[ECMO support in a child with cardiogenic shock due to Kingella Kingae endocarditis]. / ECMO en un lactante con shock cardiogénico secundario a endocarditis por Kingella Kingae.

INTRODUCTION: Endocarditis is a rare disease in children, especially in those without previous heart disease, and Kingella Kingae (KK) is rarely identified as the cause. Extracorporeal membrane oxyge nation (ECMO) is a support for both heart and respiratory failure. OBJECTIVE: To report the first case of infectious endocarditis (IE) due to KK which required ECMO support secondary to refractory cardiogenic shock. CLINICAL CASE: 19-months-old previously healthy female patient, with a 2-day his tory of fever, and diagnosed with hand-foot-and-mouth disease. The patient developed refractory cardiogenic shock, multiorgan failure, acute respiratory distress syndrome, and deep hemodynamic compromise that required veno-arterial ECMO support. The echography showed an image compa tible with mitral valve vegetation, confirming IE with transthoracic echocardiography. Blood culture was positive for KK. She had an ischemic stroke and required two heart surgeries, the first one for the mass resection and the second one for mitral valve repair, which had a posterior ring pseudoa neurysm. The patient had a favorable evolution and was discharged 73 days after admission. At one year of follow-up, she had no cardiological symptoms, but a mild right brachial-crural hemiparesis persisted. CONCLUSION: This is the first reported case of IE due to KK that required extracorporeal life support. KK endocarditis is an uncommon pathology that can cause multiorgan failure, which can be successfully supported with ECMO.

In search of the pre- and post-neolithic genetic substrates in Iberia: evidence from Y-chromosome in Pyrenean populations.

The male-mediated genetic legacy of the Pyrenean population was assessed through the analysis of 12 Y-STR and 27 Y-SNP loci in a sample of 169 males from 5 main geographical areas in the Spanish Pyrenees: Cinco Villas (Western Pyrenees), Jacetania and Valle de Arán (Central Pyrenees) and Alto Urgel and Cerdaña (Eastern Pyrenees). In the Iberian context, the Pyrenean samples present some specificities, being characterizeded by a high proportion of chromosomes R1b1b2-M269 (including the usually uncommon R1b1b2d-SRY(2627) and R1b1b2c-M153 types) or I2a2-M26 and low proportions of other haplogroups. Our results indicate that an old pre-Neolithic substrate is preponderant in populations of the whole Pyrenean fringe. However, AMOVA revealed a high level of substructure within Pyrenean populations, partially explained by drift effects as well as by the signature of an ancient genetic differentiation between Western and Eastern Pyrenees.

AFLP and breeding system studies indicate vicariance origin for scattered populations and enigmatic low fecundity in the Moroccan endemic Hypochaeris angustifolia (Asteraceae), sister taxon to all of the South American Hypochaeris species.

We used Amplified Fragment Length Polymorphism markers (AFLP) and breeding system studies to investigate the population structure and reproductive biology of Hypochaeris angustifolia (Asteraceae: Cichorieae). This species is endemic to altiplanos of the Atlas Mountains (Morocco) where it occurs in scattered populations, and it is the sister species to c. 40 species of this genus in South America. PCoA, NJ, and Bayesian clustering, revealed that the populations are very isolated whilst AFLP parameters show that almost all populations have marked genetic divergence. We contend that these features are more in accord with a vicariance origin for the scattered populations of H. angustifolia, rather than establishment by long-distance dispersal. The breeding system studies revealed that H. angustifolia is a self-incompatible species, with low fecundity in natural and in experimental crosses, probably due to a low frequency of compatible phenotypes within and between the populations.

Phylogeography of the invasive weed Hypochaeris radicata (Asteraceae): from Moroccan origin to worldwide introduced populations.

