Emerging of ptxP3 lineage in Bordetella pertussis strains circulating in a population in northeastern Mexico.

We determined the molecular epidemiology of Bordetella pertussis isolates to evaluate its potential impact on pertussis reemergence in a population of Mexico. Symptomatic and asymptomatic cases were included. Pertussis infection was confirmed by culture and real-time polymerase chain reaction (PCR). Selected B. pertussis isolates were further analysed; i.e. clonality was analysed by pulsed-field gel electrophoresis (PFGE) and ptxP-ptxA, prn, fim2 and fim3 typing was performed by PCR and sequencing. Out of 11 864 analysed samples, 687 (5.8%) were positive for pertussis, with 244 (36%) confirmed by both culture and PCR whereas 115 (17%) were positive only by culture and 328 (48%) were positive only by PCR. One predominant clone (clone A, n = 62/113; 55%) and three major subtypes (A1, A2 and A3) were identified by PFGE. All 113 selected isolates had the allelic combination ptxP3-ptxA1. The predominant clone A and the three major subtypes (A1, A2 and A3) corresponded to the emerging genotypes ptxP3-ptxA1-prn2-fim2-1-fim3-2 and ptxP3-ptxA1-prn2-fim2-1-fim3-1. In conclusion, the presence of an endemic clone and three predominant subtypes belonging to the genotypes ptxP3-ptxA1-prn2-fim2-1-fim3-2 and ptxP3-ptxA1-prn2-fim2-1-fim3-1 were detected. This finding supports the global spread/expansion reported for these outbreaks associated genotypes.

Echocardiographic study of structure and functional cardiac profile of football referees.

AIM: The aim of this study was to analyze, through echocardiography, the structure and functional cardiac profile of national category Spanish soccer referees. METHODS: The sample consisted of 54 licensed referees, who belonged to the Football Inter-Insular Federation of Las Palmas. The sample presented a mean age of 28.52 ± 6.39 years, a height of 1.76 ± 0.07 m, a body mass of 77.26 ± 10.74 kg and a Body Mass Index of 24.90 ± 2-73 kg/m2. The diastolic and systolic dimensions of the left ventricle were 50.03 ± 4.79 mm and 33.74 ± 5.23 mm, respectively. The thicknesses of the interventricular septum and the posterior wall of the left ventricle were 9.77 ± 1.53 mm and 9.47 ± 1.54 mm, respectively. The left ventricular mass was 112.80 ± 26.53 g/m2, the diastolic volume of the left ventricle 135.09 ± 39.63 mL and the ejected volume 47.34 ± 12.44 mL/m2. RESULTS: This study shows that the echocardiographic profile of football referees is characterized by presenting an increase in the left ventricular mass caused by an increase of the cardiac chambers and a normal systolic and diastolic function. The values obtained by football referees were higher than those found in sedentary people and lower than in professional football players. CONCLUSION: These differences may be due to the different physical training workloads employed by football players and referees.

Physical demands of top-class soccer assistant refereeing during high-standard matches.

This study examined the physical demands experienced by top-class assistant referees during high-standard football matches. Computerized match analyses and heart rate recordings were performed on 18 international assistant referees during the FIFA Confederations Cup 2005. Total distance covered averaged 5752+/-554 m, of which 34% was covered at a high-intensity (>13 km.h (-1)). Sidewards movements represented 30% of total match distance. Both total distance (r=0.67; P<0.01) and high-intensity activities (r=0.52; P<0.05) were related to the displacements of the ball in the same match. The distance covered by high-speed running in this tournament was 255% greater (P<0.001) than that covered during the under-17 World Championship 2003. Mean heart rate during the game was 140+/-11 b.min (-1) (78+/-4% HR (max)). Mean heart rate during a 5-min interval of the match was related in part (r=0.31; P<0.001) to the amount of high-intensity activities performed within the same match-period. The results of this study show that the physical demands imposed on assistant referees are influenced by the movements of the ball and the standard of the competition.

Impact of donor age on the results of liver transplantation in hepatitis C virus-positive recipients.

