Miliarial-type gout in association with chronic use of glucocorticoids.

A 59-year-old male patient with long-standing tophaceous gout (more than 30 years) characterized by polyarticular involvement and recurrent disseminated tophi formation; his past medical history is relevant for poor adherence to urate-lowering medications, as well as persistent use of self-prescribed systemic glucocorticoids. Despite achieving therapeutic goals for serum uric acid levels, new tophi formation with an intradermal location in the form of "miliarial-type gout" was documented. Due to functional limitations, the patient underwent surgical resection of the olecranon bursa. This case illustrates a widespread and recurrent tophi formation associated with long-standing gout and regular and sustained glucocorticoid use, despite an adequate disease control based on serum urate levels and involving an intradermal location of tophi presenting as "miliarial-type" lesions. In addition, the coexistence of urate and cholesterol crystal deposition disease in olecranon gouty bursitis is presented. Finally, a sonographic extended field of view of lesions distributed along the patient's extremities is presented as a novel characterization of this condition.

Polymorphisms CYP2R1 rs10766197 and CYP27B1 rs10877012 in Multiple Sclerosis: A Case-Control Study.

BACKGROUND: Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease. Low vitamin D levels have been reported to be a risk factor for MS, and genetic variances could be implicated. The aim of this study was to evaluate the association of MS with rs10766197 polymorphism of CYP2R1 gene and rs10877012 polymorphism of CYP27B1 gene. The second aim was to analyse whether these polymorphisms are associated with the severity of the progression of MS. Material and Methods. In a case-control study, we included 116 MS patients and 226 controls, all of whom were Mexican Mestizo. MS was diagnosed by McDonald criteria (2017). A complete neurological evaluation was performed to evaluate the severity of disease progression. Serum 25-hydroxyvitamin D [25(OH) vitamin D] levels were measured by ELISA. Single nucleotide polymorphisms rs10766197 of CYP2R1 gene and rs10877012 SNP of CYP27B1 gene were genotyped by real-time PCR. RESULTS: Serum 25(OH) vitamin D levels were lower in MS patients than in controls (p = 0.009). No differences were observed between serum 25(OH) vitamin D levels of MS patients with severe progression compared to low progression (p = 0.88). A higher frequency of the A allele of CYP2R1 rs10766197 was observed between MS patients and controls (p = 0.05). No differences were observed in the frequency of T allele of CYP27B1 rs10877012 (p = 0.65). In subanalysis, patients with GA + AA genotypes of CYP2R1 rs10766197 had an increased risk of MS compared to controls (p = 0.03). No increased risk was observed in GT + TT genotypes of CYP27B1 rs10877012 (p = 0.63). No differences were observed in allele frequencies of either polymorphism between patients with severe vs. low disease progression. CONCLUSION: Lower serum 25(OH) vitamin D levels were observed in MS patients than in controls, although these levels were not associated with disease progression. Carriers of GA + AA genotypes of CYP2R1 rs10766197 had an increased risk of MS. None of these polymorphisms was associated with severe progression of MS.

Cutting through the fat: a retrospective analysis of clinical outcomes, cost, and quality of life with the addition of panniculectomy to ventral hernia repair in overweight patients.

BACKGROUND: Due to the increased prevalence of overweight patients with ventral hernia, abdominal wall reconstruction combining ventral hernia repair (VHR) with panniculectomy (VHR-PAN) in overweight patients is increasingly considered. We present a retrospective comparison between VHR-PAN and VHR alone in overweight patients by examining costs, clinical outcomes, and quality of life (QoL). METHODS: Patients with body mass index (BMI) > 25.0 kg/m2 underwent VHR-PAN or VHR alone between September 2015 and May 2017 with a single surgeon and were matched into cohorts by BMI and age (n = 24 in each cohort). QoL was assessed using the Hernia-related Quality of Life Survey (HerQLes). Cost was assessed using billing data. Statistical analyses were performed using Fisher's exact tests, Mann-Whitney U tests, and regression modeling. RESULTS: Hernia defect size (p = 0.127), operative time (p = 0.140), mesh placement (p = 0.357), and recurrence rates (p = 0.156) did not vary significantly between cohorts at average follow up of one year. 60% of patients completed QoL surveys, with 61% net improvement in VHR-PAN postoperatively (p = 0.042) vs 36% in VHR alone (p = 0.054). Mean total hospitalization costs were higher for VHR alone (p = 0.019). Regression modeling showed no significant independent contribution of procedure performed due to differences in cost, wound complications, or hernia recurrence. CONCLUSIONS: At mean follow up of 2 years, VHR-PAN patients reported a comparable increase in QoL to those who received VHR alone without significantly different cost and complication rates. Concurrent VHR-PAN may therefore be a safe approach for overweight patients presenting with hernia and excess abdominal skin.

