Internal hernia after laparoscopic left colectomy: case series and review of the literature

Objective: Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods: We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results: The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management. (AU)

Variante anatómica de la vía biliar durante la colecistectomía laparoscópica / Anatomical variant of the bile duct during laparoscopic cholecystectomy / Variante anatômica do ducto biliar durante colecistectomia laparoscópica

Se presenta la colangiografía intraoperatoria obtenida durante la colecistectomía laparoscópica de una paciente de 58 años con el diagnóstico de colecistitis aguda.

COVID19: uncovering interindividual variability for tailoring appropriate therapeutic interventions / COVID19: a variabilidade individual da resposta imunoinflamatória

The severity of SARS-CoV2 infection, Covid19 disease, should account for the diversity of human individual immu-noinflammatory responses. Serum immunological markers during Covid19 illness may lead to individualized thera-peutics with better outcomes. Efficient treatment for Covid19 may require: 1) early disease detection, 2) combined drug therapy for 3) targeting the virus replication cycle, and 4) individualized drug treatment for specific immu-noinflammatory human profile responses administered in a 5) timely manner. Covid19 is unlikely to be the last emergent human disease with fast pandemic potential. Gathering knowledge on the individual human host profiles of immunoinflammatory responses is an opportunity that could lead us to understand individual differences in re-sponse to infection at the individual and population level, paving the way to faster, more efficient strategies to tack-le upcoming infectious diseases. This is a position paper based on an integrative non-exhaustive literature revision (AU)

A diversidade das respostas imunoinflamatórias individuais humanas muito provavelmente tem papel na gravidade da doença Covid19 causada pela infecção pelo vírus SARS-CoV2. Marcadores imunológicos séricos durante a Covid19 po-dem guiar a escolha de terapias individualizadas com melhores resultados. O tratamento eficiente para Covid19 pode exigir: 1) detecção precoce da doença, 2) terapia medicamentosa combinada com alvo ao 3) ciclo de replicação do ví-rus e 4) terapia anti-inflamatória individualizada para perfis de respostas imunoinflamatórias humanas, administradas em tempo hábil. É improvável que a Covid19 seja a última doença humana emergente com potencial de alastramento veloz pandêmico. Reunir conhecimento sobre perfis de respostas imunoinflamatórias individuais dos hospedeiros humanos é uma oportunidade ímpar que pode nos levar a entender as diferenças dessas respostas entre indivíduos, abrindo caminho para estratégias terapêuticas mais rápidas e eficientes no combate à futuras epidemias (AU)

Association between headache and tinnitus among medical students / Associação entre cefaleia e zumbido em acadêmicos de medicina

ABSTRACT Background: Headache is a very common complaint and it is increasingly prevalent among university students. Tinnitus consists of subjectively perceived sounds that occur in the absence of an external auditory signal. Presence of headache and tinnitus in association has implications for therapy and prognosis, because this describes the temporality of the symptoms. Recognition of the epidemiological profile of symptomatic students might contribute to interventions. Objective: To investigate the prevalence of the association between headache and tinnitus, and to describe the epidemiological profile of the study population and the chronological order of appearance of these symptoms. Methods: Cross-sectional, observational and analytical study on a sample representative of an academic center. Data referring to the epidemiological and clinical profile of headache and tinnitus among medical students were collected through an online questionnaire built using the Google Forms tool. Results: Out of the 234 participants, 26.1% reported having tinnitus and headache (p < 0.001). The participants with headache were more likely to be women (p = 0.045), white (p = 0.009) and 21-25 years old (p = 0.356). Among right-sided, left-sided and non-unilateral headaches, tinnitus was present predominantly in the non-unilateral type, but without statistical significance. Regarding timing, 18.0% of the students said that tinnitus started before headache, 57.4% said that headache started before tinnitus and 24.6% said that they started simultaneously. Conclusions: An important association between headache and tinnitus regarding lateralization and temporality was demonstrated. Thus, these data match the presumption that headache and tinnitus have a physiopathological connection.

RESUMO Antecedentes: A cefaleia é uma queixa muito frequente e a prevalência em estudantes universitários vem sendo cada vez mais comum. Os zumbidos constituem percepções subjetivas de sons que acontecem na ausência de um sinal auditivo externo ou não. A correlação desses sintomas é importante para fins terapêuticos e prognóstico, pois descrever a temporalidade dos sintomas e conhecer o perfil epidemiológico dos estudantes sintomáticos pode contribuir com intervenções. Objetivo: Investigar a prevalência da relação da cefaleia e zumbido, descrever o perfil epidemiológico da população estudada e a ordem temporal do aparecimento desses dois sintomas. Métodos: Estudo de corte transversal, observacional e analítico representativo de um centro acadêmico. Foram coletados dados referentes ao perfil epidemiológico e clínico da cefaleia e zumbido entre acadêmicos de Medicina, por meio de um questionário online construído na ferramenta Google Forms. Resultados: Dos 234 participantes, 26,1% relataram a presença de zumbido e cefaleia. Os participantes com cefaleia apresentaram maior probabilidade de serem mulheres, da raça branca e ter entre 21-25 anos. Dentre as cefaleias sem unilateralidade, as localizadas à direita e as localizadas à esquerda, o zumbido predominou no tipo sem unilateralidade, entretanto sem significância estatística. Observou-se que 18,0% dos acadêmicos relataram o início do zumbido antes da cefaleia, 57,4% relataram o início da cefaleia antes do zumbido, e 24,6% início simultâneo. Conclusões: Foi demonstrada uma importante relação entre cefaleia e zumbido acerca da lateralidade e temporalidade. Assim, esses dados se encaixam na presunção de que a cefaleia e o zumbido possuem uma ligação fisiopatológica.

