CONTENT TIMISOARA MEDICAL JOURNAL - VOLUME 61, Numbers 3-4/2011 MEDICINE
Original Articles
An Improved Model of Severe Sepsis in Pigs Daniel Erces, Bettina Zsikai, Lajos Bizanc, Peter Sztanyi, Gergely Vida, Mihaly Boros, Lucian Jiga, Mihai Ionac, Yvette Mandi, Jozsef Kaszaki
Original Articles
An Original Stereotactic Device for Trans-Thoracic CT-Guided Biopsy. An Experimental Study Ovidiu Burlacu, Alexandru Nicodin, T. Jurma, F. Ioanovici, I. Petrache, Octavian Cretu, D. Iliescu, Camelia Budisan
Original Articles
Surgical Management of Infrarenal Aortic Aneurysm - a Single Center one Year Experience Claudiu Rascanu, A. Krikun, E. Klenk
Original Articles
Morbidity and Initial Results of Urethroplasty with Oral mMcosa Graft, Collected from the Lower Lip Under Local Anesthesia Jozsef Szabo1, Radu Boja2, Vlad Petcu3, Florin Dinca3, Paul Rotariu3, Roxana Nica4, Florentina Nalbaru4, Alexandra Stirbu4, Ionel Ciobanu3, Ion Tocaciu3, Daniel Sarb3
Original Articles
Minimally Invasive Prostate Cancer Diagnosis by Gluthatione S-Transferase P1 (GSTP1) Gene Methylation Analysis in Serum Specimens Raluca Dumache
1a
, Victor Dumitrascu , Radu Minciu , Dana David , Anca Tudor, Bogdan Bumbacila
5a
, Maria Puiu
Original Articles
Complications of Roux-En-Y Gastric Bypass Performed By Laparotomy. Comparison With the Laparoscopic Approach Described in the Literature Laurentiu V. Sima, Alexandra C. Sima, Radu G. Dan, Gelu M. Breaza, Octavian M. Cretu
Original Articles
The Role of Multimodal Analgesia in Patients With Tubal Pathology Treated by Laparoscopic Surgery Laura Gavril, Adrian Cotirlet, Florentina Pricop
Original Articles
The Analysis of Atherosclerotic Carotid Involvement in Symptomatic Coronary Patients with Mitral/Aortic Annulus Calcification Silvia Georgiana Ionescu, Irina Popescu, Adina Ionac, Sorin Pescariu, Stefan Iosif Dragulescu
Original Articles
Multiple Electrodes Aggregometry - a New Method to Assess the Platelet Reactivity in Non-ST Elevation Acute Coronary Syndrome Patients Daniela Maximov, Adina Ionac, Alina Lupu, Cristian Mornos, Stefan I. Dragulescu
Original Articles
Role of Carotid Intima-Media Thickness for Cardiovascular Risk Evaluation Cristina Florea, Sorin Ursoniu, Daniela Gurgus, Adrian Gruici, Dacian Purcarita, Jurgen Jahraus, Raul B. Suciu, Stelian Siminoc, Alina Koussini, Elena A. Ardeleanu
Original Articles
Trends in Bacterial Pathogens of Lower Respiratory Tract Infections in Children Giorgiana F. Brad, Ioan Sabau, Marioara Boia, Tamara Marcovici , Adrian Craciun, Kundnani Nilima, Calin M. Popoiu
Original Articles
Considerations on Juvenile Idiopathic Arthritis Dalia Dop, Dumitru Bulucea, Carmen Elena Niculescu
Original Articles
Correlations Between Clinical Forms and Biomarkers in Juvenile Idiopathic Arthritis Andrea Somogyi Militaru, Ioan Sabau
Original Articles
A Comparison of the Evaluation Scales for Disease Activity Used in Ankylosing Spondylitis: Which One Is More Reliable? Razvan G. Dragoi, Claudiu Avram, Radu Petroman, Oana Suciu, Elena Amaricai, Dan A. Nemes, Mihai Dragoi
Original Articles
Clinical Differences in Seasonal and Non-Seasonal Depression Radu Romosan, Tiberiu Mircea, Felicia Romosan
1,2,3
, Monica Ienciu
1,2
2,3
, Lucian Ile
, Cristina Bredicean
1,2,3
, Ion Papava
1,2,3
,
M. Milin
Original Articles
Incorporation of Isoflavonoid Genistein in Beta Ramified Cyclodextrins - an Option for Improving Water Solubility Corina Tiulea Danciu, Cristina Dehelean, Codruta M. Soica, Camelia Peev, Andrei Motoc
Review Articles
Infections, Antibiotics and Pregnancy Simona Sipos, Mirabela Dima, Camelia Budisan, Adina Bucur, Victor Dumitrascu
Review Articles
The Place of Echocardiography in the Assessement of Patients Receiving Cardiotoxic Cancer Therapies: New Horizons Cristian Mornos, Adina Ionac
Review Articles
Minimal Residual Disease - Generalities and Perspectives Florina Boldeanu
1,2
, Valentin L. Ordodi, Alexandra Gruia, Mirabela Cristea, Elena Gai, Margit Serban
Case Reports
Replacement of the Ascending Aorta and the Aortic Arch for Acute Type A Aortic Dissection Dan Bindea, Sigismund Papp, Luminita Slabu, Simona Oprita, Alexandra Todoran, Teodora Mihai, Traian Scridon
Case Reports
Left Ventricular Non-Compaction - Case Report Irina Popescu, Georgiana Ionescu, Cristian Mornos, Dan Gavrilescu, Dragos Cozma, Flavia Goanta, Adina Ionac
ORIGINAL ARTICLES
AN IMPROVED MODEL OF SEVERE SEPSIS IN PIGS Daniel Erces1, Bettina Zsikai1, Lajos Bizanc1, Peter Sztanyi1, Gergely Vida1, Mihaly Boros1, Lucian Jiga2, Mihai Ionac2, Yvette Mandi3, Jozsef Kaszaki1
REZUMAT Obiectiv: Dezvoltarea unui model de studiu al sepsei pe animalul mare de laborator prin inducerea peritonitei fecale, cu reproducerea caracteristicilor macrohemodinamice, microcirculatorii si inflamatorii, obiectivate in sepsa umana incipienta. Material si metode: Porcii pitici anesteziati au fost supusi peritonitei fecale (n = 9; 0,5 g/kg i.p., autofecale) sau operatiei-control (ser fiziologic i.p., n = 6). Gazimetria a fost monitorizata hemodinamic invaziv la 15-24 ore postchirurgical. Microcirculatia sublinguala a fost exprimata prin modificarile velocitatii eritrocitare (MVE) (prin imagistica spectrala a polarizarii octogonale), in timp ce intervalul PCO2 intestinal a fost masurat prin tonometrie indirecta. Nivelele plasmatice ale proteinei HMGB1 si oxidului nitric/nitrat (NOx) au fost determinate din probe de sange venos. Rezultate: Presiunea arteriala medie a scazut treptat sub 70 mm Hg la animalele cu sepsis, in timp ce frecventa cardiaca si debitul cardiac au crescut constant. In ciuda reactiilor hiperdinamice, MVE a scazut, in timp ce intervalul PCO2 a crescut semnificativ, in comparatie cu grupul control. Concentratiile plasmatice ale NOx si HMGB1 au fost semnificativ crescute la 6-16 ore de la debutul peritonitei. Concluzii: Raportam dezvoltarea unui nou model experimental de studiu al sepsei prin inducerea peritonite fecale la animalul de laborator. Datele obtinute in vivo sugereaza ca acest model experimental este relevant clinic si poate avea un rol inovator in dezvoltarea terapiilor anti-sepsa. Cuvinte cheie: sepsa, circulatie hemodinamica, microcirculatie sublinguala
ABSTRACT Objective: Our aim was to develop a large animal model of sepsis, induced by fecal peritonitis, which reproduces the characteristic macrohemodynamic, microcirculatory and inflammatory changes seen in early human sepsis. Material and methods: Anesthetized minipigs were subjected to fecal peritonitis (n = 9; 0.5 g/kg i.p. autofeces) or sham-operation (i.p. saline, n = 6). Invasive hemodynamic monitoring was started with regular blood gas analyses between the 15-24 hr of the insult. Sublingual microcirculation was characterized by red blood cell velocity (RBCV) changes (with orthogonal polarization spectral imaging), while the intestinal PCO2 gap was measured by indirect tonometry. The plasma levels of high mobility group box protein 1 (HMGB1) and nitrite/nitrate (NOx) were determined from venous blood samples. Results: The mean arterial pressure gradually decreased below 70 mm Hg in septic animals, while the heart rate and cardiac output increased constantly. In spite of the hyperdynamic reaction the sublingual RBCV decreased, while intestinal PCO2 gap increased significantly as compared with the control group. The NOx and HMGB1 plasma concentrations were significantly elevated between 6-16 hr of peritonitis. Conclusion: We report on the introduction of a new animal model fecal peritonitis-induced sepsis. The in vivo data suggest that this experimental model is of clinical relevance and may play useful roles in the development of novel, sepsis-related therapies. Key Words: sepsis, hyperdynamic circulation, sublingual microcirculation, high mobility group box protein 1
INTRODUCTION Sepsis remains a leading cause of mortality in intensive care units (ICUs), without specific therapeutic options. Basic medical research utilizing animal models has provided a greater understanding Institute of Surgical Research, University of Szeged, Hungary, 2 Pius Branzeu Center for Microsurgery and Laparoscopic Surgery, Victor Babes University of Medicine and Pharmacy, Timisoara, 3 Department of Medical Microbiology and Immunobiology, University of Szeged, Hungary 1
Correspondence to: Mihály Boros MD, PhD, DSc, Institute of Surgical Research, University of Szeged, PO Box 427, H-6701 Szeged, Hungary, Tel. +36-62-545103 Email: boros@expsur.szote.u-szeged.hu Received for publication: Oct. 11, 2011. Revised: Dec. 14, 2011.
of its underlying mechanisms, and today the involvement of canonical inflammatory pathways such as the activation of the complement system, leukocytes, lipid mediators and adhesions molecules has been relatively well defined. Nevertheless, the parallel development of clinical treatment strategies did not progress significantly during the last decades. Since similarities between the human and animal responses to septic insults should help to understand the key factors of therapeutic control, the lack of success clearly demonstrates that the currently used in vivo models do not completely mimic human septic conditions.1,2 By definition, a model is a tool via which to understand or describe a system or phenomenon, and the “goodness of fit” through usability testing is its most important characteristic. This suggests that a model with improved clinical relevance may play a _____________________________ Daniel Erces et al
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more useful role in the development of novel, sepsisrelated therapies.3 Our goal was to narrow the gap between experimental and human sepsis by putting much greater emphasis on the reproduction of ICU scenarios and the consequences of intensive treatment. By this approach, not only the septic insult-induced changes, but other, therapy-caused alterations could be considered, similarly to those seen in clinical conditions. To this aim a standardized porcine model of protracted peritonitis was created using intraperitoneal autologous fecal inoculum and complex resuscitation strategies. This communication reports on the most important specific features of the setup, including reproducible macrohemodynamic and microcirculatory variables, and characteristic biochemical data.
MATERIAL AND METHODS The study protocol was approved by the Ethical Committee for the Protection of Animals in Scientific Research at the University of Szeged. The experiments were performed on Vietnamese minipigs of both sexes (average weight 23 ± 3kg) which were underwent a 16-hr preoperative fasting with water ad libitum; the animals were randomly allocated into control (sham-operated; n = 6) and septic groups (n = 9). Anesthesia was induced with an intramuscular injection of a mixture of ketamine (20 mg/kg) and xylazine (2 mg/kg) and maintained with a continuous infusion of propofol (6 mg/kg/hr iv). An endotracheal tube was inserted and the animals were ventilated mechanically with room air (Harvard Apparatus, South Natick, MA, U.S.A.) The tidal volume was set at 12±2 mL/kg, and the respiratory rate was adjusted to maintain the end-tidal carbon dioxide pressure (controlled by capnometry) and the partial arterial carbon dioxide pressure in the range of 35-45 mm Hg (4.6-5.9 kPa). The adequacy of the depth of anesthesia was assessed by monitoring the jaw tone regularly. A central venous catheter with three lumina (7 F; Edwards Lifesciences LLC, Irvine, U.S.A) was introduced into the jugular vein using aseptic surgical technique, for blood sampling and for fluid administration, respectively. Sepsis was induced with an intraperitoneal injection of autofaeces mixture into the abdominal cavity (0.5 g/kg faeces in 200 ml saline and cultivated at 38°C through 6 hrs until the induction of peritonitis). Control animals were treated with 200 ml of sterile saline in the same manner. Thereafter, a single nalbuphine (0.5 mg/kg iv) injection was used _____________________________
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for postoperative analgesia and the sedated animals were brought back to their cages. Invasive haemodynamic monitoring was started 15 hr later. A transpulmonary thermodilution catheter (PiCCO, PULSION Medical Systems AG, Munich, Germany) was placed in the femoral artery and a pulmonary artery catheter (PV2057 VoLEF Catheter, PULSION Medical Systems AG, Munich, Germany) was introduced via the femoral vein by tracing the pressure signals. A midline laparotomy was performed and a tonometric probe was introduced into the small intestine through a small incision to record mucosal pCO2 changes. Thereafter the most commonly used volume therapies were applied in the septic group of animals. Infusion of crystalloid-colloid fluid combinations [lactated Ringer’s solution at a rate of 10 ml/kg/hr; hydroxyethyl starch in a dose of 5 ml/ kg/hr (Voluven 6%; 130 kDa/0.4; Fresenius Kabi Deutschland GmbH, Homburg, Germany)] was started for supporting intravascular volume through 4 hrs (between 16th and 20th hour of the experiments). At the final part of the study period vasopressor therapy (0.015 µg/kg/hr norepinephrine in 20 ml saline iv) was started if the MAP decreased under 65 mmHg to avoid the kidney failure (the pressor treatment was necessary in 4 out of 9 animals). The sham-operated group was infused with crystalloid solution (lactated Ringer’s solution) during this time at a rate of 10 ml/ kg/hr. Hemodynamic measurements Mean arterial pressure (MAP) and cardiac output were registered by PiCCO monitor, while central venous pressure (CVP) and pulmonary artery pressure (PAP) signals were monitored continuously with a computerized data-acquisition system (SPELL Haemosys; Experimetria Ltd., Budapest, Hungary). The systemic vascular resistance (SVR) was calculated via the standard formula TPR = (MAP - CVP)/cardiac output. pCO2 gap measurements A difference between local tissue and arterial pCO2 (paCO2) levels is a sensitive parameter with which to evaluate the effectiveness of therapy aimed at counteracting a microcirculatory dysfunction in the gastrointestinal (GI) tract.4 A silastic balloonfree tonometric probe (Tonosoft Medical Technical and R&D Ltd., Hungary) was introduced through a small enterotomy into the intestinal lumen to monitor intramucosal pCO2 levels by capnometry.5 For calculation of the pCO2 gap values, simultaneously taken paCO2 levels were subtracted from the tonometric pCO2 levels. Arterial blood samples were taken regularly, and blood-gas parameters were
measured with a blood-gas analyzer (Cobas b121, Roche, Austria). Intravital videomicroscopy of the microcirculation The intravital orthogonal polarization spectral (OPS) imaging technique (Cytoscan A/R, Cytometrics, Philadelphia, Pennsylvania, USA) was used for non-invasive visualization of the sublingual microcirculation.6 The OPS method makes use of reflected polarized light, which allows noninvasive imaging of the microcirculation on the surface of solid organs without the need for fluorescence contrast enhancement. In brief, linearly polarized light is scattered in the tissue and serves as a virtual light source. Images are obtained at 548 nm wavelength, which is the isobestic point for oxy- and deoxyhemoglobin. In this way red blood cells in the microcirculation appear in black on the white background of the surrounded tissue. A 10x objective was placed onto the surface of the sublingual area, and microscopic images were recorded with an S-VHS video recorder (Panasonic AG-TL 700, Matsushita Electric Ind. Co. Ltd, Osaka, Japan). Quantitative assessment of the microcirculatory parameters was performed off-line by frame-to-frame analysis of the videotaped images. Red blood cell velocity (RBCV, μm/s) changes in the postcapillary venules were determined in three separate fields by means of a computer-assisted image analysis system (IVM Pictron, Budapest, Hungary). All microcirculatory evaluations were performed by the same investigator. Plasma nitrite/nitrate level measurements The levels of plasma nitrite/nitrate (NOx), stable end-products of nitric oxide (NO), were measured by the Griess reaction. The assay depends on the enzymatic reduction of nitrate to nitrite, which is then converted into a colored azo compound detected spectrophotometrically at 540 nm.7 High mobility group box protein 1 measurements in plasma Two-ml blood samples were drawn from the jugular vein into chilled polypropylene tubes containing EDTA (1 mg ml-1) at baseline, the 6th, 16th hour and at the end of the observation period (24th). The blood samples were centrifuged at 1200g for 10 min at 4oC. The plasma samples were then collected and stored at -70oC until assay. Plasma concentration of high mobility group box protein 1 (HMGB1) was measured by a commercially available HMGB1 ELISA kits (Shino-Test Corporation, Kanagawa, Japan). Statistical analysis Data analysis was performed with a statistical software package (SigmaStat for Windows, Jandel
Scientific, Erkrath, Germany). Nonparametric methods were used. Friedman repeated measures analysis of variance on ranks was applied within the groups. Time-dependent differences from the baseline (time 0), or from the beginning of the invasive monitoring (the 16th hr of the observation period) for each group were assessed by Dunn’s method, and differences between groups were analyzed with MannWhitney test. In the Figures, median values and 75th and 25th percentiles are given. P values < 0.05 were considered significant.
