Hematoma espontáneo de recto anterior del abdomen: experiencia en nuestro centro / Rectus sheath haematoma: experience in our center

Fundamento: Describir las características clínicas de los pacientes diagnosticados de hematoma espontáneo de músculo recto abdominal (HEMR), los factores predisponentes y precipitantes y el manejo terapéutico. Pacientes y métodos: Estudio descriptivo retrospectivo de 46 HEMR diagnosticados desde 2002 hasta 2016. Se analizan datos epidemiológicos, clínicos, pruebas diagnósticas y modalidad de tratamiento. Resultados: La mediana de edad fue de 81 años, 61% mujeres. Los factores desencadenantes más frecuentes fueron la tos persistente y la inyección de heparina de bajo peso molecular. El 70% estaban anticoagulados, de ellos el 57% presentaba INR en rango supraterapéutico y en el 45% se suspendió la anticoagulación de manera definitiva tras el ingreso. El 41% presentaban insuficiencia renal crónica y la creatinina en el momento del diagnóstico fue superior a la basal (p<0,001). El tratamiento fue conservador en la mayoría de casos; se realizó radiología intervencionista en tres pacientes (6,5%) y cirugía abierta en cuatro (8,7%). El tratamiento invasivo se aplicó a pacientes con hematomas de mayor tamaño y con mayores requerimientos transfusionales, y se asoció a una mayor estancia media (p<0,001). Conclusiones: El HEMR es más frecuente en pacientes ancianos, tratados con acenocumarol y en rango supraterapéutico y conlleva con frecuencia la suspensión definitiva del tratamiento anticoagulante. La insuficiencia renal aparece relacionada con la sobredosificación del tratamiento anticoagulante y con la producción del hematoma. El tamaño del HEMR y los requerimientos transfusionales son factores que parecen relacionados con mayor necesidad de tratamiento invasivo mediante embolización arterial o cirugía (AU)

Background: To describe the clinical characteristics of patients diagnosed with spontaneous abdominal rectus muscle hematoma (RSH), predisposing and precipitating factors, and therapeutic management. Method: Retrospective descriptive study of 46 RSH diagnosed from 2002 to 2016. Epidemiological, clinical, diagnostic tests and treatment were analyzed. Results: The median age of patients was 81 years, 61% were female. The most frequent triggers were persistent coughing and injection of low molecular weight heparin. Seventy percent were anticoagulated, of which 57% had INR in the supratherapeutic range, and in 45% anticoagulation was definitively discontinued after admission. Forty-one percent presented chronic renal failure; moreover, creatinine at the time of diagnosis was higher tan baseline (p <0.001). In most cases, treatment was conservative; interventional radiology was performed on three patients (6.5%) and open surgery on four (8.7%). Invasive treatment was employed with patients who had larger hematomas and higher transfusion requirements, and this was associated with a longer mean stay (p<0.001). Conclusions: RSH is more frequent in elderly patients, treated with acenocumarol and in the supratherapeutic range, and frequently entails permanent suspension of anticoagulant therapy. Renal insufficiency is related to the overdosage of the anticoagulant treatment and to the production of the hematoma. The size of RSH and transfusión requirements are factors that seem to be related to a greater need for invasive treatment through arterial embolization or surgery (AU)

[Rectus sheath haematoma: experience in our centre]. / Hematoma espontáneo de recto anterior del abdomen: experiencia en nuestro centro.

BACKGROUND: To describe the clinical characteristics of patients diagnosed with spontaneous abdominal rectus muscle hematoma (RSH), predisposing and precipitating factors, and therapeutic management. METHOD: Retrospective descriptive study of 46 RSH diagnosed from 2002 to 2016. Epidemiological, clinical, diagnostic tests and treatment were analyzed. RESULTS: The median age of patients was 81 years, 61% were female. The most frequent triggers were persistent coughing and injection of low molecular weight heparin. Seventy percent were anticoagulated, of which 57% had INR in the supratherapeutic range, and in 45% anticoagulation was definitively discontinued after admission. Forty-one percent presented chronic renal failure; moreover, creatinine at the time of diagnosis was higher than baseline (p <0.001). In most cases, treatment was conservative; interventional radiology was performed on 3 patients (6.5%) and open surgery on 4 (8.7%). Invasive treatment was employed with patients who had larger hematomas and higher transfusion requirements, and this was associated with a longer mean stay (p<0.001). CONCLUSIONS: RSH is more frequent in elderly patients, treated with acenocumarol and in the supratherapeutic range, and frequently entails permanent suspension of anticoagulant therapy. Renal insufficiency is related to the overdosage of the anticoagulant treatment and to the production of the hematoma. The size of RSH and transfusion requirements are factors that seem to be related to a greater need for invasive treatment through arterial embolization or surgery. Key words. Spontaneous rectus sheath hematoma. Abdominal wall disease. Anticoagulant therapy. Transcatheter embolization. Abdominal pain.

