Resecciones hepáticas: análisis de los cambios en las técnicas quirúrgicas, anestésicas y transfusionales / Hepatic resection: analysis of changes in transfusional, surgical and anesthesic techniques

Introducción: La cirugía de resección hepática se ha caracterizado desde sus inicios por una alta tasa de morbimortalidad, relacionada esencialmente con el riesgo de hemorragias y con la necesidad de transfusiones masivas. La experiencia acumulada en 900 intervenciones permitió el desarrollo de una conducta quirúrgico-anestésica que incorpora métodos más modernos y elementos propios, con el objetivo de disminuir el consumo de sangre. Objetivo: Conocer el impacto de las modificaciones en la técnica anestésica, quirúrgica y en las indicaciones de transfusión de hemocomponentes, en enfermos sometidos a resecciones hepáticas, practicadas por el mismo equipo anestésico, quirúrgico y transfusional, en 18 años de experiencia. Material y método: Dos grupos de enfermos sometidos a resecciones hepáticas comparables. Grupo 1: 45 enfermos consecutivos intervenidos entre 1983 y 1987. Técnica anestésica, neuroleptoanestesia y anestesia inhalatoria. Transfusión de hemocomponentes a demanda. El parámetro intraoperatorio más importante fue la tensión arterial. Grupo 2: 45 enfermos consecutivos intervenidos en el año 2000. Técnica anestésica endovenosa. Transfusión de sangre separada en hemocomponentes y sangre autóloga, de acuerdo con las guías de la Asociación Americana de Anestesia (ASA) y de los Servicios de Anestesia y Medicina Transfusional. Parámetros intraoperatorios más importantes: tensión arterial media y presión venosa central. La última variable debe permanecer por debajo de 5 cm de H2O. Se utilizaron además drogas vasoactivas. Resultados: Grupo 1: transfundidos 778 por ciento; grupo 2: 53,3 por ciento (p=0,027). Promedio de horas en respirador: grupo 1: 19 horas; grupo 2: 4 horas (p=0,0001). Promedio de horas en la unidad de cuidados intensivos: grupo 1: 36 horas; grupo 2: 2:30 horas (p=0,06). Promedio de días de internación: grupo 1: 12; grupo 2: 7 (p=0,006). Morbilidad del grupo 1: 71 por ciento; grupo 2: 26,7 por ciento (p=0,0001). Mortalidad: grupo 1: 6,7 por ciento; grupo 2: 0 por ciento (p=0,24). Conclusiones: Las modificaciones en la técnica quirúrgica, anestésica y transfusional permitieron disminuir el consumo de hemocomponentes, una desconexión precoz del respirador, menor cantidad de tiempo en la unidad de cuidados intensivos, menor estadía hospitalaria y una disminución en la morbimortalidad.

Resecciones hepáticas: análisis de los cambios en las técnicas quirúrgicas, anestésicas y transfusionales / Hepatic resection: analysis of changes in transfusional, surgical and anesthesic techniques

