Antibiotics for appendicectomy in children and adolescents during the perioperative period: an integrative review / Antibióticos para apendicectomia em crianças e adolescentes no perioperatório: uma revisão integrativa

ABSTRACT Objective: To analyze the preoperative use of antibiotics in children and adolescents requiring appendectomy. Data source: Integrative review was performed in the MEDLINE, Latin American and Caribbean Health Sciences (LILACS) and Cochrane databases and the PubMed portal, with no time limit. The keywords used were: appendicitis, child, adolescent and antibacterial with Boolean AND. The articles included were published in Portuguese, English or Spanish and whose participants were under 18 years of age. Review articles and guidelines were excluded. The studies were classified according to their level of evidence and 24 papers were selected. Data collection and analysis: Seven randomized clinical trial studies (level of evidence II), eight cohorts (level III), seven retrospective observational studies (level V) and two historical documentary analysis (level IV) were selected. The studies addressed antibiotics used in acute appendicitis in both uncomplicated and complicated cases. Antibiotics initiated in the preoperative period showed a decrease in the rates of surgical wound infections. First-line (empiric) regimens were tested for sensitivity to microorganisms in peritoneal material cultures, however the results were controversial. Broad-spectrum antibiotics have been suggested in some studies because they have good coverage, but in others they have not been recommended because of the risk of developing bacterial resistance. Shorter administration time and earlier change to the oral route reduced hospitalization time. Conclusions: There are several clinical protocols with different antibiotics. However, there is no standardization concerning the type of antibiotic drug, time of use, or route.

RESUMO Objetivo: Analisar o uso de antibióticos em crianças e adolescentes no perioperatório de apendicectomia. Fonte de dados: Realizou-se uma revisão integrativa, nas bases de dados MEDLINE, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e Cochrane e no portal PubMed, sem limite de tempo. As palavras-chave utilizadas foram: apendicite, criança, adolescente e antibacterianos com booleano AND. Os artigos incluídos foram publicados nos idiomas português, inglês ou espanhol e cujos participantes tivessem idade inferior a 18 anos. Os artigos de revisão e diretrizes foram excluídos. A qualidade da evidência foi analisada, e foram selecionados 24 artigos. Síntese dos dados: Sobre os estudos selecionados, sete foram ensaios clínicos randomizados (nível de evidência II), oito coortes (nível III), sete observacionais retrospectivos (nível V) e duas análises documentais históricas (nível IV). Os estudos abordaram antibióticos usados na apendicite aguda em suas formas não complicada e complicada. Os antibióticos iniciados no pré-operatório evidenciaram diminuição nas taxas de infecção da ferida cirúrgica. Os esquemas de primeira linha (empíricos) foram testados em relação à sensibilidade dos microrganismos nas culturas de material peritoneal, no entanto os resultados foram controversos. Sugeriram-se antibióticos de amplo espectro em alguns estudos por apresentar boa cobertura, no entanto em outros eles não foram recomendados, pelo risco de desenvolver resistência bacteriana. O menor tempo de administração e a mudança mais precoce para a via oral reduziram o tempo de internação. Conclusões: Existe um grande número de protocolos clínicos com antibióticos diversos, no entanto não existe padronização em relação ao tipo de antibiótico, tempo de uso nem via.

ANTIBIOTICS FOR APPENDICECTOMY IN CHILDREN AND ADOLESCENTS DURING THE PERIOPERATIVE PERIOD: AN INTEGRATIVE REVIEW.

OBJECTIVE: To analyze the preoperative use of antibiotics in children and adolescents requiring appendectomy. DATA SOURCE: Integrative review was performed in the MEDLINE, Latin American and Caribbean Health Sciences (LILACS) and Cochrane databases and the PubMed portal, with no time limit. The keywords used were: appendicitis, child, adolescent and antibacterial with Boolean AND. The articles included were published in Portuguese, English or Spanish and whose participants were under 18 years of age. Review articles and guidelines were excluded. The studies were classified according to their level of evidence and 24 papers were selected. DATA COLLECTION AND ANALYSIS: Seven randomized clinical trial studies (level of evidence II), eight cohorts (level III), seven retrospective observational studies (level V) and two historical documentary analysis (level IV) were selected. The studies addressed antibiotics used in acute appendicitis in both uncomplicated and complicated cases. Antibiotics initiated in the preoperative period showed a decrease in the rates of surgical wound infections. First-line (empiric) regimens were tested for sensitivity to microorganisms in peritoneal material cultures, however the results were controversial. Broad-spectrum antibiotics have been suggested in some studies because they have good coverage, but in others they have not been recommended because of the risk of developing bacterial resistance. Shorter administration time and earlier change to the oral route reduced hospitalization time. CONCLUSIONS: There are several clinical protocols with different antibiotics. However, there is no standardization concerning the type of antibiotic drug, time of use, or route.

