Postoperative blood loss in coronary surgery. No real impact of fibrinolysis detected by thromboelastography and D-dimers. A prospective, randomized study

Although in many cardiac surgery centers pharmacological strategies based on fibrinolytic inhibitors are used on a routine basis, detailed knowledge of fibrinolysis during various settings of coronary surgery is still limited. Sixty-five patients scheduled for coronary surgery were randomized into 3 groups: group A--conventional coronary artery bypass grafting, group B--off-pump surgery, and group C--coronary artery bypass grafting with modified, rheoparin coated cardiopulmonary bypass with the avoidance of reinfusion of cardiotomy blood into the circuit. The sampling time points for rotation thromboelastographic evaluations were as follows: preoperatively, 15 minutes after sternotomy, on the completion of peripheral bypass anastomoses, at the end of the procedures, and 24 hours after the end of surgery. D-dimer levels were evaluated before surgery, at the end of procedures, and 24 hours after surgery. Thromboelastographic signs of fibrinolysis (evaluated by Lysis Onset Time-intergroup differences at 60 and 150 minutes of assessment: P = 0.003 and P < 0.001, respectively) were clearly detectable during cardiopulmonary bypass in group A, but not at any time in groups B and C. At the other sampling times all thromboelastographic parameters were similar in all groups. In group A, no exceptional bleeding tendency (during 24 hours), as compared to groups B and C (geometric means and 95% confidence intervals: group A: 686.7 [570.8; 826.1] mL, group B: 555.3 [441.3; 698.9] mL, group C: 775.6 [645.1; 932.3] mL, P = 0.157), and no significant correlations between Lysis Onset Time, postoperative blood loss, and D-dimer levels were found. No significant differences in postoperative blood loss related to cardiac surgeons and assistant surgeons were detected. Thromboelastographic signs of increased fibrinolysis were detectable in the important proportion of coronary surgery patients operated on with the use of conventional cardio-pulmonary bypass, but not in off-pump patients and those operated on with the biocompatible surface-modified circuit without reinfusion of cardiotomy suction blood. These signs resolved spontaneously at the end of surgery and were not associated with increased postoperative bleeding. No significant correlation with D-dimer levels was found.     

Identification of a new chemical class of antimalarials

The increasing spread of drug-resistant malaria strains underscores the need for new antimalarial agents with novel modes of action (MOAs). Here, we describe a compound representative of a new class of antimalarials. This molecule, ACT-213615, potently inhibits in vitro erythrocytic growth of all tested Plasmodium falciparum strains, irrespective of their drug resistance properties, with half-maximal inhibitory concentration (IC(50)) values in the low single-digit nanomolar range. Like the clinically used artemisinins, the compound equally and very rapidly affects all 3 asexual erythrocytic parasite stages. In contrast, microarray studies suggest that the MOA of ACT-213615 is different from that of the artemisinins and other known antimalarials. ACT-213615 is orally bioavailable in mice, exhibits activity in the murine Plasmodium berghei model and efficacy comparable to that of the reference drug chloroquine in the recently established P. falciparum SCID mouse model. ACT-213615 represents a new class of potent antimalarials that merits further investigation for its clinical potential.     

The role of endoglin in atherosclerosis

Endoglin (CD 105, TGF-β receptor III) is a homodimeric transmembrane glycoprotein that plays a regulatory role in TGF-β signaling. Its functional role in the context of atherosclerosis has yet to be defined and should be stated here. Therefore, we focused on the role of endoglin in atherosclerosis in both humans and experimental animals. Endoglin expression was demonstrated in atherosclerotic vessels predominantly in endothelial cells and smooth muscle cells in various types of blood vessels in mice and humans, suggesting its participation in atherogenesis. Endoglin expression was also related to the expression of eNOS in endothelium, repair of the vessel wall, plaque neoangiogenesis, production of collagen and stabilization of atherosclerotic lesions. In addition, increased levels of soluble endoglin were associated with hypercholesterolemia, atherosclerosis, acute myocardial infarction and were related to inhibition of TGF-β signaling in the vessel wall. Moreover, soluble endoglin levels were significantly lowered after a series of extracorporeal eliminations in patients with familial hypercholesterolemia. Additionally, statin treatment decreased levels of soluble endoglin and increased its expression in aorta, which was related to reduced atherosclerosis in mice. In conclusion, we propose that measurement of soluble endoglin might give information about progression of the atherosclerotic process or the efficacy of therapeutic interventions, which is the task that must be answered in clinical trials.     

Factors associated with weight changes in successful quitters participating in a smoking cessation program

Objective

To identify possible predictors of post-cessation weight gain in smoking abstainers.

