Risk scores' performance and their impact on operative decision-making in left-sided endocarditis: a cohort study.

The accuracy of contemporary risk scores in predicting perioperative mortality in infective endocarditis (IE) remains controversial. The aim is to evaluate the performance of existent mortality risk scores for cardiovascular surgery in IE and the impact on operability at high-risk thresholds. A single-center retrospective review of adult patients diagnosed with acute left-sided IE undergoing surgery from May 2014 to August 2019 (n = 142) was done. Individualized risk calculation was obtained according to the available mortality risk scores: EuroScore I and II, PALSUSE, Risk-E, Costa, De Feo-Cotrufo, AEPEI, STS-risk, STS-IE, APORTEI, and ICE-PCS scores. A cross-validation analysis was performed on the score with the best area under the curve (AUC). The 30-day survival was 96.5% (95%CI 91-98%). The score with worse area under the curve (AUC = 0.6) was the STS-IE score, while the higher was for the RISK-E score (AUC = 0.89). The AUC of the majority of risk scores suggested acceptable performance; however, statistically significant differences in expected versus observed mortalities were common. The cross-validation analysis showed that a large number of survivors (> 75%) would not have been operated if arbitrary high-risk threshold estimates had been used to deny surgery. The observed mortality in our cohort is significantly lower than is predicted by contemporary risk scores. Despite the reasonable numeric performance of the analyzed scores, their utility in judging the operability of a given patient remains questionable, as demonstrated in the cross-validation analysis. Future guidelines may advise that denial of surgery should only follow a highly experienced Endocarditis Team evaluation.

High D dimers and low global fibrinolysis coexist in COVID19 patients: what is going on in there?

BACKGROUD: COVID-19 coagulopathy linked to increased D-dimer levels has been associated with high mortality (Fei Z et al. in Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet (London, England) 395(10229):1054-62, 2020). While D-dimer is accepted as a disseminated intravascular coagulation marker, rotational thromboelastometry (ROTEM) also detects fibrinolysis (Wright FL et al. in Fibrinolysis shutdown correlates to thromboembolic events in severe COVID-19 infection. J Am Coll Surg (2020). Available from https://pubmed.ncbi.nlm.nih.gov/32422349/ [cited 14 Jun 2020]; Schmitt FCF et al. in Acute fibrinolysis shutdown occurs early in septic shock and is associated with increased morbidity and mortality: results of an observational pilot study. Ann Intensive Care 9(1):19, 2019). We describe the ROTEM profile in severely ill COVID-19 patients and compare it with the standard laboratory coagulation test. METHODS: Adult patients diagnosed with COVID-19 admitted to the ICU were prospectively enrolled after Ethics Committee approval (HCB/2020/0371). All patients received venous thromboembolism prophylaxis; those on therapeutic anticoagulation were excluded. The standard laboratory coagulation test and ROTEM were performed simultaneously at 24-48 h after ICU admission. Sequential organ failure assessment (SOFA), disseminated intravascular coagulation (DIC) and sepsis-induced coagulopathy (SIC) scores were calculated at sample collection. RESULTS: Nineteen patients were included with median SOFA-score of 4 (2-6), DIC-score of 1 (0-3) and SIC-score of 1.8 (0.9). Median fibrinogen, D-dimer levels and platelet count were 6.2 (4.8-7.6 g/L), 1000 (600-4200 ng/ml) and 236 (136-364 109/L), respectively. Clot firmness was above the normal range in the EXTEM and FIBTEM tests while clot lysis was decreased. There was no significant correlation between ROTEM or D-dimer parameters and the SOFA score. CONCLUSION: In COVID-19 patients, the ROTEM pattern was characterized by a hypercoagulable state with decreased fibrinolytic capacity despite a paradoxical increase in D-dimer levels. We suggest that, in COVID-19 patients, the lungs could be the main source of D-dimer, while a systemic hypofibrinolytic state coexists. This hypothesis should be confirmed by future studies.

Tuberculosis of the esophagus.

