograda en el uso del REBOA en pacientes con hemorragia no compresible del torso. Nuestros resultados muestran que el REBOA puede usarse como un nuevo actor en la resucitación de control de daños del paciente con trauma severo, para este fin, nosotros proponemos dos nuevos algoritmos para el manejo de pacientes hemodinámicamente inestables: uno para trauma cerrado y otro para trauma penetrante. Se reconoce que el REBOA tiene sus limitaciones, las cuales incluye un periodo de aprendizaje, su costo inherente y la disponibilidad. A pesar de esto, para lograr los mejores resultados con esta nueva tecnología, el REBOA debe ser usado en el momento correcto, por el cirujano correcto con el entrenamiento y el paciente correcto.

Experiencia en la práctica clínica real de la efectividad y la tolerabi- lidad de tapentadol de liberación prolongada para el tratamiento de dolor crónico postraumático producido por accidentes de trabajo / Real-world clinical practice experience of the effectiveness and tolerability of pro- longed-release tapentadol for the treatment of chronic post-traumatic pain caused by occupational accidents

Se llevó a cabo un estudio observacional para analizar si tapentadol de liberación prolongada (LP) puede considerarse un tratamiento de primera línea para pacientes con dolor crónico postraumático (DCPT). Métodos: Se presenta una serie de casos de la práctica clínica real de pacientes con DCPT producido por accidentes de trabajo. Antes de ingresar al estudio, todos los pacientes recibían tramadol, que se interrumpió cuando se inició la administración de tapentadol LP. Las evaluaciones de dolor incluyeron una escala de valoración numérica, el cuestionario DN4 y la escala de Impresión Global de Cambio del Paciente (PGIC, Patients' Global Impression of Change). Se recuperaron y registraron los eventos adversos. Resultados: 94 pacientes participaron en el estudio y 77 (82 %) completaron todas las visitas predefinidas. Cerca de la mitad de los pacientes informaron dolor crónico que tenía una duración de al menos 3 años; se observó un componente neuropático en el 87 % de los pacientes. El puntaje de dolor se redujo en 1,5 puntos luego del primer mes de tratamiento con tapentadol LP y en 2,48 puntos luego de 4 meses (p<0,05). También se asoció la administración de tapentadol LP con una reducción del 28,9 % de la dosis concomitante de pregabalina (p<0,01). De acuerdo con el cuestionario PGIC, el 74 % y el 77,9 % de los pacientes informó mejoría luego de uno y cuatro meses de tratamiento, respectivamente. El perfil de seguridad fue consistente con los datos actuales sobre tapentadol LP. Conclusión: El dolor osteomuscular crónico es una enfermedad prevalente que se caracteriza por tener resultados terapéuticos deficientes y se asocia a una mayor discapacidad y una mala calidad de vida. En este estudio de la práctica clínica real en pacientes que trabajan y que cuentan con un componente de dolor neuropático elevado, se observó que tapentadol LP produce efectos beneficiosos en términos del control del DCPT, y se obtuvieron índices altos de eficacia y seguridad.

An observational study was carried out to analyze whether prolonged-release (PR) tapentadol may be considered a first-line treatment for patients with chronic post-traumatic pain (PTD). Methods: A case series of cases of patients with PTFE caused by work accidents in a real clinical practice setting is described. Before entering the study, all patients were receiving tramadol, which was discontinued when PR tapentadol was started. Pain assessments included a numerical rating scale, the DN4 questionnaire, and the Patients' Global Impression of Change (PGIC) scale. Adverse events were retrieved and described. Results: 94 patients participated in the study and 77 (82%) completed all the predefined visits. About half of the patients reported chronic pain that lasted for at least 3 years. A neuropathic component was reported in 87% of patients. The pain score was reduced by 1.5 points after the first month of treatment with PR tapentadol and by 2.48 points after 4 months (p < 0.05). Administration of PR tapentadol was also associated with a concomitant reduction of pregabalin dose of 28.9% (p < 0.01). According to the PGIC questionnaire, 74% and 77.9% of patients reported improvement after one and four months of treatment, respectively. The safety profile was consistent with current data on PR tapentadol. Conclusion: Chronic musculoskeletal pain is a prevalent disease characterized by poor therapeutic results and associated with increased disability and poor quality of life. In our study in a real clinical practice setting with patients with a high neuropathic pain component, PR tapentadol produced beneficial effects in terms of DCPT control, and high efficacy and safety rates were obtained. Keywords: tapentadol, chronic pain, pain caused by work accidents, chronic post-traumatic pain, evidence from real clinical practice.

