Reação a drogas com eosinofilia e sintomas sistêmicos (DRESS): desafio no diagnóstico e tratamento / Drug reaction with eosinophilia and systemic symptoms (DRESS): a diagnostic and treatment challenge

Introdução: A reação a medicamentos com eosinofilia e sintomas sistêmicos (DRESS) trata-se de uma doença grave, sendo sua gravidade relacionada ao grau de acometimento visceral, e sua taxa de mortalidade de cerca de 10%. Seu diagnóstico é desafiador, e a utilização do escore RegiSCAR como ferramenta facilita a formação deste diagnóstico. Objetivo: Analisar os aspectos clínicos, laboratoriais, evolução e classificação dos casos segundo o RegiSCAR dos pacientes internados no serviço de Alergia e Imunologia do Hospital do Servidor Público Estadual de São Paulo, com o diagnóstico de DRESS. Método: Trata-se de um estudo retrospectivo baseado na análise de prontuários de pacientes atendidos no período entre janeiro de 2006 a janeiro de 2020. Resultados: Neste estudo verificou-se maior prevalência do sexo feminino, e a DRESS acometeu principalmente adultos e idosos, tendo como comorbidades mais frequentes as doenças cardiovasculares. Dos sintomas clínicos, 69,2% dos pacientes apresentava febre, e a alteração laboratorial mais encontrada foi a presença de eosinofilia. A lesão cutânea mais frequente foi o exantema maculopapular, e os medicamentos, os anticonvulsivantes. O tempo prévio de uso do medicamento foi de 2,1 semanas, e todos os pacientes receberam corticoide sistêmico como tratamento principal, e 3 pacientes fizeram uso da imunoglubulina humana como tratamento adicional. A mortalidade foi de 7% na fase aguda, e 14% por causas secundárias. Conclusão: A DRESS é uma síndrome complexa grave e potencialmente fatal, cujo diagnóstico é desafiador. O uso do escore preconizado pelo RegiSCAR demonstrou ser importante auxílio na confirmação do diagnóstico e na diferenciação de outras doenças. A mortalidade encontrada destaca a gravidade da doença. Reconhecer e excluir a droga implicada e iniciar um tratamento precoce permite maior chance de sobrevida para estes pacientes.

Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a serious disease. Its severity is related to the degree of visceral involvement and its mortality rate is approximately 10%. Diagnosis is a challenge, although RegiSCAR scores can facilitate the process. Objective: To analyze clinical and laboratory data, clinical course, and classify cases according to RegiSCAR scores among patients diagnosed with DRESS who were admitted to the Allergy and Immunology service of the Hospital do Servidor Público Estadual de São Paulo. Method: This retrospective study analyzed the medical records of patients seen between January 2006 and January 2020. Results: There was a higher prevalence of women, with DRESS mainly affecting adults and older adults; cardiovascular diseases were the most frequent comorbidity. The most common clinical symptom was fever (69.2%), while the most common laboratory finding was eosinophilia. The most frequent skin lesion was maculopapular rash, and anticonvulsants were the main prescribed drug class. The drug was used for a mean of 2.1 weeks, and all patients received systemic corticosteroids as the main treatment. Human immunoglobulin was used as an additional treatment in 3 patients. Mortality was 7% in the acute phase and 14% due to secondary causes. Conclusion: DRESS is a severe, complex, and potentially fatal syndrome whose diagnosis is challenging. RegiSCAR scores helped confirm diagnosis and differentiate it from other diseases. The disease's mortality highlights its severity. Recognizing and excluding the implicated drug and initiating early treatment led to a greater chance of survival for these patients.

Reações cutâneas graves em crianças: como se comportam? / Severe cutaneous adverse reactions in children: how do they behave?

Introdução: As reações cutâneas graves a medicamentos (RCGM) compreendem um grupo de doenças caracterizadas por hipersensibilidade tardia a um ou vários tipos de fármacos. Por ser uma doença potencialmente fatal, o diagnóstico precoce, bem como o início do tratamento, são de suma importância. Objetivo: Analisar a evolução das RCGM em pacientes pediátricos acompanhados em dois hospitais da cidade de São Paulo, SP. Método: Trata-se de um estudo retrospectivo baseado na análise de prontuários de pacientes atendidos no período de 2002 a 2018 em dois hospitais da capital paulista. Resultados: Não houve diferença entre os sexos, prevaleceu a faixa etária dos adolescentes, e os medicamentos mais implicados com o desenvolvimento das lesões cutâneas foram os anticonvulsivantes, sendo os principais a carbamazepina e fenitoína, sem diferença entre eles, seguidos dos antibióticos betalactâmicos. No tratamento, todos os pacientes fizeram uso de corticoides sistêmicos e anti-histamínicos, sendo que oito pacientes também receberam imunoglobulina intravenosa e um recebeu ciclosporina. A taxa de mortalidade foi baixa e, em relação às complicações e sequelas, a autoimunidade foi a mais encontrada. Conclusão: Os casos de RCGM são eventos raros na faixa etária pediátrica, todavia de alta morbimortalidade e risco de sequelas. O diagnóstico e tratamento precoces contribuem para um melhor prognóstico, sendo de suma importância a identificação da medicação associada, bem como a retirada da mesma.

