Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Recovery or Bridge to Heart Replacement Therapy in Refractory Cardiogenic Shock.

PURPOSE OF THE REVIEW: The purpose of this review is to describe the outcomes following refractory cardiogenic shock (CS) requiring mechanical circulatory support and factors associated with successful and unsuccessful weaning from VA-ECMO. Based on the presented data, we will propose a weaning and bridging algorithm with the aim of facilitating this complex process. RECENT FINDINGS: Refractory CS requiring VA-ECMO support is associated with high early mortality. Approximately 1/3 of the patients weaned from ECMO do not survive until hospital discharge. When evaluating the ability to wean from ECMO etiology of CS, hemodynamics, end-organ function, pulmonary blood oxygenation, metabolic status, and echocardiographic assessments must be considered. When cardiopulmonary function is not recoverable, heart replacement therapies (HRT) should be considered early as patients may have better outcomes. Durable weaning from VA-ECMO is obtainable in well-selected patients. Patients should be separated from the ECMO circuit in the presence of myocardial recovery, hemodynamic stability, and restored end-organ function. If myocardial recovery is unsatisfactory (severe LV dysfunction), HRT should be considered early in suitable candidates. Future research is needed to identify predictors of sustained myocardial recovery.

Ornithodoros capensis sensu stricto (Ixodida: Argasidae) in Coiba National Park: first report for Panama, with notes on the O. capensis group in Panamanian shores and Costa Rica.

Ornithodoros capensis sensu lato (s.l.) is a morphologically similar group of soft ticks that parasitizes mostly seabirds in continental and offshore territories worldwide. Ornithodoros capensis sensu stricto (s.s.) has been previously recorded in many islands and coastal localities along the American continent; however, some records from Central America remain obscure. In this work we performed morphological and molecular analyses on soft ticks collected in Coiba National Park, an archipelago located in the Pacific Ocean off the coast of Panama, confirming the occurrence of O. capensis s.s. in this country for the first time. In addition, a morphological examination of museum specimens collected in Costa Rica, and a further locality in Panama, confirmed that O. capensis s.l. is established in the former country, and that its distribution along Panamanian shores is likely larger.

In vitro Validation of Quantitative Light-Induced Fluorescence for the Diagnosis of Enamel Fluorosis in Permanent Teeth.

This study aimed to validate quantitative light-induced fluorescence (QLF) as a diagnostic tool for mild and moderate enamel fluorosis in permanent teeth, comparing it to visual diagnosis and histological assessment completed using polarized light microscopy (PLM). The buccal surfaces of 139 teeth were visually classified using the Thylstrup and Fejerskov Index (TFI) into sound (TFI 0; n = 17), mild (TFI 1-2; n = 69), and moderate (TFI 3-4; n = 43) fluorosis. Fluorosis was then assessed with QLF (variables ΔF, A, and ΔQ at 5-, 15-, and 30-radiance thresholds) using as reference areas the entire surface and a region of interest (ROI), identified as the most representative region of a fluorosis lesion. PLM images of longitudinal thin sections including the ROI were assessed for histological changes. Correlations among TFI, PLM, and QLF were determined. A receiver-operating characteristic curve was conducted to determine QLF's diagnostic accuracy when compared to the TFI and PLM assessments. This was used to assess the probability that the images were correctly ranked according to severity as determined by PLM and TFI. A positive correlation was found between QLF and PLM, and between QLF and TFI. QLF showed the highest sensitivity and specificity for the diagnosis of mild fluorosis. There was also a strong agreement between TFI and PLM. The selection of a ROI resulted in a stronger correlation with TFI and PLM than when the entire surface was used. The study results indicate that defining an ROI for QLF assessments is a valid method for the diagnosis of mild and moderate enamel fluorosis.

A Randomized Controlled Trial of a Mobile Health Intervention to Promote Self-Management After Lung Transplantation.

