Fistulizing Epstein-Barr virus-positive plasmablastic lymphoma in an HIV-positive man

Plasmablastic lymphoma (PBL) is an unusual subtype of non-Hodgkin lymphoma recently classified as a diffuse immunoblastic lymphoma with a plasma-cell immunophenotype. Originally described in the oral cavity of HIV-positive patients, it has also been recognized to occur rarely at other sites. We describe a previously unreported fistulizing presentation of Epstein-Barr virus (EBV)-positive PBL, reviewing its association with HIV-1 infection and its importance as an AIDS-defining malignancy.

Simultaneous carbon and nitrogen removal from municipal wastewater in full-scale unaerated/aerated submerged filters

Characterization and evaluation of a biological submerged filter was carried out on a full-scale pilot plant performing removal of biochemical oxygen demand (BOD) and total nitrogen (TN) from pre-treated urban wastewater. The average influent values of BOD5, chemical oxygen demand (COD) and TN were 370, 1,015 and 60 mg/L, respectively. The pilot plant produced good discharge quality during steady-state operation. Average effluent BOD5, COD and TN values were 11, 58 and 15 mg/L, respectively. The reactor had been operating beyond its organic design capacity (200 population equivalent (PE)). At 480 PE the removal achieved for BOD, COD and TN were 98, 97 and 78%, respectively. This technology can absorb pollutant overloads while maintaining stable performance. Denitrification was performed by using sewage itself as carbon source. It was used as an intermittent aeration cycle in the unaerated cell to improve the denitrification process. The predenitrification with submerged unaerated filter has proved to be an efficient process for advanced removal of TN.

IL-17 and Regulatory Cytokines (IL-10 and IL-27) in L. braziliensis Infection

Cutaneous leishmaniasis (CL) is characterized by high production of pro-inflammatory cytokines and development of pathology. Individuals with subclinical L. braziliensis infection (SC) have a positive skin test to leishmania, but do not develop disease. We evaluated whether the downregulation of inflammatory response in SC is mediated by IL-10 and IL-27 and whether IL-17 is associated with control of infection. Participants include SC individuals, patients with CL and healthy subjects. Cytokines protein and mRNA were detected by ELISA and real-time PCR. IFN-γ and TNF-α levels were higher in CL than in SC group. The IL-10 levels and mRNA for IL-10 were similar in both SC and CL. mRNA for IL-27 was increased in cells from SC after stimulation with L. braziliensis antigen. There was a tendency for increased levels of IL-17 in SC compared to CL. The weak type 1 immune response observed in SC L. braziliensis infection is not because of the regulatory effects of IL-10 and IL-27. The control of Leishmania infection may be mediated by innate immune response with participation of IL-17. The results from this pilot study warrant further larger studies to investigate the potential contributions of IL-17 and IL-27 to the control of L. braziliensis infection.

The effect of coronary reoperation on the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries

Does coronary artery reoperation improve the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries? To examine this question, we retrospectively reviewed 1117 patients who had coronary bypass grafting and then underwent a postoperative coronary angiogram that showed a stenosis (> or = 20%) of at least one vein graft. Reoperation within 1 month of the postoperative angiogram was performed for 394 patients (REOP group) whereas 723 patients (MED group) received initial medical treatment (no reoperation or percutaneous transluminal coronary angioplasty within 1 year). Compared with the MED group, patients in the REOP group were older, more symptomatic, more likely to have left main stenosis, and had fewer patent bypass grafts (all p < 0.001). In-hospital mortality for the REOP group was 4.3%. Mean postangiogram follow-up of the entire group was 73 months. On the basis of the interval between the primary operation and the postoperative angiogram, patients were designated as having early (< 5 years) or late (> or = 5 years) saphenous vein graft stenosis. Univariate and multivariate analyses were used to identify factors influencing the survival of these subgroups. Reoperation was not identified as a variable improving the survival of patients with early vein graft stenoses. For patients with late vein graft stenoses, moderate or severe impairment of left ventricular function (p < 0.0001), advanced age (p < 0.0001), triple-vessel or left main stenosis (p = 0.0011), and stenosis in a vein graft to the left anterior descending artery (p = 0.0019) decreased survival, whereas reoperation improved survival (p = 0.0007). The improvement in survival with reoperation was particularly strong for patients with a stenotic vein graft to the left anterior descending artery. For that subset, survival was 84% and 74% for the REOP group versus 76% and 53% for the MED group at 2 and 4 years after catheterization, respectively (p = 0.004). For patients with stenotic vein grafts to the right coronary artery or circumflex coronary artery (or both), survival was 92% and 87% for the REOP group versus 89% and 78% for the MED group at 2 and 4 years after catheterization, respectively (p = 0.13). Even for patients with class I or II symptoms, reoperation prolonged survival (p = 0.002 with multivariate testing). Reoperation improves the survival of patients with late vein graft stenoses, particularly those with stenotic grafts to the left anterior descending coronary artery.

