Combined open and laparoscopic approach for repair of flank hernias: technique description and medium-term outcomes of a single surgeon.

PURPOSE: A residual bulge in the lateral abdominal wall is a reason for patient dissatisfaction after flank hernia repair (FHR). We hypothesized that combining a laparoscopically-placed intraperitoneal mesh (IPOM) with onlay hernia repair performed through a small open incision would increase repair durability and decrease such residual bulges. We aim to report our medium-term outcomes with this technique. METHODS: Patients who have undergone FHR using the technique described above from March 2013 through June 2017 were identified in a prospectively maintained database. Outcomes of interest included surgical site infections (SSI), surgical site occurrences (SSO), surgical site occurrences requiring procedural intervention (SSOPI) and hernia recurrence. RESULTS: Sixteen patients were identified (62% females; mean age 59 ± 8 years, mean body mass index 29.5 kg/m2). Mean hernia width was. 6.4 ± 3 cm and 31% were recurrent hernias previously repaired through an onlay approach. Mean operative time was 159 ± 40 min, fascial closure was achieved in all cases, and there were no intraoperative complications. Median length of stay was 3 days (IQR 3-4), and there were no unplanned readmissions or reoperations. At a median 37-month follow-up (IQR 21-55), wound morbidity rate was 12.5% (2 seromas). There were no SSI/SSOPI and one hernia recurrence (6%) was detected at 12 months postoperatively. CONCLUSION: Combining laparoscopic IPOM with open onlay hernia repair resulted in low recurrence and acceptable wound morbidity rates, with no residual bulges noted at medium-term follow-up. Further studies with larger number of patients and other surgeon's experiences are necessary to determine the role of such technique in the surgical armamentarium for flank hernia repair.

Neutron activation analysis of wheat samples.

The deficiency of essential micronutrients and excess of toxic metals in cereals, an important food items for human nutrition, can cause public health risk. Therefore, before their consumption and adoption of soil supplementation, concentrations of essential micronutrients and metals in cereals should be monitored. This study collected soil and two varieties of wheat samples-Triticum aestivum L. (Jordão/bread wheat), and Triticum durum L. (Marialva/durum wheat) from Elvas area, Portugal and analyzed concentrations of As, Cr, Co, Fe, K, Na, Rb and Zn using Instrumental Neutron Activation Analysis (INAA) to focus on the risk of adverse public health issues. The low variability and moderate concentrations of metals in soils indicated a lower significant effect of environmental input on metal concentrations in agricultural soils. The Cr and Fe concentrations in soils that ranged from 93-117 and 26,400-31,300mg/kg, respectively, were relatively high, but Zn concentration was very low (below detection limit <22mg/kg) indicating that soils should be supplemented with Zn during cultivation. The concentrations of metals in roots and straw of both varieties of wheat decreased in the order of K>Fe>Na>Zn>Cr>Rb>As>Co. Concentrations of As, Co and Cr in root, straw and spike of both varieties were higher than the permissible limits with exception of a few samples. The concentrations of Zn in root, straw and spike were relatively low (4-30mg/kg) indicating the deficiency of an essential micronutrient Zn in wheat cultivated in Portugal. The elemental transfer from soil to plant decreases with increasing growth of the plant. The concentrations of various metals in different parts of wheat followed the order: Root>Straw>Spike. A few root, straw and spike samples showed enrichment of metals, but the majority of the samples showed no enrichment. Potassium is enriched in all samples of root, straw and spike for both varieties of wheat. Relatively to the seed used for cultivation, Jordão presented higher transfer coefficients than Marialva, in particular for Co, Fe, and Na. The Jordão and Marialva cultivars accumulated not statistically significant different concentrations of different metals. The advantages of using INAA are the multielementality, low detection limits and use of solid samples (no need of digestion).

Effect of particulate matter, atmospheric gases, temperature, and humidity on respiratory and circulatory diseases' trends in Lisbon, Portugal.

This study addresses the significant effects of both well-known contaminants (particles, gases) and less-studied variables (temperature, humidity) on serious, if relatively common, respiratory and circulatory diseases. The area of study is Lisbon, Portugal, and time series of health outcome (daily admissions in 12 hospitals) and environmental data (daily averages of air temperature, relative humidity, PM(10), SO(2), NO, NO(2), CO, and O(3)) have been gathered for 1999-2004 to ascertain (1) whether concentrations of air pollutants and levels of temperature and humidity do interfere on human health, as gauged by hospital admissions due to respiratory and circulatory ailments; and (2) whether there is an effect of population age in such admissions. In general terms, statistically significant (p < 0.001) correlations were found between hospital admissions and temperature, humidity, PM(10), and all gaseous pollutants except CO and NO. Age appears to influence respiratory conditions in association with temperature, whereas, for circulatory conditions, such an influence likely involves temperature as well as the gaseous pollutants NO(2) and SO(2).

