A morbidade materna near miss em um centro de referencia de saude da mulher

Orientadores: Jose Guilherme Cecatti, Mary Angela ParpinelliDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Objetivos: Fazer uma ampla revisão da literatura internacional e nacional, compilando dados publicados sobre a ocorrência de morbidade materna grave (near miss) em diferentes contextos; analisar a ocorrência de near miss em uma maternidade brasileira de nível terciário, utilizando diferentes conjuntos de critérios; e caracterizar os determinantes primários da morbidade grave, sua demanda assistencial e o desfecho materno-fetal. Sujeitos e métodos: a revisão foi realizada a partir da busca eletrônica de artigos publicados e indexados nas bases bibliográficas MedLine e SciELO, além da busca manual em periódico brasileiro e na lista de referências bibliográficas dos artigos identificados pelos unitermos ¿maternal near miss¿. Os artigos foram qualitativamente avaliados pelo tipo de desenho de estudo, procedência, disponibilidade de dados originais e tipo de critério utilizado para a definição de near miss. Foi ainda realizado um estudo descritivo em um centro terciário de referência à saúde da mulher, entre 01 de julho de 2003 e 30 de junho de 2004. De 2.929 mulheres que tiveram parto na instituição, foram identificados os casos de morbidade grave segundo critérios propostos por Mantel e Waterstone, através de visita diária às instalações da maternidade. A revisão dos prontuários e a coleta dos dados de interesse foram realizadas no momento da alta hospitalar. As principais medidas de efeito estudadas foram: a ocorrência de near miss e seus fatores determinantes primários, critério de identificação como near miss, tempo total de permanência hospitalar, tempo de permanência em UTI e número e tipos de procedimentos especiais realizados. Resultados: Foram incluídos na revisão 33 estudos da literatura, com uma razão média de near miss de 7,5/1000 partos. No centro de referência foram identificados 124 casos de near miss, correspondente a uma razão de 42/1000 partos, e ocorreram dois óbitos maternos. Foram realizados 126 procedimentos especiais, 102 deles realizados em mulheres admitidas na UTI para suporte intensivo (80,9%). O número médio de procedimentos especiais por mulher foi de 1,04 (±1,91) e os mais freqüentes foram a instalação de acesso venoso central, a realização de ecocardiografia e a ventilação artificial invasiva. A média de permanência hospitalar foi de 10,3 dias (±13,24). O tempo de permanência hospitalar e o número de procedimentos especiais foram significativamente maiores quando utilizados os critérios de Mantel. Conclusões: A incidência de near miss tende a ser maior nos países em desenvolvimento e quando utilizada a definição de disfunção orgânica. A incidência de near miss foi elevada e os critérios propostos por Mantel permitiram a identificação de um subgrupo de mulheres com manejo clínico mais complexo, considerando-se o tempo de permanência hospitalar e a demanda por procedimentos especiais. Os determinantes primários de morbidade materna grave foram coincidentes com as principais causa básicas conhecidas de morte maternaAbstract: Objectives: to perform a wide review of the international and national literature and to combine reported data on the occurrence of severe maternal morbidity (near miss) in several contexts; to evaluate the occurrence of near-miss in a tertiary Brazilian maternity, using different sets of criteria, to identify their primary determinants, their demand for care and the maternal and fetal outcomes. Methods: the review was performed through an electronic search of the published articles indexed in the bibliographic databases of MedLine and SciELO, besides a manual search in Brazilian journal and in the list of references of the articles identified through the uniterms ¿maternal near miss¿. The articles were qualitatively evaluated according to their study design, local, availability of original data and kind of criteria used for the definition of near miss. A descriptive study was also performed at a tertiary referral center for the women¿s health, between 1st. July 2003 to 30th. June 2004. From the total of 2929 women who delivered at the institution during the period, the cases of maternal near miss morbidity were identified through a daily visit in the wards of the maternity according to the criteria proposed by Mantel and by Waterstone. At the moment of hospital discharge a review of the clinical records and data collection were performed. The main outcome measures studied were the occurrence of near miss and their primary determinant factors, criteria for identification as a near miss case, total time of hospital stay, time of stay in ICU and number and kind of special procedures performed. Results: thirty three studies were identified and evaluated as adequate for inclusion in the review and the mean near miss ratio was 7.5/1000 deliveries. A total of 124 cases of near-miss were identified in the referral center, corresponding to a ratio of 42/1000 deliveries, and there were two maternal deaths. For these cases, 126 special procedures were performed, 102 of them among women admitted in ICU for intensive care (80.9%). The mean number of special procedures by each woman was 1.04 (±1.91) and the most frequent were central venous access, echocardiography and invasive mechanical ventilation. The mean total time of hospital stay was 10.3 days (±13.24). The total time of hospital stay and the number of special procedures were significantly higher when the criteria of Mantel were used. Conclusions: there is a trend of higher incidence of near miss in developing countries and when using the definition of organ dysfunction. The incidence of near miss was high and the criteria proposed by Mantel allowed the identification of a sub-group of women with a more complex clinical management, considering the total time of hospital stay and the demand for special procedures. The primary determinants of severe maternal morbidity were coincident with the main known basic causes of maternal deathMestradoTocoginecologiaMestre em Tocoginecologi

