Association between mean arterial pressure and neurological outcome in survivors of a cardiac arrest undergoing targeted temperature management

Background

Besides targeted temperature management (TTM), no other therapeutic strategy has shown to improve neurological outcome in cardiac arrest patients. Recently, it has been suggested that higher levels of mean arterial blood pressure (>90 mmHg) may have a protective neurological effect in this population, yet data is scarce.

Objective

To describe the association between neurological outcomes and MAP during TTM.

Methods

Retrospective study of a prospective database including survivors of a cardiac arrest undergoing TTM and admitted to the acute cardiac care of a tertiary university hospital from September 2007 to July 2020. MAP was recorded from arrival and hourly during TTM. Neurological outcome was graded 3 months after initial event using the Pittsburgh Cerebral Performance Category (CPC) scale and patients were divided classified as follows: Group A patients with CPC of 1 to 2 (good neurological outcome), and group B, with CPC 3 to 5 (poor neurological outcome or death). As CPC 5 comprises patients who have died but whose cause of death may not be related to their neurological condition, we sort to control this potential source of bias, by including a variable of “severe neurological injury”, which includes patients with CPC 3–4 and those CPC 5 who died due to WLST due to poor neurological prognosis/brain death.

Results

A total pf 431 patients were analysed. Baseline and cardiac arrest characteristics are depicted in Table 1. Patients in group B had a higher proportion of non-witnessed cardiac arrest, out-of-hospital cardiac arrest, non-shockable rhythm, and longer time before ROSC. The relation between MAP and neurological outcome is shown in Table 2. The were no differences of MAP in day 1 and 3 between groups. MAP was statistically higher in Group A during day 2 or rewarming phase. Mean MAP during day 1 and 2; and during day 1, 2 and 3 was also significantly higher in group A. However, when same analysis was performed under the variable “severe neurological injury” no statistically significant differences were observed.

Conclusion

There is no association between MAP and neurological outcomes, when true “severe neurological injury” is analysed. Therefore, and until further data is obtained, following actual practical guidelines or avoiding hypotension seems to be the goal in this population, as higher MAP may also have deleterious effects.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital La Paz

Iron-reducing bacteria decompose lignin by electron transfer from soil organic matter

Iron-reducing bacteria (IRB) are crucial for electron transfer in anaerobic soil microsites. The utilization of the energy gathered by this mechanism by decomposers of organic matter is a challenging and fascinating issue. We hypothesized that bacteria reducing Fe(III) (oxyhydr)oxides to soluble Fe(II) obtain electrons from reduced soil organic matter (SOM_r) involving lignin oxidation. Iron-reducing bacteria were isolated from topsoils of various climates (humid temperate, cold temperate, subpolar), vegetation types (mostly grasslands and forests), and derived from various parent materials treatments assigned as Granitic, Volcanic-allophanic, Fluvio-glacial, Basaltic-Antarctic and Metamorphic. After the screening of IRB by phospholipid fatty acid (PLFA) analysis and PCR identification (full-length 16S rDNA), the IRB were inoculated to 20 samples (five soils and 4 replicates) and a broad range of parallel processes were traced. Geobacter metallireducens and Geobacter lovleyi were the main Geobacteraceae-strains present in all soils and strongly increased the activity of ligninolytic enzymes: lignin peroxidase and manganese peroxidase. Carbon dioxide (CO₂) released from IRB-inoculated soils was 140% higher than that produced by Fenton reactions (induced by H₂O₂ and Fe(II) addition) but 40% lower than in non-sterile soils. CO₂ release was closely correlated with the produced Fe (II) and H₂O₂ consumption. The highest CO₂ was released from Basaltic-Antarctic soils with the highest Fe content and was closely correlated with lignin depolymerization (detection by fluorescence images). All IRB oxidized the lignin contained in the SOM within a wide pH range and in soils from all parent materials. We present a conceptual model showing electron shuttling from SOM containing lignin (as a C and energy source) to IRB to produce energy and promote Fe(III) (oxyhydr)oxides reduction was proposed and discussed.

