Clomiphene treatment may be effective in refractory episodic and chronic cluster headache / Tratamento de 15 casos episódicos e crônicos de cefaleia em salvas de difícil controle com clomifeno

ABSTRACT Objective To describe the evolution of 15 patients who were treated for difficult-to-control episodic and chronic cluster headaches with clomiphene. Methods Clomiphene treatment was used for seven chronic and eight episodic cluster headache patients. The chronic patients were refractory to the medication being used, and the episodic patients, in addition to being resistant to conventional medication, had longer cluster headache periods, exceeding the average time of previous cluster cycles. Our main analysis was of the time to pain-free, complete remission, and the length of pain-free time and complete remission. Results Clomiphene was used for 45-180 days. The average time to being pain-free was 15 days and cluster remission was up to 60 days. The average time between being pain-free until cluster remission was 26 days. Conclusions Clomiphene treatment was significantly efficient. It interrupted chronicity in all patients, suggesting the capability of changing the pattern of attacks. It proved to be safe and well tolerated.

RESUMO Objetivo Descrever a evolução de 15 casos de cefaleia em salvas de difícil controle, episódicos e crônicos, tratados com clomifeno. Métodos Foram tratados 7 casos crônicos e 8 episódicos. Os crônicos, refratários aos medicamentos preventivos em uso e os episódicos, além de refratários, apresentaram salva mais longa que as anteriores. Foram analisados o tempo para a ausência das crises, fim da salva e o tempo entre os dois parâmetros. Resultados O clomifeno foi usado por 45 a 180 dias. A média de tempo para a remissão das crises foi de 15 dias e da salva foi de 60 dias. A média entre o fim das crises e da salva foi de 26 dias. Conclusão O clomifeno foi eficaz em ambos os padrões. Foi capaz de interromper a cronicidade em todos os casos, o que sugere uma ação neuromodulatória capaz de mudar o padrão das crises. Mostrou-se seguro e bem tolerado.

Effects of ischemic preconditioning in a pig model of large-for-size liver transplantation

OBJECTIVE: In most cases of pediatric liver transplantation, the clinical scenario of large-for-size transplants can lead to hepatic dysfunction and a decreased blood supply to the liver graft. The objective of the present experimental investigation was to evaluate the effects of ischemic preconditioning on this clinical entity. METHODS: Eighteen pigs were divided into three groups and underwent liver transplantation: a control group, in which the weights of the donors were similar to those of the recipients, a large-for-size group, and a large-for-size + ischemic preconditioning group. Blood samples were collected from the recipients to evaluate the pH and the sodium, potassium, aspartate aminotransferase and alanine aminotransferase levels. In addition, hepatic tissue was sampled from the recipients for histological evaluation, immunohistochemical analyses to detect hepatocyte apoptosis and proliferation and molecular analyses to evaluate the gene expression of Bax (pro-apoptotic), Bcl-XL (anti-apoptotic), c-Fos and c-Jun (immediate-early genes), ischemia-reperfusion-related inflammatory cytokines (IL-1, TNF-alpha and IL-6, which is also a stimulator of hepatocyte regeneration), intracellular adhesion molecule, endothelial nitric oxide synthase (a mediator of the protective effect of ischemic preconditioning) and TGF-beta (a pro-fibrogenic cytokine). RESULTS: All animals developed acidosis. At 1 hour and 3 hours after reperfusion, the animals in the large-for-size and large-for-size + ischemic preconditioning groups had decreased serum levels of Na and increased serum levels of K and aspartate aminotransferase compared with the control group. The molecular analysis revealed higher expression of the Bax, TNF-alpha, I-CAM and TGF-beta genes in the large-for-size group compared with the control and large-for-size + ischemic preconditioning groups. Ischemic preconditioning was responsible for an increase in c-Fos, IL-1, IL-6 and e-NOS ...

A simplified experimental model of large-for-size liver transplantation in pigs

OBJECTIVE: The ideal ratio between liver graft mass and recipient body weight for liver transplantation in small infants is unknown; however, if this ratio is over 4%, a condition called large-for-size may occur. Experimental models of large-for-size liver transplants have not been described in the literature. In addition, orthotopic liver transplantation is marked by high morbidity and mortality rates in animals due to the clamping of the venous splanchnic system. Therefore, the objective of this study was to create a porcine model of large-for-size liver transplantation with clamping of the supraceliac aorta during the anhepatic phase as an alternative to venovenous bypass. METHOD: Fourteen pigs underwent liver transplantation with whole-liver grafts without venovenous bypass and were divided into two experimental groups: the control group, in which the weights of the donors were similar to the weights of the recipients; and the large-for-size group, in which the weights of the donors were nearly 2 times the weights of the recipients. Hemodynamic data, the results of serum biochemical analyses and histological examination of the transplanted livers were collected. RESULTS: The mortality rate in both groups was 16.5% (1/7). The animals in the large-for-size group had increased serum levels of potassium, sodium, aspartate aminotransferase and alanine aminotransferase after graft reperfusion. The histological analyses revealed that there were no significant differences between the groups. CONCLUSION: This transplant method is a feasible experimental model of large-for-size liver transplantation. .

