Search

The aim of this study was to evaluate the effect of a recipient's obesity on posttransplant complications and patient and graft survival. A single-institution, retrospective study was performed on obese renal transplant recipients (BMI ≥ 30 kg/m, n = 102) from January 2010 to December 2018, matched with non-obese recipients (BMI < 30 kg/m, n = 204). For comparison, for every obese patient we selected 2 nonobese patients with a similar age, sex, and period of transplantation. The comparative analysis included patient and graft survival as primary outcomes and graft function and postoperative complications as a secondary outcome. Recipient demographics were comparable in both groups except for diabetic nephropathy in obese patients (P = .0006). Obesity was strongly related to a poorer patient survival (risk ratio [RR] = 2.83 confidence interval [CI] 95% 1.14-7.04; P = .020) but there was no observed difference in graft survival (P = .6). While early graft function was inferior in the obese population (RR = 2.41; CI 95% 1.53-3.79; P = .00016), during late follow-up, no statistically significant differences were observed between both groups (P = .36). Obese recipients had a significantly higher risk of delayed graft function (RR = 1.93; CI 95% (1.19-3.1), P = .0077), heart infarction (RR = 7; CI 95% 1.68-29.26; P = .0042), wound infections (RR = 8; CI 95% 1.96-32.87; P = .0015), diabetes aggravation (RR = 3.13; CI 95% 1.29-7.6; P = .011), and surgical revision for eventration (RR = 8; CI 95% 1.22-52.82; P = .026) when compared with nonobese recipients. Despite the inferior early kidney graft function in obese recipients, there was no difference observed at the long-term follow-up. However, recipient obesity demonstrated a negative effect on patient survival and postoperative complications.

Severe acute malnutrition (SAM) contributes to nearly 1 million deaths annually worldwide, with diarrhea and pneumonia being the common morbidity associated with mortality. To assess the effect of probiotics on diarrhea, pneumonia, and nutritional recovery in children with uncomplicated SAM. A randomized, double-blind, placebo-controlled study was conducted involving 400 children with uncomplicated SAM randomly assigned to ready-to-use therapeutic food (RUTF) either with (n = 200) or without (n = 200) probiotics. Patients received 1 mL daily dose of a blend of Lacticasebacillus rhamnosus GG and Limosilactobacillus reuteri DSM 17938 (dosage, 2 billion colony-forming units; 50:50) or placebo during 1 mo. They were simultaneously fed with the RUTF for 6 to 12 wk, depending on patients' recovery rates. The primary outcome was the duration of diarrhea. Secondary outcomes included diarrheal and pneumonic incidence, nutritional recovery, and transfer to inpatient care rate. For children with diarrhea, the number of days of disease was lower in the probiotic group (4.11; 95% CI: 3.37, 4.51) than that in the placebo group (6.68; 95% CI: 6.26, 7.13; P < 0.001). For children aged 16 mo or older, the risk of diarrhea was lower in the probiotic group (75.6%; 95% CI: 66.2, 82.9) than that in the placebo group (95.0%; 95% CI: 88.2, 97.9; P < 0.001), but no significant difference of the risk for the youngest. In the probiotic group, nutritional recovery happened earlier: at the 6th wk, 40.6% of the infants were waiting for nutritional recovery, contrasting with 68.7% of infants in the placebo group; but the nutritional recovery rate at the 12th wk was similar between the groups. Probiotics had no effect on pneumonic incidence and transfer to inpatient care. This trial supports using probiotics for the treatment of children with uncomplicated SAM. Its effect on diarrhea could positively affect nutritional programs in resource-limited settings. This trial was registered https://pactr.samrc.ac.za as PACTR202108842939734.

The kinetics of IgG antibodies after coronavirus disease 2019 (COVID‐19) remain poorly understood. We investigated factors influencing severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) IgG antibody levels and time to seronegativation during the follow‐up of severe and critically ill patients. We retrospectively reviewed serological evaluations drawn during the follow‐up of severe or critical laboratory‐proven COVID‐19 patients hospitalized at a large academic hospital. Specific IgG titers were measured using a chemiluminescent assay targeting anti‐spike and anti‐nucleocapsid protein IgG. The influence of time, demographic factors, clinical and paraclinical characteristics, and COVID‐19 therapeutics on IgG levels were assessed through linear regression using a mixed‐effect model, and delay until IgG negativation through a Weibull regression model. The cohort included 116 patients with a total of 154 IgG measurements drawn at a median of 79 days after diagnosis. IgG antibodies were increased with age (p = 0.005) and decreased significantly over time (p = 0.0002). Using elapsed time and age as covariates, we demonstrated higher IgG levels in patients with a higher body mass index (BMI) (p = 0.0026) and lower IgG levels in immunocompromised patients (p = 0.032). A high BMI was further found to delay and immunodeficiency to hasten significantly seronegativation, whereas no significant effect was observed with corticosteroids. These data highlight the waning over time of IgG antibodies after severe or critical COVID‐19. Age, BMI, and immunosuppression also appear to influence the IgG kinetics, while short‐term corticotherapy does not. Those data improve the understanding of SARS‐CoV‐2 serology while further research should determine the determinants of long‐term seroprotection., Highlights Anti‐SARS‐CoV‐2 IgG antibody levels measured during follow‐up of severe and critical COVID‐19 were studied. We analyzed the influence of time, demographics, clinical and paraclinical characteristics and COVID‐19 treatments on specific IgG levels and time to seronegativation. Time and immunodepression were associated to reduced IgG levels at follow‐up, while age and BMI were associated to increased levels. Corticosteroids given as short‐term treatment for COVID‐19 did not show influence. BMI and immunodepression were respectively associated with decreased and increased rates of seronegativation.

BACKGROUND: The management of surgical site infection (SSI) after craniotomy remains challenging with few existing recommendations. PATIENTS AND METHODS: We reviewed the medical files of patients who underwent surgery between 2009 and 2018 to manage infection after craniotomy at our tertiary hospital. The Cox proportional hazards model and the Renyi test were used to investigate the association between relapse or all-cause mortality and selected variables. We compared infections with and without intra-cranial involvement using the Fisher test and the Wilcoxon rank sum test. RESULTS: Seventy-seven episodes of infection were identified in 58 patients. The proportion of relapse was estimated to be 32.2% (± standard deviation [SD] 6.9) at five years. Intra-cranial infection was present in 15.6% of the cases (n = 12). Bone flap was removed in the majority of cases (93.5%) and the overall median duration of antibiotic therapy was six weeks (interquartile range [IQR] 6-12 weeks). Staphylococcus aureus was associated with a higher risk of relapse (p = 0.037). The administration of parenteral antibiotic agents (p = 0.012) and bone flap removal (p = 0.0051) were correlated with less relapse. In contrast, immunosuppressive drug use and radiotherapy were correlated with a higher risk of relapse (p = 0.014 and p = 0.031, respectively) and a higher all-cause mortality (p = 0.0093 and p < 0.0001, respectively). We found no difference between infections with and without intra-cranial involvement. CONCLUSIONS: Bone flap removal and parenteral antibiotic agents remain important in the management of SSI after craniotomy and were associated with less relapse in our study. More studies are needed to better determine the optimal treatment of this infection.

