Does incidental calcium deposition in non-cardiac CT scans predict cardiovascular morbidity and mortality in young adults? A retrospective study

Background

The calcium score in cardiac CT scan represents an effective tool in the diagnosis of coronary artery disease. However, few studies have examined the value of incidental arterial calcification (AC) in non-cardiac CT scans, especially in young adults with no prior cardiovascular morbidity.

Purpose

To evaluate the association between incidental AC and the incidence of cardiovascular events, as well as the association between atherosclerotic risk factors and AC in young adults with no known cardiovascular disease.

Methods

A retrospective study in patients aged 40–50 years old with no history of cardiovascular disease that underwent chest CT scan between 1.9.2012–31.8.2013 for reasons not related to cardiovascular disease. We assessed the presence of AC in the aorta and coronary arteries and its association with the rates of coronary catheterization for acute coronary syndrome (CCACS), emergency room (ER) visits or hospitalizations for cardiovascular disease and cardiac mortality. Furthermore, we examined the association between atherosclerotic risk factors (hypertension, smoking, hyperlipidemia and diabetes) and AC.

Results

308 patients were included in the study, 150 men and 158 women with average follow-up period of 7.2+0.29 years. AC was found in 88 (28.6%) patients. AC was more frequent in men than in women (35% vs. 20.9%, OR=2.18, P=0.006). Patients with AC underwent more CCACS than those without (11.6% vs. 0.5%, OR = 29.1, P=0.0001). Patients with AC had more ER and hospital admissions (33.7% vs. 14.4%, P<0.0001, OR=3). Individuals with hypertension, smoking, and hyperlipidemia exhibited higher rates of AC (OR=2.66, 4, and 1.9, respectively). A statistically significant excess mortality in those with AC was not demonstrated (P=0.076).

Conclusion

AC appears to be associated with cardiovascular morbidity and increased incidence of CCACS. Primary preventive strategies in patients with AC may reduce cardiovascular morbidity.

Funding Acknowledgement

Type of funding sources: None.

Long-term secondary cardiovascular prevention programme in patients subjected to coronary artery bypass surgery

AIMS

Patients with coronary heart disease (CHD) are at very high risk of recurrent events. A strategy to reduce excess risk might be to deliver structured secondary prevention programmes, but their efficacy has been mostly evaluated in the short term and in experimental settings. This is a retrospective case-control study aimed at assessing, in the real world, the efficacy of a secondary prevention programme in reducing long-term coronary event recurrences after coronary artery bypass surgery (CABG).

METHODS AND RESULTS

Programme participants (henceforth 'cases') were men and women aged <75 years subjected to CABG between 2002 and 2014, living within 100 km of the hospital. Key programme actions included optimization of treatments according to the most updated European preventive guidelines, surveillance of therapy adherence, and customized lifestyle counselling. Controls were analogous patients not involved in the programme because living farther than 100 km away, matched 1:1 with cases for gender, age at CABG, and year of CABG. Both groups (n = 1248) underwent usual periodic cardiology follow-up at our centre. Data on symptomatic or silent CHD recurrences were obtained from the hospital electronic health records. Cox analysis (adjusted for baseline differences between groups) shows that programme participation was associated with a significantly lower incidence throughout 5 years post-CABG of symptomatic [hazard ratio (95% confidence interval): 0.59 (0.38-0.94)] and silent [0.53 (0.31-0.89)] coronary recurrences.

CONCLUSION

In a real-world setting, taking part in a structured longstanding secondary prevention programme, in addition to usual cardiology care, meaningfully lowers the risk of coronary recurrences.

Paradoxical Neochords to Treat Systolic Anterior Motion in Hypertrophic Obstructive Cardiomyopathy

We describe an approach to address the left ventricular outflow tract obstruction in hypertrophic obstructive cardiomyopathy with concomitant systolic anterior motion of mitral valve. The two main purposes of this approach are to enlarge the left ventricular outflow tract through a "moderate" myectomy and to "discipline" the excessive movement of the mitral valve anterior leaflet through paradoxical chords implantation, and similarly, the papillary muscle too, if necessary, by hanging paradoxical chords between the papillary muscle itself and the posterior mitral annulus.

