Approach to the patient with acute limb ischemia: diagnosis and therapeutic modalities

Good patient outcomes depend on the rapidity and completeness with which re-establishment of arterial blood flow to the limbs occurs. Patients with a greater magnitude of ischemic tissue--such as with an acute aortic occlusion--have worse outcomes than patients with a segmental artery occlusion such as a popliteal arterial thrombosis. Limb loss is high in any situation in which a delay in diagnosis occurs. It is unclear whether or not endovascular therapy will supercede traditional surgery because the etiologies of ALI are too broad to make sweeping conclusions at this time. The author and others [14,15], including those who have promulgated the use of thrombolytic therapy, have come to reasonable conclusions regarding how to deal with ALI: The diagnosis of ALI should be established rapidly. Determine its classification based on the patient's history and physical examination, and promptly institute anticoagulant therapy. Determine whether or not the patient should be taken emergently for surgical thromboembolectomy or a revascularization procedure versus arteriogram and possible thrombolysis. Adjunctive therapy such as antiplatelet agents (e.g., GIIb/IIIa antagonists) and other anticoagulant agents must be better investigated before recommendations can be made. Save life over limb. Emergent guillotine amputation is sometimes required to save a patient's life.     

Success and complication rates of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography--a prospective study]

The aim of the prospective study was to evaluated the efficacy and the complications of 2,820 ERCP-examinations in 1,717 consecutive patients (performed over a three-year period). The rate of success was 82.8% for diagnostic ERCP, 96.6% for endoscopic sphincterotomy, 76.8% for the extraction of stones on common bile tract, 87.5% for drainage in bile tract obstruction, respectively. The rate of all complications amounted to 7.9% (4.9% diagnostic ERCP, 9.2% therapeutic ERCP, in detail: 3.8% acute pancreatitis, 2.1% cholangitis, 1.3% bleeding, 0.2% perforation, 0.5% other respectively). The total mortality was 0.1% (three cases of death). The frequency of complications increased with the number of procedure at the papilla Vateri in patients, who underwent needle knife papillotomy in combination with standard papillotomy.     

Kidney transplant in diabetic patients: modalities, indications and results

Background

Diabetes is a disease of increasing worldwide prevalence and is the main cause of chronic renal failure. Type 1 diabetic patients with chronic renal failure have the following therapy options: kidney transplant from a living donor, pancreas after kidney transplant, simultaneous pancreas-kidney transplant, or awaiting a deceased donor kidney transplant. For type 2 diabetic patients, only kidney transplant from deceased or living donors are recommended. Patient survival after kidney transplant has been improving for all age ranges in comparison to the dialysis therapy. The main causes of mortality after transplant are cardiovascular and cerebrovascular events, infections and neoplasias. Five-year patient survival for type 2 diabetic patients is lower than the non-diabetics' because they are older and have higher body mass index on the occasion of the transplant and both pre- and posttransplant cardiovascular diseases prevalences. The increased postransplant cardiovascular mortality in these patients is attributed to the presence of well-known risk factors, such as insulin resistance, higher triglycerides values, lower HDL-cholesterol values, abnormalities in fibrinolysis and coagulation and endothelial dysfunction. In type 1 diabetic patients, simultaneous pancreas-kidney transplant is associated with lower prevalence of vascular diseases, including acute myocardial infarction, stroke and amputation in comparison to isolated kidney transplant and dialysis therapy.

Conclusion

Type 1 and 2 diabetic patients present higher survival rates after transplant in comparison to the dialysis therapy, although the prevalence of cardiovascular events and infectious complications remain higher than in the general population.     

New therapeutic modalities in the treatment of graft-versus-host disease

Acute and chronic GvHD are still a major concern in allogeneic hematopoietic stem cell transplantation, still contributing substantially to morbidity and mortality in this therapeutic procedure. Over the past decade, many advances have been made with regard to the prevention and treatment of GvHD using various drugs such as cyclosporine A, FK506, mycophenolate mofetil and/or monoclonal IL-2 receptor antagonists. Despite these measurements with regard to the prevention of acute GvHD, it is very difficult to treat these clinical conditions successfully. However, if patients do not experience any GvHD often the desired effect of graft versus leukemia (GvL) remains absent increasing the probability of a relapse, in particular, in patients transplanted, which are considered at higher risk for relapse. At the present time, new strategies in the prevention of acute GvHD are in progress in particular the use of genetic manipulated donor T cells expressing suicide genes. Further clinical and laboratory studies are required in order to improve the prevention and, in particular, the therapy of established GvHD.     

