Anaesthesia in a parturient with systemic mastocytosis.

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Consideraciones anestésicas en una parturienta con mastocitosis sistémica / Anesthetic considerations in a laboring woman with systemic mastocytosis

La mastocitosis se caracteriza por la expansión clónica de mastocitos, con acumulación anormal en diferentes órganos. Perioperatoriamente, numerosos estímulos pueden originar la liberación de sustancias vasoactivas por parte de los mastocitos. Las parturientas con mastocitosis sistémica plantean una dificultad al anestesiólogo: por un lado, el dolor y el estrés del parto pueden causar una mayor activación de los mastocitos y, por otro, la administración de fármacos puede desencadenar posiblemente la liberación de mediadores de los mastocitos. Los autores describen un caso de una embarazada de 34 años de edad con mastocitosis sistémica que solicita analgesia para el parto. Se realizó analgesia epidural tras la inducción del parto, una vez consideradas las particularidades anestésicas. El procedimiento epidural, el parto y la expulsión transcurrieron sin incidentes. Se aporta una revisión de la mastocitosis sistémica y se abordan sus consideraciones anestésicas.(AU)

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.(AU)

Anesthetic considerations in a laboring woman with systemic mastocytosis. / Consideraciones anestésicas en una parturienta con mastocitosis sistémica.

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Fluticasone/formoterol dry powder versus budesonide/formoterol in adults and adolescents with uncontrolled or partly controlled asthma.

UNLABELLED: This 12-week study compared the efficacy and safety of a fixed combination of fluticasone propionate plus formoterol (FL/F) 250/12 µg b.i.d. administered via a dry powder inhaler (DPI) (Libbs Farmacêutica, Brazil) to a combination of budesonide plus formoterol (BD/F) 400/12 µg b.i.d. After a 2-week run-in period (in which all patients were treated exclusively with budesonide plus formoterol), patients aged 12-65 years of age (N = 196) with uncontrolled asthma were randomized into an actively-controlled, open-labeled, parallel-group, multicentre, phase III study. The primary objective was to demonstrate non-inferiority, measured by morning peak expiratory flow (mPEF). The non-inferiority was demonstrated. A statistically significant improvement from baseline was observed in both groups in terms of lung function, asthma control, and the use of rescue medication. FL/F demonstrated a statistical superiority to BD/F in terms of lung function (FEV(1)) (p = 0.01) and for asthma control (p = 0.02). Non-significant between-group differences were observed with regards to exacerbation rates and adverse events. In uncontrolled or partly controlled asthma patients, the use of a combination of fluticasone propionate plus formoterol via DPI for 12-weeks was non-inferior and showed improvements in FEV(1) and asthma control when compared to a combination of budesonide plus formoterol. ( CLINICAL TRIAL NUMBER: ISRCTN60408425).

Nasal eosinophilia: an indicator of eosinophilic inflammation in asthma.

BACKGROUND: It is noteworthy that there is a clear clinical, epidemiological and pathophysiological association between upper and lower airway inflammation in rhinitis and asthma. OBJECTIVE: The aim of this study was to compare the eosinophil counts in induced sputum and nasal lavage fluids in asthma, checking their association and the accuracy of nasal eosinophilia as a predictor of sputum eosinophilia by a cross-sectional study. METHODS: The clinical evaluation, asthma control questionnaire (ACQ), pre- and post-bronchodilator spirometry, nasal and sputum sample was performed. The nasal eosinophilia was analysed by a receiver operating curve and logistic regression model. RESULTS: In 140 adults, the post-bronchodilator forced expiratory volume in 1 s (FEV(1)) did not differ between patients with or without sputum eosinophilia (0.18). After adjusted for upper airway symptoms, age, ACQ score and post-bronchodilator FEV(1), sputum eosinophilia was associated with 52 times increase in odds of nasal eosinophilia, whereas each 1% increase in bronchodilator response was associated with 7% increase in odds of nasal eosinophilia. CONCLUSION: This study brings further evidence that upper airway diseases are an important component of the asthma syndrome. Furthermore, monitoring of nasal eosinophilia by quantitative cytology may be useful as a surrogate of sputum cytology in as a component of composite measurement for determining airway inflammation.

