Composite aortic root replacement in acute type A dissection: time to rethink the indications?

OBJECTIVE: The indications for aortic root replacement in acute type A dissection are unclear. We reviewed the immediate and long-term outcome of consecutive patients in a series in which a low-threshold policy of composite aortic root replacement had evolved. METHODS: From a prospectively compiled aortic surgery database, we identified 162 patients who had either supracoronary interposition grafting, Group A (n=89), or composite root replacement, Group B (n=73) for acute type A dissection. Patients receiving total arch replacements were excluded. Operative and clinical details were analyzed and patient survival was compared to an age and gender matched census cohort. Need for reoperation on the proximal or distal aorta was also noted. Follow-up totaled 795.5 patient-years. RESULTS: Hospital mortality rates were identical in both groups (12.3%: 11 deaths in group A; 9 in group B). Chronic pulmonary disease, diabetes, malperfusion, hemodynamic compromise and aortic root dilatation were independent risk factors for hospital death. Actuarial survival estimates at 1, 5 and 10 years were 79% (71-88%), 64% (53-75%), and 55% (41-68%) for group A, and 79% (70-86%), 73% (62-83%), and 65% (52-78%) for group B (P=0.48). Age and operative patency of the ascending false lumen were independent risk factors for death after hospital discharge. Proximal aortic reoperation was required for four patients in group A and none in group B (P=0.085). CONCLUSION: A strategy of replacement rather than repair of the dissected aortic root for specific indications in type A dissection yielded high survival and low proximal reoperation rates. These results support an aggressive policy of composite root replacement in acute type A dissection.     

Risk factors for Epstein–Barr virus reactivation after renal transplantation: Results of a large,multi-centre study

Epstein–Barr virus (EBV) reactivation is a very common and potentially lethal complication of renal transplantation. However, its risk factors and effects on transplant outcome are not well known. Here, we have analysed a large, multi-centre cohort (N = 512) in which 18.4% of the patients experienced EBV reactivation during the first post-transplant year. The patients were characterized pre-transplant and two weeks post-transplant by a multi-level biomarker panel. EBV reactivation was episodic for most patients, only 12 patients showed prolonged viraemia for over four months. Pre-transplant EBV shedding and male sex were associated with significantly increased incidence of post-transplant EBV reactivation. Importantly, we also identified a significant association of post-transplant EBV with acute rejection and with decreased haemoglobin levels. No further severe complications associated with EBV, either episodic or chronic, could be detected. Our data suggest that despite relatively frequent EBV reactivation, it had no association with serious complications during the first post-transplantation year. EBV shedding prior to transplantation could be employed as biomarkers for personalized immunosuppressive therapy. In summary, our results support the employed immunosuppressive regimes as relatively safe with regard to EBV. However, long-term studies are paramount to support these conclusions.     

Temporal-difference prediction errors and Pavlovian fear conditioning: role of NMDA and opioid receptors

Three experiments studied temporal-difference (TD) prediction errors during Pavlovian fear conditioning. In Stage I, rats received conditioned stimulus A (CSA) paired with shock. In Stage II, they received pairings of CSA and CSB with shock that blocked learning to CSB. In Stage III, a serial overlapping compound, CSB --> CSA, was followed by shock. The change in intratrial durations supported fear learning to CSB but reduced fear of CSA, revealing the operation of TD prediction errors. N-methyl- D-aspartate (NMDA) receptor antagonism prior to Stage III prevented learning, whereas opioid receptor antagonism selectively affected predictive learning. These findings support a role for TD prediction errors in fear conditioning. They suggest that NMDA receptors contribute to fear learning by acting on the product of predictive error, whereas opioid receptors contribute to predictive error.     

Combination therapy of focused ultrasound and radio-frequency for noninvasive body contouring in Asians with MRI photographic documentation

Previous studies have shown that single or multiple treatments by focused ultrasound are effective and safe. However, most include focused ultrasound only and not radio-frequency treatment. There is paucity of magnetic resonance imaging (MRI) measurements and pictures in the literature. This study aimed to assess the efficacy, safety, and pain and satisfaction levels of the combination therapy of focused ultrasound and radio-frequency for improving body contours. Thirty-two Asian patients received 3 sequential treatments every 2 weeks in the abdominal region. Safety parameters and adverse events were recorded. The subjects’ pain and satisfaction levels were evaluated using a five-point Likert scale. Two patients underwent MRI study randomly. There was a mean reduction in circumference of 3.91?±?1.8 cm (p?≤?0.001). In MRI measurement, the average in fat thickness reduction was 21.4 and 25 % on the upper and lower abdomen, respectively. There were three mild and self-limited localized adverse events. The satisfaction survey showed that 71.9 % was satisfied with the results, while pain level evaluation showed that 90.5 % felt no pain. Combination therapy of focused ultrasound and radio-frequency for noninvasive body contouring is an effective, safe, and painless procedure in Asians. Although the change is minor compared to traditional surgical procedure, it is real, definite, and effective.     

