Real needle for minimal invasive procedures training using motion sensors and optical flow

Minimally invasive percutaneous insertion procedures are widely used techniques in medicine. Their success is highly dependent on the skills of the practitioner. This paper presents a haptic simulator for training in these procedures, whose key component is a real percutaneous insertion needle with a sensory system incorporated to track its 3D location at every instant. By means of the proposed embedded vision system, the attitude (spatial orientation) and depth of insertion of a real needle are estimated. The proposal is founded on a novel depth estimation procedure based on optical flow techniques, complemented by sensory fusion techniques with the attitude calculated with data from an Inertial Measurement Unit (IMU) sensor. This procedure allows estimating the needle attitude with an accuracy of tenths of a degree and the displacement with an accuracy of millimeters. The computational algorithm runs on an embedded computer with real-time constraints for tracking the movement of a real needle. This haptic needle location data is used to reproduce the movement of a virtual needle within a simulation app. As a fundamental result, an ergonomic and realistic training simulator has been successfully constructed for healthcare professionals to acquire the mental model and motor skills necessary to practice percutaneous procedures successfully.

Software Suite Training Tool for MSK Exploration and Botulinum Toxin Infiltration Based on Ultrasound Imaging for the Spasticity Treatment

Nowadays, one of the choice techniques for the spasticity treatment is the ultrasound-guided infiltration of Botulinum Toxin, because it is safe and effective. In order to medical professionals can carry out this technique, they need training and education. One of the safest and most time-free ways to facilitate the acquisition of practical medical skills is through simulators. In this paper we present an innovative technological environment, which includes an ultrasound simulator for training in muscle exploration and infiltration. The simulation platform will guide health professionals, with great realism and high degree of interactivity, in the autonomous training of all the tasks involved in the spasticity treatment procedure by infiltration of Botulinum Toxin, without the need for a real patient or costly phantoms.

Detection of Zoonotic Protozoa Toxoplasma gondii and Sarcocystis suihominis in Wild Boars from Spain

Food safety regulations require the control of the presence of protozoa in meats destined for human consumption. Wild boar (Sus scrofa) meat may constitute a source of zoonoses. A 23.8% (688/2881) seroprevalence of anti-Toxoplasma gondii antibodies and 72.2% (662/910) Sarcocystis sarcocysts prevalence were detected among wild boars hunted in Southwestern areas of Spain. Identity of Sarcocystis spp. was performed by RFLP-PCR and sequencing, detecting S. miescheriana (7/8) and the zoonotic S. suihominis (1/8). Risk assessment studies of these coccidian in meats destined to human consumption are needed.

Polidocanol foam stability in terms of its association with glycerin

Objectives:

Foam sclerotherapy effectiveness mainly depends on the concentration of the sclerosing agent and foam stability. The objective of this study was to determine if the addition of glycerol at different concentrations contributes to the stability of polidocanol foam.

Materials and methods:

Control Group: 3% polidocanol. Group 1: polidocanol 3% + glycerin 1.66%. Group 2: polidocanol 3% + glycerin 3.3%. Group 3: polidocanol 3% + Glycerin 5%. Tessari standard method. Five recordings were made for each mixture. Early visual liquefaction time and half liquid time decay were recorded in seconds. Microscopic measurement of the foams. Mixtures surface tension measurement (N/m).

Results:

Early visual liquefaction: Control Group: 27 (± 3.11); Group 1: 67.8 (± 6.49); Group 2:48.6 (± 8.2); and Group 3: 35.8 (± 4.49). Half-liquid time: Control: 129.2 (± 11.00); Group 1: 260.4 (±18.99); Group 2: 224.6 (±13.03); and Group 3: 189.2 (±8.52). Bubbles/mm2–diameter–wall thickness: Control: 68–98 μm-7 μm; Group 1: 189–60 μm-9 μm; Group 2: 76–92 μm-12 μm; and Group 3: 49–112 μm-20 μm. Surface tension: Control = 5.54 N/m; Group 1 = 5.45 N/m; Group 2 = 5.35 N/m; and Group 3 = 5.21 N/m.

Conclusions:

Small amounts of glycerin highly increase the stability and quality of polidocanol foam. This simple chemical method is easily reproducible and applicable.