Síndrome da encefalopatia posterior reversível em paciente com COVID-19 submetida à oxigenação por membrana extracorpórea / Posterior reversible encephalopathy syndrome in a patient submitted to extracorporeal membrane oxygenation for COVID-19

RESUMO Uma mulher com 63 anos de idade compareceu ao pronto-socorro com história aguda de febre, prostração e dispneia. Recebeu diagnóstico de quadro grave da COVID-19 e síndrome do desconforto respiratório agudo. Apesar de suporte clínico intensivo, cumpriu os critérios para ser submetida à oxigenação venovenosa por membrana extracorpórea. No dia 34, após 7 dias de desmame da sedação com evolução positiva de seu quadro neurológico, apresentou uma crise tônico-clônica generalizada limitada, não relacionada com desequilíbrio hidroeletrolítico ou metabólico, que levou à necessidade de investigação diagnóstica. Seus exames de imagem cerebral revelaram síndrome da encefalopatia posterior reversível. Este caso enfatiza a questão das complicações neurológicas em pacientes com COVID-19 grave e a importância do diagnóstico e suporte precoces.

ABSTRACT A 63-year-old woman presented to the emergency department with an acute history of fever, prostration and dyspnea. She was diagnosed with severe COVID-19 acute respiratory distress syndrome and, despite optimized critical care support, met the indications for veno-venous extracorporeal membrane oxygenation. On day 34, after 7 days of wean sedation with a positive evolution of neurologic status, she presented a limited generalized tonic-clonic seizure not related to hydroelectrolytic or metabolic imbalance, which led to a diagnostic investigation; her brain imaging tests showed a posterior reversible encephalopathy syndrome. This case emphasizes the issue of neurological complications in patients with severe COVID-19 infection and the importance of early diagnosis and support.

Non-surgical periodontal treatment for drug-influenced gingival enlargement: a four-year follow-up case report

ABSTRACT: Drug-influenced gingival enlargement is considered to be an important side effect related to the use of some medications and often produces important esthetic changes for patients, as well as clinical symptoms such as pain, bleeding, abnormal tooth movement and occlusion problems. Anticonvulsants, immunosuppressants and antihypertensive drugs have been reported as the main inducers of these periodontal disorders. This case report describes the 4-year clinical follow-up of a young patient with a history of excessive gingival enlargement as a consequence of drug therapy for epilepsy (phenytoin and phenobarbital); the nonsurgical periodontal treatment of the excessive gingival enlargement was associated with the replacement of the patient's epilepsy medications with valproic acid. We conclude that intensive mechanical control of bacterial biofilms, instruction on oral hygiene guidelines and behaviors and the substitution of alternative anticonvulsant medications are the best way to control the drug-influenced gingival enlargement.

Nivel de conocimientos de dengue, signos de alarma y prevención en distrito de reciente brote / Level of knowledge of dengue, warning signs and prevention in a district with evidence of a recent outbreak

Introducción: El dengue es la enfermedad metaxénica con mayor velocidad de propagación en el mundo, siendo un problema creciente de salud pública de países de áreas tropicales. En países endémicos se evidencian bajos niveles de conocimientos de dengue; por ello en Lambayeque, región endémica con brotes importantes en los últimos años, es necesario determinar el nivel de conocimientos sobre dengue. Objetivo: Valorar el nivel de conocimientos sobre el dengue, signos de alarma y prevención en pobladores. Material y Métodos: Estudio cuantitativo, descriptivo transversal. Diseño no experimental. El estudio se realizó en 618 pobladores de un distrito de Chiclayo en 2018, seleccionados mediante muestreo probabilístico aleatorio por conglomerados multietápico. Se utilizó un instrumento que evalúa los conocimientos globales comprendidos por conocimientos generales, signos de alarma, y prevención. Se utilizó la prueba Chi-cuadrado para asociar nivel de conocimientos con características sociodemográficas. Resultados: El nivel de conocimientos sobre el dengue fue bajo en 76,2 por ciento de pobladores. El nivel de conocimientos generales, resultó nivel intermedio en 57,4 por ciento; 45 por ciento desconoce la transmisión de la enfermedad, y 34 por ciento no reconoce al agente etiológico; de las manifestaciones clínicas, la más relacionada con el dengue fue la fiebre, seguido de cefalea y dolor osteomuscular. El 74,9 por ciento presentó un nivel bajo conocimientos sobre signos de alarma. El nivel de conocimientos de prevención fue intermedio y bajo en 93 por ciento. Conclusiones: El nivel de conocimientos de dengue en pobladores de un distrito de reciente brote es bajo(AU)

