Neuroblastoma in the Era of Precision Medicine: A Clinical Review

The latest advances in treatment for patients with neuroblastoma are constantly being incorporated into clinical trials and clinical practice standards, resulting in incremental improvements in the survival of patients over time. Survivors of high-risk neuroblastoma (HRNBL), however, continue to develop treatment-related late effects. Additionally, for the majority of the nearly 50% of patients with HRNBL who experience relapse, no curative therapy currently exists. As technologies in diagnostic and molecular profiling techniques rapidly advance, so does the discovery of potential treatment targets. Here, we discuss the current clinical landscape of therapies for neuroblastoma in the era of precision medicine.

Vein of Galen Malformation Manifesting as High-Output Heart Failure

The sudden onset of vomiting in a previously healthy term neonate has a broad differential requiring a thorough history and physical examination. When this does not reveal the underlying cause, a workup must be performed to rule out potentially devastating diagnoses that must be addressed in a timely fashion. In infants, this clinical presentation could be due to infections such as sepsis or meningitis, gastrointestinal causes such as anatomical abnormalities or ingestions, or cardiac causes such as congenital heart disease. Conversely, inborn errors of metabolism or neurologic issues such as vascular anomalies or a tumor with associated increased intracranial pressure could also be the culprit. In this report, we discuss the case of a previously healthy newborn with a rare cause of vomiting and feeding intolerance, which was ultimately discovered to be due to the vein of Galen malformation.

Retrospective study to assess the impact of hepatitis C virus infection on the prognosis and management of multiple myeloma

e20001

Background: Multiple Myeloma (MM) is a neoplasm of the post-germinal center, terminally differentiated B-cells. MM accounts for 1% of all types of cancer and 10% for all hematologic malignancies. Chronic hepatitis C virus (HCV) is an infection that affects over 71 million patients worldwide. Cytotoxic agents and immunosuppressive therapy as steroids are the main line of therapy in lymphoid malignancies, but these drugs may exacerbate chronic viral hepatitis and cause uncontrolled replication of hepatitis viruses. The impact of HCV infection on MM patients remains unclear. Objective: To assess the impact of HCV infection on the prognosis and management of MM patients. Methods: A 10-year retrospective study of MM patients was conducted at Cairo University Clinical Oncology Department from January 2009 to April 2019. Results: During this time, 150 patients were diagnosed with MM, 109 (72.7%) were HCV negative, 24 (16%) were HCV positive, and 17 (11.3%) with unknown HCV status. The median age was 51 and 54 years for HCV negative and positive groups respectively, with a statistically insignificant difference (p-value > 0.2). In the multivariate analysis, HCV infection was not an independent factor related to overall survival (OS), however age, creatinine and hemoglobin levels correlated significantly with OS (p < 0.009, 0.008, 0.031 respectively). The median OS for the HCV negative group was 31.11 months (95% CI: 22.62 - 39.61) compared to 37.66 months (95% CI: 7.19 - 68.13) for the HCV positive group. The median progression-free survival (PFS) for all patients was 18.9 months, for HCV positive patients was 15.36 months (95% CI: 13.18 – 17.54), and for HCV negative patients was 20.49 months (95% CI: 14.13 – 26.85). Age below 60 years and creatinine level less than 2 mg/dL were statistically significant for favorable disease-free survival (DFS) (p < 0.030, 0.034 respectively). Conclusions: Age, creatinine and hemoglobin levels are significant prognostic factors in MM but HCV status doesn’t affect the overall survival or progression-free survival. HCV infection should not contraindicate MM therapy.

Bempegaldesleukin (BEMPEG; NKTR-214) efficacy as a single agent and in combination with checkpoint-inhibitor therapy in mouse models of osteosarcoma

Survival of patients with relapsed/refractory osteosarcoma has not improved in the last 30 years. Several immunotherapeutic approaches have shown benefit in murine osteosarcoma models, including the anti-programmed death-1 (anti-PD-1) and anti-cytotoxic T-lymphocyte antigen-4 (anti-CTLA-4) immune checkpoint inhibitors. Treatment with the T-cell growth factor interleukin-2 (IL-2) has shown some clinical benefit but has limitations due to poor tolerability. Therefore, we evaluated the efficacy of bempegaldesleukin (BEMPEG; NKTR-214), a first-in-class CD122-preferential IL-2 pathway agonist, alone and in combination with anti-PD-1 or anti-CTLA-4 immune checkpoint inhibitors in metastatic and orthotopic murine models of osteosarcoma. Treatment with BEMPEG delayed tumor growth and increased overall survival of mice with K7M2-WT osteosarcoma pulmonary metastases. BEMPEG also inhibited primary tumor growth and metastatic relapse in lungs and bone in the K7M3 orthotopic osteosarcoma mouse model. In addition, it enhanced therapeutic activity of anti-CTLA-4 and anti-PD-1 checkpoint blockade in the DLM8 subcutaneous murine osteosarcoma model. Finally, BEMPEG strongly increased accumulation of intratumoral effector T cells and natural killer cells, but not T-regulatory cells, resulting in improved effector:inhibitory cell ratios. Collectively, these data in multiple murine models of osteosarcoma provide a path toward clinical evaluation of BEMPEG-based regimens in human osteosarcoma.