OBJECTIVE: Hepatitis C virus (HCV)-cirrhosis is the most frequent indication for orthotopic liver transplantation (OLT) among adults in most European and American transplant centers. The aim of this study was to analyze the impact of donor age on graft survival among HCV-positive cirrhotic transplant patients. MATERIALS AND METHODS: We performed an observational, retrospective study between March 1997 and December 2004, analyzing 340 liver transplantations. The patients were divided into 4 groups, considering whether the HCV infection was the indication for OLT and whether the age of the donor was older or younger than 48 years: group 1 (HCV, <48 years); group 2 (HCV, >48 years); group 3 (non-HCV, <48 years); and group 4 (non-HCV, >48 years). RESULTS: A univariate analysis showed that posttransplantation graft survival was clearly influenced by recipient HCV serologic status (P = .018). However, no graft survival differences were found when the analysis variable was age (>48 or <48 years). When both variables were studied, a positive HCV serology did not modify graft survival when the donor age was <48 years (P = .32), but had a statistically significant negative impact when the age was >48 years (P = .02). CONCLUSIONS: The use of older donors for HCV recipients resulted in worse graft and patient survivals in our study. This difference in survival was not present in non-HCV recipients or when grafts for HCV recipients were procured from younger donors. Donor age <30 years was a protective factor for graft survival among HCV recipients.

Outcome and morbidity of pancreas transplantation in a single Spanish institution.

BACKGROUND: Pancreas transplantation is nowadays the only treatment to reestablish normal blood glucose in diabetic patients. Moreover, transplantation may also prevent and possibly even revert diabetes-related complications. We present our results with the first 4 years of a pancreas transplantation program. MATERIALS AND METHODS: From February 2000 to June 2004, we performed 43 pancreas transplants in 42 recipients. In all cases the technique was enteric drainage of the exocrine secretions and systemic venous derivation to the inferior vena cava for endocrine secretions. RESULTS: A simultaneous pancreas-kidney transplant was performed in 37 (88.1%) patients, a pancreas after kidney in 4 (9.5%) patients, and a retransplant in 1 (2.4%) patient. Glycosylated hemoglobin and C peptide returned to normal values in all cases. Patient and graft survivals were 91% and 84%, respectively, after a median follow-up of 19 months. The rate of reoperations was 31% with an overall 16% graft loss. CONCLUSIONS: Our results were comparable to those of larger series.

True impact of the indication of cirrhosis and the MELD on the results of liver transplantation.

UNLABELLED: Our Aim was to determine the impact of cirrhosis and the preoperative MELD score on the immediate postoperative mortality and hospital stay as well as survival at 1, 5, and 8 years in liver transplantation. MATERIALS AND METHODS: Transplanted cirrhotic patients were selected who did not display some of the main known risk factors affecting recipient. Donor and surgical technique were included in this analysis. These exclusion criteria for recipient factors were emergency transplants and retransplants; for donor factors, age over 60 years, ischemia time over 10 hours, and moderate or severe steatosis on back-bench biopsy; and for surgery, prior complex upper abdominal surgery (mainly derivative and gastroduodenal surgery). Among 340 total liver transplants including 16 retransplants performed from March 1997 to December 2005, 197 patients met the selection criteria. The mean age of the recipients was 52 years (17-67) and the donors, 39 years (11-60). The transplant indication was cirrhosis in all cases: HCV in 69 cases (35%); alcohol in 55 (28%); hepatocarcinoma in 38 (19%); HBV in 19 (10%); PBC in 8 (4%), and other etiologies in 8 cases (4%). The MELD scores were divided as group 1, <10 points (33 cases = 17%); group 2, 10 to 18 points (136 cases = 69%); and group 3, >18 points (28 cases = 14%). The statistical analysis was performed with SPSS 11.0. RESULTS: Postoperative mortality (up to 3 months) was 16 cases (8%). The median ICU and hospital stays were 3 and 13.5 days, respectively. Overall survivals at 1, 5, and 8 years were 89%, 80%, and 77%, respectively. The survival for the same periods according to MELD group was 97%, 97%, and 97% for group 1; 87%, 76%, and 72% for group 2; and 85%, 81%, and 81% for group 3 (P = NS). The survival according to the three main indications at 1, 5, and 8 years was: HCV, 91%, 80%, and 80%; alcohol, 87%, 80%, and 71%; and hepatocarcinoma, 84%, 80%, and 80% (P = NS). No significant differences were observed among early deaths between MELD groups or transplant indications. CONCLUSIONS: In a favorable liver transplant setting including acceptable donors, absence of prior complex abdominal surgery in the recipient, and nonemergency transplants, neither the cause of the cirrhosis nor its severity, as measured preoperatively by the MELD, were predictive of early postoperative death or long-term survival.

