Bilateral giant renal angiomyolipoma associated with hepatic lipoma in a patient with tuberous sclerosis

OBJECTIVE: To report a case of bilateral giant renal angiomyolipoma associated with tuberous sclerosis, with successful treatment, and to review the literature concerning angiomyolipoma treatment. CASE REPORT: Patient with tuberous sclerosis and angiomyolipoma diagnosed by ultrasonography during her pregnancy. At that time, the angiomyolipoma on the right side was 9 cm in diameter. Conservative management was selected during her pregnancy. The patient returned 7 years later, with a 24.7 x 19.2 x 10.7 cm tumor on the right side and another of 13 x 11.5 x 6.5 cm on the left side, in addition to multiple small angiomyolipomas. A nephron-sparing surgery with tumoral enucleation was performed on the right side, and after 3 months, the tumor on the left side was removed. Renal function in the post-operative period was preserved, and contrast medium progression was uniform and adequate in both kidneys. CONCLUSION: We conclude that an angiomyolipoma larger than 4 cm should be removed surgically, since they have a greater growth rate and pose a risk of hemorrhage. Resection of smaller tumors is safe and has decreased morbidity. Tumoral enucleation is an effective treatment method that preserves kidney function.

Blue rubber bleb nevus syndrome: case report

The case of a patient with blue rubber bleb nevus syndrome who is infected by acquired immunodeficiency syndrome virus due to multiple blood transfusions is presented. This case shows that although it is a rare systemic disorder, blue rubber bleb nevus syndrome has to be considered in the differential diagnosis of chronic anemia or gastrointestinal bleeding. Patients should be investigated by endoscopy, which is the most reliable method for detecting these lesions. The patient underwent gastroscopy and enteroscopy via enterotomy with identification of all lesions. Minimal resection of the larger lesions and string-purse suture of the smaller ones involving all the layers of the intestine were performed. The string-purse suture of the lesions detected by enteroscopy proved to be an effective technique for handling these lesions, avoiding extensive intestinal resection and stopping the bleeding. Effective management of these patients demands aggressive treatment and should be initiated as soon as possible to avoid risks involved in blood transfusions, as occurred in this case.

A skin-picking disorder case report: a psychopathological explanation

We describe the case of a 44-year-old woman, without known previous psychiatric history, hospitalized after a significant hemorrhage caused by self-inflicted deep facial dermal lesions (with muscle exposition). Psychopathological possible explanations of this case, as in similar reviewed ones, are related to frustration, aggression, and impulsivity.

Immediate and long term evolution of valve replacement in children less than 12 years old

OBJECTIVE: The aim of this work was the follow-up and evaluation of valve replacement in children under 12 years of age. METHODS: Forty-four children less than 12 years old were underwent valve replacement at INCOR-HCFMUSP between January 1986 and December 1992. Forty (91%) were rheumatic, 39 (88.7%) were in functional classes II or IV, 19 (43.2%) were operated upon on an emergency basis, and 6 (13.6%) had atrial fibrillation. Biological prostheses (BP) were employed in 26 patients (59.1%), and mechanical prostheses (MP) in 18 (40.9%). Mitral valves were replaced in 30 (68.7%), aortic valves in 8 (18.2%), a tricuspid valve in 1 (2.3%), and double (aortic and mitral) valves in 5 (11.4) of the patients. RESULTS: Hospital mortality was of 4.5% (2 cases). The mean follow-up period was 5.8 years. Re-operations occurred in 63.3% of the patients with BP and in 12.5% of those with MP (p=0.002). Infectious endocarditis was present in 26.3% of the BP, but in none of the cases of MP (p=0.049). Thrombosis occurred in 2 (12.5%) and hemorrhage in one (6.5%) of the patients with a MP. Delayed mortality occurred in 5 (11.9%) of the patients over a mean period of 2.6 years; four had had BP and one had a MP (NS). Actuarial survival and re-operation-free curves after 10 years were respectively, 82.5±7.7 (SD)% and 20.6±15.9%. CONCLUSION: Patients with MP required fewer re-operation, had less infectious endocarditis and lower late mortality rates compared with patients with bioprostheses. The former, therefore, appear to be the best valve replacement for pediatric patients.

Multiple Embolism in a Female Patient with Infective Endocarditis: Low Back Pain and Hematuria as the Initial Clinical Manifestations

A 59-year-old female patient with mitral valve prolapse and a previous history of lumbosacral spondyloarthrosis and lumbar disk hernia had an episode of infective endocarditis due to Streptococcus viridans, which evolved with peripheral embolism to the left kidney, spleen, and left iliac artery, and intraventricular cerebral hemorrhage. Her clinical manifestations were low back pain and hematuria, which were initially attributed to an osteoarticular condition. Infective endocarditis is a severe polymorphic disease with multiple clinical manifestations and it should always be included in the differential diagnosis by clinicians.

Comparison of ACUITY and CRUSADE Scores in Predicting Major Bleeding during Acute Coronary Syndrome

Background:The ACUITY and CRUSADE scores are validated models for prediction of major bleeding events in acute coronary syndrome (ACS). However, the comparative performances of these scores are not known.Objective:To compare the accuracy of ACUITY and CRUSADE in predicting major bleeding events during ACS.Methods:This study included 519 patients consecutively admitted for unstable angina, non-ST-elevation or ST-elevation myocardial infarction. The scores were calculated based on admission data. We considered major bleeding events during hospitalization and not related to cardiac surgery, according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥ 3 g, and intracranial, intraocular or fatal bleeding).Results:Major bleeding was observed in 31 patients (23 caused by femoral puncture, 5 digestive, 3 in other sites), an incidence of 6%. While both scores were associated with bleeding, ACUITY demonstrated better C-statistics (0.73, 95% CI = 0.63 - 0.82) as compared with CRUSADE (0.62, 95% CI = 0.53 - 0.71; p = 0.04). The best performance of ACUITY was also reflected by a net reclassification improvement of + 0.19 (p = 0.02) over CRUSADE’s definition of low or high risk. Exploratory analysis suggested that the presence of the variables ‘age’ and ‘type of ACS’ in ACUITY was the main reason for its superiority.Conclusion:The ACUITY Score is a better predictor of major bleeding when compared with the CRUSADE Score in patients hospitalized for ACS.

O potassio plasmático em infecções bacterianas experimentais

Arrangement of potassium in the tissues having been mentioned, as well as the rôle it plays in some pathological processes such as suprarenal insufficiency, anaphylactic shock and shock caused by hemorrhage or traumatism, experiences were undertaken to establish the rates of plasma potassium during bacteria infections artificially developed in rabbits by K. pneumoniae. P. aeruginosa and S. enteridits. It was concluded that during the period of the infections, the rate of potassium of the plasma increases almost immediately after the inoculation and stays high when the infections are of a serious or mortal character; the rate continue to increase until the death of the animal occurs. When these infections are not very serious, as in the cases of infections resulting from inoculations of bacteria as not recent — and consequently with attenuated virulence — K pneumoniae, or P aeruginosa and S enteriditis, to which rabbits are naturally very resistant, the rate of potassium of the plasma increases after an intravenous inoculation of germs according to the septicemic period of the infection; however, when, because of its natural resistance, the animal overcomes the infection, the amount of potassium gradually decreases and finally gets back to the normal rate. The action of cortin on potassium of the plasma was also tested on animals suffering from acute infections caused by K. pneumoniae, which, under normal conditions cause death of the rabbits, nor did it increase the rate of potassium of the plasma when a larger amount of bacteria (300,000,000) was inoculated. However, cortin inoculated several times prevented a higher rate of potassium in the plasma during the development of the infection when a smaller number of bacteria (150,000,000) was inoculated, which quantity, under normal conditions, always causes mortal infections. When cortin is discontinued 20 hours after the inoculation of germs, the infection increases fastly and the animal dies in a very short time. Now, if the injections of cortin continue to be given every hour until the 26th hour instead of only until the 20th hour, the amount of potassium in the plasma — very high if the hormones substance is no longer inoculated — gradually becomes smaller and finally comes back to the normal rate if the inoculations continue to be made; it will increase again only if the substance is no longer injected; after a few hours the injection is gone, potassium is found to come back to its former rate, and in consequence the animal is perfectly cured of an infection otherwise mortal. ln view of the results thus obtained, it was concluded that, during the development of those infections, the checking of the rate of potassium of the plasma provided a means of controlling the resistance of a body suffering from an infection, that rate increasing when the infection is developing and becoming more severe, or getting back to normal when the infection decreases. The checking of the rate of potassium of the plasma also made known the action of cortin on the tissues, which is found to control the permeability of the cells to potassium. Suggestions were made that potassium of the plasma be thereofre checked during infections in the human body, to make possible proving that the phenomena studied in those animals also take place in the human body. In case this is found to be true, we sould possess an important element to check organic vitality during infections.

Avaliação crítica da cirurgia na hipertensão portal esquistossômica

There are over 100.000 patients affected by schistosomotic portal hipertension, that may suffer rupture of the esophageal varices. Besides the portal hypertension, local factors must be emphazised as responsible for the three distal centimeters of the esophagus, called "zona vulnerável" (vulnerable zone). The beter liver functional reserve of these schistosomotic patients as compared to the cirrhotic, present two favorable condititions: (1) beter possibility of conservative treatment during acute hemorrhage; (2) elective surgical treatment may be undergo without a mandatory step of large portal descompression. The Author only indicate surgical treatment in patients with hemorrhage antecedence and his preference consist in splenectomy plus obliterative suture of the varices at the "vulnerable zone" and when possible, ligature of left gastric vein also; 358 patients were undergone surgery with operative mortality 3.07%, 347 were followed during 1 to 25 years; late mortality 8.38%; recurrence hemorrage 11.58%; none porto-sustemic encephalopaty was observed.

Surgical indication in Schistosomiasis mansoni portal hypertension: follow-up from 1985 to 2001

The study had the objective to evaluate the benefits of surgical indication for portal hypertension in schistosomiasis patients followed from 1985 to 2001. Schistosoma mansoni eggs were confirmed by at least six stool examinations or rectal biopsy. Clinical examination, abdominal ultrasonography, and digestive endoscopy confirmed the diagnosis of esophageal varices. A hundred and two patients, 61.3% male (14-53 years old) were studied. Digestive hemorrhage, hypersplenism, left hypochondrial pain, abdominal discomfort, and hypogonadism were, in a decreasing order, the major signs and symptoms determining surgical indication. Among the surgical techniques employed, either splenectomy associated to splenorenal anastomosis or azigoportal desvascularization, esophageal gastric descompression and esophageal sclerosis were used. Follow-up of patients revealed that, independent on the technique utilized, a 9.9% of death occurred, caused mainly by digestive hemorrhage due to the persistence of post-treatment varices. The authors emphasize the benefits of elective surgical indication allowing a normal active life.

Inflammatory effects of snake venom metalloproteinases

Metalloproteinases are abundant enzymes in crotaline and viperine snake venoms. They are relevant in the pathophysiology of envenomation, being responsible for local and systemic hemorrhage frequently observed in the victims. Snake venom metalloproteinases (SVMP) are zinc-dependent enzymes of varying molecular weights having multidomain organization. Some SVMP comprise only the proteinase domain, whereas others also contain a disintegrin-like domain, cysteine-rich, and lectin domains. They have strong structural similarities with both mammalian matrix metalloproteinases (MMP) and members of ADAMs (a disintegrin and metalloproteinase) group. Besides hemorrhage, snake venom metalloproteinase induce local myonecrosis, skin damage, and inflammatory reaction in experimental models. Local inflammation is an important characteristic of snakebite envenomations inflicted by viperine and crotaline snake species. Thus, in the recent years there is a growing effort to understand the mechanisms responsible for SVMP-induced inflammatory reaction and the structural determinants of this effect. This short review focuses the inflammatory effects evoked by SVMP.

Camallanus cotti Fujita, 1927 (Nematoda, Camallanoidea) in ornamental aquarium fishes: pathology and morphology

The pathology induced by the nematode Camallanus cotti in the aquarium fishes Beta splendens (beta fish) and Poecilia reticulata (guppy) consisted of gross and microscopic lesions, the former characterized by abdominal swelling with reddish parasites protruding from the anus in both fish hosts and the latter, similar in the beta fishes and guppies, by hemorrhage, congestion, edema, a few glandular elements, and extensive erosion areas in the rectum mucosa, with a marked thickening of the wall and absence of inflammatory infiltrate. Lesions were associated with the presence of several worms attached to the wall or free in the rectal lumen. This is the second reference of the parasite in Brazil and the first report of pathological findings related to this nematode species that is also briefly redescribed and illustrated for the first time on the basis of Brazilian samples.

Collection of tracheal aspirate: safety and microbiological concordance between two techniques

Objective: To evaluate the safety of the performance of the traditional and protected collection techniques of tracheal aspirate and to identify qualitative and quantitative agreement of the results of microbiological cultures between the techniques. Method: Clinical, prospective, comparative, single-blind research. The sample was composed of 54 patients of >18 years of age, undergoing invasive mechanical ventilation for a period of ≥48 hours and with suspected Ventilator Associated Pneumonia. The two techniques were implemented in the same patient, one immediately after the other, with an order of random execution, according to randomization by specialized software. Results: No significant events occurred oxygen desaturation, hemodynamic instability or tracheobronchial hemorrhage (p<0.05) and, although there were differences in some strains, there was qualitative and quantitative agreement between the techniques (p<0.001). Conclusion: Utilization of the protected technique provided no advantage over the traditional and execution of both techniques was safe for the patient.


Predictors of red blood cell transfusion after cardiac surgery: a prospective cohort study

Abstract OBJECTIVE To identify predictors of red blood cell transfusion (RBCT) after cardiac surgery. METHOD A prospective cohort study performed with 323 adults after cardiac surgery, from April to December of 2013. A data collection instrument was constructed by the researchers containing factors associated with excessive bleeding after cardiac surgery, as found in the literature, for investigation in the immediate postoperative period. The relationship between risk factors and the outcome was assessed by univariate analysis and logistic regression. RESULTS The factors associated with RBCT in the immediate postoperative period included lower height and weight, decreased platelet count, lower hemoglobin level, higher prevalence of platelet count <150x10 3/mm3, lower volume of protamine, longer duration of anesthesia, higher prevalence of intraoperative RBCT, lower body temperature, higher heart rate and higher positive end-expiratory pressure. The independent predictor was weight <66.5Kg. CONCLUSION Factors associated with RBCT in the immediate postoperative period of cardiac surgery were found. The independent predictor was weight.

An ABC for decision making

The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw- Hill Education); British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters); Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations.

Computed tomography angiography in patients with active gastrointestinal bleeding

Abstract Gastrointestinal bleeding represents a common medical emergency, with considerable morbidity and mortality rates, and a prompt diagnosis is essential for a better prognosis. In such a context, endoscopy is the main diagnostic tool; however, in cases where the gastrointestinal hemorrhage is massive, the exact bleeding site might go undetected. In addition, a trained professional is not always present to perform the procedure. In an emergency setting, optical colonoscopy presents limitations connected with the absence of bowel preparation, so most of the small bowel cannot be assessed. Scintigraphy cannot accurately demonstrate the anatomic location of the bleeding and is not available at emergency settings. The use of capsule endoscopy is inappropriate in the acute setting, particularly in the emergency department at night, and is a highly expensive method. Digital angiography, despite its high sensitivity, is invasive, presents catheterization-related risks, in addition to its low availability at emergency settings. On the other hand, computed tomography angiography is fast, widely available and minimally invasive, emerging as a promising method in the diagnostic algorithm of these patients, being capable of determining the location and cause of bleeding with high accuracy. Based on a critical literature review and on their own experience, the authors propose a computed tomography angiography protocol to assess the patient with gastrointestinal bleeding.