Ani s 11-Like Protein Is a Pepsin- and Heat-Resistant Major Allergen of Anisakis spp. and a Valuable Tool for Anisakis Allergy Component-Resolved Diagnosis.

BACKGROUND: Anisakis simplex is a fish parasite responsible for gastrointestinal and allergic symptoms in humans. The Ani s 11-like protein has been proposed as an Anisakis allergen because its primary structure is similar to that of Ani s 11. The aims of this work were to analyse the frequency of detection of the Ani s 11-like protein and assess its diagnostic value. METHODS: rAni s 11-like protein, rAni s 5 and rAni s 4 were expressed in Escherichia coli and rAni s 1 was produced in Pichia pastoris. Recombinant allergen detection patterns in 37 Anisakis-sensitised patients were determined. The stability to pepsin digestion and heat treatment of rAni s 11-like protein was also analysed by IgE immunoblotting. RESULTS: Ani s 11-like protein is a major allergen detected by 78% of Anisakis-allergic patients, and 13.5% of patients detect only the rAni s 11-like allergen. This allergen is heat stable because it retains its capability of binding IgE after boiling for 30 min and it is resistant to pepsin digestion for 120 min. CONCLUSIONS: These data indicate that the Ani s 11-like protein is a pepsin- and heat-resistant major allergen (Ani s 11.0201) of Anisakis spp. and a valuable tool for Anisakis allergy component-resolved diagnosis.

Early intravenous immunoglobulin replacement in hypogammaglobulinemic heart transplant recipients: results of a clinical trial.

BACKGROUND: Immunoglobulin G (IgG) hypogammaglobulinemia (HGG) is a risk factor for development of severe infections after heart transplantation. We performed a clinical trial to preliminarily evaluate the efficacy and safety of early administration of intravenous immunoglobulin (IVIG) for prevention of severe infection in heart recipients with post-transplant IgG HGG. METHODS: Twelve heart recipients with IgG HGG detected in a screening phase of the clinical trial (IgG <500 mg/dL) were recruited. Patients received IVIG (Flebogamma 5%), as follows: 2 doses of 200 mg/kg followed by up to 5 additional doses of 300 mg/kg to maintain IgG >750 mg/dL. IgG and specific antibody titers to distinct microorganisms were tested during follow-up. The primary outcome measure was development of severe infection during the study period. Data on the primary outcome were matched with those of 13 recipients with post-transplant HGG who were not included in the clinical trial and with those of 11 recipients who did not develop HGG during the same study period. RESULTS: Mean time to detection of HGG was 15 days. IgG and specific antibody reconstitution (anti-cytomegalovirus, anti-Haemophilus influenza, and anti-hepatitis B surface antigen antibodies) was observed in IVIG-treated patients. Severe infection was detected in 3 of 12 (25%) IVIG-treated recipients, in 10 of 13 (77%) HGG non-IVIG patients, and in 2 of 11 (18%) non-HGG patients (log-rank, 15.31; P=.0005). No severe IVIG-related side effects were recorded. CONCLUSION: Data from this study demonstrate that prophylactic IVIG replacement therapy safely modulates HGG and specific antimicrobial antibodies. Our data also preliminarily suggest that IVIG replacement therapy might decrease the incidence of severe infection in heart recipients with HGG.

Hereditary angioedema in Spain: medical care and patient journey.

