Inositol 1,4,5-trisphosphate receptor type 3 (ITPR3) is overexpressed in cholangiocarcinoma and its expression correlates with S100 calcium-binding protein A4 (S100A4).

Cholangiocarcinoma (CCA) is the second most malignant neoplasm in the liver that arises from the biliary tree. CCA is associated with a poor prognosis, and the key players involved in its pathogenesis are still not well understood. Receptor tyrosine kinases (RTKs), such as epidermal growth factor receptor (EGFR), can mediate intracellular calcium (Ca2+) signaling pathways via inositol 1,4,5-trisphosphate (InsP3), activating inositol 1,4,5-trisphosphate receptors (ITPRs) and regulating tumor growth. ITPR isoform 3 (ITPR3) is the main intracellular Ca2+ release channel in cholangiocytes. The effects of intracellular Ca2+ are mediated by calcium-binding proteins such as Calmodulin and S100 calcium-binding protein A4 (S100A4). However, the clinicopathological and biological significance of EGFR, ITPR3 and S100A4 in CCA remains unclear. Thus, the present work investigates the immunoexpression of these three proteins in 59 CCAs from patients who underwent curative surgical treatment and correlates the data with clinicopathological features and survival. High ITPR3 expression was correlated with CA 19-9 levels, TNM stage and lymph node metastasis (N). Furthermore, ITPR3 expression was increased in distal CCA compared to control bile ducts and intrahepatic and perihilar CCAs. These observations were confirmed by proteomic analysis. ITPR3 and S100A4 clinical scores were significantly correlated. Furthermore, it was demonstrated that EGF induces calcium signaling in a cholangiocarcinoma cell line and ITPR3 colocalizes with nonmuscle myosin IIA (NMIIA). In summary, ITPR3 overexpression could contribute to CCA progression and it may represent a potential therapeutic target.

PRIMARY TUMOR LYMPHOVASCULAR INVASION NEGATIVELY AFFECTS SURVIVAL AFTER COLORECTAL LIVER METASTASIS RESECTION?

BACKGROUND: About 50% of the patients with colorectal adenocarcinoma will present with liver metastasis and 20% are synchronic. Liver resection is associated with improvement in survival in comparison to chemotherapy alone. AIM: To analyze the overall survival in patients submitted to liver resection of colorectal cancer metastasis and prognostic factors related to the primary and secondary tumors. METHODS: A retrospective analysis of a prospectively maintained database regarding demographic, primary tumor and liver metastasis characteristics. RESULTS: There were 84 liver resections due to colorectal cancer metastasis in the period. The 5-year disease-free and overall survivals were 27.5% and 48.8% respectively. The statistically significant factors for survival were tumor grade (p=0.050), lymphovascular invasion (p=0.021), synchronous metastasis (p=0.020), as well as number (p=0.004), bilobar distribution (p=0.019) and diameter of the liver metastasis over 50 mm (p=0.027). Remained as independent negative predictive factors: lymphovascular invasion (HR=2.7; CI 95% 1.106-6.768; p=0.029), synchronous metastasis (HR=2.8; CI 95% 1.069-7.365; p=0.036) and four or more liver metastasis (HR=1.7; CI 95% 1.046-2.967; p=0.033). CONCLUSION: The resection of liver metastasis of colorectal adenocarcinoma leads to good survival rates. Lymphovascular invasion was the single prognostic factor related to the primary tumor. Synchronous disease and four or more metastasis were the most significant factors related to the secondary tumor.

Donor-Derived Tuberculosis: A Case Report and the Role of Communication Gaps in Transplantation Safety.

Donor-derived tuberculosis (DD-TB) accounts for less than 5% of TB cases and is considered a rare event. In the transplant setting, the frequency of active TB is estimated to be 20 to 74 times higher than that in the general population, and it is associated with high mortality. In this context, the main strategy to minimize the risk of DD transmission is to identify high-risk donors. Despite screening recommendations, failures may result in a breakdown of safety that ends in the transmission of potentially fatal diseases. This report describes a case of DD-TB and emphasizes communication gaps that may occur between organ procurement organizations and transplant centers. Failure in reporting results, lack of exchanging information regarding recipients from the same donor, and inefficient communication between organ procurement organizations and transplant centers are lacks that may be prevented by a more efficient approach towards screening protocols and communication.

Primary tumor lymphovascular invasion negatively affects survival after colorectal liver metastasis resection? / Invasão angiolinfática no tumor primário compromete a sobrevida após ressecção de metástases hepáticas colorretais?

