Is the indocyanine green score an accurate predictor of postoperative parathyroid hormone level?

BACKGROUND: Hypoparathyroidism is common after total thyroidectomy, primarily due to inadvertent disruption of the parathyroid gland blood supply during thyroid dissection. Indocyanine green helps determine the degree of vascularization and correlates with parathyroid gland vitality. It is difficult to determine how the indocyanine green score affects postoperative parathyroid hormone levels because all 4 parathyroid glands must be evaluated during surgery. We determined whether there is a correlation between intraoperative indocyanine green score and postoperative serum parathyroid hormone levels. METHODS: We retrospectively studied patients who underwent total thyroidectomy where we could identify all 4 parathyroid glands and establish a global indocyanine green score. Each parathyroid gland was scored from 0 to 2 depending on indocyanine green uptake. The global indocyanine green score was the sum of the individual scores for each gland. The scores were then correlated to parathyroid hormone and calcium levels on days 1 and 10 after surgery. RESULTS: We included 83 patients, 11 of whom presented with postoperative transient hypoparathyroidism; all but one had an indocyanine green score lower than 4 of 8. There was a significant correlation between the global indocyanine green score and postoperative parathyroid hormone level. A global indocyanine green score >3.75 can exclude postoperative hypoparathyroidism with a true negative value of 98%. Indocyanine green angiography is a better diagnostic test to predict a postoperative transient hypoparathyroidism compared with visual perfusion scoring. CONCLUSION: These findings suggest that the indocyanine green score based on intraoperative indocyanine green angiography predicts parathyroid gland function. It is a valuable instrument to predict hypoparathyroidism after total thyroidectomy.

Cerebral magnetic resonance imaging reveals marked abnormalities of brain tissue density in patients with cirrhosis without overt hepatic encephalopathy.

BACKGROUND & AIMS: We applied advanced magnetic resonance imaging and Voxed based Morphometry analysis to assess brain tissue density in patients with cirrhosis. METHODS: Forty eight patients with cirrhosis without overt hepatic encephalopathy (17 Child A, 13 Child B, and 18 Child C) and 51 healthy subjects were matched for age and sex. Seventeen patients had history of overt hepatic encephalopathy, eight of them had minimal hepatic encephalopathy at inclusion, 10 other patients had minimal hepatic encephalopathy at inclusion but without history of previous overt hepatic encephalopathy, and 21 patients had none of these features. RESULTS: Patients with cirrhosis presented decreased brain density in many areas of the grey and white matter. The extension and size of the affected areas were greater in patients with alcoholic cirrhosis than in those with post-hepatitic cirrhosis and correlated directly with the degree of liver failure and cerebral dysfunction (as estimated by neuropsychological tests and the antecedent of overt hepatic encephalopathy). Twelve additional patients with cirrhosis who underwent liver transplantation were explored after a median time of 11months (7-50months) after liver transplant. At the time of liver transplantation, three patients belonged to class A of the Child-Pugh classification, five to class B and four to class C. Compared to healthy subjects, liver transplant patients showed areas of reduced brain density in both grey and white matter. CONCLUSIONS: These results indicate that loss of brain tissue density is common in cirrhosis, progresses during the course of the disease, is greater in patients with history of hepatic encephalopathy, and persists after liver transplantation. The significance, physiopathology, and clinical relevance of this abnormality cannot be ascertained from the current study.

Predictors of response to therapy with terlipressin and albumin in patients with cirrhosis and type 1 hepatorenal syndrome.

UNLABELLED: Terlipressin plus albumin is an effective treatment for type 1 hepatorenal syndrome (HRS), but approximately only half of the patients respond to this therapy. The aim of this study was to assess predictive factors of response to treatment with terlipressin and albumin in patients with type 1 HRS. Thirty-nine patients with cirrhosis and type 1 HRS were treated prospectively with terlipressin and albumin. Demographic, clinical, and laboratory variables obtained before the initiation of treatment as well as changes in arterial pressure during treatment were analyzed for their predictive value. Response to therapy (reduction in serum creatinine <1.5 mg/dL at the end of treatment) was observed in 18 patients (46%) and was associated with an improvement in circulatory function. Independent predictive factors of response to therapy were baseline serum bilirubin and an increase in mean arterial pressure of >or=5 mm Hg at day 3 of treatment. The cutoff level of serum bilirubin that best predicted response to treatment was 10 mg/dL (area under the receiver operating characteristic curve, 0.77; P < 0.0001; sensitivity, 89%; specificity, 61%). Response rates in patients with serum bilirubin <10 mg/dL or >or=10 mg/dL were 67% and 13%, respectively (P = 0.001). Corresponding values in patients with an increase in mean arterial pressure >or=5 mm Hg or <5 mm Hg at day 3 were 73% and 36%, respectively (P = 0.037). CONCLUSION: Serum bilirubin and an early increase in arterial pressure predict response to treatment with terlipressin and albumin in type 1 HRS. Alternative treatment strategies to terlipressin and albumin should be investigated for patients with type 1 HRS and low likelihood of response to vasoconstrictor therapy.

Risk factors for hepatic encephalopathy in patients with cirrhosis and refractory ascites: relevance of serum sodium concentration.

Hyponatraemia is common in patients with advanced cirrhosis and is associated with remarkable changes in brain cells, particularly a reduction in myoinositol and other intracellular organic osmolytes related to the hypo-osmolality of the extracellular fluid. It has been recently suggested that hyponatraemia may be an important factor associated with the development of overt hepatic encephalopathy (HE). To test this hypothesis, we retrospectively analysed the incidence and predictive factors of overt HE using a database of 70 patients with cirrhosis included in a prospective study comparing transjugular intrahepatic portosystemic shunts (TIPS) vs large-volume paracentesis in the management of refractory of ascites. Variables used in the analysis included age, sex, previous history of HE, treatment assignment (TIPS vs large volume paracentesis plus albumin), treatment with diuretics, serum bilirubin, serum creatinine and serum sodium concentration. Laboratory parameters were measured at entry, at 1 month and every 3 months during follow-up and at the time of development of HE in patients who developed this complication. During a mean follow-up of 10 months, 50 patients (71%) developed 117 episodes of HE. In the whole population of patients, the occurrence of HE was independently associated with serum hyponatraemia, serum bilirubin and serum creatinine. In conclusion, in patients with refractory ascites, the occurrence of HE is related to the impairment of liver and renal function and presence of hyponatraemia.

Experimental leptospirosis in capybaras (Hydrochaeris hydrochaeris) infected with Leptospira interrogans serovar Pomona.

Capybara (Hydrochaeris hydrochaeris), the largest rodent in the world, is widely distributed in South America. These animals live in areas with abundant water, which makes them a potential reservoir for Leptospira. The objective of this study was to investigate seroconversion, leptospiremia, and leptospiruria in capybaras experimentally infected with a virulent strain of Leptospira interrogans serovar Pomona. Seven capybaras were used: one control and six infected. Agglutinins against serovar Pomona were initially detected in serum 6 or 7 day after innoculation with Leptospira (10(9)-10(11) organisms, given i.v.), peaked (titer, approximately 3,200) between 9 and 27 day, and were still present at 83 day (end of study). The earliest and latest isolation of leptospires from the blood was from 2-12 day and from urine, 9-19 day after exposure. However, polymerase chain reaction and isolation results from kidney and liver samples were negative for leptospires. The control animal tested negative on all diagnostic tests. Hence, the capybara can serve as a host for Leptospira.

[Hepatorenal syndrome]. / Síndrome hepatorrenal.

Hepatorenal syndrome (HRS) is a severe complication in patients with cirrhosis and ascites. Renal insufficiency is functional and is caused by renal vasoconstriction. HRS occurs in 10% of patients with advanced cirrhosis. Diagnosis of HRS is based on ruling out other causes of renal insufficiency. There are two types of HRS: type 1 has rapid onset and progressive course and a mean survival of 15 days without treatment, while type 2 is less severe and progressive, with a mean survival of 6 months. Definitive treatment of HRS is liver transplantation. However, in the last few years administration of vasoconstrictive drugs or placement of portosystemic shunts have been shown to be effective in reversing HRS. Therefore, these measures may be used as a bridge before liver transplantation is performed. Finally, the risk of developing HRS in the context of spontaneous bacterial peritonitis can be prevented by administering albumin together with the corresponding antibiotics. In cases of severe acute alcoholic hepatitis, pentoxifylline can be administered.

Comparative efficacy of two single-dose bacterins in the control of Mycoplasma hyopneumoniae in swine raised under commercial conditions in Brazil.