TOTAL COST OF HOSPITALIZATION OF PATIENTS UNDERGOING ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY RELATED TO NUTRITIONAL STATUS.

BACKGROUND: In the Western world, the population developed an overweight profile. The morbidly obese generate higher cost to the health system. However, there is a gap in this approach with regard to individuals above the eutrofic pattern, who are not considered as morbidly obese. AIM: To correlate nutritional status according to BMI with the costs of laparoscopic cholecystectomy in a public hospital. METHOD: Data were collected from medical records about: nutritional risk assessment, nutricional state and hospital cost in patients undergoing elective laparoscopic cholecystectomy. RESULTS: Were enrolled 814 procedures. Average age was 39.15 (±12.16) years; 47 subjects (78.3%) were women. The cost was on average R$ 6,167.32 (±1830.85) to 4.06 (±2.76) days of hospitalization; 41 (68.4%) presented some degree of overweight; mean BMI was 28.07 (±5.41) kg/m²; six (10%) individuals presented nutritional risk ≥3. There was a weak correlation (r=0.2) and not significant (p <0.08) between the cost of hospitalization of the sample and length of stay; however, in individuals with normal BMI, the correlation was strong (r=0,57) and significant (p<0.01). CONCLUSION: Overweight showed no correlation between cost and length of stay. However, overweight individuals had higher cost of hospitalization than those who had no complications, but with no correlation with nutritional status. Compared to those with normal BMI, there was a strong and statistically significant correlation with the cost of hospital stay, stressing that there is normal distribution involving adequate nutritional status and success of the surgical procedure with the consequent impact on the cost of hospitalization.

RACIONAL: No mundo ocidental, a população desenvolveu um perfil de excesso de peso corporal. Os obesos mórbidos geram custo mais alto para o sistema de saúde. Entretanto, observa-se um hiato no tocante aos indivíduos acima do eutrofismo, mas não considerados obesos mórbidos. OBJETIVO: Correlacionar estado nutricional, segundo o IMC, com custo de internação de colecistectomias videolaparoscópicas. MÉTODO: Coleta de dados dos prontuários sobre: avaliação de risco nutricional, estado nutricional e custo de internação de pacientes submetidos à colecistectomia videolaparoscópica eletiva no período de janeiro de 2012 a dezembro de 2014. RESULTADOS: Foram analisados 814 procedimentos. A idade média foi de 39,15 (±12,16) anos; 47 (78,3%) eram mulheres. O custo de internação foi, em média, de R$ 6.167,32 (±1.830,85) para 4,06 (±2,76) dias de internação. Quarenta e um (68,4%) pacientes apresentavam algum grau de sobrepeso; o IMC médio foi 28,07 (±5,41) kg/m²; seis (10%) indivíduos apresentavam risco nutricional ≥3. Houve correlação fraca (r=0,2) e não significativa (p<0,08) entre o custo de hospitalização e o tempo de permanência. No entanto, em indivíduos com IMC normal, a correlação foi forte (r=0,57) e significante (p<0,01). CONCLUSÃO: Sobrepeso não demonstrou correlação entre custo e tempo de internação. Entretanto, os indivíduos com sobrepeso apresentaram custo maior de internação em relação aos que não tiveram intercorrência, mas sem correlação com o estado nutricional. Em relação aos com IMC normal, houve correlação forte e estatisticamente significante com o custo para tempo de internação, reforçando que há provável distribuição normal envolvendo estado nutricional adequado e sucesso do procedimento cirúrgico com consequente impacto no custo de internação.

