Does Helium Pneumoperitoneum Reduce the Hyperinflammatory Response in Septic Animals during Laparoscopy?

Background/Aim. An exacerbated reaction to peritoneal infection and attendant surgical procedures is characterized by an intense hyperinflammatory state, the magnitude of which is proportional to the severity of tissue injury. Laparoscopy generates lower levels of tissue damage compared with open surgery and should induce less pronounced immune responses. The aim of this study was to determine whether laparoscopy assisted by helium rather than carbon dioxide pneumoperitoneum would induce an attenuated inflammatory state in septic animals. Materials and Methods. Thirty-two Wistar rats were divided randomly into four equal groups, two of which were submitted to carbon dioxide or helium pneumoperitoneum-assisted laparoscopic cecal ligation and puncture (CLP) induced sepsis and subsequent abdominal lavage. Two control groups were submitted to identical laparoscopic procedures with carbon dioxide or helium as insufflator gas but without CLP. After 24 hours, serum levels of tumor necrosis factor alpha (TNF-α), interleukins 1 and 6 (IL-1 and IL-6, respectively), and cortisol were determined. RESULTS: Mean concentrations of I L-1 and IL-6 in the groups of septic animals submitted to laparoscopy with carbon dioxide or helium pneumoperitoneum were not significantly different but were significantly higher than those of their respective non-CLP controls. In contrast, the levels of TNF-α), interleukins 1 and 6 (IL-1 and IL-6, respectively), and cortisol were determined. CONCLUSIONS: Laparoscopy with helium insufflation was similar to carbon dioxide in relation to the inflammatory response since levels of the proinflammatory TNF-α, IL-1, and IL-6 and of the anti-inflammatory cortisol were comparable for both gases.α), interleukins 1 and 6 (IL-1 and IL-6, respectively), and cortisol were determined.

Development and validation of the Skills Assessment in Microsurgery for Brain Aneurysms (SAMBA) instrument for predicting proficiency in aneurysm surgery.

OBJECTIVE: Surgical performance evaluation was first described with the OSATS (Objective Structured Assessment of Technical Skills) and modified for aneurysm microsurgery simulation with the OSAACS (Objective Structured Assessment of Aneurysm Clipping Skills). These methods rely on the subjective opinions of evaluators, however, and there is a lack of objective evaluation for proficiency in the microsurgical treatment of brain aneurysms. The authors present a new instrument, the Skill Assessment in Microsurgery for Brain Aneurysms (SAMBA) scale, which can be used similarly in a simulation model and in the treatment of unruptured middle cerebral artery (MCA) aneurysms to predict surgical performance; the authors also report on its validation. METHODS: The SAMBA scale was created by consensus among 5 vascular neurosurgeons from 2 different neurosurgical departments. SAMBA results were analyzed using descriptive statistics, Cronbach's alpha indexes, and multivariate ANOVA analyses (p < 0.05). RESULTS: Expert, intermediate-level, and novice surgeons scored, respectively, an average of 33.9, 27.1, and 16.4 points in the real surgery and 33.3, 27.3, and 19.4 points in the simulation. The SAMBA interrater reliability index was 0.995 for the real surgery and 0.996 for the simulated surgery; the intrarater reliability was 0.983 (Cronbach's alpha). In both the simulation and the real surgery settings, the average scores achieved by members of each group (expert, intermediate level, and novice) were significantly different (p < 0.001). Scores among novice surgeons were more diverse (coefficient of variation = 12.4). CONCLUSIONS: Predictive validation of the placenta brain aneurysm model has been previously reported, but the SAMBA scale adds an objective scoring system to verify microsurgical ability in this complex operation, stratifying proficiency by points. The SAMBA scale can be used as an interface between learning and practicing, as it can be applied in a safe and controlled environment, such as is provided by a placenta model, with similar results obtained in real surgery, predicting real surgical performance.

Diagnostic accuracy of MRI for detection of tears and instability of proximal long head of biceps tendon: an evaluation of 100 shoulders compared with arthroscopy.

