Anaesthesia in a parturient with systemic mastocytosis.

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Anesthetic considerations in a laboring woman with systemic mastocytosis. / Consideraciones anestésicas en una parturienta con mastocitosis sistémica.

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Direct costs of asthma in Brazil: a comparison between controlled and uncontrolled asthmatic patients

Asthma is a common chronic illness that imposes a heavy burden on all aspects of the patient's life, including personal and health care cost expenditures. To analyze the direct cost associated to uncontrolled asthma patients, a cross-sectional study was conducted to determine costs related to patients with uncontrolled and controlled asthma. Uncontrolled patient was defined by daytime symptoms more than twice a week or nocturnal symptoms during two consecutive nights or any limitations of activities, or need for relief rescue medication more than twice a week, and an ACQ score less than 2 points. A questionnaire about direct cost stratification in health services, including emergency room visits, hospitalization, ambulatory visits, and asthma medications prescribed, was applied. Ninety asthma patients were enrolled (45 uncontrolled/45 controlled). Uncontrolled asthmatics accounted for higher health care expenditures than controlled patients, US$125.45 and US$15.58, respectively [emergency room visits (US$39.15 vs US$2.70) and hospitalization (US$86.30 vs US$12.88)], per patient over 6 months. The costs with medications in the last month for patients with mild, moderate and severe asthma were US$1.60, 9.60, and 25.00 in the uncontrolled patients, respectively, and US$6.50, 19.00 and 49.00 in the controlled patients. In view of the small proportion of uncontrolled subjects receiving regular maintenance medication (22.2 percent) and their lack of resources, providing free medication for uncontrolled patients might be a cost-effective strategy for the public health system.

Significance of schistosomal granuloma modulation.

Hepatic Schistosoma mansoni periovular granulomas undergo changes in size, cellular composition and appearance with time. This phenomenon, known as "immunological modulation", has been thought to reflect host immunological status. However, as modulation has not been observed outside the liver, participation of local factors, hitherto little considered, seems crucial. Components of the extracellular matrix of periovular granulomas of the mouse were particularly studied in three different organs (liver, lung and intestine) and during three periods of infection time (acute, intermediate and chronic) by means of histological, biochemical and immunofluorescence techniques, while quantitative data were evaluated by computerized morphometry, in order to investigate participation of local factors in granuloma modulation. Results confirmed modulation as a exclusively hepatic phenomenon, since pulmonary and intestinal granulomas, formed around mature eggs, did not change size and appearance with time. The matricial components which were investigated (Type I, III and IV collagens, fibronectin, laminin, proteoglycans and elastin) were found in all granulomas and in all organs examined. However, their presence was much more prominent in the liver. Elastin was only found in hepatic granulomas of chronic infection. The large amount of extracellular matrix components found in hepatic granulomas was the main change responsible for the morphological aspects of modulation. Therefore, the peculiar environment of the liver ultimately determines the changes identified in schistosomal granuloma as "modulation".

[Respiratory morbidity in patients with and without pulmonary obstructive syndrome after upper abdominal surgery]. / Morbidade respiratória nos pacientes com e sem síndrome pulmonar obstrutiva submetidos a cirurgia abdominal alta.

BACKGROUND: We wanted to determine the postoperative pulmonary complication after upper abdominal surgery in patients with pulmonary obstrutive syndrome. METHODS: We have studied 196 patients prospectively analyzed in preoperative period with spirometry and followed for observation of PPC. The patients were divided in four groups: COPD - those with chronic bronchitis or emphysema and VEF1/CVF< 70% (27 patients). ASMA - patients with obstruction of the airway in response to provoking stimuli (44 patients). CHRONIC BRONCHITIS-EMPHYSEMA - those with the clinical diagnoses of the respective diseases but VEF1/CVF > 70% (23 patients). NORMAL - patients without pulmonary disease and normal spirometry (102 patients). RESULTS: Postoperative pulmonary complication was recognized when the patient presented atelectasis with clinical or gasometric alterations; bronchospasm that needed bronchodilator therapy; respiratory failure; mechanical ventilation or orotracheal intubation more than 48 hours in postsurgery period; tracheobronchitis characterized by the presence of purulent sputum with normal x-ray; pneumonia. Patients with pulmonary obstruction had experienced higher rates of pulmonary complications (32% vs 6%, p<0.05). The presence of obstructive lung disease was associated with an increased number of ventilator days, but was not associated with longer intensive care unit or hospital stay. CONCLUSIONS: The incidence of postoperative pulmonary complications was strongly associated with the presence of pulmonary obstructive syndrome.

