Low-Dose Rituximab Therapy for Antibody-Mediated Rejection in a Highly Sensitized Heart-Transplant Recipient

Antibody-mediated rejection is the B-cell–mediated production of immunoglobulin G antibody against the transplanted heart. The currently available therapies for antibody-mediated rejection have had marginal success, and chronic manifestations of rejection can result in an increased risk of graft vasculopathy and perhaps require repeat transplantation. Rituximab, a monoclonal antibody directed against the CD20 receptor of B-lymphocytes and approved as therapy for lymphoma, can be used in heart-transplant patients for the management of antibody-mediated rejection.We present the case of a 52-year-old woman with high allosensitization (pre-transplantation panel reactive antibody level, 72%) who underwent successful orthotopic heart transplantation. Postoperatively, her acute antibody-mediated rejection with concomitant cellular rejection was successfully treated with low-dose rituximab. The patient died 5 months later because of multiple other medical problems. The present case suggests a role for low-dose rituximab as therapy for antibody-mediated rejection in heart-transplant patients.Key words: Antibodies, monoclonal/therapeutic use; antigens, CD20/immunology; B-lymphocytes/immunology; graft rejection/drug therapy; heart transplantation/pathology; HLA antigens/immunology; immunity, humoral/physiology/therapy; immunoglobulins, intravenous/metabolism; plasmapheresis; rituximab; time factorsAntibody-mediated rejection (AMR) in heart-transplant recipients is mediated by donor-specific antibodies and is histologically defined by linear deposits of immunoglobulin (Ig) and complement in the myocardial capillaries.¹ Antibody-mediated rejection is often accompanied by hemodynamic compromise and is associated with diminished graft survival. Standard immunosuppressive therapy, designed to target T-cell immune function, is largely ineffective against this B-cell–driven process. Various therapies for AMR, although available, can be of marginal use secondary to patients'' comorbidities.^2,3 We present the case of a woman with a history of ventricular assist device (VAD) implantation, dialysis dependence, and severe thrombocytopenia who responded well to the addition of anti-CD20 monoclonal antibody therapy with rituximab after heart transplantation.     

Circumferential Stent Fracture: novel detection and treatment with the use of StentBoost

Circumferential stent fracture is extremely uncommon, and in rare cases, it can cause stent thrombosis. Recognizing stent fracture can be difficult on conventional fluoroscopy because of poor stent radiopacity. We found that StentBoost image acquisition yields improved visibility of stent struts, enabling the identification of stent fracture and the precise positioning of new stents over previously stented segments.We report the case of a 50-year-old man who presented with acute myocardial infarction and subacute stent thrombosis a week after percutaneous transluminal coronary angioplasty and placement of a bare-metal stent. The new lesion was crossed with a guidewire, but multiple attempts to advance a balloon catheter were unsuccessful. Live StentBoost image acquisition revealed circumferential stent fracture into 2 separate sections, with abnormal angulation between the proximal and distal portions of the stent. With StentBoost guidance, the wire and balloon catheter were both easily manipulated to cross the lesion, and angioplasty and restenting were completed with good results.StentBoost can be a useful adjunctive tool for the cardiac interventionist during complex percutaneous transluminal coronary angioplasty, and it was invaluable in this challenging situation. We discuss stent fracture and the benefits of using StentBoost in such situations.     

Open Versus Closed Rhinoplasty with Primary Cheiloplasty: A Comparative Study

The repair of unilateral cleft lip nose deformity remains a challenging endeavor for reconstructive surgeons for many reasons, one of which is the timing of rhinoplasty, whether to be synchronous or staged with cleft lip repair and the technique for rhinoplasty. Many authors now favor primary rhinoplasty with the cleft lip repair. Various surgical techniques have been used, most commonly the closed and open rhinoplasty techniques. In this randomized controlled prospective study, we compare the closed rhinoplasty technique with open rhinoplasty during primary unilateral cleft lip repair. Thirty-six patients with unilateral complete cleft lip and nose deformity were selected. Out of this 19 patients were assigned randomly and operated with open rhinoplasty and 17 patients with closed rhinoplasty. The cleft lip repair was done using modified, Millard’s rotation-advancement technique in both the groups. Follow-up assessment was done after 6 months. Quantitative and qualitative analysis were done. Statistical analysis of the data was done using SPSS 11.0. Post-operatively, the alar base width difference between the open and closed rhinoplasty techniques was statistically significant. There was no statistically significant difference in other parameters compared.     

