Mild hypothermia during global cardiac ischemia opens a window of opportunity to develop heart donation after cardiac death

Although heart donation after cardiac death (DCD) could greatly improve graft availability, concerns regarding warm ischemic damage typically preclude transplantation. Improving tolerance to warm ischemia may thus open a window of opportunity for DCD hearts. We investigated the hypothesis that, compared with normothermia, mild hypothermia (32° C) initiated after ischemic onset improves cardiac functional recovery upon reperfusion. Isolated, working hearts from adult, male Wistar rats underwent global, no-flow ischemia, and reperfusion (n = 28). After ischemic onset, temperature was maintained at either 37° C for 20 or 30 min or reduced to 32° C for 40, 50, or 60 min. Recovery was measured after 60-min reperfusion. Following normothermic ischemia, recovery of rate-pressure product (RPP; per cent of preischemic value) was almost complete after 20-min ischemia (97 ± 9%), whereas no recovery was detectable after 30-min ischemia. After mildly hypothermic ischemia (32° C), RPP also recovered well after 40 min (86 ± 4%). Markers of metabolism and necrosis were similar in 37° C/20 min and 32° C/40 min groups. Simple reduction in cardiac temperature by a few degrees after the onset of global ischemia dramatically prolongs the interval during which the heart remains resistant to functional deterioration. Preservation of hemodynamic function is associated with improved metabolic recovery and reduced necrosis. The application of mild hypothermia may be a simple first step towards development of clinical protocols for DCD heart recovery.

Antegrade selective cerebral perfusion and moderate hypothermia in aortic arch surgery: clinical outcomes in elderly patients

To evaluate the outcome in elderly patients (≥ 75 years) undergoing elective aortic arch surgery with the aid of selective antegrade cerebral perfusion (SACP) and moderate hypothermic circulatory arrest (HCA).

Imaging appearances of Buerger's disease complications in the upper and lower limbs

Thromboangiitis obliterans (Buerger's disease) is a rare, non-atherosclerotic, segmental, inflammatory vasculitis that most commonly involves small and medium-sized arteries, veins and nerves of the extremities and affects tobacco smokers between the ages of 25 and 45 years. The manifestations of Buerger's disease can be extremely variable and, therefore, awareness of the condition is important for both general and musculoskeletal radiologists. This paper presents the radiological appearance of the sequelae of Buerger's disease involving the upper and lower limbs.

Neurological complications of sclerotherapy for varicose veins

Sclerotherapy has been shown to be an effective and increasingly popular therapeutic strategy for the treatment of varicose veins. However, recent reports of serious side effects, including cerebrovascular accidents (CVA) and transient ischemic attacks (TIA), as well as speech and visual disturbances, have caused serious concern regarding its use. This review evaluated the reported incidences of neurological side effects associated with the use of sclerotherapy.

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC)

To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR).

Predictors of surgical, general and follow-up complications in lumbar spinal stenosis relative to patient age as emerged from the Spine Tango Registry

Published opinions regarding the outcomes and complications in older patients have a broad spectrum and there is a disagreement whether surgery in older patients entails a higher risk. Therefore this study examines the risk of surgery for lumbar spinal stenosis relative to age in the pooled data set of the Spine Tango registry.

Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complications

Decompressive craniectomy (DC) due to intractably elevated intracranial pressure mandates later cranioplasty (CP). However, the optimal timing of CP remains controversial. We therefore analyzed our prospectively conducted database concerning the timing of CP and associated post-operative complications. From October 1999 to August 2011, 280 cranioplasty procedures were performed at the authors' institution. Patients were stratified into two groups according to the time from DC to cranioplasty (early, ≤2 months, and late, >2 months). Patient characteristics, timing of CP, and CP-related complications were analyzed. Overall CP was performed early in 19% and late in 81%. The overall complication rate was 16.4%. Complications after CP included epidural or subdural hematoma (6%), wound healing disturbance (5.7%), abscess (1.4%), hygroma (1.1%), cerebrospinal fluid fistula (1.1%), and other (1.1%). Patients who underwent early CP suffered significantly more often from complications compared to patients who underwent late CP (25.9% versus 14.2%; p=0.04). Patients with ventriculoperitoneal (VP) shunt had a significantly higher rate of complications after CP compared to patients without VP shunt (p=0.007). On multivariate analysis, early CP, the presence of a VP shunt, and intracerebral hemorrhage as underlying pathology for DC, were significant predictors of post-operative complications after CP. We provide detailed data on surgical timing and complications for cranioplasty after DC. The present data suggest that patients who undergo late CP might benefit from a lower complication rate. This might influence future surgical decision making regarding optimal timing of cranioplasty.

