Actinotignum schaalii infection: Challenges in diagnosis and treatment.

Actinotignum schaalii affects elderly people and is associated with individuals with urological-related predispositions, but can be found in a variety of locations, such as cutaneous, intraabdominal, genitourinary and surgical infections. Disseminated infections occur less frequently and are by and large related to urinary tract colonisation. This pathogen is often neglected due to growth requirements, especially in urinary tract infections. We present 107 Actinotignum schaalii isolated from genitourinary samples (80.4%), from skin and soft tissue infections (13.1%), from bone and deep tissue infection (4.7%) and from blood cultures (1.9%). The automated system Alfred 60/AST was paramount for the isolation of 77.6% of the UTI. All the isolates tested were susceptible to penicillin, ampicillin, linezolid, vancomycin, teicoplanin, rifampicin and tetracycline. In conclusion, we present a large series of Actinotignum schaalii infections. This pathogen is hard to isolate, and is resistant to commonly used empirical antimicrobials.

Capnophilic Enterobacteriaceae.

Bacteria use bicarbonate as substrate for crucial metabolic reactions. We report the first case of bacteremia by capnophilic E. coli without the YadF gene (also known as CynT2 or Can2) that needs high concentrations of CO2 to non-enzymatically produce bicarbonate. This lack may also apply to previously reported capnophilic Enterobacteriaceae.

CREB decreases astrocytic excitability by modifying subcellular calcium fluxes via the sigma-1 receptor.

Astrocytic excitability relies on cytosolic calcium increases as a key mechanism, whereby astrocytes contribute to synaptic transmission and hence learning and memory. While it is a cornerstone of neurosciences that experiences are remembered, because transmitters activate gene expression in neurons, long-term adaptive astrocyte plasticity has not been described. Here, we investigated whether the transcription factor CREB mediates adaptive plasticity-like phenomena in astrocytes. We found that activation of CREB-dependent transcription reduced the calcium responses induced by ATP, noradrenaline, or endothelin-1. As to the mechanism, expression of VP16-CREB, a constitutively active CREB mutant, had no effect on basal cytosolic calcium levels, extracellular calcium entry, or calcium mobilization from lysosomal-related acidic stores. Rather, VP16-CREB upregulated sigma-1 receptor expression thereby increasing the release of calcium from the endoplasmic reticulum and its uptake by mitochondria. Sigma-1 receptor was also upregulated in vivo upon VP16-CREB expression in astrocytes. We conclude that CREB decreases astrocyte responsiveness by increasing calcium signalling at the endoplasmic reticulum-mitochondria interface, which might be an astrocyte-based form of long-term depression.

Successful stent-grafting for iatrogenic aortic rupture and life-threatening hemoptysis.

Bronchiectasis presenting as massive hemoptysis and iatrogenic lesions of the thoracic aorta are life-threatening processes with very difficult management. We report a case of massive hemoptysis from bronchiectasis complicated with contained rupture of the descending thoracic aorta during bronchial artery embolization. Both lesions were confirmed by angiography and successfully treated by implantation of an endovascular stent-graft in the thoracic aorta. As far as we know, there are no previous reports of successful management of massive hemoptysis from bronchiectasis with an endovascular covered stent-graft prosthesis.

Perfusión de extremidad aislada en sarcomas de partes blandas irresecables: un nuevo estándar / Isolated limb perfusion for unresectable softtissue sarcomas: a new standard

La perfusión de extremidad aislada (PEA) con sólo melfalán no ha mostrado eficacia en el tratamiento de sarcomas de partes blandas (SPB) irresecables de extremidad. Esta situación se ha visto modificada con la aparición del factor de necrosis tumoral-alfa (TNF), fármaco que ataca los vasos tumorales y aumenta de tres a seis veces la captación selectiva de otros medicamentos por el tumor. Durante los últimos diez años, diversos estudios han demostrado que la combinación de TNF y melfalán, administrada mediante PEA, produce un efecto antitumoral espectacular. En la actualidad es el tratamiento estándar para los pacientes con SPB de extremidad irresecables y subsidiarios de amputación física o funcional del miembro afecto, ya que en más del 70 por ciento de los casos logra una disminución de la tumoración suficiente como para realizar posteriormente una cirugía de exéresis del residuo tumoral con conservación física y funcional de la extremidad (AU)

Scapular hibernoma fortuitously discovered on myocardial perfusion imaging through Tc-99m tetrofosmin.

A 49-year-old man was hospitalized for precordial pain. The result of a resting electrocardiograph was normal. Tc-99m tetrofosmin stress myocardial imaging was performed and uptake in the area of the left scapula was seen. The abnormality was caused by a subcutaneous tumor. Histologic examination revealed a hibernoma.

Mesenteric actinomycosis with retroperitoneal involvement.

