Clinical review: practical recommendations on the management of perioperative heart failure in cardiac surgery.

Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery.

Cell mediated immunity in Chagas' disease: Trypanosoma cruzi antigens induce suppression of the in vitro proliferative response of mononuclear cells

The partial suppression of the cell-mediated immune response by Trypanosoma cruzi antigens in patients with Chagas' disease is demonstrated in a costimulation assay with T. cruzi antigens and Mycobacterium tuberculosis purified protein derivative (PPD) or Tetanus toxoid (TT). ononuclear cells from 13 patients with chagasic infection without evidence of heart disease, 10 patients with chagasic cardiomyopathy and 7 healthy blood donors were stimulated with antigen A (autoclaved epimastigotes), PPD, TT, PPD + A, PPD + TT and TT + A. The average percentage of suppression induced by costimulation of mononuclear cells with PPD and antigen A was 47.1% in patients with chagasic infection without heart disease (INF), 38.8% in patients with chagasic cardiomyopathy (CDM) and 23.3% in healthy controls. Similar values were observed when living trypomastigotes were used. A costimulatory study with PPD and TT, PPD and A and TT and A was carried out in 8 patients with chagasic infection, in order to evaluate the possibility that this difference could be due to a nonspecific inhibitory effect. The mean suppression induced by TT + PPD was -8.9, with TT + A was 52.7 and with PPD + A was 50.1. The data reported show that T. cruzi antigens induce a specific suppression of the proliferative responseof mononuclear cells, that might be relevant to the persistence of the parasite in the host.

Evaluation of the xenodiagnosis of chronic Chagas patients infected ten years or over in an area where transmission has been interrupted - Iguatama and Pains, west Minas Gerais State, Brazil

To evaluate the results of xenodiagnosis in chronic Chagas patients infected for ten years or over in an area where transmission has been stemmed as well as the performance of these tests applied one or more times to determine the presence of the paraiste in serum-positive patients for Trypanosoma cruzi infection, 570 xenodiagnosis were performed in 246 patients by exoposing each pacient to 40 Triatoma infestans nymphs of 3 rd/4th stage once, twice or three times, at 30 days intervals. The 570 xenodiagnosis showed overall positive results in 50.7% with a peak 78% in patients under 20 years of age, and 60.5% in those over 60. Of the l58 patients who underwent three xenodiagnosis, 51 (32.3%) had three positive tests, 48 (30.3%) had all negative results, and the remainder had alternating positve and negative findings. There was no difference in number of positive results between the 1st, 2nd and 2rd tests; however, the 1st and 2nd trials added up to 53.2% and the sum total of all three trials was 57.7%.

Contrast-enhanced ultrasound after devascularisation of neuroendocrine liver metastases: functional and morphological evaluation.

OBJECTIVE: To evaluate morphological and perfusion changes in liver metastases of neuroendocrine tumours by contrast-enhanced ultrasound (CEUS) after transarterial embolisation with bead block (TAE) or trans-arterial chemoembolisation with doxorubicin-eluting beads (DEB-TACE). METHODS: In this retrospective study, seven patients underwent TAE, and ten underwent DEB-TACE using beads of the same size. At 1 day before embolisation, 2 days, 1 month and 3 months after the procedure, a destruction-replenishment study using CEUS was performed with a microbubble-enhancing contrast material on a reference tumour. Relative blood flow (rBF) and relative blood volume (rBV) were obtained from the ratio of values obtained in the tumour and in adjacent liver parenchyma. Morphological parameters such as the tumour's major diameter and the viable tumour's major diameter were also measured. A parameter combining functional and morphological data, the tumour vitality index (TVI), was studied. The Wilcoxon rank-sum test and Fisher's test were used to compare treatment groups. RESULTS: At 3 months rBF, rBV and TVI were significantly lower (P = 0.005, P = 0.04 and P = 0.03) for the group with doxorubicin. No difference in morphological parameters was found throughout the follow-up. CONCLUSIONS: One parameter, TVI, could evaluate the morphological and functional response to treatments.

Proliferation of chick embryo neuroblasts grown in the presence of horse serum requires exogenous transferrin.

We have previously shown that neuroblasts from cerebral hemispheres of 6-day-old chick embryos are able to proliferate when grown in the presence of fetal calf serum. We report here that in the presence of horse serum alone the proliferative rate of neuroblasts is strongly reduced. A high proliferative rate is restored upon the addition of bovine transferrin and to a lesser extent with added FeSO4 or hemin. These findings suggest that the transferrin of horse serum cannot be used by chick neuroblasts in vitro, while bovine transferrin exogenously added is active in promoting cell proliferation. We propose that the stimulatory activity of the fetal calf serum is due to bovine transferrin, since when this serum is fractionated by gel filtration, the fractions that stimulate the proliferation of neuroblasts grown in the presence of horse serum are located in the molecular weight area of transferrin, and they do contain transferrin as seen by immunoblotting with a specific anti-transferrin antibody.

