Graft-versus-host disease and outcome in HLA-identical sibling transplantations for chronic myeloid leukemia

Graft-versus-host disease in its acute (aGvHD) or chronic form (cGvHD) remains the most important posttransplantation factor influencing outcome after allogeneic hematopoietic stem cell transplantation (HSCT). It increases transplantation-related mortality (TRM) but reduces risk of relapse. The net effect of these 2 discordant effects determines survival. In view of current interests to exploit graft-versus-leukemia (GVL) effects, we analyzed 4174 HLA-identical sibling transplantations for chronic myeloid leukemia in first chronic phase, depending on the presence or absence and severity of GvHD with a landmark analysis. During the first 100 days, only aGvHD grades III and IV had an impact on TRM. During the time period day 100 to 3 years increasing severity of aGvHD is associated with increased TRM and decreased relapse incidence (RI) with hazard ratios (HRs) for TRM as follows: grade 0, HR = 1.0; grade I, HR = 1.52 (1.19-1.96); grade II, HR = 2.48 (1.95-3.14); grade III, HR = 5.76 (4.44-7.48); grade IV, HR = 14.7 (10.9-19.9) and likewise for RI: grade I versus 0, HR = 0.94 (0.76-1.16); grade II, HR = 0.60 (0.46-0.77); grade III, HR = 0.48 (0.29-0.81); grade IV, HR = 0.14 (0.02-0.99). Beyond 3 years, TRM and RI are determined by cGvHD. Limited cGvHD reduces RI to the same extent as extensive cGvHD but has no impact on TRM and, hence, results in best survival with an HR = 0.48 (0.32-0.71). aGvHD grade I has the highest likelihood of subsequent limited cGvHD, which results in cumulative incidence estimates of survival at 10 years being best for patients with initial aGvHD grade I: survival at 10 years grade 0 = 59%, I = 63%, II = 56%, III = 26%, IV = not applicable. These data clarify the role of GvHD in posttransplantation outcome. Considerations for long-term outcome are essential when short-term data of interventions on GvHD are analyzed.     

Coronary atherosclerosis in acute myocardial infarct. Anatomic profile of diverse causes of death]

OBJECTIVE: to study the degree of coronary obstruction by atherosclerotic plaques in a population dying with acute myocardial infarction. We defined subgroups by the degree of the obstructive lesion and compared the severity and distribution of coronary atherosclerotic lesions in different groups according to cause. STUDY DESIGN: systematic prospective study in patients dying in the acute phase of myocardial infarction in a University Hospital Coronary Unit during a four years period. POPULATION AND METHODS: we studied 193 patients corresponding 77% of the patients dead in the same period. 24 patients were excluded by technical reasons related to the preparation of necropsic material. The clinical protocol included 64 parameters and were considered the following causes of death: left ventricular failure (shock or acute pulmonary edema), left ventricular free wall rupture, interventricular septum rupture, primary asystole, pulmonary embolism and ventricular fibrillation. To study of the heart we performed the transverse slices technic after fixation; to study the epicardial coronary arteries we isolated the coronaries after fixation and made 5 mm transverse slices. The slices were macroscopic and microscopic evaluated for the degree of coronary obstruction in every 5 mm segment. We classified the degree of coronary obstruction in five grades: less than or equal to 25%; greater than 25% e less than or equal to 50%; greater than 50% e less than or equal to 75%; greater than 75% e less than 100%; and total obstruction. RESULTS: the degree of coronary obstruction in each epicardial segment were: Right ostium--grade I = 21%, grade II = 46%, grade III = 26%, grade IV = 7%, grade V = 0; Right coronary--grade I = 5%, grade II = 10%, grade III = 19%, grade IV = 28%, grade V = 38%; Left ostium--grade I = 27%, grade II = 50%, grade III = 19%, grade IV = 4%, grade V = 0; Left main--grade I = 16%, grade II = 43%, grade III = 28%, grade IV = 10%, grade V = 2%; Anterior descendent--grade I = 1%, grade II = 5%, grade III = 11%, grade IV = 34%, grade V = 49%; Left circumflex--grade I = 2%, grade II = 14%, grade III = 22%, grade IV = 40%, grade V = 22%. The number of coronary arteries with more than 75% obstruction for each group of one, two or three vessel disease were: 1 vessel--41 cases; 2 vessels--56 cases; 3 vessels--68 cases. The number of vessels with more than 75% obstruction for each cause of death were: Wall rupture--1 vessel = 20, 2 vessels = 18, 3 vessels = 11; Septum rupture--1 vessel = 0, 2 vessels = 2, 3 vessels = 2; Shock--1 vessel = 12, 2 vessels = 21, 3 vessels = 30; Acute pulmonary edema--1 vessel = 1, 2 vessels = 9, 3 vessels = 7; Asystole--1 vessel = 4, 2 vessels = 1, 3 vessels = 8; Pulmonary embolism--1 vessel = 2, 2 vessels = 5, 3 vessels = 8; Ventricular fibrillation--1 vessel = 2, 2 vessels = 0, 3 vessels = 2. CONCLUSION: in most patients dying with acute myocardial infarction, the coronary atherosclerotic lesions were present in two or three epicardial coronary arteries. The left anterior descendent artery was the more frequent artery with major lesion (greater than 75%). Major atherosclerotic lesion in just one vessel were more frequent in patients dying by cardiac rupture.     

