The gut microbiota profile in psoriasis: a Brazilian case-control study.

The pathogenesis of psoriasis, an immune-mediated chronic inflammatory skin disease, remains unclear. Studies have shown an association between psoriasis and intestinal inflammation; in this context, the influence of the gut microbiota on the immune response of psoriasis has become a focus of recent research. The present research evaluated the composition and diversity of the gut microbiota of 21 participants with psoriasis from a Brazilian referral dermatology service compared to 24 healthy controls. A stool sample was collected from each participant at the time of inclusion in the study, and the samples were analysed by sequencing the 16S rRNA gene. The recruitment of research participants involved matching between groups by sex, age, body mass index, comorbidities and smoking and the exclusion of several criteria that could potentially influence the gut microbiota and the interpretation of the data. There was an increase in the Dialister genus and Prevotella copri species in patients with psoriasis compared to the control group. A reduction in the Ruminococcus, Lachnospira and Blautia genera, as well as in the Akkermansia muciniphila species, was also verified in the psoriasis group compared to the control group. Furthermore, patients with psoriasis exhibited less gut microbiota diversity than controls.

[Bilateral and pneumomediastinal pneumothorax after transoral laser microsurgery and tracheotomy]. / Neumotórax bilateral y neumomediastino tras microcirugía transoral con láser y traqueotomía.

Transoral laser CO2 microsurgery is becoming an increasing used treatment option for cancer of the larynx and the pharynx. Amongst the advantages it has compared to open surgery and radiotherapy are, it less invasiveness, greater precision, better functional preservation of the organ, and less procedure-associated morbidity. However, this surgical technique is not without its complication, some being rare up until now, but with great clinical importance. We present the case of a patient subjected to microsurgery with a tracheotomy due to cancer of the larynx, who suffered a subcutaneous emphysema, and a bilateral and pneumomediastinal pneumothorax, requiring the appropriate measures for its control and stabilisation, which are described. A review was also performed of the current literature as regards anaesthetic considerations and the main peri-operative complications of laser microsurgery.

Frequency of specific CD8+ T cells for a promiscuous epitope derived from Trypanosoma cruzi KMP-11 protein in chagasic patients.

The K1 peptide is a CD8(+)T cell HLA-A*0201-restricted epitope derived from the Trypanosoma cruzi KMP-11 protein. We have previously shown that this peptide induces IFN-gamma secretion by CD8(+)T cells. The aim of this study was to characterize the frequency of K1-specific CD8(+)T cells in chagasic patients. Nineteen HLA-A2(+)individuals were selected from 50 T. cruzi infected patients using flow cytometry and SSP-PCR assays. Twelve HLA-A*0201(+)noninfected donors were included as controls. Peripheral blood mononuclear cells were stained with HLA-A2-K1 tetramer, showing that 15 of 19 infected patients have K1-specific CD8(+)T cells (0.09-0.34% frequency) without differences in disease stages or severity. Of note, five of these responders were A*0205, A*0222, A*0226, A*0259 and A*0287 after molecular typing. Thus, a phenotypic and functional comparison of K1-specific CD8(+)T cells from non-HLA-A*0201 and HLA-A*0201(+)infected patients was performed. The results showed that both non-HLA-A*0201 and HLA-A*0201(+)individuals have a predominant effector memory CD8(+)T cell phenotype (CCR7-, CD62L-). Moreover, CD8(+)T cells from non-HLA-A*0201 and HLA-A*0201(+)individuals expressed IL-2, IFN-gamma and perforin without any differences. These findings support that K1 peptide is a promiscuous epitope presented by HLA-A2 supertype molecules and is highly recognized by chagasic patients.

Holmium laser enucleation of the prostate and retropubic prostatic adenomectomy: morbidity analysis and anesthesia considerations.

