Bullet embolisation from the right subclavian vein to the right ventricle: a case report.

Bullet embolism to the heart is an unusual complication of penetrating gunshot injuries. A bullet may reach the heart by direct cardiac penetration or entry into the peripheral venous system with embolisation to the heart, which must be differentiated. This is a report of an unusual case of bullet embolism to the heart that was extracted by direct cardiotomy without cardiopulmonary bypass.

Endoscopic harvest of saphenous vein: a lesson learned from 1,348 cases.

BACKGROUND: Endoscopic harvest of saphenous vein is a relatively new technique developed to minimize the wound and postoperative complications. This technique has gained patients' acceptance and become popular in cardiac surgical practices. Because most centers have limited experience with this approach, the authors summarize the clinical profiles of patients undergoing endoscopic vessel harvest (EVH). METHODS: Between March 2001 and August 2006, 1,348 patients (945 men and 403 women) with a mean age of 67.2 years (range, 28-89 years) underwent EVH of saphenous vein for coronary artery bypass surgery, peripheral artery reconstruction, and miscellaneous conditions. The EVH technique was performed using the Vasoview system (Guidant, Menlo Park, CA, USA) under the assistance of carbon dioxide (CO(2)) insufflation. RESULTS: Technical success was achieved in 98.6% of the cases. Two saphenous veins were discarded because of obvious vein injury. The mean harvest time was 45 min: 68 min for the first 50 cases and 23 min for the last 200 cases. Nearly all the patients (98%) had saphenous vein harvested only from the thighs, whereas only 1.5% of the patients had saphenous vein harvested from the legs. Postoperative wound complications were experienced by 61 patients including 25 tract hematomas, 19 wound dehiscences or poor healing, 16 wound infections, and 1 overlying skin necrosis. Overall, 13 subsequent revisions were required for these complications. Detectable air embolisms occurred for 143 patients and numbness in the saphenous nerve territory for 169 patients. CONCLUSION: The findings showed EVH of saphenous vein to be a valid alternative to open saphenectomy, providing excellent surgical results. Therefore, EVH should be considered as the standard of care for saphenous vein harvest.

Successful heterotopic heart transplant after cardiopulmonary bypass rescue of an arrested donor heart.

Global heart transplantation has declined due to the donor shortage. The use of marginal donors has therefore been reintroduced. According to the history of heart transplantation, heterotopic heart transplant has played an important role in the precyclosporine era. In those circumstances, native heart and donor heart worked together to support each other against rejection or progressive heart failure. However, heterotopic transplantation has complicated surgical techniques and requirements for postoperative surveillance. Most training fellows have limited experience with this approach. At present more than 1000 cardiac surgical centers perform heart transplantation, but only 50 centers have experience in performing-heterotopic procedures. Using mechanical circulatory support for the posttransplant period is well developed in most centers. However, using mechanical circulatory support for heart donor with the intention of rescuing the heart has not been reported. Herein, we report a successful heterotopic heart transplantation after rescue with cardiopulmonary bypass of an arrested donor heart.

Hybrid pulmonary artery conduit angioplasty for heterotopic heart transplantation.

Heterotopic heart transplantation is rare in clinical practices. It carries technical difficulty not only during transplantation procedures, but also in the postoperative surveillance. We report two cases of heterotopic heart transplantation, which were complicated by pulmonary artery conduit stenosis within 2 years. We applied a less invasive approach combining cardiovascular surgeons with an interventional cardiologist. Through the donor heart right ventricular outflow tract, we performed balloon angioplasty and stent deployment. An excellent angiographic result with minimal residual pressure gradient was achieved in both patients.

Effect of dehydroepiandrosterone sulfate on carnitine acetyl transferase activity and L-carnitine levels in oophorectomized rats.

Alteration in energy metabolism of postmenopausal women might be related to the reduction of dehydroepiandrosterone sulfate (DHEAS). DHEA and DHEAS decline with age, leveling at their nadir near menopause. DHEA and DHEAS modulate fatty acid metabolism by regulating carnitine acyltransferases and CoA. The purpose of this study was to determine whether dietary supplementation with DHEAS would also increase tissue L-carnitine levels, carnitine acetyltransferase (CAT) activity and mitochondrial respiration in oophorectomized rats. Plasma L-carnitine levels rose following oophorectomy in all groups (P < 0.0001). Supplementation with DHEAS was not associated with further elevation of plasma L-carnitine levels, but with increased hepatic total and free L-carnitine (P = 0.021 and P < 0.0001, respectively) and cardiac total L-carnitine concentrations (P = 0.045). In addition, DHEAS supplementation increased both hepatic and cardiac CAT activities (P < 0.0001 and P = 0.05 respectively). CAT activity positively correlated with the total and free carnitine levels in both liver and heart (r = 0.764, r = 0.785 and r = 0.700, r = 0.519, respectively). Liver mitochondrial respiratory control ratio, ADP:O ratio and oxygen uptake were similar in both control and supplemented groups. These results demonstrate that in oophorectomized rats, dietary DHEAS supplementation increases the liver and heart L-carnitine levels and CAT activities. In conclusion, DHEAS may modulate L-carnitine level and CAT activity in estrogen deficient rats. The potential role of DHEAS in the regulation of fatty acid oxidation in postmenopausal women is worthy of investigation.

The separation of cytotoxic human peripheral blood monocytes into high and low phagocytic subsets by centrifugal elutriation.

Mononuclear cells (4 X 10(8) in a 5-ml volume) were loaded onto a Beckman JE-6B elutriator rotor spinning at 2,000 +/- 10 rpm with a flow rate of 10.0 ml/min. After lymphocytes were removed at flow rates between 10 and 11 ml/min with 500 ml of buffer, the flow rate was increased by 0.5 ml/min/fraction to collect 100-ml fractions. Highly enriched monocytes as judged by nonspecific esterase staining and morphology (70-95%) were found in each of eight fractions collected with flow rates between 11.5 to 15.0 ml/min. When stimulated with phorbol myristic acetate, these fractions mediated equivalent levels of cytotoxicity against 51Cr-labeled Chang liver cell line. Similarly, each monocyte-containing fraction was found to mediate the same level of cytotoxicity against antibody-sensitized 51Cr-labeled Chang liver cells. In contrast, cytotoxicity against the natural killer cell-sensitive K-562 cell line was found in only those fractions that contained a high percentage of lymphocytes. The fractions that were enriched in monocytes were found to differ in their ability to ingest latex. Those monocyte fractions that were collected between 11.0-12.0 ml/min consisted primarily of low numbers of latex-ingesting monocytes (less than 30%). Those monocyte fractions that were collected between 12.5 and 15.0 ml/min consisted primarily of latex-ingesting monocytes (50-70%). These data show that cytotoxic monocytes can be separated by centrifugal elutriation into at least two subsets that can be distinguished by their phagocytic activity.

Inhibitor of granulocyte-macrophage colony formation in plasma of mice rendered aplastic by allogeneic lymph node cells.

Sublethally irradiated CBA/J mice injected with lymph node cells (LNC) of C3H/He mice exhibit aplastic anemia within 3 weeks. Aplastic anemia plasma (AAP) from these mice was found to inhibit granulocyte-macrophage colony (GM-CFU) formation. This inhibitory action was not strain specific and was not generated in donor:host combination involving other strains. AAP also inhibited the formation of colonies derived from leukemic cell lines. Though this activity inhibited GM-CFU, it did not affect erythroid colony formation. Two experiments were performed to examine the mechanism of inhibition. Superoptimal concentrations of recombinant mouse granulocyte-macrophage colony-stimulating factor (GM-CSF) did not reverse AAP-induced inhibition of colony formation. Bone marrow cells preincubated with AAP for 24 h and washed were unchanged in their ability to form GM-CFU colonies. Thus, the inhibitory activity acted neither as a competitive nor a cytotoxic agent. Interferons and certain prostaglandins, known to inhibit colony formation, were not found in active concentrations in AAP. The inhibitory activity of AAP was heat stable, nondialyzable, inextractable with chloroform, precipitable with 50% ammonium sulfate, and had a molecular weight of 100,000 daltons. In contrast, control plasma from mice given only sublethal irradiation and injected with saline had significantly less inhibitory activity, which was not heat stable and was extractable with chloroform. Thus, LNC in certain host mouse strains generate a plasma activity that can inhibit the formation of normal and leukemic GM-CFU colonies.