Major trauma and severe burn: a synergistic mortality: case report and literature review / Traumatismo grave y quemadura severa: una mortalidad sinérgica: reporte de un caso y revisión bibliográfica

CASE PRESENTATION: A 42-year-old man was transferred to our institution after a highenergy accident (an explosion). He presented second-degree burns on 20% of the total body surface area (TBSA), affecting the lower hemiabdomen and the lower right limb. He also presented a supraintercondylar open fracture of the right femur (Gustilo I). The burns were treated with debridement and coverage withmesh graft, while the fracture required an early transitory transarticular external fixation with delayed definitive osteosynthesis. Our patient presented good local and systemic evolution. We can offer a eleven-month follow-up. DISCUSSION: The literature supports that the combination of trauma and burn injuries is a relatively rare pattern, which may explain the lack of knowledge and studies on this subject. This double injury has demonstrated a synergistic effect on mortality. The management of soft tissues in the coexistence of an open fracture and a burn in the same limb is a challenge. The method and timing of the treatment of the fracture directly impacts the treatment of the burn (and vice versa), and most authors tend to treat the fracture first. All of the studies reviewed emphasized the importance of the multidisciplinary approach. CONCLUSIONS: We have presented a complex case combining major trauma and severe burns. Although there is a lack of studies in the literature on this subject, the papers state that this is an unusual pattern with a synergistic effect on mortality. In our experience, the management of soft tissues and the multidisciplinary approach play a central role, as it is also stated in the literature. The management of these patients is still controversial, and more studies are needed.

PRESENTACIÓN DEL CASO: Hombre de 42 años trasladado a nuestra institución tras un accidente de alta energía (explosión). Presentaba quemaduras de segundo grado del 20% de la superficie corporal total (SCT), afectando el hemiabdomen inferior y la extremidad inferior derecha. También presentaba una fractura abierta supraintercondílea de fémur derecho (Gustilo I). Las quemaduras fueron tratadas mediante desbridamiento y cobertura mediante injerto mallado, mientras que la fractura requirió un fijador externo transarticular precoz de forma transitoria con una osteosíntesis definitiva diferida. Nuestro paciente presentó buena evolución local y sistémica. Podemos ofrecer un seguimiento a 11 meses. DISCUSIÓN: La bibliografía defiende que la lesión combinada de traumatismo y quemadura es un patrón relativamente raro, pudiendo explicar la falta de conocimiento y publicaciones al respecto. Este doble insulto ha demostrado un efecto sinérgico en la mortalidad. El manejo de las partes blandas cuando coexisten una fractura abierta y una quemadura en la misma extremidad es un desafío. El método y el momento de tratamiento de la fractura impactan de forma directa en el tratamiento de la quemadura (y viceversa); y la mayoría de los autores tienden a tratar en primer lugar la fractura. Todos los estudios analizados enfatizan la importancia del abordaje multidisciplinario. CONCLUSIONES: Hemos presentado un caso complejo combinando traumatismo grave y quemaduras severas. Aunque haya una falta de bibliografía, los estudios afirman que se trata de un patrón inusual con un efecto sinérgico sobre la mortalidad. En nuestra experiencia, el manejo de las partes blandas y el abordaje multidisciplinario tienen un rol central, tal y como defienden también los artículos publicados. El manejo de estos pacientes sigue siendo controvertido, y son necesarios más estudios.

