Search

Anaemia is frequently diagnosed during pregnancy. However, there are few data regarding its incidence, and the association with severe maternal morbidity remains uncertain and potentially biased in high-resource countries. The purpose of this study was to explore the association between gestational anaemia and severe acute maternal morbidity during and after delivery. We performed a cohort-nested case-control analysis from the epidemiology of severe maternal mortality (EPIMOMS) prospective study conducted in six French regions (2012-2013, n = 182,309 deliveries). There were 1669 women with severe acute maternal morbidity during or after delivery, according to a standardised definition obtained by expert consensus. The control group were randomly selected among women without severe morbidity who delivered in the same health centres (n = 3234). We studied the association between gestational anaemia and severe acute maternal morbidity during or after delivery overall, by cause, and by mode of delivery, using multivariable logistic regression and multiple imputation. Gestational anaemia was significantly more frequent in women with severe acute maternal morbidity (25.3%) than in controls (16.3%), p < 0.001, and mostly mild in both groups. After adjustment for confounders, women with gestational anaemia were at increased risk of overall severe acute maternal morbidity during and after delivery (adjusted OR (95%CI) 1.8 (1.5-2.1)). This association was also found for severe postpartum haemorrhage (adjusted OR (95%CI) 1.7 (1.5-2.0)), even after omitting the transfusion criterion (adjusted OR (95%CI) 1.9 (1.6-2.3)), and for severe acute maternal morbidity secondary to causes other than haemorrhage or pregnancy-related hypertensive disorders (adjusted OR (95%CI) 2.7 (1.9-4.0)). These results highlight the importance of optimising the diagnosis and management of anaemia during pregnancy.

Although liver transplantation is a widely accepted treatment for hepatocellular carcinoma (HCC), much controversy remains and there is no generally accepted set of guidelines. An international consensus conference was held on Dec 2–4, 2010, in Zurich, Switzerland, with the aim of reviewing current practice regarding liver transplantation in patients with HCC and to develop internationally accepted statements and guidelines. The format of the conference was based on the Danish model. 19 working groups of experts prepared evidence-based reviews according to the Oxford classification, and drafted recommendations answering 19 specific questions. An independent jury of nine members was appointed to review these submissions and make final recommendations, after debates with the experts and audience at the conference. This report presents the final 37 statements and recommendations, covering assessment of candidates for liver transplantation, criteria for listing in cirrhotic and non-cirrhotic patients, role of tumour downstaging, management of patients on the waiting list, role of living donation, and post-transplant management.

Item does not contain fulltext

Nota: Trabalho da Disciplina de Cirurgia Vascular do Departamento de Clínica Cirúrgica da FMUSP. Neste número especial com artigos publicados na Revista de Medicina em 1969, traz um comentário dos Drs. Fernando Luiz Torres Gomes, José Humberto Pucci de Mesquita Filho, Carlos Serrano Jr. (Departamento de Cardiologia da FMUSP).

Several lines of evidence indicate a causal role of the cytokine interleukin (IL)-6 in the development of type 2 diabetes in humans. Two common polymorphisms in the promoter of the IL-6 encoding gene IL6, -174GC (rs1800795) and -573GC (rs1800796), have been investigated for association with type 2 diabetes in numerous studies but with results that have been largely equivocal. To clarify the relationship between the two IL6 variants and type 2 diabetes, we analyzed individual data on20,000 participants from 21 published and unpublished studies. Collected data represent eight different countries, making this the largest association analysis for type 2 diabetes reported to date. The GC and CC genotypes of IL6 -174GC were associated with a decreased risk of type 2 diabetes (odds ratio 0.91, P = 0.037), corresponding to a risk modification of nearly 9%. No evidence for association was found between IL6 -573GC and type 2 diabetes. The observed association of the IL6 -174 C-allele with a reduced risk of type 2 diabetes provides further evidence for the hypothesis that immune mediators are causally related to type 2 diabetes; however, because the association is borderline significant, additional data are still needed to confirm this finding.

This article is to evaluate the results of surgical treatment of aorto-femoral graft infections. The records of 20 patients with aorto-femoral graft infections were reviewed. The patients were submitted mostly to a combination of surgical procedures. They were: a) conservative treatment; b) partial removal of the infected graft and c) total removal of the infected graft. The removal of the prosthesis, partial or total, was followed by a new arterial reconstruction in some patients. The final treatment was: total removal of the infected graft in 11 (55%) patients, total removal plus arterial reconstruction in six, partial removal in two and partial removal plus arterial reconstruction in one. The results of treatment were presented as the survival rate and the effective palliation (patient alive, lower limbs preserved and infection cured). The survival rates after one month, 12, 24, 36 and 48 months were respectively: 80%, 60%, 53%, 42% and 27%. The effective palliation rates after one month and after 48 months were respectively 50% and 27%. The highest effective palliation rate was obtained when the infected prosthesis was removed and a new arterial reconstruction performed. We conclude that the treatment of choice of aorto-femoral graft infections seems to be the total removal of the graft followed by new arterial reconstruction.

