Antenatal corticosteroid use and clinical evolution of preterm newborn infants

Objectives: To describe the use of antenatal corticosteroid and clinical evolution of preterm babies. Methods: An observational prospective cohort study was carried out. All 463 pregnant women and their 514 newborn babies with gestational age ranging from 23 to 34 weeks, born at the Brazilian Neonatal Research Network units, were evaluated from August 1 to December 31, 2001. The data were obtained through maternal interview, analysis of medical records, and follow-up of the newborn infants. Data analysis was performed with the use of chi-square, t Student, Mann-Whitney, and ANOVA tests and multiple logistic regression, with level of significance set at 5%. Results: Treatment was directly associated with the number of prenatal visits, with maternal hypertension and with the antenatal use of tocolytic agents. Babies from treated pregnant women presented better Apgar scores at the 1st and 5th minute, reduced need for intervention in the delivery room and lower SNAPPE II. They were born with higher birth weight, longer gestational age and needed less surfactant use, ventilation, and oxygenation time. After multiple logistic regression, the use of antenatal corticosteroid independently improved birth conditions, decreased ventilation time, being related to increased occurrence of neonatal sepsis. Conclusions: The use of corticosteroid was associated with better prenatal care and birth conditions, better preterm evolution but higher risk of infection. Copyright © 2004 by Sociedade Brasileira de Pediatria.

Clinical evolution of patients hospitalized due to the first episode of Acute Coronary Syndrome

AIM: to assess the clinical evolution of patients hospitalized due to the first episode of Acute Coronary Syndrome (ACS) according to its clinical manifestation. METHODS: data were collected from 234 patients, hospitalized between May 2006 and July 2009 due to the first episode of an ACS, by consulting their medical records. RESULTS: 234 patients were hospitalized, 140 (59.8%) due to Acute Myocardial Infarction (AMI). In the group with AMI, 19.3% presented complications, against 12.8% in the group with Unstable Angina (UA) (p=0.19). Angioplasty levels were higher among patients with AMI than with UA (p=0.02) and coronary artery bypass graft surgery was more frequent among UA patients (p=0.03). The majority (227; 97%) survived after the coronary event. Among the seven patients who died during the hospitalization, four had AMI (2.9%) and three UA (3.2%). CONCLUSIONS: A larger number of complications were found among infarction victims and the accomplishment of coronary artery bypass graft surgery differed between the groups.

Paracoccidioidomycosis: epidemiological, clinical, diagnostic and treatment up-dating

Paracoccidioidomycosis is an acute - to chronic systemic mycosis caused by fungi of the genus Paracoccidioides. Due to its frequent tegument clinical expression, paracoccidioidomycosis is an important disease for dermatologists, who must be up-to-date about it. This article focuses on recent epidemiological data and discusses the new insights coming from molecular studies, as well as those related to clinical, diagnostic and therapeutic aspects. In the latter section, we give particular attention to the guideline on paracoccidioidomycosis organized by specialists in this subject.

Chronic graft-versus-host disease: clinical presentation of multiple lesions of lichenoid and atrophic pattern

Graft-versus-host disease is observed mainly in recipients of hematopoietic cell transplantation and is expressed by cutaneous or systemic signals and symptoms. Graft-versus-host disease is clinically classified as acute or chronic. Chronic Graft-versus-host disease occurs in up to 70% of hematopoietic cell transplanted patients and its clinical manifestations have important impact on morbidity and quality of life. The authors report an expressive cutaneous, oral and adnexal involvement in a patient with chronic Graft-versus-host disease with multiple lesions of lichenoid and atrophic pattern.