BACKGROUND: Hereditary angioedema due to C1 inhibitor deficiency (HAE-C1INH) is a genetic rare disease characterized by recurrent, transient and unpredictable episodes of cold, non-pruriginous oedema without associated urticaria. The characteristics of the disease have a considerable impact on the quality of life of patients. The aim of this study was to increase understanding of the patient journey of HAE in Spain. METHODS: A multidisciplinary committee of 16 HAE experts (allergy, immunology, emergency department, hospital pharmacy and nursing) and 3 representatives of the Spanish Hereditary Angioedema Patient Association (AEDAF) who were patients or caregivers participated in the study. A review of the publications on HAE treatment was performed. Semi-structured interviews were performed to HAE experts, patients, or caregivers. Three meetings with the experts, patients and caregivers were held to share, discuss, and validate data obtained from literature and interviews and to build the model. RESULTS: Throughout the project, the patient journey has been drawn up, dividing it into the stages of pre-diagnosis, diagnosis and treatment/follow-up. Some areas for improvement have been identified. Firstly, there is a need to enhance awareness and training on HAE among healthcare professionals, with a particular emphasis on primary care and emergency department personnel. Secondly, efforts should be made to minimize patient referral times to allergy/immunology specialists, ensuring timely access to appropriate care. Thirdly, it is crucial to encourage the study of the relatives of diagnosed patients to early identify potential cases. Fourthly, equitable access to self-administered treatments should be ensured, facilitated by systems that enable medication delivery at home and proper education and training for patients. Equitable access to long-term prophylactic treatment should also be prioritized for all patients in need. To standardize HAE management, the development of consensus guidelines that reduce variability in clinical practice is essential. Lastly, promoting research studies to enhance knowledge of the disease and align its treatment with new developments in the healthcare field should be encouraged. CONCLUSIONS: The knowledge of the patient journey in HAE allowed us to identify improvement areas with the final aim to optimize the disease management.

Alterations of naïve and memory B-cell subsets are associated with risk of rejection and infection in heart recipients.

Rejection and infection are relevant causes of mortality in heart recipients. We evaluated the kinetics of the maturation status of B lymphocytes and its relationship with acute cellular rejection and severe infection in heart recipients. We analyzed B-cell subsets using 4-color flow cytometry in a prospective follow-up study of 46 heart recipients. Lymphocyte subsets were evaluated at specific times before and up to 1 year after transplantation. Higher percentages of pretransplant class-switched memory B cells (CD19+CD27+IgM-IgD- >14%) were associated with a 74% decrease in the risk of severe infection [Cox regression relative hazard (RH) 0.26, 95% confidence interval (CI), 0.07-0.86; P = 0.027]. Patients with higher percentages of naïve B cells at day 7 after transplantation (CD19+CD27-IgM+IgD+ >58%) had a 91% decrease in the risk of developing acute cellular rejection (RH 0.09; 95% CI, 0.01-0.80; P = 0.02). Patients with infections showed a strong negative correlation between baseline serum B-cell-activating factor (BAFF) concentration and absolute counts of memory class-switched B cells (R = -0.81, P = 0.01). The evaluation of the immunophenotypic maturation status of B lymphocytes could prove to be a useful marker for identifying patients at risk of developing rejection or infection after heart transplantation.

Buccopharyngeal route administered high polyphenolic olive oil and COVID-19: A pilot clinical trial.

