Accuracy of quantitative polymerase chain reaction in samples of frozen and paraffin-embedded healthy skin for the diagnosis of canine visceral leishmaniasis / Acurácia da reação em cadeia da polimerase quantitativa em amostras de pele íntegra congelada e parafinada no diagnóstico da leishmaniose visceral canina

The purpose of the present work was to evaluate the accuracy of quantitative polymerase chain reaction (qPCR) performed on samples of fresh frozen tissue (FT) and formalin-fixed, paraffin-embedded (FFPE) healthy skin. This is a validation study conducted with samples from 46 dogs from an endemic area in Brazil. After sample collection, DNA extractions were conducted using commercial kits and qPCR was oriented to kinetoplast DNA (kDNA) targets of the Leishmania infantum species. The results obtained for the FFPE samples showed 63.6% sensitivity and 77.1% specificity, whereas those obtained for the FT samples showed 100% and 48.6%, respectively. Poor agreement was observed for the results of the qPCR technique with FT and FFPE samples. Our results suggest freezing as the most suitable conservation method for the formation of sample databases considering DNA recovery.(AU)

O objetivo deste trabalho foi avaliar a acurácia da PCR quantitativa (qPCR) realizada em amostras de pele íntegra congelada (FT) e parafinada (FFPE). Trata-se de um estudo de validação, com amostras provenientes de 46 cães de uma área endêmica no Brasil. Após as coletas de amostras, as extrações de DNA foram realizadas utilizando-se kits comerciais, e a qPCR foi orientada para alvos do kDNA da espécie Leishmania infantum. Os resultados obtidos para as amostras FFPE foram 63,6% de sensibilidade e 77,1% de especificidade; para as amostras FT, 100% e 48,6%, respectivamente. A concordância dos resultados da técnica de qPCR com amostras FT e FFPE foi pobre. Os resultados sugerem que o congelamento é o método mais adequado de conservação para banco de amostras para recuperação de DNA.(AU)

Anaesthesia with desflurane-nitrous oxide in elderly patients. Comparison with isoflurane-nitrous oxide.

BACKGROUND: Desflurane is a new volatile anaesthetic, very little soluble. We wished to compare efficacy, safety, and emergence and recovers; profiles of desflurane-N2O versus isoflurane-N2O anaesthesia in elderly patients. EXPERIMENTAL DESIGN: single blind, prospective randomised study. SETTING: operating rooms of two major teaching hospitals affiliated with the University of Milan. PATIENTS: fifty-seven patients ASA physical status II or III, aged 65 or older, undergoing urological (non-endoscopic), orthopaedic or gynaecological (non-laparoscopic) surgery of at least one hour duration, were randomly assigned to receive general anaesthesia with either desflurane or isoflurane in 60% N2O- 40% O2, after standardised premedication and induction. MEASUREMENTS: vital signs, end-tidal agent, narcotic requirement, and adverse event appearance were monitored throughout the study. RESULTS: Twenty-eight patients received desflurane and 29 isoflurane. Demographics, anaesthesia duration and exposure, and intraoperative fentanyl requirement were comparable in the two groups. Immediate emergence from anaesthesia (time to extubation and hand grip on command) was faster in desflurane group, albeit not significantly (8.4 +/- 6.4 vs 11.0 +/- 6.5 min and 8.6 +/- 6.0 vs 11.8 +/- 6.0); on the contrary, early recovery (time to state the name and date of birth) was significantly shorter in patients receiving desflurane (11.1 +/- 6.2 vs 17.3 +/- 7.8 min and 13.1 +/- 6.0 vs 20.9 +/- 10.9 min). Only 24 patients (12 in desflurane and 12 in isoflurane group) did need postoperative fentanyl administration; among them, requirement was significantly higher in desflurane patients (3.4 +/- 1.1 vs 2.4 +/- 1.3 micrograms.kg-1. Total time in recovery room was not different between anaesthetics, as well as adverse event prevalence and severity. CONCLUSIONS: Early recovery in elderly patients is faster after desflurane than isoflurane anaesthesia; this might contribute to increased requirement of postoperative analgesia. Occurrence of adverse event is comparable between the two anaesthetics.

