Intussuscepção intestinal em gestante pós by-pass gástrico: relato de caso / Intestinal intussusception in pregnant women after gastric bypass: case report

RESUMO: Em todo o mundo, estima-se que aproximadamente 634.897 pessoas são submetidas a procedimentos bariátricos a cada ano, com gastrectomia vertical e by-pass gástrico, representando 53,6% e 30%, respectivamente. Entre pacientes operados, aproximadamente metade são mulheres em idade reprodutiva. Em adultos, a intussuscepção é tipicamente devida a um local patológico no intestino, que pode ser maligno em mais da metade dos casos. A in-tussuscepção intestinal é rara em adultos, representando 1 a 5% das obstruções intestinais mecânicas. A intussus-cepção em gestantes pós by-pass gástrico é uma patologia muito rara de origem desconhecida com alto poder de lesão e injúria de órgãos e sistemas. Suas manifestações clínicas são como abdômen agudo obstrutivo, porém, na paciente gestante dificulta o diagnóstico precoce. Este relato de caso apresenta uma paciente de 38 anos, gestante de 22 semanas, com quadro de dor abdominal de forte intensidade acompanhada de vômitos em grande quantidade há um dia, antecedente de by-pass gástrico há quatro anos. O diagnóstico do quadro de intussuscepção intestinal foi possível após o sétimo dia de internação com auxílio de exame de imagem - RNM, sendo indicado o tratamento cirúrgico para correção do caso. Evoluiu com choque séptico com necessidade de internação prolongada em leito de CTI, recebendo alta após 27 dias de internação. (AU)

ABSTRACT: Worldwide, it is estimated that approximately 634,897 people undergo bariatric procedures each year, with vertical gastrectomy and gastric bypass, representing 53.6% and 30%, respectively. Among operated patients, approxi-mately half are women of reproductive age. In adults, intussusception is typically due to a pathological site in the intestine, which can be malignant in more than half of cases. Intestinal intussusception is rare in adults, repre-senting 1 to 5% of mechanical intestinal obstructions. Intussusception in pregnant women after gastric bypass is a very rare pathology of unknown origin with high power of injury and injury to organs and systems. Its clinical manifestations are like acute obstructive abdomen, but in pregnant women it is difficult to make an early diagnosis. This case report presents a 38-year-old patient, a 22-week pregnant woman, with severe abdominal pain accom-panied by vomiting in large quantities for 1 day, a history of gastric bypass for 4 years. The diagnosis of intestinal intussusception was possible after the seventh day of hospitalization with the aid of an image exam - MRI. Surgical treatment is indicated to correct the case. He developed septic shock requiring prolonged hospitalization in an ICU bed, being discharged after 27 days of hospitalization. (AU)

Inflammatory biomarkers in infective endocarditis: machine learning to predict mortality.

Infective endocarditis (IE) is the cardiac disease with the highest rates of mortality. New biomarkers that are able to identify patients at risk for death are required to improve patient management and outcome. This study aims to investigate if cytokines, chemokines and growth factors measured at IE diagnosis can predict mortality. Patients with definite IE, according to the Duke's modified criteria, were included. Using high-performance Luminex assay, 27 different cytokines, chemokines and growth factors were analyzed. Machine learning techniques were used for the prediction of death and subsequently creating a decision tree, in which the cytokines, chemokines and growth factors were analyzed together with C-reactive protein (CRP). Sixty-nine patients were included, 41 (59%) male, median age 54 [interquartile range (IQR) = 41-65 years] and median time between onset of the symptoms and diagnosis was 12 days (IQR = 5-30 days). The in-hospital mortality was 26% (n = 18). Proinflammatory cytokines interkeukin (IL)-15 and C-C motif chemokine ligand (CCL4) were found to predict death, adding value to CRP levels. The decision tree predicted correctly the outcome of 91% of the patients at hospital admission. The high-risk group, defined as CRP ≥ 72 mg/dL, IL-15 ≥ 5·6 fg/ml and CCL4 ≥ 6·35 fg/ml had an 88% in-hospital mortality rate, whereas the patients classified as low-risk had a mortality rate of 8% (P = < 0·001). Cytokines IL-15 and CCL4 were predictors of mortality in IE, adding prognostic value beyond that provided by CRP levels. Assessment of cytokines has potential value for clinical risk stratification and monitoring in IE patients.

