Background Patients with systemic sclerosis (SSc) are at risk for developing pulmonary hypertension, which is associated with a poor prognosis. Exercise Doppler echocardiography enables the ...identification of exercise-induced increase in pulmonary artery systolic pressure (PASP) and may provide a thorough noninvasive hemodynamic evaluation. Aim The aim of this study was to evaluate the clinical and echocardiographic determinants of exercise-induced increase in PASP in a large population of patients with SSc. Methods We selected 164 patients with SSc (age 58 ± 13 years, 91% female) with normal resting PASP (<40 mm Hg) who underwent a comprehensive 2-dimensional and Doppler echocardiography and graded bicycle semisupine exercise Doppler echocardiography. Pulmonary artery systolic pressure, cardiac output, and pulmonary vascular resistance (PVR) were estimated noninvasively. Cutoff values of PASP ≥50 mm Hg and PVR ≥3.0 Wood Units at peak exercise were considered a significant exercise-induced increase in PASP and PVR, respectively. Results Sixty-nine (42%) patients showed a significant exercise-induced increase in PASP. Among them, peak PVR ≥3 Wood Units was present only in 11% of patients, about 5% of the total population. Univariate analysis showed that age, presence of interstitial lung disease, and both right and left diastolic dysfunction are predictors of peak PASP ≥50 mm Hg, but none of these parameters predict elevated peak PVR. Conclusions Exercise-induced increase in PASP occurs in almost one-half of patients with SSc with normal resting PASP. Peak exercise PASP is affected by age, interstitial lung disease, and right and left ventricular diastolic dysfunction and, only in 5% of the patients, is associated with an increase in PVR during exercise, suggesting heterogeneity of the mechanisms underlying exercise-induced pulmonary hypertension in SSc.
Background New materials (NM) such as titanium plates, cryopreserved grafts, and acellular collagen matrices are being increasingly used for chest wall reconstruction as a result of improved ...incorporation while maintaining structural stability and reduced need for removal from infected areas. Direct comparisons between NM and conventional materials (CM) in terms of local morbidity and need for prosthesis removal are lacking. Methods Between January 2005 and July 2013, 109 procedures were performed to remove chest wall tumors in 86 patients. Of these, 32 underwent complex chest wall reconstructions owing to either recurrence, defect extension (greater than 3 ribs or >100 cm2 ) or local conditions (ie, previous irradiation or infection). New materials and CM (ie, polytetrafluoroethylene and methyl methacrylate) were used in 17 (53%) and 15 (47%) patients, respectively. Of the 32 patients included in the high complexity group, 23 patients did not exhibit any postoperative complications (72%). However, 9 patients (28%) underwent both a first and a second reoperation after a median interval of 4 months from the first procedure (range, 7 days to 60 months). Vacuum-assisted closure (VAC) was instituted in all patients as a means to control sepsis and facilitate space obliteration with healthy tissue. Results In 7 patients the reason for reintervention was local wound complications. In 4 of 7 patients, the prosthesis had to be removed (3 CM and 1 NM, 4.6% of the whole series; 12.5% in the high complexity group, 5.9% for NM and 20% for CM). The median time to complete chest wall healing after VAC in patients with local sepsis was 14 months (range, 5 to 60 months). All patients are currently alive and well except for 1 who died 11 months after complete chest wall healing as a result of dissemination of metastatic chondrosarcoma. At univariate analysis, predictors of overall and grade 2 or less morbidity according to the Common Terminology Criteria for Adverse Events version 4.0 were first ( p = 0.038) and second ( p = 0.015) redo operations. Conversely, patients with a body mass index of less than 25 kg/m2 ( p = 0.049) undergoing one ( p = 0.032) or two reconstructions ( p = 0.00047) with combined materials ( p = 0.00029) were more likely to experience local wound complications and require VAC. On multiple regression analysis, redo operations (first, p = 0.032; second, p = 0.00047) and the use of combined (synthetic and biologic) materials ( p = 0.0029) were confirmed to be related to an increased incidence of wound complications. Conclusions Multiple redo operations after complex chest wall reconstruction performed with a combination of NM and CM may be associated with an increased incidence of local wound complications. Nevertheless, in these cases, the use of NM and VAC yielded a low rate (5.8% versus 20% with CM) of prosthesis removal while achieving complete wound healing.
Abstract Objective The prognosis for eating disorders (ED) is unsatisfactory, and the literature about outcome indicators is controversial. The present study evaluates the roles of self-esteem, ...personality disorders (PD), and dissociation as outcome predictors. Method Fifty-seven ED outpatients were recruited from a population beginning a Cognitive Behavioral Therapy-Enhanced (CBT-E) treatment. All patients received the Structured Clinical Interview for DSM-IV Axis I (SCID-I), the Structured Clinical Interview for DSM-IV Axis II (SCID-II), and completed the Eating Disorder Examination Questionnaire (EDE-Q), the Dissociation Questionnaire (DIS-Q), and the Rosenberg Self-Esteem Scale (RSES). One month after the end of treatment, recovery was evaluated as meeting the DSM-IV criteria for EDs. Results A small group of patients recovered (42.2%). Low self-esteem and dissociation results correlated with a negative outcome. Discussion Dissociation may be an important moderator of psychotherapy and treatment success, as already suggested by previous studies on non-eating-related disorders.
The combination of titanium plates and acellular collagen matrix was used to restore anterior chest wall integrity in a 68-year-old woman more than 30 years after a Halsted mastectomy and radiation ...treatment. A vertical rectus abdominis muscle flap was used for myocutaneous coverage of the reconstructed chest wall. Partial necrosis of the flap caused prolonged exposure of the collagen matrix and the titanium plates, which were then covered with a free skin graft. Long-term results were satisfactory despite continued infection treated with vacuum-assisted closure and surgical debridement. Recently introduced materials for chest wall reconstruction may offer resilience to infection, tolerability, and stability, and their use may be contemplated when the potential for local morbidity is high.
Among the new materials introduced for chest wall reconstruction, the use of collagen matrix is gaining increasing favor for its biomechanical properties. We describe the reconstruction of the chest ...wall with Veritas (Synovis, St Paul, MN) collagen matrix of a posterior chest wall defect after costovertebrectomy for Ewing's sarcoma. En bloc resection was performed, including partial D7 through D9 vertebrectomy along with the posterolateral segments of corresponding ribs. The collagen matrix patch was sutured to the spine stabilizer and the surrounding rib segments and was covered by previously raised latissimus dorsi and trapezius muscle flaps. Excellent stabilization was obtained.
Major tenets in the reconstruction of the anterolateral chest wall include preservation of structural stability and function and coverage of the mediastinal contents. To reach these goals, a rigid ...support has been advocated by several authors. We describe a patient with extensive anterolateral defect after sternocostal resection of chondrosarcoma. Successful reconstruction was performed by using three metallic transverse plates and an omental flap wrapped onto the plates. This method simplifies reconstruction in comparison with previously described techniques concerning complete solid coverage and leaves several options intact in the event of future recurrences.
...in line with your observation, in our population, right ventricular diastolic dysfunction seems to be related to peak PASP values more than left ventricular diastolic dysfunction, as shown by the ...multivariate analysis.
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