Short-term post-operative pain and discomfort following insertion of mini-implants for retaining mandibular overdentures: a randomized controlled trial.

The retention of removable dentures by mini-implants is a relatively recent treatment modality and may lead to minimal post-operative trauma. This study compared post-operative pain and discomfort following the insertion of mini-implants (two or four) or two standard-size implants for the retention of mandibular overdentures. One hundred and twenty edentulous participants (mean age 59.5 ± 8.5 years) were randomly allocated into three groups according to received treatment: (GI) four mini-implants, (GII) two mini-implants or (GIII) two standard implants. Seven days after implant insertion, patients answered questions (100-mm VAS) relating to pain, swelling, and discomfort with chewing, speech and hygiene, considering their experiences during the 1st and 6th day. Groups were compared by two-way anova (α = 0.05). All participants (GI: 38; GII: 42; GIII: 40) were analysed after 7 days. At the 6th day, GI felt significantly higher pain than GII and GIII. GI also reported more difficulty in performing oral hygiene practices than GIII during the 1st day. There was no significant difference between groups for the other questions and periods. No participant suffered unexpected side effects. The use of four mini-implants induces more intense post-operative pain at the 6th day than the insertion of two mini- or conventional fixtures, as well as more difficult oral hygiene on the 1st day. Clinicaltrials.gov, NCT01411683; FAPESP, 2011/00688-7 and 2011/23347-0.

New insights into HLA-G mediated tolerance.

Human Leukocyte Antigen G (HLA-G) is a nonclassical HLA class I molecule with well-characterized immunomodulatory activities. HLA-G was first described as a regulatory molecule that allows the fetus to elude the maternal immune response. In the last decade it has become evident that HLA-G is involved in modulating both innate and adaptive immune responses, in maintaining tolerance in autoimmune and inflammatory diseases and after transplantation, and in promoting immune escape in cancer and infectious diseases. HLA-G exerts its modulatory/regulatory functions directly by interacting with specific inhibitory receptors. The expression of HLA-G is finely tuned by genetic variations in the noncoding region of the locus. The recent discovery of dendritic cells-10 (DC-10) as naturally occurring HLA-G-expressing dendritic cells opens new perspectives in the identification of the molecular and cellular mechanisms underlying HLA-G-mediated tolerance. An overview on the HLA-G-mediated inhibition of innate and adaptive immune cells, on the genetic influence on HLA-G expression, and on HLA-G-expressing DC-10 is presented. Moreover, we discuss the central and critical role of DC-10 in the HLA-G-mediated tolerance.

[Vasculitis - diagnostic and therapeutic advances]. / Vasculites - Progressos diagnósticos e terapêuticos.

Vasculitis is characterized by inflammation and necrosis of blood vessels walls. It represents a heterogeneous group of conditions, whose etiopathogenic mechanisms remain unclear. Although uncommon, with an annual incidence of 40-54 cases per 1.000.000 persons, this is an important cause of multiorganic dysfunction and premature mortality. Depending on the affected vessels, it can cause diverse clinical presentations, which makes difficult its recognition. It is therefore a challenge for any clinician. This paper reviews the diagnostic and therapeutic advances of the most common forms of vasculitis, in order to optimize the approach and management of this clinical entity. We have conducted a search in Medline database on articles written in English, published for the last 10 years using the keywords: vasculitis, epidemiology, classification, diagnosis and treatment. To minimize the impact of vasculitis it is essential an early diagnosis, allowing a timely institution of the appropriate treatment. The diagnosis depends on the integration of clinical, laboratory, imaging and histopathologic data. According to the clinical condition, it may be indicated the removal of the offending antigen, the treatment of the underlying disease or specific treatment of the primary vasculitis. The introduction of immunosuppressive therapy with glucocorticoids and cyclophosphamide has revolutionized the prognosis of these patients but, despite its efficacy, it is associated with frequent relapses and significant toxicity. The study of the pathogenesis has been providing more effective and safer diagnostic and therapeutic options, for example B-cell depleting agents, but additional studies are needed to confirm the potential of these alternatives.

[Concomitant carotid and coronary artery surgery in the prevention of postoperative stroke]. / Cirurgia carotídea e coronária simultâneas na prevenção do acidente vascular cerebral pós-operatório.