A field study was conducted in Brazil to evaluate the efficacy of single vaccination of pigs with two bacterins to prevent Mycoplasma hyopneumoniae lung lesions. The first (T1) treatment group (174 pigs) was injected with 2 mL of saline solution; group T2 (177 pigs) with 2 mL of bacterin A, and group T3 (174 pigs) with 2 mL of bacterin B. On days-on-test (DOT) 0, 35, 66, 97 and 125, blood samples and tonsil swabs were collected from selected pigs for antibody determination (indirect ELISA) and PCR assay for the presence of M. hyopneumoniae. Pigs were slaughtered on DOT 126-129 and lung lesions were scored blindly. Bacterin A vaccinated pigs had significantly (P < or = 0.05) lower lung lesion scores (0.2%) than bacterin B (0.4%) or saline-treated pigs (1.2%); there was also a significantly lower (P < or = 0.05) number of pigs with lung lesions (27.1%), than bacterin B (38.2%) or saline-treated (55.4%) pigs. The two vaccines had similar (P>0.05) results in terms of mean weight gain, average daily weight gain, feed efficiency, frequency of PCR positives, and there was similar antibody conversion (ELISA). It was concluded that although the productivity parameters and antibody conversions were similar, bacterin A was more effective in preventing and reducing the severity of lung lesions than bacterin B.

Aquaporin-1 and aquaporin-2 urinary excretion in cirrhosis: Relationship with ascites and hepatorenal syndrome.

Several experimental models of cirrhosis have shown dysregulation of renal aquaporins in different phases of liver disease. We investigated the urinary excretion of both aquaporin-1 and aquaporin-2 in patients with cirrhosis at different stages of the disease. Twenty-four-hour urine was collected from 11 healthy volunteers, 13 patients with compensated cirrhosis (without ascites), and 20 patients with decompensated cirrhosis (11 with ascites without renal failure and 9 with hepatorenal syndrome). Aquaporin-1 and aquaporin-2 excretion was analyzed by immunoblotting. Urinary aquaporin-2 excretion was reduced in patients with cirrhosis compared to healthy subjects. A progressive decrease in urinary aquaporin-2 excretion was observed as the severity of cirrhosis increased, from compensated cirrhosis to cirrhosis with ascites and hepatorenal syndrome. Patients with hyponatremia had lower urinary aquaporin-2 excretion than patients without hyponatremia. Vasopressin plasma level did not correlate with aquaporin-2 excretion. There were no differences between healthy subjects and patients with cirrhosis with or without ascites in urinary excretion of aquaporin-1, but urinary aquaporin-1 excretion of those with hepatorenal syndrome was extremely low. In conclusion, patients with cirrhosis appear to exhibit a decreased abundance of renal aquaporin-2 and therefore lower water permeability in the collecting tubules. This may represent an adaptive renal response to sodium retention, with expansion of extracellular fluid volume and dilutional hyponatremia observed in those who have cirrhosis with ascites. Finally, aquaporin-1 does not appear to play a role in the progressive dysregulation of extracellular fluid volume in cirrhosis.

Renal failure in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis: value of MELD score.

BACKGROUND & AIMS: Although renal failure is a common complication of sepsis and patients with cirrhosis frequently develop sepsis, there have been no studies specifically assessing renal function in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis. The aim of this study was to investigate prospectively the frequency, characteristics, and outcome of renal failure in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis. METHODS: One hundred six consecutive patients with cirrhosis and sepsis were studied prospectively. Patients with spontaneous bacterial peritonitis were excluded. RESULTS: Twenty-nine out of 106 patients (27%) with cirrhosis and sepsis developed acute renal failure as compared with only 8 of 100 patients (8%) from a control group of cirrhotic patients without infection (P < .0001). Renal failure in the sepsis group was reversible in 22 (76%; 21% of all patients) patients and nonreversible in 7 (24%; 6% of all patients) patients. Renal failure was associated with impairment of effective arterial blood volume, without evidence of tubular damage. The occurrence and type of renal failure correlated strongly with mortality (mortality at 3 months: nonreversible renal failure, 100%; reversible renal failure, 55%; no renal failure, 13%). Among variables obtained at diagnosis of sepsis, the Model for End-Stage Liver Disease (MELD) score was the only independent predictive factor of mortality. CONCLUSIONS: Renal failure is common in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis and is associated with arterial underfilling and renal vasoconstriction. Outcome is poor, even in the setting of reversible renal failure. The MELD score is the best prognostic marker of patients with cirrhosis and sepsis.

Lethal factor to mice produced by Escherichia coli isolated from chickens with swollen head syndrome.

A lethal toxin similar to Bacillus cererus lethal toxin was detected in the culture supernatants of Escherichia coli isolated from chickens with swollen head syndrome. The lethal activity was heat-labile, protease-sensitive and killed mice within 10 min. The light microscopy of the histopathological studies revealed that the principal organ affected by this toxin was the lung but the liver and kidneys also showed lesions. The relevance of this lethal activity from E. coli remains to be determined.