OBJECTIVE: Holmium laser enucleation of the prostate (HoLEP) is an alternative to prostatic adenomectomy for the surgical treatment of benign prostatic hypertrophy. We analyzed our learning curve for this technique, and we compared it in a secondary manner with prostatic adenomectomy. MATERIALS AND METHODS: A retrospective comparative study was conducted that included the first 100 cases of HoLEP performed in our center and the latest 50 cases of retropubic adenomectomy. We collected data on the patients, the surgery, the anesthesia, the perioperative variables, the anesthesia complications and the postoperative variables, with a 6-month follow-up. We analyzed the learning curve without mentors for HoLEP and compared the characteristics of HoLEP in 2 separate phases (learning and stabilization phases) with the latest retropubic prostatic adenomectomies performed. RESULTS: Intradural anesthesia was the most common technique. The transfusion needs, length of stay (P<.01) and postoperative morbidity were lower for HoLEP than for adenomectomy. However, the retropubic adenomectomy group had larger initial prostate volumes (P<.001) and shorter surgical times (P<.001). Better surgical performance (P<.001) and a lower incidence of complications were observed in the HoLEP-B group (once the learning curve had been overcome) compared with the HoLEP-A group. CONCLUSION: In our center, HoLEP was introduced as a valid alternative to open retropubic adenomectomy, with excellent results in terms of morbidity and reduced hospital stay. In terms of the learning curve, we consider that approximately 50 patients (without mentor) is an appropriate cutoff. Local anesthesia is a good choice for the anesthesia technique.

Influence of heart transplantation on the natural history of patients with severe congestive heart failure.

In an attempt to study the influence of heart transplantation on the natural history of patients with severe congestive heart failure, we have reviewed our experience with 240 consecutive patients who were New York Heart Association class IV or III/IV, who had left ventricular ejection fraction less than 35%, who were younger than 65 years of age, and who were assessed for heart transplantation in our hospital since May 1986. Mean age was 47 +/- 12 years. Left ventricular ejection fraction was 20% +/- 6%. Eighty-seven percent were male. New York Heart Association class was IV in 88% and III/IV in 12%. The cause was ischemic heart disease in 35% of patients, valvular heart disease in 13% of patients, and primary dilated cardiomyopathy in 52% of patients. At initial assessment, heart transplantation was considered to be not indicated in 30% of patients, indicated in 51% of patients, and contraindicated in 19% of patients. During a follow-up of 13 +/- 13 months (2 to 64 months), 110 patients underwent transplantation (46%). Posttransplantation actuarial probability of survival was 70% at 3 years. Three-year probability of survival free from transplantation was significantly lower for patients older than 55 years of age (p < 0.05), for those with left ventricular ejection fraction less than 20% (p < 0.05), ischemic causes (p < 0.05), New York Heart Association class IV (p < 0.001), and indication/contraindication for transplantation (p < 0.001); no difference was noted for gender.(ABSTRACT TRUNCATED AT 250 WORDS)

Visceral Kaposi's sarcoma without mucocutaneous involvement in a heart transplant recipient.

Kaposi's sarcoma has been occasionally reported in heart transplant recipients, but its occurrence without mucocutaneous involvement is extremely rare. In these uncommon cases, the tumor can be indistinguishable from opportunistic infections, making diagnosis difficult. The case of a patient in whom visceral Kaposi's sarcoma was diagnosed by necropsy 6 months after heart transplantation is reported.

Repetitive nontreated episodes of grade 1B or 2 acute rejection impair long-term cardiac graft function.

BACKGROUND: Episodes of grade 1B or 2 acute heart rejection are usually not treated, and most of them resolve spontaneously. METHODS: With the aim to assess long-term outcome in patients with repetitive nontreated episodes of low-grade (1B, 2) acute rejection, we have studied 141 heart transplant recipients in whom the evolutive pattern of acute rejection during the first 6 months after transplantation could be determined. RESULTS: Forty-four patients (31%) had only grade 0 or 1A acute rejection episodes (pattern A); 23 patients (16%) had three or more episodes of grade 1B or 2 acute rejection without 3A or more advanced rejection (pattern B); 48 patients (34%) had one or two episodes of grade 3A, 3B, or 4 acute rejection only during the first 6 months after transplantation (pattern C); and 26 patients (19%) had three or more episodes of grade 3A, 3B, or 4 acute rejection (pattern D). Overall mortality was 11%, 26%, 19%, and 46% for patients with patterns A, B, C, and D, respectively. No difference was found among patterns with regard to incidence of graft atherosclerosis. Left ventricular ejection fraction at 1 year after transplantation was significantly lower (p < 0.05) for patients with pattern B (50% +/- 5% versus 59% +/- 7%, 59% +/- 11%, and 56% +/- 6% for patterns A, C, and D, respectively); cardiac index also was lower for patients with pattern B than for those with pattern A (3.6 +/- 0.6 versus 4.1 +/- 0.6 L/min/m2, p < 0.05). CONCLUSIONS: Although mortality was higher for patients with more severe episodes of acute rejection, only repetitive nontreated episodes of grade 1B or 2 rejection significantly impaired long-term graft function.

