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Esquistossomose é uma das doenças infecciosas mais prevalentes do mundo. As etapas de migração do helminto no organismo definem as fases da doença. Na fase aguda, a dispneia e tosse estão habitualmente associadas a opacidades em vidro fosco e consolidações nodulares. Na crônica, as manifestações pulmonares mais frequentes decorrem de hipertensão pulmonar e cor pulmonale. Relatamos um caso de esquistossomose pulmonar com apresentação nodular migratória.

Challenging lesions, difficult to diagnose through non-invasive methods, constitute an important emotional burden for each patient regarding a still uncertain diagnosis (malignant x benign). In addition, from a therapeutic and prognostic point of view, delay in a definitive diagnosis can lead to worse outcomes. One of the main innovative trends currently is the use of molecular and functional methods to diagnosis. Numerous liver-specific contrast agents have been developed and studied in recent years to improve the performance of liver magnetic resonance imaging (MRI). More recently, one of the contrast agents introduced in clinical practice is gadoxetic acid (gadoxetate disodium).To demonstrate the value of the hepatobiliary phases using gadoxetic acid in MRI for the characterization of focal liver lesions (FLL) in clinical practice.Overall, 302 Lesions were studied in 136 patients who underwent MRI exams using gadoxetic acid for the assessment of FLL. Two radiologists independently reviewed the MRI exams using four stages, and categorized them on a 6-point scale, from 0 (lesion not detected) to 5 (definitely malignant). The stages were: stage 1- images without contrast, stage 2- addition of dynamic phases after contrast (analogous to usual extracellular contrasts), stage 3- addition of hepatobiliary phase after 10 min (HBP 10'), stage 4- hepatobiliary phase after 20 min (HBP 20') in addition to stage 2.The interobserver agreement was high (weighted Kappa coefficient: 0.81- 1) at all stages in the characterization of benign and malignant FLL. The diagnostic weighted accuracy (Az) was 0.80 in stage 1 and was increased to 0.90 in stage 2. Addition of the hepatobiliary phase increased Az to 0.98 in stage 3, which was also 0.98 in stage 4.The hepatobiliary sequences improve diagnostic accuracy. With growing potential in the era of precision medicine, the improvement and dissemination of the method among medical specialties can bring benefits in the management of patients with FLL that are difficult to diagnose.

Sarcoidose é uma doença sistêmica que pode acometer vários órgãos. Relatamos o caso de uma paciente com acometimento pulmonar nodular que é uma apresentação rara da sarcoidose pulmonar. Caracteriza-se por sintomas constitucionais associados ao achado de único ou múltiplos nódulos pulmonares. A presença de granulomas geralmente não caseosos na biópsia pulmonar corrobora o diagnóstico, juntamente com a exclusão de outras doenças granulomatosas. O prognóstico costuma ser favorável, com boa resposta ao tratamento com corticosteroide oral.

O primeiro caso de COVID-19 foi identificado na China no final de 2019 e rapidamente foi declarada pandemia em consequência da elevada transmissibilidade e morbimortalidade do vírus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), seu agente etiológico. O espectro clínico é altamente variável, desde sintomas respiratórios e sistêmicos leves até quadros graves com sepse, síndrome do desconforto respiratório agudo (SDRA) e disfunção de múltiplos órgãos. Postula-se que a desproporcional resposta imune do hospedeiro humano ao vírus seja responsável pelas injúrias teciduais e hiperinflamação sistêmica. Os achados tomográficos principais incluem opacidades em vidro fosco e consolidações periféricas e podem variar ao longo do curso da doença, sendo, portanto, inespecíficos. Exames diagnósticos baseiam-se na detecção de proteínas do vírus e resposta imunológica à inflamação. Agentes antivirais e drogas imunomoduladoras estão sendo testados. Até o momento, o tratamento baseia-se em terapia de suporte, controle de sintomas clínicos e manejo de complicações.

