Acretismo placentario en gestaciones tempranas. Presentación de un caso / Placental accreta in early pregnancies. Case presentation

El acretismo placentario es la invasión de las vellosidades coriales al miometrio, siendo mayor el riesgo de presentarse en casos de placenta previa o antecedente de una o más cesáreas, causando hemorragia obstétrica mayoritariamente durante el tercer trimestre. Se presenta el caso de una paciente de 39 años de edad, con hemorragia obstétrica secundaria a acretismo placentario, en un embarazo de 19 semanas resuelto mediante histerectomía, con lo que se hace énfasis en la importancia de la sospecha y diagnóstico de acretismo en embarazos tempranos, ofreciendo así un tratamiento oportuno y disminución de la morbimortalidad materna.(AU)

Placental accreta is the invasion of the chorionic villi into the myometrium. It has a higher risk of occurring in cases of placenta previa, or a history of one or more caesarean sections, causing obstetric haemorrhage mainly during the third trimester. The case is presented of a 39-year-old patient with obstetric haemorrhage secondary to placental accreta in a 19-week pregnancy. It was resolved by hysterectomy. The importance of suspicion and diagnosis of accreta in early pregnancies is emphasised, as well as offering a timely treatment and reducing the maternal morbidity and mortality.(AU)

Development of a Luminex-Based DIVA Assay for Serological Detection of African Horse Sickness Virus in Horses.

African horse sickness (AHS) is considered a fatal re-emergent vector-borne disease of horses. In the absence of any effective treatment for AHS, vaccination remains the most effective form of disease control. The new generation of vaccines, such as one based on purified, inactivated AHS virus (AHSV, serotype 4), which does not induce antibodies against non-structural protein 3 (NS3), enables the development of diagnostic methods that differentiate infected from vaccinated animals (DIVA assays). As detecting AHS in AHSV-free countries may lead to restrictions on international animal movements and thereby cause significant economic damage, these DIVA assays are crucial for reducing movement restrictions. In this article, we describe a Luminex-based multiplex assay for DIVA diagnosis of AHS, and we validate it in a duplex format to detect antibodies against structural protein 7 (VP7) and NS3 in serum samples from horses vaccinated with inactivated AHSV4 vaccine or infected with a live virus of the same serotype. Results of the Luminex-based assay for detecting anti-NS3 antibodies showed good positive correlation with results from an in-house enzyme-linked immunosorbent assay (ELISA). Thus, the Luminex-based technique described here may allow multiplex DIVA antibody detection in a single sample in less than 2 h, and it may prove adaptable for the development of robust, multiplex serological assays.

Identification of Suitable Areas for African Horse Sickness Virus Infections in Spanish Equine Populations.

African horse sickness (AHS) is one of the most important vector-borne viral infectious diseases of equines, transmitted mainly by Culicoides spp. The re-emergence of Culicoides-borne diseases in Europe, such as the recent bluetongue (BT) or Schmallenberg outbreaks, has raised concern about the potential re-introduction and further spread of AHS virus (AHSV) in Europe. Spain has one of the largest European equine populations. In addition, its geographical, environmental and entomological conditions favour AHSV infections, as shown by the historical outbreaks in the 1990s. The establishment of risk-based surveillance strategies would allow the early detection and rapid control of any potential AHSV outbreak. This study aimed to identify the areas and time periods that are suitable or at high risk for AHS occurrence in Spain using a GIS-based multicriteria decision framework. Specifically risk maps for AHS occurrence were produced using a weighted linear combination of the main risk factors of disease, namely extrinsic incubation period, equine density and distribution of competent Culicoides populations. Model results revealed that the south-western and north-central areas of Spain and the Balearic Islands are the areas at the highest risk for AHSV infections, particularly in late summer months. Conversely, Galicia, Castile and Leon and La Rioja can be considered as low-risk regions. This result was validated with historical AHS and BT outbreaks in Spain, and with the Culicoides vector distribution area. The model results, together with current Spanish equine production features, should provide the foundations to design risk-based and more cost-effective surveillance strategies for the early detection and rapid control potential of AHS outbreaks in Spain.

