Impact of multisection and immunohistochemistry in lymph node staging of Gastric Carcinoma - Case series.

Gastric carcinoma (GC) locoregional recurrence may occur even in cases where the tumor has been completely resected, possibly due to lymph node (LN) micrometastases. It is estimated that in 10% to 30% of cases, LN micrometastases are not detected by a conventional method for histological assessment of LN metastases with hematoxylin-eosin (HE). A cross-sectional study assessed 51 patients with GC by histological evaluation of the LN micrometastases through LN multi sectioning associated with immunohistochemistry analysis with monoclonal antibodies AE1 and AE3. Total gastrectomy was performed in 51% of patients. The total number of resected LN nodes was 1698, with a mean number of resected LN of 33.3 ± 13.2 per surgical specimen, of which 187 had metastasis. After the application of LN multisection and immunohistochemistry, LN micrometastases were found in 45.1% of the cases. LN staging changed in 29.4%, and tumor staging changed in 23.5% of the cases. In patients initially staged as pN0, LN staging and tumor staging changed, both in 19.2% of the cases. In patients initially staged as pN1 or more, LN staging changed in 40.0% of them, and tumor staging changed in 28.0% of the cases. The accuracy of HE for the histological staging of LN tumoral involvement was 76%, which was considered insufficient for CG patients staging. Investigation of LN micrometastasis through LN multisection and immunohistochemistry should be performed, particularly in cases where the presence of blood and lymphatic vessel invasion has been identified after conventional histological analysis, as well as in patients with advanced GC.

Thoracic endovascular stent graft repair for ascending aortic diseases.

OBJECTIVES: We describe the preliminary results of thoracic endovascular aortic repair (TEVAR) in a group of patients with ascending aortic disease from the Global Registry for Endovascular Aortic Treatment (GREAT). METHODS: We identified TEVAR performed for diseases truly originating from the ascending aorta. Between July 2011 and May 2015, 5014 patients were enrolled; six (0.12%) were identified and included in the analysis. One further patient was withdrawn from the study due to lack of a signed consent form. Patients having a "zone 0" proximal landing zone reported for their TEVAR without the presence of an ascending aortic disease were not included. Reinterventions of previous open and endovascular repair were also excluded. RESULTS: Three males and three females were treated. Mean age was 69 years ± 10 years (range, 58-83 years). Indication for TEVAR was atherosclerotic aneurysm (n = 4; ruptured, n = 1), complicated type A dissection (n = 1, rupture), and pseudoaneurysm (n = 1). Mean maximum aortic lesion diameter was 60 mm 14 (range, 39-77 mm). Urgent intervention was performed in three (50%) cases. Primary clinical success was 100%. There was no TEVAR-related in-hospital mortality. Open conversion was never required. Complication such as cerebrovascular accidents, valve impairment, or myocardial infarction did not occur. All patients were discharged home alive. No patient was lost at a median follow-up of 26 months (range, 16-72 months). During the follow-up, no patient died and ongoing primary clinical success was maintained in all patients. Reintervention was never required; endoleaks, migrations, fractures, or ruptures were not observed. CONCLUSIONS: Preliminary "real-world" experience of ascending TEVAR shows satisfactory outcomes at short-term follow-up. Although concerns remain for "off-label" use of standard devices, TEVAR-related complications were not observed. Longer follow-up data are expected to confirm durability of these results.

General outcomes and risk factors for minor and major amputations in Brazil.

Objectives Major and minor amputations are associated with significant rates of mortality. However, little is known about the impact of unplanned redo-amputation during the same hospitalization on outcomes. The objectives of this study were to identify the risk factors associated with in-hospital mortality after both major and minor amputations as well as the results of unplanned redo-amputation on outcome. Methods Retrospective study of 342 consecutive patients who were treated with lower extremity amputation in Brazil between January 2013 and October 2014. Results The in-hospital mortality rate was higher in major compared to minor amputation (25.6% vs. 4.1%; p < 0.0001). Whereas chronic kidney disease, chronic obstructive pulmonary disease, and planned staged amputation predicted in-hospital mortality after major amputation, age, and congestive heart failure predicted mortality after minor amputation. The white blood cell count predicted in-hospital mortality following both major and minor amputation. However, postoperative infection predicted in-hospital mortality only following major amputation. Conclusions In-hospital mortality was high after major amputations. Unplanned redo-amputation was not a predictor of in-hospital mortality after major or minor amputation. Planned staged amputation was associated with reduced survival after major but not minor amputation. Postoperative infection predicted mortality after major amputation. Systemic diseases and postoperative white blood cell were associated with in-hospital mortality. This study suggests a possible link between a pro-inflammatory state and increased in-hospital mortality following amputation.

