Mesalazine dose modification based on faecal calprotectin levels in patients with ulcerative colitis in clinical remission

BACKGROUND

Faecal calprotectin (FC) shows an excellent correlation with endoscopic and histological activity of ulcerative colitis (UC) and it is the best predictor of clinical relapse. Our aim was to evaluate the usefulness of modifying the dose of mesalazine based on FC levels, in clinical practice.

METHODS

Retrospective, single-centre study in UC patients in clinical remission while treated with mesalazine which dosage was decreased (DOWN) or increased (UP) according to FC levels. The main endpoint was the long-term maintenance of clinical remission.

RESULTS

A total of 56 patients were included (39 DOWN, 17 UP). In the DOWN group, the median baseline dose of mesalazine was 3.6g/day and the median baseline FC was 36μg/g. After a median follow-up of 22 months, 28% required rescue therapy. The cumulative relapse-free survival after tapering was 91% and 82% at 12 and 24 months, respectively. In the UP group, the median baseline dose of mesalazine was 2.4g/day, with a median baseline FC of 524μg/g. After a median follow-up of 12 months, 29% required rescue therapy. The cumulative relapse-free survival after dose increase was 86% and 72% at 12 and 24 months, respectively.

CONCLUSIONS

Mesalazine dose modification based on FC monitoring seems to be a safe strategy in patients with UC in clinical remission, with a probability of clinical relapse around 20% at two years.

[Prevalence of microbiologically-confirmed influenza in patients with influenza-like illness in primary care and clinical and epidemiological characteristics]

OBJECTIVE

We evaluated the prevalence of microbiologically-confirmed influenza infection among patients with influenza-like symptoms and compared the clinical and epidemiological characteristics of patients with and without influenza infection.

METHODS

Retrospective study of a cohort of patients with influenza-like symptoms from 2016 to 2018 who participated in a clinical trial in thirteen urban primary centres in Catalonia. Different epidemiological data were collected. Patients rated the different symptoms and signs on a Likert scale (absent, little problem, moderate problem and severe problem) and self-reported the measure of health status with the EuroQol visual analogue scale. A nasopharyngeal swab was taken for microbiological isolation of influenza and other microorganisms.

RESULTS

A total of 427 patients were included. Microbiologically confirmed influenza was found in 240 patients (56.2%). The percentage of patients with moderate-to-severe cough, muscle aches, tiredness and dizziness was greater among patients with microbiologically confirmed influenza. The self-reported health status was significantly lower among patients with true flu infection (mean of 36.3 ± 18.2 vs 41.7 ± 17.8 in patients without influenza; p<0.001).

CONCLUSIONS

Clinical findings are not particularly useful for confirming or excluding the diagnosis of influenza when intensity is not considered. However, the presence of moderate-to-severe cough, myalgias, tiredness and dizziness along with a poor health status is more common in patients with confirmed flu infection.

Treatment Adherence and Clinical Outcomes of Patients with Inflammatory Bowel Disease on Biological Agents During the SARS-CoV-2 Pandemic

BACKGROUND

The outbreak of COVID19 evolved rapidly into a global pandemic, forcing hospitals, including inflammatory bowel disease (IBD) referral units, to change their practices to ensure quality of care.

AIMS

To describe the clinical outcomes and the fulfilment of the treatment schedule of patients with IBD treated with biological agents in a single-center of a red-zone of the pandemic, and to report the patients' perceptions about COVID-19 and the measures adopted at our center.

METHODS

Therapeutic adherence and clinical outcomes were collected for all patients undergoing treatment with intravenous biologicals and subcutaneous biologicals at our center. A telephone survey was also performed to assess these patients' perceptions of the COVID pandemic and the related measures adopted at their IBD unit.

RESULTS

A total of 234 patients were included (117 on intravenous and 117 on subcutaneous biologicals). Only 10% of patients postponed intravenous infusions intentionally and 5% postponed the collection of subcutaneous biologicals at the hospital pharmacy. Only five confirmed COVID-19 cases were registered (2.1%), all of them of mild severity. One hundred and fifty-five patients participated in the survey (77 on intravenous and 78 on subcutaneous drugs). Fear of going to the hospital was the most common reason for postponing biological administrations. Among those on combination therapy, only 7% admitted to have withdrawn immunosuppressants.

CONCLUSIONS

Adherence to intravenous and subcutaneous biological therapies during the pandemic was high in a single-center cohort of IBD patients even though the cumulative incidence of confirmed COVID-19 was low.

Update on management of invasive candidiasis

Given the growing incidence of invasive candidiasis in critically ill and haemato-oncological patients and its poor outcomes, an early diagnosis and treatment are need for get a better prognosis. This document reviews the current ap-proaches that help in diagnosis of invasive candidiasis based on culture-independent microbiological tests. The combination of clinical prediction scores with fungal serological markers could facilitate the approach in antifungal therapy, optimiz-ing it. This article also reviews the epidemiology and primary risk factors for invasive candidiasis in these patients, updating the therapeutic approach algorithms in both clinical contexts based on the main evidence and international guidelines.

