Perioperative management of four anaemic female Jehovah's Witnesses undergoing urgent complex cardiac surgery.

Previous studies have demonstrated that preoperative haemoglobin concentration and female gender are related to an increased need for perioperative allogeneic transfusions in cardiac surgery. Hence, urgent cardiac surgery presents a dilemma for female patients who are Jehovah's Witnesses, because of their refusal of allogeneic transfusion. This report describes the management of four high-risk anaemic female patients undergoing urgent complex cardiac surgery. In these Jehovah's Witness patients, strict application of a comprehensive blood-sparing protocol permitted safe avoidance of allogeneic transfusions. The protocol involved intraoperative acute normovolaemic haemodilution, intraoperative administration of tranexamic acid, intra- and postoperative use of a cell-saver system, postoperative administration of erythropoietin, iron and folic acid, and a careful surgical technique to avoid perioperative bleeding.

Phylogenetic internal control for HIV-1 genotypic antiretroviral testing.

Genotypic testing includes several steps (RNA purification, RT-PCR amplification, DNA sequencing, sequence editing and analysis) that should be individually controlled. In our laboratory, we have added to this step-by-step internal control a final phylogenetic quality control: this is performed every time a sequence is obtained from a patient previously subjected to the same test. Each sequence with this characteristic is routinely compared with sequences from previous samples of the same patient by multiple alignment and a neighbor-joining tree by using Kimura two-parameter method is constructed. To validate the quality control procedure, we have aligned and calculated the mean similarity of the reverse transcriptase (first 984 nucleotides) and protease (whole gene) sequences from 30 patients whose virus was completely wild-type for both reverse transcriptase and protease. In the same tree, we have added the sequences obtained from 5 out of the 30 patients, tested at a second time point. The wild type sequences have shown a mean inter-sample divergence of 2.9%, and all the sequence pairs from individual patients clustered together in the tree constructed with the nucleotide sequences, while the tree constructed with the inferred aminoacid sequences did not always permit to cluster the sequences from the same patients. This indicates that: 1) the phylogenetic analysis of nucleic acid sequences can be useful to rule out sample mix-up; 2) the belonging of a sequence to each individual patient can efficiently be assessed also in the cases of extreme divergence in terms of drug resistance mutations.

Characterization of GBV-C infection in HIV-1 infected patients.

BACKGROUND: GB virus C, a positive-stranded RNA virus, is classified in the family Flaviviridae. It is currently believed that persistent infection occurs in 25-50% of infected individuals, however, it still remains an "orphan" virus in search of a role in human pathology. Molecular epidemiological studies have demonstrated that GBV-C infection is present in about 1-1.4% of the healthy population in developed countries, that it shares routes of transmission with HIV and HCV and that the prevalence of GBV-C in these populations is higher than in blood donors. On the basis of the sequence variation among the isolates, GBV-C is classified into at least four major genotypes. Preliminary evidence has suggested that GBV-C is a lymphotropic virus that replicates mainly in the spleen and bone marrow. Recently, several reports have investigated the possible beneficial effect of GBV-C co-infection on HIV disease progression to AIDS, reduced mortality in HIV infected individuals and lower HIV viral loads, not leading to a definitive conclusion yet. AIM: To investigate the role of GBV virus C co-infection in two different subsets of HIV-infected patients, and to evaluate the prevalence of GBV-C genotypes in Northern Italy. METHODS: A total of 86 HIV positive patients were examined for GBV-C viremia (years after HIV sera conversion: 12 +/- 5). Control population (Group A): 46 patients (mean age 42 years) with <200CD4/ml during the observation period. Longterm non progressor population (Group B): 40 patients, (mean age 40 years) with >500 CD4/ml for at least 8 years and never treated with HAART. After extraction of viral RNA from plasma samples, amplification of a highly conserved region of 5'UTR was performed by nested RT-PCR. All positive samples were genotyped by sequencing, alignment with published sequences and phylogenetic analysis. CD4 cell count, HIV plasma levels were also evaluated. RESULTS: 9 out of 46 (19.56%) in Group A and 15 out of 40 (37.5%) in Group B had detectable GBV-C viremia (p=0.064, OR 2.47, percent confidence interval 0.94 to 6.51). No statistical difference was observed when disease stage was evaluated between the two groups. In Group B, after regression analysis for CD4 cell count decrease over the period observed, no significant difference was detected between GBV-C positive and negative patients. No significant difference was observed in Group B in HIV viremia and CD4 cell count at time of GBV-C detection between GBV-C infected patients and GBV-C negative patients. All Italian patients were genotype 2, the only African patient carried GBV-C genotype 1. CONCLUSIONS: Although previous results suggest that GBV-C virus may be a favorable marker for long term non progression of HIV disease, whether it plays a direct anti-HIV role or just takes advantage of non progessors' higher CD4 cell count to replicate more efficiently, still remains to be answered. Follow up of untreated patients and further evaluation of virological interactions, between the viruses and the host immune system, will be helpful to shed some light on these observations, offering new prognostic and eventually therapeutical tools for the management of HIV patients.

Human papillomavirus infection and associated cervical disease in human immunodeficiency virus-infected women: effect of highly active antiretroviral therapy.

