Closed-incision negative pressure therapy as a strategy to reduce sternal wound infection in identified high-risk patients: a multicentre propensity matched study

OBJECTIVES

The premise of this retrospective study was to evaluate the intraoperative use of closed-incision negative pressure therapy (ciNPT) to help reduce the incidence of postoperative sternal wound infections in multimorbid patients with an elevated risk of developing a sternal wound infection post cardiac surgery versus a cohort that received standard-of-care dressings.

METHODS

Data for all adult patients were collected from each cardiothoracic surgery unit across 3 hospitals in the United Kingdom. High-risk patients had 2 or more recognized risk factors. Fisher's exact test (two-tailed) and unpaired t-test were used to help analyse categorical and continuous data. Propensity matching was performed to compare the 2 groups.

RESULTS

A total of 5,288 patients who had cardiac surgery were included. Propensity matching led to 766 matched cases. There were significantly fewer sternal wound infections in the ciNPT group [43 (5.6%) vs 119 (15.5%) cases; P = 0.0001], as well as fewer deep sternal wound infections [14 (1.8%) vs 31 (4.0%) cases; P = 0.0149] and superficial sternal wound infections [29 (3.8%) vs 88 (11.4%) cases; P = 0.0001]. A higher mean length of stay in the ciNPT group was statistically significant (11.23 ± 13 vs 9.66 ± 10 days; P = 0.0083) as was a significantly higher mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (11.143 ± 13 vs 8.094 ± 11; P = 0.0001). A statistically significant higher readmission to the intensive care unit due to sternal wound infection was noted for the controls [16 (2.08%) vs 3 (0.39%) readmissions; P = 0.0042].

CONCLUSIONS

The ciNPT appears to be an effective intervention to help reduce the incidence of sternal wound infection in high-risk individuals undergoing cardiac surgery.

An exploratory cost-effectiveness analysis of a novel tissue valve compared with mechanical valves for surgical aortic valve replacement in subgroups of people aged 55-64 and 65+ with aortic stenosis in the UK

OBJECTIVE

Exploratory analysis to conceptualize and evaluate the potential cost-effectiveness and economic drivers of using a novel tissue valve compared with mechanical heart valves for surgical aortic valve replacement (SAVR) in people aged 55-64 and 65+ with aortic stenosis (AS) from a National Health Service (NHS) UK perspective.

METHODS

A decision-analytic model was developed using a partitioned survival model. Parameter inputs were obtained from published literature. Deterministic and probabilistic sensitivity analyses (DSA and PSA) were conducted to explore the uncertainty around the parameters.

RESULTS

The novel tissue valve was potentially associated with higher quality-adjusted life years (QALYs) of 0.01 per person. Potential cost savings were greatest for those aged 55-64 (£408) versus those aged 65+(£53). DSA indicated the results to be most dependent on relative differences in general mortality, procedure costs, and reoperation rates. PSA estimated around 75% of the iterations to be cost-effective at £20,000 per QALY for those aged 55-64, and 57% for those aged 65+.

CONCLUSIONS

The exploratory analysis suggests that the novel tissue valve could be a cost-effective intervention for people over the age of 55 with AS who are suitable for SAVR in the UK.

Reverse Myocardial Remodeling Following Valve Repair in Patients With Chronic Severe Primary Degenerative Mitral Regurgitation

OBJECTIVES

The aims of this study were to quantify preoperative myocardial fibrosis using late gadolinium enhancement (LGE), extracellular volume fraction (ECV%), and indexed extracellular volume (iECV) on cardiac magnetic resonance; determine whether this varies following surgery; and examine the impact on postoperative outcomes.

BACKGROUND

Myocardial fibrosis complicates chronic severe primary mitral regurgitation and is associated with left ventricular dilatation and dysfunction. It is not known if this nonischemic fibrosis is reversible following surgery or if it affects ventricular remodeling and patient outcomes.

METHODS

A multicenter prospective study was conducted among 104 subjects with primary mitral regurgitation undergoing mitral valve repair. Cardiac magnetic resonance and cardiopulmonary exercise stress testing were performed preoperatively and ≥6 months after surgery. Symptoms were assessed using the Minnesota Living With Heart Failure Questionnaire.

RESULTS

Mitral valve repair was performed for Class 2a indications in 65 patients and Class 1 indications in 39 patients. Ninety-three patients were followed up at 8.8 months (interquartile range: 7.4 months-10.6 months). Following surgery, there were significant reductions in both ECV% (from 27.4% to 26.6%; P = 0.027) and iECV (from 17.9 to 15.4 mL/m²; P < 0.001), but the incidence of LGE was unchanged. Neither preoperative ECV% nor LGE affected postoperative function, but iECV predicted left ventricular end-systolic volume index (β = 1.04; 95% CI: 0.49 to 1.58; P < 0.001) and left ventricular ejection fraction (β = -0.61; 95% CI: -1.05 to -0.18; P = 0.006). Patients with above-median iECV of ≥17.6 mL/m² had significantly larger postoperative values of left ventricular end-systolic volume index (30.5 ± 12.7 mL/m² vs 23.9 ± 8.0 mL/m²; P = 0.003), an association that remained significant in subcohort analyses of patients in New York Heart Association functional class I.

CONCLUSIONS

Mitral valve surgery results in reductions in ECV% and iECV, which are surrogates of diffuse myocardial fibrosis, and preoperative iECV predicts the degree of postoperative remodeling irrespective of symptoms. (The Role of Myocardial Fibrosis in Degenerative Mitral Regurgitation; NCT02355418).

Myocardial fibrosis in asymptomatic and symptomatic chronic severe primary mitral regurgitation and relationship to tissue characterisation and left ventricular function on cardiovascular magnetic resonance

BACKGROUND

Myocardial fibrosis occurs in end-stage heart failure secondary to mitral regurgitation (MR), but it is not known whether this is present before onset of symptoms or myocardial dysfunction. This study aimed to characterise myocardial fibrosis in chronic severe primary MR on histology, compare this to tissue characterisation on cardiovascular magnetic resonance (CMR) imaging, and investigate associations with symptoms, left ventricular (LV) function, and exercise capacity.