RESULTS In the control group, there were no significant hemodynamic changes as compared with the baseline values, and the plasma mediator levels did not change significantly during the observation period.
Figure 1. Changes in the mean arterial pressure (A) and the heart rate (B) in the control and septic groups. The plots demonstrate the median values and the 25th (lower whisker) and 75th (upper whisker) percentiles, Figure 1. *p<0.05 within groups vs. baseline values, x p<0.05 between groups vs control group values.
There were statistical significant differences in hemodynamics between control and septic groups. The MAP gradually decreased below 70 mmHg in septic animals (Fig. 1A), while the heart rate increased constantly and exceeded the control values significantly (Fig. 1B). In the septic group, the cardiac index was _____________________________ Daniel Erces et al
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remarkably elevated and surpassed significantly the control level from the 20th hr. (Fig. 2A) These changes resulted in dramatic decreases of the SVR. In the septic group the SVR started to decrease at the 18th hr of the experiments and reached the deeper point at 20th hr and then the values were kept at this low level until the end of the study. (Fig. 2B)
in NOx level as compared with the baseline values and to the control group. (Fig. 4A) The plasma HMGB1 concentration gradually increased approx. 5-fold by 16 hr after of the induction of sepsis and remained significantly higher than in the control group up to 24 hr in the observation period. (Fig. 4B)
Figure 2. Changes in cardiac output (A) and the the systemic vascular resistance (B) in the control and septic groups. The plots demonstrate the median values and the 25th (lower whisker) and 75th (upper whisker) Figure 2. percentiles, *p<0.05 within groups vs baseline values, x p<0.05 between groups vs control group values.
Figure 3. Changes in the intestinal pCO2 gap (A) and the red blood cell velocity of the sublingual microcirculation (B) in the control and septic groups. The plots demonstrate the median values and the 25th (lower whisker) and 75th (upper whisker) percentiles, *p<0.05 within groups Figure 3. vs baseline values, x p<0.05 between groups vs control group values.
The pCO2 gap is the difference between the local tissue and the arterial pCO2, and a reliable index of local tissue perfusion. The pCO2 gap of the small intestine in the septic group increased significantly at the beginning of the invasive monitoring (from the 16th hr of sepsis), and remained significantly higher than that for the sham-operated control group. (Fig. 3A) The analysis of the sublingual microcirculation, which represents the peripheral microperfusion status, revealed a gradually decreasing and statistically significantly lower red blood cell velocity in the septic group as compared to both baseline values and the control group, from the 16th hr of the experiment. (Fig. 3B) The NOx concentration in the plasma gives an estimate of the changes in NO production. Sepsis induction resulted in a statistically significant increase _____________________________
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DISCUSSIONS Several animal models try to replicate the signs and laboratory findings seen in human sepsis, where systemic hemodynamics evolves from an early hyperdynamic (“warm shock”) state to a late hypodynamic (“cold shock”) state. Such models include intraperitoneally, intravenously or intrapulmonallyadministered endotoxin (lipolysaccharide) or live bacteria.8,9 Cecal ligation and perforation or induction of bacterial peritonitis with fecal inoculum are also frequently used.10,11 However, it should be stressed that hemodynamic and microcirculatory measurements together with blood sample collections are difficult to perform in rodents, and short-term, hypodynamic models have limited clinical relevance.2
Figure 4. Changes in the plasma levels of nitrite/nitrate (A) and the high mobility group box protein 1 (B) in the control and septic groups. The plots demonstrate the median values and the 25th (lower whisker) and 75th Figure 4. (upper whisker) percentiles, *p<0.05 within groups vs baseline values, x p<0.05 between groups vs control group values.
These are all characterized by initial hypotension and low cardiac output, in contrast to the hyperdynamic circulation commonly seen in patients with septic shock. Furthermore, rodent reactions are markedly differ from human with respect to the immune response to sepsis or the tissue antioxidative capacity and susceptibility to oxidative stress.12,13 Indeed, several therapies proposed based on promising results obtained by these approaches could not be brought to the clinic, and many reviews have shown that the failure to translate basic science results from animals to humans has been mainly attributed to inappropriate animal models that do not fully mimic human sepsis. In our study we switched to larger animals, similarly to Barth et al., who used a comparable, long-term porcine fecal peritonitis model, in which the hyperdynamic circulatory reaction was present between 12-18 hrs after sepsis induction.14 However, we did not employ 24 hrs anesthesia, and in contrast to the Barthâ&#x20AC;&#x2122;s model, the hemodynamic monitoring started later, 15 hr after the insult. In this setup the intra-abdominal septic insult could be accurately standardized with the pre-defined amount
fecal inoculum, and consequently, the inflammatoryhemodynamic responses were reproducible. It has been demonstrated in ICU patients that normalization of hemodynamic status in itself is insufficient to prevent the postoperative complications, since existing microcirculatory disturbances can lead to nutritive insufficiency and multiorgan failure in spite of seemingly adequate macrocirculation.15 Non-invasive imaging techniques, such as OPS and its successor Sidestream Dark Field (SDF) imaging are optical techniques allowing assessment of the microperfusion in case of solid organs, covered with thin epithelial layer, as the sublingual mucosal surfaces.6,15 Indeed, it has been demonstrated in humans that improvement in the sublingual microvascular perfusion, as early as 24 hrs after the onset of shock, can be a good predictor of ICU mortality.16 Our study demonstrated different patterns of microvascular alterations between septic and control animals in both intestinal and sublingual regions, and these data clearly indicated the presence of substantial intestinal and peripheral hypoxia in spite of the hyperdynamic macrocirculation. The microcirculatory reaction could be a consequence of the altered synthesis of NO and proinflammatory cytokines. It is generally accepted that NO produced by constitutive NOS (cNOS), including nNOS and eNOS, are important homeostatic regulators of numerous important physiological functions. In contrast, inducible NO synthase (iNOS) is produced by inflammatory cells, induced by various stimuli such as inflammatory cytokines and bacterial endotoxin, and plays an important role in inflammation.17 Thus, a long lasting elevation of the NOx level of plasma may be considered a hallmark of inflammation in the present study. A systemic response to infection is characterised by early-phase inflammatory cytokines, such as tumor necrosis factor (TNF)-alpha or interleukin (IL)-1 beta. In this respect the high-mobility group box-1 protein (HMGB1) has recently been shown to be a late-phase mediator of sepsis with close correlation with the severity of the process.18,19 In our study the plasma HMGB1 levels peaked 16 hr after the start of septic reaction and remained significantly elevated. HMGB1 is secreted by activated monocytes or macrophages, and is released by necrotic or damaged cells. Extracellular HMGB1 mediates cell-to-cell signalling, provokes the production of inflammatory cytokines and subsequently activated cytokines can induce further release of HMGB1 into the extracellular space.20 _____________________________ Daniel Erces et alâ&#x20AC;&#x192;
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CONCLUSION The micro- and macrohemodynamic changes and many other signs, which are identical to those observed or usually detected in human septic patients, were present in this porcine model of intraabdominal sepsis. This has lead us to conclude that this large animal model characterises the circulatory failure of human sepsis correctly, and may be used for further research of the disease and to test novel therapeutic opportunities.
REFERENCES 1. Kazarian KK, Perdue PW, Lynch W, et al. Porcine peritoneal sepsis: modeling for clinical relevance. Shock 1994;1(3):201-12. 2. Dejager L, Pinheiro I, Dejonckheere E, et al. Cecal ligation and puncture: the gold standard model for polymicrobial sepsis? Trends Microbiol 2011;19(4):198-208. 3. Sadowitz B, Roy S, Gatto LA, et al. Lung injury induced by sepsis: lessons learned from large animal models and future directions for treatment. Expert Rev Anti Infect Ther 2011;9(12):1169-78. 4. Creteur J, De Backer D, Sakr Y, et al: Sublingual capnometry tracks microcirculatory changes in septic patients. Intensive Care Med 2006;32:516-23. 5. Boda D, Kaszaki J, Tálosi G: A new simple tool for tonometric determination of the pCO2 in the gastrointestinal tract. In vitro and in vivo validation studies. Eur J Anaesthesiol 2006;23:680-5. 6. Groner W, Winkelman JW, Harris AG, et al. Orthogonal polarization spectral imaging: A new method for study of the microcirculation. Nature Med 1999;5(10):1209-13.
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7. Moshage H, Kok B, Huizenga JR, et al: Nitrite and nitrate determinations in plasma: a critical evaluation. Clin Chem 1995;41:892-6. 8. Wolfárd A, Kaszaki J, Szabó C, et al. Prevention of early myocardial depression in hyperdynamic endotoxemia in dogs. Shock 2000;13:46-51. 9. Matejovic M, Krouzecky A, Rokyta R Jr, et al. Effects of combining inducible nitric oxide synthase inhibitor and radical scavenger during porcine bacteremia. Shock 2007;27:61-8. 10. Garrido AG, Figueiredo, LFP, Silva MR. Experimental models of sepsis and septic shock: an overview. Acta Cir Bras 2004;19(2):82-8. 11. Buras JA, Holzmann B, Sitkovsky M. Animal Models of sepsis: setting the stage. Nature Reviews Drug Discovery 2005;4:854-65. 12. Bauer M, Reinhart K. From mice and MOF: Rodent models, immune modulation, and outcome in the critically ill. Crit Care Med 2006;34:921-3. 13. Godin DV, Garnett ME. Species-related variations in tissue antioxidant status I-II: Differences in antioxidant enzyme profiles. Comp Biochem Physiol B 1992;103:737-48. 14. Barth E, Bassi G, Maybauer DM, et al. Effects of ventilation with 100% oxygen during early hyperdynamic porcine fecal peritonitis. Crit Care Med 2008;36:495-503. 15. Ince C. The microcirculation is the motor of sepsis. Critical Care 2005;9(S4):S13-9. 16. Sakr Y, Dubois MJ, De Backer D, et al. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med 2004;32(9):1825-31. 17. Parratt JR. Nitric oxide in sepsis and endotoxaemia. J Antimicrob Chemother 1998;41(Suppl A):31-9. 18. Wang H, Yang H, Czura CJ, et al: HMGB1 as a late mediator of lethal systemic inflammation. Am J Respir Crit Care Med 2001;164:1768-73. 19. Yang H, Ochani M, Li J, et al: Reversing established sepsis with antagonists of endogenous high-mobility group box 1. Proc Natl Acad Sci USA 2004;101:296-301. 20. Scaffidi P, Misteli T, Bianchi ME. Release of chromatin protein HMGB1 by necrotic cells triggers inflammation. Nature 2002;418:191-95.
ORIGINAL ARTICLES
AN ORIGINAL STEREOTACTIC DEVICE FOR TRANSTHORACIC CT-GUIDED BIOPSY. AN EXPERIMENTAL STUDY Ovidiu Burlacu1, Alexandru Nicodin1, T. Jurma2, F. Ioanovici3, I. Petrache1, Octavian Cretu4, D. Iliescu4, Camelia Budisan5 REZUMAT Introducere: Puncţia ghidată tomografic este o metodă deosebit de valoroasă în stabilirea diagnosticului leziunilor mediastino-pulmonare, în special în cazul în care pacientul nu poate suporta un alt tip de intervenţie chirurgicală, curativă sau diagnostică. Deşi minim invazivă, metoda este urmată de complicaţii, dintre care cele mai frecvent raportate sunt pneumotoraxul şi hemoragia. Apariţia acestor complicaţii este dependentă de o serie de variabile printre care acurateţea cu care este atinsă ţinta este determinantă. Obiective: Pentru reducerea numărului acestor complicaţii, studiul propune un dispozitiv stereotactic cu preţ de producţie scăzut care să îndeplinească criteriile de acurateţe impuse. Material şi metode: Dispozitivul este de concepţie pur mecanică, constând dintr-un sistem de coloane-cremaliere unite printr-un corp de ghidaj, un sistem goniometric de fixare a unghiului de abord al ţintei, o tijă împingător cu un ansamblu de prindere/eliberare a acului de puncţie şi un soclu monobloc. Dispozitivul este acţionat manual. S-a ales un model experimental vegetal în care s-au plasat ţinte radioopace cu dimensiuni de 0.5 cm, 1 cm şi 2 cm. Au fost făcute câte 20 de puncţii pentru fiecare ţintă cu ajutorul dispozitivului stereotactic şi acelaşi număr de puncţii prin metoda free hand. Rezultate: Cu ajutorul dispozitivului stereotactic, ţintele cu dimensiuni peste 1 cm au fost atinse din prima încercare într-un procent de 100%. Ţinta de 0,5 cm a avut un procent de 65% reuşite, respectiv a fost atinsă de 13 ori. Prin metoda free hand s-au obţinut următoarele rezultate: ţinta de 2 cm a fost atinsă de 15 ori (75%), cea de 1 cm de 11 ori (55%), iar cea de 0,5cm a avut cele mai puţine reuşite, respectiv 3 (15%). Concluzii: Puncţiile transtoracice ghidate CT asistate de dispozitivul stereotactic sunt superioare din punct de vedere al acurateţii comparativ cu metoda free hand, ceea ce înseamnă mai puţine complicaţii. Rezultatele obţinute în acest studiu sunt superpozabile cu cele prezentate în studiile internaţionale, care folosesc dispozitive sofisticate, mult mai scumpe. Cuvinte cheie: puncţie ghidată tomografic, cost scăzut, dispozitiv stereotactic original, studiu experimental
ABSTRACT Introduction: Transthoracic CT guided fine needle biopsy is extremely valuable in establishing the diagnosis for mediastino-pulmonary masses, especially when the patient cannot undergo other types of surgical intervention, be it curative or diagnostic. Although minimally invasive, the method is sometimes followed by complications, among which pneumothorax and bleeding have been most frequently reported. These complications are directly linked to various factors, the most important of them being the accuracy with which the target is reached at the first attempt. Objective: In order to reduce the number of these complications, we made a study about a low cost stereotactical device that meets the criteria of accuracy required. Material and methods: The device is a pure mechanical concept. It has a system of columns-racks united by a guiding body, a goniometrical system to properly establish the attack angle for the target, a pusher rod with an ensemble of clamping/release system for the biopsy needle and a single-block base. We chose an experimental plant model in which we put radioopaque targets with sizes of 0.5 cm, 1 cm and 2 cm. We performed 20 procedures for each of the targets by means of the stereotactical device and the same number of procedures using the free hand method. Results: Using the stereotactical device, the targets with sizes greater than 1 cm were reached at the first attempt in a percentage of 100%. The target of 0.5 cm had a percentage of 65% of succesful attempts, which means that it was touched for 13 times. By means of the free hand technique we obtained the following results: the 2 cm target was touched for 15 times (75%), the 1 cm target for 11 times (55%), while the 0.5 cm target presented the lowest rate of accuracy, that is 3 times (15%). Conclusions: The procedures of transthoracic CT guided fine needle biopsy assisted by our stereotactical device are superior in terms of accuracy, in comparison to the free hand technique, an aspect which involves fewer complications. The results we obtained using this device are comparable to those presented in international studies using more expensive and sophisticated devices. Key Words: CT guided biopsy, low cost, original stereotactical device, experimental study
INTRODUCTION Departament of Thoracic Surgery, Clinical Municipal Emergency Hospital, Timisoara, 2 Morhardt Gmbh Augsburg, Germany, 3 Department of Mecatronics, Polytechnic University, Timişoara, 4 Department of General Surgery, Clinical Municipal Emergency Hospital, Timisoara, 5 Department of Neonatology, Victor Babes University of Medicine and Pharmacy, Timisoara 1
Correspondence to: Ovidiu N. Burlacu, MD, PhD, 263A Sanmihaiu Roman, Romania, Tel. +40723-181872. Email: burlacuovidiu@gmail.com Received for publication: Sep. 06, 2011. Revised: Nov. 14, 2011.
