Case report and review of literature of a rare congenital disorder: Adams-Oliver syndrome.

BACKGROUND: Adams-Oliver syndrome is characterized by the combination of congenital scalp defects and terminal transverse limb defects. In some instances, cardiovascular malformations and orofacial malformations have been observed. Little is written with regards to the anesthetic management and airway concerns of patients with Adams-Oliver syndrome. CASE PRESENTATION: A five-year-old female with Adams-Oliver syndrome presented for repeat lower extremity surgery. Airway exam was significant for dysmorphic features, such as hypertelorism, deviated jaw, and retrognathia. Video laryngoscope was utilized for intubation due to the patients retrognathic jaw, cranial deformities, and facial dysmorphism. A vein finder with ultrasound guidance was needed to place the peripheral intravenous line due to her history of difficult intravenous access. The patient was successfully intubated with slight cricoid pressure applied to direct the endotracheal tube smoothly. Surgery and recovery were both unremarkable. CONCLUSIONS: Due to varying presentations of Adams-Oliver syndrome, anesthetic and airway management considerations should be carefully assessed prior to surgery. Anesthesiologists must take into consideration possible orofacial abnormalities that may make intubation difficult. Amniotic band syndrome and other limb defects could potentially impact intravenous access as well.

Is the thrombolysis in myocardial infarction (TIMI) score a reliable source in a rural hospital for the management of unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI)?

Background: The Thrombolysis in Myocardial Infarction (TIMI) score is considered a method for early risk stratification in patients with unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI). It is composed of seven factors and if present, each factor contributes a value of one point toward the TIMI risk score, making it a simple tool that does not require differential weights for each factor. A higher score implies a higher likelihood of adverse cardiac events and/or risk of mortality. A TIMI risk score ≥3 recommends early invasive management with cardiac angiography and revascularization. As per CDC study in 2014, Americans living in rural areas are more likely to die from leading causes such as cardiovascular diseases. An estimated number 25,000 deaths than their urban counterparts, which coincide with a TIMI risk score of ≥3, potentially limit the utility of the TIMI risk score in risk stratification in rural catherization laboratories. The objective of this study was to assess the reliability of TIMI score as early risk stratification in patients with unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI) in rural hospital. Methods: A retrospective chart review study in a rural hospital was conducted for subjects that received left heart catheterizations, exercise stress tests, or chemical stress tests for a diagnosis of UA/NSTEMI. A total of 399 subjects who underwent left heart catheterization and/or stress testing were recruited for this study. A total of 153 subjects who were transferred out to a larger facility, transitioned to comfort care, refused intervention, or passed away were excluded from the study. The 246 remaining subjects were classified into two groups, those with TIMI 0-2 compared with those having TIMI ≥ 3. A null hypothesis was postulated that there was no significant difference between the two groups with regard to prevalence of either positive stress test or evidence of obstructive coronary disease following coronary angiography. T-test and Wilcoxon rank-sum analysis were performed through SPSS statistical analysis. Results: Formal statistical analysis using T-test as well as Wilcoxon rank-sum test comparing the two groups showed p = 0.34 for T-test and p = 0.60 for Wilcoxon rank-sum test. This is consistent with the postulated null hypothesis: that there is no significant difference between the two surgery groups with respect to the mean/median TIMI score. Conclusion: There was no statistical difference between high and low TIMI score in the intervention of unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI) in a rural hospital.

Efficacy of the Benznidazole+Posaconazole combination therapy in parasitemia reduction: An experimental murine model of acute Chagas.

INTRODUCTION: Benznidazole (BZL) and Nifurtimox (NFX) are the pharmacological treatment for acute phase Chagas Disease (CD); however, therapy resistance and residual mortality development remain important unresolved issues. Posaconazole (POS) has shown a trypanocidal effect in vivo and in vitro. Thus, this study aimed at comparing the T. Cruzi parasitic load-reducing effect of the combination of BZL+POS against that of monotherapy with either, during acute phase CD, in an experimental murine model. METHODS: Nineteen Wistar rats were randomly allocated to four groups and inoculated with the trypomastigotes of T. cruzi strain´s JChVcl1. The rats were administered anti-parasites from day 20-29 post-infection. The Pizzi and Brener method was used for parasitemia measurement. Longitudinal data analysis for the continuous outcome of repeated measures was performed using parasitemia as the outcome measured at days 20, 22, 24, 27, and 29 post-infection. RESULTS: All four groups had similar parasitic loads (p=0.143) prior to therapy initiation. Among the three treatment groups, the BZL+POS (n=5) group showed the highest mean parasitic load reduction (p=0.000) compared with the control group. Likewise, the BZL+POS group rats showed an earlier therapeutic effect and were the only ones without parasites in their myocardial samples. CONCLUSIONS: Treatment of acute phase CD with BZL+POS was more efficacious at parasitemia and myocardial injury reduction, compared with monotherapy with either.