Saccular aneurysms of the extracranial internal carotid artery. Experience and review of the literature

The aim of this study was to describe the surgical technique employed and our results in the treatment of saccular aneurysms of the internal carotid artery at the extracranial level. We describe 3 cases of patients with saccular aneurysms of the extracranial internal carotid who underwent surgery at our unit within the last 3 years. We report on indications for treatment, surgical technique and results in terms of morbidity-mortality and also review the pertinent literature. Surgical treatment was indicated on the grounds of the patients being symptomatic: 2 had a history of cerebral ischemia, and 1 showed local compression symptoms. The surgical approach was presternocleidomastoid cervicotomy extended distally, and in 2 patients was accompanied by nasotracheal intubation to achieve adequate exposure. In 2 cases, we performed an aneurysmectomy with end-to-end anastomosis. In the third patient, the aneurysm neck was ligated from within the sac followed by aneurysmectomy. There was no mortality or neurological morbidity (local or general). The patients remain free from neurological symptoms with a patent carotid axis. Our clinical experience suggests that, despite the anatomically unfavorable location of this type of aneurysm and the greater complexity of the surgical technique, this patient group can be effectively treated. The frequent presence of an elongated carotid axis and an aneurysmal neck means the surgeon can easily restore arterial continuity by direct procedures.

Improved incidence of pT0 downstaged surgical specimens in locally advanced rectal cancer (LARC) treated with induction oxaliplatin plus 5-fluorouracil and preoperative chemoradiation

PURPOSE

To compare efficacy in terms of pathologic response in LARC patients treated with preoperative chemoradiation, with or without a short-intense course of induction oxaliplatin.

PATIENTS AND METHODS

From 05/98 to 10/02, 114 patients were treated with preoperative chemoradiation (4500-5040 cGy + oral Tegafur 1200 mg/day) for cT(3)-(4)N(+/x)M(0) rectal cancer. Starting 05/01, 52 consecutive patients additionally received induction FOLFOX-4, oxaliplatin (85 mg/m(2) iv d1), 5-FU (400 mg/m(2) iv bolus d1) and 600 mg/m(2) iv continuous infusion in 22 h with leucovorin (200 mg iv) d1 and d2, every 15 days (2 cycles), followed by the previously described Tegafur chemoradiation regime. Surgery was performed in 5-6 weeks. Pathological assessment investigated post-treatment T and N status in the rectal wall and peri-rectal tissues.

RESULTS

Patients, tumor and treatment characteristics were comparable between groups. Incidence of pT(0) specimens was significantly increased by induction FOLFOX-4 (P = 0.006). Total T and N downstaging were 58% versus 75% and 42% versus 40%, respectively (P = ns). T downstaging of > or =2 categories was significantly superior in FOLFOX-4 group (P = 0.029).

CONCLUSIONS

Short-intense induction FOLFOX-4 significantly improves pathologic complete response in LARC patients treated with tegafur-sensitized preoperative chemoradiation. The 44% rate of pT(0)-(1) specimens observed in the oxaliplatin group should impulse innovative surgical approaches to promote ano-rectal sphincter conserving protocols.

Experimental studies in pigs on Trichinella detection in different diagnostic matrices

A total of 72 specific pathogen-free (SPF) and Iberian pigs (three animals per group) were inoculated with 200, 1000 or 20,000 muscle larvae of T. spiralis, T. nativa, T. britovi and T. pseudospiralis. For each animal, the muscle larva burden was evaluated in nine muscle samples by digestion. The anti-Trichinella IgG kinetics in blood samples, taken twice prior and at days 5, 10, 15, 20, 25, 30, 40, 50 and 60 post-inoculation, and in muscle juice, obtained at necropsy, was evaluated by an ELISA using an excretory/secretory antigen. The mean larval recovery rate in SPF/Iberian pigs corresponded with the level of inoculum dose, and tongue, diaphragm and masseter were identified as predilection muscles. In SPF and Iberian pigs receiving 20,000 larvae of T. spiralis, an earlier seroconversion was detected from day 25 post-inoculation. At a 10-fold dilution, the muscle juice showed a good test agreement with blood serum.

