Portal hypertension

Many advances in the management of portal hypertension and variceal hemorrhage have occurred during the last 10 years. Effective therapy for primary prevention of variceal hemorrhage is now available in the form of nonselective beta-blockers. Active bleeding should be managed with terlipressin, somatostatin or its analogues, and endoscopic therapy; TIPS and surgery are reserved as salvage therapy for patients who fail endoscopic treatment. Survivors of a variceal hemorrhage should be evaluated for liver transplantation. Specific treatment may be provided with EVL while these patients await transplantation. Patients who fail endoscopic treatment may be treated by TIPS or surgery.     

Differences in circadian blood pressure variability during gestation between healthy and complicated pregnancies

BACKGROUND: Changes in circadian variation of blood pressure (BP) could be used either to predict preeclampsia or to assess its severity. We examined and compared characteristics of circadian variability in BP in women with both healthy and complicated pregnancies who were systematically monitored throughout gestation. METHODS: We analyzed 2430 BP series sampled by ambulatory monitoring for 48 h once every 4 weeks from the first obstetric visit until delivery in 235 women with uncomplicated pregnancies, 128 with gestational hypertension, and 40 with preeclampsia. The circadian pattern of BP variation for each group and trimester of gestation was established by population multiple-components analysis. RESULTS: The differences in 24-h mean and amplitude between healthy and complicated pregnancies were highly significant in all trimesters (P < 0.001). Results further indicated similar circadian characteristics between gestational hypertension and preeclampsia in the first trimester of pregnancy. The difference between these two groups in 24-h mean was statistically significant for systolic (P =.002) and diastolic BP (P =.038) in the second trimester and, to a larger extent, in the third trimester (P < 0.001). CONCLUSIONS: The differences in BP between healthy and complicated pregnancies that can be observed as early as in the first trimester of pregnancy are found when both systolic and diastolic BP for women with a later diagnosis of gestational hypertension or preeclampsia are well within the accepted range of normotension. These differences offer new end points that may lead to an early identification of hypertensive complications in pregnancy as well as to the establishment of prophylactic intervention.     

Management of dysautonomia in fibromyalgia

The realization of dysautonomia in FM has opened the possibility for new and different therapeutic interventions. Much more research is needed to better define the role of ANS in the pathogenesis of FM. If this research supports current hypotheses, therapeutic trials with disciplines and substances intended to correct autonomic dysfunction will be indicated.     

Oxidized phospholipids predict the presence and progression of carotid and femoral atherosclerosis and symptomatic cardiovascular disease: five-year prospective results from the Bruneck study.

OBJECTIVES: The purpose of this work was to determine the predictive value of oxidized phospholipids (OxPLs) present on apolipoprotein B-100 particles (apoB) in carotid and femoral atherosclerosis. BACKGROUND: The OxPLs are pro-inflammatory and pro-atherogenic and may be detected using the antibody E06 (OxPL/apoB). METHODS: The Bruneck study is a prospective population-based survey of 40- to 79-year-old men and women initiated in 1990. Plasma levels of OxPL/apoB and lipoprotein (a) [Lp(a)] were measured in 765 of 826 (92.6%) and 671 of 684 (98.1%) subjects alive in 1995 and 2000, respectively, and correlated with ultrasound measures of carotid and femoral atherosclerosis. RESULTS: The distribution of the OxPL/apoB levels was skewed to lower levels and nearly identical to Lp(a) levels. The OxPL/apoB and Lp(a) levels were highly correlated (r = 0.87, p < 0.001), and displayed long-term stability and lacked correlations with most cardiovascular risk factors and lifestyle variables. The number of apolipoprotein (a) kringle IV-2 repeats was inversely related to Lp(a) mass (r = -0.48, p < 0.001) and OxPL/apoB levels (r = -0.46, p < 0.001). In multivariable analysis, OxPL/apoB levels were strongly and significantly associated with the presence, extent, and development (1995 to 2000) of carotid and femoral atherosclerosis and predicted the presence of symptomatic cardiovascular disease. Both OxPL/apoB and Lp(a) levels showed similar associations with atherosclerosis severity and progression, suggesting a common biological influence on atherogenesis. CONCLUSIONS: This study suggests that pro-inflammatory oxidized phospholipids, present primarily on Lp(a), are significant predictors of the presence and extent of carotid and femoral atherosclerosis, development of new lesions, and increased risk of cardiovascular events. The OxPL biomarkers may provide valuable insights into diagnosing and monitoring cardiovascular disease.     

