Minimally Invasive Bilateral Lung Resections and CABG through 5 Ports.

Minimal access surgery is increasingly popular to reduce postoperative morbidity and enhance recovery. We present a case of a patient who underwent bilateral minimally invasive thoracic and cardiac surgery. An 81-year-old woman was diagnosed with T1aN0M0 left upper lobe small-cell lung cancer and underwent single-port left video-assisted thoracoscopic surgery (VATS) upper lobectomy in 2016. She developed a contralateral right lower lobe nodule and underwent a single-port right VATS wedge resection of the lower lobe nodule, subsequently confirmed as necrotising granulomatous inflammation with acid-fast bacilli, consistent with previous tuberculosis (TB) infection. On postoperative day 1, she had an episode of self-reverting ventricular tachycardia and bradycardia. Subsequent myocardial perfusion scan and coronary angiogram showed significant LV dysfunction and severe coronary artery disease with a left main stem (LMS) lesion. After agreement at MDT, an Endo-ACAB (endoscopic atraumatic coronary artery bypass grafting) was performed, via 3 ports, with the left internal mammary artery anastomosed to left anterior descending artery. She recovered well postoperatively and was discharged. Multiple sequential minimally invasive procedures are now routine and can be performed safely in patients with a complex combination of pathologies. In this case, bilateral single-port (anatomic and nonanatomic) lung resections were undertaken followed by coronary revascularisation with a total of 5 minimal access ports.

Is glycated hemoglobin related to other dysmetabolic variables implicated in the increase of cardiovascular risk in polycystic ovary syndrome? A comparative study.

BACKGROUND: In non-PCOS patients the concentration of glycated hemoglobin (HbA1C) has been employed to identify individuals at higher risk for impaired glucose tolerance (IGT) and diabetes mellitus. A few studies have examined the role of HbA1C in PCOS patients and current results are controversial. AIM: To compare the strength of the association between glycated hemoglobin and other predictors of cardiovascular risk in polycystic ovary syndrome (PCOS). METHODS: This cross-sectional study enrolled 197 PCOS patients and 72 non-PCOS women. Transvaginal ultrasound, biochemical and hormone measurement were performed. Glycated hemoglobin (HbA1C) was correlated with other variables related to dysmetabolic/vascular diseases. RESULTS: The HbA1C levels were 6.0±1.4% and 4.9±0.4% in PCOS patients and non-PCOS controls, respectively (p<0.001). The HbA1C levels were≥5.7% in 46.4% of PCOS and in none of the control subjects (OR=90.8). HbA1C was well-correlated with several anthropometric, metabolic and endocrine parameters. Stepwise multiple regression including HbA1C and other known predictors of cardiovascular risk resulted in a significant model in which body mass index (BMI) and free testosterone exhibited the best correlation with HbA1C (adjusted R(2)=0.530; F=39.8; p<0.001). CONCLUSION: HbA1C was elevated and correlated with anthropometric, biochemical and endocrine variables of metabolic/vascular disease risks in PCOS patients. Combined HbA1C, BMI and free testosterone levels provided a significant model with potential use to evaluate metabolic/vascular disease in PCOS patients.

Mini-fasting tests diagnosing endogenous hyperinsulinism: a follow-up of 26 cases.

CONTEXT: The supervised 72-h fast remains the gold standard test for the diagnosis of endogenous hyperinsulinism and has recently been suggested to be shortened or even avoided. OBJECTIVE: This study aimed to evaluate whether measurement of blood glucose, insulin and C-peptide levels after a 12 h overnight fast (mini-fasting test), in at least 3 consecutive days, could allow making or ruling out diagnosis of endogenous hyperinsulinism, according to the Endocrine Society's recent guidelines. PATIENTS AND METHODS: We performed 12 h mini-fasting test in at least 3 consecutive days, dosing blood glucose, insulin and C-peptide levels in 26 inpatient patients with pathologically proven endogenous hyperinsulinism. RESULTS: In our series, 100% of patients showed insulin levels of at least 3 µU/ml and C-peptide levels of at least 0.6 ng/ml concomitant with symptomatic hypoglycemia (≤ 55 mg/dl). CONCLUSION: It leads to the conclusion that mini-fasting test might avoid, in most cases, prolonged fasting test for the diagnosis of hypoglycemia due to endogenous hyperinsulinism.

