Occult hepatitis B virus infection: clinical implications in tuberculosis treatment.

Occult hepatitis B virus infection (OBI) is characterized by the absence of HBsAg and persistence of the virus genome (HBV-DNA) in liver tissue and/or blood. OBI has been reported in several clinical contexts. However, the clinical significance of OBI in tuberculosis (TB) treatment is unknown. We investigated the OBI prevalence and its impact on the risk of drug-induced liver injury (DILI) during TB treatment. This was a prospective cohort study with one hundred patients who were treated for TB from 2008 to 2015. Laboratory, clinical and demographic data of TB patients were extracted from medical records. Based on HBV-DNA testing of serum samples, an OBI prevalence of 12% was established; almost half of these patients had both anti-HBc and anti-HBs serological markers. Low CD4+ cell counts have been shown to be a risk factor for OBI among TB patients co-infected with HIV (P=.036). High DILI incidence was observed in this study. A multivariable Cox proportional hazard model was conducted and identified OBI (HR 2.98, 95% CI 1.30-6.86) as the strongest predictor for DILI when adjusted to CD4+ cell count (HR 0.38, 95% CI 0.17-0.90), ALT before TB treatment (HR 1.37, 95% CI 0.81-2.32) and TB extrapulmonary clinical form (HR 2.91, 95% CI 1.75-7.21). The main aim of this study was to highlight DILI as a clinical outcome during treatment of TB patients with OBI. Therefore, HBV-DNA testing should be considered routinely in monitoring DILI, and also in other clinical implications associated with OBI, reduce morbidity and mortality.

[Intravenous proton-pump inhibitor for acute peptic ulcer bleeding--is profound acid suppression beneficial to reduce the risk of rebleeding?]. / Inhibidores de la bomba de protones por vía intravenous en la hemorragia por úlcera péptica: es necesaria la supresión ácida máxima para disminuir el resangrado?

OBJECTIVE: To compare two regimens of pantoprazole administered intravenously in patients with ulcerative gastrointestinal bleeding (UGB), and a high risk of presenting with persitent or recurrent hemorrhage. MATERIAL AND METHOD: Patients were randomized into two groups: group 0--treatment with a 80 mg bolus of pantoprazole administered intravenously, followed by continuous infusion of 8 mg/h for 72 hours; group 1--treatment with 40 mg of pantoprazole administered intravenously on a daily basis. The percentage of hemorrhagic persistence/recurrence in both groups was analyzed, as were transfusion requirements, need for surgery, and mortality resulting from the hemorrhagic episode. RESULTS: There were 20 patients in group 0 and 21 in group 1. No differences were found between groups in terms of gender, age, smoking habits, use of NSAIDs, presence of hemodynamic instability or stigmata in ulcer crater (Forrest Ia: 5 vs. 14.3%, p = 0.322; Forrest Ib: 30 vs. 33.3%, p = 0.819; Forrest IIa: 60 vs. 50.1%, p = 0.753). In group 0, 90% of patients received endoscopic treatment, versus 100% in group 1, p = 0.232. In group 0, 50% of patients had a transfusion, as compared to 52.4% in group 1, p = 0.879. In group 0, 2 patients (10.5%) presented with recurrent hemorrhage, versus 3 patients (14.3%) in group 1. Surgery was required by 1 person from each group, and 1 patient in group 0 died. CONCLUSIONS: Maximum acid inhibition with a bolus and then a continuous infusion of pantoprazole does not yield better results than treatment with conventional doses in acute hemorrhagic episodes.

Cationic surfactants and other factors that affect enzymatic activities and transport.

