Specific detection of 16 micro-organisms in amniotic fluid by polymerase chain reaction and its correlation with preterm delivery occurrence

OBJECTIVE

Our purpose was to develop a specific polymerase chain reaction detection method for 16 micro-organisms in amniotic fluid and to correlate its performance with bacterial cultures and preterm delivery occurrence.

STUDY DESIGN

The study group was made up of 50 patients with preterm labor and intact membranes. The control group consisted of 23 patients not in labor and undergoing amniocentesis for either karyotype or lung maturity studies. Polymerase chain reaction and bacterial cultures were assayed in amniotic fluid of all patients. Results were correlated with pregnancy outcome.

RESULTS

Polymerase chain reaction identified micro-organisms in 23 cases in the study group (46%), whereas cultures identified only 6 (12%). All control samples were negative for polymerase chain reaction and cultures. The sensitivity of polymerase chain reaction and cultures for the identification of patients delivering before 34 weeks' gestation was 64% and 18%, respectively.

CONCLUSION

A polymerase chain reaction gene amplification method was developed to identify 16 micro-organisms in amniotic fluid. Compared with bacterial cultures, polymerase chain reaction amplification in amniotic fluid appears to be more sensitive in identifying patients delivering prematurely.

[Placental histopathology in premature rupture of membranes. Its relationship with microbiological findings, maternal, and neonatal outcome]

BACKGROUND

There is a close relationship between premature membrane rupture, bacterial infections and premature labor.

AIM

To study placental histological changes in patients with preterm membrane rupture. To establish a relationship between pathological findings, amniotic fluid and lower genital tract microbiological studies, maternal and neonatal outcome.

PATIENTS AND METHODS

Patients with premature membrane rupture of membranes between 24 and 34 weeks of gestation participated in this study. On admission, patients had no evidence of clinical chorioamnionitis, labor or fetal distress. Microbiological studies of the amniotic fluid and cervicovaginal secretions were performed and the placenta was sent for pathological study.

RESULTS

Seventy one placentas were available for the study. The main pathological findings were acute chorioamnionitis in 58%, trophoblastic proliferation in 38%, funisitis in 37%, villitis in 16%, fetal vascular lesions in 14% and no findings in 17%. Microbial invasion of amniotic cavity was present in 89% of acute chorioamnionitis. Sixty one percent of trophoblastic proliferation and all fetal vascular lesions were associated with negative amniotic and cervical cultures. Newborns with acute funisitis had a higher frequency of neonatal death (29%), severe asphyxia (42%) and neonatal infections (29%).

CONCLUSIONS

Acute chorioamnionitis is the most frequent finding in patients with preterm membrane rupture and microbial invasion of amniotic cavity. In the absence of intra amniotic infection, proliferation of the trophoblast and the presence of fetal vascular lesions predominate. Acute funisitis is strongly associated with adverse fetal outcome.

Antibiotic treatment in preterm labor and intact membranes: a randomized, double-blinded, placebo-controlled trial

Although an association between microbial invasion of amniotic cavity and preterm birth has been extensively demonstrated, there is conflicting evidence regarding the benefits of antibiotic therapy in patients with preterm labor and intact membranes. We attempted to assess the efficacy of amoxicillin and erythromycin on pregnancy outcome in those patients. A randomized, double-blinded, placebo-controlled trial was designed and implemented. A total of 196 patients with singleton pregnancies and preterm labor with intact membranes (22-36 weeks) were randomly allocated to receive either antibiotics or placebo, plus adjunctive parenteral tocolysis, and 173 patients (antibiotics group n = 83 vs. placebo group n = 90) completed the treatment. The overall prevalence of microbial invasion of the amniotic cavity was 5.2% (9/173). No significant difference between both groups was found in maternal outcomes, including duration of randomization-to-delivery interval, frequency of preterm delivery, and frequency of clinical chorioamnionitis and endometritis. Rate of cesarean section was significantly higher in the placebo group (28% vs. 12%). Regarding neonatal outcome, no significant difference was detected between both groups in neonatal death, respiratory distress syndrome, proven sepsis, and birthweight. Suspected sepsis was significantly more frequent in the placebo group (6/90 vs. 0/78). The results of this trial indicate that amoxicillin and erythromycin do not prolong pregnancy in patients with preterm labor and intact membranes. A significant reduction in the rate of cesarean section was observed in patients receiving antibiotics. A significant reduction in the rate of neonatal suspected sepsis was also demonstrated.

