Erratum of initial paper: Postmortem computed tomography angiography vs. conventional autopsy: advantages and inconveniences of each method.

PURPOSE: Postmortem computed tomography angiography (PMCTA) was introduced into forensic investigations a few years ago. It provides reliable images that can be consulted at any time. Conventional autopsy remains the reference standard for defining the cause of death, but provides only limited possibility of a second examination. This study compares these two procedures and discusses findings that can be detected exclusively using each method. MATERIALS AND METHODS: This retrospective study compared radiological reports from PMCTA to reports from conventional autopsy for 50 forensic autopsy cases. Reported findings from autopsy and PMCTA were extracted and compared to each other. PMCTA was performed using a modified heart-lung machine and the oily contrast agent Angiofil® (Fumedica AG, Muri, Switzerland). RESULTS: PMCTA and conventional autopsy would have drawn similar conclusions regarding causes of death. Nearly 60 % of all findings were visualized with both techniques. PMCTA demonstrates a higher sensitivity for identifying skeletal and vascular lesions. However, vascular occlusions due to postmortem blood clots could be falsely assumed to be vascular lesions. In contrast, conventional autopsy does not detect all bone fractures or the exact source of bleeding. Conventional autopsy provides important information about organ morphology and remains the only way to diagnose a vital vascular occlusion with certitude. CONCLUSION: Overall, PMCTA and conventional autopsy provide comparable findings. However, each technique presents advantages and disadvantages for detecting specific findings. To correctly interpret findings and clearly define the indications for PMCTA, these differences must be understood.

Heavy atom enhanced room-temperature phosphorimetry for ultratrace determination of harmane

Harmane has been proposed for the treatment of epilepsy, AIDS and leshmaniosis. Its room-temperature phosphorescence was induced using either AgNO3 or TlNO3, enabling absolute limits of detection of 0.12 and 2.4 ng respectively, with linear dynamic ranges extending up to 456 ng (AgNO3) and 911 ng (TlNO3). Relative standard deviations around 3% were observed for substrates containing 46 ng of harmane. Such sensitivity and precision are needed because harmane intake must be strictly controlled to achieve proper therapeutic response. Interference studies were performed using thalidomide, reserpine and yohimbine. Recovery of 104±6% was achieved using solid surface room-temperature phosphorimetry. The result was comparable to the one obtained by micellar electrokinetic chromatography.

Synthesis of quinoxaline 1,4-di-N-oxide derivatives on solid support using room temperature and microwave-assisted solvent-free procedures

We describe the synthesis of 12 new ethyl and methyl quinoxaline-7-carboxylate 1,4-di-N-oxide derivatives on solid supports with room temperature and microwave-assisted solvent-free procedures. Results show that solid supports have good catalytic activity in the formation of quinoxaline 1,4-di-N-oxide derivatives. We found that florisil and montmorillonite KSF and K10 could be used as new, easily available, inexpensive alternatives of catalysts. Additionally, room temperature and microwave-irradiation solvent-free synthesis was more efficient than a conventional procedure (Beirut reaction), reducing reaction time and increasing yield.

Analysis of electricity distribution network operation business models and capitalization of control room functions with DMS

Electricity distribution network operation (NO) models are challenged as they are expected to continue to undergo changes during the coming decades in the fairly developed and regulated Nordic electricity market. Network asset managers are to adapt to competitive technoeconomical business models regarding the operation of increasingly intelligent distribution networks. Factors driving the changes for new business models within network operation include: increased investments in distributed automation (DA), regulative frameworks for annual profit limits and quality through outage cost, increasing end-customer demands, climatic changes and increasing use of data system tools, such as Distribution Management System (DMS). The doctoral thesis addresses the questions a) whether there exist conditions and qualifications for competitive markets within electricity distribution network operation and b) if so, identification of limitations and required business mechanisms. This doctoral thesis aims to provide an analytical business framework, primarily for electric utilities, for evaluation and development purposes of dedicated network operation models to meet future market dynamics within network operation. In the thesis, the generic build-up of a business model has been addressed through the use of the strategicbusiness hierarchy levels of mission, vision and strategy for definition of the strategic direction of the business followed by the planning, management and process execution levels of enterprisestrategy execution. Research questions within electricity distribution network operation are addressed at the specified hierarchy levels. The results of the research represent interdisciplinary findings in the areas of electrical engineering and production economics. The main scientific contributions include further development of the extended transaction cost economics (TCE) for government decisions within electricity networks and validation of the usability of the methodology for the electricity distribution industry. Moreover, DMS benefit evaluations in the thesis based on the outage cost calculations propose theoretical maximum benefits of DMS applications equalling roughly 25% of the annual outage costs and 10% of the respective operative costs in the case electric utility. Hence, the annual measurable theoretical benefits from the use of DMS applications are considerable. The theoretical results in the thesis are generally validated by surveys and questionnaires.