The 'respect rather than resect' principle in mitral valve repair: the lateral dislocation of the P2 technique

BACKGROUND

Leaflet resection represents the reference standard for surgical treatment of mitral valve (MV) regurgitation. New approaches recently proposed place emphasis on respecting, rather than resecting, the leaflet tissue to avoid the drawbacks of the 'resection' approach.

OBJECTIVES

The lateral dislocation of mid portion of mitral posterior leaflet (P2) technique for MV repair is a nonresectional technique in which the prolapsed P2 segment is sutured to normal P1 segment. Our study evaluates the effectiveness of this technique.

PATIENTS AND METHODS

We performed the procedure on seven patients. Once ring annular sutures were placed, the prolapsed P2 segment was dislocated toward the normal P1 segment with a rotation of 90° and without any resection. If present, residual clefts between P2 and P3 segments were closed. Once the absence of residual mitral regurgitation is confirmed by saline pressure test, ring annuloplasty was completed. The valve was evaluated using transesophageal echocardiography in the operating room and by transthoracic echocardiography before discharge.

RESULTS

At the last follow-up visit, transthoracic echocardiography revealed no mitral regurgitation and normal TRANSVALVULAR gradients.

CONCLUSION

The lateral dislocation of P2 is an easily fine-tuned technique for isolated P2 prolapse, with the advantage of short aortic cross-clamp and cardiopulmonary bypass times. We think it might be very favorable in older and frail patients. Long-term follow-up is necessary to assess the durability of this technique.

Feasibility of pig and human-derived aortic valve interstitial cells seeding on fixative-free decellularized animal pericardium

Glutaraldehyde-fixed pericardium of animal origin is the elective material for the fabrication of bio-prosthetic valves for surgical replacement of insufficient/stenotic cardiac valves. However, the pericardial tissue employed to this aim undergoes severe calcification due to chronic inflammation resulting from a non-complete immunological compatibility of the animal-derived pericardial tissue resulting from failure to remove animal-derived xeno-antigens. In the mid/long-term, this leads to structural deterioration, mechanical failure, and prosthesis leaflets rupture, with consequent need for re-intervention. In the search for novel procedures to maximize biological compatibility of the pericardial tissue into immunocompetent background, we have recently devised a procedure to decellularize the human pericardium as an alternative to fixation with aldehydes. In the present contribution, we used this procedure to derive sheets of decellularized pig pericardium. The decellularized tissue was first tested for the presence of 1,3 α-galactose (αGal), one of the main xenoantigens involved in prosthetic valve rejection, as well as for mechanical tensile behavior and distensibility, and finally seeded with pig- and human-derived aortic valve interstitial cells. We demonstrate that the decellularization procedure removed the αGAL antigen, maintained the mechanical characteristics of the native pig pericardium, and ensured an efficient surface colonization of the tissue by animal- and human-derived aortic valve interstitial cells. This establishes, for the first time, the feasibility of fixative-free pericardial tissue seeding with valve competent cells for derivation of tissue engineered heart valve leaflets.

Coronary artery disease associated with severe mitral and tricuspid valve regurgitation after left pneumonectomy: report of a successful hybrid procedure

The literature concerning heart surgery after pneumonectomy is still poor. Moreover, there is still a lack of a standardized approach to such a patient in the decision-making process. Here, we report a case of a patient who had previously had left pneumonectomy for malignancy and who had coronary artery disease and mitral and tricuspid regurgitation treated with a hybrid procedure.

Acute aortic insufficiency due to rupture of an aortic valve commissure

Myxomatous degeneration generally involves the atrioventricular valves (mitral and tricuspid). Rarely, it may affect the aortic or pulmonary valve. We report a case of an acute severe aortic insufficiency due to a rupture of a commissure of the aortic valve in a patient who had previously undergone mitral valve surgery for myxomatous mitral valve prolapse.

Do statins improve outcomes and delay the progression of non-rheumatic calcific aortic stenosis?

CONTEXT

It is not known whether statin treatment improves clinical outcomes and reduces aortic stenosis progression in non-rheumatic calcific aortic stenosis.

OBJECTIVE

A meta-analysis of studies was performed comparing statin therapy with placebo or no treatment on outcomes and on aortic stenosis progression echocardiographic parameters.

