International survey on the perioperative management of pulmonary endarterectomy: the perfusion perspective.

INTRODUCTION: Pulmonary endarterectomy (PEA) is the most effective treatment available for chronic thromboembolic pulmonary hypertension (CTEPH). Patient selection, surgical technique and perioperative management have improved patient outcomes, which are traditionally linked to surgical and center experience. However, optimal perfusion care has not been well defined. The goal of the international survey was to better characterize the contemporary perfusion management of PEA and highlight similarities and controversies. METHOD: The combined caseload of 15 participating centers was 5,066 cases. Topics queried included materials and types of cardiopulmonary bypass (CPB) equipment, choice of prime, fluid management, deep hypothermia strategy, temperature management, treatment of acid-base abnormalities and intraoperative hematocrit as well as anticoagulation management for heparin-induced thrombocytopenia. CONCLUSION: Our assessment could provide a base for further advancement and may help design future studies to elucidate the impact of perfusion in this challenging field.

Eating problems in very low birthweight children are highest during the first year and independent risk factors include duration of invasive ventilation.

AIM: This study aimed to investigate the incidence and time course of eating problems in children born with a very low birthweight (VLBW) and to identify the perinatal risk factors. METHODS: We used a standard eating questionnaire to study 178 VLBW children, born between 1999 and 2005 at a median of 28.6 weeks' gestation and median birthweight of 1058 g, for the first 6 years of life. The control group comprised 74 children born full term. RESULTS: Just under a quarter of the VLBW children (24.7%) had eating problems before the age of one, and by the age of two, the cumulative incidence had increased to 28.6%. The 69 children born between 1999 and 2001 had eating problems up to the age of six, but 76.5% were resolved by the age of four. Independent risk factors were gestational age at birth, and duration of invasive ventilation and eating problems were associated with significantly poor growth. CONCLUSION: The incidence of eating problems in VLBW children was highest during the first year of life. Gestational age and the duration of invasive ventilation were independent risk factors, and eating problems contributed to continued growth failure. Eating problems require early recognition and intervention.

Long-term analysis of osseointegrated implants in non-smoker patients with a previous history of periodontitis.

AIM: To evaluate long-term clinical and radiographic parameters of osseointegrated implants in non-smoker patients with a previous history of chronic periodontitis. MATERIALS AND METHODS: Fifty-four screw-type implants with a moderately roughened surface and internal hexagonal implant-abutment connection were placed according to a two-phase protocol and 40 reference teeth were analysed at baseline, and after 5 and 10 years. Pocket probing depth (PPD), clinical attachment level (CAL) and bleeding on probing were analysed 6x/tooth in all teeth, implants and reference teeth. Radiographic peri-implant bone level was measured on the mesial and distal surfaces. The prevalence of peri-implantitis and the survival rate of the implants were assessed at the patient and implant levels. Data were analysed using descriptive statistics, Mann-Whitney U-test, and Wald Z-test, at α = 5%. RESULTS: In implants, the CAL at 5 years was 0.3 mm higher, and at 10 years 1.2 mm higher in comparison to baseline. The corresponding data for the reference teeth were 0 mm and 0.5 mm respectively. Multilevel testing showed statistical difference for PPD between implants and teeth over time. After 10 years, the mean mesial bone loss was 0.63 ± 0.26 mm, and the mean distal bone loss was 0.56 ± 0.25. The survival rates were 100% and 92.3% for the implants in the mandible and the implants in the maxilla respectively. CONCLUSIONS: Screw-type implants with internal hexagon placed in patients with a previous history of periodontitis attending a regular maintenance programme demonstrated stable clinical and radiographic results after 5 and 10 years.

