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Purpose: To evaluate the clinical outcome of 500 consecutive cases after Descemet's membrane endothelial keratoplasty (DMEK) and the effect of technique standardization., Design: Prospective, interventional case series at a tertiary referral center., Participants: A total of 500 eyes of 393 patients who underwent DMEK for Fuchs' endothelial corneal dystrophy, bullous keratopathy, or previous corneal transplant failure., Methods: Best-corrected visual acuity (BCVA), endothelial cell density (ECD), pachymetry, and intraoperative and postoperative complications were evaluated before and 1, 3, and 6 months after DMEK., Main Outcome Measures: Comparison between 2 groups (group I: cases 1-250, outcome of "early surgeries" during transition to technique standardization; group II: cases 251-500, outcome of "late surgeries" after technique standardization)., Results: At 6 months, 75% of eyes reached a BCVA of ≥20/25 (≥0.8), 41% of eyes achieved ≥20/20 (≥1.0), and 13% of eyes achieved ≥20/18 (≥1.2) (n=418) when excluding eyes with ocular comorbidities (n=57). When including all available eyes at 6 months (n=475), 66% of eyes reached a BCVA of ≥20/25 (≥0.8), and 36% of eyes achieved ≥20/20 (≥1.0). Mean ECD decreased by 37% (±18%) to 1600 (±490) cells/mm2 (n=447) at 6 months (P<0.001). Postoperative pachymetry averaged 525 (±46) μm compared with 667 (±92) μm preoperatively (P<0.001). None of these parameters differed among the 2 groups (P>0.05). (Partial) graft detachment presented in 79 eyes (15.8%), and 26 eyes (5.2%) required a secondary surgery within the first 6 months (re-bubbling in 15, secondary keratoplasty in 11). With technique standardization, the postoperative complication rate decreased from 23.2% to 10% (P<0.001) and the rate of secondary surgeries decreased from 6.8% to 3.6% (P=0.10)., Conclusions: In comparison with earlier endothelial keratoplasty techniques, DMEK may consistently give higher visual outcomes and faster visual rehabilitation. When used for the extended spectrum of endothelial pathologies, DMEK proved feasible with a relatively low risk of complications. Technique standardization may have contributed to a lower graft detachment rate and a relatively low secondary intervention rate. As such, DMEK may become the first choice of treatment in corneal endothelial disease., (Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Aims: (i) To evaluate glucometabolic status of patients without known diabetes hospitalized due to coronary artery disease (CAD), (ii) to assess markers of systemic inflammation determined during admission and to evaluate their relationship with glucometabolic status and (iii) to analyse usefulness of HbA1c determined during admission in patients with CAD to detect abnormal glucose regulation (AGR)., Materials & Methods: We studied 440 patients with CAD admitted to the cardiology ward. Patients were grouped in four groups during admission according to clinical data, fasting plasma glucose and HbA1c: diabetes, HbA1c > 5·9%, stress hyperglycaemia (SH) and normal. In 199 subjects without known diabetes, an oral glucose tolerance test (OGTT) was performed 3 months after discharge, and they were reclassified according to WHO 1998 criteria. Biochemical and inflammatory markers were measured., Results: The OGTT showed that 27·4% of subjects without known diabetes at admission had diabetes, 11·2% had impaired fasting glucose + impaired glucose tolerance, 33·5% impaired glucose tolerance, 3·6% impaired fasting glucose, and 24·4% normal glucose metabolism. Odds ratio for having diabetes 3 months after discharge in HbA1c > 5·9% group was 5·91 (P < 0·0001) and in SH group was 1·82 (P = 0·38). The best HbA1c cut-off point to predict AGR was 5·85%. HbA1c levels during admission were highly predictive of having AGR (AUC ROC 0·76 [95% CI 0·67-0·84])., Conclusion: We reported a high prevalence of AGR in subjects with CAD. Stress hyperglycaemia in patients with CAD was not associated with an increased risk of diabetes 3 months later. HbA1c in patients hospitalized with CAD was a useful tool to detect AGR., (© 2013 Stichting European Society for Clinical Investigation Journal Foundation. Published by John Wiley & Sons Ltd.)

