Clinical Sequalae Research Articles

Introduction of PCR testing reveals a previously unrecognized burden of yersiniosis in Hampshire, UK.

Introduction. Current testing practices for yersiniosis mean that its true incidence and epidemiology are not well understood. In mid-2016, the introduction of testing via a multiplex gastrointestinal PCR panel at Portsmouth hospital laboratory in Hampshire, UK, resulted in a marked increase in the number of Yersinia cases identified locally.Aim. Here we describe the epidemiology and microbiology of Yersinia cases identified at Portsmouth laboratory following the introduction of PCR testing.Methodology. A case was defined as a person with a stool specimen in which Yersinia was detected by PCR and/or culture at Portsmouth NHS Trust laboratory between 1 January 2014 and 31 December 2018. A case list was created from laboratory data submitted by Portsmouth laboratory to Public Health England (PHE), updated with speciation and serotyping data from the PHE reference laboratory. Descriptive analysis was performed.Results. Over 30 months following introduction of PCR testing, 199 cases were confirmed with Yersinia, compared to two cases in the preceding 30 months. This corresponds to a rate of 13.8 and 0.1 per 100 000 population per year respectively (P<0.0001). In total, 85% of tested isolates were Y. enterocolitica, belonging to multiple serotypes, and the rest belonged to a range of Y. enterocolitica-like species.Conclusions. Introduction of PCR testing led to the identification of a previously unrecognized burden of yersiniosis in Hampshire. The diversity of species and serotypes suggests heterogeneity in sources and transmission routes. Further research on exposures, risk factors and clinical sequalae is needed to improve our understanding of the clinical and public health impact.

Improvement in Cytokine Release Syndrome Management for the Treatment of AML Patients with Flotetuzumab, a CD123 x CD3 Bispecific Dart® Molecule for T-Cell Redirected Therapy

Improvement in Cytokine Release Syndrome Management for the Treatment of AML Patients with Flotetuzumab, a CD123 x CD3 Bispecific Dart® Molecule for T-Cell Redirected Therapy

Placental Biomarkers and Uterine Doppler Indices Predictability Capacity for Preeclampsia and its Clinical Sequalae

Placental Biomarkers and Uterine Doppler Indices Predictability Capacity for Preeclampsia and its Clinical Sequalae

A Case Series of Biopsy-Proven Eosinophilic Myocarditis at a Tertiary Care Center

BackgroundThere is limited published literature on acute eosinophilic myocarditis (EM), a rare form of acute myocarditis, wherein eosinophils invade the myocardium with wide-ranging clinical sequalae. We aim to describe our experience in the largest contemporary case series of histologically-proven EM.MethodsTwo authors independently reviewed the surgical pathology and autopsy databases for acute EM (01/2009 to 12/2017). Only patients with endomyocardial biopsy/autopsy and clinical course consistent with acute EM were included. We abstracted demographic data, comorbidities, clinical diagnostics, and clinical outcomes.ResultsSeven patients had acute EM (Table). The average age was 53-years and five subjects were women. The most common etiology of EM was idiopathic. Five patients had peripheral eosinophilia. Three patients had elevated pulmonary capillary wedge pressure and three patients had reduced cardiac output. Six patients were treated with steroids, four of whom received IV pulse dosed steroids. Two patients required intra-aortic balloon pump support, one of whom subsequently underwent durable left ventricular assist device implantation. Two patients died during index hospitalization, one of septic shock and one of refractory ventricular tachycardia.ConclusionThe etiologies, clinical presentation, and course of acute EM varied widely. Prompt diagnosis, treatment with immunosuppression, and circulatory support may reduce cardiovascular mortality in this population. There is limited published literature on acute eosinophilic myocarditis (EM), a rare form of acute myocarditis, wherein eosinophils invade the myocardium with wide-ranging clinical sequalae. We aim to describe our experience in the largest contemporary case series of histologically-proven EM. Two authors independently reviewed the surgical pathology and autopsy databases for acute EM (01/2009 to 12/2017). Only patients with endomyocardial biopsy/autopsy and clinical course consistent with acute EM were included. We abstracted demographic data, comorbidities, clinical diagnostics, and clinical outcomes. Seven patients had acute EM (Table). The average age was 53-years and five subjects were women. The most common etiology of EM was idiopathic. Five patients had peripheral eosinophilia. Three patients had elevated pulmonary capillary wedge pressure and three patients had reduced cardiac output. Six patients were treated with steroids, four of whom received IV pulse dosed steroids. Two patients required intra-aortic balloon pump support, one of whom subsequently underwent durable left ventricular assist device implantation. Two patients died during index hospitalization, one of septic shock and one of refractory ventricular tachycardia. The etiologies, clinical presentation, and course of acute EM varied widely. Prompt diagnosis, treatment with immunosuppression, and circulatory support may reduce cardiovascular mortality in this population.

