Myocardial protection with monophosphoryl lipid-A against aortic cross clamping-induced global stunning

BACKGROUND: Monophosphoryl lipid-A (MLA) has a late window (24 hours) of cardioprotection against acute myocardial infarction. It is not known whether MLA, administered, 24 hours before surgery, attenuates intraoperative ventricular dysfunction "stunning" associated with aortic cross-clamping and reperfusion during elective cardiac surgery. We determined the dose-response relationship between MLA and ventricular function in a canine model of global myocardial stunning in the absence of necrosis. The role of expression of inducible heat shock protein 70 (HSP 70i) was also investigated. METHODS: Mongrel dogs (n = 32) were intravenously injected with either a vehicle solution or 3, 5, 10, 35 ug/kg MLA. Twenty four hours later, dogs were anesthetized and instrumented, in situ, to monitor the left ventricular performance (the slope of regression between stroke-work and end diastolic length). Tissue samples were obtained to determine HSP70i using immunoblot analysis. After a period of equilibration on cardiopulmonary bypass, the aortic cross-clamp was applied at normothermia for 30 minutes followed by 60 minutes of reperfusion. ATP and catabolites were determined in transmural myocardial biopsies. Triphenyl-tetrazolium chloride (TTC) staining was used to determine myocardial necrosis. RESULTS: MLA treatment did not alter myocardial contractility or ATP metabolism. Global ischemia resulted in about 50% depletion of ATP and remained depressed during reperfusion in all groups. MLA-treated hearts had improved functional recovery in a dose dependent-manner. Significant recovery was observed at the highest dose (35 ug/kg) compared to the control group. Immunoblot analysis demonstrated significant increase in HSP 70i in the MLA-treated hearts. CONCLUSIONS: MLA exhibits a delayed (24 hours) window of protection against myocardial stunning associated with aortic cross-clamping. HSP70i expression may play a role in MLA-mediated cardioprotection.     

Periictal diffusion-weighted imaging in a case of lesional epilepsy

PURPOSE: Diffusion-weighted MR imaging (DWI) has been used for the early diagnosis of acute ischemic lesions in humans and in animal models of focal status epilepticus. We hypothesized that DWI may be a sensitive, noninvasive tool for the localization of the epileptogenic area during the periictal period. METHODS: A periictal DWI study was performed on a 35-year-old patient during focal status epilepticus with repetitive prolonged focal motor seizures originating from a lesion in the right frontal lobe. DWI results were analyzed visually and by calculating apparent diffusion coefficient (ADC) maps. RESULTS: On DWI, a single area of signal increase (decrease in ADC) was found in the region of focal electrocorticographic seizures that was mapped intraoperatively. CONCLUSIONS: Ictal/postictal DWI may be a useful technique for seizure localization in patients with lesional epilepsy.     

Detubularized Isolated Ureterosigmoidostomy: Description of a New Technique and Preliminary Results

Purpose

A technique is described to improve the evacuation pattern and, accordingly, the life-style of patients with ureterosigmoidostomy.

Materials and Methods

An inverted U-shaped sigmoid colon is detubularized, and the left colon is fixed in continuity to the posterior wall of the rectal ampulla in line with the anorectal canal. The ureters are reimplanted into the sigmoid pouch using the nipple technique.

Results

All 15 patients followed for 3 to 18 months postoperatively passed clear urine and solid feces separately, with good anal control and at convenient periods (urine 3 to 6 times and solid feces once daily). Urographic studies showed stabilization of renal morphology in 26 units, improved function in 3 and deterioration in 1. Dynamic study of the rectum in 3 patients showed a capacious rectosigmoid reservoir with low pressure.

Conclusions

The technique of detubularized isolated ureterosigmoidostomy has important advantages over conventional ureterosigmoidostomy. Patients pass urine and feces separately and at convenient intervals with good anal control. The upper urinary tract is well preserved, and there is potentially less risk of colonic carcinogenesis.     

Desire to Void and Force of Micturition in Patients with Intestinal Neobladders

Purpose

We attempted to determine how patients with an orthotopic bladder perceive the desire to void and the force achieved to evacuate the bladder.

Materials and Methods

A total of 24 men who had undergone post-cystectomy bladder substitution (ileocecal in 12, sigmoid in 6 and ileal in 6) was evaluated subjectively and objectively by pressure-flow study 1 to 3 years postoperatively.

