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Objective: To describe the clinical outcomes of patients undergoing serial observation for vestibular schwannoma (VS) and identify factors that may predict tumor growth or hearing loss., Study Design: Retrospective review., Methods: A retrospective review was conducted of patients seen at a tertiary care medical center between 2002 and 2013 with an International Classification of Diseases-9 diagnosis code of 225.1. Patients electing observation as initial management, with at least two documented imaging results, were included. Exclusion criteria comprised bilateral VS, diagnosis of neurofibromatosis type 2, and neoplasms other than VS. Decline in serviceable hearing, tumor growth, and changes in management strategy were recorded. Survival analysis to assess median time to outcomes and multiple logistic regression analyses were performed., Results: A total of 94 patients met inclusion criteria. While undergoing observation, 22.3% of patients underwent a change in management strategy to microsurgical excision or stereotactic radiotherapy. For patients with initial serviceable hearing, 24.3% observed a decline to a nonserviceable level. No significant clinical factors were identified to predict changes in hearing. Survival analysis revealed that an estimated 69.1% of patients electing observation as initial management continued to do so at 5 years. Imbalance or disequilibrium at presentation was found to be associated with an increased adjusted odds ratio (OR) (OR 2.96; 95% confidence interval, 1.03-8.50; P = 0.04) for tumor growth., Conclusion: Serial observation of VS is a viable treatment strategy for selected patients, with two-thirds of patients electing to continue this management option after 5 years. Disequilibrium as a presenting symptom may be associated with subsequent tumor growth., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Several disorders might require vaginal reconstruction, such as congenital abnormalities, injury, or cancer. Reconstructive techniques for which non-vaginal tissue is used can be associated with complications. We assessed the use of engineered vaginal organs in four patients with vaginal aplasia caused by Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS)., Methods: We invited to participate four consecutive patients who presented over a 3-year period with congenital vaginal aplasia due to MRKHS. Patients were aged 13-18 years. We obtained a vulvar biopsy of autologous tissue from every patient. We cultured, expanded, and seeded epithelial and muscle cells onto biodegradable scaffolds. The organs were constructed and allowed to mature in an incubator in a facility approved for human-tissue manufacturing. We used a perineal approach to surgically implant these organs. We recorded history, physical examination, vaginoscopy, serial tissue biopsies, MRIs, and self-administered Female Sexual Function Index questionnaire results for all patients, with a follow-up of up to 8 years., Findings: We noted no long-term postoperative surgical complications. Yearly serial biopsies showed a tri-layered structure, consisting of an epithelial cell-lined lumen surrounded by matrix and muscle, with expected components of vaginal tissue present. Immunohistochemical analysis confirmed the presence of phenotypically normal smooth muscle and epithelia. The MRIs, which showed the extent of the vaginal aplasia before surgery, showed the engineered organs and the absence of abnormalities after surgery, which was confirmed with yearly vaginoscopy. A validated self-administered Female Sexual Function Index questionnaire showed variables in the normal range in all areas tested, such as desire, arousal, lubrication, orgasm, satisfaction, and painless intercourse., Interpretation: Vaginal organs, engineered from the patient's own cells and implanted, showed normal structural and functional variables with a follow-up of up to 8 years. These technologies could be useful in patients requiring vaginal reconstruction., Funding: Wake Forest University and Hospital Infantil de México Federico Gómez., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: The objective of this study was to review the collective experience and utility of FDG-PET scans (FDG-PET) in the detection of systemic metastases in patients with stage III melanoma., Methods: A systematic search for relevant studies published between 1990 and 2012 was performed. We included English language studies that evaluated melanoma patients with stage III disease, with at least 10 patients per study, and collected statistical data to assess FDG-PET utility in the detection of distant metastases. The SIGN tool was used to evaluate methodological quality and a meta-analysis was performed using Stata statistical software to quantify the clinical utility of FDG-PET., Results: The systematic search yielded 9 studies eligible for inclusion in quantitative analyses with a total of 623 patients. The overall sensitivity of FDG-PET in detecting systemic metastases was 89.42% (95% CI: 65.07-97.46), and specificity was 88.78% (95% CI: 77.04-94.91). The pooled positive likelihood ratio was 7.97 (95% CI: 3.58-17.71) and the negative likelihood ratio was 0.12 (95% CI: 0.03-0.47). The area under the summary receiver operating curve (SROC) was 0.94 (95% CI: 0.92-0.96) and the diagnostic odds ratio (DOR) was 66.84 (95% CI: 10.66-418.89). A change in stage and/or management was noted in 22% (126/573) of patients when FDG-PET was utilized., Conclusions: Our findings indicate that FDG-PET may be useful in detecting distant metastases in patients with stage III melanoma. For this highly selected group of patients, FDG-PET has a high sensitivity, specificity and performance, frequently leading to a change in treatment plan., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objectives: To evaluate the effects of the early administration of statins during acute myocardial infarction (MI)., Design: A retrospective cohort study was carried out., Setting: National (Spain)., Patients or Participants: Patients included in the ARIAM registry from January 1999 to December 2008 with a diagnosis of MI., Interventions: None., Main Variables: We used logistic regression analysis and propensity scoring to determine whether the administration of statins during the first 24h of MI acts as a protective factor against: 1) mortality, 2) the incidence of lethal arrhythmias, or 3) cardiogenic shock., Results: A total of 36 842 patients were included in the study. Statins were administered early in 50.2% of the patients. Statin administration was associated with younger patients with known previous dyslipidemia, obesity, a history of ischemic heart disease, heart failure, presence of sinus tachycardia, use of beta-blockers, angiotensin-converting enzyme inhibitors, thrombolysis and percutaneous coronary intervention. Mortality was 8.2% (13.2% without statin versus 3% with statin, P<.001). Multivariate analysis demonstrated that statin administration acted as a protective factor against mortality (adjusted OR 0.518, 95%CI 0.447 to 0.601). Continued use of statins was associated with a reduction in mortality (adjusted OR 0.597, 95%CI 0.449 to 0.798), and the start of treatment was a protective factor against mortality (adjusted OR 0.642, 95%CI 0.544 -0.757). Statin therapy also exerted a protective effect against the incidence of lethal arrhythmias and cardiogenic shock., Conclusions: These results suggest that early treatment with statins in patients with MI is associated with reduced mortality., (Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.)