Background Living donor liver transplantation is a treatment option for unresectable hepatic tumors in children. Methods We enrolled 45 living donor transplantations performed between 1993 and 2018 for liver malignacies, which included hepatoblastoma (n = 33), hepatocellular carcinoma (n = 10), hepatic angiosarcoma (n = 1), and rhabdomyosarcoma (n = 1). Results No mortality or major morbidities were encountered in any donor, and the complication rate was 9%. In the hepatoblastoma group, 5-year overall and event-free survival rate in recipients was 87.4% and 75.8%, respectively, and mortality was significantly higher in patients after rescue transplantation (p = .001). Inferior vena cava replacement in these recipients appeared to be associated with reduced mortality (p = .034), but this was not confirmed when rescue patients were excluded (p = .629). In hepatocellular carcinoma group, both 5-year overall and event-free survival rates were 75.4% each, and invasion of hepatic veins was significantly associated with increased risk of recurrence and death (p = .028). The patient with rhabdomyosarcoma died from EBV-induced lymphoma 2 months after transplantation. The patient with angiosarcoma was in complete remission at the last follow-up. Overall, 5-year graft survival rate was 81.3%, and one patient underwent re-transplantation due to chronic rejection. Conclusions Pediatric oncological liver transplantation has become a key player in the management of malignancies with cancer cure in 84% of patients in this series. Living donor liver transplantation for pediatric recipients with unresectable tumors might be a beneficial surgical option, which is technically safe for donors and recipients, thus, allowing timely planning according to chemotherapy protocols.

BACKGROUND: In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers. METHODS: Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed. RESULTS: Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01). CONCLUSION: In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.

Background: ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has been proposed to compensate for donor shortage. To date, few studies have reported detailed ABOi LDLT results in large series of pediatric patients. C4d complement deposition in graft capillaries has been reported to be associated with antibody-mediated rejection in solid organ transplantation. Methods: A retrospective case–control study was conducted, comparing clinical outcomes of each of 34 consecutive pediatric ABOi LDLT recipients with those of 2 non-ABOi pairs (n = 68), matched according to pre-transplant diagnostic criteria, age, and date of transplantation. In addition, we studied the C4d immunostaining pattern in 22 ABOi and in 36 non-ABOi recipients whose liver biopsy was performed within the first 4 post-transplant weeks for suspected acute rejection. Results: The incidence of biliary complications was higher in ABOi recipients (p &lt, 0.05), as were the incidence of acute humoral rejection (p &lt, 0.01) and the incidence of retransplantation (p &lt, 0.05). All children who required retransplantation were older than 1 year at the time of ABOi LDLT. Positive C4d immunostaining was observed in 13/22 (59%) ABOi recipients versus 3/36 (8.3%) non-ABOi recipients (p &lt, 0.0001). Conclusions: ABOi LDLT is a feasible option for pediatric end-stage liver disease but carries increased risks for the recipient, especially for children older than 1 year, even with a specific preparation protocol. C4d immunostaining may be a hallmark of acute humoral rejection in ABOi liver transplantation.

Cirrhosis in adults is associated with modifications of systemic and liver hemodynamics, whereas little is known about the pediatric population. The aim of this work was to investigate whether alterations of hepatic and systemic hemodynamics were correlated with cirrhosis severity in children. The impact of hemodynamic findings on surgical management in pediatric living donor liver transplantation (LT) was evaluated. Liver and systemic hemodynamics were studied prospectively in 52 children (median age, 1 year; 33 with biliary atresia [BA]). The hemodynamics of native liver were studied preoperatively by Doppler ultrasound and intraoperatively using invasive flowmetry. Portosystemic gradient was invasively measured. Systemic hemodynamics were studied preoperatively by Doppler transthoracic echocardiography and intraoperatively by using transpulmonary thermodilution. Hemodynamic parameters were correlated with Pediatric End-Stage Liver Disease (PELD) score and the histological degree of fibrosis (collagen proportionate area [CPA]). Cirrhosis was associated with a 60% reduction of pretransplant total liver flow (n = 46; median, 36 mL/minute/100 g of liver) compared with noncirrhotic livers (n = 6; median, 86 mL/minute/100 g; P = 0.002). Total blood flow into the native liver was negatively correlated with PELD (P

Background: Mucin-producing hepatic cystic neoplasms (MHCN) are uncommon and potentially malignant. Methods: Nine MHCN were encountered in our centre for over 32 years. Patients’ clinical, biological, radiological and pathological features were reviewed. Lesions were classified into Mucinous Cystic Neoplasms (MCN) and Intraductal Papillary Neoplasms of the Bile duct (IPNB) (WHO 2010 classification). Results: Five MCN and 4 IPNB were reviewed. Serum and intracystic tumour markers were insufficient to diagnose malignancy. Complications were encountered in five out of nine patients (56%), mean symptom duration was 26 months (range: 1–132). Three patients were mismanaged pre-referral. Radiological features enabled preoperative diagnosis in eight out of nine patients (89%). Greater tumour size, unilocular lesion and mural nodularity indicated malignancy. Radical tumour excision was achieved in eight patients. One IPNB patient was misdiagnosed and underwent unroofing. For 103 months median follow-up, five out of six patients with benign tumours were alive and disease-free, whereas the misdiagnosed IPNB recurred with fatal malignant transformation seven years later. Among the three patients with malignancies (median follow-up: 77 months), two IPNB died, one from cancer recurrence and one from unrelated causes, whereas the malignant MCN was alive and disease-free. Conclusions: Appropriate MHCN diagnosis is crucial, yet it is often misdiagnosed and mismanaged. The prognosis after complete excision is favourable

