From Pansinusitis to Cerebritis Due to Eikenella corrodens.

Meningitis is a rare but possible complication of sinusitis. We present a case of a 21-year-old woman with a history of fever, headache and nasal obstruction who presented at the emergency department with psychomotor agitation. Orotracheal intubation and invasive mechanical ventilation were given to protect airway. Blood analysis showed leukocytosis and elevated C-reactive protein. Cerebral and maxillofacial computed tomography (CT) demonstrated pansinusitis with gas foci more prominent in the left frontal sinus with an area of ​​bone rarefaction on the posterior wall with possible communication with the cranial cavity. Lumbar puncture was performed. Empirical antibiotic and corticosteroid therapy were started. Neurosurgery (NC) and Ear Nose and Throat (ENT) surgeons declined indication for urgent surgery and she was admitted at General ICU. On the fourth day of hospitalization, a brain magnetic resonance imaging (CE-MRI) was performed, revealing subdural empyema and cerebritis adjacent to the frontal sinus. She was transferred to the reference neurosurgical center for surgical interventions and was admitted post-operatively at the Neurocritical Care Unit (NCCU). Reevaluation MRI showed residual anterior frontal empyema and absence of focus control in peri-nasal sinusitis, requiring a new ENT surgery. A Streptococcus spp was isolated from the blood, Eikenella corrodens from the pus collected from the sinuses, and the CSF was sterile. The patient completed 21 days of antibiotic therapy. She was extubated on the 19th day, with Broca's aphasia and right hemiparesis, and on the 23rd day transferred to the ENT Service and later to the Rehabilitation Service. We present a case of atypical central nervous system (CNS) infection by a rare agent, highlighting the importance of vigilance, focus control, and neurocritical care. In a severe and complex manifestation like this, the management typically involves medical and surgical interventions. Subdural empyema should be treated as a neurosurgical emergency due to the potential rapid deterioration in patient's neurological condition, attributed to secondary damage. In this case, brain multimodal monitoring, was very helpful in acute phase management. Neurocritical care teams should be involved early in patients with this presentation of CNS infection to provide optimal management, reducing complications and secondary brain lesions therefore improving patient outcomes.

Gallstone Ileus: A Rare Cause of Mechanical Bowel Obstruction.

A gallstone ileus is a rare cause of mechanical bowel obstruction, accounting for 1% to 4% of all cases. Twenty-five percent of the patients are 65 years of age or older and often present previous significant medical conditions. The authors report the case of an 87-year-old male patient, admitted with the diagnosis of community-acquired pneumonia, who later developed frequent episodes of biliary vomiting, intermittent constipation, and abdominal distension. Abdominal imaging (ultrasound and computed tomography (CT)) showed evidence of a localized inflammatory process in a small bowel loop but excluded vesicular lithiasis. After a failure in the medical approach with antibiotics, an exploratory laparotomy was performed, identifying the intestinal occlusion area, followed by an enterolithotomy at the specific area, and extraction of a 4 cm stone of acellular material. Posteriorly, the patient was treated for three weeks with a carbapenem and physical rehabilitation was promptly initiated with full recovery of his previous status. Gallstone ileus is a very challenging diagnosis and surgery is the treatment of choice. In elderly patients, it is important to promote prompt physical rehabilitation to prevent prolonged bed rest.

Exploring new antiviral targets for influenza and COVID-19: Mapping promising hot spots in viral RNA polymerases.

Influenza and COVID-19 are infectious respiratory diseases that represent a major concern to public health with social and economic impact worldwide, for which the available therapeutic options are not satisfactory. The RdRp has a central role in viral replication and thus represents a major target for the development of antiviral approaches. In this study, we focused on Influenza A virus PB1 polymerase protein and the betacoronaviruses nsp12 polymerase protein, considering their functional and structural similarities. We have performed conservation and druggability analysis to map conserved druggable regions, that may have functional or structural importance in these proteins. We disclosed the most promising and new targeting regions for the discovery of new potential polymerase inhibitors. Conserved druggable regions of putative interaction with favipiravir and molnupiravir were also mapped. We have also compared and integrated the current findings with previous research.