ABSTRACT Background: About 50% of the patients with colorectal adenocarcinoma will present with liver metastasis and 20% are synchronic. Liver resection is associated with improvement in survival in comparison to chemotherapy alone. Aim: To analyze the overall survival in patients submitted to liver resection of colorectal cancer metastasis and prognostic factors related to the primary and secondary tumors. Methods: A retrospective analysis of a prospectively maintained database regarding demographic, primary tumor and liver metastasis characteristics. Results: There were 84 liver resections due to colorectal cancer metastasis in the period. The 5-year disease-free and overall survivals were 27.5% and 48.8% respectively. The statistically significant factors for survival were tumor grade (p=0.050), lymphovascular invasion (p=0.021), synchronous metastasis (p=0.020), as well as number (p=0.004), bilobar distribution (p=0.019) and diameter of the liver metastasis over 50 mm (p=0.027). Remained as independent negative predictive factors: lymphovascular invasion (HR=2.7; CI 95% 1.106-6.768; p=0.029), synchronous metastasis (HR=2.8; CI 95% 1.069-7.365; p=0.036) and four or more liver metastasis (HR=1.7; CI 95% 1.046-2.967; p=0.033). Conclusion: The resection of liver metastasis of colorectal adenocarcinoma leads to good survival rates. Lymphovascular invasion was the single prognostic factor related to the primary tumor. Synchronous disease and four or more metastasis were the most significant factors related to the secondary tumor.

RESUMO Racional: Cerca de metade dos pacientes com adenocarcinoma colorretal apresentará metástases hepáticas. Apesar da superioridade do tratamento cirúrgico, os pacientes com elas compõem um grupo muito heterogêneo. Objetivo: Descrever o impacto de fatores relacionados ao tumor primário e ao secundário na sobrevida após ressecção de metástases hepáticas colorretais. Métodos: Análise retrospectiva de base de dados mantida prospectivamente de pacientes operados. Resultados: Foram realizadas 84 hepatectomias para ressecção de metástases hepáticas de adenocarcinoma colorretal em 73 pacientes no período. A sobrevida global e livre de doença em cinco anos foram de 48,8 e 27,5%, respectivamente. Os principais preditores de sobrevida foram grau de diferenciação (p=0,050) e invasão angiolinfática (p=0,021) do tumor primário, metástases sincrônicas (p=0,020), número (p=0,004), distribuição bilobar (p=0,019) e diâmetro máximo maior que 50 mm (p=0,027) dos nódulos hepáticos. Foram significativos a presença de invasão angiolinfática (HR=2,7; IC 95% 1,106-6,768; p=0,029), metástases sincrônicas (HR=2,8; IC 95% 1,069-7,365; p=0,036) e número de nódulos hepáticos igual ou superior a quatro (HR=1,7; IC 95% 1,046-2,967; p=0,033). Conclusão: A ressecção de metástases hepáticas de adenocarcinoma colorretal proporciona melhora da sobrevida e os principais fatores prognósticos foram a invasão angiolinfática no tumor primário, metástases sincrônicas e quatro ou mais nódulos hepáticos.

Preoperative prognostic factors in patients with ductal adenocarcinoma of the head of the pancreas. / Fatores prognósticos pré-operatórios em pacientes com adenocarcinoma ductal da cabeça do pâncreas.

OBJECTIVE: To identify the preoperative prognostic factors influencing pancreatic cancer survival following curative resection in a single Brazilian institution. METHODS: From 2005 to 2018, preoperative clinic, demographic and laboratory data were prospectively collected. Survival analysis was performed by the Kaplan-Meier method and the comparison between curves by the log-rank test. For multivariate analysis, the Cox regression model was used. RESULTS: advanced age (p = 0.012) and previous history of cancer (p = 0.026) were the preoperative factors, according to the univariate analysis, that significantly impacted survival. Patients with preoperative serum levels of CA 19.9 from 38 to 554 U/mL had a 3.15 times higher chances of death (HR 3.15; 95% CI 1.01-9.82; p = 0.047), whereas patients with the marker above 554 U/mL were 3.96 times more likely than those with the normal level (HR 3.96; 95% CI 1.19-13.10; p = 0.024), by using the multivariate analysis. Patients with previous comorbidities had a 2.90 times higher chance of death than those without associated conditions (HR 2.90; 95% CI 1.10-7.67; p = 0.032). CONCLUSION: Preoperative factors related to the worst prognosis after pancreatic ductal adenocarcinoma resection were advanced age, presence of comorbidities, previous history of cancer and elevated preoperative serum CA 19.9.

OBJETIVOS: Identificar fatores prognósticos pré-operatórios relacionados à sobrevida de pacientes com adenocarcinoma ductal da cabeça de pâncreas (ADCP) submetidos a tratamento cirúrgico com intenção curativa em uma única instituição brasileira. MÉTODO: No período de 2005 a 2018, dados clinicodemográficos e laboratoriais pré-operatórios foram prospectivamente coletados. A análise de sobrevida foi feita pelo método de Kaplan-Meier e a comparação entre as curvas pelo teste de log-rank. Para a análise multivariada utilizou-se o modelo de regressão de Cox. RESULTADOS: Os fatores pré-operatórios com impacto significativo na sobrevida à análise univariada foram a idade maior ou igual a 70 anos (p=0,012) e história pessoal prévia positiva para câncer (p=0,026). A análise multivariada, pacientes com níveis séricos pré-operatórios de CA 19.9 de 38 a 554 U/ml apresentaram 3,15 vezes maior chance de óbito (HR 3,15; IC 95% 1,01 - 9,82; p=0,047), enquanto que os pacientes com o marcador acima de 554 U/ml evoluíram com chance 3,96 vezes maior de óbito que aqueles com a dosagem normal (HR 3,96; IC 95% 1,19 - 13,10; p=0,024). Pacientes com comorbidades prévias evoluíram com chance 2,90 vezes superior de óbito que doentes sem condições associadas (HR 2,90; IC 95% 1,10 - 7,67; p=0,032). CONCLUSÃO: O ADCP mostrou ser doença agressiva para a qual os fatores pré-operatórios de pior prognóstico foram idade avançada, presença de comorbidades, história prévia de câncer e nível sérico de CA 19.9 elevado no pré-operatório.