Direct costs of asthma in Brazil: a comparison between controlled and uncontrolled asthmatic patients.

Asthma is a common chronic illness that imposes a heavy burden on all aspects of the patient's life, including personal and health care cost expenditures. To analyze the direct cost associated to uncontrolled asthma patients, a cross-sectional study was conducted to determine costs related to patients with uncontrolled and controlled asthma. Uncontrolled patient was defined by daytime symptoms more than twice a week or nocturnal symptoms during two consecutive nights or any limitations of activities, or need for relief rescue medication more than twice a week, and an ACQ score less than 2 points. A questionnaire about direct cost stratification in health services, including emergency room visits, hospitalization, ambulatory visits, and asthma medications prescribed, was applied. Ninety asthma patients were enrolled (45 uncontrolled/45 controlled). Uncontrolled asthmatics accounted for higher health care expenditures than controlled patients, US$125.45 and US$15.58, respectively [emergency room visits (US$39.15 vs US$2.70) and hospitalization (US$86.30 vs US$12.88)], per patient over 6 months. The costs with medications in the last month for patients with mild, moderate and severe asthma were US$1.60, 9.60, and 25.00 in the uncontrolled patients, respectively, and US$6.50, 19.00 and 49.00 in the controlled patients. In view of the small proportion of uncontrolled subjects receiving regular maintenance medication (22.2%) and their lack of resources, providing free medication for uncontrolled patients might be a cost-effective strategy for the public health system.

Direct costs of asthma in Brazil: a comparison between controlled and uncontrolled asthmatic patients

Asthma is a common chronic illness that imposes a heavy burden on all aspects of the patient's life, including personal and health care cost expenditures. To analyze the direct cost associated to uncontrolled asthma patients, a cross-sectional study was conducted to determine costs related to patients with uncontrolled and controlled asthma. Uncontrolled patient was defined by daytime symptoms more than twice a week or nocturnal symptoms during two consecutive nights or any limitations of activities, or need for relief rescue medication more than twice a week, and an ACQ score less than 2 points. A questionnaire about direct cost stratification in health services, including emergency room visits, hospitalization, ambulatory visits, and asthma medications prescribed, was applied. Ninety asthma patients were enrolled (45 uncontrolled/45 controlled). Uncontrolled asthmatics accounted for higher health care expenditures than controlled patients, US$125.45 and US$15.58, respectively [emergency room visits (US$39.15 vs US$2.70) and hospitalization (US$86.30 vs US$12.88)], per patient over 6 months. The costs with medications in the last month for patients with mild, moderate and severe asthma were US$1.60, 9.60, and 25.00 in the uncontrolled patients, respectively, and US$6.50, 19.00 and 49.00 in the controlled patients. In view of the small proportion of uncontrolled subjects receiving regular maintenance medication (22.2 percent) and their lack of resources, providing free medication for uncontrolled patients might be a cost-effective strategy for the public health system.

Inhaled budesonide for adults with mild-to-moderate asthma: a randomized placebo-controlled, double-blind clinical trial.

