Diagnóstico de “WhatsAppitis” : The Lancet

As facilidades advindas da incorporação de novas tecnologias no dia-a-dia, como o uso de smartphones e tablets,  facilitaram muito algumas tarefas, mas não vieram desprovidas de ônus. São cada vez mais comuns lesões osteomusculares decorrentes de postura inadequada e pouco exercício que esses gadgets acabam trazendo. Além disso podem induzir até lesão por esforço repetitivo.

Nesse contexto um dos artigos da revista Lancet desse mês foi um diagnóstico de... WhatAppitis...  uma variante nova da Nintendinitis... Veja abaixo:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60519-5/fulltext?rss=yes

The Lancet, Volume 383, Issue 9922, Page 1040, 22 March 2014

"WhatsAppitis"

Copyright © 2014 Elsevier Ltd All rights reserved.

Fonte: http://imgs.rafaelbelomo.com

A 34-year-old emergency medicine physician, 27 weeks pregnant, presented with bilateral wrist pain with sudden onset upon waking up one morning. She had no history of trauma and had not engaged in any excessive physical activity in the previous days. Hands examination revealed discomfort upon bilateral palpation of the radial styloid and mobilisation of the thumb. Physical examination was negative for Phalen's sign and Tinel's sign but positive for Finkelstein's sign. Because of the patient's pregnancy, x-rays were not taken to rule out rhizarthrosis. The diagnosis was bilateral extensor pollicis longus tendinitis of the thumb. The patient was on duty on Dec 24 (Christmas Eve), and the following day, she responded to messages that had been sent to her on her smartphone via WhatsApp instant messaging service. She held her mobile phone, that weighed 130 g, for at least 6 h. During this time she made continuous movements with both thumbs to send messages.

Fonte: http://laclinfisioterapia.blogspot.com.br
Tenossinovite de De Quervain

The diagnosis for the bilateral wrist pain was WhatsAppitis. The treatment consisted of non-steroidal anti-inflammatory drugs and complete abstinence from using the phone to send messages. Because of her pregnancy, the patient only took acetaminophen (1 g every 8 h for 3 days) with partial improvement, and did not completely abstain from using her phone, with exchange of new messages on Dec 31 (New Year's Eve).

A so-called Nintendinitis was first described in 1990,1 and since then several injuries associated with video games and new technologies have been reported. Initially reported in children, such cases are now seen in adults. Tenosynovitis caused by texting with mobile phones could well be an emerging disease. Physicians need to be mindful of these new disorders.

I declare that I have no competing interests.

Veja um vídeo com o teste de Finkelstein:

Reunião Científica da SOCETI 31/03/2014 - Programação

Caros,

Segue programação da Reunião Científica da SOCETI

Local: Torre Del Paseo, sala Viscaya, pavimento E
Data: 31/03/2014
Hora: 19h30min
Palestrantes: Dra. Juliana Campelo (Febre Persistente na UTI) e Dr. Arnaldo (Aspectos Históricos da Medicina Intensiva).

COMPARTILHEM!!!

Caso clínico para discussão no New England de 27/03/2014

Caros,

Segue caso clínico para discussão no New England de 27/03/2014:

• Mulher de 46 anos com insuficiência renal vista por um reumatologista devido a rigidez articular e na pele.

O caso original completo será disponibilizado após a discussão.

• Case 6-2008: A 46-Year-Old Woman with Renal Failure and Stiffness of the Joints and Skin. N Engl J Med 2008;358:827-38

Abraços,

Convite para Sessão Geral de Clínica Médica 31/03/2014

Caros,

Segue convite para participar da Sessão Geral de Clínica Médica encaminhado pelo Dr. Julião!

Local: Auditório da Faculdade Unichristus

Data: 31/03/2014

Hora: 19h30min

Caso Clínico para discussão no New England de 20/03/2014

Caros,

Segue caso clínico para discussão no New England de 20/03/2014:

• Homem de 39 anos admitido com sudorese noturna e dor abdominal

O caso original completo será disponibilizado após a discussão.

• Case 4-2014: A 39-Year-Old Man with Night Sweats and Abdominal Pain. N Engl J Med 2014;370:467-73.

Abraços,

Polivitamínicos: algum efeito em doenças cardíacas, perda cognitiva, câncer e morte?

Fonte: http://www.informacaonutricional.blog.br

"Dr., me passe uma vitamina bem boa!"

"Dr., qual é a melhor vitamina pra eu tomar?"

"Dr., qual a vitamina mais completa?"

Quantas vezes não escutamos essa pergunta de pacientes hígidos e eutróficos, pela crença de que polivitamínicos melhoram a saúde e/ou ajudam a ficar "fortes"? Ou pela crença da necessidade após tratamento antiparasitário?

Bem, somos responsáveis pela medicina que nós e nossos colegas praticam, então é importante esclarecermos nossos pacientes da ausência de benefícios e, na verdade, até presença de malefícios do consumo indiscriminado de polivitamínicos.

