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BACKGROUND: Juvenile Dermatomyositis (JDM) is the most common idiopathic inflammatory myopathy in children. Imaging exams are useful for muscle assessment, with ultrasonography (US) being a promising tool in detecting disease activity and tissue damage. There are few studies about muscle elastography. OBJECTIVES: Our aim was to associate clinical, laboratory, and nailfold capillaroscopy (NC) assessments with US in JDM patients; and to compare the findings of US and Strain Elastography (SE) from patients and healthy controls. METHODS: An analytic cross-sectional study was performed with JDM patients and healthy controls. Patients underwent clinical exam to access muscle strength and completed questionnaires about global assessment of the disease and functional capacity. Patients were submitted to NC and measurement of muscle enzymes. All subjects underwent US assessment, using gray scale, Power Doppler (PD), and SE. RESULTS: Twenty-two JDM patients and fourteen controls, aged between 5 and 21 years, matched for age and sex were assessed. In qualitative and semi-quantitative gray scale, we observed a higher frequency of alterations in patients (p < 0.001), while in PD, there was a higher frequency of positivity in patients' deltoids and anterior tibialis (p < 0.001). Active disease was associated with an important change in the semi-quantitative gray scale in deltoids (p = 0.007), biceps brachii (p = 0.001) and quadriceps femoris (p = 0.005). The SE demonstrated a high negative predictive value of 87.2. CONCLUSION: US was able, through gray scale, to differentiate JDM patients from controls, while PD achieved such differentiation only for deltoids and anterior tibialis. The semi-quantitative gray scale showed disease activity in proximal muscles. SE was not able to differentiate patients from controls.

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O diagnóstico da Síndrome de Sjögren (SS) é baseado em achados clínicos, sorológicos e microscópicos. O exame de ultrassom (US) evidencia danos estruturais nas glândulas salivares maiores que podem contribuir no diagnóstico da SS. Assim, o objetivo deste estudo foi analisar as características ultrassonográficas dos pacientes com SS (grupo SS), e dos pacientes com secura bucal que não preencheram os critérios atuais do Colégio Americano e Liga Europeia de Reumatologia (ACR/EULAR), (grupo Sicca não-SS); e analisar a associação da imagens do US com parâmetros clínicos, sorológicos e microscópicos. Para isso, 40 pacientes pareados, dos grupos SS (n=20) e Sicca não-SS (n=20), foram recrutados e as parótidas e submandibulares examinadas no US com o método OMERACT nos modos B e color Doppler por examinador cego. As imagens obtidas foram classificadas como ausente, leve, moderada ou severa, correspondendo aos scores 0, 1, 2 ou 3, respectivamente. Para fins de estatística, os dados foram dicotomizados em ausente ou leve e moderada ou severa. Características tais como fluxo salivar não-estimulado (FSNE), xeroftalmia, focus score (FS), bem como sorologia para fator antígeno nuclear (FAN), fator reumatoide (FR), anticorpos anti-SSA/Ro e antiSSB/La foram obtidos dos prontuários ou coletados durante o estudo. Análises estatísticas comparativas da avaliação do US, bem como a relação desta avaliação com as diferentes características foram realizadas. No grupo Sicca não-SS houve maior prevalência de glândulas salivares sem alteração ou com alteração leve, quando comparados com o grupo SS, nos quais as alterações moderada ou severa foram mais prevalentes (p<0,05). No color Doppler a glândula parótida do grupo Sicca não-SS apresentou mais fluxo vascular normal ou com alteração leve, em comparação ao grupo SS (p<0,05). Presença de xeroftalmia, anti-SSA/Ro, FAN, FR e FS positivos foram mais frequentes no grupo SS e em pacientes com alterações moderada ou severa na análise do US no modo b (p<0,05). O FSNE não diferiu entre os grupos ou com o grau de alteração das glândulas (p<0,05). As características do US das parótidas e submandibulares utilizando o sistema OMERACT modo B permitiram uma distinção entre os grupos SS e Sicca não-SS. Os resultados corroboram para que o US seja incorporado como uma possibilidade de exame não invasivo complementar no Hospital das clinicas da Universidade Federal de Minas Gerais (HC/UFMG) e em outros centros de referência de tratamento da Doença, que ainda têm tido o uso do US pouco explorado.

