A systematic review of ultrasound-guided methods for brachial plexus blockade.

We systematically reviewed 25 randomised controlled trials of ultrasound-guided brachial plexus blockade that recruited 1948 participants: either one approach vs another (axillary, infraclavicular or supraclavicular); or one injection vs multiple injections. There were no differences in the rates of successful blockade with approach, relative risk (95% CI): axillary vs infraclavicular, 1.0 (1.0-1.1), p = 0.97; axillary vs supraclavicular, 1.0 (1.0-1.1), p = 0.68; and infraclavicular vs supraclavicular, 1.0 (1.0-1.1), p = 0.32. There was no difference in the rate of successful blockade with the number of injections, relative risk (95% CI) 1.0 (1.0-1.0), p = 0.69, for one vs multiple injections. The rate of procedural paraesthesia was less with one injection than multiple injections, relative risk (95% CI) 0.6 (0.4-0.9), p = 0.004.

Prevalência de hiperidrose entre estudantes de medicina

OBJETIVO: Identificar a prevalência de hiperidrose entre os estudantes de Medicina de Manaus/AM. MÉTODOS: Estudo observacional, transversal, do tipo inquérito que analisou a prevalência de hiperidrose primária entre os alunos de Medicina da Universidade Federal do Amazonas e sua relação com o índice de massa corporal (IMC) e o stress. Os alunos foram pesados e entrevistados. Utilizou-se questionários com perguntas preconizadas pela International Hyperhidrosis Society, para relacionar a hiperidrose com as atividades diárias de cada pessoa. A análise dos resultados se deu com o cálculo da razão de prevalências e do intervalo de confiança. RESULTADOS: Entre os 293 estudantes analisados, verificou-se que um total de 16 (5,5%) estudantes apresentavam sudorese excessiva dificilmente tolerável ou intolerável, interferindo em suas atividades diárias. Nenhum apresentava causas conhecidas de hiperidrose e 50% possuíam história familiar. Em todos o acometimento foi bilateral, sendo os locais mais afetados: mãos (35,7%), pés (21,4%), axila (17,9), rosto (10,7%), costas (7,1%), tórax (3,6%) e abdome (3,6%). Não houve predomínio em relação ao sexo, idade ou IMC. Encontrou-se relação positiva com o IMC evidenciando sobrepeso e obesidade, sendo observado uma razão de prevalências de 2,48 superior em relação aos estudantes com peso normal ou abaixo do peso. CONCLUSÃO: A prevalência de hiperidrose primária entre os estudantes de Medicina de Manaus/AM foi de 5,5%, existindo uma relação positiva não estatística com o sobrepeso e a obesidade. Foi constatada ainda uma relação observacional com o stress.

Mondor's disease in puerperium: case report

Mondor's disease is a rare entity characterized by sclerosing thrombophlebitis classically involving one or more of the subcutaneous veins of the breast and anterior chest wall. It is usually a self-limited, benign condition, despite of rare cases of association to cancer. We present the case of a 32 year-old female, breast-feeding, who went to emergency due to left mastalgia for the past week. She was taking antibiotics and non-steroidal anti-inflammatory drugs, previously prescribed for suspicious of mastitis, for three days, with no clinical improvement. Physical examination showed an enlarged left breast, an axillary lump and a painful cord-like structure in the upper outer quadrant of the same breast. Ultrasound scan showed a markedly dilated superficial vein in the upper outer quadrant of left breast. The patient was given a ventropic therapy and was kept in anti-inflammatory, with progressive pain improvement. Ultrasound control was performed after four weeks, showing reperfusion.

