Adverse Clinical Outcomes and Associated Predictors in Rivaroxaban-Treated Atrial Fibrillation Patients With Renal Impairment

Renal impairment confers worse prognosis in patients with atrial fibrillation (AF) but there is scarce evidence about the influence of direct-acting oral anticoagulants in routine clinical practice. Herein, we compared clinical outcomes between patients with AF with and without renal impairment on rivaroxaban and investigated predictors for clinical outcomes in patients with AF with renal impairment. This was a multicenter study including patients with AF on rivaroxaban for at least 6 months. During 2.5 years follow-up, ischemic strokes (IS)/transient ischemic attacks (TIA)/systemic embolisms (SE)/myocardial infarctions (MI), major bleeding, and major adverse cardiovascular events (MACE) were recorded. Creatinine clearance (CrCl) was estimated using the Cockroft-Gault equation, renal impairment was defined as a CrCl <60 ml/min, and 1,433 patients (34.8% with CrCl <60 ml/min) were included. Patients with CrCl <60 ml/min showed higher event rates for major bleeding (1.87%/year vs 0.62%/year; p = 0.003) and MACE (1.97%/year vs 0.62%/year; p = 0.002) but similar event rates for IS/TIA/SE/MI (0.66%/year vs 0.67%/year; p = 0.955). In patients with renal impairment, CHA2DS2-VASc was associated with higher risk of IS/TIA/SE/MI; HAS-BLED and any dependency level were associated with higher risk of major bleeding; and male gender and heart failure were associated with higher risk of MACE. Antiplatelets were independently associated with increased risk of IS/TIA/SE/MI and MACE. In conclusion, in patients with AF on rivaroxaban, the incidence of IS/TIA/SE/MI did not increase in those with renal impairment, suggesting that rivaroxaban may be an effective option in this subgroup. In patients with AF, male gender, heart failure, dependency, antiplatelets, CHA2DS2-VASc, and HAS-BLED were associated with increased risk of adverse outcomes.

The current clinical practice for management of post-infarction ventricular septal rupture: a European survey

Aims

Many historical and recent reports showed that post-infarction ventricular septal rupture (VSR) represents a life-threatening condition and the strategy to optimally manage it remains undefined. Therefore, disparate treatment policies among different centres with variable results are often described. We analysed data from European centres to capture the current clinical practice in VSR management.

Methods and results

Thirty-nine centres belonging to eight European countries participated in a survey, filling a digital form of 38 questions from April to October 2022, to collect information about all the aspects of VSR treatment. Most centres encounter 1-5 VSR cases/year. Surgery remains the treatment of choice over percutaneous closure (71.8% vs. 28.2%). A delayed repair represents the preferred approach (87.2%). Haemodynamic conditions influence the management in almost all centres, although some try to achieve patients stabilization and delayed surgery even in cardiogenic shock. Although 33.3% of centres do not perform coronarography in unstable patients, revascularization approaches are widely variable. Most centres adopt mechanical circulatory support (MCS), mostly extracorporeal membrane oxygenation, especially pre-operatively to stabilize patients and achieve delayed repair. Post-operatively, such MCS are more often adopted in patients with ventricular dysfunction.

Conclusion

In real-life, delayed surgery, regardless of the haemodynamic conditions, is the preferred strategy for VSR management in Europe. Extracorporeal membrane oxygenation is becoming the most frequently adopted MCS as bridge-to-operation. This survey provides a useful background to develop dedicated, prospective studies to strengthen the current evidence on VSR treatment and to help improving its currently unsatisfactory outcomes.

Early approach to LDL-related risk after acute coronary syndrome: The OPTA Project

INTRODUCTION

Hyperlipidemia is the main underlying cause of atherosclerotic cardiovascular disease. Reducing low-density lipoprotein (LDL) cholesterol to recommended targets after an acute coronary syndrome (ACS) is of utmost importance as it is associated with a reduction of mortality and further cardiovascular events. Unfortunately, there are considerable gaps between guideline recommendations and clinical practice. In addition, the approach to treatment of this population is very heterogeneous, even in specialized cardiovascular units. Some easy-to-implement strategies may help to optimize the management of these patients.

AREAS COVERED

The OPTA Project was developed to identify these gaps and to provide recommendations to improve and harmonize the management of patients with ACS, with a specific focus on lipids.

EXPERT OPINION

Five areas of interest were defined: 1) evaluation of cardiovascular risk at admission, 2) development of a strategy to effectively and rapidly reduce LDL cholesterol levels, 3) determining LDL cholesterol goals (<55 mg/dL or stricter) and follow-up, 4) data collection during hospitalization, and 5) standardized discharge report. Specific recommendations are given to reduce inequalities, following the targets "the lower, the better" and "the earlier, the better".

Non-embolic outcomes in patients with cardiovascular disease and atrial fibrillation treated with rivaroxaban

Aim: It is not well known how comorbidities may change the prognosis of atrial fibrillation (AF) patients. This study was aimed to analyze the impact of cardiovascular disease on this population. Materials & methods: EMIR was a multicenter, prospective study, including 1433 AF patients taking rivaroxaban for ≥6 months. Data were analyzed according to the presence of vascular disease. Results: Coronary artery disease was detected in 16.4%, peripheral artery disease/aortic plaque in 6.7%, vascular disease in 28.3%. Patients with coronary artery disease had higher rates (per 100 patient-years) of major adverse cardiovascular events (2.98 vs 0.71; p < 0.001) and cardiovascular death (1.79 vs 0.41; p = 0.004). Those with vascular disease had higher rates of thromboembolic events (1.47 vs 0.44; p = 0.007), major adverse cardiovascular events (2.03 vs 0.70; p = 0.004), and cardiovascular death (1.24 vs 0.39; p = 0.025). Patients with peripheral artery disease/aortic plaque had similar rates. Conclusion: AF patients with vascular disease have a higher risk of non-embolic outcomes.