Outcomes and reoperations after total correction of complete atrio-ventricular septal defect

BACKGROUND: Surgical correction of complete atrio-ventricular septal defect (AVSD) achieves satisfactory results with low morbidity and mortality, but may require reoperation. Our recent operative results at mid-term were followed-up. METHODS: From June 2000 to December 2007, 81 patients (Down syndrome; n=60), median age 4.0 months (range 0.7-118.6) and weight 4.7kg (range 2.2-33), underwent complete AVSD correction. Patch closure for the ventricular septal defect (VSD; n=69) and atrial septal defect (ASD; n=42) was performed with left atrio-ventricular valve (LAVV) cleft closure (n=76) and right atrio-ventricular valve (RAVV) repair (n=57). Mortality, morbidity, and indications for reoperation were retrospectively studied; the end point 'time to reoperation' was analyzed using Kaplan-Meier curves. Follow-up was complete except in two patients and spanned a median of 28 months (range 0.4-6.1 years). RESULTS: In-hospital mortality was 3.7% (n=3) and one late death occurred. Reoperation was required in 7/79 patients (8.9%) for LAVV insufficiency (n=4), for a residual ASD (n=1), for right atrio-ventricular valve insufficiency (n=1), and for subaortic stenosis (n=1). At last follow-up, no or only mild LAVV and RAVV insufficiency was present in 81.3% and 92.1% of patients, respectively, and 2/3 of patients were medication-free. Risk factors for reoperation were younger age (<3 months; p=0.001) and lower weight (<4kg; p=0.003), and a trend towards less and later reoperations in Down syndrome (p<0.2). CONCLUSIONS: Surgical correction of AVSD can be achieved with low mortality and need for reoperation, regardless of Down syndrome or not. Immediate postoperative moderate or more residual atrio-ventricular valve insufficiency will eventually require a reoperation, and could be anticipated in patients younger than 3 months and weighing <4kg.

Expanded description of the female of Lernaeenicus longiventris Wilson, 1917, (Copepoda, Siphonostomatoida, Pennellidae) based on specimens from Mugil platanus Günter, 1880 (Perciformes, Mugilidae) of the state of Rio de Janeiro, Brazil

The description of Lernaeenicus longiventris is expanded and revised, based on specimens collected from the skin and fins of mullets, Mugil platanus Gunther, 1880, from 21 locations in coastal waters of the state of Rio de Janeiro, Brazil.

Immature stages of mosquitoes (Diptera: Culicidae) Collected during the autumn-winter period in Cordoba Province, Argentina

Eggs, immature mosquito collections were made at Cosquin, La Calera ( Chaco phytogeographic region), Villa Allende and Villa del Rosario (Espinal phytogeographic region) during April/September of two consecutive years 1989, 1990. Specific immature habitats in each locality were identified and sampled monthly. Eggs and/or immatures of Aedes albifasciatus, Ae. fluviatilis, Anopheles albitarsis, culex acharistus, Cx. apicinus, Cx. bidens, Cx. coronator, Cx. chidesteri, Cx. dolosus, Cx. maxi, Cx. quinquefasciatus, Cx. saltanensis, Psorophora ciliata and Uranotaenia lowii were collected. Three species (Cx. acharistus, Cx. dolosus and Cx. quinquefasciatus) were collected during the sampling period for all developmental stages. This suggests that immature of these species do not overwinter but continue to develop throughout the cold autumn and winter seasons.

Neotropical Monogenoidea. 23. Two new species of Gyrodactylus (Gyrodactylidae) from a Cichlid and an Erythrinid fish of Southeastern Brazil

Two new species of Gyrodactylus Nordmann, 1832 (Platyhelminthes, Monogenoidea) are described from fishes collected from southeastern Brazil. Gyrodactylus geophagensis n. sp. was collected from the body surface of the "cará", Geophagus brasiliensis (Quoy and Gaimard, 1824) (Cichlidae), from the Rio da Guarda, state of Rio de Janeiro; its major diagnostic features are the morphology of the anchor with a short, truncate superficial root and the shape of the hooks - with a long, delicate shaft. Gyrodactylus trairae n. sp. parasitizes the body surface of the "traíra", Hoplias aff. malabaricus (Bloch, 1794) (Erythrinidae), from the rio Guandu, state of Rio de Janeiro and can be easily differentiated from other species of the genus by having a thin, dorsal bridge, connecting the superficial bar with the spathulated shield. These are the first species of Gyrodactylus formally reported from Brazil. Presently, 26 species of Gyrodactylidae are known from freshwater fishes in the neotropical region; a list of these species is provided.

Neotropical Monogenoidea. 24. Rhinoxenus bulbovaginatus n. sp. (Dactylogyridae, Ancyrocephalinae) from the nasal cavity of Salminus maxillosus (Osteichthyes, Characidae) from the Rio Paraná, Paraná, Brazil

Rhinoxenus bulbovaginatus n. sp. is described from the nose of Salminus maxillosus (Characidae) collected in the basin of the rio Paraná, near the city of Porto Rico, state of Paraná, Brazil. The new species can be differentiated from the other three species in the genus by the morphology of the copulatory complex, vagina, and ventral anchor. The sister group relationship of the known species of Rhinoxenus was determined using techniques of Phylogenetic Systematics (Cladism). The resulting cladogram (C.I.=100%) indicates that the new species is most closely related to R. piranhus Kritsky, Boeger and Thatcher, 1988. The other two species of the genus, R. arietinus Kritsky, Boeger and Thatcher, 1988 and R. nyttus Kritsky, Boeger and Thatcher, 1988, both parasites of Anostomidae fishes, have a paraphyletic position in the cladogram, suggesting that the origin of at least one of them can not be associated to cospeciation.

