Opioid-free mastectomy under thoracic epidural anesthesia-analgesia in a patient with critical tracheal stenosis: a case report

Mastectomy is traditionally performed under general anaesthesia and invasive ventilation, and is often complemented with regional techniques. In this setting, tracheal stenosis can pose a challenge to airway management. The aim of this report is to describe the successful management of a 68-year-old woman with severe subglottic tracheal stenosis undergoing mastectomy due to breast cancer. Surgery was performed without airway instrumentation under an opioid-free regimen consisting of thoracic epidural, propofol and dexmedetomidine perfusion, and non-opioid analgesics. Spontaneous ventilation and adequate perioperative analgesia were achieved. Opioid-free anaesthesia without airway instrumentation, consisting of thoracic epidural anaesthesia and sedation, is a good alternative in patients undergoing mastectomy in whom airway manipulation is best avoided.

Influence of prenatal exposure to dexamethasone on neurodevelopmental behaviour

Introduction Early life stress, such as prenatal exposure to exogenous glucocorticoids (GC), can have a negative impact on brain development. Dexamethasone (DEX) is a synthetic GC used in preterm pregnancies to promote lung maturation. However, prenatal exposure to DEX induces an anxious-like behaviour in male and female offspring at adulthood. Notably, only males respond positively to therapeutics with a proposed anxiolytic.

Objectives Since the influence of prenatal DEX on neurodevelopmental behaviour remains to be elucidated and could help explain this difference in drug efficacy, we aim to clarify the effects of this GC on neurodevelopment during infancy, comparing male and female offspring neurodevelopment at this early age.

Methodology To obtain an animal model of chronic anxiety, Wistar pregnant dams were injected subcutaneously with DEX (1mg/kg) on gestational days 18 and 19. The vestibular system development, locomotion, upper limbs strength, discriminatory ability, auditory response and eye opening day were assessed in male and female offspring between P5 and P17. Animal procedures were approved by the Animal Welfare Committee and done in agreement with the law.

Results Male and female offspring prenatally exposed to DEX had a better performance in the tests assessing the vestibular system development and discriminatory ability, especially at P5 and P6. Additionally, DEX anticipated the day of eye opening and had a positive impact in the upper limb strength of the offspring of both sexes. However, the locomotor ability and auditory response were impaired comparing with controls.

Conclusion Exposure to DEX improves limb strength, balance, spatial orientation and anticipates eye opening. These results may suggest that prenatal DEX exposure promotes offspring development and maturation in both males and females. Prenatal DEX did not differently affect male and female neurodevelopment at early age. It remains to clarify the underlying motives that induce a dimorphic gender response to anxiolytic therapy in adulthood.

P852 Cancer-associated thrombotic diathesis: one of your worst nightmares

A 34-year-old male patient was diagnosed with undifferentiated sarcoma of the right thigh, with lung metastasis. He underwent primary lesion resection surgery and initiated chemotherapy with both doxorubicin and ifosfamide. Though primary tumor burden was substantially reduced, secondary lesions were found to be irresponsive to drug therapy, leading to regimen switching to both gemcitabine and docetaxel. Three months later, patient started complaining of atypical chest pain and palpitations. Electrocardiography revealed very frequent supraventricular ectopic complexes, while a transthoracic echocardiogram unveiled a pulmonary vein thrombus, which extended into the left atrium. This finding, which was further characterized by cardiovascular magnetic resonance imaging, prompted anticoagulation initiation, under the form of enoxaparin 1mg/kg bid. At this time, chemotherapeutic scheme was, again, swapped, and a cycle of both doxorubicin and olaratumab was introduced. A combined episode of inferolateral ST-segment elevation myocardial infarction and peripheral arterial embolism followed shortly thereafter. Emergent invasive coronary angiogram revealed no signs of both epicardial atherosclerosis and thrombus, whereas subsequent transthoracic echocardiography showed a massive left heart thrombus, extending into the aortic valve annulus. Anti-thrombotic approach involved increasing enoxaparin dosage to 1.5mg/kg bid but no fibrinolytic therapy. Despite a rather uneventful immediate clinical course, with no electric or hemodynamic instability and no limb-threatening ischemia, lamentably, patient died two weeks later, before thrombus definitive imaging reassessment. As no autopsy was performed, it is unclear whether a cardiovascular acute event or neoplasm inexorable progression is to blame as the primary cause of death.

Thrombosis is a common, costly and potentially fatal cancer complication. Patients receiving systemic chemotherapy for advanced diseased are at higher risk. Despite major management developments in the past fifteen years, evidence still supports traditional low-molecular-weight heparins as the first-line therapy and prognosis remains dismal.

Abstract P852 Figure.

Clinical Correlations in Hiv-1 and Hiv-2 Infected Patients

In Portugal, the prevalence of human immunodeficiency virus type 2 (HIV-2) seropositivity is higher than in other European countries or North America. Recent literature data points out a possible difference on the pathogenic potential and on the natural history of HIV-1 and HIV-2, suggesting a lower virulence of HIV-2. Facing these hypothesis and the increasing number of HIV-2 cases, we analysed two infected groups HIV-1 and HIV-2, trying to correlate the ophthalmologic lesions present in both populations and searching for a difference in the clinical presentation of the ocular disorder. We studied prospectively 214 patients with HIV infection at several stages, 83% HIV-1 and 17% HIV-2. Ocular manifestations were present in both populations with a significant prevalence in HIV-1 (48%), compared to HIV-2 (19%) (p<0.005). The ophthalmologic pathology found, particularly noninfectious retinopathy, infectious retinitis and neuro-ophthalmic disorders, were considered important for the disease's diagnosis and prognosis. All these ophthalmic findings were present in the HIV-1 population. In the HIV-2 group the most frequent lesion was noninfectious retinopathy. Within each group, HIV-1 and HIV-2, the comparison of the survival between AIDS patients with and without ocular lesions, revealed a significant shorter survival time in those with ocular pathology (p<0.001 and p<0.05). There seems to exist a certain analogy in clinical expression in both groups, although it is possible to admit a lower severity in ocular involvement in patients infected by HIV-2.

Incorporation of tocopherol acetate-containing particles in acrylic bone cement

Acrylic bone cement (BC) is used in orthopaedic surgery to anchor cemented prostheses to bone. Association of antioxidant molecules to BC may suppress reactive species injury which contributes to implant failure. Tocopherol acetate (ATA)-loaded polymethylmethacrylate (PMMA) particles (ATA(PMMA)) were prepared by single emulsion solvent evaporation technique and were incorporated into BC. An encapsulation efficiency of 84% (w/w) was obtained and drug release studies showed distinct ATA release profiles and mechanisms before and after particle incorporation into BC. Experimental data, analysed using first-order, Higuchi and Korsmeyer-Peppas models revealed that ATA was released from particles by a Fickian diffusion mechanism while a non-Fickian transport was observed upon particle incorporation in BC. There were no changes in the mechanical properties of BC specimens containing ATA(PMMA) particles, in contrast to what was observed when ATA was loaded directly into BC. Overall, ATA(PMMA) particles are potential carriers for the incorporation of an antioxidant drug into BC.

Assessment of mother-to-child HIV-1 and HIV-2 transmission: an AIDS reference laboratory collaborative study

OBJECTIVE

A prospective study was carried out to assess HIV-1 and HIV-2 mother-to-child transmission (MTCT) rates in Portugal between 1999 and 2005 by analysing the proportion of diagnosed infected children born to HIV-positive mothers.

MATERIALS AND METHODS

Serial blood samples were collected from 1315 children at risk of HIV-1 infection, 131 children at risk of HIV-2 infection and six children at risk of both HIV-1 and HIV-2 infections attending 25 Health Institutions. HIV proviral DNA was detected by nested polymerase chain reaction (PCR) and statistical analysis was performed using spss.

RESULTS

DNA PCR using HIV-1 and HIV-2 long terminal repeat (LTR) primers amplified 92.5% and 75% of maternal HIV infections, respectively. Overall, MTCT occurred in 3.4% [95% confidence interval (CI) 2.5-4.6%] of HIV-1 and 1.5% (95% CI 0.2-5.4%) of HIV-2 mother-child pairs. A significant decrease in HIV-1 MTCT was observed with time, from 7.0% (95% CI 2.6-14.6%) in 1999 to 0.5% (95% CI 0.0-2.5%) in 2005. HIV MTCT was associated with an absence of antiretroviral therapy in infected pregnant women (P<0.0001). Of the 48 infected children (46 with HIV-1 and two with HIV-2), the schedule of blood sample collection was followed for only 26 children. In 14 (53.8%) of those 26 children the infections were diagnosed in the first sample collected before they were 48 h old, suggesting in utero transmission. Despite the national recommendations for antenatal HIV testing, a high overall proportion (22.2% for HIV-1 and 44.3% for HIV-2) of mothers did not access any MTCT prevention measures, mostly because of late diagnosis in pregnancy. A small but significant proportion of HIV-2 infection was found in mothers with no identifiable link with West Africa.

