Velocity–pressure loops for continuous assessment of ventricular afterload: influence of pressure measurement site

VPloop, the graphical representation of pressure versus velocity, and its characteristic angles, GALA and β, can be used to monitor cardiac afterload during anesthesia. Ideally VPloop should be measured from pressure and velocity obtained at the same arterial location but standard of care usually provide either radial or femoral pressure waveforms. The purpose of this study was to look at the influence of arterial sites and the use of a transfer function (TF) on VPloop and its related angles. Invasive pressure signals were recorded in 25 patients undergoing neuroradiology intervention under general anesthesia with transesophageal flow velocity monitoring. Pressures were recorded in the descending thoracic aorta, abdominal aorta, femoral and radial arteries. We compared GALA and β from VPloops generated from each location and in high and low risk patients. GALA was similar in the central locations (55°[49–63], 52°[47–61] and 54°[45–62] from descending thoracic to femoral artery, median[interquartile], p?=?0.10), while there was a difference in β angle (16°[4–27] to 8°[3–15], p?<?0.0001). GALA and β obtained from radial waveforms were different (39°[31–47] compared to 46°[36–54] and 6°[2–14] compared to 16°[4–27] for GALA and β angles respectively, p?<?0.001) which was corrected by the use of a TF (45°[32–55] and 17°[5–28], p?=?ns). GALA and β are underestimated when measured with a radial catheter. Using pressure waveforms from femoral locations alters VPloops, GALA and β in a smaller extend. The use of a TF on radial pressure allows to correctly plot VPloops and their characteristic angles for routine clinical use.     

Surgical risk for patients with Chagasic achalasia and its correlation with the degree of esophageal dilation

AIM: To analyze the risk of cardiovascular complications in patients with indication for surgical treatment of Chagasic esophageal achalasia and to correlate the surgical risks with the degree of esophageal dilation, thereby proposing a risk scale index. METHODS: One hundred and twenty-four patients with Chagasic esophageal achalasia, who received surgical treatment at the Hospital das Clinicas of the Federal University of Goias, were included in this study. The patients were mostly related to the postoperative complications due to the cardiovascular system. All the patients were submitted to: (1) clinical history to define the cardiac functional class (New York Heart Association); (2) conventional 12-lead electrocardiogram at rest; and (3) contrast imaging of the esophagus to determine esophageal dilatation according to Rezende's classification of Chagasic megaesophagus. RESULTS: An assessment of the functional classification (FC) of heart failure during the preoperative period determined that 67 patients (54.03%) were assigned functional class I (FC I), 46 patients (37.09%) were assigned functional class II (FC II), and 11 patients (8.87%) were assigned functional class III (FC III). None of the patients were assigned to functional class IV (FC IV). There was a positive correlation between the functional class and the postoperative complications (FC IXFC II: P<0.001; FC IXFC III: P<0.001). The ECG was normal in 44 patients (35.48%) and presented abnormalities in 80 patients (64.52%). There was a significant statistical correlation between abnormal ECG (arrhythmias and primary change in ventricular repolarization) and postoperative complications (P<0.001). With regard to the classification of the Chagasic esophageal achalasia, the following distribution was observed: group II, 53 patients (42.74%); group III, 37 patients (29.83%); and group IV, 34 patients (27.41%). There was a positive correlation between the degree of esophageal dilation and the increase in postoperative complications (grade IIXgrade III achalasia: P<0.001; grade IIXgrade IV achalasia: P<0.001; and grade IIIXgrade IV achalasia: P = 0.017). Analyzing these results and using a multivariate regression analysis associated with the probability decision analysis, a risk scale was proposed as follows: up to 21 points (mild risk); from 22 to 34 points (moderate risk); and more than 34 points (high risk). The scale had 82.4% accuracy for mild risk patients and up to 94.6% for the high risk cases. CONCLUSION: The preoperative evaluation of the cardiovascular system, through a careful anamnesis, an ECG and contrast imaging of the esophagus, makes possible to estimate the surgical risks for Chagas' disease patients who have to undergo surgical treatment for esophageal achalasia.     

Intrahepatic and subcapsular hematoma of the liver after hepatic biopsy under laparoscopy. Contribution of ultrasonography

Over the last few years, ultrasound became important in characterization of space -occupying solid lesions of the liver. Recently, Canadian authors using this method, described a 23% incidence of intrahepatic or subcapsular hematoma after liver biopsy. We prospectively evaluated the incidence of this complication after liver biopsy under laparoscopic guidance in 8 cirrhotic patients, 7 with steatosis, 7 chronic active hepatitis and 4 with intrahepatic cholestasis. Biopsy was performed under general anesthesia provided that prothrombin activity was over 50%, serum fibrinogen was over 100% and platelets over 50.000/mm3. In none of 26 consecutive patients, was an intrahepatic or subcapsular hematoma observed.     