Postinfection Activity of Synthetic Antimicrobial Peptides Against Stemphylium vesicarium in Pear

Brown spot of pear is a fungal disease of economic importance caused by Stemphylium vesicarium that affects the pear crops in Europe. Due to the characteristics of this disease and the moderate efficacy of available fungicides, the effectiveness of control measures is very limited; however, synthetic antimicrobial peptides (AMPs) may be a complement to these fungicides. In the present study, 12 AMPs of the CECMEL11 library were screened for fungicidal activity against S. vesicarium. In vitro experiments showed that eight AMPs significantly reduced the germination of conidia. The most effective peptides, BP15, BP22, and BP25, reduced fungal growth and sporulation at concentrations below 50 μM. Leaf assays showed that preventive application of BP15 and BP22 did not reduce infection; however, when the peptides were applied curatively, infection was significantly reduced. The use of a BP15 fluorescein 5-isothiocyanate conjugate revealed that the peptide binds to hyphae and germ tubes and produces malformations that irreversibly stop their development.

[Health-care workload and instructional capacity of Spanish hospitals accredited to train residents in anesthesiology]

OBJECTIVES

To describe the health-care workload and instructional capacity of Spanish hospitals accredited to train anesthesiology residents.

METHODS

Survey of supervisors of anesthesiology residents in 2008 to determine caseloads in surgery and obstetrics as well as in pain clinics and critical care units. The results are presented for different Spanish autonomous communities. The maximum theoretical capacity for instruction in accordance with European guidelines is calculated.

RESULTS

The 100 hospitals surveyed train 325 residents per year and could theoretically increase the training opportunities they offer, within certain limits. Given optimal distribution of resources, the system could train 397 residents per year in pediatric surgery in 3-month rotations, 442 residents in neurosurgery in 2-month rotations, and 479 residents in thoracic surgery in 1-month rotations. Some Spanish communities presently have problems giving training in the settings of pediatric, thoracic, and major outpatient surgery. Furthermore, even though anesthesiologists are presently responsible for 41.6% of available critical care beds, 46 hospitals do not have a sufficient number of beds to give training in this setting. This shortage may have negative repercussions on the accreditation of training programs.

CONCLUSIONS

Although certain limitations were found, the survey showed that the training capacity of the system is greater than accreditation suggests. It would therefore be possible to increase the number of residents.

Ehlers-Danlos syndrome and periventricular nodular heterotopia in a Spanish family with a single FLNA mutation

BACKGROUND

The Ehlers-Danlos syndrome (EDS) comprises a group of hereditary connective tissue disorders. Periventricular nodular heterotopia (PNH) is a human neuronal migration disorder characterised by seizures and conglomerates of neural cells around the lateral ventricles of the brain, caused by FLNA mutations. FLNA encodes filamin A, an actin binding protein involved in cytoskeletal organisation. The amino-terminal actin binding domain (ABD) of filamins contains two tandem calponin homology domains, CHD1 and CHD2.

OBJECTIVE

To report clinical and genetic analyses in a Spanish family affected by a connective tissue disorder suggestive of EDS type III and PNH.

METHODS

A clinical and molecular study was undertaken in the three affected women. Clinical histories, physical and neurological examinations, brain magnetic resonance imaging studies, and skin biopsies were done. Genetic analysis of the FLNA gene was undertaken by direct sequencing and restriction fragment length polymorphism analysis.

RESULTS

Mutation analysis of the FLNA gene resulted in the identification of a novel mutation in exon 3 (c.383C-->T) segregating with the combination of both syndromes. This mutation results in a substitution of an alanine residue (A128V) in CHD1.

CONCLUSIONS

The findings suggest that the Ala128Val mutation causes the dual EDS-PNH phenotype. This association constitutes a new variant within the EDS spectrum. This is the first description of a familial EDS-PNH association with a mutation in FLNA.

Determination of enro?oxacin and its primary metabolite, cipro?oxacin, in pig tissues. Application to residue studies

A simple and sensitive HPLC method has been developed for the simultaneous determination of enrofloxacin (ENR) and ciprofloxacin (CIP) in pig tissue using difloxacin (DIF) as internal standard. Tissue sample preparations were carried out by adding phosphate buffer (pH 7.4, 0.1 m), followed by extraction with trichloromethane. Fluoroquinolones were separated on a reversed-phase column and eluted with aqueous buffer solution-acetonitrile (80:20, v/v). The concentrations of CIP, ENR and DIF eluted from the column, with retention times of 2.20, 2.73 and 4.38 min, respectively, were monitored by fluorescence detection at lambda(ex) 276 and lambda(em) 442 nm. The detection and quantitation limit were 8 and 25 ng/g, respectively, for both compounds. Standard curves were linearly related to concentration in the range 25-400 ng/g. The consequences of the introduction of minor reasonable variations (ruggedness studies) have also been analysed. Finally, the measurement of the tissue levels of ENR and CIP in the pig tissues after oral administration confirmed the utility of the proposed method.

