The olfactory function is impaired in patients with idiopathic inflammatory myopathies.

The aim of our study was to analyze olfactory function in patients with idiopathic inflammatory myopathies (IIM). We performed a case-control study on 60 IIM patients (48 females and 12 males) and 60 healthy controls (HC) recruited by the best friend method, matched for age, sex and lifestyle. Olfactory function was analyzed by "Sniffin' sticks test" and expressed through a score (TDI), indicating normosmia (TDI > 30), hyposmia (TDI 15-30) and anosmia (TDI < 15). Mood was investigated by Beck depression inventory (BDI) test. Statistic was performed using SPSS package. Mean ± SD TDI was significantly reduced in patients versus HC (26.8 ± 5.2 vs. 31.4 ± 3.5, p < 0.001). Anosmia was detected in two patients (3.3 %) and no HC, hyposmia in 41 patients and 14 HC (68.3 vs. 23.3 %, p < 0.0001) and normosmia in 17 patients and 48 HC (28.3 vs. 76.6 %, p < 0.0001). In the multivariate analysis carried out in the pool population of patients and HC, low TDI score was associated with age ≥50 years (p < 0.0001), disease status (p < 0.0001) and high BDI (p = 0.007). When adjusting for BDI, disease status was still associated with low TDI (p = 0.037). In IIM, TDI was lower in subjects aged ≥50 years (p = 0.008) and in patients who were taking corticosteroids (p < 0.0001). In the multivariate analysis carried out in IIM patients, low TDI was associated with age ≥50 years (p = 0.001) and prednisone intake (p < 0.0001). The olfactory function is impaired in IIM patients. An underlying immune-mediated mechanism is conceivable, yet a possible interference due to age, steroid intake and depression should be considered.

Evidence of impaired sense of smell in hereditary angioedema.

BACKGROUND: Hereditary angioedema (HAE) is an autosomal-dominant disorder resulting from C1-inhibitor (C1INH) deficiency. Smell impairments were found in patients affected with systemic lupus erythematosus, that, similarly to HAE, is characterized by the activation of the classical complement pathway with C4 consumption. In this study, we aimed at evaluating the sense of smell in patients with HAE. METHODS: Thirty patients with HAE and 30 healthy age- and sex-matched controls were evaluated for olfactory functions using the 3-stages Sniffin'-Sticks kit (threshold, discrimination, and identification [TDI]). TDI scores were analyzed according to complement levels (C1INH, C3, C4 and CH50), Beck depression inventory (BDI-II) and danazol treatment. RESULTS: A significant decrease in olfactory function was observed in patients affected with HAE compared with controls in total TDI score (P < 0.001), and in the discrimination (P < 0.001) and identification scores (P = 0.012). Anosmia was present only in patients with HAE (3.3%) who also exhibited more frequently hyposmia (53.3%vs 3.3%, P < 0.0001). Complement levels were reduced in patients with HAE. C4 serum levels showed positive correlation with total TDI score (P < 0.001), and with discrimination (P = 0.002) and identification (P = 0.011) scores. CH50 complement levels showed positive correlation with total TDI score (P < 0.001), and with threshold (P = 0.002) and discrimination (P = 0.011) scores. Sex, age, danazol treatment, BDI-II scores were not different between the patients and controls and did not influence TDI scores significantly. CONCLUSION: Evidence for an impaired sense of smell was found in patients with HAE. The reduction in olfactory function in these cases seems to correlate with complement C4 and CH50 levels. Immune and genetic mechanisms might play a role in this defect.

Deep TMS in a resistant major depressive disorder: a brief report.