Burkina Faso began rapid antiretroviral therapy (ART) scale-up in 2003 and by December 2009, 26,448 individuals were on treatment. With rapid scale-up of ART, some degree of human immunodeficiency virus transmitted drug resistance (TDR) is inevitable. Following World Health Organization methods, between June 2008 and July 2009, Burkina Faso assessed TDR in primigravid pregnant women aged <25 years attending antenatal care clinics in Ouagadougou, Burkina Faso. TDR was classified as moderate (5%-15%) for both nucleoside reverse-transcriptase inhibitors and nonnucleoside reverse-transcriptase inhibitors. The observed moderate TDR in Ouagadougou is a cause for concern and calls for closer monitoring of Burkina Faso's ART program.

Gram-positive bacteria cause a broad spectrum of disease in immunocompetent and immunocompromised hosts. Despite increasing knowledge about resistance transmission patterns and new antibiotics, these organisms continue to cause significant morbidity and mortality, especially in the health care setting. Methicillin-resistant Staphylococcus aureus poses major problems worldwide as a cause of nosocomial infection and has emerged as a cause of community-acquired infections. This change in epidemiology affects choices of empirical antibiotics for skin and skin-structure infections and community-acquired pneumonia in many settings. Throughout the world, the treatment of community-acquired pneumonia and other respiratory tract infections caused by penicillin-resistant Streptococcus pneumoniae has been complicated by resistance to β-lactam and macrolide antibacterial drugs. Vancomycin-resistant enterococci are a major cause of infection in the hospital setting and remain resistant to treatment with most standard antibiotics. Treatment of diseases caused by resistant gram-positive bacteria requires appropriate use of available antibiotics and stewardship to prolong their effectiveness. In addition, appropriate and aggressive infection control efforts are vital to help prevent the spread of resistant pathogens.

Many pancreatic cancer surgeons have been slow to adopt minimally invasive pancreatic surgery (MIPS) due a lack of formalized minimally invasive training and the perceived difficulty in dissecting pancreatic tumors and tissue away from the superior mesenteric vessels and consequent concerns for adequacy of oncologic margins and lymph node retrieval. A review of the first 29 MIPS procedures for malignant and premalignant tumors of the pancreas with the aid of a sterilizeable robotically-controlled camera holder was undertaken. As opposed to other robots currently available, this device allows for hand-assistance by the operating surgeon. Fourteen minimally invasive distal pancreatectomies (MIDP) (10 laparoscopic, 3 hand-assisted, 1 converted to open), 13 MIPDs (6 laparoscopic, 5 hand-assisted, 2 converted to open), and 2 laparoscopic central pancreatectomies have been performed. Seventeen (59%) of these patients were treated for cancer. Of these, 11 underwent a MIPD and 6 a MIDP. There were postoperative complications in seven patients (24%) at 30 days. Thirty and 90 day mortality was 3%. A sterilizeable robotically-controlled laparoscope holder that enables the operating surgeon to remain in contact with the patient and have the option of a hand-assisted approach may be particularly helpful for minimally invasive approaches to malignant and premalignant pancreatic tumors.

