Declaração de óbito não deve conter termos vagos para o registro da causa de morte

Não preencher Declaração de Óbito com termos como "parada cardíaca", "parada respiratória". 

As condições dever ser especificadas o máximo possível.                                                                                                                                           

Uso do WhatsApp em ambiente hospitalar - Parecer do CREMEC na íntegra

INFORMATIVO CREMEC PROCESSO-CONSULTA CFM nº 50/2016 – PARECER CFM nº 14/2017 INTERESSADO:Dr. P.S.R.A. Sociedade Brasileira de Citopatologia Dra. M.N.D.S.B. ASSUNTO:Uso do WhatsApp em ambiente hospitalar RELATOR:Cons. Emmanuel Fortes S. Cavalcanti EMENTA: É permitido o uso do Whatsapp e plataformas similares para comunicação entre médicos e seus pacientes, bem como entre médicos e médicos, em caráter privativo, para enviar dados ou tirar dúvidas, bem como em grupos fechados de especialistas ou do corpo clínico de uma instituição ou cátedra, com a ressalva de que todas as informações passadas tem absoluto caráter confidencial e não podem extrapolar os limites do próprio grupo, nem tampouco podem circular em grupos recreativos, mesmo que composto apenas por médicos. A CONSULTA Tendo em vista inúmeras consultas em relação ao uso do aplicativo WhatsApp, o CFM elaborou este parecer. DO PARECER Nossa coordenação jurídica, em análise desse fato, conclui, depois de sedimentada exposição que: II – DA CONCLUSÃO Diante do exposto, esta Cojur opina da seguinte forma:

Quando e como se deve utilizar corticoide na febre de Chikungunya? Fase subaguda e crônica. Doses variam. Vejam fluxogramas compilados

Afinal, quando e como se deve utilizar corticoide na febre de Chikungunya?

A febre de Chikungunya apresenta três fases:

• Aguda: do início dos sintomas até 14 dias
• Subaguda: de 14 dias até 3 meses
• Crônica: mais de 3 meses

Com relação aos sintomas articulares, cerca de 75% permanecem sintomáticos após um mês e cerca de 50% após 3 meses, ou seja, na fase crônica da doença.

Então quando utilizar corticoide?

1. Não usar na fase aguda da doença (período febril ou com menos de 14 dias de doença)
2. Não usar corticoides de depósito (Betatrinta, Diprospan etc)
3. Utilizar nas fases subaguda e crônica da doença, em geral, após não responder ao tratamento com analgésicos, opióides fracos e antiinflamatórios (vejam os algoritmos abaixo)
4. Utilizar de preferência a prednisona na dose de 10 a 20 mg/dia (recomendações da sociedade brasileira de reumatologia) ou até 0,5 mg/kg (manual de manejo do ministério da saúde).

Baixem os manuais completos abaixo:

• Chikungunya - Manejo Clínico Ministério da Saúde 2017
• Recomendações da sociedade brasileira de reumatologia para diagnóstico e tratamento da febre chikungunya

Seguem os fluxogramas dos manuais do Ministério da Saúde e da Sociedade Brasileira de Reumatologia

Ministério da Saúde

Sociedade Brasileira de Reumatologia

Distúrbios mentais estáveis não contra-indicam medicações para abandono de tabagismo

Safety of smoking cessation medications in patients with and without mental health disorders

Reports of newly emergent depression, suicidal ideation, and suicidal behavior among patients receiving bupropion or varenicline for smoking cessation raised questions about the safety of these drugs in smokers with mental health disorders. In a recent trial examining the safety of these medications, more than 8000 motivated adult smokers, approximately half with clinically stable mental health disorders, were randomly assigned to varenicline, bupropion, transdermal nicotine, or placebo for 12 weeks [1]. Compared with patients without mental health disorders, patients with such disorders were more likely to experience neuropsychiatric adverse events (including anxiety, depression, agitation, or hostility) during treatment (2.1 versus 5.8 percent). However, in both patients with and without mental health disorders, the rate of events did not differ for patients assigned to varenicline or bupropion compared with placebo. Rates of smoking abstinence were higher with each of the three drugs compared with placebo, and higher with varenicline compared with bupropion or transdermal nicotine. The findings are consistent with previous, smaller trials supporting carefully monitored use of smoking-cessation medications in smokers with stable mental health disorders.

See 'Pharmacotherapy for co-occurring schizophrenia and substance use disorder', section on 'Safety'.

1. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet 2016.

