Hereditary angioedema in Spain: medical care and patient journey

BACKGROUND

Hereditary angioedema due to C1 inhibitor deficiency (HAE-C1INH) is a genetic rare disease characterized by recurrent, transient and unpredictable episodes of cold, non-pruriginous oedema without associated urticaria. The characteristics of the disease have a considerable impact on the quality of life of patients. The aim of this study was to increase understanding of the patient journey of HAE in Spain.

METHODS

A multidisciplinary committee of 16 HAE experts (allergy, immunology, emergency department, hospital pharmacy and nursing) and 3 representatives of the Spanish Hereditary Angioedema Patient Association (AEDAF) who were patients or caregivers participated in the study. A review of the publications on HAE treatment was performed. Semi-structured interviews were performed to HAE experts, patients, or caregivers. Three meetings with the experts, patients and caregivers were held to share, discuss, and validate data obtained from literature and interviews and to build the model.

RESULTS

Throughout the project, the patient journey has been drawn up, dividing it into the stages of pre-diagnosis, diagnosis and treatment/follow-up. Some areas for improvement have been identified. Firstly, there is a need to enhance awareness and training on HAE among healthcare professionals, with a particular emphasis on primary care and emergency department personnel. Secondly, efforts should be made to minimize patient referral times to allergy/immunology specialists, ensuring timely access to appropriate care. Thirdly, it is crucial to encourage the study of the relatives of diagnosed patients to early identify potential cases. Fourthly, equitable access to self-administered treatments should be ensured, facilitated by systems that enable medication delivery at home and proper education and training for patients. Equitable access to long-term prophylactic treatment should also be prioritized for all patients in need. To standardize HAE management, the development of consensus guidelines that reduce variability in clinical practice is essential. Lastly, promoting research studies to enhance knowledge of the disease and align its treatment with new developments in the healthcare field should be encouraged.

CONCLUSIONS

The knowledge of the patient journey in HAE allowed us to identify improvement areas with the final aim to optimize the disease management.

Efficacy Studies against PCV-2 of a New Trivalent Vaccine including PCV-2a and PCV-2b Genotypes and Mycoplasma hyopneumoniae When Administered at 3 Weeks of Age

This study aimed to evaluate the efficacy of a new trivalent vaccine containing inactivated Porcine Circovirus 1-2a and 1-2b chimeras and a Mycoplasma hyopneumoniae bacterin administered to pigs around 3 weeks of age. This trivalent vaccine has already been proved as efficacious in a split-dose regimen but has not been tested in a single-dose scenario. For this purpose, a total of four studies including two pre-clinical and two clinical studies were performed. Globally, a significant reduction in PCV-2 viraemia and faecal excretion was detected in vaccinated pigs compared to non-vaccinated animals, as well as lower histopathological lymphoid lesion plus PCV-2 immunohistochemistry scorings, and incidence of PCV-2-subclinical infection. Moreover, in field trial B, a significant increase in body weight and in average daily weight gain were detected in vaccinated animals compared to the non-vaccinated ones. Circulation of PCV-2b in field trial A and PCV-2a plus PCV-2d in field trial B was confirmed by virus sequencing. Hence, the efficacy of this new trivalent vaccine against a natural PCV-2a, PCV-2b or PCV-2d challenge was demonstrated in terms of reduction of histopathological lymphoid lesions and PCV-2 detection in tissues, serum and faeces, as well as improvement of production parameters.

[Vitamin D deficiency/insufficiency on healthy infants receiving standard supplementation]

Vitamin D (VD) is essential for calcium and phosphorus metabolism. Its deficiency can cause rickets. In Chile, newborns receive 400UI/day supplementation from the first day of age until the first year.

OBJECTIVE

To describe the VD plasma levels in healthy infants who received supplementation and secondarily to correlate this with seasonality and nutritional status.

SUBJECTS AND METHOD

Cross sectional study. Infants on exclusive or mixed breastfeeding, with monthly pediatric checkups recei ving 400 UI VD supplementation were evaluated, measuring VD plasma levels at 6 months of age, weight, and length, and their nutritional status was classified according to the WHO growth referen ces (weight/age and weight/length). The VD cut-off concentration values were < 20 ng/ml, 21- 29 ng/ ml, and ≥ 30 ng/ml considered as deficiency, insufficiency, and sufficiency, respectively.

RESULTS

40 infants were studied, 40% had insufficient levels and 40% presented deficiency. Season and nutritio nal status were variables significantly related to lower VD values (Winter-Spring p = 0.007; at risk of malnutrition p = 0.038).

CONCLUSIONS

The population who received supplementation presented a high frequency of VD deficiency and insufficiency which increases during winter and spring and in subjects at risk of malnutrition.

[Vitamin D deficiency/insufficiency on healthy infants receiving standard supplementation]

Vitamin D (VD) is essential for calcium and phosphorus metabolism. Its deficiency can cause rickets. In Chile, newborns receive 400UI/day supplementation from the first day of age until the first year.

OBJECTIVE

To describe the VD plasma levels in healthy infants who received supplementation and secondarily to correlate this with seasonality and nutritional status.

SUBJECTS AND METHOD

Cross sectional study. Infants on exclusive or mixed breastfeeding, with monthly pediatric checkups recei ving 400 UI VD supplementation were evaluated, measuring VD plasma levels at 6 months of age, weight, and length, and their nutritional status was classified according to the WHO growth referen ces (weight/age and weight/length). The VD cut-off concentration values were < 20 ng/ml, 21- 29 ng/ ml, and ≥ 30 ng/ml considered as deficiency, insufficiency, and sufficiency, respectively.

RESULTS

40 infants were studied, 40% had insufficient levels and 40% presented deficiency. Season and nutritio nal status were variables significantly related to lower VD values (Winter-Spring p = 0.007; at risk of malnutrition p = 0.038).

CONCLUSIONS

The population who received supplementation presented a high frequency of VD deficiency and insufficiency which increases during winter and spring and in subjects at risk of malnutrition.

[Vitamin D deficiency/insufficiency on healthy infants receiving standard supplementation]

Vitamin D (VD) is essential for calcium and phosphorus metabolism. Its deficiency can cause rickets. In Chile, newborns receive 400UI/day supplementation from the first day of age until the first year.

OBJECTIVE

To describe the VD plasma levels in healthy infants who received supplementation and secondarily to correlate this with seasonality and nutritional status.

SUBJECTS AND METHOD

Cross sectional study. Infants on exclusive or mixed breastfeeding, with monthly pediatric checkups recei ving 400 UI VD supplementation were evaluated, measuring VD plasma levels at 6 months of age, weight, and length, and their nutritional status was classified according to the WHO growth referen ces (weight/age and weight/length). The VD cut-off concentration values were < 20 ng/ml, 21- 29 ng/ ml, and ≥ 30 ng/ml considered as deficiency, insufficiency, and sufficiency, respectively.