In an attempt to delineate the area of origin and migratory expansion of the highly successful invasive weedy species Hypochaeris radicata, we analysed amplified fragment length polymorphisms from samples taken from 44 populations. Population sampling focused on the central and western Mediterranean area, but also included sites from Northern Spain, Western and Central Europe, Southeast Asia and South America. The six primer combinations applied to 213 individuals generated a total of 517 fragments of which 513 (99.2%) were polymorphic. The neighbour-joining tree presented five clusters and these divisions were supported by the results of Bayesian analyses: plants in the Moroccan, Betic Sierras (Southern Spain), and central Mediterranean clusters are all heterocarpic. The north and central Spanish, southwestern Sierra Morena, and Central European, Asian and South American cluster contain both heterocarpic (southwestern Sierra Morena) and homocarpic populations (all other populations). The Doñana cluster includes two homocarpic populations. Analyses of fragment parameters indicate that the oldest populations of H. radicata are located in Morocco and that the species expanded from this area in the Late Quaternary via at least three migratory routes, the earliest of which seems to have been to the southwestern Iberian Peninsula, with subsequent colonizations to the central Mediterranean area and the Betic Sierras. Homocarpic populations originated in the southwestern Iberian Peninsula and subsequently spread across north and central Spain, Central Europe and worldwide, where they became a highly successful weed.

A novel supermatrix approach improves resolution of phylogenetic relationships in a comprehensive sample of danthonioid grasses.

Phylogeny reconstruction is challenging when branch lengths vary and when different genetic loci show conflicting signals. The number of DNA sequence characters required to obtain robust support for all the nodes in a phylogeny becomes greater with denser taxon sampling. We test the usefulness of an approach mixing densely sampled, variable non-coding sequences (trnL-F; rpl16; atpB-rbcL; ITS) with sparsely sampled, more conservative protein coding and ribosomal sequences (matK; ndhF; rbcL; 26S), for the grass subfamily Danthonioideae. Previous phylogenetic studies of Danthonioideae revealed extensive generic paraphyly, but were often impeded by insufficient character and taxon sampling and apparent inter-gene conflict. Our variably-sampled supermatrix approach allowed us to represent 79% of the species with up to c. 9900 base pairs for taxa representing the major clades. A 'taxon duplication' approach for taxa with conflicting phylogenetic signals allowed us to combine the data whilst representing the differences between chloroplast and nuclear encoded gene trees. This approach efficiently improves resolution and support whilst maximising representation of taxa and their sometimes composite evolutionary histories, resulting in a phylogeny of the Danthonioideae that will be useful both for a wide range of evolutionary studies and to inform forthcoming realignment of generic delimitations in the subfamily.

[Self-evaluation of conization indications since the introduction of the French colposcopy and cervico-vaginal pathology quality charter in 2 colposcopy centers]. / Auto-évaluation des indications de conisation depuis l'instauration de la charte de qualité en colposcopie et pathologie cervico-vaginale.

OBJECTIVES: Analyze the efficiency of the implementation of the colposcopy and cervico-vaginal pathology quality charter. The question was to determine whether the criteria of more than 70% of excisional conizations containing CIN2+ lesions (cervical intraepithelial neoplasia 2 or 3 or carcinoma in situ) had been reached and demonstrate a reduction of the conization rate is possible. METHODS: An epidemiological descriptive, retrospective and multicenter study was performed in "Nord Franche-Comté Hospitals" (Belfort and Montbéliard, France) during the period from November 2013 to January 2015. Inclusion criteria were patients over 25 years undergoing cervical excisions for diagnostic and/or therapeutic purposes after Pap smear screening followed by colposcopically directed biopsies. The files were selected from a data collection and studied using the computerized patient record. RESULTS: In total, 116 conizations were performed: 103 by four French Society of Colposcopy and Cervico-Vaginal Pathology (SFCPCV) members and 13 by four SFCPCV non-members. The overall result of the primary outcome showed 53% of CIN2+ lesions found in cervical conization specimens, which can be broken down to 55% for the group of SFCPCV members and to 38% for the group of SFCPCV non-members. The statistical analysis indicates a significant difference (P=0.02) in the percentage of CIN2+ lesions discovered on the surgical specimen for the group of SFCPCV members. CONCLUSIONS: This self-evaluation shows that it is essential to be a SFCPCV member and to adhere to the charter. By complying with the charter and associating the new National Cancer Institute recommendations (December 2016), it is possible to reduce the conization rate and even to surpass the target of more than 70% of excisional conizations containing CIN2+ lesions.

Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice. / Adaptación española de las guías europeas de 2016 sobre prevención de la enfermedad cardiovascular en la práctica clínica.

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]. / Adaptación española de las guías europeas de 2016 sobre prevención de la enfermedad cardiovascular en la práctica clínica.