OBJECTIVE: To determine the correlation between the two tomographic classifications for coronavirus disease (COVID-19), COVID-19 Reporting and Data System (CORADS) and Radiological Society of North America Expert Consensus Statement on Reporting Chest Computed Tomography (CT) Findings Related to COVID-19 (RSNA), in the Brazilian population and to assess the agreement between reviewers with different experience levels. METHODS: Chest CT images of patients with reverse transcriptase-polymerase chain reaction (RT-PCR)-positive COVID-19 were categorized according to the CORADS and RSNA classifications by radiologists with different levels of experience and who were initially unaware of the RT-PCR results. The inter- and intra-observer concordances for each of the classifications were calculated, as were the concordances between classifications. RESULTS: A total of 100 patients were included in this study. The RSNA classification showed an almost perfect inter-observer agreement between reviewers with similar experience levels, with a kappa coefficient of 0.892 (95% confidence interval [CI], 0.788-0.995). CORADS showed substantial agreement among reviewers with similar experience levels, with a kappa coefficient of 0.642 (95% CI, 0.491-0.793). There was inter-observer variation when comparing less experienced reviewers with more experienced reviewers, with the highest kappa coefficient of 0.396 (95% CI, 0.255-0.588). There was a significant correlation between both classifications, with a Kendall coefficient of 0.899 (p

Objective To evaluate the role of chest computed tomography in patients with COVID-19 who presented initial negative result in reverse transcriptase-polymerase chain reaction (RT-PCR). Methods A single-center, retrospective study that evaluated 39 patients with negative RT-PCR for COVID-19, who underwent chest computed tomography and had a final clinical or serological diagnosis of COVID-19. The visual tomographic classification was evaluated according to the Consensus of the Radiological Society of North America and software developed with artificial intelligence for automatic detection of findings and chance estimation of COVID-19. Results In the visual tomographic analysis, only one of them (3%) presented computed tomography classified as negative, 69% were classified as typical and 28% as indeterminate. In the evaluation using the software, only four (about 10%) had a probability of COVID-19

China was the epicenter for the novel coronavirus disease (COVID-19), which quickly spread to other Asian countries and later to Western countries; subsequently, COVID-19 was categorized as a pandemic by the World Health Organization. Diagnosis primarily depends on viral detection in respiratory samples; however, available kits are limited, lack high sensitivity, and have a long turnaround time for providing results. In this scenario, computed tomography has emerged as an efficient and available high-sensitivity method, allowing radiologists to readily recognize findings related to COVID-19. The objective of this article is to demonstrate the main tomographic findings in symptomatic respiratory patients with COVID-19 to assist medical professionals during this critical moment.A doença pelo novo coronavírus (COVID-19) teve epicentro na China e rapidamente se espalhou pelos demais países asiáticos e, posteriormente, para os países ocidentais, sendo definida como pandemia pela Organização Mundial da Saúde. O diagnóstico da COVID-19 é primariamente dependente da pesquisa do vírus nas vias aéreas superiores, mas os kits para sua confirmação ainda são limitados, não apresentam sensibilidade elevada e os resultados são demorados. Nesse cenário, a tomografia computadorizada surge como método eficiente e disponível e com alta sensibilidade, cabendo a nós radiologistas reconhecer prontamente os achados relacionados a essa doença. O objetivo deste artigo é demonstrar os principais achados tomográficos de tórax em pacientes sintomáticos respiratórios infectados pela COVID-19, de modo a auxiliar os colegas nesse momento crítico.

