GIST duodenal asociado a hemorragia digestiva alta: reporte de caso / Duodenal GIST associated with upper gastrointestinal bleeding: case report

Resumen Introducción Los tumores del estroma gastrointestinal (GIST) corresponden al 1% de todas las neoplasias gastrointestinales, sin embargo, sólo el 3-5% de estos se desarrollan en el duodeno. Objetivo Reportar el caso de un paciente masculino con localización atípica de un tumor de estroma gastrointestinal y su manejo. Caso clínico paciente masculino de 50 años con antecedente de traumatismo encefalo craneano (TEC) con daño orgánico cerebral secundario, tabaquismo, consumidor de alcohol ocasional y sometido a quistectomía branquial en la infancia, que consulta en el servicio de urgencias por cuadro de hemorragia digestiva alta con compromiso hemodinámico. Tras realizar endoscopia digestiva alta (EDA), resonancia nuclear magnética (RNM) y tomografía computada (TC) de abdomen, se pesquisa masa tumoral en segunda porción de duodenal. Discusión A pesar de que la presentación clínica de los GIST es variable, lo más frecuente es que sean pacientes asintomáticos. En algunas ocasiones, al igual que en este reporte, pueden presentarse con dolor abdominal y/o hemorragia digestiva alta. El diagnóstico preoperatorio fue difícil ya que el estudio con imágenes (TC, RNM, EDA) sólo permite establecer la sospecha; el diagnóstico definitivo se realizó con biopsia (no contamos con endosonografía en nuestro centro). Debido a los sitios de reparo anatómico, no existe una cirugía estandarizada; en este caso, debido a la localización, infiltración y características, se decidió realizar una pancreatoduodenectomía.

Introduction Gastrointestinal stromal tumors (GIST), corresponds to 1%, of all gastrointestinal neoplasms, however, only 3%-5% developed in duodenum. Aim To report a case of a male patient with atypical location of gastrointestinal stroma tumor and the treatment proposed. Case report 50-year-old male patient, with medical history of organic brain damage secondary a traumatic brain injury, smoker, occasional alcohol consumer and branquial cystomy during childhood. Consulted in the emergency department for a high digestive hemorrhage case with hemodynamic compromise. Upper digestive endoscopy, computed tomography and nuclear magnetic resonance were performed, which impresses tumor-like lesion in the second duodenal portion. Discussion Although the GIST clinical presentation is variable, most often they are asymptomatic patients. In some times, as in this report, they may present with abdominal pain and/or upper gastrointestinal bleeding. The preoperative diagnosis was difficult, because the imaging study (CT, RNM, EDA) only stablished the suspicion and the final diagnosis was made by biopsy (we don't have endosonography in our center). Due to the anatomic repair, there is not a standardized surgery, in this case, due tumor location, infiltration and characteristics, it was decided to perform a pancreatoduodenectomy.

Azithromycin for chronic eosinophilic rhinosinusitis with nasal polyp: a placebo-controlled trial.

BACKGROUND: Chronic eosinophilic rhinosinusitis with nasal polyps (CRSwNP eosinophilic) is characterised by the formation of benign and bilateral nasal polyps. We aimed to compare the effectiveness of azithromycin as an immunomodulator with the use of a placebo in patients presenting with CRSwNP concomitant with asthma and aspirin intolerance after 3 months of treatment and at a 1-year follow-up. METHODOLOGY: We performed a randomised, double-blind, placebo-controlled trial. Patients received 500 mg azithromycin orally three times/week for 12 weeks. Improvement was evaluated by staging, the Sino-Nasal Outcome Test (SNOT-22), and nasal polyp biopsy. Data collected at pretreatment and 3 months posttreatment were compared. Quality of life was evaluated at the 1-year follow-up. RESULTS: Twenty-seven and 21 patients were treated with azithromycin and a placebo, respectively. The medication was well tolerated overall. Twenty patients (74%) in the azithromycin group and three patients (14%) in the placebo group were not refer- red for surgery at the end of the 3-month treatment. Regarding subjective improvement, there was a median decrease only in the azithromycin group, and the between-group difference was significant. SNOT-22 improvement was maintained in the azithromy- cin group at the 1-year follow-up. CONCLUSIONS: Azithromycin could be considered a therapeutic option for patients presenting with CRSwNP concomitant with asthma and aspirin intolerance.

