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Background Multidrug-resistant organisms (MDROs) are a reality that can alter the paradigm of treatment and prevention of infection in patients with liver cirrhosis (LC). Objective Identify risk factors for the occurrence of MDROs in patients with LC. Patients and methods Prospective study from October 2017 to March 2018 in consecutively hospitalized patients with decompensated LC with infection. Blood, urine and ascitic fluid cultures were analyzed. A p-value ≤0.05 was considered statistically significant. Results MDROs isolated in 18 of 52 episodes of infection. MDROs were associated with the use of proton pump inhibitors (PPIs) (p = 0.0312), antibiotic therapy in the last 90 days (p = 0.0033) and discharge within preceding 30 days or current hospitalization above 48 h (p = 0.0082). There was higher 90-day mortality in patients with MDROs infection (71.4% versus 35.7%, p = 0.0316). Conclusion MDROs infections were prevalent in this cohort and associated with 90-day mortality. Use of PPIs and antibiotics increased the risk of MDROs infections, suggesting that its prescription should be restricted to formal indication. Hospitalization was associated with the onset of MDROs, so LC patients should stay at the hospital the least possible. It is relevant to investigate other factors predisposing to the emergence of these microorganisms, in order to prevent it.

The case of a pregnant woman with erythematous papules and pruritic pustules, located on the buttocks and trunk, predominantly over the linea nigra, is described. Histopathological analysis showed the presence of perivascular infiltrate consisting mainly of lymphocytes, in addition to a hair follicle permeated by an inflammatory infiltrate consisting predominantly of neutrophils, leading to the destruction of the pilosebaceous unit. Pruritic folliculitis of pregnancy is the rarest of the specific dermatoses of the gestational period. Its occurs more frequently in the 2nd and 3rd trimesters of pregnancy. It is a benign, self-limited dermatosis of unknown etiology, which shows spontaneous regression after delivery. There are no reports of increased maternal-fetal morbidity and mortality.

Introduction and objectives: Dual antiplatelet therapy (DAPT) is a mainstay for myocardial infarction (MI) therapy. However, in patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA), clear recommendations are lacking in the literature. This study aims to identify the cases in which DAPT is currently prescribed at discharge for MINOCA. Methods: The authors analyzed a cohort of patients from a multicenter national registry enrolling patients who suffered their first MI between 2010 and 2017, and underwent coronary angiography revealing absence of stenosis ≥50%. Individual antithrombotic therapy was identified. A logistic regression analysis was applied to search for predictors of DAPT. Results: From a total of 16 237 patients analyzed, 709 (4.4%) were categorized as MINOCA. Mean age was 64±13 years, 46.3% (n=409) were females. 390 (55.0%) of MINOCA patients were discharged on DAPT. Males (OR 1.67, CI 95 [1.05-2.38], p=0.027), active smokers (OR=1.82, CI 95 [1.05-3.16], p=0.033), previous percutaneous intervention (OR 3.18, CI 95 [1.48-6.81], p=0.003), ST elevation MI (OR 2.70, CI 95 [1.59-4.76], p

Objetivo: Avaliar os aspectos epidemiológicos e clínicos de morbidade grave e near miss materno. Método: Estudo transversal, retrospectivo, descritivo e analítico com regressão logística, em 7 unidades de terapia intensiva (UTI) públicas, de internações de 2011 a 2013. Resultados: os casos de morbidade grave e near miss materno tinham entre 20 e 35 anos, primíparas, sem doenças prévias, com menos de 6 consultas no pré-natal. As complicações mais frequentes foram hemorragia pós-parto e hipertensão. Conclusão: a frequência de near miss materno foi alta, sugerindo a necessidade de avaliação de risco nas emergências obstétricas para a identificação mais rápida das complicações maternas.

Objetivos: descrever o perfil socioeconômico das famílias e analisar os riscos relacionados à saúde mental, funcional e nutricional entre idosos acompanhados em uma Unidade Básica de Saúde. Método: estudo transversal e analítico. Dados coletados por entrevista com 59 idosos. Resultados: o sexo feminino tive a pior qualidade do sono; a depressão estava correlacionada à má qualidade do sono e a um maior risco de quedas. A saúde bucal ruim influenciou o estado nutricional. Conclusão: a avaliação dos riscos de desnutrição, quedas e depressão, encaminhamento para grupos de convivência, práticas integrativas e avaliação especializada, pode melhorar a qualidade de vida a médio e longo prazos.

Although lipomatous tumors are common, intra-articular occurrence is exceedingly rare and sparsely described in the literature. Regarding these rare entities, most are benign, progressively growing tumors and often occur in the knee, yet it is crucial to distinguish the less infrequent lipoma arborescens (LA) from the rarer synovial lipoma, as they differ in presentation and pathogenesis. Magnetic resonance imaging is the exam of choice in their assessment and in differential diagnosis, playing a central role nowadays. Excision and synovectomy, either arthroscopic or by arthrotomy, provide good outcomes with low recurrence rates. By reporting two surgically treated distinct cases of intra-articular lipomatous tumors of the knee, the authors intend to review the literature and discuss their etiology, clinical and imaging aspects as well as treatment approach.

Background This study aimed to assess the agreement and efficacy of the Ipswich Touch Test compared to the monofilament test in individuals with type 2 diabetes. Materials and methods A cross-sectional and analytical study was conducted. The inclusion criteria were patients with type II diabetes (n = 250) who did not present ulcers or amputation in either foot. The exclusion criteria were as follows: patients who presented sequelae of cerebrovascular disease or other neurological pathologies, as well as diagnoses of malignancy, alcohol abuse, liver cirrhosis, hepatitis B, AIDS, hypothyroidism, chronic kidney disease or lupus erythaematosus, as these clinical conditions could influence or bias the results (Won and Park in Endocrinol Metab 31:230–238, 2016). Sensitivity, specificity, predictive values, likelihood ratios, and Kappa index were calculated. Other factors assessed were glycated haemoglobin and body mass index. Results Most of the participants were female (71.2%), and glycated haemoglobin (HbA1c) was greater than 7% in 54.4% of the patients. The mean age was 59.43 years, and the mean time since diagnosis was 12.38 years. The Kappa index was 0.819 (p Conclusion The Ipswich Touch Test resented good agreement and efficacy compared to the gold standard—the 10 g monofilament test.

