Modeling conformational states of proteins with AlphaFold.

Many proteins exert their function by switching among different structures. Knowing the conformational ensembles affiliated with these states is critical to elucidate key mechanistic aspects that govern protein function. While experimental determination efforts are still bottlenecked by cost, time, and technical challenges, the machine-learning technology AlphaFold showed near experimental accuracy in predicting the three-dimensional structure of monomeric proteins. However, an AlphaFold ensemble of models usually represents a single conformational state with minimal structural heterogeneity. Consequently, several pipelines have been proposed to either expand the structural breadth of an ensemble or bias the prediction toward a desired conformational state. Here, we analyze how those pipelines work, what they can and cannot predict, and future directions.

Targeting in silico GPCR conformations with ultra-large library screening for hit discovery.

The use of deep machine learning (ML) in protein structure prediction has made it possible to easily access a large number of annotated conformations that can potentially compensate for missing experimental structures in structure-based drug discovery (SBDD). However, it is still unclear whether the accuracy of these predicted conformations is sufficient for screening chemical compounds that will effectively interact with a protein target for pharmacological purposes. In this opinion article, we examine the potential benefits and limitations of using state-annotated conformations for ultra-large library screening (ULLS) in light of the growing size of ultra-large libraries (ULLs). We believe that targeting different conformational states of common drug targets like G-protein-coupled receptors (GPCRs), which can regulate human physiology by switching between different conformations, can offer multiple advantages.

Modelling the seasonal impacts of a wastewater treatment plant on water quality in a Mediterranean stream using microbial indicators.

Faecal pollution modelling is a valuable tool to evaluate and improve water management strategies, especially in a context of water scarcity. The reduction dynamics of five faecal indicator organisms (E. coli, spores of sulphite-reducing clostridia, somatic coliphages, GA17 bacteriophages and a human-specific Bifidobacterium molecular marker) were assessed in an intermittent Mediterranean stream affected by a wastewater treatment plant (WWTP). Using Bayesian inverse modelling, the decay rates of each indicator were correlated with two environmental drivers (temperature and streamflow downstream of the WWTP) and the generated model was used to evaluate the self-depuration distance (SDD) of the stream. A consistent increase of 1-2 log10 in the concentration of all indicators was detected after the discharge of the WWTP effluent. The decay rates showed seasonal variation, reaching a maximum in the dry season, when SDDs were also shorter and the stream had a higher capacity to self-depurate. High seasonality was observed for all faecal indicators except for the spores of sulphite-reducing clostridia. The maximum SDD ranged from 3 km for the spores of sulphite-reducing clostridia during the dry season and 15 km for the human-specific Bifidobacterium molecular marker during the wet season. The SDD provides a single standardized metric that integrates and compares different contamination indicators. It could be extended to other Mediterranean drainage basins and has the potential to integrate changes in land use and catchment water balance, a feature that will be especially useful in the transient climate conditions expected in the coming years.

FIRST DAY SERUM CALCIUM AND PARATHYROID HORMONE LEVELS AS PREDICTIVE FACTORS FOR SAFE DISCHARGE AFTER THYROIDECTOMY.

CONTEXT: Permanent hypocalcemia is a rare but significant complication of thyroid surgery. OBJECTIVE: The aim of this study was to identify predictive factors of hypocalcemia and hypoparathyroidism after thyroidectomy. DESIGN: Study included 134 total patients submitted to thyroidectomy from two endocrine units (January 2015 - August 2016). METHODS: We measured total serum calcium (sCa) and intact PTH (iPTH) on postoperative day one and 1 month after surgery. RESULTS: 118 patients were women with F/M ratio of 7.3/1 and a mean age of 51.8 years. 64 patients were included in group A (iPTH <12 pg/mL) and 70 patients in group B (iPTH >12 pg/mL). sCa and hypocalcemia symptoms were correlated with iPTH, measured 24 hours after surgery. The cut-off value was for sCa 8.05 mg/dL with a sensitivity of 85.29% and a specificity of 88.0% and for iPTH 11.2 pg/mL, with a sensitivity of 82.3% and a specificity of 71.0%. SCa (< 8.05 mg/dL) was a predictive factor with a 99 (IC95%:12.86-761.58) and iPTH (<11.2 pg/mL) with a 10.77 higher risk (CI95%: 3.83-30.30) to be associated with symptoms. CONCLUSION: SCa and iPTH represent good predictive factors of early and safe hospital discharge and can predict the risk of prolonged and permanent hypoparathyroidism.