DRB1-TNF-alpha-TNF-beta haplotype is strongly associated with severe aortoiliac occlusive disease, a clinical form of atherosclerosis

Severe aortoiliac occlusive disease (AOD) is a clinical manifestation of peripheral arteriosclerosis. Atherosclerosis has been associated with some human leukocyte antigen (HLA)-DRB1 alleles, stressing its relationship with autoimmune or inflammatory disorders. Additionally, in rheumatoid arthritis patients, the DRB1*0404 allele is specifically associated with endothelial dysfunction. Our objective was to assess the role of class II HLA alleles in the susceptibility to AOD; a combined study of the nearby tumor necrosis factor (TNF) locus was also performed. We included 104 AOD patients and 504 healthy controls from Madrid. DRB1 typing and DRB1*04 subtyping was done by polymerase chain reaction amplification followed by hybridization with specific oligonucleotides. TNF-alpha and TNF-beta microsatellites were studied by polymerase chain reaction and capillary electrophoresis. None of the markers was associated with AOD, although a trend was observed for DRB1*0404 (OR = 2.18; p = 0.05). However, among DRB1*0404 individuals, the TNFa11-b4 pair was present more frequently in patients than in controls (OR = 16.0; p = 0.007). The combined appearance of TNFa11-b4 and DRB1*0404 was much more frequent in patients than in controls (OR = 5.92; p = 0.0013), a result enhanced by haplotypic estimates (OR = 10.0; p = 0.00017). Our results show that the HLA region modulates the predisposition to AOD. More specifically, they suggest that an extended haplotype encompassing DRB1*0404 and TNFa11-b4 carries a genetic factor conferring susceptibility to AOD.

Effectiveness of different adjuvants in stimulating Dichelobacter nodosus antibody in sheep vaccinated against ovine footrot

This research consists of an evaluation of the effectiveness of different substances administered as adjuvants in the stimulation of humoral immune response induced by the vaccine composed of strains A1, A2 and C of Dichelobacter nodosus. To do this, a total of 120 Merino sheep were vaccinated and revaccinated. These sheep were selected from a farm located in the region of Extremadura (Spain), and they were divided into 12 groups of 10 animals each. An additional group with 10 sheep was used as control. The immune response (titre of antibodies) was determined by agglutination tests and ELISA. The most pronounced immune response was obtained by the use of Freund's incomplete adjuvant and aluminium hydroxide as adjuvants.

Presence of immunoglobulins and antigens in serum, lung and small intestine in Ascaris suum infected and immunised pigs

The immunodetection of local Ascaris suum antigens and local and systemic antibodies were analysed in pigs reinfected with eggs or immunized with the 14, 42 and 97 kilodalton (kDa) fractions from A. suum. Twenty-one Iberian pigs were divided in 7 groups of 3 pigs. Groups 1 and 2 were uninfected and challenge control groups, respectively. Groups 3 and 4 were infected weekly with increasing doses of A. suum eggs and Group 4 was additionally treated with pyrantel pamoate. Groups 5, 6 and 7 were immunised with the 14, 42 or 97 kDa fractions from adult worms, respectively. Groups 2-7 were challenged with 10,000 infective eggs. Animals of Groups 3 and 4 showed a pulmonary granulomatous reaction with moderate number of eosinophils and leukocytes, while Groups 5-7 presented higher number of cells, especially in animals immunized with the 42 kDa fraction. These immunized groups presented abundant deposition of Ascaris body fluid (BF) and body wall (BW) antigens as well as the 14 and 42 kDa fractions in the pulmonary and intestinal tissues, while lower deposition of antigens was observed in animals of Groups 3 and 4. The immunized pigs of Groups 5 and 6 showed the highest systemic IgG titres in serum and these antibodies were negatively correlated with the number of larvae recovered in the lungs, suggesting that the IgG response may have a protective function against the ascariosis. The highest concentrations of IgA-bearing cells were observed in animals of Groups 3 and 4 compared to the immunised pigs (Groups 5-7), suggesting that local IgA production may be involved in the protection against migrating larvae. The main localisations of IgA-bearing cells were the bronchial and peribronchial areas of lungs and the lamina propia of duodenum. Low numbers of local IgG-bearing cells were observed in all animals and no IgM-bearing cells were detected in the local tissues.

