A new tool to quantify the geometrical characteristics of facial skin pores. Changes with age and a making-up procedure in Caucasian women.

BACKGROUND: Facial skin pores (FSP) are common and benign signs that generate frequent esthetic concerns or complaints. Despite their worldwide prevalence, related literature remains scarce. Hence, a new device has been developed and applied to validating studies, aiming at best describing FSP as they are self-perceived, i.e. their anatomic features, their possible alterations with age and their appearance after application of a make-up product. METHODS: Dermascore+® is an imaging device dedicated to a direct observation and acquisition of various characteristics of the skin surface. Images are captured under a high magnification and under different lighting configurations, to highlight the skin relief, based upon parallel polarized images. Dedicated software allows FSP to being detected and their morphological parameters to being extracted and computed. By measuring each detected FSP in a given region of interest, a statistically significant impact of both age and an applied cosmetic product upon their morphological features can be observed and quantified. RESULTS: Although the size and density of FSP are not affected by aging, their shape becomes elongated. A few tested make up products show variable effects that closely correlate with visual assessments made by trained estheticians. CONCLUSION: The shape of FSP present on cheeks shows age-related changes, toward a more elongated aspect, likely linked to a progressively altered (more isotropic) skin surface micro-relief. The new tool Dermascore+® allows foundations to being rapidly differentiated and screened according to their variable effects upon the visual appearance through instrumental, objective depiction of FSP.

The Tinea Hospital in Granada, 1679-1923: an institution with a long history.

The Tinea hospital in Granada, Spain, was a charitable health facility founded in the 17th century and still treating patients well into the 20th century. The hospital accepted patients from anywhere, not only those residing in the surrounding area. We describe the hospital's founding and the characteristics of the patients and caregivers. We also discuss how tinea was considered at the time, including the typology and treatment protocols applied as well as diet and hygiene measures used. It is striking that a hospital so focused on treating a single disease did not produce studies on the condition or on the application of contemporary knowledge to guide treatment.

Oxalosis and livedo reticularis.

Oxalosis is a disease caused by the deposition of calcium oxalate in extrarenal tissues, most commonly bone, myocardium, retina, blood vessels, and skin, causing the clinical manifestations of the disease. Involvement of the blood vessels of the skin can give rise to livedo reticularis, acrocyanosis, ulcers, and gangrene. We present the case of a 60-year-old woman with a history of recurrent renal lithiasis that had led to terminal renal failure requiring hemodialysis and, subsequently, peritoneal dialysis. The patient developed tender red-violaceous skin discoloration of sudden onset, consistent with livedo reticularis; the lesions progressed to form ulcers. Skin biopsy revealed oxalate vasculopathy. In this article we describe the characteristics of this rare disorder, its differentiation from calciphylaxis, and the therapeutic options.

[Peritoneal dialysis outcome. The Andalusian Registry Peritoneal Dialysis: 1999-2008]. / Diez años de diálisis peritoneal en Andalucía (1999-2008): datos epidemiológicos, tipos de tratamiento, peritonitis, comorbilidad y supervivencia de pacientes y técnica.

In this study we show the results derived from the processing of the data of the Registry of the patients on peritoneal dialysis that initiated renal replacement therapy in Andalucía between January of 1999 and December of 2008. All the information comes from the base of the Registry of Renal Patients of the Andalucia s Health Service. The results show demographic data, distribution by provinces, etiology of the end stage renal disease, reason for election of the peritoneal dialysis, inclusion or not in list of renal transplant, catheter data, withdraws and their causes, and peritonitis data of 2008. We also analyze in the report, from 1999-2008: annual incidence, diabetes, automatic peritoneal dialysis and peritonitis incidence. Finally we have studied patient and technique survival and factors affecting mortality on peritoneal dialysis, the initial comorbid conditions and its impact in the patient s survival.

Use of nonabsorbable polymer ligaclip in hand-assisted laparoscopic nephrectomy for living donor.

