Refractory Heart Failure Dependent on Short‐Term Mechanical Circulatory Support: What Next? Heart Transplant or Long‐Term Ventricular Assist Device

Chronic heart failure is a progressive and eventually fatal illness. Although the disease cannot be cured and treatment is symptom oriented, most of the patients benefit from optimum medical treatment. Patients with rapid deterioration in chronic advanced heart failure refractory to medical treatment need inotropic support and may need intra‐aortic balloon pump to maintain circulatory support, which of course cannot be prolonged beyond a certain limit. The outcome of heart transplant and long‐term ventricular assist device (VAD) in such patients is poor. The short‐term mechanical circulatory support (MCS) offered to such patients not only provides effective circulatory support and stabilizes them hemodynamically, but also halts the ensuing or reverts the established end‐organ failure. As the name suggests, the short‐term MCS offers support for the short term, usually less than a month. Although some patients with acute heart failure experience recovery of myocardial function with short‐term MCS support, others become dependent. These patients, stabilized and “stuck” with short‐term MCS, can be “rescued” with long‐term VAD or heart transplantation. Both the procedures, when done in this special situation, have their inherent advantages, disadvantages, and complications and hence need the careful consideration about the choice of the procedure. We have tried to elucidate this situation by considering the advantages and disadvantages of both options.     

Proposition for new terminologies in PCNL: what does ‘ultra-mini-micro’ actually mean?

Ever smaller miniaturised techniques are being developed for percutaneous nephrolithotomy (PCNL), with access sheaths now as small as 4.8Fr being used in adults. With the ever expanding use of the terms “micro” “mini” or “ultra” techniques, the terminology can be somewhat confusing. We propose a simple classification system to standardise the terminology for PCNL, encapsulating technological and procedural advancements.     

A commonly carried genetic variant in the delta opioid receptor gene,OPRD1, is associated with smaller regional brain volumes: Replication in elderly and young populations

Delta opioid receptors are implicated in a variety of psychiatric and neurological disorders. These receptors play a key role in the reinforcing properties of drugs of abuse, and polymorphisms in OPRD1 (the gene encoding delta opioid receptors) are associated with drug addiction. Delta opioid receptors are also involved in protecting neurons against hypoxic and ischemic stress. Here, we first examined a large sample of 738 elderly participants with neuroimaging and genetic data from the Alzheimer's Disease Neuroimaging Initiative. We hypothesized that common variants in OPRD1 would be associated with differences in brain structure, particularly in regions relevant to addictive and neurodegenerative disorders. One very common variant (rs678849) predicted differences in regional brain volumes. We replicated the association of this single‐nucleotide polymorphism with regional tissue volumes in a large sample of young participants in the Queensland Twin Imaging study. Although the same allele was associated with reduced volumes in both cohorts, the brain regions affected differed between the two samples. In healthy elderly, exploratory analyses suggested that the genotype associated with reduced brain volumes in both cohorts may also predict cerebrospinal fluid levels of neurodegenerative biomarkers, but this requires confirmation. If opiate receptor genetic variants are related to individual differences in brain structure, genotyping of these variants may be helpful when designing clinical trials targeting delta opioid receptors to treat neurological disorders. Hum Brain Mapp 35:1226–1236, 2014. © 2013 Wiley Periodicals, Inc.     

Location of Lymph Node Involvement in Patients with Esophageal Adenocarcinoma Predicts Survival

Background

The location of positive lymph nodes has been abandoned in the seventh classification of the TNM staging system for esophageal adenocarcinoma. The present study evaluates whether distribution of involved nodes relative to the diaphragm in addition to TNM 7 further refines prediction.

Methods

Pathology reports of patients who underwent esophagectomy between 2000 and 2008 for adenocarcinoma of the esophagus were reviewed and staging was performed according to the seventh UICC-AJCC staging system. In addition, lymph node involvement of nodal stations above and below the diaphragm was investigated by endoscopic ultrasonography (EUS) in a separate cohort of patients who were scheduled for esophagectomy between 2008 and 2009 at two institutions. Survival was calculated by the Kaplan–Meier method, and multivariate analysis was performed with a Cox regression model.