A randomized study comparing deflazacort and prednisone in heart transplant patients.

Prednisone is widely used by most heart transplantation units despite its frequent side effects. Deflazacort, an oral synthetic steroid with fewer side effects, has been successfully used in patients after heart transplantation, but a prospective study comparing deflazacort and prednisone in transplant patients is lacking. We have carried out, in the last year, a prospective trial of deflazacort versus prednisone involving 35 consecutive heart transplant patients. Two of these patients died perioperatively (surgical mortality, 5.7%), and another two were excluded from the protocol because of diabetes mellitus in one patient and active infection before transplantation in the other patient. Thus 31 patients were enrolled in the 3-month study. All of them were treated with antithymocyte globulin, 10 mg/kg/day for 3 days after transplantation, azathioprine, and cyclosporine; patients were randomly assigned groups: 15 patients to receive deflazacort therapy, 1.5 mg/kg/day, and 16 patients to receive prednisone therapy, 1 mg/kg/day, starting the first day after transplantation. Steroids were rapidly tapered, reaching the maintenance dose at 2 to 3 weeks after transplantation (prednisone, 0.15 mg/kg/day; deflazacort, 0.25 mg/kg/day). Both groups were similar in terms of age, gender, ABO identity, serum cyclosporine levels, azathioprine dosage, and pretransplantation serum glucose and lipids levels. Seven endomyocardial biopsies were performed on each patient, at 1, 2, 3, 5, 7, 10, and 13 weeks after transplantation. Incidence of acute rejection was similar between prednisone and deflazacort groups; 33% of patients receiving prednisone therapy and 42% of patients receiving deflazacort therapy had one episode of 3A or higher rejection (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

[Infectious endocarditis due to Q fever: a recurrent disease. Apropos a new case]. / Endocarditis infecciosa por fiebre Q: una enfermedad recurrente. A propósito de un nuevo caso.

We report a case of a patient with an aortic prosthetic valve who had Q fever endocarditis, glomerulonephritis and rapidly progressive renal failure. He was seen in 1987 and successfully treated by heart valve surgery and a one-year course of doxycycline. Five years later, the patient had another episode of Q fever endocarditis, involving the native mitral valve, complicated with acute renal failure and severe mitral regurgitation that required hemodialysis and mitral valve replacement. The outcome was again successful. This case report raises the question of whether Q fever endocarditis can be eradicated, and also the required duration of antibiotic therapy for this disease.

[Acute pericarditis as initial clinical manifestation of hypereosinophilia syndrome]. / Pericarditis aguda como manifestación clínica inicial del síndrome hipereosinófilo.

The case of a patient in whom acute pericarditis was the initial manifestation of an idiopathic hypereosinophilia is reported. Endomyocardial abnormalities were not found by echocardiography. Response to prednisone therapy was good; symptoms, pericardial effusion and eosinophilia early disappeared after therapy. Some clinical aspects of this uncommon disease are discussed.

[Patients with an acute myocardial infarct treated in a coronary unit or in a general cardiology ward A comparative study]. / Pacientes con infarto agudo de miocardio tratados en unidad coronaria o en sala general de cardiología. Un estudio comparativo.