BACKGROUND: Laparoscopic living donor nephrectomy for kidney transplantation is a technique that began in South America only recently. This procedure offers several advantages compared with open nephrectomy due to the minor pain, better cosmetic results, and shorter length of hospital stay. Herein we have described our experience with the use of nonabsorbable polymer ligaclip (NPL) to control the renal artery, vein, and ureter in hand-assisted laparoscopic donor nephrectomy (HALN). METHODS: We performed a review of 85 HALNs for renal transplantation at our institution between January 2004 and August 2007. We evaluated the preoperative characteristics of the donor, surgical parameters, and complications. RESULTS: Fifty six percent of donors were men. Mean donor age was 34.4 years (range = 18 to 60). Left-sided nephrectomy was performed in 85%. Mean surgical time was 132 minute (range = 90 to 240) and among the last 35 nephrectomies, 120 minute (range = 90 to 180). Mean warm ischemia time was 240 seconds (range = 120 to 420). Conversion rate was 1.1%. Mortality was one case (1.1%) secondary to an episode of massive pulmonary thromboembolism. Mean length of hospital stay was 2.5 days (range 2 to 5) and mean blood loss, 125 mL. No complication related to the NPL was observed. CONCLUSIONS: Laparoscopy living donor nephrectomy was a safe procedure for kidney transplantation. The training and experience of the surgeon was reflected in shorter times of surgery. The NPL was safe and cost-effective, not increasing morbidity of the procedure.

Experience with Alemtuzumab (Campath-1H) as induction agent in renal transplantation followed by steroid-free immunosuppression.

BACKGROUND: The purpose of this study was to describe the initial experience with alemtuzumab as induction followed by steroid-free immunosuppression in kidney transplantation. METHODS: One hundred patients who received renal transplants from living and deceased donors were followed for a median period of 12 months (range = 1 to 12). A 30-mg intravenous dose of Alemtuzumab was administered on the transplant day, preceded by a 500-mg methylprednisolone dose. Maintenance immunosuppression consisted in the use of a calcineurin inhibitor in association with mycophenolic acid. Maintenance C2 levels of cyclosporine were between 400 and 600 ng/dL; or of tacrolimus, between 4 and 7 ng/dL. Prophylaxis included valgancyclovir, trimethoprim-sulfamethoxasole, and nystatin. All patients were evaluated for acute rejection episodes, adverse events, or death. RESULTS: The cumulative incidences of acute rejection at 1, 3, 6, and 12 months were 0%, 4% (n = 4), 5% (n = 5), and 8% (n = 8), respectively. Most episodes were Banff 1 a or b (88%). The infectious complication rate was 23%. There was no case of cytomegalovirus infection or posttransplant lymphoproliferative disease. Three patients died: one due to tuberculosis; one, sepsis; and one, an acute coronary event. No patient was lost to follow-up. CONCLUSIONS: This study suggested the safety and efficacy of Campath-1H as an induction agent in renal transplant recipients.

Conversion therapy to everolimus in renal transplant recipients: results after one year.

BACKGROUND: Two new diagnoses have been causing graft loss during long-term follow-up, namely, chronic nephropathy and anticalcineurinic toxicity. The advent of the mammalian target of rapamycin (m-TOR) obviates anticalcineurine toxicity and reduces posttransplant malignancy incidence with good inmunosuppressive potential. We examinated the renal and metabolic behavior in renal transplant recipients who required conversion from an anticalcineurinic (cyclosporine or tacrolimus) to an m-TOR inhibitor (everolimus) as part of their immunosuppressive maintenance therapy. MATERIALS AND METHODS: Twenty-one first renal transplant recipients had everolimus added to their inmunosuppressive therapy combined with an antimetabolite (mycophenolate mofetil or sodium mycophenolate). The mean age of the patients was 35 +/- 17 years (range, 6 to 65). The prevalence of male recipients was 57%; the overall mean weight, 64 kg (range, 48 to 95). All patients were hispanic with 15 transplants from cadaveric donors (71%). The mean follow-up posttransplant was 18 months (range, 3 to 40) and the mean follow-up on everolimus, 10 months (range, 2 to 22). RESULTS: There was no mortality or graft loss, but there were 3 (17%) biopsy-confirmed acute rejection episodes. There were no significant changes in metabolic function pre- or postconversion. Regarding renal function, the mean creatinine serum showed a trend to decline: preconversion 1.7 mg/dL; postconversion 1.5 mg/dL. In 10 patients, it was possible to discontinue at least one antihypertensive medication (48%). CONCLUSIONS: Everolimus was an effective medication to manage renal transplant patients. It produced metabolic stability and low myelotoxicity, despite combination with an antimetabolite (mycophenolic acid). Also, reduction of antihypertensive medications was an additional benefits for many patients.