Prevalence of Chlamydia pneumoniae in the atherosclerotic plaque of patients with unstable angina and its relation with serology

BACKGROUND: Chlamydia pneumoniae has been associated with coronary artery disease by both seroepidemiological studies, and by direct detection of the micro-organism in atherosclerotic lesions. This bacteria could play a potential role in the development of acute coronary events. We examined coronary arteries from patients with unstable angina in order to verify an endovascular presence of C. pneumoniae, and to determine if there is any relationship between serology of acute infection by this pathogen and its presence inside the atherosclerotic plaque of these patients. METHODS: We analysed a total of 76 atherosclerotic plaques obtained from 45 patients who underwent coronary artery bypass surgery. In all patients unstable angina was present within the prior 3 weeks. The presence of C. pneumoniae in the plaque was determined by nested polymerase chain reaction (PCR). Antichlamydial immunoglobulin G (IgG), A (IgA) and M (IgM) was examined by microimmunofluorescence and compared to the PCR result. FINDINGS: DNA of C. pneumoniae was detected in 57 (75%) of 76 atherosclerotic lesions. In most cases (74/76: 97%) a positive IgA, IgM or IgG result was seen. Seven (12%) and 54 (94%) of the 57 PCR positive plaques came from patients with a positive IgM and IgA result, respectively. There was no statistical significant difference between PCR positive and PCR negative plaques in patients with a positive or negative serological result. Clinical characteristics were similarly distributed in patients with and without infected lesions. INTERPRETATION: C. pneumoniae organisms are frequently found in the atherosclerotic lesions of patients undergoing coronary surgery for unstable angina. Neither serological results of acute or recent infection by C. pneumoniae nor clinical characteristics are useful in predicting the individual risk of harbouring C. pneumoniae in the coronary lesions of patients with unstable angina.     

Clinical features and predictive factors in psoriatic arthritis-related uveitis

OBJECTIVES: To analyze the clinical features of uveitis in psoriatic arthritis (PsA) and to investigate the factors predicting its appearance. PATIENTS AND METHODS: Retrospective cohort study (1991-2000) of 71 patients diagnosed with PsA according to the criteria of Moll and Wright. All patients were studied according to a standard protocol. The group was divided into 3 articular categories: axial, oligoarticular, and polyarticular. Human leukocyte antigen (HLA)-Cw typing was performed by the polymerase chain reaction-sequence specific oligonucleotide probes (PCR-SSOP) method in 65 patients and in 177 healthy donors. HLA-DR typing was done by serologic methods in the 71 patients and in 82 healthy donors from the same racial and geographic origin. The HLA-B27 allele also was tested among the study population. All subjects with possible inflammatory ocular disease received a complete ophthalmologic examination at the Ophthalmology Department of our hospital. Only patients with uveitis were analyzed. Univariate and multivariate analyses were applied. RESULTS: Thirteen patients had uveitis (18% of this series), 4 (31%) had an insidious onset, and the remaining had acute-onset uveitis. Five cases (39%) had bilateral-simultaneous uveitis. Ten (77%) presented with anterior uveitis only, 2 with anterior and posterior pole involvement, and only 1 case with isolated posterior pole involvement. Four patients needed oral corticosteroids; 2 of them also used immunosuppresive drugs. None of our patients developed sequelae or complications. In univariate analysis, uveitis was associated with inflammatory back pain (P =.02), sacroiliac pain (P =.001), syndesmophytes (P =.001), bilateral sacroileitis (P =.0001), HLA-DR13 (P =.002), and HLA-B27 (P =.026). In multivariate analysis, the predictive factors for uveitis were bilateral sacroileitis (OR 17, 95% CI: 3.7-76, P =.0002), HLA-DR13 (OR 24, 95% CI: 3.78-150, P =.0056), and syndesmophytes (OR 9.7, 95% CI: 0.97-97, P =.05). CONCLUSIONS: Insidious onset, bilaterality, posterior pole involvement, and chronicity are common in PsA patients with uveitis. In this study, extensive axial involvement (bilateral sacroileitis and syndesmophytes), and the HLA-DR13 antigen were the best predictors for the appearance of uveitis.     

