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The term "mastocytosis" denotes a heterogeneous group of disorders characterised by abnormal growth and accumulation of mast cells (MC) in one or more organ systems. Symptoms result from MC chemical mediator's release, pathologic infiltration of neoplastic MC in tissues or both. Multiple molecular, genetic and chromosomal defects seem to contribute to an autonomous growth, but somatic c-kit D816V mutation is more frequently encountered, especially in systemic disease. We present a literature review of mastocytosis and a rare case report of an 18 month-old-girl with a bullous dermatosis, respiratory distress and anaphylaxis, as clinical manifestations of mastocytosis. The developments of accepted classification systems and novel useful markers allowed a re-evaluation and updating of the classification of mastocytosis. In paediatric age cutaneous forms of disease prevail and may regress spontaneously. SM is more frequently diagnosed in adults and is a persistent (clonal) disease of bone marrow. The clinical course in these patients is variable. Today diagnostic criteria for each disease variant are reasonably well defined. There are, however, peculiarities, namely in paediatric age, that makes the diagnostic approach difficult. Systemic disease may pose differential diagnostic problems resulting from multiple organ systems involvement. Conversely, the "unexplained" appearance of those symptoms with no skin lesions should raise the suspicion of MC disease. This case is reported in order to stress the clinical severity and difficult diagnostic approach that paediatric mastocytosis may assume.

Pore-forming toxins (PFTs) are commonly associated with bacterial pathogenesis. In eukaryotes, however, PFTs operate in the immune system or are deployed for attacking prey (e.g. venoms). This review focuses upon two families of globular protein PFTs: the cholesterol-dependent cytolysins (CDCs) and the membrane attack complex/perforin superfamily (MACPF). CDCs are produced by Gram-positive bacteria and lyse or permeabilize host cells or intracellular organelles during infection. In eukaryotes, MACPF proteins have both lytic and non-lytic roles and function in immunity, invasion and development. The structure and molecular mechanism of several CDCs are relatively well characterized. Pore formation involves oligomerization and assembly of soluble monomers into a ring-shaped pre-pore which undergoes conformational change to insert into membranes, forming a large amphipathic transmembrane beta-barrel. In contrast, the structure and mechanism of MACPF proteins has remained obscure. Recent crystallographic studies now reveal that although MACPF and CDCs are extremely divergent at the sequence level, they share a common fold. Together with biochemical studies, these structural data suggest that lytic MACPF proteins use a CDC-like mechanism of membrane disruption, and will help understand the roles these proteins play in immunity and development.

The term "mastocytosis" denotes a heterogeneous group of disorders characterised by abnormal growth and accumulation of mast cells (MC) in one or more organ systems. Symptoms result from MC chemical mediator's release, pathologic infiltration of neoplastic MC in tissues or both. Multiple molecular, genetic and chromosomal defects seem to contribute to an autonomous growth, but somatic c-kit D816V mutation is more frequently encountered, especially in systemic disease. We present a literature review of mastocytosis and a rare case report of an 18 month-old-girl with a bullous dermatosis, respiratory distress and anaphylaxis, as clinical manifestations of mastocytosis. The developments of accepted classification systems and novel useful markers allowed a re-evaluation and updating of the classification of mastocytosis. In paediatric age cutaneous forms of disease prevail and may regress spontaneously. SM is more frequently diagnosed in adults and is a persistent (clonal) disease of bone marrow. The clinical course in these patients is variable. Today diagnostic criteria for each disease variant are reasonably well defined. There are, however, peculiarities, namely in paediatric age, that makes the diagnostic approach difficult. Systemic disease may pose differential diagnostic problems resulting from multiple organ systems involvement. Conversely, the "unexplained" appearance of those symptoms with no skin lesions should raise the suspicion of MC disease. This case is reported in order to stress the clinical severity and difficult diagnostic approach that paediatric mastocytosis may assume.

Converting to a certified organic strawberry production system takes time. Growers must monitor the long-term consequences of new production factors and evaluate new cultural techniques.