Specific systemic IgG1, IgG2 and IgM responses in pigs immunized with infective eggs or selected antigens of Ascaris suum

A total of 35 pigs aged 15 weeks old, and 21 pigs aged 8 weeks old were divided into 7 groups. Groups 1 and 2 were uninfected and challenge control groups, respectively. Groups 3 and 4 were infected weekly with 6 increasing doses of Ascaris suum eggs, and group 4 was additionally treated with pyrantel. Groups 5, 6, and 7 were immunized weekly with the 14, 42, or 97 kDa fractions from adult worms, respectively. Animals of groups 2-7 were challenged with 10000 A. suum eggs 7 days after the last infection/immunization. Serum was sampled weekly and specific IgG1, IgG2, and IgM responses were measured. Pigs of groups 5, 6, and 7 showed high IgG1 and IgG2 responses especially against adult worms antigens, while infected groups had high IgG1 and IgM responses, especially against larva. The IgG1 responses were negatively correlated to the numbers of larvae in the lungs, and positively associated with the liver white spot numbers. There was a positive correlation between IgG2 and the numbers of white spots and lung larvae, while IgM was negatively correlated with these parasitological measures. These findings are discussed and it is suggested that acquired resistance against A. suum larvae is correlated with the induction of IgG1 and IgM, and not with IgG2, and that future vaccination protocols may focus on inducing the Th2 activity.

Role of HLA-DR in the pathogenesis of abdominal aortic aneurysm

OBJECTIVE

to establish a possible role for autoimmunity in the aetiology of abdominal aortic aneurysm (AAA) by examining human leukocyte antigen class II (HLA-II) immune response genes.

MATERIALS AND METHODS

HLA-II typing was performed in a series of 72 AAA patients and a control group of 380 healthy subjects.

RESULTS

a higher incidence of the allele subtype HLA-DR B1*0401 was detected in the AAA group with respect to the control group (12.5 vs 5.2%; p = 0.02, OR 2.59). In contrast, the HLA-DR B1*01 allele tended to behave as a protective factor for AAA (12.5% AAA vs 21.3% controls; p = 0.09, OR 0.5).

CONCLUSIONS

the association observed here between HLA-DR B1*0401 and HLA-DR B1*01 and unspecific AAA is similar to that reported in several autoimmune diseases. This similarity suggests an essential role for autoimmune factors in the formation of the AAA.

Immunohistochemical distribution of antigens in liver of infected and immunized pigs with Ascaris suum

In the present work, we carry out an immunopathological study of the swine ascariosis, under different conditions (control, infection and immunization). Twenty-one Iberian pigs were used and divided in seven groups. Groups 1 and 2 were the uninfected and challenged controls, respectively. Groups 3 and 4 were weakly infected with increasing doses of Ascaris suum eggs and treated with pyrantel (Group 4). Groups 5-7 were immunized with 14, 42 and 97 kDa proteins from the parasite, respectively. Groups 2-7 were challenged with 10,000 infective eggs 7 days before the sacrifice. The focal parasitic granulomata with eosinophils and lymphocytes were the main histopathological lesions in the liver of reinfected pigs, while more marked cellular infiltrate and abundant connective tissue were seen in the livers of immunized animals. There were important deposits of antigens in the livers of immunized and infected pigs. Antigens were mainly located in the connective tissue, with positive staining detection of the somatic larvae antigen, the body wall from the adult worms and the 14-, 42- and 97-kDa proteins. However, cholangiols, biliary ducts and macrophages presented an immunohistochemical positive stain against excretory-secretory and somatic antigens from the larvae and the body fluid antigen from the adult parasite. The detection of A. suum antigens in the liver of infected pigs improves the diagnosis of swine ascariosis. It may be possible to apply these procedures for diagnosis of human ascariosis in liver biopsies since A. suum from swine have been previously used as a substitute for the study of the human parasite Ascaris lumbricoides.

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study

To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained.

RESULTS

A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05).

