Tuberculosis de tobillo. A propósito de un caso en la infancia / Ankle tuberculosis. A case in childhood

La tuberculosis osteoarticular del tobillo es una presentación infrecuente de la tuberculosis ósea (10% de los casos). La baja frecuencia de presentación y la clínica inespecífica hace que sea habitual el retraso en el diagnóstico y en el tratamiento. El estudio radiológico es normal en fases iniciales, y la analítica no muestra alteraciones características. La TAC y la RM son útiles en el diagnóstico. La quimioterapia es la base del tratamiento, y la cirugía puede ser necesaria para obtener el diagnóstico y como parte del tratamiento. Presentamos el caso una niña de 22 meses afecta de tuberculosis de tobillo. El diagnóstico se confirmó mediante biopsia sinovial. No hubo antecedentes de contacto personales ni familiares con enfermos de tuberculosis. No existía ningún factor de riesgo para la enfermedad. No tuvo foco pulmonar. El diagnóstico fue tardío (un año tras el inicio de la clínica). El tratamiento fue médico (tuberculostáticos) y precisó cirugía para evitar actitud en equino y un mayor deterioro articular. El resultado clínico y funcional fue bueno tras un seguimiento de 20 años (AU)

Articular tuberculosis of the ankle joint is a rare presentation of skeletal tuberculosis (10% of cases). This unusual location and the low index of clinical suspicion leads to delays in diagnosis and treatment. Radiographic and analytic studies are unspecific in the first stage. CAT and MRI are useful in diagnosis. Chemotherapy is the mainstay of treatment and surgery is often required to establish the diagnosis and in the treatment. We report a case of ankle tuberculosis in a 22 month-old child. The diagnosis was confirmed by synovial biopsy. There was no patient or family contact with tuberculosis patients. There was no risk factor. There was no lung disease. Diagnosis was made 1 year after onset of symptoms. The treatment was with chemotherapy and surgery was performed as preventive treatment of equinus deformity and osteoarthritis. Good clinical and functional outcome was achieved after 20 years of follow up (AU)

Ankle tuberculosis. A case in childhood. / Tuberculosis de tobillo. A propósito de un caso en la infancia.

Articular tuberculosis of the ankle joint is a rare presentation of skeletal tuberculosis (10% of cases). This unusual location and the low index of clinical suspicion leads to delays in diagnosis and treatment. Radiographic and analytic studies are unspecific in the first stage. CAT and MRI are useful in diagnosis. Chemotherapy is the mainstay of treatment and surgery is often required to establish the diagnosis and in the treatment. We report a case of ankle tuberculosis in a 22 month-old child. The diagnosis was confirmed by synovial biopsy. There was no patient or family contact with tuberculosis patients. There was no risk factor. There was no lung disease. Diagnosis was made 1 year after onset of symptoms. The treatment was with chemotherapy and surgery was performed as preventive treatment of equinus deformity and osteoarthritis. Good clinical and functional outcome was achieved after 20 years of follow up.

[Positive impact on the Expanded Program on Immunization when sending call-back SMS through a Computerized Immunization Register, Bobo Dioulasso (Burkina Faso)]. / Impact positif sur le Programme élargi de vaccinations de l'envoi de SMS de rappel à partir d'un registre informatisé, Bobo-Dioulasso (Burkina Faso).

The impact of a Computerized Immunization Register (CIR) on Expanded Program on Immunization (EPI), with sending SMS to parents before immunization sessions, has never been studied in sub-Saharan Africa. The objective of this study is to measure EPI quickness and completeness of vaccinations after sending call-back SMS to parents through CIR put in place in a health center. In a health center, chosen at random (Colma 1) in the city of Bobo Dioulasso, Burkina Faso, West Africa, mothers, at first EPI session, if they had a mobile phone available at hand or in her surrounding, were randomized for receiving, or not, a call-back SMS before following EPI sessions, after child registration on a Francophone CIR (Siloxane's Intervax ©). Mothers, which were sent SMS and did not correctly followed sessions were asked through mobile phone why their child was late for EPI. 523 newborns were included in the study, with 253 whose parents were sent SMS, and 268 being informed of sessions only by ordinary methods. At second EPI session at 2 months of age, there was a statistical significant increase of coverage for children whose parents received SMS (p<0.001). Quickness to come also to this session was significantly shorter when parents received SMS (p=0.03). At third EPI session at 3 months of age, attendance to EPI for children whose parents were sent SMS was significantly better (p<0.001). Quickness to come to this session was shorter for children with SMS (p=0.02). At fourth EPI session at 4 months of age, attendance for children with SMS was significantly better for children whose parents were sent SMS (p<0.001). Quickness to come to this session was better but not significantly different (p=0.49). Out of 101 children registered as late for EPI sessions in Colma 1 CIR, even with call-back SMS, 19 (19%) parents could not be reached on the telephone. 31/82 (38%) mothers had shifted for EPI to a more proximate vaccination center (Colma 2), and 5 (6%) to private or civil servants clinic. 14/82 (17%) mothers had been travelling far from health center. Ten (12%) admitted neglect of EPI sessions. Two (2%) children had deceased, and one mother did not come back to Colma 1 after her child's AEFI. One child has been dismissed two times of vaccination following recommendation not to open a measles multi-dose vial for a single child, and did not come back. Of 523 children registered in CIR, 77 (14.7%) could not be found in the paper registers of Colma 1. Quickness and completeness for EPI is increased by sending SMS with help of CIR. An official number should be given for each child registered in CIR, consulted by health staff admitting children in urgency, allowing EPI vaccinations completion. With CIR safeguards, CIR should replace paper registers and should be used to send EPI reports by internet at central levels, helping MOH coverage determination and MAPI surveillance. The fall of coverage due to restriction policy not to open a multidose vial for a single child is low. Health staff should institute telephone call-back for badly immunized children registered on CIR and incorporate in it, with SMS call-back, pregnant women, to better complete prenatal sessions and tetanus vaccination.

