Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone

OBJECTIVE: To investigate the pattern of nodal metastasis, morbidity, recurrence rates of papillary thyroid carcinoma (PTC), and parathyroid hormone (PTH) responses following neck dissection (ND) plus total thyroidectomy (TT). SUMMARY BACKGROUND DATA: While hypoparathyroidism develops after TT plus ND, little is known of postoperative PTH response. METHODS: Of 155 PTC patients, 82 underwent TT plus bilateral central ND with/without lateral ND, while 73 underwent TT alone. The nodal metastasis pattern was determined and the recurrence, morbidity, and postoperative levels of serum calcium and PTH were compared between 2 groups. RESULTS: Of the 82 node dissection patients, metastatic nodes were present in the central neck of 51 (62.2%) and the lateral neck of 21 (25.6%) patients, most frequently in the ipsilateral and pretracheal central nodes and lateral jugular nodes. Four regional recurrences (2.6%) were found in 3 patients of the no node dissection group and one of the node dissection group (P = 0.37) during the follow-up lasting a mean 52 months. Overall morbidity and hypocalcemia was higher in the node dissection group than the no node dissection group (41 of 82, 50%; vs. 9 of 73, 12.3%; P < 0.001; 25 of 82, 30.5%; vs. 7 of 73, 9.6%; P = 0.001). Serum PTH levels significantly decreased immediately postoperatively in the node dissection group and remained low for several weeks thereafter. CONCLUSIONS: Serum PTH levels were significantly reduced following ND in PTC patients. Our data suggest that, when performing therapeutic ND plus TT, particular effort should be made to preserve the parathyroid glands and to monitor their function.     

Predictive Factors of Level IIb Lymph Node Metastasis in Patients with Papillary Thyroid Carcinoma

Background  The extent of neck dissection (ND) appropriate for necks yielding clinical evidence of metastases of papillary thyroid carcinoma (PTC) is controversial. The need for Ievel IIb lymph node (LN) dissection is particularly uncertain in view of its association with postoperative shoulder dysfunction. In the present study, we examined the frequency, pattern, and predictive factors of level IIb LN metastases in PTC patients with clinically positive lateral neck nodes. Methods  We reviewed the medical records of 76 PTC patients who underwent therapeutic lateral ND for the treatment of clinically positive lateral neck nodes between March 2005 and July 2008. ND specimens were separately obtained for analyzing LN involvement with respect to neck level. Results  Metastatic disease at levels II, III, IV, and V, was seen in 40 (52.6%), 55 (72.4%), 52 (68.4%), and 12 (15.8%) of the patients, respectively. The metastasis rate in level IIb was 11.8% (9 of 76). By univariate analysis, the rate of level IIb LN metastasis was significantly higher in patients with positive level IIa LNs and positive LNs in all lateral neck levels (levels IIa + III + IV) (P < .05). Multivariate analysis showed that positive LN involvement in all lateral neck levels (IIa + III + IV) was an independent predictive factor of level IIb LN metastasis (P = .044, odds ratio = 9.692). Conclusions  Level IIb LN dissection may be omitted in the treatment of positive neck nodes in PTC patients if multilevel involvement including level IIa involvement is absent.     

Comparison of serum calcium change following thyroid and nonthyroid neck surgery

OBJECTIVE: Compare serum calcium changes following thyroid and nonthyroid/parathyroid neck surgery. STUDY DESIGN: Controlled historic cohort study of 190 patients undergoing total thyroidectomy (TT, n = 97), completion thyroidectomy (CT, n = 27), and lateral neck dissection (ND, n = 66). RESULTS: Each group experienced significant corrected serum calcium drop pre-op to POD #1 (mean change (mg/dL) TT = 0.97, CT = 0.79, ND = 0.46; all P < 0.001) with significantly greater drop in TT and CT (P < 0.0001). TT and ND had significantly greater calcium drop from pre-op to PACU than CT (0.54, 0.43, 0.15; P = 0.04). TT and CT experienced significantly greater calcium drop from PACU to POD #1 than ND (0.45, 0.53, 0.05; P < 0.0001). No significant difference in hypocalcemia rate between TT and CT. CONCLUSIONS: Perioperative calcium drop in nonthyroid neck surgery is likely hemodilutional, occurring intraoperatively, whereas in thyroid surgery it likely results from both hemodilution and parathyroid dysfunction with the latter manifesting after PACU. Postoperative calcium monitoring should be similar following total and completion thyroidectomy due to similar rates of hypocalcemia and mean calcium drops. EBM rating: B-3b.     

