SAPS 3 is not superior to SAPS 2 in cardiac surgery patients

Objectives. Cardiac surgery patients are excluded from SAPS2 but included in SAPS3. Neither score is evaluated for this exclusive population; however, they are used daily. We hypothesized that SAPS3 may be superior to SAPS2 in outcome prediction in cardiac surgery patients. Design. All consecutive patients undergoing cardiac surgery between January 2007 and December 2010 were included in our prospective study. Both models were tested with calibration and discrimination statistics. We compared the AUC of the ROC curves by DeLong's method and calculated OCC values. Results. A total of 5207 patients with mean age of 67.2 ± 10.9 years were admitted to the ICU. The mean length of ICU stay was 4.6 ± 7.0 days and the ICU mortality was 5.9%. The two tested models had acceptable discriminatory power (AUC: SAPS2: 0.777–0.875; SAPS3: 0.757–893). SAPS3 had a low AUC and poor calibration on admission day. SAPS2 had poor calibration on Days 1–6 and 8. Conclusions. Despite including cardiac surgery patients, SAPS3 was not superior to SAPS2 in our analysis. In this large cohort of ICU cardiac surgery patients, performance of both SAPS models was generally poor. In this subset of patients, neither scoring system is recommended.     

Morphologic expression of the left coronary artery in pigs. An approach in relation to human heart

Introduction

In spite of its importance as an experimental model, the information on the left coronary artery in pigs is sparse.

Objective

To determine the morphologic features of the left coronary artery in pigs.

Methods

We evaluated 158 pig hearts. The left coronary artery was perfused with synthetic resin after their ostia had been catheterized. Diameters and courses of the vascular beds were measured with an electronic caliper (Mitutoyo^®).

Results

The diameter of left coronary artery was 6.98 ± 1.56 mm and its length was 3.51±0.99 mm. It was found to end up by bifurcating itself into the anterior interventricular artery and the circumflex artery in 79% of the cases, and by trifurcating in 21% of the cases, with the presence of the diagonal artery. The anterior interventricular artery ended up at the apex in 79.7% of the cases, and the circumflex artery at the posterior aspect of the left ventricle in 64% of the case, this artery never reached the posterior interventricular sulcus. An anastomosis between the terminal branches of the anterior interventricular artery and the posterior interventricular artery was found in 7.6% of the specimens. The antero-superior branch of the anterior interventricular artery occurred in 89.9% of the hearts. A left marginal branch was observed in 87.9% of the cases with a diameter of 2.25±0.55 mm.

Conclusion

Compared with humans, pigs have shorter left coronary artery trunks and branches; even the circumflex artery never reaches the posterior interventricular sulcus. Our findings are useful for the design of experimental hemodynamic and procedural models.     

Results of a comparative study analyzing octogenarians with renal cell carcinoma in a competing risk analysis with patients in the seventh decade of life

ObjectivesTo analyze clinicopathological features and survival of surgically treated patients with renal cell carcinoma (RCC)≥80 years of age in comparison with patients between the ages of 60 and 70 years.Materials and methodsThe data for 2,516 patients with a median follow-up of 57 months were retrieved from a multinational database (Collaborative Research on Renal Neoplasms Association [CORONA]), including data for 6,234 consecutive patients with RCC after radical or partial nephrectomy. Comparative analysis of clinicopathological features of 241 octogenarians (3.9% of the database) and 2,275 reference patients between the ages of 60 and 70 years (36.5%) was performed. Multivariable regression analysis adjusted for competing risks was applied to identify the effect of advanced age on cancer-specific mortality (CSM) and other-cause mortality (OCM). Furthermore, instrumental variable analysis was employed to reduce residual confounding by unmeasured parameters.ResultsSignificantly more women were present (50% vs. 40%, P = 0.004), and significantly less often nephron-sparing surgery was performed in octogenarians compared with the reference group (11% vs. 20%, P<0.001). Although median tumor size and stages did not significantly defer, older patients less often had advanced or metastatic disease (N+/M1) (4.6% vs. 9.6%, P = 0.009). On multivariable analysis, higher CSM (hazard ratio = 1.48, P = 0.042) and OCM rates (hazard ratio = 4.32, P<0.001) were detectable in octogenarians (c-indices = 0.85 and 0.72, respectively). Integration of the variable age group in multivariable models significantly increased the predictive accuracy regarding OCM (6%, P<0.001), but not for CSM. Limitations are based on the retrospective study design.ConclusionsOctogenarian patients with RCC significantly differ in clinical features and display significantly higher CSM and OCM rates in comparison with their younger counterparts.     

