Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: Frequent and dangerous

Purpose: The pathophysiology of acute coronary syndromes (ACS) after noncardiac surgery is not established yet. Thrombosis over a vulnerable plaque or decreased oxygen supply secondary to anemia or hypotension may be involved. The purpose of this study was to investigate the pathophysiology of ACS complicating noncardiac surgery. Methods: Clinical and angiographic data were prospectively recorded into a database for 120 consecutive patients that had an ACS after noncardiac surgery (PACS), for 120 patients with spontaneous ACS (SACS), and 240 patients with stable coronary artery disease (CAD). Coronary lesions with obstructions greater than 50% were classified based on two criteria: Ambrose's classification and complex morphology. The presence of Ambrose's type II or complex lesions were compared between the three groups. Results: We analyzed 1470 lesions in 480 patients. In PACS group, 45% of patients had Ambrose's type II lesions vs. 56.7% in SACS group and 16.4% in stable CAD group (P < 0.001). Both PACS and SACS patients had more complex lesions than patients in stable CAD group (56.7% vs. 79.2% vs. 31.8%, respectively; P < 0.001). Overall, the independent predictors of plaque rupture were being in the group PACS (P < 0.001, OR 2.86; CI, 1.82-4.52 for complex lesions and P < 0.001, OR 3.43; CI, 2.1-5.6 for Ambrose's type II lesions) or SACS (P < 0.001, OR 8.71; CI, 5.15-14.73 for complex lesions and P < 0.001, OR 5.99; CI, 3.66-9.81 for Ambrose's type II lesions). Conclusions: Nearly 50% of patients with perioperative ACS have evidence of coronary plaque rupture, characterizing a type 1 myocardial infarction. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Comparison between endoscopic and open surgery in 37 patients with nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a rare benign vascular tumor of the nasopharynx. Although the treatment of choice is surgery, there is no consensus on what is the best approach. Aim: To compare surgical time and intraoperative transfusion requirements in patients undergoing endoscopic surgery versus open / combined and relate the need for transfusion during surgery with the time between embolization and surgery. Material and Methods: Study descriptive, analytical, retrospective study with a quantitative approach developed in the Otorhinolaryngology department of a teaching hospital. Analyzed 37 patients with angiofibroma undergoing surgical treatment. Data obtained from medical records. Analyzed with tests of the Fisher-Freeman-Halton and Games-Howell. Was considered significant if p <0.05. Study design: Historical cohort study with cross-sectional. Results: The endoscopic approach had a shorter operative time (p <0.0001). There is less need for transfusion during surgery when the embolization was performed on the fourth day. Conclusion: This suggests that the period ahead would be ideal to perform the process of embolization and endoscopic surgery by demanding less time would be associated with a lower morbidity. This study, however, failed to show which group of patients according to tumor stage would benefit from specific technical.

Clinical and nutritional status in the late postoperative of pancreaticoduodenectomy. Influence of pylorus preservation procedure

PURPOSE: To evaluate the nutritional status of patients in the late postoperative period of pancreaticoduodenectomy (PD) and compare the long-term outcome according to pylorus-preserving (PPPD) or the standard technique (SPD) in which the pylorus is resected. METHODS: This prospective study was conducted twelve months prior or more in patients who had underwent PD (PD Group, n=15) and health volunteers (Control Group, n=15). At a post hoc analysis, the PD Group was divided in PPPD Subgroup (n=9) and SPD Subgroup (n=6), according to the PD techniques. Gastrointestinal complaints and nutritional status were evaluated, apart from a biochemical assessment; Student t-test or Mann-Whitney test were used. RESULTS: The patients recovered their body weight and the gastrointestinal complaints were uncommon. The PD Group showed higher energy and protein intake even though BMI was lower than in Control Group. There were no differences in laboratorial data, except for higher glycemia, serum alkaline phosfatase and C-reactive protein in PD Group. There was no difference in the various parameters evaluated when the Subgroups (PPPD and SPD) were compared. CONCLUSION: For long-term pancreaticoduodenectomy, the gastrointestinal symptoms are minimal and the patients had the clinical and nutritional status preserved, regardless of pylorus preservation.