Organ donation in Latin America.

Recently in Latin America, there has been a strong influence of the "Spanish model" of organ procurement. In 2001, The "Punta Cana Group" was created by Latin American transplantation coordinators with the objective of registering and improving the system of donation and procurement. In many countries there is no universal financial support from the government for medical treatment, including dialysis and transplantation. In other countries there is complete financial support for all of the population, including immunosuppressive drugs. Practically all countries have transplantation laws that follow ethical concepts, such as brain death diagnosis criteria, forms of consent, criteria of allocation, and inhibition of commerce. The rate of potential donors notified in countries that perform transplantations with deceased donors varied from 6 to 47 per million population yearly (pmp/y); The rate of effective donors varied from 1 to 20 pmp. In 2004, the mean rate of effective donors in Latin America was 5.4 pmp. The family refusal rate for the donation of organs varied from 28% in Uruguay to 70% in Peru. In some countries, such as Puerto Rico, Uruguay, and Cuba, it was more than 15 pmp, whereas in others countries deceased donors were practically not used. The number of patients on the waiting list for solid organ transplants in 12 Latin American countries is 55,000. Although the donation rate has increased by 100% during the last 10 years, it is lower than that in Europe (15 pmm/y) or the United States (20 pmp/y).

Safety assessment of the conversion from mycophenolate mofetil to enteric-coated mycophenolate sodium in stable renal transplant recipients.

The immunosuppressant mycophenolate mofetil (MMF; CellCept) has greatly improved transplant recipients' clinical outcomes, but its efficacy may be limited by dose adjustments due to adverse events (AEs). An enteric-coated formulation of mycophenolate sodium (EC-MPS; myfortic), designed to improve gastrointestinal tolerability is now available. This Latin-American, prospective, multicenter, open-label, 6-month trial assessed the safety and tolerability of converting renal transplant recipients from MMF to EC-MPS. In total, 237 renal transplant recipients (stable > or = 3 months' posttransplant) receiving MMF (< or =1000 mg b.i.d.) were enrolled. Adults (n = 218) were converted to EC-MPS 720 mg b.i.d. (equimolar to MMF 1000 mg b.i.d.) even if they were initially receiving <1000 mg MMF b.i.d. (ie, 47 adults received a higher than equimolar dose of EC-MPS). Children (n = 19) were converted to EC-MPS 450 or 432 mg/m2 b.i.d. Patients also received cyclosporine microemulsion (Neoral) and corticosteroids. There were three acute rejections and no graft failures. The incidence of AEs was 59.9% (in those receiving a higher than equimolar EC-MPS dose it was 57.4%). In all, 22% of patients had gastrointestinal AEs, 37% had infections, and 4.8% had hematological AEs. Only 24 patients (10%) had an AE-related dose reduction. Seven of these patients had received higher than equimolar doses of EC-MPS. Patients can be safely converted from different doses of MMF to a standard dose of EC-MPS. The requirement for EC-MPS dose reduction to manage AEs was relatively low. Use of EC-MPS is a valid alternative for renal transplant recipients receiving maintenance MMF treatment.

Ultrastructure of the paraphysis cerebri of the water snake Natrix maura L.