Pediatric Manubriosternal Dislocation: A Case Report and Review of Literature

Pediatric sternal dislocation is an extremely rare event, with less than 15 cases reported in the literature. We report the case of a traumatic sternal segment dislocation in an 8-year-old male that was caused by an unsuccessful backflip resulting in a direct force to the chest. The diagnosis was made by chest computed tomography. Open reduction and internal fixation (ORIF) were performed with a good outcome noted at follow-up. In addition to a thorough description of this case, we have included an organized review of existing literature with an aim to establish trends in presentation, clinical course, and outcomes among sternal dislocation in the pediatric population.

Hemorrhagic Giant Cell Tumor of the Occipital Skull Base: A Case Report and Literature Review

Giant cell tumor of bone is a benign but locally aggressive osteolytic neoplasm that represents 3% to 5% of all primary bone tumors, primarily found at the epiphyses of long bones. Less than 1% are of calvarial origin. Herein, we report a rare case of a nine-year-old girl with a hemorrhagic giant cell tumor of the left occipital skull base.

Severe Pancytopenia Induced by Valproic Acid

Valproic acid is commonly used to treat pediatric epilepsy. This drug is usually well-tolerated; its side effects are typically mild, with hepatotoxicity being the most widely recognized one. Bone marrow suppression is a rarely seen complication in patients with valproic acid levels more than 125 mcg/mL. Reported cases indicate an increased incidence of hematologic toxicity; however, evidence for management is limited. We report a case of bone marrow suppression induced by a high dose of valproic acid in a 10-year-old male.

Group B Streptococcus Osteomyelitis in a Healthy Adolescent

Group B Streptococcus (GBS), Streptococcus agalactiae, is a bacterium often screened for pregnant women and associated with neonatal infections. However, GBS disease is also rising among non-pregnant adults, especially among immunocompromised patients. The median age of non-pregnant adults with invasive GBS disease is 64 years. It can present as skin and soft tissue infection, osteomyelitis, pneumonia, urosepsis, and meningitis. There is very limited data on GBS disease occurring in the pediatric population past the infancy stage. In this report, we present a case of a 16-year-old male with GBS osteomyelitis.

Abstract A03: Autophagy and HSP27: A potential link to define autophagy fate in osteosarcoma

Survival in osteosarcoma (OS) has not improved in over a decade, thus the need for new therapeutic strategies. Autophagy, a catabolic process used by cells to survive under stress, has been implicated in resistance to chemotherapy. We previously demonstrated aerosol gemcitabine (GCB) efficacy against OS lung metastasis and showed GCB to induce autophagy through the Akt/mTOR signaling pathway. Whether autophagy contributes to tumor response or resistance to GCB has been the focus of our studies. What determines whether chemotherapy-induced autophagy will lead to survival or death is unknown. We found phosphorylated heat shock protein 27 (pHSP27) to potentially define the outcome of chemotherapy-induced autophagy in OS. Small heat shock proteins, specifically HSP27, are upregulated in many cancers, including OS, and associated with treatment resistance. The purpose of this study is to investigate if induction of pHSP27 predicts the role of chemotherapy-induced autophagy in OS lung metastasis. We hypothesize that when pHSP27 is induced, blocking autophagy will lead to increased sensitivity to GCB. Furthermore, inhibition of pHSP27 may revert the effect of GCB-induced autophagy in OS cells by decreasing sensitivity to GCB. We showed in the LM7 and CCH-OS-D human metastatic OS cells in vitro, that GCB induces autophagy as determined by the conversion of microtubule-associated light chain 3 one to two (LC3I/LC3II), increase in Beclin 1, and decrease in p62 protein expression. Sensitivity of LM7 cells to GCB was enhanced after autophagy inhibition by hydroxychloroquine (HCQ), a pharmacologic inhibitor and shRNA targeting Beclin 1, suggesting autophagy as a prosurvival mechanism whereas in CCH-OS-D cells inhibition of autophagy decreased cell sensitivity to GCB, concluding here that induction of autophagy leads to cell death. We demonstrated that pHSP27 is significantly higher in GCB-treated LM7 cells as compared to CCH-OS-D cells. We also showed that inhibition of HSP27 by shRNA targeting HSP27 has no effect on GCB-induced autophagy in LM7 cells. Treatment of shHSP27LM7 with GCB resulted in an increase in LC3I/LC3II conversion and a decrease in p62. We further revealed this in vivo by conducting a pilot study in which shHSP27LM7 cells were injected i.v. into nude mice. 6 weeks later, lung metastases were confirmed. Animals were divided into two groups: untreated and aerosol GCB treated (1mg/mL three times a week). Mice were sacrificed after 2 weeks of therapy. Transmitted electron microscopy demonstrated an increase in the number of autophagosomes in lung metastasis from mice treated with GCB, confirming induction of autophagy in the absence of HSP27. Lastly, in order to demonstrate that inhibition of HSP27 will change GCB-induced autophagy response in LM7 cells, we treated shHSP27LM7 cells with the combination GCB+HCQ and showed increased viability compared to the LM7 GipZ control cells, confirming preliminarily our hypothesis that induction of pHSP27 will determine chemotherapy-induced autophagy response in OS.

Citation Format: Grace Nehme, Kumar Felix, Andrew Wahba, Diana M. Fandino, Nancy Gordon. Autophagy and HSP27: A potential link to define autophagy fate in osteosarcoma [abstract]. In: Proceedings of the AACR Special Conference on Targeting PI3K/mTOR Signaling; 2018 Nov 30-Dec 8; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Res 2020;18(10_Suppl):Abstract nr A03.

Spontaneous Tonsillar Hemorrhage due to Infectious Mononucleosis

Spontaneous tonsillar hemorrhage is defined as continuous bleeding for more than one hour, or more than 250 mL of blood loss regardless of the duration of bleeding. It is associated with various pathologic conditions, including acute or chronic tonsillitis, peritonsillar or parapharyngeal abscess, infectious mononucleosis, carotid aneurysm or pseudoaneurysm, and tonsil cancer. It is a rare complication with very limited data reported in the literature. Reported cases indicate an increased incidence in young patients, associated with a higher mortality rate. We report a rare case of spontaneous tonsillar hemorrhage due to infectious mononucleosis in a previously healthy 16-year-old female.

Severe necrotizing pneumonia complicated by empyema in a neonate

Necrotizing pneumonia is a severe complication of pneumonia, characterized by local destruction of lung tissue with development of multiple small cavities (abscesses) and may be associated with empyema. Empyema is an unusual complication in neonates with limited data reported. We present a healthy term neonate with late-onset sepsis caused by Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia due to severe necrotizing pneumonia associated with advanced stage empyema. To the best of our knowledge this is the youngest reported patient with multifocal lung abscesses associated with stage 2 empyema treated successfully without surgical intervention.

Abstract 3210: A potential immunotherapeutic approach for the treatment of osteosarcoma

Purpose: Survival of osteosarcoma (OS) patients has remained stagnant for the past 30 years thus the need for new therapeutic strategies.

NKTR-214 is a novel cytokine therapy that provides sustained activation of the IL-2 pathway with a bias to the IL-2 receptor CD122 (IL-2Rbeta gamma) so that it can selectively expand and proliferate CD8+ T cells. Compared to recombinant human IL-2, NKTR-214 demonstrated superior therapeutic benefit in a melanoma mouse model and was well-tolerated. Because systemic IL-2 has shown limited efficacy against OS, we hypothesize that NKTR-214 could potentially offer increased therapeutic benefit.

Methods: The K7M2/K7M3 disseminated and orthotopic OS mouse models were used. Three doses of NKTR-214 were given intravenously every 9 days. In the K7M2 disseminated model a prophylactic or therapeutic approach was taken where treatment was started right after tumor injection or when there was evidence of lung metastases. In the K7M3 orthotopic model, treatment was started once tumor was established (day 20) or 10 days after tumor injection. Bone tumor size was assessed by serial plain X-rays. Immunohistochemistry was performed to assess histologic tumor response (bone and lung) as well as evidence of immune cell infiltrate. Tumor immune infiltrate was analyzed by flow cytometry.

Results: We demonstrated therapeutic effect of NKTR-214 as a single agent. In the disseminated model, NKTR-214 administered every 9 days i.v. prophylactically resulted in an increase in the median survival of mice with OS lung metastases (21 days untreated vs. 51 days NKTR-214). Survival was similar when therapeutic treatment was started after tumor nodules were apparent in the lung and continued every 9 days (51 days vs 52.5 days). In the orthotopic model, we demonstrated NKTR-214 efficacy against K7M3 primary bone tumor and the development of pulmonary metastases. The total tibia tumor area in the NKTR-214-treated group was significantly lower than in the untreated group (p&lt;0.01). Likewise, the total lung metastases tumor area as well as the number of micrometastases was significantly lower in the treated as compared to the untreated group (p&lt;0.009). We also demonstrated increase in the number of CD8+ and CD4+ T cells in mice treated with NKTR-214 single agent as compared to the untreated group. This data provides rationale for the use of NKTR-214 alone or in combination with checkpoint inhibitors or adoptively transferred NK cells or T cells as a potential effective therapy for OS.

Conclusion: In conclusion, our findings demonstrate that NKTR-214 is effective in controlling the growth of primary OS, regrowth of tumor after amputation and inhibition of lung metastasis formation. These pre-clinical studies provide the basis for potential translation of NKTR-214-based immunotherapeutic regimens for OS into the clinic.

Citation Format: Marlene Hennessy, Souri Felix, Andrew Wahba, Saul Kivimae, Takahiko Miyama, Mariella Cabrera, Maria Gabriela Segura, Jonathan Zalevsky, Willem Overwijk, Nancy Gordon. A potential immunotherapeutic approach for the treatment of osteosarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3210.

Follicular output rate can predict clinical pregnancy in women with unexplained infertility undergoing IVF/ICSI: a prospective cohort study

This study aimed to determine whether follicular output rate (FORT) can predict the clinical pregnancy rate in women with unexplained infertility undergoing IVF/ICSI. This was a prospective study conducted at Dar El Teb subfertility centre in Cairo between June 2014 and July 2016. A total of 303 women with unexplained infertility, who were undergoing IVF/ICSI, were divided into three groups according to FORT tertile values. FORT was calculated as pre-ovulatory follicle count/antral follicle count × 100. There was a progressive and significant increase from the low to the high FORT groups in the clinical pregnancy rate (29.9%, 43.3% and 57.8%; P < 0.001), number of retrieved oocytes (5.4 ± 1.5, versus 6.8 ± 2.8, and 7.4 ± 2.1; P < 0.001), and fertilization rate (48.4 ± 21.8 versus 55.3 ± 20.3 and 57.4 ± 19.2; P = 0.006). Multivariate logistic regression analysis revealed that the correlation between FORT and pregnancy was independent of potential confounding factors (P = 0.008). We concluded that FORT is an independent variable affecting the clinical pregnancy rate in IVF/ICSI cycles. Higher FORT values had better oocyte yield and clinical pregnancy rates in women with unexplained infertility undergoing IVF/ICSI with potentially normal ovarian response.

