EXPERIENCE IN THE EVALUATION OF CHILDREN WITH HEPATOSPLENOMEGALY AT A TEACHING AMBULATORY, S��O PAULO, BRAZIL

Objectives: Describe cases of children with hepatosplenomegaly (HS) attended at the General Pediatric Teaching Ambulatory (AGER) of Instituto da Crian��a, S��o Paulo, identifying the main causes, evolution, necessity for hospitalization and/or referral to specialists. Methodology: Retrospective analysis of the records of children presenting HS on admission at AGER from September 1, 1993 to August 31, 1996. Results: Of the 89 children included (age range, 1 to 148 months; median, 24 months), 64 (72%) were referred from other services for HS investigation. Most common presenting complaints were: fever - 39 (44%); pallor - 26 (29%); weight loss - 21 (24%) and jaundice - 14 (16%). Main alterations noticed on physical examination were: pallor - 47 (53%) and short stature - 17 (19%). Anemia was diagnosed in 70 children (79%); 35 children (39%) had infections; 7 (8%) metabolic disorders and 5 (6%) neoplastic disorders. The most frequent infections were of the urinary tract - 9 (10%) and hepatitis A - 6 (7%).Thirty six children (40%) were referred to specialists, 17 of which were already diagnosed. Conclusions: Most of the children with HS present deficiency anemia associated with infections which the general pediatrician is able to diagnose. Persistence of unexplained HS for more than 2 months, especially when there is substantial volume enlargement or alteration in the organs consistency, is an indication for referral to specialists.

Os enfermeiros e as representa����es sociais sobre o envelhecimento : implica����es nos cuidados promotores da autonomia da pessoa idosa hospitalizada

RESUMO: O envelhecimento da popula����o tende a aumentar em todo o mundo, trazendo consequ��ncias a n��veis sociais, econ��micos, e de sa��de. As hospitaliza����es e a necessidade de cuidados de enfermagem �� popula����o idosa tendencialmente aumentam pela maior fragilidade, derivada do aumento das situa����es de doen��a cr��nica e depend��ncia. Os cuidados de enfermagem podem ser influenciados pelas representa����es sociais acerca do envelhecimento, estando associados mitos e estere��tipos, e levar �� desvaloriza����o da individualidade e autonomia da pessoa idosa. Neste sentido, preconiza-se a realiza����o de cuidados em parceria com a pessoa idosa, que promovam a sua autonomia e empowerment. Este estudo tem como objectivo compreender o modo como as representa����es sociais dos enfermeiros acerca do envelhecimento influenciam os cuidados de enfermagem na promo����o da autonomia do idoso hospitalizado. Realiz��mos um estudo qualitativo, com recurso �� entrevista e a t��cnica por associa����o livre de ideias, sendo entrevistados 17 enfermeiros de um servi��o de internamento de medicina. Da an��lise dos resultados, constat��mos que para os enfermeiros do estudo a representa����o social negativa acerca do envelhecimento foi a mais evidenciada, associada a situa����es como: depend��ncia, doen��a, solid��o, isolamento, necessidades, tristeza, peso na sociedade/problemas/dificuldades; levando �� desvaloriza����o das capacidades f��sicas, mentais, psicol��gicas, e da autonomia da pessoa idosa. Como factores dificultadores da promo����o do respeito e autonomia da pessoa idosa referiram a motiva����o, caracter��sticas do enfermeiro e da pessoa idosa e os constrangimentos institucionais. Contudo alguns enfermeiros utilizam estrat��gias facilitadoras da promo����o da autonomia como a: apresenta����o, proximidade, disponibilidade, promo����o da esperan��a, avalia����o da situa����o, e capacita����o f��sica e mental. Conclu��mos que as representa����es sociais negativas acerca do envelhecimento condicionam os cuidados de enfermagem na promo����o da participa����o da pessoa idosa nos cuidados e nas decis��es relativas a si. Os cuidados realizados em parceria, influenciados por uma vis��o positiva da pessoa idosa, valorizam a sua individualidade e toda a sua hist��ria de vida fomentando a sua autonomia.---------- ABSTRACT: Population aging is a global phenomenon, felt particularly in developed countries, with consequences at the social, economic and health-related levels. Hospitalization rates and nursing care needs among the elderly are on the rise in part due to the increased fragility of this population which experience greater levels of dependency and chronic disease. The quality of nursing care may be influenced by social representations of aging, associated with myths and stereotypes, that may lead to the devaluation of the individuality and autonomy of elderly persons. To this end, advocates for care in partnership with the elderly person, that promote their empowerment and autonomy. The present study aims to understand the manner in which social representations held by nurses with regards to the phenomenon of aging influence nursing care, with particular emphasis on the promotion of autonomy among hospitalized elderly patients. This study is a qualitative study, utilizing interviews and the free association of ideas technique, with a total of 17 interviews conducted on nurses working in a hospital ward. According to our results, nurses harbour negative social representations concerning the aging process, associating the latter with dependency, disease, loneliness, needs, sadness, burden on society/problems/difficulties, all of which may lead to the devaluation of the physical, mental, and psychological capacities of the elderly, negatively impacting upon their autonomy. Among those factors found to hinder the promotion of respect and autonomy of the elderly in this study, are personal motivation, characteristics of the nurse and the elderly person and institutional barriers. However, some nurses made use of a number of strategies that promoted patient autonomy, namely: presentation, proximity, availability, the promotion of hope, situation evaluation and physical and mental capacitation. In conclusion, negative social representations concerning aging condition the quality of nursing care, particularly, in what concerns the promotion of patient participation in care and self determination. Nursing interventions carried out in collaboration with the patient, influenced by a positive view of the elderly, value the individuality and life history of these individuals, thereby fomenting their autonomy

Sobrecarga vivenciada por familiares cuidadores de pacientes esquizofr��nicos e sua rela����o com a depress��o

RESUMO: A partir da desinstitucionaliza����o psiqui��trica, a ��nfase nas pol��ticas p��blicas de sa��de mental passou para os servi��os comunit��rios e para per��odos mais curtos de hospitaliza����o. As fam��lias, ent��o, tornaram-se as principais provedoras de cuidados cotidianos e de apoio aos pacientes. As dificuldades e o despreparo em assumir este novo papel t��m gerado um sentimento de sobrecarga nos familiares, o que pode afetar sua sa��de f��sica e mental. V��rios estudos investigaram as consequ��ncias de se tornar um cuidador de um paciente psiqui��trico, mas poucos pesquisaram o impacto na sa��de mental desses cuidadores. A presente pesquisa investigou a rela����o entre a sobrecarga e a sa��de mental dos familiares cuidadores de pacientes psiqui��tricos. Participaram deste estudo 74 familiares cuidadores de pacientes com diagn��stico de esquizofrenia, atendidos no ambulat��rio do Servi��o de Refer��ncia em Sa��de Mental, da cidade de Divin��polis, MG. Os familiares participaram de uma entrevista estruturada. Nela foram aplicadas a Escala de Avalia����o da Sobrecarga dos Familiares de Pacientes Psiqui��tricos (FBIS-BR) e, para avaliar a sa��de mental dos cuidadores, a Escala de Depress��o de Beck (BDI). Foram realizadas an��lises estat��sticas descritivas, univariadas e multivariadas. Os resultados mostraram que a maioria dos cuidadores era do sexo feminino (78,40%), pais (62,20%) e com idade m��dia de 59,14 anos. Os cuidadores apresentaram uma m��dia de sobrecarga global objetiva de 2,05 (DP �� 0,54), em uma escala de 1 a 5 pontos, e uma m��dia de sobrecarga global subjetiva de 2,44 (DP �� 0,71), em uma escala de 1 a 4 pontos. Os resultados da escala BDI mostraram que 42 cuidadores poderiam ser classificados com depress��o m��nima (56,80%), 17 com depress��o leve (23,00%), 7 com depress��o moderada (9,50%) e 8 com depress��o grave (10,80%). Foram encontradas correla����es positivas significativas entre o grau de sobrecarga global e das subescalas e o n��vel de depress��o. As an��lises multivariadas mostraram que o principal preditor de depress��o dos cuidadores foi a sobrecarga global subjetiva. Outros preditores foram a obrecarga objetiva das rotinas di��rias e da supervis��o dos comportamentos problem��ticos dos pacientes e a sobrecarga subjetiva das preocupa����es com o paciente. As informa����es levantadas mostraram o impacto do papel de cuidador na sa��de mental dos familiares e apontaram para a necessidade de uma maior aten����o, por parte dos gestores e profissionais da ��rea, aos cuidadores de pacientes psiqui��tricos.----------ABSTRACT: The emphasis in public policy on mental health was transferred to community services and for shorter periods of hospitalization from the psychiatric deinstitutionalization. Then the families become the first provider of daily care and support to patients. The difficulties and unprepared to assume this new role has generated a sense of overload in the relatives, which can affect your physical and mental health. Several studies have investigated the consequences of becoming a caregiver of a psychiatric patient, but few scholars have researched the impact on the mental health of caregivers. The present study has investigated the relationship between overload and mental health of family caregivers of psychiatric patients. The study included 74 family caregivers of patients with schizophrenia and outpatient clinic of the Department of Mental Health Reference, in Divin��polis, Minas Gerais, Brazil. The Rating Scale Burden of Relatives of Psychiatric Patients and the scale of Beck Depression Inventory (BDI) to assess the mental health of caregivers were applied in the interview. Descriptive statistics and univariate and multivariate analysis have performed. The results showed that the majority of caregivers were female (78.40%), parents (62.20%) and mean age of 59.14 years. The caregivers had an average burden overall objective of 2.05 (�� 0.54) on a scale of 1 to 5 points, and a subjective global average burden of 2.44 (�� 0.71) in a scale of 1 to 4 points. The results of the BDI showed that 42 caregivers could be classified with minimal depression (56.80%), 17 with mild depression (23.00%), 7 with moderate depression (9.50%) and 8 with severe depression (10 80%). Significant positive correlations were found between the degree of overloading and global subscales and depression levels. Multivariate analysis showed that the main predictor of caregivers' depression was the global subjective burden. Other predictors were the objective burden of daily routines and supervision of problem behaviors of patients and subjective burden of the concerns about patient. The resulting information showed the impact of caregiver role in the mental health of relatives and pointed to the need for higher attention of managers and professionals to caregivers of psychiatric patients.