Contribution of the Fenton reaction and ligninolytic enzymes to soil organic matter mineralisation under anoxic conditions

Mechanisms of carbon dioxide (CO₂) release from soil in the absence of oxygen were studied considering the Fenton process, which encompasses the reaction of H₂O₂ with Fe(II) yielding a hydroxyl radical (OH), in combination with manganese peroxidase (MnP) and lignin peroxidase (LiP). This study aimed to explain the high rate of soil organic matter (SOM) mineralisation and CO₂ release from humid temperate rainforest soils under oxygen-limited conditions. The investigated mechanisms challenge the traditional view that SOM mineralisation in rainforest is slow due to anaerobic (micro)environments under high precipitation and explain intensive CO₂ release even under oxygen limitation. We hypothesised that the Fenton reaction (FR) greatly contributes to the CO₂ released from SOM mineralised under anaerobic conditions especially in the presence of ligninolytic enzymes. We used a novel technique that combines labelled H₂¹⁸O₂ and Fe(II) to induce the FR and measured CO¹⁸O, Fe(II) solubilisation, and peroxide consumption in a closed gas circulation system for 6 h. Maximal CO₂ amount was released when the FR was induced in combination with LiP addition. The CO₂ efflux with LiP was 10-fold that of abiotic FR reactions without enzymes, or in soils amended with MnP. This was consistent with i) the contribution of ¹⁸O from peroxide to CO₂ release, ii) peroxide consumption, and iii) Fe(II) solubilisation by FR. The amount of consumed peroxide was closely correlated with the CO¹⁸O derived from soil without enzyme addition or with LiP addition. Concluding, abiotic Fenton Reaction coupled with oxidative enzymes, such as LiP, are crucial for SOM oxidation under anaerobic conditions, e.g. in temperate rainforest soils.

Meta-analysis of heavy metal effects on soil enzyme activities

Enzyme activities (EAs) respond to contamination in several ways depending on the chemical form and content of heavy metals and metalloids (HMs) and their interactions with various soil properties. A systematic and mechanistic understanding of EA responses to HM contamination in soil is necessary for predicting the consequences for nutrient availability and the cycling of carbon (C), nitrogen (N), phosphorus (P) and sulphur (S). In this study, a meta-analysis based on 671 observations found the activities of seven enzymes to decrease in response to soil contamination with Pb, Zn, Cd, Cu and As. HM contamination linearly reduced the activities of all enzymes in the following order: arylsulfatase > dehydrogenase > β-glucosidase > urease > acid phosphatase > alkaline phosphatase > catalase. The activities of two endoenzymes: arylsulfatase (partly as exoenzyme) and dehydrogenase were reduced by 72% and 64%, respectively. These reductions were two times greater than of exoenzymes: β-glucosidase, urease, acid phosphatase, alkaline phosphatase and catalase (partly endoenzyme). This reflects the much stronger impact of HMs on living microorganisms and their endoenzymes than on extracellular enzymes stabilized on clay minerals and organic matter. Increasing clay content weakened the negative effects of HM contamination on EAs. All negative effects of HMs on EAs decreased with soil depth because HMs remain mainly in the topsoil. EAs involved in the cycling of C and S were more affected by HMs than the enzymes associated with the cycling of N and P. Consequently, HM contamination may alter the stoichiometry of C, N, P and S released by enzymatic decomposition of organic compounds that consequently affect microbial community structure and activity.

Cannabinoid hyperemesis syndrome, a treatment discussion

Introduction

Cannabinoid hyperemesis syndrome (CHS), is characterized by recurrent episodes of severe nausea and intractable vomiting, preceded by chronic use of cannabis. A pathognomonic characteristic is compulsive bathing in hot water. The resolution of the problem occurs when cannabis use is stopped. However, patients are often reluctant to discontinue cannabis. Treatment with anti-emetic medication is ineffective. Case series suggested haloperidol as a potential treatment. Other antipsychotics as olanzapine has been used as anti-emetic treatment in chemotherapy.