Chagas disease in the immunosuppressed patient.

This review addresses relevant aspects of Chagas disease in the immunocompromised host. Chagas disease--one of the world's most neglected diseases-has become a global public health concern. Novel transmission modalities, such as organ transplantation, evidence of parasite persistence in chronically infected individuals--with the potential for reactivation under immunosuppression--and the prolonged survival of immunosuppressed patients call for an appraisal of the disease in this particular setting. The management and outcome of solid organ transplantation in the infected recipient with special focus on heart transplantation is addressed. The guidelines for management and the outcome of the recipients of organs from infected donors are discussed, and comments on haematopoietic stem cell transplantation are included. Finally, Chagas disease in other situations of impairment of the immune system, such as HIV/AIDS and autoimmune diseases, are considered. Immunosuppression has become an increasingly frequent condition that might modify the natural history of Trypanosoma cruzi infection. A number of strategies are available for Chagas disease management in the immunosuppressed patient. First, according to recent recommendations from the health authorities in Argentina, most infected patients would benefit from being treated at diagnosis. This has not been validated for patients with different immunosuppressive disorders. A different strategy would involve treating only patients with documented reactivation (either parasitaemia or clinical manifestations). These different approaches are discussed. To reach a diagnosis of parasitaemia, monitoring is essential, either with conventional methods or with molecular techniques that are not yet available in all centres. Collaborative studies are needed to improve the level of evidence, which will allow for better guidelines.

An improved DNA isolation technique for PCR detection of Strongyloides stercoralis in stool samples.

Strongyloides stercoralis is a nematode that causes severe infections in immunocompromised patients. The low parasitic burden of chronically infected patients makes diagnosis difficult to achieve by conventional methods. Here, an in-house (IH) method for the isolation of parasite DNA from stools and a PCR assay for the molecular diagnosis of S. stercoralis were optimized. DNA yield and purity improved with the IH method which included a step of incubation of stool samples with a glycine-SDS buffer and mechanical disruption prior to DNA extraction. For the PCR assay, the addition of bovine serum albumin was required to neutralize inhibitors present in stool. The analytical sensitivity of the PCR using DNA as template, isolated with the IH method, was superior to the commercial one. This study demonstrates that a combined method that adds the step of glycine-SDS buffer incubation plus mechanical disruption prior to DNA isolation with the commercial kit increased PCR sensitivity to levels of the IH method. Finally, our assay was tested on 17 clinical samples. With the IH method for DNA isolation, a S. stercoralis specific band was detected by PCR in the first stool sample in all patients (17/17), while with the commercial kit, our S. stercoralis-specific band was only observed in 7 samples. The superior efficiency of the IH and combined methods over the commercial kit was demonstrated when applied to clinical samples with low parasitic burden. These results show that the DNA extraction procedure is a key to increase sensitivity of the S. stercoralis PCR assay in stool samples. The method developed here could help to improve the molecular diagnosis of S. stercoralis.

Development of the ITER magnetic diagnostic set and specification.

ITER magnetic diagnostics are now in their detailed design and R&D phase. They have passed their conceptual design reviews and a working diagnostic specification has been prepared aimed at the ITER project requirements. This paper highlights specific design progress, in particular, for the in-vessel coils, steady state sensors, saddle loops and divertor sensors. Key changes in the measurement specifications, and a working concept of software and electronics are also outlined.

Cirugía sin ingreso de pacientes con fístulas arteriovenosas para hemodiálisis. Actividad integrada en un servicio de cirugía general / Outpatient surgeries of patients with arteriovenous fistulas for hemodialysis. Integrated activity in a general surgery unit

