Initial absence of N20 waveforms from median nerve somatosensory evoked potentials in a patient with cardiac arrest and good outcomes

A 34-year-old male was brought to the hospital with a chest gunshot wound. Pulseless upon arrival, blood pressure was absent for 10 minutes. A thoracotomy resulted in return of spontaneous circulation. On hospital day 5, with brainstem reflexes present, he was unresponsive to call or pain, exhibited generalized hyperreflexia and bilateral Babinskys. Median nerve somatosensory evoked potentials (mSSEPs) and brainstem auditory evoked potentials were obtained. International Federation of Clinical Neurophysiology recommendations for mSSEPs and brainstem auditory evoked potentials were followed. Despite absence of the N20 responses from cortical mSSEPs no withdrawal from care was agreed upon. After awaking on day 7, mSSEPs were repeated and present. The patient survived and was discharged with minor deficits. Bilateral absence of N20 responses from mSSEPs performed beyond 48 hours after resuscitation from cardiac arrest is highly associated with bad neurological outcomes. However, variation due to hypothermia, noisy signals, medications, and brain hypo-perfusion must be taken into account.

The development of ethical guidelines for telemedicine in South Africa

Telemedicine has the potential to assist in the provision of healthcare in South Africa (SA). This means of healthcare service provision involves patients, doctors and machines working together, with few constraints imposed by geography, or national or institutional boundaries. Although the practice is largely beneficial, certain legal and ethical challenges arise from the use of electronic healthcare services. Certain ethical challenges are identified as: the changing nature of the traditional doctor-patient relationship; standards of care;quality of care; privacy; confidentiality; data protection; accountability; liability; consent; record-keeping; data storage; and authentication.While various legal, regulatory and governance measures offer potential solutions and remedies for protection, ethical direction may be achieved through statutory bodies set up to promote and foster ethical compliance with normative healthcare standards. Recently, the Health Professions Council of SA (HPCSA) made an attempt to address the ethical issues by publishing a set of telemedicine guidelines.Despite this, issues around the practice of telemedicine remain unresolved. This article seeks to inform the development of a new ethical framework by addressing three distinct and relevant ethical issues: the fiduciary nature of healthcare and the changing nature of the doctor-patient relationship; privacy, confidentiality and the sensitivity of health data; and informed consent. It does so by proposing a broader and more nuanced solution to these ethical obstacles by identifying conceptual and operational difficulties within the existing HPCSA telemedicine guidelines, and advancing suggestions for reform. This speaks to a more highly integrated perspective that is culturally and contextually aware, and which affirms the need to strike a balance between individual rights protection and transformative, ethical, healthcare innovation

Robotic extralevator excision of a retrorectal giant aggressive angiomyxoma

Aggressive angiomyxoma (AA) is a very rare mesenchymal tumor most commonly found in the pelvic and perineal regions. For the complete excision of retrorectal tumors, with extension through the levator muscle into the ischioanal space, open anterior and posterior approaches are typically required. Herein, we report our experience with robotic excision of a giant presacral AA with extralevator extension into the ischioanal space and extraction via Pfannenstiel incision, which we found to be technically feasible, efficacious, and safe to perform. Mayo Clinic Institutional Review Board exemption status was obtained for this study.

Transanal total mesorectal excision for low rectal cancer: pros and cons / 中华胃肠外科杂志

Colorectal cancer is the 3rd most commonly diagnosed cancer, with rectal cancer specifically accounting for 1/3 of new cases. Despite advances in care, there is still a lack of standardization in diagnosis, staging, and treatment, with associated high rates of positive margins, recurrence, and mortality. The gold standard for curative resection remains a total mesorectal excision(TME), and the quality of the TME is one of the most important prognostic factors for local recurrence. The proper TME specimen with negative resection margins is inherently challenging due to patient and tumour-related factors. These difficulties have not been overcome with the laparoscopic approach. Transanal TME (taTME) is an innovative surgical technique developed to overcome the limitations in exposure and instrumentation in low pelvic surgery by approaching the rectum from below. Interest in taTME continues to grow worldwide, and structured training programs and case registries have been developed to aid safe implementation of this new technique in clinical practice. As the utilization of taTME and indications for the procedure continue to expand, structured programs to standardize teaching, training, and safe expansion will aid the safe spread of the taTME technique. With the growing popularity, a review of the pros and cons of the taTME is timely.

