Endoscopic ligation of the anterior ethmoidal artery: a cadaver dissection study

Anterior ethmoidal artery (AEA) ligation may be necessary in cases of severe epistaxis not controllable with traditional therapy. Endoscopic endonasal ligation of the AEA is not used frequently; there are few studies in the literature for standardization of the endoscopic technique for this vessel. Aim: To demonstrate the feasibility of periorbital AEA ligation in a transethmoidal endoscopic approach. Methods: A prospective study where 50 nasal cavities were dissected. After anterior ethmoidectomy and partial removal of lamina papyracea, the periorbital area was carefully dissected along a subperiosteal plane to identify the AEA. The vessel was exposed within the orbit and dissected. Results: Data on technical difficulties, complications, the learning curve and anatomical variations were gathered. Conclusion: An endonasal endoscopic approach to the AEA within the orbit was shown to be feasible. Identifying the artery is not difficult, and this technique avoids external incisions. This approach appears to be an excellent alternative for approaching the AEA. Further clinical studies are needed to demonstarte the benefits of this technique.

Severe hemorrhagic corpus luteum complicating anticoagulation in antiphospholipid syndrome

Antiphospholipid syndrome (APS) is a disorder of coagulation that causes thrombosis as well as pregnancy-related complications, occurring due to the autoimmune production of antibodies against phospholipid. Full anticoagulation is the cornerstone therapy in patients with thrombosis history, and this can lead to major bleeding. During a 3-year period, 300 primary and secondary APS patients were followed up at the Rheumatology Division of the authors` University Hospital. Of them, 255 (85%) were women and 180 (60%) were of reproductive age. Three of them (1%) had severe hemorrhagic corpus luteum while receiving long-term anticoagulation treatment and are described in this report. All of them were taking warfarin, had elevated international normalized ratio (> 4.0) and required prompt blood transfusion and emergency surgery. Therefore, we strongly recommend that all women with APS under anticoagulation should have ovulation suppressed with either intramuscular depot-medroxyprogesterone acetate or oral desogestrel. Lupus (2011) 20, 523-526.

Bowel dilation as a predictor of adverse outcome in isolated fetal gastroschisis

Objectives This study was designed to evaluate bowel diameter as a predictor of adverse outcome in isolated fetal gastroschisis Methods Retrospective study involving 94 singleton pregnancies Ultrasound measurements of herniated bowel transverse diameter (BTD) were performed up to 3 weeks before delivery Adverse outcome was intrauterine/neonatal death and/or bowel complications Results Last BTD was recorded at 35 6 +/- 1 6 weeks and mean interval to delivery was 6 2 +/- 5 0 days Intrauterine/neonatal death occurred in 10 (10 6%) cases, bowel complications were observed in 8 (8 5%) BTD >= 15, >= 20, >= 25, and >= 30 mm were found in 87, 46, 13, and 4% of pregnancies with a favorable outcome. respectively BTD >= 25 mm sensitivity was 38%. and positive and negative predictive values were 38 and 87% For BTD >= 30 mm. the values were 19, 50, and 85% Observed/expected BTD ROC curve showed an area of 0 67, best cut-off value at 1 39, prediction values were similar to those for BTD >= 25 mm Bowel dilatation was also significantly associated with lower rate of primary surgical closure. longer period to full oral feeding, and prolonged hospital stay Conclusions Bowel dilatation demonstrated up to 3 weeks before delivery is a predictor of intestinal complications and is associated with lower late of primary surgical closure, longer period to achieve full oral feeding. and hospital stay Copyright (C) 2010 John Wiley & Sons, Ltd

Prematurity prevention: the role of progesterone

Purpose of review This review summarizes the evidence of the effectiveness of progesterone on the rate of preterm birth and evaluates the most recent studies. Recent findings The incidence of preterm delivery is about 7-11% of all pregnant women and preterm birth is one of the most important causes of neonatal morbidity and mortality. Interventions to reduce such complications have been attempted for several years. Most efforts so far have been tertiary interventions, such as treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. Some of these measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Recently, researches have suggested prophylactic progesterone could reduce the preterm birth rate in a select group presenting previous preterm birth and a short cervical length by transvaginal scan at mid-trimester pregnancy. Summary This review intends to define the current indication for administration of progesterone for pregnant women. On the basis of current knowledge, progesterone should be offered to women with a documented history of a previous spontaneous birth at less than 37 weeks and for those found to have a short cervical length of 15 mm or less. Studies are needed to evaluate progesterone efficacy on other risk factors.

