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Hang Cheng,1 Jeffrey W Clymer,1 Rana A Qadeer,2 Nicole Ferko,2 Behnam Sadeghirad,2 Chris G Cameron,2 Joseph F Amaral1 1Ethicon Inc, Cincinnati, OH, USA; 2Cornerstone Research Group, Burlington, ON, Canada Background: As compared to conventional techniques, recent meta-analyses have reported cost savings with Harmonic devices; however, only in thyroidectomy. Thus, the aim of this study was to evaluate the costs associated with Harmonic devices versus conventional techniques across a range of surgical procedures. Methods: A systematic search of MEDLINE, EMBASE, and Cochrane Library was conducted from inception to October 01, 2016 without language restrictions to identify randomized controlled trials comparing Harmonic devices to conventional techniques and reporting procedure costs (operating time plus operating equipment/consumables/device costs). Costs were pooled using the ratio of geometric means, and a random effects model was applied. Sensitivity analyses varying statistical methods, number of included studies, and cost outcomes were completed to test the robustness of the results. Results: Thirteen studies met the inclusion criteria. A total of 561 and 540 participants had procedures performed with Harmonic devices and conventional methods, respectively, with procedures including gastrectomy, thyroidectomy, colectomy, cholecystectomy, Nissen fundoplication, and pancreaticoduodenectomy. As compared to conventional methods, Harmonic devices reduced total procedure costs by 8.7% (p=0.029), resulting in an absolute reduction of US$227.77 from mean conventional technique costs, derived primarily from a reduction in operating time costs. When operating time costs, excluding operating equipment/consumables/device costs, were analyzed, costs were reduced by $544 per procedure with the use of Harmonic devices. The results from all sensitivity analyses demonstrated cost reductions with Harmonic devices. Conclusion: This systematic review and meta-analysis showed that despite a higher device cost, Harmonic devices provide a statistically significant reduction in procedure costs, derived primarily from a reduction in operating time costs, across surgical procedures. In addition to functionality benefits, Harmonic devices may represent a potentially cost saving method to reduce overall hospital resource use. Future research should focus on potential costs and benefits from use of Harmonic devices in procedures not covered here. Keywords: Harmonic, ultrasonic, meta-analysis, costs, surgery, efficiency, operating time

Brian D Bertke,1 Patrick J Scoggins,1 Alissa L Welling,1 Tamara V Widenhouse,1 Chaoyang Chen,2 Srinivasu Kallakuri,2 John M Cavanaugh,2 Jeffrey W Clymer,1 Joseph F Amaral1 1Ethicon, Inc., Cincinnati, OH, USA; 2Spine Research Laboratory, Bioengineering Center, Wayne State University, Detroit, MI, USA Background: A new ultrasonic device, Harmonic Focus®+, has been developed that is smaller and delivers energy more efficiently than its predecessor via the inclusion of Adaptive Tissue Technology. This study was undertaken to compare its dissection capabilities to an advanced bipolar electrosurgery device in benchtop and preclinical evaluations. Methods: In ex vivo testing, Focus+ and LigaSure™ Small Jaw were evaluated for physical dimensions, device and tissue temperature after repeated applications to porcine jejunum, and burst pressure of vessel seals, transection time, and tissue sticking in 3–5 mm porcine carotid arteries. In in vivo testing, the devices were tested on intact porcine carotid arteries for thermal damage via collagen denaturation and in muscle incisions near rat sciatic nerve for acute inflammation via hematoxylin and eosin and for impaired axonal transport via β-APP. Results: Focus+ was smaller than the Small Jaw in width and height, yet it had a longer active blade and larger jaw aperture. Device temperatures were not different after application, but thermal spread (tissue temperature above 50°C) was 78% greater for Small Jaw (9.6 mm) than for Focus+ (5.4 mm). Burst pressures of sealed vessels were not significantly different between the devices: 900 (±466) mmHg for Focus+ versus 974 (±500) mmHg for Small Jaw. Small Jaw had a shorter individual transection time (5.0 seconds compared to 6.3 seconds for Focus+), whereas Focus+ had 70% less tissue sticking. Thermal damage, neural inflammation, and impaired axonal transport were all significantly lower for Focus+ compared to Small Jaw, by 19%, 57%, and 50%, respectively. Conclusion: With the addition of Adaptive Tissue Technology, Harmonic Focus+ builds upon the manifold advantages of ultrasonic devices in procedures requiring meticulous dissecting capability. Improvements in energy sensing and controlled delivery produce lower tissue temperatures and less thermal damage, especially critical when working near nerves. Focus+ produces vessel seal strengths equivalent to advanced bipolar devices and, although individual device activations are longer, the reduction in tissue sticking is expected to materially lessen operative time in clinical practice. Keywords: Harmonic, Focus, precision, vessel sealing, thyroidectomy, dissection

Richard W Timm, Ryan M Asher, Karalyn R Tellio, Alissa L Welling, Jeffrey W Clymer, Joseph F Amaral Ethicon Inc., Cincinnati, OH, USA Introduction: Ultrasonic energy is a mainstay in the armamentarium of surgeons, providing multifunctionality, precision, and control when dissecting and sealing vessels up to 5 mm in diameter. Historically, the inability to seal vessels in the 5–7 mm range has been perceived as an inherent limitation of ultrasonic technology. The purpose of this study was to evaluate sealing of vessels up to 7 mm in diameter with an ultrasonic device that modulates energy delivery during the sealing period. Methods: In ex vivo benchtop and in vivo acute and survival preclinical models, a new ultrasonic device, Harmonic ACE®+7 Shears (Harmonic 7), was compared with advanced bipolar devices in sealing vessels 1–7 mm in diameter with respect of burst pressure, seal reliability, and seal durability. Lateral thermal damage and transection time were also evaluated. Results: Ex vivo tests of Harmonic 7 demonstrated significantly greater median burst pressures than an advanced bipolar device both for vessels

Introduction: Background: açaí is the fruit of the palm tree Euterpe oleracea Martius, which is native to the Amazon region. This fruit has been extensively studied due to its potential effects on human health. Studies have also evaluated the potential effect of açaí on the inflammatory response, but there are still few studies that have assessed this property in humans. Objective: in this study we aimed to evaluate the effects of 200 g of açaí pulp consumption per day during four weeks on a rich panel of inflammatory biomarkers. Methods: a prospective nutritional intervention study was conducted on forty apparently healthy women who consumed 200 g of açaí pulp per day for four weeks. A panel of serum inflammatory markers were evaluated before and after the nutritional intervention, namely, cell adhesion molecules (ICAM-1, IVAM-1, P-selectin, MCP-1, and fractalkine), interleukins (IL-1β, IL-6, IL-8, IL-10, and IL-17) and adipokines (adiponectin, leptin, visfatin, and adipsin). The data were analyzed using paired Student's t-test to evaluate the effect of the intervention using PASW Statistics, version 17.0, and a p-value of < 0.05 was considered significant. Results: four weeks of açaí pulp consumption decreased p-selectin, leptin, and visfatin concentrations in the serum of the participating women. Conclusion: these results show that consumption of açaí pulp was able to modulate important biomarkers of the inflammatory process in apparently healthy women.

