Transient elastography: a new noninvasive diagnostic tool for assessment of chronic allograft nephropathy.

PURPOSE: Chronic allograft nephropathy (CAN) is the most common cause of kidney allograft failure. Protocol biopsies remain the "gold standard" in CAN recognition. However, renal allograft biopsies have numerous limitations. It is an invasive procedure connected with risk of complications, patient discomfort, and sampling errors. The aim of our study was to investigate the usefulness of transient elastography (TE) for the assessment of kidney allograft fibrosis in renal transplant recipients (RTRs). METHODS: In this cross-sectional study, we involved 52 RTRs. Renal allograft stiffness was used to assess its fibrosis by using transient elastography (Fibroscan, Echosense, Paris, France). In 23 patients with a deterioration of graft function, percutaneous renal allograft biopsy was performed closely around the time of TE. RESULTS: We have found that the renal allograft stiffness was highly negatively correlated with estimated glomerular filtration rate (eGFR) (r = -0.640; p < 0.0001). However, renal allograft stiffness showed a statistically significant difference between patients who had an eGFR > 50 ml/min per 1.73 m(2) and patients with eGFR < 50 ml/min per 1.73 m(2) (28 ± 2.7 vs. 33.9 ± 5.5 kPa; p = 0.0003). Also, there was a highly positive correlation between renal allograft stiffness and extent of interstitial fibrosis on renal biopsy (r = 0.727; p = 0.0001). CONCLUSION: According to our results, parenchymal stiffness obtained by TE reflects interstitial fibrosis. Therefore, TE provides the opportunity for noninvasive screening of CAN.

Modulation of early functional recovery of Achilles tendon to bone unit after transection by BPC 157 and methylprednisolone.

OBJECTIVE AND DESIGN: In the presented study we compared the effect of stable peptide BPC 157 and methylprednisolone on early functional recovery after Achilles tendon to bone transection in a rat model before collagen healing started. MATERIAL AND METHODS: Surgical transection of the right Achilles tendon to bone area was performed in seventy two Wistar Albino male rats. Healing Achilles tendon edges were harvested at days 1-4 following the transection. Using Achilles functional index (AFI), myeloperoxidase activity, histological inflammatory cell influx and vascular index early functional recovery was evaluated. TREATMENT: Agents (stable peptide BPC 157 10 microg methylprednisolone 5 mg, normal saline 5 ml) were given alone (/kg b.w., intraperitoneally, once daily, first 30 min after surgery, last 24 h before analysis). Control group received normal saline 5 ml/kg. RESULTS: BPC 157 improved functional recovery (AFI values increased at all time points, p <0.05) by anti-inflammatory (decreased myeloperoxidase (MPO) activity and histological inflammatory cell influx, p <0.05) and increased new blood vessel formation (increased vascular index, p <0.05). Methyprednisolone decreased MPO activity and histological inflammatory cell influx, (p <0.05) but also decreased new blood vessel formation and did not affect early functional recovery. CONCLUSIONS: Stable peptide BPC 157 with combined anti-inflammatory action and induction of early new blood vessel formation facilitates early functional recovery in Achilles tendon to bone healing.

Successful treatment of mucormycosis endocarditis complicated by pulmonary involvement.

Cardiac mucormycosis is an exceedingly rare condition. This case report describes mucormycosis endocarditis in an immunocompromised patient with ulcerative colitis. His condition was further complicated by multiple septic emboli to the lungs. His management included surgical excision of the right atrial endocarditic vegetation and antifungal treatment with high-dose liposomal amphotericin B.

Surgical treatment of a postpartal spontaneous left main coronary artery dissection.

We report on a 34-year-old woman who presented with acute anterolateral myocardial infarction 12 weeks postpartum. Cardiac catheterization documented a left main coronary artery dissection with complete occlusion of the left anterior descending artery. The surgical treatment and the complicated postoperative course are discussed here.

Iatrogenic coronary artery fistula in a patient with a single coronary artery.

Here, we report on a case of coronary artery fistula that developed following the repair of a double-outlet right ventricle (DORV) with infundibular pulmonary stenosis in a patient who has a single coronary artery. The major concern in this case was that of reduction of coronary blood flow from the patient's only coronary artery to the myocardium distal to the fistula.