Os custos das fracturas de etiologia osteopor��tica em mulheres : institucionaliza����o na Rede Nacional de Cuidados Continuados (RNCCI) e lares de 3�� idade

RESUMO - Contexto: A osteoporose �� uma doen��a sist��mica associada �� diminui����o da resist��ncia ��ssea que condiciona o aparecimento de fracturas por traumatismos de baixa energia as quais reduzem em muitos casos a esperan��a e a qualidade de vida, implicando um elevado n��mero de horas de dedica����o dos cuidadores e conduzindo, em muitos casos, �� necessidade de institucionaliza����o dos doentes. Em Portugal, ocorrem cerca de 40.000 fracturas anualmente, das quais 8.500 do f��mur proximal, que se estima consumirem mais de 50 milh��es de euros s�� em cuidados hospitalares1. Objectivo: Avaliar o impacto econ��mico da institucionaliza����o na Rede Nacional de Cuidados Continuados Integrados e Lares da 3�� idade por fractura de etiologia osteopor��tica em mulheres no ano 2009, em Portugal. M��todos: O estudo come��a por analisar sucintamente os aspectos cl��nicos, sociais e epidemiol��gicos da osteoporose, focando a perda de autonomia e qualidade de vida dos doentes v��timas deste epis��dio e a subsequente necessidade de institucionaliza����o. Descrevem-se os custos associados �� institucionaliza����o na RNCCI, em Portugal, ano 2009, utilizando como fonte principal a base de dados da institui����o ���Gestcare CCI���, complementada com dados da literatura. Apuram-se os custos totais associados ao encaminhamento dos doentes para Lares de 3�� Idade em Portugal no ano 2009, utilizando-se informa����o proveniente de um painel de Delphi modificado e dados da literatura. A valoriza����o dos recursos tem por base os pre��os em vigor no territ��rio nacional, expressos nos decretos-lei devidamente referenciados. Resultados: No ano 2009 em Portugal foram empregues cerca de 2,5 milh��es de euros no internamento das mulheres na RNCCI, na perspectiva da sociedade, sendo cerca de 2,2 milh��es atribu��veis �� osteoporose (90%). Cerca de 91% dos custos totais s��o alocados �� fractura osteopor��tica da anca (2 milh��es ���). Para a fractura vertebral, ��mero e punho os custos foram mais baixos - 7,1%, 1,3% e 1% dos custos totais da osteoporose, respectivamente. Nos Lares de 3�� idade, estimou-se a admiss��o de aproximadamente 14.372 doentes com fractura osteopor��tica em diferentes localiza����es, em 2009, Portugal, com um custo que oscilou entre os 19 e os 21,6 milh��es de euros. A fractura osteopor��tica da anca foi a mais incidente e a que representou custos mais elevados para a Seguran��a Social ��� entre 17,5 e 19,7 milh��es de euros. Considerando como refer��ncia os 52 milh��es de euros gastos em 2006 no tratamento hospitalar da fractura da anca (DGS, 2006), o encaminhamento das mulheres para a RNCCI e Lares da 3�� Idade corresponde a 42% do bolo total. Assim, os resultados nacionais enquadram-se no que se encontra descrito na literatura internacional - os custos atribu��veis �� hospitaliza����o oscilaram entre 17%50 e 63%29 da despesa total da doen��a e das institucionaliza����es entre os 16%58 e os 59%51. Conclus��es: Em Portugal o impacto econ��mico da institucionaliza����o por fractura osteopor��tica, sobretudo por fractura da anca, n��o �� desprez��vel e mostra que existiriam poupan��as significativas se fosse poss��vel reduzir a preval��ncia da doen��a em Portugal. Face ��s altera����es demogr��ficas associadas ao envelhecimento da popula����o, �� expect��vel que a incid��ncia e custos com o tratamento das fracturas do colo do f��mur, mais associadas �� osteoporose, venham a subir nos pr��ximos anos, pelo que o combate �� doen��a deve ser considerada uma prioridade nacional. A decis��o pela op����o por determinados programas de preven����o da doen��a ou da comparticipa����o ou n��o de determinada terap��utica necessita contudo de ser complementada com a medi����o da dimens��o dos benef��cios terap��uticos. --- ABSTRACT - Background: Osteoporosis is a systemic disease associated with the loss off the bone strength and it is one of the major causes of low energy fractures, which in many cases reduce life hope and quality. This happens because it has associated extensive treatments and it usually carries loss of independence, implying many hours of caregivers dedication and leading, in many cases, to the institutionalization of the patients. In Portugal, about 40,000 fractures occur annually, which 8,500 are proximal femur, and that are estimated to consume over 50 million euros only in hospital care. Objective: Evaluate the economic impact of institutionalization on the Integrated Continued Care National Network (RNCCI) and Care Homes associated to osteoporotic fractures in women, in the year 2009 in Portugal. Methods: The study begins by reviewing briefly the clinical, social, and epidemiological studies of osteoporosis and osteoporotic fractures, focusing on the patient autonomy loss and life quality. The total and average costs per episode associated with the institutionalization in RNCCI are described, in Portugal, year 2009, using as main data source the application "Gestcare CCI", complemented with literature data. The total costs associated with the patients referral for the Care Homes in Portugal in 2009 is also calculated, using information from a modified Delphi panel and some literature data. The resources valuation is based on prices prevailing in Portugal. Results: In 2009, women relocation in RNCCI consumed approximately 2.5 million euros, which 2.2 million are attributable to osteoporosis (90%). About 91% of the total costs are allocated to osteoporotic hip fracture (��� 2 million). For vertebral, humerus, and wrist fracture, the associated costs were lower, 7.1%, 1.3%, and 1% of total costs of osteoporosis treatment, respectively. In Care Homes, an intake of approximately 14 372 patients with osteoporotic fracture was estimated, at a cost that is between 19 and 21.6 million euros. The osteoporotic hip fracture was the most frequent and represented higher costs for Social Security - between 17.5 and 19.7 million euros. Taking as reference the 52 million spent in 2006 with hospital treatment of hip fracture (DGS, 2006), referring women to RNCCI and Care Homes represents 42% of the total costs. The results are in accordance with the international literature - costs attributable to hospitalization ranged between 17% and 63% of total expenditure of illness and institutionalization between 16% and 59%. Conclusions: In Portugal, the economic impact of institutionalization for osteoporotic fracture, particularly for hip fracture, is not negligible. It was shown that there would be significant savings if it were possible to reduce the prevalence of the disease in Portugal. Femoral fractures were the second most frequent diagnosis in RNCCI in 2008 and 2009 (16% of all episodes recorded). The execution of RNCCI in 2008 was 75 million euros, and 2.7% consumed by hip fracture and 0.3% by wrist, humerus, and spine fractures. The average cost per episode in 2009, from the perspective of society, for hip fracture, vertebral, humerus, and wrist (or non-osteoporotic) was ��� 5,195, ��� 5,160, ��� 5,030, and ��� 4,854 respectively. Thus, considering an average cost per episode in RNCCI from January to March of 3230���, the expense related to the treatment of these patients in RNCCI in 2009 was higher. For the Care Homes, an intake of approximately 14 372 patients with osteoporotic fracture in 2009 was estimated, at a cost to Social Security that ranged from 19 to 21.6 million ���. The osteoporotic hip fracture was the most frequent and it was shown to absorve higher resources from Social Security - between 17.5 and 19.7 million ���. This was followed by the analysis of vertebral and humerus fracture and the results showed that these fractures have a low incidence and low proportion of institutionalization, with a significantly lower cost - only about 4.7% and 3.3% of total expenditure, respectively. With demographic changes associated to ageing, it is expected that the incidence and treatment cost of the femoral neck fractures, more commonly associated with osteoporosis, will climb in coming years, so the fight against the disease should be considered a national priority. The decision to choose a certain disease prevention program or to reimburse a certain drug not should only account about the costs, but also the benefits of it. In fact, the size and impact of this problem, makes it necessary to focus all interventions in the prevention of these episodes either by using an appropriate therapy, either through real programs for disease prevention. Once the problem is installed, we must measure the health gains associated with the patient institutionalization by conducting additional research.