Introduction: Dengue is the fastest-spreading metaxenic disease in the world and a growing public health problem in tropical countries. Low levels of knowledge of dengue are evidenced in endemic countries; for this reason, it is necessary to determine the level of knowledge in relation to this disease in Lambayeque since it is an endemic region with important outbreaks in recent years. Objective: To assess the level of knowledge of dengue, warning signs and prevention in residents of a district with a recent outbreak. Material and Methods: A quantitative, descriptive cross-sectional study with non-experimental design was carried out in 618 residents of a district of Chiclayo in 2018. The participants were selected by random probability sampling through multistage conglomerate sampling. An instrument was used to assess global knowledge understood by general knowledge, warning signs, and prevention. The Chi-square test was used to associate the level of knowledge with sociodemographic characteristics. Results: The results show that 76.2 percent of residents had a low level of knowledge of dengue and 57.4 percent of them had an intermediate level of general knowledge; also 45 percent did not know about the transmission of the disease and 34 percent did not recognize the etiologic agent. Fever was the most common clinical manifestation related to dengue, followed by headaches and musculoskeletal pain. In addition, 74.9 percent of people presented a low level of knowledge of warning signs and 93 percent had intermediate and low levels of knowledge of prevention measures. Conclusions: There is a low level of knowledge of dengue in residents of a district with evidence of a recent outbreak(AU)

Double barreled wet colostomy. Case report and description of the surgical technique / Colostomia úmida em dupla-boca. Relato de caso e descrição da técnicacirúrgica

ABSTRACT Pelvic exenteration has showed to be beneficial therapeutically and palliatively in locally advanced colorectal cancer. Reconstruction of urinary transit posterior to a cystectomy has always been challenging with many associated complications. We present a 58-year-old male with locally advanced rectal cancer in which a pelvic exenteration and a double-barreled wet colostomy (DBWC) was created for urinary reconstitution. We present the surgical technique of DBWC. DBWC is a good alternative to other urinary reconstructions because fecal and urinary derivation occurs in only one stoma, the stoma output is easier to manage, and fewer complications are seen compared to other urinary reconstructions. Long-term surveillance is mandatory in patients with a DBWC because there is an increased risk of neoplasm in the reservoir.

RESUMO A exenteração pélvica mostrou-se benéfica, tanto terapêutica quanto paliativamente, em casos de câncer colorretal localmente avançado. A reconstrução do trânsito urinário após uma cistectomia sempre foi desafiadora, com muitas complicações associadas. Os autores apresentam o caso de um homem de 58 anos de idade com câncer retal localmente avançado, submetido a uma exenteração pélvica e uma colostomia úmida em dupla-boca (CUDB) para reconstituição urinária. Os autores apresentam a técnica cirúrgica da CUDB, uma boa alternativa para outras reconstruções urinárias, já que a derivação fecal e urinária ocorre em apenas um estoma, a saída do estoma é mais fácil de gerenciar e o método apresenta menos complicações em comparação com outras reconstruções urinárias. A vigilância a longo prazo é obrigatória em pacientes com CUDB, pois há um risco aumentado de neoplasia no reservatório.

A vesico-peritoneal fistula in a patient with history of diverticulitis-related colovesical fistula repair: a case report

A vesico-peritoneal fistula is an epithelialized communication between the peritoneal cavity and the urinary bladder. It is a rare entity scarcely reported in medical literature. High index of suspicion is needed for diagnosis and treatment. Here we expose the case of a vesico-peritoneal fistula presenting with chronic abdominal pain 4 years after sigmoidectomy. A 38-year-old male presented with lower quadrant abdominal pain. He had history of sigmoidectomy with colorectal anastomosis and bladder repair due to diverticular disease-related colovesical fistula 5 years prior to admission. Elevated serum creatinine levels and oliguria were documented. Intraperitoneal free fluid was found by computed tomography (CT) scan. Percutaneous drainage was performed, and laboratory test showed elevated peritoneal creatinine levels. CT-Cystography revealed a vesico-peritoneal fistula. Dissection of fistulous tract and primary closure of bladder defect was achieved. Vesico-peritoneal fistulas have been described as surgical procedure complications with a variable postoperative time of presentation. Low index of suspicion led to delayed diagnosis, finally suspected by intraperitoneal fluid analysis and confirmed by cystography. Intraperitoneal reabsorption of urine elevated serum creatinine levels mimicking renal failure. Management ranges from conservative to surgical procedures, in this case fistulous tract dissection and primary bladder closure was accomplished. Vesico-peritoneal fistulas are rarely reported. Common clinical findings include chronic abdominal pain and free intraperitoneal fluid. Misdiagnosis of acute renal failure is frequent due to elevated serum creatinine levels and oliguria.  Laparoscopic dissection of fistulous tract and primary closure of bladder defect is a safe option as treatment of this condition.