Influence of Nd:YAG or Er:YAG laser surface treatment on microtensile bond strength of indirect resin composites to resin cement. Lasers surface treatment of indirect resin composites.

This study evaluated the influence of the surface pretreatment of indirect resin composite (Signum, Admira Lab and Sinfony) on the microtensile bond strength of a resin cement. Sixty samples made of each brand were divided into 6 groups, according to surface treatment: (1) control; (2) controlled-air abrasion with Al2O3; (3) Er:YAG Laser 200 mJ, 10 Hz, for 10s; (4) Er: YAG Laser 300 mJ, 10 Hz, for 10 s; (5) Nd:YAG 80 mJ, S15Hz for 1 min; (6) Nd:YAG 120mJ, 15 Hz for 1 min. After treatments, all the groups received an application of 37% phosphoric acid and adhesive. The pair of blocks of the same brand were cemented to each other with dual resin cement. The blocks were sectioned to obtain resin-resin sticks (1 x1 mm) and analyzed by microtensile bond testing. The bond strength values were statistically different, irrespective of the surface treatment performed, with highest values for Sinfony (43.81 MPa) and lowest values for Signum (32.33 MPA). The groups treated with the Nd:YAG laser showed the lowest bond strength values and power did not interfere in the results, both for Nd:YAG laser and Er:YAG. Controlled-air abrasion with Al203 is an efficient surface treatment method and the use of the Nd:YAG and Er:YAG lasers reduced bond strength, irrespective of the intensity of energy used.

Negative affect as a predisposing factor for cortisol release after an acute stress--the impact of unpleasant priming.

Glucocorticoids have a key role in stress responses. There are, however, substantial differences in cortisol reactivity among individuals. We investigated if affective trait and mood induction influence the reactivity to psychological stress in a group of 63 young adults, male (n=27) and female (n=36), aged ca. 21 years. On the experimental day the participants viewed either a block of pleasant or unpleasant pictures for 5 min to induce positive or negative mood, respectively. Then, they had 5 min to prepare a speech to be delivered in front of a video-camera. Saliva samples were collected to measure cortisol, and questionnaire-based affective scales were used to estimate emotional states and traits. Compared to basal levels, a cortisol response to the acute speech stressor was only seen for those who had first viewed unpleasant pictures and scored above the average on the negative affect scale. There were no sex differences. In conclusion, high negative affect associated with exposure to an unpleasant context increased sensitivity to an acute stressor, and was critical to stimulation of cortisol release by the speech stressor.

Resilience and vagal tone predict cardiac recovery from acute social stress.

Previous studies showed that heart period decreases during and recovers after an acute stress. We investigated if individual predispositions and emotional priming influence heart period recovery after a speech stress task. Psychometric scales and resting cardiac vagal tone were used to measure individual traits. The presentation of a sequence of either pleasant or unpleasant pictures, as emotional primers, preceded the speech stress. Heart period was measured throughout the experiment. Stress induced tachycardia irrespective of emotional priming or traits. In the recovery period, participants with higher resting cardiac vagal tone or presenting higher resilience significantly reduced the heart acceleration. Furthermore, these traits interacted synergistically in the promotion of the recovery of heart period. Pleasant priming also improved recovery for participants with lower negative affect. In conclusion, the stress recovery measured through heart period seemed dependent upon individual predispositions and emotional priming. These findings further strengthen previous observations on the association between greater cardiac vagal tone and the ability to regulate emotion.

Toward totally endoscopic coronary artery surgery.