Development of a Microsphere-based Immunoassay for Serological Detection of African Horse Sickness Virus and Comparison with Other Diagnostic Techniques.

African horse sickness (AHS) is a viral disease that causes high morbidity and mortality rates in susceptible Equidae and therefore significant economic losses. More rapid, sensitive and specific assays are required by diagnostic laboratories to support effective surveillance programmes. A novel microsphere-based immunoassay (Luminex assay) in which beads are coated with recombinant AHS virus (AHSV) structural protein 7 (VP7) has been developed for serological detection of antibodies against VP7 of any AHSV serotype. The performance of this assay was compared with that of a commercial enzyme-linked immunosorbent assay (ELISA) and commercial lateral flow assay (LFA) on a large panel of serum samples from uninfected horses (n = 92), from a reference library of all AHSV serotypes (n = 9), on samples from horses experimentally infected with AHSV (n = 114), and on samples from West African horses suspected of having AHS (n = 85). The Luminex assay gave the same negative results as ELISA when used to test the samples from uninfected horses. Both assays detected antibodies to all nine AHSV serotypes. In contrast, the Luminex assay detected a higher rate of anti-VP7 positivity in the West African field samples than did ELISA or LFA. The Luminex assay detected anti-VP7 positivity in experimentally infected horses at 7 days post-infection, compared to 13 days for ELISA. This novel immunoassay provides a platform for developing multiplex assays, in which the presence of antibodies against multiple ASHV antigens can be detected simultaneously. This would be useful for serotyping or for differentiating infected from vaccinated animals.

Systematic review of surveillance systems and methods for early detection of exotic, new and re-emerging diseases in animal populations.

In this globalized world, the spread of new, exotic and re-emerging diseases has become one of the most important threats to animal production and public health. This systematic review analyses conventional and novel early detection methods applied to surveillance. In all, 125 scientific documents were considered for this study. Exotic (n = 49) and re-emerging (n = 27) diseases constituted the most frequently represented health threats. In addition, the majority of studies were related to zoonoses (n = 66). The approaches found in the review could be divided in surveillance modalities, both active (n = 23) and passive (n = 5); and tools and methodologies that support surveillance activities (n = 57). Combinations of surveillance modalities and tools (n = 40) were also found. Risk-based approaches were very common (n = 60), especially in the papers describing tools and methodologies (n = 50). The main applications, benefits and limitations of each approach were extracted from the papers. This information will be very useful for informing the development of tools to facilitate the design of cost-effective surveillance strategies. Thus, the current literature review provides key information about the advantages, disadvantages, limitations and potential application of methodologies for the early detection of new, exotic and re-emerging diseases.

Consistency of response and image recognition, pulmonary nodules.

OBJECTIVE: To investigate the effect of recognition of a previously encountered radiograph on consistency of response in localized pulmonary nodules. METHODS: 13 radiologists interpreted 40 radiographs each to locate pulmonary nodules. A few days later, they again interpreted 40 radiographs. Half of the images in the second set were new. We asked the radiologists whether each image had been in the first set. We used Fisher's exact test and Kruskal-Wallis test to evaluate the correlation between recognition of an image and consistency in its interpretation. We evaluated the data using all possible recognition levels-definitely, probably or possibly included vs definitely, probably or possibly not included by collapsing the recognition levels into two and by eliminating the "possibly included" and "possibly not included" scores. RESULTS: With all but one of six methods of looking at the data, there was no significant correlation between consistency in interpretation and recognition of the image. When the possibly included and possibly not included scores were eliminated, there was a borderline statistical significance (p = 0.04) with slightly greater consistency in interpretation of recognized than that of non-recognized images. CONCLUSION: We found no convincing evidence that radiologists' recognition of images in an observer performance study affects their interpretation on a second encounter. ADVANCES IN KNOWLEDGE: Conscious recognition of chest radiographs did not result in a greater degree of consistency in the tested interpretation than that in the interpretation of images that were not recognized.