CONCLUSION

HIV-2 transmission rates are low (1.5% in this study), and this may have led to a lower uptake of interventions, but in the absence of interventions transmission does occur. HIV-1 transmission was also associated with a lack of intervention, mostly as a result of late presentation. Use of primers restricted to a single sequence led to false-negative maternal results in a significant proportion of cases. In part this may have been attributable to very low HIV DNA loads as well as primer template mismatches. HIV infection was not documented in children born to mothers with negative HIV DNA PCR results.

Evaluation of investments in recycling centres for construction and demolition wastes in Brazilian municipalities

There are very few construction and demolition (C&D) waste recycling centres in Brazil. To encourage the building and operation of new units, data were collected and analysed relating to C&D waste management and recycling in Brazil. Based on the results of this analysis, a conceptual model is presented for conducting viability studies of future C&D waste recycling centres. Applying this model to verify the viability of private recycling centres, the results show that under current market conditions in Brazil, C&D waste recycling centres are not financially feasible based solely on revenue from the sale of processed products. Nevertheless, under the same market conditions, the recycling centres could be economically viable for public authorities depending on the particular circumstances of each municipality. The feasibility, however, depends on continuity and the production volume reached. The conceptual model, the results of its applications and the discussions about the experiences of existing centres can strongly support public authorities and private initiatives in their decision-making about investments in Brazil and in other developing countries.

Molecular Mobility in Glass Forming Fananserine: A Dielectric, NMR, and TMDSC Investigation

PURPOSE

This study was conducted to characterize the molecular mobility of supercooled fananserine and derive from this analysis the non-Arrhenius and nonexponential properties of the primary alpha-relaxation.

METHODS

The use of three investigation techniques of the molecular mobility, namely, dielectric relaxation, modulated differential scanning calorimetry, and proton nuclear magnetic resonance, allowed us to describe the dynamic properties of supercooled fananserine on a wide range of frequencies and temperatures, ranging from the melting temperature T(m) = 372 K down to the glass transition temperature T(g) = 292 K.

RESULTS

We emphasized the capacity of these three techniques to give a coherent set of information. We used the coupling-model theory to interpret the dielectric results. It allowed us to identify two relaxation processes (alpha and beta), corresponding to different molecular motions. The temperature evolution of the alpha-relaxation indicates that fananserine is a fragile glass former, as reflected by the steepness index value, m = 77. The temperature T(o) where the relaxation times diverge was also determined.

CONCLUSIONS

The description of the dielectric relaxation data in terms of the Kohlrausch-Williams-Watt relaxation function has shown the existence of an additional low-amplitude relaxation process assigned to the so-called Johari-Goldstein process. Mainly concerned by the primary alpha-process directly involved in the glass formation, we derived from this analysis the characteristic features of this process and showed that supercooled fananserine is characterized by a strongly non-Arrhenius and nonexponential behavior.

Recombination of nanometric vesicles during freeze-drying

Concentrated dispersions of nanometric lipid vesicles (mean diameter 20 nm) in water/maltose solutions have been freeze-dried and then redispersed in water, yielding again dispersions of lipid vesicles. At each stage of the freeze-drying process, the organization of the vesicles in the dispersion and their size distribution were examined through small-angle neutron scattering and gel permeation chromatography. It was found that the osmotic deswelling of the vesicles caused them to recombine into larger vesicles. A single burst of recombination events occurred when the maltose concentration in the aqueous phase rose above 100 g/L. The final vesicle population was monopopulated, with a central diameter about twice as large as that of the original dispersion.