OBJECTIVE: To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for detection of instability and tears of the proximal long head of biceps tendon (LHBT). To assess intraobserver and interobserver agreement. MATERIALS AND METHODS: We performed a retrospective analysis of prospectively collected data of 100 consecutive shoulders who underwent non-contrast 1.5-T MRI prior to arthroscopic surgery due to rotator cuff injury. Images were independently analyzed by two musculoskeletal radiologists. LHBT was evaluated for presence of tearing (intact, longitudinal split, partial-thickness, or full-thickness) and position (normal, subluxated, and dislocated). Anterosuperior rotator cuff tears were also assessed. The reference standard was arthroscopic surgery. The ramp test was performed in order to evaluate LHBT stability. Diagnostic performance measures were determined and Kappa coefficients assessed agreement. RESULTS: Concerning the detection of overall tears, sensitivity ranged from 71 to 73% and specificity was 73%. The specificity for full-thickness tears ranged from 75 to 96%. Overall displacement showed sensitivity ranging from 51 to 58% and specificity ranging from 70 to 86%. The specificity of overall displacement combined with anterosuperior rotator cuff tears ranged from 73 to 91%. Interobserver Kappa values were between 0.59 and 0.69. Intraobserver Kappa values were between 0.74 and 0.82. CONCLUSIONS: MRI has moderate accuracy and good agreement for detection of LHBT tears and instability. There is a tendency for increased specificity for full-thickness tears and for instability in the coexistence of anterosuperior rotator cuff tears.

Isolation and identification of Candida species in patients with orogastric cancer: susceptibility to antifungal drugs, attributes of virulence in vitro and immune response phenotype.

BACKGROUND: Because of the inherent immunosuppression of cancer patients opportunistic infections by Candida spp, occur frequently. This study aimed to identify Candida species in the oral mucosa of 59 patients with orogastric cancer (OGC) and to analyze the immunological phenotype of these patients. METHODS: The yeasts were identified by MALDI-TOF mass spectrometry (MS). For all isolates, we performed phospholipases and proteinases assays, in vitro adherence to buccal epithelial cells (BEC), minimum inhibitory concentration of antifungal drugs and determined the cytokine profile by Cytometric Bead Array flow citometry assay. RESULTS: C. albicans was the most prevalent species in OGC patients (51.6 %) and control group (66.7 %). Candida spp. strains isolated from OGC patients exhibited better adherence to BEC (p = 0.05) than did the control group. Phospholipases production by Candida strains from OGC patients was lower (51.6 %) than in the control group (61.9 %). Proteinases were detected in 41.9 % and 4.8 % of the yeasts from OGC patients and control group, respectively. Significant differences were found in the serum of OGC patients compared to the control group for IL-2, IL-10, TNF-α, IFN-γ and IL-17. CONCLUSIONS: The results of this work suggest increased virulence of yeasts isolated from OGC patients and, that this may interfere with the immune phenotype.

Aspectos distintos de ressonância magnética de músculos entre dermatomiosite e polimiosite / Different aspects of magnetic resonance imaging of muscles between dermatomyositis and polymyositis

Introdução: Embora a dermatomiosite (DM) e a polimiosite (PM) compartilhem diversos aspectos clínicos em comum, cada uma delas apresenta características fisiopatológicas e histológicas próprias. É possível que estas diferenças também se reflitam macroscopicamente, como, por exemplo, em imagens musculares vistas em ressonância magnética (RM). Objetivos: Comparar simultaneamente a RM de diversos compartimentos musculares das coxas de pacientes com DM e PM adultos. Materiais: Estudo transversal, em que foram avaliadas, entre o período de 2010 a 2013, as imagens de RM das coxas realizadas em aparelho de 1,5 Tesla (T) com sequências ponderadas em T1 e T2 com supressão de gordura, para rastreamento, de 11 DM e 11 PM (Bohan e Peter, 1975) recém-diagnosticados, em atividade clínica e laboratorial. Resultados: A média de idade na ocasião da RM, o tempo entre o início de sintomas e a realização das RM, a distribuição de sexos e a terapia medicamentosa foram comparáveis entre os dois grupos (p>0,050). Em termos de RM, edema muscular foi encontrado significantemente em DM, e principalmente na região proximal dos músculos. A área de lipossubstituição dos músculos foi encontrada predominantemente em PM. Essa lipossubstituição, quando de uma forma parcial, ocorreu principalmente nos terços médio e distal, enquanto que a forma total transcorreu apenas no terço distal dos músculos. Não houve nenhuma área de fibrose muscular. Conclusões: A DM e a PM apresentam características distintas entre si em RM de músculos, a exemplo de distinções fisiopatológicas e histológicas. .