Antioxidant activity of milk protein hydrolysate in alloxan-induced diabetic rats

We investigated the effects of milk protein concentrate (MPC) and milk protein concentrate hydrolysate (MPCH) as antioxidant agents in rats. Six groups of healthy (non-diabetic) and type-II diabetic rats were used: (1) healthy rats (control), (2) alloxan-induced rats (diabetic control group), (3) healthy rats treated orally with MPC, (4) diabetic rats treated orally with MPC, (5) healthy rats treated orally with MPCH, and (6) diabetic rats treated orally with MPCH. We concluded that treatment with MPC or MPCH reduced the level of thiobarbituric acid reactive substances in healthy and diabetic rats. Treatment with MPC or MPCH improved activities of antioxidant enzymes (catalase, superoxide dismutase, reduced glutathione, glutathione-S-transferase, and glutathione peroxidase) in healthy and diabetic rats. From the present data, we concluded that both MPC and MPCH contain potent antioxidants and could improve the health of rats or other animals with diabetes mellitus.

Chronic postsurgical pain in patients 5 years after cardiac surgery: A prospective cohort study

BACKGROUND

Chronic postsurgical pain (CPSP) is a common complication after many surgical procedures, including cardiac surgery. The prevalence of CPSP after cardiac surgery ranges from 9.5% to 56%. Most studies on CPSP after cardiac surgery are retrospective and long-term prospective studies are scarce. The aim of this study was to follow CPSP and health-related quality of life (HRQOL) prospectively in a cohort of patients, emphasizing the prevalence from 12 months to 5 years.

METHODS

A total of 534 patients (23% ≥75 years, 67% men) were consecutively included before surgery. Study-specific questionnaires and the Brief Pain Inventory (BPI) were used to measure CPSP at baseline, 12 months and 5-year follow-up. Short-Form Health Survey (SF-36) was used to measure HRQOL.

RESULTS

Among 458 patients who were alive after 5 years, 82% responded (n = 373). The majority, 89.8% (335/373), did not report CPSP, neither 12 months nor 5 years after surgery. Among the 38 patients who reported CPSP after 12 months, 24 (63%) patients did not report CPSP after 5 years. The overall prevalence of CPSP after 5 years was 3.8% (14/373). Patients reporting CPSP and resolved CPSP had lower scores on HRQOL and more pain preoperatively than patients who did not report CPSP.

CONCLUSIONS

The prevalence of CPSP was lower in this study than previously reported. Among the patients reporting CPSP at 12 months, 63% did not report CPSP after 5 years. Hence, the observed decline in CPSP is in line with studies evaluating CPSP in noncardiac surgery.

SIGNIFICANCE

The prevalence of chronic postsurgical pain (CPSP) at 5 years after surgery of 3.8% is lower than previously reported. The majority of patients reporting CPSP after 12 months did not report CPSP after 5 years.

Levosimendan improves contractility in vivo and in vitro in a rodent model of post-myocardial infarction heart failure

AIM

As few studies have presented a thorough analysis of the effect of levosimendan (LEV) on contractility, our purpose was to investigate in vivo cardiac function as well as in vitro cardiomyocyte function and calcium (Ca(2+) ) handling following LEV treatment.

METHODS

Rats with post-myocardial infarction heart failure (HF) induced by ligation of the left anterior descending coronary artery and sham-operated animals were randomized to the infusion of LEV (2.4 μg kg(-1) min(-1) ) or vehicle for 40 min. Echocardiographic examination was coupled to pressure-volume sampling in the left ventricle before (B) and after (40 min) infusion. Isolated left ventricular cardiomyocytes were studied in an epifluorescence microscope.

RESULTS

HF LEV (n = 6), HF vehicle (n = 7), sham LEV (n = 5) and sham vehicle (n = 6) animals were included. LEV infusion compared to vehicle in HF animals reduced left ventricular end-diastolic pressure and mean arterial pressure (both P < 0.001) and improved the slope of the preload-recruitable stroke work (P < 0.05). Administrating LEV to HF cardiomyocytes in vitro improved fractional shortening and Ca(2+) sensitivity index ratio, and increased the diastolic Ca(2+) (all P < 0.01).

CONCLUSION

In HF animals, LEV improved the contractility by increasing the Ca(2+) sensitivity. Furthermore loading conditions were changed, and LEV could consequently change organ perfusion. An observed increase in diastolic Ca(2+) following LEV treatment and clinical implications of this should be further addressed.

Pre-operative and intraoperative determinants for prolonged ventilation following adult cardiac surgery

BACKGROUND

Prolonged ventilation is a serious complication after cardiac surgery, but few risk prediction models exist. Our objectives were to develop a specific risk prediction model based on pre-operative variables, to identify whether selected intraoperative variables could improve prediction, and to compare our model with the EuroSCORE.

METHODS

Data from 5027 patients undergoing open-heart surgery in 2000-2007 were used for logistic regression model development. Internal validation was performed by bootstrapping. Discrimination and calibration were assessed with areas under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test. Our pre-operative model was compared with predictions based on the additive and logistic EuroSCORE.

