C-kit protein expression in Wilms' tumour: an immunohistochemical study.

AIM: The use of a non-toxic tyrosine kinase receptor inhibitor, Imatinib Mesylate (IM), has become an ever-more common therapeutic alternative in some Kit (CD117) over-expressing neoplasms. As the treatment eligibility for these drugs hinges on CD117 expression, Kit immunostaining has recently been widely examined in various tumours. There are only limited data in the literature on the expression of c-kit expression in Wilms' Tumour. We examined CD117 expression in Wilms' tumour in order to correlate this marker with clinico-pathological data and to clarify its prognostic impact. METHODS: This study included 40 cases of Wilms' tumour. Sections from paraffin-embedded tumour samples were immunostained by standard ABC technique using c-kit polyclonal antibody with antigen retrieval. RESULTS AND CONCLUSIONS: In the case of C-kit positive examples, the staining was focal, with patch distribution. On univariate analysis, significantly higher c-kit expression was observed in neoplasms in a more advanced stage of development than those in a less advanced stage (p=0.0055). In addition, over-expression of this marker was significantly correlated with the death of patients (p=0.0294) and recurrences of disease (p=0.0118). Moreover, all our Wilms' tumour anaplastic subtypes showed over-expression of c-kit and this was significantly higher than in favourable histology examples (p=0.0182). The results of multivariate analysis, instead, did not reveal any correlation of c-kit expression and prognosis. In our opinion these results could be due to the number of cases considered which is not particularly high. However, it seems likely that c-kit expression could be a secondary event related to tumour progression and could be influenced by chemotherapy and unfavourable histology.

Effects of potassium sorbate on postharvest brown rot of stone fruit.

The effect of potassium sorbate (K-sorb), a low-toxicity chemical, to control Monilinia spp. was investigated. Preliminary in vitro studies found the MIC of K-sorb for conidial germination and mycelial growth was, respectively, 260 and 1,250 mg/ liter. Immersion of naturally infected peach and nectarine fruit in a solution (15 g/liter) of K-sorb for 120 s reduced brown rot by over 80% in four of five trials. Although treated fruits showed a significant reduction in firmness with respect to the control, they did not reach the overripe stage and retained acceptable quality parameters. In an attempt to elucidate the mechanism of action for K-sorb, the inhibition of enzymatic activity by K-sorb was also tested. In a radial diffusion assay, the addition of K-sorb to agarose reduced polygalacturonase (PG) activity across the concentrations considered. The greatest reduction (54.3%, with respect to the control) was obtained at a sorbate concentration of 15 g/liter. PG kinetic activity of Monilinia laxa observed by a spectrophotometric assay peaked after 40 min in all samples tested. PG activity was significantly higher in the control than in the samples with increased K-sorb concentrations. In conclusion, based on these findings, K-sorb can be recommended as a low-toxicity antifungal compound against Monilinia spp. in peaches and nectarines with its mode of action probably depending in part on the inhibition of PG activity in M. laxa.

A prospective study on children with initial diagnosis of transient hypogammaglobulinemia of infancy: results from the Italian Primary Immunodeficiency Network.

Transient hypogammaglobulinemia of infancy (THI) is a heterogeneous disorder characterized by reduced serum IgG levels in early infancy. A putative diagnosis is initially made after exclusion of other causes of hypogammaglobulinemia while a definitive diagnosis of THI can only be made a posteriori in patients with normalization of IgG levels. The aim of this study is to characterize clinical and immunological features of children with an initial diagnosis of THI in correlation to natural outcome, and to assess predictive laboratory parameters of clinical evolution for this disorder. We prospectively analysed clinical and immunological characteristics of 77 THI children at initial diagnosis and of 57 patients at follow-up. Memory B cell subsets and in vitro immunoglobulin production were evaluated. Seventy patients (91 percent) showed clinical symptoms. Patients suffered from infections (91 percent), allergies (47 percent) and autoimmune disease (4 percent). During follow-up 41/57 children (72 percent) normalized IgG values, mostly within 24 months of age (p less than 0.001), allowing the diagnosis of THI. The 16 children who did not normalize their IgG levels showed a higher frequency of severe infections and autoimmune disease (p less than 0.01). Moreover, they expressed a reduced frequency of IgM and switched memory B cells (p less than 0.01) and an inability to produce IgG in vitro (p less than 0.02). We conclude that most patients with an initial diagnosis of THI spontaneously recover within 24 months of age and have a benign clinical course, while a subgroup of children with undefined hypogammaglobulinemia share a clinical and immunological profile with other primary immunodeficiencies. Early recognition of children with hypogammaglobulinemia during infancy who are likely to suffer from permanent immunodeficiencies later in life would allow prompt and appropriate laboratory and clinical interventions.