The diagnosis of Sjögren's Syndrome (SS) is based on clinical, serological, and microscopic findings. Ultrasound (US) examination can reveal structural damage in major salivary glands, which can contribute to the diagnosis of SS. Therefore, the objective of this study was to analyze the ultrasonographic characteristics of patients with SS (SS group) and patients with dry mouth who did not meet the current criteria of the American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) for SS (non-SS sicca group). Additionally, we aimed to analyze the association of US images with clinical, serological, and microscopic parameters. For this purpose, 40 matched patients from the SS group (n=20) and non-SS sicca group (n=20) were recruited, and the parotid and submandibular glands were examined using the OMERACT method in B and color Doppler modes by a blinded examiner. The obtained images were classified as absent, mild, moderate, or severe, corresponding to scores 0, 1, 2, or 3, respectively. For statistical purposes, the data were dichotomized as absent or mild and moderate or severe. Characteristics such as unstimulated whole saliva flow rate (UWS), xerophthalmia, focus score (FS), as well as serology for antinuclear antibody (ANA), rheumatoid factor (RF), anti-SSA/Ro, and anti-SSB/La were obtained from medical records or collected during the study. Comparative statistical analyses of the US evaluation, as well as the relationship of this evaluation with different characteristics, were performed. In the non-SS sicca group, there was a higher prevalence of salivary glands with no alteration or mild alteration when compared to the SS group, in which moderate or severe changes were more prevalent (p<0.05). In the color Doppler, the parotid gland in the non-SS sicca group showed more normal vascular flow or mild alteration compared to the SS group (p<0.05). The presence of xerophthalmia, positive anti-SSA/Ro, ANA, RF, and FS was more frequent in the SS group and in patients with moderate or severe changes in the B-mode US analysis (p<0.05). UWS did not differ between the groups or with the degree of gland alterations (p<0.05). The US characteristics of the parotid and submandibular glands using the OMERACT B-mode system allowed for differentiation between the SS and non-SS sicca groups. The results support the incorporation of US as a non-invasive complementary examination at the Hospital das Clínicas da Universidade Federal de Minas Gerais (HC/UFMG) and at other reference centers for the treatment of the disease, where the use of US has been underutilized.

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Abstract Background Juvenile Dermatomyositis (JDM) is the most common idiopathic inflammatory myopathy in children. Imaging exams are useful for muscle assessment, with ultrasonography (US) being a promising tool in detecting disease activity and tissue damage. There are few studies about muscle elastography. Objectives Our aim was to associate clinical, laboratory, and nailfold capillaroscopy (NC) assessments with US in JDM patients; and to compare the findings of US and Strain Elastography (SE) from patients and healthy controls. Methods An analytic cross-sectional study was performed with JDM patients and healthy controls. Patients underwent clinical exam to access muscle strength and completed questionnaires about global assessment of the disease and functional capacity. Patients were submitted to NC and measurement of muscle enzymes. All subjects underwent US assessment, using gray scale, Power Doppler (PD), and SE. Results Twenty-two JDM patients and fourteen controls, aged between 5 and 21 years, matched for age and sex were assessed. In qualitative and semi-quantitative gray scale, we observed a higher frequency of alterations in patients (p < 0.001), while in PD, there was a higher frequency of positivity in patients' deltoids and anterior tibialis (p < 0.001). Active disease was associated with an important change in the semi-quantitative gray scale in deltoids (p = 0.007), biceps brachii (p = 0.001) and quadriceps femoris (p = 0.005). The SE demonstrated a high negative predictive value of 87.2. Conclusion US was able, through gray scale, to differentiate JDM patients from controls, while PD achieved such differentiation only for deltoids and anterior tibialis. The semi-quantitative gray scale showed disease activity in proximal muscles. SE was not able to differentiate patients from controls.

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Resumo Fundamento Existem informações conflitantes sobre se a ultrassonografia pulmonar avaliada por linhas B tem valor prognóstico em pacientes com insuficiência cardíaca (ICa). Objetivos Avaliar o valor prognóstico da ultrassonografia pulmonar avaliada por linhas B em pacientes com ICa. Métodos Quatro bases de dados (PubMed, EMBASE, Cochrane Library e Scopus) foram sistematicamente pesquisadas para identificar artigos relevantes. Reunimos a razão de risco (RR) e o intervalo de confiança de 95% (IC) de estudos elegíveis e realizamos análises de heterogeneidade, avaliação de qualidade e viés de publicação. Os dados foram agrupados usando um modelo de efeitos fixos ou de efeito aleatório. Um valor de p <0,05 foi considerado para indicar significância estatística. Resultados Nove estudos envolvendo 1.212 participantes foram incluídos na revisão sistemática. As linhas B > 15 e > 30 na alta hospitalar foram significativamente associadas ao aumento do risco de desfecho combinado de mortalidade por todas as causas ou hospitalização por ICa (RR, 3,37, IC de 95%, 1,52-7,47; p = 0,003; RR, 4,01, IC de 95%, 2,29-7,01; p <0,001, respectivamente). O ponto de corte da linha B > 30 na alta foi significativamente associado ao aumento do risco de hospitalização por ICa (RR, 9,01, IC de 95%, 2,80-28,93; p <0,001). Além disso, o ponto de corte da linha B > 3 aumentou significativamente o risco de desfecho combinado de mortalidade por todas as causas ou hospitalização por ICa em pacientes ambulatoriais com ICa (RR, 3,21, IC de 95%, 2,09-4,93; I2 = 10%; p <0,00001). Conclusão As linhas B podem predizer mortalidade por todas as causas e hospitalizações por ICa em pacientes com ICa. Outros grandes ensaios clínicos randomizados são necessários para explorar se lidar com as linhas B melhoraria o prognóstico nos ambientes clínicos. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background There is conflicting information about whether lung ultrasound assessed by B-lines has prognostic value in patients with heart failure (HF). Objectives To evaluate the prognostic value of lung ultrasound assessed by B-lines in HF patients. Methods Four databases (PubMed, EMBASE, Cochrane Library, and Scopus) were systematically searched to identify relevant articles. We pooled the hazard ratio (HR) and 95% confidence interval (CI) from eligible studies and carried out heterogeneity, quality assessment, and publication bias analyses. Data were pooled using a fixed-effects or random-effect model. A p value < 0.05 was considered to indicate statistical significance. Results Nine studies involving 1,212 participants were included in the systematic review. B-lines > 15 and > 30 at discharge were significantly associated with increased risk of combined outcomes of all-cause mortality or HF hospitalization (HR, 3.37, 95% CI, 1.52-7.47; p = 0.003; HR, 4.01, 95% CI, 2.29-7.01; p < 0.001, respectively). A B-line > 30 cutoff at discharge was significantly associated with increased risk of HF hospitalization (HR, 9.01, 95% CI, 2.80-28.93; p < 0.001). Moreover, a B-line > 3 cutoff significantly increased the risk for combined outcomes of all-cause mortality or HF hospitalization in HF outpatients (HR, 3.21, 95% CI, 2.09-4.93; I2 = 10%; p < 0.00001). Conclusion B-lines could predict all-cause mortality and HF hospitalizations in patients with HF. Further large randomized controlled trials are needed to explore whether dealing with B-lines would improve the prognosis in clinical settings.

