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Introduction:  Repair of large congenital diaphragmatic hernias (CDHs) is challenging. As primary repair is not always feasible, patches are commonly used. An alternative treatment is split abdominal wall muscle flap repair, which uses vascularized autologous tissue. The aim of this study was to analyze the long-term outcome of large CDH defects undergoing split abdominal wall muscle repair., Materials and Methods:  This is a retrospective review (2003-2016) of large CDH treated by split abdominal wall muscle flap repair., Results:  In a total of 107 CDH patients, the abdominal muscle flap technique was used in 10 (9.3%); 7 had been prenatally treated with tracheal occlusion. Two patients experienced recurrence at 2 months and 6 years, respectively. Only one patient required abdominoplasty due to abdominal wall muscle weakness. Two patients developed progressive scoliosis; one of them required orthopaedic treatment. Minor chest wall deformities were detected in seven, but only one required orthopaedic treatment. The lung-to-head ratio was 0.79 in patients developing musculoskeletal deformities, and 1.5 in those without this complication ( p  < 0.05). Median follow-up was 11.2 years (3.5-14.2), and all patients were alive at the time of writing this article., Conclusion:  The split abdominal wall muscle flap technique is a valid option for repair of large CDH. Associated musculoskeletal deformities seem to be influenced not only by the repair technique used but also by the degree of pulmonary hypoplasia and inherent pathophysiological changes., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Aims: Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a life-threatening entity with a highly heterogeneous genetic background. Cardiac magnetic resonance (CMR) imaging can identify fibrofatty scar by late gadolinium enhancement (LGE). Our aim is to investigate genotype-phenotype correlation in ARVC/D mutation carriers, focusing on CMR-LGE and myocardial fibrosis patterns., Methods and Results: A cohort of 44 genotyped patients, 33 with definite and 11 with borderline ARVC/D diagnosis, was characterized using CMR and divided into groups according to their genetic condition (desmosomal, non-desmosomal mutation, or negative). We collected information on cardiac volumes and function, as well as LGE pattern and extension. In addition, available ventricular myocardium samples from patients with pathogenic gene mutations were histopathologically analysed. Half of the patients were women, with a mean age of 41.6 ± 17.5 years. Next-generation sequencing identified a potential pathogenic mutation in 71.4% of the probands. The phenotype varied according to genetic status, with non-desmosomal male patients showing lower left ventricular (LV) systolic function. LV fibrosis was similar between groups, but distribution in non-desmosomal patients was frequently located at the posterolateral LV wall; a characteristic LV subepicardial circumferential LGE pattern was significantly associated with ARVC/D caused by desmin mutation. Histological analysis showed increased fibrillar connective tissue and intercellular space in all the samples., Conclusion: Desmosomal and non-desmosomal mutation carriers showed different morphofunctional features but similar LV LGE presence. DES mutation carriers can be identified by a specific and extensive LV subepicardial circumferential LGE pattern. Further studies should investigate the specificity of LGE in ARVC/D., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Introduction and Objectives: Hyperkalemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction because it limits the use of effective drugs. We report estimates of the magnitude of this problem in routine clinical practice in Spain, as well as changes in potassium levels during follow-up and associated factors., Methods: This study included patients with acute (n=881) or chronic (n=3587) heart failure recruited in 28 Spanish hospitals of the European heart failure registry of the European Society of Cardiology and followed up for 1 year. Various outcomes were analyzed, including changes in serum potassium levels and their impact on treatment., Results: Hyperkalemia (K + > 5.4 mEq/L) was identified in 4.3% (95%CI, 3.7%-5.0%) and 8.2% (6.5%-10.2%) of patients with chronic and acute heart failure, respectively, and was responsible for 28.9% of all cases of contraindication to mineralocorticoid receptor antagonist use and for 10.8% of all cases of failure to reach the target dose. Serum potassium levels were not recorded in 291 (10.8%) of the 2693 chronic heart failure patients with reduced ejection fraction. During follow-up, potassium levels increased in 179 of 1431 patients (12.5%, 95%CI, 10.8%-14.3%). This increase was directly related to age, diabetes, and history of stroke and was inversely related to history of hyperkalemia., Conclusions: This study highlights the magnitude of the problem of hyperkalemia in patients with heart failure in everyday clinical practice and the need to improve monitoring of this factor in these patients due to its interference with the possibility of receiving optimal treatment., (Copyright © 2019 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: Indocyanine Green (ICG) fluorescence is a new tool for navigated minimal invasive and open surgery, with multiple possible uses, that can increase safety and improve surgical results, facilitating intraoperative decision making. We hereby present our pilot series using ICG navigation in different procedures of pediatric surgery., Material and Methods: As a proof of concept, between May 2017 and March 2019, we have used this technique as a help for decision making in these scenarios: visualization of the biliary tract, vascular and lymphatic structures, neoplastic tissue and other anatomic landmarks. The route of administration, timing and dosage changed depending on the indication. A 30º optic, with a conventional and near-infrared light emitter, connected to a high definition system specially equipped was used., Results: We considered that the technique might be useful in 20 patients (22 procedures): 6 involving the biliary tract (5 cholecystectomies, 1 choledochal stenosis), 9 oncologic procedures (5 laparoscopic and 4 open), 7 miscellanea (pulmonary nodule resections, long-gap esophageal atresia, anastomotic leak, etc). There were no complications regarding ICG administration. We considered that the system provided relevant information or affected intraoperative decision making in 90% of the cases., Conclusions: ICG navigation was easy to perform and complication free. Our preliminary results suggest that ICG navigation, in open and endoscopic procedures, might provide a qualitative leap regarding safety and facilitate the performance of certain pediatric surgical procedures, particularly in oncology, liver surgery and neonatal surgery.

