Impact of Percutaneous Transluminal Angioplasty for Treatment of Cerebral Vasospasm on Subarachnoid Hemorrhage Patient Outcomes

Background

Percutaneous transluminal angioplasty (PTA) has been introduced for treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). While angiographic improvement is consistently reported, clinical improvement following the procedure varies, and limited data is available regarding overall impact on outcome.

Methods

The authors performed a retrospective analysis of all hospital admissions with aneurysmal SAH over a 6 year period. The length of stay, discharge outcomes (measured by modified Rankin scale [mRS] at discharge), and 1-year mortality among patients with SAH before (4 year period) and after (2 year period) institution of PTA for cerebral vasospasm were compared. Embolization for intracranial aneurysm was used as a therapeutic option throughout the study duration. The effect of institution of PTA for vasospasm after adjusting for age, clinical severity, and use of aneurysm embolization on both discharge outcomes and 1-year mortality in multivariate analysis was evaluated.

Results

A total of 146 patients with aneurysmal SAH were admitted during the study duration. There was no difference between the 89 patients admitted in pre-angioplasty period and 57 patients admitted in post-angioplasty period in regards to age, medical co-morbidities, and admission clinical severity of patients (measured by Hunt and Hess grade and Glasgow coma scale). A total of 18 (32%) patients underwent PTA with or without intra-arterial vasodilator treatment in the second period of the study. There was a non significant decrease in rates of severe disability and death (mRS 5–6) at discharge (45 vs. 33%, P = 0.09) and 1-year mortality (32 vs. 22%, P = 0.26) after introduction of PTA for cerebral vasospasm after adjusting for potential confounders. There was no significant difference between the two time periods in regards to length of stay.

Conclusion

A non significant trend was noted with reduced rate of severe disability and mortality at discharge and 1-year mortality after the introduction of PTA for cerebral vasospasm associated with SAH without increasing the length of hospital stay.     

The effect of magnesium sulfate on large cerebral artery blood flow in preeclampsia

Objectives.?To determine the effect of a 6 gram intravenous bolus of magnesium sulfate on maternal cerebral blood flow in women with preeclampsia.

Study Desiqn.?Velocity-encoded phase-contrast magnetic resonance imaging studies were performed on twelve preeclamptic women prior to and immediately after infusion of a 6 gram magnesium sulfate loading dose. Cerebral blood flow was determined at the bilateral proximal middle and posterior cerebral arteries. Study participants returned 6 weeks postpartum for a non-pregnant measurement of cerebral blood flow. The Wilcoxon paired-sample test was used with statistical significance defined as p<0.05.

Results.?There was no significant difference in cerebral vessel diameter nor blood flow for any of the examined arteries between the pre- and post magnesium sulfate therapy states.

Conclusions.?The absence of a significant difference in cerebral blood flow of the middle and posterior cerebral arteries before and after infusion of a 6 gram loading dose of magnesium sulfate in women with preeclampsia could suggest the absence of vasoconstriction of the large cerebral arteries in preeclampsia and question the role of magnesium sulfate as a vasodilator of these arteries.     

Sodium signals in cerebellar Purkinje neurons and Bergmann glial cells evoked by glutamatergic synaptic transmission

Glial cells express specific high-affinity transporters for glutamate that play a central role in glutamate clearance at excitatory synapses in the brain. These transporters are electrogenic and are mainly energized by the electrochemical gradient for sodium. In the present study, we combined somatic whole-cell patch-clamp recordings with quantitative Na+ imaging in fine cellular branches of cerebellar Bergmann glial cells and in dendrites of Purkinje neurons to analyze intracellular Na+ signals close to activated synapses. We demonstrate that pressure application of glutamate and glutamate agonists causes local Na+ signals in the mM range. Furthermore, we analyzed the pharmacological profile, as well as the time course and spatial distribution of Na+ signals following short synaptic burst stimulation of parallel or climbing fibers. While parallel fibers stimulation resulted in local sodium transients that were largest in processes close to the stimulation pipette, climbing fibers stimulation elicited global sodium transients throughout the entire cell. Glial sodium signals amounted to several mM, were mainly caused by sodium influx following inward transport of glutamate and persisted for tens of seconds. Sodium transients in dendrites of Purkinje neurons, in contrast, were mainly caused by activation of AMPA receptors and had much faster kinetics. By reducing the driving force for sodium-dependent glutamate uptake, intracellular sodium accumulation in glial cells upon repetitive activity might provide a negative feedback mechanism, promoting the diffusion of glutamate and the activation of extrasynaptic glutamate receptors at active synapses in the cerebellum.     

Impact of adult-to-adult living donor liver transplantation on access to transplantation and patients' survival: an 8-year single-center experience.

