Hospital São Domingos

Postoperative pain after bariatric surgery is a significant clinical challenge, with approximately 61.4% of patients reporting persistent pain. Intraperitoneal local anesthetic instillation (IPLA) has been proposed as a strategy to reduce pain and opioid-related adverse effects. However, as its effectiveness in bariatric procedures remains controversial, this meta-analysis was conducted to clarify the role of IPLA in this setting. This systematic review and meta-analysis was conducted following PRISMA guidelines and was prospectively registered in PROSPERO. We performed a comprehensive search in Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science for randomized controlled trials (RCTs) IPLA instillation with a control group in patients undergoing bariatric surgery. The primary outcomes were postoperative pain intensity, need for rescue analgesia, and supplementary opioid consumption. Secondary outcomes included postoperative nausea and vomiting (PONV), nausea, vomiting, and shoulder pain. Data were synthesized using a random-effects model to calculate Risk Ratios (RR) for binary outcomes and Standardized Mean Differences (SMD) and Mean Differences (MD) for continuous outcomes. The methodological quality of the trials was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. The analysis included 13 randomized controlled trials with a total of 1205 participants, of whom 624 were in the intraperitoneal local anesthetic (IPLA) group and 581 were in the control group. The pooled results showed that IPLA significantly reduced postoperative pain intensity (SMD: -0.96, 95% CI -1.72 to -0.20; p=0.01) and the need for rescue analgesia (RR: 0.52, 95% CI 0.31-0.89). However, there was no significant difference in postoperative opioid consumption (SMD: -0.56, 95% CI -1.13 to 0.01; p=0.05). Additionally, no significant effects were found for the incidence of postoperative nausea and vomiting (PONV) or shoulder pain. High heterogeneity was noted in most of the analyses. IPLA reduces postoperative pain in bariatric surgery but does not decrease opioid consumption or adverse events. A suggested reduction in rescue analgesia was not robust. Due to high heterogeneity, the findings' clinical applicability is limited, highlighting the need for standardized trials. PROSPERO protocol CRD420251085223-July 2025.

Relato de Caso: A 63-year-old man with a history of smoking, obesity, arterial hypertension, diabetes mellitus, and previous deep venous thrombosis (DVT) in the left leg was admitted to the emergency department due to myocardial infarction. Upon admission, laboratory tests revealed serum creatinine of 2.3 mg/dL (normal, 0.9–1.3 mg/dL) and urea of 79 mg/dL (normal, 10–40 mg/ dL). Coronary angiography revealed severe and complex lesions in all three arteries. Surgical myocardial revascularization was performed without complications. The patient was discharged on the 19th postoperative day in satisfactory condition with a creatinine of 1.93 mg/dL. However, he presented to the hospital again 7 days after discharge, complaining of chest pain and dyspnea. Chest angiotomography revealed a right-sided pulmonary embolism, while venous Doppler imaging of the lower limbs showed no signs of a recent DVT. The patient was started on full anticoagulation with unfractionated heparin, later transitioning to apixaban. Hematological investigations for hypercoagulable disorders yielded negative results. During outpatient follow-up, 24-hour proteinuria was 264 mg/day and creatinine level rose to 3.53 mg/dL. Doppler of the renal arteries showed abdominal aortic atheromatosis without significant stenosis, with a fusiform aneurysmal dilation in the infrarenal segment measuring approximately 8.4 cm in length and 4.4 cm in diameter. and normal kidney size. Despite the patient’s history of hypertension, retinal imaging was normal. Due to the continuous and unexplained progressive deterioration of renal function (creatinine level, 4.19 mg/dL), a kidney biopsy was performed at the 5-month follow-up, which showed cholesterol crystal embolism (CCE) of the renal arterioles. The kidney biopsy also showed slight thickening of the tunica intima in some arteries. The patient had stable kidney function and did not require renal replacement therapy during a year follow-up. CCE may occur after intra-arterial procedures and is rarely spontaneous. Cholesterol crystals and atheroma debris embolize from proximal large arteries to distal small arteries, mechanically obstructing vascular beds and leading to an inflammatory response, leukocyte infiltration, and complement activation in the target organs.