Intracranial mesenchymal chondrosarcoma with osteoid formation: report of a pediatric case.

CASE REPORT: We present a case of a 14-year-old girl with a 3-week history of severe progressive headache and intermittent vomiting. Magnetic resonance imaging (MRI) revealed a large intensely enhancing mass, which seemed to arise from the right side of the cerebral fossa with implant base in the inferior face of the tentorium and significant mass effect on the nearby structures. A presumptive preoperative diagnosis of meningioma was made. Subtotal surgical resection was performed using the occipital approach. Histologically the neoplasms had the classic features of a mesenchymal chondrosarcoma associated with the focal presence of osteoid matrix. DISCUSSION: Clinical features, therapeutic approaches and prognosis of this rare tumour are discussed with regard to the known 30 cases in the literature.

Non-conventional methods for the control of post-harvest pear diseases.

Pears are highly perishable products, especially during the post-harvest phase, when considerable losses can occur. Among the fungal diseases, blue mold caused by Penicillium expansum, grey mould caused by Botrytis cinerea, Mucor rot caused by Mucor piriformis are common on pear fruits. Other (weak) pathogens like Phialophora malorum, Alternaria spp., and Cladosporium herbarum tend to infect wounds and senescent fruits. A post-harvest fungicide treatment can reduce decay but effectiveness decreases with the appearance of resistant strains. There is a clear need to develop new and alternative methods of controlling post-harvest diseases. The emerging technologies for the control of post-harvest fungal diseases are essentially threefold: application of antagonistic microorganisms, application of natural antimicrobial substances and application of sanitizing products. Two biological control products, Aspire (Candida oleophila I-182) (Ecogen, Langhorne, PA, USA) and Bio-Save 110 (Pseudomonas syringae) (EcoScience, Worcester, MA, USA; formerly Bio-Save 11) are currently registered in the USA for post-harvest application to pears. Other potential biocontrol agents have been isolated from fruit and shown to suppress post-harvest decay in pear. It is important that evaluation of these microorganisms be carried out in a product formulation because the formulation may improve or diminish antagonistic efficacy depending on the concentration of chemical product and the duration of exposure to the treatment. Plants produce a large number of secondary metabolites with antimicrobial effects on post-harvest pathogens. Detailed studies have been conducted on aromatic compounds, essential oils, volatile substances and isothiocyanates, with encouraging results. In particular, allyl-isothiocyanate used as a volatile substance, controls blue mould in 'Conference' and 'Kaiser' pear inoculated with a thiabendazole-resistant strain. Sanitizing products such as chlorine dioxide, peracetic acid and ozone have considerable fungicidal activity against P. expansum and M. piriformis, depending on the concentration of chemical product and the duration of exposure to the treatment. Sanitizing solutions can be integrated easily with current handling and storage practices; however, further research is required to define the effective procedures better.

Low temperature metabolism of apple phenolics and quiescence of Phlyctaena vagabunda.

The content of chlorogenic acid, (+)-catechin, (-)-epicatechin, phloretin glycosides, and quercetin glycosides in fresh and stored Golden Delicious apples (Malus domestica Borkh) was determined. The relative amount of phenolics in the peel, with the exception of chlorogenic acid and (-)-epicatechin, was higher than that in the flesh. In addition, quercetin glycosides were detected only in the skin. These compounds were tested for fungicidal activity against Phlyctaena vagabunda Desm., the causal agent of a postharvest rot. Chlorogenic acid only inhibited P. vagabunda spore germination and mycelial growth in vitro. Changes of apple phenolics and polyphenol oxidase activity during cold storage and the biological activity of these phenolics have also been analyzed with reference to the development of quiescent infections during cold storage plus shelf life at room temperature. The results obtained suggested that phloridzin and chlorogenic acid in combination with polyphenol oxidase activity could function to arrest P. vagabunda in quiescent infections associated with immature and ripening apple fruit.