Purpose: Percutaneous ablation techniques, including microwave ablation (MWA) and radiofrequency ablation (RFA), have become important minimally invasive treatment options for liver cancer. This systematic review compared MWA with RFA for treatment of liver cancer., Methods: The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was conducted for randomized and observational studies published from 2006 onwards. A random-effects model was used for meta-analyses and local tumor progression (LTP), technique efficacy, overall survival (OS), disease-free survival (DFS), intrahepatic de novo lesions (IDL), extrahepatic metastases (EHM), length of stay (LOS), and complications were analyzed. Subgroup and sensitivity analyses were also conducted., Results: Of 1379 studies identified, 28 randomized and observational studies met inclusion criteria. The main analysis demonstrated that LTP was significantly reduced by 30% with MWA versus RFA (RR=0.70; P=0.02) (all studies) and by 45% with MWA versus RFA (RR=0.55; P=0.007) (randomized studies only). There were no significant differences between MWA and RFA for other efficacy and safety outcomes. Higher frequency (2450 MHz) and larger tumor size (≥2.5 cm) are amongst variables that may be associated with improved outcomes for MWA. Sensitivity analyses were generally congruent with the main results., Conclusion: MWA is at least as safe and effective as RFA for treating liver cancer and demonstrated significantly reduced LTP rates. Future studies should assess time and costs associated with these two treatment modalities., Competing Interests: SG, JWC, MBG, and JFA are employees of Ethicon, Inc. (manufacturer of Neuwave microwave ablation instrumentation). RAQ, NCF, BS, and GWJW are employees of Cornerstone Research Group, who were sponsored to perform this study by Ethicon, Inc. MBG reports stocks and stock options from Johnson & Johnson during the conduct of the study. The authors report no other conflicts of interest in this work.

Background: Hepatic resection (HR) is the gold standard liver cancer treatment, but few patients are eligible due to comorbidities or tumor location. Microwave ablation (MWA) is an important complementary liver cancer treatment to HR. This systematic review compared MWA with HR for liver cancer treatment., Methods: A systematic search of MEDLINE, EMBASE, and CENTRAL was conducted for randomized and observational studies published from 2006 onwards. The primary outcome was local tumor recurrence (LTR), and a random effects model was used for meta-analyses., Results: Of the 1845 studies identified, 1 randomized and 15 observational studies met the inclusion criteria. LTR was significantly increased with MWA versus HR (risk ratio (RR) = 2.49; P = 0.016). In secondary measures, HR provided significantly higher 3- and 5-year overall survival (RR = 0.94; P = 0.03 and RR = 0.88; P = 0.01, respectively) and 3-year disease-free survival (RR = 0.78; P = 0.009). MWA exhibited significantly shorter length of stay (weighted mean difference (WMD) = - 6.16 days; P < 0.001) and operative time (WMD = - 58.69 min; P < 0.001), less intraoperative blood loss (WMD = - 189.09 mL; P = 0.006), and fewer complications than HR (RR = 0.31; P < 0.001). When MWA was combined with HR and compared with either modality alone, complications and blood loss were significantly lower with the combination treatment; however, there were no differences in other outcomes. Subgroup and sensitivity analyses were generally aligned with the main results., Conclusions: MWA can be an effective and safe alternative to HR in patients/tumors that are not amenable to resection. More randomized and economic studies should be performed that compare the two treatments, especially to determine the target population that benefits most from MWA.

Dietary supplementation with conjugated linoleic acid (CLA) has been proposed for weight management and to prevent gut inflammation. However, some animal studies suggest that supplementation with CLA leads to the development of nonalcoholic fatty liver disease. The aims of this study were to test the efficiency of CLA in preventing dextran sulfate sodium (DSS)-induced colitis, to analyze the effects of CLA in the liver function, and to access putative liver alterations upon CLA supplementation during colitis. So, C57BL/6 mice were supplemented for 3 weeks with either control diet (AIN-G) or 1% CLA-supplemented diet. CLA content in the diet and in the liver of mice fed CLA containing diet were accessed by gas chromatography. On the first day of the third week of dietary treatment, mice received ad libitum a 1.5%-2.5% DSS solution for 7 days. Disease activity index score was evaluated; colon and liver samples were stained by hematoxylin and eosin for histopathology analysis and lamina propria cells were extracted to access the profile of innate cell infiltrate. Metabolic alterations before and after colitis induction were accessed by an open calorimetric circuit. Serum glucose, cholesterol, triglycerides and alanine aminotransaminase were measured; the content of fat in liver and feces was also accessed. CLA prevented weight loss, histopathologic and macroscopic signs of colitis, and inflammatory infiltration. Mice fed CLA-supplemented without colitis induction diet developed steatosis, which was prevented in mice with colitis probably due to the higher lipid consumption as energy during gut inflammation. This result suggests that CLA is safe for use during gut inflammation but not at steady-state conditions., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: In the present study we investigated gender-specific associations of low birth weight (LBW) and shorter relative leg length with metabolic syndrome (MetS) after adjusting for sociodemographic characteristics and health-related behaviours. We also investigated whether these associations are independent of age at menarche and BMI at 20 years old., Design: Cross-sectional analysis., Subjects: Baseline data from 12 602 participants (35-74 years) of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), 2008-2010., Setting: MetS was defined according to the revised National Cholesterol Education Program Adult Treatment Panel III guidelines. LBW (<2·5 kg) and age- and sex-standardized relative leg length (high, medium and low) were the explanatory variables studied. The strength of the associations between the explanatory variables and MetS was estimated by Poisson regression with robust variance., Results: MetS prevalence was 34·2 %; it was more prevalent in men (36·8 %) than in women (32·2 %). In multivariate analysis, LBW was associated (prevalence ratio; 95 % CI) with MetS only in women (1·28; 1·24, 1·45). Shorter leg length was associated with MetS in both men (1·21; 1·09, 1·35 and 1·46; 1·29, 1·65 for low and medium lengths, respectively) and women (1·12; 1·00, 1·25 and 1·40; 1·22, 1·59 for low and medium lengths, respectively). Additional adjustments for age at menarche and BMI at 20 years old did not change the associations., Conclusions: Poor nutritional status as estimated by LBW and lower leg length in childhood was associated with a higher prevalence of MetS, although LBW was a significant factor only among women.

Background: Individuals with a family history of systemic arterial hypertension (FHSAH) and / or prehypertension have a higher risk of developing this pathology., Objective: To evaluate the autonomic and vascular functions of prehypertensive patients with FHSAH., Methods: Twenty-five young volunteers with FHSAH, 14 normotensive and 11 prehypertensive subjects were submitted to vascular function evaluation by forearm vascular conductance(VC) during resting and reactive hyperemia (Hokanson®) and cardiac and peripheral autonomic modulation, quantified, respectively, by spectral analysis of heart rate (ECG) and systolic blood pressure (SBP) (FinometerPRO®). The transfer function analysis was used to measure the gain and response time of baroreflex. The statistical significance adopted was p ≤ 0.05., Results: Pre-hypertensive individuals, in relation to normotensive individuals, have higher VC both at rest (3.48 ± 1.26 vs. 2.67 ± 0.72 units, p = 0.05) and peak reactive hyperemia (25, 02 ± 8.18 vs. 18.66 ± 6.07 units, p = 0.04). The indices of cardiac autonomic modulation were similar between the groups. However, in the peripheral autonomic modulation, greater variability was observed in prehypertensive patients compared to normotensive individuals (9.4 [4.9-12.7] vs. 18.3 [14.8-26.7] mmHg2; p < 0.01) and higher spectral components of very low (6.9 [2.0-11.1] vs. 13.5 [10.7-22.4] mmHg2, p = 0.01) and low frequencies (1.7 [1.0-3.0] vs. 3.0 [2.0-4.0] mmHg2, p = 0.04) of SBP. Additionally, we observed a lower gain of baroreflex control in prehypertensive patients compared to normotensive patients (12.16 ± 4.18 vs. 18.23 ± 7.11 ms/mmHg, p = 0.03), but similar delay time (-1.55 ± 0.66 vs. -1.58 ± 0.72 s, p = 0.90)., Conclusion: Prehypertensive patients with FHSAH have autonomic dysfunction and increased vascular conductance when compared to normotensive patients with the same risk factor.