Consenso colombiano de fibrinólisis selectiva con catéter en enfermedad vascular tromboembólica / Colombian consensus on selective thrombolysis with catheter in thromboembolic vascular disease

Resumen En los pacientes con trombosis arterial o venosa, in situ o por embolia, el uso de fibrinolíticos (como el rtPA) administrados directamente en el trombo a través de un catéter selectivo en el sitio de la oclusión, permite una resolución más rápida de la oclusión trombótica o embólica con menos dosis total del agente fibrinolítico y por ende con menos complicaciones hemorrágicas que con el uso sistémico. Las indicaciones en las cuales se puede considerar la fibrinólisis selectiva con catéter son básicamente la isquemia aguda de una extremidad por oclusión arterial, la tromboembolia pulmonar, la trombosis venosa profunda iliofemoral (proximal), la trombosis venosa profunda proximal axilo-subclavia, la trombosis de los accesos venosos para diálisis y en los pacientes pediátricos en los casos de trombosis o embolia arterial con extremidad isquémica y en casos seleccionados de trombosis venosa profunda proximal de extremidades. En este consenso describirá cada una de las indicaciones a través de un protocolo para el manejo con rtPA en cada situación, cómo monitorizar su uso y cómo tartar las complicaciones hemorrágicas.

Abstract In patients with arterial or venous thrombosis, in situ or due to an embolism, the use of fibrinolytics (such as recombinant tissue-type plasminogen activator, rtPA) administered directly into the clot through a selective catheter into the occlusion site. This can lead to a more rapid resolution of the thrombotic or embolic occlusion with a lower dose of the fibrinolytic agent, and therefore with less problems with haemorrhages than with systemic use. The situations in which selective fibrinolysis with a catheter can be considered are mainly, acute ischaemia of a limb due to a blocked artery, pulmonary thromboembolism, proximal ileo-femoral deep venous thrombosis, proximal axillo-subclavian deep venous thrombosis, and in the thrombosis of the venous access for dialysis It is also indicated in paediatric patients in cases of arterial thrombosis or embolisms with an ischaemic limb, and in selective cases of proximal deep venous thrombosis of the limbs. In this consensus, a description will be given of each one of the indications, with a protocol for the management with rtPA in each one of them, as well as monitoring its use and the management of haemorrhage complications.

Funcionamiento del ciclo de Krebs durante la sepsis y el choque séptico. Una mirada al metabolismo intermediario durante condiciones de hipoxia / The krebs cycle during sepsis and septic shock: a look at intermediate metabolism in hypoxia

El choque séptico es una patología que involucra alteraciones hemodinámicas y compromiso de la microvasculatura que derivan en una disfunción celular que conlleva a la falla orgánica múltiple propia de esta enfermedad. Los protocolos de manejo actuales se centran en la normalización de variables macrohemodinámicas y biomarcadores relacionados con la hipoxia tisular, convirtiéndose en un desafío clínico que requiere el reconocimiento temprano, el control de la infección y la optimización del estado hemodinámico del paciente. En los últimos años se ha identificado que la disfunción multiorgánica que se observa en el choque séptico se encuentra relacionada con el desarrollo de disfunción mitocondrial. Se han planteado dos posibilidades para explicar el surgimiento de esta disfunción mitocondrial, que son el convectivo e inmunometabólico. Dentro del contexto metabólico se observa que el ciclo de Krebs puede funcionar en un entorno de hipoxia mediante la fragmentación y reorientación de sus reacciones enzimáticas, permitiendo la adaptación al metabolismo intermediario a la noxa séptica.

Septic shock is a condition involving hemodynamic alterations and microvascular dysfunction which lead to cellular dysfunction which is typically linked with multiple organ failure. Current management guidelines focus in reestablishing normal macro hemodynamics and biomarkers related with tissue hypoxia. This poses a clinical challenge requiring early recognition, effective infection control and optimization of hemodynamic status in the septic patient. Over the last years multiple organ involvement in septic shock has been correlated with impairment of mitochondrial function. Convective transport and immune cell metabolism have been proposed as two possible reasons for mitochondrial dysfunction during sepsis. Within the metabolic context it is evidenced that the Krebs cycle remains operational even in hypoxic environments by means of fragmentation and reprogramming of enzyme-mediated reactions, activating intermediate metabolism adaptation mechanisms in response to a septic noxa.