The Approach to Tetanic Hypocalcemia Caused by Vitamin D Deficiency.

Recently studies have shown that over half of infants, children and teenagers may be inadequately supplemented. A high prevalence of vitamin D deficiency in children has been observed worldwide, even in sunny countries. Regardless of the recommendations, vitamin D supplementation is sometimes underestimated, supporting the idea that for children in sunny country it is unnecessary. In the modern area of supplementation, tetany seems to be a problem of the past. Usually it occurs at 3 to 6 months of age, that's why diagnostic suspicion may be low after this age. We report a case of severe hypocalcemia presented with tetany, in an18-months-old child with severe vitamin D deficiency, because of not receiving vitamin D as supplementation. With underestimation of vitamin D supplementation, tetany may emerge again. Through our report we aim to highlight the aggressive approach to tetanic hypocalcemia in children with vitamin D deficiency and to sensitize a rigorous surveillance in order to ensure adequate vitamin D supplementation by pregnant, breastfeeding mothers, children and adolescents.

Early diagnosis of PI3Kδ syndrome in a 2 years old girl with recurrent otitis and enlarged spleen.

Heterozygous gain of function mutations in the gene encoding p110δ subunit of PI3K have been recently associated with activated PI3K-δ syndrome (APDS), a novel combined immune deficiency characterized by recurrent sinopulmonary infections, lymphopenia, reduced class-switched memory B cells, lymphadenopathy, CMV and/or EBV viremia and EBV-related lymphoma. Here we report a dominant gain of function PIK3CD mutation (E1021K) in a patient presenting with recurrent otitis media, massive splenomegaly, and persistent EBV-viraemia. The immunological studies showed low IgA level, but normal IgM, IgG, and normal antibody response to diphtheria and tetanus toxoid vaccination. Analysis of B lymphocyte subsets revealed abnormal expansion of transitional B cells, and low percentage of switched CD27+IgD- and CD27+IgD+ memory B cells. Analysis of T cell compartment unveiled prevalence of terminally differentiated cells. This study suggests that PIK3CD gain of function mutations should be suspected despite incomplete phenotype in patients with early onset splenomegaly, persistent EBV viremia and abnormal B and T cell subsets despite normal IgG levels. Currently the optimal treatment is still debated, but prompt management can hopefully diminish incidence of severe long-lasting sequelae (i.e. bronchiectasis, ear and sinus damage).

PCA3 como biomarcador de segunda línea en un programa de screening oportunista prospectivo, aleatorizado y controlado / PCA3 as a second-line biomarker in a prospective controlled randomized opportunistic prostate cancer screening programme

Objetivos: Determinar el comportamiento del PCA3 como un marcador de segunda línea en un programa de cribado oportunista de cáncer de próstata (CaP) y su comparación con la calculadora de riesgo 3 del cribado aleatorizado europeo en cáncer de próstata (ERSPC RC-3). Material y métodos: En total de 5.199 hombres de 40-75 años se hicieron la prueba del antígeno prostático específico (PSA) y un tacto rectal (TR). Aquellos con TR normal y PSA ≥ 3ng/ml se realizaron un PCA3. Todos los hombres con PCA3 ≥ 35 se hicieron biopsia inicial (BxI) -12 cilindros-. Aquellos con PCA3 < 35 se aleatorizaron 1:1 a BxI u observación. Los resultados se comparan con los obtenidos con la aplicación de la calculadora ERSPC RC-3. Resultados: PCA3 se testó en 838 hombres (16,1%). En los grupos PCA3(+) y PCA3(-), las tasas de detección global de CaP fueron del 40,9 y del 14,7% a una mediana de seguimiento de 21,7 meses (p < 0,001. En el grupo PCA3(+) (n = 301, 35,9%), se identificó CaP en 115 hombres en BxI (38,2%). En el brazo aleatorizado, 256 se hicieron BxI y se objetivó CaP en 46 (18,0%) (p < 0,001). La potencial tasa de ahorro de biopsias siguiendo el corte PCA3 = 35 hubiera sido de 64,1% frente a la de 76,6% si hubiéramos usado ERSPC RC-3. Sin embargo, la tasa estimada de falsos negativos de CaP de alto grado (CaPAG = Gleason ≥ 7) se hubiera reducido un 37,1% (de 89 a 56 pacientes) al usar el PCA3. Si hubiéramos usado el corte 35 de PCA3 para no realizar BxI, hubiésemos dejado de diagnosticar un 14,7% de CaP y un 9,1% de CaP clínicamente significativo, a un seguimiento medio aproximado de 2 años. Conclusiones: Cuando se usa PCA3-35 como biomarcador de segunda línea en hombres con PSA ≥ 3ng/ml y TR normal, se puede obviar la BxI un 12,5% menos que usando la ERSPC RC-3, pero reduciendo los falsos negativos un 36,2%. A un seguimiento de 21,7 meses, este protocolo dual no hubiera detectado un 9,1% de CaP clínicamente significativo, por lo que el seguimiento con estrictos criterios de biopsia basados en PSA y TR es obligatorio en casos con PCA3 < 35