Morbidade respiratória nos pacientes com e sem síndrome pulmonar obstrutiva submetidos a cirurgia abdominal alta / Respiratory morbidity in patients with and without pulmonary obstructive syndrome after upper abdominal surgery

OBJETIVO: Estudar a morbidade respiratória nos pacientes com síndrome pulmonar obstrutiva submetidos a cirurgia abdominal alta. CASUÍSTICA E MÉTODO: Durante o pré-operatório, 196 pacientes candidatos à cirurgia abdominal alta eletiva responderam a um questionário padronizado e logo em seguida realizaram espirometria. Houve acompanhamento no pós-operatório até a alta hospitalar ou óbito. Os pacientes foram divididos em quatro grupos: 27 pacientes com DPOC (diagnóstico de bronquite crônica ou enfisema e VEF1/CVF < 70 por cento), 44 pacientes com diagnóstico de asma (obstrução das vias aéreas desencadeada por estímulos provocatívos) com ou sem alteração da espirometria. Outros 23 pacientes apresentavam o complexo bronquite crônica-enfisema, (quadro clínico sugestivo de bronquite ou enfisema porém com VEF1/CVF maior que 70 por cento). O grupo de 102 pacientes apresentou normalidade do ponto de vista clínico e espirométrico. Considerou-se como CPP: atelectasia com repercussão clínica e ou gasométrica, broncoespasmo que necessitou de tratamento, insuficiência respiratória aguda, ventilação mecânica e/ou entubação orotraqueal prolongada, infecção traqueobronquica e pneumonia. RESULTADOS: A incidência de complicações foi maior no grupo de pacientes com limitação do fluxo aéreo (32 por cento) em relação aos normais(6 por cento). Ao estudarmos os quatro grupos separadamente, foi observado que os pacientes com DPOC, apesar de apresentaram maior morbidade no pós-operatório, não diferiram dos demais pneumopatas. Complicaram, respectivamente, (DPOC 37 por cento, BE 34 por cento, asma 29 por cento, normal 6 por cento). Os obstrutivos triplicaram seu tempo de permanência no ventilador (média 3,1 e 1,1; respectivamente, com p<0,05). No entanto, não houve diferença em relação ao tempo de permanência na UTI e no tempo total de dias no pós-operatório. CONCLUSÃO: Os pacientes com limitação do fluxo aéreo apresentaram maior morbidade no pós-operatório de cirurgia abdominal alta. A magnitude deste fator de risco se reflete num risco relativo quase que cinco vezes maior em relação aos pneumopatas com os pacientes normais.

Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery.

OBJECTIVE: To investigate associations between preoperative variables and postoperative pulmonary complications (PPC) in elective upper abdominal surgery. DESIGN: Prospective clinical trial. SETTING: A tertiary university hospital. PATIENTS: 408 patients were prospectively analyzed during the preoperative period and followed up postoperatively for pulmonary complications. MEASUREMENTS: Patient characteristics, with clinical and physical evaluation, related diseases, smoking habits, and duration of surgery. Preoperative pulmonary function tests (PFT) were performed on 247 patients. RESULTS: The postoperative pulmonary complication rate was 14 percent. The significant predictors in univariate analyses of postoperative pulmonary complications were: age >50, smoking habits, presence of chronic pulmonary disease or respiratory symptoms at the time of evaluation, duration of surgery >210 minutes and comorbidity (p <0.04). In a logistic regression analysis, the statistically significant predictors were: presence of chronic pulmonary disease, surgery lasting >210 and comorbidity (p <0.009). CONCLUSIONS: There were three major clinical risk factors for pulmonary complications following upper abdominal surgery: chronic pulmonary disease, comorbidity, and surgery lasting more than 210 minutes. Those patients with three risk factors were three times more likely to develop a PPC compared to patients without any of these risk factors (p <0.001). PFT is indicated when there are uncertainties regarding the patient's pulmonary status.

Myofibroblasts in schistosomal portal fibrosis of man.

