Applications of the Near Attack Conformation (NAC) approach in the search for Acetylcholinesterase reactivators.

The Near Attack Conformation (NAC) approach states that the efficiency of an enzyme-catalyzed reaction depends on the prior attainment of optimal conditions for substrate atom organization and positioning for bond formation. These conditions are prerequisites for the transition state (TS) in which the involved atoms are within the van der Waals range of contact and positioned at an angle similar to that achieved after bond formation. The successful application of this approach to investigate the reactivation mechanism of acetylcholinesterase inhibited by nerve agents has contributed to a better understanding of this mechanism and demonstrated consistent corroboration with experimental data. In this article, we summarize the accomplishments achieved thus far and outline future perspectives.

Programa de Segurança do Paciente Focado nas Estratégias do Stewardship de Antimicrobianos para Staphylococcus Spp / Patient safety program focused on antimicrobial stewardship strategies for Staphylococcus spp

Introdução: A sedimentação do Programa de Stewardship de Antimicrobianos (ATMs), além de reduzir a indução da resistência bacteriana, assegura maior segurança aos pacientes. Este estudo teve por objetivo descrever o perfil de sensibilidade do Staphylococcus aureus e Staphylococcus coagulase negativo (S. CON) nas unidades de internação adulta do hospital para instrumentalizar as equipes e realizar o gerenciamento de ATMs. Métodos: Este estudo retrospectivo foi realizado através de busca em prontuário eletrônico de culturas laboratoriais com S. aureus e S. CON, independentemente do foco, dos anos de 2017, 2018 e 2019, das unidades de internação adultas não críticas e UTI adulto. Para análise, foi realizado o cálculo de coeficiente de sensibilidade absoluto e de médias. As variáveis qualitativas foram apresentadas em relação ao agente etiológico, antibiótico e local de isolamento, com posterior identificação de variabilidade e possibilidades terapêuticas disponíveis. Resultados: Apesar de ocorrer similaridade na distribuição das cepas de Staphylococcus spp. nos locais analisados do hospital, observou-se divergência entre os perfis de sensibilidade do S. aureus e S. CON. Existe superioridade no perfil de sensibilidade do S. aureus em comparação com o S. CON em relação a todos ATMs. A sensibilidade do S. aureus à oxacilina, ainda, possibilita tratamento com ß-lactâmicos; entretanto, a escolha de outras classes de ATMs torna-se necessária em casos de infecções complexas e graves. Conclusão: A análise periódica do perfil de sensibilidade aos ATMs é uma estratégia a ser alcançada para um eficaz programa de gerenciamento de ATMs, com fundamentação de protocolos e melhor assistência dos pacientes.

Introduction: The sedimentation of the antimicrobial stewardship program (ASP) reduces the induction of bacterial resistance and ensures greater patient safety. This study aimed to describe the sensitivity profile of Staphylococcus aureus and negative-coagulase Staphylococcus (CoNS) in adult inpatient units of the hospital to instrumentalize the teams and perform ASP management. Methods: This retrospective study was conducted by searching electronic medical records for laboratory cultures with S. aureus and CoNS, regardless of the focus, from 2017, 2018, and 2019, from the adult non-critical inpatient units and adult ICU. For the analysis, the study calculated the absolute sensitivity coefficient and means. Qualitative variables were related to the etiologic agent, antibiotic, and isolation site, with subsequent identification of variability and available therapeutic possibilities. Results: Although similarity occurred in the distribution of Staphylococcus spp. strains in the analyzed hospital sites, divergence was observed between the sensitivity profiles of S. aureus and CoNS. There is superiority in the sensitivity profile of S. aureus over CoNS concerning all ASP. The sensitivity of S. aureus to oxacillin still allows treatment with ß-lactams. However, the choice of other classes of ASP becomes necessary in cases of complex and severe infections. Conclusion: Periodic analysis of the ASP sensitivity profile is a strategy to achieve an effective ASP management program to support protocols and better patient care.

Síndrome Respiratória Aguda Grave por Influenza A/B: Análise da Situação Vacinal / Severe Acute Respiratory Syndrome due to Influenza A/B: Analysis of Vaccination Status

Introdução: A Influenza é uma doença respiratória altamente contagiosa, prevenível por vacinação, afetando todos os grupos etários,com morbidade e mortalidade variáveis. O objetivo deste estudo foi analisar a relação da situação vacinal dos pacientes com Influenza A/B atendidos com Síndrome Respiratória Aguda Grave. Métodos: Estudo retrospectivo, a partir das notificações do Sistema de Informação de Agravos de Notificação Compulsório do Brasil, de pacientes com esquema vacinal conhecido para Influenza A/B em um hospital-escola do interior do Rio Grande do Sul (2012 a 2018). Resultados: Foram incluídos 596 casos de SRAG, sendo 179 (30,0%) por vírus respiratórios [92 (51,4%) Influenza A/B e 87 (48,6%) outros vírus respiratórios]. Na faixa etária de maiores de 50 anos, a frequência foi 28,2%, 6 meses a 1 ano foi de 19,6%, seguido de 13% no grupo etário de 2 a 4 anos. O esquema vacinal estava completo em 59,8% dos casos, sendo que em 37,5% dos pacientes apresentavam esquema vacinal incompleto. O tratamento antiviral foi administrado em 90,2% do pacientes com SRAG por Influenza A/B, e a alta hospitalar ocorreu em 91,3% dos casos. Conclusão: A vacinação é uma estratégia para prevenção de complicações relacionadas à Influenza. No entanto, a SRAG é uma apresentação com diagnóstico diferencial amplo, e as causas virais necessitam de confirmação para uma otimização da terapêutica antiviral. A equipe de saúde deve estar atenta a pacientes com riscos de SRAG, a fim de minimizar os desfechos negativos, mesmo nos vacinados.

Introduction: Influenza is a highly contagious respiratory disease, preventable by vaccination, affecting all age groups, with variable morbidity and mortality. The objective of this study was to analyze the relationship between the vaccination status of Influenza A/B patients seen with Severe Acute Respiratory Syndrome. Methods: Retrospective study, from notifications of the Brazilian Compulsory Notification Agencies Information System (Sistema de Informação de Agravos de Notificação Compulsório do Brasil), of patients with known vaccination schemes for Influenza A/B in a teaching hospital in the interior of Rio Grande do Sul (2012 to 2018). Results: Of the 596 cases of SARS included, 179 (30.0%) were due to respiratory viruses [92 (51.4%) Influenza A/B and 87 (48.6%) other respiratory viruses]. In the age group over 50 years, the frequency was 28.2%, from 6 months to 1 year old was 19.6%, followed by 13% in the age group of 2 to 4 years. The vaccination schedule was complete in 59.8% of cases, with 37.5% having an incomplete vaccination scheme. Antiviral treatment was administered in 90.2% of the patients with SARS by Influenza A/B, and hospital discharge occurred in 91.3% of the cases. Conclusion: Vaccination is a strategy to prevent complications related to Influenza. However, SARS is a presentation with wide differential diagnosis, and the viral causes need confirmation for an optimization of the antiviral therapy. The healthcare team must be aware of patients at risk of SARS to minimize negative outcomes, even in vaccinated patients.

Development and validation of the MMCD score to predict kidney replacement therapy in COVID-19 patients

BackgroundAcute kidney injury (AKI) is frequently associated with COVID-19 and the need for kidney replacement therapy (KRT) is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting the need for KRT in hospitalized COVID-19 patients. MethodsThis study is part of the multicentre cohort, the Brazilian COVID-19 Registry. A total of 5,212 adult COVID-19 patients were included between March/2020 and September/2020. We evaluated four categories of predictor variables: (1) demographic data; (2) comorbidities and conditions at admission; (3) laboratory exams within 24 h; and (4) the need for mechanical ventilation at any time during hospitalization. Variable selection was performed using generalized additive models (GAM) and least absolute shrinkage and selection operator (LASSO) regression was used for score derivation. The accuracy was assessed using the area under the receiver operating characteristic curve (AUC-ROC). Risk groups were proposed based on predicted probabilities: non-high (up to 14.9%), high (15.0 - 49.9%), and very high risk ([≥] 50.0%). ResultsThe median age of the model-derivation cohort was 59 (IQR 47-70) years, 54.5% were men, 34.3% required ICU admission, 20.9% evolved with AKI, 9.3% required KRT, and 15.1% died during hospitalization. The validation cohort had similar age, sex, ICU admission, AKI, required KRT distribution and in-hospital mortality. Thirty-two variables were tested and four important predictors of the need for KRT during hospitalization were identified using GAM: need for mechanical ventilation, male gender, higher creatinine at admission, and diabetes. The MMCD score had excellent discrimination in derivation (AUROC = 0.929; 95% CI 0.918-0.939) and validation (AUROC = 0.927; 95% CI 0.911-0.941) cohorts an good overall performance in both cohorts (Brier score: 0.057 and 0.056, respectively). The score is implemented in a freely available online risk calculator (https://www.mmcdscore.com/). ConclusionThe use of the MMCD score to predict the need for KRT may assist healthcare workers in identifying hospitalized COVID-19 patients who may require more intensive monitoring, and can be useful for resource allocation.