The therapeutic role of 5-HT1A and 5-HT2A receptors in depression

The selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed antidepressant drugs, because they are well tolerated and have no severe side effects. They rapidly block serotonin (5-HT) reuptake, yet the onset of their therapeutic action requires weeks of treatment. This delay is the result of presynaptic and postsynaptic adaptive mechanisms secondary to reuptake inhibition. The prevention of a negative feedback mechanism operating at the 5-HT autoreceptor level enhances the neurochemical and clinical effects of SSRIs. The blockade of 5-HT2A receptors also seems to improve the clinical effects of SSRIs. These receptors are located postsynaptically to 5-HT axons, mainly in the neocortex. Pyramidal neurons in the prefrontal cortex are particularly enriched in 5-HT2A receptors. Their blockade may affect the function of prefrontal-subcortical circuits, an effect that probably underlies the beneficial effects of the addition of atypical antipsychotic drugs, which are 5-HT2A receptor antagonists, to SSRIs in treatment-resistant patients.

Nocardia otitidiscaviarum (GAM-5) induces parkinsonian-like alterations in mouse

Parkinson's disease, a major neurodegenerative disorder in humans whose etiology is unknown, may be associated with some environmental factors. Nocardia otitidiscaviarum (GAM-5) isolated from a patient with an actinomycetoma produced signs similar to Parkinson's disease following iv injection into NMRI mice. NMRI mice were infected intravenously with a non-lethal dose of 5 x 10(6) colony forming units of N. otitidiscaviarum (GAM-5). Fourteen days after bacterial infection, most of the 60 mice injected exhibited parkinsonian features characterized by vertical head tremor, akinesia/bradykinesia, flexed posture and postural instability. There was a peak of nocardial growth in the brain during the first 24 h followed by a decrease, so that by 14 days nocardiae could no longer be cultured. At 24 h after infection, Gram staining showed nocardiae in neurons in the substantia nigra and occasionally in the brain parenchyma in the frontal and parietal cortex. At 21 days post-infection, tyrosine hydroxylase immunolabeling showed a 58% reduction of tyrosine hydroxylase in the substantia nigra, and a 35% reduction of tyrosine hydroxylase in the ventral tegmental region. Dopamine levels were reduced from 110 +/- 32.5 to 58 +/- 16.5 ng/mg protein (47.2% reduction) in brain from infected mice exhibiting impaired movements, whereas serotonin levels were unchanged (191 +/- 44 protein in control and 175 +/- 39 ng/mg protein in injected mice). At later times, intraneuronal inclusion bodies were observed in the substantia nigra. Our observations emphasize the need for further studies of the potential association between Parkinson's disease or parkinsonism-like disease and exposure to various nocardial species.

Sedación en la endoscopia digestiva. Resultados de una encuesta hospitalaria en Cataluña

INTRODUCTION

The need for sedation is increasing in digestive endoscopy units (DEU). There are no data on the use of sedation in DEU in Catalonia (Spain).

OBJECTIVE

To evaluate the use of sedation in DEU in Catalonia.

MATERIAL AND METHOD

A questionnaire on the practice of sedation was designed and sent to the heads of medical and nursing staff of the DEU of 63 public and private hospitals in Catalonia. Two mailings were sent with an interval of three months between each. The questionnaire included 62 items on the characteristics of the hospital and the DEU, number of explorations, frequency of sedation use, drugs employed, participation of an anesthesiologist, use of monitoring, and complications.

RESULTS

Forty-four DEU (70%) corresponding to 31 public hospitals and 13 private hospitals completed the questionnaire. Evaluation of sedation patterns was based on 105,904 explorations performed in the various DEU (56,453 gastroscopies, 47,278 colonoscopies and 2,173 endoscopic retrograde cholangiopancreatographies (ERCP) in 2001. Sedation, sedation-analgesia or anesthesia was used in 17% of gastroscopies, 61% of colonoscopies and 100% of ERCP. Sedation was administered by an anesthesiologist in 7% of gastroscopies, 25% of colonoscopies and 38% of ERCP. Anesthesiologist administration was more frequent in private than in public centers (gastroscopies: 25% vs. 2%; colonoscopies: 57% vs. 9%, p < 0.001). No deaths associated with the use of sedation were reported. Eighty-nine percent of the DEU complied with standard recommendations for the practice of sedation.

CONCLUSIONS

In Catalonia, the use of sedation is highly variable, depending on the endoscopic procedure and the DEU. Use of sedation in infrequent in gastroscopy, fairly widespread in colonoscopy and routine in ERCP. Anesthesiologist administration is significantly more frequent in private hospitals. Most DEU follow standard sedation practices.