Surfactants influence functions of proteins in cell signalling. Because molecular mechanisms of surfactants are poorly understood, the cationic surfactant effect on three metabolically important enzymes--L-glutamate dehydrogenase, L-lactate dehydrogenase, and L-malate dehydrogenase--were investigated at a physiologically relevant pH range (6.5-7.4). How a cationic, a non-ionic, and an anionic surfactant could differentially influence these enzymes, and how these surfactants could influence the interfacial mass transport of these enzymes across a polycarbonate membrane in a separation cell were also investigated. Provided the charge density was the same, cationic surfactants affected enzymatic activities similarly, regardless of their molecular masses. Hence, a cationic surfactant behaved similarly to a hydrophilic anionic surfactant; however, the cationic surfactant also enhanced enzymatic activity at pH 6.5 and a moderately high concentration (150 ppm). The hydrophilic surfactant enhanced enzymatic activity and the hydrophobic surfactant depressed enzymatic activity. Addition of 0.1 ppm of the hydrophilic anionic surfactant decreased the amount of enzyme permeation through the membrane, but 0.1 ppm of the non-ionic surfactant had no effect, whereas 0.1 ppm of the hydrophobic surfactant increased enzyme permeation. These results have physiological and signalling implications in nanobiotechnology.

[Changes in the etiology, outcome, and characteristics of patients with acute gastrointestinal bleeding between 1999 and 2005]. / Cambios en la etiología, resultados y características de los pacientes con hemorragia digestiva aguda grave a lo largo del perido 1999-2005.

OBJECTIVES: To analyze the evolution of the following variables in patients admitted to a Blood Unit for gastrointestinal bleeding throughout 1999-2005: etiology, comorbid diseases, use of NSAIDs/anticoagulants, and mortality. MATERIAL AND METHODS: We analyzed the evolution of the following causes of GIB that required admission to the Blood Unit from 1999 to 2005: duodenal ulcer (DU), gastric ulcer (GU), portal hypertension (PHT), and others. We also analyzed changes in the percentage of patients admitted with comorbid disease, use of NSAIDs/anticoagulants, and mortality. RESULTS: 1,611 Patients with a mean age of 60.45 years (59.7-61.2) were included in this study; 76.41% were males (74.3-78.5). DU was the cause of bleeding in 22.20% of cases (20.2-24.3), GU in 18.40% of cases (16.6-20.4), and PHT in 33.60% of cases (31.3-36.0). In all, 34.5% (32.6-37.3) of patients were taking NSAIDs, 7.1% (6.0-8.6) were receiving anticoagulant therapy, 72.6% (70.4-74.8) presented with comorbid disease, and overall mortality was 6.27% (5.16-7.59). Throughout the 1999-2005 period there was an increase in the number of patients with comorbid diseases (p < 0.02), and a decrease in cases of DU (p < 0.04), without significant differences in the remaining variables. CONCLUSIONS: DU, GU and PHT account for three quarters of admissions to our Blood Unit. Over the last seven years, there has been a decrease in cases due to DU, and an increase in patients with comorbid disease; overall mortality rates have remained stable.

Start-up of the Anammox process in a membrane bioreactor.

The start-up of an Anammox process was studied in a membrane sequencing batch reactor (MSBR) in which a submerged hollow fibre membrane module was used to retain the biomass. The reactor was seed with Anammox biomass and fed using the Van de Graaf medium. During a first operating stage, salt precipitation was observed and interfered with microbial activity and caused a decrease of the nitrogen removal rate of the reactor from 100 to only 10 mgl(-1) per day. Salt precipitation was avoided by diminishing adequately the Ca and P concentrations of the Van de Graaf medium during the last operating stage. This action increased quickly the activity of the system, and nitrogen removal rate reached up to 710 mgl(-1) per day with almost full nitrite removal. Sporadic flotation of the sludge was observed in the MSBR. The use of the membrane avoided biomass wash-out from the system. Moreover, a surprising fact was that Anammox biomass did not grow in flocs in the MSBR, but in granules. This fact showed that this kind of microorganisms have a trend to grow in aggregates. Results indicated that the use of the MSBR could be a suitable system for nitrogen removal by using the Anammox reaction.

[Pulmonary ventricle bypass operations]. / Cirurgias de derivação do ventrículo pulmonar.

