Importance of multiplane transesophageal echocardiography in the diagnosis of pulmonary embolism]

Pulmonary thromboembolism (PTE) is a clinical entity difficult to diagnose, its setting is often confused with other pathological entities. The inexistence of isotopic techniques in most centres and the difficulty and delay in performing a pulmonary angiography leads transesophageal echocardiography (TEE) to be, a method of increasing importance for its diagnosis. From January 1996 to November 1997, echocardiographic evaluation was requested for 33 patients due to clinical suspicion of pulmonary thromboembolism. A transthoracic assessment was made previously in 21 patients (average ages 58.3 years, 52% males) which had signs of right overload (dilatation of the right cavities, anomalous movement of the intraventricular septum and pulmonary hypertension) a TEE was performed. The TEE was negative in 10 patients (TEEn) without evidence of thrombi in the trunk and main branches of the pulmonary artery (PA); there was one death on this group for repeated pulmonary microembolisms confirmed by necropsy. The TEE was positive in 11 patients (TEEp) with evidence of thrombi in the PA trunk in 3 patients, bilaterally in both branches in 3 patients and in the right branch in 5 patients. There were dilatations of the right cavities in all patients, paradoxal movement of the interventricular septum and bulging of the intra-auricular septum to the left atria. Foramen ovale was detected in 2 patients. The best visualisation of the PA was achieved in the intermediate planes between 30-70 degrees and between 90-130 degrees (plane for transverse slice of the right branch of the pulmonary artery). In 7 patients with TEEp, PTE was confirmed by CT-scan (visualisation of the thrombi in the trunk and main branches of the PA) and/or ventilation-perfusion scintigraphy and/or pulmonary angiography. In three cases of massive pulmonary embolism in young patients, with severe pulmonary hypertension, thrombolysis was performed with rTPA, under TEE control before and after rTPA in one of the cases. In conclusion, transesophageal echocardiography is an easy technique to be performed in the case of clinical suspicion of PTE. The existence of a negative examination does not invalidate the existence of PTE since only the trunk and the main branches of the PA are accessible by this technique. The detection of thrombi at this level in patients with clinical suspicion of massive pulmonary embolism confirms the diagnosis and supports the indication of thrombolysis.     

The quality of mortality statistics. Galicia 1987

We intend to study the reliability of the mortality statistics in Galicia (1987), comparing the basic cause of death, with that we obtain by the Autopsy Report (AR). After independently studying 90 AR, three physicians selected the basic cause of death, subsequently coded by the same team. All this persons were blind in relation with the previous certification. 41.1% of the causes of death agreed in 4 digit, 45.6% agreed in 3 digit and the 63.3% remained in the same ICD-9 group. Taking into account all the mistakes found, the 13.3% took place due to an incomplete definition, but the classification remained correct. The 10.0% due to an error in the logic sequence, the 15.6% by an error in the selection of the cause of death and, in the 20.0% there was no relationship between causes. For cardiovascular diseases, the Predictive Positive Value (PPV) was 76.9%, the Sensibility (S) was 83.0% and the Specificity (Sp) 90.9%. For the tumors, the value of the PPV and the S was 73.7% and the Sp was 92.9%. In spite of selection bias because of the method used, we think that the information produced is useful for evaluating the quality of mortality statistics in Galicia. When comparing our results with similar studies, we find an acceptable level.     

Study of the psychometric qualities of the Brief Social Phobia Scale (BSPS) in Brazilian university students

PurposeTo perform a psychometric analysis of the Brazilian version of the Brief Social Phobia Scale (BSPS).Materials and methodsHundred and seventy-eight university students of both genders aged on average 21.2 years and identified as Social Anxiety Disorder (SAD) cases and non-cases was studied, with the structured clinical interview for DSM-IV being used as a parameter. The different instruments were applied in an individual manner in the presence of a rater and of an observer.ResultsThe BSPS showed adequate internal consistency (0.48–0.88) and concurrent and divergent validity with the Beck Anxiety Inventory (BAI) (0.21–0.62), Social Phobia Inventory (0.24–0.82) and Self Statements During Public Speaking Scale (SSPS) (0.23–0.31). Discriminative validity revealed a sensitivity of 0.88–0.90 and a specificity of 0.81(0.83 for cut-off notes of 18/19. Factorial analysis demonstrated the presence of six factors that jointly explained 71.79% of data variance. Construct validity indicated some limits of the scale regarding the diagnosis of SAD. Inter-rater reliability was strong (0.86–1.00, p < 0.001).ConclusionsThe BSPS is adequate for use with university students, although further studies in different cultures, samples and contexts are still necessary.     