Serum calprotectin is a biomarker of carotid atherosclerosis in patients with primary Sjögren's syndrome.

OBJECTIVES: We aimed to identify the association of carotid atherosclerosis with the traditional risk factors, disease features, cytokine profile, and calprotectin in patients with primary Sjögren's syndrome (pSS). METHODS: 63 primary pSS patients and 63 age- and sex-matched healthy controls underwent carotid ultrasound, clinical and laboratory examination. The presence of carotid plaques was taken as carotid atherosclerosis. The covariates of carotid atherosclerosis were identified in univariate and multivariate regressions. RESULTS: Patients with pSS had higher prevalence of carotid atherosclerosis (13% vs. 2%, p<0.05) and higher serum levels of calprotectin, tumour necrosis factor receptor 2 (TNF-R2), hepatocyte growth factor (HGF), and monocyte chemoattractant protein-1 (MCP-1) than controls. Sex, menopause, and the prevalence of traditional cardiovascular did not differ between groups (all p>0.05). In univariate analyses, serum calprotectin, most traditional cardiovascular (age, male sex, metabolic syndrome, hypertension, hypertriglyceridaemia, and serum creatinine), and some disease-associated risk factors (glucocorticoid or saliva substitute use, constitutional domain of Eular-Sjögren's syndrome disease activity index - EULAR) were associated with a higher risk for plaque. In a multivariate analysis, having pSS and higher serum calprotectin were associated with carotid atherosclerosis independent of traditional risk factors. CONCLUSIONS: pSS have a higher prevalence of carotid atherosclerosis, which is associated with higher serum calprotectin level independent of traditional cardiovascular risk factors. Our findings suggest calprotectin as a biomarker of subclinical atherosclerosis in pSS.

Early experience with off-the-shelf endografts using a zone 0 proximal landing site to treat the ascending aorta and arch.

OBJECTIVE: Acute type A aortic syndromes and its chronic complications are fatal diseases traditionally treated by open surgery, with high mortality rates. An endovascular approach to the ascending aorta could reduce the morbidity and mortality associated with open surgery. Our aim was to report our initial experience in treating ascending aortic pathology using commercially available descending thoracic endografts. METHODS: From 2007 to 2012, 69 patients presented to our center in Belo Horizonte, Brazil, with acute type A aortic syndrome or its chronic complications. Of the 69 patients, 8 high-risk patients had suitable anatomy, and 7 agreed to participate in the present study. RESULTS: Of the 7 patients, 4 had penetrating ulcers, 2 had acute dissections, and 1 had chronic dissection with an aneurysm. The technical success rate was 87%, with 1 intraoperative death from acute aortic valve insufficiency. The proximal landing zone was, on average, 21 mm above the aortic valve in all patients. Three patients required intraoperative cervical debranching due to a lesion in the distal third of the ascending aorta, compromising the supra-aortic branches. The distal landing zone was at zone 0 in 4 patients, zone 2 in 1 patient, and in zone 4 in 2 patients. The mean follow-up was 26.3 months. Two repeat dissections developed an average of 2 months after treatment. Both presented with acute dissection that was treated with additional open surgery and both patients survived. Thereafter, no patient had presented again with an acute aortic syndrome or other referable symptoms. CONCLUSIONS: Endovascular treatment of the ascending aorta is feasible. We had 4 good mid-term results in 7 patients who had presented with penetrating ulcers or aneurysm formation. Acute dissections seem to be more unstable, and additional research is mandatory.

Progression of carotid atherosclerosis in patients with systemic lupus erythematosus.

