Daniel Ferreira

From Mobile Computers to Mobile Information? A Case Study of Physicians' Mobile Information Use

Physicians are faced with questions and uncertainties regarding information/knowledge for the best care of their patients. There are several sources of medical information available from which they can retrieve the necessary answers, such as colleagues, textbooks or software on personal digital assistants (PDA). This case study evaluates how physicians seek medical knowledge when they face a clinical challenge. Our observational study took place in one of the US Veterans Affair (VA) Hospitals, during August 2006, with combined observation of, and interviews with, physicians. Search for information was significantly different in strategy and materials used depending on location, temporality and complexity of the question.

Enfisema lobar congénito: Relato de caso

Resumo O enfisema lobar congenito (ELC) e uma malformacao pouco frequente do desenvolvimento pulmonar, que pode ser a causa de insuficiencia respiratoria em lactentes. Esta doenca caracteriza -se pela hiperinsuflacao de um ou mais lobos pulmonares com compressao de parenquima normal e deslocamento contralateral do mediastino, causando insuficiencia respiratoria. O diagnostico clinico e confirmado por exames radiologicos simples. O tratamento de escolha nos casos graves e a lobectomia, que apresenta resultados superiores ao tratamento clinico. Nosso proposito e relatar um caso desta rara patologia em lactente atendida em nosso servico com quadro de insuficiencia respiratoria grave, sendo submetida a exames complementares tendo diagnostico presuntivo de ELC. A doente foi submetida a lobectomia superior esquerda, com excelente evolucao pos -operatoria.

Venous thromboembolism risk and prophylaxis in the Portuguese hospital care setting: The ARTE study

INTRODUCTION Venous thromboembolism (VTE) is a relatively common complication during hospital stay and determination of VTE risk is critical to choosing the best prophylactic strategy for each patient. OBJECTIVES In the present study we studied the risk profile for VTE in hospitalized patients in a group of hospitals in Portugal. METHODS Based on an open cohort of 4248 patients hospitalized in surgical, internal medicine, orthopedic or oncology departments, we determined thromboembolic risk at admission by applying a new score, modified from the Caprini and Khorana scores. Thrombotic, embolic and bleeding events and death were assessed during hospital stay and at three and six months after discharge. RESULTS The median duration of hospital stay was five days and thromboembolic prophylaxis was implemented in 67.2% (n=2747) of the patients. A low molecular weight heparin was used as prophylaxis in the majority of cases (88.3%). Most patients were classified as high (68%) or intermediate risk (27%). The overall incidence of thromboembolic events was 1.5%. Major bleeding events were recorded in 3.89% of patients and all-cause mortality was 3.4%. CONCLUSIONS In this study, we propose a modified VTE risk score that effectively risk-stratifies a mixed inpatient population during hospital stay. The use of this score may result in improvement of thromboprophylaxis practices in hospitals.

Are intraventricular gradients a cause of false positive treadmill exercise tests

BACKGROUND Treadmill exercise testing has low specificity for the detection of significant epicardial coronary artery disease (CAD). A possible mechanism to explain some of the false positives is transient subendocardial ischemia induced by intraventricular gradients (IVG) during stress. The development of IVG during dobutamine stress echocardiography (DSE) occurs in 8-38% of non-selected populations. OBJECTIVES To determine: 1. the prevalence of IVG in a selected population of false positives on treadmill stress testing; 2. whether this prevalence is different from that described for non-selected populations; 3. whether patient characteristics are related to the presence of IVG; 4. the relation between the presence of IVG and the occurrence of ECG abnormalities, symptoms and blood pressure. METHODS AND RESULTS We evaluated 50 consecutive patients with false positive treadmill stress tests (normal CT coronary angiography, nuclear perfusion tests or angiography) with DSE (2D and Doppler evaluation). All DSE exams were negative for ischemia. Stress-induced IVG was seen in 34 of the 50 patients (68%) and 16 patients (32%) did not develop IVG (p<0.05). The prevalence of IVG in our selected population (68%) was significantly higher than that described for non-selected populations (8-38%) (p<0.001). Most patient characteristics (gender, age, risk factors for CAD, treatment with beta-blockers/calcium antagonists, significant valvular disease/left ventricular hypertrophy [LVH], symptoms, and blood pressure during stress) were not statistically associated with the prevalence of IVG (p>0.05). However, the presence of IVG was associated with the occurrence of ischemic ST depression during dobutamine stress echo (p<0.05). CONCLUSIONS 1. The prevalence of IVG during dobutamine stress echocardiography in a selected population of false positives on treadmill stress testing is very high, occurring in more than two-thirds of patients. 2. This prevalence is significantly higher than that described for non-selected populations. 3. Age, gender, risk factors for CAD, treatment with beta-blockers/calcium channel antagonists, significant valvular disesase/LVH, symptoms and blood pressure during stress were not associated with the presence or absence of IVG. 4. The presence of IVG is associated with the occurrence of ischemic ST changes during dobutamine stress echocardiography.

Renal failure in decompensated heart failure patients: Double trouble

The association between cardiac and renal disease has been an area of growing interest in recent years. The interactions between these organs play an important role in control of blood pressure, renal sodium and water excretion, arterial perfusion and tissue oxygenation, and, most importantly, extracellular fluid balance, including intravascular volume. It is therefore not surprising that, when one organ becomes dysfunctional, the other may be affected as well. Heart failure (HF) interacts with renal disease via several pathophysiological pathways in both acute and chronic settings. The expression ‘cardiorenal syndrome’ has often been used in the last decade to define this interdependency of the kidneys and the heart, and as an umbrella term for worse outcome when the two organs fail simultaneously. A recent review of the pathophysiological pathways of this syndrome was recently published by Schefold et al. Although the concept of the cardiorenal syndrome is helpful when describing these heart-kidney interactions, it should be emphasized that the current definition of cardiorenal syndrome includes all forms of two-way connections and is not specific to HF.

Risk stratification after acute coronary syndromes: Scores, scores and yet another score

Identification of high-risk patients soon after an acute coronary syndrome (ACS) event has been a challenge for clinicians in the past two or three decades. Numerous studies have clearly demonstrated that more intensive, even aggressive, management of these patients results in significantly better outcomes, in particular in the reduction of major adverse cardiac events. Both ST-elevation myocardial infarction (STEMI) and nonSTEMI (NSTEMI) patients have been the subject of risk stratification studies and a number of risk scores have been proposed. Some of these scores were tested in populations of clinical trials (of which the TIMI scores are the best known), but others (such as the GRACE score) were derived from large registries, with the obvious advantages of reflecting real-life patients, including older and sicker patients.

Valor prognóstico dos métodos de imagem na embolia pulmonar aguda

Pulmonary embolism (PE) is the third most common cause of acute cardiovascular disease after myocardial infarction and stroke. Prompt diagnosis, risk stratification and treatment of patients with PE can reduce the associated mortality. Developments in imaging technology in recent years have led to changes in approaches to PE, one of the most significant being the replacement of conventional pulmonary angiography as the gold standard for diagnosis of PE by multidetector computed tomography (MDCT) angiography, whose superiority is acknowledged in the most recent European Society of Cardiology (ESC) guidelines on PE. MDCT has rapidly become the most widely used exam to confirm the diagnosis of acute PE, as well as to identify signs of right ventricular (RV) dysfunction, or to provide alternative diagnoses. While the role of MDCT in diagnosis of acute PE is well established, its value in establishing the prognosis of these patients is still the subject of considerable research.