Delayed repair of aortic dissection in sickle cell anaemia as a combined cardiac and vascular surgical approach

We discuss a patient who presented with a type B aortic dissection with a retrograde progression in the context of sickle cell anaemia. Given the involvement of the superior mesenteric artery and concern for bowel ischaemia, a delayed approach was considered. Subsequently, a frozen elephant trunk was performed in the hybrid theatre with the back-up of the vascular surgeon for mesenteric protection. A technically demanding procedure followed by a prolonged and challenging postoperative course finally led to a successful outcome. We argue that the case presented is an example of how a close cooperation between professionals can offer additional options to treatment based on a mixture of skills and background to achieve the desired outcome

Cardiac and vascular surgeons for the treatment of aortic disease : a successful partnership for decision-making and management of complex cases

Traditionally, cardiac and vascular surgeons have been treating diseases of the aorta as individual specialists. Neither cardiac nor vascular surgeons have ever considered the aorta as a whole, which can be diseased throughout its length at the same time requiring a more thoughtful and different approach. Aortic dissection and aneurysmal disease may well benefit from a multidisciplinary approach. In the context of this review, we discuss examples of joint operating between cardiac and vascular surgeons that may well become a more routine approach in more units in the future

Is age an independent determinant of mortality in cardiac surgery as suggested by the EuroSCORE?

BACKGROUND: The proportion of older patients in cardiac surgery is continuously increasing. 37% of patients undergoing heart surgery in Germany in the year 2000 were 70 years of age and older. We have studied the role of age as a determinant of mortality in cardiac surgery in our institutional patient population. METHODS: We have calculated the EuroSCORE and the corresponding age-adjusted EuroSCORE in 8769 patients who underwent heart surgery between January 1996 and January 2002 and collected the information on the occurrence of postoperative complications and 30-days mortality. RESULTS: The multimorbidity increased with ascending age. Both the EuroSCORE and the age-adjusted EuroSCORE values increased significantly with age in the whole group of patients as well as in the group of patients who were alive 30 days after heart surgery. The incidence of postoperative complications and 30-days mortality increased significantly with age. In patients who died within 30 days after surgery, the EuroSCORE increased significantly with age, whereas the age-adjusted EuroSCORE did not. The occurrence of diabetes mellitus, arterial hypertension and atrial fibrillation, i.e., the risk factors not considered by the EuroSCORE, exhibited a significant age dependence in our patients. The univariate analysis identified the significant dependence of 30-days mortality on diabetes and atrial fibrillation. The stepwise logistic regression analysis showed the dependence of mortality on diabetes. CONCLUSIONS: On the background of the well-known age-dependent structural and functional changes of different body organs, our data show that age is a significant risk indicator in cardiac surgery, strongly correlating with morbidity and mortality. Consequently, special preventive and therapeutic measures are required in clinical environment in the case of elderly patients undergoing cardiac surgery

Genetic Analyses of Heme Oxygenase 1 (HMOX1) in Different Forms of Pancreatitis

Contains fulltext : 107993.pdf (publisher's version ) (Open Access)BACKGROUND: Heme oxygenase 1 (HMOX1) is the rate limiting enzyme in heme degradation and a key regulator of inflammatory processes. In animal models the course of pancreatitis was ameliorated by up-regulation of HMOX1 expression. Additionally, carbon monoxide released during heme breakdown inhibited proliferation of pancreatic stellate cells and might thereby prevent the development of chronic pancreatitis (CP). Transcription of HMOX1 in humans is influenced by a GT-repeat located in the promoter. As such, HMOX1 variants might be of importance in the pathogenesis of pancreatitis. METHODS: The GT-repeat and SNP rs2071746 were investigated with fluorescence labelled primers and by melting curve analysis in 285 patients with acute pancreatitis, 208 patients with alcoholic CP, 207 patients with idiopathic/hereditary CP, 147 patients with alcoholic liver cirrhosis, and in 289 controls, respectively. GT-repeat analysis was extended to a total of 446 alcoholic CP patients. In addition, we performed DNA sequencing in 145 patients with alcoholic CP, 138 patients with idiopathic/hereditary CP, 147 patients with alcoholic liver cirrhosis, and 151 controls. Exon 3 screening was extended to additional patients and controls. RESULTS: S- and L-alleles of the GT-repeat, genotypes and alleles of SNP rs2071746 and non-synonymous variants detected by sequencing were found with similar frequencies in all groups. CONCLUSIONS: Although functional data implicate a potential influence of HMOX1 variants on the pathogenesis of pancreatitis, we did not find any association. As rare non-synonymous HMOX1 variants were found in patients and controls, it is rather unlikely that they will have functional consequences essential for pancreatitis development

A Common Variant of PNPLA3 (p.I148M) Is Not Associated with Alcoholic Chronic Pancreatitis

Contains fulltext : 110441.pdf (publisher's version ) (Open Access)BACKGROUND: Chronic pancreatitis (CP) is an inflammatory disease that in some patients leads to exocrine and endocrine dysfunction. In industrialized countries the most common aetiology is chronic alcohol abuse. Descriptions of associated genetic alterations in alcoholic CP are rare. However, a common PNPLA3 variant (p.I148M) is associated with the development of alcoholic liver cirrhosis (ALC). Since, alcoholic CP and ALC share the same aetiology PNPLA3 variant (p.I148M) possibly influences the development of alcoholic CP. METHODS: Using melting curve analysis we genotyped the variant in 1510 patients with pancreatitis or liver disease (961 German and Dutch alcoholic CP patients, 414 German patients with idiopathic or hereditary CP, and 135 patients with ALC). In addition, we included in total 2781 healthy controls in the study. RESULTS: The previously published overrepresentation of GG-genotype was replicated in our cohort of ALC (p-value <0.0001, OR 2.3, 95% CI 1.6-3.3). Distributions of genotype and allele frequencies of the p.I148M variant were comparable in patients with alcoholic CP, idiopathic and hereditary CP and in healthy controls. CONCLUSIONS: The absence of an association of PNPLA3 p.I148M with alcoholic CP seems not to point to a common pathway in the development of alcoholic CP and alcoholic liver cirrhosis

Type 1 Autoimmune Pancreatitis in Europe: Clinical Profile and Response to Treatment.

Background and aimsAutoimmune pancreatitis (AIP) is an immune-mediated disease of the pancreas with distinct pathophysiology and manifestations. Our aims were to characterize type 1 AIP in a large pan-European cohort and study the effectiveness of current treatment regimens.MethodsWe retrospectively analyzed adults diagnosed since 2005 with type 1 or not-otherwise-specified AIP in 42 European university hospitals. Type 1 AIP was uniformly diagnosed using specific diagnostic criteria. Patients with type 2 AIP and those who had undergone pancreatic surgery were excluded. The primary endpoint was complete remission, defined as the absence of clinical symptoms and resolution of the index radiological pancreatic abnormalities attributed to AIP.ResultsWe included 735 individuals with AIP (69% male; median age 57 years; 85% White). Steroid treatment was started in 634 patients, of whom 9 (1%) were lost to follow-up. The remaining 625 had a 79% (496/625) complete, 18% (111/625) partial, and 97% (607/625) cumulative remission rate, while 3% (18/625) did not achieve remission. No treatment was given in 95 patients, who had a 61% complete (58/95), 19% partial (18/95), and 80% cumulative (76/95) spontaneous remission rate. Higher (≥0.4 mg/kg/day) corticosteroid doses were no more effective than lower ( 2 weeks (OR 0.908; 95%CI 0.818-1.009). Elevated IgG4 levels were independently associated with a decreased chance of complete remission (OR 0.639; 95%CI 0.427-0.955). Relapse occurred in 30% of patients. Relapses within 6 months of remission induction were independent of the steroid tapering duration, induction treatment duration, and total cumulative dose.ConclusionPatients with type 1 AIP and elevated IgG4 level may need closer monitoring. For remission induction, a starting dose of 0.4 mg/kg/day for 2 weeks followed by a short taper period seems effective. This study provides no evidence to support more aggressive regimens

