Laparoscopic Duodenal-Jejunal Bypass for the Treatment of Duodenal Obstruction Caused by Annular Pancreas: Description of a Surgical Technique

Annular pancreas is a rare congenital anomaly, which is only surgically treated in symptomatic cases. Surgical treatment consists of bypassing the duodenal transit by gastrojejunal or duodenal-jejunal anastomosis. In the absolute majority of published cases, laparotomy is the most widely used access technique. The aim of this article is to report a case of an annular pancreas and describe the technical steps involved in carrying out a laparoscopic duodenal-jejunal anastomosis, for correction of the duodenal obstruction. The patient`s recovery was uneventful; she was discharged on the fourth postoperative day and remained asymptomatic for the 2-year, outpatient follow-up period. Laparoscopic duodenal-jejunal bypass is shown to be feasible and safe, and produce less surgical trauma, when carried out by an experienced surgeon who is duly trained and familiar with the laparoscopic technique.

Anterior Selective Amygdalohippocampectomy: Technical Description and Microsurgical Anatomy

OBJECTIVE: We introduce a technique for performing a selective amygdalohippocampectomy (AH) through a minisupraorbital approach. METHODS: A minisupraorbital craniotomy and an anterior selective AH were performed in 8 cadaver heads (16 sides). The anatomic specimens were analyzed, and the extent of resection of the hippocampus and amygdala was evaluated. Surgically relevant measurements were performed using anatomic specimens. An image-guided system was used to document the extent of the anterior AH. Laboratory data were used to support the clinical application of the technique. RESULTS: The anterior route allowed removal of the amygdala and hippocampus, as confirmed by anatomic assessment. The image-guided system and anatomic evaluation confirmed that the amygdala and hippocampus can be accessed and removed through this route. The mean distance between the anterior aspect of the uncus and the tip of the temporal horn was 17.0 +/- 4.6 mm; the mean distance from the head of the hippocampus to the posterior border of the cerebral peduncles was 26.0 +/- 3.2 mm. Clinical application resulted in satisfactory removal of the amygdala and hippocampus. CONCLUSION: The anterior route for selective AH is a logical and straightforward approach to the mesial temporal lobe. Compared with other variations, it is less invasive and destructive, especially in terms of the fibers of the optic pathway, temporal stem, and lateral temporal neocortex.

Height and weight gains in a nutrition rehabilitation day-care service

Objective: To evaluate nutritional recovery patterns in 106 undernourished children assisted by the Center of Nutritional Recovery and Education (CREN, in Portuguese) between January 1995 and December 1999. Design: CREN assists undernourished children aged 0 to 72 months living in the southern regions of Sao Paulo, in an outpatient setting. Nutritional status was assessed by Z-scores of weight-for-age, height-for-age and weight-for-height. Nutritional recovery evaluation considered Z-score gains in weight-for-age and height-for-age, grouping into four categories (Z-score increment of 0.50 between groups). Children with birth weight less than 2500 g were classified as low birth weight (LBW), while those born at term and with LBW were classified as small for gestational age. Setting: CREN (Center of Nutritional Recovery and Education in Portuguese), Sao Paulo, Brazil. Subjects: One hundred and six children from CREN. Results: Among the 106 evaluated children, ninety-eight (92.5%)recovered their weight or height and seventy-two (67.9%) recovered both. Nearly half of studied children presented a nutritional recovery (increase in Z-score) of more than 0.50 in height-for-age (46.2%) and about 40% in weight-for-age (38.7%). Multivariate analysis showed that treatment duration and initial weight-for-age contributed to weight-for-age Z-score increment, explaining 25% of the variation; and treatment duration, initial height-for-age and weight-for-age Z-score increment contributed to height-for-age Z-score increment, explaining 62% of the variation. Conclusions: Our findings show that nutritional recovery among children who attended CREN was influenced primarily by the degree of nutritional deficit at admission. It has also been shown that biological variables are more important than socio-economic status in determining the rate of nutritional recovery.