Identificación de biomarcadores sanguíneos para la detección de lesiones premalignas y el diagnóstico del cáncer gástrico / Identification of Blood Biomarkers for Detecting Premalignant Lesions and Gastric Cancer

Introducción: el cáncer gástrico es muy frecuente en Colombia y es la primera causa de muerte por cáncer. De acuerdo con la cascada de Correa existen unas etapas progresivas en la formación de esta enfermedad, que van de la gastritis, pasando por la atrofia, metaplasia y displasia, hasta el cáncer. En esas etapas intermedias se pudiera detectar y prevenir, pero no existen marcadores en sangre diferentes al pepsinógeno que puedan ayudar a detectar las etapas premalignas ni a diagnosticar el cáncer. Por lo cual, las investigaciones que ayuden a descubrir nuevos biomarcadores son de gran importancia. Objetivos: el objetivo de este trabajo es identificar marcadores moleculares (perfil de expresión de ARNm) que distingan a los pacientes con condiciones premalignas (atrofia, metaplasia) y cáncer gástrico, de aquellos pacientes que solo tienen gastritis. Metodología: se tomaron pacientes en cada una de las etapas de la cascada de Correa, los cuales proporcionaron una muestra, previo consentimiento firmado, de 2,5 mL de sangre en ayunas para el análisis de expresión de genes tomadas después de la endoscopia inicial. La sangre se colocó en un tubo de ARN sanguíneo PAXgene; luego, el ARN se extrajo de la sangre y se analizó usando una plataforma de microarrays, los cuales identificaron cambios de expresión de ARN mensajero que permitieron diferenciar cada una de las etapas descritas. Resultados: se incluyeron 89 pacientes, y en los hallazgos endoscópicos se encontró gastritis crónica antral en 27 pacientes (30,3%), cáncer gástrico avanzado en 25 (28%), pangastritis crónica en 15 (16,8%), cáncer temprano en 7 (7,8%), sospecha de metaplasia intestinal en 6 (6,7%), sospecha de gastritis atrófica en 3 (3,3%) y úlcera péptica en 2 casos (2,2%). Cuando se revisó el informe patológico se halló gastritis crónica en 34 pacientes (22 mujeres), adenocarcinoma intestinal en 20 (4 mujeres), metaplasia intestinal 18 casos (13 mujeres), cáncer tipo difuso en 11 (7 mujeres), displasia de bajo grado en 4 y de alto grado en 1, y atrofia sola en 1 paciente. En el análisis de expresión genética se encontraron 48 genes que permitieron determinar a los pacientes con gastritis crónica de aquellos con cáncer gástrico. También se hallaron 14 genes para diferenciar los pacientes con cáncer difuso de los de tipo intestinal, y un grupo de 48 genes que ayudó a distinguir los pacientes con gastritis crónica de los de metaplasia intestinal. Conclusiones: este es el primer trabajo en Colombia, y a nivel mundial, que permite identificar nuevos biomarcadores a través de la expresión genética del ARN mensajero, el cual diferencia en sangre las etapas de la cascada de Correa, y permite diagnosticar el cáncer gástrico. Es probable que en un futuro se puedan utilizar como una prueba diagnóstica o de seguimiento.

