Pretransplant and perioperative predictors of early heart transplantation outcomes

Aim

To identify predictors of 3-month mortality after heart transplantation in a Croatian academic center.

Methods

A retrospective review of institutional database identified 117 heart transplantations from January 2008 to July 2014. Two children <14 years were excluded from the study. The remaining 115 patients were dichotomized into survivors and non-survivors adjudicated at 3-months postoperatively, and their demographic, clinical, and longitudinal hemodynamic data were analyzed.

Results

3-month survival after heart transplantation was 86%. Non-survivors were older (59 ± 8 vs 50 ± 14 years, P = 0.009), more likely to have previous cardiac surgery (44% vs 19%; odds ratio [OR] 3.28, 95% confidence interval [CI] 1.08-9.90; P = 0.029), lower body mass index (BMI) (25 ± 4 vs 28 ± 2 kg/m², P = 0.001), and be diabetics (44% vs 23%; OR 2.57, 95% CI 0.86-7.66; P = 0.083). Creatinine clearance was marginally superior among survivors (59 ± 19 vs 48 ± 20 mL/min, P = 0.059). Donor age and sex did not affect outcomes. Non-survivors were more likely to have had ischemic cardiomyopathy (69% vs 32%, P = 0.010). Postoperative utilization of epinephrine as a second line inotropic agent was a strong predictor of mortality (63% vs 7%; OR 21.91; 95% CI 6.15-78.06; P < 0.001). Serum lactate concentrations were consistently higher among non-survivors, with the difference being most pronounced 2 hours after cardiopulmonary bypass (9.8 ± 3.5 vs 5.2 ± 3.2 mmol/L, P < 0.001). The donor hearts exhibited inferior early hemodynamics in non-survivors (cardiac index 3.0 ± 1.0 vs 4.0 ± 1.1 L/min/m², P = 0.001), stroke volume (49 ± 24 vs 59 ± 19 mL, P = 0.063), and left and right ventricular stroke work indices (18 ± 8 vs 30 ± 11 g/beat/m², P < 0.001 and 5 ± 3 vs 7 ± 4 g/beat/m², P = 0.060, respectively). Non-survivors were more likely to require postoperative re-sternotomy (50% vs 12%; OR 7.25, 95% CI 2.29-22.92; P < 0.001), renal replacement therapy (RRT) (69% vs 9%; OR 22.00, 95% CI 6.24-77.54; P < 0.001), and mechanical circulatory assistance (MCS) (44% vs 5%; OR 14.62, 95% CI 3.84-55.62; P < 0.001). Binary logistic regression revealed recipient age (P = 0.024), serum lactates 2 hours after CPB (P = 0.007), and epinephrine use on postoperative day 1 (P = 0.007) to be independently associated with 3-month mortality.

Conclusion

Pretransplant predictors of adverse outcome after heart transplantation were recipient age, lower BMI, ischemic cardiomyopathy, reoperation and diabetes. Postoperative predictors of mortality were inferior donor heart hemodynamics, epinephrine use, and serum lactate concentrations. Non-survivors were more likely to require re-sternotomy, MCS, and RRT. Heart failure (HF) presents a major public health burden, and its management consumes a large proportion of the health care budget (1,2). While the clinical syndrome of HF is multifactorial in origin, its cardinal symptoms are remarkably similar irrespective of the diverse underlying cardiac pathology. The adverse impact of HF on the quality of life and overall mortality has brought the issue into focus of the contemporary medical community. The already high financial burden of HF will likely increase in parallel to increasing age of the general population. Contrariwise, the number of orthotopic heart transplantation (OHT) worldwide has plateaued over the past decade (3). The unmatched need for donor organs has served as a strong impetus for the development of alternative lines of management, including mechanical circulatory assistance. While we have witnessed both an accelerated evolution of ventricular assist devices and their wider dissemination within the HF population, the high incidences of associated complications reduce the effectiveness of this line of management. The contemporary armamentarium for HF management also includes pharmaceutical modulation of multiple targets and biventricular pacing. This complex array of management tools notwithstanding, OHT remains the unchallenged gold standard when it comes to long-term outcomes for patients with end-stage HF (4). The importance of effective utilization of available organs is paramount in the setting of a pronounced shortage of suitable allografts. The aim of this study was to identify the predictors of adverse 3-month outcome following heart transplantation in a tertiary-care academic center.     

