Anesthetic management of a patient with type 1 neurofibromatosis and an occult pheochromocytoma: a case report

Abstract Neurofibromatosis type 1 is a complex genetic disorder affecting multiple organ systems. Cardiovascular manifestations include hypertension, often associated with concomitant pheochromocytoma. We present a hypertensive crisis during induction of anesthesia in a patient with neurofibromatosis type 1, scheduled for abdominal myomectomy, which revealed an undiagnosed pheochromocytoma. The case highlights the importance of assessing all patients with neurofibromatosis type 1 for pheochromocytoma, because if it is left undiagnosed, it can be disastrous in the setting of anesthesia and surgery.

Use of a Double-Channel Gastroscope Reduces Procedural Time in Large Left-Sided Colonic Endoscopic Mucosal Resections

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) of large colorectal lesions is associated with increased procedural time. The objective of this study was to evaluate the effect of double-channel gastroscope (DCG) use on the procedural time of EMRs in the rectosigmoid area. METHODS: All EMRs for sessile or flat rectosigmoid lesions > or =2 cm performed between July 2011 and September 2012 were retrospectively analyzed. RESULTS: There were 55 lesions > or =2 cm in the rectosigmoid area in 55 patients, of which 26 were removed by EMR using a DCG (DC group) and 29 by using an ordinary colonoscope or gastroscope (OS group). The mean size of the removed polyps, morphology, adverse effects, and other parameters were similar between the two groups. The mean procedural time was significantly lower in the DC group than in the OS group (24.4+/-18.3 minutes vs. 36.3+/-24.4 minutes, p=0.015). Moreover, in a subgroup of patients with polyps >40 mm, the statistical difference in the mean procedural time between the DC and OS groups was even more pronounced (33+/-21 minutes vs. 58.7+/-20.6 minutes, p=0.004). CONCLUSIONS: Our data suggest that the use of a DCG in the resection of large nonpedunculated rectosigmoid lesions significantly reduces the procedural time.

Chironomus amissum sp. n. (Diptera, Chironomidae) from southeastern Brazil

The paper presents a description of larva, pupa, imago (male) and karyotype of Chironomus amissum from southeastern Brazil. It belongs to pseudothummi cytocomplex with 2n=8 and chromosome arm combinations: AE BF CD G. Several fixed homozygous inversions distinguished arm A of the new species from that of Chironomus columbiensis Wülker et al. 1989 and Chironomus anonymus Williston, 1896. One homozygous inversion of arm F differentiated it from C. anonymus. Species-specific characters were presented in the larva, pupa and imago.

Neste artigo é apresentada a descrição de larva, pupa, adulto macho e cariótipo de Chironomus amissum, uma nova espécie do sudeste brasileiro. Ela pertence ao citocomplexo pseudothummi com 2n=8 e cromossomos com combinações de braços: AE BF CD G. Várias inversões homozigóticas diferem o braço A da nova espécie em relação às espécies Chironomus columbiensis Wülker et al. 1989 e Chironomus anonymus Williston, 1896. Uma inversão homozigótica do braço F diferencia essa espécie de C. anonymus. Caracteres que diferenciam a espécie nova são também apresentados para larva, pupa e adulto.

Differential expression of hypoxia-inducible factor 1α in non-small cell lung cancer and small cell lung cancer

OBJECTIVES: The aim of this study was to compare the expression of hypoxia-inducible factor 1α and vascular endothelial growth factor in small cell lung cancer and subtypes of non-small cell lung cancer and examine their relationships with clinicopathologic factors, response to treatment and survival. METHODS: We examined samples obtained by bronchial endoscopic biopsy from 55 patients with inoperable lung cancer (16 with adenocarcinoma, 17 with squamous cell carcinoma, and 22 with small cell lung cancer). Hypoxiainducible factor 1α and vascular endothelial growth factor were detected using immunohistochemistry. The diagnosis, treatment, and follow-up of patients were conducted according to the standard practice. RESULTS: A significant difference (p=0.022) in hypoxia-inducible factor 1α expression was observed between nonsmall cell lung cancer (75.8% positive) and small cell lung cancer (45.5% positive). The frequency of hypoxiainducible factor 1α nuclear expression was 88.2% in squamous cell carcinoma, 62.5% in adenocarcinoma, and 45.5% in small cell lung cancer. A significant correlation was observed between hypoxia-inducible factor 1α and vascular endothelial growth factor expression (Fisher's exact test, p=0.001) when all types of lung cancer were examined, either collectively or separately. CONCLUSIONS: The expression of hypoxia-inducible factor-1α differs significantly between subtypes of lung cancer. These findings could help elucidate the biology of the different types of non-operable lung carcinomas and have implications for the design of new therapeutic approaches for lung cancer.