Integrated data analysis and equilibrium reconstruction on a millisecond time base are used to gain edge profiles with high spatial and temporal resolution. The measured radial electric field profiles for a series of discharges with different gas fuelling levels show their minimum at the position of maximal ratio of pressure gradient and density (?p/n). The analysis of electron density and temperature profiles in between edge localized modes (ELMs) reveals a characteristic sequence of phases, starting with a fast recovery phase, a quiet pressure build-up phase and a strongly fluctuating phase before the next ELM breaks out. These phases are described in terms of profile development, the behaviour of maximal gradients as well as their positions.

The survival of patients who have cancers of the gastrointestinal tract is poor even after surgical resection of all gross disease. In an initial consecutive series of patients with metastatic or recurrent cancers, an attempt to improve survival with combined nonspecific immunostimulation by the intraperitoneal administration of BCG followed by oral BCG cycled with chemotherapy was studied. The results suggested that a population of patients with gastric and colonic cancers showed improved survival with this treatment. A randomized trial of combined chemoimmunotherapy versus chemotherapy alone was begun on November 1, 1974, for all cancers of the stomach and pancreas and all colorectal cancers beyond stage C by Dukes' classification. The initial results with patients entered by December 31, 1975, and followed until March 1, 1976, are reported.

Biopsy specimens of the skin were taken from 10 patients with acute meningococcemia who exhibited mainly maculopurpuric lesions. The specimens were studied by light, electron, and immunofluorescent microscopy in an attempt to obtain information on the pathogenesis of vascular injury. Light microscopy disclosed a large number of Neisseria meningitidis organisms, both in the endothelial cells and being phagocytized by neutrophils. Vascular injury was characterized (by means of both light and electron microscopy) by endothelial necrosis, thrombosis, and necrosis of other elements of the vascular wall, such as muscle cells and pericytes. Immunoglobulins and complement were also found in the vascular wall in most cases. Hypercoagulability was demonstrated in some patients. These findings suggest that the cutaneous lesions of meningococcemia fulfill most of the gross and histologic criteria of the local Shwartzman reaction, but that immunological factors probably contribute to pathogenesis.

The artificial endocrine pancreas was adapted to assist with the intraoperative localization of an insulin-secreting islet cell adenoma in a 23-year-old patient with a five-month history of hypoglycemic attacks. Glycemia was monitored in continuously withdrawn whole blood, and dextrose was infused to maintain euglycemia by an artificial endocrine pancreas with a closed loop that excluded its usual insulin delivery capability. The dextrose infusion rate was established in accordance with a control algorithm whose parameters were chosen to amplify changes in dextrose delivery rate for small alterations in the measured baseline glucose concentration. The dextrose infusion rate preoperatively was 155 mg. per minute and decreased to 100 mg. per minute with initiation of surgery. An area in the tail of the pancreas suspected of containing the insulinoma was excluded from the circulation by a noncrushing clamp. After 14 minutes the dextrose infusion progressively decreased to 27 mg. per minute reflecting a glycemic rise of 15 mg. per deciliter. These changes were taken to represent a fall in ambient insulin activity. This was subsequently confirmed directly by the demonstration of reduction in immunoreactive insulin and progressive increase in both plasma free fatty acid levels and postoperative glucose intolerance. Exclusion of the insulinoma from the circulation resulted also in a rapid decrease of circulating proinsulin concentration giving an estimated half-life of 25 minutes.

Listeriosis usually manifests at the extremes of age, during pregnancy or among immunocompromised individuals as an acute meningoencephalitis with or without associated septicemia. Localized infections are rare. We investigated the incidence of Listeria monocytogenes cholecystitis using the data of the Listeria reference laboratory of the University of Würzburg/FRG. Out of 467 culture proven L.m-infections in the years 1986 and 1987, two cases were localized infections of the gall bladder. Although studies of the microbiology of gallbladder infections have not demonstrated the recovery of Listeria monocytogenes as a pathogen in acute or chronic cases of cholecystitis, these two cases substantiate the existence of this rare form of listeriosis as an entity and support the theory of the importance of the gastrointestinal tract in the pathogenesis of Listeria infections.

Antibodies are proteins which are produced in vertebrates after stimulation with an antigen. They are specifically directed against the antigen which has caused their production.

To evaluate the feasibility of intrapartum fetal pulse oximetry, the distribution of fetal oxygen saturation values, and the relation with the neonatal outcome in a population with an abnormal fetal heart rate (FHR).A prospective multicenter observational study, from June 1994 to November 1995. Fetal oxygen saturation was continuously recorded using a Nellcor N-400 fetal pulse oximeter in case of abnormal FHR during labor. Simultaneous readings of fetal oxygen saturation and of fetal blood analysis (FBA) were obtained at inclusion and before birth. Feasibility, adverse effects, distribution of fetal oxygen saturation values and relation with neonatal outcome were assessed.74 patients were included. From 172 attempted sensor placements, the procedure was impossible in three cases and fetal oxygen saturation values were obtained in 164 cases (95.3%). Physicians considered sensor placement an easier task than FBA attempt (easy in 87.5% vs 78.9% for FBA, p = 0.03). The mean reliable signal time (+/- SD) was 64.7 +/- 32% during the first stage. There were no serious adverse effects in the study population. The mean fetal oxygen saturation during the first stage of labor was 42.2 +/- 8.0% (10th-90th centile range: 30-53%). Fetal oxygen saturation was significantly correlated with scalp pH (r = 0.29; p = 0.01) but not with neonatal umbilical artery pH or gas values. There was a significant association between a low fetal oxygen saturation (30%) and a poor neonatal condition.The feasibility of fetal pulse oximetry is satisfactory in clinical practice. It is easy to use and provides a fair rate of recorded values, even in a population with suspicion of fetal distress. A low fetal oxygen saturation is significantly associated with an abnormal neonatal outcome.

When a melito-diabetic patient presents trophic infected injury on the limb, it is essential an evaluation of the circulatory conditions for therapeutic procedures orientation. In some circumstances, although arterial pulsation is absent, there is no ischemia of tissues. In these cases, the maintenance treatment, with eventual resection of the necrosed and infected tissues may be adopted. Evolution of 70 diabetic patients with trophic injuries on extremities were submitted to a maintenance treatment. Age of patients varied from 28 to 88 years, with an average of 56.8. The most occurrence was verified in women, with 42 cases. Diabetes non-dependant on insuline (type II) was observed in 64 patients (91.5%), being the remaining 6 patients of type I. Diabetic retinopathy was observed in 14 (20%) of the patients, neuropathy in 22 (31%) and nephropathy in 8 patients (11.4%). All the patients presented arterial pulsation until the popliteal region. They were divided in 2 groups, considering trunk arteries of legs: Group I, pervial legs arteries, composed by 48 patients; Group II, occluded legs arteries, with 22 patients. In what refers to the anatomic local of the injuries, patients were classified in three groups: Group A, formed by 32 patients (45.7%), presenting injuries in one or two toes only, without affecting the metatarsic region; Group B, formed by 16 patients (22.9%), trophic injuries affecting the metatarsic region and Group C, formed by 22 patients (31.4%), injuries affecting the calcaneous region. Injuries in both of the groups were caused by mechanical traumatism. Duration of the injury in the inferior member varied from 7 to 48 days, resulting in a 12 days average. Analyzing pervicacity in trunk arterias and evolution of patients, it may be observed that there has been a significantly better result in those with all the pulses present (81.3% x 45.5%)(p0,05)(Table IV). INTRODUÇÃO: Quando um portador de diabete melito apresenta lesão trófica infectada do membro inferior, é indispensável a avaliação das condições circulatórias a fim de se orientar o procedimento terapêutico. Em determinadas situações, apesar da ausência de batimentos arteriais, não há isquemia tecidual. Nestes casos, o tratamento conservador, com eventual ressecção de tecidos necróticos e infectados pode ser adotado. MATERIAL E MÉTODOS: Foi estudada a evolução de 70 pacientes diabéticos com lesão trófica de extremidade submetidos ao tratamento conservador.A idade dos doentes variou de 28 a 88 anos, com média de 56,8. O sexo mais acometido foi o feminino, em 42 casos. O diabetes não insulino-dependente (tipo II) foi observado em 64 pacientes (91,5%), sendo os outros 6 do tipo I. A retinopatia diabética foi constatada em 14 (20%) pacientes, neuropatia em 22 (31%) e nefropatia em 8 doentes (11,4%). Todos os pacientes apresentavam batimentos arteriais até a região poplítea. Eles foram divididos em 2 grupos com relação as artérias tronculares da perna: Grupo I, Artérias de pernas pérvias, constituído por 48 pacientes; Grupo II, Artérias de pernas ocluídas, constituído por 22 pacientes. Quanto à localização anatômica das lesões, os pacientes foram divididos em três grupos: Grupo A: formado por 32 pacientes (45,7%) com acometimento exclusivo de um ou mais dedos sem atingir a região metatarsiana; Grupo B, formado por 16 pacientes (22,9%) com acometimento tráfico atingindo a região metatársica; Grupo C, formado por 22 pacientes (31,4%) com lesão acometendo a região calcânea. As lesões em ambos os grupos foram causadas por traumatismos mecânicos. O tempo da presença de lesão em membro inferior variou de 7 a 48 dias, com média de 12 dias. RESULTADOS E CONCLUSÃO: Ao ser analisada a perviedade em artérias tronculares e evolução dos pacientes, verifica-se que houve resultado significativamente melhor naqueles com todos os pulsos presentes (81,3% x 45,5%) (p < 0,01). Ao estudarmos o local da lesão associando-o com o prognóstico dos casos, observamos que para feridas em extremidade digital, o resultado é significativamente melhor que nos locais mais proximais (87,5% x 59,1%) (p 0,05) (tabela IV).