Rabbit antithymocyte globulin, a "custom-made" pan-anti-T-cell antibody produced in rabbits, is currently being evaluated in the United States and may, within several years, become approved by the Food and Drug Administration. Because we have used this agent for induction of immunosuppression for 10 years in cardiac recipients and because the results appear to be more favorable than those obtained with other agents (horse antithymocyte globulin, antilymphocyte globulin, OKT3), we have reviewed our experience. For the purpose of analysis, all non-bridge-to-transplant cardiac recipients have been divided into three groups on the basis of immunosuppression protocol: group I (March 1979 to January 1983), 28 patients treated with rabbit antithymocyte globulin, steroids, and azathioprine; group II (January 1983 to March 1985), 29 patients treated with rabbit antithymocyte globulin, cyclosporine, and steroids; and group III (March 1985 to January 1989), 98 patients treated with rabbit antithymocyte globulin, cyclosporine, steroids, and azathioprine. Actuarial data showed advantage for group III in survival rate (1 year 94%, 2 years 91%, 3 years 88%), freedom from rejection (30% free at 1 year), freedom from infection (50% free at 1 year), freedom from death from rejection (99% free at 1 year), and freedom from death from infection (97% freedom at 1 year). Actuarial survival rates and freedom from death from rejection and infection are comparable for any of our groups with contemporary published data. In the past 3 years, we have had no death from acute rejection or from posttransplant infection. Time-related rates of infection by etiologic agents have shown a significant reduction in early bacterial, viral, and nocardial infections between groups I and III. With rabbit antithymocyte globulin 200 mg intramuscularly every day for 3 days, our current protocol, T-cells are significantly reduced and local and systemic toxicity is almost unnoticeable. A progressively increasing cyclosporine dose along with rapid tapering steroid and maintenance azathioprine immunosuppressive induction appears to be the therapy of choice in cardiac transplantation.

En este artículo se define agroecología como la aplicación de los conceptos y prinicipios ecológicos al diseño y manejo de los sistemas alimentarios sostenibles. Se presentan los argumentos principales que sostienen la validez, importancia y pertinencia del enfoque agroecológico, no solo para entender los procesos involucrados en la producción de alimentos, sino para proponer alternativas que conduzcan a esos procesos para operar en sistemas sostenibles. El concepto clave, que guía el razonamiento metodológico y epistemológico en este análisis, es el de sostenibilidad. Para alcanzar sostenibilidad la metodología agroecológica no solo se ancla en la Ecología, lo cual se describe en el trabajo, sino que percibe la producción de alimentos como un proceso que involucra a los productores y consumidores interactuando en forma dinámica. In this article agroecology is defined as the application of ecological concepts and principles to the design and management of sustainable food systems. The principal arguments are presented that support the validity, importance, and application of the agroecologial focus, not only in order to understand the processes involved in food production, but also to propose alternatives that help these processes to operate in sustainable systems. The key concept that guides the methodological and epitistemalogical rationale of this analysis is sustainability. In order to achieve sustainability the agroecological methodology not only links to Ecology, as is described in the text, but perceives food production as a process involving producers and consumers operating in a dynamic interaction.

The authors describe the clinical and imagiologic challenges faced at the Emergency Room while observing a 48-year-old woman, submitted to a Nissen fundoplication 16 months earlier. She presented herself with a one-month total progressive dysphagia, epigastric pain and regurgitation. Intraoperative findings demonstrated an intraabdominal fundoplication, closure of diaphragmatic crura and part of the gastric greater curvature and body herniated through a small posterior defect on the diaphragm, with a gigantic serosal cystic mass and associated perforation. Data from posterior clinical investigation shows a traffic accident 34 years ago. Although described before, the association of late traumatic diaphragmatic hernia and gastric intrathoracic perforation is rare (2.5%) and difficult to diagnose. A revision of the literature is performed concerning the pathophysiologic mechanisms of late diaphragmatic rupture, its clinical presentation and diagnosis, as for Nissen fundoplication complications, its prevention and management.