METHODS

Patients with class I or IIa indications for surgery underwent CMR and cardiopulmonary exercise testing. LV biopsies were taken at surgery and the extent of fibrosis was quantified on histology using collagen volume fraction (CVFmean) compared to autopsy controls without cardiac pathology.

RESULTS

120 consecutive patients (64 ± 13 years; 71% male) were recruited; 105 patients underwent MV repair while 15 chose conservative management. LV biopsies were obtained in 86 patients (234 biopsy samples in total). MR patients had more fibrosis compared to 8 autopsy controls (median: 14.6% [interquartile range 7.4-20.3] vs. 3.3% [2.6-6.1], P < 0.001); this difference persisted in the asymptomatic patients (CVFmean 13.6% [6.3-18.8], P < 0.001), but severity of fibrosis was not significantly higher in NYHA II-III symptomatic MR (CVFmean 15.7% [9.9-23.1] (P = 0.083). Fibrosis was patchy across biopsy sites (intraclass correlation 0.23, 95% CI 0.08-0.39, P = 0.001). No significant relationships were identified between CVFmean and CMR tissue characterisation [native T1, extracellular volume (ECV) or late gadolinium enhancement] or measures of LV function [LV ejection fraction (LVEF), global longitudinal strain (GLS)]. Although the range of ECV was small (27.3 ± 3.2%), ECV correlated with multiple measures of LV function (LVEF: Rho = - 0.22, P = 0.029, GLS: Rho = 0.29, P = 0.003), as well as NTproBNP (Rho = 0.54, P < 0.001) and exercise capacity (%PredVO2max: R = - 0.22, P = 0.030).

CONCLUSIONS

Patients with chronic primary MR have increased fibrosis before the onset of symptoms. Due to the patchy nature of fibrosis, CMR derived ECV may be a better marker of global myocardial status. Clinical trial registration Mitral FINDER study; Clinical Trials NCT02355418, Registered 4 February 2015, https://clinicaltrials.gov/ct2/show/NCT02355418.

Production of organic fertilizer from olive mill wastewater by combining solar greenhouse drying and composting

Olive mill wastewater (OMW) is generated during the production of olive oil. Its disposal is still a major environmental problem in Mediterranean countries, despite the fact that a large number of technologies have been proposed up to date. The present work examines for the first time a novel, simple and low-cost technology for OMW treatment combining solar drying and composting. In the first step, OMW was dried in a chamber inside a solar greenhouse using swine manure as a bulking agent. The mean evaporation rate was found to be 5.2 kg H₂O/m²/d for a drying period of 6 months (February-August). High phenol (75%) and low nitrogen (15%) and carbon (15%) losses were recorded at the end of the solar drying process. The final product after solar drying was rich in nutrients (N: 27.8 g/kg, P: 7.3 g/kg, K: 81.6 g/kg) but still contained significant quantities of phenols (18.4 g/kg). In order to detoxify the final product, a composting process was applied as a second step with or without the use of grape marc as bulking agent. Results showed that the use of grape marc as a bulking agent at a volume ratio of 1:1 achieved a higher compost temperature profile (60 °C) than 2:1 (solar drying product: grape marc) or no use (solar drying product). The end product after the combination of solar drying and composting had the characteristics of an organic fertilizer (57% organic carbon) rich in nutrients (3.5% N, 1% P, 6.5% K) with quite low phenol content (2.9 g/kg). Finally, the use of this product for the cultivation of pepper plants approved its fertility which was found similar with commercial NPK fertilizers.

A prospective study examining the role of myocardial Fibrosis in outcome following mitral valve repair IN DEgenerative mitral Regurgitation: rationale and design of the mitral FINDER study

Background

The optimal management of chronic severe primary degenerative mitral regurgitation (MR) is to repair the valve but identification of the optimal timing of surgery remains challenging. Current guidelines suggest ‘watchful waiting’ until the onset of symptoms or left ventricular (LV) dysfunction but these have been challenged as promoting ‘rescue surgery’. Better predictors are required to inform decision-making in relation to the necessity and timing of surgery. Chronic volume overload is a stimulus for adverse adaptive LV remodelling. Subclinical reduction in LV strain before mitral repair predicts a fall in LV ejection fraction following surgery and is thought to reflect the development of myocardial fibrosis in response to chronic volume overload. Myocardial fibrosis can be detected non-invasively using cardiac magnetic resonance (CMR) imaging techniques as an expansion of the extracellular volume (ECV).

Methods/design

This study investigates whether: 1) patients with above median ECV will have smaller reduction in end-systolic volume index (as a measure of the degree of reverse LV remodelling) on CMR following mitral valve repair, compared to those with below median ECV; and 2) higher ECV on CMR, validated through histology, adversely impacts upon post-operative complications and symptomatic improvement following surgery.

This is a multi-centre, prospective, cross-sectional comparison of patients prior to and 9 months following surgery for chronic severe primary degenerative MR. To establish the natural history of ECV in MR, an additional cohort of patients with asymptomatic MR who do not wish to consider early repair will be followed. Investigations include CMR, cardiopulmonary exercise test, stress echocardiography, signal-averaged electrocardiogram, 24-h electrocardiogram monitoring, laboratory tests and patient-reported outcome measures. Patients undergoing surgery will have cardiac biopsies performed at the time of mitral valve repair for histological quantification of fibrosis.

Discussion

This study will advance our understanding of ventricular remodelling in MR, its impact on patient symptoms and ventricular response following surgery. Establishing the link between myocardial fibrosis (measured on CMR and validated through histology), with early ventricular dysfunction, will offer physicians a novel non-invasive biomarker that can further inform the timing of surgery.

Trial registration

This trial was registered at ClinicalTrials.gov (NCT02355418) on 30th November 2015.

The outcomes of triple-valve surgery: eleven years' experience from a single center

BACKGROUND AND AIM OF THE STUDY

Triple-valve surgery is a challenging and complex procedure with significant risk, even at centers experienced at performing such operations. The study aim was to investigate the early and late outcomes of this surgery, performed at a single center for the past 11 years.

