Effects of mTOR inhibitor–related proteinuria on progression of cardiac allograft vasculopathy and outcomes among heart transplant recipients

We have previously described the use of sirolimus (SRL) as primary immunosuppression following heart transplantation (HT). The advantages of this approach include attenuation of cardiac allograft vasculopathy (CAV), improvement in glomerular filtration rate (GFR), and reduced malignancy. However, in some patients SRL may cause significant proteinuria. We sought to investigate the prognostic value of proteinuria after conversion to SRL. CAV progression and adverse clinical events were studied. CAV progression was assessed by measuring the Δ change in plaque volume (PV) and plaque index (PI) per year using coronary intravascular ultrasound. Proteinuria was defined as Δ urine protein ≥300 mg/24 h at 1 year after conversion to SRL. Overall, 137 patients were analyzed (26% with proteinuria). Patients with proteinuria had significantly lower GFR (P = .005) but similar GFR during follow-up. Delta PV (P < .001) and Δ PI (P = .001) were significantly higher among patients with proteinuria after adjustment for baseline characteristics. Multivariate Cox regression analysis showed higher all-cause mortality (hazard ratio 3.8; P = .01) with proteinuria but similar risk of CAV-related events (P = .61). Our results indicate that proteinuria is a marker of baseline renal dysfunction, and that HT recipients who develop proteinuria after conversion to SRL have less attenuation of CAV progression and higher mortality risk.     

Tumor necrosis factor‐alpha antagonist administration recovers skeletal muscle dysfunction in ovariectomized rats

Skeletal muscles deteriorate after ovariectomy. Molecular pathway of this deterioration has not been defined. Tumor necrosis factor (TNF)‐alpha activation is assumed to trigger muscle atrophy and administration of its antagonist is hypothesized to recover this atrophy in rats. Slow‐twitch soleus and fast‐twitch extensor digitorum longus muscle functions were investigated in intact, ovariectomized (OVX), and OVX plus 10 µg/g/week TNF‐alpha antagonist administered female rats. Maximum isometric twitch and tetanic contraction responses were lower in the OVX groups. Maximum isometric twitch amplitudes recovered in the extensor digitorum longus but not in the soleus muscles after TNF‐alpha antagonist administration. The decrease in responses to tetanic stimulations recovered in the OVX–TNF group at frequencies higher than 20 Hz in both muscle types. OVX animals body weight was 21% higher than intact animals. Muscle weight to body weight ratios of the OVX groups were higher than the control group which recovered after TNF‐alpha antagonist administration. Findings suggest that the functional loss in OVX rat muscles is TNF‐alpha pathway dependent. Skeletal muscle atrophy and function after OVX recovered by TNF‐alpha antagonist administration. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:275–280, 2011     

The appearance of free-air in the abdomen with related pneumatosis cystoides intestinalis: Three case reports and review of the literature

INTRODUCTION

Pneumatosis sistoides intestinalis (PSI) is a rare condition with unknown origin, defined as the appearance of gas-filled cysts in the intestinal wall. It usually occurs due to respiratory infections, tumor or collagen disease, traumas, immunosuppression.

PRESENTATION OF CASE

Three patients with PSI were examined that followed up and treated in our clinic. The first patient was hospitalized for emergency treatment of previously diagnosed free-air under the diaphragm. He had a defense on physical examination and free-air was detected in X-ray and abdomen CT. We decided to laparatomy and peroperatively, stenotic pylorus with an abnormally increased stomach and gas-filled cysts were seen in the terminal ileum. Antrectomy and gastrojejunostomy with partial ileum and cecum resection and end ileostomy were performed. The second patient underwent laparatomy because of intraperitoneal free-air and acute abdomen. Partial ileum and cecum resection and ileotransversostomy were performed. The third patient with intraperitoneal free-air was treated with antibiotics, oxygen treatment and bowel rest.

DISCUSSION

PSI is usually asymptomatic. Plain radiographs, USG, CT, upper gastrointestinal endoscopy, colonoscopy can use for diagnosis. Treatment of PSI depends on the underlying cause; include elemental diet, antibiotics, steroids, hyperbaric oxygen therapy and surgery.

CONCLUSION

In patients with asymptomatic and symptomatic PSI are different treat. Symptomatic PSI can be safely treated antrectomy and gastrojejunostomy with partial ileum and cecum resection.     

Evaluation and management of acute upper airway obstruction

Upper airway obstruction can occur suddenly and result in a patient's rapid deterioration. In this article we provide a structured approach to identifying those patients with acute airway compromise and stratifying them according to clinical urgency. This includes ways of distinguishing both the level of obstruction and its severity, based on the clinical signs and symptoms, and the role and timing of investigations. We describe the key aspects of emergency management, including temporizing measures and airway adjuncts. Management of rare, but important, situations are discussed such as post-thyroidectomy haematoma, occlusion of tracheostomy and laryngectomy stomas and post-obstruction pulmonary oedema (POPE) is discussed. We describe the situation when an emergency surgical airway should be considered, along with our technique of performing one.     

