Duration of Antiplatelet Therapy After Complex Percutaneous Coronary Intervention In Patients at High Bleeding Risk: a MASTER DAPT trial sub-analysis

AIMS

To assess the effects of 1- or ≥3-month dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients who received biodegradable-polymer sirolimus-eluting stents for complex percutaneous coronary intervention (PCI) and/or acute coronary syndrome (ACS).

METHODS AND RESULTS

In the MASTER DAPT trial, 3383 patients underwent noncomplex (abbreviated DAPT, n = 1707; standard DAPT, n = 1676) and 1196 complex (abbreviated DAPT, n = 588; standard DAPT, n = 608) PCI. Co-primary outcomes at 335 days were net adverse clinical events (NACE; composite of all-cause death, myocardial infarction, stroke, and Bleeding Academic Research Consortium [BARC] 3 or 5 bleeding events); major adverse cardiac or cerebral events (MACCE; all-cause death, myocardial infarction, and stroke); and type 2, 3, or 5 BARC bleeding.NACE and MACCE did not differ with abbreviated versus standard DAPT among patients with complex (hazard ratio [HR]: 1.03, 95% confidence interval [CI]: 0.69-1.52, and HR: 1.24, 95% CI: 0.79-1.92, respectively) and noncomplex PCI (HR: 0.90, 95% CI: 0.71-1.15, and HR: 0.91, 95% CI: 0.69-1.21; Pinteraction = 0.60 and 0.26, respectively). BARC 2, 3 or 5 was reduced with abbreviated DAPT in patients with and without complex PCI (HR: 0.64; 95% CI: 0.42-0.98, and HR: 0.70; 95% CI: 0.55-0.89; Pinteraction = 0.72). Among the 2,816 patients with complex PCI and/or ACS, NACE and MACCE did not differ and BARC 2, 3 or 5 was lower with abbreviated DAPT.

CONCLUSION

In HBR patients free from recurrent ischemic events at 1 month, DAPT discontinuation was associated with similar NACE and MACCE and lower bleeding rates compared with standard DAPT, regardless of PCI or patient complexity.

Healing and early stent coverage after ultrathin strut biodegradable polymer-coated sirolimus-eluting stent implantation: SiBi optical coherence tomography study

AIMS

The aim of SiBi study was to evaluate the early vascular healing and neointimal coverage after implantation of ultrathin (60 μm) biodegradable polymer-coated Tetriflex (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) sirolimus-eluting stent (SES) using optical coherence tomography (OCT) at 4 to 6 weeks after implantation.

METHODS

SiBi was a single-center, observational, investigator-initiated study. From January 15, 2018 to April 15, 2018, total 29 consecutive patients who had consented and underwent OCT examination at 4-6 weeks after Tetriflex SES implantation were enrolled. All OCT images were analyzed at an independent core laboratory by analysts who were blinded to patient and procedural information.

RESULTS

Of 29 patients, four patients were excluded, as those OCT images were technically inadequate for analysis. Therefore, 25 patients were included in final OCT analysis. Average OCT analysis was performed after 35.3 ± 5 days of Tetriflex implantation. Total 14,024 stent struts in 1,520 cross sections were analyzed. Strut tissue coverage was observed in 91.26 ± 5.53% of struts and malapposed struts were seen in 0.89 ± 1.67%. The mean neointimal hyperplasia (NIH) thickness on the covered struts was 50 ± 30 μm.

CONCLUSION

A large percentage of struts were found to be covered with thin layer of NIH evenly distributed along the stent length at around 1 month from stent implantation. The results of this pilot study serve as ethical and scientific backbone to conduct an adequately powered clinical trial to evaluate outcomes of short dual-antiplatelet therapy in context of ultrathin strut stent.

Serial evaluation of vascular responses after implantation of everolimus-eluting coronary stent by optical coherence tomography

AIM

To evaluate healing response at strut-level and cross-section level after implanting an ultra-thin strut, everolimus-eluting stent with biodegradable polymer (Tetrilimus) using optical coherence tomography (OCT) at 3 and 6 months.