Lung transplant recipients are encouraged to perform self-management behaviors, including (i) monitoring health indicators, (ii) adhering to their regimen, and (iii) reporting abnormal health indicators to the transplant coordinator, yet performance is suboptimal. When hospital discharge was imminent, this two-group trial randomized 201 recipients to use either the mobile health (mHealth) intervention (n = 99) or usual care (n = 102), to compare efficacy for promoting self-management behaviors (primary outcomes) and self-care agency, rehospitalization, and mortality (secondary outcomes) at home during the first year after transplantation. The mHealth intervention group performed self-monitoring (odds ratio [OR] 5.11, 95% confidence interval [CI] 2.95-8.87, p < 0.001), adhered to medical regimen (OR 1.64, 95% CI 1.01-2.66, p = 0.046), and reported abnormal health indicators (OR 8.9, 95% CI 3.60-21.99, p < 0.001) more frequently than the usual care group. However, the two groups did not differ in rehospitalization (OR 0.78, 95% CI 0.36-1.66, p = 0.51) or mortality (hazard ratio 1.71, 0.68-4.28, p = 0.25). The positive impact of the mHealth intervention on self-management behaviors suggests that the intervention holds promise and warrants further testing.

Hard ticks (Acari: Ixodidae) of livestock in Nicaragua, with notes about distribution.

We document the species of ticks that parasitize livestock in Nicaragua. The study was based on tick collection on cattle and horses from 437 farms in nine departments. Of 4841 animals examined (4481 cows and 360 horses), 3299 were parasitized, which represent 68 % of the bovines and 67 % of the equines in study: 59 cows and 25 horses were parasitized by more than one species. In addition, 280 specimens of the entomological museum in León were examined. The ticks found on cattle were Rhipicephalus microplus (75.2 % of the ticks collected), Amblyomma mixtum (20.8 %), A. parvum (2.6 %), A. tenellum (0.7 %), A. maculatum (0.7 %). While the ticks collected from the horses were: Dermacentor nitens (41.5 %), A. mixtum (31.7 %), R. microplus (13.8 %), A. parvum (6.5 %), A. tenellum (3.3 %), D. dissimilis (2.4 %) and A. maculatum (0.8 %).

A novel dual ex vivo lung perfusion technique improves immediate outcomes in an experimental model of lung transplantation.

The lungs are dually perfused by the pulmonary artery and the bronchial arteries. This study aimed to test the feasibility of dual-perfusion techniques with the bronchial artery circulation and pulmonary artery circulation synchronously perfused using ex vivo lung perfusion (EVLP) and evaluate the effects of dual-perfusion on posttransplant lung graft function. Using rat heart-lung blocks, we developed a dual-perfusion EVLP circuit (dual-EVLP), and compared cellular metabolism, expression of inflammatory mediators, and posttransplant graft function in lung allografts maintained with dual-EVLP, standard-EVLP, or cold static preservation. The microvasculature in lung grafts after transplant was objectively evaluated using microcomputed tomography angiography. Lung grafts subjected to dual-EVLP exhibited significantly better lung graft function with reduced proinflammatory profiles and more mitochondrial biogenesis, leading to better posttransplant function and compliance, as compared with standard-EVLP or static cold preservation. Interestingly, lung grafts maintained on dual-EVLP exhibited remarkably increased microvasculature and perfusion as compared with lungs maintained on standard-EVLP. Our results suggest that lung grafts can be perfused and preserved using dual-perfusion EVLP techniques that contribute to better graft function by reducing proinflammatory profiles and activating mitochondrial respiration. Dual-EVLP also yields better posttransplant graft function through increased microvasculature and better perfusion of the lung grafts after transplantation.

Molecular screening of tick-borne microorganisms in ticks from rural areas of Panama, with the first record of Ehrlichia minasensis in Rhipicephalus microplus from Central America.

During a molecular screening of rickettsial, borrelial and protozoal agents in ticks from rural areas of Panama, we detected DNA of Rickettsia amblyommatis in four Amblyomma mixtum collected from horses in a locality in Los Santos province. Ehrlichia minasensis and Anaplasma marginale were identified from three and two Rhipicephalus microplus, respectively, collected on cows from Chiriqui province. No DNA from other tick-borne agents was found. These results increase the information of R. amblyommatis and A. marginale in Panama, and also mark the first record of E. minasensis in Central America.