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Os autores descrevem os desafios clínicos e imagiológicos enfrentados no serviço deurgência ao observarem uma mulher de 48 anos, submetida 16 meses antes afundoplicatura de Nissen, com quadro de disfagia progressiva total com um mês deevolução, epigastralgia e regurgitação. Os achados intra-operatórios demonstraram afundoplicatura em posição intra-abdominal, os pilares diafragmáticos encerrados e partedo corpo gástrico, herniado por pequeno defeito posterior do diafragma, com massaquística serosa gigante e perfuração associadas. Dados da investigação clínica posteriorconcluem existência de acidente de viação 34 anos antes. Apesar de já anteriormentedescrita, a associação de hérnia diafragmática traumática tardia e perfuração gástricaintratorácica é rara (

In the last decades growing evidence of a worldwide increase in atopic diseases and sensitisation to common allergenswas provided. Prevalence of asthma is increasing most rapidly among children, especially where urbanisation takes place. Several risk factors that we can observe in developing countries or in inner-city communities of the developed countries contribute to asthma morbidity and mortality. Poverty, climate, exposure to tobacco, viral infection, outdoor air pollution and chemical irritants are included in the most important risk factors (1). The results of Phase 1 of the International Study on Asthma and Allergic Diseases in Childhood (ISAAC) (2) demonstrated that prevalence of childhood asthma from most developing countries is similar to those observed in developed regions. The different realities however demanded for differentiated solutions on how to effectively and efficiently provide comprehensive asthma health care services. Moreover, asthma education and self management must be increased in developed and developing countries with different strategies because in many countries peoplewith commonChronical RespiratoryDiseases (CRD) including asthma have no access to acceptable standing of health care (3).

This paper describes the development of software tools for the automation of data collection, processing, display and storage of information for the Atmospheric Phenomena Laboratory at the University of Puerto Rico-Mayaguez (UPRM). Undergraduate Electrical and Computer Engineering students have had a key role in the development of hardware and software tools for a lightning location system. Students developed software applications using Oracle, Access, Labview and Visual Basic. These applications completed the prototype network of the lightning location system, which consists of three remote stations, linked through the University of Puerto Rico's computer network. These software tools provide lightning detection and location capabilities that will contribute to the development of an isokeraunic map and a custom model to predict lightning occurrences. Students gained a meaningful research experience in which they learned and applied electrical and computer engineering concepts in the solution of complex software problems.

Interfacial strain and substoichiometric silicon oxides are the two principal causes that result in the redshift of the transverse and longitudinal optical phonons of the asymmetric stretch of O in the Si-O-Si bridging bond of thermal ${\mathrm{SiO}}_{2}$ with decreasing oxide thickness. Analyses to comprehend these effects, therefore, require a consideration of both strain and interfacial substoichiometry. A method to isolate the contributions of strain and substoichiometry towards the observed shifts is proposed. The procedure, which utilizes a simple optical model and an effective medium approximation, allows an estimation of the average strain and substiochiometry in films of different thicknesses. Analyses of oxides formed at two different temperatures (550 and 700 \ifmmode^\circ\else\textdegree\fi{}C) with dry and wet oxygen reveal how process conditions affect the interface properties.

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Submitted by Dulce Barreto (mdulce.barreto@chlc.min-saude.pt) on 2013-05-14T14:58:51Z No. of bitstreams: 1 Allergy 2003_58_683.pdf: 1416722 bytes, checksum: 27acd07ed3d20365f7b6935dded4a3e4 (MD5) Made available in DSpace on 2013-05-14T14:58:52Z (GMT). No. of bitstreams: 1 Allergy 2003_58_683.pdf: 1416722 bytes, checksum: 27acd07ed3d20365f7b6935dded4a3e4 (MD5) Previous issue date: 2003

This article presents the analyses of the author on the difficulty that Roman Catholicism has in accepting the concept of human rights, particularly with respect to women. According to Emile Poulat, the rights of man are based on three suppositions underlying the liberal theory of rights, which explains the conflict between Catholicism and liberalism. In addition, the invention of the principle of individuality, in consequence to the transformation in the legal realm, opposes both the Catholic social order and the religious order subsequently developing a conflict of rights. Moreover, Catholicism propagates a traditional conception of women and identifies their essence in maternity, which is incompatible with the affirmation of individual rights for women. Furthermore, this article presents the fundamentalist aspect of Catholicism in Brazil. It presents case examples, which illustrates the two-sided nature of the religion and allows the evaluation of the difficulty confronted by Catholic women in fighting for their rights. It concludes that the Roman Catholic Church in Brazil is one of the most powerful adversaries of the development of women's reproductive health and rights. However, it is characterized by a fundamentalism, which is opposed to the expansion of the scope of autonomy of thought and action for some women.