Objectives: PCA3 performance as a single second line biomarker is compared to the European Randomised Study of Screening for Prostate Cancer risk calculator model 3 (ERSPC RC-3) in an opportunistic screening in prostate cancer (PCa). Material and methods: 5,199 men, aged 40-75y, underwent prostate-specific antigen (PSA) screening and digital rectal examination (DRE). Men with a normal DRE and PSA ≥3ng/ml had a PCA3 test done. All men with PCA3 ≥ 35 underwent an initial biopsy (IBx) -12 cores-. Men with PCA3 < 35 were randomized 1:1 to either IBx or observation. We compared them to those obtained with ERSPC RC-3. Results: PCA3 test was performed on 838 men (16.1%). In PCA3(+) and PCA3(-) groups, global PCa detection rates were 40.9% and 14.7% with a median follow-up (FU) of 21.7 months (P <.001). In the PCA3(+) arm (n = 301, 35.9%), PCa was identified in 115 men at IBx (38.2%). In the randomized arm, 256 underwent IBx and PCa was found in 46 (18.0%) (P < .001). The biopsy-sparing potential would have been 64.1% as opposed to 76.6% if we had used ERSPC RC-3. However, the estimated false negative cases for HGPCa would have been reduced by 37.1% (89 to 56 patients). Moreover, if we had applied PCA3-35 to avoid IBx, 14.7% PCa and 9.1% of clinical significant PCa patients would not have been diagnosed during this FU. Conclusions: When PCA3-35 is used as a second-line biomarker when PSA ≥ 3ng/ml and DRE is normal, IBx could be avoided in 12.5% less than if ERSPC RC-3 is used and would reduce the false negative cases by 36.2%. At a FU of 21.7 months, this dual protocol would miss 9.1% of clinically significant PCa, so strict FU is mandatory with established biopsy criteria based on PSA and DRE in cases with PCA3 < 35

Reestenosis asintomáticas de stents de arteria femoral superficial: ¿tratamiento endovascular o manejo conservador? / Asymptomatic restenosis of superficial femoral artery stents: Endovascular treatment or conservative management

Objetivo: Comparar la evolución clínica de las reestenosis > 70% asintomáticas de los stents de arteria femoral superficial (AFS) con tratamiento endovascular vs. tratamiento conservador. Pacientes: Estudio descriptivo de cohortes históricas de pacientes con stent femoral con reestenosis del 70-99% asintomática, desde enero del 2010 a diciembre del 2015. Se formaron 2 grupos de pacientes: manejo conservador vs. tratamiento endovascular. Material y métodos: Comparamos: curvas de superviencia libre de amputación mayor (SLA) y supervivencia libre de isquemia crítica o claudicación limitante (< 250m) (SLIC) desde la colocación del primer stent hasta la aparición de isquemia crítica o realización de amputación mayor (log-rank, Kapplan-Meier). Analizamos la permeabilidad primaria y la permeabilidad primaria asistida. Resultados y conclusiones: Se diagnosticaron un total de 23 reestenosis >70% en 20 pacientes de 78 años de edad media (DE 9,6). Seguimiento medio: 30,1 meses. En 12 pacientes (52,2%) se realizó tratamiento médico (AAS y estatinas) + endovascular, y en 11 (47,8%) únicamente tratamiento médico. No hubo diferencias en la SLA (p = 0,967). Observamos que la SLIC fue mayor en el grupo de manejo conservador que en el de tratamiento endovascular (p = 0,031). La permeabilidad primaria fue de 14,2 meses (IC 8,2-20,2), y la permeabilidad primaria asistida de 65,5 meses (IC 57,4-77,5). En nuestra experiencia tratar las lesiones graves asintomáticas de los stents de AFS no disminuye el riesgo de amputación, isquemia crítica o claudicación limitante respecto a la evolución natural de las mismas. En pacientes asintomáticos la conducta expectante puede ser una buena opción, sin que ello suponga un aumento del riesgo de amputación o isquemia crítica a medio plazo (AU)

