Impact of Complete Revascularization in the ISCHEMIA Trial

BACKGROUND

Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported.

OBJECTIVES

Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management.

METHODS

ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management.

RESULTS

ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR.

CONCLUSIONS

The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Role of High-Sensitivity C-reactive Protein Levels in Predicting the Risk of Six-Month Event Rates in Patients With Chronic Stable Angina Undergoing Percutaneous Transluminal Coronary Angioplasty With a Drug-Eluting Stent

Introduction This prospective observational study reports the association between baseline high-sensitivity C-reactive protein (hs-CRP) levels and adverse events at six months in patients who were diagnosed with symptomatic chronic stable angina and then underwent percutaneous transluminal coronary angioplasty (PTCA) with a drug-eluting stent (DES). Methods A total of 104 patients were examined with chronic stable angina over a period of six months. Before conducting percutaneous coronary intervention (PCI), the baseline levels of hs-CRP were measured, and based on the levels, the patients were grouped into high and low hs-CRP groups. Results The primary causes of death or the need for repeat revascularization or myocardial infarction or angina were concluded after assessing the patients for six months. A total of 104 patients were studied, among which 72 (69.23%) had low hs-CRP and 32 (30.77%) had high hs-CRP levels. The number of males in this study was 68 (65.38%) and females were 36 (34.62%). The mean age of the patients was 55.26 ± 10.31 years. There were no significant differences among the groups in terms of gender, age, comorbidities, and risk factors except for certain predisposing factors like dyslipidemia and smoking. Moreover, we did not find any significant difference among the groups in the cause of death and myocardial infarction after a follow-up of six months. However, we observed a higher need for revascularization and angina outcomes in the group with high hs-CRP compared to low hs-CRP. Conclusion It can be concluded that a higher risk of angina and repeat revascularization is related to a high baseline hs-CRP but there is no evidence whether it is somehow linked to myocardial infarction and mortality or not.

Target Vessel Versus Complete Revascularization in Non-ST Elevation Myocardial Infarction Without Cardiogenic Shock

Introduction

The role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR.

Methods

It was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes.

Results

The mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively.

Conclusion

CR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.

Outcomes in the ISCHEMIA Trial Based on Coronary Artery Disease and Ischemia Severity

BACKGROUND

The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy.

METHODS

In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory-interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest).

RESULTS

Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio [HR], 0.89 [95% CI, 0.61-1.30]; severe ischemia HR, 0.83 [95% CI, 0.57-1.21]; P=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 [95% CI, 0.86-1.69] versus mild/no ischemia; HR for severe ischemia, 1.37 [95% CI, 0.98-1.91]; P=0.04 for trend, P=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 [95% CI, 1.06-6.98]) and MI (HR, 3.78 [95% CI, 1.63-8.78]) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% [95% CI, 0.2%-12.4%]), but 4-year all-cause mortality was similar.

CONCLUSIONS

Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01471522.

Looking Deep Into the Palpitation - Pheochromocytoma Presenting as Sinus Node Dysfunction

A 23-year-old male came to the outpatient department with a history of intermittent palpitations and headaches for the past six to eight months. He was diagnosed with hypertension and had a junctional rhythm on an electrocardiogram (ECG). On further workup for his hypertension, he was found to have elevated levels of serum metanephrines and computed tomography (CT) and positron emission tomography (PET) scan revealed pheochromocytoma. He was subsequently operated upon and his arrhythmia subsided after surgery. We discuss our approach to this scenario, which leads us to a rather rare cause of sinus node dysfunction.

Impact of COVID-19 on Thrombus Burden and Outcome in Acute Myocardial Infarction

Background Cardiovascular manifestations are one of the most common complications in coronavirus disease 2019 (COVID-19) infection and are associated with increased mortality. However, the impact of COVID-19 infection on thrombus burden and the outcome of acute myocardial infarction (AMI) has not been studied. Methods This was a retrospective, observational study that included all adult patients (>18 years) diagnosed with AMI with or without COVID-19 infection. Epidemiological, laboratory, clinical, interventional, and outcome data were extracted and the impact of COVID-19 on thrombus burden and the primary clinical composite endpoint of all-cause death during hospital admission or 30 days after discharge was studied. Results The study population included 336 patients, including 56 patients with COVID and AMI and 280 patients with AMI without COVID-19 infection. Chest pain was the most common symptom (84.8%) while one or more co-morbidity was present in 117 (34.8%) patients. Forty-eight patients in the AMI with COVID group had ST-segment elevation myocardial infarction (STEMI) while 256 patients in the AMI without COVID group had STEMI, eight patients in the AMI with COVID group had non-ST-segment elevation myocardial infarction (NSTEMI), and 24 in the AMI without COVID group had NSTEMI. Patients with COVID-19 co-infection had a higher thrombus burden as compared to the patients without COVID-19 AMI group (p-value 0.008). The primary outcome in the form of all-cause mortality was seen in 13 (3.9%) patients, which was also more in the AMI with COVID group. Conclusion COVID-19 in AMI is a state of high thrombus burden associated with higher mortality, especially in patients with chronic co-morbidities.

