Turtle Shell Kinesis Underscores Constraints and Opportunities in the Evolution of the Vertebrate Musculoskeletal System.

Species groups that feature traits with a low number of potentially variable (evolvable) character states are more likely to repeatedly evolve similar phenotypes, that is, convergence. To evaluate this phenomenon, this present paper addresses anatomical alterations in turtles that convergently evolved shell kinesis, for example, the movement of shell bones to better shield the head and extremities. Kinesis constitutes a major departure from the evolutionarily conserved shell of modern turtles, yet it has arisen independently at least 8 times. The hallmark signature of kinesis is the presence of shell bone articulations or "hinges," which arise via similar skeletal remodeling processes in species that do not share a recent common ancestor. Still, the internal biomechanical components that power kinesis may differ in such distantly related species. Complex diarthrodial joints and modified muscle connections expand the functional boundaries of the limb girdles and neck in a lineage-specific manner. Some lineages even exhibit mobility of thoracic and sacral vertebrae to facilitate shell closure. Depending on historical contingency and structural correlation, a myriad of anatomical alterations has yielded similar functional outcomes, that is, many-to-one mapping, during the convergent evolution of shell kinesis. The various iterations of this intricate phenotype illustrate the potential for the vertebrate musculoskeletal system to undergo evolutionary change, even when constraints are imposed by the development and structural complexity of a shelled body plan. Based on observations in turtles and comparisons to other vertebrates, a hypothetical framework that implicates functional interactions in the origination of novel musculoskeletal traits is presented.

Resumen Los grupos de especies que presentan rasgos con un bajo número de estados de carácter potencialmente variables (evolutivos) tienen más probabilidades de evolucionar repetidamente fenotipos similares. El presente artículo aborda las alteraciones anatómicas en las tortugas que evolucionaron de manera convergente el cierre cinético del caparazón y plastrón. El cierre cinético mejora la protección de la cabeza y las extremidades. Este rasgo constituye una desviación importante en la historia evolutiva de las tortugas modernas, sin embargo, ha surgido independientemente al menos ocho veces. La cinesis se define por la presencia de articulaciones óseas o "bisagras" que surgen a través de procesos similares de remodelación esquelética en especies que no comparten un ancestro común reciente. No obstante, los componentes biomecánicos internos relacionados con la cinesis pueden diferir en especies tan distantemente relacionadas. Las articulaciones diartródias complejas y las conexiones musculares modificadas expanden los límites funcionales del cuello y las cinturas escapulohumeral y pélvica de una manera específica del linaje. Algunos linajes incluso exhiben movilidad de vertebras torácicas y sacras para facilitar el cierre cinético. Dependiendo de la contingencia histórica y la correlación estructural del sistema musculoesquelético, varias alteraciones anatómicas han producido resultados funcionales similares durante la evolución convergente de la cinesis. Las diversas iteraciones de este fenotipo ilustran el potencial del sistema musculoesquelético de los vertebrados para experimentar cambios evolutivos, incluso cuando existen limitaciones impuestas por el desarrollo y la complejidad estructural del plan corporal de las tortugas. Sobre la base de observaciones en tortugas y comparaciones con otros vertebrados, se presenta un marco hipotético que implica interacciones funcionales en el origen de nuevos rasgos musculoesqueléticos.

Influence of surgical quality (according to postoperative radiography) on mortality, complications and recovery of walking ability in 1425 hip fracture patients.