Dorsal displacement of the facial nerve in acoustic neuroma surgery: clinical features and surgical outcomes of 21 consecutive dorsal pattern cases

In acoustic neuroma surgery, the facial nerve (FN) course varies among patients, but a dorsal pattern is rarely observed. We retrospectively reviewed and classified 556 acoustic neuromas operated on via a lateral suboccipital retrosigmoid (LSO) approach into two groups: dorsal (group D) and non-dorsal (group ND). The clinical features and outcomes including functional preservation of the FN, the extent of tumor resection, and the retreatment rate were compared. Among 556 cases, 21 (3.8 %) patients with dorsal patterns were identified. No significant differences in clinical features or preoperative status were noted between groups D and ND. No significant differences in functional FN preservation were found between groups D and ND in the immediate postoperative period (90.5 and 83.0 %, respectively) or 1-year postoperatively (95.2 and 97.0 %, respectively). Compared with group ND, the extent of tumor resection was significantly less (p?<?0.0001) and the retreatment rate was significantly higher in group D (hazard ratio, 33.6; 95 % confidence interval [CI], 11.7–96.1; p?<?0.0001). In one dorsal pattern case, surgical resection was abandoned based on the intraoperative findings. Dorsal displacement of the FN was accurately predicted with preoperative imaging evaluations in just two cases. Functional preservation of the FN during acoustic neuroma surgery is achievable if the FN runs along the dorsal side of the tumor. However, a dorsal pattern, especially when the FN is broadened, is clearly associated with less complete tumor removal and a higher rate of retreatment than typical pattern cases.     

Gravity is an important determinant of oxygenation during one‐lung ventilation

Background: The role of gravity in the redistribution of pulmonary blood flow during one‐lung ventilation (OLV) has been questioned recently. To address this controversial but clinically important issue, we used an experimental approach that allowed us to differentiate the effects of gravity from the effects of hypoxic pulmonary vasoconstriction (HPV) on arterial oxygenation during OLV in patients scheduled for thoracic surgery. Methods: Forty patients with chronic obstructive pulmonary disease scheduled for right lung tumour resection were randomized to undergo dependent (left) one‐lung ventilation (D‐OLV; n=20) or non‐dependent (right) one‐lung ventilation (ND‐OLV; n=20) in the supine and left lateral positions. Partial pressure of arterial oxygen (PaO₂) was measured as a surrogate for ventilation/perfusion matching. Patients were studied before surgery under closed chest conditions. Results: When compared with bilateral lung ventilation, both D‐OLV and ND‐OLV caused a significant and equal decrease in PaO₂ in the supine position. However, D‐OLV in the lateral position was associated with a higher PaO₂ as compared with the supine position [274.2 (77.6) vs. 181.9 (68.3) mmHg, P<0.01, analysis of variance (ANOVA)]. In contrast, in patients undergoing ND‐OLV, PaO₂ was always lower in the lateral as compared with the supine position [105.3 (63.2) vs. 187 (63.1) mmHg, P<0.01, ANOVA]. Conclusion: The relative position of the ventilated vs. the non‐ventilated lung markedly affects arterial oxygenation during OLV. These data suggest that gravity affects ventilation–perfusion matching independent of HPV.     

A late neurological complication following posterior correction surgery of severe cervical kyphosis