Immunologically mediated aplastic anemia in mice: effects of varying the source and composition of donor cells.

Experimental aplastic anemia (EAA) can be induced in CBA/J mice when they are sublethally irradiated and injected with lymph node cells (LNC) from C3H/He mice. Mice injected with LNC die of severe pancytopenia and marrow aplasia. In the present study, cells from other anatomical locations and subsets of LNC were examined for their ability to induce and to modulate EAA. Of peritoneal, splenic, and thymic cells, only cells from the thymus had EAA activity. C3H/He bone marrow cells did not induce any adverse effects in sublethally or lethally irradiated CBA/J mice. LNC, when depleted of B or phagocytic cells, retained EAA activity. In contrast, LNC depleted of T cells had significantly less EAA activity. Furthermore, when T cells of LNC were separated into peanut agglutinin (PNA)-receptor-positive and negative fractions, only the PNA- cells were able to induce EAA. EAA activity was lost when LNC were irradiated (1000 rad). The inability of splenic or bone marrow cells to induce EAA could have been due to the presence of cells that suppressed EAA activity. When splenic or bone marrow cells were coinjected with LNC, EAA was not induced. Coinjected irradiated splenic cells, but not bone marrow cells, were still able to inhibit EAA activity. Bone marrow cells seemed to inhibit EAA by replacing stem cells that were lost during the EAA process. On the other hand, splenic cells appeared to suppress EAA activity of LNC. Thus, radiosensitive PNA- T cells of lymph nodes or thymus were capable of inducing EAA, and their activity could be modulated by radioresistant splenic cells.

Immunologically mediated aplastic anemia in mice: evidence of hematopoietic stromal injury and injury to hematopoietic stem cells.

Immunologically mediated aplastic anemia (AA) results when lymph node cells (LNC) from C3H/He mice are injected intravenously (i.v.) into H-2 identical CBA/J mice previously given 600 cGy sublethal total-body gamma irradiation (TBI). Previously, we showed that T lymphocytes injure pluripotent hematopoietic stem cells and cause severe pancytopenia and death in 80 to 100% of mice within 3 to 4 weeks, with changes in the bone marrow suggesting stromal injury. The following models were used to study the stroma: (1) Transplantation of femurs from AA mice into normal syngeneic CBA/J mice. After 6 weeks, colony-forming unit-spleen (CFU-S) levels in the femur implants were measured in both AA and control mice (600 cGy TBI only). (2) Development of Dexter long-term bone marrow cultures from AA and control mice, which were used to support hematopoietic bone marrow cells (colony-forming units-granulocyte/macrophage [CFU-GM]) from normal mice. (3) Cellulose ester membranes (CEM) were coated with hematopoietic stroma from AA and control mice and then implanted intraperitoneally (i.p.) into syngeneic CBA/J mice. Six months later, the CEM were removed and analyzed for the presence of trilineal hematopoiesis and bone. Injury to the hematopoietic stroma was documented by the following: (1) Femurs from AA mice had a decreased number of CFU-S compared to controls; (2) Dexter cultures from AA mice formed abnormal stromal layers with a decreased capacity to support CFU-GM from normal donor mice; and (3) CEM coated with stromal cells from AA mice had a decreased capacity to support trilineal hematopoiesis and bone compared to CEM coated with marrow stroma from control mice.