Critical analysis of thoracotomies performed in the emergency room in 10 years

OBJECTIVE: To conduct a critical analysis of thoracotomies performed in the emergency rooms.METHODS: We analyzed mortality rates and survival as outcome variables, mechanism of injury, site of injury and anatomic injury as clinical variables, and gender and age as demographic variables of patients undergoing thoracotomy in the emergency room after traumatic injury.RESULTS: Of the 105 patients, 89.5% were male. The average age was 29.2 years. Penetrating trauma accounted for 81% of cases. The most common mechanism of trauma was wound by a firearm projectile (gunshot), in 64.7% of cases. Patients with stab wounds (SW) accounted for 16.2% of cases. Overall survival was 4.7%. Survival by gunshot was 1.4%, and by SW, 23.5%. The ERT following blunt trauma showed a 100%mortality.CONCLUSION: The results obtained in the Emergency Hospital of Porto Alegre POA-HPS are similar to those reported in the world literature.

Early detection of severe sepsis in the emergency room in adults - Clinical utility of prognostic markers

Vaikean sepsiksen varhainen tunnistaminen päivystyspoliklinikalla – merkkiaineiden käyttökelpoisuus aikuispotilaiden arvioinnissa Päivystyspotilaan vakavan yleisinfektion eli sepsiksen varhainen tunnistaminen ja taudin vaikeusasteen arviointi on päivystävälle lääkärille tärkeä haaste. Arvioimme prospektiivisessa kohorttitutkimuksessa eri merkkiaineiden hyödyllisyyttä sepsiksen varhaisessa tunnistamisessa ja vaikeusasteen arvioinnissa. Työssä I ja III oli 539 päivystyspotilasta, joilta kliinikko päätti ottaa veriviljelyn sepsistä epäillen. Tutkimuksessa II oli 525 potilasta ja tutkimuksessa IV 537 potilasta. Tutkimuksessa I plasman C-reaktiivisen proteiinin (CRP) pitoisuuksia verrattiin plasman prokalsitoniinin (PCT) ja interleukiinin (IL-6) pitoisuuksiin. Tutkimuksessa II verrattiin plasman baktersidisen/ permeabiliteettia lisäävän proteiinin (BPI), ryhmän IIA fosfolipaasi A2:n (PLA2GIIA) ja CRP:n pitoisuuksia sekä valkosolujen määriä toisiinsa. Tutkimuksessa III arvioitiin liukoisen urokinaasi-tyyppisen plasminogeenin aktivaattorireseptorin (suPAR) ja tutkimuksessa IV pentraksiini 3:n (PTX3) määrityksen käyttökelpoisuutta. Tutkimuksessa I todettiin päivystystilanteessa mitattujen korkeiden PCT - ja IL-6 - pitoisuuksien ennustavan vaikean sepsiksen kehittymistä paremmin kuin korkean CRP:n. Tutkimuksessa II plasman PLA2GIIA vaikutti hiukan paremmalta vaikean sepsiksen ennustajalta kuin CRP tai veren valkosolutaso, mutta BPI ei ollut hyödyllinen. Tutkimuksessa III korkea plasman suPAR- pitoisuus osoittautui itsenäiseksi kuolleisuuden riskitekijäksi ja se liittyi myös vaikean sepsiksen kehittymiseen. Tutkimuksessa IV korkea PTX3 - pitoisuus toimi samaan tapaan kuin suPAR. Kokonaisuutena PCT osoittautui parhaaksi merkkiaineeksi ennustamaan elinhäiriön kehittymistä ja suPAR kuolleisuutta. PTX3 ei tarjonnut merkittävää lisäetua PCT:iin ja suPAR:iin verrattuna. CRP osoitti suhteellisen hyvin bakteeri-infektion esiintymistä, mutta ennusteellista arvoa sillä ei ollut. suPAR on kiinnostava kuolleisuuden ja elinhäiriön kehittymisen merkkiaine.

