Evaluation of Charlson's comorbidity index in elderly living in nursing homes

The object of this article was to validate the predictive value of Charlson's comorbidity index for the prediction of short-term mortality or morbidity in elderly people. The design was a cohort study comparing survival and hospitalization in institutionalized elderly people with different levels of comorbidity at baseline. The setting was 16 Flemish nursing homes for the elderly. The subjects were 2,727 inhabitants of which full data were available for 2,624. The outcome measures were hazard ratios resulting from Cox regression analysis, comparing 6 months survival in patients with moderate and a high level to low level of comorbidity. Odds ratios resulting from multiple logistic regression analysis comparing the occurrence of at least one hospitalization during the follow-up period in surviving patients of the same groups. Mortality adjusted for age group was significantly increased in patients with a moderate (HR = 2.00) and even more in those with a high level (HR = 3.62) of comorbidity. Hospitalization was more frequent in both groups (OR = 1.54 and 2.19, respectively), with statistical significance only being reached for the highest group. Adjustment for age, gender, mobility status, and disorientation did not change the general picture. Charlson's comorbidity index is a predictor of short-term mortality in institutionalized elderly patients and, to a lesser extend, also of hospitalization. These results support its use as a measure for introducing comorbidity as a covariable in longitudinal studies with a geriatric population.

[Ruptured thoracic aorta aneurysm: endovascular treatment]

In 1991, a technique to exclude aortic aneurysms from circulation inserting an endoluminal graft through the femoral artery, was described. This procedure, usually used for elective abdominal aneurysms, can also be used in the thoracic aorta. We report a 41 years old male with a Marfan syndrome, presenting with a descending aorta aneurysm that ruptured to the mediastinum and pleural cavity. He was compensated hemodynamically and an endovascular stent-graft was deployed at the ruptured zone, through the femoral artery. The postoperative evolution of the patient was uneventful. This technique will allow a less invasive treatment of ruptured aortic aneurysms.

Factors increasing the mortality rate for patients with ruptured abdominal aortic aneurysms

The objective of this report was to analyze the current surgical results of operative treatment in patients suffering ruptured AAA (abdominal aortic aneurysms) and to define those independent predictive factors for mortality. During a period of 2 years, from January 1996 to December 1997, 144 patients operated on for ruptured AAA in 10 hospitals were included in a multicenter retrospective study. Among the collected variables concerning each patient, those with potential relation to surgical mortality were studied: gender, age, diabetes, hypertension, cardiopathy, pulmonary obstructive disease, preoperative renal dysfunction, symptomatic cerebrovascular disease, peripheral vascular disease, hematocrit on admission, preoperative hypotension < 80 mmHg, loss of consciousness, cardiac arrest, aortic aneurysm location (infrarenal versus non-infrarenal), iliac involvement, aneurysm size, type of rupture, left renal vein ligature, ligature of a patent inferior mesenteric artery, place of aortic cross-clamping, type of grafting, exclusion of both hypogastric arteries, venous technical complications, associated surgery, use of cell saver, intraoperative blood loss, and postoperative complications (renal failure, sepsis, coagulopathy, cardiac complications, pulmonary complications, colon ischemia, prosthetic graft complications, and need for reoperation). Those variables with statistical significance in the univariate analysis were introduced into a multivariate logistic regression model to determine the independent predictors of death. From our results we concluded that surgery for ruptured abdominal aortic aneurysms continues to have an excessively high mortality rate. Even though some preoperative variables could be identified as predictors of mortality, an absolute mortality risk has not yet been determined and the decision to negate surgery should be individualized rather than taken on that basis only. Early diagnosis and treatment of symptomatic aneurysms would improve mortality figures and selective screening should be contemplated.

Early Detection of Tubulo-Interstitial Kidney Disease in Children Using Highly Discriminating SDS-Gel Electrophoresis

Tubulo-interstitial kidney disease is characterized by moderate proteinuria < 1 g/day of low molecular weight proteins in range of MW 10.000-50.000. Even in the physiological proteinuria of < 150 mg/day, tubulo-interstitial kidney disease may exist. Using optimized sodium dodecyl sulfate polyacrylamid gel electrophoresis (SDS-PAGE) according to the method of Melzer, even in proteinuria of less than 150 mg/day all relevant proteins for diagnosis of glomerular or tubulo-interstitial kidney disease can be detected. This study evaluates the tubulo-interstitial kidney disease due to polychemotherapy for different types of cancer in 115 children and in 16 children with pyelo-ureteral junction obstruction. Fifty-two and 63 children were followed up during and after chemotherapy, respectively. During therapy, renal damage was recorded in 43% of patients with leukemia, 56% with nephroblastoma, and 79% with other tumors. Tubular protein patterns were seen up to three years after termination of chemotherapy (25% in acute lymphoplastic leukemia, 35% in nephroblastoma and 62% in other tumors). Patients with persistent complete tubular proteinuria or mixed glomerular/tubular proteinuria were found to have a high risk for irreversible renal failure. Children with congenital pyelo-ureteral junction obstruction could also be classified according to SDS-PAGE protein patterns. Patients without parenchymal lesions did not need surgery. Most of those with pathologic findings in SDS-PAGE exhibited partial or complete remission after surgery. The highly discriminating SDS-PAGE permits a rapid, sensitive, reproducible, and reliable analysis of urine proteins for diagnosis and follow-up of all kinds of congenital or acquired renal parenchymal kidney diseases.

Differential expression of the multidrug resistance-related protein MRP1 in the histological compartments of nephroblastomas

Nephroblastomas (Wilms' tumors) are curable with survival rates above 80%. Some tumors, however, fail to respond to therapy and those patients have a poor prognosis. In a search for prognostic markers, we investigated the expression of the multidrug resistance-related protein 1 (MRP1) in 32 nephroblastomas by means of immunohistochemistry. The immunohistochemical results were validated with a real-time RT-PCR technique. MRP1 expression was heterogeneous and predominantly found in the blastemal and epithelial compartments compared to the stromal elements of nephroblastomas. We found significant relationships of MRP1 expression to survival of patients and to expression of p53, HSP70, and LRP/MVP. The relationship between MRP1 and p53 expression is a clue that the transcriptional control of MRP1 by p53 reported for other tumor types may also take place in nephroblastomas. The correlation of MRP1 to other drug resistance genes, e.g. HSP70 and LRP/MVP in nephroblastomas indicates that the co-expression of different drug resistance genes may be under a common regulation of still unknown transcription factors.

Differential expression of the heat shock protein 70 in the histological compartments of nephroblastomas

Nephroblastomas (Wilms' tumors) are curable with survival rates above 80%. Nevertheless, some tumors fail to respond to therapy and those patients have a poor prognosis. Prognostic factors for nephroblastomas have still not been satisfactorily explored. In an effort to unravel molecular markers for non-responding nephroblastomas, we investigated by means of immunohistochemistty the expression of heat-shock protein 70 (HSP70) in formalin-fixed and paraffin-embedded tissue samples from 32 children afflicted with nephroblastoma. The results were validated using real-time RT-PCR. HSP70 expression was confined to blastemal and epithelial components, while the tumor stroma was negative. HSP70 expression was greater, if the tumors had been chemotherapeutically treated prior to operation, indicating that cytostatic drugs induce HSP70. Furthermore, high HSP70 expression was confined to tumors from children who survived, whereas tumors from dead patients were negative or weakly-positive for HSP70. Though the number of cases analyzed was small, they provide an indication that HSP70 expression may be of prognostic value.

Differential expression of the lung resistance-related protein/major vault protein in the histological compartments of nephroblastomas

Nephroblastomas (Wilms' tumors) are curable with survival rates above 80%. Some tumors, however, fail to respond to therapy and those patients have a poor prognosis. In a search for molecular markers of drug resistance, we investigated the expression of lung resistance protein (LRP) in tissue samples from 32 children with nephroblastoma by means of immunohistochemistry. LRP is a human major vault protein (MVP) and is associated with multidrug resistance of tumors. LRP/MVP expression was found in the blastemal and epithelial compartments but to a significantly lesser extent in the stromal compartment of Wilms' tumors. Expression was generally heterogeneous with respect to staining intensity and percentage of positive cells. We found significant relationships between LRP/MVP expression and chemotherapeutic pre-treatment of tumors and tumor stage. The immunohistochemical results were validated with a real-time RT-PCR technique and a significant association between protein and mRNA expression was observed.

