Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although ...percutaneous closure is increasingly undertaken.
Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older 72 (64-77) vs. 67 (61-73) years, P < 0.001 and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach aHR 1.44 (1.01-2.05), P = 0.042, and number of vessels with coronary artery disease aHR 1.22 (1.01-1.47), P = 0.043 were independently associated with long-term mortality.
Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.
A 60‐year‐old male presented with sudden onset chest pain and pulmonary edema. The investigation confirmed torrential aortic regurgitation of a bicuspid valve. At surgery, a ruptured fibrous strand ...was identified which had been supporting the left–right cusp commissure with loss of attachment to the aortic wall. This case demonstrates that fibrous strands may be present as a supporting structure of the aortic valve, and rupture can be a rare cause of torrential aortic regurgitation, similar in pathogenesis to how it may be associated with acute severe mitral regurgitation and chordae tendineae rupture.
Introduction
Axillary nodal status is one of the most important prognostic factors in breast cancer. In the present study we used it to determine the predictors of axillary lymph node metastases in ...breast cancer and to determine if there is a group of patients in whom minimal axillary surgery is indicated.
Methods
This article reports a retrospective study of 953 patients with T1 and T2 invasive breast carcinomas seen in the University Malaya Medical Centre between January 2001 and December 2005, where axillary dissection was done.
Results
Of the 953 patients, 283 (29.7%) had breast-conserving surgery, and the rest had mastectomies. In this series, 463 patients (48.6%) were younger than 50 years of age; 365 patients (38.3%) had lymph node involvement. The Malays tend to have more axillary node metastases (45.1%) than the Chinese (36.9%); however, there was no significant relationship between age and race and lymph node involvement. Some 23.9% of grade 1 cancers were node positive, compared to 42.9% of grade 2/3 cancers. Tumor size ranged from 0.2 cm to 5 cm; 55.5% of tumors were T2 (>2–5 cm). There were only 13 (1.4%) T1a tumors (>0.1–0.5 cm). Node involvement was documented in 7.7% of T1a tumors, 12.3% of T1b tumors (>0.5–1 cm), 29.2% of T1c tumors, and 48.2% of T2 tumors. In patients who had no lymphovascular invasion (LVI), 24.4% had axillary node metastases, compared with 52.2% of patients where LVI was reported. On univariate analysis, our study found that tumor diameter >2 cm, presence of lymphovascular invasion, and higher tumor grade (2 & 3) were factors significantly associated with a higher risk of nodal metastases. On multivariate analysis, however, only lymphovascular invasion and tumor size were independent predictors based on the logistic regression.
Conclusions
In T1 tumors, axillary lymph node dissection will overtreat almost 75% of cases; therefore a sentinel lymph node biopsy is justified in these tumors. Sentinel lymph node biopsy has been shown to reduce the complications of formal axillary dissection, such as shoulder stiffness, pain, and lymphedema. In patients with T2 tumors, where almost 45% have lymph node involvement, sentinel node biopsy may not be cost effective.
Immunosuppression for lung transplantation Ng, Choo Y; Madsen, Joren C; Rosengard, Bruce R ...
Frontiers in bioscience (Landmark. Print),
01/2009, Letnik:
14, Številka:
5
Journal Article
Recenzirano
Odprti dostop
As a result of advances in surgical techniques, immunosuppressive therapy, and postoperative management, lung transplantation has become an established therapeutic option for individuals with a ...variety of end-stage lung diseases. The current 1-year actuarial survival rate following lung transplantation is approaching 80%. However, the 5- year actuarial survival rate has remained virtually unchanged at approximately 50% over the last 15 years due to the processes of acute and chronic lung allograft rejection (1). Clinicians still rely on a vast array of immunosuppressive agents to suppress the process of graft rejection, but find themselves limited by an inescapable therapeutic paradox. Insufficient immunosuppression results in graft loss due to rejection, while excess immunosuppression results in increased morbidity and mortality from opportunistic infections and malignancies. Indeed, graft rejection, infection, and malignancy are the three principal causes of mortality for the lung transplant recipient. One should also keep in mind that graft loss in a lung transplant recipient is usually a fatal event, since there is no practical means of long-term mechanical support, and since the prospects of re-transplantation are low, given the shortage of acceptable donor grafts. This chapter reviews the current state of immunosuppressive therapy for lung transplantation and suggests alternative paradigms for the management of future lung transplant recipients.
Lung transplant recipients with documented gastroesophageal reflux disease (GERD) are at increased risk for graft dysfunction. Here, we present the first large-animal model of gastric aspiration ...after allogeneic lung transplantation and some preliminary data demonstrating the effect of chronic aspiration on the direct and indirect pathways of allorecognition.
