Adding Extracorporeal Membrane Oxygenation to Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest Due to Pulmonary Embolism: A Case Report

We present a challenging cardiopulmonary resuscitation scenario of an out-of-hospital cardiac arrest (OHCA) in a 21-year-old healthy woman recovering from a lower limb fracture who collapsed during a rehabilitation session at a community center. The combination of witnessed arrest, administration of immediate cardiopulmonary resuscitation, and effective communication to emergency services enabled a timely cannulation of extracorporeal membrane oxygenation in a cardiopulmonary resuscitation reference center. The cause of the cardiac arrest was pulmonary embolism, and the intensive care unit team opted for thrombolysis when she arrived after 40 minutes of cardiopulmonary resuscitation. The circulatory support given by venoarterial extracorporeal membrane oxygenation enabled adequate perfusion until the restoration of cardiac blood flow at 75 minutes after cardiac arrest. Despite the initial success, several life-threatening complications occurred. Anticoagulation is of paramount importance during extracorporeal support, as is thrombolysis in massive pulmonary embolism with cardiac arrest. However, this led to several complications. We highlight the importance of liaising with a wider team in such cases, including hepatobiliary surgery, vascular surgery, and interventional radiology, as doing so saved this patient's life without deficits.

The Characteristics and Laboratory Findings of SARS-CoV-2 Infected Patients during the First Three COVID-19 Waves in Portugal-A Retrospective Single-Center Study

Background and Objectives: Given the wide spectrum of clinical and laboratory manifestations of the coronavirus disease 2019 (COVID-19), it is imperative to identify potential contributing factors to patients' outcomes. However, a limited number of studies have assessed how the different waves affected the progression of the disease, more so in Portugal. Therefore, our main purpose was to study the clinical and laboratory patterns of COVID-19 in an unvaccinated population admitted to the intensive care unit, identifying characteristics associated with death, in each of the first three waves of the pandemic. Materials and Methods: This study included 337 COVID-19 patients admitted to the intensive care unit of a single-center hospital in Lisbon, Portugal, between March 2020 and March 2021. Comparisons were made between three COVID-19 waves, in the second (n = 325) and seventh (n = 216) days after admission, and between discharged and deceased patients. Results: Deceased patients were considerably older (p = 0.021) and needed greater ventilatory assistance (p = 0.023), especially in the first wave. Differences between discharged and deceased patients' biomarkers were minimal in the first wave, on both analyzed days. In the second wave significant differences emerged in troponins, lactate dehydrogenase, procalcitonin, C-reactive protein, and white blood cell subpopulations, as well as platelet-to-lymphocyte and neutrophil-to-lymphocyte ratios (all p < 0.05). Furthermore, in the third wave, platelets and D-dimers were also significantly different between patients' groups (all p < 0.05). From the second to the seventh days, troponins and lactate dehydrogenase showed significant decreases, mainly for discharged patients, while platelet counts increased (all p < 0.01). Lymphocytes significantly increased in discharged patients (all p < 0.05), while white blood cells rose in the second (all p < 0.001) and third (all p < 0.05) waves among deceased patients. Conclusions: This study yields insights into COVID-19 patients' characteristics and mortality-associated biomarkers during Portugal's first three COVID-19 waves, highlighting the importance of considering wave variations in future research due to potential significant outcome differences.

Cholesteryl hemiazelate identified in CVD patients causes in vitro and in vivo inflammation

Oxidation of PUFAs in LDLs trapped in the arterial intima plays a critical role in atherosclerosis. Though there have been many studies on the atherogenicity of oxidized derivatives of PUFA-esters of cholesterol, the effects of cholesteryl hemiesters (ChEs), the oxidation end products of these esters, have not been studied. Through lipidomics analyses, we identified and quantified two ChE types in the plasma of CVD patients and identified four ChE types in human endarterectomy specimens. Cholesteryl hemiazelate (ChA), the ChE of azelaic acid (n-nonane-1,9-dioic acid), was the most prevalent ChE identified in both cases. Importantly, human monocytes, monocyte-derived macrophages, and neutrophils exhibit inflammatory features when exposed to subtoxic concentrations of ChA in vitro. ChA increases the secretion of proinflammatory cytokines such as interleukin-1β and interleukin-6 and modulates the surface-marker profile of monocytes and monocyte-derived macrophage. In vivo, when zebrafish larvae were fed with a ChA-enriched diet, they exhibited neutrophil and macrophage accumulation in the vasculature in a caspase 1- and cathepsin B-dependent manner. ChA also triggered lipid accumulation at the bifurcation sites of the vasculature of the zebrafish larvae and negatively impacted their life expectancy. We conclude that ChA behaves as an endogenous damage-associated molecular pattern with inflammatory and proatherogenic properties.