Características epidemiológicas de la endocarditis infecciosa. Experiencia de seis años / Epidemiological characteristics of infective endocarditis. Six years of experience

Resumen Introducción: La endocarditis infecciosa continúa siendo una condición amenazante para la vida, que puede afectar cualquier órgano y sistema, con alta mortalidad, atribuible principalmente a Staphylococcus aureus. Implica un reto diagnóstico y terapéutico, que requiere un cuidado multidisciplinario. Objetivo: Describir las características clínicas y microbiológicas en pacientes con endocarditis infecciosa. Materiales y método: Estudio observacional descriptivo basado en la revisión de historias clínicas en un centro médico de referencia en Medellín, Colombia, incluyendo pacientes mayores de 18 años hospitalizados durante el periodo de enero de 2011 a febrero de 2017. Resultados: 130 pacientes, con edad promedio de 53 años (± 16). La hipertensión arterial y la enfermedad renal crónica fueron la comorbilidad más frecuente (55% y 38%, respectivamente). La fiebre fue el síntoma cardinal (90%). Predominó la endocarditis infecciosa de válvula nativa (85.7%), afectando principalmente la mitral (40%). El agente etiológico más frecuente fue S. aureus (sensible a oxacilina 44%), y se complicaron con embolia el 52.5% y con falla cardiaca el 30.8%. La mortalidad intrahospitalaria fue del 39.2%. Conclusiones: La endocarditis infecciosa tiene variadas manifestaciones clínicas, entre las que destacan la embolia sistémica y la falla cardiaca aguda, que condicionan una mortalidad elevada (mayor que la reportada en otros estudios). El aislamiento microbiológico más frecuente es el bacteriano, principalmente S. aureus, como lo muestra la tendencia global.

Abstract Background: Infective endocarditis continues to be a life-threatening condition, can involve every organ system, with high mortality, attributable mainly to Staphylococcus aureus. It implies a diagnostic and therapeutic challenge, which requires multidisciplinary care. Objective: To describe the clinical and microbiological characteristics in patients with infectious endocarditis. Materials and method: Descriptive observational study, based on the review of medical records in a reference medical center in Medellín, Colombia. Including patients over 18 years hospitalized during the period from January 2011 to February 2017. Results: 130 patients, with an average age of 53 years (± 16). Hypertension and chronic kidney disease was the most common comorbidity (55% and 38%, respectively). Fever was the cardinal symptom (90%). Native valve infective endocarditis predominated (85.7%), mainly affecting the mitral valve (40%). The most frequent etiologic agent was Staphylococcus aureus (oxacillin sensitive 44%), embolism was the main complication by 52.5% followed by heart failure (30.8%). In-hospital mortality was 39.2%. Conclusions: Infective endocarditis has varied clinical manifestations, including systemic embolism and acute heart failure, which lead to high mortality (higher than that reported in other studies). The most frequent microbiological isolation is bacterial, mainly Staphylococcus aureus, as shown by the global trend.

Efficacy of the Benznidazole+Posaconazole combination therapy in parasitemia reduction: An experimental murine model of acute Chagas

Abstract INTRODUCTION: Benznidazole (BZL) and Nifurtimox (NFX) are the pharmacological treatment for acute phase Chagas Disease (CD); however, therapy resistance and residual mortality development remain important unresolved issues. Posaconazole (POS) has shown a trypanocidal effect in vivo and in vitro. Thus, this study aimed at comparing the T. Cruzi parasitic load-reducing effect of the combination of BZL+POS against that of monotherapy with either, during acute phase CD, in an experimental murine model. METHODS Nineteen Wistar rats were randomly allocated to four groups and inoculated with the trypomastigotes of T. cruzi strain´s JChVcl1. The rats were administered anti-parasites from day 20-29 post-infection. The Pizzi and Brener method was used for parasitemia measurement. Longitudinal data analysis for the continuous outcome of repeated measures was performed using parasitemia as the outcome measured at days 20, 22, 24, 27, and 29 post-infection. RESULTS All four groups had similar parasitic loads (p=0.143) prior to therapy initiation. Among the three treatment groups, the BZL+POS (n=5) group showed the highest mean parasitic load reduction (p=0.000) compared with the control group. Likewise, the BZL+POS group rats showed an earlier therapeutic effect and were the only ones without parasites in their myocardial samples. CONCLUSIONS: Treatment of acute phase CD with BZL+POS was more efficacious at parasitemia and myocardial injury reduction, compared with monotherapy with either.

SNP/haplotype associations of CCR2 and CCR5 genes with severity of chagasic cardiomyopathy.

BACKGROUND: Chronic inflammation plays a major role in the tissue injury seen in the chronic chagasic cardiomyopathy. The CCR2 and CCR5 chemokine receptors are involved with the type of cellular infiltrate present in cardiac tissue and CCR5-gene variants were previously associated with this pathology. METHODS AND RESULTS: This is a replication study in an independent cohort with larger sample size. Nine SNPs of CCR5 and CCR2 were typified to confirm the association previously found with Chagas disease. Evidence of association with severity was found for the A allele of rs1799864 of CCR2 (pad=0.02; OR=1.91, 95% CI=1.10-3.30), the T allele of the rs1800024 of CCR5 (pad=0.01; OR=1.95, 95% CI=1.13-3.38), and the HHF(∗)2 haplotype (p=0.03, OR=1.65, 95% CI=1.03-2.65). These results were replicated in the study combined with previous data. In this analysis it was replicated the allele T of rs2734648 (pad=0.009, OR=0.52, 95% CI=0.32-0.85) with protection. In addition, the allele G of rs1800023 (pad=0.043, OR=0.61, 95% CI=0.38-0.98), and the HHC haplotype (p=0.004, OR=0.62, 95% CI=0.44-0.86) were also associated with protection. In contrast, the allele A of rs1799864 of CCR2 (pad=0.009; OR=1.90, 95% CI=1.17-3.08); and the allele T of rs1800024 of CCR5 (pad=0.005, OR=1.98, 95% CI=1.22-3.23) were associated with greater severity. No evidence of association between symptomatic and asymptomatic patients was observed. CONCLUSIONS: These results confirm that variants of CCR5 and CCR2 genes and their haplotypes are associated with the severity but not with susceptibility to develop chagasic cardiomyopathy.