Social network analysis of Equidae movements and its application to risk-based surveillance and to control of spread of potential Equidae diseases.

Movements of animals and animal products are one of the most important ways of disease introduction and spread between regions and countries. Maybe one of the most complex animal species in terms of diversity of uses, nature and extent of movements are equidae, for which animal movement records are usually not available. The study presented here is the first characterization of a complete and reliable network of equidae movements in Castile and Leon, which is one of the most important equidae production regions of Spain. Social network analysis and space-time cluster analysis were used to describe the contact patterns of the equidae network and to identify the most important premises, areas and time periods for potential disease introduction or spread into the region. The studied network was complex, with very heterogeneous types of premises and diverse nature and extent of the movements compared with other livestock species, which have important implications for prevention and control of equidae diseases. Centrality measures revealed that production and reproduction farms and centres of livestock competition were the most important type of premises in the studied network. Cluster analyses allowed to identify seventeen significant spatio-temporal clusters of premises at high risk of dispatching or receiving equidae, which formed four interconnected compartments. These clusters were mainly located in the north-west region and in the second part of the year. The results of this study may be useful to design risk-based surveillance and control programmes of equidae diseases and increase the speed of detection and control of potential secondary outbreaks in future epidemics. Consequently, these results will help to minimize the great economic and sanitary impact of equidae diseases. The analytical approach used here may be easily extended to characterize the equidae movement patterns in other countries and regions of the world.

Development and evaluation of a SYBR Green real-time RT-PCR assay for evaluation of cytokine gene expression in horse.

Cytokine secretion is one of the main mechanisms by which the immune system is regulated in response to pathogens. Therefore, the measurement of cytokine expression is fundamental to characterizing the immune response to infections. Real-time quantitative reverse transcriptase-polymerase chain reaction (RT-qPCR) is widely used to measure cytokine mRNA levels, but assay conditions should be properly evaluated before analyzing important equine infections through relative quantification of gene expression. The aim of this study was to develop and evaluate a set of RT-qPCR assays for a panel of the most common cytokines in horses involved in innate and adaptive immune responses. Eight cytokines (interleukin (IL)-1ß, IL-2, IL-4, IL-10, IL-12, TNFα, IFNß and IFNγ) and a housekeeping gene (ß-actin) were detected and amplified with the same annealing temperature in a SYBR Green RT-qPCR assay of samples of mitogen-stimulated peripheral blood mononuclear cells from a healthy horse and whole blood from a horse infected with African horse sickness virus. The method gave good efficiency for all genes tested, allowing quantification of relative expression levels. These SYBR Green RT-qPCR assays may be useful for examining cytokine gene expression in horses in response to exposure to economically important pathogens.

Laparoscopic and percutaneous radiofrequency ablation of the kidney: acute and chronic porcine study.

OBJECTIVES: The chronic effects of renal radiofrequency ablation are unknown. Herein, we investigate the anatomic and physiologic sequelae of laparoscopic and percutaneous renal radiofrequency ablation in acute and chronic porcine models. METHODS: Our study comprised two phases-an acute phase and a chronic phase. In the acute phase, bilateral laparoscopic renal radiofrequency ablation was performed in 6 animals (12 renal units), which were euthanized immediately after surgery. In the chronic study, bilateral percutaneous renal radiofrequency ablation was performed in 5 animals (10 renal units). One animal each was euthanized at postoperative day 3, 7, 14, 30, and 90. RESULTS: Ultrasound-monitored laparoscopic (n = 12) and percutaneous (n = 10) radiofrequency ablations of the lower pole of the kidney were technically successful in each instance. No intraoperative complications occurred. In the survival experiments, the radiolesions showed gradual spontaneous resorption and ultimate renal autoamputation, while maintaining pelvocalyceal integrity as confirmed by ex vivo retrograde ureteropyelogram. Serum creatinine and hematocrit remained stable in all survival animals. Postoperative complication occurred in 1 chronic animal with nonobstructive small bowel dilation at autopsy. CONCLUSIONS: Laparoscopic and percutaneous renal radiofrequency ablation are technically feasible. The anatomic and physiologic sequelae of renal radiosurgery are favorable. Improved techniques of real-time monitoring of the evolving renal radiolesion are necessary.

