Severe acute pancreatitis: eight fundamental steps revised according to the 'PANCREAS' acronym

Severe acute pancreatitis remains a life-threatening condition, responsible for many disorders of homeostasis and organ dysfunction. By means of a mnemonic 'PANCREAS', eight important steps in the management of severe acute pancreatitis are highlighted. These steps follow the principle of goal-directed therapy and should be borne in mind after diagnosis and during clinical treatment. The first step is perfusion: the goal is to reach a central venous pressure of 12-15mmHg, urinary output 0.5-1ml/kg/hour and inferior vena cava collapse index greater than 48%. Next is analgesia: multimodal, systemic and combined pharmacological agent and epidural block are possibilities. Third is nutrition: precocity, enteral feeding in gastric or post-pyloric position. Parenteral nutrition works best in difficult cases to achieve the individual total caloric value. Fourth is clinical: mild, moderate or severe pancreatitis according to the Atlanta criteria. Radiology is fifth: abdominal computed tomography on the fourth day for prognosis or to modify management. Endoscopy is sixth: endoscopic retrograde cholangiopancreatography (cholangitis, unpredicted clinical course and ascending jaundice); management of pancreatic fluid collection and 'walled-off necrosis'. Antibiotics come next: infectious complications are common causes of morbidity. The only rational indication for antibiotics is documented pancreatic infection. The last step is surgery: the dogma is represented by the 'three Ds' (delay, drain, debride). The preferred method is a minimally invasive step-up approach, which allows for gradually more invasive procedures when the previous treatment fails.

Pharmacogenomics - the state of the art in drug prescription

Introduction The different response to various drugs by individuals has been increasingly debated, since it has been concluded that there are large differences in response and increasing occurrence of adverse reactions. This set of issues led to more and more research on the implementation of genetic testing in the very near future, leading to benefits for the patient. The purpose of pharmacogenetics is to analyse each individual’s genetic variability in response to therapy, increasing efficiency and safety. On the other hand, pharmacogenomics studies how the expression of a set of genes interferes in individual’s responses to drugs, taking into account pharmacokinetics and pharmacodynamics. This concept also seeks to reduce adverse reactions and toxicity, maximizing drug efficiency.

Objectives The present work aims at gathering information on the proposed theme, making the survey of drugs available on the market elucidating how it allows the adjustment of the dose to be administered to the patient according to their genetic profile.

Methodology Databases such as Pubmed, Science Direct and Google Scholar were consulted and data were collected from 2015 until 2019. Paper was selected first by abstract and after by full text reading of the article.

Results On this review we will list the drugs associated with each biomarker and the respective therapeutic area to which they belong, compiled by the Food and Drug Administration (FDA). This list includes the main therapeutic area: oncology, haematology, anaesthesiology and psychology. Biomarkers allow us to identify phenotype-associated variations in drug response, making it possible to understand whether drugs will have a beneficial effect, no effect or if there is a risk of toxicity.

Conclusion This question requires a risk-benefit assessment, since it involves social, ethical and economic problems.

Adenosine A2A receptor regulation of microglia morphological remodeling-gender bias in physiology and in a model of chronic anxiety

Developmental risk factors, such as the exposure to stress or high levels of glucocorticoids (GCs), may contribute to the pathogenesis of anxiety disorders. The immunomodulatory role of GCs and the immunological fingerprint found in animals prenatally exposed to GCs point towards an interplay between the immune and the nervous systems in the etiology of these disorders. Microglia are immune cells of the brain, responsive to GCs and morphologically altered in stress-related disorders. These cells are regulated by adenosine A_2A receptors, which are also involved in the pathophysiology of anxiety. We now compare animal behavior and microglia morphology in males and females prenatally exposed to the GC dexamethasone. We report that prenatal exposure to dexamethasone is associated with a gender-specific remodeling of microglial cell processes in the prefrontal cortex: males show a hyper-ramification and increased length whereas females exhibit a decrease in the number and in the length of microglia processes. Microglial cells re-organization responded in a gender-specific manner to the chronic treatment with a selective adenosine A_2A receptor antagonist, which was able to ameliorate microglial processes alterations and anxiety behavior in males, but not in females.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Transtracheal puncture: a forgotten procedure

Transtracheal puncture has long been known as a safe, low-cost procedure. However, with the advent of bronchoscopy, it has largely been forgotten. Two researchers have suggested the use of α-amylase activity to diagnose salivary aspiration, but the normal values of this enzyme in tracheobronchial secretions are unknown. We aimed to define the normal values of α-amylase activity in tracheobronchial secretions and verify the rate of major complications of transtracheal puncture. From October 2009 to June 2011, we prospectively evaluated 118 patients without clinical or radiological signs of salivary aspiration who underwent transtracheal puncture before bronchoscopy. The patients were sedated with a solution of lidocaine and diazepam until they reached a Ramsay sedation score of 2 or 3. We then cleaned the cervical region and anesthetized the superficial planes with lidocaine. Next, we injected 10 mL of 2% lidocaine into the tracheobronchial tree. Finally, we injected 10 mL of normal saline into the tracheobronchial tree and immediately aspirated the saline with maximum vacuum pressure to collect samples for measurement of the α-amylase level. The α-amylase level mean ± SE, median, and range were 1914 ± 240, 1056, and 24-10,000 IU/L, respectively. No major complications (peripheral desaturation, subcutaneous emphysema, cardiac arrhythmia, or hemoptysis) occurred among 118 patients who underwent this procedure. Transtracheal aspiration is a safe, low-cost procedure. We herein define for the first time the normal α-amylase levels in the tracheobronchial secretions of humans.