Aortic Dissection With Complete Occlusion of Left Main Coronary Artery Presenting as Acute ST-Segment Elevation Myocardial Infarction

Acute Aortic Dissection (AAD) is a life-threatening condition, which presents with a wide variety of symptoms ranging from being asymptomatic to sudden cardiac death. A retrograde extension of AAD can lead to partial or complete occlusion of coronary vessels, leading to an exceedingly rare presentation in the form of acute Myocardial Infarction (MI). A prognosis of AAD depends on prompt diagnosis and urgent surgical intervention to re-establish coronary blood flow. Here, we report a case of AAD, presenting as acute anterolateral wall MI, due to total occlusion of the left main coronary artery.

An Unusual Intracoronary Honeycomb Pattern in a Patient with Coronary Artery Disease with Dextrocardia

This case highlights the diagnostic dilemma and emphasis the role of Optical Coherence Tomography (OCT) to differentiate between spontaneous coronary artery dissection and recanalized thrombus with multiple channels in a patient with dextrocardia.

Predictors of no-reflow phenomenon following percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVES

No reflow during percutaneous coronary intervention (PCI) is a complex issue with serious outcomes. Multiple studies have studied predictors of no-reflow during primary PCI, but data on patients with the late presentation is sparse, which constitutes the majority of patients in peripheral centers. This study aimed to determine predictors of no-reflow during PCI in patients with ST-segment elevation myocardial infarction (STEMI) in 7 days.

METHODS

It was a single-center prospective case-control study performed at a tertiary care center and included 958 patients with STEMI who underwent PCI within 7 days of symptom onset. Baseline and angiographic data of patients undergoing PCI were recorded and patients divided into reflow and no-reflow group.

RESULTS

Of 958 who underwent PCI, 182 (18.9%) showed no-reflow by myocardial blush grade (MBG)<2. No-reflow group had a higher mean age (66.46±10.71 vs. 61.36±9.94 years), lower systolic blood pressure (SBP) on admission (100.61±26.66 vs. 112.23±24.35, P<0.0001), a higher level of peak Troponin I level (9.37±2.81 vs. 7.66±3.11ng/dL, P<0.0001), low left ventricular ejection fraction (36.71±3.89 vs. 39.58±4.28% respectively P<0.0001). Among angiographic data and procedural features, multivariable logistic regression analysis identified that advanced age, reperfusion time>6hours, SBP<100mmHg on admission, functional status of Killip class for heart failure≥3, lower EF (≤35%), low initial myocardial blush grade (≤1) before PCI, long target lesion length, larger reference diameter of vessel (>3.5mm) and high thrombus burden on angiography were found to be independent predictors of no-reflow (P<0.05).

CONCLUSION

No-reflow phenomenon after PCI for STEMI is complex and multifactorial and can be identified by simple clinical, angiographic, and procedural features. Preprocedural characters of the lesion and early perfusion decides the fate of the outcome.

Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey

Background

The impact of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for diagnosis and management of hypertension on the prevalence of hypertension in India is unknown.

Methods

We analyzed data from the Cardiac Prevent 2015 survey to estimate the change in the prevalence of hypertension. The JNC8 guidelines defined hypertension as a systolic blood pressure of ≥140 ​mmHg or diastolic blood pressure of ≥90 ​mmHg. The 2017 ACC/AHA guidelines define hypertension as a systolic blood pressure of ≥130 ​mmHg or diastolic blood pressure of ≥80 ​mmHg. We standardized the prevalence as per the 2011 census population of India. We also calculated the prevalence as per the World Health Organization (WHO) World Standard Population (2000–2025).

Results

Among 180,335 participants (33.2% women), the mean age was 40.6 ​± ​14.9 years (41.1 ​± ​15.0 and 39.7 ​± ​14.7 years in men and women, respectively). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%) and 2,878 (1.6%) participants belonged to age group 18–19, 20–44, 45–54, 55–64, 65–74 and ​≥ ​75 years respectively. The prevalence of hypertension according to the JNC8 and 2017 ACC/AHA guidelines was 29.7% and 63.8%, respectively- an increase of 115%. With the 2011 census population of India, this suggests that currently, 486 million Indian adults have hypertension according to the 2017 ACC/AHA guidelines, an addition of 260 million as compared to the JNC8 guidelines.

Conclusion

According to the 2017 ACC/AHA guidelines, 3 in every 5 Indian adults have hypertension.

Role of strain imaging for assessment of myocardial viability in symptomatic myocardial infarction with single vessel disease: An observational study

PURPOSE

To study and evaluate the predictive value of strain imaging parameters in patients undergoing viability assessment postmyocardial infarction (MI) in comparison with Dobutamine stress echocardiography (DSE) alone.

METHODS

This was a prospective observational study (October, 2016-March, 2018), which recruited 100 symptomatic patients with MI, and angiographically proven single vessel disease, LV dysfunction with severe hypokinesia/akinesia on 2D echocardiography and viability proven by baseline DSE. Patients undergoing primary PCI were excluded. Patients were recruited in two groups: DSE alone (first group) and strain imaging with DSE (second group). Revascularization was done in all patients. Patients were assessed at 3 months for functional recovery by 2D echocardiography.

RESULTS

On 3 month follow-up after revascularization, 37 patients (74%) in first group and 33 patients (66.67%) in second group had functional recovery. Dobutamine-stimulated strain parameters such as circumferential strain (CS; P = .005), radial velocity (RV; P < .001), longitudinal strain (LS; P < .001), and longitudinal strain rate (LSR; P < .001) were found to be a significant predictor of viability. The greatest area under the curve (AUC) for the ROC curves was obtained for low dose dobutamine RV (AUC = 0.92), low dose dobutamine LS (AUC = 0.94), and low dose dobutamine LSR (AUC = 0.88). Positive predictive value of the combination of low dose DSE with strain parameters (RV-97.2%, LS-97.4%, and LSR-87.5%) for myocardial viability was significantly higher than low dose DSE positive/low dose strain parameters negative patients as well as low dose DSE group alone.

