Radiographic morphology of canines tested for sexual dimorphism via convolutional-neural-network-based artificial intelligence

The permanent left mandibular canines have been used for sexual dimorphism when human identification is necessary. Controversy remains whether the morphology of these teeth is actually useful to distinguish males and females. This study aimed to assess the sexual dimorphism of canines by means of a pioneering artificial intelligence approach to this end. A sample of 13,046 teeth radiographically registered from 5838 males and 7208 females between the ages of 6 and 22.99 years was collected. The images were annotated using Darwin V7 software. DenseNet121 was used and tested based on binary answers regarding the sex (male or female) of the individuals for 17 age categories of one year each (i.e. 6-6.99, 7.7.99… 22.22.99). Accuracy rates, receiver operating characteristic (ROC) curves and confusion matrices were used to quantify and express the artificial intelligence's classification performance. The accuracy rates across age categories were between 57-76% (mean: 68%±5%). The area under the curve (AUC) of the ROC analysis was between 0.58 and 0.77. The best performances were observed around the age of 12 years, while the worst were around the age of 7 years. The morphological analysis of canines for sex estimation should be restricted and allowed in practice only when other sources of dimorphic anatomic features are not available.

30 years of the ABFO study: Reproduction in a Brazilian sample

The ABFO study on third molar development is a benchmark in the scientific literature of dental age estimation. In its 30th anniversary, the study has been reproduced in the present external validation. Standardized comparative outcomes were obtained and discussed across studies. The sample consisted of 1.087 panoramic radiographs of Brazilian females (n=542, 49.87%) and males (n=545, 50.13%) between 14 and 22.9 years. All available third molars were classified into developmental stages following Mincer's adaptation of Demirjian's system (8 sequential stages, from A to H). The mean chronological age of individuals within each stage was assessed. The probability of an individual being ≥ 18 years was calculated for each third molar, sex and stage. Maxillary and mandibular third molars showed a similar development with an agreement between stages of about 90%. In general, males developed 0.5 years (6 months) earlier than females. The probability of being an adult increased considerably when at least one third molar is in stage G. Maxillary third molars had higher coefficients of determination (right: 0.704; left: 0.702), showing that statistical models with these teeth could explain better the age estimation outcomes. The reproducibility of the ABFO study on third molar development led to reference tables and probability measures for the studied Brazilian population.

Assessment of humoral immune response to two mRNA SARS-CoV-2 VACCINES (Moderna and Pfizer) in healthcare workers fully vaccinated with and without a history of previous infection

Aims

Presence of anti‐S1 region of SARS‐CoV‐2 spike protein was analysed, at two and eight months, in 477 immunocompetent healthcare workers in Zaragoza, Spain, vaccinated with mRNA‐1273 (Moderna) or BNT162b2 (Pfizer).

Methods and results

Antibody analysis was performed with Alinity i System (Abbott). At 2 months, 100% of vaccinated had anti‐S1 IgG (mean = 13,285 AU ml⁻¹). This value was significantly higher with Moderna (18,192 AU ml⁻¹) than with Pfizer (10,441 AU ml⁻¹). The mean value of anti‐S1 IgG after vaccination was significantly higher in patients with than without previous infection (18,539 vs. 7919 AU ml⁻¹); in both groups was significantly higher with Moderna than with Pfizer (21,881 vs. 15,733 AU ml⁻¹ and 11,949 vs. 6387 AU ml⁻¹), respectively. At 8 months, 100% of patients were IgG positive, with higher levels with Moderna than with Pfizer. Nevertheless, in ensemble of cases, a mean decrease of antibody levels of 11,025 AU ml⁻¹ was observed.

Conclusion

At 2 and 8 months after vaccination, IgG response persists with both vaccines but with important decrease which suggests the need for revaccination.

Significance and impact of study

The study contributes to know the immune status after vaccination with two of more used anti‐SARS‐CoV‐2 vaccines. This knowledge is important for establishing the best vaccination strategy

Antimicrobial effect of nanostructured membranes for guided tissue regeneration: an in vitro study

OBJECTIVE

The purpose of this in vitro study was to evaluate the antibacterial effect of a novel non-resorbable, bioactive polymeric nanostructured membrane (NMs), when doped with zinc, calcium and doxycycline.

METHODS

A validated in vitro subgingival biofilm model with six bacterial species (Streptococcus oralis, Actinomyces naeslundii, Veillonela parvula, Fusobacterium nucleatum, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans) was used. The experimental NMs, with and without being doped with doxycycline, calcium and zinc, were placed on hydroxyapatite (HA) discs. As positive control membranes, commercially available dense polytetrafluoroethylene (d-PTFE) membranes were used and, as negative controls, the HA discs without any membrane. The experimental, positive and negative control discs were exposed to a mixed bacterial suspension, at 37 °C under anaerobic conditions, during 12, 24, 48 and 72 h. The resulting biofilms were analyzed through scanning electron microscopy (SEM), to study their structure, and by quantitative polymerase chain reaction (qPCR), to assess the bacterial load, expressed as colony forming units (CFU) per mL. Differences between experimental and control groups were evaluated with the general linear model and the Bonferroni adjustment.

RESULTS

As shown by SEM, all membrane groups, except the NMs with doxycycline, resulted in structured biofilms from 12-72 hours. Similarly, only the membranes loaded with doxycycline demonstrated a significant reduction in bacterial load during biofilm development, when compared with the control groups (p < 0.001).

SIGNIFICANCE

Doxycycline-doped nanostructured membranes have an impact on biofilm growth dynamics by significant reducing the bacterial load.

