Survival and Quality of Life among Patients with Severe Lower Extremity Peripheral Arterial Disease

Lower extremity peripheral arterial disease (PAD) is associated with decreased functional status, diminished quality of life (QoL), amputation, myocardial infarction, stroke, and death. Nevertheless, public awareness of PAD as a morbid and mortal disease is low. The aim of this study was to assess the incidence of major lower extremity amputation due to PAD, the extent of reamputations, and survival after major lower extremity amputation (LEA) in a population based PAD patient cohort. Furthermore, the aim was to assess the functional capacity in patients with LEA, and the QoL after lower extremity revascularization and major amputation. All 210 amputees due to PAD in 1998–2002 and all 519 revascularized patients in 1998–2003 were explored. 59 amputees alive in 2004 were interviewed using a structured questionnaire of QoL. Two of each amputee age-, gender- and domicile-matched controls filled in and returned postal self-administered QoL questionnaire as well as 231 revascularized PAD patients (the amount of these patients who engaged themselves to the study), and one control person for each patient completed postal self-administered QoL questionnaire. The incidence rate of major LEA was 24.1/100 000 person-years and it was considerably high during the years studied. The one-month mortality rate was 21%, 52% at one-year, and the overall mortality rate was 80%. When comparing the one-year mortality risk of amputees, LEAs were associated with a 7.4-fold annual mortality risk compared with the reference population in Turku. Twenty-two patients (10%) had ipsilateral transversions from BK to AK amputation. Fifty patients (24%) ended up with a contralateral major LEA within two to four amputation operations. Three bilateral amputations were performed at the first major LEA operation. Of the 51 survivors returning home after their first major LEA, 36 (71%) received a prosthesis; (16/36, 44%) and were able to walk both in- and outdoors. Of the 68 patients who were discharged to institutional care, three (4%) had a prosthesis one year after LEA. Both amputees and revascularized patients had poor physical functioning and significantly more depressive symptoms than their controls. Depressive symptoms were more common in the institutionalized amputees than the home-dwelling amputees. The surviving amputees and their controls had similar life satisfaction. The amputees felt themselves satisfied and contented, whether or not they lived in long-term care or at home. PAD patients who had undergone revascularizations had poorer QoL than their controls. The revascularized patients’ responses on their perceived physical functioning gave an impression that these patients are in a declining life cycle and that revascularizations, even when successful, may not be sufficient to improve the overall function. It is possible that addressing rehabilitation issues earlier in the care may produce a more positive functional outcome. Depressive symptoms should be recognized and thoroughly considered at the same time the patients are recovering from their revascularization operation. Also primary care should develop proper follow-up, and community organizations should have exercise groups for those who are able to return home, since they very often live alone. In rehabilitation programs we should consider not only physical disability assessment but also QoL.

Ocorrência e variabilidade genética do Tomato severe rugose virus em tomateiro e pimentão no Estado de São Paulo

Um levantamento para avaliar a ocorrência de begomovírus nas culturas de pimentão e tomateiro no estado de São Paulo foi realizado entre janeiro/2007 e julho/2008. O DNA total de amostras de pimentão (710) e de tomateiro (103) foi extraído e a presença de begomovírus foi testada por PCR. Paralelamente, as mesmas amostras foram avaliadas por amplificação por círculo rolante (RCA) seguidas de PCR, e algumas amostras positivas analisadas por RCA-RFLP com a enzima de restrição HpaII, a fim de se conhecer a variabilidade genética dos isolados. Os resultados demonstraram que, para a técnica de PCR, 99 amostras de pimentão (13,94%) e 39 de tomateiro (37,86%) foram positivas para a presença de begomovírus, enquanto que por RCA-PCR, 333 (46,90%) de pimentão e 82 (79,61%) de tomateiro mostrando a maior sensibilidade desta técnica. Seqüências correspondentes à região 5' da capa protéica (CP) e um segmento de gene da região intergênica foram analisadas e indicaram apenas a presença da espécie Tomato severe rugose virus (ToSRV). Porém, seqüenciamento parcial de clones obtidos a partir de produto RCA de tomateiro permitiu a detecção de infecção mista de ToSRV e Tomato yellow vein streak virus (ToYVSV). Por RCA-RFLP quatro padrões de restrição foram observados para o ToSRV em pimentão, enquanto que em tomateiro observaram-se 18 padrões.Os resultados indicam maior diversidade genética dos begomovírus em tomateiro quando comparada com os de pimentão.

Avaliação de danos causados pelo Tomato severe rugose virus (ToSRV) em cultivares de pimentão

A espécie Tomato severe rugose virus (ToSRV) é a predominante em áreas de cultivo de pimentão no Estado de São Paulo. Sua ocorrência na cultura é relativamente recente de modo que não existem informações sobre os danos causados nesta cultura. Os objetivos do presente trabalho foram avaliar a produtividade e qualidade dos frutos de pimentão de três cultivares (Magda, Amanda e Rubia R) quando infectadas com o ToSRV. Verificou-se acentuada redução no número de frutos e menor crescimento das plantas, porém, o ToSRV não influenciou significativamente na massa, diâmetro e comprimento dos frutos. Os resultados obtidos até o momento permitem concluir que o ToSRV causa danos em pimentão e que há necessidade de estudos visando resistência ao ToSRV.

Obtenção de plantas de feijão-caupi resistentes ao Cowpea severe mosaic virus e ao Cowpea aphid-borne mosaic virus

Dentre os vírus que infectam o feijão-caupi (Vigna unguiculata L. Walp.) destacam-se, respectivamente, pela severidade e ampla ocorrência o Cowpea severe mosaic virus (CPSMV) e o Cowpea aphid-borne mosaic virus (CABMV). Portanto, objetivaram-se, no presente trabalho, obter e avaliar plantas de feijão-caupi com resistência ao CPSMV e ao CABMV, visando ao desenvolvimento de cultivares essencialmente derivadas e novas cultivares. Realizaram-se oito cruzamentos seguidos de retrocruzamentos, utilizando a linhagem TE 97-309G-9 e a cultivar Patativa como genitores resistentes, e as cultivares BR3-Tracuateua, BRS-Urubuquara, BRS-Novaera, BRS-Guariba e Pretinho como genitores suscetíveis. As gerações F2 e F2RC1 foram desafiadas quanto à resistência por meio de inoculação mecânica com isolados do CPSMV e do CABMV. Nas gerações F2RC1, além da resistência foram avaliados os caracteres: número de dias para o início da floração, comprimento das vagens, número de grãos. vagem-1, peso de cem grãos e produção de grãos.planta-1. Todos os indivíduos F2 e F2RC1 foram analisados pelo teste χ² e se ajustaram à frequência esperada de 15 plantas suscetíveis 1 planta resistente a ambos os vírus. As médias das plantas F2RC1 resistentes, de cada retrocruzamento, foram comparadas com a média do seu respectivo genitor recorrente pelo teste 't' e as médias dos retrocruzamentos foram comparadas pelo teste de Scott-Knott. Foi detectada variabilidade genética entre os retrocruzamentos para todos os caracteres. Todos os retrocruzamentos foram considerados promissores para produção de cultivares essencialmente derivadas resistentes ao CPSMV e ao CABMV e as plantas selecionadas possuem características que possibilitam a seleção de linhagens com grãos de bom padrão comercial e altamente produtivas.

Avaliação da Dispersão primária e secundária do Tomato severe rugose virus para genótipos de Capsicum spp. por Bemisia tabaci MEAM1

A mosca branca Bemisia tabaci (Hemiptera: Aleyrodidae) é considerada uma das pragas agrícolas mais ameaçadoras em todo o mundo, pelo seu efeito direto na sucção de seiva das plantas e principalmente pelo seu efeito indireto de transmitir vírus, em especial os begomovírus. No Brasil, a espécie de begomovírus predominante em solanáceas é o Tomato severe rugose vírus - ToSRV. Uma possibilidade de manejo da doença é a utilização de cultivares resistentes ou tolerantes tanto ao vírus, como ao inseto vetor. Foram avaliados neste trabalho a dispersão primária e secundária do ToSRV por Bemisia tabaci, espécie MEAM1, também conhecida como biótipo B, em cultivares tolerantes ao ToSV Capsicum baccatum (IAC-1357) C. annuum (IAC-1566) e C. frutescens (IAC-1544). O genótipo (IAC-1544) apresentou menor número de plantas infectadas pelo ToSRV no ensaio de dispersão primária e nenhuma eficiência na transmissão do isolado na dispersão secundária. Estes resultados colaboram para o melhoramento de pimentão e pimentas visando a resistência ao ToSRV e seu inseto vetor.