Introducción: El aumento de pacientes que precisan trata- miento renal sustitutivo, sobre todo en el grupo de pacien- tes sometidos a hemodiálisis, supone un reto en incremen- to de actividad y de ocupación de recursos para los servicios de cirugía. Las complicaciones relacionadas con los accesos vasculares son la causa fundamental de ingresos en muchas unidades de diálisis. La cirugía sin ingreso puede disminuir la ocupación de camas hospitalarias, reduce la lista de espe- ra y las complicaciones relacionadas con un ingreso innece- sario. Material y métodos: Hemos realizado un estudio prospectivo de las intervenciones realizadas en el período 1998-2009 para la creación o la reparación de fístulas arte- riovenosas (FAV) para hemodiálisis, con el objetivo de cono- cer el nivel de ambulatorización, resultados, complicaciones y su posible impacto en la tasa de ingresos de los pacientes en hemodiálisis. La actividad fue realizada dentro del fun- cionamiento global del servicio de cirugía general sin uni- dad específica de cirugía mayor ambulatoria (CMA). Las in- tervenciones las realizaron varios cirujanos del servicio interesados en el tema, pero sin dedicación exclusiva a éste (su actividad es la de cualquier cirujano general) y sin guar- dias específicas. La cirugía ambulatoria se organizó dentro de la actividad ordinaria del servicio de cirugía general sin una unidad específica, ni cirujanos especialmente dedica- dos a la misma. Resultados: Desde la apertura de nuestro hospital en 1998 hasta diciembre de 2009 hemos realizado un total de 2.413 intervenciones en 1.229 pacientes (prime- ros accesos y reparaciones de los mismos). La cirugía programada supuso el 74,8% de las intervenciones; el 25,2% res- tante fueron intervenciones urgentes. El porcentaje global cirugía ambulatoria fue del 82% (89% en cirugía programa- da y 60% en cirugía urgente). Se produjeron un 6% de in- gresos imprevistos. No hubo mortalidad postoperatoria. El número de ingresos fue de 0,09 episodios por paciente año con una estancia media de 0,2 días por paciente y año. Con- clusiones: La mayoría de las intervenciones relacionadas con las FAV, incluso la cirugía urgente, se pueden realizar en ré- gimen ambulatorio dentro de la actividad habitual de un servicio de cirugía. Se evitan así costes asociados con la ocu- pación de camas hospitalarias y se disminuyen las complicaciones relacionadas con el ingreso (AU)

ntroduction: The increase of prevalent haemodialysis patients is a challenge for surgery units. Vascular access related complications are the main cause of hospital admissions in many dialysis units. Outpatient surgery could decrease waiting lists, cost related and complications associated to vascular access. Material and methods: We have performed a prospective study of the vascular access related surgery in a ten years period. Outpatient surgery was included with the rest of the activity in a general surgery unit and was performed by not exclusive dedicated surgeons. Results: Since 1998 to December 2009 we performed 2,413 surgical interventions for creating and repairing arteriovenous fistula in 1,229 patients, including elective and emergency surgery (74.8% and 25.2% respectively). Outpatient procedures were performed in 82% of cases (89% in elective and 60% in emergency surgery). There were unexpected admissions secondary to surgical complications in 6% of patients. There wasn’t postoperative mortality. The rate of admissions were 0.09 episodes and 0.2 days per patient/year. Conclusions: Outpatient surgery is possible in a high percentage of patients to perform or to repair an arteriovenous fistula, including emergency surgery. Vascular access surgery can be included in ordinary activity of a surgical unit. Outpatient vascular access surgery decreases unnecessary hospital admissions, reduces costs and nosocomial complications (AU)

[Outpatient surgeries of patients with arteriovenous fistulas for hemodialysis. Integrated activity in a general surgery unit]. / Cirugía sin ingreso de pacientes con fístulas arteriovenosas para hemodiálisis. Actividad integrada en un servicio de cirugía general.

INTRODUCTION: The increase of prevalent haemodialysis patients is a challenge for surgery units. Vascular access related complications are the main cause of hospital admissions in many dialysis units. Outpatient surgery could decrease waiting lists, cost related and complications associated to vascular access. MATERIAL AND METHODS: We have performed a prospective study of the vascular access related surgery in a ten years period. Outpatient surgery was included with the rest of the activity in a general surgery unit and was performed by not exclusive dedicated surgeons. RESULTS: Since 1998 to December 2009 we performed 2,413 surgical interventions for creating and repairing arteriovenous fistula in 1,229 patients, including elective and emergency surgery (74.8% and 25.2% respectively). Outpatient procedures were performed in 82% of cases (89% in elective and 60% in emergency surgery). There were unexpected admissions secondary to surgical complications in 6% of patients. There wasn't postoperative mortality. The rate of admissions were 0,09 episodes and 0,2 days per patient/year. CONCLUSIONS: Outpatient surgery is possible in a high percentage of patients to perform or to repair an arteriovenous fistula, including emergency surgery. Vascular access surgery can be included in ordinary activity of a surgical unit. Outpatient vascular access surgery decreases unnecessary hospital admissions, reduces costs and nosocomial complications.

