The Integrative Weaning Index in Elderly ICU Subjects.

BACKGROUND: With increasing life expectancy and ICU admission of elderly patients, mechanical ventilation, and weaning trials have increased worldwide. METHODS: We evaluated a cohort with 479 subjects in the ICU. Patients younger than 18 y, tracheostomized, or with neurologic diseases were excluded, resulting in 331 subjects. Subjects ≥70 y old were considered elderly, whereas those <70 y old were considered non-elderly. Besides the conventional weaning indexes, we evaluated the performance of the integrative weaning index (IWI). The probability of successful weaning was investigated using relative risk and logistic regression. The Hosmer-Lemeshow goodness-of-fit test was used to calibrate and the C statistic was calculated to evaluate the association between predicted probabilities and observed proportions in the logistic regression model. RESULTS: Prevalence of successful weaning in the sample was 83.7%. There was no difference in mortality between elderly and non-elderly subjects (P = .16), in days of mechanical ventilation (P = .22) and days of weaning (P = .55). In elderly subjects, the IWI was the only respiratory variable associated with mechanical ventilation weaning in this population (P < .001). CONCLUSIONS: The IWI was the independent variable found in weaning of elderly subjects that may contribute to the critical moment of this population in intensive care.

Sleep quality and quality of life in patients with epilepsy in a public teaching hospital in Rio de Janeiro, Brazil / Qualidade de sono e qualidade de vida em pacientes com epilepsia em um hospital público de ensino no Rio de Janeiro, Brasil

The main aim of this paper was to estimate the prevalence of the "bad sleepers", correlate the "sleep quality" with the quality of life, and to study the risk factors for "sleep quality" in 98 unselected adult patients with epilepsy in a cross-sectional study performed in a public teaching hospital. They answered/were evaluated: clinical-socio demographics questions, Pittsburg Sleep Quality Index, Depression and Anxiety Beck Inventories, and SF-36 Health Survey. They were found a high rate of "bad sleepers"; statistically significant difference between "sleep quality" in relation to age, depression and anxiety symptoms, and three SF-36 concepts (physical role, vitality, and mental health). After multiple linear regression analysis, it was found that vitality and anxiety, besides mental health, were the predictors of lower quality of life in "bad sleepers". However, there was not any statistically significant difference regarding seizure frequency, nor number of antiepileptic drugs. Consequently, risk factors for low "sleep quality" have to be managed.

O principal objetivo deste trabalho foi estimar a prevalência dos "maus dormidores", correlacionar a "qualidade do sono" com a qualidade de vida e estudar os fatores de risco para "qualidade do sono" em 98 pacientes adultos não selecionados com epilepsia em um estudo transversal realizado em um hospital público de ensino. Eles responderam/foram avaliados: questões clínicas e sociodemográficas, Índice de Pittsburg de Qualidade de Sono, Inventários de Beck de depressão e ansiedade e Questionário de Qualidade de Vida SF-36. Foram encontradas alta taxa de "maus dormidores"; diferença estatisticamente significativa entre "qualidade do sono" e idade, sintomas de depressão e ansiedade, além de três conceitos do SF-36 (papel físico, vitalidade e saúde mental). Após análise por regressão linear múltipla, encontrou-se que a vitalidade e a ansiedade, além da saúde mental, foram preditores de baixa qualidade de vida nos "maus dormidores". No entanto, não houve qualquer diferença estatisticamente significativa em relação à frequência de crises, nem número de drogas antiepilépticas. Consequentemente, fatores de risco para baixa "qualidade do sono" têm de ser controlados.

[Emerging comorbidities in Graves' disease patients treated with radioiodine with more than 10 years of follow-up]. / Avaliação do surgimento de comorbidades em pacientes com doença de Graves tratados com iodo radioativo em acompanhamento por mais de 10 anos.