Introducción: La cirugía de resección hepática se ha caracterizado desde sus inicios por una alta tasa de morbimortalidad, relacionada esencialmente con el riesgo de hemorragias y con la necesidad de transfusiones masivas. La experiencia acumulada en 900 intervenciones permitió el desarrollo de una conducta quirúrgico-anestésica que incorpora métodos más modernos y elementos propios, con el objetivo de disminuir el consumo de sangre. Objetivo: Conocer el impacto de las modificaciones en la técnica anestésica, quirúrgica y en las indicaciones de transfusión de hemocomponentes, en enfermos sometidos a resecciones hepáticas, practicadas por el mismo equipo anestésico, quirúrgico y transfusional, en 18 años de experiencia. Material y método: Dos grupos de enfermos sometidos a resecciones hepáticas comparables. Grupo 1: 45 enfermos consecutivos intervenidos entre 1983 y 1987. Técnica anestésica, neuroleptoanestesia y anestesia inhalatoria. Transfusión de hemocomponentes a demanda. El parámetro intraoperatorio más importante fue la tensión arterial. Grupo 2: 45 enfermos consecutivos intervenidos en el año 2000. Técnica anestésica endovenosa. Transfusión de sangre separada en hemocomponentes y sangre autóloga, de acuerdo con las guías de la Asociación Americana de Anestesia (ASA) y de los Servicios de Anestesia y Medicina Transfusional. Parámetros intraoperatorios más importantes: tensión arterial media y presión venosa central. La última variable debe permanecer por debajo de 5 cm de H2O. Se utilizaron además drogas vasoactivas. Resultados: Grupo 1: transfundidos 778 por ciento; grupo 2: 53,3 por ciento (p=0,027). Promedio de horas en respirador: grupo 1: 19 horas; grupo 2: 4 horas (p=0,0001). Promedio de horas en la unidad de cuidados intensivos: grupo 1: 36 horas; grupo 2: 2:30 horas (p=0,06). Promedio de días de internación: grupo 1: 12; grupo 2: 7 (p=0,006). Morbilidad del grupo 1: 71 por ciento; grupo 2: 26,7 por ciento (p=0,0001). Mortalidad: grupo 1: 6,7 por ciento; grupo 2: 0 por ciento (p=0,24). Conclusiones: Las modificaciones en la técnica quirúrgica, anestésica y transfusional permitieron disminuir el consumo de hemocomponentes, una desconexión precoz del respirador, menor cantidad de tiempo en la unidad de cuidados intensivos, menor estadía hospitalaria y una disminución en la morbimortalidad. (AU)

Clinical efficacy of goserelin (Zoladex) in the treatment of uterine myomas in infertile patients.

This study investigated the efficacy of Zoladex depot 3.6 mg (goserelin acetate) during a 4-month treatment of infertile patients with uterine myomas of different size and location. The investigation comprised 30 patients aged 22-42 years, distributed into 2 groups regarding uterine and myoma volume. The first group included patients with uterine myomas less than 70 ml and uterus less than 300 ml. The second group included patients in whom these volumes exceeded the above mentioned values. Zoladex depot was administered every 28 days for 4 months with ultrasonographic follow-up of volume decrease, whereas patients with submucous myomas underwent control hysteroscopy. The obtained results point to efficacy of Zoladex in decreasing the volumes of both myomas and uterus by more than 50%, which correlates with literature data. Of particular interest is complete disappearance of myomas in about 60% of patients of the first group. Serum concentrations of follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) were followed-up prior to and during Zoladex therapy where multivariate variance analysis showed statistically significant differences. The side effects were recorded and are similar to those of other GnRH analogues.

Effects of adrenalectomy and gonadectomy on sex and stress-induced differences in bicuculline-induced convulsions.

The effects of adrenalectomy, gonadectomy and combined adrenalectomy plus gonadectomy on the previously described sex-dependent anticonvulsive effect of swim stress were studied in rats. The convulsive signs (myoclonic twitch, generalized convulsions, tonic hindlimb extension) were produced by constant i.v. infusion of gamma-aminobutyric acid(A) (GABA(A)) antagonist bicuculline, which started 15 min after termination of swim stress (10-min swim at 18-19 degrees C). Adrenalectomy decreased the threshold doses of bicuculline producing the first myoclonic twitch and the onset of generalized convulsions only in females. In adrenalectomized females, but not in males, swim stress enhanced the threshold dose of bicuculline producing generalized convulsions, but, unlike in adrenal-intact animals, it failed to enhance the dose of bicuculline producing tonic hindlimb extension. In gonadectomized stressed and unstressed animals all sex differences disappeared, and swim stress enhanced in both sexes only the threshold doses of bicuculline producing tonic hindlimb extension. Adrenalectomized plus gonadectomized animals displayed clear sex differences in doses of bicuculline necessary to produce all the convulsive signs. In the same animals swim stress postponed, especially in females, the onset of the first myoclonic twitch and generalized convulsions, but not the onset of tonic hindlimb extension. In summary, our results suggest that hormones of the adrenal and gonadal glands are only partly responsible for decreased susceptibility, especially of female rats, to the GABA(A) antagonist bicuculline. Moreover, they have demonstrated that stress produces a gender-specific anticonvulsive effect even in the animals completely deprived of steroid hormones of peripheral origin.