Chromobacterium violaceum infection in Brazil. A case report

We report the second case of infection with Chromobacterium violaceum that occurred in Brazil. A farm worker living in the State of S��o Paulo presented fever and severe abdominal pain for four days. At hospitalization the patient was in a toxemic state and had a distended and painful abdomen. Chest X-ray and abdominal ultrasound revealed bilateral pneumonia and hypoechoic areas in the liver. The patient developed failure of multiple organs and died a few hours later. Blood culture led to isolation of C. violaceum resistant to ampicillin and cephalosporins and sensitive to chloramphenicol, tetracyclin, aminoglicosydes, and ciprofloxacin. Autopsy revealed pulmonary microabscesses and multiple abscesses in the liver. The major features of this case are generally observed in infections by C. violaceum: rapid clinical course, multiple visceral abscesses, and high mortality. Because of the antimicrobial resistance profile of this Gram-negative bacillus, for appropriate empirical antibiotic therapy it is important to consider chromobacteriosis in the differential diagnosis of severe community infections in Brazil.

Evaluation of penicillin therapy in patients with leptospirosis and acute renal failure

The effectiveness of specific antibiotic treatment in severe leptospirosis is still under debate. As part of a prospective study designed to evaluate renal function recovery after leptospirosis acute renal failure (ARF) (ARF was defined as Pcr > or = 1.5 mg/dL), the clinical evolutions of 16 treated patients (T) were compared to those of 18 untreated patients (nT). Treatment or non-treatment was the option of each patient's attending infectologist. The penicillin treatment was always with 6 million IU/day for 8 days. No difference was found between the two groups in terms of age, gender, number of days from onset of symptoms to hospital admission, or results of laboratory tests performed upon admission and during hospitalization, but proteinuria was higher in the treated group. There were no significant difference in the other parameters employed to evaluate patients' clinical evolution as: length of hospital stay, days of fever, days to normalization of renal function, days to total bilirubins normalized or reached 1/3 of maximum value and days to normalization of platelet counts. Dialytic treatment indication and mortality were similar between group T and nT. In conclusion, penicillin therapy did not provide better clinical outcome in patients with leptospirosis and ARF.

Health care marketing: the theory of planned behavior applied to patients' choise between private and public providers in the portuguese health care system.

Dissertation submitted in partial fulfillment of the requirements for degree of Master in Statistics and Information Management.

Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in S��o Paulo, Brazil

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations. The authors conducted a prospective study to evaluate the occurrence, clinical patterns, and seasonal trends of viral infections among hospitalized children with lower respiratory tract disease (Group A). The presence of respiratory viruses in children's nasopharyngeal was assessed at admission in a pediatric ward. Cell cultures and immunofluorescence assays were used for viral identification. Complementary tests included blood and pleural cultures conducted for bacterial investigation. Clinical data and radiological exams were recorded at admission and throughout the hospitalization period. To better evaluate the results, a non- respiratory group of patients (Group B) was also constituted for comparison. Starting in February 1995, during a period of 18 months, 414 children were included- 239 in Group A and 175 in Group B. In Group A, 111 children (46.4%) had 114 viruses detected while only 5 children (2.9%) presented viruses in Group B. Respiratory Syncytial Virus was detected in 100 children from Group A (41.8%), Adenovirus in 11 (4.6%), Influenza A virus in 2 (0.8%), and Parainfluenza virus in one child (0.4%). In Group A, aerobic bacteria were found in 14 cases (5.8%). Respiratory Syncytial Virus was associated to other viruses and/or bacteria in six cases. There were two seasonal trends for Respiratory Syncytial Virus cases, which peaked in May and June. All children affected by the virus were younger than 3 years of age, mostly less than one year old. Episodic diffuse bronchial commitment and/or focal alveolar condensation were the clinical patterns more often associated to Respiratory Syncytial Virus cases. All children from Group A survived. In conclusion, it was observed that Respiratory Syncytial Virus was the most frequent pathogen found in hospitalized children admitted for severe respiratory diseases. Affected children were predominantly infants and boys presenting bronchiolitis and focal pneumonias. Similarly to what occurs in other subtropical regions, the virus outbreaks peak in the fall and their occurrence extends to the winter, which parallels an increase in hospital admissions due to respiratory diseases.

Effectiveness of influenza vaccination in elderly outpatients in S��o Paulo city, Brazil

To investigate the effectiveness of the influenza vaccine in a population of elderly outpatients, we compared the occurrence and frequency of influenza like illness (ILI), respiratory illness and hospitalization in vaccinated and non-vaccinated subjects. All the outcomes were clinically defined. The two groups were similar with respect to demographics, health situation and habits. The influenza vaccine contributed to the protection of the elderly investigated, since the vaccinated subjects referred a significantly lower number of ILI than the non-vaccinated. There is a need for more studies about the effectiveness of the influenza vaccine in our country in elderly and other groups of our population.

Penicillin at the late stage of leptospirosis: a randomized controlled trial

There is evidence that an early start of penicillin reduces the case-fatality rate of leptospirosis and that chemoprophylaxis is efficacious in persons exposed to the sources of leptospira. The existent data, however, are inconsistent regarding the benefit of introducing penicillin at a late stage of leptospirosis. The present study was developed to assess whether the introduction of penicillin after more than four days of symptoms reduces the in-hospital case-fatality rate of leptospirosis. A total of 253 patients aged 15 to 76 years with advanced leptospirosis, i.e., more than four days of symptoms, admitted to an infectious disease hospital located in Salvador, Brazil, were selected for the study. The patients were randomized to one of two treatment groups: with intravenous penicillin, 6 million units day (one million unit every four hours) for seven days (n = 125) and without (n = 128) penicillin. The main outcome was death during hospitalization. The case-fatality rate was approximately twice as high in the group treated with penicillin (12%; 15/125) than in the comparison group (6.3%; 8/128). This difference pointed in the opposite direction of the study hypothesis, but was not statistically significant (p = 0.112). Length of hospital stay was similar between the treatment groups. According to the results of the present randomized clinical trial initiation of penicillin in patients with severe forms of leptospirosis after at least four days of symptomatic leptospirosis is not beneficial. Therefore, more attention should be directed to prevention and earlier initiation of the treatment of leptospirosis.