METHODS

This was prospective, multi-centre, single-arm, and investigator-initiated study performed at seven Indian sites between January, 2017 and September, 2018. OCT evaluations were performed in 57 patients who underwent Tetrilimus stent implantation. Follow-up OCT was scheduled at 3 months for first 16 patients and at 6 months for 41 patients. Primary outcomes included degree of strut coverage, malapposition and thickness of neointimal hyperplasia (NIH) over covered struts.

RESULTS

Sixty one Tetrilimus stents were implanted to treat 59 lesions in 57 patients. Paired (baseline and follow-up) OCT data was available for 12 patients and 30 patients at 3 and 6 months, respectively. At 3 months, rapid early healing was indicated by 95.48% covered struts per lesion with very low (0.11 ± 0.06 mm) NIH. At 6 months, NIH accumulation was greater (0.21 ± 0.07 mm) as compared to 3 months. 99.77% of struts per lesion were covered at 6 months. There was a very symmetrical healing as shown by very low eccentricity index. There was no difference in vascular healing between stents with small to moderate size vessels (≤3.00 mm) and large size vessels (>3.00 mm).

CONCLUSION

Present study demonstrated nearly complete endothelization and low NIH accumulation at 3 and 6 months following implantation of ultra-thin strut everolimus-eluting biodegradable polymer-coated Tetrilimus stent. Moreover, though being an ultra-thin strut stent, there was no difference in vascular healing and eccentricity after implantation of the Tetrilimus stents with smaller and larger diameters.

Comparison of neointimal coverage between ultrathin biodegradable polymer-coated sirolimus-eluting stents and durable polymer-coated everolimus-eluting stents: 6 months optical coherence tomography follow-up from the TAXCO study

Aim

The TAXCO study was designed to compare the degree of neointimal coverage and the prevalence of malapposition at 6 months subsequent to implantation of ultrathin biodegradable polymer‐coated sirolimus‐eluting stents (SES) and durable polymer‐coated everolimus‐eluting stents (EES) of thin strut thickness using optical coherence tomography (OCT).

Methods

The TAXCO study included a total of 42 patients who gave consent and underwent OCT examination between August 2017 and September 2017. Of 42, five patients' OCT examinations were of insufficient quality for quantitative analysis. Thus, the OCT analysis group consisted of 37 patients. Among them, 16 patients were treated with Xience (Abbott Vascular) and 21 with Tetriflex (Sahajanand Medical Technologies Pvt. Ltd., Surat, India), 6 (±1) months earlier at our institution. The OCT was performed using a C7 Dragonfly™ imaging catheter (St. Jude Medical Inc.). All OCT images were analyzed at an independent core laboratory (Cardiovascular Research Center, São Paulo, Brazil) by analysts who were blinded to patient and procedural information.

Results

A total of 763 crosssections (6,882 struts) were analyzed in Xience group, and 1,127 crosssections (9,968 struts) in Tetriflex group. At 6 months, on per‐lesion basis, no significant differences were observed between Xience group and Tetriflex group in mean percentage of uncovered struts (1.87 ± 3.86 vs. 2.42 ± 3.46, p = .137) and malapposed struts (0.05 ± 0.2 vs. 0.21 ± 0.69, p = .302). Strut‐level neointimal thickness also did not differ between Xience group and Tetriflex group (0.18 ± 0.12 vs. 0.14 ± 0.08 mm, p = .286).

Conclusion

This OCT study found no significant difference in strut coverage and neointimal thickness at 6 months after implantation of biodegradable polymer‐coated Tetriflex, when compared with durable polymer‐coated Xience.

Twelve-month comparative analysis of clinical outcomes using biodegradable polymer-coated everolimus-eluting stents versus durable polymer-coated everolimus-eluting stents in all-comer patients

Aim

The purpose of the present study was to examine whether clinical differences exist between the biodegradable polymer (BDP)–coated Tetrilimus everolimus-eluting stent (EES) and the durable polymer (DP)–coated Xience EES by comparing the major adverse cardiac event (MACE) rate at 12 months in all-comer patients.

Methods

This study was designed as a multicentre, observational, retrospective, investigator-initiated study between January 2016 and October 2016. Two hundred thirteen patients who underwent percutaneous coronary intervention (PCI) with the BDP-EES were compared with 204 patients who underwent PCI with the DP-EES, irrespective of lesion complexity, comorbidities and acute presentation. The primary end point was MACE defined as a composite of cardiac death, myocardial infarction and target lesion revascularization.

