Diaphragmmatic eventration: long-term follow-up and results of open-chest plicature

Objective: Diaphragmmatic eventration is a relatively uncommon entity with a simple surgical correction technique - plication of the diaphragm. This study aims to assess the clinical and ventilatory impact of this technique. Materials: From April 1988 to February 2007, we operated on 20 patients (12 men) with diaphragmmatic eventration using the postero-lateral approach and correction by radial plication. The mean age of the patients studied was 56.3+/-15.6 years (range: 13-74 years). A traumatic cause was identified in 13 patients; one patient had a congenital cause and the remainder were of idiopathic origin. Chronic obstructive pulmonary disease and arterial hypertension were present in one-half of the study group, while diabetes mellitus was present in three patients. Dyspnoea was the most common complaint in 75% of the patients, and thoracic pain was present in 25%. The mean forced expiratory volume in 1s (FEV(1)) and vital capacity (VC) were 66.2+/-15.3% and 70.4+/-16% of the predicted values, respectively. Results: There was no operative mortality. Apart from a patient with moderate/severe pain and another who had pneumonia, there were no other important perioperative complications. Average drainage time was 3.3+/-1.6 days (range: 2-7 days). Hospitalisation time was 6.2+/-1.6 days (5-10 days). Follow-up was complete, for a mean of 59.6+/-55.1 months (4-206 months). There were three late deaths (one sudden, one stroke and one trauma). Eight of the 17 survivors (47%) are asymptomatic. According to the MRC/ATS grading system, the dyspnoea score was 2.06+/-0.97 preoperatively and 1.06+/-1.14 postoperatively (p=0.007). At follow-up, the FEV(1) was 76.1+/-20.1% and the VC was 78.4+/-17.3% (p>0.1). Two patients had chronic pain. Conclusion: Plication of the diaphragm is a safe and efficient procedure. Most patients experienced significant clinical improvement with enhancement of the FEV(1) and VC. Chronic surgical pain still remains a potential problem with the classical approach

The Kite Latissimus Dorsi Flap for Breast Reconstruction: An Attempt to Reduce Lateral Chest Wall Deformity and Axillary Bulking

The latissimus dorsi flap is a commonly used tissue transfer for volume replacement in partial or total breast reconstruction. In this era of cosmetic awareness and oncoplastic breast surgery, two main defects are related to the conventional technique: the back scar and the bulkiness on the lateral chest wall, under the axilla. Axillary bulking, a disturbing defect for the majority of patients, is a persistent consequence, independent of the technique used, even when the proximal tendon is cut. We describe a new approach, the kite latissimus dorsi flap, consisting of harvesting the flap, partially or totally, with pedicle dissection from the muscle, extending dissection, perforator style if needed, until the external border of the breast (anterior axillary line) is reached. The muscle is then cut at that level, leaving no unnecessary volume under the axilla, which would cause bulkiness and chest wall deformity.info:eu-repo/semantics/publishedVersio

Anatomic Predictors for Late Mortality after Standard Endovascular Aneurysm Repair

Objective: Abdominal aortic aneurysm (AAA) management involves a decision process that takes into account anatomic characteristics, surgical risks, patients' preferences, and expected survival. Whereas larger AAA diameter has been associated with increased mortality after both standard endovascular aneurysm repair (EVAR) and open repair, it is unclear whether survival after EVAR is influenced by other anatomic characteristics. The purpose of this study was to determine the importance of baseline anatomic features on survival after EVAR. Methods: All patients treated at a tertiary teaching center with EVAR for intact standard infrarenal AAA from 2000 to 2014 were included. The civil data registry was queried to determine survival status; causes of death were obtained from death certificates. The primary study end point was to determine the impact of baseline morphologic features on all-cause and cardiovascular mortality after EVAR. Results: This study included 404 EVAR patients (12.1% women; mean age, 73 years) with a median follow-up of 5.8 years (interquartile range, 3.1-7.4 years). The 5- and 10-year overall survival rates for the entire population after EVAR were 70% (95% confidence interval [CI], 66%-75%) and 43% (95% CI, 37%-50%), respectively. Only AAA diameter >70 mm (hazard ratio [HR], 1.75; 95% CI, 1.20-3.56) was identified as an independent anatomic predictor of all-cause mortality. Death due to cardiovascular causes occurred in 60 (38.5%) patients. Aneurysm-related mortality was responsible for six of the cardiovascular-related deaths. In multivariable analysis, both neck diameter ≥30 mm (HR, 2.16; 95% CI, 1.05-4.43) and AAA diameter >70 mm (HR, 2.45; 95% CI, 1.34-4.46) were identified as independent morphologic risk factors for cardiovascular mortality, whereas >25% circumferential neck thrombus (HR, 0.32; 95% CI, 0.13-0.77) was protective. Conclusions: This study suggests that patients with AAA diameters >70 mm are at increased risk of all-cause and cardiovascular mortality. In addition, patients with infrarenal neck diameters ≥30 mm have a greater risk of cardiovascular mortality, although AAA-related deaths were not more frequent in this group of patients. Consequently, a more aggressive management of cardiovascular medical comorbidities may be warranted to improve survival after standard EVAR in these patients.info:eu-repo/semantics/publishedVersio

