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Whipple's disease (WD) is a rare systemic disease of infectious etiology which involves the small intestine but can virtually affect any organ. We present here five cases (four males and one female) ranging in age from 20 to 59 years. All patients had intestinal involvement associated or not with clinical manifestations linked to this organ. Vegetation in the tricuspid valve was observed in one patient, suggesting endocarditis caused by Tropheryma whippelii, with disappearance of the echocardiographic alterations after treatment. In one of the male patients the initial clinical manifestation was serologically negative spondylitis, with no diarrhea occurring at any time during follow-up. Ocular involvement associated with intestinal malabsorption and significant weight loss were observed in one case. In the other two cases, diarrhea was the major clinical manifestation. All patients were diagnosed by histological examination of the jejunal mucosa and, when indicated, of extraintestinal tissues by light and electron microscopy. After antibiotic treatment, full remission of symptoms occurred in all cases. A control examination of the intestinal mucosa performed after twelve months of treatment with sulfamethoxazole-trimethoprim revealed the disappearance of T. whippelii in four patients. The remaining patient was lost to follow-up.

Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.

Objectives: Data on cardiac arrest survivors from developing countries are scarce. This study investigated clinical characteristics associated with in-hospital mortality in resuscitated patients following cardiac arrest in Brazil., Design: Retrospective analysis of prospectively collected data., Setting: Ninety-two general ICUs from 55 hospitals in Brazil between 2014 and 2015., Patients: Adult patients with cardiac arrest admitted to the ICU., Interventions: None., Measurements and Main Results: We analyzed 2,296 patients (53% men; median 67 yr (interquartile range, 54-79 yr]). Eight-hundred patients (35%) had a primary admission diagnosis of cardiac arrest suggesting an out-of-hospital cardiac arrest; the remainder occurred after admission, comprising an in-hospital cardiac arrest cohort. Overall, in-hospital mortality was 83%, with only 6% undergoing withholding/withdrawal-of-life support. Random-effects multivariable Cox regression was used to assess associations with survival. After adjusting for age, sex, and severity scores, mortality was associated with shock (adjusted odds ratio, 1.25 [95% CI, 1.11-1.39]; p < 0.001), temperature dysregulation (adjusted odds ratio for normothermia, 0.85 [95% CI, 0.76-0.95]; p = 0.007), increased lactate levels above 4 mmol/L (adjusted odds ratio, 1.33 [95% CI, 1.1-1.6; p = 0.009), and surgical or cardiac cases (adjusted odds ratio, 0.72 [95% CI, 0.6-0.86]; p = 0.002). In addition, survival was better in patients with probable out-of-hospital cardiac arrest, unless ICU admission was delayed (adjusted odds ratio for interaction, 1.63 [95% CI, 1.21-2.21]; p = 004)., Conclusions: In a large multicenter cardiac arrest cohort from Brazil, we found a high mortality rate and infrequent withholding/withdrawal of life support. We also identified patient profiles associated with worse survival, such as those with shock/hypoperfusion and arrest secondary to nonsurgical admission diagnoses. Our findings unveil opportunities to improve postarrest care in developing countries, such as prompt ICU admission, expansion of the use of targeted temperature management, and implementation of shock reversal strategies (i.e., early coronary angiography), according to modern guidelines recommendations., Competing Interests: Drs. Soares and Salluh are shareholders of Epimed Solutions®. They are partially supported by research grants from National and State funding agencies (Conselho Nacional de Desenvolvimento Científico e Tecnológico and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro). The remaining authors have disclosed that they do not have any conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS., Methods: This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice., Results: On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only., Conclusion: Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.

