Locoregional versus general anesthesia in carotid surgery: Is there an impact on peri-operative myocardial ischemia? Results of a prospective monocentric randomized trial.

PURPOSE: The incidence of cardiac morbidity and mortality in patients who undergo carotid surgery ranges from 0.7% to 7.1%, but it still represents almost 50% of all perioperative complications. Because no data are available in literature about the impact of the anesthetic technique on such complications, a prospective randomized monocentric study was undertaken to evaluate the role of local anesthesia (LA) and general anesthesia (GA) on cardiac outcome. METHODS: From November 1995 to February 1998, 107 patients were classified by the cardiologist as cardiac patients (IHD; history of myocardial infarction, previous myocardial revascularization procedures, or myocardial ischemia documented by means of positive electrocardiogram [ECG] stress test results) or noncardiac patients (NIHD; no history of chest pain or negative results for an ECG stress test). The patients were operated on after the randomization for the type of anesthesia (general or local). Continuous computerized 12-lead ECG was performed during the operative procedure and 24 hours postoperatively. The end points of the study were ECG modifications (upsloping or downsloping more than 2 mm) of the sinus tachycardia (ST) segment. RESULTS: Fifty-five patients were classified as IHD, and 52 were classified as NIHD. Twenty-seven of the 55 IHD patients (49%) and 24 of 52 NIHD patients (46%) were operated on under GA. Thirty-six episodes of myocardial ischemia occurred in 22 patients (20.5%). Episodes were slightly more frequent (58%) and longer in the postoperative period (intraoperative, 10 +/- 5 min; postoperative, 60 +/- 45 min; P <. 001). As expected, the prevalence of myocardial ischemia was higher in the group of cardiac patients than in noncardiac group (15 of 55 patients [27%] vs 7 of 52 patients [13%]; P <.02). By comparing the two anesthetic techniques in the overall population, we found a similar prevalence of patients who had myocardial ischemia (GA, 12 of 52 [23%]; LA, 10 of 55 [18%]; P = not significant) and a similar number of ischemic episodes per patient (GA, 1.5 +/- 0.4; LA, 1.8 +/- 0.6; P = not significant). Episodes of myocardial ischemia were similarly distributed in intraoperative and postoperative periods in both groups. It is relevant that under GA, IHD patients represent most of the population who suffered myocardial ischemia (83%). On the contrary, in the group of patients operated on under LA, the prevalence was equally distributed in the two subpopulations. CONCLUSION: The results confirm the different hemodynamic impact of the two anesthetic techniques. Patients who received LA had a rate of myocardial ischemia that was half that of patients who had GA. The small number of cardiac complications do not permit us to make any definitive conclusion on the impact of the two anesthetic techniques on early cardiac morbidity, but the relationship between perioperative ischemic burden and major cardiac events suggests that LA can be used safely, even in high-risk patients undergoing carotid endarterectomy

Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events

Objectives: This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event. Methods: The study involved patients with acute neurologic impairment, defined as >= 4 points on the National Institutes of Health Stroke Scale (NIHSS) evaluation related to a carotid stenosis >= 50% who underwent urgent CEA. Preoperative workup included neurologic assessment with the NIHSS on admission or immediately before surgery and at discharge, carotid duplex scanning, transcranial Doppler ultrasound imaging, and head computed tomography or magnetic resonance imaging. End points were perioperative (30-day) neurologic mortality, significant NIHSS score improvement or worsening (defined as a variation >= 4), and hemorrhagic or ischemic neurologic recurrence. Patients were evaluated according to their NIHSS score on admission (4-7 or >= 8), clinical and demographic characteristics, timing of surgery (before or after 6 hours), and presence of brain infarction on neuroimaging. Results: Between January 2005 and December 2009, 62 CEAs were performed at a mean of 34.2 +/- 50.2 hours (range, 2-280 hours) after the onset of symptoms. No neurologic mortality nor significant NIHSS score worsening was detected. The NIHSS score decreased in all but four patients, with no new ischemic lesions detected. The mean NIHSS score was 7.05 +/- 3.41 on admission and 3.11 +/- 3.62 at discharge in the entire group (P = 8 on admission had a bigger score reduction than those with a lower NIHSS score (NIHSS 4-7; mean 4.95 +/- 1.03 preoperatively vs 1.31 +/- 1.7 postoperatively, NIHSS >= 8 10.32 +/- 1.94 vs 4.03 +/- 3.67; P < .001). Conclusions: In patients with acute neurologic event, a high NIHSS score does not contraindicate early surgery. To date, guidelines recommend treatment of symptomatic carotid stenosis <= 2 weeks from onset of symptoms to minimize the neurologic recurrence. Our results suggest that minimizing the time for intervention not only reduces the risk of recurrence but can also improve neurologic outcome. (J Vasc Surg 2011;53:622-8.