Usefulness of N-acetylcysteine or ascorbic acid versus placebo to prevent contrast-induced acute kidney injury in patients undergoing elective cardiac catheterization: a single-center, prospective, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a serious complication of procedures requiring contrast media associated with rising costs, prolonged hospitalization, and increased mortality. The aim of this study was to assess whether prophylactic administration of standard dosages of intravenous N-acetylcysteine or ascorbic acid reduce the incidence of CI-AKI in patients with chronic renal insufficiency undergoing elective cardiac catheterization. METHODS: In a single-center, prospective, randomized, double-blind, placebo-controlled trial, the preventive effects of N-acetylcysteine and ascorbic acid were evaluated in 520 patients with chronically impaired renal function (serum creatinine ≥1.3 mg/dL) undergoing elective cardiac catheterization. The study drugs (600 mg N-acetylcysteine, 500 mg ascorbic acid, placebo) were administered intravenously twice (at 24 hours and 1 hour before the procedure). Serum creatinine, estimated glomerular filtration rate (eGFR) and serum urea were assessed at baseline and at 24 hours and 72 hours after contrast media exposure. CI-AKI was defined as a postangiographical increase in serum creatinine ≥0.5 mg/dL. Results. The incidence of CI-AKI was 27.6% in the N-acetylcysteine group (P=.20 vs placebo group) and in 24.5% in the ascorbic acid group (P=.11 vs placebo group). CI-AKI occurred in 32.1% of the placebo group. CONCLUSIONS: Standard doses of N-acetylcysteine and ascorbic acid did not prevent CI-AKI in patients at high risk undergoing cardiac catheterization with non-ionic, low-osmolality contrast agent.

Expression and secretion levels of Th1 and Th2 cytokines in patients with aggressive periodontitis.

The role of Th1 and Th2 cytokines in the pathogenesis of aggressive periodontitis has not been previously examined. The aim of this study was to analyse the expression and production of IL-2, IFN-γ, IL-4 and IL-13 in CD4+ cells from the peripheral blood of patients with aggressive periodontitis (AgP) and periodontally healthy controls. Gene expression was analysed in inactivated and activated CD4+ cells by real-time PCR. Cells were activated for 4, 8 and 24 h with anti-CD3/CD28 antibody, phytohemagglutinin (PHA), and Porphyromonas gingivalis (P.g.) outer membrane protein (OMP). Protein levels were measured in supernatants of activated CD4+ cells by bead-based immunoassay (CBA). Statistics were performed using U test (p < 0.05). In controls, IL-4 expression was increased in inactivated CD4+ cells (p = 0.05), and IFN-γ and IL-2 expressions were increased in activated CD4+ cells: IFN-γ with anti-CD3/anti-CD28, P.g. OMP and PHA (p < 0.05); IL-2 with P.g. OMP and PHA (p < 0.05). In patients, although IL-4 and IL-13 expressions were higher in activated CD4+ cells, there were no differences compared to controls. The production of IL-4 and IL-2 was higher in the patients' CD4+ cells activated with PHA (p < 0.05). Although the results showed a predominantly Th1 mRNA profile in activated CD4+ cells of controls, protein concentrations showed no clear Th1 or Th2 profiles. The functional pathways of the Th cell immune response in aggressive periodontitis are still not well understood in order to develop individualised diagnostic and treatment plans.

Anemia before coronary artery bypass surgery as additional risk factor increases the perioperative risk.

BACKGROUND: A negative relationship between anemia before coronary artery bypass graft (CABG) surgery and the perioperative mortality has been shown. We tried to clarify whether anemia only expresses an increased perioperative risk or is a risk factor per se in a two-institution database. METHODS: In the years 2005 and 2006, 185 of 3,311 patients undergoing isolated first-time CABG surgery had anemia defined as hematocrit less than 33% or Hb≤11 g/dL. Preoperative and postoperative data of patients having anemia and patients having normal hematocrit were compared using χ2-tests or Fisher's exact tests regarding structural group differences. To determine factors influencing perioperative mortality, methods of logistic regression were used. RESULTS: The 30-day mortality of anemic patients (12.9%) was significantly higher (p<0.001) than the mortality of nonanemic patients (2.2%). Patients having anemia, though, had a worse risk profile before surgery: high European System for Cardiac Operative Risk Evaluation values (median, 7 in anemic patients versus 4 in nonanemic patients), acute myocardial infarction (9.7% in anemic versus 2% in nonanemic patients), diabetes mellitus (45.4% in anemic versus 33.3% in nonanemic patients), and cardiogenic shock (5.4% in anemic versus 0.8% in nonanemic patients) were significantly more frequent in the anemic group. However, taking these risks in account, the logistic regression revealed preoperative anemia still to be a mortality-increasing factor in patients undergoing CABG surgery (odds ratio 3.727, confidence interval: 2.196 to 6.324). Furthermore, anemia was a risk factor for perioperative morbidity (major adverse cardiovascular events) after CABG surgery (odds ratio 2.199, confidence interval: 1.423 to 3.397). CONCLUSIONS: In our patient group undergoing CABG surgery, preoperative anemia increased the mortality risk by 3.4, even when taking the higher perioperative risk of anemic patients into consideration.