Pubic bone anchoring devices for the surgical treatment of urinary stress incontinence in patients with severe genital prolapse

The aim of this study was to test a surgical technique for the treatment of stress urinary incontinence associated with genital prolapse through a transvaginal suspension anchored to the pubic bone. Thirty-seven patients with severe genital prolapse and urodynamically proven stress incontinence were operated on with this procedure from February 1998 to May 2000. Preoperatively a detailed history, pelvic examination and urodynamic studies were carried out. The degree of prolapse was assessed pre- and postoperatively in the lithotomy position in accordance with the classification proposed by Baden and Walker [8]. Two titanium bone screws with no. 1 polypropylene sutures attached to them and a battery-operated screw inserter are used to fix the vaginal sutures to the pubic bone bilaterally. The procedure is performed transvaginally with no abdominal or suprapubic incisions. Objective outcomes were assessed by symptom assessment, clinical examination and a full urodynamic evaluation at 6 months postoperatively, and annually by clinical evaluation. Subjective outcomes were assessed by directly interviewing the patients about their postoperative urinary symptoms and asking them to classify their level of satisfaction. An objective cure rate (no objective loss of urine during coughing in the absence of a simultaneous detrusor contraction) at the 6-month postoperative urodynamic evaluation was observed in 23 of 37 patients (62%). Recurrent anterior vaginal wall prolapse (grade 2) had developed in 7 of 37 patients (27%). Subjectively, 73% of the patients expressed satisfaction with the procedure. Early results using two bone screws into the pubis to fix the periurethral and perivesical tissues and vagina to the posterior surface of the pubic bone were disappointing. Based on our results we have abandoned the use of this procedure to correct stress incontinence associated with severe genital prolapse.

Molecular characterization of two natural hotspots in the Drosophila buzzatii genome induced by transposon insertions

Transposable elements (TEs) have been implicated in the generation of genetic rearrangements, but their potential to mediate changes in the organization and architecture of host genomes could be even greater than previously thought. Here, we describe the naturally occurring structural and nucleotide variation around two TE insertions in the genome of Drosophila buzzatii. The studied regions correspond to the breakpoints of a widespread chromosomal inversion generated by ectopic recombination between oppositely oriented copies of a TE named Galileo. A detailed molecular analysis by Southern hybridization, PCR amplification, and DNA sequencing of 7.1 kb surrounding the inversion breakpoints in 39 D. buzzatii lines revealed an unprecedented degree of restructuring, consisting of 22 insertions of ten previously undescribed TEs, 13 deletions, 1 duplication, and 1 small inversion. All of these alterations occurred exclusively in inverted chromosomes and appear to have accumulated after the insertion of the Galileo elements, within or close to them. The nucleotide variation at the studied regions is six times lower in inverted than in noninverted chromosomes, suggesting that most of the observed changes originated in only 84,000 years. Galileo elements thus seemed to promote the transformation of these, otherwise normal, chromosomal regions in genetically unstable hotspots and highly efficient traps for transposon insertions. The particular features of two new Galileo copies found indicate that this TE belongs to the Foldback family. Together, our results strengthen the importance of TEs, and especially DNA transposons, as inducers of genome plasticity in evolution.

Molecular characterization of two natural hotspots in the Drosophila buzzatii genome induced by transposon insertions

Transposable elements (TEs) have been implicated in the generation of genetic rearrangements, but their potential to mediate changes in the organization and architecture of host genomes could be even greater than previously thought. Here, we describe the naturally occurring structural and nucleotide variation around two TE insertions in the genome of Drosophila buzzatii. The studied regions correspond to the breakpoints of a widespread chromosomal inversion generated by ectopic recombination between oppositely oriented copies of a TE named Galileo. A detailed molecular analysis by Southern hybridization, PCR amplification, and DNA sequencing of 7.1 kb surrounding the inversion breakpoints in 39 D. buzzatii lines revealed an unprecedented degree of restructuring, consisting of 22 insertions of ten previously undescribed TEs, 13 deletions, 1 duplication, and 1 small inversion. All of these alterations occurred exclusively in inverted chromosomes and appear to have accumulated after the insertion of the Galileo elements, within or close to them. The nucleotide variation at the studied regions is six times lower in inverted than in noninverted chromosomes, suggesting that most of the observed changes originated in only 84,000 years. Galileo elements thus seemed to promote the transformation of these, otherwise normal, chromosomal regions in genetically unstable hotspots and highly efficient traps for transposon insertions. The particular features of two new Galileo copies found indicate that this TE belongs to the Foldback family. Together, our results strengthen the importance of TEs, and especially DNA transposons, as inducers of genome plasticity in evolution.

