Is slim better than paunchy?

BACKGROUND

Aortopulmonary mismatch (APM) in transposition of the great arteries (TGA) may be accountable for dilatation of neoaortic root and regurgitation of neoaortic valve as late complications of arterial switch operation (ASO). The manuscript from Arcieri et al. highlights an important aspect of the ASO technique: should we approach APM during ASO and what would be the best strategy to do so?

DISCUSSION

Techniques to approach APM at the time of ASO have been published sporadically and are very rarely employed by surgeons. Reconstruction of the neoaorta is generally achieved by trimming the suture line between the pulmonary root (neoaortic root) and ascending aorta resulting in an abnormal dilated and bulky neoaortic root already at the time of ASO.

CONCLUSION

Reduction of the pulmonary root dimension by ressection of a fragment of the pulmonary artery wall possibly results in a more homogenous neoaorta with consequent better hemodynamics. We believe that approaching APM during ASO will have a compelling positive impact on the late survival of patients with complex TGA.

Fontan operation: a technique in evolution

OBJECTIVES

Recent experimental flow studies based on angiography and magnetic resonance have shown that total cavopulmonary anastomosis (TCPA) is a valid concept for surgical treatment of many congenital heart defects, but there is not agreement of the best surgical arrangement. Our purpose is to analyze the immediate results with three different techniques of TCPA.

METHODS

We sought to analyze retrospectively all TCPA realized from January 2005 to July 2008; there were 40 patients, all with previous Glenn anastomosis, with mean age of 6.4 +/- 3.2 years. Three different techniques were employed: Group 1 (G1) lateral tunnel, Group 2 (G2) extracardiac conduits, Group 3 (G3) intracardiac conduit directed to the left pulmonary artery. All patients had a fenestration done.

RESULTS

G1 had 11 patients, G2 10 patients and G3 19 patients. Preoperative data were similar in the 3 groups (P>0.05). Surgical mortality was higher in Groups 1 and 2 (9.1% and 10%) compared to Group 3 (0%) but there was no statistical significance (P=0.3841). Pleural effusion was absent in Group 3 (0%), which was statistically significant in relation to the other groups (P=0.0128). The hospitalization time was also significantly lower in G3 (8 days) in relation to G1 (18 days) and G2 (13 days) (P=0.0164).

CONCLUSION

Intracardiac TCPA was associated with lower postoperative morbidity and is currently our preferred technique.

GLUT-1 in oral benign vascular lesions

AIM

To investigate the accuracy of histological diagnosis of oral hemangioma, oral vascular malformation and oral pyogenic granuloma according to immunohistochemical evaluation of the human erythrocyte-type glucose transporter protein (GLUT-1), and to observe the immunoexpression of this protein in oral varix.

MATERIALS AND METHODS

Immunohistochemistry for GLUT-1 was performed in 93 histologically diagnosed cases of oral benign vascular lesions: 17 vascular malformations, 19 hemangiomas, nine varix, and 48 pyogenic granulomas. Descriptive analyses were performed.

RESULTS

None of the cases of the oral benign vascular lesions evaluated were immunopositive to GLUT-1. The 19 cases histologically diagnosed as oral hemangioma that showed negative staining to GLUT-1 were reclassified as oral pyogenic granuloma or oral vascular malformations. The histological evaluation itself is not enough to obtain the correct diagnosis of oral HEM as none of the sample cases were true hemangioma. All sample cases with initial vascular malformation or pyogenic granulomas classification were negative to GLUT-1, demonstrating the accuracy of histological diagnosis of these lesions itself. Oral varix showed negative staining to GLUT-1 in blood vessels.

CONCLUSIONS

GLUT-1 is an useful, effective and important auxiliary marker for the diagnosis of oral benign vascular lesions.

CLINICAL RELEVANCE

This study showed that histological diagnosis alone is not sufficient to correct diagnoses of oral hemangioma. Moreover, immunohistochemistry to GLUT-1 is a useful and easy diagnostic method that may be used to avoid such misdiagnosis. Accurate diagnosis of these oral lesions has an important clinical relevance allowing: (1) correct management, (2) adequate communication among the multidisciplinary team (dentist, dermatologist, pediatrist, radiologist, pathologist, and surgeon), (3) understanding of the biological behavior of the lesions, and (4) facilitate the development of new therapeutic modalities. Thus, supporting the use of this marker in medical and dentistry communities is warranted.

