Midterm follow-up of arterial switch operation for transposition of the great arteries with intact ventricular septum and left-ventricular outflow tract obstruction

Objective: We report the mid-term follow-up of patients, who underwent arterial switch operation (ASO) for transposition of the great arteries (TGA) with intact ventricular septum and left-ventricular outflow tract obstruction (LVOTO) over a 10-year period from 2000 to 2009. Methods: Thirteen TGA patients (3.9% of our ASO cohort) with intact ventricular septum and LVOTO underwent ASO. LVOTO was defined as pulmonary valve z-score ≤ −2.0 (n = 3) or peak LVOT gradient ≥40 mmHg with (n = 7) or without (n = 3) anatomic subvalvar stenosis on echocardiography. Median age and weight were 14 days (range, 7–130 days) and 3.2 kg (range, 2.1–4.6 kg). The LVOT abnormalities included fibromuscular narrowing (n = 5) and atrioventricular valve-related findings (n = 5). LVOT clearance was achieved by resection of accessory mitral tissue (n = 2) only. Results: Follow-up was 100% complete. There were no early or late deaths. Freedom from re-operation for neo-aortic valve regurgitation and/or LVOTO was 100% at a median follow-up of 38 months (range, 6–115 months). All patients had functional status appropriate for their age. Three patients had mild aortic regurgitation. The median Doppler estimated LVOT systolic gradient was 12 mmHg (range, 0–18 mmHg) for the entire cohort at the latest follow-up. Conclusions: Mid-term outcomes of ASO for a highly selected group of patients with pulmonary valve annulus z-score ≤ −2.0 ≥ −0.4, resectable organic LVOTO, and dynamic peak LVOT gradient ≥40 mmHg remain satisfactory, with a need for long-term follow-up.     

Seroepidemiology of hepatitis a in the croatian population

Background

Hepatitis A virus (HAV) has a worldwide distribution, although this distribution tends to be uneven among geographical regions and population groups. The prevalence of anti-HAV antibodies in the general population varies widely among countries. In Europe, the seroprevalence of HAV is reported to range from 32% to 88%.

Objectives

The aim of this study was to determine the seroprevalence of HAV among the general Croatian population.

Materials and Methods

During a 2-year period (2008-2009), a total of 791 serum samples were tested for the presence of anti-HAV total (IgM+IgG) and anti-HAV IgM antibodies using an automated enzyme-linked fluorescent assay (Mini Vidas; bioMérieux, Marcy l''Etoile, France).

Results

The overall anti-HAV seroprevalence was 41.6%. The observed difference in the seroprevalence rates among male and female patients was not statistically significant (44% vs. 39.6%, P = 0.218). A marked increase in anti-HAV seropositivity with age was observed (P < 0.001). The seroprevalence did not differ significantly between participants residing in rural regions (45.3%) and those residing in urban regions (40.6%, P = 0.292).

Conclusions

Our results corroborate those of seroprevalence studies in other developed countries. More than half of the Croatian population (59.4%) is susceptible to HAV infection. Older age is an important predictor for being anti-HAV positive.     

New ��L value�� parameter simplifies and enhances hip ultrasound interpretation in the detection of developmental dysplasia of the hip

Purpose  

The purpose of this study was to simplify and enhance the ultrasound (US) analysis of the infant’s hip by introducing a novel parameter named “L value” into the widely used Graf method.     

Preoperative evaluation of patients with history of allergy

The prevalence of allergic reactions in general opulation shows a constant rise. It has been estimated that up to 40% of surgical patients have a positive history of some kind of allergy. These patients represent a challenge during perioperative evaluation, since they can be exposed to a large variety of drugs and substances during surgery and anesthesia. A lot of adverse drug reactions show similar clinical presentation with allergic reactions. The latter are usually poorly explored since preoperative allergology testing is performed in a limited number of patients. Management of patients with history of allergy is impeded by the fact that most of allergens cross-react in a manner that is not always easy to predict. Allergies can manifest themselves with a broad spectrum of clinical symptoms, ranging from mild skin symptoms such as itch and urticaria, to a life-threatening anaphylactic reactions followed by hypotension, bronchospasm and cardiovascular collapse. Prevention of allergic reactions during perioperative period requires detailed history taking in order to identify patients at risk, optimization of anesthesia strategy, pharmacological premedication and further allergology diagnostic work-up in selected cases.     