Impact of high-energy diets on the rumen environment and digital cushion in confined cattle / O impacto de dietas de alto valor energético sobre o ambiente ruminal e o tecido digital em bovinos confinados

This study aimed to identify gross and microscopic changes, caused by high-energy diets, in the rumen environment and hoof of confined beef cattle. The study sample comprised 40 confined heifers (Bos taurus) with no disease history divided into four experimental groups using different diets: Group 1 (D1, control), 48:52 forage:concentrate ratio; Group 2 (D2), 30:70 forage:concentrate ratio; Group 3 (D3), 30:70 forage:concentrate ratio + sucrose; Group 4 (D4), 100% concentrate. All animals underwent clinical examination, assessment of ruminal fluid pH and lameness, and sample collection after slaughter for histopathology of the hoof laminae and digital cushion and ruminal tissue. All dependent variables of the study were compared using the SPSS 20.0 statistical software. The variables that did not show normality (HR, RM, ST, and CRT) were compared with application of the Kruskal-Wallis test followed by the Dunnet's multiple comparison test. All other variables were submitted to analysis of variance (ANOVA) followed by Tukey's test. The different diets had an impact on the rumen environment (p<0.05) of the heifers assessed, with momentary general depression in the first 12 h after sucrose induction (D3), as well as mild clinical signs in D4. The animals in D3 and D4 presented lower motility (p<0.05) and ruminal pH (p<0.01) than those in D1. Of the 40 heifers, 27.5% (n=11) showed gross lesions in the epithelium of ruminal pillars, whereas 22.5% (n=9) of those in D3 and D4 presented these lesions. Sole corium thickness varied between heifers in D3 compared with those in D1 and D2 (p<0.05). Therefore, high-energy diets, as used in this study, alter some clinical parameters and the rumen environment, causing lesions in the rumen mucosa, and of lesser intensity, in the hoof corium and laminae, suggestive of laminitis.(AU)

O objetivo deste trabalho foi identificar alterações macroscópicas e microscópicas provocadas por dietas de alto valor energético no ambiente ruminal e casco de bovinos de corte (Bos taurus) em confinamento. Foram utilizadas 40 novilhas mantidas em confinamento, sendo divididas em 4 grupos experimentais: Grupo D1(controle) - 48% de volumoso e 52% de concentrado; Grupo D2 - 30% de volumoso e 70% de concentrado; Grupo D3 - 30% de volumoso e 70% de concentrado + sacarose; Grupo D4 - 100% de concentrado. Foi realizado exame clínico dos animais, avaliação do pH ruminal, da claudicação, além de coletas de amostras post-mortem para análises histopatológicas da região laminar do casco, coxim digital e do rúmen. Todas as variáveis dependentes do estudo foram comparadas por meio do software estatístico SPSS 20.0. As variáveis sem normalidade (FC, MR, Tc e TPC) foram comparadas pelo teste de Kruskal Wallis, seguido pelo teste de comparação múltipla de Dunnet. Todas demais foram submetidas a análise de variância (ANOVA), seguida pelo teste de Tukey. Foi observado impacto das distintas dietas ao ambiente ruminal (p<0,05). Os grupos D3 e D4 exibiram menor motilidade (p<0,05) e pH ruminal (p<0,01). 27,5% (n=11) dos animais tiveram registros macroscópicos de lesões no epitélio dos pilares ruminais enquanto que os submetidos às dietas 3 e 4 foi observada ocorrência de 22,5% (n=9) de lesões macroscópicas no rúmen. As espessuras do córium solear variaram entre os grupos que receberam a indução de sacarose em relação ao grupo controle e novilhas alimentadas com a dieta 2 (p<0,05). Sendo assim dietas com elevada densidade energética, na condição em que foi empregada, alteraram alguns parâmetros clínicos e o ambiente ruminal, provocando lesões na mucosa do rúmen e de pouca intensidade no córium e tecido laminar, sugestiva de laminite.(AU)

Comparison of the anti-inflammatory effectiveness of dexamethasone as pre-surgical and post-surgical therapy in mandibular third molar surgery: a randomized clinical trial / Comparación de la efectividad antiinflamatoria de dexametasona como terapia prequirúrgica y postquirúrgica en la cirugía del tercer molar mandibular: ensayo clínico aleatorizado

Objective: To compare the anti-inflammatory effectiveness of dexa-methasone as pre-surgical and post-surgical therapy in mandibular third molar surgery. Materials and methods: Randomized clinical trial conducted in 60 patients in need of mandibular third molar extraction, ages ranging from 16 to 35 years old, at the Department of Oral and Maxillofacial Surgery of the Arzobispo Loayza National Hospital during the period of January-March, 2016. Patients were distributed in two randomized groups: Group A received 4mg dexamethasone intramuscular before the surgery, and Group B received the same medication post-surgery. Facial edema was assessed using the distance between facial points, trismus was evaluated using the interincisal distance, and pain intensity was determined using a Numerical Scale (NS). Results: Facial edema values were lower in Group A at 60 minutes (p=0.002) and after the first (p=0.001) and third days (p=0.009), compared to Group B. Regarding trismus, no significant differences between the groups were found. Regarding pain intensity, the highest point was recorded at 6 hours in both groups; however, no significant differences between the groups were found. Conclusion: Pre-surgical dexamethasone administration produced a significantly greater reduction in facial edema after mandibular third molar surgery.