Influence of narrow-band UVB phototherapy on cutaneous microbiota of children with atopic dermatitis

OBJECTIVE

In the present work, the effect of narrow-band ultraviolet B (UVB) phototherapy on a cutaneous microbial population was evaluated in patients with atopic dermatitis (AD) and compared with control patients (vitiligo).

METHODS

Count, isolation and identification of cutaneous microbiota from anticubital fossa were performed in 10 controls and 10 AD patients, both submitted to similar levels (P > 0.05) of UVB phototherapy (4.3 +/- 0.9 and 4.3 +/- 0.8 accumulated joules, respectively). Additionally, Staphylococcus aureus isolates were screened for the production of exotoxins.

RESULTS

The total and staphylococcal cutaneous microbial population levels were higher (P < 0.05) in AD patients than in the controls. All these population levels decreased (P < 0.05) for both AD and control patients after UVB phototherapy, which also decreased the SCORAD for AD patients. All patients with AD and 50% of controls were carriers of S. aureus, and harboured the bacteria simultaneously on skin and anterior nares. All of the S. aureus strains recovered from AD patient skin produced toxin and the B type was the most frequently detected (70%), followed by C (20%) and A (10%) toxins. Only 40% of the S. aureus isolates from control patients produced toxin. After UVB treatment, microbial population levels of AD patients were similar (P > 0.05) to the ones found in control patients before phototherapy, and toxin production ability of S. aureus isolates decreased drastically.

CONCLUSION

The results of the present study show the beneficial effect of UVB phototherapy on AD and suggest that this may be attributable not only to reduction of skin surface bacteria but also to the suppression of superantigen production from S. aureus.

Flow cytometric determination of cellular sources and frequencies of key cytokine-producing lymphocytes directed against recombinant LACK and soluble Leishmania antigen in human cutaneous leishmaniasis

Leishmaniasis, caused by infection with the protozoan parasite Leishmania, affects millions of individuals worldwide, causing serious morbidity and mortality. This study directly determined the frequency of cells producing key immunoregulatory cytokines in response to the recombinant antigen Leishmania homolog of receptors for activated kinase C (LACK) and soluble leishmania antigen (SLA), and it determined relative contributions of these antigens to the overall cytokine profile in individuals infected for the first time with Leishmania braziliensis. All individuals presented with the cutaneous clinical form of leishmaniasis and were analyzed for proliferative responses to LACK antigen and SLA, frequency of lymphocyte subpopulations (analyzed ex vivo), and antigen-induced (LACK and SLA) cytokine production at the single-cell level (determined by flow cytometry). The following were determined. (i) The Th1-type response previously seen in patients with cutaneous leishmaniasis is due to gamma interferon (IFN-gamma) production by several different sources, listed in order of contribution: CD4(+) T lymphocytes, CD4(-), CD8(-) lymphocytes, and CD8(+) T lymphocytes. (ii) SLA induced a higher frequency of lymphocytes producing IFN-gamma and tumor necrosis factor alpha (TNF-alpha) than did LACK. (iii) LACK induced an activation of monocyte populations as reflected by an increased percentage of CD14-positive cells. (iv) Neither SLA nor LACK induced detectable frequencies of cells producing interleukin-4 (IL-4) or IL-5. These data demonstrated a multifaceted immune response to SLA in human leishmaniasis involving Th1 CD4(+) T lymphocytes (IFN-gamma(+) and IL-10(-)/IL-4(-)), Tc1 CD8(+) T cells (IFN-gamma(+), and IL-10(-)/IL-4(-)), and a high frequency of TNF-alpha-producing lymphocytes. Moreover, it was determined that the recombinant antigen LACK acts as a weak inducer of Th1-type lymphocyte responses compared to SLA.