[Mental health in Bonaire - an inspiration for the Dutch New Mental Health Movement]. / De ggz in Bonaire - een inspiratie voor de beweging 'de nieuwe ggz'.

BACKGROUND: In 2010 the bes-islands in the Caribbean became a special municipality of the Netherlands. Healthcare was upgraded to match Dutch standards over a short period of time. With a population of 15,518 inhabitants in 2010 (19,408 in 2016), Bonaire received its own fact-team (flexible assertive community treatment). It subsequently became a unique experiment for the Dutch New Mental Health Movement.
AIM: To describe the development of a modern mental health care system in a limited geographic area.
METHOD: Site visitation, interviews and analysis of historical data sources.
RESULTS: The local mental health team takes integral responsibility for all the mh care needs in Bonaire. There is no intricate diagnostic referral system. Consultation access lines are short. The team was able to dramatically reduce the need for hospitalization. Collaboration with the somatic hospital and general practitioners runs smoothly and the facilities offer complementary care. Societal integration is insured due to mental health professionals living interspersed in the neighborhood, the low threshold allowing them to respond to signals efficiently. There is a natural development of the following three domains of care: reduction of symptoms, societal participation and personal remission.
CONCLUSION: Integrated mental health services in a geographically small area, as presented by the Dutch New Mental Health Movement, enables the possibility of recovery oriented care.

The influence of Castanhão reservoir on nutrient and suspended matter transport during rainy season in the ephemeral Jaguaribe river (CE, Brazil).

Measurements of nutrient and suspended matter concentrations and loads entering and leaving the Castanhão reservoir during the rainy season were carried out to assess the influence of this large reservoir on land-sea fluvial transport in the ephemeral Jaguaribe river basin. Spatial variation indicated statistically significant attenuation of concentrations only for total phosphorous and suspended matter across the reservoir. Strong retention of nutrients and suspended matter loads by the reservoir was observed with average trapping efficiency of 89% for dissolved silicon, 98% of soluble reactive phosphorus, 71% for ammonium, 87% for total nitrogen, 98% for total phosphorus and 97% for suspended matter compared to the reservoir inflow. The dam operational procedure defined by the ephemeral conditions of the river reduced water releases compared to reservoir inflow and induced strong retention of nutrient and suspended matter loads within the reservoir when fluvial transfer occurs in this semiarid watershed.

The influence of castanhão reservoir on nutrient and suspended matter transport during rainy season in the ephemeral Jaguaribe river (CE, Brazil) / Influência do açude Castanhão no transporte de nutrientes e materiais em suspensão durante a estação chuvosa no intermitente rio Jaguaribe (CE, Brasil)

Measurements of nutrient and suspended matter concentrations and loads entering and leaving the Castanhão reservoir during the rainy season were carried out to assess the influence of this large reservoir on land-sea fluvial transport in the ephemeral Jaguaribe river basin. Spatial variation indicated statistically significant attenuation of concentrations only for total phosphorous and suspended matter across the reservoir. Strong retention of nutrients and suspended matter loads by the reservoir was observed with average trapping efficiency of 89% for dissolved silicon, 98% of soluble reactive phosphorus, 71% for ammonium, 87% for total nitrogen, 98% for total phosphorus and 97% for suspended matter compared to the reservoir inflow. The dam operational procedure defined by the ephemeral conditions of the river reduced water releases compared to reservoir inflow and induced strong retention of nutrient and suspended matter loads within the reservoir when fluvial transfer occurs in this semiarid watershed.(AU)