OBJECTIVO: Pretendeu-se com este estudo determinar a prevalência e identificar factores de risco para sensibilização ao látex em crianças com espinha bífida. MÉTODOS: Estudaram-se 57 crianças com espinha bífida, com uma idade média de 5.6 anos(6 meses a 18 anos) e uma relação sexo M/F de 0.8/1. A todas as crianças foram efectuados questionário, bateria de TC incluindo látex (extractos UCBStallergenes, Lofarma e ALK-Abelló), aeroalergenos comuns e frutos (UCB-Stallergenes) e determinação sérica de IgE total (AlaSTAT). RESULTADOS: A prevalência de sensibilização ao látex foi de 30%; apenas duas crianças sensibilizadas (12%) apresentavam sintomatologia relacionada com a exposição (urticária/angioedema e rinite). Foram identificados como factores de risco para sensibilização ao látex: idade ≥ 5 anos (p=0.008; OR=6.0, IC95%=1.7-22.1); existência de 4 ou mais intervenções cirúrgicas (p

Various devices that can be inserted transvenously to close an ostium secundum atrial septal defect are undergoing clinical trials. Although these are safe and effective in most instances, they may occasionally dislodge or fail to "button" properly, causing migration and embolization. We report two cases in which the occluder and counteroccluder of the Sideris device for transvenous atrial septal defect occlusion (Custom Medical Devices, Amarillo, Tex.) failed to "button" appropriately, migrating in the right atrium in one patient and embolizing to the pulmonary artery in the second patient. An emergency operation was required to retrieve the device and repair the atrial septal defect.

Optic nerves of adult fish and amphibia can successfully regenerate, in part because their glial cells, unlike those of mammals, provide an environment permissive to regrowth. We altered the environment of regenerating dorsal root axons in the frog, Rana pipiens, by grafting segments of optic nerve to test the permissiveness of CNS glial cells to other sensory neurons. We compared these preparations to grafts of segments of sciatic nerve. After allowing various times for survival, light and electron microscopy were used to evaluate the grafts. An agglomeration of astrocytes, tightly joined by desmosomes, initially formed in the center of the optic nerve grafts. Around this grew regenerating dorsal root axons, accompanied by Schwann cells. At early stages, some axons formed dilated terminal structures, which were not seen in peripheral nerve grafts. The appearance of blood vessels within the graft and the dispersion of cells allowed larger numbers of axons to grow through the graft. By eight weeks, 48% of dorsal root sensory axons had grown through optic nerve grafts, compared to 84% for sciatic nerve. These results suggest that astrocytes from optic nerve are not inhibitory to, and provide a suitable substrate for, regrowing sensory neurons.

The purpose of this study was to assess the effects of acute pharmacological interventions on the ischemia-reperfusion damage in a canine model of hypothermic global myocardial ischemia. Three experimental groups each consisting of seven animals were subjected to 2 h of global ischemia followed by 1 h of reperfusion. Group A (control) used Tyers' iso-osmolar potassium cardioplegia solution; group B received allopurinol (40 mg/kg), 95% intravenously (IV) systemically with 5% added to the final infusion of Tyers' solution. In group C, superoxide dismutase (6.5 mg/kg) was used, one third of the total dose in the final delivery of the Tyers' cardioplegia solution and two thirds IV during the initial 5 min of reperfusion. In all three groups, myocardial temperature was maintained between 15 and 19 degrees C. Methods of evaluation included hemodynamic and echocardiographic parameters of ventricular function. Assessment was performed at three time periods: pre-cardiopulmonary bypass (control), 60 min postreperfusion and immediately post-volume loading (at 2 h after cardiopulmonary bypass). No significant deterioration of myocardial function was observed in either of the experimental groups after the use of these preservation techniques. Comparison of regression slopes based on analysis of covariance for myocardial performance, systolic function, and diastolic compliance did not demonstrate any significant differences between the groups. Two hours of global ischemia was not sufficient to cause measurable damage to the myocardium on the basis of which the pharmacological intervention with allopurinol and superoxide dismutase could be evaluated. The controversy surrounding the use of allopurinol and superoxide dismutase is discussed with the findings of this experimental protocol and is brought up for scientific dialogue.