Analysis of serious non-AIDS events among HIV-infected adults at Latin American sites.

OBJECTIVE: Acquired immune deficiency appears to be associated with serious non-AIDS (SNA)-defining conditions such as cardiovascular disease, liver and renal insufficiency and non-AIDS-related malignancies. We analysed the incidence of, and factors associated with, several SNA events in the LATINA retrospective cohort. MATERIALS AND METHODS: Cases of SNA events were recorded among cohort patients. Three controls were selected for each case from cohort members at risk. Conditional logistic models were fitted to estimate the effect of traditional risk factors as well as HIV-associated factors on non-AIDS-defining conditions. RESULTS: Among 6007 patients in follow-up, 130 had an SNA event (0.86 events/100 person-years of follow-up) and were defined as cases (40 with cardiovascular events, 54 with serious liver failure, 35 with non-AIDS-defining malignancies and two with renal insufficiency). Risk factors such as diabetes, hepatitis B and C virus coinfections and alcohol abuse showed an association with events, as expected. The last recorded CD4 T-cell count prior to index date (P = 0.0056, with an average difference of more than 100 cells/µL) and area under the CD4 cell curve in the year previous to index date (P = 0.0081) were significantly lower in cases than in controls. CD4 cell count at index date was significantly associated with the outcome after adjusting for risk factors. CONCLUSIONS: The incidence and type of SNA events found in this Latin American cohort are similar to those reported in other regions. We found a significant association between immune deficiency and the risk of SNA events, even in patients under antiretroviral treatment.

Initial surgical experience in laparoscopic total mesorectal excision for middle and lower third rectal cancer: short-term results

INTRODUCTION: Total mesorectal excision (TME) of the rectum has been advocated as the gold standard surgical treatment of middle and lower third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in terms of safety and its oncological adequacy. OBJECTIVE: To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients. METHODS: One hundred and thirty-two patients with middle or inferior rectal cancer were admitted to our unit and underwent TME from December 1998 to February 2008. Eighty-nine patients were approached with laparoscopy. Patients staged cT3/4 cTxN+ or uTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcomes were registered. RESULTS: In the laparoscopic group 80 anterior resections (including 4 intersphincteric resections and manual colo- anal anastomosis) and 9 abdominal-perineal resections were performed. 33.3% of patients were enrolled in "long-course" neoadjuvant chemo-radiotherapy (partial and complete response rates 88.2% and 11.8%, respectively). Protective lateral ileostomy was performed in 72% of patients. Mean operative time was 254.3+/-38.3 min and mean blood loss was 215+/-180 ml. Conversion rate was 12.7%. Morbidity rate was 39.3% without mortality. The rate of anastomotic leaks was 13.48%, reoperation rate 13.48%, recovery rate 3.1+/-1.4 days and hospital stay 10.4+/-4.6 days. Concerning adequacy of oncologic resection, mean distance of the tumour from the anal verge was 4.3+/-2.2 cm. Nodal sampling of 12.4+/-4.8 were obtained. Six patients (6/89, 6.74%) had a R1 margin: 3 distal and 3 circumferential. Median follow-up was 29 months and local recurrence rate was 5.79%. Four-year cumulative overall survival was 78% and disease-free survival was 63% (Kaplan-Meier method). CONCLUSIONS: Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is oncologically safe (AU)

[Risk factors associated with multiple-species candidemia]. / Factores de riesgo asociados a candidemias causadas por múltiples especies.

The incidence of fungemia has increased over the past decade. Multiple-species candidemia (MSC) has been infrequently reported. From 1998 to 2004, of 155 patients with diagnosis of candidemia at the Hospital de Clinicas (University of Buenos Aires), seven cases of MSC were identified (6 adults and 1 newborn) and compared with 21 cases of similar age and sex with monomicrobial candidemia. There were no differences in clinical data and outcome, except for the mediana duration of hospital stay (39 days for patients with MSC vs. 18 days for patients with monomicrobial candidemia, the mean time of central venous catheter permanence previous to candidemia (32 days for patients with MSC vs. 12 days for patients with monomicrobial candidemia and the duration of candidemia (5 days for MSC and 1 day for monomicrobial candidemia. In conclusion, although MSC episodes are less common than those caused by monomicrobial candidemia, modifiable risk factors such as duration of hospitalization and central venous catheter permanence account for the development of MSC.