Somatostatin receptor scintigraphy predicts impending cardiac allograft rejection before endomyocardial biopsy

The invasive nature of endomyocardial biopsy has led to a search for alternative diagnostic modalities for the detection of cardiac allograft rejection. To date, no non-invasive test meets all the requirements for the detection of acute and chronic rejection. The rejection process usually presents with lymphocyte infiltration with or without myocyte necrosis, which indicates the severity of cardiac allograft rejection and the necessity of treatment. Activated lymphocytes express somatostatin receptors; thus somatostatin receptor imaging could be used to target them. The aim of this study was to assess the feasibility of using somatostatin receptor imaging to target activated lymphocytes in the process of cardiac allograft rejection. Thirteen somatostatin receptor imaging studies were performed on ten cardiac allograft recipients 12-4,745 days after transplantation, simultaneously with endomyocardial biopsy, to assess the imaging of activated lymphocytes in comparison with histological findings. Somatostatin receptor imaging was performed 4 h after the injection of 110 MBq of the somatostatin analogue indium-111 pentetreotide. 111In-pentetreotide uptake was visually scored and semi-quantitatively estimated by the calculation of a heart-to-lung ratio (HLR). The visual score correlated with the HLR. Intense/moderate uptake on visual assessment and an HLR >1.6 was observed in eight studies. In three of these studies there was significant rejection in the simultaneous endomyocardial biopsy [International Society of Heart and Lung Transplantation (ISHLT) rejection grade 3A/4]. Intense/moderate uptake was associated with mild or no rejection in the remaining five patients, and in four of them the next endomyocardial biopsy performed 1 week later demonstrated significant rejection requiring treatment. Two patients with low uptake and an HLR <1.6 had no evidence of rejection either in the simultaneous endomyocardial biopsy or in the endomyocardial biopsy performed the following week. These preliminary results indicate the feasibility of targeting activated lymphocytes with somatostatin receptor imaging in the detection of cardiac allograft rejection. Somatostatin receptor imaging may predict impending rejection at least 1 week before the endomyocardial biopsy becomes positive. The late appearance of diagnostic endomyocardial biopsy probably reflects a lag-time between lymphocytic activation and induction of myocyte damage. Furthermore, somatostatin receptor imaging at 4 h may in any case allow earlier intervention in the event of rejection, given the time required for histological processing of endomyocardial biopsy.

Description of a DNA amplification procedure for the detection of bacteriophages of Bacteroides fragilis HSP40 in environmental samples

A molecular test based on DNA amplification by PCR was developed for the detection of bacteriophages of Bacteroides fragilis strain HSP40 in the environment. These specific phages are associated with faecal contamination of human origin. A homologous DNA region of 1.5 kb, identified previously by hybridisation, was used to design primers for the detection of B. fragilis HSP40 phages. A nested-PCR procedure for the DNA amplification of those phages was developed. The sensitivity of the nested-PCR was between 10(-1) and 10(-2) PFU for purified HSP40 phage solutions, sewage and seawater samples, and between 1 and 10 PFU for river water samples. Specific amplification of HSP40 phages was observed when viral suspensions of 10(3) PFU/ml or lower were used. Common levels of B. fragilis phages found in sewage are 10(1)-10(2) PFU/ml. A total of 24 water samples (sewage, river water and seawater) were tested both by PCR and by plaque assay, to evaluate the efficiency of the molecular method in field samples. The data obtained by PCR in environmental samples showed good concordance with the PFU counts and a higher sensitivity.

Detection of phages infecting Bacteroides fragilis HSP40 using a specific DNA probe

Nine bacteriophage isolates of Bacteroides fragilis, obtained from urban sewage and pig faeces samples using four different host strains (HSP40, RYC4023, RYC2056 and RYC3318), were compared on the basis of morphology, host range, DNA restriction patterns, DNA hybridisation and protein composition. All the phages are siphovirus and, as judged from cleavage by restriction endonucleases, their genome is composed of double-stranded DNA of similar size ( approximately 51-kb). Host range analysis differentiated two types of phages: (1) phages that clearly infect B. fragilis strains HSP40 (B40-2, B23-1, B23-2, B23-3 and B23-4, of which B40-8 is the phage type); and (2) the group of bacteriophages that were not infectious for HSP40 (B56-1, B56-2 and B18-1). Similarity in DNA restriction patterns and protein characteristics was found in the HSP40 infectious phages. Anti-B40-8 serum recognised only the proteins of the phages of this type. Although all phages showed similar major protein sizes, minor specific bands were detected. Bacteriophages B56-1, B56-2 and B18-1 showed heterogeneity in their DNA restriction profiles although some degree of DNA-DNA homology between all genomes was observed. Southern blot analysis with phage B40-8 DNA based probes identified a 1.5-kb DNA region homologous for all HSP40 phage isolates, but absent in the genome of the other phage isolates that did not infect this bacterial strain. The homologous region was used as a specific probe to specifically detect B. fragilis HSP40 phages.