INTRODUCTION: Waning immunity after vaccination justifies the need for additional effective COVID-19 treatments. Immunomodulation of local immune response at the oropharyngeal mucosa could hypothetically activate mucosal immunity, which can prevent SARS-CoV-2 main immune evasion mechanisms in early stages of the disease and send an effective warning to other components of immune system. Olive polyphenols are biologically active compounds with immunomodulatory activity. There are previous studies based on immunomodulation with olive polyphenols and respiratory infections using an enteral route, which point to potential effects on time to resolution of symptoms. The investigators sought to determine whether participants following immunomodulation with tiny quantities of high polyphenolic olive oil administered through an oromucosal route could have a better outcome in COVID-19. SUMMARY: This pilot clinical trial investigated the effect of buccopharyngeal administered high polyphenolic olive oil on COVID-19 incidence, duration, and severity. IMPORTANCE: Waning immunity after vaccination justifies the need of further research for additional effective treatments for COVID-19. OBJECTIVE: Immunomodulation of local immune response at the buccopharyngeal mucosa could hypothetically activate mucosal immunity, which would in turn difficult SARS-CoV-2 immune evasion mechanisms in early stages of the disease and send an effective warning to other components of immune system. Olive polyphenols are biologically active compounds with immunomodulatory activity. There are previous studies based on immunomodulation with olive polyphenols and respiratory infections, using an enteral route, which suggest potential shortening of time to resolution of symptoms. The investigators sought to determine whether participants following immunomodulation with tiny quantities of high polyphenolic olive oil administered through an oromucosal route could have a better outcome in COVID-19. DESIGN, SETTING, AND PARTICIPANTS: Double blind, randomized pilot clinical trial conducted at a single site, Talavera de la Reina, Spain. Potential study participants were identified by simple random sampling from the epidemiological database of contact patients recently diagnosed of COVID-19 during the study period. A total of 88 adult participants were enrolled and 84 completed the 3-month study, conducted between July 1, 2021 and August 31, 2022. INTERVENTION: Participants were randomized to receive oromucosal administered high polyphenolic olive oil, 2 mL twice a day for 3 months or no treatment. MAIN OUTCOME AND MEASURES: Primary outcomes were incidence, duration, and severity of COVID-19 after intervention. RESULTS: There were no differences in incidence between both groups but there were significant differences in duration, the median time to resolution of symptoms was 3 days in the high polyphenolic olive oil group compared with 7 days in the no-treatment group. Although time to resolution is directly related to severity, this study did not find any differences in severity. CONCLUSION AND RELEVANCE: Among full-vaccinated adults recent infected with COVID-19, a daily intake of tiny quantities of oromucosal administered high polyphenolic olive oil before infection significantly improved the time to symptom resolution. This finding strongly support the appropriateness of further deep research on the use of oromucosal administered high polyphenolic olive oil as an effective immune strategy against COVID-19.

Simultaneous monitoring of cytomegalovirus-specific antibody and T-cell levels in seropositive heart transplant recipients.

PURPOSE: Human cytomegalovirus (CMV) active infection (CMV infection) poses serious risks to CMV-seropositive heart transplant recipients. We evaluated the usefulness of simultaneous assessment of CMV-specific values for parameters of the humoral (antibodies) and cellular (CD4+ and CD8+ T-cells) immune responses in the identification of heart recipients at risk of developing CMV infection after transplantation. METHODS: We prospectively studied 38 CMV-seropositive heart recipients. Anti-CMV antibody titers were assessed using enzyme-linked immunosorbent assays. CD4+ and CD8+ T-cell responses to overlapping peptide pools of the CMV proteins pp65 and immediate early protein-1 (IE1) were evaluated by flow cytometry. Immunological studies were performed before transplantation and at 30 days after transplantation. Patients with CMV infection were compared with heart recipients without CMV infection. RESULTS: During the 6-month follow-up period, 13 (34.2%) patients developed CMV infection. At baseline, the mean anti-CMV-IgG antibody titer was lower in patients who developed CMV infection. This difference remained at 30 days after transplantation. One month after transplantation, the mean percentage of IE1-specific CD8+ T cells that are IFNg-positive (CD8/IFNg + IE1) was lower in CMV-infected patients. The predictive value of these variables at 30 days was increased when they were combined. Cox regression analysis revealed an association between the risk of developing CMV infection and the combination marker (low anti-CMV titer [<16,100] and low CD8/IFNg + IE1 percentages [<0.40%], relative hazard, 6.07; p = 0.019). The combination marker remained significant after adjustment for clinical variables. CONCLUSIONS: This novel approach of a simultaneous assessment of specific anti-CMV antibody titers and CD8/IFNg + IE1 percentages might help identify heart transplant recipients with an increased risk of developing CMV infection.

Transplantation for complex congenital heart disease in adults: a subanalysis of the Spanish Heart Transplant Registry.