Left orthotopic lung transplants (n=3) were performed in miniature swine across a major histocompatibility complex class I disparity, followed by 12 days of high-dose cyclosporine A. At the time of transplantation, a transtracheal catheter was placed at the carina, above the bronchial anastomosis. A gastrostomy tube was placed for daily aspiration of gastric contents. Subsequently, graft lungs were instilled with gastric aspirate daily (3 mL/hrX8 hr/day) for 50 days. Recipients were followed up with daily complete blood count, scheduled chest radiographs, and biopsies. In vitro studies, including cell-mediated lympholysis, mixed lymphocyte reactions, and peptide proliferation assays, were performed. Results from these three recipients were compared with those of historical controls (n=6) who were treated identically, except for the tracheal cannulation and simulated gastric aspiration.
Two of the experimental animals were euthanized with nonviable lungs soon after the postoperative day 50 biopsy. In both cases the native lung was normal. The third animal survived over 180 days without the evidence of chronic rejection. After immunosuppressive treatment, all animals demonstrated donor-specific hyporesponsiveness by assays of direct alloresponse (cell-mediated lympholysis, mixed lymphocyte reaction). A significant response to synthetic donor-derived class I peptide, however, was seen in all animals. A more pronounced and diffuse response was seen in the animals rejecting their grafts. The historical controls showed medium-term graft survival with evidence of chronic rejection in the majority of animals, as previously reported.
In a model of GERD after lung transplantation, a spectrum of clinical outcomes was observed. The in vitro data suggest that acid reflux enhances the indirect alloresponse to processed donor class I antigen, giving mechanistic insight into the manner in which GERD may be deleterious to the transplanted lung.
Solid organ transplantation is limited by an insufficient number of organs to meet the needs of a growing population of patients with end-organ failure. A second problem is that, after successful ...transplantation, many organs fail owing in large part to chronic immunologic injury or so called "chronic rejection". In other circumstances, the organ "outlives" the recipient, often because the recipient succumbs to medical conditions related to chronic immunosuppression. This review focuses on two future therapies that could solve these problems, specifically, tolerance induction to permit long-term patient and graft survival and xenotransplantation to provide an unlimited supply of donor organs. The primary focuses are the most promising ongoing transplantation research that could be encountered by clinical surgeons in the near future.
The objective of this study was to explore the roles and perceptions of general practitioners (GPs) in the management of erectile dysfunction (ED). This qualitative study used focus group discussions ...and in-depth interviews. This study was conducted based on 28 GPs from an urban area in Malaysia who had managed patients with ED and prescribed anti-ED drugs. Main outcome measures included the roles of GPs in managing patients with ED (active or passive), perceptions regarding ED and the treatment, and factors influencing their decision to prescribe. Majority of the GPs assumed a passive role when managing patients with ED. This was partly due to their perception of the disease being nonserious. Some also perceived ED as mainly psychological in nature. The anti-ED drugs were often viewed as a lifestyle drug with potentially serious side effects. The fear of being perceived by patients as 'pushing' for the drug and being blamed if the patients were to develop serious side effects also hampered the management of this disease. GPs who participated in this study remained passive in identifying and treating patients with ED and this was attributed to their perception of the disease, drug treatment and patient's background.
Previous reports showed that vitamin E in palm oil consists of various isomers of tocopherols and tocotrienols α‐tocopherol (α−T), α‐tocotrienol, γ‐tocopherol, γ‐tocotrienol, and δ‐tocotrienol), and ...this is normally analyzed using silica column HPLC with fluorescence detection. In this study, an HPLC‐fluorescence method using a C30 silica stationary phase was developed to separate and analyze the vitamin E isomers present in palm oil. In addition, an α‐tocomonoenol (α−T1) isomer was quantified and characterized by MS and NMR. α−T1 constitutes about 3–4% (40±5 ppm) of vitamin E in crude palm oil (CPO) and is found in the phytonutrient concentrate (350±10 ppm) from palm oil, whereas its concentration in palm fiber oil (PFO) is about 11% (430±6 ppm). The relative content of each individual vitamin E isomer before and after interesterification/transesterification of CPO to CPO methyl esters, followed by vacuum distillation of CPO methyl esters to yield the residue, remained the same except for α−T and γ−T3. Whereas α−T constitutes about 36% of the total vitamin E in CPO, it is present at a level of 10% in the phytonutrient concentrate. On the other hand, the composition of γ−T3 increases from 31% in CPO to 60% in the phytonutrient concentrate. Vitamin is present at 1160±43 ppm, and its concentrations in PFO and the phytonutrient concentrate are 4,040±41 and 13,780±65 ppm, respectively. The separation and quantification of α−T1 in palm oil will lead to more in‐depth knowledge of the occurrence of vitamin E in palm oil.
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