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Background: Liver failure patients have traditionally been empirically transfused prior to invasive procedures. Blood transfusion is associated with immunologic and nonimmunologic reactions, increased risk of adverse outcomes and high costs. Scientific evidence supporting empirical transfusion is lacking, and the best approach for blood transfusion prior to invasive procedures in cirrhotic patients has not been established so far. The aim of this study is to compare three transfusion strategies (routine coagulation test-guided - ordinary or restrictive, or thromboelastometry-guided) prior to central venous catheterization in critically ill patients with cirrhosis., Methods/design: Design and setting: a double-blinded, parallel-group, single-center, randomized controlled clinical trial in a tertiary private hospital in São Paulo, Brazil., Inclusion Criteria: adults (aged 18 years or older) admitted to the intensive care unit with cirrhosis and an indication for central venous line insertion. Patients will be randomly assigned to three groups for blood transfusion strategy prior to central venous catheterization: standard coagulation tests-based, thromboelastometry-based, or restrictive. The primary efficacy endpoint will be the proportion of patients transfused with any blood product prior to central venous catheterization. The primary safety endpoint will be the incidence of major bleeding. Secondary endpoints will be the proportion of transfusion of fresh frozen plasma, platelets and cryoprecipitate; infused volume of blood products; hemoglobin and hematocrit before and after the procedure; intensive care unit and hospital length of stay; 28-day and hospital mortality; incidence of minor bleeding; transfusion-related adverse reactions; and cost analysis., Discussion: This study will evaluate three strategies to guide blood transfusion prior to central venous line placement in severely ill patients with cirrhosis. We hypothesized that thromboelastometry-based and/or restrictive protocols are safe and would significantly reduce transfusion of blood products in this population, leading to a reduction in costs and transfusion-related adverse reactions. In this manner, this trial will add evidence in favor of reducing empirical transfusion in severely ill patients with coagulopathy., Trial Registration: ClinicalTrials.gov, identifier: NCT02311985 . Retrospectively registered on 3 December 2014.

The objective of this study was to identify the initial value of blood lactate that best correlates with 28-day mortality in resuscitated septic shock patients. This was a retrospective cohort study including 443 patients admitted to an intensive care unit (ICU) with severe sepsis or septic shock from the emergency department. A receiver-operating characteristic (ROC) curve was drawn to obtain the best cutoff value for initial blood lactate associated with 28-day mortality. Patients were then dichotomized according to the chosen lactate cutoff, and sensitivity, specificity, and positive and negative predictive values were calculated. Baseline blood lactate level more than 2.5 mmol/L showed the largest area under the ROC curve to predict 28-day mortality (ROC area, 0.70; 95% confidence interval [CI], 0.62-0.79), with sensitivity, specificity, and negative predictive value of 67.4%, 61.7%, and 94.2%, respectively. Mortality at 28 days was 16.9% (31/183) in patients with initial lactate more than 2.5 mmol/L and 5.8% (15/260) in patients with initial lactate at most 2.5 mmol/L (relative risk, 2.93; 95% CI, 1.63-5.28; P < 0.001). Initial blood lactate levels more than 2.5 mmol/L (hazard ratio [HR], 2.86; 95% CI, 1.53-5.33; P = 0.001) and Sepsis-related Organ Failure Assessment score at ICU admission (HR, 1.18; 95% CI, 1.09-1.27; P < 0.001) were associated with increased 28-day mortality in the adjusted Cox regression. In this retrospective cohort study, a lactate level more than 2.5 mmol/L was the best threshold to predict 28-day mortality among severe sepsis and septic shock patients. Further prospective studies should address the impact on morbidity and mortality of this threshold as a trigger to resuscitation in this population of critically ill patients., Competing Interests: RRF, LLR, and TDC equally contributed to this work. The authors report no conflicts of interest.