Does administering albumin to postoperative gastroschisis patients improve outcome?

OBJECTIVES: Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS: One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS: Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4 percent and 92.0 percent, respectively), were similar for both phases. CONCLUSIONS: The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.

Evolution of critically ill patients with gastroschisis from three tertiary centers

OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers. METHODS: From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables. RESULTS: 163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1 percent). The mean serum sodium level was 127.4¡6.7 mEq/L, and the mean serum albumin level was 2.35¡0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9 percent. CONCLUSION: In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.

Qual é a melhor solução de hidratação parenteral a ser utilizada no tratamento pós-operatório de recém-nascidos com gastrosquise?: experiência do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP / Which is the best solution for parenteral infusion in the postoperative treatment for newborns with gastroschisis?: experience of Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP

Objetivos: Recém-nascidos (RN) com gastrosquise apresentam oligúria, anasarca, íleoadinâmico prolongado e infecção. O objetivo desse estudo foi utilizar nova abordagem para melhora da evolução pós-operatória. Método: Estudo com 103 RN foi dividido em duas fases: 1ª - infusão de grandes volumes de solução cristalóide, introdução precoce de fórmulas integrais e colocação de cateter venoso central com duplo-lúmen; 2ª - administração de soluções cristalóides em menores volumes, com infusão de colóides quando necessário, introdução tardia de dieta semi-elementar e colocação decateter PICC. Foram estudadas diferentes variáveis e feitas correlações com níveis séricos de sódio e albumina, necessidade de expansão com solução colóide, tempo de nutrição parenteral, período de tempo para início da dieta enteral e dieta plena, tempo de intubação oro-traqueal (IOT) e de internação, necessidade e tipo de cateter venoso central, complicações e sobrevida. Resultados: O nível de natremia da 2ª fase foi maior que da 1ª. Houve forte correlação entre hiponatremia e aumento do tempo de IOT. Necessidade de expansão com solução colóide se associou a maior tempo de IOT, tempo para início da dieta e tempo de internação. Frequênciade infecções nos RN com cateter central foi maior na 1ª fase. Os índices de sobrevida nas duas fases foram semelhantes (83,4% e 91,8%). Conclusões: Restrição da infusão de cristalóides com administração criteriosa de soluções colóides pode prevenir hiponatremia, a qual se relaciona a períodos de IOT mais prolongados. Cateteres do tipo PICC se associam a menor frequência de infecções.

Objectives: Newborns with gastroschisis display oliguria, anasarca, prolonged gastrointestinal dysfunction and infections. We proposed a different approach, aiming to improve postoperative outcome. Methods: The study with 103 newborns was divided in two phases: 1st - infusion of large volumes of crystalloid solution, milk formulae were early introduced and double lumen catheters were inserted; 2nd - maintenance fluids were restricted and colloid solutions were administered when necessary, late introduction of semi elemental formulae and PICCs were precociously inserted. Several data were evaluated and correlated with serum levels of sodium and albumin, necessity of colloid solutions infusion, time of parenteral nutrition, time to fisrt and full feeds, number of ventilation and inhospital days, need and kind of central catheter, complications and survival in both phases. Results: Natremia levels were higher in the 2nd than in the 1st phase. There was a strong correlation between hyponatremia and increased number of days on mechanical ventilation. Need of colloid solution boluses were associated with prolonged intubation periods, time to first feed and hospitalization. Frequency of systemic infections in patients with central catheters was higher in the 1st phase. Survival rates were similar (83.4% and 91.8%). Conclusions: In newborns with gastroschisis, restriction of crystalloid solutions infusion and judicious administration of colloids can prevent hyponatremia, which correlates with prolonged orotracheal intubation periods. Early insertion of PICCs is associated with less systemic infections than venous dissection.

Hipertensão renovascular: revisão de literatura / Renovascular hypertension: article review

Objetivo: Os autores fazem uma revisão de literatura sobre hipertensão renovascular, com enfoque principal acerca do tratamento. Método: Levantamento bibliográfico através dos sistemas de busca LILACS e MEDLINE. Conclusão: Em pacientes com estenose da artéria renal (EAR) por displasia fibromuscular, há um benefício satisfatório através da angioplastia por cateter-balão (PTRA), com baixos índices de reestenose, melhora do controle da pressão e normalização ou melhora da função renal. Em pacientes com EAR aterosclerótica, a reestenose pós-TRA é muito frequente, sendo tal ocorrência minimizada de forma bem significante com o advento dos stents. O tratamento percutâneo tem suas limitações, como creatinina sérica maior que 3,0 mg/dl. as cirurgias de bypass têm melhor resultado que os procedimentos percutâneos. Devemos lembrar que procedimentos de revascularização, cirúrgicos e percutâneos só tem validade, quando comprovada a viabilidade renal, caso contrário, a nefrectomia é inevitável