Respiratory physiotherapy can increase lower esophageal sphincter pressure in GERD patients

Background: Inspiratory muscle training (IMT) has been shown to increase diaphragm thickness. We evaluated the effect of IMT on mid-respiratory pressure (MRP) in patients with gastroesophageal reflux disease (GERD) and hypotensive lower esophageal sphincter (LES), and compared the results with a sham group. Methods: Twenty consecutive patients (progressive loading group) and 9 controls (sham group) were included. All patients had end expiratory pressure (EEP) between 5 and 10 mmHg, underwent esophageal manometry and pulmonary function tests before and after 8 weeks of training, and used a threshold IMT twice daily. The threshold IMT was set at 30% of the maximal inspiratory pressure for the progressive loading group; while, the threshold for sham-treated patients was set at 7 cmH(2)O for the whole period. Results: There was an increase in MRP in 15 (75%) patients in the progressive loading group, with an average gain of 46.6% (p<0.01), and in six (66%) patients in the sham group with a mean increase of 26.2% (p<0.01). However, there was no significant difference between the groups (p = 0.507). The EEP also increased compared with measurements before training (p<0.01), but it did not differ between groups (p = 0.727). Conclusion: IMT increased LES pressure in patients with GERD, in both the treatment and sham groups, after an eight-week program. Although there was no statistically significant difference between groups, suggesting the pressure increase in LES occurs regardless of the resistance load of the threshold IMT. These findings need to be confirmed in further studies with a larger sample. Registration number: 0922/09. (C) 2012 Elsevier Ltd. All rights reserved.

Coronary to Bronchial Artery Fistula: Are We Treating it Right?

Fistulas between coronary artery and bronchial artery may be present from birth, with few hemodynamic consequences, and may remain closed due to similarity of the filling pressures at these 2 sites.(1) They can also be secondary to pulmonary artery occlusive disease or chronic pulmonary inflammation.(2,3) These pulmonary changes may cause a dilation of the fistula and make it functional, causing angina pectoris by coronary steal syndrome, which is the most common symptom. The presentation may also be composed of episodes of hemoptysis, heart failure, and infective endocarditis. However, most patients remain asymptomatic. The ones that need treatment may not have a good response to the medical management, requiring an intervention. This can be done using embolization coils, stents grafts, and performing surgical ligation of the fistulas.(2-4) J INVASIVE CARDIOL 2012;24(11):E303-E304

Endovascular repair of a traumatic arteriovenous fistula involving the iliac bifurcation using an iliac branch device

Endovascular techniques have shown to be useful in the management of vascular injuries because they transform a complex and potentially dangerous procedure into a safe one. We present the case of a 39-year-old man with congestive heart failure and abdominal bruit 11 years after an abdominal gunshot wound. Imaging studies revealed an arteriovenous fistula involving the left iliac artery bifurcation, and an iliac branch device was used to treat it. Symptoms resolved, and follow-up imaging showed patency of the graft and closure of the arteriovenous communication. To our knowledge, this is the first report of a nonaneurysmal disease treated with this device. (J Vasc Surg 2012;55:1474-6.)

Pharyngocutaneous fistula following total laryngectomy

Pharyngocutaneous fistula (PCF) is the most common complication after total laryngectomy. Objectives: To establish the incidence of this complication and to analyze the predisposing factors. Method: This is a cross-sectional study of a historical cohort including 94 patients who underwent total laryngectomy. The following aspects were correlated to the occurrence of PCF: gender, age, tumor site, TNM staging, type of neck dissection, previous radiation therapy, previous tracheotomy, and use of stapler for pharyngeal closure. The following were considered in PCF cases: the day into postoperative care when the fistula was diagnosed, duration of occurrence, and proposed treatment. Results: Twenty (21.3%) patients had PCF. The incidence of PCF was statistically higher in T4 tumors when compared to T2 and T3 neoplasms (p = 0.03). The other analyzed correlations were not statistically significant. However, 40.9% of the patients submitted to tracheostomy previously had fistulae, against 21.1% of the patients not submitted to this procedure. Conclusion: Advanced primary tumor staging is correlated with higher incidences of PCF.