La autotrascendencia en la prevención del consumo de alcohol en adolescentes hijos de padres consumidores / Self-transcendence in the prevention of alcohol consumption among adolescents sons of consumer parents / A autotranscedência na prevenção do consumo de álcool em adolescentes filhos de pais consumidores

Resumen Introducción: Múltiples factores propician el abuso en el consumo de alcohol en adolescentes hijos de padres consumidores, entre ellos, el desconocimiento de sus recursos personales para enfrentar la situación. En este sentido, la Teoría de Autotrascendencia de Reed, ha sido utilizada como sustento teórico en diversas problemáticas como el consumo de alcohol. Objetivo: Elaborar una propuesta para la gestión del cuidado de Enfermería, orientada a la prevención del consumo de alcohol en adolescentes hijos de padres consumidores, basada en la Teoría de Autotrascendencia de Pamela Reed. Metodología: Análisis y adaptación de la teoría de Reed con la utilización del modelo de marco lógico como herramienta para la planificación de indicadores, medios de verificación y supuestos, de acuerdo al objetivo planteado. Resultado: Se presenta un proyecto de gestión del cuidado de Enfermería que incluye siete sesiones con actividades que abordan los conceptos vulnerabilidad, factores moderadores-mediadores, autotrascendencia y autoconocimiento-autoestima, para promover el desarrollo de la trascendencia "hacia dentro", de forma que permita el propio conocimiento y aceptación de elementos que contribuyan a la adopción de conductas saludables, para la prevención de ingesta de bebidas alcohólicas. Conclusión: La aplicación de la Teoría de Autotrascendencia de Pamela Reed, en la estructuración de un proyecto de gestión con adolescentes hijos de padres consumidores de alcohol, es una propuesta orientada a una problemática de salud que actualmente viven los jóvenes como población vulnerable.

Abstract Introduction: Multiple factors induce the abuse in the consumption of alcohol among adolescents sons of consumer parents, including the lack of awareness on the personal resources to face the situation. In this sense, the Reed's Self-Transcendence Theory has been used as theoretical foundation in issues such as alcohol consumption. Objective: Based on Reed's Self-Transcendence Theory, to elaborate a nursing care management proposal oriented towards the prevention of alcohol consumption among adolescents sons of consumer parents. Methodology: Analysis and adaptation of Reed's theory with the utilization of the logical frame model as a tool to address the planning of indicators and the corresponding means of verification. Result: A project is presented on nursing care management which includes seven sessions with activities addressing the concepts of vulnerability, moderating and mediating factors, self-transcendence, and self-knowledge and esteem in order to promote the development of the transcendence "to the inside", thus strengthening the awareness, knowledge, and acceptance of elements which contribute to the adoption of healthy behaviors and prevention of alcohol consumption. Conclusion: The use of Pamela Reed's Self-Transcendence Theory is an option to help structure nursing care management models which address the problem of alcohol consumption among the adolescents as a vulnerable population.

