Management of multidrug resistant Gram-negative bacilli infections in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations.

Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant (MDR) Gram-negative bacilli (GNB), as they are frequently exposed to antibiotics and the healthcare setting, and are regulary subject to invasive procedures. Nevertheless, no recommendations concerning prevention and treatment are available. A panel of experts revised the available evidence; this document summarizes their recommendations: (1) it is important to characterize the isolate's phenotypic and genotypic resistance profile; (2) overall, donor colonization should not constitute a contraindication to transplantation, although active infected kidney and lung grafts should be avoided; (3) recipient colonization is associated with an increased risk of infection, but is not a contraindication to transplantation; (4) different surgical prophylaxis regimens are not recommended for patients colonized with carbapenem-resistant GNB; (5) timely detection of carriers, contact isolation precautions, hand hygiene compliance and antibiotic control policies are important preventive measures; (6) there is not sufficient data to recommend intestinal decolonization; (7) colonized lung transplant recipients could benefit from prophylactic inhaled antibiotics, specially for Pseudomonas aeruginosa; (8) colonized SOT recipients should receive an empirical treatment which includes active antibiotics, and directed therapy should be adjusted according to susceptibility study results and the severity of the infection.

Cardiovascular morbidity and mortality after liver transplantation: The protective role of mycophenolate mofetil.

Cardiovascular (CV) diseases are recognized longterm causes of death after liver transplantation (LT). The objective of this multicenter study was to analyze the prevalence and the evolution of CV risk factors and CV morbidity and mortality in 1819 LT recipients along 5 years after LT. The influence of baseline variables on survival, morbidity, and mortality was studied.

Blood loss in endoscopic sinus surgery: assessment of variables.

Objective: To identify the variables that influence blood loss in endoscopic sinus surgery performed under uniform conditions of preoperative topical vasoconstriction and surgical technique.

Study Design: Blind, nonrandomized, observational study.

Setting: One hundred thirty-eight consecutive patients who underwent endoscopic sinus surgery with the same technique in a university hospital over a 9-month period.

Radiochemotherapy with cisplatin and oral tegafur in advanced head and neck cancer: long-term results of a phase II study.

Aims And Background: To evaluate the tolerance and efficacy of an original concurrent radiochemotherapy regimen in locally advanced head and neck cancer.

Methods: Sixty-four patients with stage III or IV squamous cell carcinoma arising from a head and neck mucosal site were eligible. Simultaneous radiochemotherapy consisted of two courses of continuous infusional cisplatin (20 mg/m2/d, days 1-4 and 29-32) and oral tegafur (1200 mg/d, days 1-14 and 29-43), together with conventional radiation therapy up to a total dose of 70-75 Gy over nine weeks.

Anti-idiotypic Immunotherapy in follicular lymphoma patients: results of a long follow-up study.

A specific immune response against the individual idiotypic determinants of clonal immunoglobulins can be elicited in patients with B-cell malignancies. We analyze the clinical outcome and the presence of tumor cells in the blood of 8 patients with follicular lymphoma, vaccinated with autologous idiotype protein from their lymphoma cells. After a median follow-up of 90 months (range: 54 to 128), all patients, except 1, remain in complete clinical remission and 5 are in complete molecular remission.

Calcification of the posterior cricoid lamina simulating a foreign body in the aerodigestive tract (2005:11b).

This interpretation corner case, reporting a man with suspicion of ingestion and perforation of the oesophagus by a foreign body, highlights the danger of false appearances on plain radiographs for detection of foreign bodies in the aerodigestive tract. Plain radiographs and CT revealed a needle-shaped calcified object between the cricoid plate and the oesophagus lumen, which turned out to be an abnormal cricoid calcification. There is also a discussion about the role of radiology in the detection of foreign bodies in the aerodigestive tract.

Intraclonal variability of VH genes in follicular lymphoma patients who have received anti-idiotypic immunotherapy.