Is there a role for pyloric exclusion after severe duodenal trauma?

Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.

Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury

OBJECTIVE: to determine predictive factors for prognosis of decompressive craniectomy in patients with severe traumatic brain injury (TBI), describing epidemiological findings and the major complications of this procedure.METHODS: we conducted a retrospective study based on analysis of clinical and neurological outcome, using the extended Glasgow outcome in 56 consecutive patients diagnosed with severe TBI scale treated in the emergency department from February 2004 to July 2012. The variables assessed were age, mechanism of injury, presence of pupillary changes, Glasgow coma scale (GCS) score on admission, CT scan findings (volume, type and association of intracranial lesions, deviation from the midline structures and classification in the scale of Marshall and Rotterdam).RESULTS: we observed that 96.4% of patients underwent unilateral decompressive craniectomy (DC) with expansion duraplasty, and the remainder to bilateral DC, 53.6% of cases being on the right 42.9% on the left, and 3.6% bilaterally, with predominance of the fourth decade of life and males (83.9%). Complications were described as transcalvarial herniation (17.9%), increased volume of brain contusions (16.1%) higroma (16.1%), hydrocephalus (10.7%), swelling of the contralateral lesions (5.3%) and CSF leak (3.6%).CONCLUSION: among the factors studied, only the presence of mydriasis with absence of pupillary reflex, scoring 4 and 5 in the Glasgow Coma Scale, association of intracranial lesions and diversion of midline structures (DML) exceeding 15mm correlated statistically as predictors of poor prognosis.

Burden of Influenza in Children

Background: Most children with influenza are treated as outpatients but, especially among young children, influenza-attributable illnesses often result in hospitalization. However, relatively scarce data exist on the clinical picture and the full disease burden of pediatric influenza. Prompt diagnosis of influenza could enable the institution of antiviral therapy and adequate cohorting of patients. Data are needed to help clinicians correctly suspect influenza at the time of hospital admission. Aims and methods: We conducted a prospective 2-year cohort study of respiratory infections in children aged ≤13 years to determine the incidence of influenza in outpatient children and to assess the clinical presentation of influenza in various age groups seen in primary care. We also determined the rates of different complications attributable to influenza and the absenteeism of the children and their parents due to the child’s influenza infection. We then conducted a further 16-year retrospective study of children ≤16 years of age, hospitalized with virologically confirmed influenza. We estimated the population-based rates of hospitalizations and determined the primary admission diagnoses of the hospitalized children in different age groups. Results: The average annual rate of influenza was highest (179 / 1000) among children <3 years old. In this age group, acute otitis media was diagnosed as a complication of influenza in 40% of children. High fever was the most prominent sign of influenza, and 20% of children <3 years of age had a fever ≥40oC. Most children had rhinitis already during the first days of the illness. The average annual incidence of influenzarelated hospitalization was highest (276 / 100,000) among infants <6 months of age, of whom 52% were primarily admitted due to sepsis-like illnesses. Respiratory symptoms accounted for 38% of the hospitalizations. Conclusions: Influenza causes a substantial burden of illness on outpatient children and their families. The clinical presentation of influenza is most severe in children <3 years of age. The high incidence of influenza-associated hospitalizations among infants aged <6 months calls for more effective ways to prevent influenza in this age group. The clinical manifestations of influenza vary widely in different age groups of children at the time of hospital admission. Awareness of this phenomenon is important for the early recognition of the illness and the potential initiation of effective antiviral treatment of these patients.

Total esophagogastrectomy in the neoplasms of the esophagus and esofagogastric junction: when must be indicated?

Objective: to analyse the indications and results of the total esophagogastrectomy in cancers of the distal esophagus and esophagogastric junction. Methods: twenty patients with adenocarcinomas were operated with a mean age of 55 ± 9.9 years (31-70 years), and 14 cases were male (60%). Indications were 18 tumors of the distal esophagus and esophagogastric junction (90%) and two with invasion of gastric fundus (10%) in patients with previous gastrectomy. Preoperative colonoscopy to exclude colonic diseases was performed in ten cases. Results: the surgical technique consisted of median laparotomy and left cervicotomy, followed by transhiatal esophagectomy associated with D2 lymphadenectomy. The reconstructions were performed with eight esophagocoloduodenoplasty and the others were Roux-en-Y esophagocolojejunoplasty to prevent the alkaline reflux. Three cases were stage I / II, while 15 cases (85%) were stages III / IV, reflecting late diagnosis of these tumors. The operative mortality was 5 patients (25%): a mediastinitis secondary to necrosis of the transposed colon, abdominal cellulitis secondary to wound infection, severe pneumonia, an irreversible shock and sepsis associated with colojejunal fistula. Four patients died in the first year after surgery: 3 (15%) were due to tumor recurrence and 1 (5%) secondary to bronchopneumonia. The 5-year survival was 15%. Conclusion: the total esophagogastrectomy associated with esophagocoloplasty has high morbidity and mortality, requiring precise indication, and properly selected patients benefit from the surgery, with the risk-benefit acceptable, contributing to increased survival and improved quality of life

Extrauterine leiomyomata presenting with sepsis requiring hemicolectomy

Extrauterine leiomyomas are rare, benign, and may arise in any anatomic sites. Their unusual growth pattern may even mimic malignancy and can result in a clinical dilemma. Occasionally, uterine leiomyomas become adherent to surrounding structures. They also develop an auxiliary blood supply, and lose their original attachment to the uterus, thus becoming 'parasitic'. Parasitic myomas may also be iatrogenically created after uterine fibroid surgery, particularly if morcellation is used. This report presented two cases of parasitic myomas with sepsis, both requiring right hemicolectomy. It reviewed the pertinent literature.

Acetabular deepening in the treatment of severe canine hip dysplasia

A technique to restore acetabular anatomy by deepening the acetabular cavity and reconstructing the femoral head ligament and the joint capsule was tested on nine large breed dogs with severe hip dysplasia and acute subdislocation or dislocation. The technique consisted of two phases. First, all dogs were submitted to bilateral pectinotomy. In a second surgical intervention on the same dogs the acetabulum was approached and deepened, and the femoral head ligament and the joint capsule were reconstructed. In general, within 30 days of the surgery dogs could stand on the operated member to walk. Except for two dogs, all the others recovered pelvic member locomotive ability within 60-90 days after surgery. It is concluded that acetabuloplasty is a good alternative for treatment of severe canine hip dysplasia.

Severe diarrhea outbreak in beef calves (Bos indicus) caused by G6P[11], an emergent genotype of bovine rotavirus group A

The episodes of diarrhea caused by neonatal bovine rotavirus group A (BoRVA) constitute one of the major health problems in the calf rearing worldwide. The main G (VP7) and P (VP4) genotypes of BoRVA strains involved in the etiology of diarrhea in calves are G6P[1], G10P[11], G6P[5], and G8P[1]. However, less frequently, other G and P genotypes have been described in BoRVA strains identified in diarrheic fecal samples of calves. This study describes the identification and molecular characterization of an emerging genotype (G6P[11]) in BoRVA strains involved in the etiology of a diarrhea outbreak in beef calves in a cattle herd of high production in extensive management system. The diarrhea outbreak, which showed high morbidity (60%) and lethality (7%) rates, occurred in calves (n= 384) Nelore (Bos indicus) up to 30-day-old from the State of Mato Grosso do Sul, Brazil. BoRVA was identified in 80% (16/20) of the fecal samples analyzed by polyacrylamide gel electrophoresis (PAGE) technique. In all PAGE-positive fecal samples were amplified products with 1,062-bp and 876-bp in the RT-PCR assays for VP7 (G type) and VP4 (VP8*) (P type) of BoRVA, respectively. The nucleotide sequence analysis of VP7 and VP4 genes of four wild-type BoRVA strains showed G6-III P[11]-III genotype/lineage. The G6P[11] genotype has been described in RVA strains of human and animal hosts, however, in calves this genotype was only identified in some cross-sectional studies and not as a single cause of diarrhea outbreaks in calves with high morbidity and lethality rates as described in this study. The monitoring of the G and P genotypes of BoRVA strains involved in diarrhea outbreaks in calves is important for both animal and public health by allowing the identification of the most frequent genotypes, the characterization of novel genotypes and to identify reassortments with genotypes described in animal and human hosts. The results of this study show the importance of the monitoring of the genotypes of BoRVA strains involved in episodes of bovine neonatal diarrhea as for characterization of frequency of occurrence and pathogenic potential of uncommon genotypes as for monitoring of the emergency of different BoRVA genotypes not included in commercial vaccines.

Blockade of the action of nitric oxide in human septic shock increases systemic vascular resistance and has detrimental effects on pulmonary function after a short infusion of methylene blue

To investigate the role of nitric oxide in human sepsis, ten patients with severe septic shock requiring vasoactive drug therapy and mechanical ventilation were enrolled in a prospective, open, non-randomized clinical trial to study the acute effects of methylene blue, an inhibitor of guanylate cyclase. Hemodynamic and metabolic variables were measured before and 20, 40, 60, and 120 min after the start of a 1-h intravenous infusion of 4 mg/kg of methylene blue. Methylene blue administration caused a progressive increase in mean arterial pressure (60 [55-70] to 70 [65-100] mmHg, median [25-75th percentiles]; P<0.05), systemic vascular resistance index (649 [479-1084] to 1066 [585-1356] dyne s-1 cm-5 m-2; P<0.05) and the left ventricular stroke work index (35 [27-47] to 38 [32-56] g m-1 m-2; P<0.05) from baseline to 60 min. The pulmonary vascular resistance index increased from 150 [83-207] to 186 [121-367] dyne s-1 cm-5 m-2 after 20 min (P<0.05). Mixed venous saturation decreased from 65 [56-76] to 63 [55-69]% (P<0.05) after 60 min. The PaO2/FiO2 ratio decreased from 168 [131-215] to 132 [109-156] mmHg (P<0.05) after 40 min. Arterial lactate concentration decreased from 5.1 ± 2.9 to 4.5 ± 2.1 mmol/l, mean ± SD (P<0.05) after 60 min. Heart rate, cardiac filling pressures, cardiac output, oxygen delivery and consumption did not change. Methylene blue administration was safe and no adverse effect was observed. In severe human septic shock, a short infusion of methylene blue increases systemic vascular resistance and may improve myocardial function. Although there was a reduction in blood lactate concentration, this was not explained by an improvement in tissue oxygenation, since overall oxygen availability did not change. However, there was a significant increase in pulmonary vascular tone and a deterioration in gas exchange. Further studies are needed to demonstrate if nitric oxide blockade with methylene blue can be safe for patients with septic shock and, particularly, if it has an effect on pulmonary function.

Long-term outcome of 25 children and adolescents with severe aplastic anemia treated with antithymocyte globulin

Severe aplastic anemia (SAA) is probably an immune-mediated disorder, and immunosuppressive therapy is recommended for patients with no available donor for bone marrow transplant. Between October 1984 and November 1987, 25 consecutive children and adolescents with SAA with no HLA-compatible marrow donor received equine antithymocyte globulin (ATG) (15 mg kg-1 day-1) for 10 days. The patients were evaluated 6 weeks, 6 months, and 12 months after starting ATG treatment. Thereafter, patients were evaluated yearly until July 1998. Median age was 10 years (range, 1.5-20 years), granulocyte counts on referral ranged from 0.032 to 1.4 x 10(9)/l (median 0.256 x 10(9)/l), and 12 patients had granulocyte counts <0.2 x 10(9)/l. At a median follow-up of 9.6 years (range, 8.6-11.8 years), 10 patients (40%) remained alive with good marrow function. No morphologic evidence of hematological clonal disorders has been observed, although two patients probably have acquired clonal chromosomal abnormalities (trisomy 8 and del(6)q21, respectively). Responses to ATG were observed between 6 weeks and 6 months from the start of treatment in 60% of evaluable patients. The response rate was not different in patients whose granulocyte count at diagnosis was <0.2 x 10(9)/l, or in those who were <10 years of age. This study supports the view that, when compared with supportive measures, ATG is an effective treatment for children or adolescents with SAA. Although these results are inferior to those reported for marrow transplantation or more intensive immunosuppressive regimens, these patients who responded to ATG are long-term survivors with stable peripheral blood counts and a low rate of relapse.