Postcardiotomy centrifugal mechanical ventricular support

From August 1979 through August 1991, 91 patients were supported with centrifugal mechanical ventricular assist. Major indications for its use were postcardiotomy ventricular failure (79) or as a bridge to cardiac transplantation (12). In postcardiotomy use (0.2% of all cardiac procedures), there were 54 male (68.4%) and 25 female patients (31.6%) with a mean age of 54.8 years and a mean duration of use of 3.56 days (range, 1 hour to 19 days). Forty-nine patients (62%) were successfully weaned, and 20 (25.3%) were hospital survivors. In 57 patients the device was inserted to wean from cardiopulmonary bypass, whereas in 22 it was employed later in the postoperative period because of low cardiac output or sudden arrest. Thirty-four (59.6%) of the 57 patients in the former group were weaned, and 15 (26.3%) were discharged, results similar to those in the latter group with 15 (68.2%) weaned and 5 (22.7%) discharged. Morbidity associated with use of centrifugal blood pumps included bleeding (87.3%; mean transfusion requirement, 53.2 units), renal failure (46.8%), cerebrovascular accident (12.7%), thromboembolism (12.7%), and hepatic insufficiency (12.7%). After a mean follow-up of 45.4 months (range, 2 to 142 months), 7 patients had died (35% late mortality), 1 patient is in functional class IV, and all others are in functional class I or II. Lower survival was associated with biventricular failure and renal failure but not with age or sex of the patient.

Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study

We tested the efficacy and safety of aprotinin in 169 patients undergoing isolated reoperative myocardial revascularization. Patients were randomly assigned to high-dose aprotinin, low-dose aprotinin, or placebo treatment groups in a double-blind, placebo-controlled study. Treatment groups did not differ significantly with respect to age, sex, red cell mass, number of grafts, use of internal thoracic artery, or incidence of preoperative aspirin therapy. Patients treated with aprotinin had a significant reduction in postoperative chest tube drainage (720 +/- 753, 866 +/- 1,636, and 1,121 +/- 683 mL, respectively, for high-dose aprotinin, low-dose aprotinin, and placebo; p < 0.001). Transfusion requirements were reduced in aprotinin-treated patients (2.1 +/- 4.2, 4.8 +/- 11.8, and 4.1 +/- 6.2 units for high-dose, low-dose, and placebo, respectively; p < 0.001). A similar reduction in chest tube drainage and transfusion requirements was seen in patients using aspirin preoperatively. Q-wave myocardial infarctions were increased in the aprotinin subgroups (17.5%, 14.3%, and 8.9% for high-dose, low-dose, and placebo groups; not significant). Acute vein graft thrombosis was found in six of 12 vein grafts studied at postmortem examination in patients receiving aprotinin but not in any of five grafts in patients receiving placebo. We conclude that aprotinin is extremely effective in reducing bleeding and transfusion requirements and may increase the risk of graft thrombosis.

Errors in thermodilution cardiac output measurements caused by rapid pulmonary artery temperature decreases after cardiopulmonary bypass

When systemic cooling and rewarming are performed during cardiopulmonary bypass (CPB), the pulmonary artery temperature typically decreases after CPB. This decrease may be rapid enough to cause substantial underestimation of cardiac output (CO) measured by thermodilution, due to changing baseline temperature during the thermodilution measurement. In 16 patients undergoing CPB for coronary artery grafts, digital recording of pulmonary artery temperature was done during room-temperature thermodilution CO (TDCO) injections. TDCO were computed with and without correction for baseline temperature decrease. Prior to CPB, the temperature change was -0.013 degrees C/min, producing no significant effect on CO measurements; the coefficient of variation of CO measurements was 5.1%. One minute after CPB the temperature change was -0.144 degrees C/min, producing a CO measurement error of -0.57 +/- 0.52 l/min (SD), or about 11% of the average CO; the range of the error was 0.05 to -2.0 l/min. Ten minutes after CPB the temperature change was -0.063 degrees C/min, and CO error was -0.31 +/- 0.36 (0.15 to -1.20) l/min. At 30 min the temperature change was -0.012 degrees C/min (not significant), and CO error was -0.13 +/- 0.14 l/min. Duration of CPB was 104 +/- 30 min, with rewarming for 44 +/- 13 min; the average minimum bladder temperature was 25.1 +/- 2.3 degrees C during cooling and 36.7 +/- 0.7 degrees C at the end of CPB. Under these conditions TDCO measurements within the first 10 min after CPB often underestimate the true CO.