We report a case of a patient with esophageal tuberculosis, a very uncommon form of extrapulrhonar tuberculosis. Initially, because of constitutional symptomatology and radiological findings of mediastinal lymph node enlargement, lymphoma was considered. However, the endoscopic findings of ulcerative masses and a sinus tract revealed by esophagram were suspicious of tuberculous origin. Diagnosis was achieved after bacterial examination of smear samples from esophageal ulcers that revealed bacillus tuberculous and histological demonstration of caseating granulomas in cervical lymph nodes. Tuberculous mediastinal lymphadenitis was thought to be source of the spread to esophagus.The patient was successfully treated with a three antituberculous drugs regimen. In spite of its rarity, even in patients without risk factors, the diagnosis would be considered in the differential diagnosis of uncertain esophageal lesions.

Idiopathic intracranial hypertension: descriptive analysis in our setting.

INTRODUCTION: Idiopathic intracranial hypertension is a disorder characterised by increased intracranial pressure without evidence of an expansive intracranial process or cerebrospinal fluid cytochemical alterations. PATIENTS AND METHOD: We reviewed the medical records of patients with idiopathic intracranial hypertension admitted to our hospital between 1999 and 2009 and who met the modified Dandy criteria. We collected the following data: age, body mass index (BMI), outlet pressure of cerebrospinal fluid, cardiovascular history, imaging studies, treatment, and outcome. RESULTS: We analysed 61 patients (19 males and 42 females) with a mean age of 35.38 years. A BMI above the normal range was determined for 72.13% of the patients, although 47.37% of males showed normal weight. Fifty per cent of patients had a cardiovascular risk factor, especially dyslipidaemia, hypertension, and contraceptive drugs in women. Headache was the main presenting symptom, followed by visual field defects and other visual disturbances. Bilateral papilledema was present in 81.96% of the patients. CONCLUSIONS: The approximate incidence is 1.2/100,000 individuals/year. The condition is more common in young women with higher body weight and it is also associated with contraceptive drugs. Headache with bilateral papilloedema and impaired visual acuity stand out as the main symptoms. An interesting finding from this study is that male patients had a lower BMI, a lower incidence of headache and increased visual impairment.

[Association between single nucleotide genetic polymorphisms in ABC transporter genes with drug-resistant epilepsy in the Spanish population]. / Asociación entre los polimorfismos genéticos de nucleótido único en genes transportadores ABC con la epilepsia farmacorresistente en la población española.

INTRODUCTION: Almost a third of all patients with epilepsy (30%) fail to respond to pharmacological treatment. The presence of single nucleotide polymorphisms (SNPs) in the individual may influence the variability of the response to drug treatment. The transporter hypothesis posits that the presence of SNPs in the genes encoding ABC proteins would affect the bioavailability of antiseizure drugs at the epileptogenic focus, giving rise to refractoriness. The aim of the present study was to evaluate the association of 13 polymorphisms in the ABCB1, ABCC2, ABCC5 and ABCG2 genes with drug-resistant epilepsy (DRE) in a Spanish population. SUBJECTS AND METHODS: A case-control study was conducted involving 327 patients with epilepsy: 227 resistant to drug therapy and 100 in whom their medication enabled them to control their symptoms, according to International League Against Epilepsy criteria. In the peripheral blood leukocyte DNA that was extracted, polymorphisms in the ABC transporter genes were studied. The iPlex® Gold and Mass ARRAY technology platform was used. The allele and genotypic frequencies of the case and control groups, p-value, odds ratio and 95% confidence intervals were compared. RESULTS: The allele and genotypic frequency of the present study was similar to that reported in population-based databases. For the SNPs studied, no significant differences (p > 0.05) were found in any of the inheritance models analysed. CONCLUSIONS: Our results suggest that there is no association between the polymorphisms analysed in the ABC genes and DRE in the Spanish population. Nevertheless, further studies will confirm or refute these results.

