Consequence of atrial fibrillation and the risk of embolism after percutaneous mitral commissurotomy: the necessity of the maze procedure

Background

We sought to investigate the incidence and risk of embolism after percutaneous balloon mitral commissurotomy (PMC) and delineated the necessity of the maze procedure in patients with atrial fibrillation (AF).

Methods

Clinical records of 326 patients, who underwent PMC between April 1988 and March 2003, and 162 patients, who underwent mitral valve surgery (MVS) combined with the maze procedure (MVS/maze) in the same period, were reviewed. We examined the consequence of cardiac rhythm and the incidence and risk of embolism after PMC. Next our current criteria for indication of the maze procedure, which included duration of AF less than 10 years, voltage of f wave on electrocardiography greater than 0.1 mV, cardiothoracic ratio less than 70%, and left atrial dimension less than 70 mm, were applied to all patients. These criteria were satisfied by 190 patients of PMC (PMC group) and 114 patients of MVS/maze (MVS/maze group) and the early and late results of the two groups were compared.

Results

Thirty-eight patients suffered from embolic complications after PMC. Of these 33 patients experienced AF before intervention. The actuarial embolism-free rate at 10 years was 81.9% in patients with AF before PMC and 92.9% in patients with sinus rhythm before PMC (p = 0.01). Univariate predictors of embolism after PMC included previous embolic history (p = 0.01), AF (p = 0.01), pressure gradient (p = 0.01), age (p = 0.03), and mitral valve area (p = 0.04). Multivariate analysis identified AF as the independent predictor of embolism in the late follow-up period (p = 0.03). In a comparative study of the selected patients the actuarial AF-free rates after MVS/maze were 89.9% at 1 year and 85.7% at 5 years and were significantly higher than those of 17.3% at 1 year and 4.2% at 5 years after PMC (p < 0.0001). The actuarial embolism-free rate in the MVS/maze group was 98.0% at 5 years and was significantly higher than that of 84.8% at 5 years and 82.4% at 10 years in the PMC group (p = 0.01).

Conclusions

PMC alone is not sufficient with regard to sinus rhythm recovery and prevention of embolism. Surgical treatment concomitant with the maze procedure may be beneficial for patients with AF.     

Smad3 deficiency attenuates renal fibrosis, inflammation,and apoptosis after unilateral ureteral obstruction

BACKGROUND: Transforming growth factor-beta (TGF-beta) has been implicated in the development of renal fibrosis induced by unilateral ureteral obstruction (UUO). However, there is little information on signaling pathways mediating TGF-beta activity involved in molecular and cellular events leading to renal fibrosis induced by UUO. In this study, we sought to determine whether Smad3, a major signaling component of TGF-beta, mediated renal fibrosis induced by UUO. METHODS: Renal fibrosis, inflammation, and apoptosis induced by UUO were macroscopically and histologically compared between wild-type mice and Smad3 null mice. RESULTS: Gross appearance of the kidney after UUO showed relatively intact kidney in Smad3 null mice [Smad3(-/-) mice] when compared with that of wild-type mice [Smad3(+/+) mice]. Renal interstitial fibrosis based on the interstitial area stained with Aniline-blue or Sirius red solution was significantly attenuated in the obstructed kidney of Smad3(-/-) mice when compared with that of Smad3(+/+) mice. Deposition of type I and type III collagens were also significantly reduced in the obstructed kidney of Smad3(-/-) mice. In addition, the numbers of myofibroblasts, macrophages, and CD4/CD8 T cells infiltrated into the kidney after UUO were significantly attenuated in the obstructed kidney of Smad3(-/-) mice when compared with that of Smad3(+/+) mice. Furthermore, terminal deoxynucleotidyltransferase-mediated deoxyuridine triphosphate (dUTP) nick-end labeling (TUNEL) staining after UUO showed significantly reduced number of tubular apoptotic cells in the obstructed kidney of Smad3(-/-) mice when compared with that of Smad3(+/+) mice. Endogenous Smad pathway was activated in the obstructed kidney after UUO in wild-type mice as judged by the increase of phosphorylated Smad2 or phosphorylated Smad2/3-positive cells in renal interstitial area. CONCLUSION: Smad3 deficiency attenuated renal fibrosis, inflammation, and apoptosis after UUO, suggesting that Smad3 was a key molecule mediating TGF-beta activity leading to real fibrosis after UUO.     

