Management of the sensitized adult heart transplant candidate

Eckman PM, Hanna M, Taylor DO, Starling RC, Gonzalez‐Stawinski GV. Management of the sensitized adult heart transplant candidate.
Clin Transplant 2010: 24: 726–734. © 2010 John Wiley & Sons A/S. Abstract: Heart transplant recipients sensitized to human leukocyte antigens comprise a challenging subgroup of patients. Sensitization has been associated with a variety of effects that determine short‐term and long‐term outcomes. These include a higher rate of acute rejection and graft loss, and a heightened risk for developing cardiac allograft vasculopathy. Because of improvements in both tissue typing and immunomodulatory therapies coupled with the growing population receiving mechanical circulatory support/LVAD, the percent of sensitized patients listed for heart transplantation has increased, inflicting a greater burden to the already scarce donor pool. Despite these potentially adverse developments, pre‐transplant immunologic management has resulted in decreased waiting times and outcomes that were not possible over 10 yr ago. The following review will focus on the contemporary management of the sensitized heart transplant candidate and highlight therapies that have allowed the successful transplantation of this growing and challenging patient population, including several approaches in development.     

A COMPARISON OF THE ANTICONVULSANT EFFECTS OF PROPOFOL AND THIOPENTONE AGAINST PENTYLENETETRAZOL-INDUCED CONVULSIONS IN THE RAT

1. The anticonvulsant effects of subanaesthetic doses of propofol and thiopentone against PTZ-induced seizures and mortality were examined in the rat. 2. Administration of propofol (50 mg/kg, i.p.) 5 min prior to PTZ treatment increased the 2 h CD50 and the 24 h LD50 of PTZ by 3.4-fold, whereas thiopentone pretreatment (20 mg/kg, i.p.) increased these values by more than five-fold. 3. Both propofol and thiopentone prolonged the latency to the onset of clonic seizure but the effects of the former were more marked. 4. The data demonstrate that propofol was more effective than thiopentone in providing complete protection against PTZ-induced seizures for the first 30-40 min of observation and that thiopentone, because of its sustained effects, was more effective in reducing the cumulative incidence of seizures and mortality over 2 and 24 h, respectively. 5. We conclude that propofol is a very effective anticonvulsant and provides complete protection of short duration against PTZ-induced seizures in the rat.     

Surgical correction of congenital constriction band syndrome in children: Replacing Z-plasty with direct closure

Congenital constriction band syndrome is a sporadic condition that may also be present in association with other congenital anomalies. It has an incidence varying from one in 1200 to one in 15,000 live births. There is a significant predilection for the upper extremities and distal limbs. The two main objectives for the treatment of congenital constriction band syndrome are improvement of function and improvement of cosmetic appearance. Different surgical techniques, such as Z-plasty, have been described and used for decades; however, direct closure after the excision of the constricting band seems to be the simplest and most appropriate, allowing the fatty tissue to naturally reposition itself under the skin. This technique is used in a two-stage approach to avoid affecting distal circulation to the limb.     

False aneurysm of perforating branch of the profunda femoris artery following intertrochanteric fracture, a rare vascular complication: clinical, radiological features and management: case report and review of the literature

Rare cases of pseudoaneurysm of the profunda femoris artery following hip fractures have been described in the literature. Awareness of this complication and a high level of suspicion allow early diagnosis and treatment, and thereby reduce the morbidity of this condition. We present a case of a false aneurysm of a perforating branch of the profunda femoris artery following osteosynthesis of an intertrochanteric fracture, which was treated successfully by coil embolisation.     

Treatment of Old World cutaneous leishmaniasis with dapsone, itraconazole, cryotherapy, and imiquimod, alone and in combination