CONCLUSION

Evaluation of strain parameters with low dose DSE is clinically feasible for the detection of myocardial viability and adds incremental value to the subjective and semiquantitative wall-motion scoring. LS at low dose DSE with WMSI was found to have the highest positive predictive value.

Ruptured submitral aneurysm

Submitral aneurysm is a rare entity, with around few hundred cases reported till date. Presentation can be varied. We describe here a case of submitral aneurysm in a young male with rupture into the left atrium cavity.

Surgical management of anomalous pulmonary venous connection to the superior vena cava--early results

BACKGROUND

The anatomical variability in patients with anomalous pulmonary venous connection to superior vena cava presents a surgical challenge. The problem is further compounded by the common occurrence of postoperative complications like arrhythmias and obstruction of the superior vena cava or pulmonary veins. We present our experience of managing this subset using the two patch and Warden's techniques.

PATIENTS AND METHODS

Between June 2011 and September 2012, 7 patients with APVC to the SVC were operated in our institute. After delineating the anatomy, five of them had a two patch repair and two were managed with Warden's technique.

RESULTS

There was no in-hospital mortality or early mortality over a mean follow-up of 9.66 ± 3.88 months (range 6-15 months). All the patients on follow-up had unobstructed pulmonary venous and SVC drainage on echocardiography and all of them were in normal sinus rhythm.

CONCLUSIONS

Anomalous pulmonary venous connection to superior vena cava is a challenging subset of patients in whom the surgical management needs to be individualized. The detailed anatomy must be delineated using echocardiography with or without CT angiography before deciding the surgical plan. This entity can be repaired with excellent immediate and early results. However, these patients must be closely followed up for complications like systemic and pulmonary venous obstruction and sinus node dysfunction.

Serum zinc and magnesium level in newly diagnosed type-2 diabetic subjects

This cross sectional study aimed to determine serum levels of zinc and magnesium in 80 newly diagnosed type 2 diabetic (Group I) and 80 healthy non-diabetic subjects (Group II). Diabetic patients without any complications were studied. It was carried out in the Department of Biochemistry, Mymensingh Medical College in cooperation with the out patient Department of Endocrinology of Mymensingh Medical College, Bangabandhu Sheikh Mujib Medical University and BIRDEM Hospital, Dhaka during the period from July 2008 to June 2009. A total of 160 subjects aged 55-65 years were enrolled for this study. Of them 80 were newly diagnosed type 2 diabetic (Group I) and 80 were apparently healthy non-diabetic (Group II) subjects. For both case and control, persons having no current medication, intercurrent illness, macro or microvascular complications and history of renal failure were selected. Atomic Absorption Spectrophotometer (AAS) was used to estimate the serum levels of zinc and magnesium. The Plasma zinc (72.07±6.84μg/dl) and magnesium (1.86±0.17mg/dl) significantly decreased in type 2 diabetic patients when compared with control (76.59±6.10μg/dl, 1.99±0.17mg/dl). It is concluded that type 2 diabetes mellitus can result in changes in zinc and magnesium levels. As the present study sample was small so it is difficult to draw any definite conclusion. However, the estimation and supplementation of both zinc and magnesium may be suggested in those cases.

Nerve reconstruction in patients with obstetric brachial plexus injury results in worsening of glenohumeral deformity: a case-control study of 75 patients

Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction. This study suggests that less invasive management, addressing the muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover.

Interactions of bacterial polysaccharides with cationic dyes: physicochemical studies

Capsular polysaccharides (SPS) are an integral component of gram-negative bacteria, and also have potential use as vaccine. In this paper, interactions of SPS isolated from Klebsiella strains K20 and K51 with cationic dyes pinacyanol chloride (PCYN) and acridine orange (AO) were studied by absorbance and fluorescence measurements. Both the polysaccharides having glucuronic acid as the potential anionic site induced strong metachromasy (blue shift approximately 100 nm) in the PCYN. The spectral changes were studied at different polymer/dye molar ratios (P/D = 0-40). A complete reversal of metachromasy was observed upon addition of co-solvents, suggesting the breakaway of dye molecules from the biopolymer matrix. Binding constant, changes in free energy, enthalpy and entropy of the dye polymer complex were also computed from the spectral data at different temperatures to reveal the nature of the interaction. Quenching of fluorescence of AO by the polymers and the incorporated mechanisms were also explored.

Preparation and characterization of an anionic dye-polycation molecular films by electrostatic layer-by-layer adsorption process

This communication reports the formation and characterization of self-assembled films of a low molecular weight anionic dye amaranth and polycation poly(allylamine hydrochloride) (PAH) by electrostatic alternating layer-by-layer (LBL) adsorption. It was observed that there was almost no material loss occurred during adsorption process. The UV-vis absorption and fluorescence spectra of amaranth solution reveal that with the increase in amaranth concentration in solution, the aggregated species starts to dominate over the monomeric species. New aggregated band at 600 nm was observed in amaranth-PAH mixture solution absorption spectrum. A new broad low intense band at the longer wavelength region, in the amaranth-PAH mixture solution fluorescence spectrum was observed due to the closer association of amaranth molecule while tagged into the polymer backbone of PAH and consequent formation of aggregates. The broad band system in the 650-750 nm region in the fluorescence spectra of different layered LBL films changes in intensity distribution among various bands within itself, with changing layer number and at 10 bilayer LBL films the longer wavelength band at 710 nm becomes prominent. Existence of dimeric or higher order n-meric species in the LBL films was confirmed by excitation spectroscopic studies. Almost 45 min was required to complete the interaction between amaranth and PAH molecules in the one-bilayer LBL film.

