The jararacuçu, one of the most dreaded snakes of Brazil, southern Bolivia, Paraguay and northeastern Argentina, is a heavily-built pit viper which may grow to a length of 2.2 m. Up to 1000 mg (dry weight) of highly-lethal venom may be milked from its venom glands on a single occasion. It has accounted for 0.8% to 10% of series of snake bites in São Paulo State, Brazil. We examined 29 cases of proven jararacuçu bites recruited over a 20-year period in two São Paulo hospitals. Severe signs of local and systemic envenoming, (local necrosis, shock, spontaneous systemic bleeding, renal failure) were seen only in patients bitten by snakes longer than 50 cm; bites by shorter specimens were more likely to cause incoagulable blood. Fourteen patients developed coagulopathy, six local necrosis (requiring amputation in one) and five local abscesses. Two became shocked and four developed renal failure. Three patients, aged 3, 11 and 65 years, died 18.75, 27.75 and 83 h after being bitten, with respiratory and circulatory failure despite large doses of specific antivenom and intensive-care-unit management. In two patients, autopsies revealed acute renal tubular necrosis, cerebral oedema, haemorrhagic rhabdomyolysis at the site of the bite and disseminated intravascular coagulation. In one survivor with chronic renal failure, renal biopsy showed bilateral cortical necrosis; the patient remains dependent on haemodialysis. Effects of polyspecific Bothrops antivenom were not impressive, and it has been suggested that anti-Bothrops and anti-Crotalus antivenoms should be given in combination.
During the period between August 1991 and November 1995, seven patients under age 17 were submitted to videolaparoscopic cholecystectomy (LC). Two were males and five females with ages ranging from 12 to 16 years (mean 13.8 years). The diagnosis of chronic cholecystitis with gallstones was made by the clinical history and physical and ultrasonographic examinations. There was no evidence of an association with hemolytic diseases, familial hyperlipidemia or Glucose-6-phosphate dehydrogenase (G6PD) deficiency. The surgery was performed under general anesthesia and the abdomen approached by four ports: a 10 mm umbilical incision, a 5 mm cystic, a 5 mm one at the xiphoid appendix and a 10 mm one at the left lateral margin of the left rectus abdominal muscle between the umbilical scar and the xiphoid appendix. Operative time averaged 120 minutes (105-150 min). One case required conversion to laparotomic approach because of Mirizzi's Syndrome, which was diagnosed by intraoperative cholangiography performed in all cases. There were no deaths or major postoperative complications. Hospital stays ranged from 1-3 days in the six patients submitted to LC. Thus LC in children can be considered a good method, requiring only more care regarding the use of proper equipment, complete and careful dissection of the biliary hilus, and intraoperative cholangiography. The latter is indispensable, as these children can present a higher rate of anatomic anomalies. The advantages of this technique include a less painful postoperative period with a faster recovery, and it is especially recommended in children, who are less tolerant to physical restriction and pain than adults.
Patrick Jack Spencer pelo voto de confiança, amizade, incentivo e pela sua paciência em ensinar-me, sendo fundamental sua contribuição no desenvolvimento deste trabalho. À Dra. Maria de Fátima Domingues Furtado do Laboratório de Herpetologia do Instituto Butantan, pelo fornecimento dos venenos. À Dra. Myrian Callefo do Museu de Herpetologia do Instituto Butantan pela ajuda na obtenção dos dados dos venenos. À Dra. Solange Serrano do Centro de Toxinologia Aplicada e à Laura P. Narvaes do Laboratório de Herpetologia do Instituto Butantan pelo fornecimento do substrato sintético para a realização de alguns experimentos. Ao Dr. Rui Seabra do CEVAP de Botucatu pelo fornecimento do soro antibotrópico comercial. Ao amigo Alisson T. Bucchi, do CEVAP de Botucatu pelo auxílio na análise dos géis. Ao amigo Sandro Detoni, que me ajudou a escrever a geomorfologia da Ilha de São Sebastião. Aos amigos "Johnny" e "Zé Maria" pelos ensinamentos, conversas, amizade e pela ampla ajuda e colaboração, auxiliando enormemente na execução deste trabalho. Às minhas queridas amigas Renata, Susana e Taís que muitas vezes pararam seus experimentos para auxiliar-me nos meus. À Lucélia que me ensinou a montar o aparato da eletroforese corretamente. Ao Dr. Jean Queiroz, que sempre me incentivou e ajudou, tornando-se um grande amigo. À minha irmã Raíssa, Rodrigo e Natália pela estadia em sua residência. Á minha irmã Wanessa e ao Sérgio que muitas vezes me forneceram carona. À Claudinha que sangra os camundongos como ninguém. À Dra. Olga que sempre organizou festas surpresas em meu aniversário, pelo seu carinho. Aos amigos Paulo, Naldo, Luciano, Alexandre e Rogério que tiveram o "árduo trabalho" de me aturar como hóspede no CRUSP. Àqueles que considero irmãos pela cumplicidade, críticas sinceras, amizade e grandioso ensinamento obtido através de suas experiências na vida e na bancada, que deram-me as mãos e muitas vezes se "descabelaram" com minhas atitudes, pessoas especiais e muito importantes na realização deste trabalho e na minha vida: Alberto, Eduardo, Murilo e Janaína. À Rosa pela sua amizade, bom humor, pelos muitos ensinamentos e por corrigir meu "portunhol". À "Dna. Gê" pelo café nosso de cada dia. Ao "Seu Zé Longino" pela amizade e brincadeiras. Á Dra. Rute, pela amizade e respeito. Às minhas "irmãs científicas" Karina e Érika pela amizade e carinho, auxílio na bancada e por agüentar meus desabafos. Ao amigo Dr. Franco, pela amizade, companheirismo e incentivo. À "Neidinha" pelo auxílio e por todos os cuidados com os animais do biotério no IPEN. Ao amigo Mosca, que sempre me deu carona e pelos seus e-mails engraçados. Ao amigo Walker pela amizade e bom humor. A todos os orientadores do Centro de Biotecnologia do IPEN que de alguma maneira contribuíram neste trabalho. Aos animais que contribuem para o avanço dos conhecimentos. Aos demais amigos e companheiros de trabalho: Andrés,
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