Objectives

To describe three cases of patients with CHS whom showed a successful response to olanzapine, even when, haloperidol had failed.

Aims

To present an alternative treatment for CHS which can offer benefits over haloperidol.

Methods

We present three cases of patients who suffered from CHS and were admitted to emergency department. All patients were treated with olanzapine after conventional anti-hemetic treatment failure. One patient was also unsuccessfully treated with haloperidol.

Results

All three patients showed a good response to olanzapine treatment. Different presentations were effective: velotab and intramuscular. Their nausea, vomits and agitation were ameliorated. They could be discharge after maintained remission of symptoms.

Conclusions

Olanzapine should be considered as an adequate treatment for CHS. Its suitable receptorial profile, its availability in different routes of administration and its side effects profile could offer some benefits over haloperidol.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

P6471Pronostic impact of significant valvular disease in long-term survivors of out-of-hospital-cardiac arrest

Background

There is scarce evidence about the prevalence and clinical relevance of moderate to severe valvular heart disease (VHD) in survivors of out of hospital cardiac arrest (OHCA).

Purpose

To determine whether VHD influence prognosis of OHCA survivors.

Methods

All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Univariate and multivariate Cox-proportional hazard models were employed.

Results

A total of 201 patients were included in the analysis. Mean age was 57.6±14.2 years and 168 (83.6%) were male. Eighteen patients (9.0%) had moderate or severe VHD during index admission (Table 1). Patients with VHD were less frequently of male sex, [11 (61.1%) vs 157 (85.8%), p=0.014], experienced less acute coronary syndrome-related arrhytmias [2 (11.1%) vs 85 (46.5%), p=0.005], and had a lower pH at hospital admission (6.9±1.6 vs 7.2±0.15, p=0.008). During a median follow-up of 40.3 (18.9–69.1) months, patients with VHD showed higher mortality [7 (38.9%) vs 28 (15.3%), p=0.004] and more heart failure-related admissions [7 (38.9%) vs 15 (8.2%), p<0.001]. Only five patients received surgical or percutaneous treatment for VHD during follow-up, with no deaths in this subgroup. Moderate or severe VHD proved to be an independent predictor of global cardiovascular events and specifically heart failure episodes (Figure 1).

Table1 Variable With valvular disease Without valvular disease p value Age, mean±DS, years 63.5±13.2 57.0±14.1 0.066 Hypertension, n (%) 12 (66.7) 95 (51.9) 0.231 Diabetes, n (%) 5 (27.8) 24 (13.1) 0.149 Dyslipidaemia, n (%) 7 (38.9) 79 (43.2) 0.726 Smokin habit, n (%) 4 (22.2) 90 (49.2) 0.045 Witnessed cardiac arrest, n (%) 18 (100) 175 (95.6) 1.000 Time from CA to ROSC, mean±DS, minute 19.1±7.5 21.2±13.1 0.506 Shockable rhythm, n (%) 13 (72.2) 163 (89.1) 0.055 LVEF at hospital discharge (%) 42.8±12.1 46.9±14.6 0.254

Figure 1

Conclusion

The presence of significant VHD in survivors after OHCA is a predictor of poor outcomes. Specific management of VHD may be specially relevant in this high-risk patients and guideline-oriented therapy, including surgery and percutaneous intervention should be encouraged when indicated.

P5349Platelet/lymphocyte ratio as an inflammatory marker and predictor of short-term neurological outcomes in survivors after cardiac arrest

Background

Platelet/lymphocyte ratio (PLR), an inflammatory marker associated with poor outcomes in different clinical situations, may play a role in the proinflammatory state triggered during hypoxic-ischemic brain injury secondary to cardiac arrest.

