Liver transplant-associated graft-versus-host disease

BACKGROUND: Graft-versus-host disease (GVHD) is an important, underdiagnosed cause of mortality associated with liver transplantation. We identified 12 cases of GVHD among 1,082 liver transplantations performed in patients at our institution between 1991 and 1998. Patients typically developed fever, skin rash, diarrhea, or pancytopenia within 2 to 6 weeks after their transplant. Treatment generally involved increased immune suppression and hematopoietic cytokines (granulocyte colony stimulating factor, granulocyte monocyte colony stimulating factor); however, all but one patient died, most often from sepsis. Early in its course, GVHD was difficult to distinguish from cytomegalovirus disease or drug reactions. The diagnosis was confirmed by demonstration of substantial donor lymphoid chimerism. METHODS: To identify risk factors for severe GVHD, a retrospective analysis was performed comparing index cases with the rest of the cases in our institutional experience. RESULTS: Closely matched human leukocyte antigen recipients, those older than 65 years, and recipients with donors more than 40 years younger were at higher risk for GVHD. One case occurred in a patient with a congenital immunodeficiency. CONCLUSIONS: Liver transplant-associated GVHD is a progressive and fatal disease. Future approaches should focus on prevention and might include avoidance of closely matched human leukocyte antigen donors, treatment of the donor to reduce the number of lymphocytes, or reduction of immunosuppression in the early posttransplant period.     

Serologic markers of brain injury and cognitive function after cardiopulmonary bypass

OBJECTIVE: To examine the association between biochemical markers of brain injury (MBI) and the inflammatory response in relation to neurocognitive deficiency (NCD) after cardiopulmonary bypass (CPB). SUMMARY BACKGROUND DATA: In cardiac surgery, NCD is a common but underdiagnosed complication with an unclear pathophysiology leading to significant morbidity. Despite extensive investigation, identification of a MBI for clinical use and clarifying the pathophysiology of NCD have not been achieved. METHODS: Forty patients undergoing CABG and/or valve procedures using CPB were administered a validated neurocognitive battery preoperatively and postoperatively at day 4 and 3 months. S-100b, neuron specific enolase (NSE), and tau protein were assayed as MBIs preoperatively and postoperatively at 6 hours and day 4. C-reactive protein (CRP), interleukin (IL)-6, C3a, and total peroxide levels were also quantified from serum. Impact of cardiotomy suction and antifibrinolytics on markers of brain injury was assessed. RESULTS: The incidence of early NCD was 40% (16 of 40). NSE and tau protein at the 6-hour time point were both significantly elevated in the presence of NCD (NCD group) compared with those without NCD (NORM group) (8.69 +/- 0.82 vs. 5.98 +/- 0.61; P = 0.018 and 68.8 vs. 29.2%; P = 0.015; respectively). S-100b increase was not different between the NCD and NORM groups. Cardiotomy suction significantly elevated S-100b levels, whereas NSE and tau were not significantly influenced. Aprotinin did not have an effect on NCD or levels of MBIs. Also, the NCD group had significantly elevated CRP and peroxide levels compared with the NORM group at postoperative day 4 while C3a was significantly elevated at 6 hours. CONCLUSION: NSE and tau are better associated with NCD and less influenced by cardiotomy suction compared with S-100beta. Inflammatory and oxidative stress is associated with NCD post-CPB.     

Ophthalmic Manifestations of Metastatic Breast Cancer

Metastatic breast cancer is the most common primary tumor metastasizing to the ocular structures. An analysis of 30 patients demonstrated a wide spectrum of ophthalmic manifestations including cranial nerve involvement, brain involvement with papilledema, Horner's syndrome, and choroidal and orbital tumors. The mean age of patients presenting with an ophthalmic sign was 54 years and the mean interval from the diagnosis of breast cancer to the development of the ophthalmic sign was 4.9 years. The carcinoembryonic antigen (CEA) was useful in confirming the diagnosis of metastatic disease as it was elevated in 18 of the 22 patients in whom it was measured. The estrogen receptor assay, performed on metastatic tissue removed from the orbit, can indicate the sensitivity of the breast cancer to hormonal therapy.     