To investigate the effect of using volunteer screeners in active tuberculosis case-finding in South Kivu, the Democratic Republic of the Congo, especially among groups at high risk of tuberculosis infection.To identify and screen high-risk groups in remote communities, we trained volunteer screeners, mainly those who had themselves received treatment for tuberculosis or had a family history of the disease. A non-profit organization was created and screeners received training on the disease and its transmission at 3-day workshops. Screeners recorded the number of people screened, reporting a prolonged cough and who attended a clinic for testing, as well as test results. Data were evaluated every quarter during the 3-year period of the intervention (2014-2016).Acceptability of the intervention was high. Volunteers screened 650 434 individuals in their communities, 73 418 of whom reported a prolonged cough; 50 368 subsequently attended a clinic for tuberculosis testing. Tuberculosis was diagnosed in 1 in 151 people screened, costing 0.29 United States dollars (US$) per person screened and US$ 44 per person diagnosed. Although members of high-risk groups with poorer access to health care represented only 5.1% (33 002/650 434) of those screened, they contributed 19.7% (845/4300) of tuberculosis diagnoses (1 diagnosis per 39 screened). The intervention resulted in an additional 4300 sputum-smear-positive pulmonary tuberculosis diagnoses, 42% (4 300/10 247) of the provincial total for that period.Patient-led active tuberculosis case-finding represents a valuable complement to traditional case-finding, and should be used to assist health systems in the elimination of tuberculosis.Étudier les effets de l'utilisation d'examinateurs volontaires dans le dépistage de la tuberculose active au Sud-Kivu, en République démocratique du Congo, en particulier dans les groupes exposés à un risque élevé d'infection tuberculeuse.Afin d'identifier et d'examiner des groupes à haut risque dans des communautés isolées, nous avons formé des examinateurs volontaires, qui étaient principalement des individus ayant eux-mêmes reçu un traitement contre la tuberculose ou ayant un antécédent familial de la maladie. Une organisation à but non lucratif a été créée et les examinateurs ont reçu une formation sur la maladie et sa transmission dans le cadre d'ateliers de 3 jours. Les examinateurs ont enregistré le nombre de personnes examinées, faisant état d'une toux prolongée et qui se sont rendues dans un centre de consultation pour bénéficier d'un dépistage, ainsi que les résultats des examens. Les données ont été évaluées tous les trimestres pendant les 3 ans qu'a duré l'intervention (2014-2016).L'acceptabilité de l'intervention était élevée. Les volontaires ont examiné 650 434 membres de leurs communautés, parmi lesquels 73 418 ont fait état d'une toux prolongée; 50 368 se sont ensuite rendus dans un centre de consultation pour bénéficier d'un dépistage de la tuberculose. La tuberculose a été diagnostiquée chez 1 personne examinée sur 151, pour un coût de 0,29 dollar des États-Unis (US$) par personne examinée et 44 US$ par personne diagnostiquée. Bien que les membres des groupes à haut risque qui ont un accès plus restreint aux soins de santé ne représentaient que 5,1% (33 002/650 434) des personnes examinées, ils représentaient 19,7% (845/4300) des cas de tuberculose diagnostiqués (1 personne diagnostiquée sur 39 personnes examinées). L'intervention a donné lieu à 4300 autres diagnostics de la tuberculose pulmonaire à frottis positif, soit 42% (4300/10 247) du total de la province pour la période considérée.Le dépistage de la tuberculose active par les patients complète utilement le dépistage traditionnel et devrait être utilisé pour aider les systèmes de santé à éradiquer la tuberculose.Investigar el efecto del uso de examinadores voluntarios para la detección de casos de tuberculosis activa en Kivu del Sur (República Democrática del Congo), sobre todo entre los grupos de alto riesgo de infección por tuberculosis.Para identificar y examinar los grupos de alto riesgo en comunidades remotas, hemos formado a examinadores voluntarios, principalmente aquellos que habían recibido tratamiento para la tuberculosis o tenían antecedentes familiares de la enfermedad. Se creó una organización sin ánimo de lucro y los examinadores recibieron formación sobre la enfermedad y su transmisión en talleres de tres días. Los examinadores registraron el número de personas examinadas que mostraban una tos prolongada y que acudían a una clínica para hacerse la prueba, así como los resultados de la prueba. Los datos se evaluaron cada trimestre durante el periodo de tres años de la intervención (2014-2016).La aceptación de la intervención fue elevada. Los voluntarios examinaron a 650 434 personas en sus comunidades, 73 418 de las cuales presentaron una tos prolongada; posteriormente, 50 368 acudieron a una clínica para someterse a pruebas de tuberculosis. Se diagnosticó tuberculosis a 1 de cada 151 personas examinadas, lo que costó 0,29 USD por persona examinada y 44 USD por persona diagnosticada. Aunque los miembros de los grupos de alto riesgo con peor acceso a la atención de la salud representaban solo el 5,1 % (33 002/650 434) de los examinados, supusieron el 19,7% (845/4300) de los diagnósticos de tuberculosis (1 diagnóstico por cada 39 examinados). La intervención dio como resultado 4300 diagnósticos adicionales de tuberculosis pulmonar con frotis de esputo positivo, el 42% (4300/10 247) del total provincial durante el periodo.La búsqueda de casos de tuberculosis activa dirigida por el paciente representa un complemento valioso a la búsqueda de casos tradicional y debería utilizarse para ayudar a los sistemas sanitarios a eliminar la tuberculosis.دراسة تأثير الاستعانة بأفراد فحص متطوعين في اكتشاف حالات السل النشطة في جنوب كيفو، بجمهورية الكونغو الديمقراطية، وخاصة بين المجموعات المعرضة لخطر مرتفع للإصابة بالسل.بهدف التعرف على المجموعات المعرضة لخطر مرتفع في المجتمعات النائية وفحصها، قمنا بتدريب بأفراد فحص متطوعين، وخاصة أولئك الذين تلقوا العلاج من مرض السل أو لديهم تاريخ عائلي للمرض. تم إنشاء منظمة غير هادفة للربح، وحصل أفراد الفحص على تدريب على المرض وكيفية انتقال العدوى الخاصة به، في حلقات عمل استمرت لمدة ثلاثة أيام. سجل أفراد الفحص عدد الأشخاص الذين تم فحصهم، والذين أفادوا بوجود سعال لفترة ممتدة، وحضروا للعيادة للخضوع للكشف، فضلاً عن نتائج الكشف. تم تقييم البيانات كل ثلاثة أشهر خلال فترة التدخل التي استمرت لمدة 3 سنوات (2014 إلى 2015).كانت مقبولية التدخل عالية. قام المتطوعون بفحص 650434 فرداً في مجتمعاتهم المحلية، وأفاد 73418 منهم بوجود سعال طويل؛ أتى 50368 منهم لاحقا للعيادة لإجراء اختبار للكشف عن مرض السل. تم تشخيص الإصابة بمرض السل في 1 من بين 151 شخصا تم فحصهم، بتكلفة قدرها 0.29 دولار أمريكي لكل شخص تم فحصه، و 44 دولاراً أمريكياً للشخص الذي تم تشخيص إصابته بالمرض. على الرغم من أن أعضاء المجموعات المعرضة لخطر كبير، والذين يعانون من مستوى أقل من الحصول على الرعاية الصحية، لم يمثلوا سوى 5.1٪ (33002/650434) من الأشخاص الذين تم فحصهم، إلا أنهم قد ساهموا بنسبة 19.7٪ (845/4300) من تشخيصات السل (تشخيص واحد لكل 39 فحصاً). أدى التدخل إلى عدد 4300 تشخيصاً إضافياً بمرض السل الرئوي بفحص مسحة اختبار البصاق، بنسبة 42٪ (4300/10247) من إجمالي المقاطعات لتلك الفترة.يمثل اكتشاف حالات السل النشط بين المرضى عنصر تكميلي قيّم للكشف التقليدي عن الحالات، وينبغي الاستعانة به لمساعدة النظم الصحية في القضاء على مرض السل.研究使用疾病筛查志愿者对于在刚果民主共和国南基伍省，尤其是结核病感染高风险群体中，发现开放性结核病的病例的作用。.为识别和筛选偏远地区的高风险群体，我们对疾病筛查志愿者进行培训，主要是那些自己接受过结核病治疗或有此疾病家族史的人。我们创建了一个非营利组织，疾病筛查人员在为期 3 天的研讨会中接受了针对此疾病及其传播的培训。疾病筛查人员记录被筛查人员数，报告持续咳嗽人员、参与临床测试人员和测试结果。在为期 3 年（2014-2016 年）的干预中，每季度评估一次数据。.干预的接受度非常高。志愿者对其社区中 650434 人进行筛查，其中 73418 人报告有长期咳嗽，50368 人相继参与结核病临床测试。在筛查人群中每 151 人中就有 1 人诊断为结核病，筛查每人花费 0.29 美元 (US$)，诊断每人花费 44 美元。尽管享受医疗服务机会较少的高风险群体仅占所有被筛查人员的 5.1% (33002/650434)，他们却占确诊结核病患者（每 39 位筛查者中就有 1 人诊断）的 19.7% (845/4300)。此干预确诊了另外 4300 例痰涂片阳性肺结核，占该期间省总数的 42% (4300/10247)。.患者主导开放性结核病的病例发现是对传统病例发现的宝贵补充，应用来协助医疗卫生体系消除结核病。.Изучить влияние использования добровольцев в качестве специалистов по скрининговому обследованию на степень выявления случаев заболевания активным туберкулезом в провинции Южное Киву, Демократической Республики Конго, особенно среди групп с высоким риском инфицирования туберкулезом.Чтобы выявить и отобрать группы с высоким риском инфицирования в отдаленных сообществах, авторы обучили специалистов-добровольцев проведению скринингового обследования (в основном тех, кто сам ранее получал лечение от туберкулеза или имел семейную историю заболевания). Была создана некоммерческая организация, которая организовала трехдневные семинары, где специалисты по скрининговому обследованию прошли курс, посвященный туберкулезу и способам передачи этой инфекции. Специалисты по скрининговому обследованию регистрировали количество людей, прошедших скрининг, лиц с продолжительным кашлем и тех, кто обратился в клинику для тестирования, а также результаты тестирования. Данные оценивались каждый квартал в течение трехлетнего периода вмешательства (2014–2016 гг.).Приемлемость вмешательства была высокой. Волонтеры отобрали 650 434 человека в своих общинах, у 73 418 из которых был отмечен продолжительный кашель; 50 368 впоследствии обратились в клинику для тестирования на туберкулез. Туберкулез был диагностирован у 1 из 151 человека, прошедшего скрининговое обследование. Расходы на проведение скрининга составили 0,29 долл. США на человека, прошедшего скрининговое обследование, и 44 долл. США на человека, у которого туберкулез был подтвержден диагнозом. Несмотря на то что доля людей, входящих в группы повышенного риска с плохим доступом к медицинскому обслуживанию, составила лишь 5,1% (33 002/650 434) из тех, кто прошел скрининговое обследование, эта же доля людей составила 19,7% (845/4300) случаев подтвержденного диагнозом туберкулеза (1 диагноз на 39 прошедших скрининговое обследование). Это вмешательство привело к дополнительным 4300 диагнозам туберкулеза легких с положительным результатом мазка мокроты, что составило 42% (4300/10 247) от общего количества провинций за этот период.Выявление случаев заболевания активным туберкулезом при активном участии самих пациентов представляет собой ценное дополнение к традиционному методу выявления случаев этого заболевания и должно использоваться для оказания помощи системам здравоохранения в борьбе с туберкулезом.