Early prediction of poor outcome in patients with acute asthma in the emergency room

Early identification of patients who need hospitalization or patients who should be discharged would be helpful for the management of acute asthma in the emergency room. The objective of the present study was to examine the clinical and pulmonary functional measures used during the first hour of assessment of acute asthma in the emergency room in order to predict the outcome. We evaluated 88 patients. The inclusion criteria were age between 12 and 55 years, forced expiratory volume in the first second below 50% of predicted value, and no history of chronic disease or pregnancy. After baseline evaluation, all patients were treated with 2.5 mg albuterol delivered by nebulization every 20 min in the first hour and 60 mg of intravenous methylprednisolone. Patients were reevaluated after 60 min of treatment. Sixty-five patients (73.9%) were successfully treated and discharged from the emergency room (good responders), and 23 (26.1%) were hospitalized or were treated and discharged with relapse within 10 days (poor responders). A predictive index was developed: peak expiratory flow rates after 1 h <=0% of predicted values and accessory muscle use after 1 h. The index ranged from 0 to 2. An index of 1 or higher presented a sensitivity of 74.0, a specificity of 69.0, a positive predictive value of 46.0, and a negative predictive value of 88.0. It was possible to predict outcome in the first hour of management of acute asthma in the emergency room when the index score was 0 or 2.

Discrepancies between clinical diagnoses and autopsy findings

Autopsy examination is considered to be an essential element for medical auditing and teaching. Despite the significant progress in diagnostic procedures, autopsy has not always confirmed the clinical diagnosis. In the present study, we compared the diagnosis recorded on medical charts with reports of 96 autopsies performed at the University Teaching Hospital of the Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil, between 1975 and 1982, and of 156 autopsies performed at the same institution between 1992 and 1996. The clinical diagnosis of the basic cause of death was confirmed at autopsy in 77% of cases. The percent confirmation fell to 60% when the immediate terminal cause of death was considered, and in 25% of cases, the terminal cause was only diagnosed at autopsy. The discrepancies between clinical and autopsy diagnosis were even larger for secondary diagnoses: 50% of them were not suspected upon clinical diagnosis. Among them, we emphasize the diagnosis of venous thromboses (83%), pulmonary embolisms (80%), bronchopneumonias (46%) and neoplasias (38%). Iatrogenic injuries were very frequent, and approximately 90% of them were not described in clinical reports. Our results suggest that highly sensitive and specific diagnostic tests are necessary but cannot substitute the clinical practice for the elaboration of correct diagnoses.

Effect of air pollution on pediatric respiratory emergency room visits and hospital admissions

In order to assess the effect of air pollution on pediatric respiratory morbidity, we carried out a time series study using daily levels of PM10, SO2, NO2, ozone, and CO and daily numbers of pediatric respiratory emergency room visits and hospital admissions at the Children's Institute of the University of São Paulo Medical School, from August 1996 to August 1997. In this period there were 43,635 hospital emergency room visits, 4534 of which were due to lower respiratory tract disease. The total number of hospital admissions was 6785, 1021 of which were due to lower respiratory tract infectious and/or obstructive diseases. The three health end-points under investigation were the daily number of emergency room visits due to lower respiratory tract diseases, hospital admissions due to pneumonia, and hospital admissions due to asthma or bronchiolitis. Generalized additive Poisson regression models were fitted, controlling for smooth functions of time, temperature and humidity, and an indicator of weekdays. NO2 was positively associated with all outcomes. Interquartile range increases (65.04 µg/m³) in NO2 moving averages were associated with an 18.4% increase (95% confidence interval, 95% CI = 12.5-24.3) in emergency room visits due to lower respiratory tract diseases (4-day moving average), a 17.6% increase (95% CI = 3.3-32.7) in hospital admissions due to pneumonia or bronchopneumonia (3-day moving average), and a 31.4% increase (95% CI = 7.2-55.7) in hospital admissions due to asthma or bronchiolitis (2-day moving average). The study showed that air pollution considerably affects children's respiratory morbidity, deserving attention from the health authorities.