Purpose

To study PLR dynamics and its relationship with neurologic outcomes in survivors after CA treated with target-temperature-management (TTM).

Methods

Observational retrospective study from a prospective database of survivors of in-hospital and out-of-hospital CA admitted to our Acute Cardiac Care Unit between August 2006 to December 2018. All patients received TTM according to our local protocol.

Results

A total of 466 patients were included. Mean age was 62.7±14.4 years and 102 (21.9%) were women. Baseline characteristics are shown in Table 1. 430 (92.2%) of CA were witnessed, 312 (67.0%) had ventricular fibrillation as initial cardiac rhythm. Among them, 236 (51.1%) survived until hospital discharge and 208 (45.1%) presented favorable neurological outcomes (a score 1 or 2 on cerebral performance category (CPC)). The mean value of PLR at admission and during targeted temperature was 100.4±5.2 and 224.5±7.3 respectively (mean difference 123.1±7.1, p<0.0001). This increase in PLR was significantly higher among patients with worse neurological outcomes (CPC 3–5, mean DPLR 138.2±5.5) at 3 months compared with survivors with CPC 1–2 (mean DPLR 108.2±6.3, p=0.0348 for paired comparison between both groups).

Table 1 Hypertension, n (%) 235 (54.9) Diabetes, n (%) 113 (26.4) Dyslipidaemia, n (%) 171 (40.0) Smocking habit, n (%) 208 (48.5) Time to ROSC mean ± SD, min 26.6±18.6 Mean arterial pressure at HA mean±DS, mmHg 81.3±22.1 pH at HA mean ± SD 7.18±0.16 Lactic at HA mean ± SD 6.37±4.42 ROSC: return of spontaneus circulation; HA: hospital admission.

Conclusion

Our findings reflect the impact of inflammation in neurological outcomes after OHCA treated with TTM. Major increases of PLR constitute a novel marker of poor prognosis during early assessment of OHCA patients.

Clozapine induced diarrhea

Introduction

Clozapine (CZP) is the only antipsychotic approved for resistant schizophrenia 1. Due to its side effects, CZP is not the first therapeutic option in a psychotic episode. Its anticholinergic effects often cause constipation, however, diarrhea have also been described in literature.

Objectives

We describe a patient with two episodes of severe diarrhea after clozapine initiation, which lead to CZP discontinuation.

Aims

Discuss about the differential diagnosis of diarrhea in CZP patients and the needing of a further studies for clarify the more appropriate management in CZP induced diarrhea.

Methods

We present a case report of a 46 years man diagnosed with schizoaffective disorder who presented two episodes of severe diarrhea with fever, which forced his transfer to internal medicine and UCI after CZP initiation.

Results

At the first episode analytical, radiological and histological findings led to Crohn's disease diagnosis, which required budesonide and mesalazine treatment. In the second episode, the digestive team concluded that the episode was due to clozapine toxicity despite the controversial findings (clostridium toxin and Crohn's compatible biopsies)

Conclusions

Diarrhea caused by CZP has been controversial in the literature. However due to the severity of digestive episodes and the paucity of alternative treatments further studies for a better understanding of its physiopathology are warranted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Polydipsia and intermittent hyponatremia

Introduction

Hyponatraemia occurs in 4% of schizophrenic patients. Dilutional hyponatraemia, due to inappropriate retention of water and excretion of sodium, occurs with different psychotropic medications and could lead to hippocampal dysfunction. This complication is usually asymptomatic but can cause severe problems, as lethargy and confusion, difficult to diagnose in mentally ill patients.

Objectives

To describe a case of a patient with psychotropic poli-therapy, admitted three times due to hyponatremia and the pharmacological changes that improved his condition.

Aims

To broadcast the intermittent hyponatraemia and polydipsia (PIP), a not rare condition, suffered by treated schizophrenic patients and discuss its physiopathology and treatment thorough a case report.

