Interobserver and intraobserver variability affecting the assessment of loss of autofluorescence of oral mucosal lesions.

OBJECTIVES: The assessment of loss of tissue autofluorescence (LAF) has been proposed as an adjunct to comprehensive oral examination to enhance the detection of mucosal lesions harbouring dysplasia or carcinoma. The assessment of LAF is not based on completely objectified parameters therefore intraobserver and interobserver variability cannot be neglected alongside the issue of correct interpretation of LAF. The present study evaluated intraobserver and interobserver variability in the clinical assessment of LAF as performed by oral medicine practitioners (OMPs) or general dental practitioners (GDPs). MATERIALS AND METHODS: Couples of clinical pictures, acquired under white incandescent dental operatory light and during the assessment of LAF performed by VELscope were retrieved. Four OMPs and eight GDPs were asked to assess the pictures and to score the LAF. Kappa statistics allowed the assessment of intra- and inter-observer related variability. RESULTS: Pictures of 109 lesions representative of all oral mucosal sites and clinical appearances were selected. OMPs had a better intraobserver agreement than GDPs (substantial versus moderate). The moderate (k = 0.506) interobserver agreement observed among both OMPs and GDPs in a 2-score model (positive versus negative), lowered down to poor values only among GDPs when a 3-score or 4-score model (including uncertain judgements) was applied. CONCLUSIONS: A good agreement (k>0.8) was never observed and the present results are similar to previously reported data about conventional oral examination. Irrespective of the diagnostic accuracy, the assessment of AF seems not to be able to improve observer-related variability in the clinical assessment of oral mucosal lesions.

DNA aneuploidy relationship with patient age and tobacco smoke in OPMDs/OSCCs.

The aim of this study was to investigate the relationship between tobacco smoke habit, patient age, DNA aneuploidy and genomic DNA copy number aberrations (CNAs) in oral potentially malignant disorder (OPMD) and oral squamous cell carcinoma (OSCC) patients. DNA aneuploidy was detected by high-resolution DNA flow cytometry (hr DNA-FCM) on DAPI stained nuclei obtained from multiple tissue samples from OPMDs/OSCCs in 220 consecutive patients. Nuclear genomic aberrations were determined in a subset of 65 patients by genome-wide array comparative genomic hybridization (aCGH) using DNA extracted from either diploid or aneuploid nuclei suspension sorted by FCM. DNA aneuploidy and mean nuclear genomic aberrations were associated with patients' age. In particular, DNA aneuploidy strongly associated with age in non-smoker OPMDs/OSCCs patients. OSCCs from smokers showed a lower prevalence of DNA aneuploidy compared to OSCCs from non-smokers. A higher occurrence of DNA aneuploidy (particularly in smokers' OPMDs) was observed in patients characterized by involvement of a single oral subsite. Our study suggests that: 1) DNA aneuploidy in non-smokers is mainly related to aging; 2) OPMDs/OSCCs involving multiple oral subsites in smokers are less likely to develop DNA aneuploidy compared to non-smokers; 3) OSCC development is characterized by both CIN and CIN-independent mechanisms and that the latter are more relevant in smokers. This study provides evidence that DNA diploid OPMDs may be considered at lower risk of cancerization than DNA aneuploid ones in non-smokers but not in smokers.

Genomic DNA Copy Number Aberrations, Histological Diagnosis, Oral Subsite and Aneuploidy in OPMDs/OSCCs.

Oral potentially malignant disorders (OPMDs) characterized by the presence of dysplasia and DNA copy number aberrations (CNAs), may reflect chromosomal instability (CIN) and predispose to oral squamous cell carcinoma (OSCC). Early detection of OPMDs with such characteristics may play a crucial role in OSCC prevention. The aim of this study was to explore the relationship between CNAs, histological diagnosis, oral subsite and aneuploidy in OPMDs/OSCCs. Samples from OPMDs and OSCCs were processed by high-resolution DNA flow cytometry (hr DNA-FCM) to determine the relative nuclear DNA content. Additionally, CNAs were obtained for a subset of these samples by genome-wide array comparative genomic hybridization (aCGH) using DNA extracted from either diploid or aneuploid nuclei suspension sorted by FCM. Our study shows that: i) aneuploidy, global genomic imbalance (measured as the total number of CNAs) and specific focal CNAs occur early in the development of oral cancer and become more frequent at later stages; ii) OPMDs limited to tongue (TNG) mucosa display a higher frequency of aneuploidy compared to OPMDs confined to buccal mucosa (BM) as measured by DNA-FCM; iii) TNG OPMDs/OSCCs show peculiar features of CIN compared to BM OPMDs/OSCCs given the preferential association with total broad and specific focal CNA gains. Follow-up studies are warranted to establish whether the presence of DNA aneuploidy and specific focal or broad CNAs may predict cancer development in non-dysplastic OPMDs.