Preoperative risk score for prediction of long-term outcomes after hepatectomy for intrahepatic cholangiocarcinoma: Report of a collaborative, international-based, external validation study.

PURPOSE: A preoperative risk score (PRS) to predict outcome of patients with intrahepatic cholangiocarcinoma treated by liver surgery could be clinically relevant.To assess accuracy for broadly adoption, external validation of predictive models on independent datasets is crucial. The objective of this study was to externally validate the score for prediction of long-term outcomes after liver surgery for intrahepatic cholangiocarcinoma proposed by Sasaki et al. and based on preoperative albumin, neutrophil-to-lymphocytes-ratio, CA19-9 and tumor size. METHODS: Patients treated by liver surgery for intrahepatic cholangiocarcinoma at 11 international HPB centers from 2001 to 2018 were included in the external validation cohort. Harrell's c-index and Hosmer-Lemeshow analyses were used to test PRS discrimination and calibration. Kaplan-Meier curve for risk groups as described in the original study were displayed. RESULTS: A total of 355 patients with 174 deaths during the follow-up period (median = 41.7 months, IQR 32.8-50.6) were included. The median PRS value was 14.7 (IQR 10.7-20.6), with normal distribution across the cohort. A Cox regression on PRS covariates found coefficients similar to those of the derivation cohort, except for tumor size. Measures of discrimination estimated by Harrell's c-index was 0.61(95%CI:0.56-0.67) and Hosmer-Lemeshow p = 0.175. The Kaplan-Meyer estimation showed reasonable discrimination across risk groups, with 5years survival rate ranging from 20.1% to 0%. CONCLUSION: In this external validation cohort, the PRS had mild discrimination and poor calibration performance, similarly to the original publication. Nevertheless, its ability to identify different classes of risk is clinically useful, for a better tailoring of a therapeutic strategy.

Associated Clinical and Laboratory Markers of Donor on Allograft Function After Heart Transplant.

INTRODUCTION: Primary graft dysfunction is a major cause of mortality after heart transplantation. OBJECTIVE: To evaluate correlations between donor-related clinical/biochemical markers and the occurrence of primary graft dysfunction/clinical outcomes of recipients within 30 days of transplant. METHODS: The prospective study involved 43 donor/recipient pairs. Data collected from donors included demographic and echocardiographic information, noradrenaline administration rates and concentrations of soluble tumor necrosis factor receptors (sTNFR1 and sTNFR2), interleukins (IL-6 and IL-10), monocyte chemoattractant protein-1, C-reactive protein and cardiac troponin I. Data collected from recipients included operating, cardiopulmonary bypass, intensive care unit and hospitalization times, inotrope administration and left/right ventricular function through echocardiography. RESULTS: Recipients who developed moderate/severe left ventricular dysfunction had received organs from significantly older donors (P =0.020). Recipients from donors who required moderate/high doses of noradrenaline (>0.23 µg/kg/min) around harvesting time exhibited lower post-transplant ventricular ejection fractions (P =0.002) and required longer CPB times (P =0.039). Significantly higher concentrations of sTNFR1 (P =0.014) and sTNFR2 (P =0.030) in donors were associated with reduced intensive care unit times (≤5 days) in recipients, while higher donor IL-6 (P =0.029) and IL-10 (P =0.037) levels were correlated with reduced hospitalization times (≤25 days) in recipients. Recipients who required moderate/high levels of noradrenaline for weaning off cardiopulmonary bypass were associated with lower donor concentrations of sTNFR2 (P =0.028) and IL-6 (P =0.001). CONCLUSION: High levels of sTNFR1, sTNFR2, IL-6 and IL-10 in donors were associated with enhanced evolution in recipients. Allografts from older donors, or from those treated with noradrenaline doses >0.23 µg/kg/min, were more frequently affected by primary graft dysfunction within 30 days of surgery.