Candida auris in Intensive Care Setting: The First Case Reported in Portugal

Candida auris is an opportunistic human pathogen that has rapidly spread to multiple countries and continents and has been associated with a high number of nosocomial outbreaks. Herein, we report the first case of C. auris in Portugal, which was associated with a patient transferred from Angola to an ICU in Portugal for liver transplantation after a SARS-CoV-2 infection. C. auris was isolated during the course of bronchoalveolar lavage, and it was subjected to antifungal susceptibility testing and whole-genome sequence analysis. This isolate presents low susceptibility to azoles and belongs to the genetic clade III with a phylogenetic placement close to African isolates. Although clade III has already been reported in Europe, taking into account the patient's clinical history, we cannot discard the possibility that the patient's colonization/infection occurred in Angola, prior to admission in the Portuguese hospital. Considering that C. auris is a fungal pathogen referenced by WHO as a critical priority, this case reinforces the need for continuous surveillance in a hospital setting.

The Impact of the Serum Extraction Protocol on Metabolomic Profiling Using UPLC-MS/MS and FTIR Spectroscopy

Biofluid metabolomics is a very appealing tool to increase the knowledge associated with pathophysiological mechanisms leading to better and new therapies and biomarkers for disease diagnosis and prognosis. However, due to the complex process of metabolome analysis, including the metabolome isolation method and the platform used to analyze it, there are diverse factors that affect metabolomics output. In the present work, the impact of two protocols to extract the serum metabolome, one using methanol and another using a mixture of methanol, acetonitrile, and water, was evaluated. The metabolome was analyzed by ultraperformance liquid chromatography associated with tandem mass spectrometry (UPLC-MS/MS), based on reverse-phase and hydrophobic chromatographic separations, and Fourier transform infrared (FTIR) spectroscopy. The two extraction protocols of the metabolome were compared over the analytical platforms (UPLC-MS/MS and FTIR spectroscopy) concerning the number of features, the type of features, common features, and the reproducibility of extraction replicas and analytical replicas. The ability of the extraction protocols to predict the survivability of critically ill patients hospitalized at an intensive care unit was also evaluated. The FTIR spectroscopy platform was compared to the UPLC-MS/MS platform and, despite not identifying metabolites and consequently not contributing as much as UPLC-MS/MS in terms of information concerning metabolic information, it enabled the comparison of the two extraction protocols as well as the development of very good predictive models of patient's survivability, such as the UPLC-MS/MS platform. Furthermore, FTIR spectroscopy is based on much simpler procedures and is rapid, economic, and applicable in the high-throughput mode, i.e., enabling the simultaneous analysis of hundreds of samples in the microliter range in a couple of hours. Therefore, FTIR spectroscopy represents a very interesting complementary technique not only to optimize processes as the metabolome isolation but also for obtaining biomarkers such as those for disease prognosis.

Complications during transport of adult patients on extracorporeal membrane oxygenation

INTRODUCTION

Transport on extracorporeal membrane oxygenation (ECMO) is a risky and complex procedure. Although most published data support the feasibility of interhospital transport on ECMO, data concerning intra-facility transportation and frequency and severity of complications during ECMO transport of adult patients are still scarce. The aim of this study was to assess transport arrangements and complications during intra and interhospital ECMO-supported patients transport at a high-volume ECMO center.

METHODS

Retrospective single-center descriptive study evaluating the prevalence and severity of complications associated with the transportation of adult patients on ECMO support between 2014 and 2022 in our ECMO center.

RESULTS

We performed 393 transfers of patients on ECMO support. Those comprised 206 intra-facility, 147 primary, 39 secondary and one tertiary transports. For primary and tertiary transportations, the average transfer length was 118.6 km (range 2.5-1446) and the mean total transport time was 5 h 40 min. The majority of transportations were made by ambulance (93.2%). Complications occurred in 12.7% of all transports and were more frequent in intra-facility and primary/tertiary transfers. Most complications were patient (46%) and staff related (26%). Risk category two was the most frequent (50%), and only five complications were classified as risk category 1 (10%). No deaths occurred during all patient transport.