A randomized controlled trial of the effect of spironolactone on left ventricular mass in hemodialysis patients

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European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update

Context

The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.

Human spleen cell generation of factors stimulating human pluripotent stem cell, erythroid, and myeloid progenitor cell growth

Mitogen-stimulated murine spleen cells produce humoral substances capable of supporting murine hematopoiesis and pluripotent stem cell proliferation in vitro. Thus, we evaluated conditioned media generated by human spleen cells (SCM) in the presence or absence of mitogens for factors stimulatory for human pluripotent (CFU-GEMM), erythroid (BFU- E), and myeloid (CFU-GM) precursors. Two and one half percent to 10% SCM stimulated proliferation of all three types of precursor cells from nonadherent buoyant human marrow target cells. Mitogen-stimulated SCM augmented CFU-GM (175% to 225%), whereas CFU-GEMM and BFU-E growth was essentially unchanged. Cell separation procedures used to determine which cells provided these microenvironmental stimuli indicated that nonadherent mononuclear spleen cells provided the bulk of the CSF-GM, whereas adherent cells (95% nonspecific esterase + monocyte- macrophages) and nonadherent cells provided similar proportions of CSF- mix and erythroid burst-promoting activity (BPA). The nonadherent cells generating high levels of CSF-mix, BPA, and CSF-GM were predominantly Leu-1-negative, ie, non-T, cells. In the presence or absence of mitogens, SCM was a more potent source (1.3- to 3.8-fold) than peripheral leukocyte CM of the growth factors for the three progenitor cell types. Specific in situ cytochemical stains for analyzing morphology of myeloid colonies demonstrated that SCM stimulated the proliferation of the same types and proportions of colonies as human placental CM, suggesting that these CMs may contain similar CSF-GMs. These data show the contribution of spleen cell subsets to the generation of hematopoietic growth factors and the responsiveness of these cells to various mitogenic stimuli.     

Motor imagery of hand actions: Decoding the content of motor imagery from brain activity in frontal and parietal motor areas

How motor maps are organized while imagining actions is an intensely debated issue. It is particularly unclear whether motor imagery relies on action‐specific representations in premotor and posterior parietal cortices. This study tackled this issue by attempting to decode the content of motor imagery from spatial patterns of Blood Oxygen Level Dependent (BOLD) signals recorded in the frontoparietal motor imagery network. During fMRI‐scanning, 20 right‐handed volunteers worked on three experimental conditions and one baseline condition. In the experimental conditions, they had to imagine three different types of right‐hand actions: an aiming movement, an extension–flexion movement, and a squeezing movement. The identity of imagined actions was decoded from the spatial patterns of BOLD signals they evoked in premotor and posterior parietal cortices using multivoxel pattern analysis. Results showed that the content of motor imagery (i.e., the action type) could be decoded significantly above chance level from the spatial patterns of BOLD signals in both frontal (PMC, M1) and parietal areas (SPL, IPL, IPS). An exploratory searchlight analysis revealed significant clusters motor‐ and motor‐associated cortices, as well as in visual cortices. Hence, the data provide evidence that patterns of activity within premotor and posterior parietal cortex vary systematically with the specific type of hand action being imagined. Hum Brain Mapp 37:81–93, 2016. © 2015 The Authors. Human Brain Mapping Published by Wiley Periodicals, Inc.     