Background: We performed an umbrella review of systematic reviews summarizing the evidence on the Harmonic scalpel (HS) compared with conventional techniques in surgical oncology (including lymph node dissection)., Methods: We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from inception to end of March of 2017 for meta-analyses or systematic reviews of randomized trials comparing HS to conventional techniques in surgical oncology. We assessed the quality of included systematic reviews with AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and assessed the certainty in evidence for each pooled outcome using GRADE (Grading of Recommendations Assessment, Development, and Evaluation)., Results: We identified ten systematic reviews on breast cancer (n = 3), gastric cancers (n = 3), oral, head, and neck cancers (n = 1), and colon cancers (n = 3). Most reviews received a higher rating using AMSTAR. For operative time, systematic reviews reported a reduction of 25 to 29 min for HS compared with conventional methods across oncology types, with the exception of breast cancer where little differences were observed (very low to moderate quality of evidence (GRADE)). For blood loss and drainage volume, the majority of reviews reported statistically significant reductions with HS, and reductions ranged from 42 to 141 mL, and from 42 to 292 mL, respectively (very low to moderate quality of evidence). Hospitalization days were reported to decrease with use of HS by 0.2 to 3.2 days; however, reductions were only statistically significant for half of the included reviews (low to moderate quality of evidence). Regarding perioperative complications, two of six reviews reported a significantly reduced risk with HS use (breast cancer surgery) (moderate to high quality evidence))., Conclusion: Across surgical oncology types, the majority of included systematic reviews showed a statistically significant or numerical improvement in surgical outcomes with use of the HS compared with conventional methods. Well-designed randomized studies with large sample sizes will help to provide more precise estimates and reduce the risk of heterogeneity.

Background:: A family history of hypertension is associated with vascular and autonomic abnormalities, as well as an impaired neurohemodynamic response to exercise., Objective:: To test the hypothesis that normotensive individuals with a family history of hypertension present an impaired peripheral vascular resistance response to exercise., Methods:: The study included 37 normotensive volunteers of both sexes who were sedentary, eutrophic, and nonsmokers, comprising 23 with (FH+; 24 ± 3 years) and 14 without (FH-; 27 ± 5 years) a family history of hypertension. Blood pressure, heart rate (DIXTAL®), forearm blood flow (Hokanson®), and peripheral vascular resistance were simultaneously measured for 3 minutes during rest and, subsequently, for 3 minutes during an isometric exercise at 30% of maximal voluntary contraction (Jamar®)., Results:: At rest, the FH+ and FH- groups present similar mean blood pressure (83 ± 7 versus 83 ± 5 mmHg, p = 0.96), heart rate (69 ± 8 bpm versus 66 ± 7 bpm, p = 0.18), forearm blood flow (3 ± 1 mL/min/100 mL versus 2.7 ± 1 mL/min/100 mL, p = 0.16), and peripheral vascular resistance (30 ± 9 units versus 34±9 units, p = 0.21), respectively. Both groups showed a significant and similar increase in mean blood pressure (∆ = 15 ± 7 mmHg versus 14 ± 7 mmHg, p = 0.86), heart rate (∆ = 12 ± 8 bpm versus 13 ± 7 bpm, p = 0.86), and forearm blood flow (∆ = 0.8 ± 1.2 mL/min/100 mL versus 1.4 ± 1.1 mL/min/100 mL, p = 0.25), respectively, during exercise. However, individuals in the FH+ group showed no reduction in peripheral vascular resistance during exercise, which was observed in the FH- group (∆ = -0.4 ± 8.6 units versus -7.2 ± 6.3 units, p = 0.03)., Conclusion:: Normotensive individuals with a family history of hypertension present an impaired peripheral vascular resistance response to exercise., Fundamento:: O histórico familiar para hipertensão arterial está relacionado a anormalidades vasculares e autonômicas, bem como disfunções no comportamento neuro-hemodinâmico durante o exercício físico., Objetivo:: Testar a hipótese de que indivíduos normotensos com histórico familiar de hipertensão arterial apresentam resposta prejudicada da resistência vascular periférica durante o exercício físico., Métodos:: Foram avaliados 37 normotensos de ambos os sexos, sedentários, eutróficos e não tabagistas, sendo 23 com histórico familiar positivo (HF+, 24 ± 3 anos) e 14 com histórico familiar negativo (HF-, 27 ± 5 anos) para hipertensão arterial. Foram identificados pressão arterial, frequência cardíaca (DIXTAL®), fluxo sanguíneo muscular do antebraço e resistência vascular periférica local (Hokanson®) por 3 minutos durante o repouso e, em seguida, 3 minutos durante exercício isométrico de preensão palmar a 30% da contração voluntária máxima (Jamar®)., Resultados:: Em repouso, os grupos HF+ e HF- apresentaram valores semelhantes de pressão arterial média (83 ± 7 mmHg versus 83 ± 5 mmHg, p = 0,96), frequência cardíaca (69 ± 8 bpm versus 66 ± 7 bpm, p = 0,18), fluxo sanguíneo muscular (3 ± 1 mL/min/199 mL versus 2,7 ± 1 mL/min/100 mL, p = 0,16) e resistência vascular periférica (30 ± 9 unidades versus 34 ± 9 unidades, p = 0,21), respectivamente. Durante o exercício, HF+ e HF- mostraram aumento significativo e semelhante da pressão arterial média (∆ = 15 ± 7 mmHg versus 14 ± 7 mmHg, p = 0,86), frequência cardíaca (∆ = 12 ± 8 bpm versus 13 ± 7 bpm, p = 0,86) e fluxo sanguíneo muscular (∆ = 0,8 ± 1,2 mL/min/100 mL versus 1,4 ± 1,1 mL/min/100 mL, p = 0,25), respectivamente. Entretanto, no grupo HF+ não houve redução significativa da resistência vascular periférica durante o exercício, fato que ocorreu no grupo HF- (∆ = -0,4 ± 8,6 unidades versus -7,2 ± 6,3 unidades, p = 0,03)., Conclusão:: Indivíduos normotensos com histórico familiar de hipertensão arterial apresentam resposta prejudicada da resistência vascular periférica durante o exercício físico.

Competing Interests: Conflito de interesse: Os autores declararam não haver conflitos de interesse que precisam ser informados.