Optical crosstalk seriously limits the photon-counting resolution of silicon photomultipliers. In this work, realistic analytical models to describe the crosstalk effects on the response of these photodetectors are presented and compared with experimental data. The proposed models are based on the hypothesis that each pixel of the array has a finite number of available neighboring pixels to excite via crosstalk. Dead-time effects and geometrical aspects of the propagation of crosstalk between neighbors are taken into account in the models for different neighborhood configurations. Simple expressions to account for crosstalk effects on the pulse-height spectrum as well as to evaluate the excess noise factor due to crosstalk are also given. Dedicated measurements were carried out under both dark-count conditions and pulsed illumination. Moreover, the influence of afterpulsing on the measured pulse-height spectrum was studied, and a measurement of the recovery time of pixels was reported. High-resolution pulse-height spectra were obtained by means of a detailed waveform analysis, and the results have been used to validate our crosstalk models., 21 pages, 13 figures

The uncertainty in the absolute value of the air-fluorescence yield still puts a severe limit on the accuracy in the primary energy of ultra-high-energy cosmic rays. The precise measurement of this parameter in laboratory is in turn conditioned by a careful evaluation of the energy deposited in the experimental collision chamber. In this work we discuss on the calculation of the energy deposition and its accuracy. Results from an upgraded Monte Carlo algorithm that we have developed are compared with those obtained using Geant4, showing excellent agreement. These updated calculations of energy deposition are used to apply some corrections to the available measurements of the absolute fluorescence yield, allowing us to obtain a reliable world average of this important parameter., Comment: 11 pages, 4 figures, International Symposium on Future Directions in UHECR Physics, 13-16 February 2012, CERN, Geneva (Switzerland)

Well-known complications of heart-lung transplantation include mediastinal bleeding and phrenic nerve injury. Conventional technique places the hila behind the phrenic nerves. We have placed the hila in front of the phrenic nerve in our last 10 patients, using direct caval anastomoses when feasible. This minimizes traction on and dissection around the phrenic nerves, and allows anterior rotation of the heart-lung block for easier hemostasis of the posterior mediastinum after implantation.

Intelligent organizations (IO) represent a valuable tool to organize and guide dengue fever surveillance, prevention and control interventions. IO entail state of the art technology in managerial science to generate behavioral frameworks of organizational structures and policies. They present a systematic description of problems and construct computerized models to develop systemic thinking; they produce a shared vision and build progressive mental learning and advancement models. Also, IO promote team building and personal control skills. Scientific-technological advances have produced a wealth of information in medicine, with the corresponding growth of organizations and difficulty of responses because of sudden and incessant change. This new environment calls for the application of IO know-how. This article is oriented to prove the usefulness of the IO technology in the ordering and systematization of the reports about the medical sciences facts. Dengue was chosen to exemplify the use of IO technology as it represents an increasing health problem in America, as well as in Mexico; it is so complex that it can evolve to a more serious problem, besides it can be analyzed within a systemic method.

its capacity to generate a great number of radical sprouts. The spreading of Ailanthus in Cagliari’s district has led to high concentration of its pollen grains in April–June, as detected by the pollen trap. Although Ailanthus was mentioned in two ancient books of allergology (1, 2), has been ignored in the recent literature. The possible sensitization to Ailanthus pollen in patients suffering from allergic symptoms (rhinitis, asthma and conjunctivitis) in this season, which corresponds with the presence of many other pollens (grass, olive, Parietaria, plantain, amaranth) has been investigated. The pollen was collected from Ailanthus female trees in the Cagliari province, extracted overnight at 5% w/v in phosphate-buffered saline (PBS), centrifuged, the surnatant filtered on Millipore membranes and dialysed. The antigen was covalently bound to solid-phase polystyrene balls and tested by standard radioallergosorbent test (RAST) procedure (reagents Sferikit , Lofarma SpA, Milan, Italy) with the sera of 54 randomly selected patients with allergic symptoms in April–June 2001. The same pollen was used to prepare a diagnostic extract for skin-prick testing according to standard procedure. The 54 patients were skin-prick tested with Ailanthus extract and other common commercial extracts (Lofarma SpA, Milan, Italy). Forty-two patients tested RAST-positive to common allergens, 10 tested RAST-positive also to Ailanthus extract, in class 1 or 2. The 10 Ailanthus-positive patients were skin-prick positive to other allergens also: six to Dermatophagoides, eight to grass, seven to Parietaria and six to olive pollen. Specific-IgE by RAST were positive in seven of 10 Ailanthuspositive patients, six in class I and one in class II. These results suggest the possibility that a cross-reaction between Ailanthus and other pollens could explain the constant multisensitization observed in Ailanthus-positive patients. In conclusion, the pollen of Ailanthus needs to be considered as a possible allergenic source, and its extract should be introduced in the diagnostic screening panels in areas where this tree is widespread. *Hospital Azienda Ospedaliera Giuseppe Brotzu Centro di Allergologia e Immunologia Clinica Via Peretti 09134 Cagliari Italy Tel.: +39 070 539383 Fax: +39 070 539803