[Endovascular therapy of superior vena cava syndrome: clinical case]

The treatment of superior vena cava syndrome is usually oriented to the underlying cause, that can be too slow in emergency cases. We report a 49 years old woman with a multiple myeloma that was admitted due to a superior vena cava syndrome caused by a central venous catheter used for chemotherapy for 20 weeks. She was successfully treated with thrombolysis, angioplasty and stent placement. The patient died 7 months later due to the underlying disease. Long term catheters are the responsible for 20 to 30% of superior vena cava syndromes. Endovascular treatment of the syndrome is successful in 60 to 100% of cases with a symptomatic relapse in 4 to 45% of patients.

Visceral leishmaniasis in a German child who had never entered a known endemic area: case report and review of the literature

We describe a case of visceral leishmaniasis in a 15-month-old German child. Diagnosis was significantly delayed because the patient had no history of travel to known endemic areas. Congenital or blood transfusion-associated leishmaniasis was ruled out. Possible modes of transmission (including a potential new autochthonous focus of the disease in central Europe) are discussed.

Differential expression of the drug resistance markers DNA topoisomerase II alpha and glutathione S-transferase-pi in the histological compartments of Wilms' tumors

More than 80% of the patients presenting with Wilms' tumor can be cured today. Some patients, however, fail to respond to chemotherapy. The objective of this study was to analyze the immunohistochemical distribution of two markers of cytostatic drug resistance, e.g. DNA topoisomerase II alpha (Topo II alpha) and glutathione S-transferase-pi (GST-pi) in 23 Wilms' tumor patients who had undergone an operation between 1984 and 1997. Eight patients had stage I disease, seven stage II, three stage III, four stage IV, and one stage V disease. Five tumors showed high malignancy histology. Investigations were carried out on formalin-fixed and paraffin-embedded tissue sections using the indirect immunoperoxidase method. Topo II alpha was predominantly present in the epithelial components of the specimens. It was more frequently found in anaplastic tumors. There was no difference in the presence of Topo II alpha in the epithelial components between specimens derived from treated and untreated patients. Topo II alpha was, however, less expressed in the blastemal and stromal elements of specimens after preoperative treatment. If GST-pi was present, it was confined to the epithelial components except for one case. While no expression of GST-pi was found in preoperatively untreated Wilms' tumors, it was present in epithelial compartments in 57% of tumors after chemotherapy. In conclusion, preoperative chemotherapy led to compartment-specific alterations in the expression levels of both markers indicating a contribution to treatment response of Wilms' tumors.

p53 expression in Wilms' tumor: a possible role as prognostic factor

Although a correlation between anaplasia and mutations of the p53 tumor suppressor gene has been found in Wilms' tumor (WT) a prognostic significance of p53 in WT remains largely unresolved. The goal of this study was to obtain a better understanding of the role of p53 expression in WT. Immunohistochemical analysis was performed on formalin-fixed paraffin-embedded tumor tissues from 21 patients treated in our clinic between 1984 and 1996. Eight patients presented with stage I, six with stage II, two with stage III, four with stage IV and one patient with stage V disease. According to the presence of anaplasia, four cases were categorized as of unfavorable histology based on the criteria of the National Wilms' Tumor Study Group. Seven out of 21 WTs were positive for p53. One out of the eight patients with stage I and one out of the six patients with stage II disease scored positive for p53 as were 2/2 patients with stage III and 3/4 patients with stage IV disease. Four tumors scored positive for anaplasia (one stage I, one stage II and two stage IV disease) and all four belonged to the p53 positive group. Three of these patients died of progressive disease. Immunopositivity in general was focal in the blastemal and epithelial parts of the tumors, with differences in intensity of staining ranging from moderate to strong. Positivity in the stromal components was restricted to single cells. Statistical analysis revealed significant correlations of p53 expression to anaplasia and to survival, respectively. The association of p53 expression to tumor stage was of borderline significance. To support immunohistochemistry, we performed PCR/SSCP and DNA sequence analyses on two cases, one whose immunopositivity suggested a mutated p53, and another case which was immunonegative. A CGG --> TGG base change in codon 282 of exon 8 was found in the immunopositive tumor. In conclusion, p53 may be of prognostic relevance for poor outcome being present in close association with unfavorable histology of WTs.