Brucella endocardititis: clinical particularities and therapeutic modalities

Brucella infective endocarditis is an uncommon, but serious complication of brucellosis. The aortic valve is the most commonly affected cardiac valve. Due to characteristics of the infection, medical therapy alone is not sufficient in treating the disease and best results are obtained with surgery combination. We describe a case of Brucella endocarditis involving the aortic valve suspected in front of the clinical data and the results of serology, confirmed by the culture of the native valves. In association with the medical treatment, management valve replacement lead to a favorable medium-term evolution.     

Cancer rates, medical comorbidities, and treatment modalities in the oldest patients

Cancer disproportionately afflicts older patients, with 56% of incident diagnoses and 71% of deaths occurring in this population. Yet little is known about the "oldest of the old", oncology patients underrepresented in clinical trials. We examined elderly veterans diagnosed with lung, colorectal, prostate or head-neck cancer in 2005 (n=194,797), analyses comparing treatment receipt by age group, 70-84 versus 85-115. Treatment was more common among younger elders, including surgery (1.3% versus 0.6%), chemotherapy (2.1% versus 0.8%) and radiation (1.7% versus 0.7%). Differences were sharper for certain cancers, e.g., chemotherapy for lung (9.0% versus 2.9%), or colorectal surgery (5.8% versus 3.4%). Cancer prevalence is high among elders yet treatment rates appear extremely low, despite evidence of well-tolerated treatment. Toxicity concerns and comorbidities may inhibit pursuit of definitive treatment. As we reconcile definitions of 'elderly' with appropriate treatment options, compassionate care requires identifying geriatric oncology guidelines that improve survival and quality of life.     

Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities

Mesenteric ischemia(MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI(CMI), with the first being subdivided into four categories. Therefore, acute MI(AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and nonocclusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography(CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.     

Reevaluation of the expanded indications in undifferentiated early gastric cancer for endoscopic submucosal dissection

BACKGROUNDAlthough the criteria for the indication of endoscopic submucosal dissection (ESD) for undifferentiated early gastric cancer (UD-EGC) have been recently proposed, accumulating reports on the non-negligible rate of lymph node metastasis (LNM) after indicated ESD raise questions on the reliability of the current criteria. AIMTo investigate the prevalence and risk factors of LNM in UD-EGC cases meeting the expanded indication for ESD.METHODSWe retrospectively reviewed 4780 UD-EGC cases that underwent surgical resection between January 2008 and February 2019 at Asan Medical Center, a tertiary university hospital in Korea. To identify the risk factors of LNM of UD-EGC meeting the expanded criteria for ESD, we performed a case-control study by matching the cases with LNM to those without at a ratio of 1:4. We reviewed the clinical, endoscopic, and histologic features of the cases to identify features with a significant difference according to the presence of LNM. Univariate and multivariate logistic regression analyses were performed to estimate the odds ratios (ORs).RESULTSOf the 4780 UD-EGC cases, 1240 (25.9%) were identified to meet the expanded indication for ESD. Of the 1240 cases, 14 (1.1%) cases had LNM. Among the various clinical, endoscopic, and histopathological features that were evaluated, mixed histology (tumors consisting of 10%-90% of signet ring cells) had a marginally significant association (P = 0.059) with the risk of LNM. Moreover, diffuse blurring of the muscularis mucosae (MM) underneath the tumorous epithelium, a previously unrecognized histologic feature, had a significant association with the absence of LNM (P = 0.028). Multivariate logistic regression analysis showed that the blurring of MM was the only explanatory variable significantly associated with a reduced risk of LNM (OR: 0.12, 95%CI: 0.02-0.95; P = 0.045).CONCLUSIONThe risk of LNM is higher than expected when using the current expanded indication for UD-EGC. Histological evaluation could provide useful clues for reducing the risk of LNM.     

Thromboses of the right cardiac cavities: echocardiographic diagnosis and therapeutic indications apropos of 2 cases and review of the literature

Two cases of pulmonary emboli are reported: a thrombus was detected by echocardiography in the right atrium in the first case and in the right ventricle in the second. Following a review of the 28 cases published to date, criteria are given for distinguishing between those thrombi embolizing from the peripheral veins and those arising in the right cavities of the heart. Therapeutic recommendations are also given.