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

[Obstetrical prognosis of patients after a previous caesarean section performed before 32 weeks of amenorrhea]. / Pronostic obstétrical des patientes présentant un antécédent de césarienne réalisée avant 32 semaines d'aménorrhée.

OBJECTIVE: To assess delivery mode, maternal morbidity including uterine rupture and scar dehiscence and neonatal outcome, during a pregnancy after a previous caesarean delivery before 32 weeks of amenorrhea. METHODS: A retrospective descriptive study was carried out at the Besançon University Hospital during an 8-year period. We identified 292 consecutive patients presenting a singleton pregnancy delivery before 32 weeks of amenorrhea. We analysed the next pregnancy. Patients presenting more than one caesarean section were excluded from this study. RESULTS: Out of the 292 patients, 62 met inclusion criteria. The average gestational age of the first caesarean section was 29 weeks and 3 days. Among these patients, 17 (27.4%) had a planned caesarean delivery after caesarean (CDAC) and 45 (72.6%) had a trial of vaginal delivery (TVD) with a success rate of 71.1%, that is a total of 51.6% of vaginal delivery after a previous early caesarean section. In case of a failed TVD, arterial pH (P<0.005), Apgar score at one minute (P<0.05) and at 10minutes (P<0.05) were significantly lower compared to the CDAC group. Regarding perinatal outcome, there was no significant difference (P=0.31) between the groups in intention to treat. The only uterine rupture (1.6%) was noticed during a caesarean section at 26 weeks and 3 days, in a patient initially included in the TVD group. Five uterine scar-dehiscences (8.1%) were discovered including 80% during caesarean section, at an average term of 32 weeks and 2 days of amenorrhea. CONCLUSION: After an early caesarean section, trial of vaginal delivery can be implemented if local conditions are favorable. There is no difference in maternal morbidity, success of labour and neonatal outcome if previous caesarean section was performed before 32 weeks or at term. It appears however that uterine rupture rate (complete or incomplete) is slightly higher in comparison to a previous caesarean at term, which might occur prematurely and before labour.

[Impact of the external cephalic version on the obstetrical prognosis in a team with a high success rate of vaginal delivery in breech presentation]. / Impact de la version par manœuvre externe sur le pronostic obstétrical dans une équipe à fort taux de réussite de l'accouchement vaginal du siège.

OBJECTIVES: To analyse the impact of external cephalic version (ECV) on caesarean section rate in a team with a high success rate of vaginal delivery in breech presentation. MATERIALS AND METHODS: Retrospective monocentric study including 298 patients with a breech presentations between 33 and 35weeks of amenorrhea followed at our university hospital and delivered after 35weeks, between 1st January 2011 and 31st December 2013. Patients were divided into 2 groups: planned ECV (n=216 patients) versus no planned ECV (n=57 patients). RESULTS: Our rate of successful vaginal breech delivery over the period of the study was 61.1%. We performed 165 ECV, with a 21.8% success rate. The average term of the attempt of ECV was 36.7weeks of amenorrhea. The caesarean section rate was not significantly different in the planned ECV group, even after adjustment on age, parity and previous caesarean delivery (adjusted OR=1.67 [0.77-3.61]). Attempt of ECV did not reduce the number of breech presentation at delivery (61.1% versus 61.4% [P=0.55]). CONCLUSION: Planned ECV in our center with a high level of breech vaginal delivery did not significantly impact our cesarean section rate.

Studies on the structural requirement for ligand binding to the neuropeptide Y (NPY) receptor from rat cerebral cortex.

Analogues of the NPY model peptide NPY 1-4-Aca-25-36 were synthesized by solid phase peptide synthesis using the tea-bag method for parallel peptide synthesis. The affinity of the peptides as ligands to the NPY receptor in rat cerebral cortex was investigated. The model compound NPY 1-4-Aca-25-36 was a relatively poor ligand to the NPY receptor in rat brain (IC50 = 0.40 microM). Arg35 and Arg33 were both important for ligand recognition by the NPY receptor. Substitutions in several positions in the region corresponding to the C-terminal part of NPY resulted in analogues with only minor reduction of the affinity for the NPY receptor.

Investigation of the importance of the N-terminal peptide bonds of substance P by synthetic pseudopeptide analogs.

