Sequential convective therapies (SCT): a prospective study on feasibility, safety, adequacy and tolerance of on-line hemofiltration and hemodiafiltration in sequence

Sequential dialysis techniques (i.e pure ultrafiltration followed by dialysis) have been used in the past, due to their capability to remove large volumes of fluids without inducing hemodynamic instability. The disadvantages of inadequate efficiency and lack of technology lead to the decline of such methods. Hemofiltration (HF) and hemodiafiltration (HDF) are recently being utilized in a greater proportion thanks to on-line fluid preparation systems. Each process (HF and HDF) has its own benefits in the removal of small, medium and high-molecular weight substances and in hemodynamic stability. Sequential convective therapies (SCT) such as hemofiltration-hemodiafiltration in sequence (HF-HDF) may combine the benefits and eliminate the disadvantages of each method and should be studied in order to explore their potential application in modern dialysis. Furthermore they can be easily applied nowadays, due to the development of new sophisticated dialysis machines. In order to evaluate the feasibility, safety, efficiency and tolerance of different SCT methods we studied 3 schedules: SCT1: 1h pre-dilution HF followed by 3h of post-dilution HDF (in the HF mode we lost 25% of the total fluid that had to be removed). SCT2: 1h pre-dilution HF followed by 3h of post-dilution HDF (in the HF mode we lost 50% of the total fluid that had to be removed). SCT3: 2h pre-dilution HF followed by 2h of post-dilution HDF (in the HF mode we lost 50% of the total fluid that had to be removed). We studied 6 chronic hemodialysis patients using the same machine (AK200 ULTRA), with on-line fluid preparation system and the same type of dialyzer (Polyflux 210). SCT schedules were compared to on-line HF, on-line HDF and high flux dialysis performed with the same dialyzers. The treatments resulted safe, easy, feasible and well tolerated with an improved hemodynamic response to high volume convective therapies. Adequacy of treatment was satisfactory in all SCT schedules while middle molecular weight solute clearance and removal resulted higher in treatments with higher convective component. SCT might represent an interesting option for the future especially in patients with hemodynamic instability and requirements for interventions during treatment.     

Transluminal coronary angioplasty. Technic and immediate results

Controlled crushing of the intimal plaque and of the underlying vessel wall are the determinants of transluminal dilatation of coronary stenoses. The technique of angioplasty has been recently modified in many laboratories, by the use of new catheters and dilatation policies. Data from the NHLBl Registry indicate a 59% primary success rate, being 29% and 12% respectively the failures due either to inability to cross or to dilate the stenosis. A retrospective analysis of successful procedures has highlighted factors that positively affect the results: recent onset of the angina, lack of calcifications, iterative ballooning at high pressures and the experience of the angiographer. Main complications were angina becoming unstable (5.7%) and acute coronary occlusion (4.4%); an emergency bypass operation had to be done in 6.3% of the cases, whereas myocardial infarctions scored 4.4% and hospital deaths less than 1%. Preliminary results of Centro De Gasperis concern 18 attempts to dilate LAD stenoses: primary success rate was 44% with a failure rate of 39% and 17% regarding inability to cross or only to dilate stenosis, respectively. The above results are less favorable than those reported in NHLBl Registry and very much less than those reported by selected laboratories; they are however acceptable in view of the suboptimal characteristics of the materials used and the limited experience of the team.     

Linfadenectomía inguinal vídeo endoscópica: resultados quirúrgicos y oncológicos

IntroductionWe evaluated the reproducibility of video endoscopic inguinal lymphadenectomy (VEIL) and we report our initial experience in the treatment of penile cancer with palpable inguinal lymph nodes.Material and methodsFrom July 2006 to November 2010 were conducted 33 VEIL in 20 patients as complementary treatment for penile cancer in two referral hospitals in Latin America. We analyzed the epidemiological and clinical characteristics of patients and surgical and oncologic outcomes.ResultsFifty-five percent of the patients included were clinical stage N0 and 45% were N +. Thirteen patients underwent bilateral VEIL and the remaining seven underwent VEIL unilateral and conventional open surgery in the contralateral limb. The average operative time for VEIL was 119 minutes and mean resected lymph nodes was 8 per lymphadenectomy. The overall complication rate was 33.2%. No patient had skin necrosis. The lymphatic complication rate was 27.2%. Of the 6 cases in which the saphenous vein was preserved (18.2%) there were no lymphatic complications (P = ,2). The overall survival rate was 80% and cancer-specific survival was 90%. Mean follow-up was 20 months.ConclusionsVEIL in the adjunctive treatment of penile cancer is safe, reproducible and may be an alternative to conventional lymphadenectomy. Patients with palpable lymphadenopathy also may benefit from this technique. Oncological results seem to be adequate however require longer follow-up to be confirmed.     

Prognostic value of cutaneous reinnervation with GAP-43 in oxaliplatin-induced neuropathy

Journal of Neurology - Oxaliplatin-induced neuropathy (OIN) implies axonal damage of both small and large sensory nerve fibers. We aimed at comparing the neurophysiological changes occurred after...     

Anterior inguinal hernioalloplasty by the modified Valenti's technique. Preliminary results of our experience

The authors dwell upon the deep changes which the surgery of the inguinal hernia has recorded in the last years with the aim to reduce the rate of relapses and based on the philosophy tension free repair, particularly on the prosthetic patch and plug hernioplastics which represent the evolution of this concept and among these must be includes the D.SR.P. and flat plug hernia repair, that they have set with a sort of eclecticism and of integration of some of the operation times of Valenti's and Trabucco's methodologies and of some prosthetic protections used by themselves. Then, they dwell upon the rational of the variant in the Valenti's original technique put forward them, and this variant arise from a critical testing, they perform their preliminary clinic experience about primitive inguinal hernia repair through the methodology that has been proposed, then they declare that they can confirm it from the point of view of the effectiveness and safety only after further confirmations based on far wider surveys and on longer "follow-up" and after an objective comparison between this one and the two methods of whom it forms the technical compromise.     