To determine the effect of highly active antiretroviral therapy (HAART) on high-risk human papillomavirus (HR-HPV) infections and related cervical lesions, the virologic and cytologic markers of HPV infection were prospectively studied in 163 human immunodeficiency virus (HIV)-infected women, including 27 untreated, 62 treated with reverse transcriptase inhibitors, and 74 treated with HAART. A high prevalence of both infections with HR-HPV types (68%) and squamous intraepithelial lesions (SILs; low grade, 20.2%; high grade, 6.2%) was observed. The risks of infection and disease were inversely correlated with CD4 cell counts (P=.015 and P=.022, respectively). During the observation period (mean, 15.4 months; range, 6-24 months), CD4 cell counts increased significantly only in subjects receiving HAART (P<.001). Persistence of HR-HPV infection and progression of SILs were comparable in the 3 groups. These results indicate that, even in the era of HAART, HIV-infected women should be monitored carefully for the emergence of high-grade SILs and cervical cancer.

Aortic valve repair for traumatic aortic insufficiency.

Prolapse of a commissural portion of the aortic valve due to partial intimal tear following a blunt chest trauma is a rare condition. Aortic valve repair is a technically demanding operation and the presence of aortic incompetence due to leaflet prolapse often leads to aortic valve replacement. We report the case of a patient with aortic insufficiency due to commissural disruption following a road traffic accident, and in whom aortic valve repair was performed.

A rural cancer outreach program lowers patient care costs and benefits both the rural hospitals and sponsoring academic medical center.

The Rural Cancer Outreach Program (RCOP) between two rural hospitals and the Medical College of Virginia's Massey Cancer Center (MCC) was developed to bring state-of-the-art cancer care to medically underserved rural patients. The financial impact of the RCOP on both the rural hospitals and the MCC was analyzed. Pre- and post-RCOP financial data were collected on 1,745 cancer patients treated at the participating centers, two rural community hospitals and the MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins and profit (or loss) of the program. The RCOP may have enhanced access to cancer care for rural patients at less cost to society. The net annual cost per patient fell from $10,233 to $3,862 associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to the Medical College of Virginia fell by more than 40 percent compared with only an 8 percent decrease for all other cancer patients. The rural hospitals experienced rapid growth of their programs to more than 200 new patients yearly, and the RCOP generated significant profits for them. MCC benefited from increased referrals from RCOP service areas by 330 percent for cancer patients and by 9 percent for non-cancer patients during the same time period. While it did not generate a major profit for the MCC, the RCOP generated enough revenue to cover costs of the program. The RCOP had a positive financial impact on the rural and academic medical center hospitals, provided state-of-the-art care near home for rural patients and was associated with lower overall cancer treatment costs.

Endoaneurysmal repair of a congenital right coronary sinus aneurysm.

An 82-year-old woman complained of lightheadedness, dizziness, syncope, palpitations, and chest pains of 2 years' duration. Chest X-ray demonstrated cardiomegaly, while transesophageal echocardiography (TEE) disclosed an aneurysm of the right coronary sinus (RCS), 6 x 6 cm in diameter, filled with clots and obstructing the right ventricular (RV) outflow tract. A total cardiopulmonary bypass was instituted with hypothermia to 28 degrees C esophageal temperature. After removing the clots, we applied an endoaneurysmal repair with a synthetic patch to the entry of the aneurysm and closed the aneurysm itself. We recommend our approach of an endoaneurysmal repair for similar aneurysms of the coronary sinus of Valsalva.

Acceptance of a speech interface for biomedical data collection.

Speech interfaces have the potential to address the data entry bottleneck of many applications is the field of medical informatics. An experimental study evaluated the effect of perceptual structure on a multimodal speech interface for the collection of histopathology data. A perceptually structured multimodal interface, using speech and direct manipulation, was shown to increase speed and accuracy. Factors influencing user acceptance are also discussed.

Feasibility study of voice-driven data collection in animal drug toxicology studies.

The object of this study was to determine the feasibility of using voice recognition technology to enable hands-free and eyes-free collection of data related to animal drug toxicology studies. Specifically, we developed and tested a prototype voice-driven data collection system for histopathology data using only voice input and computer-generated voice responses. The overall accuracy rate was 97%. Additional work is needed to minimize training requirements and improve audible feedback. We conclude that this architecture could be considered a viable alternative for data collection in animal drug toxicology studies with reasonable recognition accuracy.

A new technique for hemodilution, preparation of autologous platelet-rich plasma and intraoperative blood salvage in cardiac surgery.

We have developed a new system for the production of autologous platelet-rich plasma and red blood cell concentrates to be used in autologous transfusion support of cardiac surgery patients. In 15 operations no homologous blood products were required. Costs were diminished since with the same harness it was possible to carry out the intraoperative blood salvage and concentrate the erythrocytes contained in the oxygenator and its lines. Indirect costs were also reduced since no infective complication was observed due to homologous blood products.

[Acute dissection of the thoracic aorta. Proposal of a new surgical technic]. / La dissezione acuta dell'aorta toracica. Proposta di una nuova tecnica chirurgica.

Acute aortic dissection is a challenging surgical disease. Replacement of the supracoronary aorta alone can be followed by recurrent aneurysm formation at the level of the residual aortic root. The Bentall procedure prevents this late complication but intraoperative haemorrhage may be severe and valve replacement is always mandatory. A new surgical technique is presented which has been adopted in seven consecutive patients with no deaths. With this procedure, strengthening of the aortic root is obtained by inserting three Dacron Double Velour patches "between" the internal and external aortic lamina, one for each sinus of Valsalva. The patches override the coronary ostia which are left wide patent, and are anchored directly to the aortic anulus by single mattress sutures which reduce the size of the anulus. Suspension of the valve leaflets to the patches overriding each other at the commissures together with anuloplasty reestablish valve continency. The two aortic stumps are secured with running sutures over the free edge and a tubular Dacron graft is then anastomosed to them. The procedure reinforces the aortic root, will prevent recurrent aneurysm formation and avoids at the same time valve replacement, when unnecessary, and coronary arteries reimplantation.