DATA SOURCES

The authors searched Medline and Pubmed up to January 2010.

DATA EXTRACTION

Two independent reviewers independently abstracted information on study design (prospective vs retrospective or randomised vs non-randomised), study and participant characteristics. Fixed and random effects models were used. A-priori subanalyses assessed the effect of statins on low-quality (retrospective or non-randomised) and on high-quality (prospective or randomised) studies separately.

RESULTS

Meta-analysis identified 10 studies with a total of 3822 participants (2214 non-statin-treated and 1608 statin-treated); five studies were classified as prospective and five as retrospective; concerning randomisation, three trials were randomised whereas seven were not. No significant differences were found in all-cause mortality, cardiovascular mortality or in the need for aortic valve surgery. Lower-quality (retrospective or non-randomised) studies showed that, in statin-treated patients, the annual increase in peak aortic jet velocity and the annual decrease in aortic valve area were lower, but this was not confirmed by the analysis in high-quality (prospective or randomised) studies. Statins did not significantly affect the progression over time of peak and mean aortic gradient.

CONCLUSIONS

Currently available data do not support the use of statins to improve outcomes and to reduce disease progression in non-rheumatic calcific aortic valve stenosis.

Tent-shape technique: another procedure to repair P2 of posterior leaflet of mitral valve

In this report, we describe a new procedure to repair the prolapsing high mid-scallop of the mitral valve (MV) posterior leaflet (P2) with detailed consideration of the anatomy and physiology of the MV. A new artificial chord is implanted in the body of the P2 at the same height of non-prolapsing P1 and P3, and the remaining part of the prolapsing P2 is anchored to the artificial chord taking the shape of a tent.

EuroSCORE performance in valve surgery: a meta-analysis

BACKGROUND

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to predict immediate outcomes after adult cardiac operations, but less than 30% of the cases used to develop this score were valve procedures. We studied EuroSCORE performance in valve procedures.

METHODS

We performed a meta-analysis of published studies reporting the assessment of discriminatory power of the EuroSCORE by receiver operating characteristics (ROC) curve analysis in adult valve operations. A comparison of observed and predicted mortality rates was also performed.

RESULTS

A literature search identified 37 potentially eligible studies, and 12 were selected for meta-analysis comprising 26,621 patients with 1250 events (mortality rate, 4.7%). Meta-analysis of these studies provided an average area under the curve (AUC) value of 0.730 (95% confidence interval [CI], 0.717 to 0.743). The same results were obtained when meta-analyses were performed separately in studies categorized on reliability of uncertainty estimation: in the seven studies reporting reliable uncertainty estimation (8175 patients with 358 events; mortality rate, 4.4%), the ROC curve provided an average AUC value of 0.724 (95% CI, 0.699 to 0.749). The five studies not reporting reliable uncertainty estimation (18,446 patients with 892 events; mortality rate, 4.8%) had an average AUC of 0.732 (95% CI, 0.717 to 0.747). We documented a constant trend to overpredict mortality by EuroSCORE, both in the additive and especially in the logistic form.

CONCLUSIONS

The EuroSCORE has low discrimination ability for valve surgery, and it sensibly overpredicts risk. Alternative risk scoring algorithms should be seriously considered.

Performance of EuroSCORE in CABG and off-pump coronary artery bypass grafting: single institution experience and meta-analysis

AIMS

To assess EuroSCORE performance in predicting in-hospital mortality in on-pump coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCAB).

METHODS AND RESULTS

Additive and logistic EuroSCORE were computed for consecutive patients undergoing CABG (n = 3440, 75%) or OPCAB (n = 1140, 25%) at our hospital from 1999 to September 2007. The areas under the receiver operating characteristic (ROC) curves (AUCs) were used to describe performance and accuracy. No difference in performance between CABG and OPCAB and between additive and logistic EuroSCORE (additive EuroSCORE AUCs of 0.808 and 0.779 for CABG and OPCAB, respectively; logistic EuroSCORE AUCs of 0.813 and of 0.773 for CABG and OPCAB, respectively) was found, although a marked tendency to overpredict mortality by both models was evident. A meta-analysis of previously published data was done, and a total of eight studies representing 19 212 and 5461 patients undergoing CABG and OPCAB, respectively, met inclusion criteria. Meta-analysis confirmed similar performance of EuroSCORE in CABG and OPCAB: estimated AUCs were 0.767 and 0.766 for CABG and OPCAB, respectively, with an estimated difference of 0.001 (95% CI -0.061 to 0.063).

CONCLUSION

Additive and logistic EuroSCORE algorithms performed similarly, and cumulative evidence suggests comparable performance in CABG and OPCAB procedures; both risk models, however, significantly overestimated mortality.

Surgery of left ventricular aneurysm: a meta-analysis of early outcomes following different reconstruction techniques

BACKGROUND

The purpose of this study is to assess the effects of linear and geometric left ventricular aneurysm reconstruction on early postoperative outcomes.

METHODS

A search of computerized databases supplemented with manual bibliographic review was performed for all peer-reviewed English language publications concerning randomized and nonrandomized studies reporting the results of left ventricular reconstruction after both linear and geometric reconstruction techniques. Meta-analyses of several short-term outcomes were performed.

RESULTS

No randomized trial was identified. Eighteen nonrandomized trials were found with a total of 1,814 and 803 patients who underwent linear and geometric reconstruction, respectively. Meta-analysis of all studies (n = 18) revealed an increased risk of in-hospital death for patients undergoing linear reconstruction (relative risk = 1.59, 95% confidence interval: 1.12 to 2.26, p = 0.01). The subanalysis of studies in which linear reconstruction was adopted mainly in the first period of time, and geometric reconstruction was adopted in a later phase, still showed a significant advantage in terms of in-hospital mortality for patients undergoing geometric reconstruction (n = 11 studies, relative risk = 1.89, 95% confidence interval: 1.22 to 2.93, p = 0.004). By contrast, when the two surgical approaches were carried out in the same time lag, there was no difference between linear and geometric reconstruction techniques (n = 7 studies, relative risk = 1.04, 95% confidence interval: 0.57 to 1.92, p = 0.89). No differences in the other outcomes of interest were observed.

CONCLUSIONS

The advantage for geometric reconstruction techniques in terms of in-hospital mortality shown in some studies can be an effect of learning curve or of improvement over time in management of these difficult patients. Further studies are required to clarify this issue.

Therapeutic hypothermia for comatose survivors after cardiac arrest

BACKGROUND

Unconscious adults with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32-34 degrees C (ILCOR recommendations, 2003) when the initial rhythm is ventricular fibrillation.

OBJECTIVES

To assess the technique, safety and efficacy of mild induced hypothermia in patients after OHCA due to VF.

METHODS

Patients were cooled using the MTRE CritiCool external cooling system. Cold intravenous fluids were added to achieve faster cooling in 17 patients. Data were collected prospectively and patients were analyzed according to their neurological outcome on discharge, defined by their cerebral performance category.

RESULTS

From February 2002 to September 2006, 51 comatose VF patients with OHCA underwent MIH. Treatment was discontinued early in five because of hemodynamic instability; goal temperature was reached in 98% and maintained for an average of 19.5 hours; 61% had a favorable outcome (CPC 1-2) and 37% died. Improved outcome was observed with longer hypothermia time and possibly when time from collapse to return of spontaneous circulation was < 25 minutes.

CONCLUSIONS

MIH, using an external cooling system, is simple and feasible, reduces mortality and protects neurological function. Four major factors seem to influence outcome: age, co-morbidities, duration of hypothermia, and possibly the length of time from collapse to return of spontaneous circulation.

Left common carotid artery as inflow site in coronary artery bypass grafting

Porcelain aorta is associated to significantly increased risk of atheromatous embolization in patients who undergo cardiac surgery. We described three cases in which coronary artery bypass grafting was performed off-pump and the saphenous vein graft was anastomosed proximally to the left common carotid artery. This technique permitted avoidance of ascending aortic manipulation and reduce the risk of atheromatous embolization.

Similar long-term results of mitral valve repair for anterior compared with posterior leaflet prolapse

OBJECTIVE

The results of mitral valve repair for anterior leaflet prolapse have been less gratifying than those reported for posterior leaflet prolapse. We compared the long-term durability of 2 different surgical techniques: the edge-to-edge repair, which is used for the treatment of anterior leaflet prolapse, and quadrangular resection, which has been adopted for correction of posterior leaflet prolapse.

METHODS

From 1991 through April 2004, 133 patients with anterior leaflet prolapse and 605 with posterior leaflet prolapse caused by degenerative mitral disease underwent valve repair. The edge-to-edge repair was used for correction of anterior leaflet prolapse, and quadrangular resection of the posterior leaflet, with or without sliding plasty, was used for correction of posterior leaflet prolapse. All patients received a concomitant annuloplasty procedure.

RESULTS

No hospital deaths occurred in the anterior leaflet prolapse group, whereas 2 (0.3%) patients died in the posterior leaflet prolapse group (P = .7). Follow-up was 100% and 97.2% complete in the anterior and posterior leaflet prolapse groups, respectively. At 10 years, overall survival was 91% +/- 4.06% for anterior leaflet prolapse and 93.5% +/- 1.81% for posterior leaflet prolapse (P = .18), and freedom from cardiac death was 95.8% +/- 2.83% for anterior leaflet prolapse and 97.4% +/- 0.95% posterior leaflet prolapse (P = .27). Freedom from reoperation was 96% +/- 2.3% in the anterior leaflet prolapse group and 96.5% +/- 1.18% in the posterior leaflet prolapse group (P = .37). At follow-up (mean, 4.5 +/- 3.12 years; range, 1 month-13.2 years), New York Heart Association functional class I or II was documented in 93.2% of patients in the anterior leaflet prolapse group and 92.8% in the posterior leaflet prolapse group (P = .98).

CONCLUSIONS

The long-term results of the edge-to-edge repair in the setting of anterior leaflet prolapse are similar to those obtained with quadrangular resection for the treatment of posterior leaflet prolapse.

Minimally invasive mitral valve repair as a routine approach in selected patients

OBJECTIVE

To report our experience with minimally invasive mitral valve repair.

METHODS

From 1999 to 2003,104 patients underwent mitral valve repair through a right anterolateral minithoracotomy. Most of them were in New York Heart Association functional class I-Il, had normal ejection fraction and were in sinus rhythm. Eighty-five patients suffered from severe mitral regurgitation due to degenerative disease (n = 82) or healed endocarditis (n = 3) and 19 patients had severe mitral stenosis. Sixty-two patients underwent edge-to-edge repair due to anterior/bileaflet prolapse, 23 had a quadrangular resection of the posterior leaflet and 19 a commissurotomy.

RESULTS

No conversions to sternotomy were necessary. Mean cardiopulmonary bypass and aortic cross-clamp times were 75 +/- 14 and 54 +/- 8 min, respectively. Median mechanical ventilation and intensive care unit stay times were 6 and 13 h, respectively. No in-hospital deaths and no major postoperative complications occurred. At a mean follow-up of 27.4 +/- 10.6 months, all patients but two were in New York Heart Association functional class I. The survival rate was 100% and freedom from reoperation was 95.2 +/- 3.3% at 4 years. No or mild residual mitral regurgitation was detected at echocardiography in 100 patients (96%) and moderate insufficiency was found in two (1.9%). The degree of satisfaction in terms of cosmetic result and postoperative discomfort was very high.

CONCLUSIONS

Mitral valve repair can be effectively performed through a minimally invasive approach achieving excellent mid-term results and a high degree of patient satisfaction in terms of comfort, cosmetic result and prompt recovery. At our institution, this approach has now become the standard procedure for mitral valve disease in young and active patients.

Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency

BACKGROUND

Off-pump coronary artery bypass graft surgery (OPCAB) is increasingly becoming a widely used technique and challenges conventional on-pump coronary artery bypass grafting as the standard surgical therapy for coronary artery disease. Little information, however, is available concerning postoperative performance of bypass grafts done with this new technique. The aim of this study is to assess differences in graft patency between OPCAB and coronary artery bypass grafting by meta-analysis of data published in randomized trials.

METHODS

A literature search for the period beginning January 1990 until December 2004 supplemented with manual bibliographic review was performed for all peer-reviewed English-language publications. A systematic overview (meta-analysis) of randomized trials was conducted to assess differences between OPCAB and coronary artery bypass grafting in graft occlusion rates.

