Ultrasound Blocks for the Anterior Abdominal Wall - Adult and Pediatric Surgery

Somatic post-surgical pain is invalidating and distressing to patients and carries the risk of important complications. The anterior abdominal wall is involved in most surgical procedures in general, gynecologic, obstetric, urological, vascular and pediatric surgery. Combined multimodal strategies involving nerve blocks, opiates, and non-steroidal anti-inflammatory drugs for systemic analgesia are necessary for optimal pain modulation. Anterior abdominal wall blocks, transverse abdominal plexus block, iliohypogastric and ilioinguinal nerveblock, genitofemoral nerve block and rectus sheath block have an important role as components of multimodal analgesia for somatic intraoperative and postoperative pain control. Ultrasound visualization has improved the efficacy and safety of abdominal blocks and implemented the application in the clinical setting. For this reason, they are a very important tool for all anesthesiologists who aim to treat effectively patients’ pain. This guide provides an evidence based comprehensive and necessary overview of anatomical, anesthesiological and technical information needed to safely perform these blocks.

Applicability of Two International Risk Scores in Cardiac Surgery in a Reference Center in Brazil

Background:The applicability of international risk scores in heart surgery (HS) is not well defined in centers outside of North America and Europe.Objective:To evaluate the capacity of the Parsonnet Bernstein 2000 (BP) and EuroSCORE (ES) in predicting in-hospital mortality (IHM) in patients undergoing HS at a reference hospital in Brazil and to identify risk predictors (RP).Methods:Retrospective cohort study of 1,065 patients, with 60.3% patients underwent coronary artery bypass grafting (CABG), 32.7%, valve surgery and 7.0%, CABG combined with valve surgery. Additive and logistic scores models, the area under the ROC (Receiver Operating Characteristic) curve (AUC) and the standardized mortality ratio (SMR) were calculated. Multivariate logistic regression was performed to identify the RP.Results:Overall mortality was 7.8%. The baseline characteristics of the patients were significantly different in relation to BP and ES. AUCs of the logistic and additive BP were 0.72 (95% CI, from 0.66 to 0.78 p = 0.74), and of ES they were 0.73 (95% CI; 0.67 to 0.79 p = 0.80). The calculation of the SMR in BP was 1.59 (95% CI; 1.27 to 1.99) and in ES, 1.43 (95% CI; 1.14 to 1.79). Seven RP of IHM were identified: age, serum creatinine > 2.26 mg/dL, active endocarditis, systolic pulmonary arterial pressure > 60 mmHg, one or more previous HS, CABG combined with valve surgery and diabetes mellitus.Conclusion:Local scores, based on the real situation of local populations, must be developed for better assessment of risk in cardiac surgery.

Impact of Intensive Physiotherapy on Cognitive Function after Coronary Artery Bypass Graft Surgery

Background: Coronary artery bypass graft (CABG) is a standard surgical option for patients with diffuse and significant arterial plaque. This procedure, however, is not free of postoperative complications, especially pulmonary and cognitive disorders. Objective: This study aimed at comparing the impact of two different physiotherapy treatment approaches on pulmonary and cognitive function of patients undergoing CABG. Methods: Neuropsychological and pulmonary function tests were applied, prior to and following CABG, to 39 patients randomized into two groups as follows: Group 1 (control) - 20 patients underwent one physiotherapy session daily; and Group 2 (intensive physiotherapy) - 19 patients underwent three physiotherapy sessions daily during the recovery phase at the hospital. Non-paired and paired Student t tests were used to compare continuous variables. Variables without normal distribution were compared between groups by using Mann-Whitney test, and, within the same group at different times, by using Wilcoxon test. The chi-square test assessed differences of categorical variables. Statistical tests with a p value ≤ 0.05 were considered significant. Results: Changes in pulmonary function were not significantly different between the groups. However, while Group 2 patients showed no decline in their neurocognitive function, Group 1 patients showed a decline in their cognitive functions (P ≤ 0.01). Conclusion: Those results highlight the importance of physiotherapy after CABG and support the implementation of multiple sessions per day, providing patients with better psychosocial conditions and less morbidity.

Cardiac Surgery Costs According to the Preoperative Risk in the Brazilian Public Health System

AbstractBackground:Heart surgery has developed with increasing patient complexity.Objective:To assess the use of resources and real costs stratified by risk factors of patients submitted to surgical cardiac procedures and to compare them with the values reimbursed by the Brazilian Unified Health System (SUS).Method:All cardiac surgery procedures performed between January and July 2013 in a tertiary referral center were analyzed. Demographic and clinical data allowed the calculation of the value reimbursed by the Brazilian SUS. Patients were stratified as low, intermediate and high-risk categories according to the EuroSCORE. Clinical outcomes, use of resources and costs (real costs versus SUS) were compared between established risk groups.Results:Postoperative mortality rates of low, intermediate and high-risk EuroSCORE risk strata showed a significant linear positive correlation (EuroSCORE: 3.8%, 10%, and 25%; p < 0.0001), as well as occurrence of any postoperative complication EuroSCORE: 13.7%, 20.7%, and 30.8%, respectively; p = 0.006). Accordingly, length-of-stay increased from 20.9 days to 24.8 and 29.2 days (p < 0.001). The real cost was parallel to increased resource use according to EuroSCORE risk strata (R$ 27.116,00 ± R$ 13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectively; p < 0.001). SUS reimbursement also increased (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$935,00; p < 0.001). However, as the EuroSCORE increased, there was significant difference (p < 0.0001) between the real cost increasing slope and the SUS reimbursement elevation per EuroSCORE risk strata.Conclusion:Higher EuroSCORE was related to higher postoperative mortality, complications, length of stay, and costs. Although SUS reimbursement increased according to risk, it was not proportional to real costs.

Incidence and Predictors of Cardiovascular Complications and Death after Vascular Surgery

AbstractBackground:Patients undergoing arterial vascular surgery are considered at increased risk for post-operative complications.Objective:To assess the incidence and predictors of complications and death, as well as the performance of two models of risk stratification, in vascular surgery.Methods:This study determined the incidence of cardiovascular complications and deaths within 30 days from surgery in adults. Univariate comparison and logistic regression assessed the risk factors associated with the outcomes, and the receiver operating characteristic (ROC) curve assessed the discriminatory capacity of the revised cardiac risk index (RCRI) and vascular study group of New England cardiac risk index (VSG-CRI).Results:141 patients (mean age, 66 years; 65% men) underwent the following surgeries: carotid (15); lower limbs (65); abdominal aorta (56); and others (5). Cardiovascular complications and death occurred within 30 days in 28 (19.9%) and 20 (14.2%) patients, respectively. The risk predictors were: age, obesity, stroke, poor functional capacity, altered scintigraphy, surgery of the aorta, and troponin change. The scores RCRI and VSG-CRI had area under the curve of 0.635 and 0.639 for early cardiovascular complications, and 0.562 and 0.610 for death in 30 days.Conclusion:In this small and selected group of patients undergoing arterial vascular surgery, the incidence of adverse events was elevated. The risk assessment indices RCRI and VSG-CRI did not perform well for complications within 30 days.

Reproductive biology of Hyla goiana (Anura, Hylidae)

Male-male and male-female interactions, reproductive habitat, and vocalizations of Hyla goiana B. Lutz, 1968 a member of H. polytaenia species group, are described. Three groups of calling males were surveyed along a small stream, at the Estação de Pesquisa e Desenvolvimento Ambiental de Galheiro, Perdizes municipality, State of Minas Gerais, Brazil. The mean distance between the nearest calling neighbors was 2.7 m, in accordance with an uniform distribution. Clutches (mean 180 eggs) were deposited in the stream, submerged and attached to plants. In two observed courtships the female moved towards a calling male that rapidly clasped her. In the male-male interaction, the males emitted advertisement and encounter calls and then engaged in physical combat. The males have a prepollical fang-like spine on each hand and several of them were observed with scratches on dorsum. The advertisement call consists of alternating harsh notes and a trilled of brief notes. The frequency of the call is lower than that of H. aff. polytaenia and H. cipoensis B. Lutz, 1968. The clutch characteristics of H. goiana are similar to those described for H. polytaenia Cope, 1870 and H. cipoensis.

Reproductive biology of the sesarmid crab Armases rubripes (Decapoda, Brachyura) from an estuarine area of the Sahy River, Sepetiba Bay, Rio de Janeiro, Brazil

The aim of this work was to gain knowledge about reproductive biology of the crab Armases rubripes (Rathbun, 1897) from an estuarine area of the Sepetiba Bay. Samples were taken monthly from February 2003 to January 2004 in the Sahy River estuary (22º56'S; 44º01'W), Rio de Janeiro, Brazil. The crabs were collected by hand during 15-minute catch-effort sessions conducted by two people. In the laboratory, the specimens were separated by sex, carapace width was measured and gonadal stage was checked macroscopically. A total of 830 individuals were caught - 304 males, 373 females (60 ovigerous females) and 153 juveniles. The ovigerous females were found almost year-round, except in November and April, showing a continuous reproductive period. They presented a size range from 8.2 to 15.0 mm carapace width (12.1 ± 1.7 mm). Color and macroscopical aspects determined five gonadal stages for males and females (immature, rudimentary, intermediary, developed and resting). First sexual maturity was estimated at 6.5 mm of carapace width for males and 8.1 mm for females. Individual fecundity varied from 200 to 11,460 eggs (4,458 ± 2,739 eggs). Mean egg size was 0.248 ± 0.026 mm, varying from 0.213 to 0.333 mm, while the volume ranged from 0.0051 to 0.0188 mm³ (0.0082 ± 0.0029 mm³).

Reproductive isolation among three populations of the genus Grammostola from Uruguay (Araneae, Theraphosidae)

Ethological isolation of individuals from three allopatric Grammostola populations of Uruguay, G. iheringi (Keyserling, 1891), G. mollicoma (Auserer, 1875) northern population and G. mollicoma southern population, was tested under laboratory conditions. Grammostola iheringi behaved as a reproductive isolated species, whereas the two populations of G. mollicoma did not show ethological isolation between them. However, ecological isolating reproductive mechanisms could be acting on G. mollicoma populations. Artificial burrows seem to be important for reproductive isolation in these species.

Population and reproductive features of the western Atlantic hermit crab Pagurus criniticornis (Anomura, Paguridae) from Anchieta Island, southeastern Brazil

The population of the hermit crab Pagurus criniticornis (Dana, 1852) was studied based on seasonal abundance, size frequency distribution, sex ratio, reproductive period, fecundity and shell relationship. Specimens were collected monthly by SCUBA diving in the infralittoral area of Anchieta Island, Ubatuba. A total of 1,017 individuals was analyzed. Animal size (minimum and maximum shield length, respectively) was 0.7 and 2.9 mm for males, 0.6 and 2.8 mm for non-ovigerous females, and 1.0 and 2.5 mm for ovigerous females. The sex ratio was 1:1.29. Sexual dimorphism was recorded by the presence of males in the largest size classes. Ovigerous females were captured during all months along the year, with percentages varying from 8% (July) to 84.3% (February) in relation to the total females collected. Mean ± SD fecundity was 168 ± 125 eggs and tended to increase with increasing hermit size. Shells of four gastropod species [Cerithium atratum (Born, 1778), Morula nodulosa (Adams, 1845), Anachis lyrata (Sowerby, 1832) and Modulus modulus (Linnaeus, 1758)] were occupied by ovigerous females of P. criniticornis but fecundity was not significantly different in relation to the different shell types. The profile showed continuous and intense reproduction of P. criniticornis probably related to strategies developed to compensate for interspecific competition in the studied insular area.

Reproductive ecology of the invader species gekkonid lizard Hemidactylus mabouia in an area of southeastern Brazil

Hemidactylus mabouia Moreau de Jonnés, 1818 is a "fixed" clutch size exotic species well established in Brazil. In this paper we investigate some reproductive strategies adopted to minimize the costs of invariant clutch size to this invader species living in an environment with marked climatic seasonality in Southeastern Brazil (22°56’S; 46°55’W). The study was carried out from April 2002 to March 2003. Females and males attain maturity at 47.9mm and 46.9mm SVL, respectively. Larger females tended to produce larger eggs. The reproduction occurred throughout the year, but only at the wet season the females increase the clutch frequency. There was a significant variation in mean testis volume among the months throughout the year and the largest means were recorded between August and December. Maternal investment on egg size, increase on clutch frequency and seasonal increase on testis volume can represent important reproductive strategies of this invader species living in an non-urban habitat whit climatic seasonality (dry and cold weather season).

Reproductive behavior of Leptodactylus mystacinus (Anura, Leptodactylidae) with notes on courtship call of other Leptodactylus species

Here we present data on the reproductive behavior of Leptodactylus mystacinus (Burmeister, 1861), including details on courtship behavior. We also describe and compared the courtship calls of L. mystacinus, L. furnarius Sazima & Bokermann, 1978 and Leptodactylus sp. (L. aff. andreae). Field works were conducted in Uberlândia (central Brazil). During courtship, a female approaches a calling male and is led to a previously excavated chamber; a female can approach a silent male that beat his hands and/or feet on the ground as well. The courtship call of L. mystacinus consists of one single arch-shaped note (duration = 0.04 s) repeated 258 times per minute; the courtship calls of L. furnarius (0.06 s, 84 times per minute) and Leptodactylus sp. (0.15 s, 5 times per minute) also are arch-shaped. The courtship behavior of L. mystacinus is similar to that of other species of the L. fuscus (Schneider, 1799) group; unique to it is that males can beat his hands and/or feet on the ground while courting. The male behavior of conducting the female to a previously excavates chamber and the arch-shaped courtship call may represent other shared derived features of members of the L. fuscus group, including the former Adenomera species.

Reproductive biology and sexual dimorphism in Cnemidophorus vacariensis (Sauria, Teiidae) in the grasslands of the Araucaria Plateau, southern Brazil

The reproductive cycle and sexual dimorphism of the lizard Cnemidophorus vacariensis Feltrim & Lema, 2000 were studied on the basis of data gathered between August 2004 and August 2006 in Vacaria, Rio Grande do Sul, Brazil. Snout-vent length (SVL) of sexually mature males varied between 48.8 and 72.9 mm (x = 63.3 ± 6.0 mm; n = 76) and, for females, between 57.4 and 81.8 mm (x = 70.0 ± 5.9 mm; n = 73). Other morphological characteristics were also compared between sexes. Reproduction was seasonal, and observations indicate two clutches in the same reproductive season. Clutch size and other reproductive characteristics were analyzed as well as the relation between reproduction and environmental factors. Cnemidophorus vacariensis is apparently endemic to highland plateaus in southern Brazil and has been classified as vulnerable on some lists of threatened fauna in this country. Some suggestions for conservation measures are presented, due to the observed degradation of this species' environment.

Reproductive biology of Leptodactylus fuscus (Anura, Leptodactylidae) in the subtropical climate, Rio Grande do Sul, Brazil

The aim of this study was to characterize, for the central region of the State of Rio Grande do Sul, Brazil, the reproductive biology of Leptodactylus fuscus (Schneider, 1799), based on the analysis of gonadal development of males and females, reproductive effort, size-fecundity relationships, and occurrence of sexual dimorphism in body size. Mature individuals were found from October 1996 to February 1997 and from October 1997 to December 1997. The highest input of juveniles in the population was recorded in March 1997. There was a positive and significant correlation between the number of mature individuals and the mean monthly temperature. The population did not present sexual dimorphism in size. Males presented significant correlation only between snout-vent length and testes length. All females had oocytes at four different maturation stages and there were no significant correlations regarding size-fecundity variables. The correlation between ovarian size factor and females snout-vent length was not significant either. The main difference between this population and those that inhabit tropical climate was that temperature was responsible for stimulating the reproduction activity, instead of rainfall.