Isolated Tumor Cells in Sentinel Lymph Nodes of Invasive Breast Cancer: Cell Displacement or Metastasis?

The goal of this study was to determine whether the presence of isolated tumoral cells (ITCs) in sentinel lymph nodes (SLNs) after core needle biopsy (CNB) is related to the time interval between CNB and surgery and to histopathologic features of invasive breast cancer. Data from 633 consecutive patients with no micrometastasis or metastasis on both frozen sections and definitive pathologic examination of SLNs were retrieved from a prospective data base. No association was found between ITCs and the time interval between CNB and SLNB. The association was significant with tumor size, the tumor lymphovascular invasion (LVI) and the histologic type of the tumor. This study adds supplementary data to the association between tumoral LVI and ITCs in SLNs, The time interval between CNB procedure and SLNB was not related to affect presence of ITCs, which might not suggest the iatrogenic origin of these cells.     

Autonomous T cell trafficking examined in vivo with intravital two-photon microscopy

The recirculation of T cells between the blood and secondary lymphoid organs requires that T cells are motile and sensitive to tissue-specific signals. T cell motility has been studied in vitro, but the migratory behavior of individual T cells in vivo has remained enigmatic. Here, using intravital two-photon laser microscopy, we imaged the locomotion and trafficking of naive CD4(+) T cells in the inguinal lymph nodes of anesthetized mice. Intravital recordings deep within the lymph node showed T cells flowing rapidly in the microvasculature and captured individual homing events. Within the diffuse cortex, T cells displayed robust motility with an average velocity of approximately 11 microm x min(-1). T cells cycled between states of low and high motility roughly every 2 min, achieving peak velocities >25 microm x min(-1). An analysis of T cell migration in 3D space revealed a default trafficking program analogous to a random walk. Our results show that naive T cells do not migrate collectively, as they might under the direction of pervasive chemokine gradients. Instead, they appear to migrate as autonomous agents, each cell taking an independent trafficking path. Our results call into question the role of chemokine gradients for basal T cell trafficking within T cell areas and suggest that antigen detection may result from a stochastic process through which a random walk facilitates contact with antigen-presenting dendritic cells.     

Efficacy of multipurpose solutions for rigid gas permeable lenses

The use of multipurpose solutions for cleaning and disinfecting rigid gas permeable lenses has replaced single purpose solutions, but there are no reports of the efficacy of these multipurpose solutions, or of the effects of storage conditions on their disinfecting capacities. This study investigated activity against four bacterial and two fungal species, and the effects of storage in a refrigerator, at room temperature, at elevated temperature in both dry and humid conditions and with exposure to sunlight. The disinfecting solutions were challenged with the micro-organisms initially upon opening and then at 2-weekly intervals up to 12 weeks after being stored under the different conditions. Solutions were opened daily to simulate use. One solution failed to meet Food and Drug Administration (FDA) criteria to reduce numbers of bacteria by three log dilutions and of fungi by one log dilution. Storage reduced activity of all solutions over the 12-week period, but not below the requirements of the FDA. Storage in the refrigerator tended to reduce disinfecting capacity more quickly. Multipurpose solutions for rigid gas permeable (RGP) lenses lose activity over the 3 months recommended time of use but remain satisfactory for use over this time in the conditions tested. Practitioners need to remind patients to replace their solutions regularly and should advise against storage in the refrigerator. Multipurpose solutions for RGP lenses have simplified cleaning and disinfecting processes and the current formulations have improved disinfecting capacity compared to former disinfecting solutions, which is particularly important for wearers of orthokeratology lenses.     

Serum leptin and pathological findings at the time of radical prostatectomy

PURPOSE: Obesity has been associated with a higher risk of progression following radical prostatectomy (RP). Obese men have higher serum leptin, a hormone produced by adipocytes, which has also been shown to be an in vitro prostate cancer growth factor. We examined whether serum leptin correlates with advanced pathological findings at RP. MATERIALS AND METHODS: Preoperative serum from 225 men treated with RP between 1998 and 1999 was examined for serum leptin. Multivariate logistic regression analysis was used to determine whether serum leptin was predictive of extraprostatic extension (pT3a). RESULTS: Serum leptin highly correlated with body mass index (Spearman r = 0.602, p <0.001). Serum leptin was not associated with total or percent free prostate specific antigen (PSA), biopsy or prostatectomy Gleason score, age or height. On multivariate analysis with total and percent free PSA, clinical stage, age, biopsy Gleason score, body mass index, serum leptin, and height as variables considered for entry into the model, serum PSA (p = 0.009), clinical stage (p = 0.019) and serum percent free PSA (p = 0.041) were the only variables predictive of extraprostatic extension. Serum leptin was not significantly associated with pathological stage (pT3a). CONCLUSIONS: In the current study of predominantly white men with mainly low risk disease there was no statistically significant association between serum leptin and pathological stage (pT3a) at RP. In this cohort serum leptin was not a good biomarker for predicting advanced stage at RP.