[Hyperprolactinemia and disorders of the menstrual cycle]. / Hiperprolaktinemija i poremecaji menstrualnog ciklusa.

INTRODUCTION: The authors presented physiological conditions associated with increased prolactin values (sleep, stress, hypoglycemia, nipples stimulation, pregnancy and lactation) as well as the causes of pathological hyperprolactinemia. MATERIAL AND METHODS: The results of radioimmunoassay study have been analyzed in concern to the values of follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin (PRL) obtained from the serum of 100 women with increased PRL levels. The "HOECHT" sets were used for the analysis, whereas the values up to 20.9 microgrammes per litre were rated normal. The patients were distributed into 4 groups in concern to the level of PRL increase: 1st group--twenty (n = 20) patients with PRL values from 21-29.9 micrograms/l, 90 blood samples analyzed; 2nd group-forty (n = 40) patients with PRL values f; 30-49.9 micrograms/l, 183 blood samples analyzed; 3rd group--twenty (n = 20) patients with PRL values from 50-99.9 micrograms/l, 83 blood samples analyzed; 4th group--twenty patients (n = 20) with PRL values more than 100 micrograms/l, 78 blood samples analyzed. The values of FSH and LH recorded in the women with hyperprolactinemia were compared with mean values of the same hormones presented in IU/l from the follicular phase of the cycle in the control group which comprised 50 women of reproductive age having normal ovulatory menstrual cycle. RESULTS: The mean values of FSH and LH in the 1st group have not presented with statistically significant difference in relation to the control group. Prevalence of menstrual disorders was 30%, which was statistically significantly higher than in general population. FSH values in the 2nd group were almost the same as in the control group whereas the values of LH were significantly higher. The rate of polycistic ovary syndrome (PCOS) in this group has been significant, also the increased rate of anovulatory cycles from 30 to 67.5%. A mild increase of menstrual cycle rhythm disorders, from 35 to 40% has been recorded. The values of FSH and LH in the 3rd group were significantly lower than in the control group. The significance level was higher for FSH (p < 0.01) then LH (p < 0.05). There was a sudden increase of the cycle rhythm disorders in this group reaching 90%. The 4th group presented with significantly lower values of FSH and LH in relation to the control group, whereas the cycle rhythm disorders occurred in all patients. DISCUSSION: The obtained results were compared with the literature data and some explanations given. CONCLUSIONS: The values of FSH an LH were statistically significantly lower in the 3rd and 4th group. The 2nd group was characteristic for the sudden increase of the number of anovulatory cycles from 30 to 67.5%, whereas the 3rd group presented with the abrupt increase of menstrual cycle rhythm disorders, from 40 to 90%.

[Prolactin and the menstrual cycle]. / Prolaktin i menstrualni ciklus.

In order to estimate serum prolactin levels during particular menstrual cycle phases, the authors analyzed values of follicle-stimulating hormone, luteinizing hormone and prolactin in 50 women of reproductive age with normal menstrual cycles and established ovulation. Blood samples were taken 3-5 times during follicullar, ovulatory and lutheal phase of menstrual cycle. There were 582 radioimmunoassays performed (194 per each hormone), and the upper referent value for prolactin was 20.9 ug l. The 2nd group comprised women (250) with menstrual cycle disorders (olygomenorrhea and amenorrhea) in whom involvement of hyperprolactinemia in these conditions have been done. The obtained results showed that the mean prolactin value changed in each phase of the menstrual cycle. The highest one was recorded in the periovulatory period, whereas the difference was statistically significant in relation to the follicular and lutheal phase (p < 0.05). The difference between the follicular and lutheal phase was not statistically significant, 54 (21.6%) women from the group of menstrual cycle disorders presented with increased values of prolactin.