[Severe abdominal complications in patients treated with heart transplantation: the problem of clinical inexpressiveness]

INTRODUCTION

In transplanted patients, immunosuppressive drugs can mask habitual pathologies that impede their diagnoses and management. Abdominal pathology gives up to 2-20%, 50% of which is surgical, with a mortality of 10-40%. The most frequently detected pathologies are: acute pancreatitis, peptic ulceration and intestinal obstruction.

OBJECTIVES

To determine the alarm parameters, more adequate diagnostic procedures and the most frequent causes of morbidity and mortality in order to attempt to avoid them.

METHODS

In our center 225 heart transplantations were performed from May 1984 to October 1997. The severe abdominal complications, time of appearance, implication of immunosuppressive drugs and presence of rejection were studied in these patients.

RESULTS

35 severe abdominal complications were detected (incidence 12.9%), with the majority differing (> 1 year following transplant). The most frequently detected pathologies were digestive hemorrhages and perforations. Acute pancreatitis was 11%. The immunosuppressive drugs used were prednisona, cyclosporin and azathioprine. In 12 out of 29 patients the abdominal complication was in the context of acute rejection.

CONCLUSIONS

Even with some non-specific abdominal symptoms in these group of patients it is important to rule out severe pathologies such as acute pancreatitis or empty viscera perforation. The detection of amylases and lypases in the blood and an echographic or tomographic abdominal study should be performed early with a digestive hemorrhage it is important to perform an endoscopy. If the surgical intervention seems imminent it's better to perform it without any delay, because it has been demonstrated that the delay is worse than the probable rejection.

Burden of myocardial damage in cardiac allograft rejection: scintigraphic evidence of myocardial injury and histologic evidence of myocyte necrosis and apoptosis

BACKGROUND

Because myocardial damage determines morbidity and outcomes in heart transplant rejection, assessment of total burden of myocardial damage is highly desirable. In addition to myocyte necrosis, programmed cell death, or apoptosis, has recently been shown to contribute to cardiac allograft rejection. In the present study, we noninvasively determined myocardial damage by antimyosin scintigraphy and compared it with necrotic and apoptotic myocardial damage in endomyocardial biopsy (EMB) specimens.

METHODS AND RESULTS

Forty scintigraphic and histologic studies were simultaneously performed. Of these, 19 patients had no EMB evidence of allograft rejection (group I, International Society of Heart and Lung Transplantation [ISHLT] grade 0/4), 12 had mild rejection (group II, ISHLT grades 1A and 1B), and 9 had evidence of moderate allograft rejection (group III, ISHLT grades 2, 3A, and 3B). None of the biopsies demonstrated severe allograft rejection (ISHLT grade 4/4). The severity of global myocyte damage in 40 patients was assessed by antimyosin scintigraphy. Endomyocardial biopsies were performed in these patients within 48 hours of imaging study; biopsy specimens were characterized for presence of myocyte necrosis and apoptosis. Evidence of myocyte necrosis was observed in 9 (23%) of 40 EMB specimens. Nineteen EMB specimens of group I had no inflammation and no myocyte necrosis, 12 of group II specimens showed interstitial mononuclear cell infiltration (only) but no myocyte necrosis, and all 9 of group III specimens had evidence of cellular infiltration and myocyte damage. Myocyte necrosis was assessed by hematoxylin-eosin and trichrome staining of EMB specimens. On the other hand, apoptosis of myocytes, as assessed by TUNEL staining of DNA fragments, was seen in 22 (55%) of the 40 biopsy specimens: 47%, 58%, and 67% in groups I, II and III, respectively. Abnormal antimyosin scan findings, indicating presence of myocardial damage, were observed in 9 of the 19 patients in group I and in all patients in groups II and III. Although positive antimyosin scan results in group III patients are concordant with the presence of histologic myocardial necrosis, myocardial uptake of antimyosin antibodies in groups I and II (no apparent myocyte damage at light microscopic examination) could reflect either sampling error of the biopsy or ongoing apoptotic myocyte damage.

CONCLUSIONS

Apoptosis of myocytes is frequently observed during cardiac allograft rejection. The presence of apoptotic myocytes in the absence of histologic rejection activity in patients with antimyosin uptake suggests that apoptosis could be an additional mechanism of transplant-associated myocardial damage.

Postoperative pain management and recovery after remifentanil-based anaesthesia with isoflurane or propofol for major abdominal surgery. Remifentanil Study Group

We have assessed if recovery times after morphine or fentanyl, given before terminating remifentanil anaesthesia with isoflurane or propofol, are compromised. We studied patients undergoing elective, major abdominal surgery, allocated randomly to receive remifentanil and isoflurane (n = 277) or remifentanil and propofol (n = 274) anaesthesia. Twenty-five minutes before the end of surgery, patients received fentanyl 0.15 mg or morphine 15 mg in a randomized, double-blind manner followed by a second dose (fentanyl 0.05 mg, morphine 7 mg) for moderate or severe pain in recovery. Recovery was rapid and at an Aldrete score > or = 9 (median 12-15 min), 42-51% of patients reported none or mild pain. However, 26-35% of patients reported severe pain and > 90% required a second dose of opioid within 21-27 min after anaesthesia.