CONCLUSION

Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Resistance against migrating ascaris suum larvae in pigs immunized with infective eggs or adult worm antigens

Resistance to Ascaris suum infections was investigated in 8- and 15-week-old Iberian pigs. Groups of 3 or 5 pigs were immunized weekly for 6 weeks with antigens of adult A. suum: a 97 kDa body wall (BW) fraction, a 42 kDa fraction of pseudocoelomic fluid (PF) or a 14 kDa PF-fraction; or were inoculated with increasing doses of infective eggs (500-20,000), with or without abbreviation by pyrantel pamoate. All immunized pigs and unimmunized control pigs, were challenged with 10,000 infective eggs 7 days after the last immunization. The number of liver lesions and lung larvae was substantially lower in the older pigs than in the younger ones 7 days after challenge, but the resistance in immunized pigs of both age groups was similar in comparison to the challenge controls of the same age. The highest degree of resistance against lung larvae was observed in pigs immunized with A. suum eggs (97-99%). The pigs immunized with the 14 kDa and 42 kDa PF-fractions were also well protected (67-93%), while no protection was produced by the 97 kDa BW fraction (0-49%). The reduction of white spots following immunization was less evident, with a maximum of 82% reduction in egg-inoculated young pigs.

Comparison of IgM, IgG1 and IgG2 responses to Trichinella spiralis and Trichinella britovi in swine

Pigs infected with T. spiralis and T. britovi were followed by double (IgG) and triple antibody ELISA (IgG1, IgG2 and IgM) during a 12-week-period. Specific IgG and IgG1 responses were similar and showed a significant relation with the infecting doses and intensity of infection. Response to T. britovi was slightly lower than in groups infected with the same dose of T. spiralis. IgG2 response was weak and almost undetectable in the lowest infected pigs, but relationship with the intensity of infection was unclear. IgM antibodies showed rapid but transient increases, generally simultaneous to peaks of IgG response.

Should the cell saver autotransfusion system be routinely used in elective aortic surgery?

The objective of this study is to identify the aortic surgery procedures in which the use of the Cell Saver autotransfusion system is beneficial in terms of the amount of autologous blood recovered and the reduction in blood bank demands. An evaluation of the cost-effectiveness of the system is also presented. Four hundred and thirty-four elective aortic interventions were retrospectively reviewed to examine the use of intraoperative autotransfusion (IAT). Evaluation was made of risk factors, preoperative hematological variables, the volume of IAT-processed reinfused blood, and homologous transfusion requirements over the period of hospitalization. The routine use of the IAT system was cost-effective in the interventions for AAA and TAA. In patients subjected to aortobifemoral bypass for aortoiliac occlusive disease, IAT served to alleviate demands on blood bank inventories, although in our center its use led to a slight increase in net cost. The routine use of IAT during unilateral revascularization due to occlusive disease offered no benefits in terms of reduced homologous transfusion requirements or cost-effectiveness.

Sylvatic trichinellosis in southwestern Spain

The epidemiology of Trichinella spp. in their main sylvatic hosts, wild boar (Sus scrofa ferus and red fox (Vulpes vulpes), in Extremadura (southwestern Spain) was studied. We examined 88 Trichinella spp.-positive wild boar muscle-tissue samples from a total of 29,333 killed animals, referred to the Veterinary Parasitology Department (University of Extremadura, Spain) by the Extremadura Veterinary Service. Additionally, 227 red foxes killed during the hunting season and thus not subject to veterinary controls were examined for trichinellosis. Trichinella spp. larvae were found in six (3%) of the red foxes. All samples were examined using direct diagnostic techniques, including trichinoscopy and artificial digestion. The mean intensity of infection was 74.8 larvae/g (LPG) of muscle tissue in wild boars, compared to 30.6 LPG in foxes. Trichinella spiralis (sensu stricto) predominated over T. britovi in wild boars. Random amplified polymorphic DNA (RAPD) and alloenzyme typing showed that 74% of infected wild boars had only T. spiralis, 21% had only T. britovi, and 5% showed mixed infections. In contrast, 33% of infected foxes were infected only with T. spiralis, while 67% had T. britovi, suggesting a clear predominance of the latter in foxes. We suspect the existence of a paranthropic or sylvatic cycle in large areas of this region; given the ease of transfer between sylvatic and domestic or semi-domestic animals, this implies a high epidemiological risk.