Maintaining water quality within tolerable limits is a basic need of the riverside communities in the Amazon. Using endemic aquatic organisms as biological models is useful for monitoring the environment. In this study, potential cytotoxic and genotoxic damages in Plagioscion squamosissimus (commonly known as silver croaker) from the Marajó Archipelago were evaluated using a flow cytometry assay and a survey of micronuclei (MN) frequency as well as other nuclear abnormalities (NA). P. squamosissimus specimens were collected at four locations in the Marajó Archipelago. Blood samples from these fish were used in the flow cytometry assay and piscine micronucleus test, and the resulting data were analyzed using analysis of variance (ANOVA). We did not observe a difference in the erythrocyte cell cycle distribution among the samples (P=0.9992), which suggests the absence of cytotoxic agent-induced apoptosis. The piscine micronucleus test exhibited differences in the samples from São Sebastião da Boa Vista (SSBV), and those from Anajás produced the highest mutagenicity indices. The MN frequencies were low for all groups, but the groups exhibited significantly different frequencies (P=0.0033). Reniform nuclei, nuclei with extensions, and lobed nuclei were combined and considered NA. The frequency differences for these NA were significant among sampling sites (P <0.0001). This report is the first to use flow cytometry in fish to evaluate cytotoxic agent-induced apoptosis. The micronucleus test results indicate the presence of pollutants that can change the genetic material of the fish studied. We also demonstrate that the Amazonian fish P. squamosissimus is important not only as a comestible species but also as an adequate model for biomonitoring in aquatic environments., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Primary appendectomy is the current standard of care for treating uncomplicated acute appendicitis, but interest in conservative treatment with antibiotics alone has been increasing in recent years. Clinical trials so far have shown controversial results., Methods: A series of meta-analyses were reviewed. Studies comparing surgery versus antibiotics alone for treating uncomplicated acute appendicitis in adults were included. Descriptive statistics and data on treatment effects were retrieved and summarized., Results: The conservative approach has a success rate of around 60 % and is associated with shorter pain duration, reduced analgesic medication, faster resolution of the inflammation process, lower expenses and quicker return to work. On the other hand, medical treatment leads to high (up to 20 %) readmission rates and more often requires surgery. An operative approach is associated with higher treatment success rates (>90 %) and very a low mortality rate., Conclusion: Based on the current body of evidence, the use of antibiotics for primary treatment of uncomplicated acute appendicitis cannot be routinely recommended. Appendectomy remains the gold-standard treatment.

Severe sepsis and septic shock represent a major healthcare challenge. Much of the improvement in mortality associated with septic shock is related to early recognition combined with timely fluid resuscitation and adequate antibiotics administration. The main goals of septic shock resuscitation include intravascular replenishment, maintenance of adequate perfusion pressure and oxygen delivery to tissues. To achieve those goals, fluid responsiveness evaluation and complementary interventions - i.e. vasopressors, inotropes and blood transfusion - may be necessary. This article is a literature review of the available evidence on the initial hemodynamic support of the septic shock patients presenting to the emergency room or to the intensive care unit and the main interventions available to reach those targets, focusing on fluid and vasopressor therapy, blood transfusion and inotrope administration., (Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Severe sepsis and septic shock represent a major healthcare challenge. Much of the improvement in mortality associated with septic shock is related to early recognition combined with timely fluid resuscitation and adequate antibiotics administration. The main goals of septic shock resuscitation include intravascular replenishment, maintenance of adequate perfusion pressure and oxygen delivery to tissues. To achieve those goals, fluid responsiveness evaluation and complementary interventions - i.e. vasopressors, inotropes and blood transfusion - may be necessary. This article is a literature review of the available evidence on the initial hemodynamic support of the septic shock patients presenting to the emergency room or to the intensive care unit and the main interventions available to reach those targets, focusing on fluid and vasopressor therapy, blood transfusion and inotrope administration., (Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