Associated clinical and laboratory markers of donor on allograft function after heart transplant

Abstract Introduction: Primary graft dysfunction is a major cause of mortality after heart transplantation. Objective: To evaluate correlations between donor-related clinical/biochemical markers and the occurrence of primary graft dysfunction/clinical outcomes of recipients within 30 days of transplant. Methods: The prospective study involved 43 donor/recipient pairs. Data collected from donors included demographic and echocardiographic information, noradrenaline administration rates and concentrations of soluble tumor necrosis factor receptors (sTNFR1 and sTNFR2), interleukins (IL-6 and IL-10), monocyte chemoattractant protein-1, C-reactive protein and cardiac troponin I. Data collected from recipients included operating, cardiopulmonary bypass, intensive care unit and hospitalization times, inotrope administration and left/right ventricular function through echocardiography. Results: Recipients who developed moderate/severe left ventricular dysfunction had received organs from significantly older donors (P =0.020). Recipients from donors who required moderate/high doses of noradrenaline (>0.23 µg/kg/min) around harvesting time exhibited lower post-transplant ventricular ejection fractions (P =0.002) and required longer CPB times (P =0.039). Significantly higher concentrations of sTNFR1 (P =0.014) and sTNFR2 (P =0.030) in donors were associated with reduced intensive care unit times (≤5 days) in recipients, while higher donor IL-6 (P =0.029) and IL-10 (P =0.037) levels were correlated with reduced hospitalization times (≤25 days) in recipients. Recipients who required moderate/high levels of noradrenaline for weaning off cardiopulmonary bypass were associated with lower donor concentrations of sTNFR2 (P =0.028) and IL-6 (P =0.001). Conclusion: High levels of sTNFR1, sTNFR2, IL-6 and IL-10 in donors were associated with enhanced evolution in recipients. Allografts from older donors, or from those treated with noradrenaline doses >0.23 µg/kg/min, were more frequently affected by primary graft dysfunction within 30 days of surgery.

Soluble tumor necrosis factor receptors as predictors of 1-year mortality and renal dysfunction after liver transplantation.

BACKGROUND: Several risk factors influence survival after liver transplantation (LT). Some research has demonstrated a relationship between soluble tumor necrosis factor receptors (sTNFRs) and worse clinical liver disease outcomes, but there are no data showing an association between sTNFRs and outcomes after LT. The primary aim of this study was to determine whether an association exists between perioperative sTNFRs and renal dysfunction or mortality after LT. METHODS: Data were collected prospectively from 122 patients submitted to deceased-donor orthotopic LT. Blood samples were collected at seven different perioperative times and analyzed by ELISA. The statistical analysis included univariate analysis followed by logistic regression. The predictive value of significant variables was assessed using ROC curves. RESULTS: One-month and 1-year LT survivals were 91% and 81%, respectively. Increased levels of soluble tumor necrosis factor receptor 1 (sTNF-R1) after 24h of graft perfusion were associated with postoperative Renal Replacement Therapy (RRT) (OR 1.25) and 1-year mortality (OR 1.1). RRT was associated with 30-day and 1-year LT mortality, with OR 19.78 and 45.45, respectively. CONCLUSION: A higher sTNF-R1 level measured 24h after graft perfusion is an independent predictor of RRT and 1-year mortality after LT.

The impact of a chest tube management protocol on the outcome of trauma patients with tube thoracostomy.

OBJECTIVE: to investigate the effect of standardized interventions in the management of tube thoracostomy patients and to assess the independent effect of each intervention. METHODS: A chest tube management protocol was assessed in a retrospective cohort study. The tube thoracostomy protocol (TTP) was implemented in August 2012, and consisted of: antimicrobial prophylaxis, chest tube insertion in the operating room (OR), admission post chest tube thoracostomy (CTT) in a hospital floor separate from the emergency department (ED), and daily respiratory therapy (RT) sessions post-CTT. The inclusion criteria were, hemodynamic stability, patients between the ages of 15 and 59 years, and injury severity score (ISS) < 17. All patients had isolated injuries to the chest wall, lung, and pleura. During the study period 92 patients were managed according to the standardized protocol. The outcomes of those patients were compared to 99 patients treated before the TTP. Multivariate logistic regression analysis was performed to assess the independent effect of each variable of the protocol on selected outcomes. RESULTS: Demographics, injury severity, and trauma mechanisms were similar among the groups. As expected, protocol compliance increased after the implementation of the TTP. There was a significant reduction (p<0.05) in the incidence of retained hemothoraces, empyemas, pneumonias, surgical site infections, post-procedural complications, hospital length of stay, and number of chest tube days. Respiratory therapy was independently linked to significant reduction (p<0.05) in the incidence of seven out of eight undesired outcomes after CTT. Antimicrobial prophylaxis was linked to a significant decrease (p<0.05) in retained hemothoraces, despite no significant (p<0.10) reductions in empyema and surgical site infections. Conversely, OR chest tube insertion was associated with significant (p<0.05) reduction of both complications, and also significantly decreased the incidence of pneumonias. CONCLUSION: Implementation of a TTP effectively reduced complications after CTT in trauma patients.

Associated factors to empyema in post-traumatic hemotorax.