Experimental arthritis exacerbates Aggregatibacter actinomycetemcomitans-induced periodontitis in mice

Aim This study aimed to investigate whether chronic antigen-induced arthritis (AIA) influences infection-induced periodontitis (PD) in mice and whether PD modifies the clinical course of AIA. The contribution of anti-TNF-a therapy was also evaluated. Materials and methods The PD was induced in C57BL/6 mice by oral infection with Aggregatibacter actinomycetemcomitans. AIA was induced after infection. Anti-TNF-a and chlorhexidine therapies were used to investigate the role of TNF-a and oral infection on PD and AIA interaction. Maxillae, knee joints, lymph nodes and serum samples were used for histomorphometric, immunoenzymatic and/or real time-PCR analyses. Results Antigen-induced arthritis exacerbated alveolar bone loss triggered by PD infection. In contrast, PD did not influence AIA in the evaluated time-points. PD exacerbation was associated with enhanced production of IFN-? in maxillae and expression of the Th1 transcription factor tBET in submandibular lymph nodes. Increased serum levels of IL-6 and C-reactive protein were also detected. Anti-TNF-a and antiseptic therapies prevented the development and exacerbation of infectious-PD. Anti-TNF-a therapy also resulted in reduced expression of IFN-?, TNF-a and IL-17 in maxillae. Conclusions Altogether, the current results indicate that the exacerbation of infection-induced PD by arthritis is associated with an alteration in lymphocyte polarization pattern and increased systemic immunoreactivity. This process was ameliorated by anti-TNF-a and antiseptic therapies.

Negative and positive predictive values of nerve monitoring in thyroidectomy

Background Recurrent nerve injury is 1 of the most important complications of thyroidectomy. During the last decade, nerve monitoring has gained increasing acceptance in several centers as a method to predict and to document nerve function at the end of the operation. We evaluated the efficacy of a nerve monitoring system in a series of patients who underwent thyroidectomy and critically analyzed the negative predictive value (NPV) and positive predictive value (PPV) of the method. Methods. NIM System efficacy was prospectively analyzed in 447 patients who underwent thyroidectomy between 2001 and 2008 (366 female/81 male; 420 white/47 nonwhite; 11 to 82 years of age; median, 43 years old). There were 421 total thyroidectomies and 26 partial thyroidectomies, leading to 868 nerves at risk. The gold standard to evaluate inferior laryngeal nerve function was early postoperative videolaryngoscopy, which was repeated after 4 to 6 months in all patients with abnormal endoscopic findings. Results. At the early evaluation, 858 nerves (98.8%) presented normal videolaryngoscopic features after surgery. Ten paretic/paralyzed nerves (1.2%) were detected (2 unexpected unilateral paresis, 2 unexpected bilateral paresis, 1 unexpected unilateral paralysis, 1 unexpected bilateral paralyses, and 1 expected unilateral paralysis). At the late videolaryngoscopy, only 2 permanent nerve paralyses were noted (0.2%), with an ultimate result of 99.8% functioning nerves. Nerve monitoring showed absent or markedly reduced electrical activity at the end of the operations in 25/868 nerves (2.9%), including all 10 endoscopically compromised nerves, with 15 false-positive results. There were no false-negative results. Therefore, the PPV was 40.0%, and the NPV was 100%. Conclusions. In the present series, nerve monitoring had a very high PPV but a low NPV for the detection of recurrent nerve injury. (C) 2011 Wiley Periodicals, Inc. Head Neck 34: 175-179, 2012

Signs and Symptoms of Temporomandibular Dysfunction in Fibromyalgic Patients

Objective: The objective of this study was to determine the frequency of signs and symptoms of temporomandibular disorder (TMD) in fibromyalgic patients. Methods: Sixty subjects of both sexes (mean age, 49.2 +/- 13.8 years) with fibromyalgia (FM) diagnosis were included in this study. All patients were examined by a calibrated investigator to identify the presence of TMD using the Research Diagnostic Criteria for TMD. Results: The most common signs (A) and symptoms (B) reported by FM patients were (A) pain in the masticatory muscles (masseter, 80%; posterior digastric, 76.7%), pain in the temporomandibular joint (83.3%), and 33.3% and 28.3%, respectively, presented joint sounds when opening and closing the mouth; (B) headache (97%) and facial pain (81.7%). In regard to the classic triad for the diagnosis of the TMD, it was found that 35% of the FM patients presented, at the same time, pain, joint sounds, and alteration of the mandibular movements. It was verified that myofascial pain without limitation of mouth opening was the most prevalent diagnosis (47%) for the RDC subgroup I. For the subgroup II, the disk displacement with reduction was the most prevalent diagnosis (21.6%). For the subgroup III, 36.7% of the subjects presented osteoarthritis. Conclusions: Thus, there is a high prevalence of signs and symptoms of TMD in FM patients, indicating the need for an integrated diagnosis and treatment of these patients, which suggest that the FM could be a medium- or long-term risk factor for the development of TMD.