Results

Baseline clinical and lesion characteristics of both the groups were similar, although the BDP-EES group had a significantly higher number of patients with diabetes mellitus (39.9% vs. 30.4%; p = 0.042) and type C lesion (67.4% vs. 48.1%; p < 0.001) than the DP-EES group. The 12-month MACE rate was 4.2% for the BDP-EES group versus 4.9% for the DP-EES group (p = 0.740). Mortality was lower in the BDP-EES group than in the DP-EES group (0.9% vs. 2.0%; p = 0.441).

Conclusion

The present comparative analysis shows that the BDP-coated Tetrilimus EES was as safe and effective as the DP-coated Xience EES during the 12-month follow-up period despite complex lesion characteristics.

Seven-year clinical outcomes in patients undergoing percutaneous coronary intervention with biodegradable polymer coated sirolimus-eluting stent: Results from a single-center real-world experience

Objective

The aim of the present study was to assess seven-year clinical outcomes of biodegradable polymer coated Supralimus sirolimus-eluting stent (S-SES) [Sahajanand Medical Technologies Pvt. Ltd., Surat, India] in real-world patients with coronary artery disease.

Methods

This observational, retrospective study was carried out in all 346 consecutive enrolled patients who underwent percutaneous coronary intervention (PCI) with the S-SES, between April 2008 and December 2009, at a single center. We analyzed major adverse cardiac events (MACE) [a composite of cardiac death, myocardial infarction (MI), target lesion revascularization (TLR) and target vessel revascularization (TVR)] as primary outcomes at seven-year follow-up.

Results

Out of 346 patients, seven-year follow-up was obtained in 327 (94.5%) patients and hence results were analyzed for 327 patients. At seven-year, MACE occurred in 41 (12.5%) patients, consisting of 23 (7.0%) cardiac deaths, 14 (4.3%) TLR, and 4 (1.2%) TVR. The incidence of late stent thrombosis was observed in 3 (0.9%) patients. At follow-up of seven-year, the cumulative event-free survival was found to be 84.7% by Kaplan-Meier method.

Conclusions

The present study demonstrated satisfactory and sustained seven-year clinical outcomes as evidenced by the low rates of MACE and ST for the biodegradable polymer coated S-SES.

Clinical outcomes in 995 unselected real-world patients treated with an ultrathin biodegradable polymer-coated sirolimus-eluting stent: 12-month results from the FLEX Registry

OBJECTIVES

To evaluate, in the FLEX Registry, clinical outcomes of an ultrathin (60 µm) biodegradable polymer-coated Supraflex sirolimus-eluting stent (SES) for the treatment of coronary artery disease. Additionally, to determine the vascular response to the Supraflex SES through optical coherence tomography (OCT) analysis.

SETTING

Multicentre, single-arm, all-comers, observational registry of patients who were treated with the Supraflex SES, between July 2013 and May 2014, at nine different centres in India.

PARTICIPANTS

995 patients (1242 lesions) who were treated with the Supraflex SES, between July 2013 and May 2014, at nine different centres in India. A total of 47 participants underwent OCT analysis at 6 months' follow-up.

INTERVENTIONS

Percutaneous coronary intervention with Supraflex SES, PRIMARY AND SECONDARY OUTCOME MEASURES: The primary endpoint-the rate of major adverse cardiac events (defined as a composite of cardiac death, myocardial infarction (MI), target lesion revascularisation (TLR))-was analysed during 12 months.

RESULTS

At 12 months, the primary endpoint occurred in 36 (3.7%) of 980 patients, consisting of 18 (1.8%) cardiac deaths, 16 (1.6%) MI, 7 (0.7%) TLR and 2 (0.2%) cases of non-target lesion target vessel revascularization. In a subset of 47 patients, 1227 cross-sections (9309 struts) were analysed at 6 months by OCT. Overall, a high percentage of struts was covered (98.1%), with a mean neointimal thickness of 0.13 ± 0.06 µm.

CONCLUSIONS

The FLEX Registry evaluated clinical outcomes in real-world and more complex cohorts and thus provides evidence that the Supraflex SEX can be used safely and routinely in a broader percutaneous coronary intervention population. Also, the Supraflex SES showed high percentage of stent strut coverage and good stent apposition during OCT follow-up.

