Parada cardiorrespiratória após infarto agudo do miocárdio por vasoespasmo coronariano. Relato de caso e revisão da literatura / Cardiorespiratory arrest after acute myocardial infarction due to coronary vasospasm. Case report and literature review

A angina vasoespástica é uma causa incomum de parada cardíaca e arritmias ventriculares. No entanto, os sobreviventes dessas complicações têm um risco aumentado de recorrência, apesar da função ventricular normal e do tratamento médico otimizado. Descrevemos o caso de uma ex-tabagista de 50 anos que teve parada cardiorrespiratória secundária a vasoespasmo coronariano grave.

Vasospastic angina is an uncommon cause of cardiac arrest and ventricular arrhythmias. However, survivors of these complications are at an increased risk of recurrence, despite normal ventricular function and optimized medical therapy. We describe a case of a 50-year-old former smoker who developed cardiorespiratory arrest secondary to severe coronary vasospasm.

Trend in the incidence rates of accidents with venomous animals in children and adolescents in Brazil (2007-2019) / Tendência das taxas de incidência de acidentes com animais peçonhentos em crianças e adolescentes no Brasil (2007-2019)

ABSTRACT Objective: To estimate the temporal trend of the incidence rates of accidents with venomous animals in children and adolescents in Brazil. Methods: An ecological time-series study was carried out between 2007 and 2019. Data were obtained from the Brazilian Information System on Diseases of Compulsory Declaration (Sistema de Informação de Agravos de Notificação - SINAN). The time series of incidence rates of accidents with venomous animals were stratified by age group (children aged 0 to 9 years and adolescents aged 10 to 19 years), Brazilian macro-regions (North, Northeast, Midwest, Southeast, and South), and type of accident (snake, scorpion, spider, and caterpillar). For trend analysis, the Prais-Winsten model and the Annual Percent Change (APC) were used. Results: The time series of the incidence rate of accidents with venomous animals in children and adolescents from the North, Northeast, Midwest, and Southeast macro-regions and in children from the South region showed an upward trend. The average annual incidence rates were higher in the age group of 10 to 19 years, except for the South macro-region. Accidents with scorpions, snakes, and spiders, in this order, were the most frequent; the trends in the time series stratified by type of animal varied according to the geographic macro-region. Conclusions: There was an upward trend in the incidence rate of accidents with venomous animals in children and adolescents in Brazil, except for adolescents in the South macro-region of the country.

RESUMO Objetivo: Estimar a tendência temporal das taxas de incidência de acidentes com animais peçonhentos em crianças e adolescentes no Brasil. Métodos: Foi realizado um estudo ecológico de séries temporais, entre 2007 e 2019. Os dados foram obtidos do Sistema de Informação de Agravos de Notificação (SINAN). As séries temporais das taxas de incidência com animais peçonhentos foram estratificadas por faixa etária (crianças de 0 a 9 anos e adolescentes de 10 a 19 anos), macrorregiões brasileiras (Norte, Nordeste, Centro-Oeste, Sudeste e Sul) e tipo de acidente (serpente, escorpião, aranha e lagarta). Para análise de tendência, foi utilizado o modelo de Prais-Winsten e calculada a variação percentual anual das taxas (Annual Percentage Change — APC). Resultados: As séries históricas da taxa de incidência de acidentes com animais peçonhentos em crianças e adolescentes das macrorregiões Norte, Nordeste, Centro-Oeste e Sudeste e em crianças da macrorregião Sul apresentaram tendência ascendente. As taxas de incidências anuais médias foram maiores na faixa etária de 10 a 19 anos, exceto na macrorregião Sul. Os acidentes com escorpiões, serpentes e aranhas, nesta ordem, foram os mais frequentes; as tendências das séries históricas estratificadas por tipo de animal variaram conforme a macrorregião. Conclusões: Houve tendência ascendente na taxa de incidência de acidentes com animais peçonhentos em crianças e adolescentes no Brasil, exceto nos adolescentes da macrorregião Sul do país.

Trend in the incidence rates of accidents with venomous animals in children and adolescents in Brazil (2007-2019).

OBJECTIVE: To estimate the temporal trend of the incidence rates of accidents with venomous animals in children and adolescents in Brazil. METHODS: An ecological time-series study was carried out between 2007 and 2019. Data were obtained from the Brazilian Information System on Diseases of Compulsory Declaration (Sistema de Informação de Agravos de Notificação - SINAN). The time series of incidence rates of accidents with venomous animals were stratified by age group (children aged 0 to 9 years and adolescents aged 10 to 19 years), Brazilian macro-regions (North, Northeast, Midwest, Southeast, and South), and type of accident (snake, scorpion, spider, and caterpillar). For trend analysis, the Prais-Winsten model and the Annual Percent Change (APC) were used. RESULTS: The time series of the incidence rate of accidents with venomous animals in children and adolescents from the North, Northeast, Midwest, and Southeast macro-regions and in children from the South region showed an upward trend. The average annual incidence rates were higher in the age group of 10 to 19 years, except for the South macro-region. Accidents with scorpions, snakes, and spiders, in this order, were the most frequent; the trends in the time series stratified by type of animal varied according to the geographic macro-region. CONCLUSIONS: There was an upward trend in the incidence rate of accidents with venomous animals in children and adolescents in Brazil, except for adolescents in the South macro-region of the country.