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Abstract Background: Hepatic congestion is a frequent finding in patients with heart failure (HF). Physical examination has limitations in quantifying systemic congestion and requires correlation with echocardiographic and laboratory data (usually B-type natriuretic peptide, BNP, or N-terminal pro-B type natriuretic peptide, NT-proBNP). Hepatic elastography evaluates liver stiffness using a transducer that transmits low-frequency vibrations (50 Hz), and the speed of shear waves propagating through the tissues is measured by ultrasound. The faster the vibrations propagate in the hepatic parenchyma, the stiffer the liver, which, in case of HF, can be correlated with hepatic congestion. Objective: In this systematic review, case-controls, cohort studies, and randomized clinical trials were searched in MEDLINE, LILACS and Cochrane Database of Systematic Review, to evaluate the use of elastography in the detection of hepatic congestion in patients with HF. Methods: From the 49 articles retrieved, seven were selected for review, according to the inclusion and exclusion criteria. The most used methods for the diagnosis and evaluation of HF were echocardiography combined with BNP and NT-proBNP measurements. Results: Elastography performed at bedside was able to establish a significant correlation between increased liver stiffness and increased venous capillary pressure. In addition, liver elastography performed at hospital discharge was able to predict rehospitalization and mortality. Conclusion: Liver elastography is a non-invasive method that can be useful in predicting prognosis and mortality of individuals with HF, contributing to the clinical management of these patients.

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ABSTRACT Introduction: simulation based teaching is a powerful tool in medical education, allowing hands on practice under a controlled environment and with repeated maneuvers. Central venous access venipuncture is one of the most frequent procedures carried out in the hospital setting, due to its various clinical indications and, when performed with the help of ultrasonography, the risk of adverse events is minimized. Aim: to develop, to describe and to test a porcine model that simulates the central venous access puncture aided by ultrasonography. Method: a low cost porcine model was developed to train medical students and residents on central venous access guided by ultrasonography. Both students and medical residents underwent a theoretical training regarding the model, followed by a hands-on training session. Afterwards, the participants assessed the model by answering a questionnaire. Results: there were 51 participants. The average score regarding the similarity between the model and the human anatomy was 9.15. When the characteristics were separately assessed, the mean scores regarding the similarity of the vessels, anatomic disposition and ultrasonographic characteristics as well as the venipuncture were, respectively, 9.27; 9.31; 9.54 and 8.86. Conclusion: The model was approved and considered appropriate for the training of central venous venipuncture by all the participants. Furthermore, it is a low cost, simple and reproducible model, that presents high similarity with the human anatomy. Therefore, it may be used as an aid to train people on ultrasonography guided central venous access.

RESUMO Introdução: o ensino baseado em simulação é poderosa ferramenta para o aprendizado na educação médica, permitindo a prática de procedimentos em ambientes controlados e por repetidas vezes. A realização de acesso venoso central é um dos procedimentos médicos mais realizados em ambiente hospitalar, tendo várias indicações e, quando realizada com o auxilio da ultrassonografia, os riscos das complicações do procedimento são minimizados. Objetivo: desenvolver, descrever e aplicar um modelo porcino para simulação de acesso venoso central guiado por ultrassonografia. Métodos: modelo porcino de baixo custo foi desenvolvido para treinamento de acesso venoso central guiado por ultrassonografia. Estudantes de medicina e médicos residentes receberam treinamento teórico em relação ao procedimento, seguido de treinamento prático no modelo. Posteriormente, os participantes avaliaram o modelo desenvolvido por meio de um questionário. Resultados: o estudo contou com 51 participantes. O escore médio de semelhança geral do modelo com a realidade foi 9,15. Quando separadas por características, as médias dos escores de semelhança da imagem dos vasos, da disposição anatômica das estruturas, das características ultrassonográficas e da punção foram, respectivamente, 9,27; 9,31; 9,54 e 8,86. Conclusão: o modelo foi aprovado e considerado útil para treinamento do procedimento por todos os participantes, além de ter baixo custo, ser simples, reprodutível e apresentar alta semelhança com a realidade, podendo ser utilizado como adjunto no treinamento de acesso venoso central guiado por ultrassonografia.

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A cistite enfisematosa (CE) se trata de um acúmulo intraluminal de gás na vesícula urinária, proveniente da fermentação de substratos presentes na urina por microorganismos, como bactérias e fungos. Tal condição é relativamente rara e de ocorrência mais comum em pacientes que excretam de forma anormal glicose na urina, como por exemplo, em pacientes diabéticos. Relata-se no presente trabalho um caso de CE em uma paciente não diabética.(AU)

The emphysematous cystitis is an intraluminal accumulation of gas in the urinary vesicle, resulting from the fermentation of substrates present in the urine by microorganisms such as bacteria and fungi. Such a condition is relatively rare and more common in patients who have abnormal urine glucose excretion, such as in diabetic patients. The present study reports a case of CE in a non-diabetic patient.(AU)

La cistitis enfisematosa se trata de una acumulación intraluminal de gas en la vesícula urinaria, proveniente de la fermentación de sustratos presentes en la orina por microorganismos, como bacterias y hongos. Esta condición es relativamente rara y de ocurrencia más común en pacientes que excretan de forma anormal glucosa en la orina, como por ejemplo, en pacientes diabéticos. Se relata en el presente trabajo un caso de CE en una paciente no diabética.(AU)

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A cistite enfisematosa (CE) se trata de um acúmulo intraluminal de gás na vesícula urinária, proveniente da fermentação de substratos presentes na urina por microorganismos, como bactérias e fungos. Tal condição é relativamente rara e de ocorrência mais comum em pacientes que excretam de forma anormal glicose na urina, como por exemplo, em pacientes diabéticos. Relata-se no presente trabalho um caso de CE em uma paciente não diabética.

The emphysematous cystitis is an intraluminal accumulation of gas in the urinary vesicle, resulting from the fermentation of substrates present in the urine by microorganisms such as bacteria and fungi. Such a condition is relatively rare and more common in patients who have abnormal urine glucose excretion, such as in diabetic patients. The present study reports a case of CE in a non-diabetic patient.

La cistitis enfisematosa se trata de una acumulación intraluminal de gas en la vesícula urinaria, proveniente de la fermentación de sustratos presentes en la orina por microorganismos, como bacterias y hongos. Esta condición es relativamente rara y de ocurrencia más común en pacientes que excretan de forma anormal glucosa en la orina, como por ejemplo, en pacientes diabéticos. Se relata en el presente trabajo un caso de CE en una paciente no diabética.

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La cistitis enfisematosa se trata de una acumulación intraluminal de gas en la vesícula urinaria, proveniente de la fermentación de sustratos presentes en la orina por microorganismos, como bacterias y hongos. Esta condición es relativamente rara y de ocurrencia más común en pacientes que excretan de forma anormal glucosa en la orina, como por ejemplo, en pacientes diabéticos. Se relata en el presente trabajo un caso de CE en una paciente no diabética.

The emphysematous cystitis is an intraluminal accumulation of gas in the urinary vesicle, resulting from the fermentation of substrates present in the urine by microorganisms such as bacteria and fungi. Such a condition is relatively rare and more common in patients who have abnormal urine glucose excretion, such as in diabetic patients. The present study reports a case of CE in a non-diabetic patient.

A cistite enfisematosa se trata de um acúmulo intraluminal de gás na vesícula urinária, proveniente da fermentação de substratos presentes na urina por microorganismos, como bactérias e fungos. Tal condição é relativamente rara e de ocorrência mais comum em pacientes que excretam de forma anormal glicose na urina, como por exemplo, em pacientes diabéticos. Relata-se no presente trabalho um caso de CE em uma paciente não diabética.

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Abstract Pulmonary congestion is an important clinical finding in patients with heart failure (HF). Physical examination and chest X-ray have limited accuracy in detecting congestion. Pulmonary ultrasound (PU) has been incorporated into clinical practice in the evaluation of pulmonary congestion. This paper aimed to perform a systematic review of the use of PU in patients with HF, in different scenarios. A search was performed in the MEDLINE and LILACS databases in February 2017 involving articles published between 2006 and 2016. We found 26 articles in the present review, 11 of which in the emergency setting and 7 in the outpatient setting, with diagnostic and prognosis defined value and poorly studied therapeutic value. PU increased accuracy by 90% as compared to physical examination and chest X-ray for the diagnosis of congestion, being more sensitive and precocious. The skill of the PU performer did not interfere with diagnostic accuracy. The presence of B-lines ≥ 15 correlated with high BNP values (≥ 500) and E/e' ratio ≥ 15, with prognostic impact in IC patients at hospital discharge and those followed up on an outpatient basis. In conclusion, when assessing pulmonary congestion in HF, PU has an incremental value in the diagnostic and prognostic approach in all scenarios studied.

