Use of dissecting sealer may affect the early outcome in patients submitted to hepatic resection

Background. Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness. Patients and methods. All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality. Results. Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150 min. Total operative time range was 120–480 min. The average blood loss was 325 ml (range 50–600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients. Conclusion. The water-cooled high frequency monopolar device is useful for reducing ischemia–reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery.     

Common variant in AMPD1 gene predicts improved clinical outcome in patients with heart failure

BACKGROUND: This study was undertaken to identify gene(s) that may be associated with improved clinical outcome in patients with congestive heart failure (CHF). The adenosine monophosphate deaminase locus (AMPD1) was selected for study. We hypothesized that inheritance of the mutant AMPD1 allele is associated with increased probability of survival without cardiac transplantation in patients with CHF. METHODS AND RESULTS: AMPD1 genotype was determined in 132 patients with advanced CHF and 91 control reference subjects by use of a polymerase chain reaction-based, allele-specific oligonucleotide detection assay. In patients with CHF, those heterozygous (n=20) or homozygous (n=1) for the mutant AMPD1 allele (AMPD1 +/- or -/-, respectively) experienced a significantly longer duration of heart failure symptoms before referral for transplantation evaluation than CHF patients homozygous for the wild-type allele (AMPD1 +/+; n=111; 7.6+/-6.5 versus 3.2+/-3.6 years; P<0.001). The OR of surviving without cardiac transplantation >/=5 years after initial hospitalization for CHF symptoms was 8.6 times greater (95% CI: 3.05, 23.87) in those patients carrying >/=1 mutant AMPD1 allele than in those carrying 2 wild-type AMPD1 +/+ alleles. CONCLUSIONS: After the onset of CHF symptoms, the mutant AMPD1 allele is associated with prolonged probability of survival without cardiac transplantation. The mechanism by which the presence of the mutant AMPD1 allele may modify the clinical phenotype of heart failure remains to be determined.     

One-year outcome of patients submitted to routine fractional flow reserve assessment to determine the need for angioplasty.

AIMS: In patients submitted to coronary angiography, fractional flow reserve (FFR) assessment by a pressure wire can be used to guide the decision for revascularization. Routine application of FFR assessment and 1-year outcome of patients are poorly documented. The aim of this study was to report a 4-year single-centre experience where the use of FFR for decision making in equivocal lesions is encouraged. METHODS AND RESULTS: A prospective registry was designed to collect clinical and angiographic characteristics, as well as 1-year clinical follow-up for all patients submitted to FFR assessment. The decisional cut-off point for revascularization was 0.80. Over a 4-year period, out of 6415 coronary angiographies, FFR was measured in 407 (6.3%) patients (469 lesions). FFR was assessed through 4 or 5 Fr diagnostic catheters in 330 (81%). Median FFR value was 0.87 (0.80; 0.93). On the basis of FFR results, 271 (67%) patients were treated with medical therapy alone. A subset of 71 (17%) patients were not treated in accordance with the results of FFR. All patients but four (i.e. 99%) had 1-year clinical follow-up. Three hundred and forty four (85%) were free from clinical event, six (1.5%) patients died, five (4%) had an acute coronary syndrome, and 20 (5%) underwent target-vessel revascularization. Event-free survival was comparable in patients with vs. without revascularization (0.94 +/- 0.02 and 0.93 +/- 0.01, respectively). Patients had significantly better 1-year outcome when treated in accordance with the results of the FFR assessment. CONCLUSION: In routine practice, FFR assessment during diagnostic angiography was performed in 6.3%. On the basis of FFR, two-thirds of patients with 'intermediate' lesions were left unrevascularized, with a favourable outcome, when FFR was above 0.80. These data suggest that routine use of FFR during diagnostic catheterization is feasible, safe, and provide help to guide decision making.     

Response to highly active antiretroviral therapy strongly predicts outcome in patients with AIDS-related lymphoma

BACKGROUND: AIDS-related lymphoma (ARL) remains a frequent complication of HIV infection. We analyzed the outcome of patients with ARL with respect to the use and efficacy of highly active antiretroviral therapy (HAART) and to potential prognostic factors. METHODS: This multicenter cohort study included patients with systemic ARL diagnosed between 1990-2001. We evaluated overall survival and the effects of several variables on overall survival using the Kaplan-Meier method and the extended Cox proportional hazards model. Response to HAART was used as a time-dependent variable and was defined as a CD4 cell count increase of >/= 100 x 106 cells/l and/or at least one viral load < 500 copies/ml during the first 2 years following diagnosis of ARL. RESULTS: Among 203 patients with ARL, median overall survival was 9.0 months [95% confidence interval (CI), 7.6-12.4 months]. In the univariate analyses, age < 60 years, no previous AIDS, CD4 cell counts >/= 200 x 106 cells/l, hemoglobin > 11 g/dl, Ann Arbor stages I-II and A, no extranodal lesion, response to HAART, and complete remission showed statistically significant association with prolonged overall survival. In the multivariate Cox model, the only factors independently associated with overall survival were response to HAART [relative hazard (RH), 0.32; 95% CI, 0.16-0.62], complete remission (RH, 0.24; 95% CI, 0.15-0.36), previous AIDS (RH, 1.92; 95%CI, 1.23-3.01) and extranodal involvement (RH, 2.85; 95% CI, 1.47-5.51). CONCLUSIONS: Efficacy of HAART was independently associated with prolonged survival in this large cohort of patients with ARL. Information on patient's response to HAART is crucial for the evaluation of future treatment strategies.     

