[ABO incompatibility in organ transplant. Report of case and review of the literature].

One case of a multiple organs donor that resulted in kidney and heart transplants with inadvertent ABO incompatibility is described. The renal recipients showed the presence of high anti A antibodies titers. The reviewed publications have revealed that the preparation of the receptor with plasmapheresis and splenectomy, before the transplantation may prevent the hyperacute rejection on ABO incompatible organs allografts. In emergency situations, liver transplantation is accepted with ABO incompatible donor without previous treatment.


[Use of recombinant human erythropoietin in the treatment of anemia in hemodialyzed patients: a multicentric study].

Recombinant human erythropoietin (rHu-EPO) therapy was given to 25 patients undergoing long-term hemodialysis, for 12 weeks, in 5 Brazilian dialysis centers. The dose of rHu-EPO was given intravenously thrice weekly, initially at 50 Units/kg/dose. If the target hemoglobin concentration (10g/dL) was not achieved by four weeks the dose was increased to 75 and 100 Units/kg/dose. After 4 weeks hemoglobin concentration had achieved 10g/dL in only one patient, and, after 8 weeks, 10 patients (40% of all cases) had hemoglobin levels higher than the target concentration. After 12 weeks, the hemoglobin increased from 7.1 +/- 1.1 to 9.6 +/- 1.2 g/dL, the target hemoglobin concentration was achieved in 15 patients (60% of all cases). There was a significant (p < 0.05) increase in hematocrit (from 22 +/- 4 to 31 +/- 4 vol%), in body weight (from 55.03 +/- 12.24 to 56.16 +/- 12.86kg), and in serum phosphorus (from 5.85 +/- 2.02 to 6.82 +/- 2.34 mg/dL). There were no significant changes in blood pressure, serum levels of creatinine, of potassium, and of transferrin. Increase in blood pressure (in 3 patients), fever (in 2 patients), increase in the heparin dose needs (in 2 cases), and vascular access thrombosis (in 1 patient) were the most important adverse effects observed during rHu-EPO therapy. Thus, the anemia of chronic renal failure may be easily corrected with adequate amounts of recombinant human erythropoietin. Attention must be paid to some adverse effects during reversal of anemia.


[Beclomethasone dipropionate, in high dose, in the treatment of patients with chronic persistent asthma].

The efficacy of inhaled beclomethasone dipropionate (BDP) was examined in 8 patients with chronic persistent asthma, uncontrolled by inhaled bronchodilators and oral theophylline. Beclomethasone was administered at a dose of 1500 mcg a day, using a metered dose inhaler containing 250 mcg of BDP per dose. The medication was administered twice daily, three 250 mcg puffs at 8 A.M. and three at 8 P.M. The patients were assessed by means of clinical examination, diary records and daily Peak Flow Rate (PFR) measurement made at home. The therapeutic responses were measured over an 8-wk period. The clinical score (0-4) improved significantly (3.25 +/- 0.71 before and 0.75 +/- 0.89 after [p < 0.001]), and the peak flow rate rose from baseline mean value of 48.0% +/- 11.9 (predicted value) to 78.8% +/- 16.7% with significant improvement (p < 0.01). Of the total of 8 patients, 5 achieved complete control of symptoms and normal values of PFR, 1 remained with sporadic wheezing but with significant improvement of PFR and 2, despite the clinical efficacy in symptom relief, persisted without significant improvement on PFR values. Transitory hoarseness occurred in 1 patient. No other side-effects were observed.


[Epidemiology of bacteremias at a university hospital].

The epidemiological aspects of bacteremias were determined in a university hospital, according to service, age, sex and place of acquisition (nosocomial or community-acquired). From August 1985 through July 1986 the incidence rate of bacteremias at the Sao Paulo Hospital was 21.7/1000 admissions. Such a high rate is probably related to the characteristics of the patients admitted to the hospital. The incidence was higher in the extremes of age and was similar in either sex. Approximately 60% of the bacteremias were nosocomial including 9.1% that were present at admission in patients transferred from other hospitals. The most frequent isolated pathogen was S. aureus. The most important source of bacteremia was the respiratory tract followed by the gastrointestinal and urinary tracts.


Dispersal in sub-Saharan baboons.

In most mammalian species, males tend to leave their natal group and disperse farther than females, while females tend to be philopatric. Primates generally follow this rule, although long-term studies of a variety of species are revealing an increasing number of exceptions. This paper reviews dispersal patterns in 3 subspecies of savanna baboons (Papio cynocephalus cynocephalus, P. cynocephalus anubis, P. cynocephalus ursinus) which exhibit very similar patterns of social organization. Males usually disperse from the natal group at 8-10 years of age. Female dispersal is rare but well documented. Inbreeding avoidance as well as enhanced mating opportunities are suggested as ultimate causes of dispersal. Several proximate factors implicated in the timing of dispersal events are also reviewed.


[The patients' perception about their illness: a pilot study].

This preliminary study aims at inquiring the patients' perceptions about their own illness process. Therefore, 19 clinical inpatients from the Hospital de Clínicas de Porto Alegre interviewed. After a qualitative data analysis, it was observed that in a medical consultation there are, at least, two perspectives concerning the illness process. First, the physician's perspective, taking into account systems and organs structural and/or functional abnormalities (disease), and second, the patient's perspective, based on her or his perception of events that occur when getting sick (illness). In addition, the patient's perspective generally presents a preoccupation with the etiology of the disease. Keeping in mind these different viewpoints, it is crucial to establish the medical-patient dialog, aiming at reaching a better relationship between the patient and her/his physician.


[Medical audit in surgery].

Recording clinic data is essential to the process of evaluation of medical proceedings but, unfortunately, it is not a common practice among us. Therefore practitioners are not able to recall all their own medical records. We must know the therapeutic results to improve preceding decisions. Is has been hard to characterize the quality of medical care because of the lack of clinic data. Medical auditorship applies itself to define philosophical questions and to determine useful values in professional and scientific fields, available to any surgeon. Establishing an auditorship is first a need, second a choice. The evaluation of successful therapy and the rates of morbidity and mortality is the minimum we can expect in the immediate future.


[Nontoxic multinodular goiter: evaluation of recurrence rate and function after partial thyroidectomy. Retrospective analysis of 39 cases].

The postoperative goiter recurrence and hypophysial-thyroid function in 39 patients who underwent partial thyroidectomy for nontoxic multinodular goiter, during the 1970-1983 period, was evaluated, seeking relations among thyroid function, extension of surgery and goiter recurrence. The incidence of recurrent goiter was approximately 15%, most of these goiters having been identified ten or more years after thyroidectomy. More extensive surgery lowered the recurrence rate but increased the risk of subclinical-hypothyroidism. No statistical significant differences with regard to serum T3, T4, F T4 and TSH (basal and after TRH) of patients with and without recurrent goiter were found. Thus, the maintenance of a recurrent nontoxic goiter does not seem to depend exclusively on increased serum TSH levels. In one patient, the postoperative treatment with thyroxine did not prevent the appearance of recurrent goiter. Since most patients who underwent thyroidectomy remain euthyroid and the goiter recurs in only a small number, the routine postoperative use of thyroid hormone for the prophylaxis of multinodular goiter recurrence seems to be questionable.


[Rheumatic manifestations of acquired immunodeficiency syndrome (AIDS)].

120 AIDS patients (mean age 33 +/- 9 years, 108 males) were evaluated regarding rheumatic manifestations. According to CDC's classification, 18.3% belonged to group II, 28.3% to group III, and 53.4% to group IV. Arthralgia was present in 33 patients (27.5%), and in only 8 could be associated with infections other than HIV (5 cases of tuberculosis, 3 P. carinii, and 1 gonococcal infection). Incidence of arthralgia was equal in either sex. Arthritis was present in 8 patients, 2 of them with Reiter's syndrome. In 6 patients arthralgia was the first symptom (3 with arthritis) before AIDS diagnosis. There was a higher incidence of dry mouth, dry eyes, and muscular complaints in patients with arthralgia than in patients without arthralgia. Antinuclear antibodies and rheumatoid factor were absent in the serum of the patients studied. Arthritic manifestations possibly occur in AIDS, even in patients without other clinical manifestations, as a reactive state to HIV infection.


[Estimation of the number of potential organ donors in the city of São Paulo].

There is a concept that the small number of transplants is due to the shortage of donors or the refusal of the next of kin to make to donation. In order to evaluate the potential number of donors in São Paulo the autopsies performed at the Forensic Medical Institute (IML) were studied during 1990 and 1991. The autopsies carried out during 1990 and 1991 were studied. During the same period we also analysed the reports of possible donors received by the organ searching team of the Escola Paulista de Medicina (EPM). During 1990 and 1991, 11601 and 11607 autopsies were respectively carried out (32 autopsies/day). The analysis of 500 autopsies during 10/90 and of 1039 during 05/91 showed that 27% had a traumatic brain injury (TBI) as the sole cause of death and 70% were cared for in a hospital. From 01/90 to 12/91 the organ searching team of the EPM received reports of 296 possible donors. Of the 296 reports, 219 families were contacted and 59% authorized the donation. Considering the number of deaths exclusively caused by TBI that passed through any hospital and the rate of donations obtained by our team, there is a number of potential donors in São Paulo sufficient to saturate the working capacity of all teams, if the seeking system is efficient.


Influence of low dose enteric-coated aspirin on platelet function.

Little is known about the effect of low dose, enteric-coated aspirin on human blood platelet function. This study was conducted to evaluate the acute effects of a single daily dose of commercially available enteric-coated aspirin on platelet biochemistry, physiology and function. Blood for these studies was obtained from drug-free volunteer donors prior to ingestion of aspirin or following ingestion, either before breakfast or following lunch. Response of platelets to the action of weak agonists was evaluated. In addition, ability of platelets to convert radiolabeled arachidonic acid to thromboxane was monitored. Results of our studies show that a single daily dose of 50 mg of aspirin taken either before breakfast or after lunch effectively prevented the secondary wave aggregation response, as well as secretion of dense body contents when stimulated by agonists such as epinephrine and ADP. Aspirin ingestion caused a dose-dependent inhibition of platelet cyclooxygenase activity as evidenced by the extent of arachidonic acid converted to thromboxane by platelets exposed to aspirin for different time periods. Based on these observations, it is suggested that low dose aspirin may be very useful and desirable to restrain platelet activity in clinical situations in which increased thromboxane formation may initiate vascular hypertension and platelet hyperactivity.