Periodontitis, Edentulism, and Risk of Mortality: A Systematic Review with Meta-analyses

Periodontitis has been independently associated with the chronic noncommunicable diseases that most frequently lead to death worldwide. The aim of the present systematic review was to study whether people with periodontitis/edentulism are at increased risk of all-cause and cause-specific mortality as compared with those without periodontitis/edentulism. Cohort studies were included that 1) evaluated periodontitis or edentulism as exposures in relation to all-cause or cause-specific mortality as an outcome and 2) reported effect estimates as hazard ratios, risk ratios, or odds ratios with 95% CIs or crude numbers. Two review authors independently searched for eligible studies, screened the titles and abstracts, did full-text analysis, extracted the data from the published reports, and performed the risk-of-bias assessment. In case of disagreement, a third review author was consulted. Study results were summarized through random effects meta-analyses. A total of 57 studies were included, involving 48 cohorts and 5.71 million participants. Periodontitis was associated with increased risk of all-cause mortality (risk ratio, 1.46 [95% CI, 1.15 to 1.85]) and mortality due to cardiovascular diseases (1.47 [1.14 to 1.90]), cancer (1.38 [1.24 to 1.53]), coronary heart disease (2.58 [2.20 to 3.03]), cerebrovascular diseases (3.11 [2.42 to 3.98]), but not pneumonia (0.98 [0.69 to 1.38]). Edentulism (all types) was associated with increased risk of all-cause mortality (1.66 [1.46 to 1.88]) and mortality due to cardiovascular diseases (2.03 [1.50 to 2.74]), cancer (1.55 [1.24 to 1.94]), pneumonia (1.72 [1.07 to 2.78]), coronary heart disease (2.98 [2.43 to 3.65]), and cerebrovascular diseases (3.18 [2.24 to 4.51]). Periodontitis and its ultimate sequela (edentulism) are associated with an increased risk of all-cause and cause-specific mortality (PROSPERO CRD42018100095).

Implications of grey zone results for routine hepatitis C virus screening with the ARCHITECT HCV-Ag assay

AIMS

Hepatitis C virus antigen (HCV-Ag) detection requires retesting for samples with grey zone results (GzR), adding cost and time and decreasing reliability. Our aim in this study was to evaluate the frequency and significance of GzR during the use of the automated Architect HCV-Ag assay in routine clinical practice.

METHODS AND RESULTS

We studied HCV-Ag levels in 952 serum samples using the ARCHITECT HCV-Ag assay. GzR were detected in 33 samples; 25 were reactive on retesting and 19 were anti-HCV positive. Seventeen of these 19 samples were tested for HCV-RNA and were all reactive (viral loads <10⁴  IU ml^-1 ). The remaining six samples were anti-HCV nonreactive and had undetectable HCV-RNA. Eight GzR samples were nonreactive on retesting, seven were anti-HCV nonreactive (three underwent HCV-RNA quantification and were all nonreactive), and one was anti-HCV reactive (HCV-RNA nonreactive). No significant differences were found on comparing HCV-Ag values.

CONCLUSIONS

Grey zone results found to be negative on retesting do not need additional technique testing, except in donor screening scenarios, where the use of molecular methods would be advisable.

SIGNIFICANCE AND IMPACT OF THE STUDY

 The proposed diagnostic algorithm confirms that, eventhough GzR occur, hepatitis C virus antigen is a robust alternative to HCV-RNA detection in the active detection of infections.

[Pilot experience with indocyanine green navigation in pediatric surgery]

INTRODUCTION

Indocyanine Green (ICG) fluorescence is a new tool for navigated minimal invasive and open surgery, with multiple possible uses, that can increase safety and improve surgical results, facilitating intraoperative decision making. We hereby present our pilot series using ICG navigation in different procedures of pediatric surgery.

MATERIAL AND METHODS

As a proof of concept, between May 2017 and March 2019, we have used this technique as a help for decision making in these scenarios: visualization of the biliary tract, vascular and lymphatic structures, neoplastic tissue and other anatomic landmarks. The route of administration, timing and dosage changed depending on the indication. A 30º optic, with a conventional and near-infrared light emitter, connected to a high definition system specially equipped was used.

RESULTS

We considered that the technique might be useful in 20 patients (22 procedures): 6 involving the biliary tract (5 cholecystectomies, 1 choledochal stenosis), 9 oncologic procedures (5 laparoscopic and 4 open), 7 miscellanea (pulmonary nodule resections, long-gap esophageal atresia, anastomotic leak, etc). There were no complications regarding ICG administration. We considered that the system provided relevant information or affected intraoperative decision making in 90% of the cases.

CONCLUSIONS

ICG navigation was easy to perform and complication free. Our preliminary results suggest that ICG navigation, in open and endoscopic procedures, might provide a qualitative leap regarding safety and facilitate the performance of certain pediatric surgical procedures, particularly in oncology, liver surgery and neonatal surgery.

Antibacterial effects of polymeric PolymP-n Active nanoparticles. An in vitro biofilm study

OBJECTIVE

to study the antibacterial effect of polymeric PolymP-n Active nanoparticles using an in vitro subgingival biofilm model.

METHODS

Hydroxyapatite discs coated with five modalities of nanoparticles (NPs): NPs, NPs doped with zinc, calcium, silver and doxycycline, PBS as control, and Streptococcus oralis, Actinomyces naeslundii, Veillonella parvula, Fusobacterium nucleatum, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans were studied in a static in vitro biofilm model (12, 24, 48, and 72h). Nano-roughness of the different disc surfaces (SRa, in nm) and morphological characteristic of the biofilms (thickness (μm) and bacterial viability) were studied by different microscopy modalities. Quantitative Polymerase Chain Reaction was used to assess the effect of the nanoparticles on the bacterial load (colony forming unit per milliliter) (CFUmL^-1). Analysis of variance and post-hoc testing with T3 Dunnett́s, and Student Newman Keuls correction was used. Results were considered statistically significant at p<0.05.

RESULTS

Surfaces containing the different nanoparticles showed significant increments in roughness when compared to controls (p<0.05). A similar biofilm formation and dynamics was observed, although reductions in bacterial viability were detected in biofilms in contact with the different nanoparticles, more pronounced with silver and doxycycline NPs. Doxycycline-NPs biofilms resulted in unstructured biofilm formation and significantly lower number of the six species when compared with the other nanoparticles specimens and controls (p<0.001 in all cases).

