Timing of Pulmonary Valve Replacement: How Much Can the Right Ventricle Dilate Before it Looses Its Remodeling Potential?

Congenital heart disease patients that develop secondary pulmonary regurgitation require a pulmonary valve replacement (PVR) in their follow-up. The indications for PVR in asymptomatic patients are debated. Most guidelines consider a RV end-diastolic volume (RVEDV) over 150 ml/m(2) as an indication for PVR. We analyzed clinical, echocardiographic and MRI variables of patients that underwent a surgical PVR between September 2006 and February 2013. The included patients were asymptomatic, without pulmonary stenosis and with both pre- and post-surgery MRI. Thirty-five patients (74.3 % males) were included. Mean age at PVR was 25.8 years (SD = 7.18), and weight was 64.5 Kg (SD = 12.03). The main diagnosis was tetralogy of Fallot (n = 28), pulmonary atresia (n = 2), primary pulmonary regurgitation (n = 2) and pulmonary regurgitation after percutaneous treatment (n = 2). The maximal RVEDV pre-PVR was 267 ml/m(2), and right ventricular end-systolic volume (RVESV) was 183 ml/m(2). RV size and function were established by MRI: Pre-PVR Post-PVR p RVEDV (ml/m(2)) 162 (SD = 39.1) 94 (SD = 23.6) <0.001 RVESV (ml/m(2)) 87 (SD = 28.9) 44 (SD = 15.7) <0.001 RVEF 44.8 % (SD = 8.17) 52 % (SD = 9.9) <0.001 Patients with a RVEDV under 170 ml/m(2) combined with a RVESV under 90 ml/m(2) had a favorable RV remodeling, defined as RVEDV under 110 ml/m(2) (sensitivity 87.5 %), RVESV under 55 ml/m(2) (sensitivity 100 %) and RVEF over 50 % (sensitivity 100 %). When deciding the optimal PVR timing in asymptomatic patients, both RVEDV and RVESV should be considered. Our results suggest that higher volumes than used in the clinical practice can achieve a good remodeling. Therefore, PVR could be performed later in the follow-up reducing the number of cardiac interventions.

Pharmacokinetics of ceftazidime administered to lactating and non-lactating goats.

The aim of this work was to determine the pharmacokinetics of intravenous (i.v.) and intramuscular (i.m.) ceftazidime administered to lactating (LTG; n=6) and non-lactating (NLTG; n=6) healthy Creole goats in 2 trials (T1 and T2). During T1 and T2, goats randomly received a single dose of i.m. or i.v. ceftazidime (10 mg/kg). Serum concentration of iv ceftazidime in NLTG and LTG goats is best described by 2 and 3 compartment models, respectively. The pharmacokinetic parameters of iv and im ceftazidime administered to LTG and NLTG showed statistically significant differences (P < 0.05) in the constants (lamda(z), T1 vs. T2 [i.v.] 0.5 +/- 0.1 vs. 0.3 +/- 0.1/h; T1 vs. T2 [i.m.] 0.5 +/- 0.2 vs. 0.3 +/- 0.1/h) and in the mean times (t(1/2), T1 vs. T2 [i.v.] 1.6 +/- 0.3 vs. 2.3 +/- 0.6 h; T1 vs. T2 [i.m.] 1.6 +/- 0.7 vs. 2.6 +/- 0.9 h) of elimination. The bioavailability of ceftazidime in LTG and NLTG was 113.0 +/- 17.8 and 96.0 +/- 18.0%, respectively. Ceftazidime concentration in milk at 2 h was: i.v. = 1.9 +/- 0.2 and i.m. = 2.4 +/- 0.5 microg/ml; the penetration in milk was i.v. = 18.3 +/- 13.5 and im = 14.3 +/- 10.6%. Ninety-six hours after i.v. and i.m. administration, residues of the drug were not found in milk. In conclusion, ceftazidime, when administered to goats, showed high concentration times in serum, good penetration into milk and a bioavailability that makes it suitable to be used by the i.m. route.

Torsión intraútero de un quiste ovárico. Presentación neonatal atípica / Intrauterine torsion of ovarian cyst. Atypical neonatal presentation

La ecografía prenatal y posnatal nos ha permitido conocer realmente los datos sobre la frecuencia y la evolución de los quistes ováricos fetales. Aunque la mayoría de estos quistes involucionan en el transcurso de los primeros meses de vida, pueden presentar complicaciones durante el periodo fetal o posnatal, entre las cuales la torsión ovárica es la más frecuente. Presentamos el caso de una niña de 5 meses de edad, remitida a nuestro servicio de cirugía pediátrica por una tumoración intraabdominal, que resultó ser una autoamputación ovárica, complicación derivada de un quiste ovárico fetal que provocó una torsión ovárica intraútero. Revisamos los conocimientos actuales sobre los quistes ováricos fetales, haciendo especial hincapié en su manejo médico y quirúrgico posnatal (AU)

Pre- and postnatal echographies have allowed us to know reliable data about frequency and evolution of fetal ovarian cysts. Though most of these cysts involute during the first months of life, sometimes complications may appear during fetal or neonatal periods, being the ovarian torsion the most frequent. We present a case report of a 5 months-old female patient referred to our Pediatric Surgery Service with an intraabdominal tumoration. This tumoration resulted to be an ovarian autoamputation, which is a complication derived from a fetal ovarian cyst which caused an intrauterine ovarian torsion. We revise the current knowledge about fetal ovarian cysts emphasizing its postnatal surgical and clinical management (AU)

Pharmacokinetics of trifluralin in blood and heart tissue of mice.

