Never to be missed again - an analysis of 55 consecutive cases of traumatic diaphragmatic hernia.

BACKGROUND: This report reviews our clinical experience with 55 cases of traumatic diaphragmatic hernia at a Brazilian university hospital. Traumatic diaphragmatic hernia is an uncommon injury and presents diagnostic and therapeutic challenges. Occasionally, it is missed in trauma patients and is usually associated with significant morbidity and mortality. This analysis aimed to improve the diagnostic outcomes of trauma patient care. METHODS: Retrospective design analysis of database records of trauma patients at HC-Unicamp were performed to investigate incidence, trauma mechanism, diagnosis, herniated organs, associated injuries, trauma score, morbidity and mortality. RESULTS: Fifty-five patients were analysed. Blunt trauma was two-fold more frequent than penetrating trauma and was associated with high-grade injury; motor vehicle collision was the most common mechanism. Left-sided hernia was four-fold more frequent than that on the right side, although critical injuries were more frequently associated with the right side. The stomach was the most herniated organ in both trauma mechanisms. Preoperative diagnosis was mostly performed using chest radiography (55%). Postoperative diagnosis was mostly performed via laparotomy rather than laparoscopy. Associated injuries were observed in 43 patients (78%) and the mortality rate was 20% for both the sides. CONCLUSION: Isolated injuries are rare, and the presence of associated injuries increases morbidity and mortality. Chest radiography in the trauma bay is useful as an initial examination, although it is not suitable for use as a definitive method. Despite the use of laparoscopy in a few cases, laparotomy is the most common approach.

Risk and protective behaviors for chronic non-communicable diseases among Brazilian adults.

OBJECTIVES: This study aimed to analyze behavioral patterns of protective and risk factors for chronic non-communicable diseases (NCDs) among adults and to explore the association between these patterns and sociodemographic characteristics using data from the National Health Survey 2013. STUDY DESIGN: This was a cross-sectional study. METHODS: This is a population-based study, nationwide, of individuals aged ≥18 years (n = 60,202). The sampling process used was grouping with three selection stages: census sector, households, and individuals. The factor analysis by principal component was used to identify behavioral patterns of protective and risk factors for NCDs. Linear regression was used to explore the association between patterns and sociodemographic characteristics. RESULTS: Two behavioral patterns were identified: a 'protective pattern' featured by consumption of vegetable, fruits/natural fruit juice, and low-fat milk and recommended physical activity practice during leisure time; and a 'risk pattern' characterized by consumption of high-fat meat and soft drinks, alcohol abuse, and smoking habit. Adherence to the protective pattern was associated with older White women who had higher levels of education, were economically active, and lived in the urban areas of the country. Younger, economically active men living in the urban areas were associated with the risk patterns. CONCLUSIONS: Two behavioral patterns for NCDs have been identified and are distributed non-randomly in the adult Brazilian population. These findings are expected to contribute to better targeting health promotion and prevention of NCDs.

Origin and main ramifications of coeliac artery in Cerdocyon thous.

BACKGROUND: Cerdocyon thous is the canid with the greatest geographical coverage in South America. The aim of this study was to describe the origin, skeletopy, length and main branches of the coeliac artery in C. thous. MATERIALS AND METHODS: The dissections were performed on 14 cadavers of adult specimens, 6 males and 8 females, with a rostrosacral length average of 67.00 ± 4.7 cm and 62.09 ± 5.7 cm, respectively. The specimens were collected dead on highways on the banks of the Atlantic Forest (Rio de Janeiro) and the Pampa biome (Rio Grande do Sul) in Brazil. The cadavers were fixed and preserved in a formaldehyde solution until dissection. The coeliac artery was dissected, the length was measured "in situ" and its main branches were recorded. The coeliac artery emerged as a single artery in all dissected animals. RESULTS: The average length of the coeliac artery was 1.43 ± 0.17 cm in males and 1.39 mm ± 0.24 cm in females, with no significant difference in this measurement between sexes. The predominant skeletopy was at the level of the second lumbar vertebra (57.1%), positioned on average 1.43 cm cranially to the cranial mesenteric artery. In most individuals (92.9%), the classic trifurcation was formed: the coeliac artery branched into the hepatic, left gastric, and lienal arteries. Only 1 male animal presented a bifurcation formed between the hepatic artery and a gastrolienal trunk. CONCLUSIONS: These anatomical characteristics are similar to those of other species of the Canidae family, possibly due to their phylogenetic proximity.

