[Pulmonary embolism. Modern concepts]. / Tromboembolismo pulmonar. Conceitos actuais.

Pulmonary embolism is a common disorder and an important cause of morbidity and mortality. Since genetic predisposition appears to explain only about one fifth of cases, identification of other risk factors is critical. Pulmonary embolism ranges from incidental, clinically unimportant thromboembolism to massive embolism with sudden death. The initial diagnostic approach in patients with suspected pulmonary embolism commonly involves transesophageal echocardiography and ventilation-perfusion scanning. In patients with indeterminate findings on these exams, thoracic spiral computed tomography, magnetic resonance imaging and magnetic resonance angiography have shown promise. Pulmonary angiography is becoming less used because it is invasive and expensive. Unfractioned heparin is considered the treatment of choice for most patients with pulmonary embolism, except those with hemodynamic instability, who may need thrombolytic therapy. There is limited information on the efficacy and safety of low-molecular-weight heparin for the initial treatment of symptomatic pulmonary embolism. An up to date review of the international literature focused in the epidemiology, pathophysiology, diagnosis, potential treatment and prognosis is presented.

[Malignant mesothelioma--a diagnostic challenge]. / Mesotelioma maligno um desafio diagnóstico.

Malignant mesothelioma is a rare neoplasm associated, in 80% of the cases, with exposure to asbestos fibres, with a latency period between 20 and 50 years. The treatment is palliative in most cases because of the extension of the disease at the time of diagnosis. Mesothelioma is a resistant tumour to chemotherapy and radiotherapy. Overall survival varies between 4 and 18 months, rarely over 5 years. The authors present a case of a 82-year-old man, ex-sailor, with prostatic neoplasm in hormonal "escape" phase, admitted with cough and dyspnea. The chest radiograph showed extensive right pleural effusion. The diagnostic hypothesis were metastatic, infectious and primitive neoplasm origin. Pleural biopsy revealed epithelial malignant mesothelioma confirmed by thoracoscopy, associated with prolongated occupational exposure to asbestos fibres. Without surgery indication the patient was submitted to chemotherapy with gencitabin and cisplatin associated with pleurodesis. Although he improved clinically, the presence of two malignant neoplasms, a rare situation in clinical practice, is associated with a poor prognosis, especially condicionated by the epithelial malignant mesothelioma in Butchart stage II. Finally, we discussed new differential diagnostic techniques with metastatic adenocarcinoma and target therapies under study.

[Erythrocytic acid phosphatase genetic polymorphism and cardiovascular risk in health children and adolescents]. / Polimorfismo genético da Fosfatase Acida do eritrócito e risco cardiovascular em crianças e adolescentes saudáveis.

OBJECTIVE: To correlate, in a sample of healthy children and adolescents, the activity of the enzyme acid phosphatase (ACP) with its different genetic phenotypes and of these with some cardiovascular risk parameters such as body mass index (BMI), percentage of total fat mass (%TFM), trunk fat (TF), insulin resistance, and the arterial blood pressure (BP). DESIGN AND METHODS: The sample was composed of 173 healthy children and adolescents, 96 (55.5%) F and 77 (44.5%) M, with ages between 10 and 16 years (mean: 13.04 +/- 1.68). The ACP activity was determined through a spectrophotometric method and its phenotypes through isoelectric focusing electrophoresis. BMI (Kg/m2) and the BP were obtained by standardized methods. Glycemia determined by the glucose oxidase method and insulinemia by RIA method. Insulin resistance based on the homeostasis model assessment (HOMA) was calculated as: [fasting insulin (microU/ml) x fasting glucose (mmol/l)]: 22.5. The %TFM and TF were determined by dual energy x-ray absorptiometry (DXA). The statistical methods used were ANOVA, the Pearson correlation and the Student's test. RESULTS: The distribution of the phenotypes were the following--absolute versus relative frequencies: BB-74 (48.4%), AB-52 (34%), AA-16 (10.5%), BC-7 (4.6%), AC-3 (2%) and CC-1 (0.7%). ACP activities (mean: 321.04 +/- 84.56) were significantly different among the phenotypes (p < 0.001). The smallest activity was observed in the AA individuals, the highest in CC, followed by BC (247.17 +/- 66.52 and 767.30 and 362.44 +/- 91.56 respectively). Glycemia was higher in the AA individuals (4.61 +/- 0.37) compared to CC + BC (4.40 +/- 0.31) (p = 0.08). A direct correlation was verified between HOMA and BP, both diastolic (p = 0.013, r = 0.250) and systolic (p = 0.015, r = 0.246), as well as of these with BMI (mean: 20.57 +/- 3.24) and insulinemia (p = 0.016, r = 0.215; p = 0.004, r = 0.280 and p = 0.007, r = 0.240; p = 0.008, r = 0.261 respectively for diastolic and systolic BP). There were no significant difference of BMI between sexes, nor of this as well as of % TFM and TF among the different genetic phenotypes of ACP. CONCLUSIONS: The smallest enzymatic activity of ACP seems to be associated with the AA individuals, where a trend for higher glycemia was verified. BMI, HOMA and insulinemia, due to their significant direct relationship with diastolic and systolic BP in this sample of children and adolescents may warrant more future attention in the evaluation of cardiovascular risk. There were no significant differences of HOMA, BMI, %TFM, TF nor of BP among the different ACP genetic phenotypes.