Introduction In the field of tuberculosis (TB), and particularly in regard to paediatric TB (PedTB), clinical skills of health professionals play an important role in determining quality of care. In an era where novel diagnostic technologies and efficient treatment regimens are being made available for the poorest, we must not divert our attention from the importance of clinical skills, as this deliverable remains the cornerstone of individualized patient care and ultimately the best assurance for optimal use of resources. The aim of our work was to study the epidemiology of PedTB and the determinants of PedTB under-detection in the South-Kivu Province of the Democratic Republic of Congo (DRC), a setting with nearly no technical resources allowing to support the clinical diagnosis of PedTB, i.e. chest X-rays, rapid molecular tests or culture laboratories. Methods We collected TB notification data from 2010 to 2015 and analysed the space-time variations in notification for the different forms of TB among the 113 health facilities (HF) the South-Kivu Province, a region with a low HIV incidence. The different forms of TB notified were: smear positive pulmonary TB (SS+PTB), smear negative pulmonary TB (SS-PTB) and extra-pulmonary TB (EPTB). We further analysed the distribution of these different forms of the disease per age group and explored the possibility to predict the detection of PedTB. Results Significant differences were observed between HF in regard to the proportion of paediatric TB and the proportion of SS-TB among adults. We found a strong correlation between the proportion of PedTB and three major factors: the proportion of TB cases with no bacteriological confirmation (SS-TB) among adults, the number of TB cases notified by the HF and the fact that the HF was supported or not by Medecins Sans Frontieres (MSF). The proportion of SS-TB among adults was found to be a valid indicator for predicting the level of detection of PedTB at the same HF. Conclusion Our observations strongly suggest that under-detection of PedTB is associated with insufficient clinical skills and technical resources at the HF level which similarly affects other forms of the disease, in particular SS-TB. We demonstrated that, in the specific context of South-Kivu, under-detection of PedTB can be predicted by a low SS-TB/SS+PTB ratio in the adult population. In the context of severely under-resourced settings, this ratio could be used to rapidly identify HF that should benefit in priority from deeper evaluation, and eventually targeted interventions.

Venous thromboembolism has been reported in association with cytomegalovirus (CMV) infection both in immunocompromised and immunocompetent patients. In this population, it is yet undetermined whether CMV alone provokes VTE or other predisposing conditions are involved.1007 VTE patients consecutively recruited in one academic hospital were analyzed retrospectively in order to identify acute CMV infection. Acquired and inherited risk factors were screened. Only adults and immunocompetent patients were included.Among 1007 consecutive VTE patients, we identified 10 patients with synchronous acute CMV infection. Patients with coexistent VTE and acute CMV infection were younger (37.5 years vs. 56.6 years; p = 0.0088) and exhibited a female predominance (90% vs. 56%; p = 0.026), in comparison to the whole cohort. Hereditary thrombophilia was identified in 9 out of 10 patients. Acquired risk factors for VTE like estrogens administration and pregnancy were equally prevalent in patients with and without CMV infection.Acute CMV infection is a potential contributor to VTE whenever other prothrombotic conditions are required. This should help clinicians to privilege a limited duration of anticoagulant treatment like in other provoked VTE.

Background. Efforts are needed to improve the long-term efficiency of childhood obesity treatment. To adapt strategies, the identification of subgroups of patients with a greater weight loss may be useful. Objective. To analyze the results of a chronic care program for childhood obesity and to determine baseline factors (medical, dietary, and psychosocial) associated with successful weight loss. Subjects and Method. We set up a family-targeted and individually adapted interdisciplinary long-term care program. We reviewed the medical files of 144 children (59 boys and 85 girls; y; mean BMI-z-score: ) who had ≥2 interdisciplinary visits and ≥1-year treatment. Results. Mean treatment length was 2.2 y (1–6.7 y) with visits/year. The duration of treatment did not depend on the initial weight loss, but this was predictive of the weight change over time. Furthermore any additional weight loss was observed with time whatever the initial weight change. High levels of physical activity and daily water intake from baseline conditions were associated with a greater weight loss after 9 months of intervention. In contrast, a high baseline consumption of soft drinks resulted in lower weight loss. Family specific factors such as being a single child or the child’s family support were identified as baseline factors which may contribute to better results. Conclusion. Our study suggests that the benefit of a chronic weight control program supports the need for its integration into the current concept of treatment. Better prevention policy and parental support may improve the success of the childhood obesity treatment.