Brazilian consensus on gastroesophageal reflux disease: proposals for assessment, classification, and management

The Brazilian Consensus on Gastroesophageal Reflux Disease considers gastroesophageal reflux disease to be a chronic disorder related to the retrograde flow of gastroduodenal contents into the esophagus and/or adjacent organs, resulting in a variable spectrum of symptoms, with or without tissue damage. Considering the limitations of classifications currently in use, a new classification is proposed that combines three criteria-clinical, endoscopic, and pH-metric-providing a comprehensive and more complete characterization of the disease. The diagnosis begins with the presence of heartburn, acid regurgitation, and alarm manifestations (dysphagia, odynophagia, weight loss, GI bleeding, nausea and/or vomiting, and family history of cancer). Also, atypical esophageal, pulmonary, otorhinolaryngological, and oral symptoms may occur. Endoscopy is the first approach, particularly in patients over 40 yr of age and in those with alarm symptoms. Other exams are considered in particular cases, such as contrast radiological examination, scyntigraphy, manometry, and prolonged pH measurement. The clinical treatment encompasses behavioral modifications in lifestyle and pharmacological measures. Proton pump inhibitors in manufacturers' recommended doses are indicated, with doubling of the dose in more severe cases of esophagitis. The minimum time of administration is 6 wk. Patients who do not respond to medical treatment, including those with atypical manifestations, should be considered for surgical treatment. Of the complications of gastroesophageal reflux disease, Barrett's esophagus presents a potential development of adenocarcinoma; biopsies should be performed, independent of Barrett's esophagus extent or location. In this regard the designation "short Barrett's" is not important in terms of management and prognosis.     

Small intestine transplantation

BACKGROUND: Significant progress has been made in clinical small bowel transplantation over the last decade mainly due advances in biotechnology and new immunosuppressive regiments. This transplantation has now been indicated to treat special cases of intestinal failure. AIM: This review highlights recent developments in the area of small bowel transplantation. MATERIAL AND METHODS: Over 600 reports on clinical and experimental small bowel transplantation were reviewed. Aspects concerning research development, different immunosuppressive strategies, patient and graft monitoring, and improvements in surgical techniques are discussed. RESULTS: About 700 small bowel transplantation were performed in 55 transplant centers, 44% intestine-liver, 41% isolated intestinal graft and 15% multivisceral transplantation. Rejection and infection are the main limitation of this procedure. Actual 5 years post transplantation graft survival of the total international experience is 46% for isolated intestinal graft, 43% for combined intestine-liver and nearly 30% for multivisceral transplantation. Higher graft and patient survival are seen at the more experienced centers. In a series of 165 intestinal transplantation at University of Pittsburgh, PA, USA, actuarial patient survival was reported to be over 75% at one year, 54% at 5 years and 42% at 10 years. Over 90% patients from Pittsburgh program resume an unrestricted oral diet. CONCLUSION: Small bowel transplantation has advanced from an experimental strategy to a feasible alternative for patients with permanent intestinal failure. Further refinements in graft acceptance, immunosuppressive regiments, infection management and prophylaxis, surgical techniques as well as appropriated patient referral and selection are crucial to improve outcomes.     

Patched, the receptor of Hedgehog, is a lipoprotein receptor

The Hedgehog (Hh) family of secreted signaling proteins has a broad variety of functions during metazoan development and implications in human disease. Despite Hh being modified by two lipophilic adducts, Hh migrates far from its site of synthesis and programs cellular outcomes depending on its local concentrations. Recently, lipoproteins were suggested to act as carriers to mediate Hh transport in Drosophila. Here, we examine the role of lipophorins (Lp), the Drosophila lipoproteins, in Hh signaling in the wing imaginal disk, a tissue that does not express Lp but obtains it through the hemolymph. We use the up-regulation of the Lp receptor 2 (LpR2), the main Lp receptor expressed in the imaginal disk cells, to increase Lp endocytosis and locally reduce the amount of available free extracellular Lp in the wing disk epithelium. Under this condition, secreted Hh is not stabilized in the extracellular matrix. We obtain similar results after a generalized knock-down of hemolymph Lp levels. These data suggest that Hh must be packaged with Lp in the producing cells for proper spreading. Interestingly, we also show that Patched (Ptc), the Hh receptor, is a lipoprotein receptor; Ptc actively internalizes Lp into the endocytic compartment in a Hh-independent manner and physically interacts with Lp. Ptc, as a lipoprotein receptor, can affect intracellular lipid homeostasis in imaginal disk cells. However, by using different Ptc mutants, we show that Lp internalization does not play a major role in Hh signal transduction but does in Hh gradient formation.     

Predicting Non-Suicidal Self-Injury in Young Adults with and without Borderline Personality Disorder: a Multilevel Approach Combining Ecological Momentary Assessment and Self-Report Measures

Psychiatric Quarterly - Non-suicidal self-injury (NSSI) is an increasingly prevalent phenomenon associated with many detrimental outcomes, ranging from poor academic performance to suicide...     

Correction to: Patient perspectives on the therapeutic profile of botulinum neurotoxin type A in cervical dystonia

Journal of Neurology - The article Patient perspectives on the therapeutic profile of botulinum neurotoxin type A in cervical dystonia, written by Cynthia Comella, Joaquim J. Ferreira, Emilie Pain,...     

Increased PLA2 activity in individuals at ultra-high risk for psychosis

European Archives of Psychiatry and Clinical Neuroscience - Phospholipase A2 is the main enzyme in the metabolism of membrane phospholipids. It comprises a family of enzymes divided into iPLA2,...