Dimethylarginine metabolism during acute and chronic rejection of rat renal allografts.

BACKGROUND: Dimethylarginines are inhibitors of NO synthesis and are involved in the pathogenesis of vascular diseases. In this study, we ask the question if asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) levels change during fatal and reversible acute rejection, and contribute to the pathogenesis of chronic vasculopathy. METHODS: The Dark Agouti to Lewis rat strain combination was used to investigate fatal acute rejection. Fischer 344 kidneys were transplanted to Lewis rats to study reversible acute rejection episode and the process of chronic rejection. Isograft recipients and untreated Lewis rats were used as controls. l-arginine derivatives were determined by HPLC, and ADMA-metabolizing enzymes were studied by quantitative RT-PCR and western blotting. RESULTS: Renal transplantation transiently increased dimethylarginine levels independent of acute rejection. ADMA plasma levels did not importantly differ between recipients undergoing fatal or reversible acute rejection, whereas SDMA was even lower in recipients of Fisher 344 grafts. In comparison to isograft recipients, ADMA and SDMA levels were slightly elevated during reversible, but not during the process of chronic rejection. Increased dimethylarginine levels, however, did not block NO synthesis. Interestingly, protein methylation, but not ADMA degradation, was increased in allografts. CONCLUSIONS: Our data do not support the concept that renal allografts are protected from fatal rejection by dimethylarginines. Dimethylarginines may play a role in triggering chronic rejection, but a contribution to vascular remodelling itself is improbable. In contrast, differential arginine methylation of yet unknown proteins by PRMT1 may be involved in the pathogenesis of acute and chronic rejection.

Accuracy of photographic assessment compared with standard anthropometric measurements in nonsynostotic cranial deformities.

OBJECTIVE: Anthropometric landmarks of the skull have traditionally been used to describe cranial deformities resulting from nonsynostotic plagiocephaly or brachycephaly. Recently, digital photography has become an important tool for characterizing facial and cranial pathologies. The purpose of this study was to compare standard anthropometric cranial measurements with measurements taken from cranial photographs. PATIENTS: Standardized digital images in the supracranial view and cranial anthropometric measurements were obtained from 122 children between the ages of 3 and 15 months. The photographs were assessed using Quick Ceph® software. The cephalic index and cranial vault asymmetry index were used to indicate the degree of cranial deformity. Children were classified into plagiocephaly, brachycephaly, and the combination of both. To determine interobserver variability, two clinicians separately measured the cephalic index and cranial vault asymmetry index from digital photographs in 70 infants of the plagiocephalic group. RESULTS: To compare interassay reliability for these methods of obtaining the cephalic index and cranial vault asymmetry index, the differences between photographically and anthropometrically derived values were plotted against anthropometrically derived values alone (Bland-Altman plots). The photographic method satisfied the limits of agreement (cephalic index, 7.51%; cranial vault asymmetry index, 6.57%) and showed slightly lower values represented by the respective bias (cephalic index, 1.79%; cranial vault asymmetry index, 3.03%). Comparison between observers revealed excellent agreement, detected by the intraclass correlation coefficient of .982 for the cephalic index and .946 for the cranial vault asymmetry index. CONCLUSION: Our results demonstrate that digital photography is a reliable tool for quantifying cranial deformities. Furthermore, it is rapid, noninvasive, and reproducible. However, we continue to use both methods in clinical practice.

Response of proopiomelanocortin and gonado- or lactotroph systems to in-vitro fertilisation procedures stress.

OBJECTIVE: To analyse for the first time the response of the corticotroph-type and the melanotroph-type pituitary proopiomelanocortin (POMC) system with regard to in-vitro fertilisation (IVF) treatment using self-developed highly specific non-cross-reacting radioimmunoassay. SETTING: University hospital. patients: A total of 28 patients undergoing IVF oocyte retrieval. Cross sectional exploratory study, one factorial design with repeated measurements on one factor, non-parametric tests. Blood was collected before anaesthesia (t(A)) (n=28) and immediately after oocyte retrieval (t(B)) (n=28). MAIN OUTCOME MEASURE(S): beta-endorphin immunoreactive material (IRM), acetyl-N-beta-endorphin IRM, beta-lipotropin IRM, ACTH, cortisol, estradiol, progesterone, prolactin, luteinizing hormone, and follicle-stimulating hormone. For determination of authentic beta-endorphin [beta-endorphin (1-31)] a highly specific two-site fluid phase immunoprecipitation radioimmunoassay was developed, which did not cross-react with any beta-endorphin derivative or any other opioid peptide tested. RESULTS: No response of acetyl-N-beta-endorphin IRM and of authentic beta-endorphin (1-31) was observed to oocyte retrieval in contrast to a significant increase of corticotroph-type proopiomelanocortin derivatives. A significant rise in prolactin plasma concentration indicates a pronounced lactotroph response to oocyte retrieval stress. No significant correlation between POMC derivates and prolactin and between POMC derivatives and gonadotropins or sexual steroids except for ACTH and progesterone and for beta-endorphin IRM and estradiol was observed. CONCLUSION: IVF treatment stress led to significant corticotroph-type POMC and lactotroph responses, but not to responses of authentic beta-endorphin or melanotroph-type POMC in women undergoing oocyte retrieval.