CONCLUSIONS

Most transports carry minor problems that entail a negligible risk to the patient. When ECMO-supported transport is performed by an experienced team, the severe complications are not related with an increased morbimortality.

Anesthesia and surgery in very precarious conditions. Clinical cases

We performed herniorrhaphy on 21 children (4 of them infants) and 3 adults, in very precarious conditions, in a hospital in a economically depressed area of the Democratic Republic of Congo. Anesthesia technique used in adults was subarachnoid and intravenous and intramuscular ketamine in children. Ketamine is an irreplaceable anesthetic in many parts of the world without resources, where the minimum safety means are not available. Knowing the simple anesthetic techniques, but with less risk, can also be useful in resourceful places, in unexpected situations. Greater solidarity is needed, both from anesthesia societies and from anesthesiologists, to alleviate the great deficiencies in well-trained professionals and means in places without resources.

Cytokine Adsorption Therapy during Extracorporeal Membrane Oxygenation in Adult Patients with COVID-19

Respiratory failure and systemic inflammation are paramount features of severe SARS-CoV-2 disease (COVID-19). Extracorporeal membrane oxygenation (ECMO) therapy has a potential role in patients with refractory disease. An inflammatory response due to blood contact with hemofilters, functioning as a synergic inflammatory stimulus, can lead to a hyperinflammatory state, relatable to cytokine release syndromes. After the first patient succumbed to a refractory vasodilatory shock believed to be due to hyperinflammatory state, a strategy of blood purification through cytokine adsorption therapy (CAT) with CytoSorb® was designed. In this case series, the authors describe the initial experience with such strategy. CAT was employed with no direct complications and helped controlling the inflammatory state, with all patients halting vasopressor support in 72 h and biomarker levels (C-reactive protein, ferritin, and interleukin-6) showing negative trends in most patients. Analysis of inflammatory biomarkers evolution highlighted 2 biomarker profiles related to the presence or absence of superinfection at the time of CAT implementation. In this case series of severe COVID-19 patients, 3 patients died − irreversible lung fibrosis, complications of critical hypoxemia before ECMO induction and complications of systemic anticoagulation were the causes. This case series aimed to contribute to the body of evidence substantiating CAT utilization in hyperinflammatory patients, namely, COVID-19 patients requiring ECMO rescue.

REPAIR OF RUPTURED ABDOMINAL AORTIC ANEURYSM AFTER CARDIAC ARREST: A CASE REPORT

The management of abdominal aortic aneurysms, especially ruptured abdominal aortic aneurysms, continues to challenge vascular surgeons. A ruptured abdominal aortic aneurysm is associated with a high mortality rate. If cardiopulmonary resuscitation is required before surgical repair, mortality rates are said to be even higher. However, cardiac arrest in patients with ruptured abdominal aortic aneurysm does not accurately predict a nonsalvageable state or preclude functional survival. In these cases, agressive management may be the only hope for survival, and cardiac arrest should not as such contraindicate repair. The objective of this study is to present a successful case of repair of ruptured abdominal aortic aneurysm after cardiac arrest.

Prognostic significance of specific EEG patterns after cardiac arrest in a Lisbon Cohort

Objective

To evaluate if EEG patterns considered highly malignant are reliable predictors not only of poor neurological outcome but also reliable predictors of death.

Methods

Retrospectively, EEGs from Cardiac Arrest (CA) patients of two teaching hospitals in Lisbon were classified into 3 groups: highly malignant, malignant, and benign groups. Outcome was assessed at 6 months after CA by CPC (Cerebral Performance Categories) scale. We evaluated the accuracy of these patterns to predict poor neurological outcome and death.

Results

We included 106 patients for analysis. All patients with a highly malignant EEG (n = 37) presented a poor neurological outcome. Those patterns were also associated with death. Malignant EEG patterns were not associated with poor neurological outcome. Benign EEG patterns were associated with good neurological recovery (p < 0.0001).

Conclusion

Highly malignant EEG patterns were strongly associated with poor neurological outcome and can be considered to be predictors of death.

Significance

This study increased the knowledge about the value of EEG as a tool in outcome prediction of patients after cardiac arrest.

