Medicina do trabalho- laboral

#Hypertension artérielle

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 Qu’est-ce que c’est ?

Imagem relacionada

 

L’hypertension artérielle est définie par une augmentation des chiffres de la pression artérielle, habituellement en rapport avec des anomalies de fonctionnement du système vasculaire.

L’hypertension artérielle est définie par deux chiffres :

  • La pression artérielle systolique (PAS), chiffre le plus élevé, qui mesure la pression artérielle au moment où le cœur se contracte pour éjecter le sang hors de ses cavités. On parle de systole cardiaque.
  • La pression artérielle diastolique (PAD), chiffre le plus bas, qui mesure la pression artérielle au moment où le cœur est en période de remplissage de ses cavités et donc de repos. On parle de diastole cardiaque.
Cette infographie présente les deux types de mesure de la pression artérielle.

 

Les enjeux de l’hypertension artérielle sont tels qu’il s’agit d’un véritable problème de santé publique. De nombreuses études épidémiologiques ont cherché à en apprécier la fréquence et les risques.

L’hypertension artérielle est responsable de 7 millions de morts par an dans le monde, et le nombre d’hypertendus devrait atteindre d’ici à 2025 1,5 milliards de personnes! En France, 31% des 18-74 ans sont hypertendus, indique l’enquête ENNS parue en 2009. Celle-ci précique que: « sur 15 millions d’hypertendus connus, 12 sont traités par des médicaments, mais la pression artérielle n’est contrôlée que chez la moitié. Et un hypertendu sur deux ne connaît pas son état ».

 

blob:http://sante.lefigaro.fr/a4b04c50-c3c8-4c99-84d4-225e8d18dcba

Anúncios

#Know your chest pain (evaluation by history, examination & relevant investigation)

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Resultado de imagem para chest pain

Chest pain is a common presenting symptoms of disorders that can range from trivial to life threatening.

Causes:

Cardiovascular: (Angina, Myocardial infarction,Acute aortic dissection,Pericarditis)
Gastrointestinal:(Reflux esophagitis, Peptic ulcer disease, esophageal spasm)
Pulmonary: (Pneumonia, Pneumothorax, Pulmonary embolism)
Musculoskeletal: (Chest wall injuries, Herpes zoster, Costochondritis, Secondary tumors of the rib)
Emotional: (Depression)
Evaluation by history:

Character:

The character of angina is tight and crushing, while the pain from aortic dissection has a tearing quality. Esophageal reflux may be described as a burning pain, and peptic acid-related pain tends to be deep and gnawing.
Location: the pain from angina and esophageal  reflux may be located retrosternally, and they both can radiate to the jaw or down into the left arm.
The pain from pericarditis may be centrally located and radiate to the shoulders (trapezius ridge pain).
Pain from aortic dissection often radiate =s into the back and occasionally into the abdomen (depending on the extent of the dissection) . pulmonary pain can be located anywhere in the thorax.
Precipitating factors:

Angina may be precipitated by effort, a defining characteristics. Other known precipitants of angina are emotion, food and cold weather. If angina occurs at rest for more than 20 minutes it should be treated as a myocardial infarction until proven otherwise.
Esophageal reflux is often related to meals and precipitated by changes in posture, such as bending or lying.
Pain originating from pericarditis and pulmonary origin is often pleuritic, i.e worse on inspiration, however musculoskeletal pain can also be worse on breathing due to movement of the thorax.
Relieving factors:

Both esophageal spasm and angina may be relieved by GTN (glyceral trinitrite?) which relaxes smooth muscle.
Antacids will relieve the pain of esophageal reflux but not angina.
The pain associated with pericarditis may be relieved by sitting forwards.
History of trauma:

A blunt or stretching injury immediately suggests the underlying etiology of chest wall tenderness and it is important to diagnose rib fractures that can result from more severe trauma.

Emotion: Occasionally chest pain is a somatic manifestation of patients with depression or anxiety but it is essential to exclude all organic causes before accepting depression or anxiety as the underlying cause. Moreover a serious etiology may co-exist.

Examination:

Temperature: Pyrexia can occur with pneumonia, myocardial infarction, pericarditis and herpes zoster infection.
Pulse: Heart rate on its own is not discriminating as pain invariably leads to tachycardia. However palpating both upper and lower limb pulses may be useful. Occasionally peripheral pulses are absent in patients with aortic dissection.
JVP: The JVP  is elevated with congestive cardiac failure and acute right ventricular failure, an occasional complication of inferior myocardial infarction and pulmonary embolism (when more than 60% of the pulmonary vascular supply is occluded).
Palpation of the chest:

Chest wall tenderness would imply a musculoskeletal cause. The presence of unilateral tenderness confined to a single or adjacent group of dermatomes would suggest either central ( vertebral or spinal origin) or peripheral nerve pathology (herpes zoster infection).

