[Reversal of acenocoumarol anticoagulation with activated factor VII in massive hemorrhage following rupture of a splenic artery pseudoaneurysm]

A 66-year-old man with a metallic valve and under treatment with acenocoumarol developed hypovolemic shock after rupture of a splenic artery pseudoaneurysm. We managed to reverse anticoagulation within 60 minutes by administering 20 mg of vitamin K and 4.8 mg of activated recombinant factor VII. No thromboembolic adverse events were observed. We discuss the pharmacologic effects of coumarin derivatives and their antagonists, as well as the use of activated factor VII in the reversal of anticoagulation by these drugs.

Interplay between human leukocyte antigen genes and the microbial colonization process of the newborn intestine

Coeliac disease (CD) development involves genetic (HLA-DQ2/DQ8) and environmental factors. Herein, the influence of the HLA-DQ genotype on the gut colonization process of breast-fed children was determined. A cohort of 20 newborns, with at least one first-degree relative with CD, were classified according to their HLA-DQ genotype into high, intermediate and low genetic risk groups, showing 24-28%, 7-8% and less than 1% probability to develop CD, respectively. Faecal microbiota was analysed at 7 days, 1 and 4 months of children's age by fluorescence in situ hybridization. When considering all data, Gram-negative bacteria and Bacteroides-Prevotella group proportions were higher (P<0.05) in the high than in the intermediate and low genetic risk groups. E. coli, Streptococcus-Lactococcus, E. rectale-C. coccoides, sulphate-reducing bacteria, C. lituseburense and C. histolyticum group proportions were also significantly higher (P<0.05) in the high than in the low genetic risk group. Correlations between these bacterial groups and the genetic risk were also detected (P<0.05). In addition, the number and type of CD relative seemed to influence (P<0.050) these bacterial proportions in children at CD risk. At 4 months of age, similar relationships were established between the high genetic risk to develop CD and the proportions of Streptococcus-Lactococcus (P<0.05), E. rectale-C. coccoides (P<0.05), C. lituseburense (P<0.05), C. histolyticum (P<0.05), Bacteroides-Prevotella (P<0.10) groups and total Gram-negative bacteria (P<0.05). The results suggest a relationship between HLA-DQ genes and the gut microbial colonization process that could lead to a change in the way this disorder is investigated.

Effect of the response to first-line chemotherapy (chemo) in the chemotherapy-induced anemia control with the administration of Erithropoyetins (Epos) in metastatic non-small cell lung cancer (NSCLC) patients (pt)

e20647

Background: The aim of this retrospective study, is to measure the influence of the tumor control with chemo on the results of the chemo-induced anemia treatment with epos in pts with nsclc, that were non-anemic before chemo, and in whom the only recorded cause of anemia was chemotherapy treatment. cycle. Methods: We analyzed 57 stage IV nsclc pt (21 Squamous, 26 Adenocarcioma, 4 Lare cell, 6 non specified), 41 male, 16 female, 30 with tumor progression (progression) and 27 with partial response (responders). Average age was 60.3 years (CI 95%: 57.2; 63.4). Pt were treated between April 2004 and May 2008. Any patient with disease stabilization was included. 52 pt were treated with platin-gemcitabine, and 5 with cisplatin-paclitaxel. 17 pt received Erithropoyetin-α and 40 darbepoetin. Pt who received radiotherapy as part of their treatment, were excluded of the analysis. Pt began treatment of epos when hemoglobin (hgb) was <12gr/dl. Epos treatment was discontinued if the hgb level increased over 13gr/dl. No patient received epos with the first chemo cycle. Results: Pt with progression began the epos significantly before ( 100% before 4th chemo, 50% in the 2nd cycle) than responders ( 100% before 5th cycle, 7,4% at 2nd cycle) (p<0.001). Pt with progression, had a lower value of hgb at the beginning of the epos (median 9.82 in responders; 8.89 in progression; p=0.009). Recovery of the anemia was observed in 25.9% of the responders front to 3.3% of the pt with progression (p=0.014). No significant differences appeared in the requirements for red-cells transfusion (14.8% responders vs 30% progression; p=0.172). The mean hgb increase by each chemo cycle with epos was of 0.74gr/dl in responders and of 0.25gr/dl in pt with progression (p<0.001 CI 95%: 0.232–0.748 for the odds ratio). The mean absolute hgb increase in responders was singnificanly greater than in pt with progression (1.49 gr/dl vs 0.7 gr/dl p=0.008CI 95% 0.21–1.368 for the difference of the means). Conclusions: From the obtained data, we can conclude that the tumor response can have a direct impact on the efficacy of chemo-induced anemia treatment with epos; and that anemia control may reflect beneath disease control.

No significant financial relationships to disclose.