Predictors of patient compliance during Class II division 1 malocclusion functional orthodontic treatment

ObjectivesTo determine factors that could predict Class II/1 malocclusion patient compliance during functional treatment.Materials and MethodsThe sample consisted of 77 subjects (aged 11–13 years; 47% girls) presenting with Class II/1 malocclusion. Inclusion criteria were distal molar relationship, overjet greater than 5 mm, and confirmed pubertal growth spurt. Removable functional appliances (62% Twin Block [TB], 38% Sander Bite Jumping [BJ]) with built-in maxillary expansion screws were used. Follow-up period was 1 year. Patients and parents independently filled out the Child Perception Questionnaire, Parental/Caregiver Perception Questionnaire, and Family Impact Scale to assess emotional and social well-being, oral symptoms, functional limitations, parental emotions, family activities, conflicts, and financial burden as possible predictors of compliance during treatment. Sex, overjet, and appliance type were also analyzed.ResultsThere were more noncompliant than compliant patients (55% vs 45%). Parental perception of altered emotional well-being of their children was the strongest predictor, increasing compliance odds 3.4 times (95% confidence interval [CI], 1.2–9.4; P = .017). Patients were 3.2 times (95% CI, 1.1–9.3; P = .033) more likely to cooperate with TB compared with BJ appliance. OJ ≥ 8 mm increased compliance odds 3.1 times (95% CI, 1.0–9.4; P = .044).ConclusionsParental perception of child''s emotional well-being alteration, severity of malocclusion, and type of appliance are major predictors of compliance. Psychosocial issues and oral function limitations reported by children and family impact are of negligible influence.     

The influence of war on the oral health of professional soldiers

AIM: Professional soldiers, although trained to deal with specific conditions, are not immune to war stress induced behavioural changes, and since oral diseases are behaviour-related some changes in the oral cavity could be expected. PARTICIPANTS AND METHODS: The study was conducted on 640 professional soldiers in the Croatian Army, aged 19-49 years. The study group consisted of 336 soldiers in active service during the war in Croatia (1991-1997), while control group included 304 soldiers in peacetime service. Decayed, Missing and Filled Teeth Index (DMFT) and Community Periodontal Index (CPI) as well as questionnaires concerning dental behaviour and diet were employed. RESULTS: War group soldiers had significantly poorer oral health with DMFT being 14.4 in the war group and 13.1 in the controls, respectively (p < 0.001). The war group also showed a significantly higher number of periodontal pockets and excluded sextants, but lower numbers of healthy sextants (1.3 war group and 2.1 control; p < 0.001). Significant differences between the war and peacetime groups according to the number of dental visits, daily brushing frequency and diet were found. There was a tendency towards the deterioration of oral health with increase in time spent in battle fields. CONCLUSION: War conditions have a significant influence on the increased prevalence and severity of oral diseases for professional soldiers.     

Skeletal components of class III malocclusions and compensation mechanisms

Summary  The aim of this retrospective study was to assess the skeletal characteristics of sagittal maxillary and mandibular discrepancies resulting in class III malocclusions and compensation mechanisms in one Caucasian European population (Croatian). The study sample included 107 patients (63 females and 44 males), aged between 11 and 18 years of age (mean age 14·6 ± 2·2), with a class III malocclusion. Forty-three angular and linear measurements were assessed from the pre-treatment lateral cephalographs of each subject. anova , Tukey post hoc and t -test were used for statistical analysis. The most common differential skeletal type was mandibular prognathism with a normal maxilla (43%), followed by maxillary retrognathism with a normal mandibular position (19·6%), while the combination of maxillary retrognathism and mandibular prognathism was found to be rare (<5%). Subjects with maxillary retrognathia, appeared to also have a vertical facial pattern, suggesting a tendency towards vertical growth as a possible compensation mechanism. Those with mandibular prognathia tended to exhibit a horizontal facial growth pattern and typically included more pronounced dento-alveolar compensation, that is, proclination of maxillary and retroclination of mandibular incisors. There were no differences observed in gender, overjet or soft tissue profiles between different sagittal skeletal types. Dominant protrusive mandible in Croatians can be related to European Caucasian ancestry, where this entity is historically described as 'Habsburg jaw'.     