Objective: To compare the clinical outcomes of asymptomatic >70% in-stent restenosis in the superficial femoral artery (SFA) treated using an endovascular procedure or conservative treatment. Patients: A historical cohort study was performed on patients with femoral artery stent with an asymptomatic in-stent restenosis of 70-99% from January 2010 to December 2015. The patients were divided into two groups: conservative management vs. endovascular treatment. Material and methods: The variables compared were, limb salvage and critical ischaemia or limiting claudication free survival rates (<250m) from initial stent treatment until the appearance of critical ischaemia or major amputation (log-rank, Kaplan Meier). Primary patency and assisted primary patency were analysed. Results and conclusions: A total of 23 >70% in-stent restenosis were diagnosed in 20 patients who had a mean age of 78 years old (SD 9.6). The mean follow-up was 30.1 months. Medical (aspirin and statins) and endovascular treatment was received by 12 patients (52.2%), and 11 patients (47.8%) received medical treatment only. No differences were seen in limb salvage. Critical ischaemia or limited claudication free survival rates were higher in the conservative treatment group than in the endovascular group (P = .031). Primary patency was 14.2 months (95% CI: 8.2-20.2), and assisted primary patency was 65.5 months (95% CI: 57.4-77.5). In our experience, treatment of severe asymptomatic lesions of in-stent stenosis in the SFA does not reduce the risk of amputation, critical ischaemia or limiting claudication. Conservative treatment could be a good option in asymptomatic patients, without increasing the risk in amputation and critical ischaemia (AU)

PCA3 as a second-line biomarker in a prospective controlled randomized opportunistic prostate cancer screening programme. / PCA3 como biomarcador de segunda línea en un programa de screening oportunista prospectivo, aleatorizado y controlado.

OBJECTIVES: PCA3 performance as a single second line biomarker is compared to the European Randomised Study of Screening for Prostate Cancer risk calculator model 3 (ERSPC RC-3) in an opportunistic screening in prostate cancer (PCa). MATERIAL AND METHODS: 5,199 men, aged 40-75y, underwent prostate-specific antigen (PSA) screening and digital rectal examination (DRE). Men with a normal DRE and PSA ≥3ng/ml had a PCA3 test done. All men with PCA3 ≥35 underwent an initial biopsy (IBx) -12 cores-. Men with PCA3 <35 were randomized 1:1 to either IBx or observation. We compared them to those obtained with ERSPC RC-3. RESULTS: PCA3 test was performed on 838 men (16.1%). In PCA3(+) and PCA3(-) groups, global PCa detection rates were 40.9% and 14.7% with a median follow-up (FU) of 21.7 months (P<.001). In the PCA3(+) arm (n=301, 35.9%), PCa was identified in 115 men at IBx (38.2%). In the randomized arm, 256 underwent IBx and PCa was found in 46 (18.0%) (P<.001). The biopsy-sparing potential would have been 64.1% as opposed to 76.6% if we had used ERSPC RC-3. However, the estimated false negative cases for HGPCa would have been reduced by 37.1% (89 to 56 patients). Moreover, if we had applied PCA3-35 to avoid IBx, 14.7% PCa and 9.1% of clinical significant PCa patients would not have been diagnosed during this FU. CONCLUSIONS: When PCA3-35 is used as a second-line biomarker when PSA ≥3ng/ml and DRE is normal, IBx could be avoided in 12.5% less than if ERSPC RC-3 is used and would reduce the false negative cases by 36.2%. At a FU of 21.7 months, this dual protocol would miss 9.1% of clinically significant PCa, so strict FU is mandatory with established biopsy criteria based on PSA and DRE in cases with PCA3 <35.

Amoxicillin haptenates intracellular proteins that can be transported in exosomes to target cells.

