An Uncommon Presentation of Cryptococcal Meningoencephalitis

Cryptococcal meningoencephalitis (CM) remains a common cause of central nervous system infections. Patients usually present with headache, fever, malaise, and altered mental status over several weeks. Signs are often absent, but they may include meningism, papilledema, cranial nerve palsies, and depressed level of consciousness. Individuals with CM can occasionally present with small vessel vasculitis causing cerebral lesions. The literature regarding patterns of cerebrovascular injury in CM is scarce.

We describe a case of CM in which an unusual presentation was observed: transient focal neurological symptoms initially with absence of fever that led to a misleading primary diagnosis of transient ischemic attack. Since neurological symptoms may be a manifestation of a cryptococcal infection, it is necessary to have a high degree of suspicion for this pathology in the presence of focal neurological deficits, even in patients with vascular risk factors, requiring a thorough etiological investigation.

A Fatal Cause of Rapidly Progressive Heart Failure in a Middle-Aged Woman

Primary cardiac neoplasms are rare, with 3/4 cases being benign. Most malignant neoplasms are sarcomas. Clinically, they present as pseudovalvular obstruction or remote embolism and rarely as a paraneoplastic syndrome. Median survival depends on complete resection rather than histologic type. We describe the case of a 65-year-old woman who presented to the hospital with a three-month history of asthenia, anorexia, weight loss, and progressive worsening of exertional dyspnea. Transthoracic echocardiogram showed a bulky mass in the auricles with significant transvalvular obstruction of the mitral valve. The CT scan showed a voluminous mass in the interauricular septum with the invasion of both atria and restriction of flow in both pulmonary veins. A transvenous biopsy was performed and histology revealed a primary intimal sarcoma. The patient was not eligible for surgery and was proposed for palliative chemotherapy, but she succumbed to her illness in less than two weeks. This report describes this rare and rapidly fatal disease and reviews the literature.

Rheuma SPACE - Standard Practice Aiming Clinical Excellence: the first Portuguese Rheumatology Department evaluation

The Portuguese Rheumatology Society (SPR) embraced quality as a major goal and launched, in early 2015, a program to aim for excellence in global clinical care: Rheuma SPACE - Standard Practice Aiming Clinical Excellence. Evaluating daily reality is the first step in a quality development timeline, ultimately contributing for health gains. Herein we describe the results of the evaluation of the quality indicators defined for this project and the improvement strategies identified. The Rheuma SPACE project included three phases: 1) establishing a set of quality indicators and an excellence quality model; 2) assessment of the current care at Rheumatology departments concerning the defined quality indicators in the scope of the excellence model; and 3) elaboration of global and customized reports for each participating Rheumatology department, resulting in the identification of improvement opportunities. Ten Rheumatology departments, countrywide, including larger and smaller institutions, were asked to participate in Rheuma SPACE. This resulted in an individual report for each department along with global benchmarking practices analysis. Furthermore, a list of improvement initiatives was developed. We concluded that departments lack physicians and need exclusively dedicated nurses. Time dedicated to research and audit activities should be specifically allocated. Internal contracting is well established, and professionals are committed to targets. Processes are still suboptimal, needing standardization of triage criteria, more frequent follow-up, as well as better medical records and multidisciplinary coverage. Regarding outcomes, patients are satisfied with the provided care and professionals with the working environment. However, department facilities for the former, and career related aspects, for the latter should improve. With this innovative study conducted in Portugal we expect to have enlightened tailored opportunities for improvement, ensure patient-focused practices and be able to define the indispensable quality requirements for excellence.

Rheuma SPACE - Standard Practice Aiming Clinical Excellence: description of the methodological approach

BACKGROUND

Quality of care is a key component of the right to health, and the route to equity and dignity. The aim of the project Rheuma SPACE - Standard Practice Aiming Clinical Excellence was to develop a set of quality indicators focused in rheumatoid arthritis care and apply them to rheumatology departments of the Portuguese National Health Service in order to benchmark the care for these patients. This article details the methodology that was applied.

METHODOLOGY

This was a single country, three-phase project, each phase comprising multiple steps. The first step defined quality indicators and the excellence quality model to be used. It involved a literature search for international benchmarking of quality of care initiatives and indicators, followed by a pre-selection of an initial set of indicators. The set of indicators was latter on narrowed after an online Delphi round with all Portuguese rheumatologists and two consensus meetings involving the study task force. A set of 26 quality indicators was defined, within the three classic Donabedian dimensions of healthcare quality: Structure (9), Processes (11), and Outcomes (6). These indicators cover eleven domains of quality of care: personnel and organizational structure, training and research, facilities, equipment and information technology, budgeting and financial resources, access to care, clinical records, patient communication, multidisciplinary management, clinical outcomes, and patient and personnel satisfaction. Decision on quality and excellence thresholds for each of the 26 quality indicators was agreed upon a consensus meeting gathering principal investigators of the eight Rheumatology Departments that decided to participate, task force core set members and invited representatives of all Portuguese Departments/Units. Rheumatoid arthritis was the chosen disease model of the project based on the reliability of the outcomes to be measured in the context of this condition. The second step was the assessment of the participating Rheumatology Departments. During eighteen months, research teams applied the 26 quality indicators to their own Departments. The third step comprised data analysis and the elaboration of individual Rheumatology Department reports and of a global public report.

RESULTS

Eight Departments, comprising 80 specialists, 20 residents and 30 nurses, covering 5.904.080 inhabitants, underwent quality evaluation. More than one thousand patients (1,325) and 113 health professionals' surveys were analysed, as well as data from 570 clinical records and 3,927 medical appointments on rheumatoid arthritis patients.

DISCUSSION

26 quality indicators were used for the first evaluation of Portuguese Rheumatology Departments, turning Rheuma SPACE into a pioneer project. Data analysis and benchmarking will be the subject of a further publication.

