Meningite criptocócica fatal em paciente com lúpus eritematoso sistêmico juvenil

Cryptococcosis is a fungal infection caused by Cryptococcus neoformans, generally associated with immunodefi y and immunosuppressive agents, and it is rarely reported in system- ic lupus erythematosus (SLE), particularly in juvenile SLE (JSLE). From January 1983 to June 2011, 5,604 patients were followed at our University Hospital and 283 (5%) of them met the American College of Rheumatology (ACR) classifi criteria for SLE. Only one (0.35%) of our JSLE patients had cryptococcal meningitis and is described in this report. A 10-year old girl was diagnosed with JSLE. By the age of 15 years, she presented persistent headaches, nausea and vomiting for a 5 day period without fever, after a cave-exploring trip. At that moment, she was under 10 mg/day of prednisone, azathioprine and hydroxychloroquine. A lumbar puncture was performed and India ink preparation was positive for cryptococcosis, cerebrospinal fl culture yielded Cryptococcus neoformans and serum cryptococcal antigen titer was 1:128. Azathioprine was suspended, and liposomal amphotericin B was introduced. Despite of treatment, after four days she developed amaurosis and fell into a coma. A com- puter tomography of the brain showed diffuse ischemic areas and nodules suggesting fungal infection. Four days later, she developed severe sepsis and vancomycin and meropenem were prescribed, nevertheless she died due to septic shock. In conclusion, cryptococcal meningitis is a rare and severe opportunistic infection in juvenile lupus population. This study rein- forces the importance of an early diagnosis and prompt introduction of antifungal agents, especially in patients with history of contact with bird droppings.     

Vasculite mesentérica em paciente com lúpus eritematoso sistêmico juvenil

Lupus mesenteric vasculitis (LMV) is a rare cause of acute abdominal pain. Few cases of LMV have been reported in adults, children and adolescents. However, to our knowledge, the prevalence of that severe vasculitis in a pediatric population with lupus is yet to be studied. This study reviewed data from 28 consecutive years and included 5,508 patients being followed up at the hospital of the Faculdade de Medicina of the Univesidade de São Paulo (FMUSP). We identified 279 (5.1%) patients meeting the American College of Rheumatology classification criteria for the diagnosis of systemic lupus erythematosus (SLE), one of whom (0.4%) had LMV. That male patient was diagnosed with SLE at the age of 11 years. At the age of 13 years, he was hospitalized with diffuse and acute abdominal pain, nausea, bilious vomiting, abdominal distension, rebound tenderness, and abdominal muscle guarding. The patient underwent laparotomy immediately, and segmentary intestinal ischemia with intestinal wall edema and adhesions were identified. Partial small bowel resection with lysis of the adhesions was performed, as were pulses of intravenous methylprednisolone. The histopathologic analysis evidenced mesenteric arteritis. After 13 days, the diffuse and intense abdominal pain recurred, and the patient underwent a new laparotomy, during which adhesive small bowel obstruction with intestinal gangrene was identified. New intestinal resection was performed, and the patient received pulses of intravenous methylprednisolone and infusion of immunoglobulin. Thus, LMV is a rare and severe abdominal manifestation of the pediatric population with lupus, and can be the only manifestation of disease activity. In addition, this study stresses the importance of the early diagnosis and immediate treatment.     

Frequência de anticorpos antiparvovírus B19 em artrite reumatoide e lúpus eritematoso sistêmico

ObjectiveTo determine the frequency of antiparvovírus B19 (B19) antibodies in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), and the possible correlation of anti-B19 seropositivity with disease activity and quality of life.Patients and methodsSerum samples from 57 patients with RA, 45 with SLE and 65 healthy controls were used. We applied protocol with clinical data, and the Disease Activity Score 28 (DAS 28), Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and Health As- sessment Questionnaire (HAQ) indexes. The anti-B19 serology was done by enzyme-linked immunosorbent assay (ELISA).ResultsThe mean age of patients was 42.74 ± 14.09 years, and of controls was 38.38 ± 13.42 years. 79 patients had active disease (77.5%), and 23 had inactive disease (22.5%). Anti-B19 (IgG) was positive in 49 (86.0%; CI 95% 77.0 – 95.0) RA patients, 38 (84.4%; CI 95% 73.9 – 95.0) SLE patients, and 40 (61.5%; CI 95% 49.7 – 73.4) controls (p = 0.002). Anti-B19 (IgM) was posi-tive in 3 (5.3%; CI 95% 0.0 – 11.1) RA patients, in 7 (15.6%; CI 95% 5.0 – 26,2) SLE patients, and in 1 (1.5%; CI 95% 0.0 – 4.5) control (p = 0.011). There was no correlation of anti-B19 reactivity with disease activity and with DAS 28, HAQ and SLEDAI indexes.ConclusionThis study demonstrated that the studied population is exposed to infection by B19, which demands attention with its manifestations, especially among patients at great- est risk, such as those immunosuppressed.     