Clinical Coronary In-Stent Restenosis Follow-Up after Treatment and Analyses of Clinical Outcomes / Reestenose Clínica de Stent Coronariano: Seguimento após Tratamento com Análise de Desfechos Clínicos

Background: Clinical in-stent restenosis (CISR) is the main limitation of coronary angioplasty with stent implantation. Objective: Describe the clinical and angiographic characteristics of CISR and the outcomes over a minimum follow-up of 12 months after its diagnosis and treatment. Methods: We analyzed in 110 consecutive patients with CISR the clinical presentation, angiographic characteristics, treatment and combined primary outcomes (cardiovascular death, nonfatal acute myocardial infarction [AMI]) and combined secondary (unstable angina with hospitalization, target vessel revascularization and target lesion revascularization) during a minimal follow-up of one year. Results: Mean age was 61 ± 11 years (68.2% males). Clinical presentations included acute coronary syndrome (ACS) in 62.7% and proliferative ISR in 34.5%. CISR was treated with implantation of drug-eluting stents (DES) in 36.4%, Bare Metal Stent (BMS) in 23.6%, myocardial revascularization surgery in 18.2%, balloon angioplasty in 15.5% and clinical treatment in 6.4%. During a median follow-up of 19.7 months, the primary outcome occurred in 18 patients, including 6 (5.5%) deaths and 13 (11.8%) AMI events. Twenty-four patients presented a secondary outcome. Predictors of the primary outcome were CISR with DES (HR = 4.36 [1.44–12.85]; p = 0.009) and clinical treatment for CISR (HR = 10.66 [2.53–44.87]; p = 0.001). Treatment of CISR with BMS (HR = 4.08 [1.75–9.48]; p = 0.001) and clinical therapy (HR = 6.29 [1.35–29.38]; p = 0.019) emerged as predictors of a secondary outcome. Conclusion: Patients with CISR present in most cases with ACS and with a high frequency of adverse events during a medium-term follow-up. .

Fundamento: A Reestenose Intrastent Clínica (RISC) é a principal limitação da angioplastia coronariana com implante de stent. Objetivo: Descrever as características clínicas e angiográficas da RISC e os desfechos em seguimento de pelo menos doze meses após seu diagnóstico e tratamento. Métodos: Em 110 pacientes consecutivos com RISC, analisaram-se a apresentação clínica, as características angiográficas, o tratamento e os desfechos primário combinado (morte cardiovascular, Infarto Agudo Miocárdio não fatal [IAM]) e secundário combinado (angina instável com internação, revascularização de vaso alvo e lesão alvo) em seguimento mínimo de um ano. Resultados: A média de idade da amostra foi de 61 ± 11 anos (68,2% do sexo masculino). A apresentação clínica foi como Síndrome Coronariana Aguda (SCA) em 62,7%, com RIS proliferativa em 34,5% dos casos. O tratamento realizado foi o implante de Stent Farmacológico (SF) em 36,4%; de Stent Não Farmacológico (SNF) em 23,6%; cirurgia de revascularização em 18,2%; angioplastia por balão em 15,5%; e tratamento clínico em 6,4%. Com seguimento mediano de 19,7 meses, o desfecho primário ocorreu em 18 pacientes, com seis (5,5%) óbitos e 13 (11,8%) IAM, e o secundário em 24 pacientes. Foram preditores de desfecho primário a RISC em SF (HR = 4,36; [1,44 - 12,85], p = 0,009) e o tratamento clínico da RISC (HR = 10,66, [2,53 - 44,87], p = 0,001). O tratamento da RISC com SNF (HR = 4,08 [1,75 - 9,48], p = 0,001) e tratamento clínico (HR = 6,29 [1,35 - 29,38], p = 0,019) foram preditores do desfecho secundário. Conclusão: A RISC se apresenta como SCA na maioria dos casos e os pacientes apresentam elevada frequência de eventos adversos durante o seguimento de médio prazo. .

Clinical Coronary In-Stent Restenosis Follow-Up after Treatment and Analyses of Clinical Outcomes.