Use of single-enzyme amplified fragment length polymorphism for typing Clostridium perfringens isolated from diarrheic piglets

Clostridium perfringens is an important pathogen in human and veterinary medicine. In swine, the agent is responsible for necrotic enteritis and enterotoxemia characterized by diarrhea, weight loss, delayed development and, in some cases, death. In the present study amplified fragment length polymorphism analyses (AFLP) was used to characterize 54 C. perfringens strains isolated from swine presenting diarrhea. Analysis of the results showed 29 distinct profiles with discriminatory index equal to 0.97. Partial correlation between the origin of the isolates and groups was drawn, and correlation was possible in only 18.5 percent of the samples. Characterization of the strains in biotypes (A, B, C, D and E), production of beta-2 toxin and enterotoxin were performed by means of the polymerase chain reaction (PCR). Biotypes A, C and D were observed among the strains analyzed. All samples were positive for presence of the gene encoding beta-2 toxin and negative for the gene encoding enterotoxin. AFLP have shown to be a simple, fast, low cost method with high discriminative power and good reproducibility, presenting a great potential in epidemiological studies involving C. perfringens strains of animal origin.

Clostridium perfringens é um importante agente infeccioso em medicina veterinária e humana. Em suínos, o agente é responsável pela enterite necrótica e enterotoxemia, caracterizadas por diarréia, perda de peso, atraso no desenvolvimento e morte. No presente estudo foi utilizado o polimorfismo do comprimento de fragmentos amplificados (AFLP), para caracterizar 54 isolados de C. perfringens obtidos de suínos com diarréia. A análise dos resultados do AFLP demonstrou 29 perfis distintos com índice discriminatório igual a 0,97. A correlação entre a origem dos isolados e os agrupamentos obtidos foi parcial, sendo apenas possível a correlação total de 18,5 por cento das amostras estudadas. A caracterização das cepas em biotipos (A, B, C, D e E), produção da toxina beta-2 e enterotoxina foi realizada através da reação da polimerase em cadeia (PCR). Dentre as cepas analisadas foram observados os biotipos A, C e D, sendo que todas as amostras foram positivas para a presença do gene codificador da toxina beta-2 e negativas para o gene codificador da enterotoxina. Neste estudo, o AFLP demonstrou ser uma metodologia simples, rápida, de baixo custo, com alto poder discriminatório e boa reprodutibilidade, apresentando grande potencial para estudos epidemiológicos envolvendo cepas de C. perfringens de origem animal.

Identification of bacterial agents of enteric diseases by multiplex PCR in growing-finishing pigs

A enterite proliferativa suína, a espiroquetose colônica, a disenteria suína e a salmonelose são as doencas entéricas mais freqüentes em suínos das fases de crescimento e terminacão no Brasil. O diagnóstico destas doencas através de técnicas bacteriológicas tradicionais é difícil, lento e no caso da enterite proliferativa suína, impossível. A deteccão destes agentes através da reacão de polimerase em cadeia é altamente sensível e específica e está se tornando uma ferramenta muito útil no diagnóstico em Medicina Veterinária. No presente estudo foram testadas duas técnicas de PCR sob a forma de "multiplex"para deteccão e identificacão simultânea dos agentes bacterianos envolvidos na enterite proliferativa suína, na espiroquetose colônica, na disenteria suína e na salmonelose em amostras de fezes diarreicas. O DNA obtido de culturas puras de cada agente sozinho ou misturado em diferentes combinacões e concentracões foram amplificados utilizando a Multiplex PCR específica para Lawsonia intracellularis e Salmonella, ou Brachispyra pilosicoli e Brachispyra hyodysenteriae. Após a padronizacão, a M-PCR foi aplicada na deteccão dos quatro agentes em 541 amostras de fezes diarreicas de suínos provenientes de diferentes Estados do Brasil. O agente mais freqüente foi Lawsonia intracellularis (13 per center), seguido pela Salmonella spp. (4,8 per center), B. hyodysenteriae (1,4 oer center), B. pilosicoli (1 per center) e suas diferentes associacões. Os resultados obtidos indicam que as duas reacões testadas permitem a deteccão destes quatro importantes patógenos entéricos de maneira rápida e específica.

Do connective tissue components induce plasma activation in vivo?