The trachea deviates away from the side of tension pneumothorax and chest expansion is decreased on the same side of pneumonia and pneumothorax. Dullness to percussion will be noted in an area of consolidation with pneumonia and hyperresonance with pneumothorax.

Auscultation of the chest:

The unilateral absence of breath sounds is consistent with a pneumothorax, more localized loss occurs over an effusion. Localized areas of crepitation suggest lobar pneumonia while widespread crepitation suggest multilobar involvement. A friction rub may be auscultated with both pericardial and pleuritic disease.

Lower limbs: hemiparesis can occur with aortic dissection, and a hot swollen, tender calf or thigh may give a clue to an underlying deep vein thrombosis.

Invetigation: General

ECG: Angina or a myocardial infarction will result in ecg changes. So it is important investigation for evaluation of chest pain.
FBC: A elevated white count will be expected with pneumonia and to a lesser extent in a myocardial infarction.(2) Serum Cardiac markers. Following a myocardial infarction, cardiac troponin rises within 6 hours and remains elevated for up to 2 weeks.
Chest X ray. It helps to rule out any pathology in the lungs and also any fracture in the ribs.
Specific investigations:

V/Q scan: It will show a mismatch in the majority of pulmonary embolism.
Pulmonary angiography: It is possible to visualise the site and extent of the embolism and it may also be possible to extract the emboli using the catheter.
CT aortography: Confirm and asses the extent and site of the dissection of the aorta.
Upper GI tract endoscopy: Esophagitis
Esophageal manometry: Abnormal esophageal pressure
The heart score for a patient of chest pain in emergency department.

Image result for heart score

It is important to perform a prompt history, examination and initial investigations in patients who present with chest pain as a number of conditions require urgent management.If tension pneumothorax is suspected as a cause of chest pain, do not wait for a chest film. Decompress the pneumothorax immediately with a large-bore cannula inserted into 2nd  intercostal space in the midclavicular line.

 

Doctors-online

#Cinco indicadores para predecir el #riesgo cardiovascular en personas sanas (J Am College Cardiol)

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La presión arterial, la actividad física, el índice de masa corporal (IMC), el consumo de fruta y verdura y el hábito tabáquico son los indicadores de salud necesarios para predecir el riesgo cardiovascular en individuos sanos, según un estudio realizado en el Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC).

Una investigación publicada en el Journal of American College of Cardiology (JACC) ha demostrado la fiabilidad y utilidad del índice Fuster-BEWAT -una herramienta basada en estos cinco indicadores de salud cardiovascular-, ya que tiene la misma eficacia a la hora de predecir la presencia y extensión de aterosclerosis subclínica (sin síntomas) en individuos de mediana edad sin enfermedad cardiovascular conocida que el índice de salud cardiovascular ideal (ICHS).

Actualmente, el índice ICHS es la herramienta de uso más común en el ámbito de la prevención primaria y promoción de la salud, recomendada por la American Heart Association, que incluye además valores de colesterol y glucosa.

Ahora, el estudio Progression and Early Detection of Atherosclerosis (PESA), una investigación llevada a cabo en el CNIC en colaboración con el Banco Santander, valida el uso del índice Fuster-BEWAT, una herramienta desarrollada por un equipo liderado por Valentín Fuster, director General del CNIC, para la evaluación del riesgo de aterosclerosis subclínica en entornos donde no se disponga de recursos materiales para la determinación de los niveles de colesterol y glucosa ya que, al contrario del método estándar ICHS, no precisa análisis de sangre para su cálculo.

De hecho, los autores han encontrado que tanto el ICHS como el índice Fuster-BEWAT son capaces de predecir de manera similar la presencia de placas de ateroma, la cantidad de calcio en las arterias coronarias (un signo precoz de enfermedad coronaria) y el número de territorios afectados.

Estudios previos, como el estudio PURE, coordinado por Salim Yusuf y publicado recientemente en The Lancet, ya habían indicado que el análisis de sangre a veces puede no ser necesario a la hora de evaluar el riesgo cardiovascular, lo que supone una ventaja en las regiones con recursos sanitarios limitados.

Según Héctor Bueno, del Instituto de investigación i+12 del Hospital Universitario 12 de Octubre (Madrid) y otro de los autores de la investigación, dado que ambas herramientas muestran una capacidad predictiva equivalente, “el índice Fuster-BEWAT puede considerarse una opción más práctica y económica para la promoción de la salud cardiovascular, especialmente en aquellas regiones con escasos recursos económicos, donde la carga de enfermedad cardiovascular está creciendo de manera más alarmante”.