Staged management of giant abdominal wall defects: acute and long-term results

INTRODUCTION: Shock resuscitation leads to visceral edema often precluding abdominal wall closure. We have developed a staged approach encompassing acute management through definitive abdominal wall reconstruction. The purpose of this report is to analyze our experience with this technique applied to the treatment of patients with open abdomen and giant abdominal wall defects. METHODS: Our management scheme for giant abdominal wall defects consists of 3 stages: stage I, absorbable mesh insertion for temporary closure (if edema quickly resolves within 3-5 days, the mesh is gradually pleated, allowing delayed fascial closure); stage II, absorbable mesh removal in patients without edema resolution (2-3 weeks after insertion to allow for granulation and fixation of viscera) and formation of the planned ventral hernia with either split thickness skin graft or full thickness skin closure over the viscera; and stage III, definitive reconstruction after 6-12 months (allowing for inflammation and dense adhesion resolution) by using the modified components separation technique. Consecutive patients from 1993 to 2001 at a single institution were evaluated. Outcomes were analyzed by management stage, with emphasis on wound related morbidity and mortality, and fistula and recurrent hernia rates. RESULTS: Two hundred seventy four patients (35 with sepsis, 239 with hemorrhagic shock) were managed. There were 212 males (77%), and mean age was 37 (range, 12-88). The average size of the defects was 20 x 30 cm. In the stage I group, 108 died (92% of all deaths) because of shock. The remaining 166 had temporary closure with polyglactin 910 woven absorbable mesh. As visceral edema resolved, bedside pleating of the absorbable mesh allowed delayed fascial closure in 37 patients (22%). In the stage II group, 9 died (8% of all deaths) from multiple organ failure associated with their underlying disease process, and 96% of the remaining 120 had split-thickness skin graft placed over the viscera. No wound related mortality occurred. There were a total of 14 fistulae (5% of total, 8% of survivors). In the stage III group, to date, 73 of the 120 have had definitive abdominal wall reconstruction using the modified components separation technique. There were no deaths. Mean follow-up was 24 months, (range 2-60). Recurrent hernias developed in 4 of these patients (5%). CONCLUSIONS: The staged management of patients with giant abdominal wall defects without the use of permanent mesh results in a safe and consistent approach for both initial and definitive management with low morbidity and no technique-related mortality. Absorbable mesh provides effective temporary abdominal wall defect coverage with a low fistula rate. Because of the low recurrent hernia rate and avoidance of permanent mesh, the components separation technique is the procedure of choice for definitive abdominal wall reconstruction.     

Resuscitation with a novel hemoglobin-based oxygen carrier in a Swine model of uncontrolled perioperative hemorrhage