Changes in messenger RNA abundance of amino acid transporters in rat mammary gland during pregnancy, lactation, and weaning

During lactation, the mammary gland increases the needs for nutrients to fulfill the milk production requirements. Among these nutrients, amino acids play an important role for the synthesis of milk proteins. Amino acids are supplied to the mammary gland through amino acid transporters, although some are synthesized in situ. The purpose of this study was to establish the pattern of changes in messenger RNA abundance of the amino acid transporters ASC, system L, EAAC1, GLAST, CAT-1, and Tau in the mammary gland of the rat during different stages of pregnancy and lactation. Rats were fed during pregnancy and lactation a 20% casein diet. Food intake increased significantly during the lactation period. Amino acid transporter ASC expression increased during the first days of pregnancy about 2-fold, and it was increased in a lesser extent again during the peak of lactation. The expression of system L (LAT-1) and CAT-1 transporters was increased only during the lactation period. On the other hand, the expression of the transporters for anionic amino acids EAAC1 and GLAST was low during both stages. Finally, taurine transporter expression decreased during pregnancy; and it was significantly lower during lactation. These results showed that amino acid transporters were not expressed similarly in the mammary gland during pregnancy and lactation, indicating that the expression of these transporters did not respond only to the metabolic needs of the gland but depended on the dietary protein supply and possibly the specific hormonal changes that occur during pregnancy and lactation.

Assessing the reproducibility of the microscopic diagnosis of sessile serrated adenoma of the colon

INTRODUCTION

sessile serrated adenoma (SSA) is a recently described lesion that may be related to the development of up to 15% of colorectal cancers (CRCs).

OBJECTIVE

to determine the accuracy of morphological criteria for the diagnosis of SSA by assessing concordance between pathologists.

MATERIAL AND METHODS

concordance between two pathologists in the diagnosis of serrated lesions of the colon was studied for 195 lesions (187 hyperplastic polyps and 7 serrated adenomas). Size, location, morphology, and sampling method were collected of each lesion. Both pathologists were unaware of the previous diagnosis, macroscopic characteristics, and location of lesions. Possible diagnoses were: SSA, traditional serrated adenoma (TSA), hyperplastic polyp (HP), serrated polyp, tubular adenoma, or mixed lesions. Diagnostic doubts had to be described. Concordance between both observers was assessed using the kappa index (ê). The influence of collected variables on concordance degree was also evaluated.

RESULTS

overall agreement on the histological diagnosis was poor (ê = 0.14), and so was agreement on the diagnosis of SSA (ê = 0.23). Concordance in the diagnosis of SSA improved with size > 5 mm (ê = 0.64) and proximal location (ê = 0.43).

CONCLUSION

in a real clinical setting, the existing morphological criteria for SSA identification may be difficult to use.

[Paresthesia and spinal anesthesia for cesarean section: comparison of patient positioning]

OBJECTIVE

To determine the incidence of paresthesia during lumbar puncture performed with the patient in different positions.

MATERIAL AND METHODS

A single-blind prospective study of patients scheduled for elective cesarean section, randomized to 3 groups. In group 1 patients were seated in the direction of the long axis of the table, with heels resting on the table. In group 2 they were seated perpendicular to the long axis of the table, with legs hanging from the table. In group 3 they were in left lateral decubitus position. Lumbar punctures were performed with a 27-gauge Whitacre needle.

RESULTS

One hundred sixty-eight patients (56 per group) were enrolled. Paresthesia occurred most often in group 3 (P = .009). We observed no differences in blood pressure after patients moved from decubitus position to the assigned position. Nor did we observe between-group differences in blood pressure according to position taken during puncture.

CONCLUSION

Puncture undertaken with the patient seated, heels on the table and knees slightly bent, is associated with a lower incidence of paresthesia than puncture performed with the patient seated, legs hanging from the table. Placing the patient's heels on the table requires hip flexion and leads to anterior displacement of nerve roots in the dural sac. Such displacement would increase the nerve-free zone on the posterior side of the sac, thereby decreasing the likelihood of paresthesia during lumbar puncture. A left lateral decubitus position would increase the likelihood of paresthesia, possibly because the anesthetist may inadvertently not follow the medial line when inserting the needle.

[Trapped epidural catheter: reconstruction of computed tomography images]

A trapped epidural catheter without a knot is a rare complication. During placement of an epidural catheter for analgesia during labor, resistance made it impossible to position the catheter within the epidural space. A second catheter was inserted to provide the required analgesia. When the second catheter was removed, computed tomography (CT) revealed that the tip of the first catheter was close to the the right facet joint space. A second attempt to extract the catheter failed. In light of this situation, the patient was seated with the spine slightly bent to one side, a guidewire was inserted through the catheter lumen, and the catheter and guidewire were gently pulled; the catheter was extracted without causing the tip to break up. Three-dimensional CT reconstruction allowed the catheter tip and characteristics of the joint surfaces to be observed. We discuss protcols and alternative strategies that can be followed when an epidural catheter is difficult to remove, including the most appropriate images to use for guidance.