RESULTS

40 infants were studied, 40% had insufficient levels and 40% presented deficiency. Season and nutritio nal status were variables significantly related to lower VD values (Winter-Spring p = 0.007; at risk of malnutrition p = 0.038).

CONCLUSIONS

The population who received supplementation presented a high frequency of VD deficiency and insufficiency which increases during winter and spring and in subjects at risk of malnutrition.

Long-term outcome of early steroid withdrawal in pediatric renal transplantation

BACKGROUND

Steroid use in renal transplant is related to multiple adverse effects. Long-term effects of early withdrawal steroids in pediatric renal transplant were assessed.

METHODS

Renal transplant children with low immunological risk treated on basiliximab, tacrolimus, and mycophenolate with steroid withdrawal or steroid control were evaluated between 2003 and 2019. Clinical variables, treatment adherence, acute rejection, graft loss, and death were analyzed through hazard ratios, and Kaplan-Meier and multivariate analyses.

RESULTS

The study included 152 patients, 71.1% steroid withdrawal, mean follow-up 8.5 years, 64.5% structural abnormalities, and 81.6% deceased donor. At 12 years of transplant, event-free survival analysis for graft loss or death showed no significant difference between steroid withdrawal and control steroid treatment (85.9% vs. 80.4%, p = .36) nor in acute rejection at 10 years (18.5% vs. 20.5%, p = .78) or in donor-specific antibody appearance (19.6% vs. 21.4%, p = .98). Delta height Z-score was increased in the steroid withdrawal group (p < .01). The main predictor of graft loss or death was non-adherence to treatment (p = .001; OR: 17.5 [3.3-90.9]).

CONCLUSIONS

Steroid withdrawal therapy was effective and safe for low-risk pediatric renal transplant in long-term evaluation. Non-adherence was the main predictor of graft loss or death.

Exploratory field study on the effects of porcine circovirus 2 (PCV-2) sow vaccination at different physiological stages mimicking blanket vaccination

Background

The objective of the present study was to explore the benefits of Porcine circovirus 2 (PCV-2) blanket vaccination in a sow herd on productive parameters, PCV-2 infection and immune status in sows and their progeny. For this purpose, 288 sows were distributed among four balanced experimental groups. One group remained as negative control group and the other three received 1 mL of PCV-2 Ingelvac Circoflex® intramuscularly at different productive cycle moments: before mating, mid gestation (42–49 days post-insemination) or late gestation (86–93 days post-insemination); phosphate buffered saline (PBS) was used as negative control item. Reproductive parameters from sows during gestation and body weight of their progeny from birth to weaning were recorded. Additionally, blood was collected from sows at each vaccination time and piglets at 3 weeks of age. Moreover, up to 4 placental umbilical cords (PUC) per sow were taken at peri-partum. Sera from sows and piglets were analysed for PCV-2 antibody detection using an enzyme-linked immunosorbent assay (ELISA). Sera from sows and PUC were tested to quantify viraemia using a real time quantitative polymerase chain reaction (qPCR) assay.

Results

Globally, results indicated that vaccinated sows showed heavier piglets at birth and at weaning, less cross-fostered piglets, lower viral load at farrowing as well as in PUC, and higher antibody levels at farrowing, compared to non-vaccinated ones. When all groups were compared among them, sows vaccinated at mid or late gestation had heavier piglets at birth than non-vaccinated sows, and lower proportion of PCV-2 positive PUC. Also, cross-fostering was less frequently practiced in sows vaccinated at pre-mating or mid gestation compared to non-vaccinated ones.

Conclusions

In conclusion, the present study points out that PCV-2 sow vaccination at different time points of their physiological status (mimicking blanket vaccination) offers benefits at production and serological and virological levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40813-021-00213-2.

Incidence of COVID-19 in outpatients with cancer receiving active treatment in the context of a pandemic: An Andalusian cohort study

Background

Leading scientific societies have recommended delaying and/or suspending active cancer treatment during the COVID-19 pandemic. Nevertheless, data on this novel infection in patients with a diagnosis of cancer receiving active treatment are scarce and it is unknown if these recommendations could have repercussions on future progress of the disease. The main objective of this study is to learn the COVID-19 incidence rate in outpatients with cancer receiving active treatment.

Methods

This work is a retrospective cohort study that included all patients with a diagnosis of cancer who received active cancer treatment in two Andalusian hospitals between February 26 and May 13, 2020. Variables regarding the patient, tumor, and development of COVID-19 were collected. A descriptive analysis was performed and the cumulative incidence of COVID-19 in these patients was evaluated.

Results

A total of 673 patients were included. The median age was 62 years. There was a low rate of comorbidity and 12.1% had an ECOG >2. Breast cancer was the most common cancer (41%), followed by colorectal and lung cancer. Stage IV cancer was reported in 52.7% of patients. The most common treatment was chemotherapy (53.9%). Treatment was delayed or suspended in 6% of patients. Only three patients developed COVID-19. The cumulative incidence was 0.44% and one person died due to infection.

Conclusions

In the present retrospective cohort study we found a low incidence of COVID-19 infection in patients with cancer receiving active treatment in an outpatient setting. The sociodemographic factors of Andalusia may explain why these results differ from those presented by other colleagues in Spain, but raise questions about whether universal recommendations may put the benefits of antineoplastic therapy at risk.

Eimeria ninakohlyakimovae casts NOX-independent NETosis and induces enhanced IL-12, TNF-α, IL-6, CCL2 and iNOS gene transcription in caprine PMN

Eimeria ninakohlyakimovae represents a highly pathogenic coccidian parasite causing severe haemorrhagic typhlocolitis in goat kids worldwide. NETosis was recently described as an efficient defense mechanism of polymorphonuclear neutrophils (PMN) acting against different parasites in vitro and in vivo. In vitro interactions of caprine PMN with parasitic stages of E. ninakohlyakimovae (i. e. oocysts and sporozoites) as well as soluble oocyst antigens (SOA) were analyzed at different ratios, concentrations and time spans. Extracellular DNA staining was used to illustrate classical molecules induced during caprine NETosis [i. e. histones (H3) and neutrophil elastase (NE)] via antibody-based immunofluorescence analyses. Functional inhibitor treatments with DPI and DNase I were applied to unveil role of NADPH oxidase (NOX) and characterize DNA-backbone composition of E. ninakohlyakimovae-triggered caprine NETosis. Scanning electron microscopy (SEM)- and immunofluorescence-analyses demonstrated that caprine PMN underwent NETosis upon contact with sporozoites and oocysts of E. ninakohlyakimovae, ensnaring filaments which firmly entrapped parasites. Detailed co-localization studies of E. ninakohlyakimovae-induced caprine NETosis revealed presence of PMN-derived DNA being adorned with nuclear H3 and NE corroborating molecular characteristics of NETosis. E. ninakohlyakoimovae-induced caprine NETosis was found to be NOX-independent since DPI inhibition led to a slight decrease of NETosis. Exposure of caprine PMN to vital E. ninakohlyakimovae sporozoites as well as SOA resulted in up-regulation of IL-12, TNF-α, IL-6, CCL2 and iNOS gene transcription in stimulated PMN. Since vital E. ninakohlyakimovae-sporozoites induced caprine NETosis, this effective entrapment mechanism might reduce initial sporozoite epithelial host cell invasion during goat coccidiosis ultimately resulting in less macromeront formation and reduced merozoites I production.