Resumo Introdução: Múltiplos fatores propiciam o abuso no consumo de álcool em adolescentes filhos de pais consumidores, entre eles, o desconhecimento de seus recursos pessoais para afrontar a situação. Neste sentido, a teoria de Autotranscedência de Reed, foi utilizada como sustento teórico nas diversas problemáticas como o consumo de álcool. Objetivo: Elaborar uma proposta para a gestão do cuidado de Enfermagem, orientada à prevenção do consumo de álcool em adolescentes filhos de pais consumidores, baseada na Teoria de Autotranscedência de Pamela Reed. Metodologia: Análise e adaptação da teoria de Reed com a utilização do modelo de marco lógico como ferramenta para a planificação de indicadores, médios de verificação e supostos, conforme ao objetivo exposto. Resultado: Apresenta-se um projeto de gestão do cuidado de Enfermagem que inclui sete sessões com atividades que abordam os conceitos vulnerabilidade, fatores moderadores-mediadores, autotranscedência e autoconhecimento-autoestima, para promover o desenvolvimento da transcendência "para dentro", de forma que permita o próprio conhecimento e aceitação de elementos que contribuam à adopção de condutas saudáveis, para a prevenção de ingesta de bebidas alcoólicas. Conclusão: A aplicação da Teoria de Autotranscedência de Pamela Reed, na estruturação de um projeto de gestão com adolescentes filhos de pais consumidores de álcool, é uma proposta orientada a uma problemática de saúde que atualmente vivem os jovens como população vulnerável.

Reduction of postendodontic pain after one-visit root canal treatment using three irrigating regimens with different temperature.

OBJECTIVE: The aim of this clinical trial was to assess whether controlled irrigation with three different irrigation regimens with different temperature would result in reduction of post-endodontic pain after one-visit root canal treatment (RCT). MATERIALS AND METHODS: A total of 240 (129 females and 111 male) aged 18 - 65 years were referred and integrated in this clinical trial, All patients presented with a vital maxillary or mandibular molar, premolar or front teeth designated for conventional root canal treatment for prosthetic reasons detected with only vital pulps. All canals were cleaned and shaped with Reciproc instruments, and were used with a micro motor (VDW, Munich Germany). Final irrigation was done with cold (4°C, 2.5°C, and room temperature) 17% EDTA and 10 mL of cold saline solution. RESULTS: A total of 240 of 279 patients (129 females and 111 male) aged 18 - 65 years were referred and integrated in this clinical trial, whereas 29 were rejected as not completing the requirements needed. All patients presented with a vital maxillary or mandibular molar, premolar, or front teeth designated for intentional endodontic RCT for prosthetic reasons. No statistically significant difference (P > 0.05) among the groups was found regarding degree or duration of pain. There was no statistically significant difference (P > 0.05) among the 4oC and 2.5oC groups. CONCLUSION: The approach in both selecting the patients participating in the study and analyzing the data in this randomized clinical trial allows us to conclude that cryotherapy is an aid of clinical procedures to clean and shape the canals to reduce the occurrence of postendodontic pain and the need for medication in patients presenting with a diagnosis of vital pulp.

Neonatal Fc receptor antagonist efgartigimod safely and sustainably reduces IgGs in humans.

BACKGROUND: Intravenous Ig (IVIg), plasma exchange, and immunoadsorption are frequently used in the management of severe autoimmune diseases mediated by pathogenic IgG autoantibodies. These approaches modulating IgG levels can, however, be associated with some severe adverse reactions and a substantial burden to patients. Targeting the neonatal Fc receptor (FcRn) presents an innovative and potentially more effective, safer, and more convenient alternative for clearing pathogenic IgGs. METHODS: A randomized, double-blind, placebo-controlled first-in-human study was conducted in 62 healthy volunteers to explore single and multiple ascending intravenous doses of the FcRn antagonist efgartigimod. The study objectives were to assess safety, tolerability, pharmacokinetics, pharmacodynamics, and immunogenicity. The findings of this study were compared with the pharmacodynamics profile elicited by efgartigimod in cynomolgus monkeys. RESULTS: Efgartigimod treatment resulted in a rapid and specific clearance of serum IgG levels in both cynomolgus monkeys and healthy volunteers. In humans, single administration of efgartigimod reduced IgG levels up to 50%, while multiple dosing further lowered IgGs on average by 75% of baseline levels. Approximately 8 weeks following the last administration, IgG levels returned to baseline. Efgartigimod did not alter the homeostasis of albumin or Igs other than IgG, and no serious adverse events related to efgartigimod infusion were observed. CONCLUSION: Antagonizing FcRn using efgartigimod is safe and results in a specific, profound, and sustained reduction of serum IgG levels. These results warrant further evaluation of this therapeutic approach in IgG-driven autoimmune diseases. TRIAL REGISTRATION: Clinicaltrials.gov NCT03457649. FUNDING: argenx BVBA.