P1249 Straight from the heart

Introduction

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge and is still associated with high mortality. Systemic complications are frequently present, and an adequate assessment and management are needed.

Purpose

Our aim is to show the importance of an early recognition of IE complications.

Clinical case

We present a case of 54 years old women with a past medical history unremarkable. The patient presented to the hospital with high fever and was admitted with a diagnosis of a psoas abscess and staphilococus aureus bacteremia. After one week of antibiotic treatment the patient was transferred to an intensive care unit due to septic shock and respiratory failure. The patient needed to be intubated and ventilated and was on treatment with vancomycin and meropenem. During admission, several infectious loci were identified, including cerebral and pulmonar involvement. An echocardiography identified mild mitral regurgitation, moderate tricuspid regurgitation and confirmed the presence of two vegetations, one in tricuspid valve with 30mm and one in mitral valve with 5mm. Nevertheless, the patient improved clinically. After 15 days of treatment, the patient was extubated and was transferred to the cardiology ward for follow-up. Although clinically stable and without any complain, repeated echocardiographic evaluation identified left ventricular apical aneurysm and partial resolution of vegetations. A coronariography was performed and did not identified any coronary lesion. A magnetic resonance confirmed the ischemic aetiology of the lesions and a diagnosis of embolic myocardial infarction was made. Considering a good resolution of infection, and being the patient stable and asymptomatic, she was discharged after 6 weeks of antibiotic therapy for follow up in cardiology and neurosurgery consultations.

Discussion and conclusion

Despite appropriate antimicrobial treatment, embolic complications are common and usually develop during initial stage of IE. This case shows several embolic complications of IE, including embolic myocardial infarction and cerebral embolism. Although aggressive antibiotic administration was successful in this particular case and cardiac surgery was avoided, the identification of complications allowed a more strict follow up and was determinant for a good clinical result.

Abstract P1249 Figure.

Acute-on-Chronic Liver Failure: A Portuguese Single-Center Reference Review

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by an acute deterioration of a patient with cirrhosis, frequently associated with multi-organ failure and a high short-term mortality rate. We present a retrospective study that aims to characterize the presentation, evolution, and outcome of patients diagnosed with ACLF at our center over the last 3 years, with a comparative analysis between the group of patients that had ACLF precipitated by infectious insults of bacterial origin and the group of those with ACLF triggered by a nonbacterial infectious insult; the incidence of acute kidney injury and its impact on the prognosis of ACLF was also analyzed. Twenty-nine patients were enrolled, the majority of them being male (89.6%), and the mean age was 53 years. Fourteen patients (48.3%) developed ACLF due to a bacterial infectious event, and 9 of them died (64.2%, overall mortality rate 31%); however, no statistical significance was found (p < 0.7). Of the remaining 15 patients (51.7%) with noninfectious triggers, 11 died (73.3%, overall mortality rate 37.9%); again there was no statistical significance (p < 0.7). Twenty-four patients (83%) developed acute kidney injury (overall mortality rate 65.5%; p < 0.022) at the 28-day and 90-day follow-up. Twelve patients had acute kidney injury requiring renal replacement therapy (41.37%; overall mortality rate 37.9%; p < 0.043). Hepatic transplant was performed in 3 patients, with a 100% survival at the 28-day and 90-day follow-up (p < 0.023). Higher grades of ACLF were associated with increased mortality (p < 0.02; overall mortality 69%).

Conclusions

ACLF is a heterogeneous syndrome with a variety of precipitant factors and different grades of extrahepatic involvement. Most cases will have some degree of renal dysfunction, with an increased risk of mortality. Hepatic transplant is an efficient form of therapy for this syndrome.

The accuracy of PiCCO® in measuring cardiac output in patients under therapeutic hypothermia: Comparison with transthoracic echocardiography

BACKGROUND

Invasive cardiac monitoring using thermodilution methods such as PiCCO® is widely used in critically ill patients and provides a wide range of hemodynamic variables, including cardiac output (CO). However, in post-cardiac arrest patients subjected to therapeutic hypothermia, the low body temperature possibly could interfere with the technique. Transthoracic Doppler echocardiography (ECHO) has long proved its accuracy in estimating CO, and is not influenced by temperature changes.

OBJECTIVE

To assess the accuracy of PiCCO® in measuring CO in patients under therapeutic hypothermia, compared with ECHO.