Medidas de concentrações e fluxos de nutrientes e material particulado em suspensão de entrada e saída do Açude Castanhão foram efetuadas para determinar a influência de um grande reservatório no transporte fluvial entre o continente e o oceano na bacia hidrográfica intermitente do Rio Jaguaribe. A variação espacial indicou uma atenuação estatisticamente significativa ao longo do reservatório somente para as concentrações de fósforo total e material particulado em suspensão. Os resultados indicam uma forte retenção de nutrientes e do material particulado em suspensão com eficiências de retenção de 89% para sílica dissolvida, 98% para fósforo solúvel reativo, 71% para amônia, 87% para nitrogênio total, 98% para fósforo total e 97% para o material particulado em suspensão em relação aos fluxos de entrada no reservatório. A rotina de operação da barragem definida pela condição intermitente do Rio Jaguaribe reduz a descarga de água comparada com a entrada no reservatório e induz forte retenção do fluxo fluvial de nutrientes e material particulado em suspensão pelo reservatório.(AU)

The influence of castanhão reservoir on nutrient and suspended matter transport during rainy season in the ephemeral Jaguaribe river (CE, Brazil) / Influência do açude Castanhão no transporte de nutrientes e materiais em suspensão durante a estação chuvosa no intermitente rio Jaguaribe (CE, Brasil)

Measurements of nutrient and suspended matter concentrations and loads entering and leaving the Castanhão reservoir during the rainy season were carried out to assess the influence of this large reservoir on land-sea fluvial transport in the ephemeral Jaguaribe river basin. Spatial variation indicated statistically significant attenuation of concentrations only for total phosphorous and suspended matter across the reservoir. Strong retention of nutrients and suspended matter loads by the reservoir was observed with average trapping efficiency of 89% for dissolved silicon, 98% of soluble reactive phosphorus, 71% for ammonium, 87% for total nitrogen, 98% for total phosphorus and 97% for suspended matter compared to the reservoir inflow. The dam operational procedure defined by the ephemeral conditions of the river reduced water releases compared to reservoir inflow and induced strong retention of nutrient and suspended matter loads within the reservoir when fluvial transfer occurs in this semiarid watershed.

Medidas de concentrações e fluxos de nutrientes e material particulado em suspensão de entrada e saída do Açude Castanhão foram efetuadas para determinar a influência de um grande reservatório no transporte fluvial entre o continente e o oceano na bacia hidrográfica intermitente do Rio Jaguaribe. A variação espacial indicou uma atenuação estatisticamente significativa ao longo do reservatório somente para as concentrações de fósforo total e material particulado em suspensão. Os resultados indicam uma forte retenção de nutrientes e do material particulado em suspensão com eficiências de retenção de 89% para sílica dissolvida, 98% para fósforo solúvel reativo, 71% para amônia, 87% para nitrogênio total, 98% para fósforo total e 97% para o material particulado em suspensão em relação aos fluxos de entrada no reservatório. A rotina de operação da barragem definida pela condição intermitente do Rio Jaguaribe reduz a descarga de água comparada com a entrada no reservatório e induz forte retenção do fluxo fluvial de nutrientes e material particulado em suspensão pelo reservatório.

Hamartoma de glándula peribiliar: reporte de dos casos / Peribiliar gland hamartoma: report of two cases

El hamartoma peribiliar (HPB) o adenoma de conductos biliares corresponde a un tumor hepático benigno, que representa tan solo el 1,3 por ciento de todos los tumores primarios del hígado. Macroscópicamente corresponde a una lesión redondeada bien delimitada, subcapsular, siendo habitualmente diagnosticado como un hallazgo intra-operatorio o de autopsia. Se presentan dos pacientes con diagnóstico incidental de HPB realizado en la Unidad de Anatomía Patológica del Hospital Hernán Henríquez de Temuco.

Peribiliary gland hamartoma (PGH) or bile duct adenoma corresponds to a benign liver tumor, which represents only 1.3 percent of all primary liver tumors. Corresponds to a macroscopically well-defined round lesion, subcapsular, and is usually diagnosed as an intra-operative findings or autopsy. We report two patients with incidental diagnosis of PGH conducted in the Pathology Unit of the Hospital Hernán Henríquez in Temuco.