METHODS

A total of 45 consecutive patients (19 males, 26 females; mean age 69.42 +/- 12.72 years) underwent triple-valve surgery at the authors' institution between 2000 and 2011. The mean logistic EuroSCORE was 22.46 +/- 12.8%. The most common aortic valve pathology was calcific degeneration (40%), while the mitral valves were mostly rheumatic (31%) or degenerative (26%). The tricuspid valve pathology was functional regurgitation in 64% of patients. The aortic valve procedures were all replacements, while the mitral valves were either repaired (n = 20) or replaced (n = 25). The tricuspid valves were almost exclusively repaired (n = 43). Univariate and multivariate analyses were performed to highlight predictors of mortality. A Kaplan-Meier analysis was also performed.

RESULTS

The operative mortality was 8.9% (n = 4). Survival at one, three, and five years was 91%, 85.5% and 66.4%, respectively. Morbidity was not particularly high: the incidence of all postoperative neurological complications was 13%, that of transient renal impairment was 18%, and pacemaker implantation 8.9%.

CONCLUSION

The results of triple-valve surgery were considerably improved compared to historical reports. Early mortality was close to that occurring after less complex procedures, while late survival was comparable to that after single-valve surgery. It is believed that the best results are achieved by centers experienced in valve procedures. Compared to older studies, rheumatic disease was not the most frequent requirement for of triple-valve surgery among the present patients.

Glutathion-S-Transferase P1 polymorphisms association with broncopulmonary dysplasia in preterm infants

BACKGROUND

Oxidative stress, characterized by the excretion of pre-oxidative and anti-oxidative proteases, has a key role in the pathogenesis of bronchopulmonary dysplasia (BPD). One of the many host anti-oxidant enzymes is glutathione-S-transferase P1 (GSTP1), with three polymorphic alleles having been identified: homozygous ile, heterozygous ile/val and homozygous val isomorph. The aim of this study was to examine the genetic predisposition to BPD in the GSTP1 polymorphisms.

METHODS

A prospective case-control study was carried out in the 2nd Neonatal Intensive Care Unit of Aristotle University in Thessaloniki, Greece during 2008. The genetic polymorphisms of GSTP1 in 28 preterms <32 weeks gestational age (GA) with BPD compared to 74 controls (33 preterms without BPD and 41 healthy terms) were examined.

RESULTS

The homozygous ile isomorph was predominant in all groups (preterms with BPD: 82%, preterms without BPD: 70%, healthy terms: 78%), followed by the heterozygous ile/val (14%, 18% and 20% respectively) and the homozygous val isomorph (4%, 12% and 2% respectively). The homozygous ile isomorph was also identified in the majority of preterms with mild (80%), moderate (100%) and severe (73%) BPD. The GSTP1 genetic distribution did not differ between the groups and GSTP1 polymorphisms were not associated with the severity of BPD.

CONCLUSIONS

This study could not confirm an association between GSTP1 polymorphisms and the development of BPD or the severity of the disease.

Giant thoracoabdominal ganglioneuroblastoma in a 17-year-old patient

The most common malignant neurogenic tumors in children are neuroblastic tumors, classified as ganglioneuroblastoma or neuroblastoma. Ganglioneuroblastomas usually occur at the sympathetic ganglia in the mediastinum, whereas neuroblastomas occur in the abdominal cavity. We describe a case of large posterior mediastinal ganglioneuroblastoma extending from the aortic arch to the left renal hilum in a 17-year-old boy. Despite chemotherapy, post-treatment computed tomography showed disease progression. The patient underwent a thoracolaparotomy incision and excision of the tumor. These malignant mediastinal tumors can potentially grow to a very large size. If alternative treatment has failed, resection can be accomplished with relative safety.

Psychotic symptoms in normal pressure hydrocephalus

Normal Pressure Hydrocephalus due to idiopathic aqueductal stenosis is a chronic abnormal accumulation of cerebrospinal fluid in the cerebral ventricles caused by an obstruction in the Sylvian aqueduct. This leads to a dilatation of the ventricular system and to subsequent damage of the adjacent parenchyma. Although NPH typically presents with the progressive 'triad' of cognitive impairment, gait disturbance and urinary incontinence, it has been described that it rarely manifests in the form of predominant psychotic symptoms. It has been suggested that thought and perceptual disorders could develop secondary to the damage caused by NPH. Although precise anatomical correlates have not yet been established, certain cerebral regions -primarily the frontal cortex, mesencephalic and diencephalic structures of the brain- have been implicated in the pathogenesis of hydrocephalic psychosis. Because frontal lobe lesions are traditionally known to facilitate one's inability to integrate and correct perceptual distortions in the face of contradictory evidence, frontal lobe dysfunction may be integral in delineating the etiology of delusions in NPH. We present the case of a 30-year-old female, admitted involuntarily to our acute psychiatric department because she exhibited aggressive behavior while being in an agitated state with delusions of persecution. Her neurological examination disclosed subtle bradykinesia. Neuropsychological batteries and intelligence testing revealed mild cognitive impairment and a CT scan showed considerable dilatation of the ventricular system due to idiopathic aqueductal stenosis. While a conservative approach was chosen for the treatment of NPH, our patient was initiated on 2nd generation antipsychotics showing marked improvement of her psychiatric symptomatology. The atypical presentation of hydrocephalus in the aforementioned case underlines the necessity to thoroughly investigate the possible presence of an underlying organic factor in those patients who present with predominant psychotic symptoms in association with soft non-localising neurological signs and mild cognitive deficits. Furthermore, our patient's marked improvement indicates that, in cases where the primary cause is treated conservatively, hydrocephalic psychosis could respond to 2nd generation antipsychotics. In light of this case report, we reviewed past and present literature on the matter.

Assessment of lung ventilation in infants with respiratory distress syndrome using electrical impedance tomography

AIM

The aim of the present study was to determine immediate changes of global and regional lung function after exogenous surfactant administration in mechanically ventilated infants with respiratory distress syndrome (RDS) using electrical impedance tomography (EIT) measurements.

MATERIALS AND METHODS

A prospective study was conducted in a Neonatal Intensive Care Unit at a university hospital. Seventeen preterm infants (<12 hours old) suffering from RDS were included in this study. Interventions taken were low-pressure recruitment maneuver, surfactant administration and minimal adjustments in ventilator settings. Repeated EIT measurements (401 in total) were performed before and after (15 min - 30 min) surfactant administration. Global lung function changes were assessed with two markers, namely absolute resistivity (AbsR) and normalized impedance change (ΔZ); redistribution of regional lung ventilation was assessed as well. Airway pressure and arterial blood gases were recorded.