Role of Hypoxia in Photodynamic Therapy of Tumors

The photodynamic therapy of tumors is based on a photosensitization reaction that produces oxygen-derived cytotoxic species. The availability of oxygen is therefore a necessary condition to obtain the desired effect. However, most tumors develop regions that have outgrown their vascular supply, and therefore present severe hypoxia. In many hypoxic, yet viable areas, oxygen partial pressures almost two orders of magnitude lower that in normal tissues have been measured by other authors. It is here suggested that hypoxic cells are resistant to the therapy and hence are a source of postirradiation recurrence of the tumors. Methods are reviewed and discussed that can be used to: (a) improve the tumor oxygenation status prior to, or during irradiation; (b) destroy hypoxic cells; and, (c) allow the reoxygenation of the tumor by using fractionated irradiation protocols which increase tumor photosensitivity. Hyperthermia, a therapy to which hypoxic cells are particularly sensitive, is discussed. Cellular and vascular parameters that should be considered when discussing the synergism between hyperthermia and photodynamic therapy are listed. The new research field of hypoxia mapping by nondestructive, noninvasive, imaging techniques is briefly discussed.

Aorto-left ventricular tunnel: a rare cause of heart failure in the newborn

Aorto-left ventricular tunnel is a rare congenital cardiac anomaly, consisting of a short abnormal pathway, usually from a sinus of Valsalva into the left ventricular cavity. It is usually diagnosed with echocardiography. We report a case of a newborn presenting with heart murmur and rapid progression to heart failure and left ventricular enlargement due to an aorto-left ventricular tunnel. Despite successful closure of the tunnel, the patient required a Ross procedure due to progressive aortic disease.

Enzyme-Histochemistry Technique for Visualizing the Dipeptidyl-Peptidase IV (DPP-IV) Activity in the Liver Biliary Tree

Dipeptidyl-peptidase IV is an enzyme involved in a lot of biochemical processes, where it modifies a number of regulatory proteins by removing the terminal peptides by hydrolysis. Here we describe a histochemical method to demonstrate with accuracy and precision its in situ activity on cryostatic section of Wistar rat liver by means of a simultaneous azo-coupling method.

[Acute kidney injury after pediatric cardiac surgery: risk factors and outcomes. Proposal for a predictive model]

OBJECTIVES

To characterize the epidemiology and risk factors for acute kidney injury (AKI) after pediatric cardiac surgery in our center, to determine its association with poor short-term outcomes, and to develop a logistic regression model that will predict the risk of AKI for the study population.

METHODS

This single-center, retrospective study included consecutive pediatric patients with congenital heart disease who underwent cardiac surgery between January 2010 and December 2012. Exclusion criteria were a history of renal disease, dialysis or renal transplantation.

RESULTS

Of the 325 patients included, median age three years (1 day-18 years), AKI occurred in 40 (12.3%) on the first postoperative day. Overall mortality was 13 (4%), nine of whom were in the AKI group. AKI was significantly associated with length of intensive care unit stay, length of mechanical ventilation and in-hospital death (p<0.01). Patients' age and postoperative serum creatinine, blood urea nitrogen and lactate levels were included in the logistic regression model as predictor variables. The model accurately predicted AKI in this population, with a maximum combined sensitivity of 82.1% and specificity of 75.4%.

CONCLUSIONS

AKI is common and is associated with poor short-term outcomes in this setting. Younger age and higher postoperative serum creatinine, blood urea nitrogen and lactate levels were powerful predictors of renal injury in this population. The proposed model could be a useful tool for risk stratification of these patients.

The hybrid approach for palliation of hypoplastic left heart syndrome: Intermediate results of a single-center experience

INTRODUCTION

Hypoplastic left heart syndrome (HLHS) is a major cause of cardiac death during the first week of life. The hybrid approach is a reliable, reproducible treatment option for patients with HLHS. Herein we report our results using this approach, focusing on its efficacy, safety and late outcome.

METHODS

We reviewed prospectively collected data on patients treated for HLHS using a hybrid approach between July 2007 and September 2014.

RESULTS

Nine patients had a stage 1 hybrid procedure, with seven undergoing a comprehensive stage 2 procedure. One patient completed the Fontan procedure. Five patients underwent balloon atrial septostomy after the hybrid procedure; in three patients, a stent was placed across the atrial septum. There were three deaths: two early after the hybrid procedure and one early after stage two palliation. Overall survival was 66%.

CONCLUSIONS

In our single-center series, the hybrid approach for HLHS yields intermediate results comparable to those of the Norwood strategy. The existence of dedicated teams for the diagnosis and management of these patients, preferably in high-volume centers, is of major importance in this condition.

Dipeptidylpeptidase-IV activity and expression reveal decreased damage to the intrahepatic biliary tree in fatty livers submitted to subnormothermic machine-perfusion respect to conventional cold storage

Graft steatosis is a risk factor for poor initial function after liver transplantation. Biliary complications are frequent even after normal liver transplantation. A subnormothermic machine perfusion (MP20) preservation procedure was developed by our group with high potential for reducing injury to hepatocytes and sinusoidal cells of lean and fatty livers respect to conventional cold storage (CS). We report the response of the biliary tree to CS or MP20, in lean and obese Zucker rat liver. Dipeptidylpeptidase-IV (DPP-IV), crucial for the inactivation of incretins and neuropeptides, was used as a marker. Liver morphology and canalicular network of lean livers were similar after CS/reperfusion or MP20/reperfusion. CS preservation of fatty livers induced serious damage to the parenchyma and to the canalicular activity/ expression of DPP-IV, whereas with MP20 the morphology and canalicular network were similar to those of untreated lean liver. CS and MP20 had similar effects on DPP-IV activity and expression in the upper segments of the intrahepatic biliary tree of fatty livers. DPP-IV expression was significantly increased after MP20 respect to CS or to the controls, both for lean and obese animals. Our data support the superiority of MP20 over CS for preserving fatty livers. Dipeptidylpeptidase-IV activity and expression reveal decreased damage to the intrahepatic biliary tree in fatty livers submitted to subnormothermic machine-perfusion respect to conventional cold storage.

The role of propranolol in the treatment of infantile hemangioma

INTRODUCTION

Infantile hemangioma (IH) is one of the most common childhood tumors. There are various medical or surgical therapeutic options, all with suboptimal results. Recently, the successful use of propranolol for involution of IH was described. We report the results of a single-center experience with this therapeutic option.

OBJECTIVE

To prospectively assess the efficacy and safety of propranolol in children with infantile hemangioma.