ABSTRACT We aimed to integrate local and scientific knowledge to select tree species for elaborate silvopastoral systems with the proposition of a multi-criteria decision-making support tool. We conducted a pilot study in the south of Espírito Santo, a tropical Brazilian region. The survey of trees took place on 136.9 ha of pastureland at nine rural properties. We interviewed 42 family farmers that practiced cattle ranching and had trees in their pastures. A multi-attribute utility function was created to select and order ten tree species with cultural and ecological potential for pasture afforestation. We evaluated these species regarding their interactions with soil cover, herbaceous biomass and bovine grazing. The ten selected tree species showed orderly decreased EESI (Ethnoecological Selection Index) values ranging from 0.8327 to 0.5958. All ten species were native, 30% were nitrogen fixers, 70% had Use Value, and none were invasive. Regarding soil cover, herbaceous biomass, and grazing, the under the crown and outside the crown strata showed no statistical differences between them. The crown base height and herbaceous ground cover positively correlated, while the canopy cover and herbaceous ground cover negatively correlated. The EESI creates an interface between the traditional knowledge of family farmers and scientific knowledge.

The sustained administration of deep neuromuscular blockade (NMB) improves surgical conditions compared to moderate NMB and might be effective in the laparoscopic Roux-en-Y gastric bypass (LRYGB). This study aimed to evaluate the effect of sustained intravenous deep NMB on improving surgical conditions and pain intensity following LRYGB. This randomized, double-blind clinical trial was conducted in São Luís, Maranhão, Brazil, between October 2021 and December 2023. Patients undergoing LRYGB were randomly assigned to moderate (reversed with 2mg/kg of sugammadex) or deep NMB (reversed with 4mg/kg of sugammadex). Seventy-one patients were evaluated in the study, divided into moderate NMB with 37 patients and deep NMB group with 34 patients. There was no difference between the groups regarding gender, age, weight, height, and comorbidities. Also, in the duration of anesthesia (moderate, 2h 26min; deep, 2h 27min; p = 0.876), duration of surgery (moderate, 1h 39min; deep NMB: 1h 40min; p = 0.931), time to extubation (moderate, 5min; deep, 7min; p = 0.252), time to the first morphine request (moderate, 30min; deep, 25min on average; p = 0.776), mean morphine consumption in 24h (moderate, 14mg; deep, 10mg; p = 0.133), and sevoflurane consumption (moderate, 50mL; deep 50mL; p = 0.884). There was nosignificant difference between the groups in pain scores at none of the evaluated moments.The Leiden-Surgical Rating Scale revealed a significant difference between the groups at 20/30min (p = 0.015) and 60/70min (p = 0.027), respectively. This study demonstrated improved surgical field visibility with deep compared to moderate NMB, without significant differences in other evaluated variables.

This is the first paper in a compilation of subfamilies synoptic taxonomic treatments of the Miridae in Espírito Santo (ES), Brazil based on extensive fieldwork and review of local collections. Starting with Bryocorinae, Cylapinae, and Deraeocorinae. This manuscript recognizes three subfamilies, 8 tribes, 31 genera, and 45 species from the region. Diagnoses, hostplant/plant associations and predator prey information, distribution data, and remarks are provided. Illustrations of adults and, for most species, morphological characters of male genitalia are given to help identification. Keys are included for identification, including other subfamilies, tribes, and genera not yet found in the state of ES to increase the comparative accuracy.

regimens.Nevertheless, since the withdrawal of bPIs in HTE PWH lowers the genetic barrier of the antiretroviral regimen, this therapeutic strategy should only be considered as a bridge and requires strict virological monitoring.In addition, in vitro data suggest that temsavir may potentially increase the exposure of paclitaxel by inducing OATP1B1/3 and BCRP activity Although the clinical relevance of this pDDI is currently unknown, it is important to advise clinicians to monitor for the potential development of paclitaxel-related toxicity in PWH concomitantly treated with fostemsavir.In any case, the potential effect of temsavir on paclitaxel disposition, if any, is expected to be negligible when compared with the well-known and clinically relevant DDI between chemotherapy and bPIs. FundingThis study was carried out as part of our routine work. Transparency declarations

A colecistectomia é um procedimento cirúrgico comum para a remoção da vesícula biliar, que pode ser realizada através de técnicas abertas ou laparoscópicas. A colecistectomia por videolaparoscopia tem se tornado cada vez mais popular devido às suas vantagens, como menor tempo de recuperação e menor dor pós-operatória. Com isso, pode ter repercussões na recuperação dos pacientes.

