Reproducibility (test–retest) of vestibular evoked myogenic potential

IntroductionThere is still no consensus in the literature as to the best acoustic stimulus for capturing vestibular evoked myogenic potential (VEMP). Low-frequency tone bursts are generally more effective than high-frequency, but recent studies still use clicks. Reproducibility is an important analytical parameter to observe the reliability of responses.ObjectiveTo determine the reproducibility of p13 and n23 latency and amplitude of the VEMP for stimuli with different tone-burst frequencies, and to define the best test frequency.MethodsCross-sectional cohort study. VEMP was captured in 156 ears, on the sternocleidomastoid muscle, using 100 tone-burst stimuli at frequencies of 250, 500, 1000, and 2000 Hz, and sound intensity of 95 dB nHL. Responses were replicated, that is, recorded three times on each side.ResultsNo significant difference was observed for p13 and n23 latencies of the VEMP, captured at three moments with tone-burst stimuli at 250, 500, and 1000 Hz. Only the frequency of 2000 Hz showed a difference between captures of this potential (p < 0.001). p13 and n23 amplitude analysis was also similar in the test–retest for all frequencies analyzed.Conclusionp13 and n23 latencies and amplitudes of VEMP for tone-burst stimuli at frequencies of 250, 500, and 1000 Hz are reproducible.     

Efeitos Terapêuticos da Tripla Antiagregação Plaquetária em Pacientes Femininas Idosas com Diabetes e Infarto Agudo do Miocárdio

BackgroundDual antiplatelet therapy (DAPT) is the cornerstone treatment of acute myocardial infarction (AMI).ObjectiveThe present study aimed to investigate the efficacy and safety of triple antiplatelet therapy (TAPT) in elderly female patients with diabetes and ST segment elevation myocardial infarction (STEMI), who had undergone percutaneous coronary intervention (PCI).MethodsWe designed a randomized, single-blind study. Control group A (97 elderly male patients with diabetes and STEMI, whose CRUSADE scores were < 30) received aspirin, ticagrelor, and tirofiban. A total of 162 elderly female patients with diabetes and STEMI were randomly divided into two groups according to CRUSADE score. Group B (69 patients with CRUSADE score > 31) received aspirin and ticagrelor. Group C (93 patients with CRUSADE score < 30) received aspirin, ticagrelor and tirofiban. P values < 0.05 were considered statistically significant.ResultsCompared to the findings in group A, post-PCI Thrombolysis in Myocardial Infarction (TIMI) grade 3 blood flow and TIMI myocardial perfusion grade 3 were significantly less prevalent in group B (p < 0.05). When compared to groups A and C, the incidence of major adverse complications was significantly higher in group B (p < 0.05).ConclusionTAPT could effectively reduce the incidence of major complications in elderly female patients with diabetes and STEMI. However, close attention should be paid to hemorrhage in patients receiving TAPT. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)     

Bloqueio do plano do eretor da espinha com técnica de múltiplos cateteres para esofagectomia aberta: relato de caso

Background and objective

Erector spinae plane block is a valid technique to provide simultaneously analgesia for combined thoracic and abdominal surgery.

Hearing in Noise Test Brazil: standardization for young adults with normal hearing

IntroductionIndividuals with the same ability of speech recognition in quiet can have extremely different results in noisy environments.ObjectiveTo standardize speech perception in adults with normal hearing in the free field using the Brazilian Hearing in Noise Test.MethodsContemporary, cross-sectional cohort study. 79 adults with normal hearing and without cognitive impairment participated in the study. Lists of Hearing in Noise Test sentences were randomly in quiet, noise front, noise right, and noise left.ResultsThere were no significant differences between right and left ears at all frequencies tested (paired t − 1 test). Nor were significant differences observed when comparing gender and interaction between these conditions. A difference was observed among the free field positions tested, except in the situations of noise right and noise left.ConclusionResults of speech perception in adults with normal hearing in the free field during different listening situations in noise indicated poorer performance during the condition with noise and speech in front, i.e., 0°/0°. The values found in the standardization of the Hearing in Noise Test free field can be used as a reference in the development of protocols for tests of speech perception in noise, and for monitoring individuals with hearing impairment.     

Passive euthanasia in response to attempted suicide: one form of aggressiveness by relatives

A total of 88 interviews were conducted with 40 people attempting suicide who were receiving care in an intensive-care unit, and 129 interviews were carried out with their relatives and friends. The subjects were divided into 3 diagnostic groups: neurosis (n = 14), abuse (n = 19) and psychosis (n = 7). The incidence of relatives' failure to provide care after the suicide attempt--turning-away reactions as well as do not resuscitate orders, a form of passive euthanasia--was investigated. In 8 cases, partners of patients in the abuse and neurosis groups showed turning-away reactions. In 2 cases, relatives of elderly patients in the neurosis group said to the doctor that life-preserving measures should not be taken. Relatives explained their behaviour by saying that they had the best interests of the suicidal individual at heart. In-depth interviews, however, revealed that these reactions were a manifestation of the relatives own psychic conflicts, brought forth by the confrontation with the depressed and suicidal patient. Turning-away reactions and do not resuscitate orders might be interpreted as expressing the relatives' aggressiveness towards the suicidal individual and attempts to escape from a difficult situation. It is important that doctors stand up for the interests of suicidal people, which at times may conflict with relatives' interests, and help the relatives to sort out their problems and wishes with respect to the problem areas of passive euthanasia.     

