Severe acute pancreatitis: eight fundamental steps revised according to the 'PANCREAS' acronym.

Severe acute pancreatitis remains a life-threatening condition, responsible for many disorders of homeostasis and organ dysfunction. By means of a mnemonic 'PANCREAS', eight important steps in the management of severe acute pancreatitis are highlighted. These steps follow the principle of goal-directed therapy and should be borne in mind after diagnosis and during clinical treatment. The first step is perfusion: the goal is to reach a central venous pressure of 12-15mmHg, urinary output 0.5-1ml/kg/hour and inferior vena cava collapse index greater than 48%. Next is analgesia: multimodal, systemic and combined pharmacological agent and epidural block are possibilities. Third is nutrition: precocity, enteral feeding in gastric or post-pyloric position. Parenteral nutrition works best in difficult cases to achieve the individual total caloric value. Fourth is clinical: mild, moderate or severe pancreatitis according to the Atlanta criteria. Radiology is fifth: abdominal computed tomography on the fourth day for prognosis or to modify management. Endoscopy is sixth: endoscopic retrograde cholangiopancreatography (cholangitis, unpredicted clinical course and ascending jaundice); management of pancreatic fluid collection and 'walled-off necrosis'. Antibiotics come next: infectious complications are common causes of morbidity. The only rational indication for antibiotics is documented pancreatic infection. The last step is surgery: the dogma is represented by the 'three Ds' (delay, drain, debride). The preferred method is a minimally invasive step-up approach, which allows for gradually more invasive procedures when the previous treatment fails.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Adenosine A2A receptor regulation of microglia morphological remodeling-gender bias in physiology and in a model of chronic anxiety.

Developmental risk factors, such as the exposure to stress or high levels of glucocorticoids (GCs), may contribute to the pathogenesis of anxiety disorders. The immunomodulatory role of GCs and the immunological fingerprint found in animals prenatally exposed to GCs point towards an interplay between the immune and the nervous systems in the etiology of these disorders. Microglia are immune cells of the brain, responsive to GCs and morphologically altered in stress-related disorders. These cells are regulated by adenosine A2A receptors, which are also involved in the pathophysiology of anxiety. We now compare animal behavior and microglia morphology in males and females prenatally exposed to the GC dexamethasone. We report that prenatal exposure to dexamethasone is associated with a gender-specific remodeling of microglial cell processes in the prefrontal cortex: males show a hyper-ramification and increased length whereas females exhibit a decrease in the number and in the length of microglia processes. Microglial cells re-organization responded in a gender-specific manner to the chronic treatment with a selective adenosine A2A receptor antagonist, which was able to ameliorate microglial processes alterations and anxiety behavior in males, but not in females.

Transtracheal puncture: a forgotten procedure.

Transtracheal puncture has long been known as a safe, low-cost procedure. However, with the advent of bronchoscopy, it has largely been forgotten. Two researchers have suggested the use of α-amylase activity to diagnose salivary aspiration, but the normal values of this enzyme in tracheobronchial secretions are unknown. We aimed to define the normal values of α-amylase activity in tracheobronchial secretions and verify the rate of major complications of transtracheal puncture. From October 2009 to June 2011, we prospectively evaluated 118 patients without clinical or radiological signs of salivary aspiration who underwent transtracheal puncture before bronchoscopy. The patients were sedated with a solution of lidocaine and diazepam until they reached a Ramsay sedation score of 2 or 3. We then cleaned the cervical region and anesthetized the superficial planes with lidocaine. Next, we injected 10 mL of 2% lidocaine into the tracheobronchial tree. Finally, we injected 10 mL of normal saline into the tracheobronchial tree and immediately aspirated the saline with maximum vacuum pressure to collect samples for measurement of the α-amylase level. The α-amylase level mean ± SE, median, and range were 1914 ± 240, 1056, and 24-10,000 IU/L, respectively. No major complications (peripheral desaturation, subcutaneous emphysema, cardiac arrhythmia, or hemoptysis) occurred among 118 patients who underwent this procedure. Transtracheal aspiration is a safe, low-cost procedure. We herein define for the first time the normal α-amylase levels in the tracheobronchial secretions of humans.