TITLE: Asociación entre los polimorfismos genéticos de nucleótido único en genes transportadores ABC con la epilepsia farmacorresistente en la población española.Introducción. El 30% de los pacientes con epilepsia no responde al tratamiento farmacológico. La presencia de polimorfismos genéticos de nucleótido único (SNP) en el individuo puede influir en la variabilidad de respuesta al tratamiento farmacológico. La hipótesis de transportadores plantea que la presencia de SNP en los genes que codifican las proteínas ABC repercutiría en la biodisponibilidad de los fármacos anticrisis en el foco epileptógeno, lo que ocasionaría refractariedad. El objetivo del presente estudio fue evaluar la asociación de 13 polimorfismos en los genes ABCB1, ABCC2, ABCC5 y ABCG2 con la epilepsia farmacorresistente (EFR) en población española. Sujetos y métodos. Se realizó un estudio de casos y controles que incluyó a 327 pacientes con epilepsia: 227 farmacorresistentes y 100 farmacocontrolados según los criterios de la Liga Internacional contra la Epilepsia. En el ADN de leucocitos de sangre periférica extraído se estudiaron los polimorfismos en los genes transportadores ABC. Se utilizó la plataforma tecnológica iPlex® Gold y Mass ARRAY. Se compararon las frecuencias alélicas y genotípicas del grupo de casos y del de controles, el valor de p, la odds ratio y los intervalos de confianza al 95%. Resultados. La frecuencia alélica y genotípica del presente estudio fue similar a la comunicada en las bases de datos poblacionales. En los SNP estudiados no se encontraron diferencias significativas (p > 0,05) en todos los modelos de herencia analizados. Conclusiones. Nuestros resultados sugieren que no existe asociación entre los polimorfismos analizados en los genes ABC con la EFR en población española. Sin embargo, otros estudios adicionales confirmarán o descartarán estos resultados.

Second victim phenomenon in a surgical area: Online survey.

BACKGROUND AND AIM OF STUDY: An effective and accessible first source of support for second victims (SV) is usually the colleagues themselves, who should have tools to help emotionally and detect the unusual course of a SV. The aim of this work is to assess health professionals' perception of the phenomenon, as well as their capability to apply psychological first aid. MATERIAL AND METHODS: Observational descriptive study through online surveys answered anonymously. Participants were different health professionals from surgical area, mainly from a third-level hospital. RESULTS: 329 responses, 67 anaesthesiologists, 110 anaesthesiologists in training, 152 nurses. 78.4% had felt SV, more frequent among anaesthesiologists; however, 58% had never heard of the term. Guilt was the most frequent emotion. Residents were more afraid of judgmental colleagues and thought more about drop out their training. From those who sought help, most did it through a colleague, but most did not feel useful in helping a SV. 66% affirmed there is a still punitive, evasive or silent culture about medical incidents. CONCLUSIONS: Despite the frequency of the phenomenon there is still lack of knowledge of the term SV. Impact of the phenomenon is heterogenous and changes based on experience and responsibility. Colleagues are the first source of emotional help but there is a lack of tools to be able to provide it. Institutions are urged to create training programs so that professionals can guarantee «psychological first aid¼.

Second victim phenomenon in a surgical area: online survey. / El fenómeno de segunda víctima en un área quirúrgica: Encuesta online.

BACKGROUND AND AIM OF STUDY: An effective and accessible first source of support for second victims (SV) is usually the colleagues themselves, who should have tools to help emotionally and detect the unusual course of a SV. The aim of this work is to assess health professionals' perception of the phenomenon, as well as their capability to apply psychological first aid. MATERIAL AND METHODS: Observational descriptive study through online surveys answered anonymously. Participants were different health professionals from surgical area, mainly from a third-level hospital. RESULTS: 329 responses, 67 anaesthesiologists, 110 anaesthesiologists in training, 152 nurses. 78.4% had felt SV, more frequent among anaesthesiologists; however, 58% had never heard of the term. Guilt was the most frequent emotion. Residents were more afraid of judgmental colleagues and thought more about drop out their training. From those who sought help, most did it through a colleague, but most did not feel useful in helping a SV. 66% affirmed there is a still punitive, evasive or silent culture about medical incidents. CONCLUSIONS: Despite the frequency of the phenomenon there is still lack of knowledge of the term SV. Impact of the phenomenon is heterogenous and changes based on experience and responsibility. Colleagues are the first source of emotional help but there is a lack of tools to be able to provide it. Institutions are urged to create training programs so that professionals can guarantee «psychological first aid¼.

Quantification of Photosynthetic Enzymes in Leaf Extracts by Immunoblotting.