Though a possible cause of late neurological deficits after posterior cervical reconstruction surgery was reported to be an iatrogenic foraminal stenosis caused not by implant malposition but probably by posterior shift of the lateral mass induced by tightening screws and plates, its clinical features and pathomechanisms remain unclear. The aim of this retrospective clinical review was to investigate the clinical features of these neurological complications and to analyze the pathomechanisms by reviewing pre- and post-operative imaging studies. Among 227 patients who underwent cervical stabilization using cervical pedicle screws (CPSs), six patients who underwent correction of cervical kyphosis showed postoperative late neurological complications without any malposition of CPS (ND group). The clinical courses of the patients with deficits were reviewed from the medical records. Radiographic assessment of the sagittal alignment was conducted using lateral radiographs. The diameter of the neural foramen was measured on preoperative CT images. These results were compared with the other 14 patients who underwent correction of cervical kyphosis without late postoperative neurological complications (non-ND group). The six patients in the ND group showed no deficits in the immediate postoperative periods, but unilateral muscle weakness of the deltoid and biceps brachii occurred at 2.8 days postoperatively on average. Preoperative sagittal alignment of fusion area showed significant kyphosis in the ND group. The average of kyphosis correction in the ND was 17.6° per fused segment (range 9.7°–35.0°), and 4.5° (range 1.3°–10.0°) in the non-ND group. A statistically significant difference was observed in the degree of preoperative kyphosis and the correction angles at C4–5 between the two groups. The diameter of the C4–5 foramen on the side of deficits was significantly smaller than that of the opposite side in the ND group. Late postoperative neurological complications after correction of cervical kyphosis were highly associated with a large amount of kyphosis correction, which may lead foraminal stenosis and enhance posterior drift of the spinal cord. These factors may lead to both compression and traction of the nerves, which eventually cause late neurological deficits. To avoid such complications, excessive kyphosis correction should not be performed during posterior surgery to avoid significant posterior shift of the spinal cord and prophylactic foraminotomies are recommended if narrow neuroforamina were evident on preoperative CT images. Regardless of revision decompression or observation, the majority of this late neurological complication showed complete recovery over time.     

Technical improvements in the lateral suboccipital approach for neurovascular decompression of the trigeminal and facial nerves

Summary Some refinements of the surgical procedure are described in 12 patients (five females, seven males) operated on for neurovascular decompression (ND) in the presence of trigeminal neuralgia and hemifacial spasm. The patients were operated upon in the supine position, in which the use of a lumbar drainage facilitates the dissection from the beginning. The lateral suboccipital approach was performed by means of a semi-osteoplastic craniotomy with the use of bone chips to close the bone defect so that a good cosmetic effect could be achieved.     

One-year predictive factors for various aspects of neck disorders.

STUDY DESIGN: A longitudinal epidemiologic study conducted over 12 months among active workers in different occupations. The study was primarily designed to evaluate intervention for prevention of low back and other spinal disorders. OBJECTIVE: To determine factors that predict incidence, recurrence, and persistence of neck disorders (ND), taking into account various dimensions of ND. SUMMARY OF BACKGROUND DATA: Neck pain is often supposed to have essentially the same risk factors as back pain; however, there is comparatively little data relevant to this issue. Moreover, there is a lack of prospective studies that take into account a diversity of predictive factors. METHODS: The Nordic questionnaire for the analysis of musculoskeletal symptoms was completed twice at a 12-month interval by 568 workers. Predictive factors were studied with logistic models for four dimensions of ND from the second questionnaire: 1) any ND in the past 6 months; 2) ND for more than 30 days; 3) treatment for ND; and 4) visit to a health care professional for ND. The predictive factors were obtained from the first questionnaire and included gender, age, occupational group, level of psychological distress and psychosomatic problems, and ND at baseline. RESULTS: Female gender and older age were predictors of ND. Headaches or pain in the head, psychological distress, and psychosomatic problems were predictors for all dimensions of ND. These effects were observed for both incidence and persistence of ND. CONCLUSIONS: The results emphasize the role of psychosomatic and psychological factors in the occurrence and course of ND for various dimensions of the disorder.     

Changes in hemodynamics in patients who underwent extended mediastinal lymphadenectomy through median sternotomy for primary lung cancer.