SIGNIFICANCE

Polymeric PolymP-n Active nanoparticles when combined with silver and doxycycline showed a significant antibacterial effect when tested in an in vitro subgingival biofilm model.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Ultrasensitive Kilo-Pixel Imaging Array of Photon Noise-Limited Kinetic Inductance Detectors Over an Octave of Bandwidth for THz Astronomy

We present the development of a background-limited kilo-pixel imaging array of ultrawide bandwidth kinetic inductance detectors (KIDs) suitable for space-based THz astronomy applications. The array consists of 989 KIDs, in which the radiation is coupled to each KID via a leaky lens antenna, covering the frequency range between 1.4 and 2.8 THz. The single pixel performance is fully characterised using a representative small array in terms of sensitivity, optical efficiency, beam pattern and frequency response, matching very well its expected performance. The kilo-pixel array is characterised electrically, finding a yield larger than 90% and an averaged noise-equivalent power lower than 3  ×  10 - 19  W/Hz 1 / 2 . The interaction between the kilo-pixel array and cosmic rays is studied, with an expected dead time lower than 0.6% when operated in an L2 or a similar far-Earth orbit.

Large Angle Optical Access in a Sub-Kelvin Cryostat

The development of lens-antenna-coupled aluminum-based microwave kinetic inductance detectors (MKIDs) and on-chip spectrometers needs a dedicated cryogenic setup to measure the beam patterns of the lens-antenna system over a large angular throughput and broad frequency range. This requires a careful design since the MKID has to be cooled to temperatures below 300 mK to operate effectively. We developed such a cryostat with a large opening angle θ = ± 37 . 8 ∘ and an optical access with a low-pass edge at 950 GHz . The system is based upon a commercial pulse tube cooled 3 K system with a 4 He - 3 He sorption cooler to allow base temperatures below 300 mK . A careful study of the spectral and geometric throughput was performed to minimize thermal loading on the cold stage, allowing a base temperature of 265 mK . Radio-transparent multi-layer-insulation was employed as a recent development in filter technology to efficiently block near-infrared radiation.

Congenital anomalies of the pulmonary arteries: spectrum of findings on computed tomography

OBJECTIVE

Congenital anomalies of the pulmonary arteries are uncommon. They can occur in isolation or in association with congenital heart defects. Isolated congenital anomalies remain undiscovered until they are reported as incidental findings on imaging tests, usually not until adolescence. We review the embryological development and normal anatomy of the pulmonary arteries as well as the spectrum of computed tomography findings for various congenital anomalies: unilateral interruption of the pulmonary artery, anomalous origin of the left pulmonary artery (pulmonary artery sling), idiopathic aneurysm of the pulmonary artery, and other anomalies associated with congenital heart defects.

CONCLUSION

Congenital anomalies of the pulmonary arteries represent a diagnostic challenge for clinicians and radiologists. Computed tomography is useful for their diagnosis, and general radiologists need to be familiar with their imaging appearance because they are often discovered incidentally.

Superconducting Coplanar Waveguide Filters for Submillimeter Wave On-Chip Filterbank Spectrometers

We show the first experimental results which prove that superconducting NbTiN coplanar-waveguide resonators can achieve a loaded Q factor in excess of 800 in the 350 GHz band. These resonators can be used as narrow band pass filters for on-chip filter bank spectrometers for astronomy. Moreover, the low-loss coplanar waveguide technology provides an interesting alternative to microstrip lines for constructing large scale submillimeter wave electronics in general.

[Conservative management of liver trauma and its complications: current gold-standard]

INTRODUCTION

The liver is the second most frequently involved organ in abdominal trauma in children. The aim of this study was to review the characteristics of liver traumas (LT) in children, its treatment and complications.

MATERIAL AND METHODS

Retrospective study of patients with LT treated between 2010-2014. We analyzed data regarding diagnosis, conservative management (CM), complications and treatment.

RESULTS

Twenty-four patients of LT with a mean age of 9.8 years (SD: 3.4) were treated at our center. Liver injury degrees according to the Organ Injury Scale of American Association for Surgery of Trauma (AAST) were: grade I (4), grade II (6), grade III (8), grade IV (5) and grade V (1). CT angiography was performed in 23 patients. Four of the six patients with initial hemodynamic instability required blood transfusion; of those, two required angioembolization for active bleeding in extrahepatic locations and a third required damage control surgery. Three patients presented late-onset complications: 2 large size bilomas which underwent spontaneous resolution and a third patient with a right biloma and section of the left bile duct who required a multidisciplinary approach. Median hospital stay was 6 days (r 1-92). With a mean follow-up of 17.75 months (SD: 16.35) (r: 2-57) long-term survival was 96%. The patient who received surgery died due to a post-traumatic brain injury.

CONCLUSION

CM seems to be the treatment of choice in LT regardless of injury degree. Surgery should be reserved for cases refractory to CM due to the associated high mortality.

[Congenital portosistemic shunt. Importance of early treatment]

AIM

Congenital portosistemic shunt (CPSS) is an uncommon condition that can cause serious complications such as encephalopathy and liver tumors at risk of malignant degeneration. Occlusion of the shunt by surgery or interventional radiology can prevent and even improve such complications. In some cases, liver transplantation is the only curative option. We describe our experience with this condition.

PATIENTS AND METHODS

Between 1992 and 2013, eight children (four male and four female) were diagnosed with CPSS (four extrahepatic and four intrahepatic) in our center, of which seven were diagnosed after 2007. The mean age at diagnosis was 5.5 years (1 month-15 years). Five patients had associated comorbidities.

RESULTS

Five patients had developed hyperammonemia and intellectual impairment, one of those manifested with an onset of coma. Four patients have developed at diagnosis liver tumors, including focal nodular hyperplasia/regenerative nodules (n=3) and adenomas (n=3). One patient with multiple tumors required a hepatectomy owing to compressive symptoms. Two patients, developed malignant degeneration, a child under five years treated with liver transplantation and another in adulthood treated with hepatectomy. In one patient, diagnosed in the neonatal period, the shunt occlusion occurred spontaneously. Direct portography with the occlusion test was performed in five patients, the shunt was occluded with interventional radiology in three cases, surgery in one and liver transplantation in the remaining.