Cervical spondylotic myelopathy and radiculopathy treated by oblique corpectomies without fusion

Oblique corpectomy (OC) is an alternative technique for the resection of spondylotic spurs ventral to the cervical spinal cord contributing to cervical spondylotic myelopathy (CSM) and cervical spondylotic radiculopathy (CSR). To evaluate the efficacy of OC for the treatment of cervical spondylotic myeloradiculopathy, we reviewed our experience with OC. Twenty-six patients, 18 males and 8 females, were studied. They averaged 51.3 years of age (range 30-72), Thirteen had myelopathy and 13, radiculopathy. Both magnetic resonance (MR) imaging and computed tomography (CT) were performed preoperatively to define the extent of pathology. The Modified Japanese Orthopedic Association (JOA) score was used to grade the quality of the outcome. Neurologic and radiologic results were assessed. Good and excellent results were observed in 76.9% of the cases with myelopathy. Improvement of radicular symptoms was noted in 84.6% of the cases with radiculopathy. Neuroimaging studies confirmed satisfactory anatomical decompression in all patients. Sagittal alignment decreased from 13 degrees to 12 degrees. The degree of postoperative recovery seemed to be directly related to the age and severity of the preoperative myelopathy. This surgical technique has shown excellent clinical outcomes with fast recovery and adequate anatomical decompression in patients with CSM and CSR.     

Primary peripheral T-cell lymphoma of the face other than mycosis fungoides. Computed tomography and magnetic resonance findings

OBJECTIVE: To describe the radiologic findings of primary peripheral T-cell lymphoma (PTCL) of the face other than mycosis fungoides. METHODS: Computed tomography (CT) and magnetic resonance imaging (MRI) findings of 5 consecutive patients with pathologically proven primary facial PTCL other than mycosis fungoides were retrospectively evaluated. Patients with PTCL involving the sinonasal cavity or lymph nodes were excluded. RESULTS: Diagnoses of patients included in this study consisted of natural killer/T-cell lymphoma (n = 2), subcutaneous panniculitis-like T-cell lymphoma (n = 1), anaplastic large cell lymphoma (n = 1), and PTCL not otherwise specified (n = 1). Infiltration or swelling of the superficial space of the face was noted on both CT and MRI, mimicking inflammation or infection. Also seen were well-enhancing small nodular (n = 2) or infiltrative mass-like lesions (n = 2) within the areas of infiltration, which showed intermediate signal intensity on T2-weighted images. One patient demonstrated infiltration and swelling alone. CONCLUSIONS: Primary facial PTCL is a rarely encountered tumor and demonstrates infiltration or swelling mimicking inflammation or infection. Nodular or infiltrative mass-like lesions may be helpful for its diagnosis.     

Gastrointestinal stromal tumor of the retroperitoneum: CT and MR findings

Gastrointestinal stromal tumor (GIST) is a non-epithelial neoplasm arising from the wall of the gastrointestinal (GI) tract. Although the majority of GISTs are located in the GI tract, some GISTs occur in the omentum, mesentery and retroperitoneum. GIST arising in the retroperitoneum is extremely rare, and its radiological findings have not been well described. We report a case of primary retroperitoneal GIST and discuss its imaging findings.     

Long-term follow-up of glucose tolerance function after pancreaticoduodenectomy: comparison between pancreaticogastrostomy and pancreaticojejunostomy

BACKGROUND: The objectives of the present study are to determine the long-term changes in glucose tolerance function after pancreaticoduodenectomy and to compare the effects of pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG).Patients and methods The present study consisted of 51 patients who received a pancreaticoduodenectomy for tumors of the pancreatic head area and survived more than 7 postoperative years without tumor recurrence. According to the type of pancreatic anastomosis, they were classified into 2 groups of 25 PJ patients and 26 PG patients. Changes in the patterns of a 75-g oral glucose tolerance test (OGGT) (normal, impaired glucose tolerance [IGT], and diabetic [DM] patterns) and the need for beginning diabetic treatment (oral hypoglycemic agents or insulin) were compared between groups. RESULTS: Within 3 months after surgery, 14 (56%) patients in the PJ group had normal OGTT patterns, 8 (32%), IGT patterns, and 3 (25%), DM patterns. In the PG group, the patterns of OGTT were similar with 16 (62%) normal patterns, 6 (23%) IGT patterns, and 4 (15%) DM patterns. During the first 7 postoperative years, the 2 groups showed similar results: (1) none of the patients with normal patterns developed functional decline in glucose tolerance; (2) a high percentage of patients with initial IGT or DM patterns developed worsening glucose intolerance (7 [64%] of 11 PJ patients vs 7 [70%] of 10 PG patients); (3) the onset of functional decline in glucose tolerance occurred predominantly within the first 3 postoperative years; and (4) no specific causative event prior to the subsequent functional decline was detected. CONCLUSION: The decline of glucose tolerance after pancreaticoduodenectomy seems to be associated with a low reserve of endocrine function rather than anastomotic procedures or their related complications. Regardless of the types of pancreatic anastomosis, a close follow-up of glucose tolerance function is recommended during the first 3 postoperative years, especially among IGT or DM patients.     

