Background:Thrombocytopenia is a possible risk factor for bleeding after band ligation of esophageal varices.However,elevated von Willebrand factor(VWF)in cirrhosis improves platelet function and could decrease this r...Background:Thrombocytopenia is a possible risk factor for bleeding after band ligation of esophageal varices.However,elevated von Willebrand factor(VWF)in cirrhosis improves platelet function and could decrease this risk.Our objective was to assess platelet function in patients with cirrhosis undergoing esophageal variceal ligation(EVL).Methods:The assessment consisted of platelet count,antigen and activity of VWF and VWF-cleaving protease ADAMTS-13 activity,and a platelet adhesion and aggregation test simulating vascular flow in vivo(Impact-RR)prior to EVL.Results:Totally 111 patients were divided into three groups according to platelet count:(1)<50×109/L(n=38,34.2%);(2)50×109/L to 100×109/L(n=47,42.3%);and(3)>100×109/L(n=26,23.4%).No statistically significant difference was found in the aggregate size of platelets[group 1:41.0(31.8–67.3)μm 2;group 2:47.0(33.8–71.3)μm 2;and group 3:47.0(34.0–66.0)μm 2;P=0.60]and no significant correlation was found between aggregate size and platelet count(Spearman r=0.07;P=0.47).Surface coverage was 4.1%(2.8%–6.7%),8.5%(4.0%–10.0%),and 9.0%(7.1%–12.0%)(P<0.001)in groups 1,2 and 3,respectively and correlated with platelet count(Spearman r=0.39;P<0.0001).There was no significant difference between groups in VWF or ADAMTS-13.Post-EVL bleeding occurred in six(5.4%)patients(n=2 in group 1,n=1 in group 2,and n=3 in group 3;P=0.32).Patients with bleeding had higher MELD scores[15.0(11.3–20.3)versus 12.0(10.0–15.0);P=0.025],but no difference was demonstrated for platelet function parameters.Conclusion:Platelet function is preserved even in the presence of thrombocytopenia,including in the patients with post-EVL bleeding.展开更多
The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conven...The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conventional semen parameters and sperm functional tests. An electronic search to collect the data was performed using the PubMed/MEDLINE databases until July 2015. Data pooled from a variety of study designs indicate that varicocelectomy improves semen parameters in the majority of the treated men with clinical varicocele and abnormal semen parameters regardless of the chosen surgical method. Surgical varicocele repair was beneficial not only for alleviating oxidative stress-associated infertility but also to improve sperm nuclear DNA integrity. However, given the low magnitude of the effect size in sperm DNA integrity, further research is needed to elucidate its clinical significance. Conflicting results on the effect of varicocele treatment on natural fertility seem to be due to heterogeneous study designs and, more importantly, patient selection criteria. When these issues are controlled, current evidence indicates that treatment of subclinical varicocele is not warranted, as it does not seem to improve fertility. On the contrary, fair evidence indicates that varicocele treatment should be offered to infertile patients with palpable varicocele and abnormal semen parameters. This evidence supports the current guidelines issued by the American Urological Association and European Association of Urology, which state that varicocele treatment should be offered to male partners of infertile couples presenting for evaluation with clinical varicocele and semen parameters alterations.展开更多
Objective: Establish normative data for tympanic electrocochleography(TM ECoch G) parameters in normal hearing adults without Meniere's disease's(MD) symptoms. Describe TM ECoch G variables that help to distin...Objective: Establish normative data for tympanic electrocochleography(TM ECoch G) parameters in normal hearing adults without Meniere's disease's(MD) symptoms. Describe TM ECoch G variables that help to distinguish normal from MD ears.Material and methods: We enrolled 100 subjects(N =200 ears), 59 females, aged between 19 and 71 years from 09/2010 to 04/2014. Inclusion criteria: normal otomicroscopy, hearing thresholds≤25 dB nHL from 250 to 4000 Hz, normal tympanogram, no symptoms of MD according to the AAO-HNS 1995 criteria and Gibson's score <7. We excluded subjects with dizziness, aural fullness or other symptoms of endolymphatic hydrops. The following parameters were analyzed: SP/AP amplitude ratio, SP/AP area ratio and the difference between AP latency with rarefaction and condensation stimuli.Results: There was no significant difference between right and left ears(Intraclass correlation coefficient < 0.6). SP/AP amplitude ratio varied between 0.084 and 0.356 and SP/AP area ratio between 0.837 and 1.671(percentiles 5 and 95). The AP latency difference to rarefaction and condensation clicks was between 0.0 and 0.333 ms.Conclusion: Normative data for TM ECoch G parameters were established in 100 normal hearing subjects without MD. These data can be used to distinguish normal from pathological findings and in follow-up of MD patients.展开更多
Approximately 10% of patients with gastrointestinal stromal tumors (GIST) develop other neoplasms, either synchronously or metachronously. In this report we describe coexistence of a gastrointestinal stromal tumor and...Approximately 10% of patients with gastrointestinal stromal tumors (GIST) develop other neoplasms, either synchronously or metachronously. In this report we describe coexistence of a gastrointestinal stromal tumor and a hepatic perivascular epithelioid cell tumor (PEComa) in a 51-year-old woman with no evidence of tuberous sclerosis. A subcapsular hepatic nodule (0.8 cm in diameter) was found during surgery for symptomatic gastric neoplasm (15 cm in diameter) arising from the lesser curvature. Both tumors revealed histomorphological and immunohistochemical features confirming a diagnosis of a small incidental hepatic PEComa and a high risky extramural gastric GIST, respectively. The patient remained disease-free 25 mo after surgery with no evidence of tumor recurrence or new neoplasms. To our knowledge, this is the first report of PEComa in a patient with GIST. Hepatic lesions detected synchronously or metachronously in patients with GISTs may represent histogenetically distinct lesions and should be sampled to confirm or exclude metastatic GISTs.展开更多
