Surgery for aortic valve endocarditis: treatment options for aortic abscess.

BACKGROUND: Patients with infective endocarditis show a large diversity of anatomical presentations, which has been a complicating factor for the surgical treatment of this condition, especially in those who develop abscesses in the aortic ring or intracardiac fistulae. For this reason, surgeons have been developing tactical options to repair it. There is consensus around the fact that the removal of infected tissue promotes radical cleaning, and that the outcome of the treatment has been improved by the manufacture of biological glues which facilitate the closure of abscesses and by the creation of new valve replacements. OBJECTIVE: To demonstrate yet one more treatment option for aortic abscess for selected cases: a valved conduit placed in infra-coronary position. METHODS: We employed the technique in three patients: in two of them we employed a valved conduit with a mechanical prosthesis and in one of them a valved conduit with a biological prosthesis. Two patients needed associated procedures such as replacement of mitral valve in one of them and tricuspid valvoplasty in the other. All cases involved reoperation of prostheses in aortic position. RESULTS: The progression during surgery and in the early postoperative period was satisfactory and the three patients were discharged from the Intensive Care Unit and were sent to hospital rooms. One of the patients progressed to death during hospital stay due to severe comorbidities which were present in the preoperative period, and which related to esophageal varices and hepatic involvement. The other two progressed well in the late postoperative period. CONCLUSION: We believe that this option is yet one more alternative for the treatment of abscesses with great involvement of aortic ring structures and mitro-aortic continuity.

Cirurgia da endocardite em valva aórtica: opção para tratamento de abscesso aórtico / Surgery for Aortic Valve endocarditis: treatment options for aortic abscess

FUNDAMENTO: A grande diversidade de apresentações anatômicas encontradas em pacientes com endocardite infecciosa, especialmente nos que desenvolvem abscessos do anel aórtico ou fistulas intracardíacas, tem sido um complicador para o tratamento cirúrgico dessa doença. Por esse motivo, os cirurgiões têm desenvolvido opções táticas para sua correção. A consciência geral de que a retirada do tecido infectado promove uma limpeza radical, o aparecimento de colas biológicas que facilitam o fechamento dos abscessos e o surgimento de novos substitutos valvares melhoraram o resultado do tratamento. OBJETIVO: Demonstrar mais uma opção no tratamento do abscesso aórtico, para casos selecionados, tubo valvulado em posição infra-coronariana. MÉTODOS: Empreendemos a técnica em três pacientes: em dois, empregamos tubo valvulado com prótese mecânica, e em um, com prótese biológica. Dois pacientes necessitaram procedimentos associados com troca da valva mitral em um deles e plástica da valva tricúspide no outro. Todos eram reoperações de próteses em posição aórtica. RESULTADOS: A evolução cirúrgica e pós-operatória imediata foi satisfatória com os três recebendo alta da Unidade de Terapia Intensiva para o quarto. Um dos pacientes evoluiu para óbito durante a internação em razão de co-morbidades graves que já apresentava no pré-operatório, relacionadas a varizes de esôfago e comprometimento hepático. Os outros dois apresentam boa evolução no pós-operatório tardio. CONCLUSÃO: Acreditamos que essa opção seja mais uma alternativa para o tratamento de abscessos com grande comprometimento de estruturas do anel aórtico e da continuidade mitro-aórtica.

BACKGROUND: Patients with infective endocarditis show a large diversity of anatomical presentations, which has been a complicating factor for the surgical treatment of this condition, especially in those who develop abscesses in the aortic ring or intracardiac fistulae. For this reason, surgeons have been developing tactical options to repair it. There is consensus around the fact that the removal of infected tissue promotes radical cleaning, and that the outcome of the treatment has been improved by the manufacture of biological glues which facilitate the closure of abscesses and by the creation of new valve replacements. OBJECTIVE:To demonstrate yet one more treatment option for aortic abscess for selected cases: a valved conduit placed in infra-coronary position. METHODS: We employed the technique in three patients: in two of them we employed a valved conduit with a mechanical prosthesis and in one of them a valved conduit with a biological prosthesis. Two patients needed associated procedures such as replacement of mitral valve in one of them and tricuspid valvoplasty in the other. All cases involved reoperation of prostheses in aortic position. RESULTS: The progression during surgery and in the early postoperative period was satisfactory and the three patients were discharged from the Intensive Care Unit and were sent to hospital rooms. One of the patients progressed to death during hospital stay due to severe comorbidities which were present in the preoperative period, and which related to esophageal varices and hepatic involvement. The other two progressed well in the late postoperative period. CONCLUSION: We believe that this option is yet one more alternative for the treatment of abscesses with great involvement of aortic ring structures and mitro-aortic continuity.