OBJECTIVES: To review the use of simultaneous carotid and coronary surgery in the prevention of perioperative stroke. METHODS: The research was conducted between May and September 2012, through Medline. The selection was based on a review of the titles and abstracts. In addition, we performed a review of reference lists of each article. RESULTS: Perioperative stroke influences the patient's prognosis after coronary artery bypass surgery and is one of the most serious and deleterious consequences of this surgical procedure. Moreover, despite perioperative stroke etiology being multifactorial, carotid disease is frequently implicated. The management of patients with extracranial carotid and coronary disease is controversial and a solid approach remains unclear. Carotid revascularization can help reduce early or long term risk. CONCLUSION: The presence of an experienced surgical team, in a center with a large number of treated patients, is critical to a successful simultaneous surgery. This approach should be considered in symptomatic carotid stenosis and asymptomatic severe bilateral stenosis. In asymptomatic patients with severe carotid stenosis, the decision should be balanced with strict patient selection criteria.

The +3187A/G HLA-G polymorphic site is associated with polar forms and reactive reaction in leprosy.

Considering that variability in immune response genes has been associated with susceptibility to leprosy and with disease severity, leprosy presents clinicopathological variants that are highly associated with the immune response, HLA-G has a well-recognized role in the modulation of the immune response, and polymorphisms at the 3' untranslated region (UTR) of the HLA-G gene may influence HLA-G production, we studied the polymorphic sites at the 3' UTR of the HLA-G gene in leprosy and their association with disease severity. We evaluated by sequencing analysis the allele, genotype, and haplotype frequencies of the 3' UTR HLA-G polymorphic sites (14-bpINDEL/+3003C-T/+3010C-G/+3027A-C/+3035C-T/+3142C-G/+3187A-G/+3196C-G) in 146 individuals presenting reactive leprosy from a highly endemic area, and associated with bacillary load and the type of reactive leprosy. A total of 128 healthy subjects were also studied. Allele, genotype, and haplotype frequencies for the 3' UTR HLA-G polymorphisms in leprosy patients did not differ from those observed in healthy donors. The +3187A allele was responsible for protection against the development of multibacillary leprosy in a dominant model (AA + AG)/GG, OR = 0.11, P = 0.018), and the +3187A allele and +3187A-A genotype were overrepresented in type II reactive leprosy reaction. The effect of genetic factors on leprosy susceptibility may be hidden by environmental components in highly endemic areas. The HLA-G + 3187A polymorphic site, which is related to unstable mRNA production, was associated with the development of polar forms of leprosy and reactive leprosy reaction.

[Results of thrombectomy for prosthetic graft occlusion. A five-years consecutive experience]. / Resultados da Trombectomia por Oclusão de Bypass Protésico. Experiência de 5 Anos Consecutivos.

OBJECTIVES: Evaluation of graft thrombectomies performed at our department, during a five years' consecutive period. METHODS: Charts of all consecutive graft thrombosis treated with surgical thrombectomy at our department between June/2006 and September/2011 were retrospectively reviewed. Thrombectomy primary patency, limb salvage and mortality rates were estimated by the Kaplan-Meier method. Differences among subgroups were tested by the Log-Rank test for time-dependent outcomes. RESULTS: A total of 57 cases were studied. Median follow-up time was 387 days. Survival rate was 84,2% at 358 days (SD=6,1%). Thrombectomy primary patency rates were 17,9 % at 1 year (SD=6,5%). Limb-salvage rates were 56,6% at 1 month (SD=6,9%) and 40,3% at 4,5 years (SD=7,1%). Re-intervention rates were 52,2% at 4,5 years and among those who were reoperated on, limb-salvage rates were 71,4% at 12 days (SD=9,9%). To assess the differences according to the type of graft operated on, cases were placed into two groups: one group included those thrombectomies performed by occlusion of any bypass for aorto-iliac revascularization (aortobifemoral, femoro-femoral, femoro-popliteal crossover, axilo-unifemoral and axilo-bifemoral) and the other group included all the others (for infra-inguinal revascularization). The first group exhibited lower survival rates (85,1% vs 96,3% at 11 days, SD<10%, p=0.024). On the other hand, this group presented higher patency rates comparing to infra-inguinal revascularization group (58,5% vs 81,3% %, SD<10%, p=0,006). Regarding limb-salvage and re-intervention rates, there were no significant differences between these two groups. Interval time between bypass surgery and thrombectomy for its occlusion had no impact on patency, neither the additional measures used along with thrombectomy for revascularization after occlusion. CONCLUSION: RESULTS of surgical thrombectomies after graft thrombosis are discouraging. Other techniques such as thrombolysis must be kept in mind in order to achieve better outcomes. In some patients one must decide wether to proceed with an attempt to salvage the initial procedure or to amputation, which may speed the patient toward the best possible outcome.