Catheter ablation of retrograde fast pathway in patients with atrioventricular nodal reentrant supraventricular tachycardia.

Atrioventricular (AV) nodal reentrant tachycardia is a common cause of supraventricular tachycardia. The present study describes catheter ablation of this form of tachycardia in 23 patients using direct current shocks. The aim of ablation was to abolish conduction through the retrograde pathway while preserving the anterograde conduction. All patients had symptomatic, drug resistant, slow-fast variety of dual atrioventricular nodal reentrant tachycardia. Using the retrograde atrial activation in the His bundle catheter as the reference, the optimal ablation site was selected by positioning an electrode catheter to obtain atrial activation synchronous with or earlier than the atrial activation at the reference electrode. Shocks of 100-300 joules were delivered at this site resulting in blockade of retrograde conduction in all patients. Ventriculo-atrial conduction studied 24 hours after the procedure was still absent in 16, modified in 2 and resumed in 3 patients. Two patients developed permanent complete heart block and were given pacemakers. At repeat electrophysiologic study performed after 2-4 months in 10 patients, the supraventricular tachycardia could not be induced. The AH interval was 67 +/- 10 msec during control study and to 115 +/- 39 msec at restudy (p < 0.001). The ventriculo-atrial conduction was absent in 7 cases and had been modified in 1 case. Over a follow up period of 1-30 months (mean 10.8 +/- 7.1 mo) 17 patients (73%) remained free of the arrhythmia without medication or pacemaker. Three other patients were easily controlled with digoxin. Thus, catheter modification of AV node results in permanent cure of the AV nodal tachycardia in majority of patients.


X-syndrome: myocardial perfusion during stress testing.

Stress T1-201 myocardial scintigraphy was carried out in 16 patients with X-syndrome. 11 patients with ischaemic heart disease (IHD) with single vessel disease served as controls. With bicycle exercise test all 16 pts with X-syndrome had various types of myocardial perfusion abnormalities. These perfusion defects were situated in the vascular beds of different coronary arteries. Myocardial perfusion defects in patients with X-syndrome were similar to those in patients with moderate, but haemodynamically significant, single vessel disease. At the same time, these perfusion defects were significantly less pronounced than those in patients with subtotal occlusion of one coronary artery. Thus, patients with X-syndrome not only have clinical features of IHD (anginal attacks), but have marked stress-induced myocardial perfusion defects.


Hemodynamic changes during dynamic exercise in patients after mitral valve replacement for chronic mitral regurgitation.

To evaluate hemodynamic changes during dynamic exercise, we investigated 13 patients after mitral valve replacement (MVR) for chronic mitral regurgitation (MR) and 5 control subjects by right heart catheterisation during supine bicycle exercise. According to the sizes of the St. Jude Medical (SJM) prosthesis during MVR, patients were divided into group A (n = 8) with SJM 31mm and group B (n = 5) with SJM 29mm. Significant rise in cardiac index (CI) was noted during exercise in both groups A and B (from 3.3 +/- 0.8 to 5.5 +/- 0.9 l/min/m2, p < 0.01 and from 3.0 +/- 0.6 to 5.6 +/- 0.6 l/min/m2, p < 0.01 respectively) and also in control subjects (from 3.4 +/- 0.7 to 6.2 +/- 0.6 l/min/m2, p < 0.01). Mean pulmonary artery and pulmonary capillary wedge pressure were significantly higher during exercise in patients of both groups A and B than control subjects (p < 0.05 and p < 0.01 respectively). Total pulmonary vascular resistance was significantly higher during exercise in both groups A and B than control subjects (p < 0.05 and p < 0.01 respectively). No difference in hemodynamics were noted between the patients of group A and B during exercise. It is concluded that response of CI to exercise in patients after MVR for chronic MR was adequate in comparison to control subjects irrespective of two different valve sizes.


Cardiac amyloidosis: hemodynamic, echocardiographic and endomyocardial biopsy studies.

Six patients with cardiac amyloidosis (four males, two females; age 27-60 years) were evaluated by us. Four patients presented with congestive heart failure, while one patient each presented with effort angina and giddiness. Extracardiac clues to the diagnosis in the form of involvement of other systems were present in only two patients. The electrocardiogram was abnormal in four patients while three exhibited roentgenographic evidence of cardiomegaly or pulmonary venous hypertension. Echocardiography suggested the diagnosis of amyloidosis in only two patients, restrictive cardiomyopathy in two other patients and dilated and hypertrophic cardiomyopathy in one patient each. Cardiac catheterisation and angiography suggested restrictive heart disease in four patients and hypertrophic cardiomyopathy in one. One patient, whose initial haemodynamic study was normal, had features of dilated cardiomyopathy at repeat study after 11 months. Endomyocardial biopsies showed amyloid deposits in all patients. We emphasise the varied clinical manifestation of cardiac amyloidosis and the need for a high index of suspicion. The diagnosis can be safely and reliably confirmed by endomyocardial biopsy.


Role of transesophageal echocardiography during balloon mitral valvuloplasty.

Transoesophageal echocardiography (TEE) was performed during balloon mitral valvuloplasty (BMV) in 40 patients of rheumatic mitral stenosis, to assess its feasibility and additional benefits. The age range was 12-35 (mean 20 +/- 6) years. Patients were in an unsedated state and the procedure was tolerated by all without any complication. High resolution images of the interatrial septum and the puncture assembly were obtained which guided the septal puncture. In eight (20%) patients, puncture assembly had to be readvanced into superior vena cava and withdrawn down to obtain a satisfactory position for puncture. In 2 additional cases, the puncture assembly was redirected towards the fossa ovalis region under TEE guidance alone to obtain a successful septal puncture. TEE was not found useful in either negotiating the mitral valve or positioning the balloon catheter across it.


Diagnosis of the sinus venosus defect by echocardiography and angiocardiography.

A retrospective analysis of forty five cases of sinus venosus defect was done to compare the ability of transthoracic echocardiography, transesophageal echocardiography and cineangiography in diagnosing this lesion. Left atrial and superior vena cava angiography delineated sinus venosus defect accurately in all the 45 cases (100%). Transthoracic cross-sectional echocardiography combined with colour flow mapping could visualize this defect in 28 out of 45 cases (62.2%) and proved inferior to transesophgeal technique which diagnosed the defect in all the 8 cases (100%) studied. An anomalous venous connection associated with sinus venosus defect was best diagnosed at cardiac catheterization although transesophgeal technique seems promising.


Plasma adenosine and cardiovascular responses to dipyridamole in fetal sheep.

The effects of dipyridamole infusion on fetal arterial plasma adenosine level, [ADO], and the systemic cardiovascular system were studied in 10 fetal sheep at 130-135 days gestational age. Dipyridamole (0.25 mg/kg) was infused into the fetuses intravenously during normoxia and hypoxia. Plasma [ADO] was measured using high-performance liquid chromatography, (HPLC), and fetal heart rate and arterial blood pressure were monitored throughout the study. These studies were performed in the absence and presence of theophylline, an adenosine receptor antagonist. During normoxia (PO2, 23.8 +/- 2.0 Torr), dipyridamole infusion increased fetal plasma [ADO] from 0.82 +/- 0.10 microM to 1.41 +/- 0.16 microM within 1 min (P < 0.01) and fetal heart rate from 157 +/- 6 bpm to 174 +/- 7 bpm (P < 0.01), but did not change mean blood pressure. Fetal plasma [ADO] and fetal heart rate returned to basal levels quickly. Treatment with theophylline did not alter the elevation of plasma [ADO] after dipyridamole infusion, but abolished responses of fetal heart rate to dipyridamole infusion. After 15 min of hypoxia with an average arterial PO2 of 15.4 +/- 1.1 Torr, fetal plasma [ADO] increased to 1.15 +/- 0.14 microM (P < 0.01). Dipyridamole infusion then further raised fetal plasma [ADO] to 1.67 +/- 0.27 microM (P < 0.01). The duration of the increase of fetal plasma [ADO] after dipyridamole infusion was no longer in hypoxia than in normoxia, however there was no significant change in the pattern of transient fetal bradycardia and persistent hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)


Developmental changes in plasma erythroid colony-stimulating activity in mice: cyclic erythropoiesis associated with rapid growth.

To establish a role of erythropoietin (Epo) in regulation of fetal and neonatal erythropoiesis, plasma erythroid colony-stimulating activity (ECSA) in developing mice was measured by an erythroid colony-forming assay using fetal mouse liver cells. The ECSA in fetal and neonatal plasmas showed dose-response curves parallel to standard Epo curve and additive effects with standard Epo on the colony formation. Most of the plasma ECSA was neutralized by an anti-Epo monoclonal antibody. These results suggest that the plasma ECSA detected by the present bioassay is predominantly due to Epo. On day 12-14 of gestation, the plasma ECSA levels were at the highest values; thereafter the levels oscillated up to the age of 4 weeks. The packed cell volume (PCV) also oscillated, but with the reverse phase. Oscillation in PCV was associated with the growth. There was an inverse relationship between plasma ECSA and PCV levels throughout the prenatal and early postnatal periods. The results indicate that erythropoiesis in fetal and neonatal mice is regulated mainly on the basis of PCV-ECSA feedback control mechanism.


Selected physiologic measures and behavior during paternal skin contact with Colombian preterm infants.

A descriptive study of eleven healthy preterm infants was conducted in which cardiorespiratory (heart and respiratory rates, oxygen saturation), thermal (abdominal, toe and tympanic temperatures) and state behavior responses to two hours of paternal skin-to-skin contact within the first 17 hours of birth in Colombia, South America were evaluated. Infant physiologic and behavioral state measures were recorded each minute as was paternal skin temperature and behavior. Infant heart and respiratory rates increased during paternal contact as did abdominal and core temperatures. Fathers were able to keep their infants sufficiently warm, and five infants became hyperthermic (tympanic temperature greater than 37.5 degrees C) despite cooling measures while being held in this climate. Infants slept most of the time while being held and fathers seldom gazed at, spoke to, or touched their infants while holding them. When mothers are unavailable, fathers may be an alternate source of warmth and comfort to infants.


Intracardiac blood flow velocities and cardiac output in normal fetuses: a prospective pulsed Doppler echocardiographic study.