Establishing the hystopathological diagnosis for mediastino-pulmonary masses is of great importance both for the selection of the surgical patients and for the pre-operative management of these patients. Moreover, in cases when the stage of the disease represents a contraindication for surgery, the precise hystopathological diagnosis is crucial for the oncological treatment of the patients. One of the most commonly used procedures for establishing the _____________________________ Ovidiu Burlacu et al
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diagnosis of mediastinopulmonary masses is CT guided fine needle biopsy/aspiration.1,2 The most frequent complications resulting from this procedure are pneumothorax, with a percentage of 8-64%, and bleeding accompanied or not by hemoptysis, 2-26%.3-8 The occurrence rate of these complications is a variable depending on several factors: the distance between the pleura and the mass, the size of the mass, the condition of the lung parenchyma, the number of procedure attempts in order to reach the target and the experience of the surgeon.3
OBJECTIVE In order to minimize these complication rates, we analysed all the variables described above. The only variable we can influence is the last one â&#x20AC;&#x201C; avoiding the repetition of the procedure. Therefore, we propose a very easy to use, low cost stereotactical guidance device, which helps the surgeon introduce the needle with precision into the mediastinoplumonary mass, eliminating the risks of missing the target.
Figure 2. The stereotactical Fig. 2. Thedevice. stereotactical device
In another experimental study conducted in Germany, another model of the device is described, also having good performance, but, likewise, having the disadvantage of a very high cost and of complex manipulation. (Fig. 3)
MATERIAL AND METHODS There is a wide range of stereotactic devices for transthoracic biopsies presented in international studies, devices with very good performance (the average deviation from the target core is of 1-3 mm), but they are expensive technical solutions and present very high complexity, which makes them very difficult to operate.9-16 For examplification, we reproduce some pictures of guidance devices imagined in various international studies. A multicentric study performed in three prestigious universities, John Hopkins Baltimore (USA), Szeged University (Hungary), Denki University in Tokyo (Japan), presented a guidance device which had very good performance, but which required high budget and a specialized team. We exemplify some of the images of this study. (Figures 1,2)
1The schematics the device device attaced to a computer tomograph device Figure 1. The Fig. schematics of ofthe attaced to a computer tomograph device.
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Figure 3. The Medarpa system.system Fig. 3. experimental The Medarpa experimental
Given the data presented above, we imagined a very simple solution, at a low cost, but sufficiently precise to allow reaching a small size target, thus avoiding the repetition of the procedure which would increase the number of complications. Technical conception The device was designed and crafted together with specialists from the Department of Mecatronics of the Polytechnic University of Timisoara and specialists of the Medical Equipment Division of Morhardt Gmbh Augsburg, Germany. The conception is purely mechanical and the ensemble has the following components: (Fig. 4) - Two columns-racks positioned on the X-Y axes; (Fig. 5)
Figure 4. The stereotactical guidance device (overview).
Figure 7. The goniometrical system. Fig. 7 The goniometrical system
Fig.4. The stereotactical guidance device (overview)
Figure 5. The columns-racks disposed on the X and Y axis. Fig.5 The columns-racks disposed on the Xcontains and Y axis the two - A translation module which columns and which, inside, has a system of cogged wheels responsible for the translatory motion both horizontally and vertically; (Fig. 6)
Figure 8. The pushing rod with the needle fixation/release mechanism. Fig.8 The pushing rod with the needle fixation/release mechanism
Figure 9. The single block base of the device. Fig. 9 The single block base of the device
Figure 6. The translation module. Fig.6 The translation module
- The goniometrical system that helps fix the angle of needle insertion; the goniometrical system stands at the end of the horizontal lever; (Fig. 7) - The pushing-rod, with the needle mounting/ release mechanism at one end; (Fig. 8) - A single-block base of the device that ensures the stability of the whole ensemble. (Fig. 9)
We opted for this concept with the purpose of eliminating the two drawbacks associated with the devices presented in other studies – high production and maintainance costs and the complexity of the device that makes it difficult to handle by the surgeon. On the other hand, our goal was to achieve the same level of performance. To test the device, we chose a fruit – Citrus Maximus - as an experimental model, for various reasons: (Fig. 10) - It has almost the same diameter as the normal _____________________________ Ovidiu Burlacu et al
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human adult/child thorax (12 - 27 cm); - The peel is approximately 2.5 cm thick with a density similar to the human soft parietal tissues; - The core is 80% water and has compartments with alveolate aspect, being architecturally the most similar vegetable model to the human lung in terms of consistency and structure; - We can easily introduce inside it radioopaque targets of different sizes; - Due to its round shape, it can be easily rotated in its holder, ensuring multiple attack angles and allowing us to test the accuracy of the device in reaching the targets. Figure The 12. The radioopaque surface markers and the target. Fig.12. radioopaque surface markers and the target
The CT program calculated the attack angle of the target, then we proceeded to the fixation of the target onto the goniometrical system of the device. After attaching the needle to the fixation system we inserted it into the fruit by pushing the rod. (Fig. 13) We did this for all the 3 dimensions of the targets. We must mention that the results of the procedures assisted by our device are independent of the surgeon’s experience.
Figure 10. The fixation of the experimental model.
After making the device, we moved on to testing it.Fig.10. ForThethis purpose, we used a 20 G biopsy needle fixation of the experimental model with a length of 8 cm. Inside the plant we placed radioopaque targets with sizes of 0.5, 1 and 2 cm in diameter. (Fig. 11)
Figure 13. Needle insertion.
RESULTS
Figure 11. The visualisation of targets of 0.5, 1 and 2 cm.
After the tomographic scan of the fruit, we localised the target inside and randomly established the place of needle insertion by placing radioopaque markers on the surface of the model. (Fig. 12) Fig.11. The visualisation of targets of 0.5, 1 and 2cm _____________________________
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Fig.13. Needle insertion
Study of the experimental model We performed 20 procedures of puncture for each of the three targets placed at 8 cm away from the needle insertion point. The targets with sizes of 1 and 2 cm were touched in all of the cases (100%), although there was an average deviation from the target’s core of up to 0.4 cm, in comparison to the existing devices that recorded a deviation of up to 0.3 cm. (Fig. 14) At 8 cm distance from the insertion point, the deviation of our device did not lead to missing the target. For
the 0.5 cm target, 13 out of 20 attempts reached the target which was at 8 cm away from the needle insertion point(65%), reporting 7 failures. When we reduced the distance between the insertion point and the target by placing it closer to the surface of the model, the number of successful attempts increased proportionally with the reduced distance – 18 attempts (90%) for a distance of 4 cm. (Fig. 15) For this situation we recorded a 0.2 cm deviation from the target’s core in comparison to other studies that reported 0.0 cm deviation.
was reached for 11 times (55%) and the 0.5 cm target was reached less succesfully, only for 3 times (15%) see Table 1.
Table 1: Comparative results for the two guided FNA m
Table 1. Comparative results for the two guided FNA methods. Target with size 0.5cm
Target with size 1 cm
Target with size 2 cm
Succesful target approach using the stereotactical device (20 attempts)
13 (65%)
20 (100%)
20 (100%)
Succesful target approach using the free hand method (20 attempts)
3 (15%)
11 (55%)
15 (75%)
DISCUSSIONS
Fig.14.CT control for reaching the 2 cm Figure 14. CT control for reaching thesized 2 cmtarget sized target.
Figure 15. The CT control of reaching the 0.5 cm target
In order to compare our results, we performed Fig.15. The CT control of reaching the 0.5 cm target punctures on all the three targets situated at a distance of 8 cm from the needle insertion point without using the stereotactic device, by means of the free hand method. For the objectivity of the study the free hand procedures were conducted by a surgeon who had not been made aware of the stereotactical device and the results we obtained using it. The results were: the 2 cm target was reached for 15 times (75%), the 1 cm target
From the point of view of its accuracy, the results we obtained for targets larger than 1 cm by using the device we designed are identical to the results reported by international studies – 100% succesful attempts. When we compared the results of this technique to the free hand method, we noticed that we obtained a percentage of 100% versus 65% succeful attempts, which proves the usefulness of our device. For the targets of 0.5 cm, the stereotactical assisted procedures are clearly superior to the classical method (65% succesful attempts in comparison to 15%), but the accuracy of our device is lower than the one reported by other experimental studies. On the other hand, in our experience which includes more than 2000 transthoracic fine needle biopsies performed on patients with mediastinopulmonary masses, less than 1% of these cases had masses with dimensions under 1 cm, thus the addressability of the device in this area is very low. Another advantage of the device we proposed is represented by its low production cost, approximately 20 times lower than in the case of the existing ones, as well as the fact that it is easy to use, being accesible even to unexperienced surgeons. We chose the vegetable experimental model over human cadavers or living sleeping animals for the following reasons: - High costs; - Human cadavers are not similar to living patients due to different tissuse density caused by preservation solutions, and, consequently, the dehydration of the tissues could interfere with the needle trajectory; - The difficulty of introducing radioopaque targets within the model.
CONCLUSIONS The device we conceived and created is simple, precise and very easy to manipulate, while its accuracy _____________________________ Ovidiu Burlacu et al
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is comparable to that presented by other similar devices for targets larger than 1 cm. It also has the advantage of a reasonably low production cost.
REFERENCES 1. Collins LG, Haines C, Perkel R, et al. Lung cancer: Diagnosis and management. Am Fam Physician 2007;75(1):56-63. 2. Rivera MP, Mehta AC. Evidence-based clinical practice guidelines (2nd Edition). Initial diagnosis of lung cancer. Chest 2007;132;131S-148S. 3. Yeow KM, Tsay PK, Cheung YC, et al Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: retrospective analysis of 631 procedures. J Vasc Interv Radiol 2003;14:581-8. 4. Haramati LB, Austin JHM. Complications after CT-guided needle biopsy through aerated versus non-aerated lung. Radiology 1991;181:778. 5. Anderson CL, Acevedo Crespo JC, Lie TH. Risk of pneumothorax not increased by obstructive lung disease in percutaneous needle biopsy. Chest 1994;105:1705-8. 6. Fish GD, Stanley JH, Miller KS, et al. Postbiopsy pneumothorax: estimating risk by chest radiography and pulmonary function tests. AJR 1988;150:71-4. 7. Charig MJ, Phillips AJ. CT-guided cutting needle biopsy of lung lesions â&#x20AC;&#x201C; safety and efficacy of an out-patient service. Clin Radiol 2000;55:964-9.
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8. Kazerooni EA, Lim FT, Mikhail A, et al. Risk of pneumothorax in CTguided transthoracic needle aspiration biopsy of the lung. Radiology 1996;198:371-5. 9. Aviram G, et al. CT-guided lung biopsies using a novel optical navigation system: Initial human experience. Presented at RSNA 2009. 10. Schwarz Y,. et al. New optical navigation system for image guided biopsies and ablations: Initial In-vitro, animal and human evaluation. Presented at Computer Assisted Radiology and Surgery Conference, 2009. 11. Paul N, et al . Safety and accuracy of an optically guided stereotactic computer needle guidance system in patients undergoing CT-FNAB of lung nodules. Presented at European Congress of Radiology 2010. 12. Fichtinger G, Deguet A, Fischer G, et al. Image overlay for CT-guided needle insertions. Computer Aided Surgery 2005;10(4):241-55. 13. Khan MF, Dogan S, Maataoui A, et al. Navigation-based needle puncture of a cadaver using a hybrid tracking navigational system. Invest Radiol 2006;41(10):713-20. 14. Xu S, Fichtinger G, Taylor RH, et al. 3D motion tracking of pulmonary lesions using CT fluoroscopy images for robotically assisted lung biopsy. Proceedings SPIE: Visualization, Image-Guided Procedures and Display, Medical Imaging, Vol. 5367,pp. 394-402, 2004. 15. Xu S, Fichtinger G, Lindisch D, et al. Validation of 3D motion tracking of pulmonary lesions for image-guided lung biopsy. Proceedings SPIE: Visualization, Image-Guided Procedures and Display, Medical Imaging, Vol. 5744, pp. 60-68, 2005. 16. Bakal CW, Silberzweig JE, Cynamon J, et al. Vascular and interventional radiology: principles and practice. Thieme Ed: New York, 2002.
ORIGINAL ARTICLES
SURGICAL MANAGEMENT OF INFRARENAL AORTIC ANEURYSM - A SINGLE CENTER ONE YEAR EXPERIENCE Claudiu Rascanu, A. Krikun, E. Klenk REZUMAT
Introducere: A fost efectuata o analiza retrospectiva a 42 de cazuri de anevrisme aortice infrarenale care au fost operate in anul 2008 in unitatea noastra. Material si metode: Au fost analizate datele demografice ale pacientilor, tehnica operatorie, complicatiile potoperative, durata tratamentului pe sectia de terapie intensive (STI), durata spitalizarii si mortalitatea perioperativa. Rezultate: In grup au fost incluse 2 anevrisme rupte, 9 anevrisme simptomatice si 31 asimptomatice. In 11 cazuri tratamentul a fost endovascular (EVAR) si in 31 de cazuri operativ conventional. Marea majoritate a celor 31 de anevrisme operate conventional nu au fost din punct de vedere anatomic compatibile cu EVAR. Un caz de anevrism perforat a fost tratat cu o endoproteza aorto-monoiliacala si cu un pontaj femoro-femoral, iar cel de al doilea caz a fost operat conventional. In timp ce in grupul EVAR nu a fost inregistrat nici un deces, in grupul pacientilor operati deschis s-a inregistrat o mortalitate de 6,45%. Concluzii: In grupul de pacienti luati in studiu, tratamentul anevrismelor abdominale prin EVAR s-a dovedit superior operatiilor conventionale, deschise, in ce priveste rata complicatiilor postoperatorii si mortalitatea. Cuvinte cheie: anevrisme de aorta abdominala; reparatie aortica deschisa; tratament aortic endovascular
ABSTRACT Background: We studied retrospectively 42 repairs for infrarenal aortic aneurysm performed during the year 2008 in our vascular surgery unit. Material and methods: The demographic data of the patients, the operative technique, the postoperative complications, the length of staying on ICU and in the hospital and the perioperative mortality have been retrospectively investigated. Results: In the whole cohort there were 2 ruptured, 9 symptomatic and 31 asymptomatic infrarenal aneurysms. Eleven of these procedures were endovascular repairs (EVAR) and 31 open repairs (OAR). The majority of all 31 OAR were anatomically not suitable for EVAR. One of the patients with a ruptured aneurysm was treated with an aorto-monoiliac endograft and with a crossover bypass. The other one underwent open surgery. In the EVAR group was no case of perioperative death, while in the OAR group there was recorded a 6.45% perioperative mortality rate. Conclusions: In the studied group of patients, the treatment of aortic aneurysms elective EVAR has proved itself superior to OAR in terms postoperative complications and mortality. Key Words: abdominal aortic aneurysm; open aneurysm repair; endovascular aortic repair
BACKGROUND The aortic surgery is one of the most interesting and challenging fields of vascular surgery with an explosive development over the last decades. Nowadays the endovascular repair of the infrarenal aortic aneurysm is a widely accepted approach modality. The preoperative evaluation and the anatomical features of the aneurysm play a very important role in patient selection for open or endovascular repair of aortic aneurysm. The aim of this study is to present our shortterm results and not to debate about advantages and disadvantages of open or endovascular procedures.
Vascular Surgery Unit, St. Johannes Hospital, Duisburg, Germany Correspondence to: Dr. med. Claudiu Rascanu, Klinik für Gefäßchirurgie, St. Johannes Hospital, An der Abtei 7-11, 47166 Duisburg, Germany, Tel. +49-203546-2551 Email: c.rascanu@kkd.de Received for publication: Apr. 08, 2011. Revised: Aug. 05, 2011.