RESULTS

Surfactant administration resulted in a statistically significant increase of both the AbsR and ΔZ markers. Moreover, there was a ventilation shift towards dorsal - dependent lung areas with less asymmetry in the right-to-left air distribution.

CONCLUSIONS

Surfactant administration in the recruited lung with RDS modifies regional ventilation, as assessed by EIT, contributing to a more homogeneous air distribution. Furthermore, significant changes in EIT markers reflect improvement of global lung function after surfactant administration.

The use of Nitinol clips for primary sternal closure in cardiac surgery

PURPOSE

Deep sternal wound complications after cardiac surgery have an incidence of 2 to 8% and carry a significant mortality. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips on the incidence of postoperative deep sternal wound complications.

METHODS

We retrospectively reviewed 1119 consecutive patients that underwent major cardiac surgery via median sternotomy in our centre. Sternal closure was performed using Nitinol clips in 235 patients (Group I) and standard stainless steel wires in 884 patients (Group II). The risk factors that were identified between the two groups were age, EuroSCORE, body mass index, diabetes and pulmonary comorbidity.

RESULTS

The overall incidence of deep sternal wound complications was 2.2% (25/1119).The incidence was higher in Group II (2.3%) compared to Group I (1.7%) (p = 0?8).Mechanical sternal dehiscence occurred in 2 patients in Group II. Mortality related to sternal wound complications was 8% (2/21) in Group II whereas in Group I was 0%.

CONCLUSION

The incidence of sternal wound complications and the mortality related to them were lower in patients undergoing sternal closure with Nitinol clips. A randomized study to further evaluate the possible advantages of Nitinol clips is warranted.

Is brain death diagnosis in newborns feasible?

Brain death as the irreversible and permanent loss of cerebral and brainstem function, is relatively uncommon among newborns who need life support. It is considered the result of an acute and irreversible central nervous system insult. Asphyxia, severe intracranial hemorrhage and infection are the most common causes of brain death in children. BD diagnosis is usually based on clinical criteria. Because of major differences of brain function in this age group, brain death should be established with extreme caution. Comparative to adults' longer observational periods (at least 24 hours apart) and specific neurodiagnostic tests, by at least two expert physicians, are needed to ascertain an irreversible loss of brain function. The objective of this article is to present current guidelines for BD determination in newborns and to refer their application in Greece.

An unusual complication from hemostatic packing to control bleeding during cervical mediastinoscopy and an off-pump approach for the later exploration of the superior vena caval injury

Cervical mediastinoscopy has been widely used and is considered a safe method for the histologic diagnosis and staging of many conditions. Hemorrhage still remains one of the main possible complications, and hemostasis is usually achieved without any further surgical intervention. We present a previously unreported complication of absorbable hemostatic gauze packing, which led to superior vena caval injury and multiple pulmonary emboli, necessitating further surgical repair with the use of a veno-venous shunt.

Identification of a mutation in the MTM1 gene, associated with X-linked myotubular myopathy, in a Greek family

X-linked myotubular myopathy (XLMTM) is a rare congenital myopathy, usually characterized by severe hypotonia and respiratory insufficiency at birth, in affected, male infants. The disease is causally associated with mutations in the MTM1 gene, coding for phosphatase myotubularin. We report a severe case of XLMTM with a novel mutation, at a donor splicing site (c.1467+1G) previously associated with severe phenotype. The mutation was also identified in the patient's mother, providing an opportunity for sound genetic counseling.

Electrical Impedance Tomography: a new study method for neonatal Respiratory Distress Syndrome?

Treatment of cardiorespiratory system diseases is a procedure that usually demands data collection on terms of the anatomy and the operation of the organs that are under study. Electrical Impedance Tomography (EIT) is an alternative approach, in comparison to existing techniques. With EIT electrodes are placed in the perimeter of the human body and images of the estimated organ are reconstructed, using the measurement of its impendence (or resistance) distribution and determining its alteration through time, while at the same time the patient is not exposed to ionizing radiation. Its clinical use presupposes the correct placement of the electrodes over the perimeter of the human body, the rapid data collection and electrical safety. It is a low cost technique and it is implemented near the patient. It is able to determine the distribution of ventilation, blood supply, diffused or localized lung defects, but it can also estimate therapeutic interventions or alteration to assisted ventilation of the neonate. EIT was developed at the beginning of the 1980s, but it has only recently begun to be implemented on neonates, and especially in the study of their respiratory system function. The low rate of image analysis is considered to be a drawback, but it is offset by the potential offered for the estimation of lungs' function (both under normal and pathological conditions), since ventilation and resistance are two quite similar concepts. In this review the most important studies about EIT are mentioned as a method of estimating respiratory distress syndrome in neonates. In terms of the above mentioned development, it is supposed that this technique will offer a great amount of help to the doctor in his / her estimations of the cardiorespiratory system and to his / her selection of the best intervening strategies.

Paliperidone augmentation for refractory obsessive-compulsive disorder: A case report

Introduction

Despite the substantial clinical improvements provided by the pharmacologic and cognitive-behavior therapies of OCD, it has been estimated that 40%–60% of patients still remains refractory to conventional treatment.

Objectives

Medication augmentation can be an effective and well-tolerated short-term treatment strategy for non-responders to first-line pharmacotherapy of obsessive-compulsive disorders.

Aims

To investigate the efficacy of paliperidone as augmenting agent in the treatment of resistant OCD patient.

Methods

In the present case, we present a 6 months follow-up of an obsessive-compulsive patient treated with paliperidone ER and fluvoxamine. Paliperidone ER was started at 6 mg/day and increased up to a maximum of 12 mg/day. The clinical symptoms were measured by Y-BOCS and efficacy measures with CGI and PSP scale scores.