RESULTS

Literature search yielded five comparable randomized studies, for a total of 872 and 998 grafts performed during OPCAB and coronary artery bypass grafting procedures, respectively. Meta-analysis of these studies showed an increased risk of graft occlusion in the OPCAB group of patients, both when all the studies were analyzed together (odds ratio, 1.51; 95% confidence intervals, 1.15 to 1.99; p = 0.003), and when low-quality (odds ratio, 1.46; 95% confidence intervals, 1.05 to 2.03; p = 0.02) and high-quality (odds ratio, 1.65; 95% confidence intervals, 0.99 to 2.75; p = 0.05) studies were analyzed separately.

CONCLUSIONS

Cumulative analysis of the few prospective randomized studies currently available in the literature documents a reduction in postoperative patency of coronary artery bypass grafts performed during OPCAB procedures. The risk of reduced graft patency needs to be considered when choosing OPCAB as tailored strategy for selected patients.

Surgical ablation of atrial fibrillation with a novel bipolar radiofrequency device

OBJECTIVE

When used for epicardial ablation, unipolar devices do not predictably yield transmural scars. Bipolar radiofrequency proved highly effective on the animal model, but clinical experience is still initial. We describe acute electrophysiologic findings and follow-up results of epicardial ablation with a novel bipolar radiofrequency device.

METHODS

A bipolar ablator was used to perform a simplified left atrial lesion set in 90 consecutive patients with atrial fibrillation undergoing open heart surgery. Pacing thresholds were assessed during surgery to validate 24 pulmonary vein encircling lines (12 patients). Follow-up was 100% complete.

RESULTS

In 67 of 90 patients (84%), mitral valve disease was the main indication to surgery. Atrial fibrillation was continuous in 74 patients (82%) and intermittent in 16 patients (18%). Pacing threshold assessment showed a complete conduction block in 22 of 24 pulmonary vein couples (92%) after a single ablation and in all patients after doubling of the encircling lines. No complications related to the ablation procedure were recorded. The sinus rhythm restoration rate was 79% at 3 months, 87% at 6 months, and 89% (17/18 patients) at 1 year. Postablation organized arrhythmias consisted in right atrial flutter in 2 patients (2%) and left atrial flutter in 6 patients (7%).

CONCLUSIONS

Epicardial ablation with bipolar radiofrequency grants acute transmurality. A simplified lesion set proved highly effective in eliminating atrial fibrillation at 1-year follow-up. Our data suggest that addition of a lesion to the mitral annulus is advisable to prevent left atrial flutter.

Hyperinsulinemic hypoglycemia in Beckwith-Wiedemann syndrome due to defects in the function of pancreatic beta-cell adenosine triphosphate-sensitive potassium channels

BACKGROUND

Beckwith-Wiedemann syndrome (BWS) is a congenital overgrowth syndrome that is clinically and genetically heterogeneous. Hyperinsulinemic hypoglycemia occurs in about 50% of children with BWS and, in the majority of infants, it resolves spontaneously. However, in a small group of patients the hypoglycemia can be persistent and may require pancreatectomy. The mechanism of persistent hyperinsulinemic hypoglycemia in this group of patients is unclear.

PATIENTS AND METHODS

Using patch-clamp techniques on pancreatic tissue obtained at the time of surgery, we investigated the electrophysiological properties of ATP-sensitive K(+) (K(ATP)) channels in pancreatic beta-cells in a patient with BWS and severe medically-unresponsive hyperinsulinemic hypoglycemia.

RESULTS

Persistent hyperinsulinism was found to be caused by abnormalities in K(ATP) channels of the pancreatic beta-cell. Immunofluorescence studies using a SUR1 antibody revealed perinuclear pattern of staining in the BWS cells, suggesting a trafficking defect of the SUR1 protein. No mutations were found in the genes ABCC8 and KCNJ11 encoding for the two subunits, SUR1 and KIR6.2, respectively, of the K(ATP) channel. Genetic analysis of this patients BWS showed evidence of mosaic paternal isodisomy.

CONCLUSIONS

In this novel case of BWS with mosaic paternal uniparental disomy for 11p15, persistent hyperinsulinism was due to abnormalities in K(ATP) channels of the pancreatic beta-cell. The mechanism/s by which mosaic paternal uniparental disomy for 11p15 causes a trafficking defect in the SUR1 protein of the K(ATP) channel remains to be elucidated.