Clinical implications of epidural fat in the spinal canal. A scanning electron microscopic study

BACKGROUND AND OBJECTIVES

This review of articles summarizes recent developments in relation to fat located in the epidural space and also in dural sleeves of spinal nerve roots in order to improve our understanding of the clinical effects of the epidural blockade.

METHOD

Medline search was carried cross-matching of the following words: "epidural fat", "epidural space", "adipose tissue" and "fat cells" from 1966 to 2008 in which articles referring to different pathologies that alter the epidural fat were also reviewed. Techniques used by different authors included the use of samples from dissections, cryomicrotome sections, as well as light and electron microscopy.

RESULTS

Fat in the epidural space has a metameric distribution along the spinal canal that can be altered in some pathological conditions. Epidural fat is not evenly distributed. At cervical level fat is absent while in the lumbar region, fat in the anterior and posterior aspects of the epidural space forms two unconnected structures. Fat cells are found also in the thickness of dural sleeves enveloping spinal nerve roots but not in the region of the dural sac. Epidural lipomatosis is characterized by an increase in epidural fat content. When a patient has a combination of kyphosis and scoliosis of the spine, the epidural fat distributes asymmetrically. Spinal stenosis is frequently accompanied by a reduction in the amount of epidural fat around the stenotic area.

CONCLUSIONS

The epidural space contains abundant epidural fat that distributes along the spinal canal in a predictable pattern. Fat cells are also abundant in the dura that forms the sleeves around spinal nerve roots but they are not embedded within the laminas that form the dura mater of the dural sac. Drugs stored in fat, inside dural sleeves, could have a greater impact on nerve roots than drugs stored in epidural fat, given that the concentration of fat is proportionally higher inside nerve root sleeves than in the epidural space, and that the distance between nerves and fat is shorter. Similarly, changes in fat content and distribution caused by different pathologies may alter the absorption and distribution of drugs injected in the epidural space.

[Is oxygen therapy truly useful and necessary during elective cesarean section under spinal anesthesia?]

OBJECTIVE

To analyze maternal and fetal well-being with and without the application of oxygen therapy.

MATERIAL AND METHODS

Randomized trial of full-term parturients who had received prenatal care during pregnancy. The women were healthy and classified as ASA 1. They were scheduled for delivery by cesarean section under spinal anesthesia and randomized to 2 groups to breathe room air or air providing an inspired oxygen fraction of 40% through a face mask. We assessed the well-being of the neonate immediately after birth with the Apgar test and by measuring umbilical cord blood gases.

RESULTS

One hundred thirty women were enrolled. Both groups were similar, with no differences in demographic or hemodynamic variables, time from uterine incision to fetal extraction, neonatal birth weight, presence of umbilical cord abnormalities, type of resuscitation required by the neonate, or Apgar score in the first or fifth minute. Oxygen saturation in maternal blood by pulse oximetry was higher after 10 minutes in the group of women who received supplemental oxygen through face masks. We also observed significant differences in umbilical cord arterial blood between the room air and supplemental oxygen groups, respectively, as follows: PaCO2, 51.14 mm Hg vs 54.33 mm Hg (P=.016); bicarbonate, 22.19 mEq L(-1) vs 23.23 mEq L(-1) (P=.012); lactate, 1.85 mmol L(-1) vs 1.64 mmol L(-1) (P=.038). The PO2 in venous blood also differed significantly: 25.53 mm Hg vs 28.13 mm Hg, respectively (P=033).

CONCLUSIONS

Breathing supplemental oxygen or not during elective cesarean delivery of healthy parturients under spinal anesthesia does not have a significant effect on neonatal well-being.

Porcine circovirus 2 inclusion bodies in pulmonary and renal epithelial cells

Porcine circovirus 2 (PCV2) is the cause of postweaning multisystemic wasting syndrome (PMWS). The most common lesions of PMWS are lymphohistiocytic to granulomatous lymphadenitis, interstitial pneumonia and interstitial nephritis, with intracytoplasmic amphophilic botryoid inclusion bodies in macrophages. In addition to these typical changes, intracytoplasmic botryoid inclusion bodies were observed in bronchial, bronchial glandular, and renal tubular epithelium of several pigs from 4 different farms in Western and Eastern Canada. PCV2 inclusion bodies were demonstrated to be located in the cytoplasm of epithelial cells by immunohistochemical staining for PCV2 and cytokeratin antigens and by ultrastructural demonstration of viral particles in the inclusion bodies within renal tubular epithelium.

Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial

OBJECTIVE

To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up.

DESIGN

Randomised controlled trial.

SETTING

University hospital in Sweden.

POPULATION

A total of 165 women diagnosed with a third- to fourth-degree perineal tear.

METHODS

The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up.

MAIN OUTCOME MEASURES

Anal incontinence measured by the validated Pescatori incontinence score.