Resumo A congestão pulmonar é um achado clínico importante em paciente com insuficiência cardíaca (IC). Exame físico e radiografia do tórax têm acurácia limitada na detecção da congestão. A ultrassonografia pulmonar (UP) vem sendo incorporada à prática clínica na avaliação da congestão pulmonar. Este artigo teve como objetivo realizar revisão sistemática sobre a utilização da UP em pacientes com IC, nos diferentes cenários. Foi realizada uma pesquisa nas bases de dados MEDLINE e LILACS no mês de fevereiro de 2017 envolvendo artigos publicados entre 2006 e 2016. Foram encontrados 26 artigos na presente revisão, 11 deles no cenário da emergência e 7 em cenário ambulatorial, com valor diagnóstico e prognóstico definido e valor terapêutico pouco estudado. A UP aumentou a acurácia em 90% em relação ao exame físico e à radiografia do tórax para o diagnóstico da congestão, sendo mais sensível e precoce. A qualificação do executor da UP não interferiu na acurácia diagnóstica. O achado de linhas B ≥ 15 teve correlação com BNP elevado (≥ 500) e relação E/e' ≥ 15, com impacto prognóstico em pacientes com IC ambulatoriais e na alta hospitalar. Conclui-se que, na avaliação da congestão pulmonar na IC, a UP tem valor incremental na abordagem diagnóstica e prognóstica em todos os cenários encontrados.

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Abstract Study objective: The purpose of this study was to assess whether application of dorsal table tilt and body rotation to a parturient seated for neuraxial anesthesia increased the size of the paramedian target area for neuraxial needle insertion. Setting: Labor and Delivery Room. Patients: Thirty term pregnant women, ASA I-II, scheduled for an elective C-section delivery. Interventions: Lumbar ultrasonography was performed in four seated positions: (F) lumbar flexion; (FR) as in position F with right shoulder rotation; (FT) as in position F with dorsal table-tilt; (FTR) as in position F with dorsal table-tilt combined with right shoulder rotation. Measurements: For each position, the size of the 'target area', defined as the visible length of the posterior longitudinal ligament was measured at the L3-L4 interspace. Main results: The mean posterior longitudinal ligament was 18.4 ± 4 mm in position F, 18.9 ± 5.5 mm in FR, 19 ± 5.3 mm in FT, and 18 ± 5.2 mm in FTR. Mean posterior longitudinal ligament length was not significantly different in the four positions. Conclusions: These data show that the positions studied did not increase the target area as defined by the length of the posterior longitudinal ligament for the purpose of neuraxial needle insertion in obstetric patients. The maneuvers studied will have limited use in improving spinal needle access in pregnant women.

Resumo Objetivo do estudo: O objetivo deste estudo foi avaliar se a inclinação lateral da mesa cirúrgica e a rotação do corpo de uma parturiente sentada para anestesia neuraxial aumentou o tamanho da área-alvo paramediana para a inserção da agulha neuraxial. Ambiente: Sala de parto. Pacientes: Trinta grávidas a termo, ASA I-II, agendadas para cesárea eletiva. Intervenções: Ultrassonografia lombar foi feita em quatro posições sentadas: (F) flexão lombar; (FR) como na posição F com rotação do ombro direito; (FT) como na posição F com inclinação lateral da mesa cirúrgica; (FTR) como na posição F com inclinação lateral da mesa cirúrgica combinada com a rotação do ombro direito. Mensurações: Para cada posição, o tamanho da "área-alvo", definido como o comprimento visível do ligamento longitudinal posterior, foi medido no interespaço de L3-L4. Principais resultados: As médias do ligamento longitudinal posterior foram: 18,4 ± 4 mm na posição F; 18,9 ± 5,5 mm na posição FR; 19 ± 5,3 mm na posição FT e 18 ± 5,2 mm na posição FTR. O comprimento médio do ligamento longitudinal posterior não foi significativamente diferente nas quatro posições. Conclusões: Esses dados mostram que as posições avaliadas não aumentaram a área-alvo, conforme definido pelo comprimento do ligamento longitudinal posterior com o objetivo de inserção da agulha neuraxial em pacientes obstétricas. As manobras avaliadas terão um uso limitado na melhoria do acesso à agulha espinhal em mulheres grávidas.