METHODS

We performed a prospective analysis of clinical data of all patients with IH referred to a pediatric cardiology center for baseline cardiovascular assessment prior to propranolol therapy. Propranolol was given at a starting dose of 1 mg/kg/day and titrated to a target dose of 2-3 mg/kg/day according to clinical response. Efficacy was assessed through a photograph-based severity scoring scale. Safety was assessed by collecting data regarding significant side effects.

RESULTS

Starting in 2010, 30 patients (15 female) were referred for propranolol treatment of IH, at a median age of six months (1-63 months). The mean target propranolol dose was 2.8 mg/kg/day, with a mean duration of therapy of 12 months. All patients experienced significant reduction of IH size and volume. There were no side effects.

CONCLUSIONS

In our experience propranolol appears to be a useful and safe treatment option for severe or complicated IH, achieving a rapid and significant reduction in their size. No adverse effects were observed, although until larger clinical trials are completed, potential adverse events should be borne in mind and consultation with local specialists is recommended prior to initiating treatment.

Linear lupus erythematosus profundus as an initial manifestation of systemic lupus erythematosus in a child

The case of a 13-year-old Caucasian girl with a 1-year history of a linear plaque on her thigh is reported. Histopathologic examination of the incisional biopsy tissue established the diagnosis of lupus erythematosus panniculitis. Six months later she developed the clinical and laboratory criteria for the diagnosis of systemic lupus erythematosus (SLE). She was treated with azathioprine and oral prednisolone, with a favorable clinical outcome. Our case illustrates a child with linear lupus erythematosus profundus as an initial manifestation of SLE. To our knowledge, only eight other cases of linear lupus erythematosus profundus have been reported in the literature, five in children. In contrast to our patient, none of those cases progressed to SLE during the reported follow-up period. The authors report this case to illustrate an unusual superimposed segmental manifestation of an inflammatory polygenic disorder.

AMPK involvement in endoplasmic reticulum stress and autophagy modulation after fatty liver graft preservation: a role for melatonin and trimetazidine cocktail

Ischemia/reperfusion injury (IRI) associated with liver transplantation plays an important role in the induction of graft injury. Prolonged cold storage remains a risk factor for liver graft outcome, especially when steatosis is present. Steatotic livers exhibit exacerbated endoplasmic reticulum (ER) stress that occurs in response to cold IRI. In addition, a defective liver autophagy correlates well with liver damage. Here, we evaluated the combined effect of melatonin and trimetazidine as additives to IGL-1 solution in the modulation of ER stress and autophagy in steatotic liver grafts through activation of AMPK. Steatotic livers were preserved for 24 hr (4°C) in UW or IGL-1 solutions with or without MEL + TMZ and subjected to 2-hr reperfusion (37°C). We assessed hepatic injury (ALT and AST) and function (bile production). We evaluated ER stress (GRP78, PERK, and CHOP) and autophagy (beclin-1, ATG7, LC3B, and P62). Steatotic livers preserved in IGL-1 + MEL + TMZ showed lower injury and better function as compared to those preserved in IGL-1 alone. IGL-1 + MEL + TMZ induced a significant decrease in GRP78, pPERK, and CHOP activation after reperfusion. This was consistent with a major activation of autophagic parameters (beclin-1, ATG7, and LC3B) and AMPK phosphorylation. The inhibition of AMPK induced an increase in ER stress and a significant reduction in autophagy. These data confirm the close relationship between AMPK activation and ER stress and autophagy after cold IRI. The addition of melatonin and TMZ to IGL-1 solution improved steatotic liver graft preservation through AMPK activation, which reduces ER stress and increases autophagy.

Dipeptidylpeptidase--IV, a key enzyme for the degradation of incretins and neuropeptides: activity and expression in the liver of lean and obese rats

Given the scarcity of donors, moderately fatty livers (FLs) are currently being considered as possible grafts for orthotopic liver transplantation (OLT), notwithstanding their poor tolerance to conventional cold preservation. The behaviour of parenchymal and sinusoidal liver cells during transplantation is being studied worldwide. Much less attention has been paid to the biliary tree, although this is considered the Achille's heel even of normal liver transplantation. To evaluate the response of the biliary compartment of FLs to the various phases of OLT reliable markers are necessary. Previously we demonstrated that Alkaline Phosphatase was scarcely active in bile canaliculi of FLs and thus ruled it out as a marker. As an alternative, dipeptidylpeptidase-IV (DPP-IV), was investigated. This ecto-peptidase plays an important role in glucose metabolism, rapidly inactivating insulin secreting hormones (incretins) that are important regulators of glucose metabolism. DPP-IV inhibitors are indeed used to treat Type II diabetes. Neuropeptides regulating bile transport and composition are further important substrates of DPP-IV in the enterohepatic axis. DPP-IV activity was investigated with an azo-coupling method in the liver of fatty Zucker rats (fa/fa), using as controls lean Zucker (fa/+) and normal Wistar rats. Protein expression was studied by immunofluorescence with the monoclonal antibody (clone 5E8). In Wistar rat liver, DPP-IV activity and expression were high in the whole biliary tree, and moderate in sinusoid endothelial cells, in agreement with the literature. Main substrates of DPP-IV in hepatocytes and cholangiocytes could be incretins GLP-1 and GIP, and neuropeptides such as vasoactive intestinal peptide (VIP) and substance P, suggesting that these substances are inactivated or modified through the biliary route. In lean Zucker rat liver the enzyme reaction and protein expression patterns were similar to those of Wistar rat. In obese rat liver the patterns of DPP-IV activity and expression in hepatocytes reflected the morphological alterations induced by steatosis as lipid-rich hepatocytes had scarce activity, located either in deformed bile canaliculi or in the sinusoidal and lateral domains of the plasma membrane. These findings suggest that bile canaliculi in steatotic cells have an impaired capacity to inactivate incretins and neuropeptides. Incretin and/or neuropeptide deregulation is indeed thought to play important roles in obesity and insulin-resistance. No alteration in enzyme activity and expression was found in the upper segments of the biliary tree of obese respect to lean Zucker and Wistar rats. In conclusion, this research demonstrates that DPP-IV is a promising in situ marker of biliary functionality not only of normal but also of fatty rats. The approach, initially devised to investigate the behaviour of the liver during the various phases of transplantation, appears to have a much higher potentiality as it could be further exploited to investigate any pathological or stressful conditions involving the biliary tract (i.e., metabolic syndrome and cholestasis) and the response of the biliary tract to therapy and/or to surgery.