BACKGROUND: Congenital heart diseases (CHDs) have high infant mortality in their severe forms. When adulthood is reached, a heart transplant (HTx) may be required. Spanish adult population transplanted for CHD was analyzed and compared with the most frequent causes of HTx and between different subgroups of CHD. MATERIALS AND METHODS: A total of 6048 patients (HTx 1984-2009) were included. Pediatric transplants (<15 yr), combined transplants, reHTx, and HTx for heart diseases other than idiopathic dilated cardiomyopathy (IDCM) and ischemic heart disease (IHD) were excluded. Total patients included: 3166 (IHD = 1888; IDCM = 1223; CHD = 55). Subgroups were studied as follows: (1) single ventricle with pulmonary stenosis (n = 18), (2) single ventricle with tricuspid atresia and Glenn/Fontan surgery (n = 10), (3) congenitally corrected transposition of the great vessels (TGV) or with switch atrial surgery (n = 10), and (4) CHD with right ventricle overload (n = 17). RESULTS: Survival probability was different between groups (p = 0.0001). Post hoc analysis showed some differences between groups (CHD vs. IHD, p = 0.05; CHD vs. IDCM, p = 0.5; IHD vs. IDCM, p = 0.0001). Early mortality was different between CHD subgroups (group 1 = 19%, group 2 = 40%, group 3 = 0%, group 4 = 29%; p < 0.001); however, overall mortality did not show differences between subgroups (p = 0.5). CONCLUSIONS: The percentage of Spanish adult HTx patients for CHD is low (1%). The survival curve is better than for other HTx causes (IHD). Nevertheless, early mortality was higher, particularly in some subgroups (Fontan).

Psychological and Sociocultural Determinants in Childhood Asthma Disease: Impact on Quality of Life.

Asthma is the most common chronic disease in childhood. The presence of this pathology in children leads to the appearance of different alterations (physical, psychological, social, etc.). Due to their high influence, the aim of this study is to understand these psychological and sociocultural determinants and their impact on the quality of life of asthmatic children. In order to determine the influence of these determinants on quality of life, a narrative review of 48 articles collected in different databases was carried out. Emotions are the most powerful precursor to producing an asthmatic attack. Anxiety and depression are the pathologies that appear frequently associated with childhood asthma, together with Attention-Deficit/Hyperactivity Disorder. In addition, the personality of these children seems to be characterized by shyness and impulsivity, although exceptionally it has been associated with psychopathic behaviors, aggressiveness, and cases of psychosis. School performance is impaired and bullying occurs more frequently. Likewise, dysfunctional family relationships and lower socioeconomic status have a negative impact on the severity and management of asthma. In short, the quality of life of asthmatic children is lower due to the presence of the aforementioned psychological and sociocultural determinants.

The Effectiveness of Negative Pressure Therapy: Nursing Approach.

INTRODUCTION: Complex wounds require advanced techniques for their management and care. Wound care costs are high, so healthcare professionals need to be aware of available therapies. Negative pressure therapy is a technology for which more and more data on its effectiveness in complex wounds are being collected. OBJECTIVE: The objectives of this review were to analyze if the application of negative pressure therapy in complex wounds is effective; to compare the effectiveness of negative pressure therapy with other conventional treatments, as well as its combination with other therapies; and to evaluate the quality of life of patients undergoing negative pressure therapy and collect their main characteristics. METHODOLOGY: A bibliographic review focused on articles published between November 2015 and June 2022 was carried out. The following databases were consulted: PubMed (Medline), Google Scholar, Web of Science (WOS), Scielo and Scopus. RESULTS: The most used pressures in the studies coincide at -125 mmHg and in the range of -125 mmHg to -150 mmHg. In the pediatric population, pressure levels vary by age group. A pressure of -75 to -125 mmHg is recommended for children over 12 years of age, and -50 to -75 mmHg is recommended for children under 2 years of age. CONCLUSIONS: Negative pressure therapy stands out for its rapid rate of granulation, the prevention and effective treatment of infections, the variety and malleability of dressings, its various applications and the possibility of using it with other therapies to accelerate wound closure.

Oral challenge with pasteurized egg white from Gallus domesticus.