Esta sencillez, añade Antonio Fernández Ortiz, investigador del CNIC, “también permitiría utilizar el índice Fuster-BEWAT para la educación en entornos no sanitarios, como escuelas o universidades, y como una herramienta para calcular los beneficios que el cambio de estilo de vida con el autocuidado puede suponer para individuos en riesgo o pacientes”.

El PESA-CNIC-Santander es un estudio prospectivo dirigido por Fuster que incluye a más de 4.000 participantes de edad intermedia que evalúa la presencia y desarrollo de aterosclerosis subclínica gracias al empleo de técnicas de imagen innovadoras y su asociación con diversos factores moleculares y ambientales, incluyendo aquellos relacionados con el estilo de vida (hábitos dietéticos, actividad física, factores psicosociales y hábitos de sueño).

Los resultados del estudio muestran que los perfiles cardiovasculares más saludables se asocian con menor prevalencia y menor extensión de enfermedad subclínica en individuos sanos, evidenciando el impacto de los estilos de vida y de los factores de riesgo en las fases tempranas de la enfermedad. Dichos resultados han sido obtenidos evaluando la presencia de enfermedad subclínica en distintos territorios (placas de ateroma en arterias carótidas, iliofemorales, aorta abdominal y la cuantificación del nivel de calcio en arterias coronarias) mediante técnicas de ultrasonido (ecografía) vascular y tomografía axial computarizada.

#FDA Expands Indication for Exoskeleton in Paraplegia

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FDA Expands Indication for Exoskeleton in Paraplegia
Megan Brooks September 27, 2017

The US Food and Drug Administration (FDA) has cleared an expanded indication for the Indego exoskeleton (Parker Hannifin), a device that allows individuals with paraplegia to stand and walk, the company has announced.The Indego exoskeleton was previously cleared by the FDA in February 2016 for use by individuals with spinal cord injury levels of T4 and lower in rehabilitation facilities, and with T7 and lower injury levels for use in home and community settings

.http://img.medscapestatic.com/thumbnail_library/

Indego exoskeleton

 
The new indication expands the population that can use the device to include patients with spinal cord injury at C7 and lower injury levels in rehabilitation facilities and T3 and lower injury levels for use in home and community settings.”The new clearance by the FDA provides the Indego exoskeleton with the broadest IFU [indication for use] of any commercial exoskeleton available in the United States,” Achilleas Dorotheou, head of the human motion and control business unit for Parker Hannifin, said in a news release.”Indego is now available to a significantly larger segment of the spinal cord injury population and is an option for personal use among more than 40% of spinal cord injured Americans. We credit several VA [Veterans Affairs] medical directors with urging us to pursue this expanded clearance and it is likely that some of the 40,000 spinal cord injured veterans served by the VA system will be among the immediate beneficiaries,” Dorotheou added.The company also said it’s working on new powered and programmable variants of Indego to be submitted for regulatory approval over the next several years that will address other partial or moderate impairments, such as multiple sclerosis, stroke, and musculoskeletal weakness.

Medscape Neurology news.

Médicos brasileiros usam pele de peixe para tratar vítimas de queimaduras

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Paulo Whitaker e Pablo Garcia

FORTALEZA, Brasil (Reuters) – Pesquisadores brasileiros estão trabalhando em um novo tratamento experimental para queimaduras graves usando a pele de um peixe, a tilápia, em um procedimento pouco ortodoxo quem, segundo eles, pode aliviar a dor dos pacientes e reduzir os custos do tratamento.

Há muito tempo coloca-se pele de porco congelada ou tecido humano sobre as queimaduras para mantê-las úmidas e possibilitar a transferência do colágeno, proteína que promove a cicatrização.

Os hospitais públicos do Brasil, no entanto, não dispõem de bancos de pele humana e suína, nem das alternativas artificiais facilmente acessíveis nos países do primeiro mundo. Em vez disso, a norma é o curativo com gaze, que precisa ser trocado regularmente – algo que costuma ser doloroso.

A tilápia é um peixe abundante nos rios e nas fazendas de piscicultura no Brasil, locais estes que se multiplicam rapidamente à medida que aumenta a demanda por este peixe de água doce de sabor suave.

Cientistas da Universidade Federal do Ceará, no nordeste do Brasil, descobriram que a pele da tilápia tem níveis de umidade, colágeno e resistência às doenças comparáveis ​​aos da pele humana, e pode auxiliar na cicatrização.