The clinical impact of untreated slow ventricular tachycardia in patients carrying implantable cardiac defibrillators

INTRODUCTION

The clinical impact of slow ventricular tachycardia (VT), occurring in patients carrying implantable cardiac defibrillators (ICD), is still under debate.

METHODS AND RESULTS

From the UMBRELLA registry (multicenter, observational, and prospective study on patients with ICD), 659 episodes of slow VT were observed in 97 patients. Untreated slow VT (n = 93) had longer duration (23.7 min, CI95%: 10-39), compared with episodes treated effectively by anti-tachycardia pacing (ATP; n = 527; 0.32 min, IC95%: 0.22-0, 48) or shock (n = 39; 1 min, CI95%: 0.8-1.2). Despite of longer duration, the time to the first contact with the medical services was similar to those episodes treated by ATP (50 days [CI95%: 45-55] vs. 41 days [CI95%: 39-44]). However, both were significantly longer than the time observed in episodes treated with shock (10 days, CI95%: 6-15). This tendency was maintained with successive interrogations of the device (2nd and 3rd). There were no significant differences in mortality during follow-up (48 ± 16 months), neither other adverse outcomes, between patients who presented untreated slow TV and those who did not (log-rank p = 0.28). In a Cox regression analysis, the variable "presenting untreated episodes of slow VT" was not able to predict mortality. However, being in sinus rhythm (vs. atrial fibrillation, OR: 0.31, p = 0.009), narrower QRS (OR: 1.036, p = 0.037) and diabetes (OR 4.673, p = 0.049) appropriately predict survival.

CONCLUSIONS

Untreated slow VT does not significantly worsen patient prognosis. Our results support the limitation of therapies to ATP only, thus avoiding therapies that have been associated with increased risk of morbidity and mortality.

Comparison of Mycoplasma hyopneumoniae and porcine circovirus 2 commercial vaccines efficacy when applied separate or combined under experimental conditions

Background

Mycoplasma hyopneumoniae (Mhyo) and Porcine circovirus 2 (PCV-2) are two of the most significant infectious agents causing economic losses in the weaning to slaughter period. Due to their similar vaccination age, the objective of this study was to assess the efficacy of two already existing Mhyo (Hyogen®) and PCV-2 (Circovac®) vaccines when administered separately or combined (RTM) by means of Mhyo or PCV-2 experimental challenges.

Results

Seven groups of animals were included in the study, being three of them challenged with PCV-2, three with Mhyo and one composed of non-challenged, non-vaccinated pigs. Within each experimental challenge, non-vaccinated (NV) groups were compared with double vaccinated groups using the commercial products separated (VS) or combined (VC). Both vaccinated groups showed significant differences for most parameters measured regarding PCV-2 (serology, percentage of infected animals and viral load in tissues) and Mhyo (serology and gross lesions) when compared to NV groups. VS and VC offered similar results, being only significantly different the PCV-2 antibody values at different time points (higher in the VS group) of the study, although not at the termination day (21 days post-PCV-2 inoculation).

Conclusion

The present study expands the knowledge on the possibility of using two separate Mhyo and PCV-2 commercial vaccines as a RTM product, which offered equivalent virological, immunological and pathological outcomes as compared to these vaccines when used by separate.

Analytical Validation of Telomere Analysis Technology® for the High-Throughput Analysis of Multiple Telomere-Associated Variables

Background

A large number of studies have suggested a correlation between the status of telomeres and disease risk. High-throughput quantitative fluorescence in situ hybridization (HT Q-FISH) is a highly accurate telomere measurement technique that can be applied to the study of large cell populations. Here we describe the analytical performance testing and validation of Telomere Analysis Technology (TAT®), a laboratory-developed HT Q-FISH-based methodology that includes HT imaging and software workflows that provide a highly detailed view of telomere populations.

Methods

TAT was developed for the analysis of telomeres in peripheral blood mononuclear cells (PBMCs). TAT was compared with Terminal Restriction Fragment (TRF) length analysis, and tested for accuracy, precision, limits of detection (LOD) and specificity, reportable range and reference range.

Results

Using 6 different lymphocyte cell lines, we found a high correlation between TAT and TRF for telomere length (R² ≥ 0.99). The standard variation (assay error) of TAT was 454 base pairs, and the limit of detection of 800 base pairs. A standard curve was constructed to cover human median reportable range values and defined its lower limit at 4700 bp and upper limits at 14,400 bp. Using TAT, up to 223 telomere associated variables (TAVs) can be obtained from a single sample. A pilot, population study, of telomere analysis using TAT revealed high accuracy and reliability of the methodology.

Conclusions

Analytical validation of TAT shows that is a robust and reliable technique for the characterization of a detailed telomere profile in large cell populations. The combination of high-throughput imaging and software workflows allows for the collection of a large number of telomere-associated variables from each sample, which can then be used in epidemiological and clinical studies.

Impact of adjuvant chemotherapy on the survival of patients with breast cancer diagnosed by screening

The aim of this study is to determine the survival of patients with breast cancer treated with adjuvant chemotherapy (ACh) after the diagnosis by screening, taking comorbidity into account. This multicenter cohort study examined a population of patients taking part in four national screening programs for the early detection of breast cancer (localized or locally advanced), during the period 2000‐2008. Of the 1248 cancers detected, 266 were prevalent (21.3%), 633 were incident (50.7%), and 349 were interval (27.9%). No significant differences were detected between the three groups in terms of the distribution of comorbidity according to the CCI. After a median follow‐up of 102 months, 22.1% of the patients with interval cancer had died. The corresponding figures for the incident and prevalent cancers were 10.4% and 7.9%, respectively (P < .001). The adjusted Cox regression analysis by the stage, CCI and group revealed no differences in the risk of recurrence between the different groups according to the ACh performed. However, there were significant differences in the overall survival; for the interval cancer group without ACh, the risk of death was higher (Hazard ratio: 2.5 [1.0‐6.2]) than for the other two groups. However, for the prevalent and incident groups that did not receive ACh, there was no greater risk of death. This study shows that adjuvant chemotherapy seems to benefit patients with interval breast cancer, who have a poorer prognosis than those with prevalent or incident cancer. However, the role of ACh is unclear with respect to prevalent and incident cancers when comorbidity is taken into account.

