Application of unilateral pectoralis major muscle flap in the treatment of sternal wound dehiscence

Abstract Objective: This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of the sternal wound dehiscence. Methods: A retrospective study including patients who underwent unilateral pectoralis major muscle flap was performed for the treatment of sternotomy dehiscence due to coronary artery bypass, valve replacement, congenital heart disease correction and mediastinitis, between 1997 and 2016. Data from the epidemiological profile of patients, length of hospital stay, postoperative complications and mortality rate were obtained. Results: During this period, 11 patients had their dehiscence of sternotomy treated by unilateral pectoralis major muscle flap. The patients had a mean age of 54.7 years, the mean hospital stay after flap reconstruction was 17.9 days (from 7 to 52 days). In two patients, it was necessary to harvest a flap from the rectus abdominis fascia, in association with the pectoralis major muscle flap, to facilitate the closure of the distal wound. In the postoperative period, seroma discharge from the surgical wound was observed in six patients, five reported intense pain (temporary), three had partial cutaneous dehiscence, and two presented granuloma of the incision. Conclusion: The complex wound from sternotomy dehiscences presents itself as a challenge to surgical teams. Treatment should include debridement of necrotic tissue and preferably coverage with well-vascularized tissue. We propose that the unilateral pectoralis major muscle flap is an interesting and low morbidity option for the reconstruction of sternal wound dehiscences, with proper sternum stability and satisfactory functional and aesthetic outcomes.

Efeito de uma associação de cepas probióticas contendo lactobacillus e bifidobacterium na modulação da microbiota intestinal em pacientes constipados / Effects of association of probiotic strains containing lactobacillus and bifidobacterium on modulation of the intestinal microbiota in constipated patients

Introdução: a constipação é uma doença crônica que afeta a população mundial, podendo ser consequência do desequilíbrio da microbiota intestinal, conhecida como disbiose. Nesse contexto, os probióticos vêm sendo utilizados com o objetivo de promover o seu equilíbrio, a fim de mantê-la saudável (eubiose). Objetivo: avaliar, em um estudo duplo-cego, randomizado, placebo-controlado, se o uso de uma associação de cepas probióticas contendo lactobacillus e bifidobacterium por 28 dias pode modular a microbiota intestinal em pacientes constipados. Método: a atividade da associação de cepas probióticas foi comparada com placebo (maltodextrina) após a suplementação por 28 dias. Os pacientes foram avaliados por meio da análise de metagenômica e da melhora dos sintomas relacionados à constipação. Os dados do perfil da população de microrganismos presentes no intestino dos pacientes foram correlacionados com os resultados da avaliação dos sintomas abdominais e da percepção de bem-estar geral. O aumento do número de evacuações e a melhora do trânsito intestinal foram avaliados durante o estudo. Resultados: as proporções do gênero Bifidobacterium no grupo teste e controle foram 0.45% vs 0.24% no final do estudo, respectivamente (p<0,05). Adicionalmente, a diferença entre os grupos que receberam associação de cepas probióticas contendo lactobacillus e bifidobacterium e placebo permaneceu também significativamente alta com relação às espécies de Lactobacillus (1,21% vs 0,12%) após 28 dias de tratamento (p<0,05). Além disso, os participantes que receberam o probiótico apresentaram uma tendência de melhora sintomática baseada na comparação da sua microbiota e as respostas oriundas da avaliação dos sintomas abdominais e bem-estar geral. Nenhum evento adverso grave foi relatado. Conclusão: a formulação probiótica modulou a microbiota intestinal de forma diferente do placebo nos participantes do estudo. O consumo dos probióticos aumentou significativamente as bactérias benéficas e reduziu as potencialmente maléficas, contribuindo para o equilíbrio da microbiota intestinal.