Adaptive evolution of PB1 from influenza A(H1N1)pdm09 virus towards an enhanced fitness.

PB1 influenza virus retain traces of interspecies transmission and adaptation. Previous phylogenetic analyses highlighted mutations L298I, R386K and I517V in PB1 to have putatively ameliorated the A(H1N1)pdm09 adaptation to the human host. This study aimed to evaluate the reversal of these mutations and infer the role of these residues in the virus overall fitness and adaptation. We generate PB1-mutated viruses introducing I298L, K386R and V517I mutations in PB1 and evaluate their phenotypic impact on viral growth and on antigen yield. We observed a decrease in viral growth accompanied by a reduction in hemagglutination titer and neuraminidase activity, in comparison with wt. Our data indicate that the adaptive evolution occurred in the PB1 leads to an improved overall viral fitness; and such biologic advantaged has the potential to be applied to the optimization of influenza vaccine seed prototypes.

Optimization of A(H1N1)pdm09 vaccine seed viruses: The source of PB1 and HA vRNA as a major determinant for antigen yield.

Vaccination prevents and reduces the severity of influenza virus infections. Continuous evolution of influenza hemagglutinin (HA) and neuraminidase (NA) supports the virus to evade pre-existing immunity, which demands vaccines to be reformulated every year. Incorporation of polymerase basic protein 1 (PB1) viral RNA (vRNA) of the same origin of HA and NA vRNA has been observed in previous pandemic viruses and occasionally reported for influenza A vaccine prototype strains of prior seasons. At this point, it remains to be explored whether this phenomenon translates into an improved growth phenotype. In this work, we showed that the HA vRNA of A(H1N1)pdm09 is generally incorporated with the PB1 vRNA of the same origin, establishing the beneficial effect of the presence of PB1 and the pattern of the PB1-HA co-incorporation in the A(H1N1)pdm09 model. We further investigated the putative interplay between PB1 and antigenic proteins regarding the vRNA composition of the progeny and observed that vRNA segregation does not appear to be mainly determined by protein-protein interactions; while vRNA-vRNA interactions can be suggested as the main driving force. Our data also indicate an increase in the hemagglutination capacity and neuraminidase activity due to incorporation of PB1, HA and NA from A(H1N1)pdm09, in comparison with the recombinant virus incorporating only HA and NA from A(H1N1)pdm09 - which have the potential to improve current limitations regarding antigenicity and immunogenicity of influenza vaccines. Further knowledge of the complex vRNA-vRNA interaction network between PB1 and HA will additionally contribute to improve current vaccine formulation, and to gradually optimize the production of A(H1N1)pdm09 reverse genetics vaccine seed virus towards a higher cost-effectiveness.

COVID-19: impact on Public Health and hypothesis-driven investigations on genetic susceptibility and severity.

COVID-19 is a new complex multisystem disease caused by the novel coronavirus SARS-CoV-2. In slightly over 2 years, it infected nearly 500 million and killed 6 million human beings worldwide, causing an unprecedented coronavirus pandemic. Currently, the international scientific community is engaged in elucidating the molecular mechanisms of the pathophysiology of SARS-CoV-2 infection as a basis of scientific developments for the future control of COVID-19. Global exome and genome analysis efforts work to define the human genetics of protective immunity to SARS-CoV-2 infection. Here, we review the current knowledge regarding the SARS-CoV-2 infection, the implications of COVID-19 to Public Health and discuss genotype to phenotype association approaches that could be exploited through the selection of candidate genes to identify the genetic determinants of severe COVID-19.

NS1 protein as a novel anti-influenza target: Map-and-mutate antiviral rationale reveals new putative druggable hot spots with an important role on viral replication.