To compare the predictive value of intrapartum fetal pulse oximetry to that of fetal blood analysis for an abnormal neonatal outcome in case of abnormal fetal heart rate (FHR).A prospective multicenter observational study, from June 1994 to November 1995. Fetal oxygen saturation was continuously recorded using a Nellcor N-400 fetal pulse oximeter in case of abnormal FHR during labor. Simultaneous readings of fetal oxygen saturation and fetal blood analysis obtained before birth, i.e. either at full dilatation, or before cesarean section when indicated, were compared with the neonatal status. The criteria for an abnormal neonatal outcome were 1) an umbilical arterial blood pHor = 7.15 and 2) a combined variable including: 5 min. Apgar scoreor = 7, umbilical arterial pHor = 7.15, secondary respiratory distress, transfer in a neonatal care unit, or neonatal death.At a 7.20 threshold for fetal scalp pH, and 30% for fetal oxygen saturation (i.e. the tenth centile in the study population), the predictive value of fetal pulse oximetry was similar to that of fetal blood analysis for an arterial umbilical pHor = 7.15, and for an abnormal neonatal outcome (positive predictive value 56% vs 55%, negative predictive value 81% vs 82%, sensitivity 29% vs 35%, and specificity 93% vs 91% respectively). The receiver operating curve showed similar performance of either technique for cut-off valuesor = 7.20 for fetal blood pH andor = 30% for fetal oxygen saturation, whereas fetal pulse oximetry became superior at higher thresholds.The predictive value of intrapartum fetal pulse oximetry can be favorably compared with that of fetal blood analysis. Randomized controlled management trials can now be performed to assess potential clinical benefits of this new tool.

To report the experience in the treatment and long-term follow-up of patients with renovascular hypertension submitted to angioplasty and/or surgical revascularization, and to compare blood pressure and renal function responses to both treatment.One hundred and twenty-four patients diagnosed with renovascular hypertension, divided, according to the etiology, as atherosclerosis (76 patients), fibromuscular dysplasia (32) and arteritis (16), were submitted to isolated or associated treatment of renal revascularization by percutaneous transluminal angioplasty (71 patients) or surgery (84). The patients were followed-up during 2.5 +/- 1.5 years and we evaluate blood pressure response and renal function preservation. In relation to blood pressure control, the patients were considered as cured when normotensives without antihypertensives, improved when normotensives with fewer drugs than previously, and unchanged, when out of these criteria.From 124 patients, 20% were considered cured, 54% improved and 26% unchanged, after a mean follow-up of 2.5 +/- 1.5 years. Patients with atherosclerosis and fibromuscular dysplasia presented a higher rate of care and improvement after surgery. The blood pressure and the number of antihypertensive drugs decreased significantly during the follow-up among patients that cured or improved arterial hypertension, either after angioplasty (190 +/- 26/115 +/- 14 mmHg vs 130 +/- 34/85 +/- 7 mmHg. 2.70 vs 1.60 drugs) or after surgery (194 +/- 17/115 +/- 16 mmHg vs 143 +/- 18 mmHg vs 88 +/- 8 mmHg, 1.88 vs 1.51 drugs). It was also observed a significant decrease of serum creatinine among these patients.Renal revascularization in patients with renovascular hypertension, either by angioplasty or surgery, is beneficial to control blood pressure and to preserve renal function in the majority of patients.

The valence electrons of fullerenes may be regarded as spherical distributions with a finite width of a jellium-like potential giving rise to collective motions of this orange peel electron cloud. They cause strong enhancement of the photoionization cross section, a resonant behavior phenomenon know as plasmon excitations. The number and characteristic features of these excitations will be discussed.