Improvement in abduction of the shoulder after reconstructive soft-tissue procedures in obstetric brachial plexus palsy

Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). The transferred muscles were sutured to the teres minor muscle, not to a point of bony insertion. The mean pre-operative active abduction was 45 degrees (20 degrees to 90 degrees ). At a mean follow-up of 4.8 years (2.0 to 8.7), the mean active abduction was 162 degrees (100 degrees to 180 degrees ) while 77 (78.6%) of the patients had active abduction of 160 degrees or more. No decline in abduction was noted among the 29 patients (29.6%) followed up for six years or more. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy.

Formation of complex Langmuir and Langmuir–Blodgett films of water soluble rosebengal

This communication reports the formation of complex Langmuir monolayer at the air-water interface by charge transfer types of interaction with the water soluble N-cetyl N,N,N-trimethyl ammonium bromide (CTAB) molecules doped with rosebengal (RB), with the stearic acid (SA) molecules of a preformed SA Langmuir monolayer. The reaction kinetics of the formation of RB-CTAB-SA complex monolayer was monitored by observing the increase in surface pressure with time while the barrier was kept fixed. Completion of interaction kinetics was confirmed by FTIR study. This complex Langmuir films at the air-water interface was transferred onto solid substrates at a desired surface pressure to form multilayered Langmuir-Blodgett films. Spectroscopic characterizations reveal some molecular level interactions as well as formation of microcrystalline aggregates depending upon the molar ratios of CTAB and RB within the complex LB films. Presence of two types of species in the complex LB films was confirmed by fluorescence spectroscopy.

Formation of complex films with water-soluble CTAB molecules

This communication reports the formation of complex Langmuir monolayer at the air-water interface with the water-soluble N-cetyl N,N,N-trimethyl ammonium bromide (CTAB) molecules when interacted with the stearic acid (SA) molecules. The reaction kinetics of the formation of the CTAB-SA complex was monitored by observing the surface pressure versus time graph. Multilayered LB films of this complex doped with Congo red was successfully formed onto a quartz substrate. UV-Vis absorption and steady-state fluorescence spectroscopic characteristics of this doped LB films confirms the successful incorporation of Congo red molecules in to the CTAB-SA complex films.

Cavermap-assisted sural nerve interposition graft during radical prostatectomy

Wide excision of the neurovascular bundle and interposition nerve grafting of the cavernous nerves when there is suspected extracapsular extension at the posterolateral prostatic margin are logical applications of improved understanding of pelvic neuroanatomy. Although the indications for neurovascular bundle excision will remain controversial for the foreseeable future, evidence suggests that neurovascular bundle excision improves cancer control in some patients. The ability to predict extracapsular extension reliably at the neurovascular bundle would be a powerful addition to the urologist's armamentarium. The authors have shown, as proof of principle in bilaterally resected neurovascular bundle at the time of RRP, that sural nerve grafting can restore erectile function. The authors' data also support a role for sural nerve grafting in unilateral neurovascular bundle excision. Although the side effects of sural nerve harvest are minor, the ability to predict preoperatively which patients will benefit from such grafts would reduce the number of failures. The success of the authors' interposition nerve-grafting project has resulted, in part, from the use of a multidisciplinary team approach that includes experienced oncologic surgeons and a plastic surgeon with extensive microsurgical and nerve-grafting experience. The technique for sural nerve grafting described herein gives urologists an additional tool to improve patients' quality of life without compromising the chances of success in treating prostate cancer.

Complete ear replantation without venous anastomosis

Traumatic amputation of the entire auricle is a rare occurrence. Management ideally consists of microvascular reconstruction of auricular arterial, venous, and nerve continuity. However, appropriately sized veins are often not available and venous drainage must be accomplished with leech therapy. In occasional cases where leeches are unavailable or cannot be made to attach, mechanical drainage and anticoagulation can give satisfactory drainage. The authors present a case of mechanical wick venous drainage of a complete ear replantation, resulting in virtually normal appearance and function of the ear. In addition, the ear regained normal touch and two-point sensibility, although the great auricular nerve had not been repaired.

Nerve transfers in the upper extremity

Restoration of extremity function following nerve injury is often unpredictable. Nerve transfers in the upper extremity are important techniques in the management of many types of peripheral nerve injury. The physiologic principles of nerve transfer lead to the indications for use. The elements of planning and execution of common nerve transfers are presented in this article.