Case report: From monkeypox pharyngitis to myopericarditis and atypical skin lesions

Background

A global outbreak of the human monkeypox virus (HMPXV), first identified in May 2022, was declared a health emergency of international concern on 23 July 2022. Before the global outbreak, monkeypox cases were mostly confined to central and west African countries, where this virus is prevalent. Close contact, mainly sexual contact, is supposed to be the main route of transmission, and it is remarkable that the incidence is higher in men who have sexual relationships with other men.

Case summary

A 40-year-old Caucasian man arrived at the emergency department complaining of oppressive epigastric pain extending to the chest after a diagnosis of pharyngitis, which was suspected to be caused by the human monkeypox virus. Based on the clinical symptoms, physical examination, serum cardiac biomarkers, and electrocardiographic findings, he was diagnosed with myopericarditis. The real-time PCR for human monkeypox in skin lesions, urine, plasma, and the oropharyngeal swab was positive. The peak of troponin I was 20.6 ng/ml, and the electrocardiogram showed an upward concavity in the ST segment in diffuse leads, which was in agreement with the previous diagnosis. The presence of edema, subepicardial, and myocardial late gadolinium enhancement, and increased values on T1 mapping in the cardiac MRI were in agreement with the diagnosis of myopericarditis. Antiviral treatment with tecovirimat was started with excellent tolerability. After 6 days, the patient recovered and was discharged.

Discussion

To our knowledge, this is one of the first reported cases of myopericarditis due to human monkeypox infection, which was confirmed by a cardiac MRI following modified Lake Louise criteria. The short span between the onset of the mucocutaneous symptoms and the myocardial damage suggests a pathogenic association. Furthermore, the active viral replication in plasma samples and the negative results on real-time PCR for other viruses support this clinical association.

Impact of heart failure on the clinical profile and outcomes in patients with atrial fibrillation treated with rivaroxaban. Data from the EMIR study

BACKGROUND

The aim of this study was to analyze the impact of the presence of heart failure (HF) on the clinical profile and outcomes in patients with atrial fibrillation (AF) anticoagulated with rivaroxaban.

METHODS

Observational and non-interventional study that included AF adults recruited from 79 Spanish centers, anticoagulated with rivaroxaban ≥ 6 months before inclusion. Data were analyzed according to baseline HF status.

RESULTS

Out of 1,433 patients, 326 (22.7%) had HF at baseline. Compared to patients without HF, HF patients were older (75.3 ± 9.9 vs. 73.8 ± 9.6 years; p = 0.01), had more diabetes (36.5% vs. 24.3%; p < 0.01), coronary artery disease (28.2% vs. 12.9%; p < 0.01), renal insufficiency (31.7% vs. 22.6%; p = 0.01), higher CHA2DS2-VASc (4.5 ± 1.6 vs. 3.2 ± 1.4; p < 0.01) and HAS-BLED (1.8 ± 1.1 vs. 1.5 ± 1.0; p < 0.01). After a median follow-up of 2.5 years, among HF patients, annual rates of stroke/systemic embolism/transient ischemic attack, major adverse cardiovascular events (MACE) (non-fatal myocardial infarction, revascularization and cardiovascular death), cardiovascular death, and major bleeding were 1.2%, 3.0%, 2.0%, and 1.4%, respectively. Compared to those patients without HF, HF patients had greater annual rates of MACE (3.0% vs. 0.5%; p < 0.01) and cardiovascular death (2.0% vs. 0.2%; p < 0.01), without significant differences regarding other outcomes, including thromboembolic or bleeding events. Previous HF was an independent predictor of MACE (odds ratio 3.4; 95% confidence interval 1.6-7.3; p = 0.002) but not for thromboembolic events or major bleeding.

CONCLUSIONS

Among AF patients anticoagulated with rivaroxaban, HF patients had a worse clinical profile and a higher MACE risk and cardiovascular mortality. HF was independently associated with the development of MACE, but not with thromboembolic events or major bleeding.

Rivaroxaban for the prevention of outcomes in patients with atrial fibrillation in clinical practice: an indirect comparison of national and international registries

Objective: To analyze the effectiveness and safety of rivaroxaban in patients with atrial fibrillation (AF). Methods: The clinical profile and outcomes of the EMIR study were indirectly compared with those of ROCKET-AF, eight other Spanish observational studies and XANTUS. Results: In EMIR, mean age was 74.2 years and CHA₂DS₂-VASc was 3.5. In the rivaroxaban arm of the ROCKET-AF trial, mean age was 73 years and CHADS₂ was 3.5, whereas in the Spanish studies mean age ranged from 74.9 years to 78.4 years and CHA₂DS₂-VASc from 3.5 to 4.3. In EMIR, rates of stroke/systemic embolism, major adverse cardiovascular events, cardiovascular death and major bleeding were 0.57, 1.07, 0.63 and 1.04 events/100 patient-years, respectively. In ROCKET-AF, these numbers were 1.7, 3.91, 1.53 and 3.6 events/100 patient-years, respectively. In the Spanish studies, rates of stroke and major bleeding were 0-1.8 and 0.22-4.2 events/100 patient-years, respectively. In XANTUS, rates of stroke, major adverse cardiovascular events and major bleeding were 0.7, 1.8 and 2.1 events/100 patient-years, respectively. Conclusion: Despite the fact that rivaroxaban is prescribed for elderly patients with a high thromboembolic risk, rates of outcomes remain low.

Use of rivaroxaban attenuates renal function impairment in patients with atrial fibrillation: insights of the EMIR study

BACKGROUND

In atrial fibrillation (AF) patients on vitamin K antagonists, a progressive deterioration of renal function is common but there is limited evidence with long-term use of rivaroxaban. Herein, we investigated the change in renal function in AF patients after 2 years of rivaroxaban treatment.