Covid-19 pandemic for Emergency Medicine residents: an observational study on mental health and medical practice / Pandemia Covid-19 para residentes Medicina de Emergência: estudo observacional em saúde mental e prática médica

Abstract: Introduction: Emergency medicine is a relatively new medical specialty in Brazil, approved just in 2016. Residency training programs have been implemented ever since. The emergency environment is known to represent a death-and-life tension on the professional team, culminating with high rates of mental illness in this population. The Covid-19 pandemic seems to be affecting these rates of depression, anxiety, and burnout in health professionals. Objective: To assess the symptoms of burnout, depression, and anxiety in Brazilian medical residents of Emergency Medicine during the Covid-19 pandemic and compare the residents' beliefs regarding clinical practice related to Covid-19 patients. Methods: A quantitative study was conducted with a convenience sample of volunteer medical residents from an anonymous online survey, available during April 2020. This investigation collected sociodemographic information and used the Oldenburg Burnout Inventory (OLBI) to measure burnout; the Patient Health Questionnaire (PHQ-9) to measure depression; and the General Anxiety Disorders (GAD-7) to measure generalized anxiety disorder. This study also developed a Covid-19 Impact Questionnaire (CIQ-19) to assess the residents' beliefs and clinical practices related to Covid-19 patients. Results: The survey consisted of 63 respondents, about 26,35% of emergency medicine residents in Brazil. Only 39.6% residents felt safe while working with Covid-19 patients. Mild depressive symptoms were found in 68.2% of the residents, followed by anxiety symptoms in 50.7% and burnout in 54.0% overall. About 12% of the residents do nothing about their mental health status, while some prefer to talk with family or friends (36.1%) and discuss with their team support (24.3%) when they need mental health care. Conclusion: Emergency medicine residents have high rates of mental illness and it could get worse when submitted to stressful and unknown situations, such as the Covid-19 pandemic. Initiatives should be made to improve these physicians' mental health status. It is proposed that health institutions pay medical supervisors a closer and more unique look at physicians in training. A mentoring program proposal is an opportunity to reflect on technical and personal improvements for medical residents.

Resumo: Introdução: Medicina de emergência é uma especialidade relativamente nova no Brasil, aprovada apenas em 2016, e programas de treinamento em residência têm sido instituídos desde então. O ambiente da emergência é conhecido por representar uma tensão entre vida e morte nos profissionais, o que culmina em altos índices de adoecimento mental nessa população. A pandemia da Covid-19 aparenta estar influenciando nas taxas de depressão, ansiedade e burnout de profissionais de saúde. Objetivo: Este estudo teve como objetivos avaliar os sintomas de burnout, depressão e ansiedade em residentes de medicina de emergência brasileiros durante a pandemia da Covid-19 e comparar as crenças deles sobre a prática clínica relacionada aos pacientes com a doença. Método: Um estudo quantitativo foi realizado com uma amostra conveniente de médicos residentes voluntários, por meio de uma pesquisa on-line anônima disponível durante o mês de abril de 2020. Esta investigação coletou informações sociodemográficas e utilizou as seguintes escalas: Oldenburg Burnout Inventory (OLBI) para mensurar burnout, Patient Health Questionnaire (PHQ-9) para mensurar depressão e General Anxiety Disorders (GAD-7) para mensurar transtorno de ansiedade generalizada. Neste estudo, também foi desenvolvido um Questionário sobre o Impacto da Covid-19 (CIQ-19) para acessar as crenças e práticas clínicas relacionadas aos pacientes com Covid-19. Resultado: A pesquisa foi composta de 63 voluntários, aproximadamente 26,35% dos residentes em medicina de emergência no Brasil. Apenas 39,6% dos residentes se sentiram seguros enquanto trabalhavam com pacientes com Covid-19. Encontraram-se sintomas leves de depressão em 68,2%, seguidos de sintomas de ansiedade em 50,7% e burnout em 54,0%. Aproximadamente 12% dos residentes não fazem nada relação à própria saúde mental, alguns preferem conversar com familiares e amigos (36,1%), e outros discutem com a equipe de suporte (24,3%) quando precisam de atendimento. Conclusão: Os residentes de medicina de emergência possuem altos índices de adoecimento mental, e isso pode piorar quando submetidos a situações estressantes e desconhecidas, como a pandemia da Covid-19. Iniciativas devem ser tomadas para melhorar a saúde mental desses médicos. Propõe-se que as instituições de saúde ofereçam aos supervisores médicos uma visão mais próxima e exclusiva sobre os médicos em treinamento. A proposta de um programa de mentoria é uma oportunidade de refletir sobre melhorias técnicas e pessoais para médicos residentes.

Incidence, characteristics and long-term outcomes of patients with diabetic ketoacidosis: a prospective prognosis cohort study in an emergency department.