Aim: The optimum surgical approach of neonates with right-sided aortic arch (RAA) and esophageal atresia (EA)/tracheoesophageal fistula (TEF) is still an unsolved question. In order to propose an operative algorithm in the era of endoscopic surgery, we performed an international survey to know the current practice between pediatric endoscopic surgeons. Two of the most important societies in endoscopic pediatric surgery were queried: the International Pediatric Endosurgery Group (IPEG) and the European Society of Paediatric Endoscopic Surgeons (ESPES)., Materials and Methods: During December 2016, an anonymous online-based survey was sent to all IPEG and ESPES members, collecting data regarding perioperative management and surgical repair of EA/TEF with RAA., Results: 144 surgeons from 23 countries completed the questionnaire. 69.2% of respondents were IPEG members, 30.8% were ESPES members. 71.5% of members who answered the survey had more than 10years of surgical experience. A preoperative echocardiography was almost uniformly performed (93.1%). 31.9% of the surveyed surgeons had never treated an EA/TEF with RAA. The remaining 98 surveyed surgeons had managed 279 cases of EA/TEF with RAA. Thoracotomy was considered the preferred approach for 54.2% of the surgeons, and 51.9% chose a right-sided approach. When RAA was an intraoperative finding, 76% would perform a contralateral thoracotomy if difficulties arose. Thoracoscopy was preferred by 45.8% of surgeons. If RAA was suspected preoperatively, 63.1% preferred to attempt a left-sided thoracoscopy and only 24.2% would change their approach to a thoracotomy. If RAA was an intraoperative finding and a safe surgical repair could not be achieved through right-sided thoracoscopy, 51.5% of them chose to perform a left sided thoracoscopy, rather than convert to thoracotomy., Conclusions: Preoperative echocardiography performed by experienced examiners helps in surgical planning. Preoperative diagnosis of RAA should not discourage thoracoscopic repair, which is increasingly becoming more popular for the correction of EA/TEF. In case of an unexpected intraoperative diagnosis of RAA or operative difficulties when approaching through the right side, thoracoscopy offers a less aggressive approach., Level of Evidence: V., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction and Objectives: To analyze the prognostic value of nocturnal hypoxemia measured with portable nocturnal pulse-oximetry in patients hospitalized due to heart failure and its relation to mortality and hospital readmission., Methods: We included 38 patients who were admitted consecutively to our unit with the diagnosis of decompensated heart failure. Pulse-oximetry was considered positive for hypoxemia when more than 10 desaturations per hour were recorded during sleep. Follow-up was performed for 30.3 (standard deviation [SD] 14.2) months, the main objective being a combined endpoint of all-cause mortality and hospital readmission due to heart failure., Results: The average age was 70.7 (SD 10.7) years, 63.3% were males. Pulse-oximetry was considered positive for hypoxemia in 27 (71%) patients. Patients with positive pulse-oximetry had the most frequent endpoint (9.1% [1] vs. 61.5% [16], P = 0.003). After multivariate analysis, continuous nocturnal hypoxemia was related to the combined endpoint (HR = 8.37, 1.19-68.4, P = 0.03)., Discussion: Patients hospitalized for heart failure and nocturnal hypoxemia measured with portable pulse-oximeter have an increased risk of hospital readmission and death., (Copyright © 2017 Elsevier España, S.L.U. All rights reserved.)

