Heterogeneity of sensitization profiles and clinical phenotypes among patients with seasonal allergic rhinitis in Southern European countries-The @IT.2020 multicenter study.

BACKGROUND: Pollen allergy poses a significant health and economic burden in Europe. Disease patterns are relatively homogeneous within Central and Northern European countries. However, no study broadly assessed the features of seasonal allergic rhinitis (SAR) across different Southern European countries with a standardized approach. OBJECTIVE: To describe sensitization profiles and clinical phenotypes of pollen allergic patients in nine Southern European cities with a uniform methodological approach. METHODS: Within the @IT.2020 multicenter observational study, pediatric and adult patients suffering from SAR were recruited in nine urban study centers located in seven countries. Clinical questionnaires, skin prick tests (SPT) and specific IgE (sIgE) tests with a customized multiplex assay (Euroimmun Labordiagnostika, Lübeck, Germany) were performed. RESULTS: Three hundred forty-eight children (mean age 13.1 years, SD: 2.4 years) and 467 adults (mean age 35.7 years SD: 10.0 years) with a predominantly moderate to severe, persistent phenotype of SAR were recruited. Grass pollen major allergenic molecules (Phl p 1 and/or Phl p 5) ranged among the top three sensitizers in all study centers. Sensitization profiles were very heterogeneous, considering that patients in Rome were highly poly-sensitized (sIgE to 3.8 major allergenic molecules per patient), while mono-sensitization was prominent and heterogeneous in other cities, such as Marseille (sIgE to Cup a 1: n = 55/80, 68.8%) and Messina (sIgE to Par j 2: n = 47/82, 57.3%). Co-sensitization to perennial allergens, as well as allergic comorbidities also broadly varied between study centers. CONCLUSIONS: In Southern European countries, pollen allergy is heterogeneous in terms of sensitization profiles and clinical manifestations. Despite the complexity, a unique molecular, multiplex, and customized in-vitro IgE test detected relevant sensitization in all study centers. Nevertheless, this geographical diversity in pollen allergic patients imposes localized clinical guidelines and study protocols for clinical trials of SAR in this climatically complex region.

Prevalence and significance of MEFV gene mutations in patients with sarcoidosis.

OBJECTIVES: Sarcoidosis is a chronic granulomatous disease. Pyrin has anti-inflammatory activity in the regulation of inflammasomes and is encoded by the Mediterranean fever (MEFV) gene. MEFV gene mutations trigger the inflammatory cascade and cause familial Mediterranean fever (FMF). A relationship between various rheumatic diseases and MEFV gene mutations has been demonstrated. The aim of this study was to determine the prevalence of the MEFV gene mutation in Turkish patients with sarcoidosis and to detect any possible correlation with disease phenotype. METHOD: The study included 78 sarcoidosis patients and 85 healthy subjects matched for age, gender, and ethnicity. MEFV gene mutations were investigated with the FMF strip assay, which is based on reverse hybridization of biotinylated polymerase chain reaction (PCR) products. RESULTS: Of the 78 patients with sarcoidosis, nine (11.5%) were found to be carriers of MEFV gene mutations. The distribution of these nine mutations were: three (3.8%) V726A, two (2.5%) E148Q, two (2.5%) M680I, one (1.3%) A744S, and one (1.3%) K695R. Carriers of M694V, M694I, R761H, and P369S were not detected in any of the sarcoidosis patients. None of the sarcoidosis patients were found to be compound heterozygous carriers. The prevalence of the MEFV gene mutation carrier detected in the healthy control group was 22.4%. The distribution of the 19 MEFV gene mutations found in the healthy controls was: nine (10.6%) E148Q, two (2.3%) M694V, one (1.2%) M694I, one (1.2%) M680I, two (2.3%) V726A, one (1.2%) A744S, two (2.3%) K695R, and one (1.2%) P369S. When compared with the control group, a lower prevalence of the MEFV gene mutation carrier was found in sarcoidosis patients but this was not statistically significant (p = 0.067). In nine patients found to be MEFV gene mutation carriers, higher serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels and higher numbers patients with arthritis, enthesitis, and ankle arthritis were found (p = 0.01, p = 0.04, p = 0.028, p = 0.05, p = 0.05, respectively). CONCLUSIONS: When we compared Turkish sarcoidosis patients with the healthy control group, we found a lower prevalence of MEFV gene mutations. In sarcoidosis patients, the MEFV gene mutation carrier was found to be related to high acute-phase responses, arthritis, and enthesitis. The existence of MEFV gene mutations may have a preventive role with regard to the development of sarcoidosis. Prospective studies that include larger patient populations are needed.