Changes in bone resorption during the menstrual cycle.

To determine if the cyclic changes of female sex hormones during the menstrual cycle are related to changes in bone formation and resorption, we measured serum bone-specific alkaline phosphatase (BAP) and osteocalcin (OC) and bone resorption markers, serum and urine deoxypyridinoline (Dpyr), three times per week during one menstrual cycle in 20 healthy premenopausal women. Serum estradiol (E2) and progesterone (P) showed characteristic cyclic fluctuations. Serum Dpyr was higher during the follicular phase (FP) than in the luteal phase (p = 0.027). Serum BAP, OC, and urine Dpyr levels did not change substantially across the cycle. Serum Dpyr correlated negatively with serum E2 values measured 6 (p = 0.011) and 8 (p = 0.001) days earlier and with P measured concurrently (p = 0.033) 2 (p = 0.002), 4 (p = 0.003), and 6 (p = 0.014) days earlier. BAP correlated negatively with E2 measured 6 days earlier (p = 0.006). We found no statistically significant correlations of E2 or P with OC or urine Dpyr within women over their cycles. BAP was positively correlated with concurrent serum Dpyr (p = 0.015) during the menstrual cycle. Serum OC levels correlated inversely with age (rs = -0.48, p = 0.036). Women with higher mean urine Dpyr levels had higher mean serum OC levels (rs = 0.49, p = 0.033) and showed a trend toward lower hip bone mineral density (rs = -0.40, p = 0.078). We conclude that the low level of E2 and/or P observed during the FP of the normal menstrual cycle is associated with increased bone resorption. These relationships suggest that normal women experience monthly episodes of increased bone resorption from menarche to menopause.

Correlation of estradiol, parathyroid hormone, interleukin-6, and soluble interleukin-6 receptor during the normal menstrual cycle.

Rodent models suggest that estradiol deficiency promotes bone loss through increasing interleukin-6 (IL-6) activity. However, it is controversial as to whether these findings are applicable to humans. To evaluate estradiol-mediated modulation of IL-6 activity in relation to bone metabolism in humans, we measured serum IL-6, soluble interleukin-6 receptor (sIL-6R), estradiol (E2), progesterone, luteinizing hormone, follicle-stimulating hormone, intact parathyroid hormone (PTH), serum and urine Ca, and bone biochemical markers (serum bone-specific alkaline phosphatase, osteocalcin, and serum and urine deoxypyridinoline [Dpd]) across one menstrual cycle for 211 women. Neither IL-6 nor sIL-6R levels differed between the follicular phase (FP) and the luteal phases (LP). However, IL-6 was negatively correlated with E2 during the FP (p =0.003). Furthermore, IL-6 correlated positively with serum Ca over the entire cycle (p = 0.0091. Serum Ca correlated positively with serum (p = 0.040) and urine (p = 0.006) Dpd. PTH was significantly higher during the FP than in the LP (p = 0.004). PTH was negatively related to E2 (p = 0.002), serum Ca (p < 0.001), and urine Ca (p = 0.036), whereas it was positively correlated with IL-6 (p = 0.027). These data demonstrate that IL-6 and PTH fluctuate with E2, and serum II-6 is associated with PTH levels during the menstrual cycle. However, the role of 11-6 in bone remodeling during the normal menstrual cycle remains to be determined.

Heterogeneity of cytolytic and suppressor clones of alloactivated cells generated from soft agar colonies.