PURPOSE: To evaluate the influence of surgical quality (as evaluated in the post-surgical radiographic control) on mortality, complications and recovery of walking ability in patients older than 64 years with hip fracture. PATIENTS AND METHODS: Retrospective observational study of a single-center, consecutive cohort of 1425 patients operated from December/2012 to March/2018. Average age was 85.66±7.13 (65-108) years and 966 (67.86%) were female. Extracapsular fractures (811 cases, 56.91%) were fixed with trochanteric nails (Affixus-DePuy / PFNA-Synthes) (795 cases) or sliding-hip-screw-plates (Biomet) (16 patients). Intracapsular fractures (614, 43.09%) were treated with cannulated screws (Smith-Nephew) (134 cases) or with arthroplasty (472 bipolar and 8 total hip, Furlong-JRI or Exeter-Stryker). Postoperative radiographs were used to determine surgical quality (reduction, compression, screw position, tip-apex, stem position, Voss, intraoperative fracture). Patients were followed clinically and radiographically in outpatient clinic after 1, 3, 6, and 12 months. STATISTICAL ANALYSIS: Bivariate analysis (Pearson, Fischer, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Relative Risks (RR) were calculated. RESULTS: 196 patients (13.75%) died along follow-up, and poor reduction was found to be a risk factor for mortality both in trochanteric nail group (p=0.0495) (RR 1.510, 1.01-2.26) and in cannulated screw group (p=0.0023) (RR 6.48, 2.40-17.53); this is a previously non-published risk factor. Surgical complications included 33 infections (2.36%), 12 non-unions (1.27%), 12 cut-outs (1.47%), 7 broken nails (0.86%), 21 hemiarthroplasty dislocations (4.37%), and 8 ischemic necrosis of the femoral head (5.97%). The significant risk factors were: poor reduction for trochanteric nail breakage (p=0.041) (RR 4.47, 1.13-17.67), poor reduction for non-union in cannulated screws (p=0.035) (RR 10.91, 1.70-70.09), as well as "tip-apex distance" over 25mm in trochanteric fractures for "cut-out" type of fixation failure (p=0.0159) (RR 3.84, 1.19-12.40). Previous walking ability was restored in 564 patients (39.58%) and worsened in 581 (40.77%), but statistical relationships were not found, although follow-up data were inadequate in 212 cases (14.88%). CONCLUSIONS: Appropriate reduction of hip fractures is a significant step to reduce mortality, nail breakage and non-union. Adequate position of sliding screw (avoiding tip-apex distances over 25mm) is important to reduce "cut-out" in trochanteric fractures.

Influence of cognitive impairment on mortality, complications and functional outcome after hip fracture: Dementia as a risk factor for sepsis and urinary infection.

PURPOSE: To analyze the relation between cognitive impairment on arrival at hospital in patients older than 65 years with a hip fracture, and their mortality, medical and surgical complications, and functional outcomes. PATIENTS AND METHODS: Observational study of a single-center prospective consecutive cohort of 955 patients older than 64 years diagnosed of hip fracture from December/2012 to December/2015. Average age was 86±7.2 (65-104) years and 725 (75.9%) were female. Fractures were extracapsular in 538 cases (56.3%) and intracapsular in 417 (43.7%). Patients were controlled clinically and radiographically in outpatient clinic after 1, 3, 6, and 12 months. Data about basal cognitive status, walking ability before the fracture, medical and surgical complications, functional outcomes and mortality were collected for the year following the fracture. STATISTICAL ANALYSIS: Bivariate analysis (Pearson, Fisher, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and contingence coefficients (CC) were calculated. RESULTS: Patients with cognitive impairment showed a higher overall mortality, (p = 0,000; CC=0,197) even after hospital discharge (p = 0.000; CC=0.198). Similarly, patients with dementia presented a higher rate of respiratory infections (p = 0,029; CC=0,093), urinary tract infections (p = 0,008; CC=0,108) and sepsis (p = 0,011; CC=0,105). On the contrary, we found no correlations between mental status and surgical complications, even for prosthesis dislocation (p = 0.136). Patients with dementia started from poorer functional situations (p = 0,000; CC=0,367) and ended follow-up with lower walking ability (p = 0,000; CC=0,43), but cognitive impairment did not relate statistically with a worse functional recovery (p = 0,304): that is, the proportion of patients who maintained their previous ability to walk was similar in both groups, those with altered mental status and those without it. CONCLUSIONS: Cognitive impairment is a risk factor for mortality in patients with a hip fracture. It is also a risk factor for suffering respiratory and urinary tract infection and sepsis. These two late risks factors have not been published previously. Functional recovery is not conditioned by cognitive impairment, although further studies need to be developed to evaluate the actual role of cognitive impairment on postoperative progression of patients.

A test of Darwin's 'lop-eared' rabbit hypothesis.

Integration of evolutionary and developmental biology has stimulated novel insights on the origins and maintenance of phenotypic variation. For instance, phenotypic accommodation predicts that trait covariance originates via a novel developmental input caused by genetic change in one trait, but not the other. Darwin provided a striking example of this process in the 'lop-eared' rabbit by demonstrating that artificial selection for long external ears induced variation in the external auditory meatus. Although this intriguing pattern has been interpreted as evidence of phenotypic accommodation, it is unclear whether it exists and, if it does, whether it is selectively maintained in nature. To address this concern, we examined trait covariance in natural woodrat populations that have likely undergone selection for long ears. We demonstrated a remarkably similar covariance pattern as in the 'lop-eared' rabbit, which was associated with climatic variables along a steep arid-to-moist longitudinal gradient. Thus, our results suggest that trait covariance is likely a correlated response to selection. We relate these findings to potential origins of trait covariance owing to altered developmental interactions, such as in phenotypic accommodation. Additional evidence is needed to clarify how phenotypic accommodation and correlated selection promote and maintain trait covariance in natural populations. Nonetheless, our study is the first to support a classic Darwinian example concerning domestication and natural selection.

Effects of oral micellized natural vitamin E (D-α-tocopherol) v. synthetic vitamin E (DL-α-tocopherol) in feed on α-tocopherol levels, stereoisomer distribution, oxidative stress and the immune response in piglets.

This study evaluated the strategy of supplementing oral micellized natural vitamin E (D-α-tocopherol) to either piglets and/or sows on α-tocopherol concentrations in piglets serum and tissues after weaning. One first experiment tested the influence of the vitamin E supplementation source (natural form in water v. the synthetic form in feed) and dose administered to piglets and/or sows on serum α-tocopherol concentration, α-tocopherol stereoisomer accumulation, antioxidant capacity and immune response of weaned piglets. A second experiment studied the effect of sow source and dose vitamin E supplementation on some of these parameters in piglets. Oral supplementation to sows with natural vitamin E as a micellized form (D-α-tocopherol) at the lowest dose produced a similar concentration of α-tocopherol in serum at days 2, 14 and 28 postpartum to those supplemented with threefold higher dose of the synthetic form in feed. At day 39 of age, neither piglet supplementation source nor dose significantly affected α-tocopherol accumulation in the serum, muscle, subcutaneous fat or liver. Those piglets from sows supplemented with the micellized alcohol form had higher RRR-α-tocopherol stereoisomers (P<0.001) and lower (P<0.001) RRS- RSS- and RSR-α-tocopherol, at day 39 of age than those from sows supplemented with the synthetic form. A predominant importance of sow over piglet vitamin E supplementation was observed on stereoisomer distribution in piglets. Low doses of oral natural vitamin E supplementation to sows or piglets did not increase the oxidative stress of piglets when compared with the use of the synthetic form in feed. Immunoglobulin levels in piglet serum at day 39 were not affected by natural vitamin E supplementation at low doses in drinking water of piglets or sows when compared with the synthetic form in feed. IgA tended to be higher (P=0.145) at day 39 in piglets supplemented with natural vitamin E when compared with those supplemented with the synthetic form. Low doses of oral micellized natural vitamin E supplementation to sows is an interesting feeding strategy, when compared with the use of high doses of the synthetic form in feed, because it results in similar α-tocopherol concentrations, allows a predominant -R stereoisomer distribution in piglets and also maintains their oxidative status in vivo.

Zinc oxide at low supplementation level improves productive performance and health status of piglets.

Use of ZnO at high doses (3000 ppm) for diarrhea prophylaxis in piglets is widely extended in postweaning Spanish diets, in compliance with the national veterinary regulation. However, European feed legislation limits total dietary Zn to a maximum of 150 mg/kg of complete feed. The objective of this study was to compare a new potentiated form of ZnO, HiZox (Animine), at nutritional level (150 ppm) with pharmacological dosage (3000 ppm) of regular ZnO in starter diets on the productive performance and health status of piglets in a medium-low health status farm. A total of 144 pigs at weaning (28 d of age) were distributed in 6 piglets/pen and 12 pens/treatment. In the prestarter phase (28 to 42 d of age), all pigs received the same commercial feed, including 3000 ppm ZnO. In the starter phase (42 to 63 d of age) (T1) included 3000 ppm of regular ZnO (2500 ppm Zn), and (T2) was supplemented with 110 ppm Zn from potentiated ZnO (HiZox). Average daily feed intake, ADG, G:F, and pig-MAP serum concentration, an acute phase protein commonly used as unspecific biomarker of disease or other acute phase reactions, were measured at 42 and 63 d of life. Pen of 6 piglets was the experimental unit and data were analyzed using the GLM procedure of SAS version 9.0. Piglets fed with T2-HiZox had improved ADG and G:F (P < 0.001) compared to piglets fed with T1-ZnO. In addition, at 63 d of age, the T2 group had a lower pig-MAP serum concentration than T1 group (1.71 vs. 0.95 µg/mL; P < 0.05) indicating higher health status in the T2 group. In conclusion, in low-medium sanitary conditions and in compliance with European regulation, HiZox significantly increased piglet growth compared to pharmacological dosage of regular ZnO in the starter phase. This can be explained by a better health of pigs expressed by a lower level of inflammatory protein pig-MAP.

