Wilms tumor in children: A multivariate analysis of prognostic factors, with emphasis on inferior vena cava/right atrium extension. Results from a single-center study.

BACKGROUND: To identify prognostic factors for overall survival through the analysis of 132 patients with Wilms tumor followed at a single center, with emphasis on the inferior vena cava/right atrium extension. METHODS: Retrospective analysis of overall survival using logistic regression models and including age, sex, clinical features, associated syndromes, comorbidities, tumor size before chemotherapy, stage, presence of metastatic disease and its site, invasion of adjacent structures, inferior vena cava/right atrium extension, laterality, tumor histology, chemotherapy protocol, and radiotherapy as potential risk factors. RESULTS: From January 2000 through November 2021, 132 patients met the inclusion criteria, 64 females and 68 males; 15 (11.4%) patients presented with tumoral extension to inferior vena cava/right atrium and 44 had metastatic disease (33.3%). Based on logistic regression, the factors correlating to a fatal outcome were male sex (p = 0.046), high risk histology (p = 0.036), and the presence of metastatic disease (p = 0.003). None of the patients presenting inferior vena cava/right atrium extension died (p = 0.992). In a specific analysis of metastatic sites, hepatic metastasis alone showed correlation with a fatal outcome (p = 0.001). CONCLUSION: These results underline the importance of identifying and treating metastatic disease and high-risk tumors. The female gender as a potential driver for a less aggressive disease is a new finding that deserves further investigation. The accurate identification of inferior vena cava/right atrium extension, subsequent preoperative chemotherapy, and resection with a skilled team promoted survival rates of all patients. LEVEL OF EVIDENCE: II.

Flecainide-induced QRS complex widening correlates with negative inotropy.

BACKGROUND: The negative inotropic effect of Class IC antiarrhythmic drugs limits their use for acute cardioversion of atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to examine, in an intact porcine model, the effects of pulmonary and intravenous (IV) administration of flecainide on left ventricular (LV) contractility and QRS complex width at doses that are effective in converting new-onset AF to sinus rhythm. METHODS: Flecainide (1.5 mg/kg bolus) was delivered by intratracheal administration and compared to 2.0 mg/kg 10-minute IV administration (European Society of Cardiology guideline) and to 0.5 and 1.0 mg/kg 2-minute IV doses in 40 closed-chest, anesthetized Yorkshire pigs. Catheters were fluoroscopically positioned in the LV to monitor QRS complex width and contractility and at the bifurcation of the main bronchi to deliver intratracheal flecainide. RESULTS: Peak flecainide plasma concentrations (Cmax) were similar, but the 30-minute area under the curve (AUC) of plasma levels was 1.4- to 2.8-fold greater for 2.0 mg/kg 10-minute IV infusion than for the lower, more rapidly delivered intratracheal and IV doses. AUC for LV contractility (ie, negative inotropic burden) was 2.2- to 3.6-fold greater for 2.0 mg/kg 10-minute IV dose than for the lower, more rapidly delivered doses. QRS complex widening by flecainide was highly correlated with the decrease in LV contractility (r2 = 0.890, P <.0001, for all IV doses; r2 = 0.812, P = .01, for intratracheal flecainide). CONCLUSION: QRS complex widening in response to flecainide is strongly correlated with decrease in LV contractility. Rapid pulmonary or IV flecainide delivery reduces the negative inotropic burden while quickly achieving Cmax levels associated with conversion of AF.

T-wave heterogeneity in standard resting 12-lead ECGs is associated with 90-day cardiac mortality in women following emergency department admission: A nested case-control study.

BACKGROUND: We investigated whether T-wave heterogeneity (TWH) can identify patients who are at risk for near-term cardiac mortality. METHODS: A nested case-control analysis was performed in the 888 patients admitted to the Emergency Department (ED) of our medical center in July through September 2018 who had ≥2 serial troponin measurement tests within 6 hr for acute coronary syndrome evaluation to rule-in or rule-out the presence of acute myocardial infarction. Patients who died from cardiac causes during 90 days after ED admission were considered cases (n = 20; 10 women) and were matched 1:4 on sex and age with patients who survived during this period (n = 80, 40 women). TWH, that is, interlead splay of T waves, was automatically assessed from precordial leads by second central moment analysis. RESULTS: TWHV4-6 was significantly elevated at ED admission in 12-lead resting ECGs of female patients who died of cardiac causes during the following 90 days compared to female survivors (100 ± 14.9 vs. 40 ± 3.6 µV, p < .0001). TWHV4-6 generated areas under the receiver-operating characteristic (ROC) curve (AUC) of 0.933 in women (p < .0001) and 0.573 in men (p = .4). In women, the ROC-guided 48-µV TWHV4-6 cut point for near-term cardiac mortality produced an adjusted odds ratio of 121.37 (95% CI: 2.89-6,699.84; p = .02) with 100% sensitivity and 82.5% specificity. In Kaplan-Meier survival analysis, TWHV4-6  ≥ 48 µV predicted cardiac mortality in women during 90-day follow-up with a hazard ratio of 27.84 (95% CI: 7.29-106.36, p < .0001). CONCLUSION: Elevated TWHV4-6 is associated with near-term cardiac mortality among women evaluated for acute coronary syndrome.

