Epidemiology and outcome of HIV-infected patients admitted to the ICU in the current highly active antiretroviral therapy era.

PURPOSE: To describe the epidemiology of critical disease in HIV-infected patients during the current highly active antiretroviral therapy (HAART) era and to identify hospital mortality predictors. METHODS: A longitudinal, retrospective observational study was made of HIV-infected adults admitted to the ICU in two Spanish hospitals between 1 January 2000 and 31 December 2014. Demographic and HIV-related variables were analyzed, together with comorbidities, severity scores, reasons for admission and need for organ support. The chi-squared test was used to compare categorical variables, while continuous variables were contrasted with the Student's t-test, Mann-Whitney U-test or Kruskal-Wallis test, assuming an alpha level=0.05. Multivariate logistic regression analysis was used to calculate odds ratios for assessing correlations to mortality during hospital stay. Joinpoint regression analysis was used to study mortality trends over time. RESULTS: A total of 283 episodes were included for analyses. Hospital mortality was 32.9% (95%CI: 21.2-38.5). Only admission from a site other than the Emergency Care Department (OR 3.64, 95%CI: 1.30-10.20; p=0.01), moderate-severe liver disease (OR 5.65, 95%CI: 1.11-28.87; p=0.04) and the APACHE II score (OR 1.14, 95%CI: 1.04-1.26; p<0.01) and SOFA score at 72h (OR 1.19, 95%CI: 1.02-1.40; p=0.03) maintained a statistically significant relationship with hospital mortality. CONCLUSIONS: Delayed ICU admission, comorbidities and the severity of critical illness determine the prognosis of HIV-infected patients admitted to the ICU. Based on these data, HIV-infected patients should receive the same level of care as non-HIV-infected patients, regardless of their immunological or nutritional condition.

The circumferential resection margins status: A comparison of robotic, laparoscopic and open total mesorectal excision for mid and low rectal cancer.

INTRODUCTION: Minimally invasive surgery for rectal cancer (RC) is now widely performed via the laparoscopic approach, but robotic-assisted surgery may overcome some limitations of laparoscopy in RC treatment. We compared the rate of positive circumferential margins between robotic, laparoscopic and open total mesorectal excision (TME) for RC in our institution. METHODS: Mid and low rectal adenocarcinoma patients consecutively submitted to robotic surgery were compared to laparoscopic and open approach. From our prospective database, 59 patients underwent robotic-assisted rectal surgery from 2012 to 2015 (RTME group) were compared to our historical control group comprising 200 open TME (OTME group) and 41 laparoscopic TME (LTME group) approaches from July 2008 to February 2012. Primary endpoint was to compare the rate of involved circumferential resection margins (CRM) and the mean CRM between the three groups. Secondary endpoint was to compare the mean number of resected lymph nodes between the three groups. RESULTS: CRM involvement was demonstrated in 20 patients (15.5%) in OTME, 4 (16%) in LTME and 9 (16.4%) in the RTME (p = 0.988). The mean CRM in OTME, LTME and RTME were respectively 0.6 cm (0-2.7), 0.7 cm (0-2.0) and 0.6 cm (0-2.0) (p = 0.960). Overall mean LN harvest was 14 (0-56); 16 (0-52) in OTME, 13 (1-56) in LTME and 10 (0-45) in RTME (p = 0.156). CONCLUSION: Our results suggest that robotic TME has the same oncological short-term results when compared to the open and laparoscopic technique, and it could be safely offered for the treatment of mid and low rectal cancer.

Intrinsic myenteric denervation: a new model to increase the intestinal absorptive surface in short-bowel syndrome.

