Orifice diseases project - experience of the "Hospital das Clínicas" University of São Paulo Medical Center in day-hospital of anorectal disease

The treatment of malignant or benign colorectal pathologies that require more complex management are priorities in tertiary hospitals such as "Hospital das Clínicas" University of São Paulo Medical Center (HCFMUSP). Therefore, benign, uncomplicated orifice conditions are relegated to second place. The number of patients with hemorrhoids, perianal fistulas, fissures, condylomas and pilonidal cysts who seek treatment at the HFMUSP is very great, resulting in over-crowding in the outpatient clinics and a long waiting list for recommended surgical treatment (at times over 18 months). The authors describe the experience of the HCFMUSP over an eight-day period with day-hospital surgery in which 140 patients underwent surgery. Data was prospectively taken on the patients undergoing surgery for benign orifice pathologies including age, sex, diagnosis, surgery performed, immediate and late postoperative complications, and follow-up. 140 patients operated on over eight days were studied. 68 were males (48.75%) with ages ranging from 25 to 62 (mean 35.2 yrs.). Hemorrhoids was the most frequent condition encountered (82 hemorrhoidectomies, 58.6%), followed by perineal fistula (28 fistula repairs, 20.0%). The most common complication was headache secondary to rachianesthesia occurring in 9 patients (6.4%). One patient (0.7%) developed bleeding immediately PO that required reoperation. Mean follow-up was 104 days. Day-surgery characterized by quality care and low morbidity is feasible in tertiary public hospitals, permitting surgery for benign orifice pathologies on many patients within a short period of time.

Critical analysis of the allocation policy for liver transplantation in Brazil

Liver transplantation is now the standard treatment for end-stage liver disease. Given the shortage of liver donors and the progressively higher number of patients waiting for transplantation, improvements in patient selection and optimization of timing for transplantation are needed. Several solutions have been suggested, including increasing the donor pool; a fair policy for allocation, not permitting variables such as age, gender, and race, or third-party payer status to play any role; and knowledge of the natural history of each liver disease for which transplantation is offered. To observe ethical rules and distributive justice (guarantee to every citizen the same opportunity to get an organ), the "sickest first" policy must be used. Studies have demonstrated that death has no relationship with waiting time, but rather with the severity of liver disease at the time of inclusion. Thus, waiting time is no longer part of the United Network for Organ Sharing distribution criteria. Waiting time only differentiates between equally severely diseased patients. The authors have analyzed the waiting list mortality and 1-year survival for patients of the State of São Paulo, from July 1997 through January 2001. Only the chronological criterion was used. According to "Secretaria de Estado da Saúde de São Paulo" data, among all waiting list deaths, 82.2% occurred within the first year, and 37.6% within the first 3 months following inclusion. The allocation of livers based on waiting time is neither fair nor ethical, impairs distributive justice and human rights, and does not occur in any other part of the world.

Transplants: bioethics and justice

Bioethics, as a branch of philosophy that focuses on questions relative to health and human life, is closely tied to the idea of justice and equality. As such, in understanding the concept of equality in its original sense, that is, in associating it to the idea to treat "unequals" (those who are unequal or different, in terms of conditions or circumstances) unequally (differentially), in proportion to their inequalities (differences), we see that the so-called "one-and-only waiting list" for transplants established in law no. 9.434/97, ends up not addressing the concept of equality and justice, bearing upon bioethics, even when considering the objective criteria of precedence established in regulation no. 9.4347/98, Thus, the organizing of transplants on a one-and-only waiting list, with a few exceptions that are weakly applicable, without a case by case technical and grounded analysis, according to each particular necessity, ends up institutionalizing inequalities, condemning patients to happenstance and, consequently, departs from the ratio legis, which aims at seeking the greatest application of justice in regards to organ transplants. We conclude, therefore, that from an analysis of the legislation and of the principles of bioethics and justice, there is a need for the creation of a collegiate of medical experts, that, based on medical criteria and done in a well established manner, can analyze each case to be included on the waiting list, deferentially and according to the necessity; thus, precluding that people in special circumstances be treated equal to people in normal circumstances.