Patients with Large Neck Diameter Have a Higher Risk of Type IA Endoleaks and Aneurysm Rupture after Standard Endovascular Aneurysm Repair

Objective: Standard endovascular aneurysm repair (EVAR) is the most common treatment of abdominal aortic aneurysms (AAAs). EVAR has been increasingly used in patients with hostile neck features. This study investigated the outcomes of EVAR in patients with neck diameters ≥30 mm in the prospectively maintained Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE). Methods: This is a retrospective study comparing patients with neck diameters ≥30 mm with patients with neck diameters <30 mm. The primary end point was type IA endoleak (EL1A). Secondary end points included secondary interventions to correct EL1A, aneurysm rupture, and survival. Results: This study included 1257 patients (mean age, 73.1 years; 89.4% male) observed for a median 4.0 years (interquartile range, 2.7-4.8 years). A total of 97 (7.7%) patients had infrarenal neck diameters ≥30 mm and were compared with the remaining 1160 (92.3%) with neck diameters <30 mm. At baseline, there were no differences between groups regarding demographics and comorbidities other than cardiac disease, which was more frequent in the ≥30-mm neck diameter group (P = .037). There were no significant differences between the groups regarding neck length, angulation, thrombus, or calcification. Mean preoperative AAA diameter was 64.6 ± 11.3 mm in the ≥30-mm neck diameter group and 60.0 ± 11.6 mm in the <30-mm neck diameter group (P < .001). Stent graft oversizing was significantly less in the ≥30-mm neck diameter group (12.2% ± 8.9% vs 22.1% ± 11.9%; P <. 001). Five patients (5.2%) in the ≥30-mm neck diameter group and 30 (2.6%) with neck diameters <30 mm developed EL1A, yielding a 4-year freedom from EL1A of 92.4% vs 96.6%, respectively (P = .09). Oversizing was 21.8% ± 13.0% for patients developing EL1A and 21.3% ± 12.4% for the remaining cohort (P = .99). In adjusting for neck length, AAA diameter, and device oversizing, patients with neck diameter ≥30 mm were at greater risk for development of EL1A (hazard ratio, 3.0; 95% confidence interval, 1.0-9.3; P = .05). Secondary interventions due to EL1A did not differ between groups (P = .36). AAA rupture occurred in three patients with neck diameter ≥30 mm (3.1%) and in eight patients with neck diameter <30 mm (0.7%; hazard ratio, 5.1; 95% confidence interval, 1.4-19.2; P = .016); two cases were EL1A related in each group. At 4 years, overall survival was 61.6% for the ≥30-mm neck diameter group and 75.2% for the <30-mm neck diameter group (P = .009), which remained significant on correcting for sex and AAA diameter (P = .016). Conclusions: In this study, patients with infrarenal neck diameter ≥30 mm had a threefold increased risk of EL1A and fivefold risk of aneurysm rupture after EVAR as well as worse overall survival. This may influence the choice of AAA repair and underlines the need for regular computed tomography-based imaging surveillance in this subset of patients. Furthermore, these results can serve as standards with which new, possibly improved technology, such as EndoAnchors (Medtronic, Santa Rosa, Calif), can be compared.info:eu-repo/semantics/publishedVersio