OBJECTIVES: Extended bilateral mediastinal lymphadenectomy (ND3alpha) through median sternotomy for lung cancer has been reported to show longer survival compared to that after ipsilateral mediastinal lymphadenectomy (ND2a) through posterolateral thoracotomy for node-positive lung cancer. However, a high incidence of morbidity or mortality has also been found. The present prospective study was conducted to clarify the influence of this procedure on the hemodynamics as one of the factors influencing postoperative course. METHODS: Between December 1999 and January 2001, at the Nippon Medical School Hospital, 10 patients underwent pulmonary resection with ND2a through a posterolateral thoracotomy, while another 10 patients underwent pulmonary resection with ND3alpha through median sternotomy. Changes in the hemodynamics were evaluated preoperatively and at 6, 12, 24 and 48 hours postoperatively. RESULTS: Those who underwent ND3alpha showed higher peripheral vascular resistance for 24 hours postoperatively resulting from the longer surgery and increased blood loss, than those who underwent ND2a. The pulmonary capillary wedge pressure was elevated in those who underwent ND3alpha comparing to that in those who underwent ND2a. Stroke index decreased in patients who underwent NDalpha comparing to that in those who underwent ND2a. Even though the right ventricular ejection fraction showed minimal change, both the ventricular stroke work indices were depressed at 48 hours postoperatively in patient who underwent ND3alpha. CONCLUSION: ND3alpha was concluded to have affected the cardiopulmonary circulation, compared to ND2a, and to be more invasive than ND2a. To perform ND3alpha, preoperative patient selection is an important factor to archive the advantage of increased survival by this procedure.     

萘降解细菌的分离及其降解和转座基因的分子检测

用富集培养法，从工业废水和活性污泥中分离到9个高效降解萘的细菌菌株（ND7～ND15）．对菌株ND7、ND8、ND9和ND10所进行的16SrDNA序列分析表明，它们都属于假单胞菌属（Pseudomonas）．PCR实验结果表明，上述4个菌株都含有蔡降解基因nahAc、nahG、nahH和catA，ND7和ND8菌株还含有萘降解基因nahU.DNA杂交实验结果表明，上述9个萘降解菌株都含有转座酶基因tnpA1和解体酶基因tnpR．这些结果表明，萘降解细菌的降解基因和转座基因具有高度的保守性．酶学实验证明，ND7、ND8、ND9和ND10菌株都具有儿茶酚1，2-双加氧酶活力和儿萘酚2，3-双加氧酶活力，但在不同菌株中这两种酶的比活力有明显不同．     

Changes in hemodynamics in patients who underwent extended mediastinal lymphadenectomy through median sternotomy for primary lung cancer

Objectives: Extended bilateral mediastinal lymphadenectomy (ND3α) through median sternotomy for lung cancer has been reported to show longer survival compared to that after ipsilateral mediastinal lymphadenectomy (ND2a) through posterolateral thoracotomy for node-positive lung cancer. However, a high incidence of morbidity or mortality has also been found. The present prospective study was conducted to clarify the influence of this procedure on the hemodynamics as one of the factors influencing postoperative course. Methods: Between December 1999 and January 2001, at the Nippon Medical School Hospital, 10 patients underwent pulmonary resection with ND2a through a posterolateral thoracotomy, while another 10 patients underwent pulmonary resection with ND3α through median sternotomy. Changes in the hemodynamics were evaluated preoperatively and at 6, 12, 24 and 48 hours postoperatively. Results: Those who underwent ND3α showed higher peripheral vascular resistance for 24 hours postoperatively resulting from the longer surgery and increased blood loss, than those who underwent ND2a. The pulmonary capillary wedge pressure was elevated in those who underwent ND3α comparing to that in those who underwent ND2a. Stroke index decreased in patients who underwent ND3α comparing to that in those who underwent ND2a. Even though the right ventricular ejection fraction showed minimal change, both the ventricular stroke work indices were depressed at 48 hours postoperatively in patient who underwent ND3α. Conclusion: ND3α was concluded to have affected the cardiopulmonary circulation, compared to ND2a, and to be more invasive than ND2a. To perform ND3α, preoperative patient selection is am important factor to archive the advantage of increased survival by this procedure.     

No change in O2 saturation but measurable difference in thenar flexor power after radial artery harvest.