gLISA: geosynchronous laser interferometer space antenna concepts with off-the-shelf satellites.

We discuss two geosynchronous gravitational wave (GW) mission concepts, which we generically name gLISA. One relies on the science instrument hosting program onboard geostationary commercial satellites, while the other takes advantage of recent developments in the aerospace industry that result in dramatic satellite and launching vehicle cost reductions for a dedicated geosynchronous mission. To achieve the required level of disturbance free-fall onboard these large and heavy platforms, we propose a new drag-free system, which we have named "two-stage" drag-free. It incorporates the Modular Gravitational Reference Sensor (developed at Stanford University) and does not rely on the use of µN thrusters. Although both mission concepts are characterized by different technical and programmatic challenges, individually they could be flown and operated at a cost significantly lower than those of previously envisioned gravitational wave missions, and in the year 2015 we will perform at JPL a detailed selecting mission analysis.

Prognostic implications of evaluation of contractile reserve in akinetic and hypokinetic segments during low dose dobutamine echocardiography in patients with acute myocardial infarction.

BACKGROUND: Previous studies have reported the prognostic value of myocardial viability (MV) detected using low-dose dobutamine echocardiography (DbE). However, viability was frequently evaluated as improvement in regional wall motion score index, which includes increased function in hypokinetic segments, in which viable myocardium is necessarily present. It is not known whether an evaluation focusing on akinetic segments, in which the possible presence of viable myocardium is unknown, might have more prognostic value. The aim of this study was to compare the prognostic value of the improvement of myocardial function during dobutamine infusion in akinetic and hypokinetic regions in patients with acute myocardial infarction (AMI). METHODS: 191 patients with uncomplicated AMI and at least one akinetic segment were retrospectively selected from those consecutively examined at our echo-laboratory to evaluate MV using DbE. Myocardial viability was evaluated both as an increment in RWMSI (Delta RWMSI), which takes into consideration improvement in both akinetic and hypokinetic regions, and as an improvement of function in akinetic (Delta akinetic) and hypokinetic (Delta hypokinetic), segments considered separately. Follow-up evaluation was performed at 30+/-13 months. RESULTS: On the basis of the Delta RWMSI, 94/191 patients were judged to have myocardial viability, whereas considering myocardial viability in akinetic segments only, 72/191 patients showed viability. At follow-up 18 patients had died (six viable considering Delta RWMSI; three viable considering Delta akinetic). The presence of a previous AMI, the site of AMI, RWMSI and the number of akinetic segments, and Delta RWMSI and Delta akinetic were related to mortality at univariate Cox analysis. At multivariate stepwise Cox regression analysis Delta akinetic, but not Delta hypokinetic proved to be significantly related to mortality. The Kaplan-Meier survival curves were no different in patients with or without viable myocardium evaluated as Delta RWMSI, while they were significantly different considering patients with or without viability in akinetic segments (P=0.04). CONCLUSION: In conclusion our study confirms the prognostic importance of the evaluation of myocardial viability in infarcted patients. However, it points out that it is the presence of viability in akinetic segments that affects long-term survival in these patients. This supports the hypothesis that other mechanisms, above and beyond the effect on regional wall motion, are involved in the beneficial effects of myocardial viability.

Relationship between mitral regurgitation and myocardial viability after acute myocardial infarction: their impact on prognosis.