Evaluation of Carbon Nanotube Incorporation in Cementitious Composite Materials.

Over the last decades, new materials with outstanding performance have been introduced in the construction industry. Considering these new technologies, it is worth mentioning that nanotechnology has revolutionized various areas of engineering. In the area of civil engineering and construction, cement is used for various purposes and the search to improve its performance has been receiving growing interest within the scientific community. The objective of this research was to evaluate the behavior of cement mortar produced by the addition of multi-walled carbon nanotubes (MWCNTs) in different concentrations by comparing their physical and mechanical properties with the properties of the nanotube-free composite. Motivated by the lack of consensus in the literature concerning to the optimal dosage of CNTs in cementitious matrices, three different carbon nanotube ratios, 0.20, 0.40 and 0.60 wt % Portland cement, were investigated with the aim of evaluating the mechanical properties. Destructive tests were carried out to determine the compressive strength, flexural strength and split tensile strength. Additionally, a non-destructive test was performed to determine the dynamic elastic modulus and density. Scanning electron microscopy (SEM) images showed the interaction between the MWCNTs and the hydration products of Portland cement mortar. The results indicated the potential contribution of 0.40 wt % cement CNTs to the enhancement of the mechanical properties of the cement composite as a promising construction material.

Nova sede fortalece atuação da escola de Blumenau / New headquarters strengthens performance of Blumenau school

Aos 57 anos, ETSUS Blumenau inaugura novo prédio que irá abrigar as formações técnicas e especializações dos profissionais do sistema de saúde da região. (AU)

[Large infectious thoracoabdominal aortic aneurysm in a chronic contained rupture, treated successfully using the "simplified technique"]. / Volumoso aneurisma infeccioso da aorta toracoabdominal em rotura contida tratado com sucesso pela "técnica simplificada"

The clinical case of a 72-years old male is reported, admitted into a Medical Department through the Emergency Service, with a clinical picture of heavy lumbar pain, with walking compromise and acute urinary retention, lasting for several hours. Laboratory analysis revealed a marked elevation of acute inflammatory parameters and a renal failure, expressed by 108 mg/dl of urea and 4.4 mg/dl of creatinine. The patient was admitted with the provisional diagnosis of acute prostatitis, pos-renal acute renal insufficiency and dorso-lumbar pathology of unknown etiology. Three consecutive and subsequent hemocultures allowed the isolation of a Streptococcus pneumonae strain and a CT dorso lumbar spine evaluation disclosed a D11 to D12 spondylodiscitis, with a partial destruction of the vertebral bodies and an extensive throracoabdominal aortic aneurysm adjacent to those vertebrae, with some characteristic features of an infectious aneurysm. Simultaneously, an hemothorax on the left chest was noticed, consequence of a chronic contained rupture of the aneurysm. Following an intensive and specific antibiotic therapy and with an almost completed recovery of the renal function, he underwent surgical management, consisting in the evacuation and drainage of the hemothorax, followed by resection of the aneurysm and extensive tissular debridmente, culminating in the vascular reconstruction utilizing the "simplified technique", introduced in 1984 by A. Dinis da Gama for the surgical management of thoracoabdominal aortic aneurysms. The patiente tolerated the procedure well, with no intercorrences or complications and the post operative course was unventfull. One month later, a CT-angio control disclosed the revascularization procedure working in excellent condition. Finally, an orthopedic artrodhesis of the injuried vertebrae was performed, allowing an easy and pain-free walking and he was discharged on day 60, under antibiotic treatment. The main features of this clinical case are emphasized and discussed, namely those aspects related to its pathogenesis, clinical presentation, diagnosis and surgical management.

[Surgical management of a dissecting aneurysm of the thoracic aorta in a patient with Marfan's syndrome - case report]. / Tratamento cirúrgico de um aneurisma dissecante da aorta torácica numa doente com síndrome de marfan - Caso clínico.

Marfan's Syndrome is a rare connective tissue disease whose surgical treatment presents several challenges. The existing criteria and recommendations on how and when to surgically approach this disease is almost exclusively confined to the root and ascending aorta, in contrast to the variability of indications on the involvement of the remaining segments of the thoracic and abdominal aorta, due to the multiplicity, morphology and topography of these involvements. This case report is related to a 39 year old woman with Marfan's syndrome, with a type B chronic dissection and a segmentar aneurysm of the proximal descending thoracic aorta with 6,1cm of maximum diameter. The clinical and imagiologic evaluation pointed out the absence of any disorder of the heart, root or ascending aorta. The patient underwent surgical management of the dissecting aneurysm through a transthoracic approach to the aneurysm, with fenestration of the distal aorta and exclusion of the aneurism and intercostal arteries. The efficacy and result of the procedure in addition to the rarity of the vascular pathology presented by the patient, even in the context of a Marfan, completely justify the presentation and disclosure of this clinical case.

[Infra-inguinal prosthetic graft infection in vascular surgery. A case report and review of the literature]. / Infeção protésica infra-inguinal em cirurgia vascular. A propósito de um caso clínico.

Prosthetic vascular graft infection is a rare but very severe complication coursing with high morbi-mortality rates. Its treatment requires appropriate surgical procedures combined with adequate antimicrobial treatment in reference centers. The authors report the clinical case of a 71 years old patient, diagnosed with early prosthetic graft infection 3 months after implantation of a femoro-femoral crossover and a prosthetic- popliteal bypass, treated conservatively, with extensive surgical debridement, preservation of the graft and empirical bactericidal broad spectrum antibiotherapy. The clinical case offers the opportunity to review and discuss the diagnosis and therapeutic issues in prosthetic vascular graft infections. Research is needed to allow an estimation of the risks and benefits of the different therapeutic approaches.

[Endovascular femoro-popliteal revascularization in critical limb ischemia: predictive factors for patency]. / Prognóstico das intervenções endovasculares no sector femoro-popliteu em quadros de isqemia crítica dos membros inferiors: factores determinantes da permeabilidade.

OBJECTIVES: The objective of this study was to evaluate the results of endovascular treatment of the superficial femoral artery and to identify some possible predictors of poor prognosis. METHODS: All patients with femoropopliteal artery occlusive disease submitted to endovascular treatment in the internment section of the first author, between July 2007 to September 2010, were reviewed. Intention to treat analysis was performed. Patient's demographics and angiographic anatomic characteristics (results were standardized according to TransAtlantic Inter-Society Consensus II) were analyzed. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. We performed a univariate and bivariate analysis in order to determine factors temporally associated with a poor prognosis of endoluminal therapy. Results were evaluated in view of absence of re-stenosis, absence of re-intervention, patency and overall limb salvage rate. RESULTS: A total of 34 patients corresponding to 36 lower limbs were treated during this period (mean age 65±12 years; males: 80%). Seventy-five percent of patients presented with chronic lower limb ischemia stage IV according to the Leriche-Fontaine classification, while the remaining 25% presented with chronic lower limb ischemia stage III. The lesions classified according to the TASC II document included 9 lesions TASC II B (25%), 20 lesions TASC II C (55%) and 7 lesions TASC II D (19%). Runoff at the tibial level was 1.8±0.6 patent vessels. The success rate was 94%. Mean follow-up was 13.5 months (varying 1-31 months) from the date of initial intervention. Five lower limbs (14%) presented with re-stenosis. Primary patency rates were 91% at 1 month and 77% at 6 months. Limb salvage rate was 88% at 12 months. Subgroup analysis revealed that primary patency rates were highly dependent on patient gender, lesion type and infra-popliteal runoff patent vessels. CONCLUSIONS: Endovascular treatment of femoropopliteal sector is associated with high technical success rate. The best results were obtained in male patients with segmental, stenotic lesions and with a runoff of at least two vessels.

[Leiomyosarcoma of the superficial femoral vein. Case report]. / Leiomiossarcoma da veia femoral superficial. Caso clínico.