Introduction: Although dermatomyositis (DM) and polymyositis (PM) share many clinical features in common, they have distinct pathophysiological and histological features. It is possible that these distinctions reflect also macroscopically, for example, in muscle alterations seen in magnetic resonance images (MRI). Objectives: To compare simultaneously the MRI of various muscle compartments of the thighs of adult DM and PM. Materials: The present study is a cross-sectional that included, between 2010 and 2013, 11 newly diagnosed DM and 11 PM patients (Bohan and Peter's criteria, 1975), with clinical and laboratory activity.They were valued at RM thighs,T1 and T2 with fat suppression, 1.5 T MRI scanner sequences. Results: The mean age at the time of MRI, the time between onset of symptoms and the realization of the MRI distribution of sex and drug therapy were comparable between the two groups (p>0.050). Concerning the MRI, muscle edema was significantly found in DM, and mainly in the proximal region of the muscles. The area of fat replacement was found predominantly in PM. The partial fat replacement area occurred mainly in the medial and distal region, whereas the total fat replacement area occurred mainly in the distal muscles. There was no area of muscle fibrosis. Conclusions: DM and PM have different characteristics on MRI muscles, alike pathophysiological and histological distinctions. .

[Different aspects of magnetic resonance imaging of muscles between dermatomyositis and polymyositis]. / Aspectos distintos de ressonância magnética de músculos entre dermatomiosite e polimiosite.

INTRODUCTION: Although dermatomyositis (DM) and polymyositis (PM) share many clinical features in common, they have distinct pathophysiological and histological features. It is possible that these distinctions reflect also macroscopically, for example, in muscle alterations seen in magnetic resonance images (MRI). OBJECTIVES: To compare simultaneously the MRI of various muscle compartments of the thighs of adult DM and PM. MATERIALS: The present study is a cross-sectional that included, between 2010 and 2013, 11 newly diagnosed DM and 11 PM patients (Bohan and Peter's criteria, 1975), with clinical and laboratory activity. They were valued at RM thighs, T1 and T2 with fat suppression, 1.5 T MRI scanner sequences. RESULTS: The mean age at the time of MRI, the time between onset of symptoms and the realization of the MRI distribution of sex and drug therapy were comparable between the two groups (p>0.050). Concerning the MRI, muscle edema was significantly found in DM, and mainly in the proximal region of the muscles. The area of fat replacement was found predominantly in PM. The partial fat replacement area occurred mainly in the medial and distal region, whereas the total fat replacement area occurred mainly in the distal muscles. There was no area of muscle fibrosis. CONCLUSIONS: DM and PM have different characteristics on MRI muscles, alike pathophysiological and histological distinctions.

Chlorhexidine as a factor that promotes peritoneal adhesions in rats with induced peritonitis.

PURPOSE: To investigate the effects of chlorhexidine on the formation of adhesions and dilation of the colon at the oral end of anastomosis in the presence of peritonitis. METHODS: Peritonitis was induced in male Wistar rats by cecal ligation and puncture (CLP). Abdominal cavities were irrigated with tepid solutions containing 0.9% saline (SAL group; n=8) or 0.05% chlorhexidine (CHD group; n=8), after which colon anastomoses were performed. Control rats (n=8) were submitted to colon anastomoses but not to CLP. Animals were euthanised seven days after surgery and the incidence of adhesions, the degree of dilation of colon loops and an index were calculated to determine variables correlation. RESULTS: No animals exhibited macroscopic signs of residual peritonitis or abdominal abscesses. Adhesions were observed in 75% of control and 100% of SAL and CHD animals. Dilation of intestinal loops at the oral end of anastomosis was observed in control (50%), SAL (57.2%) and CHD (66.7%) animals. The calculated index was 1.25 in group A; 1.86 in group B; and 2.0 group C. CONCLUSION: Chlorhexidine promoted stronger adhesions and a greater dilatation of colonic loops than control group.