The impact of 30 ml/kg hydroxyethyl starch 130/0.4 vs hydroxyethyl starch 130/0.42 on coagulation in patients undergoing abdominal surgery.

Background & objectives: Hydroxyethyl starches (HES) 130/0.4 (Voluven®) and 130/0.42 (Venofundin®) impair coagulation less than older HES solutions with higher molecular weight and molar substitution. Thus, these may be used in high doses up to 50 ml/kg/day. The aim of this study was to investigate and compare the effects of HES 130/0.4 versus HES 130/0.42 on coagulation after the intraoperative infusion of 30 ml/kg in patients undergoing major abdominal surgery. Methods: Fifty two patients scheduled for elective major abdominal surgery were randomized to receive 30 ml/kg of HES 130/0.4 or HES 130/0.42 intraoperatively. Coagulation variables were assessed before and after infusion of the colloid solution using thrombelastography. Results: Data from 49 patients, 25 patients in the HES 130/0.4 and 24 in the HES 130/0.42 group, were analyzed. Measurements of reaction time, kinetic time, α-angle, maximum amplitude and coagulation index before and after colloid infusion did not differ between the groups. Within each group, after colloid infusion, reaction time did not change significantly, while α-angle, maximum amplitude and coagulation index values were significantly decreased (P<0.01, P<0.001 and P<0.001, respectively in HES 130/0.4 group and P<0.01, P<0.001 and P<0.01, respectively in HES 130/0.42 group). Kinetic time was significantly increased (P<0.001) in both the groups. In both groups, all thrombelastographic measurements after colloid infusion were found within normal limits. Interpretation & conclusions: HES 130/0.4 and HES 130/0.42 showed similar, not clinically significant effects on coagulation, as assessed by thrombelastography, when a dose of 30 ml/kg was administered in patients undergoing major abdominal surgery.

The effects of mild hypothermia on coagulation tests and haemodynamic variables in anaesthetized rabbits / Efectos de la hipotermia leve sobre las pruebas de coagulación y las variables hemodinámicas en conejos anestesiados

OBJECTIVE: Hypothermia has been associated with coagulation defects. The purpose of this experimental study was to investigate the effect of mild hypothermia on clinically used coagulation tests and on haemodynamic variables. METHODS: Νine New Zealand rabbits were subjected to mild core hypothermia by administration of general anaesthesia and exposure to room temperature of 22°C for 60 minutes. Blood samples were obtained at normothermia and mild hypothermia for measurement of prothrombin time, activated partial thromboplastin time, fibrinogen levels, platelet count and haemoglobin concentration. Hypothermic values were compared to the normothermic values. Additionally, the progressive temperature drop and haemodynamic changes (blood pressure, heart rate) were recorded. RESULTS: Core temperature decreased significantly over time changing from 39.4 ± 0.27 to 36.6 ± 0.28°C (p = 0.0001). Prothrombin time and activated partial thromboplastin time decreased at hypothermia, but the changes were not statistically significant (p = 0.203 and p = 0.109, respectively). Platelet count, fibrinogen levels and haemoglobin concentration decreased significantly (p = 0.0001, p = 0.03 and p = 0.027) but remained within normal limits. Mean arterial pressure and heart rate declined significantly over time (p = 0.0001 and p = 0.0001, respectively). CONCLUSION: The results of this study suggest that short term mild hypothermia may affect the coagulation mechanism to a clinically nonsignificant extent, while haemodynamic responses are significantly suppressed.