Total cost of hospitalization of patients undergoing elective laparoscopic cholecystectomy related to nutritional status / Custo total de internação de pacientes submetidos à colecistectomia videolaparoscópica eletiva relacionado ao estado nutricional

ABSTRACT Background: In the Western world, the population developed an overweight profile. The morbidly obese generate higher cost to the health system. However, there is a gap in this approach with regard to individuals above the eutrofic pattern, who are not considered as morbidly obese. Aim: To correlate nutritional status according to BMI with the costs of laparoscopic cholecystectomy in a public hospital. Method: Data were collected from medical records about: nutritional risk assessment, nutricional state and hospital cost in patients undergoing elective laparoscopic cholecystectomy. Results: Were enrolled 814 procedures. Average age was 39.15 (±12.16) years; 47 subjects (78.3%) were women. The cost was on average R$ 6,167.32 (±1830.85) to 4.06 (±2.76) days of hospitalization; 41 (68.4%) presented some degree of overweight; mean BMI was 28.07 (±5.41) kg/m²; six (10%) individuals presented nutritional risk ≥3. There was a weak correlation (r=0.2) and not significant (p <0.08) between the cost of hospitalization of the sample and length of stay; however, in individuals with normal BMI, the correlation was strong (r=0,57) and significant (p<0.01). Conclusion: Overweight showed no correlation between cost and length of stay. However, overweight individuals had higher cost of hospitalization than those who had no complications, but with no correlation with nutritional status. Compared to those with normal BMI, there was a strong and statistically significant correlation with the cost of hospital stay, stressing that there is normal distribution involving adequate nutritional status and success of the surgical procedure with the consequent impact on the cost of hospitalization.

RESUMO Racional: No mundo ocidental, a população desenvolveu um perfil de excesso de peso corporal. Os obesos mórbidos geram custo mais alto para o sistema de saúde. Entretanto, observa-se um hiato no tocante aos indivíduos acima do eutrofismo, mas não considerados obesos mórbidos. Objetivo: Correlacionar estado nutricional, segundo o IMC, com custo de internação de colecistectomias videolaparoscópicas. Método: Coleta de dados dos prontuários sobre: avaliação de risco nutricional, estado nutricional e custo de internação de pacientes submetidos à colecistectomia videolaparoscópica eletiva no período de janeiro de 2012 a dezembro de 2014. Resultados: Foram analisados 814 procedimentos. A idade média foi de 39,15 (±12,16) anos; 47 (78,3%) eram mulheres. O custo de internação foi, em média, de R$ 6.167,32 (±1.830,85) para 4,06 (±2,76) dias de internação. Quarenta e um (68,4%) pacientes apresentavam algum grau de sobrepeso; o IMC médio foi 28,07 (±5,41) kg/m²; seis (10%) indivíduos apresentavam risco nutricional ≥3. Houve correlação fraca (r=0,2) e não significativa (p<0,08) entre o custo de hospitalização e o tempo de permanência. No entanto, em indivíduos com IMC normal, a correlação foi forte (r=0,57) e significante (p<0,01). Conclusão: Sobrepeso não demonstrou correlação entre custo e tempo de internação. Entretanto, os indivíduos com sobrepeso apresentaram custo maior de internação em relação aos que não tiveram intercorrência, mas sem correlação com o estado nutricional. Em relação aos com IMC normal, houve correlação forte e estatisticamente significante com o custo para tempo de internação, reforçando que há provável distribuição normal envolvendo estado nutricional adequado e sucesso do procedimento cirúrgico com consequente impacto no custo de internação.

Conhecimento de estudantes de medicina sobre o funcionamento do Serviço de Atendimento Móvel de Urgência (Samu) / Knowlegde of medical students about the functioning of the Mobile Emergency Medical Service (SAMU)

O presente estudo teve por objetivo avaliar o nível de conhecimento dos estudantes de Medicina sobre o funcionamento do Serviço de Atendimento Móvel de Urgência (Samu) , dada a importância deste serviço para a população e seu papel fundamental no Sistema Único de Saúde (SUS) . Para tanto, acadêmicos do primeiro ao 12ºsemestre foram entrevistados mediante um questionário padronizado. Concluiu-se que mesmo acadêmicos de Medicina, indivíduos que se encontram imersos na área da saúde, possuem conhecimento aquém do esperado sobre o Samu, independentemente do período cursado, fazendo-nos questionar o conhecimento da população em geral sobre o tema e a importância da realização de novos estudos e comparação de dados em âmbito nacional.

This study aimed to assessthe knowledge of medical students about the functioning of the pre-hospital emergency medical service (EMS), given the importance of this service to the population and its role in the Unified Health System (SUS). Therefore, first to sixth year students were interviewed using a standardized questionnaire. The conclusion was drawn that even medical students, individuals who are immersed in health, have an unsatisfying level of knowledge about the SAMU, regardless of the stage of their studies, leading us to query the knowledge of the general public about this service and the importance of conducting further studies and making comparisons of nationwide data.

