Prognostic Role of Admission C-Reactive Protein Level as a Predictor of In-Hospital Mortality in Type-A Acute Aortic Dissection: A Meta-Analysis.

BACKGROUND: Acute aortic dissection (AD) is a lethal vascular disease, accounting for over 90% cases of acute aortic syndrome. Despite advances in understanding associated risk factors, the long-term prognosis for AD patients is still poor. Several prognostic biomarkers have been used for AD as per the IRAD, such as older age (>70 years), onset of chest pain and hypotension, but they are not effective in all patients. Instead, C-reactive protein (CRP) is a consistent inflammatory marker. CRP levels are abnormally increased in AD. However, the prognostic value of serum CRP level in AD remains unclear. OBJECTIVE: To perform a systematic review and meta-analysis (registration no CRD42017056205) to evaluate whether CRP is a biomarker associated with in-hospital mortality in type-A AD. METHODS: PubMed, Web of Science, CNKI, SciELO, and EMBASE were searched for papers published from January 2000 to October 2017 for studies on the prognostic role of CRP at admission in type-A AD patients. Outcome data were extracted and pooled hazard ratios (HRs) were calculated. RESULTS: 18 (N = 2875 patients) studies met the inclusion criteria. Elevated CRP level was associated with a significantly increased risk of in-hospital mortality in patients with type-A AD (HR = 1.15, 95% CI: 1.06-1.25, p = 0.001). The pooled sensitivity of CRP in type-A AD patients was 77% (95% CI 69%-84%, p < 0.001), and the specificity was 72% (95% CI 66%-78%, p < 0.001). CONCLUSION: Elevated CRP level is significantly associated with increased risks of in-hospital mortality in patients with type-A AD. CRP is a convenient prognostic factor in type-A AD patients.

The influence of deep hypothermia on inflammatory status, tissue hypoxia and endocrine function of adipose tissue during cardiac surgery.

Changes in endocrine function of adipose tissue during surgery, such as excessive production of proinflammatory cytokines, can significantly alter metabolic response to surgery and worsen its outcomes and prognosis of patients. Therapeutic hypothermia has been used to prevent damage connected with perioperative ischemia and hypoperfusion. The aim of our study was to explore the influence of deep hypothermia on systemic and local inflammation, adipose tissue hypoxia and adipocytokine production. We compared serum concentrations of proinflammatory markers (CRP, IL-6, IL-8, sIL-2R, sTNFRI, PCT) and mRNA expression of selected genes involved in inflammatory reactions (IL-6, TNF-α, MCP-1, MIF) and adaptation to hypoxia and oxidative stress (HIF1-α, MT3, GLUT1, IRS1, GPX1, BCL-2) in subcutaneous and visceral adipose tissue and in isolated adipocytes of patients undergoing cardiosurgical operation with hypothermic period. Deep hypothermia significantly delayed the onset of surgery-related systemic inflammatory response. The relative gene expression of the studied genes was not altered during the hypothermic period, but was significantly changed in six out of ten studied genes (IL-6, MCP-1, TNF-α, HIF1-α, GLUT1, GPX1) at the end of surgery. Our results show that deep hypothermia suppresses the development of systemic inflammatory response, delays the onset of local adipose tissue inflammation and thus may protect against excessive expression of proinflammatory and hypoxia-related factors in patients undergoing elective cardiac surgery procedure.

Predictors of infection after pulmonary endarterectomy for chronic thrombo-embolic pulmonary hypertension.

OBJECTIVE: Pulmonary endarterectomy (PEA) is an effective and potentially curative treatment for chronic thrombo-embolic pulmonary hypertension (CTEPH). The postoperative course after PEA is accompanied by a number of complications, which contribute to the high rate of early postoperative mortality. Markers allowing the early detection of infectious complication during the postoperative period may be of major clinical importance. The aim of the prospective study was to analyse a predictive value of five inflammatory markers to recognise inflammatory complications accompanying PEA before the first clinical signs of infection. METHODS: Eighty-two patients with CTEPH, who underwent PEA using cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), were included into the study. Procalcitonin (PCT), tumour necrosis factor-α, interleukin (IL)-6, IL-8 and C-reactive protein arterial concentrations were measured before sternotomy and repeatedly up to 72h after the end of surgery. Haemodynamic parameters, infectious and non-infectious complications were recorded. RESULTS: Postoperative course was uncomplicated in 59/82 patients (group 1). Fourteen out of 82 patients (group 2) developed an infection in the first 3 days after surgery (bronchopneumonia, n = 9; bacterial sepsis, n = 5). Nine out of 82 patients (group 3) developed non-infectious complications in the same period. PCT and IL-6 were the only significant independent predictors of infection in days 1-3 after PEA. The area under receiver operating characteristic (ROC) curve calculated for PCT to predict postoperative infection was 0.83 (95% confidence interval (CI): 0.74-0.92) compared with 0.74 (95% CI: 0.68-0.81) for IL-6. With the cut-off 2.3 ng ml(-1), the test characteristics of PCT were as follows: sensitivity, 86%; specificity, 83%; negative predictive value, 92%; and positive predictive value, 84%. CONCLUSIONS: The increase in PCT and IL-6 may allow patients at increased risk of infection after PEA to be identified, allowing earlier institution of antibiotic treatment. These changes that occur before infection can be detected clinically. This finding may make the daily monitoring of PCT post-PEA useful.

