Tuberculosis infection in HIV vs. non-HIV patients.

OBJECTIVES: Tuberculosis (TB) is the most common opportunistic infection and cause of mortality among people living with HIV, and it is possible that it may also influence the evolution of the HIV infection. We assessed the differences between HIV-positive and -negative people infected with TB. METHODS: The present study is a cross-sectional retrospective study by electronic record revision. We included patients admitted to a tertiary hospital with a diagnosis of TB between 2011 and 2016, comparing those with HIV coinfection with non-HIV patients, according to demographic and clinical characteristics. RESULTS: This study included 591 patients, of whom 32% were HIV-coinfected. HIV-TB patients were younger, with a predominance of male gender. Considering TB risk factors, there was a higher prevalence of homelessness and intravenous drug use in the HIV group. In the non-HIV group, direct contact with other patients with TB and immunosuppression were more prevalent. Relative to TB characteristics, the HIV-coinfected group presents with a higher prevalence of disseminated disease and a higher occurrence of previous TB infection. Cancer was the most frequent cause of immunosuppression in the HIV group and the number testing positive for TB via microbiological culture was lower. Assessment of microbiological resistance and in-hospital mortality showed similar numbers in both groups. CONCLUSIONS: There are few papers comparing clinical course of TB between HIV-infected and non-infected patients. Our study differs from others in the literature as we focused on a country with middling incidence of TB and further characterized the differences between HIV-infected and non-infected patients which can contribute to the management of these patients.

Liver retransplantation in patients with acquired familial amyloid polyneuropathy: a Portuguese center experience.

In 1995 Furtado et al performed the first domino transplantation using a donor liver with familial amyloid polyneuropathy (FAP), thereby increasing the pool of donors. Our experience showed that the onset of FAP symptoms occurs earlier in some patients. Patients with FAP acquired by transplantation are candidates for liver retransplantation to minimize the progression of symptoms. Liver retransplantation is considered to be a high-risk procedure and has lower survival compared with the first transplantation. We evaluated the risk of liver retransplantation in patients with acquired FAP. We did a retrospective analysis of these patients based on the records of perioperative data. From 1995 to 2004 we carried out 81 domino transplantations, of which 10 were submitted to liver retransplantation because of acquired FAP. The better outcomes in this group lead us to think that the liver retransplantation in patients with acquired FAP is not associated with the same risks of liver retransplantation in candidates with graft failure.

Evaluation of operative risk in de novo familial amyloid polyneuropathy retransplantation.

Familial amyloid polyneuropathy (FAP) is the most common hereditary amyloidosis, characterized by progressive peripheral sensory and motor neuropathy. The livers of patients with FAP are used in domino liver transplantation in selected cases to increase the number of grafts available. In our department 10 patients underwent liver retransplantation (ReLTx) in the absence of liver dysfunction by de novo FAP after domino liver transplantation. Our aim was to compare the differences in the consumption of blood products and intraoperative hemodynamic support among patients with FAP undergoing liver transplantation (LTx) and patients with de novo FAP undergoing ReLTx in the same time frame. The anesthetic records of all patients who underwent LTx for FAP and ReLTx for de novo FAP were analyzed, from January 2009 to May 2014. Patients were divided into 2 groups: group 1 patients with FAP, and group 2 patients with de novo FAP. Statistical differences in the value of preoperative creatinine were found. Hemoglobin levels, preoperative international normalized ratio (INR), use of blood products, aminergic support, and surgical time showed no statistical difference. Major bleeding rates would be expected in patients undergoing ReLTx. Changes in renal function, chronic immunosuppressive therapy, and age may contribute to the increase in intraoperative complications. We did not find statistically significant differences, leading us to the conclusion that de novo FAP does not seem to be a predictor of perioperative risk.

Incidentally discovered hepatocellular carcinoma in explanted liver: clinical, histopathologic features and outcome.

BACKGROUND: Incidental hepatocellular carcinomas (iHCCs) are tumors discovered on the explanted liver that were not present on imaging before transplantation. The natural history, histopathologic characteristics, and prognosis are not clearly defined. METHODS: We compared the characteristics of iHCC and previously known hepatocellular carcinoma (pkHCC) in patients who underwent liver transplantation from 1998 to 2012 in a retrospective study. RESULTS: During this period a total of 675 patients were transplanted; 56 patients (9%) had pkHCC and 12 (2%) had iHCC. The sex and age distributions were similar. The median Model for End-Stage Liver Disease score in iHCC patients was 17.0 versus 13.0 in patients with pkHCC (P = .001). Thirty-three percent of iHCC patients had multiple tumors, and 25% had bilobar involvement. The median cumulative tumor size in iHCC was 1.8 cm, and 5.5 cm in pkHCC (P = .005). Incidence of microvascular invasion was not different (16.7% vs 38.9%; P = .191). American Joint Committee on Cancer T1 stage was found in 58.3% of patients with iHCC and in 22.2% of pkHCC patients. Patients with iHCC had 1-, 3-, and 5-year survivals, respectively, of 100%, 83% and 64%, compared with 80%, 66%, and 38% for patients with pkHCC (P = .138). None of the patients with iHCC had recurrence of HCC, whereas incidence of recurrence in pkHCC patients was 12.5%. CONCLUSIONS: iHCC occurred in patients with more advanced liver disease. The cumulative tumor size of iHCC was smaller but one-third were multifocal. Survival was similar to patients with pkHCC, and recurrence was not noted in patients with iHCC.

Haemodynamics during liver transplantation in familial amyloidotic polyneuropathy: study of the intraoperative cardiocirculatory data of 50 patients.