Drug allergy in tertiary care in Turkey: results of a national survey. The ADAPT study: adult drug allergy perception in Turkey.

BACKGROUND: No data are available on the incidence of drug hypersensitivity (DH) reactions in outpatient settings of tertiary allergy/immunology clinics. Our aims were to document the frequency of outpatient hospital admissions due to DH reactions to allergy/immunology clinics in adults and the management of these reactions in real life. We also investigated whether drug allergy affected social and medical behaviours of the patients. METHODS: This multi-centre study was performed for one year with the participation of 11 out of 16 tertiary allergy/clinical immunology clinics in Turkey. The study group consisted of the patients with DH reactions. Results of a questionnaire including drug reactions and management were recorded. RESULTS: Among 54,863 patients, 1000 patients with DH were enrolled with a median of 2.1% of all admissions. In real life conditions, the majority of approaches were performed for finding safe alternatives (65.5%; 1102 out of 1683) with 11.7% positivity. Diagnostic procedures were positive in 27% (154/581) of the patients. The majority of the patients had higher VAS scores for anxiety. A total of 250 subjects (25%) reported that they delayed some medical procedures because of DH. CONCLUSION: Our results documented the frequency of admissions due to DH reactions to allergy/clinical immunology clinics for the first time. Although physicians mostly preferred to perform drug tests in order to find safe alternatives, considering the fact that DH was confirmed in 27% of the patients, use of diagnostic tests should be encouraged, if no contraindication exists in order to avoid mislabelling patients as DH.

Accuracy improvement in Cranio-Maxillofacial soft tissue simulation using a muscle embedded meshing approach.

In the presented paper, we propose to improve the state-of-the-art approach for Cranio-Maxillofacial (CMF) soft tissue simulation by considering a new image-based meshing approach that accurately models the interface between different tissue types. The proposed approach has been initially evaluated on soft tissue deformations of four patients undergoing CMF surgery using post-operative CT scans. The results indicate improved prediction and robustness of the surgical planning outcome when compared to the state-of-the-art method while decreasing the simulation time.

Spontaneous brachial pseudo-aneurysm in a 12-year-old with kyphoscoliosis-type Ehlers-Danlos Syndrome.

The Ehlers-Danlos Syndrome (EDS) is a rare connective tissue disorder characterised by fragility of the soft connective tissues and widespread manifestations in skin, ligaments, joints, blood vessels and internal organs. We report a case of a 12-year-old boy, previously diagnosed with kyphoscoliosis-type EDS (type VI), presenting with a left brachial artery pseudo-aneursym with history of multiple spontaneous and post-traumatic arterial ruptures. Surgical management of this patient was performed successfully by primary repair of brachial artery lesion.

Haptic Simulator for Prostate Brachytherapy with Simulated Needle and Probe Interaction.

This paper presents a haptic simulator for prostate brachytherapy. Both needle insertion and the manipulation of the transrectal ultrasound (TRUS) probe are controlled via haptic devices. Tissue interaction forces that are computed by a deformable tissue model based on the finite element method (FEM) are rendered to the user by these devices. The needle insertion simulation employs 3D models of needle flexibility and asymmetric tip bevel. The needle-tissue simulation allows a trainee to practice needle insertion and targeting. The TRUS-tissue interaction simulation allows a trainee to practice the 3D intraoperative TRUS placement for registration with the preoperative volume study and to practice TRUS axial translation and rotation for imaging needles during insertions. Approaches to computational acceleration for realtime haptic performance are presented. Trade-offs between accuracy and speed are discussed. A graphics-card implementation of the numerically intensive mesh-adaptation operation is also presented. The simulator can be used for training, rehearsal, and treatment planning.

Pseudoaneurysm of the supracoeliac aorta following blunt trauma in a 83-year-old woman.

We report on the case of an 83-year-old hemiplegic female patient presenting with post-traumatic pseudoaneurysm of the supracoeliac aorta, treated with 38 mm x 100 mm Talent Endoluminal Stent-Graft (Medtronic Inc., Santa Rosa, CA) using local anaesthesia. The patient was discharged on day 3 and the 8 month follow-up was without complications.

Staged hybrid approach to chronic type B aortic dissection involving the distal arch associated with aortic root aneurysm.

Open surgical repair of complex aortic pathologies using cardiopulmonary bypass and deep hypothermic circulatory arrest still carries a substantial rate of mortality and morbidity. Endovascular stent-graft placement has developed as a safe and effective treatment modality for various diseases of the aorta. We report on the case of a 65-year-old female presenting with symptomatic type B aortic dissection with aneurysm of the ascending aorta and the aortic root. The patient was treated with a flanged composite graft custom made from a branched 24-mm Dacron graft for entire prosthetic transposition of the supra-aortic branches. Metachronously, the patient underwent endovascular stent-grafting of the descending aorta. She was discharged free of complications on day 10.