We have more than 10 years experience in endovascular treatment of aortic aneurysm and the long terms result are encouraging. The decision is made individually after carefully evaluation of the patients in concordance to technical possibilities and preference of the patients. Predictors of 1-year mortality can identify patients less likely to benefit from elective AAA repair. Age, chronic obstructive pulmonary disease (COPD), renal failure, suprarenal clamping have significant impact on 1-year mortality after open AAA repair.1 Our patients are well informed and they play an active role in making of decisions about surgical procedures. In the last years the preference of the patients for endovascular procedures is substantially higher. We are able to perform open repair or EVAR even in emergency situation 24 hours a day. EVAR is still subject of controversies in vascular surgery, but is nowadays a wide accepted treatment modality.2,3 Despite the actually trend for endovascular procedures, we recorded over last year an increased number of complex aneurysm with short aortic neck length and tortuous or sclerotic iliac arteries, which lead to an almost three times higher proportion of open repairs in our patients group. _____________________________ Claudiu Rascanu et al
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MATERIAL AND METHODS We performed a retrospective study of 42 repairs for infarenal aortic aneurysms which were treated during 2008 in our vascular surgery unit. Suprarenal and thoracic aortic aneurysms were excluded. All patient records and the data from quality control programme of the german society of vascular surgery were evaluated. We investigated retrospectively the demographic data of the patients, the operative technique, the postoperative complications, the length of staying on ICU an in the hospital and the perioperative mortality. We divided these collective in two groups, one for open repair and one for endovascular procedures. In the whole cohort were 2 ruptured, 9 symptomatic and 31 asymptomatic infrarenal aneurysms. 11 of these procedures were endovascular repairs (EVAR) and 31 conventional open operations. To asses the associated diseases we used the ASA score.
the infrarenal aorta in more than a half of the patients with a Dacron “tube” graft with the distal anastomosis above or on the aortic bifurcation. (Table 1) In 7 patients aorto-biiliac reconstruction with a bifurcated Dacron graft was performed. In another 3 cases bifurcated grafts were connected on one side with the iliac artery and on the other side with the femoral artery. Two patients were treated with an aorto-bifemoral bypass. In this study arm 3 patients underwent further surgery for complications. We recorded one case of bowel ischemia, one relevant postoperative bleeding and one obstruction of the prosthetic graft. Another 4 patients developed after surgery cardiac, renal and pulmonary complications. The median length of staying on ICU was 4.74 days (range 1:18) and the median duration of hospitalisation was 21.70 (range 5:75 days). We recorded 2 cases of postoperative death (6.45%), both in symptomatic patients with an ASA 3 score. Table 1. Types of reconstruction of the AAA in open surgery.
OPEN ANEURYSM REPAIR GROUP
Graft type
n
%
Tubegraft
19
61.2%
Thirty-one cases of open surgery for infrarenal aortic aneurysm have been performed in our unit in year 2008. The median age was 68.5 years (range 51:85) and there were 3 females (9,67%) and 28 male patients (90,32%) in these group. There were 1 ruptured, 7 symptomatic and 23 elective aortic aneurysms. The median diameter of the aneurysms was 60.2 mm (range 50-120 mm). In one case the diameter was not determined because the patient underwent surgery due to a rupture before a CT-scan could have been done. The great majority of open repaired AAA`s were anatomically not suitable for EVAR. The main limitation was the short proximal aortic neck. In 3 patients a suprarenal aortic cross clamping was necessary. With one exception all patients underwent CT-scan and angiography. In conformity with the ASA Score there were 5 ASA 1 patients (16.20%), 18 ASA II patients (58.06%) and 8 ASA III patients (25%). Ten patients had no heart diseases (32.25%). Twenty-one of them (67.74%) had a stable coronary heart disease with an ejection fraction (EF) > 35%. Almost one half of this cohort (48.38%, n= 15) had a mild form of COPD and only one patient (3.20%) had a severe COPD. The renal function was normal (serum creatinine < 2 mg/dl) in 93.54% (n=29). The median duration of the open aneurysm repair was 166.45 minutes (range 90:270 minutes). As graft material synthetic Dacron prosthesis was used. The configuration of the reconstruction was determined by the possibilities of the distal anastomosis. We replaced
Aorto-biliacal-Bypass
7
22.58%
Aorto-ilio-femoral Bypass
3
9.67%
Aorto-bifemoral Bypass
2
6.45%
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EVAR GROUP We performed EVAR for infrarenal aortic aneurysms in 11 patients, all males, with a median age 77.36 years (range 56-86). Six patients were octogenarians, 9 individuals had an ASA III Score and 2 of them an ASA II score. Regarding the comorbidities, 8 patients (72.72%) showed a stable coronary heart disease with an EF >35% and a moderate COPD. The median diameter of the aneurysms was 62mm (range 42-86 mm). In nine patients we repaired the aneurysms with a bifurcated aorto-biiliac modular endografts, in one patient with a tube endograft. One hybrid repair with an aortomonoiliac endograft and femoro-femoral crossover bypass for a ruptured aneurysm in the 85 years old patient was performed with a very good result. Despite a type I endoleak (Fig. 2, 3) we couldn’t identify an expansion of the aneurysm and the patient is actually in a good clinical condition. In EVAR arm of this study, the length of staying on ICU was 3.27 days and the duration of staying in hospital was in average 11 days. In the EVAR group a conversion operation due to secondary aneurysm expansion was necessary and there was no case of perioperative death in this cohort.
Figure 1. Comparison between duration of treatment on ICU and overall length of staying in hospital for OAR and EVAR Group. Figure 3. The contrast enhanced CT Scan with a transversal view of the same patient a type IA endoleak after EVAR for rAAA.
Figure 2. Sagital aspect of an endoleak type I A in an 85 year old patient with a ruptured aortic aneurysm.
DISCUSSION After careful evaluation and in accordance with the preferences of the patients we chose individually the conventionally open or endovascular procedures for infrarenal aortic aneurysm. Due to our more than a decade experience in endovascular procedures and good middle term results, we consider EVAR a reliable approach in selected patients. In all symptomatic patients we perform surgery as soon as possible. In patients with asymptomatic AAA a careful interdisciplinary evaluation was performed in order to assess the perioperative risc. The strong association between atherosclerosis risk factors and abdominal aortic aneurysms was in our patients also obvious.4 We do not use any score systems to predict the outcome of the patients, systems which are in the contemporary literature controversial.1,5
When an asymptomatic AAA must be operated remains controversial. The early operation for patients with small AAA seems to show no immediate benefit due to early postoperative complications. In long term analysis there is no significant survival differences for surgery between small (40-55mm) and big (>55mm) AAA.6 The small AAA`s in our study are mainly symptomatic. Due to the increasing use of endovascular techniques in the territory, we recorded a change in the quality of aneurysm referred to our unit. A great part of these AAA`s were complex and not compatible with the endovascular techniques. The preoperative mortality for open repairs of 6.45% is due to the small size of these study statistically insignificant and must be analysed in the future in a greater context. The main limitation for the endovascular procedure remains the proximal aneurysm neck which must be minimum 15 mm long. The last generation of devices are more flexible and allow the placement through tortuous iliac arteries. Angulations of the iliac arteries of more then 90 degree are generally a contraindication for EVAR. Patients who undergo elective EVAR had substantially lower postoperative complications and there was no case of perioperative death in this group, even in ruptured aneurysms. These patients, with a median age of over 77 years, most of them octogenarians, almost reached the average life expectancy in West Europe and benefit immediately from a minimal invasive procedure and a low rate of perioperative complications. Anyway more evidence is needed on the long-term outcome after EVAR in larger samples in order to assess the durability of this less invasive procedure.7 Some publications report a lower _____________________________ Claudiu Rascanu et alâ&#x20AC;&#x192;
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mortality after EVAR for rAAA than for open repair of rAAA8, the evidence level remains controversial. The significance of the endoleaks, especially of type II must be critically evaluated. The presence of a type I or a type II endoleak during EVAR significantly increases the likelihood of a postoperative endoleak and should prompt a high degree of suspicion during follow-up.9
CONCLUSIONS This study represents a retrospective analysis of one year experience in the surgical treatment of AAA in our unit. We recorded over the 12 month period of these study an increased number of infrarenal AAA which were not suitable for EVAR. Due to the increasing use of endovascular techniques, a greater part of open repairs are more complex, which leads consecutively to a higher complications rate. Patients who undergo elective EVAR had substantially lower postoperative complications. There was no case of perioperative death in the EVAR group, even for ruptured aneurysms. Our results in the endovascular treatment of ruptured AAA are encouraging, especially in elderly patients at high operative risk.
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REFERENCES 1. Beck AW, Goodney PP, Nolan BW et al. Vascular Study Group of Northern New England. Predicting 1-year mortality after elective abdominal aortic aneurysm repair. J Vasc Surg 2009;49(4):838-43. 2. Eliason JL, Upchurch GR Jr. Endovascular treatment of aortic aneurysms: state of the art. Curr Treat Options Cardiovasc Med 2009;11(2):136-45. 3. Upchurch GR Jr, Eliason JL, Rectenwald JE, et al. Endovascular abdominal aortic aneurysm repair versus open repair: why and why not? Perspect Vasc Surg Endovasc Ther. 2009;21(1):48-53. 4. Forsdahl SH, Singh K, Solberg S, et al. Factors for abdominal aortic aneurysms: a 7-year prospective study: the Tromsø Study, 1994-2001. Circulation 2009;119(16):2202-8. 5. Visser JJ, Williams M, Kievit J, et al. 4-A Study Group. Prediction of 30-day mortality after endovascular repair or open surgery in patients with ruptured abdominal aortic aneurysms. J Vasc Surg 2009;49(5):1093-9. 6. Brown LC, Thompson SG, Greenhalgh RM, et al. UK Small Aneurysm Trial Participants. Fit patients with small abdominal aortic aneurysms (AAAs) do not benefit from early intervention. J Vasc Surg 2008;48(6):1375-81. 7. Ballotta E, Da Giau G, Gruppo M, et al. Elective abdominal aortic aneurysm repair in the very elderly: a systematic review. Minerva Med 2009;100(1):95-103. 8. Rayt HS, Sutton AJ, London NJ, et al. A systematic review and metaanalysis of endovascular repair (EVAR) for ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2008;36(5):536-44. 9. Sampaio SM, Shin SH, Panneton JM, et al. Intraoperative endoleak during EVAR: Frequency, nature, and significance. Vasc Endovascular Surg 2009;43(4):352-9.
ORIGINAL ARTICLES
MORBIDITY AND INITIAL RESULTS OF URETHROPLASTY WITH ORAL MUCOSA GRAFT, COLLECTED FROM THE LOWER LIP UNDER LOCAL ANESTHESIA Jozsef Szabo1, Radu Boja2, Vlad Petcu3, Florin Dinca3, Paul Rotariu3, Roxana Nica4, Florentina Nalbaru4, Alexandra Stirbu4, Ionel Ciobanu3, Ion Tocaciu3, Daniel Sarb3 REZUMAT Introducere: Uretroplastia cu mucoasă bucală este o metodă terapeutică acceptată în patologia uretrală și în ultimii ani a fost cea mai răspândită metodă utilizată în rezolvarea stricturilor uretrei anterioare. Material și metode: S-a realizat un studiu retrospectiv al celor 15 pacienți operați prin uretroplastie peniană cu mucoasă bucală recoltată de la nivelul buzei inferioare în anestezie locală în perioada 2007-2011. Au fost evaluate rezultatele uretroplastiilor, morbiditatea și complicațiile intervențiilor și s-a evaluat gradul de satisfacție al pacienților prin două chestionare. Rezultate, discuții: Majoritatea pacienților (80%) nu au acuzat durere sau parestezii în momentul prelevării, iar durerile postoperatorii au fost ușoare (26,6%). Referitor la rezultatele uretroplastiilor, numărul redus de cazuri nu oferă concluzii clare din punct de vedere statistic. Scopul articolului este în principal de a prezenta posibilitatea accesului la uretroplastia cu mucoasă bucală fără anestezie generală. Recoltarea de grefă de mucoasă bucală în anestezie locală de la nivelul buzei inferioare este bine suportată de pacienți, deși nu oferă material de substituție de aceeași calitate și dimensiune, comparativ cu grefa de la nivelul obrajilor. Concluzii: Grefa de mucoasă bucală rămâne un material excelent și acceptat pe scară largă pentru substituția uretrală. Recoltarea grefei de mucoasă bucală în anestezie locală este o procedură sigură și în general acceptată de pacienți. Cuvinte cheie: mucoasă bucală, grefă, strictură uretrală, uretroplastie
ABSTRACT Introduction: Urethroplasties using oral mucosa are an accepted therapeutic method in urethral pathology and in recent years was the most commonly method used in solving anterior urethral strictures. Material and methods: A retrospective study was performed involving 15 patients with penile urethral strictures operated using oral mucosa harvested from the lower lip under local anesthesia in 2007-2011. Results of the urethroplasties were evaluated, morbidity and complications of the interventions, patient satisfaction were assessed using two questionnaires. Results, discussion: Most patients (80%) did not experience pain or numbness at the time of harvesting, and postoperative pain was mild (26.6%). Because of the limited number of cases, the results of the urethroplasties do not provide statistically clear conclusions. Paper mainly raises the possibility of urethroplasty using buccal mucosa without the use general anesthesia. Buccal mucosa graft harvesting in local anesthesia of the lower lip is well tolerated by patients, although the material it offers for substitution is not the same quality and size compared with the graft in the cheeks. Conclusions: buccal mucosa graft remains an excellent and widely accepted material for urethral substitution. Buccal mucosa graft harvesting in local anesthesia is a safe procedure and generally well accepted by patients. Key Words: oral mucosa, graft, urethral stricture, urethroplasty
INTRODUCTION Urethral strictures are common in the elderly urological patients, especially after transurethral prostate or bladder resections. Moreover, elderly patients undergo more frequently urethral catheter placement before other surgical interventions, for clinically apparent or asymptomatic prostatic benign hyperplasia. Department of Urology, Odorheiu Secuiesc Municipal Hospital, Department of Urology, Targu-Mures University of Medicine and Pharmacy, 3 Department of Urology, Cluj-Napoca Military Hospital, 4 Department of Anesthesia and Intensive Care, Cluj-Napoca Military Hospital 1 2
Correspondence to: Szabó József, 7 Bisericii Str., Odorheiu Secuiesc, Harghita County, Tel. +40-745-195-996 Email: office@samed.ro Received for publication: Sep. 11, 2011. Revised: Nov. 14, 2011.