[Invasive fungal infections in liver transplant recipients: analysis of 21 cases]

BACKGROUND

Invasive fungal infections (IFI) are one of the most important causes of mortality in liver transplant (LT) recipients. The aim of this study was to describe the characteristics of IFI in the LT program of our institution with an special emphasis in the differences between Candida infections (CI) and that caused by other fungi (NCI).

PATIENTS AND METHODS

Retrospective analysis of the hospital charts of 21 patients who underwent a LT from February 1987 to December 1995. The diagnosis of IFI required the histological evidence of tissue invasion or a positive culture in a tissue sample or in an usually sterile fluid. Esophageal candidiasis was not considered as IFI. Antifungal prophylaxis was performed either with nystatin or fluconazole.

RESULTS

Twenty-one of 356 patients (6%) developed a total of 23 episodes of IFI. Pathogens were Candida spp. (n = 10), Aspergillus (n = 8), Zygomicetes (n = 4) and Cryptococcus (n = 1). Fifty-seven percent of the episodes of IFI (80% of those caused by Candida and 38% of those produced by other fungi; p < 0.05) developed in the first 3 months after transplantation and only 5 episodes appeared after the sixth month. The diagnosis of IFI was done at autopsy in 6 patients (29%). Overall, NCI (13 episodes) predominated over CI (10 episodes), being the later the cause of the 54% of the episodes in the first 178 recipients but only the 30% in the last 178 patients (p = 0.09). No differences were found in the distribution of the risk factors amongst those patients with CI or NCI. Seventeen of the 21 patients (71%) died and 15 of these deaths (72%) were attributable to fungi; 15 patients who died either did not receive amphotericin (n = 6) or received a cumulative dose lower than 500 mg. Six patients received a cumulative dose of more than 1.5 g (mean, 3.2 g) and four of them were cured. Mortality in the nonfungal infection group was 26% (p < 0.001).

CONCLUSIONS

IFI was a rare but severe complication in our LT recipients. The relative frequency of CI was progressively decreasing during the study period, being NCI the predominant infections. Amphotericin therapy was effective only when a high cumulative dose could be administered.

Serum Carotenoid Concentration Changes during Sexual Maturation in Farmed Rainbow Trout (Oncorhynchus mykiss)

One hundred forty individually tagged rainbow trout (Oncorhynchus mykiss) were fed diets supplemented with astaxanthin (100 mg/kg) or canthaxanthin (80 mg/kg) during sexual maturity. Only 20 subjects were followed to the end of experience. Blood sampling was withdrawn each month to evaluate pigment concentrations. In females a decrease took place 1 month before spawning, whereas in males variations were not so marked. Females had a higher carotenoid concentration than males. Mean serum levels of astaxanthin ranged in female rainbow trout from 2.80 to 3.33 µg/mL and from 0.67 to 2.32 µg/mL for canthaxanthin. Serum astaxanthin levels in male trout ranged from 0.99 to 3.28 µg/mL and for canthaxanthin from 0.78 to 1.28 µg/mL. Between-subject (V(b)) and within-subject (V(s)) variations appeared. Serious error can occur when single measurement are used to categorize individuals. Carotenoid levels in the serum of trout during spawning period would not be an adequate indicator for muscle pigmentation.