OBJECTIVE: to analyze the associated factors with empyema in patients with post-traumatic retained hemothorax. METHODS: prospective observational study. Data were collected in patients undergoing PD during emergency duty. Variables analyzed were age, sex, mechanism of injury, side of the chest injury, intrathoracic complications of RH, laparotomy, specific injuries, rib fractures, trauma scores, days to diagnosis, diagnostic method of RH, primary indication of PD, initial volume drained, length of the first tube removal, surgical procedure. Cumulative incidence of empyema, pneumonia and pulmonary contusion and the proportion of patients with empyema or without empyema in each category of each variable analyzed were obtained. RESULTS: the cumulative incidence of PD among trauma patients was 1.83% and the RH among those with PD was 10.63%. There were 20 cases of empyema (32.8%). Most were male in the age from 20 to 29, victims of injury by firearm on the left side of the thorax. The incidence of empyema in patients with injury by firearms was lower compared to those with stab wound or blunt trauma; higher among those with drained volume between 300 and 599 ml. The median hospital lenght of stay was higher among those with empyema. CONCLUSION: the incidence of PD was 1.83% and RH was 10.63%, these results are consistent with the low severity of the patients involved in this study and consistent with the literature. The incidence of empyema proved to be negatively associated with the occurrence of injury by firearms and positively associated with a drained volume between 300 and 599 ml, compared with lower or higher volumes.

Associated factors to empyema in post-traumatic hemotorax / Fatores associados ao empiema em pacientes com hemotórax retido pós-traumático

ABSTRACTObjective:to analyze the associated factors with empyema in patients with post-traumatic retained hemothorax.Methods:prospective observational study. Data were collected in patients undergoing PD during emergency duty. Variables analyzed were age, sex, mechanism of injury, side of the chest injury, intrathoracic complications of RH, laparotomy, specific injuries, rib fractures, trauma scores, days to diagnosis, diagnostic method of RH, primary indication of PD, initial volume drained, length of the first tube removal, surgical procedure. Cumulative incidence of empyema, pneumonia and pulmonary contusion and the proportion of patients with empyema or without empyema in each category of each variable analyzed were obtained.Results: the cumulative incidence of PD among trauma patients was 1.83% and the RH among those with PD was 10.63%. There were 20 cases of empyema (32.8%). Most were male in the age from 20 to 29, victims of injury by firearm on the left side of the thorax. The incidence of empyema in patients with injury by firearms was lower compared to those with stab wound or blunt trauma; higher among those with drained volume between 300 and 599 ml. The median hospital lenght of stay was higher among those with empyema.Conclusion:the incidence of PD was 1.83% and RH was 10.63%, these results are consistent with the low severity of the patients involved in this study and consistent with the literature. The incidence of empyema proved to be negatively associated with the occurrence of injury by firearms and positively associated with a drained volume between 300 and 599 ml, compared with lower or higher volumes.

RESUMOObjetivo:analisar os fatores associados ao empiema em pacientes com hemotórax retido pós-traumático.Métodos:estudo prospectivo observacional. Os dados foram coletados de pacientes submetidos à drenagem pleural de emergência. Foram analisadas: idade, sexo, mecanismo de trauma, lado da lesão torácica, complicações intratorácicas decorrentes do hemotórax retido, laparotomia, lesões específicas, fratura de arcos costais, índices de trauma, dias até o diagnóstico, método diagnóstico do HR, indicação primária da drenagem pleural, volume inicial drenado, dias de permanência do primeiro dreno, procedimento cirúrgico. Obteve-se a incidencia acumulada de empiema, pneumonia e contusão pulmonar e a incidência de empiema em cada categoria das variaìveis analisadas.Resultados:a incidência acumulada de drenagem pleural por trauma foi 1,83% e a de hemotórax retido entre aqueles com derrame pleural foi de 10,63%. Houve 20 casos de empiema (32,8%). A maioria tinha entre 20 e 29 anos, era do sexo masculino e sofreu ferimento por arma de fogo. A incidência de empiema entre pacientes com ferimento por arma de fogo foi inferior aos demais mecanismos; superior entre aqueles com volume drenado entre 300 e 599 ml. O tempo mediano de permanência hospitalar foi maior nos pacientes com empiema.Conclusão:as incidências de derrame pleural e hemotórax retido entre aqueles com DP nessa amostra de baixa gravidade dos pacientes foram, respectivamente, 1,83% e 10,63%. A incidência de empiema revelou-se negativamente associada à ocorrência de ferimento por arma de fogo e positivamente associada a volume drenado entre 300 e 599 ml, bem como, ao tempo mediano de permanência hospitalar.

