A simplified technique for laparoscopic jejunostomy and gastrostomy tube placement

BACKGROUND: Percutaneous endoscopic gastrostomy and jejunostomy tube placement have long been considered the standard for supplying enteral nutrition when oral intake is not possible. Both have well-documented roles and limitations and are associated with a higher than generally appreciated incidence of aspiration. A distally placed tube in the jejunum decreases the chance of this morbid complication. Additionally, when percutaneous endoscopic gastrostomy is indicated but cannot be done for technical reasons, a minimally invasive alternative is desirable. METHODS: In prior series, the techniques suggested for laparoscopic enteral access have characteristics that are either difficult for the average surgeon to duplicate, or use nonstandard anchoring techniques of the bowel to the abdominal wall. A simple, laparoscopically directed, percutaneous technique utilizing cost-effective appliances is described, and suggested indications are outlined. RESULTS: This technique has been successfully applied in 46 patients with minimal complications. CONCLUSIONS: A simplified technique for laparoscopic jejunostomy and gastrostomy tube placement is described. This has been successfully deployed in 46 patients with minimal morbidity. The procedure lessens the need for sophisticated suturing skills and duplicates standard small bowel to abdominal wall fixation methods.     

Recent Evidence of Hantavirus Circulation in the American Tropic

Hantaan virus was discovered in Korea during the 1970s while other similar viruses were later reported in Asia and Europe. There was no information about hantavirus human infection in the Americas until 1993 when an outbreak was described in the United States. This event promoted new studies to find hantaviruses in the Americas. At first, many studies were conducted in Brazil, Argentina, Chile, Uruguay and Paraguay, while other Latin American countries began to report the presence of these agents towards the end of the 20th century. More than 30 hantaviruses have been reported in the Western Hemisphere with more frequent cases registered in the southern cone (Argentina, Chile, Uruguay, Paraguay, Bolivia and Brazil). However there was an important outbreak in 2000 in Panama and some rare events have been described in Peru, Venezuela and French Guiana. Since hantaviruses have only recently emerged as a potential threat in the tropical zones of the Americas, this review compiles recent hantavirus reports in Central America, the Caribbean islands and the northern region of South America. These studies have generated the discovery of new hantaviruses and could help to anticipate the presentation of possible future outbreaks in the region.     

The incidence of Trypanosoma cruzi antibodies in patients with dilated myocardiopathy at the Instituto Nacional de Cardiología Ignacio Chávez]

Our objective was to measure the incidence of humoral immune response against Trypanosoma cruzi among patients with a definitive diagnosis of dilated cardiomyopathy at the Instituto Nacional de Cardiología "I. Chávez" over a year. Thirty seven patients were collected, 15 of them (40%) had antibodies against T. cruzi in two different tests, indirect immunofluorescence and ELISA, the presence of IgG antibody was confirmed through Western blot. There was not differences in clinical picture of cardiomyopathy nor on paraclinical studies. However, there was a significant difference in regard socio economical indexes between the group with positive anti T. cruzi antibodies. They had a predominant rural origin, poor housing and were aware of the vector bug. Also they recalled primary infection in their childhood--American trypanosomiasis could be on important etiologic factor for dilated cardiomyopathy in our country.     

COLONIZATION OF PALM TREES BY Rhodnius neglectus AND HOUSEHOLD AND INVASION IN AN URBAN AREA,ARA?ATUBA,S?O PAULO STATE, BRAZIL

The objective of this study is to report on the colonization of palm trees by Rhodnius neglectus, its invasion in an urban area, in Araçatuba - São Paulo, and the control and surveillance measures that have been put in place. Domiciliary triatomine searches occurred in apartments upon the inhabitants'' notification. The collected insects were identified and examined for natural infection and food sources with a precipitin test. To search the palm trees, tarps were used to cover the floor, and a “Munck” truck equipped with a tree-pruning device was utilized. Chemical control was performed with the utilization of a manual compression. In 2009, 81 specimens of Rhodnius neglectus were collected from the domiciles by the population. The precipitin test revealed a presence of human blood in 2.7% of the samples. Entomological studies were carried out in these domiciles and in those located within a radius of 200 meters. The search performed in the palm trees resulted in the capture of 882 specimens of triatomines, negative for tripanosomatids. Mechanical and chemical controls were carried out. New searches conducted in the palm trees in the same year resulted in the capture of six specimens. The mechanical and chemical controls of the palm trees, together with the population''s work, proved to be effective, therefore preventing these insects'' colonization of the city''s domiciles.     

Human variation and CYP enzyme contribution in benfuracarb metabolism in human in vitro hepatic models

Human responses to the toxicological effects of chemicals are often complicated by a substantial interindividual variability in toxicokinetics, of which metabolism is often the most important factor. Therefore, we investigated human variation and the contributions of human-CYP isoforms to in vitro metabolism of benfuracarb. The primary metabolic pathways were the initial sulfur oxidation to benfuracarb-sulfoxide and the nitrogen-sulfur bond cleavage to carbofuran (activation). The K_m, V_max, and CL_int values of carbofuran production in ten individual hepatic samples varied 7.3-, 3.4-, and 5.4-fold, respectively. CYP2C9 and CYP2C19 catalyzed benfuracarb sulphur oxidation. Carbofuran formation, representing from 79% to 98% of the total metabolism, was catalyzed predominantly by CYP3A4. The calculated relative contribution of CYP3A4 to carbofuran formation was 93%, while it was 4.4% for CYP2C9. The major contribution of CYP3A4 in benfuracarb metabolism was further substantiated by showing a strong correlation with CYP3A4-selective markers midazolam-1′-hydroxylation and omeprazole-sulfoxidation (r = 0.885 and 0.772, respectively). Carbofuran formation was highly inhibited by the CYP3A inhibitor ketoconazole. Moreover, CYP3A4 marker activities were relatively inhibited by benfuracarb. These results confirm that human CYP3A4 is the major enzyme involved in the in vitro activation of benfuracarb and that CYP3A4-catalyzed metabolism is the primary source of interindividual differences.     

Minilaparoscopy without General Anesthesia for the Diagnosis of Acute Appendicitis

The timely diagnosis of intra-abdominal pathology continues to be an elusive problem. Delays in diagnosis and therapeutic decision making are continuing dilemmas in patients who are females of childbearing age, elderly, obese or immunosuppressed. Minilaparoscopy without general anesthesia potentially can provide an accurate, cost-effective method to assist in the evaluation of patients with acute abdominal pain.Laparoscopy without general anesthesia is not a new technique, but with the combination of two emerging factors— 1) the introduction of new technology with the development of improved, smaller laparoscopes and instruments, and 2) the shifting of emphasis on healthcare to a more cost-effective managed care environment--its value and widespread utilization is being reconsidered.We report the case of a 22 year old female with an acute onset of increasing abdominal and pelvic pain. Despite evaluation by general surgery, gynecology, emergency room staff, as well as, non-invasive testing, a clear diagnosis could not be made. In view of this, minilaparoscopy without general anesthesia was performed and revealed an acute, retrocecal appendicitis. The diagnosis was made with the assistance from the conscious patient. The utilization of this technique greatly expedited the treatment of this patient. Full-sized laparoscopic equipment was then used to minimally invasively remove the diseased appendix under general anesthesia. Both procedures were well tolerated by the patient.