Main determinants of PON1 activity in hemodialysis patients

BACKGROUND/AIMS

Cardiovascular diseases are the major cause of morbidity and mortality in hemodialysis (HD) patients. These patients present reduced paraoxonase 1 (PON1) activity that depends on genetic and non-genetic factors; however, how these factors influence PON1 activity in HD patients is poorly clarified. Our aim was to evaluate the influence of two polymorphisms and non-genetic factors on PON1 activity in HD patients.

METHODS

We evaluated 183 HD patients under recombinant human erythropoietin (rhEPO) treatment and 22 healthy individuals. The lipid profile [total cholesterol, triglycerides, HDL-c, LDL-c, apolipoprotein (Apo) A-I, Apo B, lipoprotein(a) and oxidized low-density lipoprotein (Ox-LDL)], inflammatory markers [adiponectin, interleukin-6 (IL-6) and C-reactive protein (CRP)], PON1 activity and PON1 gene polymorphisms (L55M and Q192R) were evaluated.

RESULTS

HD patients presented higher levels of IL-6, CRP and Ox-LDL/LDL-c, and lower PON1 activity, total cholesterol, HDL-c, LDL-c, Apo A and Apo B; the most frequent genotype was heterozygosity for L55M polymorphism and homozygosity for the Q allele, the more frequent genotype of Q192R polymorphism. Multiple regression analysis identified heterozygosity and homozygosity for L55M and Q192R polymorphisms, very low-density lipoproteins, LDL-c, Apo A and CRP levels, time on dialysis and rhEPO dose, as the independent variables significantly associated with PON1 activity. The associations with CRP, rhEPO and time on dialysis were negative.

CONCLUSION

Our results show that the reduced PON1 activity in HD patients who are not under statin therapy is strongly associated with inflammation, longer time on dialysis and high rhEPO doses, suggesting that the reduction in PON1 activity may worsen the prognosis of these patients.

Lobe-specific heterogeneity and matrix metalloproteinase activation after ischemia/reperfusion injury in rat livers

Studies assessing the effects of partial-hepatic ischemia/reperfusion (I/R) injury focused on the damage to the ischemic-lobe, whereas few data are available on non-ischemic lobe. This study investigated whether acute liver I/R does affect non-ischemic lobe function via modulation of extracellular matrix remodeling. Male Sprague-Dawley rats underwent left lateral- and median-lobe ischemia for 30 min and reperfusion for 60 min or sham operation. After reperfusion, blood samples and hepatic biopsies from both the ischemic (left-lobe, LL) and the non-ischemic lobe (right-lobe, RL) were collected. Serum hepatic enzymes and TNF-alpha, tissue matrix metalloproteinases (MMP-2, MMP-9), liver morphology, malondialdehyde (MDA), and myeloperoxidase (MPO) were evaluated. Liver I/R injury was confirmed by altered increased hepatic enzymes and TNF-alpha. I/R induced an altered morphology and an increase in MMP-2 and MMP-9 activity not only in left-ischemic lobe (LL) but also in the right-non-ischemic (RL) lobe. A lobar difference was detected for MDA formation and MPO activity in both sham and I/R submitted rats, with higher levels in the left lobe for both groups. This study indicates that an increase in MMPs, which may be TNF-alpha-mediated, occurs in both the ischemic- and the non-ischemic lobes; the heterogeneous lobe concentrations of MDA and MPO suggest that the random sampling of liver tissue should be avoided.

Tumor interstitial fluid as modulator of cancer inflammation, thrombosis, immunity and angiogenesis

Tumor interstitial fluid (TIF) is a watery phase that accumulates inside the tumor interstitium. Its genesis and fate depend on various factors, namely tumor type, metabolic state of the tumor, expression of vascular endothelial growth factor, and absence of lymphatic system. For almost 30 years TIF remained a neglected entity until it was demonstrated that TIF, and in particular its high pressure, constitutes an important obstacle to drug delivery and immunotherapy. The present review not only summarizes the abundant literature on the processes of TIF genesis and on its effects on therapy but it also presents data that, in our opinion, point towards what is perhaps the real physiological purpose of TIF: a primitive means of providing nourishment, oxygen, cytokines and matrikines to tumor cells that furthermore promotes the invasion of the normal surrounding tissue and passive metastatization through lymphatics. It is also an inducer of inflammation through increased osmolarity due to albumin loss. Recently, a role for TIF as a possible source of biomarkers has also been suggested.

[Importance of primary indications for fetal echocardiography proposed by the Portuguese Health Department]

BACKGROUND

Congenital heart disease is the most frequent congenital malformation, affecting about 5-8 newborn per thousand live births. Nowadays it is possible to do prenatal diagnosis of these conditions with fetal echocardiography (EcoF) but because health resources are limited this exam must be ordered according to the criteria established by the Portuguese Health Department.

AIMS

Evaluate the importance of the referral criteria for fetal echocardiography attending to the cardiac anomalies identified. To determine prevalence and mortality rates in fetus with cardiac anomalies.

METHODS

Retrospective analysis of the clinical records of 733 fetus to which was performed EcoF in the Prenatal Cardiology consultation of a tertiary center of Pediatric Cardiology, between 2006 and 2008. Were registered demographic data, referral motif, EcoF results and follow-up data. The referral motif was classified in two groups: (I) The "Risk Group"--which referral was consistent with the Health department indications and this included major causes (family, maternal, fetal) and minor causes (other situations), and the "No risk Group" (II)--which referral wasn't consistent with those indications.

RESULTS

During this period were performed 871 fetal echocardiograms to 705 pregnant women. The median maternal age was 32 years (15-45 years) and mean gestational age was 26 weeks (± 4 wk). The "Risk group" included 89.5% of the sample. Were identified 52 cases (7%) with cardiac anomalies in fetal echocardiography: 42 structural anomalies, 8 rhythm anomalies and 2 pericardial effusions. These abnormalities were distributed as follows: "Risk Group"--family cause (3), maternal cause (3), fetal cause (39), minor cause (5) and "No Risk Group" (2). The "Risk Group" had more cardiac abnormalities (6.8% vs 0.3%) (p>0.05), specially the "fetal cause subgroup" (p<0.05). Were missed on follow up 10 positive cases, there was 3 medical pregnancy interruptions and 3 children died. Eleven positive cases maintain follow-up on Pediatric Cardiology consultation.