Epidemiology and outcomes of deep surgical site infections following lung transplantation.

We conducted a retrospective study of deep surgical site infections (SSIs) among consecutive patients who underwent lung transplantation (LTx) at a single center from 2006 through 2010. Thirty-one patients (5%) developed SSIs at median 25 days after LTx. Empyema was most common (42%), followed by surgical wound infections (29%), mediastinitis (16%), sternal osteomyelitis (6%), and pericarditis (6%). Pathogens included Gram-positive bacteria (41%), Gram-negative bacteria (41%), fungi (10%) and Mycobacterium abscessus, Mycoplasma hominis and Lactobacillus sp. (one each). Twenty-three percent of SSIs were due to pathogens colonizing recipients' native lungs at time of LTx, suggesting surgical seeding as a source. Patient-related independent risk factors for SSIs were diabetes and prior cardiothoracic surgery; procedure-related independent risk factors were LTx from a female donor, prolonged ischemic time and number of perioperative red blood cell transfusions. Mediastinitis and sternal infections were not observed among patients undergoing minimally invasive LTx. SSIs were associated with 35% mortality at 1 year post-LTx. Lengths of stay and mortality in-hospital and at 6 months and 1 year were significantly greater for patients with SSIs other than empyema. In conclusion, deep SSIs were uncommon, but important complications in LTx recipients because of their diverse microbiology and association with increased mortality.

Lung transplantation in patients with prior cardiothoracic surgical procedures.

The full spectrum of prior cardiothoracic procedures in lung transplant candidates and the impact of prior procedures on outcomes after lung transplantation (LTx) remain unknown, though the impact is considered to be large. Patients transplanted at our institution from 2004 to 2009 were identified (n = 554) and divided into two groups: patients who had undergone cardiothoracic surgical (CTS) procedures prior to LTx (n = 238) and patients who had not (non-CTS: n = 316). Our primary endpoint was survival. Secondary endpoints included allograft function and the incidence of major complications including reexploration due to bleeding, prolonged ventilation, renal insufficiency and primary graft dysfunction. Long-term survival was not significantly different between the groups whereas postoperative bleeding, nerve injury, respiratory and renal complications were higher in the CTS group. Posttransplant peak FEV1 was lower in the CTS group (73.4% vs. 86.9%, p < 0.05). In multivariate analysis, performance of a chemical pleurodesis procedure and prolonged cardiopulmonary bypass were significantly associated with mortality (OR, 1.7; CI, 1.5-2.0; p < 0.005). Our results suggest that patients with LTx and prior CTS remain technically challenging and experience worse outcomes than patients without prior CTS. A surgical strategy to minimize cardiopulmonary bypass time is critical for these challenging LTx patients.

Ticks (Ixodida) on humans from central Panama, Panama (2010-2011).

From January 2010 to December 2011, a total of 138 cases of ticks feeding on humans were reported from 11 locations in central Panama. Five of these locations were situated in forest environments, three in rural landscapes and three in urban areas. The ticks were submitted to the Gorgas Memorial Institute, where nine species were identified among 65 specimens: Amblyomma cajennense s.l., A. dissimile, A. naponense, A. oblongoguttatum, A. ovale, A. sabanerae, A. tapirellum, Haemaphysalis juxtakochi and Rhipicephalus sanguineus s.l. The remaining 73 specimens consisted of unidentified immature ticks, all belonging to the genus of Amblyomma. Rhipicephalus sanguineus s.l. was the species most frequently associated with humans, particularly in urban environments. In rural landscapes, tick bites were most often caused by A. cajennense s.l., whereas A. tapirellum was the species most often found parasitizing humans in forest environments. These data provide information on the tick species most commonly associated with humans in forested environments, rural areas and cities around the Panama Canal.

[Alpha-Lactalbumin as an ingredient of infant formula]. / Alpha-Lactoalbúmina como ingrediente de fórmulas infantiles.