Introduction: Gastric cancer is very common in Colombia where it is the leading cause of death due to cancer. According to the Pelayo Corre, there is a cascade of stages from gastritis through atrophy, metaplasia and dysplasia to cancer. In the intermediate stages, it might be possible to detect and prevent the development of cancer, but there are no known markers in the blood other than pepsinogen to help to detect premalignant stages and diagnose cancer. Research is the key to discovery of new biomarkers. Objective: The aim of this work is to identify molecular markers (mRNA expression profiles) that distinguish patients who have premalignant conditions (atrophy, metaplasia) and gastric cancer from patients who only have gastritis. Methodology: Following an initial endoscopy, patients in each stage of the Pelayo cascade fasted and then provided a 2.5 ml blood sample which was analyzed for gene expression. All participating patients signed consent forms prior to tests. The blood was placed in a PAXgene RNA Blood tube, RNA was extracted from the blood and then analyzed. A microarray platform which identified changes in messenger RNA expression was used to differentiate each of the stages described. Results: Endoscopic findings for the eighty-nine patients included showed that 25 (28%) had advanced gastric cancer, 7 (7.8%) had early cancer, 27 (30.3%) had chronic antral gastritis, 15 (16.8%) had chronic pangastritis, three (3.3%) were suspected of having atrophic gastritis, six (6.6%) were suspected of having intestinal metaplasia, and two (2.2%) had peptic ulcers. Pathological reports showed 20 cases of intestinal adenocarcinoma (4 women), 11 cases diffuse cancer (7 women), 34 cases of chronic gastritis (22 women), one case of atrophy alone, 18 cases of intestinal metaplasia (13 women), four cases of low-grade dysplasia, and one case of high-grade dysplasia. The analysis of genetic expression found 48 genes which could be used for differentiation of patients with chronic gastritis from patients with gastric cancer. We also found 14 genes that could be used to differentiate patients with diffuse cancer from patients with intestinal type gastric cancer, and a group of 48 genes that could be used to differentiate patients with chronic gastritis from those with intestinal metaplasia. Conclusions: This is the first work anywhere in the world that has identified new biomarkers through the genetic expression of messenger RNA which differentiates the stages of the Pelayo Correa cascade and permits diagnosis of gastric cancer. It is likely that in the future they may be used as diagnostic and/or follow-up tests.

Disaggregating health inequalities within Rio de Janeiro, Brazil, 2002-2010, by applying an urban health inequality index / Desagregando desigualdades na saúde no Rio de Janeiro, Brasil, 2002-2010, através da aplicação de um índice urbano de desigualdade de saúde / Disgregando desigualdades en el ámbito de la salud en Río de Janeiro, Brasil, 2002-2010, mediante la aplicación de un índice urbano de desigualdad en salud

Abstract An urban health index (UHI) was used to quantify health inequalities within Rio de Janeiro, Brazil, for the years 2002-2010. Eight main health indicators were generated at the ward level using mortality data. The indicators were combined to form the index. The distribution of the rank ordered UHI-values provides information on inequality among wards, using the ratio of the extremes and the gradient of the middle values. Over the decade the ratio of extremes in 2010 declined relative to 2002 (1.57 vs. 1.32) as did the slope of the middle values (0.23 vs. 0.16). A spatial division between the affluent south and the deprived north and east is still visible. The UHI correlated on an ecological ward-level with socioeconomic and urban environment indicators like square meter price of apartments (0.54, p < 0.01), low education of mother (-0.61, p < 0.01), low income (-0.62, p < 0.01) and proportion of black ethnicity (-0.55, p < 0.01). The results suggest that population health and equity have improved in Rio de Janeiro in the last decade though some familiar patterns of spatial inequality remain.

Resumo Um índice de saúde urbana foi utilizado para quantificar desigualdades na saúde no Rio de Janeiro, Brasil, 2002-2010. Oito indicadores de saúde foram gerados no nível dos bairros utilizando dados de mortalidade. Os indicadores foram combinados para formar o índice. A distribuição ordenada dos valores do índice fornece informações sobre a desigualdade entre os bairros, por meio da relação entre os extremos e o gradiente dos valores médios. Ao longo da década, a proporção dos extremos caiu em 2010 em relação a 2002 (1,57 vs. 1,32), assim como a inclinação dos valores médios (0,23 vs. 0,16). A divisão espacial entre o sul afluente e o norte carente está ainda visível. Os valores do índice correlacionam com indicadores socioeconômicos e urbanos como o preço do metro quadrado de apartamentos (0,54, p < 0,01), baixa escolaridade da mãe (-0,61, p < 0,01), baixa renda (-0,62, p < 0,01) e proporção de pretos étnicos (-0,55, p < 0,01). Os resultados sugerem que a equidade na saúde no nível da população tem melhorado no Rio de Janeiro na última década, embora padrões familiares da desigualdade espacial permaneçam.

