Aging and glycation promote erythrocyte phagocytosis by human endothelial cells: Potential impact in atherothrombosis under diabetic conditions.

BACKGROUND AND AIMS: Atherothrombotic plaques of type 2 diabetic (T2D) patients are characterized by an increased neovascularization and intraplaque hemorrhage. The clearance of erythrocytes may be carried out by vascular cells. We explored the potential of human endothelial cells to bind and phagocyte in vitro aged and/or glycated erythrocytes as well as erythrocytes obtained from diabetic patients. METHODS: Fresh, aged and glycated-aged erythrocytes from healthy volunteers and T2D patients were tested for their binding and phagocytosis capacity as well as the potential functional consequences on endothelial cells (viability, proliferation and wound healing capacity). Immunohistochemistry was also performed in human carotid atherothrombotic samples (from patients with or without T2D). RESULTS: Aging and glycation of erythrocytes induced phosphatidylserine (PS) exposure and oxidative stress leading to enhanced endothelial cell binding and engulfment. Phagocytosis by endothelial cells was more pronounced with aged and glycated erythrocytes than with fresh ones. Phagocytosis was enhanced with T2D versus healthy erythrocytes. Furthermore, endothelial wound healing potential was significantly blunted after exposure to glycated-aged versus fresh erythrocytes. Finally, we show that interactions between erythrocytes and endothelial cells and their potential phagocytosis may occur in vivo, in atherothrombotic conditions, in neovessels and in the luminal endothelial lining. CONCLUSIONS: Endothelial cells may play an important role in erythrocyte clearance in an atherothrombotic environment. Under diabetic conditions, erythrocyte glycation favors their engulfment by endothelial cells and may participate in endothelial dysfunction, thereby promoting vulnerable atherothrombotic plaques to rupture.

Airway and esophageal stenting in patients with advanced esophageal cancer and pulmonary involvement.

BACKGROUND: Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC. METHODS AND FINDINGS: The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58+/-\-8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/-10 weeks and was significantly shorter in group 1 (6+/-7.6 weeks) than in group 2 (28+/-11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases. CONCLUSION: Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience.

Serious acute chikungunya virus infection requiring intensive care during the Reunion Island outbreak in 2005-2006.

OBJECTIVE: To report the clinical and laboratory findings of adults with serious chikungunya virus acute infection hospitalized in an intensive care unit. DESIGN: Case series study from August 2005 to May 2006. SETTING: Medical intensive care unit, South Reunion Hospital. PATIENTS: We observed 33 episodes of confirmed acute chikungunya virus infection (chikungunya virus-IgM or reverse transcription-polymerase chain reaction positive in the serum) admitted to the intensive care unit. INTERVENTIONS: We collected cerebrospinal fluid, serum, and sometimes tissue samples from patients with suspected chikungunya fever in our intensive care unit. These samples underwent viral testing for evidence of acute chikungunya virus infection. MEASUREMENTS AND MAIN RESULTS: Of the 33 patients, 19 (58%) had chikungunya virus specific manifestations, 8 (24%) had associated acute infectious disease and 6 (18%) exacerbations of previous complaints. Among the chikungunya virus specific manifestations, we identified 14 cases of encephalopathy, one case each of myocarditis, hepatitis and Guillain Barré syndrome. Eighty-five percent of patients had a McCabe score = 1 (for nonfatal or no underlying disease). Mortality was 48%. CONCLUSIONS: Chikungunya virus infection may be responsible for very severe clinical presentation, including young patients with unremarkable medical histories. Chikungunya virus infection is strongly suspected to have neurologic, hepatic, and myocardial tropism leading to dramatic complications and high mortality rate.

Cryopreserved arterial allograft reconstruction for peripheral graft infection.

OBJECTIVE: This prospective, observational study evaluated the safety and efficacy of cryopreserved arterial allograft reconstruction in the management of major peripheral arterial graft infections. METHODS: From April 1996 to May 2003, data from patients with major peripheral arterial graft infection who underwent graft excision and cryopreserved arterial allograft reconstruction were prospectively collected. Arterial allografts were harvested from multiple organ donors and cryopreserved at -80 degrees C. The patients were observed for survival, limb salvage, persistence or recurrence of infection, and allograft patency. The results were calculated with the Kaplan-Meier method. RESULTS: During the 7-year study period, 17 patients (14 men, 3 women; mean age, 68 years) with major peripheral graft infection underwent graft excision and cryopreserved arterial allograft reconstruction. Eight patients (47%) had systemic sepsis, 5 (29%) had acute ischemia at the time of the allograft reconstruction, and 9 (53%) had experienced anastomotic rupture. Allograft reconstruction was performed as an emergency procedure in 7 patients (41%). There were no perioperative deaths or early amputations. Two patients had allograft ruptures in the groin during the early postoperative period. The mean follow-up period was 34 months (range, 8 to 80 months). There was no persistent or recurrent infection, and none of the patients received long-term (>3 months) antibiotic therapy. Reoperation for allograft revision, excision, or replacement was performed in 2 patients. The 18-month primary and secondary allograft patency rates were 68% and 86%; the overall limb salvage rate was 82% at 2 years. CONCLUSION: Our experience with cryopreserved arterial allograft in the management of major peripheral bypass graft infection suggests that this technique seems to be a useful option for treating one of the most dreaded vascular complications.