Advances in patient care often germinate from keen clinical insights and a needs-based approach to innovation. Although there is an important role for incremental improvements to existing solutions, transformational innovation is what truly drives real shifts in clinical outcomes and subsequently patient satisfaction, market access, and economic value. A good example of this is the evolution of the coronary stent market. The best innovation programs are focused on unmet needs rather than solutions, call for a careful articulation of the specific problems to be solved, involve a deep dive within a clinical area, and seek to prioritize research and development investments into areas where the greatest impact can be expected. To enhance its ability to pursue breakthrough innovation, Johnson and Johnson (J&J) has organized itself along priority disease areas, created the global J&J Innovation organization to pursue external technology and know-how, and continues to partner closely with clinical practitioners. The process undertaken at J&J to acquire a microwave ablation technology and enter the interventional oncology space is a recent case study of these innovation principles and organizational focus in action., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The aim of this study was to screen physic nut (Jatropha curcas) genotypes that differ in their phosphorous (P) use, using mixed models. The experiment was conducted in a greenhouse located in the experimental area of the Centro de Ciências Agrárias of the Universidade Federal do Espírito Santo, in Alegre, ES, Brazil. The experiment was arranged in a randomized block design, using a 10 x 3-factorial scheme, including ten physic nut genotypes and two environments that differed in their levels of soil P availability (10 and 60 mg/dm 3 ), each with four replications. After 100 days of cultivation, we evaluated the plant height, stem diameter, root volume, root dry matter, aerial part dry matter, total dry matter, as well as the efficiency of absorption, and use. The parameters were estimated for combined selection while considering the studied parameters: stability and adaptability for both environments were obtained using the harmonic mean of the relative performance of the predicted genotypic values. High genotype by environment interactions were observed for most physic nut traits, indicating considerable influences of P availability on the phenotypic value. The genotype Paraíso simultaneously presented high adaptability and stability for aerial part dry matter, total dry matter, and P translocation efficiency. The genotype CNPAE-C2 showed a positive response to P fertilization by increasing both the total and aerial part dry matter., Competing Interests: The authors declare no conflict of interest.

Objectives: Harmonic devices have become a world-wide standard for dissection and hemostasis in thyroidectomy. Numerous systematic reviews have reported superior operating times, blood loss, post-operative pain, length of stay, and overall safety outcomes. What has not been extensively evaluated in a robust manner is their economic impact. The purpose of this study is to evaluate the hospital costs associated with open thyroidectomy using Harmonic devices compared with conventional techniques for hemostasis., Methods: A systematic review of Medline, Scopus, and CENTRAL was performed from January 1, 2000 to May 23, 2014 without language restrictions for randomized clinical trials comparing Harmonic surgical devices to conventional methods in thyroidectomy. The main outcome measure was total reported costs. Costs were pooled using the ratio of means and a random effects model. Sensitivity analyses assessed whether differences in patient and trial characteristics, healthcare setting, or choice of statistical model affected outcomes., Results: Seven studies met the inclusion criteria. A total of 476 participants had procedures performed with Harmonic devices and 478 with conventional monopolar electrosurgery and clamp, cut and tie techniques. Compared with conventional techniques, Harmonic devices reduced total reported costs by 10% (p = 0.007), resulting in a $229 US dollars (USD) absolute reduction from mean baseline costs. Results remained relatively robust to additional sensitivity analyses., Conclusions: This systematic review and meta-analysis demonstrates that the Harmonic family of surgical devices is associated with a reduction in total reported costs in thyroidectomy compared with conventional techniques. A large portion of the overall savings derives from a reduction in operative costs.

Objectives: The aim of the present study was to evaluate the effect of açai pulp (Euterpe oleracea Martius) intake on the prevention of oxidative damage by measuring the activity of antioxidant enzymes and biomarkers of protein oxidation in women., Methods: A nutritional intervention study was conducted with thirty-five healthy women who were asked to consume 200 g/d of açai pulp for 4 wk. Blood samples were collected, and blood pressure and anthropometric parameters were measured before and after the experimental period. Antioxidant enzymes, superoxide dismutase, catalase, glutathione, production of reactive oxygen species, and total antioxidant capacity were evaluated in polymorphonuclear cells. Serum concentration of protein carbonyl and sulfhydryl groups were also determined., Results: The açai intake increased catalase activity, total antioxidant capacity, and reduced the production of reactive oxygen species. Furthermore, it reduced serum concentration of protein carbonyl and increased total serum sulfhydryl groups., Conclusions: These results show the antioxidant benefit of dietary açai for the healthy women included in the present study, and may increase understanding of the beneficial health properties of this fruit., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The present study was developed to respond to the need for an increase in crop yield in the mountain region of Caparaó (southern Espírito Santo State, Brazil), an area of traditional coffee production. This study aimed to analyze the diversity and characterize the crop yield of genotypes of Coffea arabica L. with potential for cultivation in high plant density systems. In addition, it also aimed to quantify the expression of agronomic traits in this cultivation system and provide information on the genotypes with the highest cultivation potential in the studied region. The experiment followed a randomized block design with 16 genotypes, four repetitions, and six plants per experimental plot. Plant spacing was 2.00 x 0.60 m, with a total of 8333 plants per hectare, representing a high-density cultivation system. Coffee plants were cultivated until the start of their reproductive phenological cycles and were evaluated along four complete reproductive cycles. Genotypes with high crop yield and beverage quality, short canopy, and rust resistance were selected. C. arabica genotypes showed variability in almost all characteristics. It was possible to identify different responses among genotypes grown in a high plant density cultivation system. Although the chlorophyll a content was similar among genotypes, the genotypes Acauã, Araponga MG1, Sacramento MG1, Tupi, and Catuaí IAC 44 showed a higher chlorophyll b content than the other genotypes. Among these, Sacramento MG1 also showed high leafiness and growth of vegetative structures, whereas Araponga MG1, Pau-Brasil MG1, and Tupi showed high fruit production. In addition, Araponga MG1 had also a higher and more stable crop yield over the years.

Introduction: Several meta-analyses have been performed comparing the use of a variety of ultrasonic devices in thyroidectomy to conventional procedures. These studies have shown the superiority of ultrasonic devices for most outcomes studied including faster operative time and less blood loss, and equivalent or better safety for recurrent laryngeal nerve paresis and hypocalcemia. The current work is the first to examine a single ultrasonic device specifically designed for thyroid surgery, the Harmonic Focus, in order to confirm its efficacy and safety in thyroidectomy., Methods: A comprehensive literature search without language restrictions was performed for randomized clinical trials comparing Harmonic Focus and conventional clamp, cut and tie in thyroidectomy. Outcome measures included operating time, blood loss, post-operative pain, length of hospital stay, hypocalcemia and recurrent laryngeal nerve paresis. Risk of bias was analyzed for all studies. Meta-analysis was performed using random effects models with the inverse-variance method for mean differences of continuous variables and the Mantel-Haenszel method for risk ratios of dichotomous variables., Results: A total of 14 studies met the inclusion criteria. Harmonic Focus reduced operative time by 29 min, a 31 % decrease (p < 0.001), intra-operative blood loss by 45 ml (p < 0.001), post-operative pain (p < 0.001), length of hospital stay by 0.68 days (p = 0.005), drainage volume by 29 ml (p = 0.01), and occurrence of transient hypocalcemia by 40 % (p = 0.001). There were no significant differences between Harmonic Focus and conventional procedures in rate of persistent hypocalcemia, or rates of transient and persistent recurrent laryngeal nerve paresis., Conclusion: This is the first meta-analysis of Harmonic Focus in thyroid surgery. In agreement with meta-analyses previously performed on ultrasonic devices, use of the Harmonic Focus has been shown to be a more effective surgical procedure compared to conventional methods in thyroidectomy. The low occurrence of hypocalcemia and recurrent laryngeal nerve paresis confirms that Harmonic Focus can improve thyroidectomy efficiency without increasing the risk of complications.