CONTEXT: Budesonide is an inhaled corticosteroid with high topical potency and low systemic activity recommended in the treatment of chronic asthma. OBJECTIVE: This study was conducted to determine the efficacy and safety of inhaled budesonide via a breath-activated, multi-dose, dry-powder inhaler. TYPE OF STUDY: Multicenter randomized parallel-group, placebo-controlled, double-blind, clinical trial. SETTING: Multicenter study in the university units. PARTICIPANTS: Adult patients with mild-to-moderate asthma that was not controlled using bronchodilator therapy alone. PROCEDURES: Comparison of budesonide 400 microg administered twice daily via a breath-activated, multi-dose, dry-powder inhaler with placebo, in 43 adult patients (aged 15 to 78 years) with mild-to-moderate asthma (FEV1 71% of predicted normal) that was not controlled using bronchodilator therapy alone. MAIN MEASUREMENTS: Efficacy was assessed by pulmonary function tests and asthma symptom control (as perceived by the patients) and the use of rescue medication. RESULTS: Budesonide 400 microg (bid) was significantly more effective than placebo in improving morning peak expiratory flow (mean difference: 67.9 l/min; P < 0.005) and FEV1 (mean difference: 0.60 l; P < 0.005) over the 8-week treatment period. Onset of action, assessed by morning peak expiratory flow, occurred within the first two weeks of treatment. CONCLUSIONS: Budesonide via a breath-activated, multi-dose, dry-powder inhaler results in a rapid onset of asthma control, which is maintained over time and is well tolerated in adults with mild-to-moderate asthma.

[General situation and perspectives of chagas disease in Northeastern Region, Brazil]. / Esboço geral e perspectivas da doença de Chagas no Nordeste do Brasil.

Primary and secondary data show the importance and distribution of human Chagas disease (HCD) in Northeast Brazil. Among the 27 detected vector species, Triatoma infestans, Panstrongylus megistus, Triatoma brasiliensis and Triatoma pseudomaculata are epidemiologically important. Major medical impact is attributed to T. infestans and P. megistus, the most domiciliated and vulnerable species, while the other two are native and more difficult to control. Regional differences in transmission and medical impact of HCD exist in the Northeast, where in general the disease appears to be less harmful than in other Brazilian regions like the Southeast and State of Goiás. There is a downward trend in HCD transmission and morbidity in the Northeast, its control in the region is a cause of concern because of the decommissioning of the National Health Foundation without a corresponding assimilation of its routine activities by regional and municipal institutions.

Significance of schistosomal granuloma modulation.

Hepatic Schistosoma mansoni periovular granulomas undergo changes in size, cellular composition and appearance with time. This phenomenon, known as "immunological modulation", has been thought to reflect host immunological status. However, as modulation has not been observed outside the liver, participation of local factors, hitherto little considered, seems crucial. Components of the extracellular matrix of periovular granulomas of the mouse were particularly studied in three different organs (liver, lung and intestine) and during three periods of infection time (acute, intermediate and chronic) by means of histological, biochemical and immunofluorescence techniques, while quantitative data were evaluated by computerized morphometry, in order to investigate participation of local factors in granuloma modulation. Results confirmed modulation as a exclusively hepatic phenomenon, since pulmonary and intestinal granulomas, formed around mature eggs, did not change size and appearance with time. The matricial components which were investigated (Type I, III and IV collagens, fibronectin, laminin, proteoglycans and elastin) were found in all granulomas and in all organs examined. However, their presence was much more prominent in the liver. Elastin was only found in hepatic granulomas of chronic infection. The large amount of extracellular matrix components found in hepatic granulomas was the main change responsible for the morphological aspects of modulation. Therefore, the peculiar environment of the liver ultimately determines the changes identified in schistosomal granuloma as "modulation".

[Respiratory morbidity in patients with and without pulmonary obstructive syndrome after upper abdominal surgery]. / Morbidade respiratória nos pacientes com e sem síndrome pulmonar obstrutiva submetidos a cirurgia abdominal alta.