Background: Desmin ( DES ) mutations cause severe skeletal and cardiac muscle disease with heterogeneous phenotypes. Recently, DES mutations were described in patients with inherited arrhythmogenic right ventricular cardiomyopathy/dysplasia, although their cellular and molecular pathomechanisms are not precisely known. Our aim is to describe clinically and functionally the novel DES -p.Glu401Asp mutation as a cause of inherited left ventricular arrhythmogenic cardiomyopathy/dysplasia., Methods: We identified the novel DES mutation p.Glu401Asp in a large Spanish family with inherited left ventricular arrhythmogenic cardiomyopathy/dysplasia and a high incidence of adverse cardiac events. A full clinical evaluation was performed on all mutation carriers and noncarriers to establish clinical and genetic cosegregation. In addition, desmin, and intercalar disc-related proteins expression were histologically analyzed in explanted cardiac tissue affected by the DES mutation. Furthermore, mesenchymal stem cells were isolated and cultured from 2 family members with the DES mutation (1 with mild and 1 with severe symptomatology) and a member without the mutation (control) and differentiated ex vivo to cardiomyocytes. Then, important genes related to cardiac differentiation and function were analyzed by real-time quantitative polymerase chain reaction. Finally, the p.Glu401Asp mutated DES gene was transfected into cell lines and analyzed by confocal microscopy., Results: Of the 66 family members screened for the DES -p.Glu401Asp mutation, 23 of them were positive, 6 were obligate carriers, and 2 were likely carriers. One hundred percent of genotype-positive patients presented data consistent with inherited arrhythmogenic cardiomyopathy/dysplasia phenotype with variable disease severity expression, high-incidence of sudden cardiac death, and absence of skeletal myopathy or conduction system disorders. Immunohistochemistry was compatible with inherited arrhythmogenic cardiomyopathy/dysplasia, and the functional study showed an abnormal growth pattern and cellular adhesion, reduced desmin RNA expression, and some other membrane proteins, as well, and desmin aggregates in transfected cells expressing the mutant desmin., Conclusions: The DES -p.Glu401Asp mutation causes predominant inherited left ventricular arrhythmogenic cardiomyopathy/dysplasia with a high incidence of adverse clinical events in the absence of skeletal myopathy or conduction system disorders. The pathogenic mechanism probably corresponds to an alteration in desmin dimer and oligomer assembly and its connection with membrane proteins within the intercalated disc., (© 2017 American Heart Association, Inc.)