Patients with SARS-CoV-2 may be affected by the acute respiratory distress syndrome (ARDS), which has been associated with high mortality rate. As no specific drugs are available for ARDS, mesenchymal stem cells (MSC) seems to be a promising cell therapy due to immunomodulatory effects on reducing and healing inflammation-induced lung and other tissue injuries. The goal of this Phase I clinical trial was to explore the safety and efficacy of bone marrow-derived MSC (BM-MSC) infusions in patients with COVID-19 ARDS. The inclusions criteria were age between 18 to 70 years and PaO2/FiO2≤200mmHg. The BM-MSC infusions were as follow: one to 3 infusions intravenous doses of BM-MSC of 1x10 6 cells/kg; each dose could be administered with an interval between 3 to 7 days. The primary endpoint was safety (adverse events) within 6 hours; cardiac arrest or death within 24 hours post-infusion. The secondary endpoint includes patient survival at 30 days after the first infusion. Six patients were included in the trial and treated with at least one infusion of BM-MSC. The median age was 60,3 years (54 to 69), 5 were male. The median time between the worsening of respiratory distress and the BM-MSC infusion was 10 days (3 to 31 days). The median of PaO2/FiO2 before infusion was 151.86 (127.80-164.44) and median PaCO2 was 63,85 (39 to 117). One patient was treated with 3 MSC doses, two patients with 2 doses and 3 patients one dose. No serious adverse effects were observed within 24 hours post-infusion; only one death was observed following 30 days of cell administration. None of them showed adverse events during BM-MSC infusion. Only one patient showed signs of pulmonary infection one week after first BM-MSC infusion. This patient was at increased risk for infection due to prolonged intubation and a high dose of corticosteroid. Therefore, it was not possible to conclude its association with BM-MSC treatment. Only two patients showed clinical improvement after BM-MSC infusion. Patient 1 had BM-MSC infusion 72 hours after worsening of respiratory parameters, and thorax CT suggested the hypothesis of cryptogenic organizing pneumonia, which led to decision of using methylprednisolone 125mg I.V. for 3 days and carry on with MSC infusion. We observed a decrease in CRP levels from 126 to 67 mg/dL on day 1 after the first infusion, and PaO2/FiO2 ratio improved from 155 to 297 mmHg on day 5. He received the second dose within 7 days interval and by day 11 of the first infusion a new thorax TC showed complete resolution of alveolar consolidation areas in both lungs (Figure 1A and 1B). Patient 2 had BM-MSC administration 11 days after respiratory worsening and also presented improvement of PaO2/FiO2 ratio (148 to 215 mmHg after 2 days of infusion) and had thorax CT images suggesting cryptogenic organizing pneumonia with administration of methylprednisolone 250mg I.V. Nevertheless, the second dose was not administered due to ventilator-associated pneumonia and urinary infection. Four patients showed a non-sustained increase of PaO2/FiO2 ratio, with higher median PCO2 levels of 69,3 mmHg (range, 61,2 to 117) comparing to 39 and 47,3 mmHg of patients 1 and 2, respectively. PCO2 parameter could be a marker to indicate a worse response to MSC treatment, since it could point out chronic phases of COVID-19 disease. The patients died due to COVID-19 complications. No difference in inflammatory markers, such as interleukin 6, C-protein reactive test, procalcitonin, ferritin was observed before and after treatment. Inclusion criteria did not defined interval between respiratory worsening and first BM-MSC infusion. Four patients had chronic phase of COVID-19 without inflammatory markers and hypercapnia. It could be related to severity of pulmonary disease, such as reported in chronic obstructive pulmonary disease. Two patients were discharged after MSC treatment and they received methylprednisolone to treat cryptogenic organizing pneumonia. There are only a few clinical trials and observational studies evaluating the use of high-dose of glucocorticoid for severe COVID-19 pneumonia. Therefore, it is not possible to conclude that use of glucocorticoid has contributed to favorable outcomes. In conclusion, BM-MSC showed to be a secure therapeutic option for severe COVID-19 pneumonia, possibly with superior benefit in acute phases and lower PCO2 levels. Further studies involving a large cohort or randomized controlled trials are warranted. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Paciente, 62 anos, encaminhada para estudo angiotomografico das coronarias devido a alteracao isquemica detectada em teste de esforco de rotina. Relatava hipertensao e dislipidemia, ambas controladas sob tratamento medicamentoso, e pratica regular de atividade fisica. Sem queixas cardiovasculares ou alteracoes ao exame fisico. Angiotomografia coronaria evidenciou origem comum das arterias coronarias atraves de tronco comum de curto trajeto, emergindo do seio de Valsalva direito e trifurcando-se em coronaria direita (CD), circunflexa (CX) e descendente anterior (DA). A CD com trajeto [...]