缺血预适应对冠脉血流影响的实验研究——多普勒血流显像技术与电镜检查的对照

目的　本文应用冠脉血流显像技术评价缺血再灌注及预适应对冠脉血流的影响。方法　将 2 5条杂种犬分为三组 :缺血再灌注组 (IR组 )、持续缺血再灌注前先行反复三次短暂性缺血预处理组 (IP +IR组 )及在预处理之前静脉注射NOS抑制剂L -NAME组 (简称L -NAME组 )。计算左室射血分数 (LVEF)及再灌后LVEF恢复值 (再灌注 1h值-缺血 1h值 )。应用冠脉血流显像程序观察各组犬前降支结扎前和持续缺血再灌注 1h后其远端内血流改变 ,测量减速度、减速时间以及舒张期血流充盈时间 ,并应用R -R间距对其中时间指标进行校正。处死犬后 ,经冠状动脉口加压注射Evan’s蓝 ,然后将切成的心肌短轴层片放入 2 %TTC中染色 ,观察颜色变化 ,判断坏死区 (NA)和危险区 (RA)心肌。从危险区中采集心肌标本放置于固定液中 ,进行电镜检查。结果　两预处理组的射血分数恢复值高于IR组 ,均有显著性差异 (P <0 .0 5 )。IR组减速时间和舒张期充盈时间的校正值均低于预处理的其他两组 ,有极其显著性差异 (P <0 .0 1)。IR组NA :RA值明显高于预处理的其他两组 (P <0 .0 0 1)。电镜显示 ,IR组毛细血管基膜明显受损 ,而IP +IR组和L -NAME组损伤程度较IR组明显减轻。结论　应用冠脉血流显像技术可以发现缺血再灌注后血流形式改变为减速度增快、减     

Inferior pedicle breast reduction and long nipple-to-inframammary fold distance: How long is safe?

BackgroundFree nipple grafting indications in breast reduction surgery are outdated. Safety of inferior pedicle technique for large resections and long pedicles has not been clearly defined. We evaluated patients who underwent inferior pedicle reduction mammoplasty to define the safety constraints of the inferior pedicle.MethodsA retrospective review of patients who underwent inferior pedicle reduction mammoplasty due to symptomatic macromastia at Mayo Clinic over a six-year period was conducted. Patients with prior breast surgeries were excluded. Demographics, breast measurements, and surgical outcomes were collected. Univariate and multivariate analyses were performed to assess for predictors of necrosis.ResultsOverall, 288 patients (576 breasts) underwent inferior pedicle breast reduction from 2014 to 2019. The mean sternal notch-to-nipple (SNN) distance was 31.5 cm (standard deviation[SD]:4.2; range[r]:16–48), and the mean nipple-to-inframammary fold (N-IMF) distance was 14.8 cm (SD:4.0; r:7.5–27). The mean resection weight was 699.6 g (SD:310.4; r:125–2,385). The median follow-up was 3.9 months (interquartile range[IQR]:2.8–9.0). The overall skin or nipple areolar complex necrosis rate was 2.1%; the overall complication rate was 14.8%. On multivariate analysis, overall necrosis was not found to be associated with the N-IMF distance (adjusted odds ratio[aOR]:1.05, 95%-CI 0.88–1.16). Resection weight was statistically associated with an increased risk of overall necrosis (aOR:1.003, 95%-CI 1.001–1.005), adjusting for N-IMF and SNN distances.ConclusionInferior pedicle breast reduction offers low risk of necrosis and can be safely performed in patients regardless of the N-IMF distance. No association was found between N-IMF distance and overall necrosis in our cohort, including lengths >15 cm. However, large resections could increase the risk of necrosis.     

Intraoperative Surgical Sealant Application during Cardiac Defect Repair

Bleeding can occur as a sequela to cardiac surgery. Surgical products—such as conventional sutures and clips, and somewhat less conventional sealants—have been developed to prevent this event. Among these, CoSeal is a sealant used at our institution; here we report the cases of 2 patients in whom CoSeal was used successfully as either a supplement or an alternative to suture repair. This sealant was found to be useful in attaining hemostasis both in high-pressure ventricular repair and in the rupture of a friable coronary sinus adjacent to vital structures (in this instance, a left circumflex coronary artery).