Liver regeneration in living-related donors after harvesting of liver segments II and III or II, III and IV

BackgroundCT-assisted volumetry permits an estimation of the volume of the graft in liver transplantation, as well as monitoring the donor''s liver regeneration. The aim of the study was to observe the restitution of liver tissue in donors after harvesting of the liver fragment for living-related liver transplantation (LRLT).MethodsThe size of the whole liver and of segments II, III and IV was assessed by preoperative CT volumetry in 29 living-related liver donors. Segments II and III were harvested in 22 patients, segments II, III and IV in 6 patients. The remnant liver was assessed by CT volumetry on the 7th and 30th postoperative days.ResultsThe correlation between the calculated volume of the graft and its weight was linear (r=0.56, p<0.04). Postoperative CT volumetry of the liver of living-related donors showed a different pattern of volume restoration (regeneration index) at both 7 and 30 days between donors who sacrificed segments II and III and those who sacrificed segments II, III and IV. The mean regeneration indexes were significantly higher in donors of segments II, III and IV as compared with donors of segments II and III (7 days, p<0.02; 30 days, p<0.05).DiscussionIt is possible that the donor''s liver displays a different pattern of growth due to the alteration in blood supply to segment IV.     

Early healing after treatment of coronary lesions by thin strut everolimus,or thicker strut biolimus eluting bioabsorbable polymer stents: The SORT-OUT VIII OCT study

Aims

Early healing after drug-eluting stent (DES) implantation may reduce the risk of stent thrombosis. The aim of this study was to compare patterns of early healing after implantation of the thin strut everolimus-eluting Synergy DES (Boston Scientific) or the biolimus-eluting Biomatix Neoflex DES (Biosensors).

Methods and Results

A total of 160 patients with the chronic or acute coronary syndrome were randomized 1:1 to Synergy or Biomatrix DES. Optical coherence tomography (OCT) was performed at baseline and at either 1- or 3-month follow-up. The primary endpoint was a coronary stent healing index (CSHI), a weighted index of strut coverage, neointimal hyperplasia, malapposition, and extrastent lumen. A total of 133 cases had OCT follow-up and 119 qualified for matched OCT analysis. The median CSHI score did neither differ significantly between the groups at 1 month: Synergy 8.0 (interquartile range [IQR]: 3.0; 14.0) versus Biomatrix 8.5 (IQR: 4.0; 15.0) (p = 0.47) nor at 3 months: Synergy 6.5 (IQR: 2.0; 13.0) versus Biomatrix 6.0 (IQR: 4.0; 11.0) (p = 0.83). Strut coverage was 84.6% (IQR: 72.0; 97.9) for Synergy versus 77.6% (IQR: 70.1; 90.3) for Biomatrix (p = 0.15) at 1 month and 90.3% (IQR 79.0; 98.8) (Synergy) versus 83.9% (IQR: 77.5; 92.6) (Biomatrix) (p = 0.068) at 3 months. Pooled 1 - and 3-month coverage was 88.6% (IQR: 74.4; 98.4) for Synergy compared with 80.7% (IQR: 73.2; 90.8) for Biomatrix (p = 0.02).

Conclusions

The early healing response after treatment with the Synergy or Biomatrix DES did not differ significantly as determined by a healing index. The Synergy DES showed overall better early stent strut coverage.     