CONCLUSIONS

The treatment of the SPSC must be early to prevent and even to reverse its complications, avoiding liver transplantation. Currently, interventional radiology is essential in the strategy to follow and treatment of these patients.

[Rupture of a superior mesenteric artery aneurysm in pediatric age: case report and literature review]

INTRODUCTION

Splanchnic artery aneurysms are rare in children. High mortality from rupture justifies its treatment, with various therapeutic options among which stand out surgery and recently, endovascular treatment.

CASE REPORT

A 11 year old girl presented with abdominal pain and sudden drop in hematocrit. The urgent abdominal CT angiography showed a saccular aneurysm of the superior mesenteric artery (SMA) at 4 cm from the ostium with dissection and active bleeding. A selective angiography was performed which confirmed the dissection. A self-expanding stent was placed in the main trunk of the SMA and a transcatheter coil and onyx embolization of the aneurysm was performed. The control angiogram showed no evidence of residual perfusion of the false lumen and demonstrated proper vascularization of the distal jejunum-ileal branches. Dual antiplatelet therapy with aspirin and dipyridamole was begun. After 24 months of follow-up the patient is asymptomatic.

COMMENTS

Endovascular treatment of a SMA aneurysm is effective in the pediatric patient, even in emergency situations.

Fluctuations in the electron system of a superconductor exposed to a photon flux

In a superconductor, in which electrons are paired, the density of unpaired electrons should become zero when approaching zero temperature. Therefore, radiation detectors based on breaking of pairs promise supreme sensitivity, which we demonstrate using an aluminium superconducting microwave resonator. Here we show that the resonator also enables the study of the response of the electron system of the superconductor to pair-breaking photons, microwave photons and varying temperatures. A large range in radiation power (at 1.54 THz) can be chosen by carefully filtering the radiation from a blackbody source. We identify two regimes. At high radiation power, fluctuations in the electron system caused by the random arrival rate of the photons are resolved, giving a straightforward measure of the optical efficiency (48±8%) and showing an unprecedented detector sensitivity. At low radiation power, fluctuations are dominated by excess quasiparticles, the number of which is measured through their recombination lifetime.

Electromagnetic radiation detectors based on superconducting resonators have a range of potential uses from astronomy to quantum computing. De Visser et al. demonstrate a superconductor detector with unprecedented sensitivity limited only by fluctuations in the electron system of the superconductor.

Novel histologic scoring system for long-term allograft fibrosis after liver transplantation in children

The existing systems for scoring fibrosis were not developed to evaluate transplanted livers. Our aim was to design and validate a novel fibrosis scoring system specifically adapted to assess liver allograft fibrosis (LAF). Clinical data, histology, transient elastography (TE) and AST/platelet ratio index (APRI) were reviewed in 38 pediatric liver transplant (LT) recipients. Protocol liver biopsies performed at 6 months and 7 years post-LT were reviewed by three pathologists who assessed LAF using the METAVIR and Ishak systems. LAF was also scored separately in portal (0-3), sinusoidal (0-3) and centrolobular areas (0-3). Scoring evaluations were correlated with fibrosis quantification using morphometry, and also with TE and APRI. Statistical correlations between morphometry and METAVIR were 0.571 (p < 0.000) and 0.566 (p < 0.000) for the Ishak system. The novel score (0-9) for separate assessment of portal, sinusoidal and centrolobular fibrosis showed a better correlation with morphometry (0.731; p < 0.000) and high intra-/interobserver agreement (0.966; p < 0.000 and 0.794; p < 0.000, respectively). No correlation was found between TE or APRI and morphometry or the three histologic scores. In conclusion, this novel semiquantitative fibrosis scoring system seems to more accurately reflect LAF than the existing scoring system and may become a practical tool for staging fibrosis in LT.

Model alternative strategies for tuberculosis and Human immune deficiency virus case-finding in hard-to-reach populations in rural Eastern Nigeria

BACKGROUND

Since roughly half of all cases of active tuberculosis (TB) and Human immune deficiency virus (HIV) infection currently go undetected, there is a compelling need to pursue research aimed at improving case-finding, particularly among hard-to-reach populations.

OBJECTIVE

To identify and simplify TB/HIV case finding in Eastern Nigeria.

METHODS

This study involved an extensive pre-intervention Knowledge, Aptitude, Behavioural, Practice (KABP) Survey which revealed the specific limitations to TB/HIV case-finding using semi-structured questionnaires, key informant interviews and focus group discussions. The second component investigated the role of existing strategies and resources in the study area, and identified ways of optimizing these strategies and also provided alternative strategies. The third phase evaluated the performance of the different strategies and the most effective methods of optimizing their use.

RESULTS

The pre- intervention KABP Survey showed that the majority of the population could ill afford the costs imposed by delays in TB/HIV diagnosis and treatment. Most of the patients dropped out completely at any stage on the path to successful treatment due to several reasons. Working at motor parks, accepted stop points and several other ways were found as effective methods of reaching the hard-to-reach population.

CONCLUSION

Findings from this study can be used for designing appropriate TB/HIV management and case- finding training materials for the training and use of TB/HIV health workers as well as providing information on TB/HIV case finding for National policy. Thorough consideration of the findings and subsequent implementation of them are highly recommended.

Logistics and strategy of multiorgan procurement involving total face allograft

The face is the latest body structure to be added to the field of transplantation and the learning curve is ongoing. In the scenario of multiorgan recovery, the face is a nonvital 'organ' structure compared with other life-saving organs. To date, the face has been the first 'organ' to be procured in a multiorgan procurement. A technique for simultaneous recovery of the whole face, heart, lungs, liver, pancreas and kidneys is described. Thirty professionals participated in the procedure, of whom 13 were surgeons. No tracheotomy was performed. A mask of the donor's face was made from a mold impression. Duration of the procedure from skin incision to the end of surgery was 7.3 h. The face was perfused with Wisconsin solution through a cannula inserted into the aortic arch between the origin of the brachiocephalic arterial trunk and the left subclavian artery. Blood requirements consisted of 4 units of packed red blood cells. After the procedure, the mask was placed on the donor's face. All recovered grafts functioned immediately. In summary, simultaneous multiorgan procurement including the whole face is feasible, effective and saves time without jeopardizing life-saving organs and without the need for tracheotomy.