Fonsecaea pedrosoi cerebral phaeohyphomycosis ("chromoblastomycosis"): first human culture-proven case reported in Brazil

Cerebral phaeohyphomycosis ("chromoblastomycosis") is a rare intracranial lesion. We report the first human culture-proven case of brain abscesses due to Fonsecaea pedrosoi in Brazil. The patient, a 28 year-old immunocompetent white male, had ocular manifestations and a hypertensive intracranial syndrome. Magnetic resonance imaging (MRI) of the brain revealed a main tumoral mass involving the right temporo-occipital area and another smaller apparently healed lesion at the left occipital lobe. A cerebral biopsy was performed and the pathological report was cerebral chromoblastomycosis. The main lesion was enucleated surgically and culture of the necrotic and suppurative mass grew a fungus identified as Fonsecaea pedrosoi. The patient had received a knife wound sixteen years prior to his hospitalization and, more recently, manifested a pulmonary granulomatous lesion in the right lung with a single non-pigmented form of a fungus present. It was speculated that the fungus might have gained entrance to the host through the skin lesion, although a primary respiratory lesion was not excluded. The patient was discharged from the hospital still with ocular manifestations and on antimycotic therapy and was followed for eight months without disease recurrence. Few months after he had complications of the previous neuro-surgery and died. A complete autopsy was performed and no residual fungal disease was found.

Caracteriza����o e Impacte das quedas de doentes, como indicador de qualidade, num hospital E.P.E.

RESUMO - Introdu����o: As quedas dos doentes s��o um dos principais eventos adversos que podem ocorrer em contexto hospitalar, levando por um lado, ao aumento de encargos econ��micos e sociais, e por outro a consequ��ncias f��sicas e psicol��gicas nos doentes e respectiva fam��lia. Para a sua preven����o, �� necess��rio investir na seguran��a do doente atrav��s de uma avalia����o e consequente gest��o do risco de quedas. Este trabalho insere-se na estrat��gia de melhorar a seguran��a do doente e a qualidade dos cuidados prestados. Objectivos: Avaliar em que medida o formul��rio existente responde ��s actuais necessidades de gest��o do risco de quedas e suas consequ��ncias. Por outro lado, com base numa extensa revis��o da literatura nacional e internacional, e tendo em conta as din��micas de qualidade e seguran��a do doente que t��m sido criadas no hospital em estudo, propor um formul��rio mais eficaz que permita responder aos desafios que se colocam nos dias de hoje. Metodologia: Tratou-se de um estudo descritivo explorat��rio assente no paradigma quantitativo. A popula����o do estudo foi constitu��da por 98 doentes que sofreram quedas durante o internamento no ano de 2010, num hospital E.P.E. (Entidade P��blica Empresarial) Conclus��o: As quedas ocorreram mais frequentemente em indiv��duos do sexo masculino com doen��as c��rebro-vasculares e infecciosas, sendo que na maioria das vezes n��o resultaram em consequ��ncias graves. O formul��rio que aqui se recomenda tem a vantagem de ser informatizado e caracterizar aspectos relacionados com os custos. ---------------- ABSTRACT - Introduction: Falls of patients are one of the main adverse events that may occur in a hospital context, leading on the one hand, to an increase of economic and social burden, and, on the other hand, physical and psychological consequences for patients and their families. For its prevention, we need to invest in patient safety through an assessment and consequent management of the fall risk. This work is inserted in the strategy to improve the Patient safety and the quality of health care. Objectives: To assess the extent to which the form responds to current needs of managing the fall risk and their consequences. On the other hand, on the basis of an extensive review of national and international literature, and taking into account the dynamics of quality and safety of the patient that are created at the hospital in study, to propose a form more efficient in order to respond to the challenges that we face nowadays. Methodology: It was an exploratory descriptive study based on the quantitative paradigm. The population study was constituted by 98 patients who had suffered falls during hospitalization in the year 2010, in a hospital E.P.E. Conclusion: Falling occurred more frequently in male individuals with cerebral-vascular and infectious diseases, and in most of the time, falls have not resulted in serious consequences. The form recommended here has the advantage of being computerized and characterize aspects related with costs.