Influence of Plaque Characteristics on Early Vascular Healing in Patients With ST-Elevation Myocardial Infarction

ObjectivesTo compare the early vascular healing of ruptured plaques (RP) and non-ruptured plaques (NRP) one month after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI), using optical coherence tomography (OCT).BackgroundVascular healing and strut coverage are important factors in reducing the risk of stent thrombosis after PCI. Influence of underlying lesion characteristics and differences in healing response between RP and NRP are unknown.MethodsTwenty-six STEMI-patients underwent PCI and implantation of a polymer-free drug-coated Biofreedom stent (BF-BES). OCT was performed pre-PCI, post-PCI and at 1-month follow-up. The patients were divided into two groups: RP = 15 and NRP = 11. OCT analyses of culprit lesion, post stent implantation at baseline and follow-up were performed to determine the difference in vascular healing based on presence of uncovered and/or malapposed stent struts and intraluminal filling defects.ResultsThe stent coverage did not differ significantly between the two groups at 1-month follow-up with percentage of uncovered struts: RP 26.5% [IQR 15.0–49.0] and NRP 28.1% [IQR 15.5–38.8] for NRP (p = 0.78). At 1-month, RP showed an increased percentage of late acquired malapposed struts (1.4% [IQR 0.8–2.4] vs. 0.0% [IQR 0.0–1.4], p = 0.03) and a larger total malapposition area (1.3 mm² [IQR 0.4–2.5] vs. 0.0 mm² [IQR 0.0–0.9], p = 0.01), compared to NRP.ConclusionThree out of four struts were covered within one month after stenting. The vascular healing was comparable in RP and NRP on stent coverage. However, RP had more and larger late acquired malapposition areas.     

Rat liver fibrosis regresses better with pegylated interferon alpha2b and ursodeoxycholic acid treatments than spontaneous recovery.

BACKGROUND/AIMS: Fibrosis and cirrhosis are common complications of chronic liver diseases. An imbalance between fibrogenesis and fibrolysis results in scarring of the liver parenchyma. We aimed to investigate the possible antifibrotic effectiveness of a newly modified interferon molecule peginterferon alpha2b (PEG-IFNalpha2b) which has better antiviral activity, and ursodeoxycholic acid (UDCA). METHODOLOGY: Liver fibrosis was established on 60 male Sprague Dawley rats with CCl4 in 12 weeks. After cessation of CCl4 Group I was left for spontaneous recovery. Group II was treated with PEG-IFN 1.5 microg/kg/week, Group III with UDCA 25 mg/kg/day and Group IV with combination of both drugs. All rats were killed at week 16. Histopathologic fibrosis scores, tissue hydroxyproline, TIMP-1 and MMP-13 levels were determined. Hepatic stellate cell apoptosis was detected by dual staining with TUNEL technique and anti-alpha smooth muscle actin. RESULTS: Fibrosis scores were lower in Group II, III and IV than Group I (p<0.05 for group I vs. II and III; p<0.01 for group I vs. IV). Tissue hydroxyproline levels were significantly decreased in Group II, III and IV when compared to Group I (p<0.05 for group I vs. II, p<0.01 for group I vs. III and IV). Lower liver TIMP-1 and higher MMP-13 levels were measured in Group II, III, and Group IV than Group I (p<0.01 for TIMP-1 and p<0.01, for MMP). Activated HSC apoptosis was significantly increased in Group II, III and IV when compared to Group I (p<0.01, for all). There was significantly higher apoptosis in Group II than Group III and IV (p<0.01). CONCLUSION: Treatment with both PEG-IFNalpha2b and UDCA improved CCl4 induced rat liver fibrosis. Significantly higher effects were obtained using these agents in combination.     

The effects of the immunomodulators on the colonic anastomosis in an experimental model of intraperitoneal sepsis

BACKGROUND/AIMS: The present study examined the effects of G-CSF and Levamisole used as immunomodulators on the colonic anastomosis healing in the presence of an intraabdominal infection. METHODOLOGY: 40 male Spraque-Dawley rats were randomly allocated to 4 groups each consisting of 10 animals. Standard colonic anastomosis, peritonitis and colonic anastomosis, peritonitis and colonic anastomosis and G-CSF, peritonitis and colonic anastomosis and Levamisole were applied to groups I, II, III and IV, respectively. The cecum of the rats in groups II, III and IV was ligated and perforated to create an intraabdominal sepsis model. G-CSF 50 microg/kg/day were given subcutaneously to group III and Levamisole 5 mg/kg/day were given perorally to group IV in the postoperative period until sacrifice. The rats were sacrificed on the fourth postoperative day. Bursting pressure and hydroxyproline level measurements of the anastomosis were evaluated. RESULTS: Bursting pressures of all groups were lower than the control group (p<0.001). The mean bursting pressure of group III was significantly higher than group II (p<0.05). The mean level of hydroxyproline in group III was significantly higher than group II (p<0.05) however; overall, it was lower in all groups than the control (p<0.05). CONCLUSIONS: This study demonstrated that intraabdominal sepsis adversely affects healing of colonic anastomosis, and healing of the anastomosis becomes better and the mortality rate decreases by the use of G-CSF.     