Logistics and strategy of multiorgan procurement involving total face allograft

The face is the latest body structure to be added to the field of transplantation and the learning curve is ongoing. In the scenario of multiorgan recovery, the face is a nonvital 'organ' structure compared with other life-saving organs. To date, the face has been the first 'organ' to be procured in a multiorgan procurement. A technique for simultaneous recovery of the whole face, heart, lungs, liver, pancreas and kidneys is described. Thirty professionals participated in the procedure, of whom 13 were surgeons. No tracheotomy was performed. A mask of the donor's face was made from a mold impression. Duration of the procedure from skin incision to the end of surgery was 7.3 h. The face was perfused with Wisconsin solution through a cannula inserted into the aortic arch between the origin of the brachiocephalic arterial trunk and the left subclavian artery. Blood requirements consisted of 4 units of packed red blood cells. After the procedure, the mask was placed on the donor's face. All recovered grafts functioned immediately. In summary, simultaneous multiorgan procurement including the whole face is feasible, effective and saves time without jeopardizing life-saving organs and without the need for tracheotomy.

No-touch hepatic hilum technique to treat early portal vein thrombosis after pediatric liver transplantation

A 'no-touch' hilum technique used to treat early portal vein complications post-liver transplantation in five children with body weight <10 kg is described. Four patients developed thrombosis and one portal flow absence secondary to collateral steal flow. A vascular sheath was placed through the previous laparotomy in the ileocolic vein (n = 2), inferior mesenteric vein (n = 1) or graft umbilical vein (n = 1). Portal clots were mechanically fragmented with balloon angioplasty. In addition, coil embolization of competitive collaterals (n = 3) and stent placement (n = 1) were performed. The catheter was left in place and exteriorized through the wound (n = 2) or a different transabdominal wall puncture (n = 3). A continuous transcatheter perfusion of heparin was subsequently administered. One patient developed recurrent thrombosis 24 h later which was resolved with the same technique. Catheters were removed surgically after a mean of 10.6 days. All patients presented portal vein patency at the end of follow-up. Three patients are alive after 5 months, 1.5 and 3.5 years, respectively; one patient required retransplantation 18 days postprocedure and the remaining patient died of adenovirus infection 2 months postprocedure. In conclusion, treatment of early portal vein complications following pediatric liver transplantation with this novel technique is feasible and effective.

Graded contrast echocardiography in pulmonary arteriovenous malformations

To compare the results of transthoracic contrast echocardiography (TTCE) adding a grading scale with the results of thoracic computed tomography (CT) in order to optimise the use of both techniques. 95 patients with hereditary haemorrhagic telangiectasia (HHT) were examined with TTCE and thoracic CT to detect pulmonary arteriovenous malformations (PAVMs). According to previous studies, TTCE was divided into a four grade scale depending on the degree of opacification of the left ventricle after the administration of a contrast agent. Of the 95 patients (50.5% female; mean age 46 yrs), none with normal or grade 1 TTCE had detectable PAVMs on thoracic CT. Shunts of grades 2, 3 and 4 were associated with PAVMs according to thoracic CT in 25, 80, and 100% of the cases. There was a statistically significant association between the TTCE grade and the detection of a PAVM by thoracic CT. There were also statistically significant associations between TTCE grade and the cardiac cycle when the contrast was first visible in the left atrium, and size of the feeding artery. Graded TTCE and timing of left atrium opacification may be useful techniques in selecting HHT patients for PAVM screening with thoracic CT scans.

Post-transplant lymphoproliferative disorders in children: the role of chemotherapy in the era of rituximab

PTLD are the most frequent neoplasms in children postorgan transplantation. We describe our experience in the treatment of 14 children (three with early and 11 with late-onset disease) treated with a step-wise protocol developed at our institution. Treatment consisted of reducing immunosuppressants, followed by rituximab and chemotherapy if required. Rituximab, incorporated into the protocol in 2001, has been determinant for the total chemotherapy burden patients need to achieve remission. In seven patients who did not receive rituximab, anthracycline total dose ranged from 160 to 240 mg/m(2), while only one of the patients receiving rituximab required DOXO (range: 0-120 mg/m(2)) (p = 0.003). The use of alkylating agents was also notably lower in patients receiving rituximab (median dose = 1200 mg/m(2)) compared with those who did not receive rituximab (median dose = 5800 mg/m(2)) (p = 0.006). Twelve patients are in remission and two died, one from refractory disease and the other from septic shock. Two-year OS and EFS were 85.7% and 57%, respectively. In conclusion, our experience with the use of rituximab in children with PTLD after solid organ transplantation appeared to be associated with a lesser requirement for alkylating agents and anthracyclines compared with historical subjects, suggesting a reduction in the side effects of these agents.

[Long term follow-up of bile duct stenosis treated with interventional radiology in pediatric liver transplantation]

The reported incidence of biliary strictures following pediatric liver transplantation has ranged between 5-34%, with a higher incidence in segmental grafts. Currently, percutaneous transhepatic balloon dilatation of biliary strictures is considered as the first line treatment owing to its minimal invasiveness. Between 1995-2006, 20 children who underwent liver transplantation developed biliary complications treated with interventional radiology. 16/20 developed biliary stricture, of whom 10 were treated with percutaneous transhepatic balloon dilatation. The mean age at the procedure was 6.6 years (range 8 m--14 years). The allograft types included whole (n=4), split (n=3), and reduced (n=3) livers. The procedure was performed at a mean time post-transplantation of 2.6 years. All patients are alive with a mean follow-up post-procedure of 24 months (range: 4 months-11 years). Currently, only 4 have a normal appearing biliary tree by imaging techniques and 6 developed stricture recurrence; of whom 3 developed biliary cirrhosis (2 splits, 1 reduced), one patient underwent successful rescue surgery, one was treated again percutaneously, and the remaining was lost to followup. In conclusion, treatment of percutaneous transhepatic balloon dilatation of biliary strictures is effective avoiding surgical correction. However, stricture recurrence in the medium- long term follow-up is frequent, particularly in segmental grafts. [corrected]

Non-anatomical intestinal transplantation

INTRODUCTION

Intestinal transplantation is the only long-range treatment option for patients with intestinal failure. We report an exceptional case of isolated intestinal transplantation with the implant in a non-anatomical position.

