New endoscopic procedure for bladder wall closure: results from the porcine model

Upper urinary tract urothelial carcinomas are usually managed by radical nephroureterectomy (RNU), often followed by intravesical chemotherapy to minimize recurrence. Open surgery is the gold standard procedure for RNU, but it associates with high morbidity, and it has been increasingly replaced by minimally invasive strategies, such as laparoscopy and endoscopy. Although effective, endoscopic ureteral excision leaves the bladder unsutured, increasing the risk of tumor spillage, and precluding the immediate administration of intravesical chemotherapy. Here we describe a new method to close the bladder wall after ureteral excision, using barbed sutures via the endoscopic access. Our results in 8 female pigs demonstrate that this method is effective to close the bladder wall. The procedure was completed in a median time of 24 min, and no adverse events were registered in the follow-up or at the three-week necropsy. This technique improves a previous approach described by our group because the device is more flexible and allows to tie the knots inside the bladder. Barbed sutures have been used in the clinical practice for other types of surgeries, and therefore this method can further be adapted to human patients with no safety concerns. Its use may allow to administer intravesical chemotherapy, which reduces tumor recurrence and improves patient outcomes.The authors acknowledge Ana Goios for support in manuscript writing and technical editing, and for producing original illustrations for Figure 3. Doctoral grant of CUF Jose de Mello Saude

Surgical Myocardial Revascularization of Patients with Ischemic Cardiomyopathy and Severe Left Ventricular Disfunction

OBJECTIVE: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. METHODS: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/ rest. Survival was determined by Kaplan-Meier analysis. RESULTS: Mean left ventricular ejection fraction was 29±4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32±5% to 39±5%, p <0.001. Gated left ventricular ejection fraction at exercise/ rest increased markedly after surgery: from 27±8%/ 23±7% to 37±5%/ 31±6%, p <0.001. CONCLUSIONS: In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/ functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/ rest

ST-Elevation myocardial infarction network: systematization in 205 cases reduced clinical events in the public health care system

BACKGROUND: The major cause of death in the city of São Paulo (SP) is cardiac events. At its periphery, in-hospital mortality in acute myocardial infarction is estimated to range between 15% and 20% due to difficulties inherent in large metropoles. OBJECTIVE:To describe in-hospital mortality in ST-segment elevation acute myocardial infarction (STEMI) of patients admitted via ambulance or peripheral hospitals, which are part of a structured training network (STEMI Network). METHODS: Health care teams of four emergency services (Ermelino Matarazzo, Campo Limpo, Tatuapé and Saboya) of the periphery of the city of São Paulo and advanced ambulances of the Emergency Mobile Health Care Service (abbreviation in Portuguese, SAMU) were trained to use tenecteplase or to refer for primary angioplasty. A central office for electrocardiogram reading was used. After thrombolysis, the patient was sent to a tertiary reference hospital to undergo cardiac catheterization immediately (in case of failed thrombolysis) or in 6 to 24 hours, if the patient was stable. Quantitative and qualitative variables were assessed by use of uni- and multivariate analysis. RESULTS: From January 2010 to June 2011, 205 consecutive patients used the STEMI Network, and the findings were as follows: 87 anterior wall infarctions; 11 left bundle-branch blocks; 14 complete atrioventricular blocks; and 14 resuscitations after initial cardiorespiratory arrest. In-hospital mortality was 6.8% (14 patients), most of which due to cardiogenic shock, one hemorrhagic cerebrovascular accident, and one bleeding. CONCLUSION: The organization in the public health care system of a network for the treatment of STEMI, involving diagnosis, reperfusion, immediate transfer, and tertiary reference hospital, resulted in immediate improvement of STEMI outcomes.FUNDAMENTO: A principal causa de óbitos na cidade de São Paulo (SP) é por eventos cardíacos. Em hospitais periféricos de São Paulo estima-se a mortalidade hospitalar no infarto agudo entre 15% e 20%, pelas dificuldades existentes. OBJETIVO: Descrever a mortalidade intra-hospitalar do Infarto Agudo do Miocárdio com Supradesnivelamento de ST (IAMCSST) de pacientes admitidos via ambulância ou hospitais periféricos, como resultado da organização de uma estruturada rede de treinamento. MÉTODOS: Equipes de quatro prontos-socorros (Ermelino Matarazzo, Campo Limpo, Tatuapé e Saboya) e das ambulâncias avançadas do Serviço de Atendimento Móvel de Urgência (Samu) foram treinadas para uso de tenecteplase (TNK) ou para encaminhamento para angioplastia primária. Uma central de leitura de eletrocardiogramas foi usada quando necessário. Após uso de trombolítico, um hospital terciário recebia o paciente que era submetido a cinecoronariografia imediata (trombólise sem sucesso) ou entre 6 e 24 h, caso estável. Variáveis quantitativas, qualitativas foram avaliadas em análise uni e multivariável. RESULTADOS: De janeiro 2010 a junho 2011, 205 pacientes consecutivos utilizaram a rede de atendimento, ocorrendo 87 infartos de parede anterior, 11 bloqueios de ramo esquerdo, 14 bloqueios atrioventricular total, e em 14 houve reanimação pós-parada cardiorrespiratória inicial. A mortalidade intra-hospitalar foi de 6,8% (14 casos), a maioria por choque cardiogênico, um por acidente vascular encefálico hemorrágico e um por sangramento. CONCLUSÃO: A organização em instituições públicas de uma rede de tratamento, envolvendo diagnóstico, reperfusão, transporte imediato e hospital de retaguarda resultou em melhora imediata dos resultados de IAMCSST.Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM)Serviço de Atendimento Móvel de UrgênciaPrefeitura Municipal de São Paulo Secretaria de SaúdeHospital Municipal Prof. Dr. Alípio Correa NettoUNIFESP, EPMSciEL

Characterization of interactions between natural organic matter and metals by tangential-flow ultrafiltration and ICP OES

Molecular size fractionation of the natural organic matter (NOM) in water samples from the Serra de Itabaiana National Park (Brazil) was used to characterize the temporal behavior of metal ion complexation. A special five-stage tangential-flow ultrafiltration device was used to separate NOM in six size fractions (F1: > 100; F2: 100-50; F3: 50-30; F4: 30-10; F5: 10-5; F6: > F3 > F2 = F4 > F6 > F5. Fractions F2 and F5 were the most humified, and F6 the least. New distributions of DOC and metals were observed after 30 days when high concentrations of metals were added to filtered samples. Highest DOC was still found in F1, with carbon contents decreasing in the following order: F1 > F2 > F3 > F4 > F5 > F6. The studied metals presented similar and homogeneous distributions in all fractions. Values of log K were similar for samples in natura and 30 days after addition of metals (7.1 and 7.0, 6.6 and 6.9, and 7.2 and 7.0 for Al, Cu and Fe-NOM, respectively), indicating a new dynamic equilibrium in the metals distribution after 30 days. The species formed between NOM and spiked metals showed distribution patterns that changed as a function of complexation time, indicating a transformation of the NOM binding sites, suggesting that the collective effect of the fractions is more important than individual site properties, and confirming that the most humified fractions exert a large influence on the complexation of metals in aquatic environments. _________________________________________________________________________________________ ABSTRACT: O fracionamento por tamanho molecular da matéria orgânica natural (MON) de amostras de água do Parque Nacional Serra de Itabaiana (Brasil) foi utilizado para caracterização temporal da complexação de íons metálicos. Um sistema de ultrafiltração em cinco estágios foi usado para separar a MON em seis frações (F1: > 100; F2: 100-50; F3: 50-30; F4: 30-10; F5: 10-5; F6: > F3 > F2 = F4 > F6 > F5. As frações F2 e F5 foram as mais humificadas e F6 a menos humificada. Após 30 dias com adição de elevadas concentrações de metais nas amostras filtradas novas distribuições de COD e metais foram observadas. Maior COD ainda foi encontrado na F1 com teores de carbono decrescendo na seguinte ordem: F1 > F2 > F3 > F4 > F5 > F6. Os metais apresentaram distribuições similares e homogêneas em todas as frações. Valores de log K foram similares para as amostras in natura e para aquelas de 30 dias após a adição dos metais (7,1 e 7,0; 6,6 e 6,9; e 7,2 e 7,0 para Al, Cu e Fe-MON, respectivamente), indicando uma nova condição de equilíbrio na distribuição dos metais após 30 dias. As espécies formadas entre MON e os metais adicionados mostraram um modelo de distribuição que mudou em função do tempo de complexação, indicando uma transformação dos sítios de ligação da MON, sugerindo que o efeito coletivo das frações é mais importante que as propriedades individuais e confirmando que as frações mais humificadas exercem grande influência na complexação de metais em ambientes aquáticos