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STUDY OBJECTIVE: The purpose of this study was to assess whether application of dorsal table tilt and body rotation to a parturient seated for neuraxial anesthesia increased the size of the paramedian target area for neuraxial needle insertion. SETTING: Labor and Delivery Room. PATIENTS: Thirty term pregnant women, ASA I-II, scheduled for an elective C-section delivery. INTERVENTIONS: Lumbar ultrasonography was performed in four seated positions: (F) lumbar flexion; (FR) as in position F with right shoulder rotation; (FT) as in position F with dorsal table-tilt; (FTR) as in position F with dorsal table-tilt combined with right shoulder rotation. MEASUREMENTS: For each position, the size of the 'target area', defined as the visible length of the posterior longitudinal ligament was measured at the L3-L4 interspace. MAIN RESULTS: The mean posterior longitudinal ligament was 18.4±4mm in position F, 18.9±5.5mm in FR, 19±5.3mm in FT, and 18±5.2mm in FTR. Mean posterior longitudinal ligament length was not significantly different in the four positions. CONCLUSIONS: These data show that the positions studied did not increase the target area as defined by the length of the posterior longitudinal ligament for the purpose of neuraxial needle insertion in obstetric patients. The maneuvers studied will have limited use in improving spinal needle access in pregnant women.

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A paralisia de laringe consiste na perda da capacidade de abdução das cartilagens aritenóides durante a inspiração. Pode ser congênita ou adquirida, secundária a trauma, neoplasia, polineuropatia ou endocrinopatia. O diagnóstico tem como base os sinais clínicos e exame de imagem da laringe. Uma cadela, de 9 anos de idade, da raça Labrador Retriever foi atendida no hospital veterinário com quadro de dispnéia inspiratória, intolerância ao exercício, sobrepeso, inquietação e taquicardia. Após oxigenoterapia, foram solicitados hemograma, perfil bioquímico, hemogasometria e exame radiográfico do tórax, porém, o diagnóstico definitivo de paralisia de laringe foi obtido por meio da ultrassonografia da região cervical ventral e laringoscopia. Nestes exames foram observados movimentos assimétricos das cartilagens aritenóides durante a inspiração. Desta forma, foi instituído o tratamento emergencial de traqueostomia. Após quatro dias foi realizada a técnica de lateralização aritenóide unilateral. Ao longo de 14 dias de internação, o padrão respiratório da paciente foi restaurado, resultando na alta do animal.

Laryngeal paralysis consists of the loss of the capacity of abduction of arytenoid cartilages during inspiration. The etiology may be congenital or acquired, secondary to trauma, neoplasia, polyneuropathy or endocrinopathy. The diagnosis is based on clinical signs and on the examination of the larynx. A 9-year-old Labrador Retriever was treated at the veterinary hospital, with symptoms of inspiratory dyspnea, exercise intolerance, overweight, restlessness and tachycardia. After oxygen therapy, complete blood count, biochemicals, hemogasometry and chest radiography were requested. The definitive diagnosis of laryngeal paralysis was obtained by ultrasonography of the ventral cervical region and laryngoscopy. Asymmetric movements of the arytenoid cartilages were observed during inspiration. Therefore, emergency tracheostomy treatment was instituted. After the assessment of the operative risks, it was chosen to perform the unilateral laryngeal lateralization procedure. Throughout 14 days of hospitalization, the patient's respiratory pattern was restored, resulting in the discharge of the animal.

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A paralisia de laringe consiste na perda da capacidade de abdução das cartilagens aritenóides durante a inspiração. Pode ser congênita ou adquirida, secundária a trauma, neoplasia, polineuropatia ou endocrinopatia. O diagnóstico tem como base os sinais clínicos e exame de imagem da laringe. Uma cadela, de 9 anos de idade, da raça Labrador Retriever foi atendida no hospital veterinário com quadro de dispnéia inspiratória, intolerância ao exercício, sobrepeso, inquietação e taquicardia. Após oxigenoterapia, foram solicitados hemograma, perfil bioquímico, hemogasometria e exame radiográfico do tórax, porém, o diagnóstico definitivo de paralisia de laringe foi obtido por meio da ultrassonografia da região cervical ventral e laringoscopia. Nestes exames foram observados movimentos assimétricos das cartilagens aritenóides durante a inspiração. Desta forma, foi instituído o tratamento emergencial de traqueostomia. Após quatro dias foi realizada a técnica de lateralização aritenóide unilateral. Ao longo de 14 dias de internação, o padrão respiratório da paciente foi restaurado, resultando na alta do animal.(AU)

Laryngeal paralysis consists of the loss of the capacity of abduction of arytenoid cartilages during inspiration. The etiology may be congenital or acquired, secondary to trauma, neoplasia, polyneuropathy or endocrinopathy. The diagnosis is based on clinical signs and on the examination of the larynx. A 9-year-old Labrador Retriever was treated at the veterinary hospital, with symptoms of inspiratory dyspnea, exercise intolerance, overweight, restlessness and tachycardia. After oxygen therapy, complete blood count, biochemicals, hemogasometry and chest radiography were requested. The definitive diagnosis of laryngeal paralysis was obtained by ultrasonography of the ventral cervical region and laryngoscopy. Asymmetric movements of the arytenoid cartilages were observed during inspiration. Therefore, emergency tracheostomy treatment was instituted. After the assessment of the operative risks, it was chosen to perform the unilateral laryngeal lateralization procedure. Throughout 14 days of hospitalization, the patient's respiratory pattern was restored, resulting in the discharge of the animal.(AU)