Two dimensional and pulsed Doppler echocardiographic studies were performed in human fetuses with the aim to establish normal values for blood flow velocities and cardiac output in Indian subjects. Thirteen pregnant mothers were prospectively followed up at 4 weeks interval from 19 to 40 weeks of gestation. Blood flow velocity spectra across aortic, pulmonary, mitral and tricuspid valves were analyzed to obtain peak flow velocity (cm/sec) and velocity time integral. Aortic and pulmonary diameters were measured at the valve level from two dimensional echocardiographic images and ventricular stroke volume calculated. The values were plotted against fetal age (weeks) and fetal weight (gms). Our results showed that there is a linear increase of the measured Doppler data, with increasing gestational age and weight. These values may be used as a reference for the Indian population.


Collagen and elastin in rabbit fetal lung: ontogeny and effects of steroids.

Ontogeny of lung collagen and elastin were studied in fetal rabbit from day 25 to term. Collagen (isolated by hot trichloroacetic acid treatment) and elastin (contained in the residue) were hydrolyzed and the hydroxyproline and desmosine quantitated by hplc. Hydroxyproline slightly increased from day 25 to day 30 (204 to 244 micrograms/100g dry weight). Over the same period desmosine increased from 2.2 to 5.1 micrograms/100 mg dry weight (P < 0.01). The effect of antenatal corticosteroids on the lung of prematurely-delivered fetuses was also evaluated. Betamethasone (B) was given to pregnant does at a dose of 0.2 mg/kg 24 and 48 h before delivery of the fetuses at 26, 27 and 28 days. In treated animals elastin concentration increased significantly by about 22% on day 26 (P = 0.05), by 29% on day (P < 0.02) and by 47% on day 28 (P < 0.02). Hydroxyproline was not affected by steroid treatment at any gestational age. This suggests that steroids affect fetal lung development also via changes in connective tissue.


The effects of 21 or 30% O2 plus umbilical cord occlusion on fetal breathing and behavior.

We have shown previously that continuous fetal breathing can be induced by 100% O2 alone or combined with umbilical cord occlusion (Baier, Hasan, Cates, Hooper, Nowaczyk & Rigatto, 1990). To know whether it could also be induced by lower O2 concentrations plus cord occlusion, we studied 9 chronically instrumented fetal sheep (16 experiments) using our window model. After a baseline cycle [1 low voltage + 1 high voltage electrocortical activity (ECoG) epoch] the fetal lung was distended via an endotracheal tube to about 30 cm H2O. Inspired N2 (control) and 21 or 30% O2 were given for one cycle each. While on 21% or 30% O2 the umbilical cord was occluded (balloon cuff). In 10 out of 16 experiments breathing output (% maximum of integral of EMGdi x f) increased after cord occlusion from 80 +/- 48 (N2) to 2871 +/- 641 (SEM; P < 0.01); in 7 of them breathing became continuous. Arterial PO2 increased from 14 +/- 1 (N2) to 33.5 +/- 5 Torr (occlusion; P < 0.01). In the other 6 experiments breathing output decreased from 319 +/- 116 (N2) to 86 +/- 38 (occlusion; P < 0.01) and arterial PO2 changed from 18 +/- 1 (N2) to 22 +/- 5 Torr (occlusion; P = 0.4). Arterial PCO2 increased similarly after occlusion in both groups, those which did respond with increased breathing (to 46 +/- 2 Torr) and those which did not respond (to 48 +/- 3 Torr; P = 0.6). The percent low voltage ECoG and the behavioral score increased after occlusion in the responder group only.(ABSTRACT TRUNCATED AT 250 WORDS)


Ontogeny of glutamate and gamma-aminobutyric acid release in the hippocampus of the guinea pig.

The ontogeny of the L-glutamate (GLU) and gamma-aminobutyric acid (GABA) neuronal systems in the guinea pig hippocampus was investigated with respect to tissue amino acid content, and spontaneous and K(+)-stimulated release of GLU and GABA. Transverse hippocampal slices were prepared from the guinea pig fetus at day 45 (brain growth spurt), 55 and 63 of gestation (term, about 68 days), from the 5-days-old neonate, and from the young adult. GLU and GABA release was determined as efflux from hippocampal slices into Krebs'-bicarbonate medium using a dynamic, submerged, superfusion apparatus. Hippocampal GLU content decreased during development, whereas GABA content was constant for all the ages investigated. The magnitude of spontaneous GLU efflux decreased during development; there was no measurable spontaneous GABA efflux. The K+ concentration-GLU efflux response curve was bell-shaped for the fetus at the three selected gestational ages, and was curvilinear for the neonate and adult. The apparent EC75 of K(+)-stimulated GLU efflux was higher for the neonate and adult compared with the fetus. In contrast, the K+ concentration-GABA efflux response curve was curvilinear, and the apparent EC75 of K+ was similar for all the ages investigated. K(+)-stimulated efflux of GLU and GABA was Ca++ dependent, but this was not the case for spontaneous GLU efflux. These data indicate that, in the guinea pig hippocampus, the GLU neuronal system is developing throughout gestation, whereas the GABA neuronal system appears to mature before the brain growth spurt.


[Interactions between propranolol, isosorbide and nitroglycerin].

We studied interactions between propranolol and nitrates, used in subjects with stable angina pectoris on effort. Basal pharmacokinetic indexes were estimated on measured levels of propranolol concentration. It was found, that nitrates used with propranolol at the same time decrease its concentration in serum and bioavailability, and increase propranolol clearance calculated for whole body, its distribution volume and shorten propranolol life half-time in the blood serum.


[Concentrations of trace metals in Ariopsis bonillai (Pisces: Siluriformes) of Santa Marta, Colombian Caribe].

To determine changes in the contents of some heavy metals (Cd, Zn, Cu) in the fish Ariopsis bonillai, at Ciénaga Grande de Santa Marta, Colombia, monthly samples were taken between July 1987 and June 1988. The highest concentrations in the muscle appear between November and February (4.24 micrograms Cd/g, 109.4 micrograms Zn/g and 13.3 micrograms Cu/g), during the periods of lower salinity, at the end of the rainy season, and at the beginning of the dry season. Metals were measured also in the liver: values for Zn and Cu were ten times higher than in the muscle. About the first half of the year, the values tend to be similar. Cd differences were not as strong as for the other metals.


Characterization of a proteolytic enzyme from Lachesis muta venom (Serpentes: Viperidae).

A proteolytic enzyme from L. muta stenophrys was isolated by gel filtration on Bio Gel P-100 followed by FPLC on MONO S column. The enzyme exhibited proteolytic activity toward casein, hemoglobin and fibrinogen with a pH optimum around 10. The activity was inhibited by EDTA while trypsin inhibitors were not inhibitory. It is a glycoprotein, Mr 14 kDa with a high content of Asp, Glu, and Leu residues and a low content of Cys and Trp. The protease is devoid of myotoxic, hemorrhagic, esterolytic and amidolytic activities. It lyses the alfa and beta chains of human fibrinogen and releases kinin from L.M.W. kininogen. No release of histamine was observed upon incubation with mast cells.


[Isolation of Vibrio cholerae no-01 in the Gulf of Nicoya, Costa Rica].

In a bacteriological study on samples of bivalves, mud and surface waters from the Gulf of Nicoya, Costa Rica, 18 strains of non-01 Vibrio cholerae and 50 of V. mimicus were isolated. The samples were enriched in alkaline peptone water, and streaked on MacConkey and inositol-brilliant green bile agars. Biochemical and serological tests were used for their identification. Both species were isolated from all sampling sites (Lepanto, Jicaral and Puntarenas) with either of the two agar media, even though these were not specific for vibrios.


[Ultrastructure of mucous cells from the oviduct epithelium of the rabbit (Lepus cuniculus). Preliminary study].

Authors studied the ultrastructural features of the mucous cells present in the three segments of the rabbit oviduct in anoestrous. Results showed that only one kind of mucous cell was present in the isthmus while two different kinds of mucous cells were found in the ampulla and infundibulum. The ultrastructural features observed in the isthmic cells correlated well with the histochemical data already described in that segment. However such correlations could not be made between the ampulla and infundibulum. Authors suggest that the ampulla can be considered a transitional segment between isthmus and infundibulum.


[Number and thickness of myelinic fibres of the phrenic nerve of young and aged rats].

The phrenic nerve of albino rats was studied for age changes in number of fibres, myelin sheath thickness and axon calibre. There is no significant morphological differences between nerves from young and aged rats and no difference with age was found in the number of fibres, myelin sheath thickness and axon calibre.


Normal host defenses and impairments associated with the delayed resolution of pneumonia.

The lung is constantly exposed to infectious challenges and depends on a complex system of defense mechanisms to facilitate the clearance of pathogens and prevent the development of infection. Both the upper airway and lower respiratory tract have mechanical, humoral, and cellular mechanisms in place to protect the airways from diverse microorganisms. Impairment in any arm of this system can result in the predisposition of the host to respiratory infections, which may be of a recurrent nature. Defects may be congenital or acquired, and may be iatrogenic in the hospitalized patient. An understanding of these defects may lead to more effective therapies and preventive modalities for decreasing the number and severity of respiratory infections.


Normal resolution of community-acquired pneumonia.

Resolution of pneumonia has to be considered as two different phases: resolution of the acute illness and resolution of radiographic opacities. Age, comorbidities, immunosuppression, and etiological agent(s) are all important in determining whether the acute illness resolves; there is a considerable mortality rate from pneumonia requiring hospitalization. The major concern when there is slow radiographic resolution of pneumonia is the possibility of an underlying malignancy. In 96% of patients whose pneumonia has not resolved in 30 days, an underlying disease is found; emphysema, chronic bronchitis, or bronchogenic carcinoma are the most common. Normal resolution of community-acquired pneumonia has to be defined in terms of the severity of the illness, comorbidity (ies), and infecting pathogen(s).


Chronic and recurrent pneumonia.

Recurrent pneumonia is defined as two or (usually) more separate episodes of lower respiratory tract infection that generally are accompanied by fever, leucocytosis, and purulent sputum production. These episodes are separated by an asymptomatic interval of at least 1 month or clearing of the chest visible by radiograph. Clinical improvement and radiological clearing should result after appropriate antimicrobial therapy. Chronic pneumonia is an illness that lasts at least 6 weeks and is caused by a microorganism. The chest radiograph usually shows diffuse or focal shadows. The incidence of either chronic or recurrent chest infections is unknown. Neither condition is common, but when present, they frequently present a difficult diagnostic challenge. Chronic pneumonias are usually caused by slow-growing organisms, such as fungi or mycobacteria. Occasionally, chronic pneumonias cannot be diagnosed, even when lung biopsy specimens are cultured or studied histopathologically. When a patient presents with recurrent pulmonary parenchymal infections, the clinician needs to identify the likely etiologies. Possible etiologies are structural abnormalities, underlying medical conditions, and immunological abnormalities, including infection by the human immunodeficiency virus (HIV).