OBJECTIVES: To evaluate the occurrence of cardiovascular disease and malignant tumors and the mortality rate in patients who received radioiodine treatment for hyperthyroidism due to Grave's disease with at least ten years of follow-up. MATERIALS AND METHODS: The medical records of all patients who were treated with I131 for Graves' disease at Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, were reviewed retrospectively, between January, 1981 and November, 1999. RESULTS: Data from 107 patients (14 men and 93 women), with median age of 54 years were analyzed. Comparing the group of patients who were treated with I131 therapy with a group of euthyroid patients post-treatment with antithyroid drugs, a significant increase in the occurrence of hypertension and dyslipidemia was observed, but not in mortality rate. CONCLUSION: To evaluate the real influence of the treatment with radioactive iodine in the occurrence of these comorbidities and the mortality rate, we need a longer follow-up. The age and time of exposure to the effects of hyperthyroidism seem to influence the occurrence of these comorbidities.

Avaliação do surgimento de comorbidades em pacientes com doença de Graves tratados com iodo radioativo em acompanhamento por mais de 10 anos / Emerging comorbidities in Graves' disease patients treated with radioiodine with more than 10 years of follow-up

OBJETIVOS: Avaliar o surgimento de comorbidades cardiovasculares e/ou neoplásicas e a taxa de mortalidade nos pacientes com hipertireoidismo em decorrência da doença de Graves tratados com iodo radioativo há mais de 10 anos. MATERIAIS E MÉTODOS: Estudo retrospectivo com análise de prontuários do Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, entre janeiro de 1981 e novembro de 1999. RESULTADOS: Foram avaliados 107 pacientes (93 mulheres e 14 homens), com uma mediana de idade de 54 anos. Comparando o grupo de pacientes que receberam iodo radiativo com grupo de pacientes eutireoidianos pós-tratamento com drogas antitireoidianas (DAT), foi observado aumento significativo no surgimento de hipertensão arterial (HAS) e dislipidemia, mas não na taxa de mortalidade. CONCLUSÃO: Para avaliar a real influência da terapêutica com iodo radioativo no surgimento dessas comorbidades e na taxa de mortalidade, é necessário um tempo maior de acompanhamento. A idade e o tempo de exposição aos efeitos do hipertireoidismo parecem influenciar no surgimento dessas comorbidades.

OBJECTIVES: To evaluate the occurrence of cardiovascular disease and malignant tumors and the mortality rate in patients who received radioiodine treatment for hyperthyroidism due to Grave's disease with at least ten years of follow-up. MATERIALS AND METHODS: The medical records of all patients who were treated with I131 for Graves' disease at Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, were reviewed retrospectively, between January, 1981 and November, 1999. RESULTS: Data from 107 patients (14 men and 93 women), with median age of 54 years were analyzed. Comparing the group of patients who were treated with I131 therapy with a group of euthyroid patients post-treatment with antithyroid drugs, a significant increase in the occurrence of hypertension and dyslipidemia was observed, but not in mortality rate. CONCLUSION: To evaluate the real influence of the treatment with radioactive iodine in the occurrence of these comorbidities and the mortality rate, we need a longer follow-up. The age and time of exposure to the effects of hyperthyroidism seem to influence the occurrence of these comorbidities.

Correlação entre marcadores de injúria miocárdica, disfunção ventricular e mortalidade na sepsis / The correlation between markers for myocardial injury, ventricular dysfunction and mortality in sepsis

Introdução: O choque séptico é a principal causa de morte nas unidades de terapia intensiva, sendo a depressão miocárdica um importante fator causal nesse desfecho. Objetivo: Avaliar a função ventricular e o tipo de alteração contrátil (regional ou difusa) presentes em pacientes na fase aguda da sepsis e sua correlação com marcadores de injúrias miocárdica e mortalidade. Método: Foram estudados prospectiva e, consecutivamente, 45 pacientes sépticos, admitidos na unidade de terapia intensiva no período de 24 meses. Foi realizado um ecocardiograma transtorácico (ETT) na fase aguda da sepsis, junto com ecocardiograma (ECG) e dosagem sérica troponina I (TNI). Em um segundo momento, foram analisadas a frequência e a correlação das alterações funcionais ao ecocardiograma, da elevação da TNI e a taxa de mortalidade dos pacientes. O ETT foi repetido nos pacientes que sobreviveram após a resolução do quadro séptico. Resultados: Dos 45 pacientes estudados, o ECG mostrou alterações isquêmicas em 40% e o ecocardiograma apresentou alteração regional ou difusa em 44% dos pacientes estudados. A TNI esteve elevada em 53% dos pacientes, dos quais 77% apresentavam disfunção ventricular esquerda (DVE) na fase aguda da sepsis. O ETT evolutivo foi realizado em 24 pacientes (53%%), mostrando melhora parcial...

Central corneal thickness in patients with systemic sclerosis: a controlled study.

PURPOSE: To compare the central corneal thickness (CCT) of patients with systemic sclerosis (SSc) and control subjects. METHODS: The study group comprised 37 consecutive patients with SSc, and the control group comprised 23 healthy individuals similar in age and sex. CCT value was measured by ultrasound pachymetry. RESULTS: In the SSc group, the mean CCT in the right eye was 534.9 ± 33.5 µm and 536.9 ± 32.4 µm in the left eye. In the control group, the mean CCT was 533.0 ± 32.9 µm in the right eye and 533.1 ± 33.6 µm in the left eye. The mean CCT was not significantly different in the SSc group compared with the control group for both the right (P = 0.83) and left (P = 0.67) eyes. CONCLUSIONS: CCT measurements do not significantly differ in patients with SSc compared with healthy control subjects.

Alveolar recruitment maneuver in patients with subarachnoid hemorrhage and acute respiratory distress syndrome: a comparison of 2 approaches.

PURPOSE: The purpose of the study was to compare 2 alveolar recruitment maneuvers (ARMs) approaches in patients with subarachnoid hemorrhage (SAH) and acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS: Sixteen SAH patients with ARDS were randomized in 2 similar groups. One received ARM with continuous positive airway pressure (CPAP) of 35 cm H(2)O for 40 seconds (CPAP recruitment), whereas the other received pressure control ventilation with positive-end expiratory pressure of 15 cm H(2)O and pressure control above positive end-expiratory pressure of 35 cm H(2)O for 2 minutes (pressure control recruitment maneuver [PCRM]). Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were measured before and after ARM. The ratio of arterial oxygen tension to fraction of inspired oxygen was measured before and 1 hour after the ARM. RESULTS: After ARM, ICP was higher in CPAP recruitment (20.50 ± 4.75 vs 13.13 ± 3.56 mm Hg; P = .003); and CPP was lower in CPAP recruitment (62.38 ± 9.81 vs 79.60 ± 6.8 mm Hg; P = .001). One hour after the ARM, the ratio of arterial oxygen tension to fraction of inspired oxygen increased significantly only in PCRM (108.5 to 203.6; P = .0078). CONCLUSION: In SAH patients with ARDS, PCRM did not affect ICP and decreased CPP in safe levels, besides improving oxygenation.

A new integrative weaning index of discontinuation from mechanical ventilation.

INTRODUCTION: Indexes predicting weaning outcome are frequently inaccurate. We developed a new integrative weaning index aimed at improving the accuracy of the traditional indexes. METHODS: Three hundred and thirty-one patients mechanically-ventilated for more than 24 hours were evaluated. Initially, the threshold values of each index that best discriminate between a successful and an unsuccessful weaning outcome were determined in 115 patients. In the second phase, the predictive performance of these values was tested prospectively in the other 216 patients. Frequency/tidal volume ratio (f/Vt ratio), tidal volume (Vt), tracheal airway occlusion pressure 0.1 s (P 0.1), the product of P 0.1 and f/Vt (P 0.1 x f/Vt), respiratory rate (f), static compliance of the respiratory system (Cst,rs), ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2 ratio) and the new integrative weaning index IWI (Cst,rs x arterial oxygen saturation/f/Vt ratio) were evaluated in all patients. The readiness for weaning and the decision to return to mechanical ventilation was made by the physician in charge, based on the signs of poor tolerance. The receiver operating characteristic (ROC) curves were calculated in order to evaluate the predictive performance of each index. The Bayes' theorem was used to assess the probability of each test of predicting weaning. RESULTS: In the prospective-validation set, successful weaning was observed in 183 patients (84.7%) and weaning failure in 33 (15.27%). IWI presented the highest accuracy, with the area under the ROC curves larger than that under the curves for the f/Vt ratio (0.96 x 0.85 respectively; P = 0.003), and also larger than that under the curves for the other indexes. IWI presented a higher probability of successful weaning when the test was positive (0.99) and a lower probability when the test was negative (0.14). Measurement of Cst,rs during the weaning process was considered one of the study limitations. CONCLUSIONS: IWI was the best predictive performance index of weaning outcome and can be used in the intensive care unit setting. TRIAL REGISTRATION: controlled-trials.com ISRCTN92117906.