Introduction and Objectives: Nonischemic sudden cardiac death (SCD) is predominantly caused by cardiomyopathies and channelopathies. There are many diagnostic tests, including some complex techniques. Our aim was to analyze the diagnostic yield of a systematic diagnostic protocol in a specialized unit., Methods: The study included 56 families with at least 1 index case of SCD (resuscitated or not). Survivors were studied with electrocardiogram, advanced cardiac imaging, exercise testing, familial study, genetic testing and, in some cases, pharmacological testing. Families with deceased probands were studied using the postmortem findings, familial evaluation, and molecular autopsy with next-generation sequencing (NGS)., Results: A positive diagnosis was obtained in 80.4% of the cases, with no differences between survivors and nonsurvivors (P=.53). Cardiac channelopathies were more prevalent among survivors than nonsurvivors (66.6% vs 40%, P=.03). Among the 30 deceased probands, the definitive diagnosis was given by autopsy in 7. A diagnosis of cardiomyopathy tended to be associated with a higher event rate in the family. Genetic testing with NGS was performed in 42 index cases, with a positive result in 28 (66.6%), with no differences between survivors and nonsurvivors (P=.21)., Conclusions: There is a strong likelihood of reaching a diagnosis in SCD after a rigorous protocol, with a more prevalent diagnosis of channelopathy among survivors and a worse familial prognosis in cardiomyopathies. Genetic testing with NGS is useful and its value is increasing with respect to the Sanger method., (Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Aim: To analyze the current risk of an anesthetic event during surgical acts in pediatric patients with anterior mediastinal masses (AMM) in a tertiary oncology center, using the previously published risk factors to plan the procedure., Materials and Methods: Retrospective study (2009-2015) of pediatric patients with AMM who underwent surgical procedures at debut. Published risk factors (symptoms, radiological findings), with special focus on the statistically significant ones, diagnosis, surgical and anesthetic procedure, special measures, and anesthetic events were recorded. Patients were classified as high or low-risk when airway or vascular compression or severe symptoms were present., Main Results: Retrospective study (2009-2015) of pediatric patients with AMM who underwent surgical procedures at debut. Published risk factors (symptoms, radiological findings), with special focus on the statistically significant ones, diagnosis, surgical and anesthetic procedure, special measures, and anesthetic events were recorded. Patients were classified as high or low-risk when airway or vascular compression or severe symptoms were present., Conclusions: Preoperative evaluation of risk in AMM through clinical history and CT/MRI and surgical/anesthetic planning leads to excellent outcomes. The least aggressive procedures should be favored, but if needed, planned general anesthesia under experienced hands is safe even in risk patients.

Aim: Nissen fundoplication (NF) is a procedure with technical difficulties and variable functional prognosis the lower the patient's age is. Our objective is to analyze the peculiarities of this procedure when performed in children under 1 year., Materials and Methods: Retrospective study of the NF in our center from 1999 to 2014. We review the differences between children under 1 year of age and the leftover of the series: history, indications, surgical approach and postoperative outcomes., Results: A total of 233 patients (57.1% male) were operated at a median age of 2.3years (1 month-17.31years), of which 82 (35.2%) were younger than 1 year. It Open surgery was performed in 118 patients (86.6% of children under 1 year and 31.1% over 1 year, p <0.05) and laparoscopic in 115. The median follow-up was 3.92 ± 3.24 years. Patients under 1 year had a higher number of comorbidities (91.5% vs 81.5%), respiratory symptoms (76.8% vs 49.7%) and postoperative complications (20.7% vs 9.9% OR = 2.4), with statistically significant differences (p <0.05). There were not differences in the Nissen's failure rate (15.9% vs 8.6%) or the need of reoperation (15.9% vs 7.9%)., Conclusions: Patients under 1 year operated by NF form a group with particular indications and comorbidities. Although the outcomes among these patients are favourable, surgical complications are more frequent than in older children.

ADP-glucose pyrophosphorylase (AGPase) catalyzes the rate-limiting step of bacterial glycogen and plant starch biosynthesis, the most common carbon storage polysaccharides in nature. A major challenge is to understand how AGPase activity is regulated by metabolites in the energetic flux within the cell. Here we report crystal structures of the homotetrameric AGPase from Escherichia coli in complex with its physiological positive and negative allosteric regulators, fructose-1,6-bisphosphate (FBP) and AMP, and sucrose in the active site. FBP and AMP bind to partially overlapping sites located in a deep cleft between glycosyltransferase A-like and left-handed β helix domains of neighboring protomers, accounting for the fact that sensitivity to inhibition by AMP is modulated by the concentration of the activator FBP. We propose a model in which the energy reporters regulate EcAGPase catalytic activity by intra-protomer interactions and inter-protomer crosstalk, with a sensory motif and two regulatory loops playing a prominent role., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: Paediatric LTI is associated with significant morbid-mortality. Although historically first line treatment was surgical, conservative management is making headway. The purpose of this study was to analyze the management and surgical indications of LTI treated at our institution., Material and Methods: Retrospective study of patients with LTI treated between 2007 and 2014., Results: Six out of seven patients, with a median age of 4 years (2-15), had blunt traumas and one had an open trauma. Respiratory distress, pain and subcutaneous emphysema were presented in 71.4% of the patients. Five children were intubated (3 pre-hospital care and 2 after reaching the hospital), all of them underwent fibrobronchoscopy, determining the location, the extention, and assessing the possibility of extubation. Esophagoscopy was made in 2 cases. The remaining 2 cases were bounded to observation as they did not have respiratory symptoms or progressive emphysema, precluding bronchoscopy. Conservative management was followed in 71.4% of the patients, with a 100% success rate. Conservative management criteria were no progression of emphysema or respiratory distress, regardless the degree and location of the lesions. Two patients needed surgery: one tracheoesophageal fistula caused by a button battery, and the other was a tracheal open section associated with vascular injury. Both of them recovered uneventfully., Conclusions: If the respiratory symptoms or the emphysema do not progress, patients with LTI can be managed conservatively, regardless of size or location of the injury. Associated esophageal lesions and open injuries require surgical management. An early diagnosis is mandatory in order to minimize morbidity and mortality.