Carotid artery revascularization through a radiated field.

OBJECTIVE: Extracranial carotid stenosis is a complication of external head and neck irradiation. The safety and durability of carotid artery revascularization through a radiated field has been debated. We describe the immediate and long-term results in a series of 27 consecutive patients who received treatment over 12 years. METHODS: From May 1990 to May 2002, 27 consecutive patients underwent 30 primary carotid artery revascularization procedures. All patients had received previous radiation therapy within a mean interval of 10 years (range, 1-26 years), with average radiation dose of 62 Gy (range, 50-70 Gy). Moderate to severe scarring of the skin or radiation fibrosis was present in three fourths of patients. Thirteen patients (48%) had undergone radical neck dissection, and 2 patients had a permanent tracheotomy. The indications for carotid surgery included high-grade (>70%) symptomatic stenosis in 18 patients (60%) and high-grade asymptomatic stenosis in 12 patients (40%). General anesthesia with systematic shunting was used in 18 patients (60%), and regional anesthesia with selective shunting was used in 12 patients (40%). Operations included standard carotid endarterectomy (n = 20), with patch angioplasty (n = 12) or direct closure (n = 8); carotid interposition bypass grafting (n = 7); and subclavian to carotid bypass grafting (n = 3). Primary closure of the surgical wound was performed in all procedures without any special muscular or skin flaps. All patients were followed up for a mean of 40 months (range, 3-99 months). RESULTS: There was one (3.3%) perioperative death, from massive intracerebral hemorrhage; and 1 patient had a transient ischemic attack. In-hospital complications included neck hematoma in 2 patients, which required surgical drainage in 1 patient. There was neither delayed wound healing nor infection. Twelve patients died during follow-up, of causes not related to treatment. None of the surviving patients had further stroke, and all remained asymptomatic. Follow-up duplex scans showed asymptomatic recurrent stenosis greater than 60% in 3 patients, 2 of whom with stenosis greater than 80% underwent repeat operation. Risk for recurrent stenosis greater than 60% at 18 months was 16.6%. Recurrent stenosis occurred in 2 of these patients after saphenous vein bypass, and in 1 patient after endarterectomy with vein patch angioplasty. CONCLUSION: The clinical results and sustained freedom from symptoms and stroke over 40-month follow-up suggests that carotid revascularization through a radiated field is a safe and durable procedure in patients at high surgical risk, despite a marked incidence of recurrent stenosis.

Endoscopic transthoracic sympathectomy for upper limb hyperhidrosis: limited sympathectomy does not reduce postoperative compensatory sweating.

OBJECTIVE: Compensatory sweating is the most common and troublesome complication of thoracodorsal sympathectomy. Whether the magnitude of compensatory sweating is related to the extent of sympathectomy is unclear. We investigated the association between the extent of sympathectomy and the occurrence and severity of compensatory sweating after endoscopic transthoracic sympathectomy for upper limb hyperhidrosis. METHODS: From September 1992 to June 2000, data from patients undergoing thoracoscopic sympathectomy to treat primary upper limb hyperhidrosis in our department were prospectively collected. Routine follow-up with clinical examination was performed at 1, 3, and 6 months for the first postoperative year and every year thereafter. Late follow-up (February 2001) was with a standardized questionnaire by mail or telephone concerning compensatory sweating and patient satisfaction. Associations between the extent of sympathectomy and the occurrence and severity of compensatory sweating were analyzed with logistic regression and adjusted for age, gender, and relevant confounding factors. RESULTS: Two hundred sixty-eight sympathectomies were consecutively performed in 134 patients (99 female, 35 male; mean age, 27.8 +/- 6.7 years). In the 84 patients with palmar hyperhidrosis, eight underwent T1-T2 resection, four T1-T3 resection, eight T2-T3 resection, and 64 T2-T4 resection. In the 43 patients with palmar and axillary hyperhidrosis, eight underwent T1-T5 resection and 35 T2-T5 resection. The seven patients with isolated axillary hyperhidrosis underwent T3-T5 sympathectomy. No deaths occurred; one conversion for bleeding, one permanent Horner's syndrome, and six minor complications did occur. The initial cure rate was 99.2%. The initial satisfaction rate was 97%. The mean follow-up period was 44.3 months (range, 7 to 100 months), and complete follow-up was available in 132 patients (98.5%). Ninety-five patients (71.9%) had compensatory sweating develop. Seventy patients (53%) judged their compensatory sweating to be minor and intermittent, and 25 patients (19%) judged it severe (16% embarrassing, 3% disabling). On univariate and multivariate analysis, the extent of denervation was not associated with the occurrence or the severity of compensatory sweating. The late satisfaction rate was 91.5%. Compensatory sweating and temporary relief/recurrence were equally considered to be the main causes of dissatisfaction. CONCLUSION: Compensatory sweating was the most common long-term complication of thoracodorsal sympathectomy for primary hyperhidrosis. Its incidence and severity were not associated with the extent of sympathectomy.