A randomized prospective analysis of alteration of hemostatic function in patients receiving tranexamic acid and hydroxyethyl starch (130/0.4) undergoing off pump coronary artery bypass surgery

Postoperative hemorrhagic complications is still one of the major problems in cardiac surgeries. It may be caused by surgical issues, coagulopathy caused by the side effects of the intravenous fluids administered to produce plasma volume expansion such as hydroxyl ethyl starch (HES). In order to thwart this hemorrhagic issue, few agents are available. Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes to promote blood conservation; but the possible complications of thrombosis of coronary artery graft, precludes their generous use in coronary artery bypass graft surgery. The issue is a balance between agents that promote coagulation and those which oppose it. Therefore, in this study we have assessed the effects of concomitant use of HES and TA. Thromboelastogram (TEG) was used to assess the effect of the combination of HES and TA. With ethical committee approval and patient's consent, 100 consecutive patients were recruited for the study. Surgical and anesthetic techniques were standardized. Patients fulfilling our inclusion criteria were randomly allocated into 4 groups of 25 each. The patients in group A received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in group B received Ringer's lactate + TA at same dose. The patients in the Group C received 20 ml/kg of HES. Group D patients received RL. Fluid therapy was goal directed. Total blood loss was assessed. Reaction time (r), α angle, maximum amplitude (MA) values of TEG were assessed at baseline, 12, 36 hrs. The possible perioperative myocardial infraction (MI) was assessed by electrocardiogram (ECG) and troponin T values at the baseline, postoperative day 1. Duration on ventilator, length of stay (LOS) in the intensive care unit (ICU) were also assessed. The demographical profile was similar among the groups. Use of HES increased blood loss significantly (P < 0.05). Concomitant use of TA reduced blood loss when used along with HES. r value was prolonged at 12 hours in all the groups and α angle was reduced at 12 hours in all the groups, where as MA value was reduced at 12 th hour in the HES group compared to the baseline and increased in TA + HES group. These findings were statistically significant. No significant change in Troponin T values/ECG, duration of ventilation and LOS ICU was observed. No adverse events was noticed in any of the four groups. HES (130/0.4) used at a dose of 20 ml/kg seems to produce coagulopathy causing increased blood loss perioperatively. Hemodilution produced by fluid therapy seems to produce Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES appears to reverse these changes without causing any adverse effects in patients undergoing OPCAB surgery.     

Unfavourable outcomes in orthognathic surgery

Unfavourable outcomes are part and parcel of performing surgeries of any kind. Unfavourable outcomes are results of such work, which the patient and or the clinician does not like. This is an attempt to review various causes for unfavorable outcomes in orthognathic surgery and discuss them in detail. All causes for unfavorable outcomes may be classified as belonging to one of the following periods A) Pre- Treatment B) During treatment Pre-Treatment: In orthognathic surgery- as in any other discipline of surgery- which involves changes in both aesthetics and function, the patient motivation for seeking treatment is a very important input which may decide, whether the outcome is going to be favorable or not. Also, inputs in diagnosis and plan for treatment and its sequencing, involving the team of the surgeon and the orthodontist, will play a very important role in determining whether the outcome will be favorable. In other words, an unfavorable outcome may be predetermined even before the actual treatment process starts. During Treatment: Good treatment planning itself does not guarantee favorable results. The execution of the correct plan could go wrong at various stages which include, Pre-Surgical orthodontics, Intra and Post-Operative periods. A large number of these unfavorable outcomes are preventable, if attention is paid to detail while carrying out the treatment plan itself. Unfavorable outcomes in orthognathic surgery may be minimized If pitfalls are avoided both, at the time of treatment planning and execution.KEY WORDS: Orthognathic surgery, outcome, unfavourable     

Incidence and Consequence of Close Margins in Patients with Ductal Carcinoma-In Situ Treated with Mastectomy: Is Further Therapy Warranted?

Background

The impact of close margins in patients with ductal carcinoma-in situ (DCIS) treated with mastectomy is unclear; however, this finding may lead to a recommendation for postmastectomy radiotherapy (PMRT). We sought to determine the incidence and consequences of close margins in patients with DCIS treated with mastectomy.

Methods

The records of 810 patients with DCIS treated with mastectomy from 1996 through 2009 were reviewed. Clinical and pathologic factors were analyzed with respect to final margin status. Median follow-up was 6.3 years.

Results

Overall, 94 patients (11.7 %) had close margins (positive, n = 5; negative but ≤1 mm, n = 54; 1.1–2.9 mm, n = 35). Independent risk factors for close margins included multicentricity, pathologic lesion size ≥1.5 cm, and necrosis, but not age, use of skin-sparing mastectomy, or immediate reconstruction (p > 0.05). Seven patients received PMRT, and none had a locoregional recurrence (LRR). Among the remaining 803 patients, the 10-year LRR rate was 1 % (5.0 % for margins ≤1 mm, 3.6 % for margins 1.1–2.9 mm, and 0.7 % for margins ≥3 mm [p < 0.001]). The 10-year rate of contralateral breast cancer was 6.4 %. On multivariate analysis, close margins was the only independent predictor of LRR (p = 0.005).

Conclusions

Close margins occur in a minority of patients undergoing mastectomy for DCIS and is the only independent risk factor for LRR. As the LRR rate in patients with close margins is low and less than the rate of contralateral breast cancer, PMRT is not warranted except for patients with multiple close/positive margins that cannot be surgically excised.