Microhabitat use by species of the genera Bothrops and Crotalus (Viperidae) in semi-extensive captivity

Many factors influence microhabitat including climate and the occurrence of predators, prey and suitable shelters. The influence of predators in a semi-extensive breeding system is minimized due to frequent monitoring of the area. This situation enables the independent analysis of such other variables as refuges and temperature. Some specimens of the Viperidae family are kept in a semi-extensive breeding system at the Butantan Institute for display and study. These animals are widely distributed in the Atlantic Forest and Cerrado, two biomes with distinct climatic characteristics. We compared the daily activity pattern and microhabitat use of the species Bothrops jararaca and Crotalus durissus terrificus. Our main questions were whether rattlesnakes and lancehead snakes respond to habitat selection differently in similar climatic conditions and if they choose similar microhabitats. Species of the genus Bothrops were frequently found under shelters regardless of the time of day. On the other hand, snakes of the genus Crotalus were frequently found sheltered during the early morning, then migrated to sunnier areas and returned to shelters in late afternoon.

Molecular evolution of the period gene in sandflies.

The molecular evolution of the clock gene period was studied in Phlebotomine sandflies (Diptera: Psychodidae). Comparison of the synonymous and nonsynonymous substitution rates between sandflies and Drosophila revealed a significantly higher evolutionary rate in the latter in three of the four regions analyzed. The differences in rate were higher in the sequences flanking the Thr-Gly repetitive domain, a region that has expanded in Drosophila but remained stable and short in sandflies, a result consistent with the coevolutionary scenario proposed for this region of the gene. An initial phylogenetic analysis including eight neotropical sandfly species and one from the Old World was also carried out. The results showed that only the subgenus Nyssomyia is well supported by distance (neighbor-joining) and maximum parsimony analysis. The grouping of the other species from the subgenus Lutzomyia and Migonei group shows very low bootstrap values and is not entirely consistent with classical morphological systematics of the genus Lutzomyia.

New molecular markers for phlebotomine sand flies.

Using degenerate-primers PCR we isolated and sequenced fragments from the sand fly Lutzomyia longipalpis homologous to two behavioural genes in Drosophila, cacophony and period. In addition we identified a number of other gene fragments that show homology to genes previously cloned in Drosophila. A codon usage table for L. longipalpis based on these and other genes was calculated. These new molecular markers will be useful in population genetics and evolutionary studies in phlebotomine sand flies and in establishing a preliminary genetic map in these important leishmaniasis vectors.

[The heart transplant. The initial experience of the Instituto do Coração de Pernambuco]. / Transplante de coração. Experiência inicial no Instituto do Coração de Pernambuco.

PURPOSE: To describe the initial experience of a heart transplant program in Recife, Pernambuco. METHODS: Six patients in the final stage of heart failure were submitted to heart transplant. There were 4 male and 2 female patients, ranging in age from 15 to 61 years (mean, 43.8). Four had coronary heart disease and two dilated cardiomyopathy. The conventional operative technique of orthotopic heart transplant was used. All patients received a triple drug immunosuppressive therapy. RESULTS: There was one death due to acute rejection on the 28th postoperative day. The 5 survivors are in functional class I in a mean follow-up period of 113 days. CONCLUSION: The initial experience of a heart transplant program in Recife, Pernambuco, suggests that good long term results could be expected.

A tecnica de Estlander com prolongamento miomucoso em reconstrucao labial. / The Estlander technique as a myomucous prolongation in the lip reconstruction

E apresentado um caso de reparacao do labio superior pos-excisao tumoral em que e utilizada a tecnica de Estlander adjuvada por um retalho miomucoso para reparacao do defeito resultante. Apos breve revisao bibliografica, e descrito o procedimento, devidamente documentado com esquemas e fotografias. Os autores concluem que o prolongamento miomucoso introduzido na tecnica original de Estlander fornece bons resultados esteticos e funcionais, referindo apenas o incoveniente de um segundo tempo para confeccao de nova comissura