Forensic Analysis of 72 Cases with Multiple Organ Dysfunction Syndrome Caused by Traffic Accidents / 法医学杂志

Objective To investigate the epidemiological and forensic characteristics of multiple organ dysfunction syndrome （MODS） after severe trauma and explore the reference indexes for determining traumatic MODS. Methods In terms of the number of organs or systems involved in MODS, the number of failures of each organ or system, the first failing organ and the survival time after organ failure, 72 cases of MODS death caused by traffic accidents were retrospectively analyzed. The cases were divided into two groups according to the mean injury severity score （ISS）. The t test was used to analyze the differences in the number of organs or systems involved in MODS in the two groups. Chi-square test was used to analyze the differences in the types of first failing organs and the differences between the two groups in the number of cases of organ or system failure involved in MODS. Wilcoxon signed-rank test was used to analyze the differences between the two groups in survival time of MODS after trauma. Kaplan-Meier survival curve was drawn and Log-Rank test was performed. Results The number of MODS involved organs or systems after trauma in ISS≤35 group was 3-5, and 2-4 in the ISS>35 group （P<0.05）. The cases of MODS organ or system failure after trauma occurred more in brain and lung in the two groups. The first failing organ after trauma was mainly the lung or kidney. The median time of first organ failure after trauma was 2.00 d, the median survival time of MODS after trauma in ISS≤35 group was 6.00 d, and 2.33 d in ISS>35 group （P<0.05）. The survival curve of ISS≤35 group was relatively high and declined gradually, while the survival curve of ISS>35 group was relatively low and the decline was steep （P<0.05）. Conclusion The epidemiological and forensic characteristics of MODS caused by traffic accidents have certain specificity. The ISS and the forensic characteristics of MODS at ISS>35 can be used as reliable reference indexes for evaluation of the causal relationship among trauma, MODS and death.

Triple open dislocation in the index finger of the hand without a high-energy trauma / Triple luxación abierta del segundo dedo de la mano tras traumatismo de baja energía

A simultaneous double dislocation (both proximal [PIP] and distal [DIP] interphalangeal joints) of a triphalangeal finger is a rare entity. The most common hand affected is the right hand. In the case of a closed triple dislocation (metacarpophalangeal [MCP], PIP and DIP joints); there are only two cases in the literature revised. In this case, we report an open triple dislocation in the index finger of the left-hand of a 54-year-old man treated by closed reduction and 3 weeks of immobilization followed by active mobilization with satisfactory results.

La luxación simultánea de las articulaciones interfalángicas proximal (IFP) y distal (IFD) de un dedo de tres articulaciones es una rara entidad. La mano que es afectada con más frecuencia es la derecha. Con relación a una triple luxación cerrada (articulación metacarpofalángica [MCF], IFP e IFD), sólo hay descritos dos casos en la literatura revisada. En este caso, describimos una triple luxación abierta del segundo dedo de la mano en un varón de 54 años de edad tratada mediante reducción cerrada,e inmovilización durante 3 semanas seguida de movilización activa supervisada, con resultado final satisfactorio.

Síndrome de fournier: ações do enfermeiro, uma revisão literária / Fournier syndrome: nurse's actions, a literary review / Síndrome de fournier: acciones de enfermera, una revisión literaria

A Síndrome de Fournier é um processo infeccioso severo que atinge os tecidos moles com avanço acelerado, possui etiologia polimicrobiana, com presença predominante de micro-organismos aeróbicos e anaeróbicos gram positivos e negativos. A finalidade deste trabalho é identificar por meio de revisão bibliográfica o conhecimento e atuação do enfermeiro sobre a síndrome de founier para que a sistematização de enfermagem seja executada de uma forma eficaz, prestando um atendimento eficiente ao paciente. Foi realizada revisão literária entre os anos de 2009 a 2019. Foram enfatizados a aplicabilidade da sistematização da assistência de enfermagem no tratamento, diagnóstico, complicações de acordo com a atuação do enfermeiro. Verificou-se que o tratamento incluiu a antibioticoterapia de amplo espectro e a cobertura mais indicada e utilizada foi à papaína. A oxigenoterapia hiperbárica foi aliada ao tratamento, porém questionada por alguns autores. Conclui- se que, de acordo com a revisão bibliográfica, não há dados publicados suficientes para realizar a análise.(AU)