BACKGROUND: Trifluralin displays anti-Trypanosoma cruzi activity and a potential therapeutic effect for the treatment of Chagas disease. We assessed peroral and intramuscular trifluralin pharmacokinetics in mouse blood and heart tissue. METHODS: A parallel experimental design was used. Healthy adult male CF1 albino mice (n = 108, 25-35 g bw) received a single peroral or intramuscular trifluralin dose (50 mg/kg in peanut oil). Blood and heart tissue samples were taken at set times after intramuscular and peroral trifluralin administration. Feces and tissue samples were taken 12 h after intramuscular trifluralin administration. Trifluralin concentrations in whole blood, feces and tissues were determined by HPLC. RESULTS: After intramuscular and peroral administration, maximum whole blood concentration (C(max)) was attained at 30 min and 2.0 h (t(max)) (28.2 +/- 0.7 and 7.8 +/- 0.033 microg/ml; p < 0.05). C(max) in heart tissue was attained at 1.0 and 2.0 h (0.6 +/- 0.004 and 0.2 +/- 0.002 microg/g; p < 0.05). Liver, perirenal and subcutaneous fat concentrations were 55.1, 66.3 and 59.7 ng/mg tissue protein. Peroral and intramuscular penetration ratios determined by comparing heart tissue areas under the curve were 6.3 and 4.0%, respectively. CONCLUSION: Intramuscular trifluralin could be a new alternative for the treatment of Chagas disease.

Hypoplastic left heart syndrome diagnosed in fetal life: associated findings, pregnancy outcome and results of palliative surgery.

OBJECTIVES: To analyze the main prenatal characteristics of hypoplastic left heart syndrome (HLHS), its association with extracardiac anomalies including increased nuchal translucency (NT) and the outcome of affected patients. METHODS: We searched our database for classical forms of HLHS (aortic atresia, mitral and aortic atresia and critical aortic stenosis evolved to a severely hypoplastic left ventricle) prenatally diagnosed between 1998 and 2006. Data on 101 fetuses were retrieved and analyzed. RESULTS: The main reason for referral was suspected heart defect on a routine ultrasound scan (82%). The mean gestational age at diagnosis was 21 weeks. Most cases were detected at < or = 22 weeks (72%), the upper limit for termination of pregnancy (TOP) in our country (Spain). An intact atrial septum was diagnosed in 11 of the 58 fetuses (19%) in which pulmonary vein blood flow was assessed, and this diagnosis was proved to be correct in the six liveborn babies. Most fetuses (68%) had an isolated HLHS. Fourteen fetuses (14%) were chromosomally abnormal and all had associated extracardiac defects. NT was above the 95th centile in 21 of the 74 cases (28%) in which this measurement was available. 79% (58/73) of the cases in which HLHS was detected at < or = 22 weeks were terminated, and no differences in the rate of TOP were found through the study period. Among the 43 continuing pregnancies, seven fetuses died in utero and there were 36 live births; in 12 cases the parents opted for compassionate care and 24 chose to have the infant surgically treated. In the cohort of intention-to-treat cases, the overall survival rate was 36% (9/25). This rate improved from 18% (2/11) in the period 1998-2002 to 50% (7/14) in 2003-2006. There were no survivors in cases with intact atrial septum or when there were associated defects. At follow-up, 2/9 survivors suffered from significant neurological morbidity. CONCLUSIONS: Fetal echocardiography allows an accurate diagnosis of HLHS, which is made in most instances in the first half of pregnancy. Despite the advantage offered by the prenatal detection of HLHS, which provides the opportunity to plan perinatal management, our up-to-date results show that the outlook for these fetuses is still poor, and highlight the importance of presenting these figures when counseling parents with affected fetuses.

Uso de la Sonda de doble balón en Epistaxis / x

La epistaxis es una patologia muy comén, que puede cohibir sola o requerir tratamiento médico el cual es muy diverso. La sonda de doble balón es uno de ellos, creada para el control de la hemorragia, que es un cateter de silicon de 13 cm. de longitud con una vía aérea central y dos balones inflables independientes que distendidos ejercen presión hemostática en la cavidad nasal...

Interactions of prostaglandin E1, bradykinin and histamine and the increase of plasma fibrinogen in rats.

