Marcelo Dias Sanches

Tuberculosis in liver transplant recipients: a single Brazilian center experience.

Background. Tuberculosis (TB) is an important opportunistic infection in transplant recipients worldwide. The frequency of Mycobacterium tuberculosis disease varies among different regions, but the incidence of TB in adult liver transplant (LT) recipients is largely unknown. The estimated frequency ranges from 0.7% to 2.3%, with mortality rate up to 30%. However, these data are based on individual case reports or series with small samples. In LT recipients, therapy is generally associated with significant hepatotoxicity and interactions with immunosuppressive drugs. Methods. This retrospective analysis included 319 patients who underwent LT at University Hospital, Federal University of Minas Gerais, Brazil, between September 1994 and July 2007 and survived more than 1 month. Among these, TB was diagnosed in five patients. No patients received chemoprophylaxis before or after LT. Results. All five patients were women, mean age 39.6±16.5 years. Two patients had disseminated TB, two pulmonary involvement, and one extrapulmonary disease. Cultures were positive in four patients. Overall, four patients received isoniazid, rifampin, and pyrazinamide for 6 to 12 months, with good tolerance, but one patient presented recurrence. Another patient presented raised hepatic enzymes levels after initiating therapy. All patients are alive and well. Conclusions. In this series, the TB frequency after liver transplantation was 1.57%, with no confirmed hepatotoxicity with conventional treatment and an excellent survival rate (100%).

Hyperbaric oxygen therapy aggravates liver reperfusion injury in rats

PURPOSE To evaluate the effects of hyperbaric oxygen (HO) therapy in the protection against liver ischemia/reperfusion injury. METHODS Thirty-two male Wistar rats were divided into four groups of eight animals each: group A - laparotomy and liver manipulation, group B - liver ischemia and reperfusion, group C - HO pretreatment for 60 min followed by liver ischemia and reperfusion, and group D - pretreatment with ambient air at 2.5 absolute atmospheres for 60 min followed by liver ischemia and reperfusion. Plasma was assayed for aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH). Intra-arterial blood pressure was monitored continuously. Myeloperoxidase activity in the liver and lung was assessed 30 min after reperfusion. RESULTS Plasma AST, ALT and LDH increased after reperfusion in all animals. Plasma ALT values and myeloperoxidase activity in the liver parenchyma were higher in HO-pretreated animals than in groups A, B and D. HO had a negative hemodynamic effect during liver reperfusion. CONCLUSION Liver preconditioning with hyperbaric oxygen therapy aggravated liver ischemia/reperfusion injury in rats as demonstrated by plasma ALT and liver myeloperoxidase activity.

Perfil lipídico de obesos antes e após a derivação gástrica a Fobi-Capella

RESUMO: Objetivo: Este estudo analisa de forma retrospectiva o perfil lipidico de pacientes submetidos a derivacao gastrica a Fobi-Capella, na Santa Casa de Belo Horizonte de setembro de 1999 a setembro de 2003. Metodo: Foram avaliados os protocolos de acompanhamento de 143 pacientes, analisando os valores de colesterol total (CT), colesterol associado a lipoproteina de alta densidade (HDL), colesterol associado a lipoproteina de baixa densidade (LDL), triglicerides (TG) e o indice de massa corporal (IMC) no pre-operatorio e um ano apos a operacao. A presenca de dislipidemia foi definida como alteracao em pelo menos um dos exames. Foi feita a comparacao entre os valores do pre-operatorio com os do pos-operatorio. Resultados: Os valores sericos medios do CT, HDL, LDL e TG foram de 201,7 mg%, 47,9 mg%, 122,6 mg% e 153,7% respectivamente. Nao houve diferenca nestes valores quando estratificados pelo IMC. A prevalencia de dislipidemia foi de 61,5% no pre-operatorio. Apos um ano da operacao, houve queda de 12,5% no CT, 14,3% no LDL, 29,5% nos TG e aumento de 18,5% no HDL. Ocorreu normalizacao em 73,9% dos pacientes que apresentavam pelo menos uma das dosagens alterada. Conclusao: A prevalencia da dislipidemia foi elevada nos pacientes submetidos a derivacao gastrica a Fobi-Capella. Ocorreu melhora dos parâmetros avaliados do perfil lipidico apos um ano da operacao (Rev. Col. Bras. Cir. 2006; 33(2): 91-95). Descritores: Obesidade morbida; Derivacao gastrica; Hiperlipidemia; Colesterol; Triglicerideos; Periodo pos-operatorio.

Metabolic long-term follow-up of functioning simultaneous pancreas-kidney transplantation versus pancreas transplantation alone: insights and limitations.