BACKGROUND: Diabetic ketoacidosis is the most frequent hyperglycemic complication in the evolution of diabetes mellitus. Common precipitating factors include newly diagnosed diabetes mellitus, noncompliance with therapy and infections. However, few studies have been conducted in Brazil and none were prospective in design. OBJECTIVE: To describe the incidence, clinical and laboratory characteristics and precipitating factors of diabetic ketoacidosis among emergency department patients in a tertiary-level teaching hospital in Brazil. We also aimed to identify immediate and long-term mortality within two years. DESIGN AND SETTING: Prospective prognosis cohort study conduct at a tertiary-level teaching hospital in São Paulo, Brazil. METHODS: All patients > 12 years old presenting diabetic ketoacidosis who were admitted to the emergency department from June 2015 to May 2016 were invited to participate. RESULTS: The incidence of diabetic ketoacidosis per 1,000 admissions was 8.7. Treatment noncompliance and infection were the most common causes of diabetic ketoacidosis. The immediate mortality rate was 5.8%, while the six-month, one-year and two-year mortality rates were 9.6%, 13.5% and 19.2%, respectively. Death occurring within two years was associated with age, type 2 diabetes, hypoalbuminemia, infection at presentation and higher sequential organ failure assessment (SOFA) score at admission. CONCLUSIONS: Diabetic ketoacidosis among patients presenting to the emergency department was relatively frequent in our hospital. Treatment noncompliance and infection were major precipitating factors and presence of diabetic ketoacidosis was associated with immediate and long-term risk of death.

Incidence, characteristics and long-term outcomes of patients with diabetic ketoacidosis: a prospective prognosis cohort study in an emergency department

ABSTRACT BACKGROUND: Diabetic ketoacidosis is the most frequent hyperglycemic complication in the evolution of diabetes mellitus. Common precipitating factors include newly diagnosed diabetes mellitus, noncompliance with therapy and infections. However, few studies have been conducted in Brazil and none were prospective in design. OBJECTIVE: To describe the incidence, clinical and laboratory characteristics and precipitating factors of diabetic ketoacidosis among emergency department patients in a tertiary-level teaching hospital in Brazil. We also aimed to identify immediate and long-term mortality within two years. DESIGN AND SETTING: Prospective prognosis cohort study conduct at a tertiary-level teaching hospital in São Paulo, Brazil. METHODS: All patients > 12 years old presenting diabetic ketoacidosis who were admitted to the emergency department from June 2015 to May 2016 were invited to participate. RESULTS: The incidence of diabetic ketoacidosis per 1,000 admissions was 8.7. Treatment noncompliance and infection were the most common causes of diabetic ketoacidosis. The immediate mortality rate was 5.8%, while the six-month, one-year and two-year mortality rates were 9.6%, 13.5% and 19.2%, respectively. Death occurring within two years was associated with age, type 2 diabetes, hypoalbuminemia, infection at presentation and higher sequential organ failure assessment (SOFA) score at admission. CONCLUSIONS: Diabetic ketoacidosis among patients presenting to the emergency department was relatively frequent in our hospital. Treatment noncompliance and infection were major precipitating factors and presence of diabetic ketoacidosis was associated with immediate and long-term risk of death.

Construction and validation of an in-hospital transport simulation scenario.

OBJECTIVE: To build and validate the content of a clinical simulation scenario for teaching in-hospital transport of critically ill patients. METHODS: A descriptive study of construction and validation of a clinical simulation scenario for teaching in-hospital transport. A scenario based on the literature was built, followed by validation, using the Delphi technique, by five specialists, with an agreement of 80%. The experts were selected through snowball sampling. An instrument was developed containing 26 topics to be assessed for relevance, clarity, objectivity, feasibility, current content, vocabulary, and a field for observations. RESULTS: Two rounds were carried out by the specialists to reach a consensus of 80%. According to the experts´ recommendation, the initial scenario was written more clearly and objectively, and divided into two parts: patient preparation and patient transport. CONCLUSION: In this study, the construction and validation of the scenario for teaching in-hospital transport were successfully performed. It may be applied in several services to evaluate the training of nursing undergraduate students, as well as for the professional improvement of those who work in the in-hospital transport service.

Construction and validation of an in-hospital transport simulation scenario / Construção e validação de cenário de simulação de transporte intra-hospitalar

ABSTRACT Objective To build and validate the content of a clinical simulation scenario for teaching in-hospital transport of critically ill patients. Methods A descriptive study of construction and validation of a clinical simulation scenario for teaching in-hospital transport. A scenario based on the literature was built, followed by validation, using the Delphi technique, by five specialists, with an agreement of 80%. The experts were selected through snowball sampling. An instrument was developed containing 26 topics to be assessed for relevance, clarity, objectivity, feasibility, current content, vocabulary, and a field for observations. Results Two rounds were carried out by the specialists to reach a consensus of 80%. According to the experts´ recommendation, the initial scenario was written more clearly and objectively, and divided into two parts: patient preparation and patient transport. Conclusion In this study, the construction and validation of the scenario for teaching in-hospital transport were successfully performed. It may be applied in several services to evaluate the training of nursing undergraduate students, as well as for the professional improvement of those who work in the in-hospital transport service.

RESUMO Objetivo Construir e validar o conteúdo de um cenário de simulação clínica para ensino do transporte intra-hospitalar de pacientes críticos. Métodos Estudo descritivo de construção e validação de um cenário de simulação clínica para o ensino de transporte intra-hospitalar. Foi construído um cenário fundamentado na literatura seguido da validação, por meio da técnica Delphi, por cinco especialistas, com nível de concordância de 80%. Os especialistas foram selecionados por meio da amostragem do tipo bola de neve. Foi desenvolvido um instrumento contendo 26 tópicos, para serem avaliados quanto a pertinência, clareza, objetividade, exequibilidade, conteúdo atual e vocabulário. Havia ainda um campo para observações. Resultados Foram realizadas duas rodadas pelos especialistas para a obtenção de consenso de 80%. De acordo com a recomendação dos especialistas, o cenário inicial foi escrito de forma mais clara e objetiva, e divido em duas partes: preparo do paciente e transporte do paciente. Conclusão Neste estudo, foram realizadas, com êxito, a construção e a validação do cenário para ensino do transporte intra-hospitalar. Ele poderá ser aplicado em diversos serviços para avaliação da formação dos graduandos de enfermagem, assim como para aprimoramento profissional daqueles que atuam no serviço de transporte intra-hospitalar.

Mentoria virtual durante a pandemia de Covid-19: percepções de mentorandos e mentores / Virtual mentoring during the Covid-19 pandemic: perceptions of mentees and mentors

Resumo: Introdução: A pandemia de Covid-19 impôs à educação médica novas modalidades de ensino a distância. Com isso, os programas de mentoria, prática do processo de formação em Medicina, precisaram se adequar à nova situação com a implementação da mentoria virtual destinada aos alunos. Relato de experiência: O grupo de mentoria reforçou a importância desse processo para a formação profissional, principalmente diante dos anseios e das inseguranças causados pela pandemia. A mudança para os encontros virtuais foi bem recebida pelos mentores e mentorandos. Por fim, o processo de mentoria virtual permitiu a discussão de temas mais leves, conversas com menos timidez sobre assuntos difíceis e reforçando a identidade do grupo. Discussão: Os programas de mentoria precisam investir em melhores treinamentos para os mentores, como forma de promover a qualidade do processo grupal, sem contar com os benefícios que isso traria ao mentor que passou a atuar de modo remoto com seus mentorandos. A pandemia acirrou as divergências entre gerações e os domínios das ferramentas virtuais por parte dos grupos de mentores e mentorandos. Os mentores e docentes do processo de formação médica precisam atentar para o sofrimento mental e as fragilidades dos alunos, na tentativa de minimizar esses problemas por meio da mentoria, das narrativas e do compartilhamento de experiências que permitem a suspensão do automatismo cotidiano. Conclusão: Não se observou nenhum tipo de prejuízo acerca da mentoria virtual, e não existe empecilho para que ela continue na modalidade remota, após a pandemia de Covid-19.

Abstract: Introduction: The Covid-19 pandemic imposed new forms of distance learning on medical education. Thus, mentoring programs, a practice in the medical education process, needed to adapt to the new situation with the implementation of virtual mentoring for students. Experience report: The mentoring group reinforced the importance of this process for professional training, especially in view of the anxieties and insecurities caused by the pandemic. The move to virtual meetings was well received by mentors and mentees. Finally, the virtual mentoring process allowed lighter topics to be discussed, more open conversations about difficult issues and reinforced the identity of that group. Discussion: Mentoring programs need to invest in better training for mentors, as a way to promote the quality of the group process, not to mention the benefits that this would bring to the mentor who started to work remotely with their mentors. The pandemic increased the discrepancies between generations and the mastering of virtual tools by mentors and mentees. Mentors and teachers in the medical education process need to pay attention to the mental suffering and weaknesses of students, in an attempt to minimize these problems through mentoring according to the narratives and the sharing of experiences that help break the automatized daily routine. Conclusion: No damage was observed about virtual mentoring, and there would be no obstacle for it to remain in remote mode after the Covid-19 pandemic.

Clinical simulation strategies for knowledge integration relating to initial critical recognition and management of COVID-19 for use within continuing education and health-related academia in Brazil: a descriptive study.

BACKGROUND: The COVID-19 pandemic has led to an immense need to develop training on case recognition and management, with a focus on patients' and health professionals' safety at several levels of healthcare settings in Brazil. Different simulation strategies can be included in the diverse clinical care phases for these patients. OBJECTIVE: To suggest a complete simulation-based training program for Brazilian hospitals and/or academic institutions at this moment of the pandemic. DESIGN AND SETTING: Descriptive analysis on possible simulated clinical cases using different methodologies, thereby supporting suspected or confirmed COVID-19 patients. METHODS: This was a reflective theoretical descriptive study on an educational program based on clinical simulation, with four practical phases at different performance and complexity levels. Wearing, handling and adequately disposing of personal protective equipment, along with specific respiratory procedures in different healthcare settings up to intensive care for seriously infected patients were addressed. RESULTS: This program was designed for application at different Brazilian healthcare levels through different clinical simulation strategies. Summaries of expected performance were suggested in order to standardize technical capacity within these simulation settings, so as to serve these levels. CONCLUSIONS: Developing training programs for situations such as the current COVID-19 pandemic promotes safety not only for patients but also for healthcare workers. In the present context, clear definition of which patients need hospital outpatient or inpatient care will avoid collapse of the Brazilian healthcare system. Institutions that do not have simulated environments can, through the examples described, adopt procedures to promote didactic information in order to help healthcare professionals during this time.