Um possível mecanismo de ação para o efeito anticonvulsivante do p-cimeno / A plausible mechanism of action for the anticonvulsant effect of p-cymene

O presente estudo teve como objetivo investigar o efeito anticonvulsivante do p-cimeno (CIM), bem como verificar a concentração das monoaminas (dopamina(DA), noradrenalina (NA), serotonina (5-HT), e seus metabólitos (ácido dihidroxifenilacético (DOPAC), ácidohomovanílico (HVA) e ácido 5-hidroxi-indol-acético (5-HIAA)) no hipocampo de camundongos tratados com cloridrato de pilocarpina 400 mg/kg (P400; i.p.) e nos grupos tratados com a associação de CIM (50, 100 ou150 mg/kg) e P400. Nesse estudo foi avaliada a latência para a primeira crise epiléptica e a taxa de mortalidade. Os resultados revelaram que o CIM produziu um aumento na latência para primeira crise epilética, bem como promoveu uma proteção significativa contra a mortalidade induzida pelo processo convulsivo. O monoterpeno nas doses testadas também foi capaz de produzir um aumento da latência para instalação do estado de mal epilético induzido por pilocarpina. Além disso, durante os estudos para identificar o mecanismo de ação nenhum dos efeitos do p-cimeno nesse modelo foram bloqueados pelo pré-tratamento com atropina. Complementando os estudos para identificar o provável mecanismo de ação do p-cimeno, foi verificado que os efeitos desse monorterpeno foram revertidos pelo flumazenil, um antagonista do sistema GABAérgico, sugerindo que esse monoterpeno pode atuar por meio desse sistema. Também, em nossos resultados também foi visto uma diminuição dos níveis de DA e um aumento do conteúdo de seus metabólitos (DOPAC e HVA) durante as crises epilépticas. Por outro lado foi detectado um aumento na concentração de NA e 5-HT, e uma diminuição no metabólito da 5-HT (5-HIAA) durante as crises epilépticas. Dessa forma, o CIM na presença do estímulo convulsivo, reverte os efeitos produzidos nos níveis das monoaminas e seus metabólitos observados durante as crises epilépticas, sugerindo que este monoterpeno produz efeito anticonvulsivante por meio da modulação direta do sistema GABAérgico e indiretamente por...

The aim of this study was to investigate the anticonvulsant effect of p-cymene (CYM) and to determine the concentrations of monoamines (dopamine (DA), noradrenaline (NA) and serotonin (5-HT)), and their metabolites (dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA)) in the hippocampus of mice treated with pilocarpine hydrochloride 400 mg/kg (P400; i.p.) and in groups treated with a combination of CYM (50,100 or 150 mg/kg) and P400. We assessed the latency to the first epileptic seizure and the mortality rate. Results showed that CYM produced an increase in latency to the first seizure, as well as providing significant protection against mortality induced by seizures. Higher doses of the monoterpene were also able to prolong the latency to the onset of status epilepticus induced by pilocarpine. Moreover, in an experiment to throw light on the mechanism of action of p-cymene, none of its effects was blocked by pretreatment with atropine. In further studies to identify the probable mechanism of CYM, it was observed that the effectsof this monoterpene were reversed by flumazenil, anantagonist of the GABAergic system, suggesting that it may act through this cerebral system. Furthermore, our results also showed a fall in DA levels and an increase in the contents of its metabolites (DOPAC and HVA) during seizures. On the other hand, increases in NA and 5-HT concentrations and a decrease in that of the 5-HTmetabolite (5-HIAA) were detected during seizures. Thus, CYM, in the presence of a convulsant stimulus, reverses the effects on levels of monoamines and their metabolites observed during seizure activity, suggesting that this monoterpene produces its anticonvulsant effect by modulating the GABAergic system directly and/or indirectly, through changes in monoamine (DA, NA and 5-HT) contents opposite to those observed during the convulsive process in the hippocampal region. However,further studies are necessary to...