[Prevalence of Trypanosoma cruzi infection in opossum (Didelphis albiventris) in Santiago del Estero, Argentina]. / Estudio de la prevalencia de la infección por Trypanosoma cruzi en zarigüeyas (Didelphis albiventris) en Santiago del Estero, Argentina.

The opossum of the genus Didelphis is one of the principal wild reservoirs of Trypanosoma cruzi and is widely distributed in the Western Hemisphere. Didelphis albiventris is the most common marsupial in Amamá and Trinidad, two communities in the province of Santiago del Estero, Argentina. The D. albiventris population is replaced every year, and the opossum normally has two reproductive periods, one at the beginning of the spring and another at the beginning of the summer. The two litters are weaned, and they leave the mother's marsupial pouch to join the population, the first (G1) at the beginning of the summer and the second (G2) at the beginning of the fall. Between 1988 and 1991 409 D. albiventris opossums were studied, and xenodiagnoses showed that 35% of them were infected with T. cruzi. Annual cycles of renewed infection were observed, with prevalences that ranged between 22% and 43%. The acquisition of the parasite occurred over the entire year, from the summer through the spring. The prevalence of infection increased with age. The G1 individuals tended to present higher prevalences than the G2 individuals, probably from being exposed to transmission for a longer period of time. In the first two (younger) age categories for the opossums, G2 individuals showed higher prevalences than did the G1 individuals. This indicates a significant increase in transmission intensity during the fall. Opossums should be regarded as a potential source of T. cruzi entry to the domestic transmission cycle.

Sex differences in the response to GABA antagonists depend on the route of drug administration.

Sex differences in the responses to two GABA-related convulsants (bicuculline, picrotoxin) were studied in rats and mice following intraperitoneal (i.p.) and intravenous (i.v.) drug administration. Following i.p. administration male and female rats were equally sensitive to bicuculline, while female rats were more sensitive to picrotoxin. After i.v. infusion the threshold doses of bicuculline and picrotoxin producing running/bouncing clonus (RB clonus) were significantly lower in male than in female rats, i.e. male rats were more sensitive to both convulsants than females. Following i.p. administration, at some doses female mice were more sensitive to bicuculline and male mice to picrotoxin, although ED50 values between the sexes were not significantly different. After i.v. infusion, doses of bicuculline producing RB clonus and death were significantly lower in male than in female mice, i.e. male mice were more sensitive to bicuculline. The two sexes of mice were equally sensitive to i.v. administration of picrotoxin. While sex and species differences obtained following i.p. drug administration could presumably be explained by differences in pharmacokinetics, the i.v. route of drug administration is suggested as a reliable technique in the studies of sex and species differences in pharmacodynamics.

Seasonal influence on platelet 5-HT levels in patients with recurrent major depression and schizophrenia.

The influence of seasons on platelet serotonin (5-HT) concentration was determined in 88 unipolar depressed and 117 schizophrenic male inpatients, and 90 normal male controls. Platelet 5-HT concentrations showed moderate, but insignificant intragroup seasonal variations in healthy controls and in the groups of depressed (psychotic and nonpsychotic) and schizophrenic (positive and negative) patients. In spring, platelet 5-HT concentrations were higher in schizophrenic patients than in normal controls or in depressed patients, while in other seasons platelet 5-HT concentrations were not significantly different between the groups. Higher platelet 5-HT concentrations were detected in psychotic when compared to nonpsychotic depressed patients in summer, fall, and winter. Increased platelet 5-HT concentrations observed in schizophrenic patients with positive symptoms clearly separated these patients from patients with negative schizophrenia, especially in spring, summer, and fall. Our results indicate the necessity to match patients with regard to the season of the sampling, and to divide depressed and schizophrenic patients into subtypes.