We present the case of a female patient who developed persistently elevated levels of cardiac troponin (cTn) after a previous episode of clinically presumed myocarditis. Extensive investigation concluded that the presence of heterophile antibodies was causing false positive cTn elevation. (Level of Difficulty: Intermediate.), Graphical abstract, We present the case of a female patient who developed persistently elevated levels of cardiac troponin (cTn) after a previous episode of clinically…

International audience; The interest in implementing digital pathology (DP) workflows to obtain whole slide image (WSI) files for diagnostic purposes has increased in the last few years. The increasing performance of technical components and the Food and Drug Administration (FDA) approval of systems for primary diagnosis led to increased interest in applying DP workflows. However, despite this revolutionary transition, real world data suggest that a fully digital approach to the histological workflow has been implemented in only a minority of pathology laboratories. The objective of this study is to facilitate the implementation of DP workflows in pathology laboratories, helping those involved in this process of transformation to identify: (a) the scope and the boundaries of the DP transformation; (b) how to introduce automation to reduce errors; (c) how to introduce appropriate quality control to guarantee the safety of the process and (d) the hardware and software needed to implement DP systems inside the pathology laboratory. The European Society of Digital and Integrative Pathology (ESDIP) provided consensus-based recommendations developed through discussion among members of the Scientific Committee. The recommendations are thus based on the expertise of the panel members and on the agreement obtained after virtual meetings. Prior to publication, the recommendations were reviewed by members of the ESDIP Board. The recommendations comprehensively cover every step of the implementation of the digital workflow in the anatomic pathology department, emphasizing the importance of interoperability, automation and tracking of the entire process before the introduction of a scanning facility. Compared to the available national and international guidelines, the present document represents a practical, handy reference for the correct implementation of the digital workflow in Europe.

Review question / Objective: The objective of this scoping review is to map the instruments validate for the Portuguese older population (65+ years old) that assess loneliness; and to identify their psychometric properties and contexts where they have been in use. The questions for this scoping review are: What are the validated instruments for Portugal that assess loneliness in the older individuals? What are the psychometric properties of those instruments? In which contexts were the loneliness assessment instruments used? Eligibility criteria: Participants – This scoping review will consider all studies that included older adults with 65 years and over. Concept – This review will be included studies that assess loneliness or cover loneliness by validated instruments that address different dimensions, including, but not limited to, emotional or social. Context – This scoping review will consider studies that used validated instruments the loneliness in Portuguese older adults including, but not limited to the context of community, intermediate care, long-term care or acute care. Types of sources - This scoping review will consider quantitative and mixed-method studies. In the quantitative designs include experimental, quasi-experimental, observational and analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion.

Background: Energy expenditure (EE) evaluation in Intensive Care Unit (ICU) patients can be very challenging. Critical illness is characterized by great variability in EE, which is influenced by the disease itself and the effects of treatment. Indirect calorimetry (IC) is currently the gold standard to measure EE in Intensive Care Unit (ICU) patients. However, calorimeters are not widely available, and predictive formulas (PF) are still commonly used, leading to under or overfeeding and deleterious consequences.Important metabolic changes occur and catabolism becomes prominent in critically ill patients.Both hyper and hypometabolism can be observed, but hypermetabolic patients appear to have higher mortality rates compared to metabolically normal patients. This study aimed to assess hypermetabolism incidence and compare clinical outcomes between hypermetabolic and normometabolic patients in ICU. Methods: A single-center, retrospective, and observational study was conducted in the ICU of the Hospital do Divino Espírito Santo in Ponta Delgada, between August 2018 and February 2021. Only invasively mechanically ventilated patients were included. Resting energy expenditure (REE) was predicted by 25 kcal/kg/day formula to obtain predicted resting energy expenditure (PREE), and REE was measured by IC to obtain measured resting energy expenditure (MREE). According to their metabolic state (PREE/MREE), patients were divided into hypermetabolic (≥1.3) and normometabolic (

Transient cortical blindness (TCB) is an uncommon complication following coronary angiography. This report describes a case of TCB after coronary…, Transient cortical blindness (TCB) is an uncommon complication following coronary angiography. This report describes a case of TCB after coronary angiography in a patient admitted for acute myocardial infarction. The patient’s vision recovered completely within 16 h, and cardiac magnetic resonance imaging performed 2 months later revealed no significant abnormalities. (Level of Difficulty: Beginner.), Graphical abstract

Background The inadequate management of solid waste impacts populations’ health and quality of life, and disproportionately affects developing countries. This study aims to describe a protocol for epidemiological diagnosis, the purpose being to estimate the prevalence of chronic and communicable and non communicable diseases in waste pickers, and the occupational and environmental risk factors to which these are exposed. Methods This is a cross-sectional study, based on survey design in an area of extreme social vulnerability – the largest garbage dump in Latin America. Using a multidimensional research protocol, divided in three stages: 1- The identification of the subjects, and the scheduling of tests; 2- Situational diagnosis through interviews, anthropometric evaluation, measuring blood pressure, collecting hair and nail samples to detect exposure to heavy metals and undertaking laboratory tests; 3- The return of the waste pickers to receive the test results, followed by referral to the health team and to report occupational accidents. Results One thousand twenty-five waste pickers undertook tests and interviews. The majority were women (67.0%), with 36–45 years old (45.7%), and 96.0% had children. In total, 27.3% of the participants did not attend to any school and 47.7% were educated only up to primary level. The majority of waste pickers (68.70%) reported accidents and most of them (89.69%) were related to sharp objects. The mean time working in this open dump was 15 years. According the anthropometric measure, 32.6% were overweight and 21.1% were obese. The most common reported diseases were: osteomuscular disorders (78.7%); arboviruses (28.6%); episodic diarrhea (24.9%); hypertension (24.2%); bronchitis (14.3%); intestinal worms (12.6%) and diabetes (10.1%). According to the blood tests, the values outside the reference limits were: Uric acid (23.89%); creatinine (54.06%); GGT range (16.04%); SGOT - Serum Glutamic Oxaloacetic Transaminase (5.29%); SGPT - serum Glutamic-Pyruvic Transaminase (35.52%). Conclusions This study is the first to evaluate multiple risks and diseases in the majority of waste pickers working in the largest garbage dump of a continent. These findings highlight the importance to address urgently the environmental, social and health impacts related to the management of solid waste in developmental countries to protect these workers and their families. Electronic supplementary material The online version of this article (10.1186/s12889-019-6879-x) contains supplementary material, which is available to authorized users.

Background: Approximately 2-4% of individuals worldwide with diabetes mellitus have foot ulcers. This study aims to assess the factors affecting the outcomes of severe foot ulcers in diabetic individuals. Methods: An analytical prospective cohort study was conducted from March 1st, 2015, to March 1st, 2017. A total of 34 individuals was selected. The study included patients with foot ulcers below the ankle who were at risk of amputation. All tests used a 7%. Body mass index and osteomyelitis were the two significant variables in logistic regression. Conclusions: In this study, osteomyelitis was the main complication related to the risk of amputation, and elevated body mass index and osteomyelitis were the significant factors that induced a slower healing time.

