Reinforcing the valuable role of gastric ultrasound for volume and content assessment: an observational study

Abstract Background Pulmonary aspiration is one of the most important complications in anesthesiology. Assessment of gastric content by ultrasound is a good method to quantify gastric volume and to determine the risk of intraoperative pulmonary aspiration. The aim of this study is to determine the accuracy of the gastric ultrasonography in the qualitative analysis of gastric content, mainly in the analysis of small amounts of liquid content. Methods Gastric ultrasound was performed to 36 patients before upper gastrointestinal endoscopy (UGI), making two longitudinal scans at the epigastric level, one in supine position and the other in right lateral decubitus position, measuring two diameters and the area of the gastric antrum and assessing the content characteristics determining whether it was an empty stomach or contained fluid or solid content. Subsequently, the ultrasound findings were compared with UGI findings. Results Gastric areas were analyzed by the trace and the lengths of the craniocaudal and anteroposterior axes concluding that there are no significant differences between the two methods. No statistically significant difference was found between UGI and US assessment technics. No statistically significant difference was found between the estimated volume by UGI and US. Conclusions Though our study has some limitations, qualitative analysis of gastric content using ultrasound followed by endoscopy enabled the conclusion that there are no differences in the qualitative assessment regarding these two techniques, supporting the important role of point-of-care gastric ultrasound (POCGUS) in the assessment of pulmonary aspiration risk by the anesthesiologist in the perioperative period.

Spirometry for the diagnosis of airway obstruction in patients with risk factors for COPD: the GOLD and lower limit of normal criteria / Espirometria para o diagnóstico de obstrução das vias aéreas em pacientes com fatores de risco para DPOC: os critérios GOLD e limite inferior da normalidade

ABSTRACT Objective: The identification of persistent airway obstruction is key to making a diagnosis of COPD. The GOLD guidelines suggest a fixed criterion-a post-bronchodilator FEV1/FVC ratio < 70%-to define obstruction, although other guidelines suggest that a post-bronchodilator FEV1/FVC ratio < the lower limit of normal (LLN) is the most accurate criterion. Methods: This was an observational study of individuals ≥ 40 years of age with risk factors for COPD who were referred to our pulmonary function laboratory for spirometry. Respiratory symptoms were also recorded. We calculated the prevalence of airway obstruction and of no airway obstruction, according to the GOLD criterion (GOLD+ and GOLD−, respectively) and according to the LLN criterion (LLN+ and LLN−, respectively). We also evaluated the level of agreement between the two criteria. Results: A total of 241 individuals were included. Airway obstruction was identified according to the GOLD criterion in 42 individuals (17.4%) and according to the LLN criterion in 23 (9.5%). The overall level of agreement between the two criteria was good (k = 0.67; 95% CI: 0.52-0.81), although it was lower among the individuals ≥ 70 years of age (k = 0.42; 95% CI: 0.12-0.72). The proportion of obese individuals was lower in the GOLD+/LLN+ category than in the GOLD+/LLN− category (p = 0.03), as was the median DLCO (p = 0.04). Conclusions: The use of the GOLD criterion appears to be associated with a higher prevalence of COPD. The agreement between the GOLD and LLN criteria also appears to be good, albeit weaker in older individuals. The use of different criteria to define airway obstruction seems to identify individuals with different characteristics. It is essential to understand the clinical meaning of discordance between such criteria. Until more data are available, we recommend a holistic, individualized approach to, as well as close follow-up of, patients with discordant results for airway obstruction.