The expansion of agriculture to new areas in order to increase the competitiveness of coffee producing countries has resulted in cultivation expanding into regions with lower natural fertility. This scenario has created the need to differentiate genotypes of Conilon coffee based on their tolerance to low levels of nutrients in the soil, especially phosphorus, which imposes high limitations on crop yield in tropical regions. In this context, the objective of this study was to identify differential tolerance among genotypes of Conilon coffee cultivated in environments with different levels of phosphorus availability in the soil. The experiment was conducted in a controlled environment, following a completely randomized design, with three replications in a factorial scheme 13 x 3, the factors were as follows: 13 genotypes of Conilon coffee from groups of different ripening cycles and three environments with different levels of phosphorus availability in the soil (fertilization without phosphorus supply, and phosphorus supply at 50 and 100% of recommendations). Discrimination of tolerance was based on 14 variables, including vegetative growth, accumulation of dry matter, nutrient content, and nutritional efficiencies. Estimates of genetic parameters indicated high genotypic variability for genotypes cultivated in environments with low phosphorus availability in the soil. It was possible to classify genotypes 22, 23, 24, 67, 76, 77, and 83 as tolerant of a low availability of phosphorus in the soil during early development. There was no clear relationship between ripening cycles and the tolerance of the genotypes to low phosphorus availability in the soil.

The aim of the present study was to investigate the effect of a protein-free diet in the induction of food allergy and oral tolerance in BALB/c mice. The experimental model used was mice that were fed, since weaning up to adulthood, a balanced diet in which all dietary proteins were replaced by amino acid diet (Aa). The absence of dietary proteins did not prevent the development of food allergy to ovalbumin (OVA) in these mice. However, Aa-fed mice produced lower levels of IgE, secretory IgA and cytokines. In addition, when compared with mice from control group, Aa-fed mice had a milder aversive reaction to the allergen measured by consumption of OVA-containing solution and weight loss during food allergy development. In addition, mice that did not have dietary proteins in their diets were less susceptible to induction of oral tolerance. One single oral administration was not enough to suppress specific serum Ig and IgG1 levels in the Aa-fed group, although it was efficient to induce suppression in the control group. The present results indicate that the stimulation by dietary proteins alters both inflammatory reactivity and regulatory immune reactivity in mice probably due to their effect in the maturation of the immune system.

Background: Aging is a multifactorial process that leads to changes in the quantity and quality of skeletal muscle and contributes to decreased levels of muscle strength., Objective: This study sought to investigate whether the isometric muscle strength, fat-free mass (FFM) and power of the electromyographic (EMG) signal of the upper and lower limbs of women are similarly affected by aging., Method: The sample consisted of 63 women, who were subdivided into three groups (young (YO) n=33, 24.7 ± 3.5 years; middle age (MA) n=15, 58.6 ± 4.2 years; and older adults (OA). n=15, 72.0 ± 4.2 years). Isometric strength was recorded simultaneously with the capture of the electrical activity of the flexor muscles of the fingers and the vastus lateralis during handgrip and knee extension tests, respectively. FFM was assessed using dual-energy X-ray absorptiometry., Results: The handgrip strength measurements were similar among groups (p=0.523), whereas the FFM of the upper limbs was lower in group OA compared to group YO (p=0.108). The RMSn values of the hand flexors were similar among groups (p=0.754). However, the strength of the knee extensors, the FFM of the lower limbs and the RMSn values of the vastus lateralis were lower in groups MA (p=0.014, p=0.006 and p=0.013, respectively) and OA (p=0.000, p=0.000 and p<0.000, respectively) compared to group YO., Conclusions: The results of this study demonstrate that changes in isometric muscle strength in MLG and electromyographic activity of the lower limbs are more pronounced with the aging process of the upper limb.

Dehydrodieugenol, known as bis-eugenol, is a eugenol ortho dimer, and both compounds were able to exhibit anti-inflammatory and antioxidant activities in previous studies. Furthermore, eugenol showed antidepressant-like effect; however, the biological actions of bis-eugenol on experimental models for screening antidepressant activity are still unknown. The present study investigated a possible antidepressant-like activity of bis-eugenol in the forced swimming test (FST) and tail suspension test (TST) in mice and the involvement in the monoaminergic system in this effect. In addition, a neurochemical analysis on brain monoamines of mice acutely treated with bis-eugenol was also conducted. Bis-eugenol decreased the immobility time in the FST and TST without accompanying changes in ambulation in the open field test at 10 mg/kg, i.p.. Nevertheless, it induced ambulation at 25 and 50 mg/kg doses. The anti-immobility effect of bis-eugenol (10 and 50 mg/kg, i.p.) was prevented by pretreatment of mice with p-chlorophenylalanine (PCPA, 100 mg/kg, i.p., an inhibitor of serotonin synthesis, for four consecutive days), yohimbine (1 mg/kg, i.p., an α2-adrenoceptor antagonist), SCH23390 (15 μg/kg, s.c., a dopamine D1 receptor antagonist) and sulpiride (50 mg/kg, i.p., a dopamine D2 receptor antagonist). Monoamines analysis using high-performance liquid chromatograph revealed significant increase in the 5-HT, NE and DA levels in brain striatum. The present study indicates that bis-eugenol possesses antidepressant-like activity in FST and TST by altering dopaminergic, serotonergic and noradrenergic systems function., (© 2012 The Authors Fundamental and Clinical Pharmacology © 2012 Société Française de Pharmacologie et de Thérapeutique.)

Vessel sealing devices effectively produce hemostatic seals with minimal thermal damage, but the strength of seals decreases as vessel diameter increases. Because vessels sealed at an angle to the vessel require a greater functional seal diameter than those sealed perpendicularly to the vessel, it was hypothesized that perpendicular seals would have comparably higher burst pressures. Ex vivo, porcine carotid arteries of nominal diameters of 5, 6, and 7 mm were sealed perpendicularly to and at a 45° angle to the longitudinal axis of the vessels, and burst pressures of the sealed vessels were measured. Overall burst pressures were 51% greater for perpendicular seals than for angled seals (P<.001). Mean burst pressures for the 5-mm angled and 7-mm perpendicular groups, which have similar seal lengths, were not significantly different (P=.959). Analysis using the functional diameter as a covariate indicated that the seal length is the primary variable in determining burst pressure, and not some other inherent characteristic of angled versus perpendicular sealing. These results suggest that at least for vessels ≥5 mm in diameter, surgeons should approach vessels perpendicularly and not at an angle, for the highest possible seal strength. The development of articulated sealing and cutting devices would provide greater seal strength, in addition to improved maneuverability, especially in laparoscopic surgery, where angles of approach may be limited by the fixed location of surface cannulas.

