Pentoxifylline associated to hypertonic saline solution attenuates inflammatory process and apoptosis after intestinal ischemia/reperfusion in rats

PURPOSE:To evaluate intestinal inflammatory and apoptotic processes after intestinal ischemia/reperfusion injury, modulated by pentoxifylline and hypertonic saline.METHODS:It was allocated into four groups (n=6), 24 male Wistar rats (200 to 250g) and submitted to intestinal ischemia for 40 min and reperfusion for 80 min: IR (did not receive any treatment); HS group (Hypertonic Saline, 4ml/kg-IV); PTX group (Pentoxifylline, 30mg/kg-IV); HS+PTX group (Hypertonic Saline and Pentoxifylline). All animals were heparinized (100U/kg). At the end of reperfusion, ileal fragments were removed and stained on hematoxylin-eosin and histochemical studies for COX-2, Bcl-2 and cleaved caspase-3.RESULTS:The values of sO2 were higher on treated groups at 40 minutes of reperfusion (p=0.0081) and 80 minutes of reperfusion (p=0.0072). Serum lactate values were lower on treated groups after 40 minutes of reperfusion (p=0.0003) and 80 minutes of reperfusion (p=0.0098). Morphologic tissue injuries showed higher grades on IR group versus other groups: HS (p=0.0006), PTX (p=0.0433) and HS+PTX (p=0.0040). The histochemical study showed lesser expression of COX-2 (p=0.0015) and Bcl-2 (p=0.0012) on HS+PTX group. A lower expression of cleaved caspase-3 was demonstrated in PTX (p=0.0090; PTXvsIR).CONCLUSION:The combined use of pentoxifylline and hypertonic saline offers best results on inflammatory and apoptotic inhibitory aspects after intestinal ischemia/reperfusion.São Paulo University Medical SchoolUSP Medical SchoolFederal University of São Paulo Medical SchoolUSP School of MedicineUSP School of Medicine Department of SurgeryUSP Medical School Department of SurgeryUNIFESP, Medical SchoolSciEL

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

The effect of pentoxifylline and hypertonic saline in intestinal ischemia / reperfusion and their consequences in the lung: an experimental study in rats