Percepção de pessoas com transtornos mentais acerca dos cuidados fisioterapêuticos: estudo qualitativo / Perception of people with mental disorders about physiotherapeutic care: qualitative study

INTRODUÇÃO: A inserção da fisioterapia nas equipes de cuidados à saúde mental tem se tornado cada vez mais necessária, devido à importância e efetividade em promover qualidade de vida em indivíduos com transtornos mentais. OBJETIVO: Compreender a percepção de pessoas com transtornos mentais acerca dos cuidados fisioterapêuticos. ESTRATÉGIA METODOLÓGICA: Estudo descritivo de abordagem qualitativa, realizado com nove indivíduos com transtornos mentais no Centro de Saúde Mental e Reabilitação Dr. Álvaro Rubin de Pinho, na cidade de Salvador, Bahia, Brasil, em julho/2021. Os dados foram coletados por meio do questionário sociodemográfico e entrevista semiestruturada, que posteriormente foram transcritas e analisadas conforme análise de conteúdo de Bardin. RESULTADOS: Mediante a exploração dos conteúdos, emergiram três categorias: "O olhar dos indivíduos com transtornos mentais acerca da fisioterapia"; "Atenção e o cuidado no sofrimento psíquico" e "Efetividade fisioterapêutica na saúde mental". Evidenciou-se que os indivíduos percebem que a fisioterapia proporcionou melhora nos aspectos físicos, mentais e sociais, além de atuar como coadjuvante no tratamento. CONSIDERAÇÕES FINAIS: A assistência fisioterapêutica contribui na promoção da saúde, reabilitação psicossocial e melhora da qualidade de vida nos indivíduos com transtornos mentais.

INTRODUCTION: The insertion of physiotherapy in mental health care teams has become increasingly necessary due to its importance and effectiveness in promoting life quality in individuals who suffer with mental disorders. OBJECTIVE: To understand the perception of people from mental disorders about physiotherapeutic care. METHODOLOGICAL STRATEGY: Descriptive study of qualitative approach, carried out with nine individuals with mental disorders at the Dr. Alvaro Rubin de Pinho Mental Health and Rehabilitation Center, in the city of Salvador, Bahia, Brazil, in July/2021. The collected material was acquired through a sociodemographic questionnaire and a semi-structured interview, which was later transcribed and analyzed according to Bardin's content analysis. RESULTS: Through the exploration of the contents, three categories emerged: "Perspectives of individuals with mental disorders about physiotherapy"; "Attention and care in psychic suffering", and "Physiotherapeutic effectiveness in mental health". It became evident that the individuals realize that physiotherapy provided improvement in the physical, mental, and social aspects, besides acting as an adjunct in the treatment. FINAL CONSIDERATIONS: Physiotherapeutic assistance contributes to health promotion, psychosocial rehabilitation, and improvement of the quality of life of individuals with mental disorders.

Hypothyroidism does not lead to worse prognosis in COVID-19: findings from the Brazilian COVID-19 registry

BackgroundIt is not clear whether previous thyroid diseases influence the course and outcomes of COVID-19. The study aims to compare clinical characteristics and outcomes of COVID-19 patients with and without hypothyroidism. MethodsThe study is a part of a multicentric cohort of patients with confirmed COVID-19 diagnosis, including data collected from 37 hospitals. Matching for age, sex, number of comorbidities and hospital was performed to select the patients without hypothyroidism for the paired analysis. ResultsFrom 7,762 COVID-19 patients, 526 had previously diagnosed hypothyroidism (50%) and 526 were selected as matched controls. The median age was 70 (interquartile range 59.0-80.0) years-old and 68.3% were females. The prevalence of underlying comorbidities were similar between groups, except for coronary and chronic kidney diseases, that had a higher prevalence in the hypothyroidism group (9.7% vs. 5.7%, p=0.015 and 9.9% vs. 4.8%, p=0.001, respectively). At hospital presentation, patients with hypothyroidism had a lower frequency of respiratory rate > 24 breaths per minute (36.1% vs 42.0%; p=0.050) and need of mechanical ventilation (4.0% vs 7.4%; p=0.016). D-dimer levels were slightly lower in hypothyroid patients (2.3 times higher than the reference value vs 2.9 times higher; p=0.037). In-hospital management was similar between groups, but hospital length-of-stay (8 vs 9 days; p=0.029) and mechanical ventilation requirement (25.4% vs. 33.1%; p=0.006) were lower for patients with hypothyroidism. There was a trend of lower in-hospital mortality in patients with hypothyroidism (22.1% vs. 27.0%; p=0.062). ConclusionIn this large Brazilian COVID-19 Registry, patients with hypothyroidism had a lower requirement of mechanical ventilation, and showed a trend of lower in-hospital mortality. Therefore, hypothyroidism does not seem to be associated with a worse prognosis, and should not be considered among the comorbidities that indicate a risk factor for COVID-19 severity.