Childhood factors associated with asthma remission after 30 year follow up

BACKGROUND: Factors contributing to either "complete" or "clinical" remission of asthma are important to know since there is no cure for the disease. METHODS: A cohort of 119 allergic asthmatic children was examined three times with a mean follow up of 30 years. They were aged 5-14 years at visit 1 (1966-9), 21-33 years at visit 2 (1983-6), and 32-42 years at visit 3 (1995-6). Complete remission of asthma at visit 3 was defined as no asthma symptoms, no use of inhaled corticosteroids, normal lung function (FEV1 >90% predicted), and no bronchial hyperresponsiveness (PC10 >16 mg/ml). Clinical remission was defined as no asthma symptoms and no use of inhaled corticosteroids. RESULTS: 22% of the group was in complete remission of asthma at visit 3 and a further 30% was in clinical remission (total 52%); 57% of subjects in clinical remission had bronchial hyperresponsiveness and/or a low lung function. Logistic regression analyses showed that a higher FEV1 in childhood and more improvement in FEV1 from age 5-14 to 21-33 were associated with both complete and clinical asthma remission at age 32-42. CONCLUSIONS: Complete remission of asthma was present in a small subset of asthmatics while half the subjects showed clinical remission. Both complete and clinical remission were associated with a higher lung function level in childhood and a higher subsequent increase in FEV1. These results support the view that defining remission only on the basis of symptoms and medication use will overlook subjects with subclinical active disease and possibly associated airway remodelling.     

Bone marrow chimerism and tolerance induced by single-dose cyclophosphamide

BACKGROUND: Establishment of hematopoietic chimerism is the most stable strategy for donor-specific tolerance. Safer pretreatment regimens are needed for clinical application. We evaluated the efficacy of a simple protocol using cyclophosphamide (CYP) on induction of chimerism and organ transplant tolerance across major histocompatibility complex (MHC) barriers in the rat. MATERIALS AND METHODS: Bone marrow cells from BN (RT1(n)) donors were infused to LEW (RT1(l)) recipients on day 0 after a single injection of CYP at various doses on day -1. Donor-derived hematopoietic chimerism was evaluated by flowcytometry. The recipients received BN or third party (BUF) heart allografts on day 100. RESULTS: While pretreatment with 200 mg/kg of CYP induced high levels of hematopoietic chimerism, six of eight recipients died of severe graft-versus-host-disease (GVHD). CYP at dose of 150 mg/kg induced 36.5 +/- 24.1% of donor-derived chimerism on day 10, and sustained macrochimerism was seen until day 100 without GVHD. Pretreatment with 100 mg/kg of CYP resulted in only transient chimerism (4.8 +/- 5.2%) which disappeared by day 20. In the recipients with 50 mg/kg of CYP, donor bone marrow cells were rapidly rejected and no chimerism was observed. The recipients with 150 mg/kg of CYP accepted BN heart allografts (>100 days x 5), while rejecting BUF allografts by day 12 (n = 4). BN heart allografts were rejected in the recipients with 100 (MST: 57 days, n = 5) and 50 mg/kg (MST: 7 days, n = 5) of CYP. CONCLUSIONS: A single dose of CYP can induce hematopoietic chimerism across MHC-barriers. The dose of 150 mg/kg seems to be optimal to induce organ transplant tolerance without developing GVHD.     

A report card on outcomes for surgically treated gastrointestinal cancers: are we improving?

INTRODUCTION: Longitudinal analyses of cancer registries provide an opportunity for population-based explanations of epidemiology and survival-related outcomes. This study used two population-based data sets to report on nine surgery-related cancers over the past three decades. MATERIALS AND METHODS: Using the SEER cancer database (1973-1999), all patients (>18 years old) with adenocarcinoma of esophagus, gastric, biliary system, pancreas, small bowel, colon, rectum; esophageal squamous cell carcinoma (ESC), or hepatocellular (HCC) carcinoma (n = 379,640) were analyzed. Changes in incidence rates, stage at diagnosis, and 5-year cancer and stage-specific survivals were determined. A separate database, the California inpatient database (1990-2000), was concurrently used to evaluate inpatient mortality after surgical resection (n = 34,057). RESULTS: Incidence rates increased for three cancers (esophageal, HCC, small bowel); decreased for three (rectal, gastric, ESC); and stayed constant for three (biliary, pancreatic, colon). More patients presented with local/regional disease in the 1990s versus 1970s for eight tumors (except small bowel, P < 0.05). Five-year overall survival improved for all but small bowel (P < 0.05); and local stage survival was improved for all except small bowel and biliary (P < 0.05). Finally, inpatient mortality rates improved significantly for liver, esophageal, pancreatic, and gastric resections (P < 0.05) over the past decade. CONCLUSIONS: For these nine surgically treated cancers, we are detecting disease at earlier and therefore more treatable stages, and surgical care and outcomes also appear to have improved. Continued reexamination of longitudinal trends of surgically relevant outcomes is important for future improvement of surgical care.