Paraphyseal epithelial cells of Natrix maura have been studied with light and electron microscopy. They showed a clear polarity apically related to the third ventricle and, basally, to a connective tissue layer which surrounded the whole organ. The apical surface of the cells, attached by junctional complexes, showed many microvilli, scarce cilia, and some pinocytotic coated vesicles. In their apical cytoplasm many mitochondria and a well-developed golgi apparatus and endoplasmic reticulum were observed. Whereas lamellar bodies were abundant and closely related with mitochondria, glycogen particles were absent. Basal cell membrane showed infoldings where pinocytotic coated vesicles were detected. In the connective tissue layer, fenestrated sinusoids and fibrocytes, as well as rare unmyelinated nerve fibers engulfed by Schwann cells, were present. The possible active role of paraphyseal cells in exchanging substances between cerebrospinal fluid and blood is discussed.

Energetic behaviour of mitochondria isolated from rat livers perfused with a perfluorodecalin + N,N-perfluorodiethylcyclohexylamine emulsion.

Rat livers have been perfused with a saline control medium or with a perfluorocarbon emulsion containing perfluorodecalin and N,N-perfluorodiethylcyclohexylamine, and the respiratory rates and transmembrane electrical potentials of mitochondria isolated following perfusion have been evaluated. The results indicate that the perfluorocarbon emulsion used, by providing a good oxygen supply to the perfused liver, allowed to preserve the efficiency of mitochondrial oxidative phosphorylation.

Noninvasive evaluation of venous function in chronic venous disease.

Measurements of calf volume changes during treadmill ambulation were taken using mercury-in-Silastic (silicone rubber) strain gauges for noninvasive study of venous function in patients with chronic venous disease. Seventy-four limbs were evaluated: 24 with postphlebitic changes, 26 with superficial varicosities, and 24 normal. Calf volume changes as measured by mercury-in-Silastic strain-gauge plethysmography (MISSGP) during ambulation correlated well (r = 0.8) with simultaneously obtained direct venous pressure measurements. The refill time as measured by MISSGP also correlated with the pressure restoration time (r = 0.8). Patients with moderate-to-severe obstructive patterns as shown by contrast venography were found to decrease their calf volume with MISSGP significantly less (P less than 0.001) than did those patients with minimal or no obstruction of venous outflow as depicted by venography. MISSGP is shown to be a useful method of quantitatively evaluating the efficiency of the calf venous pump, the degree of reflux, and the severity of venous obstruction.

The expanded polytetrafluoroethylene graft. Three years' experience with 362 grafts.

A total of 362 polytetrafluoroethylene (PTFE) grafts were implanted in patients as vascular substitutes in a variety of vascular reconstructive procedures. A total of 184 were used in femoropopliteal bypass operations. Cumulative patency rates showed 74% patency at the end of the first year of observation and 58% after two and three years. Seventeen grafts were used for femorotibial bypasses, with a cumulative patency rate of 40.4% after one year. Ninety-eight grafts were implanted in the upper or lower extremity to serve as vascular access for hemodialysis. For this group, the cumulative one-year patency rate was 83%. Sixty-three additional grafts were implanted in various other anatomic locations. Based on this experience, the PTFE graft seems to be a promising and versatile vascular prosthesis, although it should be used cautiously.

Complications of percutaneous intra-aortic balloon pump use in patients with peripheral vascular disease.

Percutaneous intra-aortic balloon pump use may carry an increased risk for patients with peripheral vascular disease. To determine the incidence and types of associated complications, the medical records of 144 patients who underwent a total of 153 percutaneous intra-aortic balloon pump insertions were reviewed. Patients were divided into two groups. Group 1 was composed of 20 patients with a history of peripheral vascular disease. Group 2 was composed of 124 patients without such history; they underwent a total of 133 insertions. Nineteen major complications (12%) occurred, 12 in group 1 (60% of 20 insertions) and seven in group 2 (5% of 133 insertions). Major complications were further classified by their nature: embolic, occlusive, and technical. All three types of complications occurred more frequently in group 1. Embolic complications occurred more frequently in patients with aneurysms and proved the most lethal, with two of six deaths in group 1 resulting from this complication.

Limb salvage using high-pressure intermittent compression arterial assist device in cases unsuitable for surgical revascularization.

