Synergistic effect of the association between lidocaine and magnesium sulfate on peri-operative pain after mastectomy: A randomised, double-blind trial.

BACKGROUND: Recently, the use of venous adjuvants, such as lidocaine and magnesium sulfate, has been gaining ground in multimodal analgesia. However, no study has evaluated the impact a combination of the two drugs. OBJECTIVES: To evaluate the efficacy of venous adjuvants in reducing opioid consumption and pain scores after mastectomy. DESIGN: Randomised, double-blind, parallel-group, noninferiority clinical trial with a 1 : 1 : 1 : 1 allocation ratio. SETTING: Hospital de Base do Distrito Federal, Brasilia, Federal District, Brazil from November 2014 to December 2017. PATIENTS: One-hundred and ninety-eight patients were electively scheduled for mastectomy. Seventy-eight were excluded. INTERVENTIONS: Intra-operative infusions of remifentanil (0.1 µg kg min), lidocaine (3 mg kg h), magnesium sulfate (50 mg kg + 15 mg kg h) or lidocaine with magnesium sulfate were used. All patients received standard general anaesthesia. MAIN OUTCOME MEASURES: Peri-operative opioid consumption and pain scores. RESULTS: The patients who received both lidocaine and magnesium sulfate group (n=30) consumed less alfentanil during surgery (P < 0.001) and less dipyrone (P < 0.001) and morphine (P < 0.001) in the postoperative period. Only two patients (6.7%) in the lidocaine and magnesium sulfate group needed morphine (P < 0.001). These requirements were significantly lower when compared with patients who received remifentanil (n=30; 76.6%) and magnesium sulfate (n=30; 70%; odds ratio 46.0, 95% confidence interval 8.69 to 243.25, P < 0.001, and odds ratio 32.66, 95% confidence interval 6.37 to 167.27, P < 0.001, respectively). The patients of the lidocaine and magnesium sulfate group had lower pain scores in the first 24 h postoperatively using the numerical rating scale and verbal rating scale at discharge from the postanaesthesia care unit (P < 0.001), after 12 h (P < 0.001) and after 24 h (P < 0.001) when compared with the other three groups. CONCLUSION: Our findings suggest a synergistic effect of the use of both lidocaine and magnesium in peri-operative pain. This may be another potential strategy in the multimodal analgesia regimen. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02309879.

Survival after adjuvant chemoradiotherapy or surgery alone in resectable adenocarcinoma at the gastro-esophageal junction.

BACKGROUND AND AIMS: Longterm survival after curative resection for adenocarcinoma at the gastro-esophageal junction (GEJ) range between 18% and 50%. In the pivotal Intergroup-0116 Phase III trial by Macdonald et all, adjuvant chemoradiotherapy improved both disease-free and overall survival in curatively resected patients with mainly gastric adenocarcinoma. We compared survival data for curatively resected patients with adeno-carcinoma solely at the gastro-esophageal junction (GEJ), treated with surgery alone or surgery and adjuvant chemoradio-therapy. METHODS: From 2003 to 2009, 211 patients underwent curative resection. Surgery alone was performed in 95 pa-tients and 116 patients received adjuvant therapy after resection. All patients underwent Lewis-Tanner operation with D1 node resection including coliac nodes (D1+). Informations about recurrence and death were collected from the Danish Cancer Register and the Central Death Register. Patients who died after experiencing severe complications after surgery were excluded from the survival analysis. Patients with T0N0 or T1N0 were also excluded because patients of this category were not given adjuvant therapy according to the Macdonald protocol. RESULTS: Patients with positive node status in the resected specimen, the 3-year disease-free survival after adjuvant chemoradiotherapy (n = 91) or surgery alone (n = 43) was 24% and 37%, respectively. Median time of survival was prolonged by 10 month in favour of those who received chemoradiotherapy. However, after controlling for the confounding effect of age and node status, only positive node status in the resected specimen had significant partial effect on survival. CONCLUSION: Chemoradiotherapy according to the Intergroup-0116 protocol might still be a reasonable option after curative resection in patients with GEJ adenocarcinomas and positive lymph node status, who did not receive neoadjuvant chemotherapy.

Ocular melanoma: Keep your eyes open for late brain metastases.

BACKGROUND: The most frequent intraocular malignant tumor is choroidal melanoma (CM). Although brain metastasis is a common feature of other types of cancers, metastasis of CM to the brain is a rare entity. CASE DESCRIPTION: The authors report a case of a 28-year-old woman presenting with a single brain metastasis, 10 years after the treatment of a CM. She underwent a total en-bloc resection of the lesion, and the diagnosis was confirmed histopathologically. The patient concomitantly received whole-brain irradiation therapy combined with chemotherapy, with a survival period of 24 months. CONCLUSION: The present case report draws attention to the necessity of a close and lifelong follow-up of patients treated for this malignancy. The international literature is also reviewed.

Perfil ambulatorial em cardiologia pediátrica na cidade de Ribeirão Preto - resultados preliminares / Characteristics of the cardiology outpatient clinic in the Ribeirão Preto city