Resumen Se utilizó un índice de salud urbana para cuantificar desigualdades en el ámbito de la salud en Río de Janeiro, Brasil, 2002 a 2010. Se han generado ocho indicadores de salud a nivel de barrios, utilizando datos de mortalidad. Los indicadores fueron combinados para formar el índice. La distribución ordenada de los valores del índice ofrece información de la desigualdad, a través de la relación entre los extremos y el gradiente de los valores medios. A lo largo de la década la proporción de los extremos disminuyó en 2010, en comparación con 2002 (1,57 vs. 1,32), al igual que el gradiente de los valores medios (0,23 vs. 0,16). La división espacial entre el opulento sur y el norte desfavorecido es todavía visible. Los valores del índice se correlacionan con los indicadores socioeconómicos y urbanos, como el precio de los apartamentos (0,54, p < 0,01), la baja educación materna (-0.61, p < 0.01), baja renta (-0,62, p < 0,01) y la población afrobrasileña (-0,55, p < 0,01). Los resultados sugieren que la equidad en salud ha mejorado en Río de Janeiro en la última década, aunque los patrones familiares de desigualdad espacial permanecen.

Violence-related injury in emergency departments in Brazil / Lesiones relacionadas con la violencia en los servicios de emergencia de Brasil

Objective. This article describes the characteristics of violence-related injury (VRI) cases presenting at emergency departments (EDs) in Brazil and compares circumstances for assaultrelated and self-inflicted cases.Methods. The study is cross-sectional. The data describe cases seen in September 2006 in 62 EDs, representing all 26 states and the Federal District. A total of 4 835 case records were analyzed. Basic statistical tabulations were complemented by logistic regression analysis to assesspotential associations between type of violence (assault or self-harm) and multiple factors. Results. Males comprised 72.8% of cases while those aged 20 to 29 comprised 35.4%. Alcoholuse was reported or suspected in 42.7% of cases, more commonly among males. Assault victims comprised 91.4% of cases versus self-inflicted injuries, which accounted for 8.6%. Threefourthsof the assault victims were male, while over half of the self-inflicted injury victims were female. The leading mechanism for assaults was physical force/blunt objects (46.2%), whereaspoisoning was the predominant mechanism for self-inflicted injuries (71.4%). Younger females were significantly more likely to have been victims of self-inflicted injuries than younger males, while younger males were more likely to have been victims of assault; this finding is more pronouncedin cases where alcohol use was reported. Self-inflicted injuries were significantly more likely to occur in residences, while assaults were more likely to occur away from home. Conclusion. These results can improve understanding of the scope and characteristics of VRIs in Brazil (and thus contribute to national injury prevention efforts), and help identifyareas for future research.

Objetivos. Se describen las características de los casos de lesiones relacionadas con la violencia (LRV) que se presentan en los servicios de emergencia en Brasil y se comparanlas circunstancias de los casos relacionados con asaltos y los autoinfligidos. Métodos. En este estudio de corte transversal se describen los casos atendidos en septiembre de 2006 en 62 servicios de emergencia de 26 estados y el Distrito Federal. Se analizaron 4 835 casos por medio de tabulaciones estadísticas básicas y se evaluó mediante análisis de regresión logística la posible asociación entre los tipos de violencia (asalto o lesión autoinfligida) y diversos factores.Resultados. De los casos, 72,8% eran hombres y 35,4% tenían entre 20 y 29 años. Se informó o sospechó del consumo de bebidas alcohólicas en 42,7% de ellos, más frecuentementeen hombres. De los casos, 91,4% eran víctimas de asaltos y 8,6% de lesiones autoinfligidas. Tres cuartas partes de las víctimas de asaltos eran hombres y la mitad de las lesiones autoinfligidas fueron en mujeres. El principal mecanismo de asalto fue la fuerzafísica/objetos romos (46,2%), mientras que el veneno fue el mecanismo predominante en las lesiones autoinfligidas (71,4%). Las mujeres jóvenes presentaron una probabilidadsignificativamente mayor de haber sufrido lesiones autoinfligidas que los hombres jóvenes, mientras que estos tuvieron una mayor probabilidad de haber sido víctimas de asaltos, especialmente cuando se informó de consumo de alcohol. Las lesiones autoinfligidas tuvieron una probabilidad significativamente mayor de ocurrir en el hogar, mientras que los asaltos fueron más probables fuera de casa. Conclusiones. Estos resultados pueden ayudar a comprender mejor el alcance y las características de las LRV en Brasil —y así contribuir a los esfuerzos nacionales de prevención de lesiones— y a identificar nuevas áreas de investigación.