OBJECTIVES: Objective measures of morbidity will be required to establish the radial artery (RA) as a viable long term alternative to saphenous vein. The RA is the dominant arterial supply to the thenar musculature. We hypothesised that RA harvest should decrease O2 saturation and thenar muscle power. METHODS: RA was harvested from non-dominant (ND) limbs only (left n = 58, right n = 21). Oximeter values of O2 saturation were taken from the thumb of the dominant (D) and non-dominant (ND) limb pre and post operatively. A syringe filled with 25 cc of air is emptied against a one way valve connected to a pressure generator MX 100 by MEDEX, Inc, Ohio, USA. Three measures of thenar flexor power (TFP) were taken and mean values obtained in the ND and D limbs. RESULTS: O2 saturation ranged from 92 to 98% in the thumb of the ND limbs 24 h post RA harvest. The values for TFP (mean +/- SD) were 1246 +/- 246 mmHg (ND) and 1240 +/- 258 mmHg (D) pre-operatively and 1216 +/- 250 (ND) and 1259 +/- 233 (D) post operatively. The changes in TFP between the ND and D limbs (37.0 +/- 60.6 ND and 1.86 +/- 65.9 D) were significant for the D against the ND limb (P < 0.001). This reduction in TFP for the harvested limb was also found when considering handedness (28.0 +/- 24.2 and 40.3 +/- 69.2 for the left and right handed patients respectively). CONCLUSION: Our findings confirm the hypothesis that there are objective differences in TFP pre and post RA harvest at 3 months. Further studies are required to assess the clinical significance and persistence of the loss of TFP.     

Shoulder function after accessory nerve-sparing neck dissections

BACKGROUND: This study was designed to observe the effect of preserving the spinal accessory nerve (SAN) during neck dissection (ND) and adjuvant radiotherapy (ART) after ND on shoulder function. METHODS: Fifty-seven patients with head and neck cancer who had undergone primary tumor resection and various types of NDs were enrolled in this prospective study. Postoperative shoulder joint range of motion was evaluated by goniometry, and muscle strength was measured manually. SAN function was evaluated with electromyography (EMG) with respect to percentage of denervation and presence of neurogenic involvement. Patients were grouped by treatment as follows: radical ND (RND) versus modified radical ND (MRND)/selective ND (SND) and ART versus no ART. RESULTS: Shoulder joint range of motion and shoulder muscle strength were significantly better in the MRND/SND group than in the RND group. However, EMG findings were similar in the RND and MRND/SND groups. When all patients who underwent ND, RND, or MRND/SND were compared with the control group, statistically significant changes in shoulder joint range of motion and shoulder muscle strength were found. Also, denervation and neurogenic involvement of the SAN were significantly higher after all NDs than in the control group. ART did not affect range of motion of the shoulder joint, shoulder muscle strength, or the degree of denervation and neurogenic involvement in any of the ND groups. CONCLUSIONS: ART does not have a negative effect on shoulder function after ND. SAN is always functionally impaired even if we preserve it macroscopically during ND.     

Evolution of the absorption profile of cyclosporine A in renal transplant recipients: a longitudinal study of the de novo and maintenance phases.

BACKGROUND: Therapeutic drug monitoring for cyclosporine microemulsion (CsA-ME) is often performed using either trough levels (C0) or levels at 2 h post-dose (C2). This analysis assessed changes in C0 and C2 and their relationship to CsA-ME dose over time post-transplant in renal transplant patients. METHODS: Data were obtained from MO2ART, a prospective multicentre trial in which CsA-ME dose was adjusted based on C2 level. All 98 patients in whom C0 and C2 were available at day 5, month 3 and month 12 were included, out of 234 who completed the 12 month study. Normalized dose (ND) of CsA-ME, defined as dose per kilogram body weight, was calculated, together with C0/ND, C2/ND and C2/C0. RESULTS: C0/ND and C2/ND both increased between day 5 and month 3: C0/ND from 33+/-15 to 53+/-24 (ng/ml)/(mg/kg) and C2/ND from 161+/-64 to 248+/-80 (ng/ml)/(mg/kg). Between month 3 and month 12, C2/ND remained stable but C0/ND decreased to 42+/-20 (ng/ml)/(mg/kg) while the C2/C0 ratio increased from 5.2+/-1.9 to 6.5+/-2.3, indicating an acceleration of drug elimination. The inter-individual coefficient of variation was higher for C0/ND than for C2/ND at 3 months (45 vs 32%, P<0.05) and at 12 months (48 vs 31%, P<0.01). CONCLUSIONS: CsA clearance accelerates between months 3 and 12 post-transplant, resulting in lower C0 levels for a given exposure (as measured by C2). As a consequence, C0 monitoring may progressively underestimate CsA exposure during the first year post-transplant. C2 monitoring contributes to improved individualized CsA-ME treatment in both the de novo phase and beyond month 3.     