Alpha-Lactalbumin is the main whey protein in human milk rising 2,44 g/L in mature milk. It has a key function in the synthesis of lactose from glucose and galactose in the mammary gland although this compound has also other beneficial effects on the infant health due to the high proportion of essential aminoacids (tryptophan and cysteine). It seems also to increase iron absorption in the digestive track, and in in vitro experiments, linked to oleic acid (HAMLET complex), has shown anticarcinogenic effects against cellular tumor such as human papilloma. In addition, this complex has been reported to exhibit antimicrobial properties against Streptococcus pneumoniae, Haemophilus influenzae, enteropathogenic strains of Escherichia coli and Salmonella thypimurium. However, the in vivo synthesis of HAMLET complex during milk digestion has not been proved yet. Infant formula have been improved considerably during the last decades not only adapting nutrient concentrations to infants requirements but also by the addition of new bioactive ingredients such as alpha-lactalbumin, to have the same functional effect as in breast fed babies.

Internal rotation analysis of the microwave and millimeter wave spectra of fluoral (CF3CHO).

The rotational spectrum (4-40 GHz and 50-330 GHz) has been measured and analyzed for trifluoroacetaldehyde, also known as fluoral (CF3CHO), which is one of the degradation products of the fluorinated contaminants emitted into the atmosphere. The complexity of the spectroscopic analysis of this molecule arises from the strong coupling between the internal rotation motion of CF3 group and the overall rotation of the molecule. The value obtained for its coupling constant (ρ = 0.91723481(49)) is comparable to the corresponding value of methanol (CH3OH, ρ = 0.81), which is known for its complex spectrum. A total of 12,322 transitions of the ground, the first and second excited torsional states (ΔE1υt = 62.0183(13)cm-1; ΔE2υt = 120.3315(13)cm-1) with J ≤ 50 were included in the analysis that was performed employing the rho-axis-method (RAM), and the RAM36 code. A fit within experimental error (root mean square deviation equals to 35 kHz) has been achieved for this dataset using 47 parameters of the RAM torsion-rotation Hamiltonian. In the course of the analysis, it became evident that for such high ρ value, as it is determined for fluoral, a larger than usual torsional basis set at the first diagonalization step of the two-step diagonalization procedure is required for achieving a fit within experimental error.

Ticks infesting humans in Central America: A review of their relevance in public health.

Ticks are blood-sucking arthropods that parasitize most groups of terrestrial or semiaquatic vertebrates. Humans are accidental hosts to the ticks; however, in humans the ticks can cause damages varying from simple irritation to severe allergies, toxicosis, paralysis, and the transmission of pathogens, some of which can be fatal. Central America represents a narrow isthmus between North and South America and is considered a biodiversity hotspot. The importance of tick-borne diseases in this region is manifested by fatal outbreaks caused by Rickettsia rickettsii, severe and mild cases of other rickettsioses, ehrlichiosis, and tick-borne relapsing fevers, in addition to cases paralysis and strong allergic reactions. Even so, this information is scarce in most countries of this region, and there are no epidemiological data. In this article we present a review of the ticks that parasitize humans in Central America, covering data from the 19th Century to the present day. Of nearly 80 tick species reported in Central America, 28 species are reported on humans. This list includes species that thrive within homes, grazing areas and, to a lesser extent, in wild environments, both in lowland and high mountain forests. The most important genus in this region is Amblyomma, followed by Rhipicephalus and Ornithodoros, and to a lesser extent Haemaphysalis, Ixodes and Dermacentor. These data provide information on the tick species most commonly associated with humans in Central America, and highlight the potential for tick-borne diseases in wild, rural and urban regions.

Comprehensive rotational study and astronomical search for cyclopropanecarboxaldehyde.