BACKGROUND: Clinical in-stent restenosis (CISR) is the main limitation of coronary angioplasty with stent implantation. OBJECTIVE: Describe the clinical and angiographic characteristics of CISR and the outcomes over a minimum follow-up of 12 months after its diagnosis and treatment. METHODS: We analyzed in 110 consecutive patients with CISR the clinical presentation, angiographic characteristics, treatment and combined primary outcomes (cardiovascular death, nonfatal acute myocardial infarction [AMI]) and combined secondary (unstable angina with hospitalization, target vessel revascularization and target lesion revascularization) during a minimal follow-up of one year. RESULTS: Mean age was 61 ± 11 years (68.2% males). Clinical presentations included acute coronary syndrome (ACS) in 62.7% and proliferative ISR in 34.5%. CISR was treated with implantation of drug-eluting stents (DES) in 36.4%, Bare Metal Stent (BMS) in 23.6%, myocardial revascularization surgery in 18.2%, balloon angioplasty in 15.5% and clinical treatment in 6.4%. During a median follow-up of 19.7 months, the primary outcome occurred in 18 patients, including 6 (5.5%) deaths and 13 (11.8%) AMI events. Twenty-four patients presented a secondary outcome. Predictors of the primary outcome were CISR with DES (HR = 4.36 [1.44-12.85]; p = 0.009) and clinical treatment for CISR (HR = 10.66 [2.53-44.87]; p = 0.001). Treatment of CISR with BMS (HR = 4.08 [1.75-9.48]; p = 0.001) and clinical therapy (HR = 6.29 [1.35-29.38]; p = 0.019) emerged as predictors of a secondary outcome. CONCLUSION: Patients with CISR present in most cases with ACS and with a high frequency of adverse events during a medium-term follow-up.

Análise dos casos de endocardite infecciosa em um hospital terciário / Analysis of infectious endocarditis cases in a tertiary hospital

Introdução e objetivos: a endocardite infecciosa (EI) é uma doença com alta morbimortalidade, apesar do aprimoramento do diagnóstico e da terapia antimicrobiana. A identificação precoce de pacientes com alto risco de morte ou complicações pode melhorar o desfecho dessa doença. O objetivo foi analisar os casos de EI em um hospital terciário e seus desfechos intra-hospitalares. Pacientes e métodos: analisados retrospectivamente 93 episódios confirmados de EI, em 91 pct, no período de janeiro de 2001 a dezembro de 2008. As variáveis analisadas foram: dados clínicos, infecciosos, modalidade terapêutica e desfechos na evolução hospitalar. A análise estatística utilizou teste do qui-quadrado, Odds Ratio e teste de Mann-Whitney. Resultados: a mortalidade intra-hospitalar ocorreu em 35% (IC 95%; 26-41%), as próteses valvares foram acometidas em 60,23% dos casos, as hemoculturas sem isolamento ocorreram em 36,56%. Nas hemoculturas positivas, o principal agente etiológico isolado foi o Staphylococcus aureus (31,18%), o S. aureus multissensivel em 22,8% e o S. aureus MARSA em 8,6%. A intervenção cirúrgica foi realizada em 48,39% e o principal indicador cirúrgico foi a falha ao tratamento clínico (20,43%). Pacientes que tiveram a ICCcomo desfecho apresentaram mortalidade de 57,14% (p= 0,004 e OR de 3,76, IC 95% ; 1,41- 10,03) e aqueles com marca-passo como sítio de infecção, mortalidade de 66,67%. Conclusões: a EI permanece com elevada morbimortalidade. A mortalidade difere em relação aos agentes etiológicos, estado cardíaco prévio, sítio de infecção e aumento da idade.

Introduction and objective: infectious endocarditis (IE) is a disease with high morbidity and mortality despite improvements in diagnosis and antimicrobial therapy. The early identification of patients at high risk of death or complications can improve the outcome of this disease. The objective was to analyze IE cases in a tertiary hospital and their in-hospital outcomes. Patients and methods: 93 episodes of IE were retrospectively analyzed in 91 patients, between January of 2001 and December of 2008. The analyzed variables were: clinical and infectious data, therapeutic modality, and outcomes during hospital developments. The statisticalanalysis employed the Chi-square, odds ratio, and Mann-Whitney tests. Results: the in-hospital mortality occurred in 35% (IC 95%; 26-41%), valve prostheses were involved in 60.23% of cases, and blood cultures without isolation occurred in 36.56%. In positive blood cultures, the main etiological agent isolated was Staphylococcus aureus in 31.18%, multi sensitive S. aureus in 22.8%, and S. aureus MARSA in 8.6%. Surgical intervention was performed in 48.39% of the patients and the main surgical indicator was failure of clinical treatment (20.43%) Patients who have had ICC as outcome presented 57.14% mortality (p = 0.004 and OR of 3.76, IC 95%;1.41-10.03); mortality rate of 66.67% as observed in those with pacemakers as the site of infection. Conclusions: IE remains with high morbidity and mortality. Mortality rates vary according to the etiological agent, prior cardiac state, site of infection, and increased age.