Teaching how to deliver bad news: a systematic review / La enseñanza de cómo dar malas noticias: una revisión sistemática / Ensino de comunicação de más notícias: revisão sistemática

Abstract "Bad news", defined as information with huge emotional valence and potential to change personal perspectives, is, by definition, a challenge for physicians. However, the subject is not always taught in medical schools. This systematic literature review compiles all articles regarding communication of bad news after researching in databases for "medical school" and "bad news" in English, Portuguese and Spanish. The criterion was to include articles that elucidated about teaching techniques. From all 313 papers, we included 27 and classified their strategies. Most results showed that mixed strategies are more common and that, in general, the subject is well-received and appreciated by students, who reported an improvement in communicative capability after the training. We conclude that all techniques are valid and medical schools should focus on integrating this training in their regular curriculum.

Resumen "Mala noticia", definida como una información que conlleva un gran peso emocional y tiene el potencial de cambiar las perspectivas personales; constituye un desafío para los médicos. Sin embargo, este tema no siempre es enseñado en las facultades de medicina. Esta revisión sistemática de la literatura compila todos los artículos encontrados sobre la comunicación de malas noticias luego de buscar "medical school" y "bad news", en inglés, portugués y español, en bases de datos. El criterio empleado fue incluir artículos que tratasen sobre técnicas de enseñanza. De los 313 artículos, incluimos 27 y clasificamos sus estrategias. La mayoría de los resultados mostró que las estrategias mixtas son las más comunes y que, en general, el tema es bien recibido y valorado por los estudiantes, quienes informan que obtienen una mejora en la capacidad comunicativa luego de la formación. Concluimos que todas estas técnicas son válidas y que las facultades de medicina deben enfocarse en integrar esta capacitación en su currículo regular.

Resumo "Má notícia", definida como informação que carrega grande peso emocional e potencial de mudar perspectivas pessoais, é, por definição, desafio para os médicos. Entretanto, nem sempre esse assunto é abordado em faculdades de medicina. Esta revisão sistemática contém todos os artigos encontrados sobre comunicação de más notícias em bases de dados por "medical school" e "bad news" em inglês, português e espanhol. O critério de inclusão abrangia artigos que elucidavam técnicas de ensino. De todos os 313 artigos, 27 foram incluídos, tendo suas estratégias classificadas. A maioria dos resultados mostrou que as estratégias mistas são mais comuns e que, em geral, o tema é bem aceito e valorizado pelos estudantes, que afirmam melhora na capacidade comunicativa depois do treinamento. Conclui-se que todas as técnicas são válidas e que as faculdades de medicina devem focar em integrar esse treinamento no currículo regular.

What do Cochrane systematic reviews say about the management of irritable bowel syndrome?

BACKGROUND: Irritable bowel syndrome (IBS) is a clinical disorder associated with high socioeconomic burden. Despite its importance, management of IBS remains difficult and several interventions have been hypothesized as beneficial for this condition. This study identified and summarized all Cochrane systematic reviews (SRs) about the effects of interventions for managing IBS patients. DESIGN AND SETTING: Review of systematic reviews, carried out in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). METHODS: Review of Cochrane SRs addressing interventions for IBS. RESULTS: We included six SRs assessing acupuncture, bulking agents, antispasmodics, antidepressants, herbal medicines, homeopathy, hypnotherapy and psychological therapy for IBS. The certainty of evidence ranged from unknown to moderate, mainly due to imprecision in the estimates and high risk of bias from the primary studies included. There was moderate certainty of evidence that acupuncture had no important benefit regarding improvement of symptoms and quality of life, compared with sham acupuncture. There was also very low certainty of evidence that homeopathic asafoetida, used alone or in association with nux, was better than placebo regarding self-reported overall improvement. CONCLUSION: There was moderate certainty of evidence that acupuncture had no important benefit regarding improvement of symptoms and quality of life. Further well-designed and well-conducted randomized clinical trials are needed in order to reduce the uncertainties regarding the most commonly used interventions for patients with IBS.

Identification of warning signs for prevention of in-hospital cardiorespiratory arrest / Identificação dos sinais de alerta para a prevenção da parada cardiorrespiratória intra-hospitalar / Identificación de las señales de alerta para la prevención de la parada cardiorrespiratoria intrahospitalaria

ABSTRACT Objective: to identify the occurrence of warning signs and changes in vital signs in individuals who experienced in-hospital cardiorespiratory arrest and correlate them with the occurrence of this event. Method: this is a retrospective, analytical and quantitative study that included 218 medical records of patients who suffered in-hospital cardiorespiratory arrest and identified warning signs and alterations in vital signs. Mean, standard deviation, median, minimum and maximum values were calculated for the continuous variables, and frequency and percentage for the categorical variables. We compared the age and occurrence of cardiorespiratory arrest with the occurrence of warning signs using the Chi-Square Test and the Mann Whitney non-parametric test (p-value < 0.05). Results: 62.1% of the patients presented signs and symptoms of shock, 44.9% of neurological alteration, 40.4% of malaise, 15.2% presented signs suggestive of acute coronary syndrome, and 25.9% presented mental confusion. In the last measurement of vital signs before cardiorespiratory arrest, the majority of patients had altered abnormal (32.6%) and severely abnormal (23.9%) heart rate, and abnormal (37.1%) and severely abnormal (27.0%) respiratory rate. Conclusion: the warning signs identified were: shock, neurological signs, malaise and acute coronary syndrome. The prevalent changes in vital signs were: heart rate, respiratory rate and O2 saturation. Patients with severely abnormal systolic blood pressure were not discharged and those with abnormal respiratory rate did not survive 6 months after cardiorespiratory arrest.

RESUMO Objetivo: identificar ocorrência dos sinais de alerta e alterações nos sinais vitais em indivíduos com parada cardiorrespiratória intra-hospitalar e correlacioná-los à ocorrência desse evento. Método: estudo retrospectivo, analítico e quantitativo que incluiu 218 prontuários de pacientes que sofreram parada cardiorrespiratória intra-hospitalar e identificados sinais de alerta e alterações nos sinais vitais. Para variáveis contínuas, calculou-se média, desvio padrão, mediana, mínimo e máximo; para as categóricas, frequência e percentual. Comparou-se a idade e ocorrência de parada cardiorrespiratória com ocorrência de sinais de alerta pelo Teste Qui-Quadrado e Teste não paramétrico de MannWhitney (p-valor<0,05). Resultados: 62,1% dos pacientes apresentaram sinais e sintomas de choque, 44,9% neurológicos, 40,4% mal-estar, 15,2% sugestivos de síndrome coronariana aguda e 25,9% confusão mental. Na última mensuração dos sinais vitais antes da parada cardiorrespiratória, a maioria apresentou frequência cardíaca alterada, anormal (32,6%) e severamente anormal (23,9%), frequência respiratória anormal (37,1%) e severamente anormal (27,0%). Conclusão: identificou-se como sinais de alerta: sinais de choque, neurológicos, mal-estar e síndrome coronariana aguda. Alterações nos sinais vitais prevalentes foram: frequência cardíaca, respiratória e saturação de O2. Pacientes com pressão arterial sistólica severamente anormal não receberam alta e aqueles com frequência respiratória anormal não sobreviveram em 6 meses após a parada cardiorrespiratória.

RESUMEN Objetivo: identificar la presencia de señales de alerta y alteraciones en los signos vitales en individuos con parada cardiorrespiratoria intrahospitalaria y correlacionarlos a la ocurrencia de ese evento. Método: estudio retrospectivo, analítico y cuantitativo que incluyó 218 prontuarios de pacientes que sufrieron paro cardiorrespiratorio intrahospitalario e identificados signos de alerta y alteraciones en los signos vitales. Para variables continuas, se calculó la media, desviación estándar, mediana, mínima y máxima; para las categóricas, se calculó la frecuencia y el porcentaje. Se comparó la edad y ocurrencia de parada cardiorrespiratoria con ocurrencia de señales de alerta por el Test Chi-cuadrado y Test no paramétrico de MannWhitney (p-valor <0,05). Resultados: 62,1% de los pacientes presentaron signos y síntomas de shock, 44,9% neurológicos, 40,4% malestar, 15,2% sugestivos de síndrome coronario agudo y 25,9% confusión mental. En la última medición de los signos vitales antes de la parada cardiorrespiratoria, la mayoría presentó frecuencia cardiaca alterada, anormal (32,6%) y severamente anormal (23,9%), frecuencia respiratoria anormal (37,1%) y severamente anormal (27,0%). Conclusión: como signos de alerta se identificaron: signos de shock, neurológicos, malestar y síndrome coronario agudo. Los cambios en los signos vitales prevalentes fueron: frecuencia cardíaca, respiratoria y saturación de O2. Los pacientes con presión arterial sistólica severamente anormal no recibieron alta y aquellos con frecuencia respiratoria anormal no sobrevivieron en 6 meses después de la parada cardiorrespiratoria.

Testosterona e acidente vascular encefálico isquêmico / Testosterone and ischemic stroke