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A presença de corpos estranhos localizados na pele, sua dimensão, constituição e exata localização muitas vezes não são perceptíveis ao exame clínico dermatológico. Apesar de seu caráter benigno, a existência de corpos estranhos à pele provocam alta morbidade. A ultrassonografia de alta frequência tem sido amplamente utilizada nas diferentes áreas da Dermatologia. O avanço tecnológico com a introdução de aparelhos de alta frequência e resolução torna esse método útil na identificação e orientação da remoção de corpos estranhos localizados na pele. Apresentamos caso em que a ultrassonografia de alta frequência foi utilizada na identificação e retirada de um ferrão de arraia.

The presence of foreign bodies located on the skin, their size, constitution and precise location are often not perceptible on dermatological clinical examination. Despite their benign nature, the presence of foreign bodies in the skin is associated to high morbidity. High frequency ultrasonography has been widely used in different areas of Dermatology. Technological development and the introduction of devices offering high frequency and high resolution makes this method useful in identifying and guiding the removal of foreign bodies located in the skin. The authors describe a case where high frequency ultrasonography was used to identify and remove a rayfish stinger.

RESUMO

O câncer de mama em homens é uma patologia relativamente incomum. Atinge um homem para cada mil mulheres. Representa menos de 1% de todos os cânceres em homens e é responsável por 0,1% da mortalidade de câncer no sexo masculino. Apesar de ser incomum, alguns estudos vêm demonstrando um aumento na incidência destes tumores. Os fatores de risco incluem hiperestrogenismo, idade, ascendência judaica, história familiar e Síndrome de Klinefelter. Os dados sobre patologia mostram que 90% dos tumores são ductais invasivos, 80% apresentam receptores de estrógeno e 80 a 90% receptores de progesterona positivos. O tratamento é extrapolado dos estudos sobre câncer de mama feminina: cirurgia, hormonioterapia, quimioterapia e radioterapia, que são usados seguindo os guidelines femininos.

Breast cancer in men is a relatively an uncommon disease. Reaches one man for every thousand women. Represents less than 1% of all cancers in men and is responsible for 0.1% of cancer mortality in males. Although it is uncommon, some studies have demonstrated an incidence increase of these tumors. Risk factors include hyperestrogenism, age, Jewish ancestry, family history and Klinefelter Syndrome. The data on pathology showed that 90% of tumors are invasive ductal, 80% have estrogen receptors and 80 to 90% progesterone receptor positive. The treatment is extrapolated from female breast cancer studies: surgery, hormone therapy, chemotherapy and radiotherapy, wich are used following the guidelines female.

RESUMO

Relatamos um caso de uma paciente assintomática, cuja mamografia demonstrou nódulo contendo calcificações e ultrassonografia, imagem semelhante a agrupamento de pequenos cistos. Este achado é inespecífico, mas pode ser encontrado em vários transtornos proliferativos benignos ou fibrocísticos e também no carcinoma ductal in situ. Foi também obtida a tomossíntese e a ressonância magnética, que confirmaram os achados.

It was related a case of an asymptomatic patient, whose mammography presented a nodule with calcification and the ultrasound images showed a group of small cysts. This is a nonspecific finding, but can be found in several benign or fibrocystic proliferative diseases, and even in ductal carcinoma in situ. The findings confirmation was made by digital breast tomosynthesis and magnetic resonance.

RESUMO

OBJECTIVE: To evaluate the reliability of fetal heart rate (FHR) parameters analyzed by computerized cardiotocography (cCTG) in predicting myocardial damage in pregnancies with placental insufficiency. STUDY DESIGN: We evaluated 38 patients with placental insufficiency detected before 34 weeks of gestation. All patients underwent 30 min of cCTG (Sonicaid Fetal Care, version 2.2) and Doppler of umbilical artery, middle cerebral artery, and ductus venosus. Umbilical vein blood samples were collected at birth to determine fetal cardiac Troponin T, and a ≥0.09ng/ml value was deemed a sign of myocardial damage. RESULTS: The fetuses with myocardial damage (39%) showed significantly increased values of umbilical artery pulsatility index z-score (P=0.003), ductus venosus pulsatility index z-score (P=0.007), basal FHR (P=0.033) and periods of low episodes (P=0.038). The number of small accelerations and the short-term variation (STV) were significantly reduced in the group with myocardial damage (P=0.013 and P=0.003, respectively). Logistic regression analysis identified STV and gestational age at delivery as independent predictors for fetal myocardial damage, with area under ROC curve of 0.91. CONCLUSIONS: Computerized cardiotocography parameters may be useful in the management of early onset placental insufficiency, and the association of STV with gestational age could play a role in detecting myocardial injury in pregnancies with placental insufficiency.