[The use of high resolution computerized tomography (HRCT) for the diagnosis of rejection and for monitoring air-way anastomosis in patients who have undergone lung transplantation. Preliminary study]. / L'impiego della Tomografia Computerizzata ad alta risoluzione (HRCT) per la diagnosi di rigetto e per il monitoraggio dell'anastomosi sulla via aerea nei pazienti sottoposti a trapianto di polmone. Studio preliminare.

March, 1991, to June, 1992, five lung transplantations for end-stage lung disease were successfully performed at the Ospedale Maggiore Policlinico in Milan. All patients underwent high-resolution CT (HRCT) of the lung in a complex follow-up program to identify specific abnormalities of acute and chronic rejection (bronchiolitis obliterans) and to monitor the resolution of the bronchial anastomosis. Twenty-two HRCT exams were performed. In patients with acute rejection HRCT failed to identify specific abnormalities of lung parenchyma. In contrast, in one patient with pathological evidence of early bronchiolitis obliterans HRCT showed decreased peripheral vascularization. In the study of the bronchial anastomosis, HRCT showed optimal anastomosis resolution in 4 patients, whereas in one patient with a granuloma demonstrated by fibrobronchoscopy it confirmed the lesion showing also a small pneumomediastinum. Even though the HRCT finding of decreased peripheral vascularization does not appear to be specific for bronchiolitis obliterans, it may be of value in suggesting the diagnosis of early bronchiolitis obliterans in lung transplant. HRCT should be used in all patients with bronchoscopic diagnosis of bronchial complication to study the lesion and its mediastinal spread.

A new device for mechanical ventilation of infants and small children.

A new device for use with adult ventilators to allow neonatal and paediatric mechanical ventilation is described. It met International Standards Organisation standards during in vitro evaluation and gave good results when applied in vivo to ten children undergoing elective surgery. The device provided a safe and cost-effective means of delivering mechanical ventilation by an adult ventilator to neonatal and paediatric patients receiving general anaesthesia.

[Endoscopic monitoring in lung transplantation. Transplantation Group of the Maggiore Policlinico Hospital of Milan]. / Il monitoraggio endoscopico nel trapianto di polmone. Gruppo Trapianto di Polmone dell'Ospedale Maggiore Policlinico di Milano.

During the period March 1991-June 1992 5 single lung transplantations were successfully performed at the Ospedale Maggiore Policlinico in Milan. All patients underwent regular fibrobronchoscopies within the context of a complex follow-up programme in order to monitor the resolution of the bronchial anastomosis and identify the onset of intercurrent lung infections and rejections using bronchioalveolar lavage (BAL) and transbronchial biopsies (TBB). Forty-four fibrobronchoscopies were performed of which 24 for anastomotic follow-up, BAL and TBB, and 20 for the simple monitoring of the anastomosis. Fibrobronchoscopies confirmed the optimal resolution of bronchial anastomosis in 4 patients, whereas one patient showed a granulomatous anastomotic reaction which was successfully treated using local steroid injections. Although recovery was normal in one patient, kinking appeared in the bronchus of the receiving lung which was successfully treated by the insertion of Gianturco prosthesis. BAL enabled the identification of 2 CMV infections, one Pseudomonas aeruginosa, one Haemophilus influenzae and one Pneumocystis carinii infection. TBB allowed 3 cases of CMW lung infection and 7 episodes of rejection to be diagnosed. The authors' personal experience confirms the decisive role played by bronchoscopy in the follow-up of lung transplant patients. This procedure allowed bronchial anastomosis to be closely monitored and was of vital importance in the diagnosis of lung infections and rejection.

[Anesthetic care for fibrobronchoscopy in patients with chronic terminal respiratory insufficiency undergoing evaluation for isolated lung transplantation]. / Assistenza anestesiologica per fibrobroncoscopia a pazienti insufficienti respiratori cronici terminali in valutazione per trapianto di polmone isolato.