Elemental levels in tree-bark and epiphytic-lichen transplants at a mixed environment in mainland Portugal, and comparisons with an in situ lichen.

Samples of Platanus hybrida Brot. bark and Flavoparmelia caperata (L.) Hale thalli, from a clean area in northern Portugal (Baião), were transplanted into an exposure location at the south-western Atlantic coast, impacted by urban-industrial emissions (Sines), for a 10-month long experiment. Bark pieces were confined into nylon bags (2-mm mesh), and lichen thalli kept with their bark substrate (Pinus pinaster (Ait.) Sol.). Every two months, a double set of transplants (one for bark, one for lichens) was brought back into the laboratory, together with native samples of Evernia prunastri (L.) Ach. Following suitable cleansing and preparation procedures, field samples were put through INAA for elemental assessment. The results indicate that, regardless of signal magnitude, (1) concentrations in bark and lichen transplants are significantly correlated with atmospheric deposition for an appreciable number of elements; (2) there are a number of significant correlations between transplanted and native samples, and again between the latter and the deposition; and (3) the elements with biological patterns that follow the deposition in either transplanted or native samples (Co, V) are the very ones whose bioaccumulation seems to benefit from an alternation of wet-dry periods, which fits the precipitation record of the test site during the exposure term.

Experimental training model of pancreas transplant.

UNLABELLED: Pancreas transplant (Ptx) is the gold standard for the treatment of type I diabetes, mainly when associated with renal failure. The number of Ptx is increasing worldwide, but in developing countries, such as Brazil, the number of centers is small and transplant surgeons need to practice the technique. METHODS: For this model, 21 pancreas harvestings were performed in patient corpses after death from extra-abdominal causes, without pancreatic disease and peritoneal or systemic infection. The vessels of the grafts were prepared on the backtable according to the usual practice in humans. The pancreas was implanted in the inferior vena cava and aorta of mixed breed dogs, with 10 exocrine-bladder drainage and 11 duodenum-ileal anastomosis. RESULTS: There were anastomotic strictures of the portal vein in dogs 1 and 2. There was no arterial stricture or large bleeding. None of the animals died until the revascularization of the graft. Dogs 2, 5, and 8 died during the exocrine anastomosis. The arterial flow was initially high, but at the end of the procedure there were thromboses of small arteries. CONCLUSION: The experimental surgical technique model is feasible, repeating the stages of clinical pancreatic transplantation and allowing the training of surgeons.

Gravimetric and chemical features of airborne PM 10 AND PM 2.5 in mainland Portugal.

This paper describes concentration amounts of arsenic (As), particulate mercury (Hg), nickel (Ni) and lead (Pb) in PM(10) and PM(2.5), collected since 1993 by the Technological and Nuclear Institute (ITN) at different locations in mainland Portugal, featuring urban, industrial and rural environments, and a control as well. Most results were obtained in the vicinity of coal- and oil-fired power plants. Airborne mass concentrations were determined by gravimetry. As and Hg concentrations were obtained through instrumental neutron activation analysis (INAA), and Ni and Pb concentrations through proton-induced X-ray emission (PIXE). Comparison with the EU (European Union) and the US EPA (United States Environmental Protection Agency) directives for Ambient Air has been carried out, even though the sampling protocols herein--set within the framework of ITN's R&D projects and/or monitoring contracts--were not consistent with the former regulations. Taking this into account, 1) the EU daily limit for PM(10) was exceeded a few times in all sites except the control, even if the number of times was still inferior to the allowed one; 2) the EU annual mean for PM(10) was exceeded at one site; 3) the EPA daily limit for PM(2.5) was exceeded one time at three sites; 4) the EPA annual mean for PM(2.5) was exceeded at most sites; 5) the inner-Lisbon site approached or exceeded the legislated PMs; 6) Pb levels stayed far below the EU limit value; and 7) concentrations of As, Ni and Hg were also far less than the reference values adopted by EU. In every location, Ni appeared more concentrated in PM(2.5) than in coarser particles, and its levels were not that different from site to site, excluding the control. The highest As and Hg concentrations were found in the neighbourhood of the coal-fired, utility power plants. The results may be viewed as a "worst-case scenario" of atmospheric pollution, since they have been obtained in busy urban-industrial areas and/or near major power-generation and waste-incineration facilities.

Intraosseous hypertonic saline solution for resuscitation of uncontrolled, exsanguinating liver injury in young Swine.

