Congenital vein valve aplasia

Congenital vein valve aplasia is often misdiagnosed and its symptoms misinterpreted as being caused by previous deep venous thrombosis. The present article reviews the literature providing data on etiology, symptomatology, and phlebographic appearance in congenital vein valve aplasia. A personal experience with 10 cases focuses on the clinico-physiological results with compression therapy and surgical treatment of superficial venous insufficiency. Compressive support with a tourniquet or a compressive stocking did not improve muscle pump function or venous reflux, as assessed by foot volumetry, and venous hypertension was not affected. Nevertheless, no patient developed leg ulcers during consistent use of compressive stockings. Surgical removal of incompetent saphenous veins, perforators, and varicosities in a subgroup of 6 patients (8 limbs) was followed by an improved muscle pump function and decreased venous hypertension which persisted 4 years post-operatively. Only 1 patient has been suited for deep venous reconstruction with transplantation of a valve-containing vein segment from the axillary vein to the popliteal vein, but it is still too early to assess the results of this procedure. Our findings demonstrate that consistent compressive therapy is paramount in the management of patients with congenital vein valve aplasia. Surgical treatment of the superficial venous insufficiency provides a long-lasting improvement of muscle pump function and venous hypertension. Curative vein valve transplantation or transposition is possible only in a minority of these patients.

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Resumen Los pacientes con aplasia valvular venosa congénita con frecuencia son motivo de diagnóstico equivocado y sus síntomas indebidamente interpretados como el resultado de episodios previos de trombosis venosa profunda. El presente artículo revisa la literatura y suministra datos relativos a la etiología, sintomatología, y apariencia flebográfica en la aplasia congénita valvular venosa. Una experiencia personal con 10 casos fue enfocada hacia el estudio de los resultados clínico fisiológicos con terapia compresiva y el tratamiento quirÚrgico de la insuficiencia venosa superficial. El soporte compresivo con torniquete o media elástica no mejoró la función de bombeo muscular ni el reflujo venoso a juzgar por la volumetría pédea, ni tampoco modificó la hipertensión venosa. Sinembargo, ninguno de los pacientes desarrolló Úlceras de las piernas mientras hubo el uso consistente de medias elásticas compresivas. La resección quirÚrgica de las venas safenas incompetentes, de las perforantes, y de las várices en un subgrupo de 6 pacientes (8 extremidades) resultó en mejoría de la función de bombeo muscular y disminución de la hipertensión venosa, lo cual ha persistido por 4 años postoperatorios. Sólo un paciente ha sido condicionado para reconstrucción venosa profunda con trasplante de un segmento venoso portador de válvula de la vena axilar a la vena poplítea, pero el resultado de este procedimiento es todavía demasiado temprano para ser valorado. Nuestros hallazgos demuestran que la terapia compresiva consistente es de importancia capital en el manejo de pacientes con aplasia valvular venosa congénita. El tratamiento quirÚrgico de la insuficiencia venosa superficial provee mejoría prolongada de la función de bombeo muscular y de la hipertensión venosa. El trasplante o la transposición curativa de válvulas venosas es posible apenas en una minoría de este grupo de pacientes.

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Résumé Les malades qui présentent une aplasie valvulaire veineuse voit celle-ci ignorée et leurs symptômes mal interprétés car ils sont attribués à une thrombose veineuse profonde. Cet article passe en revue la littérature et apporte des données sur l'étiologie, la symptomatologie, et l'aspect phlébographique de cette affection. Une expérience personnelle de 10 cas a été centrée sur les résultats cliniques et physiologiques obtenus par la compression et le traitement chirurgical de l'insuffisance veineuse superficielle. La compression par un tourniquet ou par un bas compressif n'améliore pas la fonction de pompe des muscles ou le reflux veineux ainsi qu'en témoigne la volumétrie du pied et l'hypertension veineuse n'est pas modifiée. Néanmoins aucun patient n'a développé un ulcère de jambe lors de l'emploi des bas compressifs. L'ablation chirurgicale des veines saphènes incompétentes, des perforantes et des varicosités chez 6 malades (8 membres) a été suivie d'une amélioration de la fonction de la pompe musculaire et d'une diminution de l'hypertension veineuse qui persistait encore 4 ans après une intervention. Un malade seulement a été candidat à la reconstruction du système veineux profond à l'aide d'un transplant de veine axillaire contenant une valve et remplaÇant la veine poplitée mais l'opération est trop récente pour que son résultat puisse Être apprécié. Nos constatations démontrent que la compression est un élément thérapeutique de grande valeur pour traiter l'aplasie vaivulaire veineuse congénitale. Le traitement chirurgical de l'insuffisance veineuse superficielle procure une amélioration de longue durée de la fonction de pompe des muscles et de l'hypertension veineuse. La transplantation de veine valvulée a visée curative et la transposition ne s'appliquent qu'à un petit groupe de malades.

