Mortality Predictors After Liver Transplant in the Intensive Care Unit.

BACKGROUND: The goal of this study was to evaluate the predictive factors of mortality in patients after liver transplantation in an intensive care unit from the University Hospital. METHODS: This observational study was conducted by using a database analysis of University Hospital. The sample consisted of patients after liver transplantation registered in the database. The study variables of Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Disease Classification II (APACHE II), Model for End-Stage Liver Disease, and Child-Pugh scores, and the days of hospitalization in intensive care unit, mechanical ventilation time, and reintubation rate, were correlated. Statistical analysis was performed by using the χ2 test or Fisher exact test, the Mann-Whitney test, and logistic regression analysis. RESULTS: Fifty-eight individuals were analyzed. In the death group, the days of hospitalization in the intensive care unit were within 12 ± 14 days, the time of mechanical ventilation was 180 ± 148 hours, the APACHE II value was 17.6 ± 7.3, the Sequential Organ Failure Assessment score was 8.2 ± 2.7, and reintubation was 40%. In the multivariate regression, the predictive indexes of mortality were the mortality given by APACHE II (odds ratio, 1.1; CI, 1.03-1.17; P = .004), mechanical ventilation time (odds ratio, 1.02; CI, 1.01-1.04; P = .001), and reintubation (odds ratio, 9.06; CI, 1.83-44.9; P = .007). An increase of 1 unit in APACHE II mortality increases the risk of death by 10.2%, and each hour of mechanical ventilation increases the risk of death by 2.6%. CONCLUSIONS: The time of mechanical ventilation, orotracheal reintubation, and the mortality given by APACHE II were the variables that best predicted death in this study.

Neurological complications prevalence and long-term survival after liver transplantation.

INTRODUCTION: Neurological postsurgical complications are a significant cause of morbidity and mortality occur in transplant recipients impacting their survival. METHODS: We analyzed the medical records of 269 patients who underwent transplantation between 2000 and 2011, after application of the exclusion criteria Neurological complications were examined according to the period in which they appeared: immediate (1-30 day) early (31-180 days), and late (after 180 days). The survival analysis was based on the first complication. RESULTS: The majority of transplant recipients were males (73.2%) and white (97.1%) with an overall median age of 49 (range, 18-73) years. Regarding the etiology for transplantation, the most common causes were hepatitis C virus (56.5%) and alcohol (33.1%). Complications, appearing in 29.4% (immediate), 31.5% (early), and 39.1% (late) cases, were encephalopathy, confusion, tremors, headache, and stroke. Patients who had the first complication between 1 and 6 months showed greater mortality than those who had one after 6 months. CONCLUSIONS: Neurological complications led to longer hospital stays with greater early morbidity and mortality. Knowledge of these complications appears to be extremely important for the multidisciplinary transplantation team to decrease its prevalence as well as to diagnose and treat early.

A new phlebotomine fossil species Trichopygomyia killickorum sp. n. (Diptera: Psychodidae) found in the Dominican Republic amber.

A description is given of male sandfly found in a piece of amber from Dominican Republic that dates from the Miocene period (20-15 m.y.a). It is assigned to the genus Trichopygomyia Barreto. The position of the spines on the style and the shape of the dorsal lobes of the paramere separate this fly from other species of the genus: it is here named Trichopygomyia killickorum sp. n.

[Technical aspects of intracranial pressure monitoring by subarachnoid method in severe head injury]. / Aspectos técnicos da monitorização da pressão intracraniana pelo método subaracnóideo no traumatismo craniencefálico grave.

Two hundred and six patients with severe head injury (Glasgow Coma Scale of 8 points or less after nonsurgical resuscitation on admission), managed at Intensive Care Unit-Hospital das Clínicas - Universidade Estadual de Campinas were prospectively analysed. All patients were assessed by CT scan and 72 required neurosurgical intervention. All patients were continuously monitored to evaluate intracranial pressure (ICP) levels by a subarachnoid device (11 with subarachnoid metallic bolts and 195 with subarachnoid polyvinyl catheters). The ICP levels were continuously observed in the bedside pressure monitor display and their end-hour values were recorded in a standard chart. The patients were managed according to a standard protocol guided by the ICP levels. There were no intracranial haemorrhagic complications or hematomas due the monitoring method. Sixty six patients were punctured by lateral C1-C2 technique to assess infectious complications and 2 had positive cerebrospinal fluid samples for Acinetobacter sp. The final results measured at hospital discharge showed 75 deaths (36,40%) and 131 (63,60%) survivors. ICP levels had significantly influenced the final results (p<0,001). The subarachnoid method to continuously assess the ICP levels was considered applicable, safe, simple, low cost and useful to advise the management of the patients. The ICP record methodology was practical and useful. Despite the current technical advances the subarachnoid method was considered viable to assess the ICP levels in severe head injury.