UNLABELLED: Cavopulmonary connections have been extensively used in the palliation of complex forms of congenital heart disease requiring some form of right heart bypass. We examine the mid term outcomes of pulmonary ventricle bypass operations in a single institution and performed by the same surgical team. POPULATION: Between March 1999 and April 2006, 62 patients underwent pulmonary ventricle bypass operations: bidirectional cavopulmonary anastomosis (Glenn procedure), total cavopulmonary connections (Fontan procedure) and one and a half ventricle correction in two cases. Age at operation averaged three years (range: 0.42-25 years) for the Glenn procedure and seven years (range: 3-14 years) for the Fontan procedure. There were 36 male patients (58%) and 26 female patients (42%). The most common indication for surgery was the single ventricle defect, present in 66% of patients. Associated lesions included: transposition of the great arteries in 16 patients (35.6%), bilateral superior vena cava in four patients (8.9%), situs ambigus in five patients (11%), situs inversus in another patient (2.2%), Ebstein disease in one patient (2.2) and coronary fistula in another patient (2.2%). Sub-aortic stenosis was present in one patient (2.2%). Palliative surgery was performed in all, but three patients (5%), before the Fontan procedure. RESULTS: Thirty two patients underwent bidirectional cavopulmonary anastomosis and thirty patients underwent cavopulmonary connections, total or 2nd stage. Mean cardiopulmonary bypass times were 50.6+/-21.9 minutes for the Glenn procedure and 88.5+/-26.3 minutes for the Fontan procedure. There was no intra-operative mortality, but two patients (3.2% (died in the first month after surgery; one due to failure of the Glenn circuit and sepsis and the other due to a low cardiac output syndrome and multi-organ dysfunction. Mean ventilation time was 5.2+/-1.7 hours for the Glenn operation and 6.2+/-3.2 hours for the Fontan operation. The mean length of stay in ICU was 3.4+/-2.8 days for patients undergoing the Glenn operation and 4.6+/-3.1 days for patients undergoing the Fontan operation and the mean length of hospital stay was 10.6+/-5.8 days for the Glenn operation and 19.1+/-12.6 days for the Fontan operation respectively. The mean follow up time was 4+/-2.1 years (minimum 0 years and maximum seven years), most patients being in NYHA class I. Epicardiac pacemakers were implanted in three patients due to arrhythmias. Two re-operations (6.7%) were needed, both in the same patient, after the Fontan procedure, this patient eventually died a few years after surgery. CONCLUSIONS: The immediate and mid term outcomes of pulmonary ventricle bypass operations can have excellent results. From our point of view there has been an improvement, namely in the use of the extracardiac conduit technique in the 2nd stage of the Fontan operation.

Mitral Valve Surgery for Rheumatic Lesions in Young Patients.

BACKGROUND: The appropriateness of rheumatic mitral valve repair remains controversial due to the risks of recurrent mitral dysfunction and need for reoperation. The aims of this study were to determine the overall short- and long-term outcomes of pediatric rheumatic mitral valve surgery in our center. METHODS: Single-center, observational, retrospective study that analyzed the results of rheumatic mitral valve surgery in young patients, consecutively operated by the same team, between 1999 and 2014. RESULTS: We included 116 patients (mean age = 12.6 ± 3.5 years), of which 66 (57%) were females. A total of 116 primary surgical interventions and 22 reoperations were performed. Primary valve repair was possible in 86 (74%) patients and valve replacement occurred in 30 (26%). Sixty percent of the patients were followed up beyond three months after surgery (median follow-up time = 9.2 months [minimum = 10 days; maximum = 15 years]). Long-term clinical outcomes were favorable, with most patients in New York Heart Association functional class I (89.6%) and in sinus rhythm (85%). Freedom from reoperation for primary valve repair at six months, five years, and ten years was 96.4% ± 0.25%, 72% ± 0.72%, and 44.7% ± 1.34%, respectively. Freedom from reoperation for primary valve replacement at six months, five years, and ten years was 100%, 91.7% ± 0.86%, and 91.7% ± 0.86%, respectively. Mitral stenosis as the primary lesion dictated early reintervention. CONCLUSIONS: Despite the greater rate of reoperation, especially when the primary lesion was mitral stenosis, rheumatic mitral valve repair provides similar clinical outcomes as compared with replacement, with the advantage of avoiding anticoagulation.

Treatment of hepatitis C virus with interferon in hemodialysis patients awaiting kidney transplant.