Retrospective studies have demonstrated an accelerated growth rate of abdominal aortic aneurysms in heart transplant patients. This prospective study was undertaken to define the relationship between cardiac hemodynamics and posttransplant aortic dilation.Sixty-eight patients undergoing heart (n = 60) or heart-lung (n = 8) transplantation were prospectively evaluated with abdominal ultrasonography before transplantation and annually after transplantation. Risk factors implicated in aneurysm growth, including age, indication for transplantation, immunosuppression, posttransplantation hypertension, and abdominal aortic dimension before transplantation were recorded. All patients underwent annual coronary artery catheterization and multiple gated acquisition scanning.Thirty-seven patients (54%) had no change in aortic diameter after transplantation (pretransplantation and posttransplantation diameter = 1.8 +/- 0.3 cm), over a mean follow-up period of 28 +/- 14 months. In the remaining 31 (46%) patients, aortic diameter increased by 0.5 +/- 0.6 cm over 31 +/- 15 months (p0.05). Four (6%) of these 31 patients had abdominal aortic aneurysms (mean aortic diameter = 5.0 +/- 0.8 cm). The mean increase in aortic diameter among these 4 patients was 1.8 +/- 0.2 cm (annual rate of growth = 0.96 +/- 0.3 cm/year). Patients experiencing an increase in aortic dimension after transplantation had significantly lower (p0.005) pretransplantation ejection fractions (17.1% +/- 10.5% vs 28.6% +/- 18.1%) and, as a consequence, significantly greater (p0.05) increases in their ejection fractions after transplantation compared with patients with stable aortic dimensions (42.7% +/- 12.6% vs 31.8% +/- 18.0%).Of 68 heart transplant patients prospectively evaluated, aortic diameter increased in 31 (46%); new aneurysms developed in four of these patients. Greater incremental increases in cardiac ejection fraction were significant correlates with aortic enlargement.

We report a case of bacterial endocarditis in a heart transplant recipient that was diagnosed 6 weeks after operation when a transesophageal echocardiogram revealed vegetations on both sides of the atrial septum. The patient also had postoperative mediastinitis and pericarditis. He underwent two mediastinal explorations, pericardiectomy, and 22 weeks of antibiotics and is free of infection 1 year after transplantation. We presume that the source of infection was contamination of the donor heart by the donor's right lung, which was harvested en bloc with the heart.

Since 1987, five women with end-stage cardiomyopathy and a history of treated breast carcinoma have undergone transplantation at our institution. All patients underwent extensive multidisciplinary pretransplantation evaluation to rule out metastatic disease. Disease-free interval before heart transplantation ranged from 5 to 11 years (mean, 7.6 years). All patients received immunosuppression in accordance with a standard protocol of rabbit antithymocyte globulin, cyclosporine, prednisone, and azathioprine. Mean postoperative follow-up is 49 months. All patients are alive and have no symptoms 18 to 73 months after transplantation. In carefully selected patients with a history of breast carcinoma, heart transplantation can be performed with good functional results and satisfactory late survival.