CLINICAL CASE

The patient was a thirty-eight-year-old man (60 kg weight, 180 cm height, 18.3 body mass index) with intestinal failure and home parenteral nutrition due to a short-bowel syndrome for which intestinal transplantation was indicated. The patient had a vascular malformation with the cava vein located left to the aorta, and the intestine was implanted with a 180 masculine rotation around the mesenteric axis, so that the implant s superior mesenteric artery and vein matched the recipient s cava and aorta. Postoperative follow-up was excellent and the patient was discharged after six weeks with a 10-kg gain in body weight.

DISCUSSION

This non-anatomical intestinal implantation of the small bowel, previously unreported, offers technical advantages over other options. Adequate intestinal function represents a unique model to prove the viability of intestinal implants in a non-anatomical position.

Intraoperative flow measurement of native liver and allograft during orthotopic liver transplantation in children

Hepatic hemodynamic changes during liver transplantation (OLT) in children have not yet been studied. We measured intraoperative portal vein flow (PVF) and hepatic arterial flow (HAF) (mL/min) in 53 children and 58 grafts during OLT. Flows were measured in the native organ and in the allograft. In the native liver, PVF and HAF are similar; after transplantation they return to the physiological situation. No flow differences were seen between whole and partial grafts. Among the 8 (14%) portal vein thromboses, PVF was lower in both the native liver and the graft than in the no thrombosis group (P < .05). PVF <5 mL/min/kg was a risk factor to develop PV thrombosis. No graft loss occurred in 3 cases without PVF at the time of OLTs despite the observation that repermeabilization was not possible. In 4 patients with PVF <5 mL/min/kg, after tying a spontaneous spleno-renal shunt (n = 3) or performing a porto-renal vein anastomosis (n = 1), PVF reached >20 mL/min/kg, avoiding thrombosis. In conclusion, PVF and HAF measurements during pediatric OLT may predict patients at high risk for development of PV thrombosis.

Recurrence of hepatocellular carcinoma after liver transplantation

Outcome after liver transplantation (OLT) clearly depends on recurrence of hepatocellular carcinoma (HCC). After recurrence, patient outcome will depend on the time and site of appearance. The aim of this study was to analyze the therapeutic implications of tumor recurrence behavior. From October 1988 to December 2005, 685 patients received OLT, including 202 due to HCC (32%). We analyzed 28 recurrences (15.2%) among 184 patients who survived at least 3 months (minimum follow-up 1 year). According to the time of recurrence, we divided the patients into early recurrence (ER < 12 months; n = 9; 32.1%) and late recurrence (LR > 12 months n = 19; 67.9%). Actuarial survivals at 1, 5, and 10 years were 82%, 65%, and 50% and disease-free survival, 80%, 58%, and 46%, respectively. Risk factors for recurrence were: vascular invasion (P < .01), bad differentiation (P < .01), and previous hepatectomy (P < .05). After OLT, ER presented at: 5.7 +/- 2.3 months (range 3-10) vs 33.5 +/- 24.3 months (range 12-103) for LR P < .001). Survival postrecurrence (SPR) was shorter: 3.1 +/- 2.4 (range 1-8) months vs 16.4 +/- 14.2 (range 1-5) months (P < .001). Treatment was offered to one ER (11%) and to eight LR (47.1%; P < .05), achieving in these cases longer SPR: 20.1 +/- 14 vs 6.9 +/- 9 months (P < .05). The most common sites of recurrence were liver (n = 7), lung (n = 7), bone (n = 5), adrenal gland (n = 2), peritoneum (n = 2), lymph node (n = 2), skin (n = 2) or cerebral (n = 1). Early recurrences showed short survivals; no treatment could be offered to these patients. Liver recurrence appeared early. In contrast, most lung recurrences appeared later with the possibility of treatment and longer SPR. Bone recurrence appeared later, usually associated with other locations. Treatment was palliative and prognosis was worse. Skin and lymph node recurrences can be treated curatively with prolonged survival. In conclusion, HCC recurrence was difficult to treat curatively and was only prevented by employing restricted criteria.

Liver Transplantation in Childhood With More Than 10 Years of Follow-up: Analysis of a Single-Center Experience

We pioneered pediatric liver transplantation (OLT) in Spain (June 1985). The aim of this study was to evaluate the current status of our OLT recipients with more than 10 years follow-up.

MATERIALS AND METHODS

The 50 patients with >10 years follow-up had a mean age at OLT of 5.6 years with 60% showing a main indication of biliary atresia. All but one (tacrolimus) received cyclosporine.

RESULTS

No patient loss occurred among these patients. Eighteen patients had follow-up >15 years and 12 >20 years. The incidence of acute rejection was 56%; chronic rejection, 16%; and lymphoproliferative disorders, 12%. Seven (14%) required retransplantation at a mean of 4.2 years after the first OLT due in four instances to chronic rejection. After 10 years of follow-up, one patient developed portal vein thrombosis and three biliary strictures. All patients remain on immunosuppression. In 64% cyclosporine was switched to tacrolimus or another agent. One patient developed acute rejection at 19.2 years. In 14% of patients the liver function test is abnormal with serum creatinine is >1.5 mg/dL in 10%; one requires insulin and three, antihypertensive drugs. Noncompliance with medications was detected in 10%. Three recipients had offspring.