Heart metastasis of extraskeletal myxoid chondrosarcoma.

Isolated, remote heart metastasis of myxoid chondrosarcoma is extremely rare. We present an unusual case of isolated remote metastasis of extraosseus myxoid chondrosarcoma from the right ankle region to the right ventricle, its clinical course, and treatment in a 46-year-old woman. Although heart biopsy done before the surgery revealed myxoma, histopathologic diagnosis of the heart tumor was confirmed after its surgical resection from the right ventricle. Nine months after the surgery the patient was doing well but, seven months later, she died in the local hospital because of global heart failure. On the autopsy, the only metastatic lesion found was in the heart. The pericardium and heart muscle were infiltrated with the tumor, whereas all other organs were free from malignant dissemination.

[Stenotrophomonas maltophilia as a cause of hospital infections--typing of clinical isolates using pulsed field gel electrophoresis] ]. / Stenotrophomonas maltophilia kao uzrocnik bolnickih infekcija--tipizacija klinickih izolata metodom elektroforeze u pulzirajucem polju (PFGE).

Stenotrophomonas maltophilia (S. maltophilia) has been recognised now as an important cause of hospital infections. As S. maltophilia is resistant to many antibiotics, attempts have been made to identify the sources of S. maltophilia infection and route of its transmission. From July till October 1998, 22 isolates of S. maltophilia were obtained from 20 patients hospitalised at eight different wards. Strain typing was performed by macrorestriction analysis of chromosomal DNA by use of PFGE (XbaI and SpeI enzymes, in a CHEF DR III drive module). PFGE analysis of 22 S. maltophilia isolates revealed 9 different types designated by letters A to I. The source and route of the spread of infection could not be identified. These results may indicate that we had clusters of S. maltophilia infection in cardiosurgery ward and ICU by types A, B, C and D; in neurosurgical ICU by type E and in urology ICU by type H.

Indirect demonstration of the lifetime function of human thymus.

The aim of this study was to test the hypothesis that human thymus maintains its function as the site of early T cell development throughout life, but to a progressively diminishing extent. Mononuclear cell suspensions prepared from the samples of 39 human thymuses were analysed for the total number of cells per gram of thymus tissue, percentage of single marker-positive CD2, CD4 and CD8 cells, percentages of double-positive CD4CD8 and CD2CD8 cells, double-negative CD4CD8 cells, absolute numbers of these cells per gram of tissue, and extent of the in vitro proliferation upon stimulation with concanavalin A (Con A), phytohaemagglutinin (PHA) and pokeweed mitogen (PWM) mitogens. The main outcome measures were flow cytometric data on thymus lymphoid cell composition (according to CD classification), expressed as percentages and numbers of cells per gram of thymus tissue. The total number of mononuclear cells expressed per gram of thymus tissue exponentially decreased with age. The slope of none of the analysed cell subpopulations differed from the slope of the line constructed for age-related decline of the total number of mononuclear cells (-0.024 on a semilogarithmic scale). The thymuses of all ages contained all analysed cell subpopulations in approximately the same proportions: percentages of these cell subpopulations did not change with age, except for all CD4+ (P=0.017) and double-positive CD4+CD8+ (P=0.016) cells, which tended to decrease with age. The extent of proliferation of thymus cells upon stimulation with T and B cell mitogens was unrelated to age. We conclude that the thymus retains its function as the site of differentiation of T lymphocytes throughout life. With respect to the number of involved lymphoid cells, the function exponentially decreases with age.

Penetrating cardiothoracic war wounds.

OBJECTIVE: Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of treatment for such injuries, and there are not many large series of such patients in recent literature. METHODS: We analysed a group of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992. RESULTS: There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac, wounds and in 10 (3.7%) patients both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and 1 patient which involved descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary procedure was suture in 17 patients (in 10 patients with the additional suture of the lung), suture + extraction of the foreign body in 4 patients, 2 of them with cardiopulmonary bypass. Complications were pericardial effusion in 6 patients, arrhythmia in 2 patients, myocardial infraction in 1 patient and migration of the foreign body in 1 patient. Patients, 7, died, five of the group with concomitant injuries, two of thoracic and one of cardiac injuries (5, 1.2 and 4.2%, respectively). CONCLUSIONS: Penetrating cardiothoracic wounds are among the most serious injuries in war, either in combat or among civilians. In spite of their nature, they can be treated successfully with relatively low mortality and morbidity.

The cardiac migration of a Kirschner wire. A case report.

In June of 1995, a 48-year-old woman was admitted to an outlying hospital with a history of stomach pain several weeks in duration. A few years before, she had undergone orthopedic surgery because of bilateral coxarthrosis. Total endoprosthesis had been implanted at both hips. Chest radiography showed a metal foreign body (apparently a Kirschner wire) in the heart, whereas right-hip radiography showed no Kirschner wire. Echocardiography indicated that the wire was in the right ventricle. The patient underwent open-heart surgery, and the 5-cm-long Kirschner wire was removed from the right ventricle through a right atriotomy. To the best of our knowledge, this is the only reported instance of intracardiac embolization of a Kirschner wire.

Wound infection after median sternotomy during the war in Croatia.

From 1990 to 1994 at Clinical Hospital Center, Zagreb, 1904 median sternotomies were performed for cardiac operations. Patients shared the same intensive care unit (ICU) with the wounded persons, admitted to the hospital from battlefield. Infection developed in 124 patients, an incidence of 6.51%. Methicillin resistant Staphylococcus aureus (MRSA) was isolated from 90, methicillin resistant Staphylococcus epidermidis (MRSE) from 19, and gram negative bacilli (GNB) from 56 patients, Pseudomonas aeruginosa in 2, and Clostridium pneumoniae in 1 case. Ninety-six patients (5.04%) developed superficial localized infection of subcutaneous tissues and they were treated with frequent dressing changes with antibiotic-soaked gauze in combination with systemic antibiotics. Twenty-eight patients (1.47%) developed mediastinitis and sternal dehiscence. They were treated by operative debridement followed by reclosure of the sternum with continuous antibiotic irrigation. We obtained satisfactory results with our method of closure of sternum which is a modification of Robicsek's technique. Nine of them required further operation. In seven cases we performed muscle flaps and in two omentoplasty. One hundred and twenty patients were discharged in satisfactory condition. The uncontrolled mediastinal sepsis caused death in 4 patients. Higher infection rate after median sternotomy during 1991 and 1992 could be possibly explained with the war circumstances in Croatia, and especially with MRSA strain becoming endemic in surgical ICU.

[Management of surgery patients with implanted cardiac pacemakers]. / Postupak s kirurskim bolesnikom--nosiocem elektrostimulatora srca.

Patients having cardiac pacemaker implanted may be subjected to various general surgery procedures. Application of electrosurgery for the purpose of resection and coagulation, provides a high frequency electric field which produces electric voltage on the electrodes of the pacing system. This voltage may be detected within the pacing system, and various arrhythmias can be provoked in correlation with underlying rhythm and mode of pacing. Preoperative patient control and proper pacemaker programming can prevent the pacing malfunctions due to the electrosurgery application. Appropriate positioning of the neutral electrode in relation to the pacing system avoids the electric fields intersection and decreases their interference.

[Causes of complications in the early postoperative period after heart surgery]. / Uzroci komplikacija u ranom poslijeoperacijskom tijeku u kardiokirurskih bolesnika.

In this study we have evaluated 32 patients who underwent open heart surgery with extracorporeal circulation. The aim of the study was to determine the influence of duration of surgical procedure, amount of bleeding after surgery, duration of assisted ventilation, need for mechanical and pharmacological assistance on the occurrence of complications in the early postoperative period. Sixteen patients who developed signs of systemic infection were evaluated. Other 16 patients had similar clinical characteristics and they were operated on the same day or within the same week as patients in the first group and they served as the controls. There was a statistically significant difference between those two groups in the duration of surgical procedure, amount of blood loss after surgery, amount of transfusions and duration of mechanical ventilation. The group of patients with systemic infection and other complications required in the majority cases left ventricular support and developed multiorgan system failure that resulted in a higher rate of mortality. In conclusion, this study shows that the causes of complications and systemic infection in the early postoperative period could be due to a greater blood loss following surgery, demand for blood transfusions and duration of mechanical ventilation.

[Relation between the size of the left-right shunt and pulmonary resistance in congenital heart defects]. / Odnos velicne lijevo-desnog shunta i plucne vaskularne rezistencije pri prirodenim greskama srca.