Results

We found that obsessive-compulsive symptoms improved after 4weeks. Patient showed a significant improvement over the 6 months follow-up for Yale-Brown Obsessive Compulsive Scale total score at week 24 as compared with baseline (from a score of 34 to a score of 12). A significant improvement in the mean PSP scale score was also seen and “much improved” on the CGI score from baseline to end point. A mean bodyweight change of ≤2 kg over the 24-week study period observed, but there were no clinically meaningful changes in glucose, insulin and blood lipid levels. There was no adverse event reported after the augmentation with paliperidone.

Conclusions

Adding paliperidone to SSRIs could be a valid strategy for treatment-resistant OCD patients and additional efficacy studies and randomized, double-blind studies are needed.

Factitious disorder case series with predominant psychological signs and symptoms

Introduction

Patients with factitious disorder intentionally produce or feign signs of medical or mental disorders. The only apparent objective of this behavior is to assume the role of a patient without an external incentive. The high rate of comorbidity with other psychiatric disorders together with the knowledge that factitious disorder lies on a continuum between somatoform disorders and malingering renders the early detection and diagnosis of cases with feigned psychological signs and symptoms more demanding.

Objective and method

Poor documentation of factitious disorder with predominant psychological signs and symptoms in the current literature reveals a blind spot in the diagnostic approach. With this in mind three cases were followed and reviewed to illustrate the elusive character of this clinical entity and demonstrate the importance of its early consideration in the differential diagnosis.

Results

Three patients presented to our acute psychiatric department with an extensive constellation of mood and psychotic symptoms. All patients underwent a thorough neuropsychological and medical evaluation. The diagnosis of factitious disorder was mainly based on their inconclusive mental status examination which could not definitively support the presence of another psychiatric or medical disorder, on the observation that their behavior on the psychiatric unit proved inconsistent with their chief complaints and on the past history from collateral sources which confirmed a pattern of multiple hospitalizations.

Conclusions

Factitious disorder should be considered in patients with inconsistent psychiatric presentations and negative diagnostic results who are high utilizers of acute care facilities such as the emergency room and inpatient services.

Massive Subcutaneus Emphysema following Endoscopic Retrograde Cholangiopancreatography with Sphincterotomy

Although endoscopic retrograde cholangiopancreatography (ERCP) is an effective procedure for the diagnosis and treatment of the pancreatic and extrahepatic biliary tract diseases, it is still related with several complications. A female patient who underwent an ERCP with sphincterotomy developed massive subcutaneous emphysema along with pneumomediastinum and pneumoperitoneum. Although mild respiratory distress occurred, based on the absence of intaabdominal leakage of gastrografin, the patient was managed conservatively. In conclusion, the retroperitoneal air collection related to ERCP is well recognized even in the absence of obvious perforation and may spread to adjacent areas, causing serious complications.

Pulmonary artery banding for hemi-truncus arteriosus in adulthood

Anomalous origin of the right pulmonary artery from the ascending aorta, also called hemi-truncus arteriosus, is a rare congenital cardiovascular malformation. Around 95% of the reported cases with hemi-truncus arteriosus present in infancy. We describe a case of a 41-year-old female presenting with a long-standing history of intermittent haemoptysis. Cardiac catheterisation confirmed the diagnosis of hemi-truncus arteriosus. The definitive treatment of hemi-truncus arteriosus in adulthood is an extremely high-risk procedure. We decided to perform palliative right pulmonary artery banding which represents a simple but effective procedure for the management of this complex condition.

Merkel cell carcinoma of the upper extremity: case report and an update

Background

Merkel cell carcinoma is a rare but aggressive cutaneous primary small cell carcinoma. It is commonly seen in elderly affecting the head, neck, and extremities. Macroscopically may be difficult to distinguish MCC from other small cells neoplasms especially oat cell carcinoma of the lung.

Case presentation

It is presented a case report concerning a 72 years old male with a MMC on the dorsal aspect of the right wrist. The patient underwent a diagnostic excisional biopsy and after the histological confirmation of the diagnosis a second excision was performed to achieve free margins. No postoperative radiation or adjuvant chemotherapy was given and within 9 years follow up no recurrence was reported.

Conclusion

Although most cases present as localized disease treatment should be definitive due to high rates of local or systemic recurrence. Treatment includes excision of the lesion, lymphadenectomy, postoperative radiotherapy and chemotherapy depending on the stage of the disease. Even when locoregional control is achieved close surveillance is required due to high rates of relapse.

Cholestatic hepatitis with severe systemic reactions induced by trimethoprim-sulfamethoxazole

Trimethoprim-Sulfomethoxazole (TMP-SMX) related hepatotoxicity and associated severe systemic reaction are not frequent and documented only in case reports. We report a case of a 30-year-old man, who underwent a 15-day therapy with TMP-SMX for urinary tract infection and two weeks later developed acute cholestatic hepatitis, fever and a skin rash followed by severe systemic reaction. He was admitted in Intensive Care unit and with supportive therapy and prednisolone administration, he showed subsequent improvement over a period of few days. He had fully recovered months later. All tests for other causes of liver disease were negative and his liver biopsy showed evidence of drug-induced hepatic injury.

Bivalirudin anticoagulation for cardiopulmonary bypass: an unusual case

The standard agent used for systemic anticoagulation during cardiopulmonary bypass is heparin. Alternative methods of anticoagulation are required for patients with heparin hypersensitivity. We present the case of a patient with heparin hypersensitivity who was anticoagulated with bivalirudin during cardiopulmonary bypass for coronary artery bypass grafting. This presented unusual challenges surrounding the monitoring of anticoagulation and the method of myocardial protection.

Low-molecular-weight heparin (enoxaparin) as adjuvant therapy in the treatment of active ulcerative colitis: a randomized, controlled, comparative study

BACKGROUND

Heparin could be beneficial to the treatment of active ulcerative colitis because of its anticoagulant, anti-inflammatory and immunomodulatory properties.

AIM

To evaluate the tolerability, safety and efficacy of low-molecular-weight heparin as adjuvant therapy in patients with active ulcerative colitis.

METHODS

Thirty-four adult patients with active ulcerative colitis were consecutively included in a prospective, randomized, comparative study, and were treated for 12 weeks. Eighteen patients in the 'standard therapy' group were treated with aminosalicylates and weekly tapered corticosteroids. Sixteen patients in the 'heparin therapy' group were treated with standard therapy plus enoxaparin 100 Anti-Xa IU/kg/day subcutaneously.