Mitral regurgitation (MR) after acute myocardial infarction (AMI) is an important prognostic factor. Although its mechanisms are still debated, ventricular remodeling probably plays an important role. Because myocardial viability (MV) in the infarct zone reduces infarct expansion and ventricular remodeling, it is also possible that its presence counteracts the development of mitral regurgitation in infarcted patients. To evaluate this issue 191 patients with uncomplicated AMI, wall motion abnormalities (akinesis) and semiquantitative evaluation of MR were retrospectively selected from those consecutively examined at our echo-laboratory to evaluate MV using low-dose dobutamine echocardiography (DbE). Follow-up evaluation was performed at 30+/-13 months. Seventy-nine patients had no MR; 86 patients had grade 1 MR, 11 patients had grade 2 MR, nine patients had grade 3 MR, and six patients had grade 4 MR. Patients with significant MR (>grade 1) were older (63+/-7 vs. 59+/-10 years, P=0.03), had lower reduction of RWMSI (DeltaRWMSI) during DbE (0.08+/-0.11 vs. 0.22+/-0.28, P=0.01), more stenotic vessels at coronary angiography (2.35+/-0.93 vs. 1.67+/-1.12, P=0.01), and more frequently had anterior-inferior AMI (P<0.0001); they also had a non-significant tendency to higher RWMSI (2.04+/-0.38 vs. 1.92+/-0.28, P=0.06). In a multivariate regression analysis, DeltaRWMSI proved to be significantly related to the grade of MR (P=0.02). Eighteen patients died during follow-up. Death was more frequent in patients with MR (10/165 vs. 8/26, P=0.0003). At multivariate stepwise Cox regression analysis both the extent of ventricular dysfunction and the presence of MR were significantly related to mortality (P<0.0001 and P=0.01, respectively); DeltaRWMSI showed a non-significant tendency to influence mortality (P=0.09). When MR was excluded from the multivariate analysis, DeltaRWMSI remained significantly related to mortality (P=0.05). In conclusion our study suggests that the presence of MV in infarcted patients influences the development of MR. This reduction of MR may be one of the mechanisms by which MV affects mortality after AMI and should be considered in all studies that evaluate MV after myocardial infarction.

Long-term prognostic value of the stenosis of the infarct-related artery and the presence of viable myocardium in akinetic ventricular regions in infarcted patients.

BACKGROUND: Recent studies have reported that adequate perfusion of the infarct-related artery improves survival in patients with myocardial infarction, independently of left ventricular pump function. However, it is not known whether or not this reduction in mortality is independent of myocardial viability within the infarct zone. The aim of this study was to evaluate the prognostic value of the patency of the infarct artery and the presence of myocardial viability in akinetic regions in patients with myocardial infarction. METHODS: Low-dose dobutamine echocardiography was performed in 154 patients with recent or previous myocardial infarction and known coronary anatomy. In each patient three vascular regions were defined. Each akinetic region was considered viable if function improved during dobutamine echocardiography, and irrorated by a not stenotic akinetic area-related artery if the supplying vessel had a stenosis < 75% or had been successfully revascularized within 1 month of dobutamine echocardiography. RESULTS: At follow-up of 34 +/- 14 months, 19 patients died of cardiac death. At univariate Cox analysis end-diastolic and end-systolic volumes, ejection fraction, previous myocardial infarction, regional wall motion score index, and stenosis of the akinetic area-related artery were related to mortality. At multivariate analysis, stenosis of the akinetic area-related artery remained a significant predictor of mortality (p = 0.04), with higher mortality (13/66 vs 6/88, p = 0.02) in patients with a stenotic akinetic area-related artery, without differences in ejection fraction (35 +/- 9 vs 34 +/- 10%). Mortality was lower in patients with myocardial viability if they had a not stenotic akinetic area-related artery (1/43 vs 4/21, p = 0.02), while no difference was found among non-viable patients, with or without stenosis of the akinetic area-related artery (5/45 vs 9/45). CONCLUSIONS: The present study confirms the prognostic role of the patency of the infarct-related artery. However, it suggests that the lower mortality in patients with a patent artery supplying akinetic infarcted regions is related to the presence of myocardial viability in these regions.

Prognostic value of detection of myocardial viability using low-dose dobutamine echocardiography in infarcted patients.