The QT Interval Dynamic in a Human Experimental Model of Controlled Heart Rate and QRS Widening

Background: there is increasing interest for computing corrected QT intervals in patients with prolonged depolarization. We aimed to analyze the effect of prolonged QRS in the QT and in the diagnostic accuracy of frequency-correction. Methods and Results: in 28 patients admitted for self-expanding aortic valve implantation, sequential pacing was performed in the AAI mode in two different phases: before and immediately after the release of the prosthesis. We evaluated the accuracy of the Bazett, Fridericia, Framingham and Hodges formulas with the reference of the QT at 60 bpm (QTc/deviation). The widening of the QRS was the main contributor to the QT prolongation (Pearson 0.79; CI95%: 0.75-0.84). Prolongation in other intervals (ST segment and T-wave) significantly contribute in the higher frequency range (p < 0.05). The Bazett's formula displayed the highest QTc/deviation, while Framingham and Hodges retrieved the lowest QTc/deviation and the best fit (p < 0.001). In addition, the Bazett's formula displayed the highest correlation between variations in the QTc/deviation and the widening of the QRS (Pearson coefficient -0.54; p < 0.001) in comparison with the Fridericia, Framingham and Hodges formulas (-0.51, -0.37 and -0.38 respectively; p < 0.001). There was also a linear effect of the heart rate in the QTc/deviation obtained with the Bazett's formula (p = 0.015), not observed for other formulas. Conclusions: The prolonged depolarization of the ventricles introduces direct and linear prolongation in the QT interval, but also a non-linear distortion in cardiac repolarization that contributes for QT prolongation at the higher frequency range. The Bazett's formula displays significantly higher sensitivity to prolongation of ECG intervals.

Insights for Stratification of Risk in Brugada Syndrome

Brugada syndrome (BrS) is an inherited disease with an increased risk of sudden cardiac death (SCD). However, testing identifies genetic disorders in only 20-30% of patients analysed, indicating a gap in knowledge of its genetic aetiology. Diagnosis relies on ECG, and risk stratification in BrS patients is challenging, primarily because of the complexity of the issue. As a result, clinicians fail to provide the appropriate strategy for SCD prevention for many patients. Several variables and interventions are being studied to improve diagnostics and maximise patient protection. In addition, the scientific community must increase efforts to provide patient care according to knowledge and research for improving stratification of risk. In this article, the authors summarise contemporary evidence on clinical variables and provide an overview of future directions in risk stratification and SCD prevention.

Unravelling the effects of berry size on ‘Tempranillo’ grapes under different field practices

Small berries are considered to produce the best red wines as berry size determines the skin to pulp ratio and may affect wine composition. However, contrasting results have been reported about this postulate. In this context, the aim of this work was to assess the influence of berry size on grape compositional attributes in ‘Tempranillo’ grapevines under different irrigation, crop load and defoliation regimes. Grapes were collected from different experiments performed during three years in a ‘Tempranillo’ vineyard (Valencia, Spain). Grape size distribution was assessed and several traits were measured for each size category: number of seeds, seed and skin weight, total soluble solids, titratable acidity, pH, total phenolic index and anthocyanin concentration. Berry size exerted a significant effect on grape composition; smaller berries having higher sugars and anthocyanins concentrations. However, irrigation, crop load and defoliation also affected these compositional traits, producing greater berries with similar traits than those smaller, but coming from rain-fed and not defoliated treatments. Depending on the field practices applied, grape compositional attributes can be modulated for a given berry size. Therefore, wineries can use berry size classification for selecting those from a given size for making different wine styles.

Delta of the local ventriculo-atrial intervals at the septal location to differentiate tachycardia using septal accessory pathways from atypical atrioventricular nodal re-entry

Aims

Tachycardia mediated by septal accessory pathways (AP) and atypical atrioventricular nodal re-entry (AVNRT) require careful electrophysiologic evaluation for differential diagnosis. We aim to describe the differential behaviour of local ventriculo-atrial (VA) intervals which predicts the tachycardia mechanism.

Methods and results

The local VA intervals at the para-Hisian septum were measured under three different situations: (i) tachycardia; (ii) sustained entrainment from the right ventricular apex (RVA); and (iii) continuous pacing from the RVA during sinus rhythm. Differences were computed as follows: Δ-VAentr = VA during entrainment - VA during tachycardia; and Δ-VApac = VA while pacing during sinus rhythm - VA during tachycardia. In contrast to AVNRT, we hypothesized that an invariable retrograde conduction through the septal AP will keep the result of the subtractions close to 0 ms in cases of ortodromic atrioventricular re-entrant tachycardia (AVRT). We analysed 55 atypical AVNRT (45% posterior type) and 82 AVRT (10 anteroseptal, 18 para-Hisian, 12 mid-septal, and 42 posteroseptal). Δ-VAentr was longer for AVNRT (98.5 ± 40.3 ms) compared with septal AP (-5.7 ± 19.3 ms; P < 0.001). A value of 50 ms showed 98.7% sensitivity and 92% specificity (AUC 0.99; 95% CI 0.98-1). According to physiological criteria, a negative Δ-VAentr remains unobserved in the case of AVNRT (positive predictive value 100% for septal AP). Δ-VApac was also longer for AVNRT (66.5 ± 14.6 ms) compared with septal AP (-9.7 ± 3.3 ms; P < 0.001). A value of 50 ms showed 100% sensitivity and 74% specificity (AUC 0.86; 95% CI 0.76-0.93).

Conclusions

Delta of the local VA intervals enables distinction between atypical AVNRT and AVRT mediated by septal AP.

Parasite prevalence in Mycobacterium spp. infected dairy goats in the region of Murcia (south-east Spain)

Eighty-four Murciano-Granadina dairy goats slaughtered in the region of Murcia (South-East Spain) were necropsied to evaluate parasitic infections. The majority of the animals (94.0%) were parasitised and multiple infections were present. Twenty-one parasite species were found, including 18 nematode species (Muellerius capillaris, Dictyocaulus filaria, Neostrongylus linearis, Cystocaulus ocreatus, Teladorsagia circumcincta, T. occidentalis, T. trifurcata, Marshallagia marshalli, Camelostrongylus mentulatus, Trichostrongylus capricola, Nematodirus abnormalis, N. filicollis, N. spathiger, T. vitrinus, T. colubriformis, Trichuris spp., Chabertia ovina and Skrjabinema ovis); one trematode species (Dicrocoelium dendriticum); one arthropod species (Oestrus ovis); and one protozoa genus (Eimeria spp.). Additionally, 17.85% of the animals were Mycobacterium spp. positive. Therefore, comparison between parasite prevalence, intensity and abundance in tuberculosis-positive and -negative animals was performed. Statistically significant differences between the prevalence of lungworms and gastrointestinal nematodes in Mycobacterium spp. infected and free goats were found. The paper discusses this co-infection between Mycobacteriaceae and endoparasites.