CONCLUSIONS

Most of the cases fulfilled the referral criteria established by the Health Department, but there was no statistically significant difference in the prevalence of fetal cardiac anomalies in pregnant women with and without risk factors. The fetal cause was the best related to the presence of cardiac disease. The prevalence of cardiac anomalies and the mortality rate may be underestimated in this sample due to the loss of positive cases in the follow-up.

Decreased apoptosis in fatty livers submitted to subnormothermic machine-perfusion respect to cold storage

Machine perfusion at subnormothermic temperature (20°C), MP20, was developed by Vairetti et al. and showed to afford a better preservation of fatty livers respect to traditional cold storage (CS) in terms of enzyme release into the perfusate and bile, glycogen stores, energy charge and oxidative stress. Here we investigated whether it also caused decreased cell death by apoptosis. Fatty and lean Zucker rats were submitted to MP20 or CS for 6 h and reperfused normothermically for 2 h. Apoptotic cells were revealed by immunohistochemistry of activated caspase-3 and M30 (new epitope on CK18 degraded by caspase-3) and by the TUNEL assay. Portal pressure was also determined. A statistically significant reduction of hepatocyte apoptosis, but especially of sinusoidal cells was determined for fatty livers submitted to MP20 respect to CS. Portal pressure was significantly lower after MP20 respect to CS. The reduction of sinusoidal cell death by apoptosis without need for anti-apoptotic therapies appears particularly positive since apoptotic sinusoidal cells hinder microcirculation in the sinusoids and are thrombogenic. These results further confirm the potential of MP20 for preserving fatty livers that would be otherwise discarded as grafts, and thus for increasing the donor pool for liver transplantation.

Melatonin protects steatotic and nonsteatotic liver grafts against cold ischemia and reperfusion injury

Chronic organ-donor shortage has required the acceptance of steatotic livers for transplantation purposes despite the higher risk of graft dysfunction or nonfunction associated with the cold ischemia-reperfusion injury. This study evaluated the use of melatonin as an additive to Institute Georges Lopez (IGL-1) solution for protecting nonsteatotic and steatotic liver grafts against cold ischemia-reperfusion injury. In the current investigation, we used an ex vivo isolated perfused rat liver model. Steatotic and nonsteatotic livers were preserved for 24 hr (4°C) in University of Wisconsin or IGL-1 solutions with or without melatonin, as well as in University of Wisconsin solution alone. Thereafter, livers were subjected to 2-hr reperfusion (37°C). We assessed hepatic injury (transaminases) and function [bile production and sulfobromophthalein (BSP) clearance, vascular resistance], as well as other factors potentially implicated in the high vulnerability of steatotic livers against ischemia-reperfusion injury (oxidative stress and related inflammatory mediators including nitric oxide and cytokines). We also evaluated well-known cytoprotective factors as hemeoxygenase 1 (HO-1). Fatty livers preserved in IGL-1 solution enriched with melatonin showed lower transaminase levels and higher bile production and BSP clearance when compared to those obtained for livers maintained in IGL-1 solution alone. A significant diminution of vascular resistance was also observed when melatonin was added to the IGL-1 solution. The melatonin benefits correlated with the generation of nitric oxide (through constitutive e-NOS activation) and the prevention of oxidative stress and inflammatory cytokine release including tumor necrosis factor and adiponectin, respectively. The addition of melatonin to IGL-1 solution improved nonsteatotic and steatotic liver graft preservation, limiting their risk against cold ischemia-reperfusion injury.

Altered alkaline phosphatase activity in obese Zucker rats liver respect to lean Zucker and Wistar rats discussed in terms of all putative roles ascribed to the enzyme

Biliary complications often lead to acute and chronic liver injury after orthotopic liver transplantation (OLT). Bile composition and secretion depend on the integrated action of all the components of the biliary tree, starting from hepatocytes. Fatty livers are often discarded as grafts for OLT, since they are extremely vulnerable to conventional cold storage (CS). However, the insufficiency of donors has stimulated research to improve the usage of such marginal organs as well as grafts. Our group has recently developed a machine perfusion system at subnormothermic temperature (20°C; MP20) that allows a marked improvement in preservation of fatty and even of normal rat livers as compared with CS. We sought to evaluate the response of the biliary tree of fatty liver to MP20, and a suitable marker was essential to this purpose. Alkaline phosphatase (AlkP, EC 3.1.3.1), frequently used as marker of membrane transport in hepatocytes and bile ducts, was our first choice. Since no histochemical data were available on AlkP distribution and activity in fatty liver, we have first settled to investigate AlkP activity in the steatotic liver of fatty Zucker rats (fa/fa), using as controls lean Zucker (fa/+) and normal Wistar rats. The AlkP reaction in Wistar rats was in accordance with the existing data and, in particular, was present in bile canaliculi of hepatocytes in the periportal region and midzone, in the canals of Hering and in small bile ducts but not in large bile ducts. In lean ZR liver the AlkP reaction in Hering canals and small bile ducts was similar to Wistar rat liver but hepatocytes had lower canalicular activity and besides presented moderate basolateral reaction. The difference between lean Zucker and Wistar rats, both phenotypically normal animals, could be related to the fact that lean Zucker rats are genotypically heterozygous for a recessive mutated allele. In fatty liver, the activity in ductules and small bile ducts was unchanged, but most hepatocytes were devoid of AlkP activity with the exception of clusters of macrosteatotic hepatocytes in the mid-zone, where the reaction was intense in basolateral domains and in distorted canaliculi, a typical pattern of cholestasis. The interpretation of these data was hindered by the fact that the physiological role of AlkP is still under debate. In the present study, the various functions proposed for the role of the enzyme in bile canaliculi and in cholangiocytes are reviewed. Independently of the AlkP role, our data suggest that AlkP does not seem to be a reliable marker to study the initial step of bile production during OLT of fatty livers, but may still be used to investigate the behaviour of bile ductules and small bile ducts.

