Interventions for necrotising pancreatitis

BACKGROUND: Acute necrotising pancreatitis carries significant mortality, morbidity, and resource use. There is considerable uncertainty as to how people with necrotising pancreatitis should be treated. OBJECTIVES: To assess the benefits and harms of different interventions in people with acute necrotising pancreatitis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 4), MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers to April 2015 to identify randomised controlled trials (RCT). We also searched the references of included trials to identify further trials. SELECTION CRITERIA: We considered only RCTs performed in people with necrotising pancreatitis, irrespective of aetiology, presence of infection, language, blinding, or publication status for inclusion in the review. DATA COLLECTION AND ANALYSIS: Two review authors independently identified trials and extracted data. We calculated the odds ratio (OR) and mean difference with 95% confidence intervals (CI) using Review Manager 5 based on an available-case analysis using fixed-effect and random-effects models. We planned a network meta-analysis using Bayesian methods, but due to sparse data and uncertainty about the transitivity assumption, performed only indirect comparisons and used Frequentist methods. MAIN RESULTS: We included eight RCTs with 311 participants in this review. After exclusion of five participants, we included 306 participants in one or more outcomes. Five trials (240 participants) investigated the three main treatments: open necrosectomy (121 participants), minimally invasive step-up approach (80 participants), and peritoneal lavage (39 participants) and were included in the network meta-analysis. Three trials (66 participants) investigated the variations in the main treatments: early open necrosectomy (25 participants), delayed open necrosectomy (11 participants), video-assisted minimally invasive step-up approach (12 participants), endoscopic minimally invasive step-up approach (10 participants), minimally invasive step-up approach (planned surgery) (four participants), and minimally invasive step-up approach (continued percutaneous drainage) (four participants). The trials included infected or sterile necrotising pancreatitis of varied aetiology.All the trials were at unclear or high risk of bias and the overall quality of evidence was low or very low for all the outcomes. Overall, short-term mortality was 30% and serious adverse events rate was 139 serious adverse events per 100 participants. The differences in short-term mortality and proportion of people with serious adverse events were imprecise in all the comparisons. The number of serious adverse events and adverse events were fewer in the minimally invasive step-up approach compared to open necrosectomy (serious adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study; adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study). The proportion of people with organ failure and the mean costs were lower in the minimally invasive step-up approach compared to open necrosectomy (organ failure: OR 0.20, 95% CI 0.07 to 0.60; 88 participants; 1 study; mean difference in costs: USD -11,922; P value < 0.05; 88 participants; 1 studies). There were more adverse events with video-assisted minimally invasive step-up approach group compared to endoscopic-assisted minimally invasive step-up approach group (rate ratio 11.70, 95% CI 1.52 to 89.87; 22 participants; 1 study), but the number of interventions per participant was less with video-assisted minimally invasive step-up approach group compared to endoscopic minimally invasive step-up approach group (difference in medians: 2 procedures; P value < 0.05; 20 participants; 1 study). The differences in any of the other comparisons for number of serious adverse events, proportion of people with organ failure, number of adverse events, length of hospital stay, and intensive therapy unit stay were either imprecise or were not consistent. None of the trials reported long-term mortality, infected pancreatic necrosis (trials that included participants with sterile necrosis), health-related quality of life at any time frame, proportion of people with adverse events, requirement for additional invasive intervention, time to return to normal activity, and time to return to work. AUTHORS' CONCLUSIONS: Low to very low quality evidence suggested that the minimally invasive step-up approach resulted in fewer adverse events, serious adverse events, less organ failure, and lower costs compared to open necrosectomy. Very low quality evidence suggested that the endoscopic minimally invasive step-up approach resulted in fewer adverse events than the video-assisted minimally invasive step-up approach but increased the number of procedures required for treatment. There is currently no evidence to suggest that early open necrosectomy is superior or inferior to peritoneal lavage or delayed open necrosectomy. However, the CIs were wide and significant benefits or harms of different treatments cannot be ruled out. The TENSION trial currently underway in Netherlands is assessing the optimal way to perform the minimally invasive step-up approach (endoscopic drainage followed by endoscopic necrosectomy if necessary versus percutaneous drainage followed by video-assisted necrosectomy if necessary) and is assessing important clinical outcomes of interest for this review. Implications for further research on this topic will be determined after the results of this RCT are available

Pollen viability and germination in Jatropha ribifolia and Jatropha mollissima (Euphorbiaceae): Species with potential for biofuel production

The aim of this work is to assess pollen viability using the staining  technique and in vitro germination with different concentrations of sucrose in Jatropha ribifolia and Jatropha mollissima, contributing to the knowledge of the reproductive biology and subsidizing their conservation,  management and utilization. Pollen viability was measured by dye method. Acetocarmine, acetic orcein and cotton-blue stain were used. The culture medium for pollen germination was solidificated by the addition of 1% agar combined with 0 (control), 10, 20, 30 and 40% of sucrose. The data were submitted to analysis of variance at 5% probability. All dyes used in this experiment allowed easy differentiation between fertileand non fertile pollen. The rate of formation of pollen tubes was higher in medium with 10% of sucrose for both species because the trend is that the sucrose concentration increases the supply of carbon, changes the osmotic potential and inhibits the formation of pollen tube in vitro.Key words: Plant reproduction, male gametophyte, hybridization, germplasm

Analysis of vancomycin use and associated risk factors in a university teaching hospital: a prospective cohort study

Background: Vancomycin use is considered inappropriate in most hospitals. A particular concern is the recent emergence of S. aureus with decreased susceptibility to vancomycin, making it important to reduce overall exposure to vancomycin to minimize the incidence of VRE ( vancomycin- resistant enterococci). the aim of this work was to analyze the use of vancomycin and the risk factors associated with inappropriate treatment.Methods: A prospective survey was conducted on all patients receiving vancomycin between 1(st) March 2002 and 30(th) September 2002 in a university- school hospital. Appropriateness of vancomycin use was assessed, according to the criteria established by the Centers for Disease Control and Prevention ( CDC), at two time points: first, at the beginning of therapy, and second, continuing after 72 hours.Results: A total of 557 patients received vancomycin. Three hundred seventy- four ( 67.1%) were under 60 years old, 374 ( 67.1%) had prolonged stays (> two weeks) in hospital, and 455 ( 81.7%) were in the intensive care unit ( ICU). Two hundred sixty- three patients ( 47.2%) had some invasive device. in 324 ( 58.2%) patients the duration of vancomycin treatment was up to two weeks. Vancomycin was inappropriately used in 65.7% during the first 24 hours and in 67% at the 72 hours point according to CDC criteria [ 4]. the inappropriateness of vancomycin use during the first 24 hours was related to: patients aged less than 60 ( OR 1.7; CI 95% 1.1 - 2.5), non- ICU patients ( OR 1.5; CI 95% 1.0 - 2.4) and patients without neutropenia ( OR 7.5; CI 95% 2.4 - 22.7). At 72 hours, the inappropriateness of vancomycin use was related to: patients aged less than 60 ( OR 1.5; CI 95% 1.0 - 2.3), non- ICU patients ( OR 1.7; CI 95% 1.1 - 2.7) and patients without neutropenia ( OR 8.0; CI 95% 2.6 - 24.3).Conclusion: Vancomycin was abused. Patients aged less than 60, non- ICU patients and those who did not present neutropenia were the principal groups at risk of inappropriate use.Universidade Federal de São Paulo, Dept Infect Dis, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Infect Dis, São Paulo, BrazilWeb of Scienc

Extensin network formation in Vitis vinifera callus cells is an essential and causal event in rapid and H2O2-induced reduction in primary cell wall hydration

<p>Abstract</p> <p>Background</p> <p>Extensin deposition is considered important for the correct assembly and biophysical properties of primary cell walls, with consequences to plant resistance to pathogens, tissue morphology, cell adhesion and extension growth. However, evidence for a direct and causal role for the extensin network formation in changes to cell wall properties has been lacking.</p> <p>Results</p> <p>Hydrogen peroxide treatment of grapevine (<it>Vitis vinifera </it>cv. Touriga) callus cell walls was seen to induce a marked reduction in their hydration and thickness. An analysis of matrix proteins demonstrated this occurs with the insolubilisation of an abundant protein, GvP1, which displays a primary structure and post-translational modifications typical of dicotyledon extensins. The hydration of callus cell walls free from saline-soluble proteins did not change in response to H₂O₂, but fully regained this capacity after addition of extensin-rich saline extracts. To assay the specific contribution of GvP1 cross-linking and other wall matrix proteins to the reduction in hydration, GvP1 levels in cell walls were manipulated <it>in vitro </it>by binding selected fractions of extracellular proteins and their effect on wall hydration during H₂O₂incubation assayed.</p> <p>Conclusions</p> <p>This approach allowed us to conclude that a peroxidase-mediated formation of a covalently linked network of GvP1 is essential and causal in the reduction of grapevine callus wall hydration in response to H₂O₂. Importantly, this approach also indicated that extensin network effects on hydration was only partially irreversible and remained sensitive to changes in matrix charge. We discuss this mechanism and the importance of these changes to primary wall properties in the light of extensin distribution in dicotyledons.</p

Influenza B-Associated Atypical Hemolytic Uremic Syndrome

Introduction: Influenza A infections have been described to cause secondary hemolytic uremic syndrome and to trigger atypical hemolytic uremic syndrome (aHUS) in individuals with an underlying genetic complement dysregulation. To date, Influenza B has only been reported to trigger aHUS in 2 patients. In 61% of aHUS cases, mutations are found in H, B and I factors, membrane cofactor protein (MCP), C3 and thrombomodulin. MCP (CD46) mutations account for 10-15% of cases. Clinical Case: A 13-year-old boy was transferred to a terciary pediatric centre with acute renal lesion in the context of HUS. Evidence was found for Influenza B infection and results for other etiologic agents were negative. He was treated with Oseltamivir for 5 days. Etiologic study revealed decreased C ́3 (0,81 g/L), normal C ́4 (0,27 g/L) and all antibodies were negative: anti-Beta2 GP1 IgG / IgM, anti-cardiolipine IgG / IgM, anti-neutrophil-citoplasm-PR3 and MPO. Alternate complement pathway study (AH 50) were 112 % of normal value (reference value >70%) and ADAMTS 13 activity were 0.79 (values above 0.67 may be found in aSHU as well as other microangiopathic trombopathies). Molecular study of complement including 11 genes (CFH, CD46 (MCP), CFI, C3, THBD, CFB,CFHR5, CFHR1 CFHR3, CFHR4, DGKE) found a pathogenic heterozygotic missense variant on CD46 (MCP) gene, c.554A>G, p.Asp185Gly, associated with aHUS. Conclusions: aHUS patients should be screened for all known disease-associated genes. Screening should not be stopped after finding a mutation to avoid missing other genetic susceptibility factors influencing disease phenotype, particularly in patients with MCP or CFI mutations, because they have a higher probability of also carrying mutation in another gene than patients with CFHor C3 mutations. Influenza B is a trigger for aHUS and might be underreported as such. Influenza vaccination may protect patients at risk.info:eu-repo/semantics/publishedVersio

Acute hemorrhagic oedema of infancy

O edema hemorrágico agudo infantil é uma forma rara de vasculite leucocitoclásica cutânea, que ocorre em crianças com menos de 4 anos de idade. As principais manifestações são lesões cutâneas purpúricas, edema periférico e febre. Apesar dos achados clínicos serem dramáticos, quer na aparência das lesões, quer na rapidez de instalação, o prognóstico permanece excelente, com recuperação espontânea em poucas semanas. A sua origem está pouco esclarecida, mas infecções subjacentes, fármacos e vacinas têm sido referidas como possíveis factores etiológicos. Descrevemos uma criança de 7 meses com quadro clínico e histológico típicos de edema hemorrágico agudo infantil que surgiu na sequência de uma infecção do tracto urinário, em tratamento com amoxicilina e ácido clavulâmico.info:eu-repo/semantics/publishedVersio