In the unpublished series of the Department of Urology of the Odorheiu Secuiesc Municipal Hospital, the etiology of the urethral strictures in the elderly was as follows: - 60% following urethral catheter placement or rigid cystoscopy; - 26% after transurethral prostate resection; - 12% after transurethral bladder tumor resection; - 2% idiopathic. The timeframe between the intervention on the urinary tract and the clinical manifestation of the stricture is variable, and depends on the severity and location of the stricture, and on the level of the patient’s perception as well. Generally, a urethral stricture becomes symptomatic when the minimum diameter of the urethra is under 11 Ch.1 Due to the associated pathology and anesthesia risks, the elderly patient is treated by internal optical urethrotomy as initial treatment. The results have _____________________________ Jozsef Szabo et al
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been evaluated by Pansadoro and Emiliozzi in 1996.2 Recurrence rate for the penile urethra stricture is 84%, and 58% for bulbar urethra. After the second urethrotomy, the outcomes are worse in most cases. Urethroplasty with oral mucosa graft is a more suitable intervention, with higher success rates on the long term. The graft is placed dorsally on the penile urethra, on the albuginea of the cavernous bodies, which represent an appropriate mechanical and vascular supporting structure. Ventral placement is risky, as the frequently thin and scarred spongy body cannot always cover it, and provide vascular supply to the graft. Placement can be performed dorsally as onlay, obtaining an extra 2.5 cm, or as dorsal inlay (Asopa), obtaining only 1.5 cm, and requiring the incision of the superior urethral wall.3,4 A thin superior urethral wall will make the dorsal inlay procedure difficult, and a severe spongiofibrosis will raise difficulties in the dissection and rotation of the spongy body for dorsal incision. In such cases skin flaps or two-step interventions will be employed. Recent literature has demonstrated the superiority of urethroplasty with oral mucosa graft of the penile urethra versus internal urethrotomy.5,6 Basically, oral mucosa collection is performed under general anesthesia with naso-tracheal tube. Anesthesia of the elderly patient has several risks due to associated diseases. Cognitive decline following general anesthesia of the elderly is an established and published entity.7-10 Patients with additional risks are those with cardiac or chronic obstructive broncho-pulmonary pathologies, bronchial asthma or respiratory failure.9,10 Lumbar anesthesia provides a means for controlling the penile and perineal areas, while the oral mucosa collection can be performed under local anesthesia.11 Oral mucosa can be collected only from the inferior lip, providing a smaller (4/1.5 cm) graft. Nevertheless, a graft of only 3/1.5 cm may be sufficient, considering the known elasticity of this type of grafts. Morbidity related to oral mucosa graft collection is dependent on the size of the graft and anatomical site of collection.12
MATERIAL AND METHODS A retrospective study has been performed, of the 15 patients who underwent penile urethroplasty with oral mucosa graft, collected from the lower lip under local anesthesia. The interventions have been performed between 2007 and 2011. The follow-up period was 3 to 50 months. The patients were aged 54 â&#x20AC;&#x201C; 72 years. _____________________________
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The following parameters were assessed: the results of the urethroplasties, morbidity and complications of the interventions, as well as the degree of the patientâ&#x20AC;&#x2122;s satisfaction using two questionnaires - one concerning the urethral surgery, and the other concerning the oral mucosa graft collection. (Appendix 1, 2). The second questionnaire was taken and translated from the article published by Barbagli et al.12 Patients with urethroplasty performed on the bulbar urethra, and those with oral mucosa collected under general anesthesia were not included. Operating technique Collection of oral mucosa graft
The collection technique needs to be simple, safe and reproducible, based on solid anatomical foundations, and performed using adequate tools.13 Preoperative preparation
Preoperative diagnosis includes urine culture, retrograde and voiding urethrography, and urethroscopy. Clinical examination and patient history will establish as accurately as possible the etiology of the urethral stricture in order to aid in deciding the operating technique. The site and length of the stricture should be evaluated carefully as well, as these will determine preoperatively the characteristics of the oral mucosa graft. The oral cavity has to be evaluated preoperatively in order to identify any local pathology that might contraindicate oral mucosa grafting. Patients in need of a graft will be evaluated preoperatively in order to identify any local pathology that might contraindicate oral mucosa grafting. Patients requiring a thin graft (for penile urethroplasty) will be informed that collection will be performed from the lower lip mucosa. Patients with oral mucosa disorders or limited jaw opening will be informed that in their case genital or extragenital (thigh, retroauricular) skin graft will be used for urethroplasty. Patients undergoing urethroplasty with oral mucosa will receive intravenous broad spectrum antibiotic (ex. Ceftriaxone 1g, every 12 hours) a day before the intervention, on the day of the intervention, and for the following 3 days. Three days before the intervention the patient will receive an oral disinfectant (oral clorhexidine), and will continue rinsing for 3 days after the intervention. Description of lower lip grafting under local anesthesia
Before lumbar anesthesia we used an anesthetic spray containing 1% xylocaine applied to the oral cavity and lower lip. Then we proceeded with collection of the graft. An assistant holds the lower lip visible, and after lifting of the graft through infiltration with a solution
containing 1% xyline and 1:100,000 adrenaline, the graft is collected in a 3/1.5 cm sized elliptical shape. In some cases a 4/1.5 cm graft can be obtained, depending on the local anatomy. Lateral extension of the dissection beyond the canines may lead to mental nerve damage and consecutive paresthesia. Excision at less than 1 cm from the edge of the lip may cause the inward retraction of the lower lip, leading to an unpleasant esthetic result. Likewise, the graft margin should be over 1 cm away from the dental arch. The graft is anchored with suture lines, and it is carefully detached from the underlying adipose tissue using a blunt scissor. Entering the underlying muscles may cause a harder to control hemorrhage. After grafting a compress is left in place, and an ice bag is applied to the lower lip in order to facilitate hemostasis and reduce pain. A hemostatic compress is left in the oral cavity between the dental arch and the lower lip until the afternoon of the day of the intervention. Electrocautery use is not required for hemostasis. The graft is anchored on suture lines, and after preparation it is ready for urethroplasty.
with Clorhexidine was continued. Only one patient (6.6%) had moderate pain requiring continuation of antialgic therapy for 7 days after discharge. In two cases (13.3%) paresthesia of the lower lip occurred, and in one case (6.66%) there was an increased sensibility at the grafting site. These complex cases required collection of a larger graft. Additional hemostasis with suture lines was required as well. There were no cases of oral cavity infections after graft collection. After one month post-intervention the patients were satisfied, and none of them experienced difficulties during smiling or opening their mouth. There were no cases of â&#x20AC;&#x153;dry mouthâ&#x20AC;? after the intervention. Out of the total of 15 patients, 11 (73.3%) declared that they would accept another intervention with oral mucosa graft collection (if needed). Only four patients (26.7%) declared that for the time being, they did not want this type of intervention. The oral mucosa graft collected by this method has been used in seven patients for penile urethroplasty, with the graft placed as ventral onlay (Figs. 1, 2).
Postoperative care
Immediately after collection of the graft an ice bag is placed on the cheek to prevent hematoma formation and reduce pain. Initially the patient will be on a liquid and cold (ice-cream) diet, then he will continue with semi-liquid diet, and finally he will return to his normal diet. The patient is mobilized from bed in the first postoperative day, and he is typically discharged on the 4th postoperative day. Antialgic medication need is usually minor. The pain is usually manageable with non-steroid anti-inflammatory drugs or Paracetamol. Antibiotic treatment will continue until removal of the urethral or suprapubic catheter.
Figure 1. Graft placed as ventral onlay.
RESULTS The oral mucosa graft has been collected from the inferior lip without any incident. After grafting an ice bag was applied. Separate hemostasis sutures were placed in 5 cases. None of the 15 patients had postoperative bleeding. Normal diet was resumed on the third postoperative day. The majority of the patients (80%) did not have pain at the time of graft collection. Only 13.3% felt mild discomfort, and there was moderate pain controlled by antialgic medication in 6.66% of the cases. The majority of the patients (93.3%) had no pain (66.6%) or had mild pain (26.6%) and swelling of the lip, which remitted after 2-3 days. The ice bag has been removed on the second day, and oral irrigation
Figure 2. Graft placed as ventral onlay at the penile-bulbar level. _____________________________ Jozsef Szabo et alâ&#x20AC;&#x192;
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In two cases the stricture was localized at the penile-bulbar level. In both cases postoperative results were good, and the patients declared themselves pleased on the PROMs questionnaire. In five cases the stricture was localized at the middle segment of penis, at about 2-3 cm from the navicular urethra. In three of these cases, the patients were pleased after the intervention, and they did not require other procedures. In the fourth case the intervention was repeated, and dorsal placement graft urethroplasty has been performed. The patient is presently pleased by the result. The fifth patient preferred urethral dilations, and for the moment refused another urethroplasty intervention. The oral mucosa graft has been used in two cases for penile urethroplasty, with the graft placed as dorsal onlay (Barbagli type). The two patients were satisfied after the intervention, having a satisfactory urine flow according to the PROMs questionnaire. In one case, cystourethrography demonstrated a pseudo-diverticulum of the urethra at the site of grafting, but lacking any clinical or urodynamic significance. (Fig. 3) The oral mucosa graft has been placed as dorsal onlay (Asopa type) in two cases with mid-penile stricture. In two cases recurrence occurred early, after 1-2 months following the intervention. There were two cases where the superior urethral wall was diminished and scarred. The patients refused the second intervention with oral mucosa. In these cases perinostomy has been performed. The patients are presently relatively satisfied, and have voiding comfort.
urethra and the navicular urethra. In one case recurrence of the stricture occurred after the second step. The patient refused another intervention so far, undergoing periodic urethral dilations. After the second step of the urethroplasty the other two patients have a good urine flow, and are pleased with their voiding.
DISCUSSION Urethroplasty with oral mucosa is an accepted treatment method in urethral pathology. As a ground rule, graft collection from the cheek or the inferior lip is performed under general anesthesia, and preferably with naso-tracheal intubation in order to keep the oral cavity clear. Collection under local anesthesia is rarely seen in the literature.11 Initially we were reticent because of our concerns related to patient discomfort. Most of the patients (80%) did not experience pain at the time of collection. Using only lumbar anesthesia the patients started a liquid diet in the evening of the day of the intervention. Postoperative pain was absent in 66.6% of the cases, and it was mild in 26.6%. Mild pain has been kept under control by minor antalgic medication (paracetamol, anti-inflammatory drugs), and remitted after 2 days of oral irrigation with clorhexidine, and ice applied locally. Patients experiencing postoperative pain also had an inflammatory border around the grafting site for 24-72 hours. (Fig. 4)
Figure 4. Grafting site with inflammatory border on the third postoperative day. Figure 3. Urethral pseudo-diverticulum at the graft placed as dorsal onlay.
In one case, disease evolution was favorable after urethroplasty, and presently the patient has a good urine flow, and voiding comfort. The oral mucosa graft has been used for twostaged urethroplasty (Bracka) in the distal penile _____________________________
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Lower lip paresthesia occurred in 13.3% of the cases. In these cases a larger graft was required. After 3 months, only one patient (6.66%) had paresthesia or collection site sensibility. This patient needed a larger graft compared to the standard size, and hemostasis suture lines were also required.
The number of cases is limited, and larger patient populations need to be studied in order to establish the efficiency and morbidity of the method. The collection of the lower lip graft can be performed under local anesthesia. Patients refusing another intervention with oral mucosa graft collected using this method were the ones where urethroplasty failed. Reticence about the method may also be attributed to the failure of reconstructive surgery. The lower lip graft is thinner than the cheek graft. Urethroplasty using this type of graft is indicated for shorter strictures. Aesthetic aspects of the lower lip, characteristic to each patient are also to be considered. Parodontitis or local lesions may restrict or contraindicate access and collection of an adequate graft. If collection is performed correctly and preserving anatomical boundaries, lower lip grafting is accepted by patients, and can be used for 3-4 cm long strictures. Collection under local anesthesia provides the benefit of avoiding general anesthesia with its increased risks to the elderly patient. Intervention costs are lower with local anesthesia and lumber anesthesia, but sometimes there is not enough material for urethroplasty. Thus, preoperative case selection is essential for a satisfactory outcome. Concerning the results of urethroplaties, the small number of cases cannot provide statistically clear conclusion. Essentially, the aim of the article is to raise the possibility of performing oral mucosa urethroplasty in elderly patients, where general anesthesia is not indicated. Classification of the penile urethra strictures into distal (close to the navicular fossa), mid-penile (at the penile sheath), and proximal (at the penilescrotal angle) groups has been performed based on anatomical and surgical reasons. Ventral onlay type urethroplasty has been more efficient at the penile-bulbar level than in the mid-penile segment. This could be explained by a better developed spongy body in the proximal penile area, which allows for an adequate covering of the oral mucosa graft. In the mid-penile area the dorsal onlay procedure had a superior success rate compared to the ventral onlay procedure, and the dorsal inlay urethroplasty as well. Dorsal placement provided a better support of the graft compared to the ventral one, and the urethral lumen was more easily augmented than in case of the Asopa procedure, where the thin urethral superior wall did not always allow for sufficient mobilization. In one case a small pseudo-diverticulum occurred at the site of dorsal onlay grafting, but without any urodynamic consequences.
The Bracka type intervention proved efficient in the distal penile urethra, but required a larger graft, which lead to collection site complications (paresthesia, local sensibility).
CONCLUSIONS The oral mucosa graft continues to be an excellent and widely accepted material for urethral substitution. Oral mucosa graft collection is a safe procedure, commonly accepted by patients. As a result of careful selection of cases and use of a technique guided by anatomical principles, this procedure provides urethral stricture patients a good quality substitute, without causing deformation and trauma of the genital region, like the penile skin flaps do, and without increasing the surgical trauma, like in case of the bladder mucosa or intestinal submucosa. Oral mucosa graft collection under local anesthesia from the lower lip is a solution for the elderly patient to avoid general anesthesia. It is better tolerated by the patients, although it does not provide same quality and size substitution material like a cheek graft.
APPENDIX 1 Thank you for completing this questionnaire. The following questions are designed to measure the effect that urethral strictures have on patientsâ&#x20AC;&#x2122; lives. Some questions may look the same, but each one is different. Please take time to read and answer each question carefully, and tick the box that best describes your symptoms over the past 4 weeks. If you currently have a urethral or suprapubic catheter (a catheter through the lower abdomen) please start from question 10. 1. Is there a delay before you start to urinate? Never Occasionally Sometimes Most of the time All of the time 2. Would you say that the strength of your urinary stream isâ&#x20AC;Ś Normal Occasionally reduced Sometimes reduced Reduced most of the time Reduced all of the time 3. Do you have to strain to continue urinating? Never Occasionally Sometimes Most of the time All of the time 4. Do you stop and start more than once while you urinate? Never Occasionally Sometimes Most of the time All of the time 5. How often do you feel your bladder has not emptied properly after you have urinated? Never Occasionally _____________________________ Jozsef Szabo et alâ&#x20AC;&#x192;
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Sometimes Most of the time All of the time 6. How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself? Never Occasionally Sometimes Most of the time All of the time 7. Are you able to prevent the escape of urine if you press your penis, or squeeze it between your legs? Yes No 8. Overall, how much do your urinary symptoms interfere with your life? Not at all A little Somewhat A lot 9. Please ring the number that corresponds with the strength of your urinary stream over the past month.
10. Do you have erections? Yes, with normal erectile rigidity Yes, with moderately reduced erectile rigidity Yes, with severely reduced erectile rigidity No 11. Are you able to ejaculate? Yes, in normal amounts Yes, with moderately reduced quantity Yes, with severely reduced quantity No 12. Do you experience pain or discomfort during ejaculation? No Yes, slight pain / discomfort Yes, moderate pain / discomfort Yes, severe pain / discomfort 13. During erection does the tip of your penis swell like the rest? Yes Not 14. Did you notice tingling or decreased sensation in the penis or scrotum in the last month? Yes No 15. In general, how much do sexuality related symptoms interfere with your life? Not at all A little Somewhat A lot _____________________________
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16. Are you satisfied with the outcome of your operation? Yes, very satisfied Yes, satisfied No, unsatisfied No, very unsatisfied 17. If you were unsatisfied or very unsatisfied is that because: The urinary condition did not improve The urinary condition improved but there was some other problem The urinary condition did not improve and there was some other problem as well 18. By placing a tick in one box in each group below, please indicate which statements best describe your own health state today: Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed
APPENDIX 2 Complications of buccal mucosa harvesting Name: Surname: Date of birth: Age at time of surgery: Date of surgery: Type of urethroplasty: - Penile - Bulbar Origin of the harvested graft: - Right cheek - Left cheek - Both cheeks - Lower lip - Lower lip and cheek - Primary / Secondary Early postoperative complications: 1.Have you had troublesome bleeding within 3 days of surgery? a. Yes b.No 2.How would you assess the pain during surgery? a. Absent b. Light c. Moderate
d. Severe 3.How would you assess the pain within 3 days of surgery? a. Absent b. Light c. Moderate d. Severe 4.How would you rate the swelling of your mouth within 3 days of surgery? a. Absent b.Light c.Moderate d.Severe 5.After surgery, how long have resumed normal diet? a. After three days b. After 6 days c. After 10 days 6. What bothered more after surgery? a. Pain in the penis b. Pain in the mouth 7. Did you take pain pills within 3 days after harvesting the graft? a. Yes b. No Late postoperative complications: 1.How many days did your mouth or lip feel numb after surgery? a. 1 week b. 1 month c. 3 months 2.How would you rate the lip numbness due to scarring? a.Absent b.Light c.Moderate d.Severe 3.Have you had an oral (mouth) infection after surgery? a. Yes b.No 4.After the operation have you noticed any alteration in sensitivity or perception of the lips? a. Numbness b.Pain c.I do not feel anything 5.A few months after the operation have you noticed that you have trouble opening your mouth? a. No b.Light c.Moderate d.Severe 6. Have you noticed a few months after the operation that you have trouble smiling? a.No b.Light c.Moderate d.Severe 7. Have you noticed a few months after the operation that you have dry mouth? a. No
b.Light c.Moderate d.Severe 8.Have you noticed a few months after surgery that your mouth swells after you eat? a.No b.Light c.Moderate d.Severe 9. You have resumed your normal diet after surgery? a. Yes b.No 10. How much time has passed after surgery until you returned to your normal diet? a. Up to 1 month b. 2 months c. 3 months 11. Would you accept another oral mucosa harvesting intervention? a. Yes b. No
REFERENCES 1. Smith J.C. Urethral resistance to micturition. Br J Urol 1968;40:125-56. 2. Pansadoro V., Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: long-term followup. J Urol. 1996 Jul;156(1):73-5. 3. Asopa H.S., Garg M., Singhal G.G., et al. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology 2001 Nov;58(5):657-9. 4. Pisapati V.L., Paturi S., Bethu S., et al. Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. Eur Urol. 2009 Jul;56(1):201-5. 5. Pansadoro V., Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: long-term followup. J Urol 1996 Jul;156(1):73-5. 6. Barbagli G. EAU update in the treatment of anterior urethral strictures - 23rd Annual EAU Congress EAU – CAU Session. 7. Ancelin M.L., de Roquefeuil G., Scali J., et al. Long-term post-operative cognitive decline in the elderly: the effects of anesthesia type, apolipoprotein E genotype, and clinical antecedents. J Alzheimers Dis 2010;22(Suppl.3):105-13. 8. Mason S.E., Noel-Storr A., Ritchie C.W. The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium: a systematic review with meta-analysis. J Alzheimers Dis. 2010;22(Suppl.3):67-79. 9. Laurent V, Abback PS, Christian P, Obiang N, Soufir L, RouquetteVincenti I. Anaesthesia in elderly people. Soins Gerontol. 2011 JanFeb;(87):29-32. 10. Muravchick S. The elderly outpatient: current anesthetic implications. Curr Opin Anaesthesiol 2002 Dec;15(6):621-5. 11. Goel A., Dalela D., Sinha R.J., et al. Harvesting buccal mucosa graft under local infiltration analgesia – mitigating need for general anesthesia. Urology. 2008 Sep;72(3):675-6. 12. Barbagli G., Vallasciani S., Romano G., et al. Morbidity of oral mucosa graft harvesting from a single cheek. Eur Urol 2010 Jul;58(1):33-41. 13. Markiewicz M.R., Margarone J.E., Barbagli G., et al. Oral mucosa harvest: an overview of anatomic and biologic considerations. EAUEBU Update Series 2007;5:179-87.