INTRODUCTION: Short-bowel syndrome (SBS) is caused by resection of massive portions of the small intestine and is characterized by symptoms related to malabsorption, of which severe weight loss is the most apparent. Surgical treatments for SBS are not yet satisfactory. In rats, the myenteric denervation by benzalkonium chloride (BAC) leads to development of megaileum with visceral dilatation and mucosal hyperplasia and increases the intestinal transit time. Such operation in the remaining intestinal segment after massive small bowel resection could increase the duration of contact between luminal nutrients and ileal mucosal epithelium, and furthermore, it could increase the superficial area of the mucosa. Thus, our aim in this study was to evaluate the epithelial morphology and body weight changes of animals after intrinsic ileal denervation associated with extensive small intestine resection. MATERIAL AND METHODS: Wistar rats were submitted to resection of 80% of small intestinal length (Group R). Another group (B) of animals also received topical serosal application of BAC 0.3%. Control animals were submitted to simulated surgery (Group C). Animals were weighed weekly and sacrificed after 90 days. Intestinal walls were collected for histological procedure and morphometry. RESULTS: At the end of the experimental period all groups showed weight increase, which was reduced in the R group (P < 0.01). Interestingly, the denervated Group B showed a marked increase in weight, similar to the control animals. Morphometric analysis of the mucosal layer area showed a major increase in mucosal surface area, mainly in Group B. CONCLUSIONS: Our results showed that the ileal intrinsic denervation associated with massive intestinal resection induced an increase in the superficial absorptive area and was able to improve the postsurgical conditions for the animals, with accentuated weight increase. This procedure may be a useful model for further studies related to the role of the enteric nervous system on intestinal adaptations after extensive resections and may provide a new approach for the surgical treatment of short-bowel syndrome.

Effect of a necrogenic dose of diethylnitrosamine on vitamin E-deficient and vitamin E-supplemented rats.

In order to evaluate the effects of a necrogenic dose of diethylnitrosamine (DEN) on vitamin E-deficient and vitamin E-supplemented rats, a single dose of the drug (200 mg/kg body weight) was injected intraperitoneally at the end of 10 weeks of treatment with the diets. The hepatic necrosis and lipoperoxidation provoked by DEN were evaluated 24, 48, 72 and 120 hours after the injection and were found to be more intense in the deficient group (thiobarbituric acid reactive substances (TBARS): 5.20 +/- 1.48 nmol/mg protein; necrosis volume: 68.99 +/- 8.36%; P < 0.05) during the second period. Also, in the same group and during the same period, mean plasma and hepatic vitamin E concentrations and mean liver glutathione concentration were the lowest detected, suggesting the occurrence of antioxidant consumption due to the toxic action of DEN. In contrast to vitamin E deficiency, which permitted the drug to exert stronger toxic effects, 20-fold supplementation with vitamin E did not provide additional protection against the lipoperoxidation and necrosis provoked by DEN (P < 0.05). The results suggest that other mechanisms in addition to lipoperoxidation provoked by free radicals originating from the metabolism of nitrosamines by the cytochrome P-450-dependent enzymatic system may be involved in the hepatotoxic action of these substances.

Effect of different dietary levels of vitamin E on lipid peroxidation in rats.

The regulation of normal oxidative balance include the maintenance of adequate levels of dietary antioxidants such as vitamin E. The objective of this investigation was to study the effect of three different dietary levels of vitamin E (normal, supplemented 20 times higher and deficient) on plasma and liver lipid peroxidation, assayed by determination of thiobarbituric acid reactive substances (TBARS) and vitamin E in plasma and liver and hepatic reduced glutathione. Administration of dietary vitamin E caused a dose-dependent increase in liver and plasma concentration of this vitamin to 42.11 micrograms/g liver and 29.52 mumol/l respectively, in the supplemented group, and a low concentration of TBARS, 0.67 nmol/mg protein, in liver. The group receiving the diet without vitamin E showed high values of hepatic TBARS, 2.95 nmol/mg protein, and low values of reduced glutathione and reduced concentration of hepatic and plasma vitamin E (1.75 micrograms/g liver and 3.67 mumol/l, respectively). In conclusion, the vitamin E deficiency alone induces the liver lipid peroxidation in rats, and maintenance of adequate or higher vitamin E levels acts as a protective factor against free radical generation.

Contribuicao a tecnica da postectomia. / Contribution to postectomy technique

Os autores propoem uma nova tecnica para a realizacao da postectomia. Baseiam-se na experiencia de 281 casos. Analisam comparativamente a tecnica e discutem os resultados