Atrial Fibrillation and Stroke Risk After Coronary Artery Bypass Grafting Surgery.

Background: The present multicentre study was aimed at determining the effect of preoperative atrial fibrillation (preop-AF) as stroke risk factor in coronary artery bypass graft surgery (CABG) during the perioperative period. Methods: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish centers. Baseline variables related with perioperative stroke risk were recorded and analysed. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) stroke risk schema was used to stratify stroke risk and compare predicted vs observed neurologic outcomes in this study. Results: 26347 patients were enrolled in the study. Prevalence of preop-AF was 4.2%, and was associated significantly with major cardiovascular comorbidities. The stroke rate was 1.38% (365 strokes), and it was slightly higher for patients with preop-AF vs non preop-AF, 1.82% vs 1.36%, p = 0.2. NNECVDSG schema showed good predictive ability calculating the area under the receiver operating characteristic curve (c-statistic 0.696; 95% CI 0.668 to 0.723). To investigate the associations of baseline preoperative variables with perioperative CABG-stroke a logistic regression model was performed. Preop-AF impact on perioperative stroke was lower that other variables. Preop-AF did not show an adverse impact in the quartiles groups according to NNECVDSG Stroke Risk Index. Conclusion: Risk of perioperative stroke in isolated CABG surgery patients is not significantly increased by preop-AF.

Respiratory tract infections after cardiac surgery: impact on hospital morbidity and mortality.

AIM: Nosocomial pneumonia (NP) and tracheobronchitis after cardiac surgery are associated with worse outcomes. The aim of this study was to identify risk factors associated with NP and tracheobronchitis after cardiac surgery and to determine the impact of these infections on hospital morbidity and mortality. METHODS: We evaluated 1600 adult patients undergoing cardiac surgery under standard cardiopulmonary bypass. Data were collected prospectively. All NP and tracheobronchitis episodes were confirmed by a semiquantitative culture of endotracheal aspirate. Logistic regression analysis was done to identify risk factors for respiratory tract infection and mortality. RESULTS: The rate of NP was 1.2% (15.6 episodes per 1000 days of mechanical ventilation) and that of tracheobronchitis was 1.6% (21 episodes per 1000 days of mechanical ventilation). Significant independent risk factors for respiratory tract infection (pneumonia or tracheobronchitis) were: left ventricular ejection fraction < 30% (P = 0.001), chronic renal failure (P < 0.0001) and urgent surgery (P < 0.0001). Patients with NP had significantly higher mortality (42% versus 0.9%, P < 0.0001) than patients without respiratory tract infection. The median hospital length of stay was significantly longer in patients with pneumonia (42 days) and tracheobronchitis (28 days) than in patients without any respiratory tract infection (11 days, P < 0.0001). CONCLUSION: NP after cardiac surgery is associated with severe outcomes. Independent risk markers for respiratory tract infection were left ventricular ejection fraction < 30%, chronic renal failure and urgent surgery.

[Acyclovir-induced acute renal failure: An under-estimated secondary effect?]. / Insuficiencia renal aguda por aciclovir, un efecto secundario infraestimado?

The increasing use of oral or IV acyclovir to treat infections caused by herpesviridae family involves a rise in the number of observed adverse effects. Neuro- and nephrotoxicity are most serious observed and reported secondary effects. The monitoring of renal function is essential to detect these cases since it develops as a non-oliguric renal failure. Because of this, the outpatient and oral use of the drug can result in an underestimation of the number of cases reported. We report two patients with genital herpes and viral encephalitis that required IV acyclovir. Both inpatients developed an acute renal failure that resolved after the drug was withdrawn.

Insuficiencia renal aguda por aciclovir, ¿un efecto secundario infraestimado? / Acyclovir-induced acute renal failure: an under-estimated secondary effect?