DESIGN AND PATIENTS

Thirty paired COECHO/COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest. Eighteen paired measurements were obtained at under 36°C and 12 at ≥36°C. A value of 0.5l/min was considered the maximum accepted difference between the COECHO and COPiCCO values.

RESULTS

Under conditions of normothermia (≥36°C), the mean difference between COECHO and COPiCCO was 0.030 l/min, with limits of agreement (-0.22, 0.28) - all of the measurements differing by less than 0.5 l/min. In situations of hypothermia (<36°C), the mean difference in CO measurements was -0.426 l/min, with limits of agreement (-1.60, 0.75), and only 44% (8/18) of the paired measurements fell within the interval (-0.5, 0.5). The calculated temperature cut-off point maximizing specificity was 35.95°C: above this temperature, specificity was 100%, with a false-positive rate of 0%.

CONCLUSIONS

The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of <36°C, demonstrating the inaccuracy of PiCCO® for cardiac output measurements in hypothermic patients.

Therapeutic hypothermia after cardiac arrest: outcome predictors

OBJECTIVE

The determination of coma patient prognosis after cardiac arrest has clinical, ethical and social implications. Neurological examination, imaging and biochemical markers are helpful tools accepted as reliable in predicting recovery. With the advent of therapeutic hypothermia, these data need to be reconfirmed. In this study, we attempted to determine the validity of different markers, which can be used in the detection of patients with poor prognosis under hypothermia.

METHODS

Data from adult patients admitted to our intensive care unit for a hypothermia protocol after cardiac arrest were recorded prospectively to generate a descriptive and analytical study analyzing the relationship between clinical, neurophysiological, imaging and biochemical parameters with 6-month outcomes defined according to the Cerebral Performance Categories scale (good 1-2, poor 3-5). Neuron-specific enolase was collected at 72 hours. Imaging and neurophysiologic exams were carried out in the 24 hours after the rewarming period.

RESULTS

Sixty-seven patients were included in the study, of which 12 had good neurological outcomes. Ventricular fibrillation and electroencephalographic theta activity were associated with increased likelihood of survival and improved neurological outcomes. Patients who had more rapid cooling (mean time of 163 versus 312 minutes), hypoxic-ischemic brain injury on magnetic resonance imaging or neuron-specific enolase > 58ng/mL had poor neurological outcomes (p < 0.05).

CONCLUSION

Hypoxic-ischemic brain injury on magnetic resonance imaging and neuron-specific enolase were strong predictors of poor neurological outcomes. Although there is the belief that early achievement of target temperature improves neurological prognoses, in our study, there were increased mortality and worse neurological outcomes with earlier target-temperature achievement.

Is this septic shock? A rare case of distributive shock

The authors report a rare case of shock in a patient without significant clinical history, admitted to the intensive care unit for suspected septic shock. The patient was initially treated with fluid therapy without improvement. A hypothesis of systemic capillary leak syndrome was postulated following the confirmation of severe hypoalbuminemia, hypotension, and hemoconcentration--a combination of three symptoms typical of the disease. The authors discussed the differential diagnosis and also conducted a review of the diagnosis and treatment of the disease.

Just another abdominal pain? Psoas abscess-like metastasis in large cell lung cancer with adrenal insufficiency

The authors report the case of a 69-year-old man with chronic obstructive pulmonary disease and previous pulmonary tuberculosis, who presented to the emergency department with abdominal and low back pain, anorexia and weight loss, rapidly evolving into shock. An initial CT scan revealed pulmonary condensation with associated cavitation and an iliopsoas mass suggestive of a psoas abscess. He was admitted in an intensive care unit unit; after a careful examination and laboratory assessment, the aetiology was yet undisclosed. MRI showed multiple retroperitoneal lymphadenopathies, bulky nodular adrenal lesions and bilateral iliac lytic lesions. Hypocortisolism was detected and treated with steroids. A CT-guided biopsy to the psoas mass and lytic lesions identified infiltration of non-small lung carcinoma. The patient died within days. Psoas metastases and adrenal insufficiency as initial manifestations of malignancy are rare and can be misdiagnosed, particularly in the absence of a known primary tumour.

Acute bacterial meningitis in the intensive care unit and risk factors for adverse clinical outcomes: retrospective study

BACKGROUND

Bacterial meningitis constitutes a medical emergency. Its burden has driven from childhood to the elderly and the immunocompromised population. However, the admission of patients with bacterial meningitis to the intensive care unit (ICU) has been sparsely approached, as have the prognostic factors associated with an adverse clinical outcome.

METHODS

We performed a retrospective analysis during a 7-year period of patients older than 18 years admitted to 2 polyvalent ICUs. Clinical, demographic, and outcome data were collected to evaluate its clinical impact on the outcome of patients with acute bacterial meningitis.

RESULTS

We identified 65 patients with the diagnosis of acute bacterial meningitis (mean Acute Physiology and Chronic Health Evaluation II, 23; hospital mortality, 40%). Upon clinical presentation, their most frequent signs were fever (84%), seizures (21.5%), and a low Glasgow Coma Scale (GCS) score (GCS<8; 58.4%). Fifty-five patients (85%) required organ support. A definite microbiological diagnosis was achieved in 45 patients. An adverse clinical outcome was noted in 46 patients (71%). These patients were older (P=.005), had higher Physiology and Chronic Health Evaluation II score (P=.022), and had lower GCS (P=.022). In the multivariate analysis, older age (per year; adjusted odds ratio [aOR], 1.059) was associated with an adverse outcome, whereas a higher GCS (per point; aOR, 0.826) and presence of fever upon admission (aOR, 0.142) increase the chance of a good recovery.

CONCLUSIONS

Patients with acute bacterial meningitis admitted to ICU had substantial morbidity and mortality. Those with low GCS or absence of fever have a particularly high risk of an adverse outcome.

Predicting outcome after cardiopulmonary arrest in therapeutic hypothermia patients: clinical, electrophysiological and imaging prognosticators

INTRODUCTION

Predicting outcome in comatose survivors of cardiac arrest is based on data validated by guidelines that were established before the era of therapeutic hypothermia. We sought to evaluate the predictive value of clinical, electrophysiological and imaging data on patients submitted to therapeutic hypothermia.

MATERIALS AND METHODS

A retrospective analysis of consecutive patients receiving therapeutic hypothermia during years 2010 and 2011 was made. Neurological examination, somatosensory evoked potentials, auditory evoked potentials, electroencephalography and brain magnetic resonance imaging were obtained during the first 72 hours. Glasgow Outcome Scale at 6 months, dichotomized into bad outcome (grades 1 and 2) and good outcome (grades 3, 4 and 5), was defined as the primary outcome.

RESULTS

A total of 26 patients were studied. Absent pupillary light reflex, absent corneal and oculocephalic reflexes, absent N20 responses on evoked potentials and myoclonic status epilepticus showed no false-positives in predicting bad outcome. A malignant electroencephalographic pattern was also associated with a bad outcome (p = 0.05), with no false-positives. Two patients with a good outcome showed motor responses no better than extension (false-positive rate of 25%, p = 0.008) within 72 hours, both of them requiring prolonged sedation. Imaging findings of brain ischemia did not correlate with outcome.

DISCUSSION

Absent pupillary, corneal and oculocephalic reflexes, absent N20 responses and a malignant electroencephalographic pattern all remain accurate predictors of poor outcome in cardiac arrest patients submitted to therapeutic hypothermia.

CONCLUSION

Prolonged sedation beyond the hypothermia period may confound prediction strength of motor responses.

[Treatment of adolescent varicocele: is percutaneous embolization better?]

There are still doubts as to the most suitable criteria when considering surgery as the indication and optimal treatment for adolescent varicocele.

MATERIAL AND PATIENTS

We reviewed the hospital and primary health care histories of patients diagnosed by ultrasound for varicocele over the last 7 years. The data was taken from computerised clinical histories and hard copy back-up material stored and processed in computer format.

RESULTS

We studied 135 cases (mean age 12.8 years). These patients (125) were referred for scrotal swelling or as a result of chance detection, except for 10 patients who reported pain or scrotal asymmetry. Seventy-three underwent surgery and 62 continued as controls over the study period. The surgical indication was significant progressive asymmetry in testicular volume (28 children), high grade varicocele (41) as well as other reasons (4). We undertook percutaneous embolization in 44 patients (with a 66% relapse rate) and laparoscopic section of the spermatic cord with no arterial preservation in 29 (no relapses but 7 post-surgery hydroceles). No testicles were lost. At the end of the study 10 children continued as controls, 34 were discharged after recovery, 56 were referred to urology due to their age group, and 35 were lost to the study.