TNF receptor-associated periodic syndrome (TRAPS): Description of a novel TNFRSF1A mutation and response to etanercept

TRAPS is the most common of the autosomal dominant periodic fever syndromes. It is caused by mutations in the TNFRSF1A gene, which encodes for the type 1 TNF-receptor (TNFR1). We describe here a Brazilian patient with TRAPS associated to a novel TNFRSF1A de novo mutation and the response to anti-TNF therapy. The patient is a 9-year-old girl with recurrent fevers since the age of 3 years, usually lasting 3 to 7 days, and recurring every other week. These episodes are associated with mild abdominal pain, nausea, vomiting and generalized myalgia. Recurrent conjunctivitis and erysipela-like skin lesions in the lower limbs also occur. Laboratory studies show persistent normocytic normochromic anemia, thrombocytosis, elevated erythrocyte sedimentation rate and C-reactive protein. IgD levels are normal. Mutational screening of TNFRSF1A revealed the association of a novel C30F mutation with the common R92Q low-penetrance mutation. The R92Q mutation is seen in 5% of the general population and is associated with an atypical inflammatory phenotype. The patient had a very good response to etanercept, with cessation of fever and normalization of inflammatory markers. Our report expands the spectrum of TNFRSF1A mutations associated with TRAPS, adding further evidence for possible additive effects of a low-penetration R92Q and cysteine residue mutations, and confirms etanercept as an efficacious treatment alternative.

Phenotype-genotype analysis of cryopyrin-associated periodic syndromes (CAPS): Description of a rare non-exon 3 and a novel CIAS1 missense mutation

We describe in this paper the phenotype-genotype analysis of a Brazilian cohort of patients with cryopyrin-associated periodic syndromes (CAPS). Patient 1 presented with an urticarial rash and recurrent fever exacerbated by cold weather, arthritis, and anterior uveitis, thus, receiving a clinical diagnosis of familial cold autoinflammatory syndrome. CIAS1 sequencing identified the T436I mutation, previously associated to a clinical phenotype of chronic infantile neurological cutaneous and articular/neonatal onset multisystem inflammatory disease. Patient 2 developed a papular exanthema with daily fever shortly after birth, frontal bossing, patellae enlargement, and cognitive and motor impairments. Sequencing identified the exceedingly rare G755R CIAS1 mutation in exon 4. Patient 3 developed skin rash and articular symptoms 6 h after birth, followed by aseptic meningitis. He was found to have the novel C148Y missense mutation in CIAS1. This report expands the spectrum of CIAS1 mutations associated to clinical disease, suggests that the same mutation can be associated with different clinical syndromes, and supports the evidence that CAPS patients should always be screened for mutations outside exon 3.

Mucosal leishmaniasis: description of case management approaches and analysis of risk factors for treatment failure in a cohort of 140 patients in Brazil

Background Mucosal leishmaniasis is caused mainly by Leishmania braziliensis and it occurs months or years after cutaneous lesions. This progressive disease destroys cartilages and osseous structures from face, pharynx and larynx. Objective and methods The aim of this study was to analyse the significance of clinical and epidemiological findings, diagnosis and treatment with the outcome and recurrence of mucosal leishmaniasis through binary logistic regression model from 140 patients with mucosal leishmaniasis from a Brazilian centre. Results The median age of patients was 57.5 and systemic arterial hypertension was the most prevalent secondary disease found in patients with mucosal leishmaniasis (43%). Diabetes, chronic nephropathy and viral hepatitis, allergy and coagulopathy were found in less than 10% of patients. Human immunodeficiency virus (HIV) infection was found in 7 of 140 patients (5%). Rhinorrhea (47%) and epistaxis (75%) were the most common symptoms. N-methyl-glucamine showed a cure rate of 91% and recurrence of 22%. Pentamidine showed a similar rate of cure (91%) and recurrence (25%). Fifteen patients received itraconazole with a cure rate of 73% and recurrence of 18%. Amphotericin B was the drug used in 30 patients with 82% of response with a recurrence rate of 7%. The binary logistic regression analysis demonstrated that systemic arterial hypertension and HIV infection were associated with failure of the treatment (P < 0.05). Conclusion The current first-line mucosal leishmaniasis therapy shows an adequate cure but later recurrence. HIV infection and systemic arterial hypertension should be investigated before start the treatment of mucosal leishmaniasis. Conflicts of interest The authors are not part of any associations or commercial relationships that might represent conflicts of interest in the writing of this study (e.g. pharmaceutical stock ownership, consultancy, advisory board membership, relevant patents, or research funding).