Sex differences in bicuculline-induced convulsions: interaction with stress and ligands of benzodiazepine binding sites.

The response to i.v. administration of bicuculline and its interaction with the benzodiazepine agonist diazepam and antagonist flumazenil were studied in male and female handling stressed and swim stressed rats. Both handling stressed and swim stressed male rats needed less bicuculline to produce myoclonic twitch and running/bouncing (RB) clonus than females. Besides, a lower dose of bicuculline produced tonic hindlimb extensor convulsion (THE) in male than in female swim stressed rats. Flumazenil failed to affect seizure thresholds for bicuculline either in handling stressed or in swim stressed animals. Sex differences remained present after diazepam pre-treatment as well. While diazepam enhanced doses of bicuculline producing all three convulsive signs similarly in both handling and swim stressed rats (141-162%), swim stress had the lowest anticonvulsive effect for the onset of myoclonic twitch (110% in males and 117% in females) and the highest for THE (148% in males and 188% in females). The anticonvulsive effect of diazepam was not sex-dependent, while the anticonvulsive effect of swim stress was greater in female than in male rats. The results suggest that greater sensitivity of male rats to bicuculline and the anticonvulsive effect of swim stress do not result from the release of endogenous modulators of benzodiazepine binding sites.

Regional differences in NaCl-induced increase of the potency of bicuculline to displace [3H]muscimol binding.

It has been shown that the potency of bicuculline to displace [3H]muscimol binding to crude brain membranes can be enhanced markedly by different anions. This study shows that although bicuculline alone was a more potent displacer of [3H]muscimol binding in cortical than in cerebellar membranes, the NaCl (250 mM)-induced leftward shift of the bicuculline inhibition curve of [3H]muscimol binding was considerably higher in cerebellum than in cortex. The some concentration of NaCl failed to affect either the affinity or the density of cortical and cerebellar [3H]muscimol binding sites. The results suggest that sodium chloride is able to reveal regional differences in bicuculline potency.

[Infertility and endometriosis]. / Infertilitet i endometrioza.

The goal of this study was to set the relation between infertility and endometriosis. It included 500 infertile female patients who underwent laparoscopy in order to find out the cause of infertility. The prevalence of endometriosis in these patients was 26%, that is significantly higher than in the control group which consisted of 200 randomly chosen fertile women in whom prevalence of endometriosis was 5%. Patients with endometriosis mainly belong to the group of 25-29 years of age with a median duration of infertility of 2-4 years. Endometriosis occurs three times more often in the group of patients with primary sterility than in patients with secondary sterility. Majority of patients (71.5%) are with minimal or mild endometriosis.

Influence of gender and gonadectomy on bicuculline-induced convulsions and on GABAA receptors.

The response to IV administration of GABAA receptor antagonist bicuculline was studied in young (30 days) and in adult gonad-intact or gonadectomized male and female rats. The properties of GABAA receptors, obtained from cortex and cerebellum 30 days following gonadectomy, and the affinity of muscimol and bicuculline for cortical and cerebellar GABA binding sites were also studied. While young rats failed to show sex differences, the threshold doses of bicuculline producing the first myoclonic twitch and running/bouncing clonus (RB clonus) were lower in adult male than female rats. Fifteen days after gonadectomy or sham operation male rats needed less bicuculline to the onset of myoclonic twitch and RB clonus than identically treated females, while orchidectomized rats needed more bicuculline to the onset of tonic hindlimb extension than all other groups examined. All sex differences disappeared 30 days following gonadectomy. At the same time, in males gonadectomy decreased the affinity and enhanced the density of cortical 3H-muscimol binding sites. In female rats, gonadectomy only decreased the affinity of cortical GABAA receptors. Only regional but not sex differences were observed in the affinity of muscimol and bicuculline for GABAA receptors. Sex differences in the threshold doses of bicuculline-producing convulsions do not correlate either with the properties of cortical and cerebellar GABAA receptors or with the affinity of bicuculline for the same binding sites.

