Cardiac Surgery with Cardiopulmonary Bypass in Low-Weight or Preterm Neonates: A Retrospective Study Analyzing Early Outcome

Background: Most outcome studies in congenital cardiac surgery for “low weight” neonates include patients undergoing surgery without cardiopulmonary bypass (CPB). The primary objective of our study was to identify risk factors for in-hospital mortality in neonates weighing less than 3 Kg and undergoing surgery with CPB. In addition, we compared the effect of early surgery with CPB (before 37W-gestational age (GA)) for congenital heart disease to delayed surgery until a corrected GA of 37 weeks in an attempt to promote weight gain. Methods: Retrospective single-center study including all patients operated between 1997 and 2017. Uni- and multivariable analysis were used to analyze outcome. Results: 143 patients were included. The median weight was 2.7 Kg and 49 (34.3%) weighted <2.5 Kg. 80% of the patients were Risk stratification STAT categories ≥3. 114 patients (80%) were operated without delay (usual timing, median age 9 days), whereas 29 patients (20%) entered a delayed strategy (median age 30 days). In-hospital mortality was 21.7%. By multivariate analysis, dysmaturity, preoperative positive ventilation, post-operative ECMO requirement or resuscitation, and any residual lesion were predictors of in-hospital death. In-hospital mortality in the usual timing group and the delayed group were 21.1% and 24.1%, respectively (p = 0.71). In-hospital mortality for neonates operated prior to 37W-GA (n = 10) was 27.3%. Conclusions: Predictors of in-hospital mortality in neonates less 3 Kg requiring CPB surgery did not differ from those unveiled in other contemporary studies. Our data demonstrates that a strategy of delaying surgery in selected patients resulted in similar clinical outcome.     

A critical evaluation of the concomitant use of the implantable Doppler probe and the Vacuum Assisted Closure system in free tissue transfer

Introduction of the Vacuum-Assisted Closure (V.A.C.) system has revolutionized the approach to a multitude of clinical settings. Yet, its use precludes adequate clinical monitoring of skin-grafted free flaps, thus, making a reliable monitoring system essential if broad clinical application is aspired. In a clinical study, the usefulness of the combination of the V.A.C. and implantable Doppler probe was critically evaluated in patients with microsurgical lower extremity reconstruction. We retrospectively analyzed the usefulness of the implantable Doppler probe in five consecutive patients treated in our department from January to July 2007. Inclusion criteria were lower extremity reconstruction by means of skin-grafted free tissue transfers with subsequent application of the V.A.C. device. Five consecutive patients (four males, one female) with a mean age of 37.8 years (range, 8-58 years) matched the criteria mentioned above. Of note, the two pediatric patients (8-year-old male and 12-year-old female) suffered from significant posttraumatic stress disorder necessitating concomitant psychological care by the Department of Psychiatry. All flaps healed uneventfully displaying no signs of vascular compromise. Interpretation of the Doppler signal was simple and well received by the nursing staff. The combination of V.A.C. and the implantable Doppler probe enhances patient comfort due to a reduction of the number of dressing changes while still allowing continuous free flap monitoring. Interpretation of the signal transmitted by the probe is simple and potentially reduces misinterpretations due to different levels of experience.     

Multiple myeloma presenting as acute tubulointerstitial nephritis and normal serum protein electrophoresis

Multiple myeloma is uncommon in individuals younger than 40 years. Renal involvement is common in this disease, but acute tubulointerstitial nephritis is very rare. In 20% of patients, only the light chain is produced and serum protein electrophoresis is normal; however, in urine protein electrophoresis of these patients, the M spike is present. We reported a case of multiple myeloma in a 39-year-old man with acute tubulointerstitial nephritis. Serum protein electrophoresis was normal and there was no bone lytic lesion. Remission of multiple myeloma was achieved after treatment with thalidomide and dexamethasone; however, kidney failure was not improved and the patient was maintained on hemodialysis.     