A simple approach to nipple discharge

Evaluation and management of patients with nipple discharge (ND) aims to identify carcinoma when present, and in benign cases, stop the discharge when bothersome. We reviewed our recent experience with ND to develop a simple and effective algorithm to manage these patients. Records of all patients with ND evaluated from December 1996 through June 1999 were reviewed. Patients were liberally offered duct excision for a clinical suspicion of malignancy (persistent clear or bloody fluid) or to stop bothersome discharge. Patients with breast imaging abnormalities (mammography or ultrasound) related to their ND underwent biopsy and were considered separately. Of 104 patients with ND, 11 underwent biopsy as a result of mammographic findings; three of these cases proved malignant. The remaining 93 patients were evaluated with 55 tests that did not demonstrate malignancy, including ductography, discharge fluid cytology, serum prolactin and thyroid-stimulating hormone levels, and image-guided breast or nipple biopsy. Thirty-nine patients underwent duct excision with only a single patient demonstrating malignancy. Clinical follow-up has not identified malignancy in any patient managed nonoperatively. When diagnostic breast imaging is negative, malignancy related to ND is uncommon. Patients with ND should have diagnostic breast imaging and, if it is negative, should be offered duct excision. There is little role for ductography, cytology, or laboratory studies in evaluating these patients.     

Experimental study of extracorporeal lung resection in dogs: ex situ sleeve resection and autotransplantation of the pulmonary lobe after extended pneumonectomy for central lung cancer

OBJECTIVE: Extracorporeal lung resection as an alternative to pneumonectomy for central lung cancer is a procedure in which the unilateral lung is extirpated, removing the pulmonary lobe with the cancers and replanting the residual pulmonary lobe. The aim of this study was to investigate whether extracorporeal lung resection for lung cancer can be performed safely. METHODS: Nineteen dogs were divided into the control and extracorporeal lung resection groups. The former (n = 5) underwent lung autotransplantion, and the latter was subdivided into ND1 (n = 7) and ND2 (n = 7) groups on the basis of the manner of lymph node dissection. By comparing the 3 groups, the adverse effects of lymph node dissection were examined. RESULTS: All dogs in the control group had no complications. Four dogs in the ND1 group survived for 90 to 630 days after the operation. In the ND2 group 5 dogs succumbed within 30 days after the operation, although the other 2 dogs survived for 391 and 573 days, respectively. Bronchopulmonary fistulas were seen in 1 of the ND1 dogs and 3 of the ND2 dogs. Two of the latter were free of thrombus formation in the pulmonary arteries and veins of the autografts. In the ND2 group, compared with the control and ND1 group, the tissue blood flow at the bronchial anastomotic site indicated reduction between the 3rd and 14th postoperative days. CONCLUSION: The extensive lymph node dissection had severe adverse effects on bronchial anastomotic healing in extracorporeal lung resection. Therefore extracorporeal lung resection can be applied to only a very limited number of patients with N0 or N1 disease.     

Worsened long-term outcomes and postoperative complications in octogenarians with lung cancer following mediastinal lymph-node dissection

We evaluated the effects of mediastinal lymph-node dissection on outcomes in octogenarians with primary lung cancer. Outcomes and postoperative complications were retrospectively investigated in 48 octogenarians with anatomically resected lung cancer, of whom 23 underwent a mediastinal lymph-node dissection (ND2 group) and 25 a limited lymphadenectomy (ND0-1 group). Forty-three patients underwent a lobectomy, two a pneumonectomy, and three a segmentectomy. The five-year survival rate for all was 35%, while that for those in pathological stage I was 43.3% and for those in stage II+III was 21.2%. As for lymph node dissection, the five-year survival rate for the ND0-1 group (54.3%) was superior to that for the ND2 group (21.7%) (P=0.022). For patients in pathological stage I, those rated ND0-1 had a better five-year survival than those rated ND2 (61.9% vs. 28.6%) (P=0.041). In addition, mediastinal lymph-node dissection increased the incidence of postoperative cardiac complications (P=0.004). Our results indicate that major pulmonary resection with mediastinal lymph-node dissection is associated with a higher rate of mortality in octogenarians with lung cancer.     