Laboratory Evaluation of Spasmodic Dysphonia

To evaluate the utility of comprehensive laboratory evaluation in patients with spasmodic dysphonia (SD). Retrospective chart review. A review of the medical records of 40 patients diagnosed with spasmodic dysphonia from 2009-2018 was preformed to evaluate abnormal test results that were significant when compared with abnormal results of the general population and for any other clinically relevant pathology. Erythrocyte sedimentation rate, ceruloplasmin levels, and anti-AChR were found to be elevated at levels considered statistically significant (p <0.05). Furthermore, we found levels of cholesterol, thyroid-stimulating hormone (TSH), T3, fasting blood glucose, creatine kinase, immunoglobulin, antinuclear antibody (ANA), and alpha-fetoprotein (AFP) levels to be abnormal at a greater rate in our population, but these were not statistically significant. Workup revealed several underlying conditions including thyroid neoplasms, hypothyroidism, and laryngopharyngeal reflux. Additionally, brain MRI revealed age-related ischemic pathology in an elevated number of patients, but with no obvious clinical sequalae. There is an association between serological values and spasmodic dysphonia that can aid in diagnosing pathology, as well as establishing a directed workup. Additionally, our study shows the utility of comprehensive evaluation in identifying undetected disease.

Multidisciplinary care in tenosynovial giant cell tumours.

Tenosynovial giant cell tumour is a rare neoplastic condition of the joint that generally affects patients younger than 40 years. 1 Tap WD Wainberg ZA Antony SP et al. Structure-guided blockade of CSF1R kinase in tenosynovial giant-cell tumor. N Engl J Med. 2015; 373: 428-437 Crossref PubMed Scopus (325) Google Scholar It is not a malignancy per se, but for many, it is far from a benign disease and often causes substantial morbidity and disability due to pain, joint destruction, the need for repeated surgical intervention, and the use of analgesics and narcotics. Although not life-threatening, tenosynovial giant cell tumours can disrupt daily living and adversely alter an individual's life trajectory. Tenosynovial giant cell tumour is a complex disease with a wide breadth of clinical sequalae. Understanding of this disease has changed substantially in the past 10 years after causative genomic events were described. 2 West RB Rubin BP Millar MA et al. A landscape effect in tenosynovial giant-cell tumor from activation of CSF1 expression by a translocation in a minority of tumor cells. Proc Natl Acad Sci USA. 2006; 103: 690-695 Crossref PubMed Scopus (363) Google Scholar The discovery of these genomic events has allowed for the development and application of promising therapeutics targeting CSF1 signalling, which are further driving our knowledge base and greatly informing clinical practice. 1 Tap WD Wainberg ZA Antony SP et al. Structure-guided blockade of CSF1R kinase in tenosynovial giant-cell tumor. N Engl J Med. 2015; 373: 428-437 Crossref PubMed Scopus (325) Google Scholar , 3 Cassier PA Italiano A Gomez-Roca CA et al. CSF1R inhibition with emactuzumab in locally advanced diffuse-type tenosynovial giant cell tumours of the soft tissue: a dose-escalation and dose-expansion phase 1 study. Lancet Oncol. 2015; 16: 949-956 Summary Full Text Full Text PDF PubMed Scopus (236) Google Scholar The introduction of CSF1 receptor inhibitors came with the realisation that much needed to be learned about what patients with tenosynovial giant cell tumours go through and how the medical community could best serve them. This realisation prompted the medical and pharmaceutical community to partner with patients, patient advocacy, and patient support groups to learn more about the disease, to develop novel patient-reported outcome measures 4 Gelhorn HL Tong S McQuarrie K et al. Patient-reported symptoms of tenosynovial giant cell tumors. Clin Ther. 2016; 38: 778-793 Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar and potentially new imaging techniques, 1 Tap WD Wainberg ZA Antony SP et al. Structure-guided blockade of CSF1R kinase in tenosynovial giant-cell tumor. N Engl J Med. 2015; 373: 428-437 Crossref PubMed Scopus (325) Google Scholar and to review and scrutinise historical experiences. 5 Palmerini E Staals EL Maki RG et al. Tenosynovial giant cell tumour/pigmented villonodular synovitis: outcome of 294 patients before the era of kinase inhibitors. Eur J Cancer. 2015; 51: 210-217 Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar This effort is paramount because the correct application of targeted therapies in tenosynovial giant cell tumours is not straightforward. Although active, many drugs have serious side-effects and associated financial costs. Much still needs to be learned about appropriate application, patient selection, timing of therapy, and length of use; decisions that need to be made in a multidisciplinary fashion, inclusive of the patient and their care team. Surgical outcomes of patients with diffuse-type tenosynovial giant-cell tumours: an international, retrospective, cohort studyThis study of patients with diffuse-type tenosynovial giant-cell tumour provides a comprehensive and up-to-date disease overview, assessing the clinical profile and management of the disease in multiple specialised referral centres. Surgical treatment of diffuse-type tenosynovial giant cell tumours is not a definitive treatment for every patient because it involves a high risk for local recurrent disease and a relatively high risk for postoperative complications. After surgical treatment in treatment-naive patients, risk factors for recurrent disease in individual patients were not identified in what we believe is the largest cohort to date. Full-Text PDF