Atlanto-axial dislocation in children.

The authors present 14 cases of C1 C2 dislocations in children (8 boys and 6 girls; mean age, 6.9 years) seen at the Orthopedics and Traumatology Institute of the University Hospital, Faculty of Medicine, University of São Paulo from 1978 to 1990. In view of the disappointing results obtained by conservative treatment in 6 of the 14 patients, the authors recommend early atlanto-axial arthrodesis in cases of C1 C2 dislocation in children.


Study of anatomical bases of a latero-dorsal flap of the forearm preserving the radial artery.

The authors studied the dorso-lateral cutaneous branches of the radial artery in 26 forearms of fresh cadavers following injection of latex. Three to eight branches were identified, with frequent anastomoses. Extensive venous drainage was also observed. One to three cutaneous branches arose within a 3-cm region close to the radial styloid precess. This provides a basis for an island flap supplied by these branches and thus, it is possible to maintain the radial artery intact.


Isolated vertebral blocks in the cervical spine.

The author presents a review of seven cases with isolated vertebral block of the cervical spine, studied in 1980 in order to verify if the etiology was congenital or acquired. This kind of bony alteration of the spine confused in the literature with Klippel-Feil's syndrome, which is a congenital constellation of bone alterations. The author concludes that, even in two cases with a diagnosis of rheumatoid arthritis, the vertebral block probably was not related to the inflammatory pathology. For one case of severe rheumatoid arthritis, it is proposed that the congenital block may have been present before the onset of the inflammatory disease. The cervical vertebral block can be considered to be an asymptomatic radiological finding.


Finger replantation.

The objective of this study was to determine the influence of the following factors on the survival rate of replanted digits: patient's age, type and level of amputation, time of ischemia, number of arteries and veins anastomosed and type of vascular repair. A total of 60 digits were replanted by the author from 1980 to 1990. The results showed no significant correlation between the survival rate and the factors studied. However, the surgeon's experience played an important role in the survival rate of replanted digits.


Sex variation at the time of sonographic appearance of the proximal tibial epiphyseal ossification center.

The time of sonographic appearance of the proximal tibial epiphyseal ossification center and its sexual variation was assessed in 659 normal pregnancies. Proximal tibial center appears between 34-37 weeks gestation. In female fetuses, it appears between 34-35 weeks and in males, between 35-36 weeks (P < 0.001). There was a tendency of female proximal tibial center appearance to precede male appearance, by approximately one week. This difference, however, didn't show statistical significance.


Splenic viability after segmental devascularization.

The terminal vascular architecture is related to the segmental pattern of this organ. However, several interlobar vascular anastomoses communicate the spleen parts. In order to verify the efficacy of those anastomoses, the present work studied experimentally the viability of the spleen after selective external devascularization, in rats and dogs. All animals developed segmental necroses and eventual abscesses limited to the devascularized portion of the organ. These results demonstrate that the intraparenchymatous anastomoses do not maintain the viability of externally devascularized regions of the spleen. The data presented in this paper are worth to be considered in therapeutic conservative splenectomies.


[The relationship between the fluoride level in the jaw and the metabolic activity of the "supporting skeleton"].

Experiments with 118 rats revealed a reduction of fluorine levels in the jaw and the symmetrical femoral bone in reduced metabolism due to hypodynamia, elevated metabolism due to femoral bone injury, and in combination exposure. These findings should be borne in mind when prescribing fluorine.


Utilization of cytogenetic technics in paternity investigation.

The joint analysis of several genetic markers in cases of paternity investigation renders possible a cumulative probability of 99.7% of chance of exclusion of a falsely accused father. The role of heteromorphisms of the Y chromosome size was appraised in this work, with more than one genetic marker, in 20 expertise examinations in paternity investigation, where the children were male. The results found with this method, in association with the research on erythrocytic and leucocytic antigens showed the exclusion of two falsely accused men. Cytogenetics analysis with Giemsa stain in combination with leukocyte (HLA system) and erythrocyte antigens investigation demonstrated the exclusion of two men falsely accused.


Heart murmur in pediatrics: innocent or pathologic?

In a sample of 256 children referred to the São Paulo Hospital for consultation because of heart murmurs the incidence of innocent murmur was 41%. A clinical history and physical examination was performed in every child. The diagnosis was confirmed without the use of laboratory tests in only 5.5% of the cases: 32% of the children were submitted to chest x-ray and electrocardiogram; an echocardiogram had to be performed in 61% of the children and in 1.1% the catheterism was necessary to make the diagnosis. In the great majority of children with high suspicion of innocent murmur a good history and physical examination will suffice to confirm the diagnosis. If heart disease is suspected, laboratory tests should be performed for further evaluation. Any physician should be able to distinguish between pathologic and innocent murmurs based on their clinic features. The authors present a short review about the subject.


Common variable immunodeficiency: a clinical and laboratory evaluation of 15 cases.

The clinical and laboratory data for 15 patients with common variable immunodeficiency (CVI) (5 females and 10 males aged 3 years and 6 months to 40 years at first examination) were evaluated. The age of onset of infectious signs and symptoms ranged from 6 months to 35 years. Recurrent pulmonary infections predominated (86.6%), followed by chronic diarrhea (46.6%). Approximately 60% of the patients with pulmonary complaints presented chronic sequelae (bronchiectasis). Two developed a polymyositis-like picture. No neoplasms were observed. All patients presented immunoglobulin levels below 300 mg/dl and absence of antibody responses to poliovirus and to hemagglutinin. Two patients were negative when tested for autoimmunity. Cell immunity tested by the lymphoproliferative response in the presence of phytohemagglutinin was normal in 11 patients and depressed in 4. A decrease in the helper T population and inversion of the OKT4/8 ratio occurred in 13. Cimetidine treatment (1200 mg/day) applied to 5 patients for 4 weeks did not produce any clinical or laboratory improvement. Gamma globulin is the treatment of choice for these patients.


Study of the inclination of the joint line in supracondylar osteotomy of the femur for valgus deformity.

The inclination of the joint line after supracondylar osteotomy of the femur for valgus deformity was studied in 22 patients and 26 knees. The patients (4 males and 18 females) were 17 to 77 years old (mean, 49.5 years). The obliquity of the joint line was measured in positive degrees (medial inclination) and negative degrees (lateral inclination). Mean obliquity was +3.1 degrees in the preoperative study and -2.0 degrees in the post-operative study. Significant horizontality of the joint line was obtained when the two periods were compared (mean, 5.0 degrees).


[The determination of human mandibular deformations by using optical holography].

A scheme of holographic investigation in counter-current bundles was used to study mandibular deformations in functional exercise. He-Ne laser LGN-215, generating was used as a source of light. To record the holographic interferograms, high-resolution plates of the PFG-03 type were employed, fixed directly on the object. The findings evidence that in contractions of the anterior and posterior masticatory muscles the mandible is exposed to deformation in the horizontal and frontal planes, most marked near the teeth and alveolar process. The deformation near the angle is more marked than in the chin area.


[Mycobacteria in the development of periodontal foci of infection].

A total of 162 samples of material from the periodontal foci of infection were examined microbiologically and morphologically to detect mycobacteria and their biologically changed variants. The regularities of the pathologic process development in periodontal tissues of subjects without tuberculosis were found to fully conform to the current concept of a latent tuberculous infection. The periodontal foci of infection may be regarded as reservoirs of persistent mycobacteria, whose main form, L variant, was detected in 71.6% of cases. Clinical and morphologic manifestations of periodontitis depend on the stability of the persistent mycobacteria L forms.


[Morphological changes in the tissues of the prosthetic field with the use of different designs of metal ceramic bridge dentures].

The results of experimental morphologic studies carried out in 23 dogs evidence that the status of the denture bed tissue beneath a whole-cast bridge cermet denture depends on the tightness of the denture adhesion to the gingival mucosa. If the denture poorly adheres to its bed, no marked changes in the structural components of the gingiva and the underlying bone support are detectable. If the denture adheres tightly to the gingiva, marked inflammatory dystrophic and destructive changes develop both in the gingiva and in the alveolar crest bone tissue. A complex of structural changes in the epithelium, connective tissue base of the gingival mucosa, and alveolar bone crest were traced. The results evidence that inflammatory dystrophic changes in the gingiva augment and result in the development of erosive ulcerative elements in the gingiva in case of a prolonged tight adhesion of the denture to the denture bed; sometimes decubital ulcers may develop in the gingiva. The resorptive processes take place in the underlying bone tissue, causing like smooth resorption of bone matter or to lacunar resorption. Diffuse rarification of bone tissue is also typical of such cases. Excessive pressure of the denture body in case of its tight adhering to denture bed seems to be detrimental not only for the epithelium, but for deeper structures of the gingival mucosa and the underlying bone structures as well.


[Changes in dentin permeability for microorganisms during caries treatment].

Effects of a number of chemicals and of the time elapsed since the preparation on dentine permeability for microorganisms were under study. Dentine permeability was found the highest immediately after the preparation and after acid treatment. Potassium oxalate and calcium hydroxide reduced dentine permeability.


[The laser therapy and laser acupunture of patients with chronic recurrent aphthous stomatitis].

Laser therapy and laser acupuncture of the biologically active sites were administered to 24 patients with chronic recurrent aphthous stomatitis. The biologically active sites were selected individually with due consideration for the underlying somatic condition. Good results were achieved in the patients with the fibrous form of chronic aphthous stomatitis. Secretory and serum immunoglobulin levels were monitored over the course of laser treatment.


[The efficacy of preparations with antioxidant action in the combined treatment of phlegmons of the maxillofacial area].

The efficacy of hexamethylene tetramine (urotropin) was studied in 62 patients with maxillofacial phlegmons. The resultant good effect is explained by the pathogenetic action of the drug. The antiinflammatory effect of urotropin may be explained, on the one hand, by its known antiseptic effect, and, on the other hand, by its membrane-protective effect on the cellular elements, this creating the optimal conditions for the wound reparation.


[The therapy of inflammatory diseases of the maxillofacial area with the use of imidazole derivatives].

