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IntroductionAchievement of optimal vancomycin exposure is crucial to improve the management of patients with life-threatening infections caused by susceptible Gram-positive bacteria and is of particular concern in patients with augmented renal clearance (ARC). The aim of this study was to develop a dosing nomogram for the administration of vancomycin by continuous infusion for the first 24 hours of therapy based on the measured urinary creatinine clearance (8 h CLCR).MethodsThis single-center study included all critically ill patients treated with vancomycin over a 13-month period (group 1), in which we retrospectively assessed the correlation between vancomycin clearance and 8 h CLCR. This data was used to develop a formula for optimised drug dosing. The efficiency of this formula was prospectively evaluated in a second cohort of 25 consecutive critically ill patients (group 2). Vancomycin serum concentrations between 20 to 30 mg/L were considered adequate. ARC was defined as 8 h CLCR more than 130 ml/min/1.73 m2.ResultsThe incidence of ARC was 36% (n = 29/79) and 40% (10/25) in group 1 (n = 79) and 2 (n = 25), respectively. The mean serum vancomycin concentration on day 1 was 21.5 (6.4) and 24.5 (5.2) mg/L, for both groups respectively. On the treatment day, vancomycin plasma clearance was 5.12 (1.9) L/h in group 1 and correlated significantly with the 8 h CLCR (r2 = 0.66; P <0.001). The achievement of adequate vancomycin serum concentrations in group 2 was 84% (n = 21/25) versus 51% (n = 40/79) – P <0.005.ConclusionsThis new vancomycin nomogram enabled the achievement of adequate serum concentrations in 84% of the patients on the first day of treatment.

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Total thyroidectomy, radioiodine (RAI) therapy, and TSH suppression are the mainstay treatment for differentiated thyroid carcinomas (DTCs). Treatments for metastatic disease include surgery, external-beam radiotherapy, RAI, and kinase inhibitors for progressive iodine-refractory disease. Unresectable locoregional disease remains a challenge, as standard therapy with RAI becomes unfeasible. We report a case of a young patient who presented with unresectable papillary thyroid carcinoma (PTC), and treatment with sorafenib allowed total thyroidectomy and RAI therapy. A 20-year-old male presented with severe respiratory distress due to an enlarging cervical mass. Imaging studies revealed an enlarged multinodular thyroid gland, extensive cervical adenopathy, severe tracheal stenosis, and pulmonary micronodules. He required an urgent surgical intervention and underwent tracheostomy and partial left neck dissection, as the disease was deemed unresectable; pathology revealed PTC. Treatment with sorafenib was initiated, resulting in significant tumor reduction allowing near total thyroidectomy and bilateral neck dissection. Postoperatively, the patient underwent radiotherapy for residual tracheal lesion, followed by RAI therapy for avid cervical and pulmonary disease. The patient's disease remains stable 4 years after diagnosis. Sorafenib has been approved for progressive RAI-refractory metastatic DTCs. In this case report, we describe a patient with locally advanced PTC in whom treatment with sorafenib provided sufficient tumor reduction to allow thyroidectomy and RAI therapy, suggesting a potential role of sorafenib as an induction therapy of unresectable DTC.

Neste ensaio apresentamos algumas reflexões sobre publicidade e alimentação saudável no mundo contemporâneo onde o consumo exerce papel de grande relevância. Buscamos enfatizar dois aspectos, entre tantos outros ainda por serem explorados na literatura científica do campo alimentar-nutricional: a hegemonia do paradigma biomédico e a fragmentação da vida humana quando campanhas publicitárias anunciam alimentos associando-os à ideia de alimentação saudável. Consideramos que não podemos viver somente como naquela publicidade onde nossos desejos são acionados, sem limites, onde mundo é só de sonhos e o objetivo principal é vender mais e lucrar mais, ainda que para isso se tenha feito uso de estratégias de disseminação de algumas informações de cunho biomédico-nutricional. O encontro entre alimentação e saúde, ou seja, alimentação saudável, deve pressupor, no nosso entendimento, a valorização da ação do sujeito, inclusive por meio de informações qualificadas e contextualizadas na vida social de modo a que se possa desenhar projetos de felicidade. Um sujeito fortalecido em sua identidade, íntegro e total que, entre sonhos e concretudes, pode ousar a buscar o conhecer e o pensar sobre si mesmo no mundo, sobre sua alimentação e sua saúde.