Reversible dilated cardiomyopathy associated with amphotericin B therapy.

WHAT IS KNOWN AND OBJECTIVE: Amphotericin B (AmB) is commonly used to treat a broad spectrum of fungal infections and leishmaniasis. Its use is limited by numerous adverse effects. Reversible dilated cardiomyopathy associated with AmB is a rare disorder with only four previously reported cases, and all of them referring to patients who presented with a predisposing factor for heart failure. CASE SUMMARY: A previously healthy 45-year-old man with visceral leishmaniasis treated with AmB developed acute dilated cardiomyopathy. Other causes of heart failure as well-known predisposing factors for this condition were ruled out. As with previously reported cases, the cardiac function of our patient returned to normal shortly after. WHAT IS NEW AND CONCLUSION: We describe the first case of dilated cardiomyopathy associated with the administration of AmB in a patient without any known predisposing factor for developing cardiac dysfunction. Available evidence suggests that AmB may induce cardiotoxicity. Further investigations are needed to clarify this issue.

Occult hepatitis B virus infection in liver transplant patients in a Brazilian referral center

Estimates of occult hepatitis B virus (HBV) infection prevalence varies among different studies depending on the prevalence of HBV infection in the study population and on the sensitivity of the assay used to detect HBV DNA. We investigated the prevalence of occult HBV infection in cirrhotic patients undergoing liver transplantation in a Brazilian referral center. Frozen liver samples from 68 adults were analyzed using a nested polymerase chain reaction assay for HBV DNA. The specificity of the amplified HBV sequences was confirmed by direct sequencing of the amplicons. The patient population comprised 49 (72.1%) males and 19 (27.9%) females with a median age of 53 years (range=18-67 years). Occult HBV infection was diagnosed in three (4.4%) patients. The etiologies of the underlying chronic liver disease in these cases were alcohol abuse, HBV infection, and cryptogenic cirrhosis. Two of the patients with cryptic HBV infection also presented hepatocellular carcinoma. Markers of previous HBV infection were available in two patients with occult HBV infection and were negative in both. In conclusion, using a sensitive nested polymerase chain reaction assay to detect HBV DNA in frozen liver tissue, we found a low prevalence of occult HBV infection in cirrhotic patients undergoing liver transplant, probably due to the low prevalence of HBV infection in our population.

Occult hepatitis B virus infection in liver transplant patients in a Brazilian referral center.

Estimates of occult hepatitis B virus (HBV) infection prevalence varies among different studies depending on the prevalence of HBV infection in the study population and on the sensitivity of the assay used to detect HBV DNA. We investigated the prevalence of occult HBV infection in cirrhotic patients undergoing liver transplantation in a Brazilian referral center. Frozen liver samples from 68 adults were analyzed using a nested polymerase chain reaction assay for HBV DNA. The specificity of the amplified HBV sequences was confirmed by direct sequencing of the amplicons. The patient population comprised 49 (72.1%) males and 19 (27.9%) females with a median age of 53 years (range=18-67 years). Occult HBV infection was diagnosed in three (4.4%) patients. The etiologies of the underlying chronic liver disease in these cases were alcohol abuse, HBV infection, and cryptogenic cirrhosis. Two of the patients with cryptic HBV infection also presented hepatocellular carcinoma. Markers of previous HBV infection were available in two patients with occult HBV infection and were negative in both. In conclusion, using a sensitive nested polymerase chain reaction assay to detect HBV DNA in frozen liver tissue, we found a low prevalence of occult HBV infection in cirrhotic patients undergoing liver transplant, probably due to the low prevalence of HBV infection in our population.

Automatic knowledge extraction from chemical structures: the case of mutagenicity prediction.

This work proposes a new structure-activity relationship (SAR) approach to mine molecular fragments that act as structural alerts for biological activity. The entire process is designed to fit with human reasoning, not only to make the predictions more reliable but also to permit clear control by the user in order to meet customized requirements. This approach has been tested on the mutagenicity endpoint, showing marked prediction skills and, more interestingly, bringing to the surface much of the knowledge already collected in the literature as well as new evidence.

Corneal cross-linking for the treatment of keratoconus in a patient with ipsilateral myelinated retinal nerve fiber layer.