ObjectiveThe present study seeks to assess the impact of gestational hypertensive disorders on premature newborns below 34 weeks and to establish the main morbidities and mortality in the neonatal period and at 18 months.Materials and methodsA retrospective observational study was carried out with 695 premature newborns of gestational age (GA) between 24 and 33 weeks and 6 days, born alive in the Neonatal ICU of Brasília’s Mother and Child Hospital (HMIB), in the period from January 1, 2014, to July 31, 2019. In total, 308 infants were born to hypertensive mothers (G1) and 387 to normotensive mothers (G2). Twin pregnancies and diabetic patients with severe malformations were excluded. Outcomes during hospitalization and outcomes of interest were evaluated: respiratory distress syndrome (RDS), brain ultrasonography, diagnosis of bronchopulmonary dysplasia (BPD), diagnosis of necrotizing enterocolitis, retinopathy of prematurity, breastfeeding rate at discharge, survival at discharge and at 18 months of chronological age and relationship between weight and gestational age.ResultsNewborns with hypertensive mothers had significantly lower measurements of birth weight and head circumference. The G1 group had a higher risk small for gestational age (OR 2.4; CI 95% 1.6–3.6; p ConclusionAmong the analyzed outcomes, arterial hypertension during pregnancy can increase the risk of low weight, small babies for gestational age (SGA), deaths in the neonatal period and enterocolitis, with no differences in weight and survival at 18 months of chronological age. Arterial hypertension presents a high risk of prematurity in the neonatal period, with no difference at 18 months of age.

Despite possessing only 32 residues, the tsetse thrombin inhibitor (TTI) is among the most potent anticoagulants described, with sub-picomolar inhibitory activity against thrombin. Unexpectedly, TTI isolated from the fly is 2000-fold more active and 180 Da heavier than synthetic and recombinant variants. We predicted the presence of a tyrosine O-sulfate post-translational modification of TTI, prompting us to investigate the effect of the modification on anticoagulant activity. A combination of chemical synthesis and functional assays was used to reveal that sulfation significantly improved the inhibitory activity of TTI against thrombin. Using X-ray crystallography, we show that the N-terminal sulfated segment of TTI binds the basic exosite II of thrombin, establishing interactions similar to those of physiologic substrates, while the C-terminal segment abolishes the catalytic activity of thrombin. This non-canonical mode of inhibition, coupled with its potency and small size, makes TTI an attractive scaffold for the design of novel antithrombotics.

Brain metastases remain an unmet clinical need in breast oncology, being frequently found in HER2-overexpressing and triple-negative carcinomas. These tumors were reported to be highly cancer stem-like cell-enriched, suggesting that brain metastases probably arise by the seeding of cancer cells with stem features. Accordingly, we found that brain-tropic breast cancer cells show increased stem cell activity and tumorigenic capacity in the chick embryo choriallantoic membrane when compared to the parental cell line. These observations were supported by a significant increase in their stem cell frequency and by the enrichment for the breast cancer stem cell (BCSC) phenotype CD44+CD24&minus, /low. Based on this data, the expression of BCSC markers (CD44, CD49f, P-cadherin, EpCAM, and ALDH1) was determined and found to be significantly enriched in breast cancer brain metastases when compared to primary tumors. Therefore, a brain (BR)-BCSC signature was defined (3&ndash, 5 BCSC markers), which showed to be associated with decreased brain metastases-free and overall survival. Interestingly, this signature significantly predicted a worse prognosis in lymph node-positive patients, acting as an independent prognostic factor. Thus, an enrichment of a BCSC signature was found in brain metastases, which can be used as a new prognostic factor in clinically challenging breast cancer patients.

Introduction: Iodine is an essential micronutrient and its deficiency can severely impact children’s development. In 2012, the Thyroid Study Group of the Portuguese Society of Endocrinology, Diabetes and Metabolism discovered that the median urinary iodine concentration (mUIC) level in schoolchildren of São Miguel was far too low at 70.9 μg/L. In response, the government implemented a salt iodization program to help normalize levels. This investigation evaluated the efficacy of such an approach. Methods: Urinary iodine concentration (UIC) was evaluated in 362 schoolchildren from São Miguel using the fast colorimetric method. Results: mUIC was 106.7 μg/L, significantly higher than that observed in 2012 (p < 0.001). Over half (55.5%) of the schoolchildren had a UIC >100 μg/L versus 23.0% in 2012 (p < 0.001). 9.4% of schoolchildren had a UIC p < 0.001). Discussion/Conclusion: Five years after the implementation of the government salt iodization program, the mUIC increased from 70.9 to 106.7 μg/L. This study confirms the efficacy of the adopted measures in schoolchildren population.

Introduction: Following the 2014 International Society of Urological Pathology meeting, a rapidly growing body of evidence by several researchers has been demonstrating a poor prognosis in association with cribriform morphology. The aim of our study was to describe the presence of cribriform foci in specimens of radical prostatectomies and to evaluate whether demographic and clinical characteristics are associated with the presence of cribriform pattern. Materials and methods: This cohort study was based on 70 radical retropubic prostatectomies specimens collected between 2012 and 2016 and evaluated for the association of the cribriform pattern with age, prostate-specific antigen at surgery day, Gleason on biopsy, Gleason after radical prostatectomy, extracapsular extension, vesicles invasion, margins, multiparametric magnetic resonance imaging, and post-operative radiotherapy. Results; From the univariable analysis, biochemical prostatespecific antigen recurrence (p = 0.001), extracapsular extension (p = 0.003), pre-operative prostate-specific antigen (p = 0.017), vesicles invasion, (p = 0.038) and post-operative radiotherapy (p < 0.001) showed an association with the presence of cribriform pattern. There was also a significant difference of cribriform pattern and Gleason 7 in needle biopsy (p = 0.020) and cribriform pattern and Gleason 8 or 9 in radical prostatectomy specimen (p = 0.036). Conclusions: In our study, the increase in preoperative prostate-specific antigen had a high association with cribriform pattern. Further evidence is needed to discriminate preoperative prostate specific antigen values that might potentially be associated with the presence of cribriform pattern. Raising our knowledge about the cribriform pattern can be an excellent opportunity to correctly identify and treat patients who will eventually die from prostate cancer, sparing treatment in those who will not.

