Venous thromboembolism events after breast reconstructions with DIEP free flaps in 192 consecutive case.

BACKGROUND: Patient candidates for breast reconstruction with free deep inferior epigastric perforator flap (DIEP) may present several risk factors for venous thromboembolism (VTE). Risk identification is essential for appropriate VTE prophylaxis measures to be put in place. This study aims to investigate VTE incidence after DIEP flap breast reconstruction and to assess the accuracy of the Caprini Risk Assessment Model (RAM), which is the unique score validated to assess the VTE risk for plastic surgery procedures and identify patients at high VTE risk. METHODS: A chart review was conducted of 192 consecutive patients who underwent breast reconstruction with a DIEP flap from 1999 to 2016. VTE rate was assessed and the Caprini score was calculated for each patient and correlated with the VTE incidence. RESULTS: During the 90 post-operative days, four patients presented a pulmonary embolism (2.1%) and two patients (1%) had deep venous thrombosis (overall VTE incidence of 3.1%). Most patients (92.2%) were assessed as high-risk (Caprini score >5) and all VTE occurred among this group. Apart from the Caprini score, no specific single risk factor could be identified for VTE. CONCLUSIONS: Our data confirm that the Caprini RAM is a valuable assessment tool for VTE risk measurement among all patients undergoing autologous breast reconstruction. As most candidates for DIEP flap belong to the high-risk group, combined anticoagulation prophylaxis methods are required for most cases, particularly chemoprophylaxis up to four weeks postoperatively.

Modified Sugiura Operation for Idiopathic Portal Hypertension with Bleeding Oesophageal Varices. A Case Report.

A case of a 36 years old man presenting massive upper GI bleeding due to oesophageal varices developed in the context of an idiopathic portal cavernoma and extensive porto-splenic thrombosis is discussed. He underwent a successful modified Sugiura operation (oesophago-gastric devascularisation and splenectomy [OGDS]) completed with interventional endoscopic treatment of residual oesophageal varices. The benefit of the modified Sugiura procedure proposed for the treatment of upper GI variceal bleeding developed in the context of splanchnic venous thrombosis is discussed. The procedure is a valid therapy in the treatment of symptomatic extra-hepatic hypertension when other options are inapplicable.

Leiomyosarcoma of the Inferior Vena Cava Level II Including Both Renal Veins : Surgical Approach.

A 66 years old male developping an acute lower right limb oedema due to an extended venous thrombosis of the common femoral and iliac veins was diagnosed to have a leiomyosarcoma of the inferior vena cava (IVC) involving both renal veins. The characteristics and management of this level II IVC leiomyosarcoma are discussed with particular attention to the renal vein reconstruction and neo-adjuvant therapy.

Leiomyosarcoma of the Inferior Vena Cava Level II Including Both Renal Veins: Surgical Approach.

A 66 years old male developping an acute lower right limb oedema due to an extended venous thrombosis of the common femoral and iliac veins was diagnosed to have a leiomyosarcoma of the inferior vena cava (IVC) involving both renal veins. The characteristics and management of this level II IVC leiomyosarcoma are discussed with particular attention to the renal vein reconstruction and neo-adjuvant therapy.

Enhancement in the histological diagnosis of leprosy in patients with only sensory loss by demonstration of mycobacterial antigens using anti-BCG polyclonal antibodies.

This study was undertaken to assess whether the immunoperoxidase technique using anti-BCG serum is able to confirm the diagnosis of early leprosy among patients whose unique clinical manifestation is a localized area of sensory loss, in a higher proportion than the routine mycobacterial staining methods, namely hematoxylin-eosin and Wade. The study was held in the north of a hyper-endemic area of leprosy, Manaus, Amazonas (Brazil). Fifty-one paraffin-embedded skin biopsy blocks were retrieved and processed for the immunohistochemical study, by means of anti-BCG polyclonal antibodies for the detection of mycobacterial antigens. The routine stains confirmed the leprosy diagnosis in 17% of the cases, while the immunostaining method confirmed it in 47%. The McNemar test showed that the observed difference between these two techniques was statistically significant (p = < 0.05). In the same way, 50 blocks of skin conditions considered in the differential histopathological diagnosis of early leprosy were processed for the immunohistochemical test to analyze the possibility of false-positive results which occurred in 8 (16%) patients. The study suggests that immunostaining may increase the proportion of the routine histological diagnosis of leprosy in patients who have sensory loss only, even while using biopsies obtained in fieldwork conditions. This is very advantageous in hyper-endemic areas and in areas that are in the post-elimination period of leprosy control where sensory loss may be a sentinel sign of the disease.

Distinct histopathological patterns in single lesion leprosy patients treated with single dose therapy (ROM) in the Brazilian Multicentric Study.