Restoration of the rabbit corneal surface after total epithelial debridement and complete limbal excision

How is the corneal epithelium restored when all of it plus the limbus have been eliminated? This investigation explored the possibility that this may be achieved through the conjunctival epithelium. The corneal epithelium of the right eye of 12 rabbits (Oryctolagus cuniculus) was totally scraped followed by surgical excision of the limbus plus 1.0-1.5 mm of the adjacent conjunctiva. Antibiotics and corticosteroids were applied for 1 week after surgery. Histological and immunohistochemical techniques were used to monitor the events taking place on the eye surface 2 weeks and 1, 3 and 6 months thereafter. Initially, the corneal surface was covered by conjunctival-like epithelium. After 1 month and more prominently at 3 and 6 months an epithelium displaying the morphological features of the cornea and reacting with the AE5 antibody was covering the central region. It is likely that the corneal epithelium originated from undifferentiated cells of the conjunctiva interacting with the corneal stroma.

Lean and Fat Mass Loss in Obese Patients Before and After Roux-en-Y Gastric Bypass: A New Application for Ultrasound Technique

This study aims to evaluate the thickness of the femoral quadriceps and biceps brachii and brachialis muscles bilaterally and the adjacent subcutaneous fat in patients undergoing gastric bypass Roux-en-Y before and after surgery, using ultrasound as the diagnostic method of choice. We studied 12 patients undergoing this surgical method preoperatively and during the first, third, and sixth postoperative months. During these periods, patients were evaluated by ultrasound to determine the thickness of subcutaneous adipose tissue and muscle of the upper and lower limbs. Postoperatively, these patients showed a reduction in the thickness of the upper and lower extremities muscle and adipose tissue as compared to their preoperative values. There was a significant difference in the loss of muscle thickness in all postoperative months and in the thickness of fatty tissue in the sixth month after surgery, compared to the preoperative muscle and fatty tissue thickness. Ultrasound can be considered as the diagnostic method of choice when assessment of the fat and lean body mass is required in morbidly obese patients before and after bariatric surgery.

Videofluoroscopic evaluation of mastication and swallowing in individuals with TMD

To study mastication and swallowing disorders in patients with temporomanclibular disorders (TMD). Objective: To investigate mastication and swallowing disorders in patients with severe TMD referred to surgery. Materials and Methods: Clinical and experimental study involving ten individuals with TMD submitted to deglutition videofluoroscopy. These patients did not have posterior teeth, mastication pain and food replacement in favor of pasty consistence food. The assessment of the oral and pharyngeal phases approached the following aspects: side of onset and preferential side for chewing, premature escape, remains of food residues in the oral cavity or in the pharyngeal recesses, number of necessary swallowing efforts, laryngeal penetration and/or tracheal aspiration. Results: During mastication and the oral phase we observed tongue compensatory movements upon chewing (n = 7; 70%), premature escape (n = 4; 40%), food remains in the cavity after swallowing (n = 5; 50%) and an excessive number of deglutition efforts (n = 5; 50%). On the pharyngeal phase we observed food remains in the valleculae (n = 6; 60%), in the pyriform sinuses (n = 4; 40%); laryngeal penetration (n = 1; 10%) and tracheal aspiration (n = 4; 40%). Conclusion: TMD patients may have alterations in their chewing and swallowing patterns, with laryngeal penetration and/or tracheal aspiration. The study indicates the need for a multidisciplinary assessment because of dysphagia in TMD patients.