Femoral versus Radial Access in Primary Angioplasty. Analysis of the ACCEPT Registry / Via de Acesso Femoral versus Radial na Angioplastia Primária. Análise do Registro ACCEPT

Background: The radial access provides a lower risk of bleeding and vascular complications related to the puncture site in comparison to the femoral access. Recent studies have suggested a reduction in mortality associated with the radial access in patients with acute myocardial infarction undergoing percutaneous coronary intervention. Objective: To compare the occurrence of adverse cardiovascular ischemic and hemorrhagic events in patients undergoing primary angioplasty according to the type of arterial access route. Methods: From August 2010 to December 2011, 588 patients undergoing primary percutaneous coronary intervention during acute ST-segment elevation myocardial infarction were assessed; they were recruited from 47 centers participating in the ACCEPT registry. Patients were grouped and compared according to the arterial access used for the procedure. Results: The mean age was 61.8 years; 75% were males and 24% had diabetes mellitus. There was no difference between groups as regards the procedure success rate, as well as regards the occurrence of death, reinfarction, or stroke at six months of follow-up. Severe bleeding was reported in 1.1% of the sample analyzed, with no statistical difference related to the access used. Conclusions: The femoral and radial accesses are equally safe and effective for the performance of primary percutaneous coronary intervention. The low rate of cardiovascular events and of hemorrhagic complications reflects the quality of the participating centers and the operators expertise with the use of both techniques. .

Fundamentos: O acesso radial promove menor risco de sangramento e complicações vasculares relacionadas ao sítio de punção quando comparado ao acesso femoral. Estudos recentes sugerem redução de mortalidade favorável ao primeiro em pacientes com infarto agudo do miocárdio submetidos à intervenção coronária percutânea. Objetivo: Comparar a ocorrência de eventos cardiovasculares adversos isquêmicos e hemorrágicos em pacientes submetidos à angioplastia primária conforme a via de acesso arterial. Métodos: No período de agosto de 2010 a dezembro de 2011, foram avaliados 588 pacientes que realizaram intervenção coronária percutânea primária na vigência de um infarto agudo do miocárdio com supradesnivelamento de ST, incluídos em 47 centros participantes do registro ACCEPT. Os pacientes foram agrupados e comparados de acordo com a via de acesso arterial utilizada para a efetivação do procedimento. Resultados: A média de idade foi de 61,8 anos, sendo 75% pertencentes ao sexo masculino e 24% portadores de diabetes melito. Não houve diferença entre os grupos na taxa de sucesso do procedimento, bem como na ocorrência de óbito, reinfarto ou acidente vascular encefálico aos seis meses de seguimento. Sangramento grave foi relatado em 1,1% da amostra analisada, sem diferença estatística conforme a via de acesso utilizada. Conclusões: As vias de acesso femoral e radial são igualmente seguras e eficazes para a realização de intervenção coronária percutânea primária. A baixa taxa de eventos cardiovasculares, bem como de complicações hemorrágicas, reflete a qualidade dos centros participantes e a experiência dos operadores com a utilização de ambas as técnicas. .

Microbiopsy a novel sampling technique to early detect dysplastic/malignant alterations in oral mucosal lesions: practicability by general dentists.

BACKGROUND: When used in oral medicine clinics, microbiopsy is able to obtain tissue fragments suitable for a highly sensitive first-level diagnosis of dysplastic/malignant alterations in oral mucosal lesions. If feasible by general dentists, this sampling technique could reduce the diagnostic delay for oral malignant and premalignant lesions. This study assesses the adequacy of microbiopsy samples when taken by general dentists. METHODS: Fifty dentists, without specific training on oral medicine, volunteered for enrolment. They were given brief training and asked to prospectively sample any mucosal lesion observed during their routine practice. The sample adequacy features were assessed. RESULTS: The dentists sampled 152 lesions; there were 92.1% of adequate samples (140/152), and the BMZ was visible in 78.6% of these (110/140). Neither the clinical aspect nor lesion site affected either the adequacy or the presence of BMZ. CONCLUSIONS: The high adequacy rate observed and the advantages histological specimens have over cytological ones go to support the feasibility of microbiopsy taken by general dentists for the characterization of oral mucosal lesions and in selecting those requiring further assessment in specialized oral medicine centres.

Choristoma involving the floor of the mouth and the anterior tongue: a case of teratoid cyst with gastric and respiratory epithelia.

Oral dysontogenic cysts result from defective embryonic development. Among them teratoid cysts are the most unusual presentation and may be lined by gastric, intestinal, respiratory, squamous, ciliated epithelium or even pancreatic structures. Teratoid cysts containing respiratory and gastrointestinal epithelium have typically been called choristomas. This article describes a 15-year-old boy presenting a choristoma involving both the floor of the mouth and the anterior tongue and characterized by the presence of squamous epithelium with skin adnexa, gastric and respiratory epithelium.