Transfer of flexor carpi ulnaris branch of the ulnar nerve to the pronator teres nerve: histomorphometric analysis

Partial median-nerve injury high in the upper extremity, resulting from brachial plexus neuritis or trauma, can affect the pronator teres muscle and result in the inability to pronate the forearm. A nerve transfer from an ulnar nerve-innervated branch to the flexor carpi ulnaris (FCU) muscle to the branch to the pronator teres (PT) is an attractive option in this clinical scenario. This study, a histomorphometric analysis of nine cadaver specimens harvested at the proposed FCU branch to PT branch transfer site, demonstrates sufficient similarities between the two branches in total number of nerve fibers (371.6 with SEM 35.1, and 361.9 with SEM 47.1; p = 0.87) and nerve cross-sectional area (122,181 microm2 with SEM 14,546 microm2, and 142,492 microm2 with SEM 19,633 microm2; p = 0.42), to predict a functional transfer result. In addition, clinical application of this transfer resulted in functional pronation strength of M4+.

Interposition of sural nerve restores function of cavernous nerves resected during radical prostatectomy

PURPOSE

The permanent loss of erectile function when both neurovascular bundles are widely resected at radical prostatectomy as well as the successful use of autologous nerve grafts in reconstructive surgery led us to perform bilateral nerve grafts in an effort to restore erectile function in potent patients treated for prostate cancer who underwent radical retropubic prostatectomy and resection of both neurovascular bundles.

MATERIALS AND METHODS

Radical retropubic prostatectomy with deliberate resection of both neurovascular bundles was recommended for high grade, locally extensive prostate cancer in 9 select, sexually active men who reported normal erectile function. After the prostate was removed but before vesicourethral anastomosis an autologous sural nerve graft was interposed between the divided ends of the cavernous nerves bilaterally. Erectile function was monitored by patient interview, questionnaire and nocturnal penile tumescence testing after the operation.

RESULTS

Four to 5 months postoperatively patients noticed slowly improving spontaneous erections, as manifested by mild tumescence regularly every several hours. Nocturnal penile tumescence testing with the RigiScan device at 4 to 6 months in 2 cases revealed erections that approached minimal criteria for normalcy. Approximately 14 months after surgery a rigid erection sufficient for penetration and intercourse developed in 1 patient. He described this event as "an erection of substance-hard, not just fluffy."

CONCLUSIONS

We have developed a technique using sural nerve grafts to restore continuity of the cavernous nerves, which are resected during radical prostatectomy. The early return of spontaneous partial erections in our patients suggests that interposition nerve grafts may enhance the recovery of erectile function when the neurovascular bundles are resected.

Antibody to transforming growth factor beta reduces collagen production in injured peripheral nerve

Epineurial scarring in peripheral nerve after injury inhibits normal axonal regeneration primarily due to fibroblast deposition of type I collagen. The transforming growth factor beta (TGF-beta) family is an important class of signaling molecules that has been shown to stimulate fibroblasts to produce collagen. The aim of this study was to design a prototypic therapeutic system in which the neutralization of TGF-beta in crushed rat sciatic nerve would decrease collagen formation. A total of 45 experimental Lewis rats were used. Group 1 animals (20 rats) sustained a unilateral crush injury to the sciatic nerve with injection of phosphate buffer solution. Group 2 animals (20 rats) sustained a unilateral crush injury to the sciatic nerve with injection of phosphate-buffered saline and goat, anti-rat, panspecific TGF-beta antibody. Group 3 control animals (five rats) underwent only exposure of sciatic nerve with injection of antibody. All animals were killed at 14 days and sciatic nerve specimens were harvested at that time. Slides of experimental tissue were processed using a 35S-labeled oligomer for procollagen alpha-1 mRNA, then dipped in photographic emulsion and examined by darkfield autoradiography. Morphometric analysis of pixel counts was then performed. A significant reduction in total pixel count per high-power field and in total number of fibroblasts per high-power field was found in crushed rat sciatic nerve treated with anti-TGF-beta antibody when compared with those treated only with phosphate-buffered saline. These findings are consistent with successful reduction in procollagen induction after a crush injury by topical administration of blocking antibody against transforming growth factor beta. The concept of growth factor blockade for therapeutic collagen reduction is attractive in the context of nerve injury, and the current article provides a model for future clinical application.

Epidural spinal cord stimulation for treatment of chronic pain--some predictors of success. A 15-year experience

BACKGROUND

We have used epidural spinal cord stimulation (SCS) for pain control for the past 15 years. An analysis of our series of 235 patients has clarified the value of specific prognostic parameters in the prediction of successful SCS.

METHODS

Patients were followed up for periods ranging from 6 months to 15 years with a mean follow-up of 66 months. The mean age of the 150 men and 85 women in the study was 51.4 years. Indications for SCS included failed back syndrome (114 patients), peripheral vascular disease (39 patients), peripheral neuropathy (30 patients), multiple sclerosis (13 patients), reflex sympathetic dystrophy (13 patients), and other etiologies of chronic intractable pain (26 patients).

RESULTS

One hundred and eighty-nine patients received permanent devices; 111 (59%) of these patients continue to receive satisfactory pain relief. Pain attributable to failed back syndrome, reflex sympathetic dystrophy, peripheral vascular disease of lower limbs, multiple sclerosis, and peripheral neuropathy responded favorably to spinal cord stimulation. In contrast, paraplegic pain, cauda equina syndrome, stump pain, phantom limb pain, and primary bone and joint disease pain did not respond as well. Cases of cauda equina injury had promising initial pain relief, but gradually declined after a few years. After long-term follow-up, 47 of the 111 successfully implanted patients were gainfully employed, compared with 22 patients before implantation. The successful patients reported improvements in daily living as well as a decrease in analgesic usage. Multipolar stimulation systems were significantly more reliable (p < 0.001) than unipolar systems. Complications included hardware malfunction, electrode displacement, infection, and tolerance.

CONCLUSION

Aside from etiologies of pain syndromes as a prognostic factor, we have identified other parameters of success. In patients who have undergone previous surgical procedures, the shorter the duration of time to implantation, the greater the rate of success (p < 0.001). The diagnosis of failed back syndrome must be considered a confounding factor in our analysis. Those patients whose pain did not follow a surgical procedure had better responses to SCS than patients who had multiple surgical procedures prior to their first implant. The advent of multipolar systems has significantly improved clinical reliability over unipolar systems. Age, sex, and laterality of pain did not prove to be of significance.

Spatial pattern of type I collagen expression in injured peripheral nerve

The authors studied the spatial expression and regulation of messenger RNA for the alpha subunit of collagen type I in crushed rat sciatic nerve to provide a basis for future therapeutic manipulation. Sciatic nerves in 20 male or female adult Lewis rats were crushed for 60 seconds; the unharmed contralateral sciatic nerves served as controls. Twenty-one days after injury the experimental animals were killed and their tissue was harvested. The spatial expression of collagen type I was determined by using in situ hybridization techniques. Quantification of fibroblast number and total signal was performed through computerized morphometry. Collagen upregulation was evident in epineurial and perineurial layers, with the epineurium displaying higher activity. The cells responsible for procollagen type I production were fibroblasts. No activity was seen in the endoneurium. Morphometric findings indicated that collagen upregulation in the epineurium and perineurium occurred at both pretranscriptional and posttranslational levels when compared to controls; a paired t-test analysis confirmed statistical significance for all comparisons between injured and control tissues. Epineurial fibroblasts are responsible for the collagen production associated with crushed peripheral nerve injury in the rat. Regulation occurs pretranscriptionally as well as posttranslationally. It is interesting to speculate that the delivery of agents directed against collagen production (such as neutralizing antibodies to growth factors) into epineurial tissues proximate to the time and location of clinical nerve injury might mitigate later deleterious effects of excess collagen production in axonal regeneration.

Improvement of limb circulation in peripheral vascular disease using epidural spinal cord stimulation: a prospective study

Spinal cord stimulation was used in 46 patients for pain associated with lower extremity ischemic vascular disease that was considered to be nonreconstructable. Thirty-nine patients who had a follow-up examination between 2 and 36 months after the procedure form the basis of this report. Thirty (77%) of 39 cases were considered successful. Clinical endpoints indicating failure included amputation, vascular reconstruction, poor pain relief, or hardware malfunction. The transcutaneous partial pressure of oxygen (TcPO2) increased in both target and control feet. In patients with good outcome with a preimplantation TcPO2 of less than 30 mm Hg, TcPO2 increased significantly (p < 0.05). Pulse volume recording improved significantly (p < 0.05) at the thigh, metatarsal, and great toe levels in successfully treated patients. Peak blood flow velocity also showed a significant increase in patients with good outcome (p < 0.05). Patients with a TcPO2 of less than 10 mm Hg following stimulation tended to undergo amputation within the first 3 months. Improvement in pain control, combined with an increase in TcPO2 values that was greater than 10 mm Hg, were significant early predictors of long-term success. An initial increase in peak blood flow velocities (measured in Doppler studies) of greater than 10 mm also signified a good long-term outcome. Spinal cord stimulation appears to be a useful therapeutic modality for controlling pain and improving perfusion in a select group of patients with end-stage ischemic vascular disease considered nonreconstructable. The best results were seen in patients with severe claudication and rest pain without trophic changes in the foot. The mechanism of this beneficial effect is not yet completely understood.

Deep brain stimulation for intractable pain: a 15-year experience

OBJECTIVE

During the past 15 years, we prospectively followed 68 patients with chronic pain syndromes who underwent deep brain stimulation (DBS). The objective of our study was to analyze the long-term outcomes to clarify patient selection criteria for DBS.

METHODS

Patients were referred from a multidisciplinary pain clinic after conservative treatment failed. Electrodes for DBS were implanted within the periventricular gray matter, specific sensory thalamic nuclei, or the internal capsule. Each patient was followed on a 6-monthly follow-up basis and evaluated with a modified visual analog scale.

RESULTS

Follow-up periods ranged from 6 months to 15 years, with an average follow-up period of 78 months. The mean age of the 54 men and 14 women in the study was 51.3 years. Indications for DBS included 43 patients with failed back syndrome, 6 with peripheral neuropathy or radiculopathy, 5 with thalamic pain, 4 with trigeminal neuropathy, 3 with traumatic spinal cord lesions, 2 with causalgic pain, 1 with phantom limb pain, and 1 with carcinoma pain. After initial screening, 53 of 68 patients (77%) elected internalization of their devices; 42 of the 53 (79%) continue to receive adequate relief of pain. Therefore, effective pain control was achieved in 42 of 68 of our initially referred patients (62%). Patients with failed back syndrome, trigeminal neuropathy, and peripheral neuropathy fared well with DBS, whereas those with thalamic pain, spinal cord injury, and postherpetic neuralgia did poorly.

CONCLUSION

DBS in selected patients provides long-term effective pain control with few side effects or complications.

Spinal cord stimulation is effective in the management of reflex sympathetic dystrophy

OBJECTIVE

The purpose of this study was to determine the efficacy of spinal cord stimulation (SCS) in patients with symptoms of reflex sympathetic dystrophy (RSD), a disabling clinical condition with significant consequences of morbidity and loss of productivity.

METHODS

We have used epidural SCS for pain control during the past 15 years. An analysis of our records revealed 12 consecutive patients diagnosed as having RSD before undergoing SCS. Eight of the 12 patients had undergone previous ablative sympathectomy. The mean age of the nine men and three women was 38.2 years. All suffered extremity injuries from a variety of causes.

RESULTS

All 12 patients experienced relief of pain after trial stimulation and had their systems permanently implanted. At an average of 41 months follow-up, all patients were using their stimulators regularly and only two were receiving adjunctive minor pain medication. The level of pain present pre- and postoperatively was determined by administering a modified McGill Pain Questionnaire and a visual analog scale to each patient. Eight patients reported excellent pain relief, and four patients described good results. Five minor complications occurred.

CONCLUSION

SCS is an effective treatment for the pain of RSD, including recurrent pain after ablative sympathectomy. The low morbidity of this procedure and its efficacy in patients with refractory pain related to RSD suggest that SCS is superior to ablative sympathectomy in the management of RSD.

Management of neuromas in the hand

Injury to a peripheral nerve in the hand can result in loss of motor and sensory function. In addition, incomplete or abnormal regeneration can cause painful sequelae. The approach to neuromas in the hand requires familiarity with the basic aspects of nerve regeneration as well as the neurophysiology of pain mechanisms.

Spinal cord stimulation for chronic pain in peripheral neuropathy

BACKGROUND

Spinal cord stimulation (SCS) has been used for the relief of chronic, intractable pain for over 2 decades. Recent technologic improvements in hardware have resulted in improved clinical outcome. We report our experience with epidural spinal cord stimulation for pain control of peripheral neuropathy for the past 15 years.

METHODS

An analysis of our series of 276 patients revealed 30 patients diagnosed with peripheral neuropathy. The mean age of the 16 men and 14 women in the study was 62.4 years. The anatomic sources of pain included thorax, as well as upper and lower limbs. Causes of intractable pain included postherpetic neuralgia, intercostal neuralgia, causalgic pain, diabetic neuropathy, and idiopathic neuropathy.

RESULTS

Nineteen patients reported relief of pain on trial stimulation and had their systems permanently implanted. At an average of 87 months' follow-up, 14 of these patients achieved long-term success in control of chronic pain (47% of all patients included in this study). Six patients reported excellent pain relief (> 75% pain relief), eight described good results (> 50% pain relief), and six had poor pain relief (< 50% pain relief).

CONCLUSION

SCS is an effective therapy for pain syndromes associated with peripheral neuropathy. Causalgic and diabetic neuropathic pain seem to respond relatively well. whereas postherpetic pain and intercostal neuralgia syndromes seem to respond less favorably to the long-term beneficial effects of SCS. This information will be useful in the selection of patients with peripheral neuropathic pain who could be helped by SCS.

Symptomatic epidural lipomatosis secondary to obesity. Case report

The authors present a case of thoracic spinal cord compression secondary to epidural lipomatosis in an obese patient. This patient represents the 10th case of epidural lipomatosis secondary to simple obesity reported in the literature. The diagnosis is based on three criteria: 1) medical history and physical examination consistent with segmental spinal cord compression; 2) epidural fat thickness greater than 7 mm in the region of compression, based on magnetic resonance imaging (preferred) or computerized tomographic imaging; and 3) a height-to-weight ratio greater than 27.5 kg/m2. This specific correlation between epidural fat thickness measurement and calculation of height-to-weight ratio has not previously been reported. Surgical decompression through a posterior laminectomy and excision of excess epidural fat resulted in immediate reversal of the patient's symptoms. Knowledge of the association of epidural lipomatosis with obesity in the absence of glucocorticoid imbalance is important in discerning what may be an underrecognized syndrome.

Reflex sympathetic dystrophy. The controversy continues

The chronic pain syndrome encompassed by the term RSD is poorly understood. The confusion is caused in large part by frequent misdiagnosis and excessive use of sympatholytic procedures in inappropriate circumstances. Recently, pain specialists have redefined the specific criteria for regional pain syndromes having sympathetic maintaining factors, emphasizing application of placebo testing in diagnosis and attention to anatomic principles in pharmacologic and surgical treatment. The authors believe that three-phase bone scanning is a valuable adjunct to clinical judgment in making the proper diagnosis. Current thinking suggests that sympathetic maintained pain exists but that it may comprise only approximately 10% of regional pain cases. Once the appropriate diagnosis is made, classically described sympatholytic procedures are reasonably used. Alternative techniques, such as spinal cord stimulation, may have an important role in refractory cases of sympathetically maintained pain.

The regulation of collagen in fetal skin wounds: mRNA localization and analysis

The deposition of collagen in fetal skin wounds has been shown in several animal models. The authors used a radiolabeled RNA antisense probe, complementary to the mRNA for the alpha-1 chain of human procollagen type I, to assess regulation of this collagen species in fetal and adult rabbit wounds. Dorsal skin wounds were placed on fetal and maternal animals at the beginning of the third trimester, and were harvested 3, 5, and 7 days later. In situ RNA/RNA hybridization was performed on suitable specimens, and morphometric analysis was carried out with a computerized LECO image analyzer. Fetal wounds exhibited an inflow of mesenchymal cells that produced collagen type I at levels higher than the surrounding tissue; this activity was highest on days 3 and 5 after wounding. Adult wounds had increased fibroblast presence by day 7, producing collagen type I at levels higher than those of adjacent unwounded tissue. Morphometric analysis of the signal produced by in situ hybridization and of the number of cells producing the signal in a given field showed that fetal wounds appear to produce collagen type I by an increase in the number of cells in the area of the wound--not by induction of the gene for procollagen type I. In contrast, adult wounds had both fibroblast migration and induction of procollagen type I mRNA synthesis. These findings imply multilevel regulation of collagen production in the adult and posttranslational regulation in the fetus.

The expression of transforming growth factor type beta in fetal and adult rabbit skin wounds

Transforming growth factor, subtype beta (TGF-beta) exists in several isoforms and is known to have important roles in adult wound healing by promoting collagen and extracellular matrix component deposition. It is also believed that TGF-beta influences normal developmental processes during embryo-genesis. Immunolocalization of two isoforms, TGF-beta 1 and TGF-beta 2, in healing fetal and adult rabbit skin wounds shows distinctly different forms of expression of these molecules. TGF-beta 1 and TGF-beta 2 are both expressed within the developing fetal dermis, but no differential upregulation in the area of the healing wound is noted. In contrast, the expression of TGF-beta 1 and TGF-beta 2 is increased in adult wounds by day 7 after wounding, within macrophages that are abundant by this time. High levels of TGF-beta 1 and TGF-beta 2 within adult wounds might indicate that the relative paucity and differential distribution of these factors in fetal wounds are important in the production of scar in adults and the absence of scar in the fetus. Further, these patterns of expression suggest fundamental differences between fetal and adult tissues in accomplishing wound repair.

Studies on induction of metachromasy in cationic dye pinacyanol chloride by Klebsiella K7 capsular polysaccharide

The acidic capsular polysaccharide isolated from Klebsiella K7 induced metachromasy in the cationic dye pinacyanol chloride indicating its chromotropic character. Interaction of the biopolymer with the cationic dye was studied by visible absorption spectrophotometry, and thermodynamic parameters of the interaction evaluated. The polymer induced a metachromatic blue shift in the spectrum from 600 nm to 495 nm. The spectral changes were studied during interaction of the dye with the polymer at different polymer/dye molar ratios (P/D = 0 approximately 50). Effects of co-solvents on the stability of the dye-polymer compound were studied. A complete reversal of metachromasy was observed upon addition of different alcohols and urea solution. Thermodynamic parameters obtained from the spectral data indicated chromotropic character of the polymer in interacting with the cationic dye molecules in solution.

Chromotropic character of bacterial acidic polysaccharides: Part III--Interaction of cationic dye pinacyanol chloride with Klebsiella K15 capsular polysaccharide

Interaction of cationic dye pinacyanol chloride with the acidic capsular polysaccharide isolated from Klebsiella serotype K15 has been investigated by spectral measurements. Klebsiella K15 polysaccharide consists of hexasaccharide repeating units containing one residue each of glucuronic acid and glucose, and four residues of galactose. Glucuronic acid acts as the potential anionic site and the biopolymer interacts with the dye cations. It induces metachromasy in the dye and a blue shift of about 100 nm is observed in the visible absorption spectrum of the dye. Spectral measurements have been carried out at different polymer/dye molar ratios. Stoichiometry of polymer and dye in the polyanion-dye compound (1:1) indicates that every potential anionic site of the polyanion is associated with the dye cation, and stacking conformation is thus suggested. Effect of different non-aqueous solvents in reversing metachromasy has also been studied. Interaction studies exhibit chromotropic character of the biopolymer.

Chromotropic character of bacterial acidic polysaccharides: Part II--Induction of metachromasy in cationic dye pinacyanol chloride by Klebsiella K10 capsular polysaccharide

The acidic capsular polysaccharide isolated from Klebsiella K10 exhibited chromotropic character with respect to induction of metachromasy in the cationic dye pinacyanol chloride (1-ethyl-2-[3-(1-ethyl-2(1H)-quinolylidene)propenyl]quinolinium chloride). Klebsiella K10 polymer consists of hexasaccharide repeating units containing one residue of glucuronic acid along with other neutral sugars in each repeating unit. It induces a metachromatic blue shift in the visible absorption spectrum of the dye from 600 nm to 500 nm. The spectral changes have been studied during interaction of the dye cations with the polyanions at different polymer/dye molar ratios. The polyanion-dye compounds are formed with polymer/dye stoichiometry of 1:1, indicating formation of stacking conformation. The complete reversal of polymer-induced metachromasy has also been observed by the addition of ethanol and urea.

Structural studies on the capsular polysaccharide of Klebsiella serotype K40

The capsular polysaccharide of Klebsiella serotype K40 contained D-mannose, D-glucuronic acid, D-galactose, and L-rhamnose in the approximate molar ratios 1:1:1:2. The primary structure of the capsular polysaccharide has been investigated mainly by methylation analysis, periodate oxidation, characterization of oligosaccharides, base degradation reaction, and 1H and 13CNMR spectroscopy. The polysaccharide does not contain any pyruvic acetal or O-acetyl substitution. It has a pentasaccharide repeating unit of the following primary structure: alpha-D-Manp 1----4 ----4)-beta-D-GlcpA-(1----2)-alpha-L-Rhap-(1----3)-beta-D-Ga lp-(1----2)-alpha- L-Rhap-(1----.