Neotropical monogenoidea. 25. Anacanthorus penilabiatus n. sp. (Dactylogyridae, Anacanthorinae) from Piaractus mesopotamicus (Osteichthyes, Serrasalmidae), cultivated in the State of São Paulo, Brazil

Anacanthorus penilabiatus n. sp. is described from the serrasalmid fish, Piaractus mesopotamicus (Holmberg, 1887), cultivated in the Centro de Aqüicultura, Universidade Estadual Paulista. The new species is characterized by having a relatively straight copulatory organ with a long "lip" on the distal margin and a median longitudinal flap, and a copulatory ligament. The large size of the infrapopulations of this species of parasite indicates that it should be considered a potential agent causing losses in aquaculture of the fish host.

Classification of immature stage habitats of Culicidae (Diptera) collected in Córdoba, Argentina

In order to classify mosquito immature stage habitats, samples were taken in 42 localities of Córdoba Province, Argentina, representing the phytogeographic regions of Chaco, Espinal and Pampa. Immature stage habitats were described and classified according to the following criteria: natural or artificial; size; location related to light and neighboring houses; vegetation; water: permanence, movement, turbidity and pH. Four groups of species were associated based on the habitat similarity by means of cluster analysis: Aedes albifasciatus, Culex saltanensis, Cx. mollis, Cx. brethesi, Psorophora ciliata, Anopheles albitarsis, and Uranotaenia lowii (Group A); Cx. acharistus, Cx. quinquefasciatus, Cx. bidens, Cx. dolosus, Cx. maxi and Cx. apicinus (Group B); Cx. coronator, Cx. chidesteri, Mansonia titillans and Ps. ferox (Group C); Ae. fluviatilis and Ae. milleri (Group D). The principal component analysis (ordination method) pointed out that the different types of habitats, their nature (natural or artificial), plant species, water movement and depth are the main characters explaining the observed variation among the mosquito species. The distribution of mosquito species by phytogeographic region did not affect the species groups, since species belonging to different groups were collected in the same region.

The use of polyvinyl alcohol glutaraldehyde as solid-phase in ELISA for plague

Discs of polyvinyl alcohol cross-linked with glutaraldehyde were synthesized under acid catalysis (H2SO4). Then, the antigen F1 purified from Yersinia pestis was covalently linked to this modified polymer. Afterwards, an enzyme-linked immunosorbent assay (ELISA) was established for the diagnosis of plague in rabbit and human. The best conditions for the method were achieved by using 1.3 ¼g of F1 prepared in 0.067 M phosphate buffer, pH 7.2, containing 1 M NaCl (PBS); anti-IgG peroxidase conjugate diluted 6,000 times and as a blocking agent 3% w/v skim milk in PBS. The titration of positive rabbit serum according to this procedure detected antibody concentrations up to 1:12,800 times. The present method, the conventional ELISA and passive haemagglutination assay are compared.

Expression of substance P and preprotachykinin mRNA by primary sensory neurons in culture: regulation by factors present in peripheral and central target tissues.

Primary sensory neurons display various neuronal phenotypes which may be influenced by factors present in central or peripheral targets. In the case of DRG cells expressing substance P (SP), the influence of peripheral or central targets was tested on the neuronal expression of this neuropeptide. DRG cells were cultured from chick embryo at E6 or E10 (before or after establishment of functional connections with targets). Preprotachykinin mRNA was visualized in DRG cell cultures by either Northern blot or in situ hybridization using an antisense labeled riboprobe, while the neuropeptide SP was detected by immunostaining with a monoclonal antibody. In DRG cell cultures from E10, only 60% of neurons expressed SP. In contrast, DRG cell cultures performed at E6 showed a significant hybridization signal and SP-like immunoreactivity in virtually all the neurons (98%). The addition of extracts from muscle, skin, brain or spinal cord to DRG cells cultured at E6 reduced by 20% the percentage of neurons which express preprotachykinin mRNA and SP-like immunoreactivity. Our results indicate that factors issued from targets inhibit SP-expression by a subset of primary sensory neurons and act on the transcriptional control of preprotachykinin gene.

Taxonomy and biology of Culex (Culex) maxi Dyar (Diptera: Culicidae) in South America

Culex (Culex) maxi Dyar is described in the adult, pupal and larval stages, and the male genitalia and parts of the fourth-instar larva are illustrated. The larva is described for the first time. The paper includes a summary of available information on the taxonomy, bionomics and distribution of the species. The taxonomy and identification of the species are reviewed in light of current knowledge of the subgenus Culex in the New World.