INTRODUCTION: Repetitive transcranial magnetic stimulation (rTMS) has proven effective. Recently, a greater intracranial penetration coil has been developed. We tested the efficacy of the coil in the treatment of resistant major depression. METHODS: Our sample included seven patients suffering from major depression who were treated using Brainsway's H1-coil connected to a Magstim rapid 2 stimulator. Deep TMS treatment was given to each patient in five sessions per week over a period of 4 weeks. Patients were treated with 120% intensity of the motor threshold and a frequency of 20 HZ with a total of 1,680 pulses per session. RESULTS: Five patients completed 20 sessions: one attained remission (Hamilton Depression Rating Scale (HDRS)=9); three patients reached a reduction of more than 50% in their pre-treatment HDRS; and one patient achieved a partial response (i.e., the HDRS score dropped from 21 to 12). Average HDRS score dropped to 12.6 and average Hamilton Anxiety Rating Scale score dropped to 9.Two patients dropped out: one due to insomnia and the second due to a lack of response. DISCUSSION: Compared to the pooled response and remission rates when treating major depression with rTMS, deep TMS as used in this study is at least similarly effective. Still, a severe limitation of this study is its small sample size, which makes the comparison of the two methods in terms of their effectiveness or side effects impossible. Greater numbers of subjects should be studied to achieve this aim. CONCLUSIONS: An H1 deep TMS coil could be used as an alternative treatment for major depressive disorder.

The management of vascular injuries associated with total hip arthroplasty.

Approximately 100,000 total hip reconstructions are done annually in the United States. The nature of the surgical technique in a field close to the iliac and femoral vessels makes the occurrence of vascular injury an occasional but serious complications. We have reviewed retrospectively our experience of five cases of vascular injuries with total hip replacement and an additional 63 cases in the literature to identify those patients at risk and to define the management of these injuries. For the entire group of 68 patients, most injuries were sustained on the left side (66%), and 39% were seen in revisions. Complications were related to cement incorporation of the iliac vessels (44%), aggressive medial retraction (17%), excessive traction on atherosclerotic vessels (10%), and improper technique in preparation of the acetabulum. The most commonly injured vessels were the external iliac artery (36), common femoral artery (17), and external iliac vein (6). Twenty-seven of these injuries required emergent surgery, most for hemorrhage (66%). Injuries consisted of thromboembolic complications leading to distal ischemia (46%), vessel lacerations (26%), pseudoaneurysms (25%), and arteriovenous fistulas (3%). Vascular repair was individualized and included suture repair, thrombectomy and patch angioplasty, embolectomy, and arterial and venous bypass procedures. There was an overall 7% mortality and a 15% incidence of limb loss. Risk factors include (1) revision procedures, (2) left-sided procedures, and (3) intrapelvic migration of the acetabular component of the hip prosthesis. Elective vascular workup and preliminary retroperitoneal exposure of the iliac vessels at time of hip arthroplasty is recommended for patients at risk.

A new primate model for the study of intravenous thrombotic potential and its modification.

Advances in venous reconstruction have been limited by inherent venous thrombogenicity and the absence of a suitable prosthetic material for use in the venous system. We have designed an in vivo experimental model to evaluate early blood-material interactions within the venous system and to quantitate drug efficacy in the alteration of platelet function and fibrin deposition in the baboon. An 8F catheter was placed percutaneously in the femoral vein of an adult male baboon. Indium 111-labeled autogenous platelets or iodine 125-labeled human fibrinogen was infused before the introduction, into the inferior vena cava, of a linear array of 5 x 15 mm alternating Dacron and polytetrafluoroethylene samples attached to a benzalkonium-heparin-treated guide wire. At 60 or 120 minutes the samples were removed and a 1 ml aliquot of blood was drawn. The materials and blood samples were counted in a gamma well counter, and the material counts were normalized to the circulating label present in the 1 ml blood sample. The experiment was repeated after pretreatment with heparin, aspirin, or dextran. Whole blood clotting times and bleeding times were monitored. The results showed decreased platelet and fibrin deposition on polytetrafluoroethylene when compared with Dacron in the venous system. Aspirin, heparin, and dextran were all found to decrease platelet and fibrin deposition onto intravenously placed graft material samples (p less than 0.05, Student's t test). The data confirm the ability of the model to evaluate quantitatively anticoagulants, antiplatelet agents, and prospective graft materials for use in venous reconstructions.

The systemic activation of platelets by Dacron grafts.