Childhood astrovirus-associated diarrhea in the ambulatory setting in a Public Hospital in Cordoba city, Argentina

Human astroviruses have been increasingly identified as important agents of diarrheal disease in children. However, the disease burden of astrovirus infection is still incompletely assessed. This paper reports results on the epidemiological and clinical characteristics of astrovirus-associated diarrhea, as well as the impact of astrovirus infection on the ambulatory setting at a Public Hospital in C��rdoba city, Argentina. From February 2001 through January 2002, 97 randomly selected outpatient visits for diarrhea among children < 36 months old were enrolled. A single specimen of stool from each child was collected and tested for astrovirus antigen by enzyme immunoassay. Astroviruses were detected in 12.37% of the diarrheal episodes. All the positive cases occurred in children 4 to 18 months, but the highest rate was in children aged 4 to 6 months (23.80%). The clinical symptoms of astrovirus associated-diarrhea were fever 41.66%, vomiting 25.00% and dehydration 8.33%; overall 16.66% required hospitalization. Astrovirus was identified through the year and no seasonally pattern was detected (cool semester 15.21% versus warm semester 9.80% p > 0.05). According to our estimation about one out of seventy-four children in this cohort would be assisted annually for an astroviral-diarrheal episode in the Public Hospital and one out of eight diarrheal cases could be attributed to astrovirus infection. Astrovirus is a common symptomatic infection in pediatric outpatient visits in the public hospital in the study area, contributing 12.37% of the overall morbidity from diarrhea.

Mixomas Card��acos, 13 Anos de Experi��ncia no seu Diagn��stico Ecocardiogr��fico

INTRODUCTION: Transthoracic echocardiography is the method of choice for the diagnosis of cardiac myxomas, but the transesophageal approach provides a better definition of the location and characteristics of the tumor. The authors review their thirteen years' experience on the echocardiographic diagnosis of this pathology. METHODS: From 1994 to 2007, 41 cardiac tumors were diagnosed in our echocardiographic laboratory, of which 27 (65.85%) were cardiac myxomas. The exams and the patients' clinical files were retrospectively reviewed. RESULTS: Of the 27 patients, 22 (81.5%) were female, with a mean age of 62.1 +/- 13.6 years (25-84 years). The predominant clinical features were due to the obstruction caused by the tumor in more than two thirds of the patients, followed by constitutional symptoms in one third and embolic events in 30%. In the lab results, anemia was found in three patients and elevated sedimentation rate and CRP in two. In two patients the myxoma was found by chance. All the cases were of the sporadic type, although we found a prevalence of thyroid disease of 14% (4 patients). All patients underwent urgent surgical resection except one, in whom surgery was refused due to advanced age and comorbidities. The myxomas followed a typical distribution with 24 (88.8%) located in the left atrium, 18 of them attached to the atrial septum (AS) and two to the mitral valve. In one patient, the tumor involved both atria. The other two cases originated in the right atrium at the AS. Embolic phenomena were more frequent in small tumors (p = 0.027) and in those with a villous appearance (p = 0.032). Obstructive manifestations were associated with larger tumors (p = 0.046) and larger left atria (p = 0.048). In our series, there were no deaths during hospitalization or in the follow-up period of 5.2 +/- 3.7 years in 19 patients. There were two recurrences, both patients being successfully reoperated. CONCLUSION: Myxoma is the most common cardiac tumor. Transesophageal echocardiography provides excellent morphologic definition, aiding in diagnosis and follow-up. Most clinical manifestations are obstructive and are associated with larger tumors. Small tumors with a friable appearance have a higher chance of embolization. Surgical resection is usually curative and the long-term prognosis is excellent.

Detection of EBV-DNA in serum samples of an immunosuppressed child during a three years follow-up: association of clinical and PCR data with active infection

Twenty-four whole blood and serum samples were drawn from an eight year-old heart transplant child during a 36 months follow-up. EBV serology was positive for VCA-IgM and IgG, and negative for EBNA-IgG at the age of five years old when the child presented with signs and symptoms suggestive of acute infectious mononucleosis. After 14 months, serological parameters were: positive VCA-IgG, EBNA-IgG and negative VCA-IgM. This serological pattern has been maintained since then even during episodes suggestive of EBV reactivation. PCR amplified a specific DNA fragment from the EBV gp220 (detection limit of 100 viral copies). All twenty-four whole blood samples yielded positive results by PCR, while 12 out of 24 serum samples were positive. We aimed at analyzing whether detection of EBV-DNA in serum samples by PCR was associated with overt disease as stated by the need of antiviral treatment and hospitalization. Statistical analysis showed agreement between the two parameters evidenced by the Kappa test (value 0.750; p < 0.001). We concluded that detection of EBV-DNA in serum samples of immunosuppressed patients might be used as a laboratory marker of active EBV disease when a Real-Time PCR or another quantitative method is not available.