Laparoscopic pocket splenopexy for wandering spleen: a case report

Wandering spleen is a very uncommon condition. Because of the risk of pedicle torsion and splenic ischemia, severe consequences may occur if not diagnosed and treated in time. Unfortunately, splenectomy is sometimes necessary (ie, when splenic infarction occurs). Once the diagnosis of wandering spleen is made, splenopexy is the treatment of choice. There are numerous techniques designed for splenopexy, either by open surgery or by minimally invasive approaches. We describe here a laparoscopic procedure that allows an excellent fixation of the spleen using the patient's own tissues. After a 2-year follow-up, the organ remains in place with good perfusion.     

Paraoxonase-1 activity modulates endothelial function in patients with peripheral arterial disease

Increased arterial stiffness is associated with risk variables of metabolic syndrome in middle-aged and older adults. However, information regarding the influence of the metabolic syndrome on arterial stiffness and its rate of change with age in young adults is limited. These aspects were examined in a sample of 806 asymptomatic, healthy young adults aged 24–44 years from a black–white community. Brachial to ankle pulse wave velocity (baPWV) measured by an oscillometric method was used as an index of arterial stiffness. baPWV increased with the increasing number of metabolic syndrome components, defined by National Cholesterol Education Program Adult Treatment Panel III (1256, 1314, and 1422 cm/s for those with 0, 1–2, and 3–5 components, respectively, P for trend <0.001). Furthermore, the rate of change (slope) of baPWV with age increased as the number of metabolic syndrome components increased (4.1, 10.7, and 18.7 cm/s per year for those with 0, 1–2, and 3–5 components, respectively; P for comparison of slopes <0.001). These findings by showing the deleterious effects of metabolic syndrome on arterial stiffness and its age-related increase in young adults underscore the importance of this syndrome in cardiovascular risk assessment even in a younger population. Further longitudinal studies are needed to confirm the current cross-sectional findings.     

Prognostic value of elevated white blood cell count in hypertension

BACKGROUND: Chronic low-grade inflammation may contribute to vascular injury and atherogenesis, and has been described in association to high blood pressure (BP). However, as yet the prognostic significance of white blood cell (WBC) count in the setting of uncomplicated hypertension has not been investigated. METHODS: In the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) study, 1617 white patients with essential hypertension (aged 49 +/- 12 years, 55% men) without prevalent cardiovascular or renal disease underwent off-treatment baseline clinical evaluation and were then followed up for 11 years (average 4.9 years). RESULTS: The WBC count had a direct association with smoking status, serum triglycerides, body mass index, and 24-h BP, and an inverse one with age (all P < .05). During follow-up, 146 patients developed a major fatal or nonfatal cardiovascular event (1.9 events per 100 patient-years). Patients who will develop a cardiovascular event had a higher WBC count (7.08 +/- 1.6 v 6.68 +/- 1.6 x 10(9) cells/L, P = .004). Event rate increased progressively from the first to the fourth quartile of WBC count distribution (1.2, 1.8, 1.9, and 2.3 events per 100 patient-years; P < .01 by log-rank test). After adjustment (Cox model) for the effect of age, gender, diabetes, serum cholesterol, glomerular filtration rate, smoking, left ventricular hypertrophy, and 24-h systolic BP, cardiovascular event risk increased by 24% (95% confidence interval +4% to +48%; P = .019) for each 2 x 10(9) cells/L increase in WBC. CONCLUSIONS: After adjustment for average 24-h BP, established risk factors and target organ damage, an elevated WBC count remains an independent predictor of cardiovascular morbidity in hypertensive patients.     

Ambulatory arterial stiffness index is not a specific marker of reduced arterial compliance

Ambulatory arterial stiffness index (AASI), a measure based on the relative behavior of 24-hour systolic and diastolic blood pressure (BP), has been suggested as a marker of arterial stiffness and a predictor of cardiovascular mortality. However, a narrow range of diastolic BP values over the 24 hours tends to flatten the regression slope and to artificially increase AASI. We explored the possible influence of different ranges of 24-hour diastolic BP fluctuations, such as those related to nocturnal BP fall, on AASI, and on its relationship with target organ damage. In 515 untreated hypertensive patients, AASI was directly related to age (r=0.30) and 24-hour systolic BP (r=0.20), whereas it was inversely related with nocturnal systolic and diastolic BP reduction (r=-0.28 and -0.46, respectively; all P<0.001). A direct relationship was found between AASI and left ventricular mass index (r=0.17; P<0.001), but this relation was no longer significant after adjustment for age, sex, body mass index, daytime systolic BP, and day-night systolic BP reduction (all P<0.05). AASI was directly related to carotid-femoral pulse wave velocity, an intrinsic measure of aortic stiffness (r=0.28; P<0.001), but no independent relation was found in a multiple linear regression. Our conclusions are as follows: (1) AASI is strongly dependent on the degree of nocturnal BP fall in hypertensive patients; (2) there is no significant relation between AASI and left ventricular mass after proper adjustment for confounders; and (3) the relation between AASI and a widely accepted measure of aortic stiffness, such as pulse wave velocity, is weak and importantly affected by other factors.     