Dacron (polyester fiber), a stimulus to platelet aggregation in vitro, accumulates platelets to a greater extent in vivo than autogenous artery, polytetrafluoroethylene (PTFE) or human umbilical vein (HUV). We conducted a series of experiments using the ex vivo shunt in the baboon to determine whether or not systemic activation of platelet function was produced by a Dacron graft. Two 5 centimeter segments of 4 millimeter internal diameter graft materials were placed in series in the ex vivo shunt perfused at 25 milliliters per minute flow rate for two and one-half hours. Deposition of autologous Indium 111 labeled platelets was monitored. The ex vivo shunt procedures were divided into two groups, both with PTFE as the proximal graft: one with a distal Dacron graft (n = 21), the second with PTFE or HUV distally (n = 17). In this study, an increase in platelet deposition on the proximal PTFE graft represents systemic platelet activation caused by the distal graft. Increased platelet deposition on PTFE was noted at all time points in the presence of a Dacron graft (p less than 0.05). This property of Dacron has important clinical implications, potentially accelerating the progression of vascular disease, increasing the failure rate of composite grafts and subsequent arterial reconstruction.

Hemodynamics and prostacyclin release in the early phases of aortic surgery: comparison of transabdominal and retroperitoneal approaches.

Although the retroperitoneal aortic approach (RP) is advocated to reduce myocardial ischemia and cardiac-related death, inadequate physiologic data exist to support this contention. As the aorta is exposed via the transabdominal approach (TA) we noted some patients have manifested reduced systemic vascular resistance (SVR) associated with tachycardia, reduced blood pressure, and facial flushing. To determine whether RP offered physiologic advantages over TA we compared cardiac dynamics and blood levels of 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), the stable metabolite of prostacyclin, during exposure of the aorta in 52 patients (33 with TA and 19 with RP), comparable in age, cardiac history, medications, and body surface area. Serial measurements of mean arterial pressure, heart rate, wedge pressure, pulmonary artery pressure, cardiac index, and 6-keto-PGF1 alpha were obtained. Results revealed decreased mean arterial pressure and systemic vascular resistance, increased cardiac index and heart rate, and facial flush occurring 10 minutes after the bowel was explored in TA. This was not observed in RP. These hemodynamic alterations correlated in time and magnitude with a fourteen fold increase in 6-keto-PGF1 alpha. These changes in cardiac indexes can produce increased myocardial oxygen consumption with the risk for myocardial ischemia, particularly in patients with coronary artery disease. The absence of this response to bowel exploration in RP may account for some of the observed advantages in "high-risk" aortic reconstruction.

The management of early in situ saphenous vein bypass occlusions.

To determine the causes and optimum management of early in situ bypass occlusions, we reviewed our experience of 13 thromboses occurring within the first 30 postoperative days in 148 in situ saphenous vein reconstructions. All early thrombosed bypasses were performed for limb salvage, with 31% of bypasses to the popliteal level and 69% to infrapopliteal vessels. The median time to occlusion was 24 hours. All patients underwent reoperation. Graft failure was due to retained venous valves in 31% of the procedures, other technical problems in 38%, and inadequate outflow in 31%. Reoperative surgery was individualized. In grafts explored for thrombosis, the one-year graft patency rate was 46%, and the limb salvage rate was 54%. Graft patency did not appear to correlate with the presumed cause of initial graft occlusion. Our results indicate that an aggressive surgical approach is appropriate in early in situ graft thrombosis.

The effect of low molecular weight dextran on platelet deposition onto prosthetic materials.

Low molecular weight dextran (LMD) has recently been shown in a randomized, multicenter trial to improve early patency in difficult lower extremity vascular bypass. The question remained as to whether this effect was due to plasma volume expansion by LMD or to its effects on platelets and coagulation. To analyze this we have studied the effects of LMD on platelet-graft interactions using an ex vivo baboon shunt. Indium 111-labeled autologous platelet deposition on expanded polytetrafluoroethylene and knitted Dacron grafts was monitored at a flow rate of 25 ml/min for 21/2 hours. LMD was given by intravenous bolus at a dose of 5 ml/kg and was followed by a continuous infusion of 10 ml/hr. Flow through the shunt was started after the initial dextran bolus. Control studies were performed in a similar manner without dextran. An additional series of experiments was performed with a 5 to 10 ml/kg bolus of 5% human serum albumin to analyze the contribution of plasma volume expansion to platelet deposition in this model. The results revealed a significant (p less than 0.05) reduction in platelet deposition on both graft materials with the LMD infusion. No difference was seen between the control group and the albumin group. These studies provide direct in vivo evidence of the antiplatelet effect of LMD.