Comparison of Clinical Outcomes Following Single versus Multivessel Percutaneous Coronary Intervention Using Biodegradable Polymer Coated Sirolimus-Eluting Stent in an All-comers Patient Population

BACKGROUND

Drug-eluting stents (DES) have been shown to reduce the rate of acute complications and the need for subsequent revascularization in cases where single-vessels are treated. The performance of DES in patients with multivessel disease and complex lesions, however, remains controversial. This study assessed and compared clinical outcomes following single vs. multivessel percutaneous coronary intervention (PCI), using the Supraflex sirolimus-eluting stent (SES), in an all-comers patient population.

METHODS

We conducted retrospective, multicenter, all-comers, observational study of 995 patients, who underwent either single-vessel PCI (n=769 patients; group-I) or multivessel PCI (n=226 patients; group-II), treated with the biodegradable polymer coated Supraflex SES, between July-2013 and May-2014 at nine different centers in India. Pre-specified primary endpoint, rate of major adverse cardiac events (MACE) [defined as composite of cardiac death, myocardial infarction (MI), target lesion revascularization (TLR) and non-target lesion target vessel revascularization (non-TL TVR)], was analyzed during 12 months after the post-index procedure. We also analyzed the incidence of stent thrombosis (ST) as a safety endpoint during the follow-up period, as defined by the Academic Research Consortium (ARC).

RESULTS

Of the whole study group, 1,242 lesions were treated in 995 patients (mean age 61.6±10.8 years; 80.0% male) with average stent length of 26.8±9.3 mm. Multivessel PCI patients were older, had a higher prevalence of arterial hypertension, were smoker, had a family history of coronary artery disease, previous stroke and previous PCI compared to single-vessel PCI patients. Follow-up was available in 99.0% (761/769) of patients with single-vessel intervention and 96.9% (219/226) of patients with multivessel intervention at the end of 12 months. In-hospital MACE was similar for both the groups [group-I, 3 (0.4%) vs. group-II, 1 (0.4%); p=1.000]. The observed MACE for group-I and group-II, at 30 days, 6 and 12 months follow-up were 9 (1.2%) vs. 2 (0.9%); p=1.000, 15 (2.0%) vs. 7 (3.2%); p=0.302 and 24 (3.2%) vs. 12 (5.5%); p=0.109, respectively. The cumulative incidence curves for MACE showed no significant differences between the two groups, at the end of 12 months (p=0.109).

CONCLUSION

Our study shows that use of the Supraflex SES in single and multivessel coronary artery disease produces good clinical outcomes during 12 months of follow-up with a low rate of revascularization, despite complex lesion morphology.

Paclitaxel-Eluting versus Everolimus-Eluting Coronary Stents in Diabetes

BACKGROUND

The choice of drug-eluting stent in the treatment of patients with diabetes mellitus and coronary artery disease who are undergoing percutaneous coronary intervention (PCI) has been debated. Previous studies comparing paclitaxel-eluting stents with stents eluting rapamycin (now called sirolimus) or its analogues (everolimus or zotarolimus) have produced contradictory results, ranging from equivalence between stent types to superiority of everolimus-eluting stents.

METHODS

We randomly assigned 1830 patients with diabetes mellitus and coronary artery disease who were undergoing PCI to receive either a paclitaxel-eluting stent or an everolimus-eluting stent. We used a noninferiority trial design with a noninferiority margin of 4 percentage points for the upper boundary of the 95% confidence interval of the risk difference. The primary end point was target-vessel failure, which was defined as a composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization at the 1-year follow-up.

RESULTS

At 1 year, paclitaxel-eluting stents did not meet the criterion for noninferiority to everolimus-eluting stents with respect to the primary end point (rate of target-vessel failure, 5.6% vs. 2.9%; risk difference, 2.7 percentage points [95% confidence interval, 0.8 to 4.5]; relative risk, 1.89 [95% confidence interval, 1.20 to 2.99]; P=0.38 for noninferiority). There was a significantly higher 1-year rate in the paclitaxel-eluting stent group than in the everolimus-eluting stent group of target-vessel failure (P=0.005), spontaneous myocardial infarction (3.2% vs. 1.2%, P=0.004), stent thrombosis (2.1% vs. 0.4%, P=0.002), target-vessel revascularization (3.4% vs. 1.2%, P=0.002), and target-lesion revascularization (3.4% vs. 1.2%, P=0.002).