While the number of candidates for liver transplantation has increased in the recent years, the pool of cadaveric donor organs has remained constant and the waiting time progressively increases. These facts led us to start a program of adult-to-adult living-donor liver transplantation in 1998. The aim of this study was to compare the outcome of all patients put on the waiting list since 1998. Between January 1, 1998, and January 1, 2005, 505 patients were put on the waiting list in our center, and living donor liver transplantation was considered in 57 cases (11.3%). At the time of evaluation (April 1, 2006), liver transplantation was performed in 377 patients (46 living donor liver transplantations), and 89 patients died on waiting list. On an intention-to-treat basis, the 1-year survival rate from the time of listing was 87.5% in the "living donor" group vs. 76.2% in the "cadaveric donor" group (P < 0.05), whereas the 1-year survival after liver transplantation was similar (92.3% vs. 86.9%). Our living donor liver transplantation program was able to improve the access to liver transplantation by reducing waiting time and the number of deaths on waiting list, despite the fact that these patients were more critically ill (liver failure and/or liver cancer).     

Conversion from mycophenolate mofetil to enteric-coated mycophenolate sodium in liver transplant patients presenting gastrointestinal disorders: a pilot study.

Gastrointestinal (GI) disorders are one of the main adverse events in patients treated by mycophenolic acid (MPA). The aim of this prospective study was to evaluate the effect of conversion from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) in liver transplant patients presenting GI side-effects Since January 2003, stable liver transplant patients receiving MMF and presenting GI disorders, without evidence of other origin than MMF were enrolled. Conversion was performed without a washout period at an equimolar daily dosage. Thirty-six patients were included after a median delay of 45 months after liver transplantation (LT) (16 women and 20 men, median age of 47 years). Diarrhoea was the main clinical symptom (n = 28, 77.7%). At the time of inclusion, patients were treated with MMF since 18 months (range 3-28) and GI disorders were known for 9 months (range 3-12). After a median follow-up of 12 months after conversion, GI disorders were resolved in 20 patients (55%), improved in 6 patients (17%) and not modified or worsened in 10 patients (28%). Our results strongly suggest that conversion from MMF to EC-MPS in liver transplant patients can improve gastrointestinal disorders in a majority of the patients, and therefore might be considered as the best therapeutic option.     

Leiomyosarcoma of the inferior vena cava: experience in 22 cases

From 1979 to 2004, 22 patients were seen with leiomyosarcomas of the inferior vena cava (IVC). Twenty were treated surgically. Involvement of the IVC included the infrarenal segment in 3 cases, the suprarenal and/or retrohepatic segment in 13, and the suprahepatic segment in 4. Nineteen patients underwent wide tumor resection followed by ligation of the IVC in 5 cases, replacement with a PTFE prosthesis in 13, and cavoplasty in 1. An intracardiac tumor extension was resected during hypothermic circulatory arrest in 1 patient. Vascular exclusion of the liver was used in 5 cases and simple clamping of the IVC in 13 cases. There were 1 intraoperative death due to cardiac failure and 3 postoperative deaths due to multiple organ failure, liver failure, and duodenal fistula after treatment of a bleeding ulcer. Fifteen of the 16 surviving patients underwent adjuvant chemotherapy associated with radiation therapy in 4 cases. One patient was lost from follow-up at 10 months. Four patients including one with metastasis are still alive with a mean follow-up of 18.3 months. Eleven patients died after a mean follow-up period of 43.7 months due to local recurrence and/or distant metastasis in 9 cases and complications of chemotherapy in 2. The 3- and 5-year mean actuarial survival rates in patients who underwent resection were 52.0% and 34.8%, respectively. Leiomyosarcoma of the IVC is a serious disease. Although surgical resection combined with chemotherapy is usually not curative, it can achieve reasonably long-term survival. We recommend aggressive operative management using the latest vascular surgery and oncology techniques.     

Characteristics of paediatric burns seen at a tertiary centre in a low income country: a five year (2004-2008) study

Background

Children are the most risk prone in cases of burns. The previous epidemiologic study of paediatric burns in Lagos-Nigeria was carried four decades ago. A new study becomes necessary in view of the increasing incidences of petroleum related fire disasters in Nigeria.

Patients and methods

: Children up to the age of 14 years admitted for major burns at the Lagos State University Teaching Hospital (LASUTH), Ikeja-Lagos, Nigeria between January 1, 2004 and December 31, 2008 were studied. Information about the demographics, mechanism/circumstances of burns, associated injuries, surface extent (TBSA) and depth, modes of management and outcome, length of admission, and post mortem findings in cases of death were collected.

Results

: A total of 298 children with major burns were seen; 198 were males and 100 females. The ages ranged from 1 day to 14 years with mean of 4.56 ± 3.95 years. Forty percent of the cases occurred among the toddlers and 25.5% in the 2-5 years age group. Fire was the leading cause of burns, occurring in 198 (66.4%) cases. The TBSA ranged from 1% to 100% with mean of 29.67 ± 21.98. The mortality rate was 29.9%. Autopsy showed asphyxia as the primary cause of death in 14 (48.27%) cases, multiple organ dysfunctions in 27.59% and septicaemia in 13.79%.

Conclusion

This study identifies the main causes of paediatric burns and the major factors responsible for morbidity and mortality at the present time in a low income country. The level of awareness about burns prevention among the populace and health care facilities should be improved.     