[Prevalence of anti-thyroid peroxidase and anti-adrenal 21-hidroxylase in type 1 diabetes patients]. / Prevalência do anti-TPO e anti-21-hidroxilase no paciente diabético tipo 1.

UNLABELLED: There is still no consensus about the best strategy to screen Addison's disease (AD) in type 1 diabetes mellitus (T1DM) patients. OBJECTIVE: The aim of this study was to determine the frequency of anti-21-hydroxilase (anti-21OH) in a multiethnic T1DM population and investigate if its presence is associated with any adrenal dysfunction or thyroid autoimmunity. METHODS: Forty individuals underwent an interview and blood was drawn for anti-thyroperoxidase (anti-TPO), anti-21OH, TSH, free T4 and cortisol measurement. RESULTS: Anti-21OH was found in 7.5% (n = 3), none with adrenal dysfunction. This antibody was not exclusively seen in patients with anti-TPO (+). Anti-TPO was positive in 25% and associated with higher TSH levels (p = 0.034) and older age (p = 0.009). CONCLUSIONS: Although the frequency of anti-TPO in this sample was similar to previous studies, a higher prevalence of anti-21-OH was found. However, no coexisting adrenal dysfunction was detected, which does not support universal screening for AD in this group.

Prevalência do anti-TPO e anti-21-hidroxilase no paciente diabético tipo 1 / Prevalence of anti-thyroid peroxidase and anti-adrenal 21-hidroxylase in type 1 diabetes patients

Ainda não está definida a estratégia ideal para rastrear a doença de Addison em pacientes com diabetes melito tipo 1 (DMT1). Objetivo: O objetivo deste estudo foi determinar a prevalência do anticorpo anti-21-hidroxilase (AC anti-21OH) em pacientes DMT1 de etnia diversificada e investigar sua associação à disfunção adrenal e autoimunidade tireoidiana. Métodos: Quarenta indivíduos foram avaliados, submetidos à entrevista e à dosagem de AC antitireoperoxidase (anti-TPO), anti-21OH, TSH, T4 livre e cortisol. AC anti-21OH foi encontrado em 7,5% (n = 3)dos casos, sem disfunção adrenal associada. Resultados: Positividade para anti-21OH não ocorreu exclusivamente em pacientes com anti-TPO (+). Este foi detectado em 25% dos casos e associado a níveis de TSH mais elevados (p = 0,034) e à idade mais avançada (p = 0,009). Conclusões: Embora nossa frequência de anti-TPO (+) seja similar à da literatura, a presença de anti-21OH (+) foi superior. Entretanto, esses AC não foram associados à disfunção hormonal, o que parece não justificar o rastreamento universal da doença de Addison.

There is still no consensus about the best strategy to screen Addison’s disease (AD) in type 1 diabetes mellitus (T1DM) patients. Objective: The aim of this study was to determine the frequency of anti-21-hydroxilase (anti-21OH) in a multiethnic T1DM population and investigate if its presence is associated with any adrenal dysfunction or thyroid autoimmunity. Methods: Forty individuals underwent an interview and blood was drawn for anti- thyroperoxidase (anti-TPO), anti-21OH, TSH, free T4 and cortisol measurement. Results: Anti-21OH was found in 7.5% (n = 3), none with adrenal dysfunction. This antibody was not exclusively seen in patients with anti-TPO (+). Anti-TPO was positive in 25% and associated with higher TSH levels (p = 0.034) and older age (p = 0.009). Conclusions:Although the frequency of anti-TPO in this sample was similar to previous studies, a higher prevalence of anti-21-OH was found. However, no coexisting adrenal dysfunction was detected, which does not support universal screening for AD in this group.

Sentinel lymph node identification in breast cancer: a comparison study of deep versus superficial injection of radiopharmaceutical.