BACKGROUND: We wanted to determine the postoperative pulmonary complication after upper abdominal surgery in patients with pulmonary obstrutive syndrome. METHODS: We have studied 196 patients prospectively analyzed in preoperative period with spirometry and followed for observation of PPC. The patients were divided in four groups: COPD - those with chronic bronchitis or emphysema and VEF1/CVF< 70% (27 patients). ASMA - patients with obstruction of the airway in response to provoking stimuli (44 patients). CHRONIC BRONCHITIS-EMPHYSEMA - those with the clinical diagnoses of the respective diseases but VEF1/CVF > 70% (23 patients). NORMAL - patients without pulmonary disease and normal spirometry (102 patients). RESULTS: Postoperative pulmonary complication was recognized when the patient presented atelectasis with clinical or gasometric alterations; bronchospasm that needed bronchodilator therapy; respiratory failure; mechanical ventilation or orotracheal intubation more than 48 hours in postsurgery period; tracheobronchitis characterized by the presence of purulent sputum with normal x-ray; pneumonia. Patients with pulmonary obstruction had experienced higher rates of pulmonary complications (32% vs 6%, p<0.05). The presence of obstructive lung disease was associated with an increased number of ventilator days, but was not associated with longer intensive care unit or hospital stay. CONCLUSIONS: The incidence of postoperative pulmonary complications was strongly associated with the presence of pulmonary obstructive syndrome.

Morbidade respiratória nos pacientes com e sem síndrome pulmonar obstrutiva submetidos a cirurgia abdominal alta / Respiratory morbidity in patients with and without pulmonary obstructive syndrome after upper abdominal surgery

OBJETIVO: Estudar a morbidade respiratória nos pacientes com síndrome pulmonar obstrutiva submetidos a cirurgia abdominal alta. CASUÍSTICA E MÉTODO: Durante o pré-operatório, 196 pacientes candidatos à cirurgia abdominal alta eletiva responderam a um questionário padronizado e logo em seguida realizaram espirometria. Houve acompanhamento no pós-operatório até a alta hospitalar ou óbito. Os pacientes foram divididos em quatro grupos: 27 pacientes com DPOC (diagnóstico de bronquite crônica ou enfisema e VEF1/CVF < 70 por cento), 44 pacientes com diagnóstico de asma (obstrução das vias aéreas desencadeada por estímulos provocatívos) com ou sem alteração da espirometria. Outros 23 pacientes apresentavam o complexo bronquite crônica-enfisema, (quadro clínico sugestivo de bronquite ou enfisema porém com VEF1/CVF maior que 70 por cento). O grupo de 102 pacientes apresentou normalidade do ponto de vista clínico e espirométrico. Considerou-se como CPP: atelectasia com repercussão clínica e ou gasométrica, broncoespasmo que necessitou de tratamento, insuficiência respiratória aguda, ventilação mecânica e/ou entubação orotraqueal prolongada, infecção traqueobronquica e pneumonia. RESULTADOS: A incidência de complicações foi maior no grupo de pacientes com limitação do fluxo aéreo (32 por cento) em relação aos normais(6 por cento). Ao estudarmos os quatro grupos separadamente, foi observado que os pacientes com DPOC, apesar de apresentaram maior morbidade no pós-operatório, não diferiram dos demais pneumopatas. Complicaram, respectivamente, (DPOC 37 por cento, BE 34 por cento, asma 29 por cento, normal 6 por cento). Os obstrutivos triplicaram seu tempo de permanência no ventilador (média 3,1 e 1,1; respectivamente, com p<0,05). No entanto, não houve diferença em relação ao tempo de permanência na UTI e no tempo total de dias no pós-operatório. CONCLUSÃO: Os pacientes com limitação do fluxo aéreo apresentaram maior morbidade no pós-operatório de cirurgia abdominal alta. A magnitude deste fator de risco se reflete num risco relativo quase que cinco vezes maior em relação aos pneumopatas com os pacientes normais.

Pathology of the spleen in hepatosplenic schistosomiasis. Morphometric evaluation and extracellular matrix changes.

Histological, ultrastructural, morphometric and immunohistochemical data obtained from the study of spleens removed by splenectomy from 34 patients with advanced hepatosplenic schistosomiasis revealed that the main alterations were congestive dilatation of the venous sinuses and diffuse thickening of the splenic cords. Splenic cord thickening was due to an increase of its matrix components, especially type IV collagen and laminin, with the conspicuous absence of interstitial collagens, either of type I or type III. Deposition of interstitial collagens (types I and III) occurred in scattered, small focal areas of the red pulp, but in the outside of the walls of the venous sinuses, in lymph follicles, marginal zone, in the vicinity of fibrous trabeculae and in sidero-sclerotic nodules. However, fibrosis was not a prominent change in schistosomal splenomegaly and thus the designation "fibro-congestive splenomegaly" seems inadequate. Lymph follicles exhibited variable degrees of atrophy, hyperplasia and fibrous replacement, sometimes all of them seen in different follicles of the same spleen and even in the same examined section. Changes in white pulp did not seem to greatly contribute to increasing spleen size and weight, when compared to the much more significant red pulp enlargement.

Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery.

OBJECTIVE: To investigate associations between preoperative variables and postoperative pulmonary complications (PPC) in elective upper abdominal surgery. DESIGN: Prospective clinical trial. SETTING: A tertiary university hospital. PATIENTS: 408 patients were prospectively analyzed during the preoperative period and followed up postoperatively for pulmonary complications. MEASUREMENTS: Patient characteristics, with clinical and physical evaluation, related diseases, smoking habits, and duration of surgery. Preoperative pulmonary function tests (PFT) were performed on 247 patients. RESULTS: The postoperative pulmonary complication rate was 14 percent. The significant predictors in univariate analyses of postoperative pulmonary complications were: age >50, smoking habits, presence of chronic pulmonary disease or respiratory symptoms at the time of evaluation, duration of surgery >210 minutes and comorbidity (p <0.04). In a logistic regression analysis, the statistically significant predictors were: presence of chronic pulmonary disease, surgery lasting >210 and comorbidity (p <0.009). CONCLUSIONS: There were three major clinical risk factors for pulmonary complications following upper abdominal surgery: chronic pulmonary disease, comorbidity, and surgery lasting more than 210 minutes. Those patients with three risk factors were three times more likely to develop a PPC compared to patients without any of these risk factors (p <0.001). PFT is indicated when there are uncertainties regarding the patient's pulmonary status.

Evaluation of an educational programme for socially deprived asthma patients.

The aim of this study was to evaluate the effectiveness of an asthma education programme in moderate and severe asthma patients in a longitudinal, prospective and randomized study with a control group. Fifty-three asthmatic patients were studied, 26 of whom were assigned to the educational group and 27 to the control group. The educational group attended the programme regularly for a period of 6 months. The programme included information about asthma, instruction on the appropriate use of medication and training in the metered dose inhaler (MDI) technique, and information about the identification and control of asthma attacks and the recognition of early signs of exacerbation. The control group was submitted to the routine care provided at the Asthma Clinic, with no formal instruction regarding asthma control. The groups were identical with regard to severity parameters, skills, lung function and quality of life at the beginning of the trial. At the end of the study, the education group showed significant differences when compared with the control group (education/control (mean values)) with respect to: visits to the asthma emergency room over the previous 6 months, 0.7/2 (p=0.03); nocturnal symptoms, 0.3/0.7 (p=0.04); score of symptoms, 1.3/2 (p=0.04). Improvements were also observed in skills and quality of life, knowledge of how to deal with attacks and how to control the environmental triggering factors, 73/35 (<0.05); correct use of the MDI, 8/4 (0.001); understanding of the difference between relief and anti-inflammatory medication, 86/20 (<0.05); and in the global limitation quality of life score, 28/50 (0.02). It is concluded that the educational programme led to a significant improvement in asthma morbidity and that the implantation of educational programmes is possible for special populations when these programmes are adapted to the socioeconomic profile of the patients, with a significant gain in terms of the reduction of symptoms and improved pulmonary function and quality of life of asthmatics.

Evaluation of bone metabolism after the use of an inhaled glucocorticoid (flunisolide) in patients with moderate asthma.