A randomized trial to promote health belief and to reduce environmental tobacco smoke exposure in pregnant women

Exposure to environmental tobacco smoke (ETS) is widespread among women in Iran. This study aimed to explore the impact of education on health belief and environmental tobacco smoke exposure in pregnant women. This randomized trial was administrated to 130 pregnant women exposed to ETS. The face-to-face education was provided for the intervention group after completing the questionnaire compiled on the constructs of the health belief model and self-reports of weekly ETS exposure. The theoretical constructs and weekly ETS exposure were compared in the study groups at the intake, third, fourth and fifth sections. In the intervention group, perceived susceptibility/severity and perceived benefits increased and the weekly ETS exposure decreased on the third as opposed to the first section (P < 0.05). Perceived susceptibility/severity and benefits significantly correlated with weekly ETS exposure in the intervention group (P < 0.05). The findings of this study point to the fact that education about the impacts of ETS exposure of pregnant women is an effective way to increase the theoretical constructs according to the health belief model and is associated with a reduction of ETS exposure. But this is not sufficient for making smoke-free homes.     

In vitro differences between venous and arterial-derived smooth muscle cells: potential modulatory role of decorin

OBJECTIVE: We analyzed the phenotypic and functional differences between venous and arterial smooth muscle cells (SMC) and the role of decorin in modulating these differences. METHODS AND RESULTS: SMC were isolated from the jugular veins and carotid arteries of male white New Zealand rabbits. Venous SMC demonstrated increased proliferation (2-fold, p<0.001), migration (1.7-fold, p<0.001), and collagen synthesis (4-fold, p<0.001), with decreased adhesion to collagen and fibronectin (1.2-fold, p<0.01) compared to arterial SMC. Higher levels of gelatinase activity (MMP-2 and MMP-9) and tissue inhibitor of metalloproteinase (TIMP) were also observed in venous SMC. Venous SMC demonstrated increased expression of SMemb and decreased expression of SM1--markers of a dedifferentiated and differentiated phenotype, respectively. Arterial SMC produced increased levels of the inhibitory proteoglycan, decorin, compared to venous SMC. Conditioned medium from arterial SMC (ASMC-CM) significantly decreased DNA synthesis, collagen synthesis, and gelatinase activity in venous SMC. Removal of decorin from ASMC-CM by immunoprecipitation significantly reversed the inhibitory effects of ASMC-CM on venous SMC proliferation and collagen synthesis but did not affect gelatinase activities. CONCLUSION: Venous SMC are more dedifferentiated and demonstrate increased proliferative and synthetic capacity than arterial SMC. Differential decorin expression between arterial and venous SMC contributes to these differences in biologic behavior. Venous SMC properties may contribute to accelerated atherosclerosis in venous bypass grafts.     

Arterial repair after stenting and the effects of GM6001, a matrix metalloproteinase inhibitor

OBJECTIVES: This study compared the extracellular matrix (ECM) and cellular responses after stenting to balloon angioplasty (BA) and to determine the late effects of matrix metalloproteinase (MMP) inhibition on arterial repair after stenting. BACKGROUND: Although stenting is the predominant form of coronary intervention, there is limited understanding of the early and late arterial response. METHODS: In a double-injury rabbit model, adjacent iliac arteries in 87 animals received BA (3.0 mm diameter) or stenting (3.0 mm NIR). Rabbits were treated for 1 week postprocedure with either GM6001 (100 mg/kg per day), an MMP inhibitor or placebo and sacrificed at 1 week or at 10 weeks' postprocedure. Arteries were analyzed for morphometry, collagen content, gelatinase activity, cell proliferation and DNA content.RESULTS: Stented arteries had significant increases in collagen content (2-fold) at 10 weeks compared to BA-treated arteries. At one week, overall gelatinase activity was increased >2-fold in stented arteries, with both 72 kD and 92 kD gelatinase activity. Stented arteries also had increases in both intimal DNA content (1.5-fold) and absolute cell proliferation (4-fold). Compared to placebo, GM6001 significantly inhibited intimal hyperplasia and intimal collagen content, and it increased lumen area in stented arteries without effects on proliferation rates. CONCLUSIONS: Stenting causes a more vigorous ECM and MMP response than BA, which involves all layers of the vessel wall. Inhibition by MMP blocks in-stent intimal hyperplasia and offers a novel approach to prevent in-stent restenosis.