Percutaneous pulmonary valve implantation: initial experience

INTRODUCTION

Patients with congenital heart disease who undergo surgical implantation of a conduit between the right ventricle and the pulmonary artery (RV-PA conduit) may develop stenosis and/or insufficiency over time. These cases, which are associated with arrhythmias, RV dysfunction and sudden death, remain a challenge for surgical re-intervention, due to its complexity and associated morbidity and mortality. Percutaneous pulmonary valve implantation (PPVI) is therefore a valid alternative.

OBJECTIVE

To report our center's initial experience with PPVI.

METHODS

Prospective assessment of clinical, echocardiographic, magnetic resonance, hemodynamic and angiographic data from our series of PPVI.

RESULTS

Six patients in NYHA functional class +/- II underwent PPVI. All had significant conduit dysfunction and five had stenosis. The procedure consisted of implanting a bare metal stent to reduce the risk of fracture of the Melody valved stents (Medtronic) that were then successfully deployed in all. The immediate hemodynamic results showed a reduction in RV pressure (94 +/-27 to 44 +/- 7 mmHg), RV/LV pressure ratio (94 +/-27 to 44 +/- 7%) and conduit gradient (65 +/- 28 to 11 +/- 4 mmHg), and no insufficiency. The median duration of the procedure was 180 minutes, with no major complications. Patients were discharged a median of two days after the procedure. After a median follow-up of 7.8 months, patients are in functional class I (5) or II (1), with no evidence of conduit dysfunction on non-invasive assessment.

CONCLUSIONS

Our results are similar to the excellent results reported in larger series. PPVI is a valid therapeutic option in patients with conduit dysfunction.

Human liver autofluorescence: an intrinsic tissue parameter discriminating normal and diseased conditions

BACKGROUND AND OBJECTIVE

Autofluorescence (AF) emission is an intrinsic parameter that can provide real-time information on morpho-functional properties of biological tissue, being strictly related with their biochemical composition and structural organization. The diagnostic potentials of AF-based techniques have been investigated on normal, fibrotic, and steatotic liver tissues, in reference to histological features as evidenced by specific histochemical stainings.

MATERIALS AND METHODS

AF emission under excitation at 366 nm has been examined on cryostatic tissue sections obtained from biopsies collected during surgical operation, by means of fluorescence imaging and microspectrofluorometric techniques.

RESULTS

NAD(P)H, collagen, and vitamin A were found to be the endogenous fluorophores characterizing normal, fibrotic, and steatotic liver tissue AF, respectively. The differences of their photo-physical properties, in terms of emission amplitude, spectral shape, and response to irradiation, give rise to modifications of overall AF signal collected from tissues that allow the liver conditions to be distinguished.

CONCLUSION

The study provides a valid premise for a development of AF-based optical biopsy techniques for a real-time discrimination of liver anatomo-pathological patterns.

Hypoxia inducible factor-1α accumulation in steatotic liver preservation: Role of nitric oxide

AIM: To examine the relevance of hypoxia inducible factor (HIF-1) and nitric oxide (NO) on the preservation of fatty liver against cold ischemia-reperfusion injury (IRI).

METHODS: We used an isolated perfused rat liver model and we evaluated HIF-1α in steatotic and non-steatotic livers preserved for 24 h at 4°C in University of Wisconsin and IGL-1 solutions, and then subjected to 2 h of normothermic reperfusion. After normoxic reperfusion, liver enzymes, bile production, bromosulfophthalein clearance, as well as HIF-1α and NO [endothelial NO synthase (eNOS) activity and nitrites/nitrates] were also measured. Other factors associated with the higher susceptibility of steatotic livers to IRI, such as mitochondrial damage and vascular resistance were evaluated.

RESULTS: A significant increase in HIF-1α was found in steatotic and non-steatotic livers preserved in IGL-1 after cold storage. Livers preserved in IGL-1 showed a significant attenuation of liver injury and improvement in liver function parameters. These benefits were enhanced by the addition of trimetazidine (an anti-ischemic drug), which induces NO and eNOS activation, to IGL-1 solution. In normoxic reperfusion, the presence of NO favors HIF-1α accumulation, promoting also the activation of other cytoprotective genes, such as heme-oxygenase-1.

CONCLUSION: We found evidence for the role of the HIF-1α/NO system in fatty liver preservation, especially when IGL-1 solution is used.

Pulmonary asymmetry on chest X-ray

The unilateral absence of one pulmonary artery is a rare congenital abnormality. The authors report a clinical case of a two-year-old boy with no previous medical history who was referred for evaluation after the detection of pulmonary asymmetry on the chest X-ray with a right mediastinal shift. The CT scan and pulmonary perfusion scintigraphy pointed to an absent right pulmonary artery, which was confirmed by right heart catheterization and cardiac magnetic resonance imaging. This is an important pathology because early diagnosis and timely correction can prevent future complications. Since at this time the patient is asymptomatic, the authors opted for careful clinical vigilance.

Percutaneous closure of atrial septal defects: a decade of experience at a reference center

INTRODUCTION

Atrial septal defects (ASD) are among the most common congenital anomalies and account for 10% of congenital heart disease in the pediatric age-group and 30% in adults. Closure is indicated when there is evidence of hemodynamic significance or after a paradoxical embolic event. Ten years ago, percutaneous closure became the treatment of choice in our center for all patients with a clear indication and favorable anatomy. In this paper we report the experience of this first decade.

OBJECTIVE

To assess the short- and long-term results of our ten-year experience with percutaneous closure of atrial septal defects.

METHODS

We studied retrospectively all patients with ASD treated with a percutaneous approach between November 1998 and December 2008. The pediatric age-group consisted of patients younger than 19 years old. Demographic data, clinical indications, minor and major complication rates, success rate and long-term outcome were assessed.

RESULTS

In the first ten years of experience 510 patients, of whom 166 were in the pediatric group, were treated in our center by a team of adult and pediatric cardiologists. The overall success rate of the procedure was 98% (97.5% in ASD and 99.5% in patent foramen ovale (PFO). The minor complication rate was 3% (3.4% in ASD and 2% in PFO). The most frequent complication was supraventricular tachycardia. The major complication rate was 1.2% (0.6% in ASD and 2% in PFO). Two patients developed cardiac tamponade due to hemopericardium that was resolved by pericardiocentesis, without need for surgery. One patient had an arterial pseudoaneurysm corrected by vascular surgery. There was no device embolization and no need for urgent surgery in this population. During follow-up two patients had recurrence of ischemic stroke, one had a transient ischemic attack and another had a hemorrhagic stroke. Mortality was 0.6% (0.6% in ASD and 0.5% in PFO). There were no in-hospital deaths. During follow-up there were two deaths, both in the adult group.