Cytokines profile in cystic fibrosis patients with nasal polyps.

UNLABELLED: Nasal polyposis often complicates the progress of patients with cystic fibrosis and there has been little study about the importance of cytokines in the polyps of such individuals. OBJECTIVE: To assess RNAm expression for interleukins 4, 5, 6, 8, GM-CSF and IFN-gamma by RT-PCR in eosinophilic and non-eosinophilic polyps of patients with cystic fibrosis. MATERIAL AND METHOD: A total of 124 persons were evaluated, of which thirteen patients with cystic fibrosis and nasosinusal polyps were selected--three were eosinophilic and ten were non-eosinophilic. The control group was composed of eleven individuals with normal otorhinolaryngological exam and the mean age was 18 years (3-57). The middle turbinate mucosa and nasal polyps were biopsied from the control group and the cystic fibrosis group respectively, and these were analyzed with RT-PCR. The middle turbinate mucosa was biopsied in the control group and in the cystic fibrosis group polyps that was analyzed to RT-PCR. The polyps of cystic fibrosis patients were also further anaylsed for subjected to a second biopsy in order to determine the percentage of eosinophils. IL-4, IL-5, IL-6, IL-8, IFN-gamma and GM-CSF transcriptions were analyzed. RESULTS: There was no difference in IL-5, IL-8 and GM-CSF when compared to the eosinophilic, non-eosinophilic and control groups (p>0.05). When compared to the eosinophilic and non-eosinophilic groups, higher IL-4 and IL-6 values (p=0.01 and p=0.01 respectively) were observed. When analyzed separately with the control group, IL-4 (p=0.01) expression was higher in the eosinophilic group, while IFN-gamma (p=0.03) was lower in the non-eosinophilic group. IL-5, IL-8, GM-CSF are non-specific cytokines present in the nasosinusal sinonasal polyps of cystic fibrosis patients. IL-4 and IL-6 are important mediators in the eosinophilic sinonasal polyps, while low IFN-gamma may be related to lower eosinophils in non-eosinophilic polyps.

Padrão respiratório e movimento toracoabdominal de crianças respiradoras orais / Breathing pattern and thoracoabdominal motion in mouth-breathing children

OBJETIVO: Caracterizar o padrão respiratório e o movimento toracoabdominal de crianças respiradoras orais, na faixa etária entre oito e dez anos, e compará-lo ao de seus pares respiradoras nasais. MÉTODOS: Estudo observacional realizado em laboratório universitário. O número amostral calculado com base em um estudo piloto com dez crianças em cada grupo, perfazendo um total de 20 crianças, foi de 50 para um nível de significância de 0,05 e um poder estatístico de 0,80. Participaram do estudo 26 crianças respiradoras orais e 25 respiradoras nasais. A pletismografia respiratória por indutância calibrada foi o instrumento utilizado para a análise das seguintes variáveis, entre outras: freqüência respiratória (FR), contribuição da caixa torácica para o volume corrente ( por centoCT/Vc), ângulo de fase (Angfase) e a razão entre o tempo para alcançar o pico de fluxo inspiratório e o tempo inspiratório (PifT/Ti). A saturação periférica da hemoglobia em oxigênio (SpO2) foi medida pela oximetria de pulso. A análise estatística foi realizada por meio do teste t de Student para grupos independentes e do teste U de Mann-Whitney, em função da distribuição das variáveis. RESULTADOS: No total, 4.816 ciclos respiratórios foram analisados, sendo 2.455 de respiradores orais e 2.361 de respiradores nasais, com média de 94 ciclos por criança. Não houve diferença significativa entre os grupos nas variáveis estudadas (FR=20,00±2,68 versus 20,73±2,58, p=0,169; por centoCT/Vc=39,30±11,86 versus 38,36±10,93, p=0,769; Angfase=14,53±7,97 versus 13,31±7,74, p=0,583; PifT/Ti=57,40±7,16 versus 58,35±5,99, p=0,610; SpO2=96,42±1,52 por cento versus 96,88±1,01 por cento, p=0,208; respectivamente). CONCLUSÕES: Estes resultados sugerem que as crianças respiradoras orais apresentam padrão respiratório e movimento toracoabdominal semelhantes às de respiradores nasais de mesma faixa etária.