Synthetic Substance P analogs where each of the first five peptide bonds are replaced by the peptide bond surrogate Gly psi [CH2CH2]Gly are investigated as ligands to the Neurokinin 1 (NK1) receptor from rat cerebral cortex. The affinities of these analogs are then compared with the corresponding Gly-Gly analogs. With this model system replacement of the peptide bond between position 4 and 5 with psi [CH2CH2] resulted in a 7-fold reduction of affinity. Substitution of other peptide bonds resulted in only minor changes in affinity. Although the N-terminal hexapeptide is important for high affinity binding to the NK1 receptor the present study provides evidence for that this effects is not caused by the side chains of the amino acids in position 1-6 or as results of intramolecular hydrogen bonding with the C-terminal part of the peptide. A possible exception is the peptide bond that in the native peptide connects Pro4 and Gln5.

Backbone-to-backbone cyclized and linear pseudopeptide analogs of substance P as ligands to the substance P receptor from rat brain.

Two series of backbone modified substance P analogs were synthesized. In the first group of analogs the N-terminal region of substance P, SP(1-4), was replaced by a polyamine segment or aliphatic omega-amino fatty acid residues. Two of these analogs displaced 125I-Bolton-Hunter labeled substance P from rat brain synaptosomes with IC50 values of 1.3 +/- 0.5 and 1.6 +/- 0.3 nM, respectively. These affinities are similar to that of substance P (IC50 1.3 nM). The second group of analogs were a set of backbone-to-backbone cyclized pseudopeptides. In these analogs two peptide bonds at the C-terminal portion of substance P were replaced by the reduced peptide bonds (psi[CH2NH]) which were further reductively alkylated with 3(4-methylbenzylthio)propanal. After cleavage from the resin the peptides were oxidized into a cyclic disulfide. All of the cyclic analogs of substance P interacted with the NK1 receptor from rat brain with IC50 values in the micromolar range.

The effects of the posterior sagittal approach on rectal function (experimental study).

The posterior sagittal transsphincteric approach has been used for the treatment of anorectal malformations in children and for other acquired conditions mainly in adults. Although the reports on clinical results indicate that the division of the sphincteric mechanism does not harm the function of the voluntary muscles, there are no experimental objective evaluations of the rectal function and fecal continence after a posterior sagittal transsphincteric approach. Sixteen dogs were studied forming four groups of four animals each. Group I was subjected to a posterior sagittal approach only without opening of the rectum. Group II underwent a posterior sagittal approach plus posterior and anterior rectotomy. Group III underwent a posterior sagittal approach plus a perirectal dissection, and group IV underwent only a perirectal dissection without posterior sagittal incision. All animals were evaluated clinically and manometrically preoperatively and postoperatively and were followed up to 12 weeks. Results indicated that the perirectal dissection with and without posterior sagittal incision provoked the most severe changes in bowel control and manometric parameters. Posterior sagittal approach with or without rectotomy provoked minimal or no changes in bowel function and rectal manometry. This experimental study supports the clinical experiences and indicates that the posterior approach does not interfere with the function of the sphincteric mechanism.

Removal of EDTA by UV-C/hydrogen peroxide.

Mineralization of a 5 mM EDTA solution at pH 3 was evaluated via TOC removal under UV-C irradiation in the presence of H2O2 at various conditions. The highest TOC removal (78%) was obtained using a 40:1 H2O2/EDTA molar ratio, after 540 min irradiation. However, a 20:1 ratio gave slightly lower results, being economically more attractive. Best results of TOC removal were obtained under pH controlled conditions. Addition of TiO2 (1 g l(-1)) was detrimental, even in the presence of H2O2, indicating that at this concentration, TiO2 inhibits the mineralization, probably by scattering or by screening of the light.

[Anesthesia for vertebral osteoclasis in a patient with severe predominantly cervical spondylitis ankylopoietica]. / Anestesia para la intervención de osteoclasia vertebral en un paciente con espondilitis anquilopoyética grave de predominio cervical.

We present a patient suffering severe, mainly cervical, ankylopoietic spondylitis who was scheduled for posterior vertebral osteoclasis under local anesthesia. We describe handling of anesthesia, particularly airway control by flexible bronchoscopy in an awake, locally anesthetized patient sedated with benzodiazepines and inhalational anesthetics as compared with other alternatives: an awake patient who is not intubated, under local anesthesia and sedated with narcotics and gaseous anesthetics, or a patient under general anesthesia with placement of a flexible bronchoscope and neurological monitoring by evoked potentials. The surgical technique was Simmons' posterior vertebral osteoclasis, with the column extended and immobilized with wire.

