Remnant Muscle Preservation on Hamstring Tendon Autograft During ACL Reconstruction Promotes Volumetric Increase With Biological and Regenerative Potential.

BACKGROUND: The removal of all adherent muscle tissue from the hamstring graft during anterior cruciate ligament reconstruction (ACLR) is common practice. However, there is a paucity of research to justify this removal or evaluate its biological implications. PURPOSE/HYPOTHESIS: The purpose of this study was to (1) evaluate the histological characteristics of the myotendinous muscle tissue harvested from hamstring tendons, (2) compare the final diameter of the prepared graft before and after the removal of the remnant musculature, and (3) evaluate patients who were treated with and without preservation of the graft-adhered muscle. The hypothesis was that the adherent musculature of the graft would have cells that could contribute to graft incorporation and revascularization, assist in the proprioceptive capacity of the neoligament, and increase the graft's diameter. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We divided 84 patients into 2 groups: group 1 underwent ACLR using hamstring tendon autograft with adherent musculature, and group 2 underwent ACLR using hamstring tendon autograft stripped of its remnant muscle. All patients had minimum 2-year follow-up. The muscle harvested from the graft in group 2 was submitted for histological examination, and the graft diameter before and after muscle removal was compared. The Tegner activity scale and Lysholm scores were determined preoperatively and at 12 and 24 months postoperatively. RESULTS: There was a significant difference in graft diameter between groups. The evaluation of the graft diameter in group 2 showed a decrease of 11.52% after removal of muscle tissue from the tendon graft. Patients from group 1 had better Tegner and Lysholm scores (mean ± SD) after 12 months (Tegner, 8.03 vs 7 [P = .004]; Lysholm, 95.48 ± 1.2 vs 87.54 ± 3.21 [P = .002]) and better Lysholm scores after 24 months (95.76 ± 2.1 vs 89.32 ± 2.47; P = .002). The muscle tissue of the analyzed fragments presented a pattern with fibrous tissue beams, invaginating regularly and sequentially from the myotendinous junction into the muscles. CONCLUSION: Preserving the muscle tissue on tendon grafts promoted a volumetric increase in the final autograft diameter and demonstrated biological and regenerative potential. Patients who underwent ACLR using the tendon with the muscle attached had better functional scores at 2-year follow-up as compared with patients treated using the tendon with the muscle removed.

Psoriasis and pregnancy in the biologic era, a feared scenario. What do we do now?

Psoriasis is a chronic, multifactorial inflammatory disease; its clinical severity can vary widely. Treatment of severe cases during pregnancy is of special interest. To date there is scarce information available and most data comes from other medical specialties that use similar treatments. Immunosuppressors are strongly discouraged during pregnancy and breastfeeding. Amongst biologic agents, anti-TNFα having been the longest on the market has allowed for the most experience. It is known that transplacental transport of these drugs does not occur until gestational week 22, once organogenesis is completed. Within this group certolizumab pegol, seems to be the safest choice, as its molecular structure does not cross the placental barrier. Beyond pregnancy, it is important to take into account these drugs' half-life and passage to breast milk, as well as its impact on neonatal immunization.

Análise de custo por resposta dos medicamentos biológicos no tratamento da psoríase moderada a grave sob as perspectivas dos sistemas de saúde público e privado, no Brasil / Cost per responder analysis of biologic drugs for the treatment of moderate to severe psoriasis under Brazilian public and private healthcare systems perspectives

Objetivo: Estimar o custo por resposta dos medicamentos biológicos no tratamento da psoríase moderada a grave sob as perspectivas do Sistema de Saúde Suplementar (SSS) e Sistema Único de Saúde (SUS), representado pela Secretaria de Estado da Saúde de São Paulo, no Brasil. Métodos: Quatro medicamentos biológicos foram considerados na análise: adalimumabe, etanercepte, infliximabe e ustequinumabe. Os dados de eficácia foram obtidos de uma metanálise publicada, que avaliou a resposta PASI 75 dos medicamentos na semana 24 de tratamento. O custo do tratamento foi obtido considerando o preço de aquisição dos medicamentos, conforme perspectiva analisada, e a posologia preconizada na bula de cada um deles. Análise de sensibilidade foi conduzida a fim de avaliar o impacto das incertezas nos resultados encontrados. Resultados: A análise mostrou que, sob a perspectiva do SSS, ustequinumabe apresentou o menor custo por resposta PASI 75 (R$ 66.371) por ano de tratamento, seguido por infliximabe (R$ 139.605), adalimumabe (R$ 152.501) e etanercepte (R$ 179.812). Resultado semelhante foi observado na perspectiva do SUS, no qual ustequinumabe apresentou custo por resposta PASI 75 de R$ 47.229, seguido por infliximabe (R$ 75.145), adalimumabe (R$ 90.292) e etanercepte (R$ 130.523). Ajuste de dose para ustequinumabe mostrou ser o parâmetro mais sensível na análise de sensibilidade. Conclusão: Avaliações econômicas são ferramentas importantes para auxiliar gestores de saúde no processo de tomada decisão. A presente análise mostrou que, dentre as alternativas comparadas, ustequinumabe é o medicamento biológico que apresenta o menor custo por resposta PASI 75 (mais custo-efetivo), independentemente da perspectiva analisada (público ou privado).

