Design and implementation of the TRACIA: intracoronary autologous transplant of bone marrow-derived stem cells for acute ST elevation myocardial infarction.

OBJECTIVE: To describe the design of a protocol of intracoronary autologous transplant of bone marrow-derived stem cells for acute ST-elevation myocardial infarction (STEMI) and to report the safety of the procedure in the first patients included. METHODS: The TRACIA study was implemented following predetermined inclusion and exclusion criteria. The protocol includes procedures such as randomization, bone marrow retrieval, stem cells processing, intracoronary infusion of stem cells in the infarct-related artery, preand- post MRI, pre-and-post SPECT with radioisotope ventriculography, and clinical follow-up at 6 months. RESULTS: Eight patients with a diagnosis of acute STEMI and duration of symptoms of ?24 hours that were perfused successfully through primary percutaneous coronary intervention (PPCI) with a LVEF of ?45% were assigned randomly to two groups (n = 4 each). One group treated with stem cells and the other corresponded to the control group. Neither death, re-infarction, no need for revascularization or thrombosis of the stent were observed at follow-up. CONCLUSIONS: The initial experience at the Instituto Nacional de Cardiología Ignacio Chávez in the treatment of acute STEMI by means of autologous transplantation of bone marrow-derived stem cells is encouraging. Implementation was possible in the first eight patients with no complications.

Design and implementation of the TRACIA: intracoronary autologous transplant of bone marrow-derived stem cells for acute ST elevation myocardial infarction / Diseño e implementación del estudio TRACIA: Trasplante intracoronario Autológo de Células madre para Infarto Agudo del miocardio con elevación de segmento ST

Objective: To describe the design of a protocol of intracoronary autologous transplant of bone marrow-derived stem cells for acute ST-elevation myocardial infarction (STEMI) and to report the safety of the procedure in the first patients included. Methods: The TRACIA study was implemented following predetermined inclusion and exclusion criteria. The protocol includes procedures such as randomization, bone marrow retrieval, stem cells processing, intracoronary infusion of stem cells in the infarct-related artery, pre-and-post MRI, pre-and-post SPECT with radioisotope ventriculography, and clinical follow-up at 6 months. Results: Eight patients with a diagnosis of acute STEMI and duration of symptoms of <24 hours that were perfused successfully through primary percutaneous coronary intervention (PPCI) with a LVEF of <45% were assigned randomly to two groups (n = 4 each). One group treated with stem cells and the other corresponded to the control group. Neither death, re-infarction, no need for revascularization or thrombosis of the stent were observed at follow-up. Conclusions: The initial experience at the Instituto Nacional de Cardiología Ignacio Chávez in the treatment of acute STEMI by means of autologous transplantation of bone marrow-derived stem cells is encouraging. Implementation was possible in the first eight patients with no complications.

Objetivo: Describir el diseño y la implementación de un protocolo de transplante autólogo intracoronario de células madre derivadas de médula ósea en infarto agudo al miocardio con elevación del ST y reportar la seguridad del procedimiento en los primeros pacientes incluidos. Métodos: El estudio TRACIA se implementó con base en criterios de inclusión y exclusión predeterminados. El protocolo incluye la aleatorización, obtención de médula ósea, procesamiento de células madre, infusión intracoronaria de células madre, RM basal y al seguimiento, SPECT con ventriculografía radioisotópica basal y post-procedimiento, y seguimiento clínico a seis meses. Resultados: Ocho pacientes con diagnóstico de infarto agudo del miocardio con elevación del ST y duración de síntomas <24 horas que fueron reperfundidos exitosamente con angioplastia primaria y con fracción de expulsión <45%, fueron aleatorizados a dos grupos; uno de ellos fue tratado con células madre y el otro grupo permaneció como control. No se observó muerte, re-infarto, necesidad de revascularización o trombosis del Stent durante el seguimiento. Conclusiones: La experiencia inicial en el Instituto Nacional de Cardiología Ignacio Chávez en el tratamiento del infarto agudo del miocardio con elevación del ST mediante trasplante autólogo de células madre derivadas de médula ósea, es alentadora. La implementación sin complicaciones fue posible en los primeros ocho pacientes.

Subclavian artery stenosis: a review for the vascular medicine practitioner.