Influence of degree of hepatic steatosis on graft function and postoperative complications of liver transplantation.

The aim of this study was to evaluate the impact on initial graft function of the degree of steatosis detected in the back-table biopsy, and its repercussion on the clinical results of the transplant (early posttransplant mortality and morbidity). We undertook a retrospective analysis of 300 liver transplants performed at our center from 1997 to 2004. A wedge liver biopsy was done routinely during back-table surgery (available in 294 transplants). The degree of steatosis was classified as: S0-no steatosis, 201 transplants; S1-mild steatosis (<30%), 58 transplants; S2-moderate steatosis (30% to 60%), 18 transplants; and S3-severe steatosis (>60%), 17 transplants. The ischemia-reperfusion (I/R) injury, based on the maximum mean peak aspartate transferase in the first 72 posttransplant hours, tended to be greater as the degree of graft steatosis increased: S0, 1316; S1, 1985; S2, 2446; and S3, 2955 (P < .005 between S0 and S3). This greater initial hepatic dysfunction was correlated in the group with severe steatosis with a higher rate of severe renal failure requiring hemofiltration/hemodialysis: S0, 9%; S1, 15%; S2, 11%; and S3, 41% (P < .001); as well as with a higher early mortality (90 days): S0, 10%; S1, 21%; S2, 11%; and S3, 41% (P < .001). The Kaplan-Meier survival curve showed a significant difference (log-rank and Breslow) between the group with severe steatosis and the group with no steatosis (P = .002). We conclude that the degree of liver graft steatosis is an important determinant of I/R injury, although this progressive increase in the I/R injury with the degree of steatosis only had clinical repercussions in the case of severe steatosis.

Preoperative factors and models predicting mortality in liver transplantation.

We analyzed preoperative factors related to postoperative mortality after liver transplantation among a cohort of 268 consecutive liver transplant patients over 6 years. We studied the impact of 10 recipient variables, 14 donor features, and three operative aspects. We also studied the correlation with death and survival using various predictive scores (Child, Cordoba Score, MELD, and UCLA). Univariate analysis showed that the factors with a significant association with postoperative mortality were the use of noradrenaline in the donor, total ischemia time (>12 hours), and transplant indication (hepatitis C virus versus the rest). Multivariate analysis of mortality showed the impact of female donor sex, recipients over >60 years, recipient albumin less than 2.8, and total graft ischemia time more than 12 hours. Univariate analysis of 1-year survival showed a statistically significant relation with D/R gender similarity, as well as donor GOT (>170) and GPT (>140) values. Multivariate analysis of 1-year survival showed donor GOT (>170) and donor/recipient gender similarity to be significant. Concerning the prediction models, Child-Pugh (AB versus C) best determined postoperative mortality (P < .006), MELD was predictive of 1-year survival (P < .03). The most important variables related to postoperative mortality were total ischemia time over 12 hours, recipient albumin less than 2.8, and age above 60 years. The variable with most impact on 1-year survival was the degree of graft hepatocyte lesion as determined by GOT. The Child-Pugh system is still the best indicator of postoperative mortality, although MELD may also be a good predictor of survival.

Apex cryopreservation of several strawberry genotypes by two encapsulation-dehydration methods.

This paper presents results from a study to develop cryopreservation procedures for apices of several strawberry genotypes. Five Fragaria x ananassa Duch. cultivars and two wild species (F. chiloensis and F. virginiana) have been screened using the encapsulation-dehydration method and/or a protocol which compromises vitrification and encapsulation-dehydration. Apices were encapsulated in an alginate gel, precultured on media containing high levels of sucrose (0.8 M, conventional protocol), or a combination of 0.4 M sucrose and 2 M glycerol. Recovery rates varied among genotypes (23-63%). The latter method reduced considerably the time needed for the cryogenic procedure by eliminating the pre-treatment with 0.8 M sucrose for 19 h prior to dehydration, as required by the conventional procedure.