Follicular carcinoma of the thyroid gland: prognostic factors, treatment, and survival

Prognostic variables and treatment outcomes of 82 patients treated at the Northern Israel Oncology Center were reviewed. There were 59 women and 23 men in this series. The female/male ratio was 2.6/1. Median age was 46 years. Median follow-up was 11.4 (range: 3.8-24 years). Median tumor size was 3.6 cm. When first seen, 4 patients had lymph node involvement and 11 (13%) had distant metastases. Surgical treatment was total thyroidectomy in 37 patients (45%), subtotal thyroidectomy in 38 (46%), and lesser procedures in 7 (9%). Sixty-six patients (80%) were treated after surgery with 131I to ablate thyroid remnants. Doses ranged between 30 and 80 mCi. The 20-year overall actuarial survival rate was 65%. The actuarial survival rate of patients <40 years of age was 96% versus 33% in patients >50 years of age (p = 0.0008). Patients with distant metastases at presentation had inferior survival compared with patients without metastases. In conclusion, we found subtotal thyroidectomy followed by 131I and hormone therapy to provide survival similar to that with total thyroidectomy, with less morbidity. Risk factors include: age > or =40 at the time of diagnosis, presence of distant metastases, capsular invasion, tumor size > or =2 cm, and male gender.

HLA class II associations with rheumatic heart disease are more evident and consistent among clinically homogeneous patients

BACKGROUND

Discrepancies in reported HLA class II associations with rheumatic heart disease (RHD) may have been due to inaccuracies of serological typing reagents and/or lack of defined clinical classification of patients analyzed. The molecular association between HLA and RHD was investigated in patients with defined clinical outcome.

METHODS AND RESULTS

Class II allele/haplotype distribution was determined in 2 groups of RHD patients (n=88) and a control group (n=59). Patients were divided into the mitral valve disease (MVD) category (ie, those with mitral regurgitation with or without mitral stenosis) and the multivalvular lesions (MVL) category, with impairment of aortic and/or tricuspid valves in addition to mitral valve damage. The MVD category (n=65) accounted for 74% of patients and included significantly fewer recurrent RF episodes compared with MVL patients (P=0.002).

CONCLUSIONS

Significant increases in DRB1*0701 and DQA1*0201 alleles and DRB1*0701-DQA1*0201 haplotypes were found in patients. Removal of the MVL patients from analysis increased the strength of HLA associations among the MVD sample. The frequency of DQA1*0103 allele was decreased and the DQB1*0603 allele was absent from the patient group, suggesting that these alleles may confer protective effects against RHD. DQ alleles in linkage disequilibrium with DR alleles appear to influence risk/protection effect: whereas the DRB1*13-DQA1*0501-3-DQB1*0301 haplotype showed a trend toward risk, the DRB1*13-DQA1*0103-DQB1*0603 haplotype was absent in the RHD sample. Our data indicate that certain class II alleles/haplotypes are associated with risk or protection from RHD and that these associations appear to be stronger and more consistent when analyzed in patients with relatively more homogeneous clinical manifestations.

[Differentiated thyroid cancer in Arabs in northern Israel]

Prognostic factors and survival rate of 53 Arabs with differentiated carcinoma of the thyroid treated here were reviewed. Papillary carcinoma was diagnosed in 35 (66%) and follicular carcinoma in 18 (34%): the female/male ratio was 2.3/1 and the median age 32. Age, gender, tumor size, histology and tumor stage were important prognostic factors. The 20-year actuarial survival rate of the entire group was 96%. The probable reason for the high survival rate was the low median age.

[Destruction of residual varicose collaterals by subcutaneous dilaceration with a needle]

The persistence of collaterals after a properly conducted surgical treatment of varicose veins of the lower limbs often presents a problem which is difficult to resolve. The authors put forward a simple and original method, in which a long and slightly curved triangular needle is used, without incisions, to destroy by dilaceration the collaterals whatever their degree of dilatation and their location. This technique has also been used as a first stage preceding stripping, and over a 5 year period has given results in 70 patients which are very satisfactory both from the point of view of efficacy as well as from the aesthetic point of view.

Diverticulum of the left ventricle. Report of a case

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