RESULTS

Age, previous cardiac surgery, peripheral arterial disease, left ventricular hypertrophy, chronic pulmonary disease, renal insufficiency, pre-operative hemoglobin concentration, urgent or emergency operation, and operation other than isolated coronary artery bypass grafting were identified as pre-operative predictors for prolonged ventilation (model I). Discrimination and accuracy were excellent (AUC: 0.848 and shrinkage factor: 94%). Calibration was good (Hosmer-Lemeshow test: P = 0.43). Inclusion of a few intraoperative variables somewhat improved the model, increasing shrinkage factors (96%) and discrimination ability (AUC model II = 0.870 and model III = 0.875 for two alternative such models). Our pre-operative model showed better performance than the logistic or additive EuroSCORE.

CONCLUSIONS

The pre-operative risk prediction model for prolonged ventilation with easily obtainable variables in routine clinical work performed well and was only slightly improved by inclusion of intraoperative variables. Performance was better than with the EuroSCORE.

Mortality risk prediction in cardiac surgery: comparing a novel model with the EuroSCORE

BACKGROUND

Several models for prediction of early mortality after open-heart surgery have been developed. Our objectives were to develop a local mortality risk prediction model, compare it with the European System for Cardiac Operative Risk Evaluation (EuroSCORE), and investigate whether the addition of intra-operative variables could enhance the accuracy of risk prediction.

METHODS

All 5029 patients undergoing open-heart surgery in 2000-2007 were included in the study. Logistic regression with bootstrap methods was used to develop a pre-operative risk prediction model for in-hospital mortality. Next, several intra-operative variables were added to the pre-operative model. Calibration and discrimination were assessed, and the model was internally validated for prediction in future datasets. We thereafter compared the pre-operative model with the additive and logistic EuroSCOREs.

RESULTS

Our pre-operative model included eight risk factors that are routinely registered in our department: age, gender, degree of urgency, operation type, previous cardiac surgery, and renal, cardiac, and pulmonary dysfunction. The model estimated mortality accurately throughout the dataset except in the 1% of patients at extremely high risk, in which mortality was somewhat overestimated. The estimated shrinkage factor was 0.930. The areas under the receiver operating characteristic curve for our pre-operative model and the logistic EuroSCORE were 0.857(0.823-0.891) and 0.821(0.785-0.857) (P=0.02). There was no significant difference in performance between the pre-operative and the intra-operative model (P>0.10).

CONCLUSION

Our pre-operative model was simple and easy to use, and showed good predictive ability in our population. Internal validation indicated that it would accurately predict mortality in a future dataset.

Chronic pain after cardiac surgery: a prospective study

BACKGROUND

Chronic pain is a complication of several surgical procedures. The prevalence of chronic pain reported after cardiac surgery varies from 18% to 61%. However, most studies are retrospective, do not use validated instruments for pain measurement or include only pain at the sternum site. The aim of the present study was to assess chronic pain and health-related quality of life (HRQOL) after cardiac surgery.

METHODS

In a prospective, population-based study, we included 534 patients (413 males) and assessed chronic pain and HRQOL before, 6 months after, and 12 months after cardiac surgery. Pain was measured by the Brief Pain Inventory, while HRQOL was measured by the Short-Form 36 (SF-36).

RESULTS

Five hundred and twenty-one patients were alive 12 months after surgery; 462 (89%) and 465 (89%) responded after 6 and 12 months, respectively. Chronic pain was reported by 11% of the patients at both measurements. Younger age was associated with chronic pain [odds ratio 0.7 (95% confidence interval: 0.5-0.9)] at 12 months. Patients with chronic pain reported lower scores on seven of eight SF-36 subscales.

DISCUSSION

In conclusion, we observed a lower prevalence of chronic pain after cardiac surgery than in previous studies. Still, more than one out of 10 patients reported chronic pain after cardiac surgery. Chronic pain appears to affect HRQOL. Thus, given the large number of patients subjected to cardiac surgery, this study confirms that chronic pain after cardiac surgery is an important health care issue.

Sonoclot analysis in elderly compared with younger patients undergoing coronary surgery

BACKGROUND

The Sonoclot analyzer is a point-of-care method for assessment of the clotting mechanism in whole blood. The results are available within 20 min. The aim of the present study was to investigate whether repeated Sonoclot analyses could identify peri-operative differences in hemostatic function between elderly and younger patients undergoing coronary artery bypass grafting (CABG). In addition, we investigated whether Sonoclot analyses could identify disturbances in hemostatic function leading to post-operative bleeding.

METHODS

Twenty-five elderly and 25 younger patients undergoing CABG were included. Blood samples for Sonoclot analyses were drawn pre-operatively, during surgery, and during the first 20 post-operative hours. The Sonoclot variables sonACT, clot rate, time-to-peak, amplitude of the peak, and R3 were analyzed, and the results were compared between the two groups. Post-operative blood loss volumes were recorded and correlated to the Sonoclot variables. The Sonoclot variables were also correlated to previously reported results on various hemostatic variables measured in the same patient population.

RESULTS

There was a significant difference in sonACT between the two groups (P=0.018). There were no differences between the groups in any of the other Sonoclot variables. There were no significant correlations between any of the Sonoclot variables and post-operative bleeding, or between the Sonoclot variables and other hemostatic variables.

CONCLUSIONS

The difference in sonACT between the two groups indicates a reduced hemostatic function in the elderly patients. However, repeated Sonoclot analyses were not able to identify more specific disturbances in hemostatic function, and did not predict increased post-operative bleeding.

