Tryfon Vainas

Serum C-Reactive Protein Level Is Associated With Abdominal Aortic Aneurysm Size and May Be Produced by Aneurysmal Tissue

Background—Abdominal aortic aneurysms (AAA) are characterized by extensive transmural inflammation and C-reactive protein (CRP) has emerged as an independent risk factor for the development of cardiovascular disease. Therefore, we evaluated a possible association between serum CRP and aneurysm dimension in patients with asymptomatic AAA. Furthermore, the possibility of CRP production by aneurysmal tissue has been examined. Methods and Results—Serum CRP was determined highly sensitive (hs CRP) and aneurysmal size was measured in 39 patients with AAA. The presence of CRP mRNA was assessed in the aneurysmal tissue of 16 patients. Mean (SD) hs CRP was 3.23 (2.96) mg/L. After log-transformation, hs CRP correlated significantly with aneurysmal size (r =0.477, P =0.002). When the patients were divided into 3 equally sized groups according to hs CRP level, aortic diameter increased from lowest to upper hs CRP-tertile (49 mm, 61 mm, and 67 mm, respectively;P <0.05 for 3rd versus 1st tertile). This association persisted after correction for risk factors. CRP mRNA was found in 25% of aneurysmal aortic tissues. Conclusions—This is the first report showing that serum hs CRP is associated with aneurysmal size and that—in at least some patients—CRP may be produced by aneurysmal tissue. These data underscore the inflammatory nature of AAA formation, suggesting that serum hs CRP may serve as a marker of AAA disease and that CRP produced in vascular tissue might contribute to aneurysm formation.

Pressure Ulcers and Prolonged Hospital Stay in Hip Fracture Patients Affected by Time-to-Surgery

Background:Hip fractures are associated with high morbidity. Pressure ulcer formation after hip surgery is often related to delayed patient mobilization. The objectives of this study were to determine whether time-to-surgery affects development of pressure ulcers postoperatively and, thus, length of hospital stay.Patients and Methods:We performed a retrospective analysis of consecutive hip fracture patients, aged 60 years and above, who underwent surgery between 1995 and 2001. The primary outcome was in-hospital development of pressure ulcers. The secondary outcome measure was the overall length of hospital stay. Analyses were adjusted for relevant confounders.Results:Of the 722 patients enrolled, 488 patients (68%) received surgery at 12 h after admission. Approximately 30% (n = 214) developed pressure ulcers during admission, whilst 19% of patients operated within 12 h of admission developed pressure ulcers. Time-to-surgery was an independent predictor of both development of pressure ulcers (OR = 1.7, 95% confidence interval [CI] = 1.2–2.6; p = 0.008) and length of hospital stay (11.3 vs 13.3 days in the early and the late surgery group, respectively, p = 0.050). Furthermore, development of pressure ulcers was associated with prolonged postoperative hospital stay (19.5 vs 11.1 days for patients with and without pressure ulcers, respectively, p = 0.001)Interpretation:In hip fracture patients, time-to-surgery was an independent predictor of both postoperative pressure ulcer development and prolonged hospital stay. These data suggest that the implementation of an early surgery protocol following admission for hip fractures may reduce both the postoperative complications and overall hospital stay.

Chlamydia pneumoniae Serology Is Associated With Thrombosis-Related but Not With Plaque-Related Microembolization During Carotid Endarterectomy

Background and Purpose— Chlamydia pneumoniae has repeatedly been associated with atherosclerotic disease. Our study was designed to clarify whether this association is based on C pneumoniae-induced transformation of a stable into an unstable atherosclerotic plaque or on stimulation of hypercoagulability leading to increased thrombotic arterial occlusions by C pneumoniae infection. Transcranial Doppler ultrasonographic monitoring of the middle cerebral artery during carotid endarterectomy offers the opportunity to study, before removal of the plaque, atherothrombotic emboli dislodging from an unstable carotid plaque (plaque-related emboli) and emboli related to (excessive) thrombus formation at the endarterectomy site after removal of the plaque and restoration of flow (thrombosis-related emboli). Methods— C pneumoniae IgA (≥1/16) and IgG (≥1/64) seropositivity was assessed in 53 patients with symptomatic carotid artery disease undergoing carotid endarterectomy. The removed carotid plaques were studied histologically to assess plaque instability. Results— Plaque- and thrombosis-related emboli were registered in 43 patients with an adequate transtemporal window. IgA seropositivity (58%) was associated significantly with thrombosis-related embolization (P =0.030) but not with plaque-related embolization or with histological plaque instability. Conclusions— C pneumoniae serology is associated with microembolization after endarterectomy and restoration of flow. Since these microemboli represent platelet aggregations and are related to cerebrovascular complications, our data suggest that C pneumoniae infection contributes to cerebrovascular events in patients with carotid artery disease through stimulation of thrombosis.