[Phlebotomine sand flies in the State of Tocantins, Brazil (Diptera: Psychodidae)]. / Flebotomíneos do Estado de Tocantins, Brasil (Diptera: Psychodidae).

Between 1997-1998, the authors carried out sporadic collection of sand flies in the municipalities of Paraíso de Tocantins, Monte do Carmo, Porto Nacional and Monte Santo all in the Tocantins State of northern Brazil. Human bait was used in Monte Santo and a battery operated light trap in other municipalities. The ecotypes chosen for the traps were in the peridomiciles, inside the houses, in the forest and the orchard. We identified 2,677 sand flies, belonging to 32 species. The most abundant species of sand flies were Lutzomyia whitmani, Lutzomyia longipalpis, Lutzomyia carmelinoi, Lutzomyia evandroi, Lutzomyia longipennis and Lutzomyia antunesi. Collections from the forest showed greater diversity of species, while the largest number of sand flies were caught around the houses. Several species known or suspected to be vectors of Leishmania in other regions of Brazil were captured.

Multiple organ failure in septic patients.

Multiple organ failure (MOF) is the main cause of death in ICUs, especially affecting septic patients. It is strongly related to number of systems with failure, type of system involved, risk factors such as age, previous chronic diseases, delayed or inadequate resuscitation, persistent infection, immune suppression, and others. The prognoses is worse for patients rather than in elective or emergency surgical patients. The objective of this article is to provide data from our university teaching hospital ICU related to the incidence of septic patients, the distribution of MOF, and distribution of failure among each of the organs. The mortality rate, relationship between mortality and age, and mortality and types of organs affected were evaluated. The main bacterial causes of sepsis were also identified. A retrospective evaluation was done of 249 patients admitted to the ICU in a 4 month period during 1999. Fifty four patients had sepsis diagnosed by ACCS/SCCM criteria. There were 37 men and 17 women; 24 medical and 30 post-surgical patients (9 after elective surgery and 21 emergency patients). APACHE II score was calculated on admission and MOF, measured for the first five days, was diagnosed using Marshall and Meakins criteria. The statistical method used was non-parametric Mann-Whitney test, p<0.05 was considered significant. The incidence of sepsis was recorded in 54/249 patients (22%). Thirty of these 54 patients (56%) died. Death occurred in 2 of 11 patients with one organ failure (18%), in 14/27 with 2 or 3 organ failures (52%), and 14/16 with 4 or more organ failures (88%). None of the three patients 15 to 20 years old died, 17/32 (55%) patients age 21-60 years, and >61 years 13/19 (68%), died. There were 23 patients with positive bacterial culture. The most frequent bacteria found were: Pseudomonas aeruginosa (5), multiresistant Acinetobacter baumanii (3), Staphylococcus epidermidis (3), Enterobacter aerogenes (3), Klebsiella pneumoniae (2) and multiresistant Staphylococcus aureus (2). The mean value +/- SD of APACHE II (mortality risk) for survivors was 21 +/- 18 and for non-survivors 42 +/- 26 (p<0.001). We conclude that MOF due to sepsis in an ICU is frequent, with high mortality related to the number of failing organs, age and high APACHE II.

Flebotomíneos do Estado de Tocantins, Brasil (Diptera: Psychodidae) / Phlebotomine sand flies in the State of Tocantins, Brazil (Diptera: Psychodidae)

Between 1997-1998, the authors carried out sporadic collection of sand flies in the municipalities of Paraíso de Tocantins, Monte do Carmo, Porto Nacional and Monte Santo all in the Tocantins State of northern Brazil. Human bait was used in Monte Santo and a battery operated light trap in other municipalities. The ecotypes chosen for the traps were in the peridomiciles, inside the houses, in the forest and the orchard. We identified 2,677 sand flies, belonging to 32 species. The most abundant species of sand flies were Lutzomyia whitmani, Lutzomyia longipalpis, Lutzomyia carmelinoi, Lutzomyia evandroi, Lutzomyia longipennis and Lutzomyia antunesi. Collections from the forest showed greater diversity of species, while the largest number of sand flies were caught around the houses. Several species known or suspected to be vectors of Leishmania in other regions of Brazil were captured.

Nos anos de 1997 e 1998 realizaram-se capturas esporádicas de flebotomíneos nos municípios de Paraíso de Tocantins, Monte do Carmo, Porto Nacional e Monte Santo, todos localizados no estado de Tocantins, região norte do Brasil, com o intuito de conhecer a fauna flebotomínica da região. No município de Monte Santo utilizou-se isca humana e nos demais armadilhas luminosas CDC. Os ecótopos utilizados foram: peridomicílio, intradomicílio, mata e pomar. Foram capturados 2.677 flebotomíneos, pertencentes a 32 espécies. As mais freqüentes foram Lutzomyia whitmani, Lutzomyia longipalpis, Lutzomyia carmelinoi, Lutzomyia evandroi, Lutzomyia longipennis e Lutzomyia antunesi. As capturas na mata apresentaram maior diversidade de espécies, enquanto no peridomicílio houve maior número de exemplares capturados. Foram capturadas neste estado várias espécies vetoras em outras regiões do Brasil.

[Cutaneous leishmaniasis in the Metropolitan Region of Belo Horizonte: clinical, laboratorial, therapeutic and prognosis features (1989-1995)]. / Leishmaniose tegumentar na Região Metropolitana de Belo Horizonte: aspectos clínicos, laboratoriais, terapêuticos e evolutivos (1989-1995).

This study investigated clinical, laboratorial, therapeutic and prognostic aspects of American cutaneous leishmaniasis in Belo Horizonte in 358 patients with cutaneous leishmaniasis (CL) and 25 with mucocutaneous leishmaniasis (MCL). Compared to CL patients, the MCL patients reported longer duration of disease and higher frequency of other diseases, suggesting that debilitation caused by leishmaniasis or other conditions might contribute to activation and/or mucous dissemination of the parasite. The sensitivity of skin test, indirect immunofluorescence reactions and direct detection of parasites was 78.4, 79.3 and 68.3%, respectively. The treatment with meglumine antimoniate presented 100% efficacy, but 59% patients had side-effects. During two years of follow-up, there were 32/318 relapses after successful treatment. Most relapses (31/32) were of CL patients treated with 15 mg Sb5+/kg/day. The negative response to skin test was the only factor associated with a significant threefold increased risk of relapse. Higher dose or longer duration of treatment might improve the prognosis in these patients.

A new sand fly, Lutzomyia campograndensis sp. n. (Diptera: Psychodidae: Phlebotominae) from the State of Mato Grosso do Sul, Brazil.

During studies of the phlebotomine sand fly fauna of Campo Grande, State of Mato Grosso do Sul, Brazil, a new species was captured with CDC light trap and is described here. The new species resembles Lutzomyia lutziana (Costa Lima) and is named Lutzomyia campograndensis sp. n. after the type locality.

Leishmaniose tegumentar na Região Metropolitana de Belo Horizonte: aspectos clínicos, laboratoriais, terapêuticos e evolutivos (1989-1995) / Cutaneous leishmaniasis in the Metropolitan Region of Belo Horizonte: clinical, laboratorial, therapeutic and prognosis features (1989-1995)

This study investigated clinical, laboratorial, therapeutic and prognostic aspects of American cutaneous leishmaniasis in Belo Horizonte in 358 patients with cutaneous leishmaniasis (CL) and 25 with mucocutaneous leishmaniasis (MCL). Compared to CL patients, the MCL patients reported longer duration of disease and higher frequency of other diseases, suggesting that debilitation caused by leishmaniasis or other conditions might contribute to activation and/or mucous dissemination of the parasite. The sensitivity of skin test, indirect immunofluorescence reactions and direct detection of parasites was 78.4, 79.3 and 68.3%, respectively. The treatment with meglumine antimoniate presented 100% efficacy, but 59% patients had side-effects. During two years of follow-up, there were 32/318 relapses after successful treatment. Most relapses (31/32) were of CL patients treated with 15 mg Sb5+/kg/day. The negative response to skin test was the only factor associated with a significant threefold increased risk of relapse. Higher dose or longer duration of treatment might improve the prognosis in these patients.

Foram investigados aspectos clínicos, laboratoriais, terapêuticos e evolutivos da leishmaniose tegumentar americana em Belo Horizonte. O estudo incluiu 358 pacientes com leishmaniose cutânea (LC) e 25 com leishmaniose mucosa (LM). Comparados aos pacientes com LC, aqueles com LM apresentaram maior tempo de doença e relato de outras doenças concomitantes, sugerindo que a debilitação pela leishmaniose e/ou outras doenças podem contribuir para a ativação e/ou disseminação mucosa do parasito. As sensibilidades das reações intradérmica, de imunofluorescência indireta e da pesquisa direta do parasito foram de 78,4, 79,3 e 68,3%, respectivamente. O tratamento com antimoniato de meglumina foi 100% eficaz, com 59% de efeitos colaterais ao longo do tratamento. A recidiva após tratamento ocorreu em 32 (10,1%) dos 318 casos seguidos por até dois anos. A maioria das recidivas (31 dos 32 casos) ocorreu em pacientes com LC tratados com 15mg Sb5+/kg/dia. Na investigação de critérios de cura, a reação intradérmica negativa foi o único fator associado a um risco três vezes maior de recidiva. Um aumento da dose ou do tempo de tratamento talvez melhore o prognóstico nestes pacientes.

Phlebotomine sand flies in the State of Piauí, Brazil (Diptera: Psychodidae: Phlebotominae).

In 1997, 1998 and 1999 we performed several captures in the State of Piauí, in the counties of Barro Duro, Campo Maior, Castelo, Floriano, Picos, São Raimundo Nonato and Teresina. We used CDC light traps inside houses, in a primary forest and in one cave. Seventeen species were collected being Lutzomyia longipalpis, Lutzomyia samueli, Lutzomyia whitmani and Lutzomyia lenti the most captured species. The genus Brumptomyia, L. whitmani, Lutzomyia sordellii, Lutzomyia carmelinoi, Lutzomyia termitophila, Lutzomyia peresi and Lutzomyia quinquefer are reported for first time in Piauí. We call the attention for the presence of L. whitmani and L. longipalpis, important vectors of leishmaniasis in various regions of South America.

Lutzomyia naftalekatzi, a new species of phlebotomine sand fly (Diptera: Psychodidae) from Zona da Mata region, Pernambuco, Brazil.

Lutzomyia naftalekatzi, a new phlebotomine sand fly belonging to the L. aragaoi species group, is described from specimens collected in Zona da Mata region of Pernambuco, Brazil.

[Cerebral hemometabolism: variability in the acute phase of traumatic coma]. / Hemometabolismo cerebral: variações na fase aguda do coma traumático.

OBJECTIVE: to evaluate the interrelationships between cerebral and systemic hemometabolic alterations in patients with severe traumatic brain injury managed according to a standardized therapeutic protocol. DESIGN: prospective, interventional study in patients with traumatic coma. SETTING: a general Intensive Care Unit in a teaching hospital. PATIENTS AND METHODS: twenty-seven patients (21M e 6F), aging 14 - 58 years, with severe acute brain trauma, presenting with three to eight points on the Glasgow Coma Scale, were prospectively evaluated according to a cumulative protocol for the management of acute intracranial hypertension, where intracranial pressure (ICP) and cerebral extraction of oxygen (CEO2) were routinely measured. Hemometabolic interrelationships involving mean arterial pressure (MAP), ICP, arterial carbon dioxide tension (PaCO2), CEO2, cerebral perfusion pressure (CPP) and systemic extraction of oxygen (SEO2) were analyzed. INTERVENTIONS: routine therapeutic procedures. RESULTS: no correlation was found between CEO2 and CPP (r = -0.07; p = 0.41). There was a significant negative correlation between PaCO2 and CEO2 (r = -0.24; p = 0.005) and a positive correlation between SEO2 and CEO2 (r = 0.24; p = 0.01). The mortality rate in this group of patients was 25.9% (7/27). CONCLUSION: 1) CPP and CEO2 are unrelated; 2) CEO2 and PaCO2 are closely related; 3) during optimized hyperventilation, CEO2 and SEO2 are coupled.

Notes on phlebotomine sand flies (Diptera: psychodidae) from Amapá State, North Brazil.

Eighteen species of sand fly were collected from Amapá Sate, Brazil, with Centers for Disease Control light traps during May 1998. Five species (Lutzomyia aragaoi, L. inpai, L. brachipyga, L. inflata, and L. richardwardi) represent new records for the Amapá.

[First record of finding Lutzomyia longipalpis (Lutz & Neiva, 1912) in the urban area of Brazil]. / Primeiro encontro de Lutzomyia longipalpis (Lutz & Neiva, 1912) na área urbana de Campo Grande, MS, Brasil.

This is a report of the first finding of visceral leishmaniasis' vector Lutzomyia longipalpis in the urban area of Campo Grande, State of Mato Grosso do Sul. The importance of this finding regarding the transmission of the disease in this area is discussed.

Description of Lutzomyia bianchigalatiae n. sp. A sand fly within the subgenus Pintomyia Costa Lima 1932 (Diptera; Psychodidae).

A new sand fly species is described based on males collected in Bananal, municipality of Mariana and the female from Sabará city, State of Minas Gerais, Brazil. Taxonomic remarks, geographic distribution and the description of new species are presented. The name Lutzomyia (Pintomyia) bianchigalatiae is in honour of Dr Eunice Aparecida Bianchi Galati, friend and researcher at the Faculdade de Saúde Pública, Universidade de São Paulo.

[Neurogenic pulmonary edema. Report of 2 cases]. / Edema pulmonar neurogênico. Relato de dois casos.

Neurogenic pulmonary edema is a rare and serious complication in patients with head injury. It also may develop after a variety of cerebral insults such as subarachnoid hemorrhage, brain tumors and after epileptic seizures. Thirty six patients with severe head injury and four patients with cerebrovascular insults treated in Intensive Care Unit of HC-UNICAMP from January to September 1995 were evaluated. In this period there were two patients with neurogenic pulmonary edema, one with head injury and other with intracerebral hemorrhage. Diagnosis was made by rapid onset of pulmonary edema, severe hypoxemia, decrease of pulmonary complacence and diffuse pulmonary infiltrations, without previous history of tracheal aspiration or any other risk factor for development of adult respiratory distress syndrome. In the first case, with severe head trauma, neurogenic pulmonary edema was diagnosed at admission one hour after trauma, associated with severe systemic inflammatory reaction, and good outcome in three days. The second case, with hemorrhagic vascular insult, developed neurogenic pulmonary edema the fourth day after drainage of intracerebral hematoma and died.

[From death concepts to brain death diagnostic criteria]. / Dos conceitos de morte aos critérios para o diagnóstico de morte encefálica.

The authors present considerations about death and brain death concepts, as well the legal aspects for its diagnosis in Brazil. They also present the UNICAMP Protocol for the Diagnosis of Brain Death, revised and according with the current law, with standard techniques for the diagnostic exam. They emphasize the importance of a mature ethical position for this frequent and challenging situation.

[A canine survey in a recent focus of cutaneous leishmaniasis in the city of Sabará, the metropolitan area of Belo Horizonte]. / Inquérito canino em foco recente de leishmaniose tegumentar no Município de Sabará, região metropolitana de Belo Horizonte.

In 1992, a dog naturally infected with Leishmania was found in a periurban area of Sabará, state of Minas Gerais, where human cutaneous leishmaniasis had been previously described. The parasite was classified as Leishmania, subgenus Viannia, which L. braziliensis, the main species of parasite present in the southeast Brazil, also belongs. In order to assess the importance of the dog in the transmission cycle of the disease, a canine survey was undertaken. Six hundred thirty-one dogs were examined and the prevalence of seropositive dogs for crude Leishmania amazonensis antigen was 3.2%. The presence of infected people and seropositive dogs either near or in the same house was observed. This fact suggests some transmission in the domiciliary environment, with the dogs being a risk factor for human infection in that periurban area. In the other hand, the low percentage of seropositive dogs points towards a secondary importance of these animals in the transmission of Leishmaniasis in that recent focus of the disease.