Hypopressive exercise (HE) has been contraindicated for people with cardiovascular disease because it involves isometric postures performed with low-pulmonary volume breath-holds, which are thought to increase blood pressure. The objective of this study was to analyze the hemodynamic responses to HE performed in the seated posture on systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) in normotensive females. Ten women (age = 31.2 ± 6.3 years) with previous experience in HE participated. Three sets of eight breathing cycles of HE breathing were completed. The HE breathing protocol consisted of three complete breathing cycles of controlled latero-costal inhalations and slow deep exhalations followed by a breath-hold and rib-cage expansion after every third exhalation. Measurements of SBP, DBP, MAP and HR were assessed at baseline, at the end of each set and at the end of minute 5, 10, 15 and 20 during the recovery period. The measurement of hemodynamic variables used a digital photoplethysmography device. Significant differences for SBP (baseline compared to SET2, p = 0.0182) and MAP (baseline compared to SET1, p = 0.0433; and SET2, p = 0.0072) were found. No significant differences were found in the recovery periods compared with baseline. Medium effect size for HR during REC5 (ES = 0.50) and REC10 (ES = 0.56) was observed. These findings indicate that HE in the seated posture performed by normotensive females leads to significant increases in SBP and MAP with no significant increase of HR and no hypotensive effect during recovery period. Our preliminary results should be supported by future randomized controlled trials., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Two authors of this manuscript, Carolina Lemes Mendes and Tamara Rial Rebullido, teach courses based on hypopressives., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The performance of severity-of-illness scores varies in different scenarios and must be validated prior of being used in a specific settings and geographic regions. Moreover, models' calibration may deteriorate overtime and performance of such instruments should be reassessed regularly. Therefore, we aimed at to validate the SAPS 3 in a large contemporary cohort of patients admitted to Brazilian ICUs. In addition, we also compared the performance of the SAPS 3 with the MPM 0 -III., Methods: This is a retrospective cohort study in which 48,816 (medical admissions = 67.9%) adult patients are admitted to 72 Brazilian ICUs during 2013. We evaluated models' discrimination using the area under the receiver operating characteristic curve (AUROC). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration)., Results: Mean SAPS 3 score was 44.3 ± 15.4 points. ICU and hospital mortality rates were 11.0 and 16.5%. We estimated predicted mortality using both standard (SE) and Central and South American (CSA) customized equations. Predicted mortality rates were 16.4 ± 19.3% (SAPS 3-SE), 21.7 ± 23.2% (SAPS 3-CSA) and 14.3 ± 14.0% (MPM 0 -III). Standardized mortality ratios (SMR) obtained for each model were: 1.00 (95% CI, 0.98-0.102) for the SAPS 3-SE, 0.75 (0.74-0.77) for the SAPS 3-CSA and 1.15 (1.13-1.18) for the MPM 0 -III. Discrimination was better for SAPS 3 models (AUROC = 0.85) than for MPM 0 -III (AUROC = 0.80) (p < 0.001). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration): the SAPS 3-CSA overestimated mortality throughout all risk classes while the MPM 0 -III underestimated it uniformly. The SAPS 3-SE did not show relevant deviations from ideal calibration., Conclusions: In a large contemporary database, the SAPS 3-SE was accurate in predicting outcomes, supporting its use for performance evaluation and benchmarking in Brazilian ICUs.

A 26-year-old postpartum female presented with symptoms characteristic of dengue fever on the 16th day of puerperium. On the third day of the illness, the patient presented a clinical picture consistent with shock. Tests determined primary infection with dengue virus serotype 2. Cardiac tamponade was confirmed by echocardiography. This rare manifestation is described in a patient without any associated comorbidity.

The azygos anterior cerebral artery is a rare variant, characterized by the absence of the anterior communicating artery and the union of two proximal segments of the anterior cerebral artery, forming a single trunk and ascending through the interhemispheric fissure. The incidence in the population varies from 0.3 to 2%. The presence of occlusion for this vessel causes bifrontal infarcts, with potentially devastating functional consequences, hence the importance of recognizing this anatomical variation in imaging exams., Competing Interests: The authors declare that they have no conflict of interests.

Objective: In Brazil, there are no data on the preferences of intensivists regarding hemodynamic monitoring methods. The present study aimed to identify the methods used by national intensivists, the hemodynamic variables they consider important, the regional differences, the reasons for choosing a particular method, and the use of protocols and continued training., Methods: National intensivists were invited to answer an electronic questionnaire during three intensive care events and later, through the Associação de Medicina Intensiva Brasileira portal, between March and October 2009. Demographic data and aspects related to the respondent preferences regarding hemodynamic monitoring were researched., Results: In total, 211 professionals answered the questionnaire. Private hospitals showed higher availability of resources for hemodynamic monitoring than did public institutions. The pulmonary artery catheter was considered the most trusted by 56.9% of the respondents, followed by echocardiograms, at 22.3%. Cardiac output was considered the most important variable. Other variables also considered relevant were mixed/central venous oxygen saturation, pulmonary artery occlusion pressure, and right ventricular end-diastolic volume. Echocardiography was the most used method (64.5%), followed by pulmonary artery catheter (49.3%). Only half of respondents used treatment protocols, and 25% worked in continuing education programs in hemodynamic monitoring., Conclusion: Hemodynamic monitoring has a greater availability in intensive care units of private institutions in Brazil. Echocardiography was the most used monitoring method, but the pulmonary artery catheter remains the most reliable. The implementation of treatment protocols and continuing education programs in hemodynamic monitoring in Brazil is still insufficient.