[The role of fertilization in vitro in the treatment of infertility]. / Mesto vantelesne oplodnje u lecenju bracne neplodnosti.

Artificial insemination presents of one broadly accepted methods of assisted reproduction. Indicative spheres for the healing of sterility by this method are permanently outspreading. Its primary application has been induced due to irreparable damages of oviducts but the indications for its use have been expanded in both women and men. One third of the total number of sterile married couples has the need for some of existing methods for assisted reproduction. Micromanipulative techniques of artificial insemination have practically solved all until recently unbridgeable difficulties in the treatment of marital sterility caused by man. Artificial insemination presents a treatment methodology tightly connected with a series of ethical, social and legal problems which are of great interest for the society also.

Gonadal hormones and picrotoxin-induced convulsions in male and female rats.

The sensitivity to the GABA-blocking agent picrotoxin was studied in young and adult male and female rats, in rats treated with gonadal hormones and in gonadectomized male and female rats. Picrotoxin was equipotent in producing convulsions in male and female 20-day-old rats. Adult females tended to be more, while adult males were considerably less sensitive to picrotoxin than young rats. Picrotoxin was equipotent in displacing t-[3H]butylbicycloorthobenzoate ([3H]TBOB) binding to crude cortical and cerebellar membranes from male and female rat brain. Chronic treatment of male rats, beginning with 30 days of age, with estradiol benzoate enhanced their sensitivity to picrotoxin, while an analogous treatment of female rats with testosterone propionate was ineffective. Thirty days following castration adult male rats had shorter latencies to the appearance of picrotoxin-induced convulsions and a higher incidence of death. Ovariectomy in females failed to modify the sensitivity to picrotoxin. The results suggest that gonadal hormones have a crucial role in the development of sex related differences in the response of rats to picrotoxin and presumably to other GABA-related drugs. When developed, the male type of reactivity appears to depend more, and the female type less on the presence of circulating hormones in the blood.

Effect of age on platelet 5-HT concentrations in healthy controls, depressed and schizophrenic patients.

The influence of age on platelet 5-HT concentrations was investigated in 85 male unipolar depressed inpatients, 113 male schizophrenic inpatients and 81 normal male controls. The correlation coefficients between platelet 5-HT concentrations and age within groups were very low and nonsignificant. Our results suggest that higher platelet 5-HT content, observed in schizophrenic patients, could not be ascribed to the influence of age.

[Immunologic characteristics of peritoneal fluid in endometriosis]. / Imunoloske karakteristike peritonealne tecnosti kod endometrioze.

Increased volume of peritoneal fluid is found more frequently in patients with endometriosis (51%) than in infertile patients without endometriosis (13%). Immunologic analysis of the peritoneal fluid shows that in patients with endometriosis the level of immunoglobulin G (IgG) increases. We analyzed 34 samples of peritoneal fluid from patients with and 13 from patients without endometriosis. The mean value of IgG in the group of patients with endometriosis was 7.73g/L and 3.94g/L in the control group. This difference is statistically significant, but there is no statistically significant difference in regard to immunoglobulin A (IgA), while it has been significant for immunoglobulin M (IgM) only in the third stage of the disease. In certain stages of illness there are no statistically significant differences in values of all three immunoglobulin types. A golden standard of immunoglobulin G in peritoneal fluid is 5g/L and in regard to this level we calculated the following: sensitivity, specificity, prognostic value and accuracy of the test. Sensitivity and positive prognostic value reached 85.3%. On the basis of these findings it can be concluded that if no endometriosis can be seen during laparascopy while the volume of peritoneal fluid is increased, immunologic analysis should be performed. If IgG values are 5g/L or higher, the patient should be treated as a patient with possible "precursor endometriosis".