Hydration of an amphiphilic excipient, Gelucire® 44/14

The incorporation of drugs into Gelucires has been reported to increase the dissolution rate of poorly soluble drugs, often leading to improved drug bioavailability. In pharmaceutical applications, it is important to know how the excipient interacts with the drug, and how the mixture behaves during manufacturing, storage as well as during administration. The uptake of water by an amphiphilic excipient, Gelucire 44/14, has been investigated in two ways: storage in humid air and addition of liquid water. During exposure to humid air, the uptake goes in stages that correspond to the dissolution of the components of the excipient, starting with the most hydrophilic ones: glycerol, then polyethylene glycol (PEG), PEG esters (PEG monolaurate and PEG dilaurate), and finally glycerides (trilaurin). At each stage, the remaining crystals are in equilibrium with an interstitial solution made of water and the dissolved components. In this range of hydrations, the total uptake is close to the sum of the equilibrium hydrations of the components. In the pharmaceutical formulation, the active ingredient could dissolve in the liquid phase. At larger hydrations, obtained through addition of liquid water, the state of Gelucire 44/14 differs from those of its components. Gelucire 44/14 forms a lamellar phase and this phase melts at 30 degrees C whereas the pure PEG esters form hexagonal and cubic mesophases. The cubic mesophases do not melt until the temperature exceeds 40 degrees C. At body temperature, all crystals in Gelucire 44/14 melt to an isotropic fluid as soon as the total water content exceeds 5%. Therefore the formulation of amphiphilic excipients can be optimized to avoid the formation of mesophases that impede dissolution of the excipient at body temperature.

Coupling of nuclear localization signals to plasmid DNA

This chapter focuses on a methodology for covalently associating nuclear localization signal (NLS) peptides to DNA, in which cationic NLS peptides are covalently bound to plasmid DNA by photoactivation. Described here are the synthesis and characterization of these conjugates.

Novel method for covalent fluorescent labeling of plasmid DNA that maintains structural integrity of the plasmid

We have developed a chemical strategy for covalent coupling of fluorophores to plasmid DNA. A p-azido-tetrafluoro-benzyl-lissamine conjugate was synthesized and purified. This conjugate was used to covalently associate fluorescent molecules to plasmid DNA by photoactivation. In contrast to nick-translated plasmid DNA, plasmid-lissamine conjugates appeared on gel as supercoiled DNA. Reporter gene was expressed after transfection of the plasmid-lissamine conjugates in NIH 3T3 cells, although gene transfer efficiency was decreased by 60% as compared with unlabeled DNA. Intracellular traffic of plasmid-lissamine conjugates was studied in transfected cells. After cytoplasmic microinjection, fluorescent plasmid did not diffuse from the site of injection and appeared to be progressively degraded in the cytoplasm.

Coupling of a targeting peptide to plasmid DNA by covalent triple helix formation

The nuclear localization signal (NLS) of the SV40 large T antigen efficiently induces nuclear entry of proteins. We have developed a strategy for covalent coupling of one or a controlled number of NLS peptides to plasmid DNA at a specific site by triple helix formation. A psoralen-oligonucleotide-NLS peptide conjugate was synthesized and characterized by proteolysis with trypsin. This conjugate was used to covalently associate one NLS peptide to plasmid DNA by triple helix formation and photoactivation. The oligonucleotide-NLS peptide conjugate interacted with the NLS-receptor importin alpha. The reporter gene was expressed after transfection of the modified plasmid in NIH 3T3 cells, indicating no loss of the gene expression functionality of the plasmid. On the other hand, no increase in expression was observed as a result of the NLS peptide. This site-specific coupling technology can be used to couple to a plasmid other ligands targeting to a specific receptor.

Intracellular fate and nuclear targeting of plasmid DNA

One of the major steps limiting nonviral gene transfer efficiency is the entry of plasmid DNA from the cytoplasm into the nucleus of the transfected cells. The nuclear localization signal (NLS) of the SV40 large T antigen is known to efficiently induce nuclear targeting of proteins. We have developed two chemical strategies for covalent coupling of NLS peptides to plasmid DNA. One method involves a site-specific labeling of plasmid DNA by formation of a triple helix with an oligonucleotide NLS peptide conjugate. After such modification with one NLS peptide per plasmid molecule, plasmid DNA remained fully active in cationic lipid-mediated transfection. In the other method, we randomly coupled 5-115 p-azidotetrafluorobenzyllissamine-NLS peptide molecules per plasmid DNA by photoactivation. Oligonucleotide-NLS and plasmid lissamine-NLS conjugates interacted specifically with the NLS-receptor importin alpha. Plasmid-lissamine-NLS conjugates were not detected in the nucleus, after cytoplasmic microinjection. Plasmids did not diffuse from the site of injection and plasmid-lissamine-NLS conjugates appeared to be progressively degraded in the cytoplasm. The process of plasmid DNA sequestration/degradation stressed in this study might be as important in limiting the efficiency of nonviral gene transfer as the generally recognized entry step of plasmid DNA from the cytoplasm into the nucleus.