The progression of carotid atherosclerosis in lupus patients is frequently encountered, and it is determined by both traditional and nontraditional risk factors. Of the 181 patients initially included in the study, 157 patients were reevaluated after 39(37-42) months. The progression of atherosclerosis was defined as the increase in the intima-media thickness (IMT) >0.15 mm and/or an increase of the plaque score. The predictive factors of progression were identified using the Poisson regression model. The median of the cohort age at baseline was 38 years (range 29-46 years; 96.2% female, 75.8% nonwhite). Carotid atherosclerosis progression was observed in 43 patients (27.4%), an increased plaque score was observed in nine patients (5.7%), an increase of IMT >0.15 mm was observed in 31 (19.7%), and both issues were present in three patients (1.9%). The univariate determinants of atherosclerosis progression were age, systemic lupus erythematosus (SLE) duration, and higher serum level of triglycerides (p < 0.05). The presence of nephrotic proteinuria (p = 0.063), stage 3 or greater chronic kidney disease (p = 0.091), and longer duration of prednisone use (p = 0.056) showed a tendency towards association with progression of atherosclerosis. The independent risk factors for progression were the SLE duration (p = 0.008, RR = 1.06, 95% CI = 1.03-1.10) and the presence of nephrotic proteinuria (p = 0.022, RR = 4.22, 95% CI = 2.18-8.15). The progression of atherosclerosis occurred in a substantial number of young SLE patients during a short-term follow-up. The independent factors associated with this progression emphasize the importance of SLE in determining atherosclerosis in these individuals.

Relationship between quality of life and the CEAP clinical classification in chronic venous disease.

OBJECTIVES: To evaluate the quality of life (QOL) of patients with chronic venous disease (CVD) and to analyze the relationship between QOL and disease severity. METHODS: This was a cross-sectional study with a convenience sample of 50 participants with a diagnosis of CVD. The participants were classified according to disease severity using the CEAP clinical classification (Clinical manifestations, Etiological factors, Anatomical distribution of disease, Pathophysiological findings). They were then divided into two groups: CEAP 1, 2 and 3 (less clinically compromised) and CEAP 4, 5 and 6 (more clinically compromised). QOL was evaluated using the SF-36 questionnaire. The Mann-Whitney U test was used to compare the SF-36 scores between the groups. The Spearman correlation was used to evaluate the association between QOL and the CEAP. Differences were considered statistically significant with p < 0.05. The SPSS statistical software version 16.0 was used for the analyses. RESULTS: Seventy-four percent of the sample was female. The mean age was significantly higher (p<0.001) among participants classified as CEAP 4, 5 and 6 (56.6+/-10.3) than among those classified as CEAP 1, 2 and 3 (40.6+/-10.7). All the domains of the physical component of the SF-36 presented significantly lower scores in the CEAP 4, 5 and 6 group (p<0.05), thus showing greater physical and functional impairment. Only the domains of the physical component presented statistically significant negative correlations with the CEAP. CONCLUSIONS: The physical and functional characteristics were more impaired, especially in the more severe forms of CVD. These findings may contribute to a better understanding of the effects of CVD on QOL and better management of therapeutic interventions in this population.

Correlação entre classificação clínica ceap e qualidade de vida na doença venosa crônica / Relationship between quality of life and the ceap clinical classification in chronic venous disease

OBJETIVOS: Avaliar a qualidade de vida (QV) na doença venosa crônica (DVC) e analisar a relação entre QV e severidade da doença. MÉTODOS: Trata-se de um estudo transversal com uma amostra de conveniência de 50 pacientes com DVC diagnosticada. Os pacientes foram classificados quanto à severidade da DVC pela classificação clínica da Clinical manifestations, Etiologic factors, Anatomic distribuition of disease, Pathophysiologic findings (CEAP) e agrupados em: CEAP 1, 2, 3 (menos comprometidos clinicamente) e CEAP 4, 5, 6 (mais comprometidos clinicamente). A QV foi avaliada pelo questionário SF-36. Para comparação dos escores do SF-36 entre os grupos foi utilizado o teste Mann-Whitney U e para verificar associação entre QV e CEAP, o coeficiente de correlação de Spearman. Foi considerada diferença estatisticamente significativa p<0,05. O programa estatístico SPSS, versão 16.0 foi utilizado para as análises. RESULTADOS: 74 por cento da amostra eram mulheres e a média de idade foi significativamente maior (p<0,001) entre os indivíduos CEAP 4, 5, 6 (56,6±10,3) do que entre os CEAP 1, 2, 3 (40,6±10,7). Todos os domínios do Componente Saúde Física (CSF) do SF-36 apresentaram escores significativamente menores no grupo CEAP 4, 5, 6 (p<0,05), representando maior comprometimento físico e funcional. Apenas os domínios do CSF apresentaram correlação negativa e estatisticamente significativa com a CEAP. CONCLUSÕES: Os aspectos físicos e funcionais foram mais comprometidos, sobretudo nas formas mais graves da DVC. Estes achados podem contribuir para melhor compreensão dos efeitos da DVC na QV e melhor direcionamento das intervenções terapêuticas nessa população.