Effect of insulin on exocrine pancreatic secretion in healthy and diabetic anaesthetised rats.

This investigation characterised the effects of exogenous insulin on exocrine pancreatic secretion in anaesthetised healthy and diabetic rats. Animals were rendered diabetic by a single injection of streptozotocin (STZ, 60 mg kg(-1) I.P.). Age-matched controls were injected citrate buffer. Rats were tested for hyperglycaemia 4 days after STZ injection and 7-8 weeks later when they were used for the experiments. Following anaesthesia (1 g kg(-1) urethane I.P.), laparotomy was performed and the pancreatic duct cannulated for collection of pure pancreatic juice. Basal pancreatic juice flow rate in diabetic rats was significantly (p < 0.001) increased whereas protein and amylase outputs were significantly (p < 0.001) decreased compared to control rats. Insulin (1 IU, I.P.) produced in healthy rats significant increases in pancreatic flow rate, amylase secretion and protein output compared to basal (p < 0.05). Insulin action also included a reduction in blood glucose (152.7 +/- 16.9 mg dl(-1), n = 6, prior to insulin and 42.0 +/- 8.4 mg dl(-1), n = 4, 100 min later). In fact, flow rate and glycaemia showed a strong negative correlation (p < 0.01, Pearson). Pretreatment with atropine (0.2 mg kg(-1), I.V.) abolished the effects of insulin on secretory parameters despite a similar reduction in glycaemia; in this series of experiments the correlation between flow rate and blood glucose was lost. In diabetic rats, insulin (4 IU, I.P.) did not modify exocrine pancreatic secretion. There was a fall in blood glucose (467.6 +/- 14.0 mg dl(-1), n = 10, prior to insulin and 386.6 +/- 43.6 mg dl(-1), n = 7, 120 min later). Rats, however, did not become hypoglycaemic. Similar results were observed in diabetic atropinized rats. The results of this study indicate that the effects of insulin on exocrine pancreatic secretion in anaesthetised healthy rats are mediated by hypoglycaemia-evoked vagal cholinergic activation.

Estudio de seguridad, fase I de ensayo clínico, de la gammaglobulina hiperinmune anti-hepatitis B administrada unisitio y junto con la vacuna AgsHB recombinante: resultados preliminares / Safety study, phase I clinical trial, of the antihepatitis B hyperimmune gammaglobulin administered in one site and together with the HbasAg recombinant vaccine: preliminary results

Se utilizó el preparado vacunal de la vacuna AgsHB recombinante con la gammaglobulina hiperinmune anti-hepatitis B (inmunización pasiva de anticuerpos) y se evaluó la seguridad (fase I de ensayos clínicos) de la gammaglobulina al ser administrada unisitio junto con la vacuna anti-hepatitis B. Se inmunizaron 25 voluntarios sanos entre 20 y 50 años de edad, con el preparado vacunal de gammaglobulina hiperinmune (200 UI/mL) y vacuna anti-hepatitis B (20 mg AgsHB/dosis), las que se administraron unisitio y de forma conjunta en la región deltoidea, en el tiempo 0-1 meses dentro del esquema de inmunización de la vacuna (0-1-3 meses). No se detectaron efectos indeseables locales ni sistémicos en ninguno de los participantes. La inocuidad observada permite continuar con fases posteriores de estudios clínicos

Estudio de seguridad, fase I de ensayo clínico, de la gammaglobulina hiperinmune anti-hepatitis B administrada unisitio y junto con la vacuna AgsHB recombinante: resultados preliminares / Safety study, phase I clinical trial, of the antihepatitis B hyperimmune gammaglobulin administered in one site and together with the HbasAg recombinant vaccine: preliminary results