BACKGROUND: Allergic reactions to ß-lactams are among the most frequent causes of drug allergy and constitute an important clinical problem. Drug covalent binding to endogenous proteins (haptenation) is thought to be required for activation of the immune system. Nevertheless, neither the nature nor the role of the drug protein targets involved in this process is fully understood. Here, we aim to identify novel intracellular targets for haptenation by amoxicillin (AX) and their cellular fate. METHODS: We have treated B lymphocytes with either AX or a biotinylated analog (AX-B). The identification of protein targets for haptenation by AX has been approached by mass spectrometry and immunoaffinity techniques. In addition, intercellular communication mediated by the delivery of vesicles loaded with AX-B-protein adducts has been explored by microscopy techniques. RESULTS: We have observed a complex pattern of AX-haptenated proteins. Several novel targets for haptenation by AX in B lymphocytes have been identified. AX-haptenated proteins were detected in cell lysates and extracellularly, either as soluble proteins or in lymphocyte-derived extracellular vesicles. Interestingly, exosomes from AX-B-treated cells showed a positive biotin signal in electron microscopy. Moreover, they were internalized by endothelial cells, thus supporting their involvement in intercellular transfer of haptenated proteins. CONCLUSIONS: These results represent the first identification of AX-mediated haptenation of intracellular proteins. Moreover, they show that exosomes can constitute a novel vehicle for haptenated proteins, and raise the hypothesis that they could provide antigens for activation of the immune system during the allergic response.

INCIDENTAL PARATHYROIDECTOMY DURING THYROID SURGERY - RISK, PREVENTION AND CONTROVERSIES; AN EVIDENCE-BASED REVIEW.

BACKGROUND: Postoperative hypocalcemia after thyroid surgery has a high prevalence ( 16-55% in different series). Incidental parathyroidectomy (IP) is a less discussed complication of thyroidectomy with consequences not properly defined. The aim of our study was to find incidence, risk factors and how to prevent IP. METHODS: Extensive search of English literature publications via PubMed was performed and 73 papers from 1980 to 2017 were analysed using the GRADE system/classification, quality of evidence was classified as "strong" when the result is highly unlikely to change existing recommendation and "weak" when opposite. RESULTS: Incidence of IP is 3.7-24.9%, while prevalence of permanent hypoparathyroidism is less frequent 6-12%. Direct relation between IP and hypoparathyroidism/hypocalcemia remains controversial. Female patients, ectopic parathyroids, small thyroids, Graves', malignancy, redo surgeries and total thyroidectomy favour IP. Routine visualization of parathyroids, new hemostatic devices, magnifying instruments and fluorescence can prevent incidental removal of parathyroids. Incidence of IP during videoassisted or robotic thyroidectomies was similar to open procedures. High volume, experienced and younger surgeons have lower complication rates (including hypoparathyroidism). CONCLUSIONS: Incidental parathyroidectomy is more frequent than we might have expected. It should be avoided and parathyroid glands should be kept in situ. Majority of studies are retrospective (low degree of evidence according to previous mentioned GRADE classification) and further meta-analysis or randomized control studies are welcome in order to define the impact of incidental removal of parathyroids on postoperative outcome.

A COMPARATIVE ANALYSIS OF THE INITIAL EAST EUROPEAN CENTER EXPERIENCE WITH A WESTERN HIGH-VOLUME CENTER FOR OPEN MINIMALLY INVASIVE PARATHYROIDECTOMY (OMIP) AS TREATMENT OF PRIMARY HYPERPARATHYROIDISM.

OBJECTIVE: To compare results of treatment of primary hyperparathyroidism (PHPT) in two teaching hospitals (eastern and western Europe) and to establish conclusions regarding quality of surgery for PHPT in Romania. METHODS: We reviewed two prospectively collected databases of patients submitted to open minimally invasive parathyroidectomy (OMIP) for symptomatic PHPT in two centers from Romania and the United Kingdom (UK). We included patients with biochemically proven PHPT and positive pre-operative localization studies. We excluded patients with negative localization studies, suspected multiglandular disease, concomitant thyroid disorders and chronic renal failure. RESULTS: 60 patients were included, 27 in group A (Romanian cohort) and 33 in group B (UK cohort). We noted significant differences between groups in pre-operative serum calcium and phosphorus levels (p<0.5). There were no differences between groups regarding the presence of symptoms; in group A we had significantly more patients with renal calculi history (p=0.02), digestive symptoms (p=0.006) and osteitis fibrosa cystica (p=0.01). Two patients from the UK group had lithium associated hyperparathyroidism and 2 patients had genetic disease. Intraoperative parathyroid hormone measurement (ioPTH) was available only for group B and frozen sections were selectively used in both groups. Both the adenoma size and weights were significantly higher in group A. The median operative time was significantly longer in Romanian group (p=0.001); in this group we noted the single conversion to traditional cervicotomy (3.7%) from all studied patients. In group A we noted two patients (7.4%) with failed parathyroidectomy and persistent PHPT; the cure rate was 92.5% for Romanian group and 97% for the UK group. CONCLUSIONS: OMIP can be performed safe with a high cure rate in "small" volume endocrine centres with results comparable to western experienced endocrine centres. Romanian patients presented with more severe PHPT with more frequent end-organ damage, due probably to late diagnosis.

