Objective: To evaluate the frequency of the real association between paracoccidioidomycosis (PCM) and tuberculosis (TB) as well as the rate of previous TB misdiagnosis in individuals with PCM among the patients treated in the Pulmonology Division of the State University of Campinas Hospital das Clínicas, Campinas, Brazil. Methods: A retrospective study of 227 adult patients with PCM (chronic form) treated between 1980 and 2005. Results: Of the 227 patients studied, 36 (15.8%) had been previously treated for TB. However, only 18 (7.9%) presented positive sputum smear microscopy results. The remaining 18 (7.9%) neither presented positive sputum smear microscopy nor showed improvement after receiving specific anti-TB treatment. Conclusion: Although the existence of an association between PCM and TB has been documented in the literature, misdiagnosis is common due to the superimposition of and the similarity between their clinical and radiographic presentations, thereby warranting the need for bacteriological diagnosis before initiating specific treatment.

BackgroundEmergency clerkships expose students to a stressful environment that require multiple tasks, which may have a direct impact on cognitive load and motivation for learning. To address this challenge, Cognitive Load Theory and Self Determination Theory provided the conceptual frameworks to the development of a Moodle-based online Emergency Medicine course, inspired by real clinical cases.MethodsThree consecutive classes (2013–2015) of sixth-year medical students (n = 304) participated in the course, during a curricular and essentially practical emergency rotation. “Virtual Rounds” provided weekly virtual patients in narrative format and meaningful schemata to chief complaints, in order to simulate real rounds at Emergency Unit. Additional activities such as Extreme Decisions, Emergency Quiz and Electrocardiographic challenge offered different views of emergency care. Authors assessed student´s participation and its correlation with their academic performance. A survey evaluated students´ opinions. Students graduating in 2015 answered an online questionnaire to investigate cognitive load and motivation.ResultsEach student produced 1965 pageviews and spent 72 hours logged on. Although Clinical Emergency rotation has two months long, students accessed the online course during an average of 5.3 months. Virtual Rounds was the most accessed activity, and there was positive correlations between the number of hours logged on the platform and final grades on Emergency Medicine. Over 90% of students felt an improvement in their clinical reasoning and considered themselves better prepared for rendering Emergency care. Considering a Likert scale from 1 (minimum load) to 7 (maximum load), the scores for total cognitive load were 4.79±2.2 for Virtual Rounds and 5.56±1.96 for real medical rounds(p<0,01).ConclusionsA real-world inspired online course, based on cognitive and motivational conceptual frameworks, seems to be a strong tool to engage students in learning. It may support them to manage the cognitive challenges involved in clinical care and increase their motivation for learning.

RESUMO -OBJETIVOS. Determinar, através de um estudo randomizado e duplo-cego, o efeito de injeções intralesionais de triancinolona associadas à dilatação esofágica nos casos de estenose corrosiva.MÉTODOS. Quatorze pacientes adultos (seis homens e oito mulheres) portadores de graves estenoses corrosivas do esôfago foram randomizados em dois grupos: Grupo A: tratados com dilatação esofágica e posterior injeção intralesional de triancinolona 10 mg/ ml; Grupo B: tratados com dilatação esofágica e posterior injeção de solução fisiológica 0,9% (placebo , seguida pela ingestão de ácidos, com risco de cerca de 25% 3 . A ingestão de álcalis resulta em corrosão da orofaringe e esôfago. A lesão é profunda, devido à necrose do tipo liqüefativa ou de saponificação das camadas superficiais da parede esofágica [2][3][4][5][6][7][8][9] . Em contraste, a necrose produzida pela ingestão de ácidos é do tipo coagulativa e mais superficial 3 e tende a poupar o esôfago.O fator mais importante para o prognósti-co da resposta terapêutica é a profundidade da lesão. Existem três graus de lesão:Grau I -Penetração superficial -lesão superficial da mucosa. Não haverá estenoses 7,8 . Grau II -Penetração média -lesão ultrapassa a mucosa expondo submucosa e camada muscular 7,8 . Grau III -Penetração profunda -resulta em lesão transmural do esôfago ou parede gástrica. Pode ocorrer perfuração 7,8 . Entre 20% e 40% dos pacientes com lesões grau II e III irão desenvolver estenose 7 . Trata-se de uma situação sem cura definitiva e o tempo de tratamento é indeterminado.Em até uma semana após a lesão, há a formação de tecido de granulação com a proliferação de novos vasos e fibroblastos. Estes últimos formam novas fibras de colágeno, duro e inflexível, durante a segunda e terceira semanas seguintes à ingestão. Em lesões grau II e III ocorre dano à camada muscular e as fibras musculares lesadas não regeneram sendo substituídas por tecido fibroso. A contração *Correspondência: Rua Cel. Quirino, 1299 Ap. 61 13025-002 -Campinas -SP destas fibras de colágeno ("cross-link") resulta em progressiva diminuição do comprimento e redução da luz do esôfago, após a terceira semana 2 . Depois de seis semanas, a epitelização está completa e a lesão é revestida por uma camada densa de fibrose que pode formar múltiplos canais ou até obstruir completamente a luz do esôfago 7 . Pode haver deslocamento, no sentido cranial, da transição esôfago-gástrica, determinando o aparecimento de hérnia esofágica e sintomas de refluxo gastroesofágico. O refluxo, por sua vez, determina maior agressão ao esôfago 10 . O tratamento visa o alívio dos sintomas e é feito através de dilatações esofágicas periódicas.Os corticoesteróides diminuem a resposta inflamatória, interferem na síntese de colá-geno, fibrose e cicatrização crônica, inibindo a formação de reestenoses após as dilatações 4,5 . Após os excelentes resultados observados no tratamento de cicatrizes dermatológicas (quelóides, queimaduras, etc.) com corticoesteróides [11][12][13] , acreditou-se que o seu emprego poderia ser muito...