OBJETIVO: La hipotermia ha sido asociada con defectos de coagulación. El propósito de este estudio experimental fue investigar el efecto de la hipotermia leve sobre las pruebas de coagulación de uso clínico, así como sobre las variables hemodinámicas. MÉTODOS: Nueve conejos de Nueva Zelanda fueron sometidos a hipotermia central leve mediante la administración de anestesia general y exposición a una temperatura ambiente de 22°C durante 60 minutos. Se obtuvieron muestras de sangre en condiciones de normotermia e hipotermia leve para medir el tiempo de protrombina, el tiempo de tromboplastina parcial activada, los niveles de fibrinógeno, el conteo de plaquetas, y la concentración de hemoglobina. Se compararon los valores hipotérmicos con los valores normotérmicos. Además, se registraron la caída progresiva de la temperatura y los cambios hemodinámicos (presión sanguínea, frecuencia cardíaca). RESULTADOS: La temperatura corporal central disminuyó significativamente con el tiempo, cambiando de 39.4 ± 0.27 a 36.6 ± 0.28°C (p = 0.0001). El tiempo de protrombina y el tiempo de tromboplastina parcial activado disminuyeron en la hipotermia, pero los cambios no fueron estadísticamente significativos (p = 0.203 y p = 0.109, respectivamente). El conteo de plaquetas, los niveles de fibrinógeno y la concentración de la hemoglobina disminuyeron significativamente (p = 0.0001, p = 0.03 y p = 0.027) pero permanecieron dentro de los límites normales. La presión arterial promedio y la frecuencia cardíaca disminuyeron significativamente con el tiempo (p = 0.0001 y p = 0.0001, respectivamente). CONCLUSIÓN: Los resultados de este estudio sugieren que la hipotermia leve a corto plazo puede afectar el mecanismo de la coagulación hasta un punto clínicamente no significativo, mientras que respuestas hemodinámicas se suprimen significativamente.

Association between factors predicting and assessing the airway and use of intubating laryngeal mask airway

The Intubating Laryngeal Mask Airway Fastrach[TM] [ILMA] has been used with success in difficult intubation cases. The purpose of this study is to evaluate the effect of mouth opening, Mallampati classification, thyromental distance and Cormack-Lehane Grade, on the ease of ILMA use. Eighty one patients ASA I-II, were assessed preoperatively for mouth opening, Mallampati classification and thyromental distance. After induction with propofol and rocuronium, the first investigator recorded Cormack-Lehane Grade by direct laryngoscopy. Subsequently an appropriate size ILMA was inserted by the second investigator and correct placement was confirmed by adequate ventilation and normal capnogram. A maximum of three ILMA insertion attempts were allowed and the number was recorded. Then blind intubation was attempted and classified as follows, according to Intubation Difficulty Grade [IDG]: IDG-1: intubation succeeded: at first attempt requiring no or minor ILMA manipulations. IDG-2: intubation succeeded at second attempt requiring major ILMA manipulations or size change. IDG-3: intubation failed after the second attempt or oesophageal intubation occurred at either attempt. In failure of the technique direct laryngoscopy was the alternative approach. Success rates in insertion of ILMA and in blind intubation were 100% and 92.6% respectively. No difference was found between Cormack-Lehane Grade I-II and II-IV or Mallampati classification and number of ILMA insertion attempts or IDG. There was also no correlation between mouth opening, or thyromental distance and number of ILMA insertion attempts or IDG. It is concluded that easiness of ILMA use is irrelevant to mouth opening, thyromental distance, Mallampati classification or Cormack-Lehane Grade

Pregnancy at term does not alter the responses to a mechanical and an electrical stimulus after skin emla application