Purpose of Review: Using perioperative goal-directed therapy (GDT) or peroperative hemodynamic optimization significantly reduces postoperative complications and risk of death in patients undergoing noncardiac major surgeries. In this review, we discuss the main changes in the field of perioperative optimization over the last few years., Recent Findings: One of the key aspects that has changed in the last decade is the shift from invasive monitoring with pulmonary artery catheters (PACs) to less or minimally invasive monitoring systems. The evaluation of intravascular fluid volume deficits has also changed dramatically from the use of static indices to the assessment of fluid responsiveness using either dynamic indices or functional hemodynamic. Finally, attention has been directed toward more restrictive strategies of crystalloids as maintenance fluids., Summary: GDT is safe and more likely to tailor the amount of fluids given to the amount of fluids actually needed. This approach includes assessment of fluid responsiveness and, if necessary, the use of inotropes; moreover, this approach can be coupled with a restrictive strategy for maintenance fluids. These strategies have been increasingly incorporated into protocols for perioperative hemodynamic optimization in high-risk patients undergoing major surgery, resulting in more appropriate use of fluids, vasopressors, and inotropes.

Background: Prediction of perioperative cardiac complications is important in the medical management of patients undergoing noncardiac surgery. However, these patients frequently die as a consequence of primary or secondary multiple organ failure (MOF), often as a result of sepsis. We investigated the early perioperative risk factors for in-hospital death due to MOF in surgical patients., Methods: This was a prospective, multicenter, observational cohort study performed in 21 Brazilian intensive care units (ICUs). Adult patients undergoing noncardiac surgery who were admitted to the ICU within 24 hours after operation were evaluated. MOF was characterized by the presence of at least 2 organ failures. To determine the relative risk (RR) of in-hospital death due to MOF, we performed a logistic regression multivariate analysis., Results: A total of 587 patients were included (mean age, 62.4 ± 17 years). ICU and hospital mortality rates were 15% and 20.6%, respectively. The main cause of death was MOF (53%). Peritonitis (RR 4.17, 95% confidence interval [CI] 1.38-12.6), diabetes (RR 3.63, 95% CI 1.17-11.2), unplanned surgery (RR 3.62, 95% CI 1.18-11.0), age (RR 1.04, 95% CI 1 0.01-1.08), and elevated serum lactate concentrations (RR 1.52, 95% CI 1.14-2.02), a high central venous pressure (RR 1.12, 95% CI 1.04-1.22), a fast heart rate (RR 3.63, 95% CI 1.17-11.2) and pH (RR 0.04, 95% CI 0.0005-0.38) on the day of admission were independent predictors of death due to MOF., Conclusions: MOF is the main cause of death after surgery in high-risk patients. Awareness of the risk factors for death due to MOF may be important in risk stratification and can suggest routes for therapy.

On April 26th, 2005, an accident caused a leak of 60,000L of Diesel Oil Type "B", freighted by train wagons upstream on a mangrove area within Guanabara Bay, Southeast Brazil. After the accident, samples from animals with different biological requirements were collected in order to monitor polycyclic aromatic hydrocarbons concentrations for the following 12months. Sessile, mobile, carnivorous, omnivorous, organic detritus feeders, planktivorous and suspension feeders were some of the attributes compared. Concentrations of PAHs did not vary in relation to different dietary habits and the best response was from the sessile suspensivorous barnacles. A background level of <50microgkg(-1) was suggested based on the reference site and on values observed in the following months after the accident. The highest values of PAH concentrations were observed in barnacles in the first month immediately after the spill, decreasing to background levels after few months. Barnacles are suggested as a sentinel species., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Objective: Anemia is common in severely ill patients, and blood sampling plays a relevant causative role. Consequently, blood transfusions are frequent an related to several complications. Trying to reduce the transfusion-related risk, minimizing blood loss is mandatory. Thus, this work aimed to evaluate a closed blood sampling system as a strategy to spare unnecessary blood losses and transfusions., Methods: This was a prospective, randomized, controlled, multicenter, 6 months, clinical trial. The patients were assigned to either VAMP (Venous Arterial Blood Management Protection) group, using a closed blood sampling system, or control group. The groups' transfusion rate, as well as hemoglobin (Hb) and Hematocrit (Ht) changes were compared for 14 days., Results: Were included 127 patients, 65 assigned to the control group, and 62 to VAMP. During the intensive care unit stay, both groups experienced both hemoglobin and hematocrit drops. However, when the final Ht and Hb were compared between the groups, a difference was identified with higher values in the VAMP group (p=0.03; p=0.006, respectively). No statistical difference was found for both groups transfusion rates, although the VAMP group had an absolute 12% blood transfusion reduction., Conclusion: The use of a closed blood sampling system was able to minimize blood count values changes, however failed to reduce transfusions rate.