Factores de riesgo asociados a candidemias causadas por múltiples especies / Risk factors associated with multiple-species candidemia

Los episodios de candidemia han aumentado en la última década. Sin embargo, la publicación de casos de candidemias causadas por múltiples especies (CME) es infrecuente. De un total de 155 candidemias diagnosticadas entre 1998 y 2004 en el Hospital de Clínicas de la Universidad de Buenos Aires, se identificaron 7 casos de CME (6 adultos y 1 neonato), cuyos datos clínicos y evolutivos se compararon con 21 casos de candidemias producidas por una única especie de Candida (CUE) en pacientes de similar edad e igual sexo. No se hallaron mayores diferencias clínicas o evolutivas entre los pacientes con CME y CUE; sin embargo, la mediana del tiempo de internación y del tiempo promedio de permanencia de los catéteres venosos centrales con anterioridad a la candidemia (39 y 32 días para los pacientes con CME vs. 18 y 12 días para aquellos con CUE, respectivamente) resultaron ser factores predisponentes relevantes. La duración de la candidemia fue más prolongada en los pacientes con CME que en los afectados por CUE (5 días vs. 1 día). En conclusión, aunque los episodios de CME son menos frecuentes que los causados por una única especie de Candida, factores de riesgo potencialmente controlables como el tiempo de internación y el tiempo de utilización de catéteres venosos centrales tienen mayor importancia en el desarrollo de CME.

The incidence of fungemia has increased over the past decade. Multiple-species candidemia (MSC) has been infrequently reported. From 1998 to 2004, of 155 patients with diagnosis of candidemia at the Hospital de Clínicas (University of Buenos Aires), seven cases of MSC were identified (6 adults and 1 newborn) and compared with 21 cases of similar age and sex with monomicrobial candidemia. There were no differences in clinical data and outcome, except for the mediana duration of hospital stay (39 days for patients with MSC vs. 18 days for patients with monomicrobial candidemia, the mean time of central venous catheter permanence previous to candidemia (32 days for patients with MSC vs. 12 days for patients with monomicrobial candidemia and the duration of candidemia (5 days for MSC and 1 day for monomicrobial candidemia. In conclusion, although MSC episodes are less common than those caused by monomicrobial candidemia, modifiable risk factors such as duration of hospitalization and central venous catheter permanence account for the development of MSC.

Seguimiento prospectivo del acceso vascular en hemodiálisis mediante un equipo multidisciplinar / Prospective monitoring of vascular access in hemodialysis by means of a multidisciplinary team

Introducción: Las guías de expertos recomiendan programas de monitorización del acceso vascular (AV) en hemodiálisis mediante equipos multidisciplinares. Material y métodos: Presentamos la experiencia, de 5 años de seguimiento prospectivo del AV mediante un equipo multidisciplinar. Describimos los indicadores de calidad alcanzados y los factores asociados a supervivencia en AV incidentes. Resultados: Se estudiaron 317 AV, 73% fístulas arteriovenosas autólogas (FAV) y el resto PTFE, en 282 pacientes. Se produjeron 88 trombosis: tasa de trombosis/acceso año de 0,06 para FAV y 0,38 en PTFE. El 66,6% de reparaciones del AV fueron electivas, realizándose cirugía urgente en el 76% de las trombosis. No precisaron catéter el 62,5% de los pacientes. Los ingresos relacionados con las complicaciones de FAV y PTFE fueron el 11,4% del total. El 80% de pacientes valorados previamente en la consulta de prediálisis comenzó hemodiálisis con un AV desarrollado. La supervivencia media de las FAV incidentes fue de 1.575 ± 55 días vs 1.087 ± 102 de los PTFE (p < 0,008). La supervivencia al año, 2 años y 3 años de las FAV fue del 89%, 85% y 83% y en los PTFE de 83, 67 y 51% respectivamente. La regresión de Cox demostró que el tipo de AV es el factor más importante asociado a supervivencia, OR 0,4 [0,2-0,8] para las FAV (p < 0,01). La supervivencia añadida de todos los AV incidentes reparados tras disfunción fue de 1.062 ± 97 días vs 707 ± 132 en los reparados por trombosis; log rank 5,17, p < 0,02. El aumento de riesgo en los AV reparados tras trombosis frente a disfunción fue de 4,2 p <: 0,01. Conclusiones: El seguimiento del AV de forma multidisciplinar ha conseguido: tasa baja de trombosis, elevado número de reparaciones tanto electivas como después de una trombosis, poca necesidad de catéteres y pocos ingresos. Las FAV se asociaron a una mejor supervivencia. Los AV reparados por disfunción vs trombosis presentaron mayor supervivencia