Objetivo: Comparar la efectividad antiinflamatoria de dexametasona como terapia prequirúrgica y postquirúrgica en la cirugía del tercer molar mandibular. Materiales y métodos: Ensayo clínico aleatorizado que incluyó a 60 pacientes de 16 a 35 años del Servicio de Cirugía Bucal y Maxilofacial del Hospital Nacional Arzobispo Loayza con necesidad de exodoncia de tercer molar mandibular durante el periodo de enero a marzo del 2016. Se distribuyeron en dos grupos aleatoriamente: El grupo A recibió prequirúrgicamente 4 mg de dexametasona vía intramuscular y el grupo B recibió la misma medicación postquirúrgicamente. Se evaluó el edema facial, mediante la distancia entre puntos faciales, el trismus mediante la distancia interincisal y la intensidad de dolor mediante la Escala Numérica (EN). Resultados: Los valores del edema facial fueron menores en el grupo A a los 60 minutos (p=0,002), primer (p=0,001) y tercer día (p=0,009) en comparación al grupo B. Respecto al trismus, no se encontró diferencia significativa entre los grupos durante las evaluaciones realizadas. Respecto al dolor, la mayor intensidad se percibió a las 6 horas en ambos grupos; sin embargo, no se encontró diferencia significativa entre los grupos durante todas las evaluaciones realizadas. Conclusión: La administración prequirúrgica de dexametasona produjo una significativa mayor reducción del edema facial posterior a la cirugía del tercer molar mandibular.

Systemic and clinical treatment of gingival hyperplasia associated with use of anticonvulsant

ABSTRACT: Anticonvulsants are drugs that can modify the gingival tissues response to inflammatory processes in the presence of dental plaque, inducing gingival overgrowth. Preexisting gingival inflammation induced by dental plaque seems to be a favorable condition to the development and/or expression of gingival overgrowth. This study describes a case in which the use of phenytoin and phenobarbital anticonvulsant associated with the presence of dental plaque provided a large and severe extent of gingival alteration. We concluded that it was possible to achieve a good result in the patient with an intensive mechanical control of dental plaque, oral hygiene orientations and substitution of the drug for other alternative medication.

Factores de riesgo asociados a mortalidad por paro cardiaco intraoperatorio en el Hospital Nacional Guillermo Almenara Irigoyen, 2011-2015 / Risk factors associated with mortality due to intraoperative cardiac arrest at Hospital Nacional Guillermo Almenara Irigoyen, 2011-2015

Introducción. La incidencia y mortalidad de paro cardiaco intraoperatorio (PCI) son indicadores de la calidad de atención y eficiencia en centros quirúrgicos. Objetivo. Determinar los factores de riesgo asociados a mortalidad por PCI en el Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú, durante los años 2011 a 2015. Métodos. Se realizó un estudio observacional, descriptivo y retrospectivo de PCI ocurridos en el periodo de estudio, donde se determinó el riesgo relativo. Resultados. Entre los años 2011 a 2015 ocurrieron 88 PCI de un total de 74 096 cirugías realizadas; la incidencia de PCI fue de 11,87 x 10 000 cirugías. De los 88 PCI, 39 pacientes fallecieron (44,3%); la mortalidad intraoperatoria fue 5,26 x 10 000 cirugías. Los factores de riesgo asociados a mortalidad por PCI fueron: RCP mayor de 20 minutos (RR: 3,9), clasificación ASA (RR: 3,4), cirugía cardiovascular (RR: 2,9), causas quirúrgicas (RR:2,9), etapa de mantenimiento anestésico (RR:2,0). Conclusiones. En el periodo de estudio la incidencia de PCI fue de 11,87 x 10 000 cirugías; los factores de riesgo asociados a mortalidad por PCI fueron la RCP mayor de 20 minutos, alto riesgo ASA, cirugía por enfermedad cardiovascular, eventos adversos relacionados con cirugías y mantenimiento anestésico.

Introduction. The incidence and mortality of intraoperative cardiac arrest (PCI) are indicators of quality of care and efficiency in surgical centers. Objective. To determine the risk factors associated with mortality due to PCI in the Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru, during the years 2011 to 2015. Methods. An observational, descriptive and retrospective study of PCI occurred during the study period, where the relative risk was determined. Results. Between the years 2011 to 2015 there were 88 PCI out of a total of 74 096 surgeries performed; the incidence of PCI was 11,87 x 10 000 surgeries. Of the 88 PCI, 39 patients died (44,3%); the intraoperative mortality was 5,26 x 10 000 surgeries. The risk factors associated with mortality due to PCI were: CPR greater than 20 minutes (RR: 3,9), ASA classification (RR: 3,4), cardiovascular surgery (RR: 2,9), surgical causes (RR: 2,9 ), anesthetic maintenance stage (RR: 2,0). Conclusions. During the study period, the incidence of PCI was 11,87 x 10 000 surgeries; the risk factors associated with mortality due to PCI were CPR greater than 20 minutes, high ASA risk, surgery for cardiovascular disease, adverse events related to surgeries and anesthetic maintenance.