Se utilizó el preparado vacunal de la vacuna AgsHB recombinante con la gammaglobulina hiperinmune anti-hepatitis B (inmunización pasiva de anticuerpos) y se evaluó la seguridad (fase I de ensayos clínicos) de la gammaglobulina al ser administrada unisitio junto con la vacuna anti-hepatitis B. Se inmunizaron 25 voluntarios sanos entre 20 y 50 años de edad, con el preparado vacunal de gammaglobulina hiperinmune (200 UI/mL) y vacuna anti-hepatitis B (20 mg AgsHB/dosis), las que se administraron unisitio y de forma conjunta en la región deltoidea, en el tiempo 0-1 meses dentro del esquema de inmunización de la vacuna (0-1-3 meses). No se detectaron efectos indeseables locales ni sistémicos en ninguno de los participantes. La inocuidad observada permite continuar con fases posteriores de estudios clínicos(AU)

Eritema indurado de Bazin. Presentación de 4 casos / Erythema induratum of Bazin. Four cases report

El eritema indurado de Bazin es un cuadro anatomopatológico considerado como una tuberculosis nodular hipodérmica, caracterizada por presentar nódulos rojizos, indurados pequeños, separados por piel sana que ocasiona ligeras molestias y se localizan en la cara posterior de las piernas en mujeres jóvenes y que se presentan principalmente en invierno. Presentamos 4 casos que respondieron bien al tratamiento antifímico que aunado a estudios recientes basados en la amplificación de la reacción en cadena de la polimerasa (PCR) apoyan que el origen de este padecimiento es una reacción inflamatoria inapropiada a la presencia de M. tuberculosis en contra de lo expuesto por Lever, Ebel Hartinger, Schneider y Ondeut, que afirman que el eritema indurado de Bazin es una vasculitis de arterias y venas con necrosis grasa de origen desconocido y por lo tanto su tratamiento debe ser a base de corticoesteroides. El inicio de los 90 marca el surgimiento de la tuberculosis y con ello el advenimiento de nuevos casos de eritema indurado de Bazin, razón por la cual es importante que el médico general esté familiarizado con esta entidad para brindar una atención adecuada a estas pacientes.

Adaptation of the exocrine pancreas to dietary fats.

This article reviews studies on the adaptation of the exocrine pancreas to dietary fat. We include all the latest information about the mechanisms that underlie the adaptation of the secretory mechanism of the exocrine pancreas to the amount and the type of dietary fat. We review the kinetics of pancreatic adaptation and the mediators of the adaptive response of the pancreas including cellular and molecular mechanisms (modulation of intracellular messengers and gene expression of the different enzymes and secretagogues involved in the adaptation process). At the same time we include our results in this field in dogs and humans.

Oral administration of a turmeric extract inhibits LDL oxidation and has hypocholesterolemic effects in rabbits with experimental atherosclerosis.

The oxidation of low-density lipoproteins (LDL) plays an important role in the development of atherosclerosis. Curcumin is a yellow pigment obtained from rhizomes of Curcuma longa and is commonly used as a spice and food colouring. Curcumin and turmeric extracts have several pharmacological effects including antitumour, anti-inflammatory, antioxidant and antiinfectious activities although the precise mechanisms involved remain to be elicited. We evaluated the effect of an ethanol-aqueous extract obtained from rhizomes of C. longa on LDL oxidation susceptibility and plasma lipids in atherosclerotic rabbits. A total of 18 rabbits were fed for 7 weeks on a diet containing 95.7% standard chow, 3% lard and 1. 3% cholesterol, to induce atherosclerosis. The rabbits were divided into groups, two of which were also orally treated with turmeric extract at doses of 1.66 (group A) and 3.2 (group B) mg/kg body weight, respectively. A third group (group C) acted as a control. Plasma and LDL lipid composition, plasma alpha-tocopherol, plasma retinol, LDL TBARS, LDL lipid hydroperoxides and analysis of aortic atherosclerotic lesions were assayed. The low but not the high dosage decreased the susceptibility of LDL to lipid peroxidation. Both doses had lower levels of total plasma cholesterol than the control group. Moreover, the lower dosage had lower levels of cholesterol, phospholipids and triglycerides in LDL than the 3.2-mg dosage. In conclusion, the use of this extract could be useful in the management of cardiovascular disease in which atherosclerosis is important.