Various devices that can be inserted transvenously to close an ostium secundum atrial septal defect are undergoing clinical trials. Although these are safe and effective in most instances, they may occasionally dislodge or fail to "button" properly, causing migration and embolization. We report two cases in which the occluder and counteroccluder of the Sideris device for transvenous atrial septal defect occlusion (Custom Medical Devices, Amarillo, Tex.) failed to "button" appropriately, migrating in the right atrium in one patient and embolizing to the pulmonary artery in the second patient. An emergency operation was required to retrieve the device and repair the atrial septal defect.

A standard and important criterion for donor acceptance is to match the donor's body weight to within 20% of the recipient's body weight. However, to meet the increasing demand of patients who need heart transplantation, frequently a heart that is below the standard criteria for donation is accepted. Of the 200 consecutive patients who underwent heart transplantation at the University of Arizona, 27 patients received a heart from a smaller donor with a weight difference of more than 30% (range 30% to 46%). The early mortality and late survival of these 27 patients were not different when compared with those of the patients who received transplants from donors with a weight difference of less than 30%. The probability of freedom from rejection and infection and postoperative ejection fraction were also similar between the two groups. Therefore, we believe that the widely accepted donor-recipient weight-match criterion of 20% can be safely extended.

A case of emphysematous pyelonephritis to E. coli, in a 63-year-old female diabetic patient is presented herein. Imaging techniques (plain abdomen X-Ray, ultra-sonography and computed tomography) allowed the authors to make the diagnosis. Percutaneous nephrostomy, combined with medical therapeutics, contributed to a favourable clinical evolution of the patient.

Eleven episodes of Coccidioides immits infection (cocci) were documented in nine of 199 heart transplant recipients. Cocci was confirmed by fungal cultures and treated with 1 gram of intravenous amphotericin B, after which all patients were put on ketoconazole 200 mg orally twice a day. Two recurrent cocci episodes were noted, both occurring when ketoconazole maintenance therapy was discontinued. When compared with the group of patients without cocci, actuarial survival at 1 and 5 years was identical. We conclude that cocci does not seem to affect the early and late clinical outcome and that prophylactic use of ketoconazole (or other oral antifungal agents) after successful treatment of the initial infection is recommended.

In this report, we describe the successful utilization of an external right ventricular assist device as vascular access for hemodialysis and continuous arteriovenous hemodialysis in a critically ill patient on biventricular mechanical assist support. Utilization of the right ventricular assist device lines provided relatively easy and safe dialysis access and temporarily reduced the risks associated with the conventional vascular access techniques.

By using both aortic annular and supraannular aortic wall tandem suture lines, we have, in our experience, markedly improved hemostasis in aortic root replacement with composite conduits of two types. Using this technique, 4 of 5 patients required 2 units or less of transfused red blood cells. Two patients did not receive transfusions. The technique consists of using interrupted mattress sutures to anchor the lower part of the valve sewing ring to the aortic annulus. The upper part of the sewing ring is then anchored with a running suture line to the cut edge of the supraannular aortic wall.

Cytomegalovirus (CMV) infection of the upper gastrointestinal tract is a major cause of morbidity in heart transplant recipients. Since April 1985, 201 patients underwent heart transplantation at our institution. Immunosuppressive therapy was with a triple drug regimen of cyclosporin A, prednisone, and azathioprine. Fifty-three of these patients had upper gastrointestinal symptoms, which primarily consisted of abdominal pain or nausea and vomiting despite prophylactic treatment with antacids, H 2 blockers, or both. A total of 79 esophagogastroduodenoscopies were performed in this group; 15 patients required more than one esophagogastroduodenoscopy for recurrent symptoms. Of these 53 patients with persistent gastrointestinal symptoms, 16 (30.2%) had diffuse erythema or ulceration of the gastric mucosa (14), esophagus (1), and duodenum (1) with biopsy results that were positive for CMV on viral cultures (incidence, 8%). All patients with positive biopsy results were treated with intravenous ganciclovir at a dose of 10 mg · kg −1 · day −1 in two divided doses for a period of 2 weeks. Recurrence developed in 6 patients (37.5%) and necessitated repeated therapy with ganciclovir. None of the 16 patients died as a result of gastrointestinal CMV infection. Patients who were seronegative for CMV and received a seropositive heart experienced earlier clinical manifestation of CMV infection. Infection of the upper gastrointestinal tract with CMV is a major cause of morbidity in cardiac transplant patients that may progress to a life-threatening complication if left untreated. Early diagnosis with esophagogastroduodenoscopy and biopsy for viral cultures is essential for documentation and proper management.