Chlorambucil-induced inappropriate antidiuresis in a man with chronic lymphocytic leukemia

The syndrome of inappropriate antidiuretic hormone (SIADH) has been described in patients suffering from leukemia or lymphoma involving the central nervous system. Several alkylating agents have also been associated with this syndrome. We describe a patient with chronic lymphocytic leukemia, without evidence of central nervous system involvement, who suffered from SIADH presumably caused by small doses of chlorambucil.

Viral pollution in the environment and in shellfish: human adenovirus detection by PCR as an index of human viruses

A study of the presence of human viruses (adenoviruses, enteroviruses, and hepatitis A viruses [HAVs]) in environmental and shellfish samples was carried out by applying DNA and cDNA amplification techniques by PCR. The detection of human adenoviruses by PCR was also examined as a potential molecular test to monitor viral pollution. The samples studied were urban and slaughterhouse sewage, river water, seawater, and shellfish. Enteroviruses were quantified by PFU in Buffalo green monkey kidney cells and fecal coliforms and phages of Bacteroides fragilis HSP40 were also evaluated in some of the samples. The amplification of viral DNA and cDNA has shown a high prevalence of human viruses that would not be detected by the use of classical techniques, such as the quantification of PFU in cell lines. The results of the analysis of slaughterhouse sewage samples together with the test of farm animal feces indicate that the adenoviruses and the HAVs detected in the environment are mostly of human origin. A significative correlation between the detection of human viruses by PCR and the values of bacteriophages of B. fragilis HSP40 in urban raw sewage was observed. Human adenoviruses were the viruses most frequently detected throughout the year, and all the samples that were positive for enteroviruses or HAVs were also positive for human adenoviruses. The results suggest that the detection of adenoviruses by PCR could be used as an index of the presence of human viruses in the environment where a molecular index is acceptable.

Efficacy of augmented immunosuppressive therapy for early vasculopathy in heart transplantation

OBJECTIVES

The present study was undertaken to prospectively and comparatively evaluate the role of serial myocardial perfusion imaging and coronary angiography for the detection of early vasculopathy in a large patient population and also to determine the short- and long-term efficacy of augmented immunosuppressive therapy in the potential reversal of the early vasculopathy.

BACKGROUND

Allograft vasculopathy is the commonest cause of death after the first year of heart transplantation. Anecdotal studies have reported the efficacy of augmented immunosuppressive therapy after early detection of vascular involvement. However, no prospective study has evaluated the feasibility of early detection and treatment of allograft vasculopathy.

METHODS

In 76 cardiac allograft recipients, 230 coronary angiographic and 376 scintigraphic studies were performed in a follow-up period of 8 years. Angiography was performed at 1 month and every year after transplantation, and thallium-201 scintigraphy at 1, 3, 6 and 12 months after transplantation and twice a year thereafter. Prospective follow-up of 76 patients showed that 18 developed either angiographic or scintigraphic evidence of coronary vasculopathy. All episodes were treated with 3-day methylprednisolone pulse and antithymocyte globulin.

RESULTS

Twenty-two episodes of vasculopathy were diagnosed and treated in these 18 patients. Of these 22 episodes, two were detected only by angiography, seven by both angiography and scintigraphy, four by scintigraphy and histologic evidence of vasculitis and nine episodes only by thallium-201 scintigraphy studies. Angiographic and/or scintigraphic resolution was observed in 15 of the 22 episodes (68%) with augmented immunosuppression. The likelihood of regression was higher when treatment was instituted within the first year of transplantation (92%) than after the first year (40%) (p = 0.033). Eighty percent of patients who responded to follow-up.

CONCLUSIONS

The present study suggests that early detection of allograft coronary vasculopathy is feasible with surveillance myocardial perfusion or coronary angiographic studies. When identified early after transplantation, immunosuppressive treatment may result in regression of coronary disease.

Molecular basis of antimicrobial resistance in non-typable Haemophilus influenzae

Strains of the facultative anaerobe Haemophilus influenzae, both type b and non typable strains, are frequently multiresistant. The measurement of the antibiotic permeability of Haemophilus influenzae outer membrane (OM) shows that antibiotics can cross through the OM easily. Thus, enzymatic activity or efflux pumps could be responsible for multiresistance. An efflux system closely related to AcrAB of Escherichia coli is present in Haemophilus influenzae. However, their role in multiresistance seems irrelevant. Classical mechanisms such as plasmid exchange seems to be playing a major role in the multidrug resistance in Haemophilus influenzae.