Saphenofemoral arteriovenous fistula as hemodialysis access

Abstract Background An upper limb arteriovenous (AV) fistula is the access of choice for haemodialysis (HD). There have been few reports of saphenofemoral AV fistulas (SFAVF) over the last 10-20 years because of previous suggestions of poor patencies and needling difficulties. Here, we describe our clinical experience with SFAVF. Methods SFAVFs were evaluated using the following variables: immediate results, early and late complications, intraoperative and postoperative complications (up to day 30), efficiency of the fistula after the onset of needling and complications associated to its use. Results Fifty-six SFAVF fistulas were created in 48 patients. Eight patients had two fistulas: 8 patent (16%), 10 transplanted (20%), 12 deaths (24%), 1 low flow (2%) and 20 thrombosis (39%) (first two months of preparation). One patient had severe hypotension during surgery, which caused thrombosis of the fistula, which was successfully thrombectomised, four thrombosed fistulae were successfully thrombectomised and revised on the first postoperative day. After 59 months of follow-up, primary patency was 44%. Conclusion SFAVF is an adequate alternative for patients without the possibility for other access in the upper limbs, allowing efficient dialysis with good long-term patency with a low complication rate.

Esophageal contractions, bolus transit and perception of transit after swallows of liquid and solid boluses in normal subjects

CONTEXT: Esophageal dysphagia is the sensation that the ingested material has a slow transit or blockage in its normal passage to the stomach. It is not always associated with motility or transit alterations. OBJECTIVES: To evaluate in normal volunteers the possibility of perception of bolus transit through the esophagus after swallows of liquid and solid boluses, the differences in esophageal contraction and transit with these boluses, and the association of transit perception with alteration of esophageal contraction and/or transit. METHODS: The investigation included 11 asymptomatic volunteers, 4 men and 7 women aged 19-58 years. The subjects were evaluated in the sitting position. They performed swallows of the same volume of liquid (isotonic drink) and solid (macaroni) boluses in a random order and in duplicate. After each swallow they were asked about the sensation of bolus passage through the esophagus. Contractions and transit were evaluated simultaneously by solid state manometry and impedance. RESULTS: Perception of bolus transit occurred only with the solid bolus. The amplitude and area under the curve of contractions were higher with swallows of the solid bolus than with swallows of the liquid bolus. The difference was more evident in swallows with no perception of transit (n = 12) than in swallows with perception (n = 10). The total bolus transit time was longer for the solid bolus than for the liquid bolus only with swallows followed by no perception of transit. CONCLUSION: The results suggest that the perception of esophageal transit may be the consequence of inadequate adaptation of esophageal transit and contraction to the characteristics of the swallowed bolus.

Infective endocarditis with left to right intracardiac fistula due to Streptococcus anginosus - a rare complication caused by an even rarer bacterium

Although infective endocarditis (IE) has been described in reports dating from the Renaissance, the diagnosis still challenges and the outcome often surprises. In the course of time, diagnostic criteria have been updated and validated to reduce misdiagnosis. Some risk factors and epidemiology have shown dynamic changes since degenerative valvular disease became more predominant in developed countries, and the mean age of the affected population increased. Despite streptococci have been being well known as etiologic agents, some groups, although rare, have been increasingly reported (e.g., Streptococcus milleri.) Intracardiac complications of IE are common and have a worse prognosis, frequently requiring surgical treatment. We report a case of a middle-aged diabetic man who presented with prolonged fever, weight loss, and ultimately severe dyspnea. IE was diagnosed based on a new valvular regurgitation murmur, a positive blood culture for Streptococcus anginosus, an echocardiographic finding of an aortic valve vegetation, fever, and pulmonary thromboembolism. Despite an appropriate antibiotic regimen, the patient died. Autopsy findings showed vegetation attached to a bicuspid aortic valve with an associated septal abscess and left ventricle and aortic root fistula connecting with the pulmonary artery. A large thrombus was adherent to the pulmonary artery trunk and a pulmonary septic thromboemboli were also identified.