A utilização da Ozonioterapia no tratamento da lombalgia associada à hérnia de disco lombar ­ Uma Revisão Sistemática / Ozonetherapy in the treatment of Low Back Pain associated to Lumbar Disk Herniation ­ A systematic review

INTRODUÇÃO: Ozonioterapia é uma ferramenta terapêutica utilizada para o tratamento de dor lombar associada a hérnia de disco lombar. Objetivo: o objetivo dessa revisão sistemática foi ratificar a relevância desse tratamento na prática clínica e enfatizar sua possível utilização na fisioterapia. MATERIAIS AND MÉTODOS: PRISMA e PICOS foram utilizados para analisar o desenho dos manuscritos. A seleção dos manuscritos foi realizada através de busca nas bases de dados PUBMED, Periódicos CAPES e Scielo. Quatro ensaios clínicos foram selecionados de acordo com os critérios de inclusão criado para essa estudo. RESULTADOS: Todos os autores confirmaram a eficiência da ozonioterapia como método terapêutico na reversão da sintomatologia álgica de pacientes com hérnia de disco lombar. Ozonioterapia associada ao tratamento fisioterapêutico pode contribuir no alívio da dor associada a dor lombar influenciando na qualidade de vida dos pacientes. CONCLUSÃO: Ozonioterapia é uma opção terapêutica efetiva para pacientes com dor lombar associada a hérnia de disco lombar. [AU]

INTRODUCTION: Ozonetherapy is a therapeutic tool used in the treatment of low back pain associated to herniation of lumbar disks. OBJECTIVE: The objective of this systematic review was to ratify the relevance of this treatment in clinical practice, besides emphasizing its possible utilization on physiotherapy. MATERIALS AND METHODS: PRISMA and PICOS were used to analyze the manuscripts design. Manuscripts selection was made by a research in the PUBMED, Periódicos CAPES and Scielo databases. Four clinical trials were selected according to the inclusion criterias designer for the study. RESULTS: All the authors confirmed the efficiency of ozonetherapy as a therapeutic method in reversing the algic symptomatology of pacients whit lumbar disc herniation. Ozonetherapy associated to the physiotherapeutic treatment can contribute pain relief related to low back pain by influencing the improvement in patients quality of life. CONCLUSION: Ozonetherapy is an effective therapeutic option for patients whit low back pain associated whit lumbar disk herniation. [AU]

Enxerto de tecido conjuntivo subepitelial e retalho coronal em recessões gengivais múltiplas / Subepithelial connective tissue graft and coronal fl ap in multiple gingival recessions

Algumas das principais indicações para o recobrimento de superfícies radiculares expostas por recessão gengival compreendem a hipersensibilidade dentinária cervical e o tratamento de defeitos estéticos. Este trabalho descreveu o tratamento de recessão gengival múltipla classe III de Miller em um periodonto delgado, após 36 meses de uma intervenção cirúrgica com enxerto gengival livre. O tratamento cirúrgico periodontal proposto foi o recobrimento radicular por meio de enxerto de tecido conjuntivo subepitelial associado a retalho reposicionado coronalmente na região vestibular dos elementos 31, 41 e 42. Após 90 dias, foi possível observar o recobrimento parcial da recessão, aumento da espessura tecidual e o controle do biofi lme pelo paciente, promovendo maior proteção da região e redução do risco de recidiva das recessões. Diante da resolução do caso clínico apresentado, pôde-se concluir que a técnica do enxerto de tecido conjuntivo subepitelial associado ao retalho reposicionado coronalmente, quando bem indicada e realizada, pode ser empregada com sucesso em áreas de recessões múltiplas e periodonto com espessura reduzida.

Some of the main indications for the root coverage of gingival recessions include cervical dentin hypersensitivity and treatment of aesthetic defects. This manuscript describes the treatment of a Miller's Class III multiple gingival recession 36 months after a free gingival graft surgical procedure. The periodontal surgical treatment proposed was the subepithelial connective tissue graft associated with a coronally repositioned fl ap at vestibular region of elements 31, 41 and 42. After 90 postoperative days, it was possible to observe an increase on tissue thickness and biofi lm control by the patient, promoting a greater protection of the region and reducing the risk of recession recurrence. It can be concluded that the subepithelial connective tissue graft technique associated with the coronal repositioned fl ap, when well indicated and performed, can be successfully used in multiple recessions and periodontal regions with reduced thickness.