Relation between pulmonary vascular resistance (PVR) and left-to-right (L-D) shunt has been statistically tested in 87 patients with congenital heart diseases. In all patients, PVR and L-D shunt were calculated from the catheterization test results. Among 87 patients, 45 (52%) were female and 42 (48%) male children. The average age at the catheterization was 4.63 (min 6 mo, max 15 yr). Patients were divided into two groups with regard to the level of PVR. The first group consisted of patients with PVR higher than 160 dyn sec cm-5, and the second group with PVR lower than 160 dyn sec cm-5. The whole group was also divided according to VSD, and separate correlation was done for ASD with PVR below 160 dyn sec cm-5. A negative statistically significant correlation was observed between the height of PVR and size of L-D shunt among the entire group with PVR higher than 160 dyn sec cm-5, regardless of congenital heart disease (N = 29, r = -0.4676, P < 0.05). Also, a negative statistically significant correlation was found between PVR and L-D shunt in VSD, with PVR higher than 160 dyn sec cm-5 (N = 17, r = -0.669, P < 0.05). Among patients with low PVR, there was no negative statistically significant correlation between PVR and L-D shunt, neither for the whole group (N = 58, r = 0.1174, P > 0.05), nor among the patients with VSD r = -0.0133, P > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Mitochondrial cardiomyopathy and scapuloperoneal spinal muscular atrophy in a child.

A 14-year old boy was admitted for signs of heart failure and scapuloperoneal muscle weakness. He fulfilled the clinical, functional and diagnostic criteria for dilated cardiomyopathy. There was also a moderate increase in pulmonary vascular resistance. The immunohistochemical examination of the heart muscle revealed a slightly positive phytohemagglutinin reaction and minimal IgM deposits without complement. The electron microscopy examination disclosed increased numbers of abnormal mitochondria disrupting the usual cell structure; the mitochondria were of various sizes with irregular and abnormal structure of the cristae. The scapuloperoneal spinal muscular atrophy was mild and diagnosed according to clinical and electromyographic findings. Light microscope examination of the skeletal muscle revealed hypotrophic fibers. This patient is presumed to have postinflammatory mitochondriopathy and is currently being managed on low-dose digitalis, diuretics and captopril.

[Residual postoperative murmurs in children with congenital heart defects]. / Rezidualni postoperacijski sumovi u djece s prirodenim greskama srca.

Fifty-four children without postoperative complications were admitted to the Department of Pediatrics, University Hospital Rebro, following a complete surgical correction of ventricular septal defect (VSD), atrial septal defect - secundum type (ASD II) and patent ductus arteriosus (PDA) in the period from June, 1989, to February, 1991. Twenty-two patients were treated surgically for VSD, 17 for ASD II and 15 for PDA. There were 23 male and 31 female children. In the early postoperative period, 57% of all the examinees had a murmur with the innocent or functional characteristics. The murmur was significantly more frequent among children with VSD than among children of other groups (ASD II, PDA). Sex, age and hematocrit did not influence this difference. There were 8 anemic children (3 with operated VSD, 4 with ASD II, and 1 with PDA). From this, it may be concluded that anemia also did not cause this difference. However, anemic children represented 50% of the examinees with a murmur among the operated for ASD II and 33% among those treated surgically for PDA. When these anemic children were eliminated, the others operated on for ASD II and PDA probably had the innocent murmurs, since the proportion of examinees with a murmur fits into the incidence of innocent murmurs in the population. The children operated for VSD have had a greater proportion of examinees with a murmur, and most likely, some of these murmurs do not belong to a group of innocent or functional murmurs. Their cause is unknown, as yet (probably, small organic lesion).(ABSTRACT TRUNCATED AT 250 WORDS)

[War injuries of the thorax]. / Ratne ozljede prsnog kosa.

Chest injuries are very common in war circumstances. Chest injury is commonly associated with other injuries of intrathoracic organs and development of shock, which has to be treated immediately. Our patients with war chest injuries are presented, along with our approach to the treatment of these injuries. "The conservative treatment" is stressed, with particularly importance of proper chest drainage, as a corner stone of proper and successful therapy. Shock treatment and prevention of atelectasis does present an unavoidable procedure of this type of therapy.