Lymph node transfer in the treatment of postmastectomy lymphedema

Background: Lymphedema is a debilitating disorder with few treatment options. Clinical studies have shown that microvascular lymph node transfer may improve the lymphatic function of the affected limb. This study provides information about the clinical efficacy and safety of this procedure. Further, the biological background of this technique is clarified with an analysis of postoperative production of lymphatic growth factors and cytokines related to lymphangiogenesis. Patients and Methods: The effect of lymph node transfer to recipient and donor sites was analyzed with lymphoscintigraphy, limb circumference measurements, and appearance of clinical symptoms. Axillary seroma samples were analyzed from four patient groups: Axillary lymph node removal (ALND), Microvascular breast reconstruction (BR), lymph node transfer (LN) and combined lymph node transfer and breast reconstruction (LN-BR). Results: The postoperative lymphatic transport index was improved in 7/19 patients. Ten patients were able to reduce or discontinue compression therapy 6 - 24 months postoperatively. The donor lower limb lymphatic flow was slightly impaired (Ti >10) in 2 patients. No donor site lymphedema symptoms appeared during the 8 – 56-month follow-up. A high concentration of the VEGF-C protein was detected in the seroma fluid of all flap transfer groups. The concentration of the anti-inflammatory and anti-fibrotic cytokine IL-10 was increased in the LN-BR group samples when compared to the ALND or BR group. Conclusions: According to this preliminary study, the lymph node transfer seems to be beneficial for the lymphedema patients. However, a randomized study comparing the effect of BR and LN-BR is needed to evaluate the clinical efficacy of lymph node transfer. In addition, the effect of this surgery on the donor site needs to be studied further. The clinical effects of the lymph node transfer might be partly mediated by increased production of the lymphangiogenic growth factor (VEGF-C) as well as the anti-fibrotic cytokine (IL-10).

Sinningia allagophylla(Gesneriaceae): in vitro cultivation of a native plant of the Brazilian cerrado

We used axillary buds as initial explants for hormone interaction studies required for in vitro cultivation of S. allagophylla. Callus production was achieved on gelled Murashige & Skoog medium (MS) supplemented with indole-3-acetic acid (IAA= 0.1 and 0.5 mg.l­1 alone or combined with 6 benzylaminopurine) (BA= 0.01 and 0.1 mg.l-1). A hormone balance between IAA and BA that would encourage shoot bud development was not found. Nodal segments from axenic cultures grown in the presence of cytokinin (0.1 mg.1­1 of BA) without any auxin on MS medium with half-strength macronutrients were used as a standard explant source for subsequent experiments on optimum mineral culture media composition for S. allagophylla in vitro cultivation. We found that explants kept in vitro on gelled Gamborg et al. (B5) mineral composition culture medium showed better shoot and specially root growth than on MS medium. Comparisons of the ammonium and nitrate ratios of MS and B5 media indicate that B5 medium has a substantial reduced ammonium ion when compared to MS medium, as well as a lower total nitrogen level. The growth response pattern obtained in vitro may be evidence of the adaptation of this species to soils of poor mineral composition as found in the Brazilian cerrado, as well as an indication that nitrogen levels play a key role for S. allagophylla growth.

In vitro culture of Phyllanthus stipulatus (Euphorbiaceae)

An efficient micropropagation protocol was developed for the medicinal plant Phyllanthus stipulatus (Euphorbiaceae) using nodal segments for axillary shoot proliferation. Maximum multiplication rates (8-9 shoots per explant) was achieved on MS media supplemented with either 2.5-5.0 muM IBA. The best basal media for axillary shoot proliferation when 0.62 muM BA was supplemented were MS, MS/2 and AR (4-5 shoots per explant). Rooting was achieved with 100% of the microshoots on MS medium without growth regulators. Regenerated plants were successfully acclimatized and about 88% of plantlets survived under ex vitro conditions. Flowering was observed in 81% of the ex vitro grown plantlets after 12 weeks of acclimatization. High frequency callus initiation and growth was achieved when nodal segment explants were inoculated either in the vertical position, in the light on MS medium supplemented with 5.0 muM NAA or horizontally oriented, in the dark on MS supplemented with 5.0 muM NAA or 1.25-5.0 muM BA or 2iP. Root cultures were successfully established on MS medium containing 1.1 muM NAA. The optimized micropropagation, callus and root culture protocols offer the possibility to use cell/organ culture techniques for vegetative propagation and secondary metabolism studies.

Flowering and fruiting of Aulonemia aristulata: a gynomonoecious woody bamboo species from Atlantic Forest in Brazil

Aulonemia aristulata (Döll) McClure is a lignified bamboo species endemic to Brazil. This species occurs in southeastern forests and can reach high density at forest edges, dominating the understory of canopy-disturbed forest patches. The goal of this study was to describe the flowering period, floral biology, fruiting and seedling recruitment of A. aristulata in natural conditions in two areas located in a segment of the Atlantic Forest. Data on the morphology of the synflorescences and florets, timing and sequence of the anthesis events and floral visitors were recorded. Natural pollinators (open pollination or control) as well as spontaneous self-pollination were also checked. Pollen viability was estimated using the acetocarmine technique. Aulonemia aristulata is monocarpic (semelparous) with gregarious flowering. All culms in both studied areas blossomed and fruited between August and November 2007, dying subsequently between December 2007 and April 2008. Two types of synflorescences and flowers were observed: terminal with bisexual and protandric florets, with the anthesis lasting for 3-4 days; and axillary, with morphologically bisexual, but functionally female, florets and anthesis lasting for 3-4 days. The latter were also observed in the rhizome of plants whose aerial portion had been removed. The presence of axillary synflorescences with pistillate flowers is described here for the first time in Aulonemia species. Moreover, this is the first report of gynomonoecy in woody bamboo. Fruiting from bisexual florets under natural conditions (35%) was superior to that obtained from bagged synflorescences (11.5%). Fruiting from functional female florets was around 20%. Pollen viability was on the average of 90%. The results suggest that Aulonemia aristulata is anemophilous. The massive bamboo seedling recruitment observed after dieback with the ability to colonize open areas could promote the regeneration of Aulonemia aristulata.

Leaf and calycine colleters in Odontadenia lutea (Apocynaceae - Apocynoideae - Odontadenieae): their structure and histochemistry

The structure and histochemistry of colleters found on the vegetative and floral apices of Odontadenia lutea are described. Colleters occur on vegetative apices starting at the fourth node, with 68 to 80 colleters being found at each node. Each leaf primordium has only one colleter of axillary origin, 3-5 intra-petiolar, and 12-16 inter-petiolar (intra-stipular). There are four types of colleters: standard, bipartite standard, sessile, and bipartite sessile. Colleters on the reproductive apices alternate with the sepals and are sessile, reduced sessile, tripartite laminar sessile, or asymmetrical. All of the colleters have a central nucleus of parenchymatous cells covered by a palisade uniseriate secretory epidermis and a thin cuticle. Secretory idioblasts were observed in the parenchymatous axis. Vascularization was observed only in standard axillary and laminar colleters. Crystals were observed in the parenchyma of the axillary colleter. Histochemical tests demonstrated that there was no rupturing or distension of the cuticle during the secretion process. Mucilage was identified using the PAS reaction as well as by Mayer's reagent and Ruthenium red staining. The calycine colleters had two distinct secretory phases, the first synthesizing mucilage and the second producing phenolic compounds.

The Effects of the Breast Cancer Mammography Screening Programme in Women aged 40 to 84 years in Turku, Finland (1987-2009)

The objective of this thesis was to evaluate whether a more extensive mammography screening programme (TurkuMSP) conducted by the city of Turku, had an effect on breast cancer (BC) incidence, survival, or mortality in years 1987 to 2009. Despite the fact that some studies have suggested a 20 percent reduction in BC mortality due to mammography screening, there are findings of harm to subjects, which are claimed to negate the benefits of screening. Thus, the aims of this study are most pertinent. A total of 176 908 screening examinations were performed in 36 000 women aged 40−74 during the years 1987−1997. In all, 685 primary BCs were found in the screened women, either screen-detected (n=531) or during screening intervals (n=154). Survival and BC recurrence rate of women with screen-detected BC was compared to 184 women with clinical BCs detected among individuals who did not take part in the screening. The invitation interval, which may influence the outcome, was studied in the age group 40 to 49 by inviting those born in even calendar years annually for mammography screening and those born in odd years, triennially. In addition, BC incidence and mortality in the total female population of Turku aged 40 to 84 years was compared with the respective figures of Helsinki and the rest of Finland, both during the pre-screening era (1976-1986) and the screening era (1987-2009). The study was designed to compare women by age groups, because women aged 50 to 59 were generally screened in all of Finland, whereas only in Turku women aged 40 to 49 and 60 to 74 were screened in addition. Data regarding cancer recurrence were derived from the Finnish Cancer Registry and data on deaths were collected from Statistics Finland. In survival analyses, screened women with invasive BC had a significantly higher survival rate than the women with clinical BC. The survival benefit started to appear already during the first follow-up years and was evident in all age groups. A marginal survival extension was also seen in screened women when BC had spread to ipsilateral axillary nodes already at diagnosis. Recurrence-free survival rate after BC treatment was significantly more favorable among the screened women compared with women with BC found clinically. The screening invitation interval did not significantly influence BC mortality in the subset of women aged 40 to 49 years. There were no consistent differences in the changes of BC incidence between Turku and the comparison areas during the screening era. In Turku, the BC mortality incidence in women aged 55−69 years was significantly lower during the screening era (from 1987 to 1997) compared with the pre-screening era, whereas no such change was found in the city of Helsinki or Tampere. When comparing the changes in incidence-based BC mortality during years 1987 to 2009 in Turku to those of Helsinki and the rest of Finland, there was a suggestion of more than 20 percent lower mortality in Turku among oldest age group (75-84 years) compared with the reference residential areas, but the differences were not consistently significant. Interpretation of the study results should be made with caution because there were no random control groups, and on the other hand, the number of cases in subgroups was fairly low to yield definite conclusions. Also due to the many statistical analyses, some of the findings may be due to chance. The results are, however, suggestive for a decrease of BC mortality in the elderly age groups due to wide mammography screening. This finding needs confirmation in further studies before recommending an expansion of mammography screening to women up to the age of 74 years

High frequencies of plexiform neurofibromas, mental retardation, learning difficulties, and scoliosis in Brazilian patients with neurofibromatosis type 1

A clinical study of Brazilian patients with neurofibromatosis type 1 (NF1) was performed in a multidisciplinary Neurofibromatosis Program called CEPAN (Center of Research and Service in Neurofibromatosis). Among 55 patients (60% females, 40% males) who met the NIH criteria for the diagnosis of NF1, 98% had more than six café-au-lait patches, 94.5% had axillary freckling, 45% had inguinal freckling, and 87.5% had Lisch nodules. Cutaneous neurofibromas were observed in 96%, and 40% presented plexiform neurofibromas. A positive family history of NF1 was found in 60%, and mental retardation occurred in 35%. Some degree of scoliosis was noted in 49%, 51% had macrocephaly, 40% had short stature, 76% had learning difficulties, and 2% had optic gliomas. Unexpectedly high frequencies of plexiform neurofibromas, mental retardation, learning difficulties, and scoliosis were observed, probably reflecting the detailed clinical analysis methods adopted by the Neurofibromatosis Program. These same patients were screened for mutations in the GAP-related domain/GRD (exons 20-27a) by single-strand conformation polymorphism. Four different mutations (Q1189X, 3525-3526delAA, E1356G, c.4111-1G>A) and four polymorphisms (c.3315-27G>A, V1146I, V1317A, c.4514+11C>G) were identified. These data were recently published.

Sentinel node biopsy in breast cancer: results in a large series

Sentinel lymph node biopsy (SLNB) is an appropriate method for the evaluation of axillary status in cases of early breast cancer. We report our experience in treating cases evaluated using SLNB. We analyzed a total of 1192 cases assessed by means of SLNB from July 1999 to December 2007. SLNB processing was successfully completed in 1154 cases with the use of blue dye or radiolabeled 99mTc-Dextran-500, or both. Of these 1154 patients, 857 were N0(i-) (no regional lymph node metastasis, negative immunohistochemistry, IHC), 96 were N0(i+) (no regional lymph node metastasis histologically, positive IHC, no IHC cluster greater than 0.2 mm) and 201 were N1mi (greater than 0.2 mm, none greater than 2.0 mm). Most of the tumors (70%) were invasive ductal carcinomas and tumors were staged as T1 in 770 patients (65%). A total of 274 patients underwent SLNB and axillary dissections up to April 2003. The inclusion criteria were tumor size equal to or less than 3 cm in diameter, no clinically palpable axillary lymph nodes, no neoadjuvant therapy. In 19 cases, the SLN could not be identified intraoperatively. A false-negative rate of 11% and a negative predictive value of 88.2% were obtained for the 255 assessable patients. The overall concordance between SLNB and axillary lymph node status was 92%. SLNB sensitivity for nodes was 81% and specificity was 100%. The higher sensitivity, specificity, accuracy, and lower false-negative rates of SLNB suggest that this method may be an appropriate alternative to total axillary dissection in early breast cancer patients.