Histological description of Cerdocyon thous (Linnaeus, 1766) respiratory system / Descrição histológica do sistema respiratório de Cerdocyon thous (Linnaeus, 1766)

The massive agricultural expansion converted the Cerdocyon thous, a South American native predator, in vulnerable specie. Basic data, such as histological description, are important to raise awareness on animal species, helping on preservation strategies. Considering the difficult in obtain samples, as the euthanasia of wild animals for this purpose is not allowed, data on histology are very scarce or inexistent. The objective of this paper was to provide a detailed histological description of the trachea and bronchial tree of the crab-eating fox Cerdocyon thous (Linnaeus, 1766). The specimens (one adult male and one adult female) used were provided by the Federal University of Pelotas (Pelotas, RS, Brazil) Rehabilitation Center of Wild Fauna (NURFS). Tissue samples were fixed in 10% formalin and included in paraffin. After slicing, samples were stained with HE (hematoxylin and eosin), PAS (periodic acid-Schiff) and resorcin fuchsin. Trachea had an average diameter of 7.87mm, and approximately 57% of the mucosa ciliated pseudo-stratified columnar epithelium was composed of goblet cells, mostly in the dorsal region. Bronchia and bronchioles had a mucosal fold with higher number of goblet cells. Using all these techniques there is no great remarkable differences from C. thous trachea and lung, when compared with the previous described structures for carnivores and most mammals, except for the goblet cells "regionalization". Described results are important to understand the animal physiological and behavioral habits, allowing the development of preservation and protection strategies.(AU)

A expansão agrícola maciça tornou o Cerdocyon thous, um predador nativo sul-americano, vulnerável. Dados básicos, tais como descrição histológica, são importantes para aumentar o conhecimento sobre as espécies, ajudando nas estratégias de preservação. A eutanásia de animais selvagens para a coleta de amostras não é permitida, por isso os dados sobre a histologia são muito escassos ou inexistentes. O objetivo deste trabalho foi de fornecer uma descrição histológica detalhada da traqueia e árvore brônquica do cachorro do mato Cerdocyon thous (Linnaeus 1766). Os espécimes (um macho e uma fêmea adultos) utilizados foram fornecidos pela Universidade Federal de Pelotas (Pelotas, RS, Brasil), Centro de Reabilitação da Fauna (NURFS). As amostras de tecido foram fixadas em formalina a 10% e incluídas em parafina. Após o corte, as amostras foram coradas com HE (hematoxilina e eosina), PAS (ácido periódico de Schiff) e resorcina fucsina. A traqueia tinha um diâmetro médio de 7,87 milímetros e aproximadamente 57% do diâmetro do epitélio colunar pseudo-estratificado ciliado da mucosa composto por células caliciformes, principalmente na região dorsal do órgão. Os brônquios e bronquíolos apresentaram cararísticas similares aos outros animais, contudo aparenta ter maior número de células caliciformes. Usando distintas técnicas de coloração, observou-se que não há diferenças notáveis da traqueia e do pulmão de C. thous quando comparados com os dados para carnívoros e para a maioria dos mamíferos, exceto a regionalização de células caliciformes. Os resultados descritos são importantes para compreender a fisiologia dos animais e hábitos comportamentais, permitindo o desenvolvimento de estratégias de preservação e proteção.(AU)

Resolução de desarmonia gengival do arco superior durante tratamento ortodôntico através de cirurgia periodontal / Resolution of upper gingival arch disarmony during orthodontic treatment by periodontal surgery

A busca por padrões de sorriso que atendam aspectos visuais harmônicos inclui uma pequena exposição gengival. Na presença de um sorriso alto podemos observar a exposição total das coroas clínicas dos dentes anterossuperiores e uma faixa contínua de tecido gengival, podendo, este padrão clínico/periodontal, ser influenciado por sexo e idade, entre outros. O objetivo deste trabalho foi descrever um tratamento cirúrgico periodontal na região dos dentes anteriores superiores de uma paciente em tratamento ortodôntico com a finalidade de estabelecer uma estética periodontal satisfatória ao paciente. Concluímos que a intervenção cirúrgica periodontal visando o estabelecimento de contorno gengival e diminuição da linha gengival no sorriso alem do mostrou-se satisfatória no planejamento estético da paciente (AU)

The demand for smile patterns that meet visual harmonic aspects includes a small gingival exposure. In the presence of a high smile we can observe the total exposure of the clinical crowns of the anterior superior teeth and a continuous range of gingival tissue, and this clinical/periodontal pattern can be influenced by sex and age, among others. The objective of this study was to describe a periodontal surgical treatment in the region of the maxillary teeth in a patient with orthodontic treatment, in order to establish a satisfactory periodontal aesthetic for the patient. We conclude that the periodontal surgical intervention aiming at the establishment of gingival contour and reduction of the gingival line in the smile proved highly efficient in the aesthetic planning of the patient (AU)