Porpuse: Now a day the expert guide line recommend the monitoring programs of the vascular access (VA) by a multidisciplinary team. Material and method: We present the experience over the last five years, of a prospective VA surveillance by a multidisciplinary team. The quality indicators reached are described as the associated factors for survival of the new VA. Results: Three hundred seventeen VA have been studied, 73% were arteriovenous fistulas (AVF) and the rest were polytetrafluoroethylene (PTFE) grafts at 282 patients. The main causes of dysfunctions were elevated dynamic venous presion (42,5%) and the decreased blood flow (36.4%) with a 88% of positive predictive value. Over the 5 years there was 88 thrombosis (24 AVF and 64 PTFE grafts), that means a hazard thrombosis global rate of 0,15 access/year, which were distributed in 0.06 for AVF and 0,38 in PTFE grafts. Two hundred and one repair of the VA were done: 66.6% were elective repair after a proper review by the multidisciplinary team and the rest of them were done after the AV thrombosis happened. Urgent rescue surgery were done in 76% of the thrombosis. The 62,5% of the patients do not needed a catheter after vascular access thrombosis. The complication relation with AVF and PTFE were 11,4% of the total patientes hemodialysis hospitalizations. The 65,2% of the VA were new access. The 57% of patients were properly review in the pre-dialysis unit at least once and 80% of them start haemodialysis with a mature access. The average survival (Kaplan Meier) of the new AVF was 1,575 ± 55 days vs 1,087 ± 102 of the PTFE grafts (p < 0.008). The survival after 1, 2 and 3 years for the AVF was 89%, 85% and 83% and for the PTFE graft 3% 67% and 51% respectively. The Cox regression have proved that the type of vascular access is the strongest factor associated to VA survival. The survival added of VA repaired due to dysfunction was 1,062 ± 97 days vs 707 ± 132 due to thrombosis, log rank 5,17 (p < 0,02). The increasing risk of those repaired after a thrombosis vs dysfunction is 4,2 p < 0,01. Conclusions: The monitoring of the vascular access by a multidisciplinary team has reached: low rate of thrombosis, high elective number of repairs of the VA, high urgent rescue surgery after a thrombosis and a few number catheter needed and hospitalizations. The AVF are associated a greater survival that PTFE. The VA repair due to dysfunction vs thrombosis had a greater survival as well

[Prospective monitoring of vascular access in hemodialysis by means of a multidisciplinary team]. / Seguimiento prospectivo del acceso vascular en hemodialisis mediante un equipo multidisciplinar.

PURPOSE: Nowadays, expert guidelines recommend the monitoring programs of the vascular access (VA) by a multidisciplinary team. MATERIAL AND METHOD: We present the experience over the last five years, of a prospective VA surveillance by a multidisciplinary team. The quality indicators reached are described as the associated factors for survival of the new VA. RESULTS: Three hundred seventeen VA have been studied, 73% were arteriovenous fistulas(AVF) and the rest were polytetrafluoroethylene (PTFE) grafts at 282 patients. The main causes of dysfunctions were elevated dynamic venous pressure (42.5%) and the decreased blood flow (36.4%) with a 88% of positive predictive value. Over the 5 years there was 88 thrombosis (24 AVF and 64 PTFE grafts), that means a hazard thrombosis global rate of 0.15 access/year, which were distributed in 0.06 for AVF and 0.38 in PTFE grafts. Two hundred and one repairs of VA were done: 66.6% were elective repair after a proper review by the multidisciplinary team and the rest of them were done after the AV thrombosis happened. Urgent rescue surgeries were done in 76% of the thrombosis. 62.5% of the patients did not need a catheter after vascular access thrombosis. The complication relation with AVF and PTFE were 11.4% of the total patients hemodialysis hospitalizations. 65.2% of the VA were new access. 57% of patients were properly reviewed in the pre-dialysis unit at least once and 80% of them start haemodialysis with a mature access. The average survival (Kaplan Meier) of the new AVF was 1,575+/-55 days vs 1,087+/-102 of the PTFE grafts (p < 0.008). The survival after 1, 2 and 3 years for the AVF was 89%, 85% and 83% and for the PTFE graft 3% 67% and 51% respectively. The Cox regression has proved that the type of vascular access is the strongest factor associated to VA survival. The survival added of VA repaired due to dysfunction was 1,062 +/- 97 days vs 707 +/- 132 due to thrombosis, log rank 5.17 (p < 0,02). The increasing risk of those repaired after a thrombosis vs dysfunction is 4.2 p < 0,01. CONCLUSIONS: The monitoring of the vascular access by a multidisciplinary team has reached:low rate of thrombosis, high elective number of repairs of the VA, high urgent rescue surgery after a thrombosis and a few number catheter needed and hospitalizations. AVF are associated with greater survival than PTFE. The VA repair due to dysfunction vs thrombosis had a greater survival as well.