METHODS

The EMIR registry is an observational and multicentre study including AF patients treated with rivaroxaban for at least 6 months prior to inclusion. Changes in analytical parameters were recorded during 2 years of follow-up. Renal function was estimated using the Cockroft-Gault equation.

RESULTS

1433 patients (638, 44.5% women, mean age of 74.2 ± 9.7 years) were included. Creatinine clearance (CrCl) was available at baseline and at 2 years in 1085 patients. At inclusion, 33.2% of patients had impaired renal function (CrCl <60 ml/min). At 2 years, we were not able to find changes in the proportion of patients with impaired renal function, which increased to 34.6% (p = 0.290). However, the baseline mean CrCl was 76.0 ± 30.5 ml/min and slightly improved at 2 years (77.0 ± 31.8 ml/min; p = 0.014). Overall, the proportion of patients with CrCl <60 ml/min at baseline that had CrCl ≥60 ml/min at 2 years was significantly higher compared to that of patients with CrCl ≥60 ml/min at baseline and CrCl <60 ml/min after (22.2% vs. 13.1%; p < 0.001) CONCLUSIONS: In AF patients on long-term rivaroxaban therapy, a decrease in renal function was not observed. We even observed a slight improvement in the patients with renal impairment. These results reinforce the idea that rivaroxaban may be a safe option even in patients with renal impairment.

Outcomes and predictive value of the 2MACE score in patients with atrial fibrillation treated with rivaroxaban in a prospective, multicenter observational study: The EMIR study

Background

The aim of the study was to evaluate the performance of the 2MACE in patients with atrial fibrillation (AF) treated with rivaroxaban and to improve the accuracy of 2MACE.

Methods

This was a post-authorization and observational study of AF adults treated with rivaroxaban for ≥ 6 months. The primary endpoint was any of the major adverse cardiac events (MACE), namely, cardiovascular death, non-fatal myocardial infarction, and myocardial revascularization. The area under the curve (AUC) was calculated to evaluate the performance of 2MACE, and a new score, 2MACER to predict MACE.

Results

A total of 1433 patients were included (74.2 ± 9.7 years, CHA₂DS₂-VASc 3.5 ± 1.5, 26.9% 2MACE ≥ 3). The annual event rates (follow-up 2.5 years) were 1.07% for MACE, 0.66% for thromboembolic events and 1.04% for major bleeding. Patients with 2MACE ≥ 3 (vs. < 3) had higher risk of stroke/systemic embolism/transient ischemic attack (odds ratio [OR] 5.270; 95% confidence interval [CI] 2.216–12.532), major bleeding (OR 4.624; 95% CI 2.163–9.882), MACE (OR 3.202; 95% CI 1.548–6.626) and cardiovascular death (OR 3.395; 95% CI 1.396–8.259). 2MACE was recalculated giving 1 more point to patients with baseline a glomerular filtration rate < 50 mL/min/1.73 m² (2MACER); (2MACER vs. 2MACE: IDI 0.1%, p = 0.126; NRI 23.9%, p = 0.125; AUC: 0.651 [95% CI 0.547–0.755] vs. 0.638 [95% CI 0.534–0.742], respectively; p = 0.361).

Conclusions

In clinical practice, AF patients anticoagulated with rivaroxaban exhibit a low risk of events. 2MACE score acts as a modest predictor of a higher risk of adverse outcomes in this population. 2MACER did not significantly increase the ability of 2MACE to predict MACE.

Thromboembolic and bleeding events with rivaroxaban in clinical practice in Spain: impact of inappropriate doses (the EMIR study)

Aim: To analyze the frequency and variables related to inappropriate rivaroxaban dosage in clinical practice and its impact on outcomes after 2 years. Materials & methods: Postauthorization, observational, multicenter study, in which atrial fibrillation patients, treated with rivaroxaban ≥6 months were included. Results: A total of 1421 patients (74.2 ± 9.7 years, CHA₂DS₂-VASc 3.5 ± 1.6) were included. Overall, 22.9% received rivaroxaban 15 mg. The proper dose of rivaroxaban was taken by 83.3% (9.7% underdosed, 7.0% overdosed). Older age and renal insufficiency were associated with inadequate rivaroxaban dosage. There was a trend toward higher all-cause mortality among underdosed patients (adjusted hazard ratio 1.39; 95% CI 0.75-2.58), and more bleedings in overdosed patients (2.29 vs 0.80 events/100 patient-years; p = 0.14). Conclusion: In clinical practice, rivaroxaban is properly dosed in most patients.

Recommendations of the Geriatric Cardiology Section of the Spanish Society of Cardiology for the Assessment of Frailty in Elderly Patients With Heart Disease

Frailty is an age-associated clinical syndrome characterized by a decrease in physiological reserve in situations of stress, constituting a state of vulnerability that involves a higher risk of adverse events. Its prevalence in Spain is high, especially in elderly individuals with comorbidity and chronic diseases. In cardiovascular disease, frailty is associated worse clinical outcomes and higher morbidity and mortality in all scenarios, in both acute and chronic settings, and could consequently influence diagnosis and treatment. However, frailty is often not addressed or included when planning the management of elderly patients with heart disease. In this article, we review the available scientific evidence and highlight the most appropriate scales for the measurement and assessment of frailty, some of which are more useful and have better predictive capacity than others, depending on the clinical context. We also underline the importance of properly identifying and assessing frailty in order to include it in the treatment and care plan that best suits each patient.