Two of six domino transplantations performed at our institution required permanent pacemaker implantation as a result of persistent sinoatrial node dysfunction and symptomatic nodal rhythm. Retrospective analysis of several potential etiologic factors showed that the only obvious difference between these two patients and the remaining four domino transplant recipients without this complication was the technique used during harvesting of the cardiac graft. The hearts from the two patients with sinoatrial node dysfunction were harvested using a "right atrial cuff preservation" technique, and the hearts of the remaining four patients were harvested with a standard bicaval division technique. Based on this experience, we think that this right atrial cuff preservation harvesting technique carries a potential risk for sinoatrial node damage, and we do not recommend its use for domino transplantation.

The improved longevity of heart transplant recipients demands heightened awareness of the long-term complications of the procedure. Between 1979 and 1990, 232 patients received 241 heart transplants at our institution. Accelerated coronary atherosclerosis occurred in 45 (19%) of the 232 patients, typically appearing within 2 years of transplantation, whereas peripheral vascular disease (PVD) appeared in 23 (10%) of the 232 patients, usually within 3 years of transplantation. In the patients with PVD, 13 had occlusive disease, nine had aneurysms, and one patient suffered a vertebral artery dissection. Accelerated coronary atherosclerosis afflicted 12 (52%) of the 23 patients affected by PVD (p0.05) and preceded the development of PVD in all 12. Logistic regression analysis revealed risk factors predictive of the development of PVD after transplantation to be a pretransplant history of ischemic cardiomyopathy and posttransplant hypertension and hypertriglyceridemia (p0.05), with the presence of more than one risk factor increasing the probability of development of PVD. Those patients thus identified as at risk should be closely monitored for the development of PVD. Aggressive medical management of hypertension and hyperlipidemia in this subpopulation may forestall or prevent the development of peripheral vascular disease after heart transplantation.

Three hundred thirty-eight endomyocardial biopsies, performed as part of the routine annual evaluation at 1 or more years after transplantation in 211 patients, were reviewed. In only two instances (0.6%) were the histologic findings suggestive, but not pathognomonic, of acute rejection. Both patients were treated for rejection and are doing well at 4 and 6 years postoperatively. On the basis of the results of this study, we believe that routine yearly heart biopsies in asymptomatic patients are not necessary for long-term care of patients after heart transplantation, and we believe they should be performed only if there is clinical suspicion of rejection or as part of a research protocol.

Preservation of the donor heart is an important and controversial subject in heart transplantation. This study compares simple hypothermic storage and hypothermic perfusion in a swine model of heart transplantation (n = 14). The donor hearts of group A (n = 7) were placed in simple hypothermic storage for 5 hours. The donor hearts of group B (n = 7) were placed onto a perfusion apparatus for 5 hours, with pressure maintained at 28 cm of H2O and a myocardial temperature of 8 to 10 degrees C. In both groups the hearts were initially protected with isosmolar potassium cardioplegic solution. The perfusate in group B contained moderate sodium, mannitol, glucose, insulin, and oxygen. The ischemic interval within both groups was 6 hours including orthotopic transplantation. Investigation was conducted at three time periods: prepreservation, postpreservation, and immediately after loading. For both groups there was nonsignificant depression of myocardial function (cardiac index, stroke index, stroke work index, ejection fraction, and wall stress) at the postpreservation period. After volume loading, for the hypothermic perfusion group there was significant improvement of myocardial function (cardiac index, p less than 0.01; stroke index, p less than 0.01) with no significant change in heart rate, systemic vascular resistance, and systolic blood pressure. There was also significant improvement in myocardial performance (p less than 0.05) for the hypothermic perfusion group after volume loading. Ultrastructural changes were minimal for both groups, and there were no major heart transplantation after 6 hours of ischemia; however, hearts retain their contractile capacity better after hypothermic perfusion than after simple hypothermic storage.(ABSTRACT TRUNCATED AT 250 WORDS)