Da operaçâo do empyema /

Tesis Univ. Río de Janeiro.

Infarto Cerebral del territorio Vértebro-Basilar: Comunicación de una serie de pacientes asistidos en el Hospital de Clínicas de Montevideo

Introducción: El ataque cerebro vascular tiene una elevada incidencia y mortalidad en Uruguay representando, aquellos de la circulación posterior, un porcentaje importante de ellos. En este estudio describimos características basales, clínicas, diagnósticas y terapéuticas de una serie de pacientes con ataque cerebro vascular de la circulación posterior. Material y métodos: Estudio observacional descriptivo. Inclusión: pacientes con diagnóstico de ataque cerebro vascular de la circulación posterior atendidos en el Hospital de Clínicas entre junio de 2007 y 2014. Resultados: Se incluyeron 140 pacientes con una edad media de 68 años y elevada frecuencia de factores de riesgo clásicos para enfermedad cerebro vascular. Predominó la clínica cerebelosa y piramidal, con un puntaje medio bajo en la escala de NIHSS (5,2) y una baja sensibilidad de la Tomografía de cráneo para el diagnóstico. La etiología determinada más prevalente fue la cardioembolia. Un quinto de los pacientes consultó antes de las 4,5 horas y el 3,8% de los pacientes fue tratado con trombolisis iv. Discusión y comentarios: Se trata de la mayor serie de ataque cerebro vascular de la circulación posterior reportada en nuestro país, la forma de presentación fue similar a la descrita en la literatura. La escala de NIHSS infravaloró la severidad de este tipo de ataque cerebro vascular. La tomografia de cráneo tuvo baja sensibilidad diagnóstica y el porcentaje de resonancias magnéticas realizadas fue bajo. Un bajo número de pacientes consultó en ventana para trombolisis iv y solo al 3,8% de los casos se le realizó dicho tratamiento.

Analysis of Outcome of Intraplueral Streptokinase in Pediatric Empyema Thoracis even in Advanced Stages: A Prospective Study

Background: Empyema thoracis in children causes significant morbidity. Standard treatment of Empyema thoracis includes tube drainage and antibiotics. But the tube drainage often fails. Intrapleural Streptokinase has been used in empyema thoracis with good success rate. Objectives: We evaluated the efficacy of intra-pleural Streptokinase in management of empyema thoracis even in advanced stages. Patients and Methods: A total of 28 patients with empyema thoracis requiring intercostal tube drainage aged zero to twelve years were included in the study who were admitted in Pediatric intensive care unit. 15,000 units/kg of Streptokinase was instilled into the pleural cavity. Response was assessed by clinical outcome, after unclamping and subsequent chest radiography and serial chest ultrasounds. Results: Streptokinase enhanced drainage in all patients with complete resolution of empyema thoracis in 26 patients. Two patients were referred for surgery. Only 7.2% required surgery. Streptokinase was equally effective if started before or after seven days. Conclusions: Intrapleural Streptokinase is the preferred treatment for treating pediatric empyema thoracis even in advanced stages and can avoid surgery.

Meningencefalites bacterianas agudas em crianças: complicações e sequelas neurológicas

We studied 271 children under age of 15 with diagnosis of acute bacterial meningencephalitis treated at Medical School in Ribeirão Preto, University of São Paulo, between 1980 and 1990. The patients were divided in two groups: 1) those who had not received previous antibiotics treatment (NTP), with 153 cases; and 2), those who had received previous antibiotics treatment (PT), with 118 cases. The etiological agent was more frequently identified in NPT group, while ventriculitis was more frequent in PT group. Mortality rate accounted for 19,5% of all cases, and 29.7% of children under 12 months of age. Acute meningitis caused by Streptococcus pneumoniae was frequently followed by increased mortality. Convulsive disorders and hemiparesis predominante among children under 12 months of age. On the neurosurgical point of view, ventriculitis, subdural hygroma, hydrocephalus, subdural empyema and brain abscess were identified and treated

Sistematização da origem, da distribuição e dos territórios da artéria cerebral caudal na superfície do encéfalo em gatos

Foram estudados 26 encéfalos de gatos, adultos, sem diferenciação de sexo, sem raça definida, corados com látex e fixados por solução aquosa de formaldeído. As artérias cerebrais caudais, direita e esquerda, apresentaram-se únicas em 96,1 e 88,4% dos casos, respectivamente. Em 69,2% dos casos no antímero direito e 80,8% no esquerdo, a artéria cerebral caudal originou-se pela anastomose entre o ramo caudal da artéria carótida interna, com maior contribuição, e o ramo terminal da artéria basilar. Em 88,4% dos casos no antímero direito e em 84,6% no esquerdo, a artéria cerebral caudal originou a artéria tectal rostral e um ramo caudal. O ramo caudal bifurcou-se e vascularizou os colículos rostrais e caudais dos corpos quadrigêmeos e em alguns casos contribuiu na formação do plexo coroide do terceiro ventrículo. A artéria tectal rostral seguiu ventralmente ao lobo piriforme e durante seu trajeto liberou ramos para o hipocampo e, no antímero esquerdo, supriu a superfície dorsal do tálamo, contribuindo para a formação do plexo coroide do terceiro ventrículo.

