Miracle-dz/UniFAR-FTUs huggingface dataset:
Hepatectomia videolaparoscópica: experiência pessoal com 107 casos

OBJECTIVE: To analyze our experience after 107 laparoscopic hepatectomies and discuss the technical evolution of laparoscopic hepatectomy in the last five years. METHODS: Between April 2007 and April 2012 we performed 107 laparoscopic hepatectomies in 105 patients. The mean age was 53.9 years (17 to 85). Fifty-three patients were male. All interventions were performed by the authors. RESULTS: from the total of 107 operations, there was need for conversion to open technique in three cases (2.8%). Sixteen patients (14.9%) had complications. Two patients died, a mortality of 1.87%. One death was due to massive myocardial infarction, unrelated to the procedure, which was uneventful and showed no conversion or bleeding. The other death was due to failure of the stapler. Twenty patients (18.7%) required blood transfusion. The most frequent type of hepatectomy was bisegmentectomy of segments 2-3, (33 cases), followed by right hepatectomy (22 cases). Seventy-two procedures (67.3%) were performed by the technique of Glissonian access. CONCLUSION: The dissemination of results is of utmost importance. The technical difficulties, complications and even death, inherent in this complex type of surgery, need to be clearly disclosed. This procedure should be performed in a specialized center with knowledgeable staff. The technique of laparoscopic Glissonian access, described by our staff, facilitates the realization of anatomical hepatectomies.
A Case of Misidentification of Aspergillus versicolor Complex as Scopulariopsis Species Isolated from a Homograft

A Case of Misidentification of Aspergillus versicolor Complex as Scopulariopsis Species Isolated from a Homograft Hee Jae Huh, Jang Ho Lee, Kyung Sun Park, Tae-Gook Jun, I-Seok Kang, Yae-Jean Kim, Chang-Seok Ki, Nam Yong Lee Departments of Laboratory Medicine & Genetics, Thoracic and Cardiovascular Surgery, and Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Barriers to adherence to hypertension guidelines among GPs in southern Sweden: A survey

Objective. To evaluate barriers to adherence to hypertension guidelines among publicly employed general practitioners (GPs). Design. Questionnaire-based survey distributed to GPs in 24 randomly selected primary care centres in the Region of Skåne in southern Sweden. Subjects. A total of 109 GPs received a self-administered questionnaire and 90 of them responded. Main outcome measures. Use of risk assessment programmes. Reasons to postpone or abstain from pharmacological treatment for the management of hypertension. Results. Reported managing of high blood pressure (BP) varied. In all, 53% (95% CI 42–64%) of the GPs used risk assessment programmes and nine out of 10 acknowledged blood pressure target levels. Only one in 10 did not inform the patients about these levels. The range for immediate initiating pharmacological treatment was a systolic BP 140–220 (median 170) mmHg and diastolic BP 90–110 (median 100) mmHg. One-third (32%; 95% CI 22–42%) of the GPs postponed or abstained from pharmacological treatment of hypertension due to a patient's advanced age. No statistically significant associations were observed between GPs’ gender, professional experience (i.e. in terms of specialist family medicine and by number of years in practice), and specific reasons to postpone or abstain from pharmacological treatment of hypertension. Conclusion. These data suggest that GPs accept higher blood pressure levels than recommended in clinical guidelines. Old age of the patient seems to be an important barrier among GPs when considering pharmacological treatment for the management of hypertension.
Management of an Unintentional Warfarin Overdose With Oral Vitamin K in the Outpatient Setting Prior to Elevation of the International Normalized Ratio

Abstract Anticoagulation therapy with warfarin continues to present ongoing therapeutic dilemmas because of the complexity associated with its narrow therapeutic range. Warfarin dosing regimens can be complicated and require frequent adjustments, which presents a significant opportunity for error, especially in patients that require extensive pharmacotherapy outside of anticoagulation. This case describes a 64-year-old patient during the warfarin dose titration phase of her anticoagulation therapy that confuses the physical appearance of her tablets, resulting in a warfarin overdose. Because warfarin overdosing rarely is discovered within minutes of its occurrence, standard reversal strategies in response to an elevated international normalized ratio (INR) that would be implemented do not apply to her case. Thus, oral vitamin K was administered to prevent the anticipated international normalized ratio rise that would be predicted. This prospective outpatient intervention prevented a hospital admission and reduced the patient's hemorrhagic risk related to excessive anticoagulation.
Effects of hydroxyethyl starch resuscitation on extravascular lung water and pulmonary permeability in sepsis-related acute respiratory distress syndrome *