BACKGROUND: Here we explore a method of using robotics to reduce morbidity and mortality in conventional coronary surgery. METHODS: Using a robotic surgical system two surgeons completed five steps: (1) 80 synthetic suture exercises; (2) 76 left internal thoracic artery to left anterior descending (LIMA-to-LAD) on porcine hearts; (3) cadaveric port placement for assessing optimal access; (4) endoscopic stabilization in the live porcine model; and, finally (5) eight clinical LIMA-to-LADs performed robotically. RESULTS: After 70 hours training, mean dry lab times fell from 7.0 and 5.8 min to 5.7 and 5.1 min in the two surgeonstab series. Wet lab times fell from 40.1 and 28.5 min to 28.8 and 19.2 min. In the clinical series of eight patients there were no mortalities; all had uncomplicated postoperative recovery and all were angina free at 6-week follow-up. CONCLUSION: The learning curve for robotic training is short, and reproducible results can be achieved clinically, after appropriate training, resulting in real patient benefit.

Correlation between uncoupled ATP hydrolysis and heat production by the sarcoplasmic reticulum Ca2+-ATPase: coupling effect of fluoride.

The sarcoplasmic reticulum Ca(2+)-ATPase transports Ca(2+) using the chemical energy derived from ATP hydrolysis. Part of the chemical energy is used to translocate Ca(2+) through the membrane (work) and part is dissipated as heat. The amount of heat produced during catalysis increases after formation of the Ca(2+) gradient across the vesicle membrane. In the absence of gradient (leaky vesicles) the amount of heat produced/mol of ATP cleaved is half of that measured in the presence of the gradient. After formation of the gradient, part of the ATPase activity is not coupled to Ca(2+) transport. We now show that NaF can impair the uncoupled ATPase activity with discrete effect on the ATPase activity coupled to Ca(2+) transport. For the control vesicles not treated with NaF, after formation of the gradient only 20% of the ATP cleaved is coupled to Ca(2+) transport, and the caloric yield of the total ATPase activity (coupled plus uncoupled) is 22.8 kcal released/mol of ATP cleaved. In contrast, the vesicles treated with NaF consume only the ATP needed to maintain the gradient, and the caloric yield of ATP hydrolysis is 3.1 kcal/mol of ATP. The slow ATPase activity measured in vesicles treated with NaF has the same Ca(2+) dependence as the control vesicles. This demonstrates unambiguously that the uncoupled activity is an actual pathway of the Ca(2+)-ATPase rather than a contaminating phosphatase. We conclude that when ATP hydrolysis occurs without coupled biological work most of the chemical energy is dissipated as heat. Thus, uncoupled ATPase activity appears to be the mechanistic feature underlying the ability of the Ca(2+)-ATPase to modulated heat production.

Underlying and proximate determinants of diarrhoea-specific infant mortality rates among municipalities in the state of Céara, north-east Brazil: an ecological study.

This ecological study examines the variations in diarrhoea-specific infant mortality rates among municipalities in the State of Ceará, north-east Brazil, using data from a community health workers' programme. Diarrhoea is the main cause of postneonatal deaths in Ceará, and diarrhoea mortality rates vary substantially among municipalities, from 7 to 50 per thousand live births. To determine the inter-relationships between potential predictors of diarrhoea-specific infant mortality, eleven variables were classified into proximate determinants (i.e. adequate weight gain and exclusive breast-feeding in first 4 months) and underlying determinants (i.e. health services and socioeconomic variables). The health services variables included percentage with prenatal care up-to-date, participation in growth monitoring and immunization up-to-date, while the socioeconomic factors included female illiteracy rate, per capita gross municipality product and percentage of households with low income, percentage of households with inadequate water supply and inadequate sanitation, and urbanization. Using linear regression analysis variables were included from each group to build regression models. The significant determinants of variability in diarrhoea-specific infant mortality between municipalities were prevalence of infants exclusively breast-feeding, percentage of infants with adequate weight gain, percentage of pregnant women with prenatal care up-to-date, female illiteracy rate and inadequate water supply. These findings suggest that community-based promotion of exclusive breast-feeding in the first 4 months and care-giving behaviours that prevent weight faltering, including weaning practices and feeding during and following diarrhoea episodes, may further reduce municipality-level diarrhoea-specific mortality. Primary heath care strategies addressing these two proximate determinants provide only a partial solution to reducing diarrhoeal disease mortality. Improvements in municipal health services (prenatal care) and socioeconomic status variables, including water supply and maternal education, can also contribute to reduction of infant mortality due to diarrhoea. These results may be used by government health officials to set priorities by considering not only the strength of the association between selected risk factors and diarrhoea mortality rates, but also the prevalence of the risk factors being considered at the municipality level. Finally, the methods used are applicable to other settings with community-based primary health care decentralized to the state or municipal level.