Rosai-Dorfman disease with spontaneous resolution: case report of a child.

Rosai-Dorfman disease is a self-limiting condition caused by histiocyte proliferation within the sinusoids of lymph nodes and in extranodal tissue. It is a rare disease, particularly in children, that progresses with extensive lymphadenopathy. This paper reports on the case of a 2-year-old child with progressive cervical lymphadenopathy associated with persistent fever and radiological findings suggestive of lymphoma. Histopathological and immunohistochemistry studies of a lymph node biopsy established the diagnosis of Rosai-Dorfman disease. Both lymphadenopathy and fever resolved spontaneously.

Rosai-Dorfman disease with spontaneous resolution: case report of a child

Rosai-Dorfman disease is a self-limiting condition caused by histiocyte proliferation within the sinusoids of lymph nodes and in extranodal tissue. It is a rare disease, particularly in children, that progresses with extensive lymphadenopathy. This paper reports on the case of a 2-year-old child with progressive cervical lymphadenopathy associated with persistent fever and radiological findings suggestive of lymphoma. Histopathological and immunohistochemistry studies of a lymph node biopsy established the diagnosis of Rosai-Dorfman disease. Both lymphadenopathy and fever resolved spontaneously.

Refractory congenital chylous ascites.

Refractory congenital chylous ascites (CCA) is an uncommon clinical condition. Few cases have been described and no gold standard treatment has been defined so far. This report describes a case of refractory CCA in a newborn child which was treated by surgery. Preoperative lower-limb lymphoscintigraphy associated with intraoperative patent blue testing and fibrin glue application were useful in order to provide a successful outcome.

Corticosteroids reduce glial fibrillary acidic protein expression in response to spinal cord injury in a fetal rat model of dysraphism.

BACKGROUND: Exposure of the spinal cord in myelomeningocele (MM) throughout gestation increases spinal injury. Astrocyte activation evidenced by glial fibrillary acidic proteins (GFAP) indicates the extent of injury. Corticosteroids modulate GFAP synthesis, but their effect in MM is unclear. The purpose of this study was to evaluate the GFAP expression in a fetal rat model of dysraphism and the effect of corticosteroid treatment on this marker and on clinical neurological disabilities. METHODS: Dysraphism was surgically created in 2 groups of 48 rat fetuses; group 1: control, and group 2: treated with corticosteroid. Each group was subdivided into fetuses with surgically created MM, controls and shams on day 18.5 of gestation (term = 22 days). Fetuses were harvested on day 21.5, examined for evidence of neurological deficits, and the following clinical parameters were registered: kyphosis, tail deformities, leg deformities, leg paralysis or paresis and pain perception. The fetuses were fixed for GFAP immunostaining. RESULTS: All fetuses with MM in group 1 presented neurological deficits and glial reactions with GFAP expression, as opposed to controls and shams. In group 2, corticosteroid treatment prevented some neurological deficits (18-25%), reducing glial response and GFAP expression. CONCLUSIONS: Experimentally induced dysraphism in the rat fetus is related to glial response and increased GFAP expression in the spinal cord. Corticoid treatment clinically improved nerve injury in some fetuses. It reduced glial reaction and GFAP expression.

Does bronchopulmonary dysplasia change the postoperative outcome of herniorrhaphy in premature babies?

BACKGROUND: Inguinal hernia is a common surgical condition in premature neonates. Because of physiological immaturity, they can present with lung-related diseases, such as bronchopulmonary dysplasia (BPD), which may influence the time for operation and the postoperative outcome after hernia repair. The aim of this study was to analyze the role of BPD in the outcome of premature infants who underwent herniorrhaphy. METHODS: Fifty-two premature infants who underwent hernia repair from 1996 to 2004 at CAISM-UNICAMP were included in this study. Seventeen babies had BPD and 35 did not. The features reviewed included: (i) associated preoperative morbidity; (ii) birth data and the hernia; and (iii) hernia diagnosis, surgery and postoperative outcome data. Three sets of analysis were undertaken. The first compared features with and without BPD. The second was an univariate analysis to detect associations between those features and postoperative complications. Finally, a multivariate analysis to determine the effect of BPD when adjusted for other factors. RESULTS: Some features were different between the studied groups, such as birth weight, age at herniorrhaphy and time of preoperative mechanical ventilation. There was no statistical difference in weight at surgery, duration of postoperative ventilation and weight at discharge between those with BPD and those without. Univariate and multivariate analysis found no association between different studied variables, including BPD, and incidence of postoperative respiratory complications. CONCLUSION: These data suggest that all premature infants, with or without BPD, should be treated with equal concern regarding the possibility of postoperative pulmonary complications.

Nutritional state and herniorrhaphy in premature infants.

The incidence of inguinal hernia in premature infants is significantly high, and the optimal timing for its correction is controversial. Furthermore, whether the nutritional status of neonates will alter hernia diagnosis and postoperative results has not been demonstrated. The aim of this study was to analyze the results of premature neonates who underwent inguinal hernia repair before hospital discharge, comparing clinical features and perioperative data of two distinct nutritional groups. It was verified that early inguinal hernia repair is feasible without an escalation in the incidence of complications, thereby reducing the risk of incarceration and avoiding subsequent hospitalization. Moreover, premature infants had similar postoperative outcomes regardless of their nutritional status.

Esplenectomia laparoscópica nas doenças hematológicas / Laparoscopic splenectomy in hematological disorders

Objetivo: Relatar a experiência inicial do Centro Infantil Boldrini com a esplenectomia laparoscópica (EL) em crianças e adultos jovens. Método: Foram revisados os prontuários de 40 pacientes (mediana da idade de 6,6 anos; 1 a 22,8) submetidos à EL entre Julho de 2000 e Maio de 2002. As principais indicações de acordo com a doença de base foram: doença falciforme (DF) em 20 pacientes (50%), esferocitose hereditária em 10(25 %), púrpura trombocitopência idiopática em oito (20 %), doença de Hodgkin em um e anemia hemolíticaa esclarecer em um. Resultados: Trinta e oito esplenectomias foram completadas por via laparoscópica (duas conversões) e em doze foi realizada adicionalmente a colecistectomia. A mediana do tempo operatório foi de 127,5 minutos (90 – 240 min) e sete (17,5 %) baços acessórios foram encontrados. Sangramento intra-operatório foi significativo apenas nas duas conversões, mas não houve necessidade de transfusões. A mediana do peso dos baços foi de 250 g (106 – 1000; n=36). Complicações pós-operatórias ocorreram em sete (17,5 %) pacientes e, nos portadores de DF, 35% desenvolveram síndrome torácica aguda. A mediana da permanência hospitalar pós-operatória foi de dois dias (2 - 14). O seguimento variou de 23 dias a dois anos (mediana de 11 meses). Conclusões: A EL pode ser realizada de modo seguro mesmo em baços de grande tamanho e é opçãoatrativa que pode substituir o procedimento aberto. Em pacientes com DF, a taxa de complicações permanecealta, sugerindo mecanismos outros que vão além da escolha da via de acesso cirúrgica.

Background: Laparoscopic splenectomy (LS) is becoming the procedure of choice in the treatment of children with hematological disorders. However, concerns remains regarding conversion rates, dissection and extraction of the spleen. The authors analyze their early experience at Boldrini’s Children CancerCenter – Brazil in 40 LS performed in children and young adults. Methods: Retrospective review of the charts of 40 patients (median age of 6.6 years; range 1 to 22.8) who underwent LS, between July/ 2000 and May/ 2002. The main indications were sickle cell disease (SCD) (20 - 50 %), hereditary spherocytosis (10 - 25 %) and idiopathic thrombocytopenic purpura (8 - 20 %). Results: All but two splenectomies were performed exclusively by laparoscopy, and 12 patients also underwent a concomitant cholecystectomy. The mean operating time was 127.5 minutes (90 – 240m). In seven patients (17.5%) accessory spleens were found and removed. Intraoperative bleeding was significant only in the two cases that required conversion to an open procedure, although no transfusion was needed. The median weight of the spleen was 250 g (range 106g – 1000g; n=36). Complications were observed in seven patients (17.5 %) with SCD that developed acute chest syndrome. There were no deaths in this series and the median postoperative stay at the hospital was two days (2 - 14). Follow-up ranged from 23 days to two years. Conclusions: On the basis of our experience, LS is a safe procedure, even to treat large spleens and became an attractive option that might replace the open procedure. In SCD patients, the rate of complications remains high, suggesting mechanisms other than the scope of the choice of surgical approach.