DISCUSSION AND CONCLUSION

In this population the success rate was high and most of the complications were minor. The results of this collaboration between adult and pediatric cardiologists in the first ten years of activity confirm the safety and efficacy of percutaneous closure of septal defects, when there is careful patient selection and a standardized technique.

[Painful scalp ulcers]

Temporal arteritis is a systemic vasculitis mainly affecting large and medium sized vessels, temporal artery in particular. The authors report the case of a male who presented with large painful scalp ulcers over the temporo-parietal area, ipsilateral headache, amaurosis fugax and jaw claudication. Temporal arteries were thickened, painful and pulseless. Laboratory work revealed erythrocyte sedimentation rate of 63 mm and normochromic and normocytic anaemia. On histopathology transmural acute and chronic inflammation and multiple giant cells were patent in temporal artery wall. Ophthalmologic observation revealed significant visual impairment, mainly on the right eye. Regarding temporal arthritis diagnosis, prednisolone 1 mg/Kg/day was introduced. Clinical improvement was outstanding, although visual impairment remained. This case emphasizes early diagnosis and treatment importance in the avoidance of definitive sequela.

Isolated aortic coarctation: experience in 100 consecutive patients

INTRODUCTION

Coarctation of the aorta (CoA) is a stenosis usually located in the descending aorta. Treatment consists of surgical or percutaneous removal of the obstruction and presents excellent immediate results but significant residual problems often persist.

OBJECTIVES

To describe the presentation, treatment and long-term evolution of a population of 100 unselected consecutive patients with isolated CoA in a single pediatric cardiology center.

METHODS

This was a retrospective study of all patients with isolated CoA treated during4 the last 21 years (1987-2008).

RESULTS

The patients (n=100, 68.3% male) were diagnosed at a median age of 94 days (1 day to 16 years). The clinical presentation differed between patients aged less or more than one year, the former presenting with heart failure and the latter being asymptomatic with evidence of hypertension (88 and 63%, respectively; p < 0.01). Treatment, a median of 8 days after diagnosis, was surgical in 79 cases (20 end-to-end anastomosis, 31 subclavian flap, 28 patch) and percutaneous in the remaining 21 (15 balloon angioplasty, 6 with stenting). The mean age of surgical patients was younger than in those treated percutaneously (3.4 vs. 7.5 years; p < 0.01). Immediate mortality was 2% and occurred in the surgical group. There was no late mortality, in a mean follow-up of 7.2 +/- 5.4 years. Recoarctation occurred in 8 patients (6 surgical, 2 percutaneous). There are 46 patients who currently have hypertension (19 at rest, 27 with effort), their median age at diagnosis being older than the others (23 vs. 995 days; p < 0.01).

CONCLUSIONS

Isolated CoA has an excellent short-term prognosis but a significant incidence of long-term complications, and should thus no longer be seen as a simple obstruction in the descending aorta, but rather as a complex pathology that requires careful follow-up after treatment. Its potentially insidious presentation requires a high level of clinical suspicion, femoral pulse palpation during physical examination of newborns and older children being particularly important. Delay in treatment has an impact on late morbidity and mortality. Taking into account the data currently available on late and immediate results, the final choice of therapeutic technique depends on the patient's age, associated lesions and the experience of the medical-surgical team. Hypertension should be closely monitored in the follow-up of these patients, as well as its risk factors and complications.

Cardiac tumors: the 17-year experience of pediatric cardiology department

INTRODUCTION

Primary cardiac tumork may be benign or malignant and may arise anywhere in the endocardium, myocardium or pericardium. They are rare in pediatric age-groups, with a prevalence in autopsy findings of 0.0017 to 0.28%; most are benign, malignant tumors accounting for only 10% of the total.

OBJECTIVE AND METHODS

The purpose of this paper is to report the 17-year (1989-2006) experience of primary cardiac tumors in a single center. The clinical data and histopathological diagnoses were collected from a retrospective chart review.

RESULTS

We identified 12 patients, with a mean age at diagnosis of 23 months, in two cases diagnosed in the fetal period. The frequent cause of referral was tuberous sclerosis, followed by a cardiac murmur. The diagnosis of primary cardiac tumor was based on echocardiography and/or magnetic resonance imaging. The patients all underwent 24-hour electrocardiographic Holter monitoring, and the most common finding was nonspecific repolarization abnormalities. The most frequent cardiac tumor was rhabdomyoma (67%), usually associated with tuberous sclerosis, followed by fibroma (17%) and fibroelastoma (8%) Although biopsy is the diagnostic gold standard, it was only performed in two patients. Surgical removal of the tumor was performed in a single patient (with fibroelastoma) due to the perceived risk of pulmonary embolization.

DISCUSSION AND CONCLUSIONS

In our population, the most frequent tumor was rhabdomyoma associated with tuberous sclerosis. Most patients were asymptomatic, and the diagnosis was made in routine observations on patients with tuberous sclerosis or with a cardiac murmur. A histopathological diagnosis is only warranted in the rarest forms of cardiac tumors.

Octreotide--additional conservative therapy for postoperative chylothorax in congenital heart disease

INTRODUCTION

Chylothorax is a rare but serious postoperative condition in children with congenital heart disease. Conventional medical treatment consists of specific long-term dietary modification, and surgical reintervention, such as lymphatic duct ligation, may be indicated in refractory cases. In recent years, an additional conservative treatment, octreotide, a synthetic analog of somatostatin, has been used in management of congenital and postoperative chylothorax.

METHODS

The objective of this work was to analyze the efficacy and safety of this treatment for chylothorax after congenital heart surgery. We reviewed the records of sixteen patients with chylothorax after surgery for congenital heart disease between January 1999 and December 2007, and collected the following data: demographic information; type of surgical procedure; onset, duration and management of chylothorax and treatment; and duration of hospital stay. To analyze efficacy we compared these parameters in children receiving conventional treatment only with those receiving octreotide. To analyze safety we compared the adverse effects of both treatments. Octreotide was administered at a dose of 4 to 10 microg/kg/hour, with monitoring of side effects.