Objectives: Due to the dramatic medical breakthroughs and an increasingly ageing population, the proportion of patients who are at risk of dying following surgery is increasing over time. The aim of this study was to evaluate the outcomes and the epidemiology of non-cardiac surgical patients admitted to the intensive care unit., Methods: A multicenter, prospective, observational, cohort study was carried out in 21 intensive care units. A total of 885 adult surgical patients admitted to a participating intensive care unit from April to June 2006 were evaluated and 587 patients were enrolled. Exclusion criteria were trauma, cardiac, neurological, gynecologic, obstetric and palliative surgeries. The main outcome measures were postoperative complications and intensive care unit and 90-day mortality rates., Results: Major and urgent surgeries were performed in 66.4% and 31.7% of the patients, respectively. The intensive care unit mortality rate was 15%, and 38% of the patients had postoperative complications. The most common complication was infection or sepsis (24.7%). Myocardial ischemia was diagnosed in only 1.9% of the patients. A total of 94 % of the patients who died after surgery had co-morbidities at the time of surgery (3.4 ± 2.2). Multiple organ failure was the main cause of death (53%)., Conclusion: Sepsis is the predominant cause of morbidity in patients undergoing non-cardiac surgery. In this patient population, multiple organ failure prevailed as the most frequent cause of death in the hospital.

Objective: The main purpose of this study was to compare performance of the Ramsay and Richmond sedation scores on mechanically ventilated critically ill patients, in a university-affiliated hospital., Methods: This was a 4-month prospective study, which included a total of 45 patients mechanically ventilated, with at least 48 hours stay in the intensive care unit. Each patient was assessed daily for sedation mode, sedative and analgesic doses and sedation level using the Ramsay and Richmond scores. Statistical analysis was made using Student's t-test, Pearson's and Spearman's correlation, and constructing ROC-curves., Results: A high general mortality of 60% was observed. The length of sedation and daily dose of medication did not correlate with mortality. Deep sedation (Ramsay > 4 or Richmond < -3) was positively correlated with probability of death with an AUC > 0.78. An adequate level of sedation (Ramsay 2 to 4 or Richmond 0 to -3) was sensitively correlated with probability of survival with an AUC > 0.80. A low level of sedation was observed in 63 days evaluated (8.64%), and no correlation was found between occurrence of agitation and unfavorable outcomes. Correlation between Ramsay and Richmond scores (Pearson's > 0.810 - p<0.0001) was good., Conclusion: In this study, Ramsay and Richmond sedation scores were similar for the assessment of deep, insufficient and adequate sedation. Both have good correlation with mortality in over sedated patients.

A multiplex nested PCR method for detection of Vibrio cholerae O1 using a single tube was developed (MSTNPCR). Firstly, single-tube nested PCR (STNPCR) with primers directed to ctxA gene was standardized, and its detection limit was compared to simple PCR and two-step nested PCR. Secondly, primers directed to rfbN gene were added to the reaction. The detection limit of the multiplex reaction was determined using V. cholerae O1 DNA and V. cholerae O1 grown in alkaline peptone water (APW). STNPCR was shown to be approximately 100-fold more sensitive than simple PCR and 10 times less sensitive than two-step nested PCR. This drawback is compensated by a lower risk of cross-contamination. The addition of a second target did not impair the detection limit of STNPCR (as little as 1 pg of V. cholerae O1 DNA detected). MSTNPCR could specifically detect up to three V. cholerae O1 cells or colony forming units (cfu) directly from the APW growth. A diagnostic kit consisting of a set of microtubes having the inner primers fixed onto the inside of the tube cap and a set of tubes containing the reaction mixture was evaluated for stability, and it proved to be stable for five months at -20 degrees C. Therefore, MSTNPCR would be useful in the detection of V. cholerae O1 directly from environmental waters in cholera endemic areas and in complementing the identification of toxigenic strains isolated by culture.