En la actualidad, el mayor uso de aciclovir, por vía intravenosa u oral, para tratar infecciones de la familia Herpesviridae, conlleva un aumento del número de efectos adversos descritos. La neurotoxicidad y nefrotoxicidad son los efectos secundarios más graves que se han comunicado. La monitorización de la función renal es fundamental para detectar estos casos, pues cursa como insuficiencia renal no oligúrica. Por ello, el uso ambulatorio y oral del fármaco puede dar lugar a una infraestimación del número de casos totales. Presentamos los casos de 2 pacientes que por su patología de base (herpes genital y encefalitis viral) precisaron aciclovir intravenoso, y que durante su estancia hospitalaria desarrollaron insuficiencia renal aguda no oligúrica, que cedió al suspender la administración del fármaco

The increasing use of oral or IV acyclovir to treat infections caused by herpesviridae family involves a rise in the number of observed adverse effects. Neuro- and nephrotoxicity are most serious observed and reported secondary effects. The monitoring of renal function is essential to detect these cases since it develops as a non-oliguric renal failure. Because of this, the outpatient and oral use of the drug can result in an underestimation of the number of cases reported. We report two patients with genital herpes and viral encephalitis that required IV acyclovir. Both inpatients developed an acute renal failure that resolved after the drug was withdrawn

Oral human immunoglobulin for children with autism and gastrointestinal dysfunction: a prospective, open-label study.

Immunoglobulin secretion onto mucosal surfaces is a major component of the mucosal immune system. We hypothesized that chronic gastrointestinal (GI) disturbances associated with autistic disorder (AD) may be due to an underlying deficiency in mucosal immunity, and that orally administered immunoglobulin would be effective in alleviating chronic GI dysfunction in these individuals. In this pilot study, twelve male subjects diagnosed with AD were evaluated using a GI severity index (GSI) while receiving daily dosing with encapsulated human immunoglobulin. Following eight weeks of treatment, 50% of the subjects met prespecified criteria for response in GI signs and symptoms and showed significant behavioral improvement as assessed by the Autism Behavior Checklist and parent and physician rated Clinical Global Impression of Improvement.

Diagnosis and outcomes of enterovirus infections in young infants.

BACKGROUND: Enterovirus (EV) infections commonly cause fever in infants younger than 90 days of age. The polymerase chain reaction (PCR) has improved our ability to diagnose EV infections. OBJECTIVE: To evaluate the utility of blood and cerebrospinal fluid (CSF) specimens for the diagnosis of EV infections by PCR and to describe a large cohort of EV-infected infants. DESIGN/METHODS: Febrile infants younger than 90 days of age evaluated for sepsis at Primary Children's Medical Center in Salt Lake City, UT, were enrolled in a prospective study designed to identify viral infections from December 1996 to June 2002. All patients had bacterial cultures of blood, urine and CSF. Testing for EV was performed by PCR and/or viral cultures. Patients who were positive for EV were identified for this study. RESULTS: Of 1779 febrile infants enrolled, 1061 had EV testing and 214 (20%) were EV-positive. EV infections were diagnosed by PCR of blood, CSF or both in 93% of infants. PCR testing was positive in blood in 57%, and blood was the only positive specimen for 22% of EV infected infants. PCR of CSF was positive in 74%. The mean age of infants with EV infection was 33 days, with 18% younger than 14 days and 5% younger than 7 days. Fifty percent of EV-positive infants had CSF pleocytosis. Of EV PCR-positive infants, 91% were admitted, and 2% required intensive care. Possible serious EV disease was diagnosed in <1%, and there were no deaths. Twelve infants (5.6%) had concomitant urinary tract infection, and 3 (1%) had bacteremia. CONCLUSIONS: EV infections are common in febrile infants younger than 90 days. Blood and CSF are equally likely to yield positive results by PCR, but the combination of both specimens improved the diagnostic yield.

Accuracy of blood culture for early diagnosis of mediastinitis in febrile patients after cardiac surgery.