The impact of diabetes on vascular complications following cadaver renal transplantation

To assess the impact of diabetes on vascular complications occurring in renal transplant recipients, we compared the incidence of vascular disease in 283 non-diabetic (ND) and 99 diabetic (D) patients who received primary cadaver renal transplants at our center between 1/1/76 and 12/31/85. The median observation time in the ND patients was 31 months, and in D patients it was 20 months. Both ND and D patients were subdivided into group A if they had preexisting clinical vascular disease and group B if they had no prior disease. The vascular complications between the ND and D patients were analyzed in 3 subsets: prevalence of vascular disease prior to renal transplantation; posttransplant recurrent vascular disease in group A; and posttransplant vascular disease, new, in group B. The results showed that, prior to renal transplantation, D patients have a higher prevalence of clinical vascular disease (33%), compared with ND patients (13%) (P = .00001). In group A, the recurrence rate of vascular disease after transplantation was also higher in D patients (67%) compared with ND patients (40%) (P = .05). In group B, the incidence of posttransplant vascular disease (new) was significantly higher in D patients (33%) compared with the ND patients (13%) (P = .002). Also, the amputation rate was significantly higher in D patients (18%) compared with ND patients (0.4%) (P = .000001). Our data suggest that morbidity from vascular disease is significantly increased in diabetic renal transplant recipients compared with nondiabetic patients. Such increased morbidity from vascular disease in the diabetic patients may also be observed in the period before renal transplantation.     

Molecular phylogenetics of Newcastle disease viruses isolated from vaccinated flocks during outbreaks in Southern India reveals circulation of a novel sub‐genotype

Newcastle disease (ND) is an economically important, contagious poultry viral disease reported across the globe. In India, ND is endemic and episodes of ND outbreaks despite strict vaccinations are not uncommon. We isolated and characterized seven ND viruses from vaccinated commercial poultry farms during severe disease outbreaks in Tamil Nadu, in Southern India, between April 2015 and June 2016. All the seven isolates were categorized as virulent by mean death time (48–54 hr) in embryonated chicken eggs. Also, their sequences carried the virulence signature of multi‐basic amino acid residues in their fusion protein cleavage site (RRQ/RR/KRF). Phylogenetic and evolutionary distance analyses revealed circulation of a novel sub‐genotype of genotype XIII, class II ND viruses, herein proposed as sub‐genotype XIIIe. The genetic divergence between the circulating virulent strains and the vaccine strains could possibly explain the disease outbreak in the vaccinated flocks. Further, our study signifies the need to implement routine epidemiological surveillance and to revisit the current vaccination program.     

Evidence for the role of neutrophils in reperfusion injury after cold cardioplegic ischemia in neonatal lambs.

The role of neutrophils in reperfusion injury after hypothermic, cardioplegia-protected ischemia is incompletely understood but may involve neutrophil-endothelial interactions. We examined 33 isolated blood-perfused neonatal lamb hearts arrested for 2 hours with 15 degrees C potassium cardioplegic solution and reperfused with unmodified blood (group C, n = 9), with neutrophil-depleted (Sepacell filter) blood (group ND, n = 9), with the addition of CV-3988, a platelet-activating factor antagonist, to the perfusate (group NA, n = 9), and with neutrophil-depleted blood plus CV-3988 (group ND/NA, n = 6). The percent recovery of isovolumic left ventricular developed pressure at a fixed balloon volume at 30 minutes after reperfusion in groups ND (84.8% +/- 11.8%, mean +/- standard deviation), NA (89.9% +/- 11.5%), and ND/NA (87.8% +/- 6.4%) were higher than in group C (73.1% +/- 7.9%) (p less than 0.05). Groups NA (105.5% +/- 13.7%) and ND/NA (108.0% +/- 11.2%) achieved higher percent recovery of coronary blood flow than group C (84.4% +/- 10.4%) (p less than 0.05). In each heart, we also tested coronary vascular resistance response to infusion of acetylcholine 10(-6) mol/L to assess endothelial function. Percent recovery of coronary vascular resistance response to acetylcholine was higher in groups ND (56.8% +/- 31.4%), NA (56.3% +/- 17.3%), and ND/NA (58.7% +/- 24.8%) than in group C (13.3% +/- 38.3%) (p less than 0.05). These results show that, after ischemia/reperfusion, groups ND, NA, and ND/NA had better recovery of both mechanical and endothelial function than group C. The parallel changes in recovery of mechanical and endothelial function suggest that neutrophil-endothelial interactions may be a significant factor in reperfusion injury.