Guanabara Bay (GB) is considered to be one of the most polluted environments of the southern Brazilian coastline. This typical estuarine system is impacted by the heavy discharge of both industrial and domestic waste from the Rio de Janeiro metropolitan area. The mollusc community structure and distribution was investigated between 2000 and 2001, using a three month sampling design of 38 stations, according to austral seasons. Species abundance was aggregated into progressively higher taxa matrices (genus, family, order) and were analysed using multivariate techniques. Mollusc distribution in GB varied significantly in space and time and was probably ruled by the organic enrichment effects of hypoxia and altered redox conditions coupled with prevailing patterns of circulation. Within the sectors of GB an increasing gradient in mollusc diversity and occurrence was observed, ranging from the azoic and impoverished stations in the inner sector to a well-structured community in terms of species composition and abundance inhabiting the outer sector. The non-metric multidimensional scaling (nMDS) and cluster analysis showed similar results when species were aggregated into genera and families, while greater difference occurred at coarser taxonomic identification (order). The literature about taxonomic sufficiency has demonstrated that faunal patterns at different taxonomic levels tend to become similar with increased pollution. In Guanabara Bay, an analysis carried out solely at family level is perfectly adequate to describe the ecophysiological stress. Further aggregation to order level changed the perceived patterns of differences. However, a different taxonomic resolution can be chosen depending on the type of ecological patterns investigated.

Background and Objectives: The main cardiovascular function is to maintain the adequate perfusion e oxygen delivery to the cells. Physiologically, this is controlled by the cellular metabolic rate. The critically ill patients are in high danger of tissue hipoperfusion and this is directly related to cellular injury and organ dysfunction. Therefore, the tissue perfusion monitoring makes part and is indissociated of hemodynamic evaluation of the critically ill patient and is indicated to all this patients. The objective was to define recommendations about clinical utility of different tolls to bedside perfusion monitoring., Methods: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty five physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MedLine in the period from 1996 to 2004., Results: Recommendations were done about the utility of clinical monitoring of tissue perfusion, temperature gradient and transcutaneous oxygen monitoring, serum lactate, base excess, SvO² and ScvO², gastric and sublingual capnometry, CO² venous-arterial gradient and Orthogonal Polarization Spectral (OPS)., Conclusions: The homodynamic compensation of a critically ill patient isn’t complete unless the tissue perfusion is corrected. Many different methods of monitoring is available and are useful in clinical practice, however, none has accuracy and effectiveness characteristics to be used independently of clinical context.

Background and Objectives: Use of Pulmonary Artery Catheter (PAC) is still a debatable issue, mainly due to questions raised about its security and efficacy. This study reproduced in a sample of Brazilian physicians, another one conducted amidst American doctors, in which was pointed out the heterogeneity of clinical decisions guided by data obtained from PAC., Methods: During the Brazilian Congress of Intensive Care Medicine (Curitiba 2004), doctors were asked to answer a survey form with three vignettes. Each of them contained PAC data and one half of the surveys contained echocardiographic information. Every doctor was asked to select one of six interventions for each vignette. A homogeneous answer was considered when it was selected by at least 80% of the respondents., Results: Two hundred and thirty seven doctors answered the questionnaires. They selected completely different therapeutic interventions in all three vignettes and none of the interventions achieved more than 80% agreement. Variability persisted with the choices guided by echocardiography., Conclusions: As in the original study, we observed total heterogeneity of therapeutic interventions guided by CAP and echocardiography. These results could be caused by lack of knowledge about basic pathophysiologic concepts and maybe we had to improve its teaching at the medical school benches.

Background and Objectives: Shock occurs when the circulatory system cannot maintain adequate cellular perfusion. If this condition is not reverted irreversible cellular injury establishes. Shock treatment has as its initial priority the fast and vigorous correction of mean arterial pressure and cardiac output to maintain life and avoid or lessen organic dysfunctions. Fluid challenge and vasoactive drugs are necessary to warrant an adequate tissue perfusion and maintenance of function of different organs and systems, always guided by cardiovascular monitorization. The recommendations built in this consensus are aimed to guide hemodynamic support needed to maintain adequate tisular perfusion., Methods: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty five physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004., Results: Recommendations were made answering 17 questions about hemodynamic support with focus on fluid challenge, red blood cell transfusions, vasoactive drugs and perioperative hemodynamic optimization., Conclusions: Hemodynamic monitoring by itself does not reduce the mortality of critically ill patients, however, we believe that the correct interpretation of the data obtained by the hemodynamic monitoring and the use of hemodynamic support protocols based on well defined tissue perfusion goals can improve the outcome of these patients.

A parametrization methodology for evaluating the solvation free energy, using the polarizable continuum model implemented in Gamess software, is presented in a formulation which makes use of a group contribution conception to construct the cavities. The systems studied include alkanes, alcohols, aldehydes and ketones embeded in a continuous medium simulating the water as the solvent. For each family, the CH2, OH, and C=O moieties of atoms are put together in single spheres forming a group. The cavities are constructed in two different ways, one for the electrostatic component and the other for nonelectrostatic contributions, i.e., the cavitation, dispersion, and repulsion components of free energy of solvation. A multivariate analysis is performed to obtain an assembly of variables, for each homologous series, able to give the results which are close to experiment. The analysis is addressed in order to (i) compare the theoretical free energy of solvation with the experimental trends of the solutes in aqueous media, when the chain is increased, (ii) compare the behavior of each component of free energy with the increasing CH2 number, (iii) investigate the influence of the oxygen atom on the components, and (iv) quantify the relative contribution of each component to the final free energy of solvation for some homologous series.

Background and Objectives: Cardiac output and preload as absolute data do not offer helpful information about the hemodynamic of critically ill patients. However, monitoring the response of these variables to volume challenge or inotropic drugs is a very useful tool in the critical care setting, particularly for patients with signs of tissue hypoperfusion. Although PAC remains the " gold standard" to measure cardiac output and preload, new and alternative technologies were developed to evaluate these hemodynamic variables., Methods: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty three physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004., Results: Recommendations regarding the use of arterial pulse pressure variation during mechanical ventilation, continuous arterial pulse contour and lithium dilution cardiac output measurements, esophageal Doppler waveform, thoracic electrical bioimpedance, echocardiography and partial CO2 rebreathing for monitoring cardiac output and preload were created., Conclusions: The new and less invasive techniques for the measurement of cardiac output, preload or fluid responsiveness are accurate and may be an alternative to PAC in critically ill patients.

Background and Objectives: Monitoring of vital functions is one of the most important tools in the management of critically ill patients. Nowadays is possible to detect and analyze a great deal of physiologic data using a lot of invasive and non-invasive methods. The intensivist must be able to select and carry out the most appropriate monitoring technique according to the patient requirements and taking into account the benefit/risk ratio. Despite the fast development of non invasive monitoring techniques, invasive hemodynamic monitoring using Pulmonary Artery Catheter still is one of the basic procedures in Critical Care. The aim was to define recommendations about clinical utility of basic hemodynamic monitoring methods and the Use of Pulmonary Artery Catheter., Methods: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty-five physicians and nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004., Results: Recommendations were made based on 55 questions about the use of central venous pressure, invasive arterial pressure, pulmonary artery catheter and its indications in different settings., Conclusions: Evaluation of central venous pressure and invasive arterial pressure, besides variables obtained by the PAC allow the understanding of cardiovascular physiology that is of great value to the care of critically ill patients. However, the correct use of these tools is fundamental to achieve the benefits due to its use.

The advent of genomics, proteomics, and microarray technology has brought much excitement to science, both in teaching and in learning. The public is eager to know about the processes of life. In the present context of the explosive growth of scientific information, a major challenge of modern cell biology is to popularize basic concepts of structures and functions of living cells, to introduce people to the scientific method, to stimulate inquiry, and to analyze and synthesize concepts and paradigms. In this essay we present our experience in mixing science and education in Brazil. For two decades we have developed activities for the science education of teachers and undergraduate students, using microscopy images generated by our work as cell biologists. We describe open-air outreach education activities, games, cell modeling, and other practical and innovative activities presented in public squares and favelas. Especially in developing countries, science education is important, since it may lead to an improvement in quality of life while advancing understanding of traditional scientific ideas. We show that teaching and research can be mutually beneficial rather than competing pursuits in advancing these goals.