Na China, pesquisadores testaram a pele de tilápia em roedores para estudar as propriedades cicatrizantes dela, mas os cientistas brasileiros afirmam que os testes em andamento em Fortaleza são os primeiros feitos com humanos.

“O uso da pele de tilápia em queimaduras não tem precedentes”, disse o Dr. Odorico de Moraes, professor da Universidade do Ceará. “A pele dos peixes geralmente é jogada fora, então estamos usando esse produto e convertendo-o em benefício social”.

O tratamento com a pele de tilápia pode acelerar a cicatrização em vários dias e reduzir a necessidade de analgesia, dizem os pesquisadores brasileiros.

Os técnicos do laboratório da universidade trataram a pele do peixe com vários agentes esterilizantes e a enviaram para São Paulo a fim de submetê-la à irradiação, matando assim qualquer vírus antes de proceder o acondicionamento e a refrigeração do material. Uma vez limpa e tratada, esta pele acondicionada e refrigerada pode durar até dois anos, dizem os pesquisadores. O tratamento remove inteiramente o odor típico de peixe.

Nos ensaios clínicos, este tratamento alternativo foi utilizado em pelo menos 56 pacientes para o tratamento de queimaduras de segundo e terceiro graus. Os pacientes, cujos membros foram recobertos de pele de peixe, pareciam criaturas saídas de um filme de ficção científica.

O mecânico de carros Antonio Janio teve uma queimadura grave no braço por vazamento de um cilindro de gás de solda. Ele diz que o tratamento com a pele de tilápia é mais eficaz do que as compressas com gaze, que precisam ser trocadas a cada dois dias.

A pele de peixe tem níveis elevados de colágeno tipo 1, permanece úmida por mais tempo do que a gaze e não precisa ser trocada com frequência.

A pele de tilápia é aplicada diretamente na área queimada e recoberta com atadura, sem a necessidade usar nenhum tipo de creme. Após cerca de 10 dias, os médicos removem a atadura. A pele da tilápia, que secou e soltou-se da queimadura pode ser removida.

“Use a pele da tilápia. É excelente”, disse Janio. “Acaba com a dor. Você nem precisa tomar remédio. No meu caso, não precisei, graças a Deus”.

Dr. Moraes disse que o tratamento com a pele de tilápia custa 75% menos do que o creme de sulfadiazina tipicamente usado nos pacientes queimados no Brasil, pois é um produto barato, feito com uma parte que sobra do peixe.

Os pesquisadores esperam que o tratamento seja viável comercialmente e incentivam as empresas a processar a pele de tilápia para uso médico.

Para ver as fotografias, clique em: http://reut.rs/2qkgXGF

Stop bringing work home!

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Working from home contributes to burnout among family doctors.

A number of recent studies have highlighted rising levels of burnout among hospital doctors, with one recent Irish study showing one in three doctors have suffered burnout and four out of five experience significant work stress.

Figures suggest the prevalence of burnout may be even higher among primary care doctors, with a survey by the American Medical Association and the Mayo Clinic finding 54.4 per cent of doctors reported at least one sign of burnout, with those working in family medicine among the worst affected (63 per cent reporting burnout).

New research has now shed light on the factors that are most associated with burnout among medical professionals. Almost 2,000 family doctors in the US were surveyed as part of the research, with 25 per cent reporting symptoms of burnout.
Less control over workload, lack of sufficient time for documentation, stress owing to their job and more time spent on electronic medical records (EMRs) at home, were all associated with the presence of burnout. Writing in JAMA , the authors said future interventions to reduce burnout and improve patient care and doctor satisfaction can be targeted toward addressing such workplace factors.

BMJ RapidRecs guideline warns against arthroscopy for most patients with degenerative knee damage

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The new clinical practice guideline was developed under the BMJ Rapid Recommendation project.

An international panel of experts has strongly recommended against the use of arthroscopy in nearly all patients with degenerative knee disease.

Most guidelines continue to support the use of arthroscopy in key subgroups. However, a randomised controlled trial published in the BMJ  in June 2016 found that, among patients with degenerative medial meniscus tear, outcomes with knee arthroscopy were no better than those seen with exercise therapy.

The findings prompting a panel to be convened to review all current relevant research on the issue. The resulting Rapid Recommendation  has concluded that arthroscopy does not, on average, result in lasting improvement in pain or function.

Given that there is evidence of harm and no evidence of important lasting benefit in any subgroup, “the panel believes that the burden of proof rests with those who suggest benefit for any other particular subgroup before arthroscopic surgery is routinely performed in any sub-group of patients”.

The new clinical practice guideline was developed under the BMJ Rapid Recommendation project, which aims to have synopses and decision-support tools available to clinicians within 90 days of identification of potentially practice-changing evidence.