Background: Given the variety of available hand-held dynamometers and their different handle shapes, reliability studies are needed., Objectives: To compare the accuracy and reliability between three different hand-held dynamometers and analyze the influence of their handles on grip strength., Methods: The tests were performed with the Jamar® dynamometer, the Takei® dynamometer and the EMG System Manual Transducer with modified handle. Eighteen healthy volunteers aged 20.0±1.3 years without history of musculoskeletal disorders or trauma in the evaluated limbs were included. Data normality was tested using the Shapiro-Wilk test. To verify possible differences between the dynamometers, repeated measures ANOVA was administered, followed by Tukey post-hoc tests. Reliability between measurements was evaluated using intraclass correlation coefficient (ICC) and agreement was tested using Bland and Altman plots. The dynamometers calibration process was evaluated using linear regressions., Results: We observed statistically significant differences on the female group between the Jamar® and the Takei® dynamometers (females p<0.001 and males p=0.022) and the EMG System Manual Transducer (female p<0.001 and males p=0.007). However, the Takei® dymamometer and the EMG System Manual Transducer were similar for both female (p=0.161) and male groups (p=0.850). Although acceptable values of intraclass correlation coefficients between measurements were identified, low agreement between the Jamar® dynamometer and all other instruments was found., Conclusions: The results demonstrated that there is an influence of the dynamometer's handle shapes on the measurements of grip strength. Furthermore, the results demonstrated the need for previous calibration of this type of instrument.

The immature immune system requires constant stimulation by foreign antigens during the early stages of life to develop properly and to create efficient immune responses against later infections. We have previously shown that intake of antigenic dietary protein is critical for inducing maturation of the immune system as well as for the development of T helper type 1 (Th1) immunity. In this study, we show that administration of an amino acid (aa)-based diet during the development of the immune system subsequently resulted in inefficient control of Leishmania major infection in adult C57BL/6 mice. Compared with mice fed a control protein-containing diet, adult aa-fed mice showed a decreased interferon (IFN)-gamma response to parasite antigens and insufficient production of nitric oxide (NO), which is crucial to parasite death. However, no deviation towards Th2-specific immunity to L. major was observed. Phenotypic analysis of antigen-presenting cells (APCs) from aa-fed mice revealed deficient levels of the costimulatory molecules CD40 and CD80, and low levels of interleukin (IL)-12 produced by peritoneal macrophages, revealing an early stage of maturation of these cells. APCs isolated from aa-fed mice were unable to stimulate a Th1 response in vitro. Both phenotypic features of T cells from aa-fed mice and their ability to produce a Th1 response in the presence of mature APCs were unaffected when compared with T cells from control mice. The results presented here support the notion that regulation of Th1 immunity to infection includes environmental factors such as dietary proteins, which provide a natural source of stimulation that contributes to the process of maturation of APCs.

The present study examined the antinociceptive effects of (O-methyl) N-benzoyl-tyramine (riparin I, ripI) isolated from the unripe fruit of Aniba riparia in chemical and thermal behavioral models of pain, such as acetic acid-induced abdominal writhing, formalin, and hot-plate tests in mice. Moreover, the involvement of the nitric oxide pathway as well as the opioid system in the antinociceptive action of ripI in the formalin test was investigated. RipI was administered both orally and intraperitoneally to male mice at single doses of 25 and 50 mg/kg. In the acetic acid-induced abdominal writhing, ripI decreased the number of writhings at both doses. In addition, in the formalin test, ripI reduced the paw licking time at both phases of the test. The effect of the highest dose of ripI in mice formalin test on the early phase was not reversed by naloxone (opioid receptor antagonist) but it was reversed by l-arginine (a nitric oxide precursor) in the late phase, suggesting that ripI may not act through opioid system and possibly acts through inhibition of nitric oxide pathway. In the hot-plate test, ripI increased the reaction time in the hot-plate test at the dose of 25 mg/kg, i.p., confirming the result found in the formalin test. Based on the obtained results, it is suggested that ripI presents antinociceptive activity that may be due to peripheral mechanisms (nitric oxide pathway) and central mechanisms, discarding the involvement of opioid system.

Background and Objectives: Amniotic fluid embolism is a rare occurrence; it has a sudden onset and high morbidity. The objective of this report was to present a case of amniotic fluid embolism in a primipara undergoing analgesia for vaginal delivery. CASE REPORT This is a 38-year old pregnant woman with amniotic sac ruptured, cervix with 5-cm dilation, complaining of severe pain; the patient was agitated, diaphoretic, and with tachysystoly. After venipuncture, Ringer's lactate with 5 IU of oxytocin was infused slowly, blood pressure (BP) 110 x 70 mmHg, heart rate (HR) 115 bpm with sinus rhythm, and SpO2 98%. It was decided to use a combined technique: 2.5 mg of heavy bupivacaine and 20 microg of fentanyl were administered in the subarachnoid space and a catheter was inserted into the epidural space. Twenty minutes after the institution of analgesia, the patient complained of sudden onset of severe pruritus, she was agitated, with nausea and vomiting, pale, HR 160 bpm, tachypneic, SpO2 80%, and BP could not be detected. Normal saline (500 mL) associated with hydrocortisone, ephedrine (50 mg), and oxygen with a face mask at 10 L.min(-1) were administered. At that moment, she presented BP 60 x 30 mmHg, HR 150 bpm, and SpO2 92%. Since BP tended to decrease, a total of 7 mg of metaraminol were administered divided in several doses. After vaginal delivety the patient was transferred to the ICU with BP90 x 60 mmHg, HR 110, and tachypnea. Two hours later, she developed bleeding and hypotension; disseminated intravascular coagulation (DIC) was diagnosed and the patient treated with crystalloid solutions, packed red blood cells and fresh frozen plasma. She was discharged from the ICU in the 3rd postoperative day (PO)., Conclusions: Due to the dramatic presentation, severity, and fast installation of the symptoms, the speed and objectivity of the measures instituted to maintain vital signs are fundamental and decisive for survival of pregnant patients. We alert for the importance of monitoring during labor analgesia.

Isopulegol is a monoterpene alcohol intermediate in the preparation of (-)-menthol and it is present in the essential oils of various plants. This work presents behavioral effects of isopulegol in animal models of open field, elevated plus maze (EPM), rota rod, hole board, barbiturate-induced sleeping time, tail suspension and forced swimming tests in mice. Isopulegol was administered intraperitoneally to male mice at single doses of 25 and 50 mg/kg, while diazepam 1 or 2 mg/kg and imipramine 10 or 30 mg/kg were used as standard drugs. The results showed that, similar to diazepam (1 mg/kg), both doses of isopulegol significantly modified all the observed parameters in the EPM test, without alter the general motor activity in the open field test. In the same way, both doses of isopulegol increased the number of head dips in the hole-board test. Forced swimming and tail suspension tests showed that isopulegol (25 and 50 mg/kg) was able to induce a significant increase in the immobility time, in opposite to imipramine, a recognized antidepressant drug. There was a decrease in the sleep latency time and prolongation of the pentobarbital-induced sleeping time with both doses of Isopulegol. Different from diazepam (2 mg/kg), isopulegol (25 e 50 mg/kg) had no effect on the motor coordination of animals in the rota rod test. These results showed that isopulegol presented depressant- and anxiolytic-like effects.