Influenza NS1 is a promising anti-influenza target, considering its conserved and druggable structure, and key function in influenza replication and pathogenesis. Notwithstanding, target identification and validation, strengthened by experimental data, are lacking. Here, we further explored our previously designed structure-based antiviral rationale directed to highly conserved druggable NS1 regions across a broad spectrum of influenza A viruses. We aimed to identify NS1-mutated viruses exhibiting a reduced growth phenotype and/or an altered cell apoptosis profile. We found that NS1 mutations Y171A, K175A (consensus druggable pocket 1), W102A (consensus druggable pocket 3), Q121A and G184P (multiple consensus druggable pockets) - located at hot spots amenable for pharmacological modulation - significantly impaired A(H1N1)pdm09 virus replication, in vitro. This is the first time that NS1-K175A, -W102A, and -Q121A mutations are characterized. Our map-and-mutate strategy provides the basis to establish the NS1 as a promising target using a rationale with a higher resilience to resistance development.

Unlocking COVID therapeutic targets: A structure-based rationale against SARS-CoV-2, SARS-CoV and MERS-CoV Spike.

There are no approved target therapeutics against SARS-CoV-2 or other beta-CoVs. The beta-CoV Spike protein is a promising target considering the critical role in viral infection and pathogenesis and its surface exposed features. We performed a structure-based strategy targeting highly conserved druggable regions resulting from a comprehensive large-scale sequence analysis and structural characterization of Spike domains across SARSr- and MERSr-CoVs. We have disclosed 28 main consensus druggable pockets within the Spike. The RBD and SD1 (S1 subunit); and the CR, HR1 and CH (S2 subunit) represent the most promising conserved druggable regions. Additionally, we have identified 181 new potential hot spot residues for the hSARSr-CoVs and 72 new hot spot residues for the SARSr- and MERSr-CoVs, which have not been described before in the literature. These sites/residues exhibit advantageous structural features for targeted molecular and pharmacological modulation. This study establishes the Spike as a promising anti-CoV target using an approach with a potential higher resilience to resistance development and directed to a broad spectrum of Beta-CoVs, including the new SARS-CoV-2 responsible for COVID-19. This research also provides a structure-based rationale for the design and discovery of chemical inhibitors, antibodies or other therapeutic modalities successfully targeting the Beta-CoV Spike protein.

An update of posterior retroperitoneoscopic adrenalectomy - Case series.

INTRODUCTION: Posterior retroperitoneoscopic adrenalectomy (PRA) has advantages over transperitoneal approach. A second group of 10 patients is analyzed and compared with the first 10 procedures. Conclusions on feasibility, safety and learning curve are taken. MATERIAL AND METHODS: A retrospective analysis of a second group of 10 patients submitted to PRA was conducted. All patients with functioning and non-functioning adrenal tumors <6-8 cm and without features of malignancy were included. A comparison with the previous 10 cases was conducted, and the results of all 20 cases were compared with other surgeons. RESULTS: Pre-operative diagnoses: Conn's syndrome - 8 (80%); Pheochromocytoma - 1 (10%); Non-functioning tumor (≥ 4 cm) - 1 (10%). Mean size of adrenal tumors was 2,9 cm. Mean operative time for first group was 46,7 min and 31,1 min for the second (p = 0,036). Postoperative in-hospital days decreased in the second group (p = 0,01). Conversion rate was equal (10%). Morbidity and mortality were similar. DISCUSSION: Comparing the evolution of operative time in both groups, a constant and faster operative time was noted for the second group and a decreasing linear tendency was noted as more cases were being performed. Postoperative in-hospital days lowered in the second group, because with experience we started discharging patients earlier. Outcomes are stable between both groups. Our results match other authors data. CONCLUSION: These results are consistent with our first report and support the small learning curve for PRA, which is technically feasible and safe. Operative time and in-hospital days are influenced by surgeon's experience. More cases need to be collected so that these results can be validated.