Avaliando pensamento suicida: O que protege? O que aumenta o risco? Perda de fatores protetivos aumenta o risco

Avaliando pensamento suicida: BMJ Practice pointer

(BMJ) - Perguntar sobre suicídio não torna o paciente mais propício a se ferir ou aumenta a chance de suicídio. Identifique fatores de risco para suicídio, mas também pergunte sobre fatores protetivos.

Fatores de Risco

• Episódio prévio de lesão autoprovocada ou tentativa prévia
• Sexo Masculino
• Desemprego
• Problemas de saúde
• Morar sozinho
• Solteiro / Não ter relação fixa
• Dependência de álcool e drogas
• Doença mental ativa

Fatores Protetivos

• Forte fé religiosa
• Suporte familiar para encontrar soluções para problemas
• Ter crianças em casa
• Senso de responsabilidade com outros
• Capacidade de resolução de problemas

Nota: Perda de fatores protetivos pode aumentar o risco de suicídio.

Parar de fumar: Melhor parar de uma vez que diminuir aos poucos

Após decidir uma dada para parar de fumar, pacientes que param abruptamente parecem ter mais chance de sucesso do que os que diminuem até parar.

Abrupt smoking cessation compared with gradual smoking reduction

Earlier evidence from randomized trials had suggested that, after a quit date is set, abstinence rates were equivalent for patients who reduced smoking prior to the quit date or stopped smoking abruptly on the quit date. However, more recent studies suggest that among smokers who plan to quit in the near future, quit rates are higher for patients who stop abruptly. The most recent randomized trial included 697 smokers in England and found that gradual smoking cessation (decreasing by 75 percent in the two weeks prior to quitting) was associated with decreased likelihood of abstinence at four weeks when compared with abrupt smoking cessation (39 versus 49 percent) [1].

See 'Overview of smoking cessation management in adults', section on 'Setting a quit date'.

1. Lindson-Hawley N, Banting M, West R, et al. Gradual versus abrupt smoking cessation: A randomized, controlled noninferiority trial. Ann Intern Med. 2016; 164:585.

Clinical Pearls - Dematology 2017

Segue artigo com casos clínicos e pérolas clínicas em dermatologia discutidos na sessão de hoje. 

Clinical Pearls in Dermatology 2017. Newman CC, et al. (2017), http://dx.doi.org/10.1016/j.disamonth.2017.03.003i

V Congresso Cearense de Geriateia e Gerontologia - 21 a 23 de setembro 2017 - Divulgação

Corticoide para faringite aguda: pouco benefício, não prescrever de rotina

De novo sobre corticoides...
Estudo mostra benefícios modestos e lembremos dos efeitos colaterais

Dexamethasone and acute pharyngitis pain in adults

Studies of oral glucocorticoids for acute pharyngitis pain have generally found only modest benefit but have been limited by confounding factors such as concurrent antibiotic use. In an office-based randomized trial that compared a single dose of dexamethasone with placebo for adults who visited a primary care clinician for acute pharyngitis and were not given an immediate prescription for antibiotics, there was no difference in the proportion of patients who achieved full pain relief at 24 hours, and there was only a small difference in symptom relief at 48 hours (35 versus 27 percent with placebo) [2]. These results support our suggestion to not prescribe glucocorticoids routinely for acute pharyngitis and to limit their use to severely symptomatic patients.

See 'Symptomatic treatment of acute pharyngitis in adults', section on 'Limited role of glucocorticoids'.

2. Hayward GN, Hay AD, Moore MV, et al. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial. JAMA 2017; 317:1535.

Fotos mês de Abril - Clínica Médica (tardou, mas chegou!)

Fotos do mês de Abril

F

Mesmo cursos breves de corticoides: 2x mais fraturas, 3x mais TVP e 5x a chance de Sepse em um mês

A prescrição de corticoides (e mesmo corticoides de depósito[!]) não tem sido incomum para alívio sintomático de quadros relativamente banais como infecções de vias aéreas sem maiores complicações e outras afecções como dores articulares leve e quadros inflamatórios diversos.

A despeito da melhora sintomática importante que trazem, critérios judiciosos para a prescrição dessas medicações devem ser tomados, pois não são isentos de riscos! Lembrem-se do Dr. Otho: "O corticoide leva o paciente para a mesa de Laennec sorrindo".

Segundo estudo do BMJ, no primeiro mês após uso de corticoides, há 2 vezes mais chances de fratura, 3 vezes mais chance de trombose venosa profunda e 5 vezes o risco de sepse. Esses eventos se manifestaram mesmo com 5-6 dias de curso e com doses de somente 20 mg equivalente de prednisona. 

Vejam mais informações e link para o artigo abaixo.