DISCUSSION

In the controversy over the treatment of varicocele our experience shows a high degree of relapses after embolization. Section of the spermatic vessels (including the artery) with no lymphatic preservation is highly effective but involves 27% post-op hydroceles, usually self-limiting (only one had later to undergo surgery), with no testicular atrophy or other complications.

CONCLUSIONS

We prefer complete laparoscopic section of the spermatic pedicle to embolization but it would be advisable to introduce modifications to avoid post-surgical hydrocele. Embolization must be reserved for patients with one testicle or with bilateral disease. Efforts must be made to communicate more effectively, in order to reduce the high drop-out rate.

Neutron-mirror-neutron oscillations: how fast might they be?

We discuss the phenomenological implications of the neutron (n) oscillation into the mirror neutron (n'), a hypothetical particle exactly degenerate in mass with the neutron but sterile to normal matter. We show that the present experimental data allow a maximal n-n' oscillation in vacuum with a characteristic time tau much shorter than the neutron lifetime, in fact as small as 1 sec. This phenomenon may manifest in neutron disappearance and regeneration experiments perfectly accessible to present experimental capabilities and may also have interesting astrophysical consequences, in particular, for the propagation of ultra high energy cosmic rays.

[The vacuum chest wall lifter in the treatment of pectus excavatum]

Since 2002, the Eckart Klobe vacuum has been used in our Service as an innovate and non-invasive procedure in patients with pectus excavatum. This vacuum method contributes not only to hold promise as a valuable adjunct in minimally invasive surgery, but also as an effective method to lift and fix the funnel for repairing pectus excavatum in some patients. Our experience is limited to the use of this device in 10 patients, during the Nuss technique. This procedure has been useful for safer passage of the introducer, and as a definitive treatment in a 10 years old girl with pectus excavatum and a Haller index of 5.1 with successful result after one year of treatment. The aim of this study is to report the safety and efficacy of this procedure in appropriate patients. Long-term results will be necessary to confirm this method as an alternative to more invasive techniques.

Prevalence and associations of an abnormal ankle-brachial index in systemic lupus erythematosus: a pilot study

BACKGROUND

Accelerated atheroma is a well recognised complication of systemic lupus erythematosus (SLE). Its aetiology is multifactorial and several methods may be used to detect early signs of atheroma.

METHODS

Patients aged </=55 years were screened using the ankle-brachial index (ABI). Ninety one patients aged </=55 years and fulfilling the revised American College of Rheumatology criteria for SLE were studied. The ABI was measured using a contour wrapped 12 cm cuff attached to a mercury sphygmomanometer and an 8 MHz Doppler probe in the arms and legs; a ratio of <1 was considered abnormal.

RESULTS

The mean (SD) age of the patients was 39.0 (9.2) years. Of the 91 patients studied, 34 (37%) had an abnormal ABI. Only one patient was mildly symptomatic. Abnormal ABI correlated with age but not with disease duration, cumulative steroid dosage, ECLAM score, or any other traditional risk factors for atherosclerosis. In comparison with population studies, the prevalence of an ABI<1 in the patients with SLE with a mean age of 39 years was similar to that in adults aged over 80.

CONCLUSION

In this pilot study, patients with SLE with a mean age of 39 years had a high prevalence of an abnormal ABI. The ABI is a simple non-invasive tool for the early detection of accelerated atheroma in SLE.

Anti-dsDNA, anti-Sm antibodies, and the lupus anticoagulant: significant factors associated with lupus nephritis

BACKGROUND

Lupus nephritis (LN) is a common manifestation in patients with systemic lupus erythematosus (SLE). Autoantibodies and ethnicity have been associated with LN, but the results are controversial.

OBJECTIVE

To study the immunological and demographic factors associated with the development of LN.

PATIENTS AND METHODS

A retrospective case-control study of 127 patients with biopsy-proven LN, and 206 randomly selected patients with SLE without nephritis as controls was designed. All patients had attended our lupus unit during the past 12 years. Standard methods were used for laboratory testing.

