Estrangulated obturatory hernia. Case report of a challenging diagnosis of obstructive syndrome

INTRODUCTION AND IMPORTANCE

Obturator hernia accounts for less than 1 % of all documented cases of pelvic hernias. It most commonly presents as an obstructive syndrome in elderly, multiparous, slim women, characterized by a wider pelvis that facilitates the passage of the hernia sac through the obturator foramen alongside the obturator nerve. In this case, adhering to the SCARE (Updating Consensus Surgical CAse REport) checklist criteria, we present a typical scenario involving an elderly woman who was initially misdiagnosed with a fecaloma, concealing an obturator hernia.

CASE REPORT

An 85-year-old patient, displaying prodromal signs of senile disease, presented for medical attention with incapacitating abdominal pain in the right iliac fossa, accompanied by nausea and vomiting. Rectal examination revealed the presence of a fecaloma, and glycerin administration was performed rectally. The patient's condition worsened with the development of mental confusion and hyperactive delirium. Abdominal Computer tomography scan (CT scan) revealed right obturator hernia with enteral segment insinuation and dilation of the proximal bowel. An infraumbilical laparotomy was performed. The herniation of an ileal segment and the right ovary through the obturator foramen was identified. The content proved irreducible to manual maneuvers, leading to obturator muscle section following the dissection of the Retzius space. The right round ligament of the uterus was sectioned, and we manage to preserve the Obturatory branch of the lumbar plexus throughout dissection. A polypropylene mesh was positioned and secured with non-absorbable sutures on the Cooper's ligament, iliac crest, and obturator muscle and segmental enterectomy with primary anastomosis using a linear stapler was performed.

CLINICAL DISCUSSION

This demanding case brings to the spotlight the importance of reevaluating even the usual cases. We provide our experience bringing together an unusual diagnosis after the conduction of a once diagnosed fecaloma that almost went down to a perforated acute abdomen. Hence the importance of suspect obturator hernia in unknown obstructive abdomen in elderly women.

CONCLUSION

With this report we aim to raise awareness of careful propaedeutic inquiry of acute abdomen. We provide our experience bringing together the diagnosis that agrees with our literature review. Elderly patients commonly challenge the clinical evaluation, especially those with signs of senile disease. Thereby, inkling hidden diagnosis in typical scenarios can improve the patient's care in emergency settings.

Papillary thyroid carcinoma: the impact of histologic vascular invasion

BACKGROUND

The American Thyroid Association (ATA) recurrence risk prediction system considers vascular invasion (VI) as a relative indicator for adjuvant radioactive iodine (RAI) treatment, nevertheless VI final role in PTC management is yet to be defined. This study aims to assess the impact of histologic VI in papillary thyroid carcinoma (PTC).

METHODS

A retrospective study with PTC patients admitted in our Thyroid Cancer Unit, between January 1960 and December 2016 was performed. We reviewed 905 patient records with 275 having full information about VI on their pathological reports. Demographic and clinical variables were obtained, and univariate/multivariate analysis was performed in order to obtain potential predictive prognostic factors.

RESULTS

Fifty-one out 275 patients presented VI (18.5%; 95% CI 14.4-23.6%), these individuals had larger tumors (median 19 mm vs. 12 mm, P<0.001) with more frequent extraglandular invasion (54.0% vs. 17.1%, P<0.001), regional lymph nodes involvement (29.8% vs. 12.6%, P=0.003)and distant metastasis (10.9% vs. 1.9%, P=0.003) at diagnosis. VI was an independent predictor for regional lymph node and/or distant metastasis at diagnosis (OR 2.93 [IC 95% 1.16-7.41, P=0.008]). After a median follow-up time was 68.5 months patients with VI presented higher rates of local recurrence and lymph node metastasis recurrence.

CONCLUSIONS

In this study, the presence of VI in PTC is associated to higher rate of lymph node and distant metastasis at diagnosis. Its presence should be probably considered an adverse prognostic factor in PTC, perhaps justifying more aggressive therapeutic and follow-up approaches in such cases.

Leg dystrophic calcification as a consequence of chronic diabetic foot infection: a case report

Foot ulceration and infection is associated with a substantial increase in morbidity and mortality in patients with diabetes. We present a clinical case of recurrent diabetic foot infection with an atypical clinical evolution. A 58-year-old male patient with type 1 diabetes and a history of bilateral Charcot foot neuroarthropathy was followed at our Diabetic Foot Clinic for an unhealed plantar foot ulcer for >1.5 years with recurrent episodes of infection. He was admitted to hospital due to foot ulcer reinfection with sepsis and ipsilateral lower limb cellulitis. The foot infection was found to be associated with an underlying abscess in the anterior compartment of the leg, with a cutaneous fistulous course with extensive alterations of an inflammatory nature. Exudate from the lesion was drained and tissue biopsied, revealing Serratia marcescens and Klebsiella oxytoca with dystrophic calcification (DC). Surgical excision of dystrophic tissue with debridement of the fistulous tracts was performed. The excised material corroborated the presence of fibroadipose connective tissue with marked DC, as well as areas of mixed inflammation compatible with a chronic infectious aetiology. Targeted long-term antibiotic therapy was implemented, for a total of six weeks, with a favourable clinical evolution and complete closure of the lesion at the final follow-up. DC results from calcium deposition in degenerated tissues without evidence of systemic mineral imbalance and is a potential cause of non-healing ulcers. Few cases of DC have been reported in diabetic foot patients and its treatment remains challenging and controversial. A longer follow-up period is necessary to verify the effectiveness of our approach.

Bone anchor as fixation method for abdominal wall reconstruction. A case report about a ten times recurred inguinal hernia

INTRODUCTION

While the use of bone anchor fixation for abdominal wall reconstruction for supra-pubic incisional hernia is well described (Yee et al., 2008 [1]), we show in this case report, written in line with the SCARE criteria (Agha et al., 2020 [2]), a novel use of this tool as an adjunct in the repair of a ten time recurrent inguinal hernia.

CASE REPORT

A 65 years old multiparous, diabetic non-obese female, with previous abdominoplasty was submitted for left inguinal hernia for ten times, between multiples complications between infection, more than one mesh excision by anterior approach and laparoscopic approach. The wide range of procedures culminated in a destruction of the abdominal wall, making it impossible for a usual fixation of mesh in the region. Therefore, a multidisciplinary approach was planned for the patient with a bone anchor as a mesh fixation method. With a year follow up we did not observe a local hernia recurrence.

CLINICAL DISCUSSION

Hernia itself is a multifactorial disease. As a anatomical defect, surgery is the only effective treatment. Our report brings a novel approach to a challenging case with many previous unsuccessful applications of conventional surgeries. Hence, we stimulate the multidisciplinary discussion for enhancing post operatory outcomes and a better point of care for the patient.

The influence of simultaneous pancreas-kidney transplantation on the evolution of diabetic foot lesions and peripheral arterial disease

PURPOSE

Simultaneous pancreas-kidney transplantation (SPKT) remains the best treatment option in patients with type 1 diabetes and chronic kidney failure. There are only a few studies addressing the potential ischemic deterioration of peripheral arterial disease (PAD) due to blood diverting from the iliac artery to the kidney graft. We aimed to evaluate diabetic foot lesions and PAD evolution in SPKT recipients and investigate if they are more frequent in ipsilateral lower limb of kidney graft.

METHODS

We developed a retrospective cohort, including patients submitted to SPKT in our tertiary center, between 2000 and 2017. Diabetic foot lesions and PAD frequencies were compared in the period before and after transplantation.

RESULTS

Two hundred and eleven patients were included, 50.2% (n = 106) female, with a median age at transplantation of 35 years (IQR 9). After a median follow-up period of 10 years (IQR 7), patient, kidney, and pancreatic graft survival were 90.5% (n = 191), 83.4% (n = 176), and 74.9% (n = 158), respectively. Before transplant, 2.8% (n = 6) had PAD and 5.3% (n = 11) had history of foot lesions. In post-transplant period, 17.1% (n = 36) patients presented PAD and 25.6% (n = 54) developed diabetic foot ulcers, 47.6% (n = 35) of which in the ipsilateral and 53.3% (n = 40) in the contralateral lower limb of the kidney graft (p = 0.48). Nine patients (4.3%) underwent major lower limb amputation, 3 (30%) ipsilateral and 7 (70%) contralateral to the kidney graft (p = 0.29).

CONCLUSIONS

Diabetic foot lesions were not more frequent in the ipsilateral lower limb of the kidney graft, therefore downgrading the 'steal syndrome' role in these patients.

Levothyroxine malabsorption or pseudomalabsorption? A question in the management of refractory hypothyroidism

PURPOSE

The levothyroxine absorption test (LT4AT) is an important tool for distinguishing hypothyroidism due to malabsorption from 'pseudomalabsorption' conditions. Our aim was to review our institution's LT4AT results and assess its role in the management of patients with refractory hypothyroidism.

METHODS

We performed a retrospective study of all patients evaluated for refractory hypothyroidism who underwent LT4AT in our tertiary center between 2014 and 2020. Its results and the impact on thyroid function management during follow-up were assessed.

RESULTS

Ten female patients were included with a mean age of 40 years (min-max: 26-62). Mean weight was 72 kg (min-max: 43-88) and baseline LT4 dosage ranged from 2.5 to 5.3 µg/kg/day. The most common causes of hypothyroidism were postsurgical in 50% (n = 5) and autoimmune in 20% (n = 2). During LT4AT, normal LT4 absorption was found in all but one individual (mean FT4 increase of 231%, min-max: 85-668). The only patient with objective LT4 absorption impairment (maximal increase of 48% by hour 5) presented also Helicobacter pylori gastritis and prior history of 'intestinal surgery' during childhood. No adverse events were reported during any of the LT4ATs. During follow-up (median 11.5 months (IQR 23)), three patients obtained euthyroidism and six had improved their hypothyroidism state.

CONCLUSIONS

The LT4AT is an effective and safe way to assess refractory hypothyroidism and provides valuable information to distinguish LT4 malabsorption from 'pseudomalabsorption'. Our data suggest that most patients with suspicious LT4 malabsorption perform normally during LT4AT. This test provides relevant information for better management of patients with refractory hypothyroidism.

Non-thyroidal second primary malignancy in papillary thyroid cancer patients

INTRODUCTION

The occurrence of non-thyroidal second primary malignancy (NTSPM) in patients with papillary thyroid cancer (PTC) is well documented, but epidemiological data are conflicting.

OBJECTIVE

The aim of this study was to evaluate the incidence of NTSPM in a large series of patients with PTC and to assess its potential risk factors.

METHODS

Single-center cohort study with retrospective data collection conducted on consecutive PTC patients diagnosed from 1988 to 2018 with a minimum follow-up time of 2 years. NTSPM was defined as any primary malignancy with histological confirmation occurring in an anatomical site other than the thyroid. According to the timing of occurrence, NTSPM were subdivided into anachronous, synchronous or metachronous (diagnosed >6 months before, within 6 months and >6 months after PTC diagnosis, respectively).

RESULTS

We included 773 individuals (83.3% females), median age at PTC diagnosis was 47.0 (IQR: 37.0-58.0) years and median follow-up time was 9.9 (6.2-16.3) years. Incidence of NTSPM was 15.5% (n = 120) and its standard incidence ratio (SIR) was higher when compared to the general population (SIR: 2.70). Family history of malignancy and younger age at diagnosis were associated respectively with 206 and 4% increased risk of developing metachronous neoplasia (HR: 2.06 (95% CI: 1.10-3.86) and 1.04 (95% CI: 1.02-1.05), respectively).

CONCLUSION

In our series, the occurrence of NTSPM was not uncommon and its incidence was higher compared to the general population. First-degree family history of malignancy was a strong risk factor for multiple primary malignancies.

25-OH Vitamin D Levels and Cognitive Performance: Longitudinal Assessment in a Healthy Aging Cohort

Background: Declining serum levels of 25-hydroxyvitamin D [25(OH)D, a biomarker of vitamin D status] with aging is a well-recognized phenomenon. However, scarce information is available on the relation between 25(OH)D levels and cognitive performance over time in older individuals. Our purpose was to evaluate, longitudinally, the association of 25(OH)D with cognitive function in a healthy older adults’ cohort.

Methods: Sixty-four individuals over 55 years-old with no cognitive impairment, clustered as healthy “Poor” and “Good” cognitive performers, were followed for an average of 18 months. Seasonal-adjusted 25(OH)D serum levels (measured by high-performance liquid chromatography-tandem mass spectrometry) were related, longitudinally, with cognitive (memory and general/executive) composite scores.

Results: Overall seasonal-adjusted median serum 25(OH)D level was of 47 nmol/l [interquartile range (IQR), 38–60 nmol/l]. A negative correlation between baseline 25(OH)D and the general/executive composite score was found in the “Poor” cognitive performers (r^s = −0.52, p = 0.006), an association lost after adjusting 25(OH)D levels for the season. No effect was found in both groups between seasonal-adjusted 25(OH)D levels and the variation of both memory and general/executive composites during follow-up when adjusted for age, gender and education level.

Conclusion: In this healthy older population with no cognitive impairment, lower serum levels of 25(OH)D were not longitudinally associated with poorer cognitive scores.

P5522ST elevation myocardial infarction networks: relationship of hub-spoke distance with transfer time and clinical outcomes in rescue PCI

Background

In the establishment of ST elevation myocardial infarction (STEMI) systems of care, transfer times between primary care units (PCU) and the cardiac catheterization lab (CCL) are pillars to therapeutic success. Objective: To analyze the relationship between PCU-CCL distance with transport time and main clinical outcomes in STEMI patients (p) treated with pharmaco-invasive therapy (PIT) and referred for rescue PCI after failed fibrinolysis.

Methods

Between January 2010 and December 2018, of the 2241 patients who received tenecteplase in PCU inserted in a large city STEMI network, 801 (35.7%) evolved without reperfusion criteria after 90 minutes (persistence of chest pain, less than 50% reduction on ST elevation or hemodynamic instability), being urgently transferred to the CCL. The PCU were divided according to the distance to the tertiary center in Group 1: between 5 and 9km (N=208p), Group 2: between 16 and 18km (N=315p) and Group 3: between 22 and 30km=266p). Considering an alpha of 0.05, sample size n=801 and an effect size of 0.11, a power of 0.80 was obtained.

Results

The groups were comparable for baseline features (Table 1). Group 2 (intermediate distances) had the highest median transport time (G1 260 interquartile 145–437 min vs G2 355 interquartile 206–573 min vs G3 241 interquartile 125–418 min; p<0.01 for G2). There were no differences between the groups regarding cardiogenic shock (G1 24.5% vs G2 23.3% vs G3 24.1%, p=0.9) or in-hospital death (G1 17.4% vs G2 12.3% vs G3 13.0%, p=0.2).

Table 1. Group's baseline features G1: Short distances G2: Intermediate distances G3: Long distances p value (5–9 km) N=208 (16–18 km) N=315 (22–30 km) N=266 Age (median) 57.5 (51–64) 57 (49–66) 59 (52–67) 0.27 Female 29.7% 28.3% 35.1% 0.19 Hypertension 67.3% 60.9% 64.4% 0.31 Diabetes 37.0% 32.1% 37.8% 0.30 Renal failure 10.3% 9.7% 6.3% 0.21 Anterior STEMI 56.1% 58.4% 62.4% 0.36 Pain-to-needle time (median min) 197.5 (137–330) 195 (120–295) 195 (125–345) 0.38

Conclusion

In STEMI patients with failed fibrinolysis treated with pharmaco-invasive therapy, the PCU-CCL distance was not related to transfer time or to outcomes of in-hospital death and cardiogenic shock. The longer transport time of hospitals located at intermediate distance can possibly reflect local logistical difficulties and are not due to hub-spoke distance. Continuous improvement in structuring and coordination of public STEMI networks is aimed.

Human Immunodeficiency Virus (HIV) 2 Superinfection in a Patient Receiving Antiretroviral Therapy With Longstanding HIV-1 Viral Load Suppression

Dual human immunodeficiency virus (HIV) 1 and HIV-2 superinfections are rare but challenging. A HIV-1–infected patient receiving effective antiretroviral therapy was investigated for a severe CD4⁺ cell count decline. HIV-2 superinfection was diagnosed and genotypic test revealed mutations conferring resistance to most drug class, limiting options for treatment.

Abstract P4-12-06: Cost-effectiveness analysis of pertuzumab plus trastuzumab for advanced HER2-positive breast cancer in Brazil: A public health system perspective

Objectives:

Addition of pertuzumab to trastuzumab and docetaxel (THP) results in significant clinical benefits for women with HER2-positive metastatic breast cancer. Despite evidence of important overall survival and quality of life improvements, for the Brazilian patients depending on the public health system chemotherapy alone (CT) remains the standard treatment. Previous request for trastuzumab incorporation was denied by Brazilian Ministry of Health (MoH) due to high individual costs.

In an innovative way, the Brazilian Society of Clinical Oncology made a price negotiation directly with the pharmaceutical company, aiming to propose a formal request for the incorporation of these technologies to the National Committee for Health Technology Incorporation (CONITEC).

Our objective was to evaluate the cost-effectiveness of THP versus CT in patients with HER2-positive advanced breast cancer, under the perspective of the Brazilian public health system.

Methods:

A cost-effectiveness analysis was conducted using a Markov model over a lifetime horizon. The model considers three health states: 1st-line treatment without progression; disease progression (with chemotherapy or best supportive care) and death. Transition probabilities and mortality rates were extracted from randomized studies. Costs of standard chemotherapy, complications, and surveillance were obtained from price tables regulated by the MoH. Pertuzumab and trastuzumab prices were those negotiated with the manufacturing company. Benefits are presented in life-years (LY) and costs in USD (using exchange rate for Brazilian Real to USD = 3.50). The relation between costs and benefits were used to present the incremental cost-effectiveness ratio (ICER) per life-year saved. We have performed one-way deterministic sensitivity analyses with cost of monoclonal antibodies to define the ideal price in Brazil.

Results:

Patients with HER2-positive metastatic breast cancer treated with CT were projected to have 1.87 LY, with a total cost of $12,118. THP was projected to increase the life expectancy of these patients by 1.48 years, with an incremental cost of $63,685 per patient. Thus, the ICER was $42,893 per LY-gained.

Conclusions:

The World Health Organization recommendation of three times gross domestic product per capita have defined our cost-effectiveness threshold. Despite the discount price, at a willingness-to-pay (WTP) threshold of $25,615 per LY, THP is not a cost-effective strategy compared to CT. An additional reduction around 58.67% in the pertuzumab price would be necessary to make THP cost-effective in Brazil.

Discussion about the incorporation of trastuzumab to CT using the discount prices is in progress.

Citation Format: Carvalho AC, Vasconcelos VCA, Sasse AD. Cost-effectiveness analysis of pertuzumab plus trastuzumab for advanced HER2-positive breast cancer in Brazil: A public health system perspective [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-06.

Circulating levels of adiponectin and extent of coronary artery disease in patients undergoing elective coronary angiography

Adiponectin (APN), an adipose tissue-released adipokine with demonstrated anti-inflammatory and anti-atherogenic properties, is encoded by a gene whose polymorphisms are associated with presence of coronary artery disease (CAD). Serum APN levels are inversely related with presence and complexity of CAD. Within this context, we sought to compare levels of total APN and its high molecular weight form (HMW APN) according to clinical presentation and extent of CAD in patients undergoing elective cardiac catheterization. From March 2008 to June 2010, clinical data and blood samples for APN and HMW APN measurements were collected from 415 subjects undergoing cardiac catheterization at two tertiary centers. CAD extent was estimated by the number of coronary arteries with significant stenosis (≥70% obstruction in a major coronary artery) and by Duke Jeopardy Score (DJS). Serum APN levels were similar between groups with stable or unstable CAD (APN 9.20±5.88 vs 9.47±6.23 μg/mL, P=0.738, and HMW APN 5.31±3.72 vs 5.91±4.16 μg/mL, P=0.255), even after stratification by the number of arteries involved (single-vessel vs multivessel disease: APN 9.39±5.76 vs 9.26±6.27 μg/mL, P=0.871; HMW APN 5.29±3.79 vs 5.83±4.04 μg/mL, P=0.306) and DJS score (APN, P=0.718; HMW APN, P=0.276). We conclude that APN and HMW APN serum levels are similar across clinical presentations and different extents of CAD, despite being significantly lower in the presence of obstructive CAD.

Can artificial neural networks be used to predict the origin of ozone episodes?

Tropospheric ozone is a secondary pollutant having a negative impact on health and environment. To control and minimize such impact the European Community established regulations to promote a clean air all over Europe. However, when an episode is related with natural mechanisms as Stratosphere-Troposphere Exchanges (STE), the benefits of an action plan to minimize precursor emissions are inefficient. Therefore, this work aims to develop a tool to identify the sources of ozone episodes in order to minimize misclassification and thus avoid the implementation of inappropriate air quality plans. For this purpose, an artificial neural network model - the Multilayer Perceptron - is used as a binary classifier of the source of an ozone episode. Long data series, between 2001 and 2010, considering the ozone precursors, (7)Be activity and meteorological conditions were used. With this model, 2-7% of a mean error was achieved, which is considered as a good generalization. Accuracy measures for imbalanced data are also discussed. The MCC values show a good performance of the model (0.65-0.92). Precision and F1-measure indicate that the model specifies a little better the rare class. Thus, the results demonstrate that such a tool can be used to help authorities in the management of ozone, namely when its thresholds are exceeded due natural causes, as the above mentioned STE. Therefore, the resources used to implement an action plan to minimize ozone precursors could be better managed avoiding the implementation of inappropriate measures.

Population mobility and the changing epidemics of HIV-2 in Portugal

INTRODUCTION

Portugal is the European country with the highest frequency of HIV-2 infection, which is mainly concentrated in West Africa. The cumulative number of notified HIV-2 infections in Portugal was 1813 by the end of December 2008. To better characterize the dynamics of HIV-2 infection in the country and to obtain data that may be of use in the prevention of the spread of HIV-2, we evaluated a large pooled sample of patients.

PATIENTS AND METHODS

Five Portuguese hospitals provided data on HIV-2-infected patients from 1984 to the end of 2007. Data concerning demographic characteristics and clinical variables were extracted. Patients were stratified according to date of diagnosis in approximately 5-year categories.

RESULTS

The sample included 442 patients, accounting for 37% of all HIV-2 infections notified in Portugal during that period. HIV-2-infected patients showed clearly different characteristics according to the period of diagnosis. Until 2000, the majority of HIV-2-infected patients were Portuguese-born males living in the north of the country. From 2000 to 2007, most of the patients diagnosed with HIV-2 infection had a West African origin, were predominantly female and were living in the capital, Lisbon. The average age at diagnosis and loss to follow-up significantly increased over time.

CONCLUSION

HIV-2 infection has been documented in Portugal since the early 1980s and its epidemiology appears to reflect changes in population movement. These include the movements of soldiers and repatriates from African territories during the independence wars and, later, migration and mobility from high-endemicity areas. The findings of this study stress the importance of promoting migrant-sensitive health care.

Prevalence of malocclusion in primary dentition in a population-based sample of Brazilian preschool children

AIM

The purpose of the present study was to assess the prevalence of malocclusion in the primary dentition in a randomised representative sample of Brazilian preschool children.

MATERIALS AND METHODS

A cross-sectional survey was carried out in Belo Horizonte, Brazil, involving 1069 male and female preschool children from 60 to 71 months of age, randomly selected from public and private preschools and daycare centers. A questionnaire addressing demographic data was sent to parents/guardians in order to characterise the sample. The oral examination of the children was performed by a single, previously calibrated dentist (kappa inter-examiner agreement value = 0.82). The criterion for the categorisation of malocclusion was at least one of the following conditions: posterior crossbite, overjet (> 2 mm), anterior crossbite, anterior open bite and deep overbite. Univariate analysis was performed using the SPSS software

RESULTS

The prevalence of malocclusion was 46.2%. Deep overbite was the most prevalent alteration (19.7% of the sample). Posterior crossbite was diagnosed in 13.1% of the children; 10.5% had accentuated overjet; 7.9% had anterior open bite; and 6.7% had anterior crossbite.