Historical biogeography of the leopard (Panthera pardus) and its extinct Eurasian populations

Background: Resolving the historical biogeography of the leopard (Panthera pardus) is a complex issue, because patterns inferred from fossils and from molecular data lack congruence. Fossil evidence supports an African origin, and suggests that leopards were already present in Eurasia during the Early Pleistocene. Analysis of DNA sequences however, suggests a more recent, Middle Pleistocene shared ancestry of Asian and African leopards. These contrasting patterns led researchers to propose a two-stage hypothesis of leopard dispersal out of Africa: an initial Early Pleistocene colonisation of Asia and a subsequent replacement by a second colonisation wave during the Middle Pleistocene. The status of Late Pleistocene European leopards within this scenario is unclear: were these populations remnants of the first dispersal, or do the last surviving European leopards share more recent ancestry with their African counterparts? Results: In this study, we generate and analyse mitogenome sequences from historical samples that span the entire modern leopard distribution, as well as from Late Pleistocene remains. We find a deep bifurcation between African and Eurasian mitochondrial lineages (~ 710 Ka), with the European ancient samples as sister to all Asian lineages (~ 483 Ka). The modern and historical mainland Asian lineages share a relatively recent common ancestor (~ 122 Ka), and we find one Javan sample nested within these. Conclusions: The phylogenetic placement of the ancient European leopard as sister group to Asian leopards suggests that these populations originate from the same out-of-Africa dispersal which founded the Asian lineages. The coalescence time found for the mitochondrial lineages aligns well with the earliest undisputed fossils in Eurasia, and thus encourages a re-evaluation of the identification of the much older putative leopard fossils from the region. The relatively recent ancestry of all mainland Asian leopard lineages suggests that these populations underwent a severe population bottleneck during the Pleistocene. Finally, although only based on a single sample, the unexpected phylogenetic placement of the Javan leopard could be interpreted as evidence for exchange of mitochondrial lineages between Java and mainland Asia, calling for further investigation into the evolutionary history of this subspecies

Data mart based risk stratification in heart surgery: comparison to a prospective risk score validation

Arnrich B, Albert AA, Walter JA, Rosendahl UP, Ennker J. Data mart based risk stratification in heart surgery: comparison to a prospective risk score validation. In: The Thoracic and Cardiovascular Surgeon. Vol Suppl. 1. Stuttgart: Thieme; 2006: 113.Aim: A data mart system was developed which integrates all relevant data from various hospital information systems (HIS) to support easy comprehensive research. The consolidated data set has enabled us to apply six commonly used risk scores in a large patient population. The present study evaluates the validity of this approach. Methods: Current and historical data from three HIS (surgical, anesthesiological, and laboratory) were extracted and integrated in a data mart system. By reconstructing the semantic meaning of all score variables we could retrospectively apply six cardiac risk schemes for postoperative mortality in 13882 of 15364 patients (90.4%). Using the area under ROC curve (c-index), the scores were evaluated with regard to their discriminative power and compared with a prospectively scored collective of 504 patients from Geissler et. al. [2000]. Results: The performances of the data mart based risk scores were equal or even better than the prospective controls: Euro 0.786 vs. 0.786, Initial Parsonnet 0.784 vs. 0.755, Cleveland Clinic 0.782 vs. 0.731, Pons 0.761 vs. 0.745, Ontario Province Risk 0.752 vs. 0.752, and French 0.750 vs. 0.719. In both populations the Euro- and Initial-Parsonnet-Score have the best discriminative power while the difference between the two scores is smaller in the data mart set. Conclusion: The data mart approach enables individual hospitals in a very flexible way to apply and validate a variety of risk models by using data from daily clinical practice. The resulting risk scores show a high validity and are valuable tools for risk-adjusted outcome analysis