     

Fibroblast Growth Factor 23, Hepatocyte Growth Factor,Interleukin‐6, High‐Sensitivity C‐Reactive Protein and Soluble Urokinase Plasminogen Activator Receptor. Inflammation Markers in Chronic Haemodialysis Patients?

Sera from 84 haemodialysis (HD) patients and 68 healthy blood donors were analysed with commercially available ELISA techniques for fibroblast growth factor 23 (FGF‐23), hepatocyte growth factor (HGF), interleukin‐6 (Il‐6), high‐sensitivity C‐reactive protein (hs‐CRP) and soluble urokinase plasminogen activator receptor (suPAR), to find a possible correlation of FGF‐23 and HGF with the earlier recognized inflammatory markers Il‐6 and hs‐CRP or suPAR. All patients studied had significantly elevated levels of FGF‐23, HGF, hs‐CRP and suPAR as compared to the controls. Il‐6 and hs‐CRP correlated for patients (R = 0.6) as well as for patients and controls altogether. Ln (natural logarithm) of HGF correlated weakly with Ln Il‐6 and Ln CRP (R 0.28–0.37). Ln FGF‐23 correlated only with Ln HGF (r = ?0.25) in controls. Ln HGF correlated with ln suPAR (r = 0.6) in both patients and controls. Although elevated as compared to controls, we found no correlation of FGF‐23 with the recognized inflammatory markers Il‐6, hs‐CRP, nor HGF or the new marker suPAR in HD patients. Ln HGF correlated with Ln Il‐6, Ln CRP and Ln suPAR. Although probably involved in vessel disease, FGF‐23 and HGF may play other roles than acting in inflammatory vessel disease in HD patients. Further studies are necessary to evaluate the role of these immunological markers in chronic haemodialysis patients with atherosclerosis.     

A novel blood-based biomarker for detection of autism spectrum disorders

Autism spectrum disorders (ASD) are classified as neurological developmental disorders. Several studies have been carried out to find a candidate biomarker linked to the development of these disorders, but up to date no reliable biomarker is available. Mass spectrometry techniques have been used for protein profiling of blood plasma of children with such disorders in order to identify proteins/peptides that may be used as biomarkers for detection of the disorders. Three differentially expressed peptides with mass–charge (m/z) values of 2020±1, 1864±1 and 1978±1 Da in the heparin plasma of children with ASD that were significantly changed as compared with the peptide pattern of the non-ASD control group are reported here. This novel set of biomarkers allows for a reliable blood-based diagnostic tool that may be used in diagnosis and potentially, in prognosis of ASD.     

Sclerostin,TNF‐alpha and Interleukin‐18 Correlate and are Together with Klotho Related to Other Growth Factors and Cytokines in Haemodialysis Patients

Patients with chronic renal failure are known to have renal osteodystrophy (bone disease) and increased calcification of vessels. A new marker of bone disease, sclerostin, the two pro‐inflammatory cytokines tumour necrosis factor‐alpha (TNF‐alpha) and interleukin‐18 (IL‐18), and the fibroblast growth factor‐23 (FGF‐23) receptor‐associated marker Klotho were tested in 84 haemodialysis (HD) patients and in healthy controls. The patients had significantly higher levels of the three former markers than of the controls while Klotho was significantly higher in the controls. Low level, but significant, correlations were observed in the patient group when the levels of these four markers were compared to each other and to those of 5 cytokines and growth factors tested earlier; high‐sensitive CRP (hsCRP), interleukin‐6 (IL‐6), hepatocyte growth factor (HGF), fibroblast growth factor‐23 (FGF‐23) and soluble urokinase plasminogen activator (suPAR). Ln sclerostin correlated positively to Ln hsTNF‐alpha, Ln HGF and Ln suPAR. Ln hsTNF‐alpha correlated positively to Ln sclerostin, Ln hsCRP, Ln IL‐6, Ln FGF‐23, Ln suPAR and Ln IL‐18. Ln IL‐18 correlated positively to Ln suPAR and Ln TNF‐alpha. Ln Klotho correlated negatively to Ln hsCRP but did not correlate to Ln FGF‐23. The markers studied here may be involved in the calcification of vessels seen in HD patients due to a combination of inflammation and bone disease. The mechanisms are still not fully known but may be of importance for future therapeutic possibilities in this group of patients.     

