Conversion to a sirolimus-based regimen is associated with lower incidence of BK viremia in low-risk kidney transplant recipients.

BACKGROUND: BK viral nephropathy is an increasingly recognized cause of early allograft loss in kidney transplantation. This study aimed to determine whether a sirolimus (Sir)-based calcineurin inhibitor-sparing regimen is associated with a lower incidence of BK viremia. METHODS: This was a single-center retrospective study. Patients were either on tacrolimus (Tac)-based or on Sir-based immunosuppression. Conversion from Tac to Sir occurred at or after 3 months if patients were <62 years of age, had calculated panel reactive antibodies of <20%, and did not have acute early rejection. RESULTS: Incidence of clinically significant BK viremia was 17.9% in the Tac group and 4.3% in the Sir group. Cox regression multivariate analysis showed that male gender (hazard ratio [HR] = 2.87) and switch to Sir (HR = 0.333) impacted the incidence of BK viremia. Kaplan-Meier analysis showed a higher BK-free survival in the Sir group. A trend was seen toward shorter time to resolution of BK viremia and lower peak viremia in the Sir group. Patients on Sir had a higher estimated glomerular filtration rate at each time point; 34% of patients discontinued Sir because of side effects. CONCLUSION: Conversion to Sir-based maintenance immunosuppression at or about 3 months after kidney transplantation correlates with a lower incidence of BK viremia.

Temporary inactive status on renal transplant waiting list: causes, risk factors, and outcomes.

Approximately 30% of all patients listed for a kidney transplant in the United States are on inactive status. The consequences of temporary inactivation and rates of transplantation in this group of patients have not been reported. We undertook a retrospective cohort study at our transplant center examining all patients listed between 2001 and 2007. We examined the rate of inactivation, risk factors, duration, and outcomes including transplantation rates and patient survival while on the waiting list and after transplantation. There were 436 patients included in the analysis; 322 (73.9%) were never inactivated and 114 patients (26.1%) were temporarily inactive. The most common causes for inactivation were cardiovascular and suspected malignancy. Time to reactivation was similar among different causes. Waiting times for transplantation (excluding time of inactivation) was 18.7 ± 0.9 versus 39.9 ± 2.3 months for active compared with temporarily inactive patients (log-rank P < .0001). Sixty-five percent of patients were reactivated within 24 months. Approximately one-third of patients were never reactivated. Patient survival was similar among both groups. Temporary inactivation is an independent risk factor for a prolonged waiting time even if time of inactivation is not accounted for. Effective strategies for monitoring patients temporarily inactive on the waiting list should be developed.

A randomized, double-blind, and placebo-controlled study with tranexamic acid of bleeding and fibrinolytic activity after primary coronary artery bypass grafting.

Cardiopulmonary bypass is frequently associated with excessive blood loss. Platelet dysfunction is the main cause of non-surgical bleeding after open-heart surgery. We randomized 65 patients in a double-blind fashion to receive tranexamic acid or placebo in order to determine whether antifibrinolytic therapy reduces chest tube drainage. The tranexamic acid group received an intravenous loading dose of 10 mg/kg, before the skin incision, followed by a continuous infusion of 1 mg kg(-1) h(-1) for 5 h. The placebo group received a bolus of normal saline solution and continuous infusion of normal saline for 5 h. Postoperative bleeding and fibrinolytic activity were assessed. Hematologic data, convulsive seizures, allogeneic transfusion, occurrence of myocardial infarction, mortality, allergic reactions, postoperative renal insufficiency, and reopening rate were also evaluated. The placebo group had a greater postoperative blood loss (median (25th to 75th percentile) 12 h after surgery (540 (350-750) vs 300 (250-455) mL, P = 0.001). The placebo group also had greater blood loss 24 h after surgery (800 (520-1050) vs 500 (415-725) mL, P = 0.008). There was a significant increase in plasma D-dimer levels after coronary artery bypass grafting only in patients of the placebo group, whereas no significant changes were observed in the group treated with tranexamic acid. The D-dimer levels were 1057 (1025-1100) microg/L in the placebo group and 520 (435-837) microg/L in the tranexamic acid group (P = 0.01). We conclude that tranexamic acid effectively reduces postoperative bleeding and fibrinolysis in patients undergoing first-time coronary artery bypass grafting compared to placebo.