Fibrolamellar hepatocellular carcinoma(FLHCC) is a rare malignant liver neoplasm, commonly observed in adolescents and young adults of both genders. The disease is more common in Caucasians and in patients without a p...Fibrolamellar hepatocellular carcinoma(FLHCC) is a rare malignant liver neoplasm, commonly observed in adolescents and young adults of both genders. The disease is more common in Caucasians and in patients without a prior history of liver disease. The best treat-ment option is a surgical resection associated with liver hilum lymph node dissection. However, there is no established systemic drug treatment for patients with locally advanced or metastatic disease. We report on a patient with advanced FLHCC, initially considered un-resectable due to invasion of the right and the middle hepatic veins and circumferential involvement of the left hepatic vein. Following the treatment with gem-citabine-oxaliplatin systemic chemotherapy, the patient exhibited a significant tumor reduction. As a result, a complete resection was performed with an extended right hepatectomy associated with a partial resection of the inferior vena cava, a wedge resection in segment 2, and lymphadenectomy of the hepatic hilum. The case was unusual due to the significant tumor downstaging with gemcitabine-oxaliplatin, potentially enabling cura-tive resection. More studies are needed to confirm the efficacy of the systemic drug treatment for FLHCC.展开更多
Acute coronary syndromes （ACS） are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortali...Acute coronary syndromes （ACS） are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortality is greater in older age patients presenting ACS. Despite the higher prevalence and greater risk, elderly patients are underrepresented in major clinical trials fi：om which evidence based recommendations are formulated. The authors describe, in this article, the challenges in the diagnosis and management of ST elevation myocardial infarction in the elderly, and discuss the available evidence.展开更多
Perivascular epithelioid cell tumor(PEComa) is a rare mesenchymal neoplasia and currently well recognized as a distinct entity with characteristic morphological,immunohistochemical and molecular findings.We report a c...Perivascular epithelioid cell tumor(PEComa) is a rare mesenchymal neoplasia and currently well recognized as a distinct entity with characteristic morphological,immunohistochemical and molecular findings.We report a case of PEComa arising in the antrum of a 71-year-old female with melena.The tumor,located predominantly in the submucosa as a well delimited nodule,measured 3.0 cm in diameter and was completely resected,with no evidence of the disease elsewhere.Histologically,it was composed predominantly of eosinophilic epithelioid cells arranged in small nests commonly related to variably sized vessels,with abundant extracellular material,moderate nuclear variation and discrete mitotic activity.No necrosis,angiolymphatic invasion or perineural infil-tration was seen.Tumor cells were uniformly positive for vimentin,smooth muscle actin,desmin and melan A.Although unusual,PEComa should be considered in the differential diagnosis of gastric neoplasia with characteristic epithelioid and oncocytic features and prominent vasculature.展开更多
This paper investigates the effects of the physical properties on the microstructure and weldability of explosive welding by joining two metals with a significant contrast in thermophysical properties:stainless steel ...This paper investigates the effects of the physical properties on the microstructure and weldability of explosive welding by joining two metals with a significant contrast in thermophysical properties:stainless steel and copper.Sound welds between stainless steel and copper were obtained,and the interfacial morphology was wavy,regardless of the position of the materials.The weldability of dissimilar pairs was found to be more dependent on the relationship between the physical properties of the base materials than on the absolute value of the material property.When there is a significant difference in thermal conductivity between the flyer and the base plate,together with a material with a low melting temperature,the weldability of the pair is often poor.The relative position of the plates affects the interfacial microstructure even when similar morphologies are found.For the metallic pairs studied,the wave size was bigger for the configuration in which the ratio between the density of the flyer and the density of the base plate is smaller.The same phenomenon was observed for the impedance:bigger waves were found for a smaller ratio between the impedance of the flyer and the impedance of the base plate.展开更多
AIM To evaluate the correlation between degree of kinetic growth(k GR) of the liver following portal vein embolization(PVE) liver and the enhancement of the during the hepatobiliary phase of contrast administration an...AIM To evaluate the correlation between degree of kinetic growth(k GR) of the liver following portal vein embolization(PVE) liver and the enhancement of the during the hepatobiliary phase of contrast administration and to evaluate if the enhancement can be used to predict response to PVE prior to the procedure.METHODS Seventeen patients were consented for the prospective study.All patients had an MR of the abdomen with GdEOB-DTPA.Fourteen patients underwent PVE.The correlation between the kG R of the liver and the degree of enhancement was evaluated with linear regression(strong assumptions) and Spearman's correlation test(rank based,no assumptions).The correlation was examined for the whole liver,segments I,VIII,VII,VI,V,IV,right liver and left liver.RESULTS There was no correlation between the degree of enhancement during the hepatobiliary phase and kG R for any segment,lobe of the liver or whole liver(P = 0.19 to 0.91 by Spearman's correlation test).CONCLUSION The relative enhancement of the liver during the hepatobiliary phase with Gd-EOB-DTPA cannot be used to predict the liver response to PVE.展开更多
Immune checkpoint inhibitors have shown to be very effective when treating lung cancer. Nivolumab, a programmed death-1 (PD-1) inhibitor has been approved for the treatment of metastatic non-squamous and squamous NSCL...Immune checkpoint inhibitors have shown to be very effective when treating lung cancer. Nivolumab, a programmed death-1 (PD-1) inhibitor has been approved for the treatment of metastatic non-squamous and squamous NSCLC. Immunotherapy with checkpoint inhibitors are associated with toxicities defined as immune-related adverse events (irAEs). The most common irAEs are rash, colitis, hepatitis, pneumonitis, and endocrinopathies. Although any organ system can be affected, other rare irAEs can occur and affect the bone marrow, pancreas, and the neurologic and cardiac systems. Pericardial effusion induced by immunotherapy is uncommon and has been described only in a few case reports. Immune-related adverse events usually develop within the first weeks to months after treatment initiation. This is a case report of a 52-year-old male patient with metastatic squamous-cell lung cancer who had a massive pericardial effusion secondary to treatment with nivolumab as second line treatment. During his hospital stay, the patient underwent pericardiocentesis and treatment with corticosteroids. A CT scan after these treatments revealed complete tumor response and minimal pericardial effusion. Nivolumab was definitively ceased. The patient continues to show complete response for 16 months. In general, Nivolumab is well-tolerated and has an excellent safety profile. However, it is important to be aware of life-threatening immune-related adverse events, particularly cardiac toxicity. Consensus guidelines regarding the treatment of the most common irAEs have been established. The optimal management of irAEs is based on clinical experience. It’s crucial to report new or rare irAEs to conduct prospective trials to evaluate the best treatment strategy.展开更多
BACKGROUND： Fibrolamellar hepatocellular carcinoma （FLHCC） is a rare disease with an indolent behavior. Its prognosis is better than that of patients with hepatocellular carcinoma. The authors present their experie...BACKGROUND： Fibrolamellar hepatocellular carcinoma （FLHCC） is a rare disease with an indolent behavior. Its prognosis is better than that of patients with hepatocellular carcinoma. The authors present their experience with resection of FLHCC. METHODS： Twenty-one patients with FLHCC were treated at our institution between 1990 and 2012. Of these patients, 14 were subjected to resection of the tumor. Patient demographics, medical history, results of imaging studies and laboratory tests, surgical data, and pathologic findings were evaluated. RESULTS： The median age of the patients at the diagnosis of the tumor was 20 years and 14 patients were female. None of the patients had tumor-associated chronic liver disease or cirrhosis. The mean tumor size was 12.8 cm （range 6-19） and 18 patients had a single liver nodule. Fourteen patients were subjected to hepatectomy and six of them had lymph node metastases resected. Pathologic evaluation revealed that 5 （35.7%） patients had major vascular invasion. Tumor recurrence was seen in 8 patients （66.7%）, during a follow-up. The median survival time for patients who were subjected to resection was 36 months. The 5-year overall survival rate and disease free survival rate were 28.0% and 8.5%, respectively. Univariate analysis showed that vascular invasion was the only variable associated with the disease free survival rate.CONCLUSIONS： Despite an aggressive treatment, patients with FLHCC presented unexpected low survival rates. It seems that an underestimated malignant behavior is attributed to this disease, and that the forms of adjuvant treatment should be urgently evaluated.展开更多
Currently, Brazilian buses are divided in three categories： city buses, intercity buses and coaches. That categorization results from the understanding that citizens only need to move around urban perimeters. However...Currently, Brazilian buses are divided in three categories： city buses, intercity buses and coaches. That categorization results from the understanding that citizens only need to move around urban perimeters. However, the current bus models available do not fully meet legal demands or cater for all of society＇s demands. Rural workers and students that live in rural areas also must be conveyed in buses and minibuses. Municipal and state directives prohibit employers to convey them in improper vehicles, such as trucks. Social demands, on the other hand, can be i[llustrated by federal and state programs that provide vehicles to transport students who dwell in rural settings. Accordingly, this paper proposes a new categorization of bus models available in the Brazilian market, which should account for the unique local operating conditions rural buses face, instead of only considering the type of service they provide. Further, a purpose-built vehicle is suggested i[n order to cater for the needs of rural workers and students. Rural students represent, in average, five million rural school bus riders.展开更多
Background: Oxidative stress and inflammation are related to the pathophysiology of diabetes mellitus (DM), being involved in the development of micro-and macrovascular complications. Physical activity is beneficial f...Background: Oxidative stress and inflammation are related to the pathophysiology of diabetes mellitus (DM), being involved in the development of micro-and macrovascular complications. Physical activity is beneficial for DM patients, but little is known about the relationship between redox and inflammation biomarkers and the level of physical activity in these patients. Based on this, this research aims to evaluate the effects of physical activity level on redox stress parameters and inflammatory markers in T2DM patients. Methods: Eighty-four patients with T2DM were divided according to their physical activity level: group A (n = 48), sedentary;group B (n = 11) active (3 times a week, 150 min) and group C (n = 25), highly active (5 times a week, 150 - 300 mins, at least). Anthropometric and biochemical parameters, superoxide dismutase (SOD) and glutathione peroxidase (GPx) activities, as well as GSH, sRAGE and ICAM-1 levels were assessed. Results: Glycated haemoglobin, total cholesterol, and LDL-cholesterol levels were lower in the highly active group in comparison to other groups. Plasma SOD activity was higher in group C compared to Group A, while ICAM-1 levels were significantly higher in group B when compared to other groups. Conclusion: Our results suggest that the practice of physical activity is beneficial to T2DM patients, especially at high volume and frequency.展开更多
Radiodermatitis is a constant complication after radiotherapy with no efficient drug for prevention and treatment. Its physiopathology is complex, possibly related to injury of epidermis and endothelial cells from the...Radiodermatitis is a constant complication after radiotherapy with no efficient drug for prevention and treatment. Its physiopathology is complex, possibly related to injury of epidermis and endothelial cells from the basal layer by radiolysis, overproduction of free radicals, pro-inflammatory cytokines, and inflammation. PTCTS gel is an after sun cosmetic gel composed by anti-oxidative plant extract rich in natural nanoparticles and thermal water (Complex A) and recombinant protein of Trypanosoma cruzi transialidase (Complex B), with high anti-oxidative and anti-apoptotic effects, presenting anti-aging and healing cutaneous properties. Objective: To study the safety and efficacy of PTCTS gel for topic use in volunteer subjects with healthy skin, and in patients with radiodermatitis, in different concentrations of Complexes A and B. Material and Methods: The project was approved by the Ethical Committee of Arnaldo Vieira de Carvalho Institute, Sao Paulo, Brazil. The individuals were submitted to laboratorial toxicity study through tests for liver and kidney function, levels of blood glucose and blood count before and after 7 days of PTCTS application. We studied two groups: GI-22 volunteers with healthy skin, presenting articular or skeletal muscle pain and GII-38 patients in radiotherapy for breast or head and neck cancer, with radiodermatitis grade 2 or 3. The patients were evaluated before and after 1.0 ml/cm2 PTCTS gel application, twice a day. We tested Complex B in four different concentrations, and Complex A concentrations varied inversely. Results: No irritation signs were observed in GI nor GII group, 64% of GI had important decrease in the intensity of the muscular or articular pain, and 99% of GII showed regression of radiodermatitis, all exhibiting relief of pain. No patient presented hematologic, renal or hepatic toxicity. Conclusion: PTCTS cosmetic gel is a safe option for radiodermatitis treatment, with no side effects or laboratorial toxicity in different concentrations. This product presented excellent clinical results even if used diluted 4 times more than the original product and may be a good option for treatment of radiodermatitis. Further studies may show if it is also indicated in the prevention of the lesion, and if it is better than products containing corticoids.展开更多
Radiotherapy as monotherapy or in combination with chemotherapy, has contributed to the drop in mortality rates related to neoplasms in the last 60 years. However, irradiation may promote heart damage and involvement ...Radiotherapy as monotherapy or in combination with chemotherapy, has contributed to the drop in mortality rates related to neoplasms in the last 60 years. However, irradiation may promote heart damage and involvement is very common. As a result, VHD （valvular heart disease） is one of the earliest cardiovascular events post-radiotherapy. What it concerns to valve disease induced by chemotherapeutics, there are still only few studies. However, patients treated with chemotherapy in combination with radiotherapy had twice the risk of developing the disease when compared to those treated by radiotherapy alone. The heart injury caused by radiotherapy begins with damage to the endothelium and results in fibrosis and diffuses calcification primarily of the mitral and aortic valves. The echocardiography is the tool of choice to the patient’s assessment and follow-up after exposure. Prevention is the best option to face the valve damage induced by radiation.展开更多
Background: Rest single-photon emission computed tomographic(SPECT) perfusion imaging identifies acute myocardial ischemia in patients with chest pain in the emergency department; however, the costs are high and radio...Background: Rest single-photon emission computed tomographic(SPECT) perfusion imaging identifies acute myocardial ischemia in patients with chest pain in the emergency department; however, the costs are high and radioisotopic services are usually not available 24 h a day. Planar imaging through a portable gamma camera may be useful in this setting. However, planar imaging might be associated with less predictive values in comparison with a gated SPECT imaging. We sought to evaluate rest planar myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia. Methods: Patients within 6 h of chest pain onset and nondiagnostic electrocardiograms(ECGs) underwent planar myocardial perfusion imaging. Studies showing perfusion defects were considered suggestive of acute coronary syndromes. The results of planar scintigraphy were compared with the clinical diagnosis and outcomes. All patients were followed up and monitored for the occurrence of major cardiac events 120 days after hospital discharge. Results: 71 patients underwent scintigraphy. Twenty-one(30%) patients had acute coronary syndromes, 15(21%) had major cardiac events(8 had myocardial infarction and 7 underwent myocardial revascularization). Planar scintigraphy demonstrated perfusion defects in 21 patients, 16 (76%) patients with acute coronary syndromes, 12(80%) patients who had major cardiac events and in 7(88%) patients with myocardial infarction. The negative predictive value of planar scintigraphy was 90%for diagnosis of acute coronary syndromes and 94%for detecting major cardiac events. Conclusion: Early planar myocardial perfusion imaging allowed rapid and accurate risk stratification of emergency departments patients with possible myocardial ischemia and nondiagnostic ECGs.展开更多
Background: Angiotensin-converting enzyme is involved in the pathophysiology of heart failure. We hypothesized that clinical characteristics as well as survival rate in patients with heart failure of different etiolog...Background: Angiotensin-converting enzyme is involved in the pathophysiology of heart failure. We hypothesized that clinical characteristics as well as survival rate in patients with heart failure of different etiologies may be modulated by functional variants DD, ID and II of the angiotensin-converting enzyme gene. Methods: We studied 333 patients with heart failure, aged 43.3±10.5 years, 262(78.7%) men and 71(21.3%) women. Heart failure was ascribed to idiopathic dilated cardiomyopathy in 125 patients. Heart failure was caused by ischemic heart disease in 63 patients, Chagas’disease in 58, hypertensive heart disease in 41, alcoholic cardiomyopathy in 24, and was due to other etiologies in 22 patients. Statistical analysis was performed with the χ2 test, Student’s t-test, analysis of variance, Kaplan-Meier and Cox proportional hazards methods. Results: The DD genotype was associated with increased systolic left ventricular diameter(p=0.031). Earlier onset of symptoms was observed in patients with alcoholic cardiomyopathy and DD genotype(p=0.033, codominant D) and in patients with hypertensive cardiomyopathy and DD genotype(p=0.048, codominant D; p=0.024, recessive D). Mortality was higher in patients older than 50 years with DD genotype(p=0.007, codominant D; p=0.002, recessive D). Variables independently associated with higher mortality in patients older than 50 years were age, diabetes mellitus, Chagas’disease etiology and DD genotype. Conclusions: These results add evidence for an association of the DD genotype of the angiotensin-converting enzyme gene with earlier onset of symptoms and decreased survival rate of selected patients with heart failure.展开更多
OBJECTIVE:The aim of this study was to estimate the probability of spontaneous delivery at 34 weeks or less according to cervical assessment by transvaginal scan associated with previous obstetric history. METHODS: Ul...OBJECTIVE:The aim of this study was to estimate the probability of spontaneous delivery at 34 weeks or less according to cervical assessment by transvaginal scan associated with previous obstetric history. METHODS: Ultrasound transvaginal cervical length and presence of funneling were evaluated in 1,958 singleton pregnancies between 21 and 24 weeks of gestation. For the prediction of preterm delivery, the results of cervical assessment were analyzed in association with the previous obstetric history of preterm delivery, spontaneous miscarriage, and curettage. Sensitivity, specificity, and positive and negative predictive values for the various cutoff cervical lengths in the groups with or without previous history of preterm delivery were calculated. Multivariable regression analysis was used to identify the predictive factors for preterm delivery at 34 weeks or less. RESULTS: The incidence of spontaneous delivery at gestational age of 34 weeks or less was 3.4%. The mean cervical length was 30.1 mm (standard deviation 10.1 mm) in the group with previous history of prematurity (a = 180) and 35.8 mm (standard deviation 7.9 mm) in the group without previous history of prematurity (P <.001). The mean cervical length in the group of patients who delivered at or before 34 weeks was 23.8 mm, and for patients who delivered after 34 weeks it was 35.6 mm (P < .001). The mean gestational age at delivery was significantly lower in the group with funneling compared with the group without funneling (33.5 weeks versus 38.8 weeks, P < .001). Logistic regression analysis demonstrated that cervical length, funneling, and history of previous preterm delivery were independent contributors for preterm delivery. CONCLUSION: Ultrasound cervical assessment may be useful in the prediction of preterm delivery, but it should also be considered in association with the obstetric history of prematurity.展开更多
文摘Background:Thrombocytopenia is a possible risk factor for bleeding after band ligation of esophageal varices.However,elevated von Willebrand factor(VWF)in cirrhosis improves platelet function and could decrease this risk.Our objective was to assess platelet function in patients with cirrhosis undergoing esophageal variceal ligation(EVL).Methods:The assessment consisted of platelet count,antigen and activity of VWF and VWF-cleaving protease ADAMTS-13 activity,and a platelet adhesion and aggregation test simulating vascular flow in vivo(Impact-RR)prior to EVL.Results:Totally 111 patients were divided into three groups according to platelet count:(1)<50×109/L(n=38,34.2%);(2)50×109/L to 100×109/L(n=47,42.3%);and(3)>100×109/L(n=26,23.4%).No statistically significant difference was found in the aggregate size of platelets[group 1:41.0(31.8–67.3)μm 2;group 2:47.0(33.8–71.3)μm 2;and group 3:47.0(34.0–66.0)μm 2;P=0.60]and no significant correlation was found between aggregate size and platelet count(Spearman r=0.07;P=0.47).Surface coverage was 4.1%(2.8%–6.7%),8.5%(4.0%–10.0%),and 9.0%(7.1%–12.0%)(P<0.001)in groups 1,2 and 3,respectively and correlated with platelet count(Spearman r=0.39;P<0.0001).There was no significant difference between groups in VWF or ADAMTS-13.Post-EVL bleeding occurred in six(5.4%)patients(n=2 in group 1,n=1 in group 2,and n=3 in group 3;P=0.32).Patients with bleeding had higher MELD scores[15.0(11.3–20.3)versus 12.0(10.0–15.0);P=0.025],but no difference was demonstrated for platelet function parameters.Conclusion:Platelet function is preserved even in the presence of thrombocytopenia,including in the patients with post-EVL bleeding.
文摘The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conventional semen parameters and sperm functional tests. An electronic search to collect the data was performed using the PubMed/MEDLINE databases until July 2015. Data pooled from a variety of study designs indicate that varicocelectomy improves semen parameters in the majority of the treated men with clinical varicocele and abnormal semen parameters regardless of the chosen surgical method. Surgical varicocele repair was beneficial not only for alleviating oxidative stress-associated infertility but also to improve sperm nuclear DNA integrity. However, given the low magnitude of the effect size in sperm DNA integrity, further research is needed to elucidate its clinical significance. Conflicting results on the effect of varicocele treatment on natural fertility seem to be due to heterogeneous study designs and, more importantly, patient selection criteria. When these issues are controlled, current evidence indicates that treatment of subclinical varicocele is not warranted, as it does not seem to improve fertility. On the contrary, fair evidence indicates that varicocele treatment should be offered to infertile patients with palpable varicocele and abnormal semen parameters. This evidence supports the current guidelines issued by the American Urological Association and European Association of Urology, which state that varicocele treatment should be offered to male partners of infertile couples presenting for evaluation with clinical varicocele and semen parameters alterations.
文摘Objective: Establish normative data for tympanic electrocochleography(TM ECoch G) parameters in normal hearing adults without Meniere's disease's(MD) symptoms. Describe TM ECoch G variables that help to distinguish normal from MD ears.Material and methods: We enrolled 100 subjects(N =200 ears), 59 females, aged between 19 and 71 years from 09/2010 to 04/2014. Inclusion criteria: normal otomicroscopy, hearing thresholds≤25 dB nHL from 250 to 4000 Hz, normal tympanogram, no symptoms of MD according to the AAO-HNS 1995 criteria and Gibson's score <7. We excluded subjects with dizziness, aural fullness or other symptoms of endolymphatic hydrops. The following parameters were analyzed: SP/AP amplitude ratio, SP/AP area ratio and the difference between AP latency with rarefaction and condensation stimuli.Results: There was no significant difference between right and left ears(Intraclass correlation coefficient < 0.6). SP/AP amplitude ratio varied between 0.084 and 0.356 and SP/AP area ratio between 0.837 and 1.671(percentiles 5 and 95). The AP latency difference to rarefaction and condensation clicks was between 0.0 and 0.333 ms.Conclusion: Normative data for TM ECoch G parameters were established in 100 normal hearing subjects without MD. These data can be used to distinguish normal from pathological findings and in follow-up of MD patients.
基金Fundao para o Desenvolvimento da UNESP-FUNDUNESP, So Paulo, Brazil
文摘Approximately 10% of patients with gastrointestinal stromal tumors (GIST) develop other neoplasms, either synchronously or metachronously. In this report we describe coexistence of a gastrointestinal stromal tumor and a hepatic perivascular epithelioid cell tumor (PEComa) in a 51-year-old woman with no evidence of tuberous sclerosis. A subcapsular hepatic nodule (0.8 cm in diameter) was found during surgery for symptomatic gastric neoplasm (15 cm in diameter) arising from the lesser curvature. Both tumors revealed histomorphological and immunohistochemical features confirming a diagnosis of a small incidental hepatic PEComa and a high risky extramural gastric GIST, respectively. The patient remained disease-free 25 mo after surgery with no evidence of tumor recurrence or new neoplasms. To our knowledge, this is the first report of PEComa in a patient with GIST. Hepatic lesions detected synchronously or metachronously in patients with GISTs may represent histogenetically distinct lesions and should be sampled to confirm or exclude metastatic GISTs.
文摘Fibrolamellar hepatocellular carcinoma(FLHCC) is a rare malignant liver neoplasm, commonly observed in adolescents and young adults of both genders. The disease is more common in Caucasians and in patients without a prior history of liver disease. The best treat-ment option is a surgical resection associated with liver hilum lymph node dissection. However, there is no established systemic drug treatment for patients with locally advanced or metastatic disease. We report on a patient with advanced FLHCC, initially considered un-resectable due to invasion of the right and the middle hepatic veins and circumferential involvement of the left hepatic vein. Following the treatment with gem-citabine-oxaliplatin systemic chemotherapy, the patient exhibited a significant tumor reduction. As a result, a complete resection was performed with an extended right hepatectomy associated with a partial resection of the inferior vena cava, a wedge resection in segment 2, and lymphadenectomy of the hepatic hilum. The case was unusual due to the significant tumor downstaging with gemcitabine-oxaliplatin, potentially enabling cura-tive resection. More studies are needed to confirm the efficacy of the systemic drug treatment for FLHCC.
文摘Acute coronary syndromes （ACS） are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortality is greater in older age patients presenting ACS. Despite the higher prevalence and greater risk, elderly patients are underrepresented in major clinical trials fi：om which evidence based recommendations are formulated. The authors describe, in this article, the challenges in the diagnosis and management of ST elevation myocardial infarction in the elderly, and discuss the available evidence.
文摘Perivascular epithelioid cell tumor(PEComa) is a rare mesenchymal neoplasia and currently well recognized as a distinct entity with characteristic morphological,immunohistochemical and molecular findings.We report a case of PEComa arising in the antrum of a 71-year-old female with melena.The tumor,located predominantly in the submucosa as a well delimited nodule,measured 3.0 cm in diameter and was completely resected,with no evidence of the disease elsewhere.Histologically,it was composed predominantly of eosinophilic epithelioid cells arranged in small nests commonly related to variably sized vessels,with abundant extracellular material,moderate nuclear variation and discrete mitotic activity.No necrosis,angiolymphatic invasion or perineural infil-tration was seen.Tumor cells were uniformly positive for vimentin,smooth muscle actin,desmin and melan A.Although unusual,PEComa should be considered in the differential diagnosis of gastric neoplasia with characteristic epithelioid and oncocytic features and prominent vasculature.
基金sponsored by FEDER funds through the program COMPETE-Programa Operacional Factores de Competitividadeby national funds through FCT-Funda??o para a Ciência e a Tecnologia,under the project UIDB/00285/2020。
文摘This paper investigates the effects of the physical properties on the microstructure and weldability of explosive welding by joining two metals with a significant contrast in thermophysical properties:stainless steel and copper.Sound welds between stainless steel and copper were obtained,and the interfacial morphology was wavy,regardless of the position of the materials.The weldability of dissimilar pairs was found to be more dependent on the relationship between the physical properties of the base materials than on the absolute value of the material property.When there is a significant difference in thermal conductivity between the flyer and the base plate,together with a material with a low melting temperature,the weldability of the pair is often poor.The relative position of the plates affects the interfacial microstructure even when similar morphologies are found.For the metallic pairs studied,the wave size was bigger for the configuration in which the ratio between the density of the flyer and the density of the base plate is smaller.The same phenomenon was observed for the impedance:bigger waves were found for a smaller ratio between the impedance of the flyer and the impedance of the base plate.
基金Supported by The NIH/NCI and used the Department of Biostatistics Resource Group,No.P30CA016672
文摘AIM To evaluate the correlation between degree of kinetic growth(k GR) of the liver following portal vein embolization(PVE) liver and the enhancement of the during the hepatobiliary phase of contrast administration and to evaluate if the enhancement can be used to predict response to PVE prior to the procedure.METHODS Seventeen patients were consented for the prospective study.All patients had an MR of the abdomen with GdEOB-DTPA.Fourteen patients underwent PVE.The correlation between the kG R of the liver and the degree of enhancement was evaluated with linear regression(strong assumptions) and Spearman's correlation test(rank based,no assumptions).The correlation was examined for the whole liver,segments I,VIII,VII,VI,V,IV,right liver and left liver.RESULTS There was no correlation between the degree of enhancement during the hepatobiliary phase and kG R for any segment,lobe of the liver or whole liver(P = 0.19 to 0.91 by Spearman's correlation test).CONCLUSION The relative enhancement of the liver during the hepatobiliary phase with Gd-EOB-DTPA cannot be used to predict the liver response to PVE.
文摘Immune checkpoint inhibitors have shown to be very effective when treating lung cancer. Nivolumab, a programmed death-1 (PD-1) inhibitor has been approved for the treatment of metastatic non-squamous and squamous NSCLC. Immunotherapy with checkpoint inhibitors are associated with toxicities defined as immune-related adverse events (irAEs). The most common irAEs are rash, colitis, hepatitis, pneumonitis, and endocrinopathies. Although any organ system can be affected, other rare irAEs can occur and affect the bone marrow, pancreas, and the neurologic and cardiac systems. Pericardial effusion induced by immunotherapy is uncommon and has been described only in a few case reports. Immune-related adverse events usually develop within the first weeks to months after treatment initiation. This is a case report of a 52-year-old male patient with metastatic squamous-cell lung cancer who had a massive pericardial effusion secondary to treatment with nivolumab as second line treatment. During his hospital stay, the patient underwent pericardiocentesis and treatment with corticosteroids. A CT scan after these treatments revealed complete tumor response and minimal pericardial effusion. Nivolumab was definitively ceased. The patient continues to show complete response for 16 months. In general, Nivolumab is well-tolerated and has an excellent safety profile. However, it is important to be aware of life-threatening immune-related adverse events, particularly cardiac toxicity. Consensus guidelines regarding the treatment of the most common irAEs have been established. The optimal management of irAEs is based on clinical experience. It’s crucial to report new or rare irAEs to conduct prospective trials to evaluate the best treatment strategy.
文摘BACKGROUND： Fibrolamellar hepatocellular carcinoma （FLHCC） is a rare disease with an indolent behavior. Its prognosis is better than that of patients with hepatocellular carcinoma. The authors present their experience with resection of FLHCC. METHODS： Twenty-one patients with FLHCC were treated at our institution between 1990 and 2012. Of these patients, 14 were subjected to resection of the tumor. Patient demographics, medical history, results of imaging studies and laboratory tests, surgical data, and pathologic findings were evaluated. RESULTS： The median age of the patients at the diagnosis of the tumor was 20 years and 14 patients were female. None of the patients had tumor-associated chronic liver disease or cirrhosis. The mean tumor size was 12.8 cm （range 6-19） and 18 patients had a single liver nodule. Fourteen patients were subjected to hepatectomy and six of them had lymph node metastases resected. Pathologic evaluation revealed that 5 （35.7%） patients had major vascular invasion. Tumor recurrence was seen in 8 patients （66.7%）, during a follow-up. The median survival time for patients who were subjected to resection was 36 months. The 5-year overall survival rate and disease free survival rate were 28.0% and 8.5%, respectively. Univariate analysis showed that vascular invasion was the only variable associated with the disease free survival rate.CONCLUSIONS： Despite an aggressive treatment, patients with FLHCC presented unexpected low survival rates. It seems that an underestimated malignant behavior is attributed to this disease, and that the forms of adjuvant treatment should be urgently evaluated.
文摘Currently, Brazilian buses are divided in three categories： city buses, intercity buses and coaches. That categorization results from the understanding that citizens only need to move around urban perimeters. However, the current bus models available do not fully meet legal demands or cater for all of society＇s demands. Rural workers and students that live in rural areas also must be conveyed in buses and minibuses. Municipal and state directives prohibit employers to convey them in improper vehicles, such as trucks. Social demands, on the other hand, can be i[llustrated by federal and state programs that provide vehicles to transport students who dwell in rural settings. Accordingly, this paper proposes a new categorization of bus models available in the Brazilian market, which should account for the unique local operating conditions rural buses face, instead of only considering the type of service they provide. Further, a purpose-built vehicle is suggested i[n order to cater for the needs of rural workers and students. Rural students represent, in average, five million rural school bus riders.
文摘Background: Oxidative stress and inflammation are related to the pathophysiology of diabetes mellitus (DM), being involved in the development of micro-and macrovascular complications. Physical activity is beneficial for DM patients, but little is known about the relationship between redox and inflammation biomarkers and the level of physical activity in these patients. Based on this, this research aims to evaluate the effects of physical activity level on redox stress parameters and inflammatory markers in T2DM patients. Methods: Eighty-four patients with T2DM were divided according to their physical activity level: group A (n = 48), sedentary;group B (n = 11) active (3 times a week, 150 min) and group C (n = 25), highly active (5 times a week, 150 - 300 mins, at least). Anthropometric and biochemical parameters, superoxide dismutase (SOD) and glutathione peroxidase (GPx) activities, as well as GSH, sRAGE and ICAM-1 levels were assessed. Results: Glycated haemoglobin, total cholesterol, and LDL-cholesterol levels were lower in the highly active group in comparison to other groups. Plasma SOD activity was higher in group C compared to Group A, while ICAM-1 levels were significantly higher in group B when compared to other groups. Conclusion: Our results suggest that the practice of physical activity is beneficial to T2DM patients, especially at high volume and frequency.
文摘Radiodermatitis is a constant complication after radiotherapy with no efficient drug for prevention and treatment. Its physiopathology is complex, possibly related to injury of epidermis and endothelial cells from the basal layer by radiolysis, overproduction of free radicals, pro-inflammatory cytokines, and inflammation. PTCTS gel is an after sun cosmetic gel composed by anti-oxidative plant extract rich in natural nanoparticles and thermal water (Complex A) and recombinant protein of Trypanosoma cruzi transialidase (Complex B), with high anti-oxidative and anti-apoptotic effects, presenting anti-aging and healing cutaneous properties. Objective: To study the safety and efficacy of PTCTS gel for topic use in volunteer subjects with healthy skin, and in patients with radiodermatitis, in different concentrations of Complexes A and B. Material and Methods: The project was approved by the Ethical Committee of Arnaldo Vieira de Carvalho Institute, Sao Paulo, Brazil. The individuals were submitted to laboratorial toxicity study through tests for liver and kidney function, levels of blood glucose and blood count before and after 7 days of PTCTS application. We studied two groups: GI-22 volunteers with healthy skin, presenting articular or skeletal muscle pain and GII-38 patients in radiotherapy for breast or head and neck cancer, with radiodermatitis grade 2 or 3. The patients were evaluated before and after 1.0 ml/cm2 PTCTS gel application, twice a day. We tested Complex B in four different concentrations, and Complex A concentrations varied inversely. Results: No irritation signs were observed in GI nor GII group, 64% of GI had important decrease in the intensity of the muscular or articular pain, and 99% of GII showed regression of radiodermatitis, all exhibiting relief of pain. No patient presented hematologic, renal or hepatic toxicity. Conclusion: PTCTS cosmetic gel is a safe option for radiodermatitis treatment, with no side effects or laboratorial toxicity in different concentrations. This product presented excellent clinical results even if used diluted 4 times more than the original product and may be a good option for treatment of radiodermatitis. Further studies may show if it is also indicated in the prevention of the lesion, and if it is better than products containing corticoids.
文摘Radiotherapy as monotherapy or in combination with chemotherapy, has contributed to the drop in mortality rates related to neoplasms in the last 60 years. However, irradiation may promote heart damage and involvement is very common. As a result, VHD （valvular heart disease） is one of the earliest cardiovascular events post-radiotherapy. What it concerns to valve disease induced by chemotherapeutics, there are still only few studies. However, patients treated with chemotherapy in combination with radiotherapy had twice the risk of developing the disease when compared to those treated by radiotherapy alone. The heart injury caused by radiotherapy begins with damage to the endothelium and results in fibrosis and diffuses calcification primarily of the mitral and aortic valves. The echocardiography is the tool of choice to the patient’s assessment and follow-up after exposure. Prevention is the best option to face the valve damage induced by radiation.
文摘Background: Rest single-photon emission computed tomographic(SPECT) perfusion imaging identifies acute myocardial ischemia in patients with chest pain in the emergency department; however, the costs are high and radioisotopic services are usually not available 24 h a day. Planar imaging through a portable gamma camera may be useful in this setting. However, planar imaging might be associated with less predictive values in comparison with a gated SPECT imaging. We sought to evaluate rest planar myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia. Methods: Patients within 6 h of chest pain onset and nondiagnostic electrocardiograms(ECGs) underwent planar myocardial perfusion imaging. Studies showing perfusion defects were considered suggestive of acute coronary syndromes. The results of planar scintigraphy were compared with the clinical diagnosis and outcomes. All patients were followed up and monitored for the occurrence of major cardiac events 120 days after hospital discharge. Results: 71 patients underwent scintigraphy. Twenty-one(30%) patients had acute coronary syndromes, 15(21%) had major cardiac events(8 had myocardial infarction and 7 underwent myocardial revascularization). Planar scintigraphy demonstrated perfusion defects in 21 patients, 16 (76%) patients with acute coronary syndromes, 12(80%) patients who had major cardiac events and in 7(88%) patients with myocardial infarction. The negative predictive value of planar scintigraphy was 90%for diagnosis of acute coronary syndromes and 94%for detecting major cardiac events. Conclusion: Early planar myocardial perfusion imaging allowed rapid and accurate risk stratification of emergency departments patients with possible myocardial ischemia and nondiagnostic ECGs.
文摘Background: Angiotensin-converting enzyme is involved in the pathophysiology of heart failure. We hypothesized that clinical characteristics as well as survival rate in patients with heart failure of different etiologies may be modulated by functional variants DD, ID and II of the angiotensin-converting enzyme gene. Methods: We studied 333 patients with heart failure, aged 43.3±10.5 years, 262(78.7%) men and 71(21.3%) women. Heart failure was ascribed to idiopathic dilated cardiomyopathy in 125 patients. Heart failure was caused by ischemic heart disease in 63 patients, Chagas’disease in 58, hypertensive heart disease in 41, alcoholic cardiomyopathy in 24, and was due to other etiologies in 22 patients. Statistical analysis was performed with the χ2 test, Student’s t-test, analysis of variance, Kaplan-Meier and Cox proportional hazards methods. Results: The DD genotype was associated with increased systolic left ventricular diameter(p=0.031). Earlier onset of symptoms was observed in patients with alcoholic cardiomyopathy and DD genotype(p=0.033, codominant D) and in patients with hypertensive cardiomyopathy and DD genotype(p=0.048, codominant D; p=0.024, recessive D). Mortality was higher in patients older than 50 years with DD genotype(p=0.007, codominant D; p=0.002, recessive D). Variables independently associated with higher mortality in patients older than 50 years were age, diabetes mellitus, Chagas’disease etiology and DD genotype. Conclusions: These results add evidence for an association of the DD genotype of the angiotensin-converting enzyme gene with earlier onset of symptoms and decreased survival rate of selected patients with heart failure.
文摘OBJECTIVE:The aim of this study was to estimate the probability of spontaneous delivery at 34 weeks or less according to cervical assessment by transvaginal scan associated with previous obstetric history. METHODS: Ultrasound transvaginal cervical length and presence of funneling were evaluated in 1,958 singleton pregnancies between 21 and 24 weeks of gestation. For the prediction of preterm delivery, the results of cervical assessment were analyzed in association with the previous obstetric history of preterm delivery, spontaneous miscarriage, and curettage. Sensitivity, specificity, and positive and negative predictive values for the various cutoff cervical lengths in the groups with or without previous history of preterm delivery were calculated. Multivariable regression analysis was used to identify the predictive factors for preterm delivery at 34 weeks or less. RESULTS: The incidence of spontaneous delivery at gestational age of 34 weeks or less was 3.4%. The mean cervical length was 30.1 mm (standard deviation 10.1 mm) in the group with previous history of prematurity (a = 180) and 35.8 mm (standard deviation 7.9 mm) in the group without previous history of prematurity (P <.001). The mean cervical length in the group of patients who delivered at or before 34 weeks was 23.8 mm, and for patients who delivered after 34 weeks it was 35.6 mm (P < .001). The mean gestational age at delivery was significantly lower in the group with funneling compared with the group without funneling (33.5 weeks versus 38.8 weeks, P < .001). Logistic regression analysis demonstrated that cervical length, funneling, and history of previous preterm delivery were independent contributors for preterm delivery. CONCLUSION: Ultrasound cervical assessment may be useful in the prediction of preterm delivery, but it should also be considered in association with the obstetric history of prematurity.