RESULTS

Seventeen patients in the 'standard therapy' group and 15 patients in the 'heparin therapy' group completed the study. Tolerability and compliance to therapy were excellent and no withdrawals were noted because of complications. There was a significant improvement in the disease severity in both groups (P<0.001), without any difference between them (P=not significant). Both treatment groups showed similar proportions of disease improvement (65% and 73%, respectively; P=not significant). There were no significant differences in inflammation (fibrinogen, ESR, CRP) and coagulation (thrombin-antithrombin complex, F1+2, D-dimers) parameters during and at the end of the study between treatment groups.

CONCLUSION

Adjuvant administration of low-molecular heparin in patients with active ulcerative colitis is safe and well tolerated, but no additive benefit over standard therapy for ulcerative colitis was noted.

Adefovir dipivoxil added to ongoing lamivudine therapy in patients with lamivudine-resistant hepatitis B e antigen-negative chronic hepatitis B

BACKGROUND

Long-term treatment with lamivudine is required to control viral replication in patients with hepatitis B e antigen-negative chronic hepatitis B, but is associated with a high rate of viral resistance. The role of adefovir dipivoxil in these patients has not been definitively evaluated.

AIM

To address the role of adefovir in the management of patients with lamivudine-resistant hepatitis B e antigen-negative chronic hepatitis B.

METHODS

Patients were assigned to receive adefovir 10 mg once daily plus ongoing lamivudine 100 mg once daily for 52 weeks. The primary end point was reduction in serum hepatitis B virus DNA level (hepatitis B virus DNA response). Secondary end points included the proportion of patients with undetectable hepatitis B virus DNA at week 52 (complete virological response) and the percentage of patients with normalization of alanine transferase level at week 52 (biochemical response).

RESULTS

A total of 49 consecutive patients were enrolled in this study. After 52 weeks of treatment, all patients had an hepatitis B virus DNA response and 57.1% had complete virological response. Biochemical response occurred in 75.6% of patients.

CONCLUSIONS

Administration of adefovir in patients with lamivudine-resistant chronic hepatitis B results in significant suppression of viral replication. Nevertheless, continuous therapy will probably be needed in order to maintain remission in these patients.

Bioequivalence study of two brands of enalapril tablets after single oral administration to healthy volunteers

OBJECTIVE

To compare the relative bioavailability and bioequivalence of 2 enalapril tablet formulations in healthy volunteers under fasting conditions.

METHODS

An open-label, single-dose, randomized, two-period, crossover trial with a 1-week washout period in 24 healthy volunteers. The 2 enalapril 20 mg tablet formulations used were Antiprex (Elpen, Greece) as test and Renitec (Vianex, Greece) as reference preparation. Serial blood samples were collected at 19 points for 36 h. Plasma samples were analyzed for enalaprilat, the pharmacologically active metabolite of enalapril, by a validated GC/MS assay. Pharmacokinetic parameters, such as AUC(0-infinity), AUC(0-t), C(max) T(max), t1/2 and MRT were calculated from plasma concentrations for both formulations. Statistical comparisons (ANOVA and 90% confidence intervals) of AUC(0-infinity), AUC(0-t) and C(max) data were evaluated after logarithmic transformation, and differences of T(max) were tested non-parametrically.

RESULTS

The parametric 90% confidence intervals of the geometric mean values of the test/reference ratios were 88.0 - 117.6% (point estimate: 101.8%) for AUC(0-infinity), 88.7 - 118.9% (point estimate: 102.7%) for AUC(0-t), and 91.0% - 123.4% (point estimate: 106.0%) for C(max) No statistically significant differences were found between the 2 preparations for T(max) t1/2 and MRT values.

CONCLUSIONS

From the results of the present study, it is concluded that the test and reference tablet formulations of enalapril are bioequivalent for both the extent and the rate of absorption and therefore the 2 products can be considered to be interchangeable in clinical practice.

Treatment of complications of hepatic hydatid disease by ERCP

BACKGROUND

The aim of this study was to evaluate the effectiveness of endoscopic sphincterotomy for preoperative and postoperative complications of hepatic hydatid disease.

METHODS

Nineteen patients underwent endoscopic treatment for complications of hepatic hydatid disease. Indications for ERCP in 5 patients treated before surgery (Group A) were obstructive jaundice in 1 and acute cholangitis in 4. In 14 patients treated after surgery (Group B), the indication was acute cholangitis in 6, obstructive jaundice 2, and persistent external drainage in 6 patients.

OBSERVATIONS

In group A, ERCP detected hydatid vesicles within the bile duct. All patients underwent endoscopic sphincterotomy and clearance of the duct with no complications. The 6 patients in Group B with persistent external drainage had biliary fistulas that resolved after endoscopic treatment within 10 to 20 days. Among the 8 patients with postoperative obstructive jaundice or acute cholangitis, 7 had cyst remnants obstructing the bile duct and 1 had findings of sclerosing cholangitis. All underwent endoscopic sphincterotomy and clearance of the bile duct without complications. After treatment, all patients, with the exception of the one with sclerosing cholangitis, remained asymptomatic.

CONCLUSION

Endoscopic sphincterotomy is a safe and effective treatment for biliary complications of hepatic hydatid disease.

Endoscopic band ligation of Dieulafoy-like lesions in the upper gastrointestinal tract

BACKGROUND AND STUDY AIMS

Endoscopic band ligation (EBL) is currently considered to be the treatment of choice for esophageal variceal bleeding. This study reports on the efficacy and safety of EBL in patients with Dieulafoy-like bleeding lesions in the upper gastrointestinal tract.

PATIENTS AND METHODS

Between December 1994 and February 2000, 23 patients with upper gastrointestinal tract hemorrhage (median age 58, range 28-75) were treated using EBL. EBL was used as a rescue therapy in four patients and as the initial treatment in 19 patients.

RESULTS

The site of bleeding was the stomach in 10 patients, Billroth II anastomosis in 10, the first part of the duodenum in one, the second part of the duodenum in one, and the jejunum in one patient. Endoscopic band ligation was successful in 22 of the 23 patients. The remaining patient, a young man with a Dieulafoy-like lesion in the jejunum, had recurrent bleeding on day 5 after EBL and underwent elective surgery.