First trimester serum biomarkers to predict gestational diabetes in a high-risk cohort: Striving for clinically useful thresholds

ObjectivesScreening and diagnosis of gestational diabetes (GDM) has been a source of controversy. The prevalence has increased in line with an obesity epidemic and a trend towards delayed child-bearing. Treatment of even modest glycaemic impairment in pregnancy has been shown to be beneficial in preventing its clinical sequalae. However the cumbersome nature and timing of the oral glucose tolerance test coupled with debate around universal versus risk factor based screening have been problematic. This group aimed to investigate a panel of biomarkers which have shown promise in the literature to predict GDM from the first trimester in a group of high risk women. MethodsSerum samples were drawn on 248 women deemed at risk of GDM before 15 weeks’ gestation to measure C-reactive protein, sex hormone binding globulin, adiponectin and 1,5 anhydroglucitol. Patients underwent an oral glucose tolerance test as per IADPSG criteria at 28 weeks’ gestation. Multiple logistic regression was used to examine the link between incidence of GDM and early pregnancy serum biomarkers. ResultsAdiponectin levels in the first trimester are independently linked to the risk of GDM. Serum adiponectin <8.9 μg/ml gives an odds ratio of 3.3 for GDM.Mean 1,5 AG levels are significantly lower in those that go on to develop GDM. SHBG levels measured in the first trimester were linked to the risk of GDM. However, this was no longer statistically significant once BMI, ethnicity and family history were taken into consideration. First trimester measurement of CRP is not a useful indicator of GDM risk. ConclusionsFirst trimester measurement of Adiponectin and 1,5 Anhydroglucitol are potential early biomarkers for the later onset of GDM. Risk stratification using these biomarkers may facilitate early diagnosis and management of GDM to mitigate against its complications.

A caecal perforation from foreign body ingestion in a child with autistic spectrum disorder

Foreign body ingestion is a common medical issue. However, quite often the diagnosis of foreign body ingestion can be a challenge as clinical presentation is variable, often with non-specific symptoms. It is reported that 80- 90% of ingested foreign bodies can pass through the gastrointestinal tract without any clinical sequalae; rarely, 1%, cause bowel perforation. This report presents the case of a 13-year-old boy with autistic spectrum disorder brought in by his parents with undifferentiated abdominal pain and non-specific symptoms including recent flu-like symptoms, generalised weakness, and lethargy. It was difficult to obtain a thorough history and examination due to his developmental disorder. Diagnostic laparoscopy was subsequently conducted and an unexpected finding of a caecal perforation from an ingested metal wire was noted. Primary closure of the caecal perforation was performed post metal wire removal. The patient recovered well with no post-operative complications. As clinicians, we should have a high index of suspicion for foreign body induced viscus perforation when patients present with atypical abdominal pain, especially in those with paediatric developmental disorders such as autism. Patients with autism often increase the difficulty of clinical diagnosis due to poor history taking and a challenging physical examination. Overall, an emergency diagnostic laparoscopy is recommended if the patient has any suspicion of an acute abdomen.