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Bones are believed to be an effective barrier to obtain sonographic images. In fact, the large difference between acoustic impedances of surfaces of the soft and bone tissues generates significant image artifacts. However, transmission of the ultrasound beam depends on bone thickness and structure. Therefore, the temporal bone has been used as an acoustic window to access the brain of adult patients with ultrasonography. The purpose of this study was to assess the brain of adult dogs using ultrasonography with and without bone interposition, compare the images, and correlate them with the brain anatomy. Ten mesaticephalic adult dogs were used, and the ultrasound examination was performed through the magnum orifice and on the temporal, lateral parietal, and frontal bones. A small craniotomy was performed in the frontal bone for examination without bone interposition. We were able to acquire images of the brain with bone interposition. However, resolution of these images was lower than the ones obtained by craniotomy. Important anatomical structures were identified. Regarding the correlation and the wide availability of ultrasound equipment, it was concluded that ultrasound can be used as a tool for monitoring expansive intracranial lesions or in intraoperative procedures.(AU)

Os ossos são tidos como uma barreira intransponível para obtenção de imagens sonográficas, pois a grande diferença entre as impedâncias acústicas das superfícies de tecidos moles e ósseos gera importantes artefatos de reflexão, contudo, a transmissão do feixe ultrassônico depende da espessura e da estrutura óssea e neste caso o osso temporal tem sido usado como uma janela acústica para o acesso, por ultrassonografia, do encéfalo de pacientes adultos. O presente trabalho examinou o encéfalo de cães adultos com o emprego da ultrassonografia com e sem a interposição do crânio, comparou as imagens obtidas e as correlacionou com a anatomia encefálica. Foram examinados dez cães adultos, mesaticefálicos. O exame ultrassonográfico foi realizado através do orifício magno e dos ossos temporal, parietal (porção lateral) e frontal. No exame sem a interposição óssea foi realizada uma pequena craniotomia no osso frontal. As imagens do encéfalo com a interposição óssea apresentaram resolução inferior as obtidas por craniotomia. Importantes estruturas anatômicas foram identificadas. Devido à correlação e a sua ampla disponibilidade, concluiu-seque o aparelho de ultrassom pode ser usado para o acompanhamento de lesões intracranianas expansivas, bem como em procedimentos intraoperatórios.(AU)

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Background: Ultrasound is commonly used in queens for diagnosis and monitoring of pregnancy and may also be used to estimate the date of birth in cats with unknown date of mating, representing a valuable aid in clinical practice and in reproductive programs. The determination of gestational age can be made based on sonographic fetal measurements. In bitches, the conformation of the cranium should be considered in proportional variations in measurements because it interferes with predicting parturition date. Although domestic cats do not show a large variation in terms of size, they present variation in the cranial conformation. So far, there is no study that has produced mathematical equations for determination of gestational age in cats considering these differences. Thus, there is a widespread use of these equations that can lead to mistakes in this estimation. This study aimed to verify the accuracy of prediction of delivery date in cats of different cranial conformation through mathematical equations enshrined in clinical practice, using different sonographic measurements and verify the effect of litter size on the accuracy of determination of days to delivery. Materials, Methods & Results: Sonographic examinations were performed on pregnant brachycephalic and mesaticephalic cats. Biparietal and abdominal diameters and depth of the fetal diencephalo-telencephalic vesicle were measured. The average value of each structure was calculated and ultrasound prediction of days before delivery was obtained by applying equations derived from growth curves that have been already published. All mathematical equations used in predicting the date for delivery showed lower percentage of success, regardless of the type of the parameter and cranial ultrasound used. The biparietal diameter was the most reliable measure for estimating the date of delivery. The litter size did not influence the accuracy of determining the date of delivery. Discussion: Although queens have ovulation induced by copulation and date of birth would be more easily predicted than in bitches, with a good accuracy and subsequent birth date, it is extremely important to be able to plan clinical delivery assistance or a c-section. In this study, the application of the equations derived from the growth curves of biparietal and abdominal diameter and depth of the fetal diencephalo-telencephalic vesicle resulted in little accurate predictions of delivery date for the three and sonographic parameters for both types cranial. The generalization use of these equations for cats may lead to errors in the estimation of gestational age. Although the equations used in this study are old, we opted for their use in this work, because they are still widely used in ultrasound practice, still being cited in recent publications on this subject. Studies that performed the ultrasound monitoring of pregnancy in cats and dogs show that the fetus ordinary course follows a well-defined development with particular characteristics of development at specific times during pregnancy. This makes clear that the evaluation of these characteristics is useful for predicting the day of delivery and can also be applied in other breeds, unlike the mathematical equations that are specific to each breed standard. Thus, it is suggested that the estimate of gestational age is made in conjunction with the fetometry and observation of fetal growth and subsequent organogenesis, avoiding the use of one of the tools individually so that one has higher reliability in this prediction. Thus, it was concluded that the mathematical equations already published are not individually sufficient for accurate determination of date of birth in brachycephalic and mesaticephalic cats.

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