Introduction and Objectives: Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal circulation., Methods: 20 patients are included: 10 in the submammary group (7 ostium secundum, 2 sinus venosus, 1 ostium primum) and 10 in the axillary group (7 ostium secundum, 3 sinus venosus). Mean age and weight are 6.4±3.62 years (range 3-13) and 23.5±8.74 Kg (range 12-38) in the submammary group, and 5.5±2.04 years (range 3-9) and 19.7±5.88 Kg (range 14-29) in the axillary one, respectively. Muscles are spared (pectoralis in submammary and latissimus in axillary). The whole procedure (cannulation and correction) is performed through a single incision, with no side ports., Results: No residual defects were found at discharge. Surgical approach maneuvers are more cumbersome through the axillary than the submammary approach. In a peer comparison, extracorporeal circulation and cross-clamp time were similar in both groups (P>.05)., Conclusions: 1. Axillary approach is as safe as submammary access in selected patients and for defects approached through the atrium. 2. Cosmetic result is excellent., (Copyright © 2010 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

We report the first case of a post-acupuncture soft tissue infection due to Mycobacterium fortuitum. Two months after finishing an acupuncture treatment session, an immunocompetent 23-year-old woman developed cellulitis at the side of the needle insertions and the acid-fast bacillus was isolated from a closed abscess. The patient was successfully treated with a proper drug combination. We review the literature concerning the infection source and the risks for skin and soft tissue infection due to mycobacteria after acupuncture. The infection source in most cases is unknown but is probably associated with the inadequate sterilization of the needles or the puncture site. We show that these infections are not rare but difficult to diagnose. To avoid delays in the definitive diagnosis, infection with mycobacteria should be considered for skin and soft tissue infections, in particular late-onset infections, which are negative for routine bacterial cultures and without a clinical response to antibiotics used for acute pyogenic infections. Bacterial cultures from this lesion should be maintained for at least six weeks before discharged as negative.

Leptospirosis is caused by numerous serovars of Leptospira interrogans. The infection is acquired through the contact of softened skin, mucous and conjunctive with the urine of animals and humans infected by animal carriers. The aim of this study was to determine the clinical and epidemiological features of leptospirosis in Bolívar state Venezuela and to compare the sensibility and specificity of the LEPTO-Dipstick, with the test of macroscopic agglutination in plate with the termorresistent antigen (TR). Thirty one sample of serums were processed of patients with leptospirosis clinic, admitted in the Hospital Universitario "Ruiz y Páez" of Ciudad Bolívar during 12 months. Detection IgM antibodies of anti-Leptospiras was carried out by means of LEPTO-Dipstick and antigen TR. The Microscopic Agglutination Test (MAT) was also, carried out. The general prevalence of leptospirosis in patients who attended the "Ruiz y Paez" Hospital was of 80.6% (n = 25) by means of the determination of the termorresistent antigen. The most frequent serovars identified in Bolívar State, were the serovars: icterohaemorrhagiae, copenhageni (21.3%), autummalis and australis (12.8%). TR antigen and LEPTO Dipstick had a sensibility of 80% and a specificity of 25%. The agreement between both methods was null (Kappa: -0.2). Bolívar state has a high leptospirosis prevalence and the infection should be discarded in those patients with long-term fever and risk factors for the illness.

Acinetobacter sp. are gram-negative bacteria and usually resistant to multiple antibiotics. They are a customary cause of nosocomial infections, but are uncommon etiologic agents of endocarditis. We present a case of endocarditis caused by Acinetobacter iwoffi in a composite aortic graft with a St. Jude prosthetic valve, using the Bono and Bentall procedure, complicated with multiple graft dehiscenses causing first a peritube pseudoaneurysm and finally severe paraprosthetic valve regurgitation to the left ventricle which required emergency surgery.