Implante percutâneo de stent em artérias carótidas e vertebrais: dados do REMAT (Registro Madre Teresa) / Carotid and vertebral artery stenting: REMAT data (Madre Teresa Registry)

INTRODUÇÃO: O acidente vascular encefálico (AVE) é a principal causa de morbidade e mortalidade no Brasil. Entre 10% e 30% dos AVEs estão associados à doença carotídea e 8%, à artéria vertebral. O tratamento endovascular das lesões extracrania­nas é alternativa à endarterectomia. Analisamos os resultados e avaliamos os preditores de eventos adversos em pacientes submetidos a angioplastia carotídea e vertebral com implante de stents. MÉTODOS: Incluídos assintomáticos com lesão > 70% ou sintomáticos com lesão > 50% em artérias carótidas e sintomáticos com lesão > 70% em artérias vertebrais. Avaliamos desfecho primário, definido como a incidência combinada de morte relacionada ou não ao procedimento, AVE maior, AVE menor ou infarto agudo do miocárdio (IAM). RESULTADOS: Realizadas 224 intervenções com implante de stents em 199 pacientes consecutivos, com predomínio do sexo masculino (73,9%), idade de 69,8 ± 9,9 anos e 37,7% eram diabéticos. Pacientes sintomáticos representaram cerca de dois terços dos casos e as lesões mais tratadas foram as lesões de novo (96,4%). As artérias carótidas internas esquerda (46%) e direita (44,6%) foram os vasos mais abordados. Desfecho combinado primário ocorreu em 5%, mortalidade relacionada ao procedimento em 1%, mortalidade não-relacionada ao procedimento em 1%, AVE menor em 1,5% e IAM em 1,5%. Pacientes com antecedente de doença arterial coronária mostraram chance de apresentar desfecho primário 4 vezes maior [odds ratio (OR) 4,32, intervalo de confiança de 95% (IC 95%) 1,09-17,21; P = 0,038]. CONCLUSÕES: Em nosso estudo obtivemos alto índice de sucesso e baixa ocorrência de eventos adversos, que demonstram a segurança e a eficácia do implante percutâneo de stent em artérias carótidas e vertebrais.

BACKGROUND: Stroke remains the leading cause of morbidity and mortality in Brazil. Epidemiological data suggest that 10% to 30% of all strokes are due to atherosclerotic carotid artery disease and 8% due to vertebral artery disease. Endovascular treatment of extracranial lesions is an alternative to endarterectomy. We evaluated the results and predictors of adverse events in patients undergoing carotid and vertebral artery stenting. METHODS: Asymptomatic patients with lesion > 70% or symptomatic patients with lesions > 50% in carotid arteries and symptomatic patients with lesion > 70% in vertebral arteries were included. We evaluated the primary endpoint, defined as the composite incidence of death (procedural or non-procedural), major stroke, minor stroke or myocardial infarction (MI). RESULTS: Two hundred and twenty-four interventions with stenting were performed in 199 consecutive patients with a prevalence of males (73.9%), 69.8 ± 9.9 years of age and 37.7% were diabetics. Symptomatic patients represented about two thirds of the cases and the most commonly treated lesions were de novo lesions (96.4%). The left (46%) and right (44.6%) internal carotid arteries were the most commonly approached vessels. Composite primary endpoint was observed in 5% of the patients, procedure-related mortality in 1%, non-procedure related mortality in 1%, minor stroke in 1.5% and MI in 1.5%. Patients with a history of coronary artery disease had a 4-fold probability of presenting the primary endpoint [odds ratio (OR) 4.32, 95% confidence interval (CI 95%) 1.09-17.21); P = 0.038]. CONCLUSIONS: In our study we obtained a high success rate and had a low rate of adverse events, demonstrating the safety and efficacy of percutaneous stent implantation in the carotid and vertebral arteries.

Infarto do miocárdio semsupradesnivelamento do segmento ST:características clínicas, angiográficas eevolução intra-hospitalar dos pacientes / Myocardial infarction without ST segment elevation: clinical and angiographic characteristics, and evolution of inpatients

Fundamento: as características angiográficas dos pacientes com infarto sem supradesnivelamento do segmento ST (IAMSSST) reforçam medidas mais agressivas, independentemente do escore de risco. Objetivo: analisar e descrever as características clínicas basais, dados angiográficos da artéria relacionada ao infarto (ARI) e as complicações clínicas ocorridas na evolução intra-hospitalar em pacientes com IAMSSST submetidos à intervenção coronariana percutânea (ICP). Métodos: estudo de coorte retrospectivo de 81 pacientes com IAMSSST e ARI identificada. Analisados dados clínicos e angiográficos, incluindo localização da ARI, TIMI fluxo pré e pós-procedimento, grau de estenose arterial, ventriculografia e tipo de stent implantado. Resultados: os 81 pacientes analisados realizaram ICP. A média de idade foi de 66,94 anos. Observou-se elevado grau de estenose superior a 90% ou de oclusão total da ARI em 66,7% dos casos e TIMI fluxo de grau reduzido (graus 0,1 e 2) em 53,1%. A lesão da artéria circunflexa (CX) predominou em 42,5%, seguida pela descendente anterior (DA) em 30% e pela coronária direita (CD) em 27,5%. Em 88,23% das vezes em que a CX esteve acometida predominaram as lesões mais graves (superior a 90% ou oclusão). A disfunção ventricular moderada ou grave foi encontrada em 42 pacientes (54,54%); 12 (14,81%) apresentaram complicação intra-hospitalar. A insuficiência cardíaca foi detectada em seis casos (7,40%), seguida por angina IIIC de Braunwald e sangramento com necessidade de hemotransfusão com dois casos cada (2,46%). Um caso evoluiu com óbito (1,23%). Conclusão: na presente análise os pacientes com IAMSSST apresentaram alto número de oclusões e lesões graves, superior a 90% (66,7%), e elevado grau de TIMI fluxo reduzido (graus 0, 1 e 2): 53, 1%. Obteve-se elevado índice de sucesso na recanalização da ARI (96,29%).