Endovascular Treatment of Tentorial Dural Arteriovenous Fistulae

Tentorial dural arteriovenous fistula (DAVF) is a rare vascular disease, which accounts for less than 4% of all cases of intracranial DAVF Because of the high risk of intracranial hemorrhage, patients with tentorial DAVF need aggressive treatment. Management approaches are still controversial, and endovascular treatment has emerged as an effective alternative. In the current work, we describe our experience with the endovascular approach in the treatment of these deep and complex DAVF of the tentorium. Eight patients were treated between January 2006 and July 2009. Six patients (75%) presented with intracranial hemorrhage related to the DAVF rupture. Four patients (50%) had subarachnoid bleeding and two had intraparenchymal hematoma. Endovascular treatment was performed via the transarterial route alone in five cases (62.5%), by the transvenous approach in two cases (25.0%) and in a combined procedure using both arterial and venous routes in one patient (12.5%). Complete obliteration of the fistula was achieved in all cases. The outcome at 15 months was favorable (modified Rankin scale 0-3) in seven (87.5%) patients. Complete cure of the lesion was confirmed in these cases. This paper reports on the effectiveness of endovascular treatment in tentorial DAVF management The choice of the venous versus the arterial approach is determined by regarding different anatomical dispositions.

Abdominal compression: A new intraoperative maneuver to detect chyle fistulas during left neck dissections that include level IV

Background Chyle fistulas may occur after left neck dissections that include level IV, due to injury of the thoracic duct or of 1 of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. In this cohort study, we sought to describe a simple new maneuver, intraoperative abdominal compression, which can effectively help to identify an open major lymphatic duct on level IV at the end of a neck dissection. Patients and Methods From March 1989 to September 2010, 206 patients underwent neck dissections involving left level IV, and underwent intraoperative abdominal compression. There were 119 men and 87 women, with ages ranging from 18 to 81 years (median, 52 years). One hundred forty-four patients had squamous cell carcinomas, 54 had thyroid carcinomas, 5 had malignant melanomas, and 3 had salivary cancers. Distribution by type of left neck dissection was: selective including levels II, III, and IV (73 cases; 35.4%), selective including levels II, III, IV, and V (55 cases; 26.6%), selective including levels I, II, III, and IV (12 cases; 5.8%), modified radical (47 cases; 22.8%), and radical (19 cases; 9.2%). In all cases, at the end of the procedure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with nonabsorbable sutures. After ventilating the patient, the intraoperative abdominal compression was repeated to reassure complete occlusion of the lymphatic vessel. Results In 13 cases (6.3%), a chyle leak was detected after performing the intraoperative abdominal compression. All leaks except for 2 were successfully controlled after 1 attempt. In these 2 patients, a patch of muscle and fat tissue was applied with fibrin glue on the top. In 1 of these patients, another chyle leak in a different location was detected only at the second intraoperative abdominal compression, and was also effectively closed. Postoperatively, there were 2 (1%) chyle fistulas, both among these 13 cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 193 patients in whom intraoperative abdominal compression did not demonstrate lymphatic leak. Conclusion To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, intraoperative abdominal compression was able to detect an open lymphatic vessel in 6.3% of the cases, as well as to assure its effective sealing in the remaining 93.7% of the patients. Moreover, no life-threatening high-volume fistula was noted in this study. (C) 2012 Wiley Periodicals, Inc. Head Neck, 2012

Descrição morfológica do diafragma do sagui-de-tufo-branco (Callithrix jacchus)