RESULTS

A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces.

CONCLUSION

Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.

[Continuous subarachnoid analgesia and anesthesia for labor and cesarean section in a patient who had previously undergone surgery for ependymoma]

We report the case of a 38-year-old primipara who had undergone surgery 2 years earlier for an intradural ependymoma at L2-L3 and who was currently asymptomatic. A combined epidural-subarachnoid block was performed for analgesia during labor but this technique was only effective for the first 2 hours. When analgesia via epidural cannula was no longer adequate, it was decided to perform a continuous subarachnoid block. Later, the fetus's head was seen to be too large to fit through the pelvis; for cesarean section, the mother was administered fractionated doses of local anesthetic via the subarachnoid cannula until analgesia reached T4. The patient did not develop postdural puncture headache. Continuous subarachnoid anesthesia may be considered the technique of choice where the patient has a history of spinal surgery.

[Aquagenic keratoderma: 3 new cases and a review of the literature]

Aquagenic keratoderma is a rare type of transient acquired keratoderma that is triggered or exacerbated by immersion of the palms or soles in water. It is characterized by whitish or translucent papules with central punctate depressions that coalesce in macerated edematous plaques. It appears within a few minutes of exposure to water and subsides soon after drying. We describe 3 new cases of aquagenic keratoderma in a 28-year-old man with a history of Behçet disease, an 18-year-old woman, and a 20-year-old man. We discuss the clinical and histopathologic features, treatment options, and course of the lesions in the cases described in the literature.

Bioaccumulation of persistent organic pollutants in female common dolphins (Delphinus delphis) and harbour porpoises (Phocoena phocoena) from western European seas: geographical trends, causal factors and effects on reproduction and mortality

Concentrations of polychlorinated biphenyls (PCBs) in blubber of female common dolphins and harbour porpoises from the Atlantic coast of Europe were frequently above the threshold at which effects on reproduction could be expected, in 40% and 47% of cases respectively. This rose to 74% for porpoises from the southern North Sea. PCB concentrations were also high in southern North Sea fish. The average pregnancy rate recorded in porpoises (42%) in the study area was lower than in the western Atlantic but that in common dolphins (25%) was similar to that of the western Atlantic population. Porpoises that died from disease or parasitic infection had higher concentrations of persistent organic pollutants (POPs) than animals dying from other causes. Few of the common dolphins sampled had died from disease or parasitic infection. POP profiles in common dolphin blubber were related to individual feeding history while those in porpoises were more strongly related to condition.

Acquired angioedema associated with hereditary angioedema due to C1 inhibitor deficiency

Angioedema caused by C1 inhibitor deficiency is a rare disorder that may be either hereditary or acquired, the latter being mainly associated with lymphoproliferative disorders. A 51-year-old woman who had suffered from episodes of acute peripheral edema since she was 12 was diagnosed with hereditary angioedema at the age of 40 and remained stable with stanozolol. Due to a worsening of her symptoms she was reassessed and low levels of C1q and an abnormal lymphocyte count were detected. Immunophenotyping of peripheral blood revealed 9% monoclonal lambda B cells with a follicular center phenotype. The histopathology was consistent with a grade II follicular lymphoma stage IV-A.With chemotherapy, the hematologic disease was controlled and C1q levels returned to normal values. This represents a rare case of a patient with hereditary angioedema who developed acquired angioedema due to a lymphoma that was associated with a reduction in the levels of C1q as her symptoms worsened.

Chlorthalidone inhibits the KvLQT1 potassium current in guinea-pig ventricular myocytes and oocytes from Xenopus laevis

BACKGROUND AND PURPOSE

Chlorthalidone is used for the treatment of hypertension as it produces a lengthening of the cardiac action potential. However, there is no experimental evidence that chlorthalidone has electrophysiological effects on the potassium currents involved in cardiac repolarization.

EXPERIMENTAL APPROACH

Ventricular myocytes and oocytes, transfected with human ionic channels that produce IK current, were exposed to different concentrations of chlorthalidone. Action potentials and potassium currents were recorded using a patch clamp technique. To determine which component of the current was affected by chlorthalidone, human channel proteins (hERG, minK and KvLQT1) were used.

KEY RESULTS

Chlorthalidone prolonged the ventricular action potential at 50 and 90% by 13 and 14%, respectively. The cardiac potassium currents I(to) and IK(1) were not affected by chlorthalidone at any concentration, whereas the delayed rectifier potassium current, IK, was blocked in a dose-response, voltage-independent fashion. In our preparation, 100 microM chlorthalidone blocked the two components of the delayed rectifier potassium current with the same potency (50.1+/-5% for IK(r) and 54.6+/-6% for IK(s)) (n=7, P<0.05). The chlorthalidone-sensitive current was slow and saturated at potentials greater than +30 mV. In our conditions only the KvLQT1 potassium current was affected by the drug, by 14%.