[Epidemiological aspects of ciprofloxacin-resistant Escherichia coli at a general hospital]

The susceptibility to ciprofloxacin of 7288 Escherichia coli clinical isolates from 5667 patients was determined over a 4-year period (1995-1998). Information about the patients' age, sex, specimen type, date, origin and susceptibility to Escherichia coli isolates was studied, and the c2 test was used for statistical comparison. Overall, 1003 (17.70&#37;) patients out of the 5667 included in the study presented ciprofloxacin resistance. The annual resistance observed over this 4-year period was not considered statistically significant. The resistant isolates were more frequent among men, in urine specimens and in outpatients, and increased with different age groups. The average age of patients with resistant isolates was 61.29 years (SD 21.56) and that of patients with susceptible isolates was 39.76 years (SD 27.41). A similar rate of resistance was observed among outpatients from health centers and those from hospital outpatient services. The higher resistance rates were found in outpatients from the urology department. The resistance to other fluoroquinolones remained the same and was not significant for norfloxacin; it increased starting from 1997 for pefloxacin at the expense of ciprofloxacin-sensitive isolates.

Influence of infection intensity on predilection sites in swine trichinellosis

The muscular distribution of Trichinella spiralis or T. britovi was studied by digestion in 59 experimentally infected pigs and seven wild boars. Crus muscle was the predilection site in 89.3% of 28 heavily infected swine with 146-3634 larvae per gram (lpg), but in 51.6% of middle to light infections (0.005-59 lpg) the basis of the tongue showed higher larval densities than the crus muscle. The basis of the tongue was also the predilection site in 71.4% of wild boars. Highest counts in other muscles were found only in lightly infected pigs. The influence of intensity of infection, host species, and Trichinella species on muscle distribution is discussed.

Arteriovenous fistula as a complication of lumbar disc surgery: case report

Arteriovenous fistula (AVF) is a rare, late complication of lumbar disc surgery. It is often not suspected and the symptoms are diagnosed as heart failure or deep venous thrombosis. We report a case in which the patient developed leg swelling and high-output congestive heart failure due to a left ilioiliac AVF after lumbar laminectomy.

[Indices of prediction of neurologic focality during carotid endarterectomy carried out under regional anesthesia]

OBJECTIVES

To examine the relations between the development of neurologic events and the following variables: degree of stenosis of the contralateral carotid artery, prior neurologic symptoms and stump pressure of the ipsilateral internal carotid artery in patients undergoing carotid endarterectomy under regional anesthesia.

PATIENTS AND METHODS

We undertook a prospective study of 92 patients undergoing carotid endarterectomy with a blockade of the superficial and deep cervical plexus. Neurological integrity was assessed and internal carotid artery stump pressure was monitored. Contralateral carotid artery stenosis and neurologic disease present before surgery were studied.

RESULTS

Neurologic events developed when the carotid artery was clamped in 9.7% of patients. Mean stump pressure was significantly lower in symptomatic patients (43 +/- 11 mmHg) than in asymptomatic patients (74.6 +/- 24 mmHg) (p < 0.001). Neurologic symptoms developed during clamping of the carotid in 27.2% of the patients with stump pressure less than or equal to 50 mmHg, but in only 4.2% of those with stump pressure surpassing 50 mmHg. Stump pressure was significantly lower in patients with contralateral carotid stenosis. The incidence of neurologic events during clamping was unrelated to contralateral carotid condition, however. Likewise, neurologic symptoms before surgery was also unrelated. In six of the nine patients with neurologic events, internal carotid stump pressure was less than or equal to 50 mmHg, indicating that the sensitivity of this parameter to the development of neurologic events in our series was 66%.

CONCLUSIONS

Although internal carotid artery stump pressure identifies a subset of patients likely to have a higher incidence of neurologic events during carotid artery clamping, it can not be considered the only criterion for placement of an intraluminal shunt to prevent such events. The state of the contralateral carotid artery and preexisting neurologic symptoms are not objective screening criteria for identifying patients at high risk of neurologic events during carotid clamping.

Nontraumatic lower extremity amputations in diabetic and non-diabetic subjects in Madrid, Spain