Comparaison de l’Airtraq, du X-Lite et du laryngoscope standard pour la chirurgie thyroïdienne: une étude clinique randomisée

Purpose

To compare the performance of the Airtraq, X-Lite, and direct laryngoscopes for tracheal intubation for elective thyroid surgery.

Methods

In this randomized prospective study, Patients who were ASA (American Society of Anesthesiologists) I or II physical status I or II and patients undergoing thyroid surgery were included in this randomized prospective study. Patients with attributes for difficult intubation criteria were excluded. After induction of anesthesia with fentanyl, propofol, and cisatracurium, patients were randomized into three groups according to the intubating device used: Airtraq laryngoscope (Airtraq), X-Lite video laryngoscope (X-lLite), and direct laryngoscope with a Macintosh blade (Direct). The primary outcome measurement was the time needed for tracheal intubation. Secondary outcomes included intubation difficulty score (IDS), Cormack-Lehane classification, as well as hemodynamic and respiratory effects.

Results

One hundred and five patients were included. Mean (standard deviation) time for intubation was 28.2 (2.1) sec in the Airtraq group vs 36.6 (3.7) sec in the X-Lite group (P < 0.001), and 41.1 (4.4) sec in the Direct group (P < 0.001). Compared with to the direct laryngoscope, the Airtraq provided better visualization of the glottis (P = 0.003) with fewer attempts (P < 0.001) and lower IDS (P < 0.001). The intubation difficulty score was lower with the Airtraq than with the X-Lite (P = 0.003). Patients in the X-Lite and Direct groups showed more hemodynamic variations than those in the Airtraq group. There was only one failed intubation, in the direct group.

Conclusion

In thyroid surgery, the Airtraq and X-Lite laryngoscopes decrease time to intubation when compared with direct laryngoscopy.     

Could metabolic liver function tests predict mortality on waiting list for liver transplantation? A study on 560 patients

Ecochard M, Boillot O, Guillaud O, Roman S, Adham M, Mion F, Dumortier J. Could metabolic liver function tests predict mortality on waiting list for liver transplantation? A study on 560 patients.
Clin Transplant 2011: 25: 755–765. © 2010 John Wiley & Sons A/S. Abstract: Background: Allocation of graft in liver transplantation (LT) depends mainly on Model for End Stage Liver Disease (MELD) score. We studied the prognostic ability of three metabolic liver function tests in 560 cirrhotic patients listed for transplantation, in comparison with MELD and Child–Turcotte–Pugh (CTP) scores. Methods: Indocyanine green retention rate (ICG), aminopyrine breath test (ABT), and galactose elimination capacity were performed at the time of listing in addition to standard biological parameters. Seventy‐three patients died on waiting list, 438 were transplanted, and 73 died after LT. Cox regression analysis and receiver operating characteristic curves with c‐statistics were calculated after stratification according to CTP and MELD score. Results: For the mortality before transplantation, c‐statistics showed that ICG and ABT had a slightly better prognostic ability (0.73 and 0.68, respectively) than MELD score (0.66), and similar to CTP score (0.70). ABT’s prognostic ability remained significant once the MELD score (below and above 20) had already been taken into account. Only ICG had a prognostic ability to predict the survival after LT, even after stratification according to MELD and CTP score. Conclusions: Our results strongly support that ABT and ICG may be useful in the ranking of the patients in LT list, adding prognosis information in association with MELD score.     

Fluorescence-supported lymphography and extended pelvic lymph node dissection in robot-assisted radical prostatectomy: a prospective,randomized trial

Purpose

To demonstrate the benefits of fluorescence-supported extended pelvic lymph node dissection (ePLND) compared to regular ePLND in robot-assisted radical prostatectomy.

Methods

120 patients with intermediate- or high-risk prostate cancer were prospectively randomized (1:1): in the intervention group, indocyanine green (ICG) was injected transrectally into the prostate before docking of the robot. In both groups, ePLND was performed including additional dissection of fluorescent lymph nodes (LN) in the ICG group.

Results

After drop-out of two patients, 59 patients were allocated to the control (A) and intervention group (B) with a median PSA of 8,6 ng/ml. Median console time was 159 (A) vs. 168 (B) min (p?=?0.20) with a longer time for ICG-ePLND: 43 (A) vs. 55 min (B) (p?=?0.001). 2609 LN were found with significantly more LN after ICG-supported ePLND with a median of 25 vs. 17 LN in A (p?<?0.001). Nodal metastases were detected in 6 patients in A (25 cancerous LN) vs. 9 patients in B (62 positive LN) (p?=?0.40). In seven of nine patients, ICG-ePLND identified at least one cancer-positive LN (sensitivity 78%), 27 of 62 cancerous LN were fluorescent. Symptomatic lymphocele occurred in one patient in a and in three patients in b (p?=?0.62). After a median follow-up of 22.9 months, PSA levels were similar.

Conclusions

While ICG-ePLND seems to be beneficial for a better understanding of the lymphatic drainage and a more meticulous diagnostic approach, the sensitivity is not sufficient to recommend stand-alone ICG lymph node dissection.