Postsurgical mediastinitis (PSM) remains a major cause of morbidity and mortality in patients undergoing cardiac surgery procedures. Although prompt diagnosis is crucial in these patients, neither clinical data nor imaging techniques have shown enough sensitivity or specificity for early diagnosis of PSM. The aim of the present study was to assess the validity of blood cultures as a diagnostic test for the early detection of PSM in patients who become febrile after cardiac surgery procedures. During a 4-year period (1999-2002), patients who developed fever (>37.8 degrees C) in the first 60 days after a cardiac surgery procedure were evaluated. Blood cultures were drawn from these patients. PSM was defined as deep infection involving retrosternal tissue and/or the sternal bone directly observed by the surgeon and confirmed microbiologically. Three criteria for positivity of blood cultures were applied: bacteremia, staphylococcal bacteremia, or Staphylococcus aureus bacteremia. For purposes of the analysis, a positive blood culture in patients with PSM was considered a true-positive test and a negative blood culture a false-negative test. Otherwise, in febrile patients without PSM in the postsurgery period, a positive blood culture was considered a false-positive test and a negative blood culture a true-negative test. Blood cultures were drawn from 266 febrile patients in the postsurgery period. PSM occurred in 38 patients (26 cases due to S. aureus, 8 to Staphylococcus epidermidis, 3 to gram-negative enteric bacteria, and one to Pseudomonas aeruginosa). Within the 60-day postsurgical period, blood culture as a diagnostic test was most accurate in patients with S. aureus bacteremia, providing 68% sensitivity, 98% specificity, a positive predictive value of 87%, and a negative predictive value of 95%. If the analysis was limited to the period during which patients are at maximum risk for PSM (day 7-20), the values in patients with S. aureus bacteremia were as follows: 73% sensitivity, 98% specificity, 90% positive predictive value, and 93% negative predictive value. Blood culture is an accurate test for the early diagnosis of PSM in febrile patients after cardiac surgery, particularly in institutions where S. aureus is prevalent in this context. A negative blood culture practically excludes PSM and, during the period of maximum risk for PSM, the presence of S. aureus bacteremia should compel early surgical management.

Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections.

OBJECTIVE: The risk of serious bacterial infection (SBI) in febrile infants who are classified as low risk (LR) or high risk (HR) by the Rochester criteria has been established. LR infants average a 1.4% occurrence of SBI, whereas HR infants have an occurrence of 21%. The occurrence of SBI in Rochester LR or HR infants with confirmed viral infections is unknown. The objective of this study was to determine the occurrence of SBI in Rochester LR and HR infants with and without viral infections. METHODS: All febrile infants who were 90 days or younger and evaluated at Primary Children's Medical Center between December 1996 and June 2002 were eligible. Infants were classified as Rochester LR or HR, and discharge diagnoses were collected. Viral testing for enteroviruses, respiratory viruses, rotavirus, and herpesvirus was performed as indicated by study protocol, clinical presentation, and season of the year. Results of all bacterial cultures were reviewed. RESULTS: Of 1779 infants enrolled, 1385 (78%) had some form of viral diagnostic testing and 491 (35%) had 1 or more viruses identified. By the Rochester criteria, 456 (33%) infants were classified as LR and 922 (67%) infants as HR. For infants with viral infections, the occurrence of SBI was significantly lower than in infants without a viral infection (4.2% vs 12.3%). Rochester HR virus-positive (HR+) infants had significantly fewer bacterial infections than HR virus-negative (HR-) infants (5.5% vs 16.7%). When compared with HR- infants, HR+ infants were less likely to have bacteremia, urinary tract infection, or soft tissue infections, and HR+ infants had a similar occurrence of bacteremia as LR infants (0.92% vs 1.97%). CONCLUSIONS: Febrile infants with confirmed viral infections are at lower risk for SBI than those in whom a viral infection is not identified. Viral diagnostic data can positively contribute to the management of febrile infants, especially those who are classified as HR.

Short report: Prevalence of fecal Encephalitozoon sp. spores among hospitalized patients in Nepal.