Fournier syndrome is a severe infectious process that affects fast-advancing soft tissues, has a polymicrobial etiology, with predominant presence of aerobic and anaerobic gram positive and negative microorganisms. The purpose of this study is to identify through literature review the knowledge and performance of nurses about the Fournier syndrome so that nursing systematization is performed effectively, providing efficient care to the patient. A literature review was conducted between 2009 and 2019. The applicability of the systematization of nursing care in the treatment, diagnosis, and complications according to the nurse's performance was emphasized. The treatment was found to include broad spectrum antibiotic therapy and the most appropriate coverage used was papain. Hyperbaric oxygen therapy was combined with treatment but questioned by some authors. It is concluded that, according to the literature review, there are not enough published data to perform the analysis.(AU)

El síndrome de Fournier es un proceso infeccioso severo que afecta los tejidos blandos con un progreso acelerado, tiene una etiología polimicrobiana, con una presencia predominante de microorganismos gram positivos y negativos aerobios y anaerobios. El objetivo de este trabajo es identificar, mediante una revisión bibliográfica, el conocimiento y el desempeño de las enfermeras sobre el síndrome de Founier para que la sistematización de enfermería se realice de manera efectiva, brindando una atención eficiente al paciente. Se realizó una revisión literaria entre los años 2009 a 2019. Se enfatizó la aplicabilidad de la sistematización de la atención de enfermería en el tratamiento, diagnóstico, complicaciones según el desempeño de la enfermera. Se descubrió que el tratamiento incluía antibióticos de amplio espectro y la cobertura más indicada y utilizada fue la papaína. La oxigenoterapia hiperbárica se combinó con el tratamiento, pero algunos autores la cuestionaron. Se concluye que, según la revisión de la literatura, no hay suficientes datos publicados para realizar el análisis.(AU)

Aplicação do plasma de baixa temperatura sob pressão atmosférica no controle de biofilmes e reparo inicial de feridas infectadas / Application of low temperature plasma under atmospheric pressure in biofilm control and wound infected repair initial

O manejo clínico e tratamento das feridas crônicas têm sido considerados grandes desafios nas áreas médicas. Infecções por biofilmes em feridas crônicas afetam milhões de pessoas no mundo a cada ano e muitas mortes ocorrem como consequência. O plasma de baixa temperatura sob pressão atmosférica (LTAPP) é uma mistura gasosa contendo partículas carregadas, radicais livres e radiação. As ações biológicas das espécies reativas geradas concomitantemente, em particular antimicrobiana, anti-inflamatória e indutora de reparação tecidual, mostram-se altamente promissoras dentro do contexto do controle das feridas crônicas. O objetivo deste estudo foi avaliar os efeitos LTAPP frente a biofilmes monoespécie e multiespécies de micro-organismos frequentemente isolados de feridas crônicas. Além disso, objetivou-se avaliar estudar os efeitos citotóxicos e genotóxicos do LTAPP nos parâmetros físicos eficazes para o controle dos biofilmes A seguir, o protocolo eficaz e seguro foi avaliado in vivo utilizando modelo murino e modelo de úlcera dermal em coelhos. O LTAPP foi capaz de reduzir as UFC/mL de biofilmes monoespécie e mutiespécie a partir de 5 minutos de exposição. O LTAPP, nos parâmetros efetivos antibiofilme, apresentou-se seguro para uso em ensaios in vivo, pois não foi cito ou genotóxico. O tratamento com LTAPP levou à maior redução da área da ferida quando comparado ao grupo controle, em ambos os modelos de ferida com infecção polimicrobiana. Redução da resposta inflamatória foi observada no modelo de úlcera dermal no tempo de 8 dias. Não houve evidências de que o LTAPP aumente significativamente a proliferação celular. Com base nos resultados obtidos, conclui-se que o LTAPP acelera o processo de reparação de feridas, porém o mecanismo de ação ainda precisa ser elucidado(AU)