Objectives: The Pierre Robin sequence (PRS) is defined by retromicrognathia, glossoptosis, and sleep apnea and can also be associated with cleft palate. Diagnosis, management and mandibular catch-up growth are still controversial issues in PRS patients. The aim of our retrospective study was to evaluate in three dimensions (3D) the airway space and mandibular morphology in PRS compared to a normal control group patients in the pre-orthodontic period of life. The null hypothesis was that we would not find a significant difference between the PRS and control group patients in oropharyngeal airway volume measurements. Material and methods: We analyzed 9 PRS patients (mean age: 8 years-old) who underwent cleft palate surgery in the first four months of life, performed by the same surgeon using the same technique. Cone-beam computed tomography (CBCT) was performed in these patients after local ethical committee approval. The control group consisted of 15 patients (mean age: 9 years-old) with CBCT already performed for other reasons. 3D Slicer was used in both groups for semi-automatic segmentation of the airway space. Two independent observers performed semi-automatic segmentations twice in each patient with a one- week interval between the two series of measurements. Airway volume was automatically measured using 3D Slicer. We also developed a 3D cephalometric analysis with Maxilim software in order to define a 3D mandibular morphology which consisted of 25 landmarks, 4 planes, and 23 distances. Two independent observers performed the 3D cephalometric analysis twice for each patient, with a one- week interval between the two series of measurements. Results: There was no significant difference in the intra- and inter-observer measurements between the PRS and control groups for airway space volume (p

OBJECTIVES: To evaluate a simple treatment algorithm in sternal wound infection (SWI) allowing for primary closure and to describe the different surgical techniques and their associated morbidity and mortality. METHODS: A retrospective analysis of all patients operated on between 1996 and 2004 in a single tertiary care institution. All epidemiological and surgical data were prospectively collected in our database. Univariate and multivariate analysis were used to determine preoperative and perioperative risks factors for 90-day and long-term mortality. RESULTS: Out of 5905 procedures, 146 sternal wound infections were documented (2.4%). The respective incidence of SWI for CABG, isolated valve, or combined procedures were 2.8%, 1.1%, and 3.2%. Pathogens involved were S. epidermidis (44.5%), S. aureus (31.5%), and gram-negative rods (19.2%). Re-operation was required in 131/146 patients. Mean time to the first re-operation was 17.3+/-12 days. Modalities of treatment consisted of drainage alone (44 patients), rewiring (25 patients), debridement, rewiring and mediastinal lavage (52 patients), and partial/complete sternal resection (10 patients). Additional procedures were required in 49 patients (37.7%). The 90-day mortality for uninfected patients and patients with superficial SWI were 4.4% and 2.8% (p=0.78) whereas for patients with deep SWI, 90-day mortality was 14.5% (DSWI vs others, p

Scrub typhus should be considered in any febrile patient presenting with a macular rash, a polyadenopathy, an eschar, or a history of environmental exposure in endemic areas. The differential diagnosis includes malaria, typhoid fever, leptospirosis, and arboviroses. Doxycycline 100 mg twice daily for 7 days should be initiated as soon as the disease is suspected.

Context: Obesity in childhood is associated with an increased mortality due to cardiovascular (CV) diseases in adulthood, independent of adult weight. Recent studies in children indicate that the atherosclerosis process starts at an early age and is linked to obesity. Objective: The aim of the study was to investigate determinants of increased carotid intima-media thickness (IMT), an early marker of atherosclerosis, in obese children. Design: A total of 104 obese children [age, 12.7 ± 0.2 yr; body mass index (BMI)-z-score, 2.8 ± 0.7] underwent an oral glucose tolerance test. Fasting levels of glucose, insulin, C-reactive protein and adhesion molecules (sICAM, sVCAM, sE-selectin), lipid profile, adiponectin, and resistin were determined. IMT was measured by ultrasound. Insulin resistance was estimated by the homeostatic model assessment index. Baseline measurements of blood parameters were obtained from 93 nonobese children (age, 13.0 ± 0.2 yr; BMI-z-score, −0.2 ± 0.9), and IMT was measured in 23 other control children with similar characteristics. Results: Univariate analysis showed a significant positive correlation between IMT and relative BMI, the degree of systolic hypertension, fasting insulin levels, homeostatic model assessment-R index, and resistin concentrations, whereas an inverse correlation with adiponectin levels was found. No correlation was obtained between IMT and classical CV risk factors such as positive familial history of type 2 diabetes or precocious CV disease, visceral obesity, or the lipid profile. C-reactive protein and adhesion molecule levels were not associated with IMT in our obese population. When controlled for sex, Tanner stage, and relative BMI, only adiponectin levels remained an independent determinant of IMT. Conclusion: Adiponectin more than conventional CV risk factors and inflammation status may be related to early atherosclerosis in obese children.

Background: Children with Prader-Willi Syndrome (PWS) have been considered at risk for central adrenal insufficiency (CAI). Hypothalamic dysregulation has been proposed as a common mechanism underlying both stress-induced CAI and central respiratory dysfunction during sleep. Objective: To evaluate CAI and sleep-related breathing disorders in PWS children. Patients and methods: Retrospective study of cortisol response following either insulin tolerance test (ITT) or glucagon test (GT) in 20 PWS children, and comparison with 33 non-Growth Hormone deficient (GHD) controls. Correlation between sleep related breathing disorders and cortisol response in 11 PWS children who received both investigations. Results: In PWS children, the cortisol peak value showed a significant, inverse correlation with age (Kendall's t = -0.411; p = 0.012). A similar though non-significant correlation was present between cortisol increase and age (t = -0.232; p = 0.16). Similar correlations were found in controls. In only 1 of 20 PWS children (5 %), ITT was suggestive of CAI. Four patients had an elevated central apnea index but they all exhibited a normal cortisol response. No relationship was found between peak cortisol or cortisol increase and central apnea index (respectively p = 0.94 and p = 0.14) or the other studied polysomnography (PSG) parameters. Conclusions: CAI assessed by ITT/GT is rare in PWS children. Our data do not support a link between CAI and central respiratory dysregulation.

The presence of the 20210A allele of the prothrombin gene has recently been shown to be a risk factor of venous thromboembolism, probably mediated through increased prothrombin levels. The aim of the study was to determine the frequency of the prothrombin 20210A allele in 193 consecutive unselected patients with venous thromboembolism and 100 healthy controls and to analyze the clinical profile associated with this new inherited thrombophilic factor. In agreement with previous reports, we found a frequency of 7.3% of heterozygous carriers of the 20210A allele among patients and 1% among controls. We confirm that plasma prothrombin levels are more elevated in the individuals bearing the prothrombin 20210A allele compared with those who do not. We did not find any relationship between the presence of the prothrombin 20210A allele and either a family history of thromboembolism, the rate of recurrences or the age at disease onset. However, the co-inheritance in the same individual of both prothrombin 20210A allele and factor V Leiden was associated with a significantly lower age at disease onset suggesting a synergistic contribution of both abnormalities.

OBJECTIVE: To evaluate the sensitivity of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) plasma measurement to detect bacteremia in patients presenting sepsis signs, and to evaluate the potential benefit of such measurement in terms of early antimicrobial therapy initiation. METHODS: Plasma was obtained from 166 hospitalized patients for whom blood cultures were drawn for sepsis. Clinical data and antimicrobial therapies were noted. IL-6, TNF and C-reactive protein (CRP) were measured. The sensitivities of these markers were retrospectively compared with the accuracy of the attending physician in initiating empirical antimicrobial therapy. The setting was an 850-bed university hospital. RESULTS: Thirty-four bacteremias and 69 non-bacteremic infections were noted. In 63 others, no infection was documented. Median (range) IL-6 plasma levels in the three groups of patients were 462 (15--50 850), 189 (15--38 300) and 91 (10--13 750) pg/mL, respectively (p0.01). The corresponding TNF-alpha plasma levels were 37.5 (15--2400), 15 (15--240) and 15 (15--200) pg/mL, respectively (p0.01). CRP plasma levels were 10.7 (0.6--30.2), 10.3 (0.6--34.4) and 7.3 (0.6--20.9) mg/dL, respectively (p=0.12). With respect to these three parameters, IL-6 and TNF-alpha appear better than CRP for predicting bacteremia. Clinical features resulted in starting empirical antimicrobial therapy in only 62% of the bacteremic patients. On the other hand, 68% of these bacteremic patients had high IL-6 plasma levels (200 pg/mL). A combination of clinical features and high IL-6 levels would have permitted early treatment for 82% of the bacteremic patients. CONCLUSIONS: IL-6 and TNF-alpha thus appear to be useful and earlier markers of bacteremia in septic patients. By contrast, CRP is neither sensitive nor specific in this setting.