HYPOTHESIS: Intermittent compression therapy for patients with inoperable chronic critical ischemia with rest pain or tissue loss may have beneficial clinical and hemodynamic effects. STUDY DESIGN: Case series of 14 consecutive ischemic legs that underwent application of a 3-month treatment protocol during a 2(1/2)-year study. SETTING: Veterans Administration Hospital. PATIENTS: Thirteen patients with 14 critically ischemic legs (rest pain, n = 14; tissue loss, n = 13) who were not candidates for surgical reconstruction were treated with rapid high-pressure intermittent compression. The patients had a mean age of 76.2 years, 8 were diabetic, and they represented 10% of referrals for chronic critical ischemia. They were not amenable to revascularization owing to lack of outflow arteries (n = 7), lack of autogenous vein (n = 5), or poor general medical condition (n = 3). INTERVENTION: All patients were instructed to use the arterial assist device for 4 hours a day at home for a 3-month period. MAIN OUTCOME MEASURES: Limb salvage and calibrated pulse volume amplitude. RESULTS: After 3 months, 9 legs had a significant increase in pulse-volume amplitude (P< .05). These legs were salvaged, whereas the 4 amputated legs demonstrated no hemodynamic improvement. We noted a direct correlation between patient compliance and clinical outcome. Patients in whom limb salvage was achieved used their compression device for longer periods of time (mean time, 2.38 hours a day) compared with those who underwent amputation (mean time, 1.14 hours a day) (P< .05). These mean hours of use were derived from an hour counter built into the compression units. CONCLUSIONS: Intermittent high-pressure compression may allow limb salvage in patients with limb-threatening ischemia who are not candidates for revascularization. Further studies are warranted to assess intermittent compression as an alternative to amputation in an increasingly older patient population.

Coronary and carotid operations under prospective standardized conditions: incidence and outcome.

BACKGROUND: No randomized trial has yet evaluated the hypothetical benefit of carotid endarterectomy with coronary artery bypass grafting. This prospective review was undertaken to determine the differences between observed and predicted complication rates, as well as to define new predictors and assess costs in a standardized population. METHODS: A prospective nonrandomized study was undertaken over a 4-year period involving all coronary artery bypass graftings done at one institution. Operative procedure was standardized. All patients underwent preoperative screening for carotid disease. If 80% or more stenosis was present, combined coronary artery bypass grafting and carotid endarterectomy was performed. RESULTS: Of 2,071 patients, 1,987 had coronary artery bypass grafting only. In that group there were 34 strokes (1.7%) and 41 deaths (2.0%). Eighty-four patients underwent combined coronary artery bypass grafting/carotid endarterectomy and in that group there were four strokes (4.7%) and five deaths (5.9%). Independent risk factors for postoperative stroke were age (odds ratio 1.09; 95% confidence interval 1.04, 1.3), hypertension (odds ratio 2.67; 95% confidence interval 1.22, 5.23), extensively calcified aorta (odds ratio 2.82; 95% confidence interval 1.34, 5.97), and bypass time (odds ratio 1.01; 95% confidence interval 1.00, 1.02). Cost of a stroke was significant (p < 0.05) in both groups. CONCLUSIONS: Patients with carotid disease fall into a higher risk group than patients without it. This increased risk is not because of carotid disease alone. Patients without significant carotid disease, who suffered a perioperative stroke, fell into an even higher risk category. Furthermore, carotid endarterectomy was not a significant risk factor by either the univariate or the multivariate analysis.

Single-and dual-energy CT with monochromatic synchrotron x-rays.

