Prognosis of Paradoxical Low-Flow Low-Gradient Aortic Stenosis: A Severe, Non-critical Form, With Surgical Treatment Benefits.

Objectives: To determine the risk of mortality and need for aortic valve replacement (AVR) in patients with low-flow low-gradient (LFLG) aortic stenosis (AS). Methods: A longitudinal multicentre study including consecutive patients with severe AS (aortic valve area [AVA] < 1.0 cm2) and normal left ventricular ejection fraction (LVEF). Patients were classified as: high-gradient (HG, mean gradient ≥ 40 mmHg), normal-flow low-gradient (NFLG, mean gradient < 40 mmHg, indexed systolic volume (SVi) > 35 ml/m2) and LFLG (mean gradient < 40 mmHg, SVi ≤ 35 ml/m2). Results: Of 1,391 patients, 147 (10.5%) had LFLG, 752 (54.1%) HG, and 492 (35.4%) NFLG. Echocardiographic parameters of the LFLG group showed similar AVA to the HG group but with less severity in the dimensionless index, calcification, and hypertrophy. The HG group required AVR earlier than NFLG (p < 0.001) and LFLG (p < 0.001), with no differences between LFLG and NFLG groups (p = 0.358). Overall mortality was 27.7% (CI 95% 25.3-30.1) with no differences among groups (p = 0.319). The impact of AVR in terms of overall mortality reduction was observed the most in patients with HG (hazard ratio [HR]: 0.17; 95% CI: 0.12-0.23; p < 0.001), followed by patients with LFLG (HR: 0.25; 95% CI: 0.13-0.49; p < 0.001), and finally patients with NFLG (HR: 0.29; 95% CI: 0.20-0.44; p < 0.001), with a risk reduction of 84, 75, and 71%, respectively. Conclusions: Paradoxical LFLG AS affects 10.5% of severe AS, and has a lower need for AVR than the HG group and similar to the NFLG group, with no differences in mortality. AVR had a lower impact on LFLG AS compared with HG AS. Therefore, the findings of the present study showed LFLG AS to have an intermediate clinical risk profile between the HG and NFHG groups.

Implementing Enhanced Recovery After Surgery (ERAS) Program on a Specialty Nursing Unit.

Implementing Enhanced Recovery After Surgery (ERAS) guidelines is an effective method to standardize patient care, improve patient outcomes, and develop quality improvement projects. Completing the required ERAS Implementation Program provided by the International ERAS Society enabled the hepatopancreaticobiliary surgery team at Carolinas HealthCare System to successfully implement evidence-based practice changes for pancreaticoduodenectomy patients on an acuity-adjustable unit resulting in improved care and cost reduction.

Perioperative Care Implementation: Evidence-Based Practice for Patients With Pancreaticoduodenectomy Using the Enhanced Recovery After Surgery Guidelines 
.

BACKGROUND: Pancreatic adenocarcinoma is an aggressive cancer that carries a poor prognosis. Pancreaticoduodenectomy (PD) offers the only potential cure, but the associated morbidity is high. The Enhanced Recovery After Surgery (ERAS) evidence-based guidelines for perioperative care for PD can be used to reduce variations in practice.
. OBJECTIVES: The primary aim was to evaluate the feasibility of the ERAS guidelines for patients undergoing PD. Secondary aims were to assess length of stay (LOS), readmission within 30 days, 30-day mortality, and total surgical complication rates.
. METHODS: Guideline feasibility was evaluated by percentage completion and compliance to each of the perioperative phases of the guideline. Hospital LOS, 30-day readmission, 30-day mortality, and total surgical complication rates were compared before and after ERAS implementation. 
. FINDINGS: The ERAS guidelines were feasible and safely implemented with no change in LOS, readmission, morbidity, and mortality rates.

Cerebral regional oxygen saturation and serum neuromarkers for the prediction of adverse neurologic outcome in pediatric cardiac surgery.

BACKGROUND: The aim of this study is to determine the utility of non-invasive bedside neuromonitoring, including cerebral regional oxygen saturation (rSO2) measured by near-infrared spectroscopy and serum biomarkers, in identifying children at risk from adverse neurological outcome after heart surgery. METHODS: Prospective observational study including 39 consecutive children undergoing heart surgery with cardiopulmonary bypass (CPB) and normal neurologic exam prior to surgery. Cerebral rSO2 was measured at baseline (prior to surgery) and then continuously during surgery and for the first 16 h post-operatively. Neuromarkers [neuron-specific enolase (NSE), S100ß, glial fibrillary acidic protein (GFAP), and brain-derived neurotrophic factor (BDNF)] were measured in serum at baseline, immediately after CPB and at 16 h post-operatively. Adverse neurological outcome was defined as an abnormal pediatric cerebral performance category (PCPC) scale score at 12 months after surgery. RESULTS: Sixteen children (41 %) had an abnormal PCPC scale score at the 12-month evaluation after surgery. In children with unfavorable neurological outcomes, mean cerebral rSO2 values were lower and the area-under-the-curve below a threshold of 40 and 20% below baseline were also increased. No significant differences were found in serum neuromarkers between groups at the time points that were assessed. CONCLUSIONS: Bedside determination of cerebral rSO2 may have some utility in identifying children at risk for adverse neurological outcome after heart surgery in children. Additional studies that are sufficiently powered to control for the many covariates in this patient population will be required to fully interrogate this important question. The role of serum neuromarkers in the immediate post-operative period do not appear to be helpful in this question, though more thorough interrogation of delayed periods may ultimately demonstrate some utility in answering this question.