Qualitative and quantitative composition of associations of the agents of odontogenic infection were studied making use of present-day bacteriologic methods and of analysis of the microflora sensitivity to trichopol and nitazole, imidazole derivatives. The microflora was found to be represented by associations with the predominance of obligate and facultative anaerobes. The anaerobes were found highly sensitive to trichopol, both in vivo and in vitro, and even more so to nitazole, the drug manufactured in this country.


[The kinin system indices in the blood of patients with phlegmons of the maxillofacial area].

Blood plasma initial protamine-splitting activity, levels of prekallikrein, fast and slow kallikrein inhibitors were measured in patients with maxillofacial phlegmons making use of K. N. Veremeenko's method. All these parameters were found changed in the patients on the day of their hospitalization; on days 5-7 of treatment a trend to their normalization was observed, the differences between these values in the patients and normal controls becoming insignificant. The kinin system activation reflected the severity of the patients' condition.


[The extracorporeal connection of a donor spleen in the treatment of suppurative diseases of the face and neck complicated by sepsis].

Analyzes the results of extracorporeal connection of donor spleen in 9 patients with purulent diseases of the face and neck, complicated with sepsis. Presents the indications for the use of this treatment modality and its technique. Describes the changes in the clinical picture and time course of the basic homeostasis parameters over the course of therapy. Reduction of mortality rates to make them as low as 12.5% demonstrates a high efficacy of the suggested treatment as part of multiple-modality complex used in the treatment of odontogenic and surgical sepsis.


[Phosphorus-potassium metabolism in puerperae with late toxicosis and its correlation with the status of the maxillodental system].

A deficiency of mineral components in the breast milk and saliva and shifts in the protein, carbohydrate, and lipid metabolism are observed in puerperae with a history of late gestosis; this fact tells negatively on the maxillodental system of the mother and her baby.


[The incidence and dynamics of the development of alveolitis over the course of a year].

Analysis of the results of 8019 operations for removal of teeth, carried out within 5 years by one physician under the same conditions, has shown that alveolitis developed in 1.87 +/- 0.15% of cases, on an average. The risk of alveolitis was found the highest from December to March and the lowest from June to September, as evidenced by estimation of the index of the seasonal fluctuations in the morbidity (a total of 120 to 140 teeth were removed within a month, on an average).


[The x-ray picture of chronic odontogenic osteomyelitis of the mandible in adults in the past and today].

Analysis of mandibular roentgenograms of 286 patients with odontogenic osteomyelitis has lead the authors to a conclusion on the predominance of diffuse forms of the condition with marked sequestration in the 30's and 40's. Currently hyperplastic osteomyelitis occurs in 12% of cases.


[The results of the surgical treatment of fractures of the mandibular condyle in children].

The results of surgical treatment of fractures of the mandibular condyle are analyzed in 36 children (39 surgeries) aged 3 to 17; 33 of the operations were carried out in fractures complicated with the dislocation of the condylar head. Reposition and osteosynthesis of the fragments were carried out in 17 cases, replantation of the condyle in 10, and arthroplasty of the temporomandibular joint in 12 patients. Good late anatomico-functional and esthetic results were achieved in 84.6% of cases; this is explained by a differentiated approach to the choice of surgical strategy, an effective system of rehabilitation measures, including early exercise, orthodontic treatment, and low-frequency electromyostimulation.


[Vasodilator preparations in the combined treatment of mandibular fractures with disordered regional hemodynamics].

A total of 130 patients with mandibular fractures of various sites were observed. One group of these patients were administered routine treatment, the other group patients were administered drugs improving the local circulation along with the physical modalities. Local circulation normalized two times sooner in this latter group, which fact accelerated the reparative processes and the treatment resulted in a sooner coalition of bone fragments and recovery of the working ability and functional parameters.


[Mobilization of the facial nerve in surgical interventions in the parotid-maxillary area (the topographic anatomical validation)].

A method for facial nerve mobilization is suggested, developed on cranial preparations of adult subjects. The authors have distinguished characteristic topographic and anatomic regularities that are essential in surgery of the mastoid process and parotid-masticatory area for tumor or nontumorous involvement of the parotid gland in case of the facial nerve involvement in the process.


[Age-related changes in the secretory function of the salivary glands].

A total of 326 healthy subjects aged 21 to 80 were examined. Total sialometry without stimulation and that stimulated with supermint chewing gum was carried out. Mixed salivary secretion in health was found to make up approximately 3.4 ml in 10 min. Salivary secretion stimulation with the chewing gum enhanced this secretion 1.5-3 times. Salivary secretion was found to decrease with age. The maximal secretion levels were found in both men and women aged 21 to 30, being higher in men. Normal values of mixed salivary secretion of men and women can be estimated according to the following formulae: for men it is equal to [-0.09(X-25) +5.71] ml, for women to [-0.06(X-25) +4.22] ml, where X is the subject's age in years.


[The need and possibility for disinfecting impressions in orthodontics (a review of the literature)].

Reviews the data on a high risk of viral and bacterial infection of dentists in connection with the high prevalence of AIDS and viral hepatitis B and on the possibility of infection of dental patients and the staff by microorganisms transfer on the impressions. Presents the present-day methods and means for disinfection of the impression material. Emphasizes inadequate knowledge of the dentists about the virucidal efficacy and the possibility of the impressions changing their properties in disinfection, which fact results in inaccuracy of the ready articles.


[The distal transposition of the premolars and molars in the adult maxilla].

Clinical examinations of 100 patients and analysis of the diagnostic models of their jaws and teleroentgenograms of the head profiles (a total of 63 parameters were analyzed in 73 subjects) have revealed that distal transposition of the maxillary lateral teeth is indicated in their unilateral mesial transposition. There should be enough space for the teeth on the other side of the jaw in this case, and the median line between the central incisors should not be displaced from the center. An apparatus to carry out such transposition is suggested. The teeth were moved as far as 2 to 7.5 mm within 2.5-7.5 months. The late results are good.


[The self-regulation of maxillodental anomalies in preschoolers and schoolchildren].

The authors analyze the data that characterize the incidence and peaks of autoregulation of maxillodental abnormalities in 535 children aged 2 to 16. Autoregulation of deep occlusion was found to occur at the age of 4-7, of prognathic occlusion at 2-5, of the cross occlusion and of abnormalities of the position of individual teeth at the age of 7-10.


[The indications for the surgical treatment of chronic periodontitis of the permanent teeth in children and adolescents of different health groups].

Chronic granulating and granulomatous periodontitis of 250 permanent teeth was treated in children and adolescents aged 7 to 17, surgery had to be resorted to in 44 (18%) cases. Three groups of indications for radical treatment of chronic periodontitis in children were distinguished: difficulties in or impossibility of conservative treatment, inefficacy of conservative treatment, and somatic indications. The conservative and surgical methods together are most often indicated for patients in whom the adverse conditions of treatment (the first group of indications) are associated with an aggravated somatic status. Radical methods of treatment helped attain bone tissue recovery sooner (in 5-6 months) than after conservative therapy alone (in 8-9 months) and completely liquidate chronic foci of odontogenic infection.


[The possibilities for the objective assessment of the color of dental materials on the Quartz-4-type spectrophotometer].

The authors analyzed the possibility of using the Quartz 4 type acoustic-optic spectrophotometer to identify the shades of stomatologic materials. Analysis of spectral aperture coefficient curves was carried out for 10 shades of plastics used to make permanent dentures Sinma-M. The authors came to the conclusion on the usefulness of such method of identification of the stomatologic material shades and even of the intermediate gradations of these shades. Using this method, it is possible to control the material surface color homogeneity.


[The clinico-laboratory characteristics of the hard dental tissues in children born to multiparous women].

A total of 900 children aged 3, 6, and 12 were examined. The findings evidence a lowered rate of salivary secretion and salivary levels of Ca and P, as well as a lower solubility of enamel for Ca and P in the children born fifth-eight. The incidence of dental hypoplasia and caries in these children was higher than in those born second in the family. Pregnancy aggravations (anemia, gestosis, etc.) in women who had had multiple deliveries and frequent diseases of their infants are the factors conducive to the reduction of dental resistance to caries and hypoplasia. The children born after multiple deliveries of their mothers should be referred to a risk group, and they should be observed by dentists and pediatricians since infancy. In regions with low fluorine levels in potable water antenatal caries prevention with fluorine preparations should be carried out. The program of comprehensive prevention of dental diseases should comprise both medical and social aspects.


[Mini-forum: rhinoplasty by external approach. Collumello-trans-alar approach of open rhinoplasty: advantages].

For several years, the authors have been using a columellar transalar incision through the medial crus along the nasal septum, reaching the vault and continued laterally by a transalar cartilaginous incision. The nasal tip is thus opened like a car-hood, leaving the alar cartilage attached to the skin and exposing the triangular cartilage and the nasal septum. This approach allows septoplasty to be performed with excellent exposure. The tip is easily revised backwards allowing anomalies to be viewed directly. The advantages of this external approach compared with the classical external Rethi's approach are multiple: simplicity and rapidity of the technique, excellent access to triangular cartilages and the triangular-septum junction; possibility of always going from an endonasal approach to an external one and excellent access to the tip. Moreover, there is no long term swelling of the tip. The indications of this external approach are asymmetry of the tip, excessive tip projection, saddle nose deformities and secondary rhinoplasties. No complication has been observed in a series of 32 patients with a follow-up of 6 to 48 months. There is no disturbance of the tip position and the skin scar is imperceptible.


[Masticatory function in children in the early periods of the development of the bite].

The authors suggest a test for accurate assessment of the masticatory function in subjects of various age groups. The results may be used as reference values in assessment of the function of the masticatory system in patients with various dental diseases.


[Miniforum: rhinoplasty by external approach. Technical aspects of rhinoplasty by external approach].

The authors present the principle techniques of external transcolumellar rhinoplasty and stress the excellent exposure it provides, allowing effective treatment under direct vision of the anatomical structures of the nose tip, nasal spine and septum. Based on a series of 186 operated cases with a follow-up of between one and more than six years, the advantages and indications of this technique are briefly defined. The best indications are difficult nose tips, whether rhinoplasty is primary or, more particularly, when it is secondary.


[Mini-forum: rhinoplasty by external approach. External or endonasal approach for rhinoplasty?].