CONTEXT: At least a dozen molecules with a formyl group (HCO) have been observed to date in the interstellar medium (ISM), suggesting that other such species exist and remain to be discovered. However, there is still a lack of high-resolution spectroscopic data for simple molecular species of this type that could provide a basis for their detection. AIMS: Cyclopropanecarboxaldehyde, c-C3H5CHO, is a small molecule containing a formyl group and is therefore an interesting candidate for astrophysical detection. The rotational spectrum of cyclopropanecarboxaldehyde has been observed before, but its experimental rotational parameters are not precise enough to allow its detection in the millimetre-wave domain. METHODS: We measured the rotational spectrum of cyclopropanecarboxaldehyde in the frequency ranges 31.5-50 GHz and 72-116.5 GHz using the GACELA (GAS CEll for Laboratory Astrophysics) broadband high-resolution rotational spectrometer constructed at the Yebes Observatory. The spectroscopic study was supported by high-level theoretical calculations which were used in the identification of the vibrational excited states of cyclopropanecarboxaldehyde. RESULTS: Our analysis of the rotational spectrum of cyclopropanecarboxaldehyde allowed us to obtain accurate rotational parameters for the ground state of both cis and trans isomers, which were used to derive sufficiently reliable predictions up to 300 GHz. In addition to the ground states, we identified 12 and 6 vibrationally excited states for the trans and cis isomers, respectively, including fundamental modes, multiple excitation quanta, and combination states. We find that the gas phase concentration of the trans isomer is almost 1.2 times larger than that of the cis one. These new experimental rotational parameters were employed to search for cyclopropanecarboxaldehyde in the warm molecular clouds Orion KL and Sgr B2(N) using the spectral surveys captured by ALMA (Orion) and IRAM 30 m (Sgr) at 1 mm and 3 mm, respectively.

Discovery of the acetyl cation, CH3CO+, in space and in the laboratory.

Using the Yebes 40m and IRAM 30m radiotelescopes, we detected two series of harmonically related lines in space that can be fitted to a symmetric rotor. The lines have been seen towards the cold dense cores TMC-1, L483, L1527, and L1544. High level of theory ab initio calculations indicate that the best possible candidate is the acetyl cation, CH3CO+, which is the most stable product resulting from the protonation of ketene. We have produced this species in the laboratory and observed its rotational transitions Ju = 10 up to Ju = 27. Hence, we report the discovery of CH3CO+ in space based on our observations, theoretical calculations, and laboratory experiments. The derived rotational and distortion constants allow us to predict the spectrum of CH3CO+ with high accuracy up to 500 GHz. We derive an abundance ratio N(H2CCO)/N(CH3CO+)~44. The high abundance of the protonated form of H2CCO is due to the high proton affinity of the neutral species. The other isomer, H2CCOH+, is found to be 178.9 kJ mol-1 above CH3CO+. The observed intensity ratio between the K=0 and K=1 lines, ~2.2, strongly suggests that the A and E symmetry states have suffered interconversion processes due to collisions with H and/or H2, or during their formation through the reaction of H 3 + with H2CCO.

Molecular screening for tick-borne bacteria and hematozoa in Ixodes cf. boliviensis and Ixodes tapirus (Ixodida: Ixodidae) from western highlands of Panama.

The first molecular screening for Rickettsia, Anaplasma, Ehrlichia, Borrelia, Babesia and Hepatozoon was carried out in questing Ixodes cf. boliviensis and Ixodes tapirus from Talamanca Mountains, Panama, using specific primers, sequencing and phylogeny. Phylogenetic analyses for the microorganisms in Ixodes cf. boliviensis confirmed the presence of Rickettsia sp. strain IbR/CRC endosymbiont (26/27 ticks), three genotypes of the Borrelia burgdorferi (sensu lato) complex (4/27 ticks), Babesia odocoilei (1/27 ticks), and Hepatozoon sp. (2/27 ticks), tentatively designated Hepatozoon sp. strain Chiriquensis. Phylogenetic analyses for the microorganisms in I. tapirus revealed an undescribed Rickettsia sp., tentatively designated Rickettsia sp. strain Itapirus LQ (6/6 ticks), and Anaplasma phagocytophilum (2/6 ticks). To the best of our knowledge, this is the first report of B. burgdorferi (s.l.) complex, A. phagocytophilum, B. odocoilei, and Hepatozoon sp. in Ixodes ticks from Central America, and also the first detection of Rickettsia spp. in Ixodes species in Panama. In light of the importance of these findings, further studies are needed focusing on the role of I. tapirus and I. cf. boliviensis as vectors, and the vertebrates acting as reservoirs.

Rickettsia amblyommatis isolated from Amblyomma mixtum (Acari: Ixodida) from two sites in Panama.