Co-occurrence and seasonal and environmental distributions of the sandflies Lutzomyia longipalpis and Nyssomyia whitmani in the city of Puerto Iguazú, northeastern Argentina

The aim of this work was to study the distribution of Phlebotominae (Diptera: Psycodidade) abundance in time and space in an area in northeastern Argentina with vector transmission of visceral and tegumentary leishmaniasis. For this, 51 households were selected using a 'worst scenario' criterion where one light trap was set during two consecutive nights in peridomiciles in the transitions between the four seasons, and the environment was surveyed simultaneously. The relationships of phlebotomine assemblage structure and the most abundant species with seasonality and environmental variables were evaluated using a canonical correspondence analysis and generalized linear mixed models, respectively. A total of 5110 individuals were captured. Lutzomyia longipalpis (Lutz & Neiva, 1912) and Nyssomyia whitmani (Antunes & Coutinho, 1939) were the most abundant species captured in all samplings (98.3% of the total capture). The period of highest abundance of Lu. longipalpis was early autumn, and it was distributed in the most urbanized areas. Nyssomyia whitmani occupied mainly the less urbanized areas, showing peaks of abundance in early spring and summer. Other species were captured in low numbers and showed seasonal-spatial variations similar to those of Ny. whitmani. We confirmed Leishmania spp. vector persistence throughout the year in spatial patches of high abundance even during the less favorable season.

A prospective international Aspergillus terreus survey: an EFISG, ISHAM and ECMM joint study

OBJECTIVES

A prospective international multicentre surveillance study was conducted to investigate the prevalence and amphotericin B susceptibility of Aspergillus terreus species complex infections.

METHODS

A total of 370 cases from 21 countries were evaluated.

RESULTS

The overall prevalence of A. terreus species complex among the investigated patients with mould-positive cultures was 5.2% (370/7116). Amphotericin B MICs ranged from 0.125 to 32 mg/L, (median 8 mg/L).

CONCLUSIONS

Aspergillus terreus species complex infections cause a wide spectrum of aspergillosis and the majority of cryptic species display high amphotericin B MICs.

Aortitis With Associated Left Main Coronary Artery Stenosis: Role of Cardiac Computed Tomography

We report on a 49-year-old man who presented to the emergency department with progressive angina. Echocardiography displayed severe aortic regurgitation and aortic valve thickening. The suspected diagnosis was acute aortic syndrome. Cardiac computed tomography showed circumferential thickening of the aortic wall and left main coronary artery ostial stenosis. Histologic examination showed diffuse aortic inflammation. No damage of any other organ or vascular structure was reported, and the final diagnosis was nonspecific aortitis. Differential diagnosis, prognosis, and therapeutic strategies are discussed.

Clinical Experience with Ivabradine in Acute Heart Failure

Objective: Ivabradine has been shown to improve symptoms and to reduce rehospitalization and mortality in patients with severe chronic heart failure (HF). Its indication in acute HF is not clear. Acute HF patients could also benefit from HR reduction, as myocardial consumption and oxidative stress are related to tachycardia. Moreover, beta-blockers are contraindicated in cardiogenic shock and should not be initiated with congestive signs. Accordingly, we evaluated the role of ivabradine in acute HF patients. Methods: This was a retrospective analysis of 29 consecutive patients treated for acute HF in the Cardiac ICU, and for whom ivabradine was initiated during hospitalization between January 2011 and January 2014. All patients were in sinus rhythm and had a heart rate (HR) >70 bpm. Catecholamine use was necessary in 16 patients (57.1%) during the hospitalization, in 14 (87.5%) of these before ivabradine treatment. Results: Systolic blood pressure showed no variation during the first 24 h of ivabradine administration or at discharge. HR showed an absolute reduction of 10 bpm at 6 h (p < 0.001), 11 bpm at 24 h (p = 0.004) and 19 bpm (p < 0.001) at discharge. No episodes of significant bradycardia or hypotension were recorded after starting the drug. Conclusions: HR reduction with ivabradine in acute HF is well tolerated. It represents an attractive option, especially when there is excessive catecholamine-related tachycardia; this should be appropriately evaluated in randomized trials.

Austromegabalanus psittacus barnacle shell structure and proteoglycan localization and functionality

Comparative analyzes of biomineralization models have being crucial for the understanding of the functional properties of biominerals and the elucidation of the processes through which biomacromolecules control the synthesis and structural organization of inorganic mineral-based biomaterials. Among calcium carbonate-containing bioceramics, egg, mollusk and echinoderm shells, and crustacean carapaces, have being fairly well characterized. However, Thoraceca barnacles, although being crustacea, showing molting cycle, build a quite stable and heavily mineralized shell that completely surround the animal, which is for life firmly cemented to the substratum. This makes barnacles an interesting model for studying processes of biomineralization. Here we studied the main microstructural and ultrastructural features of Austromegabalanus psittacus barnacle shell, characterize the occurrence of specific proteoglycans (keratan-, dermatan- and chondroitin-6-sulfate proteoglycans) in different soluble and insoluble organic fractions extracted from the shell, and tested them for their ability to crystallize calcium carbonate in vitro. Our results indicate that, in the barnacle model, proteoglycans are good candidates for the modification of the calcite crystal morphology, although the cooperative effect of some additional proteins in the shell could not be excluded.

Evaluation of a multilayered chitosan-hydroxy-apatite porous composite enriched with fibronectin or an in vitro-generated bone-like extracellular matrix on proliferation and diferentiation of osteoblasts

The use of extracellular matrix (ECM) molecules from tissues is an interesting way to induce specific responses of cells grown onto composite scaffolds to promote adhesion, proliferation and differentiation. There have been several studies on the effects on cell proliferation and differentiation of osteoprogenitor cells cultured onto composites, either adding some ECM molecules or grown in the presence of growth factors. Other studies involve the use of osteoblasts cultured on a three-dimensional (3D) matrix, enriched with ECM molecules produced by the same cells grown previously inside the composite. Here, the effect of enrichment of a novel multilayered chitosan-hydroxyapatite composite with ECM molecules produced by osteoblasts, or the addition of 25 or 50 µg/ml fibronectin to the composite, on proliferation and differentiation of osteoblasts cultured on these composites was studied. The results showed an increase in the number of osteoblasts from day 1 of culture, which was higher in the group grown onto composites enriched with the highest concentration of fibronectin or with ECM molecules produced naturally by osteoblasts cultured previously on them, when compared with the control group. However, this increment tended to decline in all groups after day 7 of culture, the day when they reached the highest peak of proliferation. Differentiation expressed as alkaline phosphatase activity followed the proliferation pattern of the cells cultivated on the scaffolds. The results demonstrate the potential offered by these enriched 3D multilayered composites for improving their ability as bone grafting material.