Comparison of language impairment in late-onset depression and Alzheimer`s disease

Objectives: Depression and dementia are highly prevalent in the elderly. Language impairment is an inherent component of Alzheimer`s disease (AD), which can also be encountered in depressed patients. The aim of this study wasto compare the profiles of language abilities in late-onset depression and mild AD groups. Methods: We studied 25 patients with late-onset depression (mean age 73.6 +/- 6.6 years; schooling 9.1 +/- 5.7 years) and 30 patients with mild AD (77.6 +/- 5.4 years; 7.5 +/- 7.1 years) using the Arizona Battery for Communication Disorders of Dementia (ABCD), compared to a group of 30 controls (73.8 +/- 5.8 years; 9.1 +/- 5.4 years). Cut-off scores to discriminate between Controls x Depression and Depression x AD were determined. Results: Depressed patients` scores were similar to AD in confrontation naming, concept definition, following commands, repetition and reading comprehension (sentence). Episodic memory and mental status subtests were useful in differentiating depressed patients from AD, a result that was reproduced when using analysis of covariance to control for the effect of age in the same subtests (p = 0.01 and 0.04, respectively). Conclusion: Language impairment resembling AD was found in the aforementioned language subtests of the ABCD in elderly depressed patients; the mental status and episodic memory subtests were useful to discriminate between AD and depression. The ABCD has proven to be a suitable tool for language evaluation in this population and should aid in the differentiation of AD and pseudodementia (as that of depression).

Description of Nosocomial Infection Prevention Practices by Anesthesiologists in a University Hospital

Kishi D; Videira RLR Description of Nosocomial Infection Prevention Practices by Anesthesiologists in a University Hospital. Background and objectives: Anesthesiologists play an important role in the prevention of nosocomial infections. In anesthetic practice, physiologic barriers are routinely breached, allowing patient contamination with microorganisms and the consequent development of infection. The lack of adhesion to recommended practices can facilitate transmission of microorganisms. It is important to describe prophylactic practices of anesthesia-related nosocomial infections performed by anesthesiologists. Methods: Structured questionnaires were distributed to be answered voluntarily and anonymously by anesthesiologists. Results: Among 112 anesthesiologists, 75% answered the questionnaire. Surgical mask is used by 95.2% of anesthesiologists, 96.3% wear gloves frequently, 98.9% wear sterile gloves for neuraxial block, 91.3% use sterile technique for central venous puncture, 95.1% wash their hands between cases, 91.6% try to maintain the endotracheal tube sterile, 96.3% discard the prefilled propofol syringe at the end of each anesthesia, 30% clean the vials before using it in the neuraxial blocks, and 19.8% clean the vials before intravenous use. Conclusions: Respondents showed good adhesion to practices of nosocomial infection prophylaxis and to improve them educational multidisciplinary campaigns are necessary.