MDR1 polymorphism influences the outcome of multiple myeloma patients

The multidrug resistance gene (MDR1) has been reported to be an additional prognostic factor in acute myeloid leukaemia patients. This study evaluated the prognostic role of MDR1 in the outcome of 115 multiple myeloma patients treated with DAV (dexamethasone, doxorubicin [adryamicin] and vincristine) regimen followed by autologous transplantation. In particular, when investigating the C3435T polymorphism, a prognostic value of MDR1 genotypes for overall survival (OS) was observed. Our data suggested a longer OS for patients with C/T and T/T genotypes (log-rank test, P = 0.02) compared with patients with C/C genotype.     

The clinical features and outcome of 2009 H1N1 influenza infection in allo-SCT patients: a British Society of Blood and Marrow Transplantation study

The clinical course of 2009 H1N1 influenza in Allo-SCT patients is unknown. Data were collected in the UK from October 2009 to April 2010 on laboratory-confirmed cases of H1N1 influenza in Allo-SCT recipients. H1N1 infection was diagnosed in 60 patients, median age 42 years, at a median of 10 months post-SCT. Twenty-one patients (35%) developed pneumonia and nine (15%) required admission to intensive care units. Actuarial mortality was 7% at 28 days and 19% 4 months post-diagnosis of 2009 H1N1 influenza. Increasing age and pre-existing lung disease were risk factors for pneumonia (P=0.006 and 0.037, respectively); older age was a risk factor for death (P=0.012). Morbidity and mortality from 2009 H1N1 influenza in SCT patients exceeds that of immunocompetent patients, but parallels that in other critically ill hospitalised cohorts; the elderly and those with chronic pulmonary disease are at greatest risk.     

Pouch size influences clinical outcome of pouch construction after total gastrectomy:A meta-analysis

AIM:To assess the clinical significance of pouch size in total gastrectomy for gastric malignancies.METHODS:We manually searched the English-language literature in PubMed,Cochrane Library,Web of Science and BIOSIS Previews up to October 31,2013.Only randomized control trials comparing small pouch with large pouch in gastric reconstruction after total gastrectomy were eligible for inclusion.Two reviewers independently carried out the literature search,study selection,data extraction and quality assessment of included publications.Standard mean difference(SMD)or relative risk(RR)and corresponding 95%CI were calculated as summary measures of effects.RESULTS:Five RCTs published between 1996 and2011 comparing small pouch formation with large pouch formation after total gastrectomy were included.Eating capacity per meal in patients with a small pouch was significantly higher than that in patients with a large pouch(SMD=0.85,95%CI:0.25-1.44,I2=0,P=0.792),and the operative time spent in the small pouch group was significantly longer than that in the large pouch group[SMD=-3.87,95%CI:-7.68-(-0.09),I2=95.6%,P=0].There were no significant differences in body weight at 3 mo(SMD=1.45,95%CI:-4.24-7.15,I2=97.7%,P=0)or 12 mo(SMD=-1.34,95%CI:-3.67-0.99,I2=94.2%,P=0)after gastrectomy,and no significant improvement of postgastrectomy symptoms(heartburn,RR=0.39,95%CI:0.12-1.29,I2=0,P=0.386;dysphagia,RR=0.86,95%CI:0.58-1.27,I2=0,P=0.435;and vomiting,RR=0.5,95%CI:0.15-1.62,I2=0,P=0.981)between the two groups.CONCLUSION:Small pouch can significantly improve the eating capacity per meal after surgery,and may improve the post-gastrectomy symptoms,including heartburn,dysphagia and vomiting.     