Results

Some 327 patients who had undergone esophagectomy for cancer were included. Multivariate analysis revealed that patients with from three to six involved lymph nodes in the resection specimen on both sides of the diaphragm had a twofold higher chance of dying compared to patients with the same number of involved lymph nodes on one side of the diaphragm. EUS assessment of lymph node metastases relative to the diaphragm in 102 patients showed that nodal involvement on both sides of the diaphragm was associated with worse survival than when nodes on one side or no nodes are involved [HR (95 % CI) 2.38 (1.15–4.90)].

Conclusions

A combined staging system that incorporates distribution of lymph nodes relative to the diaphragm refines prognostication after esophagectomy as assessed in the resected specimen and pretreatment as assessed by EUS. This improved staging has the potential to have a great impact on clinical decision making as to whether to embark upon potentially curative or palliative treatments.     

Pyogenic Liver Abscess Following Pancreaticoduodenectomy: Risk Factors,Treatment, and Long-Term Outcome

Background

Pancreaticoduodenectomy (PD) remains a challenging operation with a 40 % postoperative complication rate. Pyogenic liver abscess (PLA) is an uncommon complication following PD with little information on its incidence or treatment. This study was done to examine the incidence, risk factors, treatment, and long-term outcome of PLA after PD.

Methods

We retrospectively reviewed 1,189 patients undergoing PD (N?=?839) or distal pancreatectomy (DP) (N?=?350) at a single institution over a 14-year period (January 1, 1994–January 1, 2008). Pancreatic databases (PD and DP) were queried for postoperative complications and cross-checked through a hospital-wide database using ICD-9 codes 572.0 (PLA) and 006.3 (amebic liver abscess) as primary or secondary diagnoses. No PLA occurred following DP. Twenty-two patients (2.6 %) developed PLA following PD. These 22 patients were matched (1:3) for age, gender, year of operation, and indication for surgery with 66 patients without PLA following PD.

Results

PLA occurred in 2.6 % (22/839) of patients following PD, with 13 patients (59.1 %) having a solitary abscess and 9 (40.9 %) multiple abscesses. Treatment involved antibiotics and percutaneous drainage (N?=?15, 68.2 %) or antibiotics alone (N?=?7, 31.8 %) with a mean hospital stay of 12 days. No patient required surgical drainage, two abscesses recurred, and all subsequently resolved. Three patients (14 %) died related to PLA. Postoperatively, patients with biliary fistula (13.6 vs. 0 %, p?=?0.014) or who required reoperation (18.2 vs. 1.5 %, p?=?0.013) had a significantly higher rate of PLA than matched controls. Long-term follow-up showed equivalent 1-year (79 vs.74 %), 2-year (50 vs. 57 %), and 3-year (38 vs. 33 %) survival rates and hepatic function between patients with PLA and matched controls.

Conclusions

Postoperative biliary fistula and need for reoperation are risk factors for PLA following PD. Antibiotics and selective percutaneous drainage was effective in 86 % of patients with no adverse effects on long-term hepatic function or survival.     

Accuracy of the Dentaport ZX apex locator for working length determination when retreating molar root canals

The aim of this study was to evaluate the accuracy of the Dentaport ZX apex locator for working length determination during root canal retreatment of mandibular molars. Fifteen extracted mandibular first molars with separate mesial canals and apical foraminae and one distal canal were selected. The mesiobuccal and distal canals were investigated; the length with the file tip at the major diameter was defined as the tooth length (TL). The canals were prepared with ProTaper files to 1 mm short of this and filled with gutta‐percha and AH Plus sealer. One week later, the root fillings were removed using ProTaper retreatment files. Tooth length was remeasured and recorded as the retreatment tooth length (RTL). Then electronic measurements were taken at the major (electronic apex locator (EAL) major) and minor (EAL minor) foraminae as suggested by the instrument display. These lengths were compared with RTL and measurements 0.5 and 1 mm short of this distance. For both canals, no significant difference was found between RTL and EAL major, and 0.5 mm short of RTL and EAL minor (P > 0.05). There were significant differences found between all other readings. The Dentaport ZX could not detect the minor foramen accurately but was able to indicate the major foramen in molars undergoing a root canal retreatment procedure.