Direct lipiodol injection used for a radio-opaque lung marker: stability and histopathologic effects

The objective of this study was to evaluate the effects on the histopathologic findings of directly injected lipiodol into lung and to identify the existence of remaining lipiodol in the lung according to the follow-up time. Forty rats were randomly assigned to 1 of 4 groups: group I (n = 10) served as the control group and received 0.2 mL of normal saline; groups II (n = 10), III (n = 10), and IV (n = 10) served as experimental groups and received 0.1-0.2 mL of lipiodol under fluoroscopy. At 3 hours (groups I and II), 24 hours (group III), and 1 week (group IV) after injection, the radiographic presence of lipiodol and histopathologic findings of each group were evaluated. Minimal acute lung injuries developed and the radio-opaque lipiodol nodule remained in group II. In group III, acute lung injuries were the most serious. However, acute injuries disappeared and foamy macrophages accumulated within the alveolar space in group IV. In this group, remaining lipiodol was also identified on radiograph. Directly injected lipiodol caused acute lung injury, which disappeared at 1 week along with the resolving process. On radiographs, directly injected lipiodol remained after 1 week. Lipiodol could be used as a safe and stable biomaterial for marking pulmonary nodules.     

The National Pressure Ulcer Long-Term Care Study: outcomes of pressure ulcer treatments in long-term care

OBJECTIVES: To identify resident, wound, and treatment characteristics associated with pressure ulcer (PrU) healing in long-term care residents. DESIGN: Retrospective cohort study with convenience sampling. SETTING: Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States. PARTICIPANTS: Eight hundred eighty-two residents, aged 18 and older, with length of stay of 14 days or longer, who had at least one Stage II to IV PrU. MEASUREMENTS: Data collected for each resident over a 12-week period included resident characteristics, treatment characteristics, and change in PrU area. Data were obtained from medical records, Minimum Data Set, and other records. RESULTS: Two multiple regression models, one for each stage grouping (Stage II, Stage III and IV), were completed. The area of Stage II PrU was reduced more with moist (F=21.91, P<.001) than with dry (F=13.41, P<.001) dressings. PrUs cleaned with saline or soap showed less decrease in area (F=12.34, P<.001) than PrUs cleaned with other cleansers such as antiseptic, antibiotic, or commercial cleansers. Change in area of Stage III and IV PrUs was related to sufficient enteral feeding (F=5.23, P=.02), enteral feeding without higher acuity levels (F=3.94, P=.048), size of PrU (very large (F=120.89, P=.001) and large (F=27.82, P=.001)), and type of dressing (moist (F=14.70, P<.001) and dry (F=5.88, P=.02)). Stage III and IV PrUs increased in area when debrided (F=5.97, P=.02). The overall models were significant (Stage III and IV, F=20.30, coefficient of determination (R2)=0.06, P<.001; Stage II, F=40.28, R2=0.13, P<.001) but explained little of the variation in change in PrU area. CONCLUSION: In this sample of nursing facility residents, use of moist dressings (Stage II, Stage III and IV) and adequate nutritional support (Stage III and IV) are strong predictors of PrU healing.     

Effectiveness of rubber band ligation in haemorrhoids and factors related to relapse.

PURPOSE: to assess the effectiveness of ambulatory rubber band ligation (RBL) in the treatment of symptomatic internal haemorrhoids and to identify factors related to relapse. PATIENTS AND METHODS: prospective study of 232 patients treated with rubber band ligation for symptomatic haemorrhoids (grade I-III or grade IV with severe contraindication for surgery) from November 1996 to November 2000 at the outpatient clinic. Ligation was performed with a Stille AB (Comedic) ligator and suction pump, placing 1-3 bands per session and with up to three sessions per patient. Effectiveness of treatment was defined as the absence of symptoms and was confirmed by anoscopy by checking the residual scar after the cushions' detachment. Categorical variables were compared using the shi-squared test, whereas Student's t-test was used for continuous variables. Logistic regression was employed to identify clinical factors related to relapse. RESULTS: a total of 331 bands were placed during 235 sessions in the 163 patients who completed follow-up (70%). Mean age was 45.6 years, with males accounting for 64.4%. Most patients (86.5%) had grade II or grade III haemorrhoids. Overall morbidity was 6%. The most frequent complications were rectal tenesmus (11%), slight or mild anal pain (7.4%), dysuria (4.3%) and transient anal bleeding (3.7%). The treatment was effective in 86% of patients after a mean follow-up of 32 months. Efficacy was high for grades I and II (100% and 97.4% ) but decreased for grade III (69.8%; p<0.001) and grade IV (0%; p<0.001). Most relapses occurred within the first 24 months (87%) and were not significantly related to age, gender, duration of symptoms, itching, bleeding, pain, tenesmus or bowel habit, but were significantly related to the presence of prolapse and its grade (p<0.001), and to the involvement of left posterior, right lateral and anterior pedicles (p<0.05). CONCLUSIONS: ambulatory RBL is a safe and effective treatment for grade I, II and III symptomatic haemorrhoids, and is associated with low morbidity. Recurrence is uncommon and occurs mainly within the first 24 months, being related to the presence and grade of prolapse as well as to its location, but bears little relation to the rest of factors analysed.     