Effects of gestation and transition diets, piglet birth weight, and fasting time on depletion of glycogen pools in liver and 3 muscles of newborn piglets.

The experiment was conducted to assess the effects of maternal nutrition in late gestation on glycogen pools of newborn piglets of different birth weights and to assess how rapidly the glycogen pools in the liver and 3 muscles are mobilized during fasting. Until d 108 of gestation, 48 sows were fed a gestation standard diet (GSD) with low dietary fiber (DF, 17.1%), or 1 of 3 diets with high DF (32.3 to 40.4%) consisting of pectin residue (GPR), potato pulp (GPP), or sugar-beet pulp (GSP). From d 108 until farrowing, sows were fed 1 of 6 transition diets with low or high dietary fat: one group received a standard diet (TSD; control) containing 3% animal fat, another group received the TSD diet + 2.5 g/d of hydroxy-methyl butyrate as topdressing (THB), and 4 other groups received diets with 8% added fat from coconut oil (TCO), sunflower oil (TSO), fish oil (TFO), or 4% octanoic acid + 4% fish oil (TOA). Two piglets per litter (the second and fifth born) were blood sampled, and 1 was killed immediately after birth, whereas the other, depending on the litter, was killed after 12, 24, or 28.5 to 36 h (mean 32.5 h) of fasting. Samples of liver, LM, M. semimembranousus (SM), and M. diaphragm (DP) were collected and analyzed for glycogen concentration. No dietary effects (P > 0.20) on glycogen concentrations in liver, LM, SM, or DP were observed. The weight of the liver was affected by gestation diet (P < 0.05) and was greater in GSD and GSP piglets (36.7 and 36.3 g) than in GPR piglets (32.6 g), and intermediate (33.6 g) in GPP piglets. Liver weight, estimated muscle mass, and glycogen pools (P < 0.001) were affected by birth weight, whereas glycogen concentrations in liver and LM, SM, and DP muscles were not (P > 0.05). Liver weight; glycogen concentrations in liver, LM, SM, and DP; and glycogen pools in liver and muscles decreased (P < 0.001) with increasing duration of fasting, and at 32.5 h of fasting, glycogen concentration was reduced by 80% in liver, 64% in DP, 46% in SM, and 36% in LM. Based on a broken-line model, labile glycogen in SM, a locomotory muscle, was estimated to be depleted after 16.4 h of fasting. In conclusion, piglet size had a major impact on estimated glycogen pools, whereas sow nutrition in late gestation had a minor impact, if any. Furthermore, varying proportions of pools of glycogen present in liver and selected muscles were mobilized, and data indicate that newborn piglets are fatally depleted of energy after 16 h of fasting.

The association of Triatoma maculata (Ericsson 1848) with the gecko Thecadactylus rapicauda (Houttuyn 1782) (Reptilia: Squamata: Gekkonidae): a strategy of domiciliation of the Chagas disease peridomestic vector in Venezuela?

OBJECTIVE: To investigate the bioecological relationship between Chagas disease peridomestic vectors and reptiles as source of feeding. METHODS: In a three-story building, triatomines were captured by direct search and electric vacuum cleaner search in and outside the building. Then, age structure of the captured Triatoma maculata (T. maculata) were identified and recorded. Reptiles living in sympatric with the triatomines were also searched. RESULTS: T. maculata were found living sympatric with geckos (Thecadactylus rapicauda) and they bit residents of the apartment building in study. A total of 1 448 individuals of T. maculata were captured within three days, of which 74.2% (1 074 eggs) were eggs, 21.5% were nymphs at different stages, and 4.3% were adults. CONCLUSIONS: The association of T. maculata and T. rapicauda is an effective strategy of colonizing dwellings located in the vicinity of the habitat where both species are present; and therefore, could have implications of high importance in the intradomiciliary transmission of Chagas disease.

Dietary CLA alters intramuscular fat and fatty acid composition of pig skeletal muscle and subcutaneous adipose tissue.

The present study was conducted to determinate the responsiveness of different levels of dietary conjugated linoleic acid (CLA) on intramuscular fat (IMF) and fatty acid composition of skeletal muscle and fat in pigs fed from 59.5 to 133.5kg. Forty female Large Whitex(Large WhitexLandrace) pigs were used. Four levels (0%, 0.5%, 1% and 2%) of a commercial enriched CLA oil supplementation (60% of CLA isomers, 30% cis-9, trans-11 and 30% trans-10, cis-12) were fed to pigs. Carcass, ham, foreleg and loin weights were recorded. Dietary CLA enrichment increased the loin weight (P<0.01) and the combined weights of hams+forelegs+loins (P<0.02). IMF content in Longissimus dorsi was also increased by dietary CLA treatment (P<0.001) and a linear response was observed. Dietary CLA increased saturated fatty acids (SFA) and decreased monounsaturated fatty acids (MUFA) in muscle and adipose tissue (P<0.001). Feeding 1% CLA to finishing swine increases IMF in heavy pigs slaughtered at an average weight of 133.5kg.

Physical activity-induced alterations on tissue lipid composition and lipid metabolism in fattening pigs.

In a first experiment one group of pigs was maintained in free-range conditions according to the traditional way in a Mediterranean forest (exercised-1) and another group was housed individually and received acorns (sedentary-1). In a second experiment two groups of pigs were fed a mixed diet for the whole experimental period. One of these groups was housed individually in 8m(2) pens (sedentary-2). The other group was housed in a corridor and forced to walk daily (exercised-2). The subcutaneous fat and neutral lipids of muscle from the exercised pigs fed acorns had higher C18:1n-9, MUFA, C18:1/C18:0, MUFA/SAT and lower C16:0 and SAT when compared with the fat from the pigs fed acorns in confinement. Those exercised animals fed the mixed diet had also lower C16:0 and SAT in subcutaneous fat and lower SAT and higher C18:2, C18:3, PUFA and MUFA/SAT in neutral lipids when compared with the sedentary pigs, which may indicate that delta-9-desaturase activity was higher in exercised than in sedentary pigs. Exercised pigs had higher acid and neutral esterases and lower neutral lipase activity than sedentary pigs. No differences in the α-tocopherol concentration and TBARS values of meat samples among the pigs that received a mixed diet either exercised or sedentary were observed. The moderate exercise reduced the postprandrial concentrations of triglycerides in plasma, but did not reduce other plasma levels.

Recomendaciones para mejorar la atención en enfermería / Recommendations to improve attention in nursing

El personal de enfermería desempeña una actividad fundamental en los servicios de salud, con fuerte apego a principios científicos y éticos; sus intervenciones permiten fortalecer la calidad en los servicios de salud, através de acciones interdisciplinarias. Se analizaron las inconformidades relacionadas con atención de enfermería que recibió la Comisión Nacional de Arbitraje Médico (CONAMED) de junio de 1996 a diciembre de 2001. Con base en el análisis se elaboraron recomendaciones dirigidas a prevenir el conflicto, mejorar la práctica de enfermería y propiciar la adecuada comunicación con el paciente, familiares y equipo interprofesional de salud. Se integró un grupo representativo de las instituciones educativas y gremiales de enfermería más prestigiadas y reconocidas, para su validación externa. De esta manera, la CONAMED y el grupo de validación externa, proponen al personal de enfermería atender las siguientes recomendaciones: 1) Mantener una comunicación efectiva con las personas a las que proporciona atención; 2) Reconocer en la persona su concepción holística; 3) Proporcionar cuidados que garanticen la atención libre de riesgos y daños innecesarios; 4) Establecer una coordinación efectiva con el equipo interprofesional de salud; 5) Actuar con base en los principios éticos que rigen la práctica profesional de enfermería.