Urine cytology as a screening method for polyoma virus active infection.

Polyoma virus nephropathy (PVN) occurs in 3% to 4% of renal transplants, causing graft loss in about 50% of cases. The presence of viral cytopathic changes in graft epithelial cells is the only diagnostic tool for PVN. However, identification of cells with viral inclusions (decoy cells) in urine can be used as a screening tool for viral replication of or for active infection with PV. The aim of the present study was to identify the occurrence of PV active infection in renal transplant recipients. Two hundred forty urine cytology samples, collected from 80 transplant patients with stable renal function, were collected on a monthly basis and stained with the Pap smear for decoy cells. Active infection with polyoma virus was confirmed by urine immunostaining. All samples were analyzed blindly and classified as negative or positive (>1 decoy cell/sample). Among 240 urine cytologies collected from 48 men and 32 women, decoy cells were identified in 37.5%. No differences were observed in serum creatinine or immunosuppressive regimen between patients with positive versus negative cytology. No graft losses occurred secondary to PVN in the present study setting. The incidence of decoy cells in this series (37.5%) was consistent with previous reports (20% to 40%), suggesting that active infection may be confirmed by PV immunohistochemistry. The absence of PVN in this group may be attributed to the low doses of immunosuppressive drugs in the late posttransplant transplant period, but also to the unknown incidence of polyoma virus infection in Brazil.

Tumor grade heterogeneity in urothelial bladder carcinoma--proposal of a system using combined numbers.

OBJECTIVE: There is no consensus for grading when more than one grade is present in bladder carcinoma. We propose a grading system that considers the primary (most common) and secondary (second most common) grade of bladder cancer. Grade was correlated with stage of the tumors. MATERIAL AND METHODS: We studied 293 bladder transurethral resections or radical cystectomies. Grade was considered as 1, 2 or 3 according to the 1999 World Health Organization system. The number was repeated when only one grade was seen. A final score was obtained which ranged from 2 to 6. All cases were also graded according to the highest grade area even if it was focal. RESULTS: According to the highest grade area, the distribution was 80 (74.07%), 27 (25.00%) and 1 (0.92%) for grade 1; 31 (24.03%), 69 (53.48%) and 29 (22.48%) for grade 2; and 0 (0%), 17 (30.35%) and 39 (69.64%) for grade 3, corresponding to the stages Ta, T1 and T2-T3, respectively. Using the system of combined numbers, grade 2 was stratified into subgroups 1 + 2 and 2 + 2 which are statistically different (p < 0.05) when considering stage. In grade 3, there was also a trend for statistical difference (p = 0.066) between grades 2 + 3 and 3 + 3. CONCLUSIONS: The grading system of combined numbers, stratifies grade 2 into subgroups 1 + 2 and 2 + 2, and grade 3 into subgroups 2 + 3 and 3 + 3 which are statistically different when considering stage. This grading system of combined numbers takes into consideration tumor heterogeneity and may be of value in prospective studies for analysis of prognosis and therapeutic response.

Cystic struma ovarii: a rare presentation of an infrequent tumor.

CONTEXT: Struma ovarii, a rare neoplasm, is a monophyletic teratoma composed of thyroid tissue. It is generally considered to account for less than 5% of mature teratomas. CASE REPORT: A diagnosis of struma ovarii may be the source of many diagnostic problems. It may be cystic and microscopic examination may only reveal a few typical thyroid follicles, resulting in confusion with other cystic ovarian tumors. Extensive sampling should be undertaken and immunohistochemistry may be decisive in establishing the thyroid nature of the epithelial lining. The authors report two cases of cystic struma ovarii, and discuss diagnostic criteria and the limitations of frozen biopsies in these tumors.