BACKGROUND: Since raw egg may cause digestive toxic infections, we assessed whether pasteurized raw egg white is as reliable as fresh raw egg white in the diagnosis of egg allergy. METHODS: Thirty-two egg-allergic children were challenged with both pasteurized and fresh raw egg white. Open challenges were carried out with increasing doses of pasteurized raw egg white and fresh raw egg white administered every 60 min. RESULTS: Eleven children (34.4%) had positive challenges with pasteurized raw egg white. Twenty-one children (65.62%) who tolerated pasteurized raw egg white also had a negative challenge with fresh raw egg white. If the challenge with pasteurized raw egg white resulted positive, the study was stopped. The protein profile and IgE-binding capacity of both pasteurized and fresh egg white were almost identical as observed by SDS-PAGE and IgE immunoblotting. In the IgE immunoblotting-inhibition and ImmunoCAP-inhibition assays, both extracts behaved in a similar way. CONCLUSIONS: We did not find any relevant allergenic differences between fresh and pasteurized egg white. This study supports the use of pasteurized egg white in the diagnosis of allergy to fresh raw egg proteins.

Physiological Response of Quality Cardiopulmonary Resuscitation, Crossover Trial on Mannequin in Extreme Temperature Conditions.

BACKGROUND: To determine the relationship between physiological fatigue and the quality of cardiopulmonary resuscitation (CPR) in trained resuscitators in hostile thermal environments (extreme cold and heat) simulating the different conditions found in an out-of-hospital cardiorespiratory arrest. METHODS: Prospective observational study involving 60 students of the health sciences with training in resuscitation, who simulated CPR on a mannequin for 10 min in different thermal environments: thermo-neutral environment (21 °C and 60% humidity), heat environment (41 °C and 98% humidity) and cold environment (-35 °C and 80% humidity). Physiological parameters (heart rate and lactic acid) and CPR quality were monitored. RESULTS: We detected a significant increase in the number of compressions per minute in the "heat environment" group after three minutes and in the mean rate after one minute. We observed a negative correlation between the total number of compressions and mean rate with respect to mean depth. The fraction of compressions (proportion of time in which chest compressions are carried out) was significant over time and the mean rate was higher in the "heat environment". Physiological parameters revealed no differences in heart rate depending on the resuscitation scenario; however, there was a greater and faster increase in lactate in the "heat environment" (significant at minute 3). The total proportion of participants reaching metabolic fatigue was also higher in the "heat environment". CONCLUSIONS: A warm climate modifies metabolic parameters, reducing the quality of the CPR maneuver.

Conversion From Immediate-Release Tacrolimus to Prolonged-Release Tacrolimus in Stable Heart Transplant Patients: A Retrospective Study.

BACKGROUND: Lifelong adherence with post-transplant immunosuppression is challenging, with nonadherence associated with greater acute rejection (AR) risk. METHODS: This retrospective study evaluated conversion from immediate-release tacrolimus (IRT) to prolonged-release tacrolimus (PRT), between January 2008 and December 2012 in stable adult heart transplant recipients. Cumulative incidence rate (IR) of AR and infection pre- and postconversion, safety, tacrolimus dose and trough levels, concomitant immunosuppression, and PRT discontinuation were analyzed (intention-to-treat population). RESULTS: Overall, 467 patients (mean age, 59.3 [SD, 13.3] years) converted to PRT at 5.1 (SD, 4.9) years post transplant and were followed for 3.4 (SD, 1.5) years. During the 6 months post conversion, 5 patients (1.1%; 95% CI, 0.35%-2.48%) had an AR episode and IR was 2.2/100 patient-years (95% CI, 0.91-5.26). Incidence of rejection preconversion varied by time from transplant to conversion. Infection IR was similar post- and preconversion (9.2/100 patient-years [95% CI, 7.4-11.3] vs 10.6/100 patient-years [95% CI, 8.8-12.3], respectively; P = .20). Safety variables remained similar post conversion. The IR of mortality/graft loss was 2.3/100 patient-years (95% CI, 1.7-3.1). CONCLUSIONS: Conversion from IRT to PRT in heart transplant recipients in Spain was associated with no new safety concerns and appropriate immunosuppressive effectiveness.

Relapsing Rhodococcus equi infection in a heart transplant recipient successfully treated with long-term linezolid.