CONCLUSIONS AND IMPLICATIONS

Chlorthalidone was demonstrated to have a direct effect on cardiac ventricular myocytes; it blocked the delayed rectifier potassium current (IK), specifically the KvLQT1 component of the potassium current. These results indicate that it has potential for use as an antiarrhythmic but further studies are needed.

Biological and ecological factors related to trace element levels in harbour porpoises (Phocoena phocoena) from European waters

Selected trace elements (Cd, Cu, Hg, Se, Zn) were measured in the kidneys and the liver of 104 harbour porpoises (Phocoena phocoena) stranded along the coasts of France, Galicia (Spain), Ireland, Scotland (UK), and the Netherlands. Generally, relatively low concentrations of toxic elements were encountered in the tissues of European porpoises, except for two individuals, which displayed high hepatic Hg concentrations. Also, elevated Cd levels obtained in Scottish porpoises could be related to their feeding preferences and this result suggests an increase of the proportion of cephalopods in their diet with latitude. Moreover, significant geographical differences were seen in hepatic Zn concentrations; the elevated Zn concentrations displayed by porpoises from the Netherlands may relate their poor health status. Variation in metal concentrations within porpoises from the North Sea is likely to reflect a long-term segregation between animals from northern (Scotland) and southern areas (the Netherlands), making trace elements powerful ecological tracers.

Melatonin administration prevents cardiac and diaphragmatic mitochondrial oxidative damage in senescence-accelerated mice

Cardiac and diaphragmatic mitochondria from male SAMP8 (senescent) and SAMR1 (resistant) mice of 5 or 10 months of age were studied. Levels of lipid peroxidation (LPO), glutathione (GSH), GSH disulfide (GSSG), and GSH peroxidase and GSH reductase (GRd) activities were measured. In addition, the effect of chronic treatment with the antioxidant melatonin from 1 to 10 months of age was evaluated. Cardiac and diaphragmatic mitochondria show an age-dependent increase in LPO levels and a reduction in GSH:GSSG ratios. Chronic treatment with melatonin counteracted the age-dependent LPO increase and GSH:GSSG ratio reduction in these mitochondria. Melatonin also increased GRd activity, an effect that may account for the maintenance of the mitochondrial GSH pool. Total mitochondrial content of GSH increased after melatonin treatment. In general, the effects of age and melatonin treatment were similar in senescence-resistant mice (SAMR1) and SAMP8 cardiac and diaphragmatic mitochondria, suggesting that these mice strains display similar mitochondrial oxidative damage at the age of 10 months. The results also support the efficacy of long-term melatonin treatment in preventing the age-dependent mitochondrial oxidative stress.

La artrodesis de las cuatro esquinas con placa circular

Objetivo: La artrodesis de las cuatro esquinas del carpo fue descrita inicialmente para el tratamiento del colapso avanzado del carpo e incluye la extirpación del escafoides y la fusión de los huesos semilunar, piramidal, hueso grande y ganchoso. Se ha utilizado la fijación con placas circulares con el objetivo de conseguir una fijación estable inmediata. El propósito de este estudio es evaluar la efectividad de estas placas en esta artrodesis mediocarpiana y valorar sus indicaciones así como ciertas consideraciones técnicas.

Material y métodos: En este estudio se ha incluido una serie de 20 pacientes intervenidos para practicar una artrodesis de las cuatro esquinas con placa SpiderÒ que presentaban un estadio II ó III de proceso degenerativo avanzado del carpo. También se ha utilizado esta técnica para otras indicaciones como las lesiones osteocondrales de la cabeza del hueso grande, necrosis avascular de la cabeza del hueso grande, artrosis mediocarpiana o inestabilidad mediocarpiana. El seguimiento medio ha sido de 18 meses (R= 8-25).

Resultados y conclusiones: Se ha conseguido el 100% de consolidaciones, y una importante disminución del dolor en todos los casos, manteniéndose una flexión palmar postquirúrgica de 34º (R= 12-45º); una flexión dorsal de 29º (R= 12-45º); una desviación radial postoperatoria de 12º (R= 0-16º) y una desviación cubital de 17º (R= 0-20º). Se apreció un aumento de la fuerza de agarre tras la cirugía y todos los pacientes volvieron a sus actividades previas.

Esta técnica quirúrgica ofrece una fijación estable inmediata que permite una movilización precoz tras la cirugía. Es importante el relleno de injerto de escafoides o cresta iliaca en los espacios entre los huesos a artrodesar.

[Fat inside the dural sheath of lumbar nerve roots in humans]

OBJECTIVES

Epidural fat deposition, which varies at different levels of the vertebral column, generates a reservoir from which retained lipophilic substances could be redistributed. The aim of the study was to determine whether fat is deposited within or underneath the dural sheath or whether it is only found within the epidural space, outside the sheath.