Introduction: Recurrence of spontaneous pneumothorax (SP) is more frequent in pediatric patients. The purpose of our study was to identify factors associated with this recurrence., Material and Methods: Retrospective review of the chart of patients with SP treated at our institution between 2004 and 2014. Statistic methods (χ2 and logistic regression) were used analyzing age, gender, side and size of pneumothorax and therapeutic approach as possible predictive factors of SP recurrence., Results: A total of 81 SP cases in 43 patients (29 men, 14 women) were reviewed: 50 primary (PSP) and 31 secondary (SSP). Median age at presentation was 15,1 years (0.5-18.59). Follow up was 3.52 years (0.21-18.59). Twenty-three cases (28.4%) underwent surgery (22 thoracoscopies, 1 thoracotomy), consisting of bleb resection with abrasive and chemical pleurodesis. Ipsilateral recurrence after surgery was 21.7% (22.2% in PSP, 20% in SSP, p = 0.096) and 41.4% after non-surgical treatment. Age was a risk factor for recurrence (p= 0.049; OR = 1.16), especially between 10 and 15 years (44.6% in front of 19%, p = 0.013). Male gender and size >20% were associated with higher recurrence risk in SSP that received non-surgical treatment (p<0.05)., Conclusions: Recurrences of SP in children are frequent even after surgical treatment. Age (preadolescence and early adolescence), male gender and initial size of pneumothorax may be factors associated with higher recurrence risk.

Background/aim: Neither cervicotomy nor postero-lateral thoracotomy allow safe surgical access to the lower cervical spine and high posterior mediastinum with full control of the vascular and neural structures involved. We report our favorable experience with cervico-sternotomy for accessing this region., Patients and Methods: Six patients were operated upon between 1998 and 2011 for either removal of huge cervico-thoracic neural ganglioneuromas (n = 2) or anterior arthrodesis for congenital (n = 2), neuropathic (n = 1) or osteolytic scoliosis (n = 1). In all cases, cervicotomy was followed by sternotomy, thymectomy, division of the innominate vein and dissection of jugular veins, carotid arteries and vagus nerves., Results: The tumors measured 10.9 x 3.9 x 8.7 cm and 8 x 6 x 5 cm, and involved the paravertebral chain from the aortic arch to the base of the skull and from the left lung hilus to the thyroid region respectively. In the scoliosis patients, anterior vertebral fixation between C5 and T5 was readily feasible. Blood transfusion was avoided. Horner's syndrome and transient lymphedema were the only complications. Median operative time was 210 minutes (range 180-240 minutes) and median estimated blood loss was 2.7 cc/kg (0-13.8 cc/kg). Median hospital stay was 7 days (range 5-18 days)., Conclusions: Cervico-sternotomy is an optimal approach for this anatomical region in children. It offers better exposure of the anterior cervico-thoracic spine and the thoracic inlet than cervicotomy or thoracotomy. Control of the nervous and vascular structures was safely achieved in all cases and postoperative discomfort was surprisingly limited.

Primary malignant tumors of the heart are a rare condition. The most common type is the cardiac angiosarcoma. The symptoms of this disease are very nonspecific and can be very difficult to diagnose by conventional imaging techniques. We report the case of a male patient with cardiac angiosarcoma who also had a rare complication, this being cardiac rupture, which required the use of (18)F-FDG PET-CT to demonstrate the mass malignancy and to reach a definitive diagnosis., (Copyright © 2013 Elsevier España, S.L. and SEMNIM. All rights reserved.)

Background: Advanced heart failure (HF) is associated with high morbidity and mortality; it represents a major burden for the health system. Episodes of acute decompensation requiring frequent and prolonged hospitalizations account for most HF-related expenditure. Inotropic drugs are frequently used during hospitalization, but rarely in out-patients. The LAICA clinical trial aims to evaluate the effectiveness and safety of monthly levosimendan infusion in patients with advanced HF to reduce the incidence of hospital admissions for acute HF decompensation., Methods: The LAICA study is a multicenter, prospective, randomized, double-blind, placebo-controlled, parallel group trial. It aims to recruit 213 out-patients, randomized to receive either a 24-h infusion of levosimendan at 0.1 μg/kg/min dose, without a loading dose, every 30 days, or placebo., Results: The main objective is to assess the incidence of admission for acute HF worsening during 12 months. Secondarily, the trial will assess the effect of intermittent levosimendan on other variables, including the time in days from randomization to first admission for acute HF worsening, mortality and serious adverse events., Conclusions: The LAICA trial results could allow confirmation of the usefulness of intermittent levosimendan infusion in reducing the rate of hospitalization for HF worsening in advanced HF outpatients.

Phosphatidyl-myo-inositol mannosyltransferase A (PimA) is an essential glycosyltransferase (GT) that initiates the biosynthetic pathway of phosphatidyl-myo-inositol mannosides, lipomannan, and lipoarabinomannan, which are key glycolipids/lipoglycans of the mycobacterial cell envelope. PimA belongs to a large family of peripheral membrane-associated GTs for which the understanding of the molecular mechanism and conformational changes that govern substrate/membrane recognition and catalysis remains a major challenge. Here we used single molecule force spectroscopy techniques to study the mechanical and conformational properties of PimA. In our studies, we engineered a polyprotein containing PimA flanked by four copies of the well characterized I27 protein, which provides an unambiguous mechanical fingerprint. We found that PimA exhibits weak mechanical stability albeit displaying β-sheet topology expected to unfold at much higher forces. Notably, PimA unfolds following heterogeneous multiple step mechanical unfolding pathways at low force akin to molten globule states. Interestingly, the ab initio low resolution envelopes obtained from small angle x-ray scattering of the unliganded PimA and the PimA·GDP complexed forms clearly demonstrate that not only the "open" and "closed" conformations of the GT-B enzyme are largely present in solution, but in addition, PimA experiences remarkable flexibility that undoubtedly corresponds to the N-terminal "Rossmann fold" domain, which has been proved to participate in protein-membrane interactions. Based on these results and on our previous experimental data, we propose a model wherein the conformational transitions are important for the mannosyltransferase to interact with the donor and acceptor substrates/membrane.

Purpose: Our objective is to describe a new experimental model of amniotic band in rats and to show the initial morphological results., Methods: The model was created by ligation of a hind limb with silk on day 17 of gestation; in selected fetuses ligation was withdrawn on day 19 of gestation. Fetuses were removed by cesarean section on day 21 of gestation, analyzing their weights and morphological characteristics of their hind legs. We used 10 pregnant SD rats, weighing 263 g (231-279). One hundred and thirteen fetuses were analyzed divided into 6 groups: fetuses from control rats (n=28), uterine opening and closing (n=7), band creation (n=28), band creation and subsequent removal (n=14) and not intervened fetuses of the litters in which the band was created (n=19) and that the band was created and removed (n=17). Comparisons between groups were made using parametric tests considering p<0.05 as a threshold for significance., Results: Operated fetuses (band creation and band creation and removal) showed statistically significant differences in weight (mean=4.56 g and 4.4 g) and length of their hind limbs (mean=3.97 mm and 5.34 mm) compared to the rest of the groups. The rate of abortions in operated fetuses was 16.6% and the rate of amputations was 8.3%., Discussion: A viable and reproducible experimental model of amniotic band is described, with potential applications in both the study of the disease and the role of fetal surgery thereon.

Considerable progress has been made in recent years in our understanding of the structural basis of glycosyl transfer. Yet the nature and relevance of the conformational changes associated with substrate recognition and catalysis remain poorly understood. We have focused on the glucosyl-3-phosphoglycerate synthase (GpgS), a "retaining" enzyme, that initiates the biosynthetic pathway of methylglucose lipopolysaccharides in mycobacteria. Evidence is provided that GpgS displays an unusually broad metal ion specificity for a GT-A enzyme, with Mg(2+), Mn(2+), Ca(2+), Co(2+), and Fe(2+) assisting catalysis. In the crystal structure of the apo-form of GpgS, we have observed that a flexible loop adopts a double conformation L(A) and L(I) in the active site of both monomers of the protein dimer. Notably, the L(A) loop geometry corresponds to an active conformation and is conserved in two other relevant states of the enzyme, namely the GpgS·metal·nucleotide sugar donor and the GpgS·metal·nucleotide·acceptor-bound complexes, indicating that GpgS is intrinsically in a catalytically active conformation. The crystal structure of GpgS in the presence of Mn(2+)·UDP·phosphoglyceric acid revealed an alternate conformation for the nucleotide sugar β-phosphate, which likely occurs upon sugar transfer. Structural, biochemical, and biophysical data point to a crucial role of the β-phosphate in donor and acceptor substrate binding and catalysis. Altogether, our experimental data suggest a model wherein the catalytic site is essentially preformed, with a few conformational changes of lateral chain residues as the protein proceeds along the catalytic cycle. This model of action may be applicable to a broad range of GT-A glycosyltransferases.

HER3 (ERBB3) is a catalytically inactive pseudokinase of the HER receptor tyrosine kinase family, frequently overexpressed in prostate and other cancers. Aberrant expression and mutations of 2 other members of the family, EGFR and HER2, are key carcinogenic events in several types of tumors, and both are well- validated therapeutic targets. In this study, we show that HER3 is required to maintain the motile and invasive phenotypes of prostate (DU-145) and breast (MCF-7) cancer cells in response to the HER3 ligand neuregulin-1 (NRG-1), epidermal growth factor (EGF) and fetal bovine serum. Although MCF-7 breast cancer cells appeared to require HER3 as part of an autocrine response induced by EGF and FBS, the response of DU-145 prostate cancer cells to these stimuli, while requiring HER3, did not appear to involve autocrine stimulation of the receptor. DU-145 cells required the expression of HER3 for efficient clonogenicity in vitro in standard growth medium and for tumorigenicity in immunodeficient mice. These observations suggest that prostate cancer cells derived from tumors that overexpress HER3 are dependent on its expression for the maintenance of major attributes of neoplastic aggressiveness, with or without cognate ligand stimulation.

Introduction: The prognosis in patients with acute coronary syndrome without persistent ST segment elevation (NSTEACS) differs depending on cardiac troponin levels. Clinical practice guidelines published by the Spanish Society of Cardiology and the ACC/AHA consider patients with NSTEACS and markedly elevated troponin levels as high risk patients. The aim of this study was to identify factors related to markedly elevated troponin I levels in NSTEACS., Patients and Method: We measured troponin I levels in 219 consecutive patients with NSTEACS and normal CK-MB values, and identified 2 groups: patients with markedly elevated troponin levels (more than 10-fold the normal upper limit), and patients with normal or slightly elevated troponin levels (less than a 10-fold increase above the normal limit). We also analyzed clinical and angiographic variables. Logistic regression was used to calculate age- and sex-adjusted associations for the main variables., Results: Forty-one patients (19%) had markedly elevated troponin levels, and 178 (81%) showed normal or slightly elevated troponin I levels. Patients with markedly elevated levels had more frequently prolonged angina, class IIb angina, more severe ECG changes, a higher number of diseased vessels on coronary angiography, and greater severity of the culprit lesion. The culprit stenosis in these patients was more often characterized as ulcerated, showing visible thrombus, and excentric, bifurcated and irregular. Class IIIb angina (odds ratio [OR] = 3.1; CI 95%, 1.1-8.6), bifurcation (OR=6.04; CI 95%, 2.5-14.3), ulceration (OR=3.2; CI 95%, 1.07-9.7) and visible thrombus (OR=2.7; CI 95%, 1.1-6.3) in the culprit lesion were predictive factors associated with markedly elevated levels of troponin I independently of age or sex., Conclusions: Markedly elevated troponin I levels in patients with NSTEACS are associated with a more severe clinical presentation and increased complexity of the culprit lesion on coronary angiography.