INTRODUCTION: Hepatitis C virus (HCV) infection is associated with worsening disease progression after renal transplant, and to date there is no available treatment for use at this stage. It has therefore been recommended to treat HCV infection with interferon (IFN) during the dialysis period while the patient is on the waiting list for transplantation. METHODS: We analyzed data from 27 patients on hemodialysis awaiting transplant, who were under IFN treatment for chronic HCV infection (dominant genotype, 1b). The starting regime was IFN alpha-2b, 3 MU x 3/week (n = 20) or pegylated IFN alpha-2a, 135 mg/week (n = 7). If there was clearance of HCV RNA in the first 3 to 6 months, we attempted to prolong IFN treatment for 1 year, although in many patients the dose had to be reduced. A sustained response was defined as viral clearance for at least 12 months after the end of treatment. RESULTS: Viremia was negative in 13 patients (48.1%) at the end of treatment, but two of these patients relapsed, to give an overall long-term response rate of 11 patients (40.7%) and incomplete follow-up in three patients. Viral clearance was not achieved in 11 patients. In three patients (12%), IFN had to be suspended before finishing the third month of therapy due to side effects (mainly pancytopenia and intolerance of a previous kidney graft). Seven patients showing a sustained response underwent transplant, maintaining a negative viremia result. CONCLUSIONS: IFN treatment was effective in a high proportion of dialysis patients with HCV infection, with response rates possibly even higher than for the general population. However, its use is restricted by a high incidence of side effects.

[Ventricular assist in children]. / Assistência ventricular em crianças.

We describe the use of the Berlin Heart biventricular mechanical assistance device, as a bridge to transplant in a two-years old child suffering from end stage dilated cardiomiopathy. Ventricular support lasted for 3,5 months and led to successful transplantation. We describe the clinical case, the protocols used as well as present indications, techniques and problems related to the use of mechanical heart support in children.

Evaluation of different criteria for the separation of pleural transudates from exudates.

OBJECTIVES: To determine the relative usefulness of different criteria for the separation of pleural transudates from exudates. DESIGN: Prospective evaluation of patients referred for thoracentesis. SETTING: Community teaching hospital. PATIENTS: Three hundred fifty-one consecutive patients with pleural effusions referred for thoracentesis. Fifty-four of these patients were excluded from the analysis. MEASUREMENTS: We recorded clinical characteristics and final diagnosis and measured pleural fluid and serum levels of total protein, lactate dehydrogenase, and cholesterol. All patients included were followed up until final diagnosis. MEAN RESULTS: Forty-four (15 percent) pleural effusions were transudates and 253 (85 percent) were exudates. The criteria of Light et al, with a sensitivity of 98 percent and a specificity of 77 percent for exudates, showed the best accuracy (95.2 percent). Moreover, when the cutoff used for the criteria of Light et al was modified according to our own laboratory results, specificity rose to 93 percent with almost a similar accuracy (94 percent). Protein pleural fluid/serum ratio > 0.5 and pleural fluid cholesterol > 60 mg/dl showed equal specificity (91 percent), but the former had better sensitivity for exudates (88 percent vs 81 percent). CONCLUSIONS: When the proportion of exudates included is 85 percent or more, as in the present series, the criteria of Light et al remain the method that offers the highest accuracy for segregating transudates from exudates.

Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics.

