Concomitant Reconstruction of Arch Vessels during Repair of Aortic Dissection

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients.     

Impact of advanced age on myocardial perfusion, distal embolization, and mortality patients with ST-segment elevation myocardial infarction treated by primary angioplasty and glycoprotein IIb–IIIa inhibitors

Despite mechanical reperfusion, the outcome is still unsatisfactory in elderly patients with ST-segment elevation myocardial infarction (STEMI). The vast majority of studies have been conducted without extensive use of glycoprotein (Gp) IIb–IIIa inhibitors, which have been associated with improved perfusion and survival. Thus the aim of the current study was to evaluate the impact of age on the angiographic and clinical outcome patients with STEMI undergoing primary angioplasty with Gp IIb–IIIa inhibitors. Our population is represented by a total of 1,662 patients undergoing primary angioplasty for STEMI included in 11 randomized trials comparing early versus late administration of Gp IIb–IIIa inhibitors. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty. A total of 231 (13.9 %) patients were older than 75 years. Elderly patients showed a larger prevalence of female gender, hypertension, and diabetes, more advanced Killip class at presentation and longer time to treatment, but a smaller prevalence of smoking. All patients were treated with GP IIb–IIIa inhibitors. Elderly patients showed a significantly impaired postprocedural thrombolysis in myocardial infarction (TIMI) flow (TIMI 0–2: 17.7 vs 10.3 %, P = 0.002) and myocardial perfusion (myocardial blush grade 0–1: 38.3 vs 26.5 %, P = 0.001), and higher prevalence of distal embolization (19.2 vs 9.8 %, P < 0.001), whereas no difference was observed in terms of ST-segment resolution. At follow-up, elderly patients showed a significantly higher mortality (3.2 vs 11.0 %, hazard ratio (HR) (95 % confidence interval (CI)) = 3.78 (2.31–6.16), P < 0.001), which was confirmed after adjustment for baseline confounding factors (HR (95 % CI) = 5.01 (2.63–9.55), P < 0.0001). This study showed that among patients with STEMI undergoing primary angioplasty, advanced age is an independent predictor of mortality after primary angioplasty. Higher rates of distal embolization and poor myocardial perfusion, in addition to the worse risk profile, contribute toward explaining the impact of aging on mortality.     

Effect of perioperative complications and functional outcomes on health-related quality of life after radical prostatectomy

Purpose

Radical prostatectomy is a commonly performed procedure with perioperative complication rates of 30 % using standardized reporting methodology. We aim to determine whether perioperative complications and functional outcomes impact quality of life 1 year after surgical treatment.

Patients and methods

Quality of life, functional and oncological outcomes were assessed in patients who underwent open retropubic radical prostatectomy at a single academic institution between 2003 and 2009, preoperatively and 1 year after surgery using the EORTC QLQ-C30, the IIEF-5 and an institutional questionnaire. Perioperative complications were recorded using the Clavien–Dindo classification. Patients without complications were compared to patients with any, low- or high-grade complications. The global health score domain of the EORTC QLQ-C30 is reported for various oncological and functional outcomes and contrasted to stratified categories of complications and functional outcomes.

Results

A full dataset was available for 29.5 % (n = 856) of all patients. The overall complication rate was 27.5 % (235/856). A total of 307 complications were recorded of whom 88.9 % (273/307) were low grade. In this study, population global health perception did not decline after surgery (70.5 ± 21.2 vs. 74.4 ± 19.7; p < 0.0001). Complications showed only statistical but no clinical meaningful influence on global health perception as well as on functional and symptom scales. Patients who met combined outcome criteria experienced the best postoperative global health score (86.0 ± 13.1 and 86.0 ± 14.2).

Conclusions

Perioperative complications and functional outcomes have a measurable impact on quality of life 1 year following surgery. While perioperative complications have a statistical effect, functional outcomes showed a clinically more profound effect on postoperative global health perception.     