Introduction: constipation is a chronic disease that affects the world population, being a consequence of the imbalance of the intestinal microbiota, known as dysbiosis. In light of this context, the probiotics have been used to trigger microbiota intestinal balance, in order to keep it healthy (eubiose) Aim: to evaluate in a double-blind, randomized, placebo-controlled study whether the use of association of probiotic strains containing lactobacillus and bifidobacterium for 28 days can modulate the intestinal microbiota of the constipated participants. Methods: the activity of association of probiotic strains was compared to placebo (maltodextrin) after 28 days of consumption. The patients were evaluated by using metagenomics analyses and improved constipation symptoms. The dates of microorganisms population profile into patients gut were correlated with results of abdominal symptoms evaluation and well-being perception. The increase in the number of evacuations and the intestinal transit were evaluated during the study. Results: the proportions of the genus Bifidobacterium in the test groups and the control group were 0.45% vs 0.24% at the end of the study, respectively (p<0.05). Additionally, the difference between the groups that received association of probiotic strains containing lactobacillus and bifidobacterium and the placebo remained higher for species of the genus Lactobacillus (1.21% vs 0.12%) after 28 days of use (p<0.05). Furthermore, the participants who received the probiotic had a tendency to improve symptomatic based on comparisons of their microbiota and the responses provided patients' abdominal symptoms and well-being. There were no reports of serious adverse events during the study. Conclusion: the probiotic formulation modulated the intestinal microbiota differently from the placebo in constipated participants included in this study. The use of this probiotic significantly increased beneficial bacteria and decreased potentially harmful microbes, which contributed to the maintenance of a healthy intestinal microbiota.

Aumento da mucasa queratinizada em área peri-implantar com enxerto gengival livre / Keratinized tissue augmentation in peri-implantar area with free gingival graft

Geralmente, a mucosa queratinizada em pacientes edêntulos totais apresenta-se reduzida, o que poderia afetar a função mastigatória, estética e funcional nas reabilitações com implantes dentais. A saúde do tecido peri-implantar é importante para preservar os princípios biológicos da Osseointegração. O relato deste caso teve por objetivo descrever o aumento da mucosa queratinizada em área peri-implantar, em um segundo tempo cirúrgico, com enxerto gengival livre. Uma paciente do sexo feminino, com 74 anos de idade, desdentada total foi encaminhada para a equipe de Implantodontia e Periodontia da Faculdade de Odontologia Araçatuba, Universidade Estadual Paulista (Unesp) com a queixa principal de falta de estabilidade de sua prótese inferior. Para resolução do caso, foi indicada uma sobredentadura suportada por dois implantes 4 mm x 11,5 mm Master Easy Grip (Conexão Sistema de Prótese, Arujá/SP). Durante a segunda fase da cirurgia, foi realizado um enxerto gengival livre e posicionado na face vestibular de cada implante. Após três meses de acompanhamento, o enxerto apresentou-se com boa aparência, excelente cor e ótima qualidade clínica do enxerto. Diante do exposto, pôde-se concluir que o enxerto gengival livre é uma opção de tratamento confiável para aumento da mucosa queratinizada, ajudando a manter a saúde do tecido peri-implantar, diminuindo o acúmulo de placa e evitando o trauma mecânico da escovação e mastigação.

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period.

Lactate and base deficit are predictors of mortality in critically ill patients with cancer

OBJECTIVE: Cancer patients frequently require admission to intensive care unit. However, there are a few data regarding predictive factors for mortality in this group of patients. The aim of this study was to evaluate whether arterial lactate or standard base deficit on admission and after 24 hours can predict mortality for patients with cancer. METHODS: We evaluated 1,129 patients with severe sepsis, septic shock, or postoperative after high-risk surgery. Lactate and standard base deficit collected at admission and after 24 hours were compared between survivors and non-survivors. We evaluated whether these perfusion markers are independent predictors of mortality. RESULTS: There were 854 hospital survivors (76.5 percent). 24 h lactate .1.9 mmol/L and standard base deficit , -2.3 were independent predictors of intensive care unit mortality. 24 h lactate .1.9 mmol/L and 24 h standard base deficit , -2.3 mmol/Lwere independent predictors of hospital death. CONCLUSION: Our findings suggest that lactate and standard base deficit measurement should be included in the routine assessment of patients with cancer admitted to the intensive care unit with sepsis, septic shock or after highrisk surgery. These markers may be useful in the adequate allocation of resources in this population.