Intra-aortic balloon pumping recruits graft flow reserve by lowering coronary resistances

Background

The intra-aortic balloon pump (IABP) is used worldwide as an anti-ischemic strategy and to reduce myocardial workload. However, whether IABP augments coronary flow after coronary bypass via a passive increase in diastolic pressure or an active response of the coronary bed remains uncertain.

Methods

We analyzed transit-time flow measurements and the contemporary changes in coronary resistances obtained during 1:1 IABP and during its cessation in 144 consecutive patients receiving prophylactic IABP before isolated coronary artery bypass grafting (n = 340 graft segments).

Results

Normally functioning grafts showed lower coronary resistances, greater percentage decrease in resistance, and greater increases in average maximum diastolic and mean flow during 1:1 IABP compared with IABP cessation (P < .001). Arterial and sequential saphenous vein grafts showed better flowmetry and greater reductions in coronary resistances compared with single venous grafts. Accordingly, graft flow reserve (defined as mean flow during 1:1 IABP/mean flow with IABP off) was recruited (graft flow reserve > 1) during 1:1 IABP in all normally functioning grafts, with higher values in single arterial or sequential saphenous vein grafts than in single venous grafts (both P < .001). Coronary resistances were higher in 7 failed grafts versus normal-functioning grafts at baseline; these did not decrease during 1:1 IABP and showed worse transit-time flow results.

Conclusions

IABP recruits graft flow reserve by lowering coronary resistance in functioning grafts. Arterial and sequential venous grafts showed greater reduction in coronary resistance compared with single saphenous grafts.     

Addition of iron to erythropoiesis-stimulating agents in cancer patients: a meta-analysis of randomized trials

Background  

Iron supplementation could improve the hematopoietic response of erythropoiesis-stimulating agents (ESAs) used for chemotherapy-induced anemia.     

A practical definition of minor stroke

It is generally assumed that minor stroke (MS) is an ischemic stroke with a short-term, good functional outcome. However, no clear definition of MS exists. Modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS) are still the most accredited standards, but scores and timing of the assessment are not homogeneous. As suggested by a qualified sample of Italian neurologists, the index parameter chosen in our analysis was mRS at the time of hospital discharge. The database of the SIRIO study (a large observational study of 2,573 patients with stroke admitted in Italian hospitals in 2005) was used to identify an mRS threshold to define MS. Reference was made to outcome markers such as rate of discharge to home, 1-year disability and 1-year mortality. The rate of discharge progressively decreased with increase in mRS, while the rates of 1-year mortality and disability progressively increased. Our proposal is one of defining a stroke “minor” when the rate of discharge to home is above the SIRIO database overall value and the 1-year mortality and disability is below the respective overall values. This definition is consistent with a score ≤2 on the mRS.     

Hollow screws: a diagnostic tool for intracranial empyema

Background

Subdural (SDE) and epidural empyema (EDE) are life-threatening intracranial infections. They require immediate diagnosis and treatment. However, in some cases, magnet resonance imaging (MRI) is not able to contribute to diagnosis; therefore, surgical exploration is indicated. Hollow screws used for decompression of chronic subdural haematoma (cSDH) are valuable tools for minimally invasive biopsy in awake patients when SDE and EDE are suspected.

Methods

Between 2006 and 2010, eight patients in our department underwent biopsy of a suspected SDE or EDE using hollow screws. In these cases, MRI or computed tomography (CT) were not able to provide sufficient diagnostic security to indicate primary craniotomy. Diagnostic and therapeutic efficacy was evaluated on preoperative and postoperative imaging. The focus was on qualitative parameters, such as contrast enhancement or impaired diffusion on diffusion-weighted images (DWI).

Results

The application of the hollow screw under local anaesthesia permitted an exact diagnosis in all cases. In one case, the suspected diagnosis of cSDH could be refuted by diagnostic puncture. In four cases of uncertain diagnosis, the application of the hollow screw revealed a cSDH. Seven of eight patients previously received neurosurgical treatment; three of those cases were SDE or EDE and four were cSDH. Cases of SDE and EDE needed further craniotomy after diagnostic puncture, whereas patients with cSDH were sufficiently treated by hollow screws.

Conclusions

Given their comparably wide diameter, hollow screws allow a sufficient sample size and, therefore, lead to precise diagnosis of SDE and EDE without significant operative risks or strains for the patient.