[Combined sciatic and inguinal paravascular nerve block: a valid alternative for arthroscopic knee surgery]. / Bloqueo ciático y paravascular inguinal para cirugía artroscópica de rodilla, una alternativa válida.

OBJECTIVE: To assess the effectiveness of a combined transgluteal sciatic and inguinal paravascular nerve block for arthroscopic knee surgery. MATERIAL AND METHODS: Prospective descriptive study of 88 patients scheduled for arthroscopic knee surgery. Using a nerve stimulator and a transgluteal approach, we infiltrated the sciatic nerve with 20 mL of 1.5% mepivacaine. Then, with the patient in supine position, we located the femoral nerve and inserted a plastic catheter into the descending inguinal canal, applying pressure near the tip, to inject 20 mL of 1% mepivacaine. We evaluated a) anesthetic effectiveness, b) tolerance of the pressure cuff, c) time in the intensive care recovery unit, and d) time until reversal of the block. RESULTS: Anesthesia was efficacious for 89.77% of the patients: excellent for 54 patients (61.36%), good for 25 (28.41%), and insufficient for 9 (10.23%). The pressure cuff was well tolerated by 70 patients (79.54%) and caused discomfort for 18 (20.45%). Mean postoperative stay in the intensive care recovery unit was 19.05 (SD 8.11) minutes. Reversal took place at a mean 204.09 (SD 22.59) minutes for the sensory nerve block and at 223.45 (SD 20) minutes for the motor block. CONCLUSIONS: The combined sciatic and inguinal paravascular block is effective for arthroscopic knee surgery and offers an alternative when other anesthetic techniques cannot be used. Use of a pressure cuff may require complementary sedation.

[Continuous parascalene block for shoulder surgery]. / Bloqueo paraescalénico continuo en la cirugía del hombro.

OBJECTIVE: To evaluate the efficacy and incidence of side effects of parascalene brachial plexus block for shoulder surgery and for postoperative analgesia. PATIENTS AND METHODS: This prospective descriptive study enrolled 186 patients scheduled for conventional (open) and arthroscopic shoulder operations. The parascalene approach to the brachial plexus was used, with an 18-G x 4.5 cm cannula (30 degrees bevel), applying the technique of detecting perforation of the prevertebral fascia. Mepivacaine 1.5% was administered for anesthesia, beginning with a test dose of 5 ml followed by doses of 25 ml. Bupivacaine 0.125% with 1/400,000 adrenaline was given for postoperative analgesia. Two groups were established according to type of surgery. In group A were patients undergoing open surgery and those with articular stiffness undergoing arthroscopic surgery; analgesics were delivered in continuous perfusion of 5 to 8 ml/h. Group B patients, who underwent arthroscopic surgery, received the analgesic in boluses of 10 to 14 ml every 4 to 6 hours. We assessed perception of perforation of the fascia, provocation of paresthesia, number of puncture attempts, anesthetic efficacy, postsurgical analgesia (visual analogue scale from 0 to 10) and complications. RESULTS: Blockade was effective for 155 of the 186 patients (83.33%). In 118 (63.44%) the perception of perforation of the prevertebral fascia was ostensible, in 52 (27.95%) it was slight and in 16 (8.6%) it was undetectable. Paresthesia was triggered by the cannula in 18 cases (9.13%) and by the test dose in 181 cases (97.31%). The mean number of puncture attempts was 1.2 +/- 0.09 per patient. During the early postoperative period analgesia was adequate for 92 (84.40%) of the 109 patients in group A. In group B, 45 patients (97.82%) required 1 to 2 analgesic doses (mean 1.4 +/- 2 doses) and one patient (2.17%) needed 6 doses within the first 24 hours. Catheters remained inserted as long as 36 hours to 10 days (mean 3.5 days) in group A. In group B they had been removed by 24 hours. Complications were transitory and slight. No cases of pneumothorax, no intra- or epidural anesthesia was required and no instances of vascular puncture occurred. CONCLUSIONS: The parascalene approach is easy to use and entails few risks while providing excellent anesthetic conditions for open and arthroscopic shoulder operations. It is useful for ambulatory analgesia to facilitate early rehabilitation after surgery.

