Coexistencia de artritis séptica y microcristalina: un reto diagnóstico. A propósito de 25 casos

ObjectiveSeptic arthritis is a medical emergency and crystal-induced arthritis is a risk factor for its development. If both occur simultaneously, crystal-induced arthritis may mask the diagnosis of infection and delay antibiotic therapy.MethodRetrospective analysis of patients with coexistence of septic and crystal-induced arthritis. We included only patients with isolation of crystals in synovial fluid analysis and positive culture of synovial fluid and/or blood culture.ResultsA total of 25 patients (17 men and 8 women) with a mean age of 67 years. The most commonly affected joint was the knee. In synovial fluid cytological studies, the most frequently identified crystals were monosodium urate. Risk factors included diabetes and chronic renal failure. The most frequently isolated germs were methicillin-sensitive S. aureus (48%), methicillin-resistant S. aureus (12%) and Mycobacterium tuberculosis (12%). In all, 36% of subjects required surgical drainage (excluding those caused by M. tuberculosis). Clinical outcome was favorable in 56%, although intercurrent complications were usual (40%). Mortality was 8%.ConclusionsCoexistence of septic and crystal-induced arthritis represents a diagnostic challenge and requires a high index of suspicion. Gout was the most prevalent crystal-induced arthritis. S. aureus was the most commonly causative pathogen, with a high rate of methicillin-resistant S. aureus infection. If treated early, the outcome is usually favorable, making synovial fluid microbiological study imperative.     

Local excision for ypT2 rectal cancer--much ado about something.

BACKGROUND: The role of local excision for pT2 distal rectal cancer has been challenged because of the observation of high rates of lymph node metastases and local failure. However, neoadjuvant chemoradiation therapy (CRT) has led to increased local disease control and significant tumor downstaging, possibly decreasing rates of lymph node metastases. In this setting, a possible role for local excision of ypT2 has been suggested. METHODS: A total of 401 patients with distal rectal cancer underwent neoadjuvant CRT. Tumor response assessment was performed after at least 8 weeks from CRT completion. One hundred and twelve patients with complete clinical response were not immediately operated on and were excluded from the study, and 289 patients with incomplete clinical response were managed by radical surgery. Patients with final pathological stage ypT2 were analyzed to determine the risk of unfavorable pathological features that could represent unacceptable risk for local failure after local excision. RESULTS: Eighty-eight (30%) patients had ypT2 rectal cancer. Final ypT status was not associated with pretreatment radiological staging (p = 0.62). ypT status was significantly associated with the risk of lymph node metastases, risk of perineural and vascular invasion, and recurrence (p = 0.001). Lymph node metastases were present in 19% of patients with ypT2 rectal cancer. The risk of lymph node metastases in ypT2 was associated with the presence of perineural invasion (47% vs 4%; p = <0.001), vascular invasion (59% vs 6%; p < 0.001), and decreased mean interval CRT surgery (12 vs 18 weeks; p < 0.001), but not with mean tumor size (3.2 vs 3.1 cm; p = 0.8). Disease-free and overall survival rates were significantly better for patients with ypT2N0 (p = 0.02 and 0.006, respectively). Fifty-five (63%) patients with ypT2 had at least one unfavorable pathological feature for local excision (lymph node metastases, vascular or perineural invasion, mucinous type or tumor size >3 cm). CONCLUSION: Lymph node metastases were present in 19% of patients with ypT2 and were significantly associated with poor overall and disease-free survival rates. The risk of lymph node metastases could not be predicted by radiological staging or tumor size. Radical surgery should be considered the standard treatment option for ypT2 rectal cancer after CRT.     

Influence of subacute starvation on cardiac response to isoproterenol in rats.

Several studies have reported that the heart is severely affected by chronic malnutrition. However, the influence of these alterations on cardiac function remains unclear. The aim of this study was to evaluate the effects of subacute starvation on the heart chronotropic response to a beta-adrenergic agonist (isoproterenol). Twelve rats were fed rat chow ad libitum or a 50%-restricted diet for 17 days. The rats were killed, the right atrium was isolated and incubated, and in vitro spontaneous cardiac contractions and frequency were registered. Cumulative doses of isoproterenol were added to the solution until maximal cardiac frequency was achieved. A deficit of 25% in the weight gain was observed in study rats compared with controls (92.6 +/- 10.2 vs. 113.8 +/- 19.2 g, p less than 0.05). Mean daily food intake was 4.8 +/- 0.1 and 9.8 +/- 0.5 g/day for semistarved and control rats, respectively. The in vitro cardiac frequency of the semistarved rats was similar to that of controls (290 +/- 15 and 305 +/- 23 beats/min, respectively, NS). However, when isoproterenol was added to the solution, maximal cardiac frequency of the semistarved rats (435 +/- 51 beats/min) was lower than that of control rats (508 +/- 34 beats/min, p less than 0.005). These findings suggest that subacute starvation may alter the cardiac response to beta-adrenergic agonists.