[Trapped epidural catheter: reconstruction of computed tomography images]

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

[Percutaneous thrombin injection for closure of femoral pseudoaneurysms: preliminary experience]

An arterial pseudoaneurysm is an uncommon complication of cardiovascular procedures associated with considerable morbidity and increased hospital costs. Percutaneous thrombin injection is one approach to therapy. We describe our initial experience with this technique in 3 patients, with special attention to the utility of sonographic guidance. In all cases complete closure was achieved, although one patient required additional brief extrinsic compression with the ultrasound probe.

Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease

OBJECTIVE

To determine the frequency of occurrence and long term evolution of subclinical carditis in patients with acute rheumatic fever.

DESIGN

Valvar incompetence was detected by clinical examination and Doppler echocardiographic imaging during the acute and quiescent phases of rheumatic fever. Patients were followed prospectively and submitted to repeat examinations at one and five years after the acute attack. Persistence of acute mitral and aortic lesions detected solely by echocardiography (subclinical disease) was compared with that of disease detected by clinical examination as well (thereby fulfilling the latest 1992 Jones criteria for rheumatic carditis).

SETTING

Three general hospitals with a university affiliation in Chile.

PATIENTS

35 consecutive patients fulfilling the revised Jones criteria for rheumatic fever. Clinical and echocardiographic examination was repeated in 32 patients after one year and in 17 after five years. Ten patients had subclinical carditis on admission, six of whom were followed for five years.

MAIN OUTCOME MEASURES

Auscultatory and echocardiographic evidence of mitral or aortic regurgitation during the acute attack or at follow up.

RESULTS

Mitral or aortic regurgitation was detected by Doppler echocardiographic imaging in 25/35 rheumatic fever patients as opposed to 5/35 by clinical examination (p = 0.03). Doppler echocardiography revealed acute valvar lesions in 10 of 20 rheumatic fever patients who had no auscultatory evidence of rheumatic carditis (subclinical carditis). Three of these subclinical lesions and three of the clinical or auscultatory lesions detected on admission were still present after five years of follow up, emphasising that subclinical lesions are not necessarily transient.

CONCLUSIONS

Doppler echocardiographic imaging improves the detection of rheumatic carditis. Subclinical valve lesions, detected only by Doppler imaging, can persist. Echocardiographic findings should be accepted as a major criterion for the diagnosis of rheumatic fever.

Escherichia coli membrane fluidity as detected by excimerization of dipyrenylpropane: sensitivity to the bacterial fatty acid profile

A coordinated study of membrane fluidity and fatty acid composition has been carried out in Escherichia coli W3110. The lipid acyl chain profile of the bacteria, altered by growing cells in steady state at 30, 37, 42, or 45 degrees C, was determined by gas chromatography of the fatty acid methyl esters. In parallel experiments, total membranes obtained from cells of the above-mentioned cultures were labeled with dipyrenylpropane and their relative fluidity was measured on the basis of the excimer to monomer fluorescence intensity ratio of the fluorophore. It has been found that, at constant assay temperature, fluidity determined with dipyrenylpropane decreases gradually with the growth temperature increment, from 30 to 45 degrees C. Interestingly, when fatty acid composition is taken into account, fluidity increases linearly in the range under study, with the proportion of unsaturated fatty acyl chains, both variables being highly correlated (0.924 </= r(2) </= 0.996). Our results show that dipyrenylpropane is a reliable and quantitative indicator of changes in membrane fluidity, driven by modifications in the acyl chain composition of bacterial lipids.

[Single-system ectopic ureters. A review of 19 cases]

Single system ectopic ureters are usually associated with multiple congenital abnormalities and the corresponding renal units is frequently abnormal. 19 cases of single system ectopic ureters were diagnosed and treated in our hospital during the last 20 years. The patients were less than 11 years old. The abnormality was bilateral in two cases and the 63% of all had associated malformations, being the anorectal abnormalities the most frequent. The incidence of reflux into the ectopic ureter was 57%, and the association to unilateral or contralateral renal agenesis, 26.3%. Thirteen ectopic ureters were reimplanted successfully into the bladder, and the cases of nonfunctioning kidneys were removed (nephroureterectomy). The follow-up period was 10 months to 14 years, developing the 68% of the cases without any complication and a good renal function. Two patients were transplanted due to a kidney failure. Diagnosis is often extremely difficult and requires a high degree of suspicion. This diagnosis may be incidental, and it may be made during investigation of patients with other malformations. An early diagnosis and treatment must be made in order to avoid a disturbance of renal function. We wish to point up the high incidence of reflux into the ectopic ureter and the high association to renal agenesis in the single system ectopic ureters in comparison with ectopic ureter of duplex system.

Spontaneous biliary perforation and necrotizing enterocolitis

A case of spontaneous bile-duct perforation in a 5-month-old boy with a history of necrotizing enterocolitis in his 1st week of life is reported. To our knowledge, this is the second case reported with such an antecedent, supporting a vascular etiology for some cases of spontaneous biliary perforation.