Perineal reconstruction using an inferior gluteal artery perforator flap after abdominoperineal resection.

The abdominoperineal resection is a surgical procedure which implies the removal of rectum, anal canal and the creation of a terminal colostomy. The most frequent complications of this type of surgery are haemorrhage, surgical wound complications, persistent perineal sinus and perineal hernia. Intraoperative haemorrhage or contamination and neoadjuvant radiotherapy are risk factors for the development of perineal complications. Perineal wound infection, with subsequent healing delay, has multifactorial aetiology and its incidence can reach up to 66% according to literature. The prevention of these complications requires adequate surgical technique to avoid or minimise the known risk factors. The treatment of a perineal wound complication depends on the clinical and radiographic findings. When there is no wound resolution in 6 months, it is considered a persistent sinus and treatment will probably require a flap. Several options of surgical treatment are available however, there are no randomised studies to determine which one is the best.

Fournier's Gangrene: 10-Year Experience of a Plastic Surgery and Burns Department at a Tertiary Hospital.

INTRODUCTION: Fournier gangrene is a polymicrobial life threatening infection of perineal subcutaneous soft tissues with its point of origin in urologic, colorectal or skin diseases. Although more frequent in elderly and men, it can affect all genders and age groups. Perianal abscess, diabetes mellitus and Escherichia coli are the most frequent cause, predisposing comorbidity, and microorganism found in tissue culture analysis respectively. The objective of this study was to describe the experience of a Plastic Surgery Department of a tertiary Hospital in reconstructing Fournier's gangrene perineal defects and its detailed demography. MATERIAL AND METHODS: The sample is composed of all patients with Fournier gangrene admitted in the Plastic Surgery and Burns Department. The authors retrospectively collected and analyzed demographic and clinical data during a period of 10 years including gender, age, length of stay, cause, number of debridements, predisposing factors, microbial culture results, surgical reconstructive techniques and its associated complications, additional surgical procedures and outcomes. RESULTS: Fifteen patients were identified: 14 males (93%) and one female (7%); mean age was 66.9 years (range: 46 - 86); mean, length of stay was 46.8 days (range: 20 - 71 days) and mean number of debridements was 3.3 (range: 1 - 4). The most frequent predisposing factor was diabetes mellitus, the major cause was perianal (n = 2) and skin abscess (n = 2). Eight (53.3%) patients had no identifiable source of Fournier gangrene. Various types of reconstructive techniques were employed; and 5 additional surgical interventions (33.3%) were undertaken (one cystostomy, two orchidectomy, two ileostomy); six patients (40%) presented reconstructive technique complications with adequate final outcome. DISCUSSION: In contrast with the literature, where Escherichia coli was the most frequently isolated agent, Staphylococcus aureus was the most frequent microorganism found in tissue biopsy/pus collection analysis. A higher than expected number of patients (n = 8) had no identifiable source of Fournier gangrene. This findings can be explained by the retrospective non-multicentre study limitation, with a potencial source of bias patients that were transferred from other hospitals in advanced stage, without point of origin of Fournier's gangrene identified. CONCLUSION: Early recognition and extensive necrotic tissue debridement, along with prompt and adequate antimicrobial treatment, are the mainstay of Fournier gangrene management, thus reducing morbidity and mortality in these patients. Surgical reconstruction challenges derived from this condition should be addressed by specialized teams due to the risk of dysfunctional sequelae and conspicuous deformities. Taking in account the single-center and retrospective observational character of the present study, these premises require proper validation from a multicenter prospective study.