Diagnosis and treatment of osteoporosis in Brazil.

The definition of Osteoporosis as proposed by WHO is widely accepted amongst Brazilian physicians. The main diagnostic tool in Brazil is Bone Densitometry (DXA). Both public and private health insurance systems reimburse the densitometry test. DXA have been used also for monitoring changes in BMD. Biochemical markers and peripheral methods of bone assessment are not widely used in Brazil. Estrogens, Vitamin D and its metabolites, Salmon Calcitonin, Ipriflavone, Tibolone, Etidronate, Alendronate, Raloxifene and Risendronate are currently available for treating osteoporosis. Since 1995, Brazilian Society of Clinical Densitometry have been educating Bone Densitometry Professionals and all clinicians in order to improve their ability to turn DXA results into adequate clinical decisions.

Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers' health care-seeking behaviors during their infants' fatal illness.

Promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, but these two conditions remain the leading causes of infant deaths in most developing countries. Identification of the factors contributing to these deaths may contribute to reduce infant mortality from preventable causes. To gain insight into the circumstances and maternal and health services factors that may contribute to infant deaths we used a verbal autopsy method to interview mothers of all infants who died during the previous 12 months (June 1995-May 1996) in 11 municipalities in the State of Ceara, Northeast Brazil. Our results revealed that one-third of the deaths occurred in a hospital and two-thirds at home. Almost all the infants who died at home, however, had been examined one or more times by a doctor, and 36% of them had been hospitalized during the disease episode that resulted in death. For most (85%) of these children the causes of death were diarrhea or acute respiratory infection, and it is likely that death could have been averted if appropriate treatment had been initiated promptly. Three major groups of factors that alone or in combination appeared to contribute to most deaths were delays in seeking medical care on behalf of the parents, medical interventions reported as ineffective by mothers and delays in providing medical care to children who arrived at the hospital too late in the day to be scheduled for consultation. Our findings suggest that government efforts to further reduce infant mortality in Ceara should focus on health education interventions that address quality of home care, recognition of signs of severity and danger and importance of seeking timely medical care: and on improving the quality of care provided at community health centers and hospitals. Measures likely to improve infants' chance of survival include: ensuring prompt access to medical consultation for young children brought to health centers or hospitals with potentially life-threatening symptoms related to infections, health education to mothers on the need for continued home care after discharge and to return to the medical care facility if the child does not recover, and that they have access to medicine prescribed by hospital physicians. Further benefits could be obtained by using community health workers, now integrated into the Family Medicine Program (PSF) health teams, to provide health education, supervise home care, refer mothers to health centers and facilitate their access to hospitals.

Dietary lipids affect human ethanol-inducible CYP2E1 gene expression in vivo in mononuclear cells.

We tested the hypothesis that dietary cholesterol modulate human ethanol-inducible CYP2E1 expression in vivo in circulating mononuclear cells. Healthy volunteers (n= 10) were submitted to a low fat low cholesterol diet for 4 days (day 0-day 3, LFLC). Cholesterol (595 +/- 56 mg/day) was then reintroduced for 7 days (day 4-day 10, LFHC). In the same time, controls subjects (n=7) did not change their habitual daily diet. CYP2E1 mRNA levels, evaluated in mononuclear cells, decreased in experimental subjects during both LFLC and LFHC from 100% to 53 +/- 5%, (p<0.001) with a main decrease during LFLC period (100% to 71 +/- 16%, p=0.05). Immunoreactive CYP2E1 showed a similar pattern and decreased from 100 to 62 +/- 12% during the trial (p<0.05). No significant change occured in control subjects. Between day 0 and day 11, changes in CYP2E1 mRNA correlated positively with plasma cholesterol (r2=0.67, p<0.001) and HDL cholesterol concentrations (r2=0.61, p<0.001). In contrast, no correlation was found between plasma fatty acids concentrations and CYP2E1 expression. The present results suggest that lipid factors regulate CYP2E1 expression, in vivo, in human mononuclear cells. In particular, plasma cholesterol concentrations may play an important role in this regulation.