The impact of a chest tube management protocol on the outcome of trauma patients with tube thoracostomy / Impacto de um protocolo de cuidados a pacientes com trauma torácico drenado

ABSTRACTObjective:to investigate the effect of standardized interventions in the management of tube thoracostomy patients and to assess the independent effect of each intervention.Methods:A chest tube management protocol was assessed in a retrospective cohort study. The tube thoracostomy protocol (TTP) was implemented in August 2012, and consisted of: antimicrobial prophylaxis, chest tube insertion in the operating room (OR), admission post chest tube thoracostomy (CTT) in a hospital floor separate from the emergency department (ED), and daily respiratory therapy (RT) sessions post-CTT. The inclusion criteria were, hemodynamic stability, patients between the ages of 15 and 59 years, and injury severity score (ISS) < 17. All patients had isolated injuries to the chest wall, lung, and pleura. During the study period 92 patients were managed according to the standardized protocol. The outcomes of those patients were compared to 99 patients treated before the TTP. Multivariate logistic regression analysis was performed to assess the independent effect of each variable of the protocol on selected outcomes.Results:Demographics, injury severity, and trauma mechanisms were similar among the groups. As expected, protocol compliance increased after the implementation of the TTP. There was a significant reduction (p<0.05) in the incidence of retained hemothoraces, empyemas, pneumonias, surgical site infections, post-procedural complications, hospital length of stay, and number of chest tube days. Respiratory therapy was independently linked to significant reduction (p<0.05) in the incidence of seven out of eight undesired outcomes after CTT. Antimicrobial prophylaxis was linked to a significant decrease (p<0.05) in retained hemothoraces, despite no significant (p<0.10) reductions in empyema and surgical site infections. Conversely, OR chest tube insertion was associated with significant (p<0.05) reduction of both complications, and also significantly decreased the incidence of pneumonias.Conclusion:Implementation of a TTP effectively reduced complications after CTT in trauma patients.

RESUMOObjetivo:avaliar a implantação do Cuidado Padronizado com o Dreno de Tórax (CPDT) em um hospital público, referência para o trauma, e o impacto independente de cada um dos itens do protocolo no período do estudo sobre desfechos selecionados.Métodos: coorte retrospectiva avaliando implementação do Cuidado Padronizado para o Dreno de Tórax (CPDT). Foram incluídos pacientes entre 15 e 59 anos de idade, hemodinamicamente estáveis, com Injury Severity Score inferior a 17, com lesão isolada na parede do tórax, pulmão e pleura. Foram comparados 99 pacientes antes do CPDT com 92 depois do CPDT. Foi realizada comparação de desfechos selecionados por meio de diferença de proporções. A regressão logística multivariada foi feita para análise do efeito independente de cada variável do protocolo.Resultados:não houve diferença entre os grupos quanto às variáveis sociodemográficas, índice de gravidade e mecanismo de trauma. A implementação do CPDT resultou no aumento no percentual de todos os itens do protocolo. Houve redução significativa (p<0,05) de hemotórax retido, empiema, pneumonia, infecções de ferida operatória e nova operação, queda do percentual de pacientes retornados com complicações, tempo de internação e de permanência do dreno. A fisioterapia revelou-se independentemente associada à redução de sete dos oito desfechos (p<0,05). O antibiótico presuntivo revelou tendência de associação com a redução de empiema e de infecções de ferida operatória (p<0,10) e esteve associado à redução do hemotórax retido (p<0,05). A drenagem no centro cirúrgico esteve associada à redução de empiema, pneumonia e infecção de ferida operatória (p<0,05).Conclusão:a implementação do CPDT foi efetiva na redução de complicações de pacientes com dreno de tórax.

Pre-Transplant Aerobic Capacity and Prolonged Hospitalization After Liver Transplantation.

INTRODUCTION: Patients with end stage liver disease (ESLD) referred for liver transplantation (LT) are forwarded to pulmonary evaluation before being operated. ESLD is associated with muscle wasting, reduced exercise tolerance and aerobic capacity. OBJECTIVES: We assessed the association between aerobic capacity (AC), liver disease severity and postoperative LT outcomes in a series of LT candidates in a university affiliated hospital in Brazil. METHODS: Pre-LT oxygen uptake at peak (pre-VO2peak), liver disease severity, and early pos-LT outcomes such as length of intensive care unit (ICU) stay, <5 and ≥5 days and hospitalization, <20 and ≥20 days and postoperative mortality were compared. Pre-VO2peak was measured through the cardiopulmonary exercise testing (CPET). Severity of liver disease was estimated by the Model for End-Stage Liver Disease (MELD) categorization into MELD < 18 and MELD ≥ 18 groups. Student's t-test was used to compare these groups. A logistic regression model was built to verify the effect of those variables on the length of ICU stay, length of hospitalization and postoperative mortality. RESULTS: A total of 47 patients were include in analysis. Pre-VO2peak was similar to that of healthy sedentary individuals (75 ± 18%) and worse in the MELD ≥ 18 group as compared to the MELD < 18 group (19.51 ± 7.87 vs 25.21 ± 8.76 mL/kg/min, respectively; p = 0.048). According to the multivariate analysis, only a lower pre-VO2peak (<20.09 ± 4.83 mL/kg/min) was associated to a greater length of hospitalization (p = 0.01). CONCLUSIONS: In LT candidates, a reduced pre-VO2peak may predict a higher risk of greater pos-LT length of hospitalization. The length of ICU stay and postoperative mortality were not associated with variables studied. This finding should be evaluated in other studies before making specific recommendations about a routine use of CPET in LT candidates.