Considering that tissue injury caused by laparotomy significantly increases the liver synthesis of plasma fibrinogen, and that PGE1, bradykinin and histamine are released into the injured tissues, the effect of above mentioned inflammatory agents and of the adrenal medulla on plasma fibrinogen levels in rats was studied. The subcutaneous administration of PGE1, bradykinin or histamine does not modify plasma fibrinogen levels acting independently comparing with non-injected animals or injected with the drug vehicle. Bradykinin + histamine did not modify plasma fibrinogen levels either. However the administration of prostaglandin E1 + bradykinin + histamine reproduced the increase of fibrinogen characteristics of laparotomy. This increase was partially but significantly inhibited in rats that had undergone bilateral removal of the adrenal medulla or administration of PGE1 + bradykinin + histamine + bupivacaine (a local anesthetic), but it was not modified when the adrenal medullectomy was unilateral. It is concluded that plasma fibrinogen increase is obtained only when PGE1 acts in presence of bradykinin or histamine and the adrenal medulla should be partially responsible for said increase.

Rôle of histamine on plasma fibrinogen levels in rats with surgical injury (laparotomy).

The probable rôle of endogenous histamine in the increase of plasma fibrinogen in rats submitted to tissue injury (laparotomy) was studied. In laparotomized rats with 10 mg kg-1 day-1 of diphenhydramine (a H1-histamine receptor blocker) plasma fibrinogen decreased significantly as compared to the group of rats laparotomized only (P less than 0.02), reaching values similar to those observed in rats laparotomized with removal of the adrenal medulla or laparotomized with severing of splanchnic nerves. There is a significant difference between these latter groups and the normal noninjured group (P less than 0.01). Plasma fibrinogen did not modify (as compared with the uninjured group) in rats injected only with histamine (1 mg kg-1 day-1) or with diphenhydramine. Taking into account the results obtained and the mechanism of action of diphenhydramine, it would seen that endogenous histamine takes part in the increase of plasma fibrinogen in laparotomized rats, perhaps indirectly through stimulation of the adrenal medulla secretion.

Effects of indomethacin on plasma fibrinogen levels in rats with tissue injury.

The present investigation was designed to study the effect of indomethacin (5 mg kg-1 day-1) on plasma fibrinogen levels in laparotomized rats. Whereas tissue injury significantly increased plasma fibrinogen when compared to normal uninjured rats, indomethacin completely blocked that effect. Conversely, indomethacin did not prevent fibrinogen increase in laparotomized rats injected with epinephrine, with spinal cord transection + epinephrine or with adrenal medullectomy + epinephrine. Indomethacin or epinephrine administration to normal rats did not modify plasma fibrinogen. Taking into account that epinephrine is a key hormone in plasma fibrinogen response in laparotomized rats, and according to our results, prostaglandins might act by two possible pathways: 1) by decreasing of the pain threshold of the sensory nerve endings and stimulating sympathetic adreno-medullar system; 2) by entering into the blood stream and enhancing epinephrine action on plasma fibrinogen. It would appear that indomethacin inhibits both pathways.

Effects of the administration of progesterone and adrenal medullectomy on the plasma fibrinogen levels in rats with surgical injury (laparotomy).

The probable rôle played by the adrenal medulla in the decrease of plasma fibrinogen due to the administration of progesterone (0.5 mg kg-1 day-1 during 72 h) in rats submitted to surgical injury (laparotomy) was studied. The results obtained lead to assume that the decrease of plasma fibrinogen observed in laparotomized rats injected with progesterone is indirectly produced through inhibition of the adrenal medulla. The action of progesterone on the plasma fibrinogen would be a pharmacological effect of the drug, since in doses of 0.10 mg kg-1 day-1 the decrease of the fibrinogen is not observed in laparotomized rats. The administration of progesterone in non injured rats does not modify the plasma fibrinogen as compared to the group of non injected rats.

Effects of diethylstilbestrol, 17 beta estradiol, and progesterone on plasma fibrinogen levels in rats submitted to tissue injury (laparotomy).

Participation of estrogens (17 beta estradiol, diethylstilbestrol) and progesterone in the increase of plasma fibrinogen levels in female rats submitted to tissue injury (laparotomy) was studied. Ovariectomy avoided the increase of fibrinogen observed in laparotomized rats, while the administration of 17 beta estradiol or diethylstilbestrol to laparotomized-ovariectomized rats increased fibrinogen to levels similar to those observed in the group of laparotomized rats without other treatment. On the other hand, progesterone inhibited the increase of fibrinogen which is typical of laparotomy in both groups: one of laparotomized rats and the other of laparotomized rats injected with estrogens. Neither estrogens nor progesterone modify plasma fibrinogen levels in uninjured rats. It is concluded that estrogens might participate in the fibrinogen increase observed after tissue injury in female rats, and on the contrary, the administration of progesterone would render that increase null.