CONCLUSIONS

Endoscopic band ligation is an effective and safe endoscopic treatment for Dieulafoy-like lesions. It is easy to use and relatively inexpensive.

Relative bioavailability of two isosorbide dinitrate sublingual tablet formulations administered as single doses in healthy subjects

OBJECTIVE

The purpose of this study was to evaluate the relative bioavailability and bioequivalence of a test and a reference sublingual tablet each containing 5 mg of isosorbide dinitrate in healthy volunteers.

METHODS

The study was conducted as an open-label, randomized, single-dose, two-period crossover design in 20 healthy volunteers with a washout period of 7 days, under fasting conditions. Plasma concentrations of the major active metabolite isosorbide 5-mononitrate were quantified, using a validated capillary gas chromatographic assay, with electron-capture detection. The pharmacokinetic parameters used to assess the bioequivalence of the two preparations were AUC(0-infinity) and AUC(0-infinity) for the extent of absorption and Cmax and tmax for the rate of absorption.

RESULTS

The calculated 90% confidence intervals of the geometric mean values of the test/reference ratios were 98.2% to 103.2% (point estimate; 100.7%) for AUC(0-infinity) 96.9% to 103.8% (point estimate; 100.3%) for AUC(0-infinity), and 87.9% to 98.2% (point estimate; 92.9%) for Cmax. No statistically significant difference was found for tmax and elimination half-life (t 1/2) values.

CONCLUSION

From the results of the present study, it is concluded that the test and reference isosorbide dinitrate sublingual preparations are bioequivalent in both extent and rate of absorption and it can be assumed that they are therapeutically equivalent and exchangeable in clinical practice.

Human Bioequivalence Study of Clarithromycin from Two Tablet Formulations after Single Oral Administration

OBJECTIVE

The objective of this study was to compare the relative bioavailability and bioequivalence of a test (Claromycin®, GA Pharmaceuticals) and a reference (Klaricid®, Abbott) tablet containing 500mg clarithromycin in healthy volunteers under fasting conditions.

METHODS

This was a nonblinded, single-dose, randomised, two-period, crossover study in 16 healthy volunteers conducted under fasting conditions. Plasma samples were analysed for clarithromycin by a validated high performance liquid chromatography assay with electrochemical detection.

RESULTS

One volunteer did not receive the reference tablet. The parametric 90% confidence intervals of the geometric mean values of the test/reference ratios analysed for 16 participants were 84.2 to 111.6% (point estimate 97.3%) for the area under the plasma concentration-time curve for time zero to infinity (AUC0-∞), 82.2 to 117.6% (point estimate 98.3%) for time zero to time t (AUC0-t), and 74.4 to 142.9% (point estimate 103.1%) for peak plasma concentration (Cmax). No statistically significant differences were found between the formulations for the time to reach Cmax (tmax) and elimination half-life values. When the results were analysed for 15 participants, the 90% confidence intervals were 84.1 to 111.9% for AUC0-∞, 82.8 to 119.1% for AUC0-t, and 74.1 to 143.6% for (Cmax)

CONCLUSIONS

From the results of this study, it is concluded that the two tablet preparations of clarithromycin are bioequivalent in both the extent and the rate of absorption.

Sensitivity and tolerance to ethanol in mouse lines selected for ethanol-induced hypothermia

Within-family selective breeding techniques have been used to create two lines of mice to be insensitive (HOT) and two lines to be sensitive (COLD) to the hypothermic effects of an acute 3.0-g/kg ethanol (EtOH) injection. Previous studies have found HOT mice to be relatively resistant to the development of tolerance to this effect, whereas COLD mice readily develop tolerance. The breeding program is currently in selected Generation 52, and the HOT and COLD mice differ by about 10 degrees C (average of both replicates) in their selected hypothermic response. Starting with selection Generation 20, separate lines of mice were inbred from the HOT-2 and COLD-2 selected lines, while selection continued for the original two replicate lines of HOT and COLD mice. To assess whether different dose treatments would produce differential tolerance development in the HOT and COLD selected lines, we administered different dose regimens across 5 days to HOT and COLD mice. The COLD mice developed tolerance while the HOT mice did not, regardless of total EtOH administered. In a separate study, we administered EtOH (3.0 g/kg) to mice for 3 days to assess a shorter tolerance paradigm. We also present here responses to the selection dose of 3.0-g/kg EtOH in the inbred HOT (IHOT-2) and COLD (ICOLD-2) mice tested after 41 generations of brother-sister mating. In addition, we report recent attempts to find doses of EtOH that would produce an equivalent initial hypothermic response in each of the six lines (HOT-1, COLD-1, HOT-2, COLD-2, ICOLD-2, and IHOT-2). When doses were selected to produce similar initial hypothermic sensitivity, tolerance was tested by giving three daily doses and examining the attenuation of the hypothermic response on the third day. All three COLD lines developed significant tolerance, while the HOT lines did not. The HOT and COLD mice provide a genetic model to study mechanisms mediating acute EtOH-induced hypothermia as well as tolerance development.

Relative bioavailability study of two nifedipine tablet formulations in healthy male volunteers

OBJECTIVE

To assess the bioequivalence of two oral formulations containing 10 mg of nifedipine. The test preparation were Macorel tablets, the reference preparation were Adalat tablets.

SUBJECTS, MATERIAL AND METHODS

The study was designed as a single-dose, three-period crossover randomized design to 18 non-smoker, healthy male volunteers under fasting conditions. Seventeen volunteers completed the study. Plasma samples were analyzed for nifedipine by HPLC after solid-phase extraction. The pharmacokinetic parameters used to assess the bioequivalence of the two formulations were AUC(0-infinite) and AUC(0-t) for the extent of absorption and Cmax and Tmax for the rate of absorption. Statistical comparisons of AUC(0-infinite) AUC(0-t), and Cmax data were evaluated after logarithmic transformation by two-way analysis of variance (ANOVA), and differences of Tmax were tested non-parametricaly.

RESULTS

Point estimates (90% confidence intervals) of the test/reference ratios were 97.4% (87.6%-108.3%) for AUC(0-infinite) 97.0% (85.6%-110.1%) for AUC0-t, and 107.7% (89.1%-130.7%) for Cmax. No statistically significant difference was found for Tmax and elimination half-life values.