Fatty acid profile of Escherichia coli during the heat-shock response

The possible changes in the fatty acid profile of Escharichia coli during heat-shock have been investigated. Bacteria growing in steady-state at 30 degrees C were subjected to an abrupt temperature upshift to 45 degrees C and held at the high temperature for various periods of time in order to elicit the heat-shock response. Fatty acid compositions of lipids extracted from samples taken at different times after the temperature upshift, as well as from cultures in steady-state at 30 and 45 degrees C, were determined by gas-chromatography. It has been found that the total unsaturates to total saturates ratio decreases gradually during heat-shock and that 30 min after the temperature jump, the reduction is equivalent to 57% of the difference between ratios corresponding to steady-state cultures at 30 and 45 degrees C. Consistent with this remodeling of lipid acyl chains, there is a decrease in the excimerization rate of the fluidity probe dipyrenylpropane incorporated into sonicated E. coli lipid extracts. Such modifications occur within the time-span of the heat-shock response, as judged from our previous measurements of the kinetics of change in heat-shock proteins induction ratio. Together, these results indicate that the control of membrane fluidity during the heat-shock response can be accounted for, at least in part, by an important change in the fatty acid composition of Escherichia coli lipids.

[Laparoscopic transsection of Ladd's bands: a new indication for therapeutic laparoscopy in neonates]

Within the last ten years and by the introduction of some new instruments, laparoscopy is a safe and effective method that has been further extended in children. We report our experience in the treatment of laparoscopy on a seven day old newborn affected by malrotation with an intermittent duodenal obstruction. The treatment consisted of a duodenal liberation after the section was easily performed in congenital Ladd's bands. The spiral twists of the small intestine found in the upper gastrointestinal series, disappeared in a new study done after surgery. We consider this operation as a new indication for an operative laparoscopy. It allows a good visualization of this congenital abnormality, and it is easy to perform with a significantly reduced operative trauma.

Long-gap esophageal atresia: reconstruction preserving all portions of the esophagus by Schärli's technique

For distances of over 4-5 cm, esophageal replacement is almost always necessary in esophageal atresias. We present the technical details and describe our experience with esophageal reconstruction by elongation of the lesser curvature (Schärli's technique) in four cases of very long atresias. A retrosternal transposition was made without a thoracotomy in two children, and an orthotopic mediastinal route through a right thoracotomy was done in two others. There were two main complications: anastomotic leaks in three patients that closed spontaneously, and too-rapid gastric emptying, resulting in dumping symptoms that improved with time and diet. One patient developed an anastomotic stricture that responded to bouginage, while another had temporary feeding problems. Esophageal reconstruction by elongation of the lesser curvature provides a relatively simple method of esophageal replacement in children in that all portions of the esophagus are preserved. We propose this technique for early establishment of esophageal continuity in neonates.

The interaction of phospholipase A2 with liposomes: an immunological approach to its study

Porcine pancreatic phospholipase A2 (PLA2) has been incubated for 2 hours at 34 degrees C with rabbit anti-pig pancreatic PLA2 polyclonal antiserum in the absence or presence of phosphatidylcholine liposomes in different physical states. Subsequent assay of hydrolysis -triggered through addition of 5 mM Ca2+- at 34 degrees C, shows that preincubation with antiserum in the presence of 1,2-dimyristoyl-3-sn-phosphatidylcholine liquid-crystalline vesicles, renders the PLA2 activity undetectable, similarly to what is found if preincubation is carried out in the absence of liposomes. In contrast, 1,2-dipalmitoyl-3-sn-phosphatidylcholine liposomes, which at 34 degrees C are in the gel-phase, protect the enzyme from the antiserum effect. The results are consistent with a stronger binding of PLA2 to gel phase, as compared to liquid crystalline vesicles and suggest that through the physical interaction with liposomes in the gel state, the enzyme is shielded from reaction with the antibodies. Taking into account the characteristic hydrolysis profiles of vesicles in different physical states, it can be concluded that the above interpretation agrees with the proposal that PLA2-membrane association promotes the interfacial activation of the enzyme.

Role of type X collagen on experimental mineralization of eggshell membranes

Type X collagen is a transient and developmentally regulated collagen that has been postulated to be involved in controlling the later stages of endochondral bone formation. However, the role of this collagen in these events is not yet known. In order to understand the function of type X collagen, if any, in the process of biomineralization, the properties of type X collagen in eggshell membranes were further investigated. Specifically, calvaria-derived osteogenic cells were tested for their ability to mineralize eggshell membranes in vitro. Immunohistochemistry with specific monoclonal antibodies was used to correlate the presence or absence of type X collagen or its propeptide domains with the ability of shell membranes to be mineralized. The extent of mineralization was assessed by Von Kossa staining, scanning electron microscopy and energy-dispersive spectroscopy. The results indicate that the non-helical domains of type X collagen must be removed to facilitate the cell-mediated mineralization of eggshell membranes. In this tissue, intact type X collagen does not appear to stimulate or support cell-mediated mineralization. We postulate that the non-helical domains of type X collagen function in vivo to inhibit mineralization and thereby establish boundaries which are protected from mineral deposition.

Cantrell's pentalogy. Report of four cases and their management

Four neonates with the uncommon Cantrell's pentalogy seen in our hospital within a 6-month period without any apparent factor in common are described, with a review of the world literature. The first case was diagnosed prenatally at 15 weeks' gestation, the earliest intrauterine finding in the literature. The occurrence of imperforate anus with the syndrome, observed in one of the cases, has not been previously reported. Two were operated upon and only one of the four survived. This high mortality was confirmed by similar cases reported by other authors.

[Solid ovarian tumors in childhood]

We evaluate our experience in solid ovarian tumors at the Children's Hospital La Fe. The main aims of the study were finding out relevant clinical data for a correct clinical approach, and the optimal surgical attitude in order to obtain tumor relieving with preservation of fertility when possible. A review of 28 girls under 14 years with solid ovarian tumors was carried out. Previous history, initial symptoms and signs, analytical and radiological explorations, treatment and evolution were analysed. 17 benign and 11 malignant tumors were found. Main clinical data were acute abdominal pain and palpation of a mass. Surgery was performed in all of them: salpyngo-oophorectomy in 23 and oophorectomy in 5, with tumoral resection. All patients survive, with periodic follow-up. We remark the frequency of acute abdominal pain as initial symptom of an ovarian tumor, and the importance of a surgical attitude that, intending to be curative, would preserve fertility.