Background: The angiographic characteristics of patients with myocardial infarction without ST segment elevation account for the need of aggressive measures irrespective of risk score. Objective: To analyze and describe basic clinical characteristics, angiographic data of infarct-related arteries and clinical complications in the course of inpatients? progress upon percutaneous coronary intervention. Methods: This is a retrospective cohort study of 81 patients whose infarct-related artery had been identified. The study involved the analysis of clinical and angiographic data, including localization of the infarct-related artery, pre- and post-surgery TIMI flow, level of arterial stenosis, ventriculography and type of implanted stent. Results: All the 81 patients analyzed had undergone percutaneous coronary interven-tion. Average age was 66.94 years. The results point to high level of superior stenosis (>90%) or total occlusion of the infarct-related artery (66.7 %), and low TIMI flow grades of 0 1 and 2 (53.1%). Lesion in the circumflex artery prevailed in 42.5 % of the cases, followed by the anterior descending artery (30 %), and the right coronary artery (27.5 %). Cases with affected circumflex artery usually had the mostsevere lesions (above 90 % or occlusion). Mild or serious ventricular dysfunction was found in 42 patients (54.54%); 12 patients (14.81 %) had complications while in hospital. Cardiac insufficiency was detected in 6 cases (7.40%), followed by 2 cases (2.46 %) of angina of type IIC according to Braunwald Classification, and 2 cases of bleeding requiring blood transfusion. One case progressed to death (1.23 %).Conclusion: The analysis pointed to high numbers of occlusions and severe lesions, over 90% (66.7%), and high rate (53.1 %) of reduced TIMI flow (grades 0. 1 and 2). The number of successful recanalization of the infarct-related artery was high (96.29 %).

Field effect in oral precancer as assessed by DNA flow cytometry and array-CGH.

OBJECTIVE: 'Field cancerization' is an accepted model for oral carcinogenesis. So far, genetically altered fields have been just reported in the presence of carcinomas. This study assessed the distant mirror fields (MFs) of oral precancer by DNA high-resolution flow cytometry (hr DNA-FCM) and array-Comparative Genomic Hybridization (a-CGH). METHODS: Five leukoplakias without dysplasia (OLs), seven dysplastic leukoplakias (DOLs), and 12 corresponding visually normal and non-dysplastic MFs were analyzed. DNA aneuploidy (DNA Index, DI ≠ 1) was detected by hr DNA-FCM on DAPI stained nuclei suspensions. The epithelial DNA aneuploid subclones were FCM-sorted to obtain genomic DNA for a-CGH. RESULTS: Mirror fields, OLs, and DOLs showed increasing prevalence of DNA aneuploidy of, respectively, 8%, 20%, and 57%. The average number of chromosome aberrations (Ch-Abs) was 2.8 in MFs, 3 in OLs, and 10.6 in DOLs. MFs relative to OLs and DOLs had average numbers of Ch-Abs, respectively, of 1.8 and 3.6. Ch-Abs were also observed in DNA diploid sublines, and often the same aberrations were observed in both MFs and corresponding OLs/DOLs. CONCLUSION: DNA aneuploidy and Ch-Abs in MFs, the last ones being mainly gains, indicate an early onset of field effect in oral carcinogenesis.