The authors report the clinical case of a 56 years old man who developed a deep venous thrombosis of the left lower extremity, managed conventionally with subcutaneous heparin. Physical examination revealed a large tumor of the middle third, antero lateral view of the left thigh. CT and NMR studies, disclosed an extensive multilobulated tumor along the femoral vessels, with medial deviation of the superficial femoral artery and a surgical biopsy revealed the diagnosis of leiomyosarcoma of the femoral vein, grade 3 of malignancy. The patient underwent a complete resection of the tumor, followed by chemotherapy. Two months after the operation a staging CT scan disclosed multiple micronodular metastasis in both lungs and six months later he was found asymptomatic and in good condition. A review of the literature concerning primary malignant tumors of the veins of the extremities is made, with emphasis on main features of its biology, clinical presentation, methods of diagnosis, treatment and results.

[The utilization of the "simplified technique" in the simultaneous management of independent thoracic and abdominal aortic aneurysms. A clinical report]. / Aneurismas independentes da aorta torácica e abdominal tratados simultaneamente pela "técnica simplificada". Caso clinico.

The coexistence of independent aneurysms of the thoracic and abdominal aorta in a single individual, with operative indication has been regarded, since ever, as an enormous challenge to the vascular surgeons and is a source of controversy, regarding the hierarchy, priorities and methods of expeditious management. The authors report the clinical case of a 65 years old male, with a descending thoracic aortic aneurysm, extended to the abdominal visceral vessels, having 6.5 cm of maximum size, together with an infrarenal aortic aneurysm, with 4.5 cm of major diameter. The patient underwent the surgical treatment of both aneurysms, in the same operation, utilizing the "simplified technique", introduced by ourselves in 1984, for the management of thoracoabdominal aortic aneurysms. The efficacy, safety and excellency of the procedure as well as of the clinical result, assessed by angio-CT scans, allow us to enhance one more indication for the "simplified technique" in the management of complex aortic pathology, thus justifying its presentation and divulgation.

[High output heart failure due to an iatrogenic arteriovenous fistula after cardiac catheterization]. / Insuficiência cardíaca de alto débito secundária a fístula arterio-venosa iatrogénica pós cateterismo cardíaco.

The occurrence of an arteriovenous fistula is a potential complication of cardiac catheterization. Most of these fistulas cause no harm. We report the clinical case of a 70 years old woman with high-output heart failure caused by an arteriovenous fistula (FAV) in the groin. The fistula was successfully closed by surgical repair and the heart failure was resolved. This case confirms the potential harmfulness for the vascular bed of certain surgical/endovascular interventions and intravascular monitoring techniques. When heart failure of uncertain etiology appears in patients previously submitted to one of the above mentioned procedures, a careful clinical examination can lead to a correct diagnosis of iatrogenic FAV, whose surgical correction is usually followed by the restoration of a normal cardiac function.

[Recurrent systemic paradoxical embolism: a clinical report]. / Embolismo paradoxal sistémico recorrente: a propósito de um caso clínico.

Paradoxical embolism (EP) occurs when a venous thrombus passes into the arterial circulation, most commonly through an intracardiac shunt. A patent foramen ovale (FOP) is present in 25-35%of people at all ages. It is now possible to detect FOP by contrast echocardiography and it has been shown that there exists quite frequently a spontaneous transient right-to-left shunt during systole and, moreover, a right-to-left shunt during Valsalva maneuver and coughing. Acute or chronic pulmonary hypertension are also causes of shunt. This phenomenon has been associated with catastrophic outcomes such as stroke, visceral infarction and ischemic limb. We report the case of a 31-year old man with multiple paradoxical thromboemboli into his right kidney, spleen, small bowel and left brachial artery. Paradoxical embolism was suspected and confirmed by transoesophageal contrast echocardiography, disclosing FOP with right-to-left shunt. Successful percutaneous closure of patent foramen ovale with Amplatzer(R) PFO occluder 18 mm allowed subsequent oral antiaggregation with acetilsalicilic acid 150 mg/day and clopidogrel 75 mg/day. A new case gives the opportunity to review mechanisms, diagnosis and therapeutic issues. Treatment strategies for FOP in recurrent PE include antiplatelet agents, anticoagulants, surgical closure, or percutaneous closure devices. The completion of ongoing, randomized clinical trials comparing percutaneous closure devices with medical management is urgently needed to clarify if the risks of invasive endovascular device placement are outweighed by a long-term reduction in recurrent vascular events.