A randomized, double-blind, and placebo-controlled study with tranexamic acid of bleeding and fibrinolytic activity after primary coronary artery bypass grafting

Cardiopulmonary bypass is frequently associated with excessive blood loss. Platelet dysfunction is the main cause of non-surgical bleeding after open-heart surgery. We randomized 65 patients in a double-blind fashion to receive tranexamic acid or placebo in order to determine whether antifibrinolytic therapy reduces chest tube drainage. The tranexamic acid group received an intravenous loading dose of 10 mg/kg, before the skin incision, followed by a continuous infusion of 1 mg kg-1 h-1 for 5 h. The placebo group received a bolus of normal saline solution and continuous infusion of normal saline for 5 h. Postoperative bleeding and fibrinolytic activity were assessed. Hematologic data, convulsive seizures, allogeneic transfusion, occurrence of myocardial infarction, mortality, allergic reactions, postoperative renal insufficiency, and reopening rate were also evaluated. The placebo group had a greater postoperative blood loss (median (25th to 75th percentile) 12 h after surgery (540 (350-750) vs 300 (250-455) mL, P = 0.001). The placebo group also had greater blood loss 24 h after surgery (800 (520-1050) vs 500 (415-725) mL, P = 0.008). There was a significant increase in plasma D-dimer levels after coronary artery bypass grafting only in patients of the placebo group, whereas no significant changes were observed in the group treated with tranexamic acid. The D-dimer levels were 1057 (1025-1100) æg/L in the placebo group and 520 (435-837) æg/L in the tranexamic acid group (P = 0.01). We conclude that tranexamic acid effectively reduces postoperative bleeding and fibrinolysis in patients undergoing first-time coronary artery bypass grafting compared to placebo.

[Nemaline congenital myopathy:clinical features and histopathological findings in nine patients]. / Miopatía congénita nemalínica: manifestaciones clínicas y hallazgos histopatológicos en nueve pacientes.

INTRODUCTION: Nemaline myopathy is a type of congenital myopathy which presents with hypotonia, muscle weakness which is predominantly proximal, lax ligaments, areflexia and skeletal deformities. It is characterized by the presence of intrasarcolemal or intranuclear rods which can be seen with the red color optical microscope using the Gomori technique, and a defect in the Z line of the sarcomere, detected on electron microscopy (EM). PATIENTS AND METHODS: A retrospective study of the cases of nemaline congenital myopathy diagnosed in our hospital between 1984 and 1997. All patients had clinical laboratory analysis (muscle enzymes), and electromyographic and histopathological (muscle biopsy) studies. In 5 cases EM was done. RESULTS: Nine patients, four males and five females were studied. Diagnosis was made during the first year of life in 7 cases (77.7%), and was characterized by hypotonia, severe areflexia and proximal muscle weakness, whilst the remainder were diagnosed in adolescence when they presented with a juvenile form of the disorder, with muscle weakness, amyotrophy and scoliosis. Muscle biopsy showed nemaline bodies in a variable proportion of fibres. Intranuclear rods were not identified in any case. In the 5 cases in which ultrastructural studies were done, alterations were detected in the Z line of the sarcomere. The immunohistochemical profile of the rods was positive for alphaactin. CONCLUSIONS: There are no clinical features which permit distinction from other forms of congenital myopathy, so muscle biopsy is necessary for diagnosis. There is great phenotype and prognostic variety in this disorder.

Valve repair in children with congenital mitral lesions: late clinical results.

Mitral valve repair may be performed without ring support with advantages related to results and complications. The objective of this study was to analyze the long-term clinical results following surgical repair and reconstruction without the use of rings in cases of congenital mitral lesions in children less than 12 years of age. Twenty-one patients who had undergone surgery during the period from 1975 to 1998 were evaluated. The mean age was 4.6 +/- 3.4 years. Females represented 47.6% of the total. Mitral regurgitation was present in 57.1% (12 patients), stenosis in 28.6% (6 patients), and the mixed lesion group represented 14.3% (3 patients). Perfusion time was 43.1 +/- 9.5 minutes and ischemic time 29.4 +/- 10.5 minutes. Follow-up time was 41.5 +/- 53.6 months for the regurgitation group, 46.3 +/- 32.0 months for the stenosis group, and 39.41 +/- 37.51 months for the mixed lesion group. Echocardiographical follow-up time was 37.17 +/- 39.51 months for the regurgitation group, 42.61 +/- 30.59 months for the stenosis group, and 39.41 +/- 37.51 months for the mixed lesion group. Operative mortality was 9.5% (two cases). There were no late deaths. In the regurgitation group, 10 patients (83.3%) were asymptomatic (p = 0.004). In the echocardiographical follow-up, most of the patients had minimal regurgitation. In the clinical follow-up of the stenosis group all patients were in functional class I (NYHA). The mean transvalvular gradient measured by echocardiography was from 8 to 12 mmHg with a mean gradient of 10.7 mmHg. In the mixed lesion group there was one reoperation at postoperative month 43. There were no cases of endocarditis or thromboembolism. Mitral valve repair in congenital lesions is associated with good late results. The majority of cases in the regurgitation group remain asymptomatic and do not require reoperation. Rings or annular support are not necessary in such cases. Satisfactory repair is more difficult to achieve in cases of mitral stenosis due to valvular abnormalities and the seriousness of the associated lesions.