Peripheral artery disease assessment typically focuses on the evaluation of lower extremity symptoms and physical findings. Few practitioners consider the importance of upper extremity arterial disease; which, besides causing hand and arm symptoms, can be associated with significant neurologic and cardiac sequelae. A review of the existing literature through PubMed using the search term 'subclavian stenosis' was performed. The latest original articles, including clinical studies, case reports and limited reviews of this topic were adapted. A comprehensive article review focusing on the diagnostic and treatment approach for subclavian stenosis was prepared. In conclusion, vascular medicine practitioners including cardiologists and vascular surgeons caring for patients with arterial disease should routinely assess for subclavian stenosis. There are excellent screening tools and effective medical therapies which can be instituted if diagnosed early. When the need for revascularization arises, percutaneous modalities are favored given their proven long-term efficacy, decreased morbidity and mortality, and cost-effectiveness.

Multivessel coronary artery disease predicts mortality, length of stay, and pressor requirements after liver transplantation.

The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between August 1, 2004 and August 1, 2007 to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P = 0.046), increased length of stay (22 versus 15 days, P = 0.050), and postoperative pressor requirements (27% versus 4%, P = 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup.

The prevalence of genetic and serologic markers in an unselected European population-based cohort of IBD patients.

BACKGROUND AND AIM: The aetiology of inflammatory bowel disease (IBD) is unknown, but it has become evident that genetic factors are involved in disease susceptibility. Studies have suggested a north-south gradient in the incidence of IBD, raising the question whether this difference is caused by genetic heterogeneity. We aimed to investigate the prevalence of polymorphisms in CARD15 and TLR4 and occurrence of anti-Saccharomyces cerevisiae (ASCA) and antineutrophil cytoplasmic antibodies (pANCA) in a European population-based IBD cohort. METHODS: Individuals from the incident cohort were genotyped for three mutations in CARD15 and the Asp299gly mutation in TLR4. Levels of ASCA and pANCA were assessed. Disease location and behaviour at time of diagnosis was obtained from patient files. RESULTS: Overall CARD15 mutation rate was 23.9% for CD and 9.6% for UC patients (P < 0.001). Mutations were less present in the Scandinavian countries (12.1%) versus the rest of Europe (32.8%) (P < 0.001). Overall population attributable risk was 11.2%. TLR4 mutation rate was 7.6% in CD, 6.7% in UC patients and 12.3% in healthy controls (HC), highest among South European CD patients and HC. ASCA was seen in 28.5% of CD patients with no north-south difference, and was associated with complicated disease. pANCA was most common in North European UC patients and not associated with disease phenotype. CONCLUSION: The prevalence of mutations in CARD15 varied across Europe, and was not correlated to the incidence of CD. There was no association between mutations in TLR4 and IBD. The prevalence of ASCA was relatively low; however related to severe CD.

Does pregnancy change the disease course? A study in a European cohort of patients with inflammatory bowel disease.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) often affects patients in their fertile age. The aim of this study was to describe pregnancy outcome in a European cohort of IBD patients. As data are limited regarding the effect of pregnancy on disease course, our second objective was to investigate whether pregnancy influences disease course and phenotype in IBD patients. METHODS: In a European cohort of IBD patients, a 10-yr follow-up was performed by scrutinizing patient files and approaching the patients with a questionnaire. The cohort comprised 1,125 patients, of whom 543 were women. Data from 173 female ulcerative colitis (UC) and 93 Crohn's disease (CD) patients form the basis for the present study. RESULTS: In all, 580 pregnancies, 403 occurring before and 177 after IBD was diagnosed, were reported. The rate of spontaneous abortion increased after IBD was diagnosed (6.5% vs. 13%, p = 0.005), whereas elective abortion was not significantly different. 48.6% of the patients took medication at the time of conception and 46.9% during pregnancy. The use of cesarean section increased after IBD diagnosis (8.1% vs 28.7% of pregnancies). CD patients pregnant during the disease course, did not differ from patients who were not pregnant during the disease course regarding the development of stenosis (37% vs 52% p = 0.13) and resection rates (mean number of resections 0.52 vs 0.66, p = 0.37). The rate of relapse decreased in the years following pregnancy in both UC (0.34 vs 0.18 flares/yr, p = 0.008) and CD patients (0.76 vs 0.12 flares/yr, p = 0.004). CONCLUSIONS: Pregnancy did not influence disease phenotype or surgery rates, but was associated with a reduced number of flares in the following years.

Detection of myocardial viability could be improved by rest GIK (glucose-insulin-potassium solution)-Tc 99m sestamibi compared with TL-201 reinjection, in post myocardial infarction patients.

