[Incidence and prevalence of autoimmune hepatitis in the area of the Hospital de Sagunto (Spain)]

Thirteen cases of autoimmune hepatitis (AIH) were diagnosed from 1990 to 2003 in the area of the Hospital de Sagunto (Valencia, Spain), which attends a population of 112,003 inhabitants aged more than 14 years (54,622 males and 57,381 females). The diagnostic criteria of the International Autoimmune Hepatitis Group were used and patients who, despite having a probable diagnosis of AIH, presented hepatitis C virus infection were excluded. The diagnosis was probable in one patient and definitive in 12. All patients, 11 females and two males aged 45.9 12.2 years (range: 28-66), were classified as AIH type 1. Among the population aged more than 14 years, the mean annual incidence of AIH was 0.83 cases/100,000 inhabitants (95% CI, 0.44-1.42) (range: 0-2.68), showing a significant trend to increase (b = 0.132; p = 0.019). The incidence was higher in women than in men (RR = 5.24; 95% CI, 1.16-23.62). The mean annual incidence was 1.37 (95% CI, 0.68-2.46) (range: 0-3,49) in women and was 0.26 (95% CI, 0.02-0.96) (range: 0-1.83) in men. By age, the maximum mean annual incidence was observed in the group aged 55-64 years (1.6 cases/100,000 inhabitants). The prevalence of AIH in September 2003 was 11.61 cases/100,000 inhabitants aged more than 14 years (95% CI, 6.78-19.86). The prevalence was 3.66 (95% CI, 1-13.35) in men and was 19.17 (95% CI, 10.70-34.33) in women.

Candidiasis sistémica y tratamiento con infliximab

The use of infliximab in patients with luminal or fistulizing Crohn's disease refractory to medical treatment (steroids and immunomodulatory drugs) is increasingly widespread. Although the incidence of serious infections in patients undergoing infliximab treatment is not higher than that of controls, systemic fungal infections in patients treated with this antibody have been anecdotally described. We report a case of systemic candidiasis in a patient with refractory Crohn's disease who was treated with infliximab associated with corticosteroids and azathioprine and discuss the role that infliximab could have played in the development of this complication.

Enfermedad de Wilson con afectación neurológica grave: respuesta al tratamiento combinado con trientina y acetato de cinc

In patients with Wilson's disease and neurological manifestations, treatment with D-penicillamine can cause worsening of neurological symptoms, usually in the first few weeks of treatment. Because the neurological damage can be severe and irreversible, the use of D-penicillamine is controversial, and several authors believe that it should be avoided. Studies of the use of ammonium tetrathiomolybdate as an alternative chelating agent for the initial treatment of neurologic Wilson's disease are still in the experimental phase. Published experience on the simultaneous use of trientine, another chelating agent, and zinc, which blocks intestinal absorption of copper, is promising but limited. We present the case of a 17 year-old boy with severe neurologic Wilson's disease that had first presented six years previously. The patient showed a complete recovery after six months of treatment with a combination of trientine and zinc acetate.

Behavior of the pulmonary autograft in systemic circulation after the Ross procedure

OBJECTIVE

The purpose of this study was to evaluate performance in systemic circulation following pulmonary autograft aortic root replacement by means of serial postoperative echocardiographic studies.

METHODS

From November 1997 to November 1999, 30 patients (21 males, 9 females) with a mean age of 29.97 +/- 12.97 years (age range 6-54 years) underwent pulmonary autograft aortic root replacement. Seven of these patients (23.33%) were less than 15 years old. Postoperative echocardiographic measurements of the neo-aortic root were performed within three months of operation, at six months, one year, and annually thereafter. Analysis of this study includes 22 patients with at least three months of follow-up.