Clinical outcomes and predictive factors in patients with liver metastasis from breast cancer treated with gemcitabine and cisplatin (GC) salvage regimen

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Background: Liver metastasis (mets) from breast cancer is typically associated with poor prognosis. GC is a good option, since patients (pts) have often failed anthracycline and taxane therapy and liver dysfunction may preclude these regimens. Methods: Retrospective study designed to evaluate the clinical outcomes and predictive factors in pts with metastatic breast cancer treated with GC, with special interest for liver mets. Results: From 2004 to 2007, 56 pts were treated with GC. Median age was 52.1 years, 33 pts had PS 0–1, 26 were hormone receptor (HR) negative, 32 had been treated with 3 or more chemotherapy (CT) regimens and 34 had liver mets. The median overall survival (OS) was 7,1 mo (95% CI; 4.3–9.7), the progression free survival was 3.3 mo (95% CI; 2.2–5.5) and the clinical response rate was 25%. OS was 4.0 mo (95% CI; 2.3–8.9) for pts with liver mets and 9.7 mo (95% CI; 6.9–12.9) for pts without liver mets (p = 0.03). No factor showed correlation with OS in pts with liver mets, including age < 45 years (median OS [95% CI]: 2.8 mo [1.8–11.5] versus 4.5 mo [2.5–8.9]; p = 0.74), PS 0–1 (median OS [95% CI]: 7.3 mo [2.5–11.5] versus 2.8 mo [0.8–9.7]; p = 0.55), HR positivity (median OS [95% CI]: 7.3 mo [2.0–11.5] versus 5.9 mo [1.9–9.7]; p = 0.87), bilirubin level ≥ 5 times the superior limit of the normality (median OS [95% CI]: 5.9 mo [0.5–16.7] versus 4.5 mo [2.5–9.7]; p = 0.45), progression free interval after the previous CT ≤ 1 mo (median OS [95% CI]: 4.0 mo [2.0–9.7] versus 7.1 mo [2.5–14.7]; p = 0.93) and previous treatment with ≥ 3 CT regimens (median OS [95% CI]: 7.3 mo [1.0–11.0] versus 4.0 mo [2.0–9.7]; p = 0.93). Conclusions: These data is in accordance with the literature concerning the dismal prognosis in liver mets from breast cancer and the clinical activity of GC. We could not define predictive factors in this cohort, which was probably due to the relatively small number of pts.

No significant financial relationships to disclose.

Molecular evolution of the period gene in sandflies

The molecular evolution of the clock gene period was studied in Phlebotomine sandflies (Diptera: Psychodidae). Comparison of the synonymous and nonsynonymous substitution rates between sandflies and Drosophila revealed a significantly higher evolutionary rate in the latter in three of the four regions analyzed. The differences in rate were higher in the sequences flanking the Thr-Gly repetitive domain, a region that has expanded in Drosophila but remained stable and short in sandflies, a result consistent with the coevolutionary scenario proposed for this region of the gene. An initial phylogenetic analysis including eight neotropical sandfly species and one from the Old World was also carried out. The results showed that only the subgenus Nyssomyia is well supported by distance (neighbor-joining) and maximum parsimony analysis. The grouping of the other species from the subgenus Lutzomyia and Migonei group shows very low bootstrap values and is not entirely consistent with classical morphological systematics of the genus Lutzomyia.

New molecular markers for phlebotomine sand flies

Using degenerate-primers PCR we isolated and sequenced fragments from the sand fly Lutzomyia longipalpis homologous to two behavioural genes in Drosophila, cacophony and period. In addition we identified a number of other gene fragments that show homology to genes previously cloned in Drosophila. A codon usage table for L. longipalpis based on these and other genes was calculated. These new molecular markers will be useful in population genetics and evolutionary studies in phlebotomine sand flies and in establishing a preliminary genetic map in these important leishmaniasis vectors.

[The heart transplant. The initial experience of the Instituto do Coração de Pernambuco]

PURPOSE

To describe the initial experience of a heart transplant program in Recife, Pernambuco.

METHODS

Six patients in the final stage of heart failure were submitted to heart transplant. There were 4 male and 2 female patients, ranging in age from 15 to 61 years (mean, 43.8). Four had coronary heart disease and two dilated cardiomyopathy. The conventional operative technique of orthotopic heart transplant was used. All patients received a triple drug immunosuppressive therapy.

RESULTS

There was one death due to acute rejection on the 28th postoperative day. The 5 survivors are in functional class I in a mean follow-up period of 113 days.

CONCLUSION

The initial experience of a heart transplant program in Recife, Pernambuco, suggests that good long term results could be expected.