Stress cardiomyopathy is characterised by reversible left ventricular dysfunction. It simulates an acute coronary syndrome (ACS), presenting with precordial pain or dyspnoea, changes of the ST segment, T wave, or QTc interval on electrocardiogram, and raised cardiac enzymes. Typical findings are disturbances of segmental contractility (apical hypokinesia or akinesia), with normal epicardial coronary arteries. The true prevalence is unknown, as the syndrome may be under-diagnosed; it is more common in postmenopausal women. There is usually a trigger in the form of physical or psychological stress. The electrocardiographic, echocardiographic, and ventriculographic changes resolve spontaneously over a variable period of time (from days to months). There are a number of pathophysiological theories, none of which has been shown to be definitive, suggesting that all of them may be involved to some extent. The prognosis is generally favourable, and recurrence is very rare.

Background: Given the difficulty level of minimally invasive pancreatoduodenectomy (MIPD), limited data exist for a comparison to open pancreatoduodenectomies. As the technique becomes more diffuse, issues regarding the adequacy of oncologic margins and lymph node retrieval need to be addressed., Methods: All published cases of MIPD were examined. Variables analyzed included conversion rates, operating room time, estimated blood loss, length of stay, follow-up, complications, mortality, lymph node retrieval, and margins., Results: Twenty-seven articles describing outcomes after MIPD were found, and a total of 285 cases were described. Main malignancy treated was pancreatic adenocarcinoma, accounting for 32% of all cases. Eighty-seven percent were performed totally laparoscopically, and 13% were performed with a hand-assisted approach to facilitate the reconstruction step of the procedure. The rate of conversion to an open procedure was 9%. Estimated blood loss had a weighted average (WA) of 189 mL. Average length of stay had a WA of 12 days, and average follow-up had a WA of 14 months. The overall complication rate was 48%, and the overall mortality rate was 2%. Average lymph nodes retrieved ranged from 7 to 36 nodes, with a WA of 15 nodes, and positive margins of resection were reported to be positive in 0.4% of patients with malignant disease., Conclusions: This review found similar outcomes with respect to perioperative morbidity and mortality rates compared to open pancreatoduodenectomies. The oncologic goals of pancreatic resection may be able to be achieved by MIPD, but longer follow-up and larger series are still needed.

Objectives: To evaluate the frequency and the factors associated with performance of echocardiography in acute coronary syndrome (ACS) patients during their stay in intensive care units or coronary care units (ICU/CCU)., Methods: Retrospective cohort study including all patients diagnosed with acute coronary syndrome-unstable angina (UA), acute myocardial infarction (AMI)-included in the 'ARIAM' Spanish multi-centre register. The study period was from June 1996 to December 2005. The follow-up period is limited to the time of stay in the Intensive Care Units or Coronary Care Units (ICUs/CCUs). A univariate analysis was carried out on the patients with UA and AMI according to whether or not echocardiograms were performed during their stay in ICU/CCU. In addition the data was evaluated for any temporal variation in the performance of echocardiography, and two multivariate analyses were carried out to evaluate the factors associated with performance of echocardiography in UA and AMI patients., Results: The study period included 45,688 AMI patients and 17,277 UA patients. Echocardiograms were performed in 26.87% AMI patients and 16.75% UA patients. In total, 15,172 echocardiograms were performed in ACS patients (23.6%). The multivariate analysis demonstrated that the variables associated with the performance of echocardiography in UA were: Killip and Kimball class, cigarette smoking, family history of cardiovascular events, cardiogenic shock, uncontrolled angina, mechanical ventilation and treatment with ACE inhibitors, while the presence of previous AMI was associated with fewer echocardiograms being performed. In AMI, the multivariate analysis showed the following variables to be associated with the performance of echocardiography: Killip and Kimball class, Q-AMI, right heart failure, the need for insertion of Swan-Ganz catheter, cardiogenic shock, high-degree AV block and the administration of ACE inhibitors, while age was associated with fewer being performed. Over the 10 years of the study period, there was a discrete but significant increase in the use of echocardiography in patients in ICU/CCU., Conclusions: Echocardiography is not commonly used in ACS patients while in ICU/CCU. UA and AMI patients who did have echocardiograms during their stay in ICU/CCU were chiefly those presenting heart failure and major complications, and represent a subpopulation with poor prognosis. The performance of echocardiography in ACS patients increased slightly over the length of their stay in ICU/CCU.