Rhabdomyolysis and acute renal failure in a child with para-influenza type 1 infection

We present a rare case of para-influenza type 1 virus-induced rhabdomyolysis, complicated by acute renal failure (ARF). The child underwent continuous venovenous haemofiltration and has shown full clinical and biochemical recovery. ARF due to rhabdomyolysis in para-influenza type 1 infection in a child has, to the best of our knowledge, not been previously reported.     

The pituitary-adrenal axis of fetal rats after maternal dexamethasone treatment

Elevated glucocorticoid level in the gravid female circulation affects number of endocrine functions in fetuses and offspring. In this research female rats were injected with dexamethasone (Dx) in three consecutive daily doses of 1.0, 0.5, 0.5 mg/kg body weight, starting from day 16 of pregnancy. The influence of this treatment on the pituitary adrenocorticotrophic (ACTH) cells and adrenal glands of 19-day-old fetuses was examined immunocytochemically and by morphometric analysis. Moreover, the proliferative activity of adrenocortical cells was estimated after application of the mitotic inhibitor Oncovine. Administration of Dx to pregnant rats induced a decline of fetal ACTH cell immunopositivity and significant decreases of ACTH cell volume (23%, p<0.05), volume density (41%, p<0.05), and its number per unit area (17%, p<0.05) in comparison to the control 19-day-old fetuses. Reduced proliferative activity of adrenocortical cells (31%; p<0.05) in zona glomerulosa, as well as the volume of this zone were detected. The volume and number of fetal adrenocortical cells in the inner zone and chromoblasts were not significantly reduced after Dx treatment of pregnant rats. These results show that maternal Dx administration in the period when the fetal hypothalamo-pituitary-adrenal (PA) axis begins its function inhibited the PA axis. Reduced ACTH cell function and mitotic activity led to suppression of adrenocortical cell multiplication in zona glomerulosa, the region of the adrenal cortex where most proliferating cells were found in control 19-day-old fetuses. Thus, increased glucocorticoid levels during late pregnancy caused developmental modifications involving the fetal PA axis, which could be the basis of the altered endocrine responsiveness in adult life.     

Road traffic noise and sleep disturbances in an urban population: cross-sectional study

Aim

To explore the relationship between sleep disturbances caused by traffic noise and relevant personality traits, such as extroversion-introversion, neuroticism, and subjective noise sensitivity.

Methods

A cross-sectional study was carried out from January to April 2005 in a central municipality of Belgrade, the capital of Serbia and Montenegro. Noise measurements were performed at 12 measurement sites three times at daytime and twice at night. On the basis of noise measurement results, three streets with the highest and three streets with the lowest values of equivalent sound pressure level (Leq) were chosen to represent noisy (>65 dB(A)) and quiet (<55dB(A)) areas, respectively. The respondents from both areas were asked to fill out the questionnaire on noise-related health problems. The final sample consisted of 310 respondents, 192 from noisy area and 118 from quiet area.

Results

Respondents from noisy area reported having significantly more difficulties with falling asleep, being woken up by noise at night more often, and having more difficulties with falling back to sleep. They also complained of poorer sleep quality and tiredness after sleep and they slept by an open window in summer less often. Noise annoyance, subjective noise sensitivity, and neuroticism were significantly correlated with difficulties with falling asleep, time needed to fall asleep, poorer sleep quality, tiredness after sleep, and use of sleeping pills. After adjustment for potential modifying personality traits including subjective noise sensitivity, neuroticism, and extroversion, residence in noisy area was shown to be a significant predictor for difficulties with falling asleep (odds ratio [OR], 2.71; 95% confidence interval [CI], 1.27-5.80), difficulties with falling back to sleep (OR, 1.87; 1.02-3.40), waking up at night (OR, 2.60; 1.49-4.52), sleeping by closed windows (OR, 13.51; 5.84-31.25), having poor sleep quality (OR, 2.99; 1.13-7.89), and feeling tired after sleep (OR, 2.50; 1.11-5.63).