Effectiveness, Explainability and Reliability of Machine Meta-Learning Methods for Predicting Mortality in Patients with COVID-19: Results of the Brazilian COVID-19 Registry

ObjectiveTo provide a thorough comparative study among state-of-the-art machine learning methods and statistical methods for determining in-hospital mortality in COVID-19 patients using data upon hospital admission; to study the reliability of the predictions of the most effective methods by correlating the probability of the outcome and the accuracy of the methods; to investigate how explainable are the predictions produced by the most effective methods. Materials and MethodsDe-identified data were obtained from COVID-19 positive patients in 36 participating hospitals, from March 1 to September 30, 2020. Demographic, comorbidity, clinical presentation and laboratory data were used as training data to develop COVID-19 mortality prediction models. Multiple machine learning and traditional statistics models were trained on this prediction task using a folded cross-validation procedure, from which we assessed performance and interpretability metrics. ResultsThe Stacking of machine learning models improved over the previous state-of-the-art results by more than 26% in predicting the class of interest (death), achieving 87.1% of AUROC and macro F1 of 73.9%. We also show that some machine learning models can be very interpretable and reliable, yielding more accurate predictions while providing a good explanation for the why. ConclusionThe best results were obtained using the meta-learning ensemble model - Stacking. State-of the art explainability techniques such as SHAP-values can be used to draw useful insights into the patterns learned by machine-learning algorithms. Machine-learning models can be more explainable than traditional statistics models while also yielding highly reliable predictions.

ABC2-SPH risk score for in-hospital mortality in COVID-19 patients: development, external validation and comparison with other available scores

ObjectiveTo develop and validate a rapid scoring system at hospital admission for predicting in-hospital mortality in patients hospitalized with coronavirus disease 19 (COVID-19), and to compare this score with other existing ones. DesignCohort study SettingThe Brazilian COVID-19 Registry has been conducted in 36 Brazilian hospitals in 17 cities. Logistic regression analysis was performed to develop a prediction model for in-hospital mortality, based on the 3978 patients that were admitted between March-July, 2020. The model was then validated in the 1054 patients admitted during August-September, as well as in an external cohort of 474 Spanish patients. ParticipantsConsecutive symptomatic patients ([≥]18 years old) with laboratory confirmed COVID-19 admitted to participating hospitals. Patients who were transferred between hospitals and in whom admission data from the first hospital or the last hospital were not available were excluded, as well those who were admitted for other reasons and developed COVID-19 symptoms during their stay. Main outcome measuresIn-hospital mortality ResultsMedian (25th-75th percentile) age of the model-derivation cohort was 60 (48-72) years, 53.8% were men, in-hospital mortality was 20.3%. The validation cohorts had similar age distribution and in-hospital mortality. From 20 potential predictors, seven significant variables were included in the in-hospital mortality risk score: age, blood urea nitrogen, number of comorbidities, C-reactive protein, SpO2/FiO2 ratio, platelet count and heart rate. The model had high discriminatory value (AUROC 0.844, 95% CI 0.829 to 0.859), which was confirmed in the Brazilian (0.859) and Spanish (0.899) validation cohorts. Our ABC2-SPH score showed good calibration in both Brazilian cohorts, but, in the Spanish cohort, mortality was somewhat underestimated in patients with very high (>25%) risk. The ABC2-SPH score is implemented in a freely available online risk calculator (https://abc2sph.com/). ConclusionsWe designed and validated an easy-to-use rapid scoring system based on characteristics of COVID-19 patients commonly available at hospital presentation, for early stratification for in-hospital mortality risk of patients with COVID-19. Summary boxesWhat is already known on this topic? O_LIRapid scoring systems may be very useful for fast and effective assessment of COVID-19 patients in the emergency department. C_LIO_LIThe majority of available scores have high risk of bias and lack benefit to clinical decision making. C_LIO_LIDerivation and validation studies in low- and middle-income countries, including Latin America, are scarce. C_LI What this study adds O_LIABC2-SPH employs seven well defined variables, routinely assessed upon hospital presentation: age, number of comorbidities, blood urea nitrogen, C reactive protein, Spo2/FiO2 ratio, platelets and heart rate. C_LIO_LIThis easy-to-use risk score identified four categories at increasing risk of death with a high level of accuracy, and displayed better discrimination ability than other existing scores. C_LIO_LIA free web-based calculator is available and may help healthcare practitioners to estimate the expected risk of mortality for patients at hospital presentation. C_LI

Accidental catheterization of epidural venous plexus: tomographic analysis / Cateterização acidental do plexo venoso peridural: análise tomográfica

ABSTRACT BACKGROUND AND OBJECTIVES: Inadvertent venous catheterizations occur in approximately 9% of lumbar epidural anesthetic procedures with catheter placement and, if not promptly recognized, can result in fatal consequences. The objective of this report is to describe a case of accidental catheterization of epidural venous plexus and its recording by computed tomography with contrast injection through the catheter. CASE REPORT: A female patient in her sixties, physical status II (ASA), underwent conventional cholecystectomy under balanced general anesthesia and an epidural with catheter for postoperative analgesia. During surgery, there was clinical suspicion of accidental catheterization of epidural venous plexus because of blood backflow through the catheter, confirmed by the administration of a test dose through the catheter. After the surgery, a CT scan was obtained after contrast injection through the catheter. Contrast was observed all the way from the skin to the azygos vein, passing through anterior and posterior epidural venous plexuses and intervertebral vein. CONCLUSION: It is possible to identify the actual placement of the epidural catheter, as well as to register an accidental catheterization of the epidural venous plexus, using computed tomography with contrast injection through the epidural catheter.