RESULTS

The incidence of chylothorax in our population was 1.6%. It occurred more often after Glenn and Fontan procedures (8 patients). Octreotide was begun three days after diagnosis of chylothorax and continued for a median of seventeen days (ranging from 4 to 26 days), until complete resolution. Side effects were frequent (in 3 of the 8 patients) but of no clinical relevance. All patients responded to the therapy and there was no indication for further surgical intervention.

DISCUSSION AND CONCLUSIONS

Octreotide is safe and effective in the treatment of postoperative chylothorax in children with congenital heart disease. It is a useful adjunctive therapy to the conventional treatment of this complication.

Subnormothermic machine perfusion protects steatotic livers against preservation injury: a potential for donor pool increase?

We tested whether rat liver preservation performed by machine perfusion (MP) at 20 degrees C can enhance the functional integrity of steatotic livers versus simple cold storage. We also compared MP at 20 degrees C with hypothermic MP at 8 degrees C, and 4 degrees C. Obese and lean male Zucker rats were used as liver donors. MP was performed for 6 hours with a glucose and N-acetylcysteine-supplemented Krebs-Henseleit solution. Both MP and cold storage preserved livers were reperfused with Krebs-Henseleit solution (2 hours at 37 degrees C). MP at 4 degrees C and 8 degrees C reduced the fatty liver necrosis compared with cold storage but we further protected the organs using MP at 20 degrees C. Necrosis did not differ in livers from lean animals submitted to the different procedures; the enzymes released in steatotic livers preserved by MP at 20 degrees C were similar to those showed in nonsteatotic organs. The adenosine triphosphate/adenosine diphosphate ratio and bile production were higher and the oxidative stress and biliary enzymes were lower in steatotic livers preserved by MP at 20 degrees C as compared with cold storage. In livers from lean rats, the adenosine triphosphate/adenosine diphosphate ratio appears better conserved by MP at 20 degrees C as compared with cold storage. In steatotic livers preserved by cold storage, a 2-fold increase in tumor necrosis factor-alpha levels and caspase-3 activity was observed as compared with organs preserved by MP at 20 degrees C. These data are substantiated by better morphology, higher glycogen content, and lower reactive oxygen species production by sinusoidal cells in steatotic liver submitted to MP at 20 degrees C versus cold storage. MP at 20 degrees C improves cell survival and leads to a marked improvement in hepatic preservation of steatotic livers as compared with cold storage.

Aortopulmonary window. Experience of eleven cases

Aortopulmonary (AP) window is a communication between the ascending aorta and the main pulmonary artery, in the presence of two separate arterial valves arising from separate subarterial ventricular outflow tracts. It is a rare anomaly that accounts for approximately 0.1% to 0.2% of all congenital heart disease. The purpose of this study was to assess clinical features, surgical treatment and outcome of patients with aortopulmonary window referred to a tertiary pediatric cardiac center over a 30-year period. Eleven patients were diagnosed with AP window, ten with the proximal type and one with the distal type defect. Age at first evaluation ranged from three days to 13 years (mean 44.5+/-63.3 months; median three months). Echocardiography enabled correct diagnosis in the four most recent cases. Seven patients underwent closure of the AP window through a transaortic approach and three patients underwent ligation. Simultaneously, significant associated cardiac anomalies were corrected in three patients: correction of interrupted aortic arch in two patients and closure of ventricular septal defect and Dacron patch enlargement of the right ventricular outflow tract in one patient. One patient was not operated because of fixed high pulmonary vascular resistance. Operative mortality was 10% (1/10) and there were no late deaths. Mean follow-up was 10+/-4.9 years. All nine surviving operated patients are asymptomatic, without medication, with no residual defects and without pulmonary hypertension. In conclusion, advances in diagnostic and surgical approaches to AP window in recent years have enabled earlier intervention with good outcome.

Further studies on long-term preservation of rat liver: Celsior versus UW solution

The effects of Celsior solution were compared with those of the University of Wisconsin solution (UW) after 18 or 48 hours of cold storage in a perfused rat liver model. Lactate dehydrogenase (LDH), hyaluronic acid (HA) uptake, thiobarbituric acid-reactive substances (TBARS), tissue reduced (GSH) and oxidized glutathione (GSSG) and ATP were evaluated. Histochemical in situ evaluation ofLDH and reactive oxygen species (ROS) were also performed. No significant difference in LDH release, HA uptake, TBARS, ATP levels and GSH/GSSG ratio were observed between UW and Celsior solution when the livers were preserved for 18 hours. By contrast, when preservation was performed for 48 hours, LDH release, TBARS and ROS formation were higher and the ATP levels, GSH/GSSG ratio and HA uptake were lower in the liver preserved by Celsior as compared with UW. Celsior solution was as effective as UW in liver preservation up to 18 hours but the superiority of UW over Celsior solution was obtained when liver was preserved for 48 hours.

Liver autofluorescence properties in animal model under altered nutritional conditions

Autofluorescence spectroscopy is a promising and powerful approach for an in vivo, real time characterization of liver functional properties. In this work, preliminary results on the dependence of liver autofluorescence parameters on the nutritional status are reported, with particular attention to vitamin A and lipid accumulation in liver tissue. Normally fed and 24 h starving rats were used as animal models. Histochemical and autofluorescence analysis showed that lipids and vitamin A colocalize in the liver parenchyma. Fasting condition results in a parallel increase in both lipids and vitamin A. Autofluorescence imaging and microspectrofluorometric analysis carried out on unfixed, unstained tissue sections under 366 nm excitation, evidenced differences in both spectral shape and response to continuous irradiation between liver biopsies from fed and starving rats. As to photobleaching, in particular, fitting analysis evidenced a reduction of about 85% of the signal attributable solely to vitamin A during the first 10 s of irradiation. The tissue whole emission measured in fed and starving rat livers exhibited reductions of about 35% and 52%, respectively, that are closely related to vitamin A contents. The findings open interesting perspectives for the set up of an in situ, real time diagnostic procedure for the assessment of liver lipid accumulation, exploiting the photophysical properties of vitamin A.