Aortas isolated from sinoaortic-denervated rats exhibit rhythmic contractions that are regulated by pharmacologically distinct calcium sources

Sinoaortic denervation is characterized by arterial pressure lability, without sustained hypertension. Aortas isolated from rats with sinoaortic denervation present rhythmic contractions. We studied the participation of distinct Ca2+ sources in the maintenance of the oscillations. Three days after the surgeries, aortic rings were placed in an organ chamber, and the incidence of aortas presenting rhythmic contractions was measured. Specific drugs were employed to analyse the participation of the Ca2+ released from the sarcoplasmic reticulum [2-APB (diphenylborinic acid 2-aminoethyl ester), thapsigargin and ryanodine] and external Ca2+ entry [Bay K 8644, verapamil and DMB (dimethylbenzyl amiloride)] on the rhythmic contractions. Additionally, we verified the effects of chloride channel blocker NPPB [5-nitro-2-(3-phenylpropylamino)benzoic acid] on the maintenance of the rhythmic contractions. Under phenylephrine stimulus, sinoaortic-denervated rat aortas exhibited rhythmic contractions in the frequency of 4.5 +/- 0.50 cycles/min. and an amplitude of 0.465 +/- 0.05 g. 2-APB, thapsigargin and ryanodine inhibited the rhythmic contractions. Bay K 8644 increased the oscillations, reaching maximum values with a concentration of 50 nM (18.5 +/- 2.5 cycles/min.). The rhythmic contractions were inhibiting by verapamil and Ca2+-free solution. DMB and NPPB did not alter the oscillations. In conclusion, we observed that aorta isolated from sinoaortic-denervated rats present rhythmic contractions. Moreover, drugs that impaired intracellular Ca2+ release from sarcoplasmic reticulum interrupted the oscillations. The oscillations also depend on the extracellular Ca2+ entry through L-type Ca2+.

The expression of messenger RNAs coding for growth factors, their receptors, and eph-class receptor tyrosine kinases in normal and ototoxically damaged chick cochleae

Messenger RNAs coding for growth factors and receptor tyrosine kinases were measured by quantitative competitive and by semi-quantitative reverse-transcription polymerase chain reaction in whole and dissected chick inner ears. The fibroblast growth factor (FGF) receptor 1 chick embryonic kinase (CEK) 1 was expressed in all structures examined (otocyst, hatchling whole cochlea, cochlear nerve ganglion, and cochlear and vestibular sensory epithelia), although slightly more heavily in the otocyst. The related fibroblast growth factor receptors CEK 2 and 3 were preferentially expressed in the nerve ganglion and in the vestibular sensory epithelium, respectively. FGF 1 mRNA was low in early development, increasing to mature levels at around embryonic age 11 days, while FGF2, mRNA was expressed at constant levels at all ages. In response to ototoxic damage, FGF1 mRNA levels were increased in the early damaged cochlear sensory epithelium. Immunohistochemistry for CEK1 showed that normal hair cells expressed the receptor heavily on the hair cell stereocilia, while with early damage, CEK1 came to be expressed heavily on the apical surfaces of the supporting cells. In normal chicks, the CEK4 and CEK8 eph-class receptor tyrosine kinases were expressed relatively heavily by the cochlear nerve ganglion, and CEK10 was expressed relatively heavily by the cochlear hair cell sensory epithelium. The results suggest that the FGF system may be involved in the response of the cochlear epithelium to ototoxic damage. The eph-class receptor tyrosine kinase CEK10 may be involved in cell interactions in the cochlear sensory epithelium, while CEK4 and CEK8 may play a role in the cochlear innervation.

Efficacy and safety of iodopovidone pleurodesis in malignant pleural effusions

Background and objective: Pleurodesis is one of the best methods of controlling malignant pleural effusions (MPE), a distressing complication of metastatic disease. In recent studies of a wide range of pleural diseases, iodopovidone was used as a sclerosing agent for pleurodesis and demonstrated good results with low morbidity. The aim of this study was to evaluate the efficacy and safety of iodopovidone pleurodesis in MPE. Methods: A retrospective analysis was performed on patients with MPE who underwent pleurodesis at our institution between 2005 and 2008. All patients underwent instillation of 20 mL of 10% iodopovidone, 80 mL of normal saline and 2 mg/kg of lidocaine through a chest tube, which was clamped for 2 h. The tube was removed when the daily output of fluid was < 200 mL. Data on the requirement for additional pleural procedures, adverse events and survival were collected. Results: Sixty-one pleurodesis procedures were performed in 54 patients. No procedure-related mortality was observed. Adverse events occurred after 11 (18%) pleurodesis procedures. The most frequent complication was mild thoracic pain that occurred immediately after 10 (16.4%) procedures, and one patient developed pleural empyema that was treated with drainage and antibiotics. A success rate of 98.4% was observed. Except for the patient who developed pleural empyema, none of the other patients had recurrences of pleural fluid or required additional pleural procedures during the follow-up period (mean of 5.6 months). Conclusions: Iodopovidone pleurodesis was successful and was associated with only a few minor complications. It appears to be a good option for the management of recurrent MPE.

Microsurgical Anatomy of the Posterior Cerebral Artery in Three-Dimensional Images

OBJECTIVE: To describe the microsurgical anatomy, branches, and anatomic relationships of the posterior cerebral artery (PCA) represented in three-dimensional images. METHODS: Seventy hemispheres of 35 brain specimens were studied. They were previously injected with red silicone and fixed in 10% formalin for at least 40 days. Four of the studied specimens were frozen at -10 degrees to -15 degrees C for 14 days, and additional dissection was done with the Klingler`s fiber dissection technique at x6 to x40 magnification. Each segment of the artery was measured and photographed to obtain three-dimensional stereoscopic images. RESULTS: The PCA origin was in the interpeduncular cistern at the pontomesencephalic junction level in 23 specimens (65.7%). The PCA was divided into four segments: P1 extends from the PCA origin to its junction with the posterior communicating artery with an average length of 7.7 mm; P2 was divided into an anterior and posterior segment. The P2A segment begins at the posterior communicating artery and ends at the most lateral aspect of the cerebral peduncle, with an average length of 23.6 mm, and the P2P segment extends from the most lateral aspect of the cerebral peduncle to the posterior edge of the lateral surface of the midbrain, with an average length of 16.4 mm; P3 extends from the posterior edge of the lateral surface of the midbrain and ends at the origin of the parieto-occipital sulcus along the calcarine fissure, with an average length of 19.8 mm; and the P4 segment corresponds to the parts of the PCA that run along or inside both the parieto-occipital sulcus and the distal part of the calcarine fissure. CONCLUSIONS: To standardize the neurosurgical practice and knowledge, surgical anatomic classifications should be used uniformly and further modified according to the neurosurgical experience gathered. The PCA classification proposed intends to correlate its anatomic segments with their required microneurosurgical approaches.

Bronchial Complications Following Lung Transplantation

Introduction. Bronchial complications owing to the airway anastomosis in lung transplantation are important causes of morbidity and mortality. They occur in up to 27% of cases as defined by stenosis, necrosis, and dehiscence. Treatment depends on the type of complication. Objective. To report our experience to treat this complication. Methods. Between 2000 and 2007, we performed 71 lung transplants of which 36 were bilateral. The total number of anastomoses was 107:52 to the right and 55 to the left. The telescoping technique was initially used (14 initial unilateral transplants), and after October, 2003 it was changed to an end-to-end anastomosis (57 transplants and 93 anastomoses). Results. Eight patients developed bronchial complications including two that were bilateral. There were 4 stenosis, 3 dehiscences, and 3 necrosis complications (9.4%). The complication rate for telescoping anastomosis was 21.4%, and for the end-to-end technique, 7.5%. The treatment of the stenosis used metallic or plastic self-expandable stents. Two bronchial dehiscences resulted in case of bronchopleural fistulae, empyema, and death; the other patient experienced spontaneous resolution. Concerning bronchial necrosis, I patient developed fistulization to the pulmonary artery and massive hemoptysis, and the other with bilateral necrosis, a spontaneous resolution. Conclusion. Our bronchial anastomosis complication rate was comparable with that in other reports. The rate for the telescoping technique was greater compared with the end-to-end technique. The treatment of bronchial stenosis with a self-expandable prosthesis showed good results.

Neurovascular compression in painful tic convulsif

This article describes the case of a 67-year-old woman who presented with a typical left hemifacial spasm of 8-month duration. After 2 months, she experienced lacinating and sharp shock-like pain in the left side of her face affecting the V1 and V2 territories and a discrete attenuation of nauseous reflex on the left side. CT angiography and MRI revealed significant compression of left cranial nerves V, VII, VIII, IX and X by a giant and tortuous vertebro-basilar arterial complex. This case illustrates the nonlinearity of the relationship between the presence of the stressor factor and the actual manifestation of the disease.

Novel application of biological glue in the management of a complicated pneumothorax in cystic fibrosis

Spontaneous pneumothorax is a frequent complication in advanced lung disease of cystic fibrosis. We describe a case of a complicated pneumothorax in a 21-year old-woman with cystic fibrosis who was effectively treated with the application of biological glue via a minithoracotomy. (C) 2002 Wiley-Liss, Inc.

Zumbido em paciente com megadolicobasilar: relato de caso

O zumbido pode se manifestar como sintoma de diversas doenças, que podem ser congênitas, infecciosas, neoplásicas, neurológicas, traumáticas, metabólicas, vasculares e mistas. Apresenta-se com intensidade variável, e em sua forma mais severa pode ser altamente incomodativo e angustiante. A investigação do diagnóstico diferencial nos casos de zumbido deve ser cuidadosamente conduzida, com base em diferentes tipos de exames complementares, como a audiometria tonal liminar, imitanciometria, audiometria de respostas evocadas de tronco cerebral e exames de imagem, principalmente a ressonância nuclear magnética. Neste artigo, mostraremos em um caso de zumbido secundário a rara alteração anatômica da artéria basilar, chamada megadolicobasilar, causando compressão do VIII par craniano, para salientar a importância dos exames complementares na investigação e conduta do paciente com zumbido.

O diagnóstico das zonas mortas na cóclea e sua importância no processo de reabilitação auditiva

Cada vez mais na prática da audiologia é indispensável um bom diagnóstico audiológico, para que se tenha conhecimento das necessidades do paciente para seleção e adaptação de próteses auditivas. OBJETIVO: Expor literaturas recentes que referem conceitos de zonas mortas na cóclea, estratégias de diagnóstico e a importância deste no processo de seleção e adaptação de próteses auditivas. METODOLOGIA: Realizou-se um levantamento bibliográfico sobre zonas mortas na cóclea. As zonas mortas na cóclea foram descritas como regiões onde as células ciliadas internas e/ou neurônios adjacentes não se encontram funcionais. Assim, nessas regiões a informação gerada pela vibração da membrana basilar não é transmitida ao sistema nervoso central. Porém, um tom com freqüência correspondente a zona morta, desde que suficientemente intenso, pode ser percebido em regiões próximas a esta zona, onde às células ciliadas internas e/ou fibras nervosas ainda apresentam-se funcionais. CONCLUSÃO: A identificação das zonas mortas na cóclea está sendo utilizada visando melhores resultados no processo de seleção e adaptação de próteses auditivas, pois as informações geradas pelas CCI ao nervo auditivo são importantes para um melhor reconhecimento dos sons, principalmente os sons da fala.

Ajuste Directo- Restrição do Artigo 113º Nº 2

O Código dos Contratos Públicos(CCP), em vigor desde 2008, elenca cinco tipos de procedimentos pré-contratuais que tal, como a própria Administração Publica, estão subordinados a princípios fundamentais, que emanam quer do ordenamento jurídico nacional, quer do ordenamento comunitário. Entre estes postulados, o principio da concorrência parece assumir algum relevo, pela sua importância para o funcionamento do Mercado Único Europeu, sendo um dos princípios que o próprio CCP define como especialmente aplicável á contratação publica. Dos procedimentos pré-contratuais enumerados por aquele diploma, a Administração Publica portuguesa tem demonstrado uma predilecção pelo ajuste directo, possivelmente por ser mais célere e flexível. Contudo, o recurso a este procedimento vem sendo alvo de escrutínio por potencialmente, ferir o principio da concorrência. a escolha, procurando fazê-lo á luz desse principio basilar da contratação publica, a concorrência. A presente pesquisa analisa as varias modalidades do ajuste directo, a sua tramitação, os fundamentos que são invocados para a sua escolha, procurando fazê-lo á luz desse principio basilar da contratação publica, a concorrência. Neste contexto, as restrições impostas pelo artigo 113º/2 ganham um particular destaque, podendo aceitar-se este artigo como mais um mecanismo do legislador para garantir uma maior concorrencialidade do procedimento por ajuste directo.