UNLABELLED: GIK solutions improve detection of myocardium viability after acute infarction because they could change the metabolic conditions, improving myocardial perfusion defects. METHODS AND RESULTS: Seventy four patients (52 men, 22 women, mean age 53.3.08 +/- 12.14 years) with previous myocardial infarction (evolution time, 4.2 +/- 3.1 months) underwent pharmacological stress (dipyridamole), rest redistribution and reinjection Tl-201 image as well rest/stress Tc-99m Sestamibi, after the intravenous administration of GIK (200 g glucose +/- 30 UI regular insuline +/- 40 mEq potassiumchloride/500 mL in continuous infusion during 3 hours), Group A (N = 22) or oral administration of 70 g of glucose+/- 40 mEq of potassium chloride taking in advantage the endogenous insulin secretion, to non-diabetic patients (group B = GB, N = 26) and group C (GC, diabetic patients N = 26). All of the 74 patients received 10 mg of sublingual Isorbide previous to 25 mCi of Tc99m Sestamibi administration in a different 2 days protocol. A total of 1,480 myocardial segments were assessed and numbered, and the severity of perfusion defects in the segments involved, were compared between Thallium 201 rest reinjection and GIK-MIBI as the main objective of the study. Involved territories number: 4.02 +/- 2.50 vs. 6.88 +/- 2.12, p = 0.005 for AD; 5.2 +/- 1.44 vs. 6.35 +/- 1.11, p = 0.05 for RC and 1.58 +/- 1.01 vs. 2.05 +/- 1.05, p = 0.05 Cx. For GIK-MIBI vs. Tl-201 reinjection respectively, and defect severity: 8.2 +/- 6.04 vs. 13.22 +/- 5.38, p = 0.01 for LAD; 11.72 +/- 5.08 vs. 15.13 +/- 4.42, p = 0.005 for RC and 2.66 +/- 2.09 vs. 4.69 +/- 3.58, p = 0.003 Cx . For GIK-MIBI vs. Tl-201 reinjection respectively, were found. CONCLUSION: Our data suggest that GIK-MIBI protocol is a safe and easy procedure which improves the detection of perfusion reversible defects compared with Tl-201 reinjection, obtaining better information regarding myocardial viability, with lower acquisition time and less cost.

A rare case of multiple lymphomatous polyposis with widespread involvement of the gastrointestinal tract.

Multiple lymphomatous polyposis (MLP) is an uncommon type of primary non-Hodgkin gastrointestinal (GI) B-cell lymphoma characterized by the presence of multiple polyps along the GI tract. Malignant cells of MLP have mantle cell characteristics and thus are considered to be the counterpart of the mantle cell lymphoma (MCL) in the GI tract. Since 1961, no more than 70 well-documented cases have been published. We report the case of 53-year-old man diagnosed as having MLP. The patient presented with diffuse abdominal pain, chronic lower GI bleeding, peripheral lymphadenopathy, and weight loss. The lymphomatous polyps extended from the esophagus to the rectum, with bone marrow infiltration. Immunohistologic findings were characteristic of MCL. The patient was treated with a combined cyclophosphamide, vincristine, and prednisone chemotherapy regimen, resulting in a partial response.

Development of autoimmune sensorineural hearing loss after endolymphatic sac decompression: two case reports.

OBJECTIVE: To present two case reports that the authors believe demonstrate the creation of autoimmune hearing loss in a healthy ear in response to endolymphatic sac surgery in an opposite ear felt to be afflicted with Ménière's Disease. In both cases, unexpected trama was incurred in performing the original surgery for endolymphatic sac decompression. STUDY DESIGN: Two case reports. SETTING: Ambulatory office and hospital in a tertiary referral center. PATIENTS: Two patients selected for their unique development of autoimmunity in the ear that was not operated on. INTERVENTIONS: Surgical intervention (endolymphatic sac surgery) for Ménière's Disease. MAIN OUTCOME MEASURES: Audiometry and clinical assessment. RESULTS: Audiometric results of two patients believed to have developed autoimmune sensorineural hearing loss as the result of surgical trauma delivered to the patient's opposite ear. CONCLUSION: It is believed that the two patients presented developed autoimmune sensorineural hearing loss in an opposite nonsurgical ear in response to surgical intervention (believed to be traumatic) in their original Ménière's Disease ear.