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ORIGINAL ARTICLES
MINIMALLY INVASIVE PROSTATE CANCER DIAGNOSIS BY GLUTHATIONE S-TRANSFERASE P 1 (GSTP1) GENE METHYLATION ANALYSIS IN SERUM SPECIMENS Raluca Dumache1a, Victor Dumitrascu2, Radu Minciu3, Dana David1, Anca Tudor4, Bogdan Bumbacila5a, Maria Puiu6 REZUMAT Introducere: Cancerul de prostată (CaP) reprezintă a doua cauză de mortalitate în rândul bărbaţilor pe plan mondial. Hipermetilarea genei glutation S-transferaza P1(GSTP1) apare cel mai frecvent la debutul procesului de carcinogeneză prostatică. Obiective: Scopul acestui studiu a fost de a analiza valoarea diagnostică a hipermetilării genei GSTP1 din probele de ser în diferenţierea pacienţilor cu diagnostic de CaP, respectiv hiperplazie benignă de prostată (HBP) prin metode minim invazive. Material şi metode: Hipermetilarea genei GSTP1 a fost investigată la nivelul ADN-ului genomic extras din probele de ser provenite de la 91 bărbaţi cu diagnosticul de CaP şi 94 cu HBP. ADN-ul genomic extras a fost supus tratării bisulfitice şi analizat prin metoda metilării specifice reacţiei de polimerizare în lanţ, fiind apoi corelat cu parametrii clinico-patologici ai pacienţilor. Rezultate: Nivele ale hipermetilării genei GSTP1 au fost prezente în cazul a 89 din 91 (92.86%) bărbaţí cu CaP şi în cazul a 10 din 94 (11%) bărbaţi din lotul control cu HBP. Concluzii: În acest studiu am evaluat abilitatea genei GSTP1 de a diferenţia pacienţii cu CaP şi HBP din probele de ser prin metode minim invazive. Cuvinte cheie: cancer de prostată, hiperplazie benignă de prostată, glutation S-transferaza P1, metilare specifică reacţiei de polimerizare în lanţ
ABSTRACT Introduction: Prostate cancer (PCa) represents the most commonly diagnosed type of malignancy among men in Western countries, and the second cause of cancer-related deaths among men worldwide. Alterations in the methylation patterns of promoter CpG islands have been associated with the transcriptional inhibition of genes in many human cancers, including PCa. Objective: The aim of our study was to analyse the diagnostic value of aberrant promoter hypermethylation of gene glutathione S-transferase P1(GSTP1) in serum DNA to discriminate between prostate cancer (PCa) and benign prostatic hyperplasia (BPH) patients by minimally invasive methods. Material and methods: Aberrant promoter hypermethylation was investigated in DNA isolated from serum samples of 91 patients with diagnostic of PCa and 94 with BPH (control subjects). Extracted genomic DNA was bisulfite treated and analyzed using methylation-specific polymerase chain reaction (MS-PCR). Results: Promoter hypermethylation of GSTP1 gene was detected in serum samples from 89 of 91 (92.86%) patients with PCa. Serum samples from the 94 controls without genitourinary cancer, revealed promoter hypermethylation of GSTP1 gene in 10 (10.6%) of the 94 patients. Receiver operating curve (ROC) included clinico-pathological parameters such as: serum PSA levels, pathological stage, Gleason score, hypermethylation status of GSTP1 gene, and gave a predictive accuracy of 96% with a sensitivity and specificity of 98% and 89%, respectively. Conclusions: In our study we have evaluated the ability of GSTP1 gene to discriminate between PCa and BPH patients in serum samples ,by minimally invasive methods. Key Words: prostate cancer, benign prostatic hyperplasia (BPH), glutathione S-transferase P1, methylation-specific polymerase chain reaction
INTRODUCTION
Department of Biochemistry, Victor Babes University of Medicine and Pharmacy, Timisoara, 2 Department of Laboratory Medicine, Clinical Emergency County Hospital Timisoara, 3 Department of Urology, 4 Department of Medical Informatics and Biostatistics, 5 Department of Clinical Pharmacy, 6 Department of Medical Genetics, Victor Babes University of Medicine and Pharmacy, Timisoara a Because of the equal contribution to this work, both authors should be regarded as first author. 1
Correspondence to: Raluca Dumache, MD, PhD, Department of Biochemistry, Victor Babes University of Medicine and Pharmacy, 2 E. Murgu Sq., 300041 Timisoara Email: raluca.dumache@umft.ro Received for publication: Oct. 13, 2011. Revised: Dec. 14, 2011. _____________________________
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Prostate cancer (PCa) represents the most prevalent malignancy among men and the second cause of cancer related deaths worldwide.1 If diagnosed in its early stages, when the tumor is confined to the prostatic capsule, PCa can be treated. Diagnosis and clinical management of PCa are often confounded because of the lack of symptoms and the absence of minimally invasive diagnostic techniques that could be used to detect the early stages of the disease. The only molecular biomarker used for early detection and recurrence monitoring after radical prostatectomy is prostate-specific antigen (PSA).2 Measurement of the serum PSA levels alone is neither sensitive, nor specific for a definite diagnosis of prostate adenocarcinoma.
It has been demonstrated that most of the patients who had either an abnormal finding on digital rectal examination (DRE) or elevated serum PSA levels, require transrectal biopsies with ultrasound guidance (TRUS). Serum PSA levels are increased in benign prostatic hyperplasia (BPH), prostatitis, or prostatic ischemia.3 Approximatelly one third from these men are found to have a negative biopsy result. Using these approaches, about 25% of men with false-negative prostate biopsy , are prone to develop PCa. It is known that the process of carcinogenesis develops in time , because of multiple molecular events, which include changes in gene expression,through epigenetic mechanisms.4 The epigenetic alterations have been detected first in genomic DNA isolated from tissue samples from different types of tumors, especially DNA hypermethylation in the promoter region of tumor suppressor genes. Cytosine-phosphate guanine islands (CpG) are susceptible to hypermethylation in unknown growth conditions, and may develop some pathways leading to the development of certain types of tumors.5 Using molecular biotechnology, some types of cancers have been detected from several bodily fluids, including urine in urological cancers, saliva in head and neck cancer, sputum and bronchoalveolar lavage in lung cancer.6 Unlike RNA and proteins alterations, DNA methylation biomarkers are stable in bodily fluids and occur in definite regions, unlike DNA mutations.7 Therefore, DNA methylation biomarkers might be used as noninvasive biomarkers in early detection of cancer and in monitoring the disease outcome. The earliest and commonest alteration which occurs during prostate carcinogenesis is represented by the hypermethylation of the glutathione S-transferase P1 (GSTP1) gene. GSTP1 hypermethylation has been detected by methylation-specific polymerase chain reaction (MS-PCR) method, in various bodily fluids such as urine, ejaculates or blood serum or plasma. GSTP1 hypermethylation has been reported to be present in up to 100% in PCa tissue, in up to 2/3 of high grade prostatic intraepithelial neoplasia (HGPIN), rarerly in benign prostatic hyperplasia(BPH) and is absent in normal prostatic tissues.8,9
AIM OF THE STUDY The main objective of our study was to determine the clinical utility of this new biomarker in serum samples to distinguish between PCa patients and BPH patients by minimally invasive methods.
MATERIALS AND METHODS Patients and samples collection In our study we included 91 cases with PCa histological confirmed and 94 BPH cases (cancerfree controls), hospitalized between January 2008 to February 2010 in the Department of Urology, Clinical County Emergency Hospital Timisoara. The study was conducted in accordance with The World Medical Association Declaration of Helsinki from 2008 statements and written informed consent was obtained from each patient. The eligibility criteria for the PCa patients’ selection were: 1. Clinical tumor stage I or II; 2. No clinical evidence of lymph nodes or distant metastases; 3. No treatment with hormone or radiation therapy before blood samples collection The average patient age ± SD in the BPH group was 61 ± 8 years and 63 ± 6 years in the PCa group. At the time of enrollment, the 91 patients presented tumors that were clinical stage I (n=54 [59%]) and stage II (n=37 [41%]). After the pathologic examination of radical prostatectomy specimens, enrolled patients were grouped according to tumor stage, as follows: pT2, n=47 (52%), and pT3, n= 44(48%). Patients were grouped according to Gleason score (GS) intervals as follows: 3 through 4, n= 17 (19%); 5 through 6, n=39 (43%), 7 through 10, n=35 (38%). Preoperative serum PSA levels were in range of 4.0 to 34 ng/ml. 1. Blood collection and DNA isolation Five milliliters of blood were drawn and collected in a serum separator tube containing clot activator and gel (Vacutainer, Becton Dickinson, USA). Tubes were inverted 8 times and centrifuged within 2 hours of collection for 10 minutes at 1500 X g. Using ZR Serum DNA (Zymo Research, U.S.A) we extracted DNA from 1 ml serum following the manufacturer’s protocol, and stored it at – 80 ºC until further analysis. 2. Bisulfite treatment and methylation-specific PCR (MS-PCR) analysis Using EZ DNA Methylation Kit® (Zymo Research, Orange, CA) protocol, 2 μg of genomic DNA from each patient sample was treated with denaturation buffer, sodium bisulfite (converting unmethylated cytosine residues to uracil), and desulfonation buffer, with elution of the bisulfite-modified DNA into 10 μl of buffer. Two sets of primers were used to amplify each region of interest: one pair recognized a sequence in which CpG sites are unmethylated (bisulfite modification to UpG) and the other recognized a sequence in which CpG sites are methylated (modified _____________________________ Raluca Dumache et al
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by bisulfite treatment).The reaction volume was of 50 μl containing: 10 μl of distillated water in which we added 25 μl Taq Polymerase mix, 2.5 μl from each forward and reverse primer (Eurogentec®, Belgium). To amplify the regulatory region of GSTP1 we used 2 μl of the bisulfite-modified DNA as a template for the MS-PCR reaction. The PCR conditions were as follows: Hot start at 95ºC for 5 minutes (to fully denaturate the bisulfite modified genomic DNA), 35 amplification cycles (94 ºC for 30 seconds for denaturation, 58ºC for 30 seconds for primer annealing and 72ºC for 60 seconds for extension), and a final full extension at 75ºC for 4 minutes. The primers used for the amplification reaction were as follows: Forward primers: 5 ’ - T T C G G G G T G TAG C G G T C G T C - 3 ’ (methylated); 5’-GATGTTTGGGGTGTAGTGGTTGTT-3’ (unmethylated); Reverse primers: 5 ’ - G C C C C A ATAC TA A AT C AC G AC G - 3 ’ (methylated); 5’-CCACCCCAATACTAAATCACAACA-3’ (unmethylated) Sodium bisulfite-modified DNA from healthy donors’ lymphocites served as unmethylated negative control. To detect the methylation levels of gene GSTP1 in patients with PCa and BPH we separated electrophoretically the MS-PCR products on a 2% Seakem agarose gel (Lonza, Switzerland) and visualized them under an ultraviolet (U.V) transluminator (Vilbert Lourmat®, France).
Figure 1. Serum molecular detection of GSTP1hypermethylation by MSPCR analysis.
Statistical analysis Data were analyzed by SPSS statistical package version 12 (SPSS Inc, Chicago,USA), with χ2 test, Spearmann rank correlations and Mann-Whitney tests to comparison between groups and finding the correlations. A P-value < 0.05 was considered significant.
RESULTS Correlations between the clinicopathological features and GSTP1 hypermethylation: _____________________________
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1. Hypermethylation status of GSTP1 gene in serum samples We observed that PCa patients undergoing disease progression had significantly increased methylation levels of GSTP1 gene when compared with BPH patients (Chi square test, p<0.001). In PCa patients, 89 (97.8%) of 91 presented hypermethylated levels of GSTP1 gene, whereas 10 (10.6%) of the 94 BPH patients had hypermethylated GSTP1 gene. The sensitivity and specificity of GSTP1 hypermethylation levels in discriminating PCa patients from BPH were determined by receiver operating curve (ROC) analysis. GSTP1 gene had a sensitivity of 98%, a specificity of 89% and yielded an area under the curve (AUC) of 0.936 (95 % CI; 0.895 to 0.977; p< 0.001), as presented in Figure 2.
Figure 2. Receiver operating curve (ROC) analysis of GSTP1 gene hypermethylation levels in prostate cancer patients.
2. Hypermethylated levels of GSTP1 gene correlates with serum PSA levels According to Spearman rank-correlation, a significantly correlation has been found between serum PSA levels and GSTP1 hypermethylation in PCa patients (r=0.831; p<0.001). 3. Correlation of pathologic tumor stage with GSTP1 hypermethylation levels In PCa patients with pT3 stage we observed significantly increased methylation levels of gene GSTP1, when compared with pT2 stage (p<0.001; Mann-Whitney test). 4. Correlation of Gleason score (GS) with pathologic tumor stage According to the Spearman rank-correlation test, a significant correlation between GS and the pathological stage exists (r=0.749; p<0.001). Increased GS score were significantly associated with pT3 stage.
DISCUSSION
The evaluation of serum samples obtained from PCa patients, presents some advantages because, unlike tissue biopsy or imagistics, blood sampling is a minimally invasive method which does not present the risk of morbidity, and can be repeated to monitor the changes which occur during disease progression or to detect the recurrence of the disease.10,11 The main goal of our study was to determine whether serum detection of GSTP1 methylation levels can discriminate PCa men from those with BPH by minimally invasive methods, and the second aim of the study was to investigate possible correlations between GSTP1 methylation levels and different clinico-pathological parameters. Sensitivity of 98% and specificity of 89% in distinguishing malignant cells, were determined by receiver operator curve (ROC) and the discriminatory power of the test was given by the area under the curve (AUC) which was 0.936 (95% CI;0.895 to 0.977; p<0.001).12 The results obtained by us, can be considered good for a minimally invasive serum diagnostic test. The different levels of GSTP1 hypermethylation between neoplastic and nonneoplastic prostatic tissue,suggests the fact that measurement of GSTP1 hypermethylation levels could be more useful in distinguishing men at low risk for PCa from those with a clinically silent PCa,in comparison with the measurement of serum PSA levels.13 De Marzo et al. reported in their studies that methylation levels of GSTP1 gene are present in men with proliferative inflamatory atrophy (PIA) and highgrade prostatic intraepithelial neoplasia (HGPIN), indicating that GSTP1 methylation occurs at the beginning of prostate carcinogenesis.14 Detection of serum GSTP1 hypermethylation in patients with negative biopsy should be sufficient evidence to warrant the concern of the presence of an occult disease. The presence of methylation levels of GSTP1 gene in 10 (10.6%) men with previously BPH, indicates that they could harbor an occult microscopic foci of PCa in the context of BPH, which was omitted by prostatic biopsy. During the study, repeat biopsies have been performed to the 10 patients with BPH found with hypermethylated GSTP1 levels in serum samples. All of them (100%) have been found to have cancer on repeat biopsy. Abnormal GSTP1 methylation levels found in serum samples may help in identification of men who are at risk for harboring prostate cancer despite negative prostate biopsy. Henrique et al. found in serum samples from PCa patients GSTP1 hypermethylation levels ranging
between 15 % and 70%.15 In our study we found the hypermethylation levels up to 90%. These results could be explained by the use of quantitative MS-PCR rather than a conventional MS-PCR method. MS-PCR seems to be more sensitive in serum and currently, no evidence showed that qMS-PCR could be more specific. Also, Maruyama et al. reported in one study the correlations between hypermethylation levels of GSTP1 gene from serum samples in PCa patients and Gleason score, serum PSA levels and pathologic stage.16 Patients with elevated serum PSA levels can have either PCa or BPH, and repeat biopsies can provide up to 20% detection rate after an initial negative biopsy. Because only 30-40% of patients with serum PSA levels between 4 and 10 ng/ml have PCa, there are a lot of patients with negative prostate biopsies who would benefit from improved ability to discriminate between cancer and benign lesions, by noninvasive diagnosis methods, as described in our study.17 The limitations of our study include the small number of patients and the lack of long-term followup. Further studies in the area of noninvasive detection of PCa include : the detection of PCa in its early stages from voided urine samples using a panel of tumoral biomarkers by qMS-PCR method, and the detection of disease recurrence in men following radical prostatectomy from preoperative serum samples.