[Modern ethics. Various considerations, particularly based on hospital experience]

The four basic principles of modern medical ethics are presented and discussed. The historic evolution of the hospital is analysed concerning the organisation and the social function of the hospital. The author presents some considerations about the relation between the patient and the hospital, clinical investigation and informed consent, confidentiality and technological progress. The problems of the end-of-life of the hospitalised patient is discussed, with an overview of the do-not-resuscitate orders.

[Thermal colorectal lesions]

A case report of thermal burns of the rectum and colon in a 94-year-old woman. The thermal lesions were caused by a scalding water enema. Flexible sigmoidoscopy was useful in documenting the extension of the lesions and histology was helpful in documenting the diagnosis. The authors review the enema's complications.

[Acute pancreatitis of biliary etiology. The case histories of the Department of General Surgery of S. Francisco Xavier Hospital (1990-1993)]

Gallstones and alcohol are the most important causes of acute pancreatitis, accounting for 80% of cases. One hundred and four cases of Acute Gallstone Pancreatitis were retrospectively studied, representing 39.5% of all cases of Acute Pancreatitis that have been treated between 1990-93. Abdominal ultrasound, demonstrating gallstones in 95% of the cases, was a very useful examination in the initial study of these patients. ERCP with sphincterotomy was performed in 25 patients: 6 in a urgent basis and the others as elective procedure. Gallstones have been treated during the initial admission in 80.6% of the cases and the others at a second admission: ERCP with sphincterotomy in 14 patients as the only etiologic treatment, open cholecystectomy in 50 cases and laparoscopic cholecystectomy in 29 cases. The overall mortality rate was 3.8%--four cases.

[Donovanosis in Pará]

From 1954 to 1990 granuloma inguinale was diagnosed in 259 patients al the dermatology service of the Universidade Federal do Pará in Belém, Brazil. Among them, 56 cases had occurred in the twenty-year period 1954-1974 and as many as 133 cases were seen during the last five years only. Greater sexual liberty, poor social and economic conditions, and especially increasing homosexual behavior were implicated by the authors as chief determinants for this augmented incidence of the disease.

[Visual screening in children]

The Early Visual Screening (EVS) before verbal communication and, certainly, before one year old, is essential to prevent strabismus and/or amblyopia. We consider the PREFERENTIAL LOOKING (PL) for visual acuity determination and screening of the amblyopia and the PHOTOREFRACTION (VIDEO-REFRACTION: VPR-1) for refractive screening, adequated methods for Early Visual Screening. We suggest that these two technics are used as EVS methods, four times in childhood (newborn, 6-8 weeks, 6-8 months, 18-24 months) performed by an Ophthalmologist at a Pilot Health Center of the National Health Service. The classic methods of visual screening such as: child's reaction to the eye occlusion, pursuit movements, STYCAR balls and miniature toys, Cover test, Hirschberg test, red fundus reflex, anterior segment examination, each of these used according to the child's age, must be performed by an Ophthalmologist. We think they are a positive alternative until we are able to use the PREFERENTIAL LOOKING and VIDEO-REFRACTION in Early Visual Screening. In the kindergarten and primary school the ASTENOPIC complaints due to hipermetropia, minor astigmatism and convergent deficit as well as chronic inflammation of the anterior segment eyelids and anexus, can be related with poor school performance more than with strabismus or myopia.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of massive hemoptysis by bronchial artery embolization

Massive hemoptysis is a major clinical and surgical problem with a mortality of 80%, which is most often related to asphyxiation. Thirty-three patients with massive hemoptysis underwent selective bronchial arteriography and treatment by embolization or surgery. Lasting control of hemoptysis was achieved in 27 of 33 patients (81.8%) at follow-up ranging from one to 24 months. Hemoptysis recurred in six of 33 patients (18.2%). Mortality related to hemoptysis was three of 33 patients (9.0%), and overall mortality was six of 33 patients (18.2%). Seven patients underwent surgical treatment in addition to bronchial artery embolization. Patients with mycetoma suffered the highest relapse of bleeding and the highest mortality in this series. In these patients, bronchial artery embolization may be effective in the control of acute bleeding, but permanent control of hemoptysis is achieved only by later surgery. Bronchial artery embolization is an effective way to control massive hemoptysis with a low recurrence rate and reduced mortality among severely ill patients. Although we have had no unfavorable sequelae, reports of neurological damage following bronchial angiography indicate care in avoiding obstruction of the artery of Adamkiewicz.