Methods

A 56-year schizophrenic male was admitted for presenting disorganized behavior, agitation, auditory hallucinations, disorientation, ataxia, vomits and urinary retention. He was on clomipramine, haloperidol and clotiapine (recently added), quetiapine, fluphenazine and clonazepam. After water restriction his symptoms improved and he was discharged. Twenty-five days later, he was readmitted for presenting the same symptoms and after water restriction, he was discharged. Five days later, he was again admitted and transferred to the psychiatric ward.

Results

Haloperidol, fluphenazine and clomipramine were replaced by clozapine. These changes lead him to normalize the hypoosmolality and reduce his water-voracity. Endocrinology team did not label this episode of SIADH due to its borderline blood and urine parameters.

Conclusions

Hyponatremia is frequent in schizophrenic patients and may have severe consequences. Therefore, a prompt recognition and treatment is warranted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Large-scale conversion of helical-ribbon carbon nanofibers to a variety of graphene-related materials

The control of the oxidation time of helical-ribbon carbon nanofibers enables the production of a wide variety of graphene materials.

Modulating the Optoelectronic Properties of Silver Nanowires Films: Effect of Capping Agent and Deposition Technique

Silver nanowires 90 nm in diameter and 9 µm in length have been synthesized using different capping agents: polyvinyl pyrrolidone (PVP) and alkyl thiol of different chain lengths. The nanowire structure is not influenced by the displacement of PVP by alkyl thiols, although alkyl thiols modify the lateral aggregation of nanowires. We examined the effect of the capping agent and the deposition method on the optical and electrical properties of films prepared by Spray and the Langmuir-Schaefer methodologies. Our results revealed that nanowires capped with PVP and C8-thiol present the best optoelectronic properties. By using different deposition techniques and by modifying the nanowire surface density, we can modulate the optoelectronic properties of films. This strategy allows obtaining films with the optoelectronic properties required to manufacture touch screens and electromagnetic shielding.

Oral self-administration of buprenorphine in the diet for analgesia in mice

Postsurgical oral self-administration of analgesics in rodents is an interesting technique of providing analgesia, avoiding the negative effects of manipulation. Several strategies, using gelatin or nutella, have already been described. However, rodents require some habituation period to reach a good intake because of their neophobic behavior. The current study aimed to explore whether buprenorphine when mixed with an extruded diet offers a potential treatment option in the pain management of mice using a triple approach: by measuring the spontaneous intake in healthy animals; by using the hot-plate test; and finally by assessing the drug’s ability to provide postoperative analgesia in a surgical intervention of moderate severity (intra-utero electroporation). Mice consumed during 20 hours, similar amounts of extruded diet alone, mixed with glucosaline, and mixed with buprenorphine (0.03 mg per pellet) or meloxicam (0.25 mg per pellet) both of which were diluted in glucosaline, showing that no neophobia was associated with these administrations. Relative increase from baseline latency (% maximal possible effect) in the hot-plate test at 20 h of administration was significantly higher for oral buprenorphine in diet 0.03 mg/pellet, and diet 0.15 mg/pellet, compared with placebo and no differences were found between those oral administrations and subcutaneous buprenorphine 0.1 mg/kg measured 3 h later. The treatment was also effective in attenuating the reductions in food consumption and body weight that occur after surgery. These data suggest that providing buprenorphine with the diet is a feasible and effective way of self-administration of analgesia in mice and does not cause neophobia and may easily contribute to the refinement of surgical procedures.