CONCLUSION

Malocclusion in primary dentition is becoming a significant problem. The prevalence in the present study was high, especially vertical and transversal malocclusions.

Predisposing factors for traumatic dental injuries in Brazilian preschool children

AIM

The aim of the present study was to assess the prevalence of traumatic dental injury (TDI) in primary teeth and determine predisposing factors.

MATERIALS AND METHODS

A cross-sectional study was carried out on 388 male and female Brazilian preschool children between 60 and 71 months of age. A questionnaire addressing demographic data and history of TDI was sent to parents/caregivers. Socioeconomic status was determined using the Social Vulnerability Index (SVI), family income, number of people in the household and parents/caregivers' schooling. The chi-square test was used for the statistical analysis.

RESULTS

The prevalence of TDI was 62.1%; 61.7% of the teeth were affected by enamel fracture. Statistically significant associations were found between TDI and increased overjet [OR = 2.24, 95% CI = 1.11- 4.55] and anterior crossbite [OR = 0.38, 95% CI=0.17-0.87]. No statistically significant associations were found between TDI and number of people in the household, family income, social vulnerability, parents/caregivers' schooling, lip competence, overbite, anterior open bite and dental caries (p>0.05).

CONCLUSION

The prevalence of TDI was high and enamel fracture was the most common sign of TDI. Children with an increased overjet suffer more TDIs. Socioeconomic factors had no influence over the prevalence of TDI.

Procedures for estimation of modelling uncertainty in air quality assessment

The main objectives of this work focus, firstly, on a review of the current existent methodologies to estimate air quality modelling uncertainty, and, secondly, in the preparation of guidelines for modelling uncertainty estimation, which can be used by local and regional authorities responsible for air quality management. From the application exercise, it was concluded that it is possible to define a subset of statistical parameters able to reproduce the general uncertainties estimation. Concerning the quality indicators defined by EU directives, the results show that the legislated uncertainty estimation measures are ambiguous and inadequate in several aspects, mainly in what concerns the error measures for hourly and daily indicators based on the highest observed concentration. A relative error at the percentile correspondent to the allowed number of exceedances of the limit value was suggested and tested, showing that is a more robust and appropriate parameter for model performance evaluation.

Congenital syphilis in Italy

The cases are described of two infants who developed clinical and laboratory signs of congenital syphilis in Northern Italy, a region where the disease had not been documented for several years. The report urges greater vigilance and screening for syphilis among pregnant women and newborns, and contributes to the evidence that the incidence of syphilis is rising among women in Italy.

Electrochemical characterisation of dental alloys: its possibilities and limitations

Dental alloys are metallic biomaterials which have a broad variation of composition compared to technical alloys. It is therefore in the interest of patients and technicians to conduct a good assessment of the electrochemical behaviour of dental alloys in order to collect information about their corrosion resistance. The purpose of this work was to demonstrate possibilities and limitations of two electrochemical techniques: the voltammetry of immobilised microparticles (ViMP) onto lead, and cyclic voltammetry measurements with the help of the mini-cell system (MCS). Based on fingerprints obtained from ViMP it was possible to analyse and differentiate the dental alloys. The results obtained by MCS were comparable with ViMP, but give a better understanding of the corrosion behaviour of the materials.

Air quality management in Portugal: example of needs and available tools

The Framework Directive (FWD) and the proposed Daughter Directives are the newest legislative instruments concerning a new political strategy and air quality management approach for Europe. Additionally, the member countries of the United Nations Economic Commission for Europe have included the concepts of critical load and level for planning air pollution abatement strategies and as a base of international agreements concerning limitation of the emissions of air pollutants. These concepts imply an accurate knowledge about pollutants deposition fluxes. The paper describes the main needs and the tools available to define a strategy of air quality management in Portugal. Two study cases are presented: (1) extensive monitoring plan to assess the impact of an urban incinerator plant; and (2) contribution to a methodology to estimate critical levels for a coastal region in Portugal. These different approaches allowed illustrating the complexity of the implementation of an air pollution management strategy.

Transmission of Mycobacterium tuberculosis to contacts of HIV-infected tuberculosis patients

We assessed the infectiousness of human immunodeficiency virus (HIV)-seropositive and HIV-seronegative individuals with pulmonary tuberculosis (TB) in a prospective cohort study. We enrolled, evaluated, and followed 104 close contacts of HIV-seropositive pulmonary TB patients and 256 close contacts of HIV-seronegative pulmonary TB patients using a standardized questionnaire, symptom review, chest radiograph, HIV serology, and tuberculin skin testing (TST). Contacts were followed for > or = 12 mo. TB infection at enrollment was 27% (28/104) among contacts of HIV-seropositive TB patients and 35% (90/256) among contacts of HIV-seronegative TB patients (odds ratio [OR] = 0.68, 95% confidence interval [CI] 0.41 to 1.12; p = 0.130). TST conversion occurred in 21% (42/ 204) of subjects; 8% (5/63) of contacts of HIV-seropositive index cases and 26% (37/141) of contacts of HIV-seronegative index cases (OR = 0.24, 95% CI 0.09 to 0.65; p = 0.003). TB was diagnosed in nine contacts; eight were contacts of HIV-seronegative index cases. HIV seropositivity in the index case was independently associated with a lower risk of TB infection among contacts, even among household contacts younger than 15 yr of age. Contacts of HIV-seropositive persons with pulmonary TB were less likely to have a positive TST response at 1 yr of follow-up than contacts of HIV-seronegative persons.