RESULTS

Operative mortality was 0%. Compared with preoperative values, the mean autograft annulus diameter exhibited an increase of 8.44% in the first month (1.44 +/- 0.22 cm/m2 vs. 1.55 +/- 0.21 cm/m2, p = 0.0101). An additional aortic annular dilation of 11.33% from baseline preoperative values was observed within the first year (1.41 +/- 0.15 cm/m2 preoperatively vs. 1.57 +/- 0.22 cm/m2, p = 0.0449). After the immediate postoperative period, the pulmonary autograft seemed to adapt to systemic circulation, and there were no differences in aortic annular size between 1-3 months after surgery and the 18-21 month follow-up period (1.60 +/- 0.18 cm/m2 vs. 1.60 +/- 0.27 cm/m2, n = 10). Diameter increase was not associated with the presence of aortic regurgitation. Mean neo-aortic maximal gradient was 7.85 +/- 5.59 mm Hg (3-29 mm Hg). There was a significant decrease in left ventricular size three months after surgery (50.71 +/- 10.20 mm preoperatively vs. 44.98 +/- 7.29 mm, p = 0.0491 in aortic stenosis patients and 68.50 +/- 8.39 mm vs. 59.04 +/- 9.21 mm, p = 0.0017 in aortic insufficiency patients).

CONCLUSIONS

Pulmonary autograft annulus increases up to the first year after the Ross procedure but does not appear to progress beyond that time. The pulmonary autograft allows optimal hemodynamic performance without causing substantial aortic regurgitation, thereby permitting normalization of left ventricular dimensions and improvement of left ventricular function early in the postoperative period.

[Aortic valve replacement with pulmonary autograft (the Ross procedure) in adult and pediatric patients]

Aortic valve replacement with pulmonary autograft was first performed by Donald Ross in 1967. Initially, the procedure was not widely accepted, by Cardiologists and Cardiac surgeons fundamentally due to its complexity and demanding surgical technique, and because innumerous series two cardiac valves were at risk. The results published in the last 10-15 years established the pulmonary autograft as one of the best methods of aortic valve replacement, especially in pediatric patients and young adults. In the present article, we reviewed present indications and contraindications, and our clinical experience with 26 patients (pediatrics and adults). Analysis of the first 22 the patients with a minimum of 6 months of follow-up (180-620 days) was performed. Follow-up is complete (100%). Mean age was 31.4 +/- 12.6 years. Five patients were pediatrics (<= 14 years). Three patients (11%) with previous percutaneous procedures and 4 patients (14%) with previous surgical procedures. There was no early or late mortality. In the last follow-up, 19 of 22 (86.36%) had no autograft insufficiency (>= grade 1), and in one patient it was moderate (grade 2). The 2 remaining patients developed severe autograft insufficiency (grade 4) and were reoperated on, with satisfactory postoperative outcome. Mean maximal gradient was 7.85 +/- 5 mmHg at 18 months (3-29). Patients with preoperative aortic stenosis showed a significant reduction in myocardial mass index (208.7 +/- 32 a 95.8 +/- 28.8 g/m2) at 18 months. In these patients, septal and posterior wall thickness decreased significantly, in the first month. Two pediatric patients have developed transpulmonar gradient > 50 mmHg. One of them underwent successful stent implantation. We have not observed significant homograft insufficiency in any of our patients. All our patients remain asymptomatic (functional class I) without medical treatment. We have not observed either thromboembolic or haemorrhagic episodes, nor endocarditis. No patient is receiving anticoagulants. Clinical and echocardiographic mid term results in pulmonary autograft and homograft in our series, are excellent after the Ross procedure.

Left ventricular remodeling after pulmonary autograft replacement of the aortic valve (Ross operation)

BACKGROUND AND AIM OF THE STUDY

Aortic valve replacement (AVR) with a pulmonary autograft is an alternative treatment for young patients with aortic valve disease. Superior hemodynamic performance of the pulmonary autograft, and impact on parameters of left ventricular function were analyzed.

METHODS

Thirty patients (21 males, nine females; mean age 29.97+/-12.29 years; range: 6-54 years) underwent a Ross procedure between November 1997 and November 1999. Seven patients (23%) were children (aged <15 years). In total, 22 patients were analyzed; each had at least three months follow up. Eleven patients had predominant aortic stenosis (AS), and 11 had aortic insufficiency (AI).

