[Recommendations on telestroke in Europe]. / Evropeiskie rekomendatsii po telemeditsine insul'ta.

INTRODUCTION: This paper is an adapted translation of recommendations on telestroke provided by the European Stroke Organization. Lack of stroke specialists determines that many European rural areas remain underserved. Use of telemedicine in stroke care has shown to be safe, increase use of evidence-based therapy and enable coverage of large areas of low population density. An aim of the study is to summarise the following recommendations of the Telestroke Committee of the European Stroke Organization on the setup of telestroke networks in Europe: Hospitals participating in telestroke networks should be chosen according to criteria that include population density, transportation distance, geographic specifics and in-hospital infrastructure and professional resources. Three hospital categories are identified to be part of a hub-and-spoke network: (1) the Telemedicine Stroke Centre (an European Stroke Organization stroke centre or equivalent with specific infrastructure and setup for network and telemedicine support), (2) the telemedicine-assisted stroke Unit (equivalent to an European Stroke Organization stroke unit but without 24 h onsite stroke expertise) and (3) the telemedicine-assisted stroke ready hospital (only covering hyperacute treatment in the emergency department and transferring all patients for further treatment).

[Primary sclerosing cholangitis in children and adolescents]. / Colangite esclerosante primária em crianças e adolescentes.

Primary sclerosing cholangitis is a disease usually with a poor prognosis with a mean survival of 10-12 years, starting from the time of diagnosis. Among the different populations studied, males predominate in a ratio 2:1 with ages ranging from 20-78 (mean 42 years). This article describes four patients with this syndrome, a child of eight and three adolescents, thirteen and fourteen years old. It is possibly of autoimmune etiology, characterized by stenosis, dilatation and fibrosis involving the intrahepatic and extrahepatic biliary tree. We analyzed laboratory assays, clinical, immunological, laboratory assays, histological and cholangiographic aspects. In conclusion, in this age group perhaps of the small population sample there was no sex predominance, and 50% progressed without jaundice and without hepatomegaly. The serum levels of gamma glutamyltransferases and especially alkaline phosphatase were elevated compared to aminotransferases without increase of the serum auto antibodies. Only one patients displayed the typical histological appearance of primary sclerosing cholangitis. The diagnosis in al was confirmed by typical cholangiographic signs, restricted only to the intrahepatic biliary tree, identified in all those included in this study.

[Diffuse primary malignant mesothelioma in abdominal cavity]. / Mesotelioma maligno primário difuso em cavidade abdominal.

Two cases of diffuse malignant mesothelioma of abdominal cavity were analysed. These tumors arise from the peritoneum and are also found in the parietal and visceral pleura, pericardium and in vaginal tunic. All of them, infra or supra-diaphragmatic, are associated with asbestos exposure in at least 80% of cases. It is difficult to explain how inhaled asbestos induces peritoneal neoplasms. This aspects become very important in the diagnostic, basically why it is done at laparotomy or laparoscopy. When was proceed the biopsy of the lesions, and occasionally by identification of malignant mesothelial cells in ascitic fluid. In this two cases exposed considerations about the advanced phase of diagnostic are made, the diagnostic was performed in the majority of the collected cells, showing the advanced stage of the disease. At that time of diagnosis we observed poor evolution. We call attention to the importance of precancer diagnosis, the best chance to treatment options, always based on surgical resections, radiation or chemotherapy alone or combined. If the radical surgery is not possible, this patients must be treated by chemotherapy or radiotherapy, defined after complete staging of the disease.

[Frantz tumor--report of 2 cases. Therapeutic approach and prognosis]. / Tumor de Frantz--relato de dois casos. Medidas terapêuticas e prognóstico.

The authors report two rare pancreatic tumor cases (Frantz's tumor), which were in different evolutionary stages, emphasizing the complexity of a precise anatomopathologic diagnosis and an aggressive surgical approach, whenever possible because the excellent prognosis. They also discuss the clinical manifestation and histological origin, as well as the prognosis factors and a new approach for the liver metastasis.

[Ultrasonically guided needle biopsy in malignant focal solid nodules of the liver]. / Biopsia percutânea guiada por ultra-som em lesões nodulares sólidas focais malignas do fígado.

In the most of the cases, the diagnosis of focal solid hepatic lesions are performed by ultrasonography, computed tomography, magnetic resonance and hepatic angiography imagig. However, the distinction between benign and malignant neoplasias, sometimes is made after liver biopsy. This report is about 32 of these lesions, diagnosed after guided liver biopsy by ultrasonography. The efficacy of this propedeutic method, minimally invasive, is defined emphasizing that there are no mortality and low levels of morbidity.

Cholelithiasis in cirrhotic patients. (Analysis of cholelithiasis among patients with liver cirrhosis in São Paulo, Brazil).