INTRODUÇÃO: Pacientes com doença hepática em estágio final (DHEF), referenciados para transplante hepático (TH), são encaminhados para avaliação da função pulmonar antes de serem operados. DHEF está associada à fraqueza muscular, redução da tolerância ao exercício e capacidade aeróbica (CA). OBJETIVOS: Foi avaliada a associação entre capacidade aeróbica, a gravidade da doença hepática e os resultados pós-operatórios do TH em uma serie de candidatos a TH em um hospital universitário no Brasil. MÉTODOS: O consumo de oxigênio num teste limitado por sintomas (VO2pico) pré-TH, a gravidade da doeça hepática, e os resultados precoces pós-TH como tempo de permanênica na unidade de cuidados intensivos (UCI), <5 e ≥5 dias, tempo de permanência hospitalar, <20 e ≥20 dias e mortalidade foram comparados. O VO2pico pré-TH foi medido através do teste de exercício cardiopulmonar (TECP). A gravidade da doença hepática foi estimada pelo Modelo para doença hepática em estágio final [Modelo de End-Stage Liver Disease (MELD)] e categorizada nos grupos MELD < 18 e MELD ≥ 18. O teste t de Student foi utilizado para comparar esses grupos. Um modelo de regressão logística foi construido para verificar o efeito dessas variáveis sobre o tempo de permanência na UTI, tempo de internação e mortalidade pós-operatória. Resultados: um total de 47 pacientes foram incluídos nas análises. O VO2pico pré-TH foi semelhante ao de indivíduos saudáveis sedentários (75 ± 18%) e pior no grupo MELD ≥ 18 em comparação com o MELD < 18 (19.51 ± 7.87 vs 25.21 ± 8.76 mL/kg/min, respectivamente; p = 0.048). De acordo com a análise multivariada, somente um menor VO2pico (<20.09 ± 4.83 mL/kg/min) pré-TH foi associado a um maior tempo de internação (p = 0,01). CONCLUSÃO: Em candidatos a TH, uma redução do VO2pico pré pode predizer um maior risco de maior permanência hospitalar pós-TH. Esta constatação deve ser avaliada em outros estudos antes de fazer recomendações específicas sobre o uso rotineiro do TECP para candidatos TH. O tempo de permanência na UTI e mortalidade pós-operatória não foram associados com as variáveis estudadas.

Duodenum-preserving pancreatic head resection in solid pseudopapillary neoplasm-Report of a case.

INTRODUCTION: Solid pseudopapillary neoplasm (SPPN) was first characterized by Virginia Frantz in 1959. The duodenum-preserving pancreatic head resection (DPPHR) has been described as treatment for low-grade malignant tumors of the head of the pancreas including eight cases of SPPN. PRESENTATION OF CASE: A 16-year-old white female patient presented with abdominal pain and dyspepsia. Computed tomography scan of abdomen showed a 10×9×10cm(3) lesion on the pancreatic head. After radiological diagnosis of SPPN the patient was submitted to DPPHR. Resection was achieved with clear margins. Immunohistochemical study demonstrated positivity for progesterone receptor, ß-catenin, cytoplasmic paranuclear dot-like CD99, negativity for chromogranin and S100 protein and Ki 67 index of 1%. DISCUSSION: A large encapsulated pancreatic mass with well-defined borders that contains areas of calcifications and intratumoral hemorrhage on CT scan in a young female is virtually diagnostic of an SPPN. A particular dot-like intracytoplasmic expression of CD99 appears to be highly unique for SPPN CONCLUSION: DPPHR should be considered in cases of SPPN in the pancreas head if there is no compromise with oncologic radicality.

A pilot prospective study to evaluate whether the bladder morphology in cystography and/or urodynamic may help predict the response to botulinum toxin a injection in neurogenic bladder refractory to anticholinergics.

BACKGROUND: We have observed different clinical responses to botulinum toxin A (BTX-A) in patients who had similar urodynamic parameters before the procedure. Furthermore, some bladders evaluated by cystography and cystoscopy during the procedure had different characteristics that could influence the outcome of the treatment. The aim of this study was to assess whether cystography and urodynamic parameters could help predict which patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergics respond better to treatment with injection of BTX-A. METHODS: In total, 34 patients with spinal cord injury were prospectively evaluated. All patients emptied their bladder by clean intermittent catheterization (CIC) and had incontinence and NDO, despite using 40 mg or more of intravesical oxybutynin and undergoing detrusor injection of BTX-A (300 IU). Pretreatment evaluation included urodynamic, and cystography. Follow-up consisted of urodynamic and ambulatory visits four months after treatment. The cystography parameters used were bladder shape, capacity and presence of diverticula. Urodynamic parameters used for assessment were maximum cystometric capacity (MCC), maximum detrusor pressure (MDP), compliance and reflex volume (RV). RESULTS: After injection of BTX-A, 70% of the patients had success, with 4 months or more of continence. Before the treatment, there were significant differences in most urodynamic parameters between those who responded successfully compared to those who did not. Patients who responded successfully had greater MCC (p = 0.019), higher RV (p = 0.041), and greater compliance (p = 0.043). There was no significant difference in the MDP (0.691). The cystography parameters were not significantly different between these groups bladder shape (p = 0.271), capacity (p > 0.720) and presence of diverticula (p > 0.999). Statistical analyses were performed using SPSS (version 20.0) and included Student's t-test for two paired samples and Fisher's exact test, with a significance threshold of 0.05. CONCLUSIONS: This study suggests that the cystography parameters evaluated cannot be used to help predict the response to injection of BTX-A in the treatment of refractory NDO. However, the urodynamic parameters were significantly different in patients who responded to the treatment, with the exception of the MDP.

Portal cholangiopathy: case report / Colangiopatia portal: relato de caso

The present report describes the case of a child that after blunt abdominal trauma presented with portal thrombosis followed by progressive splenomegaly and jaundice. Ultrasonography and percutaneous cholangiography revealed biliary dilatation secondary to choledochal stenosis caused by dilated peribiliary veins, characterizing a case of portal biliopathy. The present case report is aimed at presenting an uncommon cause of this condition.

Relata-se o caso de uma criança que após trauma abdominal fechado apresentou trombose portal, seguida por esplenomegalia progressiva e icterícia. Os achados da ultrassonografia e da colangiografia percutânea mostraram dilatação de vias biliares secundária à constrição do colédoco por veias pericoledocianas dilatadas, configurando caso de colangiopatia portal. O objetivo deste relato é a apresentação de causa incomum desta condição.

Effect of "the Awakening Protocol" in the outcome of liver transplantation.

PURPOSE: To analyze mortality (7 days) or graft loss in liver transplantation (Tx) performed within the Awakening Protocol (AP) compared to sequential Tx. METHODS: Analysis of 243 liver tx (230 patients), divided into sequential tx or PD (early morning) to compare graft loss or death (7 days). Significant differences at p < 0.05 RESULTS: The PD was adopted in 32.5% of tx. The cold ischemia time (p < 0.01) and the interval until transplantation (p < 0.01) were significantly different. Age of the donor and recipient, Donor Risk Index, MELD score, and donor base excess, sodium, creatinine and glucose were not different between groups. Previous abdominal surgery was a risk factor for early mortality, but was equally distributed between the groups. There was no difference in mortality or graft loss within 7 days (p = 0.521) CONCLUSION: The adoption of PD, to start tx the morning when harvesting occurs after 10p.m. did not result in worse patient and graft survival. Transplant patients with fulminant hepatic failure and high-risk grafts do not apply to this surgical tactics.

Effect of "the Awakening Protocol" in the outcome of liver transplantation / Efeito do "Protocolo Despertar" no resultado do transplante de fígado

PURPOSE: To analyze mortality (7 days) or graft loss in liver transplantation (Tx) performed within the Awakening Protocol (AP) compared to sequential Tx. METHODS: Analysis of 243 liver tx (230 patients), divided into sequential tx or PD (early morning) to compare graft loss or death (7 days). Significant differences at p <0.05 RESULTS: The PD was adopted in 32.5% of tx. The cold ischemia time (p <0.01) and the interval until transplantation (p <0.01) were significantly different. Age of the donor and recipient, Donor Risk Index, MELD score, and donor base excess, sodium, creatinine and glucose were not different between groups. Previous abdominal surgery was a risk factor for early mortality, but was equally distributed between the groups. There was no difference in mortality or graft loss within 7 days (p = 0.521) CONCLUSION: The adoption of PD, to start tx the morning when harvesting occurs after 10p.m. did not result in worse patient and graft survival. Transplant patients with fulminant hepatic failure and high-risk grafts do not apply to this surgical tactics.

OBJETIVO: Analisar a mortalidade (7 dias) ou perda do enxerto em tx de fígado realizado dentro do Protocolo Despertar (PD), em comparação ao tx realizado de maneira sequencial. MÉTODOS: Análise retrospectiva de 243 tx de fígado (230 pacientes), divididos em tx sequencial ou PD (inicio pela manhã). Foram comparados mortalidade ou perda do enxerto (7 dias). Diferenças significantes para p<0,05. RESULTADOS: O PD foi adotado em 32,5% dos tx. O TIF (p<0,01) e o intervalo até o início do transplante (p<0,01) foram significativamente diferentes. Idade do doador e do receptor, Donor Risk Index, escore MELD, Base excess do doador, sódio, creatinina e glicemia do doador não foram diferentes entre os grupos. Antecedentes cirúrgicos abdominais foram fatores de risco para mortalidade precoce, mas estavam distribuídos igualmente entre os grupos. Não houve diferença na mortalidade ou na perda do enxerto em até 7 dias (p=0,521) CONCLUSÃO: A adoção do PD, para inicio do tx pela manhã, quando a captação ocorre após 22:00 h não acarretou piora na sobrevida dos pacientes. Transplante de pacientes com hepatite fulminante e enxertos de alto risco não se aplicam a esta tática cirúrgica.