Hidronefrose pré-natal: Experiência do grupo de medicina fetal-UNICAMP / Prenatal hydronephrosis: Experience of fetal medicine group-UNICAMP

Com aprimoramento da avaliação ultrassonagráfica pré-natal, iniciou-se o manejo precoce de crianças com uropatias. o impacto desta conduta é alvo de intensa discussão. Este trabalho objetiva analisar a experiência do grupo de medicina fetal-UNICAMP com a abordagem da hidronefrose quando diagnosticada no período pré-natal. Para tanto, foram acompanhadas 45 gestantes, atendidas no período de janeiro de 1997 a abril de 1999, cujos fetos eram portadores de hidronefrose. Dezenove desses fetos (35,5 por cento) possuíam alterações associadas a outros órgãos. A intervenção pré-natal foi realizada em 21 pacientes, sendo 18 punções de urina fetal e três derivações intra-útero; 31 neonatos eram do sexo masculino, 11 do feminino e em três indeterminado. o peso médio ao nascimento foi de 2778g. Onze neonatos evoluíram para o óbito seja intra-útero, seja no período pós natal imediato. Os 34 nenatos restantes foram acompanhados, após o nascimento, com o diagnóstico de : hidronefrose transitória em 3 (8,82 por cento), anomalia de junção uretero-pélvica (JUP) em 9 (26,5 por cento), hidronefrose não-obstrutiva em 4 (11,8 por cento), refluxo vésico-ureteral (RVU) em 7 (20,6 por cento), anomalia de junção uretero-vesical (JUV) em 5 (14,7 por cento) e válvula de uretra posterior (VUP) em 6 (17,6 por cento). O tempo médio de seguimento dos 31 pacientes com alteração ultrassonagráfica foi de 16,8 meses, variando de 6 a 37 meses. Dezessete (54,8 por cento) pacientes foram conduzidos clinicamente com manutenção da função renal. Quatorze (45,2 por cento) pacientes foram tratados cirurgicamente. Destes, seis pacientes apresentavam inicialmente baixa função renal unilateral decorrentes da anomalia de JUP5 ou JUV1, sendo submetidos a nefrectomia2 ou pieloplastia2. Outros dois realizaram reimplante ureteral. O tratamento inicial dos seis pacientes com VUP foi vesicostomia5 ou resseção de válvula precoces. Podemos concluir que o diagnóstico pré-natal de uropatias permite o acompanhamento perinatal por equipe multidisciplinar e otimiza o manejo pós natal propiciando, quando necessário, a intervenção precoce

Tratamento do carcinoma hepatocelular / Treatment of hepatocellular carcinoma

A severidade do carcinoma hepatocelular (CHC) tem fomentado notavelmente o estudo de sua terapêutica. O objetivo deste trabalho é revisar as diversas modalidades de tratamento do CHC, analisando o papel e eficácia de cada uma, bem como as novas perspectivas. A ressecção cirúrgica permanece como método de escolha. Contudo, uma série de outros técnicas como a injeção percutânea de etanol e a quimioembolização transarterial têm sido também oportunamente indicadas

Tumores germinativos do testículo: revisão de 26 casos tratados no Instituto de Câncer do Ceará / Germ cell tumors of testis - review of 26 cases treated at Institut of Cancer of Ceará

Os tumores germinativos do testículo são neoplasias relativamente raras, representando apenas 0,5 a 1 por cento dos tumores de trato urogenital. Entretanto, corresponde à neoplasia maligna mais comum em homens entre os 15 e 34 anos. Avanços recentes na quimioterapia, técnica de linfadenectomia retroperitoneal, marcadores tumorais e tomografia computadorizada resultaram em melhoria expressiva da sobrevida mesmo em casos de doença disseminada. Entre janeiro de 1989 e agosto de 1994, 26 pacientes portadores de tumores germinativos do testículo foram tratados, de maneira sistemática, no Instituto de Câncer do Ceará. Os autores fazem uma análise crítica dos casos, dando ênfase para os aspectos clínico, diagnóstico, estadiamento e sobrevida.

Role of cytokines, prostaglandins and nitric oxide in hepatic regeneration

The liver is considered the center of the metabolism. Many of its functions are controlled by a network of mediators. Hepatic regeneration is a highly regulated event also by several substances. Herein is was reviewed the literature about the role of cytokines, prostaglandins and nitric oxide in this event. Prior, it was described the known activities of each substance in the body. Further, it was examined since the production until the action of each one in regenerating livers. We could conclude that some of these mediators present a well-defined action, while others are object of great controversy. Overall, the comprehension of the liver's regeneration is very important in concern to develop new kinds of treatment in hepatology.