[Our experience in portal cavernomatosis in childhood: cross-sectional study and analysis of results]

A retrospective and transversal study of our patients with portal cavernomatosis is developed, with the aim of comparing the evolution and the present status of the patients that have undergone different therapeutical approaches. Between 1975 and 1995, 15 patients with portal cavernomatosis have been treated. Personal history, signs and symptoms at the moment of diagnosis, and treatment were analyzed. Now, the controls have been made by physical examination and ECO-Doppler of the espleno-portal system. In 6 cases the absence of bleeding made surgery unnecessary. In the 9 patients with digestive haemorrhage, it could be controlled pharmacologically, with a later surgical approach. Now, all non-operated and 6 operated patients show splenomegaly, without bleeding. The ECO-Doppler shows colateral flow, the splenomegaly in the non-operated and the surgical shunts and the hepatofugal circulation in the operated patients. Looking at our results, we believe that prophylactic surgery is not indicated. In those cases of digestive bleeding, surgery after the complete resolution of the acute disease shows good results at a short and long term.

Congenital intrahepatic portocaval shunt associated with trimethylaminuria

A case of congenital portal-systemic shunting due to an intrahepatic connection diagnosed by ultrasound scanning and color Doppler in an 8-month-old girl is reported. She began to manifest trimethylaminuria 3 years later. At 7 years of age, she is asymptomatic without therapeutic measures except for diet. This is the seventh reported case and the third in a child to our knowledge.

[Ureteral ectopia in pediatric age: treatment and evolution in 55 cases]

In the last twenty years 55 children with ureteral ectopia were diagnosed and treated in our Hospital. Thirty seven of them were female (67.3%) and they presented the urinary tract infection like the most frequent symptomatology. Seven children were diagnosed during the first days after being born because the detection of hydronephrosis in the antenatal ultrasound; 36 were associated with complete ureteric duplication (65.4%) and the other 19 with single system (34.6%). Congenital abnormalities associated were seen in 14 patients with more frequency in those which presented single-system ectopic ureter (12/14), being the imperforate anus and the kidney agenesia those the most incidence. The most frequent points of opening were the bladder neck and posterior uretra. Diagnostic work-up included some radiological studies (abdominal ultrasound, intravenous urography, sequence mictional cystourethrography and vaginogram), isotopical tests, meticulous genital exploration, cystoscopy and vaginoscopy. 49.1% underwent conservative surgical treatment (7 ipsilateral ureteroureterostomy and 20 ureteral reimplantation) and 50.9% underwent total or partial nephroureterectomy, being the type of treatment depended on functionality of renal units. After treatment, 74.5% had not any incident; among all postsurgical complications, reflux reappearance was the most frequent (3 cases).

[The use of color doppler sonography of the acute scrotum in children]

The differential diagnosis of the causes of acute scrotum only by clinical means, is often very difficult and supposes the risk of making mistakes, which leaves to several unnecessary surgical explorations. By Colour Doppler Sonography we get some information about testicular flow that helps us in the diagnosis. During the last two years 72 consecutive cases of acute scrotum in children younger than 13 years old, were seen in our hospital emergency department. They all underwent testicular bilateral sonography with color flow imaging using a 7.5 MHz linear array transducer (Model Sonolayer Toshiba SSH-140 A). The sonographical diagnosis were: 45 epididymo-orchitis (62.5%), 8 testicular torsions (11%), 7 torsions of the appendix of testis (9.7%), 7 normal explorations (9.7%), 4 acute idiopathic scrotal oedema (5.5%) and a Henoch-Schönlein purpura (1.38%). Doppler examination showed a 97.2% sensibility and 72.2% specificity in the diagnosis of epididymo-orchitis and 88.88% sensibility and 100% specificity in the diagnosis of testicular torsion. The Colour Doppler Sonography should not minimize importance to the clinical explorations, but is very useful for the diagnosis of acute scrotal process, overcoat in inflammatory diseases.

[Treatment with Ethibloc of lymphangiomas and venous angiomas]

Lymphangioma and venous angioma are a group of pathological entities which have required surgical treatment since years. Extension, localization and poor delimitation of some lesions have resulted in technical difficulties and serious complications. Our group began the sclerosing therapy with an injection of fibrin adhesive and, due to the lack of response in the first patient, a program with Ethibloc as an alternative substance was developed. We present 10 cases, 4 lymphangiomas and 6 venous angiomas. In 50% of our patients one single session of sclerotherapy was made, in 25% two sessions, and in the rest 25% three. From 10 cases, 4 are still on treatment, complete remission in 5 cases, and good evolution in one case (mixed lymphangioma). As a long-term complication, we have noticed fistulization in 3 cases, and expulsion of the sclerosing agent. In our experience, percutaneous sclerosis with Ethibloc should be the first therapeutic alternative.

[Neonatal intravaginal testicular torsion in an undescended testis]

We report a case of intravaginal testicular torsion with an unusual debut in a 30 day old patient which had undescended testis. We emphasize the need of a complete physical exploration of the child that go to the emergency service with inspecific symptoms of abdominal pain, and supposing the hemiscrotum was empty, is essential to reject a torsion of a cryptorchidic testicle. An immediate surgery is necessary in order to diagnose and treat this disturbance.

Membrane fluidity of Escherichia coli during heat-shock

The excimer-forming fluorophore dipyrenylpropane has been used to measure the relative fluidity of total membranes isolated from Escherichia coli grown at 30 or 45 degrees C, or exposed to a heat-shock from 30 to 45 degrees C for various periods of time. Parallel experiments were performed using [35S]methionine pulse-labeling of cells, to study the induction of heat-shock proteins (HSPs) at different times after the sudden change in E. coli growth-temperature from 30 to 45 degrees C. Results suggest that upon an abrupt temperature upshift from 30 to 45 degrees C, membrane fluidity adjustment to the steady-state level at the high temperature, takes place during the E. coli heat-shock response.