RESULTS

There were no operative deaths. Two patients developed severe insufficiency, and the autograft was replaced with a mechanical valve. Pre- and postoperative echocardiograms were reviewed. The mean neoaortic maximal gradient was 7.85+/-5.59 mmHg (range: 3-29 mmHg). AS patients showed reduced interventricular septal (IVS) thickness at one month (from 13.27+/-3.69 to 11.60+/-2.44 mm; p = 0.0165) and 18 months after surgery (p = 0.0104). Left ventricular posterior wall (LVPW) thickness was reduced from 12.04+/-3.75 to 9.48+/-2.47 mm (p = 0.0338) at one month and 18 months (p= 0.0128) after surgery. The left ventricular end-diastolic internal dimension (LVIDd) decreased from 50.71+/-10.20 to 44.98+/-7.29 mm (p = 0.0491) at one month after surgery. In AI patients, LVPW and IVS thicknesses showed no significant variation, and LVIDd was decreased at one month (from 68.50+/-8.39 to 59.04+/-9.21 mm; p = 0.0017) and 18 months (p = 0.0229) after surgery. Left ventricular end-systolic internal dimension (LVIDs) decreased from 44.06+/-6.39 to 39.03+/-7.99 mm (p = 0.0081) at three months after surgery. Left ventricular mass index (LVMI) in the AS group decreased from 179.01+/-62.26 to 115.74+/-37.62 g/m2 (p = 0.0021) at one month after surgery, and at 18 months was normal, with a decrease from 208.77+/-32.89 to 95.89+/-28.82 g/m2 (p= 0.0003) (n = 5). In the AI group, LVMI decreased from 186.25+/-85.21 to 140.58+/-62.02 g/m2 (p = 0.0011) at one month after surgery, and at 18 months from 217.70+/-98.02 to 146.73+/-84.55 g/m2 (p= 0.0131) (n = 5).

CONCLUSION

The pulmonary autograft procedure can be used safely to replace the aortic valve, and allows optimal hemodynamic performance, with no significant aortic regurgitation. The Ross procedure results in normalization of left ventricular dimensions and improvement of left ventricular function early in the postoperative period.

[Aortic valve replacement with a pulmonary autograft (the Ross operation) in adult and pediatric patients. A preliminary study]

INTRODUCTION AND OBJECTIVES

Aortic valve replacement with the patients own pulmonary autograft (the Ross procedure) is by now, the best surgical method for the replacement of the diseased aortic valve in certain groups of patients, this is particularly true for young adults and children or neonates with complex left ventricular outflow tract obstructions. The procedure was described by Donald Ross in 1967, and many years have passed. So in view of the accumulated experience the indications have extended to a wide group of patients which include children, neonates and young adults with formal contraindications for anticoagulation. In this publication we present our experience and our preliminary results in a group of fifteen patients which include adult and pediatric.

MATERIAL AND METHODS

In six patients the etiology of lesion was congenital and in the remainder nine the valve had an acquired lesion. Two patients had an open heart procedure before this operation both of them to relieve an obstruction to the left ventricular outflow tract. In this group of patients the Ross procedure was carried out inserting the pulmonary autograft in the aortic position as a total root which was always reconstructed with cryopreserved pulmonary homograft, the mean homograft diameter was 26.1 +/- 4 mm (19-35).

RESULTS

In all patients a transesophageal echocardiogram was performed in the operating room and postoperative, 1 or 2 months later. Only in one patient a mild aortic regurgitation was detected, no significant transaortic or transpulmonary gradients were detected postoperative. One patient was reoperated for bleeding in the postoperative course, there was no hospital mortality in our group and all the patients had an uneventful postoperative period. In the short term follow-up (41-155 days). All the patients are free of anticoagulant therapy, all them are in New York Heart Association Functional Class I.

CONCLUSIONS

The patients presented in this publication which include adult and pediatric, are the first group of patients operated in our country with some excellent preliminary results. We hope that this procedure will become popular and that other surgical groups will adopt it as another surgical tool to replace a diseased aortic valve.

Massive calcification of the left atrium: surgical implications

BACKGROUND

Massive calcification of the atrial walls ("porcelain atrium") is a rare condition that usually has been reported as an incidental radiologic findings.

METHODS

Between January 1988 and June 1993, 971 patients underwent valvular operation at our institution; 21 patients showed extensive calcification of the left atrium. In 8 patients the calcification was massive, involving almost all the atrial surface. The diagnoses were established by radiology and were confirmed at operation. The mean age of these patients (4 men, 4 women) was 55 +/- 9.6 years. All had rheumatic valve disease, were on atrial fibrillation, and had undergone at least one operation previously. Pulmonary artery pressure was severely increased, even up to systemic levels, in all patients except 1. Total endoatriectomy of the left atrium and mitral valve replacement were performed. No patient was lost during the follow-up.