Expression and clinical significance of CD44V5 and CD44V6 in resectable colorectal cancer

Purpose This study was conducted to evaluate the prognostic significance of CD44v5 and CD44v6 in resectable colorectal cancer.Materials and methods Membranous CD44v5 and CD44v6 levels were measured by an immunoenzymatic assay in tumors and surrounding mucosal samples obtained from 105 patients with resectable colorectal carcinomas.Results There were no significant differences of CD44v5 levels between tumors [median: 3.2 (range: 0.9–83.5) ng/mg protein) and surrounding mucosal samples (3 (3–146.2) ng/mg protein]. However, tumor samples showed significantly higher CD44v6 levels [19.5 (2.2–562.9) ng/mg protein] than mucosal samples [5 (5–230) ng/mg protein] (P=0.0001). Patients with higher CD44v5 or CD44v6 content in tumor samples had a considerably shorter relapse-free survival (P<0.05, for both). Patients with a higher CD44v6 content also had a shorter relapse-free and overall survival in the multivariate analysis (P<0.05).Conclusion The results of this study suggest a role of CD44v5 and CD44v6 in colorectal cancer progression. Membranous CD44v levels in primary tumors, measured by immunoenzymatic assay, may contribute to a more precise prognostic estimation in patients with resectable colorectal cancer.Supported by grants from ISCIII Red de Centros de Cancer RTICCC (C03/10) and Obra Social Cajastur     

Single-step transvenous extraction of a passive fixation lead with delayed perforation of the right ventricle

Delayed pacemaker lead perforation is a very rare complicationand most of the published reports involve active fixation leads.The authors report an uneventful transvenous extraction of apassive fixation lead, which had a delayed perforation of theright ventricle, disclosed two months after pacemaker implantation.     

Hypoxemia after heart surgery by a right-left shunt via a permeable unrecognized foramen ovale

Hypoxemia is a relatively common complication in the immediate postoperative period after cardiac surgery under cardio-pulmonary bypass, usually due to pulmonary disease. When this does not improve with oxygen therapy and in the absence of pulmonary disease, it may be due to a right-to-left shunt. We report a case with a right-to-left intracardiac shunt due to persistence of a patent foramen ovale, which became functional again under the new hemodynamic conditions after surgery under cardiopulmonary bypass and assisted ventilation. The diagnosis and physiopathological mechanism were studied by cardiac catheterisation and angiography. Contrast echocardiography should be able to detect these acquired shunts relatively easily. The diagnosis requires appropriate therapy: discontinuation of ineffective assisted ventilation as this may aggravate the situation by increasing pulmonary resistance, and anticoagulant therapy to prevent potentially disastrous paradoxical thromboembolism.     

Mutant SOD1 in cell types other than motor neurons and oligodendrocytes accelerates onset of disease in ALS mice

Dominant mutations in ubiquitously expressed superoxide dismutase (SOD1) cause familial ALS by provoking premature death of adult motor neurons. To test whether mutant damage to cell types beyond motor neurons is required for the onset of motor neuron disease, we generated chimeric mice in which all motor neurons and oligodendrocytes expressed mutant SOD1 at a level sufficient to cause fatal, early-onset motor neuron disease when expressed ubiquitously, but did so in a cellular environment containing variable numbers of non-mutant, non-motor neurons. Despite high-level mutant expression within 100% of motor neurons and oligodendrocytes, in most of these chimeras, the presence of WT non-motor neurons substantially delayed onset of motor neuron degeneration, increasing disease-free life by 50%. Disease onset is therefore non-cell autonomous, and mutant SOD1 damage within cell types other than motor neurons and oligodendrocytes is a central contributor to initiation of motor neuron degeneration.