Perforation risk and intra-uterine devices: results of the EURAS-IUD 5-year extension study

Objectives: The objective of this analysis was to identify intra-uterine devices (IUD) perforations detected from 12 to 60 months following IUD insertion, and to combine this information with (our previously published) data about perforations detected in the first 12 months to calculate cumulative perforation rates.Methods and materials: Prospective, non-interventional cohort study with new users of levonorgestrel-releasing intra-uterine systems (LNG-IUS) and copper-IUD. The original cohort included 61,448 women followed for 12 months. Of these, we had sufficient resources to perform an additional follow-up and analysis at 60 months in 39,009 women. Inclusion criteria for this analysis was insertion prior to 31 July 2010. All potential cases were validated via the health care professional or medical records. Crude and adjusted relative risks were calculated using a logistic regression model.Results: We identified 23 additional perforations (19 LNG-IUS and 4 copper-IUD) more than 12 months after insertion. Added to perforations detected at 12 months, the overall perforation rate was 2.1 per 1000 insertions (95% CI: 1.6–2.8) for LNG-IUS users (40 + 19 perforations/27,630 insertions) and 1.6 per 1000 insertions (95% CI: 0.9–2.5) for copper-IUD users (14 + 4 perforations/11,379 insertions). LNG-IUS users had a borderline higher risk of perforation compared with copper-IUD users (ORadj 1.7; 95% CI: 1.0–2.8). Forty-five (58%) of the 77 perforations were associated with suspected risk factors. Breastfeeding (RR 4.9, 95% CI: 3.0–7.8) and time since delivery (RR 3.0, CI: 1.5–5.4) remained significant risk factors in perforations detected after 12 months. No perforations resulted in serious injury to intra-abdominal or pelvic structures.Conclusions: The incidence of uterine perforations in this study was low, although higher than the commonly reported rate. Approximately one third of perforations are detected 12 months after insertion. Clinical sequalae of perforations are generally mild and associated with a very low risk of injury to intra-abdominal and pelvic structures.ImplicationsUterine perforation is a rare risk associated with intra-uterine device use. Late diagnosed perforations can occur, although women can be reassured that the morbidity associated with detection and removal is low.

Need for hypogastric artery preservation in endovascular repair for aorto – Iliac Aneurysms

Objective: Effective distal sealing in endovascular aorto-iliac aneurysm repair often requires landing in the external iliac artery, thus questioning the fate of the hypogastric artery circulation. Besides simple embolization to prevent a type 2 endo-leak, several solutions exist for hypogastric flow preservation, each laden with increasing complexity and/or financial burden. The present study evaluated the rationale of hypogastric artery preservation in this clinical setting. Methods: From January 1999 to June 2016, 749 patients underwent endovascular repair of abdominal aortic aneurysm. Among these, 112 with aneurysm involving the iliac vessels required consideration for closing one (95) or both (17) hypogastric arteries. One-hundred and three patients were male and 9 were female. The mean age was 75 (52-88). When only one hypogastric artery (with patency of the contralateral) needed sacrifice, the usual practice has been simple embolization with plugs or coils before the endografting. Nevertheless, 4 patients with unilateral iliac involvement, who had an active lifestyle, received a branched endograft for hypogastric preservation. When landing in the external iliac artery was needed bilaterally, in 16 cases one hypogastric artery was embolized and the other one was preserved with branched endografts (N=11), “double barrel” technique (N=3) or hybrid repair using an open bypass from external to internal iliac artery (N=2); in only one patient a bilateral branched endograft was used to preserve both hypogastrics. Results: Preservation of the hypogastric artery was achieved in 21 out of the 22 target vessels: one patient, who received a bran-ched endograft, experienced immediate occlusion of the hypogastric stent, without any clinical sequalae. In the early postoperative period none of the 112 patients had symptoms of critical gluteal and/or pelvic visceral ischemia. At a mean follow-up of 48 months (1-152), no further procedures were necessary for proximal and/or distal type I endoleak. All the hypogastric arteries but one, in the 20 patients in whom they were preserved, remained patent. Even though 33% of the patients (37 out of 112) reported mild to moderate gluteal claudication during the first 6 months after the procedure, the symptoms improved progressively, and residual complaints were presented at the 1 year visit or later only in 8% of cases. Moreover, no substantial changes in sexual activity were reported in any case. Conclusion: From a cost-effectiveness perspective, adjunctive procedures for monolateral hypogastric artery preservation with contralateral patency are not warranted. These techniques should be reserved for the selected few cases when both hypogastric arteries need to be sacrificed, or when there is a peculiar need for their preservation. Keywords: Aortoiliac aneurysm, Hypogastric artery, Iliac branched device, Endovascular aneurysm repairn