Cross-talk among intracellular signaling pathways mediates the diphenyl ditelluride actions on the hippocampal cytoskeleton of young rats

In the present report, we showed that diphenyl ditelluride (PhTe)(2) induced in vitro hyperphosphorylation of glial fibrillary acidic protein (GFAP), vimentin and neurofilament (NF) subunits in hippocampus of 21 day-old rats. Hyperphosphorylation was dependent on L-voltage dependent Ca(2+) channels (L-VDCC), N-methyl-d-aspartate (NMDA) and metabotropic glutamate receptors, as demonstrated by the specific inhibitors verapamil, DL-AP5 and MCPG, respectively. Also, dantrolene, a ryanodine channel blocker, EGTA and Bapta-AM, extra and intracellular Ca(2+) chelators respectively, totally prevented this effect. Activation of metabotropic glutamate receptors by (PhTe)(2) upregulates phospholipase C (PLC), producing inositol 1, 4, 5-trisphosphate (IP(3)) and diacylglycerol (DAG). Therefore, high Ca(2+) levels and DAG directly activate Ca(2+)/calmodulin-dependent protein kinase (PKCaMII) and protein kinase C (PCK), resulting in the hyperphosphorylation of Ser-57 in the carboxyl-terminal tail domain of the low molecular weight NF subunit (NF-L). Also, the activation of Erk1/2, and p38MAPK resulted in hyperphosphorylation of KSP repeats of the medium molecular weight NF subunit (NF-M). It is noteworthy that PKCaMII and PKC inhibitors prevented (PhTe)(2)-induced Erk1/2MAPK and p38MAPK activation as well as hyperphosphorylation of KSP repeats on NF-M, suggesting that PKCaMII and PKC could be upstream of this activation. Taken together, our results highlight the role of Ca(2+) as a mediator of the (PhTe)(2)-elicited signaling targeting specific phosphorylation sites on IF proteins of neural cells of rat hippocampus. Interestingly, this action shows a significant cross-talk among signaling pathways elicited by (PhTe)(2), connecting glutamate metabotropic cascade with activation of Ca(2+) channels. The extensively phosphorylated amino- and carboxyl- terminal sites could explain, at least in part, the neural dysfunction associated with (PhTe)(2) exposure.     

Attitudes and anxiety levels of medical students towards the acquisition of competencies in communication skills

Objective

Results of third year medical students’ attitudes and stress levels towards the acquisition of communication skills before and after a Communication and Clinical Skills Course (CCSC) at the Faculty of Medicine of the University of Porto (FMUP), Portugal, are presented.

Methods

115 students attending third-year CCSC completed a demographic questionnaire, State-Trait Anxiety Inventory, Communication Skills Attitudes Scale and Interpersonal Behavior Survey.

Results

Significant negative correlation was found between anxiety levels and attitudes towards learning communication skills in general as well as the teaching and learning process. At the end of the Course students reported that when compared to the start, their communication skills are less sufficient.

Conclusion

At the end of this CCSC at FMUP, students recognized its major importance and how they need to invest and improve communication skills. However, it seems important to monitor the attitudes and anxiety levels of students towards patient care and communication during the medical course and to identify ways of overcoming barriers towards learning communication skills.

Practice implications

It is recommended that there should be a complete (transversal and vertical) integration of communication skills, including effective teaching methods, assessments, and examinations in order to be valued by the students. This would necessitate curricular changes.     

Evaluation of oral antiseptic rinsing before sputum collection to reduce contamination of mycobacterial cultures

To assess whether rinsing with oral antiseptics before sputum collection would reduce contamination of mycobacterial cultures, 120 patients with suspected tuberculosis were randomly assigned to rinse with chlorhexidine or cetylpyridinium mouthwash before collection. The culture contamination rate was significantly lower after rinsing with chlorhexidine before collection, especially for cultures grown in MGIT medium.     

Patient satisfaction following day surgery

Study ObjectiveTo evaluate patient satisfaction at discharge and 30 days after day surgery, and to identify predictive factors of patient satisfaction.DesignObservational, prospective study.SettingDay surgery unit of a university hospital.Patients251 consecutive patients, aged 43 ± 15 years (56.6% women), scheduled for day surgery.InterventionsPatients were asked to answer a questionnaire.MeasurementsPatients' level of satisfaction was recorded in relation to different variables, using questions of demographics, logistics, and those relating to surgery.Main ResultsOver 95% of patients were satisfied with their care at both interviews; 74.5% of patients were completely satisfied at the discharge time; and only 62.4% had the same opinion 30 days after the surgery (P < 0.01). Postoperative pain control [odds ratio (OR) = 1.6], waiting time for surgery (OR = 1.4), and patient changing room conditions (OR = 1.3) were the most important factors influencing patient satisfaction at the time of discharge. Clinical outcome (OR = 3.2), clinical information (OR = 1.6), and postoperative pain control (OR = 1.3) were the main factors affecting patient satisfaction 30 days after surgery.ConclusionsOverall satisfaction following day surgery was at least 95% at discharge and at 30 days. However, complete satisfaction was present only in 75% at discharge and decreased to 62% at 30 days. Clinical outcome was strongly related to patient satisfaction at 30 days after surgery. Factors directly controlled by anesthesiologists such as postoperative pain and information provided, also had a significant impact on patient satisfaction.     

Preoperative mixed embolization of a paraganglioma using Onyx

Paragangliomas, or glomus tumors, are highly vascular benign tumors of the head and neck. Clinical symptoms are essentially progressive and neurological, involving infiltration of the regional cranial nerves. The usual treatment is surgery, which itself is a challenge because of the close proximity of vital structures and the considerable blood loss. Preoperative embolization can reduce morbidity, and several techniques have been described using arterial injection of particles or of cyanoacrylate directly into the tumor. This case report is of a patient treated by surgery using a new technique-preoperative embolization involving both the arteries and veins, and injection of Onyx, resulting in complete devascularization of the tumor's arteriovenous network.