INTRODUCTION AND OBJECTIVES: Coronary care units have been accepted as the standard location for treatment for patients with acute myocardial infarction. Nevertheless, controversy over their clinical impact, current role and cost-effectiveness still remains. Due to the increased incidence of coronary artery disease in Spain, coronary care units are often full, and patients with acute myocardial infarction must be cared for in a general cardiology ward. METHODS: We have studied the features and results of 420 patients with acute myocardial infarction consecutively admitted to our hospital and compared patients cared for in the coronary care unit (329 [78%]) with those cared for in the cardiology ward (91 [22%]). Admission to cardiology ward or coronary care unit was based on the clinical judgment of emergency room physicians and the bed availability. No differences in age, sex, risks factors, prior history of coronary heart disease, blood pressure on admission, extension and complications of myocardial infarction were found between both groups. RESULTS: The percentage of patients with evolved and non-Q wave acute myocardial infarction, and admission electrocardiogram not suggestive of infarction was significantly higher in ward group (23 versus 2.4%, p < 0.001; 19 versus 11%, p < 0.01; and 43 versus 15%, p < 0.01; respectively). Although patients admitted to the coronary care unit underwent intravenous thrombolysis and coronary artery revascularization procedures in a higher proportion, mortality was similar in both groups (14% for ward patients and 17% for coronary care unit patients). When patients with evolved or non-Q wave infarctions and those with admission electrocardiograms not suggestive of infarction were excluded from the analysis, mortality rates remained similar. Subgroups mortality was in general similar for patients cared for in cardiology ward or in coronary care unit, although patients without shock, with Killip class I or II, and older than 70 years, had a slightly lesser mortality when treated in the Cardiology ward (5 versus 11%, 6 versus 11%, and 14 versus 28%, respectively). By contrast, patients with shock, Killip class III or IV, and electrocardiogram at admission not suggestive of infarction, had a lesser mortality when cared for in coronary care unit. CONCLUSIONS: We conclude that some subgroups of patients with acute myocardial infarction can be, if needed, effective and safely cared for in cardiology ward.

[The echocardiographic findings in patients with brain death. The implications for their selection as heart transplant donors]. / Hallazgos ecocardiográficos en pacientes con muerte cerebral. Implicaciones para su selección como donantes para trasplante cardíaco.

INTRODUCTION AND AIMS: Brain death causes myocardial impairment by some mechanisms not yet well understood. The aim of this work was to assess the echocardiographic features found in these patients and their implication in donor selection for heart transplantation. METHODS: With this aim, we have studied 38 consecutive patients with brain death assessed as possible donors for heart transplant in our hospital in the last 3 years. Age was 23 +/- 13 years; 77% were male. No history of cardiac disease was present in any patient. An adequate transthoracic echocardiogram was obtained in 74% of patients; transesophageal view was used in the remaining 26%. RESULTS: Echocardiogram was strictly normal in only 14 patients (37%). Mild valvular alterations were found in 5 patients (13%); a dilated aortic root in 1 (3%); moderate concentric left ventricular hypertrophy in 5 (14%); mild pericardial effusion in 1 (3%); mild septal hypokinesia with normal left ventricular ejection fraction in 4 (10%); abnormal left ventricular diastolic function in 7 (18%); and diffuse hypokinesia with ejection fraction less than 60% in 14 (37%). In 7 patients (18%) ejection fraction was lower than 40% (one of them was cocaine-addict). Mean ejection fraction was 59 +/- 15% (23 to 83%). Only 2 of the 19 (10%) donor hearts implanted in our hospital showed early dysfunction after transplant, but no relation to pretransplant ejection fraction was found. Ejection fraction increased from 62% pretransplant to 73% at one week after transplant in the other 17 cases. CONCLUSIONS: Brain death commonly causes alterations of left ventricular function, and this impairment is severe in almost 20% of cases. These echocardiographic features must be known when selection of donors for heart transplantation is concerned.

[An analysis of the factors and phenomena associated with the formation of a spontaneous echo contrast in the left atrium]. / Análisis de los factores y fenómenos asociados a la formación de ecocontraste espontáneo en aurícula izquierda.

INTRODUCTION AND AIMS: To determine the factors related to the formation of spontaneous echo contrast in left atrium. PATIENTS AND METHODS: We have analyzed our series of 1,066 patients undergoing transesophageal echocardiography until December 1991. It was found in left atrium in 387 patients (36%) and was associated with another pathology in 99%. We defined spontaneous echo contrast as mild in 64% and severe in 36%. RESULTS: The prevalence of spontaneous echo contrast was greater in patients with atrial fibrillation (p < 0.001), mitral stenosis (p < 0.001), double mitral lesion (p < 0.001), prosthesis (p < 0.001), embolism (p < 0.05) and a dilated left atrium (left atrial dimension greater than 60 ml) (p < 0.01). The presence of mitral regurgitation made it less frequent (p < 0.05). Thrombi were visualized in 104 patients and they were more frequent in the presence of spontaneous echo contrast. Severe spontaneous echo contrast was significantly more frequent in patients with atrial fibrillation (p < 0.001), mitral stenosis (p < 0.05) and thrombi (p < 0.001). CONCLUSIONS: Spontaneous echo contrast in left atrium is a common finding in transesophageal studies and it is associated with another pathology in 99%. It is more frequent in patients with atrial fibrillation, mitral stenosis, embolism or prosthesis. Left atrial enlargement is one of the more important factors. It is less frequent in patients with mitral regurgitation. Thrombi are less frequent in patients without spontaneous echo contrast. Severe spontaneous echo contrast is significantly associated with mitral stenosis, atrial fibrillation and left atrial thrombi.