Urine protein analysis by gel electrophoresis and laser densitometry after chemotherapy in pediatric cancer patients

A common side effect of chemotherapy is reversible or nonreversible nephrotoxicity. SDS polyacrylamide gel electrophoresis combined with laser densitometry was evaluated as a suitable method to analyze pathologic urine proteins. A total of 52 pediatric patients were followed during and 63 patients were followed after therapy. During therapy renal damage was recorded in 43% of the leukemia patients, in 56% of nephroblastoma patients, and 75% of patients with other tumors. Three or more months after therapy pathologic patterns were seen in 25% of acute lymphoblastic leukemia patients, in 35% of patients with nephroblastoma, and in 62% of other patients. Patients with persistent complete tubular proteinuria and mixed glomerular/tubular proteinuria were found to have a high risk for irreversible renal damage and should be controlled periodically. This method permits a rapid and reliable analysis of urine proteins and is suitable for follow-up tests of renal function during and after chemotherapy.

[Carotid endarterectomy under regional anesthesia: initial experience]

BACKGROUND

Endarterectomy is the treatment of choice for internal carotid artery critical stenosis. Some authors have proposed that the use of regional anesthesia has advantages over general anesthesia.

AIM

To report our initial experience with carotid endarterectomy under regional anesthesia.

PATIENTS AND METHODS

Between 1998 and 1999, patients with critical carotid artery stenosis, asymptomatic or with transient and recovered symptoms, were selected. A C2, C3, C4 root deep cervical block and superficial block was performed, using a mixture of lidocaine and bupivacaine. A carotid endarterectomy with patch and without routine shunt insertion, with standard and neurological monitoring, was performed.

RESULTS

During the study period, 94 carotid endarterectomies were done, 22 under regional anesthesia in 21 patients (12 male, age range 58-90 years old). Ninety five percent had hypertension, 52% smoked and 38% had renal dysfunction. One patient was converted to general anesthesia. Seventeen patients were discharged within 48 hours of the procedure and the rest, within 72 hours. There was no mortality or complications.

CONCLUSIONS

Endarterectomy under regional anesthesia is less invasive, has excellent results and is well accepted by patients.

Antithrombin treatment of severe hepatic veno-occlusive disease in children with cancer

Hepatic veno-occlusive disease (VOD) is a well-known complication of chemotherapy in Wilms tumor patients, particularly young children. Although this complication resolves uneventfully in most patients, fatal cases have been reported. Severe VOD after transplantation has a high mortality rate ranging from 45% to 98%. New hemostatic therapeutic strategies have significantly improved the prognosis of VOD. Chemotherapy-related VOD in Wilms tumor usually has a good prognosis. We describe two patients with Wilms tumor and one with acute lymphoblastic leukemia, who developed severe veno-occlusive disease of the liver according to the Baltimore criteria while undergoing chemotherapy; the symptoms were hepatomegaly, ascites, hyperbilirubinemia, weight gain and, in one patient, short-term lethargy. Elevated LDH levels of 872 to 12,000 U/l were observed in our patients. All patients had thrombocytopenia between 29,000 and 40,000/microl and decreased antithrombin (AT) and protein C levels; two patients had gastrointestinal bleeding. All patients developed a coagulopathy because of severe hepatic dysfunction. Two patients received low-dose heparin at the onset of VOD. The thrombolytic therapy was rapidly changed to AT supplementation (20-80 IU/kg bw 2x per day) without heparin when thrombocytes were very low or gastrointestinal bleeding occurred. Resolution of VOD was observed in all patients receiving AT alone. The chemotherapy was discontinued in a patient with accidental actinomycin D overdosage in view of the severity of symptoms. The remaining two patients received chemotherapy according to the therapy protocol after restitution. All patients survived without sequelae with a median follow-up of 28 months (range 8-48 months).

CONCLUSION

Hepatic veno-occlusive disease is a rare but increasingly recognized complication in pediatric cancer patients receiving conventional chemotherapy. AT supplementation constitutes a good alternative treatment of severe VOD in comparison with other thrombolytic therapies, particularly in patients at high risk of bleeding.

Clinical aspects of alveolar rhabdomyosarcoma with translocation t(1;13)(p36;q14) and hypotetraploidy

Although most cases of alveolar rhabdomyosarcoma (RMS) are characterized by the chromosomal translocation t(2;13)(q35;q14), several cases have been reported with a variant t(1;13)(p36;q14). We present the clinical, morphological and cytogenetic features of an alveolar RMS in a 4-year-old boy. Chromosomal analysis revealed a hypertriploid to hypotetraploid karyotype with a t(1;13)(p36;q14) in all tumor cells. It appears that alveolar RMS with t(1;13) occurs in younger children and displays a higher incidence to upper and lower extremity than tumors with t(2;13).