Mo1254 Alcoholic Hepatitis - A Risk Factor for Complications in Patients With Liver Cirrhosis and Ascites

evaluated, 6 patients received anticoagulation while 39 did not. Progression happened in 19 (49%) of the non anticoagulated group, and 4 (67%) of the anticoagulated group. Right portal vein involvement was seen in 18 (40%) patients with progression in 67% of the time, Left PVT in 13 (28%) with a progression in 54%, and Main PVT 6 (13%) with a progression in (67%). In 1 case, PVT progressed from the main PVT to Superior mesenteric vein (SMV) and in 2 other cases from the Left portal vein to SMV. Ascites was present in 2 patients, at the time PVT diagnosis but no symptoms or adverse clinical sequalae directly related to PVT development were reported in the other 43 patients. Conclusion, in our review of 45 patients with HCC complicated by chronic PVT, there was no adverse clinical consequence. The rate of progression of PVT determined by contrast enhanced CT or MRI imaging was similar in the group treated with anticoagulation and the non anticoagulated group of patients. Thus, the need for anticoagulation, considering its risks in patients with HCC and PVT, needs to be carefully assessed. The usefulness of anticoagulation in this patient population needs to be further studied. Table 1. Characteristics and Results

The safety of rotational atherectomy at a PCI capable centre with no on-site cardiac surgery

Background and Aims: Percutaneous transluminal coronary rotational atherectomy (PTCRA) caries a small but significant risk of mechanical complications (most notably coronary artery perforation) potentially requiring urgent cardiac surgical intervention. The aim of this study is to assess the safety and efficacy of PTCRA facilitated procedures in a non-cardiac surgical centre. Methods: A retrospective analysis of the charts of 115 consecutive patients between January 2000 and December 2014 was undertaken. Patients had calcified lesions requiring PTCRA prior to stent implantation. Thirty-day mortality was the major endpoint. Results: 115 patients underwent PTCRA. Mean age 72.47 years (SD 9.62). Male (63.5%). Thirty-day survival 98.5% (95% CI 92.75% to 99.5%). 97.2% of cases were completed successfully. Artery treated: Left Anterior Descending artery (36.5%); Right Coronary Artery (31.4%). Average number of burrs 1.5; average maximum diameter 1.63mm. Temporary pacing wires utilisation 34.3% . Drug Eluting Stents (DES) was utilised in 84.4% of cases. Two patients had coronary artery perforations (Ellis Classification (EC) system); One Type 1 perforation (no clinical sequalae); one Type 3 (frank) perforation only evident post-stenting during aggressive balloon postdilatation. This patient died before surgical salvage could occur. Another death occurred in a patient with multiorgan failure– the death was unrelated to PTCRA. One patient suffered a large periprocedural myocardial infarct related to iatrogenic coronary dissection occurring during post stenting phase of procedure. Conclusion: In a hospital without on-site cardiac surgical capabilities, PTCRA was performed safely with acceptable survival outcomes at thirty days. No deaths or large MI's occurred that were directly attributable to PTCRA.