Studies of large free-ranging mammals have been revolutionized by non-invasive methods for assessing physiology, which usually involve the measurement of fecal or urinary biomarkers. However, such techniques are limited by numerous factors. To expand the range of physiological variables measurable non-invasively from free-ranging primates, we developed techniques for sampling monkey saliva by offering monkeys ropes with oral swabs sewn on the ends. We evaluated different attractants for encouraging individuals to offer samples, and proportions of individuals in different age/sex categories willing to give samples. We tested the saliva samples we obtained in three commercially available assays: cortisol, salivary alpha amylase, and secretory immunoglobulin A. We show that habituated free-ranging rhesus macaques will give saliva samples voluntarily without training, with 100% of infants, and over 50% of adults willing to chew on collection devices. Our field methods are robust even for analytes that show poor recovery from cotton, and/or that have concentrations dependent on salivary flow rate. We validated the cortisol and SAA assays for use in rhesus macaques by showing aspects of analytical validation, such as that samples dilute linearly and in parallel to assay standards. We also found that values measured correlated with biologically meaningful characteristics of sampled individuals (age and dominance rank). The SIgA assay tested did not react to samples. Given the wide range of analytes measurable in saliva but not in feces or urine, our methods considerably improve our ability to study physiological aspects of the behavior and ecology of free-ranging primates, and are also potentially adaptable to other mammalian taxa., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Anatomic and functional disorders of the lower urinary tract represent up to 40% of the causes of renal failure in children. Several centers avoid renal transplantation in these patients because of the high risk of complications and lower graft survival. The aim of this work was to determine the frequency of urinary tract abnormalities (UTAs) among our pediatric series, and to compare the frequency of complications, function, and long-term graft survival among patients without versus with UTA., Methods: This single-center, retrospective study compared outcomes between pediatric recipients with versus without UTA. We analyzed demographic features, etiology, pretransplant protocol, urinary tract rehabilitation, incidence of complications, rejection events, as well as graft function and survival., Results: Among 328 pediatric cases performed between 1998 and 2008, we excluded nine patients due to incomplete medical records, analyzing 319 procedures in 312 patients. Sixty-seven patients (21%) had UTA. The average age, weight, and height at the time of grafting were significantly lower in the urologic group: 11.1 versus 12.6 years, 28.8 versus 34.4 kg; 125.4 versus 138.4 cm, respectively. There were significantly higher frequencies of a transperitoneal approach and vena cavae and aortic anastomoses among patients with UTA (P < .001), posing a greater technical challenge in this population. No differences in creatinine levels were observed at 0.5, 1, 2, 5, and 10 years: 1.3 versus 1.6 at 5 years, and 1.4 versus 1.5 at 8 years. Urologic complications, including urinary tract infections (UTIs), occurred among 80.6% of patients with UTA versus 42.1% in the non-UTA group (P < .001). UTIs appeared predominantly in patients with UTA (62.7% vs 35.3%, P < .001), representing a 2.7-fold risk compared with those children transplanted for other reasons. Rejection incidence was similar in both groups (49.8%). There was no significant difference in 5-y (89.8% vs 85%) or 10-year (83% vs 67%) graft survivals between the groups (P = .162)., Conclusion: Our results demonstrated that with proper interdisciplinary care, graft and patient survivals of pediatric recipients with UTAs were not affected; therefore, these patients should not be rejected for transplantation., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: The aim was to evaluate factors associated with the development of heart rupture in a Spanish registry of acute myocardial infarction (AMI) patients., Material/methods: This was a retrospective study of cohorts, including all patients diagnosed with AMI included in the ARIAM Spanish multicenter registry. The study period was from June 1996 to December 2005. The follow-up period was limited to the time of stay in intensive care or coronary care units. Multivariate logistic regression was used to study the factors associated with the development of heart rupture. A propensity score analysis was also performed to determine the involvement of beta blockers, ACE inhibitors, and fibrinolytics in the development of heart rupture., Results: 16,815 AMI patients were included. Heart rupture occurred in 477 (2.8%). Heart rupture was associated with female gender, older age, the absence of previous infarct, and the administration of thrombolysis, while ACE inhibitors and beta blockers acted as protective variables. The propensity score analysis showed that fibrinolysis was a variable associated with heart rupture except in the younger subgroup and in the subgroup with less delay in administration. It was also found that beta blockers and ACE inhibitors are variables providing protection against heart rupture., Conclusions: Heart rupture is associated with older age, female gender, absence of previous infarct, and the administration of thrombolysis, while ACE inhibitors and beta blockers seem to prevent this complication.