Laparoscopic surgery is associated with reduced surgical trauma, therefore with acute-phase response of lower magnitude as compared with open surgery. We hypothesized that NOTES might induce reduced immune response as compared with laparoscopy.To compare acute-phase reactants in a controlled trial of laparoscopic peritoneoscopy and ultrasonography versus transgastric or transcolonic NOTES peritoneoscopy and intraperitoneal endoscopic US.Eighteen pigs were divided in 3 groups: laparoscopy, transgastric and transcolonic NOTES. Serum levels of IL-6 and TNF-α were determined preoperatively and at day 2. Serum levels of haptoglobin and IL-6 mRNA levels from isolated white blood cells were measured by RT-PCR at days 0, 1, 2 and 7. Necropsy was performed at sacrifice, with peritoneal fluid microbiological analysis, macroscopic and microscopic examinations on gastrotomy/colotomy or abdominal wall closure sites, liver and parietal peritoneum biopsy sites and any area suggestive of infection.The groups were similar with regards to peritoneoscopy completeness, ultrasonographic examination and biopsies. The duration of NOTES procedures was significantly longer than laparoscopic procedures. Minor complications were observed in most animals by macroscopic and microscopic examination, but NOTES procedures were associated with severe complications in 3 pigs (fistula, abscess, mortality). No significant differences in acute-phase reactants levels were found between groups.No significant difference in the acute-phase reactants could be demonstrated between surgical and NOTES procedures. NOTES was however associated with more severe septic complications. Optimal closure remains a challenge and better devices are needed to avoid them.

International audience; Background:If the prevalence of pulmonary embolism (PE) differs significantly between the US and Europe, this observation could reduce the generalizability of diagnostic protocols for PE derived in either location.Objective:To determine possible causes and potential clinical consequences of these PE prevalence differences.Methods:Secondary analysis of three prospectively collected multicenter samples (two French and one from the US) including 3174 European and 7940 American PE-suspected patients in Emergency departments (ED) (117 for Europe and 12 for US). Comparison of clinical features, resource use and outcomes of European- and US-suspected PE populations in ED.Results:European patients evaluated for PE were significantly older and had a higher clinical pretest probability (CPP) for PE. The final PE prevalence was significantly higher in Europe, in the overall sample (26.5% vs. 7.6%) and in each level of CPP. Suspected European patients categorized as low CPP had a higher posttest probability than US low CPP patients. Suspected US patients categorized as high CPP had a much lower posttest probability of PE than in Europe. The mean number of tests performed for one PE diagnosis was lower in Europe (7.4 vs. 21.6). Among patients diagnosed with PE, European patients had a higher mean severity of illness score and a higher PE-mortality rate (3.4% vs. 0.7%).Conclusions:Among patients suspected of a PE and those ultimately diagnosed with a PE, European patients had higher acuity, a higher pretest probability and worse outcome than US patients. The present study underscores the importance of disease prevalence for pretest probability scoring approaches and for significance interpretation of imaging tests.

Laparoscopic cholecystectomy is considered nowadays as the standard management of acute cholecystitis (AC). However, results from multicentric studies in the general surgical community are still lacking.A prospective multicenter survey of surgical management of AC patients was conducted over a 2-year period in Belgium. Operative features and patients' clinical outcome were recorded. The impact of independent predictive factors on the choice of surgical approach, the risk of conversion, and the occurrence of postoperative complications was studied by multivariate logistic regression analysis.Fifty-three surgeons consecutively and anonymously included 1,089 patients in this prospective study. A primary open approach was chosen in 74 patients (6.8%), whereas a laparoscopic approach was the first option in 1,015 patients (93.2%). Independent predictive factors for a primary open approach were previous history of upper abdominal surgery [odds ratio (OR) 4.13, p0.001], patient age greater than 70 years (OR 2.41, p0.05), surgeon with more than 10 years' experience (OR 2.08, p = 0.005), and gangrenous cholecystitis (OR 1.71, p0.05). In the laparoscopy group, 116 patients (11.4%) required conversion to laparotomy. Overall, 38 patients (3.5%) presented biliary complications and 49 had other local complications (4.5%). Incidence of bile duct injury was 1.2% in the whole series, 2.7% in the open group, and 1.1% in the laparoscopy group. Sixty patients had general complications (5.5%). The overall mortality rate was 0.8%. All patients who died were in poor general condition [American Society of Anesthesiologists (ASA) III or IV].Although laparoscopic cholecystectomy is currently considered as the standard treatment for acute cholecystitis, an open approach is still a valid option in more advanced disease. However, overall mortality and incidence of bile duct injury remain high.

Between 1977 and 1989, 151 patients were treated in our institution for acute sigmoid diverticulitis. Thirty-one patients were operated on for diffuse peritonitis, and were excluded from the study. One hundred twenty patients had localized disease. There were 59 men and 61 women, with a mean age of 60 years (range, 30 to 87 years). Thirteen were under 40 years of age. A "phlegmonous" diverticulitis (no pericolic abscess) was diagnosed in 78 cases (group I). A pericolic abscess was identified in 42 cases (group II). The medical treatment was successful in 97% of the patients of the group I. Only 15 patients required a delayed elective resection for recurrence or chronic complications, within the next 24 months. There were no operative deaths. All the other patients were doing well after a mean follow-up of 5 years (9-144 months), without any disease-related death. Patients presenting with a localized pericolic abscess (group II, n = 42) were initially treated either conservatively (n = 22) or by a more or less extensive drainage (n = 20). There were two deaths in the "conservative" group. Primary or delayed colonic resection was indicated in 34 cases because of uncontrolled sepsis, recurrence or secondary chronic complications. It is concluded that accurate classification of the disease is essential. If no peritonitis has developed, the presence of an abscess is the main determinant in both prognosis and treatment. Most patients who develop an acute phlegmonous diverticulitis do well with conservative treatment, and prophylactic resection is not indicated. Curative colectomy is reserved for patients developing persistent complications over the next few months.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives: Autologous mesenchymal stem cell transplantation has been shown to improve myocardial function in ischaemic cardiomyopathy. We studied one hypothetical mechanism, neo-angiogenesis, using allogeneic mesenchymal stem cell transplantation in an ischaemic swine model. Methods: Allogeneic mesenchymal stem cells were injected in the peri-infarct area (1x10(6)cellskg(-1)) 2 weeks after myocardial infarction. Myocardial infarction alone (n=3) served as a control group. In the myocardial infarction-mesenchymal stem cells group (n=6), tacrolimus was given from day 0 to day 12. Capillary density and inflammatory/rejection processes (anti-factor VIII and anti-CD3/CD68 monoclonal antibodies, respectively) were compared between groups. Results: In scarred myocardium, capillary density was similar between both ischaemic groups: 15.4 (+/-15.3) and 14.7 (+/-15.2) vessel/field in myocardial infarction-mesenchymal stem cells and myocardial infarction-alone groups (non-significant). In viable myocardium adjacent to the infarction, capillary density was significantly increased in the myocardial infarction-mesenchymal stem cells group than in the myocardial infarction-alone group (p=0.002). The number of infiltrating CD3+ cells was equivalent in both myocardial infarction-alone and myocardial infarction-mesenchymal stem cells groups (CD3+: 8.6% vs 9.3%, non-significant). However, CD68+ cell infiltration was more prominent after mesenchymal stem cell transplantation (4.7% vs 2% in myocardial infarction alone, p