RESUMO Objetivo: A identificação de obstrução persistente das vias aéreas é fundamental para o diagnóstico de DPOC. As diretrizes da GOLD sugerem um critério fixo - relação VEF1/CVF pós-broncodilatador < 70% - para definir obstrução, embora outras diretrizes sugiram que a relação VEF1/CVF pós-broncodilatador < o limite inferior da normalidade (LIN) é o critério mais preciso. Métodos: Estudo observacional com indivíduos ≥ 40 anos de idade com fatores de risco para DPOC encaminhados ao nosso laboratório de função pulmonar para espirometria. Também foram registrados sintomas respiratórios. Calculamos a prevalência de obstrução e de ausência de obstrução das vias aéreas segundo o critério GOLD (GOLD+ e GOLD−, respectivamente) e segundo o critério LIN (LIN+ e LIN−, respectivamente). Avaliamos também o grau de concordância entre os dois critérios. Resultados: Foram incluídos 241 indivíduos. Obstrução das vias aéreas foi identificada segundo o critério GOLD em 42 indivíduos (17,4%) e segundo o critério LIN em 23 (9,5%). A concordância global entre os dois critérios foi boa (k = 0,67; IC95%: 0,52-0,81), embora tenha sido menor entre os indivíduos ≥ 70 anos de idade (k = 0,42; IC95%: 0,12-0,72). A proporção de obesos foi menor na categoria GOLD+/LIN+ do que na categoria GOLD+/LIN− (p = 0,03), assim como a mediana de DLCO (p = 0,04). Conclusões: A utilização do critério GOLD parece estar associada a uma maior prevalência de DPOC. A concordância entre os critérios GOLD e LIN também parece ser boa, embora seja mais fraca em indivíduos mais velhos. A utilização de diferentes critérios para definir obstrução das vias aéreas parece identificar indivíduos com diferentes características. É essencial compreender o significado clínico da discordância entre esses critérios. Até que mais dados estejam disponíveis, recomendamos uma abordagem holística e individualizada e também um acompanhamento cuidadoso dos pacientes com resultados discordantes para obstrução das vias aéreas.

Dolor neuropático, pensemos en Enfermedad de Fabry

RESUMEN El dolor es la razón más común de consulta y de búsqueda de atención médica, y el que presenta una mayor dificultad al recibir un paciente es el dolor neuropático. Una de las neuropatías de fibras finas por excelencia es la enfermedad de Fabry, un desorden poco conocido. El objetivo de esta revisión fue cotejar la bibliografía disponible para determinar los puntos clave en el manejo de esta enfermedad, usando herramientas de búsqueda como Up To Date, Pubmed y Google Scholar. Luego de la revisión de más de 30 artículos científicos se pudo concluir que el característico dolor y la hiposensibilidad térmica se deben al acúmulo de glicolípidos que producen una neuropatía de fibras finas. Esto se asocia a un cuadro de dolores quemantes en manos y pies que puede presentar gran dificultad al momento del diagnóstico y tratamiento. De este modo, sospechar el diagnóstico conlleva una serie de pasos desde la historia clínica y examen físico, que son de gran importancia, hasta la determinación bioquímica porcentual de la ausencia de actividad de la alfa-galactosidasa A hasta los exámenes neurológicos e histológicos. Se llegó a la conclusión de que las características clínicas de esta enfermedad pueden ser típicas en la mayoría de los pacientes, sin embargo se debería conocer la fisiopatología subyacente al problema y diferenciar el manejo de un dolor crónico con el de las crisis de dolor. Esto es imperioso debido a la importancia de instaurar la terapia especifica lo antes posible.

ABSTRACT Pain is the most common reason for consulting and seeking medical attention, and the one that presents the greatest difficulty in receiving a patient is neuropathic pain. One of the neuropathies of small fibers par excellence is Fabry Disease, a little known disorder. The objective of this review was to collate the available bibliography to determine the key points in the management of this disease, using search tools such as Up To Date, Pubmed and Google Scholar. After reviewing more than 30 scientific articles, it was concluded that the characteristic pain and thermal hyposensitivity are due to the accumulation of glycolipids that produce a neuropathy of small fibers. This is associated with a picture of burning pains in the hands and feet that can present great difficulty at the time of diagnosis and treatment. Thus, suspecting the diagnosis involves a series of steps from the clinical history and physical examination, which are of great importance, to the percentage biochemical determination of the absence of activity of alpha-galactosidase A until neurological and histological examinations. It was concluded that the clinical characteristics of this disease may be typical in most patients, however, the pathophysiology underlying the problem should be known and the management of chronic pain should be differentiated from that of pain crises. This is imperative because of the importance of establishing the specific therapy as soon as possible.