Mesenteric or retroperitoneal actinomycosis is an extremely rare disease. The international databases have revealed only 10 cases affecting the mesenterium and another 52 cases affecting the retroperitoneum. We report a 78-year-old female who was admitted with complaints of abdominal pain. Laboratory examination revealed anemia and the clinical examination revealed an irregular mass in the abdomen. Ultrasound and computed tomography (CT) scans showed a solid mass in the mesenteric-retroperitoneal region. Biopsy of the nonresectable mass revealed the presence of chronic inflammation in the mesenteric area with Actinomyces colonies. The patient was treated with oral amoxicillin, 500 mg every 6 hours for 6 months. The symptoms disappeared, but the mesenteric-retroperitoneal mass remains, but smaller in size. Based on the review of the literature and the case reported here, we conclude that mesenteric-retroperitoneal actinomycosis is difficult to diagnose by means of noninvasive techniques as it can masquerade as a malignant process. An accurate diagnosis is always obtained in a histological or microbiological examination, often requiring surgical intervention. Treatment with penicillin has proven to be effective.

Mesotelioma maligno en la región inguinal de origen incierto / Malignant mesothelioma of unknown origin in the inguinal region

Se presenta un caso de mesotelioma maligno en una paciente joven, localizado en la región inguinal y sin aparente relación con ningún saco herniario ni cavidad peritoneal. Se revisa la bibliografía existente, sin encontrar ninguna otra forma igual de mesotelioma (AU)

Association between air pollution and intrauterine mortality in São Paulo, Brazil.

The associations among daily counts of intrauterine mortality and pollutant concentrations (NO2, SO2, CO, O3, and particulate matter (3/4)10 microm) were investigated for the period ranging from January 1991 to December 1992 in the city of São Paulo, Brazil. We used Poisson regression techniques, adjusted for season and weather. The association between intrauterine mortality and air pollution was strong for NO2 (coefficient = 0.0013/ microg/m3; p<0.01) but lesser for SO2 (coefficient = 0.0005/ microg/m3; p<0.10) and CO (coefficient = 0.0223/ppm; p<0.10). A significant association was observed when an index that combined these three pollutants was considered in the models instead of considering each pollutant individually (p<0.01). These associations exhibited a short time lag, not over 5 days. In addition, some evidence of fetal exposure to air pollution was obtained by disclosing a significant association between the levels of carboxyhemoglobin of blood sampled from the umbilical cord and ambient CO levels in children delivered by nonsmoking pregnant women in the period from May to July 1995. Our results suggest that air pollution in São Paulo may promote adverse health effects on fetuses.

[Prolonged rupture of the membranes and neonatal infection]. / Ruptura prolongada de membranas e infecção neonatal.

OBJECTIVE: To evaluate a schedule of assessment at birth of newborn from mothers with prolonged rupture of membranes (PROM >or= 24 hours), based on selected clinical and laboratorial parameters of infection. METHODS: Prospective study, including newborns admitted to the Nursery of the Hospital de Clínicas - University of São Paulo from May/1993 to December / 1994, whose mothers had PROM >/or 24 hours. In all newborns white blood cell count (umbilical cord and 24 hours of life) and blood culture of umbilical cord were done. Antibiotics were given to newborns with clinical signs of chorioamnionitis, GA 34 and < 37 weeks, plus at least one risk factor of infection. All newborns were classified into 4 subgroups: I (PROM 48 hours and < 7 days), III (PROM >or= 7 and < 14 days), IV (PROM >or= 14 days). RESULTS: The incidence of infection was 38.1% and was more frequent in newborns with GA < 34 weeks (p< 0.05). No statistical significance was noted among the subgroups analysed. Among the risk factors analysed, GA < 34 weeks was the main one. CONCLUSIONS: The authors recommend the use of prophylactic antibiotic therapy in newborns from mothers with PROM which have a GA

Thoracic aneurysm as a cause of chyluria: resolution by surgical treatment.

A 37-year-old man who had suffered a thoracic trauma presented night release of whitish urine 2 years later. Thoracic computed tomography and aortography demonstrated an aneurysm of the thoracic aorta. Lymphography confirmed the compression of the thoracic duct by the aneurysm. After surgical repair the patient has remained asymptomatic.

[Orthotopic heart transplantation in a patient with previously undiagnosed persistence of the left superior vena cava]. / Trasplante cardíaco ortotópico en un paciente con persistencia de vena cava superior izquierda no diagnosticada previamente.

The amount of transplants has gone through a remarkable increase during the last years. As a result, congenital anomalies of little prevalence appear more and more often while performing the transplants. The persistence of upper cava vein is one of them and, if not linked to other anomalies, it usually remains unnoticed. This article presents a case of an orthotopic cardiac transplant in a patient with an upper cava vein duplication not diagnosed before undergoing surgery, and it compares the way it was handled to diverse techniques previously described.

Cardiac surgery in patients under chronic hemodialysis.