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Eosinophilia-myalgia syndrome was described in 1989 in patients who presented progressive and incapacitating myalgia and eosinophilia in blood, fluids and secretions. Most patients report previous L-tryptophan intake. Respiratory manifestations are found in up to 80% of the cases, occasionally as the only manifestation. Treatment includes drug discontinuation and administration of corticosteroids. Here, we describe the case of a 61-year-old female admitted with acute respiratory failure after using L-tryptophan, hydroxytryptophan and other drugs. The patient presented eosinophilia, together with elevated eosinophil counts in the bronchoalveolar lavage and pleural effusion. After discontinuation of the drugs previously used, corticosteroids were administered, resulting in clinical and radiological improvement within just a few days.

Coronavirus disease-19 has imposed a new reality through the pandemic that it has caused, and this presents challenges to healthcare professionals and systems. The high rate of transmissibility of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), through droplets, aerosols and contaminated surfaces, has led to development of strict protocols for individual and collective protection for patient care, 1,2 which have been implemented throughout hospitals. Adaptations to protocols for procedures have been brought in, including use of alternative medications to minimize virus transmission in aerosol-producing procedures, donning and doffing of personal protective equipment (PPE) and other measures.The implementation of these new protocols has required training for all front-line healthcare workers, without endangering them or their patients. Use of simulations may be an appropriate way for providing training since this replicates real-environment situations in a safe environment, and thus protects both patients and professionals from unnecessary risks. Simulation training has been widely used for continuing professional development, in order to train healthcare professionals in relation to new systems, thereby enabling them to remain up-to-date regarding new demands and protocols within their clinical practice. [3][4][5][6][7] Simulation has played a key role in testing and implementing new workflow structures, new protocols and cognitive resources, 8 through offering participants the possibility to practice rare and critical events in a controlled environment. 9In the current pandemic, simulation has been shown to be useful for testing healthcare systems, processes and new protocols. [10][11][12][13][14][15] Moreover, studies have shown that simulation is an appropriate teaching tool that has the capacity to quickly prepare frontline teams for changes that are necessary, through generating gains in knowledge and skills. 10,13,16,17

Pulmonary thromboembolism is a common condition. Its diagnosis usually requires pulmonary scintigraphy, computed angiotomography, pulmonary arteriography and, in order to rule out other diagnoses, the measurement of D-dimer levels. Due to the fact that these diagnostic methods are not available in most Brazilian hospitals, the validation of other diagnostic techniques is of fundamental importance. We describe a case of a woman with chronic pulmonary hypertension who experienced a pulmonary thromboembolism event. Pulmonary scintigraphy, computed angiotomography and pulmonary arteriography were used in the diagnosis. The D-dimer test result was positive. Volumetric capnography was performed at admission and after treatment. The values obtained were compared with the imaging test results.