Argon and Nd:YAG Lasers for Caries Prevention in Enamel

Objective: The aim of this study was to investigate the effect of Nd:YAG and argon laser irradiations on enamel demineralization after two different models to induce artificial caries. Background data: It is believed that the use of the high-intensity laser on the dental structure can lead to a more acid-resistant surface. Materials and methods: Twenty-one extracted human third molars were sectioned into tooth quarters. The quarters were distributed in three groups: Group I (control), untreated; Group II, Nd:YAG laser (60 mJ, 15 pps, 47.77 J/cm(2), 30 sec); and Group III, argon laser (250mW, 12 J/cm(2), 48 sec). Tooth quarters from each group were subjected to two different demineralization models: cycle 1, a 14 day demineralization (pH 4.5; 6 h) and remineralization (pH 7.0; 18 h) solutions, 37 degrees C and cycle 2, 48 h in demineralization solution (pH 4.5). Samples were prepared in slices (60-100 mu m thick) to be evaluated under polarized light microscopy. Demineralization areas were measured (mm(2)) (n = 11). Data were analyzed by ANOVA and Tukey's test (p < 0.05). Results: Means followed by different letters are significantly different: 0.25 A (control, cycle 48 h); 0.18 AB (control, cycle 14 days); 0.17 AB (Nd:YAG, cycle 14 days); 0.14 BC (argon, cycle 48 h); 0.09 BC (Nd:YAG, cycle 48 h), and 0.06 C (argon, cycle 14 days). Conclusions: The argon laser was more effective for caries preventive treatment than Nd: YAG laser, showing a smaller demineralization area in enamel.

Pre- and Postoperative Quantitative Analysis of Contour Abnormalities in Graves Upper Eyelid Retraction

Purpose: One of the most common problems of the surgical management of Graves upper eyelid retraction is the occurrence of eyelid contour abnormalities. In the present study, the postoperative contour of a large sample of eyelids of patients with Graves orbitopathy was measured. Methods: The postoperative upper eyelid contour of 62 eyes of 43 patients with Graves orbitopathy was subjectively classified by 3 experienced surgeons in 3 categories: poor, fair, and good. The shape of the eyelid contours in each category was then measured with a recently developed custom-made software by measuring multiple midpupil eyelid distances each 15 degrees along the palpebral fissure. The upper eyelid contour of 60 normal subjects was also quantified as a control group. Results: The mean ratio between the sum of the lateral and medial midpupil eyelid distances (lateral/medial ratio) was 1.10 +/- 0.11 standard deviation in controls and 1.15 +/- 0.13 standard deviation in patients. Postoperatively, the mean midpupil eyelid distance at 90 degrees was 4.16 +/- 1.13 mm standard deviation. The distribution lateral/medial ratios of the eyelids judged as having good contours was similar to the distribution of the controls with a modal value centered on the interval between 1.0 and 1.10. The distribution of lateral/medial ratios of the eyelids judged as having poor contour was bimodal, with eyelids with low and high lateral/medial ratios. Low lateral/medial ratios occurred when there was a lateral overcorrection, giving the eyelid a flat or a medial ptosis appearance. High lateral/medial ratios were due to a central or medial overcorrection or a lateral peak maintenance. Conclusions: Postoperative upper eyelid contour abnormalities can be quantified by comparing the sum of multiple midpupil eyelid distances of the lateral and medial sectors of the eyelid. Low and high lateral/medial ratios are anomalous and judged as unpleasant. (Ophthal Plast Reconstr Surg 2012;28:429-433)

Anatomical and functional evaluation of tympanoplasty using a transitory natural latex biomembrane implant from the rubber tree Hevea brasiliensis

PURPOSE: To compare the role of transitory latex and sylastic (R) implants in tympanoplasty on the closure of tympanic perforations. METHODS: A randomized double-blind prospective study was conducted on 107 patients with chronic otitis media submitted to underlay tympanoplasty and divided at random into three groups: control with no transitory implant, latex membrane group, and sylastic (R) membrane group. RESULTS: Greater graft vascularization occurred in the latex membrane group (p<0.05). Good biocompatibility was obtained with the use of the latex and silicone implants, with no effect on the occurrence of infection, otorrhea or otorragy. CONCLUSION: The use of a transitory latex implant induced greater graft vascularization, with a biocompatible interaction with the tissue of the human tympanic membrane.

Functional and morphometric differences between the early and delayed use of phototherapy in crushed median nerves of rats

This study evaluated the functional and quantitative differences between the early and delayed use of phototherapy in crushed median nerves. After a crush injury, low-level laser therapy (GaAs) was applied transcutaneously at the injury site, 3 min daily, with a frequency of five treatments per week for 2 weeks. In the early group, the first laser treatment started immediately after surgery, and in the delayed group, after 7 days. The grasping test was used for functional evaluation of the median nerve, before, 10, and 21 days after surgery, when the rats were killed. Three segments of the median nerve were analyzed histomorphometrically by light microscopy and computer analysis. The following features were observed: myelinated fiber and axon diameters, myelin sheath area, g-ratio, density and number of myelinated fibers, and area and number of capillaries. In the proximal segment (site of crush), the nerves of animals submitted to early and delayed treatment showed myelinated fiber diameter and myelin sheath area significantly larger compared to the untreated group. In the distal segment, the myelin sheath area was significantly smaller in the untreated animals compared to the delayed group. The untreated, early, and delayed groups presented a 50, 57, and 81% degree of functional recovery, respectively, at 21 days after injury, with a significant difference between the untreated and delayed groups. The results suggest that the nerves irradiated with low-power laser exhibit myelinated fibers of greater diameter and a better recovery of function.