[Fibromuscular dysplasia of the brachial artery, an unusual cause of upper extremities ischemia. A case report and review of the literature]. / Displasia fibromuscular da artéria umeral, uma causa rara de isquemia dos membros superiores. A propósito de um caso clínico.

Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic sistemic disease of unknown etiology, primarily affecting muscular arteries of intermediate size. It has been most commonly observed in the renal, carotid, and intracerebral arteries, although it has been reported in other arterial beds. However, being an uncommon disease in general, the manifestation of FMD in the upper extremities is exceedingly rare. The authors report the case of a 69 years old female admitted with ischemia of the right hand, secondary to fibromuscular dysplasia of the midbrachial artery. The patient presented to vascular surgery clinic with a 4 month history of numbness, pain, and coolness of her right hand, with a small necrotic lesion on her right index finger. Peripheral pulses were barely palpable, and doppler-derived brachial and radial systolic pressures suggested midbrachial artery stenosis. Arteriography showed a normal arch and normal innominate, subclavian, and axillary arteries. The midbrachial artery was markedly abnormal and had alternating areas of stenosis and aneurysm formation - "string-of-beads" appearance. The patient underwent surgical excision of the abnormal right brachial artery, and reconstruction was accomplished with a reversed saphenous vein graft. Distal pulses were restored postoperatively. Pathologic examination confirmed the diagnosis of fibromuscular dysplasia. A review of the literature on the topic was made.

[Inflammatory aneurysms of the abdominal aorta, complicated by hydronephrosis and anuria. Surgical management]. / Aneurismas inflamatórios da aorta abdominal complicados com hidronefrose e anúria. Tratamento cirúrgico.

In this paper the clinical condition of two male patients, aged 58 and 65 years are presented, after being admitted as a consequence of a rare complication of an inflammatory aneurysm of the abdominal aorta, which is an ureteral compression, with hydronephrosis, anuria and acute renal failure. After having an urgent haemodialysis session, the etiology of the process was diagnosed by echography and abdominal CT-scans, followed by ureteral catheterization, restoration of diuresis and normalization of renal function. Conventional surgery was performed later, in elective conditions, and the post operative course was normal, without complications. The main features of this clinical entity, its diagnosis and multidisciplinary management are presented and discussed.

[Lower limbs revascularization originated in the descending thoracic aorta]. / Revascularização dos membros inferiores a partir da aorta torácica descendente.

The revascularization of the lower limbs through a bypass graft from the descending thoracic aorta is one of the most uncommon surgical procedures within the scope of the so-called "extra-anatomic revascularization". It is an highly selective procedure in terms of indications and is regarded as an effective hemodynamic alternative, with acceptable long-lasting results. Two patients who underwent successfully the operation are reported, followed by a discussion on the technical aspects, indications, complications and early and late results of the procedure.

Planejamento das ações em saúde bucal na ESF- Avaí em Jacinto/MG, na atenção a crianças e adolescentes de 6 a 12 anos

A cárie é uma doença que atinge as pessoas em todas as idades, podendo interferir na saúde geral e na qualidade de vida da população. Foi observado nos grupos de crianças de faixa etária de 6 a 12 anos, da área adscrita da Estratégia Saúde da Família do distrito Avaí do município do Jacinto/Minas Gerais, índices elevados de cárie. O objetivo deste estudo foi propor ações, a partir de uma revisão de literatura, que orientem o processo de trabalho da equipe de saúde bucal e interfiram no processo da doença cárie na população de faixa etária de 6 a 12 anos. Realizou-se em um primeiro momento o diagnóstico situacional do território onde foram levantados os principais problemas através de pesquisa em documentos e registros dos arquivos de saúde bucal do município, análise dos odontogramas nos prontuários de crianças de 6 a 12 anos, dados da ficha A, bem como entrevista com informante chave. Posteriormente realizou-se a pesquisa na BIREME, nas bases MEDLINE E LILACS, por artigos publicados no período de 2000 a 2012 na língua portuguesa. Foram selecionados 12 artigos e 1 tese, 2 monografias, 1 documento do Ministério da Saúde, 1 Linha Guia, 1 Caderno de Atenção Básica e 2 protocolos de atenção à saúde bucal. Conclui-se que as ações de promoção, prevenção e reabilitação devem ser realizadas forma conjunta e de acordo com as necessidades da população e a realidade local, bem como ser planejadas, além de se buscar parcerias com as escolas.