MATERIAL AND METHODS

Samples of dural sheath from the lumbar spine of human cadavers aged 65 to 72 years were analyzed by scanning electron microscopy.

RESULTS

The dural sheaths were made up of an arachnoid layer and a dura mater with a thickness of 100 to 150 microm. A large number of adipocytes were observed between the layers of the dura mater as well as beneath it.

CONCLUSIONS

Fat similar to that found in the peripheral nerves is present within and underneath the dural sheaths. The fat found in the dural sheaths would be in close contact with the axons of the nerve roots, unlike the fat contained in the epidural space. The release of lipophilic substances from the fat in the dural sheath could have a greater effect on the nerve roots due to the limited distance that separates the fat from the axons as well as to the poor vascular clearance.

[Horner's syndrome secondary to epidural anesthesia]

INTRODUCTION

The Horner's syndrome in association with the anesthetic techniques is produced by a blockade of the stellate ganglion sympathetic fibers. This complication is produced by the local anesthetic non-expected migration when it is administered either in the epidural space while performing an epidural block or inside the aponeurosis vascular elements during the performance of a brachial plexus block. Its evolution is quick, with benign incident that disappears in a few hours, without leaving any sequels. It can occur in patients without any previous clinical condition.

CLINICAL CASE

We described the case of 28 years old pregnant woman, with a body mass index of 40.6, without any previous neurological background, who was admitted into hospital for labour. She had epidural analgesia and needed a caesarean section 2 hours later. Twenty minutes after the administration of an epidural dose of local anesthetic, the patient developed a completed left side Horner's Syndrome, as well as ipsi-lateral brachial paresis, that lasted for three hours, with complete recovery.

CONCLUSIONS

Several etiopathologenic options were considered at the time, such as a possible subdural or paravertebral migration of the local anesthetic, the influence of the patient's position (decubitus) and the possible existence of fibrotic compartments in the epidurals space.

[Epidural fat in various diseases: contribution of magnetic resonance imaging and potential implications for neuro axial anesthesia]

Epidural fat is a reservoir of lipophilic substances that cushions the pulsatile movements of the dural sac, protects nerve structures, and facilitates the movement of the dural sac over the periosteum of the spinal canal during flexion and extension. Excessive epidural fat can compress the underlying structures, however, and affect the placement of catheters and the distribution of injected solutions. This review discusses changes in epidural fat related to various diseases and events: lipomatosis, epidural lymphoma, arachnoid cysts, epidural hematoma, meningiomas, angiolipomas, spondylolysis, scoliosis, spinal stenosis, and liposarcoma. Also discussed are the sequencing and protocols for magnetic resonance imaging that enable epidural fat to be observed and distinguished from neighboring structures. The relevance of epidural fat in spinal surgery is considered. Finally, we discuss the possible anesthetic implications of the abnormal deposition of epidural fat, to explain the unexpected complications that can arise during performance of epidural anesthesia.

Outcome of pregnancy in a hypothyroid woman with resistance to thyroid hormone treated with triiodothyronine

Epidemiological and research data have shown the significant role of maternal thyroid hormone in fetal neurologic development. It has been suggested that maternal hypothyroxinemia is potentially damaging for the neurodevelopment of the fetus, independently of T3 levels. We present a pregnant woman with resistance to thyroid hormone and iatrogenic hypothyroidism who was treated with triiodothyronine during the whole pregnancy. Even though maternal hypothyroxinemia was severe the children showed a normal neuropsychological development.

Characterization and regulation of the gene expression of amino acid transport system A (SNAT2) in rat mammary gland

Amino acid transport via system A plays an important role during lactation, promoting the uptake of small neutral amino acids, mainly alanine and glutamine. However, the regulation of gene expression of system A [sodium-coupled neutral amino acid transporter (SNAT)2] in mammary gland has not been studied. The aim of the present work was to understand the possible mechanisms of regulation of SNAT2 in the rat mammary gland. Incubation of gland explants in amino acid-free medium induced the expression of SNAT2, and this response was repressed by the presence of small neutral amino acids or by actinomycin D but not by large neutral or cationic amino acids. The half-life of SNAT2 mRNA was 67 min, indicating a rapid turnover. In addition, SNAT2 expression in the mammary gland was induced by forskolin and PMA, inducers of PKA and PKC signaling pathways, respectively. Inhibitors of PKA and PKC pathways partially prevented the upregulation of SNAT2 mRNA during adaptive regulation. Interestingly, SNAT2 mRNA was induced during pregnancy and to a lesser extent at peak lactation. beta-Estradiol stimulated the expression of SNAT2 in mammary gland explants; this stimulation was prevented by the estrogen receptor inhibitor ICI-182780. Our findings clearly demonstrated that the SNAT2 gene is regulated by multiple pathways, indicating that the expression of this amino acid transport system is tightly controlled due to its importance for the mammary gland during pregnancy and lactation to prepare the gland for the transport of amino acids during lactation.