Níveis de testosterona sérica já foram relacionados a piora de fatores hematológicos, função e envelhecimento vascular, contribuindo potencialmente para formação de trombos. Com o envelhecimento, dados epidemiológicos mostram declínio dos níveis de testosterona, prejuízo da função vascular e aumento das incidências de doenças vasculares, como o AVE. Objetivo: Descrever estudos que abordaram a potencial relação dos níveis de testosterona com a prevenção, apresentação clínica e prognóstico do AVE. Métodos: Uma pesquisa e seleção de artigos foi conduzida em três diferentes bases de dados (MEDLINE, SCIELO, LILACS) utilizando termos relacionados a testosterona e AVE (inglês e português), filtrada para estudos em humanos. Apenas estudos que abordaram algum aspecto da relação entre testosterona e AVE foram incluídos para discussão no presente estudo. Resultados: A busca resultou em 12 estudos relevantes para análise e discussão (7 observacionais, 3 transversais, 2 experimentais). Estudos observacionais verificaram um papel protetor da testosterona na incidência de AVE. Estudos transversais verificaram alterações endocrinológicas, como o hipogonadismo, na fase aguda do AVE, bem como melhor apresentação clínica (gravidade, tamanho da lesão). Estudos experimentais controlados verificaram benefícios clínicos e funcionais da suplementação de testosterona em pacientes em reabilitação. Conclusão: Apesar dos potenciais diversos benefícios destacados de níveis mais altos de testosterona no AVE, mais estudos que abordem de forma sistematizada o papel da testosterona em aspectos preventivos, de apresentação clínica, e de reabilitação e prognóstico serão bem vindos, para melhor manejo e otimização do tratamento do AVE.

Serum testosterone levels have already been related to endothelial function, vascular aging and hemathological factors, possibly contributing to thrombus formation. As aging progresses, epidemiological data shows declining testosterone levels, impaired vascular function and an increasing incidence of vascular diseases like stroke. Objective: The aim of present paper is to describe studies with a possible relation of testosterone levels with stroke prevention, clinical presentation, and prognosis. Methods: A research and selection of articles, filtering for humans studies only, was conducted in three different eletronic scientific databases, (MEDLINE, SCIELO, LILACS), using related and registered terms (english and portuguese) about "stroke" and "testosterone". Only studies that encompasses the role of testosterone in stroke and its different clinical aspects were included in the present review. Results: The search retrieved 12 relevant studies for analysis and discussion relating testosterone and stroke (7 observational, 3 cross sectional, 2 experimental). Observational studies verified a preventive role of testosterone levels on stroke incidence, cross-sectional studies verified endocrinologial alterations like hypogonadism on acute stroke phase and better clinical presentation (severity, brain lesion size). Experimental controled studies observed clinical benefits of testosterone supplementation in rehabilitation patients. Conclusion: Despite the potential benefits of higher levels of testosterne in stroke spectrum, more studies that systematically aproach the role of testosterone in stroke prevention, severity, clinical features, prognosis, rehabilitation and mortality will be welcome to better elaborate future medical management and otimization in stroke spectrum.

What do Cochrane systematic reviews say about cardiac arrest management?

CONTEXT AND OBJECTIVE: Cardiac arrest is associated with high morbidity and mortality and imposes a significant burden on the healthcare system. Management of cardiac arrest patients is complex and involves approaches with multiple interventions. Here, we aimed to summarize the available evidence regarding the interventions used in cardiac arrest cases. DESIGN AND SETTING: Review of systematic reviews (SRs), conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A systematic search was conducted to identify all Cochrane SRs that fulfilled the inclusion criteria. Titles and abstracts were screened by two authors. RESULTS: We included nine Cochrane SRs assessing compression techniques or devices (three SRs), defibrillation (two SRs) and other interventions (two SRs on hypothermia interventions, one on airway management and one on pharmacological intervention). The reviews included found qualities of evidence ranging from unknown to high, regarding the benefits of these interventions. CONCLUSION: This review included nine Cochrane systematic reviews that provided a diverse range of qualities of evidence (unknown to high) regarding interventions that are used in management of cardiac arrest. High-quality evidence was found by two systematic reviews as follows: (a) increased survival until hospital discharge with continuous compression, compared with interrupted chest compression, both administered by an untrained person and (b) no difference regarding the return of spontaneous circulation, comparing aminophylline and placebo, for bradyasystolic patients under cardiac arrest. Further studies are needed in order to reach solid conclusions.

What do Cochrane systematic reviews say about cardiac arrest management?

ABSTRACT CONTEXT AND OBJECTIVE: Cardiac arrest is associated with high morbidity and mortality and imposes a significant burden on the healthcare system. Management of cardiac arrest patients is complex and involves approaches with multiple interventions. Here, we aimed to summarize the available evidence regarding the interventions used in cardiac arrest cases. DESIGN AND SETTING: Review of systematic reviews (SRs), conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A systematic search was conducted to identify all Cochrane SRs that fulfilled the inclusion criteria. Titles and abstracts were screened by two authors. RESULTS: We included nine Cochrane SRs assessing compression techniques or devices (three SRs), defibrillation (two SRs) and other interventions (two SRs on hypothermia interventions, one on airway management and one on pharmacological intervention). The reviews included found qualities of evidence ranging from unknown to high, regarding the benefits of these interventions. CONCLUSION: This review included nine Cochrane systematic reviews that provided a diverse range of qualities of evidence (unknown to high) regarding interventions that are used in management of cardiac arrest. High-quality evidence was found by two systematic reviews as follows: (a) increased survival until hospital discharge with continuous compression, compared with interrupted chest compression, both administered by an untrained person and (b) no difference regarding the return of spontaneous circulation, comparing aminophylline and placebo, for bradyasystolic patients under cardiac arrest. Further studies are needed in order to reach solid conclusions.

Do not attempt resuscitation orders at the emergency department of a teaching hospital / Ordens de não ressuscitação no serviço de emergência de um hospital universitário

ABSTRACT Objective: To identify factors associated with not attempting resuscitation. Methods: A cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05). Results: No cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole. Conclusion: Advanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

RESUMO Objetivo: Identificar fatores associados à não realização de ressuscitação. Métodos: Estudo transversal realizado no serviço de emergência de um hospital universitário. A amostra foi composta por 285 pacientes, dos quais 216 foram submetidos à ressuscitação cardiopulmonar, e 69 não tiveram esta conduta. Os dados foram coletados por meio do in-hospital Utstein Style. Para comparar as tentativas de ressuscitação e as variáveis de interesse, utilizaram-se o teste do χ2, a razão de verossimilhança, o teste exato de Fisher e a análise de variância (p<0,05). Resultados: A não ressuscitação foi considerada injustificável em 56,5% dos casos, sendo que 37,7% não queriam ressuscitação e 5,8% foram encontrados mortos. Do total de pacientes, 22,4% tiveram parada cardíaca prévia, 49,1% eram independentes para Atividades de Vida Diária, e 89,8% tinham alguma história pregressa; 63,8% estavam conscientes, 69,8% estavam respirando e 74,4% tinham pulso palpável à admissão. A maioria dos eventos (76,4%) ocorreu no hospital, e a causa presumida de parada foi insuficiência respiratória em 28,7% e, em 48,4%, o ritmo inicial foi atividade elétrica sem pulso. A causa mais frequente de morte foi infecção. Os fatores que influenciaram na não realização de ressuscitação foram idade avançada, história de neoplasia e assistolia como ritmo inicial de parada. Conclusão: Idade avançada, história de neoplasia e assistolia como ritmo inicial foram os fatores que influenciaram significativamente na não realização de ressuscitação. Maior clareza na decisão de reanimar pode afetar positivamente a qualidade de vida dos pacientes.

Do not attempt resuscitation orders at the emergency department of a teaching hospital.

OBJECTIVE: To identify factors associated with not attempting resuscitation. METHODS: A cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05). RESULTS: No cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole. CONCLUSION: Advanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

Purple urine bag syndrome: case report for Streptoccocus agalactiae and literature review.

We report a case of purple urine bag syndrome, associated to Streptococcus agalactiae urinary tract infection, progressing to septic shock and death. We present a review of the literature on the subject and take the opportunity to attend readers about increasing incidence with population aging and its potential bad outcome.

Statins for aortic valve stenosis

ABSTRACT BACKGROUND: Aortic valve stenosis is the most common type of valvular heart disease in the USA and Europe. Aortic valve stenosis is considered similar to atherosclerotic disease. Some studies have evaluated statins for aortic valve stenosis. OBJECTIVES: To evaluate the effectiveness and safety of statins in aortic valve stenosis. METHODS: Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS - IBECS, Web of Science and CINAHL Plus. These databases were searched from their inception to 24 November 2015. We also searched trials in registers for ongoing trials. We used no language restrictions. Selection criteria: Randomized controlled clinical trials (RCTs) comparing statins alone or in association with other systemic drugs to reduce cholesterol levels versus placebo or usual care. Data collection and analysis: Primary outcomes were severity of aortic valve stenosis (evaluated by echocardiographic criteria: mean pressure gradient, valve area and aortic jet velocity), freedom from valve replacement and death from cardiovascular cause. Secondary outcomes were hospitalization for any reason, overall mortality, adverse events and patient quality of life. Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The GRADE methodology was employed to assess the quality of result findings and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 to create a 'Summary of findings' table. MAIN RESULTS: We included four RCTs with 2360 participants comparing statins (1185 participants) with placebo (1175 participants). We found low-quality evidence for our primary outcome of severity of aortic valve stenosis, evaluated by mean pressure gradient (mean difference (MD) -0.54, 95% confidence interval (CI) -1.88 to 0.80; participants = 1935; studies = 2), valve area (MD -0.07, 95% CI -0.28 to 0.14; participants = 127; studies = 2), and aortic jet velocity (MD -0.06, 95% CI -0.26 to 0.14; participants = 155; study = 1). Moderate-quality evidence showed no effect on freedom from valve replacement with statins (risk ratio (RR) 0.93, 95% CI 0.81 to 1.06; participants = 2360; studies = 4), and no effect on muscle pain as an adverse event (RR 0.91, 95% CI 0.75 to 1.09; participants = 2204; studies = 3; moderate-quality evidence). Low- and very low-quality evidence showed uncertainty around the effect of statins on death from cardiovascular cause (RR 0.80, 95% CI 0.56 to 1.15; participants = 2297; studies = 3; low-quality evidence) and hospitalization for any reason (RR 0.84, 95% CI 0.39 to 1.84; participants = 155; study = 1; very low-quality evidence). None of the four included studies reported on overall mortality and patient quality of life. AUTHORS CONCLUSIONS: Result findings showed uncertainty surrounding the effect of statins for aortic valve stenosis. The quality of evidence from the reported outcomes ranged from moderate to very low. These results give support to European and USA guidelines (2012 and 2014, respectively) that so far there is no clinical treatment option for aortic valve stenosis.