RESULTS

Patients with LN were significantly younger than the controls at the time of SLE diagnosis (mean (SD) 25.6 (8.8) years v 33.7 (12.5) years; p<0.0001). The proportion of patients of black ethnic origin was significantly higher in the group with nephritis (p=0.02). There were no differences in sex distribution or duration of follow up. A higher proportion of anti-dsDNA, anti-RNP, anti-Sm, and lupus anticoagulant (LA) was seen in the group with nephritis (p=0.002; p=0.005; p=0.0001; p=0.01, respectively). In univariate, but not in multivariate, analysis male sex and absence of anti-dsDNA were associated with earlier onset of renal disease (p=0.03; p=0.008). In multivariate analysis the only factors associated with nephritis were younger age at diagnosis of SLE, black race, presence of anti-dsDNA, anti-Sm, and LA. No demographic or immunological associations were seen with WHO histological classes.

CONCLUSIONS

Young, black patients with anti-dsDNA, anti-Sm antibodies, and positive LA, appear to have a higher risk of renal involvement. These patients should be carefully monitored for the development of LN.

[Early surgery in Poland syndrome]

Poland's congenital malformation presents a variable grade of complexity, depending upon the extent of the muscular and chondro-costal defect. Surgical repair for cosmetic reasons only, may be performed during childhood or puberty due to the absence of symptoms. However, this does not occur when the costal defects has a considerable size, with pulmonary herniation and impairment of respiratory function. In this cases, early surgical correction is preferred in order to adequately stabilize the chest wall. In this paper we present our experience of early surgical treatment in 5 patients affected by a complex syndrome, that were treated with autologous costal transplants and the use pof polytetrafluoroethylene to cover the chest wall defect. We discuss the surgical procedure performed, as well as the advantages of this material with respect to others described up to date and the good results obtained in one of the cases followed-up for five years.

Leptogenesis via collisions: leaking lepton number to the hidden sector

We propose a leptobaryogenesis mechanism in which the nonzero B-L of the Universe is produced in out-of-equilibrium, lepton number and CP-violating scattering processes that convert ordinary particles into particles of some hidden sector. In particular, we consider the processes l phi-->l(')phi('),l macro(')phi(') mediated by the heavy Majorana neutrinos N of the seesaw mechanism, where l and phi are ordinary lepton and Higgs doublets and l('), phi(') are their hidden counterparts. Such a leptogenesis mechanism is effective even if the reheat temperature is much smaller than the heavy neutrino masses. In particular, it can be as low as 10(9) GeV.

[Non-infectious thrombotic endocarditis: a case report]

A 48 year-old female patient, admitted with an ischemic stroke, had a transesophageal echocardiogram (TEE) that revealed a dense vegetation in the noncoronary aortic cusp, which was considered the probable source of embolism. The clinical investigation did not identify any other disease or infectious process. However the lack of histologic proof, the absence of fever, the fact that the blood cultures were persistently negative, the patient recovery with no need of antibiotics, and the results of the TEE, are highly suggestive of the presence of a non infectious thrombotic endocarditis. After 18 months of anti-platelet treatment, the patient showed no new embolic episodes and TEE demonstrated the resolution of the vegetation.

[Complex anomalies of the anterior chest wall. Personalized surgical treatment]

Among the congenital anomalies of the anterior chest wall, the group of the asymmetrical deformities, mixed or complex, are the least frequent and the ones that require a difference surgical strategy for each patient according to their anatomical features. In this paper we present our experience and findings with this type of malformation. The fundamental aspects of the surgical indications and procedure are commented. The evolution and the results are very satisfactory. We stress the positive reaction of the patients and their families after the operation.

Cardiac hydatid cyst in a child

Cardiac hydatid cyst is a rare disease, especially in children. An 11-year-old boy with a previous anaphylactic reaction and episodes of abdominal pain was admitted for workup of an acquired long systolic murmur. Echocardiographic investigation disclosed a tumor of the right ventricular anterior wall, with multiple loculations. Magnetic resonance imaging characterized it as a multilobular tumor with cyst formation and disclosed another cyst in the right pulmonary artery. With a positive ELISA reaction the child was admitted for surgery with the diagnosis of cardiac and pulmonary hydatid cysts. Cardiac surgery was performed with good results, followed by medical treatment with albendazole.

[Malformations of the anterior thoracic wall]

The different anomalies of the anterior Chest Wall are exposed. We emphasize the deformities of the sternum--Depression and Protusion Deformities--because they are the most common and the most difficult ones to treat. Based in the results of 73 patients operated upon by the author, and in the review of the bibliography, we also comment on some aspects of the surgical indication, assessment methods, surgical technique, complications and results.