We report a heart transplant recipient with Rhodococcus equi and Cryptococcus neoformans infection. Despite an initially relapsing course and the acquisition of resistance in vivo, the patient responded to 5 months of linezolid and 6 months of fluconazole. This is the 1st R. equi infection to be cured with linezolid in a heart transplant recipient.

Efficacy and Safety of de Novo and Early Use of Extended-release Tacrolimus in Heart Transplantation.

INTRODUCTION AND OBJECTIVES: The extended-release formulation of tacrolimus (ERT) allows once-daily dosage, thus simplifying the immunosuppressive regimen. This study aimed to describe the safety and efficacy of the de novo and early use of ERT in heart transplantation. METHODS: This was an observational, retrospective, multicenter study comparing the safety and efficacy of the de novo use of ERT (ERT group [n=94]), standard-release tacrolimus (SRT group [n=42]) and early conversion (EC) from SRT to ERT (EC group [n=44]). Extended-release tacrolimus was used between 2007 and 2012. One-year incidence rates of acute rejection, infection, and cytomegalovirus infection were analyzed. Safety parameters were also evaluated. RESULTS: There were no significant between-group differences in the daily dose or trough levels of tacrolimus during the first year after transplantation. The rejection incidence rates were 1.05 (95%CI, 0.51-1.54), 1.39 (95%CI, 1.00-1.78), and 1.11 (95%CI, 0.58-1.65) episodes per patient-years in the SRT group, ERT group, and EC group, respectively (P=.48). The infection incidence rates were 0.75 (95%CI, 0.60-0.86), 0.62 (95%CI, 0.52-0.71), and 0.55 (95%CI, 0.40-0.68) in the SRT group, ERT group, and EC group, respectively (P=.46). Cytomegalovirus infection occurred in 23.8%, 20.2%, and 18.2% of the patients, respectively (P=.86). No significant between-group differences were found in laboratory tests or in allograft function. There was 1 death in the SRT group and 2 in the ERT group. CONCLUSIONS: Both de novo and early use of ERT seem to have similar safety and efficacy profiles to conventional SRT-based immunosuppression.

Bloodstream infections among heart transplant recipients.

BACKGROUND: Heart transplant (HT) recipients are prone to life-threatening infections, including bloodstream infection (BSI), but information on this topic is particularly scarce. METHODS: We studied 309 consecutive HT performed at our institution between 1988 and 2003. We assessed the characteristics of each episode of BSI, prophylaxis and immunosuppression used, and possible related factors. RESULTS: Sixty episodes of BSI occurred in 15.8% of all HT recipients. Rates of BSI/transplanted patient decreased progressively throughout the study period: 21.2%, 14.3%, and 7.5% in each 5-year period (P=0.03). BSI episodes occurred a median of 51 days after transplantation. The main BSI origins were: lower respiratory tract (23%), urinary tract (20%), and catheter-related-BSI (16%). Gram-negative organisms predominated (55.3%), followed by Gram-positive (44.6%). Mortality was 59.2%, with 12.2% directly attributable to BSI. Independent risk factors for BSI after HT were: hemodialysis (OR 6.5; 95% CI 3.2-13), prolonged intensive care unit stay (OR 3.6; 95% CI 1.6-8.1), and viral infection (OR 2.1; 95% CI 1.1-4). BSI was a risk factor for mortality (OR 1.8; 95% CI 1.2-2.8). CONCLUSION: BSIs have decreased in HT recipients, but still contribute to mortality, mainly if related to pneumonia or polymicrobial infections. Reduction of early postoperative complications and viral infections are amenable goals that may further reduce BSI in this population.

Prevalence of BK virus replication among recipients of solid organ transplants.