[Neonatal dermatoses of relevant medical significance: their report in the newborn's file]

OBJECTIVE: To check the report of neonatal dermatoses of medical relevance (congenital melanocytic nevus, sebaceous nevus, cafe-au-lait spots, Port-wine stain, ash leaf maculas) in the newborn's file. METHODS: The authors carried out a cross-sectional study in two hospitals in the city of Belo Horizonte. All children born during a consecutive period of 4 months were examined within their 36 first hours of life by a dermatologist who reported all clinically relevant dermatoses (congenital melanocytic nevus, sebaceous nevus, cafeau- lait spots, Port-wine stain, ash leaf macules). Simultaneously, the dermatologist's report was cross checked with the pediatrician's. RESULTS: Neonatal dermatoses of clinical relevance were found in 42 (5.6%) out of 752 children examined during this period. However, the report in the neonate's file could be detected only in 5 (11,9%) out of 42 children. CONCLUSIONS: Clinically relevant dermatoses were underreported in the neonate's file in this study. There is a clear need to stimulate the detection and report of these skin disorders so that parental advice, treatment and genetic counseling can be adequately indicated.

Efficacy and safety of itraconazole pulse therapy: Brazilian multicentric study on toenail onychomycosis caused by dermatophytes

BACKGROUND

Itraconazole is a large spectrum triazole with known efficacy in both continuous and pulse therapy for various mycoses.

OBJECTIVES

Evaluate the efficacy and tolerability of itraconazole pulse therapy for onychomycosis of the toenails due to dermatophytes, in a prospective, open, non-comparative and multicentric investigation. Patients and methods The trial was completed by 72 patients of an initial total of 89. Treatment consisted of four cycles of itraconazole, 200 mg twice a day, for seven consecutive days each month. Patients were evaluated clinically, mycologically and biochemically before, during and at the end of the investigation, and were divided into two groups according to the measure of normal portion of the most affected nail (target nail), as follows: Group 1: 0-5.9 mm; and Group 2: more than 6 mm.

RESULTS

Improvement was satisfactory and progressive. Results were statistically significant, when comparing the three moments of the study: pre-treatment, end of therapy (fourth month) and follow-up (ninth month) in both groups.

CONCLUSIONS

Itraconazole pulse therapy was efficient and safe for the treatment of onychomycosis caused by dermatophytes, although a much higher daily dosage than the known continuous administration was used. Group 1, with nails initially more extensively affected, had a more evident improvement, by the mean variation in millimeters of normal portion of the target nail. This group showed a very satisfactory response, although not reaching total cure, thus demonstrating the great importance of early treatment of this disease. A residual therapeutic effect is maintained even after suspension of the drug. Group 2 obtained better total cure rates, and four pulses were, in general, sufficient, whereas more cycles would have been beneficial for the Group 1 patients with more extensive involvement.

Porcine mitral stentless valve mid-term clinical results

OBJECTIVES

Time testing is essential with any valvular procedure, especially when a new concept is introduced such as the mitral stentless valve. Our purpose is to evaluate the results obtained over 4 years with this operation, particularly to attest the impact of preservation of annulo ventricular continuity on the long term results of these patients.

METHODS

From March 1992 to August 1996, 120 patients had their mitral valves replaced with a porcine stentless mitral valve. The observation period was 54 months with total patients follow-up of 3424 months with a mean of 28.5 months. The age ranged from 11 to 72 years (mean 35.22 +/- 14.98). There were 73 females (60.8%) and 47 males (39.2%). The predominant etiology was rheumatic heart disease. Associated procedures were performed in 12 patients (10%), and the great majority of the patients were in functional class III and IV (NYHA).

RESULTS

Hospital mortality occurred in seven patients (5.83%) non valve related except for one early case of endocarditis. Early reoperation related to technical failure were necessary in 4 patients without mortality. Follow-up was accomplished in 101 patients and ranged from 2 to 54 months. Late reoperations were required in 16 patients (nine due to mitral insufficiency, five because of endocarditis and two for mitral stenosis). Most reoperations were related to technical failure. Among the 82 patients presently in control, 72 showed a competent mitral stentless valve, eight with stable mild mitral regurgitation and in two a decreased mitral orifice. Hemodynamic performance of the valve has been excellent in this group, particularly in patients with left ventricular dysfunction.