[Applicability of "do not do recommendations" from the National Institute for Health and Care Excellence in a quaternary care hospital]. / Resultados de la aplicabilidad de las "do not do recommendations" del National Institute for Health and Care Excellence en un hospital de alta complejidad.

AIMS: To qualitatively and quantitatively identify the level of agreement between the clinical staff of a quaternary care hospital and the National Institute for Health and Care Excellence (NICE) "do not do" recommendations, and to submit a strategic alternative for effective implementation. METHOD: An ad hoc form was designed to evaluate level of clinical disagreement from the experience and knowledge of the clinical staff, as well as the applicability, usefulness, effectivity and efficiency of all the NICE "do not do" recommendations that had been published up to June 2012, checking their stability up to the July 2014 update. Description of the process of design and implementation of the strategic alternative to improve compliance is presented. RESULTS: The great majority (90%) of Clinical Unit directors agree with the NICE recommendations, with 64% finding them useful or very useful, 52% finding them applicable, and 32% and 34% thinking they are of high effectivity and efficiency, respectively. However, 20% of the efficient ones are not being applied. Moreover, knowledge discordances that might lead to clinical disagreements were detected. A strategic intervention, combining culture and incentives for good clinical practices, has been implemented. CONCLUSIONS: The improvement in the use of the good clinical practice recommendations is directly related to the agreement of its definition and evidence. An evaluation strategy of its application by the health professionals is essential to achieve an impact in avoidable costs. Moreover, to control for harmful effects of the economic impact on patient safety, it will be necessary to simultaneously evaluate clinical/health outcome indicators tightly linked to the applied recommendations.

Mitral valve prolapse. Recent concepts and observations.

The conditions associated with prolapse of the posterior leaflet of the mitral valve are multiple. The mechanisms of mitral valve prolapse as well as the pathogenesis of pain and ectopic impulse formation are reviewed. Propranolol appears to be the drug of choice for the symptomatic treatment of patients with this syndrome since it decreases myocardial oxygen demand and wall tension thus reducing or abolishing the discrepancy between myocardial oxygen demand and supply within the mitral apparatus. It has also been reported to modify the auscultatory findings associated with this condition. The frequency of this mitral valve abnormality in patients with obstructive coronary artery disease is reviewed. It appears that prolapse of the posterior leaflet scallops in patients with significant obstructive coronary artery disease represents an intermediate stage before mitral insufficiency occurs. This group of patients with papillary muscle dysfunction includes those with prolapsed leaflets without mitral insufficiency, those with systolic murmurs and compensated heart failure and others with progressive cardiac decompensation and severe mitral regurgitation.

Atrioventricular block after reciprocating atrioventricular junctional tachycardia.

Short runs of symptomatic atrioventricular (A-V) block occurred after spontaneous cessation of reciprocating A-V junctional tachycardia in a patient with right bundle branch block, normal H-V interval and sinus nodal dysfunction. These episodes were characterized by long (more than 1 sec) P-P intervals during which the A deflections were not followed by His bundle electrograms. Three possible explanations are: (1) a posttachycardia-induced period of abnormally prolonged A-V nodal refractoriness; (2) pseudo-A-V block produced by concealed A-V junctional tachycardia, or (3) bradycardia-dependent (phase 4) A-V block at the "upper" His bundle, above the site from which the H deflection was recorded.

Bedside recognition, incidence and clinical course of right ventricular infarction.

To evaluate the incidence, clinical characteristics and course of right ventricular infarction, 96 patients with an established diagnosis of acute myocardial infarction were evaluated during a 10 month study period. Of the 44 patients with acute inferior wall myocardial infarction, 16 had bedside evidence of right ventricular dysfunction. All had a positive Kussmaul's sign, and 12 had either a right ventricular third or fourth heart sound. Inspiratory elevation of right atrial and right ventricular end-diastolic pressures was documented in nine patients. Ventricular fibrillation developed in one patient and advanced atrioventricular block in three. All 16 patients survived and were alive 3 months after infarction. The hospital course and 3 month survival rate were not different from those of the usual patient with inferior wall infarction. Approximately one third of the patients with inferior wall myocardial infarction have bedside evidence of right ventricular infarction, which usually does not alter short-term prognosis.