Pancreatic enzyme secretion in response to test meals differing in the quality of dietary fat (olive and sunflowerseed oils) in human subjects.

The aim of the present study was to investigate in human subjects whether or not the ingestion of two liquid meals that differed only in their fatty acid composition (due to the addition of olive oil (group O) or sunflowerseed oil (group S) as the source of dietary fat) would lead to differences in the pancreatic enzyme activities secreted into the duodenum. The experiments were performed in eighteen cholecystectomized subjects who, during the 30 d period immediately before surgery, modified their habitual diets in such a way that their fat composition would reflect, as far as possible, that of the experimental meals. Lipase (EC 3.1.1.3), colipase, amylase (EC 3.2.1.1), chymotrypsin (EC 3.4.21.1) and trypsin (EC 3.4.21.4) activities were measured in duodenal contents aspirated before and after the ingestion of the test meals. The plasma levels of secretin and cholecystokinin (CCK) were also examined. Duodenal enzyme activities were similar in resting conditions. No significant differences were revealed in postprandial enzyme activities, except for lipase activity, which was higher in group O, probably in relation to the greater plasma CCK concentrations observed in this group. In the absence of enzyme output data, we should not exclude the possibility that the type of dietary fat will affect human pancreatic enzyme secretion to a greater extent than is evident from the present study, for instance through a flow-mediated effect, as we previously observed in dogs.

Effect of age on the exocrine pancreatic secretion of the preruminant milk-fed goat.

The effect of age on the exocrine pancreatic function was studied in fifteen Granadina goat kids during the second, third and fourth postnatal week. The animals, chronically catheterized, were bottle-fed on goat milk twice a day. Pure pancreatic juice was collected from 1 hour before and throughout 8 hours after milk ingestion. Pancreatic flow rate, bicarbonate and chloride concentrations, total protein content and enzyme activities were determined. In resting conditions, pancreatic flow rate augmented with age, probably reflecting an increase in body and pancreas weight. Resting amylase and lipase activities recorded significant increases during the fourth week of life. That may be associated, respectively, to the immediate change to a high-starch diet and to a simultaneous decrease in the salivary lipase levels. Our results also showed age-related differences after ingestion of milk, mainly concerning the volume response and the lipase output. The latter can be explained in the same way as regarding resting conditions. With respect to the volume response, several factors could be implicated, such as the circulating levels of gastrointestinal hormones, the sensitivity of the pancreas to such stimuli, the maturation degree in the secretory mechanisms of the gland or the development of the digestive tract.

Exocrine pancreatic secretion in suckling goats. Adaptative effects of maternal milk and a milk substitute.

Suckling goats were fed ad libitum during the first month of their life by goat milk or by a milk replacer. These diets differed in the amount of fat and the type of protein. The composition of the exocrine pancreatic secretion in the basal period and in response to food were compared in both conditions. Pancreatic juice was collected one hour before meal intake up to the 8th postprandial hour. Pancreatic flow rate, bicarbonate and chloride levels, total protein and enzyme activities were measured. In resting conditions and in response to food, the lipase activity was found to be significantly lower in the group fed with milk replacer, which was poorer in fat. These results indicate an adaptation of the enzyme output to the available quantity of its substrate, similar to that described in the rat. Postprandial differences in the pancreatic flow rate, electrolytes and total protein were found between both groups. Their origin can be attributed to the protein used (soyabean) in the milk substitute. Such soya protein alters the normal clot formation in the abomasum and allows an accelerated abomasal digesta outflow and duodenal pH alkalinisation.

Postnatal development of the exocrine pancreas in suckling goat kids.