Aneurysm of the Pancreaticoduodenal Arteries Associated with a Cœliac Artery Lesion

IntroductionA ruptured aneurysm of the pancreaticoduodenalarteries without acute or chronic pancreatitis butassociated with a median arcuate ligament divisionis an exceptional event described in only 11 cases. Thecase of a ruptured pancreaticoduodenal artery aneur-ysm, associated with a cœliac artery lesion which wedescribe, illustrates the difficulty in diagnosing theserare events promptly and in instituting urgent treat-ment to arrest the bleeding followed by an electiveprocedure to prevent recurrence.Case ReportA 54-year-old man with no history of vascular diseasewas admitted to a district hospital for investigation ofvague abdominal pain mainly affecting the rightabdomen, hypotension corrected by infusion ofcrystalloid and no fever. Laboratory blood chemicalfindings including a normal hemoglobin, raisedleukocyte count and high C-reactive protein concen-tration. This presentation raised the suspicion of a gallbladder infection and the patient was kept under closeobservation overnight. The next day, hypotensiondeveloped and the patient complained of pain in theright iliac quadrant. An abdominal ultrasound scanshowed a large iliac fluid collection, but no lesionsinvolving the gall bladder or liver. Appendicitis wasdiagnosed and the patient underwent a McBurneyoperation. During surgery blood was found in theabdomen. An exploratory laparotomy revealed a largeretroperitoneal hematoma. The patient was trans-ferred to our vascular surgery unit. A CT scan aftercontrast injection revealed an intact retroperitonealhematoma (16 £ 9 £ 15 cm), with no bleeding from theaorta or the visceral arteries, and a median arcuateligament division that compressed the origin of thecœliac trunk. Because these findings suggested aruptured pancreaticoduodenal artery aneurysm arter-iography was planned to confirm the diagnosis andtreat the aneurysm by embolization. The patient, whowas by now haemodynamically stable, was kept underobservation in the ITU and transferred to the vascularsurgical unit. On day 1, a CT scan showed that thehematoma had enlarged. The patient was kept undersurveillance in the vascular unit and arteriographywas planned for the following day. During the night,the patient collapsed but responded to more IVcrystalloid and was immediately transferred to theradiological unit. While the patient was being pre-pared for arteriography, a new CT scan showed thehematoma had now increased in size and had spreadto the intraperitoneal space, filling the peri-hepaticand peri-splenic areas as well as the pelvis.The patient underwent selective arteriography tovisualize the stenosis caused by compression of thecœliac axis, to localize the bleeding pancreaticoduo-denal artery aneurysm and to proceed to treatment byembolization. Under local anesthesia, a 5-F introduce

Combining neuroprotectants in a model of retinal degeneration: no additive benefit

The central nervous system undergoing degeneration can be stabilized, and in some models can be restored to function, by neuroprotective treatments. Photobiomodulation (PBM) and dietary saffron are distinctive as neuroprotectants in that they upregulate protective mechanisms, without causing measurable tissue damage. This study reports a first attempt to combine the actions of PBM and saffron. Our working hypothesis was that the actions of PBM and saffron in protecting retinal photoreceptors, in a rat light damage model, would be additive. Results confirmed the neuroprotective potential of each used separately, but gave no evidence that their effects are additive. Detailed analysis suggests that there is actually a negative interaction between PBM and saffron when given simultaneously, with a consequent reduction of the neuroprotection. Specific testing will be required to understand the mechanisms involved and to establish whether there is clinical potential in combining neuroprotectants, to improve the quality of life of people affected by retinal pathology, such as age-related macular degeneration, the major cause of blindness and visual impairment in older adults.This work was supported by the Australian Research Council Centre of Excellence in Vision Science, by the Sir Zelman Cowen Universities Fund and the Lord Mayor’s Charitable Foundation, by Australian Travel Awards for L’Aquila Researchers (ARIA) to FDM and SR and by a Ministero dell’Istruzione, dell’Universita` e della Ricerca dedicato ai PRIN, Progetti di Ricerca di Interesse Nazionale (MIUR-PRIN) (2010-2011) research grant to SB