Myofibroblasts, cells with intermediate features between smooth muscle cells and fibroblasts, have been described as an important cellular component of schistosomal portal fibrosis. The origin, distribution and fate of myofibroblasts were investigated by means of light, fluorescent, immunoenzymatic and ultrastructural techniques in wedge liver biopsies from 68 patients with the hepatosplenic form of schistosomiasis. Results demonstrated that the presence of myofibroblasts varied considerably from case to case and was always related to smooth muscle cell dispersion, which occurred around medium-sized damaged portal vein branches. By sequential observation of several cases, it was evident that myofibroblasts derived by differentiation of vascular smooth muscle and gradually tended to disappear, some of them further differentiating into fibroblasts. Thus, in schistosomal pipestem fibrosis myofibroblasts appear as transient cells, focally accumulated around damaged portal vein branches, and do not seem to have by themselves any important participation in the pathogenesis of hepatosplenic schistosomiasis.

Interrelationship between adipocytes and fibroblasts during acute damage to the subcutaneous adipose tissue of rats: an ultrastructural study

Ultrastructural phenotypic transitional features were noted between adult adipocytes and fibroblasts in the subcutaneous adipose tissue of the dorsal pad of normal adult Wistar rats of both sexes, weighing 180-260 g, after acute injury either by the implantation of small (1.8 x 1 x 0.4 cm) perforated plastic boxes or by local heat application. Soon after the inflicted damage, fat-containing cells presented variable shapes. Early after damage, some of these cells were round, adipocyte like, with numerous and large cytoplasmic fat droplets. A few days later, fat-containing cells became elongated, with the fat droplets in their cytoplasm becoming smaller and less numerous. The cells also showed a prominent active rough endoplasmic reticulum and newly formed collagenous matrix accumulated in the interstices. Although current views consider adult adipocytes to be terminal cells, the present findings, in their time sequence, strongly suggest the transformation of adipocytes into fibroblasts after acute injury to adipose tissue.

Lung inhalation scintigraphy: development of a new aerosol system.

A new technique for lung inhalation scintigraphy is reported, developing a new aerosol system, based on the original system of Taplin [1]. With two small compact polypropylene reservoirs, this 99Tcm DTPA technique allowed continuous breathing during the inhalation period. This system proved to be a useful alternative to that using radioactive gases and the system of Taplin, due to its low cost and the ease with which several projections may be obtained.

Propedeutica dos derrames pleurais nao tuberculosos. / Propaedeutics of non-tuberculous pleural effusions

Os autores estudaram 84 casos de derrame pleural nao tuberculoso, sendo que as etiologias mais frequentes foram: empiema, parapneumonico, metastatico e insuficiencia cardiaca. As alteracoes mais acentuadas das variaveis bioquimicas e citologicas estudadas ocorreram nos casos de empiema, com as seguintes medias: proteinas 5,2g%; glicose 13,1mg%; DHL 2.668,5mU/ml; pH6,80; PCO2 96,3mmHg; contagem de globulos brancos 63.567/ml. A contagem de globulos vermelhos foi mais alta nos casos de derrame metastatico com media de 106.123/ ml. Os autores concluem que as alteracoes acima encontradas nao sao patognomonicas das etiologias citadas e enfatizam a necessidade de se interpretar os resultados com os dados clinicos, radiologicos e com outros exames de laboratorio

Acao de pressao positiva expiratoria (PPE) no edema pulmonar por aumento da permeabilidade microvascular. / The effect of positive end expiratory pressure on lung edema due to increased microvascular permeability

Com o objetivo de analisar o papel da pressao positiva expiratoria (PPE) sobre o edema pulmonar por aumento de permeabilidade microvascular foram estudados 18 caes divididos em tres grupos. No grupo I, os caes eram ventilados com respirador a volume a apos 30 minutos instalavamos PPE de 5 cmH2O. No grupo II, os caes eram ventilados com respirador a volume e provocava-se edema pulmonar por injecao endovenosa de aloxana de 90 mg/kg, e, no grupo III, procediamos como no grupo II e apos 30 minutos instalavamos 5 cmH2O de PPE.Apos 120 minutos os pulmoes foram retirados.Para avaliarmos o edema ocorrido utilizamos o pulmao esquerdo para calcularmos a relacao peso unico/peso seco (PU/PS) foi, no grupo I 4,01 +/- 0,69, grupo II 8,78 +/- 2,29, e no grupo III 8,18 +/- 2,33: os grupos II e III apresentaram aumento significante desta relacao quando comparado ao grupo I. A microscopia revelou ausencia de edema no grupo I e intenso edema em iguais proporcoes nos grupos II e III. Pudemos concluir que: a aplicacao de 5 cmH2O de PPE nao provocou edema pulmonar: e que a quantificacao do edema pulmonar decorrente de aumento de permeabilidade microvascular nao se modificou com a utilizacao de ventilacao com PPE de 5 cmH2O