Objective: To evaluate the profile of femur fractures in older adults in Brazil between 2008 and 2018. Methods: Population-based time series study with data from the Department of Informatics of the Unified Health System (Datasus), including 480,652 hospitalizations, of adults from 60 years and over, with hip fracture (ICD10-S72). Results: There was an increase of 76.9% in the hospitalization register (mean 5.87%/year) and an average incidence rate of 19.46 fractures for every 10,000 older adults. In total, 68% of hospitalizations were female, 28% from São Paulo. The average length of stay was 8.9 days, being higher in the Northern Region (11.8) and in the Federal District (18.7). Average mortality rate was 5%, being higher in men (5.45%) and over 80 years old. Northeast Region had the lowest mortality rate (3.54%). Southeast Region had the highest rate (5.53%). Total cost of hospitalizations was R$ 1.1 billion, with an average of R$ 100 million/year. Average cost per hospitalization was higher in the Southern Region (R$ 2,491.00). Conclusion: Femoral fracture is an important cause of mortality among older adults, with a higher incidence in women but higher mortality in men, with high cost to the system and regional differences. Level of Evidence II, Economic and decision analyses - developing an economic or decision model. RESUMO Objetivo: Avaliar o perfil das fraturas de fêmur em idosos no Brasil no período de 2008 a 2018. Métodos: Estudo de série temporal baseado em dados do Departamento de Informática do Sistema Único de Saúde (Datasus), incluindo 480.652 internações de pessoas com idade a partir de 60 anos e com fratura de quadril (ICD10-S72). Resultados: Houve aumento de 76,9% no registro de hospitalização (média de 5,87% por ano) e taxa de incidência média de 19,46 fraturas para cada 10 mil idosos. O estado de São Paulo respondeu por 28% do total de registros, e as internações de pacientes do sexo feminino corresponderam a 68% do total. O tempo médio de permanência foi de 8,9 dias, com maiores índices na Região Norte (11,8) e no Distrito Federal (18,7). A taxa média de mortalidade foi de 5% e atingiu os maiores valores entre os homens (5,45%) e os pacientes com mais de 80 anos. A região Nordeste apresentou a menor taxa de mortalidade (3,54%) e a região Sudeste teve a maior (5,53%). O custo total das internações foi de R$ 1,1 bilhão, com média de R$ 100 milhões ao ano. O custo médio por hospitalização foi maior na região Sul (R$ 2.491,00). Conclusão: A fratura do fêmur é importante causa de mortalidade em idosos, com maior incidência em mulheres e maior mortalidade em homens, alto custo para o sistema e diferenças regionais. Nível de Evidência II, Análises econômicas e de decisão - desenvolvimento de modelo econômico ou de decisão.

INTRODUCTION/OBJECTIVE Piecemeal endoscopic mucosal resection is a safe and effective procedure for the management of large non-pedunculated colorectal polyps. Its major limitation is the possibility of residual or recurrent adenoma and the consequent need for scheduled surveillance colonoscopies, with the implied burden for the patient and health systems. We aimed to evaluate if the Size/Morphology/Site/Access (SMSA) and Sydney EMR Recurrence Tool (SERT) scores are effective in predicting residual/recurrent adenoma after piecemeal endoscopic resection of large non-pedunculated colorectal polyps. METHODS Prospective observational cohort study of piecemeal endoscopic mucosal resection of large non-pedunculated colonic polyps performed in a tertiary center. SMSA and SERT scores were calculated in the index colonoscopy and evaluated regarding the ability to predict residual/recurrent adenoma. RESULTS One hundred fifty-eight procedures were included. Lesions mean size was 31.6 ± 10.1 mm. 65.8% were flat and 61.4% were located in the right colon. Residual/recurrent adenoma was present in 17 (10.8%) cases. SMSA 2 and SERT 0 lesions had 0.0% and 5.7% of residual/recurrent adenoma rate at 6 months, respectively, while SMSA 3-4 and SERT 1-4 lesions had a 11.5% and 14.8% rate, respectively, at 6 months. SMSA grade 2 and SERT grade 0 had a negative predictive value of 100% and 94%, respectively, for residual/recurrent adenoma. SMSA score had an area under the receiver-operating characteristics curve of 0.732 (P = 0.003), while SERT score had a value of 0.730 (P = 0.002) for residual/recurrent adenoma. CONCLUSION SMSA and SERT scores are effective tools to identify lesions with a low risk of residual/recurrent adenoma.

Chronic pancreatitis (CP) is a complex disease that should be treated by experienced teams of gastroenterologists, radiologists, surgeons, and nutritionists in a multidisciplinary environment. Medical treatment includes lifestyle modification, nutrition, exocrine and endocrine pancreatic insufficiency correction, and pain management. Up to 60% of patients will ultimately require some type of endoscopic or surgical intervention for treatment. However, regardless of the modality, they are often ineffective unless smoking and alcohol cessation is achieved. Surgery retains a major role in the treatment of CP patients with intractable chronic pain or suspected pancreatic mass. For other complications like biliary or gastroduodenal obstruction, pseudocyst drainage can be performed endoscopically. The recommendations for CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: “chronic pancreatitis etiology, natural history, and diagnosis,” and “chronic pancreatitis medical, endoscopic, and surgical treatment.” This abstract pertains to part II. A pancreatite crónica (PC) é uma doença complexa que deve ser tratada por equipas multidisciplinares experientes de gastrenterologistas, radiologistas, cirurgiões e nutricionistas. O tratamento médico inclui modificação do estilo de vida, nutrição, correção das insuficiências pancreáticas endócrina e exócrina e controle da dor. Até 60% dos doentes podem necessitar de algum tipo de terapêutica endoscópica ou cirúrgica. No entanto, independentemente da modalidade, elas serão ineficazes, se não se alcançar cessação tabágica e etílica. A cirurgia desempenha um papel importante no tratamento dos doentes com dor crónica intratável ou lesões pancreáticas suspeitas. Outras complicações como obstrução biliar, gastroduodenal, ou drenagem de pseudocistos podem ser tratadas endoscopicamente. As recomendações sobre PC foram desenvolvidas pelo Clube Português do Pâncreas (CPP), com base numa revisão da literatura para responder a questões predefinidas, posteriormente discutidos e aprovados por todos os membros do CPP. As recomendações encontram-se separadas em duas partes: “etiologia da pancreatite crónica, história natural e diagnóstico” e “tratamento médico, endoscópico e cirúrgico da pancreatite crónica.” Este resumo corresponde à parte II.

Background and study aims Colon interposition for benign strictures is associated with significant perioperative complications that carry high morbidity and mortality. Although rarely reported in the literature, adenocarcinoma can occur as a late complication in an interposed colonic segment. We report a case of a late-stage adenocarcinoma in a colonic interposition performed for benign esophageal stricture.

