Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist's perspective.

PURPOSE: Hepatic resection is the only potentially curative treatment for patients with colorectal liver metastasis (CRLM). Many multidisciplinary approaches, including the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, have been proposed to increase the resectability rate in these patients. ALPPS is the most recently described staged liver resection technique, representing an advantageous strategy to induce a rapid and marked increase in the future liver remnant (FLR) volume. The aim of this article is to describe the radiological evaluation of this procedure and its variation. METHODS: This retrospective study included 9 patients with CRLM who underwent the ALPPS procedure. Abdominal imaging studies were reviewed, with an emphasis on a rational radiological approach. The number of liver metastases, the FLR volume (pre- and postportal vein ligation), anatomical variations, potential pitfalls related to disease progression, and postoperative complications were evaluated. RESULTS: The types of hepatic resection included 4 classical ALPPS cases, 3 right ALPPS variations, and 2 left ALPPS variations. The mean FLR volume calculated in the initial evaluation was 453 mL (213-790 mL). Following the first surgery, the mean FLR volume increased to 634 mL (410-957 mL), which indicated a mean volume increase of 181.1 mL (95% CI 149.7-212.5 mL; p < 0.001) and a mean absolute volume increase of 48% (19%-88%). CONCLUSION: The ALPPS procedure is an emerging form of two-stage hepatectomy. In this context, radiologists should provide crucial preoperative and perioperative information that may change surgical planning and contribute to an improvement in the oncologic outcome.

Population genetic structure of skipjack tuna Katsuwonus pelamis from the Indian coast using sequence analysis of the mitochondrial DNA D-loop region.

Genetic structure of skipjack tuna Katsuwonus pelamis from the Indian region was investigated using sequence data of mitochondrial DNA (mtDNA) D-loop region. A total of 315 individuals were sampled from six major fishing grounds around the east and west coasts of India including the Andaman (Port Blair) and Lakshadweep (Minicoy) Islands. Nucleotide and gene diversities were high in all the sample collections. Significant genetic heterogeneity was observed for the mtDNA sequence data among sites (φ(ST) = 0·0273, P < 0·001). Analysis of molecular variance (AMOVA) showed significant genetic variation among four groups (φ(CT) = 0·0261, P < 0·05) which was also supported by spatial AMOVA results. The null hypothesis of single panmictic population of K. pelamis along the Indian coast can thus be rejected. Phylogenetic analysis of the mtDNA sequence data showed the presence of four clades of K. pelamis in the Indian waters. There was no clear pattern, however, of haplotypes and geographic location among samples. The results of this study suggest the occurrence of four genetically differentiated groups of K. pelamis across the coastal waters of India.

Ectopic ACTH syndrome caused by pheochromocytoma: computed tomography-guided percutaneous ethanol injection as an alternative treatment.

Ectopic ACTH secretion represents 8-18% of the cases of endogenous hypercortisolism. Pheochromocytomas correspond to 2-25% of the cases and surgery is the indicated treatment. We describe a case of ACTH-secreting pheochromocytoma treated with percutaneous ethanol injection (PEI) guided by computed tomography (CT). A 71-yr-old man presented with diabetes, severe hypokalemia, weight loss, muscle weakness, and hypertension. Hormonal evaluation revealed elevated levels of urinary cortisol, ACTH, catecholamines, and urinary metanephrines. There was no cortisol or ACTH response to desmopressin stimulation test. Magnetic resonance revealed bilateral adrenal nodules, larger on the left side. The suspected diagnosis was ectopic ACTH syndrome caused by pheochromocytoma. Ketoconazole treatment resulted in reduction of urinary cortisol levels but was followed by severe cholestasis and hepatic dysfunction, preventing surgery; it was substituted by octreotide with reduction of ACTH and cortisol levels, but without improvement of cholestasis. The patient presented cachexia and developed multiple pulmonary abscesses that also prevented surgical treatment, thus he was treated with percutaneous ethanol injection guided by CT of the left adrenal tumor. During the procedure, the patient had an increase in blood pressure controlled by the infusion of sodium nitroprusside followed by hypotension that required infusion of dopamine and volume expansion. Afterwards, he presented hormonal normalization, normal catecholamines levels, and clinical improvement. Histological tissue analysis confirmed pheochromocytoma. We concluded that CT-guided PEI represents an efficient alternative therapy to ectopic ACTH-secreting pheochromocytomas in patients without clinical conditions for surgery.

The use of ultrasound evaluation in the diagnosis of peritonsillar abscess.

Peritonsillar Abscess (PTA) and Peritonsillar Cellulitis (PTC) are very similar clinical conditions. The differential diagnosis between them is made by needle aspiration, a very painful and invasive method. This study was performed at the Department of Otolaryngology at the Clinical Hospital of São Paulo University Medical School. It's aim was to evaluate the use of ultrasound as a noninvasive and inexpensive method of diagnosis, differentiating abscess from cellulitis. Twenty-one consecutive patients with a clinical diagnosis of peritonsillar infection were evaluated in the emergency service with a probable diagnosis of PTA. These patients were evaluated with intraoral and percutaneous ultrasound. Needle aspiration was used to compare and confirm the diagnosis. The sensitivity was 92.3% and specificity was 62.3%. The authors conclude that ultrasound is a good method to evaluate the differences between PTA and PTC.

[HIV-associated nephropathy]. / Nefropatia associada ao HIV.

AIDS can affect many parenchymal organs but the renal involvement is of vital value for patient's prognosis. Sonography can easily analyse most of all renal insult even in those patients without symptoms.

Determination of plasma concentrations of amikacin in patients of an intensive care unit.

Considering the low therapeutic index of the aminoglycosides it is mandatory to monitor serum concentrations (SC) either to obtain therapeutic levels or to avoid toxic levels. The SC of amikacin (AMK) was evaluated in 24 inpatients in an intensive care unit of Hospital São João, mean age (+/- SD) 45.5 +/- 18.57 years. In 62.5% of the patients it was shown that SC (mean +/- SD, 16.87 +/- 1.62) was inferior to the therapeutic range. In 33.3% the values (SC 25.85 +/- 3.77) were within the therapeutic window (> 20 micrograms/ml; < 35 micrograms/ml). Only 1 patient attained toxic levels (> 35 micrograms/ml). In 4 of the patients with initial SC < 20 micrograms/ml, dosage was adjusted and thereafter therapeutic value was obtained (SC 24.65 +/- 3.38). The relation between the administered dose and the dosage usually recommended (weight X 15mg/day) was calculated. In the majority of our patients (the so-called "critically ill patients") the recommended dosages of AMK need to be increased in order to get the desired SC. In the population of this study a dosage of about 120% relative to the initial recommended dosage was necessary.