There appears to be a renewed interests in the external approach to rhinoplasty, first described 60 years ago, despite the external columellar incision, due to the excellent exposure of the cartilaginous structures provided by this approach. Progress has been made in rhinoplasty. Cartilage grafts are much more widely used than in the past and surgeons try to reconstruct a normal anatomy of the skeleton, which has become easier with this approach. However, the closed approach has demonstrated its efficacy for a long time and allows correction of a large range of deformities. The open rhinoplasty should not be the standard procedure and its indications should only be based on limitations of the closed approach. The external procedure is particularly indicated in some difficult cases of nasal tip surgery and secondary rhinoplasty.


[An analysis of dental morbidity based on patient visits].

The present-day system for assessment of the activities of dental clinics does not reflect their efficacy, for it does not take into consideration the population disease incidence and changes in this parameter. The author suggests that the incidence of dental diseases be assessed from the records of consultations at health institutions, as exemplified by a random sample of 2515 primary consultations at dental clinics. The cause of the consultation was classified in accordance with the International Disease Classification, 9th Revision. The author claims that such mode of assessment of the physicians' and clinics' work efficacy, will improve the quality of the diagnosis.


[Orbicularis oculi muscle and crow's feet. Pathogenesis and surgical approach].

Crow's feet is one of the characteristic signs of the aging face. Minor techniques designed to obliterate these lesions rapidly demonstrate their limits. The orbital fibers of the orbicularis oculi muscle play a fundamental role in the pathogenesis of wrinkles. Their contracture will create wrinkles in a similar way to the spokes of a wheel perpendicularly to the orientation of the muscle fibers. The dynamic action of the zygomatic muscles contributes to exaggerate these wrinkles. Statically, ptosis of the lateral brow and the aging skin also contributes to these lesions. Surgical treatment can be accomplished by a temporal lift or via a blepharoplasty approach. The vertical fibers of the orbicularis oculi muscle must be corrected by muscle incision or resection, muscle incision and suspension, muscle redraping and fixation, covering of the orbicularis oculi muscle with the malar SMAS. In patients with ptosis of the tail of the eyebrow one must either do a forehead lift or a mask-lift that will redrape the skin. The surface of the skin may require peeling by dermabrasion. Of course, these surgical techniques require a detailed knowledge of the anatomy of this region and especially the distribution of the branches of the facial nerve. The author analyses and compares the results of the different techniques.


[Preservation of the hairline in cervicofacial lift by double temporal and retroauricular rotation flap].

The author details in this paper the techniques he uses to limit the sequelae of face lifts in terms of hair displacement. A temporal rotation flap to avoid hair elevation in the preauricular area, with resection of a de-epithelialized triangle and an L flap in the retroauricular area to reconstruct the hairline continuity.


[Use of the free latissimus dorsi flap in the reconstruction of extensive orbital exenterations].

The authors present the use of a free latissimus dorsi myocutaneous flap for closure of large orbital exenterations. Five cases illustrate different tumor involvements and coverage possibilities. Several technical details are studied. The vascular anastomoses are performed on cervical vessels: external carotid artery internal jugular vein. The latissimus dorsi myocutaneous flap is particularly suited for reconstruction of large facial soft tissue defects around the orbit when obliteration of the orbital cavity and restoration of deficient facial skin are necessary with correct morphological results.


[Effect of inadequate filling of deflation of inflatable breast prostheses. Statistical study of 535 inflatable prostheses].

This study was based on a series of 535 inflatable prostheses used for breast reconstruction or augmentation with a mean follow-up of 5.15 years. The authors specifically analysed the statistical correlation between underinflation and deflation due to late rupture. They demonstrated a statistically significant difference between the initial filling of the prostheses which subsequently deflated and the initial filling of all prostheses of the series. The mean filling of prostheses which subsequently deflated was 89% while the mean filling of all prosthesis in the series was 100%. The various pathologies are analysed according to the cosmetic or reconstructive indications. The two series, cosmetic and reconstructive, were homogeneous in terms of filling volume and deflation; the only difference concerned the age distribution. Patients undergoing breast reconstruction with a prosthesis were older than patients undergoing augmentation surgery for small breasts. The authors discuss the advantages and disadvantages of this type of prosthesis.


[Immediate breast reconstruction by musculocutaneous flap].

Immediate breast reconstruction (IBR) after mastectomy is now quite frequent. To achieve this, an implant, in a complete muscular pocket, or a myocutaneous flap (latissimus dorsi, TRAM flap) can be chosen. Since 1983, 49 immediate breast reconstructions (11% of IBR) were performed with a myocutaneous flap in the Gustave Roussy Institute. In our experience, these techniques were principally performed because of the failure of conservative treatment (70%). Immediate complications were more frequently observed after immediate breast reconstructions with a TRAM flap (partial or minimal flap necrosis: 33%, infection: 13.5%). Late complications were more frequent in reconstructions with a latissimus dorsi flap: the prostheses were the main reasons (contracture III/IV: 25%, infection: 18%, deflation of the implant: 12%). The best long term results were described with the TRAM flap, and we now prefer this technique for immediate reconstruction with a flap.


[Partial subfascial abdominoplasty. Our technique apropos of 36 cases].

With the help of a liposuction performed behind the abdominal superficial fascia, followed by a dissection first located at the deep side of this fascia, then changing plane to the level of the umbilicus to reach the premuscle fascia plane, a new abdominoplasty is performed, that ensures safer vascularisation of skin and fat as well as better preservation of the lymphatic system. In our experience (March 1989, 36 cases), this technique avoids the most frequent risk of the abdominoplasty: seroma.


[Reconstruction of distal loss of substance in the nail-bed by a de-epithelialized flap from the digital pulp].

Twelve patients, presenting with traumatic avulsion of the distal nail bed, repaired by a de-epithelialized palmar advancement flap, were reviewed with an average follow-up of 23 months. Subjective results were considered excellent in two cases, good in seven, fair in two and poor in one patient. Nail adherence with the de-epithelialized flap was observed over almost 90% of the new nail bed. Nail dystrophy was observed in three patients, but was severe in only one. Two patients had slight curvature of their nail, while one had a severe hook-nail deformity. Mobility in the finger was always complete, and only one patient had a slightly decreased two-point discrimination on the flap.


[Value of a free osteocutaneous flap from the second metatarsal bone in the management of substance loss in the forearm, caused by gunshot wounds. Apropos of an experience in 28 cases].

The authors report their experience of the secondary treatment of forearm defects secondary to gunshot injuries. The lesions encountered involved both soft tissues and bone. After using classical techniques consisting of fibula or iliac crest osteocutaneous free flaps, they used, whenever possible, a second metatarsal osteocutaneous free flap, which enabled them to conduct a comparative study of these different procedures and they concluded on the superiority of this latter type of flap. Their experience is based on 28 cases, including 16 cases of second metatarsal osteocutaneous free flap.


[Choice of technique in covering an excision of neoplastic tissue in the inguinal area].

Cancer surgery of the groin may lead to large skin resection with exposure of the femoral vessels. A reliable coverage technique must be chosen to enable this kind of surgery. Six patients were operated on, and ten flaps were used (3 omentum - 3 rectus abdominis - 1 fascia lata - 1 gracilis - 2 latissimus dorsi free flaps). In the light of our results, omentum must be used when laparotomy is associated with inguinal resection and omentum is available. In the other cases, resection size could prohibit the use of local flaps and a contralateral rectus abdominis flap is chosen which allows coverage of the inguinal area down to the middle third of the thigh.


[Goyrand J.G.B (1803-1866), surgeon and academician from Aix en Provence].

The authors present Jean-Gaspard-Blaise Goyrand, from Aix, who is not simply remembered for his description of the wrist fracture which has retained his name. His theses concerning permanent retraction of the fingers, presented to the Royal Academy of Medicine in 1833 and 1834, were contrary to those proposed by Dupuytren and proved to be  completely accurate. All of Goyrand's work was edited by Masson in 1870, including a superb case report of giant elephantiasis of the penis and scrotum, a study on cleft lip and the technique of using collodion bands to close large wounds [corrected].


[Experimental models of torsades de pointes].

Several experimental models of torsades de pointes have been proposed these last years. They can be classified in 2 categories: morphological models designed to reproduce the ECG features of "torsade", with in vivo ventricular stimulations or with computer ECG stimulations and pharmacological models designed to obtain in vivo early after depolarizations, with toxic agents such as cesium chloride and anthopleurine, or with commercialized or new pharmaceutical drugs. These models improved electrophysiologic and pharmacologic knowledge of torsades de pointes. The respective roles of early after depolarizations in torsades initiation and of reentry in the following beats of the salvos is now recognized. Induction protocols were described, which appeared to involve an inotropic potentiation following burst or repetitive extrastimuli. A more accurate evaluation of arrhythmogenic risk associated with new drugs could be developed.


[Clinical aspects of polymorphic ventricular tachycardia].

Polymorphic ventricular tachycardia is defined as constant change of the QRS morphology. The diagnosis has important etiological, therapeutic and prognostic implications. This term covers several different entities which may be artificially distinguished by the electrocardiographic appearances during tachycardia, by changes of the resting electrocardiogramme, the mode of onset, the presence or absence of underlying cardiac disease and of intercurrent drug therapy. However, as the resting ECG may not be available in an emergency situation, or difficult to interpret, the clinical context is the key to diagnosis and treatment. Polymorphic ventricular tachycardia is classified according to the absence or presence of underlying cardiac disease respectively as torsades de pointe with long QT, torsades de pointe with a short coupling interval and catecholamine-induced ventricular tachycardia of childhood on the one hand, and, iatrogenic torsades de pointe, ventricular tachycardia in acute or chronic infarction and other cardiac diseases, on the other hand. Finally, the authors discuss the problem of polymorphic ventricular tachycardia induced by programmed ventricular stimulation.


Arrhythmia and hypertrophic cardiomyopathy.

Atrial fibrillation is the commonest arrhythmia observed in hypertrophic cardiomyopathy, and is associated with an acute deterioration in symptoms. Digoxin is the drug of choice in established atrial fibrillation and amiodarone the drug of choice in paroxysmal atrial fibrillation and ventricular arrhythmia. Non-sustained ventricular tachycardia occurs in 20% of patients and is the single best predictor of sudden death in adults. Sustained monomorphic ventricular tachycardia occurs only rarely. The mechanism of sudden death is likely to involve initiating factors such as arrhythmia and peripheral autonomic dysfunction causing haemodynamic instability and myocardial ischaemia. Myocardial disarray may provide the arrhythmogenic substrate such that haemodynamic instability and ischaemia results in ventricular fibrillation and sudden death.


[Sinus variability: value of rhythmology].

