Predicting early discharge from hospital after liver transplantation (ERDALT) at a single center: a new model.

BACKGROUND & RATIONALE: Limited information related to Liver Transplantation (LT) costs in South America exists. Additionally, costs analysis from developed countries may not provide comparable models for those in emerging economies. We sought to evaluate a predictive model of Early Discharge from Hospital after LT (ERDALT = length of hospital stay ≤ 8 days). A predictive model was assessed based on the odds ratios (OR) from a multivariate regression analysis in a cohort of consecutively transplanted adult patients in a single center from Argentina and internally validated with bootstrapping technique. RESULTS: ERDALT was applicable in 34 of 289 patients (11.8%). Variables independently associated with ERDALT were MELD exception points OR 1.9 (P = 0.04), surgery time < 4 h OR 3.8 (P = 0.013), < 5 units of blood products consumption (BPC) OR 3.5 (P = 0.001) and early weaning from mechanical intubation OR 6.3 (P = 0.006). Points in the predictive scoring model were allocated as follows: MELD exception points (absence = 0 points, presence = 1 point), surgery time < 4 h (0-2 points), < 5 units of BPC (0-2 points), and early weaning (0-3 points). Final scores ranged from 0 to 8 points with a c-statistic of 0.83 (95% CI 0.77-0.90; P < 0.0001). Transplant costs were significantly lower in patients with ERDALT (median $23,078 vs. $28,986; P < 0.0001). Neither lower patient and graft survival, nor higher rates of short-term re-hospitalization and acute rejection events after discharge were observed in patients with ERDALT. In conclusion, the ERDALT score identifies patients suitable for early discharge with excellent outcomes after transplantation. This score may provide applicable models particularly for emerging economies.

Separación de componentes videoscópica en el tratamiento de eventraciones y otros defectos de la pared abdominal: análisis de una serie inicial / Endoscopic component separaton technique in the repair of incisional hernia and other abdominal wall defects: analysis of an inital series

Antecedentes: la eventroplasta laparoscópica es una técnica con ventajas comprobadas, pero con limitaciones en defectos grandes de pared. Se ha postulado que la separación videoscópica de componentes (SCV) podría mejorar los resultados en estos casos. Objetivo: evaluar una serie de pacientes a quienes se les realizó la SCV, como complemento en la reparación de los defectos de la pared abdominal. Material y métodos: se registran el tipo y el tamaño del defecto de la pared abdominal, el tamaño de la malla utilizada, el número de fjaciones, el tempo quirúrgico, el tempo de SCV, la morbimortalidad y la recidiva. Resultados: el diámetro de los defectos fue de 12 cm y se logró el cierre en todos los casos. No hubo complicaciones intraoperatorias. En cuanto a la morbilidad posoperatoria se registraron 3 casos: 1 dolor abdominal no habitual, 1 complicación cardiológica y 1 obstrucción intestinal posoperatoria.No hubo recidivas durante el tempo de seguimiento (18,5 meses). Conclusiones: la SCV es un procedimiento de gran utilidad como complemento en la reparación de los defectos de la pared abdominal. Logra un deslizamiento de 6 a 8 cm de cada lado en los rectos abdominales hacia la línea media, permitendo disminuir el tamaño del defecto o lograr su cierre.

Background: although laparoscopic incisional hernia repair has proven advantages limitatons should be considered when applied to large abdominal wall defects. The endoscopic component separaton (ECS) technique could achieve beter results in those patents. Objective: to evaluate a number of patents who were treated with ECS as a complement of the laparoscopic repair of large wall defects. Methods: descriptive analysis of a prospective series of patents. Patents with abdominal wall defects that were treated laparoscopically associating ECS were included. The type and size of the abdominal wall defect, size of mesh the fxaton used, surgical and ECS technique tme, morbimortality and recu-rrence were recorded. Results: sixteen patents were included, the average size of the defects was 12 cm in diameter and closure was accomplished in every patent. There were no intraoperative complicatons .There were 3 cases of post operative morbidity: one patent had abdominal pain and required more painkillers than usual, one patent without cardiac history had a cardiac event and one patent had post-operative intestinal obstructon. There were no recurrences during the follow up (18 months). Conclusion: the ECS technique is a useful procedure as a complement in the repair of abdominal wall defects. A displacement of 6-8 cm of the rectus abdominis to the middle line is achieved,, allowing the reducton or the closure of the abdominal wall defect.

Laparoscopic repair of a small bowel herniation through a broad ligament defect.

A 44-year-old female presented with a diagnosis of intestinal obstruction from unknown origin. Laparoscopy revealed herniation of small bowel trough a defect in the left broad ligament. After reduction, the defect was corrected laparoscopically. The post operative recovery was uneventful.

Giant cavernous hemangioma of the adrenal gland.

INTRODUCTION: Cavernous hemangioma of the adrenal gland is a rare non-functioning benign neoplasm. PRESENTATION OF CASE: A 62-year-old woman with chronic obstructive pulmonary disease was diagnosed as having an incidental non-functioning adrenal tumor. Because of the impossibility of ruling out the presence of malignancy, conventional surgical resection was carried out. The histopathology revealed a 12.5cm×11.5cm×8cm adrenal mass with large and lacunae vascular spaces lined with mature endothelial cells. These findings were compatible with cavernous hemangioma. DISCUSSION: The majority of patients in the literature underwent surgical resection due to the impossibility of excluding malignancy, because of related symptoms in patients with large masses, or because of the risk of spontaneous tumoral rupture. CONCLUSION: These tumors are quite infrequent. Due to the low frequency and the lack of specific symptoms, most adrenal hemangiomas are diagnosed postoperatively.