Purpose: The implementation of vendor-based integrated clinical information technology was studied, and its effect on medication errors throughout the medication-use process in a health care system was evaluated., Methods: The integrated systems selected for implementation included computerized physician order entry, pharmacy and laboratory information systems, clinical decision-support systems (CDSSs), electronic drug dispensing systems (EDDSs), and a bar-code point-of-care medication administration system. The primary endpoint was the reduction in related medication errors. Secondary endpoints included the reductions in medication order turnaround time and EDDS override transactions., Results: Integrated clinical information system technology was implemented in a multihospital health care system with a phased-in approach. A positive effect of this integration on medication errors throughout the medication-use process was demonstrated. Most prescribing errors decreased significantly in the selected categories monitored, specifically drug allergy detection, excessive dosing, and incomplete or unclear orders. Pharmacists were also twice as likely to identify dosages requiring adjustment for renal insufficiency when the integrated technology was in place and more than six times as likely for drug levels outside of the therapeutic range. A positive effect on medication administration safety was also demonstrated: 73 administration-related errors were intercepted through electronic bar-code scanning for every 100,000 doses charted., Conclusion: Integration of clinical information system technology decreased selected types of medication errors throughout the medication-use process in a health care system and improved therapeutic drug monitoring in patients with renal insufficiency and in patients receiving drugs with narrow therapeutic ranges through the use of CDSS alerts.

In the present study were studied the antinociceptives properties of monoterpene R-(+)-limonene (LM) in chemical and thermal models of nociception in mice. The R-(+)-limonene was administered, intraperitoneally (i.p.), at doses of 25 and 50 mg/kg. The results showed significant inhibition produced on chemical nociception induced by intraperitoneal acetic-acid and in the second phase of subplantar formalin test, but did not manifest a significant effect in hot-plate test. The R-(+)-limonene-induced antinociception in second phase of formalin test was insensitive to naloxone (1 mg/kg, s.c.). It was also demonstrated that R-(+)-limonene (25, 50 mg/kg) neither significantly enhanced the pentobarbital-sleeping time nor impaired the motor performance in rota-rod test, indicating that the observed antinociception is unlikely to be due to sedation or motor abnormality. In conclusion it may be suggested that the R-(+)-limonene presented antinociceptive activity and that, probably, this action can be related with peripheral analgesia, but, not with the stimulation of opioids receptors.

Most contacts with food protein and microbiota antigens occur at the level of the gut mucosa. In animal models where this natural stimulation is absent, such as germ-free and antigen-free mice, the gut-associated lymphoid tissue (GALT) and systemic immunological activities are underdeveloped. We have shown that food proteins play a critical role in the full development of the immune system. C57BL/6 mice weaned to a diet in which intact proteins are replaced by equivalent amounts of amino acids (Aa diet) have a poorly developed GALT as well as low levels of serum immunoglobulins (total Ig, IgG, and IgA, but not IgM). In the present study, we evaluated whether the introduction of a protein-containing diet in 10 adult Aa-fed C57BL/6 mice could restore their immunoglobulin levels and whether this recovery was dependent on the amount of dietary protein. After the introduction of a casein-containing diet, Aa-fed mice presented a fast recovery (after 7 days) of secretory IgA (from 0.33 to 0.75 mg/mL, while in casein-fed mice this value was 0.81 mg/mL) and serum immunoglobulin levels (from 5.39 to 10.25 mg/mL of total Ig). Five percent dietary casein was enough to promote the restoration of secretory IgA and serum immunoglobulin levels to a normal range after 30 days feeding casein diet (as in casein-fed mice--15% by weight of diet). These data suggest that the defect detected in the immunoglobulin levels was a reversible result of the absence of food proteins as an antigenic stimulus. They also indicate that the deleterious consequences of malnutrition at an early age for some immune functions may be restored by therapeutic intervention later in life.

Background and Objectives: Dextran associated with 7.5% sodium chloride has positive hemodynamic effects in the long term control of hemorrhagic shock. The objective of this study was to verify whether the association of dextran with 7.5% chloride solution would be advantageous in the immediate hemodynamic evaluation of controlled hemorrhagic shock in dogs., Methods: This study included 16 dogs submitted to controlled hemorrhage until their mean arterial blood pressure reached 40 mmHg, being maintained at this level for 30 minutes. They were divided in two groups: G1 received 7.5% NaCl and G2 received 7.5% NaCl in 6% dextran 70; in both groups, 4 mL.kg-1 of the solutions were administered for three minutes. Hemodynamic and metabolic parameters were evaluated in four different phases: M1 - 10 minutes after preparation for surgery, M2 - obtained in the middle of the shock phase. M3 - two minutes after the administration of the IV solutions, M4 - 30 minutes after the beginning of the resuscitation., Results: After the resuscitation, there were no significant differences in HR, MAP, PCP, and SVRI. G2 presented the highest CI values in M4. G1 showed the smaller SvO2 values at the end of the experiment; and the C(a-v)O2 was higher in M3 and M4. For both groups, VO2 values increased in M4, and lactate plasma values increased progressively until M3, decreasing in M4. Both groups also presented increased Na plasma values and decreased hematocrit., Conclusions: G2 showed the best hemodynamic performance, especially 30 minutes after the beginning of resuscitation. Plasma expansion and tissue perfusion were also better with 7.5% NaCl in dextran.

Several new approaches have been developed to perform donor nephrectomy. These include laparoscopic donor nephrectomy and open donor nephrectomy performed through small incisions, herein referred to as "mini-open donor nephrectomy". In the past, we performed open donor nephrectomy via a standard flank incision. In October 2002, we introduced mini-open donor nephrectomy via an anterior, retroperitoneal approach. Contemporaneously, we offered the option of laparoscopic donor nephrectomy. Herein, we review our single-center experience with these three techniques. Mini-open donor nephrectomy was comparable to the laparoscopic approach for duration of narcotic requirement and donor length of stay. The laparoscopic procedure was more expensive. Both procedures demonstrated improvement over the flank approach by eliminating the risk of pneumothorax, neuropathy, and flank bulge. In addition, length of stay and narcotic requirements were higher with the flank approach. Mini-open donor nephrectomy provides a good alternative to laparoscopic surgery, offering the donor an equivalent convalescence at lower cost and potentially with reduced morbidity., (Copyright 2004 Elsevier Inc.)

Background and Objectives: Different experimental models have been used to illustrate hemodynamic and metabolic changes during hemorrhagic shock. This study aimed at observing hemodynamic and metabolic behaviors during a sequential and progressive model of hemorrhagic shock in dogs to determine which indices are earlier changed., Methods: The study involved 13 dogs under total intravenous anesthesia with sodium pentobarbital, standard ventilation and previously splenectomized. Animals were not hydrated and bleeding velocity was dictated by animals blood pressure. Evaluated parameters were: hemodynamic (heart rate - HR, mean blood pressure - MBP, systemic vascular resistance index - SVRI, stroke index - SI, cardiac index - CI, shock index - i.Shock, left ventricular stroke work index - LVSWI, pulmonary capillary pressure - PCP, central venous pressure - CVP); and metabolic (mixed venous saturation - SvO2, venous oxygen pressure - PvO2, oxygen transport - O2T, oxygen consumption - VO2, oxygen extraction - TEO2, serum lactate). Results and parameters were evaluated in 6 different moments: M1 - control, and the other moments corresponding to gradual 10% decrease in calculated volume for each animal., Results: Hemorrhage has determined significant heart rate decrease in M6 only; MBP, CI, i.Shock, LVSWI decrease in all studied moments; mild CVP and PCP change in all moments; PVO2 and SVO2 decrease in all moments; O2T decrease, VO2 stabilization and TEO2 increase in all moments; shock index was increased from M1 to M3, was decreased in M4 and again increased until M6; SVRI was increased from M1 to M4, remained unchanged in M5 and has significantly decreased in M6; lactate has increased as from M5 and M6., Conclusions: Mean blood pressure, heart rate, central venous pressure and pulmonary capillary pressure have not reflected real volume status of dogs in our experimental model, oxygen transport, consumption and extraction rate are useful parameters to determine hemorrhagic shock reversibility and prognosis.