During the past 20 years, several authors have reported increased prevalence of cholelithiasis in liver cirrhosis. This biliary disease has been implicated with the deterioration of liver function, liver disease of alcoholic origin or even the presence of hypersplenism in this patient population. This study analyzes the incidence and possible factors which are responsible for promoting cholelithiasis in cirrhosis. The study included 110 cirrhotic patients of a private center specialized in treating liver diseases. The incidence of cholelithiasis was 27.3% (25.3% in males and 33.3% in females). There was no correlation between liver function defined by Child's classification or through the laboratory examinations (AST, ALT, AP, GGT, PT, Alb, TB, DB, PA) and the presence of gallstones. No evidence was found that the etiology of cirrhosis or the presence/absence of hypersplenism affected the prevalence of cholelithiasis in this population. In conclusion, an increased prevalence of cholelithiasis was verified in this population of cirrhotics but the pathogenesis is still obscure.

[Immunological parameters in the differential diagnosis of ascites secondary to peritoneal carcinomatosis, hepatic cirrhosis, and congestive heart failure]. / Parâmetros imunológicos no diagnóstico differencial de ascite secundária à carcinomatose peritoneal, cirrose hepática e insuficiência cardíaca congestiva.

As a contribution to the study of ascites in patients with liver cirrhosis, congestive heart failure and peritoneal carcinomatosis evaluate in serum and ascites the concentrations of alphafetoprotein, carcinoembryonic antigen and fibronectin, they might suggest a diagnosis for the basic pathology. Forty-seven patients were studied, from whom 23 with cirrhosis, 17 peritoneal carcinomatosis and 7 with congestive heart failure. We conclude that: a) none of the tools usually employed in the analysis of ascitic fluid alone can make the base pathological process responsible for producing ascites; b) fibronectins were more useful for differential diagnosis between cirrhosis and carcinomatosis; c) alpha-fetoprotein and carcinoembryonic antigen were not useful for the definition for differential diagnosis.

[Hepatic hemangiomas. The importance of the image]. / Hemangiomas hepáticos. Importância da imagem.

In the authors' experience, 0.24% of the patients submitted to liver imaging (ultrasound or computerized tomography) have hemangiomas. These are shown as solid nodular lesions, mostly found by chance. Sometimes they do not appear as typical solid vascular lesions. The authors' experience and the literature are discussed. A clear and concise approach to this benign neoplasm is suggested.

[Chronic active hepatitis and possible relationship with immunosuppressive therapy]. / Hepatite crônica ativa e possível relação com terapia imunossupressora.

A 54-year-old man with Chagas cardiomyopathy that was submitted to a heart transplantation and five months later presented a progressive increase in liver enzymes. Diagnosis of chronic active hepatitis was confirmed by histopathologic studies. A transitory interruption of treatment with azathioprine and the posterior re-introduction of small doses, as well as the use of lesser amounts of cyclosporin-A improved the clinical and laboratory pictures. Despite several investigations the pathogenesis of hepatitis remained undetermined, although some type of drug injury was presumed to be involved. The eventual role of viruses as the primary inciting event could not be completely ruled out.

[Gastrin changes in the gastric antrum G-cells and in serum gastrin levels after 80% jejunoileal resection in rats]. / Alterações da gastrina nas células G do antro gástrico e da gastrinemia após ressecção de 80% de jejunoíleo rem ratos.

A study was made of the changes in the cell population producing gastrin of the gastric antrum in rats submitted to resection of 80% of jejunum-ileum. Ninety days after surgery, the animals were killed after a 12 hour nightly fast and the gastric antrum was removed with the objective of specific histological preparations (PAP method) in order to count the G-cells and the blood was taken for serum doses of gastrin. An optical microscope was used to count the cells using a histometric integraded ocular of 42 points and the counting of 10 fields of each histological cut, and the radioimmunoassay method of double antibody was used for the seric dosing of gastrin. Histometry showed a significant drop in the G-cell population of the antrum of enterectomized animals when compared to the control group. Average percentage of G-cells found were 17.55% in the control group and 7.99% in the enterectomized ones. Blood dosing of hormone showed a significant increase of gastrin in the enterectomized animals when compared to controls. Average value of gastrin dosing the control group was 110 Pg/ml and 170 Pg/ml in enterectomized animals. Therefore, the present study permits to conclude that after resection of 80% of jejunum-ileum, there was a decrease in the G-cell population with gastrin in the gastric antrum even in the presence of increased serum gastrin.

[Lipoid cell tumor of the ovary]. / Tumor de células lipóidicas do ovário.

The authors show the clinical and histopathological difficulties for the diagnosis of a rare ovarian tumor in a 13 year old girl who had a bone disease called enchondromatosis, and the adequate treatment for this case. Laparotomy was performed with unilateral salpingo-oophorectomy of the left ovary after a detailed study to detect the origin of the pelvic mass, the patient, who had metrorrhagia and pains in the lower abdomen. Three years after surgery, the patient was once again seen in the outpatient clinic with regular catamenia, requesting some oral contraceptives because she had started sexual activity. The authors conclude that the lipid cell tumor of the ovary is difficult to classify and diagnose, and that it is normally benign, and that treatment for this type of tumor, specially in youngsters, in whom one should be concerned with maintaining menstrual and reproductive function, is the unilateral oophorectomy.