Long-term cell cultures (or clones) were developed from soft agar colonies of lymphocytes alloactivated in mixed leukocyte culture reaction (MLR). Two types of colonies were identified: upper colonies that grew on the agar surface, and lower colonies found within the agar layer. Virtually all cytolytic clones originated exclusively from the upper colonies. Two groups of cytolytic clones could be distinguished, one with strong and the other with weak proliferation upon restimulation. Upper clones were capable of inhibiting primary MLR proliferation and this appeared to be related to their cytolytic effect on the stimulator. Many noncytolytic lower clones were found to suppress primary MLR cultures. Considerable heterogeneity was apparent from differences in the magnitude of suppression and the ability of the clones themselves to undergo stimulator-induced proliferation. Kinetic studies of MLR suppression were conducted to further analyze this heterogeneity. Two major kinetic patterns were observed. One showed a biphasic proliferation pattern of the MLR + clone culture. The first peak appeared to reflect an enhanced proliferation of the clone. The second phase seemed to represent diminished proliferation of the MLR responder. This type of suppression may be related to T cell growth factor depletion from MLR by the proliferating clone. The other kinetic pattern showed a consistently low proliferation of the MLR + clone culture throughout the 8-day assay period. Subsequent testing of these suppressor clones in third-party MLR cultures suggested that the specificity of suppression was unrelated to HLA-DR, MB, MT, and SB.

Comparison of prophylactic ampicillin/sulbactam with gentamicin and metronidazole in elective colorectal surgery: a randomized clinical study.

A randomized control clinical study was conducted to compare the effectiveness of prophylactic ampicillin/sulbactam in preventing wound infection after elective colorectal surgery with a combination of gentamicin and metronidazole. Over a 2-year period, 143 patients were recruited, but 15 patients were subsequently excluded due to the use of additional antibiotics for the treatment of pulmonary or urinary infection or early postoperative death without wound infection. Of the 128 evaluable patients, six of the 63 patients (9.5%) in the ampicillin/sulbactam group and seven of the 65 patients (10.7%) in the gentamicin and metronidazole group developed wound infection. We conclude that prophylactic ampicillin/sulbactam is effective in reducing the risk of wound infection following colorectal surgery.

A multidisciplinary approach to salvage the 'unsalvageable' foot.

Extensive tissue loss in a weight-bearing area of the foot almost invariably heralds limb loss. We report on a 74-year-old man with diabetes mellitus who had an ischaemic foot that was affected by prolonged pressure, which resulted in a necrotic heel. After two sessions of debridement, the calcaneum became exposed. Amputation was initially suggested but was refused by the patient. The foot was subsequently salvaged by staged operations. The first operation was a femoro-anterior tibial bypass using an autogenous saphenous vein to revascularise the foot. This was followed by debridement and attachment of a free subscapular flap to cover the defect 2 weeks later by a plastic surgeon. After 85 days of rehabilitation by physiotherapy and education of foot care by a podiatrist, the patient was discharged home and was able to walk with a walking-stick. This multidisciplinary approach

Susceptibility of Oncomelania hupensis subspecies to infection with geographic strains of Schistosoma japonicum.

Subspecies of Oncomelania hupensis were exposed to infection with zoophilic and anthropophilic strains of Schistosoma japonicum. The snails were Philippine O. h. quadrasi from the islands of Bohol, Leyte and Mindanao, O. h. formosana from Changhua and Ilan, and O. h. chiui from Taiwan, O. h. hupensis from China, O. h. nosophora from Japan and O. h. lindoensis from Indonesia. Anthropophilic strains of S. japonicum were from Bohol and Leyte in the Philippines, China, Japan and Indonesia. The zoophilic strains were from Changhua and Ilan, Taiwan. All geographic strains of the parasite developed exceptionally well and produced cercariae in 32-50% of O. h. chiui and 5-43% of the natural snail hosts. Development in other subspecies of snails with geographic strains of the parasite were variable. Only a few O. h. formosana (Changhua) could be infected with the parasites from other geographic areas and only one O. h. quadrasi each from Mindanao became infected with the Bohol and Changhua strains of S. japonicum.

Right mini-parasternotomy may be a good minimally invasive alternative to full sternotomy for cardiac valve operations-a propensity-adjusted analysis.