BACKGROUND: BK virus (BKV) has been implicated as a cause of nephritis and graft loss in 2%-9% of kidney transplant recipients, but the prevalence among recipients of other solid organ transplants (SOTs) has not been well established. Our objective was to determine the prevalence of BKV infection for all types of SOT recipients at our medical center. METHODS: A total of 156 consecutive SOT recipients were studied, of whom 49 received kidney transplants, 43 received heart transplants, and 64 received liver transplants. Samples were obtained a median of 559 days (range, 1-9481 days) after transplantation. Nested polymerase chain reaction was performed for detection of BKV DNA in urine and plasma specimens. RESULTS: BKV was found in 19% of urine specimens and 6% of plasma specimens. The prevalence of viruria after kidney, heart, and liver transplantation was 26.5%, 25.5%, and 7.8%, respectively. BKV viremia was detected in 12.2% of kidney transplant recipients and 7% of heart transplant recipients. Mean creatinine levels were higher in patients with BKV viruria or viremia (1.9 and 3.5 mg/dL, respectively) than in patients with no BKV replication (1.3 mg/dL). Independent factors related to impaired renal function were renal transplantation (odds ratio [OR], 14.4); BKV replication, including viruria or viremia (OR, 3.3); and mycophenolate use (OR, 2.6). CONCLUSION: BKV is common in all types of SOT recipients, particularly those who have received heart or kidney transplants.

[Prognosis of heart transplant candidates stabilized on medical therapy]. / Pronóstico de una población inicialmente candidata a trasplante cardíaco controlada con tratamiento médico.

INTRODUCTION AND OBJECTIVES: A significant percentage of patients selected as candidates for heart transplantation can be stabilized by medical treatment, thereby enabling indefinite postponement of inclusion on the operation list. The aim of this study was to investigate the prognosis of these patients. PATIENTS AND METHOD: We studied retrospectively 118 patients with severe left ventricular systolic dysfunction (ejection fraction < or = 35%) who were consecutively evaluated for cardiac transplantation but who did not undergo transplantation because they became clinically stable on medical treatment. The mean follow-up period was 2.14 (2.19) years. Kaplan-Meier survival analysis, and univariate and multivariate Cox proportional risk analyses of factors predicting survival were performed. RESULTS: There were 18 deaths (15.2%): 12 were sudden (66.7%), 5 were due to heart failure (27.8%), and 1, to a non-cardiac cause (5.5%). The survival rate was 88% in the first year and 82% in the following 2 years. Univariate analysis showed that the parameters associated with mortality (P< or =.05) were pulmonary artery and capillary wedge pressures, diuretic treatment, and the absence of beta-blocker therapy. In the multivariate analysis, only the absence of beta-blocker therapy remained statistically significant (P=.003; RR = 0.13; 95%CI, 0.03-0.50). CONCLUSIONS: In a population of patients with severe left ventricular systolic dysfunction who were candidates for heart transplantation but who were stabilized by medical therapy, mortality during the first year of follow-up was 12%. Beta-blocker therapy was the only variable associated with better survival.

Subcutaneous immunoglobulin replacement therapy in a heart transplant recipient with severe recurrent infections.

Intravenous immunoglobulin has been shown to decrease the risk of post-transplant infections in heart recipients with IgG hypogammaglobulinemia, however the use of subcutaneous immunoglobulin has not been reported. We report on immune reconstitution, clinical efficacy and tolerability of subcutaneous immunoglobulin replacement therapy in a heart transplant recipient with secondary antibody deficiency. Maintenance of IgG levels, specific antibodies and control of infections were observed after change from intravenous immunoglobulin to subcutaneous immunoglobulin due to poor intravenous access. Recurrences of severe infections were observed when subcutaneous immunoglobulin infusions were stopped. Our observations suggest that subcutaneous immunoglobulin replacement therapy might be effective and well tolerated in selected heart recipients.

Congenital atresia of the left main coronary artery in an adult: A rare anomaly with an unfavorable prognosis. Review of the literature.

Congenital atresia of the left main coronary artery (LMCA) is one of the rarest congenital anomalies, which may have an unfavorable prognosis leading to myocardial ischemia, ventricle dysfunction or even sudden cardiac death. There are 34 cases of LMCA in adults reported in the literature, most of them successfully treated with coronary revascularization. We report the case of an adult with LMCA who presented with terminal heart failure that required biventricular assistance and heart transplant.