OBJECTIVE: To characterize the breathing pattern and thoracoabdominal motion of mouth-breathing children aged between eight and ten years and to compare these characteristics with those of nose-breathing children of the same ages. METHODS: This observational study was carried out in a university laboratory. The sample size of 50 subjects was estimated based on the results of a pilot study with ten children in each group (total of 20 children) and considering a significance level of 0.05 and statistical power of 0.80. Twenty-six mouth-breathing and 25 nose-breathing children participated. Calibrated respiratory inductive plethysmography was used to analyze the following variables, among others: respiratory frequency (f), rib cage contribution towards tidal volume ( percentRC/Vt), phase angle (PhAng) and the ratio between time taken to reach peak inspiratory flow and total inspiratory time (PifT/Ti). Peripheral oxygen saturation of hemoglobin (SpO2) was measured using pulse oximetry. Statistical analysis was performed using the Student's t test for independent groups or the Mann-Whitney U test, according to the sample distribution of the variables. RESULTS: A total of 4,816 respiratory cycles were analyzed: 2,455 from mouth-breathers and 2,361 from nose-breathers, with a mean of 94 cycles per child. No statistically significant differences were observed between the groups, for the variables studied (f=20.00±2.68 versus 20.73±2.58, p=0.169; percentRC/Vt=39.30±11.86 versus 38.36±10.93, p=0.769; PhAng=14.53±7.97 versus 13.31±7.74, p=0.583; PifT/Ti=57.40±7.16 versus 58.35±5.99, p=0.610; SpO2=96.42±1.52 percent versus 96.88± 1.01 percent, p=0.208; respectively). CONCLUSIONS: These results suggest that mouth-breathing children show breathing patterns and thoracoabdominal motion that are similar to those of nose-breathing children in the same age group.

Prevalence and impact of chronic otitis media in school age children in Brazil. First epidemiologic study concerning chronic otitis media in Latin America.

OBJECTIVE: The first epidemiological study carried out in Latin America to investigate the prevalence of otological disease and its impact in a representative random sample of the school children population. METHODS: A cross sectional epidemiological survey to investigate the epidemiology of otitis in a representative random sample of 1119 children and adolescents from a total of 486166 elementary and high-school students, aged 6-18 years, regularly registered in one of the 521 public and private schools of the city of Belo Horizonte, in the state of Minas Gerais, southern Brazil. The interviews were conducted individually, in the school, by an otolaryngologist or a pediatrician. The interview included all of the personal data and also detailed questions regarding otological disorders and hearing. The otological examination was carried out with Mini-Heine otoscopes and the audiometric evaluation with the AudioScope 3 with 25dB intensity. The questionnaire and basic procedures for medical examination had been previously tested through a pilot test in two schools. RESULTS: The prevalence of chronic otitis media was 0.94%. Impacted wax was found in 12.3% of the students. The prevalence of abnormalities (excluding wax) in the otoscopy examination was 10.5%. It was found that 8.3% of students had a past history of otitis and 7.7% had a past history of otorrhea. These two special groups presented statistically significant associations with chronic otitis media, hearing loss and otolaryngological surgeries (when compared with the other school children). Parents and school children seemed significantly able to identify a special group of children with past history of otitis during childhood.

A dual-specific Glu-tRNA(Gln) and Asp-tRNA(Asn) amidotransferase is involved in decoding glutamine and asparagine codons in Acidithiobacillus ferrooxidans.