Cardiac transplant vasculopathy.

STUDY OBJECTIVE: Coronary allograft vasculopathy (CAV) remains the major factor limiting long-term survival after heart transplantation. The purpose of this article is to review for the nontransplant physician the concept of CAV as a disease entity after heart transplantation. DESIGN: A MEDLINE search from 1985 to 1999 was performed. Data on cardiac transplant vasculopathy were divided into pathology, pathophysiology, presentation, diagnosis, and treatment. RESULTS: CAV manifests as a unique and unusually aggressive form of coronary artery disease that differs from traditional atherosclerosis. It is believed to be caused by immunologic mechanisms that combine with nonimmunologic factors to cause endothelial injury, resulting in smooth muscle proliferation and intimal thickening. This intimal hyperplasia leads to coronary obstruction, which ultimately results in allograft failure. Diagnosis of CAV can be difficult because transplant recipients have denervated hearts and rarely present with chest pain. Various noninvasive screening methods have not proved reliable. Therefore, most transplant centers perform periodic coronary angiography for routine CAV surveillance. Treatment of CAV involves modification of risk factors and the use of pharmacologic agents that alter vascular physiology. Revascularization procedures continue to play a role as palliative therapy, but are limited in their effectiveness by the diffuse nature of this disease. CONCLUSION: Cardiac transplant vasculopathy continues to play a major dilemma regarding posttransplant care. Further research is needed to develop successful preventive and therapeutic strategies that may alter the course of this disease.

Electrophysiologic studies in a patient with atrial flutter and 1:1 atrioventricular conduction.

Intracardiac electrophysiologic studies were performed in a patient having paroxysms of atrial flutter with 1:1 atrioventricular (A-V) conduction. Although duration of conduction intervals was normal during sinus rhythm, the atrio-His (A-H) interval did not show the expected increase when the atria were stimulated at progressively higher rates. The results of pacing with the extrastimulus technique also indicated that the refractory periods of the A-H tissues were shorter than normal. Yet, intravenously administered ouabain produced a significant increase in these refractory periods. The findings in the case are compatible with a partial A-V nodal bypass with a shorter refractory period than the A-V node or with an A-V node with unusual capacity for rapid conduction. The response to ouabain therapy was that of A-V nodal tissues.

Hemodynamic response to isometric handgrip in acute myocardial infarction.

Thirteen patients underwent right cardiac catheterization during the first 24 hours after the onset of symptoms of acute myocardial infarction. All had normal (less than 12 mm Hg) pulmonary arterial diastolic pressure or normal mean pulmonary wedge pressure (7.6 +/- 0.6 mm Hg). The patients did isometric forearm contraction to a measured level of 100 mm Hg. All patients had elevation of systemic systolic blood pressure, with a mean rise of 14.2 +/- 2.9 mm Hg; heart rate rose by 12 +/- 2 beats per minute. When compared to a control group, patients with acute myocardial infarction had a significant (P less than 0.005) elevation of 5.4 +/- 1.3 mm Hg in the pulmonary arterial diastolic or pulmonary wedge pressure. This may be a result of either increased left ventricular stiffness or decreased myocardial functional reserve. In the setting of acute myocardial infarction, patients with normal left ventricular filling pressures have abnormal ventricular performance. Isometric effort is poorly tolerated and should be avoided.

Long-term clinical and hemodynamic studies after ventricular aneurysmectomy and aorta-coronary bypass.