Association of diarrhoea and upper respiratory infections with weight and height gains in Bangladeshi children aged 5 to 11 years.

INTRODUCTION: The association between infection and growth delay is not well documented in school-age children in developing countries. We conducted a prospective cohort study to examine the association between infectious disease and weight and height gains among Bangladeshi children. METHODS: A one-year follow-up study was performed to elucidate the determinants and consequences of physical growth of children under five years of age. The study included 135 households randomly selected from four villages in the Matlab area. RESULTS: The most frequent infections were upper respiratory infections (mean = 4 episodes or 27 days per year) followed by non-dysenteric diarrhoea (mean = 2.3 episodes or 15 days per year) and dysentery (mean = 0.2 episodes or 2 days per year). The number of episodes and their duration decreased significantly with age. Over a 12-month period the mean weight gain was 1.3 kg and the mean increase in height was 2.9 cm. The total number of days when diarrhoea occurred was negatively associated with annual weight gain (regression coefficient beta = -7 g per day, P = 0.02), with adjustment for age, sex, energy and protein intake, and household land ownership. The incidence of diarrhoeal disease was significantly associated with weight gain in intermediate models but only marginally associated with it in the final multivariate model (P = 0.08). Neither the incidence nor the duration of upper respiratory infections was associated with weight gain. Height gain was not significantly associated with the duration or incidence of either category of illness. Diarrhoea was a significant correlate of retarded weight gain among children above preschool age, whereas upper respiratory infections were not. DISCUSSION: Diarrhoeal morbidity slowed growth in children well beyond the weaning age, suggesting that increased attention should be given to the study of the continuous impact of diarrhoea in children aged over 5 years. An understanding of the determinants of growth in school-age children in developing countries would maximize the health and developmental outcomes that are the target of international child survival strategies at younger ages.

Relationship between health services, socioeconomic variables and inadequate weight gain among Brazilian children.

This ecological analysis assessed the relative contribution of behavioural, health services and socioeconomic variables to inadequate weight gain in infants (0-11 months) and children (12-23 months) in 140 municipalities in the State of Ceara, north-east Brazil. To assess the total effect of selected variables, we fitted three unique sets of multivariate linear regression models to the prevalence of inadequate weight gain in infants and in children. The final predictive models included variables from the three sets. Findings showed that participation in growth monitoring and urbanization were inversely and significantly associated with the prevalence of inadequate weight gain in infants, accounting for 38.3% of the variation. Female illiteracy rate, participation in growth monitoring and degree of urbanization were all positively associated with prevalence of inadequate weight gain in children. Together, these factors explained 25.6% of the variation. Our results suggest that efforts to reduce the average municipality-specific female illiteracy rate, in combination with participation in growth monitoring, may be effective in reducing municipality-level prevalence of inadequate weight gain in infants and children in Ceara.

PIP: This article assesses the relationship between health services, socioeconomic variables, and inadequate weight gain among Brazilian children. The study used ecological analysis to assess the relative contributions of these variables to variations in the prevalence of inadequate weight gain among infants and young children in 140 municipalities in the State of Caera, northeast Brazil. The assessment of the total effect of selected variables involved fitting three unique sets of multivariate linear regression models to the prevalence of inadequate weight gain among infants and children. Findings showed several significant predictors of the prevalence of inadequate weight gains. These include participation in growth monitoring and a degree of urbanization, which together account for 38.3% of the variation, and female illiteracy rate (9.7% of the variation). Overall, these factors explain 25.6% of the variation in child growth. In conclusion, the study suggests that efforts to reduce the average municipality-specific female illiteracy rate, in combination with participation in growth monitoring may be effective in reducing municipality-level prevalence of inadequate weight gain among infants and children in Caera.

Right ventricular function after pulmonary autograft replacement of the aortic valve.