Fluid resuscitation administered before hemorrhage control for trauma victims sustaining blunt abdominal injury is controversial. Prehospital fluid resuscitation is limited by difficulty in delivering large volumes of fluid in the field and time delays associated with gaining vascular access. Venous access is often a clinical dilemma in severely hypovolemic children. Intraosseous infusion is considered a useful technique for the administration of fluids in emergency situations when peripheral intravascular access is not possible. This study investigated the effectiveness of intraosseous versus intravenous infusion of hypertonic saline solution in an uncontrolled hemorrhagic shock swine model. We also tested the effect of the different sites of infusion on the intra-abdominal bleeding. Relevant hemodynamic parameters were monitored and blood samples were collected. After liver injury, 20 anesthetized immature pigs were randomized to three groups: intraosseous access, intravenous access and control. After 20 min of uncontrolled hemorrhage, the hypertonic saline solution begins in the intraosseous access and intravenous access groups of animals. Thirty minutes later, the animals were killed and intra-abdominal blood loss was measured. All the pigs presented lower pressures and lower cardiac output after 20 min of hemorrhagic shock. The intravenous and intraosseous access groups did not show a better hemodynamic performance after 10 min of fluid resuscitation. At the end of the experiment, all animals were hemodynamically similar without an improved answer to a fluid resuscitation. There were no significant differences between groups regarding intra-abdominal blood loss. It was concluded that the hypertonic saline solution in this experimental model did not promote hemodynamic improvement and there were no differences between the two sites of fluid resuscitation regarding intra-abdominal blood loss.

An evaluation of olive-tree bark for the biological monitoring of airborne trace-elements at ground level.

There is a need to start looking into the possibility of tree bark for biomonitoring. Bark from olive trees (Olea europaea Linn.) has been collected over an area in northwestern Portugal, featuring a blend of rural lands, industrial towns and coastal environments. Samples were analysed through INAA and PIXE for their elemental contents. Results from both techniques were reconciled and then compared with an extensive database on 46 trace elements in Parmelia spp. thalli from the same sites and mostly from the very bark substrates. Distribution-free, nonparametric statistics show that, despite signal magnitude, variation patterns of bark and lichen concentrations follow one another in a most significant way. Selected elements in bark also correlate to a superior extent. As far as this investigation goes, there is no reason whatsoever for discarding bark as an alternative to lower epiphytes.

Qualitative evaluation of the blood-brain barrier after the use of hypertonic saline solution in young rats.

The blood-brain barrier (BBB) controls the biochemical environment of the brain with variable permeability when comparing adults to children. Based on the knowledge that there is a greater vulnerability in the BBB of young subjects submitted to biochemical variations in the blood and in the brain, an experimental model was designed to study small volume resuscitation. Young Wistar rats were submitted to hemorrhage and resuscitated with 7.5% NaCl solution before undergoing a qualitative evaluation of their BBB. Thirty male rats were anesthetized and divided into four groups: Group 1 - submitted to hemorrhagic shock restored with hypertonic saline solution (HSS); Group 2 - submitted to hemorrhagic shock without volume restoration; Group 3 - receiving only HSS, and Group 4 - control. The data analyzed were: mean arterial blood pressure, base excess, sodium, chloride, urea, blood osmolarity and blood glucose levels. After infusing a 2% Evans blue solution, qualitative analysis of the BBB was carried out. Group 1 presented final mean blood pressure levels equivalent to groups 3 and 4. Group 2 had a significant difference in the final base excess when compared to the other groups. In groups 1 and 3, mean sodium and chloride, as well as serum osmolarity, were more elevated than groups 2 and 4. Macroscopic examination of the brain did not reveal any changes in color, which could be attributed to the opening of the BBB. It was concluded that the 7.5% NaCl solution in this experimental model did not promote qualitative changes in the BBB.

Occlusal splint therapy with a positioning orifice.

The authors studied the effect of a positioning orifice introduced in the anterior palatine region of occlusal splints for patients with craniomandibular disorders of swallowing and speech patterns. The patients were evaluated in four distinct situations. It was concluded that the splint orifice significantly favored swallowing and speech while the splint was being used, and is more comfortable for the patient.

[Submammary skin incision for longitudinal medial sternotomy]. / Incisión submamaria para esternotomía media longitudinal.

The submammary incision has been postulated as an alternative in median sternotomy approach since 1960. We used this incision in 32 females patients from 1 to 24 years. The diagnoses were atrial septal defects (ASD) 23 patients, ventricular septal defect (VSD) 2 patients, double outlet right ventricle 1 patient, supravalvular aortic stenosis 1 patient, ASD with VSD 3 patients and partial anomalous pulmonary venous connection 1 patient. Nine patients had a complication: cheloid scar 1 patient, seroma 2 patients, wound dehiscence 3 patients, and diminution of sensitivity 3 patients. We conclude, that this type of surgical approach is an excellent alternative for women with good aesthetic and psychological results. Their complications are easy to correct.