BACKGROUND: Circulatory instability frequently complicates liver transplantation for familial amyloidotic polyneuropathy (FAP) and may be a source of surgical morbidity and mortality. OBJECTIVE: To evaluate FAP intraoperative haemodynamic data and their relation to the duration of surgery, and need for anaesthetic drugs. RBC and sympathomimetic amines. SETTING: Clinical study during a four year period. PATIENTS (mean +/- SD): Group I included 50 consecutive FAP ATTR Met 30 recipients of first transplantation. Age was 35.3 +/- 7.1 years, neurological score 34.3 +/- 13 in 100 and time elapsed from first symptom 5.0 +/- 2.7 years. Group II (control), not different concerning age and sex, included 51 patients transplanted during the same period with other pathologies. METHOD: Anaesthetic protocol, monitoring and surgical techniques were similar in both groups. Data of the two groups were compared either by the Student's t-test or Fisher's exact test. RESULTS: Low values of systemic vascular resistance index were observed in both groups, with no differences between them. Systemic arterial pressures were usually lower in group I, because cardiac index and heart rate were also significantly lower, although within normal values. However, in group I, isoflurane (a vasodilator anaesthetic) was used during less time (p < 0.05) and in lower concentrations (p < 0.01) and phenylephrine was necessary in 26% of patients vs 0 patients in group II (p < 0.001). CONCLUSION: FAP patients presented a different intraoperative behaviour when compared to other patients submitted to liver transplantation. From a clinical point of view, the authors stress: 1--As a result of autonomic dysfunction, the administration of anaesthetic drugs to FAP patients always presents the risk of producing significant hypotension; even the use of ketamine does not prevent hypotension; 2--Safety is ensured by beat-to-beat surveillance of arterial pressures and the capacity to act immediately to support circulation; 3--These patients seem to be very sensitive to decreases in the pre-load; 4--Hypotension is also frequent with an adequate pre-load, usually as the result of low SVR; an infusion of a vasoconstrictor drug emerges as the most frequent treatment requested and our experience supports it as an effective one.

[Aortocoronary bypass. Intermittent clamping of the aorta versus cardioplegia]. / Bypass aorto-coronário. Clampagem intermitente da aorta versus cardioplegia.

STUDY OBJECTIVE: Cardioplegia is the standard method of myocardial protection during aorto-coronary bypass surgery. However, there are other alternatives which the authors intend to test. DESIGN: Forty consecutive, non-selected cases of coronary artery bypass surgery done with intermittent aortic crossclamping (Group A) are compared with the 40 preceding consecutive cases where cardioplegia was used (Group B). PATIENTS: The mean age of the patients of group A was 57.5 years (range 42-69 years) and that of group B was 57.1 years (range 39-76 years). Patients of group A had an incidence of previous myocardial infarct of 42.5% against 65.0% in group B. Chronic angina led to surgery in 33 cases of group A and in 32 of group B. The remainder (18.8%) had unstable angina. INTERVENTIONS: The mean number of grafts per patient was 2.9 in group A and 3.2 in group B. Internal mammary arteries were used in most patients of both groups, with 61 anastomoses in group A (1.5/patient) and 57 in group B (1.4/patient). The mean ischaemic time per graft was 7.4 min (range 5.5-11 min) in group A and 15.6 min (8.5-22 min) for group B. MAIN RESULTS: Serial analysis of myocardium-specific serum enzymes and the CPK-MB/total CPK ratio has not evidenced perioperative infarction in any patient of either group. Although enzyme levels were slightly higher in group A, the difference has not reached statistical significance. However, the electrocardiograms have shown one perioperative infarct in each group. Vasodilators were generally used in the 2 groups, for a mean of 16.8 hours, while inotropic drugs were required in only 4 cases of group A and 3 of group B. There has been no hospital mortality in either group. CONCLUSIONS: These results, in a series of non selected patients, demonstrate that intermittent crossclamping may be an acceptable alternative method of myocardial protection during aorto-coronary bypass surgery thus made simple, quick and secure.

[Surgery of the coronary vessels in the elderly]. / Cirurgia das coronárias na 3.a idade.

STUDY OBJECTIVE: The rising numbers of elderly patients with occlusive coronary artery disease amenable to surgical correction prompted us to reevaluate the benefits and risks of aorto-coronary bypass in these patients. PATIENTS: In the five-year period, from June 1980 through May 1985, 293 patients 65 years old and older (mean 69.1 years) and with a male: female ratio of 4:1, were subjected to aorto-coronary bypass. RESULTS: Operative mortality was 4.8%, higher amongst 71 patients who had endarterectomy (8.5%) and those who had concomitant valve replacement (7.7%), but lower (2.5%) in the 99 patients who had only saphenous vein grafts (p less than 0.05). The survivors were followed for three to eight years (mean 4.9 years), with a cumulative follow-up of 1.005 patient-years. Late mortality was 4.6%/patient-year (46 patients), higher in patients with valve replacement (6.0%/patients-year; p less than 0.05), but lower in patients with internal mammary artery grafts (2.6%/patient-year). Late mortality was cardiac-related in 45.6% of the cases (21/46). Two patients were reoperated upon (0.2%/patient-year) and other two had percutaneous balloon angioplasty. Thirty six patients (12.9%) had recurrent angina during the period of follow-up, but the incidence was 20% in those who had only vein grafts (p = NS). Nine patients had myocardial infarction (0.9%/patient-year) of which six (67%) were fatal. In actuarial terms, 80% of the patients survived and 95% were free from myocardial infarction after six years. CONCLUSIONS: As in younger patients, coronary surgery in the elderly patient leads to improved life quality and survival. This study appears to confirm the superiority of internal mammary artery grafts also in the old patient.