Assessment of splanchnic perfusion with gastric tonometry in the immediate postoperative period of cardiac surgery in children

OBJECTIVE - A prospective, nonrandomized clinical study to assess splanchnic perfusion based on intramucosal pH in the postoperative period of cardiac surgery and to check the evolution of patients during hospitalization. METHODS - We studied 10 children, during the immediate postoperative period after elective cardiac surgery. Sequential intramucosal pH measurements were taken, without dobutamine (T0) and with 5mcg/kg/min (T1) and 10 (T2) mcg/kg/min. In the pediatric intensive care unit, intramucosal pH measurements were made on admission and 4, 8, 12, and 24 hours thereafter. RESULTS - The patients had an increase in intramucosal pH values with dobutamine 10mcg/kg/min [7.19+/- 0.09 (T0), 7.16+/-0.13(T1), and 7.32+/-0.16(T2)], (p=0.103). During the hospitalization period, the intramucosal pH values were the following: 7.20+/-0.13 (upon admission), 7.27+/-0.16 (after 4 hours), 7.26+/-0.07 (after 8 hours), 7.32+/-0.12 (after 12 hours), and 7.38+/-0.08 (after 24 hours), (p=0.045). No deaths occurred, and none of the patients developed multiple organ and systems dysfunction. CONCLUSION - An increase in and normalization of intramucosal pH was observed after dobutamine use. Measurement of intramucosal pH is a type of monitoring that is easy to perform and free of complications in children during the postoperative period of cardiac surgery.

Acute precipitants of congestive heart failure exacerbations

BACKGROUND

Few studies have prospectively and systematically explored the factors that acutely precipitate exacerbation of congestive heart failure (CHF) in patients with left ventricular dysfunction. Knowledge of such factors is important in designing measures to prevent deterioration of clinical status. The objective of this study was to prospectively describe the precipitants associated with exacerbation of CHF status in patients enrolled in the Randomized Evaluation of Strategies for Left Ventricular Dysfunction Pilot Study.

METHODS

We conducted a 2-stage, multicenter, randomized trial in 768 patients with CHF who had an ejection fraction of less than 40%. Patients were randomly assigned to receive enalapril maleate, candesartan cilexetil, or both for 17 weeks, followed by randomization to receive metoprolol succinate or placebo for 26 weeks. Investigators systematically documented information on clinical presentation, management, and factors associated with the exacerbation for any episode of acute CHF during follow-up.

RESULTS

A total of 323 episodes of worsening of CHF occurred in 180 patients during 43 weeks of follow-up; 143 patients required hospitalization, and 5 died. Factors implicated in worsening of CHF status included noncompliance with salt restriction (22%); other noncardiac causes (20%), notably pulmonary infectious processes; study medications (15%); use of antiarrhythmic agents in the past 48 hours (15%); arrhythmias (13%); calcium channel blockers (13%); and inappropriate reductions in CHF therapy (10%).

CONCLUSIONS

A variety of factors, many of which are avoidable, are associated with exacerbation of CHF. Attention to these factors and patient education are important in the prevention of CHF deterioration.

Conventional and conventional plus modified ultrafiltration during cardiac surgery in high-risk congenital heart disease

BACKGROUND

This prospective nonrandomized study is the critical assessment of conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) techniques and their efficiency in congenital heart disease surgeries. Use of cardiopulmonary bypass (CPB) in children is associated with body water retention as a consequence of prime volume and systemic inflammatory reaction. The CUF during CPB has reduced body water excess and the MUF after CPB, removes inflammatory mediators, improves hemodynamic performance, and decreases transfusion requirements.

METHODS

Forty-one patients, aged 9 to 36 months, submitted to surgical correction for cardiac defects, using CPB, were divided into 2 similar groups: CUF (21 patients) operated between 1996-1997 were ultrafiltered during CPB, and CUF+MUF, (20 patients) operated between 1997-1998 and ultrafiltered during and after CPB. Postoperative duration of ventilator support, pediatric intensive care unit stay (PICU), hospital stay of the groups with and without preoperative pulmonary hypertension (PH), as well as transfusion requirement, hematocrit and platelet counts were compared.

RESULTS

There were no technical complications and a significant ultrafiltrate in the CUF+MUF group was observed as compared to the CUF group. No significant differences were observed between the CUF and CUF+MUF groups regarding ventilatory support, PICU stay and hospital stay. Requirements for red cell transfusion, Ht and platelet counts were not statistically different.

CONCLUSIONS

CUF and CUF+MUF were safe and efficient methods for patient stabilization independent of diagnosis and complexity of surgery. Future clinical evaluation should address a larger population of patients to research the different variables.

[Use of transesophageal echocardiography during implantation of aortic endoprosthesis (stent). Initial experience]

OBJECTIVE

To report the role played by transesophageal echocardiography during implantation of self-expanding aortic endoprostheses (stent) at a hemodynamics laboratory.

METHODS

Thirteen patients underwent stent implantation in the descending thoracic aorta with the aid of transesophageal echocardiography during the entire procedure. Indications for stenting were as follows: 8 aortic dissections, 2 true aneurysms, 2 penetrating atherosclerotic ulcers, and 1 traumatic pseudoaneurysm.

RESULTS

No complications resulting from the use of transesophageal echocardiography were observed. In 12 patients, the initial result was considered appropriate, with total or partial resolution of the major lesion confirmed by a posterior examination. In 1 patient, the procedure was suspended after transesophageal echocardiography and angiography showed that the proximal aortic diameter was inappropriate. Transesophageal echocardiography contributed to clarifying relevant points, such as aortic diameter, anatomic detail of the intimal lesion, and location and size of the communicating orifice. In addition, it facilitated placing the stent in the target lesion, reduced the time of exposure to radiation and the use of contrast medium, and provided rapid identification of intercurrent events, possibly reducing the total duration of the procedure.

CONCLUSION

The use of transesophageal echocardiography during placement of aortic stents seems appropriate. The actual advantages of the procedure will be defined in a comparative prospective study.