Objetivo: Determinar as características do atendimento ambulatorial em cardiologia pediátrica na cidade de Ribeirão Preto (RP), enfatizando o motivo do encaminhamento, diagnóstico definitivo e a conduta adotada, comparando-se a casuística de um ambulatório de hospital terciário e da clínica privada. Métodos: 674 pacientes consecutivos, com idade de 1 mês a 14 anos foram atendidos durante 5 meses em 3 locais distintos: G1 (n = 276), ambulatório de referência da rede pública; G2 (n = 198), clínica privada; G3 (n = 200), ambulatório de referência do Hospital das Clínicas (FMRP - USP). Procedência: G1: RP (73 por cento), região (27 por cento); G2: RP (63 por cento), região (17 por cento), outras regiões (14 por cento), outros Estados (6 por cento); G3: RP (27,5 por cento), região (32 por cento), outras regiões (28,5 por cento), outros Estados (12 por cento). Resultados: Motivo de encaminhamento:G1: sopro (73 por cento), dor precordial (7 por cento), arritmia (6 por cento), dispnéia (7 por cento), outros (7 por cento). G2: sopro (65 por cento), dor precordial (9 por cento), arritmia (7 por cento), seguimento pós-operatório (7 por cento), dispnéia (4 por cento), outros (8 por cento). G3: sopro (53 por cento), seguimento pós-operatório (29 por cento), arritmia (5 por cento), outros (13 por cento). Abandono de tratamento: G1: 31 por cento, G2: 21 por cento, G3: 5 por cento. Diagnóstico definitivo: G1: normais (89 por cento), anormais (11 por cento); G2: normais (63 por cento), anormais (37 por cento); G3: normais (1 por cento), anormais (99 por cento). Conduta: G1: alta (89 por cento), seguimento (8 por cento), encaminhamento intervenção (3 por cento); G2: alta (63 por cento), seguimento (35 por cento), encaminhamento intervenção (2 por cento); G3: alta (1 por cento), seguimento (99 por cento). Conclusões: A demanda de pacientes é expressiva. G1 e G2 têm características semelhantes: procedência regional, maioria encaminhada por sopro, alto índice de abandono e incidência importante de normalidade. G3 tem características terciárias: procedência ampla, baixo índice de abandono, casos normais são raros e número expressivo de pacientes operados. É necessário treinamento pediátrico para reduzir encaminhamentos nos G1 e G2. A incidência de casos de abandono do tratamento é importante e deve ser investigada.

Embryo recovery and pregnancy rates after the delay of ovulation and fixed time insemination in superstimulated beef cows.

The aim of this study was to evaluate the effect of delaying ovulation subsequent to superstimulation of follicular growth in beef cows (Bos indicus) on embryo recovery rates and the capacity of embryos to establish pregnancies. Ovulation was delayed by three treatments using either progesterone (CIDR-B) or a GnRH agonist (deslorelin). Multiparous Nelore cows (n = 24) received three of four superstimulation treatments in an incomplete block design (n = 18 per group). Cows in Groups CTRL, P48 and P60 were treated with a CIDR-B device plus estradiol benzoate (EB, 4 mg, i.m.) on Day-5, while cows in Group D60 were implanted with deslorelin on Day-7. Cows were superstimulated with FSH (Folltropin-V, 200 mg), from Day 0 to 3, using twice daily injections in decreasing amounts. All cows were treated with a luteolytic dose of prostaglandin on Day 2 (08:00 h). CIDR-B devices were removed as follows: Group CTRL, Day 2 (20:00 h); Group P48, Day 4 (08:00 h); Group P60, Day 4 (20:00 h). Cows in Group CTRL were inseminated at 10, 20 and 30 h after first detected estrus. Ovulation was induced for cows in Group P48 (Day 4, 08:00 h) and Groups P60 and D60 (Day 4, 20:00 h) by injection of LH (Lutropin, 25 mg, i.m.), and these cows were inseminated 10 and 20 h after treatment with LH. Embryos were recovered on Days 11 or 12, graded and transferred to synchronized recipients. Pregnancies were determined by ultrasonography around Day 100. Data were analyzed by mixed procedure, Kruskal-Wallis and Chi-square tests. The number of ova/embryos, transferable embryos (mean +/- SEM) and pregnancy rates (%) were as follows, respectively: Group CTRL (10.8+/-1.8, 6.1+/-1.3, 51.5), P48 (12.6+/-1.9, 7.1+/-1.0, 52.3), P60 (10.5+/-1.6, 5.7+/-1.3, 40.0) and D60 (10.3+/-1.7, 5.0+/-1.2, 50.0). There were no significant differences among the groups (P > 0.05). It was concluded that fixed time AI in association with induced ovulation did not influence embryo recovery. Furthermore, pregnancy rates in embryos recovered from cows with delayed ovulation were similar to those in embryos obtained from cows treated with a conventional superstimulation protocol.

4. Preliminary Findings of a Prospective Study of FDG-PET in Patients with Possible Lung Cancer.

Purpose: To examine the value of PET in diagnosis and staging of suspected lung cancer.Methods: 20 (13 male; mean age: 56 yr., range: 22-83 yr.) patients with chest X-ray findings suspicious of malignancy were staged a) "clinically" (X-ray, history/physical examination, lung function), b) by chest CT of thorax/upper abdomen, and c) by whole-body PET (GE Advance, visual analysis). The CT and PET studies were performed within 2 weeks of admission and read blinded to all information except the chest X-ray report. The decision to refer to mediastinoscopy/thoracotomy was made by a tumor board using clinical information, CT and PET findings. In principle, suspected metastatic lesions were biopsied before surgery. The gold standard was histology from biopsy or thoracotomy, or resolution of the X-ray findings and symptoms.Results: One patient was excluded because of uncertain diagnosis. In 3 (15%) patients surgery was avoided mainly because of the PET findings. In one SCLC patient and one lymphoma patient, PET showed extensive disease, which changed the chemotherapy regime. Accuracy was 83% for clinical stage, 79% for CT and 77% for PET. Four (20%) false positive PET findings were caused by granuloma, pneumonia and BOOP. These nodules were only 1 to <3 cm, while malignant nodules were 2-8 cm. There were no false negative PET or CT studies.Conclusion: FDG-PET is valuable in patients suspected for pulmonary malignancy, since thoracotomy was avoided in 15% of patients and in 10% of patients more extensive disease was found which changed the chemotherapy regime.