Pseudocystic form of neurocryptococcosis in pregnancy. Case report.

We report a case of neurocryptococcosis which is unique in the literature because the patient had a pseudocystic form of the disease during pregnancy and without any evidence of AIDS. The clinical picture was that of intracranial hypertension and the epidemiological background was highly suggestive of cysticercosis. CT showed multiple round hypodense lesions in the basal ganglia and cerebellum, without contrast enhancement. Since a scolex was not visible, the diagnosis of neurocysticercosis was considered probable. CSF examination was not performed in view of its high risk. The patient had progressive downhill course. Autopsy disclosed multiple gelatinous pseudocysts in the cerebral and cerebellar gray matter, containing abundant Cryptococcus neoformans. Meningeal involvement was minimal. The child was delivered by caesarean section and was free of infection, but died later of hyaline membrane disease. The neuroimaging appearances of this rare instance of the pseudocystic form of neurocryptococcosis mimicked closely neurocysticercosis and only postmortem examination allowed correct diagnosis. The pseudocystic form has so far only been reported in AIDS.

Chromophobe renal cell carcinoma: clinicopathological study of 7 cases.

Chromophobe renal cell carcinoma (CRCC) may be grossly and microscopically confused with oncocytoma. It is now believed that many, if not all, of the so-called malignant oncocytomas or oncocytomas with metastases reported in the literature were indeed chromophobe renal cell carcinomas. CRCC is characteristically positive for colloidal iron and shows cytoplasmic microvesicles in electron microscopy. This study of CRCC is thought to be the first one done in Latin America. Of a total of 106 renal epithelial neoplasms, 7 (6.6%) fulfilled the criteria for chromophobe renal cell carcinoma. This frequency in Brazil is similar to that in other parts of the world. There was no difference in age, sex, and race distribution of CRCC compared to usual renal epithelial tumors. Grossly, the CRCC ranged in size from 3.5 to 20 cm (average: 10.2 cm) in greatest dimension. Most frequently, the tumor was brown on the cut surface. The growth pattern showed compact areas in all tumors and, in most of the cases, both clear and eosinophilic cellular subtypes were seen. The electron microscopic findings favor an origin of the microvesicles from outpouchings of the outer membrane of mitochondria. The strong positivity for colloidal iron in spite of the destruction of the cytoplasmic vesicles in paraffin-embedded specimens seems to indicate that the acid mucopolysaccharides are not located inside the microvesicles. By the time of diagnosis, only one case had regional lymph node metastases and this particular case was the only one mixed (associated with the usual renal cell carcinoma). The follow-up examination after nephrectomy showed that prognosis seems to be favorable in CRCC, except when the tumor coexists with the usual renal cell carcinoma.

[Kaposiform hemangioendothelioma associated with Kasabach-Merritt syndrome] / Hemangioendotelioma kaposiforme associado à síndrome de Kasabach-Merritt.

OBJECTIVE: To describe a case of kaposiform hemangioendothelioma, the only malignant tumor of vascular origin specific of childhood.METHODS: We report a case of a 40-days-old girl who presented with a giant hemangioma of the face. Rapid enlargement of the tumor lead to laryngeal compression with severe respiratory distress. She had also a consumptive thrombocytopenic coagulopathy (Kasabach-Merritt syndrome).RESULTS: She was admitted to the pediatric intensive care unit of the Hospital das Clínicas da Universidade Estadual de Campinas and mechanical ventilation was introduced. A ten day course of dexamethasone was only partially effective. We then started alpha-2a interferon at a dose of 1.8 million units/m(2)/day by subcutaneous route, but she died four days after the onset of this therapy. The microscopic features showed a kaposiform hemangioendothelioma.CONCLUSION: We discuss this unusual fatal evolution of a rapidly growing hemangioma and its hematological complications.