Fitness effects of derived deleterious mutations in four closely related wild tomato species with spatial structure

A key issue in evolutionary biology is an improved understanding of the genetic mechanisms by which species adapt to various environments. Using DNA sequence data, it is possible to quantify the number of adaptive and deleterious mutations, and the distribution of fitness effects of new mutations (its mean and variance) by simultaneously taking into account the demography of a given species. We investigated how selection functions at eight housekeeping genes of four closely related, outcrossing species of wild tomatoes that are native to diverse environments in western South America (Solanum arcanum, S. chilense, S. habrochaites and S. peruvianum). We found little evidence for adaptive mutations but pervasive evidence for strong purifying selection in coding regions of the four species. In contrast, the strength of purifying selection seems to vary among the four species in non-coding (NC) regions (introns). Using F(ST)-based measures of fixation in subdivided populations, we suggest that weak purifying selection has affected the NC regions of S. habrochaites, S. chilense and S. peruvianum. In contrast, NC regions in S. arcanum show a distribution of fitness effects with mutations being either nearly neutral or very strongly deleterious. These results suggest that closely related species with similar genetic backgrounds but experiencing contrasting environments differ in the variance of deleterious fitness effects.

[The geriatric patient and emergency care]

Demand in emergency care has been growing progressively in recent years and this increase is more pronounced in the elderly population. Taking into account that the elderly patient requires more complex evaluations with a greater requirement for complementary tests and consultations with other specialists, longer stays in the emergency ward and a greater percentage of admissions, the progressive ageing of the population might come to have a serious repercussion on hospital emergency departments. It is vital to detect high risk elderly patients before assigning them a definitive placement. For this purpose it is important to install a sieving process amongst elderly patients who attend the emergency department in order to select those that will benefit from a comprehensive geriatric assessment and thus be able to design a specific care plan. Emergency intervention in elderly patients should not be faced exclusively as a medical problem, but functional, mental or social aspects should be taken into account. This represents a challenge for emergency care. This article considers different aspects such as the detection and assessment of the geriatric patient, as well as establishing certain recommendations for emergency setting.

Incidence of adult form of autoimmune hepatitis in Valencia (Spain)

BACKGROUND AND STUDY AIMS

There is little information on the incidence of autoimmune hepatitis (AIH) because on many occasions the disease can progress asymptomatically, different diagnostic criteria have been proposed during the last 20 years, and many epidemiological studies are based on retrospective clinical series. The aim of this study was to determine the incidence of AIH in the province of Valencia, Spain, during the year 2003.

PATIENTS AND METHODS

The Services of Gastroenterology of eight acute-care reference hospitals in the province of Valencia, Spain, covering 1,774,736 inhabitants over 14 years of age, participated in a prospective study. All newly diagnosed patients with AIH between January 1, 2003 and December 31, 2003 were eligible. The diagnosis was based on criteria of the International Autoimmune Hepatitis Group revised in 1999.

RESULTS

There were 19 new cases of AIH, 18 females and 1 male [mean (SD) age of 54.3 (11.2) years, range 23-73]. Incidence peaked in the 45-54 year age group. Eighteen cases were classified as AIH type 1 and one case as AIH type 2. The incidence rate of AIH for the year 2003 in people older than 14 years of age was 1.07 new cases per 100,000 inhabitants, with 1.96 cases per 100,000 inhabitants in females and 0.12 cases per 100,000 inhabitants in males.

CONCLUSIONS

The 2003 annual incidence of AIH in Valencia, Spain, was similar to that reported in other European countries. AIH occurred more frequently in women and in the 45-54 year age group, type 1 being the most common.

[Uncommon etiology of gastrointestinal bleeding: duodenal metastases from renal cell carcinoma]

Because of its unpredictable behavior, renal cell carcinoma is one of the most controversial neoplasms. On the one hand, patients frequently show metastases at diagnosis because of its slight manifestations, while on the other, the neoplasm can remain stable after nephrectomy and can then metastasize many years later. When this happens, the metastases usually involve more than 2 organs. The most frequent sites of metastases are the lung and lymph nodes, followed by the bones and liver, while duodenal involvement is rare. Indeed, intestinal metastases are found in only 2% of autopsies and of these, renal cell carcinoma metastases account for 7.1%. We present a case of a solitary late recurrence presenting as upper gastrointestinal bleeding 19 years after nephrectomy for clear cell renal carcinoma.

[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.