Evaluation of a refeeding plan employed after 43 days of voluntary fasting

OBJETIVO: Avaliar um esquema de realimentação utilizado em pacientes após jejum prolongado voluntário. MÉTODOS: Foi realizado estudo retrospectivo, com base em levantamento dos prontuários de 7 pacientes (média de idade de 41,6 anos e desvio-padrão=5,3) em jejum voluntário por 43 dias em jejum seguidos de 14 dias de realimentação. As variáveis estudadas foram: antropométricas, clínicas, dietéticas, laboratoriais e avaliação da composição corpórea por bioimpedância. Foram utilizadas as seguintes dietas por via oral na realimentação: oligomérica enriquecida com glutamina, associada à dieta hipogordurosa e isenta de lactose (primeira semana); dieta branda normolipídica com lactose (segunda semana). A análise descritiva dos dados apresentados incluiu média e desvio-padrão. A análise de variância ou o teste não paramétrico de Kruskal-Wallis foram utilizados para comparação dos dados nos períodos de jejum e realimentação. Utilizou-se o programa estatístico SIGMA STAT versão 2,03 sendo considerado o nível de significância de 5%. RESULTADOS: No jejum houve redução significativa do peso corpóreo (18,0% desvio-padrão=2,3), da prega cutânea do tríceps (48,2% desvio-padrão=9,0) e da hemoglobina (15,98g/dL desvio-padrão=0,99 para 12,74g/dL desvio-padrão=0,47). Na segunda semana de realimentação houve aumento significativo na contagem total de linfócitos (954 mil/mm³ desvio-padrão=242 para 1.619 mil/mm³ desvio-padrão=232) e dos distúrbios gastrointestinais, em relação à primeira semana. Não ocorreu Síndrome da Realimentação. CONCLUSÃO: O esquema de realimentação utilizado promoveu resultado global adequado, mas requer redução do aporte energético e definição de momento mais adequado para reintrodução de lactose e da dieta normolipídica.OBJECTIVE: To evaluate a refeeding plan employed in patients after a long period of voluntary fasting. METHODS: A retrospective study was done by reviewing the medical records of 7 male patients (mean age of 42.0 years; standard deviation of 5.3 years) who were refed for 14 days after a 43-day fast. The studied variables were: clinical, anthropometric; biochemical and body composition by bioimpedance analysis. The following diets were used orally in the refeeding program: glutamine-enriched oligomeric diet associated with a low-fat lactose-free diet (first week); normal-fat diet with lactose (second week). Descriptive analysis of the data included mean and standard deviation. Analysis of variance or the non-parametric Kruskal-Wallis test was used to compare data during the fasting and refeeding periods. The SIGMA STAT statistics software package version 2.03 was used to analyze data with the significance level set at 5% (p<0.05). RESULTS: During the fasting period there was a significant reduction in body weight (18.0%; standard deviation=2.3), triceps skinfold (48.2%; standard deviation=9.0) and hemoglobin concentration (from 15.98g/dL; standard deviation=0.99 to 12.74g/dL; standard deviation=0.47). During the second week of refeeding, there was a significant increase in total lymphocyte count (from 954 thousand/mm³; standard deviation=242 to 1.619 thousand/mm³; standard deviation=232); and gastrointestinal problems when compared with the first week. No case of refeeding syndrome was observed. CONCLUSION: The refeeding program used promoted a satisfactory global result but it is necessary to reduce energy intake and define the best moment to reintroduce lactose and a normal-fat diet

The effects of pneumoperitoneum and controlled ventilation on peritoneal lymphatic bacterial clearance: experimental results in rats

OBJECTIVE: To evaluate the effect of pneumoperitoneum, both alone and in combination with controlled ventilation, on peritoneal lymphatic bacterial clearance using a rat bacterial peritonitis model. METHOD: A total of 69 male Wistar rats were intraperitoneally inoculated with an Escherichia coli solution (109 colony-forming units (cfu)/mL) and divided into three groups of 23 animals each: A (control group), B (pneumoperitoneum under 5 mmHg of constant pressure), and C (endotracheal intubation, controlled ventilation, and pneumoperitoneum as in Group B). The animals were sacrificed after 30 min under these conditions, and blood, mediastinal ganglia, lungs, peritoneum, liver, and spleen cultures were performed. RESULTS: Statistical analyses comparing the number of cfu/sample in each of the cultures showed that no differences existed between the three groups. CONCLUSION: Based on our results, we concluded that pneumoperitoneum, either alone or in association with mechanical ventilation, did not modify the bacterial clearance through the diaphragmatic lymphatic system of the peritoneal cavity

Fístula colédoco-duodenal causada por tuberculose associada à SIDA

Allthough infrequent, digestive fistulae in HIV/AIDS patients have been reported throughout the digestive tract from the esophagus to the anus, with predominance of esophageal fistulae. AIDS/HIV-associated opportunistic infections may invade the digestive system and lead to fistula formation. Tuberculosis is the most common infection associated with these esophageal fistulae. We report here one case of bile duct-duodenal fistula in a female AIDS patient with associated abdominal Mycobacterium tuberculosis infection compromising lymphnodes of the hepatic pedicle where the fistula was found. According to the reviewed literature, this is the third case of bile duct-duodenal fistula associated with abdominal tuberculosis in AIDS patient, and the first where both the fistula and the tuberculosis infection were diagnosed at laparotomy for acute abdomen. Whether the AIDS patient with abdominal pain needs or not a laparotomy to treat an infectious disease is often a difficult matter for the surgeon to decide, as most of the times appropriate medical treatment will bring more benefit.Fístulas digestivas em pacientes com Síndrome da Imunodeficiência Adquirida (SIDA), embora raras, têm sido identificadas desde o esôfago até o ânus, predominando no esôfago. Infecções oportunistas relacionadas à SIDA podem acometer a parede do trato digestivo, levando a formação de fístulas. A Tuberculose é a infecção mais freqüentemente associada com fístula esofágica. Relatamos o caso de uma paciente portadora de SIDA, com tuberculose ganglionar comprometendo o hilo hepático, que evoluiu com fístula entre o ducto colédoco e o duodeno. A literatura revisada indica ser este o terceiro caso de fístula colédoco-duodenal descrito em paciente com tuberculose abdominal, associada à SIDA, e o primeiro em que a infecção pelo Mycobacterium tuberculosis e a fístula colédoco-duodenal foram diagnosticados durante laparotomia exploradora, indicada em paciente com abdome agudo. No paciente com SIDA e dor abdominal, pode ser difícil para o cirurgião decidir, se está indicada laparotomia exploradora, uma vez que, na maioria das vezes, o tratamento clínico apropriado será o melhor

Comparison of the Neutrophil Proteome in Trauma Patients and Normal Controls

Background: Neutrophils have an impressive array of microbicidal weapons, and in the presence of a pathogen, progress from a quiescent state in the bloodstream to a completely activated state. Failure to regulate this activation, for example, when the blood is flooded with cytokines after severe trauma, causes inappropriate neutrophil activation that paradoxically, is associated with tissue and organ damage. Acidic proteomic maps of quiescent human neutrophils were analyzed and compared to those of activated neutrophils from severe trauma patients. The analysis revealed 114 spots whose measured volumes differed between activated and quiescent neutrophils, with 27 upregulated and 87 downregulated in trauma conditions. Among the identified proteins, grancalcin, S100-A9 and CACNB2 reinforce observed correlations between motility and ion flux, ANXA3, SNAP, FGD1 and Zfyve19 are involved in vesicular transport and exocytosis, and GSTP1, HSPA1 HSPA1L, MAOB, UCH-L5, and PPA1 presented evidence that activated neutrophils may have diminished protection against oxidative damage and are prone to apoptosis. These are discussed, along with proteins involved in cytoskeleton reorganization, reactive oxygen species production, and ion flux. Proteins such as Zfyve19, MAOB and albumin- like protein were described for the first time in the neutrophil. In this work we achieved the identification of several proteins potentially involved in inflammatory signaling after trauma, as well as proteins described for the first time in neutrophils

O stress afeta cirurgiões durante o aprendizado tanto quanto na sua carreira profissional?

BACKGROUND: Stress affects surgeons both during training and during professional activity. OBJECTIVE: To compare stress levels affecting surgical residents during the simulated initial assessment and management in the Advanced Trauma Life Support practical exam vs initial assessment and management of trauma patients in the emergency room. METHOD: Eighteen surgical residents were evaluated under basal conditions, during the Advanced Trauma Life Support simulation, and during emergency room initial care. Heart rate, systolic arterial pressure, and diastolic arterial pressure were measured. The Student t test was used to test for differences between means, with statistical significance declared when P < .05. RESULTS: Heart rate and systolic arterial pressure were increased at the beginning and at the end of Advanced Trauma Life Support simulation and emergency room initial care. diastolic arterial pressure was only increased at the end of the Advanced Trauma Life Support simulation. Comparing values obtained during the Advanced Trauma Life Support simulation with those obtained during emergency room initial care, heart rate and systolic arterial pressure were significantly higher during the Advanced Trauma Life Support simulation both at the beginning and end of the test events. However, diastolic arterial pressure was only significantly higher for Advanced Trauma Life Support simulation compared emergency room at the end of the procedures. These results suggest that the simulation in the practical exam portion of the Advanced Trauma Life Support course is more stressful for the resident surgeon than is the actual initial assessment and care of trauma patients in an emergency room.OBJETIVO: Comparar os níveis de stress que afetam os residentes de cirurgia durante a avaliação inicial simulada nos cursos Advanced Trauma Life Support versus a avaliação do trauma do paciente na sala de emergência. MÉTODO: Dezoito residentes em cirurgia foram avaliados em condições basais no curso de Advanced Trauma Life Support e na sala de emergência. Foram medidas a freqüência cardíaca, pressões arterial sistólica e diastólica. ESTATÍSTICAS: Teste t do Estudante. Significantemente

A isquemia/reperfusão intestinal provoca hiper-reatividade brônquica e aumento do TNF-alfa sérico em ratos

INTRODUCTION: Intestinal or hepatic ischemia/reperfusion induces acute lung injury in animal models of multiple organ failure. Tumor necrosis factor (TNF)- alpha is involved in the underlying inflammatory mechanism of acute respiratory distress syndrome. Although the inflammatory cascade leading to acute respiratory distress syndrome has been extensively investigated, the mechanical components of acute respiratory distress syndrome are not fully understood. Our hypothesis is that splanchnic ischemia/reperfusion increases airway reactivity and serum TNF-alpha levels. OBJECTIVE: To assess bronchial smooth muscle reactivity under methacholine stimulation, and to measure serum TNF-alpha levels following intestinal and/or hepatic ischemia/reperfusion in rats. METHOD: Rats were subjected to 45 minutes of intestinal ischemia, or 20 minutes of hepatic ischemia, or to both (double ischemia), or sham procedures (control), followed by 120 minutes of reperfusion. The animals were then sacrificed, and the bronchial response to increasing methacholine molar concentrations (10-7 to 3 x 10-4) was evaluated in an ex-vivo bronchial muscle preparation. Serum TNF-alpha was determined by the L929-cell bioassay. RESULTS: Bronchial response (g/100 mg tissue) showed increased reactivity to increasing methacholine concentrations in the intestinal ischemia and double ischemia groups, but not in the hepatic ischemia group. Similarly, serum TNF-alpha (pg/mL) concentration was increased in the intestinal ischemia and double ischemia groups, but not in the hepatic ischemia group. CONCLUSION: Intestinal ischemia, either isolated or associated with hepatic ischemia, increased bronchial smooth muscle reactivity, suggesting a possible role for bronchial constriction in respiratory dysfunction following splanchnic ischemia/reperfusion. This increase occurred in concomitance with serum TNF-alpha increase, but whether the increase in TNF-alpha caused this bronchial contractility remains to be determined.INTRODUCÃO: A isquemia/reperfusão intestinal ou hepática induz lesão pulmonar aguda em modelos animais de falência de múltiplos órgãos. O fator de necrose tumoral (TNF-alfa) está envolvido no mecanismo inflamatório da síndrome da angústia respiratória aguda. Embora a cascata inflamatória que leva à síndrome da angústia respiratória aguda tenha sido extensamente investigada, os componentes mecânicos desta ainda não são completamente compreendidos. Nós levantamos a hipótese de que a isquemia/reperfusão esplâncnica provoca aumento da reatividade contráctil das vias aéreas, bem como aumento do TNF-alfa sérico. OBJETIVO: avaliar a reatividade da musculatura lisa brônquica sob estimulação com metacolina, e medir os níveis séricos de TNF-alfa após isquemia/reperfusão intestinal e/ou hepática em ratos. MÉTODO: Ratos Wistar foram submetidos a 45 min de isquemia intestinal, ou 20 minutos de isquemia hepática, ou a ambas (isquemia dupla), ou controle, seguidos por 120 min de reperfusão. A resposta brônquica a concentrações molares (10-7 to 3x10-4) de metacolina foi avaliada usando-se uma preparação ex-vivo de musculatura brônquica. RESULTADOS: A resposta brônquica (g/100mg de tecido) mostrou reatividade aumentada a concentrações crescentes de metacolina na isquemia intestinal e isquemia dupla, mas não na isquemia hepática. Similarmente, o TNF-alfa sérico aumentou na isquemia intestinal e isquemia dupla, mas não na isquemia hepática. CONCLUSÃO: Isquemia intestinal, quer isolada ou associada à hepática, provocou hiper-reatividade da musculatura brônquica, sugerindo um possível papel da constrição brônquica na disfunção respiratória conseqüente à isquemia/reperfusão esplâncnica. Este aumento foi simultâneo ao do TNF-alfa sérico, porém o possível efeito causal do TNF-alfa na contractilidade brônquica permanece a ser determinado

A isquemia/reperfusão intestinal provoca hiper-reatividade brônquica e aumento do TNF-alfa sérico em ratos

INTRODUCTION: Intestinal or hepatic ischemia/reperfusion induces acute lung injury in animal models of multiple organ failure. Tumor necrosis factor (TNF)- alpha is involved in the underlying inflammatory mechanism of acute respiratory distress syndrome. Although the inflammatory cascade leading to acute respiratory distress syndrome has been extensively investigated, the mechanical components of acute respiratory distress syndrome are not fully understood. Our hypothesis is that splanchnic ischemia/reperfusion increases airway reactivity and serum TNF-alpha levels. OBJECTIVE: To assess bronchial smooth muscle reactivity under methacholine stimulation, and to measure serum TNF-alpha levels following intestinal and/or hepatic ischemia/reperfusion in rats. METHOD: Rats were subjected to 45 minutes of intestinal ischemia, or 20 minutes of hepatic ischemia, or to both (double ischemia), or sham procedures (control), followed by 120 minutes of reperfusion. The animals were then sacrificed, and the bronchial response to increasing methacholine molar concentrations (10-7 to 3 x 10-4) was evaluated in an ex-vivo bronchial muscle preparation. Serum TNF-alpha was determined by the L929-cell bioassay. RESULTS: Bronchial response (g/100 mg tissue) showed increased reactivity to increasing methacholine concentrations in the intestinal ischemia and double ischemia groups, but not in the hepatic ischemia group. Similarly, serum TNF-alpha (pg/mL) concentration was increased in the intestinal ischemia and double ischemia groups, but not in the hepatic ischemia group. CONCLUSION: Intestinal ischemia, either isolated or associated with hepatic ischemia, increased bronchial smooth muscle reactivity, suggesting a possible role for bronchial constriction in respiratory dysfunction following splanchnic ischemia/reperfusion. This increase occurred in concomitance with serum TNF-alpha increase, but whether the increase in TNF-alpha caused this bronchial contractility remains to be determined.INTRODUCÃO: A isquemia/reperfusão intestinal ou hepática induz lesão pulmonar aguda em modelos animais de falência de múltiplos órgãos. O fator de necrose tumoral (TNF-alfa) está envolvido no mecanismo inflamatório da síndrome da angústia respiratória aguda. Embora a cascata inflamatória que leva à síndrome da angústia respiratória aguda tenha sido extensamente investigada, os componentes mecânicos desta ainda não são completamente compreendidos. Nós levantamos a hipótese de que a isquemia/reperfusão esplâncnica provoca aumento da reatividade contráctil das vias aéreas, bem como aumento do TNF-alfa sérico. OBJETIVO: avaliar a reatividade da musculatura lisa brônquica sob estimulação com metacolina, e medir os níveis séricos de TNF-alfa após isquemia/reperfusão intestinal e/ou hepática em ratos. MÉTODO: Ratos Wistar foram submetidos a 45 min de isquemia intestinal, ou 20 minutos de isquemia hepática, ou a ambas (isquemia dupla), ou controle, seguidos por 120 min de reperfusão. A resposta brônquica a concentrações molares (10-7 to 3x10-4) de metacolina foi avaliada usando-se uma preparação ex-vivo de musculatura brônquica. RESULTADOS: A resposta brônquica (g/100mg de tecido) mostrou reatividade aumentada a concentrações crescentes de metacolina na isquemia intestinal e isquemia dupla, mas não na isquemia hepática. Similarmente, o TNF-alfa sérico aumentou na isquemia intestinal e isquemia dupla, mas não na isquemia hepática. CONCLUSÃO: Isquemia intestinal, quer isolada ou associada à hepática, provocou hiper-reatividade da musculatura brônquica, sugerindo um possível papel da constrição brônquica na disfunção respiratória conseqüente à isquemia/reperfusão esplâncnica. Este aumento foi simultâneo ao do TNF-alfa sérico, porém o possível efeito causal do TNF-alfa na contractilidade brônquica permanece a ser determinado

Evaluation of the effects of ozone therapy in the treatment of intra-abdominal infection in rats

INTRODUCTION: The antibacterial effect of ozone (O3) has been described in the extant literature, but the role of O3 therapy in the treatment of certain types of infection remains controversial. OBJECTIVES: To evaluate the effect of intraperitoneal (i.p.) O3 application in a cecal ligation/puncture rat model on interleukins (IL-6, IL-10) and cytokine-induced neutrophil chemoattractant (CINC)-1 serum levels, acute lung injury and survival rates. METHODS: Four animal groups were used for the study: a) the SHAM group underwent laparotomy; b) the cecal ligation/puncture group underwent cecal ligation/puncture procedures; and c) the CLP+O2 and CLP+O3 groups underwent CLP+ corresponding gas mixture infusions (i.p.) throughout the observation period. IL-6, CINC-1 and IL-10 concentrations were determined by enzyme-linked immunosorbent assay (ELISA). Acute lung injury was evaluated with the Evans blue dye lung leakage method and by lung histology. P<0.05 was considered significant. RESULTS: CINC-1 was at the lowest level in the SHAM group and was lower for the CLP+O3 group vs. the CLP+O2 group and the cecal ligation/puncture group. IL-10 was lower for the SHAM group vs. the other three groups, which were similar compared to each other. IL-6 was lower for the SHAM group vs. all other groups, was lower for the CLP+O3 or CLP+O2 group vs. the cecal ligation/puncture group, and was similar for the CLP+O3 group vs. the CLP+O2 group. The lung histology score was lower for the SHAM group vs. the other groups. The Evans blue dye result was lower for the CLP+O3 group vs. the CLP+O2 group and the cecal ligation/puncture group but similar to that of the SHAM group. The survival rate for the CLP+O3 group was lower than for the SHAM group and similar to that for the other 2 groups (CLP and CLP+O2). CONCLUSION: Ozone therapy modulated the inflammatory response and acute lung injury in the cecal ligation/puncture infection model in rats, although there was no improvement on survival rates

O papel do New Trauma and Injury Severity Score (NTRISS) para predição de sobrevida

O objetivo deste estudo foi verificar se a substituição do Injury Severity Score (ISS) pelo New Injury Severity Score (NISS), na fórmula original do Trauma and Injury Severity Score (TRISS), melhora sua estimativa da taxa de sobrevida. Estudo retrospectivo realizado num centro de trauma nível I, durante um ano. A curva ROC foi utilizada para identificar o melhor indicador (TRISS ou NTRISS) para predição da probabilidade de sobrevida. O estudo incluiu 533 traumatizados, com idade média de 38±16 anos. Houve predomínio de acidentes de transporte (61,9%). Lesões externas foram mais frequentes (63,0%), seguidas por trauma craniencefálico/cervical (55,5%). A taxa de sobrevida foi de 76,9%. Houve predomínio dos valores do ISS variando de 9-15 (40,0%) e, do NISS, de 16-24 (25,5%). Probabilidade de sobrevida igual ou superior a 75,0% foi obtida para 83,4% das vítimas de acordo com o TRISS e por 78,4% de acordo com NTRISS. A nova versão apresentou melhor desempenho que o TRISS na predição de sobrevida dos doentes traumatizados estudados.El estudio objetivó verificar si la substitución del Injury Severity Score (ISS) por el New Injury Severity Score (NISS) en la fórmula original del Trauma and Injury Severity Score (TRISS) mejora su estimación de tasa de sobrevida. Estudio retrospectivo realizado en centro de trauma nivel I durante un año. Se usó curva ROC para identificar el mejor indicador (TRISS o NTRISS) para predicción de probabilidad de sobrevida. El estudio incluyó 533 traumatizados, edad media 38±16 años. Predominaron accidentes de transporte (61,9%). Prevalecieron las lesiones externas (63%), seguidas de trauma cráneo-encefálico/cervical (55,5%). Tasa de sobrevida: 76,9%. Predominaron valores de ISS variando de 9-15 (40,0%) y de NISS, de 16-24 (25,5%). Se obtuvo probabilidad de sobrevida igual o mayor a 75% para 83,4% de víctimas según TRISS y para 78,4% según NTRISS. La nueva versión (NTRISS) presentó mejor desempeño que TRISS en predicción de sobrevida en los pacientes traumatizados estudiados.The objective of this study was to verify if replacing the Injury Severity Score (ISS) by the New Injury Severity Score (NISS) in the original Trauma and Injury Severity Score (TRISS) form would improve the survival rate estimation. This retrospective study was performed in a level I trauma center during one year. ROC curve was used to identify the best indicator (TRISS or NTRISS) for survival probability prediction. Participants were 533 victims, with a mean age of 38±16 years. There was predominance of motor vehicle accidents (61.9%). External injuries were more frequent (63.0%), followed by head/neck injuries (55.5%). Survival rate was 76.9%. There is predominance of ISS scores ranging from 9-15 (40.0%), and NISS scores ranging from 16-24 (25.5%). Survival probability equal to or greater than 75.0% was obtained for 83.4% of the victims according to TRISS, and for 78.4% according to NTRISS. The new version (NTRISS) is better than TRISS for survival prediction in trauma patients