Centrally administered insulin potentiates the pressor response to angiotensin II.

The aim of the present study was to determine if insulin can modulate the pressor response to angiotensin II at brain level in normotensive rats. Anaesthetized male rats were intracerebroventricularly infused with insulin (12 mU/h, n=15) or Ringer's solution as vehicle (n=15) for 2 h. Immediately, changes in mean arterial pressure (MAP) in response to an intracerebroventricular subpressor dose of angiotensin II (5 pmol, n=10) or vehicle (n=5) were measured for 10 min. Then, hypothalami were removed and Akt and ERK1/2 phosphorylation levels were determined. In other subset of animals, PD98059 (MAPK inhibitor) or vehicle were intracerebroventricularly administered previously to insulin perfusion for 2 h and changes in MAP in response to intracerebroventricular angiotensin II (5 pmol) injection were evaluated for 10 min (n=6 for each group). Angiotensin II did not modify MAP in vehicle pre-treated rats, but increased MAP in insulin pre-treated animals. Insulin significantly increased Akt phosphorylation, but no changes were observed after angiotensin II injection in vehicle-pretreated animals. Angiotensin II or insulin infusion increased in more than two fold phospho-ERK 1/2 hypothalamic levels. Animals that received insulin infusion followed by Ang II injection presented 4.5 higher values than those which received vehicle, and nearly twice than those who received Ang II without insulin pre-treatment. PD98059 administration abolished the blood pressure response exerted by angiotensin II in insulin pre-treated rats. In conclusion, centrally administered insulin potentiates the pressor effects to angiotensin II, suggesting a novel mechanism, possibly involving MAPK activation, by which insulin influences blood pressure control at central level.

Chronic infusion of angiotensin-(1-7) improves insulin resistance and hypertension induced by a high-fructose diet in rats.

The current study was undertaken to determine whether Ang-(1-7) is effective in improving metabolic parameters in fructose-fed rats (FFR), a model of metabolic syndrome. Six-week-old male Sprague-Dawley rats were fed either normal rat chow (control) or the same diet plus 10% fructose in drinking water. For the last 2 wk of a 6-wk period of either diet, control and FFR were implanted with subcutaneous osmotic pumps that delivered Ang-(1-7) (100 ng.kg(-1).min(-1)). A subgroup of each group of animals (control or FFR) underwent a sham surgery. We measured systolic blood pressure (SBP) together with plasma levels of insulin, triglycerides, and glucose. A glucose tolerance test (GTT) was performed, with plasma insulin levels determined before and 15 and 120 min after glucose administration. In addition, we evaluated insulin signaling through the IR/IRS-1/PI3K/Akt pathway as well as the phosphorylation levels of IRS-1 at inhibitory site Ser(307) in skeletal muscle and adipose tissue. FFR displayed hypertriglyceridemia, hyperinsulinemia, increased SBP, and an exaggerated release of insulin during a GTT, together with decreased activation of insulin signaling through the IR/IRS-1/PI3K/Akt pathway in skeletal muscle, liver, and adipose tissue, as well as increased levels of IRS-1 phospho-Ser(307) in skeletal muscle and adipose tissue, alterations that correlated with increased activation of the kinases mTOR and JNK. Chronic Ang-(1-7) treatment resulted in normalization of all alterations. These results show that Ang-(1-7) ameliorates insulin resistance in a model of metabolic syndrome via a mechanism that could involve the modulation of insulin signaling.

In vitro and in vivo pharmacodynamic properties of metoprolol in fructose-fed hypertensive rats.

BACKGROUND: This study of metoprolol pharmacokinetic and pharmacodynamic properties investigates cardiac beta1-adrenoceptors activity and its involvement in the hypertensive stage in 6-week-old fructose-fed male Sprague-Dawley rats. METHODS: A microdialysis probe was inserted in the carotid artery to monitor metoprolol levels, blood pressure, and heart rate after drug administration (3-10 mg/kg intravenously). The relationship between levels and cardiovascular effects was studied using a pharmacokinetic-pharmacodynamic model with effect compartment. Dissociation constant and inverse agonism were evaluated in isolated atria. RESULTS: Metoprolol pharmacokinetics were similar in both groups. Metoprolol induced a greater hypotensive effect in fructose-fed animals (Emax: -24 +/- 1 mm Hg, n = 6, P < 0.05 vs. control) than in control rats (Emax: -14 +/- 1 mm Hg, n = 6). Bradycardic response was similar in both groups; metoprolol chronotropic potency was greater in fructose-fed rats (IC50: 123 +/- 15 ng/mL, P < 0.05 vs. control) compared to control animals (IC50: 216 +/- 36 ng/mL) after administration of 3 mg/kg. Metoprolol constants of dissociation for beta1-adrenoceptors and inverse agonism were similar in both groups. CONCLUSION: Results demonstrate the beta1-adrenoceptors involvement in the fructose hypertension. A greater potency to metoprolol in vivo chronotropic effect was found in fructose-fed rats. This greater potency was not caused by alteration in the activity of beta1-adrenoceptors.