Mixed medullary and follicular cell carcinoma of the thyroid in a 71-year-old man with history of malignant melanoma.

BACKGROUND: Mixed medullary-follicular carcinoma of the thyroid with a pleomorphic pattern is a rare malignant epithelial tumor characterized by clinical and immunohistochemical features of follicular and parafollicular thyroid cells. Different molecular mechanisms for mixed thyroid tumors have been suggested. CASE REPORT: We describe a 71-year-old man with a history of malignant melanoma with mixed medullary-follicular thyroid carcinoma. Cytology results of a fine needle aspiration biopsy were suspicious of a thyroid carcinoma. The patient underwent a total thyroidectomy for a solitary thyroid nodule in the right lobe. No lymph node metastases were present. Histopathology and immunohistochemistry revealed a mixed medullary and follicular cell carcinoma that showed characteristic patterns and calcitonin and thyroglobulin positivities in many of the tumor cells. The tumor was not associated with multiple endocrine neoplasia type 2. Detection of RET proto-oncogene point mutations in risk exons 10, 11, 13, 14, 15, and 16 was negative. Two polymorphisms, one in exon 11 G691S (GGT-->AGT) and another in exon 15 S904S (TCC-->TCG) were detected. CONCLUSIONS: A mixed differentiated thyroid tumor is a diagnostic challenge with fine needle aspiration. Definitive diagnosis remains the domain of histology because of the necessity of topographic information. The origins of this rare tumor entity are unclear. The possible association with the uncommon polymorphism G691S of the RET proto-oncogene is discussed.

Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic.

Colorectal cancer is predominantly a disease of elderly people, since over 70% of cases occur in those aged 65 years or older. Clinicians have to frequently decide whether major surgery is justified in elderly patients with a limited life expectancy. Our retrospective study was aimed to compare outcomes of primary surgery for colorectal cancer in the elderly patient population. The evaluated data were collected from the 1st Department of Surgery, Charles University, and from all over the Czech Republic. Patients were divided into three groups: the young-old (21-59 years), the older-old (60-69 years), and the oldest-old (>69 years) patients. In the collective data the youngest and the oldest groups differ significantly in the rate of early postoperative complications (12.3% versus 17.6%, p<0.001). The number of complications associated with the emergency procedures was twice as high compared to elective surgery in all groups (p<0.001). There was no correlation between age and length of hospital stay in the single surgery department. These data suggest that major oncology procedures may be undertaken in older patients in whom operative risk is reasonable, with acceptable rates of complications.

Transcutaneous electrogastrography in the perioperative period in patients undergoing laparoscopic cholecystectomy and laparoscopic non-adjustable gastric banding.

BACKGROUND: Transcutaneous electrogastrography (EGG) is a non-invasive method of examination that allows monitoring of gastric myoelectric activity. The goal of this prospective study was to describe changes in gastric motility in the early postoperative period in extremely obese patients, who underwent planned surgery--Laparoscopic Non-Adjustable Gastric Banding (LNGB) and to establish the specificity of observed differences for this intervention. PATIENTS AND METHODS: Myoelectric gastric activity was evaluated in the perioperative period in 20 extremely obese patients undergoing LNGB. The results of monitoring up to +24 h after the intervention were compared to a group of 15 healthy volunteers, and to a group of 20 patients undergoing laparoscopic cholecystectomy (LC). The recording was performed in both the patient and control groups 24 h before the operation and +5 h, +24 h and +48 h after the surgery, both in the fasting state and after stimulation with a liquid bolus. The data were recorded using the Microdigitrapper device and analyzed using the spectral analysis and Fourier transformation. RESULTS: The finding characteristic in the early postoperative period was a decrease in frequency of both spontaneous and stimulated gastric contractions (bradygastria) at +5 h after the intervention, that was followed by rapid return to baseline activity. In patients after LNGB, the normalization of motility was seen within 24 h, and in patients after LC within 48 h after the intervention. Tachygastria was not found in any patient who did not have complications, but on the contrary it was found in both patients with significant dyspepsia after LC. CONCLUSIONS: In the early postoperative period after LNGB, significant changes in myoelectric gastric activity were seen and were characterized by transient bradygastria. Comparison with the reference group of patients after LC shows that the intensity and duration of basal and stimulated bradygastria has a non-specific relationship with the extent of tissue trauma caused by the intraabdominal surgery. It is not specific for the gastric banding itself. The method of measuring the basal stimulated EGG potentials can be used in routine surgical practice as an auxiliary method for evaluation of the functional status of the gastrointestinal tract after intraabdominal surgery.