Significance of clinical-immunological patterns and diagnostic yield of biopsies in microscopic polyangiitis and granulomatosis with polyangiitis

BACKGROUND

Microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are the two major antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

OBJECTIVES

To characterize a homogenous AAV cohort and to assess the impact of clinicopathological profiles and ANCA serotypes on clinical presentation and prognosis. Clinical differences in GPA patients according to ANCA serotype and the diagnostic yield for vasculitis of biopsies in different territories were also investigated.

RESULTS

This retrospective study (2000-2021) included 152 patients with AAV (77 MPA/75 GPA). MPA patients (96.1% myeloperoxidase [MPO]-ANCA and 2.6% proteinase 3 [PR3]-ANCA) presented more often with weight loss, myalgia, renal involvement, interstitial lung disease (ILD), cutaneous purpura, and peripheral nerve involvement. Patients with GPA (44% PR3-ANCA, 33.3% MPO, and 22.7% negative/atypical ANCA) presented more commonly with ear, nose, and throat and eye/orbital manifestations, more relapses, and higher survival than patients with MPA. GPA was the only independent risk factor for relapse. Poor survival predictors were older age at diagnosis and peripheral nerve involvement. ANCA serotypes differentiated clinical features in a lesser degree than clinical phenotypes. A mean of 1.5 biopsies were performed in 93.4% of patients in different territories. Overall, vasculitis was identified in 80.3% (97.3% in MPA and 61.8% in GPA) of patients.

CONCLUSIONS

The identification of GPA presentations associated with MPO-ANCA and awareness of risk factors for relapse and mortality are important to guide proper therapeutic strategies in AAV patients. Biopsies of different affected territories should be pursued in difficult-to-diagnose patients based on their significant diagnostic yield.

Single-center experience of cerebral artery thrombectomy using the TREVO device in 60 patients with acute ischemic stroke

BACKGROUND AND PURPOSE

We sought to explore the safety and efficacy of the new TREVO stent-like retriever in consecutive patients with acute stroke.

METHODS

We conducted a prospective, single-center study of 60 patients (mean age, 71.3 years; male 47%) with stroke lasting <8 hours in the anterior circulation (n=54) or <12 hours in the vertebrobasilar circulation (n=6) treated if CT perfusion/CT angiography confirmed a large artery occlusion, ruled out a malignant profile, or showed target mismatch if symptoms >4.5 hours. Successful recanalization (Thrombolysis In Cerebral Infarction 2b-3), good outcome (modified Rankin Scale score 0-2) and mortality at Day 90, device-related complications, and symptomatic hemorrhage (parenchymal hematoma Type 1 or parenchymal hematoma Type 2 and National Institutes of Health Stroke Scale score increment ≥ 4 points) were prospectively assessed.

RESULTS

Median (interquartile range) National Institutes of Health Stroke Scale score on admission was 18 (12-22). The median (interquartile range) time from stroke onset to groin puncture was 210 (173-296) minutes. Successful revascularization was obtained in 44 (73.3%) of the cases when only the TREVO device was used and in 52 (86.7%) when other devices or additional intra-arterial tissue-type plasminogen activator were also required. The median time (interquartile range) of the procedure was 80 (45-114) minutes. Good outcome was achieved in 27 (45%) of the patients and the mortality rate was 28.3%. Seven patients (11.7%) presented a symptomatic intracranial hemorrhage. No other major complications were detected.

CONCLUSIONS

The TREVO device was reasonably safe and effective in patients with severe stroke. These results support further investigation of the TREVO device in multicentric registries and randomized clinical trials.

Timed surgery for treatment of angiofibromas in tuberous sclerosis

Angiofibromas are neoformations frequently occurring on the face of patients affected by tuberous sclerosis. Traditional methods of treating angiofibromas, such as curettage, dermabrasion, chemical peeling, cryosurgery, and laser are not entirely successful as they frequently lead to scarring and pigmentary change. We report the successful use of timed surgery, a novel electrosurgical procedure, in treating multiple angiofibromas. The technique is easy to use and very cost effective.

Treatment of "stable" vitiligo by Timedsurgery and transplantation of cultured epidermal autografts

OBJECTIVE

To optimize melanocyte/keratinocyte co-cultivation and to evaluate the effectiveness of autologous cultured epidermal grafts in the surgical treatment of stable vitiligo.

DESIGN

After optimization of melanocyte/keratinocyte cultures, achromic lesions were disepithelialized by means of programmed diathermosurgery (Timedsurgery) and covered with autologous epidermal grafts prepared from secondary cultures. Melanocyte content was evaluated by dopa reaction. The percentage of repigmentation was calculated using a semiautomatic image analysis system.

SETTING

A biosafety level 3 cell culture facility and a dermatological department in a hospital.

PATIENTS

Thirty-two patients carrying different types of vitiligo were admitted to the study and treated with autologous cultured epidermal grafts. Inclusion criteria were (1) failure of at least 2 standard medical approaches; (2) no therapy for at least 12 months; (3) absence of progression of old lesions, absence of appearance of new lesions, and absence of Koebner phenomenon within the past 18 months; and (4) absence of autoimmune disorders.

RESULTS

One hundred five achromic lesions (a total of 6078.2 cm(2)) were treated. The average percentage of repigmentation, evaluated after 12 to 36 months of follow-up, was 77%. Independent of the type of vitiligo, average percentages of repigmentation of extremities and periorificial sites were 8% (31.8 cm(2) repigmented/420.5 cm(2) transplanted) and 35% (17.6 cm(2) repigmented/50.0 cm(2) transplanted), respectively. Percentages of repigmentation of all other body sites ranged from 88% to 96% (4329.7 cm(2) repigmented/4675.2 cm(2) transplanted). Color matching was good and scar formation was not observed.

CONCLUSION

Cultured epidermal grafts can be considered a real therapeutic surgical alternative for "stable" but not lip-tip vitiligo.

Sonographic appearance of a retained surgical sponge in the neck

We report the sonographic appearance and clinical course of a retained surgical sponge in the neck beginning 6 months after a partial thyroidectomy. Sonograms showed a subcutaneous curvilinear hyperechoic interface with marked acoustic shadowing obscuring the left side of the neck. Three months later, a fistulous tract could be seen. Surgical exploration revealed a florid foreign tissue reaction due to a retained surgical sponge. Early diagnosis of retained sponges is important to enable expeditious removal before complications develop.

Surgical thimble for use in augmentation mammaplasty

A conveniently formed thimble has been created for use in dissection during augmentation mammaplasty and gynecomastia operations which forms a rigid extension to the surgeon's finger. With the aid of this instrument, which is fitted onto the third and partly onto the second phalanx of the index finger, the delicacy and maneuverability characteristics of digital dissection are on the whole retained and the surgeon avoids the use of traditional dissection instruments gripped in the hand, with which it is easy to exceed the desired limits of dissection creating nervous lesions and unequal pockets.