We examined jail environmental surfaces to explore whether they might serve as reservoirs of viable methicillin-resistant Staphylococcus aureus (MRSA). We swabbed 132 surfaces, inoculated primary and secondary mannitol salts and oxacillin-resistant screening agar, and used API tests to identify S. aureus and E-tests to determine methicillin/oxacillin resistance. We recovered S. aureus from 10 (7.6%) surfaces; eight (6.1%) isolates were MRSA. We ran pulsed-field gel electrophoresis on six resistant isolates and observed three patterns, one of which was identical to that identified in a previous study of inmates' nasal specimens. Finding MRSA-contaminated surfaces on a variety of environmental surfaces in the absence of an overt outbreak emphasizes that correctional facilities should have protocols for environmental cleaning as a component of MRSA prevention.

Background: The aim of this study was to investigate patients with unstable angina (UA) and the predictive factors of these arrhythmias and to determine whether this complication behaves as an independent variable with regard to mortality, increased length of stay in an ICU/CCU, and the performance of percutaneous coronary intervention (PCI)., Material/methods: The retrospective cohort study included all patients diagnosed with UA and included in the Spanish "ARIAM" database between June 1996 and December 2005. Univariate and multivariate analyses were performed to evaluate the factors associated with these arrhythmias. 17,616 patients were included., Results: Sustained ventricular tachycardia (SVT) occurred in 0.5%. The factors associated with its development were age, cardiogenic shock, and non-sustained ventricular tachycardia. SVT was associated with mortality (adjusted OR: 9.836, 95%CI: 1.81-53.33). Ventricular fibrillation (VF) occurred in 1%. In the multivariate study the variables that persistently associated independently with the development of VF were gender, Killip class, and high degree atrioventricular block (HDAVB). VF was associated with higher mortality (27.1% vs. 0.9%). Nevertheless, VF was not seen to be a variable independently associated with mortality in UA patients. Only VF was an independent variable in length of stay (adjusted OR: 2.059, 95%CI: 1.175-3.609). Neither SVT nor VF were independent variables associated with PCI., Conclusions: Patients with UA complicated by SVT or VF represent a special high-risk subgroup with poor prognosis, which could lead to their being stratified towards a poor prognosis subgroup.

Background: To evaluate the frequency and factors associated with cardiogenic shock (CS) in acute myocardial infarction (AMI) and unstable angina (UA) and percutaneous coronary intervention (PCI)., Material/methods: Spanish registry. The study period was June 1996 to December 2005. Follow-up was length of stay in an intensive care or coronary care unit (ICU/CCU). Multivariate studies evaluated factors associated with CS, mortality in CS, and PCI performance., Results: The study included 45.688 AMI patients and 17.277 UA patients. Cardiogenic shock occurred in 9.3% of patients with AMI and 1.79% of those with UA, frequencies that decreased over time. Variables associated with cardiogenic shock in AMI patients were female sex, age, type of infarction, diabetes, previous stroke, arrhythmia, previous angiography, complicated angina, and reinfarction. Hypertension and oral beta-blocking, ACE inhibitor, and hypolipidemic agents protected against CS. In UA, these variables were age, previous angina or AMI, right ventricular heart failure, arrhythmia. Beta-blocking agents were associated with a reduction in CS. Deaths from CS and AMI, respectively, were 62.8% and 38.7% in persons with UA. Doing PCIs has increased significantly; it is more prevalent in ex-smokers and those with right ventricular heart failure and mechanical ventilation; lower performance is associated with need for cardiopulmonary resuscitation; patients who die are older or have a history of AMI., Conclusions: There has been a slight drop in the frequency of CS and its mortality. Factors associated with CS are similar to those associated with acute coronary syndromes. The frequency of PCI was low.

Purpose: Bilateral anorchia, either congenital or acquired, often requires testicular prostheses placement and testosterone supplementation. Several types of testosterone compounds and various modes of hormone delivery are currently used clinically, however, their pharmacokinetic properties are not ideal. In this study, we explored the possibility of creating hormone releasing testicular prostheses that could continuously supply and maintain physiologic levels of testosterone in vivo over time., Methods: Chondrocytes, harvested from bovine articular cartilage, were seeded on testicular shaped polymer scaffolds at a concentration of 100 x 10(6) ml(-1). The scaffolds were maintained in a bioreactor for 4 weeks to form cartilage tissue. Subsequently, testosterone enanthate (100 microg) was injected into the central hollow space of each testicular prosthesis, and maintained for 40 weeks in culture. A sample of the medium was collected every 2 days for testosterone assays. Another group of ex vivo engineered testicular prostheses was implanted into the scrotal space of castrated athymic mice (n = 10). Intratesticular injection of testosterone enanthate was made into each prosthesis at a concentration of 100 microg. Control groups consisted of animals with castration only (n = 8) and sham operations (n = 5). Testosterone levels were measured prior and 2 weeks after castration, 1 day after testosterone administration, and weekly up to 14 weeks. The engineered testicular prostheses were retrieved at sacrifice for histomorphological and immunocytochemical analyses., Results: Milky white cartilage testicular protheses were formed by 4 weeks. The ex vivo prostheses showed an initial burst effect of testosterone followed by a broad plateau for 16 weeks (>500 ng/dl) and a decreased level of testosterone until 40 weeks. The testosterone levels were physiologic throughout 40 weeks and the entire testosterone released was calculated as 60% of the injected volume. The circulating testosterone levels in the protheses implanted animals demonstrated a maximum peak on day 1 and a continued physiologic range during the entire study period. Histologically, the retrieved testicular implants showed mature chondrocytes with a hollow center in each prosthesis., Conclusion: This study demonstrates that engineered cartilage testis can be created in bioreactors, can be implanted in vivo, and can release testosterone for a prolonged period. Furthermore, the levels of testosterone release can be maintained within the physiologic range. Periodic reinjection may potentially provide permanent physiologic hormonal replacement. This novel technology may be beneficial for patients who require testicular prostheses and chronic hormone supplementation.

