Four-arm single docking full robotic surgery for low rectal cancer: technique standardization

The authors present the four-arm single docking full robotic surgery to treat low rectal cancer. The eight main operative steps are: 1- patient positioning; 2- trocars set-up and robot docking; 3- sigmoid colon, left colon and splenic flexure mobilization (lateral-to-medial approach); 4-Inferior mesenteric artery and vein ligation (medial-to-lateral approach); 5- total mesorectum excision and preservation of hypogastric and pelvic autonomic nerves (sacral dissection, lateral dissection, pelvic dissection); 6- division of the rectum using an endo roticulator stapler for the laparoscopic performance of a double-stapled coloanal anastomosis (type I tumor); 7- intersphincteric resection, extraction of the specimen through the anus and lateral-to-end hand sewn coloanal anastomosis (type II tumor); 8- cylindric abdominoperineal resection, with transabdominal section of the levator muscles (type IV tumor). The techniques employed were safe and have presented low rates of complication and no mortality.

The rights approach to local public management: experiences from Brazil

The Fundação Getulio Vargas, São Paulo, Public Management and Citizenship Program was set up in 1996 with Ford Foundation support to identify and disseminate Brazilian subnational government initiatives in service provision that have a direct effect on citizenship. Already, the program has 2,500 different experiences in its data bank, the results of four annual cycles. The article draws some initial conclusions about the possibilities of a rights-based approach to public management and about the engagement of other agencies and civil society organizations.

Budgeting and resource allocation in universities: a public choice approach

The calls for colleges and universities to improve their productivity are coming thick and fast in Brazil. Many studies are suggesting evaluation systems and external criteria to control the quality of teaching and research in universities. Since universities and colleges are not profit-oriented organizations (considering only the legitimate and serious research and teaching organizations, of course), the traditional microeconomics and administrative variables used to measure efficiency do not have any direct function. An alternative would be to create an "as if" market control system to evaluate performance in universities and colleges. Internal budget and resources allocation mechanism can be used as incentive instruments to improve quality and productivity. It will be the main issue of this article.

Antimicrobial use and incidence of multidrug-resistant Pseudomonas aeruginosa in a teaching hospital: an ecological approach

INTRODUCTION: Multidrug-resistant Pseudomonas aeruginosa is a major threat in healthcare settings. The use of antimicrobials can influence the incidence of resistant strains by direct and indirect mechanisms. The latter can be addressed by ecological studies. METHODS: Our group attempted to analyze the relation between the use of antipseudomonal drugs and the incidence of MDR-PA among 18 units from a 400-bed teaching hospital. The study had a retrospective, ecological design, comprising data from 2004 and 2005. Data on the use of four antimicrobials (amikacin, ciprofloxacin, ceftazidime and imipenem) were tested for correlation with the incidence of MDR-PA (defined as isolates resistant to the four antimicrobials of interest) in clinical cultures. Univariate and multivariate linear regression analyses were performed. RESULTS: Significant correlations were determined between use and resistance for all antimicrobials in the univariate analysis: amikacin (standardized correlation coefficient = 0.73, p = 0.001); ciprofloxacin (0.71, p = 0.001); ceftazidime (0.61, p = 0.007) and imipenem (0.87, p < 0.001). In multivariate analysis, only imipenem (0.67, p = 0.01) was independently related to the incidence of multidrug-resistant strains. CONCLUSIONS: These findings share similarities with those reported in individual-based observational studies, with possible implications for infection control.

Fungemia in a university hospital: an epidemiological approach

INTRODUCTION: Fungemia corresponds to the isolation of fungi in the bloodstream and occurs mostly in immunosuppressed patients. The early diagnosis and treatment of these infections are relevant given the serious threat to the affected patients and possible spread to other organs, often becoming fatal. The growing number of fungemia associated with poor prognosis resulted in this research aiming to diagnose and assess the epidemiological aspects of hematogenous infections by fungi. METHODS: The study included 58 blood samples collected within a 1-year period, from patients at the Hospital das Clinicas, Federal University of Pernambuco, by venipuncture in vacuum tubes. Blood samples were processed for direct examination and culture and identification, conducted by observing the macroscopic and microscopic characteristics, as well as physiological characteristics when necessary. RESULTS: Eight (13.8%) episodes of fungemia were identified, accounting for the total sample, and these pathogens were Candida, Histoplasma, Trichosporon, Cryptococcus, and a dematiaceous fungus. C. albicans was the prevalent species, accounting for 37.5% of the cases. Most affected patients were adult males. There was no predominance for any activity, and the risk of acquired immunodeficiency syndrome was the underlying pathology most often cited. CONCLUSIONS: The isolation of fungi considered as emergent species, such as C. membranifaciens and dematiaceous species, highlights the importance of epidemiological monitoring of cases of fungemia in immunocompromised patients, as the therapy of choice depends on the knowledge of the aethiological agent.

Direct determination of calcium in milk by atomic absorption spectrometry using flow-injection analysis

A flow-injection system with sample and reagent addition by the synchronous merging zones approach for calcium determination in milk by flame AAS is proposed. Main parameters were optimized using a factorial design with central point. The optimum conditions were 2.5% (m/v) for La concentration, 8 mL min-1 for the carrier flow-rate, 20 cm for coiled reactor and 250 ìL for sample volume. Different sample preparation procedures were evaluated such as dilution in water or acid and microwave-assisted decomposition using concentrated or diluted acids. The optimized flow system was applied to determine Ca in eleven commercial milk samples and two standard reference materials diluted in water. Similar calcium levels were encountered comparing the results obtained by the proposed method (dilution in water) with those obtained using microwave-oven digestion. Results obtained in two standard reference materials were in agreement at 95% confidence level with those certified. Recoveries of spiked samples were in the 93% - 116% range. Relative standard deviation (n = 12) was < 5.4% and the sample throughput was 150 measurements per hour, corresponding to a consumption of 250 µL of sample and 6.25 mg La per determination.

A new approach to evaluate imperfection sensitivity in asymmetric bifurcation buckling analysis

A direct procedure for the evaluation of imperfection sensitivity in bifurcation problems is presented. The problems arise in the context of the general theory of elastic stability for discrete structural systems, in which the energy criterion of stability of structures and the total potential energy formulation are employed. In cases of bifurcation buckling the sensitivity of the critical load with respect to an imperfection parameter e is singular at the state given by epsilon =0, so that, a regular perturbation expansion of the solution is not possible. In this work we describe a direct procedure to obtain the relations between the critical loads, the generalized coordinates at the critical state, the eigenvector, and the amplitude of the imperfection, using singular perturbation analysis. The expansions are assumed in terms of arbitrary powers of the imperfection parameter, so that both exponents and coefficients of the expansion are unknown. The solution of the series exponents is obtained by searching the least degenerate solution. The formulation is here applied to asymmetric bifurcations, for which explicit expressions of the coefficients are obtained. The use of the method is illustrated by a simple example, which allows consideration of the main features of the formulation.

Novel retrograde puncture method to establish preperitoneal space for laparoscopic direct inguinal hernia repair with internal ring suturing

The aim of this study was to explore the clinical efficacy of a novel retrograde puncture approach to establish a preperitoneal space for laparoscopic direct inguinal hernia repair with inguinal ring suturing. Forty-two patients who underwent laparoscopic inguinal hernia repair with retrograde puncture for preperitoneal space establishment as well as inguinal ring suturing between August 2013 and March 2014 at our hospital were enrolled. Preperitoneal space was successfully established in all patients, with a mean establishment time of 6 min. Laparoscopic repairs were successful in all patients, with a mean surgical time of 26±15.1 min. Mean postoperative hospitalization duration was 3.0±0.7 days. Two patients suffered from postoperative local hematomas, which were relieved after puncturing and drainage. Four patients had short-term local pain. There were no cases of chronic pain. Patients were followed up for 6 months to 1 year, and no recurrence was observed. Our results demonstrate that preperitoneal space established by the retrograde puncture technique can be successfully used in adult laparoscopic hernioplasty to avoid intraoperative mesh fixation, and thus reduce medical costs.

Aplicação de toxina botulínica tipo A para reduzir a saliva em pacientes com esclerose lateral amiotrófica

OBJETIVO: Demonstrar o efeito da aplicação local Botox® em glândulas salivares de pacientes com diagnóstico de esclerose lateral amiotrófica (ELA), seguindo nosso protocolo institucional de tratamento da sialorréia de 2002. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Cinco pacientes com ELA avaliados na Clínica de Otorrinolaringologia da AACD (Associação de Assistência à Criança Deficiente) foram submetidos à aplicação tópica de Botox® nas glândulas salivares e acompanhados por um ano. O protocolo consiste num questionário clínico sobre as habilidades de deglutir saliva e as repercussões na qualidade de vida. Os pacientes deveriam ter tratamento odontológico prévio, intolerância aos efeitos adversos dos anti-colinérgicos, e ausência de aplicação de. Botox® em outros sítios por pelo menos seis meses. A aplicação foi guiada por ultra-sonografia para as glândulas submandibulares e a dose administrada foi de 30U em um ponto, e 20U em cada glândula parótida distribuída em dois pontos, após anestesia tópica com prilocaína. RESULTADOS: Cinco pacientes com ELA, com idade entre 45 e 59 anos foram submetidos ao tratamento de redução de saliva pela aplicação de Botox® em glândulas salivares. Nós observamos que os sintomas de sialorréia melhoraram dramaticamente em quatro pacientes. Três pacientes permaneceram quatro meses sem queixas, com acentuada melhora na qualidade de vida. Nenhum paciente apresentou efeitos colaterais locais ou sistêmicos com a aplicação de Botox® em glândulas salivares. Nós observamos que os sintomas de sialorréia melhoraram dramaticamente em quatro pacientes. Três pacientes permaneceram quatro meses sem queixas, com acentuada melhora na qualidade de vida. Nenhum paciente apresentou efeitos colaterais locais ou sistêmicos com a aplicação de Botox® em glândulas salivares.

Estudo comparativo de pacientes submetidos à cauterização submucosa com ou sem fratura lateral do corneto inferior

OBJETIVO: Comparar os efeitos da cauterização submucosa do corneto inferior com e sem a fratura lateral. FORMA DE ESTUDO: Clínico prospectivo. MATERIAIS E MÉTODOS: Foram selecionados 20 pacientes aleatoriamente com diagnóstico de hipertrofia crônica dos cornetos nasais, e divididos em dois grupos. O primeiro foi submetido à cauterização submucosa com fratura lateral do corneto, e o segundo sem a fratura. Foram avaliados cinco quesitos, comparando-se os dois métodos: dor, sangramento nasal, cicatrização, formação de crostas e perviedade nasal. O seguimento pós-operatório foi realizado no 1º, 7º, 14º e 30º dias. RESULTADOS: Quanto à dor, sangramento nasal e formação de crostas o resultado foi semelhante para ambos os grupos. Em relação à cicatrização, houve melhores resultados no grupo submetido à fratura lateral nas primeiras duas semanas do seguimento. Quanto à perviedade nasal, 80% dos pacientes submetidos à cauterização submucosa com a fratura lateral referiram boa perviedade. Por outro lado, 30% dos pacientes não submetidos à fratura lateral relataram boa perviedade. CONCLUSÃO: A realização da cauterização submucosa do corneto inferior associada à fratura lateral é mais eficaz que a realização da cauterização isoladamente.

Rendering peacekeeping instrumental? The Brazilian approach to United Nations peacekeeping during the Lula da Silva years (2003-2010)

The article analyses how Brazilian state actions and policies regarding peace operations during the Presidency of Lula da Silva relate to the country's positions and attitudes towards United Nations peacekeeping. It argues that the inconsistencies identified on the Brazilian positions reflect the lack of a clear strategic horizon guiding the country's participation in UN peacekeeping, which consequentially hinders the country emergence as a great power.

Security issues during Lula's administration: from the reactive to the assertive approach

Brazil's security agenda during Lula's administration was not homogeneous through the two mandates: the first tenure (2002-2006) revealed a reactive approach towards security topics, while the second one (2006-2010) was more assertive. More specifically, the shift occurred in terms of both its geographical scope - once it incorporated global issues in a more systematic way -, and instruments through which the security agenda was exercised, given the multilateral initiative of Unasur's CDS