Influence of anticalcineurinic therapy in plasma homocysteine levels of renal transplant recipients: a prospective study

Hyperhomocysteinemia is an independent factor for cardiovascular disease. Renal function and folate level are important determinants of total plasma homocysteine levels. The influence of anticalcineurin drugs on homocysteine levels is controversial. The aims of the study were: (1) to analyze changes in homocysteine levels after the first year of 73 renal transplants and (2) to determine the influence of immunosuppressive anticalcineurin drug therapy on fasting homocysteine concentrations. We examined homocysteine, serum creatinine, folate, and vitamin B12 concentrations immediately after transplant, at 6 months, and after 12 months from renal transplant. Also, MTHFRC677T polymorphism was investigated. Tacrolimus was administered in 28 patients and cyclosporine in 45. Homocysteine levels decreased from 28.41+/-13.71 micromol/L to 18.59+/-8.31 micromol/L after 6 months and to 17.13+/-7.06 micromol/L after 1 year. No relationship was found between homocysteine and folate levels. When anticalcineurin drugs were considered, the homocysteine levels in patients treated with tacrolimus was lower than that in patients treated with cyclosporine at month 6 after transplant (16+/-7.4 micromol/L vs 20.1+/-8.5 micromol/L, P=.03) and after 1 year (15+/-7.6 micromol/L vs 18.4+/-6.4 micromol/L, P=.04). Serum creatinine levels followed the same evolution: they were lower in patients treated with tacrolimus at 6 months (1.35+/-0.36 mg/dL vs 1.57+/-0.45 mg/dL, P=.03) and to a lesser extent at 1 year after renal transplant (1.38+/-0.35 mg/dL vs 1.54+/-0.45 mg/dL, P=.09). The homocysteine value closely related with serum creatinine in both groups. In conclusion, 1 year posttransplant, the homocysteine level was lower among patients treated with tacrolimus, the cohort that also showed the lower serum creatinine concentrations.     

Fluorine-18-fluorodeoxyglucose positron emission tomography in the preoperative assessment of thyroid nodules in an endemic goiter area

BACKGROUND: The aim of this study was to evaluate the usefulness of fluorine-18-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) in the preoperative assessment of suspicious thyroid nodules. METHODS: A total of 43 patients were examined before surgical resection. In all patients, imaging was obtained at 70 minutes after the intravenous administration of 180 MBq (18)F-FDG. Standard uptake values (SUVs) were calculated. RESULTS: A total of 16 patients with thyroid carcinomas (11 papillary, 3 follicular, 2 anaplastic), 23 thyroid adenomas (11 microfollicular, 10 Hurthle cell, 2 macrofollicular), and 4 patients with degenerative goiter were found. (18)F-FDG uptake in Hurthle cell adenoma, thyroid cancer, microfollicular adenoma, degenerative goiter, and macrofollicular adenoma was 4.4 +/- 2.2, 3.7 +/- 1.9, 1.6 +/- 0.3, 1.2 +/- 0.2, and 0.9 +/- 0.1, respectively. Significant differences were observed between thyroid carcinomas and both microfollicular adenomas and degenerative goiters (P < 0.05), and between Hurthle cell adenomas and both microfollicular adenomas as well as degenerative goiter (P < 0.05). For diagnosis of thyroid carcinoma, 100% sensitivity, 63% specificity, and 100% negative predictive value was found when a cutoff value for SUV of 2 was used. CONCLUSIONS: Our results indicate that thyroid carcinomas, in contrast to most benign thyroid nodules, demonstrate significantly increased glucose metabolism. (18)F-FDG PET is unlikely to differentiate successfully all benign tumors from malignant tumors, but it can help select patients who need surgery, especially if cytology is inconclusive or malignancy cannot be excluded.     

Should Preoperative Antibiotics Be Tailored According to Patient's Comorbidities and Susceptibility to Organisms?

Background

Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint arthroplasty patients regardless of their medical conditions or immune status; however, no studies have evaluated the individualizing of antibiotics. The aims of this study were (1) to determine if comorbidities influence the organism profile of PJIs, and (2) to investigate if the efficacy of two different perioperative antibiotics (cefazolin or vancomycin) for preventing PJI is affected by patient's comorbidities.

Remifentanil for sedation and analgesia in a preterm neonate with respiratory distress syndrome

We present the efficacy and safety of the use of remifentanil for intubation, sedation and analgesia in a preterm infant during mechanical ventilation for respiratory distress syndrome. A 34-week-old baby, born by cesarean delivery that developed respiratory distress, required intubation and ventilatory support. For intubation, the baby was given midazolam (0.2 mg.kg(-1)) and remifentanil (1 microg.kg(-1)). The intubation conditions were assessed and classified as excellent. The remifentanil infusion was started at dose 0.75 microg.kg(-1).min(-1) and the dose adjustments were made depending on the neonatal infant pain scale (NIPS), hemodynamic and respiratory changes or the presence of spontaneous movements. Pulse oximetry, respiratory rate, ECG and invasive blood pressure were continuously monitored. He was given surfactant within 2.5 h of life after which ventilator parameters could be progressively decreased. Three hours later, the remifentanil infusion was decreased to 0.5 microg.kg(-1).min(-1), and he remained sedated (NIPS < 2). Six hour after surfactant administration, blood gases and chest X ray were normal. The remifentanil infusion was then discontinued and 30 min later the baby was awake and extubated with success. There were no side effects after intubation or during the continuous infusion. The profile of remifentanil allowing a rapid recovery, the absence of side effects and a good level of sedation and analgesia support the choice of this opioid for sedation in the NICU.     

Liver Transplantation for Hepatocellular Carcinoma: Results of a Multicenter Study With Common Priorization Criteria

Objective

To evaluate the results of liver transplantation (OLT) performed for hepatocellular carcinoma (HCC) among a multicenter cohort of patients with predefined common inclusion and priorization criteria.

Patients and Methods

Over a 5-year period (January 2002-December 2006), 199 HCC patients underwent OLT in four centers in Andalusia. The morphological (Milan) inclusion criteria were priorized in two consecutive periods, according to the Model for End-stage Liver Disease score: group I, 53 patients (HCC < 2 cm = 24 points; ≥ 2 cm or multinodular = 29 points) and group II, 146 cases (HCC < 3 cm without priorization; HCC ≥ 3 cm or multinodular = 18 points).

Results

Among the 199 HCCs, 186 (93.5%) subjects were transplanted and 13 (6.5%) were excluded. There were 18 cases (9.7%) where the diagnosis was incidental and 168 were known HCC cases; 144 (85.7%) complied with the Milan criteria (Milan+); 24 (14.3%) exceeded there criteria (Milan−). According to preoperative imaging, the number of nodules and tumor mean sizes among the excluded—Milan+ and Milan− groups—were 1.8/5.3 cm, 1.4/3.5 cm, and 2.3/6.7 cm, respectively (P < .001). Percutaneous treatment during listing was delivered to 55% of the excluded cases: 49% of Milan+ and 96% of Milan−. The median time on the list was 88 days for known HCC (53 days for group I, and 97 days for group II), and 172 days for the incidental HCCs. Staging (pTNM) was correct in 64% of cases: 23% were understaged and 13% were overstaged. Overall mortality within the first 90 days was 9%, and transplant patient survival at 5 years was 61%. No differences were observed in survival rates between both study periods, although there were differences between the Milan+ (65%) and Milan− (23%) groups (P < .04). In addition, the difference in the recurrence rates was also significant between the Milan+ (7%), Milan− (24%), and the incidental (25%) groups (P < .02).

Conclusions

A common priorization policy of HCC for OLT based on morphological criteria results in a low exclusion rate on the waiting lists (6.5%). The Milan criteria are still a good cutoff to stratify the risk of recurrence, despite preoperative tumor staging being correct in only two-thirds of cases.     

Expression of adhesion molecules and RANTES in kidney transplant from nonheart-beating donors

The main difference between cadaveric kidneys from donors with a heartbeat (HBD) and kidneys from nonheart-beating donors (NHBD) is related to warm ischemia/reperfusion time which constitutes an acute inflammatory process. On the contrary, brain death induces in HBD expression of pro-inflammatory adhesion molecules, making it important to evaluate this kind of molecules in both types of donors. Human renal biopsies from NHBD, HBD and normal kidneys (ischemia time = 0) were taken and frozen just before transplant. A semi-quantitative RT-PCR method was used to determine intracellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), lymphocyte function associated antigen (LFA-1), LFA-3, CD40, CD40 ligand (CD40L) and RANTES (regulated upon activation, normal T-cell expressed and secreted) gene expression. We have detected an elevated relative gene expression of ICAM-1, VCAM-1 and RANTES in NHBD biopsies compared with normal kidneys. In the case of RANTES, the gene expression from NHBD biopsies was higher than observed in HBD biopsies. The rest of genes were not augmented in any group. Preliminary data about early outcome of transplants indicates a correlation between pretransplant RANTES high gene expression levels and early post-transplant acute rejection. The gene expression of pro-inflammatory molecules like adhesion molecules and RANTES is augmented in kidneys from cadaveric NBD just before transplant. The expression is higher probably because of the prolonged warm ischemia period. A larger clinical study is necessary to clarify the effects of these variable expressions on the transplant outcome.     