CONCLUSIONS In our study we have demonstrated the feasibility of a novel clinical strategy, which is based on minimally invasive molecular test that can be used to aid to current investigation methods for prostate cancer detection. The efficacy of this minimally invasive test for early molecular detection of PCa is important in developing future clinical management algorithms and in establishing indications regarding the surveillance or repeat biopsy.
REFERENCES 1. Garcia M, Jemal A, Ward EM, et al. Global Cancer Facts & Figures 2007. Atlanta (GA): American Cancer Society, 2007:1-50. 2. Ahmed H. Promoter methylation in prostate cancer and its application for the early detection of prostate cancer using serum and urine samples. Biomark Cancer 2010:17-33. 3. Phe V, Cussenot O, Roupret M. Methylated genes as potential biomarkers in prostate cancer. BJU Int 2010;105:1364-70. 4. Schulz WA, Hoffmann MJ. Epigenetic mechanisms in the biology of prostate cancer. Semin Cancer Biol 2009;19(3):172-80. 5. Hoque MO, Lee J, Begum, et al. High-throughput molecular analysis of urine sediment for the detection of bladder cancer by high-density _____________________________ Raluca Dumache et alâ&#x20AC;&#x192;
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single-nucleotide polymorphism array. Cancer Res 2003;63:5723-26. 6. Ellinger J, Muller SC, Stadler TC, et al. The role of cell-free circulating DNA in the diagnosis and prognosis of prostate cancer. Urol Oncol 2011;29(2):124-9. 7. Lee WH, Morton RA, Epstein JI, et al. Cytidine methylation of regulatory sequences near the pi-class glutathione S-transferase gene accompanies human prostatic carcinogenesis. Proc Natl Acad Sci USA 1994;91:11733-7. 8. Ellinger J, Bastian PJ, Haan KI,et al. Noncancerous PTGS2 DNA fragments of apoptotic origin in sera of prostate cancer patients qualify as diagnostic and prognostic indicators. Int J Cancer 2008;122:138-43. 9. Boddy JL, Gal S, Malone PR, et al. The role of cell-free DNA size distribution in the management of prostate cancer. Oncol Res 2006;16:35-41. 10. Reibenwein J, Pils D, Horak P, et al. Promoter hypermethylation of GSTP1, AR, and 14-3 sigma in serum of prostate cancer patients and its clinical relevance. Prostate 2007;67:427-32. 11. Brooks JD, Weinstein M, Lin X, et al. CG island methylation changes
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near the GSTP1 gene in prostatic intraepithelial neoplasia. Cancer Epidemiol Biomark Prev 1998;7:531-6. 12. Thompson IM, Ankerst DP, Chi C, et al. Operating characteristics of prostate-specific antigen in men with an initial PSA level of 3.0 ng/ ml or lower. JAMA 2005;294:66-70. 13. Dumache R, Miclea F, David D, et al. Aspects of molecular genetics in prostate cancer. Romanian Journal of Rare Diseases, 2010;Suppl.1:71-2. 14. De Marzo AM, Marchi VL, Epstein JI, et al. Proliferative inflammatory atrophy of the prostate. Implications for prostatic carcinogenesis. Am J Pathol 1999;155:1985-92. 15. Jeronimo C, Usadel H, Henrique R, et al. Quantitative GSTP1 hypermethylation in bodily fluids of patients with prostate cancer. Urology 2002;60:1131-5. 16. Maruyama R, Toyooka S, Gazdar AF, et al. Aberrant promoter methylation profile of prostate cancer and its relationship to clinicopathological features. Clin Cancer Res 2002;8:514-9. 17. Nelson WG, De Marzo AM, Isaacs WB. Prostate cancer. N Engl J Med 2003;349:366-81.
ORIGINAL ARTICLES
CO M P L I C AT I O N S O F RO U X - E N - Y G A S T R I C B Y PA S S PE R F O R M E D B Y L A PA ROTO M Y. CO M PA R I S O N W I T H T H E L A PA RO S CO PI C A P P ROAC H D E S C R I B E D I N T H E L I T E R AT U R E Laurentiu V. Sima1, Alexandra C. Sima2, Radu G. Dan3, Gelu M. Breaza4, Octavian M. Cretu5 REZUMAT Introducere: Chirurgica bariatrică este o metodă de tratament al obezității morbide, care a trezit un interes deosebit în ultimii ani. Din toate tipurile de intervenții practicate, cea mai frecventă este intervenția de bypass gastric Roux în Y, cu rol atât restrictiv cât și malabsorbtiv, ce dă cele mai bune rezultate din punct de vedere al scăderii în greutate. În România chirurgia bariatrică nu este practicată pe scară largă, datorită slabei adresabilități a pacienților, datorată atât lipsei de informație, cât și a recomandărilor reduse din partea medicilor de familie și nutriționiști. Material și metode: Grupul studiat a inclus 14 pacienți cu vârste între 18 și 65 de ani, cu indice de masă corporală peste 40 kg/m2, evaluați în vederea efectuării unui bypass gastric de tip Roux în Y. Intervențiile chirurgicale au fost efectuate la Clinica de Chirurgie a Spitalului Municipal Timișoara. Tehnica chirurgicală a utilizat abordul prin laparotomie xifo-ombilicală, preferată datorită costurilor ridicate ale unor intervenții laparoscopice. Urmărirea postoperatorie s-a efectuat la 1 lună, apoi din 3 în 3 luni, până la 2 ani. Rezultatele obținute au fost comparate cu cele descrise în literatură pentru intervențiile laparoscopice, punându-se accentul mai ales pe spitalizarea postoperatorie, durata intervenției, prezența complicațiilor timpurii sau tardive. Rezultate: Singurele complicații observate au fost infecții ale plăgii operatorii sau hernii incizionale. Concluzii: Dacă se iau măsuri în vederea protecției peretelui abdominal, complicațiile se pot reduce semnificativ. Tehnica laparoscopică are mai puține infecții de plagă, un număr mai mare de fistule anastomotice și un preț mult mai ridicat, fiind inaccesibilă multor pacienți cu obezitate morbidă. Rezultatele pe termen lung în ceea ce privește scăderea în greutate sun superioare în cazul intervențiilor efectuate prin laparotomie. Cuvinte cheie: obezitate, bariatric, bypass, complicații
ABSTRACT Introduction: Bariatric surgery is a method of treating morbid obesity which raised more and more interest in the past years. Among all types of intervention, the most frequently used is Roux-en-Y gastric bypass, an intervention both restrictive and malabsorbtive, which leads to best results for weight loss. In Romania, bariatric surgery, and especially Roux-en-Y gastric bypass, is not widely practiced due to poor addressability of patients, both by lack of information, and the poor recommendation from general practitioners and specialists in metabolic diseases. Material and methods: The study group includes 14 patients aged between 18 and 65 years, with BMI above 40 kg/m2, evaluated before surgery as per the indications for this kind of treatment. The study aims to present the complications that occurred in this group of patients in which Roux-en-Y gastric bypass was performed in the Surgery Department of the City Hospital Timisoara. The surgery was done by xifo-umbilical laparotomy technique, because of the very high costs of laparoscopic approach. Subsequently, patients were followed postoperatively at 1 month, and then every 3 months, up to 2 years. The results were compared to those of the laparoscopic approach described in the literature regarding length of stay, operative time, early and late complications. Results: The only complications found were wound infections and incisional hernias. Conclusions: Introducing some changes in terms of restoring the abdominal wall, there is hope to eliminate these complications. The laparoscopic technique is followed by fewer wound infections and incisional hernias, a greater number of anastomotic leakages and involves higher price, being inaccessible to many patients with morbid obesity. The long term results regarding excess weight loss have proven to be better in gastric bypass performed by laparotomy. Key Words: obesity, bariatric, bypass, complications
INTRODUCTION
Victor Babes University of Medicine and Pharmacy, Timisoara, 2 Clinical Emergency Municipal Hospital, Timisoara 1
Correspondence to: Alexandra C. Sima, Victor Babes University of Medicine and Pharmacy, 2 E. Murgu Sq., Timisoara, Tel. +40-722467247 Email: alexa_moisuc@yahoo.com Received for publication: Jul. 16, 2011. Revised: Dec. 18, 2011.
Both in itself and because of comorbidities, morbid obesity is a major health problem worldwide, requiring a multidisciplinary approach. Various therapeutic methods, both medical and surgical, were imagined over time for its treatment. Due to favourable results obtained, bariatric surgery has become, in the past years, the treatment of choice for this type of obesity. The currently used methods are Roux-en-Y gastric bypass, vertical banded gastroplasty, gastric banding and biliopancreatic bypass. _____________________________ Laurentiu Sima et al
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Bariatric surgery is addressed to patients with a body mass index (BMI) above 40 kg/m2, or a BMI between 35 and 40 kg/m2 with significant comorbidities.1 Gastric bypass is the most common procedure used to treat morbid obesity, acting by double mechanism: restrictive - reduces the gastric reservoir to 20-50 mL, and malabsorbtive - excludes a variable portion of the jejunum from the digestive tract; these induce weight loss of the patients.1,2 Gastric bypass surgery can be done both as an open and a laparoscopic procedure. When the laparoscopic approach is not possible because of very high costs, open gastric bypass remains the saving solution for obese patients. Although the morbidity rate after gastric bypass dropped from approximately 40% in the pathfinder century to 10% nowadays due to the learning curve, postoperative complications of bariatric surgery are still a problem requiring solutions.2 Complications can occur early or late. Most of the early complications are pulmonary thromboembolism, anastomotic leakage or postoperative wound suppurations.2 Late complications are numerous and more frequent, incisional hernias, dumping syndrome, iron and vitamin B12 deficiency, anemia, kidney or gall stone and intestinal obstruction being just a few.3,4 Worth mentioning are anastomotic ulcers, gastritis or digestive bleeding on distal stomach, and not least the psychological implications of gastric bypass surgery on obese patients.5
MATERIAL AND METHODS This study was conducted on a group of patients that addressed the surgeon by themselves, requesting this intervention. Before surgery, indication to undergo the procedure was assessed in accordance with international recommendations: age 18-64 years, body mass index (BMI) >40 kg/m2 or >35 kg/ m2 and the presence of at least two comorbidities (diabetes mellitus, high blood pressure, sleep apnea or respiratory insufficiency, dyslipidemia, coronary heart disease or cardiomiopathy, significant musculoskeletal dysfunction), history of morbid obesity for at least five years, strong motivation and good compliance of the patient. Patients with contraindications (history of alcohol or drug abuse, bulimia, psychosis, previous bariatric surgery or major abdominal surgery for other conditions, Cushing’s disease, chronic use of glucocorticoids, immobilization in a wheelchair before becoming obese) were not accepted. The study group included 14 patients, 9 women and 5 men. The average age was 38.69 years (between 18 and 53). Mean BMI was 46.74 (between 40 and 55.37). _____________________________
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Surgery was performed trough median xifosupraumbilical incision. After opening and exploring the peritoneal cavity, the same technique was applied in all patients: a high gastric resection, leaving a small gastric reservoir with a volume of approximately 50 ml. The distal antrum was removed to a level that was clogged with separate stitches in double layer. The Y loop was prepared by sectioning the jejunum about 25 cm from the Treitz angle. Implantation in the ileum was performed at a distance between 80 and 120 cm, depending on the patient’s BMI. Gastric anastomosis of both anterior and posterior layers was performed with continuous suture. Tactic cholecystectomy was performed in eleven patients, to prevent further biliary complications (gall stones, biliary dyskinesia) due to the section of vagus nerve.6 After bleeding check and lavage of the peritoneal cavity, a drain was placed on the posterior side near the anastomosis. Reconstruction of the abdominal wall was performed in a single layer in all patients, with separate stitches; a preparation of the abdominal wall by removing the subcutaneous tissue was done in order to reduce wound related complications. Skin was closed with BlairDonatti sutures. In the last five patients, subcutaneous drainage was placed in order to reduce the number of wound infections. Postoperative treatment consisted in anticoagulant medication depending on the patient weight, painkillers as needed, antibiotics and parenteral nutrition. A combination of two antibiotics (5 days course of third generation cephalosporin + quinolone every 12 hours) was used in all patients. All diabetic and hypertensive patients were monitored regarding sugar blood level and blood pressure for at least two times a day, depending on their preoperative condition, and the treatment was adjusted according to these measurements. The results collected from our patients were compared to those described in the literature after laparoscopic approach regarding early or late complications.
RESULTS Duration of surgery was variable, ranging between 4 and 5 hours, with an average of 4.42 hours, decreasing with surgeon’s experience. Seven of the fourteen patients were treated and monitored in the intensive care unit for the first 24 hours postoperatively because of higher risk due to their comorbidities. Postoperative evolution of the entire group of patients was favourable. Most have resumed bowel movements within 48 hours after surgery; in 4 cases this happened in the 3rd postoperative day. There
were no major complications, such as postoperative bleeding, pulmonary thromboembolism, anastomotic leakage or stomal stenosis. The duration of hospital admission was between 6 and 9 days, with an average of 6.78 days. Early complications occurred in seven patients (50%) and consisted in wound suppurations between the seventh and the fourteenth postoperative day. The germs isolated in the wound were Proteus mirabilis, Staphylococcus aureus, Klebsiella pneumoniae and Escherichia coli. Antibiotics were administered according to the antibiogram and dressings were changed 2 times per day. In all cases the evolution was favourable, with complete healing. In the last five patients, where subcutaneous drainage was used, this complication was not encountered. Five patients (35.71%) developed late complications represented by single or multiple incisional hernias with various sizes of the wall defects. All were simple hernias with epiploic content, and haven’t developed any complications. Incisional hernias occurred at different periods after surgery, but most of them developed after about 6 months. In all cases the wall defects were surgically solved. No mesh reinforcement was necessary and all patients had favourable outcome. None of the last five patients where subcutaneous drainage and preparation of the abdominal wall by the above-mentioned technique was used developed incisional hernia so far. All the diabetic and hypertensive patients required discontinuation or dose reduction of the specific medication during the follow-up period.
DISCUSSIONS By various tricks or changes in surgical technique, the frequency of some of the complications of the gastric bypass procedure can be reduced or they can even be avoided.7 Thus, to avoid complications of surgical wound (suppurative complications, incisional hernias), the subcutaneous tissue from the musculoaponeurotic wall was removed up to the level where stitches were inserted. This preparation of the abdominal wall and the use of subcutaneous drainage avoided suppurative complications and incisional hernias so far in patients where this technique had been used, but this last aspect requires further monitoring. Wound related complications are less frequent after laparoscopic approach, compared to open gastric bypass. Schauer et al reported 24 wound infections in a series of 275 patients (8.72%), while Abdel-Galil and Sabry had a 20% rate (18 from 90 patients).8,9 In other studies, wound infection rate after laparoscopic bypass
is very low (Higa et al reported 2 wound infections in 1500 patients – 0.13%). Puzziferri et al reported a 5% rate of incisional hernias after laparoscopic approach and a 39% rate after open gastric bypass in a series of 155 patients with morbid obesity (79 laparoscopic and 76 open gastric bypass).10 Among the early complications of gastric bypass cited in the literature, beside suppurative complications discussed above, the most common are pulmonary embolism and anastomotic leakage. Early mobilization of patients, the use of elastic stockings and low molecular weight heparin administered in prophylactic doses prevented thromboembolism in our patients. In order to avoid anastomotic leakage, a continuous suture with 3-0 Vicryl in a total posterior layer was performed, after previously fixing a few seroserous stitches, followed by an extramucosal anterior layer, along with a transanastomotic nasogastric tube maintained until resumption of intestinal transit, thus avoiding gastric stasis and forcing the anastomosis. There were no anastomotic leakages in our series. The frequency of fistula after laparoscopic gastric bypass varies widely in the literature, but it still remains higher compared to open surgery. Although Dillemans et al reported only 5 anastomotic leakages in a study on 2606 patients (0.19%), in some studies this rate can rise up to 5.2%.11-13 Creating a small gastro-jejunal anastomosis, usually between 1.5 and 3cm, reduces the risk of dumping syndrome by avoiding rapid passage of the food through the gastric reservoir into the jejunum.14 By using this technique, there was no dumping syndrome recorded in our patients. The development of gallstones, secondary to massive weight loss and to intraoperative sectioning of the vagus nerve during the skeletonization of stomach’s lesser curvature, has been avoided by performing routine cholecystectomy.15 There are a series of complications in the distal stump of the stomach described in the literature, among which gastrointestinal bleeding, gastritis and even gastric cancer. These complications, although rare, raise real diagnostic problems, because the distal stump of the stomach is not accessible to endoscopic exploration.3 To avoid these complications, resection of the distal stomach was done in our series. The data published in the literature seems to indicate an advantage in favour of open gastric bypass regarding the rate of stomal stenosis, and also of excess weight loss. Podnos et al found a stomal stenosis rate of 0.67% (15/2233) after open gastric bypass, compared to 4.73% (164/3464) in laparoscopic approach.16 _____________________________ Laurentiu Sima et al
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During the follow up period, this complication was not encountered in our patients. Buchwald, in his analysis of 10172 patients, found an excess weight loss of 47.5% after laparoscopic approach and 61.6% after open gastric bypass.17 The major drawback of laparoscopic gastric bypass over the open approach is the steep “learning curve”, which takes longer than other laparoscopic interventions, being one of the most complexes in general surgery.10 The length of hospital stay after laparoscopic gastric bypass is shorter, due to the lesser surgical stress. Dillemans et al reported a mean length of hospital stay of 3.35 days, 2197 of 2606 patients being discharged on the third postoperative day or earlier.11 Kothari et al reported a length of stay of 2.2+/-0.9 days in 700 patients who underwent laparoscopic gastric bypass.18 Our mean length of hospital stay was 6.78 days.