Many countries rely heavily on patients' out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe and impoverishment for others who do obtain care. Surveys in eighty-nine countries covering 89 percent of the world's population suggest that 150 million people globally suffer financial catastrophe annually because they pay for health services. Prepayment mechanisms protect people from financial catastrophe, but there is no strong evidence that social health insurance systems offer better or worse protection than tax-based systems do.

Background and Objective: The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU)., Patients and Method: A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU., Results: 14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death., Conclusions: The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI.

Collections of 11 species of shallow water Polyplacophora from El Salvador were made in July 2002. Previously only five species had been documented in El Salvador: Chaetopleura lurida (Sowerby, 1832); Ischnochiton guatemalensis (Thiele, 1910); Ceratozona angusta (Thiele, 1909); Chiton stokesii (Broderip, 1832) and Acantochitona exquisita (Pilsbry, 1893). Of these, L. guatemalensis and A. exquisita were not collected in this census. Seven other species are reported here for El Salvador for the first time: Lepidochitona beanii (Carpenter, 1857); Ischnochiton dispar (Sowerby, 1832); Stenoplax limaciformis (Sowerby, 1832); Callistochiton expressus (Carpenter, 1865); Acanthochitona arragonites (Carpenter, 1867); A. ferreirai (Lyons, 1988) and A. hirudiniformis (Sowerby, 1832). The known geographic distribution of 1. dispar is extended to the north. An un-named species of Lepidochitona is briefly described.

Up to eighty percent of all patients admitted to hospital worldwide will receive a peripheral IV and this procedure is now considered indispensable to human health. However, despite its global use, the choice of catheter is not always governed by clear and universal guidelines. After reviewing the few best-practice recommendations which exist, we propose a patient--and therapy--driven matrix for deciding on the gauge and length of peripheral catheter for the individual patient. This matrix takes patient age, clinical stability, current state of veins, therapy duration and the nature of the medication to be delivered into consideration. Use of such a matrix will not deliver a formulaic answer but will orient choices along logical, evidence-based lines. This approach will be an advance on the all-too-common reliance on habit and tradition in the choice of peripheral IV catheter.

Infection with Nocardia asteroides is a rare, life-threatening infection, which is most commonly encountered in immunocompromised patients. Cutaneous involvement is usually seen with disseminated infection but may also occur as primary cutaneous nocardiosis. We present a case of an immunocompromised patient who presented with cellulitis of the right hand and disseminated subcutaneous nodules of the lower extremities resembling erythema nodosum. Cultures from both a skin biopsy of a subcutaneous nodule on the leg as well as a surgical specimen from the debridement of her hand grew Nocardia asteroides. The patient was treated successfully with trimethoprim-sulfamethoxazole. This case likely represents primary cutaneous nocardiosis with secondary dissemination, which has been rarely reported. It also emphasizes that nocardial infection should be considered in the differential diagnosis of lesions suggestive of cellulitis or erythema nodosum in the severely immunocompromised patient.

Objective: Describe the frequency of high degree atrioventricular block (HDAVB) in patients with unstable angina (UA), analyze the variables associated with their appearance and evaluate whether HDAVB is independently associated with increased mortality or increased length of ICU stay., Design: Retrospective descriptive study of patients with UA included in the ARIAM registry., Setting: ICUs from 129 hospitals in Spain., Patients: From June 1996 to December 2003 a total of 14,096 patients were included in the ARIAM registry with a diagnosis of UA., Main Variables of Interest: Variables associated with the development of HDAVB, variables associated with the mortality of patients with UA, variables associated with the length of ICU stay of patients with UA., Results: HDAVB frequency was 1%. Development of HDAVB was independently associated with the Killip classification and the presence of sustained ventricular tachycardia or ventricular fibrillation. Crude mortality of patients was significantly increased when HDAVB was present (9% versus 1%, p < 0,001). When adjusted for other variables, HDAVB was not associated with increased mortality. Development of HDAVB in patients with UA was independently associated with an increase in the length of ICU stay (adjusted odds ratio 1.89: 95% confidence interval: 1.33-5.69)., Conclusions: Patients with UA complicated with HDAVB represent a high-risk population with an increased ICU stay.