Sinus lift augmentation using autogenous bone grafts and platelet-rich plasma: radiographic results.

OBJECTIVES: Autologous bone grafting and sinus floor elevation is a widely accepted method for reconstruction of the atrophic maxilla. The aim of this investigation was to examine the influence of platelet-rich plasma (PRP) on bone grafting in sinus floor augmentation. STUDY DESIGN: A prospective, controlled, randomized study including 34 patients undergoing sinus augmentation before implant placement was designed. The intervention group had additional treatment with PRP. Radiographic imaging was performed by computerized tomography (CT) and panoramic radiography 4 months after augmentation and before implant placement. RESULTS: Bone density showed no significant increase when PRP was used in combination with autologous bone grafting compared with autologous bone alone. CONCLUSIONS: This study showed no positive effect of PRP on bone density in CT evaluation when used in sinus floor augmentation. Bone density in the CT showed no correlation to histomorphometric evaluation.

Response to delivery stress is not mediated by beta-endorphin (1-31).

OBJECTIVE: The aim of the study was to determine the reaction of the melanotroph and corticotroph-type pituitary proopiomelanocortin (POMC) response to vaginal delivery and caesarean section stress. Furthermore, the relationship between the release of pituitary POMC fragments, gonadotropins and sexual steroids were examined. STUDY DESIGN: Blood samples were obtained from 10 women in labour on arrival in the birth room (t(A)), at cervix dilatation of 5 cm (t(B)) and immediately after spontaneous delivery (t(C)) and in 16 patients undergoing elective caesarean section before induction of anaesthesia (t(B)) and immediately after delivery (t(C)). Samples were analysed for cortisol, ACTH, authentic beta-endorphin, beta-endorphin immunoreactive material (IRM), acetyl-N-beta-endorphin IRM (NAC), beta-lipotropin (beta-LPH) IRM, oestradiol (E(2)), progesterone (P), prolactin (PRL), FSH and LH. RESULTS: NAC representing the melanotroph-type pituitary POMC system did not increase during the course of caesarean section or spontaneous labour. In contrast, a significant increase of beta-endorphin IRM, beta-LPH IRM and ACTH were observed, representing an activation of the corticotroph-type POMC system. Highly significant correlations between POMC fragment concentrations during caesarean section and spontaneous labour were also observed. Sexual steroids (E(2) and P) decreased significantly. Except for beta-endorphin IRM and E(2) in course of spontaneous delivery no significant correlation was observed between POMC fragment and gonadotropins or sexual steroids. CONCLUSION: Caesarean section and spontaneous delivery activated the corticotroph but not the melanotroph POMC system.

A randomized clinical multicentre trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part III: patient factors and treatment outcome.

OBJECTIVE: Evaluation of effects of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects. MATERIAL AND METHODS: Fifty-one patients were recruited. In the intention-to-treat population 21 patients were allocated into the sequence left treatment with enamel matrix protein derivative (EMD) and right guided tissue regeneration (GTR) and 27 in the sequence left GTR and right EMD. Evaluated patient factors were: smoking, age, gender, hypertension and oral hygiene status. Outcome parameters included change of: (a) horizontal depth of the defect at the deepest point (b) distance from the fornix of the furcation to bone crest of the defect, (c) distance from stent to the bottom of the defect, (d) pocket depth and (e) attachment level at the middle of the furcation. RESULTS: In patients 54 years of age and older, in males, in non-smokers and in patients with "poor" hygiene EMD-treated sites showed a significant higher mean reduction of the parameters d (age), b (gender, hygiene) a (smoking, hygiene) when compared with sites treated with GTR. CONCLUSIONS: These data provided an indication of a possible effect of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects.