Será a insuficiência renal uma contra-indicação relativa para as biópsias broncoscópicas?

Resumo: Em 1977, Cunningham e col. demonstraram que, nos doentes urémicos sujeitos a broncofibroscopia com biopsias, 45% tiveram hemorragias.Actualmente, não há trabalhos publicados que avaliem este risco.Os autores resolveram avaliar os processos de todas as broncofibroscopias realizadas entre 1997 e 2002 no Hospital de Bellvue, Nova Iorque, registando os resultados da ureia, da creatinina, do hemograma, do estudo da coagulação, do tipo de biópsias executadas da pré-medicação e das complicações.Os doentes eram incluídos nos trabalhos desde que tivessem a ureia superior ou igual a 30 mg/dl e/ou a creatinina superior ou igual a 2,0 mg/dl. Perante estes critérios foram incluídos no estudo 72 doentes.Vinte e cinco doentes dos 72(35 %) foram submetidos a biopsias. Sete dos 25 (28 %) foram hemodializados e 18 dos 25(72 %) não foram hemodializados. Todos os doentes hemodializados foram submetidos à broncofibroscopia 24 horas depois da hemodiálise e foram submetidos a uma perfusão de desmopressina pré-broncofibroscopia, e um doente com coagulopatia recebeu plaquetas e plasma fresco.Os doentes hemodializados submetidos a biópsias tinham valores de ureia que oscilavam entre 31-65 mg/ /dl e valores de creatinina que oscilavam entre 5,2-18,7 mg/dl, e o único doente deste grupo que fez punção aspirativa transbrônquica tinha uma ureia de 32 mg/dl e uma creatinina de 4,3 mg/dl.Em doze dos 18 doentes não submetidos a hemodiálise e submetidos a biópsias, os valores de ureia oscilavam entre 20-69 mg/dl e os valores de creatinina entre 0,9-2,5 mg/dl. Deste grupo, os quatro doentes que foram submetidos a punção aspirativa transbrônquica tinham valores de ureia entre 20-62 mg/dl e valores de creatinina entre 1,1-4,5 mg/dl. Os dois doentes sujeitos a biópsias e punção aspirativa transbrônquica tinham valores de ureia de 30 e 35 mg/dl e valores de de 1,4 e 1,5 mg/dl. Um dos 25 doentes não hemodializados teve uma complicação major, hemorragia maciça que obrigou a intervenção. Um outro deste mesmo grupo teve apenas uma hemorragia minor.Não houve complicações nos doentes hemodializados.Estes resultados sugerem que não há tantas complicações como seria de esperar nos doentes com insuficiência renal, como demonstrou Cullingam e col. em 1977. Mostram que não há complicações nos doentes hemodializados e sujeitos a uma perfusão de desmopressina antes de ser efectuada a broncofibroscopia.Estes dados obrigam à realização de novos estudos para avaliar de facto se as biópsias broncoscópicas são uma contra-indicação relativa na insuficiência renal. Palavras-chave: Broncofibroscopia, biópsias broncoscópicas, insuficiência renal, complicações hemorrágica

Housing conditions affect rat responses to two types of ambiguity in a reward-reward discrimination cognitive bias task

Decision-making under ambiguity in cognitive bias tasks is a promising new indicator of affective valence in animals. Rat studies support the hypothesis that animals in a negative affective state evaluate ambiguous cues negatively. Prior automated operant go/go judgement bias tasks have involved training rats that an auditory cue of one frequency predicts a Reward and a cue of a different frequency predicts a Punisher (RP task), and then measuring whether ambiguous cues of intermediate frequency are judged as predicting reward ('optimism') or punishment ('pessimism'). We investigated whether an automated Reward-Reward (RR) task yielded similar results to, and was faster to train than, RP tasks. We also introduced a new ambiguity test (simultaneous presentation of the two training cues) alongside the standard single ambiguous cue test. Half of the rats experienced an unpredictable housing treatment (UHT) designed to induce a negative state. Control rats were relatively 'pessimistic', whilst UHT rats were quicker, but no less accurate, in their responses in the RR test, and showed less anxiety-like behaviour in independent tests. A possible reason for these findings is that rats adapted to and were stimulated by UHT, whilst control rats in a predictable environment were more sensitive to novelty and change. Responses in the new ambiguity test correlated positively with those in single ambiguous cue tests, and may provide a measure of attention bias. The RR task was quicker to train than previous automated RP tasks. Together, they could be used to disentangle how reward and punishment processes underpin affect-induced cognitive biases. © 2014 The Authors

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Total hip arthroplasty and femoral nail lengthening for hip dysplasia and limb-length discrepancy

The application of distraction osteogenesis through the use of magnet-operated, remote-controlled intramedullary lengthening continues to provide new opportunities for accurate limb equalization. While limb-length discrepancy and deformity can be addressed by total hip arthroplasty alone, the magnitude of correction is limited by the soft-tissue envelope and complications such as sciatic nerve palsy. This 3-patient case series presents the combination of staged ipsilateral total hip arthroplasty and retrograde intramedullary femoral nail lengthening for the correction of both deformity and limb-length discrepancy. Our results report leg-length equalization, independent ambulation without assistive devices, and excellent bone and functional outcomes without complications, demonstrating that this combined technique can be used to achieve targeted lengthening and deformity correction. Keywords: Limb lengthening, Limb-length discrepancy, Total hip arthroplasty, PRECICE, Deformit

Open Hamstring Tendon Excision Following a Distal Semitendinosus Avulsion Tear: A Technique Video

Background: Hamstring injuries are commonly considered the number one reason for delayed return to play and return to sport (RTS) across several sport disciplines. Traditionally, they are treated conservatively. However, recent literature has shown surgical intervention to improve recovery and expedite RTS. One potential explanation behind this phenomenon is conservative treatment does not address the disrupted length-tendon relationship, which can cause hamstring re-injury. Indications: Operative indications for tendon excision include patients with distal semitendinosus avulsions tear with retraction, especially patients who had already failed conservative management. Elite athletes with distal hamstring tears who have experienced a delayed RTS or desired activity level should also be considered for distal hamstring excision. Technique Description: A distal 4-cm incision, which was longitudinal in line with the semitendinosus, was made over the posterior knee at the measured level of the avulsed tendon stump, 2 cm proximal to the knee flexion crease. Blunt dissection was used for the subcutaneous layers, and the overlying hypertrophic and fibrotic tendon sheath was sharply incised. The torn and retracted tendon tissue was exteriorized. An allis clamp was used to provide tension on the distal semitendinosus, and mobilization of the avulsed tendon was performed. Sheath tissue surrounding the injured tendon was removed. The stump was whipstitched to provide further traction, and the hypertrophied portion of the tendon was excised. An open tendon stripper was implemented to exercise both limbs of the semitendinosus. The subcutaneous tissue and skin were closed, and an incisional wound vac was placed. Discussion/Conclusion: Distal avulsion tears of semitendinosus tendons can lead to unsatisfactory results with conservative treatment, with delayed RTS and recurrence of symptoms. Resection of hamstring tendon tissue may eliminate the recurrence of injury, along with inflammation, fibrosis, and hemorrhage associated with retraction reinjuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication