Peritoneal and intestinal tuberculosis: an ancestral disease that poses new challenges in the technological era. Case report and review of the literature

Tuberculosis is a public health problem. The most common presentation is pulmonary disease. The diagnosis of any extrapulmonary forms are quite difficult. Clinical manifestations of gastrointestinal tuberculosis are non-specific and compatible with pathologies such as inflammatory bowel disease, advanced ovarian cancer, deep mycosis, yersinia infection and amebomas. Abdominal form is located at 6th place of the extrapulmonary forms, after lymphatic, genitourinary, osteoarticular, miliary and meningeal infections. Eventually, 25 to 75% of patients with abdominal tuberculosis will require surgery. These procedures should be limitated with the purpose to preserve small bowel. Resection should be limitated for complicated cases. The surgical indications include: Intestinal occlusion (15-60%), perforation (1-15%), abscesses and fistulas (2-30%) and hemorrhage (2%). CONCLUSIONS: In most of the cases, the diagnosis of peritoneal or intestinal tuberculosis is made during a laparoscopy or laparotomy even during surgery performed by different purposes. Excessive manipulation of the intraabdominal organs may produced unexpected bowel lesions, increasing morbidity and mortality. Medical treatment is highly effective in the resolution of moderate complications such as bowel obstruction. Resectional procedures should be reserved for complications like perforation, bleeding or stenosis non-suitable for stricturoplasty.     

Universal approach for full endoscopic decompression and percutaneous transpedicular fixation of the lumbar spine: A medial central approach (ACM)

Cohort study.This study aimed to determine the effectiveness of the universal approach of full endoscopy and percutaneous transpedicular fixation via a medial central approach (ACM) performed to surgically treat patients with lumbar degenerative surgical pathologies.Alternatives to interventionist treatments available to patients with lumbar degenerative surgical pathologies are related to recovery from minimally invasive surgery. Considering this, full endoscopic spinal decompression (full endoscopy) and percutaneous transpedicular fixation via an ACM represent advances in neurosurgical procedures, in particular, spinal surgery. Thus, the introduction of endoscopic and minimally invasive surgeries for the lumbar region has become 1 of the most important advances in modern surgery.A cohort of 79 patients undergoing full endoscopy and percutaneous transpedicular fixation was evaluated 6 times in 1 year. Pain intensity was measured using the visual analog scale (VAS), and lumbar functionality was measured using the Oswestry Disability Index (ODI). Six evaluations were performed: before surgery and on discharge after surgery as well as at 1, 3, 6, and 12 months after surgery.Before the ACM was applied, the VAS pain score was 8.52. At 11 hours post-surgery, the pain score reduced to 2.59 points (a difference of 5.73 points; P = 0.001). Of the 10 ODI domains evaluated, a difference was found between the period prior to surgery and 1 month later (P < 0.01).The universal approach to full endoscopy and lumbar percutaneous transpedicular fixation via an ACM is highly effective for patients with lumbar surgical degenerative pathologies.     

Manifestaciones cardiovasculares en pacientes hospitalizados con dengue

IntroductionCardiac complications in dengue patients are not uncommon and are not diagnosed, since they are usually mild and self-limiting.ObjectivesTo characterize the cardiovascular manifestations in hospitalized patients with dengue infection.MethodsWe conducted an observational, analytical, longitudinal, prospective epidemiological study, which included 427 patients treated at Manuel Fajardo Clinical-Surgical Teaching Hospital with diagnosis of dengue infection since April 2017 to April 2018.ResultsCardiovascular manifestations (19.7%), mainly heart rate disorders (sinus bradycardia [13.8%], atrial [4.9%] and ventricular [4.0%] extrasystoles) were frequent in dengue infection patients. Pericarditis and myocarditis were diagnosed in 1.6% and 0.2% respectively. These disorders were self-limiting in 83.3% of cases and occurred in the first days of the onset of fever in 75.0%. Advanced age (OR = 1.70), male sex (OR = 1.94), decreased platelet count (OR = 1.13) and dengue with warning signs (OR = 3.29) were related to a higher probability of presenting cardiovascular disorders in the course of a dengue infection.ConclusionsCardiovascular manifestations in dengue patients are frequent, and are related to advanced age, male sex, as well as severe forms of the disease.     

Induction and treatment of anergy in murine leprosy

Leprosy is a disease consisting of a spectrum of clinical, bacteriological, histopathological and immunological manifestations. Tuberculoid leprosy is frequently recognized as the benign polar form of the disease, while lepromatous leprosy is regarded as the malignant form. The different forms of leprosy depend on the genetic and immunological characteristics of the patient and on the characteristics of the leprosy bacillus. The malignant manifestations of lepromatous leprosy result from the mycobacterial‐specific anergy that develops in this form of the disease. Using murine leprosy as a model of anergy in this study, we first induced the development of anergy to Mycobacterium lepraemurium (MLM) in mice and then attempted to reverse it by the administration of dialysable leucocyte extracts (DLE) prepared from healthy (HLT), BCG‐inoculated and MLM‐inoculated mice. Mice inoculated with either MLM or BCG developed a robust cell‐mediated immune response (CMI) that was temporary in the MLM‐inoculated group and long‐lasting in the BCG‐inoculated group. DLE were prepared from the spleens of MLM‐ and BCG‐inoculated mice at the peak of CMI. Independent MLM intradermally‐inoculated groups were treated every other day with HLT‐DLE, BCG‐DLE or MLM‐DLE, and the effect was documented for 98 days. DLE administered at a dose of 1.0 U (1 × 10⁶ splenocytes) did not affect the evolution of leprosy, while DLE given at a dose of 0.1 U showed beneficial effects regardless of the DLE source. The dose but not the specificity of DLE was the determining factor for reversing anergy.     

CHYLOUS ASCITES RESULTING FROM KAPOSI'S SARCOMA IN AN AIDS PATIENT

Chylous ascites is an entity not previously reported in association with AIDS. A 43-yr-old maie with previous diagnosis of AIDS developed chylous ascites. Septic complications lead to his death. At autopsy, Kaposi's sarcoma (KS) lesions were present on the skin, in the omentum, mesentery, and small and large howel mucosa. A histological section of the cisterna chyli showed involvement and obstruction by KS. This represents a unique case in which the mechanism leading to the formation of chylous ascites by KS was demonstrated by the autopsy findings in an HIV-positive patient.     

Results after the adoption of a MELD/PELD‐based liver allocation policy in Argentina

In July 2005, Argentina switched from a categorical liver allocation system to a MELD/PELD‐based policy for patients with CLD. To analyze WL outcomes and survival after LT in children. From January 2000 to December 2010, 923 children were registered. Two consecutive five‐yr periods were analyzed and compared: Era I (January 2000–July 2005) (n = 379) and Era II (July 2005–December 31, 2010) (n = 544). All data were prospectively collected and analyzed using the Kaplan–Meier method. After adopting the MELD/PELD system, WL registrations increased by 44% (from 379 to 544) and the number of LT increased by only 24% (from 278 to 365). However, three‐month WL mortality rate (32% to 18%, p < 0.0001, HR 2.002 CI 95% 1.5–2.8) decreased significantly. No significant differences were observed between Era 1 and II in one‐yr post‐LT survival (77.5% vs. 84.1%, p = 0.3053) and in acute re‐LT rate (9% vs. 5%, p = 0.1746). Under the MELD/PELD‐based allocation system in Argentina, mortality on the WL significantly decreased in children with CLD without affecting post‐LT survival, although reduced access to LT was observed.     

Nitric oxide and cyclic GMP levels in sickle cell patients receiving hydroxyurea

Recent studies suggest that nitric oxide (NO) may partly be responsible for the beneficial effect of hydroxyurea (HU) in sickle cell disease (SCD) patients. NO stimulates cyclic guanosine monophosphate (cGMP) production, which mediates vasodilatation. We investigated the association between NO, cGMP and fetal haemoglobin (HbF) levels after HU administration. Our data showed that chronic HU significantly increased NO, cGMP, and HbF levels in SCD. Recently it was shown that HbF production was stimulated by cGMP-dependent protein kinase. Our results suggest that NO stimulates cGMP production, which then activates a protein kinase and increases the production of HbF.     

Efficacy of atorvastatin and gemfibrozil,alone and in low dose combination,in the treatment of diabetic dyslipidemia

To compare the effects of atorvastatin, gemfibrozil, and their combination on the components of diabetic dyslipidemia, 44 type 2 diabetic patients with low density lipoprotein cholesterol (LDLc) levels greater than 100 mg/dl and triglyceride levels less than 400 mg/dl were included. Twelve-week treatments with atorvastatin (10-20 mg/d) and gemfibrozil (900-1200 mg/d) were given in random order in an open, cross-over study and then combined (10 mg atorvastatin and 900 mg gemfibrozil) for 12 additional wk. Triglyceride, LDLc, high density lipoprotein cholesterol (HDLc), non-HDLc, apolipoprotein B (apoB), and LDL size were measured at baseline and after each treatment. Atorvastatin was more effective (P < 0.001) in lowering LDLc, non-HDLc, and apoB and in achieving treatment goals, whereas gemfibrozil lowered triglyceride levels more effectively (P < 0.001) and increased LDL size (from 25.59 +/- 0.06 to 25.69 +/- 0.06 nm; P < 0.05). Combined treatment with both drugs reduced LDLc, triglyceride, non-HDLc, and apoB by 26.5%, 24.1%, 30.4%, and 21.8%, respectively; increased HDLc by 4.8% and LDL size by 0.1 nm; and was the most effective treatment in reaching the therapeutic targets, especially in patients with triglyceride levels higher than 150 mg/dl. In conclusion, statins are first choice drugs in diabetic patients with low to moderate risk LDLc, although their combination with fibrates might be the most appropriate treatment, especially when triglyceride levels are above the therapeutic goal.     

Association of increased phagocytic NADPH oxidase-dependent superoxide production with diminished nitric oxide generation in essential hypertension

OBJECTIVE: Oxidative stress has been implicated in the pathogenesis of hypertension and its complications through alterations in nitric oxide (NO) metabolism. This study was designed to investigate whether a relationship exists between phagocytic nicotinamide adenine dinucleotide phosphate (NADPH) oxidase-dependent superoxide anion (*O2-) production and NO generation in patients with essential hypertension. METHODS: Superoxide production was assayed by chemiluminescence under baseline and stimulated conditions on mononuclear cells obtained from hypertensives (n=51) and normotensives (n=43). NO production was evaluated by determining serum NO metabolites, nitrate plus nitrite (NOx). RESULTS: Although there were no differences in baseline *O2- production between normotensives and hypertensives, the *O2- production in phorbol myristate acetate (PMA)-stimulated mononuclear cells was increased (P <0.05) in hypertensives compared with normotensives. The PMA-induced *O2- production was completely abolished by apocynin, a specific inhibitor of NADPH oxidase. Moreover, stimulation of *O2- production by angiotensin II and endothelin-1 was higher (P <0.05) in cells from hypertensives than in cells from normotensives. In addition, diminished (P <0.001) serum NOx was detected in hypertensives compared with normotensives. Interestingly, an inverse correlation (r=0.493, P <0.01) was found between *O2- production and NOx in hypertensives. CONCLUSIONS: Generation of *O2- mainly dependent on NADPH oxidase is abnormally enhanced in stimulated mononuclear cells from hypertensives. It is suggested that this alteration could be involved in the diminished NO production observed in these patients.