胃肠道、食管、腹膜后、腹腔干、颈部多发血管瘤1例

湘雅三医院消化科近年收治1例胃肠道、食管、腹膜后、腹腔干及颈部多发血管瘤患者,对其给予食管、胃血管瘤套扎及鱼肝油酸钠注射治疗,出院后随访,患者一般情况可.因本病罕见,现将其报告如下.     

Sera from patients with heparin-induced thrombocytopenia generate platelet-derived microparticles with procoagulant activity: an explanation for the thrombotic complications of heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia is characterized by moderate thrombocytopenia and thrombotic complications, whereas quinine/quinidine-induced thrombocytopenia usually presents with severe thrombocytopenia and bleeding. Using flow cytometry and assays of procoagulant activity, we investigated whether sera from patients with these immune drug reactions could stimulate normal platelets to generate platelet-derived microparticles with procoagulant activity. Sera or purified IgG from patients with heparin-induced thrombocytopenia stimulated the formation of platelet-derived microparticles in a heparin-dependent fashion. Further studies showed that heparin-induced thrombocytopenia sera also produced a marked increase in procoagulant activity. In contrast, sera from patients with quinine- or quinidine-induced thrombocytopenia did not generate platelet-derived microparticles nor generate increased procoagulant activity. However, quinine/quinidine-induced thrombocytopenia sera produced a significant increase in the binding of IgG to platelets in a drug-dependent fashion, whereas sera from patients with heparin-induced thrombocytopenia demonstrated no drug-dependent binding of IgG to platelets. We also observed increased levels of circulating microparticles in patients with acute heparin-induced thrombocytopenia compared with control patients. Our observations indicate that the generation of procoagulant platelet-derived microparticles in vivo is a plausible explanation for the thrombotic complications observed in some patients with heparin-induced thrombocytopenia.     

Concomitant vascular procedures in conjunction with myocardial revascularization: all or none? A report of a case

Patients with coronary artery atherosclerosis usually have concomitant peripheral vascular lesions. The authors describe the case of a 65-year-old woman who had multiple symptomatic lesions: severe stenosis of the left main coronary artery and the carotid arteries, a large abdominal aortic aneurysm and bilateral renal artery occlusion. To manage these and to avoid myocardial infarction and cerebrovascular accident at operation, concomitant procedures were performed as follows: coronary artery bypass grafting, aneurysm resection, carotid endarterectomy and revascularization of the larger kidney. Although the patient's hospital stay was prolonged, there was no major morbidity and her recovery was good. She returned to a normal life-style, requiring only hemodialysis on an outpatient basis.     

Psoriasis,psoriatic arthritis and type 2 diabetes mellitus: a systematic review and meta‐analysis

Several observational studies have assessed the association between psoriasis, psoriatic arthritis (PsA) and type 2 diabetes mellitus, with inconclusive results. We set out to investigate the association between psoriasis, PsA and type 2 diabetes mellitus. Observational studies assessing the relationship between psoriasis or PsA and type 2 diabetes mellitus up to December 2012 were identified by electronic and hand searches in Medline, Embase, PubMed, the Cochrane Database of Systematic Reviews and Google Scholar. For each study we collected the first author's last name, publication year, country of origin, study design, characteristics of participants (sample size, age and sex), the variables incorporated into the multivariable analyses, and the odds ratios (ORs) of psoriasis associated with diabetes along with the corresponding 95% confidence intervals (CIs). From the data provided in each article, the crude OR was also calculated. Forty‐four observational studies (in 37 articles) were identified for the final analysis. The pooled OR from random‐effects analysis was determined to be 1·76 (95% CI 1·59–1·96). The highest risk was for patients suffering from PsA (OR 2·18, 95% CI 1·36–3·50). We also observed a dose effect in the risk of suffering from type 2 diabetes mellitus, as patients considered as having severe psoriasis had higher risk (OR 2·10, 95% CI 1·73–2·55) than the pooled OR. We perform meta‐regression and sensitivity analyses to explore sources of heterogeneity among the studies and to determine how they would influence the estimates, and found no significant influence in the results of the meta‐analyses. The findings support the association between psoriasis, PsA and type 2 diabetes mellitus. Some caution must be taken in the interpretation of these results because there may be heterogeneity between studies.