RESUMO JUSTIFICATIVA E OBJETIVOS: A cateterização venosa inadvertida ocorre em aproximadamente 9% das anestesias peridurais lombares com introdução de cateter e caso não seja prontamente reconhecida pode trazer consequências fatais. O objetivo deste relato é descrever um caso de cateterização acidental do plexo venoso peridural e o seu registro por tomografia computadorizada com injeção de contraste pelo cateter. RELATO DE CASO: Paciente feminina, sexagenária, estado físico II (ASA), submetida à colecistectomia convencional sob anestesia geral balanceada e peridural com cateter para analgesia pós-operatória. Durante cirurgia houve suspeição clínica de cateterização acidental do plexo venoso peridural, por refluxo de sangue pelo cateter, fato confirmado pela administração de dose-teste pelo cateter. Feita tomografia computadorizada com injeção de contraste pelo cateter, após o termino da cirurgia. Observado todo o trajeto do contraste desde a pele até a veia ázigo, passando pelo plexo venoso peridural anterior, posterior e veia intervertebral. CONCLUSÃO: É possível a identificação do real posicionamento do cateter peridural, bem como o registro da cateterização acidental do plexo venoso peridural, por meio de tomografia computadorizada com injeção de contraste pelo cateter peridural.

Accidental catheterization of epidural venous plexus: tomographic analysis.

BACKGROUND AND OBJECTIVES: Inadvertent venous catheterizations occur in approximately 9% of lumbar epidural anesthetic procedures with catheter placement and, if not promptly recognized, can result in fatal consequences. The objective of this report is to describe a case of accidental catheterization of epidural venous plexus and its recording by computed tomography with contrast injection through the catheter. CASE REPORT: A female patient in her sixties, physical status II (ASA), underwent conventional cholecystectomy under balanced general anesthesia and an epidural with catheter for postoperative analgesia. During surgery, there was clinical suspicion of accidental catheterization of epidural venous plexus because of blood backflow through the catheter, confirmed by the administration of a test dose through the catheter. After the surgery, a CT scan was obtained after contrast injection through the catheter. Contrast was observed all the way from the skin to the azygos vein, passing through anterior and posterior epidural venous plexuses and intervertebral vein. CONCLUSION: It is possible to identify the actual placement of the epidural catheter, as well as to register an accidental catheterization of the epidural venous plexus, using computed tomography with contrast injection through the epidural catheter.

[Accidental catheterization of epidural venous plexus: tomographic analysis]. / Cateterização acidental do plexo venoso peridural: análise tomográfica.

BACKGROUND AND OBJECTIVES: Inadvertent venous catheterizations occur in approximately 9% of lumbar epidural anesthetic procedures with catheter placement and, if not promptly recognized, can result in fatal consequences. The objective of this report is to describe a case of accidental catheterization of epidural venous plexus and its recording by computed tomography with contrast injection through the catheter. CASE REPORT: A female patient in her sixties, physical status II (ASA), underwent conventional cholecystectomy under balanced general anesthesia and an epidural with catheter for postoperative analgesia. During surgery, there was clinical suspicion of accidental catheterization of epidural venous plexus because of blood backflow through the catheter, confirmed by the administration of a test dose through the catheter. After the surgery, a CT scan was obtained after contrast injection through the catheter. Contrast was observed all the way from the skin to the azygos vein, passing through anterior and posterior epidural venous plexuses and intervertebral vein. CONCLUSION: It is possible to identify the actual placement of the epidural catheter, as well as to register an accidental catheterization of the epidural venous plexus, using computed tomography with contrast injection through the epidural catheter.

Parada cardíaca súbita em anestesia geral como a primeira manifestação da origem anômala de artéria coronária esquerda / Sudden cardiac arrest in general anesthesia as the first manifestation of anomalous origin of the left coronary artery / Parada cardíaca súbita en anestesia general como la primera manifestación del origen anómalo de arteria coronaria izquierda