Avaliação da qualidade da recuperação e do estado de saúde no pós‐operatório de cirurgias eletivas

Purpose

Postoperative recovery is a complex process with physiologic, functional, and psychologic dimensions. Postoperative quality of recovery is considered as a crucial outcome following surgery and anesthesia. The objective of this study was to assess and compare the quality of postoperative recovery and health status before and after surgery, in patients undergoing elective surgery.

Avaliação de entesopatia em pacientes com fibromialgia por meio do novo índice ultrassonográfico de entesite

ObjectiveThe aim of the present study is to determine the frequency of enthesopathy in fibromyalgia (FM) by using a newly developed ultrasonography (US) method, the Madrid Sonography Enthesitis Index (MASEI).MethodsThis study was conducted on 38 consecutive patients with FM and 48 healthy sex- and age-matched controls. Six entheseal sites (olecranon tuberosity, superior and inferior poles of patella, tibial tuberosity, superior and inferior poles of calcaneus) on both lower limbs were evaluated. All US findings were identified according to MASEI. Scores of patients and controls were compared by Student's t-test and Mann-Whitney U-test. Validity was analysed by receiver operating characteristic curve. Values of P < 0.05 were considered significant.ResultsTotal enthesitis score was 7.39 ± 4.99 (mean ± SD) among FM patients and 3.7 ± 3.22 among healthy controls (P < 0.001). The receiver operating characteristic curve established an ultrasound score of > 3.5 in the FM group as the best cut-off point to differentiate between cases and controls. No statistically significant correlation was found between the MASEI score and the FM disease duration, and the location of the tender points.ConclusionsMisdiagnoses of FM are harmful to patients and the community, and the presence of enthesopathy among FM patients increases. Its detection with the MASEI score may help to discriminate FM patients presenting with ill-defined symptoms and signs, in order to prevent mistreatment.     

Comportamento da variação do volume sistólico em pacientes hemodinamicamente estáveis durante cirurgia torácica com períodos de ventilação monopulmonar

Introduction

In last few years, emphasis was placed in goal‐directed therapy in order to optimize patient's hemodynamic status and improve their prognosis. Parameters based on the interaction between heart and lungs have been questioned in situations like low tidal volume and open chest surgery. The goal of the study was to analyze the changes that one‐lung ventilation can produce over stroke volume variation and to assess the possible impact of airway pressures and lung compliance over stroke volume variation.

A aplicação desnecessária de cateterização venosa central em pacientes cirúrgicos

Background and objectives

Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement.

Relação entre consumo de tabaco e concentração de monóxido de carbono na expiração com complicações respiratórias perioperatórias

Background

The purpose of the current study was to determine the effects of preoperative cigarette smoking and the carbon monoxide level in the exhaled breath on perioperative respiratory complications in patients undergoing elective laparoscopic cholecystectomies.

Efeitos de dexmedetomidina em conjunto com o pré‐condicionamento isquêmico remoto em lesão de isquemia‐reperfusão renal em ratos

Background and objectivesThe aim of this study was to evaluate the effects of remote ischemic preconditioning by brief ischemia of unilateral hind limb when combined with dexmedetomidine on renal ischemia–reperfusion injury by histopathology and active caspase‐3 immunoreactivity in rats.Methods28 Wistar albino male rats were divided into 4 groups. Group I (Sham, n = 7): Laparotomy and renal pedicle dissection were performed at 65th minute of anesthesia and the rats were observed under anesthesia for 130 min. Group II (ischemia–reperfusion, n = 7): At 65th minute of anesthesia bilateral renal pedicles were clamped. After 60 min ischemia 24 h of reperfusion was performed. Group III (ischemia–reperfusion + dexmedetomidine, n = 7): At the fifth minute of reperfusion (100 μg/kg intra‐peritoneal) dexmedetomidine was administered with ischemia–reperfusion group. Reperfusion lasted 24 h. Group IV (ischemia–reperfusion + remote ischemic preconditioning + dexmedetomidine, n = 7): After laparotomy, three cycles of ischemic preconditioning (10 min ischemia and 10 min reperfusion) were applied to the left hind limb and after 5 min with group III.ResultsHistopathological injury scores and active caspase‐3 immunoreactivity were significantly lower in the Sham group compared to the other groups. Histopathological injury scores in groups III and IV were significantly lower than group II (p = 0.03 and p = 0.05). Active caspase‐3 immunoreactivity was significantly lower in the group IV than group II (p = 0.01) and there was no significant difference between group II and group III (p = 0.06).ConclusionsPharmacologic conditioning with dexmedetomidine and remote ischemic preconditioning when combined with dexmedetomidine significantly decreases renal ischemia–reperfusion injury histomorphologically. Combined use of two methods prevents apoptosis via active caspase‐3.     