CONCLUSIONS

OLT was an effective treatment with a good quality of life also on long-term follow-up.

[Surgical strategies in short bowel syndrome]

Management of short bowel syndrome has to be undertaken by a multidisciplinary team including gastroenterology, surgery, and nutrition, among other specialties. The final therapeutic goal is favoring intestinal adaptation by the bowel so that the patient may be weaned from parenteral nutrition. Anatomical factors influencing on adaptation are very important for deciding the best surgical option. The type of procedure will defined by age, length and functionality of the remnant bowel, the existence of intestinal dilation, the presence of bacterial overgrowth, and the presence or absence of parenteral nutrition-related complications, among others. Early closure of the stomas, if present, and correction of stenoses, if possible with stricturoplasties and with remodeling or intestinal plicature if needed, are among the basic principles of surgical management. Interventions aimed at decreasing the transit time such as the creation of valves, interposition of anti-peristaltic segments or large bowel are poorly accepted. The most accepted techniques are those elongating the bowel that may be applied only on dilated bowels. Although experience is greater with Bianchi's technique, short-term outcomes of serial transversal enteroplasty (STEP) are promising. STEP is simpler and may be applied even to previously elongated bowels by the Bianchi's technique.

Melting curve of 4He: no sign of a supersolid transition down to 10 mK

We have measured the melting curve of 4He in the temperature range from 10 to 400 mK with the accuracy of about 0.5 micro bar. Crystals of different quality show the expected T4 dependence in the range from 80 to 400 mK without any sign of the supersolid transition, and the coefficient is in excellent agreement with available data on the sound velocity in liquid 4He and on the Debye temperature of solid 4He. Below 80 mK, we have observed a small deviation from T4 dependence, which, however, cannot be attributed to the supersolid transition, because instead of decrease the entropy of the solid rather remains constant, about 2.5 x 10(-6) R.

Analysis of Discarded Livers for Transplantation

The aims were to study the causes of nonacceptance of a liver for transplantation after exploration by the donor surgical team and to compare donor characteristics of transplanted and discarded livers. All donor harvesting procedures performed by our unit from 1988 to 2004 were retrospectively studied. Donors were divided in those accepted and transplanted and those discarded by the donor surgical team. The causes of rejection were classified as hepatic and nonhepatic. Donor characteristics of accepted, transplanted livers were compared with those rejected for hepatic reasons. Seven hundred fifty four donor liver procurements were performed: 628 livers were accepted and transplanted (TL), 126 (17.5%) were discarded owing to extrahepatic (n = 16) or hepatic causes (n = 110). Extrahepatic causes were: technical (5.6%), and incidental tumors infection (7.2%). Hepatic causes were: chronic disease or cirrhosis (26.4%), ischemic or septic liver (16.8%), and steatosis (44%). Univariate analysis of donor characteristics showed a significant difference in older age, diabetes, alcohol intake, arterial hypertension, abnormal liver ultrasound (US) exam, and abnormal liver function tests in the group of discarded livers. Obesity and the finding of steatosis in US exam were the only two factors that maintained statistical significance upon multivariate analysis.

Adverse prognostic impact of CD36 and CD2 expression in adult de novo acute myeloid leukemia patients

BACKGROUND AND OBJECTIVES

A consecutive series of acute myeloid leukemias (AML) patients was analyzed in conditions which reduce the inter-assay variations (the same flow cytometer, the same observers and the same panel of monoclonal antibodies) in order to investigate the prognostic information provided by flow cytometry.

DESIGN AND METHODS

Two hundred and sixty-six bone marrow (BM) samples from 326 patients enrolled in the LMA-99 protocol from the CETLAM group were studied by multiparametric flow cytometry. Immunophenotyping studies were performed on erythrocyte-lysed BM samples. Antigen expression of leukemic cells was analyzed using triple stainings with fluorochrome-conjugated combinations of monoclonal antibodies.

RESULTS

CD2 was positive in 21 cases (8%); an associated inv(16) was detected in eight CD2+ cases (38%). Two-year overall survival (OS) rate for CD2+/inv(16)+ patients was 75%, whereas it was 0% for CD2+/inv(16)- patients and 47% for CD2- patients (p=0.0001). CD36 was expressed in 37% of patients (n=98). Two-year leukemia-free survival (LFS) rate was 34% for CD36+ patients and 55% for CD36- patients (p=0.001). In the multivariate analysis, CD2+ (RR=8.4; p=0.0001) and adverse karyotype (RR=10.2; p=0.0001) were associated with a lower CR rate, CD36+ (RR=1.5; p=0.03), CD2+ (RR=2; p=0.04) and adverse karyotype (RR=4; p=0.0001) were associated with a lower OS and CD36+ (RR=2; p=0.002) and adverse karyotype (RR=3.5; p=0.005) predicted a lower LFS.

CONCLUSIONS

CD2+ patients had a very poor OS when CD2/inv(16)+ cases were excluded. CD36 and CD2 expression at diagnosis can provide prognostically important information in adult de novo AML.

Thrombotic thrombocytopenic purpura and pregnancy: a review of ten cases

BACKGROUND AND OBJECTIVES

A series of women with pregnancy-associated thrombotic thrombocytopenic purpura, is presented. This study will focus on the relationship between thrombotic thrombocytopenic purpura and pregnancy and on maternal and neonatal outcomes.

MATERIALS AND METHODS

Among forty-six consecutive patients with thrombotic thrombocytopenic purpura, nine pregnant patients were identified.

RESULTS

Seven patients presented an acute single episode associated with pregnancy and two patients had a chronic relapsing form of the disease. None of these two patients were diagnosed during pregnancy or in the postpartum period. There was one maternal death. Fetal mortality was 33%.

CONCLUSIONS

The recurrence is rare in women who had the prior episode related to pregnancy. The risk of death for these patients seems not higher than that of the remaining patients in the series. Preterm delivery and intrauterine fetal death were frequent complications of these pregnancies.