CONCLUSIONS

In patients with diabetes mellitus and coronary artery disease undergoing PCI, paclitaxel-eluting stents were not shown to be noninferior to everolimus-eluting stents, and they resulted in higher rates of target-vessel failure, myocardial infarction, stent thrombosis, and target-vessel revascularization at 1 year. (Funded by Boston Scientific; TUXEDO-India Clinical Trials Registry-India number, CTRI/2011/06/001830).

Meta-analysis: the impact of disease activity at conception on disease activity during pregnancy in patients with inflammatory bowel disease

BACKGROUND

The rate of exacerbation of inflammatory bowel disease (IBD) during pregnancy varies in the published literature.

AIM

We sought to perform a systematic review and meta-analysis of the effects of disease activity at conception on disease course during pregnancy in women with IBD.

METHODS

Published studies and abstracts from standard sources were screened for appropriate studies. Data were pooled and analysed using funnel and forest plots. Quality assessment scores were given using GRADE criteria.

RESULTS

Fourteen studies were eligible for inclusion; ten studies contained patients with UC (N = 1130), and six studies contained patients with CD (N = 590). In patients with UC there was a significantly higher risk ratio of active disease during pregnancy in patients who commenced pregnancy with active disease (55%), when compared with those in remission at conception (36%) (RR 2.0, 95% CI: 1.5-3, P < 0.001). This risk was also higher in patients with CD (RR 2.0, 95% CI: 1.2-3.4, P = 0.006). Thirteen of the studies rated 'low' in all domains of a quality assessment, and there was significant statistical heterogeneity.

CONCLUSIONS

Patients with IBD who conceive when their disease is active are more likely to have active disease during pregnancy than those who conceive when in remission. All studies used in this analysis had a high risk of bias therefore further studies are required.

Early vascular healing with biodegradable polymer coated sirolimus-eluting coronary stent implantation: assessed by optical coherence tomography results at 4-month follow-up

AIM

The aim of this study was to evaluate the strut apposition and neointimal coverage of Supralimus-Core stent struts at 4 months after implantation using optical coherence tomography (OCT).

METHODS

The Supralimus-Core OCT study is a retrospective, single-center study evaluating strut apposition and neointimal coverage with OCT at 4 months after stent implantation. A total of 12 patients, who had 15 stents implanted were included in the study. The OCT was obtained using a C7-XR FD-OCT (frequency-domain OCT) intravascular imaging system. Strut apposition, neointimal hyperplasia (NIH) thickness and stent coverage on each stent strut were evaluated.

RESULTS

A total of 2870 struts and 1950 frames were analyzed from 15 stents. Average stent length was 29.3 mm. Average reference vessel diameter was 2.64 mm. Among 12 patients, 3 (25.0%) patients were with diabetes, 4 (26.7%) type B2 and 10 (66.7%) type C lesions. The apposed and covered struts were 2787 (97.11%), whereas malapposed and covered struts were 3 (0.10%), apposed and uncovered 49 (1.71%) and malapposed and uncovered 31 (1.08%). Mean NIH thickness was 155.1±55.2 µm.

CONCLUSION

The present study suggests that Supralimus-Core stent has a favorable vascular healing pattern at 4 months after stent implantation in terms of stent-strut coverage and strut apposition. This information indicates that the Supralimus-Core stent is a promising solution for decreasing late stent restenosis and preventing stent thrombosis.

Laparoscopy-assisted surgery for neonatal intestinal atresia: single-center experience(*)

INTRODUCTION

Neonatal intestinal atresia surgery requires careful assessment of bowel patency, resection of the affected bowel and a diligent anastomosis. Traditional anastomosis with sutures via a laparoscopic approach would lengthen the surgical time. Various minimally invasive techniques have been reported for neonatal surgery. Our technique offers improved benefits of laparoscopy while observing good principles of surgery.

MATERIALS AND SURGICAL TECHNIQUE

Using a three-port approach to aid careful laparoscopic inspection of the bowel, we performed laparoscopy-assisted neonatal intestinal atresia repair in three term neonates with no cardiorespiratory compromise. Anastomosis was manually performed after exteriorzation of the bowel via the umbilical port site without any extension of the original port-site incision. There were no complications or conversions to open approach.