BACKGROUND/AIMS: The role of very early (≤12 hours) endoscopy in nonvariceal upper gastrointestinal bleeding is controversial. We aimed to compare results of very early and early (12-24 hours) endoscopy in patients with upper gastrointestinal bleeding demonstrating low-risk versus high-risk features and nonvariceal versus variceal bleeding. METHODS: : This retrospective study included patients with nonvariceal and variceal upper gastrointestinal bleeding. The primary outcome was a composite of inpatient death, rebleeding, or need for surgery or intensive care unit admission. Endoscopy timing was defined as very early and early. We performed the analysis in two subgroups: (1) high-risk vs. low-risk patients and (2) variceal vs. nonvariceal bleeding. RESULTS: : A total of 102 patients were included, of whom 59.8% underwent urgent endoscopy. Patients who underwent very early endoscopy received endoscopic therapy more frequently (p=0.001), but there was no improvement in other clinical outcomes. Furthermore, patients at low risk and with nonvariceal bleeding who underwent very early endoscopy had a higher risk of the composite outcome. CONCLUSION: s: Very early endoscopy does not seem to be associated with improved clinical outcomes and may lead to poorer outcomes in specific populations with upper gastrointestinal bleeding. The actual benefit of very early endoscopy remains controversial and should be further clarified. info:eu-repo/semantics/publishedVersion

Decompensated liver cirrhosis has a dismal prognosis, with an overall survival of 2-4 years, which is worse than for many oncological diseases. Albumin is an important tool in the management of patients with cirrhosis, since it decreases for less than half the risk for post-paracentesis cardiocirculatory dysfunction and mortality associated with spontaneous bacterial infection, as well as, it triplicates the response to terlipressin in patients with hepatorenal syndrome. Recently, research on albumin has been a hot topic, with important new insights such as the characterization of the pleiotropic effects of albumin (which surpass its oncotic properties) and the concept of effective albumin concentration. In fact, patients with liver cirrhosis present posttranslational modifications on albumin that compromises its function. Those modified albumin forms were proved to have prognostic value and its knowledge may change the paradigm of albumin treatment. In this review, we critically summarize the latest evidence on the potential benefits of albumin in patients with end-stage liver disease.

Participants’ rights and safety must be guaranteed not only while a clinical trial is being conducted but also when a clinical trial finishes. The criteria for post-trial access to experimental drugs, however, are unclear in various countries. The objectives of this study were (i) to ascertain if there were regulations or guidelines related to patients’ access to drugs after the end of clinical trials in the countries selected in the study and (ii) to analyze trends in post-trial access in countries classified by their level of economic development. This study is a retrospective review. The data are from the records of clinical trials from 2014 registered in the World Health Organization’s International Clinical Trials Registry Platform (ICTRP) database. Among the countries selected, provision of drugs post-trial is mandatory only in Argentina, Brazil, Chile, Finland, and Peru. The plans for post-trial access tend to be more present in low- and middle-income and upper middle-income countries, in comparison with high-income countries. Studies involving vulnerable populations are 2.53 times more likely to have plans for post-trial access than studies which do not. The guaranteeing of post-trial access remains mandatory in few countries. Considering that individuals seen as vulnerable have been included in clinical trials without plans for post-trial access, stakeholders must discuss the need to develop regulations mandating the guaranteeing of post-trial access in specified situations.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are adverse drug reactions. They occur in the form of mild and sometimes severe cutaneous eruptions, with high morbidity and mortality, requiring fast and appropriate diagnosis and treatment. The aim of this study was to describe and discuss the evidence regarding the risk factors, complications and treatment of SJS and TEN in inpatients. The present study is a literature review of case reports published between January 1981 and December 2016, in the following databases: The Virtual Health Library (Biblioteca Virtual da Saude - BVS), MEDLINE (National Library of Medicine, USA), LILACS (Latin American and Caribbean Health Sciences Literature), and PUBMED – NCBI (National Center for Biotechnology Information). A total of thirteen case reports were selected. Most of the cases (54%) developed adverse reactions to anticonvulsant drugs. The most common were valproic acid, lamotrigine and carbamazepine. In 69% of all cases, the patients were female. The patients’ age range varied from 18 to 82 years old. In two cases which correspond to 15%, the patients were either infected with HIV or were receiving chemotherapy treatment for cancer. These patients had a higher possibility for immunosuppression. In relation to the actions taken as treatment, the suspension of the drugs or the treatment of the skin lesions occurred in 85 and 54% of the cases, respectively. A total of 6 cases, corresponding to 46%, occurred in the Latin American and Caribbean region. In conclusion, the use of anticonvulsants, and female gender, are among the main risk factors identified by the study. The main therapeutic action for SJS and TEN is the suspension of the use of the drug that triggered the inflammatory process and the topical treatment of the lesions caused. Key words: Stevens-Johnson syndrome, toxic epidermal necrolysis, adverse drug reaction.

Objective: To identify the risk factors for foot ulceration through the tracing of diabetic peripheral neuropathy and peripheral arterial disease in individuals with type I and II diabetes, who were assisted in reference centers of the Federal District, Brazil. Method: a cross-sectional and analytical study, with the assessment of 117 individuals in outpatient clinics of the Federal District. Continuous variables were compared through Mann-Whitney test, and categorized variables, through Chi-square test for univariate analysis and Logistics regression test for multivariate analysis. Results: painful diabetic peripheral neuropathy was present in 37 (75.5%) of the individuals with neuropathy. Deformities and loss of protective plant sensibility were related to neuropathy (p=0.014 and p=0.001, respectively). Of the 40 (34.2%) individuals in the sample who presented peripheral arterial disease, 26 (65%) presented calcification risk. Conclusion: signs of painful peripheral polyneuropathy, peripheral arterial disease, deformities, loss of protective plantar sensibility, and dry skin were identified as risk factors for ulceration. RESUMEN Objetivo: Identificar los factores de riesgo para la ulceración del pie de acuerdo con el rastreo de neuropatía diabética periférica y la enfermedad arterial periférica en los individuos diabéticos tipo I y II asistidos en los centros de referencia del Distrito Federal, Brasil. Método: Estudio transversal y analítico, con la evaluación de 117 individuos en ambulatorios del Distrito Federal. Las variables continuas fueron comparadas por medio de la prueba de Mann-Whitney, y las variables categorizadas, de las pruebas de chi cuadrado para los análisis univariados y la regresión logística para los análisis multivariados. Resultados: La neuropatía diabética periférica dolorosa estuvo presente en 37 (el 75,5%) de los individuos con neuropatía. Las deformidades y la pérdida de sensibilidad protectora plantar tuvieron relación con la neuropatía (p=0,014 y p=0,001, respectivamente). De los 40 (el 34,2%) individuos de la muestra con enfermedad arterial periférica, 26 (el 65%) presentaron riesgo de calcificación. Conclusión: Identificadas las señales de polineuropatía dolorosa periférica, la enfermedad arterial periférica, las deformidades, la pérdida de sensibilidad protectora plantar y la piel seca como los factores de riesgo para ulceración. RESUMO Objetivo: Identificar os fatores de risco para ulceração do pé mediante o rastreamento de neuropatia diabética periférica e doença arterial periférica em indivíduos diabéticos tipo I e II assistidos em centros de referência do Distrito Federal, Brasil. Método: estudo transversal e analítico, com avaliação de 117 indivíduos em ambulatórios do Distrito Federal. As variáveis contínuas foram comparadas por meio do teste de Mann-Whitney, e as variáveis categorizadas, dos testes de qui-quadrado para análises univariadas e regressão logística para análises multivariadas. Resultados: a neuropatia diabética periférica dolorosa esteve presente em 37 (75,5%) dos indivíduos com neuropatia. Deformidades e perda de sensibilidade protetora plantar tiveram relação com neuropatia (p=0,014 e p=0,001, respectivamente). Dos 40 (34,2%) indivíduos da amostra com doença arterial periférica, 26 (65%) apresentaram risco de calcificação. Conclusão: identificados sinais de polineuropatia dolorosa periférica, doença arterial periférica, deformidades, perda de sensibilidade protetora plantar e pele seca como fatores de risco para ulceração.

Alcohol abuse can result in a spectrum of liver injury that ranges from mild fatty infiltration to alcoholic hepatitis (AH), cirrhosis, and hepatocellular carcinoma. The present study aimed to evaluate current scoring systems in predicting short-term and long-term mortality because of AH.Records of 170 consecutive patients with AH admitted to a tertiary center between January 2005 and October 2015 were reviewed. Clinical and biochemical parameters were retrieved for the assessment of AH scores for the day of admission (D1) and for the seventh day of hospitalization (D7). Endpoints included admission to the ICU, and 30-day, 90-day, and 1-year mortality.The Maddrey discriminant function and the Model of End-Stage Liver Disease (MELD) were modest predictors of the need for ICU admission. In-hospital, 30-day, 90-day, and 1-year mortality were 15.9, 18.2, 21.8, and 30.0%, respectively. There was a numerical, albeit nonsignificant, trend for higher accuracy using D7 scores, especially the MELD, in predicting 30-day and 1-year mortality. Overall, all scores showed high negative predictive values (30 day: 91.2-98.7% and 1 year: 78.8-93.7%), but modest positive predictive values (30 day: 30.6-70.8% and 1 year: 42.1-61.2%). Survival rates were the highest among patients showing a decrease in the MELD, Glasgow Alcoholic Hepatitis Score, and Age, serum Bilirubin, International normalized ratio, and serum Creatinine score over the first week of admission.AH scores were comparable in identifying patients at low risk of mortality up to 1 year following admission. Reassessment of the MELD, Glasgow Alcoholic Hepatitis Score, and Age, serum Bilirubin, International normalized ratio, and serum Creatinine score scores after 1 week further improved mortality prediction.

Objective: to identify the medication profile, the prevalence of polypharmacy and associated factors among elderly people receiving care from Family Health Strategy teams. Method: an analytical, document-based, cross-sectional survey with a quantitative approach was conducted in Brazlândia in the Distrito Federal, Brazil, with a sample of 211 elderly people enrolled in and receiving care from one of the local Family Health Strategy teams. Data were submitted to bivariate analysis and multiple analysis through logistic regression. Results: a considerable number of the elderly (62, 29.4%) were undergoing polypharmacy. The majority (56, 26.5%) used three different classes of drug, with antihypertensive drugs the most used. Diabetes mellitus, cardiovascular complications and the use of antihypertensive drugs were factors associated with polypharmacy. Conclusion: polypharmacy is a worrying reality and demands a new approach on the part of professionals, as this important aspect of geriatrics should be carefully evaluated to avoid harm and iatrogeny among the elderly. Resumo Objetivo: Identificar o perfil medicamentoso, bem como a prevalência de polifarmacoterapia e os fatores associados, entre idosos assistidos em equipes da Estratégia Saúde da Família. Método: Pesquisa analítica, documental, de cunho transversal, com abordagem quantitativa. Conduzido em Brazlândia, Distrito Federal, Brasil, com amostra de 211 idosos cadastrados e acompanhados por uma das equipes da Estratégia Saúde da Família local. Os dados foram submetidos a análises bivariadas e análise múltipla através da regressão logística. Resultados: Quantidade considerável dos idosos 62 (29,4%) está em polifarmacoterapia; a maioria 56 (26,5%) utiliza três classes medicamentosas diferentes, sendo os anti-hipertensivos a mais utilizada. O diabetes mellitus, as complicações cardiovasculares e o uso de anti-hipertensivos foram os fatores associados à polifarmacoterapia. Conclusão: A polifarmacoterapia configura-se uma realidade preocupante e que demanda novas posturas por parte dos profissionais, visto que esse importante aspecto da geriatria deve ser bem avaliado, para evitar danos e iatrogenias aos idosos.

Patients undergo nutritional therapy so as to prevent malnutrition or worsening of the condition. When they are unable to receive oral nutrition, the most common form of physiological and nutritional therapy is through enteral nutrition (EN). The drug-nutrient interaction is described as occurring changes in the kinetics or dynamics of the drug or nutrient administered. The purpose of this study is to describe drug-nutrient interactions in prescriptions required for enteral nutrition in patients at the Intensive Care Unit of a General Hospital of the Federal District. A descriptive-exploratory study was undertaken with data collected from January 2011 to December 2012 at the Intensive Care Unit (ICU) of the North Wing Regional Hospital (Hospital Regional da Asa Norte – HRAN). The investigation for interactions in prescriptions was conducted using Micromedex ® software and Spearman correlation was used for the statistical analysis of variables. In the 101 prescriptions analyzed, 1190 drugs were found. The minimum amount of drugs found per patient was 7 and the maximum was 18, at an average of 12 drugs. Regarding enteral drug-nutrition interaction, the incidence was 15.94%, while drug-drug interaction occurred in 84.06% of all observed interactions. The most frequent interactions were moderate, in 44.57% of the incidences, followed by major interactions at 32.33%, and minor interactions at 13.16%, and lastly the contraindications in 9.93% of prescriptions analyzed. There was a high incidence of moderate degree drug interactions in patients under enteral nutrition therapy. Key words: Enteral nutrition, drug-drug interactions, drug-nutrient interaction.

