Psoas Abscess and Pott's Disease Masked by Concomitant Invasive Staphylococcus aureus Disease: A Case of Misleading Diagnosis.

Psoas abscess is a rare infection classified as primary or secondary depending on the etiology of infection. Staphylococcus aureus is considered the most frequent causative agent. Nevertheless, psoas abscess persistent lack of improvement or any relapse after successful treatment should remind us to exclude other potential diagnoses. Although less frequently, Pott's disease is still one of the predisposing causes, especially in patients with immunocompromised status. This clinical condition has an indolent course and requires a high index of suspicion to avoid severe morbidity. Early recognition and targeted treatment are the principal means of ensuring tuberculosis control. Here we report a very interesting case of a psoas abscess and Pott's disease in a patient suffering from a misleading diagnosis of invasive staphylococcal disease.

Prolonged chest compressions during cardiopulmonary resuscitation for in-hospital cardiac arrest due to acute pulmonary embolism.

Patients with hemodynamic collapse due to acute pulmonary embolism have a dismal prognosis if not treated rapidly. Therapeutic options include systemic thrombolytic therapy, rheolytic thrombectomy, and surgical embolectomy. However, the efficacy of thrombolytic therapy is diminished because the low-output state hinders effective delivery of the lytic agent to the thrombus. In the absence of any form of mechanical circulatory support, such as extracorporeal membrane oxygenation or cardiac surgery on site, we think that prolonged vigorous manual compressions might be the only way to support the circulation during the initial critical state, when thrombolytic therapy has been administered. We report the results of prolonged manual chest compressions (exceeding 30 minutes) on 6 patients who received tenecteplase in treatment of acute pulmonary embolism that induced in-hospital cardiopulmonary arrest. Four of 6 patients survived and were discharged from the hospital. In an era of increasing technologic complexity for patients with hemodynamic instability, we emphasize the importance of prolonged chest compressions, which can improve systemic perfusion, counteract the prothrombotic state associated with cardiopulmonary arrest, and give the lytic agent time to act.

A clinical audit of thrombolytic therapy in patients with normotensive pulmonary embolism and intermediate risk.

INTRODUCTION: There is considerable debate regarding the use of thrombolytic therapy in patients with pulmonary embolism, normal blood pressure and intermediate clinical risk, as defined by right ventricular dysfunction on transthoracic echocardiography or elevated serum markers of cardiac necrosis. AIMS AND OBJECTIVES: A clinical audit of normotensive patients diagnosed with acute pulmonary embolism using multi- detector computerized tomography pulmonary angiography (MDCTPA) and intermediate risk, was conducted to determine clinical outcomes at 30 days. The specific role played by imaging findings and clinical severity, on the decision to thrombolyse, was assessed. METHODS: The two cohorts who did (n = 15) and did not receive thrombolysis (n = 20) were compared for age, heart rate, blood pressure and oxyhemoglobin saturation at presentation, and the simplified PESI score was calculated in each patient. MDCTPA findings suggestive of adverse clinical outcome including central PE and an increased RV/LV diameter were determined for each patient. RV dysfunction on echocardiography was compared to clinical scoring, and findings on MDCTPA. RESULTS: The patients who received thrombolytic therapy were younger (48.6 ± 19.11 years versus 64.2 ± 13.83 years) (P < 0.01) and had a higher heart rate (107.6 ± 17.1/min versus 91.7 ± 17.8/min) (P < 0.05). More patients with a higher clinical severity, as determined by the simplified PESI score (12/20) and a higher shock index (0.94 ± 0.23), were thrombolysed as compared to the proportion with a lower score (3/15) (P < 0.05) or index (0.70 ± 0.20) (P < 0.005). In-hospital mortality and hemorrhagic complications at 30 days were zero in both groups. RV dysfunction by echocardiography was not a strong determinant for choosing thrombolytic therapy while central PE on MDCTPA tilted the decision towards thrombolysis. CONCLUSION: Our clinical audit revealed a predilection to use thrombolysis in younger patients with clinical severity and imaging findings on MDCTPA being the key drivers. A perception of a fragile hemodynamic status, as implied by a higher heart rate and shock index, despite a normal BP probably inclined us to thrombolyse.

O valor da saúde bucal nas empresas / Oral health in work

Ao recorrerem a prestadoras de serviços odontológicos, as empresas brasileiras alimentam um processo de terceirizaçäo e quarteirizaçäo que pöe em cheque a própria figura do profissional liberal na odontologia