Background  Cutaneous leishmaniasis (CL) is a major public health problem. The currently available therapies are expensive, not freely available, toxic, and not always curative. A simple, effective, noninvasive therapeutic approach is required for the treatment of CL.
Aims  To determine the clinical patterns of CL and to report our experience in the management of CL.
Methods  One hundred and ten patients with CL seen between January 2005 and December 2007 were included in this study. The diagnosis was based on clinical features, parasitologic diagnosis, histopathology, and culture. Each patient was treated according to disease severity with either topical (cryotherapy or imiquimod) or systemic (itraconazole or dapsone) monotherapy, or a combination of these modalities.
Results  CL was more common in adult expatriate men, with the upper limbs as the most commonly affected site. Noduloulcerative CL was the most common presentation (84.6%). Atypical CL was found in 18 patients. Skin biopsy was the most common diagnostic technique (66.6%). Monotherapy showed an overall success rate of 56.41%, whereas combination therapy was successful in 69.56% of cases. Cryotherapy alone was successful in 68.18% of cases. Imiquimod alone was ineffective.
Conclusion  A stepwise approach represents a rational and practical way of confirming CL. A combination of itraconazole/dapsone and topically applied imiquimod is safe, simple, and effective for the treatment of CL. More studies are needed to establish the role of such an approach. Cryotherapy is also safe, simple and effective for the treatment of CL.     

West Nile virus infection presenting as cerebellar ataxia and fever: case report

Evidence of West Nile encephalitis virus infection has been documented in most states of the continental United States within a short period of its first introduction in 1999. Health care providers are mostly aware of the usual presentations of this disease, eg, aseptic meningitis, encephalitis and Guillain-Barré syndrome. We present a patient whose only manifestations were cerebellar ataxia and fever.     

CHILD syndrome: A modified pathogenesis‐targeted therapeutic approach

Congenital Hemidysplasia with Ichthyosiform nevus and Limb Defects (CHILD syndrome) is a rare X‐linked dominant genodermatosis caused by mutations in the NAD(P) dependent steroid dehydrogenase‐like protein gene. Its defect leads to accumulation of toxic metabolic intermediates upstream from the pathway block and to the deficiency of bulk cholesterol, probably leading to altered keratinocyte membrane function, resulting in the phenotype seen in CHILD syndrome. Symptomatic treatment using emollients and retinoids to reduce scaling has long been used until recently, whereby new therapeutic means based on the pathogenesis‐targeted therapy have been developed. We subsequently chose to use the same pathogenesis‐based therapy using a 2% cholesterol and 2% lovastatin cream with or without glycolic acid in two of our patients. Improvement in CHILD skin lesions was seen as early as 4 weeks after initiation. The addition of glycolic acid helped improve the penetrance of the cholesterol and lovastatin cream into the thick waxy scales. Our study confirms the efficacy of the pathogenesis‐targeted therapy and introduces the possibility of modifying its formula by adding glycolic acid in order to improve the treatment.

     

Prevalence and Predictors of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy

Background and Aims

Laparoscopic sleeve gastrectomy (LSG) might be associated with a new onset or worsening of gastroesophageal reflux disease (GERD). We aim to evaluate the prevalence of post-LSG GERD symptoms and its predictors.

Methods

We included patients who underwent primary LSG at a university hospital from 2009 to 2015. We used the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire and included questions regarding regurgitation to evaluate symptoms before and after LSG; each item was scored from 1 to 5 based on the symptom severity.

Results

A total of 213 patients (mean age, 36.08 ± 10.22 years; 48.36% were men) were included. The mean preoperative body mass index (BMI) was 47.84 kg/m², mean percent total weight loss was 37.99% (95% CI, 36.64 to 39.34), mean percent excess weight loss was 84.14% (95% CI, 80.91 to 87.36), and the mean percent excess BMI loss was 84.17% (95% CI, 80.94 to 87.41). The mean heartburn score while standing increased (0.71 vs. 1.09, p < 0.01) as well as the score of heartburn requiring a diet change (0.67 vs. 1.16, p < 0.01) post-LSG. The scores for dysphagia, odynophagia, and regurgitation increased. New-onset heartburn was reported in 47.06% of our cohort. Those with high preoperative BMIs were less likely to develop new-onset or worsening symptoms of GERD (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95–0.99). More severe heartburn symptoms while standing were associated with higher risks of developing or worsening GERD symptoms (OR, 1.22; 95% CI, 1.01–1.47). None of the other variables could predict the development or worsening of the GERD symptoms.

Conclusion

Symptoms of heartburn and regurgitation are common after LSG; however, none of the variables preoperatively could strongly predict patients who would develop new onset or experience worsening of symptoms postoperatively.