OBJECTIVES: To ascertain the frequency and to describe the clinical and biochemical features of cirrhotic chylothorax. DESIGN: A descriptive clinical study. SETTING: A community teaching hospital. PATIENTS AND METHODS: Since November 1989 to October 1995, 809 patients with pleural effusions were studied by thoracentesis. Pleural effusions with a concentration of triglycerides higher than 110 mg/dL, a pleural fluid to serum triglyceride ratio higher than 1, and a pleural fluid to serum cholesterol ratio lower than 1 were considered chylothorax. RESULTS: Twenty-four patients had pleural effusions that complied with all three aforementioned biochemical conditions. Five of these 24 patients (20%), were found to have liver cirrhosis as the main cause of chylothorax and in 3 of them, an abdominal source of the effusion could be demonstrated by intraperitoneal injection of a radioisotope (99mTc-sulfur colloid). The cirrhotic chylous effusions had significantly lower (p<0.005) protein (median, 1.7; range, 1.4 to 2.7 g/dL), lactate dehydrogenase (LDH) (median, 96; range, 77 to 138 IU/L), and cholesterol (median, 25; range, 22 to 64 mg/dL) levels than chylous effusions resulting from other causes (protein: median, 4.1; range, 1.7 to 6.8 g/dL; LDH: median, 351; range, 140 to 8,600 IU/L; and cholesterol: median, 87; range, 38 to 160 mg/dL). Cirrhotic chylothorax was always a transudate according to Light's criteria. CONCLUSIONS: Chylothorax is a rare and apparently underappreciated manifestation of cirrhosis resulting from transdiaphragmatic passage of chylous ascites. Its uniform biochemical characteristics can facilitate its separation from chylous effusions of different etiology, therefore avoiding potentially harmful diagnostic and therapeutic procedures.

[Proteinuria and urinary beta 2-microglobulin as markers of tubular malfunction in the assessment of severity of acute pancreatitis]. / Proteinuria y microglobulina beta 2 urinaria, como marcadores de lesión tubular renal, en la valoración de la gravedad de la pancreatitis aguda.

INTRODUCTION: Proteinuria is a common finding in acute pancreatitis (AP). Increased urinary beta 2-microglobulin can be explained by renal tubular malfunction induced by substances released from the pancreas. The degree of renal tubular malfunction may reflect the severity of AP. AIM: To assess proteinuria and urinary beta 2-microglobulin as prognostic factors in AP. PATIENTS AND METHODS: We retrospectively studied patients with AP with symptom onset within 24 hours before admission. Random urine specimens were obtained on days 1, 2 and 3 after admission. In a subgroup of 25 patients, urine samples could be obtained within 24 hours of symptom onset on day 1. The severity of AP was established using the Atlanta criteria. Proteinuria and beta 2-microglobulin were determined and were adjusted by urinary creatinine concentrations. RESULTS: We studied 51 patients with AP (26 men and 25 women; age: 59.6 (+/-16.7 years). Fifteen cases of AP were severe and 36 were mild. The most frequent etiology was gallstones (60.1%). Levels of proteinuria were (median and interquartile range) in mg/g creatinine: day 1: 180.5 (84.0-250.9), day 2: 164.3 (16.7-421.7), and day 3: 136.7 (24.0-371.29). Differences between severe and mild AP were significant on day 2 of admission: 339.7 (191.7-471.8) versus 120,1 (11.0-382.6); p = 0.04. Levels of urinary beta 2-microglobulin in AP on days 1 to 3 postadmission were: 9.7 (1.1-93.3), 27.6 (4.7-421.4) and 88.3 (7.3-415.2) microg/mg of creatinine, respectively. When urinary beta 2-microglobulin was compared between severe and mild AP, no significant differences were found among days 1, 2 and 3. Selection of only the subgroup of patients whose urine samples were obtained within 24 h of symptom onset, did not improve the results of these urine markers for the group as a whole. CONCLUSIONS: 1) Proteinuria was slightly increased in severe AP and was able to discriminate between mild and severe episodes on day 2 of admission. 2) Urinary beta 2-microglobulin as a tubular malfunction marker did not discriminate between mild and severe AP in patients in our study.

[Fecal elastase-1 determination in the diagnosis of chronic pancreatitis]. / Determinación de la elastasa-1 fecal en el diagnóstico de la pancreatitis crónica.