Asma e exercicio: aspectos relacionados a prevalencia, sexo,idade e grau de comprometimento da funcao pulmonar. / Asthma and exercise: aspects related to incidence, sex,age and impairment of pulmonary function

Foi estudada a prevalencia de asma induzida pelo exercicio (AIE) num grupo de jovens com asma extrinseca. Foi investigada qual a influencia do sexo, idade e previo comprometimento da funcao pulmonar na resposta do asmatico ao exercicio. Foram estudados 40 pacientes, 12 do sexo masculino (30%) e 28 do sexo feminino (70%) com media de idade de 18,7 +/- 5,7 anos. Exercicio foi realizado em um cicloergometro com cargas crescentes ate se alcancar frequencia cardiaca equivalente a 85% da maxima prevista. Antes do exercicio e aos 5, 10 e 20 minutos apos seu termino foram determinados o pico do fluxo expiratorio (PFE) capacidade vital forcada (CVF), fluxo expiratorio forcado 25-75% (FEF25-75%) e volume expiratorio forcado no 1o segundo (VEF1). Considerando-se todos os parametros, 19 pacientes apresentaram AIE. VEF1 detectou 14 pacientes, FEF25-75% 15, PFE 8 e CVF 6. Nao houve diferenca de idade entre os com AIE (18,3 +/- 2,1 anos) e os sem AIE (20,0 +/- 1,8 anos) e nem entre os dois sexos no grupo com AIE (masculino = 16,4 +/- 4 anos e feminino = 19,7 +/- 6,1 anos). Dos 19 com AIE sete eram do sexo masculino (58,3% do seu grupo) e 12 do sexo feminino (42,9% do seu grupo). Nao houve diferenca entre os porcentuais do previsto para VEF1, FEF25-75% e PFE no pre-exercicio entre os grupos com e sem AIE

Funcao pulmonar na hiper-hidratacao. Estudo experimental em caes. / Pulmonary function in hyper-hydration. Experimental study in dogs

A funcao pulmonar de onze caes anestesiados e ventilados mecanicamente foi estudada antes e apos a hiper-hidratacao rapida com solucao salina fisiologica, na quantidade de 100ml/kg A pressao parcial de oxigenio (PaO2) a diferenca das pressoes alveolo-arteriais de oxigenio (P(A-a)O2) respirando O2 a 100%, nao apresentaram variacoes significantes. A complacencia efetiva (CE) de 38,6 ml/cm H2O antes da hiper-hidratacao, reduziu-se para 35,3 ml/cm H2O apos a hiper-hidratacao. A diferenca do conteudo arterio-venoso de oxigenio (C(a-v)O2) reduziu-se de 4,45 vol % para 3,07 vol %; o shunt pulmonar (Qsan/Q) elevou-se de 8,82% para 12,36%; a relacao entre o espaco morto e volume corrente (VD/VT) elevou-se de 0,35 para 0,43 o pH arterial reduziu-se de 7,38 para 7,27, e o bicarbonato plasmatico (HCO3) de 21,5 mEq/l para 16,0 mEq/l. Os autores discutem as alteracoes encontradas comparando seus achados com a literatura existente concluindo que a excessiva administracao liquida provocou acidose metabolica por diluicao dos tampoes plasmaticos. A reducao da CE e o aumento da relacao VD/VT seriam decorrentes do edema intersticial pulmonar. Este aumentando a resistencia das pequenas vias aereas contribui para a reducao da CE, bem como acumulando-se preferencialmente no tecido intersticial perivascular, pode ser responsavel pelas alteracoes na relacao ventilacao/perfusao por compressao vascular e consequente elevacao do VD/VT