1. this oaoer describes the effect if homologous plasma in contact with connective tissue on vascular perveability, edema and cell migration. 2. The contact of "non-activated"plasma with connective tissue structures does not tesults in generation of mediators responsible for increase in vascular premeability or in edema. 3. "Activated" plasma is able to induce vascular permeability and edema when in contact with connective tissue components. 4. Injection of "non-activated" or "activated" plasma induced a mild inflammatory cell migration

Morfobiologia e patogenicidade da Eimeria falciformis var. pragensis Cerná, Sénaud, Mehlhorn & Scholtyseck, 1974 em camundongo (Mus musculus) / Morphobiology and pathogenicity of Eimeria falciformis var. pragensis Cerna, Seraud, Mehlhorn & Scholtyseck, 1974 in mouse

Identificou-se, com base em características morfobiológicas, uma das espécies de Eimeria provenientes de camundongos de um biotério comercial e purificada pela técnica do oocisto único. Os oocistos eram sub-esféricos ou ovóides, medindo 21,3 x 16,9 *m, (n=780), com membrana dupla, lisa, incolor, sem micrópila, sem corpo residual oocístico e com 1 a 4 grânulos polares. Esporocistos eram elipsóides, com corpúsculo de Stieda, mediram 11,5 x 6,3 *m (n= 678) e continham corpo residual esporocístico. Todo o ciclo endógeno ocorreu no intestino grosso, com pelo menos 4 geraçöes assexuadas. Merontes maduros de 1ª geraçäo de 10,3 x 10,6 *m, com 8 a 25 merozoítas de 5,0-10,0 x 1,0-3,0 *m foram vistos inicialemtne às 24 horas pós-inoculaçäo (HPI). Merontes de 2ª geraçäo de 14,4 x 8,1 *m, com 8 a 20 merozoítas de 11,0-16,0 x 2,0 - 3,0 *m surgiram a partir de 48 HPI. Entre 72 e 96 HPI havia muitos merontes maduros de 3ª geraçäo, de dois tipos: um medindo 13,9 x 8,3 *m, com merozoítas de 17,0-19,0 x 2,0-4,0 *m e outro 7,3 x 10,4 *m, com 6 a 10 merozoítas de 8,0-13,0 x 1,0-3,0 *m. Merontes de 4ª geraçäo, de 10,4 x 11,9 *m e com 26 a 48 ou mais merozoítas de 8,0-13,0 x 2,0-3,0 *m foram vistos a partir de 132 HPI, bem como gametócitos imaturos e, às 144, já havia gametócitos maduros. O período de pré-patência foi de 6 1/2 a 7 dias pós-inoculaçäo (DPI) e a patência de 6 a 13 dias. A 23-24-C, em Dicromato de Potássio a 2,0%, 72,0% dos oocistos esporularam em 216 horas. Os camundongos infectados apresentaram, em geral, apatia, anorexia, perda de peso, diarréia ou disenteria entre o 6§ e o 10§ DPI. A mortalidade ocorreu entre o 8§ e o 13§ DPI, principalmente no 9§, e nos grupos que receberam doses mediana de oocistos. As lesöes se restringiram ao intestino grosso e se traduziram por uma enterite necrótica evoluindo depois para regeneraçäo e cura. Com base nas características morfológicas da Eimeria estudada, concluiu-se tratar da E. falciformis var. pragensis

Isolamento de parvovirus canino no Brasil / Isolation of canine parvovirus in Brazil

Foram examinadas 56 amostras de fezes, 10 de raspado de mucosa intestinal de 2 amostras de material vomitado de cäes doentes, além de 7 amostras de fezes de cäes normais, com o objetivo de isolar-se o parvovirus canino durante a epizootia de gastoenterite hemorrágica ocorrida em Säo Paulo. Das 56 amostras de fezes de cäes doentes foram isolados virus de 24 (42,8%) e das 7 amostras de fezes de cäes clinicamente normais foi isolado virus de apenas 1 (14,3%). Tanto o material vomitado quanto do raspado de mucosa intestinal obteve-se o isolamenteo de parvovirus de uma amostra apenas, correspondendo a 50% e 10%, respectivametne. A reaçäo de hemaglutinaçäo, realizada com os váios tipos de materiais clínicos, demonstrou concordância de 96,3% com o isolamento de virus nas 27 amostras positivas, evidenciando a grande utilidade prática desta reaçäo como método de triagem para determinar, nos casos de diarréia em cäes, a presença de particulas virais com esta caracteristica hemaglutinantes. Em 15 amostras de suspensäo fecal e em uma das culturas positivas foi observada, a microscopia eletrônica, a presença de particulas virais com a s características morfológicas dos parvovirus isolados e o parvovirus felino foi demonstrada pela reaçäo de inibiçäo de hemaglutinaçäo e pela imunofluorescência em 6 das amostras isoladas