UNLABELLED: The diagnosis of chronic pancreatitis is based on morphological and functional data. To evaluate exocrine function, the secretin-cholecystokinin test is the gold standard but this is invasive and frequently unavailable. Recently, fecal elastase-1 determination has been investigated as an indirect test of pancreatic function. OBJECTIVE: To evaluate the diagnostic value of fecal elastase-1 in chronic pancreatitis by comparing it with other indirect methods of evaluating pancreatic function such as the urine pancreolauryl test and fecal chymotrypsin determination. To do this, we analyzed the three diagnostic methods in four groups of patients: group I (14 patients with confirmed chronic pancreatitis); group II (5 patients with recurrent episodes of acute alcoholic pancreatitis; group III (9 patients with non-pancreatic diarrhea); group IV (8 patients with other gastrointestinal diseases). RESULTS: Compared with the control groups (groups III and IV), patients in groups I and II presented lower levels of fecal elastase-1 (groups I-II: 88 mcg/g, groups III-IV: 635 mcg/g, p < 0.0001), fecal chymotrypsin (4.3 U/g and 29.3 U/g, respectively, p < 0.0001), and pancreolauryl (14% and 54%, respectively, p < 0,001). In the diagnosis of confirmed chronic pancreatitis (group I) the fecal elastase-1 and pancreolauryl tests showed a sensitivity of 85.6% and 78.5%, respectively. However, in group II, the most sensitive test was the pancreolauryl test (80% versus 60% for the chymotrypsin test and only 40% for the fecal elastase-1 test). In contrast, the fecal elastase-1 test showed the highest specificity (94.1% versus 88.2% for the fecal chymotrypsin test and 81.3% for the pancreolauryl test). CONCLUSION: Fecal elastase-1 determination is an effective indirect method in the diagnosis of patients with advanced chronic pancreatitis. However, when the disease is in the early stages, its sensitivity is no greater than that of other indirect tests. The greatest advantage of this test is its high specificity.

[Chronic elevation of enzymes of pancreatic origin in asymptomatic patients]. / Elevación crónica de las enzimas de origen pancreático en pacientes asintomáticos.

Chronic asymptomatic elevation of pancreatic enzymes is a well known entity although little has been reported. In most cases chronic asymptomatic elevation of amylase is due to a salival isoamylase increase or macroamylasemia. However, we have studied 10 cases with an increase in amylases due to pancreatic isoamylase and an increase in the remaining pancreatic enzymes which remained elevated during the follow up period ranging from 2 to 60 months. The amylase values ranged from 186 to 1,600; the lipase from 176 to 3,989, trypsin from 476 to 2,430 and pancreatic isoamylase from 122 to 1,263. In all patients CT and echography were carried out, which discarded structural damage. Nonetheless, an indirect test of pancreatic function presented unexplained pathologic values in 4 out of 10 patients. In conclusion, we suggest that chronic asymptomatic elevation of pancreatic enzymes is of unknown etiology with no associated structural pancreatic pathology demonstrable by the usual study methods.

Transcatheter occlusion of a residual left superior vena cava causing right-to-left shunt in a Fontan patient with a new occlusion device.

We describe the management of a residual left superior vena cava connected to the coronary sinus and causing right-to-left shunt at atrial level in an 8 year-old-child, with modified Fontan operation (total cava pulmonary connection) by transcatheter closure with a new duct occluder device.

[Abnormal origin of left coronary artery from pulmonary artery]. / Origem anómala da artéria coronária esquerda a partir da artéria pulmonar.