Isquemia e reperfusão (I/R) de vasos mesentéricos que acarretam insuficiência vascular aguda são acompanhadas de insuficiência em múltiplos órgãos e estão associados a altas morbidade e mortalidade. Os benefícios da solução hipertônica e da pentoxifilina foram testados isoladamente e em conjunto para melhorar o fluxo sanguíneo e o estado de oxigenação dos tecidos com redução da reação inflamatória e de apoptose, tanto no intestino quanto no pulmão enquanto órgão alvo. Foram utilizados 24 ratos Wistar machos pesando entre 200 e 250g distribuídos em 4 grupos (n=6). Foram submetidos à laparotomia e período de isquemia por clampeamento dos vasos mesentéricos por 40 minutos. O período de reperfusão foi de 80 minutos. A cada 40 minutos foram realizadas coletas de sangue arterial para gasometria. Os animais foram alocados nos grupos: grupo I/R (IR) onde I/R foi realizada e os animais receberam 4ml/kg de solução salina isotônica. O grupo solução salina hipertônica (SH) recebeu 4ml/kg de solução hipertônica a 7,5% e o grupo pentoxifilina (PTX) recebeu 30mg/kg de pentoxifilina diluída em NaCl 0,9% em um volume total de 4ml/kg ao final da isquemia intestinal. O grupo solução salina hipertônica+pentoxifilina (SH+PTX) recebeu ambas as soluções com volume total de 4m/kg no mesmo momento. As biopsias de intestino e pulmão foram colhidas ao final do experimento e foram submetidas à coloração em HE e à imuno-histoquímica para COX 2, caspase-3 clivada e Bcl-2. Os valores de sO2 revelaram diferença estatisticamente significante aos 40 (p=0,0099) e 80 (p=0,0074) minutos de reperfusão na comparação do grupo IR com os grupos SH e SH+PTX. Os valores de lactato foram estatisticamente significantes aos 40 minutos (p=0,0069) e 80 minutos (p=0,0098) de reperfusão, entre os grupos IR e os grupos SH e SH+PTX. A avaliação histológica em HE no tecido intestinal evidenciou diferença estatisticamente significantes na comparação dos grupos SH (p=0,0200), PTX (p=0,0200) e HS+PTX (p=0,0412) com o grupo IR, assim como no tecido pulmonar, que evidenciou diferenças estatisticamente significantes na comparação de IR com SH (p=0,006), PTX (p=0,0433) e SH+PTX (p=0,0040). A marcação citoplasmática de COX 2 revelou diferença estatisticamente significante ao comparar o grupo IR com o grupo SH+PTX (p=0,0015), Na avaliação do tecido pulmonar foi observado o grupo IR estabelecendo diferenças estatisticamente significantes na comparação com os grupos SH (p=0,0455), PTX (0,0143) e SH+PTX (p=0,0455). A avaliação de apoptose por imunohistoquímica para caspase 3 clivada evidenciou diferença com significância estatística ente os grupos IR e SH (p=0,0085) e os grupos PTX e SH (p=0,0120) em tecido intestinal. Em tecido pulmonar, entre IR e PTX (p=0,0090) e SH e PTX (p=0.0412). A marcação citoplasmática de Bcl-2 evidenciou que somente entres os grupos IR e SH+PTX (p=0,0012) se estabeleceu significância estatística em tecido intestinal No pulmão a diferença foi evidenciada em relação ao grupo IR e os grupos SH (p=0,0128), PTX (p=0,0085) e SH+PTX (p=0,0066). Conclui-se que o uso associado de pentoxifilina e solução salina hipertônica oferece os melhores resultados dos pontos de vista metabólico, inflamatório e da inibição da apoptoseIschemia-reperfusion (I/R) of the mesenteric vessels cause acute vascular insufficiency and is followed by multiple organs failure and high morbidity and mortality. The benefits of hypertonic saline (NaCl 7,5%) and pentoxifylline were tested to improve metabolic and oxygen status of tissues with reduced inflammatory reaction and apoptosis, both in the gut as in the lung as target organ. 24 male Wistar rats weighing 200 to 250g. They underwent laparotomy and ischemia by clamping the mesenteric vessels for 40 minutes. The reperfusion period was 80-minute long. Every 40 minutes, blood was collected for arterial gas analysis. The animals were set into 4 groups (n=6): I/R (IR) received isotonic saline just before reperfusion (4ml/kg). Hypertonic saline group (HS) received 7.5% hypertonic saline solution (4ml/kg) and Pentoxifylline group (PTX) received pentoxifylline (30mg/kg)diluted in NaCl 0.9% at the end of the mesenteric ischemia. Hypertonic saline+pentoxifylline group (SH-PTX) received both solutions at the same doses. Biopsies of intestine and lung were collected at the end of the experiment and were subjected to HE staining and immunohistochemistry staining to COX 2, cleaved caspase-3 and Bcl-2. About the values of sO2, a statistically significant difference was established when groups were compared at 40 (p=0.0099) minutes and 80 (p=0.0074) of reperfusion. The lactate values were statistically significant after 40 (p=0.0069) and 80 (p=0.098) minutes of reperfusion as well. Histological evaluation with HE revealed a statistically significant difference in the comparison of SH (p=0.0200), PTX (p=0.0200) and HS + PTX (p=0.0412) groups compared to IR group in intestine tissue and SH (p=0.0006), PTX (p=0.0433) and HS + PTX (p=0.040) in lung tissue. Cytoplasmic staining of COX 2 revealed a statistically significant difference when comparing IR (p=0.0015) to HS+PTX in intestinal tissue. The evaluation of the lung tissue for COX 2 showed IR group setting statistically significance when compared to HS 9p=0,045), PTX (0.0143) and HS+PTX (p=0.0455) groups. The evaluation of apoptosis by immunohistochemistry for cleaved caspase 3 revealed that there was a significant difference between IR versus SH (p=0.0085) and PTX versus HS (p= 0.0120) in intestinal tissue and IR versus PTX (p=0,0090) and PTX versus SH (p=0.0412) in lung tissue. The cytoplasmic Bcl-2 expression shows that only between groups IR versus HS+PTX (p = 0.0012) statistical significance was established in intestinal tissue. Lung tissue showed the difference was evidenced in relation to IR versus SH (p=0.0128), PTX (p=0.0085) and HS+PTX (p=0.0066). It may be concluded that the combined use of pentoxifylline and hypertonic saline offers best results on metabolic, inflammatory and apoptosis inhibitory aspect

Comparison between perfusion and balloon techniques for performing anorectal manometry in children with intestinal constipation Comparação das técnicas de balão e de perfusão para a realização de manometria anorretal em crianças portadoras de constipação intestinal

INTRODUCTION: Two anorectal manometry techniques have commonly been utilized: the perfusion technique and the balloon technique. PURPOSE: To compare both techniques in children with intestinal constipation who had not undergone surgical treatment for its correction. METHODS: Thirty-nine children aged between four and fourteen years underwent anorectal manometry using both techniques at random. Resting pressure, pressure response to voluntary contraction, coughing and perianal stimulation, maximum pressure on the anal canal pressure curve, and presence of rectosphincteric reflex were registered and submitted to statistics. Vectorgraphy of the sphincter muscle complex was obtained by perfusion technique. RESULTS: The statistical comparison between the techniques revealed statistically significant differences in resting pressure (p=0.041), pressure response to voluntary contraction (p=0.026) and maximum pressure within the pressure curve (p=0.010). The rectosphincteric reflex was demonstrated in 21 patients by both techniques. CONCLUSIONS: The perfusion technique presented greater sensitivity in the following parameters: resting pressure, pressure response to voluntary contraction and maximum pressure within the pressure curve. The methods studied are equivalent regarding the measurement of pressure responses to coughing and perianal stimulation and the investigation of rectosphincteric reflex.<br>INTRODUÇÃO: A manometria anorretal tem sido aceita como uma técnica objetiva de estudar a função do complexo muscular esfincteriano. Duas técnicas para o mesmo exame têm sido utilizadas: por perfusão e por balão. OBJETIVO: Comparar as técnicas entre as crianças portadoras de constipação intestinal que não foram submetidas a tratamento cirúrgico como forma de tratamento. MÉTODOS: Trinta e nove crianças com idades entre quarto e quatorze anos foram submetidas à Manometria anorretal utilizando-se ambas as técnicas de forma randomizada. Analizou-se a pressão de repouso, a pressão de contração voluntária, a pressão de contração reflexa, a pressão máxima de contração, o reflexo reto-esfincteriano. Além desses parâmetros, o vetorgrama do canal anal foi estudado pela técnica de perfusão. A análise estatística foi feita por meio de Wilcoxon signed rank test. RESULTADOS: A comparação estatística entre as técnicas revelou diferenças significantemente estatísticas nos parâmetros: pressão de repouso (p= 0.041), Pressão de contração voluntária (p= 0.026) e pressão máxima de contração (p= 0.010). Não houve diferença estatisticamente significante nos parâmetros: pressão de contração reflexa por tosse (p= 0.141) ou por estimulação perianal (p= 0.117). O reflexo reto-esfincteriano foi demonstrado em 21 pacientes em ambas as técnicas. CONCLUSÕES: A técnica de perfusão tem maior sensibilidade para os seguintes parâmetros: pressão de repouso, pressão de contração voluntária e pressão máxima de contração. As técnicas se equivalem no que diz respeito à pressão de contração reflexa e reflexo reto-esfincteriano