Objective: To identify the myths accepted by women about to undergo hysterectomy regarding the consequences that removal of their uterus might have on their lives., Methods: A sample of 10 hospitalized women with surgical indication for hysterectomy was used to perform a qualitative study, with semi-structured interviews carried out during the preoperative period. A profile questionnaire was used with questions about personal features and semi-structured inquiries to facilitate deeper questioning. With authorization of the subjects, interviews were recorded and transcribed to perform a thematic analysis of the content., Results: The myths most often mentioned during the interviews were: loss of femininity, frigidity, change in personality, possible change in body appearance (since they would be "hollow", "empty", "have a hole inside their belly"), interference in the affective and sexual life and the belief that their companion might change in relation to them (assuming that they would be hollow, cold, and with no sexual attraction)., Conclusion: The interviewed women accepted a number of myths about the consequences that removal of their uterus would have on their lives. These myths are related to the social identity of the gender and to a lack of knowledge about their body its organs and functions.

Halobetasol propionate (HP) 0.5% ointment and cream are class I topical corticosteroids. We review the efficacy and tolerability of HP for treatment of plaque psoriasis in the English language literature. The efficacy of HP ointment and cream is consistently superior to other super-potent topical corticosteroids. Local adverse events associated with topical HP are similar to those experienced with other super-potent corticosteroids. Combination therapy with calcipotriene (calcipotriol) and tazarotene appears to be superior to monotherapy with topical HP.

Five new species of Psilocybe from the Caribbean are described: P. caribaea, P. egonii, P. subpsilocybioides, P. zapotecoantillarum and P. zapotecocaribaea. All except P. zapotecocaribaea, which is known only from Martinique, are native to Puerto Rico. Psilocybe guilartensis, previously described from Puerto Rico, is the most commonly collected species of Psilocybe in Puerto Rico. New information on morphology is provided for P. guilartensis, and an emendation of the species circumscription is presented.

Seventy strains of Bacillus thuringiensis representing 21 serovars were allocated to 38 genomic groups using pulsed field gel electrophoresis (PFGE) of restriction enzyme-digested DNA. There was a broad correlation between PFGE type and serotype for serovars darmstadiensis, israelensis, kenyae, kumamotoensis, kurstaki, sotto, thuringiensis, and tolworthi, although some serovars included atypical strains. Serovars canadensis and entomocidus were heterogeneous. Detection of crystal protein genes by polymerase chain reaction indicated an approximate correlation between PFGE type and cry gene complement. For example, cry1 products were amplified from DNA from PFGE type 17 strains of serovar aizawai and from PFGE type 23 strains of serovar tolworthi but not from a PFGE 18 strain of aizawai nor from a PFGE type 24 strain of tolworthi. These data suggest a clonal population structure to B. thuringiensis with some consistency of Cry-plasmid composition within PFGE types.

One hundred and twenty-six strains of Bacillus thuringiensis representing 57 serovars were allocated to 58 genomic types using random amplified polymorphic DNA (RAPD)-PCR patterns. Serovars darmstadiensis, israelensis, kenyae, kumamotoensis, kurstaki, morrisoni, pakistani, sotto, thuringiensis and tolworthi each encompassed identical or closely related strains. Despite this genomic homogeneity, most of these serovars also included at least one variant strain. Serovars aizawai, canadensis, entomocidus and sotto biotype dendrolimus, on the other hand, were genomically heterogeneous. Of the 57 serovars examined, 31 contained at least one strain with a closely related or identical RAPD pattern to a strain from a different serovar. We conclude that while the species is genomically diverse, the homogeneous serovars represent clonal lineages of successful insect pathogens.