Evitemos "passar por passar" polivitamínicos só para agradar o paciente ou para evitar "perder tempo" explicando... 

Americanos gastam anualmente e, em sua maioria, inadequadamente, 28 bilhões de dólares com polivitamínicos... Qual será a nossa cota??

Claro que existem patologias que necessitam da reposição vitamínica e existem situações de risco para sua depleção, então, como para todo paciente, é imprescindível uma avaliação médica com boa boa anamnese...

Mas afinal, existe algum efeito comprovado do uso de polivitamínicos em pessoas saudáveis com o objetivo de prevenir doenças cardiovasculares, perda cognitiva, câncer ou morte? Infelizmente, as evidências científicas não animadoras...

Para ajudar nos argumentos, segue texto extraído do ACP Internist com artigos publicados no Annals of Internal Medicine que ajudam a embasar.

Fonte:

http://blog.acpinternist.org/2014/02/the-last-nail-in-coffin-for.html

The last nail in the coffin for multivitamins

How much money would the U.S. auto industry be making if every car they sold never started? How much could video game console makers charge if their products didn't play any games? Well, in 2010 the U.S. dietary supplement industry sold $28 billion dollars in vitamins, minerals and other supplements that, as far as we can tell, benefited virtually no one.

Annals of Internal Medicine published 3 studies examining the effects of multivitamins. This is not the first investigation of a mysterious unexplored field. Lots of studies have already shown that in well-nourished people living in the Western Hemisphere, multivitamins are not helpful. Think of this more as sweeping away any traces of doubt.

One study explored the effects of a high-dose vitamin and mineral supplement on heart disease. About 1,700 patients who had a heart attack in the past were randomized to the supplement or a placebo. They were followed for four years to measure their rates of recurrent cardiovascular events. There was no difference in the occurrence of these events between the group receiving the supplement and the group receiving placebo.

Another study examined the effects of a multivitamin on cognitive decline. About 6,000 male physicians aged 65 and older were randomized to a multivitamin or placebo and given a battery of 5 tests of cognition and memory over 12 years of follow up. The 2 groups did the same.

The third study was a review of prior studies of vitamin and mineral supplements for the prevention of cancer or cardiovascular disease. The study conclusion was negative. There is no reason to take vitamins or minerals for cancer or cardiovascular disease prevention. And the review highlighted the harms of some vitamins. β-carotene and vitamin A increase lung cancer risk in smokers, and vitamin E increases the risk of prostate cancer.

An editorial in the same journal issue crystalized our current knowledge: In conclusion, β-carotene, vitamin E, and possibly high doses of vitamin A supplements are harmful. Other antioxidants, folic acid and B vitamins, and multivitamin and mineral supplements are ineffective for preventing mortality or morbidity due to major chronic diseases.

Their conclusion: The message is simple: Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided.

There are specific patient populations who are especially vulnerable to vitamin malabsorption, such as those who have had intestinal surgery and patients on long-term acid suppressing medications. They may be recommended specific vitamin supplements. Women in their child-bearing years should take folic acid. And it's possible that vitamin D in the elderly prevents falls. But apart from those narrow groups, well-nourished people don't benefit from supplements. (I don't take any vitamins or minerals.)

Perhaps the latest studies and the barrage of resulting media coverage will make a difference. Then maybe we could save some of that $28 billion and spend it to buy some skepticism.

Learn more:

Multivitamins Found to Have Little Benefit (Wall Street Journal)

How do Americans waste $28 billion a year? On vitamins, doctors say (Los Angeles Times)

The Case Against Multivitamins Grows Stronger (Shots, NPR's health news)

Oral High-Dose Multivitamins and Minerals After Myocardial Infarction: A Randomized Trial (Annals of Internal Medicine article. Abstract available without subscription)

Long-Term Multivitamin Supplementation and Cognitive Function in Men: A Randomized Trial (Annals of Internal Medicine article. Abstract available without subscription)

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force (Annals of Internal Medicine. Available without subscription.)

Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements (Annals of Internal Medicine editorial. Subscription required.)

A Reminder to Dump Your Multivitamin (my post from 2011 reviewing the known effects of various vitamin supplements)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

Enviado via iPhone de Rainardo Puster

Caso clínico para discussão no New England de 13/03/2014

Caros,

Segue caso clínico para discussão no New England de 13/03/2014:

• Homem de 21 anos admitido com dispneia, artralgia e infiltrados pulmonares

O caso original será disponibilizado após a discussão.

• Case 37-2012: A 21-Year-Old Man with Fevers, Arthralgias, and Pulmonary Infiltrates. N Engl J Med 2012;367:2134-46.

Abraços,

Paciente hipertenso de difícil controle: algumas dicas para abordagem inicial

Dicas de como abordar hipertensão refratária

Fonte: lookfordiagnosis.com

Não é incomum encontrar em ambulatórios e unidades básicas de saúde alguns pacientes que se apresentam, via de regra, com níveis pressóricos elevados, alguns até grau III (≥180x110 mmHg - classificação VI Diretrizes Brasileiras de Hipertensão - Arq Bras Cardiol 2010; 95(1 supl.1): 1-51), mesmo com a prescrição de múltiplos antihipertensivos. 