Patients and methods

A sample of 607 successful abstainers seen at the Centre for Tobacco-Dependent in Prague, Czech Republic, between 2005 and 2010, was included in this analysis. This sample was followed up for 1 year and included 47.9% women (N = 291) with the mean age of 48 years (18–85).

Findings

Post-cessation weight gain occurred in 88.6% of the 607 abstainers. The mean weight gain after one year post-quit was 5.1 kg (95% confidence interval 4.7–5.5 kg). Baseline characteristics associated with increased weight gain included a higher baseline smoking rate (p < 0.001), more severe cigarette dependence (p = 0.003), less physical activity (p = 0.008), and a report of increased appetite on the baseline assessment of withdrawal symptoms (p < 0.001).

Conclusions

Smokers who are more dependent and have minimal physical activity are at increased risk for post-cessation weight gain. For these smokers, incorporating interventions targeting the weight issue into tobacco dependence treatment is recommended. Further research should be done to identify reasons for this important quitting complication.     

Bioactive glass-ceramics in facial skeleton contouring

The removal of certain facial-bone defects is a prerequisite to restoration of function, stability, and appearance. Synthetic bone substitutes are beneficial in cases where other operative techniques would be an unacceptable burden for a patient. Satisfactory results can be achieved in one surgical intervention with low costs and low demand on technical equipment. Osteoconductive, biocompatible, non-resorbable glass-ceramic implants based on oxyfluoroapatite and wollastonite permit osteointegration—a direct physical and chemical bond between live bone tissue and the implant without formation of a fibrous capsule. They display better stress durability in simulated body fluid than hydroxyapatite implants do. This material was used for facial skeletal framework, contour restoration in 44 cases under conditions where other solutions were doubtful. Patients were observed for 24.8 months. Immediate healing occurred without any adverse reaction. The main problem was extrusion, observed in 20.45% cases over a 2–3 month period after the implantation. All cases, with one exception, were solved with a satisfactory final result by reoperation, implant size reduction, and increased soft tissue cover. This approach was found to be a suitable technique, especially for patients exhausted by prior incompetent treatment but still dissatisfied with their appearance. Successful reconstruction with a bone substitute may remarkably increase quality of life for affected persons and, at the same time, reduce surgery-related time and costs.     

Radio-guided sentinel node detection during the surgical treatment of rectal cancer

OBJECTIVE: The detection of sentinel nodes is performed in various types of malignant disease. The aim of this study was to evaluate the results of the radiodetection of sentinel nodes, based on the use of Tc-colloid, during the surgical treatment of rectal cancer. METHODS: In 2003-2004, 42 patients (24 males and 18 females; average ages of 62.4 and 67 years, respectively) were examined during rectal carcinoma surgical procedures. Miles abdominoperineal rectal resection was performed in nine cases; 33 patients underwent low anterior rectum resection by total mesorectal excision. On the day of the operation, a transanal submucosal infiltration of colloid labelled with radioactive 99mTc was performed; infiltration was performed strictly peritumorally. After the operation, radiodetection of the surgical specimens (using a hand-held gamma probe) was performed. The areas of higher radioactivity were marked. The specimens were then examined by a histopathologist. The nodes found closest to the marked areas were considered to be 'sentinel nodes'. The results of scintigraphy and postoperative radiodetection were checked by histological examination. All the discovered lymph nodes were examined by haematoxylin and eosin staining; when this was negative, immunohistochemical examination with cytokeratin was used for the sentinel nodes. RESULTS: In 36 of the 42 patients, the data obtained by scintigraphy and radiodetection were in agreement with histopathological proof of a sentinel node. The sensitivity of the method in this group of patients was 86% (95% confidence limits: 70.75-94.05). CONCLUSIONS: The scintigraphic method of detection of sentinel nodes in total mesorectal excision is not therapeutic, but diagnostic, and demonstrates a high level of reliability. It can be used to indicate the nodes that should be examined to detect the presence of possible micrometastases immunohistochemically. However, this method cannot be used for all detected nodes as it is very demanding. In the evaluated group of patients, there were no intraoperative or postoperative complications caused by this diagnostic method.     

Pediatric tumors of the parapharyngeal space. Three case reports and a literature review

Three cases of pediatric primary parapharyngeal space tumors, namely a Burkitt's lymphoma, lipoblastoma and a ganglioneuroma are described here, along with a literature review. These disorders are very rare, accounting for less than 20% of all parapharyngeal neoplasms. In comparison to adults, there are differences in pathomorphologic spectrum of pediatric parapharyngeal tumors. The authors describe the prevalence of malignant tumors, mainly soft tissues sarcomas. The salivary gland tumors and paragangliomas which dominate in adult populations, are extremely rare in pediatric populations where the most common benign tumor to be encountered is that of neurogenic origin. It follows that these features modify the diagnostic and therapeutic approach.