Clinical, virological, and histologic evolution of hepatitis C virus infection in liver transplant recipients

We designed a prospective study to assess the time course and evolution of hepatitis C virus (HCV) infection in 152 patients who underwent a liver transplantation (LT) in our institution. Forty-four recipients (29%) were infected by HCV after transplantation: 40 who developed recurrent infection after LT and four who acquired infection during or after LT. No differences were found in survival actuarial rates at 1, 2, and 4 years after transplantation for patients infected by HCV vs. noninfected ones. Graft hepatitis occurred in 66% of HCV-infected recipients: 18 developed chronic active hepatitis (10 of them with intense fibrosis) and 2 developed cirrhosis during the follow-up. Infection by the HCV-1b genotype was found in 79% of the infected recipients and in 100% of those in whom histologic evolution was worst. Fourteen grafts were lost in 44 HCV-infected recipients, in comparison with 12 in 108 HCV-negative patients (P = .007), mostly because of chronic rejection. HCV infection did not affect life expectancy in the midterm follow-up for LT patients. However, it was often associated with the occurrence of early and severe graft hepatitis and with a higher incidence of graft loss due to chronic rejection.

Steroid withdrawal is safe and beneficial in stable cyclosporine-treated liver transplant patients

BACKGROUND

In the immunosuppression of orthotopic liver transplant recipients, steroids are used despite their unspecific action and long-term side effects. Few studies have been carried out on steroid withdrawal and many aspects remain to be elucidated.

METHODS

A prospective study was performed to analyse the effect of steroid withdrawal on 86 patients with stable graft function, more than 1 year after orthotopic liver transplant. Thirty patients had chronic hepatitis in the graft. Seventy-two continued with cyclosporine (CsA) and 14 with CsA-azathioprine (AZA) therapy. The follow-up was 23.2 +/- 8.1 months (range 12-52 months). A paired t-test was used for statistical analysis.

RESULTS

No acute or chronic rejection occurred, and steroids were not reinstituted. There were no changes in serum transaminase levels, but bilirubin levels decreased (p < 0.01). At the end of the follow-up, we found improvements in blood pressure in hypertensive patients (systolic 156.1 +/- 8.4 mmHg vs. 139.4 +/- 8.7 mmHg, p < 0.001); body weight (72 +/- 13.5 kg vs. 70.8 +/- 13 kg, p < 0.05); serum cholesterol (211.3 +/- 42 mg/dl vs. 191.6 +/- 43.5 mg/dl, p < 0.001) and bone mineral density in lumbar spine (0.823 +/- 0.13 g/cm2 vs. 0.893 +/- 0.135 g/cm2, p < 0.001). Four of ten diabetic patients were no longer insulin-dependent and insulin requirements decreased in the remaining six. No significant biochemical changes were found in patients with hepatitis in the graft, and we found an improvement in inflammatory activity in the nine biopsied patients.

CONCLUSIONS

Steroid withdrawal with CsA monotherapy is feasible, safe and beneficial in patients who have stable liver graft function 1 year after orthotopic liver transplant. We consider that AZA therapy is not necessary unless drastic reduction of CsA levels is required because of renal dysfunction.

Changes in phenotypes of apolipoprotein E and apolipoprotein(a) in liver transplant recipients

The aim of this study has been to confirm that liver is the main site of apolipoprotein (apo) E and apo(a) synthesis, based in the changes of their phenotypes after transplantation. Apo E phenotypes were studied in 34 patients and apo(a) phenotypes in 27 of them before and after liver transplant. Thirteen patients changed the apo E phenotype after transplantation. Eight patients with E3/3 phenotype changed to the others with 2 or 4 alleles. Three patients with E4/3 phenotype changed to E3/3, one changed from E3/2 to E3/3 and another one changed from E4/2 to E3/2 phenotype after transplantation. Twenty one of the 27 patients changed the apo(a) phenotype. Thirteen of them also changed lipoprotein (Lp)(a) serum concentration at least twofold, showing in 11 an increase and in 2 a decrease, in relation with the change to phenotype associated with high and low Lp(a) concentration, respectively. Changes in apo E and apo(a) phenotypes in liver transplant recipients studied show that most of these apolipoproteins are synthesized by the liver.

[Primary ciliary dyskinesia with frontal sinus agenesis]

A 36-year-old man had a history of recurrent respiratory infections and bilateral bronchiectasis. Sinus radiography showed absence of the frontal sinuses. Electron microscopy of the bronchial mucosa revealed ultrastructural ciliary abnormalities. The clinical features and diagnosis of primary ciliary dyskinesia are described.