Hipertensão resistente ou refratária é definida como a manutenção de níveis pressóricos inadequados a despeito do uso de 3 ou mais medicações de classes diferentes sendo uma delas um diurético adequado à função renal.

Muitas vezes poderá ser necessário encaminhamento para tratamento especializado, mas antes de encaminhar com esse fim (que no nosso sistema público pode demorar meses), é interessante atentar algumas coisas. Prescrição não é sinônimo de uso adequado de medicações, bem como orientações dietéticas ser não ser sinônimo de aderência a ela. Esses e outros itens seguem abaixo em um algoritmo publicado no Current Cardiology 4ª edição junto a trechos interessantes. É curto e vale a pena ler.

Alguns trechos do texto:

"Resistant hypertension is defined as failure to achieve BP target goal despite three or more drugs, one of which should be a diuretic. The first simple step in managing resistant hypertension, after excluding WCE, nonadherence to medications, and secondary hypertension, is to determine whether patients are on an appropriate class of diuretics based on renal function. Patients with estimated glomerular filtration rate (eGFR) > 50 mL/min/1.73 m² should be treated with thiazide diuretics, particularly chlorthalidone, rather than loop diuretics because of longer half-life and proven efficacy in lowering BP. Patients with an eGFR of 30–40 mL/min/1.73 m² or less should be on loop diuretics because the ability of thiazide diuretics to promote diuresis diminishes with impaired renal function. The use of an appropriate drug combination that provides synergistic effect on BP could minimize the number of medications needed to control hypertension. Assessment of hemodynamic variables is also helpful in deciding appropriate drug combination. For example, the use of BBs and a central sympatholytic drug generally yields minimal incremental benefit and is prohibited in patients with bradycardia or heart block. These patients should be treated with vasodilators such as DHP CCBs, ACEIs, ARBs, or hydralazine (Figure 2–2). Patients with elevated resting heart rate are more likely to derive large BP reduction with BBs, diltiazem, or verapamil because elevated heart rate is usually a good indicator for hyperkinetic circulation in hypertensive patients. Addition of spironolactone should also be considered in patients with resistant hypertension despite adjustment of medications, as mentioned earlier. An increasing body of evidence suggests that low-dose spironolactone between 12.5 and 25 mg/day, which is not likely to produce a major diuretic effect, causes a dramatic fall in BP on average of 25/12 mm Hg, when used as add-on therapy in patients with uncontrolled hypertension. Antihypertensive effect of spironolactone is observed even in patients with essential hypertension without an elevated aldosterone-to-renin ratio. Combination of DHP and non-DHP CCBs appears to have additive effects on peripheral vasodilation and BP, possibly due to binding to different sites of the receptors, and should also be considered in these patients. In contrast, addition of an ARB to ACEI has modest effects on BP, on average of only 5/3 mm Hg. The addition of long-acting nitrates may be considered in patients with isolated systolic hypertension who are refractory to treatment because it has been shown to be beneficial in one small study."

Abraços,

Novo Current de Cardiologia 2014 4ª Edição - grátis pelo Portal Saúde Baseada em Evidências

Novidade no AccessMedicine!

Caros,

Foi lançado o Current Cardiology 4ª Edição (2014) que já está disponível na AccessMedicine, que todos os médicos brasileiros que tenham CRM podem acessar via Portal Saúde Baseada em Evidências do Ministério da Saúde.

Se você tem CRM e ainda não tem cadastro nessa plataforma, veja os posts antigos de como fazer isso:

• http://clinicamedicahuwc.blogspot.com.br/2013/06/uptodate-gratis-para-todos-os-medicos.html
• http://clinicamedicahuwc.blogspot.com.br/2013/06/current-medical-diagnosis-and-treatment.html

Confiram vários outros livros, como o Current Medical Diagnosis and Treatment 2014 e toda a série Current além de vários outros.

Antigamente, tínhamos acesso até ao UpToDate por aqui, mas o Ministério da Saúde cancelou. Espero que não cancelem o AccessMedicine...

Compartilhem!!!

Abraços,

Solenidade de encerramento da Residência HUWC-MEAC

Solenidade de encerramento da Residência de Clínica Médica HUWC 2012-2013

Para baixar as fotos, entre no álbum em http://flic.kr/p/kNYaFY

Descerramento da placa dos Residentes de Clínica Médica HUWC 2012-2013

Descerramento da placa dos Residentes de Clínica Médica HUWC 2012-2013

Turma Dr. Ricardo Coelho Reis

Homenageados

Agradecimentos Especiais

Para baixar fotos entre no álbum em http://flic.kr/s/aHsjU6DNNv

Feijão com Clínica - Festa de despedida da turma de R2 CM HUWC

Festa de despedida dos R2 de CM - HUWC

Para ver o ábum e baixar as fotos, clique em: http://flic.kr/s/aHsjU6LW1T