Effect of surrogate tolerogenesis on the vascular rejection of pig heart xenografts.

BACKGROUND: Organ xenografts are fulminantly rejected by antibody-mediated vascular rejection. Surrogate tolerogenesis (ST), the induction of tolerance within the donor, is effective with aorta xenografts. This preliminary study assesses the effect of ST on preformed antibodies and rejection of porcine heart xenografts. METHODS: Tolerance to the donor pig was induced by infusing recipient marrow into fetal pigs. Later, pig splenocytes were transfused and heterotopic pig hearts transplanted using chimeric or nonchimeric pigs. Anti-pig antibodies were assessed. RESULTS: With ST alone, xenografts developed cellular rejection at 4-6 days, whereas control grafts developed vascular rejection at 3-4 days (cellular vs. vascular, P<0.03). There was a reduction in preformed antibodies (P<0.03). ST combined with moderate cyclosporine prevented rejection at 9+ and 25 days in sensitized recipients compared with vascular rejection at 0.5-2 days for controls (P<0.07). CONCLUSIONS: ST seems to provide protection against vascular rejection. The cellular rejection seems sensitive to cyclosporine.

Imaging techniques in the evaluation of adenocarcinoma of the pancreas.

Adenocarcinoma of the pancreas is a highly malignant neoplasm that presents late and carries a dismal prognosis. Despite technical advances, the various imaging modalities used to evaluate and stage a pancreatic adenocarcinoma have not had a significant impact on survival rates. This article describes the various imaging modalities used to image and stage an adenocarcinoma of the pancreas and reviews their relative accuracy and limitations in diagnosing and staging this carcinoma. We conclude that for appropriate staging of adenocarcinoma of the pancreas, the combination of a computed axial tomography scan and an endoscopic ultrasound represents an efficient and cost-effective approach.

Color Doppler ultrasound assessment of urethral artery location: potential implication for technique of visual internal urethrotomy.

PURPOSE: We assessed the location of urethral arteries in patients with urethral stricture using color Doppler ultrasound. MATERIALS AND METHODS: We performed 41 color ultrasound studies of the urethra in 33 patients 17 to 76 years old. The linear array transducer was placed on the ventral surface of the penis and perineum to image the urethra and periurethral structures. In addition to evaluating the extent of stricture disease, color Doppler ultrasound determined the location of the urethral arteries at the segment with stricture. RESULTS: The number and site of the urethral arteries vary among individuals. Contrary to the common belief that these arteries are located at the 3 and 9 o'clock positions, we have found that in the bulbous urethra the arteries are at the 1 to 2 o'clock positions in 14% of cases, 3 to 4 in 22%, 5 to 6 in 17%, 7 to 8 in 18%, 9 to 10 in 18% and 11 to 12 in 11%. The arteries may be close to the surface of the urethral lumen, especially in patients who have undergone previous urethral procedures. Preoperative evaluation of urethral artery location may be helpful for preventing arterial bleeding at visual internal urethrotomy. CONCLUSIONS: Color Doppler ultrasound can effectively assess the extent of stricture disease and urethral artery sites. Because the location of the urethral arteries varies among patients, individual preoperative assessment is advisable. Color Doppler ultrasound is currently our imaging method of choice for evaluating strictures of the pendulous and bulbous urethra.

Pre-surgical CT/FEA for craniofacial distraction: I. Methodology, development, and validation of the cranial finite element model.

