C4d-the witness of humoral rejection.

OBJECTIVE: Acute antibody-mediated (humoral) rejection is a major cause of morbidity, graft loss, and mortality among heart transplant patients. Herein we have presented our experience using C4d to characterize humoral rejection. MATERIALS AND METHODS: All nonformalin-fixed cardiac graft biopsies (protocol or emergency) received between May 2007 and May 2008 were examined by immunofluorescence for C4d. RESULTS: One hundred twelve endomyocardial biopsies from 25 transplanted patients included 20 males and 5 females of ages ranging from 3 to 71 years. The number of biopsies per subject varied from 1 to 11; the timespan between transplantation and the diagnostic biopsies ranged from days to 8 years. Thirteen biopsies showed acute humoral rejection (intramyocardial capillaries positive for C4d); 31, acute cellular rejection (grades 1R, 2R); 7, both humoral and cellular rejection; and 1, acute humoral rejection and allograft vasculopathy. Some of the positive biopsies belonged to the same person, and some to transplanted individuals with signs and symptoms suggestive of rejection, while others did not. The persistence of humoral rejection, despite the disappearance of a cellular component, correlated with slower clinicoechocardiographic improvement. CONCLUSIONS: C4d positivity is a morphologic sign of humoral rejection. It may hasten the appearance and/or worsening of allograft vasculopathy independent of patient age or posttransplantation time.

Pediatric minor head trauma: indications for computed tomographic scanning revisited.

BACKGROUND: Although the use of computed tomographic (CT) scanning in severe head trauma is an accepted practice, the indications for its use in minor injury remain ill defined and subjective. We sought to define the incidence and identify risk factors for intracranial injury (ICI) after minor head trauma in children who did not have suspicious neurologic symptoms in the field or on presentation. METHODS: From January 1, 1992, until April 1, 2000, 569 blunt trauma patients (age < 16 years) with a Glasgow Coma Scale score of 14 or 15 triaged by American College of Surgeons Pediatric Mechanism Criteria at a Level I trauma center received head CT scan. Loss of consciousness (LOC) status was known for 429. This subgroup was retrospectively reviewed for mechanism, age, Injury Severity Score, LOC status, GCS score, associated injuries, and CT scan findings (normal, fracture only, or intracranial injury). Relative risk values for intracranial injury were generated and statistical significance was assessed. RESULTS: Fourteen percent (62 of 429) of study patients (GCS score of 14 and 15) had ICI. Sixteen percent of patients (35 of 215) with GCS score of 15 and (-)LOC (negative for LOC) had intracranial injury manifesting as subdural hematoma, epidural hematoma, subarachnoid hemorrhage, or brain contusion. Three required surgery for intracranial mass lesions. One patient deteriorated and required intubation and intensive care unit management. Neither (+)LOC (positive for LOC) nor GCS score of 14 increased the likelihood of intracranial injury over those patients without loss of consciousness or with GCS score of 15. Distant injury was also not an independent predictor of ICI for those with GCS scores of 14 or 15, as 84% of the ICI group had head injury only. Skull fracture was a risk factor for ICI but had poor negative predictive value, as 45% of patients with ICI did not have fractures. Similarly, minor craniofacial soft tissue trauma was a significant risk factor (relative risk, 11) that had marginal negative predictive value (0.95), as 14% (9 of 62) of ICI patients did not have superficial craniofacial injury. CONCLUSION: A normal neurologic exam and maintenance of consciousness does not preclude significant rates of intracranial injury in pediatric trauma patients. Contrary to convention, neither LOC nor mild altered mentation is a sensitive indicator with which to select patients for CT scanning. Skull fractures and superficial craniofacial injury are similarly unreliable. Identification of these patients is important for the occasional case requiring intervention and for the tracking of complications. A liberal policy of CT scanning is warranted for pediatric patients with a high-risk mechanism of injury despite maintenance of normal neurologic status in the field and at hospital screening.

Diagnóstico de taquicardia ventricular do tipo fascicular através da cardioexploraçäo eletrofisiológica trasesofágica (Cete) / Fascicular ventricular tachycardia diagnosis by transesophageal cardiostimulation study. Case report

Um paciente do sexo masculino, de 14 anos de idade, portador de taquicardia paroxística supraventricular (TPSV), diagnosticada 4 anos antes, refratária à terapêutica medicamentosa e associada a tonturas e síncope, foi encaminhado para avaliaçäo. A cardioestimulaçäo transesofágica (Cete) exerceu um importante papel na elucidaçäo diagnóstica, ao induzir de forma peculiar, atravées de estimulaçäo atrial, uma taquicardia idiopática do ventrículo esquerdo (VE). O achado da Cete foi confirmado no laboratório de eletrofisiologia, sendo realizada ablaçäo percutânea por corrente de radiofrência na regiäo médio-septal do VE, com resoluçäo do circuito da taquicardia. Quatro meses do procedimento, o paciente encontrava-se assintomático e sem o uso de drogas antiarrítmicas.