Liver trauma: What current management?

Background: The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years.Methods: The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed.Results: The study involved 83 patients, with a mean age of 33 years and a marked male predominance(85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries(81.9%) were of low severity(grades Ⅰ,Ⅱ,Ⅲ), while 15(18.1%) were of high severity(grade Ⅳ or greater). Fifty-six patients(67.5%) had multiple injuries. Surgical treatment was performed in 26(31.3%) patients. Non-operative management was undertaken in 57 cases(68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group.Conclusions: Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.     

Cardiovascular risk factors do not predict clinically defined restenosis after percutaneous transluminal angioplasty for lower limb ischemia

The purpose of this study was to evaluate risk factors predicting restenosis and primary patency after percutaneous transluminal angioplasty. Follow-up data (including cardiovascular risk factor scores according to SCVIR criteria, preinterventional and postinterventional clinical data and patient history) of all patients who underwent successful percutaneous transluminal angioplasty for lower limb ischemia were analyzed retrospectively and patients, relatives, or referring physicians underwent a telephone interview. Patients with incomplete follow-up data were examined by means of a clinical examination, including Doppler measurements and treadmill test. Additionally all angiograms were evaluated to calculate lesion length, number of treated lesions, lesion type (SCVIR score), and runoff. The outcome was categorized into four groups: early recurrence (< 1 month, group I), mean recurrence (1-6 months, group II), late recurrence (>6 months, group III), and no recurrence (group IV). According to common concepts group I was defined as early (thrombotic) reocclusion, group II as clinically defined restenosis, and group III as progression of atherosclerosis. One hundred thirty-seven patients underwent percutaneous transluminal angioplasty of 148 extremities. The groups differ significantly only with respect to a higher diabetes score for group I in comparison to group IV (p=0.002, Kruskal-Wallis test), and a worse runoff of group I compared with group IV (p =0.008). There was a trend toward a higher diabetes score for group II in comparison to group IV (p = 0.014). There were no differences with regard to hyperlipemia, hypertension, and tobacco use between patient groups. Mean primary patency was 436 days. Predictors for lower patency rates were diabetes mellitus (p<0.001), runoff (p=0.005), and number of treated lesions (p=0.007) in a stepwise, multiple regression analysis. Patients with clinically defined restenosis showed no specific risk factor profile in this study. Predictors for lower primary patency were diabetes mellitus, number of treated lesions, and runoff.     

Endoscopic management of traumatic bile leaks

BACKGROUND: Traumatic bile leaks often result in prolonged morbidity and an increased length of hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. OBJECTIVE: To evaluate the efficacy of endotherapy in the management of traumatic bile leaks. DESIGN: Retrospective evaluation of prospectively collected data. SETTING: Tertiary academic referral center. PATIENTS: Consecutive patients referred for ERCP after traumatic abdominal injury for the management of bile leaks. INTERVENTIONS: Biliary stent placement at ERCP. MAIN OUTCOME MEASURES: Resolution of a bile leak on follow-up ERCP. RESULTS: Ten patients underwent ERCP for the management of a traumatic bile leak over a 3-year period. The etiology included a penetrating injury from a gunshot wound in 5 patients, blunt injuries from a motor vehicle accident in 4 patients, and injury secondary to a fall in 1 patient. Liver injuries were grade II in 1 patient, grade IV in 7 patients, and grade V in 2 patients. A bile leak was treated by biliary stent placement in all patients, and the outcome was successful in 9 of 10 cases (90%). The mean duration of follow-up was 337 days (range, 101-821 days). Nine of 10 patients underwent surgery to control bleeding or other associated injuries. There were no ERCP-related complications. LIMITATIONS: Small number of patients. CONCLUSIONS: Consideration should be given to incorporate ERCP as first-line therapy in management of traumatic bile leaks, because endobiliary stent placement provides a successful outcome in a majority of cases, irrespective of the severity of injury.     