Rectal lactate levels in endoluminal microdialysate during routine coronary surgery

The aim of this prospective study was to determine the feasibility of intestinal endoluminal microdialysis as a new method for clinical monitoring of the adequacy of splanchnic perfusion in the large bowel. A microdialysis catheter for continuous lactate, glycerol, glucose and pyruvate measurements attached to a tonometric catheter was placed into the lumen of the recto-sigmoid junction prior to surgery in 13 patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB). Lactate was also measured in blood and muscle. CPB was associated with a 10-fold increase in luminal lactate from 0.16 (0.01) to 1.67 (0.38) mmol x l(-1) (p < 0.001). Muscular lactate increased from baseline levels 1.20 (0.21) to 1.77 (0.36) mmol x l(-1) during CPB (p = 0.01), but the muscular lactate-pyruvate ratio remained unchanged. Arterial lactate increased only slightly from 0.9 (0.05) to 1.1 (0.06) mmol x l(-1) (p = 0.027) during CPB. Increased lactate concentrations in the large bowel during CPB are suggestive of local lactate production consistent with impaired oxygen delivery. Intestinal endoluminal microdialysis is a potential clinically applicable method for monitoring intestinal metabolism. Combined with tonometry, microdialysis provides the opportunity to monitor both circulation and metabolism in the rectal mucosa.

Severe poisoning with sotalol and verapamil. Recovery after 4 h of normothermic CPR followed by extra corporeal heart lung assist

In acute poisoning with beta-blocking drugs and calcium-channel blockers patients may present with serious symptoms. We present a case of life-threatening sotalol and verapamil intoxication in a 29-year-old female suffering from depression. She was admitted to our hospital a few hours after she had taken 3.6 g verapamil and 4.8 g sotalol. On being found the patient was breathing and had a palpable pulse. On admission the patient experienced a cardiovascular collapse and CPR was started. Echocardiography confirmed cardiac standstill. After 4 h of normothermic CPR, extra corporeal heart lung assist (ECHLA) was established. Vasoactive drugs could be stopped after 2 days with ECHLA, and after 5 days the patient was extubated. The patient experienced several complications (intestinal bleeding, transient nerve paralysis, and renal failure due to rhabdomyolysis) but made a complete recovery and started working 6 months after the poisoning. She was no longer depressed.

Effects of autotransfusion of mediastinal shed blood on biochemical markers of myocardial damage in coronary surgery

BACKGROUND

Previous studies have shown conflicting results regarding the effect of autotransfusion of mediastinal shed blood after coronary artery bypass grafting (CABG) on the serum levels of myocardial band (MB) isoenzymes of creatine kinase (CK-MB) and cardiac troponins. The effect of autotransfusion on serum levels of human heart fatty acid binding protein (H-FABP), another marker of myocardial necrosis, has not been studied. The aim of the present study was to investigate the effects of autotransfusion of mediastinal shed blood on the serum levels of CK-MB, cardiac troponin T (cTnT), and H-FABP after uncomplicated primary CABG.

METHODS

Fifty patients were randomized to post-operative autotransfusion of mediastinal shed blood or no autotransfusion. Blood samples for the analysis of the biochemical markers of myocardial damage were drawn pre-operatively and 1, 4, 12, 24, 48, and 72 h after the termination of cardiopulmonary bypass. Samples from the mediastinal shed blood were collected after 1 and 4 h.

RESULTS

The levels of the biochemical markers of myocardial injury were all markedly elevated in mediastinal shed blood. Autotransfusion did not significantly affect the serum levels of cTnT or H-FABP. However, during the early post-operative hours, there was a trend towards a higher level of cTnT and H-FABP in the autotransfusion group. During the first 24 h after surgery, the autotransfusion group had a significantly higher serum level of CK-MB.

CONCLUSION

Post-operative autotransfusion of mediastinal shed blood may contribute to elevated serum levels of biochemical markers of myocardial injury.

Mitral valve incompetence following blunt chest trauma after mitral valve repair. Recognition by three-dimensional echocardiography

We present a unique case of mitral incompetence following blunt chest trauma in a 46-year-old woman who had undergone successful mitral valve repair 2 years before the accident. Three-dimensional echocardiography revealed the precise pathology, with partial avulsion of the annuloplasty ring and rupture of chordae tendineae.

The influence of the duration of cardiopulmonary bypass on coagulation, fibrinolysis and platelet function

BACKGROUND

The duration of cardiopulmonary bypass (CPB) might influence blood coagulation. This appears particularly relevant in the light of new, less invasive techniques that propose smaller incisions at the expense of a possible prolongation of time on CPB.

METHODS

The time-dependent effects on coagulation, fibrinolysis and platelet function were investigated in 94 patients scheduled for elective coronary artery bypass grafting. Tests on coagulation, fibrinolysis, and platelet function (flow cytometric assay of expression densities of glycoprotein IIb/IIIa and P-selection were performed the day before surgery and after completion of surgery.

RESULTS

A significant correlation was found between the duration of CPB and parameters of increased coagulation, decrease of platelet counts during CPB and platelet function. Longer duration of CPB led to an increased need for transfusion of red blood cells.

CONCLUSIONS

The duration of CPB affects thrombin formation as well as platelet count and function, but not the fibrinolytic system. This may prove to be a disadvantage when employing minimally invasive techniques that prolong the duration of CPB.