SUMMARY Objective: To evaluate the agreement between the three scores proposed by the II Guideline for Perioperative Evaluation of the Brazilian Society of Cardiology (SBC): the American College of Physicians algorithm (ACP), the Multicenter Study of Perioperative Evaluation (EMAPO) and Lee’s Revised Cardiac Risk Index (RCRI). Method: Patients evaluated preoperatively for non-cardiac surgery by the anesthesiology service were classified as low, moderate or high-risk according to the 3 algorithms suggested by the II Guideline. To calculate the strength of agreement between the scores, the kappa agreement index was used. Results: Four hundred and one patients were included in the sample. Cohen’s kappa inter-rater agreement between scores was 0.270 (CI: 0.222 to 0.318), corresponding to a weak agreement. Analyzing in pairs, the best correlation was between EMAPO and ACP, with kappa = 0.327. Lee’s score was the one that classified more patients as low-risk: 98.3%, while EMAPO and ACP classified as low risk 91.3% and 92.5%, respectively. Conclusion: There is poor correlation among the risk scores proposed by the II Perioperative Evaluation Guideline of the SBC.

Objetivo: relatar um caso de osteossarcoma craniofacial e revisar a literatura sobre os achados de imagem. Relato de Caso: as informações foram obtidas por revisão de prontuário. A paciente do sexo feminino, 25 anos, com parestesia e dor em hemiface direita. Os exames de imagem evidenciaram extenso tumor comprometendo seio maxilar, palato, arcada dentária e cavidade nasal e extensão à fossa infratemporal. Discussão: a maioria dos osteossarcomas craniofaciais são lesões líticas com sinais de agressividade em radiografias. A tomografia é excelente para detectar lesões ósseas e calcificações. A ressonância magnética (RM) mostrou baixo sinal nas ponderações em T1 e alto sinal em T2, com realce heterogêneo pelo meio de contraste. A tomografia computadorizada (TC) é excelente para detectar calcificações e lesões ósseas. A ressonância magnética (RM) é excelente para caracterizar a extensão da lesão. Conclusão: os achados imaginológicos trazem importantes informações para avaliação pré-operatória e monitoramento de recidivas. Objective: the objective of this study was to report a case of craniofacial osteosarcoma and review the literature on imaging findings. Case report: the information was obtained by medical records review. A 25-year-old female, with right hemiface paresthesia and pain was examined. Imaging showed extensive tumor covering the maxillary sinus, palate, dental arch, nasal cavity, and infratemporal fossa extension. Discussion: most of the craniofacial osteosarcomas in the radiography are lithic and showed signs of aggression. Tomography is efficient in detecting calcification and bone lesions, whereas magnetic resonance imaging (MRI) is effective in characterizing the growth of the lesion. Conclusion: the imaging findings reveal important information for preoperative evaluation and relapse monitoring.

Summary Introduction: Emergency medicine is an area in which correct decisions often need to be made fast, thus requiring a well-prepared medical team. There is little information regarding the profile of physicians working at emergency departments in Brazil. Objective: To describe general characteristics of training and motivation of physicians working in the emergency departments of medium and large hospitals in Salvador, Brazil. Method: A cross-sectional study with standardized interviews applied to physicians who work in emergency units in 25 medium and large hospitals in Salvador. At least 75% of the professionals at each hospital were interviewed. One hospital refused to participate in the study. Results: A total of 659 physicians were interviewed, with a median age of 34 years (interquartile interval: 29-44 years), 329 (49.9%) were female and 96 (14.6%) were medical residents working at off hours. The percentage of physicians who had been trained with Basic Life Support, Advanced Cardiovascular Life Support and Advanced Trauma Life Support courses was 5.2, 18.4 and 11.0%, respectively, with a greater frequency of Advanced Cardiovascular Life Support training among younger individuals (23.6% versus 13.9%; p