Lewis Score: A useful clinical tool for patients with suspected Crohn's Disease submitted to capsule endoscopy

Background/aimsThe Lewis Score (LS) can assess inflammatory activity on small bowel capsule endoscopy (SBCE). We aimed to evaluate the LS usefulness in the setting of suspected Crohn's Disease (CD).MethodsRetrospective single-center study including 56 patients undergoing SBCE for suspected CD. Patients were divided into three groups, according to clinical presentation: Group 1 (28 patients): suspected CD not supported by the International Conference on Capsule Endoscopy (ICCE) criteria; Group 2 (19 patients): suspected CD based on two ICCE criteria; Group 3 (9 patients): patients fulfilling three or more criteria. Inflammatory activity was assessed with the LS. The diagnosis of CD required a minimum follow-up of 6 months after SBCE, basing on clinical evaluation, endoscopic, histological, radiological, and/or biochemical investigations.ResultsSBCE detected significant inflammatory activity (LS ≥ 135) in 23 patients (41.1%), being 5 patients from Group 1 (17.8%), 11 from Group 2 (57.9%) and 7 from Group 3 (77.8%) (p < 0.05). CD was diagnosed in 23 patients (41.1%): six patients from Group 1 (21.4%), 10 from Group 2 (52.6%) and 7 from Group 3 (77.8%) (p < 0.05). CD was diagnosed in 82.6% of patients with significant inflammatory activity on CE (LS ≥ 135), but in only 12.1% of those having a LS < 135 (p < 0.05). The LS Positive Predictive Value, Negative Predictive Value, Sensitivity and Specificity were 82.6%, 87.9%, 82.6% and 87.9%, respectively.ConclusionsThe LS may be a valuable diagnostic tool in the setting of suspected CD. Patients not fulfilling the ICCE criteria have lower LS and fewer are diagnosed with CD during follow-up.     

Timing of the most recent device procedure influences the clinical outcome of Lead-associated endocarditis

Objectives The purpose of this study was to determine whether the timing of the most recent cardiac implantable electronic device (CIED) procedure,either a permanent pacemaker or implantable cardioverterdefibrillator,influences the clinical presentation and outcome of lead-associated endocarditis (LAE).Background The CIED infection rate has increased at a time of increased device use.LAE is associated with significant morbidity and mortality.Methods The clinical presentation and course of LAE were evaluated by the MEDIC (Multicenter Electrophysiologic Device Cohort) registry,an international registry enrolling patients with CIED infection.Consecutive LAE patients enrolled in the Multicenter Electrophysiologic Device Cohort registry between January 2009 and May 2011 were analyzed.The clinical features and outcomes of 2 groups were compared based on the time from the most recent CIED procedure (early,< 6 months;late,> 6 months).Results The Multicenter Electrophysiologic Device Cohort registry entered 145 patients with LAE (early=43,late=102).Early LAE patients presented with signs and symptoms of local pocket infection,whereas a remote source of bacteremia was present in 38 % of patients with late LAE but only 8 % of early LAE (P < 0.01).Staphylococcal species were the most frequent pathogens in both early and late LAE.Treatment consisted of removal of all hardware and intravenous administration of antibiotics.In-hospital mortality was low (early=7 %,late=6 %).Conclusions The clinical presentation of LAE is influenced by the time from the most recent CIED procedure.Although clinical manifestations of pocket infection are present in the majority of patients with early LAE,late LAE should be considered in any CIED patient who presents with fever,bloodstream infection,or signs of sepsis,even if the device pocket appears uninfected.Prompt recognition and management may improve outcomes.     

Resection margin influences the outcome of patients with bilobar colorectal liver metastases

AIM To evaluate the outcome of patients with bilobar colorectal liver metastases(CRLM) and identify clinicopathological variables that influenced survival.METHODS Patients with bilobar CRLM were identified from a prospectively maintained hepatobiliary database during the study period(January 2010-June 2014). Collated data included demographics, primary tumour treatment, surgical data, histopathology analysis and clinical outcome. Down-staging therapy included Oxaliplatinor Irinotecan- based regimens, and Cetuximab was also used in patients that were K-RAS wild-type. Response to neo-adjuvant therapy was assessed at the multidisciplinary team meeting and considered for surgery if all macroscopic CRLM were resectable with a clear margin while preserving sufficient liver parenchyma.RESULTS Of the 136 patients included, thirty-two(23.5%) patients were considered inoperable and referred for palliative chemotherapy, and thirty-four(25%) patients underwent liver resection. Seventy(51.4%) patients underwent down-staging therapy, of which 37(52.8%) patients responded sufficiently to undergo liver resection. Patients that failed to respond to down-staging therapy(n = 33, 47.1%) were referred for palliative therapy. There was a significant difference in overall survival between the three groups(surgery vs down-staging therapy vs inoperable disease, P 0.001). All patients that underwent hepatic resection, including patients that had down-staging therapy, had a significantly better overall survival compared to patients that were inoperable(P 0.001). On univariate analysis, only resection margin significantly influenced disease-free survival(P = 0.017). On multi-variate analysis, R0 resection(P = 0.030) and female(P = 0.036) gender significantly influenced overall survival. CONCLUSION Patients undergoing liver resection with bilobar CRLM have a significantly better survival outcome. R0 resection is associated with improved disease-free and overall survival in this patient group.