The gatC, gatA and gatB genes encoding the three subunits of glutamyl-tRNA(Gln) amidotransferase from Acidithiobacillus ferrooxidans, an acidophilic bacterium used in bioleaching of minerals, have been cloned and expressed in Escherichia coli. As in Bacillus subtilis the three gat genes are organized in an operon-like structure in A. ferrooxidans. The heterologously overexpressed enzyme converts Glu-tRNA(Gln) to Gln-tRNA(Gln) and Asp-tRNA(Asn) to Asn-tRNA(Asn). Biochemical analysis revealed that neither glutaminyl-tRNA synthetase nor asparaginyl-tRNA synthetase is present in A. ferrooxidans, but that glutamyl-tRNA synthetase and aspartyl-tRNA synthetase enzymes are present in the organism. These data suggest that the transamidation pathway is responsible for the formation of Gln-tRNA and Asn-tRNA in A. ferrooxidans.

A new technique for the use of intrathecal fluorescein in the repair of cerebrospinal fluid rhinorrhea using a hypodense diluent.

The intrathecal injection of fluorescein is used in the diagnosis and treatment of skull base liquoric fistulas since it allows precise localization of the site of drainage. The fluorescein is always diluted in cerebrospinal fluid (CSF) resulting in a hyperdense solution in relation to the CSF. For this reason it is necessary to put the patient in the Trendelenburg position for 30 to 40 minutes so that the fluorescein reaches the cerebral cisterns and is visualized at the level of the fistulae. From October 1997 to May 1999 intrathecal fluorescein in a hypodense solution was used in the repair of 23 skull base defects associated with CSF rhinorrhea. This hypodense solution was obtained by diluting 0.5 cm3 of 5% fluorescein in 10 cm3 of distilled water. This solution density is 1001, which is hypodense when compared to CSF (density range 1004-1006) and therefore allows fluorescein to reach rapidly the cerebral cisterns when the patient is recumbent. The author discusses the advantages and the lack of complications with the use of fluorescein in a hypodense solution.

Sesquiterpenoids and diterpenoids from the Chilean liverwort Lepicolea ochroleuca.

The ether extract of the Chilean liverwort Lepicolea ochroleuca yielded three sesquiterpenoids, ent-4 beta-Hydroxy-10 alpha-methoxyaromadendrane, ent-3 beta-Hydroxyspathulenol, and 1,10-Dioxotayloriane, as minor components. The major components were ledol and 13-epi-neoverrucosan-5 beta-ol, four other minor fusicoccanoids were identified.

[Psychoanalysis in the north-south conflict]. / Psychoanalyse im Nord-Süd-Konflikt.

The limitations and possibilities of psychoanalysis in a public health service are presented and discussed based on a report on the public health system in Nicaragua which has been built up consistently in cooperation with psychoanalysis since the fall of the Somoza regime in 1979. The largely successful experiment of integrating psychoanalytic thought into medical training and medical care in a country of the so-called third world has instigated reflections on the present situation in the Federal Republic of Germany. The hypothesis is discussed as to how conflict avoidance, dominant scientific criteria and the extent of political consciousness have contributed to the lacking cooperation between psychoanalysis and medicine.

Aspiración de meconio en mortinatos / Meconium aspiration in mortinates

Se practicó autopsia en trece mortinatos consecutivos que habían presentado meconio en el líquido amniótico y en los que no se efectuaron esfuerzos de resuscitación. En 11 de 13 casos se encontró evidencias histológicas de meconio intra alveolar, aún en aquéllos cuyo peso fue inferior a 1.500 g. No se encontraron anormalidades ni neumonitis. Dos de los 13 casos no presentaron aspiración de meconio ni meconio en las cavidades oro-naso faríngeas. El meconio en el líquido amniótico bajo condiciones de acidosis e hipoxia fetal, puede explicar la falla en la prevención del síndrome de aspiración, pese al manejo de la vía aérea apropiada durante o poco después del parto. La monitorización fetal contínua, en los casos con meconio en el líquido amniótico, es esencial para evitar la aspiración mediante el diagnóstico precoz de sufrimiento fetal agudo