DISCUSSION

Our technique is an improvement over previously reported limited/umbilical laparotomy approaches and blends the benefits of laparoscopy and open surgery most effectively. Careful bowel inspection and assessment of patency could be safely and systematically performed laparoscopically with limited exteriorization of the bowel for rapid hand-sewn anastomosis and without compromising bowel viability. A multicenter randomized trial will be useful to compare the open laparotomy approach with our technique.

Beta-catenin is involved in alterations in mitochondrial activity in non-transformed intestinal epithelial and colon cancer cells

BACKGROUND

Alteration in respiratory activity and mitochondrial DNA (mtDNA) transcription seems to be an important feature of cancer cells. Leukotriene D(4) (LTD(4)) is a proinflammatory mediator implicated in the pathology of chronic inflammation and cancer. We have shown earlier that LTD(4) causes translocation of beta-catenin both to the mitochondria, in which it associates with the survival protein Bcl-2 identifying a novel role for beta-catenin in cell survival, and to the nucleus in which it activates the TCF/LEF transcription machinery.

METHODS

Here we have used non-transformed intestinal epithelial Int 407 cells and Caco-2 colon cancer cells, transfected or not with wild type and mutated (S33Y) beta-catenin to analyse its effect on mitochondria activity. We have measured the ATP/ADP ratio, and transcription of the mtDNA genes ND2, ND6 and 16 s in these cells stimulated or not with LTD(4).

RESULTS

We have shown for the first time that LTD(4) triggers a cellular increase in NADPH dehydrogenase activity and ATP/ADP ratio. In addition, LTD(4) significantly increased the transcription of mtDNA genes. Overexpression of wild-type beta-catenin or a constitutively active beta-catenin mutant mimicked the effect of LTD(4) on ATP/ADP ratio and mtDNA transcription. These elevations in mitochondrial activity resulted in increased reactive oxygen species levels and subsequent activations of the p65 subunit of NF-kappaB.

CONCLUSIONS

The present novel data show that LTD(4), presumably through beta-catenin accumulation in the mitochondria, affects mitochondrial activity, lending further credence to the idea that inflammatory signalling pathways are intrinsically linked with potential oncogenic signals.

Is there a positive effect of participation on a clinical trial for patients with advanced non-small cell lung cancer?

BACKGROUND

There is general belief that patients who enrolled on a clinical trial have better outcomes compared to those who are treated outside of a trial. We analyzed if there was a 'trial effect' for patients with advanced non-small cell lung cancer (NSCLC) treated with chemotherapy.

MATERIALS AND METHODS

A retrospective analysis of cohorts of patients with advanced NSCLC who received chemotherapy inside and outside of a clinical trial were analyzed for response rates (RR), progression free survival (PFS), overall survival (OS), 1 and 2 year survival.

RESULTS

There were 194 patients who received chemotherapy of which, 54 were on a clinical trial and 140 outside of it. For the whole group, the RR, median PFS, OS, one and two-year survivals were 35.4%, six months (range, 2-70), seven months (range, 2-72), 29.8% and 9.7% respectively. The differences in RR and PFS of patients who were treated inside and outside of a clinical trial were not significant (P=0.6164, 0.0881). The differences in median OS and one-year survivals between the groups were significant (P=0.0052, 0.022). For the whole group, patients who received II line chemotherapy had better OS (P< or = 0.0001). More patients in the trial group received II line chemotherapy (P=0.0004).The difference in the median OS between the groups continued to be significant even after patients who received II line chemotherapy were censored (P=0.0437).

CONCLUSION

Patients with advanced NSCLC who were treated inside of a clinical trial had better OS compared to those who were treated outside of it.

Fusogenic peptide as diagnostic marker for detection of flaviviruses

BACKGROUND

Dengue, Japanese encephalitis, West Nile encephalitis, yellow fever are the common flaviviral diseases associated with high morbidity and mortality. The initial symptoms of most of the flaviviral infections are similar to each other as well as to some other viral diseases. Making clinical diagnosis, therefore, becomes a challenging task for the clinician. Several studies have been reported on using detection of serum antibodies against flavivirus for the diagnosis of specific flaviviral disease; no field-based pan-flavi virus detection system is available, which can be used in low-endemicity areas for differentiation of flaviviral disease from other viral diseases.