Identification of two new HLA-G alleles, G*01:01:03:03 and G*01:01:21, in Brazilian individuals.

Here we report two new non-classical class I HLA-G alleles found in the Brazilian population.

Haplotype frequencies based on eight polymorphic sites at the 3' untranslated region of the HLA-G gene in individuals from two different geographical regions of Brazil.

The Brazilian population represents an admixture of native Amerindians, Portuguese settlers and Africans who were brought as slaves during the colonization period that began in the 16th century and was followed by waves of immigrations of Europeans and Asians in the 20th century. The contribution of these different ethnic groups to the constitution of Brazilian populations from different geographic regions is variable and, in addition to environmental factors, might act by determining different allele profiles among Brazilian populations from different regions. We studied polymorphic sites at the 3' untranslated region of the HLA-G gene in individuals from a Northeastern Brazilian region and compared them to our previously published data about a Southeastern Brazilian region, located at a distance of 2589 km. Our results showed that most polymorphic sites present a similar distribution in both populations, except for the lower frequency of the +3003C allele in the Northeastern population compared to the Southeastern population. Although differences in genotypic distribution were only significant for the +3003 locus (P = 0.0201), the diversity of haplotypes was distinct for each population. These results are important for case-control studies on the association of human leucocyte antigen-G polymorphism with disease and also in terms of the genetic structure of two distinct Brazilian populations.

[The use of negative pressure therapy in vascular surgery: experience of a single center]. / A utilização do tratamento de feridas por pressão negativa em cirurgia vascular: experiência de um serviço.

OBJECTIVE: Prospective and unicentric review of the use of negative pressure wound therapy in patients with acute and chronic vascular pathology. MATERIAL AND METHODS: Between January 2010 and February 2012, there were 26 patients treated with negative pressure therapy, with a mean age of 60 years (± 14 years), 69% of which male. The most frequently encountered comorbidities were hypertension (66%), followed by diabetes mellitus (50%) and dyslipidemia (38%). 8% had chronic renal failure. The hospitalization was due to ischemic ulcers in 23%, complicated venous ulcer in 13%, diabetic foot in 8% and ruptured abdominal aortic aneurysm in 8%. The main reason for the application of negative pressure therapy was accelerate healing (62%), followed by infection control (46%). Two patients started application for abdominal compartment syndrome. All patients started treatment after hospitalization, with an average of 26 days after admission, having made application for about 13 days (± 8 days), with a medium pressure and number of exchanges, respectively, of 106mmHg (± 12 mmHg) and 3 exchanges (± 1.5). RESULTS: Therapeutic success was obtained in 23 patients (88%), with 2 submitted to major amputation. There were 3 deaths from causes unrelated to vacuotherapy. The average number of days of hospitalization after-treatment was 15 and 88% of patients underwent secondary procedures, 50% of which were cutaneous plasty. In two cases, the treatment was prolonged to ambulatory. CONCLUSION: Beginning about 15 years ago, the application of negative pressure in wound therapy has been having a growing indication, with positive results in the clinical evolution of patients, as exemplified by the results of the service experience.

[Endovascular management of a ruptured pseudoaneurysm of a rectal artery]. / Tratamento endovascular de pseudoaneurismade uma artéria rectal em rotura.

A 22-years old male patient, with a history of renovascular hypertension, was evaluated in the emergency department for abdominal pain of acute onset, interpreted as acute appendicitis. During surgery, we identified an extensive haemoperitoneum which required conversion to laparotomy without identifying focal hemorrhage. A peri-operative angiography disclosed a parietal irregularity of the upper rectal artery, without active bleeding. The patient remained stable until the 15th postoperative day, when there was clinical deterioration and hemoglobin decrease. Angio-CT revealed the presence of an upper rectal artery pseudoaneurysm with an extensive retroperitoneal and organized hematoma. The patient was proposed for surgical correction which was not carried out due to extensive inflammatory and fibrotic changes, being referred for endovascular exclusion, performed by selective catheterization and coil embolization. The procedure went without complications. Catheterization was performed upstream and downstream of the pseudoaneurysm, with microcatheter, and embolization performed with coils. Control angiography showed no filling of the aneurysm. The patient remained asymptomatic after the procedure, with clinical and analytical stability. Inferior mesenteric artery primary pseudoaneurysms are rare but potentially fatal, with formal indication for treatment, given the risks of free rupture. The use of endovascular techniques allows a minimally invasive approach, with exclusion of the PA, with high rates of primary success. Doubts remain regarding the functionality of the involved organ and long-term recurrence rates; therefore high importance is given to proper follow-up of these patients.