O papel do videolaringoscópio em programas de treinamento de intubação endotraqueal

Background

Macintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education.

Avaliação dos efeitos neurotóxicos da administração intratecal do (S)‐(+)‐cetoprofeno em medula espinhal de rato: estudo experimental randômico e controlado

Background and objectivesIntrathecal administration of non‐steroidal anti‐inflammatory drugs is more efficacious for post‐operative pain management. Cyclooxygenase inhibiting non‐steroidal anti‐inflammatory drugs like (S)‐(+)‐Ketoprofen, may be effective at lower intrathecal doses than parenteral ones. Preclinical safety regarding possible neurotoxicity associated with the intrathecal (S)‐(+)‐Ketoprofen was not evaluated. Here we analysed the neurotoxicity of intrathecally administered (S)‐(+)‐Ketoprofen in rats.MethodsA randomized placebo‐controlled experimental study was conducted. Sprague‐Dawley rats (250–300 g) aged 12–16 weeks were randomly divided into 2 treatments [100 and 800 μg (S)‐(+)‐Ketoprofen] and control (sterile water) groups. Intrathecal catheters were placed via the atlantoaxial space in anesthetized rats. Pinch‐toe tests, motor function evaluations and histopathological examinations of the spinal cord and nerve roots were performed at days 3, 7 and 21. Spinal cord sections were evaluated by light microscopy for the dorsal axonal funiculus vacuolation, axonal myelin loss, neuronal chromatolysis, neuritis, meningeal inflammation, adhesions, and fibrosis.ResultsRats in all the groups exhibited normal pinch‐toe testing response (score = 0) and normal gait at each observed time (motor function evaluation score = 1). Neurotoxicity was higher with treatments on days 3 and 7 than that on day 21 (2, 3, 0, p = 0.044; 2, 5, 0, p = 0.029, respectively). On day 7, the total scores reflecting neuronal damage were higher in the 800 μg group than those in the 100 μg and Control Groups (5, 3, 0, p = 0.048, respectively).ConclusionIntrathecal (S)‐(+)‐Ketoprofen caused dose‐dependent neurohistopathological changes in rats on days 3 and 7 after injection, suggesting that (S)‐(+)‐Ketoprofen should not be intrathecally administered.     

Efeitos das alterações no oxigênio cerebral durante cirurgia de revascularização do miocárdio sobre a disfunção cognitiva no pós‐operatório em pacientes idosos: estudo piloto

Background and objectives

Postoperative cognitive dysfunction is common after cardiac surgery. Adequate cerebral perfusion is essential and near infrared spectroscopy (NIRS) can measure cerebral oxygenation. Aim of this study is to compare incidence of early and late postoperative cognitive dysfunction in elderly patients treated with conventional or near infrared spectroscopy monitoring.

Avaliação do programa de aprimoramento em anestesia cardiovascular por seus ex‐estagiários

Background

After advancement of cardiovascular surgery, there is also exponential development of anesthetic techniques in this field. Patients with increasing clinical complexity challenge cardiac anesthesiologists to keep constantly updated. An evaluation of Brazilian's cardiovascular anesthesia fellowship at Dante Pazzanese Institute of Cardiology has been made and information has been collected to evaluate the fellowship program in cardiovascular anesthesia.

Cetamina como adjuvante de bupivacaína em bloqueio do nervo infraorbitário para analgesia após correção de lábio leporino

Objectives

We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra‐oral infra‐orbital nerve block in children undergoing cleft lip surgeries.