The forgotten Korotkoff phases: how often are phases II and III Present, and how do they relate to the other Korotkoff phases?

BACKGROUND: There are no data on the pattern of the Korotkoff phases in the normal population. This study was designed to describe the pattern of Korotkoff phase distribution in adults and children; to measure the duration of each of the phases; and to describe the differences between adults and children. METHODS: A total of 57 children (7 to 8 years old) and 59 adults (median age 47 years, range 30 to 62 years) were studied. The pressure in the arm cuff was deflated using a device to provide a consistent deflation rate. The Korotkoff sounds were recorded to MiniDisc from the bell of a stethoscope and each sound described as phase I, II, III, or IV. RESULTS: The most common pattern of Korotkoff phase distribution was for all five phases to be present (children [23/57; 40%], adults [24/59; 41%]). Phases I and IV were more common in children than in adults (56/57 [98%] v 47/59 [80%]; P = .002 for phase I; 52/57 [91%] v 44/59 [75%]; P = .018 for phase IV). Phases II and III were less common in children than in adults (32/57 [56%] v 50/59 [85%], P = .001 for phase II; 27/57 [47%] v 45/59 [76%], P = .001 for phase III). Phases I and IV were longer in children (median 3.9 [interquartile range, IQR 2.1 to 6.7] and 6.7 [IQR 3.2 to 9.8] sec, respectively) compared with adults (1.3 [IQR 0.7 to 2.7] and 1.7 [IQR 0.3 to 2.6), P < .001). CONCLUSIONS: There are clear differences in the Korotkoff phases between adults and children. The length of phases II and III increase with age with concomitant decrease in phases I and IV. These differences between adults and children remain unexplained.     

Prevention of Deleterious Effects of Reperfusion Injury Using One-Week High-Dose Allopurinol

Allopurinol has been widely used to reduce the severity of the reperfusion injury. However, conflicting data have been reported regarding the dosage, the duration of the timing, and the administrative regimen of the drug. The aim of this study was, therefore, to evaluate the effects of short versus long periods of allopurinol pretreatment on the anastomotic healing of intestines, directly after being subjected to ischemia–reperfusion (IR) stress. Furthermore, the effects of an allopurinol pretreatment on the survival rate following IR stress, was also assessed. One hundred thirty-seven male Wistar rats with a median weight of 235 (range, 180–275) g used in the study. In group I (control group, N = 20) superior mesenteric artery (SMA) and collateral vessels were isolated but not occluded. In group II, the profound IR group (PIR, N = 42), the SMA was occluded immediately distal to the aorta with collateral interruption using an atraumatic arterial clip for 30 min. In group III [two days of allopurinol (ALL) pretreatment group, 2ALL, N = 38], allopurinol (100 mg/kg body wt) was given intraperitoneally on a daily basis for two days prior to the experiment. In group IV (seven days of allopurinol pretreatment group, 7ALL, N = 37), the same pretreatment and the allopurinol schedule was performed for seven days before surgery. All animals underwent 3 cm of ileal resection and primary anastomosis, 10 cm proximal to ileocecal valve. Within each group, animals were anesthetized either on the third or seventh postoperative days. Abdominal wound healing, intraabdominal adhesions, anastomotic complications, anastomotic bursting pressure measurements, and bursting site were recorded as were the histopathologic evaluation. No rats in group I, 20 rats in group II, 18 rats in group III, and 7 rats in group IV died (P = 0.0003). Anastomotic dehiscence was found in one of 20 group I, in 11 of 22 in group II, in 9 of 20 in group III, and in 3 of 30 in group IV (P = 0.0003). On the third and seventh days, the median bursting pressures of the anastomosis were determined: 42 and 235 mm Hg in group I, 17 and 105 mm in Hg in group II, 22 and 183 mm Hg in group III, and 36 and 214 mm Hg in group IV (P < 0.0001). The burst occurred at the anastomoses in all animals tested on the third postoperative day, one in group I, six in group II, four in group III and one in group IV on the seventh postoperative day (P < 0.01). All deleterious effects of reperfusion injury on intestinal anastomosis healing, including survival rates and the histopathological parameters, were significantly prevented by seven days, but not two days, of high-dose allopurinol pretreatment.     