Objective: the aim of this study was to evaluate the clinical conditions, the existing complications, and the drug prescription profile of patients who received parenteral nutrition in the intensive care unit. Material and methods: this retrospective, analytical cohort study was carried out among individuals admitted to a public general hospital ICU. For data collection, the electronic medical records for the entire period of inpatient treatment were analyzed. Results: in total, 213 individuals who had received parenteral nutrition for a period greater than 48 hours were included in the study. Most participants were male and mean age was60 years; death occurred in 75 % of patients, and abdominal surgery was the main indication for parenteral nutrition. Hyperglycemia was the most common complication. The Mann-Whitney test showed that the individuals who died were using a higher number of medications. The increased use of medications correlated with use of PN and led to an increase in hospital length of stay and death rate (p-value0.001). There was a higher proportion of deaths among patients using standard parenteral nutrition solutions (76.9 %) as compared to the period when patients started receiving custom-made parenteral nutrition solutions (71.7 %). However, there was no statistical evidence of the association between type of nutrition and the outcome of death (p-value = 0.395). Conclusions: custom-made parenteral nutrition may result in benefits for the patients, such as a decrease in the number of medications used. The relationship between type of nutrition and the outcome of death did not prove to be statistically significant.Objetivo: el objetivo de este estudio fue evaluar las condiciones clínicas, las complicaciones existentes y el perfil de prescripción de medicamentos de los pacientes que recibieron nutrición parenteral en la unidad de cuidados intensivos. Material y métodos: este estudio de cohortes analítico y retrospectivo se llevó a cabo entre individuos ingresados en una UCI de un hospital público general. Para la recopilación de datos se analizaron los registros médicos electrónicos de todo el período de tratamiento hospitalario. Resultados: en total se incluyeron en el estudio 213 individuos que habían recibido nutrición parenteral durante un período superior a 48 horas. La mayoría de los participantes eran hombres y la edad media era60 años; se produjo la muerte en el 75 % de los pacientes y la cirugía abdominal fue la principal indicación de la nutrición parenteral. La hiperglucemia fue la complicación más común. La prueba de Mann-Whitney mostró que las personas que murieron estaban usando una mayor cantidad de medicamentos. El aumento en el uso de medicamentos se correlacionó con el uso de la PN y condujo a un aumento de la duración de la estancia hospitalaria y de la mortalidad (valor p0,001). Hubo una mayor proporción de muertes entre los pacientes que usaron soluciones de nutrición parenteral estándar (76,9 %) en comparación con el período en que los pacientes comenzaron a recibir soluciones de nutrición parenteral hechas a medida (71,7 %). Sin embargo, no hubo evidencia estadística de la asociación entre el tipo de nutrición y el resultado de la muerte (valor p = 0,395). Conclusiones: la nutrición parenteral hecha a medida puede generar beneficios para los pacientes, como una disminución de la cantidad de medicamentos utilizados. La relación entre el tipo de nutrición y el resultado de la muerte no resultó ser estadísticamente significativa.

Acute visual loss is rarely caused by a heart condition. This manuscript transcribes a case report of a 36-year-old patient with a 2-year history of aortic valve replacement due to bicuspid aortic valve endocarditis that presents to the emergency department with an acute right eye visual loss. After ophthalmologic investigation identified a central retinal artery occlusion, a transthoracic echocardiography was performed to search for a possible cardiac embolus, despite the patient presenting INR values of 2-2.5 for the last year. A mitral-aortic intervalvular fibrosa pseudoaneurysm was identified. A transoesophageal echocardiography was then performed, identifying a small clot logged inside the pseudoaneurysm that protruded to the left ventricle outflow tract. After INR-adjusted warfarin treatment to levels between 3 and 4, the pseudoaneurysm was surgically closed. This is a rare case since the likely source of embolism to the central retinal artery was the thrombus logged inside the pseudoaneurysm despite a standardly accepted therapeutic INR.

info:eu-repo/semantics/publishedVersion

OBJECTIVE: To determine Vulnerable Elders Survey (VES-13) and WHOQOL-bref cutoff points to detect poor quality of life (QoL) in older individuals. METHODS: This is a cross-sectional study, performed in all primary health care units in Samambaia, DF, Brazil. The data were collected from August 2016 to May 2017. The sample size of 466 older individuals treated in primary health care was obtained considering a 5% margin of error, 95% confidence level, 50% prevalence, and 20% possible losses, in a population of 13,259 older individuals. The subjects answered the VES-13 and WHOQOL-bref questionnaires. They were divided into 3 subgroups: poorQoL (older individuals with self-reported very poor or poor QoL AND very dissatisfied or dissatisfied with their health), goodQoL (very good or good QoL AND very satisfied or satisfied with Health) and indeterminateQoL (NOT belonging to poorQoL or goodQoL subgroups). A receiver-operating characteristic (ROC) curve was performed with poorQoL (case) versus goodQoL (control) to determine the cutoff score in VES-13 and WHOQOLbref. A diagnostic test using these cutoffs was carried out in all older individuals (n = 466). RESULTS: The VES-13 and WHOQOL-bref cutoff points to detect poorQoL were ≥ 2 and < 60, respectively. The area under ROC curve of VES-13 and WHOQOL-bref was 0.741 (CI95% 0.659- 0.823; p < 0.001) and 0.934 (CI95% 0.881-0.987; p < 0.001), respectively. In diagnostic tests, VES-13 showed 84% sensitivity and 98.2% negative predictive value, and WHOQOL-bref, 88% sensitivity and 99% negative predictive value. CONCLUSIONS: VES-13 score ≥ 2 and WHOQOL-bref score < 60 adequately detected poorQoL in patients treated in primary health care. Our data suggest that older individuals with these scores require special treatment such as geriatrics collaborative care to improve this scenario, considering QoL impact on mortality.