Conclusion

Urban population living in noisy area was at higher risk for sleep disturbances than population living in the quiet area. Furthermore, sleep disturbances were significantly and positively related to personality traits of neuroticism, subjective noise sensitivity, and noise annoyance.Noise is one of the major environmental hazards of the modern world, originating from a wide variety of sources, including traffic (air, road, or rail), industrial facilities, or social activities. About 40% of the population in the European Union are exposed to road traffic noise with an equivalent sound pressure level (Leq) exceeding 55 dB(A) at daytime, whereas 20% are exposed to levels above 65 dB(A). Noise pollution is a major public health problem in developing countries as well. It is caused mainly by road traffic; the 24-hour Leq can reach even 75-80 dB(A) along the main roads. More than 30% of Europeans are exposed to Leq exceeding 55 dB(A) at night, which may cause sleep disturbances (1). Systematic noise measurements in Serbia were performed in four cities with a population over 250 000. The results of follow-up measurements in Belgrade over 30 years showed that outdoor noise levels exceeded the allowed limits on 23 out of 27 measuring sites for 11-16 dB during day and 10-14 dB during night (2).In contrast to some other environmental problems, noise pollution continues to increase, followed by an increasing number of complaints from the exposed residents. The adverse health effects of community noise pose a serious public health problem. They include hearing impairment, interference with speech communication, disturbance of rest and sleep, psychological and performance effects, effects on one’s behavior, and subjective annoyance and interference with intended activities. Furthermore, noise has socio-cultural, esthetic, and economic effects. The estimated social costs for all noise nuisances are around 2.1% of the gross national product in industrialized countries, with about 0.2% attributable to productivity losses and 1.9% to decreases in property values (3).Healthy sleep is a prerequisite for good physiological and mental functioning. However, disturbed sleep includes biological responses that may have numerous adverse effects on health and well-being, from difficulties with falling asleep, alterations of sleep stages, and awakenings to increased blood pressure and cardiac arrhythmia (4). The pathophysiological basis for a noise-sleep relation may be the stimulation of hypothalamus-pituitary-adrenal axis, adrenal medulla, and sympathetic nervous system with a subsequent release of “stress hormones,” ie, adrenaline, noradrenaline, and cortisone (5). These biological responses might have long-term health implications including chronic fatigue syndrome, lower work productivity, increased proneness to accidents, and disturbances of blood pressure and coronary circulation.Substantial individual differences in neuroendocrine, immune, and behavioral responses to noise indicate that the level of noise itself may not be of primary importance. A close relation between arousal level and personality traits, such as introversion, neuroticism, and subjective noise sensitivity, can explain these differences (6,7). However, it is still unclear how important these personality characteristics are for the occurrence of sleep disturbances.The aim of this study was to explore the relationship between extroversion-introversion, neuroticism, and subjective noise sensitivity as personality traits and sleep disturbances caused by traffic noise. We expected personalities characterized by higher levels of introversion, neuroticism, and subjective noise sensitivity to be more prone to noise-disturbed sleep.     

Capecitabine as a radiosensitizing agent in neoadjuvant treatment of locally advanced resectable rectal cancer: prospective phase II trial

Aim

To evaluate the efficacy and toxicity of preoperative chemoradiotherapy with capecitabine in locally advanced rectal cancer.

Methods

Between June 2004 and January 2005, 57 patients with operable, clinical stage II-III adenocarcinoma of the rectum entered the prospective phase II study. Radiation dose was 45 Gy (25 × 1.8 Gy). Concurrent chemotherapy with a daily dose of 1650 mg/m² capecitabine was administered orally, divided into two equal doses per day, including weekends. Patients were evaluated weekly for acute toxicity and compliance with the protocol. Surgery was scheduled 6 weeks after the completion of the chemoradiotherapy.