Objective:Hydroxyethyl starch (HES) has greater volume expansion effect and longer intravascular persistence than crystalloids. HES also decreases microvascular permeability and capillary leakage by biophysically plugging endothelial leaks, exerting an anti-inflammatory effect, and decreasing activation of endothelial cells. The aim of our study was to determine whether medium molecular weight HES (pentastarch) resuscitation in the early stage of acute respiratory distress syndrome (ARDS) simultaneously increases cardiac output without worsening pulmonary edema and whether it attenuates pulmonary vascular permeability. Design:Prospective observational study. Setting:Twenty-bed medical intensive care unit of a tertiary medical center. Patients:Twenty patients with early-stage ARDS. Intervention:Volume expansion with a 500-mL infusion of 10% pentastarch (HES 200/0.5) at a rate of 10 mL/kg/hr. Measurements and Main Results:Baseline hemodynamics including systemic and pulmonary artery blood pressures, central venous pressure, pulmonary artery occlusion pressure, and cardiac output were obtained from an online HP Component Monitoring System and a pulmonary artery catheter. Intrathoracic blood volume (ITBV), global end-diastolic volume, extravascular lung water (EVLW), and pulmonary vascular permeability (EVLW/ITBV) were measured with a PiCCOplus monitor. Hemodynamic measurements were repeated immediately and 2, 4, and 6 hours after volume expansion. Pentastarch loading significantly increased central venous pressure, pulmonary artery occlusion pressure, pulmonary arterial pressures, and cardiac output. Pulmonary mechanics, venous admixtures, and EVLW values remained unchanged throughout the study. EVLW/ITBV significantly decreased immediately after the pentastarch infusion. Conclusions:In patients with early ARDS, pentastarch resuscitation significantly improved their hemodynamics and cardiac output without worsening pulmonary edema and pulmonary mechanics. It even attenuated pulmonary vascular permeability.
Blood lactate monitoring in critically ill patients: A systematic health technology assessment *

Objective: To decide whether the use of blood lactate monitoring in critical care practice is appropriate. We performed a systematic health technology assessment as blood lactate monitoring has been implemented widely but its clinical value in critically ill patients has never been evaluated properly. Data Source: PubMed, other databases, and citation review. Study Selection: We searched for lactate combined with critically ill patients as the target patient population. Two reviewers independently selected studies based on relevance for the following questions: Does lactate measurement: 1) perform well in a laboratory setting? 2) provide information in a number of clinical situations? 3) relate to metabolic acidosis? 4) increase workers’ confidence? 5) alter therapeutic decisions? 6) result in benefit to patients? 7) result in similar benefits in your own setting? 8) result in benefits which are worth the extra costs? Data Extraction and Synthesis: We concluded that blood lactate measurement in critically ill patients: 1) is accurate in terms of measurement technique but adequate understanding of the (an)aerobic etiology is required for its correct interpretation; 2) provides not only diagnostic but also important prognostic information; 3) should be measured directly instead of estimated from other acid‐base variables; 4) has an unknown effect on healthcare workers’ confidence; 5) can alter therapeutic decisions; 6) could potentially improve patient outcome when combined with a treatment algorithm to optimize oxygen delivery, but this has only been shown indirectly; 7) is likely to have similar benefits in critical care settings worldwide; and 8) has an unknown cost‐effectiveness. Conclusions: The use of blood lactate monitoring has a place in risk‐stratification in critically ill patients, but it is unknown whether the routine use of lactate as a resuscitation end point improves outcome. This warrants randomized controlled studies on the efficacy of lactate‐directed therapy.
Expectations and outcomes of prolonged mechanical ventilation*

Objective:To compare prolonged mechanical ventilation decision-makers’ expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon. Design:Prospective observational cohort study. Setting:Academic medical center. Patients:A total of 126 patients receiving prolonged mechanical ventilation. Interventions:None. Measurements and Main Results:Participants were interviewed at the time of tracheostomy placement about their expectations for 1-yr patient survival, functional status, and quality of life. These expectations were then compared with observed 1-yr outcomes measured with validated questionnaires. The 1-yr follow-up was 100%, with the exception of patient death or cognitive inability to complete interviews. At 1 yr, only 11 patients (9%) were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for 1-yr patient survival (n = 117, 93%), functional status (n = 90, 71%), and quality of life (n = 105, 83%). In contrast, fewer physicians described high expectations for survival (n = 54, 43%), functional status (n = 7, 6%), and quality of life (n = 5, 4%). Surrogate-physician pair concordance in expectations was poor (all &kgr; = <0.08), as was their accuracy in outcome prediction (range = 23%–44%). Just 33 surrogates (26%) reported that physicians discussed what to expect for patients’ likely future survival, general health, and caregiving needs. Conclusions:One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients’ surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates’ unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.
AGING AND GENDER EFFECTS ON RATE-PRESSURE PRODUCT: AN INDEX OF MYOCARDIAL OXYGEN CONSUMPTION