Meningoencefalitis criptocóccica refractaria en una mujer joven

RESUMEN Mujer de 23 años presenta hace 2 meses cefalea que se acompaña de visión borrosa, disartria y pérdida de la conciencia. Por líquido cefalorraquídeo se confirma meningitis a criptococo. A pesar del tratamiento con anfotericina B y fluconazol presenta empeoramiento general. Durante su evolución presentó paracoccidioidomicosis pulmonar y candidiasis vaginal. A pesar de la terapia dirigida, la paciente fallece con la tardía confirmación de una inmunodeficiencia variable común.

ABSTRACT A 23-year-old woman has been presenting headache for two months that is accompanied by blurred vision, dysarthria and loss of consciousness. Cerebrospinal fluid confirms meningitis to Cryptococcus. In spite of the treatment with amphotericin B and fluconazole she presents a general deterioration. During her evolution she presented pulmonary paracoccidiomycosis and vaginal candidiasis. Despite specific therapy, the patient dies with the late confirmation of a common variable immunodeficiency.

El cannabis en el dolor crónico ¿una indicación respaldada por evidencia científica?

RESUMEN Las controversias del cannabis medicinal se basan en múltiples factores. Mientras la legalidad de su uso es respaldada por algunas leyes gubernamentales, la desaprobación de parte de las agencias controladoras de medicamentos más importantes del mundo permanece constante. Se plantea a la fecha si hay evidencia científica fiable y actualizada que desapruebe el uso del cannabis para el dolor crónico. Para esto se utilizó herramientas de búsqueda como Pubmed, Google Scholar y Science Direct para la revisión de la literatura en internet. Las conclusiones de más de 30 artículos encontrados en la web se asemejan en la determinación de la gran necesidad de mayor evidencia científica para reafirmar la seguridad y confiabilidad del uso del cannabis para el dolor crónico incluyendo el dolor musculoesquelético, el relacionado con el cáncer, el neuropático, el de tipo y origen inespecíficos. Se revisaron también los efectos secundarios, las interacciones medicamentosas, la estandarización de embalaje y el control y vías de administración. Debido a la escasez de estudios clínicos bien diseñados con muestras sustanciales y tiempo de duración, factores imprescindibles para la calidad y fiabilidad, se concluye que no existe actualmente evidencia científica para aprobar o desaprobar su uso con fines médicos.

ABSTRACT Medicinal cannabis controversies are based on multiple factors. While the legality of its use is supported by some government laws, the disapproval on the part of the most important drug control agencies in the world remains constant. To date, it is set out if there is reliable and updated scientific evidence that disapproves of the use of cannabis for chronic pain. For this, search tools such as Pubmed, Google Scholar and Science Direct were used to review the literature on the Internet. The conclusions of more than thirty articles found on the web are similar in determining the great need for more scientific evidence to reaffirm the safety and reliability the use of cannabis for chronic pain including musculoskeletal pain, cancer-related pain, neuropathic pain and those of nonspecific type and origin. Side effects, drug interactions, packaging standardization and control and administration routes were also reviewed. Due to the scarcity of well-designed clinical studies with substantial samples and duration, essential factors for quality and reliability, it is concluded that there is currently no scientific evidence to approve or disapprove its use for medical purposes.

Levantamento dos acidentes de trabalho atendidos na emergência do Pronto-Socorro Municipal de Araruama - RJ no período de janeiro a junho de 1996 / Survey of occupational accidents treated in the emergency room of the Emergency Municipal Araruama - RJ in the period January-June 1996

O autor apresenta um levantamento estatístico dos registros de acidente de trabalho oficialmente comunicados à agência local do INSS - Instituto Nacional de Previdência Social, no período de janeiro a junho de 1996. Nesta pesquisa são destacadas as características gerais dos acidentes de trabalho, tais como: sexo, faixa etária, profissão, horário do trabalho, dia da semana e parte afetada do corpo. O autor conclui que, embora em nosso meio seja alta a incidência de Acidentes de Trabalho, há uma alarmante desproporção entre o número de trabalhadores da comunidade.