Increased fibroblast telomerase expression precedes myofibroblast α-smooth muscle actin expression in idiopathic pulmonary fibrosis

OBJECTIVE: This study sought to identify the relationship between fibroblast telomerase expression, myofibroblasts, and telomerase-mediated regulatory signals in idiopathic pulmonary fibrosis. METHODS: Thirty-four surgical lung biopsies, which had been obtained from patients with idiopathic pulmonary fibrosis and histologically classified as usual interstitial pneumonia, were examined. Immunohistochemistry was used to evaluate fibroblast telomerase expression, myofibroblast α-smooth muscle actin expression and the tissue expression of inter leu kin-4, transforming growth factor-β, and basic fibroblast growth factor. The point-counting technique was used to quantify the expression of these markers in unaffected, collapsed, mural fibrosis, and honeycombing areas. The results were correlated to patient survival. RESULTS: Fibroblast telomerase expression and basic fibroblast growth factor tissue expression were higher in collapsed areas, whereas myofibroblast expression and interleukine-4 tissue expression were higher in areas of mural fibrosis. Transforming growth factor-β expression was higher in collapsed, mural fibrosis and honeycombing areas in comparison to unaffected areas. Positive correlations were found between basic fibroblast growth factor tissue expression and fibroblast telomerase expression and between interleukin-4 tissue expression and myofibroblast α-smooth muscle actin expression. Negative correlations were observed between interleukin-4 expression and basic fibroblast growth factor tissue expression in areas of mural fibrosis. Myofibroblast α-smooth muscle actin expression and interleukin-4 tissue expression in areas of mural fibrosis were negatively associated with patient survival. CONCLUSION: Fibroblast telomerase expression is higher in areas of early remodeling in lung tissues demonstrating typical interstitial pneumonia, whereas myofibroblast α-smooth muscle actin expression predominates in areas of late remodeling. These events seem to be regulated by basic fibroblast growth factor and interleukin-4 tissue expression, respectively

Does videothoracoscopy improve clinical outcomes when implemented as part of a pleural empyema treatment algorithm?

OBJECTIVE: We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients. METHODS: This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications. RESULTS: Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p<0.01). The patients in the new algorithm group were older (41 +1 vs. 46.3+ 16.7 years, p = 0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p = 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04). CONCLUSIONS: The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery

Chemical components separation with the use of botulinum toxin A: a critical review for correction of ventral hernia

Background: Ventral hernias are prevalent results in abdominal surgeries and may represent a surgical challenge in complex&nbsp;cases, mainly due to tension in abdominal wall musculature. Failure of surgical correction may lead to a more morbid&nbsp;treatment, in addition to a considerable socioeconomic impact. In order to have a lower risk of complications, the use of&nbsp;botulinum toxin A (BTA), may be a preoperative alternative to reduce abdominal wall tension by causing sustained and&nbsp;reversible paralysis. This critical review of the literature proposes to evaluate the adjacent use of BTA in surgical ventral&nbsp;hernias corrections.Methods: Using the PubMed database, the keywords ‘ventral hernia’, and ‘botulinum toxin’ were searched using the&nbsp;Boolean operator AND. Articles were selected based on their relevance and updated information. The outcomes of interest&nbsp;included the change in ventral hernia defect width and in lateral abdominal wall muscle length, pain, hernia recurrence&nbsp;and complications.Results: A total of 20 articles from 2009 to 2018 were found. We excluded some articles due to irrelevant technique, use of&nbsp;animal models and lack of outcome data. Reduction of the abdominal wall thickness increasing its length, less perioperative&nbsp;pain, hernia reduction and the correction with less tension were observed after the use of BTA injection. No complications&nbsp;occurred during applications.Conclusion: The use of BTA seems to be a promising alternative in the management of ventral hernias due to its capacity&nbsp;of reducing tension in the abdominal wall. However, more studies are necessary to determine the efficacy of this method

Emergency removal of transplanted graft due to the failure of clinical treatment of serious acute rejection in case of small bowel transplantation: case report

Introduction: Intestinal transplantation is a complex procedure that has become more common in recent years. It can&nbsp;be performed isolated or with other organs of the digestive tract, which characterizes a multivisceral transplantation. Its&nbsp;indication mainly involves patients with irreversible intestinal failure, submitted or not to an enterectomy, and who have&nbsp;complications from parenteral nutrition. Among the main difficulties after transplantation is the immunosuppressive&nbsp;therapy, since the small intestine is an extremely immunogenic organ. Insufficient immunosuppression may cause graft&nbsp;rejection, but excessive immunosuppression may lead to Graft vs. Host Disease, where the intestine’s own immune cells&nbsp;attack Host organs. In Brazil, however, the practical experience with this type of surgery and with the management of&nbsp;immunosuppressive therapy is restricted because of the reduced number of small bowel transplants performed.&nbsp;Objective: To report a case of small bowel transplantation with graft rejection and necessity of surgical removal of the graft.&nbsp;Case Report: A male patient, 21 years old, presented a complicated acute appendicitis in July 2015, being submitted to&nbsp;appendectomy and right colectomy. After the operation, he developed thrombosis and intestinal infarction. This complication&nbsp;affected more than 90% of the patient’s small bowel, requiring extensive enterectomy. The patient developed short bowel&nbsp;syndrome and relied on parenteral nutrition. After 7 months in the home parenteral nutrition regimen, the patient underwent&nbsp;small bowel transplantation due to complications of parenteral nutrition. Immunosuppressive therapy was based on the&nbsp;use of tacrolimus. The patient presented no intercurrences until the 6th postoperative month, when he developed systemic&nbsp;histoplasmosis, staying 33 days in the intensive care unit. He presented resolution of the condition with itraconazole. At the&nbsp;18th postoperative month, he was admitted with fever and intense diarrhea. The ileoscopy examination showed intestinal&nbsp;ulcers and loss of villi. Graft biopsies were consistent with severe acute T cell mediated rejection. The patient was transferred&nbsp;to our institution to treat the rejection. The combined use of increased tacrolimus, pulse therapy with methylprednisolone,&nbsp;use of thymoglobulin and use of monoclonal antibody against tumor necrosis factor alpha were not effective. The patient`s&nbsp;general condition deteriorated and he had to be submitted to urgent removal of the transplanted graft. The patient returned&nbsp;to the parenteral nutrition regimen and underwent reconstruction of the digestive tract with anastomosis between jejunum&nbsp;and transverse colon 5 months after grafting. Currently, he is in outpatient follow-up using home parenteral nutrition

Intestine transplantation: case report

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Chemical components separation with the use of Botulinum toxin A: a critical review for correction of ventral hernia

Introdução: Hérnias ventrais são um resultado prevalente de cirurgias abdominais que podem representar um desafio cirúrgico em casos complexos, principalmente devido à tensão na musculatura da parede abdominal. A falha na correção cirúrgica pode levar a necessidade de um tratamento mais mórbido, além de um considerável impacto socioeconômico. Para que o risco de complicações seja menor, o uso da toxina botulínica A (TBA) pode ser uma alternativa pré-operatória para reduzir a tensão da parede abdominal, através de uma paralisia sustentada e reversível. Esta revisão crítica da literatura propõe avaliar o uso adjacente de TBA em correções de hérnias ventrais cirúrgicas. Métodos: Usando o banco de dados PubMed, as palavras-chave “ventral hernia” e “botullinum toxin” foram pesquisadas usando o operador “AND”. Os artigos foram selecionados com base em sua relevância e informações atualizadas. Os desfechos de interesse incluíram a mudança na largura do defeito da hérnia ventral e no comprimento do músculo da parede abdominal lateral, dor, recidiva de hérnia e complicações. Resultados: Foram encontrados 20 artigos de 2009 a 2018. Foram excluídos artigos devido à técnica irrelevante, uso de modelos animais e falta de dados sobre resultados. Redução da espessura da parede abdominal aumentando seu comprimento, menos dor perioperatória, redução de hérnia e correção com menos tensão foram observados após o uso da injeção de BTA. Nenhuma complicação ocorreu durante as aplicações. Conclusão: O uso de TBA parece ser uma alternativa promissora no manejo de hérnias ventrais devido à sua capacidade de reduzir a tensão na parede abdominal. No entanto, mais estudos são necessários para determinar a eficácia deste método.Background: Ventral hernias are prevalent results in abdominal surgeries and may represent a surgical challenge in complex cases, mainly due to tension in abdominal wall musculature. Failure of surgical correction may lead to a more morbid treatment, in addition to a considerable socioeconomic impact. In order to have a lower risk of complications, the use of botulinum toxin A (BTA), may be a preoperative alternative to reduce abdominal wall tension by causing sustained and reversible paralysis. This critical review of the literature proposes to evaluate the adjacent use of BTA in surgical ventral hernias corrections. Methods: Using the PubMed database, the keywords ‘ventral hernia’, and ‘botulinum toxin’ were searched using the Boolean operator AND. Articles were selected based on their relevance and updated information. The outcomes of interest included the change in ventral hernia defect width and in lateral abdominal wall muscle length, pain, hernia recurrence and complications. Results: A total of 20 articles from 2009 to 2018 were found. We excluded some articles due to irrelevant technique, use of animal models and lack of outcome data. Reduction of the abdominal wall thickness increasing its length, less perioperative pain, hernia reduction and the correction with less tension were observed after the use of BTA injection. No complications occurred during applications. Conclusion: The use of BTA seems to be a promising alternative in the management of ventral hernias due to its capacity of reducing tension in the abdominal wall. However, more studies are necessary to determine the efficacy of this method