Objectives: There are aging associated alterations in cardiac structure, metabolism, function. Evidence suggests alterations in myocardial metabolism contribute to the development, progression of heart failure. Hence it is essential to be aware of the impact of healthy aging on myocardial oxygen consumption. Rate-Pressure Product (RPP) is simple, non-invasive, easily measurable index of MVO 2 . Seeking the effect of aging, we measured RPP, in apparently healthy men and women of different age groups. To know the influence of gender we compared the RPP in men and women in each age group. Methods : A total 152 healthy subjects (91 men, 61 women) were classified by age into four groups. Studies included recording of anthropometric parameters, physiological parameters, brachial systolic and diastolic blood pressure and ECG. Rate-Pressure Product was calculated. Results: Subjects of both genders showed an age related (18-65 years) decline of resting heart rate. Healthy men showed a gradual decline of rate pressure product from 18-65 years. Healthy young women between 20-35 years showed higher rate pressure product compared to men. Below 20 years RPP was lower in women compared to men. Between 35-54 years the gender differences in RPP diminished. Beyond 55 years RPP was higher in women compared to men. Conclusion : Varying influence of aging on myocardial oxygen consumption observed in men and women. Healthy aging is associated with decline in myocardial oxygen consumption in men. In women no significant variation observed. In each age group gender differences in myocardial oxygen consumption observed .
Studies comparing screen-film mammography and full-field digital mammography in breast cancer screening: Updated review

Full-field digital mammography (FFDM) has several potential benefits as compared with screen-film mammography (SFM) in mammography screening. Digital technology also opens for implementation of advanced applications, including computer-aided detection (CAD) and tomosynthesis. Phantom studies and experimental clinical studies have shown that FFDM is equal or slightly superior to SFM for detection and characterization of mammographic abnormalities. Despite obvious advantages, the conversion to digital mammography has been slower than anticipated, and not only due to higher costs. Until very recently, some countries did not even permit the use of digital mammography in breast cancer screening. The reason for this reluctant attitude was concern about lower spatial resolution and about using soft-copy reading. Furthermore, there was a lack of data supporting improved diagnostic accuracy using FFDM in a screening setting, since two pioneer trials both showed nonsignificantly lower cancer detection rate at FFDM. The 10 studies comparing FFDM and SFM in mammography screening published so far have shown divergent and rather conflicting results. Nevertheless, there is a rapid conversion to digital mammography in breast cancer screening in many western countries. The aim of this article is to give an updated review of these studies, discuss the conflicting findings, and draw some conclusions from the results.
Rat model of reperfused partial liver infarction: Characterization with multiparametric magnetic resonance imaging, microangiography, and histomorphology

Background: Rat model of reperfused partial liver infarction (RPLI) has been increasingly used in studying new diagnostics and therapeutics. Purpose: To characterize the RPLI model using magnetic resonance imaging (MRI), microangiography, and histopathology. Material and Methods: RPLI was induced in eight rats by occluding hepatic inflow to the right liver lobe for 3 hours. MRI was performed at a 1.5T clinical scanner 6 hours after reperfusion to obtain T2-weighted (T2WI), T1-weighted (T1WI), contrast-enhanced (CE) T1WI, diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) maps, T1-weighted dynamic contrast-enhanced (T1-DC) perfusion-weighted imaging (PWI), and T2*-weighted dynamic susceptibility contrast-enhanced (T2*-DSC) PWI images. Rats were sacrificed for microangiography and histomorphology. In vivo morphological and functional MRI parameters, including maximum initial slope (MIS), K value, relative blood flow (rBF), relative blood volume (rBV), time to peak (TTP), and mean transit time (MTT), were matched with postmortem findings. Results: The infarcted lobe was conspicuous from normal liver with lower and higher signal intensity on T1WI (P=0.018) and T2WI (P=0.001), respectively. Contrast between infarcted and normal liver reversed on CE-T1WI after gadolinium injection. The infarction averaged 37.5% of total liver volume. DWI and ADC maps were able to detect subtle perfusion-related differences (P<0.05). With T1-DC-PWI, increased extravasation and vascular permeability were reflected by significantly greater MIS (P=0.034) and K value (P=0.014) in infarction. T2*-DSC-PWI showed lower rBF and rBV with shorter TTP and MTT in infarcted liver (P<0.05). In vivo MRI findings corresponded well with postmortem outcomes. Conclusion: RPLI in rats could be characterized by multiparametric MRI and postmortem assessments, with insight into the no-reflow phenomenon, which implies its further application for preclinical assessments of new pharmaceutics.
Evaluation of sublingual and gut mucosal microcirculation in sepsis: A quantitative analysis*