Participatory ergonomics: Understanding the contributions of reflection groups in a hospital food service

Aim: To identify how the methodology of Reflection Groups (RG) can contribute to approach social-psychological problems, so often observed as obstacles in PE efforts. The objective was also to verify the contributions from RG to the implementation of ergonomics recommendations, which were a starting point and organized group discussions. Method: A concrete case was used as an illustration, and studied in depth: RG with administration and production workers` representatives from the Department of Nutrition and Dietetics of a cardiologic hospital in Sao Paulo, Brazil. RG are temporary thinking groups, taking place outside the workplace and having delegative and consultive participation. They make use of Operative Groups, an adapted form of tripartite group, activity as an instrumental resource, group dynamic techniques and videotaping. In 2007, 31 meetings took place during paid working hours with 7 groups of different composition, ranging from 1.5 h to 3 h. Results: Additionally to the positive effects in communication and psychosocial environment, RG could also contribute to changes in interpersonal relationships, cooperation, personal and work behaviours. By dealing with aspects which could hinder the explicit task: fears, conflicts, and stereotyped beliefs and behaviours; resistance to change could be broken and group members could learn. RG allowed input about new risks; continuous information and feedback about ongoing ergonomics interventions so that immediate corrective action could be taken. The main form of participation was in administrative, organizational, and psychosocial problems which required a better clarification and identification of their real causes, commitment, and elaboration of strategies and negotiation of different stakeholders in their solution. Conclusion: RG takes advantage of homogeneous and heterogeneous groups, in face to face communication. The interactions in the groups are task-oriented (explicit task) but attaining groups` goals depends on a relational interaction (implicit task). Relevance to industry: Reflection groups can bring important contributions to ergonomics and industry because they favour the discussion, disclosure of problems and incorporation of solutions, enabling interventions in working organization, psychosocial environment and relationships in a collective and participatory approach, promoting health and social integration. (C) 2010 Elsevier B.V. All rights reserved.

A description of adaptive and maladaptive behaviour in children and adolescents with Cri-du-chat syndrome

Background Psychological tests can be useful to record adaptive and maladaptive behaviours of children with intellectual disability. The objective of this study was to describe the adaptive and maladaptive behaviour of children and adolescents with Cri-du-chat syndrome. Methods The sample consisted of 10 children and adolescents with Cri-du-chat syndrome (mean chronological age = 11.3 years, mean mental age = 18 months). The developmental quotient was calculated through the Psychoeducational Profile - Revised. An observational protocol was used to record adaptive and maladaptive behaviours. Results The number of maladaptive behaviours observed was different among participants. However, all of them had high rates of adaptive behaviours, such as rule-following. Conclusions These results, though preliminary, justify that we continue to think about the need for psychoeducational interventions aimed at stimulating the repertoire of adaptive behaviours, in people with Cri-du-chat syndrome.

Periurethral Suspension Stitch During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of the Technique and Continence Outcomes

Background: Several studies have shown that robot-assisted laparoscopic radical prostatectomy (RALP) is feasible, with favorable complication rates and short hospital times. However, the early recovery of urinary continence remains a challenge to be overcome. Objective: We describe our technique of periurethral retropubic suspension stitch during RALP and report its impact on early recovery of urinary continence. Design, setting, and participants: We analyze prospectively 331 consecutive patients who underwent RALP, 94 without the placement of suspension stitch (group 1) and 237 with the application of the suspension stitch (group 2). Surgical procedure: The only difference between the groups was the placement of the puboperiurethral stitch after the ligation of the dorsal venous complex (DVC). The periurethral retropubic stitch was placed using a 12-in monofilament polyglytone suture on a CTI needle. The stitch was passed from right to left between the urethra and DVC, and then through the periostium on the pubic bone. The stitch was passed again through the DVC, and then through the pubic bone in a figure eight, and then tied. Measurements: Continence rates were assessed with a self-administered validated questionnaire (Expanded Prostate Cancer Index Composite [EPIC] at 1, 3, 6, and 12 mo after the procedure. Continence was defined as the use of no absorbent pads or no leakage of urine. Results and limitations: In group 1, the continence rate at 1, 3, 6, and 12 mo postoperatively was 33%, 83%, 94.7%, and 95.7%, respectively; in group 2, the continence rate was 40%, 92.8%, 97.9%, and 97.9%, respectively. The suspension technique resulted in significantly greater continence rates at 3 mo after RALP (p = 0.013). The median/mean interval to recovery of continence was also statistically significantly shorter in the suspension group (median: 6 wk; mean: 7.338 wk: 95% confidence interval [CI]: 6.387-8.288) compared to the non-suspension group (median: 7 wk; mean: 9.585 wk: 95% CI: 7.558-11.612; log rank test, p = 0.02). Conclusions: The suspension stitch during RALP resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 3 mo after the procedure. (C) 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Comparative Prevalence, Correlates of Impairment, and Service Utilization for Eating Disorders Across US Ethnic Groups: Implications for Reducing Ethnic Disparities in Health Care Access for Eating Disorders