Coronary artery bypass grafting in a 12-year-old girl with familial hypercholesterolemia.

We present the case of a 12-year-old girl with familial hypercholesterolemia and coronary artery disease. She underwent triple-vessel coronary artery bypass grafting with bilateral pedicled internal mammary artery grafting without adverse events. Pediatric patients with familial hypercholesterolemia may present with premature coronary atherosclerosis requiring coronary artery bypass grafting. In situ internal mammary artery grafts should be the graft of choice.

Bronchogenic cyst invading right atrium in a 5-year-old.

Primary bronchogenic cysts of cardiac origin or extension are rare. We report here on a 5-year-old girl with a bronchogenic cyst with a diameter of 5.0 x 4.5 x 4.5 cm extending to the right atrial wall. Tumor enucleation and resection of the cyst together with the invaded right atrial wall was performed through a right posterolateral thoracotomy and an opening in the lateral pericardium. Resection of intrapericardial bronchogenic cysts is possible, although extensive invasion of cardiac structures may necessitate the use of cardiopulmonary bypass through a sternotomy.

Prosthetic aortic valve endocarditis due to Stenotrophomonas maltophilia complicated by subannular abscess.

Annular abscesses are serious complications of infectious native and prosthetic valve endocarditis. In this patient, we isolated Stenotrophomonas maltophilia, a rare cause of subaortic abscess with high mortality/morbidity rates although virulent gram-positive cocci, S. Aureus in particular, have been the most commonly isolated agents. We treated this case of endocarditis and the subannular abscess observed 1 year after the initial operation by aortic root replacement with resternotomy in addition to appropriate antibiotics.

Thoracic endoscopic surgery for hyperhidrosis: comparison of different techniques.

BACKGROUND: Hyperhidrosis is pathological perspiration in palmar, plantar or axillary surfaces. Video-assisted thoracic surgery (VATS) is currently the most commonly used therapy for hyperhidrosis. Blockage of sympathetic ganglia is achieved by segmental resection, transection and/or cauterization, and clipping of the chain. We aimed to compare the efficacy of these methods with respect to patient satisfaction, recurrence of symptoms and complications. METHODS: Eighty male patients with a mean age of 22.02 +/- 2.61 years undergoing bilateral thoracoscopic sympathectomy or sympathetic blockage to treat primary hyperhidrosis were included in this randomized study. The patients were divided into four groups depending on the technique used for sympathetic blockage; techniques included resection (n = 20), transection (n = 20), ablation (n = 20), and clipping (n = 20). RESULTS: The primary success rate for isolated palmar hyperhidrosis was 96.3 %; for palmar and axillary hydrosis it was 95.7 % and for palmar and face/scalp hyperhidrosis it was 66.7 %. No recurrence was observed. The overall success rate of the operation was 95 % and the differences between the four groups were not statistically significant. In the clipping group, the duration of the surgical procedure was significantly shorter than in the other groups. Complication rates were similar among the groups. The postoperative chest roentgenogram revealed pneumothorax in nine patients, but none of them required intervention. CONCLUSION: Thoracic endoscopic sympathetic blockage yields similar results irrespective of the surgical technique adopted.

Recurrent apical cardiac hydatid cyst presenting with angina.

Hydatid disease is a parasitic infection caused by the larvae of tapeworm Echinococcus Granulosus. Hydatid cyst of the heart is an uncommon presentation of human echinococcosis which may lead to life-threatening conditions. We present a rare case of recurrent pericardial cyst in a 42-year-old man presenting with chest pain and ECG findings. We were able to avoid risks of resternotomy with a limited anterolateral thoracotomy. A direct enucleation of the cyst was possible without the need for cardiopulmonary bypass. He was free of complications at 6-month follow-up. Diagnosis should be suspected in every case of anginal symptoms or cyst-like mass in persons coming from areas where echinococcus granulosus is endemic.

Use of a bifurcated ePTFE graft for off-pump extracardiac Fontan completion.

A 6-year-old girl underwent off-pump extracardiac Fontan completion. Intrapericardial inferior caval vein was found to be accompanied by the hepatic vein on the left side; a 20 x 10 x 10-mm bifurcated ePTFE graft was used without external shunting. This approach is practical for the surgeons and may result in lower perioperative Fontan pressures/transpulmonary gradients as well as a shorter intubation period and hospital stay.