AIM

To identify a conserved amino acid sequence among all flaviviruses and evaluate the antibody formed against the conserved peptide to develop pan-flavivirus detection system.

MATERIALS AND METHODS

In the present study we have compared amino acid sequences of several flaviviruses and identified a conserved amino acid sequence lying in domain II of envelope protein.

RESULTS

A peptide having the conserved amino acid sequence was used to generate polyclonal antibodies and these antibodies were used to detect several flaviviruses. Anti-peptide polyclonal antibodies selectively recognized flaviviruses and did not detect non-flaviviruses. Anti-peptide antibodies detected presence of virus in serum spiked with pure virus preparations.

CONCLUSION

The study offers a rationale for development of pan-flavivirus capture assay suitable for low endemic areas.

Simvastatin maintains steady patterns of GFR and improves AER and expression of slit diaphragm proteins in type II diabetes

The factors determining the course of glomerular filtration rate (GFR) and albumin excretion rate (AER) and the expression of mRNA of slit diaphragm (SD) and podocyte proteins in microalbuminuric, hypertensive type II diabetic patients are not fully understood. GFR, AER, and SD protein mRNA were studied in 86 microalbuminuric, hypertensive, type II diabetics at baseline and after 4-year random double-blind treatment either with 40 mg simvastatin (Group 1) or with 30 g cholestyramine (Group 2) per day. Both groups had at baseline a GFR decay per year in the previous 2-4 years of 3 ml/min/1.73 m(2). Both Groups 1 and 2 showed a significant decrease of low-density lipoprotein cholesterol levels after simvastatin and cholestyramine treatment (P<0.01). No change from base line values was observed as for hs-C-reactive protein and interleukin-6. A significant decrease of 8-hydroxydeoxyguanosine urinary excretion was observed after simvastatin treatment. GFR did not change from baseline with simvstatin, whereas a decrease was observed with cholestyramine treatment (simvastatin vs cholestyramine: -0.21 vs -2.75 ml/min/1.73 m(2), P<0.01). AER decreased in Group 1 (P<0.01), but not in Group 2 patients. Real-time polymerase chain reaction measurement of mRNA SD proteins (CD2AP, FAT, Actn 4, NPHS1, and NPHS2) significantly increased in kidney biopsy specimens after simvastatin, but not cholestyramine treatment. Simvastatin, but not cholestyramine, 4-year treatment maintains steady patterns of GFR, and improves AER and expression of SD proteins in type II diabetes, despite similar hypocholesterolemic effects in circulation.

Use of a tissue expander and a polyglactic acid (Vicryl) mesh to reduce radiation enteritis: case report and literature review

Management of stage IV rhabdomyosarcoma comprises systemic chemotherapy with local control by conservative surgery and radiotherapy. Abdominal radiotherapy may lead to radiation enteritis causing such serious morbidity as malabsorption, fistulae or stricture formation. The risk increases with the dose of radiation and length of bowel involved. Various methods have been utilised to displace the bowel from the radiation field. Usually these are applied in patients requiring pelvic irradiation. We report a case of metastatic alveolar rhabdomyosarcoma requiring radiotherapy to the right renal bed. Effective displacement of small bowel from the tumour site was achieved by a combined use of a tissue expander and Vicryl mesh. There were no complications from the surgery. This is the first report discussing combined use of a tissue expander and Vicryl mesh to aid radiotherapy to the renal fossa in a paediatric patient.

Congenital malformations of the diaphragm: findings of the West Midlands Congenital Anomaly Register 1995 to 2000

OBJECTIVES

To describe trends in incidence, associated anomalies, clinical outcomes and sensitivity of prenatal diagnosis for congenital malformations of the diaphragm in the West Midlands Region between 1995 and 2000.

METHODS

Information was retrieved from a population-based register of major congenital malformations in a health region of England, the West Midlands Congenital Anomaly Register (WMCAR), between 1995 and 2000.