Early resuscitation of septic shock patients reduces the sepsis-related morbidity and mortality. The main goals of septic shock resuscitation include volemic expansion, maintenance of adequate tissue perfusion and oxygen delivery, guided by central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation and arterial lactate levels. An aggressive fluid resuscitation, possibly in association with vasopressors, inotropes and red blood cell concentrate transfusion may be necessary to achieve those hemodynamic goals. Nonetheless, even though fluid administration is one of the most common interventions offered to critically ill patients, the most appropriate type of fluid to be used remains controversial. According to recently published clinical trials, crystalloid solutions seem to be the most appropriate type of fluids for initial resuscitation of septic shock patients. Balanced crystalloids have theoretical advantages over the classic solutions, but there is not enough evidence to indicate it as first-line treatment. Additionally, when large amounts of fluids are necessary to restore the hemodynamic stability, albumin solutions may be a safe and effective alternative. Hydroxyethyl starches solutions must be avoided in septic patients due to the increased risk of acute renal failure, increased need for renal replacement therapy and increased mortality. Our objective was to present a narrative review of the literature regarding the major types of fluids and their main drawbacks in the initial resuscitation of the septic shock patients.

Fever is a nonspecific response to various types of infectious or non-infectious insult and its significance in disease remains an enigma. Our aim was to summarize the current evidence for the use of antipyretic therapy in critically ill patients. We performed systematic review and meta-analysis of publications from 1966 to 2013. The MEDLINE and CENTRAL databases were searched for studies on antipyresis in critically ill patients. The meta-analysis was limited to: randomized controlled trials; adult human critically ill patients; treatment with antipyretics in one arm versus placebo or non-treatment in another arm; and report of mortality data. The outcomes assessed were overall intensive care unit mortality, changes in temperature, intensive care unit length of stay, and hospital length of stay. Three randomized controlled trials, covering 320 participants, were included. Patients treated with antipyretic agents showed similar intensive care unit mortality (risk ratio 0.91, with 95% confidence interval 0.65-1.28) when compared with controls. The only difference observed was a greater decrease in temperature after 24 hours in patients treated with antipyretics (-1.70±0.40 versus - 0.56±0.25ºC; p=0.014). There is no difference in treating or not the fever in critically ill patients.

The study aimed to evaluate the growth and development of institutionalized children from 0-6 years old. It had a descriptive, transversal and quantitative approach, and was held in a shelter from the Bureau of Labor and Social Development of the Government of the State of Ceará, in the months of March and April 2011. The sample comprised 44 children. It the sample prevailed male children (59.1%), aged 24 to 72 months (56.8%) and with time of sheltering more than one year (72.7%). It was found that the children were in the normal range of nutrition; however, 65.9% of children did not achieve at least one of the development milestones proposed by the Ministry of Health. The study suggests a reflection on how children living in shelters are being assisted by the health team, making it necessary follow up their growth and development, in order to intervene on the alterations.

A set of silica-based hybrid material samples was obtained, with different molar fractions of tetraethylorthosilicate and dimethyldimethoxysilane, as inorganic and organic sol-gel precursors, respectively. The hybrid material was used as a matrix to disperse the 2-(4'-amino-2'-hydroxyphenyl)benzothiazole, a fluorophore with large Stokes shift caused by an excited state intramolecular proton transfer phenomena (ESIPT). UV-vis and steady-state fluorescence in the solid state were applied in order to characterize the photophysical behavior of the dye. The set of samples was characterized by infrared spectroscopy, elemental analysis, and N(2) isotherms. The fluorescent pyrene dye was used as a probe for local polarity environment. For the first time, a modulation in the ESIPT fluorescence emission was achieved, being correlated to the methyl organic content of the hybrid matrix. The equilibrium between the conformers in the ground state is affected by changes in the matrix hydrophobicity. The replacement of silanol groups by methyl groups on matrix surface decreases the hydrogen bond capacity with the dye stabilizing the ESIPT conformer, in spite of the normal conformers, which will present a short wavelength emission band.

In the present case, we report the performance of coronary angioplasty with stent implantation in the right coronary artery of a patient with high-risk unstable angina and single coronary artery originating from the right coronary sinus. The anterior descending and circumflex arteries originated separately from the proximal third of the right coronary artery. This is a rare coronary anomaly and few reports of percutaneous coronary intervention are found in the literature. This case illustrates the need for a detailed anatomical assessment of the course of the coronary arteries prior to the performance of a percutaneous transluminal angioplasty, with the purpose of preventing complications.

A unique case is presented of basal cell carcinomas arising in chronic lymphedema of the lower extremity. The lesions were successfully treated with the CO2 laser.