OBJECTIVES: Sentinel lymph node biopsy (SLNB) has been performed for purposes of disease staging. SLN is usually located in the axillary region and internal mammary chain (IMC). Metastasis in internal mammary nodes can be an important prognostic factor and an indication for systemic treatment in patients with small carcinomas. The SLNB technique continues to evolve and the proper radiopharmaceutical injection route remains under discussion. This study evaluated the success rate of deep injection to identify axillary and extra-axillary SLNs and compared the results with superficial injection technique. METHODS: Forty-six patients diagnosed with breast cancer (stages I and II) were submitted to radiopharmaceutical injection. Deep injection of technetium-99m-dextran 500 was carried out in 20 patients (group A) and periareolar injection of technetium-99m-phytate was carried out in 26 patients (group B). All SLNs were studied by imprint cytology and hematoxylin and eosin staining. RESULTS: SLN identification rate was 76.1% (35 of 46). The SLN identification rate was 75% (15 of 20) for group A and 76.9% (20 of 26) for group B. Axillary SLNs were identified in 65% (13 of 20) of group A and 76.9% (20 of 26) of group B, with no statistical difference (P = 0.75). Extra-axillary SLNs were only identified in group A, and IMC was the principal extra-axillary location. CONCLUSION: Deep injection of radiopharmaceutical achieved a good SLN identification rate in axillary and extra-axillary locations and it is an important method for detecting IMC sentinel nodes.

A reologia microvascular das microesferas de perfluoropropano na presença da isquemia-reperfusão, diabetes e sepsis / The microvascular reology of ultrasound contrast in ischemia-reperfusion injury, diabetes and sepsis

Fundamentos: A adesão das microesferas aos leucócitos no tecido inflamado tem sido discutida, porém, pouco se sabe sobre seu comportamento nos capilares. A avaliação dos efeitos circulatórios desse agente pode trazer informações sobre sua ação no miocárdio. Objetivo: Avaliar o comportamento microvascular e hemodinâmico das microesferas nos seguintes grupos: controle, isquemia-reperfusão, diabetes tipo 2, diabetes com isquemia e sepsis. Métodos: Experimentalmente estudou-se a microcirculação da bolsa da bochecha de 65 hamsters machos, sendo separados por grupos conforme a indução da doença de base G-1 igual isquemia/reperfusão. GD igual diabetes, GDI igual diabetes com isquemia GS igual sepsis em relação ao GC (grupo controle). Dentro de cada grupo avaliou-se a pressão arterial...

Avaliação da bupivacaína hipobárica a 0,5 por cento na raquianestesia / Evaluation of 0.5 percent hypobaric bupivacaine in spinal anesthesia

JUSTIFICATIVA E OBJETIVOS: A raquianestesia causa alterações hemodinâmicas relacionadas com fatores próprios do paciente ou não. Um dos fatores é a densidade do anestésico em relação ao líquor, interferindo no número de dermátomos bloqueados e, conseqüentemente, no nível do bloqueio simpático e na diminuição da pressão arterial (PA). O objetivo do estudo foi avaliar a dispersão da bupivacaína hipobárica a 0,5 por cento, preparada assepticamente em laboratório e com uma densidade controlada e uniforme. MÉTODO: Trinta pacientes, ASA I, II ou III, com idade entre 18 e 60 anos, sem comorbidades circulatórias, submetidos a operações ortopédicas no membro inferior participaram do estudo. Eles foram sedados com diazepam 0,03 mg.kg-1, posicionados em decúbito lateral com o lado a ser operado para cima, e puncionados entre L3-L4, com agulha de Quincke 27G, sendo padronizados o direcionamento do bisel e a velocidade de injeção. Foram avaliados os níveis sensitivos e motor (escala modificada de Bromage). RESULTADOS: Ao fim da operação, dois pacientes (6,6 por cento) não apresentaram bloqueio motor classificado como 3 na escala de Bromage, com o bloqueio sensitivo variando entre T4 e T12. Somente 12,9 por cento dos pacientes apresentaram nível sensitivo considerado "alto" para a operação proposta (acima de T6). A diminuição da pressão arterial foi significativa sob o ponto de vista estatístico, sem atingir 20 por cento abaixo dos valores basais, portanto, sem significância clínica. A variação da freqüência cardíaca não foi significativa. CONCLUSÕES: A bupivacaína hipobárica a 0,5 por cento mostrou ser uma opção segura e com poucas repercussões hemodinâmicas para operações ortopédicas nos membros inferiores. A duração média observada, de 250 minutos, possibilita a realização de procedimentos ortopédicos de até médio porte.

BACKGROUND AND OBJECTIVES: Spinal anesthesia may cause hemodynamic changes due to factors related or not to the patient. The density of the anesthetic compared to the CSF, which interferes with the number of dermatomes blocked and, consequently, with the level of the sympathetic blockade and reduction in blood pressure (BP), is one of those factors. The objective of this study was to evaluate the dispersion of 0.5 percent hypobaric bupivacaine prepared aseptically in a laboratory, with controlled and uniform density. METHODS: Thirty patients, physical status ASA I, II, or III, ages ranging from 18 to 60 years, without cardiovascular comorbidities, who underwent orthopedic surgery of the lower limb, were enrolled in this study. They were sedated with diazepam, 0.03 mg.kg-1, placed in lateral decubitus, with the side to be operated on top. A lumbar puncture in the L3-L4 space was performed with a 27G Quincke needle, and the direction of the bevel and rate of injection were standardized. The sensitive and motor levels (modified Bromage scale) were evaluated. RESULTS: At the end of the surgery, two patients (6.6 percent) did not present a level 3 motor blockade in the Bromage scale, and the sensitive blockade varied from T4 to T12. Only 12.9 percent of the patients presented a level of sensitive blockade considered "high" for the proposed surgery (above T6). The reduction in blood pressure was statistically significant, but it did not fall below 20 percent of basal levels and, therefore, was not clinically significant. The change in heart rate was non-significant. CONCLUSIONS: It was demonstrated that 0.5 percent hypobaric bupivacaine is a safe choice, with little hemodynamic repercussion in orthopedic surgeries of the lower limbs. The mean duration of the anesthesia, 250 minutes, allows the realization of minor and medium orthopedic procedures.

JUSTIFICATIVA Y OBJETIVOS: La anestesia espinal causa alteraciones hemodinámicas relacionadas a factores propios del paciente o no. Uno de los factores es la densidad del anestésico con relación al líquor, interfiriendo en el número de dermátomos bloqueados y consecuentemente en el nivel del bloqueo simpático y la disminución de la presión arterial (PA). El objetivo del estudio fue el de evaluar la dispersión de la bupivacaína hipobárica a 0,5 por ciento, preparada asépticamente en laboratorio y con una densidad controlada y uniforme. MÉTODO: Treinta pacientes, ASA I, II o III, con edad entre 18 y 60 anos, sin comorbidades circulatorias, sometidos a operaciones ortopédicas en el miembro inferior participaron en el estudio. Se sedaron con diazepam 0,03 mg.kg-1, posicionados en decúbito lateral con el lado a ser operado para arriba, y puncionados entre L3-L4, con aguja de Quincke 27G, siendo estandarizados con bisel y a velocidad de inyección. Se evaluaron los niveles sensitivos y motor (escala modificada de Bromage). RESULTADOS: Al final de la operación, de los pacientes (6,6 por ciento) no presentaron bloqueo motor clasificado como 3 en la escala de Bromage, con el bloqueo sensitivo variando entre T4 y T12. Solamente 12,9 por ciento de los pacientes presentaron nivel sensitivo considerado "alto" para la operación propuesta (por encima de T6). La disminución de la presión arterial fue significativa bajo el punto de vista estadístico, sin llegar al 20 por ciento por debajo de los valores basales, por tanto sin significancia clínica. La variación de la frecuencia cardiaca no fue significativa. CONCLUSIONES: La bupivacaína hipobárica a 0,5 por ciento mostró ser una opción segura, y con pocas repercusiones hemodinámicas para operaciones ortopédicas en los miembros inferiores. La duración promedio observada, de 250 minutos, posibilita la realización de procedimientos ortopédicos de medio porte.

[Evaluation of 0.5% hypobaric bupivacaine in spinal anesthesia]. / Avaliação da bupivacaína hipobárica a 0,5% na raquianestesia.