Avaliaçäo da reduçäo de gradientes pressóricos e da hipertrofia ventricular após valvoplastia cirúrgica na estenose aórtica / Left ventricular hypertrophy regression immediately after aortic valve repair

INTRODUÇÇO: A correçäo cirúrgica da estenose aórtica resulta em reduçäo significativa do gradiente pressórico transvalvar, sendo acompanhada por regressäo da hipertrofia ventricular esquerda(HVE). A intensidade e a rapidez dessa regressäo tem sido objeto de avaliaçöes. A associaçäo de valvoplastia aórtica e regressäo imediata da HVE é relatada em poucos estudos. MÉTODOS: Foram estudados, prospectivamente, 11 pacientes submetidos à valvoplastia em estenose aórtica, utilizando-se ecocardiografia imediatamente antes da cirurgia e no período pós-operatório precoce (6,1 + ou - 0,9 dias). RESULTADOS: A espessura septal variou de 12,10 + ou - 1,66mm para 11,36 + ou - 1,12mm (reduçäo de 6,1 por cento) (NS) enquanto a espessura parietal variou 4,4 por cento (de 11,70 + ou - 1,41 mm para 11,18 + ou - 1,16mm) (NS). A fraçäo de ejeçöo apresentou uma variaçäo de 62,02 + ou - 18,59 por cento para 62,50 + ou - 11,74 por cento (NS). A massa ventricular esquerda variou em 6,7 por cento ( de 277,65 + ou - 114,80 g passou para 258,93 + ou - 92,38 g) (NS). O gradiente transvalvular médio regrediu de 53,6 + ou -10,3 mmHg para 23,0 + ou - 9,1mmHg, ou seja, 57 por cento (p<0.001). CONCLUSÕES: A valvoplastia alivia o gradiente pressórico aórtico satisfatoriamente e a regressäo da HVE tende a se iniciar logo após, porém ainda näo é significativa no período pós-operatório imediato

Update in internal medicine.

More than 500,000 new medical articles are published every year and available time to keep updated is scarcer every day. Nowadays, the task of selecting useful, consistent, and relevant information for clinicians is a priority in many major medical journals. This review has the aim of gathering the results of the most important findings in clinical medicine in the last few years. It is focused on results from randomized clinical trials and well-designed observational research. Findings were included preferentially if they showed solid results, and we avoided as much as possible including only preliminary data, or results that included only non-clinical outcomes. Some of the most relevant findings reported here include the significant benefit of statins in patients with coronary artery disease even with mean cholesterol level. It also provides a substantial review of the most significant trials assessing the effectiveness of IIb/IIIa receptor blockers. In gastroenterology many advances have been made in the H. pylori eradication, and the finding that the cure of H. pylori infection may be followed by gastroesophageal reflux disease. Some new antivirals have shown encouraging results in patients with chronic hepatitis. In the infectious disease arena, the late breaking trials in anti-retroviral disease are discussed, as well as the new trends regarding antibiotic resistance. This review approaches also the role of leukotriene modifiers in the treatment of asthma and discusses the benefit of using methylprednisolone in patients with adult respiratory distress syndrome, among many other advances in internal medicine.

Dedifferentiated clear cell chondrosarcoma.