Introducción El cáncer cervicouterino ocupa el segundo lugar de las neoplasias malignas que afectan a las mujeres en la República de Panamá. A pesar de que se puede detectar en fases tempranas, pacientes en fases avanzadas asociadas a falla renal todavía llegan para atención en el Instituto. El objetivo de nuestro trabajo consiste en la revisión de la evolución clínica de las pacientes con falla renal secundaria a cáncer cervicouterino en el Instituto Oncológico Nacional (ION) de Panamá en un período de 2015 a 2020 con el fin de poder hacer recomendaciones en el manejo de estas. Material y Métodos Es un estudio retrospectivo y descriptivo. Para efectos del trabajo se consideró niveles de creatinina mayores a 2 mg/dL. La evaluación de la calidad de vida se realizó mediante la aplicación de cuestionarios específicos que no son parte de la atención de los pacientes del Instituto. Para identificar los casos se realizó un cruce de datos de las pacientes con diagnóstico de cáncer cervicouterino y creatinina mayor de 2 mg/dL. Resultados. El número total de casos que pudieron ser revisados fue 65. El 94% de los casos correspondió al tipo histológico de carcinoma de células escamosas. La etapa más frecuente fue IIIB (44%). El índice ECOG 0/1 (72%). La hipertensión arterial estuvo presente en el 35% de los casos y la diabetes en 5%. Hubo pacientes en todos los rangos de creatinina que se utilizaron. De los 65 casos recibieron algún tipo de tratamiento oncológico. 36 de las 55 fueron tratadas con radioterapia o radioquimioterapia. 10 pacientes no pudieron recibir ningún tratamiento debido a mal estado general. La supervivencia global promedio fue de 7 meses. El grupo de 20-29 años tuvo una mejor supervivencia inicial, pero a los 10 meses se perdió esta diferencia. Conclusiones El promedio de la supervivencia global de las pacientes con falla renal secundaria a cáncer cervicouterino de nuestro estudio fue de 10 meses y no varió significativamente según el tipo de derivación renal utilizada.

Neuroendocrine tumors are part of a heterogeneous group of tumors located in organs such as the gastrointestinal tract (GIT), lungs, thymus, thyroid, and adrenal glands. The most prevalent sites are the small intestine, cecal appendix, and pancreas. More than 50% of these tumors are associated with metastases at the time of diagnosis. Neuroendocrine tumors are classified according to the degree of cell differentiation and the histopathological proliferation index of the lesion. Neuroendocrine tumors can be well differentiated or poorly differentiated. G3 tumors are characterized by Ki-67 expression greater than 20% and can be either well differentiated (G3 NET) or poorly differentiated (G3 NEC). Neuroendocrine carcinoma (NEC G3) is subdivided into small-cell and large-cell types. When neuroendocrine tumors present clinical and compressive symptoms, carcinoid syndrome is evident. Carcinoid syndrome occurs when the tumor produces neuroendocrine mediators that cannot be metabolized by the liver due to either the size of the tumor or their secretion by the liver itself. Several therapeutic strategies have been described for the treatment of metastatic neuroendocrine tumors, including curative or palliative surgical approaches, peptide receptor radionuclide therapy, percutaneous therapy, systemic chemotherapy, and radiotherapy. Liver surgery is the only approach that can offer a cure for metastatic patients. Liver metastases must be completely resected, and in this context, orthotopic liver transplantation has gained prominence for yielding very promising outcomes in selected cases. The aim of this study is to review the literature on OLT as a form of treatment with curative intent for patients with gastroenteropancreatic neuroendocrine tumors with liver metastasis.