Even Short-term Oral Steroids Carry Serious Risk

The millions of Americans prescribed short-term oral corticosteroids are taking a dose of risk along with their medication, according to a cohort study of more than 1.5 million adults.

Within 30 days of initiating these drugs, even at relatively low doses, users had a nearly twofold increased risk for fracture, a threefold increased risk for venous thromboembolism, and a fivefold increased risk for sepsis.

"Greater attention to initiating prescriptions of these drugs and monitoring for adverse events may potentially improve patient safety," write Akbar K. Waljee, MD, an assistant professor of gastroenterology at the University of Michigan in Ann Arbor, and colleagues. They present their findings in an article published April 12 in the BMJ.

They found that more than one in five adults included in the Clinformatics DataMart, a large national database of commercial insurance claims, received prescriptions for short-term oral corticosteroids during the 3-year study, which ran from January 1, 2012, to December 31, 2014.

Although corticosteroids are among the most common cause for hospitalization for drug-related adverse events, and various specialties have long focused on optimizing their long-term use, the short-term risks associated with the drugs have been less carefully studied.

"Although physicians focus on the long-term consequences of steroids, they don't tend to think about potential risks from short-term use," said Dr Waljee in a university news release. "We see a clear signal of higher rates of these three serious events within 30 days of filling a prescription. We need to understand that steroids do have a real risk and that we may use them more than we really need to. This is so important because of how often these drugs are used."

Of 1,548,945 adults aged 18 to 64 years included in the database, 327,452 (21.1%) received at least one outpatient prescription for short-term oral corticosteroids (30 or fewer days). The mean age of users was 45.5 years (standard deviation [SD], 11.6 years) compared with 44.1 years (SD, 12.2 years) for nonusers (P < .001). The median duration of use was 6 days (interquartile range, 6 - 12 days).

The six most common indications for the drugs were upper respiratory tract infections, spinal conditions, intervertebral disc disorders, allergies, bronchitis, and nonbronchitic lower respiratory tract disorders. Together, those indications accounted for about half of all prescriptions. The two most common physician specialties prescribing short-term oral corticosteroids were family medicine and general internal medicine.

Nearly half (46.9%) of recipients were prescribed a 6-day prepackaged methylprednisolone "dosepak," which tapers the dose from highest to lowest. Dr Waljee noted in the news release that although individual oral steroid pills can cost less than a dollar each for a 7-day course, the prepackaged version may cost several times that and often initiates therapy with a higher high dose than may be necessary.

Use was more frequent among older patients, women, and white adults, with significant regional variation (all P < .001).

Within 30 days of drug initiation, there was an increase in incidence rate of the following: sepsis, with a rate ratio of 5.30 (95% CI, 3.80 - 7.41); venous thromboembolism, with a rate ratio of 3.33 (95% CI, 2.78 - 3.99); and fracture, with a rate ratio of 1.87 (95% CI, 1.69 - 2.07).

The increased risk persisted at prednisone equivalent doses of less than 20 mg/day, with an incidence rate ratio of 4.02 for sepsis, 3.61 for venous thromboembolism, and 1.83 for fracture (all P < .001).

Rate ratios decreased during the following subsequent 31 to 90 days, however.

Although rare, hospitalizations were also more frequent in users than nonusers, with 0.05% of users admitted for sepsis compared with 0.02% of nonusers. For blood clots, the admission rate was 0.14% versus 0.09%, and for fractures, it was 0.51% vs 0.39%.

Dr Waljee and associates found it significant that the most frequent corticosteroid prescribers were not rheumatologists or other subspecialists experienced in treating inflammatory conditions long-term. "A substantial challenge to improving use of oral corticosteroids will be the diverse set of conditions and types of providers who administer these drugs in brief courses," they write. "This raises the need for early general medical education of clinicians about the potential risks of oral corticosteroids and the evidence basis for their use, given that use may not be specific to a particular disease or specialty."

On the basis of these findings, Dr Waljee recommended prescribing the smallest possible amount of corticosteroids for treating the condition in question. "If there are alternatives to steroids, we should be use those when possible," he said in the release. "Steroids may work faster, but they aren't as risk-free as you might think."

This study was supported partly supported by the University of Michigan's Institute for Healthcare Policy. The authors have disclosed no relevant financial interests.

BMJ. 2017;357:j1415. Full text

Curso de Boas Práticas em Saúde: Guardem as datas!

O curso de boas práticas em saúde, com características de treinamento introdutório para a residência médica, será desenvolvido em 5 módulos em período vespertino!

Guardem as datas!