O músculo diafragma, encontrado apenas nos mamíferos, é o principal músculo no processo respiratório, servindo de fronteira entre as cavidades torácica e abdominal. Sua importância também ganha destaque em pesquisas realizadas no âmbito dos enxertos, empregando-se diversos tipos de membranas biológicas para o reparo de defeitos diafragmáticos, os quais podem gerar hérnias diafragmáticas. Apesar de muitos estudos já conduzidos para com os primatas não humanos, especialmente no que tange a espécie do novo mundo Callithrix jacchus (Sagui-de-tufo-branco), oriundo do nordeste brasileiro, as pesquisas envolvendo o uso do diafragma em tal espécie é inexistente. Deste modo objetivou-se caracterizar a morfologia e a biometria do diafragma na espécie Callithrix jacchus de ambos os sexos, analisando possíveis divergências estruturais entre machos e fêmeas. Para tal foram utilizados quatros animais, 2 machos e 2 fêmeas, adultos, que vieram a óbito por causas naturais, provenientes de um criadouro comercial. Após fixação em solução de formaldeído 10% os animais foram devidamente dissecados para fotodocumentação e em seguida o diafragma coletado para efetuação da biometria (comprimento e largura) com o uso de um paquímetro e para o processamento histológico por meio da coloração de hematoxilina-eosina e tricrômio de masson, da porção muscular. As mensurações feitas permitiram concluir que não houve diferenças signifcativas entre machos e femeas. A topografia e a presença de três aberturas (forame da veia cava caudal, hiato aórtico e esofágico) na extensão do diafragma corroboram com descrições na literatura classica para outros mamíferos. A presença de um centro tendíneo em "V" difere do encontrado para animais como o peixe-boi e porquinho-da-india, mas é similar ao encontrado para o gambá-de-orelhas-brancas e rato albino. No que diz respeito aos achados histológicos conclui-se que as fibras musculares estão dispostas de forma organizada, apresentam diâmetro grande e núcleos basais, tendo, portanto, características similares do músculo estriado esquelético tanto nos animais machos como nas fêmeas.

Comparative Analysis of the Complications of 5347 Endomyocardial Biopsies Applied to Patients After Heart Transplantation and With Cardiomyopathies: A Single-center Study

Introduction. Endomyocardial biopsy (EMB) plays an important role in allograft surveillance to screen an acute rejection episode after heart transplantation (HT), to diagnose an unknown cause of cardiomyopathies (CMP) or to reveal a cardiac tumor. However, the procedure is not risk free. Objective. The main objective of this research was to describe our experience with EMB during the last 33 years comparing surgical risk between FIT versus no-HT patients. Method. We analyzed retrospectively the data of 5347 EMBs performed from 1978 to 2011 (33 years). For surveillance of acute rejection episodes after HT we performed 3564 (66.7%), whereas 1777 (33.2%) for CMP diagnosis, and 6 (1.0%) for cardiac tumor identification. Results. The main complications due to EMB were divided into 2 groups to facilitate analysis: major complications associated with potential death risk, and minor complications. The variables that showed a significant difference in the HT group were as follows: tricuspid Injury (.0490) and coronary fistula (.0000). Among the no-HT cohort they were insufficient fragment (.0000), major complications (.0000) and total complications (.0000). Conclusions. EMB can be accomplished with a low risk of complications and high effectiveness to diagnose CMP and rejection after HT. However, the risk is great among patients with CMP due to their anatomic characteristics. Children also constitute a risk group for EMB due to their small size in addition to the heart disease. The risk of injury to the tricuspid valve was higher among the HT group.

Extreme bariatric endoscopy: stenting to reconnect the pouch to the gastrojejunostomy after a Roux-en-Y gastric bypass

Among the possible complications of bariatric surgery, fistula and partial dehiscence of the gastric suture are well known. Reoperation often is required but results in significant morbidity. Endoscopic treatment of some bariatric complications is feasible and efficient. A modified metallic stent was placed between the gastroaesophageal junction and the alimentary jejunal limb, allowing the passage of a nasoenteric feeding tube into the jejunal limb. Endoscopy showed disruption of nearly the entire staple line at the gastric pouch. The modified stent was placed and allowed wound healing. After 31 days, the stent had migrated and was removed endoscopically. Total clousure of the fistula was reported 30 days afterward. Endoscopic treatment of some bariatric surgery complications is feasible and has been reported previously. This report presents a case of a serious leakage treated by placement of a self-expandable metal stent to bridge the fistula.