Microwave-induced covalent functionalization of few-layer graphene with arynes under solvent-free conditions

A non-conventional modification of exfoliated few-layer graphene (FLG) with different arynes under microwave (MW) irradiation and solvent-free conditions is reported. The described approach allows reaching fast, efficient and mild covalent functionalization of FLG.

Ablation of Rotor Domains Effectively Modulates Dynamics of Human: Long-Standing Persistent Atrial Fibrillation

BACKGROUND

In human long-standing persistent atrial fibrillation, rotors potentially explain atrial fibrillation maintenance, but their ablation remains controversial. We aimed to explore original phase/frequency mapping methods to locate rotors and track changes induced by their ablation.

METHODS AND RESULTS

Thirteen patients with long-standing persistent atrial fibrillation (duration, 12-72 months) underwent phase/frequency mapping (Hilbert/Fourier transforms; CARTO-Finder) of the left and right atria (PentaRay catheter). A rotor domain was defined as an area displaying at least 3 consecutive rotations. Ablation was performed by circumferential pulmonary vein isolation plus linear ablation of extrapulmonary rotor domains. We identified 19 rotor domains in 10 patients (1.8±1.1 per patient; 7 in the right atrium versus 12 in the left atrium; 15 extrapulmonary). Overall, rotor domains (9.2±2.2 rotations) displayed higher frequency of activation (6.41 Hz; 95% confidence interval, 6.24-6.57) than nonrotor domains (6.17 Hz; 95% confidence interval, 6.1-6.23; P=0.021), with interatrial frequency gradients established by the spatial location of the rotor domain (P=0.016). Fibrillatory conduction was suggested as a decrease in the frequency of the slower atria after ablation close to main interatrial conduction fascicles (P=0.035). Ablation of rotor domains (ablation line, 3.5±0.9 cm) effectively decreased the frequency of activation in both ipsilateral and contralateral atria (P<0.05 for both), whereas ablation of nonrotor domains did not. Acute conversion to sinus rhythm was observed in 2 patients after ablation of rotor domains. At 1-year follow-up, 70% remained in sinus rhythm (85% out-of-antiarrhythmic drugs).

CONCLUSIONS

Rotor domains appropriately explain long-standing persistent atrial fibrillation physiology at its frequency content. Their ablation effectively modifies dynamics on restricted ablation.

Antiphospholipid syndrome and IgA anti-beta2-glycoprotein I antibodies: when Cinderella becomes a princess

IgA anti-beta2-glycoprotein I (IgA-aB2GPI) antibodies are currently not included as a laboratory criterion of antiphospholipid syndrome (APS). In the 13th International Congress on Antiphospholipid Antibodies, Galveston, TX, (USA) in 2010, these antibodies were accepted as an APS laboratory criterion in patients who had clinical manifestations of APS but were negative for "consensus" antiphospholipid antibodies (aPL) (IgG and IgM isotypes). Consequently, individuals with thrombotic events who are negative for consensus aPL may be undiagnosed for APS. The most recent publications have confirmed that IgA-aB2GPI antibodies are a risk factor for thrombotic events. In this viewpoint, we propose that IgA-aB2GPI antibodies should be included as an APS consensus criterion and that we have to help Cinderella become a princess.

Study of β2-Glycoprotein I Polymorphisms in Patients With Chronic Renal Failure as a Predisposing Factor for the Development of Anti-β2-Glycoprotein I Auto-Antibodies

BACKGROUND

Immunoglobulin (Ig)A anti-β₂-glycoprotein I (aB2GP1) antibodies are associated with thrombotic events, cardiovascular morbidity, and death in dialysis patients. About 30% of patients with chronic renal disease are positive for IgA aB2GP1; however, the origin of these antibodies is unknown. It has been speculated that dialysis membranes, age, or etiology of renal base disease are possible precipitating factors, although these factors do not appear to be the source of antibodies. B2GP1 is a protein of 326 amino acids grouped into five domains. Eight polymorphisms have been described; the most important are Val/Leu²⁴⁷, which appears to predispose aB2GP1 antibody production in patients with anti-phospholipid syndrome, and Trp/Ser³¹⁶, which appears to have protective antibody production of aB2GP1.

METHODS

DNA samples from 92 patients with renal failure on hemodialysis were randomly collected with a 1:1 ratio for the positivity for IgA aB2GP1. Forty-six samples were positive for IgA aB2GP1 (group 1) and 46 negative for IgA aB2GP1 (group 2). All samples were anonymized to study polymorphism Val/Leu²⁴⁷ and polymorphism Trp/Ser³¹⁶.

RESULTS

No significant differences were observed between those who were positive or negative for IgA aB2GP1 in patients with renal failure treated with hemodialysis and the polymorphism located in codons 247 and 316.

CONCLUSIONS

The two groups of patients have the same prevalence in polymorphisms 247 and 316, and therefore there appears not to be a genetic predisposition in our population. New trigger factors must be studied.

Profile of patients with uveitis referred to a multidisciplinary unit in northern Spain

OBJECTIVE

To describe the main characteristics of a cohort of patients with uveitis referred to a multidisciplinary unit in northern Spain.

MATERIAL AND METHODS

Retrospective analysis of clinical records of patients evaluated in the Multidisciplinary Unit of the Navarra Hospital Complex from the period January 2010 until March 2015. An analysis was performed on the demographic characteristics, origin, types of uveitis, laterality, and aetiology. The present series was also compared with 2 previous series from Castilla y León and Barcelona.

RESULTS

A total of 500 patients were identified, with a mean age of 47.9±16.4 years, with 50% women. The most frequent type of uveitis was anterior uveitis (65.4%), followed by posterior uveitis (17.6%), panuveitis (15.2%), and intermediate uveitis (1.8%). The origin was unclassifiable in 31.2%, followed by non-infectious systemic disease in 29.2%. Ankylosing spondylitis was the most frequent cause in 10.8% of patients, followed by herpes infection in 9.2%, and toxoplasmosis in 7.8%, respectively. Compared with the 2other cohorts, the present cohort showed a higher proportion of unilateral anterior uveitis. Furthermore, the patients from the Navarra series had a higher prevalence of unilateral and idiopathic uveitis compared to the series from Barcelona.

CONCLUSIONS

The main characteristics of the present cohort of patients with uveitis are similar to those of patients from other regions of our country. Unilateral anterior uveitis and idiopathic uveitis were the most frequent in our series.