[Experimental model of auxiliary heterotopic liver-intestinal transplantation]

In pigs, orthotopic liver-intestine transplantation (LITX) has high per operative morbidity and mortality. It is due to hemodynamic, coagulation and metabolism disorders during native liver hepatectomy (total hepatic vascular exclusion) and the postoperative diarrhea secondary to initial dysfunction of the graft and enterectomy of native intestine. To avoid those disturbances and to increase the survival, we have developed a porcine model of auxiliary heterotopic LITX. The allograft was harvested in-bloc, containing the liver, duodenum, pancreas, and jejunum. In the recipient, the liver and intestine were left intact. The allograft was implanted heterotopically, caudal to the native liver. Venous drainage was achieved with anastomosis of donor (D) to recipient (R) infrahepatic cava; and arterialization with anastomosis of D aortic conduit containing the celiac axis and SMA to infra-renal R aorta. The D jejunum was hooked-up to R jejunum. The experiment was performed in 16 animals without intraoperative deaths, hemodynamic stability and no blood requirements. Four animals were left alive 7 days with functioning grafts, suggesting the model viability.

Prosthetic mesh used for inguinal and ventral hernia repair: normal appearance and complications in ultrasound and CT

The use of prosthetic mesh has now become accepted practice in the treatment of patients with both inguinal and ventral hernias. This pictorial review illustrates the various radiological appearances of these meshes and also demonstrates the post-operative complications associated with their implantation.

[Success of endoscopic management in vesicoureteral reflux, conditioned by ureteral dilatation]

INTRODUCTION

Endoscopic management has become an important alternative in the treatment of vesicoureteral reflux in children. Since 1995 we indicate it in our Hospital in children with grade II VUR (vesicoureteral reflux) after 1 year of medical management, in all children with grade III VUR and in children with grade IV VUR without reflux nephropathy. According to International Classification of reflux (IRSC), grade IV VUR differ to grade III mainly by the blunting of the calyces and the obliteration of sharp angle of the fornices. There may be seen in the high grades of reflux, important differences in the ureteral dilatation.

AIM

The aim of this work is to study the influence of ureteral dilatation in the success of endoscopic management VUR.

MATERIAL AND METHODS

A number of 245 refluxing renal units (URR) were treated endoscopically in our Hospital from 1995. We review the first 3.5 years (58 patients with 90 RRU). In a double blind study with the voiding cystourethrographies we graduated the ureteral dilatation in slight-normal, moderate and severe. The success rate after the first injection was compared between the 3 grades of ureteral dilatation.

RESULTS

3 patients had grade I VUR, 10 grade II, 54 grade III and 23 grade IV. After double blind study 39 patients had slight-normal ureteral dilatation, 39 moderate and 12 severe. There were statistical differences between the 3 grades of ureteral dilatation when we consider: all the patients, considering only grade III and IV reflux and studying only the patients with grade III reflux. However there wasn't statistical differences between grade III and IV VUR of the International Classification.

CONCLUSIONS

The results show that ureteral dilatation is an important prognostical factor of the success rate in the endoscopic management of vesicoureteral reflux in children.

[Comparison of efficacy and complications of 27G and 29G Sprottte needles for subarachnoid anesthesia]

OBJECTIVE

Post-dural puncture headache and lumbar backache are related to needle gauge and type of point used. We aimed to determine whether the incidence of post-dural puncture headache and lumbar backache could be reduced by using fine gauge pencil-point Sprotte 27G and 29G needles. We also studied increases in technical difficulty with these needles and whether or not reducing needle gauge affected anesthetic quality.

PATIENTS AND METHOD

Three hundred eighty-nine patients undergoing orthopedic or lower abdominal surgery were randomly assigned to two groups for dural puncture using two Sprotte needles: 27G or 29G. We recorded time to perform puncture, number of re-insertations of the needle, number of times the technique was abandoned and anesthetic efficacy. On the second and seventh days, the patients were interviewed by telephone to check for the presence and severity of post-dural puncture headache or lumbar backache.

RESULTS

The technical difficulty was greater with the Sprotte 29G needle, as shown by significant differences in time taken to perform the puncture and the number of re-insertions (p < 0.05). Anesthetic quality was the same in both groups and the percentage of failures was 0.5% for both. Five percent of patients in the 27G group and 3% in the 29G group experienced slight or moderate headache on the second day. No cases of severe cephalea were reported. Lumbar backache was reported on the second day by 26% and 18.5% of the patients in the 27G and 29G groups, respectively, but the rates decreased to 4.5% and 0.5% on the seventh day. The differences were significant, favoring the 29G needle.

CONCLUSIONS

The use of 29G pencil-point needles can be recommended to reduce the incidence of headache and lumbar backache in the postoperative period, in spite of the greater technical difficulty involved, given that quality of anesthesia is maintained.

Two groups of chronic myelomonocytic leukaemia: myelodysplastic and myeloproliferative. Prognostic implications in a series of a single center

The clinical records of 70 patients seen at our hospital between 1976 and 1998 and diagnosed as suffering from chronic myelomonocytic leukaemia (CMML) were reviewed in order to confirm the validity of the classification into two forms of disease that the French-American-British Co-operative Leukaemia Group (FAB) proposed in 1994: myelodysplastic (MD) and myeloproliferative (MP), depending on the peripheral white blood cell count (WBC) (less or more than 13 x 10(9)/l, respectively). After the rejection of incomplete records and lost to follow up patients, our study population consisted of 49 records. Our results confirm that, even though this classification is useful in order to separate two classes of patients, it is not enough to predict the prognosis in an accurate manner. A lot of studies have tried to find some prognostic factors, but the results have been discordant. The multivariate analysis of our group of patients showed three prognostic factors: serum lactate dehydrogenase (LDH) >1.5 times normal level, blasts in bone marrow >5%, and peripheral blood leukocytes >10 x 10(9)/l. A second multivariate analysis led us to distinguish two groups: high risk (2-3 risk factors) and low risk (0-1 risk factors) (median survival 7 and 44 months, respectively) with a very high statistic significance (P<0.0001). This score should be applied to other series of CMML patients in order to confirm its validity.