Early neonatal morbidity and mortality in growth-discordant twins

Objective. To evaluate early neonatal morbidity and mortality in twin pregnancies with growth discordance. Design. Retrospective study. Setting. Tertiary teaching hospital, Sao Paulo, Brazil. Population. A total of 151 twin pregnancies managed and delivered at the Multiple Pregnancy Unit at Sao Paulo University Hospital between 1998 and 2004. Methods. Comparison between twin pregnancies with weight discordance 20% and pregnancies concordant for fetal weight. Cases with fetal death, abnormalities, twin-to-twin transfusion and delivery before 26 weeks or in another hospital were excluded. Outcome measures. Early neonatal morbidity (Apgar at 5 minutes 7, respiratory or neurological complications, infection, necrotizing enterocolitis, length of hospital stay) and mortality. Results. Forty (26.5%) pregnancies presented discordance 20% and 111 (73.5%) were concordant. In the discordant group, 75% of pregnancies had at least one growth restricted fetus (10th centile). In concordant twin pregnancies, monochorionic cases (22.5%) presented with lower gestational age (34.3 vs. 36.2 weeks), lower birthweight (2,067 vs. 2,334 g) and a longer period of hospital stay (5.5 vs. 3.0) compared to dichorionic concordant twins. No differences between monochorionic and dichorionic subgroups were observed in discordant twins. Pregnancies in which at least one baby was born with a birthweight below the 10th centile showed that discordant pregnancies had a lower gestational age at delivery (35.2 vs. 36.8 weeks) and a longer period of hospital stay (9 vs. 4 weeks) compared to concordant cases. Neonatal mortality was similar in discordant (3.7%) and concordant (4.5%) twins. Conclusion. Early perinatal morbidity is increased in twin pregnancies with birthweight discordance 20% only when associated with fetal growth restriction and low birthweight.

Assessment of immediate conservative breast surgery reconstruction: A classification system of defects revisited and an algorithm for selecting the appropriate technique

Background: Although various techniques have been used for breast conservation surgery reconstruction, there are few studies describing a logical approach to reconstruction of these defects. The objectives of this study were to establish a classification system for partial breast defects and to develop a reconstructive algorithm. Methods: The authors reviewed a 7-year experience with 209 immediate breast conservation surgery reconstructions. Mean follow-up was 31 months. Type I defects include tissue resection in smaller breasts (bra size A/B), including type IA, which involves minimal defects that do not cause distortion; type III, which involves moderate defects that cause moderate distortion; and type IC, which involves large defects that cause significant deformities. Type II includes tissue resection in medium-sized breasts with or without ptosis (bra size C), and type III includes tissue resection in large breasts with ptosis (bra size D). Results: Eighteen percent of patients presented type I, where a lateral thoracodorsal flap and a latissimus dorsi flap were performed in 68 percent. Forty-five percent presented type II defects, where bilateral mastopexy was performed in 52 percent. Thirty-seven percent of patients presented type III distortion, where bilateral reduction mammaplasty was performed in 67 percent. Thirty-five percent of patients presented complications, and most were minor. Conclusions: An algorithm based on breast size in relation to tumor location and extension of resection can be followed to determine the best approach to reconstruction. The authors` results have demonstrated that the complications were similar to those in other clinical series. Success depends on patient selection, coordinated planning with the oncologic surgeon, and careful intraoperative management.

PREDICTIVE FACTORS FOR GAIT IN FEMORAL TRANSTROCHANTERIC FRACTURES

Objective: The objective of this study was to identify variables that could predict the quality of gait in patients with transtrochanteric femoral fractures after treatment. Materials and Methods: Hospitalized patients diagnosed with transtrochanteric femoral fractures were selected between September/2005 and August/2006 and followed-up for 6 months after the trauma date. An observational prospective study was conducted to assess the quality of gait 3 and 6 months after fracture in 31 patients (13 males and 18 females). The mean age was 76 +/- 2,7. Results: Seven patients (22,6%) passed away during the follow-up period. The patients with associated fractures or with four or more co-morbidities showed a worse quality of gait after 6 months. Patients without orthopaedic complications or who got partial weight load prior to 30 days showed a better performance. Conclusion: The quantification of predictive gait indexes allows us to propose new treatment approaches consistently to the different realities showed by each group of patients.

RESTORATION OF THE ROTATION CENTER IN MINIMALLY-INVASIVE TOTAL HIP REPLACEMENT

Objective: Our aim was to evaluate the challenges in obtaining a successful restoration of the rotation center as well as a good positioning of the acetabular component when using the minimally-invasive posterior approach for uncemented total hip replacement. Methods: In a comparative non-random prospective study, 64 adult patients underwent elective total hip arthroplasty using the minimally-invasive posterior approach performed by one single surgeon, All patients included in this study had a superior and lateral migration of the rotation center of the hip in comparison to the normal contralateral hip. Patients were excluded from the study if they presented the following: diagnosis of femoral neck fracture, displasic hip types 2, 3 and 4 (Crowe`s classification), osteoarthritis of the contralateral hip. Of the 64 patients in the study, 39 had a radiographic pre-op acetabular size planning equal or less than 50 mm and 25 patients had a radiographic pre-op acetabular size planning equal or more than 52 mm. We considered a good result the following goals: acetabular bend between 35 and 50 degrees, acetabular size according to the pre-op estimative with full contact in the three zones of DeLee-Charnley, a lower medial and vertical positioning of the rotation center in comparison with the pre-op values and a final limb discrepancy lower than 10 mm. Results: A better restoration of the rotation center, as well as, excellent acetabular positioning was found in patients with smaller acetabular size (equal or less than 50), p=0, 04. We must draw attention to two risks when using the minimally-invasive posterior approach: a vertical acetabular position and a lateral position of the acetabular component increasing the risk of a poor contact in the zone 1 due to an insufficient reaming of the medial acetabular host bone. Conclusion: We propose standard surgical approaches in patients with larger anatomical measurements (acetabular planning size more than 50).

SPONTANEOUS FRACTURE OF THE FEMORAL NECK FOLLOWING PFN REMOVAL

Femoral neck fracture without associated trauma following consolidation of a transtrochanteric fracture is a rare event. The authors report a case of transtrochanteric fracture that was treated with PFN and which presented fracturing of the femoral neck two weeks after removal of the device. This occurrence was treated with partial arthroplasty.

Genitoperineal Injuries Associated With the Use of an Orthopedic Table With a Perineal Posttraction

Background: Surgical treatment of lower extremity fractures commonly involves the use of orthopedic table with perineal post for countertraction. However, prolonged application of the perineal post has been associated with significant complications. We describe our experience in the management of genitoperineal cutaneous injuries associated with the use of a traction table. Methods: Six patients with genitoperineal complications attributed to the use of a traction table were treated at our institution over a period of 2 years. The patient`s median age was 25 (range, 2028) years and all had fractures caused by motor vehicle collision. We evaluated the clinical presentation of these perineal injuries, operative time, therapeutic approach, clinical outcomes, and hospitalization time. Results. The mean operative time of the orthopedic surgery was 318 minutes 128 minutes (range, 185-540). All patients developed a partial-thickness necrotic area involving the perineum and scrotum in 2 days to 15 days (mean, 7 +/- 5.4) after the surgery. Three patients developed infection of the necrotic tissue. All patients underwent surgical debridement 16.5 days +/- 6.5 days (range, 13-29) after the orthopedic surgery and only one debridement procedure was nec-sure was possible in one case, and in the other cases the wound healed completely by second intention. The mean hospitalization time was 26.3 days +/- 9.7 days (range, 19-44). conclusion: Genitoperineal skin necrosis induced by perineal traction posttable is a morbid complication that demands surgical debridement and prolonged hospitalization for your treatment. There are many procedures available to reduce the risk of this complication that should be used more liberally by the orthopedic surgeons.

Early identification of leptospirosis-associated pulmonary hemorrhage syndrome by use of a validated prediction model

Objective: To identify prediction factors for the development of leptospirosis-associated pulmonary hemorrhage syndrome (LPHS). Methods: We conducted a prospective cohort study. The study comprised of 203 patients, aged >= 14 years, admitted with complications of the severe form of leptospirosis at the Emilio Ribas Institute of Infectology (Sao Paulo, Brazil) between 1998 and 2004. Laboratory and demographic data were obtained and the severity of illness score and involvement of the lungs and others organs were determined. Logistic regression was performed to identify independent predictors of LPHS. A prospective validation cohort of 97 subjects with severe form of leptospirosis admitted at the same hospital between 2004 and 2006 was used to independently evaluate the predictive value of the model. Results: The overall mortality rate was 7.9%. Multivariate logistic regression revealed that five factors were independently associated with the development of LPHS: serum potassium (mmol/L) (OR = 2.6; 95% CI = 1.1-5.9); serum creatinine (mmol/L) (OR = 1.2; 95% CI = 1.1-1.4); respiratory rate (breaths/min) (OR = 1.1; 95% CI = 1.1-1.2); presenting shock (OR = 69.9; 95% CI = 20.1-236.4), and Glasgow Coma Scale Score (GCS) < 15 (OR = 7.7; 95% CI = 1.3-23.0). We used these findings to calculate the risk of LPHS by the use of a spreadsheet. In the validation cohort, the equation classified correctly 92% of patients (Kappa statistic = 0.80). Conclusions: We developed and validated a multivariate model for predicting LPHS. This tool should prove useful in identifying LPHS patients, allowing earlier management and thereby reducing mortality. (C) 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Common mental disorders during pregnancy: prevalence and associated factors among low-income women in Sao Paulo, Brazil

To estimate the prevalence of common mental disorders (CMD) and factors associated with these disorders among pregnant women of low socio-economic status (SES) in Sao Paulo. We performed a cross-sectional study with 831 women in their 20th to 30th weeks of pregnancy, who were attending antenatal clinics in primary care in Sao Paulo, Brazil. CMD were assessed with the Clinical Interview Schedule-Revised. Crude and adjusted prevalence ratios and 95% CI were calculated to examine the association between CMD and exposure variables. The prevalence of CMD was 20.2% (95% CI 17.5 to 23.0). Age at current pregnancy and at first delivery, current obstetric complications, not having friends in the community, living in a crowded household, lower occupational status and history of previous psychiatric treatment were all independently associated with increased prevalence of CMD. CMD is highly prevalent among pregnant women of low SES seen in primary care settings in Sao Paulo. A combination of distal and proximal psychosocial factors increase the risk for CMD. Primary health care professionals need to be aware of how common CMD in such settings and properly trained to deal with CMD during pregnancy.

Long-term results of the percutaneous transhepatic venoplasty of portal vein stenoses after pediatric liver transplantation

This paper has the objective to evaluate retrospectively the long-term results of transhepatic treatment of PV stenoses after pediatric LT. During an eight-yr period, 15 children with PV stenoses underwent PTA with balloon dilation or stent placement in case of PTA failure after LT. Patients` body weights ranged from 9.3 to 46 kg (mean, 15.5 kg). PV patency was evaluated in the balloon dilation and in the stent placement groups. Technical and clinical successes were achieved in all cases with no complication. Eleven patients (11/15; 73.3%) were successfully treated by single balloon dilation. Four patients (4/15; 26.7%) needed stent placement. One patient was submitted to stent placement during the same procedure because of PTA failure. The other three developed clinical signs of portal hypertension because of PV restenoses two, eight, and twenty-eight months after the first PTA. They had to be submitted to a new procedure with stent placement. The follow-up time ranged from 3 to 8.1 yr (mean, 6.3 yr). In conclusion, transhepatic treatment of PV stenoses after pediatric LT with balloon dilation or stent placement demonstrated to be a safe and effective treatment that results in long-term patency.

Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center

Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.

Loxosceles venom-induced cytokine activation, hemolysis, and acute kidney injury

Herein, we describe a confirmed case of Loxosceles spider bite that illustrates the critical complications seen in loxoscelism, including skin necrosis, rhabdomyolysis, hemolysis, coagulopathy, acute kidney failure, and electrolyte disorders. Upon initial assessment, laboratory studies revealed the following: the white blood cell count was 29 400 WBCs/mm(3), hemoglobin was 9.2g/dL, and the platelet count was 218000cells/mm(3). Coagulation studies revealed the following: international normalized ratio, 1.83; activated partial-thromboplastin time, 62s; D-dimer, 600 ng/mL (normal range < 500 ng/mL); free protein S, 37% (normal range = 64-114%); protein C, negative; and antithrombin III, negative. Various serum levels were abnormal: urea, 110mg/dL; creatinine, 3.1 mg/dL; indirect bilirubin, 3.8 mg/dL; creatine kinase, 1631 U/L, lactate dehydrogenase, 6591 U/L; potassium 6.2mmol/L. Urine tests were positive for hemoglobin and bilirubin. In addition, concentrations of interleukin-6 and tumor necrosis factor-alpha were notably elevated in the serum. In conclusion, physicians must be alert to the possibility of loxoscelism when a patient presents with the clinical and laboratory findings described above, especially if the patient resides in an endemic area. Advances in our understanding of multiple pathways and mediators that orchestrate the response to Loxosceles venom might reveal new possibilities for the management of loxoscelism. (C) 2007 Elsevier Ltd. All rights reserved.