Subclonal heterogeneity can affect idiotypic determinants present in the clonotypic immunoglobulin of B-cell follicular lymphomas (FLs) and may limit the effect of antilymphoma treatments performed by immunization of patients with their own tumor-associated idiotypic immunoglobulin. Idiotype-secreting hybridomas were obtained by fusion of tumor cells from 5 patients with FL, and the K6H6/B5 human heteromyeloma and rearranged VH genes from tumor samples and hybridomas were amplified, cloned, and sequenced. Sequences were aligned with germline genes and somatic mutations, intraclonal heterogeneity and genealogic relations of the B-cell clones in the different biopsy specimens were determined.

Human monoclonal antibodies produced in transgenic BABkappa,lambda mice recognising idiotypic immunoglobulins of human lymphoma cells.

Clonal idiotypic immunoglobulins of follicular lymphomas can be isolated by somatic fusion procedures. Idiotypic IgMs (Id-IgM) were isolated from two patients and used to immunise a strain of mice, deficient in mouse antibody production and engineered with yeast artificial chromosomes (YAC) containing fragments of the human immunoglobulin (Ig) micro/delta heavy chain and kappa/lambda light chain loci. Sequence analysis showed that hybridomas prepared from spleen cells of immunised mice expressed exclusively one of the six VH genes (VH1-2) present in the YAC transgene with different D/J rearrangements, and secrete fully human monoclonal antibodies (mAb) that recognised the tumour-specific IgM proteins.

Unrelated umbilical cord blood transplants in adults: Early recovery of neutrophils by supportive co-transplantation of a low number of highly purified peripheral blood CD34+ cells from an HLA-haploidentical donor.

Unlabelled: OBJECTIVE, METHODS, AND RESULTS: To reduce the period of posttransplant neutropenia and related early morbidity and mortality of cord blood (CB) transplants, we assessed the feasibility of co-infusion of a low number of highly purified peripheral blood CD34+ cells from a related haploidentical donor with a CB graft. Between March 1999 and May 2002, 11 patients with high-risk hematologic malignancies were transplanted using this strategy. The seven patients who received a haploidentical peripheral blood graft and a CB graft from a sibling (6) or the father (1) had prompt recovery (9-17 days, median 10) of the absolute neutrophil count (ANC) to greater than 0.

Left atrial thrombosis after heart transplantation.

Left atrial thrombosis in the absence of rheumatic heart disease and atrial fibrillation is a rare occurrence. We report two cases of left atrial pedunculated thrombus formation after orthotopic heart transplantation. Despite an uneventful post-operative course, sinus rhythm and normal contractility of the heart, large thrombi could be found several months following transplantation.

Edge-to-Edge tricuspid repair for redeveloped valve incompetence after DeVega's annuloplasty.

"Edge-to-edge" technique is a well-accepted procedure with excellent results for correction of mitral insufficiency. We describe a simple edge-to-edge combined with bicuspidalization repair method that was successfully applied in 2 patients for the treatment of redeveloped functional tricuspid regurgitation after previous annuloplasty. Significant improvement in symptoms and echocardiographic results were achieved.

Severe cutaneous vasculitis following intravenous infusion of gammaglobulin in a patient with type II mixed cryoglobulinemia.

Intravenous infusion of gammaglobulins (IVIG) is one of the treatments of choice in patients with type II mixed cryoglobulinemia (MC). We describe the case of a patient with MC who suffered an adverse generalised reaction with severe cutaneous vasculitis accompanied by a sudden increase in cryocrit levels shortly after being treated with IVIG. When the same gammaglobulin preparation was added in vitro to a sample of the patient's serum, a strong increment in cryoglobulin precipitation and depletion of the monoclonal IgM peak resulted.

Late displacement of a ventricular pacing lead after respiratory therapy.

This article presents a case of displacement of the ventricular electrode of a DDD pacemaker occurring 3 years after implantation following a session of respiratory therapy. The incident provoked the loss of the ventricular pacing and left pectoral stimulation. The different techniques for achieving airway patency that can be used in respiratory therapy of patients with permanent pacemakers are discussed.