Clorhexidine as a factor that promotes peritoneal adhesions in rats with induced peritonitis

PURPOSE: To investigate the effects of chlorhexidine on the formation of adhesions and dilation of the colon at the oral end of anastomosis in the presence of peritonitis. METHODS: Peritonitis was induced in male Wistar rats by cecal ligation and puncture (CLP). Abdominal cavities were irrigated with tepid solutions containing 0.9% saline (SAL group; n=8) or 0.05% chlorhexidine (CHD group; n=8), after which colon anastomoses were performed. Control rats (n=8) were submitted to colon anastomoses but not to CLP. Animals were euthanised seven days after surgery and the incidence of adhesions, the degree of dilation of colon loops and an index were calculated to determine variables correlation. RESULTS: No animals exhibited macroscopic signs of residual peritonitis or abdominal abscesses. Adhesions were observed in 75% of control and 100% of SAL and CHD animals. Dilation of intestinal loops at the oral end of anastomosis was observed in control (50%), SAL (57.2%) and CHD (66.7%) animals. The calculated index was 1.25 in group A; 1.86 in group B; and 2.0 group C. CONCLUSION: Chlorhexidine promoted stronger adhesions and a greater dilatation of colonic loops than control group.

Multiple myeloma complicated with pseudomonas endocartiditis / Mieloma múltiplo complicado com endocardite infecciosa por pseudomonas

Patients diagnosed with multiple myeloma are more susceptible to infections which are the major causes of morbidity and mortality associated to this disease. The main infectious agents involved are Gram-positive bacteria. However, after chemotherapy an increase in the incidence of Gram-negative strains is observed. These bacteria are also responsible for most cases of urinary tract infections. Here is reported a rare case in a 73-year-old man with multiple myeloma who developed endocarditis due to pseudomonas.

Pacientes diagnosticados com mieloma múltiplo são mais suscetíveis a infecções, que é a principal causa de morbidade e mortalidade associadas a essa doença. Os principais agentes infecciosos envolvidos são as bactérias Gram-positivas, mas, após a quimioterapia, pode haver aumento na incidência de Gram-negativos, que são responsáveis, na maioria dos casos, por infecções do trato urinário. Assim, descrevese um raro caso de um paciente de 73 anos de idade, com mieloma múltiplo diagnosticado com endocardite por pseudomonas.

Multiple myeloma complicated with pseudomonas endocarditis.

Patients diagnosed with multiple myeloma are more susceptible to infections which are the major causes of morbidity and mortality associated to this disease. The main infectious agents involved are Gram-positive bacteria. However, after chemotherapy an increase in the incidence of Gram-negative strains is observed. These bacteria are also responsible for most cases of urinary tract infections. Here is reported a rare case in a 73-year-old man with multiple myeloma who developed endocarditis due to pseudomonas.

Treatment with chlorhexidine modifies the healing of colon anastomosis in rats.

PURPOSE: To investigate the effects of chlorhexidine on the healing of colon anastomosis in the presence of peritonitis. METHODS: Peritonitis was induced in male Wistar rats by cecal ligation and puncture (CLP). The abdominal cavities of experimental animals were irrigated with warm solutions containing 0.9% saline (SAL group; n = 8) or 0.05% chlorhexidine (CHD group; n = 8), following which colon anastomosis was performed. Rats of the control group (n = 8) were submitted to colon anastomosis but not to CLP. Animals were euthanized seven days after surgery, and healing was assessed by histopathological examination and by measuring anastomotic burst pressure. RESULTS: Post-operative survival rates were 100, 87.5 and 75% for the control, SAL, and CHD groups, respectively. The degree of inflammation was significantly lower (ρ = 0.01) in the CHD group compared with the other groups, whilst the anastomotic burst pressure within the CHD group (156.7 ± 53.2 mmHg) was lower than, but not significantly different from, those of the control and SAL groups (196.3 ± 49.8, 208.6 ± 72.7 mmHg, respectively). CONCLUSIONS: Peritoneal irrigation with chlorhexidine solution is effective in the control of inflammation promoted by peritonitis but does not improve healing of colon anastomosis in rats.