Over twenty-year follow-up of the standard Hancock porcine bioprosthesis implanted in the mitral position.

BACKGROUND: To define the long-term results of 331 standard Hancock porcine bioprostheses implanted in the mitral position between 1973 and 1980. METHODS: Of 331 patients (225 male patients, 68%), mean age 49+/-10 years (range 14 to 69 years), 88% were in New York Heart Association functional class III or IV and 77% were in atrial fibrillation. Follow-up time extended more than 20 years (mean 13.9 years, range 0.3 to 24.7 years) for a total of 4,601 patient-years. RESULTS: Overall operative mortality was 6.3%. At 5, 10, 15, and 20 years, the actuarial survival rate of patients were 71%+/-2%, 46%+/-3%, 30%+/-3%, and 22%+/-2%, respectively. Actuarial estimates of freedom from structural valve deterioration were 95%+/-1%, 67%+/-3%, 32%+/-3%, and 14%+/-3%; from reoperation were 96%+/-1%, 72%+/-3%, 36%+/-4%, and 18%+/-4%; from thromboembolism were 89%+/-2%, 82%+/-3%, 74%+/-4%, and 51%+/-2%; and from anticoagulant-related hemorrhage were 98%+/-1%, 96%+/-1%, 91%+/-1%, and 86%+/-4%. Estimates of freedom from all valve-related mortality at 5, 10, 15, and 20 years were 89%+/-2%, 76%+/-3%, 64%+/-4%, and 48%+/-4%. Multivariate analysis showed younger age to be a significant risk factor for reoperation. Age at operation did not correlate with structural valve deterioration. CONCLUSIONS: The long-term results with the standard Hancock bioprosthesis implanted in the mitral position appear satisfactory, particularly up to 15 years from implantation. Protection from stroke, anticoagulant hemorrhage, and endocarditis was good.

Long-term results after aortic valve replacement with the Biocor PSB stentless xenograft in the elderly.

BACKGROUND: This study seeks to define the long-term results after Biocor PSB stentless aortic valve replacement (AVR) in elderly patients, including the effects of No-React treatment. METHODS: We reviewed the outcomes of 106 consecutive patients, aged 70+/-6 years, having Biocor PSB (93 standard, 13 No-React) AVR between October 1992 and October 1996. RESULTS: There were three early deaths (3%) and 15 late deaths (15%), during a mean follow-up of 5.8+/-1.6 years. At 8 years, survival was 82%+/-4% and freedom from cardiac death was 94%+/-3%. Freedom from valve failure was 92%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Replacement of the xenograft was required in 5 patients. Freedom from reoperation was 91%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Four bleeding and two embolic events were recorded: overall valve-related event-free survival was 81%+/-7% at 8 years (No-React: 76%+/-12% at 4 years). Age of long-term survivors averaged 77+/-5 years and their New York Heart Association status was 1.3+/-0.6 (versus 2.9+/-0.6 preoperatively, p = 0.01). CONCLUSIONS: Satisfactory freedom from cardiac events and from valve deterioration added to uniform improvement in functional status despite advanced age and high prevalence of comorbid conditions make AVR with the Biocor PSB xenograft a valid long-term therapy for the elderly. No-React treatment does not influence xenograft durability.

Occlusion of the common iliac artery secondary of fungal endocarditis: report of a case.

Fungal endocarditis becomes complicated by peripheral arterial embolization of the lower limbs in 33%-75% of cases. Although the prognosis of patients with fungal endocarditis has improved somewhat over recent years, it remains poor, especially when the disease is associated with peripheral arterial embolization. We report herein our experience of treating a patient in whom occlusion of the right common iliac artery developed secondary to endocarditis caused by Candida parapsilosis, and review the literature on this subject.

Preservation of the aortic valve in acute type A dissection complicated by aortic regurgitation.