Expression of CD40 ligand, interferon-gamma and Fas ligand genes in endomyocardial biopsies of human cardiac allografts: correlation with acute rejection

The purpose of the present study was to investigate the expression (mRNA) of CD40 ligand (CD40L), interferon-gamma (IFN-gamma) and Fas ligand (FasL) genes in human cardiac allografts in relation to the occurrence of acute cardiac allograft rejection as well as its possible value in predicting acute rejection. The mRNA levels were determined by a semiquantitative reverse transcriptase-polymerase chain reaction method in 39 samples of endomyocardial biopsies obtained from 10 adult cardiac transplant recipients within the first six months after transplantation. Biopsies with ongoing acute rejection showed significantly higher CD40L, IFN-gamma and FasL mRNA expression than biopsies without rejection. The median values of mRNA expression in biopsies with and without rejection were 0.116 and zero for CD40L (P<0.003), 0.080 and zero for IFN-gamma (P<0.0009), and 0.156 and zero for FasL (P<0.002), respectively. In addition, the levels of IFN-gamma mRNA were significantly increased 7 to 15 days before the appearance of histological evidence of rejection (median of 0.086 in pre-rejection biopsies), i.e., they presented a predictive value. This study provides further evidence of heightened expression of immune activation genes during rejection and shows that some of these markers may present predictive value for the occurrence of acute rejection.

Monitoring of intragraft and peripheral blood TIRC7 expression as a diagnostic tool for acute cardiac rejection in humans

T-cell immune response cDNA 7 (TIRC7) is a recently described T-cell costimulatory molecule that exhibits a central role in T-cell activation in vitro and in vivo. The present study was undertaken to investigate association between intragraft and peripheral blood mononuclear cell (PBMC) TIRC7 mRNA levels and cardiac allograft rejection in humans. TIRC7 gene expression levels were determined by a quantitative-competitive reverse transcriptase-polymerase chain reaction (QC-RT-PCR) in endomyocardial biopsies and in PBMC from cardiac transplant recipients. Biopsies collected during rejection or up to 15 days before rejection showed heightened TIRC7 mRNA expression in comparison with biopsies without rejection. All prerejection and rejection biopsies showed TIRC7 mRNA upregulation, while this was present in only 30% of the biopsies without rejection. Regarding TIRC7 mRNA in PBMC, transplant recipients showed lower levels than healthy individuals and, in contrast to the results obtained in biopsies, the levels were lower during rejection than in rejection-free periods. In summary, TIRC7 mRNA expression levels increase in biopsies and decrease in peripheral blood during acute cardiac rejection. We conclude that intragraft detection of TIRC7 transcripts is a useful tool not only for the diagnosis but also for the prediction of acute heart allograft rejection episodes.

Molecular characterization of invasive and noninvasive Campylobacter jejuni and Campylobacter coli isolates

Campylobacter jejuni is one of the most common causes of bacterial diarrhea worldwide and is the primary bacterial cause of food-borne illness. Adherence to and invasion of epithelial cells are the most important pathogenic mechanisms of Campylobacter diarrhea. Molecular characterization of invasive and noninvasive Campylobacter isolates from children with diarrhea and symptom-free children was performed by random amplified polymorphic DNA techniques (RAPD). A distinct RAPD profile with a DNA band of 1.6 kb was observed significantly more frequently among invasive (63%) than among noninvasive (16%) Campylobacter isolates (P = 0.000005). The 1.6-kb band was named the invasion-associated marker (IAM). Using specifically designed primers, a fragment of 518 bp of the iam locus was amplified in 85% of invasive and 20% of noninvasive strains (P = 0.0000000). Molecular typing with a PCR-restriction fragment length polymorphism assay which amplified the entire iam locus showed a HindIII restriction fragment polymorphism pattern associated mainly with invasive strains. Although cluster analysis of the RAPD fingerprinting showed genetic diversity among strains, two main clusters were identified. Cluster I comprised significantly more pathogenic and invasive isolates, while cluster II grouped the majority of nonpathogenic, noninvasive isolates. These data indicate that most of the invasive Campylobacter strains could be differentiated from noninvasive isolates by RAPD analysis and PCR using specific primers that amplify a fragment of the iam locus.

Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy

OBJECTIVES

We sought to compare the maternal and fetal outcomes of patients with severe mitral stenosis submitted to percutaneous balloon dilation versus open mitral valve commissurotomy (MVC) during pregnancy.

BACKGROUND

Heart failure in patients with mitral stenosis complicating pregnancy is a common problem in developing countries. Since 1984, percutaneous dilation of the mitral valve using a balloon catheter has become a therapeutic alternative to open heart surgery. Although the efficacy of percutaneous mitral valve balloon dilation is well established, its results have never before been compared with the results of commissurotomy during pregnancy.

METHODS

We compared the clinical and obstetric complications in 45 women who were treated with percutaneous mitral valve balloon dilation (group I, n = 21; from 1990 to 1995) or open MVC (group II, n = 24; from 1985 to 1990) for severe heart failure due to mitral stenosis during pregnancy.

RESULTS

In our study, percutaneous balloon dilation of the mitral valve had a success rate of 95% (Gorlin formula) and 90.5% (echocardiographic "pressure half-time" method), as demonstrated by the final mitral valve area achieved. This improvement was followed by a marked decrease in the mitral valve gradient, left atrial pressure and mean pulmonary artery pressure. Patients in both groups had similar improvements in symptoms. Patients who underwent percutaneous balloon dilation had significantly fewer fetal complications, with a reduction in fetal and neonatal mortality (1 death in group I vs. 8 in group II, p = 0.025).

CONCLUSIONS

Percutaneous balloon mitral valvuloplasty is safe and effective and appears to be preferable for the fetus, compared with open MVC during pregnancy.

Is the number of microembolic signals related to neurologic outcome in coronary bypass surgery?

Coronary artery bypass surgery (CABG) without cardiopulmonary bypass (CPB) may potentially reduce the number of microembolic signals (MES) associated with aortic manipulation or generated by the pump circuit, resulting in a better neurologic outcome after surgery. Our aim was to compare the frequency of MES and neurologic complications in CABG with and without CPB. Twenty patients eligible to routine CABG without CPB were randomized to surgery with CPB and without CPB and continuously monitored by transcranial Doppler. Neurologic examination was performed in all patients before and after surgery. The two groups were similar with respect to demographics, risk factors, grade of aortic atheromatous disease and number of grafts. The frequency of MES in the nonCPB group was considerably lower than in CPB patients, however, we did not observe any change in the neurologic examination during the early postoperative period. Neurologic complications after CABG may be related to the size and composition of MES rather than to their absolute numbers. A large prospective multicentric randomized trial may help to elucidate this complex issue.