JUSTIFICATIVA E OBJETIVOS: O relato de caso descreve uma situação rara e potencialmente fatal associada à administração de anestesia. Nosso objetivo foi discutir as causas de parada cardíaca súbita no período perioperatório em pacientes aparentemente saudáveis e a fisiopatologia das anomalias de origem das artérias coronárias como uma causa de parada cardíaca súbita. RELATO DE CASO: Uma mulher de 44 anos, sem sintomas prévios de doença coronariana ou arritmias, apresenta parada cardíaca súbita durante a instalação de anestesia geral em duas situações distintas. No primeiro episódio, a paciente apresentava-se com quadro de abdômen agudo, porém hemodinamicamente estável. Após a indução anestésica, ocorreu bradicardia e hipotensão arterial, refratárias à reposição de volume e vasopressores. O quadro evoluiu para assistolia. A paciente foi reanimada com sucesso e recebeu alta em boas condições. No segundo episódio, um ano após o primeiro, a paciente se encontrava em boas condições clínicas para feitura de uma cirurgia eletiva. Após a indução anestésica, a paciente desenvolveu taquicardia ventricular seguida por assistolia, que foi prontamente revertida. Após extensa investigação, foi identificada uma origem anômala da artéria coronária esquerda. CONCLUSÕES: Nosso relato é ilustrativo ao enfatizar que uma investigação diagnóstica minuciosa deve ser feita nos casos de parada cardíaca súbita perioperatória, mesmo em pacientes aparentemente saudáveis.

BACKGROUND AND OBJECTIVES: This case report describes a rare and potentially fatal condition associated with anesthesia administration. Our aim was to discuss the causes of sudden cardiac arrest during the perioperative period in apparently healthy patients and the pathophysiology of anomalous origin of the coronary arteries as a cause of sudden cardiac arrest. CASE REPORT: Female patient, 44 years old, with no previous symptoms of heart disease or arrhythmias, had a sudden cardiac arrest during general anesthesia in two different situations. In the first episode, the patient presented signs of acute abdomen, but remained hemodynamically stable. Following induction of anesthesia, the patient exhibited bradycardia and hypotension refractory to volume replacement and vasopressors. The condition progressed to asystole. The patient was successfully resuscitated and discharged from the hospital in good condition. In the second episode, one year after the first, the patient was in good clinical condition to undergo an elective surgery. After induction of anesthesia, the patient developed ventricular tachycardia followed by asystole, which was promptly reversed. After extensive investigation, an anomalous origin of the left coronary artery was identified. CONCLUSIONS: Our report is illustrative as it emphasizes that a thorough diagnostic investigation should be done in cases of sudden cardiac arrest during the perioperative period, even in patients that appear to be healthy.

JUSTIFICATIVA Y OBJETIVOS: El relato de caso describe una situación rara y potencialmente fatal asociada con la administración de anestesia. Nuestro objetivo fue discutir las causas de parada cardíaca súbita en el período perioperatorio en pacientes aparentemente sanos y la fisiopatología de las anomalías de origen de las arterias coronarias como una causa de parada cardíaca súbita. RELATO DE CASO: Mujer de 44 años, sin sintomatología anterior de enfermedad coronaria o arritmias, que presenta una parada cardíaca súbita durante la aplicación de la anestesia general en dos situaciones distintas. En el primer episodio, la paciente tenía un cuadro de abdomen agudo pero hemodinámicamente estable. Después de la inducción anestésica, ocurrió una bradicardia e hipotensión arterial, refractarias a la reposición de volumen y vasopresores. El cuadro evolucionó con asistolia. La paciente fue reanimada con éxito y recibió alta en buenas condiciones. En el segundo episodio, un año después del primero, la paciente estaba en buenas condiciones clínicas para la realización de una cirugía electiva. Después de la inducción anestésica, desarrolló una taquicardia ventricular seguida por asistolia, que fue rápidamente revertida. Después de una extensa investigación, fue identificado un origen anómalo de la arteria coronaria izquierda. CONCLUSIONES: Nuestro relato es ilustrativo porque enfatiza que una investigación diagnóstica minuciosa debe ser realizada en los casos de parada cardíaca súbita perioperatoria, incluso en los pacientes aparentemente sanos.

Sudden cardiac arrest in general anesthesia as the first manifestation of anomalous origin of the left coronary artery.

BACKGROUND AND OBJECTIVES: This case report describes a rare and potentially fatal condition associated with anesthesia administration. Our aim was to discuss the causes of sudden cardiac arrest during the perioperative period in apparently healthy patients and the pathophysiology of anomalous origin of the coronary arteries as a cause of sudden cardiac arrest. CASE REPORT: Female patient, 44 years old, with no previous symptoms of heart disease or arrhythmias, had a sudden cardiac arrest during general anesthesia in two different situations. In the first episode, the patient presented signs of acute abdomen, but remained hemodynamically stable. Following induction of anesthesia, the patient exhibited bradycardia and hypotension refractory to volume replacement and vasopressors. The condition progressed to asystole. The patient was successfully resuscitated and discharged from the hospital in good condition. In the second episode, one year after the first, the patient was in good clinical condition to undergo an elective surgery. After induction of anesthesia, the patient developed ventricular tachycardia followed by asystole, which was promptly reversed. After extensive investigation, an anomalous origin of the left coronary artery was identified. CONCLUSIONS: Our report is illustrative as it emphasizes that a thorough diagnostic investigation should be done in cases of sudden cardiac arrest during the perioperative period, even in patients that appear to be healthy.