Poly(ADP‐ribose) Polymerase 1 (PARP1) in Atherosclerosis: From Molecular Mechanisms to Therapeutic Implications

Poly(ADP-ribosyl)ation reactions, carried out by poly(ADP-ribose) polymerases (PARPs/ARTDs), are reversible posttranslational modifications impacting on numerous cellular processes (e.g., DNA repair, transcription, metabolism, or immune functions). PARP1 (EC 2.4.2.30), the founding member of PARPs, is particularly important for drug development for its role in DNA repair, cell death, and transcription of proinflammatory genes. Recent studies have established a novel concept that PARP1 is critically involved in the formation and destabilization of atherosclerotic plaques in experimental animal models and in humans. Reduction of PARP1 activity by pharmacological or molecular approaches attenuates atherosclerotic plaque development and enhances plaque stability as well as promotes the regression of pre-established atherosclerotic plaques. Mechanistically, PARP1 inhibition significantly reduces monocyte differentiation, macrophage recruitment, Sirtuin 1 (SIRT1) inactivation, endothelial dysfunction, neointima formation, foam cell death, and inflammatory responses within plaques, all of which are central to the pathogenesis of atherosclerosis. This article presents an overview of the multiple roles and underlying mechanisms of PARP1 activation (poly(ADP-ribose) accumulation) in atherosclerosis and emphasizes the therapeutic potential of PARP1 inhibition in preventing or reversing atherosclerosis and its cardiovascular clinical sequalae.

Portal Vein Thrombosis after Splenectomy

Backgroundand Aim of the work: Splenectomy is a common operation but it carries the danger of many postoperative complications. One of the most important complications is the portal vein thrombosis (PVT), which may be fatal due to development of bowel ischemia and severe portal hypertension. Due to the effect of hypobaric hypoxia and higher liability for thrombosis encountered in high altitude areas, PVT may represent an actual problem in Taif province. The aim of this retrospective study is to detect the incidence, pattern of presentation, laboratory, radiological and results of treatment of cases of PVT following splenectomy. Methods: In this study, we reviewed all cases of splenectomy performed in King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia from January 2007 to January 2012. Cases of PVT following splenectomy were analyzed for incidence, pattern of presentation, laboratory, radiological and results of treatment. Results: This study involved 50 patients (40 males and 10 females) admitted in the surgical department of King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia from January 2007 to January 2012. Eight cases of Portal vein thrombosis (16%) out of 50 splenectomies were identified. These 8 patients included: 4/10 of the patients (40%) suffering from myeloproliferative (MP), 3 of them (75%) had spleen weight greater than 3,000 g, 3/12 (25%) of the hemolytic anemia patients, and 1/10 of the patients (10%) operated upon for Hypersplenism. All patients had splenomegaly with mean weight of 1540 Gms (range 460 to 3850 g). Presenting symptoms included; anorexia in 7/8 cases (87.5%), abdominal pain in 6 (75%), and in all cases there was elevation in D-Dimer level, leukocyte and platelet counts. All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One/8 patients (12.5%) died from progressive liver cell failure; the others are alive with no clinical sequalae at a mean follow up of 27 months. CONCLUSIONS: PVT is a relatively common complication of splenectomy in patients with Splenomegaly, especially in Taif and related districts in which there is already a higher incidence of thrombotic disorders. The surgeon has to be with high index of suspicion, for early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation for successful outcome.

1092. Adenovirus-Based Vaccine Prevents Pneumonia in Ferrets Challenged with the SARS Coronavirus

Top of pageAbstract The human severe acute respiratory syndrome coronavirus (SARS-CoV) is the etiologic agent responsible for the spread of the acute respiratory syndrome in Asia and Canada that claimed several human lives in 2003. A ferret model of SARS-CoV infection was used to evaluate the efficacy of an adenovirus-based vaccine. Ferrets infected with a clinical isolate of SARS-CoV via intranasal inhalation developed a syndrome similar to that observed in humans that consisted of fever and clinical signs of toxicity. Virus replicated in lung and was recovered in nasal washes. Patchy but widely disseminated bronchopneumonia developed characterized by infiltration of neutrophils and monocytes. Animals were vaccinated with recombinant adenoviruses expressing the Spike protein of SARS-CoV prior to challenge with SARS-CoV. The most impressive therapeutic results were obtained when the animals were primed with a human adenovirus expressing Spike and boosted with a serologically distinct adenovirus from chimpanzee also expressing the Spike antigen. Following challenge with SARS-CoV the acute fever was lessened and clinical sequalae were diminished. Viral loads in lung and nasal washes were down 6 logs as compared to animals vaccinated with a control vector. There was no evidence of gross lung pathology at necropsy and histological findings were limited to mild focal inflammation in alveolar septa and around some small airways. The same prime boost strategy was also effective in rhesus macaques and resulted in SARS-CoV neutralizing antibody titers of up to 1/2560 and |[gamma]|-INF positive T cells reaching 12,000 SFC per million PBMCs as assessed by ELISPOT. These data indicate that a heterologous adenovirus-based prime boost vaccine strategy could stimulate a strong immunity that may be needed for complete protection against SARS-CoV infection.