Results

Desire to void was felt at the base of the penis or in the perineum by 20 men (83 percent). Abdominal pressure contributed to intra-reservoir pressure by 51 to 54 percent in ileocecal, 20 to 24 percent in sigmoid and 23 to 25 percent in ileal neobladders.

Conclusions

Patients perceive the desire to void when drops of urine leak into the proximal urethra from an overfilled neobladder. Urine is evacuated mainly by abdominal straining for ileal neobladders, mainly by contraction for sigmoid neobladders, and by approximately equal contributions of contraction and straining for ileocecal neobladders.     

Post-Chemotherapy Resection of Nonseminomatous Germ Cell Testicular Tumors Metastatic to the Mediastinum

Purpose

We determined if the behavior of germ cell tumors metastatic to the mediastinum is different from that of primary mediastinal germ cell tumors, a group known to have distinct clinical features.

Materials and Methods

A search of the computerized data base for germ cell tumors metastatic to the mediastinum at our university revealed 80 patients, 65 of whom underwent concomitant retroperitoneal lymph node dissection at mediastinal surgery.

Results

Of the patients 60 (75 percent) are free of disease, 14 (18 percent) died of cancer and 6 (8 percent) are living with disease. Mediastinal pathology included teratoma in 65 percent of the patients, cancer in 26 percent and fibrosis in 9 percent. Of the 65 patients who underwent retroperitoneal lymph node dissection 75 percent had teratoma, 15 percent had fibrosis and 10 percent had cancer. Mediastinal relapses after dissection were rare (4 of 80 patients).

Conclusions

Germ cell tumors metastatic to the mediastinum appear to behave similarly to those metastatic to the retroperitoneum. Primary mediastinal germ cell tumors have an entirely different clinical course. Teratoma is the predominant pathological type of post-chemotherapy germ cell cancer metastatic to the mediastinum.     

Severity of illness scores and the outcome of acute tubular necrosis

The outcome of patients with acute renal failure (ARF)due to acute tubular necrosis (ATN) was evaluated inthis study. Two hundred and twenty-two patients witha mean age of 55.l ± 17.7 years (range 19–97years; male 153, female 69) who developed ATN in theperiod from July 1991 through January 1997 werestudied. Patients were divided into four groupsaccording to their APACHE II scores at the time of thediagnosis of ATN. Group I included patients with anAPACHE II score of 14 or less (n = 70), Group II with ascore of 15–18 (n = 52), Group III with a score of 19–23(n = 58), and group IV with a score of 24 or above(n = 42). The mean APACHE II score for each of the fourstudy groups was 11 ± 0.4, 16 ± 0.2, 20 ±0.2, and 29 ± 0.7, respectively. Patient survivalwas evaluated by the Kaplan-Meier analysis withcensorship at 12 months. Survival rates at 180 dayswere 67%, 47%, 39%, and zero%, for group I through IV respectively, χ² = 27.99, p < 0.0001,with a median survival of >365, 120, 31, and 11days, for groups I through IV, respectively. For patients with oliguria (n = 88) survival at 180days was 23% vs. 58% for patients without oliguria(n = 134), p < 0.0001, median survival 13 vs. 364 d.Six months survival of those who required dialysis(n = 79) was 25% vs. 58% for those whom dialysis wasnot needed (n = 143), p = 0.001, median survival 15 vs.364 d, respectively. In patients with sepsis (n = 58),6 months survival was 35% vs. 50% for those withoutsepsis (n = 164), p = 0.013, median survival 14 vs. 169 d. In patients who required mechanical ventilation(n = 72), 6 months survival was 17% vs. 62% for those whodid not need respiratory support (n = 150), p = 0.0001,median survival 13 vs. > 365 d, respectively. Finally, 6 months survival in patients with one(kidney only), two, three, and four organ failure was76, 30, 11, and zero percent, respectively, p = 0.0001,median survival > 365, 16, 11, and 12 days,respectively. We conclude that the use of the APACHE II score forthe stratification of the severity of illness could beof clinical utility in predicting mortality inpatients with ATN. Other predictors of poor prognosisinclude the need for dialysis, the presence ofoliguria, the need for mechanical ventilation, thepresence of sepsis, and the number of failed organs. This revised version was published online in August 2006 with corrections to the Cover Date.     

Mixed hematopoietic chimerism at day 90 following allogenic myeloablative stem cell transplantation is a predictor of relapse and survival.