Metabolic syndrome and preclinical atherosclerosis: focus on femoral arteries

Several evidences revealed the relationship between the earliest stages of atherosclerosis and the components of metabolic syndrome. The aim of this study was to disclose preclinical atherosclerotic lesions in a cross-sectional observational study involving 147 patients with metabolic syndrome by the assessment of brachial flow-mediated vasodilation (FMV) and intima-media thickening at both carotid and femoral sites. The purpose was to investigate the association of this metabolic disorder with prevalent atherosclerotic damage in different vascular sites. A control group of 87 healthy subjects was also investigated. Patients had lower values of FMV and a higher mean intima-media thickness (IMT) at both the carotid and femoral sites with respect to controls. Flow-mediated vasodilation had a positive correlation with high-density lipoprotein (HDL) cholesterol and a negative one with low-density lipoprotein (LDL) cholesterol, glycemia, and insulinemia. Carotid mean IMT was directly related to LDL cholesterol and age, and inversely with HDL cholesterol; femoral mean IMT had a direct association with LDL cholesterol, triglycerides, glycemia, and insulinemia and an inverse correlation with HDL cholesterol and LDL size. LDL cholesterol, HDL cholesterol, insulin, and brachial artery diameter were predictive of brachial FMV (beta=-0.17, 0.21, -0.27, and -0.29, respectively; P<.05), whereas age, LDL cholesterol, and HDL cholesterol were independent predictors of mean carotid IMT (beta=0.19, 0.37, and -0.27, respectively; P<.05); on the other hand, LDL cholesterol, triglycerides, and insulin were independent predictors of mean femoral IMT (beta=0.32, 0.26, and 0.25, respectively; P<.05). In conclusion, the present study documented an altered endothelial function and intima-media thickening in patients with metabolic syndrome without overt cardiovascular disease. Moreover, it focused on the strong influence of metabolic syndrome on preclinical atherosclerotic lesions at the femoral site.     

Amyotrophic lateral sclerosis: the Midwestern surgical experience with the diaphragm pacing stimulation system shows that general anesthesia can be safely performed

Background

There is a paucity of literature concerning general anesthesia and surgery in patients with amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). This report summarizes the largest series of surgical cases in ALS during multicenter prospective trials of the laparoscopic diaphragm pacing system (DPS) to delay respiratory failure.

Method

The overall strategy outlined includes the use of rapidly reversible short-acting analgesic and amnestic agents with no neuromuscular relaxants.

Results

Fifty-one patients were implanted from March 2005 to March 2008 at 2 sites. Age at implantation ranged from 42 to 73 years and the percent predicted forced vital capacity (FVC) ranged from 20% to 87%. On preoperative blood gases, Pco₂ was as high as 60. Using this protocol, there were no failures to extubate or 30-day mortalities. The DPS system increases the respiratory system compliance by decreasing posterior lobe atelectasis and can stimulate respirations at the end of each case.

Conclusions

Laparoscopic surgery with general anesthesia can be safely performed in patients with ALS undergoing DPS.     

Prognostic impact of prolonged ventricular repolarization in hypertension

BACKGROUND: QT interval prolongation on the surface electrocardiogram (ECG) predicts cardiovascular complications in high-risk subjects, but its prognostic role in uncomplicated hypertension has been understudied. METHODS: For up to 13 years (average, 5.3 years), we followed up 2110 white patients with initially untreated essential hypertension (mean +/- SD age, 49 +/- 12 years; 55% men) without prevalent cardiovascular or renal disease who underwent 12-lead ECG before therapy. We excluded patients with ECG abnormalities including ischemia, necrosis, complete bundle branch block, atrial fibrillation, arrhythmias, and ventricular preexcitation. RESULTS: Heart rate-corrected QT interval (QTc) showed a weak but significant direct association with systolic blood pressure (r = 0.07; P<.001), diastolic blood pressure (r = 0.11; P<.001), and Cornell voltage (r = 0.06; P = .006). During follow-up, 84 patients developed new-onset ischemic heart disease (0.75 event per 100 patient-years). After adjustment (Cox model) for the effects of age, sex, diabetes mellitus, serum cholesterol level, serum creatinine level, smoking, left ventricular hypertrophy, and 24-hour systolic blood pressure, patients with a prolonged QTc (>or=450 milliseconds in women and >or=440 milliseconds in men) had a nearly 2-fold increase in risks of coronary events (hazard ratio, 1.95; 95% confidence interval, 1.12-3.42; P = .02) and cardiovascular death (hazard ratio, 2.05; 95% confidence interval, 1.03-4.37; P = .04). Coronary heart disease risk was independently higher by 33% (95% confidence interval, +7% to +66%; P = .01) for each 32-millisecond increase in QTc. CONCLUSIONS: Prolonged ventricular repolarization is a risk factor for ischemic heart disease and cardiovascular mortality in subjects with uncomplicated hypertension. Its prognostic significance adds to that of several traditional cardiovascular risk factors, including left ventricular hypertrophy.     

Medicinal and ethnoveterinary remedies of hunters in Trinidad

Background  

Ethnomedicines are used by hunters for themselves and their hunting dogs in Trinidad. Plants are used for snakebites, scorpion stings, for injuries and mange of dogs and to facilitate hunting success.