The perforating branches of the P1 segment of the posterior cerebral artery

The perforating branches of the P1 segment of the posterior cerebral artery are vulnerable to injury. Because of their close proximity to the basilar artery, the vulnerability occurs especially during surgical interventions for vascular pathologies such as basilar apex aneurysms. Therefore, extensive knowledge of the microsurgical anatomy of this area is mandatory to prevent poor post-operative outcomes. We microscopically examined 28 P1 segments obtained from 14 adult fresh cadaver brains (6 silicone injected, 8 freshly examined). The P1 segments ranged between 2.8 mm and 12.2 mm (mean 6.8 mm) in length with a mean outer diameter of 1.85 mm (range 0.8–4.5 mm). All 94 thalamoperforating branches identified in 27 P1 segments (mean 3.35 branches per segment) arose from the postero-superior aspect of P1 and were the most proximally originating branch in nearly all specimens (96.4%). In addition in 28 P1s, 12 short circumflex arteries (42.8%; mean 0.42 branches per segment), 16 long circumflex arteries (57.1%; mean 0.57 branches per segment) and 10 medial posterior choroidal arteries (35.7%; mean 0.35 branches per segment) were identified and all originated from the posterior or postero-inferior surface of the P1 segment. When the P1 segment had more than one type of branch, it was the short circumflex arteries that were always more proximal in origin than the others. The medial posterior choroidal arteries were always more distal in origin. All three branches were not observed together in any of the P1 segments. The findings in this, and future, anatomical studies may help to reduce the post-surgical morbidity and mortality rates after surgery for posterior circulation aneurysms.     

Effects of sex and age on strength-duration properties.

OBJECTIVE: To evaluate the possible effects of sex and age on strength-duration time constant (SDTC). METHODS: The SDTC of 126 healthy volunteers was measured following stimulation of right median nerve at the wrist. Variations in values were evaluated according to sex and age. RESULTS: The SDTC was 438.6+/-114.5 micros in women and 396.2+/-90.3 in men (P=.023). In men, as age increased, so did SDTC. However, this was not true in women. Comparing the values of women and men, aged below 40, demonstrated a difference in excitability, confined to younger patients. CONCLUSIONS: As SDTC depends on the biophysical properties of the axonal membrane and can provide some information about Na(+) channel function, these data raise the possibility of a difference in Na(+) channel function between men and women and a difference in the conductance with age. SIGNIFICANCE: The age- and sex-related differences shown in this study suggest a possible biochemical or hormonal influence on axonal excitability.     

The effect of hyperventilation on strength-duration properties in diabetic polyneuropathy.

OBJECTIVE: Hyperventilation and ischaemia increase axonal excitability by changing Na+ conductance in healthy subjects. However, the changes in excitability during and after ischaemia in diabetic patients are less than in healthy controls. This is known as ischaemic resistance. In this study, we investigated the effects of hyperventilation for 20 min on strength-duration time constant (SDTC) of motor axons of the median nerve of diabetic patients with polyneuropathy to determine whether diabetics are less affected by hyperventilation, a form of resistance similar to the ischaemic resistance of diabetics. METHODS: The SDTC of 14 diabetic patients with polyneuropathy and 10 healthy volunteers were measured following stimulation of right median nerve at the wrist prior to and after hyperventilation for 20 min. RESULTS: There was a significant increase in the SDTC in control subjects, but no significant change in the SDTC for patients with diabetic polyneuropathy. The score of the clinical response (paraesthesiae and carpopedal spasm) to hyperventilation of controls was also significantly greater in the controls than the patients. CONCLUSION: Hyperventilation for 20 min has little influence on SDTC in patients with diabetic polyneuropathy. SIGNIFICANCE: The 'resistance' of diabetic nerve is not confined to ischaemia but involves other manoeuvres that can alter axonal excitability.     

Does Salter innominate osteotomy with transiliac lengthening effect triradiate cartilage or cause posterior coverage insufficiency?

Introduction  

To treat neglected developmental dysplasia of the hip (DDH), we performed Salter innominate osteotomy with a modification of transiliac lengthening. We asked whether this modified technique caused posterior coverage problems and triradiate cartilage injury.     

Nurses' perceptions of medication errors

This study reports nurses' perceptions of medication errors and of their appropriate reporting. Thirty-three percent of the participants believed the main cause of medication errors was nurses' tiredness or exhaustion, while 30% of participants indicated that the main cause was the poor legibility or illegibility of physcians' writing on the doctor's order form. Some medication errors were not reported because nurses were afraid of reprisals (63%).