Terapia familiar: duplo vínculo e o contexto sociocultural do Recife / Family therapy: double-link and the sociocultural context of Recife

É relatada uma experiência de aplicaçäo da terapia familiar em famílias de baixa renda no Recife. Conceitua-se terapia familiar e faz-se uma descriçäo acerca do procedimento da coleta de dados sobre algumas famílias entrevistadas nos Serviços Psiquátricos da UFPE. Baseado nesses dados, sugere-se uma série de possíveis relaçöes entre as patologias identificadas nessas famílias, o conceito de "duplo vínculo" e o contexto sociocultural da populaçäo pobre do Recife. Atençäo especial é dada à predominância feminina entre as pacientes identificadas, resultantes de fatores tais como a utilizaçäo da força de trabalho, migraçöes e controle paterno. Dá-se ênfase à necessidade de recorrer-se a outras áreas do conhecimento científico, além do campo estritamente psiquiátrico, como a Sociologia, a Antropologia e a Economia, para uma frutífera aplicaçäo da terapia familiar em nosso meio. Finalmente, algumas propostas säo apresentadas, tendo em vista investigaçöes futuras sobre a possível relaçäo entre distúrbios mental e estrutura familiar patológica, considerando-se tal relaçäo fazendo parte de uma realidade social mais ampla

Terapia familiar no atendimento psiquiatrico: consideracoes iniciais sobre o tratamento de familias pobres no Recife. / Family therapy in psychiatric care:Preliminary considerations on the treatment of poor families in Recife

Empregando-se a terapia familiar no atendimento a populacao pobre do Recife, levantam-se alguns questionamentos, como fruto das experiencias no trabalho clinico de pesquisa que esta sendo realizado na clinica psiquiatrica do Departamento de Neuro-psiquiatria do CCSE da UFPE. Define-se o que se entende por terapia familiar, procurando-se chamar a atencao para os aspectos patologicos do interrelacionamento grupal, a nivel de familia, e seu comprometimento na etiopatogenia dos disturbios mentais. O sistema familiar e conceituado, em termos ciberneticos, como um todo indissociavel e intercomunicavel, em que seus membros influenciam e sao influenciados nos eventos ali ocorridos, no intuito de determinarem a natureza de suas relacoes. Ao se utilizar casos clinicos de grupos familiares atendidos, bem como resultados de pesquisas socio-economicas. Examina-se a situacao concreta das familias pobres do Recife. Por conseguinte, algumas consideracoes sao feitas sobre as implicacoes dos fatores historicos, sociais e culturais na pratica da terapia familiar

Togavirus infection in rural Thailand.

Hemagglutination inhibition tests for antibody against chikungunya virus and the four dengue viruses were performed on a rural Thai village population. The 50% and 90% prevalence indices fell at about ages 3 and 15 for dengue virus exposure. This is considerably earlier exposure than comparable urban populations. The prevalence of chikungunya virus antibody was also age related with 50% prevalence at about age 45.

Maternal carrier rates of potentially pathogenic organisms in Bangkok, Thailand.

One hundred and four healthy women delivering infants at the Royal Thai Army Hospital, Bangkok, were sampled by rectal swab for the laboratory isolation and identification of enteric bacteria of medical importance. Seventeen percent of these women had significant isolates as Salmonella, Shigella and Vibrio species. Serotypically enteropathogenic Escherichia coli were also identified in 31% of the mothers.