An evidence of intestinal mucosal injury in dengue infection

The aim of this study was to determine whether there is an association between dengue infection and intestinal mucosal injury. Serum levels of intestinal fatty acid binding protein (I-FABP) were used as a specific marker for mucosal injury. The diagnosis of all patients was serologically confirmed by anti-dengue IgG or IgM. Serum I-FABP levels of 120 patients were determined and compared to those of 25 controls using ELISA. In order to investigate serum I-FABP among dengue patients, they were categorized into 5 groups according to disease severity: dengue fever (DF), dengue hemorrhagic fever (DHF) grade I through DHF grade IV. The dengue patients had higher levels of serum I-FABP compared to 25 controls (408.0 +/- 499.3 vs 124.72 +/- 147.81 pg/ml, p=0.006). The patients with DHF grade IV had the highest levels of serum I-FABP, ALT, and AST compared to the other groups. However, there were no differences in serum I-FABP, ALT, and AST levels among patients with DF, DHF grade I, grade II, and grade III. Evidence of intestinal mucosal injury in patients with dengue infection was demonstrated. Patients with DHF grade IV had high serum I-FABP levels and had associated liver injury.     

Therapy of regional lymphadenitis following BCG vaccination

Summary In this study we presented 92 cases with regional lymphadenitis (over 1 cm in diameter) which was caused by BCG vaccination generally performed a few days after birth. The patients were divided into four therapy groups. In group I, the lymphadenitis in 26 cases was excised totally by a surgical operation and they improved in a median period of four weeks (average: 4.4). No therapy was applied in 33 patients constituting group II and their periods of improvement were 28 weeks (average: 29.1). Sixteen cases in group III were given isoniazid (INH) 10 mg/kg for six months in addition to total surgical excision and their healing period was 4.5 weeks (average: 4). Seventeen cases in group IV were administered only INH for six months and the median improvement period was found to be 27 weeks (average: 28.2). The statistical differences in terms of the improvement periods between groups I and III, and groups II and IV were found to be insignificant (p>0.05) but these differences were significant between groups I and II, groups I and IV, groups II and III, and groups III and IV (p<0.05). These results show that spontaneous healing is possible. Total excision is the best therapy for BCG lymphadenitis in suppurative forms and INH has no effect in shortening the therapy period.

---

Behandlung der regionalen Lymphadenitis nach BCG-Impfung

Zusammenfassung Bei 92 Fällen von regionaler Lymphadenitis nach BCG-Impfung (Durchmesser mehr als 1 cm) wurden vier verschiedene Therapieformen geprüft. Bei chirurgischer Exstirpation der vergrößterten Lymphknoten (n=26) betrug die mediane Heilungszeit vier Wochen (Durchschnitt 4,4 Wochen); gegenüber dieser Gruppe I benötigte Gruppe II mit 33 Kindern, die keinerlei Therapie erhielten, eine erheblich längere Heilungszeit von median 28 (Durchschnitt 29,1) Wochen. In Gruppe III wurden 16 Kinder chirurgisch und zusätzlich sechs Monate lang mit IHN in einer Dosierung von 10 mg/kg täglich behandelt, die mediane Heilungszeit betrug in diesen Fällen 4,4 (Durchschnitt 4) Wochen. Bei Gruppe IV mit 17 Fällen wurde ausschließlich medikamentös mit INH behandelt; trotz der sechswöchigen Therapie vergingen median 27 (im Durchschnitt 28,8) Wochen bis zur Heilung. Zwischen den Gruppen I und III und II und IV fanden sich keine signifikanten Unterschiede (p>0,05); dagegen waren signifikante Unterschiede mit p<0,05 zwischen den Gruppen I und II, I und IV und II und III nachzuweisen. Spontane Heilung der BCG-Lymphadenitis erwies sich als möglich; bei suppurativen Formen ist die totale Exzision das beste Vorgehen. INH verkürzte die Heilungszeit nicht.

     

Comparison of the effects of cardiac resynchronization therapy in patients with class II versus class III and IV heart failure (from the InSync/InSync ICD Italian Registry)