Endoscopic adrenalectomy, since its initial description in 1992 by Gagner et al. in Canada and by Higashaihara in Japan has emerged as the standard of care in the treatment of patients with benign adrenal neoplasms. It has been shown to be as effective as open surgery in treating adrenal pathology, with improvements in pain, cosmesis and duration of hospitalization.

Although experience with laparoscopic approaches to common duct stones is increasing, endoscopic retrograde cholangiopancreatography (ERCP) performed either before or after laparoscopic cholecystectomy (LC) remains the most common approach. Debate remains as to the best timing for ERCP in patients with suspected choledocholithiasis. Because clinical, laboratory, and radiological data are poor predictors of choledocholithiasis, many ERCPs done before LC give negative results. ERCP performed after LC with a positive intraoperative cholangiogram (i.o.p.) would eliminate many unnecessary preoperative endoscopic studies. This is a retrospective analysis of the treatment of choledocholithiasis with the combination of LC and ERCP. All patients included could have had ERCP preoperatively or postoperatively; therefore, those with cholangitis requiring emergent preoperative ERCP were excluded. Two groups of patients were compared: those who underwent ERCP followed by LC and those who underwent LC and IOC followed by ERCP. No significant differences were found with respect to age, gender, health status, clinical presentation, laboratory values (most liver functions, white blood cell count, hemoglobin, and serum amylase), surgery time, blood loss, ERCP time, time between treatment modalities, and days to regular diet. However, the preoperative ERCP group was found to have a longer hospital stay (6.7 days vs. 3.5 days, p = 0.003) and higher hospital cost ($9,406.39 vs. $12,816.23, p = 0.05). The preoperative ERCP group had two patients requiring two ERCPs to clear the common duct, one patient requiring conversion to open procedure because of failed LC, and four minor complications. The postoperative ERCP group had no failed LC, IOC, or postoperative ERCPs and one minor complication. The rate of false positive IOC was 6.7% and of negative preoperative ERCP, 43%. We conclude that in the absence of cholangitis requiring emergent endoscopic decompression, suspected choledocholithiasis can be successfully managed first with LC, ERCP being reserved for patients with a positive IOC. This eliminates many negative preoperative ERCPs.

Background: Since first reported in 1992, laparoscopic adrenalectomy has been used to remove a wide variety of adrenal neoplasms. Indications for use of this technique have not been clearly defined, nor has it been demonstrated to be more cost effective than open adrenalectomy., Methods: A retrospective comparison was made of 19 consecutive laparoscopic and open adrenalectomies performed in patients with benign adrenal neoplasms in a tertiary-care university teaching hospital over a 3-year period., Results: The two groups were well matched for side of tumor and age. Laparoscopic adrenalectomy was completed in 11 of 12 patients in whom it was attempted. The laparoscopic group had significantly smaller tumor size; shorter operative time, postoperative ileus, and postoperative stay; and decreased operative blood loss and postoperative narcotic requirement. There were no significant differences between groups for operating room or hospital charges., Conclusions: Laparoscopic adrenalectomy is cost effective and should be the preferred treatment for patients with small benign adrenal neoplasms.

Splenic epidermoid cysts are rare lesions traditionally treated by splenectomy. Concerns about overwhelming postsplenectomy sepsis have led to the development of splenic preservation procedures in the treatment of cystic diseases of the spleen. We present the first case report of successful laparoscopic complete excision of a splenic epidermoid cyst.

Gastroesophageal reflux disease (GERD) is the most common foregut disorder, with 7% of Americans experiencing heartburn daily. Symptoms of GERD are many and varied, including heartburn, chest pain, regurgitation, dysphagia, nocturnal aspiration, morning hoarseness, chronic cough, and wheezing. Fifty percent of symptomatic patients develop esophagitis, while 20% of patients with esophagitis develop complications, including ulceration, stricture, Barrett's esophagus, and aspiration pneumorritis.

Although thoracoabdominal injuries are uncommon in the athlete, they can be catastrophic if unrecognized or if diagnosis and treatment are delayed. This article reviews thoracic, intrathoracic, abdominal, and groin injuries in the athlete, and how they can be diagnosed and managed.

This report describes the use of laparoscopic accessory splenectomy in treating recurrent idiopathic thrombocytopenic purpura (ITP). The patient presented 36 months after initial splenectomy with a platelet count of 16,000 cells/microl and nontolerance of medical therapy. A technetium-99 labeled, heat-damaged red blood cell scan revealed two small foci in the upper left quadrant. This finding was confirmed by an abdominal computed tomography scan. After laparoscopic accessory splenectomy, the patient was discharged (23 h after surgery) and at 9 months showed a platelet count of 234,000 cells/microl with no medical therapy. A minimally invasive approach to accessory spleen removal can be beneficial to patients with recurrent ITP and documented accessory splenic tissue.

Ultrasonic energy is now available as a hemostatic tool to aid dissection during surgery. A new device, the Laparosonic Coagulating Shears (LCS-Ethicon/Ultracision, N. Smithfield, RI), has been developed to allow hemostatic coagulation and division of tissue. We describe the mechanism of action and its effects in the porcine model. In addition, we compare this modality with conventional electrosurgery.

The use of laparotomy and splenectomy for staging purposes in patients with Hodgkin's disease (HD) gained popularity in the early 1970s. Accurate staging and more effective treatment regimens, including combined chemotherapy and irradiation, have resulted in improved patient survival rates. Similarly, an increased number of late complications have been reported, including the development of thyroid disease, second malignancies, and septic complications related to splenectomy. Partial splenectomy has been proposed as one method of preventing overwhelming postsplenectomy sepsis. The authors present a case of recurrence of HD, which occurred in the splenic remnant 13 years after the initial treatment. This case demonstrates that the spleen is a potential for recurrent intraabdominal Hodgkin's disease after partial splenectomy; thus, the use of partial splenectomy for HD should be discouraged.

An experimental protocol was developed to determine the safety and feasibility of retroperitoneoscopic adrenalectomy in the porcine model. We describe the technique and our experience with this exciting new endoscopic surgical modality.

Ultrasonic energy has not been previously used for surgical cutting and coagulating. Work in our laboratory has led to the development of an ultrasonically activated scalpel that safely and effectively cuts and coagulates tissue in animals. The purpose of this study was to determine if ultrasonic energy can replace monopolar electrosurgery in human laparoscopic surgery. Two hundred consecutive patients underwent laparoscopic cholecystectomy with the ultrasonically activated scalpel. The scalpel was the sole energy form in 98 of the first 100 patients, and in all of the last 100 patients. There were no common duct injuries, reoperations, or mortality. No patient had more than a 3-g drop in hemoglobin or transfusion. The ultrasonically activated scalpel is a safe and effective energy form for cutting and coagulating tissue during laparoscopic cholecystectomy in humans. The absence of need of monopolar electrosurgery combined with hemostatic effectiveness supports the concept that the ultrasonically activated scalpel can replace electrosurgery for laparoscopic cholecystectomy.