CONCLUSION

Although technical complexity remains the main cause of reoperations with this valve, experience has shown that it not only provides preservation of the left ventricular function but also promised significant increase of the ejection fraction in patients with poor left ventricular function.

[Giant hemangioma treated with interferon alpha-2a]

OBJECTIVE

The authors describe a case of giant hemangioma treated with interferon alpha-2a and review the role of this drug and other therapeutic modalities in the management of vascular lesions.

METHODS

A seven month-old child with giant hemangioma and persistent bleeding, anemia and repeated infections was treated with interferon alpha-2a. The drug was administered at the dosage of 3 million units/m(2)/day, subcutaneously, for nine months.

RESULTS

Response to treatment was considered excellent, with regression of 90% of the lesion, control of bleeding, infection and anemia, and catch-up growth. No untoward effects were observed.

CONCLUSION

Interferon alpha-2a should be considered as a valid therapeutic option in selected cases of hemangioma in children.

Open clinical study of the efficacy and safety of terbinafine cream 1% in children with tinea corporis and tinea cruris

BACKGROUND

Topical application of antifungal agents is considered the treatment of choice for dermatomycoses. Most of the available drugs are fungistatic, requiring long term treatment to prevent relapses. Terbinafine is a synthetic antifungal agent that, because of its fungicidal action, provides high cure rates and low relapse rates after short periods of treatment.

METHODS

Ninety-seven children ages 2 to 15 years with a suspected diagnosis of tinea corporis and/or tinea cruris were enrolled in this open trial. After mycologic assessment to confirm diagnosis (culture and direct microscopy) terbinafine 1% cream was applied once daily during 1 week. Clinical and mycologic assessments were made at the baseline visit and on Days 7, 14 and 21. Efficacy assessment was based on 88 children (9 patients excluded by protocol violation).

RESULTS

Therapy was considered effective in 92.0% (81 of 88) of patients (complete clinical and mycologic cure or mycologic cure with minimum signs and symptoms or clinical improvement, > or = 50%). Tolerability was assessed in 97 patients on an intention-to-treat basis. Adverse reactions were itching 3% (3 of 97), itching associated with erythema exacerbation 1% (1 of 97) and contact dermatitis 1% (1 of 97).

CONCLUSION

Terbinafine 1% cream appears to be an effective and well-tolerated treatment for tinea corporis and tinea cruris in children.

Late complications after surgical exclusion of the thoracic aorta

Two patients who underwent surgical exclusion of the thoracic aorta for chronic dissecting aneurysms of the descending aorta died 4 and 8 years after surgery due to complications in part related to the operative technique. One patient developed pseudoaneurysm of the proximal aortic stump with fatal exsanguination through an aortapulmonary fistula. The other patient developed progressive dilatation of the remaining abdominal aorta with subsequent rupture. The surgical approach in this case was extremely difficult because of the previous exclusion procedure which determined a highly demanding reoperation. Although surgical exclusion of the thoracic aortic may be a useful technique in some situations, we must be aware of its early and late complications and, in our opinion, it should be seen only as an alternative treatment for very special patients with diseases of the descending thoracic aorta.

[Ventricular fibrillation in a patient with the permanent form of junctional reciprocating tachycardia]

A case of a 20 year old young man having the permanent form of junctional reciprocating tachycardia complicated by ventricular fibrillation (VF) is reported. A number of antiarrhythmic drugs either as single or combined therapy fail to control tachycardia. Paroxisms of a faster palpitation which never lasted longer than a few minutes were felt over the last six months before the occurrence of VF. At admission, a narrow QRS tachycardia 250 beats/min was recorded and soon degenerated into VF. After electrical shock with 350J permanent form of junctional tachycardia resumed. Electrophysiologic evaluation identified an accessory pathway with long conducting times in postero-septal location, enhanced atrioventricular node conduction and inducible atrial flutter. The patient underwent successful radiofrequency ablation and is doing well after 18 months of follow-up, being off antiarrhythmic drug and tachycardia free.