Intervenção coronária percutânea eletiva após fibrinólise: dados do REMAT (Registro Madre Teresa) / Elective percutaneous coronary intervention after fibrinolysis: REMAT data (Madre Teresa Registry)

Introdução: O infarto agudo do miocárdio (IAM) permanece com elevados índices de morbidade e mortalidade e representa problema de saúde pública. Analisamos os resultados e os preditores de risco de eventos adversos hospitalares em pacientes submetidos a intervenção coronária percutânea (ICP) eletiva pós-fibrinólise. Métodos: Foram selecionados 303 pacientes com diagnóstico de IAM submetidos a reperfusão farmacológica e transferidos para um centro terciário para realização de ICP eletiva. Resultados: A população era predominantemente masculina (76,6), com média de idade de 59,4 ± 11,1 anos, 18,1 eram diabéticos e 86,8 estavam em Killip I. Estreptoquinase foi empregada em 91,7, o tempo médio de realização da ICP eletiva foi de 5,6 ± 3,7 dias após a fibrinólise e o fluxo TIMI 3 (74,2) foi o mais prevalente. Os stents foram implantados em 97,7 dos pacientes e o sucesso angiográfico foi de 95,3. Mortalidade ocorreu em 3,3 dos pacientes; reinfarto, em 3,6; revascularização da lesão-alvo, em 1,3; e sangramentos maiores, em 2. A análise multivariada apontou sexo feminino, idade > 65 anos, fluxo TIMI 1, presença de trombos no vaso tratado, Killip > I e disfunção grave do ventrículo esquerdo como preditores independentes de eventos adversos hospitalares. Conclusões: A estratégia de reperfusão farmacológica seguida de transferência para realização de ICP apresenta baixas taxas de eventos adversos hospitalares e é alternativa interessante à ICP primária no cenário nacional. Necessita, no entanto, políticas públicas para aperfeiçoar a logística de manuseio desses pacientes e dispô-la de maneira eficiente a todos os hospitais de baixa e média complexidades nacionais.

Distinctive chromosomal instability patterns in oral verrucous and squamous cell carcinomas detected by high-resolution DNA flow cytometry.

BACKGROUND: Oral verrucous carcinomas (OVCs) are characterized by better prognosis than oral squamous cell carcinomas (OSCCs). Because chromosomal instability (CIN) in solid tumors is indicative of prognosis, this study investigated whether OVCs and OSCCs were characterized by differences in CIN biomarkers. METHODS: Fresh or frozen multiple tissue samples were submitted to high-resolution DNA flow cytometry (hr DNA-FCM). RESULTS: DNA aneuploid sublines were detected in 6 of 9 OVCs (66.7%) and in 20 of 25 OSCCs (80.0%). Multiple DNA aneuploid sublines were observed, respectively, in 2 of 6 (33.3%) DNA aneuploid OVCs and in 14 of 20 (70%) DNA aneuploid OSCCs (P = .163). OVCs were mainly characterized by DNA Index (DI) values in the near-diploid region (DI≠1 and DI < 1.4), whereas aneuploid OSCCs carried most frequently multiple aneuploid sublines with high DI values (DI ≥ 1.4). DNA near-diploid and high aneuploid sublines were, respectively, 87.5% and 12.5% for the OVCs versus 30% and 70% for the OSCCs (P = .004). CONCLUSIONS: Present data suggest that OVCs are characterized by a lower degree of CIN and tumor heterogeneity than OSCCs, such that they appear as "frozen" in an early stage of DNA near-diploid aneuploidy, as previously observed for oral preneoplastic lesions. These DI characteristics, which can easily be obtained by hr DNA-FCM, appear to reflect the well-known differences in aggressiveness and prognosis of OVCs and OSCCs.

Intervenções percutâneas na isquemia arterial mesentérica: indicações, técnica e tratamento / Percutaneous intervention in mesenteric arterial ischemia: indications, techniques and treatment

Os relatos científicos a respeito da isquemia arterial mesentérica sugerem que essa doença é pouco entendida, muito pouco diagnosticada e raramente tratada, apesar de sua alta letalidade. O prognóstico da isquemia mesentérica dependerá do rápido restabelecimento do fluxo sanguíneo, seja por meio de medidas clínicas, cirúrgicas, endovasculares ou da combinação destas. Neste artigo revisam-se as principais evidências diagnósticadas da isquemia mesentérica bem como as opções terapêuticas disponíveis, incluindo a intervenção percutânea como método alternativo à cirurgia, que é associada a significativa taxas de morbidade e mortalidade.

Scientific reports on mesenteric arterial ischemia suggest that the disease is not thoroughly understood, is poorly diagnosed and rarely treated, despite its high lethality. The prognosis of mesenteric ischemia depends on a fast restoration of blood flow, which may be achieved by clinical, surgical and endovascular management or by a combination of all them. This article reviews the diagnostic evidence of mesenteric ischemia and the available therapeutic options including percutaneous intervention as an alternative method to surgery, which is associated to significant mortality and morbidity rates.