Eimeria ninakohlyakimovae induces NADPH oxidase-dependent monocyte extracellular trap formation and upregulates IL-12 and TNF-α, IL-6 and CCL2 gene transcription

Extracellular trap (ET) formation has been demonstrated as novel effector mechanism against diverse pathogens in polymorphonuclear neutrophils (PMN), eosinophils, mast cells, macrophages and recently also in monocytes. In the current study, we show that E. ninakohlyakimovae triggers the deliverance of monocyte-derived ETs in vitro. Fluorescence illustrations as well as scanning electron microscopy (SEM) analyses showed that monocyte-derived ET formation was rapidly induced upon exposure to viable sporozoites, sporocysts and oocysts of E. ninakohlyakimovae. Classical features of monocyte-released ETs were confirmed by the co-localization of extracellular DNA adorned with myeloperoxidase (MPO) and histones (H3) in parasite-entrapping structures. The treatment of caprine monocyte ET structures with NADPH oxidase inhibitor diphenylene iodondium (DPI) significantly reduced ETosis confirming the essential role of reactive oxygen species (ROS) in monocyte mediated ETs formation. Additionally, co-culture of monocytes with viable sporozoites and soluble oocyst antigen (SOA) induced distinct levels of cytokine and chemokine gene transcription. Thus, the transcription of genes encoding for IL-12 and TNF-α was significantly upregulated after sporozoite encounter. In contrast IL-6 and CCL2 gene transcripts were rather weakly induced by parasites. Conversely, SOA only induced the up-regulation of IL-6 and CCL2 gene transcription, and failed to enhance transcripts of IL-12 and TNF-α in vitro. We here report on monocyte-triggered ETs as novel effector mechanism against E. ninakohlyakimovae. Our results strongly suggest that monocyte-mediated innate immune reactions might play an important role in early host immune reactions against E. ninakohlyakimovae in goats.

Evaluation of three fully automated immunoassay systems for detection of IgA anti-beta 2-glycoprotein I antibodies

INTRODUCTION

In recent years, we have been witnessing increased clinical interest in the determination of IgA anti-beta 2-glycoprotein I (aB2GPI) antibodies as well as increased demand for this test. Some ELISA-based diagnostic systems for IgA aB2GPI antibodies detection are suboptimal to detect it. The aim of our study was to determine whether the diagnostic yield of modern detection systems based on automatic platforms to measure IgA aB2GPI is equivalent to that of the well-optimized ELISA-based assays.

METHODS

In total, 130 patients were analyzed for IgA aB2GPI by three fully automated immunoassays using an ELISA-based assay as reference. The three systems were also analyzed for IgG aB2GPI with 58 patients.

RESULTS

System 1 was able to detect IgA aB2GPI with good sensitivity and kappa index (99% and 0.72, respectively). The other two systems had also poor sensitivity (20% and 15%) and kappa index (0.10 and 0.07), respectively. On the other hand, kappa index for IgG aB2GPI was >0.89 in the three systems.

CONCLUSION

Some analytical methods to detect IgA aB2GPI are suboptimal as well as some ELISA-based diagnostic systems. It is important that the scientific community work to standardize analytical methods to determine IgA aB2GPI antibodies.

BEHAVIOUR OF EARLY THYROGLOBULIN AFTER TOTAL THYROIDECTOMY FOR DIFFERENTIATED THYROID CANCER

Context

The objectives of treatment of thyroid carcinoma include hormonal suppression, radioiodine ablation and follow-up with serum thyroglobulin (Tg). Tg levels should not be measured before six weeks post-thyroidectomy.

Objective

To describe the behaviour of early postoperative Tg in patients who underwent total thyroidectomy and its ability to predict the serum Tg levels after suppression.

Design

This is a retrospective cohort study.

Subjects and methods

Adult patients who underwent total thyroidectomy with at least two postoperative measurements of serum Tg, negative TgAb and concomitant serum TSH values were included. Tg, TgAb and TSH level measurements were completed two weeks postoperatively and during the follow-up period.

Results

Twenty-nine patients fulfilled all criteria. The median serum Tg level at two weeks after surgery was 3.8 ug/L (0.3 -300) with a serum TSH level of 69.9 mU/L; 11-227. At the two-week measurement, 16 (55%) patients had serum Tg levels lower than 5 ug/L and 4 patients had levels between 5-10 µg/L.

Conclusions

Postoperative early serum Tg could be an alternative to values measured six months after surgery and could be used as a predictive tool to make earlier therapeutic decisions.

Surveillance after cardiac arrest in patients with Brugada syndrome without an implantable defibrillator: An alarm effect of the previous syncope

BACKGROUND

Debate regarding the prognosis of asymptomatic patients with Brugada syndrome (BrS) is possibly affected by the selection bias of survivors of sudden cardiac arrest (SCA). We aimed to determine variables influencing surveillance after SCA.

METHODS

We analyzed a BrS cohort of 145 patients belonging to 37 families. We compared the clinical data and circumstances surrounding SCA (i.e., place of occurrence and people accompanying the subject) in 10 patients who survived an episode of SCA (Group A) vs. 27 deceased relatives (first or second degree) who suffered sudden cardiac death (SCD; Group B). Information concerning Group B was agreed upon by at least 3 relatives. A sub-analysis was performed considering families carrying a mutation in SCN5A (Group B-Mutant).

RESULTS

Syncope was unique in predicting SCA in the BrS cohort. Comparing Groups A vs. B, there were no differences in the mean age at time of SCA/SCD (46.2 [SD 17.1] vs. 39.9 [SD 14.5] years; p=0.271), gender (male 60% vs. 74.1%; p=0.442), prior cardiomyopathy (0%), administration of cardiovascular treatments (anti-hypertensive and lipid-lowering drugs; 20% vs. 14.8%; p=0.653) or conventional cardiovascular risk factors. Environmental circumstances surrounding the SCA/SCD were not significantly different between groups. Prior syncope was more frequent in Group A (80% vs. 3.7%; p<0.001) and unique in predicting surveillance (p<0.001). Group B-Mutant displayed equivalent data.

CONCLUSIONS

A previous syncope, as an alarm symptom, might contribute to better surveillance of SCA compared with subjects with SCA as the debut of BrS. The latter might behave as a factor of selection bias.

A C60-aryne building block: synthesis of a hybrid all-carbon nanostructure

Covalent all-carbon few layer graphene and [60]fullerene conjugates can be easily formed from a versatile [60]fullerene-benzyne building block.

Targeting essential Eimeria ninakohlyakimovae sporozoite ligands for caprine host endothelial cell invasion with a phage display peptide library

Eimeria ninakohlyakimovae is an important coccidian parasite of goats which causes severe diarrhoea in young animals. Specific molecules that mediate E. ninakohlyakimovae host interactions and molecular mechanisms involved in the pathogenesis are still unknown. Although strong circumstantial evidence indicates that E. ninakohlyakimovae sporozoite interactions with caprine endothelial host cells (ECs) are specific, hardly any information is available about the interacting molecules that confer host cell specificity. In this study, we describe a novel method to identify surface proteins of caprine umbilical vein endothelial cells (CUVEC) using a phage display library. After several panning rounds, we identified a number of peptides that specifically bind to the surface of CUVEC. Importantly, caprine endothelial cell peptide 2 (PCEC2) and PCEC5 selectively reduced the infection rate by E. ninakohlyakimovae sporozoites. These preliminary data give new insight for the molecular identification of ligands involved in the interaction between E. ninakohlyakimovae sporozoites and host ECs. Further studies using this phage approach might be useful to identify new potential target molecules for the development of anti-coccidial drugs or even new vaccine strategies.