BACKGROUND: Systemic and pulmonary hypertension, possibly related to nitric oxide scavenging by free hemoglobin (Hb), is often seen during resuscitation with hemoglobin-based oxygen carriers (HBOCs). Recently, a second-generation HBOC, rHb2.0 for Injection (rHb), has been developed using recombinant human Hb that has reduced reactivity with nitric oxide. The current study evaluates the efficacy of this novel compound for resuscitation in a swine model of uncontrolled perioperative hemorrhage. METHODS: After instrumentation, animals underwent splenectomy and rapid hemorrhage to a systolic blood pressure of 35 mm Hg and isoelectric electroencephalography. 15 minutes of shock was followed by resuscitation over 30 minutes. In phase I, 18 animals were randomized into three resuscitation groups: (1) lactated Ringer's (LR) equal to three times the shed blood, the negative control group; (2) heterologous blood (BL) equal to Hb 2 g/kg, the positive control group; and (3) rHb equal to 2 g/kg, the treatment group. In phase II, six animals underwent the same experiment with a first-generation HBOC, diaspirin cross-linked Hb (DCLHb) equal to 2 g/kg, an additional control group. On day 0 after 2 hours of observation, spontaneously breathing animals were returned to their cages. Surviving animals were redosed on days 1, 2, and 3 (rHb/DCLHb 1 g/kg; LR/BL-LR 500 mL). Survivors were killed on day 5 and organs harvested for histologic examination. Group comparisons were performed using Student's t test, repeated-measures analysis of variance, and chi2 test. Significance was set at 95% confidence intervals. RESULTS: After resuscitation, systemic mean arterial pressure (MAP) (baseline = 107 +/- 15 mm Hg) was 128 +/- 34 and 108 +/- 15 mm Hg in rHb and BL animals, respectively, and remained stable. In LR and DCLHb animals, after normalization, MAP declined to 67 +/- 13 and 84 +/- 34 mm Hg, respectively. The rHb group maintained higher MAP than the LR and BL groups (p < 0.05 vs. both). With resuscitation, mean pulmonary arterial pressure (PAP) (baseline = 25 +/- 5 mm Hg) increased in rHb (40 +/- 4 mm Hg), BL (34 +/- 3 mm Hg), and DCLHb (40 +/- 3 mm Hg) groups, but stayed elevated only in the DCLHb group (36 +/- 3 mm Hg). PAP in the rHb group was similar to the BL group (p > 0.05), and both rHb and BL groups showed a higher PAP than the LR group (p < 0.05 vs. both). PAP was highest in the DCLHb group (p < 0.05 vs. rHb). Cardiac output of rHb and BL groups was similar (p > 0.05) throughout the observation period. Arterial lactate increased to 5.6 +/- 2.5 mmol/L with shock and then normalized to < 2.0 mmol/L in the rHb, BL, and LR groups within 30 minutes of resuscitation. It remained elevated to > 3.5 mmol/L and showed a delayed increase in the DCLHb group (p < 0.05). Causes and number of deaths were as follows: rHb, zero of six; BL-transfusion reaction, one of six; LR-irreversible shock, four of six; and DCLHb-ventricular failure, six of six. There was no significant increase in plasma methemoglobin (rHb) and no difference in liver or cardiac enzymes (rHb vs. BL). No histologic abnormalities were seen in the rHb group except for cytoplasmic vacuolation, a process thought to be related to metabolism of the test article. CONCLUSION: rHb2.0 for Injection, a second-generation recombinant human HBOC, performs as well as heterologous blood for resuscitation after perioperative blood loss, does not cause sustained pulmonary hypertension, maintains adequate cardiac output and oxygen delivery, and is superior to either LR or DCLHb.     

Age‐ and Sex‐Dependent Changes of Intra‐articular Cortical and Trabecular Bone Structure and the Effects of Rheumatoid Arthritis

The objective of this cross‐sectional study was to define normal sex‐ and age‐dependent values of intra‐articular bone mass and microstructures in the metacarpal heads of healthy individuals by high‐resolution peripheral quantitative computed tomography (HR‐pQCT) and test the effect of rheumatoid arthritis (RA) on these parameters. Human cadaveric metacarpal heads were used to exactly define intra‐articular bone. Healthy individuals of different sex and age categories and RA patients with similar age and sex distribution received HR‐pQCT scans of the second metacarpal head and the radius. Total, cortical, and trabecular bone densities as well as microstructural parameters were compared between 1) the different ages and sexes in healthy individuals; 2) between metacarpal heads and the radius; and 3) between healthy individuals and RA patients. The cadaveric study allowed exact definition of the intra‐articular (intracapsular) bone margins. These data were applied in measuring intra‐articular and radial bone parameters in 214 women and men (108 healthy individuals, 106 RA patients). Correlations between intra‐articular and radial bone parameters were good (r = 0.51 to 0.62, p < 0.001). In contrast to radial bone, intra‐articular bone remained stable until age 60 years (between 297 and 312 mg HA/cm³) but decreased significantly (p < 0.001) in women thereafter (237.5 ± 44.3) with loss of both cortical and trabecular bone. Similarly, RA patients showed significant (p < 0.001) loss of intra‐articular total (263.0 ± 44.8), trabecular (171.2 ± 35.6), and cortical bone (610.2 ± 62.0) compared with sex‐ and age‐adjusted controls. Standard sex‐ and age‐dependent values for physiological intra‐articular bone were defined. Postmenopausal state and RA led to significant decrease of intra‐articular bone. © 2016 American Society for Bone and Mineral Research.