Background: Severe cutaneous adverse reactions (SCARs) comprise a group of diseases characterized by late hypersensitivity to one or more types of drugs. Because they are potentially fatal, early diagnosis and initiation of treatment are of paramount importance. Objective: To analyze the evolution of SCARs in pediatric patients followed up in two hospitals in São Paulo, SP, Brazil. Methods: This is a retrospective study based on the analysis of medical records of patients treated between 2002 and 2018 in two hospitals in the state capital. Results: There was no difference between sexes, and the age group of adolescents prevailed. Anticonvulsants were the drugs most implicated in the development of skin lesions, especially carbamazepine and phenytoin, with no difference between them, followed by betalactam antibiotics. During treatment, all patients used systemic corticosteroids and antihistamines; eight patients also received intravenous immunoglobulin and one received cyclosporine. The mortality rate was low, and regarding complications and sequelae, autoimmunity was the most commonly found. Conclusion: Cases of SCAR are rare events in the pediatric age group, but morbidity, mortality, and risk of sequelae are high. Early diagnosis and treatment contribute to a better prognosis, and identification of the associated medication as well as its withdrawal are extremely important.

Inflammatory cytokines in pediatric cardiac surgery and variable effect of the hemofiltration process.

Cardiac surgery with cardiopulmonary bypass (CPB) elicits an inflammatory response and has a multitude of biological consequences, ranging from subclinical organ dysfunction to severe multiorgan failure. Pediatric patients are more prone to have a reaction that can jeopardize their outcome. Cytokines are supposed to be important mediators in this response: limiting their circulating levels is, therefore, appealing. We investigated the pattern of cytokine release during pediatric operation for congenital heart anomalies in 20 patients, and the effect of hemofiltration. Tumor necrosis factor alpha (TNF-alpha) was elevated after anesthesia induction and showed significant decrease during CPB. Hemofiltration reduced its concentration, but the effect disappeared on the following day. Interleukin-1 (IL-1) increased slowly at the end of CPB and hemofiltration had no effect. Interleukin-6 (IL-6) showed a tendency toward augmentation during rewarming and hemofiltration did not significantly affect the course. Soluble interleukin-6 receptor (sIL-6r) had a pattern similar to TNF-alpha, but hemofiltration had no effect. On the other hand, interleukin-8 (IL-8) behaved like IL-6. Our findings suggest that baseline clinical status, anesthetic drugs, and maneuvers before incision may elicit a cytokine response, whereas rewarming is a critical phase of CPB. Hemofiltration is effective in removal of TNF-alpha, but its role is debatable for the control of IL-1, IL-6, sIL-6r and IL-8 levels.

N-Salicylideneamino acidato complexes of oxovanadium(IV). The cysteine and penicillamine complexes.

Oxovanadium(IV) complexes with ligands derived from the reaction of salicylaldehyde with L-cysteine and with D- and D,L-penicillamine are prepared. The compounds are characterised by elemental analysis, spectroscopy (UV-VIS, CD, EPR), TG, DSC and magnetic susceptibility measurements (9-295 K). We discuss several aspects related to the structure of these complexes in the solid state and in solution; in particular, the possibility of forming thiazolidine complexes, and their comparison with the characterised complexes is studied by molecular mechanics and density functional theory calculations. The solution structures depend on pH and solvent, and while with L-Cys the spectroscopic results show trends similar to those of the L-Ala and L-Ser systems up to ca. pH 8-9, where thiolate coordination starts being detected, the penicillamine system is quite distinct, namely thiolate coordination occurs for pH > 6.5. In the presence of salicylaldehyde and V(IV)O the desulfydration of cysteine proceeds rapidly, but no similar reaction occurs with penicillamine, although its decomposition is also activated. The DFT calculations do not indicate any energetic basis for this distinct reactivity, which possibly results from different complexes present in the Cys and Pen systems. In the cysteine system, the N-salicylidenedehydroalanine-V(IV)O complex V is believed to form in an intermediate stage of the desulfydration. Further, addition of several nucleophiles to the cysteine reaction mixtures produce amino acid derivatives by a Michael-type base-catalysed addition, a result compatible with the formation of V. The products of these reactions were analysed by TLC and HPLC, and in some cases isolated.

Atrial natriuretic factor in normothermic and hypothermic cardiopulmonary bypass.