The Challenges For The Next Decade: Notes On The Debate On The Development Of The Emilia-Romagna Region

Facing exogenous changes and endogenous impasses, Emilia-Romagna, one of the richest regions in Europe, is undergoing transformation. In this paper, we outline the dynamics of change at the regional level, both in the changes in the interrelationships among the major actors, and the emergence of new phenomena such as demographic trends. Regional policy measures to foster local development are sketched by focusing on industrial policy, transport infrastructure plans and policy measures on learning processes, as they emerge in the changes undertaken at regional level in technical and vocational education.Regional policy, industrial dynamics, local development, learning regions, technical and vocational education

Serum IgG against Simian Virus 40 antigens are hampered by high levels of sHLA-G in patients affected by inflammatory neurological diseases, as multiple sclerosis

Background: Many investigators detected the simian polyomavirus SV40 footprints in human brain tumors and neurologic diseases and recently it has been indicated that SV40 seems to be associated with multiple sclerosis (MS) disease. Interestingly, SV40 interacts with human leukocyte antigen (HLA) class I molecules for cell entry. HLA class I antigens, in particular non-classical HLA-G molecules, characterized by an immune-regulatory function, are involved in MS disease, and the levels of these molecules are modified according with the disease status. Objective: We investigated in serum samples, from Italian patients affected by MS, other inflammatory diseases (OIND), non-inflammatory neurological diseases (NIND) and healthy subjects (HS), SV40-antibody and soluble sHLA-G and the association between SV40-prevalence and sHLA-G levels. Methods: ELISA tests were used for SV40-antibodies detection and sHLA-G quantitation in serum samples. Results: The presence of SV40 antibodies was observed in 6 % of patients affected by MS (N = 4/63), 10 % of OIND (N = 8/77) and 15 % of NIND (N = 9/59), which is suggestive of a lower prevalence in respect to HS (22 %, N = 18/83). MS patients are characterized by higher sHLA-G serum levels (13.9 \ub1 0.9 ng/ml; mean \ub1 St. Error) in comparison with OIND (6.7 \ub1 0.8 ng/ml), NIND (2.9 \ub1 0.4 ng/ml) and HS (2.6 \ub1 0.7 ng/ml) subjects. Interestingly, we observed an inverse correlation between SV40 antibody prevalence and sHLA-G serum levels in MS patients. Conclusion: The data obtained showed a low prevalence of SV40 antibodies in MS patients. These results seems to be due to a generalized status of inability to counteract SV40 infection via antibody production. In particular, we hypothesize that SV40 immune-inhibitory direct effect and the presence of high levels of the immune-inhibitory HLA-G molecules could co-operate in impairing B lymphocyte activation towards SV40 specific peptides

Elevated Levels of the Polo Kinase Cdc5 Override the Mec1/ATR Checkpoint in Budding Yeast by Acting at Different Steps of the Signaling Pathway

Checkpoints are surveillance mechanisms that constitute a barrier to oncogenesis by preserving genome integrity. Loss of checkpoint function is an early event in tumorigenesis. Polo kinases (Plks) are fundamental regulators of cell cycle progression in all eukaryotes and are frequently overexpressed in tumors. Through their polo box domain, Plks target multiple substrates previously phosphorylated by CDKs and MAPKs. In response to DNA damage, Plks are temporally inhibited in order to maintain the checkpoint-dependent cell cycle block while their activity is required to silence the checkpoint response and resume cell cycle progression. Here, we report that, in budding yeast, overproduction of the Cdc5 polo kinase overrides the checkpoint signaling induced by double strand DNA breaks (DSBs), preventing the phosphorylation of several Mec1/ATR targets, including Ddc2/ATRIP, the checkpoint mediator Rad9, and the transducer kinase Rad53/CHK2. We also show that high levels of Cdc5 slow down DSB processing in a Rad9-dependent manner, but do not prevent the binding of checkpoint factors to a single DSB. Finally, we provide evidence that Sae2, the functional ortholog of human CtIP, which regulates DSB processing and inhibits checkpoint signaling, is regulated by Cdc5. We propose that Cdc5 interferes with the checkpoint response to DSBs acting at multiple levels in the signal transduction pathway and at an early step required to resect DSB ends