Factor V Leiden and Postoperative Deep Vein Thrombosis in Patients Undergoing Open Roux-en-Y Gastric Bypass Surgery

Background: Patients undergoing bariatric surgery are at risk for deep venous thrombosis (DVT) and fatal pulmonary embolus. In the presence of genetic hypercoagulable disorders, accepted methods of DVT prophylaxis utilizing sequential compression devices and subcutaneous unfractionated heparin may not be adequate to prevent DVT or fatal PE. Methods and Results: 3 morbidly obese patients are described who underwent open Roux-en-y gastric bypass and either had a previous diagnosis of Factor V Leiden or developed thrombosis in the presence of standard prophylaxis. Each was found to have the most common point mutation for Factor V Leiden, R506Q. All 3 patients had prophylactic inferior vena caval filters placed to prevent recurrent PE. Conclusion: The presence of venous thromboembolism either without known risk factors or in the presence of standard perioperative prophylaxis for DVT should warrant a hypercoagulable work-up. Inferior vena caval filter placement is indicated in the presence of a hypercoagulable disorder prior to surgical intervention in the morbidly obese population. The recent literature is reviewed.     

Reversibility of hepatic encephalopathy after liver transplantation

Until the advent of Liver transplantation, it was widely believed that Hepatic Encephalopathy (HE) was usually reversible. The exceptions were the so called “Acquired Hepatocerebral Degeneration cases” which were considered irreversible. Paradoxically, it seems, with liver transplantation, we have seen cases that contradict these rules. Whether the “residual effects” of HE, degenerative brain injury or independent neurological insults are causing post transplant neurological deficits is not easy to discern. As more emphasis is being put on maintaining brain ‘status’ after liver transplantation, we are finding confirmation of the largely reversible nature of HE. But, enough important exceptions to this rule are occurring to make further research on this topic mandatory.     

Off‐pump,minimally invasive and robotic coronary revascularization yield improved outcomes over traditional on‐pump CABG

Coronary artery disease is a global health concern, with increasing morbidity and mortality. Surgical coronary artery bypass grafting has been performed on cardiopulmonary bypass for nearly four decades, with excellent long‐term durability. Beating‐heart coronary surgery has been increasing in frequency in an attempt to decrease cardiopulmonary bypass‐related morbidity. Furthermore, with increasing expertise and technology, minimally invasive and robotic techniques have been developed to enhance post‐operative recovery, patient satisfaction and cosmesis. Several clinical trials have demonstrated decreased morbidity and more rapid recovery following off‐pump, minimally invasive and robotic procedures when compared to on‐pump coronary artery bypass grafts (CABGs). An equivalent extent of revascularization and medium‐term anastomotic patency has been demonstrated among all approaches. Furthermore, for a large number of patients who do not have anatomy amenable to traditional coronary revascularization, adjunctive molecular therapies may provide alternative myocardial micro‐revascularization. Copyright © 2008 John Wiley & Sons, Ltd.     

Neurocysticercosis immunodiagnosis using Taenia solium cysticerci crude soluble extract, excretory secretory and lower molecular mass antigens in serum and urine samples of Indian children

Neurocysticercosis (NCC), the most common neurological disorder of parasite etiology, results from lodgment of Taenia solium cysticerci in the central nervous system and is now increasingly being recognized in children. The confirmed diagnosis is based collectively on radiological findings and serodiagnostic techniques. The serodiagnostic techniques have variable sensitivity and specificity depending upon the technique, antigens used, location and number of cysts. Crude soluble extract (CSE), excretory secretory (ES) and lower molecular mass (LMM) (10-30 kDa) antigenic fraction of T. solium cysticerci were evaluated for antibody detection in serum and urine samples by ELISA. Serum and urine samples were collected each from 125 clinically suspected and radiologically proven NCC (111 with single Computed Tomography (CT) lesions and 14 with multiple CT lesions) and 125 control subjects (60 with neurological disorders other than NCC, 40 with other parasitic diseases and 25 apparently healthy subjects). The sensitivity of the ELISA with the use of CSE, ES and LMM antigenic fractions was 38.4%, 63.2% and 30.4% with serum (cut off dilution 400), 46.4%, 44% and 47.2% with neat urine and the specificity was 88%, 76.8% and 85.6% with serum (cut off dilution 400), 66.4%, 65.2% and 58.4% with neat urine samples, respectively. The study suggests that detection of antibody to ES antigen in serum samples may serve useful purpose for the serodiagnosis of human NCC.     

Traumatic aneurysm of the callosomarginal artery.

Intracranial aneurysms are rare complications of head injury. The primary goals in the management of patients harbouring these lesions are early identification and intervention to prevent bleeding or rebleeding. The authors present a case of traumatic false aneurysm of the callosomarginal artery which was diagnosed following head injury and managed successfully with a good outcome.     

Selective output-discriminative signals in the motor cortex of waking monkeys.

Monkeys and humans have similar capacities to discriminate between the frequencies of mechanical sinusoids delivered to the glabrous skin of their hands. Combined psychophysical-electrophysiological experiments in monkeys discriminating in the range of flutter provided evidence that this capacity depends upon differences in the cycle lengths in the sets of periodically entrained activity, evoked by the stimuli discriminated, in neurons of areas 3b and 1 of the (sensory) hemisphere opposite the stimulated hand. Identical experiments have now been made, in similarly trained and discriminating monkeys, in the motor cortex (area 4) of the hemisphere opposite the arm projecting selectively to one of two targets, to indicate discrimination (five hemispheres, 1137 neurons studied). We observed a selective signal of the upcoming correct discrimination in about 25% of the neurons of area 4 active in the task. The neuronal discharge occurs selectively for stimuli either lower or higher in frequency than that of the base stimulus, and commonly begins within 200-300 msec after onset of the comparison stimulus. These neuronal discharges are aperiodic, with no sign of the stimulus frequencies. EMG recording during performance of the discrimination showed that the muscles of the arm opposite the side of recording were silent during the period of stimulus presentations. Recordings during trials in which the animal made errors showed most commonly that the output of the discrimination operation was itself in error, followed by an appropriate arm projection to the wrong target. We interpret the selective response during the comparison stimulus to be a postdiscrimination signal projected transcallosally from the sensory hemisphere to the motor area of the hemisphere controlling the responding arm. We obtained no evidence that the discrimination operation is localized to any particular area, and we surmise it to occur in the dynamic activity within the distributed system linking the sensory cortex of one hemisphere and the motor cortex of the other. One-third of the neurons of the motor cortex responded to indentation of the skin of the ipsilateral hand, at trial onset. These responses varied from those closely linked to that sensory stimulus to those linked to the upcoming movement of the contralateral hand. These onset responses did not occur when similar sequences of mechanical stimuli were delivered to alert but idling monkeys.     

Minimally invasive, robotic, and off-pump mitral valve surgery

A significant transformation is occurring in the management of mitral valve disease. Earlier surgery is now recommended. Mitral valve repair is the standard of care, and newer methods of reconstructing the mitral valve are developing. Surgery with videoscopic assistance can be effectively performed without sternotomy. Robotics systems are gaining wider adoption. Implantable devices to repair or replace the mitral valve off-pump and percutaneously are emerging.