[Visceral leishmaniasis: retrospective study on factors associated with lethality]. / Leishmaniose visceral: estudo retrospectivo de fatores associados à letalidade.

INTRODUCTION: Visceral leishmaniasis is a public health problem, with lethality reaching 10%. The recommended drug treatment is methylglucamine antimoniate. This study aimed to evaluate drug use for cases of visceral leishmaniasis treated at the Infectology Clinic of the Campo Grande University Hospital Center, State of Mato Grosso do Sul. METHODS: To collect data, we examined the medical records of 76 patients with a diagnosis of visceral leishmaniasis treated at this Infectology Clinic. RESULTS: The medical files of 76 patients (56 men and 20 women; 28.9%) showed comorbidities. The first choice drug for 88.2% of the patients was N-methylglucamine antimoniate, with a fatal outcome for 18.4%. Survival analysis showed a statistically significant difference between patients with and without comorbidities (p <0.0001) and with comorbidities who used Glucantime (p < 0.0009). The fatality rate of 18.4% indicates the low efficiency of the healthcare measures used. CONCLUSIONS: The results suggest that the prognosis becomes poor when associated with the presence of comorbidities, and that the treatment needs to be carefully administered to minimize mortality.

Leishmaniose visceral: estudo retrospectivo de fatores associados à letalidade / Visceral leishmaniasis: retrospective study on factors associated with lethality

INTRODUÇÃO: A leishmaniose visceral é um problema de saúde pública, com grau de letalidade alcançando 10 por cento. Para o tratamento medicamentoso, é recomendado o antimoniato de metilglucamina. Este estudo tem como objetivo avaliar o uso de medicamento em casos de leishmaniose visceral atendidos no Serviço de Infectologia do Núcleo de Hospital Universitário de Campo Grande Estado do Mato Grosso do Sul. MÉTODOS: Para coleta de dados, foram pesquisados prontuários de 76 pacientes com diagnóstico de leishmaniose visceral atendidos pelo Serviço de Infectologia do Hospital Universitário de Campo Grande. RESULTADOS: Foram analisados prontuários de 76 (28,9 por cento) pacientes (56 homens e 20 mulheres) apresentavam comorbidades. Como droga de 1ª escolha, 88,2 por cento dos pacientes utilizaram o antimoniato-N-metil glucamina com evolução para óbito de 18,4 por cento. A análise de sobrevida mostrou diferença estatisticamente significativa em pacientes com e sem comorbidades (p< 0,0001) e com comorbidade que fizeram uso de Glucantime® (p <0,0009). A letalidade de 18,4 por cento sinaliza ineficiência das medidas de assistência a saúde adotadas. CONCLUSÕES: Os resultados sugerem que o prognóstico da doença torna-se ruim quando associado à presença de comorbidades e que o tratamento deve ser criterioso, para minimizar a letalidade.

INTRODUCTION: Visceral leishmaniasis is a public health problem, with lethality reaching 10 percent. The recommended drug treatment is methylglucamine antimoniate. This study aimed to evaluate drug use for cases of visceral leishmaniasis treated at the Infectology Clinic of the Campo Grande University Hospital Center, State of Mato Grosso do Sul. METHODS: To collect data, we examined the medical records of 76 patients with a diagnosis of visceral leishmaniasis treated at this Infectology Clinic. RESULTS: The medical files of 76 patients (56 men and 20 women; 28.9 percent) showed comorbidities. The first choice drug for 88.2 percent of the patients was N-methylglucamine antimoniate, with a fatal outcome for 18.4 percent. Survival analysis showed a statistically significant difference between patients with and without comorbidities (p <0.0001) and with comorbidities who used Glucantime® (p < 0.0009). The fatality rate of 18.4 percent indicates the low efficiency of the healthcare measures used. CONCLUSIONS: The results suggest that the prognosis becomes poor when associated with the presence of comorbidities, and that the treatment needs to be carefully administered to minimize mortality.