Chlamydia pneumoniae serology: comparing a commercial enzyme immunoassay and microimmunofluorescence test in patients with cardiovascular disease.

Chlamydia pneumoniae has been associated with cardiovascular disease and the detection of C. pneumoniae antibodies has subsequently challenged many cardiovascular investigators. The micro‐immunofluoresence (MIF) test is considered the gold standard for detection of C. pneumoniae antibodies, but requires a high‐level of expertise for adequate interpretation. We compared an enzyme immunoassay (EIA) with a microimmunofluorescence test for the detection of C. pneumoniae IgG‐ and IgA antibodies in sera of 141 patients with atherosclerosis. The MIF test was read by two independent observers. The interobserver agreement of the MIF test for detection of seropositivity at various cut‐off levels was good for IgG and for IgA. The intra‐test agreement of the EIA was excellent for IgG and IgA. The agreement between EIA and MIF in detection of IgG‐ and IgA antibodies was adequate at low but not at high titer levels. At low titer levels, the sensitivity, specificity, positive and negative predictive value of EIA compared to the MIF test was sufficient. The sensitivity of the EIA increased, improving the agreement with the MIF at high titer levels by retesting sera with elevated titers at higher pre‐dilutions. In conclusion, the EIA shows sufficient agreement with the MIF test in the detection of C. pneumoniae seropositivity. Therefore, the EIA is a practical alternative to the MIF in the detection of C. pneumoniae antibodies in patients with cardiovascular disease, bearing in mind that the sensitivity of the EIA depends on the antibody titer.

Endovascular treatment of a hepatic artery pseudoaneurysm associated with gastrointestinal tract bleeding

Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding from the pancreatic duct originating from aneurysms or pseudoaneurysms of peripancreatic arteries. It is a life-threatening cause of gastrointestinal bleeding that should always be considered in patients with prolonged or intermittent obscure gastrointestinal blood loss, or both, especially in patients with pancreatic disorders or prior pancreatic surgery. We demonstrate an endovascular treatment strategy in a patient with a common hepatic pseudoaneurysm and upper gastrointestinal tract bleeding, with preserved flow in the hepatic artery. This treatment consisted of a covered stent placement in the hepatic artery, followed by transcatheter coil embolization of collateral feeding arteries.

TOPICAL NEGATIVE PRESSURE TECHNIQUES IN CHRONIC LEG ULCERS

Publisher Summary This chapter presents a prospective and comparative model to evaluate the efficacy of VAC treatment in recalcitrant chronic leg ulcers (CLUs) treated in an inpatient facility compared with current standard therapeutic regimens. VAC therapy provides subatmospheric pressure to a wound through a polyurethane ether (PU) or polyvinyl alcohol (PVA) foam dressing that is custom fitted to the wound size at the bedside. The choice of foam depends on the aspect of the wound bed, the size, and the type of the wound. The foam is covered with an adhesive drape to create an airtight seal. Application of subatmospheric pressure creates a moist wound environment. Chronic leg ulcers constitute a major health care problem for patients, physicians, and heath care systems alike. The patients suffer from markedly reduced quality of life; slow healing tendencies, and high recurrence rates, while the treatments are costly. Thus, this clinical problem requires renewed research into its pathophysiology and novel therapeutic approaches. One of the major problems in leg ulcer treatment is the high frequency of relapses. Interestingly, recurrence rates in CLUs after treatment with VAC therapy compared with standard wound care modalities have not been reported to date, to the best of our knowledge. Without any doubt, it would be of great advantage in daily practice if VAC revealed lower recurrence rates than standard wound care regimens.