Nurse personnel performs a fundamental activity in t health services, with strong attach at scientific and ethical principles, whose interventions can fortify the services of health quality, through interdisciplinary actions. We analyzed the compliants related to nursing attention that were received in CONAMED since June 1996 to December 2001. Wedevised recommendations directed to prevent patient-health care professionals conflicts, improve the practice of nursing and favor adequate communication with the patient, family and interprofessional health care team. Those recommendations were presented to the more prestigious and recognized educational and professional groups of nursing, for their external validation. In this manner, CONAMED and the external group of validation, propose to nurses to attend the following recommendations: 1) Maintain an effective communication with the patients that provides attention; 2) Recognize the holistic concept in the person; 3) Provide cares that guarantee tree-risk attention and prevent unnecessary damages; 4) Establish an effective coordination with the health care interprofessional team and 5) Act based on ethical principles that govern the professional practice of nursing.

Transcranial magnetic stimulation and acoustic trauma or hearing loss in children.

Transcranial magnetic stimulation is a non-invasive method used to assess motor function in humans; however, some reports suggest it may cause internal ear damage (cochlear). Eighteen patients with normal auditory function (ages 2 months to 16 years, mean 6.8 years), two medical doctors and two technicians who performed the studies were tested with brain stem auditory evoked potentials, otoacoustic emissions, acoustic reflex and a pure tone audiometric and logoaudiometric test when possible, before and after transcranial magnetic stimulation for central motor conduction studies in different neurological conditions. All the tests were repeated two weeks and two months later. Patients had no auditory protection nor history of seizures. Motor evoked potentials and silent periods were recorded from the right abductor pollicis brevis and the first dorsal interosseous muscles at rest and during weak voluntary contraction when possible. A mean of 48 transcranial magnetic stimulations with 50%-75% Tesla intensity were used. Natural logarithmic transformation of latency and amplitude data had a normal distribution. There were no significant differences in auditory function testing.

Vesicoureteral reflux: subpopulations of patients defined by clinical variables.

BACKGROUND: The first imaging evaluation of the child with urinary tract infection (UTI) is often the same for all children, regardless of the child's clinical presentation. However, this approach is simplistic and ignores considerable differences in the frequency of abnormal pathophysiology in different subpopulations of children with UTI. OBJECTIVE: Six clinical variables are evaluated as predictors of vesicoureteral reflux (VUR) in a large series of girls with UTI. MATERIALS AND METHODS: Data were collected from a consecutive series of 919 girls undergoing a first imaging evaluation for UTI. Six input variables were used: age, maximum body temperature (T(max)), number of UTIs, hospitalization, family history of childhood UTI, and rapidity of response to antibiotic therapy. The dependent variable was VUR. Data were enumerated and analyzed by logistic regression and the chi-square test. RESULTS: VUR was present in 28.8 %. The percentage with VUR varied from 56.1 % for age < 6 months and T(max) L 38.5 degrees C to 13.0 % for age L 10 years and T(max) < 38.5 degrees C. The frequency of VUR was significantly lower in girls with T(max) < 38.5 degrees C in most age groups. Logistic regression demonstrated, when all clinical variables were taken together, that only age and T(max) were independent predictors of VUR. CONCLUSIONS: Girls with UTI should not be considered to be a homogeneous group. The frequency of VUR is related to T(max) and inversely to age. Data about these subpopulations should be used in deciding which girls should undergo cystography.

[Short and intermediate term clinical outcome in patients with cardiogenic shock treated with aortic counterpulsation]. / Evoluzione clinica a breve e medio termine di pazienti cardiopatici in shock cardiogeno trattati con contropulsazione aortica.