Methicillin-resistant Staphylococcus aureus strains in Buenos Aires teaching hospitals: replacement of the multidrug resistant South American clone by another susceptible to rifampin, minocycline and trimethoprim-sulfamethoxazole.

The aim of this study was to characterize methicillin-resistant Staphylococcus aureus (MRSA) isolates recovered from different infectious sites of hospitalized patients at two university hospitals. Fourteen isolates were analyzed by repetitive sequence based PCR (Rep-PCR), randomly amplified polymorphic DNA assay (RAPD-PCR), and pulsed-field gel electrophoresis (PFGE). We found that a prevalent clone of MRSA, susceptible to rifampin, minocycline, and trimethoprim/sulfamethoxazole (RIF(s), MIN(s), TMS(s)) was present in both hospitals in replacement of the multiresistant MRSA South American clone, previously described in these hospitals. The staphylococcal chromosomal cassette (SCCmec) type I element was detected in this new clone.

Methicillin-resistant Staphylococcus aureus strains in Buenos Aires Teaching Hospitals: replacement of the multidrug resistant South American clone by another susceptible to rifampin, minocycline and trimethoprim-sulfamethoxazole / Staphylococcus aureus meticilina-resistente en hospitales universitarios de Buenos Aires: reemplazo del clon Sudamericano multi-resistente por otro sensible a rifampicina, minociclina y trimetoprima-sulfametoxazol

The aim of this study was to characterize methicillin-resistant Staphylococcus aureus (MRSA) isolates recovered from different infectious sites of hospitalized patients at two university hospitals. Fourteen isolates were analyzed by repetitive sequence based PCR (Rep-PCR), randomly amplified polymorphic DNA assay (RAPD-PCR), and pulsed-field gel electrophoresis (PFGE). We found that a prevalent clone of MRSA, susceptible to rifampin, minocycline, and trimethoprim/sulfamethoxazole (RIF S, MIN S, TMS S) was present in both hospitals in replacement of the multiresistant MRSA South American clone, previously described in these hospitals. The staphylococcal chromosomal cassette (SCCmec) type I element was detected in this new clone.

El objetivo de este trabajo fue la caracterización de aislamientos de Staphylococcus aureus meticilina-resistentes (SAMR), provenientes de diferentes procesos infecciosos de pacientes internados en dos hospitales universitarios. Catorce aislamientos fueron analizados mediante la PCR de secuencias repetitivas (Rep-PCR), la amplificación al azar de ADN polimórfico (RAPD-PCR) y la electroforesis de campo pulsado (PFGE). Encontramos que un clon prevalente de SAMR, sensible a rifampicina, minociclina y trimetoprima-sulfametoxazol (RIF S, MIN S, TMS S) estaba presente en ambos hospitales, reemplazando al clon SAMR y multi-resistente previamente descrito en estos mismos hospitales. En este nuevo clon se detectó el cassette cromosómico estafilocócico SCCmec tipo I.

Methicillin-resistant Staphylococcus aureus strains in Buenos Aires teaching hospitals: replacement of the multidrug resistant South American clone by another susceptible to rifampin, minocycline and trimethoprim-sulfamethoxazole.

The aim of this study was to characterize methicillin-resistant Staphylococcus aureus (MRSA) isolates recovered from different infectious sites of hospitalized patients at two university hospitals. Fourteen isolates were analyzed by repetitive sequence based PCR (Rep-PCR), randomly amplified polymorphic DNA assay (RAPD-PCR), and pulsed-field gel electrophoresis (PFGE). We found that a prevalent clone of MRSA, susceptible to rifampin, minocycline, and trimethoprim/sulfamethoxazole (RIF(s), MIN(s), TMS(s)) was present in both hospitals in replacement of the multiresistant MRSA South American clone, previously described in these hospitals. The staphylococcal chromosomal cassette (SCCmec) type I element was detected in this new clone.

[First non-autologous vascular access for hemodialysis: PTFE fistula]. / Primer acceso vascular no autólogo para hemodiálisis. Prótesis de PTFE humero-antecubital curva de antebrazo.

INTRODUCTION: Since 1999 to 2003 we have tried to perform an antebraquial "loop" PTFE fistula (PTFEa) as first vascular access for hemodialysis in patients without suitable superficial venous system. MATERIAL AND METHODS: We have performed a prospective study to analyze the results (permeability and complications) with this approach. RESULTS: We could perform 44 PTFEa in 46 consecutive patients (in two cases we used the axillary vein as return vessel). Early failure was 0%. One year primary and secondary permeability were 66% and 90% respectively. CONCLUSIONS: PTFEa is a good solution as first vascular access in patients without a suitable superficil venous system.