The role of outer membrane in Serratia marcescens intrinsic resistance to antibiotics

Three different porins from Serratia marcescens were described. They were named Omp1, Omp2 and Omp3 and their molecular weights were 42, 40 and 39 kDa respectively. Omp2 and Omp3 showed osmoregulation and thermoregulation in a similar way to OmpC and OmpF of Escherichia coli. Permeability coefficients of the outer membrane of this species were calculated following the Zimmermann and Rosselet method. P values were similar to those obtained in Escherichia coli, which suggests that the chromosomal beta-lactamase would play a major role in the resistance of Serratia marcescens to beta-lactam antibiotics. Both MIC values and permeabilities were modified by salycilates and acetylsalycilate. Synergism between the outer membrane and the beta-lactamase was also evaluated. When bacteria grew in the presence of a beta-lactam in the medium, the beta-lactamase accounted for most of the resistance.

[Zinc, copper, iron, calcium, phosphorus and magnesium content of maternal milk during the first 3 weeks of lactation]

Zinc, Copper, Iron. Calcium Phosphorous and Magnesium contents were determined in early milk samples in 72 mothers from Caracas city. The samples were collected during three different lactation stages: calostro (3 days), transitional (7 days) and mature milk (21 days). The more significant changes in the concentration of the studied elements were observed during the first two weeks, them they stabilize during the third week. The Zn, Cu, Fe, Ca, P and Mg average concentration found in calostro samples were 7.1 +/- 2.5 micrograms/ml; 0.52 +/- 0.15 microgram/ml; 0.49 +/- 0.14 microgram/ml; 214 +/- 62 micrograms/ml, 107 +/- 27 micrograms/ml and 33.3 +/- 7.5 micrograms/ml. respectively. For the transitional milk samples the average concentration found for the studied elements were: 4.0 +/- 1.0 micrograms/ml; 0.50 +/- 0.10 microgram/ml; 0.38 +/- 0.08 microgram/ml, 292 +/- 62 micrograms/ml; 213 +/- 36 micrograms/ml and 30.4 +/- 5.2 micrograms/ml. For the mature milk samples the results were: 2.8 +/- 2.7 micrograms/ml; 0.47 +/- 0.08 microgram/ml; 0.36 +/- 0.09 microgram/ml; 244 +/- 49 micrograms/ml; 175 +/-35 micrograms/ml and 25.2 +/- 3.3 micrograms/ml. The concentration range for all trace elements studied (Cu, Fe and Zn) can be considered normal. For the major elements (Ca, P and Mg) the results obtained in our work are similar to those reported for other countries. These facts allows to conclude that the nutritional state of this mother population is adequate to satisfy the lactate's requirements during their first live stage.

Technetium-99m-methoxyisobutylisonitrile in localization of ectopic parathyroid adenoma

Preoperative localization of ectopic parathyroid lesions is crucial for the correct treatment of patients with primary hyperparathyroidism. Invasive and noninvasive procedures, including selective venography, ultrasound, CT and MRI provide limited sensitivity in the detection of ectopic lesions. We report three patients in whom 99mTc-MIBI scintigraphy accurately detected ectopic parathyroid adenomas and was instrumental in the cure for these patients. Technetium-99m-MIBI scintigraphy provides a simple and accurate noninvasive test for the detection of ectopic parathyroid adenomas.

Outer membrane permeability of non-typable Haemophilus influenzae

The permeability to cephaloridine was studied in five Haemophilus influenzae strains (four non-typable and one type b) using the Zimmermann and Rosselet method. The beta-lactamase activity was due to a plasmid-encoded TEM-1 enzyme. High permeability coefficients were measured in all strains examined. No great differences in permeability coefficients were found, even between strains with marked differences in OMP electrophoretic profiles.

Modification by analgesics of the susceptibility to antibiotics in Serratia marcescens

The influence of analgesics at low concentrations on permeability and beta-lactamase expression have been studied "in vitro". The effect of these drugs on major outer membrane proteins and the lipopolysaccharide was evaluated. Acetylsalicylate and paracetamol induced modifications in susceptibility to a large variety of antibiotics when tested at therapeutic concentrations. The results suggested that when analgesics and antibiotics are administered simultaneously, the interaction between both kinds of drugs can alter the response of microorganisms to antibiotics.

[Eosinophilic pustular folliculitis in acquired immunodeficiency syndrome. Report of 6 cases]

Eosinophilic pustulous foliculitis (EPF) is a rare dermatosis which has been reported in association with the human immunodeficiency virus infection. Six patients infected with HIV are reported with advanced disease in whom the diagnosis of EPF was made. All patients has a highly pruritic follicular papular rash. In all cases the pathology study revealed a mixed inflammatory infiltrate with predominance of eosinophils at the infundibulum of the pilous folliculi. Two patients had eosinophilia in peripheral blood. Therapy with antihistaminic agents and topical corticosteroids was ineffective in all cases. A favourable therapeutic response was achieved with phototherapy associated with the topic application of disodium cromoglycate 4%.