Low-, medium- and high-dose steroids with or without aminocaproic acid in adult hematopoietic SCT patients with diffuse alveolar hemorrhage.

Diffuse alveolar hemorrhage (DAH) is a poorly understood complication of transplantation carrying a high mortality. Patients commonly deteriorate and require intensive care unit (ICU) admission. Treatment with high-dose steroids and aminocaproic acid (ACA) has been suggested. The current study examined 119 critically ill adult hematopoietic transplant patients treated for DAH. Patients were subdivided into low-, medium- and high-dose steroid groups with or without ACA. All groups had similar baseline characteristics and severity of illness scores. Primary objectives were 30, 60, 100 day, ICU and hospital mortality. Overall mortality (n=119) on day 100 was high at 85%. In the steroids and ACA cohort (n=82), there were no significant differences in 30, 60, 100, day, ICU and hospital mortality between the dosing groups. In the steroids only cohort (n=37), the low-dose steroid group had a lower ICU and hospital mortality (P=0.02). Adjunctive treatment with ACA did not produce differences in outcomes. In the multivariate analysis, medium- and high-dose steroids were associated with a higher ICU mortality (P=0.01) as compared with the low-dose group. Our data suggest that treatment strategies may need to be reanalyzed to avoid potentially unnecessary and potentially harmful therapies.

Automated preoperative assessment of endothelial dysfunction and risk stratification for perioperative myocardial injury in patients undergoing non-cardiac surgery.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) is a common complication with associated serious morbidity and mortality. Endothelial dysfunction might play an important role in MINS, and its rapid assessment could provide a novel method of risk stratification before surgery. METHODS: We studied 238 subjects scheduled to undergo intermediate or high-risk surgery in a two-centre prospective study to determine whether preoperative endothelial dysfunction identified by a reactive hyperaemia-peripheral arterial tonometry (RH-PAT) index could provide effective risk stratification for MINS, defined as serum troponin ≥0.04 µg litre(-1), within 3 postoperative days. RESULTS: The primary outcome occurred in 35 subjects (14.7%). Endothelial dysfunction was defined as an RH-PAT index of ≤1.22. Adjusted for age, Lee index and a composite measure of the extent of surgery, endothelial dysfunction was associated with MINS [odds ratio 10.1, 95% confidence interval (CI) 3.3-30.9, P=0.001] and increased time to discharge from hospital after surgery (hazard ratio 0.39, 95% CI 0.23-0.65, P=0.001). Endothelial dysfunction identified MINS with a sensitivity of 31%, a specificity of 96%, and a positive diagnostic likelihood ratio of 8.0. Risk classification for MINS was improved by the addition of RH-PAT-defined endothelial dysfunction to the Lee index (c-statistic increased from 0.69 to 0.77; integrated discrimination improvement 0.11, P=0.003). However, prognostic utility varied widely between sites. CONCLUSIONS: For patients undergoing non-cardiac surgery, non-invasive assessment of endothelial function might enhance preoperative risk stratification for perioperative myocardial injury. However, unexplained large inter-site variation in prognostic utility could limit widespread application and needs to be further understood.

A comparison of patient self-administered and investigator-administered measurement of quality of recovery using the QoR-40.

A 40-item questionnaire (the QoR-40) had been previously developed to measure five dimensions of quality of recovery after anaesthesia and surgery. Each of the 40 items is rated on a scale of 1 to 5, with a maximum score of 200. In this study we compared patient self-administered with investigator-administered QoR-40. We studied 62 postoperative patients within 48 hours of their surgery. Agreement between the two methods was analysed using the intraclass correlation coefficient, bias and limits of agreement. There was strong correlation between the investigator-administered and patient self-administered QoR-40 scores, intraclass correlation coefficient 0.86 (95% CI: 0.77 to 0.92), P<0.001. The bias and limits of agreement were 3.1 and -22 to 28, respectively. There were 10 (16%) patient self-administered questionnaires that were not completed at first attempt. The time to complete the questionnaire when investigator-administered was 253 (16) s [mean, (SD)], and on first attempt for patients was 362 (19) s, P<0.001. The QoR-40 is as valid measure of postoperative recovery when administered with the assistance of an investigator as compared with the patient self-administered version. Investigator-administered measurement of the QoR-40 is a more efficient use of resources, as complete and more timely data are collected.

Changes in the glucosinolate-myrosinase defense system in Brassica juncea cotyledons during seedling development.

Optimal defense theory (ODT) predicts that plant defenses will be allocated to plant organs and tissues in proportion to their relative fitness values and susceptibilities to attack. This study was designed to test ODT predictions on the myrosinase-glucosinolate defense system in Brassica juncea by examining the relationships between the fitness value of B. juncea cotyledons and the levels and effectiveness of cotyledon defenses. Specifically, we estimated fitness value of cotyledons during plant development by measuring plant growth and seed production after cotyledon damage or removal at successive seedling ages. Cotyledon removal within five days of emergence had a significant impact on growth and seed production, but cotyledon removal at later stages did not. Consistent with ODT, glucosinolate and myrosinase levels in cotyledons also declined with seedling age, as did relative defenses against a generalist herbivore, Spodoptera eridania, as estimated by bioassay. Declines in glucosinolates were as predicted by a passive, allometric dilution model based on cotyledon expansion. Declines in myrosinase activity were significantly more gradual than predicted by allometric dilution, suggesting active retention of myrosinase activity as young cotyledons expand.

Recurrent intracranial Masson's vegetant intravascular hemangioendothelioma. Case report and review of the literature.

In the central nervous system, recurrence of intracranial Masson's vegetant intravascular hemangioendothelioma (MVIH) is rare. To the authors' knowledge, only three recurrent intracranial cases have been reported. The authors report the case of a 75-year-old woman with a recurrent left-sided cerebellopontine angle and middle cranial fossa MVIH. When the patient was 62 years of age, she underwent preoperative embolization and subtotal resection of the intracranial lesion followed by postoperative radiotherapy. She was well and free from disease until 9 years postoperatively when she became symptomatic. At 71 years of age, the patient again underwent preoperative embolization and near-gross-total resection of the lesion. Follow-up imaging performed 15 months later revealed tumor recurrence, and she underwent stereotactic gamma knife radiosurgery. At a 2.75-year follow-up review, the patient's imaging studies revealed stable residual tumor. This case report is unique in that it documents the clinical and pathological features, surgical and postoperative treatment, and long-term follow-up review of a patient with recurrent intracranial MVIH and suggests that this unusual vascular lesion is a slow-growing benign tumor rather than a reactive process. Because the pathological composition of the lesion may resemble an angiosarcoma, understanding this benign vascular neoplasm is crucial so that an erroneous diagnosis of malignancy is not made and unnecessary adjuvant therapy is not given.

Judicial hanging: postmortem radiographic, CT, and MR imaging features with autopsy confirmation.

PURPOSE: To assess postmortem radiologic and pathologic findings by using modern imaging and autopsy techniques in two recent cases of judicial hangings. MATERIALS AND METHODS: Cervical spine radiography; computed tomography (CT) of the head, neck, and chest; magnetic resonance (MR) imaging of the head and cervical spine; and vertebral angiography were followed by a complete autopsy, including head and neck dissection. RESULTS: The first case (subaural knot) showed cervical spine ligamentous injury and partial disruption of the vertebral arteries without vertebral subluxation or injury to the cervical cord. The second case (submental knot) showed complete ligamentous disruption and subluxation at C2-3 with complete cord transection. In both cases, minimally displaced transverse process fractures were present, and CT and MR imaging of the head showed diffuse subarachnoid hemorrhage. CONCLUSIONS: The extent and distribution of injuries differed markedly in the two cases. The first case involved loss of consciousness probably from subarachnoid hemorrhage or cerebral hypoxia, followed by death due to cerebral anoxia. The second case involved a major spinal cord injury with subarachnoid hemorrhage.