Fluorescent antibody test, quantitative polymerase chain reaction pattern and clinical aspects of rabies virus strains isolated from main reservoirs in Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

CLINICAL CHARACTERISTICS AND SEVERITY OF PATIENTS ADMITTED TO PUBLIC AND PRIVATE ICUS

This study aimed to compare clinical characteristics, evolution and severity of adult patients admitted to public and private Intensive Care Units. It is a retrospective, longitudinal and quantitative analysis of 600 patients admitted to four Intensive Care Units of Sao Paulo, Brazil. Differences were found between patients admitted in private and public hospitals regarding the following variables: age, origin, length of stay and mortality in the critical unit, cardiologic, hematologic, neurologic and renal failures and some comorbidities. The results reveal the importance of analyzing in detail clinical characteristics and healthcare of patients admitted in public institutions, because of the high mortality found. The Intensive Care Nurse can contribute to change this scenario, because she/he plays a leading role in planning and providing resources for intensive care.

CD62L (L-selectin) shedding for assessment of functional blockade of TNF alpha in anti-TNF treated IBD patients: clinical feasibility and perspectives (DOP060)

Background Tumor necrosis factor (TNF) inhibition is central to the therapy of inflammatory bowel diseases (IBD). However, loss of response (LOR) is frequent and additional tests to help decision making with costly anti-TNF Therapy are needed. Methods Consecutive IBD Patients receiving anti-TNF therapy (Infliximab (IFX) or Adalimumab (after IFX LOR) from Bern University Hospital were identified and followed prospectively. Patient whole blood was stimulated with a dose-titration of two triggers of TLR receptors human: TNF and LPS. Median fluorescence intensity of CD62L on the surface of granulocytes was quantified by surface staining with specific antibodies (CD33, CD62L) and flow cytometry and logistic curves to these data permits the calculation of EC50 or the half maximal effective concentration TNF concentration to induce shedding [1]. A shift in the concentration were CD62L shedding occurred was seen before and after the anti-TNF agent administraion which permits to predict the response to the drug. This predicted response was correlated to the clinical evolution of the patients in order to analyze the ability of this test to identify LOR to IFX. Results We collected prospective clinical data and blood samples, before and after anti-TNF agent administration, on 33 IBD patients, 25 Crohn's disease and 8 ulcerative colitis patients (45% females) between June 2012 and November 2013. The assay showed a functional blockade of IFX (PFR) for 22 patients (17 CD and 5 UC) whereas 11 (8 CD and 3 UC) had no functional response (NR) to IFX. Clinical characteristics (e.g. diagnosis, disease location, smoking status, BMI and number of infusions) were no significantly different between predicted PFR and NR. Among the 22 Patients with PRF, only 1 patient was a clinical non responder (LOR to IFX), based on clinical prospective evaluation by IBD gastroenterologists (PJ, AM), and among the 11 predicted NR, 3 had no clinical LOR. Sensitivity of this test was 95% and specificity 73% and AUC adjusted for age and gender was 0.81 (Figure 1). During follow up (median 10 mo, 3–15) 8 “hard” outcomes occured (3 medic. flares, 4 resections and 1 new fistula) 2 in the PFR and 6 in the NR group (25% vs. 75%; p < 0.01). Correlation with clinical response is presented in Figure 2. Figure 1. Figure 2. Correlation clinical response - log EC50 changes: 1 No, 2 partial, 3 complete clinical response. Conclusion CD62L (L-Selectin) shedding is the first validated test of functional blockade of TNF alpha in anti-TNF treated IBD patients and will be a useful tool to guide medical decision on the use of anti-TNF agents. Comparative studies with ATI and trough level of IFX are ongoing. 1. Nicola Patuto, Emma Slack, Frank Seibold and Andrew J. Macpherson, (2011), Quantitating Anti-TNF Functionality to Inform Dosing and Choice of Therapy, Gastroenterology, 140 (5, Suppl. I), S689.

Influência de pré-tratamentos de células epiteliais com penicilina e eritromicina na aderência e na viabilidade intracelular de Corynebacterium diphtheriae

A difteria é uma síndrome toxêmica causada pelo Corynebacterium diphtheriae. Embora programas de imunização mantenham a doença sob controle em países desenvolvidos, a difteria ainda permanece endêmica em diversas partes do mundo, especialmente em indivíduos parcialmente imunizados para toxina diftérica. Junto a isso, nos últimos 20 anos, tem-se observado a ocorrência crescente de quadros de infecções sistêmicas causados por cepas atoxinogênicas. A penicilina e eritromicina são as principais drogas de escolha no tratamento destas infecções, entretanto, a escassez de trabalhos reavaliando a terapia de escolha e a influência dos antibióticos no processo de interação bacteriana com células epiteliais humanas são escassos, logo compreendem aspectos que justificam o presente estudo. O objetivo principal deste projeto consiste na análise da influência do pré-tratamento de células epiteliais Hep-2 com os antimicrobianos penicilina e eritromicina na colonização e viabilidade intracelular de amostras de C. diphtheriae. As monocamadas foram submetidas ao tratamento prévio com doses séricas terapêuticas de penicilina (5g mL1) e eritromicina (1,92 g mL1) por 24 horas e os antibióticos foram removidos por lavagens com PBS antes da interação com a suspensão bacteriana (MOI de 107). Três horas após a infecção, o padrão de aderência foi investigado como também, realizada a análise das bactérias viáveis associadas e internalizadas nas monocamadas. O pré-tratamento com penicilina induziu a formação de perfil de aderência difuso (AD) pelas amostras estudadas. Microorganismos que normalmente apresentam padrão de aderência localizado (AL) passaram a expressar perfil (AD) após pré-tratamento das camadas com ambos antimicrobianos. A expressão do tipo agregativo (AA) não foi influenciada pela presença de eritromicina. A penicilina e a eritromicina reduziram o número de bactérias viáveis associadas às células HEp-2 na maioria das oportunidades. Entretanto, a penicilina interferiu em maior magnitude nesse processo. As três amostras invasoras de C. diphtheriae (HC01, HC04 e BR5015), apresentaram maior capacidade de sobrevivência no compartimento intracelular, independente do pré-tratamento. A expressão dos perfis de aderência assim como a capacidade de sobrevivência no compartimento intracelular frente aos antimicrobianos testados mostraram-se independentes da produção de toxina e dos percentuais de associação com as células HEp-2. Foi observada uma maior eficiência da eritromicina na eliminação de bactérias viáveis internalizadas reforçando a utilização clínica da eritromicina tanto no tratamento de pacientes quanto na erradicação do estado de portador. Novos estudos serão desenvolvidos para investigar alterações na expressão de fatores de virulência por amostras de C. diphtheriae na interação com células HEp-2 pré-tratadas com antimicrobianos e a influência sobre a evolução clínica das infecções por corinebactérias

Risk Factors for Latex Sensitization in Children with Spina Bifida

Background: Children with spina bifida represent the major risk group for latex sensitization. Purpose: To determine the prevalence of latex sensitization in these children and to identify risk factors. Material and methods: We studied 57 patients with spina bifida. The mean age was 5.6 years and the male/female ratio was 0.8/1. In all patients a questionnaire, skin prick test (SPT) with latex (UCBStallergènes, Lofarma and ALK-Abelló), common aeroallergens and fruits (UCB-Stallergènes) and serum determination of total IgE (AlaSTAT) were performed. Results: The prevalence of latex sensitization was 30 %; only two sensitized children (12 %) had symptoms after exposure. Risk factors for latex sensitization were age 5 years (p = 0.008; OR = 6.0; 95% CI = 1.7-22.1), having at least four previous surgical interventions (p < 0.0001; OR = 18.5; 95% CI = 3.6-94.8), having undergone surgery in the first 3 months of life (p = 0.008; OR = 5.4; 95% CI = 0.7-29.2) and total serum IgE 44 IU/ml (p = 0.03; OR = 3.8; 95 %CI = 1.1-13.1). Multiple logistic regression analysis showed that only a history of four or more surgical interventions (p < 0.0001; OR = 26.3; 95 %CI = 2.9-234.2) and total serum IgE 44 IU/ml (p = 0.02; OR = 8.6; 95% CI = 1.4-53.4) were independently associated with latex sensitization. Sex, family and personal allergic history, hydrocephalus with ventriculoperitoneal shunt, cystourethrograms, intermittent bladder catheterization and atopy were not related to latex sensitization. Conclusions: In children with spina bifida, significant and independent risk factors identified for latex sensitization were multiple interventions and higher levels of total serum IgE. A prospective study will clarify the clinical evolution of assymptomatic children sensitized to latex.

Time to Left Ventricular Reverse Remodeling after Cardiac Resynchronization Therapy: Better Late than Never

INTRODUCTION: Left ventricular reverse remodeling (LVRR), defined as reduction of end-diastolic and end-systolic dimensions and improvement of ejection fraction, is associated with the prognostic implications of cardiac resynchronization therapy (CRT). The time course of LVRR remains poorly characterized. Nevertheless, it has been suggested that it occurs ≤6 months after CRT. OBJECTIVE: To characterize the long-term echocardiographic and clinical evolution of patients with LVRR occurring >6 months after CRT and to identify predictors of a delayed LVRR response. METHODS: A total of 127 consecutive patients after successful CRT implantation were divided into three groups according to LVRR response: Group A, 19 patients (15%) with LVRR after >6 months (late LVRR); Group B, 58 patients (46%) with LVRR before 6 months (early LVRR); and Group C, 50 patients (39%) without LVRR during follow-up (no LVRR). RESULTS: The late LVRR group was older, more often had ischemic etiology and fewer patients were in NYHA class ≤II. Overall, group A presented LVRR between group B and C. This was also the case with the percentage of clinical response (68.4% vs. 94.8% vs. 38.3%, respectively, p<0.001), and hospital readmissions due to decompensated heart failure (31.6% vs. 12.1% vs. 57.1%, respectively, p<0.001). Ischemic etiology (OR 0.044; p=0.013) and NYHA functional class clinical and echocardiographic outcomes than no LVRR, although with a suboptimal response compared to the early LVRR population. Ischemic etiology and NYHA functional class

A lesão de isquémia/reperfusão em transplante hepático: análise genética, morfológica e correlação clínica