BACKGROUND: The pulmonary autograft operation (the Ross procedure) involves excision of a portion of the right ventricular (RV) outflow tract, prolonged cross-clamp times, and insertion of a pulmonary homograft. There is concern about the effect of such operations on right ventricular function. METHODS AND RESULTS: Twenty-five patients undergoing either pulmonary autograft or homograft replacement of the aortic valve as part of a prospective randomized trial had echocardiographic RV long-axis measurements performed before surgery and 6 months (range 3 to 12 months) after surgery. In all patients, systolic excursion (SE) and both shortening and lengthening rates (SR and LR, respectively) were reduced postoperatively (P<0.05) (homografts: SE 1.5+/-0.4 versus 2.3+/-0.6 cm, SR 6.8+/-2.1 versus 9. 6+/-3.1 cm/s, LR 6.0+/-1.8 versus 8.9+/-3.0 cm/s; autografts: SE 1. 4+/-0.4 versus 2.2+/-0.4 cm, SR 5.8+/-3.0 versus 8.2+/-3.0 cm/s, LR 5.7+/-1.9 versus 8.5+/-3.7 cm/s). There were no differences between the 2 groups. Eighteen patients who had undergone either aortic homograft or pulmonary autograft surgery were studied between 6 and 35 months after surgery. RV volumes were assessed with the use of MRI in addition to echocardiographic RV long-axis measurements. Global volumes were increased to a similar amount in both groups (homografts: end-diastolic volume 145+/-34 mL, end-systolic volume 78+/-23 mL; autografts: end-diastolic volume 157+/-33 mL, end-systolic volume 89+/-25 mL; P=NS), whereas stroke volumes were maintained in both groups (homografts 67+/-15 mL, autografts 67+/-16 mL; P=NS). RV SE was depressed in both groups to a similar degree to that seen with the previous group (homografts 1.5+/-0.3 cm, autografts 1.4+/-0.2 cm). CONCLUSIONS: Aortic valve replacement with either a pulmonary autograft or an aortic homograft leads to a degree of persistent RV longitudinal dysfunction that is not more pronounced in those undergoing the Ross procedure. The mechanisms and long-term effects of these changes must be further studied.

Variations in infant mortality rates among municipalities in the state of Ceará, Northeast Brazil: an ecological analysis.

BACKGROUND: Infant mortality rates vary substantially among municipalities in the State of Ceará, from 14 to 193 per 1000 live births. Identification of the determinants of these differences can be of particular importance to infant health policy and programmes in Brazil where local governments play a pivotal role in providing primary health care. METHODS: Ecological study across 140 municipalities in the State of Ceará, Brazil. RESULTS: To determine the interrelationships between potential predictors of infant mortality, we classified 11 variables into proximate determinants (adequate weight gain and exclusively breastfeeding), health services variables (prenatal care up-to-date, participation in growth monitoring, immunization up-to-date, and decentralization of health services), and socioeconomic factors (female literacy rate, household income, adequate water supply, adequate sanitation, and per capita gross municipality product), and included the variables in each group simultaneously in linear regression models. In these analyses, only one of the proximate determinants (exclusively breastfeeding (inversely), R2 = 9.3) and one of the health services variables (prenatal care up-to-date (inversely), R2 = 22.8) remained significantly associated with infant mortality. In contrast, female literacy rate (inversely), household income (directly) and per capita GMP (inversely) were independently associated with the infant mortality rate (for the model including the three variables R2 = 25.2). Finally, we considered simultaneously the variables from each group, and selected a model that explained 41% of the variation in infant mortality rates between municipalities. The paradoxical direct association between household income and infant mortality was present only in models including female illiteracy rate, and suggests that among these municipalities, increases in income unaccompanied by improvements in female education may not substantially reduce infant mortality. The lack of independent associations between inadequate sanitation and infant mortality rates may be due to the uniformly poor level of this indicator across municipalities and provides no evidence against its critical role in child survival. CONCLUSIONS: These results suggest that promotion of exclusive breastfeeding and increased prenatal care utilization, as well as investments in female education would have substantial positive effects in further reducing infant mortality rates in the State of Ceará.