The clinical outcome after inferior vena cava thrombosis in early infancy

The clinical outcome after inferior vena cava thrombosis in early infancy is unknown. We report the clinical long-term follow-up of 12 patients presenting inferior vena cava thrombosis within their first months of life (gestational age: 24-41 weeks; follow-up: 7+/-3 years). Accompanying renal venous thrombosis occurred in 9, and adrenal bleeding in 4 patients. A central venous catheter was related to the thrombosis in only four patients. Heterozygous factor V Leiden mutation was found in two of the eight infants without central venous catheter. Thrombolysis was performed in seven and effective in three infants; one infant required surgical thrombectomy. In three of eight infants with ineffective or with no therapy, spontaneous recanalization occurred during follow-up. No patient died of the thrombosis. Although no long-term anticoagulatory prophylaxis was performed, none of the children with persisting occlusion (n = 5) or stenosis (n = 1) of the inferior vena cava developed symptomatic thrombo-embolic complications. However, extensive internal collaterals (n = 6), visible varicosis (n = 5), pain in the legs (n = 3) and persisting renal disease (n = 3) with arterial hypertension (n = 2) were observed during follow-up.

CONCLUSION

Inferior vena cava thrombosis of early infancy frequently persists and may cause considerable long-term morbidity. New strategies for early and long-term therapy are necessary.

[Ilio femoral thrombosis: an infrequent complication of an aortic and iliac aneurysm. Report of two cases]

Death due to rupture of and abdominal aortic or iliac aneurysm, is their most frequent complication. We report two male patients, both over seventy years old, who presented with unexplained unilateral ilio-femoral deep vein thrombosis. During diagnostic work up an aortic and iliac aneurysm, compressing the deep venous system with secondary thrombosis, was found. In both patients a prophylactic inferior vena caval filter was inserted and standard elective surgery was then performed. No perioperative complications occurred and both patients remain asymptomatic during follow up. Deep vein thrombosis due to compression by an abdominal aortic and iliac aneurysm is infrequent. It must be ruled out together with intrabdominal cancer, in the elderly patient presenting with unexplained deep vein thrombosis.

Diagnosis and stage-related treatment of disseminated intravascular coagulation in meningococcal infections

Disseminated intravascular coagulation (DIC) is a frequent complication of meningococcal sepsis in children. Despite the availability of potent antibiotics, mortality in meningococcal disease remains high (about 10%), rising to 40% in patients presenting in severe shock and consecutive DIC. As the clinical course and the severity of manifestations of systemic meningococcal infections varies there is a need for early diagnosis of the infection and of the stage of coagulopathy in order to reduce the high mortality rate. Few and rapidly available parameters are needed to classify the wide spectrum of clinical and laboratory findings in patients with DIC. The parameters include partial thromboplastin time, prothrombin time, plasma levels of fibrinogen, antithrombin III (AT III), fibrin monomers and D-dimer concentration, fibrin degradation products and the thrombocyte count. Monitoring the course of hemostasis findings in 28 pediatric patients (age between 3 months and 8 years, mean 3.1 years) with systemic meningococcal infections we observed a change of coagulation parameters already in the first stages of the infection: A prolongation of partial thromboplastin time mean 69.1 sec (range 22-150 sec, normal 30-45 sec), a decrease of prothrombin time to 45.7% (range 13-71%, normal 70-100%) and of AT III to an average level of 70% (normal 85-125%) was found 1 to 4 (-6) hours after admission. The following deterioration of prothrombin time and partial thromboplastin time turned out to be statistically significant (p < 0.05, signed rank test). The monitoring of hemostasis parameters mentioned above made it to possible define the stage of coagulopathy and thus to start a stage related therapy. Treatment consisted of shock control by liquid substitution, compensation of metabolic acidosis, correction of clotting disorders (AT III and heparin in case of pre-DIC; AT III and fresh frozen plasma in case of advanced DIC), antibiotic treatment (beta-lactam antibiotics e.g. cefotaxime or ceftriaxone), and--when necessary--catecholamine infusions. An early assessment of the coagulation disorders in meningococcal disease can be based on few coagulation parameters. Thus an appropriate treatment can be arranged in order to prevent a fatal outcome of meningococcal sepsis and to protect against the development of a Water-house-Friderichsen-syndrome.