BACKGROUND: The aim of the present study was to verify the efficacy of preserving the aortic valve in patients with acute type A aortic dissection complicated by significant aortic regurgitation. METHODS: From January 1979 to December 1996, 178 patients (125 males; mean age 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection, with an overall operative mortality rate of 21%. Based on a retrospective analysis of the preoperative angio- or echocardiographic findings, the 141 survivors were divided into 2 groups: Group 1 (G1) included 80 patients (57%) with no or mild aortic regurgitation, and Group 2 (G2) the remaining 61 patients with moderate-to-severe aortic regurgitation. The native aortic valve was preserved by means of a uniform technique consisting of reconstruction of the aortic root and sinotubular junction in 99 patients (70%) [68 in G1 (85%) and 31 in G2 (51%)]. Forty-two patients required aortic valve (8 patients; 6%) or total root replacement (34 patients; 24%). RESULTS: At a mean follow-up of 4 +/- 3.6 years (range, 6 months to 19 years), 19 of the 99 patients with a preserved aortic valve developed moderate-to-severe aortic insufficiency [19%; 7/68 in G1 (10%) and 12/31 in G2 (39%)]. Multivariate analysis revealed that moderate-to-severe preoperative aortic valve insufficiency was a significant risk factor for development of postoperative aortic valve regurgitation (p = 0.008). Reoperation was necessary in 7 G1 patients (10%) and in 8 G2 patients (26%), with an actuarial freedom from reoperation at 5 and 10 years of 93% +/- 7% and 80% +/- 9% in G1 patients, and 81% +/- 8% and 40% +/- 15% in G2 patients (p = 0.045). CONCLUSIONS: Preservation of the aortic valve and aortic root is recommended in patients with acute type A aortic dissection and absent or mild aortic insufficiency. Patients presenting with moderate-to-severe aortic regurgitation and treated conservatively present an increased risk of recurrent valvular insufficiency.

Stentless aortic xenograft valve replacement: lessons learned after 300 implants.

Early results after aortic valve replacement (AVR) with three different types of stentless xenografts suggested less satisfactory outcome with a simplified implant model (Cryolife-O'Brien) compared with two standard implant models (Biocor PSB, Toronto SPV). To assess the impact of experience on mid-term outcome after stentless AVR, results with 322 implants were reviewed. Between July 1992 and February 1999, 106 patients underwent operations to implant the Biocor PSB (group 1), 139 patients the Toronto SPV (group 2), and 77 patients the Cryolife-O'Brien valve (group 3). Mean age (70+/-6 years; 70+/-7 years; 71+/-7 years; P = .7), prevalence of male gender (56 patients, 53%; 72 patients, 55%; 38 patients, 49%; P = .4), prevalence of aortic stenosis (72 patients, 68%; 77 patients, 55%; 38 patients, 49%; P = .7), and need for associated procedures (51 patients, 48%; 54 patients, 39%; 33 patients, 43%; P = .7) were similar among all three groups, respectively. Mean aortic cross-clamp time was shorter in group 3 (96+/-24 min; 98+/-24 min; 78+/-22 min; P = .02). Early deaths (3/106, 3%; 4/139, 3%; 2/77; 3%, P = .8) and late survival were comparable (89%+/-5%, 93%+/-4%, and 85%+/-7% at 5 years, P = .1) among groups. Follow-up ranged from 1 to 84 months (mean 52+/-20 months). Five-year freedom from valve deterioration (95%+/-5%, 96%+/-3%, and 85%+/-7%, P = .008) and from reoperation (98%+/-2%, 98%+/-2%, 92%+/-4%, P = .01) was significantly poorer in group 3 patients. When valve failure resulting from technical mishaps (none in the last 60 implants) with the Cryolife-O'Brien valve was excluded, no significant difference in freedom from valve deterioration was noted (98%+/-2%, 96%+/-3%, and 95%+/-4%, P = .1). Late functional status of 290 survivors was satisfactory and comparable among groups (1.3+/-0.8, 1.1+/-0.4, and 1.4+/-0.7 New York Heart Association class, P = .5). After an initial learning curve, simplified implant stentless xenografts offer satisfactory mid-term results, which are comparable to two-suture-line implant valves. Owing to the shorter grafting time, simplified implant xenografts such as the Cryolife-O'Brien may be particularly suited for complex operations where associated procedures are required.

Results of Biocor stentless valve replacement for infective endocarditis of the native aortic valve.

The mid-term results in a selected group of 9 patients with native aortic valve endocarditis managed by aortic valve replacement (with or without complex annular reconstruction) using a totally biological stentless valve are outlined. At a mean follow-up of 48 months, there are currently 7 survivors (2 late noncardiac deaths) with 100% freedom from reoperation, valve-related complication, and endocarditis.

Aortic valve replacement with the Biocor PSB stentless xenograft.

