Bowel preparation for colonoscopy: comparison of mannitol and sodium phosphate. Results of a prospective randomized study

METHOD: Eighty patients were prospectively randomized for precolonoscopic cleansing either with 750 ml of 10% mannitol (Group M) or 180 ml of a sodium phosphate preparation (Group NaP). Laboratory examinations before and after preparation on all patients included hemoglobin, hematocrit, sodium, potassium, phosphorous, calcium and serum osmolarity. A questionnaire was used to assess undesirable side effects and patient tolerance to the solution. The quality of preparation was assessed by the endoscopist who was unaware of the solution employed. RESULTS: Statistically significant changes were verified in serum sodium, phosphorous, potassium and calcium between the two groups, but no clinical symptoms were observed. There were no significant differences in the frequency of side effects studied. Six of the eight patients in Group NaP who had taken mannitol for a previous colonoscopy claimed better acceptance of the sodium phosphate solution. The endoscopic-blinded trial reported excellent or good bowel preparation in 85% prepared with sodium phosphate versus 82.5% for mannitol (p=0.37). CONCLUSIONS: Quality of preparation and frequency of side effects was similar in the two solutions. The smaller volume of sodium phosphate necessary for preparation seems to be related to its favorable acceptance. Nevertheless, the retention of sodium and phosphate ions contraindicates the use of sodium phosphate in patients with renal failure, cirrhosis, ascites, and heart failure.

Guidelines on how to assess the validity of results presented in subgroup analysis of clinical trials

In observational studies, identification of associations within particular subgroups is the usual method of investigation. As an exploratory method, it is the bread and butter of epidemiological research. Nearly everything that has been learned in epidemiology has been derived from the analysis of subgroups. In a randomized clinical trial, the entire purpose is the comparison of the test subjects and the controls, and when there is particular interest in the results of treatment in a certain section of trial participants, a subgroup analysis is performed. These subgroups are examined to see if they are liable to a greater benefit or risk from treatment. Thus, analyzing patient subsets is a natural part of the process of improving therapeutic knowledge through clinical trials. Nevertheless, the reliability of subgroup analysis can often be poor because of problems of multiplicity and limitations in the numbers of patients studied. The naive interpretation of the results of such examinations is a cause of great confusion in the therapeutic literature. We emphasize the need for readers to be aware that inferences based on comparisons between subgroups in randomized clinical trials should be approached more cautiously than those based on the main comparison. That is, subgroup analysis results derived from a sound clinical trial are not necessarily valid; one must not jump to conclusions and accept the validity of subgroup analysis results without an appropriate judgment.

Adrenocortical tumors: results of treatment and study of Weiss's score as a prognostic factor

PURPOSE: The differential diagnosis between benign and malignant adrenal cortical tumors circumscribed to the gland is controversial. One hundred and seven patients with adrenal cortex tumors (excluding those with primary hyperaldosteronism) were studied to assess the 5-year survival rate of adults, children, patients stratified by pathological stage, and patients stratified according to Weiss's score of <3 or >3. METHODS: The patients were evaluated both clinically and biochemically. One hundred and five patients underwent surgery and were classified pathologically as stages I, II, III, or IV. The tumors were weighed, measured, and classified according to Weiss's criteria and divided into 2 groups: <3 and >3. RESULTS: After 5 years, the survival rate was 77.5% for the whole group, 74.61% for the adults, 84.3% for the children, 100% for stage I, 83.9% for stage II, 33% for stage III, and 11.7% for stage IV groups. Additionally, after 5 years, 100% of the patients with tumors with Weiss's score <3 were alive compared to 61.65% of those with Weiss's score >3. The average weights of the tumors of score <3 and >3 were 23.38 g ± 41.36 g and 376.3 ± 538.76 g, respectively, which is a statistically significant difference. The average sizes of tumors of Weiss's score <3 and >3 were 3.67 ± 2.2 cm and 9.64 ± 5.8 cm, respectively, which is also a statistically significant difference. CONCLUSIONS: Weiss's score may be a good prognostic factor for tumors of the adrenal cortex. Additionally, there was a statistically significant difference between the average weight and size of tumors with benign behavior (Weiss's score <3) and those with malignant behavior (Weiss's score >3).

Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial

OBJECTIVE: The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD: Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS: There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group. CONCLUSIONS: We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer.

Results of microsurgical anastomosis in men with seminal tract obstruction due to inguinal herniorrhaphy

The incidence of vasal injury during inguinal herniorrhaphy is estimated at 0.5%. We sought to assess the patency rates and long-term fertility outcome after microsurgical repair of vasal obstruction related to prior inguinal herniorrhaphy. METHODS: Twenty procedures were performed on 13 men diagnosed with infertility and vasal injury secondary to previous inguinal herniorrhaphy. Eight of these men had undergone bilateral and 5 unilateral inguinal herniorrhaphy. Twelve procedures were vasovasostomies, 3 were crossover vasovasostomies, 2 were vasoepididymostomies, and 3 were crossover vasoepididymostomies. Eight patients were azoospermic, 2 were severely oligospermic (<1 M/mL), 1 was oligospermic, and 2 were asthenospermic. Patency data was obtained on all 13 patients, and pregnancy data was available for 10 couples (77%), with a mean follow-up of 69.5 months. RESULTS: The overall patency rate was 65%. In the vasovasostomy group, the patency rate was 60% (9/15), and in the vasoepididymostomy group it was 80% (4/5). Among the azoospermic patients, 13 procedures were performed. The patency rate was 42.9% for the vasovasostomy (3/7), and 100% for the vasoepididymostomy procedure (4/4). The overall pregnancy rate was 40%. Of the men who underwent vasoepididymostomy, 80% (4/5) established a pregnancy. CONCLUSIONS: Microsurgical vasovasostomy after inguinal vas injury results in a reasonable patency rate but a lower pregnancy rate than that after vasectomy reversal. When microsurgical vasoepididymostomy was possible, it resulted in high patency and pregnancy rate. Crossover vasoepididymostomy, when appropriate, can be a useful alternative to inguinal vasovasostomy.

Surgical treatment of rectal prolapse: experience and late results with 51 patients

The "best" surgical technique for the management of complete rectal prolapse remains unknown. Due to its low incidence, it is very difficult to achieve a representative number of cases, and there are no large prospective randomized trials to attest to the superiority of one operation over another. PURPOSE: Analyze the results of surgical treatment of complete rectal prolapse during 1980 and 2002. METHOD: Retrospective study. RESULTS: Fifty-one patients underwent surgical treatment during this period. The mean age was 56.7 years, with 39 females. Besides the prolapse itself, 33 patients complained of mucous discharge, 31 of fecal incontinence, 14 of constipation, 17 of rectal bleeding, and 3 of urinary incontinence. Abdominal operations were performed in 36 (71%) cases. Presacral rectopexy was the most common abdominal procedure (29 cases) followed by presacral rectopexy associated with sigmoidectomy (5 cases). The most common perineal procedure was perineal rectosigmoidectomy associated with levatorplasty (12 cases). Intraoperative bleeding from the presacral space developed in 2 cases, and a rectovaginal fistula occurred in another patient after a perineal rectosigmoidectomy. There were 2 recurrences after a mean follow-up of 49 months, which were treated by reoperation. CONCLUSION: Abdominal and perineal procedures can be used to manage complete rectal prolapse with safety and good long-term results. Age, associated medical conditions, and symptoms of fecal incontinence or constipation are the main features that one should bear in mind in order to choose the best surgical approach.

Distribution of Atta (Hymenoptera - Formicidae) in "terra-firme" rain forest of Central Amazonia: density, species composition and preliminary results on effects of forest fragmentation

One hundred and fourteen hectares of a "terra-fiirme" rain forest 70 km north of Manaus, Amazonas, Brazil, were surveyed for leaf-cutting ant colonies (Atta spp). One half of this area was in isolated forest fragments (surrounded by pastures or second growth) of two sizes: 1 and 10 ha. The other half was in non-isolated fragments (connected to a large parch of forest) of the same sizes. Only two species occured in this forest: Atta sexdens sexdens L. and A. cepfhalotes L. The first was the most abundant species with a mean density of 0.35 colonies per ha. The mean density of A. cephalotes colonies was 0.03 per ha. The density of colonies was not significantly different between the isolated fragments and the continuous forest. Furthermore, the species composition did not change with isolation. However, pre-isolation data and long term monitoring are necessary to conclude that the isolation of a forest fragment has no effect upon Atta colonies. The non-uniform spatial distribution of Atta colonics within the "terra-firme" forest must be taken into account when selecting conservation areas in the Amazon, in order to preserve this important group of ants together with their native habitat.

PRELIMINARY RESULTS OF A LARGE-SCALE TREE INVENTORY OF UPLAND RAIN FOREST IN THE CENTRAL AMAZON

A large-scale inventory of trees > 10cm DBH was conducted in the upland "terra firme" rain forest of the Distrito Agropecuário da SUFRAMA (Manaus Free Zone Authority Agricultural District) approximately 65Km north of the city of Manaus (AM), Srasil. Thegeneral appearance and structure of the forest is described together with local topography and soil texture. Thepreliminary results of the Inventory provide a minimum estimate of 698 tree species in 53 families in the 40Km radius sampled, including 17 undescribed species. Themost numerically abundant families, Lecythidaceae, Leguminosae, 5apotaceae and Burseraceae as also among the most species rich families. One aspect of this diverse assemblage is the proliferation of species within certain genera, Including 26 genera In 17 families with 6 or more species or morphospecies. Most species have very low abundances of less than 1 tree per hectare. While more abundant species do exist at densities ranging up to a mean of 12 trees per ha, many have clumped distributions leading to great variation in local species abundance. The degree of similarity between hectare samples based int the Coefficient of Community similarity Index varies widely over different sample hectares for five ecologically different families. Soil texture apparently plays a significant role In determining species composition in the different one hectare plots examined while results for other variable were less consistent. Greater differences in similarity indices are found for comparisons with a one hectare sample within the same formation approximately 40Km to the south. It is concluded that homogeneity of tree community composition within this single large and diverse yet continuous upland forest formation can not be assumed.

Ants obtained from trees of a "Jacareuba" (Calophyllum brasiliense) forest plantation in Central Amazonia by canopy fogging: first results

Canopies of the locally occurring Amazonian tree species Calophyllum brasiliense. Camb. (Guttiferae, height 10 m) were fogged after dawn on the same day at five adjacent localities in a 20-year-old plantation at the Adolpho Ducke Forest Reserve near Manaus/Brazil, using natural pyrethrum (0.5%, 1.0%, 1.5%), Baythroid (0.3%) and diesel oil, respectively. The 1152 ants collected represented 52 species, 17 genera and five subfamilies. The highest number of ant species was obtained with the synthetic pyrethrum Baythroid 0.3% and with natural pyrethrum 1.5%. About 46% of the total ant species were only collected in the first hour after fogging, and 17% only during the second hour, after trees had been heavily shaken. About 73% of the total ant specimens dropped in the first hour. Data on alpha-diversity, eveness and frequency of ants indicated a rapidly decreasing knock-down effect of both the synthetic and natural pyrethrum after application. The ant fauna in the canopy of C. brasiliense is somewhat distinct compared with that of Goupia glabra Aubl. (Celastraceae, height 45 m) from the primary forest of the reserve.

Prodromal Questionnaire: translation, adaptation to Portuguese and preliminary results in ultra-high risk individuals and first episode psychosis

OBJECTIVE: The Prodromal Questionnaire (PQ) is a 92-item self-report screening tool for individuals at ultra-high risk (UHR) to develop psychosis. This study aims to present the translation to Portuguese and preliminary results in UHR and first episode (FE) psychosis in a Portuguese sample. METHODS: The PQ was translated from English to Portuguese by two bilingual researchers from the research program on early psychosis of the Instituto de Psiquiatria HCFMUSP, São Paulo, Brazil (ASAS - "Evaluation and Follow up of Adolescents and Young Adults in São Paulo") and back translated by two other researchers. The study participants (n = 11-) were evaluated through the Portuguese version of the Prodromal Questionnaire (PQ) and SIPS. RESULTS: The individuals at UHR (n = 7) presented a lower score than first episode patients (n = 4). The UHR mean scores and standard deviation on Portuguese version of the PQ were: 13.0 ± 10.0 points on positive symptoms subscale, and FE patients: 33.0 ± 10.0. CONCLUSION: The UHR and FE patients' of this study presented PQ scores similar to the ones found in the literature; what suggests that it is possible to use the PQ in Brazilian help-seeking individuals as a screening tool.

Anomalous origin of the left coronary artery from the pulmonary trunk. Clinical features and midterm results after surgical treatment

OBJECTIVE: To report the authors' experience with the anomalous origin of the left coronary artery (AOLCA) from the pulmonary trunk, emphasizing preoperative data, surgical aspects and midterm results of the follow-up. METHODS: Retrospective analysis of 11 patients operated upon at the Royal Brompton Hospital from October, 84 to April, 97. RESULTS: Nine infants had heart failure (HF) and two other children presented with dyspnea and chest pain. All had ECG changes. The echocardiogram identified the anomalous origin of the coronary artery in 7 (64%) patients and hemodynamic studies were performed in 7 patients. All infants were operated upon between the 2nd and 10th month of life. Six patients were treated with aortic reimplantation of the left coronary artery, whereas five were operated upon according to the Takeuchi technique. All patients are alive, with clear improvement of the ECG changes and ventricular function, as evaluated by echocardiography. Two patients operated upon according to the Takeuchi technique required additional surgery due to severe supravalvular pulmonary stenosis. CONCLUSION: AOLCA is a rare disease. Most patients show early signs of severe HF associated with ECG findings. Surgical therapy must be instituted early in the disease, preferentially through aortic implantation of the anomalous coronary artery, with a high possibility of success. Shortly after surgery, clinical and ECG improvement, as well as normalization of left ventricular function, should be expected.

Rheumatic carditis treated with high doses of pulsetherapy methylprednisolone. Results in 70 children over 12 years

PURPOSE: To report the result of patients treated with IV methylprednisolone divided into three groups and compare their follow-up during the last 12 years. METHODS: Seventy children with active rheumatic carditis (76 episodes) in heart failure Class III and IV (NYHA) were studied. The diagnosis was based on modified Jones' criteria. After ruling out infections and strongyloidiasis, treatment with IV methylprednisolone bolus was started three times a week until the laboratory tests became negative. Patients were divided into 3 groups, according to the time of hospital admittance: Groups 1, 2 and 3, comprising of 40, 18 and 12 children, respectively. RESULTS: Eighteen children in Group 1 (45%) were in their 1st attack: 2 series of pulsetherapy were used in 10 (25%), 3 in 9 (23%) and 4 in 21 (52%). In Group 2, 14 cases (77%) were in their 1st attack: 2 series were used in 7 (39%), 4 in 9 (50%) and 5 in 2 (11%). The echocardiogram showed a flail mitral valve in 12 (66%) of these patients (1 death occurred after mitral valvoplasty). In Group 3, 6 patients needed 5 or more series of pulsetherapy and a flail mitral valve was present in 5 (41%). One child underwent mitral valve replacement while still in the active phase, after 8 series of pulsetherapy, and another died. The number of patients who needed 5 or more series was significantly higher in Group 3. CONCLUSION: There were variations in the presentation and evolution of the cases during these 12 year. The established pulsetherapy protocol continues to be useful to treat severe cases.

Results of the surgical treatment of chronic atrial fibrillation

OBJECTIVE: Report clinical experience in surgical treatment of atrial fibrillation (AF) by Cox-maze procedure. METHODS: 61 patients underwent surgical treatment for AF. Two had primary AF and 59 AF secondary to heart disease (2 atrial septal defects, 57 mitral). Ages ranged from 20 to 74 years (mean = 49). There were 44 females (72%). The surgical technique employed was Cox 3 without cryoablation. The patients were follow-up in specific at patient clinics and underwent periodical ECG, exercise tests, echocardiogram and Holter monitoring. RESULTS: In-hospital mortality was 4.9% and late mortality 1.6%. A temporary pacemaker was used in 28 (46%) and a definitive in 7 patients (11.4%). On hospital discharge, AF remained in 17%; 63.9% had sinus rhythm, 6.9% atrial rhythm, 1.7% junctional rhythm, and 10.3% had pacemaker rhythm. In the last evaluation, AF was present in 19.5%; (70.5% sinus rhythm, 4% atrial rhythm, 2% atrial tachycardia, and 4% pacemaker rhythm). There was no report of thromboembolic episodes. Chronotropic response was considered adequate in 19%, intermediate in 29%, and inadequate in 42%. In Holter monitoring, the mean heart rate was 82±8 bpm, with a minimum of 57±7 bpm and maximum of 126±23 bpm, with supraventricular extrasystoles in 2.3±5.5% of the total heartbeats and ventricular extrasystoles in 0.8±0.5%. In the echocardiogram, the A wave was present in the left atrium in 87.5%. CONCLUSION: Maze procedure is effective and has acceptable surgical risk. Atrial or sinus rhythms remain stable with a small but remarkable frequency of atrial and ventricular arrhythmias. Left atrial contraction is present, although attenuated, as well as the chronotropic response to exercise.

Percutaneous mitral valvotomy in patients eighteen years old and younger. Immediate and late results

OBJECTIVE - To analyze immediate and late results of percutaneous mitral valvotomy (PMV) in patients <= 18 year. METHODS - Between August '87 and July '97, 48 procedures were performed on 40 patients. The mean age was 15.6 years; 68.7% were females four of whom were pregnant. RESULTS - Success was obtained in 91.7% of the procedures. Immediate complications were severe mitral regurgitation (6.3%) and cardiac tamponade (2.0%). Late follow-up was obtained in 88.8% of the patients (mean value=43.2±33.9 months). NYHA functional class (FC) I or II was observed in 96.2% of the patients and restenosis developed in five patients, at a mean follow-up of 29.7±11.9 months. Three patients presented with severe mitral insufficiency and underwent surgery. Two patients died. CONCLUSION - PMV represents a valid therapeutic option in young patients. In these patients, maybe because of subclinical rheumatic activity, restenosis may have a higher incidence and occur at an earlier stage than in others persons.

Primary coronary angioplasty and stent implantation in acute myocardial infarction. Comparative analysis of the in-hospital results in the CENIC/SBHCI registry

OBJECTIVE: Comparative analysis of the in-hospital results after primary implantation of stents or coronary balloon angioplasty in patients with acute myocardial infarction (MI). METHODS: CENIC (National Center of Cardiovascular Interventions) gathered data on 3,924 patients undergoing coronary angioplasty (in the primary form, without the previous use of thrombolytic agents) in the first 24 hours after a MI, during the period of 1996-1998. From these 3,924 patients, 1,337 (34%) underwent stent implantation. We analyzed the success of the procedure and the occurrence of adverse cardiac events. RESULTS: In patients undergoing stent implantation there were more males (77% vs 69%, p=0.001), previous by pass surgery (6.3% vs. 4.5%, p=0.01), anterior MI and stent implantation in left descending artery (55% vs. 48% vs. p=0.009), and saphenous vein bypass grafts (3.3% vs. 1.9%). the procedure was more succesful in the group of stents (97% vs. 84%, p=0.001) and reinfarction rate (2.5 vs. 4%, p=0.002). The need for emergency revascularization was similar (1% vs. 1.1%, NS). Total in-hospital mortality was lower in stent group (3.4% vs. 7. 2%, p=0.0001) and this effect was in patients Killip class III/V (19.5% vs. 32.5%, p= 0.002) because there was no difference in patients class I/II (1.7% vs. 2.8%, p=0.9). CONCLUSION: Primary stent implantation in acute myocardial infarction showed better early results than balloon angioplasty alome.