Impact of the construction of the harbor at pecém (Ceará, Brazil) upon reef fish communities in tide pools

This study aimed to assess the impact of harbor construction at Pecém (Brazil) upon the reef fish communities in tide pools. The monitoring was carried out through a visual census and sea water quality was evaluated by microbiological analyses. From March to December 2001, 1,425 individuals of 17 families and 25 species were registered. The most frequent species were Haemulon parra, Acanthurus chirurgus, Abudefduf saxatilis and Sparisoma axillare. The average species diversity for the whole period was 1.77 bits.ind -1. There was evidence that the tide pools gradually silted up, resulting in a reduction in species diversity and richness. The microbiological analyses indicated the presence of faecal coliforms in the water though not at significant levels. The present study could be useful as an early reference for future projects, using the fish communities as indicators for the impact upon the environment of the harbor construction and other human activities.

O objetivo principal desta pesquisa foi estudar os possíveis impactos sobre as comunidades de peixes que vivem em poças de maré na praia de Pecém-CE. O método de censo visual foi utilizado para o registro dos peixes, e a análise microbiológica para verificar a qualidade das águas. No período de março a dezembro de 2001 foram observados 1.425 indivíduos pertencentes a 17 famílias e 25 espécies em três poças estudadas. As espécies mais freqüentes foram Haemulon parra, Acanthurus chirurgus, Abudefduf saxatilis e o Sparisoma axillare. A diversidade média de espécies no período foi de 1,77 bits.ind-1. Durante a pesquisa foi observado um processo crescente de assoreamento na área de estudo, em decorrência da construção do porto de Pecém. No que concerne à balneabilidade das águas dessa praia, a avaliação não mostrou sinais significativos de poluição microbiológica, embora tenha sido detectada a presença de coliformes fecais. Os resultados desta pesquisa poderão servir como referência pioneira para futuros projetos de monitoramento para áreas que venham a sofrer com atividades de construção portuária.

Valor da tomografia computadorizada no planejamento cirúrgico do câncer da laringe e hipofaringe com invasão da infraglote / Value of the computed tomography in the surgical management of laryngeal and hypopharyngeal cancer with subglottic invasion

Objetivo: Avaliar a concordância interobservadores, por meio da análise da tomografia computadorizada (TC), em relação ao envolvimento da infraglote por carcinoma espinocelular (CEC) de laringe e hipofaringe e sua relação com o planejamento cirúrgico. Pacientes e método: Foram selecionados e avaliados exames de TC, do período entre 1990 a 2004, de 76 pacientes com CEC do trato aerodigestivo superior, neste estudo retrospectivo e não randomizado. Todos os pacientes eram oriundos do Departamento de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia do Hospital Heliópolis, São Paulo, Brasil, sendo 68 do gênero masculino e apenas oito do feminino, com idade variando de 32 a 73 anos. Os exames foram avaliados por quatro radiologistas, separadamente, sem o conhecimento prévio do estadiamento clínico. Todos os pacientes não haviam recebido qualquer tratamento até o momento do exame de imagem, como cirurgia, quimioterapia ou radioterapia. As informações epidemiológicas foram obtidas baseadas na revisão de prontuários médicos. Resultados: O índice Kappa obtido para estimar a concordância entre os quatro observadores foi de 0,84. Conclusão: A TC é um método relevante na avaliação da invasão da infraglote no câncer da laringe e hipofaringe e sua contribuição é relevante no planejamento cirúrgico.

Objective: to evaluate the interobserver agreement by means of computed tomography (CT) analysis regarding the involvement of the subglottis by squamous cell carcinoma (SCC). Patients and methods: Seventy-six CT images of patients with SCC (1990 to 2004) were selected and evaluated. All patients were from the Service of Head and Neck Surgery and ORL of the Hospital Heliópolis, São Paulo, Brazil. Among the patients, 68 were men and 8 were women, with ages ranging from 32 to 73 years-old. The imaging results were analyzed by four radiologists, alone without any previous knowledge of the clinical stage. No patients had received any previous treatment up to the moment of the imaging examination, such as surgery, chemotherapy or radiotherapy. Information was obtained from the medical file. Results: The Kappa Index, calculated by assessing agreement between four observers, was 0.84. Conclusions: The CT is indicated in the evaluation of the subglottic invasion in cancer of the larynx and hypopharynx, and is relevant in the surgical planning.