BACKGROUND: The midterm clinical results after aortic valve replacement with the Biocor PSB stentless xenograft on all patients operated between October 1992 and October 1996 were reviewed. METHODS: One hundred six patients, aged 70+/-6 years, had aortic valve replacement for aortic stenosis (67%), regurgitation (11%), or both (22%). Associated procedures were done in 49 patients (46%), including coronary artery bypass in 30 patients, mitral valve repair/replacement in 16, and ascending aorta replacement in 5 patients. Aortic cross-clamp and cardiopulmonary bypass times were 96+/-24 and 129+/-31 minutes, respectively. RESULTS: There were 3 (3%) early deaths due to low output (2 patients) and cerebrovascular accident (1 patient). Follow-up of survivors ranged from 6 to 66 months (mean, 39+/-14 months). Survival was 94%+/-2% and 90%+/-3% at 1 and 5 years. There were 5 late deaths due to cardiac cause (2), cancer (2), and pulmonary embolism (1 patient). No patient had structural valve deterioration, whereas 100% and 95%+/-3% were free from valve-related events at 1 and 5 years. There were two reoperations due to narrowing of the left coronary ostium and endocarditis, with an actuarial freedom from reoperation of 99%+/-1% and 98+/-1% at 1 and 5 years, respectively. Functional results demonstrated a mean peak transprosthetic gradient of 16+/-12 mm Hg, with only 1 patient (1%) with a 55 mm Hg gradient. No cases of valve regurgitation greater than mild were recorded at follow-up. Assessment of New York Heart Association functional class demonstrated a significant improvement (2.9+/-0.6 versus 1.4+/-0.7; p=0.01). All patients were free from anticoagulation. CONCLUSIONS: Aortic valve replacement using the Biocor PSB stentless xenograft offers excellent midterm survival, negligible valve deterioration, and a very low rate of valve-related events, which are comparable to estimates reported with other models of stentless xenografts and currently available stented xenografts. Hemodynamic performance is favorable and quality of life satisfactory.

Midterm results after aortic valve replacement with freehand stentless xenografts: a comparison of three prostheses.

OBJECTIVE: The ideal substitute for the diseased aortic valve is yet to be found. For the assessment and comparison of the midterm results after aortic valve replacement with three different types of freehand stentless xenografts, all patients who underwent the operation between October 1992 and April 1997 were reviewed. METHODS: Of 231 patients undergoing aortic valve replacement, 106 patients (group 1) were given the Biocor PSB (Biocor Industria e Pesquisa Ltda, Belo Horizonte, MG, Brazil); 76 patients (group 2) were given the Toronto SPV (St. Jude Medical, Inc., St. Paul, Minn.), and 49 patients (group 3) were given the O'Brien-Angell valve (Bravo Cardiovascular model 300, Cryolife, Inc., Marietta, Ga.). The first two xenografts require inflow and outflow suturelines; the third xenograft needs a single-sutureline implantation. Mean age (70 +/- 6 years; 70 +/- 7 years; 72 +/- 9 years; p = 0.6), prevalence of male sex (56 patients, 53%; 37 patients, 49%; 22 patients, 45%; p = 0.7), of aortic stenosis (72 patients, 68%; 54 patients, 71%; 37 patients, 73%; p = 0.6), and need for associated procedures (51 patients, 48%; 30 patients, 40%; 21 patients, 43%; p = 0.1) were comparable among groups. Mean aortic crossclamp time was shorter in group 3 (96 +/- 24 minutes; 100 +/- 23 minutes; 88 +/- 25 minutes;p = 0.01). RESULTS: Early deaths were 3 of 106 (3%) in group 1, 2 of 76 (3%) in group 2, and 2 of 49 (4%) in group 3. Follow-up of survivors ranged from 1 to 54 months (mean 32 +/- 13 months). Survival at 4 years was 90% +/- 3% in group 1, 95% +/- 3% in group 2, 85% +/- 8% in group 3 (p = 0.3). At 4 years, freedom from valve-related events was 95% +/- 6%, 100%, 70% +/- 8% (p = 0.004), while freedom from valve deterioration was 99% +/- 1%, 100%, 73% +/- 8% (p = 0.001), in group 1, 2, and 3, respectively (p = 0.001). At follow-up, reintervention on the xenograft was necessary in one patient (endocarditis) in group 1, none in group 2, and six in group 3 (technical cause, group 3; valve tear, group 2; pannus, group 1). Regression analysis showed O'Brien-Angell type of xenograft to be predictive of valve-related events (p = 0.02), valve deterioration (p = 0.001), and reoperation (p = 0.001) during follow-up. CONCLUSIONS: Midterm survival after stentless aortic valve replacement is good with all three xenografts. Freedom from valve-related events, valve deterioration, and reoperation are excellent with the Biocor PSB or the Toronto SPV stentless valves but less satisfactory with the O'Brien-Angell valve.