The study of heart rate variability is a mean of assessing the influence of the autonomic nervous system on the normal and pathological heart. It may be performed by temporal or spectral analysis over 24 hours or shorter periods. It is possible to define for each temporal or spectral analysis the components of the autonomic nervous system which influence these parameters. After myocardial infarction a decrease in heart rate variability indicates a poor prognosis. This post-infarction risk factor is relatively reliable compared with the other prognostic factors. A decreased heart rate variability is also observed in cardiac failure but the significance of this finding has not been established. Many other fields of application of the study of heart rate variability may be envisaged, in other cardiovascular pathologies, in the evaluation of cardiovascular therapeutic interventions or in the assessment of patients with non-cardiac pathology in which the autonomic nervous system plays an important role. A lot of research on heart rate variability is currently under way and many developments are expected in the next few years.


[Electrocardiography of atrioventricular block].

A functional physiological block protects the ventricles from the risks of excessively rapid atrial rhythms. Pathological AVB is classified in three degrees according to whether the ventricular excitation is delayed, intermittent or absent. The site of AVB can be accurately determined by endocavitary electrophysiological studies but can also be estimated from the surface electrocardiographic recordings. fundamental research has questioned the sle responsibility of conduction defects in Wenckebach and paroxysmal blocks: they suggest the presence of abnormalities of excitability in pathological zones.


[Late ventricular potentials and myocardial infarction. A critical analysis].

The identification of patients at high risk of developing severe ventricular arrhythmias or sudden death after acute myocardial infarction is one of the major preoccupations of cardiologists. In this field, electrocardiographic signal averaging represents a promising technique and the prognostic value of late potentials in the post-infarction period has been well demonstrated during the last 10 years. However, in order to use optimally the information obtained by this technique the limitations should be understood: what do late ventricular potentials represent from the electrophysiological point of view? Do they play an active role in the genesis of ventricular arrhythmias or are they only a marker? What is the best method of recording late potentials? What are the criteria of normality of signal averaged recordings? What is the predictive value of late potentials in the post-infarction period? At what moment should they be searched for? Are they affected by medical therapy? These are some of the questions which have not yet been answered and which are addressed in this article.


[Radiofrequency treatment of junctional tachycardia].

Atrioventricular nodal tachycardias due to intranodal reentry or to an accessory pathway are accessible to radical cure with radiofrequency currents applied either at the site of recording of characteristic slow potentials or at the tricuspid or mitral atrioventricular rings. One hundred and six patients with atrioventricular nodal reentry were treated by modification of the slow anterograde reentrant pathway with a 100% success rate and without any serious complications (especially atrioventricular block). One hundred and eighty six patients had one or more overt or latent accessory pathways and were treated by the same method. The ablation site was decided on indirect criteria and not by the recording of the specific activity of the accessory pathway. The success rate was 97%, also with no significant complications. The duration of the treatment was 41 +/- 22 min for the accessory pathways. The exposure time to ionising radiation was 14 +/- 14 min and 31 +/- 34 min respectively. These results suggest that the indications of radiofrequency current ablation could be extended.


[Ventricular tachycardia caused by bundle branch reentry].

Ventricular tachycardia by bundle branch reentry is a special type of ventricular tachycardia. A rare arrhythmia, it occurs in very particular conditions of ventricular dilatation and conduction defects. The diagnosis is based on electrophysiological findings associating a His potential preceding the ventriculogramme with a HV interval comparable to that observed in sinus rhythm, and spontaneous variations of the cycle length between two ventriculogrammes preceded by those of the His potentials. Contrary to what is observed in other forms of ventricular tachycardia, pacing is possible from the atrium without changes of the QRS complexes and the presence of fusion complexes excludes the diagnosis. Treatment consists of radiofrequency ablation of the right bundle branch.


[Potassium channels and arrhythmia].

Cardiac repolarisation depends mainly on the cellular extrusion of positive electrical charge related to the potassium ion through different channels. There are many potassium channels which are responsible for repolarisation in different cardiac tissues. Prolongation or shortening of the repolarisation period may be both antiarrhythmic and proarrhythmic depending on the given experimental conditions. Different potassium channels may be opened or blocked by clinically prescribed drugs. Activators of the iK(ATP) channels may exert antiarrhythmic effects by inhibiting activity induced by prolonged repolarisation. Experimentally, they may exert a proarrhythmic effect by predisposing to arrhythmias during myocardial ischemia. However, these effects have not been clearly demonstrated clinically. Potassium channel blockers may have an antiarrhythmic effect by reducing the variability of repolarisation, by prolonging the atrial and ventricular refractory periods and by their antifibrillatory actions. Nevertheless, they may have proarrhythmic effects resulting in triggered activation under particular conditions of bradycardia and/or ischemia. Examples of these effects have been reported in man. The understanding of the relationship between potassium channels and arrhythmias is particularly complex because of the multiple factors regulating the duration of repolarisation and the effects of drugs on this duration. These factors include the activity of the autonomic nervous system, the heart rate, ischemia and acidosis and the differences in response to endocardial and epicardial tissues.


[Inguinal herniorrhaphy with local anesthesia].

We review five years experience on inguinal hernia repair under local anesthesia in a small hospital in the interior of the State of São Paulo, Brazil. Sixty patients were submitted to repair and they were evaluated according to their immediate results, kind of hernia, anesthetic and operatory techniques and recurrences. The results were considered excellent in 20% of the cases, good in 65%, regular in 13.3% and in 1.7% the results were bad. No recurrence was observed up to now. Most of the patients were discharged within 24 hours. The proposed technique has provided reduced hospital expenses and low risks of infection.


[Celiac disease: report of 20 cases in Rio Grande do Norte, Brazil].

This paper shows that celiac disease exists in Northeast of Brazil and can be one of the causes of malnutrition in the State of Rio Grande do Norte. The authors present a study of 20 cases of celiac disease in the State of Rio Grande do Norte where there had not been any cases diagnosed before 1978. Ethnic aspects in the State seem to have influenced the occurrence of the disease since the European miscigenation has been more frequent than that of negroes and local indians. The cases are analysed in this paper and correlated with the literature.


[Hepatic hemangiomas. The importance of the image].

In the authors' experience, 0.24% of the patients submitted to liver imaging (ultrasound or computerized tomography) have hemangiomas. These are shown as solid nodular lesions, mostly found by chance. Sometimes they do not appear as typical solid vascular lesions. The authors' experience and the literature are discussed. A clear and concise approach to this benign neoplasm is suggested.


[Influence of age on lower esophageal sphincter pressure].

We studied the effect of aging on lower esophageal sphincter (LES) pressure of 52 normal subjects, 129 patients with Chagas' disease and 63 patients with systemic sclerosis. Three groups were compared: with ages between 10 to 29 years, 30 to 49 years and 50 to 70 years. We used a perfused catheter and the station pull-through (SPT) technique, at end expiratory phase. There was no difference in LES pressure between the three groups in normal subjects (p = 0.72) and patients with systemic sclerosis (p = 0.33). In Chagas' disease the patients with ages between 50 to 70 years had LES pressure (17 +/- 8 mmHg, mean +/- SD) lower (p = 0.03) than patients with ages between 10 to 29 years (22 +/- 9 mmHg). We conclude that in Chagas' disease the patients with ages over 50 years have LES pressure lower than patients with ages under 30 years, what does not happen with normal subjects nor systemic sclerosis patients.


[Lymph node metastasis in early rectal tumors].

Sixteen patients with early rectal carcinoma seen between January 1981 and May 1991 have been reviewed to determine the lymph node involvement (histopathological examination of the lymph nodes) and its implications for subsequent treatment. The mean age was 63 years (from 38 to 79; 10 male, six female). The site of the tumor was predominantly in the lower rectum (56.2%). The polypoid and flat-elevated ulcerated (IIa + IIc) subtype were detected in nine and seven lesions respectively. Sphincter-saving techniques were carried out in 62.5% of cases, and only five patients (31.2%) required Miles' operation. Neither postoperative complication nor death were noted. The mean follow-up period was 57 months (6 to 133 months). No recurrence or distal metastasis were found during this follow-up period. The results had shown close relation between the depth of submucosal invasion and IIa+IIc subtype lesions with lymphovascular infiltration. Although this kind of association was not accompanied by an increased number of involved lymph nodes, major surgical resection is suggested in such cases due to the risk of lymph node metastasis when invasion into the submucosa reaches the Sm1c level or deeper.


[Prevalence of antibodies to hepatitis C (anti HCV) in blood donors in Rio de Janeiro, Brazil. Its relation to ALT and anti HBC].

We have studied 933 volunteer blood donors from May to July, 1990. After a interview and screening tests for syphilis, Chagas disease, malaria and HIV, they underwent an enzyme immunoassay for HBsAg, anti HBc and anti HCV antibodies. Alanine aminotransferase (ALT) serum levels were determined by auto analyser. Most blood donors were male with mean age of 33 years (19-65). Anti HCV prevalence was 3.1% (29 from 933 blood donors). Among anti HCV+, blood donors, 44.8% (13/29) had ALT 40 UI/L, 31% (9/29) were anti HBc+ and 17.2% (5/29) had both surrogate markers simultaneously. From 109 donors with ALT 40 UI/L, 13 (11.9%) were anti HCV+, while among 153 anti HBc+ donors, the anti HCV was 5.8%. 1) we found a higher anti HCV prevalence among our blood donors than previous published reports from other countries; 2) our data show that surrogate assays do not adequately identify anti HCV blood donors, 41.4% of them would not have been excluded by anti HBc and ALT tests alone; 3) there were a correlation between anti HCV positivity with a sample to cutoff optical density ratio equal or greater than 4 and elevated ALT serum levels.


Variation and physiological significance of basal gastrinemia in normal children.

The objective of the present study was to determine the variation of normal basal gastrinemia values in children of different age ranges. Basal gastrinemia levels were measured by radioimmunoassay in 30 normal children aged 2 months to 9 years divided into 3 groups: 1) 11 children aged 2 to 6 months; 2) 9 children aged 7 to 18 months, and 3) 10 children aged 20 month to 9 years. Basal gastrinemia levels varied from 11 to 533 pg/ml (mean = 138.47, SD = 131.56) and correlated significantly to the children's ages. Differences were not statistically significant between group I (mean = 191.82, SD = 116.26) and group II (mean = 186.11, SD = 161.65) but were significant between group I and group I and group III (mean = 36.9, SD = 17.67) and between group II and group III. The results demonstrate that basal gastrinemia levels of normal children are inversely correlated with age, the highest values being observed up to 18 months of age. A marked decrease in basal gastrinemia occurs thereafter reaching levels similar to those reported for adults. The authors speculate whether the hypergastrinemia observed in the present study may be indicative of an important physiological function of gastrin in the ontogenic development of the stomach.


[Carcinosarcoma of the esophagus: diagnostic importance of partial endoscopic polypectomy].

The clinical and pathological manifestations of a case of carcinosarcoma of the esophagus are reported. Barium swallow and endoscopy revealed a polypoid mass in mid esophagus. The tumor was large, pedunculated, covered by smooth mucosa with some erosions. Histologically the tumor was composed of a mixture of invasion keratinizing cells and intermingled bundle of spindle shaped cells resembling fibrosarcoma. The tumor was removed with surgery and did not show submucosa infiltration. It was not detected any metastasis or local recurrence during the 12 months follow-up period. The diagnosis was made by an endoscopic partial polypectomy. We conclude that partial polypectomy may be of value in preoperative diagnosis of esophageal polypoid mass.


[Colon adenocarcinoma with neuroendocrine and squamous cell differentiation. A case report].

A tubular adenocarcinoma of the colon with solid area composed by small cells that was found by immunohistochemistry study using antibody to neuron-specific enolase (NSE) to possess neuroendocrine differentiation is related. In another areas of the tumor were visualized keratinizing squamous cells. The presence of neuro-endocrine and squamous cells features provide further evidence that neoplastic colonic cells have the capacity for multi-directional differentiation. The implications of this combination in relation to theories of tumor origin and differentiation and the prognostic significance of neuro-endocrine cells in malignant neoplasms of the gastrointestinal tract are discussed.


[Prevalence of the various types of gastritis in patients with upper dyspeptic symptoms].

Multiple site biopsy specimens from 153 patients were examined retrospectively for the presence of gastritis and Helicobacter-like organisms (HLO). Chronic gastritis was classified as superficial gastritis, diffuse antral gastritis, postgastrectomy (reflux) gastritis, diffuse corporal atrophic gastritis, and multifocal atrophic gastritis. In some cases technical problems did not make possible to define the type of chronic gastritis and we introduce the terms unclassified gastritis and minimal inflammatory changes to name those cases. In our opinion they represent superficial biopsies from cases of diffuse antral gastritis. Diffuse antral gastritis was found in 60% of patients followed by multifocal atrophic gastritis found in 20% of patients. HLO was searched in histological sections stained by a modified Giemsa stain. The typical curved bacilli were seen in the gastric mucus or closely attached to the top of superficial or foveolar epithelial cells in 83% of patients. Although we have noted high correlation between activity of chronic gastritis and infection by HLO such correlation was not possible between the degree of activity and the degree of infection.


Pancreatic metastasis from renal cell carcinoma.

We report a case of renal cell carcinoma that metastasized to the pancreas 7 years after the initial excision. The primary and the metastatic tumors were histologically similar. Upper gastrointestinal bleeding was the leading symptom in the present case and the cause of the patient's death.


Iron, copper and alpha 1-antitrypsin deficiency in the liver of cirrhotic and schistosomotic patients.

While a number of studies investigated iron and copper storage or alpha 1-antitrypsin (A1AT) deficiency in the liver of patients with cirrhosis, we did not find any similar study in schistosomotic patients reported in literature. We investigated the storage of both metals and the A1AT deficiency in the liver of 72 cirrhotic and 27 schistosomotic patients (5 with the hepatointestinal and 22 with the hepatoesplenic form of the disease). Forty-four patients with cirrhosis were also alcoholic, and 28 were not. Iron storage was detected in 23 patients with cirrhosis (31.9%); among these 16 (36.3%) were alcoholic and 7 (25.0%) non-alcoholic (the difference was not statistically significant). Thirteen (56.5%), 5 (21.7%) and 5 (21.7%) patients presented I-grade, II-grade, and III-grade iron storage, respectively. Copperstorage was detected in 24 cirrhotic patients (33.3%), 15 being alcoholic (34.0%) in contrast with 9 non-alcoholic patients (32.1%), a statistically non-significant difference. A1AT deficiency was observed in 2 patients with cirrhosis (2.8%), one with history of alcoholism. HBsAg and HBcAg in hepatic tissue were detected in 5 cirrhotic patients (6.9%), three of them with a history of alcoholism. Iron and copper storage and A1AT deficiency were observed in 3 patients with cirrhosis (12.5%), while iron storage and A1AT deficiency were found in 2 additional patients with cirrhosis (2.8%). The authors underline that neither iron nor copper storage nor A1AT deficiency was found in any schistosomotic patient. The authors discuss the possible importance of these data.


Increased risk of bacterial endocarditis in inflammatory bowel disease.

The purpose of this retrospective as well as prospective case-control study was to analyze a possible overrepresentation of inflammatory bowel diseases among patients with native valve endocarditis as well as the factors that predispose patients with inflammatory bowel disease to infective endocarditis. Among 213 consecutive patients treated for proven native valve endocarditis, six (2.8%) had inflammatory bowel diseases (three with ulcerative colitis and three with Crohn's disease). Three patients with inflammatory bowel disease were from the retrospective group, and three were from the prospective group. The prevalence of inflammatory bowel diseases has been determined to be 0.0641% in the Düsseldorf area. On the basis of these data, a 44-fold overrepresentation of inflammatory bowel diseases among the 213 patients with endocarditis was calculated with a statistical significance of p much less than 0.001. Inflammatory bowel disease may be considered an independent risk factor for bacterial endocarditis. Reasons may be more frequent bacteremias as a result of the higher incidence of diagnostic and therapeutic interventions, as well as increased permeability of the damaged mucosa for bacteria and the therapeutic immunosuppression in patients with active inflammatory bowel disease. Prophylaxis for bacterial endocarditis should be carefully considered before expected bacteremias in patients with highly active inflammatory bowel disease even in the absence of cardiac factors predisposing to bacterial endocarditis.


[Two cases of severe cutaneous vasculitis with thrombocytopenia associated with hepatic cirrhosis: autoimmune and infective-inflammatory component with endothelial lesion and restrictive pulmonary pattern in one case].

Two clinical cases of female patients with hepatic cirrhosis and autoimmune multisystemic involvement with infectious intercurrent are reported. Case 1 presented infective endocarditis and erysipelas on the left thigh. In the course of the clinical picture a cutaneous vasculitis developed in the same place together with autoimmune thrombocytopenia, leukopenia and pulmonary restrictive picture with inflammatory pattern. There are also elevate immune complexes and complement consumption. Case 2 presented erysipelas on the left thigh cutaneous vasculitis and complement consumption. In Case 1 the infective endocarditis was treated with antibiotic therapy during 4 weeks followed by 1 mg/kg corticoid (Prednisone) with thrombocytopenia and leukopenia reversion. Case 2 presented an improvement with antibiotic only. The relation between chronic liver diseases and systemic autoimmune phenomena is commented, special attention being paid to the cutaneous, hematological and pulmonary affection.


Cutaneous manifestations of gastrointestinal disorders. Part II.

The cutaneous manifestations of inflammatory bowel disorders, vascular disorders of the gastrointestinal tract, celiac disease, and bowel-associated dermatosis-arthritis syndrome are reviewed. The significance of these signs, guidelines for their management, and investigations are discussed.


Comparative report on endoscopic and surgical treatment for early gastric cancer in elderly patients.

Two cases of elderly patients with similar early gastric cancers who were submitted to endoscopic and surgical treatment are presented as examples. Considering older patients as a sole group in the decision-making process we discuss the pros and cons of each therapy supporting efficacy and opposing side effects in order to maintain a reasonable quality of life.


[Cytopathological test performed during colonoscopy in the diagnosis of colorectal stenosis].

The etiological diagnosis for the colorectal strictures can be very difficult. With the colonoscopy, it was possible to obtain samples with direct vision of the lesion. Consequently, the cytologic efficiency improved, with similar or even better results than histopathology. In the present study (107 patients) it was used the cytopathology performed during colonoscopy. After a specimen was obtained, it was smeared on glass slide, fixed in 95% alcohol, stained by HE, and examined microscopically, with conclusions during the procedure. The results were compared and further correlated to the histopathology of surgical specimen or based on clinical follow-up in those case not submitted to operation. The results showed a striking degree of correlation between both exams. For the cytopathology there were no inconclusive results, false-negative were less frequent than with histopathology, and only one case of false-positive (rectal villus adenoma) was observed. Considering the type, localization and perviousness of the lesion, similar conclusions were drawn, and did not affect the results, except that there were more false-negatives in both exams when the lesions were impervious. The cytopathological and histopathological studies were both highly sensitive and specific for the diagnosis of carcinoma. In conclusion, cytopathology performed during colonoscopy is safe and efficient in the study of colorectal strictures, which contributes to improve the orientation of these patients.


Nail biopsy. Indications and methods.

Nail biopsy is a safe and useful diagnostic procedure for many nail disorders when routine clinical and laboratory methods fail to produce a diagnosis. Prerequisites for nail biopsy are an understanding of the surgical anatomy of the nail, adequate anesthesia and hemostasis, and a nail abnormality for which histopathology can provide the diagnosis. Indications and methods for nail biopsy vary according to the site and type of pathology in the nail unit. Nail bed and perionychial biopsies can be performed easily and with minimal scarring. They are most commonly used to diagnose tumors as well as infectious and inflammatory disorders of the nail. The most important reason to biopsy the nail matrix is to make or exclude the diagnosis of melanoma in a patient with longitudinal melanonychia. Great care must be taken in nail matrix biopsy to minimize the risk of permanent nail dystrophy.


The search for the new pineal gland. Brain life and personhood.

The concept of "brain life," sometimes offered as the criterion for determining when personhood begins, cannot tell us what we want to know about persons. Neurological facts will not automatically yield ethical conclusions.


An analogue approach to audit in anaesthesia.

The predicted outcome of anaesthesia and surgery was compared with the immediate outcome in 508 patients by means of two 100 mm linear analogue scales. The results were used to obtain a statistically based rule by which the anaesthetist may consistently select three groups of patients for audit: group 1, patients in whom immediate outcome of anaesthesia and surgery is worse than predicted; group 2, patients whose outcome is better than predicted; and group 3, the remaining patients. The rule, which is simply adapted to departmental audit, does not necessarily need a computer but is suited to the computer as it is numerically based.