Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.
Background Postoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies. Methods The Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surgery (2011–2015). Multivariable logistic regression was used to predict risk of AKI, with multiple imputation used to account for data missing at random. Prognostic accuracy was assessed for patients at high risk (greater than 20 per cent) of postoperative AKI. Results In the validation cohorts, 12.9 per cent of patients (661 of 5106) in IMAGINE and 14.7 per cent (106 of 719 patients) in Tayside developed 7-day postoperative AKI. Using the OAKS model, 558 patients (9.6 per cent) were classified as high risk. Less than 10 per cent of patients classified as low-risk developed AKI in either cohort (negative predictive value greater than 0.9). Upon external validation, the OAKS model retained an area under the receiver operating characteristic (AUC) curve of range 0.655–0.681 (Tayside 95 per cent c.i. 0.596 to 0.714; IMAGINE 95 per cent c.i. 0.659 to 0.703), sensitivity values range 0.323–0.352 (IMAGINE 95 per cent c.i. 0.281 to 0.368; Tayside 95 per cent c.i. 0.253 to 0.461), and specificity range 0.881–0.890 (Tayside 95 per cent c.i. 0.853 to 0.905; IMAGINE 95 per cent c.i. 0.881 to 0.899). Conclusion The OAKS prognostic model can identify patients who are not at high risk of postoperative AKI after gastrointestinal surgery with high specificity. Presented to Association of Surgeons in Training (ASiT) International Conference 2018 (Edinburgh, UK), European Society of Coloproctology (ESCP) International Conference 2018 (Nice, France), SARS (Society of Academic and Research Surgery) 2020 (Virtual, UK).
Resumo:A hanseníase é uma neuropatia infectocontagiosa que acomete fibras nervosas motoras, sensitivas e autonômicas. Os reflexos da polineuropatia hansênica na função sensitiva são bem conhecidos, porém pouco se sabe sobre o efeito desta doença na função motora. Assim, o objetivo deste trabalho foi avaliar os padrões eletromiográficos de músculos dos membros superior e inferior de pacientes com hanseníase com acometimento de neuropatia periférica e compará-los com indivíduos saudáveis. Participaram do estudo 25 voluntários, de ambos os gêneros, idade entre 40 e 70 anos, divididos em 5 grupos: G1-G4 (portadores da doença com lesão no nervos tibial, fibular comum, ulnar e radial, n=5, respectivamente) e G5 (voluntários saudáveis, n=5). O sinal eletromiográfico foi captado utilizando eletrodos de superfície dos músculos gastrocnêmio (G1), tibial anterior (G2), hipotênares (G3), extensor dos dedos (G4), e em todos esses músculos para o G5. Os voluntários dos grupos G1 a G4 realizaram contração voluntária isométrica máxima de flexão plantar, dorsiflexão, abdução do dedo mínimo e extensão do carpo, respectivamente; o grupo G5 realizou todos os movimentos. Os resultados mostraram que em todos os grupos, os indivíduos portadores de hanseníase mostraram maior atividade mioelétrica comparado a indivíduos saudáveis, porém sem significância estatística. A falha no alcance à significância remete a realização de novos estudos com maior delineamento e homogeneização da amostra, de forma a controlar variáveis e estabelecer uma amostra com menor desvio padrão. Desta forma, de acordo com a metodologia empregada, conclui-se que pela análise eletromiográfica de superfície, a hanseníase parece não afetar a atividade motora. Palavras-chave: hanseníase, eletromiografia, membros. Abstract: Leprosy is an infectious and contagious IntroduçãoA hanseníase permanece como um grave problema de saúde pública no país, sendo o segundo país em número de casos da doença, representando 93% dos novos casos na América Latina [1]. Doença infectocontagiosa, de acometimento dermatoneurológico, é causada pelo bacilo Mycobacterium leprae. Em sua patologia, este parasita tem como sedes de alojamento os tecidos da pele e tecido nervoso periférico, o que gera o desenvolvimento de uma resposta imunológica importante [2]. Possui dois padrões típicos de desenvolvimento: a forma tuberculóide, caracterizada por lesões de pele secas e escamosas, com ausência de sensação; e a forma virchowiana, mais intensa e que apresenta espessamento e nódulos simétricos da pele. Em ambas formas clínicas, o comprometimento neural pode ser observado [3]. Os bacilos da tuberculose possuem um tropismo especial pelos nervos periféricos, sendo que a neuropatia da doença é caracterizada clinicamente como mista, uma vez que acomete tanto fibras nervosas motoras como sensitivas e autonômicas [4]. A ação conjunta do parasita e resposta inflamatória desencadeia o aparecimento de
Hypopigmented mycosis fungoides (HMF) is an uncommon variant of cutaneous T-cell lymphoma. It is more frequent in dark-skinned people, particularly children. The HMF diagnose is difficult, especially in early stages because this condition resembles benign skin diseases. Thus is histopathological analysis very important for the diagnosis. We report a case of a 7-year-old child with widespread HMF confirmed by histopathology that showed cells tagging along the dermal/epidermal junction and extending into the epidermis in a pattern of epidermotropism and focal cell aggregates in the epidermis (Pautrier's microabscess). We demonstrate the importance of clinical suspicion for this cutaneous neoplasia in patients with hypopigmentated lesions.
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