BACKGROUND: Despite improvements in coronary care, cardiogenic shock (CS) remains the leading cause of death in patients with dramatic cardiac diseases of which acute myocardial infarction (AMI) is the most frequent event. Conventional therapy for CS with coronary care unit (CCU) monitoring and vasopressor agents to support blood pressure has historically been associated with an 80% to 90% mortality rate in large series. Intra-aortic balloon pump (IABP) therapy for shock results in initial favourable clinical and haemodynamic responses, but ultimately, in most patients, death is merely delayed and hospital mortality still exceeds 80%. In several recent non-randomised series, coronary revascularisation performed early in the course of CS with the use of coronary artery by-pass grafting (CABG) or coronary angioplasty (PTCA) resulted in an apparent reduction in the hospital mortality rate to less than 50% in selected patients with shock. OBJECTIVES: This study reviews our experience of cardiogenic shock treatment at a time when standard care included aggressive use of the intra-aortic balloon pump counterpulsation, cardiac catheterisation, coronary angioplasty and/or coronary artery by-pass grafting, ventricular septal defect and mitral incompetence repair. METHODS: We retrospectively analysed 20 patients (13 M and 7 F, with an average age of 62 years and a half) affected by cardiogenic shock consecutively admitted to our CCU between October 1, 1992 and April 1, 1995. Fifteen patients (pts) were hospitalised for AMI, shock and pump failure (2 of them with pulmonary oedema), all with admittance delay less than 24 hours. Five patients were hospitalised for AMI with shock and mechanical defects, of which 3 pts with AMI and ventricular septal rupture and 2 pts with AMI and mitral regurgitation. All patients underwent IABP, coronary angiography (CA) and then were treated with PTCA, CABG and cardiac surgery or medical treatment. RESULTS: On the whole, 7 pts died (35%): 4 of shock, 1 of haemorrhagic complications, 1 of septic shock in the CCU, and 1 of heart failure after CABG in cardiosurgery. One more patient died of heart failure two months after discharge (late mortality 5%). Out of the 15 patients hospitalised with AMI, shock and pump failure, 13 patients with AMI and CS less than 24 hrs were treated as follows: 1 patient was successfully submitted to emergency CABG and 12 patients to PTCA of the infarct related artery (IRA). Eight patients enjoyed a good outcome, but 1 patient died of haemorrhagic complications and 4 with a persistently occluded IRA also died (3 in the CCU and 1 after CABG). Of the 2 remaining pts with AMI, shock and pulmonary oedema, 1 patient underwent CABG with success and 1 patient with the 3-vessel disease was submitted to PTCA with reperfusion of the IRA, but he died from reocclusion three days later. Out of the 5 patients with AMI, shock and mechanical defects, 3 patients with AMI and septal ventricular rupture underwent cardiac surgery and CABG with early and late success. One of the 2 patients with AMI, shock and mitral regurgitation underwent cardiac surgery with valve repair and CABG and had a good outcome, the other died from septic complications in the CCU. CONCLUSIONS: IABP is an useful device for stabilising patients in cardiogenic shock and safely performing angiography as well as PTCA, CABG or surgical correction of all mechanical complications with a more stable haemodynamic balance. Therefore, IABP is an useful tool to improve successful coronary revascularisation after direct PTCA or direct CABG. These data also suggest that the combination of successful coronary revascularisation and intra-aortic balloon pumping can improve survival in pts with cardiogenic shock complicating AMI with early pump failure.

Gabexate mesilate, a new synthetic serine protease inhibitor: a pilot clinical trial in valvular heart surgery.

OBJECTIVE: To assess the effects of gabexate mesilate ([GM], Foy, ONO Pharmaceutical Co, Osaka, Japan) on blood loss in cardiac valve replacement surgery and to establish whether GM reduces blood loss or transfusion requirements after this surgery. DESIGN: Randomized single-blind trial in 30 patients receiving either GM (2 mg/kg/h in a central venous catheter), or no GM, after heparin. SETTING: Department of Anesthesia and Intensive Care, Cardiac Surgery, in a hospital in Italy. PARTICIPANTS: Consent patients. INTERVENTIONS: Cardiac valve replacement surgery. MEASUREMENT AND MAIN RESULTS: Intraoperative and postoperative bleeding, blood transfusion, hemoglobin, and hematocrit were compared. In the GM group bleeding was reduced and no transfusions were required. CONCLUSION: GM appears to play a useful role in reducing blood loss during extracorporeal circulation in cardiac surgery.

[HIV infection]. / La infeccion del VIH.

AIDS: Questions and answers about HIV infection are explained using a boxing analogy, with T4 and T8 cells attacking the opponent, HIV-antibodies. How B cells and lymph nodes attack the protein exterior of the HIV virus is described. Viral RNA combines with the cell's DNA to allow the virus to reproduce. It remains there until the cell overflows, reappearing in the blood as the victim notices the first symptoms of AIDS.^ieng