This paper aims to describe the histomorphologic features of skin biopsies of single lesion leprosy patients recruited at outpatient clinics in four Brazilian states in the Northeast (Amazonas and Rondonia), Southeast (Rio de Janeiro) and Center-West (Goiás) between October 1997 and December 1998. Patients clinically diagnosed as single skin lesion paucibacillary (SSL-PB) leprosy had a standard 4-mm punch biopsy taken from the lesion before rifampin, ofloxacin, minocycline (ROM) therapy. The features of the cellular inflammatory infiltrates, the presence of nerve involvement and acid-fast bacilli (AFB) were used to categorize SSL-PB biopsies into different histopathological groups. Two-hundred-seventy-eight (93.0%) out of 299 patients had a skin biopsy available. Seven single lesion patients were diagnosed as BL or LL leprosy types (MB) by the histopathological exams and 12 cases were excluded due to other skin diseases. Therefore, 259 patients had skin lesions with histomorphological features compatible with PB leprosy categorized as follows: 33.6% (N = 87) of the biopsies represented well-circumscribed epithelioid cell granuloma (Group 1); 21.6% (N = 56) less-circumscribed epithelioid cell granuloma (Group 2); 12.0% (N = 31) were described as mononuclear inflammatory infiltrate permeated with epithelioid cells (Group 3), and 29.7% (N = 77) had perivascular/periadnexal mononuclear inflammatory infiltrate (Group 4). Minimal/no morphological alteration in the skin was detected in only 8 (3.1%) SSL-PB patients categorized as Group 5, who were considered to have leprosy by clinical parameters. SSL-PB leprosy patients recruited in a multicentric study presented histomorphology readings comprising the whole PB leprosy spectrum but also a few MB cases. These results indicate heterogeneity among SSL-PB patients, with a predominance of well-circumscribed and less-circumscribed epithelioid cell granulomas (Groups 1 and 2) in the sites studied and the heterogeneity of local cellular immune response.

Soluble tumor necrosis factor alpha receptors in sera from leprosy patients.

Serum levels of soluble tumor necrosis factor alpha receptor I (sTNF-RI) were elevated in patients with lepromatous (LL) reactional-state type II leprosy, and sTNF-RII levels were increased in patients with full tuberculoid (TT) or LL type II leprosy. The sTNF-R in sera from patients with type II leprosy, but not other forms of leprosy, inhibited recombinant TNF cytolytic activities in vitro. This suggests that sTNF-R regulatory activities are partially impaired in patients with leprosy.

American cutaneous leishmaniasis due to Leishmania (Viannia) guyanensis as an initial clinical presentation of human immunodeficiency virus infection.

The authors present the first report of Leishmania (Viannia) guyanensis (L.(V.) guyanenesis) associated with human immunodeficiency virus (HIV) in a Brazilian heterosexual man. It is also the first case of HIV infection associated with American cutaneous leishmaniasis in Brazilian Western Amazonia. The patient had cutaneous and mucous lesions with a negative Montenegro skin test. Histopathology showed large numbers of amastigotes, even in a lesion which had clinically healed. L.(V.) guyanenesis was typed by an immunoenzymatic technique. Various therapies were attempted, but the patient relapsed after each episode of treatment.

Contribution of brain distortion and displacement to CSF dynamics in experimental brain compression.

The present study was designed to determine the contribution of brain distortion and displacement to changes in cerebrospinal fluid (CSF) dynamics [pressure-volume index (PVI), compliance (C), and outflow resistance (Ro)] during progressive brain compression and the effect of compression on brain mechanical properties. In 10 dogs measurements were made of CSF dynamics, brain elastic behavior, cerebral perfusion pressure, local cerebral blood flow, and suprainfratentorial intracranial pressure (ICP) during the incremental expansion of a supratentorial extradural balloon. PVI appeared more as a measure of the compressibility of the cerebral vascular compartment than of intracranial bulk compliance. Reciprocal changes in CSF dynamics behaved as expected when the balloon expanded predominantly supratentorially causing a moderate increase in ICP. A significant increase in ICP, however, caused a rise in PVI and a decrease in compliance. Under these conditions PVI alone could not differentiate between a falling cerebral perfusion pressure and an increasing suprainfratentorial ICP gradient. In contrast, the compliance decreased with balloon expansion while the outflow resistance showed an inverse correlation with compliance and a linear correlation with baseline ICP; Go, an elastic response parameter, consistently decreased, implying that C, Ro, and Go can be used as a trend of intracranial compensatory reserve during intracranial mass expansion.

[Tumor markers in lung neoplasms]. / Markers tumorali nelle neoplasie polmonari.

The authors studied the variations of the markers isolated or in differently associations, in pulmonary pathology. The results from linear multivaried analysis, applied to CER, TPA, Ca 125, Ca 15.3 and calcitonin, are particularly interesting in diagnosis.

Brain tissue elasticity and CSF elastance.

In the analysis of the pressure-volume relationship of the intracranial system, the concept of brain elastance, sometimes called tissue elastance or CSF elastance, is often used. It is generally designated as Ecsf and is calculated as the slope of the pressure-volume curve of the system. Variations in Ecsf are related to, for example, changes in the buffering capacity of the system which, however, could be influenced by the cerebral vascular volume, compressibility of the meningeal membranes, and compressibility of the subpial brain tissue. Our interest is in isolating the effect of controlled changes in the intracranial system with changes in the subpial tissue only. Here we discuss the measurement of brain tissue elasticity and describe two experimental conditions in which simultaneous measurements showed distinct differences between the behaviour of the system CSF elastance and brain tissue elastic behaviour.