The clinical management and treatment of chronic wounds have been considered one of the main challenges in the medical area. Biofilm infections in chronic wounds affect millions of people worldwide each year and many deaths occur as consequence. LTAPP is a gas containing charged particles, free radicals and radiation. The biological actions of the reactive species generated concomitantly, anti-inflammatory and tissue repair inducing, are highly promising within the context of chronic wound control. The aim of the present project is to evaluate the effects of low temperature plasma under atmospheric pressure (LTAPP) on mono and multispecies biofilms frequently isolated from chronic wounds. The cyto and genotoxic effects of LTAPP in the effective parameters were also assessed. The effective and safe protocol was tested in vivo using a murine model and a rabbit dermal ulcer model. LTAPP was able to reduce significantly the mono and multispecies biofilm after 5 minutes exposure. In the anti-biofilm effective parameters, LTAPP was not cyto or genotoxic. Treatment with LTAPP reduced significantly the wound area when compared to control in both animal models. Anti-inflammatory effect was observed in dermal ulcer model at 8 days. No evidences of increase in cell proliferation caused by LTAPP were noted. According to the results, it could be concluded that LTAPP enhanced the wound repair process, however the mechanism of action must be still elucidated(AU)

Confiabilidade da ultrassonografia de músculos esqueléticos em pacientes críticos de trauma / Reliability of skeletal muscle ultrasound in critically ill trauma patients

RESUMO Objetivo: Avaliar a segurança e a viabilidade da avaliação por ultrassonografia do quadríceps no pronto-socorro, e avaliar a confiabilidade intra e entre avaliadores para aquisição e análise de imagens de ultrassonografia da espessura e da ecogenicidade muscular em pacientes críticos de trauma. Métodos: Estudo de precisão diagnóstica realizado por meio de exames e avaliações feitos por profissionais de saúde com diferentes níveis de especialização. Dois examinadores (um especialista e um novato) procederam à aquisição de imagens de ultrassom de dez pacientes. Um avaliador experiente, cego quanto aos examinadores, quantificou as imagens obtidas. Em um grupo à parte de dez pacientes, dois avaliadores (um especialista e um novato) quantificaram a espessura do músculo quadríceps femoral, assim como sua ecogenicidade (métodos quadrado ou tracejado) em imagens adquiridas por um examinador. Resultados: Identificou-se excelente confiabilidade quanto à aquisição da imagem e à sua análise (coeficientes de correlação intraclasses > 0,987; p < 0,001). O erro padrão dos valores de mensurações variou de 0,01 a 0,06 cm, para a espessura muscular, e de 0,75 a 2,04 unidades arbitrárias, para ecogenicidade muscular. Os valores de ecogenicidade foram mais elevados quando se utilizou o método quadrado do que quando se utilizou o método tracejado (p = 0,003). Conclusão: A ultrassonografia é um método seguro, viável e confiável para avaliação muscular em pacientes críticos de trauma, independentemente do nível de especialização do avaliador.

ABSTRACT Objective: To evaluate the safety and feasibility of the ultrasound assessment of quadriceps in the emergency setting. To assess the intra- and interrater reliability for the acquisition and analysis of ultrasound images of muscle thickness and echogenicity in critically ill trauma patients between health professionals with different levels of expertise. Methods: Diagnostic accuracy study. Two examiners (expert and novice) acquired ultrasound images from ten patients; an experienced, blinded analyst quantified the images. In a separate group of ten patients, two analysts (expert and novice) quantified quadriceps muscle thickness and echogenicity (square or trace method) from images acquired by one examiner. Results: Excellent reliability was found for image acquisition and analysis (intraclass correlation coefficients > 0.987; p < 0.001). The standard error of the measurement values ranged from 0.01 - 0.06cm for muscle thickness and from 0.75 - 2.04 arbitrary units for muscle echogenicity. The coefficients of variation were < 6% for thickness and echogenicity. The echogenicity values were higher when using the square technique than when using the tracing technique (p = 0.003). Conclusion: Ultrasound is safe, feasible, and reliable for muscle assessment in critically ill trauma patients, regardless of the assessor's level of expertise.