After coronary bypass surgery in the left internal mammary artery, occlusive atherosclerosis in the proximal subclavian artery can produce reverse flow in the mammary artery and myocardial ischemia (coronary-subclavian steal syndrome). This is a rare cause of recurrent myocardial ischemia. We present two patients with postoperative complete obstruction in the proximal subclavian artery and inverse flow in the mammary artery producing severe ischemia in the left anterior descending artery territory. Both patients were treated with subclavian-subclavian bypass, which in one patient was ineffective in producing an adequate anterograde flow in the left internal mammary artery. We review clinical management, diagnostic methods and therapeutic options used in the coronary-subclavian steal syndrome.

Introduction: Increasingly patients are surviving after reconstructive surgery of the ascending aorta. These patients require follow-up to detect postoperative prognostic markers, such as persistence of the flow in a false lumen, intimal rupture, or graft complications. We conducted a study with transthoracic and transesophageal echocardiography in order to detect residual abnormalities and establish the usefulness of this technique in a group of patients after Bono-Bentall surgery for ascending aorta pathology., Patients and Methods: Twelve patients were studied with transthoracic and transesophageal echocardiography, four after surgery for annulo-aortic ectasia with severe aortic insufficiency and eight for type A aortic dissection. The Bono-Bentall surgical procedure was used in all the patients with Cabrol's modification being added in three., Results: Seven of the eight (87%) patients with aortic dissection had residual abnormalities: five persistence of the distal dissection, one pseudo-aneurysm, and one peritubular haematoma. A residual lesion (pseudo-aneurysm) was found in just one of the four patients (25%) who underwent surgery for annulo-aortic ectasia. The ejection fraction was normal in those patients who had been operated on for aortic dissection and depressed in those who had annulo-aortic ectasia (60 +/- 9 vs 40 +/- 10; p = 0.005)., Conclusions: In patients undergoing surgery with the Bono-Bentall procedure there is a high incidence of residual aortic abnormalities, especially when the operation is for aortic dissection. Transesophageal echocardiography is an ideal diagnostic method for the detection and follow up of residual abnormalities after ascending aorta surgery. We believe this technique should be included in the periodic follow up of these patients.

Catecholamine-induced cardiomyopathy is a rare complication of pheochromocytoma. We present a case of pheochromocytoma that developed preoperative heart failure. Left ventricular dilation and severe hypokinesia were demonstrated by echocardiography. Heart failure was successfully treated with digitalis, diuretics and captopril. There were no surgical complications and the follow up showed and improvement on the systolic function evaluated by echocardiography and isotope ventriculography, 3 and 6 months after surgery. We review the pathophysiology and evolution of catecholamine induced cardiomyopathy. Preload reserve can be one of the adaptive mechanisms of the ventricle in catecholamine-induced cardiomyopathy. Conventional therapy of hypertension and heart failure can be effective to correct the symptoms of cardiac dysfunction.

We describe a case of primary cardiac lymphoma presenting with chest pain, complete AV block, negative T waves, and infiltration of the basal segments and right free ventricular wall on echocardiography, interpreted initially as hypertrophy. One month later the patient was readmitted with systemic disease and cardiac insufficiency. Furthermore multicentric myocardial infiltration with a nodular mass in the right atrium producing severe tricuspid stenosis was demonstrated. Surgical biopsy was performed and a high grade non-Hodgkin's lymphoma diagnosed. The patient died during the immediate post-operative period without receiving specific chemotherapeutic treatment. Reviewing the published cases, we found that primary cardiac lymphomas are fast growing tumors that infiltrate predominantly the right cavities and have limited therapeutic options.

The occurrence of iatrogenic aortic dissection after aortic valve replacement is uncommon, usually late, and exceptionally asymptomatic. We present here a case of dissecting aneurysm suspected by excessive mediastinal dilatation observed in the routine annual roentgenogram exam of a patient who has had an aortic valve prosthesis for thirteen years. The confirmation with other diagnostic methods and its successful surgical treatment are also described.