Human Anaplasmosis: The First Spanish Case Confirmed by PCR

We report a case of human anaplasmosis (HA) fulfilling the confirmation criteria: epidemiologic data and clinical picture compatible with HA; presence of a morulae within polymorphonuclear leukocyte; and positive PCR assay for Anaplasma phagocytophilum: This case report shows the presence of HA in Spain.

Lead contamination of small cetaceans in European waters--the use of stable isotopes for identifying the sources of lead exposure

Lead concentrations and isotopic composition have been measured in bone and teeth of small cetaceans belonging to three species (Delphinus delphis, Phocoena phocoena and Stenella coeruleoalba), to evaluate the toxicological risk and to determine sources of lead in the European waters. Lead concentrations, far lower than threshold value inducing toxic effects in human, were higher in teeth than in bones, but highly correlated between the two tissues (r=0.92, p<0.001). Large variations of 206Pb/207Pb values in bone tissue showed that cetaceans must be submitted to various atmospheric influences. No geographical differences appeared which is consistent with studies on their distribution indicating seasonal movements between Brittany waters and the Bay of Biscay. The negative correlation between 206Pb/207Pb ratios and age of the individuals reflected the decrease in the production of alkyl lead in Europe, i.e., the increasing use of unleaded gasoline.

Cost of febrile neutropenia management in cancer patients in Spain

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Background: Febrile neutropenia (FN), a dose-limiting event for many myelosuppressive chemotherapy (CT) regimens, often causes subsequent CT dose delays (DD) and reductions (DR), lengthens hospital stay and increases monitoring, diagnostic and treatment costs. No studies are known to date on economic costs of FN in common clinical practice in Spain. Methods: This is a multicentre, retrospective, observational chart review of adult patients with breast cancer, lung cancer or non-Hodgkin’s lymphoma (NHL) who suffered from at least one FN episode related to cytotoxic CT from 16 Spanish hospitals. Resource use and subsequent costs including days of hospitalization, number of RBC transfusions, number and type of complementary tests, use of colony-stimulating factors (CSF), antibiotics and other drugs to manage FN were assessed. Potential impact of FN on planned CT dose and/or schedule was also analysed. P-value was obtained by one-way ANOVA using the Bonferroni correction. Results: A total of 194 medical charts including 238 documented FN episodes were reviewed. Women, 59.8%; age > 60 yrs, 49.5%; breast cancer, 43% (83% treated with taxane or anthracycline-based CT); lung cancer, 22% (95.5% treated with platinum-based CT); NHL, 35% (58.2% treated with CHOP-like CT). Hospitalization due to FN lasted a median of 7 days. During the episode, 32.3% of pts needed 1 or more RBC transfusions, 97.9% required a blood test and 87% a blood culture. CSFs were used in 67.6% of pts. All pts were treated with antibiotics and 78.2% with other drugs. 58.4% of FN episodes had an impact on planned CT dose and/or schedule: DR was observed in 34.9% of cases, DD in 28% and CT withdrawal in 14.7%. Conclusions: Main drivers of cost of FN are hospitalization and antibiotic treatment. FN is more costly in NHL pts than breast or lung pts (statistically significant in lung pts). FN episodes have a relevant impact on planned CT dose and/or schedule. In each row statistically significant differences ( p<0.05) were obtained between values with the same letter.

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[Characteristics and distribution of normal human epidural fat]

Epidural fat provides sufficient cushion for the pulsatile movements of the dural sac, protects nerve structures, facilitates the movement of the dural sac over the periosteum of the spinal column during flexion and extension, and forms a pharmacologic reservoir of lipophilic substances. We review epidural fat and related structures, including their development during the fetal period when the epidural space is filled by undifferentiated loose, areolar mesenchymal tissue that surrounds the dural sac. In the adult, epidural fat has a continuous distribution and follows a certain metameric pattern. It is located mainly on the dorsal side of the epidural space, where it is organized in triangular capsules joined to the midline of the ligamentum flavum by a vascular pedicle. We consider the distribution of epidural fat in the axial and sagittal planes; its presence in the anterior, lateral and posterior epidural space; its presence in the cervical, thoracic and lumbar portions of the spinal column; and its characteristics and variations according to differing body habits and sex. Finally, we speculate on the possible anesthetic implications of epidural fat in terms of the pharmacokinetics of drugs injected into the epidural space and the tasks of locating the epidural space and inserting an epidural catheter during anesthetic procedures.

[Systematic review of group educational interventions in type-2 diabetes patients]

OBJECTIVES

To evaluate the effect of group educational interventions in type-2 diabetes patients. To analyse what kind of group intervention has the best long-term effects.

DESIGN

Systematic review.