Assessment of tryptophol genotoxicity in four cell lines in vitro: a pilot study with alkaline comet assay

Tryptophol is an aromatic alcohol and secondary metabolite of the opportunistic fungus Candida albicans. Although its toxicity profile at cell level has been poorly investigated, recent data point to cytotoxic, cytostatic, and genotoxic effects in lymphocytes and the induction of apoptosis in leukaemic blood monocytes. In this pilot study we evaluated the genotoxicity of tryptophol in vitro on four permanent cell lines of animal and human origin: ovary cells, alveolar epithelium, liver cells, and blood monocytes using the alkaline comet assay. We selected cells that might be principal targets of tryptophol and other low-molecular geno(toxins) secreted by Candida albicans during host invasion. Our results suggest that tryptophol applied in vitro at 2 mmol L(-1) for 24 h damages DNA in HepG2, A549 and THP-1 cells, obviously due to bioactivation and/or decomposition of the parent compound, which results in the formation of more genotoxic compound(s) and production of reactive species that additionally damage DNA. On the other hand, notably lower levels of primary DNA damage were recorded in CHO cells, which lack metabolic activity. Future studies with tryptophol should look further into mechanisms involved in its toxic action and should focus on other cell types prone to infection with Candida spp. such as vaginal epithelial cells or keratinocytes of human origin.     

Efficacy of IP6 + inositol in the treatment of breast cancer patients receiving chemotherapy: prospective,randomized, pilot clinical study

Background

Prospective, randomized, pilot clinical study was conducted to evaluate the beneficial effects of inositol hexaphosphate (IP₆) + Inositol in breast cancer patients treated with adjuvant therapy.

Patients and methods

Patients with invasive ductal breast cancer where polychemotherapy was indicated were monitored in the period from 2005-2007. Fourteen patients in the same stage of ductal invasive breast cancer were involved in the study, divided in two randomized groups. One group was subjected to take IP₆ + Inositol while the other group was taking placebo. In both groups of patients the same laboratory parameters were monitored. When the treatment was finished, all patients have filled questionnaires QLQ C30 and QLQ-BR23 to determine the quality of life.

Results

Patients receiving chemotherapy, along with IP₆ + Inositol did not have cytopenia, drop in leukocyte and platelet counts. Red blood cell counts and tumor markers were unaltered in both groups. However, patients who took IP₆ + Inositol had significantly better quality of life (p = 0.05) and functional status (p = 0.0003) and were able to perform their daily activities.

Conclusion

IP₆ + Inositol as an adjunctive therapy is valuable help in ameliorating the side effects and preserving quality of life among the patients treated with chemotherapy.     

Determination of spatial distribution of increase in bone temperature during drilling by infrared thermography: preliminary report

Introduction  During the drilling of the bone, the temperature could increase above 47°C and cause irreversible osteonecrosis. The spatial distribution of increase in bone temperature could only be presumed using several thermocouples around the drilling site. The aim of this study was to use infrared thermographic camera for determination of spatial distribution of increase in bone temperature during drilling. Materials and methods  One combination of drill parameters was used (drill diameter 4.5 mm; drill speed 1,820 rpm; feed-rate 84 mm/min; drill point angle 100°) without external irrigation on room temperature of 26°C. The increase in bone temperature during drilling was analyzed with infrared thermographic camera in two perpendicular planes. Thermographic pictures were taken before drilling, during drilling with measurement of maximal temperature values and after extraction of the drill from the bone. Results  The thermographic picture shows that the increase in bone temperature has irregular shape with maximal increase along cortical bone, which is the most compact component of the bone. The width of this area with the temperature above critical level is three times broader than the width of cortical bone. From the front, the distribution of increase in bone temperature follows the form of the cortical bone (segment of a ring), which is the most compact part and causes the highest resistance to drilling and subsequent friction. Conclusions  Thermography showed that increase in bone temperature spreads through cortical bone, which is the most compact and dense part, and generates highest frictional heat during drilling. The medullar cavity, because of its gelatinous structure, contributes only to thermal dissipation.     

Impulse conduction velocities in human biceps brachii muscles

Measurements of impulse conduction velocity were made in biceps brachii muscle fibers of male or female controls and of male body-builders. The technique involved exciting bundles of fibers with stimulating electrodes applied over the surface of the muscle, and recording compound action potentials with three small surface electrodes spaced 3 cm apart. By measuring latencies to the onsets and to the peaks of the negative deflections, it was possible to estimate conduction velocities in the fastest-conducting (FC) and intermediate-conducting (IC) fibers; the observed values ranged from 2.8 to 5.5 m·s⁻¹ in normal men and women. The mean conduction velocity for FC fibers was significantly higher in body-builders than in normal men and women; the mean IC value was significantly lower in women. In all three groups of subjects a decrease in conduction velocity could be demonstrated for FC fibers at the end of 1 min of maximal isometric contraction. In the body-builders, and probably in the other two groups of subjects, the FC fibers are considered to correspond to type II muscle fibers.