Transcatheter aortic valve implantation: prevention and management of complications

Assessment of elderly patients with severe aortic stenosis and decisions in terms of management strategy (conservative with or without balloon aortic valvuloplasty, transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement) are complex and warrant a multidisciplinary approach involving collaboration between experienced cardiac surgeons, interventional cardiologists, cardiac imaging specialists, anaesthesiologists, geriatricians and a specialised nursing staff. Patient history, comorbid conditions, perioperative risk stratification as well as anatomical and procedural considerations require careful review on an individual, case-by-case basis and have a major impact on treatment allocation. The aims of this article are to provide insights into the fundamental role of appropriate patient screening and selection, and to review the nature, management and prevention of the most important procedural complications associated with the TAVI procedure.

Connective tissue growth factor level is increased in patients with liver cirrhosis but is not associated with complications or extent of liver injury

Connective tissue growth factor (CTGF) is a profibrotic protein whose systemic levels are increased in liver cirrhosis. Here, association of CTGF with stages of liver injury and complications of cirrhotic liver disease has been analyzed in patients with different aetiologies of hepatic injury. CTGF is significantly increased in portal venous serum (PVS), hepatic venous serum (HVS) and systemic venous serum (SVS) of 46 patients with liver cirrhosis compared to eight liver-healthy controls. In patients´ blood samples CTGF in HVS is about 6% higher than PVS levels indicating that CTGF produced in the liver is released to the circulation. CTGF is not associated with stages of liver cirrhosis defined by CHILD-PUGH or MELD score nor with secondary complications of portal hypertension (varices, ascites, spontaneous bacterial peritonitis). Transforming growth factor β (TGFβ) induces CTGF synthesis in hepatocytes and a positive association of systemic TGFβ1 and SVS and HVS CTGF is found. Three months after placing transjugular intrahepatic portosystemic shunt (TIPS) hepatic venous pressure gradient is reduced whereas CHILD-PUGH score, TGFβ1 and CTGF are not altered in serum of 15 patients. Current data show that the cirrhotic liver releases little CTGF but SVS, HVS and PVS CTGF levels are not associated with residual liver function and complications of cirrhosis.

Therapeutic hypothermia in term infants after perinatal encephalopathy: The last 5 years in Switzerland

Background: Therapeutic hypothermia (TH) following perinatal asphyxial encephalopathy in term infants improves mortality and neurodevelopmental outcome. In Europe, most neonatal units perform active cooling whereas in Switzerland passive cooling is predominantly used. Aims: (i) To determine how many infants were cooled within the last 5 years in Switzerland, (ii) to assess the cooling methods, (iii) to evaluate the variation of temperature of different cooling methods, and (iv) to evaluate the use of neuromonitoring. Study design: Retrospective cohort study. Patients: Notes of all cooled term infants between March 2005 and December 2010 in 9 perinatal and two paediatric intensive care centres were retrospectively reviewed. Active cooling was compared to passive cooling alone and to passive cooling in combination with gel packs. Results: 150 infants were cooled. Twenty-seven (18.2%) were cooled actively, 34 (23%) passively and 87 (58.8%) passively in combination with gel packs. Variation of temperature was significantly different between the three methods. Passive cooling had a significant higher variation of temperature (SD of 0.89) than both passive cooling in combination with gel packs (SD of 0.79) and active cooling (SD of 0.76). aEEG before TH was obtained in 35.8% of the infants and 86.5% had full EEG. One cUS was performed in 95.3% and MRI in 62.2% of the infants. Conclusion: Target temperature can be achieved with all three cooling methods. Passive cooling has the highest variation of temperature. Neuromonitoring should be improved in Swiss neonatal and paediatric intensive care units. Our results stress the importance of national registries.

Long-term results and complications following uvulopalatopharyngoplasty in 116 consecutive patients