OBJECTIVE: To assess the frequency and severity of the anomalous origin of the left coronary artery (ALCA) from the pulmonary artery (PA). DESIGN OF THE STUDY: Prospective study of case series between March 1991 and December 1994. SETTING: Referral-based Paediatric Cardiology Department of a Tertiary Care Center. PATIENTS AND METHODS: Five consecutive patients (pts) with anomalous origin of the LCA from the PA; there were three infants aged 4 months and two children one 8 year and one 9 year old. There were three girls and two boys. All pts had clinical and 2D-echo and Doppler investigation prior to cardiac catheterization (CC). Indication for CC was based in the association of symptoms and signs of myocarditis or dilated cardiomyopathy of acute or subacute onset and electrocardiographic (ECG) signs of ischemia in infants. In older patients (pts) diagnosis was suspected mainly from ECG. During CC in all pts, aortograms and when necessary selective coronary angiograms were performed. Surgical correction was performed in all children. In two pts stress exercise ECG and stress Thallium studies before and after surgery were performed. RESULTS: two pts had "adult" an three had "infantile" type of ALCA from the PA. CC was performed and diagnosis was confirmed at surgery in all cases. In one child, correct diagnosis was made by ECO prior to CC and in one case LCA to PA fistula was suspected on Colour-Doppler study. No complications were attributed to CC. Several types of surgery were performed: reimplantation of the ALCA from the PA to the aorta (three pts); tunnel connection of the aorta to the ALCA via the PA (one pt) and left internal mammary to LCA anastomosis (one pt). Two infants died intraoperatively due to extensive myocardial infarction and poor left ventricular function. All the three survivors are asymptomatic after a mean follow up of 34 months. Two oldest pts are currently in New York Heart Association functional class I with normal ECG and improved myocardial perfusion on Thallium scan despite almost total occlusion of LCA at the site of implantation in the aorta as diagnosed on coronary angiogram. CONCLUSIONS: ALCA from PA is associated with major morbidity and mortality. Diagnosis should be suspected in pts with unexplained myocardial ischemia on ECG and even more if it is associated to clinical signs of dilated cardiomyopathy or myocarditis. Careful assessment on ECO and pulsed Doppler and colour flow mapping should make the diagnosis in most cases. Although surgery can be performed based only on ECO diagnosis, we strongly advise for angiography in all cases as in our experience there are false negative diagnosis by ECO. Preoperative Thallium studies can be useful for the selection of the type of surgery as pts with very little viable myocardium will not survive the establishment of a direct systemic to coronary blood flow and may be candidates for heart transplantation.

[ 2 cases of tension pneumopericardium after unilateral lung transplantation]. / Dos casos de neumopericardio a tensión tras trasplante pulmonar unilateral.

We present 2 patients who developed tension pneumopericardium after undergoing unilateral lung transplantation, describing their clinical evolution after surgery until the diagnosis of tension pneumopericardium. In both cases aspiration of air from the pericardium resulted in improved hemodynamic status. Tension pneumopericardium is rare in adults. Our patients were at high risk due to the difficulty of ventilating native and implanted lungs with different compliances. Moreover, the passage of air from the mediastinum to the pericardium is facilitated by the large opening made in order to dissect the pulmonary veins.

[Pseudomembranous colitis complicated with toxic megacolon. Report of a case]. / Colitis seudomembranosa complicada con un megacolon tóxico. A propósito de un caso.

We present a patient who developed pseudomembranous colitis a few days after suffering serious multiple traumas and after receiving a variety of antibiotic treatments. The patient, whose condition was further complicated by toxic megacolon, underwent subtotal colectomy and ileostomy. Toxic megacolon is a rare complication of enterocolitis due to C. difficile and is associated with a high rate of mortality. We review the cases published to date, describe the pathogenesis of the condition, and discuss the diagnostic criteria for pseudomembranous colitis, emphasizing treatment and possible complications.

[Fetal arrhythmia. A case load of 4 years and a half]. / Arritmias fetais. Casuística de quatro anos e meio.

In a 4 1/2 year period fetal, echocardiographic studies were performed on 1600 fetuses. In 55 with arrhythmia, 44 had supraventricular ectopic beats, resolved in all, and none had heart disease. Sustained arrhythmias occurred in 11 fetuses. Atrial flutter was present in 3 all with heart disease (Ebstein disease, right atrial tumour and WPW diagnosed after birth). Another 3 fetuses had supraventricular tachycardia (SVT), all with a normal heart. In the bradycardia group, 2 had complete heart block (CHB) associated with AVSD; 2 sinus bradycardia and one had non conducted atrial ectopic beats. Digoxin was the first choice drug for tachyarrhythmia therapy; association with Verapamil, Flecainide, Quinidine and Procainamide was used in 4 of the 6. One fetus with CHB received Orciprenaline with no results. Atrial flutter resolved or improved; in SVT 2 fetuses converted to sinus rhythm and one died in utero. All fetuses with CHB died in cardiac failure. Mortality was 27% (3 cases) in utero and global 36%. In our experience most fetal arrhythmias (90%) were transitory ectopic beats or non lasting bradycardia in normal heart and did not trigger other kinds of arrhythmias. In sustained arrhythmias, heart failure and heart disease had a negative effect on prognosis.