[Monitoring by measurement of gastrointestinal mucosal pH value (pHi)]. / Monitoring durch Messung des gastrointestinalen Mukosa-pH-Wertes (pHi).

Noninvasive measurement of mucosal pH by tonometry provides information on the adequacy of gastrointestinal mucosal oxygenation. The technique requires tonometer catheters (commercially available from Tonometrics) and a standard blood gas analyzer. After positioning of the catheter in the stomach or gut for at least 30 min, fluid is withdrawn from the prefilled balloon mounted on the catheter tip for pHi measurements. The pCO2 in the withdrawn fluid and bicarbonate concentration in the arterial blood are determined and pHi is calculated according to the Henderson-Hasselbalch equation. The tonometer technique has been validated in experimental studies and pHi has been shown to be a useful parameter to estimate adequacy of oxygenation of the mucosa surrounding the tonometer balloon. In surgical patients, pHi was found to be of high predictive value concerning incidence of complications; return of pHi towards higher values was found to be associated with a higher survival rate. In intensive care units, pHi-guided resuscitation proved to be superior to conventional therapy. Tonometric measurement of pHi is a useful parameter to monitor mucosal oxygenation and to provide information on the probability of complications and patient outcome. Further studies are needed in well-stratified patient groups with a present lower limit of pHi, triggering defined therapeutic interventions to improve mucosal oxygenation.

Tratamento de pacientes portadores de deficiência de hormônio de crescimento (DHC) com hormônio de crescimento recombinante autêntico / Treatment of patients carried of growth hormone deficiency with authentic recombinant growth hormone

Onze pacientes portadores de deficiência de hormônio de crescimento (DHC) foram tratados por três anos com hormônio de crescimento recombinante autêntico (HCr), em doses de 0,35 a 0,5U/Kg/semana. A velocidade de crescimento pré-tratamento de 2,91 ñ 1,58cm/a elevou-se a 11,07 ñ 2,52cm/a no primeiro ano, 8,62 ñ 2,81cm/a no segundo e 7,63 ñ 1,84 no terceiro ano de terapêutica. Embora tenha ocorrido importante ganho na idade estatural (deltaIE = 4,9 ñ 1 anos), houve também aceleraçäo significante da idade óssea (deltaIO = 4,3 ñ 1,4 anos), com relaçäo deltaIE/deltaIO de 1,1 ñ 0,2. Como o ganho em altura foi acompanhado de proporcional avanço de IO, a possibilidade de obter altura final normal näo seria alcançada a näo ser que a terapêutica com HCr seja instituída mais precocemente, antes do déficit estatural ser demasiadamente severo, como foi na maioria dos pacientes

[Treatment of growth hormone deficiency patients with authentic recombinant growth hormone]. / Tratamento de pacientes portadores de deficiência de hormônio de crescimento (DHC) com hormônio de crescimento recombinante autêntico.

Eleven growth hormone deficient (GHD) subjects were treated regularly for 3 years with an authentic recombinant growth hormone preparation (0.35 to 0.5U/kg/week). Growth velocity (GV) increased from a mean o 2.91 +/- 1.58cm/year during the 1st year to 8.62 +/- 2.81cm/y in the 2nd and 7.63 +/- 1.84cm/y in the 3th year of follow up. During that period height age (delta HA) increased by 4.9 +/- 1 years while bone age advanced 4.3 +/- 1.4 year (delta BA) resulting in a delta HA/delta BA of 1.1 +/- 0.2. Since the height increment was associated with BA advancement the final height within normal range could not be attained. Thus, GHr therapy should be instituted before the height deficit would became intense as it happened in the majority of our patients. Early diagnosis and therapy of GHD is important, when growth retardation is less severe, in order to allow a better final height.

Babies provide focus for quality improvement team.

The challenge of quality improvement (QI) is to take its principles and tools and apply them to active problems in the clinical laboratory. The authors describe a 2-year QI project in which the staff of the laboratory and the neonatal care unit (NCU) significantly improved the care of babies who undergo heelsticks to provide blood samples for laboratory testing. Examples of quality tools used during the project are provided. The success of the QI project is due to the consistent and ongoing efforts of both staffs to care passionately about their customers--the babies of the NCU.

Sobrevivencia prolongada apos resseccao intestinal extensa e nutricao parenteral domiciliar. / Prolonged survival after extensive intestinal resection and parenteral feeding at home

A nutricao parenteral domiciliar ou ambulatorial representa um grande avanco nas tecnicas de nutricao parenteral endovenosa. Ela tem permitido uma nutricao adequada a um limitado numero de doentes, provisoria ou definitivamente incapacitados de utilizarem a via digestiva normal. Os autores relatam um doente portador de sindrome do intestino curto e que se tem beneficiado desta terapeutica. Analisam aspectos relacionados a esta forma de suporte nutricional