the purpose of this study was to report a single academic institution's experience with radiofrequency ablation (RFA) of liver malignanciesSixty-five patients underwent RFA technique through a percutaneous (Group I: 33 patients) or a surgical approach (Group II: 32 patients). The two groups were different according to type of disease selection (more hepatocellular carcinoma in Group I and liver metastases in Group II) and tumour features (smaller size but greater number of lesions in Group II). In Group II, RFA was associated to liver resection in 23 patients (72%).The 2-month postoperative mortality and complication rates were low in both groups. The postoperative hospital stay was longer in Group II. During a median follow-up of 24 months in Group I and 21 months in Group II, the local "in-situ" recurrence rate was 41.4% and 9.1%, respectively. For RFA-treated tumours30 mm in size, the local "in-situ" recurrence rate was 40.5% in Group I and 0% in Group II. Multivariate statistical analysis demonstrated that larger tumour and a percutaneous approach for RFA were independent predictive factors of local "in-situ" liver tumour recurrence.RFA appears to be a safe technique for treating liver malignancies by both approaches. Tumour size and type of RFA approach are predictive factors of in-situ liver tumour recurrence.

Hepatic hydrothorax is a rare but challenging complication of cirrhosis. The Transjugular Intrahepatic Portosystemic Shunt (TIPS) appears as one of the most successful approach of therapy.To assess long-term efficacy and safety, we reviewed 28 patients (Child B/C: 43/57%) who underwent TIPS placement for refractory hepatic hydrothorax in our institution between 1992 and 2001.The 30-days mortality was 14%, reaching 25% at 90 days. The one-year survival without liver transplantation was 41.2%. Reduction in the volume of pleural effusion and improvement in clinical symptoms was observed in 68% while a complete radiological and echographic disappearance of hydrothorax was documented in 57%. Statistical analysis showed that poor liver function was predictive of mortality and non-response. Of the different liver function parameters and in this small series, the Child-Pugh score was more discriminating than the recently described Mayo risk score.This study shows that TIPS is effective in the treatment of hepatic hydrothorax for selected patients. Poor liver function is a strong predictive of bad outcome.

BACKGROUND: Although the internal thoracic artery was proven superior to saphenous vein graft in long-term patency, it is thought to be a more resistive conduit than the vein graft. Moreover, patency studies comparing both left and right internal thoracic arteries have provided results favoring the former. Fractional flow reserve is an established functional index of coronary blood flow. METHODS: To compare the fractional flow reserve between both internal thoracic arteries and saphenous vein grafts, 43 bypass grafts were studied 6 months after revascularization. Intra-graft pressures were measured during cardiac catheterization using a pressure-wire advanced to the first distal anastomosis of 12 left internal thoracic arteries (ITAs), 10 right ITAs and of 21 vein grafts. Pressure gradients between the aorta and the graft were measured at baseline and during a maximal hyperemia. RESULTS: At baseline, pressure gradient was recorded in the left ITA (2.9+/-2.2 mmHg), in the right ITA (1.2+/-1.2 mmHg) and in the vein graft (0.4+/-0.7 mmHg). During maximal hyperemia, pressure gradient increased to 9.6+/-3.2 mmHg in left ITA, to 4.5+/-2.0 mmHg in the right ITA (p

OBJECTIVE: To evaluate timing for surgery and management of complex valve lesions in patients with active mitral valve (MV) endocarditis. Results are based on 13 years of experience with MV repair in active endocarditis. METHOD: Between 1993 and 2005, 81 patients were operated for active MV endocarditis, of which 63 (or 78%) had MV repair. For all patients, the median time between diagnosis and surgery was 10 days. Diverse surgical techniques were applied to restore MV competence. In 59% of the patients, pericardial patches, tricuspid autograft or partial MV homografts were used as leaflet substitutes. In addition, prosthetic rings were employed in 44% of the patients. RESULTS: The overall operative mortality was 17.5%. However, considering only patients in preoperative NYHA class I or II, the operative mortality could be reduced to 4.8%. NYHA class > or =3, elevated age (above 70 years) and history of valvular were the three independent risks factors for early mortality in our multivariate analysis. The average follow-up time was 60+/-37 months. During this period, five late deaths occurred, two of which were cardiac-related. The overall 5- and 10-year survival rate was 73+/-12% and 69+/-13%, respectively. In hospital survivors, freedom from cardiac death after 5 and 10 years was 93+/-8%. Three early and five late MV reoperations occurred in seven patients, of them four could have MV re-repair. Only one endocarditis recurrence occurred after 4 months in a chronic haeamodialysed patient. Freedom from MV reoperation was 89+/-10% and 72+/-24% at 5 and 10 years, respectively. Ten-year freedom from MV replacement and from endocarditis recurrence were 95+/-5% and 98+/-1%, respectively. Annular abscesses and calcified or rheumatic MV disease were two independent risk factors associated with reoperation in our multivariate analysis. During the follow-up period, all patients were in NYHA class I or II; 89% of patients had mitral regurgitation grade < or =I, only 11% had grade II on transthoracic echocardiography. CONCLUSION: Using diverse and advanced techniques of MV repair, a reparability rate of 80% can be reached among patients with active endocarditis. We demonstrate that a high level of safety and excellent durability of MV repair can be obtained even for complex repairs.

Heparin-induced thrombocytopaenia is a dreaded, although infrequent, complication of heparin therapy. We report two cases of heparin-induced thrombocytopaenia (HIT) type II occurring in a patient treated with standard (unfractionated) heparin and in another patient given a low-weight molecular heparin. The clinical course of the first patient illustrates the potentially severe thrombotic complications of HIT. Both cases were treated successfully by danaparoid sodium. Clues to the diagnosis and treatment are briefly discussed.

Antimicrobial therapy for 428 episodes of bacteremia in an 850-bed university hospital was prospectively evaluated for 1 year to measure the impact of two factors--blood culture results and the therapy chosen by infectious diseases specialists (IDSs)--on quality of treatment and outcome. Initial shock, a simplified acute physiology score of >15, and inappropriateness of the empirical treatment were independently associated with increased mortality. Empirical treatment was appropriate in 63% of the episodes. This proportion reached 78% for the episodes treated by IDSs, compared with 54% for the others (P < .001). After availability of blood culture results, the proportion of appropriate treatments increased to 94%, with 97% for IDS-treated patients and 89% for other patients (P = .008). IDSs more frequently shifted to oral antibiotics and used fewer broad-spectrum drugs. This study underlines the impact of blood culture results and of IDSs on the prescription of appropriate treatment for bacteremia and on the better use of antimicrobial drugs.

OBJECTIVES: To assess the prevalence of activated protein C resistance (APC-R) among healthy subjects and thromboembolic patients and to determine the clinical characteristics associated with APC-R. DESIGN: A prospective study. SETTING: One academic medical centre. SUBJECTS: 91 health controls and 126 thromboembolic patients. MEASUREMENTS: Patients and control were genotyped for the factor V Leiden (VaQ506) mutation. The anticoagulant response of the patient's plasma to activated protein C was also determined. RESULTS: The frequency of APC-R was 3.3% among healthy control subjects and 22% among thrombotic patients of whom 18% were heterozygous and 4% were homozygous. The mean age at the first thrombotic event and the severity of thrombotic disease including the proportion of proximal deep vein thrombosis and the frequency of lung embolism were identical among APC-R positive and negative patients. A family history of thromboembolic disease was elicited more frequently in APC-R positive than in APC-R negative patients (57% vs. 22%, P < 0.001). The recurrence rate was higher for APCR-R positive patients (57% vs. 34%, P < 0.05). The percentage of cases with a factor predisposing to thrombosis was very similar in APC-R positive (57%) and negative (68%) patients. CONCLUSIONS: A familial history of thromboembolic disease and recurrences are significantly more frequent among APC-R positive than APC-R negative patients.