OBJECTIVE: We have investigated the effects of the inhaled corticosteroid flunisolide on bone metabolism and adrenal function in patients with moderate asthma. SUBJECTS AND DESIGN: Twenty ambulatory patients (13 females, 7 males, mean age +/- SD of 36.4 +/- 12.4 years) with moderate asthma were recruited. None had taken corticosteroids for at least 1 month. Flunisolide 500 microg was given twice a day for 10 weeks, without any other medication. Blood and urine were collected before and at the end of treatment course. Cortisol (basal and 1 h after ACTH 250 microg i.v.) was measured to evaluate adrenal function. A peak cortisol response of 496 nmol/l was considered an adequate response. Serum ionized calcium, intact PTH, plasma osteocalcin (OC) and urinary pyridinoline (Pyr) and deoxy-pyridinoline (D-Pyr) were measured to evaluate bone metabolism. Wilcoxon paired test was performed for statistical analysis. Results are expressed as mean +/- SD. RESULTS: In most patients (85%), there was no difference after treatment with flunisolide on basal and stimulated cortisol levels. We found a significant decrease of OC (3.55 +/- 1.42 to 2.97 +/- 1.05 nmol/l) and Pyr (66.4 +/- 20.0 to 59.5 +/- 24.9 pmol/micromol creatinine) levels after treatment (P < 0.05). We also observed a positive correlation between the variations seen in pre and post treatment values of OC and Pyr/D-Pyr. CONCLUSIONS: The use of inhaled flunisolide 1000 microg/day for 10 weeks had no suppressive effect on adrenal function in the majority of asthmatic patients studied. However, the effects seen on bone and mineral metabolism, evidenced by the significant fall in osteocalcin and pyridinoline levels, may indicate a possible systemic effect of this drug. Clinical consequences of long-term treatment with flunisolide need to be further evaluated.

Short-term effects of aerobic training in the clinical management of moderate to severe asthma in children.

BACKGROUND: Aerobic training has a number of well known beneficial effects in both normal and asthmatic children. However, the impact of training on the clinical management of the underlying bronchial asthma remains controversial, particularly in the most severe patients. METHODS: Clinical evaluation, spirometric tests, symptom limited maximum exercise testing, and exercise challenge tests were performed in a group of children with stable moderate to severe asthma. Forty two patients (24 boys) aged 8-16 were evaluated twice: before and after supervised aerobic training (group 1, n = 26) and two months apart (untrained group 2, n = 16). RESULTS: Spirometric and maximal exercise variables in the initial evaluation were significantly reduced in group 1 (p < 0.05) but medication and clinical scores and the occurrence of exercise induced bronchospasm (EIB) did not differ between the two groups. Aerobic improvement with training (maximal oxygen uptake and/or anaerobic threshold increment > 10% and 100 ml) was inversely related to the baseline level of fitness and was independent of disease severity. Although the clinical score and the occurrence of EIB did not change after training, aerobic improvement was associated with a significant reduction in the medication score and the daily use of both inhaled and oral steroids (p < 0.05). CONCLUSIONS: Aerobic improvement with training in less fit asthmatic children is related to a short term decrease in the daily use of inhaled and oral steroids, independent of the severity of the disease.

Myofibroblasts in schistosomal portal fibrosis of man.

Myofibroblasts, cells with intermediate features between smooth muscle cells and fibroblasts, have been described as an important cellular component of schistosomal portal fibrosis. The origin, distribution and fate of myofibroblasts were investigated by means of light, fluorescent, immunoenzymatic and ultrastructural techniques in wedge liver biopsies from 68 patients with the hepatosplenic form of schistosomiasis. Results demonstrated that the presence of myofibroblasts varied considerably from case to case and was always related to smooth muscle cell dispersion, which occurred around medium-sized damaged portal vein branches. By sequential observation of several cases, it was evident that myofibroblasts derived by differentiation of vascular smooth muscle and gradually tended to disappear, some of them further differentiating into fibroblasts. Thus, in schistosomal pipestem fibrosis myofibroblasts appear as transient cells, focally accumulated around damaged portal vein branches, and do not seem to have by themselves any important participation in the pathogenesis of hepatosplenic schistosomiasis.