Recently, surgeons have begun to treat serious congenital craniofacial deformities including craniosynostoses with mechanical devices that gradually distract the skull. As a prospective means of treatment planning for such complex deformities, FE models derived from routine preoperative CT scans (CT/FEA) would provide ideal patient specific engineering analyses. The purpose of this study was to assess the dimensional and predictive accuracy of the CT/FEA process through the development of a 3D model of a dry human calvarium subjected to two-point distraction ex vivo. Comparative skull measurements revealed that CT/FEA construction error did not exceed 1% for transcranial dimensions, and the thickness error did not exceed 8.66% or 0.31 mm. CT/FEA strain predictions for the central region of the skull, between the distraction posts, were not statistically different from homologous gage values at P < 0.05. Peripherally, however, the strain fields were less well behaved and the FE predictions showed only general qualitative agreement with gage recordings.

Staple occlusion of the infrarenal aorta: a videoscopic retroperitoneal approach.

PURPOSE: The purposes of this study were to determine whether available laparoscopic stapling devices could be used to interrupt the diseased human aorta, and to develop a videoscopic technique for retroperitoneal exposure and control of the infrarenal aorta in pigs. Our long-term goal is to develop a minimally invasive approach to the treatment of abdominal aortic aneurysms by exclusion and extraanatomic bypass. METHODS: Ten diseased, formalin-preserved human cadaver aortas underwent stapling using a laparoscopic stapling device. The aortas were then pressurized to superphysiologic levels to assess the integrity of the staple line. Ten swine underwent retroperitoneal video-assisted exploration with control and staple occlusion of the aorta and iliac artery. RESULTS: The staple line was complete and remained intact after pressurization in nine of 10 cadaver aortas, despite the presence of complex calcified disease. One aorta had a 2-mm opening through the staple line. Through the left retroperitoneal approach, the infrarenal aorta and left iliac artery could be dissected and controlled. A modified pledgeted technique used for stapling resulted in hemostasis of the staple line and exclusion of flow without injury to adjacent structures. CONCLUSIONS: The diseased human aorta can be occluded using available laparoscopic staplers. These swine experiments demonstrate the feasibility of the retroperitoneal approach for exclusion of infrarenal aortic aneurysms.

Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination.

OBJECTIVES: Color Doppler ultrasound (CDU) diagnostic criteria for varicoceles are poorly defined, and the role of CDU in diagnosing varicoceles is controversial. The purpose of this study is to assess the diagnostic accuracy of CDU for varicoceles compared to physical examination. METHODS: We prospectively studied 64 patients with CDU and collected the following data: maximum diameter of scrotal veins, the presence of a venous plexus, sum of the diameter of up to six veins of the plexus, and the duration and amplitude of flow change on Valsalva maneuver. To avoid interphysician variation, all patients were examined by one designated senior urologist with the sonographer remaining unaware of the findings. RESULTS: CDU parameters of 127 testis units in 64 patients were analyzed and compared to the physical findings. Fifty-nine testis units were positive and 57 units were negative for varicocele on physical examination. In 11 testis units, results of physical examination were inconclusive regarding the presence of varicocele. The commonly accepted CDU criterion for varicocele (maximal vein diameter of 3 mm or greater) had a sensitivity of 53% and specificity of 91% compared to physical examination. We developed a new scoring system incorporating the maximal venous diameter (score 0 to 3), the presence of a venous plexus and the sum of the diameters of veins in the plexus (score 0 to 3), and the change of flow on Valsalva maneuver (score 0 to 3). Using a total score of 4 or more to define the presence of CDU-positive varicocele, we observed a sensitivity of 93% and a specificity of 85% when compared to physical examination. All moderate to large varicoceles found on physical examination were positive by CDU diagnosis using the scoring system, but the same group had only a 68% positive rate by traditional CDU diagnostic criteria. CONCLUSIONS: Using the proposed new scoring system, CDU has been shown to be a reliable and accurate method of diagnosis for varicoceles compared to the current reference standard physical examination. CDU has the advantages of being able to objectively examine venous plexus and measure blood flow parameters and to be less observer-dependent than physical examination.