A total of 15 chronic renal failure patients on hemodialysis therapy underwent some kind of cardiovascular surgery between August 1984 and March 1993. Ten had a valve abnormality, and the remaining five had coronary artery disease. All of them were hemodialyzed the day before surgery and 24-48 h after the operation. Eleven recovered well after surgery, four died of septic shock: two of these were in septic shock prior to surgery; one was in acute congestive heart failure, and one was operated during an acute myocardial infarction. All operative deaths occurred in the patients who underwent non-elective surgery or were preoperatively in New Heart Association (NYHA) class IV. The factors having an impact on morbidity and mortality seem to be more related to the previous clinical situation and to the urgency of the operation than to the status of chronic renal failure. An early and adequate assessment of the candidates, when possible avoiding emergency surgery and acute left ventricular dysfunction, as well as careful management during cardiopulmonary bypass procedures (CPB) and the immediate post-surgical period will certainly improve the result of cardiac surgery in these patients, making it similar to those who are not in chronic renal failure.

[The implantable endocavitary cardioverter-defibrillator: the initial and short-term results]. / Cardioversor-desfibrilador implantable endocavitario: resultados iniciales y a corto plazo.

Utilization of endocavitary defibrillation electrodes avoids thoracotomy used in implantable cardioverter-defibrillator procedures, reducing associated morbi-mortality. In our institution we have used this approach in 16 patients during a two years period (July 1990-July 1992). Fifteen were males, with a mean age of 56.9 +/- 10.6 (range 32-73). Nine patients suffered ischemic cardiomyopathy, 4 non ischemic cardiomyopathy and in three there was no structural heart disease. Mean ejection fraction was 44.3 +/- 18.3% (range 20-73%). Clinical arrhythmia was ventricular tachycardia in 8 cases, ventricular fibrillation in 6 cases and both types in 2. Endocavitary implantation procedure was not completed in 3 patients, thus an open trans-sternal approach was performed. In 13 patients it was completed successfully, using a total amount of 14 units (1 patient required two procedures due to sepsis in the generator pouch). Most important intraoperative incidences have been defibrillation thresholds between 20-24 J in 4 cases, displacement of defibrillation electrode from vena cava into coronary sinus in 4 cases, epicardial patch implantation via subcostal approach in 1 case and right ventricle perforation in 1 case. No operative mortality was registered. One patient suffered sudden death during follow-up. Surgical complications were few: 1 case of lead dislodgement and 1 infected wound in the generator's pouch. Non-surgical complications were also few: 1 case with superior vena cava syndrome and 1 patient with inadequate discharges. In conclusion, due to our early experience, we believe that endocavitary implantation of an implantable cardioverter-defibrillator is the procedure of choice at the present time.

[Palliative interatrial septostomy in severe pulmonary hypertension]. / Septostomía interatrial paliativa en la hipertensión pulmonar severa.

Three patients with severe pulmonary hypertension underwent palliative atrial septostomy by dilating the interatrial septum with valvuloplasty catheter-balloons. In two cases successful dilation improved cardiac index and symptoms of cardiac failure (13 and 11 months follow-up). One patient died immediately post-septotomy due to severe hypoxemia. Severe pulmonary hypertension with low cardiac output and high right ventricular filling pressures has a very poor short-term prognosis. Atrial septostomy is a useful palliative procedure and can serve as a bridge to heart and/or lung transplantation. It is not free of risk and the resultant systemic hypoxemia can lead to dead; that is why we recommend progressive balloon diameters, stopping the procedure when improvement of cardiac index is achieved with the minimal systemic oxygen desaturation.

[The midterm (6 years) clinical results of the Carpenter-Edwards supra-annular bioprosthesis]. / Resultados clínicos a medio plazo (6 años) de la bioprótesis de Carpentier-Edwards supraanular.

We present here the clinical results with a second-generation porcine bioprosthesis, the Carpentier-Edwards supra-annular valve (CESA). Two-hundred and twenty-two CESA bioprostheses were implanted in 189 patients during a four-year period (from 1984 to 1987), either as an isolated procedure or associated to mitral or tricuspid repair. The mid-term clinical results have been evaluated after a mean follow-up of 3.4 years, being 96% complete. There were 16 in-hospital deaths (8.4%) and 6 late, potentially valve-related, cardiac deaths (1.1% patients/year). Overall, 86.7 +/- 2% of the patients were free from cardiac death at 6 years (95.1 +/- 2% of the patients surviving the operative period). Linearized rates of valve related complications were the following: 1.4% patients/year for thromboembolism (including valve thrombosis), 0.5% patients/year for treatment-related hemorrhage and 0.7% patients/year for endocarditis. We did not found any case of either intrinsic or extrinsic valve failure, unrelated to infection of thrombosis. Two patients were reoperated, one because of valve thrombosis and the other due to prosthetic valve endocarditis (reoperation rate of 0.3% patients/year). When lethal and nonlethal valve-related complications (including in-hospital deaths) were considered all together, 75.8 +/- 8.4% of the patients remained alive and free of morbid events at 6 years. When patients were grouped according to the valve replaced (aortic, mitral and multiple), best results were found with patients submitted to isolated aortic valve replacement. We conclude that the CESA bioprosthesis has an excellent mid-term clinical performance. However, longer follow-up is necessary to know if improvement in valve design and manufacturing results in increased valve durability.