Geographical distribution of B chromosomes in the grasshopper Eyprepocnemis plorans, along a river basin, is mainly shaped by non-selective historical events

The analysis of 19 populations of the grasshopper Eyprepocnemis plorans, collected along four rivers belonging to the Segura basin (Mundo, Benamor, Taibilla and Segura itself), has shown that the presence of B chromosomes ends abruptly in each river, coinciding with the existence of a narrow pass in which this grasshopper cannot live because of the absence of the appropriate habitats. The existence of a broad inland region lacking grasshoppers with B chromosomes suggests that B chromosomes arose after the first colonization of the Iberian Peninsula by E. plorans specimens from North African populations. The B chromosome seems to have spread upstream along each of these four rivers until reaching geographical barriers that have impeded its advance and thus have preserved the non-B chromosome region. The available evidence indicates that the observed geographical distribution of the B chromosome polymorphism in this zone was shaped mainly by historical non-selective events.

[Intraoperative anesthetic management of kidney failure in adult liver transplantation. Conventional hemodialysis]

OBJECTIVE

To evaluate our application of indications, use and benefits of conventional hemodialysis during surgery in patients with advanced liver disease and acute or chronic renal failure undergoing liver transplantation (LP), liver retransplantation (LRT) or combined hepatorenal transplantation (CHRT).

PATIENTS AND METHODS

We retrospectively reviewed the cases of 22 patients with advanced liver disease, 11 with acute renal failure and 11 with chronic renal failure. We performed 6 LT, 5 LRT and 11 CHRT. The following data were recorded in the periods before, during and immediately after surgery: metabolic, hemodynamic and coagulation parameters; bicarbonate, calcium and inotropic drug requirements; incidences during reperfusion of the graft; surgical technique used; and survival.

RESULTS

Seven patients (32%) needed hemodialysis, 4 (18%) needed ultrafiltration, 7 (32%) needed both and 4 (18%) required neither. For 6 patients total clamping of the inferior vena cava (ICV) was required with external venovenous bypass. For 8 patients total clamping of the IVC was performed without venovenous bypass. For 8 others IVC clamping was partial with retrohepatic preservation (piggy-back). There were 2 deaths during surgery, 4 more within the first month after surgery and 4 more in the second month. Overall survival was 36.4% among acute patients and 72.7% among CHRT patients.

CONCLUSIONS

1) Conventional hemodialysis during surgery is feasible and gives good results; 2) conventional "high efficiency" hemodialysis is more effective and useful in these patients than is either slow, continuous hemodialysis or filtration; 3) the survival rate of CHRT patients is similar to that of patients undergoing LT with normal kidney function, and 4) partial IVC clamping in the anhepatic phase may decrease the need for ultrafiltration.

Response to the hepatitis B virus vaccine in haemodialysis patients: influence of malnutrition and its importance as a risk factor for morbidity and mortality

OBJECTIVE

To assess if malnutrition influences the response to the hepatitis B virus vaccine in haemodialysis patients and whether this correlates with morbidity and mortality in these patients.

DESIGN

A 4-year prospective open study.

SETTING

Haemodialysis unit of a 434-bed University Hospital.

PATIENTS

Sixty-four patients with end-stage chronic renal failure on maintenance haemodialysis.

INTERVENTIONS

Three-dose vaccination series with recombinant hepatitis B virus vaccine.

MEASUREMENTS

Antibody formation against the vaccine, predialysis serum urea, serum albumin and prealbumin, dialysis efficacy (Kt/V), protein catabolic rate (PCR), arm muscle circumference, triceps skinfold, serum parathyroid hormone concentration, mortality and morbidity (hospital days per year of dialysis).

RESULTS

Increase in age negatively influences the formation of antibodies (P = 0.01), whereas serum albumin (P = 0.008) and predialysis blood urea concentration (P = 0.004) are positively correlated with the formation of antibodies. Responders had significantly higher levels of serum albumin and prealbumin and predialysis blood urea than non-responders. The percentage of non-responders was higher (70%) in the group with predialysis blood urea concentration between 90 and 125 mg/dl than in those with predialysis blood urea concentrations between 176 and 225 mg/dl (14.2%). Patients with serum albumin levels between 3 and 3.5 g/dl were non-responders in a higher percentage (87.5%) than those with serum albumin levels between 4.5 and 5 g/dl (18.8%). After a 4-year follow-up, survival was 20% higher in the responder group (P < 0.05). Morbidity, expressed as hospital days per year of haemodialysis, was markedly lower in the responder group (10.4 +/- 2 versus 32 +/- 14 days, P = 0.03).