AIM: Limited realworld data existed for miniparasternotomy approach with good sample size in Asian cohorts and most previous studies were eclipsed by case heterogeneity. The goal of this study was to compare safety and quality outcomes of cardiac noncoronary valve operations by miniparasternotomy and full sternotomy approaches on riskadjusted basis. METHODS: From our hospital database, we retrieved the cases of non-coronary valve operations from 1 January 2005 to 31 December 2012, including re-do, emergent, and combined procedures. Estimated EuroScore-II and propensity score for choosing mini-parasternotomy were adjusted for in the regression models on hospital mortality, complications (pneumonia, stroke, sepsis, etc.), and quality parameters (length of stay, ICU time, ventilator time, etc.). Non-complicated cases, defined as survival to discharge, ventilator use not over one week, and intensive care unit stay not over two weeks, were used for quality parameters. RESULTS: There were 283 miniparasternotomy and 177 full sternotomy cases. EuroScore-II differed significantly (medians 2.1 vs. 4.7, p<0.001). Propensity scores for choosing miniparasternotomy were higher with lower EuroScore-II (OR=0.91 per 1%, p<0.001), aortic regurgitation (OR=2.3, p=0.005), and aortic non-mitral valve disease (OR=3.9, p<0.001). Adjusted for propensity score and EuroScore-II, mini-parasternotomy group had less pneumonia (OR=0.32, p=0.043), less sepsis (OR=0.31, p=0.045), and shorter non-complicated length of stay (coefficient=7.2 (day), p<0.001) than full sternotomy group, whereas Kaplan-Meier survival, non-complicated ICU time, non-complicated ventilator time, and 30-day mortality did not differ significantly. CONCLUSION: The propensity-adjusted analysis demonstrated encouraging safety and quality outcomes for mini-parasternotomy valve operation in carefully selected patients.

Risk factors for nosocomial infection during extracorporeal membrane oxygenation.

An increasing number of patients receive extracorporeal membrane oxygenation (ECMO) for life support. This study aimed to investigate the incidence and risk factors for nosocomial infection in adult patients receiving ECMO. We reviewed the medical records of adult patients who received ECMO support for more than 72h at Far Eastern Memorial Hospital from 2001 to 2007. ECMO-related nosocomial infections were defined as infections occurring from 24h after ECMO initiation until 48h after ECMO discontinuation. There were 12 episodes of nosocomial infection identified in 10 of the 114 (8.77%) patients on ECMO, including four cases of pneumonia, three cases of bacteraemia, three surgical site infections and two urinary tract infections. The incidence of ECMO-related nosocomial infection was 11.92 per 1000 ECMO-days. The length of ECMO use and intensive care unit (ICU) stay were significantly different between patients with, and without, nosocomial infection (P<0.001). More than 10 days of ECMO use was associated with a significantly higher nosocomial infection rate (P=0.003). Gram-negative bacilli were responsible for 78% of the nosocomial infections. In the univariate analysis, the duration of ICU stay and duration of ECMO use were associated with nosocomial infection. In the multivariate analysis, only the duration of ECMO was independently associated with nosocomial infection (P=0.007). Overall, the only independent risk factor for ECMO-related nosocomial infection identified in this study was prolonged ECMO use.

Rupture of renal artery aneurysm due to Salmonella infection in a patient with systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) are prone to infection. Immunomodulation treatment increases the susceptibility. Salmonella infections in SLE patients may present with various clinical pictures, like pneumonia, septic arthritis, osteomyelitis, peritonitis, abscess and so on. The vascular complications commonly seen in the general population with salmonella infection are rarely encountered in SLE patients. Here we report an SLE patient who presented with spontaneous rupture of salmonella mycotic aneurysm involving the left renal artery. The 54 year-old woman had a stable premorbid condition and had 30 mg prednisolone per day. Acute abdomen and hypotensive shock developed suddenly without warning signs in advance. Image and tissue culture confirmed the diagnosis. The patient had an uneventful recovery. The rare clinical scenario is reported.