Dedifferentiation, a change in the histologic character and clinical behavior of a tumor to a more immature and aggressive one, occurs in approximately 11% of all chondrosarcomas. The original lesion is usually a low-grade chondrosarcoma. Clear cell chondrosarcoma is a rare cartilaginous tumor of low-grade malignancy with a preference for the ends of long bones. It is usually curable by resection. Recurrence commonly follows inadequate surgery, and metastases to lung, brain, and bones can develop. However, dedifferentiation has not yet been described in association with clear cell chondrosarcoma. Three patients are described who were initially diagnosed as having clear cell chondrosarcoma of the femur. Two were treated with en bloc resection for a clear cell chondrosarcoma. One of these had an undifferentiated sarcoma in a local recurrence after 6 years. In the second, metastasis of the clear cell chondrosarcoma developed 5(1/2) years after surgery; autopsy revealed undifferentiated sarcoma in the lung, heart, and lumbar spine. The third patient had dedifferentiated clear cell chondrosarcoma at the time of resection following the biopsy diagnosis of clear cell chondrosarcoma. All three died with metastatic disease. These three patients represent three different manifestations of dedifferentiation-at initial diagnosis, at recurrence, and at metastasis. To our knowledge, this is the first description of dedifferentiation occurring in clear cell chondrosarcoma.

Predictive factors for persistence of atrial fibrillation after mitral valve operation.

BACKGROUND: The majority of patients operated on for mitral valve disease with chronic atrial fibrillation (AF) do not recover sinus rhythm with conventional postoperative treatment. The maze procedure may be used in these circumstances. To define the precise indications for the maze procedure, it would be necessary to identify those patients based on preoperative factors. METHODS: A retrospective study was undertaken on 100 consecutive patients operated on for mitral valve disease in chronic AF. The return to sinus rhythm was analyzed with relation to age, gender, AF duration, left atrial size, left ventricular ejection fraction, lesion type, valve procedure, associated procedures, and reoperation. RESULTS: At late follow-up (more than 1 year) 26 (26%) patients presented sinus rhythm and 74 (74%) remained in AF. Statistical single parametric analysis demonstrated that mitral stenosis was a risk factor for maintaining AF, whereas regurgitation was more associated to sinus rhythm recovery. There was no relation with the other parameters with return to sinus rhythm. It should be noted, however, that 96% of this series had AF for more than 6 months preoperatively. CONCLUSIONS: The majority of patients with mitral valve disease remain in AF and this may justify the association of maze procedure. Pure regurgitation may be a single predictor for return to sinus rhythm after mitral valve operation in chronic AF.

Malignancy in pigmented villonodular synovitis.

Malignant pigmented villonodular synovitis is an extremely rare and controversial disease. We describe malignant change in pigmented villonodular synovitis of the ankle in a patient with an unusually long clinical history. Symptoms began at age 21, metastatic disease developed at age 85, and the patient died 1 year later. The histologic appearance of the malignant tumor differed from that in most reported cases, in that spindle-shaped cells predominated. Lymph node metastasis also developed, a feature uncommon to soft tissue sarcomas.

Avaliaçäo tardia por tomografia computadorizada espiral de enxertos de pericárdio bovino liso com substitutos aórticos / Late evaluation of bovine pericardium grafts as aortic substitutes by spiral computed tomography

OBJETIVO - Avaliar, morfologicamente, por tomografia computadorizada espiral, enxertos de pericárdio bovino liso empregados como substitutos aórticos. MÉTODOS - Dez pacientes foram submentidos a exame por tomografia computadorizada espiral para reconstituiçäo da imagem dos enxertos. Os critérios de seleçäo foram tempo de seguimento superior a 2 anos, enxertos de pericárdio liso näo revestido, implantados na aorta ascendente ou descendente. RESULTADOS - Os exames demonstram bom resultado cirúrgico em todos os casos, persistindo em alguns, a imagem de dissecçäo aórtica distal à anastomose. Um caso apresentava hematoma entre o enxerto e a parede aórtica, em 5 näo foram encontradas alteraçöes estruturais no pericárdio e, nos demais, foi detectada dilataçäo de grau leve, em relaçäo ao diâmetro descrito do enxerto implantado. Näo foram vistos sinais de calcificaçäo ou pseudoaneurismas. CONCLUSÄO - Os enxertos tubulares de pericárdio bovino liso, näo revestido, apresentam resultados satisfatórios quando empregados como substitutos aórticos. A médio prazo, näo foram detectados anormalidades estruturais relacionadas ao material empregado, pela tomografia computadorizada espiral, exceto dilataçäo em alguns casos.