HER-2, p53, p21 and hormonal receptors proteins expression as predictive factors of response and prognosis in locally advanced breast cancer treated with neoadjuvant docetaxel plus epirubicin combination

Abstract Background Neoadjuvant chemotherapy has been considered the standard care in locally advanced breast cancer. However, about 20% of the patients do not benefit from this clinical treatment and, predictive factors of response were not defined yet. This study was designed to evaluate the importance of biological markers to predict response and prognosis in stage II and III breast cancer patients treated with taxane and anthracycline combination as neoadjuvant setting. Methods Sixty patients received preoperative docetaxel (75 mg/m2) in combination with epirubicin (50 mg/m2) in i.v. infusion in D1 every 3 weeks after incisional biopsy. They received adjuvant chemotherapy with CMF or FEC, attaining axillary status following definitive breast surgery. Clinical and pathologic response rates were measured after preoperative therapy. We evaluated the response rate to neoadjuvant chemotherapy and the prognostic significance of clinicopathological and immunohistochemical parameters (ER, PR, p51, p21 and HER-2 protein expression). The median patient age was 50.5 years with a median follow up time 48 months after the time of diagnosis. Results Preoperative treatment achieved clinical response in 76.6% of patients and complete pathologic response in 5%. The clinical, pathological and immunohistochemical parameters were not able to predict response to therapy and, only HER2 protein overexpression was associated with a decrease in disease free and overall survival (P = 0.0007 and P = 0.003) as shown by multivariate analysis. Conclusion Immunohistochemical phenotypes were not able to predict response to neoadjuvant chemotherapy. Clinical response is inversely correlated with a risk of death in patients submitted to neoadjuvant chemotherapy and HER2 overexpression is the major prognostic factor in stage II and III breast cancer patients treated with a neoadjuvant docetaxel and epirubicin combination.

Periocular basal cell carcinoma: cost of topical immunotherapy versus estimated cost of surgical treatment

Purpose: The objective of this study was to compare the estimated cost of clinical and surgical treatment for basl cell carcinoma of the eyelid. Methods: This was a pilot study of 12 patients with basal cell carcinoma receiving treatment with 5% imiquimod cream at the ocular plastic surgery center, medical school University of Sao Paulo (HC-FMUSP, Brazil). The cost of clinical treatment was estimated based on the time of treatment and amount of medication consumed by patients in the home setting. The cost of surgical treatment was estimated by ophthalmologists with experience in reconstructive plastic surgery based on analysis of images of the same patients. Surgeons responded to a questionnaire with four questions about surgical technique, surgical materials required, estimated duration of surgery and type of anesthesia. Results: Immunotherapy lasted from 8 to 12 weeks. All patients reported each cold-stored sachet with 5% imiquimod cream lasted 3 days. According to the institution, a box with 12 sachets costs BRL 480.00. Patients required 1.58-3.11 boxes for complete treatment, corresponding to a total cost of BRL 758.40-1,492.80. Based on image analysis, surgeons evaluated surgery would require 1-3 hours. The estimated cost of surgery room and staff was BRL 263.00, to which the cost of supplies was added. Thus, the total cost of surgical treatment was BRL 272.61-864.82. On the average, immunotherapy was 57,64% more costly than surgical treatment. Conclusions: Malignant eyelid tumors are a common finding in clinical ophthalmology. Surgery is still the treatment of choice at our institution, but immunotherapy with 5% imiquimod cream may be indicated for patients with multiple lesions or high surgical risk and for patients declining surgery for reasons of fear or esthetic concerns. The ability to estimate costs related to the treatment of malignant eyelid tumors is an important aid in the financial planning of health care institutions. Further studies should evaluate the possibility of institutions equating the cost of immunotherapy and surgical treatment by acquiring similar but less expensive medications.