Four-year safety follow-up of the tetravalent dengue vaccine efficacy randomized controlled trials in Asia and Latin America.

OBJECTIVE: Our objective was to describe the risk of hospital admission for virologically confirmed dengue (VCD) and the risk of clinically severe hospitalized VCD occurring up to 4 years after the first dose (years 1 to 4) in three randomized clinical trials comparing tetravalent dengue vaccine with placebo. METHODS: The relative risks (RR) for hospitalized VCD from first dose to year 4 were estimated by year and age-group in individual and combined studies. RESULTS: Overall, from Year 1 to Year 4, 233 and 228 participants had at least one episode of hospitalized VCD in the vaccinated (n = 22 603) and placebo (n = 11 301) groups, respectively (RR = 0.511, 95% CI 0.42-0.62). Among these, 48 and 47 cases, respectively, were classified as clinically severe. In children aged ≥9 years, 88 and 136 participants had at least one episode of hospitalized VCD in the vaccinated (n = 17 629) and placebo (n = 8821) groups, respectively (RR = 0.324; 95% CI 0.24-0.43). In vaccinated participants aged <9 years, particularly in those aged 2-5 years, there were more hospitalized VCD cases compared with the control participants in Year 3 but not in Year 4. The overall RR in those aged <9 years for Year 1 to Year 4 was 0.786 (95% CI 0.60-1.03), with a higher protective effect in the 6-8 year olds than in the 2-5 year olds. CONCLUSIONS: The overall benefit-risk remained positive in those aged ≥9 years up to year 4, although the protective effect was lower in years 3 and 4 than in years 1 and 2.

Urinoma masquerading as pancreatic pseudocyst.

In this article, we report on a patient with recurrent pancreatitis who had received multiple celiac plexus injections for control of pain, and then developed a cystic mass adjacent to the body and tail of the pancreas suggestive of a pancreatic pseudocyst. The cystic mass proved to be a urinoma. The distinction between pancreatic pseudocyst and urinoma was made by CT scan with intravenous contrast utilizing delayed films, which demonstrated leakage of contrast into the cystic structure. This is the first report of a urinoma that resembled a pancreatic pseudocyst.

Spinal cord compression secondary to extramedullary hematopoiesis: a noninvasive management based on MRI.

We report the first case of spinal cord compression secondary to extramedullary hematopoiesis in which the diagnosis was made by magnetic resonance imaging (MRI). Based on the great advantage of this imaging test that visualizes the entire spine, the noninvasive approach to such patients, using low-dose radiation therapy and guided by MRI is discussed. This management appears to be both efficacious and safe.

Pulsus alternans induced by glyceryl trinitrate paste in a patient with alcoholic cardiomyopathy.

Application of a small dose of glyceryl trinitrate paste (0.25 in) resulted in severe left ventricular dysfunction with the appearance of pulsus alternans in a patient with alcoholic cardiomyopathy. The echocardiogram showed a reduction in the amplitude and velocity of motion of the left ventricular posterior wall on alternate beats. Leg elevation promptly reversed the pulsus alternans, and the echocardiographic abnormality. Glyceryl trinitrate paste should be used with caution and under close supervision in patients with liver dysfunction.

Hemodynamic correlates of echocardiographic aortic root motion. Observations on normal subjects and patients with idiopathic hypertrophic subaortic stenosis.

In ten normal subjects, we observed an initial hump in the aortic root echocardiogram after the onset of the QRS complex, following which a sharp anterior motion was noted. The onset of the anterior motion of the aortic root coincided with the onset of the upstroke of the aortic root pressure pulse and the onset of the velocity signal in five of seven patients with coronary arterial disease; in the other two, the anterior aortic motion followed the onset of the pressure and velocity signal by 10 msec. The aortic root echocardiogram was abnormal in patients with idiopathic hypertrophic subaortic stenosis; the slope (normalized for the scales of time and depth) in early systole was steeper and in the latter part of systole was flatter than normal in these patients. The slope in early diastole was flatter and the slope due to atrial contraction was steeper in the patients with idiopathic hypertrophic subaortic stenosis than in the normal subjects. These features were consistent with rapid ejection in early systole and slow filling in the early phase of ventricular diastole in idiopathic hypertrophic subaortic stenosis. Fourier analysis of the wave form of the aortic root allowed separation between patients with idiopathic hypertrophic subaortic stenosis and normal subjects.

Use of nitroglycerin ointment in congestive heart failure. Results of acute and chronic therapy.

7 consecutive patients with congestive heart failure refractory to standard therapy were treated with nitroglycerin ointment (GTNO). The pulmonary wedge pressure decreased from a control value of 30+/-1 to 15+/-1 mm Hg (mean +/-SEM), and the arteriovenous oxygen difference narrowed from 6.8+/-0.5 to 5.5+/-0.3 ml%, after GTNO therapy. The heart rate decreased in 5 patients and the systolic blood pressure was either unchanged or decreased slightly. A reduction in the echocardiographic end diastolic dimension was noted in all patients. The transmyocardial gradient (systemic artery diastolic pressure - pulmonary artery wedge pressure) increased in all except 1 subject. The double product decreased in 5 of the 7 patients. Hemodynamic improvement was maintained for 4.5-7 h. All patients were symptomatically improved on chronic GTNO treatment. Our results indicate that GTNO is a useful agent in the management of heart failure which is unresponsive to standard therapy.

Limitations of the echocardiogram in diagnosing valvular vegetations in patients with mitral valve prolapse.

In order to assess the reliability of the echocardiogram in detecting valvular vegetations in patients with mitral valve prolapse (MVP), echocardiograms from 85 consecutive patients with mitral valve prolapse were reviewed. Eleven patients had thick shaggy echoes confined to the anterior mitral leaflet; eighteen patients had shaggy echoes on the posterior leaflet; and five had abnormal echoes on both the anterior and posterior leaflets. Only one patient had clinical evidence of infective endocarditis. Redundant leaflets which present multiple surfaces for the production of echoes may explain the abnormal echoes that were observed. Patients with echographic features suggesting mild prolapse less commonly exhibited shaggy leaflet echoes than those with more severe prolapse. Because a significant proportion (40%) of patients with MVP had shaggy echoes which closely resembled those seen in valvular vegetations, we feel that the echocardiogram is of limited value in diagnosing infective endocarditis in patients with mitral valve prolapse.