[Diagnosis of hepatocellular carcinoma performed by searching for serologic tumor markers]. / O diagnóstico do carcinoma hepatocelular (CHC) realizado através da pesquisa de marcadores sorológicos tumorais.

Serum levels of alkaline phosphatase, gamma-glutamyltranspeptidase, -1 fucosidase and glutathione-S-transferase are increased in 60, 90, 75 and 64% of patients with hepatocellular carcinoma. In these patients the mean plasma fibrinogen levels is 461.78 mg/dl, while mean serum copper is 200.50 mg/dl. Serum levels of desgamma-carboxiprothrombin is over 900 mg/dl in 67% of the patients (60% of them have HB virus, mostly anti HBe positive). Forty to 95% of them have increased levels of -fetoprotein (AFP). The authors suggest that cirrhotic patients, with or without HB virus, specially those with increased AFP, should have ultrasound examination of the liver every 6 months. This method of imaging has been shown to be more sensitive than AFP (72% versus 25%) in the detection of hepatocellular carcinoma smaller than 2 cm in diameter.

[Hepatocyte necrosis and intrahepatic cholestasis in the postoperative period of patients undergoing heart surgery with the use of extracorporeal circulation: significance of clinical, epidemiologic, surgical and laboratory parameters in evaluating prognosis]. / Necrose hepatocitária e colestase intrahepática no pós-operatório de pacientes submetidos à cirurgia cardíaca com o emprego de circulação extracorpórea: importância dos parâmetros clínicos, epidemiológicos, operatórios e laboratoriais na avaliação do prognóstico.

Sixteen patients with jaundice after heart surgery with extracorporeal circulation, were studied. They were divided in 2 groups, according to the postoperative outcome; either death (group I) or hospital discharge (group II). Clinical, epidemiological, surgical and laboratorial aspects were compared in order to ascertain their role in the outcome. The results were analysed by the Student-t test. The main cause of death was low output syndrome, which occurred in 10 cases (62.5%), 5 of them died (31%). A statistically significant difference was observed in the postoperative values of serum GOT (p less than 0.01), GPT (p less than 0.01) and total bilirubin (p less than 0.01), which were then considered prognostic indicators in these patients.

[The dissecting aorta: clinical analysis and anatomo-pathologic correlations in 30 cases]. / Dissecção da aorta: análise clínica e correlação anatomopatológica de 30 casos.

The authors studied 30 cases of aortic dissection performed from January 1978 to December 1987. Dissection was classified as type A (intimal tear beginning in the ascending aorta or arch) and type B (intimal tear beginning in the descending aorta). Type A predominated (66.7%). Type B dissection was most frequent in patients older than 60. Precordial pain was the main symptom in type A cases, whereas 62.5% of type B cases showed no precordial pain. Most frequent findings in type A patients were hypotension (45.5%), murmur of aortic regurgitation (40.0%), and dyspnea (40.0%), whereas in type B patients, most frequent findings were hypertension (28.6%), and pulse deficit (42.9%). The major differential diagnosis for type A was myocardial infarction (43.8%), and for type B, peripheral artery failure (25.0%) and acute pneumonia (25.0%). 24 patients (80.0%) had hemorrhage. Hemorrhage into the pericardial sac occurred in 68.8% of type A patients, and 50.0% of type B patients had retroperitoneal hemorrhage. Systemic hypertension, atherosclerosis, medial cystic necrosis and endocrine disorders were considered predisposing factors for both type of dissection. A case of dissection after aortic valve replacement associated with ascending aorta tubular graft replacement was observed in this series. In type A patients, average survival was 6.3 days, and in type B, 11.1 days. The major cause of death was hemorrhage (70.0%).

[Intrahepatic and subcapsular hematoma of the liver after hepatic biopsy under laparoscopy. Contribution of ultrasonography]. / Hematoma intra-hepático e subcapsular do fígado após biopsia hepática sob visão laparoscópica. Contribuição ao seu estudo através da ultra-sonografia.

Over the last few years, ultrasound became important in characterization of space -occupying solid lesions of the liver. Recently, Canadian authors using this method, described a 23% incidence of intrahepatic or subcapsular hematoma after liver biopsy. We prospectively evaluated the incidence of this complication after liver biopsy under laparoscopic guidance in 8 cirrhotic patients, 7 with steatosis, 7 chronic active hepatitis and 4 with intrahepatic cholestasis. Biopsy was performed under general anesthesia provided that prothrombin activity was over 50%, serum fibrinogen was over 100% and platelets over 50.000/mm3. In none of 26 consecutive patients, was an intrahepatic or subcapsular hematoma observed.

Tumor carcinoide da vesicula biliar: apresentacao de um caso. / Carcinoid tumor of the gallbladder: report of a case

Os autores apresentam um caso de tumor carcinoide da vesicula biliar achado ocasionalmente em exame de peca cirurgica.Discutem, ainda, a raridade desse tumor nessa localizacao e comparam o presente caso com os relatorios na literatura