Activity of phospholipase A2 on a fluorescent substrate incorporated into non-hydrolyzable phospholipid liposomes

The activity of phospholipase A2 (PLA2) on phospholipid liposomes depends on the physicochemical properties of the aggregated substrate, which are subject to continuous modification by the products released during hydrolysis. We propose here an experimental design that, by means of the incorporation of a fluorescent substrate at very low molar ratio (< or = 1:500) into a nonhydrolizable liposomal matrix of 1,2-dihexadecyl-sn-glycero-3-phosphocholine (DHPC), allows the study of hydrolysis by porcine pancreatic phospholipase A2, in virtual absence of physical perturbations of the lamellar phase, by the released products. We have been able to measure immediate hydrolysis of the fluorescent substrate 1,2-di-[omega(1'-pyreno)-decanoyl]-sn- glycero-3-phosphocholine when the sonicated liposomal matrix is in the gel phase. In the liquid crystalline state, in contrast, hydrolysis is very poor even after 80 min of adding the enzyme. Both in the gel and liquid-crystalline phases, incorporation of unlabeled PLA2 products activates the hydrolysis rate to comparable levels. It appears that the conformation adopted by the substrate immersed in the gel or liquid crystalline matrix is especially important in determining its susceptibility to hydrolysis in the absence of products.

Calcium ions reverse a latency period induced by bovine serum albumin in the time course of phospholipase A2 action on 1,2-dipalmitoyl-sn-glycero-3-phosphocholine liposomes

The time course of hydrolysis of 1,2-dipalmitoyl-sn-glycero-3-phosphocholine liposomes in the gel phase catalyzed by porcine pancreatic phospholipase A2 was studied at 1 mM NaCl and variable CaCl2 concentrations, in the presence of delipidated bovine serum albumin. It has been found that the duration of the latency induced by bovine serum albumin shows an inverse dependence with CaCl2 concentration. As we showed previously, the induction of a lag phase by bovine serum albumin is related to its ability to sequester the fatty acid newly released by hydrolysis. Based on this and on our observation that there is an inverse dependence between the length of the latency period and the interfacial calcium ion concentration, it is interpreted that, while a direct effect of bovine serum albumin is the diminution of the liposome negative surface charge density by sequestration of the fatty acid released during hydrolysis, an indirect effect could be the decrease in the surface Ca2+ concentration. This, in turn, should diminish the enzyme binding to the lipid-water interface. The appearance of a latency phase seems to be the final consequence of these events.

[Renal scintigraphy with captopril in the evaluation of renovascular hypertension]

The administration of an angiotensin-converting enzyme (ACE) inhibitor transitorily reduces the GFR in a kidney with renal artery stenosis, effect that can be ascertained with scintigraphic studies using ACE inhibitors. We evaluated the clinical usefulness of captopril renography (CR) in the diagnosis of renovascular hypertension (RVH) in 51 hypertensive patients in which this diagnosis was suspected. All subjects underwent angiography and RVH was diagnosed when renal artery stenosis exceeded 60%, there was lateralization of renal vein renin or there was a concordant clinical outcome. Renography was performed 15 minutes after Lasix administration, using Tc-99m DTPA, before and 60 minutes after the oral administration of 50 mg of captopril. The scintigraphic criteria for a positive test were a decreased split renal function, a delayed peak uptake, a decreased excretion of DTPA and a prolonged transit time. In three of 28 patients in whom angiography discarded RVH, CR was positive. In the 23 patients with confirmed RVH, CR was positive in 10 of 12 with unilateral stenosis, in 3 of 8 with bilateral stenosis and 1 of 3 with stenosis in a transplanted kidney. The overall sensitivity and specificity of the test for RVH was 60.9% and 89.2% respectively. There were no changes in blood pressure or adverse effects after captopril administration. We conclude that CR in RVH is useful to select patients for further studies (angiography) and to perform a functional interpretation of angiographic alterations.

Partial biochemical and immunochemical characterization of avian eggshell extracellular matrices

There is evidence to suggest that extracellular matrix molecules, such as proteoglycans, are involved in the regulation of mineral deposition in calcifying tissues. One mineralizing system which is characterized by extremely rapid mineralization is the hen eggshell. This eggshell consists of a pair of nonmineralized eggshell membranes subjacent to the calcified eggshell proper; the eggshell proper is organized into palisades (columns) of mineralized matrix separated by pores. Between the membranes and the shell proper are compacted foci of tissue called mammillary knobs, which are thought to be sites where mineralization is initiated. Previous work from this laboratory has shown the presence of types I, V, and X collagen in the shell membranes. To address the question of the possible role of proteoglycans and glycosaminoglycans in mineralization of the eggshell, two approaches were used. First, immunohistochemistry was performed with monoclonal antibodies to various proteoglycan and glycosaminoglycan epitopes. This analysis indicates that different glycosaminoglycans are localized to discrete regions within the eggshell. Dermatan sulfate is present within the matrix of the shell proper and, to a lesser extent, the mammillary knobs and the outer portion of the shell membranes. In contrast, keratan sulfate is found in the shell membranes and prominently in the mammillary knobs. Interestingly, different keratan sulfate antibodies immunostain distinct regions of the eggshell, which suggests that various types of keratan sulfate are distributed differently. The second approach utilized was to extract the eggshell membranes and recover anionic molecules by anion-exchange chromatography. This resulted in the extraction of material which was recognized by antibodies to keratan sulfate, but not to chondroitin sulfate. This material was very large, as evidenced by its elution in the void volume of a Sepharose CL-2B column. The large size may be due to the extensive cross-links known to occur in the eggshell. If eggshell membranes are extracted at elevated temperature, the material recovered is of much smaller size. These results indicate that molecules recognized by antibodies to glycosaminoglycans are present in the eggshell, and their localized distribution relative to the calcified matrix suggests that they may be involved in the regulation of mineral deposition.