Meningite criptocóccica em gestante HIV negativa: relato de caso e revisão da literatura

INTRODUCTION: Cryptococcosis has become an important entity due to the epidemic of AIDS and therefore it is a significant opportunistic infection. However, there are case reports of cryptococcal meningitis in immune competent pregnant women. Since pregnancy is considered a period of relative immunosuppression, which likely prevents fetal rejection, this could explain the occurrence of opportunistic infections. OBJECTIVE: To report a case of cryptococcosis, and review all cases involving pregnancy and neurocryptococcal infection in immune competent pregnant patients. METHODS: Case report and systematic review of the literature using the MEDLINE and SciELO databases. DISCUSSION: A total of 27 patients were analyzed from 19 studies. The mean age at diagnosis was 26.4 years. There were six patients in their first trimester of pregnancy, 10 in the second, eight in the third and three post-partum. The most prevalent symptoms were headache (85.2%), altered vision (44.4%), altered mental status (44.4%), nausea (40.7%) and fever (33.3%). There were nine deaths (33.3%). Most of the patients received intravenous amphotericin B as treatment (77.8%). The majority (66.6%) of the patients accomplished a term delivery with healthy infants. CONCLUSION: Cryptococcal meningitis should be considered during pregnancy in cases of unexplained headache, altered vision, altered mental status, nausea and fever. Patients with a confirmed diagnosis should be admitted and treated with amphotericin B.INTRODUÇÃO: Com a epidemia da AIDS, a neurocriptococose foi melhor estudada e considerada infecção fúngica oportunista. No entanto, há casos descritos de gestantes acometidas, apesar de imunocompetentes. A gestação, por si só, pode ser considerada um período de imunossupressão, para adaptação materno-fetal, o que poderia predispor à instalação de certas infecções. OBJETIVOS: Relato de caso de gestante com neurocriptococose e revisão sistemática dos casos descritos na literatura desta patologia durante a gestação, em pacientes imunocompetentes. METODOLOGIA: Revisão sistemática com busca MEDLINE e SciELO. RESULTADOS: Foram analisadas 27 pacientes com diagnóstico de neurocriptococse na gestação. A média de idade foi 26,4 anos. Seis pacientes estavam no primeiro trimestre de gravidez ao diagnóstico, 10 no segundo, oito no terceiro e três eram puérperas. O sintoma mais prevalente foi cefaléia (85,2%), seguido por alteração visual (44,4%), confusão mental (44,4%), náusea (40,7%) e febre (33%). Houve nove óbitos maternos (33,3%). Vinte e uma pacientes foram tratadas com anfotericina B (77,8%). A maioria dos casos evoluiu com gestação a termo, com recém-nascidos saudáveis (66,6%). CONCLUSÕES: Neurocriptococose deve ser um diagnóstico a se considerar na gestação, nos casos de cefaléia, alteração visual, confusão mental, náusea e febre persistentes, sendo indicada terapia intensiva e uso de anfotericina B

Different Teaching Approaches and Use of Active Learning Strategies as Tools for Inter- and Transdisciplinary Education

This work reports a review on some of the ways in which education and research can be used to solve today’s complex problems by taking into account teaching and learning strategies that go beyond traditional teaching strategies. It revisits different teaching approaches and connects them directly to uni-, pluri-, multi-, inter-, and transdisciplinary attitudes, and how educational professionals think of the subject of teaching. This discussion reflects on how teachers tend to reproduce procedures they observed in their own graduation programs and why experienced teachers opt for inter- and transdisciplinary attitudes. Using a qualitative approach, this work illustrates the results from a Project-Based Learning strategy applied to a group of Major Engineering students to solve problems at the University’s Campus. Participants included 25 students engaged to Physics Engineering program supervised by different faculty members, experienced undergraduate and graduate students, and technicians, who had mentored the undergraduate students’ teams, all working in subjects closely related to the projects. The products developed by the teams show evidence that the students were motivated and engaged in the projects; this supports the premise that inter- and transdisciplinary approaches drive collaboration in the execution of projects, develop soft skills and permit knowledge development in an articulate and complex way thereby leading to a broader education of the students

Stages of health behavior change and factors associated with physical activity in patients with intermittent claudication

OBJECTIVE: To analyze, in people with intermittent claudication, the frequency of individuals who are in each of stages of health behavior change to practice physical activity, and analyze the association of these stages with the walking capacity. METHODS: We recruited 150 patients with intermittent claudication treated at a tertiary center, being included those > 30-year-old-individuals and who had ankle-arm index < 0.90. We obtained socio-demographic information, presence of comorbidities and cardiovascular risk factors and stages of health behavior change to practice physical activity through a questionnaire, they being pre-contemplation, contemplation, preparation, action and maintenance. Moreover, the walking capacity was measured in a treadmill test (Gardner protocol). RESULTS: Most individuals were in the maintenance stage (42.7%), however, when the stages of health behavior change were categorized into active (action and maintenance) and inactive (pre-contemplation, contemplation and preparation), 51.3% of the individuals were classified as inactive behavior. There was no association between stages of health behavior change, sociodemographic factors and cardiovascular risk factors. However, patients with intermittent claudication who had lower total walking distance were three times more likely to have inactive behavior. CONCLUSION: Most patients with intermittent claudication showed an inactive behavior and, in this population, lower walking capacity was associated with this behavior