Hypersensitivity reactions to ß-lactams: relevance of hapten-protein conjugates.

ß-Lactams (BL) are the drugs most frequently involved in allergic reactions. They are classified according to their chemical structure as penicillins, cephalosporins, monobactams, carbapenems, and clavams. All BL antibiotics have a BL ring that is fused to a 5-member or 6-member ring (except in monobactams) and has 1, 2 or 3 side chains (except in clavams). Differences in chemical structure mean that a wide range of BLs are recognized by the immune system, and patients may experience clinical reactions to one BL while tolerating others. Diagnosis is based on skin and in vitro testing, although both display low sensitivity, possibly because they are based on drugs or drug conjugates that are not optimally recognized by the immune system. BLs are haptens that need to bind to proteins covalently to elicit an immune response. These drugs have a high capacity to form covalent adducts with proteins through nucleophilic attack of amino groups in proteins on the BL ring. Allergenic determinants have been described for all BLs, although benzylpenicillin is the most widely studied. Moreover, formation of BL-protein adducts is selective, as we recently demonstrated for amoxicillin, which mainly modifies albumin, transferrin, and immunoglobulin heavy and light chains in human serum. Given the complexity of BL allergy, understanding the immunological mechanisms involved and optimization of diagnostic methods require multidisciplinary approaches that take into account the chemical structures of the drugs and the carrier molecules, as well as the patient immune response.

Hypersensitivity reactions to ß-lactams: relevance of hapten-protein conjugates

B-Lactams (BL) are the drugs most frequently involved in allergic reactions. They are classified according to their chemical structure as penicillins, cephalosporins, monobactams, carbapenems, and clavams. All BL antibiotics have a BL ring that is fused to a 5-member or 6-member ring (except in monobactams) and has 1, 2 or 3 side chains (except in clavams). Differences in chemical structure mean that a wide range of BLs are recognized by the immune system, and patients may experience clinical reactions to one BL while tolerating others. Diagnosis is based on skin and in vitro testing, although both display low sensitivity, possibly because they are based on drugs or drug conjugates that are not optimally recognized by the immune system. BLs are haptens that need to bind to proteins covalently to elicit an immune response. These drugs have a high capacity to form covalent adducts with proteins through nucleophilic attack of amino groups in proteins on the BL ring. Allergenic determinants have been described for all BLs, although benzylpenicillin is the most widely studied. Moreover, formation of BL-protein adducts is selective, as we recently demonstrated for amoxicillin, which mainly modifies albumin, transferrin, and immunoglobulin heavy and light chains in human serum. Given the complexity of BL allergy, understanding the immunological mechanisms involved and optimization of diagnostic methods require multidisciplinary approaches that take into account the chemical structures of the drugs and the carrier molecules, as well as the patient immune response (AU)

Las betalactamas (BL) son los fármacos implicados más frecuentemente en reacciones alérgicas. Se clasifican según su estructura química en penicilinas, cefalosporinas, monobactamas, carbapenems y clavamas. Poseen un anillo betalactámico que, excepto en las monobactamas, está fusionado a un anillo de cinco o seis miembros y, excluyendo las clavamas, tienen 1, 2 o 3 cadenas laterales. Las diferencias en las estructuras químicas resultan en un amplio rango de BLs, que puede ser discriminado por el sistema inmune, con inducción de reacciones clínicas a una BL y tolerancia a otras. El diagnóstico está basado en pruebas cutáneas e in vitro, aunque ambas presentan una baja sensibilidad. Esto podría deberse a que los fármacos o conjugados de fármacos empleados en estos tests que no se reconocen de manera óptima por el sistema inmune. Las BLs son haptenos que necesitan de su unión covalente a proteínas para inducir una respuesta inmunológica. Estos fármacos presentan una elevada capacidad para formar aductos covalentes con proteínas mediante el ataque nucleofílico de grupos aminos de proteínas al anillo BL. Aunque la bencilpenicilina ha sido la mejor estudiada, también se han descrito determinantes alergénicos del resto de BLs. Además, la formación de los aductos BLs-proteína muestra selectividad, así se ha demostrado recientemente para la amoxicilina, que principalmente modifica la albúmina en suero (HSA), la transferrina y las cadenas ligeras y pesadas en suero humano. Dada la complejidad de la alergia a BL, el conocimiento de los mecanismos inmunológicos implicados y la optimización de los métodos diagnósticos requieren de abordajes multidisciplinares teniendo en cuenta tanto la estructura química de los fármacos y de las moléculas portadoras, como las respuestas de los pacientes (AU)

Transthoracic versus Transhiatal esophagectomy: a permanent dilemma. our 15-year experience.

OBJECTIVE: Controversy still exists regarding the optimal surgical management of esophageal cancer. This study was performed to determine and compare early and late morbidity,mortality and overall survival after transthoracic (TTE) and transhiatal esophagectomies (THE). METHODS: Between 1997-2011, 100 patients underwent TTE or THE for squamous esophageal carcinoma (90 patients)and adenocarcinoma (10 patients). Assessed parameters included patient demographics, operative data, pathology results, postoperative morbidity and mortality and 1-3 year survival. RESULTS: Thoracic approach was preferred in cases of more advanced tumors, located in the upper and mid-third of the esophagus, in patients with a better cardiopulmonary status. Perioperative blood loss was significantly higher after transthoracic resections (p=0.0004) and these surgeries took significantly longer than transhiatal esophagectomies(p=0.02). We identified complications in 70.7% patients who under went TTE and in 59.3% patients with transhiatal approach. Respiratory complications were statistically significant in the TTE- group (p-0.0003). The 30-day mortality rates were 12.2% for patients in TTE group and 10.1% in THE patients group, respectively. The mortality ratefor the entire period of the study has been calculated at 84.4%.We have identified a survival rate after 1 year of 62.2%, after 2 years of 39.3% and after 3 years - 15.1%. CONCLUSIONS: According to the results of this study, both procedures appear to be acceptable depending on surgeon preference and appropriate patient selection.

Minilaparotomy as surgical approach for aortoiliac occlusive disease -- single center initial experience.

PURPOSE: The purpose of this study was to emphasize the benefits and indications of performing minilaparotomy as surgical approach for occlusive aortoiliac disease. MATERIAL AND METHOD: From January 2011 to July 2012, a total of 23 patients (19 men and 4 women), with a median age of 60 years (range 49-75) diagnosed with aortoiliac occlusive disease(n=22) or abdominal aneurysm (n=1), were included in a retrospective non-randomized clinical study. Among these patients 11 underwent aortic bypass procedure by minila parotomy approach (ML group) and 12 patients by standard laparotomy(SL group). Demographic and clinical data, operative data, postoperative recovery data and complications were analysed according to these two groups of patients. Follow-up consisted of clinical examination and duplex scanning at 1, 3,6 and 12 months postoperatively. RESULTS: There were no significant differences between the minilaparotomy and standard laparotomy control groups concerning clinical and demographical data. Two surgical conversions to standard laparotomy were necessary (18.18%) in the ML group due to technical difficulties. The mean operative time was shorter in the ML group (124 ± 22 minutes) and the mean aortic clamping time was similar between the two groups.Major differences between the two lots were observed postoperatively;mean blood loss was more important in the SL group (550 ml) than in the ML group (350 ml) (statistical significance p=0.001, Student test). Patients who have undergone standard laparotomy required more fluids (10000 Â+-2000 ml) in comparison to the other group (6000 ± 1000 ml) p value=0.0001, while the duration of nasogastric suction and period before resuming a liquid diet was both shorter in the ML group (1.1 ± 0.5 days) than those from the SL group (2.5 ± 0.6 days) p value=0.001. The period spent in the ICU was significantly shorter for the ML lot of patients and the median hospitalization time was 5.6 days for patients in ML group,whereas in the SL group the median hospitalization time was 8.9 days (Student test - p value 0.01). We had no 30-day mortality in any of the groups included in the study. One patient from the ML group was readmitted in postoperative day 43 and re-operated on for a prosthetic limb graft thrombosis.Two patients were lost to follow-up and the mean follow-up was 9 ± 1.5 months. CONCLUSIONS: Minilaparotomy as surgical approach for aortic diseases is a feasible, safe procedure on selected patients.