Hancock versus stentless bioprosthesis for aortic valve replacement in patients older than 75 years.

BACKGROUND: Stented aortic bioprostheses are routinely used in elderly patients. The stent, however, is obstructive and implies several hazards. Stentless aortic valves appear to be hemodynamically advantageous. However, their implantation is longer and technically more demanding, and durability is still under investigation. METHODS: Between January 1993 and December 1996, 77 patients (28 men) were prospectively randomized to undergo aortic valve replacement using the Hancock valves (group A: 40 patients, 16 men; age, 77+/-3 years; body surface area, 1.7+/-0.17 m2) or a stentless bioprostheses (group B: 37 patients, 12 men; age, 76+/-2 years; body surface area, 1.7+/-0.15 m2; Biocor, 17; Toronto SPV, 20). Preoperative variables were not significantly different between the two groups. Bypass time was 123+/-46 versus 133+/-51 minutes, and aortic cross-clamp time was 83+/-26 versus 95+/-24 minutes for group A and group B, respectively (not significant). Seven patients in group A (17.5%) and 5 in group B (13.5%) had enlargement of the aortic annulus. Valve size normalized to body surface area was 13.7+/-1.5 versus 14.1+/-1.6 mm/m2 for group A and group B, respectively (not significant). Eleven patients in group A (27.5%) and 5 in group B (13.5%) had concomitant myocardial revascularization. RESULTS: Overall perioperative mortality was 5% in group A (low cardiac output in 2 patients), and 8% in group B (low cardiac output in 1; major neurologic event in 2). Follow-up is 97% complete (group A, 14.5+/-10 months; group B, 18.5+/-12 months). One patient in group B died at 28 months of myocardial infarction. Actuarial survival at 12 and 24 months is 92% versus 91% and 92% versus 81% for group A and group B, respectively. At 6 months, patients in group A showed a peak transaortic gradient of 25+/-7 versus 20+/-9 mm Hg in group B. Progressive regression of left ventricular mass expressed as a percentage of preoperative value was 10.5% and 19% for group A and group B at 1 year postoperatively (not significant). CONCLUSIONS: Stentless valves represent a valuable alternative to conventional prostheses in patients older than 75 years, although no great advantages with their use emerge from this study. Continued evaluation particularly with regard to evidence of left ventricular remodeling and valve degeneration in the long term is warranted.

Reoperation on stentless aortic xenografts.

BACKGROUND: Stentless xenografts have been proposed as substitutes for the diseased aortic valve. Cases of valve failure requiring reoperation have thus far been sporadic. To establish the prevalence and outcome of reoperation on stentless aortic xenograft valves, all patients operated on between October 1992 and October 1996 were reviewed. METHODS: One hundred ninety-nine patients, 94 men and 105 women aged 70+/-7 years, had stentless aortic valve replacement for aortic stenosis (in 139), insufficiency (19), or both (38). Three prostheses were used, including the Biocor PSB (Belo Horizonte, Brazil) (106), Toronto SPV (St. Jude Medical, Inc., St. Paul, MN) (52), and O'Brien-Angell (Cryolife, Atlanta, GA) (41). While the Biocor PSB and Toronto SPV prostheses are designed to be implanted freehand with inflow and outflow suture lines, the O'Brien-Angell valve requires a single suture line. RESULTS: There were 7 (3.5%) total and 6 (3%) valve-related reoperative procedures during a follow-up extending up to 4 years (mean 26+/-20 months). All but one valve-related reoperation, due to endocarditis 36 months after implant, were early (less than 12 months after initial operation). Prevalence of valve-related reinterventions was 1%, 0%, and 12%, and freedom from reoperation at 3 years was 98%+/-2%, 100%, and 81%+/-8%, in patients receiving the Biocor PSB, Toronto SPV, and O'Brien-Angell valves, respectively (p = 0.0039). Cause of reoperation was technical in 3 (O'Brien-Angell), pannus in-growth in 1 (O'Brien-Angell), valve tear in 1 (O'Brien-Angell), and endocarditis in 1 (Biocor PSB). All patients survived replacement of the xenograft with a stented bioprosthesis (5) or homograft root (1) and were discharged after a mean hospital stay of 6+/-3 days (range, 4 to 12 days). At follow-up 15+/-8 months after reintervention (range, 6 to 34 months), all patients are symptom-free with no evidence of recurrent valve obstruction, regurgitation, or infection. CONCLUSIONS: Reoperation for stentless xenograft failure is a rare overall event. Implant of the O'Brien-Angell valve may be associated with a higher prevalence of early reintervention because of nonstructural failure. When needed, reoperation on a stentless xenograft is generally a simple procedure and carries a low surgical risk.