Liver function disturbances following laparoscopic cholecystectomy: incidence and significance.

Unexplained disturbances of liver function parameters after laparoscopic cholecystectomy have been reported in a few previous studies. We aimed to assess the incidence of these disturbances, and their relation to age, sex, duration of surgery, and type of gallbladder inflammation, as well as their clinical significance. All patients undergoing laparoscopic cholecystectomy at Dallah Hospital, Riyadh, Saudi Arabia, during the year 2001 were prospectively evaluated. In all the patients, six parameters of liver function (direct bilirubin, indirect bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients with suspected chronic liver disease or common bile duct pathology were excluded. Patients who showed more than a 100% increase in at least one parameter (group I) were compared with those who did not (group II) regarding age, sex, duration of surgery, and type of gallbladder inflammation. Of the patients, 67.1% showed more than a 100% increase in at least one parameter of liver function. No significant difference was noticed between the two groups regarding age, duration of surgery, or type of gallbladder inflammation. Female patients, however, showed a significantly higher incidence of liver function changes (P = .011). No clinical adverse reactions were reported in those who showed liver function changes. Changes in liver function parameters after laparoscopic cholecystectomy are common, carrying no clinical sequalae. They are more common in female patients and are not related to age, duration of surgery, or the acuteness of gallbladder inflammation. Assessment of direct bilirubin and alkaline phosphatase is sufficient for the routine evaluation of these patients postoperatively.

Is Cerebral Microembolism in Prosthetic Heart Valves Clinically Relevant?

P138 Background. High intensity transient signals (HITS) are frequently detected by TCD ultrasound in patients with mechanical PHV, but the published data about their clinical relevance is controversial. This study was undertaken to determine whether the presence of HITS is related to clinical and neuropsychological changes in patients with mechanical PHV. Methods. Patients with mechanical PHV had bilateral 30 minute TCD monitoring for microemboli (HITS) detection with and without oxygen (O 2 ) inhalation. Cognitive testing of patients included MMSE, DRS, and Microcog with two measures: General Cognitive Performance (GCP) and General Cognitive Functioning (GCF). Results. We studied 36 patients (20 females, mean age 58±13 years), 20 with mitral, 9 with aortic, and 7 with a combined PHV after median of 1.5 years of valve insertion. HITS were detected in 72% of patients. There was no difference in HITS frequency between 16 symptomatic and 20 asymptomatic patients. HITS counts were significantly decreased after O 2 inhalation (21.7±30.6 vs. 3.3±9.1 s, p=0.009 ). Table shows that no relationship exists between the number of HITS and cognitive scores of patients. Conclusion. Decreased frequency of HITS after oxygen inhalation confirms their gaseous origin. Lack of relationship between the HITS and cognitive performance suggests that cerebral microembolism in PHV is a benign epiphenomenon without any clinical neurological and neuropsychological sequalae.

Posterior C1-C2 transarticular screw fixation in the treatment of displaced type II odontoid fractures in the geriatric population—review of seven cases

BACKGROUND Seven geriatric patients presented with displaced Type II odontoid fractures. All patients underwent a posterior C1-C2 transarticular fixation between November 1994 and December 1996. Ages ranged between 63 and 88 years. METHODS Fractures were treated with placement of bilateral transarticular screws, allowing immediate fixation, except in one patient, for whom only a unilateral screw was used. An autograft interspinous strut was also placed, allowing three-point fixation. Mean follow-up was 10.6 months. RESULTS Six patients received rigid fixation and developed a stable union. One patient died before any follow-up could be obtained. Two other patients died within 1 year of unrelated causes. The remaining four patients remain active and independent. One intraoperative vertebral artery injury was identified. No clinical sequalae were noted. CONCLUSION Posterior transarticular screw fixation is a reasonable option in treating these controversial fractures. Seven geriatric patients tolerated this surgery well, and were mobilized early, avoiding complications related to external immobilization.