Central giant cell granuloma (CGCG) in childhood: surgical treatment by maintaining the tooth germs

Introduction: Central Giant Cell Granuloma (CGCG) is a nonneoplasticbenign process, of unknown etiology, more common in children and young adults. When aggressive, the lesion may result in considerable bone destruction and deformation. Oral and Maxillofacial surgery strongly depends on the nature of injury and it may vary from more conservative to more aggressive approach. Case report: The aim of the present study is to report and analyze, a giant cellcentral lesion in a 7-year-old patient on the right side of mandible body treated by surgical enucleation, curettage, and maintenance of the tooth germs. Discussion: In less aggressive lesions, curettage followed by radiographic monitoring is the most widely suggested treatment choice. However, the “gold standard” for aggressive and deforming lesions would be en-bloc resection with a safety margin. Most revisions show recurrence rates of 15 to 20%, thus clinicalmonitoring is necessary at least one year after the intervention. Conclusion: After 12 months, panoramic radiograph and computed tomography indicated new bone formation and no recurrence. In addition, good healing of soft tissues and correct eruption of the teeth #42, #43 and #44 were observed.Introduction: Central Giant Cell Granuloma (CGCG) is a nonneoplasticbenign process, of unknown etiology, more common in children and young adults. When aggressive, the lesion may result in considerable bone destruction and deformation. Oral and Maxillofacial surgery strongly depends on the nature of injury and it may vary from more conservative to more aggressive approach. Case report: The aim of the present study is to report and analyze, a giant cellcentral lesion in a 7-year-old patient on the right side of mandible body treated by surgical enucleation, curettage, and maintenance of the tooth germs. Discussion: In less aggressive lesions, curettage followed by radiographic monitoring is the most widely suggested treatment choice. However, the “gold standard” for aggressive and deforming lesions would be en-bloc resection with a safety margin. Most revisions show recurrence rates of 15 to 20%, thus clinicalmonitoring is necessary at least one year after the intervention. Conclusion: After 12 months, panoramic radiograph and computed tomography indicated new bone formation and no recurrence. In addition, good healing of soft tissues and correct eruption of the teeth #42, #43 and #44 were observed

Predictors of walking capacity in peripheral arterial disease patients

OBJECTIVE: To estimate walking capacity in intermittent claudication patients through a prediction model based on clinical characteristics and the walking impairment questionnaire. METHODS: The sample included 133 intermittent claudication patients of both genders aged between 30 and 80 years. Data regarding clinical characteristics, the walking impairment questionnaire and treadmill walking test performance were obtained. Multiple regression modeling was conducted to predict claudication onset distance and total walking distance using clinical characteristics (age, height, mass, body mass index, ankle brachial index lower, gender, history of smoking and co-morbid conditions) and walking impairment questionnaire responses. Comparisons of claudication onset distance and total walking distance measured during treadmill tests and estimated by a regression equation were performed using paired t-tests. RESULTS: Co-morbid conditions (diabetes and coronary artery disease) and questions related to difficulty in walking short distances (walking indoors - such as around your house and walking 5 blocks) and at low speed (walking 1 block at average speed - usual pace) resulted in the development of new prediction models high significant for claudication onset distance and total walking distance (p;0.05) were observed. CONCLUSION: The current study demonstrated that walking capacity can be adequately estimated based on co-morbid conditions and responses to the walking impairment questionnaire

Anaphylactic reaction to patent blue dye during sentinel lymph node biopsy in early-stage breast cancer: a case report

Sentinel lymph node biopsy in the treatment of breast cancer has been replacing lymph node resection in early cases. This treatment may be performed with blue dye and/or radiopharmaceuticals. There are reports of allergic reactions to blue dye with different degrees of severity. A case of severe anaphylactic reaction after intradermal injection of patent blue dye was reported in a patient diagnosed with ductal carcinoma in situ. The patent blue dye facilitates the detection of the sentinel lymph node, but there is the risk of triggering anaphylactic reactions. It is recommended the team involved to be very knowledgeable and prepared to diganose and treat this complication.A biópsia do linfonodo sentinela no tratamento do câncer de mama vem substituindo a linfadenectomia em casos iniciais. Este tratamento pode ser realizado com o corante azul vital e/ou radiofármaco. Há relatos de reações alérgicas ao corante com diferentes graus de severidade. Relata-se um caso de reação anafilática severa após injeção intradérmica do corante azul patente, em paciente com diagnóstico de carcinoma ductal in situ. O corante azul patente, apesar de facilitar a detecção do linfonodo, apresenta risco de desencadear reações anafilactóides. É necessário que a equipe envolvida tenha preparo para diagnosticar e tratar esta complicação.72873