RESUMO: O transplante hepático ortotópico é uma terapêutica aceite para casos selecionados de falência hepática terminal. O procedimento tem-­‐se aperfeiçoado, evidenciado pelo aumento da taxa de sobrevida de 30 para 75% aos 5 anos, mas cerca de 13 a 27% dos enxertos desenvolve falência primária (PNF) ou disfunção primária (DF) após o transplante. As consequências são devastadoras para a sobrevida do doente e do enxerto. A sua etiologia é multifactorial, incluindo factores relacionados com o dador e o receptor, tempos de isquémia, agressões cirúrgicas, bem como características anatomopatológicas do enxerto. A lesão de isquémia/reperfusão mantem-­‐se como um factor de risco intra operatório, com implicações directas sobre toda a evolução do transplante : existe uma relação íntima entre a PNF e a DF, a preservação do enxerto, a lesão de isquémia/reperfusão, e a falência do transplante. Além disso, está comprovada evidência que sugere que a lesão de I/R torna um aloenxerto mais vulnerável por aumento da imunogenicidade, aumentando a probabilidade de episódios de rejeição precoce e tardia. Com base na prática clínica quotidiana do CHBPT HCC, estudaram-­‐se 54 casos de transplante hepático, agrupados segundo grupos por alocação do enxerto respectivo: Grupo 1(n=27): dador cadáver para receptor cirrótico, Grupo 2 (n=15): dador cadáver para receptor PAF, Grupo 3 (n=12): dador PAF para receptor cirrótico. Observaram-­‐se as alterações histológicas e moleculares sobre o enxerto até ao final da operação do receptor, e as suas consequências clínicas,avaliando: -­‐ As diferentes capacidades de resistência e cada enxerto à lesão de isquémia/reperfusão. -­‐ As situações em que os factores do receptor se sobrepõem às do enxerto na definição do prognóstico, e vice versa. -­‐ A relevância das lesões histológicas e moleculares precoces no tecido hepático na evolução do enxerto e do receptor. Foram colhidas biópsias por agulha dos 54 enxertos hepáticos,42 provenientes de cadáver com coração batente(morte cerebral) e 12 provenientes de dador vivo com PAF, em três tempos diferentes do processo de colheita e transplante hepático: ­‐ A primeira(T0)antes da clampagem da aorta do dador -­‐ A segunda (T1) no final da isquémia fria -­‐ A terceira (T2) após a reperfusão do enxerto, durante o encerramento da parede abdominal. A estas amostras foi extraído RNA total, convertido em cDNA por transcrição reversa e feita a análise da expressão dos genes da CTLA4, IL-­‐1β, IL-­‐4, IL-­‐6, IL-­‐13, TNF-­‐α, Perforina, Selectina, (SELE), Fas-­‐ligando, Granzima-­‐B, Heme-­‐Oxigenase 1(HO1)e Óxido Nítrico Sintetase(iNOS2A)por PCR quantitativo segundo o método do Ct comparativo, utilizando como referência a expressão dos genes da amostra não-­‐isquémica –T0. Os fragmentos de todas as biópsias foram seccionados, para envio de amostra comparativa para processamento histológico habitual, sem qualquer alteração ao protocolo seguido habitualmente na Unidade de Transplantação do Hospital Curry Cabral. A presença de alguns parâmetros histológicos definidos, como esteatose, necrose, vacuolização, congestão sinusoidal e infiltração neutrofílica, foi registada e contabilizada numa classificação numérica. O seguimento clínico e laboratorial, bem como o acompanhamento de eventuais complicações, foi registado e correlacionado com os dados das colheitas de órgãos e com os dados das biópsias. Foram consideradas as seguintes variáveis, como as mais relevantes e objectivas para a interpretação da evolução clínica, tendo sido comparadas estatisticamente com os dados recolhidos, laboratoriais e clínicos: disfunção do enxerto, 207 pós operatórias, número de internamentos igual ou superior a 2 e rejeição crónica e/ou morte do receptor. Foram identificadas características clínicas menos favoráveis, a considerar, nalgumas circunstâncias: género feminino do receptor (sobretudo associado a enxerto masculino, p=0,077), isquémia fria superior a 500 minutos (p=0,074), isquémia quente superior a 90 minutos (p=0,099). Na análise laboratorial, distinguiram-­‐se duas características histológicas desfavoráveis e irreversíveis, como índice de mau prognóstico: a necrose e a balonização (p=0,029); no painel genético escolhido neste estudo,a expressão basal de IL-­‐1β(p=0,028), de SELE p=0,013)e de FAS-­‐L (p=0,079)relacionaram-­‐se com pior prognóstico. Algumas características protectoras intrínsecas dos enxertos só se revelaram indirectamente, como menor infiltração neutrofílica e maior expressão de HO1 e de iNOS nos enxertos PAF, não tendo sido possível provar uma interferência directa nos resultados clínicos. Não se obteve expressão mensurável de genes anti-­‐ inflamatórios nas biopsias hepáticas processadas neste estudo, como a IL13 e a I 4: assim, com a metodologia utilizada, não foi possível obter um perfil de expressão genética associado a boa evolução clínica. O perfil inverso foi sugerido apenas pela expressão basal dos 3 genes mencionados (FAS-­‐L,IL-­‐1β e SELE)no mesmo painel, com o protocolo seguido neste conjunto de 54 doentes. As características do receptor sobrepuseram-­‐se às do enxerto no caso de: -­‐ diagnóstico de PAF no receptor, que determinou uma maior predisposição para a disfunção do enxerto, o que, por sua vez, determina uma menor sobrevida. No entanto, o diagnóstico de PAF no receptor exibe uma curva de sobrevida mais favorável. -­‐ receptores com um baixo balanço de risco (BAR)definiram características favoráveis para enxertos com níveis baixos e moderados de esteatose, fazendo que esta característica, definida como um risco acrescido, não só não se manifestasse clinicamente,como parecesse um factor favorável. As características do enxerto sobrepuseram-­‐se às do receptor no caso de: -­‐ tempo de isquémia fria superior a 500 minutos -­‐ balonização, necrose, FAS-­‐L,IL-­‐1β e SELE em T0 A integração dos resultados moleculares e morfológicos com a evolução clínica, realça o papel da mobilização precoce de neutrófilos nos