Aortic arch replacement without circulatory arrest: a simplified technique with two grafts.

Aortic arch reconstruction remains a challenge for the cardiothoracic surgeon. We present our simplified technique in which we used two grafts for arch reconstruction without circulatory arrest. It is a relatively easy and quick technique consisting of a unique modification of the selective antegrade cerebral circulation system without the need for circulatory arrest in selected cases.

Abdominal aortic aneurysm surgery: retroperitoneal or transperitoneal approach?

AIM: Mortality and morbidity of abdominal aortic aneurysm surgery have decreased significantly in time and transperitoneal approach (TPA) still preserves its popularity although retroperitoneal approach (RPA) is known to cause lower incidence and shortened duration of ileus, shorter intensive care unit (ICU) and hospital stay, earlier oral intake and less patient discomfort or pain. METHODS: One hundred and fifty patients that underwent abdominal aortic aneurysm repair at our Cardiovascular Surgery Center between January, 1990 and March, 2000 were reviewed and analyzed based on the elective/emergent nature of the surgery and the type of the incision as either TPA or RPA. RESULTS: Significantly shorter mechanical ventilation (15.2+/-3.8 vs 10.1+/-2.3 hours) and nasogastric decompression periods (40.6+/-10.7 vs 9.1+/-2.2 hours), less need for intravenous fluid supplementation and shorter ICU stay (29.5+/-14.8 vs 18.6+/-1.9 hours) were observed with the retroperitoneal approach (P<0.001). Need for allogeneic blood transfusion was, similar (1.3+/-1.4 vs0.9+/-0.4, P>0.05). Analysis of mortality and morbidity revealed bleeding as the major cause of mortality for ruptured aneurysm. A similar comparison between TPA and RPA groups, however, revealed no significant difference (P>0.05). CONCLUSIONS: | Retroperitoneal approach is a reliable technique causing less fluid-electrolyte imbalance with rapid restoration of gastrointestinal physiology. It causes less discomfort to patients with reduced need for analgesia. A shorter weaning period from mechanical ventilation is among the benefits for patients with co-morbid states.

Chronic constrictive tuberculous pericarditis: risk factors and outcome of pericardiectomy.

OBJECTIVE: Data on long-term outcome of pericardiectomy are limited. This retrospective study aimed to investigate risk factors and early and late outcomes of pericardiectomy for constrictive tuberculous pericarditis. DESIGN: Seventy patients with chronic constrictive pericarditis who underwent pericardiectomy between January 1990 and August 2005 were reviewed for perioperative and long-term survival. RESULTS: Patients (49 males; median age 40 years) had a median duration of symptoms of 24 months (range 8-72) before surgery. Perioperative mortality was 8.6%. During follow-up (mean 66.4 +/- 56.4), late mortality rates at 5 and 10 years were 1.6% and 9.7%, respectively. The mean censored survival in all patients was 155.2 months (SEM 8.3, 95%CI 138.8-171.6). Readmission-free survival was 68.6% over 10 years (mean 125.4 months, SEM 10.3, 95%CI 105.2-145.6). Ascites and duration of symptoms were found to be predictors of perioperative mortality (P = 0.047 and 0.036, respectively). CONCLUSIONS: The optimal time of pericardiectomy is most important in its management. Total or near-total pericardiectomy should always be performed as early as possible.

Determinants of hospital mortality after repeat mitral valve surgery for rheumatic mitral valve disease.

OBJECTIVE: The aim of this study is to detect the risk factors for hospital mortality in patients who underwent reoperative mitral valve replacement. METHODS: Rheumatic mitral valve patients who underwent primary mitral valve replacement (386 cases) and repeat mitral valve replacement (94 cases) were analysed retrospectively. The incremental effects of the reoperative procedure on hospital mortality were studied by comparing primary and reoperative procedures and analyzing a series of possible predisposing factors. RESULTS: Operative mortality for repeat procedures was found significantly higher than the first operations (respectively 12.8% versus 4.3%, p=0.022). Risc factors affecting the hospital mortality in reoperation group were determined as advanced age, diameter of left atrium, prolonged bypass time and development of postoperative low output state. The indication for surgery also had a significant role in patients' outcome. Mortality found significantly higher in cases operated due to endocarditis or mitral mechanical valve thrombosis compared to other reoperation groups. CONCLUSION: Patients over age of 70 years, with a left atrial diameter over 60 mm, reoperated due to endocarditis and mechanical valve thrombosis, should be reevaluated for risk assessment while giving the decision of optimal operation timing. Especially patients with left ventricular hypertrophy and decreased myocardial reservoirs, efficient myocardial protection during the operation had an important role.