Cytokines and pediatric open heart surgery with cardiopulmonary bypass

It is well known that, subsequent to cardiopulmonary bypass, and particularly in children, an inflammatory response within the body can often result in a characteristic syndrome. Recently, it has been suggested that this phenomenon is due to a systemic inflammatory response, with significant involvement of cytokines. With this in mind, we investigated the behavior of tumour necrosis factor-alpha and interleukin-6 during the operative and in the immediate postoperative period in a group of children submitted to open heart surgery. We investigated any possible relation between the levels of these cytokines in the serum and the length of cardiopulmonary bypass, with the serum levels of lactate, and with the extent of use of inotropic drugs in postoperative period. The cytokines were measured in samples withdrawn after induction of anesthesia, after 10 minutes of cardiopulmonary bypass, after re-establishment of circulation, and then 2 and 24 hours after the end of cardiopulmonary bypass. The levels of tumour necrosis factor-alpha and interleukin-6 increased between the beginning and at two hours of the end of cardiopulmonary bypass. There was no correlation between the levels of these cytokines in the serum and the length of cardiopulmonary bypass, although there was a positive relation between levels of interleukin-6 and lactate in samples withdrawn at two hours of the end of bypass, and the measured levels of the cytokines correlated with the extent of inotropic drugs employed in the postoperative period.

Reconstruction of the pulmonary valve and outflow tract with bicuspid prosthesis in tetralogy of Fallot

BACKGROUND

Right ventricular outflow tract and pulmonary valve implant in patients with tetralogy of Fallot may be required to avoid late postoperative right ventricular impairment. The use of porcine bicuspid prosthesis might be a technical alternative, although comprehensive studies on the long-term use of these prostheses are not available.

METHODS

Sixty-three patients (aged 5 months to 34 years; mean, 6 years) with tetralogy of Fallot and pulmonary hypoplasia underwent surgical repair and enlargement of the right ventricular outflow using preserved porcine pulmonary bicuspid prostheses. Fifty-two patients (82.5%) were followed and underwent clinical evaluation and serial Doppler echocardiography. The first 15 patients (29.4%), with ages ranging from 5 to 16 years (mean, 8.2 years) and postoperative follow-up of 48 to 87 months (mean, 65.1 months) underwent hemodynamic and cineangiographic evaluations.

RESULTS

There were 11 deaths (17.4%) in the early postoperative period. Of the 52 surviving patients (82.5%), 51 (80.9%) were followed for 1 to 87 months (mean, 42.0 months). Four patients (7.6%) had additional treatment. Of the 15 patients (29.1%) undergoing hemodynamic evaluation, 9 (60%), had mild valvular pulmonary insufficiency and 6 (40%) had moderate insufficiency. Only the right ventricle-to-pulmonary artery pressure gradients and the right ventricular ejection fraction showed statistically significant differences between groups. Right ventricular dimension, although increased in all patients, did not show statistically significant differences.

CONCLUSIONS

Right ventricular outflow tract and pulmonary valve repair in patients with tetralogy of Fallot using a bicuspid porcine pulmonary prosthesis is a simple, reliable procedure with good results in postoperative medium term follow-up.

Structural and functional characteristics of rat hearts with and without myocardial infarct. Initial experience with Doppler echocardiography

OBJECTIVE

To assess by Doppler echocardiography the structural and functional alterations of rat heart with surgical induced extensive myocardial infarction.

METHODS

Five weeks after surgical ligature of the left coronary artery, 38 Wistar-EPM rats of both sexes, 10 of them with extensive infarction, undergone anatomical and functional evaluation by Doppler echocardiography and then euthanized for anatomopathological analysis.

RESULTS

Echocardiography was 100% sensible and specific to anatomopathological confirmed extensive miocardial infarction. Extensive infarction lead to dilatation of left ventricle (diastolic diameter: 0.89 cm vs.0.64 cm; systolic: 0. 72 cm vs. 0.33 cm) and left atrium (0.55 cm vs. 0.33 cm); thinning of left ventricular anterior wall (systolic: 0.14 cm vs. 0.23 cm, diastolic: 0.11 cm vs. 0.14 cm); increased mitral E/ A wave relation (6.45 vs. 1.95). Signals of increased end diastolic ventricle pressure, B point in mitral valve tracing in 62.5% and signs of pulmonary hypertension straightening of pulmonary valve (90%) and notching of pulmonary systolic flow (60%) were observed in animals with extensive infarction.

CONCLUSION

Doppler echocardiography has a high sensitivity and specificity for detection of chronic extensive infarction. Extensive infarction caused dilatation of left cardiac chambers and showed in Doppler signals of increased end diastolic left ventricular pressure and pulmonary artery pressure.

Multiple arterial anomalies in the newborn infant. Echocardiographic and angiographic diagnosis

Multiple arterial anomalies characterized by tortuosity and rolling of the pulmonary arteries and aorta were diagnosed on echocardiography in an asymptomatic newborn infant with a phenotype suggesting Ehlers-Danlos syndrome. These changes were later confirmed on angiography, which also showed peripheral vascular abnormalities. The electrocardiogram showed a probable hemiblock of the left anterosuperior branch, and the chest x-ray showed an excavated pulmonary trunk with normal pulmonary flow.

Association of pulmonary atresia with intact ventricular septum and aortic valve stenosis. Prenatal diagnosis

A rare association of pulmonary atresia with an intact septum was diagnosed through echocardiography in a fetus 32 weeks of gestational age. The diagnosis was later confirmed by echocardiography of the newborn infant and further on autopsy. The aortic valve was bicuspid with a pressure gradient of 81 mmHg, and the right ventricle was hypoplastic, as were the pulmonary trunk and arteries, and the blood flow was totally dependent on the ductus arteriosus.

Gap junctions in the cardiovascular and immune systems

Gap junctions are clusters of intercellular channels directly connecting the cytoplasm of adjacent cells. These channels are formed by proteins named connexins and are present in all metazoan organisms where they serve diverse functions ranging from control of cell growth and differentiation to electric conduction in excitable tissues. In this overview we describe the presence of connexins in the cardiovascular and lympho-hematopoietic systems giving the reader a summary of the topics to be covered throughout this edition and a historical perspective of the discovery of gap junctions in the immune system.