In this chapter, we describe a method to extract and quantify photosynthetic enzymes using sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting. The method is particularly suitable for characterizing altered protein amounts in leaves of plants produced from genetic engineering or gene-editing approaches. We focus on RuBisCO and RuBisCO activase, a molecular chaperone required to sustain the activity of RuBisCO and CO2 fixation, yet the method can be easily adapted to investigate other leaf proteins of interest.

Usefulness of biomarkers on infection management: with or without them?

Infectious diseases are disorders caused by many different microorganisms that produce clinical conditions with a wide variation in patient-rated symptoms and severity. Therefore, different diagnostic and prognostic tools are needed to help make the most accurate decisions at each moment of patient´s care with suspected infection. This mini review will analyse how some biomarkers reduce the level of uncertainty in the making decision process at some phases of sepsis, including prompt identification of septic patients, early initiation of empiric broad-spectrum antimicrobials, regimen and duration.

Glycoprotein biosynthesis in small intestine. 3. Enzymatic basis for the difference in the antigenicity of mucins.

Rat small intestinal mucosa was examined for ability to produce mucins with human blood group A, B, and H activity. Blood group activity of the mucins was compared to antigenic activity of red blood cells in individual rats and the enzymatic basis for differences was investigated. Red cells in all the rats examined contained human blood group A and B antigens. All rats synthesized intestinal mucins having B and H antigenic activity but 57% failed to produce mucins with blood group A activity (A(-)); the remaining 43% (A(+)) produced A substance. The activities of five glycosyltransferases including alpha(1-->2) fucosyltransferase, the determinant of human secretor status, were measured in the intestine of A(+) and A(-) rats. Four enzymes were the same in both groups, while the fifth, N-acetylgalactosaminyltransferase, was present only in A(+) rats. The specificity of this latter enzyme, as found in the rat, appeared similar to that in humans, since it catalyzed addition of N-acetyl-D-galactosamine only to acceptors which had the H determinant structure. In the presence of the enzyme, A(-) mucin could be converted to A(+) mucin; this was shown both by hemagglutination inhibition and immunoprecipitin studies of the products of incubation of A(-) mucin with UDP-N-acetyl-D-galactosamine and the enzyme. These studies indicate that the difference between A(+) and A(-) rats is due to the apparent absence of N-acetylgalactosaminyltransferase in the intestinal mucosa of A(-) rats. These rats may provide experimental models for studies on the effect of ABO and secretor status on susceptibility to ulceration and carcinogenesis.

Polymorphonuclear leukocyte transmigration promotes invasion of colonic epithelial monolayer by Shigella flexneri.

In vivo and in vitro, Shigella flexneri, an invasive pathogen of the human colon, cannot invade epithelial cells through their apical pole. To identify ways by which it may reach the cellular basolateral domain in order to invade, we have established an assay using the human colonic T-84 cell line grown on permeable filters. Human PMN were added to the basal pole of the cells, and invasive shigellae to their apical pole. Apical addition of bacteria induced strong transmigration of PMN, reaching a maximum after 1 h of incubation. Transmigration depended on a receptor-specific interaction since it was inhibited by an anti-CD18 monoclonal antibody that antagonizes binding of MAC1 on its putative epithelial cell receptor. After 1 h of PMN transmigration, shigellae started to invade the monolayer in areas of intense PMN infiltration. Invasion was clearly dependant on PMN transmigration since it was also inhibited by addition of an anti-CD18 monoclonal antibody. This in vitro assay is consistent with in vivo observations showing early PMN efflux within colonic crypts in the course of shigellosis. PMN transmigration may therefore allow invasion in the colon by opening the paracellular pathway to invasive microorganisms.

Glycosyltransferases in human blood.I. Galactosyltransferase in human serum and erythrocyte membranes.

Human serum and hemoglobin-free erythrocyte membranes were found to contain a galactosyltransferase which catalyzes the transfer of galactose from UDP-galactose to specific large and small molecular weight acceptors. The requirements for enzyme activity were found to be similar for the enzymes from both sources. However, the membrane-bound enzyme depended on a detergent for maximal activity. Mn(++) was an absolute requirement for transfer and uridine nucleoside phosphates were inhibitors. The most effective acceptor for galactose was a glycoprotein containing N-acetylglucosamine residues in the terminal position of its oligosaccharide side chains, N-acetylglucosamine was also an acceptor. While the presence of alpha-lactalbumin in the incubation medium resulted in a significant decrease in the transfer of galactose to N-acetylglucosamine, glucose, which was not an acceptor for galactose in the absence of alpha-lactalbumin, became an excellent acceptor. The serum enzyme catalyzed the transfer of 54 nmoles of galactose per milliliter of serum per hour and its apparent K(m) for UDP-galactose was 7.5 x 10(-6)M. The membrane enzyme had a similar apparent K(m). Using a quantitative assay system the enzyme was found to be present in all individuals studied, regardless of their blood type, secretor status, or sex.

Glycosyltransferases in human blood. II. Study of serum galactosyltransferase and N-acetylgalactosaminyltransferase in patients with liver diseases.

Serum galactosyltransferase activity was found to be elevated in patients with alcoholic and other liver disorders but remained at a normal level in patients with a variety of nonhepatic diseases. The properties of the galactosyltransferase in patients with liver disease were compared with those of the enzyme in the serum of normal subjects. The possible presence of inhibitors or activators in the serum was examined. Results indicated that in patients with liver disease, the rise in the serum galactosyltransferase was due to an increase in the level of the enzyme present in normal serum and not due to the appearance of a new enzyme. In the cases examined, the level of the enzyme increased with the deterioration of liver function and declined in a patient recovering from acute alcoholic hepatitis. Another glycosyltransferase, an N-acetylgalactosaminyltransferase, was not elevated in the serum of liver disease patients and, unlike the galactosyltransferase, was not detected in normal liver. The results suggest that the serum galactosyltransferase originates from the liver and that an abnormal rise in the level of this enzyme in serum is due to hepatocellular damage.

Porous monolith microfluidics for bacterial cell-to-cell communication assays.

Genetically engineered bacteria can be used for a wide range of applications, from monitoring environmental toxins to studying complex communication networks in the human digestive system. Although great strides have been made in studying single strains of bacteria in well-controlled microfluidic environments, there remains a need for tools to reliably control and measure communication between multiple discrete bacterial populations. Stable long-term experiments (e.g., days) with controlled population sizes and regulated input (e.g., concentration) and output measurements can reveal fundamental limits of cell-to-cell communication. In this work, we developed a microfluidic platform that utilizes a porous monolith to reliably and stably partition adjacent strains of bacteria while allowing molecular communication between them for several days. We measured small molecule production by the bacterial populations in response to stimuli using analytical chemistry methods and measured fluorescent output. The results are compared with communication and diffusion delay models. This porous monolith microfluidic system enables bacterial cell-to-cell communication assays with dynamic control of inputs, relatively long-term experimentation with no cross contamination, and stable bacterial population size. This system can serve as a valuable tool in understanding bacterial communication and improving biosensor design capabilities.

Regional and cellular localization of glycosyltransferases in rat small intestine. Changes in enzymes with differentiation of intestinal epithelial cells.

Optimal assay conditions were determined for four glycosyltransferases in rat small intestinal mucosal homogenates and the regional distribution and cellular localization of these enzymes was studied. For each glycosyltransferase, similar levels of activity were found in duodenal, proximal jejunal and distal ileal segments; activities of the galactosyltransferases were lower in the distal jejunal-proximal ileal segment. Planar section studies indicated that the undifferentiated crypt cells had significantly higher levels of sialyltransferase activities in the jejunum and ileum than the mature villus cells. A similar crypt to villus gradient was found for a galactosyltransferase in the ileum. These data suggest that glycoprotein synthesis may be active in the undifferentiated crypt cells and that certain glycosyltransferases may serve as marker enzymes for cellular differentiation in the intestine.

In vivo influence of p53 status on proliferation and chemoradiosensitivity in non-small-cell lung cancer.