Low plasma glutathione levels after reperfused acute myocardial infarction are associated with late cardiac events

OBJECTIVE: To clarify whether an altered redox state persists in the subacute phase of myocardial infarction and if specific redox patterns are associated with later cardiac events. METHODS: Ninety-seven patients [80 men, median 63 (interquartile range, 53, 69) years] with a first acute myocardial infarction, with (53%) or without ST segment elevation, treated with successful percutaneous interventions, were tested at 5-6 days after admission for plasma alpha-tocopherol, ascorbic acid, total and reduced homocysteine, cysteine, glutathione, cysteinylglycine and blood-reduced glutathione, all assessed by high-pressure liquid chromatography. Free malondialdehyde was evaluated by gas chromatography. A subgroup of 14 patients had adjunctive blood samples within 1 h and at 72 h after angioplasty. Blood samples from 44 patients matched for age, sex, and risk factors served as controls. Patients were followed up for median 15 (interquartile range, 9, 17) months for cardiac events. RESULTS: All plasma-reduced aminothiols, vitamins and plasma total glutathione were significantly lower in myocardial infarction at 5-6 days than in controls. In the 14 myocardial infarction patients sampled repeatedly, plasma-reduced glutathione, cysteinylglycine, total glutathione, and alpha-tocopherol significantly decreased, whereas blood-reduced glutathione, total homocysteine, and cysteine significantly increased over time. During follow-up, 20 of 97 (21%) patients had adverse cardiac events. Multivariate analysis revealed that only plasma-reduced glutathione was independently associated with events (hazard ratio 0.42, 95% confidence interval 0.18-0.99, P=0.04). CONCLUSIONS: Acute myocardial infarction patients have an altered redox state at 5-6 days after successful reperfusion with respect to controls. Low plasma levels of reduced glutathione at discharge are associated with cardiac events at follow-up.     

Coronary stent implantation is superior to balloon angioplasty for chronic coronary occlusions: six-year clinical follow-up of the GISSOC trial

OBJECTIVES: We investigated whether the benefits of stent implantation over balloon percutaneous transluminal coronary angioplasty (PTCA) for treatment of chronic total coronary occlusions (CTO) are maintained in the long term. BACKGROUND: Several randomized trials have shown that in CTO, stent implantation confers clinical and angiographic mid-term outcomes superior to those observed after PTCA. However, limited information on the long-term results of either technique is available. METHODS: Six-year clinical follow-up of patients enrolled in the Gruppo Italiano di Studio sullo Stent nelle Occlusioni Coronariche (GISSOC) trial was performed by direct visit or telephone interview. Major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, target lesion revascularization (TLR), and anginal status, were recorded. RESULTS: Freedom from MACE at six years was 76.1% in the stent group, compared with 60.4% in the PTCA group (p = 0.0555). This difference was due mainly to TLR-free survival rates (85.1% vs. 65.5% for the stent and PTCA groups, respectively; p = 0.0165). Eleven patients underwent TLR after the nine-month follow-up visit (stent group: n = 5; PTCA group: n = 6); however, in most cases, restenosis of the study occlusion was evident at nine-month angiography. CONCLUSIONS: This study represents the longest reported clinical follow-up of patients after percutaneous recanalization of CTO and demonstrates that the superiority of stent implantation over balloon PTCA is maintained in the long term. Stent and PTCA results appear to remain stable after nine-month angiographic follow-up. Stent implantation in CTO that can be recanalized percutaneously is therefore a valuable long-term therapeutic option.     

A prospective study of the evolution of coronary lesions: clinico-morphologic correlations

In order to evaluate the evolution (progression and regression) of coronary atherosclerosis, 61 patients (8 with stable angina, 9 with unstable angina, 15 with a recent myocardial infarction, 29 with multivessel coronary artery disease and treated with successful one-vessel angioplasty) were enrolled in a prospective study. In the angioplasty group, only untreated vessels were considered for the analysis. All patients underwent coronary angiography before hospital discharge and after one year, in accordance with the study protocol. In 13 patients (21%) a repeat angiography was performed at 6.3 +/- 2.7 months for clinical reasons (myocardial infarction, changing pattern angina, angina recurrence). All patients were asymptomatic or mildly symptomatic on medical therapy between the angiographic studies. Progression (decrease in internal luminal diameter at the site of stenosis greater than or equal to 20%; new onset of lesions, new episodes of total occlusions) was found in 16 out of 216 stenoses (7%) and in 14 out of 61 patients (23%). Regression (increase greater than or equal to 20% in internal luminal diameter; reopening of a previously occluded vessel) was found in 11 out of 227 lesions (5%) and in 7 out 61 patients (11%). At repeat angiography, the increase in severity was found more frequently in stenoses greater than 5 mm in length and with a reduction of greater than or equal to 75% in luminal diameter. Regression was more frequent in the occluded vessel supplying a recently infarcted area. No significant relationship was observed between lesion morphology (concentric, eccentric, with plaque ulceration, thrombi, border irregularities) and progression or regression. Lesions with plaque ulceration (with or without superimposed thrombi) were found only in patients submitted to coronary angiography close to an acute ischemic attack. Morphologic regression (disappearance of ulceration, border irregularities, thrombi) was also observed, without any significant changes occurring in the severity of the underlying stenosis. Progression may occur independently of worsening in the clinical status; on the contrary, regression was only found in patients without new cardiac events. Nevertheless, clinical status does not seem to be closely correlated to progression, regression, or changes in plaque morphology.