Late clinical and hemodynamic evaluations in 18 patients with ventricular aneurysmectomy and aorta-coronary bypass are presented. Tne patients had significant obstructive lesions in two major vessels (55 per cent), and 6 had extensive three vessel disease (33 per cent). In 13 patients, 21 aorta-coronary saphenous bypass grafts were performed in addition to aneurysmectomy. The operative mortality rate was 11 per cent. One patient died suddenly 5 months after the operation (one year mortality rate 17 per cent). The 15 surviving patients have been followed up for 12 to 41 months (average 24 months). Clinical results were considered excellent in 2 patients who have been asymptomatic (Class I, N.Y.H.A.). Nine others were considered to have good clinical results (Class II). Five patients have continued to have congestive heart failure and angina on minimal effort (Class III or IV). Six of the 11 patients considered to have excellent or good results underwent postoperative hemodynamic studies 6 to 34 months after the operation. A significant increase in cardiac index was documented in all 6 patients. Paradoxic movement was not detected in any of the postoperative ventriculograms. Five of the seven venous grafts inserted were patent. Elevated left ventricular end-diastolic pressure (LVEDP), low cardiac index, and a persistent dyskinetic area in the left ventricle were found in 2 patients considered to have poor clinical results. Clinical and hemodynamic evaluations have shown a significant improvement in most patients surviving ventricular aneurysmectomy. However, postoperative systemic embolism, myocardial infarction, progression of coronary artery disease, transient cerebral ischemic attacks, graft occlusion, arrhythmias, and mitral regurgitation in previously prolapsed mitral valve leaflets account for progressive disability and limited activity after a successful operation.

Disruption of proximal aortosaphenous vein anastomosis. Late complication of aortocoronary bypass surgery.

A 43-year-old man who had undergone aortocoronary saphenous vein bypass developed disruption of the proximal aorto-saphenous vein anastomosis. Although rare, a mediastinal hematoma secondary to leakage or disruption of an anastomotic site should be considered in patients who develop a mediastinal mass after aortocoronary bypass surgery.

Cardiac transplantation in a patient with hereditary hemochromatosis: role of adjunctive phlebotomy and erythropoietin.

We describe the case of a 36-year-old woman with hereditary hemochromatosis (HH) resulting in end-stage cardiomyopathy and treated successfully with orthotopic cardiac transplantation. Before and after transplantation, the patient underwent aggressive treatment with frequent phlebotomy. We used erythropoietin concomitantly to maintain adequate hematocrit to support continued phlebotomy. We believe that aggressive use of phlebotomy provided the patient hemodynamic benefit and hastened the return of endocrine function post-transplantation. We also believe that the patient's history of high-dose vitamin C usage may have accelerated iron deposition in the heart and other vital organs.

Effect of loading conditions on myocardial relaxation velocities determined by Doppler tissue imaging in heart transplant recipients.

BACKGROUND: Cardiac allograft rejection is accompanied by cellular infiltration and tissue edema resulting in myocardial relaxation abnormalities. Doppler tissue imaging is capable of measuring myocardial relaxation velocities and is useful in the detection of heart rejection. However, the influence of ventricular loading conditions on myocardial relaxation velocities has not been studied. This study is performed to determine whether myocardial relaxation velocities are affected by left ventricular loading conditions. METHODS: Twenty heart transplant recipients without evidence of rejection by endomyocardial biopsy underwent preload and afterload reduction with nitroglycerin. The pulmonary wedge pressure was reduced from 18.2+/-0.9 to 12.0+/-0.9 mm Hg 9 (p=0.001) and the mean blood pressure from 130.0+/-5.6 to 116.1+/-7.0 mm Hg (p=0.001). Pulsed-wave Doppler tissue imaging was performed before and after administration of nitroglycerin, and the peak myocardial relaxation velocities of the inferior wall were measured. RESULTS: Myocardial relaxation velocities did not change with the administration of nitroglycerin; 0.188+/-0.009 to 0.178+/- 0.006 m/sec (p=0.4) in spite of a significant reduction in pulmonary capillary wedge pressure. Furthermore, there was no correlation between pulmonary capillary wedge pressure, mean arterial pressure, wall stress, and myocardial relaxation velocities. CONCLUSIONS: Loading conditions on the left ventricle have no influence on myocardial relaxation velocities. Therefore in heart transplant recipients changes in myocardial relaxation velocities by Doppler tissue imaging may be useful in the diagnosis of rejection, in spite of diverse loading conditions.