A modified uvulopalatopharyngoplasty (UPPP) was carried out between January 1992 and December 2003 at the ENT Department of the Inselspital in Bern in 146 patients with habitual or complicated rhonchopathy. The operation consisted of a classical tonsillectomy or residual tonsil resection and additional shortening of the uvula. The natural mucosal fold between the uvula and the upper pole of the tonsils was carefully preserved. A wide opening to the rhinopharynx was created by asymmetric suturing of the glossopalantine and pharyngopalatine arches. A retrospective questionnaire with regard to rhonchopathy, phases of apnea, daytime drowsiness, obstruction of nasal breathing, long-term complications and patient satisfaction was used to evaluate the short-term and long-term effectiveness of the modified UPPP as well as the incidence of adverse side effects. Complete postoperative courses were evaluated in 116 patients. Surgical complications were restricted to one case with postoperative hemorrhage. A velum insufficiency or postoperative rhinopharyngeal stenosis did not occur. Eighty-three patients (72%) confirmed a persistent suppression or substantial improvement of the rhonchopathy. Disappearance or decrease of sleep apnea was confirmed in 12 (63%) out of 19 postoperative polysomnographic follow-up investigations. Long-term complications occurred in a total of 27 (23%) of 116 patients. They were confined to minor problems such as dryness of the mouth (n = 12), slight difficulty in swallowing (n = 7), discrete speech disturbances (n = 1), and slight pharyngeal dysesthesias (n = 7) with feeling of a lump in the throat and compulsive clearing of the throat. Eighty-five patients (73%) reported that they were satisfied with the postoperative result even several years after the operation. Looking back, 31 patients (27%) would no longer have the operation performed. The inadequate result of the rhonchopathy was specified as the reason by 21 patients. Ten patients had unpleasant memories of the operation because of intensive postoperative pain. Snoring and apneic phases are suppressed or improved by non-traumatic UPPP in the majority of patients. This effect persisted even years after the operation.

Mechanical thrombectomy for acute ischemic stroke: thrombus-device interaction, efficiency, and complications in vivo

BACKGROUND AND PURPOSE: Mechanical thrombectomy is a promising new modality of interventional stroke treatment. The various devices differ with regard to where they apply force on the thrombus, taking a proximal approach such as aspiration devices or a distal approach such as basket-like devices. The study compares the in vivo effectiveness and thrombus-device interaction of these 2 approaches. METHODS: Angiography and embolization with a radioopaque whole blood thrombus was performed in 10 swine. Mechanical thrombectomy was performed in 20 cranial vessels using a proximal aspiration device (Vasco35) and a distal basket-like device (Catch) with and without proximal balloon occlusion. Fifty-six retrieval attempts were made. RESULTS: The proximal device allowed fast repeated application with a low risk of thromboembolic events (3%) and vasospasm, but it had a significantly lower success rate (39.4%) in retrieving thrombotic material than the distal device (DD) (82.6%; odds ratio, 7.3; 95% CI, 2.0 to 26.4). The compaction of the thrombus during retrieval with DD increased the risk of vessel wall irritation significantly (P<0.01) and complicated retrieval into the guiding catheter. The number of embolic events was significantly higher with DD (26%; odds ratio, 11.3; 95% CI, 1.35 to 101.6) unless proximal balloon occlusion was used. CONCLUSIONS: The proximal and the distal approaches to mechanical thrombectomy proved to be effective at achieving recanalization of cranial vessels. The proximal device is faster in application and allowed repeated attempts with a low complication rate. The DD is more successful at removing thrombotic material, but its method of application and attendant thrombus compaction increase the risk of thromboembolic events and vasospasms.

Incidence of severe reproductive tract complications associated with diagnosed genital chlamydial infection: the Uppsala Women's Cohort Study

OBJECTIVE: To estimate the cumulative incidence of severe complications associated with genital chlamydia infection in the general female population. METHODS: The Uppsala Women's Cohort Study was a retrospective population based cohort study in Sweden, linking laboratory, hospital, and population registers. We estimated the cumulative incidence of hospital diagnosed pelvic inflammatory disease, ectopic pregnancy, and infertility, and used multivariable regression models to estimate hazard ratios according to screening status. RESULTS: We analysed complete data from 43 715 women in Uppsala aged 15-24 years between January 1985 and December 1989. Follow up until the end of 1999 included 709 000 woman years and 3025 events. The cumulative incidence of pelvic inflammatory disease by age 35 years was 3.9% (95% CI 3.7% to 4.0%) overall: 5.6% (4.7% to 6.7%) in women who ever tested positive for chlamydia, 4.0% (3.7% to 4.4%) in those with negative tests, and 2.9% (2.7% to 3.2%) in those who were never screened. The corresponding figures were: for ectopic pregnancy, 2.3% (2.2% to 2.5%) overall, 2.7% (2.1% to 3.5%), 2.0% (1.8% to 2.3%), and 1.9% (1.7% to 2.1%); and for infertility, 4.1% (3.9% to 4.3%) overall, 6.7% (5.7% to 7.9%), 4.7% (4.4% to 5.1%), and 3.1% (2.8% to 3.3%). Low educational attainment was strongly associated with the development of all outcomes. CONCLUSIONS: The incidence of severe chlamydia associated complications estimated from ours, and other population based studies, was lower than expected. Studies that incorporate data about pelvic inflammatory disease diagnosed in primary care and behavioural risk factors would further improve our understanding of the natural history of chlamydia. Our results provide reassurance for patients, but mean that the benefits of chlamydia screening programmes might have been overestimated.