Objective:To determine the relationship between sublingual and intestinal mucosal microcirculatory perfusion. Design:Observational, experimental study. Setting:University-affiliated large animal laboratory. Subjects:Ten fasted, anesthetized, mechanically ventilated, male pigs randomized to a sham group (n = 3) or to a hyperdynamic septic shock group (n = 7) in which cholangitis was induced by direct infusion of Escherichia coli into the common bile duct. This model was developed because it is not accompanied by changes in intra-abdominal pressure. Measurements and Main Results:The sublingual and intestinal microcirculations were simultaneously assessed at 4-hr intervals for up to 12 hrs with a modified orthogonal polarization spectral device and functional microvessel density and erythrocyte velocity were measured quantitatively. In sham animals, both regions maintained a stable functional microvessel density and erythrocyte velocity throughout the study period. In contrast, in septic animals, already after 4 hrs of sepsis, functional microvessel density was markedly decreased (>50%) in the sublingual and gut regions; mean erythrocyte velocity decreased dramatically and similarly in both regions, from 1022 ± 80 to 265 ± 43 &mgr;m/sec in the sublingual region and from 1068 ± 45 to 243 ± 115 &mgr;m/sec in the gut (p < 0.001, at T12). There was a significant correlation between the sublingual and gut microcirculations in septic animals (r2 = 0.92, p < 0.0001). Conclusions:The severity and the time course of microcirculatory changes were similar in the sublingual and in the gut region in this clinically relevant model of severe sepsis. These findings support the sublingual region as an appropriate region to monitor the microcirculation in sepsis.
Early alterations of red blood cell rheology in critically ill patients*

Objective: To investigate red blood cell rheology in a large intensive care unit population on admission, and to assess the possible influence of comorbidities on the rheology. Design: Prospective study. Setting: Medico-surgical intensive care unit with 31 beds. Subjects: All intensive care unit admissions during a 5-month period and 20 healthy volunteers. Interventions: Blood sampling. Measurements and Main Results: A total of 196 intensive care patients (160 without and 36 with sepsis) and 20 healthy volunteers were studied. Red blood cell rheology (deformability and aggregation) was assessed ex vivo using the laser-assisted optical rotational cell analyzer (LORCA; Mechatronics Instruments BV, AN Zwaag, Netherlands) within the first 24 hrs after intensive care unit admission. Red blood cell deformability was determined by the elongation index in relation to the shear stress (0.3 to 50 Pa) applied on the red blood cell membrane surface. Aggregation was assessed by the aggregation index. Septic patients were more likely to have anemia, coagulation abnormalities, and comorbidities than were nonseptic patients. Red blood cell deformability was significantly altered in septic compared to nonseptic patients and volunteers for the majority of shear stress rates studied. The aggregation index was greater in septic patients than in volunteers (67.9% [54.7–73.5] vs. 61.8% [58.2–68.4]; p < .05). Only sepsis and hematologic disease influenced the elongation index (both p < .01). Other comorbidities, like cancer, diabetes mellitus, cirrhosis, and terminal renal failure, had no effect on the elongation index. Aggregation index was related to the degree of organ failure (Sequential Organ Failure Assessment score), the red blood cell count, and fibrinogen concentrations. Conclusions: Early alterations of red blood cell rheology are common in intensive care unit patients, especially in those with sepsis. Comorbidities (other than hematologic diseases) do not significantly influence these abnormalities. These alterations could contribute to the microcirculatory alterations observed in critically ill patients.
A Total Environment Quality of Care approach to evaluation of management and care at two dementia care units in Tasmania

When improving service delivery and best practice approaches to dementia care, it is imperative that the total environment be examined rather than just enhancing staffing and programming. Achievement of an integrated approach to care involves examining all aspects that the resident and staff experience during the process of care. This study examined the impact of the total environment in the care and management of residents in two dementia units in Tasmania. The research also tested the applicability of the Total Environment Quality of Care Model and the dementia care propositions
Normal radiological unossified hip joint space and femoral head size development during growth in 675 children and adolescents

Evaluation of hip joint space width during child growth is important to aid in the early diagnosis of hip pathology in children. We established reference values for hip joint space and femoral head size for each age. Hip joint space development during growth was retrospectively investigated medial and cranial in 1350 hip joints of children using standard anteroposterior supine plain pelvic radiographs. Maximum capital femoral epiphysis diameter and femoral radii were further more investigated. Hip joint space values show a slow decline during growth. Joint space was statistically significantly (p < 0.006) larger in boys than girls. Our hip joint space measurements on supine subjects seem slightly larger than those reported by Hughes on standing subjects. Evaluation of the femoral head diameter and the radii showed a size curve quite parallel to the known body growth charts. Radii medial and perpendicular to the physis are not statistically significantly different. We recommend to compare measurements of hip joint space at two locations to age dependent charts using the same imaging technique. During growth, a divergence in femoral head size from the expected values or loss of the spherical shape should raise the question of hip disorder. Clin. Anat. 30:267–275, 2017. © 2016 Wiley Periodicals, Inc.