Keratoconus associated with myelinated retinal nerve fibers is not frequent and the relationship between the two pathologies is difficult to explain, therefore studies and further investigation are required. The etiology of each condition may suggest the role of genetic factors. Follow-up is important to evaluate the progression of keratoconus and myelination. Here we describe the unusual coexistence of keratoconus and ipsilateral myelinated retinal nerve fiber layer and, for the first time, the corneal cross-linking treatment in this condition.

Ultrasound and CT findings in hepatic and pancreatic parenchyma in acute schistosomiasis.

A case of acute toxaemic schistosomiasis is presented. Abdominal ultrasound examination revealed hepatosplenomegaly, lymphadenomegaly, heterogeneous hepatic parenchyma and heterogeneous focal lesions in the pancreas. CT confirmed lymph node enlargement and hepatosplenomegaly, and showed multiple small focal nodular lesions in the liver and focal lesions in the pancreas. To our knowledge, this is the first description of pancreatic lesions associated with acute Schistosoma mansoni infection.

Prognostic prediction ability of postoperative multifocal ERG after vitrectomy for diabetic macular edema.

PURPOSE: Diabetic macular edema (DME) causes visual loss in diabetic patients. Multifocal electroretinograms (mfERGs) have been used to assess macular function pre- and postvitrectomy for DME. METHODS: A standard three-port pars plana vitrectomy with peeling of inner limiting membrane was performed in 25 eyes of 21 patients (13 male, 8 female) with DME. For each patient, visual acuity examination, measure of retinal thickness (using optical coherence tomography), and mfERGs were performed before and 1 week, 1 month, 3 months, and 6 months after vitrectomy. RESULTS: Mean postoperative visual acuity was significantly improved (p<0.05, t test), with mean increase of 0.17 logMAR units; mean retinal thickness was significantly (p<0.001) decreased after surgery (from 537 microm to 298 microm). The increase of normalized amplitude of central ring was not significant; the mean P1 wave-amplitude increased from 0.33 to 0.40 mV; mean P1 wave-implicit time decreased 2.88 ms. We divided the patients into two groups: Group 1 (13 eyes), in which the visual recovery was less than 0.20 logMAR, and Group 2 (12 eyes), in which the visual recovery was greater than 0.20 logMAR. ERG results were statistically significantly different between the groups (p<0.025), when we consider the response recorded from the central ring. In Group 2 there is a marked reduction in implicit time of both ERGs waves, which was statistically significant for N1 wave (p=0.01). The changes of parameters of mfERG observed 6 months after surgery were consistent with those recorded just 1 week after surgery. CONCLUSIONS: Multifocal electroretinogram can be useful to predict functional prognosis in patients with diabetes who underwent vitrectomy for diabetic macular edema.

Three-port lens-sparing vitrectomy for aggressive posterior retinopathy of prematurity: early surgery before tractional retinal detachment appearance.

PURPOSE: Aggressive posterior retinopathy of prematurity (APROP) may suddenly develop into tractional retinal detachment (TRD), often resulting in poor vision if untreated. The aim of the current study is to examine the anatomic results and complications of lens-sparing vitrectomy (LSV) for stage 3 APROP, before TRD appearance. METHODS: A retrospective, noncomparative, consecutive case series of 13 eyes of 9 patients (mean gestational age 24.1+/-0.9 weeks [range: 23-25 weeks], mean birthweight of 725.8+/-107.9 grams [range: 598-897 grams]) with stage 3 APROP was carried out. The eyes did not respond to at least one session of retinal laser photocoagulation, showing signs of disease progression. All eyes underwent 20-gauge LSV before retinal detachment appearance. RESULTS: All eyes underwent 20-gauge three-port LSV and intraoperative additional laser photocoagulation. At the end of the surgery, five eyes were tamponaded with air; in eight eyes, a balanced salt solution was left in the vitreous cavity. After 13.5+/-5.3 months of follow-up (range: 4-22), the retina was completely attached in all eyes, without any signs of progression. The authors did not observe any intraoperative or postoperative complications. CONCLUSIONS: Surgical approach to stage 3 APROP refractory to laser photocoagulation could be effective and safe in order to avoid the progression of the disease.

Mixed inflammatory/regulatory cytokine profile marked by simultaneous raise of interferon-gamma and interleukin-10 and low frequency of tumour necrosis factor-alpha(+) monocytes are hallmarks of active human visceral Leishmaniasis due to Leishmania chagasi infection.