Use of Short-term Circulatory Support as a Bridge in Pediatric Heart Transplantation

Background:Heart transplantation is considered the gold standard therapy for the advanced heart failure, but donor shortage, especially in pediatric patients, is the main limitation for this procedure, so most sick patients die while waiting for the procedure.Objective:To evaluate the use of short-term circulatory support as a bridge to transplantation in end-stage cardiomyopathy.Methods:Retrospective clinical study. Between January 2011 and December 2013, 40 patients with cardiomyopathy were admitted in our Pediatric Intensive Care Unit, with a mean age of 4.5 years. Twenty patients evolved during hospitalization with clinical deterioration and were classified as Intermacs 1 and 2. One patient died within 24 hours and 19 could be stabilized and were listed. They were divided into 2 groups: A, clinical support alone and B, implantation of short-term circulatory support as bridge to transplantation additionally to clinical therapy.Results:We used short-term mechanical circulatory support as a bridge to transplantation in 9. In group A (n=10), eight died waiting and 2 patients (20%) were transplanted, but none was discharged. In group B (n=9), 6 patients (66.7%) were transplanted and three were discharged.The mean support time was 21,8 days (6 to 984h). The mean transplant waiting list time was 33,8 days. Renal failure and sepsis were the main complication and causeof death in group A while neurologic complications were more prevalent en group B.Conclusion:Mechanical circulatory support increases survival on the pediatric heart transplantation waiting list in patients classified as Intermacs 1 and 2.

Waiting time for radiotherapy in women with cervical cancer

ABSTRACT OBJECTIVE To describe the waiting time for radiotherapy for patients with cervical cancer. METHODS This descriptive study was conducted with 342 cervical cancer cases that were referred to primary radiotherapy, in the Baixada Fluminense region, RJ, Southeastern Brazil, from October 1995 to August 2010. The waiting time was calculated using the recommended 60-day deadline as a parameter to obtaining the first cancer treatment and considering the date at which the diagnosis was confirmed, the date of first oncological consultation and date when the radiotherapy began. Median and proportional comparisons were made using the Kruskal Wallis and Chi-square tests. RESULTS Most of the women (72.2%) began their radiotherapy within 60 days from the diagnostic confirmation date. The median of this total waiting time was 41 days. This median worsened over the time period, going from 11 days (1995-1996) to 64 days (2009-2010). The median interval between the diagnostic confirmation and the first oncological consultation was 33 days, and between the first oncological consultation and the first radiotherapy session was four days. The median waiting time differed significantly (p = 0.003) according to different stages of the tumor, reaching 56 days, 35 days and 30 days for women whose cancers were classified up to IIA; from IIB to IIIB, and IVA-IVB, respectively. CONCLUSIONS Despite most of the women having had access to radiotherapy within the recommended 60 days, the implementation of procedures to define the stage of the tumor and to reestablish clinical conditions took a large part of this time, showing that at least one of these intervals needs to be improved. Even though the waiting times were ideal for all patients, the most advanced cases were quickly treated, which suggests that access to radiotherapy by women with cervical cancer has been reached with equity.

A morphological protocol and guide-list on uterine cervix cytology associated to Papillomavirus infection

The present study was designed to further assess the validity of the cytological description of morphological lesions said to be related to Papillomavirus (HPV) infections in senior women. The casuistic comprised 196 cervical smears from a group of women with no clinical or morphological evidence of neoplasia, collected simultaneously with samples submitted to detection of HPV DNA by PCR in a previous study. Three experienced cytologists studied each slide in two different conditions, with an interval of 20 months between them. The first approach was performed under routine laboratory standards, whereas the second was guided by a list of 16 well-defined parameters indicative of HPV-related cytological lesions. When suspicious cases of HPV-related alterations were grouped with positive cases, they showed on average: sensitivity of 25.5%, specificity of 84.4% and positive predictive value (PPV) of 26.8%. When suspicious cases were grouped with negative cases, sensitivity decreased, whereas specificity and PPV increased, as expected. In the second reading, which followed a "guide-list", a decrease in sensitivity was observed, contrasting with a sharp increase of positive predictive value. Among the 16 cytomorphological criteria tested, "koilocytosis", "mild koilocytosis" and "condylomatous parabasal cells" yielded the best predictive value for HPV DNA detection by PCR. In conclusion, despite the low sensitivity, cytopathologic assessment of cervico-vaginal smears leads to a highly specific diagnosis of HPV infection in menopausal women, with PPV of 91.0% when directed by a guide-list of well-defined morphologic criteria.

Updated list of bat species positive for rabies in Brazil

This paper presents an updated list of bat species positive for rabies in Brazil. It was developed based on database research via the internet, of international and national literature and annals of the most important technical and scientific meetings related to rabies and chiroptera in Brazil from 1996 to 2009. The new list of rabies positive bats consists of 41 species, belonging to 25 genera and three families: Phyllostomidae 43.9%, Vespertilionidae 29.3% and Molossidae 26.8%. In addition, questions were raised regarding the lack of data, including sex, age, circumstances and location of bat capture and incomplete and outdated species identification. Results of genetic and antigenic studies performed on Brazilian rabies positive bats were shown.

List of species in the genus Lutzomyia, França, 1924 (Psychodidae, Phlebotominae) from the State of Mato Grosso

This work had the objective of listing the sand fly species that occur in the State of Mato Grosso, Brazil. Data relating to entomological surveys conducted between 1996 and 2004 were obtained from the National Health Foundation and the State Health Department, and this was supplemented with information from research carried out in the state and from the specialized literature. There were records of 106 sand fly species belonging to the genus Lutzomyia. This is a rich and diversified fauna, with some species restricted to forested areas and others recorded throughout the state, independent of the vegetation type, and in areas modified by human action, with predominance of Lutzomyia whitmani.