desempenhos menos favoráveis do enxerto hepático. -------------ABSTRACT: Orthotopic liver transplantation is na accepted therapeutic procedure for selected cases of terminal liver failure. The procedure has been improved, evidenced by the rise of survival rates from 30 to 70% at 5 years, but 13 to 27% of the liver grafts develops primary non function (PNF) or primary dysfunction (PDF) after transplantation. The consequences are devastating for the survival of the patient and of the graft. Its etiology is multifactorial, including factos related with the donor and with the recipient, ischemic times, surgical aggressions, as well as the histological characteristics of the graft. The ischemia/reperfusion lesion is still an intraoperative risk factor, with direct implications in the whole transplant outcome: there is a close interrelation between PNF and DF, graft preservation, ischemia / reperfusion lesion and graft failure. Beyond his, there is proved evidence that suggests that I/R lesion turns the allograft more vulnerable by increasing its immunogenity, increasing the probability of precocious and late rejection episodes. Based on the daily clinical practice at CHBPT /HCC, 54 cases of hepatic transplantation have been studied, grouped by allocation of each graft: Group (n=27):deceased do nortocirrhotic recipient, Group 2 (n=15): deceased donor to FAP recipient, Group 3 (n=12): FAP living donor to cirrhotic recipient. The histologic and molecular changes in the liver graft were observed until the end of the recipiente operation,together with its clinical consequences, evaluating:-­‐The different capacity of resistance of each graft to the ischemia / reperfusion lesion -­‐ The situations where the recipiente factos overlap the ones of the graft, in the definition of prognosis, and vice versa.-­‐ The relevance of the precocious histologic and molecular lesions of the hepatic tissue in the clinical outcome of the graft and the recipient. Needle biopsies were obtained from 54 liver grafts, 42 deceased brain dead donors and 12 from FAP living donors, at three diferente times of the harvesting and the hepatic transplantation: The first one (T0) before clamping the donor aorta -­‐ The second one (T2) in the end of cold ischemia time -­‐ The third one (T) after the reperfusion of the graft, during the closure of the abdominal wall. Total RNAwas extracted to these samples, converted to cDNA by reverse transcription and the analysis of gene expression was made for CTLA4,IL-­‐1β,IL-­‐4,IL-­‐6,IL-­‐13,TNF-­‐α,Perforin,E Selectin (SELE),Fas-­‐ligand,Granzyme-­‐B,Heme-­‐oxigenase 1 (HO1) and Nitric Oxide Sintetase (iNOS2A) by quantitative PCR, according with the Ct comparative method, using the expression of the non ischemic sample – T0. The fragments of all the biopsies were divided, to send a comparative sample to the usual histologic processement, keeping the same usual protocol at the Transplantation Unit of Curry Cabral Hospital. The presence of some defined histologic parameters, such as steatosis, necrosis, vacuolization, sinusoidal congestion and neutrophilic infiltration, was registered and catalogued in a numeric classification. The clinical and laboratory follow-­‐up, as well as the following of eventual complications, was registered and correlated with the data from organ procurement operations and with the data from the biopsies. The following variables were considered as the most relevant and objective ones, to the interpretation of the clinical evolution, being statistically compared with the clinical and laboratorial collected data: graft dysfunction, post-­‐operative complications, number of readmissions of 2 or more and chronic rejection and /or recipiente death. There were identified some unfavorable clinical characteristics, to be considered under certain circumstances: recipiente female gender (specially associated with malegraft, p=0,077), cold ischemia time of more than 500 minutes (p=0,074), warm ischemia time of more than 90 minutes (p=0,099). In the laboratory analysis, two histologic characteristics were identified as unfavorable and irreversible, associated with bad prognosis: necrosis and balonization (p=0,029); in the gene panel selected in this study, the basal expression of IL-­‐1β (p=0,028), SELE (p=0,013) and FAS-­‐L (p=0,079)were related with worse prognosis.Some intrinsic protective characteristics of the grafts were only indirectly revealed, such as less neutrophilic infiltration and bigger expression of HO1 and iNOS in FAP grafts, being impossible to prove any direct inte ference in the clinical results. A relevant and measurable expression of the anti inflammatory genes IL13 and IL4 was not obtained: with the used methodology, it was impossible to obtain a gene expression profile associated with a favorable clinical outcome.The inverse profile was suggested only by the basal expression of the three mentioned genes (FAS-­‐L, IL-­‐ 1β e SELE) in the same gene panel, according with the followed protocol in this group of 54 patients. The characteristics of the recipient overlapped those from the graft, in the case of :-­‐ FAP diagnosis in the recipient, which determined a bigger predisposition to graft dysfunction, which by itself determines a shorter survival. However, FAP diagnosis in the recipiente depicts a more favorable survival curve. -­‐ Recipients with a low balance risk índex (BAR) defined favorable characteristics to grafts with low and moderate grades of steatosis, making that this characteristic, associated with bad prognosis, looked like a favorable factor, and with no clinical interference. The graft characteristics overlapped those from the receptor in the case of: -­‐ Cold ischemic time more than 500 minutes -­‐ Balonization, necrosis, FAS-­‐L, IL-­‐1β and SELE at T0. The integration of molecular and morphologic results with the clinical evolution, stresses the role of a precocious neutrophils mobilization in the worse outcomes of liver grafts.