Active idiotypic vaccination in a patient with biclonal follicular lymphoma.

Specific immunological responses to the idiotypic epitopes present in the surface immunoglobulin (Ig) of the clonal tumour population can be induced for active immunotherapy in patients with B-cell non-Hodgkin lymphoma (NHL). The clonality of the tumour cells should have important implications for the success of the implemented therapy. Here we report on the case of a patient enrolled in a protocol of active idiotypic immunotherapy in which previous cytofluorometric analysis showed a major IgM+, kappap+ population in the tumoral cell suspensions.

Autoantibody activity of the immunoglobulin secreted by a follicular B-cell lymphoma.

In patients with B-cell lymphoma, only in rare cases a secreted paraprotein is found, and in very few of them an associated autoantibody activity has been demonstrated. Here we report the case of a patient with a low-grade B-cell lymphoma with a serum biclonal paraprotein (G,M)lambda and severe erythroblastopenia. Indirect immunofluorescence studies of total serum revealed cytoplasmic (Hep-2 cells) and extracellular matrix (rat tissue sections) staining, suggestive of a new specificity.

[Vasoproliferative tumors of the ocular fundus].

Purpose: To establish the differential diagnosis from choroidal melanoma and other malignant tumors.

Methods: We report 5 patients with vasoproliferative tumors studied in our Hospital since 1993; diagnosis was mainly based on clinic appearance of the lesions. Each patient had undergone indirect ophthalmoscopy and ocular echography.

The intricate relationship between evidence and clinical practice in kidney transplantation.

Clinical practice is supposed to be evidence-based but it always conveys underlying values, judgements, moral principles or axioms. We explore the evidence-based nature of clinical practice in the fast-changing field of kidney transplantation and its relationship with values in five different interventions: those well supported on evidence, focussed on the use of immunosuppressant drugs like cyclosporine, mycophenolate mofetil and tacrolimus, and the elective withdrawal of cyclosporine or steroids; disputable interventions where evidence, focussed on anti-lymphocyte antibodies, is strong but not strong enough to be applied on the majority of occasions; interventions not supported by randomised controlled trials with focus on primary treatment of vascular graft rejection and rescue treatment for acute graft rejection; interventions not widely applied despite strong evidence from sources other than randomised controlled trials, with focus on HLA-matched kidney transplants in cadaver donor and living donor transplants; and finally, a variety of interventions when evidence is lacking. Being aware of the factors influencing every clinical decision we can make the strength of evidence and the nature of the values underlying them explicit and we will find it easier to improve the process of transferring evidence into practice and openly face and acknowledge the values involved.

Testicular germ cell tumor and Down syndrome.

The association between Down syndrome and testicular germ cell tumors may be more frequent than expected according to chance, but few reports have focused on this excess. We report two cases of this association and review the English medical literature.

Stereotactic biopsy for brain tumors: is it always necessary?

Background: Stereotactic biopsy is currently being used in oncological neurosurgery despite its limitations. The purpose of this study is to compare its diagnostic reliability with that of the diagnosis based on clinical data and neuroimaging techniques.

Methods: We studied 200 patients (134 men and 66 women) who underwent 212 stereotactic biopsy procedures to assess brain tumors.

[Pneumoperitoneum: infrequent complication of lithiasic pyonephrosis].

A case of lithiasic pyonephrosis evolving with intrapyelic gas formation, with positive urinary culture for Escherichia coli, is presented. Original clinical presentation was a picture of acute peritonitis with pneumoperitoneum. Clinical and radiological findings were indicative of exploratory laparotomy.

Septic arthritis by Salmonella enteritidis after heart transplantation.

A 13-year-old boy underwent orthotopic heart transplantation for end-stage idiopathic dilated cardiomyopathy. Immunosuppressive therapy consisted of cyclosporine, azathioprine, prednisone, and antithymocyte globulin. Endomyocardial biopsies revealed persistent moderate rejection, which was treated aggressively.