BACKGROUND AND OBJECTIVES: Spinal anesthesia may cause hemodynamic changes due to factors related or not to the patient. The density of the anesthetic compared to the CSF, which interferes with the number of dermatomes blocked and, consequently, with the level of the sympathetic blockade and reduction in blood pressure (BP), is one of those factors. The objective of this study was to evaluate the dispersion of 0.5% hypobaric bupivacaine prepared aseptically in a laboratory, with controlled and uniform density. METHODS: Thirty patients, physical status ASA I, II, or III, ages ranging from 18 to 60 years, without cardiovascular comorbidities, who underwent orthopedic surgery of the lower limb, were enrolled in this study. They were sedated with diazepam, 0.03 mg.kg-1, placed in lateral decubitus, with the side to be operated on top. A lumbar puncture in the L3-L4 space was performed with a 27G Quincke needle, and the direction of the bevel and rate of injection were standardized. The sensitive and motor levels (modified Bromage scale) were evaluated. RESULTS: At the end of the surgery, two patients (6.6%) did not present a level 3 motor blockade in the Bromage scale, and the sensitive blockade varied from T4 to T12. Only 12.9% of the patients presented a level of sensitive blockade considered 'high' for the proposed surgery (above T6). The reduction in blood pressure was statistically significant, but it did not fall below 20% of basal levels and, therefore, was not clinically significant. The change in heart rate was non-significant. CONCLUSIONS: It was demonstrated that 0.5% hypobaric bupivacaine is a safe choice, with little hemodynamic repercussion in orthopedic surgeries of the lower limbs. The mean duration of the anesthesia, 250 minutes, allows the realization of minor and medium orthopedic procedures.

The effects of beta-blockers on dobutamine-atropine stress echocardiography: early protocol versus standard protocol.

BACKGROUND: To study the effects of Beta-blockers during Dobutamine Stress Echocardiography (DSE) comparing the hemodynamic benefits of an early administration of atropine in patients taking or not Beta-blockers. METHODS: One hundred and twenty-one patients were submitted to dobutamine stress echocardiography for the investigation of myocardial ischemia. The administration of atropine was randomized into two groups: A or B (early protocol when atropine was administered at 10 and 20 mcg/kg/min of dobutamine, respectively) and C (standard protocol with atropine at 40 mcg/kg/min of dobutamine). Analysis of the effects of Beta-blockers was done regarding the behavior pattern of heart rate and blood pressure, test time, number of conclusive and inconclusive (negative sub-maximum test) results, total doses of atropine and dobutamine, and general complications. RESULTS: Beta-blocked patients who received early atropine (Group A&B) had a significantly lower double product (p = 0.008), a higher mean test time (p = 0.010) and required a higher dose of atropine (p = 0.0005) when compared to the patients in this group who were not Beta-blocked. The same findings occurred in the standard protocol (Group C), however the early administration of atropine reduced test time both in the presence and absence of this therapy (p = 0.0001). The patients with Beta-blockers in Group A&B had a lower rate of inconclusive tests (26%) compared to those in Group C (40%). Complications were similar in both groups. CONCLUSION: The chronotropic response during dobutamine stress echocardiography was significantly reduced with the use of Beta-blockers. The early administration of atropine optimized the hemodynamic response, reduced test time in patients with or without Beta-blockers and reduced the number of inconclusive tests in the early protocol.

Impacto do protocolo precoce no ecocardiograma de estresse com dobutamina-atropina / Impact of the early protocol on dobutamine-atropine stress echocardiography

Objetivo: Avaliar os efeitos da administração precoce de atropina durante a ecocardiografia de estresse com dobutamina. Métodos: Foram avaliados 121 pacientes referenciados por cardiologistas clínicos para a realização do ecocardiograma de estresse com dobutamina. Os pacientes foram randomizados em três grupos:Grupo A: administração de atropina na dose de 10mg/kg/min de dobutamina; Grupo B: administração de atropina na dose de 20mg/kg/min de dobutamina; Grupo C: administração padrão de atropina na dose de 40mg/kg/min de dobutamina, em caso de não obtenção de 85 por cento de freqüência máxima prevista para a idade. Foram analisados o comportamento da freqüência cardíaca (FC) e da pressão arterial (PA) antes e após a administração da atropina; além de analisados também a duração total do teste, os resultados do teste, a dose total de dobutamina e as complicações gerais. Estes dados foram comparados entre os diferentes grupos. Resultados: O nível médio do duplo-produto foi menor no grupo C quando comparado aos pacientes do grupo B (p igual a 0,002). O mesmo ocorreu em relação ao tempo médio de teste (p igual a 0,0001) e a dose total de dobutamina (25mgx14mgx18mg), que foi significativamente maior nos pacientes do grupo C do que nos pacientes dos grupos A e B, respectivamente (p igual a 0,008)...