Background. Pancreas transplantation involves a set of procedures that, in some cases, lead to different complications and outcomes. The aim of this study was to analyze the long-term effects of pancreas transplantation regarding carbohydrate and lipid metabolism parameters to determine differences between simultaneous pancreas-kidney (SPK) transplantation and pancreas transplantation alone (PTA). Methods. Sixty-four patients (46 SPK and 18 PTA), with an immunosuppression protocol based on tacrolimus plus mycophenolate mofetil and prednisone, were evaluated for at least 1 year after transplantation. No patient made use of any hypoglycemic or hypolipidemic drugs. Comparisons were performed between SPK and PTA patients using the chi-square test, Fischers exact test, and unpaired Students t test, as appropriate. Results. Patients were 39.8±9.3 years old, predominantly male (60.9%), with a mean follow-up of 25.4±10.4 months after transplantation. The PTA group exhibited worse renal function and higher tacrolimus levels than the SPK group. Fasting glucose, 2 hr plasma glucose after overload, C-peptide, and HbA1C were within the normal range, with no statistically significant differences between the PTA and SPK groups. Insulin (INS) and the homeostasis model assessment of INS resistance index were above the normal range in both the groups. Lipids were also similar between groups. Conclusions. The majority of patients with long-term functioning pancreas transplant achieved good glucose control without use of exogenous INS or oral antidiabetic drugs, although they were hyperinsulinemic. There were no significant differences concerning glucose and lipid parameters between the SPK and PTA groups, even though the PTA patients exhibited higher tacrolimus levels and worse renal function.

The impact of functioning pancreas-kidney transplantation and pancreas alone transplantation on the lipid metabolism of statin-naive diabetic patients

Abstract: Objective:  To compare the lipid profile (total cholesterol – TC, triglycerides – TG, high density lipoprotein cholesterol – HDL‐c, low density lipoprotein cholesterol – LDL‐c and non‐HDL cholesterol – NHDL‐c) of patients with functioning pancreas–kidney transplantation (PKT) or pancreas transplantation alone (PTA) after one (T1) and two yr (T2) following their pre‐transplantation data (T0).

Pre-Transplant Aerobic Capacity and Prolonged Hospitalization After Liver Transplantation

Introduction Patients with end stage liver disease (ESLD) referred for liver transplantation (LT) are forwarded to pulmonary evaluation before being operated. ESLD is associated with muscle wasting, reduced exercise tolerance and aerobic capacity. Objectives We assessed the association between aerobic capacity (AC), liver disease severity and postoperative LT outcomes in a series of LT candidates in a university affiliated hospital in Brazil. Methods Pre-LT oxygen uptake at peak (pre-VO2peak), liver disease severity, and early pos-LT outcomes such as length of intensive care unit (ICU) stay, <5 and ≥5 days and hospitalization, <20 and ≥20 days and postoperative mortality were compared. Pre-VO2peak was measured through the cardiopulmonary exercise testing (CPET). Severity of liver disease was estimated by the Model for End-Stage Liver Disease (MELD) categorization into MELD < 18 and MELD ≥ 18 groups. Students t-test was used to compare these groups. A logistic regression model was built to verify the effect of those variables on the length of ICU stay, length of hospitalization and postoperative mortality. Results A total of 47 patients were include in analysis. Pre-VO2peak was similar to that of healthy sedentary individuals (75 ± 18%) and worse in the MELD ≥ 18 group as compared to the MELD < 18 group (19.51 ± 7.87 vs 25.21 ± 8.76 mL/kg/min, respectively; p = 0.048). According to the multivariate analysis, only a lower pre-VO2peak (<20.09 ± 4.83 mL/kg/min) was associated to a greater length of hospitalization (p = 0.01). Conclusions In LT candidates, a reduced pre-VO2peak may predict a higher risk of greater pos-LT length of hospitalization. The length of ICU stay and postoperative mortality were not associated with variables studied. This finding should be evaluated in other studies before making specific recommendations about a routine use of CPET in LT candidates.

A pilot prospective study to evaluate whether the bladder morphology in cystography and/or urodynamic may help predict the response to botulinum toxin a injection in neurogenic bladder refractory to anticholinergics

BackgroundWe have observed different clinical responses to botulinum toxin A (BTX-A) in patients who had similar urodynamic parameters before the procedure. Furthermore, some bladders evaluated by cystography and cystoscopy during the procedure had different characteristics that could influence the outcome of the treatment. The aim of this study was to assess whether cystography and urodynamic parameters could help predict which patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergics respond better to treatment with injection of BTX-A.MethodsIn total, 34 patients with spinal cord injury were prospectively evaluated. All patients emptied their bladder by clean intermittent catheterization (CIC) and had incontinence and NDO, despite using 40 mg or more of intravesical oxybutynin and undergoing detrusor injection of BTX-A (300 IU). Pretreatment evaluation included urodynamic, and cystography. Follow-up consisted of urodynamic and ambulatory visits four months after treatment. The cystography parameters used were bladder shape, capacity and presence of diverticula. Urodynamic parameters used for assessment were maximum cystometric capacity (MCC), maximum detrusor pressure (MDP), compliance and reflex volume (RV).ResultsAfter injection of BTX-A, 70% of the patients had success, with 4 months or more of continence. Before the treatment, there were significant differences in most urodynamic parameters between those who responded successfully compared to those who did not. Patients who responded successfully had greater MCC (p = 0.019), higher RV (p = 0.041), and greater compliance (p = 0.043). There was no significant difference in the MDP (0.691). The cystography parameters were not significantly different between these groups bladder shape (p = 0.271), capacity (p > 0.720) and presence of diverticula (p > 0.999). Statistical analyses were performed using SPSS (version 20.0) and included Student’s t-test for two paired samples and Fisher’s exact test, with a significance threshold of 0.05.ConclusionsThis study suggests that the cystography parameters evaluated cannot be used to help predict the response to injection of BTX-A in the treatment of refractory NDO. However, the urodynamic parameters were significantly different in patients who responded to the treatment, with the exception of the MDP.

Associated factors to empyema in post-traumatic hemotorax

OBJECTIVE to analyze the associated factors with empyema in patients with post-traumatic retained hemothorax. METHODS prospective observational study. Data were collected in patients undergoing PD during emergency duty. Variables analyzed were age, sex, mechanism of injury, side of the chest injury, intrathoracic complications of RH, laparotomy, specific injuries, rib fractures, trauma scores, days to diagnosis, diagnostic method of RH, primary indication of PD, initial volume drained, length of the first tube removal, surgical procedure. Cumulative incidence of empyema, pneumonia and pulmonary contusion and the proportion of patients with empyema or without empyema in each category of each variable analyzed were obtained. RESULTS the cumulative incidence of PD among trauma patients was 1.83% and the RH among those with PD was 10.63%. There were 20 cases of empyema (32.8%). Most were male in the age from 20 to 29, victims of injury by firearm on the left side of the thorax. The incidence of empyema in patients with injury by firearms was lower compared to those with stab wound or blunt trauma; higher among those with drained volume between 300 and 599 ml. The median hospital lenght of stay was higher among those with empyema. CONCLUSION the incidence of PD was 1.83% and RH was 10.63%, these results are consistent with the low severity of the patients involved in this study and consistent with the literature. The incidence of empyema proved to be negatively associated with the occurrence of injury by firearms and positively associated with a drained volume between 300 and 599 ml, compared with lower or higher volumes.

Duodenum-preserving pancreatic head resection in solid pseudopapillary neoplasm—Report of a case

INTRODUCTION Solid pseudopapillary neoplasm (SPPN) was first characterized by Virginia Frantz in 1959. The duodenum-preserving pancreatic head resection (DPPHR) has been described as treatment for low-grade malignant tumors of the head of the pancreas including eight cases of SPPN. PRESENTATION OF CASE: A 16-year-old white female patient presented with abdominal pain and dyspepsia. Computed tomography scan of abdomen showed a 10 × 9 × 10 cm3 lesion on the pancreatic head. After radiological diagnosis of SPPN the patient was submitted to DPPHR. Resection was achieved with clear margins. Immunohistochemical study demonstrated positivity for progesterone receptor, β-catenin, cytoplasmic paranuclear dot-like CD99, negativity for chromogranin and S100 protein and Ki 67 index of 1%. DISCUSSION A large encapsulated pancreatic mass with well-defined borders that contains areas of calcifications and intratumoral hemorrhage on CT scan in a young female is virtually diagnostic of an SPPN. A particular dot-like intracytoplasmic expression of CD99 appears to be highly unique for SPPN CONCLUSION DPPHR should be considered in cases of SPPN in the pancreas head if there is no compromise with oncologic radicality.

Impact of Model for End-Stage Liver Disease in the occurrence of infectious events and survival in a cohort of liver transplant recipients.

The Model for End-Stage Liver Disease (MELD), which predicts mortality on the waiting list before liver transplantation, has changed organ allocation criteria to prioritize severely ill patients. The aim of this study was to investigate the impact of the new criteria on the incidence of Healthcare Associated Infections (HAI) and patient survival after liver transplantation. This retrospective cohort included liver transplant recipients from 2005 to 2007. Infection notification followed the recommended criteria of the National Healthcare Safety Network (NHSN). Statistical analysis was performed using the Statistical Package for the Social Sciences. Of 142 patients, 67 (47.2%) underwent transplantation before June 2006. There were no differences between the 2 periods considering patient gender, diagnosis, age, length of hospitalization, and mean time to first infection occurrence. However, the length of intensive care unit (ICU) hospitalization (P = .006) and central venous catheter (CVC) use (P = .025) were higher in the first period of the study. Comparison of time until first systemic infection before and after changes in allocation criteria showed no significant difference (log-rank = 0.06; P = .81). There was a trend toward greater lethality during the second period of the study (P = .09). There was no difference in time to death between the 2 periods (log-rank = 0.9; P = .76). However, when comparing time to death of all patients with systemic infection versus those without this event, patients without infection showed a higher mortality rate (log-rank = 15.7; P < .001).