[Hantavirus pulmonary syndrome in southern Argentina]. / Síndrome pulmonar por Hantavirus en el sur andino argentino.

Andes virus was identified in 1995 as the etiologic agent of Hantavirus Pulmonary Syndrome (HPS) in Southern Argentina. We describe herein the main clinical characteristics of 25 HPS confirmed cases acquired in this area between 1993 and September 1999. The mean age was 34 years (range 11-70), with 72% males. Clinical characteristics were similar to those previously reported for Sin Nombre virus (SNV) cases. However, in this group of patients we also observed conjuntival injection in 10/25 (42%), facial flushing in 8/25 (33%), pharyngeal congestion in 7/25 (29%) and petechiae in 3/25 (12%). On the other hand, BUN was increased in 83% of cases (mean 0.77 g/l range 0.31-2.01). Mean serum creatinine concentration was 26.8 mg/l (range: 8.1-110 mg/l) with serum creatinine being higher than 20 mg/l in 8/15 patients (53%). Urinalysis was abnormal in 12/12 cases and was characterized by presence of proteins, red blood cells and granular casts. Aminotransferases were increased in 90% of cases with levels 5-10 times over normal values in 50% of cases. Serum creatine kinase concentration was elevated in 11/14 cases. Two patients required hemodialysis. Case fatality rate was 44% (11/25) and 10 of these cases died among the first 10 days of illness. Mononuclear myocarditis was observed in two cases, a finding that has not been reported for SNV cases. During the 1996 HPS outbreak in Southern Argentina due to Andes virus, there were epidemiological and molecular evidences of person-to-person transmission, a feature not previously shown for other members of the hantavirus genus. These data would also be indicative of some distinctive clinical characteristics of HPS caused by Andes virus, with more frequent renal involvement than in SNV cases.

Gay male couples: the importance of coming out and being out to parents.

This exploratory study applied grounded theory methodology to examine what coupled gay men thought were the relationship impacts of being out to parents and in-laws. Data were collected from an accidental sample of 40 men in 20 homosexual couples using a standardized, open-ended interview. Virtually all of the respondents who had come out to their parents experienced initial and ongoing parental and in-law disapproval for their lifestyles and relationships. However, most men believed that it benefitted their unions to be out to their parents and partner's parents. Not having to hide the relationship was seen as a primary relationship advantage. Inclusion of one's partner in family events also emerged as a significant benefit. In contrast to the existing literature, a large proportion of respondents believed that parental/in-law antagonism had no adverse impacts on their dyads. They shielded their relationships by maintaining a strong sense of independence and in turn solid intergenerational boundaries. This study provides evidence to suggest that disclosure of sexual orientation to parents may be a distinctive, important developmental task for gay men which is critical to their relationships with their partners. Based on the findings of this research, mental health practitioners would be advised to assist gay men in the establishment and maintenance of strong intergenerational boundaries to protect their unions from parental/in-law disapproval.

A randomized, controlled, phase II trial comparing escalating doses of subcutaneous interleukin-2 plus antiretrovirals versus antiretrovirals alone in human immunodeficiency virus-infected patients with CD4+ cell counts >/=350/mm3.

A total of 73 patients with baseline CD4+ cell counts >/=350 cells/mm3 who were receiving combination antiretroviral therapy (ART) were randomized to receive subcutaneous interleukin-2 (IL-2; n=36) in addition to ART or to continue ART alone (n=37). Subcutaneous IL-2 was delivered at 1 of 3 doses (1.5 million international units ¿MIU, 4.5 MIU, and 7.5 MIU per dose) by twice-daily injection for 5 consecutive days every 8 weeks. After 24 weeks, the time-weighted mean change from baseline CD4+ cell count was 210 cells/mm3 for recipients of subcutaneous IL-2, compared with 29 cells/mm3 for recipients of ART alone (P<.001). There were no significant differences between treatment groups for measures of plasma human immunodeficiency virus RNA (P=.851). Subcutaneous IL-2 delivered at doses of 4.5 MIU and 7.5 MIU resulted in significant increases in CD4+ cell count (P=.006 and P<.001, respectively), compared with that seen in control patients. These changes were not significant in the 1.5 MIU dose group compared with that in the control patients (P=.105). Side effects that occurred from subcutaneous IL-2 administration were generally low grade, of short duration, and readily managed in an outpatient environment.