Brucella endocarditis, although a rare complication of brucellosis, is the main cause of death related to this disease. This report describes a case of aortic endocarditis due to Brucella abortus in an elderly farmer with known aortic stenosis. Urgent valve replacement was performed because of progressive heart failure despite appropriate antimicrobial treatment. The infection was cured with trimethoprim-sulfamethoxazole and rifampin given for 3 months after surgery. A review of the literature reports on the 38 other cases of cured brucella endocarditis made clear the need for combined antimicrobial treatment and surgical valve replacement.

The aim of this retrospective study was to define a diagnostic strategy and to evaluate the efficacy of cotrimoxazole (CTMX) for presumed cerebral toxoplasmosis in patients with AIDS. Twelve patients with toxoplasma encephalitis were reviewed. The best diagnostical signs of reactivated acute cerebral toxoplasmosis were the association of neurological symptoms indicative of focal cerebral lesions, and a radiological picture showing ring contrast enhanced hypodense mass-lesions; serology was unreliable for the diagnosis. Five patients out of twelve were treated without delay and until death with CTMX. Only these improved their clinical and radiological status obviously. Moreover, their median survival time was clearly longer (160 days, versus 9 days) and their autopsy demonstrated the absence of active necrotizing lesions of toxoplasma encephalitis. So, CTMX seems to be an efficient therapy for suspected cerebral toxoplasmosis in AIDS. Nevertheless, further prospective randomized therapeutic trials are required to confirm this impression.

Indications for surgery were (i) severe congestive heart failure (NYHA class III) in 21 patients (32%) and cardiogenic shock in nine of them (14%), (ii) septic emboli in 22 patients (35%) including 10 cases (16%) of stroke with no intracranial bleeding, 5 cases (8%) of TIAs and3 cases (4.7%) ofcerebral abscesses and(iii) persistent sepsis in11 patients (17%). Preoperative transoesophageal echocardiography revealed vegetations in 51 patients (81%), mitral regurgitation (MR) grade 3 in 40 patients (63.5%) and intracardiac abscesses or fistulas in 17 patients (27%). Forty-two patients (67%) had isolated mitral valve endocarditis, 20 (32%) had both mitral and aortic valve endocarditis and one had mitral and tricuspid valve endocarditis. Immediate postoperative transoesophageal echocardiography indicated no residual MR in 48 patients (76.2%) and MR grade 1 in13 patients (21.6%). Inonly two patients (3.2%), a residual MRof grade2 was acceptedbecause of advanced age. NoMV stenosis was observed at this time.

SummaryWe report a case of endocarditis due to Lactobacillus plantarum, occuring on a mitral valve, as a complication of obstructive cardiomyopathy. The route of entrance is maxillary osteitis of a dental origin.Endocarditis due to Lactobacillus is a rare infection. Its major characteristic is an occasional resistance to treatment with /j-lactamines. In our case infection recurred in spite of chemotherapy with ampicillin (6 weeks) and gentamicin (14 days). A new treatment with penicillin and gentamicin for 6 weeks resulted in cure. We ascribe the initial therapeutic failure to a moderate sensitivity of the strain to /3-lactamines (M.I.C. 1,25 /ig/ml for penicillin G). We have not observed any tolerance to/5-lactamines.Endocarditis due to Lactobacillus should be treated with a combination of a /Mactamine with an aminoglycoside, in the event of the isolated strain being little sensitive to /3-lactamines.

Sixteen patients, with a total of 18 abscesses, were treated by aspiration and systemic antibiotic therapy, to which antiepileptic prophylaxis and corticosteroids were added. Diagnosis of the abscesses and monitoring of their evolution relied principally upon computed tomography; this technique was also used per-operatively when aspirating small abscesses. Bacteriological examinations were positive in all our cases and a polymicrobial flora was found in half of these. One or, eventually, two aspirations within the same week were sufficient, in most cases, to promote healing. Nevertheless, in three patients, the abscesses, however sterilized, did not show any volume reduction, probably because of adhesions to the dura mater, of a large part of the abscess surface area. One patient died from concomitant cardiac disease and one patient remained seriously disabled. Epilepsy was observed as a sequela, in six patients. This study emphasizes the role of neuroradiological and bacteriological examinations, whilst surgery may be restricted, in most cases, to a simple aspiration.

SummaryThe authors report 19 cases of adult onset Still’s disease (AOSD) and compare them with 25 cases of juvenile systemic Still’s disease. They emphasize the diagnostic difficulties in the early stages of the disease, the various systemic complications and the common evolution to chronic erosive joint lesions. In the authors’ experience, AOSD represents about 5 per ccnt of cases admitted for fever of unknown origin.

SummaryIt is useful to distinguish Streptococcus bovis among the group-D streptococci. S. bovis has different culture characters and is highly penicillin-sensitive. The discovery of this agent in blood cultures is strongly suggestive of some particular pathological conditions.In one year, we observed five patients presenting positive blood culture for S. bovis.There were four cases of infective endocarditis. This confirms the great affinity of this bacterium for the endocardium. We successfully treated all four patients with penicillin alone, for five to six weeks.There is a frequent association between S. bovis bacteriaemia and colonic adenocarcinoma. We performed thus a radiographic examination of the colon in four cases. One patient actually had a colonic carcinoma, and two others had benign colonic polyps. It seems probable that benign polyps also predispose to Streptococcus bacteriaemia or endocarditis

Background Prader-Willi syndrome (PWS) is a rare genetic neurodevelopmental disorder with different nutritional phases from suckling deficit with failure to thrive to early onset of obesity. Hyperghrelinemia has been described in PWS long before the development of obesity. Ghrelin is found in both acylated (AG) and unacylated (UAG) forms in the circulation. In contrast to AG, UAG has been shown to inhibit food intake and to be elevated in anorexia nervosa. The present project is aiming to determine the underlying mechanisms driving the different nutritional phases in PWS. Methods Measurement of at least 4 h-fasting plasma acylated and unacylated ghrelin in 37 infants with a genetic diagnosis of PWS aged from 1 month to 4 years and in 100 age-matched controls without endocrine disorder recruited prior to minor surgery. One blood sampling was analysed for each patient/control and clinical data were recorded. Eleven PWS infants underwent repetitive blood samples at 3 or 6-month intervals during routine visits. Results In infants with PWS, AG is not elevated (p = 0.45), UAG is significantly higher (p = 0.0044; confidence interval 1.06;1.33) resulting in a low AG/UAG ratio (p = 0.0056; confidence interval 0.76;0.95) compared to controls. Conclusion Unlike children and adults with PWS that have high AG and AG/UAG ratio, infants with PWS have elevated UAG that supports the concept of anorexia in the early phases of the disease. The change in AG/UAG ratio possibly drives the switch from failure to thrive to obesity. Clinical trial registration NCT02529085. Electronic supplementary material The online version of this article (doi:10.1186/s13023-016-0440-0) contains supplementary material, which is available to authorized users.