We explored the potential for clinical research of computed tomography (CT) with monochromatic x-rays using the preclinical multiple energy computed tomography (MECT) system at the National Synchrotron Light Source. MECT has a fixed, horizontal fan beam with a subject apparatus rotating about a vertical axis; it will be used for imaging the human head and neck. Two CdWO4-photodiode array detectors with different spatial resolutions were used. A 10.5 cm diameter acrylic phantom was imaged with MECT at 43 keV and with a conventional CT (CCT) at 80 kVp: spatial resolution approximately equal to 6.5 line pairs (lp)/cm for both; slice height, 2.6 mm for MECT against 3.0 mm for CCT; surface dose, 3.1 cGy for MECT against 2.0 cGy for CCT. The resultant image noise was 1.5 HU for MECT against 3 HU for CCT. Computer simulations of the same images with more precisely matched spatial resolution, slice height and dose indicated an image-noise ratio of 1.4:1.0 for CCT against MECT. A 13.5 cm diameter acrylic phantom imaged with MECT at approximately 0.1 keV above the iodine K edge and with CCT showed, for a 240 micrograms I ml-1 solution, an image contrast of 26 HU for MECT and 13 and 9 HU for the 80 and 100 kVp CCT, respectively. The corresponding numbers from computer simulation of the same images were 26, 12, and 9 HU, respectively. MECT's potential for use in clinical research is discussed.

Current status of external counterpulsation.

This article traces the development of external counterpulsation from its beginnings to the present. Initially, counterpulsation was carried out by cannulating the femoral artery. The hemodynamic goals were to reduce the afterload of the left ventricle, and to raise or augment the diastolic pressure. This gave rise to the term "counterpulsation." The intra-aortic balloon is capable of producing these salutary effects because of its proximity to the outlet of the left ventricle. The same hemodynamic effects can be obtained by external counterpulsation. However, one must produce a negative pressure during cardiac systole, and ensure that this is applied to the lower extremities. The only clinical study in which this was done was in the treatment of patients in cardiogenic shock by Soroff and colleagues. The results of the clinical studies reviewed are all suggestive of benefits derived from external counterpulsation in a variety of clinical settings. These studies suggest the following avenues for improvement in the equipment used to carry out external counterpulsation: 1. Inclusion of the vascular bed of the buttocks to be subjected to the external pressures, as advocated by Zheng. 2. Inclusion of a negative pressure blanket, as advocated by Soroff. 3. Further investigation of graded-sequential external counterpulsation, using the buttocks and negative pressure. 4. Application of external counterpulsation earlier in cardiogenic shock and for at least 4 hours in acute myocardial infarction. Our evaluation is that this method has not been studied in a way that demonstrates its full potential. We feel that it is on the threshold of being shown to be useful in all of the clinical settings reviewed, and we hope that the necessary equipment will be created to allow investigators to establish its proper place in our therapeutic armamentarium.

Arthroscopically assisted semitendinosus and gracilis tendon graft in reconstruction for acute anterior cruciate ligament injuries in athletes.

We evaluated 69 arthroscopically assisted anterior cruciate ligament reconstructions for acute tears at an average followup of 60 months. We used a distally based single semitendinosus and gracilis tendon graft passed over the top and fixed to the femur. Combined medial collateral ligament lesions were seen in 30 knees, and they were repaired when found in the distal third (18 knees). The patients were instructed to recover motion preoperatively, and an early range of motion program was used postoperatively. At followup, symptoms of giving way were seen in five knees (7%). Graft failure was seen in seven knees (10%); failure was defined as a positive pivot shift (clunk or gross) or a side-to-side difference in anterior tibial displacement greater than 5 mm, as measured with a KT-1000 arthrometer. Permanent extension loss (3 degrees to 5 degrees) was found in two knees (3%). Patellofemoral crepitation was seen in eight knees (12%), but the condition was symptomatic in only one knee. Forty-six patients (67%) were active in pivoting sports before surgery and 37 (54%) remained active in these sports at followup. We concluded that this operation is simple, effective, and has a low complication rate. Further studies are necessary to elucidate if a stronger graft (e.g., a patellar tendon) would decrease the rate of graft failure without increasing complications.

Indirect measurement of systolic blood pressure in the rabbit.

Long-term studies of rabbit blood pressure require a reliable method for repeated blood pressure measurements. Ideally, this method would be simple, noninvasive, and accurate over the range of anticipated blood pressures. To facilitate our own studies of rabbit carotid artery graft patency, we have developed a technique for the indirect measurement of systolic blood pressure in the rabbit that utilizes a photoplethysmograph sensor placed distal to an inflatable air bladder positioned over the central ear artery. We have compared measurements obtained with this method to direct measurements of aortic pressure and found a linear correlation.