A total of 25 preruminant Granadina breed goats were used. They were bottle-fed goat milk ad libitum from postnatal day 3 to 28. Until the age of 3 d, kids were fed colostrum. Body weight, pancreas weight, total protein concentration, enzyme activities in pancreatic tissue and hormone concentrations (cortisol, gastrin, T3 and T4) were determined at 3, 7, 14, 21 and 28 d of age. Our results show that the rates of pancreatic synthesis and secretion of chymotrypsin are well developed at birth in the kid, and may compensate for possible deficiencies in gastric and/or enterocytes intracellular proteolysis. In week 4, there was a marked increase in amylase activity, change that can be attributed to the beginning of the transitional period known as weaning. The significant increase in circulating concentration of cortisol during week 4 suggests the involvement of corticosteroid as a mediator of pancreatic development at weaning. Changes in blood levels of this hormone are believed to be important in the expression of amylase in the neonatal period. However, T3-T4 blood levels remained unchanged from d 3 to 28, suggesting that, in the kid, these hormones appear to have no clear influence upon the postnatal development of the exocrine pancreas.

Influence of type of dietary fat (olive and sunflower oil) upon gastric acid secretion and release of gastrin, somatostatin, and peptide YY in man.

The effects of adaptation to two diets differing in the type of dietary fat on the gastric acid secretory response to food and on the circulating levels of gastrin, somatostatin and peptide YY (PYY) were examined in humans. The study involved 18 cholecystectomized subjects previously submitted to a 30-day adaptation period to diets containing olive (group O) or sunflower oil (group S) as the fat source. During the experiments, physiological stimulation was achieved by ingestion of 200 ml of oleic acid- (group O) or linoleic acid-enriched (group S) liquid mixed meals. These resulted in an immediate rise in gastric pH. In group S, the return to the premeal value was completed within 60 min, and a further decline to values significantly lower than the basal ones was observed at the end of the study period. In contrast, ingestion of the meal containing olive oil attenuated and prolonged the pH decrease after the meal, this being associated with the suppression of postprandial gastrin response. Food ingestion induced no significant changes in plasma somatostatin concentration in either group, and no significant differences were revealed between them during the basal or postprandial situations. Plasma PYY levels were consistently higher in group O throughout the entire study period, although significance was reached only at resting. In conclusion, our results show that a 30-day adaptation period to diets containing olive oil as the main source of dietary fat results, compared with those containing sunflower oil, in an attenuated gastric secretory function in response to a liquid meal in humans. The effects of olive oil were associated with a suppression of serum gastrin and higher levels of PYY.

Effects of the amount and type of dietary fat on exocrine pancreatic secretion in dogs after different periods of adaptation.

Mongrel dogs were fed, from weaning to 6 months of age, on one of two 9% lipid diets that differed only in the type of fat content (sunflower oil or virgin olive oil) to study their effects on exocrine pancreatic secretion, in the basal period and in response to food. In addition, the results were compared with those obtained in a previous work performed by us on dogs adapted for 8 months to diets containing a higher (15%) amount of the same dietary fats to further evaluate the influence of the amount of dietary fat and the length of the adaptation period. The results from the present study show that both the volume and bicarbonate secreted in the absence of stimuli are unaffected by the quality of dietary fat. In contrast, in response to food, the pancreatic juice flow and the bicarbonate output were significantly higher in the group of animals given the sunflower oil diet. The differences seem to be related with the oleic acid content in the diets and the effectiveness of this fatty acid in triggering the release of inhibitory peptides such as pancreatic polypeptide and peptide YY. The comparison between the results from our present and previous studies supports the afore-mentioned hypothesis and confirms the existence of a clear influence of the amount and type of dietary fat, especially the oleic acid content, upon the pancreatic response to food, without ruling out a role for the duration of the adaptation period.

Regulation by diet of the pancreas enzyme content of suckling goats.

To study pancreas enzyme content regulation when the diet was modified in suckling goats, a comparison was made between kids fed a milk replacer and ones fed maternal milk. A total of 25 preruminant Granadina breed goats were bottle-fed a milk replacer ad libitum from postnatal days 3 to 28 (until the age of 3 days kids had been fed colostrum). Body weight, pancreas weight, total protein concentration, and enzyme activities in pancreatic tissue were determined at 3, 7, 14, 21 and 28 days of age, and the results were compared to those previously obtained in kids fed maternal milk for the same period. Lipase activity was significantly lower in the group fed milk replacer, which was poorer in fat. Amylase activity was higher in this group, perhaps due to the starch products present in the milk substitute. However, the postnatal evolution of chymotrypsin activity followed a similar pattern regardless of diet. Our results seem to confirm that in preruminant kids there is a nutritional regulation of pancreatic amylase and lipase activities, depending on the amounts of their respective substrates in the diet, similar to that described in nonruminants.

Absence of rapid adaptation of the exocrine pancreas of conscious dogs to diets enriched in fat or carbohydrates.

Adult mongrel dogs were fed during 8 days on one of two diets, one rich in fat (FR) and the other rich in carbohydrates (CR), in order to compare the exocrine pancreatic secretion in the basal period and in response to food. Under resting conditions, mean pancreatic juice flow and mean values of protein content, amylase and lipase activity and production were similar in both experimental groups, suggesting that the period of adaptation used did not produce any influence on the measured parameters. No significant difference between the two dietary groups was found in postprandial volume of pancreatic juice. The peak of pancreatic juice flow in FR-group was smaller but remained elevated until the end of the 5th h, possibly due to the fact of delayed gastric emptying when animals are fed with a high fat diet. No significant differences were found between the groups in neither postprandial amylase activity and secretion nor lipase activity. On the other hand, lipase output was significantly higher in FR-group but only during the 5 postprandial h. This fact may be related to some intestinal factor stimulated by the hydrolysis products of fat. Finally, our findings show that no rapid adaptation of exocrine pancreatic secretion exist to the diet, at least in our experimental conditions. Of course, this does not exclude that the phenomenon of adaptation may appear in the dog under long-term adaptation to the diet.

Post-natal changes in biliary lipids in suckling goat kids.

The post-natal composition of biliary lipids in the bile of suckling goat kids has been studied during the first month of life. Samples of hepatic and vesicular bile were obtained from animals fed with milk. Bile flow increased with age and the concentration of bile acids also rose up to 14 days of age. Cholesterol reached maximum values immediately after birth and then decreased. Bile acids conjugated with taurine predominated and this pattern of preferential tauroconjugation persisted at all ages, as has also been found in carnivores and sheep. Comparison of vesicular and hepatic bile composition revealed a poor concentration capacity of the gallbladder in pre-ruminant kids.

Taurine- and glycine-conjugated bile acids in the preruminant goat: identification by high performance liquid chromatography.

A reversed-phase high performance liquid chromatography technique has been developed for the identification of taurine- and glycine-conjugated bile acids in the bile of preruminant goats. The mobile phase consisted of two solvents: acetonitrile (A) and 5 mM potassium phosphate buffer (pH 4.5) (B). Samples (10 microliters) were eluted with a linear gradient in which acetonitrile was increased from 25 to 35%, and from 35 to 45%, at 10 min intervals. Flow rate was 1.0 ml min-1, and bile acids were detected at 200 nm. This sample high resolution technique was highly reproducible, involved a minimum of straightforward sample treatment, and required a short chromatographic development time. The technique will be of use in the systematic identifications of bile acids in preruminants.

Blood platelet function in healthy individuals of different ages. Effects of exercise and exercise conditioning.

The influence of age, physical conditioning and physical exercise on platelet function on human being is still controversial. The aim of our study were to evaluate the effect of physical exercise on platelet activation measured by beta-thromboglobulin (beta-TG) levels and the number of platelets in sedentary and athlete subjects of different ages, and also to investigate the response of these parameters during the period of recover immediately after a bicycle exercise test. Our results show differences in platelet count and beta-TG levels among the experimental groups studied, in basal conditions, in response to the exercise test and during postexercise period. These results seem to indicate that regardless age, regular physical exercise diminish age negative effects on platelet aggregation.

Biliary secretion in suckling goats: the effect of maternal milk and of a lamb milk replacer.

A total of 45 preruminant goats were fed either goat milk or a milk substitute. The postnatal development of bile secretion and biliary lipids composition of suckling goats and the influence upon these parameters of maternal milk substitution were studied during the first month of life. Samples of hepatic and gallbladder bile were obtained from kids of 1, 7, 14, 21 and 28 day-old. Bile flow rate, cholesterol, total bile salts and phospholipids were measured. Our results show that the quality of the protein and fat used in the elaboration of the milk replacer, affects the evolution of both hepatic bile flow and biliary lipids composition. Differences between gallbladder and hepatic bile composition show a scarce concentration capacity of the gallbladder with both diets and at all ages studied.