Differential Responses of the Septal Ventricle and the Atrial Signals During Ongoing Entrainment: A Method to Differentiate Orthodromic Reciprocating Tachycardia Using Septal Accessory Pathways From Atypical Atrioventricular Nodal Reentry

BACKGROUND

Differential diagnosis between tachycardia mediated by septal accessory pathways (AP) and atypical atrioventricular nodal reentry can be challenging. We hypothesized that an immediate versus delayed pace-related advancement of the atrial electrogram, once the local septal parahisian ventricular electrogram (SVE) has been advanced, may help in this diagnosis.

METHODS AND RESULTS

We focused on differential timing between SVE and atrial signals at the initiation of continuous right ventricular apical pacing during tachycardia. SVE advancement preceding atrial reset was defined as SVE advanced by the paced wave fronts while atrial signal continued at the tachycardia cycle. We analyzed 51 atypical atrioventricular nodal reentry (45% posterior type) and 80 AP tachycardias (anteroseptal [10], parahisian [18], midseptal [12], and posteroseptal [40]). SVE advancement preceding atrial reset was observed in 98% of atrioventricular nodal reentries during 4±1.1 cycles; this phenomena was observed in 6 (8%) of the atrioventricular reentrant tachycardia mediated by septal AP (P<0.001; sensitivity 98%; specificity 93%; positive predictive value 90%; negative predictive value 99%) and lasted 1 single cycle (P<0.001). Right posteroseptal AP tachycardias were distinctly characterized by atrial reset preceding SVE advancement (with ventricular fusion; specificity 100%; positive predictive value 100%). In 11 cases, it was impossible to achieve sustain entrainment. In all of them, the differential responses at the entrainment attempt allowed for appropriate diagnosis.

CONCLUSIONS

The differential response of the SVE and the atrial electrogram at the initiation of continuous right ventricular apical pacing during tachycardia effectively distinguishes between atypical atrioventricular nodal reentry and atrioventricular reentrant tachycardia mediated by septal APs.

Correlation between serum levels of vascular endothelial growth factor-C and sentinel lymph node status in early breast cancer

Axillary lymph nodes status is the most important prognosis factor in early breast cancer. This status is known by a selective sentinel lymph node biopsy (SLNB) and/or lymphadenectomy. Immunohistochemical studies of breast cancer tumour tissue have reported a relation between the increased expression of vascular endothelial growth factor-C (VEGF-C) and the risk of lymph node metastasis. We researched whether serum levels of VEGF-C could be a predictor factor of sentinel lymph node status in these patients. A prospective analysis was performed on serum from 174 patients with early breast cancer who underwent SLNB. The level of VEGF-C was determined by enzyme-linked immunosorbent assay. Clinical-pathologic variables were collected. Univariate analysis and multivariate logistic regression were conducted, taking SLNB positivity as the segmentation variable. The predictive value of VEGF-C was assessed using ROC curves. Of the sample group of 167 patients, 64 (38.3 %) had affected lymph node. Eighteen patients (28.1 %) presented micrometastasis; there were isolated tumour cells in 11 cases (17.2 %) and macrometastasis in 35 (54.6 %). The median value of VEGF-C was 6561.5 pg/ml. These values did not correlate with any clinical variables, and there was no association between the level of VEGF-C and SLNB status (p = 0.626). In the multivariate analysis, tumour size (p = 0.009) and the presence of vascular invasion (p < 0.001) were independently associated with sentinel lymph node affected. Serum levels of VEGF-C do not appear to predict sentinel lymph node status in patients with early breast cancer who undergo SLNB.

Virological and serological characterization of vaccinated and non-vaccinated piglet subpopulations coming from vaccinated and non-vaccinated sows

The present study describes the virological and serological profiles of PCV2 vaccinated (V) and non-vaccinated (NV) piglet subpopulations coming from V and NV sows in a PCV2 subclinically infected farm. Four hundred seventy-six piglets born from V or NV sows were further subdivided in a total of four groups: NV sows-NV pigs (NV-NV), NV sows-V pigs (NV-V); V sows-NV pigs (V-NV) and V sows-V pigs (V-V). Seventy-five pigs were randomly selected at the beginning of the trial from each group and they were bled at 4, 8, 12, 16, 21 and 25 weeks of age. All animals included in the trial were weighed at 4 and 25 weeks of age and their average daily weight gain (ADWG) was calculated. Serum samples obtained at different time points were used to assess PCV2 infection (viremia) and the level of antibodies by means of immunoperoxidase monolayer assay (IPMA) against this pathogen. IPMA titers (classified in high, medium or low) and PCR results (positive or negative) were analyzed using a multiple correspondence and K-means cluster analysis. According to these tests, animals included in the study were classified into the following four clusters: (1) 93 piglets that were viremic mainly from 12 to 25 weeks of age and with PCV2 antibody titers increasing over time; (2) 75 piglets with late PCV2 infection and seroconversion (later than 16 weeks of age); (3) 26 piglets with high but decreasing PCV2 antibody titers and low percentages of PCV2 PCR positive serum samples; and (4) 105 piglets with medium and high IPMA titers throughout the trial and sporadic PCR positive samples. The defined subpopulations of piglets were observed in all experimental groups (NV-NV, NV-V, V-NV and V-V) although in variable percentages. Thus, animals from clusters 1 and 2 belonged mainly to the NV-NV and V-NV groups and animals from clusters 3 and 4 were distributed mainly into the NV-V and V-V groups. Finally, the ADWG of pigs belonging to clusters 3 and 4 was significantly higher (p=0.02) than that of pigs belonging to clusters 1 and 2. Within each cluster, no statistically significant differences were found in ADWG between treatment groups.

Anaphylaxis in Adolescent/Adult Patients Treated in the Emergency Department: Differences Between Initial Impressions and the Definitive Diagnosis

OBJECTIVES

To contrast the initial suspected etiology of anaphylaxis with the postworkup diagnosis in patients attended at the emergency department (ED) of a tertiary-level hospital in Spain and to investigate the incidence, causes, and management of anaphylaxis.

METHODS

We performed an observational study of patients aged more than 15 years who came to the ED with anaphylaxis between 2009 and 2010. All clinical records from the ED were reviewed. We recorded data on clinical management, the etiology proposed by the attending emergency physician, and the cause reported by the patient. The findings were compared with the diagnosis reached after the allergy workup.