Rehabilitation of pediatric musculoskeletal sport-related injuries: a review of the literature.

AIM: The recent increase in sports participation in children and adolescents has resulted in the increase of sport-related injuries and the need for rehabilitation. The purposes of this study were to review studies involving rehabilitation of pediatric musculoskeletal sport-related injuries to determine the study design (level of evidence), inclusion of a reference to skeletal immaturity, adequacy of the description of the rehabilitation program and treatment outcome. METHODS: Medline(1950-June 2009), CINAHL(1982-June 2009), Cochrane and journals (sports, physical therapy, pediatric orthopedic) were searched using the terms: physical therapy or rehabilitation plus sports/athletic injuries or individual sports plus pediatrics, adolescent, children, youth and young. Inclusion criteria were: published in English peer-reviewed journal, examined rehabilitation/management, subjects

Long-term outcomes of short bowel syndrome requiring long-term/home intravenous nutrition compared in children with gastroschisis and those with volvulus.

INTRODUCTION: Short bowel syndrome (SBS) is a malabsorptive state that occurs following extensive small intestinal resection. The most severely affected children require intravenous feeding/parenteral nutrition (PN). Two common causes in infancy/early childhood are intestinal resection for volvulus and resection of necrotic small intestine in infants with gastroschisis. The aim of this study was to review the long-term outcomes of children with severe intestinal failure who remained dependent on PN for many months or years. We evaluated the outcomes among gastroschisis cases versus those following resection of mid-gut volvulus or congenital short gut. METHODS: We reviewed the case records over a 10-year period from 1997 of children presenting by 5 years of age with volvulus and/or congenital short gut or gastroschisis and who were dependent on long-term/home PN. We obtained data regarding the diagnosis, the small intestinal length, the presence of the ileo-cecal valve, the survivals, and the incidences of weaning from PN. RESULTS: Six children underwent resection following volvulus or congenital short gut syndromes and 7 had gastroschisis. Ten of the 13 children underwent surgery as neonates and 3 from 2-5 years of age. The residual small intestinal length was <10 cm in 1, 10-25 cm in 4, 25-50 cm in 5, 50-100 cm in 2, and >100 cm in 1 case. The ileo-cecal valve was removed in 8 children. All children were treated with PN after surgery for at least 7 months. All 7 children with gastroschisis and 1 with <10 cm small intestine after intestinal resection for volvulus still required PN after 14-120 months. Three with gastroschisis died. All 5 children with volvulus and >10 cm small intestine were weaned from PN, thriving at our review 7 months-7 years later. CONCLUSIONS: Infants and young children with short gut and >10 cm small intestine gain intestinal autonomy. In contrast, those with gastroschisis have poor outcomes and should be referred for intestinal transplantation assessment more readily than those with after intestinal resection for volvulus short gut.

Clinical, biological and ultrasonographic remission in a patient with musculoskeletal systemic lupus erythematosus with rituximab.

Systemic lupus erythematosus (SLE) is a multiorganic autoimmune disease that affects skin, osteoarticular and kidney frequently. Rituximab showed efficacy in treatment of osteoarticular and haematological SLE, but its use has been generalised for renal disease. In our case, we showed efficacy of rituximab in SLE articular disease, showing an ultrasonographic improvement.

Early effects of copper accumulation on methionine metabolism.

Wilson's disease is characterized by longterm hepatic accumulation of copper leading to liver disease with reduction of S-adenosylmethionine synthesis. However, the initial changes in this pathway remain unknown and constitute the objective of the present study. Using the Long Evans Cinnamon rat model, early alterations were detected in the mRNA and protein levels, as well as in the activities of several enzymes of the methionine cycle. Notably, the main change was a redox-mediated 80% decrease in the mRNA levels of the methionine adenosyltransferase regulatory subunit as compared to the control group. Moreover, changes in S-adenosylmethionine, S-adenosylhomocysteine, methionine and glutathione levels were also observed. In addition, in vitro experiments show that copper affects the activity and folding of methionine adenosyltransferase catalytic subunits. Taken together, these observations indicate that early copper accumulation alters methionine metabolism with a pattern distinct from that described previously for other liver diseases.