Effects of extracorporeal circulation and heparin on the phenotype of platelet surface antigens following heart surgery

In this prospective study, the time-dependent effects of extracorporeal circulation and heparin-mediated effects on platelet surface antigens in vitro were investigated using whole blood flow cytometry. Blood samples were drawn prior to and following extracorporeal circulation in 89 patients. The response of surface antigen expression (glycoprotein IIb/IIIa, P-selectin, and glycoprotein Ib) with and without in vitro stimulation was measured. A significant correlation of the duration of extracorporeal circulation with the postoperative response of glycoprotein IIb/IIIa, glycoprotein Ib, and P-selectin to in vitro activation was found. Postoperative P-selectin and glycoprotein Ib expression stimulated with ADP correlated to blood loss. Heparin in vitro significantly reduced glycoprotein Ib expression. Heparin, as well as the duration of extracorporeal circulation, independently correlated to phenotypic changes of platelets following extracorporeal circulation. The significant correlation of these variables to postoperative blood loss demonstrates their relevance to platelet function in vivo.

Low-energy cardioversion with epicardial wire electrodes: new treatment of atrial fibrillation after open heart surgery

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia after open heart surgery. Traditional treatment with a range of antiarrhythmic drugs and electrical cardioversion is associated with considerable side effects. The aim of this study was to examine the feasibility and efficacy of low-energy atrial defibrillation with temporary epicardial defibrillation wire electrodes.

METHODS AND RESULTS

Epicardial defibrillation wire electrodes were placed at the left and right atria during open heart surgery in 100 consecutive patients (age 65+/-9 years; male to female ratio 67:23). Electrophysiological studies performed postoperatively revealed a test shock (0.3 J) impedance of 96+/-12 omega (monophasic) and 97+/-13 omega (biphasic). During their hospital stay, AF occurred in 23 patients (23%) at 2.1+/-1.3 days postoperatively. Internal atrial defibrillation was performed in 20 patients. Of these patients, 80% (16/20) were successfully cardioverted with a mean energy of 5.2+/-3 J. Early recurrence of AF (< or =60 seconds after defibrillation) developed in 8 patients. Five patients had multiple episodes of AF. In total, 35 episodes of AF were treated, with an 88% success rate. Only 6 patients (30%) required sedation. No complications were observed with shock application or with lead extraction.

CONCLUSIONS

Atrial defibrillation with temporary epicardial wire electrodes can be performed safely and effectively in patients after cardiac operations. The shock energy required to restore sinus rhythm is low. Thus, patients can be cardioverted without anesthesia.

Are in-vitro platelet function tests useful in predicting blood loss following open heart surgery?

BACKGROUND

We investigated the suitability of two commercially available in-vitro bleeding tests (IVBT), the PFA-100 and the Hepcon HMS, to predict blood loss following operations with extracorporeal circulation (ECC) and compared them with conventional coagulation studies.

METHODS

In 40 patients subjected to elective open heart surgery with ECC a blood sample was taken before and after ECC to measure platelet count, prothrombin time, aPTT, D-dimers, fibrinogen, and PFA-100 and Hepcon HMS data. The postoperative blood loss was recorded hourly until removal of drains.

RESULTS

A significant correlation was found between total blood loss (250-1750 ml) and the preoperative PFA-100 (r = 0.41, p = 0.022), the preoperative platelet count (r = -0.42, p = 0.007), the preoperative D-dimer concentration in the plasma (r = 0.41, p = 0.01), and duration of ECC (r = 0.35, p = 0.044). There was no significant correlation between blood loss and the Hepcon HMS system.

CONCLUSIONS

Although a significant correlation was found between blood loss and the PFA-100 IVBT, the practical value of these tests in the clinical situation is limited due to a great variability in individual results.

Heparin-coated equipment reduces the risk of oxygenator failure

BACKGROUND

The development of an abnormal pressure gradient (APG) across the oxygenator is the most common cause of oxygenator failure during cardiopulmonary bypass. This necessitated changing the oxygenator in 4 patients in this series. A retrospective analysis of conditions predisposing to APG was performed.

METHODS

One thousand nine hundred fifty-nine operations with cardiopulmonary bypass were performed in adults. A range of membrane oxygenators was used subject to availability; 769 oxygenators were heparin-coated and 1,190 were uncoated. The pressure gradient across the oxygenator was measured under standardized conditions. An APG was defined as a gradient of greater than twice the mean.

RESULTS

An APG occurred in 44 uncoated and 3 heparin-coated oxygenators (p < 0.001). The mean age was higher for the APG group (p < 0.001). Fibrin deposits in the arterial line filter were noted in 45 patients. Logistic regression revealed that only fibrin deposition in the arterial line filter and the use of uncoated oxygenators were significantly associated with APG.

CONCLUSIONS

We conclude that a heparin-coated oxygenator effectively prevents APG. This adds significantly to the safety of open heart operations.

Predictors of blood loss after coronary artery bypass grafting

OBJECTIVE

To assess the predictive value of variables possibly associated with blood loss after coronary artery bypass grafting (CABG).

DESIGN

A prospective study.

SETTING

A university hospital.

PARTICIPANTS

Eighty-nine patients scheduled for elective CABG.

INTERVENTIONS

Blood samples were drawn before and after surgery. Chest tube drainage was measured hourly until removal of drains.

MEASUREMENTS AND MAIN RESULTS

Activation of coagulation and fibrinolysis, routine clotting tests, and expression of platelet surface antigens were analyzed using flow cytometry. A significant correlation was found among blood loss and activated partial thromboplastin time, fibrinogen, prothrombin fragment 1 + 2, D-dimers, platelet count, GPIb and P-selectin expression on platelets, use of internal thoracic artery, cross-clamp time, and thrombin-antithrombin III complex. In a multiple regression model, glycoprotein (GP) Ib expression on platelets, platelet count, use of internal thoracic artery, and D-dimers were significantly associated with blood loss. Logistic regression analysis showed that GPIb and D-dimers predicted an increased blood loss with a positive predictive value of 73% and a negative predictive value of 91%.