During the first 18 month operation of the isolated lung transplantation program at or Institution, eight patients with terminal chronic respiratory failure underwent fiberoptic bronchoscopy and broncho-alveolar lavage as part of their evaluation for isolated lung transplantation. Four patients had severe obstructive, three restrictive, and one mixed, obstructive and restrictive, disease; all of them were on continuous supplemental oxygen. Procedures were performed under topical anaesthesia, with either light sedation or simple monitored anaesthesia care. Monitoring included non-invasive blood pressure measurement, pulse oximeter and precordial stethoscope. No adverse events were recorded, except in one case, when pulse oximeter reading precipitously dropped below 80%, to a minimum of 68-69%. The procedures was terminated short of its completion, and the patient was briefly assisted with manual bag ventilation on oxygen 100%. Pulse oximeter quickly returned to normal levels (above 90%), and the patient promptly recovered, without complications. The importance of monitored anaesthesia care during fiberoptic bronchoscopy (a usually benign procedure) in critically ill patients is greatly emphasized.

Single lung transplantation for emphysema. Lessons learned on the field. The Lung Transplant Group of the Ospedale Maggiore of Milan.

Emphysematous patients that were once treated with double lung transplantation can now also be treated with single lung transplantation. However, single lung transplantation in emphysematous patients presents problems in lung size matching, choice of side to transplant and post-operative assistance. Analysing their own experience of three single lung transplants performed on emphysematous patients, the Authors evaluate the effectiveness of the operation, the results and the difficulties encountered. Single lung transplantation is a good therapeutic option for end-stage emphysematous patients. In these patients right lung transplantation is preferable and the donor organ should be oversized. Positive and expiratory pressure in the native emphysematous lung should be applied with extreme caution.

Intrathecal morphine as an adjunct to anesthesia for head and neck surgery.

Within the past 15 years, the use of spinal opiates has gained acceptance as a means of achieving postoperative analgesia during various surgical procedures, though little has been reported concerning such use in head and neck surgery. Our experience with intrathecal morphine for eight patients who have had head and neck surgery is reviewed. Mechanisms of pain and possible sites of action of intrathecal morphine as they pertain to these patients are discussed. Adequate postoperative analgesia was achieved in seven of our eight patients. Only one patient required supplemental intravenous narcotics during the initial 24-hour postoperative period. This patient had a history of chronic narcotic use, suggesting that such patients may be tolerant to intrathecal narcotics as they are to narcotics given by other routes.

Postoperative analgesia. Use of intrathecal morphine in children.

The identification of opiate receptors in the spinal cord gave rise to the suggestion that the use of intrathecal and epidural narcotics may provide effective and safe postoperative analgesia. The authors retrospectively reviewed the records of ten children who received intrathecal morphine as part of their anesthetic care over the last 2 years. Preservative-free morphine (Duramorph) in a dose of 0.02 mg/kg was administered to all patients in the lumbar intrathecal space before the start of the surgical procedure. Adequate postoperative analgesia was achieved in the ten children. No patient required supplemental analgesic agents for the initial 15-hour postoperative period. Surgical procedures included exploratory laparotomy, laryngotracheoplasty, and craniofacial reconstruction. As with narcotics administered by any route, intrathecal morphine can cause respiratory depression, and such depression may be delayed for up to 24 hours after the dose. Therefore, the postoperative respiratory status of these children should be monitored for 24 hours after the dose, preferably in an intensive care unit. With this caveat, the use of intrathecal morphine provides safe and effective postoperative analgesia in children undergoing major surgery.

Multidisciplinary approach to extracorporeal respiratory assist for acute pulmonary failure.

A case of acute post-traumatic pulmonary failure was treated by extracorporeal respiratory assist, after conventional therapy had failed. Veno-venous bypass was established, with low extracorporeal blood flow (1.6-2 l min-1), and high exchange surface area membrane lungs (7 m2), according to the technique of low-frequency positive-pressure ventilation with extracorporeal carbon-dioxide removal. After a first disconnection, the evolution of the lung disease necessitated a second surgical procedure, during which a chest tube perforated the patient's right lower, pulmonary lobe. A two-stage right thoracotomy was performed, with the patient connected to the extracorporeal system, and receiving full heparinization. Massive bleeding and severe hypoxia were encountered, but successfully overcome. The patient is now a long-term survivor.