Clinical and histological responses to laparoscopically-induced peritonitis in rats / Resposta clínica e histológica à indução de peritonite via laparoscopia em ratos

PURPOSE: To evaluate the efficacy of inducing peritonitis in rats through laparoscopic cecal ligation (CL), by means of an elastic band. METHODS: Twelve Wistar rats were subjected to cecal ligated with an elastic band applied using a specially constructed applicator. In six of the animals (the CL group) the cecal sac was preserved intact whilst in the remaining animals (the CLP group) the sac was perforated with scissors. Clinical parameters, characteristics of the peritoneal cavity and cecum, and histological features of the cecal tissue were observed in all experimental animals 8 and 24 h after surgery. RESULTS: CLP animals exhibited at least one clinical sign of sepsis within the first 8 h of observation. The peritoneal liquid was observed to be clear in almost all members of the CLP. Polymorphonucleated cells were detected in the tunica serosa of the cecum of CLP animals. In contrast, all members of the CL group were alive after 24h, and of polymorphonucleated cells in the muscle layer of the cecal wall were observed. The presence of peritoneal liquid was not detected in CL animals. CONCLUSION: Although elastic ligation of the cecum was reproducible, puncture of the cecal sac was essential for induction of sepsis.

OBJETIVO: Avaliar a eficácia de induzir peritonite em ratos através da ligadura cecal laparoscópica (CL), por meio de banda elástica. MÉTODOS: Doze ratos Wistar foram submetidos a ligadura cecal com banda elástica aplicada com dispositivo especialmente construído para este fim. Em seis animais (grupo CL), a bolsa cecal foi mantida intacta, enquanto nos outros animais (grupo CLP), a bolsa foi perfurada com tesoura. Parâmetros clínicos, características da cavidade peritonial e ceco, e histologia do tecido cecal foram examinados em todos os animais 8 e 24 horas após a cirurgia. RESULTADOS: Os animais do grupo CLP apresentaram pelo menos um sinal clínico de sepses nas primeiras 8 h de observação. Líquido peritonial claro foi observado em quase todos os membros do grupo CLP. Leucócitos polimorfonucleares foram identificados na serosa do ceco dos animais do grupo CLP. Por outro lado, todos os animais do grupo CL estavam vivos após 24 h, e leucócitos polimorfonucleares estavam restritos à muscular própria. Presença de líquido peritonial não foi detectada nos animais do grupo CL. CONCLUSÃO: A ligadura elástica do ceco foi reprodutível e a secção da bolsa cecal foi essencial para a indução de sepse.

Clinical and histological responses to laparoscopically-induced peritonitis in rats.

PURPOSE: To evaluate the efficacy of inducing peritonitis in rats through laparoscopic cecal ligation (CL), by means of an elastic band. METHODS: Twelve Wistar rats were subjected to cecal ligated with an elastic band applied using a specially constructed applicator. In six of the animals (the CL group) the cecal sac was preserved intact whilst in the remaining animals (the CLP group) the sac was perforated with scissors. Clinical parameters, characteristics of the peritoneal cavity and cecum, and histological features of the cecal tissue were observed in all experimental animals 8 and 24 h after surgery. RESULTS: CLP animals exhibited at least one clinical sign of sepsis within the first 8 h of observation. The peritoneal liquid was observed to be clear in almost all members of the CLP. Polymorphonucleated cells were detected in the tunica serosa of the cecum of CLP animals. In contrast, all members of the CL group were alive after 24h, and of polymorphonucleated cells in the muscle layer of the cecal wall were observed. The presence of peritoneal liquid was not detected in CL animals. CONCLUSION: Although elastic ligation of the cecum was reproducible, puncture of the cecal sac was essential for induction of sepsis.