Attenuation of decompressive hypoperfusion and cerebral edema by superoxide dismutase.

This study tested the hypothesis that ischemia-reperfusion injury initiated by the superoxide anion radical is a major component of postdecompression hypoperfusion and cerebral edema, and could be attenuated by superoxide dismutase (SOD). A supratentorial extradural balloon was placed in 20 fasting, lightly anesthetized, mechanically ventilated dogs and inflated in 0.5-ml increments (0.07 ml/sec) at 15-minute intervals. The end-point of balloon expansion was the onset of an isoelectric electroencephalogram, near-arrest of hemispheric cerebral blood flow (CBF) (measured by H2 clearance), and the appearance of a suprainfratentorial intracranial pressure gradient, which was held for 15 minutes. The in vivo development of brain edema was detected by measuring brain elastic response (BER) extradurally, and was correlated with postmortem measurement of brain water content (gravimetry); blood-brain barrier integrity was tested by Evans blue dye given after the insult. After decompression, the dogs were randomly assigned to one of four treatment groups: Group I received hyperventilation (PaCO2 28 +/- 1 mm Hg, mean +/- standard deviation); Group II received furosemide (2.4 mg/kg) and pentobarbital (10 mg/kg) every 8 hours; Group III received 20% mannitol in a 1.4-gm/kg bolus plus furosemide, 0.5 mg/kg; and Group IV received SOD, 15,000 U/kg every 15 minutes for 3 hours. At 4 hours of decompression Group IV had significantly greater recovery in local CBF and BER than Groups I, II, and III (p less than 0.05). The 24-hour survival rate was 20% for Group I, 60% for Group II, 80% for Group III, and 100% for Group IV. The survival rate appeared to correlate with a variable degree of postmortem intraparenchymal hemorrhages, blood-brain barrier disruption, and moderate to severe brain edema for Groups I, II, and III. In contrast, Group IV had the least brain edema (p less than 0.05) and Evans blue dye extravasation (p less than 0.05) and the fewest intraparenchymal hemorrhages. These data support the hypothesis that, under the experimental conditions described here, the superoxide anion plays a major role in the pathophysiology of postdecompression ischemic edema.

Histological observations on Montenegro's reaction in man.

The Montenegro skin test is widely used as a diagnostic method for American cutaneous leishmaniasis (ACL) but little is known about the histological changes that occur in the skin after administration of the antigen. This report is based on histological studies of biopsied material obtained, from inoculation sites, 48 hours after individuals had been given intradermal injections with a standardized Montenegro antigen. The material examined was obtained from four distinctly different test groups: naturally infected patients with parasitologically proved ACL and with positive Montenegro's reaction; individuals without previous history of ACL and not previously tested with Montenegro antigen; participants in anti-ACL vaccine trials who developed positive reactions to Montenegro antigen after vaccination; other participants in vaccine trials who had negative Montenegro responses after vaccination or had served as controls in the trials. The histological pictures of each group are described and discussed. Histologically, the reactions of vaccinated individuals were indistinguishable from those with naturally acquired infections.

Brain tissue elastic behavior and experimental brain compression.

This study was designed to test the hypothesis that the progressive expansion of an extradural mass causes detectable changes in brain mechanical response properties, in particular the nonlinear elastic behavior, before any significant changes in intracranial cerebrospinal fluid pressure can be detected. In 10 chronically prepared and anesthetized dogs, incremental inflation (0.07 ml/s) of an extradural balloon caused 1) a progressive fall in the brain nonlinear elastic parameter (G0, mmHg/mm2), 2) nonsignificant changes in brain tissue elasticity (G0, mmHg/mm), 3) a disproportionate progressive rise in subpial tension, and 4) a progressive fall in local cerebral blood flow (H2 clearance), despite a modest decrease in cerebral perfusion pressure (extracranial). In previous brain compression experiments (Brain Res. 305: 141-143, 1984) we have shown that the compression site becomes compacted and stiffer (increased G0) and its nonlinear elastic parameter (G0) increases markedly. These earlier findings, coupled with the present observation of a loss in tissue nonlinearity distally to the compression site, are most likely the major mechanisms by which, with a rapidly expanding intracranial mass, tissue pressure gradients and brain displacement, including transtentorial herniation, develop.

Deep mycoses in Amazon region.

Patients with deep mycoses diagnosed in dermatologic clinics of Manaus (state of Amazonas, Brazil) were studied from November 1973 to December 1983. They came from the Brazilian states of Amazonas, Pará, Acre, and Rondônia and the Federal Territory of Roraima. All of these regions, with the exception of Pará, are situated in the western part of the Amazon Basin. The climatic conditions in this region are almost the same: tropical forest, high rainfall, and mean annual temperature of 26C. The deep mycoses diagnosed, in order of frequency, were Jorge Lobo's disease, paracoccidioidomycosis, chromomycosis, sporotrichosis, mycetoma, cryptococcosis, zygomycosis, and histoplasmosis.