A list of mosquito species of the Brazilian State of Pernambuco, including the first report of Haemagogus janthinomys (Diptera: Culicidae), yellow fever vector and 14 other species (Diptera: Culicidae)

INTRODUCTION: Besides mosquito species adapted to urban environments (Culex quinquefasciatus, Aedes aegypti and Aedes albopictus), only 15 species of Anopheles had been recorded in the State of Pernambuco. METHODS: Human-landing mosquitoes were collected in Dois Irmãos Park, in Recife. RESULTS: The first report for the state of Haemagogus janthinomys, an important vector of yellow fever virus, and 14 other species, including Trichoprosopon lampropus, a first reported for Brazil. CONCLUSIONS: The mosquito fauna in the area is diversified and has potential medical and veterinary importance.

Amazonian Foliicolous Fungi III. A preliminary list of Ascomycotina, mostly Dothideales, sensu lato

This paper records 65 leaf-inhabiting sac fungi collected in Amazonas and Roraima during 1977-78 as part of Projeto Flora Amazônica. Lembosia miconiae (Ryan) Farr is a new combination.

A CHECK-LIST ON THE INVASIVE SPECIES OF FORESTRY PLANTATIONS IN LOWER AMAZON, NW.

The work conelete of a survey of the mvaewe plants which appeared during the first six months of seedling stage in foreet plantations of second and third rotation, in the Jari area, Brazil. The resulting list showed two types of invasives: (1) true weeds - those cosmopolitan species that are typical of disturbed habitats; and (2) pioneer species - those which were probably remnants from the original natural vegetation of the studied area.

List of type-specimens of Isoptera (Insecta) in the collection of the Museu Paraense Emílio Goeldi, State of Pará, Brazil

The collection of the Museu Paraense Emílio Goeldi (MPEG), in the city of Belém, State of Pará, Brazil, has 65 samples of type-specimens of Isoptera, representing 26 species (21 holotypes and 5 paratypes) of 18 genera. This paper lists the number of specimens of each caste in each type series, type localities with geographical coordinates, collectors, and dates of collection.

Updated List and identification key of 219 tree species of white sand forests of the Allpahuayo Mishana National Reserve, Loreto, Peru

White sand forests, although low in nutrients, are characterized not only by several endemic species of plants but also by several monodominant species. In general, plants in this forest have noticeably thin stems. The aim of this work was to elaborate a parallel dichotomous key for the identification of Angiosperm tree species occurring on white sand forests at the Allpahuayo Mishana National Reserve, Loreto, Peru. We compiled a list of species from several publications in order to have the most comprehensive list of species that occur on white sand forest. We found 219 species of Angiosperm, the more abundant species were Pachira brevipes (26.27%), Caraipa utilis (17.90%), Dicymbe uaiparuensis (13.27%), Dendropanax umbellatus (3.28%), Sloanea spathulata (2.52%), Ternstroemia klugiana (2.30%), Haploclathra cordata (2.28%), Parkia igneiflora (1.20%), Emmotum floribundum (1.06%), Ravenia biramosa (1.04%) among others. Most species of white sand forests can be distinguished using characteristics of stems, branches and leaves. This key is very useful for the development of floristic inventories and related projects on white sand forests from Allpahuayo Mishana National Reserve.

Consequences of the Prolonged Waiting Time for Patients Candidates for Heart Surgery

OBJECTIVE - To assess mortality and the psychological repercussions of the prolonged waiting time for candidates for heart surgery. METHODS - From July 1999 to May 2000, using a standardized questionnaire, we carried out standardized interviews and semi-structured psychological interviews with 484 patients with coronary heart disease, 121 patients with valvular heart diseases, and 100 patients with congenital heart diseases. RESULTS - The coefficients of mortality (deaths per 100 patients/year) were as follows: patients with coronary heart disease, 5.6; patients with valvular heart diseases, 12.8; and patients with congenital heart diseases, 3.1 (p<0.0001). The survival curve was lower in patients with valvular heart diseases than in patients with coronary heart disease and congenital heart diseases (p<0.001). The accumulated probability of not undergoing surgery was higher in patients with valvular heart diseases than in the other patients (p<0.001), and, among the patients with valvular heart diseases, this probability was higher in females than in males (p<0.01). Several patients experienced intense anxiety and attributed their adaptive problems in the scope of love, professional, and social lives, to not undergoing surgery. CONCLUSION - Mortality was high, and even higher among the patients with valvular heart diseases, with negative psychological and social repercussions.