Single aortic cross-clamp technique in coronary surgery: a prospective randomized study.

OBJECTIVE: To test the hypothesis of an improved myocardial and cerebral protection by combining blood cardioplegia and the single aortic cross-clamp technique, 100 patients were enrolled in a prospectively randomized study and stratified for preoperative conditions. METHODS: In Group I, 55 patients underwent myocardial revascularization using crystalloid cardioplegia and the conventional partial occluding clamp technique to perform proximal anastomoses, whereas in Group II, 45 patients were operated on combining blood cardioplegia and the single aortic cross-clamp technique. Unstable angina, emergency procedures, reoperations and preoperative counterpulsation accounted for an higher risk score in group II patients (P < 0.03). Operations were performed by the same surgical team. Aortic cross-clamp time was significantly longer in group II patients (59 +/- 22 vs. 47 +/- 18 min.) (P < 0.001). Other intraoperative variables were not significant. RESULTS: A 70-year-old male in group I died on post-operative day 5 as a consequence of a major neurological event. Length of ventilatory dependency, post-operative bleeding, need for blood transfusions, ICU stay, and hospital stay were similar between the two groups (P = NS). Patients in group I showed a strict correlation between the duration of surgical ischemia and post-operative myocardial necrosis. Analysis of combined mortality and morbidity events (adverse events) between the two groups, led to a significant prevalence in group I patients (P < 0.03) in spite of an higher pre-operative risk score and longer ischemic times in group II patients. Neurological lesions remained confined to group I patients. CONCLUSIONS: The combined use of blood cardioplegia, delivered via the antegrade and retrograde routes, and the single-clamp technique to perform myocardial revascularization, might enhance myocardial and cerebral protection when compared to conventional methods. Larger groups of patients are needed to support this trend.

Unexpected complication of intra-aortic balloon counterpulsation via the ascending aorta: balloon migration.

A case of intraaortic balloon pump catheter migration after an ascending aortic insertion, occurring 16 h postoperatively in a 48 year old man after myocardial revascularization, is presented. The prevention and management of this rare but serious complication of intraaortic balloon pumping is reviewed.

Prevalence, identification and significance of fiber contaminants in cervical smears.

OBJECTIVE: To determine the prevalence of fiber contaminants, to provide morphologic descriptions of various fiber types and to try to understand the significance of their presence in cervical smears. STUDY DESIGN: Fibers from cotton swab tips, hair, cardboard slide transporters, Cytobrush bristles and three commercial brands of tampons were smeared onto glass slides, Papanicolaou stained and examined. Then a prospective study of consecutively screened cervicovaginal smears from 1,368 women was undertaken to identify fiber contaminants. RESULTS: Fibers were identified in 178 cases (13%). In 120, the fibers were considered extrinsic, commonly having the microscopic features of cardboard. In 58, the fibers were considered to be intrinsic to the smear because of their presence in the same plane and alignment as the cells, an associated inflammatory cell reaction, and adherent or absorbed cellular products, occasionally hemosiderin. The most common intrinsic fibers were cotton and rayon. No statistically significant relationship was identified for the presence of intrinsic fibers and patients' ages, stated menstrual dates or pathologic lesions. CONCLUSION: Fiber contaminants are commonly present in cervicovaginal smears, usually do not originate in the patient (are "extrinsic") and have no pathologic significance. Knowledge of the microscopic features of fiber contaminants enables them to be identified confidently and distinguished from fungal hyphae and other filamentous pathogens.