Time-course development of the Cd2+ hyper-accumulating phenotype in Euglena gracilis.

To determine the onset of the Cd2+-hyperaccumulating phenotype in Euglena gracilis, induced by Hg2+ pretreatment (Avilés et al. in Arch Microbiol 180:1-10, 2003), the changes in cellular growth, Cd2+ uptake, and intracellular contents of sulfide, cysteine, gamma-glutamylcysteine, glutathione and phytochelatins during the progress of the culture were analyzed. In cells exposed to 0.2 mM CdCl2, the Cd2+-hyperaccumulating phenotype was apparent only after 48 h of culture, as indicated by the significant increase in cell growth and higher internal contents of sulfide and thiol-compounds, along with a higher gamma-glutamylcysteine synthetase activity. However, the stiochiometry of thiol-compounds/Cd2+ accumulated was similar for both control and Hg2+-pretreated cells. Moreover, the value for this ratio was 2.1 or lower after 48-h culture, which does not suffice to fully inactivate Cd2+. It is concluded that, although the glutathione and phytochelatin synthesis pathway is involved in the development of the Cd2+-hyperaccumulating phenotype in E. gracilis, apparently other pathways and sub-cellular mechanisms are also involved. These may be an increase in other Cd2+ chelating molecules such as di- and tricarboxylic acids, phosphate and polyphosphates, as well as Cd2+ compartmentation into organelles.

The composition of the incubation medium influences the sensitivity of mitochondrial permeability transition to cyclosporin A.

The aim of this work was to study permeability transition, and the influence of the composition of the incubation medium, on the inhibitory action of cyclosporin A. It was found that cyclosporin inhibited the opening of a nonspecific pore, as induced by the uncoupler carbonyl cyanide m-chlorophenylhydrazone, provided K+ was present in the incubation medium, but failed to do so if mitochondria are incubated in sucrose or Na+-based medium. It was also found that the sensitivity of mitochondria to the uncoupler depended on the incubation mixture, being more sensitive when sucrose was the osmotic support. Matrix Ca2+ release, large amplitude swelling, and drop in transmembrane electric gradient revealed permeability transition. The titration of membrane thiol groups shows them to be increased in mitochondria incubated in sucrose medium, in comparison with the values found in mitochondria incubated in KCl or NaCl medium. Our proposal is that the incubation in sucrose medium propitiated a conformational change of membrane proteins in such a way that cyclosporin was unable to bind to its target site.

Mercury pretreatment selects an enhanced cadmium-accumulating phenotype in Euglena gracilis.

Pre-treatment of heterotrophic cultures of Euglena gracilis with 1.5 microM HgCl(2) for at least 60 generations resulted in a cell population that showed both increased resistance to Cd(2+) and ability to accumulate it, when compared to non-Hg(2+)-pretreated Euglena. These Hg(2+)-enhanced capacities were evident in cells cultured in the dark in a medium with lactate, but not in cells cultured with glutamate plus malate. After culturing with 0.1 mM CdCl(2) through three consecutive transfers, the mercury-pretreated cells still grew and maintained high levels of glutathione-related metabolites, while the non-Hg(2+)-pretreated cells died. Cultures of Hg(2+)-pretreated cells, after transfer to media with or without cadmium, did not alter either their enhanced Cd(2+) accumulation or their increased production of glutathione-related metabolites. These observations suggested that the Hg(2+)-pretreated population underwent a permanent change that improved its Cd(2+) resistance. Several factors that contributed to the improved capacities included: (a) higher cellular malate, cysteine and glutathione levels induced by Hg(2+) before and after Cd(2+) exposure; and (b) increased storage of Cd(2+) in mitochondria along with increased intramitochondrial citrate, cysteine, and glutathione levels. These characteristics suggested that this Cd(2+) hyper-accumulating strain of E. gracilis might be a suitable candidate for Cd(2+)-bioremediation of polluted water systems.

Modulation by substrates of the protective effect of cyclosporin A on mitochondrial damage.

The influence of substrates on the role of cyclosporin A, to promote the closure of the permeability transition pore, was studied. It was found that in succinate-oxidizing mitochondria, cyclosporin inhibited pore opening as induced by carboxyatractyloside. The opposite occurred when mitochondrial respiration was supported by malate-glutamate, i.e., cyclosporin A was unable to block pore opening promoted by carboxyatractyloside. We propose that the failure of cyclosporin A to induce pore closure could be due to a low NADH matrix content.

Tuberculoma cerebral: manejo médico / Cerebral tuberculoma:medical management

Se reporta dos casos clínicos de Tuberculoma Cerebral tratados con quimioterapia antituberculosa asociada a corticosteroides, obteniéndose remisión completa de la sintomatología en ambos pacientes y resolución tomográfica en la paciente a quien se realizó dicho control. Se revisa los aspectos, métodos diagnósticos y tratamiento.