The effects of early administration of atropine during dobutamine stress echocardiography: advantages and disadvantages of early dobutamine-atropine protocol.

BACKGROUND: The conventional dobutamine protocol for the investigation of induced myocardial ischemia is well established. Our objective was to evaluate the effects of early administration of atropine during the dobutamine stress echocardiogram, as compared to its conventional use. METHODS: One hundred and twenty-one patients were referred to the dobutamine stress echocardiogram, for the investigation of myocardial ischemia and the administration of atropine was randomized into three groups (A, B, C at 10, 20 and 40 mcg/kg/min of dobutamine, respectively). RESULTS: The mean level of the double product was significantly lower in the group C patients when compared to group B patients (p = 0.002). The mean test time (12.8 +/- 3.1 and 18.7 +/- 3.4 p= 0.0001) and the mean total dose of dobutamine (14 x 18 x 25 mg p = 0.008) were significantly higher in group C patients than in group A & B patients. The mean test time was reduced in 6 minutes (31%) with the early administration of atropine in relation to the standard protocol. The atropine dose used in the different groups was similar. Complications were uniform in all cases. CONCLUSION: The early administration of atropine during the dobutamine-atropine stress echocardiography significantly reduces duration of the test and the dose of amine without increasing the number of complications, the total dose of atropine or the number of diagnostic tests.

Leishmaniose tegumentar americana: casuística hospitalar no Rio de Janeiro / American tegumentary Leishmaniasis: hospitalized cases in Rio de Janeiro

FUNDAMENTOS: A leishmaniose tegumentar americana distribui-se amplamente no Brasil, e o Estado do Rio de Janeiro (capital e interior) constitui área endêmica onde o vetor é encontrado dentro e ao redor das habitações. OBJETIVOS: Análise prospectiva de 48 casos de leishmaniose tegumentar americana atendidos no Hospital Universitário Clementino Fraga Filho/UFRJ, no período de 1990 a 2002. MÉTODOS: Todos os pacientes foram submetidos à biópsia de pele ou mucosa, teste de Montenegro e exame otorrinolaringológico; SbV (10 a 20mg/kg), no total de 10, 30 e 90 doses. foi empregado em 44 pacientes; em quatro casos, anfotericina B (0,5mg/kg/dose) até dose cumulativa de 30mg/kg. RESULTADOS: 28 homens e 20 mulheres na faixa etária de 10 a 89 anos, dos quais 38 (79,1 por cento) infectados no Rio de Janeiro, apresentaram úlcera de membro inferior e comprometimento de mucosa nasal como manifestações mais freqüentes; 41 casos (85,4 por cento) foram reatores à intradermorreação de Montenegro (5mm); 17 casos (35,4 por cento) foram positivos para o achado de amastigotas em macrófagos no infiltrado inflamatório dérmico; predominou o processo inflamatório crônico granulomatoso; cura clínica foi observada em 47 casos; um caso evoluiu para óbito no décimo dia de tratamento. CONCLUSÕES: O estudo da leishmaniose tegumentar (HUCFF/UFRJ) no período 1990/2002 evidenciou padrão conhecido nos aspectos epidemiológicos, clínicos e de resposta terapêutica ao antimonial (SbV) e anfotericina B.

Anti-epileptic drug intake adherence: the value of the blood drug level measurement and the clinical approach

It was evaluated the patient antiepileptic drug (AED) intake adherence in a pilot cross-sectional study carried out at a neurologic out-patient clinic of a university hospital. Ninety-three AED blood concentration (phenobarbital, phenytoin, carbamazepine) were analyzed from 24 patients. The variability of the AED blood level was measured (in the steady state period by means of the variation coefficient) and compared with the self-reported antiepileptic medication non-adherence. AED blood level according to the range (therapeutic or not), and the seizure control. It was not observed any strong correlation between the higher value of variability and the other three parameters of no adherence. The highest correlation was with the blood drug level (therapeutic or not). The evaluation of blood drug measurement alone, except in cases of extreme low adherence and variability of drug intake, is not enough for the recognition of incorrect drug intake, but the clinical markers and the self-reported adherence have to be also considered for this sort of evaluation.