Revascularizaçäo completa do miocárdio: pontes seqüenciais de veia safena, anastomoses seqüenciais da artéria torácica interna e enxertos compostos: análise de 165 casos consecutivos / Complete myocardial revascularization: sequential bypass with saphenous veins, internal thoracic artery and composed grafts: analysis of 165 consecutive cases

Buscando a revascularizaçäo completa do miocárdio, 165 casos foram analisados dentre 359 pacientes submetidos a cirurgia de revascularizaçäo do miocárdio, no período de janeiro de 1995 a janeiro de 1996, com pontos de veia safena e/ou artéria torácica interna, de forma seqüencial, ou associadas como enxertos compostos. Destes, 132 receberam pontes seqüenciais de veia safena servindo a 2 ou mais ramos arteriais coronários, 25 foram tratados através de anastomoses seqüenciais de artéria torácica interna, de forma simples, interessando aos ramos interventricular anterior e diagonais de coronária esquerda, enquanto 8 receberam enxertos compostos de artéria torácica interna direita e esquerda associados s segmentos de veias safenas, que terminavam em ramos das artérias coronárias direita e esquerda. Em 96 por cento os casos a operaçäo programadas foi realizada, obtendo-se revascularizaçäo completa. Ocorreu um único (0,6 por cento) óbito hospitalar conseqüente a infarto do miocárdio transoperatório, seguido de síndrome de baixo débito cardíaco; a morbidade nao diferiu daquela presente nos procedimentos usuais de revascularizaçäo cirúrgica do miocárdio. Os cuidados na dissecçäo e preparo dos pedículos da artéria torácica interna, bem como na retirada e preparo para implante das veias safenas, somados àqueles necessários à obtençao da perfeita anastomose seqüencial, de modo a evitar torçöes, angulaçöes e acotovelamentos dos enxertos, säo enfatizados como fundamentais para o excelente resultado obtido na série analisada. Nossos resultados entusiasmam o emprego da crescente freqüência no uso da técnica da revascularizaçäo completa do miocárdio.

Tratamento cirúrgico das dissecçöes agudas de aorta do tipo B: técnica da "tromba de elefante" modificada pelo emprego de prótese intraluminal sem sutura / Surgical treatment of acute dissections of the aorta of B type: modified elephant trink technique with the use of intraluminal prothesis without suture

Durante a última década, a cirurgia cardiovascular experimentou grande impulso, com o desenvolvimento de métodos de diagnóstico, técnicas de proteçao miocárdica e cerebral, técnicas de sutura e circulaçao extracorpórea, que, somados à maior experiência dos cirurgioes, permitiu o questionamento da indicaçao do tratamento clínico para as dissecçoes agudas de aorta do tipo B, procurando, com o tratamento cirúrgico, reduçao da alta taxa de mortalidade desta doença. A técnica da "tromba de elefante", descrita por Borst, foi adaptada por Palma e Buffolo para o tratamento das dissecçoes agudas de aorta do tipo B, oferecendo bons resultados, além de facilidade técnica por nao manipular o tecido doente e friável da aorta durante o ato cirúrgico. No período de 31/6/92 a 20/2/95, 7 pacientes foram operados com esta técnica sendo l paciente do sexo feminino e 6 do sexo masculino. Tivemos 2 (28,5 por cento) óbitos, que nao podem ser relacionados à técnica cirúrgica. Neste trabalho, apresentamos modificaçao da técnica da "tromba de elefante", com o emprego do anel intraluminal, desenvolvido em nosso Serviço, dispensando qualquer tipo de sutura para anastomose, obtendo diminuiçao acentuada do tempo de parada circulatória total, permitindo dispensar a hipotermia profunda.

Correçäo cirúrgica dos aneurismas da aorta: novo dispositivo que transforma qualquer tipo de prótese em prótese intraluminal / Surgical correction of aortic aneurysms: a new device who modified any kind of prosthesis in intraluminal prosthesis

Os autores propoem o tratamento dos aneurismas da aorta com prótese intraluminal. É usado um novo dispositivo que transforma prótese de tipo, tamanho e diâmetro diferentes em prótese intraluminal, excluindo qualquer tipo de sutura para a fixaçao, e usando apenas uma ligadura circunferencial extravascular. Entre maio de 1989 e janeiro de 1993, 22 pacientes foram submetidos a aneurismectomia da aorta usando esta técnica: 12 pacientes com dissecçao aguda da aorta tipo i e II de DeBAKEY, 1 paciente com dissecçao aguda da aorta tipo III de DeBAKEY, 2 pacientes com aneurisma da aorta descendente, 2 pacientes com aneurisma da aorta toracoabdominal e 5 pacientes com aneurisma da aorta abdominal. Três pacientes evoluíram para o óbito no pós-operatório por acidente vascular cerebral, trombose mesentérica e infecçao pulmonar, respectivamente. Os pacientes sobreviventes estao sendo seguidos trimestralmente em ambulatório e encontram-se assintomáticos. O uso do anel rígido sulcado de Delrin (R) simplifica a técnica cirúrgica, reduzindo o tempo de circulaçao extracorpórea e de parada cardíaca, dispensando o uso de hipotermia profunda e reduzindo o sangramento. Permite ainda o seu uso em qualquer local da aorta de maneira rápida, fácil e de baixo custo.