Results

A single female patient died after receiving 27 Gy, because of pulmonary embolism. All other patients completed the preoperative chemoradiotherapy according to the protocol and a definitive operation was performed in all but one of these patients. The complete pathological response was recorded in 5 patients (9.1%). Tumor (T), lymph nodes (N), and overall downstaging rates were 40%, 52.9%, and 49.1%, respectively. Total sphincter preservation rate was 65.5% (36 out of 55 patients) and the rate in 27 patients with tumors located within 5 cm of the anal opening was 37% (10 out of 27 patients). The most frequent side-effect of the combined therapy was dermatitis (grade 3 in 19 patients). After surgery, a single patient died due to sepsis during the early perioperative period. Nonlethal perioperative complications were recorded in 24/55 patients.

Conclusion

Preoperative chemoradiotherapy with oral capecitabine is safe and well tolerated. It has a downstaging potential and can increase the possibility for sphincter preservation surgery.Preoperative chemoradiation has become a standard part of treatment protocols in stage II and III rectal cancer. Compared to postoperative chemoradiotherapy, the advantage of preoperative application of chemotherapeutics and irradiation includes improved compliance, reduced toxicity, and downstaging of the tumor in a substantial number of patients. The latter may enhance the rate of curative surgery, permit sphincter preservation in patients with low-sited tumors, and have a positive impact on the quality of life of these patients (1).Although several innovative agents are being investigated in combination with radiotherapy, 5-fluorouracil (5-FU) in continuous infusion remains the gold standard in preoperative chemoradiotherapy schedules. The prolongation of exposure of cells to 5-FU results in improved antitumor activity, but requires prolonged infusion, usually through a vascular access port (VAP). Complications resulting from long-term venous access, such as bleeding and thrombosis, are not uncommon (2).Orally administered capecitabine (Xeloda^®, Hoffmann-La Roche Ltd, Basel, Switzerland) mimics the pharmacokinetics of continuous 5-FU infusion and makes chemoradiotherapy more patient-friendly. The mechanism of capecitabine activation, preferably in tumor cells, may further enhance its efficacy and tolerability, offering the potential for an enhanced therapeutic ratio (3-5). The use of capecitabine allows chronic dosing and, at the same time, avoids the discomfort and complications associated with prolonged intravenous infusion of 5-FU (2,6). Thus, the majority of patients prefer oral chemotherapy to 5-FU infusions (7).The aim of the present prospective phase II study was to evaluate the efficacy and toxicity of preoperative chemoradiotherapy with capecitabine in patients with locally advanced rectal cancer. The primary endpoint of the study was a pathologically determined complete remission rate of the disease, locally and regionally. Secondary outcomes were the rate of sphincter preservation in low-sited tumors, overall downstaging rate, and toxicity.     

Estimation of infarct size using transthoracic Doppler echocardiographic measurement of coronary flow reserve in infarct related and reference coronary artery

Background

Patients in chronic phase of myocardial infarction (MI) have decreased coronary flow reserve (CFR) in infarct related artery (IRA) that is proportional to the extent of microvascular/myocardial damage. We proposed a novel model for the assessment of microvascular damage and infarct size using Doppler echocardiography evaluation of CFRs of the IRA (LAD) and reference artery (RCA).

Methods

Our study included 34 consecutive patients (28 men, mean age 50 ± 11 years) with first anterior STEMI and single vessel disease successfully treated with primary PCI. All patients underwent SPECT MPI for the assessment of infarct size (expressed as a percentage of myocardium with fixed perfusion abnormalities) and CFR evaluation of LAD and RCA. CFR derived percentage of microvascular damage (CFR PMD) was calculated as: CFR PMD = (CFR RCA − CFR LAD) / (CFR RCA − 1) × 100 (%).

Results

CFR PMD correlated significantly with all parameters evaluating the severity of myocardial damage including: peak CK activity (r = 0.632, p < 0.001), WMSI (r = 0.857, p < 0.001), ejection fraction (r = − 0.820, p < 0.001), left ventricular end diastolic (r = 0.757, p < 0.001) and end systolic volume (r = 0.794, p < 0.001). Most importantly, CFR PMD (22 ± 17%) correlated significantly with infarct size by SPECT MPI (21 ± 17%) (r = 0.874, p < 0.001).

Conclusions

CFR PMD derived from the proposed model was significantly related to echocardiographic and enzymatic parameters of infarct size, as well as to myocardial damage assessed by SPECT MPI in patients with successfully reperfused first anterior STEMI.