Atendimento no Ambulatório de Nutrição Renal da Faculdade de Nutrição da Universidade Federal Fluminense e Hospital Universitário Antônio Pedro : efeitos de um programa de treino de força intradialítica em pacientes renais crónicos

Relatório de estágio de mestrado, Nutrição Clínica, Universidade de Lisboa, Faculdade de Medicina, 2015

Amélioration des résultats cliniques en chirurgie cardiaque

Des éléments contributifs à plusieurs facettes de la chirurgie cardiaque ont été étudiés dans la présente thèse. Le premier manuscrit adresse la problématique de l’accident cérébro-vasculaire (ACV) post-opératoire. Nous avons analysé de façon rétrospective la médication prise en pré-opératoire de 6813 patients nécessitant une chirurgie de revascularisation coronarienne. Le but étant d’établir si la présence d’une médication précise (aspirine, inhibiteur de l’enzyme de conversion de l’angiotensine, statine, bêta-bloqueur) peut agir en pré-opératoire pour diminuer le risque d’ACV. En analyse multivariée, la combinaison de la prise de bêta-bloqueurs avec une statine a produit un ratio de cote de 0,37, suggérant un effet protecteur très important. Dans le deuxième manuscrit, je présente une étude ciblant les patients avec insuffisance mitrale ischémique modérée. Trente et un patients furent randomisés entre un traitement par pontages seuls vs pontages et annuloplastie mitrale restrictive. L’insuffisance mitrale a disparu en post-opératoire immédiat en présence de l’annuloplastie alors qu’aucun effet immédiat de la revascularisation coronarienne n’était noté sur l’insuffisance mitrale. Un an suivant la chirurgie, une insuffisance mitrale légère est réapparue chez le groupe ayant subi l’annuloplastie alors que les patients du groupe pontages seuls ont remodelé leur ventricule gauche et diminué l’importance de leur insuffisance mitrale au même niveau que le groupe annuloplastie. Aucun des marqueurs d’évolution clinique, tant au niveau symptomatique qu’au niveau de la survie ne diffère entre les groupes. La troisième étude est un suivi sur 20 ans des patients ayant eu des remplacements valvulaires mitraux ou aortiques avec une prothèse mécanique Carbomedics. Cette étude démontre une excellente survie avec un taux de complications valvulaires hémorragiques, thrombotiques, thrombo-emboliques, et d’endocardite favorable comparé aux autres types de prothèse et une absence de bris mécanique.