RESULTS

The incidence of anaphylaxis was 0.08%. The most common manifestation was skin-mucosal symptoms (98.3%). Anaphylaxis was diagnosed in the ED in only 44% of the cases, regardless of severity. Only 39.7% received epinephrine, which was administered more frequently when the ED physician diagnosed anaphylaxis, regardless of severity. A total of 60 patients were subsequently seen at the allergy department. The final etiology differed from the initial suspicion in the ED in 45% of cases. The frequency of anaphylaxis of uncertain origin decreased from 33.3% to 13.3%. After the allergy workup, drugs (41.7%) were considered the main cause of anaphylaxis, followed by food (25%).

CONCLUSIONS

The incidence of anaphylaxis (0.08%) was double that estimated in the ED. Anaphylaxis is underdiagnosed. A correct diagnosis conditions the administration of epinephrine, regardless of the severity of symptoms. The real etiology of anaphylaxis should only be proposed after an allergy workup, which is recommended in all cases, as the real cause can differ considerably from the initial impression in the ED.

Bone turnover markers as predictive indicators of outcome in patients with breast cancer and bone metastases treated with bisphosphonates: results from a 2-year multicentre observational study (ZOMAR study)

BACKGROUND

We evaluated the evolution and predictive value of bone turnover markers (BTMs) and circulating tumor cells (CTCs) with respect to mortality, disease progression (DP) and skeletal-related events (SREs), in patients with bone metastatic breast cancer (BmBCa). The correlation between BTMs and CTCs was also studied.

METHODS

In a 2-year observational, multicenter study, the levels of three BTMs (N- and C-terminal telopeptides of collagen I [NTX and αα-CTX], and bone-specific alkaline phosphatase [BSAP]) and CTCs were analyzed every three months. Patients received zoledronic acid (4mg every 28days) from the baseline visit.

RESULTS

234 patients were analyzed. The levels of the BTMs were increased at baseline and significantly decreased after 3months (P<0.05). In the Cox regression univariate analyses significant hazard ratios (HRs) for death were found for pathological BSAP values at baseline (5.03 [95% CI: 1.214-20.839; P=0.0259]) and at 3months (3.41 [95% CI: 1.367-8.498; P=0.0085]). HRs >2 were found for increased baseline and 3-month levels of NTX and CTC (P<0.05). Only increased baseline BSAP levels were associated with DP (HR=2.25 [95% CI: 1.391-3.626; P=0.0009]). No biomarker was associated with SREs. In the multivariate analysis, pathologic levels at 3months of NTX and BSAP were significantly associated with mortality (HRs=3.59 [95% CI: 1.375-9.382; P=0.0091] and 3.25 [95% CI: 1.293-8.189; P=0.0120], respectively). CTC and BSAP were correlated during all study timepoints (P<0.05).

CONCLUSIONS

Baseline levels of NTX, BSAP and CTCs, and changes after treatment initiation with bisphosphonates, may be useful for the prognostic assessment of patients with BmBCa. BSAP showed the strongest prognostic value.

Time-dependent responses to provocative testing with flecainide in the diagnosis of Brugada syndrome

BACKGROUND

Time-dependent variability of electrocardiogram (ECG) in patients with Brugada syndrome could affect the interpretation of provocative testing.

OBJECTIVE

The aim of this study was to characterize ECG changes during and after flecainide infusion.

METHODS

We studied 59 consecutive patients. The ECG was continuously analyzed during the first 30 minutes of provocative testing, and a single ECG was recorded 60 minutes later. We analyzed CYP2D6 and CYP3A5 variants affecting flecainide metabolism and performed blinded measurements at lead II.

RESULTS

At baseline, ECG patterns were classified as follows: type II in 31 patients (53%), type III in 15 (25%), and normal ECG in 13 (22%). Because of induction of type I ECG, the percentage of responders progressively increased with longer recording time periods (6.8% in 10 minutes vs 11.9% in 20-30 minutes vs 18.6% in 90 minutes; P < .01). Four patients displayed a late response, which was evidenced 90 minutes after the initiation of provocative testing. QRS width differentially increased between responders and nonresponders (P < .01), with a maximum QRS width of 110 ms during the first 30 minutes being effective for identifying possible late responders (sensitivity 100%; specificity 85.6%; positive predictive value 88%; negative predictive value 100%). The incidence of CYP2D6 variants was lower in late responders than in early or delayed responders (0% vs 75% vs 100%; P = .04), while a homogeneous distribution of CYP3A5*3/*3 was observed in our population.

CONCLUSION

Response to flecainide exhibits time-dependent variability of ECG patterns and intervals. Longer periods of ECG recording increase the recognition probability of type I ECG.

[Intravitreal ranibizumab in the treatment of subretinal neovascularization in a case of punctate inner choroidopathy]

CASE REPORT

We report the case of a 28-year old woman suffering loss of visual acuity in her left eye, who presented an image suggestive of a subretinal neovascular membrane in her left eye, and bilateral retinal lesions compatible with punctate inner choroidopathy (PIC). She was treated with intravitreal ranibizumab obtaining excellent results.

DISCUSSION

The differential diagnosis must be made between PIC and the rest of "white dot syndromes" and the presumed ocular histoplasmosis syndrome (POHS). Antiangiogenic drugs may be a good alternative for the treatment of such diseases when they develop a subretinal neovascular membrane.

Analysis of the factors affecting blood loss in percutaneous nephrolithotomy: a registry of the Spanish Association of Urology in the supine position

OBJECTIVE

Percutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for removing renal stones larger than 2 cm. This study has aimed to identify the different variables that might influence decrease of hemoglobin during the surgery performed in supine position.

MATERIAL AND METHODS

A prospective, multicenter, observational study of supine PCNL, based on the Spanish Association of Urology database, was analyzed. The different preoperative and postoperative factors that might affect the decrease of hemoglobin were assessed: demographics and anthropometric data, comorbidities, size and location of the stones, anatomical variants and technical aspects of the procedure.

RESULTS

From September 2008 to December 2012, 397 supine PCNL procedures performed in 15 Spanish centers were registered. Mean hemoglobin decrease was 2.3±1.5 g/dl and overall blood transfusion rate was 5.5%. No statistically significant differences were found between genders, body mass index (BMI) and age in terms of blood loss. There were also no differences between patients with cardiovascular, hypertensive, diabetic and anticoagulant treatment background. Blood loss was not significantly influenced by stone size and location. Technical aspects of the procedure as operative time (> 120 min ≤), access to the pelvi-caliceal system (ultrasound, fluoroscopy), percutaneous tract dilation technique (Alken, balloon or Amplatz) or placement of nephrostomy (tube versus tubeless) were not associated with differences in pre-op/post-op hemoglobin. Only multiple percutaneous tracts (≥2) and middle calix access were statistically significantly (P=.03 and P=.01) related with less blood loss.

CONCLUSIONS

PCNL in supine position is a minimally invasive procedure for removal of large (≥2 cm) and multiple renal stones, with a low incidence of blood loss and minimal transfusion rate. Multiple percutaneous tracts and middle calix puncture were the only statistically significant variables associated with decrease in hemoglobin levels.