Cardiac resynchronization therapy (CRT) is recommended for patients with New York Heart Association (NYHA) class III or IV heart failure and wide QRS complexes. The aim of this study was to compare the effects of CRT in patients in NYHA class II with those in NYHA class III or IV. Nine hundred fifty-two patients (188 in NYHA class II) consecutively implanted with biventricular devices and enrolled in a national observational registry were studied. Clinical outcomes were estimated after 12 months of CRT, and long-term survival was assessed. At a median follow-up of 16 months, significantly fewer major cardiovascular events were reported in patients in NYHA class II compared with NYHA class III or IV (rate 13 vs 23 per 100 patient-years of follow-up, p<0.001). The percentage of patients who improved in NYHA class status after 12 months of CRT was lower in those in class II than in those in class III or IV (34% vs 69%, p<0.001), whereas the absolute increase in the ejection fraction was similar (8+/-9% vs 9+/-11%, p=NS), as well as the reductions in end-diastolic diameter (-3+/-8 vs -3+/-8 mm, p=NS) and end-systolic diameter (-4+/-10 vs -6+/-10 mm, p=NS). The NYHA class II group experienced lower all-cause mortality (log-rank test p=0.018). In the 2 groups, patients with major cardiovascular events during follow-up exhibited less or no reverse remodeling compared with those with better long-term clinical outcomes. In conclusion, the results of this study indicate that CRT induced similar improvements in ventricular function in the 2 groups, whereas the improvement in functional status was significantly lower for patients in NYHA class II than for those in class III or IV. A positive effect of CRT on cardiac dimensions was associated with a long-term beneficial effect on disease progression in patients in NYHA class II.     

Effect of restoration of coronary blood flow on dynamics of myocardial perfusion and function in patients with acute myocardial infarction. Data of gated technetium-99m-sestamibi SPECT

Effects of coronary blood flow restoration on dynamics of myocardial perfusion and function were studied in 50 patients with acute myocardial infarction during 6-month follow-up. Gated SPECT with 99mTc-MIBI (G-SPECT) was performed before onset of reperfusion procedures, in 24 hours, 10 days, 1 and 6 months. In patients with successful reperfusion (n=36) perfusion defect (PD) size decreased by 6.78+/-0.97% (p<0.001) and its severity by 221.3+/-85 std (p<0.001) in 24 hours. In 10 days PD size decreased by 3.9+/-0.88% (r<0.05) and severity by 149+/-39 std (p<0.05), whereas in 1 month PD size decreased by 2,18+/-1,4% (p<0.05), PD severity by 146.3+/-67 std (p<0.05). Successful reperfusion was associated with improvement of contractility: left ventricular ejection fraction increased by 3% (p<0.05) on day 10 of the disease. In patients with failed reperfusion PD size and severity decreased in 10 days by 4.8+/-4.2%, p<0.05, and 276+/-75 std, p<0.05, respectively, in 6 months PD size decreased by 3.1+/-0.9%, p<0.05, left ventricular ejection fraction did not change during follow-up. We conclude that successful reperfusion therapy promotes restoration of myocardial perfusion and improvement of its contractility.     

Delayed repair of obstetric injuries of the anorectum and vagina

PURPOSE: We categorized the various types of postobstetric injuries of the anorectum and vagina encountered in a five-year period. The operative procedures used to repair these injuries and the functional outcome after surgery were assessed. METHODS: Between 1986 and 1991, 52 patients were surgically treated for obstetric injuries of the anorectum and vagina; 48 patients were available for follow-up study. Four clinical injury types were identified: Type I, incontinent anal sphincter (11 patients); Type II, rectovaginal fistula (16 patients); Type III, rectovaginal fistula and incontinent anal sphincter (11 patients); and Type IV, cloaca-like defect (10 patients). The mean age of the patients was 30 years, the mean duration of symptoms before surgery was 13 months, and the mean follow-up period was 16 months. The major component of surgical repair for each injury type was: Type I, overlap repair of external anal sphincter; Type II, rectal mucosal advancement flap; Type III, overlap repair of external anal sphincter and rectal mucosal advancement flap; and Type IV, overlap repair of external anal sphincter, anterior levatorplasty, and anal and vaginal mucosal reconstruction. Fecal diversion was not performed in any patient. Specific questions were asked at the most recent follow-up assessment to determine results. RESULTS: Continence status postoperatively was classified as perfect, impaired, or poor; poor was defined as no improvement or worse. Postoperative continence (perfect, impaired, or poor) was, respectively: Type I (11 patients), 64 percent, 36 percent, and 0 percent; Type II (16 patients), 56 percent, 0 percent, and 44 percent; Type III (11 patients), 64 percent, 36 percent, and 0 percent; and Type IV (10 patients), 90 percent, 10 percent, and 0 percent. Vaginal discharge of stool was eliminated in all patients with a rectovaginal fistula. Subjectively, 92 percent of the patients had excellent or good results. Complications included wound hematoma (n=2), fecal impaction (n=2), urinary retention (n=1), and urinary tract infection (n=1). CONCLUSION: Patients with Type II injuries had the worst results (P < 0.001). These patients should be evaluated for anal incontinence before surgery to assess the need for a concomitant sphincteroplasty.