Avaliação da aterosclerose subclínica e de níveis plasmáticos de LDL minimamente modificada em pacientes com espondilite anquilosante e sua correlação com a atividade da doença

IntroductionAccelerated atherosclerosis has been shown in some autoimmune diseases, mainly in Systemic Lupus Erythematosus and Rheumatoid Arthritis. Although high preva- lence of corticosteroids use may be a confounding factor due to their detrimental effects on several risk factors, systemic inflammation per se is supposed to play an important role in atherogenesis in these patients.MethodsWe have evaluated sub-clinical atherosclerosis and plasma levels of circulating electronegative LDL, which represents the fraction of LDL that is minimally modified, in patients with ankylosing spondylitis (AS). Fourteen patients who fulfilled the modified New York criteria for AS were compared with 13 paired controls. Carotid intimal-media thick- ness (IMT) was assessed by ultrasonography bilaterally in common carotid artery, internal carotid artery and in the bifurcation. Groups were homogeneous regarding cardiovascular risk factors. Only a single patient in AS group was in use of corticosteroid.ResultsThe presence of active inflammation was demonstrated by elevated BASDAI and higher CRP levels and in patients versus controls (12.36 vs. 3.45 mg/dl, P = 0.002). No dif- ference was found in carotid IMT between both groups, in any site of artery. Averaged IMT (6 measurements, at 3 pre-specified sites bilaterally) was 0.72 ± 0.28 in AS group and 0.70 ± 0.45 mm in controls (P = 0.91). Minimally modified LDL did not differ significantly either between patients and controls (14.03 ± 17.40 vs. 13.21 ± 10.21; P = 0.88).ConclusionsPatients with AS did not show increased carotid IMT in comparison to con- trols. In the same way, circulating plasma levels of LDL (-), did not differ significantly in both groups.     

Tireoidite de Hashimoto pode estar associada a um subgrupo de pacientes de esclerose sistêmica com hipertensão pulmonar

IntroductionRecent studies show an association between autoimmune thyroiditis and systemic sclerosis (SSc) and suggest that this condition may interfere with the ES phenotype. However these studies evaluate the autoimmune thyroiditis as a whole and none of them specifically addresses Hashimoto's thyroiditis (HT) in SSc.ObjectiveTo investigate the presence of HT in SSc patients and its possible association with disease manifestations.MethodsClinical manifestations of hypothyroidism, TSH and anti‐thyroid auto antibodies (anti‐TPO. anti TBG and TRAb) were studied in 56 patients with SSc. SSc patients with HT were compared with SSc patients without thyroiditis.ResultsHT was observed in 19.64% of patients with SSc. No association was observed between HT and the different forms of disease or profile of autoantibodies. Likewise, there was no difference between the mean modified Rodnan score and presence of Raynaud's phenomenon, scars, digital necrosis, myositis, arthritis, sicca symptoms, esophageal dysmotility and scleroderma renal crisis when the groups were compared. On the other hand, patients with HT had higher frequency of pulmonary hypertension in relation to patients without HT (66.6% vs 22.5%, p = 0.016).ConclusionsIn the studied sample patients with ES and HT had higher prevalence of pulmonary hypertension. Long‐term follow‐up studies with a larger number of TH and SSc patients are needed to confirm these data.     

Análise sistemática da influência do antifator de necrose tumoral [anti-TNF] sobre as taxas de infecção em pacientes com artrite reumatoide

ObjectiveThe present article aims to provide a systematic review of the influence of anti- tumor necrosis factor (TNF) on infection rates in patients with rheumatoid arthritis (RA).MethodMedline was searched to obtain quality control information on infection rates in RA patients treated with anti-TNF.ResultsA high proportion of RA patients are now established users of anti-TNF agents. Data from national registries in European countries of patients with RA treated with anti-TNF suggest that biological therapies are closely linked to sepsis. Although previous studies reported a higher risk of infections, there are now emerging data with longer duration of follow-up that suggested an adjusted hazard risk of 1.2. Elderly patients and those with longstanding disease may have a higher rate of serious infections compared to their coun- terparts who were younger with early disease. There are now emerging data to suggest that anti-TNF therapy is associated with the development of neutropenia shortly after the commencement of treatment. The biologic registries found that RA patients treated with monoclonal antibodies are at increased risk of tuberculosis (TB) compared to those on TNF receptor blockers. This risk of infection needs to be weighed against the established ben- efits of TNF blockers.ConclusionCurrent evidence suggests that anti-TNF treatment in RA is closely linked to infection. Patients need to be aware of the risk of infection together with the established benefits of TNF blockers in order to give informed consent for treatment.     

Monitoração da coagulação pela tromboelastometria no intraoperatório de transplante hepático em um paciente usando varfarina – relato de caso

Introduction

Advanced hepatic disease may – in addition to the widely recognized hemorrhagic complications – occur with thrombotic events. We describe the case of a cirrhotic patient taking warfarin and whose coagulation management during liver transplantation was guided by thromboelastometry (ROTEM^®).