One of the major problems in angiogenesis research remains the lack of suitable methods for quantifying the angiogenic response in vivo. We describe the development and application of the directed in vivo angiogenesis assay (DIVAA) and demonstrated that it is reproducible and quantitative. This assay consists of subcutaneous implantation of semiclosed silicone cylinders (angioreactors) into nude mice. Angioreactors are filled with only 18 micro l of extracellular matrix premixed with or without angiogenic factors. Vascularization within angioreactors is quantified by the intravenous injection of fluorescein isothiocyanate (FITC)-dextran before their recovery, followed by spectrofluorimetry. Angioreactors examined by immunofluorescence show cells and invading angiogenic vessels at different developmental stages. The minimally detectable angiogenic response requires 9 days after implantation and >/=50 ng/ml (P < 0.01) of either fibroblast growth factor-2 or vascular endothelial growth factor. Characterization of this assay system demonstrates that the FITC-labeled dextran quantitation is highly reproducible and that levels of FITC-dextran are not significantly influenced by vascular permeability. DIVAA allows accurate dose-response analysis and identification of effective doses of angiogenesis-modulating factors in vivo. TNP-470 potently inhibits angiogenesis (EC(50) = 88 pmol/L) induced by 500 ng/ml of fibroblast growth factor-2. This inhibition correlates with decreased endothelial cell invasion. DIVAA efficiently detects differences in anti-angiogenic potencies of thrombospondin-1 peptides (25 micro mol/L) and demonstrates a partial inhibition of angiogenesis ( approximately 40%) in a matrix metalloprotease (MMP)-2-deficient mouse compared with that in wild-type animals. Zymography of angioreactors from MMP-deficient and control animals reveals quantitative changes in MMP expression. These results support DIVAA as an assay to compare potencies of angiogenic factors or inhibitors, and for profiling molecular markers of angiogenesis in vivo.

Seventy-four strains of Bacillus thuringiensis thuringiensis representing 24 serovars were examined for the presence of three enterotoxin genes/operons; the non-haemolytic enterotoxin Nhe, the haemolytic enterotoxin hbl and the Bacillus cereus toxin bceT using polymerase chain reaction. The nheBC genes were found in all strains examined, the hblCD genes in 65 of the 74 strains and bceT in 63 strains. There was little consistency of the distribution of enterotoxin loci among strains of the same serovar in serovars that were well represented in our collection. Culture supernatants from all but one strain inhibited protein synthesis in Vero cells, generally with a toxicity equivalent to that seen in strains of B. cereus isolated from incidents of food poisoning. Microbiological Societies.

In order to contribute to a better knowledge of the pediculosis capitis and scabies during March-December 1995, 1122 primary schoolchildren under 14 years of age in the city-port of Antofagasta in northern Chile (20 degrees South lat.), were examined. A total of 285 (25.4%) were found to be infested with Pediculus humanus capitis and only 20 (1.8%) with Sarcoptes scabiei. In general the rates of infestation to both ectoparasitic diseases were higher in groups of younger schoolchildren, also higher in women than in men and in those groups with high indexes of crowding and ignorance of the transmission mechanism of pediculosis capitis and scabies.

Calcitonin (CT) was administered acutely (IV 4-8 U/kg) and chronically (SC 2 U/kg/day x 150 day) to normal male rats. Measurements included heart rate (HR), mean blood pressure (MBP), cardiac index (CI), peripheral vascular resistance (PVR), and stroke volume index (SVI). The MBP was higher in CT rats examined under pentobarbital anesthesia. Upon awakening from anesthesia, rats chronically on CT exhibited impaired recovery of CI and SVI. Hemodynamic effects were not seen in rats acutely treated with CT. Heart weight was unchanged in chronic treatment with CT. Therefore, CT had minimal hemodynamic effects in the normal male rat.

We examined the hemodynamic factors associated with the lower maximal O2 consumption (VO2max) in older formerly elite distance runners. Heart rate and VO2 were measured during submaximal and maximal treadmill exercise in 11 master [66 +/- 8 (SD) yr] and 11 young (32 +/- 5 yr) male runners. Cardiac output was determined using acetylene rebreathing at 30, 50, 70, and 85% VO2max. Maximal cardiac output was estimated using submaximal stroke volume and maximal heart rate. VO2max was 36% lower in master runners (45.0 +/- 6.9 vs. 70.4 +/- 8.0 ml.kg-1.min-1, P less than or equal to 0.05), because of both a lower maximal cardiac output (18.2 +/- 3.5 vs. 25.4 +/- 1.7 l.min-1) and arteriovenous O2 difference (16.6 +/- 1.6 vs. 18.7 +/- 1.4 ml O2.100 ml blood-1, P less than or equal to 0.05). Reduced maximal heart rate (154.4 +/- 17.4 vs. 185 +/- 5.8 beats.min-1) and stroke volume (117.1 +/- 16.1 vs. 137.2 +/- 8.7 ml.beat-1) contributed to the lower cardiac output in the older athletes (P less than or equal 0.05). These data indicate that VO2max is lower in master runners because of a diminished capacity to deliver and extract O2 during exercise.