Total Luminal Volume Predicts Risk after Endovascular Aneurysm Repair

Objective: Large aneurysm diameter represents a well known predictor of late complications after endovascular aneurysm repair (EVAR). However, the role of the thrombus free lumen inside the abdominal aortic aneurysm (AAA) sac is not clear. It was hypothesised that greater luminal volume represents a relevant risk factor for late complications after EVAR. Methods: A retrospective cohort analysis was performed including all patients undergoing EVAR from 2005 to 2016 at a tertiary referral institution. Pre-operative AAA lumen volume was measured in centre lumen line reconstructions and patients were stratified into quartiles according to luminal volume. The primary endpoint was freedom from AAA related complications. Secondary endpoints were freedom from neck events (type 1A endoleak, migration >5 mm or any pre-emptive neck related intervention), iliac related events (type 1B endoleak or pre-emptive iliac related intervention), and overall survival. Results: Four hundred and four patients were included: 101 in the first quartile (Q1; <61 cm3). Patients with higher luminal volumes had wider, shorter, and more angulated proximal necks. There were more ruptured AAAs, more aorto-uni-iliac implanted devices and patients outside neck instructions for use in the 4th quartile. Five year freedom from AAA related complications was 79%, 66%, 58% and 56%, respectively (p = .007). At five years, freedom from neck related events was 86%, 84%, 73%, and 71%, respectively, for the four groups (p = .009), and freedom from iliac related events was 96%, 91%, 88%, and 88%, respectively (p = .335). On multivariable analysis, luminal volume was an independent predictor of late complications (Q4 vs. Q1 - hazard ratio: 1.91, 95% confidence interval 1.01-3.6, p = .046). Overall survival at five years was not affected by lumen volume (p = .75). Conclusion: AAA luminal volume represents an important risk factor for AAA related complications. This information may be considered when deciding tailoring surveillance protocols after EVAR. However, larger studies are needed to validate this hypothesis.info:eu-repo/semantics/publishedVersio

Universality in Systems with Power-Law Memory and Fractional Dynamics

There are a few different ways to extend regular nonlinear dynamical systems by introducing power-law memory or considering fractional differential/difference equations instead of integer ones. This extension allows the introduction of families of nonlinear dynamical systems converging to regular systems in the case of an integer power-law memory or an integer order of derivatives/differences. The examples considered in this review include the logistic family of maps (converging in the case of the first order difference to the regular logistic map), the universal family of maps, and the standard family of maps (the latter two converging, in the case of the second difference, to the regular universal and standard maps). Correspondingly, the phenomenon of transition to chaos through a period doubling cascade of bifurcations in regular nonlinear systems, known as "universality", can be extended to fractional maps, which are maps with power-/asymptotically power-law memory. The new features of universality, including cascades of bifurcations on single trajectories, which appear in fractional (with memory) nonlinear dynamical systems are the main subject of this review.Comment: 23 pages 7 Figures, to appear Oct 28 201

Intraventricular Pressure Gradients in Heart Failure

The aim of the present study was to characterize intraventricular pressure gradients (IVPGs) in an animal model of chronic heart failure. New Zealand rabbits were treated with doxorubicin (heart failure group, n=5) or saline (control group, n=5) and instrumented with pressure catheters placed in the apex and outflow-tract of left ventricle (LV) and with sonomicrometer crystals placed in the apex and base of the LV free wall. In heart failure animals, ventricular filling was delayed and slower when compared with control animals. Moreover, the physiological nonuniformity observed between apical and basal segments in normal hearts was abolished in failing hearts. Simultaneously, physiological IVPGs observed during normal ventricular filling were entirely lost in heart failure animals. During ventricular emptying physiological nonuniformity between apical and basal segments observed in control animals was also abolished in heart failure animals. In failing hearts minimal length occurred later and almost at same time both in apical and in basal myocardial segments. Simultaneously, the characteristic IVPG pattern observed in healthy hearts during systole, which promotes ventricular emptying, was not observed in failing hearts. The present study showed that diastolic IVPGs, a marker of normal ventricular filling, and systolic IVPGs, a marker of normal ventricular emptying, are abolished in heart failure

DMSO removal reduces stem-cell infusion-related toxicity and allows excellent engraftment of cryopreserved unrelated cord blood and autologous stem cells

UNIFESP, GRAACC, Pediat Oncol Inst, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilUNIFESP, GRAACC, Pediat Oncol Inst, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilWeb of Scienc

Direct and Inverse Variational Problems on Time Scales: A Survey

We deal with direct and inverse problems of the calculus of variations on arbitrary time scales. Firstly, using the Euler-Lagrange equation and the strengthened Legendre condition, we give a general form for a variational functional to attain a local minimum at a given point of the vector space. Furthermore, we provide a necessary condition for a dynamic integro-differential equation to be an Euler-Lagrange equation (Helmholtz's problem of the calculus of variations on time scales). New and interesting results for the discrete and quantum settings are obtained as particular cases. Finally, we consider very general problems of the calculus of variations given by the composition of a certain scalar function with delta and nabla integrals of a vector valued field.Comment: This is a preprint of a paper whose final and definite form will be published in the Springer Volume 'Modeling, Dynamics, Optimization and Bioeconomics II', Edited by A. A. Pinto and D. Zilberman (Eds.), Springer Proceedings in Mathematics & Statistics. Submitted 03/Sept/2014; Accepted, after a revision, 19/Jan/201