Ethik in der Intensivmedizin

In more than 30 years of development of intensive care medicine (ICM), our speciality has acquired moral and ethical standpoints, although not without public pressure and discussions. Special commissions dealing, e.g., with brain death, terminal care, ethics of foregoing life-sustaining treatment in the critically ill, withholding or withdrawing mechanical ventilation, and other issues have meen formed in a number of medical societies. International consensus conferences have helped to clarify some of the issues. With increasing experience, a multitude of ethical problems have arisen in ICM that have to be dealt with, such as the issue of quality of life. What is an unworthy life? Are we allowed to make judgments for our patients? What is cost-effectiveness in ICM? Other restrictions include bed and equipment shortages in the intensive care unit (ICU), the necessity for triage – undisputed in catastrophe medicine – and how one should proceed in managing elective patients? In situations of limited ICU bed availability, sicker patients will be admitted, sparing out patients who are less ill for observation and those with poor quality of life and poor prognosis. For the future, it will likely be necessary to define the patients who should be admitted to an ICU more than those who should not be admitted. An ICU treatment entitlement index would be directly proportional to the probability of successful outcome and the quality of the remaining life, and would be inversely related to costs for achieving success. The ICU outcome with survival, hospital mortality, and follow-up of ICU patients is considered. DNR (do not resuscitate), the dying patient, terminal care, terminal weaning – DNT (do not treat) – active and passive euthanasia, living wills, quality of life, and cost-effectiveness for ICU patients are defined. Their application in the ICU will be discussed and problems pointed out. Outcome predictions using scores (APACHE III, SAPS II, MPM) have been developed based on previous experience, but should only be applied to patient groups and for quality assurance in ICUs. The most frequent and difficult problem in the ICU is the vegetative state, which requires an exact diagnosis. The differential diagnosis from other comatose states such as coma, brain death, and locked-in-syndrome is depicted. The ethics of interrupting life-sustaining treatment in critically ill patients have been worked out by a Task Force on Ethics of the Society of Critical Care Medicine (1990). A consensus was found that the patient may judge to forego therapy; ethically it is then appropriate to withhold or withdraw therapy. According to the consensus, withdrawing an already initiated treatment should not necessarily be regarded as more problematic than a decision not to initiate treatment. In my mind, however, there is a great difference between withdrawing or withholding, e.g., ventilation. A dissentive opinion by some members of the Task Force stated that hydration and nutrition other than high-technology or parenteral nutrition are key components of patient care, and should not be equated with medical intervention. The ethical problems associated with active euthanasia (physician-assisted suicide or death) as practised in the Netherlands are also discussed. In most countries this practice seems unacceptable. From 30 years experience in ICM, there are many more ethical questions and case reports without clear solutions. Care decisions for single patients in unacceptable situations should be made after medical evaluation by the intensivist with the medical team and, if possible, by the patient and/or his or her surrogate. Legislation and solutions cannot be expected for single patients, but ethics committees could be helpful in decision-making.     

Cell-mediated immunity in leprosy and transfer of delayed hypersensitivity reactions

Eighty-nine patients with leprosy, 65 classified as lepromatous and 24 as tuberculoid, were examined in this study. Skin test responses to protein antigens and dinitrochlorobenzene (DNCB) were depressed in lepromatous patients compared to controls. Tuberculoid patients did not exhibit a significant depression to microbial antigens, but they showed a definite depression in the ability to be sensitized with DNCB. The transfer of delayed hypersensitivity reactions to tuberculin, trichophytin, and lepromin (Fernandez and Mitsuda reactions) was accomplished in lepromatous and indeterminate leprosy patients using viable lymphocytes from donors presenting positive reactions to these antigens. The lepromin reaction was also transferred to patients with South American blastomycosis and cutaneous leishmaniasis. The positive reactions of adoptive immunity were confirmed by histologic examination of skin biopsies.     

Prime number variant of concealed trigeminy

A 53-year-old man with myocardial infarction was found to have frequent premature ventricular beats. The predominant pattern was classical concealed trigeminy; i.e., the number of conducted sinus beats, S, between extrasystoles satisfied the equation S = 3n + 2, where "n" is zero or any positive integer. Two other transient patterns also occurred. The first one was characterized by exceptional values of S, which satisfied the equation S = 3n + 3. In the second transient pattern, all values of S fitted the classical equation, but there were singularly absent values; i.e., the "n" in the equation was exclusively an odd number, giving rise to only prime numbers of interectopic conducted sinus beats. It is proposed in this last form that there are two sites of fixed block proximal to a variable distal block in a re-entry loop responsible for the ventricular extrasystoles.     

Prosopo-Thoracopagus Conjoined Twins and Other Cephalopagus-Thoracopagus Intermediates: Case Report and Review of the Literature

Prosopo-thoracopagus twins are united from the face down to the umbilicus, none with union in the brain but all with visceral anomalies intermediate between those of cephalopagus and thoracopagus. In a review of over 1200 cases of conjoined twins reported during the past 100 years, there were 14 that illustrate the continuum between cephalopagus and thoracopagus, including three that were united only from the cervical region to the umbilicus. Classic cephalopagus twins are joined from the top of the head to the umbilicus, sharing a single foregut as well as two relatively normal hearts, the “posterior” one often diminished. Typical thoracopagus, however, are conjoined only from the upper thorax to the umbilicus, each twin with a normal foregut but both sharing a single complex multiventricular heart. The intermediate cases shared either a single very abnormal heart or two hearts united by double aortic arches, and all except one had a single foregut. It is these cases intermediate between cephalopagus and thoracopagus which are the subject of this report. Received September 11, 1996; accepted December 16, 1996