ResumoJustificativaAs fraturas de quadril são uma questão importante de saúde pública e estão associadas a altas taxas de mortalidade e perda de funcionalidade. As fraturas de quadril referem‐se a uma fratura que ocorre entre a borda da cabeça femoral e 5cm abaixo do trocanter menor e são comuns em emergências ortopédicas. O número de fraturas do fêmur proximal provavelmente aumentará à medida que a população envelhece. O custo médio da assistência médica durante a hospitalização inicial para fratura de quadril pode ser estimado em US$ 7.000 por paciente. As fraturas do fêmur são dolorosas e requerem analgesia adequada imediata. O tratamento da dor causada por fraturas de fêmur é difícil porque há um número limitado de analgésicos disponíveis, muitos dos quais têm efeitos colaterais que podem limitar o seu uso. Os opioides são os fármacos mais usados, mas podem trazer algumas complicações. Nesse contexto, os bloqueios do nervo femoral podem ser uma opção segura. É uma técnica de anestesia regional específica usada em medicina de emergência para proporcionar anestesia e analgesia do membro afetado.ObjetivoComparar a eficácia analgésica de fentanil versus bloqueio do nervo femoral antes do posicionamento para fazer raquianestesia em pacientes com fratura de fêmur avaliados com escalas de dor.MétodosRevisão sistemática da literatura científica. Estudos descritos como ensaios clínicos randomizados que comparam bloqueio do nervo femoral e fentanil tradicional foram incluídos. Dois autores da revisão (MR e FH) avaliaram de forma independente os estudos potencialmente elegíveis para inclusão. A metodologia da avaliação baseou‐se na ferramenta desenvolvida pela Colaboração Cochrane para avaliação de viés dos ensaios clínicos randomizados. As bases de dados Biblioteca Cochrane, PubMed, Medline e Lilacs foram consultadas para todos os artigos publicados, sem restrições de língua ou de tempo.ResultadosDois estudos foram incluídos nesta revisão. O bloqueio do nervo pareceu ser mais eficaz do que fentanil por via intravenosa para a prevenção da dor em pacientes com fratura femoral. Também reduziu o uso de analgesia adicional e diminuiu o risco de complicações sistêmicas. O bloqueio femoral reduziu o tempo de administração da raquianestesia ao paciente a ser submetido à cirurgia e facilitou a posição sentada para esse fim.ConclusãoO uso de bloqueio do nervo femoral pode reduzir o nível de dor e a necessidade de analgesia adicional. Há menos eventos adversos sistêmicos associados a esse procedimento, que não oferece maiores riscos. Mais estudos são necessários para conclusões adicionais.AbstractBackgroundHip fractures configure an important public health issue and are associated with high mortality taxes and lose of functionality. Hip fractures refer to a fracture occurring between the edge of the femoral head and 5cm below the lesser trochanter. They are common in orthopedic emergencies. The number of proximal femoral fractures is likely to increase as the population ages. The average cost of care during the initial hospitalization for hip fracture can be estimated about US$ 7,000 per patient. Femoral fractures are painful and need immediate adequate analgesia. Treating pain femoral fractures is difficult because there are limited numbers of analgesics available, many of which have side effects that can limit their use. Opiates are the most used drugs, but they can bring some complications. In this context, femoral nerve blocks can be a safe alternative. It is a specific regional anesthetic technique used by doctors in emergency medicine to provide anesthesia and analgesia of the affected leg.ObjectiveTo compare the analgesic efficacy of intravenous fentanyl versus femoral nerve block before positioning to perform spinal anesthesia in patients with femoral fractures assessed by Pain Scales.MethodsA systematic review of scientific literature was conducted. Studies described as randomized controlled trials comparing femoral nerve block and traditional fentanyl are included. Two reviewers (MR and FH) independently assessed potentially eligible trials for inclusion. The methodology assessment was based on the tool developed by the Cochrane Collaboration for assessment of bias for randomized controlled trials. The Cochrane Library, Pubmed, Medline and Lilacs were searched for all articles published, without restriction of language or time.ResultsTwo studies were included in this review. Nerve blockade seemed to be more effective than intravenous fentanyl for preventing pain in patients suffering from a femoral fracture. It also reduced the use of additional analgesia and made lower the risk for systemic complications. Femoral nerve block reduced the time to perform spinal anesthesia to the patient who will be subjected to surgery and facilitate the sitting position for this.ConclusionThe use of femoral nerve block can reduce the level of pain and the need for additional analgesia. There are less adverse systemic events associated with this and the procedure itself does not offer greater risks. More studies are required for further conclusions.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, idiosyncratic reaction characterized by diffuse maculopapular rash, facial edema, lymphadenopathy, fever, eosinophilia and/or other leukocyte abnormalities, and involvement of internal organs as liver, kidney, heart and lung.Diagnosing this entity is specifically complicated due to the multiplicity of organs involved. DRESS syndrome must be recognized promptly and the causative drug withdrawn in order to improve patient outcomes. Indeed, it is a potentially life-threatening condition, with a reported mortality between 5 and 20%.We describe a case of a 22-year old woman admitted to our hospital with acute diffuse, pruritic rash associated with crampy abdominal pain, vomiting, diarrhea and fever three weeks after starting sulfasalazine therapy.Initially, laboratory parameters revealed normal white blood cell count and normal liver enzymes, but during hospitalization, eosinophilia developed and liver enzymes, including transaminases and cholestatic parameters, dramatically increased. The diagnostic of DRESS syndrome was made and sulfasalazine was withdrawn and as there were signs of disease severity, systemic corticotherapy was initiated, with gradually improvement of the rash and symptoms resolution.The patient was discharged home after thirty days of hospitalization.

ResumoEm Portugal, estima‐se que a dor crônica afete 36.7% da população, constituindo um fenômeno multifatorial com grande impacto em nível individual, familiar, comunitário e social. No modelo de medo‐evitamento da dor, um dos mais consensuais na literatura, o medo surge como uma das variáveis que podem contribuir para o desenvolvimento e a manutenção dessa condição. Assim, instrumentos dedicados à avaliação do medo da dor, como o Fear of Pain Questionnaire (FPQ‐III), podem ser úteis na conceitualização da experiência subjetiva de dor. Em concordância, este trabalho tem como objetivo descrever a adaptação do FPQ‐III para o português europeu. Preencheram o questionário pela internet 1.094 participantes (795 mulheres; idade média=25,16, DP=7,72). Os resultados obtidos apontam para uma solução fatorial diferente da encontrada no primeiro estudo da escala original (cinco fatores: dor leve, intensa, médica, de injeção e aflita), uma boa consistência interna (entre .75 e .85), boas correlações entre subescalas (entre .30 e .59) e entre essas e a pontuação total (entre .68 e .85). Perante a necessidade de atender a várias dimensões da experiência subjetiva de dor, o questionário de medo da dor assume‐se como uma ferramenta útil que, em combinação com outras, pode contribuir para processos de avaliação e de intervenção progressivamente mais compreensivos e ajustados aos desafios levantados pela problemática de dor crônica.AbstractIn Portugal, it is estimated that chronic pain affects 36.7% of the population, constituting a multifactorial phenomenon with great impact on individual, family, community, and social levels. In the fear‐avoidance model of pain, one of the most consistent consensus in the literature, the fear arises as one of the variables that can contribute to the development and maintenance of this condition. Thus, instruments for evaluating the fear of pain, as Fear of Pain Questionnaire (FPQ‐III), may be useful in the conceptualization of the subjective experience of pain. Accordingly, this paper aims to describe the adaptation of FPQ‐III to the European Portuguese idiom. A total of 1,094 participants (795 female; mean age=25.16, SD=7.72 years old) completed the web based questionnaire. The results point to a different factor model found in the first study of the original scale (five factors: minor pain, severe pain, medical pain, injection pain, and afflicted pain), good internal consistency (0.75 to 0.85) and good correlations (between 0.30 and 0.59) between subscales and (between 0.68 e 0.85) for the total score and subscales. Given the need to meet the various dimensions of the subjective experience of pain, the Fear of Pain Questionnaire is assumed as a useful tool that, in combination with other tools, may contribute to the evaluation and intervention procedures progressively more comprehensive and adjusted to the challenges raised with the issue of chronic pain.

Visceral angioedema is a rare complication of therapy with angiotensin-converting enzyme (ACE) inhibitors. Clinical presentation includes nausea, vomiting, abdominal pain and diarrhea. Early detection of this entity can prevent recurrent episodes and unnecessary invasive procedures, including surgery. This article describes a 46-year-old-woman who presented to the emergency department with abdominal pain, associated with nausea and vomiting. She had been taking ramipril for 15 days. A computed tomography was performed which revealed thickening of a jejunal segment, with submucosal edema. ACE inhibitor-associated angioedema was suspected and the medication was discontinued, with resolution of symptoms in 48 h. After 7 months of follow-up, the patient is asymptomatic. Despite of its rarity, ACE inhibitor-induced small-bowel angioedema should be included in the differential diagnosis when patients receiving ACE inhibitor therapy present with abdominal complaints.