Introdução: A gangrena de Fournier é uma infeção polimicrobiana potencialmente fatal que afeta os tecidos moles do períneo com ponto de origem em patologias urológicas, coloretais ou cutâneas. Apesar de ser mais frequente no sexo masculino e em idosos, pode afetar ambos os géneros e qualquer idade. O abcesso perianal, a diabetes mellitus e a Escherichia coli são respetivamente a causa, a co-morbilidade e o micro-organismo mais frequentemente encontrados. Este estudo teve como objetivo descrever a experiência de um Serviço de Cirurgia Plástica e Queimados de um Hospital terciário no tratamento e reconstrução de defeitos perineais causados por gangrena de Fournier, disponibilizando detalhes sobre a sua demografia. Material e Métodos: A amostra é constituída por todos os doentes internados no serviço de Cirurgia Plástica e Queimados com o diagnóstico de gangrena de Fournier. Os autores realizaram uma colheita e análise retrospetiva de dados clínicos e demográficos durante um período de 10 anos incluindo género, idade, tempo de internamento, causa, número de desbridamentos, fatores predisponentes, resultados microbiológicos de culturas de pus, técnicas reconstrutivas cirúrgicas e suas complicações, intervenções cirúrgicas adicionais e o resultado final. Resultados: Foram identificados 15 doentes: 14 homens (93%) e uma mulher (7%); a idade média foi 66,9 anos (amplitude: 46 - 86); tempo médio de internamento foi 46,8 dias (amplitude: 20 - 71 dias) e o número médio de desbridamentos foi 3,3 (amplitude: 1 - 4). O fator predisponente mais frequente foi a diabetes mellitus, e as causas mais frequentes o abcesso perianal (n = 2) e o abcesso cutâneo (n = 2). Em oito (53,3%) doentes não foi identificada a causa da gangrena de Fournier. Foram utilizadas várias técnicas reconstrutivas e realizadas conco (33,3%) intervenções cirúrgicas adicionais (uma cistostomia, duas orquidectomias, duas ileostomias); seis doentes (40%) apresentaram complicações de técnicas reconstrutivas com resultado final adequado. Discussão: O micro-organismo mais frequentemente isolado nas culturas de pus foi o Staphylococcus aureus, o que contrasta com a literatura onde a Escherichia coli é o agente mais frequentemente isolado. Foi identificado um número superior ao esperado de doentes sem causa identificável (n = 8) de gangrena de Fournier. Estes achados podem ser explicados pelo facto de se tratar de um estudo retrospetivo multicêntrico, com um potencial viés por existirem doentes que foram transferidos de outras institucões em estado avançado de doença, sem foco de origem de gangrena de Fournier identificado. Conclusão: O precoce reconhecimento e extenso desbridamento do tecido necrosado, em conjunto com um adequado tratamento antibiótico, são os pilares do tratamento da gangrena de Fournier reduzindo assim a morbilidade e mortalidade destes doentes. Os desafios cirúrgicos reconstrutivos que advêm desta patologia devem ser abordados por uma equipa especializada, pelo risco de sequelas funcionais e estéticas. Tendo em conta o carater observacional, retrospetivo e unicêntrico do presente estudo, estas premissas requerem uma validação adequada através de um estudo prospetivo e multicêntrico.

To hit or not to hit: Large-scale sequence analysis and structure characterization of influenza A NS1 unlocks new antiviral target potential.

Influenza NS1 protein is among the most promising novel druggable anti-influenza target, based on its structure; multiple interactions; and global function in influenza replication and pathogenesis. Notwithstanding, drug development guidance based on NS1 structural biology is lacking. Here, we design a promising strategy directed to highly conserved druggable regions as a result of an exhaustive large-scale sequence analysis and structure characterization of NS1 protein across human-infecting influenza A subtypes, over the past 100 years. We have identified 3 druggable pockets and 8 new potential hot spot residues in the NS1 protein, not described before, additionally to other 16 sites previously identified, which represent attractive targets for pharmacological modulation. This study provides a rationale towards structure-function studies of NS1 druggable sites, which have the potential to accelerate the NS1 target validation. This research also contributes to a deeper comprehension and insight into the evolutionary dynamics of influenza A NS1 protein.

Multiple isolated small bowel perforations following blunt abdominal trauma.