Détection moléculaire des métastases des ganglions lymphatique dans le cancer du col de l'utérus

Le Cancer du Col Utérin (CCU) chez la femme est provoqué par le virus oncogénique VPH. La métastase lymphatique ganglionnaire est un facteur pronostique majeur pour l’évolution de ce cancer et sa présence influence la décision thérapeutique. En général, l’envahissement ganglionnaire est diagnostiqué par histologie, mais cette méthode est laborieuse et parfois prise en défaut pour détecter les micrométastases et les cellules cancéreuses isolées et pour donner des résultats rapides en per opératoire. L’outil moléculaire que nous désirons développer pour combler cette lacune est basé sur une analyse d’ARN des gènes du VPH exprimés par les cellules du CCU. Ceci sera fait par transcription réverse de l’ARN cellulaire couplé à une réaction quantitative en chaine par polymérase en temps réel (RT-qPCR). Cette technique devrait nous permettre une détection et une évaluation rapide des micrométastases pour aider à déterminer immédiatement un pronostic fiable et la thérapie associée. C’est un test précis, sensible et rapide pour détecter un envahissement ganglionnaire dans le CCU visant à améliorer la gestion thérapeutique. Le projet est basé sur trois objectifs. En premier lieu, valider les marqueurs moléculaires E6 et E7 de VPH16 et 18 à partir des échantillons frais et des échantillons fixés dans des blocs de paraffine. En deuxième lieu, déterminer la fiabilité et la sensibilité des marqueurs pour la détection des macrométastases, des micrométastases et les cellules tumorales isolées en utilisant la technique de RT-qPCR. En troisième lieu et parallèlement au travail présenté dans ce mémoire, il est nécessaire de constituer une base de données des patientes qui ont le virus VPH16 et 18 intégré dans leur génome, qui ont été traitées et dont nous connaissons déjà le diagnostic final afin de valider la méthode (biobanque). Nous avons réussi à extraire de l’ARNm de haute qualité à partir d’échantillons complexes, à détecter les gènes E6 et E7 de VPH16 et 18 en RT-qPCR, et à déterminer précisément la limite de détection de E6 et E7 dans les échantillons frais qui est une proportion de 0,008% de cellules cancéreuses. Dans les échantillons fixés dans la paraffine, cette limite est de 0,02% et 0,05% pour E6-E7-VPH16 et E6-E7-VPH18 respectivement. Ceci comparativement à une limite de détection histologique de 1% qui est déterminée par immunohistochimie de CK19. Enfin, notre protocole est validé pour VPH18 dans les ganglions lymphatiques du CCU.

Tumores presacros. Reporte de serie de casos

Introducción: Los tumores presacros son un raro y diverso grupo de lesiones que se originan en el espacio presacro, infrecuente y de difícil diagnóstico. El objetivo de este trabajo es describir una serie de casos con respecto a las características clínicas, diagnóstico y manejo. Metodología: Recolección de pacientes quienes fueron diagnosticados con tumores presacros desde el año 1988 a 2013. Revisamos la clínica, tiempo de evolución, métodos diagnósticos, el abordaje quirúrgico, patología y complicaciones. Resultados: Nueve pacientes fueron incluidos en este trabajo. 7 de los 9 pacientes presentaron como síntoma principal el dolor. El tiempo de evolución medio fue de 9.8 meses. Diagnóstico fue realizado con tacto rectal en todos los pacientes y confirmado con tomografía axial pélvica 9 pacientes y resonancia magnética nuclear pélvica en 5 pacientes. La patología: teratoma quístico maduro (n = 3), cordoma (no: 1), quiste epidermoide (no=1), fibrohistiocitoma de bajo grado (no =1), fibromatosis (no =1), angiomixoma agresivo (no =1). El abordaje quirúrgico principal fue la vía posterior de (kraske) en 6 pacientes y en 2 por laparotomía. 1 paciente no se llevó a cirugía. La resección completa se obtuvo en un 87%. No se presentó complicaciones tempranas postoperatorias. Complicaciones tardías en 1 caso (12%) por obstrucción intestinal. Se presentó 1 caso de recurrencia por resección parcial tumoral. Conclusión: Los tumores presacros son una patología infrecuente a nivel mundial, siendo un reto para el cirujano su diagnóstico y manejo.