[Brucellar pericarditis: 2 different forms of presentation for an unusual etiology]. / Pericarditis brucelósica: dos formas diferentes de presentación para una etiología poco frecuente.

Two cases of Brucella melitensis pericarditis are reported. Pericardial involvement was the first and almost only manifestation of brucellosis in the first patient while in the second, a significant pericardial effusion was discovered on a routine echocardiogram performed in a patient with clinically florid brucellosis. Some etiopathogenic aspects of this uncommon etiology are discussed.

[Clinical Characteristics and Evolution of Recurrent Infectious Endocarditis in non Drug Addicts]. / Características clínicas y evolución de la endocarditis infecciosa recurrente en no drogadictos.

INTRODUCTION AND OBJECTIVES: Recurrence of infection is observed in a high proportion of patients who have had infective endocarditis in the past. The aim of our study was to evaluate the possible differences between the first and the recurrent episodes of endocarditis, as well as to assess the outcome and prognosis of patients with recurrent endocarditis. PATIENTS AND METHOD: We reviewed a series of 13 episodes of recurrent endocarditis from among 196 cases of infective endocarditis involving non-drug-addict patients in two hospitals from 1987 to 2000. RESULTS: There were no differences between recurrent and first episodes of endocarditis according to age, sex, heart valve involved or causal microorganisms. Prosthetic valve endocarditis was more common in patients with recurrent endocarditis (86% versus 27%; p < 0.001). Although there were no differences in the rate of complications or early surgery, overall mortality was significantly higher in patients with recurrent endocarditis (53% versus 27%: p < 0.05). When early and late mortality were analysed separately, the differences did not achieve significance. CONCLUSIONS: Recurrent endocarditis was frequent in our series (7% of all cases). The features were similar to those of the first episode except for a higher rate of prosthetic valve endocarditis and a higher overall mortality.

[Long-term clinical course of acute myocarditis. Prospective study of a series of 99 patients (1987-1995)]. / Evolución a largo plazo de la miocarditis aguda. Estudio prospectivo de una serie de 99 pacientes (1987-1995).

BACKGROUND: The natural history of acute myocarditis is not well known. The aim of our study was to assess the spontaneous outcome of patients with this disease and its possible relation with progression to chronic dilated cardiomyopathy. METHODS: With this aim, we have carried out a prospective study of 99 patients consecutively diagnosed with acute myocarditis in our hospital from 1987 to April 1995, with a mean follow-up of 34 +/- 25 months. Acute myocarditis was diagnosed by clinical, echocardiographic and isotopic (detection of myocite damage) data, in absence of any other cardiac lesion. RESULTS: Mean age was 26 +/- 17 years; 70% of the patients were male. Initial symptoms were dyspnea in 58% of the patients, chest pain in 33% and arrhythmias in 9%. Severe heart failure was present in 62% of the patients, ventricular arrhythmias in 16% and supraventricular arrhythmias in 16%. Cardiothoracic index was 0.50 +/- 0.07. Left ventricular ejection fraction was 0.40 +/- 0.18, although in 44% of the patients it was lower than 0.30. Immunosuppressive therapy was not used in any case. Outcome was favorable in 70% of the patients, who had a normal ejection fraction, while 13% died or needed heart transplantation during follow-up and 17% progressed to stable chronic dilated cardiomyopathy. Final ejection fraction was 0.53 +/- 0.17, significantly higher than the initial, 0.40 +/- 0.18 (p < 0.05); this improvement in ejection fraction was mainly observed during the first month after diagnosis (0.49 +/- 0.18). The proportion of patients with an ejection fraction of less than 0.30 decreased from 44% to 21% at the end of follow-up. CONCLUSIONS: Spontaneous outcome of acute myocarditis is good in the majority of patients, although an unfavourable evolution was observed in almost 30% of the patients (death, need of heart transplantation or chronic dilated cardiomyopathy). Improvement in ventricular function mainly occurs at short-term, during the first month of evolution in our study.