INTRODUCTION: Small bowel injury is uncommon after blunt abdominal trauma. Repeated clinical assessment is important, especially when investigative imaging is negative. CASE PRESENTATION: 39-year-old male presented to the emergency department following a blunt abdominal trauma. No initial hemodynamic abnormalities were found. Abdominal CT scan was negative for small bowel perforation. Repeated clinical assessment revealed increasing abdominal pain with tachycardia, and an emergent laparotomy was undertaken. Four grade II and one grade I small bowel perforations were found, all repaired with interrupted sutures. Patient was discharged home on day 7. DISCUSSION/CONCLUSION: The diagnosis of small bowel injury is difficult and a low threshold of suspicion is crucial to reduce morbidity and mortality. Hemodynamic instability or abdominal tenderness after blunt abdominal trauma are indications for immediate surgical exploration, despite negative imaging findings. Serial clinical assessment is the main decision tool to perform an abdominal exploration.

Rare case of symmetrical peripheral gangrene due to septic shock, disseminated intravascular coagulation and inotropic use.

INTRODUCTION: Symmetrical peripheral gangrene (SPG) is a rare syndrome defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease. PRESENTATION OF CASE: A 45yo woman, admitted in intensive care unit due to urinary septic shock, in need of high doses of amines, developed cold extremities with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, liver shock, thrombocytopenia, prolonged coagulation times, increased D-Dimers and isolation of Acinetobacter baumanni in urine culture. An intravenous vasodilator was initiated with clinical benefits. After improvement and delimitation of the lesions, the patient underwent the amputation of the distal phalanges of the 2nd, 3rd and 4th fingers of the right hand and the toes of both feet. DISCUSSION/CONCLUSION: Even though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasodilators are used, in order to avoid major amputation.

Posterior retroperitoneoscopic adrenalectomy-Case series.

INTRODUCTION: Posterior retroperitoneoscopic adrenalectomy has advantages over transperitoneal technique. However many surgeons prefer the transperitoneal technique because they get a familiar and wider working space. MATERIAL AND METHODS: A retrospective analysis of the first 10 patients submitted to posterior retroperitoneoscopic adrenalectomy was conducted. Data collected included: diagnosis, size, operation time, blood loss, conversion rate, morbidity and mortality, in-hospital length of stay. Compare our outcomes with worldwide bigger series, and take conclusions on the feasibility of the technique was the objective. RESULTS: We included 2 pheochromocytomas, 1 giant cystic pheochromocytoma, 4 Conn's, 2 Cushing's, 1 non-functioning tumor with 4 cm. Mean operation time was 46,7 min for lesions ranging from 1,8 to 14 cm. Blood loss was negligible. One patient (10%) was converted to laparotomy because of a past clinical history of dorsal and lumbar trauma. No morbidity and no mortality. Mean hospital length of stay was 2,2 days. DISCUSSION: Mean operation time found in bigger series published in worldwide literature is 40-105,6 min. Complication rate reported ranges from 0 to 14,4%. No mortality has been ever reported. Blood loss reported in other series is 10-50 ml. The data found in our study matches other studies data. Since the same surgeon who had never performed the technique before operated all patients, makes us believe the technique is safe and feasible. CONCLUSION: Posterior retroperitoneoscopic adrenalectomy has a small learning curve. It is technically safe and feasible. More patients will be collected to validate these results.

Oral and dental anomalies in purebred, brachycephalic Persian and Exotic cats.