CONCLUSIONS

Postoperative D-dimers and GPIb expression may be useful to exclude nonsurgical causes in bleeding patients after CABG.

[Recurrent angina pectoris in stress caused by hemangioma of the heart]

We present the case of a 73-year-old man with a 3-week history of recurrent exertional angina confirmed by exercise stress testing. The symptoms were caused by hemangioma situated between the pulmonary artery and the left auricle. The diagnosis was confirmed by ventriculography, coronary angiography, and CT-scanning. The tumor was completely removed through a midline sternotomy without extracorporeal circulation. Histology revealed the diagnosis of a cavernous hemangioma with endothelial lined vascular channels of varying size. The patient made an uneventful recovery and remained asymptomatic during follow up. Cardiac hemangioma are rare tumors of the heart that may cause angina by interfering with the coronary blood flow. Surgery is curative for most patients.

Outcome of cardiopulmonary resuscitation following open heart surgery

The outcome of cardiopulmonary resuscitation (CPR) following cardiac surgery is not known to date. A retrospective analysis of all patients subjected to CPR during their hospital stay following heart surgery was conducted; 1.4% of patients required CPR 0.5-192 h following surgery. The mean duration of CPR was 42 +/- 29 min. Twenty-nine patients were subjected to emergency rethoractomy and 14 patients received coronary artery bypass grafting. The hospital mortality was 46%. There was a significant correlation of duration of CPR and death (r = 0.44, p = 0.004). The commonest cause of death was consecutive multiorgan failure in 12 patients. Twenty-one patients were long-term survivors without neurological sequelae. Twenty patients were in NYHA class I or II. Ventricular fibrillation and myocardial ischaemia are the commonest conditions leading to CPR in an average population of patients immediately after cardiac surgery. Aggressive treatment and emergency rethoracotomy in most cases results in long-term survival in 50%.

Fluid therapy with Ringer's solution versus Haemaccel following coronary artery bypass surgery

BACKGROUND

Crystalloid and colloid infusion can be used in volume therapy following heart surgery. In this prospective, randomised study we compared Ringer's solution (group R) to Haemaccel (group H) following coronary artery bypass grafting.

METHODS

A stringent protocol for adjusting the infusion rate was used. Haemodynamic parameters and pulmonary function were evaluated as well as chest tube drainage. The double-indicator dilution method was used to measure total blood volume index (TBVI), intrathoracic blood volume index (ITB-VI) and extravascular lung water index (EVLWI).

RESULTS

Haemodynamic stability was achieved in both groups throughout the study period, as judged from mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, and cardiac index. However, the total volume infused was significantly higher in group R. TBVI and ITBV were higher in group H, although only significant at 8 h for TBVI. Pulmonary function was similar in both groups. There was no significant difference in EVLWI, pulmonary shunt fraction, and time on mechanical ventilation. Likewise, chest tube drainage was not significantly different in both groups.

CONCLUSION

We conclude that volume therapy with Haemaccel following heart surgery requires less volume and achieves better filling of the circulation compared to Ringer's solution.

Fluid resuscitation with Haemaccel vs. human albumin following coronary artery bypass grafting

Several colloid preparations are available for fluid resuscitation following heart surgery. We conducted a randomized prospective trial to compare a polygeline infusion versus human albumin with respect to hemodynamic and pulmonary function. 20 patients were randomly assigned to receive either Haemaccel or human albumin using a standardized protocol for the first 8 hours following heart surgery. The double-indicator dilution method was used to measure total blood volume index (TBVI), intrathoracic blood volume index (ITBVI) and extravascular lung water index (EVLWI) three times during the study period. Pulmonary shunt fraction, time on ventilator, and chest tube drainage were measured as well. Hemodynamic stability was achieved in both groups throughout the study period, as judged from mean arterial pressure, pulmonary capillary wedge pressure, and cardiac index. ITBV and TBVI were higher in the albumin group, although only significant at 4 hours for TBVI. There was no significant difference in EVLWI, pulmonary shunt fraction, and time on mechanical ventilation. Likewise, chest tube drainage was not significantly different in both groups. Haemaccel is effective in maintaining hemodynamic stability following heart surgery without ill effects of lung function or chest tube drainage. Treatment costs are substantially lower compared to human albumin.

Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass

Aprotinin reduces blood loss following cardiopulmonary bypass operations (CPB) by the prevention of hyperfibrinolysis. Its influence on circulating platelets is uncertain. In this prospective trial we investigated activation, adhesion, and aggregation receptors on the platelet surface in 20 patients who underwent elective coronary artery bypass grafting. These patients were randomly assigned to receive either a high dose of aprotinin or placebo. Flow cytometry was performed to determine platelet activation [P-selectin, glycoprotein (GP) 53], adhesive (GP Ib), and aggregatory (GP IIb-IIIa) receptors on circulating platelets, before, during, and after CPB. Aprotinin had neither a significant effect on platelet activation nor on adhesive and aggregatory receptors. Plasma levels of D-dimers were measured before and after CPB to assess fibrinolytic activity. D-dimers following CPB and chest tube drainage were significantly less in the aprotinin group. We conclude that aprotinin reduces blood loss by its effect on fibrinolysis but has no direct influence on platelet function.