Revascularization can improve ventricular function in patients with viable myocardium, but whether and how the presence of viable myocardium affects prognosis of infarcted patients is still far from clear. Thus, 202 patients (173 men, 59 +/- 9 years old) with a previous or recent myocardial infarction (MI) and regional asynergies underwent low-dose dobutamine echocardiography (5-15 microg/kg per min) to assess myocardial viability and were followed for a period of 16 +/- 11 months after revascularization (89 patients) or medical therapy (113 patients). Four groups of patients were defined: (1) patients with viability, revascularized (n = 64); (2) patients with viability, treated medically (n = 52); (3) patients without viability, revascularized (n = 25); and (4) patients without viability, treated medically (n = 61). Of these patients, 45 (23%) patients suffered 57 cardiac events: 18 cardiac deaths (9%), 7 MIs, 12 unstable angina, 9 heart failures, and 11 new revascularization procedures. Patients with viability, revascularized, experienced a slightly lower event rate (22%) compared with patients with viability, treated medically, patients without viability, treated medically and patients without viability, revascularized (29%, 31%, and 36%, respectively; p = not significant [NS]). The frequency of events was then evaluated in those 108 patients with an ejection fraction < or =33%, in whom 14 cardiac deaths occurred: the incidence of cardiac death was slightly lower in patients with viability, revascularized (3/37, 8%) than in the patients with viability, treated medically (4/26, 15%), patients without viability, revascularized (2/11, 18%), or patients without viability, treated medically (5/34, 15%) (p = NS). Nonfatal cardiac events were significantly fewer (p <0.05) in patients with viability, revascularized (8%) and in patients without viability, treated medically (6%) than in patients with viability, treated medically and patients without viability, revascularized (27%). In infarcted patients with severe left ventricular dysfunction, the presence of viable myocardium, if left unrevascularized, leads to further events. On the contrary, in the absence of myocardial viability, revascularization could lead to a worse prognosis than medical therapy.

Spectroscopic studies of the met form of the extracellular hemoglobin from Glossoscolex paulistus.

Sephadex G-200 chromatography of the extracellular hemoglobin from the giant earthworm G. paulistus in the met form presents a single peak at pH 7.0 and two peaks at pH 9.0 as a result of alkaline dissociation. SDS-PAGE shows that the polypeptide chains are very similar to those observed for the oxy form and the two peaks at pH 9.0 correspond to the trimer contaminated by linkers and monomers which seems to be quite pure. The aquomet acid form is stable as an oligomer of molecular mass 3.1 x 10(6) Da only in a narrow pH range around neutrality. Increasing the pH above 7.5 leads to an irreversible transition from aquomet to hemichrome I which is the low-spin bis-imidazole complex. At pHs above 9.5-10.0 a second reversible transition takes place from hemichrome I to hemichrome II, a high-spin complex which is associated with the weakening and possible disruption of the proximal Fe--N histidine bond. Thus, increase in pH above 8.0 induces changes in the heme pocket that involve both the distal and proximal sides of the heme. EPR measurements show a very sharp decrease of the aquomet high-spin signal in the range of pH 7.0-8.0 and a very small low-spin signal even at liquid helium temperatures. The transition to hemichrome I is also accompanied by the loss of heme optical activity monitored by CD, which is consistent with the weakening of heme--globin interaction. Hemichrome I in the presence of cyanide gives the typical cyanometHb derivative which has a transition to a hemichrome at much higher pHs. This observation suggests that the dissociation of the oligomer in alkaline medium as well as the stability of the heme on the proximal side, depend both upon the ligand present at the sixth coordination position on the distal side. Hence, we believe that hemi(hemo)chrome formation in G. paulistus Hb and other invertebrate hemoglobins is a common phenomenon, not associated with protein denaturation, which may provide a fine tuning mechanism to control subunit interactions through changes in the distal side of the heme pocket.

An ESR study of pathologic red blood cell membranes (RBCM).

A comparative study of red blood cell membranes from normal subjects and beta-thalassemia and sickle cell anemia patients was performed by spin labeling at the lipidic and protein phase. The results show that the quantity of bound spin label is the same for sickle, thalassemic, and normal membranes. The data from 5-doxyl stearic acid suggest an increase in fluidity for the thalassemic membrane.

Characterization of protein spin labeling by maleimide: evidence for nitroxide reduction.

A quantitative determination of maleimide spin label (MAL) binding in oxi and met hemoglobin (Hb) and bovine serum albumin are investigated using double integration to the ESR signal. This determination permitted the observation that a considerable fraction of MAL is reduced, losing its paramagnetism. Experiments using the same spin label with myoglobin and Hb with blocked-SH groups, where reduction was not observed, indicate the involvement of SH groups in the process. The 4-hydroxy-2,2,6,6-tetramethylpiperidino-1-oxyl spin label (which is not able to bind in the SH group) is reduced too, but the dependence on the molar ratio is different in comparison with the MAL case. In both cases the reduction percentage depends on the molar ratio spin label to protein and to the protein concentration. In order to obtain the total SH groups labeled (two in the Hb case) it is necessary to use an excessive amount of label (around 18:1) in the 0.5 mM Hb concentration.