Replacement of the ascending aorta and aortic arch with bovine pericardial grafts. A preliminary report

Bovine pericardial (BP) grafts have been clinical use at Biocor Hospital since 1989 for replacement or repair of the ascending aorta (AsAo) and initial segment of the aortic arch (AoAr). The main advantages of BP grafts that have justified their clinical application are much easier surgical technique, perfect hemostasis and low cost. From Feb/89 to Feb/94, 88 BP grafts were implanted in the AsAo or the AoAr. There were 33 valved conduits, 47 non-valved conduits and 8 patches. The main indication for the procedure was acute dissection of the aorta, accounting for 50% of the cases. The total hospital mortality was 20.4%. Follow-up was obtained in all but two patients. Patients who survived 2 or more years postoperatively (n = 31) underwent either an echocardiographic or an angiographic study in order to access the behavior of the graft, which was perfect in all of them. The current follow-up is short and complications such as calcification may still develop. However the present study has clearly shown the superior handling and better hemostasis of BP grafts compared to the classical Dacron prosthesis.

[Secondary sternotomy in pediatric heart surgery]

PURPOSE

To analyze the results observed in children who underwent surgical correction of congenital anomalies, in whom the sternotomy was left open to avoid postoperative heart compression.

METHODS

Fourteen children with mean age of 11 months, with different kind of congenital malformations who underwent definitive correction were submitted to the technique of delayed sternal closure. The indication was: hemodynamic instability due to sternal approximation (8), uncontrolled bleeding (4) and preventive (2). In all patients a bovine pericardial patch was sutured to the skin edges allowing a good decompression of the heart.

RESULTS

Among the 14 children, two died in the immediate postoperative period, before the secondary sternal closure. There were two other deaths in the remaining 12 children who underwent sternal approximation, one due to acute pneumothorax and the other due to low cardiac output. The incision was closed after hemodynamic stabilization was achieved, and happened usually around the 3rd postoperative day. There were no cases of mediastinal infection.

CONCLUSION

The technique of delayed sternal closure is an important approach in pediatric cardiac surgery and can be life saving. In our experience a bovine pericardial patch proved to be effective in decompressing the heart and also in protecting the mediastinal cavity.

Surgical repair of transposition of great arteries and total anomalous pulmonary venous return to the coronary sinus (TGA with TAPVR)

The association of transposition of the great arteries (TGA) and total anomalous pulmonary venous return (TAPVR) is very rare; we report one case of this malformation with an intracardiac type of TAPVR draining into the coronary sinus. The surgical repair was performed directing the coronary sinus blood flow to the tricuspid valve. The proximity of the anatomical structures allowed an intra-atrial patch repair similar to a modified Mustard procedure. In the postoperative period the child developed low cardiac output for 2 days, requiring inotropic support and mechanical ventilation. Her recovery was otherwise uneventful. The postoperative echocardiogram showed an intact repair with perfect flow through the patch from the pulmonary veins to the right ventricle. Almost 2 years after surgery, the patient underwent cardiac catheterization that showed integrity of the surgical repair with normal pressures in all heart chambers. To our knowledge this is the first report in the medical literature of surgical treatment of this association.

[Ventricular fibrillation in a patient with ventricular dysplasia and mitral valve prolapse]

A 30 year-old male patient with arrhythmogenic right ventricular dysplasia was submitted to implantation an automatic cardioverter-defibrillator. So far he is well in a follow-up of 7 months.

The use of PTFE graft to correct anomalous drainage of persistent left superior vena cava

A new technique to correct persistent left superior vena cava (LSVC) drainage into the left atrium is described in a 14-year-old patient with situs inversus, left atrial isomerism common atrium, and mitral valve regurgitation. During surgery, occlusion of the LSVC markedly increased the venous pressure, precluding its ligation. Because of the malposition of the heart and the unusual atrial anatomy, correction with an intra-atrial baffle was not attempted. After correcting the intra-cardiac anomaly, the LSVC was divided and anastomosed to the "right" atrial appendage using a segment of PTFE graft. The postoperative course was uneventful and an angiogram demonstrated excellent performance of the graft.

RENAL AUTOTRANSPLANTATION FOR RENOVASCULAR HYPERTENSION: REPORT OF FOUR CASES(*)

Images