ECMO en un lactante con shock cardiogénico secundario a endocarditis por Kingella Kingae / ECMO support in a child with cardiogenic shock due to Kingella Kingae endocarditis

Resumen: Introducción: La endocarditis es una enfermedad poco frecuente en niños, especialmente en los sin patología cardiaca previa, y de manera extraordinaria se identifica a Kingella Kingae (KK) como la causa. La oxigenación por membrana extracorpórea (ECMO) es una forma de soporte tanto para fa lla cardiaca como respiratoria. Objetivo: Reportar el primer caso de endocarditis infecciosa (EI) por KK que requiere soporte con ECMO por shock cardiogénico refractario. Caso clínico: Lactante de 19 meses, previamente sana, que consultó por cuadro de 2 días de fiebre, diagnosticándose síndrome pie mano boca. Evolucionó con shock, falla multiorgánica, síndrome de distress respiratorio agudo y compromiso hemodinámico profundo, por lo que se le dio soporte con ECMO veno arterial. La ecoscopía mostró imagen compatible con vegetación en válvula mitral, confirmando EI con ecocardiografía transtorácica. El hemocultivo fue positivo a KK. Presentó accidente cerebrovascular isquémico. Requirió dos cardiocirugías -la primera para resección de la masa y la segunda para la reparación de la válvula mitral, que había quedado con un pseudoaneurisma del anillo- velo posterior. La paciente tuvo una evolución favorable, siendo dada de alta a los 73 días desde el ingreso. Al año de seguimien to se encontraba asintomática cardiaca, pero persistía una hemiparesia braquiocrural derecha leve. Conclusión: Este es el primer caso reportado de EI por KK que requirió soporte vital extracorpóreo. La EI por KK es una patología infrecuente, que puede provocar falla orgánica múltiple, la que puede ser soportada exitosamente con ECMO.

Abstract: Introduction: Endocarditis is a rare disease in children, especially in those without previous heart disease, and Kingella Kingae (KK) is rarely identified as the cause. Extracorporeal membrane oxyge nation (ECMO) is a support for both heart and respiratory failure. Objective: To report the first case of infectious endocarditis (IE) due to KK which required ECMO support secondary to refractory cardiogenic shock. Clinical case: 19-months-old previously healthy female patient, with a 2-day his tory of fever, and diagnosed with hand-foot-and-mouth disease. The patient developed refractory cardiogenic shock, multiorgan failure, acute respiratory distress syndrome, and deep hemodynamic compromise that required veno-arterial ECMO support. The echography showed an image compa tible with mitral valve vegetation, confirming IE with transthoracic echocardiography. Blood culture was positive for KK. She had an ischemic stroke and required two heart surgeries, the first one for the mass resection and the second one for mitral valve repair, which had a posterior ring pseudoa neurysm. The patient had a favorable evolution and was discharged 73 days after admission. At one year of follow-up, she had no cardiological symptoms, but a mild right brachial-crural hemiparesis persisted. Conclusion: This is the first reported case of IE due to KK that required extracorporeal life support. KK endocarditis is an uncommon pathology that can cause multiorgan failure, which can be successfully supported with ECMO.

A multiplex assay to detect variations in the CYP2C9, VKORC1, CYP4F2 and APOE genes involved in acenocoumarol metabolism.

OBJECTIVES: We have developed a genotyping system to determine the alleles of genes related to interindividual variability in acenocoumarol dosage requirements. This genotyping system is intended for routine clinical use and therefore it is essential that it be simple, fast and inexpensive. DESIGN AND METHODS: We developed a PCR multiplex SNaPshot reaction that targets 6 SNPs (single nucleotide polymorphisms) in CYP2C9, CYP4F2, VKORC1 and APOE genes, which are associated with acenocoumarol dose requirements. RESULTS: We tested the multiplex in 152 samples and found it to be 100% concordant with the results of other methods. CONCLUSIONS: We successfully produced a reliable multiplex system for simultaneously typing 6 SNPs. This system may be used as a model for accurate, simple and inexpensive genotyping of SNPs related to dose requirements. This information allows the prediction of drug efficiency in patients prior to treatment with acenocoumarol and the prevention of adverse drug reactions.