We retrospectively analyzed the prognostic significance of mixed chimerism and associated clinical parameters in 80 patients following unmanipulated allogenic stem cell transplantation. Chimerism studies were performed on marrow aspirates using fluorescent in situ hybridization and variable number tandem repeats techniques at day +30, day +90 and +12 months. The median overall survival (OS) was 24 months (range, 1-56 months). Mixed chimerism was found in 23, 28 and 14% of patients at day +30 (1 month), +90 (3 months), and +12 months, respectively. Day +30 chimerism studies failed to provide any prognostic information. Day +90 mixed chimeras (MC) had significantly higher relapse rates compared to day +90 complete chimeras (CC) at 6 months (P=0.03) and 18 months when compared to MC (P=0.03) following transplant. The median OS in day +90 MC and day+90 CC were, respectively (95% CI, 2-35 months), compared to 47 months (95% CI, 20-74 months) (P=0.02). In conclusion, chimerism studies on day +30 could be reserved for patients who fail to demonstrate engraftment. Day +90 MC had higher relapse rates and lower OS, and therefore may be considered for novel therapies and future studies.     

The effect of dose increase of imatinib mesylate in patients with chronic or accelerated phase chronic myelogenous leukemia with inadequate hematologic or cytogenetic response to initial treatment.

PURPOSE: Imatinib mesylate is a tyrosine kinase inhibitor with high affinity for the BCR-ABL fusion protein expressed by the hematopoietic cells in chronic myelogenous leukemia (CML). Some patients with chronic-phase or accelerated-phase CML either relapse after an initial response or are refractory to imatinib, prompting us to evaluate the efficacy of dose increase in such patients. EXPERIMENTAL DESIGN: Twelve chronic-phase patients initially receiving 400 mg/day and 4 patients with accelerated phase initially receiving either 400 mg/day (two patients) or 600 mg/day (two patients) had their dose increased (14 to 800 mg/day and 2 to 600 mg/day) because of progressive disease (usually clonal evolution) or inadequate cytogenetic response after at least 1 year of therapy. RESULTS: Six patients had major cytogenetic responses after dose increase (3 complete and 3 partial). Two others had minor cytogenetic responses. Two patients with clonal evolution transiently lost the additional clonal aberrations. Almost all of the responses occurred within 6 months, and were typically 3-6 months in duration. However, 3 patients have continuing major cytogenetic responses of >18 months duration. Dose increase was well tolerated, with thrombocytopenia, mild leukopenia, and exacerbation of prior edema being the most common adverse events. CONCLUSIONS: Although increasing the dose of imatinib can benefit a subgroup of patients with CML with either an inadequate cytogenetic response or disease progression, our results suggest the majority will not have a sustained meaningful response, and that other options, such as allogeneic stem cell transplant or investigational therapies, also need to be considered at the time of dose increase.     

Prevalence of sexually transmitted diseases (STD) among women in a suburban Sudanese community

338 women with age ranging from 15 to 69 years in a suburban Sudanese community were randomly selected and studied. Urine sample, high vaginal swabs and blood samples were investigated for bacterial vaginosis, candidiasis, trichomoniasis, gonorrhoea, HIV and syphilis. The sensitivity and specificity of some laboratory tests were evaluated. Bacterial vaginosis was found in 17.2% of the subjects, candidiasis in 10.1%, trichomoniasis in 7.7%, gonorrhoea in 1.2%, HIV in 1.2% and syphilis in 0.9% of the subjects. The sensitivity and specificity of amine test as a criterion for diagnosing bacterial vaginosis was 58.6% and 73.2%, respectively. The respective values of clue cells in wet preparation were 43.1% and 99.6%. The vaginal discharge in women with bacterial vaginosis lacked pus cells unless associated with concurrent infection.     

Brainstem ischemia and preeclampsia.

Diffuse neurological manifestations of preeclampsia are due to endothelial involvement that lead to ischemia, hemorrhage, or edema. We analyzed clinical and radiological features and the course of brainstem ischemic strokes in a preeclampsia patient. We report a case of severe preeclampsia in a 30-year-old woman who was admitted 10 hr after a vaginal delivery at home. The pregnancy was at 39 wk, with no prenatal care. At her admission, she was conscious, and she had tetraparesia, swinging deep tendon reflex testing, drowsiness, and dysarthria; the BP was at 160/100 mmHg and 4 + proteinuria; magnetic resonance imaging revealed brainstem ischemic stroke. The evolution was favorable with symptomatic treatment. The patient was discharged on the 16th day; 2 months later she had a normal recovery. Brainstem strokes are rare. They are frequently due to hemorrhage; sometimes, they can also be ischemic. Their course is favorable.