DATA SOURCES

Review of electronic data bases: CENTRAL, MEDLINE, EMBASE, CINAHL, and PASCAL, and of the bibliographic references of the studies selected. Contacts with experts to locate non-published articles. Selection of studies. Randomised clinical studies with controls and quasi-experimental studies that evaluate group education interventions aimed at type-2 diabetes patients over 18 years old. These interventions were of any length and in any context, and their target was to improve quality of life, self-control, or metabolic control. The comparison group included individual educational interventions and non-interventions. VARIABLES RESULT: Quality of life, self-control, and diabetes control (HbA1c, cholesterol, triglycerides, blood pressure, and smoking).

REVIEW METHODS

Trial selection by 3 groups with 3 researchers in each, who independently reviewed headings, abstracts and key words of all the identified trials to decide on their eligibility. The quality of trials was evaluated by the criteria defined by the Cochrane Metabolic and Endocrine Disorders Group. Researchers assessed the articles independently; and discrepancies were resolved by discussion and consensus.

Initial immunosuppression in liver transplant recipients with impaired renal function

Acute renal failure (ARF) after liver transplantation is a factor of poor prognosis associated with a high mortality. Selection of the donor, recipient, and intraoperative and postoperative treatment has crucial importance in the management of these critical patients. Thus, optimization of the use of calcineurin inhibitors (CNI), the main nephrotoxic substances in the immediate postoperative period, may decrease ARF incidence, allowing for early recovery of renal function in this period. Most protocols are based on the reduction or late introduction of CNI, based on the use of mycophenolate mofetil (MMF) with/without antiCD25 (basilximab/daclizumab). Recently, thymoglobulin (ATG) is also being tested to further delay the use of the CNI. A 20%-30% acute rejection incidence with the usual protocols allows recovery of renal function in more than 80% of patients without increasing the incidence of infections or adverse effects. However, it is still unknown whether there is a long-term negative effect of chimeric-humanized monoclonal antibodies and MMF combination on reinfection with hepatitis C virus in transplant recipients.

Relationship between pharmacokinetic parameters of cyclosporin and the incidence of acute rejection after heart transplantation

Despite two decades of use, there are limited data on the best way to monitor Cyclosporine (CsA) for heart transplantation. The aim of our study was to determine the relationships between pharmacokinetic parameters and clinical outcomes after heart transplantation and to evaluate the range of CsA trough levels provided the most effective protection against graft rejection. We retrospectively analyzed the clinical outcomes of all adult patients who received a heart transplant between January 1998 and February 2005. All had routine monitoring of CsA trough levels and scheduled endomyocardial biopsies. Rejection was defined as grade > or =3, based on International Society for Heart and Lung Transplantation (ISHLT) criteria. Follow-up period was 1 year. All patients were on CsA, corticosteroids, and azathioprine/mycophenolate mofetil with or without antilymphocyte induction (eight patients with basiliximab). Data were analyzed by unpaired Student t-test, Cox regression model, and ROC curve. Among 70 patients (60 men and 10 women) who entered the study, 34 (48.6%) had at least one acute rejection episode of grade > or =3 during the first posttransplant year. Mean CsA trough level (C(0)) measured at first week posttransplant was significantly lower in the rejection than the no-rejection group (125.17 +/- 56.9 ng/mL versus 169.33 +/- 48.27 ng/mL, P = .001). C(0) was the strongest predictor of acute graft rejection (P = .000, HR = .985.) The risk decreased by 1.5% for each unit increase of the C(0) value. ROC analysis showed that C(0) of 150 ng/mL provided the optimal cutoff. Patients with mean C(0) >150 ng/mL over the first week had less incidence of acute rejection than patients with levels <150 ng/mL (30.3% versus 64.9%) (P = .009, Cochran-Mantel-Haenszel test). In conclusion, our data suggest that in heart transplant patients it may be crucial to target early trough levels above 150 ng/mL during the first days postsurgery to avoid rejection.

[Aortopulmonary fistula complicating aortic arch aneurysm]

Aortopulmonary fistulas secondary to thoracic aneurysms are difficult to diagnose and few cases are reported in the literature. We describe the case of a patient first admitted to another hospital with a diagnosis of right upper lobe pneumonia. After the patient had been a week in hospital without improving, a computed tomography scan of the chest revealed a saccular aneurysm of the aortic arch measuring 9 cm at its widest diameter. Hemodynamics and respiratory signs deteriorated a few hours after transfer to our hospital. Physical examination revealed a systolic murmur and poor peripheral perfusion. The patient was intubated and inotropic support was provided. Upon insertion of a Swan-Ganz catheter, given suspicion of septic shock, progressive elevation of mixed venous oxygen saturation was observed. Measurement of venous oxygen saturation was 74% in the right atrium and 93% in the pulmonary artery. Left-right shunt was diagnosed and an emergency aortography revealed the aortopulmonary fistula. Emergency surgery was performed with the patient in deep hypothermia and cardiocirculatory arrest. There were no adverse events, and postoperative recovery and clinical course were good.