Influence of total parenteral nutrition on protein metabolism following acute injury: assessment by urinary 3-methylhistidine excretion and nitrogen balance.

The use of total parenteral nutrition after acute injury, either surgical or accidental, is widely accepted for its important benefits, although it is not yet completely understood whether a reduction of body protein catabolism can be effectively achieved. We applied total parenteral nutrition to 14 critically ill patients after either trauma or major surgery. Their daily nitrogen balance, urinary 3-methylhistidine and creatinine excretion, and molar 3-methylhistidine/creatinine ratio, during initial 24-hr fasting period, were respectively -0.19 +/- 0.01 (SEM) g kg-1, 5.46 +/- 0.47 mumol kg-1, 27 +/- 4 mg kg-1, and 0.030 +/- 0.005. Daily nonprotein calorie intake of 31.11 +/- 0.58 kcal kg-1, as glucose, and administration of nitrogen 0.350 +/- 0.004 g kg-1, as 10% crystalline L-aminoacids solution, and insulin 1 IU every 5.03 +/- 0.14 g of glucose, resulted in progressive decline of urinary 3-methylhistidine (4.21 +/- 0.43 mumol kg-1, p less than 0.001), creatinine (22 +/- 2 mg kg-1, NS), and their molar ratio (0.022 +/- 0.002, NS). Mean nitrogen balance resulted in 0.032 +/- 0.008 g kg-1. Since urinary 3-methylhistidine role as a marker of protein catabolism is well established, its decrease under total parenteral nutrition together with greatly improved nitrogen balance, demonstrates that our treatment can effectively quench protein catabolism, meanwhile enhancing protein synthesis.

Restoration of blood 2,3-diphosphoglycerate levels in multi-transfused patients: effect of organic and inorganic phosphate.

Blood stored in acid-citrate-dextrose (ACD) shows a progressive decrease in 2,3-diphosphoglycerate (DPG) content. Since the decrease in DPG increases hemoglobin oxygen affinity, which in turn may reduce tissue and venous PO2 and peripheral oxygen delivery, many efforts have been made to preserve or restore DPG levels in stored blood. An in vivo rejuvenating technique, employing fructose-1,6-diphosphate (FDP) at a mean dosage of 1 mmol kg-1 day-1 of phosphate, to increase the DPG circulating level in multi-transfused patients is proposed. Eighteen patients, who received at least one-third of their estimated blood volume (3990 +/- 480 (SEM) ml of ACD stored blood) in blood transfusion, were treated: nine with inorganic phosphate, and nine with FDP. Basal DPG was very low in both groups: 12.61 +/- 1.34 (SEM) and 10.42 +/- 0.98 (SEM) mumol g-1, respectively (normal value is 14.5 mumol g-1, at pH 7.40). However, DPG values increased significantly and promptly in patients receiving FDP, whereas in cases of inorganic phosphate administration, it was not significantly raised over the basal value until the third day. Phosphatemia remained normal and constant with FDP, but it rose significantly on the third day of treatment with inorganic phosphate. FDP appears to consistently and rapidly increase DPG levels after transfusion with blood stored in ACD, and to be particularly safe.

[Changes in the parameters of humoral immunity due to surgical operations or trauma]. / Alterazioni dei parametri dell'immunità umorale conseguenti ad intervento chirurgico o trauma.

Humoral immunity (immunoglobulins and C3) as well as nutritional conditions (serum albumin, transferrin) have been investigated in 23 patients in the acute phase after surgery and/or trauma. Immunoglobulin deficiency, well correlated with the severity of trauma, was observed in the most critically ill patients in the very early phase, followed by a rapid rise to near to normal values and typical immunologic response. There is no evidence that this depression of humoral immunity may enhance the risk of infectious complications in the postoperative period. Very different immunological patterns were observed in surgical patients with chronic sepsis.