The purpose of this study was to determine the incidence of non-traumatic lower extremity amputations (LEAs) in diabetic and non-diabetic subjects in Madrid, Spain, and their direct cost. All patients who underwent LEAs between the 1st of January 1994 and the 31st of December 1996, and who had lived in area 7 of the city (569,307 inhabitants) for at least the last 6 months, were identified through operating theatre records cross-checked with Vascular Surgery Department discharge records. In addition, the direct cost of LEAs per year was estimated, taking into account the length of the hospital stay, the period of rehabilitation in the outpatient clinic after discharge, and the use of artificial limbs and their maintenance. The incidence of LEAs was 1.6 (95% CI: 1.1-2.2) per 10(5) non-diabetic subjects and 46.1 (95% CI: 34.5-57.6) per 10(5) diabetic patients. Relative risk was 28. Total direct costs associated with LEAs per year were US$ 56,131 in the diabetic population and US$ 30,765 in the non-diabetic population. Thus, potential cost savings associated with excess amputations in the diabetic population was estimated at US$ 541,353 per year of US$ 94,736 per 10(5) inhabitants. It is concluded that the incidence of LEAs in both diabetic and non-diabetic populations in area 7 is the lowest reported in European countries. The potential cost savings per 10(5) inhabitants and per year is estimated at US$ 94,736.

Evidence of potential gene flow in Trichinella spiralis and in Trichinella britovi in nature

During a study on the epidemiology of trichinellosis in Spain, 91 animals and 9 samples of sausages homemade with pork were found positive for Trichinella. Parasite identification at the species level was carried out by the polymerase chain reaction with a random primer on single muscle larvae. Seventy-one animals harbored Trichinella spiralis (17 domestic pigs, 53 wild boars, 1 fox), and 17 were infected with Trichinella britovi (1 domestic pig, 13 wild boars, 3 foxes). Sausages were infected with T. spiralis. Three wild boars (3.3% of infected animals) harbored both species. The presence of both T. spiralis and T. britovi in the same host suggests that infections with 2 isolates of the same species can also occur, permitting the gene flow within the species.

Environmental and human influence on the ecology of Trichinella spiralis and Trichinella britovi in Western Europe

Surveys on Trichinella parasites in domestic and sylvatic animals collected in France, Italy, and in the Extremadura region of Spain showed that the distribution of Trichinella spiralis and Trichinella britovi is influenced by both environmental and human behaviour factors. In France, both Trichinella species are prevalent in the fox population from mountain areas and natural parks but are infrequent in wild boars (< 0.001%). In Italy, only T. britovi is present in sylvatic animals (foxes, wolves, and mustelids) living 500 m above sea level. This species is rare in wild boars (< 0.001%) in that area. Sylvatic trichinellosis is found in only 24% and 34% of French and Italian territory, respectively, while lowland areas may generally be considered Trichinella-free, because the domestic cycle is absent. The ecology of T. spiralis and T. britovi in the Extremadura shows a different picture from that observed in France and Italy because of the presence of both domestic and sylvatic cycles. The domestic cycle not only allows the maintenance of T. spiralis in the domestic environment, but it also has a great impact on the prevalence in wild boar populations. It does not influence the prevalence in vulpine populations. These data suggest (1) that domestic trichinellosis occurs only in rural areas of Western Europe in association with traditional swine-rearing practices, but not in industrialized pig farms; (2) that sylvatic trichinellosis occurs only in natural habitats which, in Western Europe, are widespread in mountain areas; (3) that the fox is the primary reservoir in the sylvatic cycle, where the parasite is maintained in a closed circuit and (4) that among sylvatic animals T. spiralis is present at lower altitude than is T. britovi.

Immunopathology of the uveitis in canine leishmaniasis

Particular immunopathological features and their effects on the vascular permeability of different ocular structures were analysed in two dogs naturally infected by Leishmania infantum. The existence of specific anti-Leishmania immunoglobulin G (IgG) in the aqueous humour was confirmed by the ELISA technique. There was no correlation between antibody levels in the aqueous humour and the related serum. The histopathological study of the eyes showed the existence of lesions in various ocular structures. The ciliary processes, ciliary body, sclerocorneal limbus, iris and lacrimal duct showed intense inflammatory zones with lymphocyte infiltrates, plasmatic cells and macrophages with amastigote forms of Leishmania. In addition vasculitis with dilation and thrombi were also detected in both cases, with consequent oedema and hyalinization. The immunohistochemistry analysis revealed the presence of granular and diffuse IgG deposits in the ciliary body, ciliary processes, sclerocorneal limbus and iris. Furthermore, numerous thrombosed vessels were observed in the sclerocorneal zone and iris. Complement 3 (C3) fraction deposits were not present in the ocular structures. The present data suggest that the ocular lesions may have an immunopathological origin.