During the months of June and July 1998, stool samples from 341 hospitalized patients (mean age, 32.7 +/- 16.3 years; range, 1-86 years) from Kathmandu, Nepal, were screened for the prevalence of Encephalitozoon sp. by use of anti-Encephalitozoon sp. monoclonal antibody 3B6-based immunofluorescence assay. The cross-sectional study revealed the presence of Encephalitozoon spores in 0.6% (2 of 341) patients. By use of direct microscopic examination, 27% (93 of 341) of patients were diagnosed with various gastrointestinal pathogens, among which Ascaris lumbricoides and Ancylostoma duodenale were the most commonly found, with prevalence rates of 8.8% (30 of 341) and 7.6% (26 of 341), respectively. To our knowledge, this is the first study to report the presence of Encephalitozoon sp. among humans in Nepal.

[Surgical reconstruction of intervalvular fibrous body in active infective endocarditis]. / Cirugía de reconstrucción del cuerpo fribroso intervalvular en la endocarditis infecciosa activa.

INTRODUCTION AND OBJECTIVES: Surgery for infective endocarditis with paravalvular abscesses and fibrous body destruction has the highest mortality and morbidity rates in this disease with high surgical risk. We report a new approach of radical resection of the abscess and affected tissues and reconstruction of the heart with pericardium as an alternative to conventional surgery. METHODS: In the last two years six patients with infective endocarditis, paravalvular abscesses and fibrous body destruction underwent surgery (five prostheses with infective endocarditis). The main indication for surgery was persistent sepsis despite adequate antibiotic treatment in five patients and congestive heart failure in one. After wide resection of the abscesses and fibrous body the heart was reconstructed with glutaraldehyde-fixed bovine pericardium. RESULTS: There was no hospital mortality. The median bypass and clamp times were 198 and 174 minutes, respectively. One patient presented complete AV block and a permanent transvenous pacemaker was implanted. Doppler echocardiographic studies performed in all the patients prior to discharge indicated that no patient had patch dehiscence or paravalvular leaks. Patients were followed a mean of 15 months with no deaths or other complications being reported. CONCLUSIONS: Resection of the abscesses and fibrous body, and reconstruction of the heart with glutaraldehyde-fixed bovine pericardial patch is a radical, feasible technique with all infected tissues being resected to thereby prevent reinfection or paravalvular leaks.

Adoptive transfer of immunity with intraepithelial lymphocytes in Cryptosporidium parvum-infected severe combined immunodeficient mice.

BACKGROUND: Intestinal infections with the protozoan parasite Cryptosporidium parvum are prevalent in both immunocompetent and immunocompromised hosts. Although C parvum is an important cause of outbreaks and opportunistic infections worldwide, little is known about protective mucosal immune responses. This is in part because animal models of infection are limited to those with genetic or induced immunodeficiencies. METHOD: In this report, we isolated immune (primed) or nonimmune (unprimed) intraepithelial lymphocytes (IEL) from BALB/cJ mouse intestines, adoptively transferred them into C parvum-infected severe combined immunodeficient (SCID) mice, and evaluated infection and cell phenotype responses. RESULTS: Control SCID mice that received no IEL shed large numbers of oocysts throughout the experimental period (day 18 to day 72). Transfer of primed IEL significantly reduced fecal oocyst shedding in recipient SCID mice compared with SCID mice that received unprimed IEL or no IEL. SCID mice transferred with unprimed IEL shed variable numbers of fecal oocysts that increased and decreased in bursts until day 57 after infection. SCID mice transferred with primed IEL exhibited significantly higher proportions of T-cell receptor (TCR) alphabeta+, CD8+, and CD8alphabeta+ EL compared with inoculated SCID mice that received unprimed or no IEL. CONCLUSION: We conclude that primed IEL from immunocompetent mice may influence protective mucosal response against cryptosporidiosis when transferred into SCID mice. In addition, the increased percentage of TCR alphabeta+, CD8+, CD8alphabeta+ IEL in recipient SCID mice may reflect mucosal cell populations involved in these responses during chronic C parvum infection.

[Reduction of blood transfusion need with aprotinin in orthopedic surgery. Spanish Study Group on the Use of Aprotinin in Hip Arthroplasty (GEEEAAC)]. / Reducción de las necesidades transfusionales con aprotinina en cirugía ortopédica. Grupo Español de Estudio del Empleo de Aprotinina en Artroplastia de Cadera (GEEEAAC).