OBJECTIVE To determine the prevalence of dental anomalies in brachycephalic cats from various geographic regions and analyze potential relationships with oral disease. DESIGN Prospective multicenter cross-sectional study. ANIMALS 50 purebred Persian (n = 42) and Exotic (8) cats. PROCEDURES Cats were anesthetized, and a complete dental examination, dental charting, 3-view oral photography, and full-mouth dental radiography were performed. RESULTS Malocclusions were observed in 36 (72%) cats. Crowding of the teeth was evident in 28 (56%) cats, with the incisors being most commonly affected. Malpositioned teeth were noted in 32 (64%) cats, with abnormal orientation being the most common anomaly followed by rotation and impaction. Numerical abnormalities were present in 38 (76%) cats, including 6 (12%) with hyperdontia and 32 (64%) with hypodontia. Periodontal disease was reported in 44 (88%) cats, and cats with periodontal disease were older than cats without. Tooth resorption was evident in 35 (70%) cats. Overall, 123 of 1,349 (8.7%) teeth had external inflammatory resorption and 82 (6.1%) had external replacement resorption. The premolar teeth were the teeth most commonly affected with inflammatory resorption, whereas the canine teeth were the teeth most commonly affected with replacement resorption. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that because of their brachycephaly, Persian and Exotic cats have unique oral and dental features that may predispose them to dental disease (eg, tooth resorption and periodontal disease). Knowledge of the particular dental anomalies common in brachycephalic cats could aid in early detection and mitigation of dental disease in these breeds.

Rare case of hepatic haematoma following endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly used diagnostic and therapeutic technique but it is not free of complications. Subcapsular hepatic haematoma is a rare but potentially fatal complication. A 71-years-old male patient resorted to the emergency department 36 hours after an uneventful ERCP presenting with severe abdominal pain and haemoglobin drop. Abdominal ultrasound and CT scan diagnosed a subcapsular hepatic haematoma. The patient was haemodynamically normal and was successfully treated with a conservative management. Signs and symptoms of hepatic haematoma following ERCP are non-specific. The most common symptom is abdominal pain. Abdominal CT, ultrasound or MRI make the diagnosis. Conservative management is possible if the patient is stable, nevertheless invasive treatment such as surgery or angiographic embolisation, may be required. A low threshold of suspicion is crucial for an early diagnosis and treatment. Fatal cases have been described but most patients have a favourable outcome.

Increase body weight to treat superior mesenteric artery syndrome.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction resulting from vascular compression of the third part of the duodenum in the angle between the abdominal aorta and SMA. CASE PRESENTATION: A 19-year-old woman with anorexia nervosa with upper gastrointestinal obstruction symptoms resorted to the emergency department. A diagnosis of SMA syndrome was made. Symptoms were solved with conservative treatment aimed at increase body weight. DISCUSSION: SMA syndrome is most commonly associated with debilitating illnesses. Patients present with acute or insidious upper gastrointestinal obstruction symptoms. Aortomesenteric artery angle of ≤25° is the most sensitive measure of diagnosis. Advances in both enteral and parenteral nutrition led to a shift towards conservative treatment. CONCLUSIONS: Low threshold of suspicion is important to make a timely diagnosis and treatment. A conservative treatment aimed at increasing body weight is the first-line approach, leaving surgical intervention for failure cases.

Reverse genetics vaccine seeds for influenza: Proof of concept in the source of PB1 as a determinant factor in virus growth and antigen yield.

Growth deficits of reverse genetics vaccine seeds have compromised effective immunization. The impairment has been attributed to sub-optimal protein interactions. Some level of dependence may exist between PB1 and antigenic glycoproteins, however, further research is necessary to clarify the extent to which it can be used in favor of seed production. Our objective was to establish proof of concept on the phenotypic outcome of PB1 source in the PR8: A(H1N1)pdm09 reassortants. Reassortants were generated with the gene constellation of the classical 6:2 PR8: HA, NApdm09 seed prototype and the 5:3 reassortant PR8: HA, NA, PB1pdm09. Viral growth and antigen yield were evaluated 12-60h post-infection. The 5:3 reassortant presented statistically significant growth and antigen yield improvements when compared to the 6:2. We believe these findings to be of promising value to vaccine research towards an improvement of reverse genetic seeds, an overall more cost-effective vaccine manufacture and timely delivery.