VATS for complete dissection of LIMA in minimally invasive coronary artery bypass grafting.

BACKGROUND: The aim of this work is to report our initial experience with minimally invasive coronary artery bypass grafting, using video-assisted thoracic surgery (VATS) to facilitate the operation and provide complete dissection of the left internal mammary artery (LIMA). METHODS: Of 44 scheduled patients, 43 patients, 30 (69.8%) male, ranging in age from 31 to 83 years (60.8 +/- 12.0 years), with a severe lesion in the anterior descending artery, were operated upon. An 8-cm left anterior minithoracotomy was performed at the fourth intercostal space. Through this incision the optical device for video-assisted thoracic surgery as well as the surgical instruments were placed to provide complete LIMA dissection. This permits dissection until the subclavian region, allowing for anastomosis without tension or distortion. Bypass circulation was not used, and the cardiac rate was decreased with the use of intravenous beta-blockers. For LIMA-to-anterior descending artery anastomosis, proximal and distal tourniquets were used and 1.5 mg/kg of heparin was administered intravenously. RESULTS: Video-assisted thoracic surgery provided a complete dissection of LIMA. The 43 patients presented satisfactory postoperative progress, being released from the hospital between 2 and 12 days after their operation, with a mean of 4 days. The patients have remained asymptomatic during a period that ranged from 1 to 13 months (6.3 +/- 3.5 months). During the follow-up, there was one death as a result of stroke and pneumonia 2 months after the release from the hospital. CONCLUSIONS: The use of video-assisted thoracic surgery through thoracotomy allows the LIMA dissection without the necessity of other incisions. The procedure also permitted more ample dissection of LIMA when compared with minithoracotomy without video-assisted thoracic surgery.

[Minimally invasive myocardial bypass surgery using video-assisted thoracoscopy]. / Cirurgia de revascularização do miocárdio minimamente invasiva com utilização da videotoracoscopia.

PURPOSE: In order to associate the major benefits of the coronary artery bypass graft (CABG) with a less aggressive procedure minimally invasive coronary artery bypass graft (MICABG) has been utilized. The aim of the work is to report our initial experience with this technical approach, using video assisted thoracic surgery (VATS) to facilitate the operation. METHODS: Twenty-six patients, 19 males with ages from 44 to 83 years old, and having isolated lesion of the anterior descending artery were operated upon. Left anterior minithoracotomy of 8-10 cm was performed at the fourth intercostal space. Through this incision the optical device for VATS as well as the surgical instruments were placed in order to provide the complete left internal mammary artery (LIMA) dissection. Bypass circulation was not used and cardiac rate was decreased with the use of intravenous betablockers. For LIMA--anterior descending artery anastomosis, proximal and distal tourniquets were used and 1.5 mg/kg of heparin was intravenously administered. RESULTS: All patients presented satisfactory postoperative evolution, being discharged from the hospital at 72 h after surgery in the majority of the cases. There were delay in two patients healing of incisions and 25 patients have remained asymptomatic, with a mean in postoperative follow-up of four months. One patient died in the second postoperative month due to stroke. CONCLUSION: MICABG makes the surgery possible with better esthetic effect, lower cost and enables faster recovery than the conventional one. The use of VATS through the thoracotomy itself, allows the LIMA dissection without other incisions. It also permitted more ample dissection of the LIMA when compared to minithoracotomy without VATS.

[Spinal cord schwannoma: case report]. / Schwannoma intramedular. Relato de caso.

The intramedullary localization of schwannomas is rare, corresponding to 0.3% of all intraspinal tumors. The authors report the case of a 52-year-old white female patient that presented with symptoms of spinal compression by the presence of an intramedullary schwannoma at the level C4-C6. There were no symptoms of neurofibromatosis, entity frequently related to the lesion. The magnetic resonance imaging examination and the per-operatory biopsy were decisive factors in planning and executing the treatment, by establishing the characteristics, location and diagnosis of the lesion. Its delimitation and posterior location have facilitated total surgical exeresis. The transoperatively histopathologic examination allowed adequate surgical procedure. The Schwann cell is not found normally in the central nervous system and its presence in this site has been subject of many theories exposed in this paper, which proposes comprehensive review of the clinical aspects, imaging diagnosis, pathology, differential diagnosis and treatment of schwannomas. It is probable that, with the advances verified in the available diagnostic methods, a greater number of these lesions may be diagnosed in the future.