Lower third molar infection with purulent discharge through the external auditory meatus. Case report and review of literature

This manuscript reports an uncommon case of inferior third molar facial abscess with purulent secretion drainage through the left external acoustic meatus. The patient's left external acoustic meatus was filled with a purulent secretion observed on a CT scan. He underwent surgery to drain the facial abscess. Despite facial abscesses being routine occurrences, the literature does not contain many case reports of odontogenic facial abscesses with drainage via the external acoustic meatus. These situations occur in two possible ways: multiple fissures in the anterior wall of the cartilaginous portion of the external acoustic meatus; and congenital defects that are occasionally present in the anterior-superior aspect of the external acoustic meatus, known as the foramen of Huschke, which allow communication between the external acoustic meatus and mandibular fossa. These defects may also predispose the patient to the spread of the infection or tumour from the external auditory canal to the infratemporal fossa and vice versa. No otological sequelae were observed in this case. The authors conclude that the hypothesis of bone malformation cannot be excluded, and affirm that any facial abscess requires appropriate and immediate treatment for adequate resolution, by removing the causal factor and providing systemic support.

Perimedullary arteriovenous fistulas in children: report on six cases

Background Perimedullary arteriovenous fistulas (PMAVFs) are rare spinal lesions and even more uncommon in children. Objective The aim of this study was to document rare occurrences of this type of arteriovenous malformation in six children treated at our institution. Methods The clinical data, radiological findings, and treatment in six cases of PMAVFs were reviewed. Six patients with PMAVFs were managed at our institution over a 5-year period. The patients (four girls and two boys), ranging in age from 6 to 15 years, presented with initially fluctuating, and eventually permanent and progressive, sudden-onset paraparesis, sensory disturbances, and sphincter dysfunction. The duration of symptoms before diagnosis ranged from 1 week to 13 years. Results All the patients underwent magnetic resonance imaging and spinal selective angiography, which demonstrated the characteristic imaging of an arteriovenous fistula. Embolization of the arteriovenous fistula was initially attempted in three patients with successful occlusion of the fistula in two. For the remaining cases, open surgery was performed, with complete occlusion of the fistula. There was no morbidity, regardless of the treatment performed. All the patients experienced neurological improvement after treatment. Conclusions No specific clinical or radiological characteristic of PMAVFs in the pediatric population was observed when our series was compared with a general series. Early diagnosis and timing of the therapeutic intervention seemed to avoid the development of irreversible ischemic myeloradiculopathy and prevented hemorrhage. Treatment for PMAVFs is difficult to standardize because these are extremely rare lesions with different angioarchitecture configurations.

ANATOMY OF NERITINA ZEBRA FROM GUYANA AND BRAZIL (MOLLUSCA: GASTROPODA: NERITIDAE)

Neritina zebra is a common brackish water gastropod living on muddy bottoms with poorly known morphological characters. The morphology, including the variety of colour and pattern of shells, and the anatomy are described. We mainly analyzed the animals collected in the estuary of the Ceara river, Ceara, Brazil, from "Parque Estadual do rio Coco", and specimens from other places deposited in institutional collections, from French Guyana (topotypes) to Sao Paulo. A complete anatomical description is performed, including illustration and discussion ninth concerned to systematics. Amongst the more important anatomical data are: heart diotocardian; kidneys solid; anterior esophagus with pair of ventral esophageal pouches; odontophore with 4 cartilages and 2 horizontal muscles (m6, m6a); males with penis dorsal-right to snout, bearing a terminal papilla; pallial oviduct triaulic, possessing 3 pallial apertures.