Modelling the dynamics of expiratory airflow to describe chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by expiratory airflow limitation, but current diagnostic criteria only consider flow till the first second and are therefore strongly debated. We aimed to develop a data-based individualized model for flow decline and to explore the relationship between model parameters and COPD presence. A second-order transfer function model was chosen and the model parameters (namely the two poles and the steady state gain (SSG)) from 474 individuals were correlated with COPD presence. The capability of the model to predict disease presence was explored using 5 machine learning classifiers and tenfold cross-validation. Median (95 % CI) poles in subjects without disease were 0.9868 (0.9858–0.9878) and 0.9333 (0.9256–0.9395), compared with 0.9929 (0.9925–0.9933) and 0.9082 (0.9004–0.9140) in subjects with COPD (p < 0.001 for both poles). A significant difference was also found when analysing the SSG, being lower in COPD group 3.8 (3.5–4.2) compared with 8.2 (7.8–8.7) in subjects without (p < 0.0001). A combination of all three parameters in a support vector machines corresponded with highest sensitivity of 85 %, specificity of 98.1 % and accuracy of 88.2 % to COPD diagnosis. The forced expiration of COPD can be modelled by a second-order system which parameters identify most COPD cases. Our approach offers an additional tool in case FEV₁/FVC ratio-based diagnosis is doubted.     

Long lasting near-obstruction stenosis of mesencephalic aqueduct without development of hydrocephalus – case report

The aim of this study is to present the five-year longitudinal magnetic resonance imaging (MRI) follow up of a patient with incidental finding of near-obstruction stenosis of the aqueduct of Sylvius due to a large pineal cyst. The patient was scanned 3 times on a 3T MR device using a set of standard structural sequences supplemented with high-resolution constructive interference of steady state (CISS) T2 sequence for precise delineation of the aqueduct of Sylvius and cardiac-gated phase-contrast sequences for the analysis of cerebrospinal fluid (CSF) movement. On all MR scans, the size of the pineal cyst and severity of near-obstruction aqueductal stenosis did not show any morphological changes. There was no significant ventricular enlargement although structural CISS sequence showed a near-obstruction stenosis and cardiac-gated phase-contrast sequences did not detect CSF movement through the aqueduct of Sylvius. Our findings are contradictory to the classic hypothesis of CSF physiology based on secretion, circulation, and absorption of CSF, which states that the impairment of CSF circulation through the aqueduct of Sylvius inevitably leads to a hypertensive hydrocephalus development involving the third and the lateral ventricle. Our research group previously proposed a new hypothesis of CSF physiology, which offers more suitable explanation for such clinical cases.Clinical practice has shown that an aqueduct of Sylvius obstruction or severe stenosis (tumoral compression, intrinsic non-tumoral pathology) could lead to a development of the triventricular hypertensive hydrocephalus (1). According to the classic hypothesis of CSF physiology, CSF is secreted inside the brain ventricles and flows unidirectionally along the subarachnoid space to be absorbed into the dural venous sinuses or into perineural lymphatic system (2,3). Therefore, a blockade of CSF flow from the third to the fourth lateral ventricle at the aqueduct of Sylvius level inevitably leads to the triventricular hypertensive hydrocephalus development. It is assumed that CSF is formed by an active secretion mainly by the choroid plexuses against hydrostatic pressure inside the CSF system, so any blockade between the site of secretion and the site of absorption will lead to CSF accumulation, CSF system enlargement, and subsequently to the development of hydrocephalus proximal to the obstruction site (1).The aqueduct of Sylvius is a narrow canal inside the mesencephalon that connects the third and the fourth lateral ventricle, thus, according to the classic hypothesis, its passability is of key importance for normal CSF physiology (2,3). An aqueduct of Sylvius stenosis sometimes leads to the compensatory changes of the CSF system that are known as “arrested hydrocephalus” (4). The compensatory mechanisms of this state are still unclear. We present a patient with long lasting near-obstruction stenosis without detectable CSF movement through the aqueduct of Sylvius, which has some similarities with the “arrested hydrocephalus” condition. Despite the functional blockade of CSF movement, no significant ventricular enlargement was observed during the follow up period of 5 years. Such findings are contradictory to the classic hypothesis of CSF hydrodynamics and classic circulatory hypothesis of hydrocephalus development. However, the new hypothesis of CSF physiology proposed by our team (Bulat, Orešković and Klarica hypothesis) (5-7) states that stenosis/blockade of aqueduct of Sylvius could favor but does not necessarily lead to the development of hydrocephalus (6,8). In this case report, we discuss pathophysiological mechanisms of hydrocephalus development from the perspective of both classic and new microcirculatory hypothesis of CSF physiology (5-7).     

Alveolar Bone Grafting in Cleft Patients from Bone Defect to Dental Implants

Cleft lip and palate is the most common congenital deformity affecting craniofacial structures. Orofacial clefts have great impact on the quality of life which includes aesthetics, function, psychological impact, dental development and facial growth. Incomplete fusion of facial prominences during the fourth to tenth week of gestation is the main cause. Cleft gaps are closed with alveolar bone grafts in surgical procedure called osteoplasty. Autogenic bone is taken from the iliac crest as the gold standard. The time of grafting can be divided into two stages: primary and secondary. The alveolar defect is usually reconstructured between 7 and 11 years and is often related to the development of the maxillary canine root. After successful osteoplasty, cleft defect is closed but there is still a lack of tooth. The space closure with orthodontic treatment has 50-75% success. If the orthodontic treatment is not possible, in order to replace the missing tooth there are three possibilities: adhesive bridgework, tooth transplantation and implants. Dental implant has the role of holding dental prosthesis, prevents pronounced bone atrophy and loads the augmentation material in the cleft area. Despite the fact that autologous bone from iliac crest is the gold standard, it is not a perfect source for reconstruction of the alveolar cleft. Bone morphogenic protein (BMP) is appropriate as an alternative graft material. The purpose of this review is to explain morphology of cleft defects, historical perspective, surgical techniques and possibilities of implant and prosthodontic rehabilitation.Key words: Cleft Lip, Cleft Palate, Alveolar bone grafting, Bone Morphogenic Proteins, Dental implants, Dental prosthesis, Orthodontic Space Closure     

In vivo toxicity evaluation of two polyoxotungstates with potential antidiabetic activity using Wistar rats as a model system

In this study, the in vivo hypoglycemic effect of a donut-shaped polyanion salt (NH₄)₁₄[Na@P₅W₃₀O₁₁₀]·31H₂O {NaP₅W₃₀} and its Ag-containing derivative K₁₄[Ag@P₅W₃₀O₁₁₀]·22H₂O·6KCl {AgP₅W₃₀}, as well as their hepatotoxicity and nephrotoxicity, was evaluated. In the screening hypoglycemic study, Wistar albino rats with streptozotocin induced diabetes were treated intraperitoneally with three single doses (5, 10, and 20 mg per kg per b.w.) of both investigated polyoxotungstates. The blood glucose levels, measured before and after 2, 4 and 6 h polyoxotungstate application, showed that both studied compounds induced the most pronounced and time dependent glucose lowering effects at the doses of 20 mg kg⁻¹. Thus, daily doses of 20 mg kg⁻¹ were administered to Wistar albino rats orally for 14 days in further toxicity examinations. The serum glucose concentration and biochemical parameters of kidney and liver function, as well as a histopathological analysis of kidney and liver tissues were evaluated 14 days after the polyoxotungstate administration. Both investigated compounds did not induce statistically significant alterations of the serum glucose and uric acid concentrations, as well as some of the liver function markers (serum alanine and aspartate aminotransferases, and alkaline phosphatase activities). However, the significant decrease in serum total protein and albumin concentrations and the increase in biochemical parameters of renal function – serum urea (up to 63.1%) and creatinine concentrations (up to 23.3%) were observed for both polyoxotungstates. In addition, the detected biochemical changes were in accordance with kidney and liver histhopathological analysis. Accordingly, the hepatotoxic and nephrotoxic effects of these potential antidiabetic polyoxotungstates could be considered as mild.

Study of the in vivo hypoglycemic effect, hepatotoxicity and nephrotoxicity of a donut-shaped polyanion salt (NH₄)₁₄[Na@P₅W₃₀O₁₁₀]·31H₂O {NaP₅W₃₀} and its Ag-containing derivative K₁₄[Ag@P₅W₃₀O₁₁₀]·22H₂O·6KCl {AgP₅W₃₀}.     

New Drugs on the Block—Emerging Treatments for Nonalcoholic Steatohepatitis

Patients with nonalcoholic steatohepatitis (NASH) are at higher risk of progression to advanced stages of fibrosis, cirrhosis, hepatocellular carcinoma and othe...