Incidence of heart failure in infarcted rats that die spontaneously

The present study reports for the first time the incidence of congestive heart failure (CHF) in previously infarcted rats that died spontaneously. Previously, pulmonary (PWC) and hepatic (HWC) water contents were determined in normal rats: 14 control animals were evaluated immediately after sacrifice, 8 placed in a refrigerator for 24 h, and 10 left at room temperature for 24 h. In the infarcted group, 9 rats died before (acute) and 28 died 48 h after (chronic) myocardial infarction. Thirteen chronic animals were submitted only to autopsy (N = 13), whereas PWC and HWC were also determined in the others (N = 15). Seven rats survived 48 h and died during anesthesia. Notably, PWC differed in normal rats: ambient (75.7 ± 1.3%) < control (77.5 ± 0.7%) < refrigerator (79.1 ± 1.4%) and there were no differences with respect to HWC. No clinical signs of CHF (dyspnea, lethargy or foot edema) were observed in infarcted rats before death. PWC was elevated in all chronic and anesthetized rats. HWC was increased in 48% of chronic and in all anesthetized rats. Our data showed that PWC needs to be evaluated before 24 h post mortem and that CHF is the rule in chronic infarcted rats suffering natural death. The congestive syndrome cannot be diagnosed correctly in rats by clinical signs alone, as previously proposed.

Nasal CPAP in the delivery room for newborns with extremely low birth weight in a hospital in a developing country

The objective of this study was to determine the feasibility of the use of continuous positive airway pressure installed prophylactically in the delivery room (DR-CPAP), for infants with a birth weight between 500 and 1000 g in settings with limited resources. During 23 months, infants with a birth weight between 500 and 1000 g consecutively received DR-CPAP. A total of 33 infants with low birth weight were enrolled, 16 (48.5%) were females. Only 14 (42.4%) received antenatal corticosteroids and only 2 of those 14 (14.3%) infants weighing 500-750 g were not intubated in the delivery room, and apnea was given as the reason for intubation of these patients. Of the 19 infants in the 751-1000 g weight range, 9 (47.4%) were intubated in the delivery room, 6 due to apnea and 3 due to respiratory discomfort. For DR-CPAP to be successful, it is probably necessary for preterm babies to be more prepared at birth to withstand the respiratory effort without the need for intubation. Antenatal corticosteroids and better prenatal monitoring are fundamental for success of DR-CPAP.

Application of continuous positive airway pressure in the delivery room: a multicenter randomized clinical trial

This study evaluated whether the use of continuous positive airway pressure (CPAP) in the delivery room alters the need for mechanical ventilation and surfactant during the first 5 days of life and modifies the incidence of respiratory morbidity and mortality during the hospital stay. The study was a multicenter randomized clinical trial conducted in five public university hospitals in Brazil, from June 2008 to December 2009. Participants were 197 infants with birth weight of 1000-1500 g and without major birth defects. They were treated according to the guidelines of the American Academy of Pediatrics (APP). Infants not intubated or extubated less than 15 min after birth were randomized for two treatments, routine or CPAP, and were followed until hospital discharge. The routine (n=99) and CPAP (n=98) infants studied presented no statistically significant differences regarding birth characteristics, complications during the prenatal period, the need for mechanical ventilation during the first 5 days of life (19.2 vs 23.4%, P=0.50), use of surfactant (18.2 vs 17.3% P=0.92), or respiratory morbidity and mortality until discharge. The CPAP group required a greater number of doses of surfactant (1.5 vs 1.0, P=0.02). When CPAP was applied to the routine group, it was installed within a median time of 30 min. We found that CPAP applied less than 15 min after birth was not able to reduce the need for ventilator support and was associated with a higher number of doses of surfactant when compared to CPAP applied as clinically indicated within a median time of 30 min.

Room temperature aging to guarantee microbiological safety of Brazilian artisan Canastra cheese

Canastra cheese is one of the oldest and most traditional cheeses made from raw milk in Brazil. However, this type of practice may have severe consequences for human health. According to the current legislation, any cheese made from raw milk must be aged for at least 60 days. Traditionally, Canastra cheese is consumed after different ripening periods, but consumers usually prefer those that are aged less than eight days. This study aimed to evaluate the effects of physicochemical and microbiological parameters, with emphasis on the pathogenic microbiota regulated by law, on cheese aged at room temperature and under refrigeration. Cheese samples were collected from eight different cheese producers located in the Serra da Canastra region twice a year (rainy and dry seasons) and analyzed with 8, 15, 22, 29, 36, and 64 days of ripening. Room temperature aging effectively reduced pathogens, reaching the total count established by law in 22 days, regardless of the season. However, ripening under refrigeration, it was ineffective in reducing the Staphylococcus aureus counts to the legislation limits, even after 64 days. Therefore, Canastra cheese should be ripened for at least 22 days at room temperature in order to fulfill the safety regulatory limits.