Intraoperative dreams reported after general anaesthesia are not early interpretations of delayed awareness

Background: Dreams are more frequently reported than awareness after surgery. We define awareness as explicit recall of real intraoperative events during anaesthesia. The importance of intraoperative dreaming is poorly understood. This study was performed to evaluate whether intraoperative dreams can be associated with, or precede, awareness. We also studied whether dreams can be related to case-specific parameters.
Methods: A cohort of 6991 prospectively included patients given inhalational anaesthesia were interviewed for dreams and awareness at three occasions; before they left the post-anaesthesia care unit, days 1–3 and days 7–14 after the operation. Uni- and multivariate statistical relations between dreams, awareness and case-specific parameters were assessed.
Results: Two hundred and thirty-two of 6991 patients (3.3%) reported a dream. Four of those also reported awareness and remembered real events that were distinguishable from their dream. Awareness was 19 times more common among patients who after surgery reported a dream [1.7% vs. 0.09%; odds ratio (OR) 18.7; P =0.000007], but memories of dreams did not precede memories of awareness in any of the 232 patients reporting a dream. Unpleasant dreams were significantly more common when thiopentone was used compared with propofol (OR 2.22; P =0.005). Neutral or pleasant dreams were related to lower body mass index, female gender and shorter duration of anaesthesia.
Conclusions: We found a statistically significant association between dreams reported after general anaesthesia and awareness, although intraoperative dreams were not an early interpretation of delayed awareness in any case. A typical dreamer in this study is a lean female having a short procedure.     

Pancreatic acinar metaplasia in the distal oesophagus and the gastric cardia: prevalence, predictors and relation to GORD

Purpose  

The nature of pancreatic acinar metaplasia (PAM) in the gastro-oesophageal junction (GOJ) remains obscure. We aimed to estimate its prevalence and investigate into its risk factors in a population-based series of first-time endoscopy patients.     

Hyponatremia complicating labour—rare or unrecognised? A prospective observational study

Objective  The aim of this study was to investigate the occurrence of hyponatraemia following delivery, with a hypothesis that hyponatraemia has a high prevalence in labouring women.
Design  Prospective observational study.
Setting  Consultant-led delivery suite in County Hospital, Kalmar, Sweden.
Sample  A total of 287 pregnant women at term (37 full gestational weeks).
Methods  Oral fluids were allowed during labour. Blood samples were collected on admission, after delivery, and from the umbilical artery and vein.
Main outcome measure  Hyponatraemia defined as plasma sodium ≤130 mmol/l after delivery.
Results  Hyponatraemia was found in 16 (26%) of the 61 mothers who received more than 2500 ml of fluid during labour. Two-thirds of fluids were orally ingested. Decrease in plasma sodium concentration during labour correlated with duration of labour and the total fluid volume administered. Analysis by multivariate logistic regression showed that hyponatraemia was significantly correlated with fluid volume ( P < 0.001) but not with oxytocin administration or epidural analgesia. Hyponatraemia correlated significantly with prolonged second stage of labour, instrumental delivery, and emergency caesarean section for failure to progress ( P = 0.002).
Conclusions  Hyponatraemia is not uncommon following labour. Tolerance to a water load is diminished during labour; therefore, even moderate fluid volumes may cause hyponatraemia. Women should not be encouraged to drink excessively during labour. Oral fluids, when permitted, should be recorded, and intravenous administration of hypotonic fluids should be avoided. When abundant drinking is unrecognised or intravenous fluid administration liberal, life-threatening hyponatraemia may develop. The possibility that hyponatraemia may influence uterine contractility merits further investigation.     

Positron emission tomography in the lung

Positron emission tomography using the ECAT II scanner to image and measure regional lung function is outlined. The combined use of transmission and emission imaging provides quantitative information about regional lung structure (density, extravascular density, and vascular volume) and function (ventilation, perfusion, ventilation-perfusion ratios, glucose metabolic rate). Clinical applications in asthma, chronic obstructive lung disease, pulmonary vascular disease, interstitial lung disease, and squamous cell carcinoma are presented. Future prospects for PET are discussed.     

Is transcutaneous PO2 monitoring during exercise a reliable alternative to arterial PO2 measurements?

Summary. Arterial PO₂ measurement during exercise is an important part in the evaluation of pulmonary disease but requires an intra-arterial cannula. However, in clinical work it would be preferable to assess PO₂ non-invasively. To evaluate such a technique, simultaneous measurements of transcutaneous PO₂ (tcPO₂) and arterial PO₂ (PaO₂), sampled from an indwelling arterial radial cannula, were made before, during and after a fatigue or symptom-limited bicycle exercise test in 16 patients referred to hospital because of dyspnoea. In total 181 paired measurements were made. Mean values (range) of PaO₂ and tcPO₂ were 11-2 kPa (5–16) and 9-5 (5–13-3), respectively. The correlation coefficient between PaO₂ and TcPO₂ was only 0–36 (P < 10^-5). By normalizing the values of tcPO₂ and PaO₂ to corresponding values at supine rest before exercise, the correlation coefficient increased to 0–80 (P < 10^-6). Using PaO₂ as golden standard, tcPO₂ described the trend in pO₂ during exercise reasonably well in all cases and this information is often sufficient for assessing the degree of pulmonary insufficiency. Thus, transcutaneous blood gas monitoring during exercise is useful for clinical evaluation of pulmonary disease, but a single arterial blood sample at rest before exercise is recommended for baseline correlation.,