RESULTS

One hundred and sixty-one confirmed cases of congenital malformations of the diaphragm were notified from 396 577 births. This gives an incidence of 4.1 per 10,000 births. After natural losses and terminations, the incidence at birth was 2.9 per 10,000 registered births. For live-born cases, the infant mortality rate was 317 per 1000 births. 47% of the cases had additional structural or chromosomal anomalies; the infant mortality rate for these complex cases was 533 per 1000, an increased relative risk of 2.37 compared with isolated lesions. 66% of the cases were diagnosed prenatally, 51% of isolated lesions and 84% of complex cases. Fourteen prenatally diagnosed cases (12%) were false-positives; however, 11 of these cases had other significant pathology. These 14 cases were not included in the 161 confirmed cases.

CONCLUSION

Congenital malformations of the diaphragm remain associated with considerable infant mortality. Most cases are now diagnosed before birth and the prognosis is adversely affected by the presence of other structural or chromosomal anomalies. This presents significant challenges for those involved in counselling the parents of affected fetuses.

Postoperative pneumatosis intestinalis in infants does not automatically preclude enteral feeding

BACKGROUND

A degree of feed intolerance after neonatal abdominal surgery is common but in an otherwise well baby enteral feeding usually is continued at the highest tolerated level. However, the presence of rectal bleeding, pneumatosis intestinalis, or portal vein gas seen on plain abdominal x-rays suggest the possibility of postoperative necrotising enterocolitis. When this happens feedings usually are stopped for 7 to 10 days, and intravenous antibiotics and total parental nutrition are commenced.

METHODS

The authors report 12 episodes of rectal bleeding and 11 episodes of pneumatosis intestinalis in 3 infants who previously had undergone neonatal abdominal surgery for intestinal malformations. In 7 of these episodes, feedings were neither stopped nor were antibiotics given. At the time of these 7 episodes, the infants were more than 3 kg in weight, had no significant cardiac or respiratory pathology, were all clinically stable, had no evidence of peritonitis, had no thrombocytopenia, and were greater than 37 weeks postconception.

RESULTS

The 3 infants were monitored closely. There were no early or late problems observed attributable to this management.

CONCLUSION

Carefully selected clinically stable patients that have postoperative pneumatosis intestinalis or exhibit rectal bleeding may be successfully managed by reduced enteral feedings with no antibiotics. J Pediatr Surg 36:1820-1823.

Transcatheter closure of a large coronary artery fistula with Amplatzer duct occluder: a new approach

We report a new retrograde approach for the successful closure of a large right coronary artery fistula in a 27-year-old man using the Amplatzer duct occluder. The device was deployed through a coronary angioplasty-guiding catheter that had been advanced through the aorta and the dilated right coronary artery into the fistula. This method simplified the procedure by eliminating the need for making a femoral artery-to-femoral vein wire loop.

Massive rectal bleeding due to jejunal and colonic tuberculosis

A case of massive rectal bleeding due to colonic tuberculosis in advanced pregnancy with intrauterine foetal death is reported. Patient was treated with resection of the left colon and left transverse end colostomy with closure of the rectal stump. Hysterotomy for the removal of the dead foetus was performed. The patient improved in health with antitubercular treatment. The colorectal anastomosis was performed after 4 months. Massive rectal bleeding in intestinal tuberculosis, though rare should be kept in mind.

Angioplasty through a stent side door

Angioplasty was performed by entering a Gianturco-Roubin stent from the side through the coils of a previously-implanted hanging stent in an ostial lesion in a saphenous vein graft. No complications and no visible damage occurred to the stent. Although this method carries a possible risk of entrapment or damage to the stent, it is feasible when other options have failed.

Six month follow-up of fourteen victims with short-term exposure to chlorine gas

Fourteen cases, 5 with pre-existing COAD, exposed to up to 30 p.p.m. chlorine gas in an accidental leakage, were followed up clinically, radiologically and by spirometry at 2 weeks, 4 weeks, 8 weeks and 6 months. All the patients were asymptomatic by 2 weeks and did not reveal any radiological abnormality. The FVC, FEV1 and FVC observed/predicted improved at 4 weeks (p less than 0.05, p less than 0.05, p less than 0.01) and the improvement in FEF0.25-0.75 reached statistical significance (p less than 0.05) at 6 months. The mean improvement in FVC was 0.84 l and FEV1 was 0.6 l at 4 weeks. The 5 patients with pre-existing COAD did not show any evidence of additional lung damage. The observations have been consistent with acute tracheobronchitis with trends towards complete recovery.