OBJECTIVES: To evaluate the quality of life (QOL) of patients with chronic venous disease (CVD) and to analyze the relationship between QOL and disease severity. METHODS: This was a cross-sectional study with a convenience sample of 50 participants with a diagnosis of CVD. The participants were classified according to disease severity using the CEAP clinical classification (Clinical manifestations, Etiological factors, Anatomical distribution of disease, Pathophysiological findings). They were then divided into two groups: CEAP 1, 2 and 3 (less clinically compromised) and CEAP 4, 5 and 6 (more clinically compromised). QOL was evaluated using the SF-36 questionnaire. The Mann-Whitney U test was used to compare the SF-36 scores between the groups. The Spearman correlation was used to evaluate the association between QOL and the CEAP. Differences were considered statistically significant with p < 0.05. The SPSS statistical software version 16.0 was used for the analyses. RESULTS: Seventy-four percent of the sample was female. The mean age was significantly higher (p<0.001) among participants classified as CEAP 4, 5 and 6 (56.6±10.3) than among those classified as CEAP 1, 2 and 3 (40.6±10.7). All the domains of the physical component of the SF-36 presented significantly lower scores in the CEAP 4, 5 and 6 group (p<0.05), thus showing greater physical and functional impairment. Only the domains of the physical component presented statistically significant negative correlations with the CEAP. CONCLUSIONS: The physical and functional characteristics were more impaired, especially in the more severe forms of CVD. These findings may contribute to a better understanding of the effects of CVD on QOL and better management of therapeutic interventions in this population.

Clinical and hemodynamic significance of the greater saphenous vein diameter in chronic venous insufficiency.

HYPOTHESIS: As the compliant greater saphenous vein (GSV) adjusts its luminal size to the level of transmural pressure, measurement of its diameter, reflecting the severity of hemodynamic compromise in limbs with GSV reflux, may simplify the hemodynamic criteria of patient selection for saphenectomy. OBJECTIVE: To evaluate the clinical significance of GSV diameter determined in the thigh and calf as a marker of global hemodynamic impairment and clinical severity in a model comprising patients with saphenofemoral junction and truncal GSV incompetence. DESIGN: A cohort study. SETTING: University-associated tertiary care hospitals in Brazil and England. PATIENTS: Eighty-five consecutive patients, aged 28 to 82 (mean, 46.2) years; 112 lower limbs with saphenofemoral junction and truncal GSV incompetence were investigated. INTERVENTIONS: Clinical examination was followed by clinical, etiological, anatomical, and pathophysiological classification (CEAP), vein duplex, and air plethysmography. The GSV diameter was measured on standing at the knee, and at 10, 20, and 30 cm above and below the knee, and in the thigh and calf, respectively, using B-mode imaging. The venous filling index (VFI), venous volume (VV), and residual volume fraction (RVF) were measured by air plethysmography. MAIN OUTCOME MEASURES: The GSV diameter was correlated with the VFI, VV, RVF, and CEAP. The value of the GSV diameter for predicting the presence of critical reflux (VFI >7 mL/s) or the absence of abnormal reflux (VFI <2 mL/s) was determined with receiver-operator curves. RESULTS: The GSV diameter increased significantly overall with CEAP (P<.001) and also increased progressively with proximity to the saphenofemoral junction. The VFI, VV, and RVF increased significantly from CEAP(0) through CEAP(4-6); the VFI correlated well with VV, RVF, and CEAP (P<.001 for all). The GSV diameter at all 7 limb levels studied correlated well with VV (except at the distal calf), VFI, RVF, and CEAP (P< or =.009 for all). A GSV diameter of 5.5 mm or less predicted the absence of abnormal reflux, with a sensitivity of 78%, a specificity of 87%, positive and negative predictive values of 78%, and an accuracy of 82%. A GSV diameter of 7.3 mm or greater predicted critical reflux (VFI >7 mL/s), with an 80% sensitivity, an 85% specificity, and an 84% accuracy. CONCLUSION: The GSV diameter proved to be a relatively accurate measure of hemodynamic impairment and clinical severity in a model of saphenofemoral junction and GSV incompetence, predicting not only the absence of abnormal reflux, but also the presence of critical venous incompetence, assisting in clinical decision making before considering greater saphenectomy.