Objective: The study compared the prevalence, correlates of functional impairment, and service utilization for eating disorders across Latinos, Asians, and African Americans living in the United States to non-Latino Whites. Method: Pooled data from the NIMH Collaborative Psychiatric Epidemiological Studies (CPES; NIMH, 2007) were used. Results: The prevalence of anorexia nervosa (AN) and binge-eating disorder (BED) were similar across all groups examined, but bulimia nervosa (BN) was more prevalent among Latinos and African Americans than non-Latino Whites. Despite similar prevalence of BED among ethnic groups examined, lifetime prevalence of any binge eating (ABE) was greater among each of the ethnic minority groups in comparison to non-Latino Whites. Lifetime prevalence of mental health service utilization was lower among ethnic minority groups studied than for non-Latino Whites for respondents with a lifetime history of any eating disorder. Discussion: These findings suggest the need for clinician training and health policy interventions to achieve optimal and equitable care for eating disorders across all ethnic groups in the United States. (C) 2010 by Wiley Periodicals, Inc.

Molecular Characterization of Patients with X-linked Hyper-IgM Syndrome: Description of Two Novel CD40L Mutations

Type 1, X-linked Hyper-IgM syndrome (HIGM1) is caused by mutations in the gene encoding the CD154 protein, also known as CD40 ligand (CD40LG). CD40L is expressed in activated T cells and interacts with CD40 receptor expressed on B lymphocytes and dendritic cells. Affected patients present cellular and humoral immune defects, with infections by intracellular, opportunistic and extracellular pathogens. In the present study we investigated the molecular defects underlying disease in four patients with HIGM1. We identified four distinct CD40L mutations, two of them which have not been previously described. P1 harboured the novel p.G227X mutation which abolished CD40L expression. P2 had a previously described frame shift deletion in exon 2 (p.I53fsX65) which also prevented protein expression. P3 demonstrated the previously known p.V126D change in exon 4, affecting the TNF homology (TNFH) domain. Finally, P4 evidenced the novel p.F229L mutation also located in the TNFH domain. In silico analysis of F229L predicted the change to be pathological, affecting the many hydrophobic interactions of this residue. Precise molecular diagnosis in HIGM syndrome allows reliable detection of carriers, making genetic counselling and prenatal diagnosis possible.

Language impairment in euthymic, elderly patients with bipolar disorder but no dementia

Background: Neurocognitive impairment is known to occur in euthymic bipolar patients, but language alterations have not been thoroughly investigated. The aim of this study is to examine the performance in language tests of a sample of elderly patients with bipolar disorder. Methods: We studied 33 eurthymic elderly patients with bipolar disorder but no dementia and 33 healthy individuals, matched for age and education, who were compared in terms of their CAMCOG global score and its subitems. Results: The scores obtained in language-related abilities for patients and controls, respectively, were: language (total): 27.3 (1) and 28.5 (1), p < 0.0001)comprehension: 8.6 (0.5) and 8.9 (0.3), p = 0.006; production: 18.7 (1) and 19.6 (0.9), p = < 0.0001; abstraction: 6.8 (1.1) and 7.3 (0.7), p = 0.016; verbal fluency: 16.3 (4.3) and 19.6 (4.1), p = 0.003. Conclusion: A mild but significant impairment in language-related ability scores was detected when comparing patients and controls.