RESULTS

Hospital mortality rate was 12.5% (1 patient) and 2 patients died in the late postoperative period. None of these deaths are attributable to the surgical procedure.

CONCLUSIONS

In toto endoatriectomy of a massively calcified atrium is an easy to perform technique that helps to replace the mitral valve and close the atrial wall.

Prediction of right ventricular ejection fraction by Doppler determination of right systolic time intervals

OBJECTIVES

This study was designed to evaluate the right ventricular function by means of the determination of right ventricular systolic time intervals measured in pulmonary artery flow detected by Doppler.

BACKGROUND

Left ventricular systolic time intervals have been used to evaluate left ventricular performance. There is, however, no information as to whether right ventricular systolic time intervals may be useful in the evaluation of right ventricular function.

METHODS

Simultaneous measurements of right ventricular ejection fraction and Doppler determination of right systolic time intervals were made in four pigs in 47 different hemodynamic conditions that permit the modification of the right ventricular ejection fraction from 15% to 68%. The preejection time, the ratio of right preejection time to right ventricular ejection time, with and without correction by the heart rate, were correlated simultaneously to invasively determined right ventricular ejection fraction and other hemodynamic parameters, measured with a modified pulmonary artery catheter with a rapidly responding thermistor.

RESULTS

There was a significant linear correlation between Doppler determination of right systolic time intervals and right ventricular ejection fraction. A similar correlation was found for preejection time (r = .80, p < .0001) and the ratio of right preejection time to right ventricular ejection time with correction by the heart rate (r = .83, p < .0001). When we used a preejection time > 70 msec as a criterion to detect a ejection fraction < 40% we found a sensitivity of 89% and specificity of 88%. A preejection time > 80 msec, as criterion of more severe ventricular disfunction (ejection fraction < 30%), displayed a sensitivity of 76% and specificity of 100%.

CONCLUSION

These results show that right ventricular systolic time intervals determined by Doppler study correlate significantly with the right ventricular ejection fraction. In view of its simplicity and its accuracy in the prediction of right ventricular ejection fraction, this method may provide useful non-invasive alternative in the prediction of right ventricular ejection fraction.

[Pneumatic dilatation in patients with esophageal achalasia]

From October 1984 to March 1992, 21 patients of Hospital Nacional Guillermo Almenara Irigoyen-IPSS, Lima, Perú, with esophageal achalasia were treated with pneumatic dilatation using a 3.5 cm diameter Rider-Moeller balloon. The mean age was 40.5 years (range: 24-54). Six were men and 15 women. The mean time with dysphagia previous to treatment was 5.3 years. A total of 29 sessions were performed, 1.38 sessions per patient. The follow-up of the first 10 patients was carried for a mean time of 48.3 months (range:6-91). A satisfactory response to treatment was obtained in 8 patients (80%). Two patients (20%) relapsed after 2 and 3 treatment sessions needing surgery. One patient suffered a esophageal perforation recovering after surgical treatment. We conclude that pneumatic dilatation with Rider-Moeller balloon is a safe and not difficult medical procedure for esophagus achalasia.

[APS-2: comparative study on populations of critical patients in Chile, United States and New Zealand]

Between 1988 and 1991, the Acute Physiologic Score (APS-2) was applied to 1000 critically ill patients admitted to an intensive care unit of a general hospital in Chile. Its predictive capacity was assessed and compared with two series from United States and New Zealand. The mean admission APS-2 in Chilean patients was 12.8 and there was a progressive increase in mortality with elevating scores; no patient with an APS-2 over 30 survived. Admission APS-2 scores in USA and New Zealand were 10.7 and 14.2. Overall mortality in Chilean patients was 28%, compared with 12% in USA and 15% in New Zealand. Within different score ranges, mortality was higher in Chilean patients than those from USA or New Zealand. It is concluded that the assessment of admission APS-2 score underlying diagnosis, physiologic age and previous health status of a patient may help to predict the success of intensive care.

[Emphysematous cystitis caused by Klebsiella pneumoniae]

Emphysematous cystitis is a very uncommon clinical activity as compared to the high incidence of urinary infections in diabetic patients. The paper explains the pathophysiological mechanisms and updates its clinical and therapeutic diagnostic choices regarding one case of favourable evolution following medical treatment.