CONCLUSION

Therefore, in accordance with the European Union bioequivalence requirements, the test and reference nifedipine preparations are bioequivalent for both the extent and the rate of absorption.

Bioequivalence of two tablet formulations of atenolol after single oral administration in healthy volunteers

The pharmacokinetic parameters of two oral formulations of 100 mg tablets of atenolol (CAS 29122-68-7; Azectol as test and another commercially available preparation as reference) were compared in an open-label, randomized, single oral dose, two-period cross-over design to 17 healthy volunteers under fasting conditions. Serial blood samples were collected prior to each administration and at 17 points within 36 h after dosing. Plasma concentrations of atenolol were measured by a validated HPLC assay with fluorometric detection. The parametric 90% confidence intervals of the geometric mean values of the test/reference ratios were 94.4% to 112.9% (point estimate: 103%) for AUC0-infinity, 93.7% to 112.8% (point estimate: 103%) for AUC0-36, and 88.3% to 112.1% (point estimate: 100%) for Cmax, within the acceptance criteria for bioequivalence (80%-125%). Tmax values were analyzed by the nonparametric Wilcoxon test and the difference was not statistically significant. Therefore, it is concluded that the test and reference atenolol formulations are bioequivalent for both the extent and the rate of absorption.

The hsp70 locus of Drosophila auraria (montium subgroup) is single and contains copies in a conserved arrangement

The restriction endonuclease pattern of a number of hsp70-homologous clones isolated from a library of heat shock cDNA from Drosophila auraria, a species belonging to the montium subgroup of the melanogaster species group, reveals two types of clones, A and B, differing in a single restriction site. Both types, as well as hsp70-specific probes derived from both hsp70 loci of Drosophila melanogaster, hybridize in situ with a single band at region 32 A of the 2L polytene arm, indicating a clustered organization of the hsp70 gene copies in D. auraria. The longest type B clone was sequenced and it was found that one strand contains an open reading frame (ORF) exhibiting great identity with a previously described hsp70 gene of D. auraria (now denoted as type A) and with its counterparts of D. melanogaster, while its second strand, unlike the type A clone, does not contain a long antiparallel coupled ORF (LAC ORF) because of a base substitution resulting in a premature stop codon. After additional data had been derived from isolation and characterization of hsp70-homologous genomic clones, together with Southern analysis of genomic DNA, we found that two hsp70 gene copies are present at the above locus of D. auraria with an inverted tandem repeat organization, while the presence of a third hsp70 gene is not clearly evident. The above results are compared with those observed at the homologous loci of some melanogaster subgroup species (D. melanogaster and its sibling species), in which, however, the hsp70 locus is duplicated, and with the more distantly related Dipteran Anopheles albimanus.

Heat shock gene expression during recovery after transient cold shock in Drosophila auraria (Diptera: Drosophilidae)

Newly synthesized polypeptides during recovery from prolonged cold treatment (0 degree to -1 degree C) of Drosophila auraria, a montium subgroup species, of the melanogaster species group, were analysed in denaturing polyacrylamide gels. In addition, during the cold shock recovery period, Northern analysis of the hsp83 mRNA was performed. A significant induction of two polypeptides, which exhibited electrophoretic mobilities, with the heat inducible 83 and 70 kD hsp83 and hsp70 was detected, but no such induction was evident in the so-called 'small' hsp genes. These results are compared and discussed with those observed in D. melanogaster.

Non-linear algorithms for processing biological signals

This paper illustrates different approaches to the analysis of biological signals based on non-linear methods. The performance of such approaches, despite the greater methodological and computational complexity is, in many instances, more successful compared to linear approaches, in enhancing important parameters for both physiological studies and clinical protocols. The methods introduced employ median filters for pattern recognition, adaptive segmentation, data compression, prediction and data modelling as well as multivariate estimators in data clustering through median learning vector quantizers. Another approach described uses Wiener-Volterra kernel technique to obtain a satisfactory estimation and causality test among EEG recordings. Finally, methods for the assessment of non-linear dynamic behaviour are discussed and applied to the analysis of heart rate variability signal. In this way invariant parameters are studied which describe non-linear phenomena in the modelling of the physiological systems under investigation.

The Drosophila montium subgroup species. Phylogenetic relationships based on mitochondrial DNA analysis

Mitochondrial DNA (mtDNA) restriction site maps for three Drosophila montium subgroup species of the melanogaster species group, inhabiting Indian and Afrotropical montium subgroup territories, were established. Taking into account previous mtDNA data concerning six oriental montium species, a phylogeny was established using distance-matrix and parsimony methods. Both genetic diversity and mtDNA size variations were found to be very narrow, suggesting close phylogenetic relationships among all montium species studied. The phylogenetic trees that were constructed revealed three main lineages for the montium subgroup species studied: one consisting of the Afrotropical species Drosophila seguyi, which is placed distantly from the other species, one comprising the north-oriental (Palearctic) species, and one comprising the southwestern (south-oriental, Australasian, Indian, and Afrotropical) species. The combination of the mtDNA data presented here with data from other species belonging to the melanogaster and obscura subgroups revealed two major clusters: melanogaster and obscura. The melanogaster cluster is further divided into two compact lineages, comprising the montium subgroup species and the melanogaster complex species; the species of the other complex of the melanogaster subgroup, yakuba, disperse among the obscura species. The above grouping is in agreement with the mtDNA size variations of the species. Overall, among all subgroups studied, the species of the montium subgroup seem to be the most closely related.

Order statistics learning vector quantizer

We propose a novel class of learning vector quantizers (LVQs) based on multivariate data ordering principles. A special case of the novel LVQ class is the median LVQ, which uses either the marginal median or the vector median as a multivariate estimator of location. The performance of the proposed marginal median LVQ in color image quantization is demonstrated by experiments.

Three computer methods to reconstruct pulpal blood vessels and nerves

This study describes three methods of computerized three-dimensional reconstruction of the main neurovascular pulpal bundle of human teeth, using serial cross-paraffin sections, digital image processing, and three-dimensional computer graphics. These methods are surface representation, representation by means of a stack of slices, and volume representation.