Rickettsia amblyommatis is widely distributed in the Americas, and has been reported to infect different species of ticks within its distribution. In Panama, R. amblyommatis is the most common Rickettsia and its presence was molecularly detected in nine species of ticks and one flea species. This work described the isolation of R. amblyommatis in Vero cells by shell vial technique, from Amblyomma mixtum ticks collected from a captive tapir from Gamboa (Colon province), and a horse from El Valle de Antón (Cocle province). These represent the first isolations of R. amblyommatis in Panama.

Alemtuzumab induction prior to cardiac transplantation with lower intensity maintenance immunosuppression: one-year outcomes.

Induction therapy with alemtuzumab (C-1H) prior to cardiac transplantation (CTX) may allow for lower intensity maintenance immunosuppression. This is a retrospective study of patients who underwent CTX at a single institution from January 2001 until April 2009 and received no induction versus induction with C-1H on a background of tacrolimus and mycophenolate. Those with C-1H received dose-reduced calcineurin inhibitor and no steroids. A total of 220 patients were included, 110 received C-1H and 110 received no induction. Recipient baseline characteristics, donor age and gender were not different between the two groups. Mean tacrolimus levels (ng/mL) for C-1H versus no induction: months 1-3 (8.5 vs. 12.9), month 4-6 (10.2 vs. 13.0), month 7-9 (10.2 vs. 11.9) and month 10-12 (9.9 vs. 11.3) were all significantly lower for the C-1H group, p < 0.001. There were no differences between the C-1H and no induction groups at 12 months for overall survival 85.1% versus 93.6% p = 0.09, but freedom from significant rejection was significantly higher for the C-1H group, 84.5% versus 51.6%, p < 0.0001. In conclusion, induction therapy after CTX with C-1H results in a similar 12 month survival, but a greater freedom from rejection despite lower calcineurin levels and without the use of steroids.

Mycoplasma hominis pericarditis in a lung transplant recipient: review of the literature about an uncommon but important cardiothoracic pathogen.

Purulent pericarditis due to Mycoplasma hominis is rare, and is usually associated with mediastinitis or pleuritis following cardiothoracic surgery. We report the first case to our knowledge of isolated purulent pericarditis caused by M. hominis in a lung transplant recipient and review previously reported cases of this disease.

The millimeter-wave spectrum and astronomical search for ethyl methyl sulfide.

CONTEXT: Sulfur-containing molecules constitute only 8% of the molecules observed in the interstellar medium (ISM), in spite of the fact that sulfur has been shown to be an abundant element in the ISM. In order to understand the chemical behavior of the ISM and specific cases like the missing sulfur reservoir, a detailed chemical molecular composition in the ISM must be mapped out. AIMS: Our goal is to investigate the rotational spectrum of ethyl methyl sulfide, CH3CH2SCH3, which ms to be a potential candidate for observation in the ISM since the simpler analogs, CH3SH and CH3CH2SH, have already been detected. Rotational spectrum of ethyl methyl sulfide has been observed before, but its experimental rotational parameters are not precise enough to allow its detection in the ISM. METHODS: The rotational spectrum of ethyl methyl sulfide in the frequency range 72-116.5 GHz was measured using a broadband millimeter-wave spectrometer based on radio astronomy receivers with fast Fourier transform backends. The spectral searches and identification of the vibrational excited states of ethyl methyl sulfide was supported by high-level ab initio calculations on the harmonic and anharmonic force fields. RESULTS: The rotational spectra for the trans and gauche conformers of ethyl methyl sulfide was analyzed, and a total of 172 and 259 rotational transitions were observed for each one, respectively. The observation of A - E internal rotation splittings allowed the experimental determination of the V 3 hindered internal rotation barrier height for both trans and gauche species. In addition, the vibrational excited states, resulting from the lowest frequency vibrational mode ν 30 were identified for both conformers. The new experimental rotational parameters were employed to search for ethyl methyl sulfide in the warm and cold molecular clouds Orion KL, Sgr B2(N), B1-b and TMC-1, using the spectral surveys captured by IRAM 30 m at 3 mm and 2 mm.