CNS effects on cardiomyoplasty in goats: preliminary study

Following cardiomyoplasty, the latissimus dorsi (LD) muscle contracts in response to both pacemaker and central nervous system (CNS) derived action potentials. To evaluate the effect of this dual stimulation on cardiac function, six goats (56 kg to 80 kg) underwent treadmill tests 4 to 5 months after surgery. Sonomicrometer crystals were used to measure changes in the left ventricular short-axis dimension (LVSAD) and regional length changes in the LD muscle. Pacing mediated stimulation resulted in 17 +/- 4% fractional shortening of the muscle pedicle lasting 400 +/- 17 msec. Walking at speeds of 0.8 and 2.4 km/hr produced muscle contractions of variable duration and intensity. LVSAD was decreased by both pacing (14%) and walking (up to 10%). Pacing in combination with walking caused erratic muscle contractions with concomitant changes in LVSAD suggestive of impaired ventricular filling. No arrhythmias were noted during exercise.

Quadricuspid aortic valve. Case report and review of the literature

Quadricuspid aortic valve is a rare congenital anomaly that may be found unexpectedly at surgery or diagnosed preoperatively by means of echocardiography or aortography. The most common hemodynamic abnormality associated with this anomaly is aortic insufficiency. We describe a representative case involving a 62-year-old man with severe aortic insufficiency and mild aortic stenosis. At operation, the aortic valve was found to have 4 cusps. The valve was replaced with a mechanical prosthesis. The patient was released 7 days after operation and was clinically well at 6-month follow-up.

Muscle powered circulatory assist device for diastolic counterpulsator

A diastolic counterpulsator that uses either skeletal muscle or pneumatic actuation was developed. The unit is positioned between the latissimus dorsi and the chest wall, without interference with collateral blood supply, and is connected in series with the descending aorta. The system was able to generate stroke volumes between 52 and 16 ccs against pressures of 60 and 140 mmHg, respectively. Stroke work at 200 msec stimulation averaged 2.8 X 10(6) ergs. Power output at an afterload of 100 mmHg, and at a rate of 60 bpm, was 0.51 W. Back-up pneumatic actuation provided by an intraaortic balloon pump resulted in a 46% increase in the endocardial viability ratio (EVR).

New crisscross-shaped port design for universal serial pumps

The long range goal is the development of a clinically useful, implantable, skeletal muscle powered cardiac assist device (MCAD). To accomplish this goal, two criteria must be met: good anatomic fit, and antithrombogenicity. Because of the relative locations of the latissimus dorsi (LD) muscle and aorta, there are two possible port arrangements: "crisscrossed" (C design), in which the ports are crossed to anastomotic sites, and "prong" shaped (P design), in which no crossover takes place. The purpose of this paper is to determine which of these designs is best from a fluid dynamic perspective, and hence has the best possibility for low thrombogenicity. Flow visualization (FV) techniques were used during two pumping conditions in a mock loop: worst case (MCAD off) and best case (MCAD driven optimally). Results of the MCAD off tests showed that both designs required immediate actuation (for example, an IABP console). However, FV studies under optimal conditions indicated superiority of the C design, most likely due to kinetic energy-induced rotary motion combined with a minimal interport distance. It is concluded that the C design provides ideal flow dynamics, even in valveless pumps, and also has application to valved devices.

Complete replacement of the ascending aorta with reimplantation of the coronary arteries in patients with full Marfan syndrome

Four patients with Marfan syndrome developed severe aortic insufficiency requiring complete replacement of the ascending aorta with reimplantation of the coronary arteries by the technique of Cabrol. All patients have remained asymptomatic in NYHA class I.

Magnetic resonance of the chest: initial experience with imaging and in vivo T1 and T2 calculations

Magnetic resonance (MR) imaging of the chest was performed in 33 patients; 28 patients had a variety of malignant tumors and five had benign processes involving the pleura, chest wall, mediastinum, hila , and pulmonary parenchyma. In addition, in vivo T1 and T2 calculations were performed on 17 malignancies and 2 benign processes. Of the 18 patients examined with both MR and computed tomography (CT), 15 MR examinations were considered to be as diagnostic as CT in demonstrating abnormalities. In two cases, CT was superior to MR. In one case without adequate vascular opacification on CT, MR was superior in differentiating a mass from pulmonary artery. It is concluded that, with current technology without respiratory or cardiac gating, MR offers little improvement in diagnosis over contrast-enhanced CT. Furthermore, it does not appear possible to predict tissue type based on T1 and T2 measurements because of a wide overlap in these values.