Características tomográficas da displasia fibrosa craniofacial: estudo retrospectivo de 14 casos / Tomographic features of craniofacial fibrous dysplasia: a retrospective study of 14 cases

OBJETIVO: Apresentar as várias formas de displasia fibrosa craniofacial em um estudo revisional com 14 exames de tomografia computadorizada. MATERIAIS E MÉTODOS: Foram selecionados 14 casos de displasia fibrosa craniofacial atendidos no Serviço de Cirurgia de Cabeça e Pescoço e Otorrinolaringologia e no Serviço de Diagnóstico por Imagem do Hospital Heliópolis, São Paulo, SP, entre 1991 e 2002. Foram avaliados, pelos autores, três dos achados tomográficos mais relevantes: o número de ossos acometidos, a apresentação radiológica predominante e a uni/bilateralidade da doença no crânio. RESULTADOS: Observou-se predomínio do padrão misto em relação à forma de apresentação da doença. Foram vistos, ainda, acometimento contíguo de dois ou mais ossos e equivalência entre casos de acometimento craniofacial unilateral e bilateral, possivelmente por conta dos pacientes serem, em sua maioria, portadores de displasia fibrosa do tipo monostótica. CONCLUSÃO: O conhecimento das características tomográficas da displasia fibrosa craniofacial é de grande importância para que seja feito planejamento cirúrgico adequado e seguimento pós-tratamento.

OBJECTIVE: To describe the different presentations of craniofacial fibrous dysplasia in a revisional study of 14 computed tomography exams. MATERIALS AND METHODS: The authors have selected 14 cases of craniofacial fibrous dysplasia attended at the Head & Neck Surgery/Otorhinolaryngology Service and Diagnostic Imaging Service of "Hospital Heliópolis", São Paulo, SP, Brazil, between 1991 and 2002. Three of the following most relevant tomographic findings were analyzed: number of bones affected, predominant radiological presentation and the disease uni- or bilaterality. RESULTS: A predominance of a mixed pattern was observed in relation to the disease presentation. Also, contiguous involvement of two or more bones was observed as well as equivalence between cases of unilateral and bilateral craniofacial involvement, possibly due the fact that most patients presented the monostotic type of fibrous dysplasia. CONCLUSION: The knowledge of tomographic features of craniofacial fibrous dysplasia is of paramount importance for surgical planning and post-treatment follow-up.

Actinomicose laríngea: relato de caso / Actinomycosis of the larynx: a case report

Relatamos um caso de actinomicose laríngea mimetizando neoplasia, com revisão da literatura a respeito dos aspectos clínicos, patológicos e de imagens. Utilizamos tomografia computadorizada, exame loco-regional, nasofibroscopia e estudo anatomopatológico. A importância do estudo se deve à raridade da enfermidade, localização atípica e particularmente ao diagnóstico diferencial com neoplasia de laringe. Não identificamos, na literatura, casos com avaliação por meio de tomografia computadorizada.

We report a case of a patient with actinomycosis of the larynx mimicking a neoplasm. A literature review, clinical features, pathology and imaging findings is also presented. This paper reports a rare disease occurring in an atypical location, simulating larynx neoplasm. To our knowledge, there is no report of this disease and locations evaluated with computed tomography.

Aneurisma de artéria hepática simulando lesão em cabeça de pâncreas: relato de caso / Hepatic artery aneurysm simulating a lesion in the head of the pancreas: a case report

O objetivo deste estudo é relatar um caso raro de aneurisma da artéria hepática simulando lesão em cabeça de pâncreas. É importante a análise precisa por tomografia computadorizada e ressonância magnética, pois desempenham papel importante no planejamento terapêutico e influenciam também o prognóstico.

The aim of this study is to report a rare case of hepatic artery aneurysm simulating a lesion in the head of the pancreas. A precise evaluation using computed tomography and magnetic resonance imaging is important in the treatment planning, which will influence the prognosis

Determinantes do estado nutricional em pacientes com AIDS / Determinants of nutritional status in AIDS patients

Os autores realizaram ampla revisao da literatura, com o objetivo de estabelecer os principais parâmetros de avaliaçao do estado nutricional dos pacientes com Aids. Sao descritos os principais determinantes da boa nutriçao, suas correlaçoes com a estimativa de sobrevida destes doentes e sua importância para o diagnóstico de desnutriçao e conseqüente instituiçao de suporte nutricional adequado, afim de melhorar nao somente a sobrevida, assim como a qualidade de vida dos pacientes com Aids, freqüentemente acometidos por desordens nutricionais e consumptivas.

Manejo terapêutico da desnutriçäo e consumo em pacientes com AIDS / Therapeutic approach of malnutrition and consumption in patients with AIDS

Os autores realizaram ampla revisao da literatura sobre desnutriçao e síndrome consumptiva em pacientes com Aids, focalizando as principais medidas terapêuticas que podem ser instituídas, com o objetivo de melhorar a qualidade de vida e mesmo a sobrevida. Essas medidas terapêuticas, que visam melhorar o estado nutricional e consumptivo dos pacientes com Aids, baseiam-se em medidas gerais de suporte; terapia antiviral; uso de agentes anabólicos, como o acetato de magestrol e a arginina; nutriçao enteral e parenteral, além da suplementaçao com determinados elementos que parecem ser de grande valia, como o zinco, selênio e os ácidos graxos poliinsaturados n-3. Tais medidas sao detalhadamente descritas nesta revisao.