CONCLUSIONS

Malnutrition negatively influences the response to the hepatitis B virus vaccine in haemodialysis patients. Non-responders have higher morbidity and mortality than responders, and therefore the absence of response to the hepatitis B vaccine can be considered as a risk factor in the haemodialysis population.

Hepatitis B vaccination results in 140 liver transplant recipients

BACKGROUND/AIMS

Human autologous liver transplantation is possible due to an adequate suppression of the body's immune response. This also causes a higher hepatitis infection rate, making hepatitis prevention very important.

MATERIALS AND METHODS

We describe our experience with hepatitis B virus vaccination in 140 adult liver transplant recipients, transplanted from 1986 to 1994 with more than one year of follow-up. Excluded were those who had hepatitis B surface antigens or antibodies to those antigens before the transplant. The vaccination schedule was 0-1-2 months with a double dose of recombinant vaccine.

RESULTS

The total response rate (surface antigen antibodies > 10 U) was 40% (56/140); the rate was 47.7% in men and 26% in women. At the end of the study, only 17.1% (24/140) of the patients had antibodies > 10 U. The response rate was higher in patients with antibodies to hepatitis B core antigen (66.6%) than in those lacking antibodies (31.7%), and more long lasting (42.4% vs 11.2%). The response rate in 116 patients with booster doses was 12.9%. Six correctly vaccinated patients (4.28%) acquired new hepatitis B virus infections after the operation.

CONCLUSIONS

The total response rate in these patients is much lower than in the general population, and there is a rapid decline of titers, probably due to immunosuppression. The role of booster doses in these patients should be clarified.

[Pulmonary nocardiosis: presentation of 3 clinical cases]

INTRODUCTION

Nocardiosis is an infectious disease that frequently involves to the respiratory tract. Nocardia asteroides is the predominant human pathogen. Nocardiosis is difficult to diagnose and that's why its incidence is not well established.

CASES

Three cases diagnosed in a Pneumology Section are reported. None of them was affected by AIDS and all of them were initially diagnosed from bronchopneumonia. Empirical antibiotherapy was initiated and because of the unsatisfactory progress, bronchoscopy was performed in all cases and in one case a transthoracic puncture was made. Nocardia spp. was then isolated and this let to began with a specific treatment. All the patients progress satisfactorily in their respiratory infection.

DISCUSSION

Although there are usually factors that predispose to nocardiosis, it can also occur in absence of these, as it happened in one of report patients. The clinical and radiological manifestations are not, in many cases enough to reach the diagnosis. Thus germ isolation is very important, and invasive procedures are often essential to obtain a quality samples to cultivate. Sulfonamides were considered drugs of choice, but nowadays, many authors propose trimethoprim-sulfamethoxazole. Imipenem, amikacin have also proved to be effective.

Proteolytic activity of lactobacilli in a model goats' milk curd system

Mesophyllic lactobacilli cultures propagated in MRS broth were inoculated in goats' milk curd slurries and incubated at 30 degrees C for 10 d. The micro-organisms tested were Lactobacillus casei subsp. casei IFPL 731 and IFPL 99, and Lactobacillus plantarum IFPL 3. Whole cells, cell-free extracts and cell lysates were evaluated for acceleration of proteolysis in the curd slurries. Conversion of water-soluble nitrogen to non-protein nitrogen and amino acid nitrogen, reverse phase-HPLC peak areas and ratio of hydrophobic to hydrophilic peptides, were all affected by the type of inoculum used as well as the strain under study. The results suggest that the accelerated-ripening model system developed, containing cell lysates, may be suitable as a good and rapid indicator of the contribution of the strains to proteolysis during cheese ripening.