Objective: To estimate the cost per responder of biologic drugs in moderate to severe psoriasis treatment from the private and public (State Health Secretariat of São Paulo) perspectives in Brazil. Methods: Four biologic drugs were considered in the analysis: adalimumab, etanercept, infliximab and ustekinumab. Efficacy data was obtained from a published metanalysis, which evaluated PASI 75 response after treatment with biologic drugs after 24 weeks of treatment. The cost of treatment was obtained considering drug acquisition cost, according to the analyzed perspective, and dosage according to each drug information label. Sensitivity analysis was performed to evaluate the impact of uncertainty in the results. Results: The analysis demonstrated that, from the private perspective, ustekinumab presented lower cost per PASI 75 response (R$ 66,371), in one year of treatment, followed by infliximab (R$ 139,605), adalimumab (R$ 152,501), and etanercept (R$179,812). Similar results were found from public perspective, with ustekinumab presenting a cost per PASI 75 response of R$ 47,229 per year of treatment, followed by infliximab (R$ 75,145), adalimumab (R$ 90,292) and etanercept (R$ 130,523). Dose adjustment for ustekinumab was shown to be the most sensitive parameter in the sensitivity analysis. Conclusion: Economic evaluations are important tools to support payers during the decision making process. The current analysis demonstrated that, among compared options, ustekinumab is the biologic with the lowest cost per PASI 75 responder (more cost-effective), regardless the perspective considered (public or private).

Tratamento de lixiviado por infiltracao rapida como alternativa para cidades de pequeno porte / Leachate treatment by rapid infiltration process as an alternative for small towns

O objetivo deste artigo é apresentar um estudo experimental de viabilidade técnica do processo de Infiltração Rápida (IR) no tratamento de lixiviado de um aterro sanitário para a remoção de matéria orgânica e nutrientes. O estudo foi realizado em escala piloto com leitos filtrantes de areia e tijolo cerâmico triturado. O monitoramento do desempenho dos reatores foi feito por meio dos parâmetros Demanda Química de Oxigênio (DQO), Sólidos Suspensos Totais (SST), Fósforo Total (PTotal), nitrogênio total Kjeldahl (NTK), N-NH3, N-NO3 -, N-NO2 -, alcalinidade, pH e temperatura. A redução média nos reatores com leito de areia média foi 32% de DQO e 43% de NTK, com leito de areia fina 27% de DQO e 47% de NTK e no reator com leito de tijolo cerâmico triturado 70% de DQO e 54% de NTK. Os resultados obtidos neste estudo são parâmetros para elaboração de projetos com processo IR em escala real para tratamento de lixiviado de aterros sanitários, especialmente para cidades de pequeno porte.

The aim of this article is to present an experimental study applying the Rapid Infiltration (RI) technique during the treatment of a landfill leachate in order to remove organic matter and nutrients. The study was conducted in a pilot scale with filter media were of sand and triturated ceramic brick. The monitoring of the reactors performance was made through parameters Chemical Oxygen Demand (COD), Total Suspended Solids (TSS), Phosphorus Total (PTotal), Total Kjeldahl Nitrogen (TKN), N-NH3, N-NO3 -, N-NO2 -, alkalinity pH and temperature. The reactors mean efficiency in the reduction of COD was 32% and NTK 43% for the reactor with sand media, for the reactor with thin sand media the COD was of 27% and TKN of 47% and for the reactor with triturated ceramic brick COD was of 70% and TKN of 54%. The results obtained in this study are very important to subsidy the elaboration of design of the RI process in field scale for landfill leachate treatment, mainly for small towns.

Assays on biological treatment of bovine brucellosis / Ensaios de tratamento biológico da brucelose bovina

biological method, for the treatment of brucelosis was tried in 37 bovines suffering of this disease. The method consisted in a serie of injetions of brucelin and a vaccine against brucelosis. Two type A a non agglutinogenic vaccine that was used in 22 animals and type B vaccine which have a low agglutinogenic power and which was used in 15 animals. After the treatment and 9 month of follow up the percentages of cure were respectivelly 38.1% for type A and 53.85% for type B vaccines.

Foi ensaiado em 37 bovinos brucélicos um método de tratamento biológico da brucelose, usando-se inoculações repetidas de uma associação: brucelina-vacina contra a brucelose. Dois tipos de vacina foram empregados: vacina A, não aglutinogênica (em 22 infectados) e vacina B de baixo poder  aglutinogênico (em 15 infectados) . Findo o tratamento, os resultados  mostraram, após nove meses de observação, os percentuais de cura de 38,1% para a vacina A e 53,85% para a vacina B.

Assays on biological treatment of bovine brucellosis / Ensaios de tratamento biológico da brucelose bovina

biological method, for the treatment of brucelosis was tried in 37 bovines suffering of this disease. The method consisted in a serie of injetions of brucelin and a vaccine against brucelosis. Two type A a non agglutinogenic vaccine that was used in 22 animals and type B vaccine which have a low agglutinogenic power and which was used in 15 animals. After the treatment and 9 month of follow up the percentages of cure were respectivelly 38.1% for type A and 53.85% for type B vaccines.

Foi ensaiado em 37 bovinos brucélicos um método de tratamento biológico da brucelose, usando-se inoculações repetidas de uma associação: brucelina-vacina contra a brucelose. Dois tipos de vacina foram empregados: vacina A, não aglutinogênica (em 22 infectados) e vacina B de baixo poder  aglutinogênico (em 15 infectados) . Findo o tratamento, os resultados  mostraram, após nove meses de observação, os percentuais de cura de 38,1% para a vacina A e 53,85% para a vacina B.