Etablierung neuer Methoden zur in vitro Kultivierung der Baumart Fraxinus excelsior L. und Entwicklung von Verfahren zur Kryokonservierung von in vitro Sprossspitzen

Die hier vorliegende Arbeit wurde im Rahmen eines europäischen Projektes mit dem Titel „Improving Fraxinus (Ash) productivity for European needs by testing, selection, propagation and promotion of improved genetic resources“ an der Niedersächsischen Forstlichen Versuchsanstalt, Abteilung Waldgenressourcen erstellt. Im Rahmen des Projektes wurden 62 Plusbäume aus einem 15 Jahre alten europäischen Herkunfts-/ Nachkommenschaftsversuch in den Niedersächsischen Forstämtern Bovenden und Dannenberg nach den Kriterien Stammform und Wuchsleistung für die vegetative Vermehrung ausgewählt. Ziel dieser Arbeit war die Optimierung bestehender in vitro Protokolle sowie die Entwicklung eines bisher noch nicht existierenden Kryokonservierungsprotokolls für in vitro Sprossspitzen. Im ersten Teil dieser Arbeit wird die Entwicklung des in vitro Protokolls für Fraxinus excelsior dargestellt. Die Optimierung der Methoden zur Etablierung, Vermehrung und Bewurzelung erfolgte durch Versuchsreihen mit unterschiedlichen Klonen, so dass insgesamt 26 der selektierten Plusbäume erfolgreich in vitro etabliert werden konnten. Achselknospen frischer Triebe der Pfropflinge der Mutterbäume stellten die beste Explantatquelle dar. Die Explantate wurden mit 0,2 % Quecksilberchlorid (HgCl2) oberflächensterilisiert bevor sie auf hormonfreies Woody Plant Medium (WPM) transferiert wurden. Nach zwei Wochen erfolgte ein Transfer auf WPM mit 4 mg/l 6-Benzylaminopurine (BAP) und 0,15 mg/l Indole-3-butyric acid (IBA). Die besten Vermehrungsraten wurden auf WPM mit 4 mg/l BAP, 0,15 mg/l IBA und 0,01 mg/l TDZ und 0,7 % Agar in Honiggläsern mit einem Plastikdeckel erzielt. Als Bewurzelungsmedium wurde 0,5 konzentriertes Murashige und Skoog (MS) Medium mit 2 mg/l IBA, 0,25 mg/l BAP und 0,8 % Agar verwandt. Im zweiten Teil der Arbeit werden die Versuchsreihen zur Entwicklung des Kryokonservierungsprotokolls von in vitro Sprossspitzen dargestellt. Zur Entwicklung der Methode wurden die Vorbehandlungsbedingungen verbessert und zwei Techniken, die Alginat- / Dehydrati-onsmethode und die Vitrifikationsmethode mit Hilfe der sogenannten PVS2-Lösung (Plant Vitrification solution number 2) getestet. Die optimierte PVS2-Methode erwies sich als die für Esche besser geeignete Technik und ließ sich erfolgreich zur Kryokonservierung juveniler und adulter Kulturen anwenden. Die Regenerationsraten lagen zwischen 50 und 100 % für juvenile bzw. 50 und 80 % für adulte Kulturen.

Factores pronósticos de cáncer de seno: Hospital Militar Central enero 2003 a diciembre 2008

Introducción: el riesgo de desarrollar cáncer de seno durante la vida es del 13,4% (1 de cada 7 mujeres) y la posibilidad de morir por la enfermedad después del diagnostico es cercana al 30%. Pacientes y Métodos: es un estudio de cohorte abierta retrospectiva en el que se analizó la sobrevida según los factores pronósticos de las pacientes con cáncer de seno del hospital militar central en el periodo de enero de 2003 a diciembre de 2008. Los factores pronósticos son: Edad, estadío del tumor al momento del diagnóstico, Grado de diferenciación del tumor, presencia de metástasis al momento del diagnóstico, presencia de metástasis, número de sitios de metástasis, erb2, presencia de ganglios afectados, número de ganglios positivos, receptores estrogénicos, receptores de progestágeno, tratamiento con trastuzumab, tratamiento con hormonoterapia; el análisis estadístico se realizó a partir de la herramienta de recolección de datos, esta base de datos fue trasladada al programa SPSS. Resultados: participaron 171 mujeres. La presencia de receptores para estrógenos positivos se correlaciona con una mayor sobrevida con una diferencia estadísticamente significativa (p=0.015). Durante el periodo de tiempo del estudio fallecieron 23 pacientes (13.4%), de las cuales 20 (86%) presentaban Carcinoma Canalicular Infiltrante y 21 (91%) presentaban estadios avanzados del carcinoma. Conclusiones: las características demográficas de nuestra población son similares a lo publicado en la literatura, sin variantes estadísticamente significativas frente a los hallazgos internacionales. En nuestro análisis hubo una fuerte correlación de la presencia de estrógenos positivos en relación al tiempo de sobrevida.

Manejo de lesiones abiertas del plexo braquial con compromiso vascular concomitante. Revisión sistemática de la literatura

El manejo de las lesiones de plejo braquial ha sido ampliamente discutido e investigado, especialmente en las lesiones cerradas por tracción. Las lesiones abiertas con compromiso vascular, muchas veces comprometen la viabilidad de la extremidad o la vida del paciente; son de difícil manejo con prioridades distintas, tiempos de establecimiento de los procedimientos que varían respecto a los hallazgos con resultados funcionales pobres por el diagnostico tardío de la lesión nerviosa. Se plantean interrogantes desde el punto de vista vascular y de la lesión nerviosa. se realiza una revisión sistemática de la literatura, encontrando puntos importantes con respecto a la exploración, el momento de la reparación nerviosa pero sin establecer resultados funcionales claros ante la deficiencia metodológica de los estudios encontrados.

Efectividad en la canalización yugular guiada por ecografía usando tres diferentes técnicas. Experimento en modelos simulados.

Introducción: El desarrollo tecnológico permite efectuar procedimientos eficientes en pacientes críticos de urgencias como canalizar vasos centrales guiados por ecografía. Éste procedimiento comparado con la técnica a ciegas ofrece ventajas como disminución de complicaciones, mejor éxito y menor tiempo de procedimiento. Hay diferentes técnicas de abordaje: transversal, longitudinal y oblicua, lo que supone diferencias en la efectividad y éxito en cada una de ellas. Materiales y métodos: Se realizó un experimento en modelos simulados con especialistas y residentes de último año de medicina de emergencias. Posterior a estandarizar los conceptos y abordajes de cada una de las técnicas, se puncionaron los modelos para determinar cuál técnica presenta mayor éxito y efectividad para canalización yugular con guía ecográfica. Resultados: El procedimiento fue efectivo en 175 réplicas (97.2%) distribuidas así: éxito 133 (73.9%), redirección 37 (20.6%) y requerimiento de segunda punción en 5 (2.8%). En la técnica transversal la efectividad fue 96.7% (n=58), en longitudinal del 100% (n=60) y en oblicua del 95.0% (n=57), (p=0.377). En residentes la efectividad fue 95.6% (n=86) y en especialistas 98.9% (n=89), (p=0.184). La distribución de éxito mostró que en los especialistas fue mayor en un 18.9% que en los residentes (p=0.004), por género los hombres tienen un éxito mayor en un 18.7% que las mujeres (p=0.009, OR=3.12, IC 95%: 1.30, 7.52). Discusión: No se encontró diferencia significativa en el uso de cualquier técnica, pero la tendencia favorece la técnica longitudinal, quien obtuvo mayor porcentaje de efectividad y éxito.