Aprotinin is a protease inhibitor of interest for its antifibrinolytic effect of reducing perioperative bleeding in certain types of surgery, with wide use in heart surgery, liver transplantation and vascular surgery. The application of aprotinin during orthopedic surgery has recently been suggested. Such use is controversial, as there is lack of consensus as to the type of patient for whom aprotinin administration would be indicated, the surgical procedure during which it would be most effective (hip or knee arthroplasty, spinal arthrodesis, major tumor or septic surgery), the doses to administer, its safety and its real efficacy for conserving homologous blood. That is to say, there is no agreement as to the cost/benefit relation of aprotinin for the various types of orthopedic surgery. This critical review of the literature leads to the conclusion that aprotinin is a promising drug for use in orthopedic surgery, given that published studies have established the benefit in blood product savings and decreased blood loss during surgery.

Reducción de las necesidades transfusionales con aprotinina en cirugía ortopédica / Reduced transfusional requirements with aprotinin in orthopedic surgery

La aprotinina es un inhibidor de las proteasas que tiene interés en la actualidad en su calidad de antifibrinolítico para disminuir el sangrado perioperatorio en determinados tipos de cirugía, y su uso está admitido ampliamente en cirugía cardíaca, en el trasplante hepático y en cirugía vascular.Recientemente se ha propuesto su empleo en cirugía ortopédica. Se trata de una indicación controvertida por la falta de unanimidad en el tipo de paciente en el que la aprotinina estaría indicada, en el procedimiento quirúrgico en el que se conseguiría una mayor efectividad (artroplastia de cadera, artroplastia de rodilla, artrodesis raquídea, cirugía mayor tumoral o séptica), en las dosis que se deben administrar, en la seguridad de su empleo y en la eficacia real en el ahorro de sangre homóloga. Es decir, no hay acuerdo en cuanto al rendimiento de la relación coste/beneficio del fármaco en los diferentes procedimientos de cirugía ortopédica.En esta revisión se hace un estudio crítico de las publicaciones al respecto, concluyendo finalmente que se trata de un fármaco prometedor en cirugía ortopédica, dado que en los estudios publicados se ha obtenido un beneficio en relación con el ahorro de hemoderivados y con la disminución de sangrado perioperatorio (AU)

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Differential intra-epithelial lymphocyte phenotypes following Cryptosporidium parvum challenge in susceptible and resistant athymic strains of mice.

The lack of immunocompetent laboratory animal models has limited our understanding of functional immune responses to Cryptosporidium parvum infection, but such responses have been studied in susceptible laboratory rodents with genetic, acquired, or induced immunodeficiencies. We previously observed that athymic C57BL/6J nude mice inoculated with C. parvum oocysts had lower or absent fecal oocyst excretion when compared to inoculated athymic BALB/cJ nude mice. This discrepancy prompted us to explore potential differences in intestinal immune responses in both strains. Prior to and after C. parvum challenge, BALB/cJ nude and C57BL/6J nude mice did not differ in either spleen cell numbers or in parasite-specific proliferation. However, both strains of mice exhibited a significant increase in intra-epithelial lymphocyte (IEL) numbers prior to and following C. parvum inoculation when compared to uninoculated controls (P<0.05). Prior to challenge, C57BL/6J nude mice had a higher percentage of both CD8+ and CD8+ gammadelta+ IEL than BALB/cJ nude mice. Following challenge, resistant C57BL/6J nude mice had a higher percentage of gammadelta+, CD4+, and CD8+ gammadelta+ IEL than uninoculated C57BL/6J nude mice and than susceptible BALB/cJ nude mice (P<0.05). Conversely, inoculated C57BL/6J nude mice had a significantly lower percentage of alphabeta+ IEL than inoculated BALB/cJ nude mice (P<0.05). We conclude that gammadelta+, CD4+, and/or CD8+ gammadelta+ IEL may influence responses to cryptosporidiosis in athymic murine models, and that the increased percentage of alphabeta+ IEL in susceptible BALB/cJ nude mice could reflect a preferential expression during chronic C. parvum infection and/or might downregulate local protective responses.