Pregnancy is associated with reduced local anesthetic requirements and increased pain thresholds, possibly due to hormonal changes and activation of endogenous opioids. We compared the responses to a mechanical and an electrical stimulus in 30 pregnant women [pregnant group] scheduled for cesarean section and 30 healthy female volunteers [control group] matched for age. Pain was assessed by Visual Analogue Scale [VAS] on two different days after skin application of EMLA or placebo cream on the forearms. EMLA and placebo cream were randomly applied on the medial surface of both forearms for 30 min in a blind cross over manner and the subjects received a mechanical stimulus generated through a pressor palpator followed by an electrical stimulus generated through a nerve stimulator. Average VAS values from both trials did not differ between pregnant and control group exposed to the mechanical or electrical stimulus after EMLA application or after mechanical or electrical stimulus after placebo cream application.. Late pregnancy is not associated with increased sensitivity to local anesthetics [EMLA] applied to the skin, under our study conditions

Topographic changes at the optic disc in 33 patients with primary open angle glaucoma / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To show frequency of progression and progres-sion at the optic disc in primary open angle glaucoma (POAG).METHODS: A total of 33 patients (66 eyes), 14 male and 19 female, aged 14 to 79 with POAG were imaged using the Heidelberg Retina Tomography II (HRT II) three or more times during follow-up periods of 6 years (2000-2006). Disc progression was determined by regression analysis of global and segmental changes in optic disc parameters. Every patient was tested by Octopus G1 once a year. Imaged optic disc parameters with scanning laser tomography were: rim area (ra), cup/disc (C/D), rim volume (rv), mean RNFL thickness (mRNFL). Imaged segments of the optic disc were: global (G), temporal (T), temporal superior (TS), temporal inferior (TI), nasal (N), nasal superior (NS) and nasal inferior (NI).RESULTS: Global frequency of progression according to c/d ratio existed in 34 eyes (51%), but 32 eyes (48%) were without frequency of progression. Progression existed in 12 eyes (18%) in temporal, 7 eyes (10.6%) in temporal superior (TS), 14 eyes (21%) in temporal inferior (TI), 8 eyes (12%) in nasal (N), 7 eyes (10.6%) in nasal superior (NS), and 13 eyes (20%) in nasal inferior (NI) segment. Without progression were 5 eyes (8%).CONCLUSION: Disc progression in our study was mostly in nasal (N) and temporal inferior (TI) segments. Most frequently were stricken temporal inferior (TI) and nasal inferior (NI), but most infrequently nasal superior (NS) segment. Most sensitive parameter was c/d ratio. Segmental scanning is of importance in POAG progression analysis.

Intoxicação hídrica durante histeroscopia: relato de caso / Water intoxication during hysteroscopy: case report

JUSTIFICATIVA E OBJETIVOS: Intoxicação hídrica e distúrbios eletrolíticos produzindo toxicidade sistêmica podem ocorrer durante ressecção prostática transuretral e cirurgia histeroscópica, sendo em geral causados pelo volume de líquido e pela duração do procedimento. RELATO DO CASO: Apresenta-se um caso incomum de intoxicação hídrica em uma paciente de 42 anos submetida à ressecção endoscópica de mioma uterino submucoso, com descrição do diagnóstico e do tratamento. CONCLUSÕES: A intoxicação hídrica pode ser resultado de sobrecarga líquida, sendo importante o controle cuidadoso dos líquidos empregados e monitorização clínica.

O nome, a coisa... e o currículo: perversos motes da perigosa glosa neo-centralista radical / The name, the thing... and the curriculum: preverse mottos of the dangerous radical neo-central explanation

Com base nos pensamentos radicais críticos de Michael Moore (2001) e José Saramago (2003) - entre outros - para quem as relações de concubinato entre os Estados e os grupos económicos têm promovido uma plataforma democrática redutora e - por isso - suicida, avançamos neste artigo com uma proposta de análise, não só em torno das nefastas implicações de alguns dos recortes do 'pervertido' modelo democrático ocidental - no qual a lógica mercantilista tem sistematicamente vilipendiado as esferas política e cultural - tanto na escolarização, em geral, quanto no currículo, em particular, processos políticos que deveriam ser inequivocamente tratados como um bem público, como também sobre as profundas contradições bem latentes na própria medula do fervor mercantilista.