Alteration of the p53 gene product is a frequent event in the progression of lung cancer. However, its importance to proliferation and response to chemoradiotherapy remains unclear. Thus, to assess its influence directly in vivo, we implanted into nude mice two kinds of human non-small-cell lung cancer (NSCLC) cells: H226br having a homozygous gene mutation in p53 (mt-p53) and H226b with intact p53 (wt-p53). We found that mt-p53 tumors grew substantially faster than wt-p53 tumors. Furthermore, treatment with cisplatin and radiation did not reduce the size of mt-p53 tumors, while wt-p53 tumors regressed by approximately 60%. Terminal-deoxytransferase-mediated dUTP-biotin nick-end labeling assay revealed apoptosis to be the mechanism responsible for the regression. Interestingly, apoptosis occurred in mt-p53 tumors although only at high doses of cisplatin and not at the magnitude detected in wt-p53 tumors. Cell labeling by staining with bromodeoxiuridine indicated that p53 is an important factor in modulating growth in NSCLC tumors. Our results are consistent with the notion that correction of a single genetic lesion enhances the therapeutic effect of chemotherapy.

Molecular and cellular mechanisms of tissue invasion by Shigella flexneri.

Shigella flexneri, a member of the family of enterobacteriaceae, causes bacillary dysentery by invading the human colonic mucosa and provoking a very intense inflammation. Recent in vitro data allow us to integrate different phenomena into a model of the infectious process during shigellosis. In vivo, bacteria appear to enter the submucosa via the M cells, specialized cells that cover the follicular structures of the intestinal mucosa. Once inside the submucosa, shigellae encounter resident tissue macrophages, which are infected, and apoptosis is rapidly induced. During programmed cell death the inflammatory cytokine interleukin-1 (IL-1) is released. Interleukin-1 triggers an inflammatory reaction characterized by extravasation of polymorphonuclear (PMN) cells. The inflammation is probably potentiated by the production of other cytokines by epithelial, endothelial, and PMN cells. Polymorphonuclear cells migrate through the epithelium into the lumen of the colon, destabilizing the integrity of the epithelial barrier. The damaged epithelium allows massive entry of bacteria into the submucosa. Further colonization of the epithelium aggravates inflammation, which in turn causes extensive tissue destruction. Both the in vitro and in vivo results that support this model are discussed.

Containment sensors for the determination of L-lactate and glucose.

This paper reports some new results on enzyme based silicon containment sensors. For the first time an L-lactate sensor in containment technology is presented. Through optimization of the buffer system the stability of the lactate sensor was enhanced and the linear response of over 10 mM was achieved. The glucose sensor has also been optimized for a large linear measurement range exceeding 30 mM. A two-enzyme chip with glucose and lactate sensor elements which were integrated on one silicon chip is presented. The response behaviour of the two-enzyme chip was very similar to the single chip behaviour. No cross-talking effects could be observed. A fabrication process for mass-production is described.

Miniaturized real-time monitoring system for L-lactate and glucose using microfabricated multi-enzyme sensors.

A miniaturized on-line monitoring system for the detection of L-lactate and glucose is presented. The system is based on a microfabricated multi-enzyme silicon sensor chip with flow channels integrated on the chip. The sensors were fabricated in containment technology. They were characterized in test solutions. The cross-talking behaviour was investigated and was found to be practically negligible. The linear measurement ranges of both glucose and lactate sensors were large enough for most practical applications. As a result of the miniaturization the analyte consumption could be reduced to a few nmol min(-1). The system was equipped with a microdialysis probe whose recovery was 45% for lactate and 37% for glucose in test solutions using a flow rate of 3 microl min(-1). Lower flow rates of 0.5 microl min(-1) resulted in recoveries of over 90%. The long-term stability of the system was acceptable. Initial measurements have also been performed in vitro using human blood serum.

Penile metastasis secondary to cecum carcinoma: a case report.

To date, only around 300 cases of metastasis to the penis have been reported and the primary cancer has been generally found in genitourinary structures. However, exceptional cases in which the primary site has been situated in organs like esophagus, pancreas, stomach have been published. We report an uncommon case in which the primary tumor was located in the cecum. To our knowledge, this is the first case of penile metastasis in which the responsible tumor was located in the cecum and in which the mode of metastasis was not direct invasion. As the tumor was restricted to the colon wall without invasion to neighbouring structures, and because colon cancer follows mainly the lymph-vascular route to its dissemination, this route is the most likely mode of the spread. By magnetic resonance imaging (MRI) on penile shaft, multiple nodules were clearly visualized. Nevertheless, as in most cases, in spite of the availability of advanced and precise diagnostic methods, the information was of little value for the patient. His survival was short.