BACKGROUND: To evaluate the plasmatic changes of atrial natriuretic factor (ANF) during and after cardiopulmonary bypass (CPB) in normothermia and hypothermia. METHODS: Twenty-three patients (n = 23) undergoing coronary artery bypass graft surgery were randomly assigned to two groups. In Group I (n = 11), the patients underwent operation in normothermia; in Group II (n = 12), the operation was performed in hypothermia (26 degrees C). RESULTS: Plasma ANF levels were determined after induction of anaesthesia, at the end of CPB and one hour postoperatively. There were no demographic differences between the two groups, diuresis (p = 0.90) and natriuresis (p = 0.95). Plasma levels of ANF were significantly elevated during and after CPB in both groups (p < 0.01). The groups differed significantly for plasma levels of ANF during CPB and postoperatively (p < 0.05), but did not differ prebypass (p = 0.08). There was no correlation in either group between ANF release and central venous pressure, natriuresis and diuresis. There was only a borderline relationship between ANF concentration and diuresis after CPB in Group I. CONCLUSION: CPB triggers the production and release of ANF. The present study demonstrates a significantly enhanced ANF release during hypothermia and reperfusion after ischaemia. Thus, these data suggest the protective role of ANF on the hypoxic myocardium, and they confirm that ANF does not play a role in diuresis and natriuresis during and after hypothermic CPB.

[A new approach to the closure of patent ductus arteriosus in premature infants]. / Sviluppo di una nuova tecnica chirurgica di chiusura della pervietà del dotto arterioso in neonati.

Minimally invasive surgical techniques have been employed successfully for a wide spectrum of cardiothoracic procedures. These approaches were proven to be as safe and effective as traditional surgical techniques. Unfortunately, it remains a lack of adequate instrumentations and anatomic features, particularly in the pediatric pool of patients. We have employed a new surgical approach for closing a patent ductus arteriosus in low weight newborn (< 2.5 kg), performing a superior extrapleuric approach. This report demonstrates that this technique is safe and reproducible, and is our opinion that it may substitute the medical management of patent ductus arteriosus.

Teoria do conhecimento e epidemiológia: um convite à leitura de John Snow / Knowledge and epidemiology theory

Säo cada vez mais visíveis os sinais de esgotamento do modelo teórico que sustentou o desenvolvimento da saúde coletiva no Brasil ( e talvez na América Latina) na década de 70 e 80. Um sinal dessa crise é a aguda perplexidade dos intelectuais da área que migraram para as tarefas de governo que se descobriram sem instrumentos teóricos e técnicos capazes de decodificar e agilizar o emaranhado burocrático das estruturas administrativas. Um outro indicador da crise intelectual é a descoberta da surpreendente consistência das bases ideológicas e programáticas da "grande medicina" especializada, que desafia agressivamente as limitaçôes do discurso generalista da medicina social/saúde coletiva. O que este texto propoe é basicamente refletir sobre alguns problemas teórico-conceituais que permanecem ainda obscuros no âmbito dessa crise intelectual.Para essa tarefa, consideramos que o retorno à leitura de um dos pais fundadores da refleäo totalizante na saúde, John Snow, é extremamente oportuna

Comentarios sobre a tendência secular da tuberculose / Comments on the secular tendency of tuberculosis

Este trabalho busca revisar uma discussäo realizada por vários autores sobre a tendência secular da mortalidade por tuberculose em diferentes formaçöes sociais. Observamos entre os autores uma concordância: 1§) em relaçäo à influência da melhoria do padräo de vida das populaçöes na queda da mortalidade pela doença); 2§) a respeito da aceleraçäo desta queda, a partir da introduçäo de quimioterapia eficaz. Vários autores consideram também a hipótese de ter ocorrido uma epidemia da doença no início do século XIX em espaços como a Inglaterra e a cidade do Rio de Janeiro via condicionantes sociais obviamente distintos e outros que näo trabalham com esta hipótese na tentativa de explicar as flutuaçöes na "tendência secular" da enfermidade

Algumas evidências da eficácia do BCG em crianças no Brasil

O autor não apresentou resumo

Política indigenista e assistência à saúde Noel Nutels e o serviço de unidades sanitárias aéreas / Indigenist policies and health care Noel Nutels and the airborne sanitary service units

Um dos aspectos pouco conhecidos na história das políticas de saúde no Brasil foi a criaçao de um serviço de assistência médica às populaçoes indígenas. Esta proposta surgiu a partir da iniciativa do médico e indigenista Noel Nutels que criou o Serviço de Unidades Sanitárias Aéreas (SUSA). Este trabalho recupera a trajetória deste serviço e busca relacioná-la com as características assumidas pela política indigenista brasileira. Política marcada pelo esforço voluntário e humanitário de alguns indivíduos que se contrapôs ao processo violento e brutal de expansao da fronteira do capitalismo nacional