Considering the complexity of the immunological events triggered during active visceral Leishmaniasis (VL), the relevance of the segregation of the immune response during human VL into type 1 and type 2 still remains unclear. For this purpose, in individuals living in risk areas for VL, we have evaluated especially asymptomatic individuals and patients with active VL, the plasmatic levels of cytokines and reactive nitrogen species under ex vivo conditions. In addition, we have also performed an analysis of intracellular cytokine patterns of circulating leucocytes after short-term culture, particularly in the absence of antigenic-specific stimulation, in order to reflect dynamic events of immune response in vivo during Leishmania chagasi infection. Although asymptomatic individuals and non-infected subjects presented a similar immunological profile, an outstanding inflammatory/regulatory profile, based on higher plasmatic levels of cytokines such as interleukin (IL)-8, interferon (IFN)-gamma, tumour necrosis factor (TNF)-alpha, IL-6 and IL-10, was associated with clinical status observed in active VL. In this context, we hypothesize that IL-10, through its ability to inhibit anti-leishmanial macrophage activation, associated with the lower frequency of TNF-alpha(+) monocytes and ordinary levels of nitrite and nitrate are the major mechanisms associated with disease onset.

Clinical value of anti-live Leishmania (Viannia) braziliensis immunoglobulin G subclasses, detected by flow cytometry, for diagnosing active localized cutaneous leishmaniasis.

OBJECTIVE: To evaluate the clinical value of flow cytometry anti-live promastigate antibody (FC-ALPA), for diagnosing active cutaneous leishmaniasis. METHOD: Serum samples from 145 individuals living in endemic areas for localized cutaneous leishmaniasis (population 1) were classified as having the disease or not and then tested for their IgG reactivity by indirect immunofluorescence assay and FC-ALPA-IgG. The results of FC-ALPA-IgG were expressed as percentage of positive fluorescent parasite. Both tests were also evaluated in serum samples of people with visceral leishmaniasis and Chagas disease (population 1A). RESULTS: In population 1, FC-ALPA-IgG performed better than the immunofluorescence assay regarding sensitivity, specificity and predictive values. Analysis of the results according to the likelihood ratios indicated that a percentage of positive fluorescent parasite 60% it reinforces diagnosis of the disease (likelihood ratio = 7.0). Immunofluorescent assay is of little value (likelihood ratio=2.04). In population 1A, both tests performed worse, but FC-ALPA-IgG achieved better statistical indexes than immunofluorescent assay. CONCLUSION: The FC-ALPA-IgG is a valuable method for serological diagnosis of localized cutaneous leishmaniasis. FC-ALPA-IgG1/ALPA-IgG2 combined analysis is an additional serological tool for discriminating localized visceral leishmaniasis, Chagas disease and visceral leishmaniasis in areas where these infections co-exist.

Immune response in human visceral leishmaniasis: analysis of the correlation between innate immunity cytokine profile and disease outcome.

We investigated the cytokine profile of cells of the innate immune response and its association with active (ACT), asymptomatic (AS) and cured (CUR) human visceral leishmaniasis (VL), as well as noninfected (NI) subjects. The frequency of cytokine-producing cells was determined after short-term in vitro incubation of whole peripheral blood samples with soluble Leishmania antigen (SLA). Our data demonstrated a predominant type 2 cytokine profile in NI and ACT. In NI, we observed an increase of IL-4+ neutrophils, IL-10+ eosinophils besides a decrease of tumour necrosis factor (TNF)-alpha+ eosinophils/monocytes. Yet in ACT, we observed an increase of IL-4+ neutrophils and natural killer (NK) cells and IL-10+ monocytes, a reduced frequency of IL-12+ and IFN-gamma+ eosinophils and lower levels of TNF-alpha+ and IL-12+ monocytes. AS presented a mixed profile, characterized by an increase of IFN-gamma+ neutrophils/eosinophils and NK cells, of IL-12+ eosinophils/monocytes, as well as increase of IL-4+ neutrophils and NK cells and IL-10+ eosinophils/monocytes. In contrast, CUR was characterized by a type 1 response with an increase of IFN-gamma+ neutrophils/eosinophils and NK cells, associated with an increase in IL-12+ monocytes. In conclusion, we show a correlation between innate immune cytokine patterns and clinical status of VL, suggesting that these cells, in addition to other factors, may contribute to the cytokine microenvironment in which Leishmania-specific T cells are primed and to disease outcome.

Variable outcome of photodynamic therapy for choroidal neovascularization associated with choroidal nevus.

PURPOSE: To report five cases of classic choroidal neovascularization (CNV) associated with choroidal nevus treated with photodynamic therapy (PDT) with verteporfin. METHODS: The patients underwent an ophthalmologic evaluation, including fluorescein angiography and indocyanine green angiography. Clinical and angiographic data were retrospectively analyzed to evaluate visual acuity outcomes and both clinical evolution and angiographic evolution. RESULTS: Two patients presented with subfoveal CNV, and three had juxtafoveal CNV. The mean follow-up was 25.8 months. Visual outcomes were extremely variable. Indeed, best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of PDT sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six. CONCLUSION: Bearing in mind that both the natural history and the post-PDT outcome may be extremely variable, further studies are needed to assess the real benefit of PDT for classic CNV secondary to choroidal nevus.

Intravitreal triamcinolone acetonide: valuation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema.

PURPOSE: The authors studied the efficacy of intravitreal triamcinolone acetonide in a case series of patients with diffuse diabetic macular edema without evidence of vitreous-macular traction refractory to laser photocoagulation. METHODS: Six eyes with clinically diffuse diabetic macular edema that failed to respond to at least two previous sessions of laser photocoagulation were included. The mean age of selected patients was 72.5+/-13.8 years, with a preoperative best-corrected visual acuity reduced to 1.48+/-0.18 logMar and a mean baseline intraocular pressure (IOP) of 15.17+/-2.64 mmHg. The authors also studied macular thickness measured by optical coherence tomography (OCT 2000 scanner, Humphrey Instruments, San Leandro, CA) - in the preoperative period it was 640.8+/-171.1 microm - and the fluorangiographic (Heidelberg Retina Angiograph, Heidelberg Engineering GmbH, Heidelberg, Germany) patterns, which showed pooling in tardy phases and leakage. Mean follow-up was 4 months. RESULTS: In each patient the authors observed a significant improvement, both functionally and anatomically. Mean best-corrected visual acuity increased in the postoperative period to 0.94+/-0.53 logMar. No patient showed decline of visual acuity at the end of follow-up. Base line macular thickness was reduced in the postoperative period to 312.2+/-157.65 microm measured by OCT and fluorangiographic patterns showed a reduction of pooling and of leakage. The most common complications described in the literature were not observed and the increase of mean IOP in the postoperative period to 18.76+/-5.72 mmHg was not significant. CONCLUSIONS: Intravitreal triamcinolone acetonide may decrease macular edema and improve visual acuity in eyes with diffuse diabetic macular edema.

Luxated intraocular lens fixation using anterior chamber slipknot of the haptic to the sclera: a simple procedure to fixate intraocular lens to the sclera.

PURPOSE: To describe a technique for suturing a luxated intraocular lens (IOL) in the vitreous cavity directly to the ciliary sulcus using intraocular slipknot without IOL extraction. DESIGN: Noncomparative interventional case series. MATERIALS AND METHODS: A three-port vitrectomy was performed in all cases. According to the Lewis procedure, two scleral flaps and relative sclerectomies were performed at 3 and 9 o'clock position. IOL was rescued from vitreous cavity by means of perfluorocarbon and stabilized in anterior chamber by intravitreal forceps. Corneal endothelium was preserved by a dispersive ophthalmic viscosurgical device coating. Double armed 10-0 polypropylene was introduced into the vitreous cavity through the 9 o'clock sclerotomy incision and both the needles were passed out of the eye by the 3-o'clock position sclerotomy, guided by a bent 27-gauge needle 1.5 mm from the limbus. Hooking the slipknot around the haptics of the IOL in the anterior chamber by means of vitreous forceps, the 10-0 polypropylene was pulled so that the IOL haptic was fixated onto the sulcus. The same procedure was used to fixate the opposite haptic to the ciliary sulcus at the opposite position. RESULTS: In all four cases, the IOL fixated stably and remained well positioned. No significant intraoperative or postoperative complications occurred. CONCLUSIONS: This technique enables secure fixation of the luxated IOL in the vitreous without extracting it.