CONCLUSIONS Roux-en-Y gastric bypass is a major surgical procedure, involving the possibility of multiple complications, both early and late. The data published in the last years shows that a proper surgical technique, either opened or laparoscopically, is correlated with a decreased risk of complications. Most of the complications can be avoided, while those that do occur can be solved relatively easily. Consistent with these data, in our group there were only complications related to the postoperative wound, which can be minimized by modifying the suturing technique of the abdominal wall. As discussed more and more nowadays, the benefits of surgery are significantly greater despite all incriminated risks, leading to the conclusion that the surgical treatment of obesity is worth to be applied; it provides the patients with the chance to regain a proper life style and, also, it decreases the risk of obesity-related diseases, primarily, but not limited to cardiovascular risk. Laparoscopic approach permits decreasing of wound related complications (infections and incisional hernias) and length of hospital stay, but involves higher costs and seems to have less satisfactory long term results regarding excess weight loss. It should be noted that the peculiarity of this group of patients undergoing bariatric surgery is represented by their self-addressing to the surgeon in order to assess the possibility of benefiting from this type of treatment.
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This study is an analysis of the surgical procedure and its early complications, but the group of patients will undergo a periodical follow-up, both in terms of late complications, and in terms of clinical and biological evolution.
REFERENCES 1. Nguyen NT, Goldman C, Rosenquist J, et al. Laparoscopic versus open gastric bypass: a randomised study of outcomes, quality of life and costs. Annals of Surgery 2001;234:234-79. 2. Buchwald H. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surgery for Obesity and Related Diseases 2005;1:371–81. 3. Brolin RE. Bariatric surgery and long-term control of morbid obesity. Journal of American Medical Association 2002;288(22):2793-6. 4. Brolin BE. Complications of surgery for severe obesity. Problems in General Surgery 2000;17:55–61. 5. Csendes A, Burdiles P, Papapietro K, et al. Results of gastric bypass plus resection of the distal excluded gastric segment in patients with morbid obesity. Journal of Gastrointestinal Surgery 2004;9(1):121-31. 6. Hamad GG, Ikramuddin S, Gourash WF, et al. Elective cholecystectomy during laparoscopic Roux-en-Y gastric bypass: is it worth the wait? Obesity Surgery, 2002;13:76-81. 7. Wolfel R, Gunther K, Rumenapf G, et al. Weight reduction after gastric bypass and horizontal gastroplasty for morbid obesity. Results after 10 years. European Journal of Surgery 1994; 160:219–25. 8. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515-29. 9. Abdel-Galil E, Sabry AA. Laparoscopic Roux-en-Y gastric bypass: evaluation of three different techniques. Obes Surg. 2002;12:639-42. 10. Puzziferri N, Austrheim-Smith IT, Wolfe BM, et al. Three-year followup of a prospective randomised trial comparing laparoscopic versus open gastric bypass. Ann Surg 2006;243(2):181–8. 11. Dillemans B, Sakran N, Van Cauwenberge S, et al. Standardization of the fully stapled laparoscopic Roux-en-Y gastric bypass for obesity reduces early immediate postoperative morbidity and mortality: a single center study on 2606 Patients. Obes Surg. 2009;19(10):1355–64. 12. Perez A, De Maria EJ. Anastomotic leaks after laparoscopic gastric bypass. The SAGES Manual 2008, IV, 193-7. 13. Birkmeyer NJ, et al. Hospital complication rates with bariatric surgery in Michigan. JAMA, 2010;304(4):435-42. 14. Brolin RE, Robertson EB, Kenler HA, et al. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Annals of Surgery 1994;220(6):782-90. 15. Saunders WB, Feldman M, Sleisenger MH, et al. Sleisenger & Fordtran’s Gastrointestinal and liver disease, 7th ed. Philadelphia, WB Saunders, 2002. 16. Podnos YD, Jimenez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass. A review of 3464 cases. Arch Surg. 2003;138:957-61. 17. Buchwald H et al. Bariatric surgery: A systematic review and metaanalysis. JAMA 2004;292:1724-37. 18. Kothari SN, Kallies KJ, Mathiason MA, et al. Excellent laparoscopic gastric bypass outcomes can be achieved at a communitybased training hospital with moderate case volume. Ann Surg, 2010;252(1):43-9.
ORIGINAL ARTICLES
THE ROLE OF MULTIMODAL ANALGESIA IN PATIENTS WITH TUBAL PATHOLOGY TREATED BY LAPAROSCOPIC SURGERY Laura Gavril1, Adrian Cotirlet2, Florentina Pricop3 REZUMAT
Obiectiv: Scopul lucrării este de a evidenţia avantajele analgeziei multimodale în tratamentul durerii acute postoperatorii la pacientele operate laparoscopic pentru patologia tubara şi consecinţele acestei terapii asupra evoluţiei postoperatorii, comparativ cu metoda clasică de tratament a durerii postoperatorii. Material si metodă: Studiul este prospectiv şi include 44 de paciente, împarţite aleatoriu în 2 grupe: lotul de studiu, 22 paciente, la care s-a practicat o schemă de analgezie multimodală (administrarea i.v, inaintea inducţiei anesteziei, de inhibitor-COX2, parecoxib sodic; infiltrarea de levobupivacaină la nivelul plasării fiecarui trocar, preincizional şi instilarea intraperitoneală de levobupivacaină la inceputul şi la sfarşitul intervenţiei) şi lotul martor, 22 paciente, la care s-a practicat o schemă de analgezie “la cerere” (nu s-au administrat substanţe analgetice non-opioide pre- sau intraoperator). Evaluarea intensităţii durerii postoperatorii s-a efectuat la ambele loturi atât în repaus-static cât şi la mobilizare uşoară- dinamic, iniţial la 4 ore apoi la 8, 12 si 24 ore. Rezultate: In primele 12 ore postoperator, scorul durerii in repaus la lotul de studiu a fost de 0,04±0,21 comparativ cu 3,22±1,19 la lotul martor, iar scorul durerii la mobilizare a fost de 0,22±0,61 la lotul de studiu comparativ cu 5,4±1,22 la lotul martor. La pacientele din lotul de studiu incidenţa greţurilor şi vărsăturilor a fost mai scazută, mobilizarea şi externarea din spital a fost mai rapidă. Concluzii: La pacientele din lotul de studiu s-a constatat o bună analgezie postoperatorie, evidenţiată prin scoruri ale durerii mici pe scara vizuală analogă (SVA), atât in repaus la pat, cât şi la mobilizarea uşoară.
ABSTRACT Objective: The aim of the study is to highlight the benefits of multimodal analgesia in the treatment of postoperative pain in patients with tubal pathology operated by laparoscopic surgery compared to classical postoperative pain management. Material and method: This study is a prospective one and included a number of 44 patients operated by laparoscopic surgery for tubal pathology. The patients were randomly divided into two groups: the study group (22 patients) received pre- and intraoperative multimodal analgesia, which included a COX-2 inhibitor (parecoxib) i.v. before induction of anesthesia, levobupivacaine infiltration before skin incision and intraperitoneal administration of levobupivacaine at the beginning and at the end of the procedure, and the control group (22 patients) had general anesthesia without any pre- or intraoperative nonopioid analgesic. Evaluation of postoperative pain intensity was performed in both groups, at rest,static, and during mobilization, dynamic, at first at 4 hours and then at 8, 12 and 24 hours. Results: In the first 12 hours postoperatively the mean pain score at rest in the study group was 2,98±0,53 compared to 4,66±1,15 in the control group and the mean pain score during mobilization was 3,81±0,88 in the study group compared to 5,91±1,47 in the control group. Incidence of PONV was lower, mobilization and hospital discharge were faster for patients in the study group. Conclusion: Pre- and intraoperative multimodal management of postoperative pain resulted in lower VAS pain scores at rest and during mobilization compared to classical postoperative pain treatment. Key Words: multimodal analgesia, visual analogue scale, tubal pathology, laparoscopic surgery
INTRODUCTION International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.
Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy, Iasi, 2 Department of Surgery, Municipal Hospital, Moinesti, 3 Department of Obstetrics and Gynecology, Elena Doamna Hospital, Iasi 1
Correspondence to: Laura Gavril, Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy, Iasi Email: cotirlet_laura@yahoo.com Received for publication: Sep. 04, 2011. Revised: Sep. 27, 2011.
Effective perioperative pain management poses a significant challenge for healthcare practitioners and personnel (anesthesiologists, surgeons, nurses, physiotherapists); the responsibility for inadequate pain control is multifactorial in origin.1 The concept of multimodal analgesia was introduced more than a decade ago as a technique to improve analgesia and reduce the incidence of opioidrelated adverse events. The rationale for this strategy is the achievement of sufficient analgesia due to the additive or synergistic effects between different classes of analgesics. This allows for a reduction in the doses of individual drugs and thus a lower incidence of adverse effects from any particular medication used for perioperative pain management.2-4 The aim of the study is to highlight the benefits of multimodal analgesia in the treatment of postoperative pain in patients with tubal pathology operated by laparoscopic surgery compared to classical postoperative pain management. _____________________________ Laura Gavril et al
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MATERIAL AND METHODS Between November 2007 - June 2011 at the Municipal Emergency Hospital Moineşti, 204 patients were operated laparoscopic for gynecological diseases. Of these, 44 patients were with tubal pathology. They were divided into: the study group (22 patients) received pre- and intraoperative multimodal analgesia and the control group, 22 patients, had general anesthesia without any pre- or intraoperative non-opioid analgesic. At all patients, they were explained the purpose, technique and risks of study and consent were taken. Laparoscopic surgery was performed with general anesthesia. Premedication with COX2-selective NSAID, intravenous Parecoxib, induction with Fentanyl, Diprivan, Atracurium and maintenance of anesthesia (Sevoflurane) were in accordance with expert advice regarding anesthesia in laparoscopic surgery.5 Postoperatively, for all the patients, analgesia was performed “on request” by a major-opioid, Morphine, or a nonopioid analgesic, used Perfalgan (paracetamol) 1g intravenous slowly diluted, or Algocalmin (metamizol) 1g intravenous slowly diluted, administered according to the intensity of pain reported by patient, quantitatively assessed on a visual analogue scale (VAS). Particularly, for the patients in the study group was applied a multimodal analgesia scheme which included a COX-2 inhibitor (Parecoxib sodium 40 mg) i.v before induction of anesthesia, 0.25% Levobupivacaine infiltration before skin incision and intraperitoneal administration of local anesthetic (40 ml Levobupivacaine 0.25%) by gynecologist, in two stages: half the calculated volume was administered immediately after the creation of the pneumoperitoneum, and the other half at the end of the operation before the withdrawal of the trocars and intraperitoneal CO2 exuflation. The evaluation of postoperative pain intensity was performed in both groups at rest, static, and at mobilization, dynamic, first at 4 hours and then at 8, 12 and 24 hours. Assessment of postoperative pain was done with pain score on visual analogue scale. VAS is practically the most used method for assessing postoperative pain, being the most sensitive. The patient indicates on a imaginary horizontal ruler marked from 0 to 10 cm, the appropriate pain position that she feels: 0 = no pain, 10 = unbearable pain. (Table 1) At a superior pain level, more than 6 – 7 points on the VAS, patients received opioid - Morphine titrated intravenous (2 mg), supplemented with subcutaneous _____________________________
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administration of Morphine for the extension of analgesic effect. At level pain between 3 and 6 points - titrated intravenous Morphine 2 mg + 40 mg Parecoxib sodium intravenously. At an inferior pain level – less than 3 – the patients received Perfalgan (Paracetamol) 1g i.v or Algocalmin (Metamizole) 1 g. Results were expressed as mean ± standard deviation. Statistical data processing was done with chi square (p <0.05 statistically significant), with a confidence interval (CI) = 95%. Table 1. Visual Analogue Scale.
RESULTS
groups of patients
The two were relatively homogeneous, without any significant differences in demographic data (age, weight and anesthetic risk) and the anesthetic technique. (Table 2) Table 2. The mean age of patients.
Laparoscopic treatment of these 44 patients involved in 14 cases of tubal cysts - 10 cystectomies, 2 salpingectomies, 1 salpingotomy and 1 anexectomy, in the case of the 15 ectopic pregnancies – 11 salpingectomies, 1 salpingotomy and 3 anexectomies and in the case of pelvic inflammatory disease pacients – 4 salpingectomies, 2 salpingotomies, 4 anexctomies and 5 adhesiolysis. (Figs 1-3)
Figure 1. Laparoscopic treatment of tubal cysts.
Tubal cysts Because of their development between foils broad ligament they requiring careful dissection to
avoid damage to the urethra and uterine pedicle, being practiced in 10 cases cystectomies after identification of the cleavage plan between the cyst wall and peritoneal leaf, 2 salpingectomies due to large size of cystic formations which greatly distorted tubal track, 1 salpingotomy when one of the formation poles was adhering to the tubal wall after adhesiolysis and 1 anexectomy (one patient aged 51 years) with sending the adnexal masses to anatomopathological examination.
Figure 2. Laparoscopic treatment of ectopic pregnancies.
purulent exudate after antibiotherapy, administered intravenously in 2 cases and 1 anexectomy with adhesiolysis for the adhesive syndrome and peritonitis. Tubo-ovarian abcess laparoscopically diagnosed at 3 patients required unilateral anexectomy after careful and difficult adhesiolysis of the intestinal loops, great omentum and sigmoid colon. In the case of four patients hydrosalpinx was laparoscopically diagnosed due to complete tubal obstruction and salpingectomy was performed. The hydrosalpinx due to adhesions of the ovary fimbria was resolved by adhesiolysis (salpingo-ovariolysis) accompanied by lysis of extra-adnexial adhesions (omental and parietal or perihepatic adhesions if Fitz Hugh Curtis syndrome). The mean operative time for laparoscopic surgery in the study group was 44.09 minutes with a range of 10 to 90 minutes and for control group patients was 53.4 minutes with a range between 25 and 100 minutes. (Table 3) Table 3. The mean laparoscopic time (minutes).
Figure 3. Laparoscopic treatment of pelvic inflammatory disease.
Tubal ectopic pregnancy Salpingectomy was performed after evacuation of the hemoperitoneum for tubal pregnancies larger than 5 cm, in case of hemodynamic instability, if the fallopian tube was functional compromised, patients who wanted surgery sterilization having the family plannig completed, if HCG> 100,000 mU/ml. Salpingotomy with tube removal and preservation of pregnancy was performed in patients who desired fertility preservation, had a stable hemodynamic status, size of ectopic pregnancy was less than 5 cm, in the absence of controlaterale tube pathology. Anexectomy was performed because of coexisting ovarian pathology (2 cases of ovarian cystic tumor in patients 44 years and 41 years) and in one case in which hemostasis was difficult in the mesosalpinx. Pelvic inflammatory disease Acute pelvic inflammatory disease – the pyosalpinx required salpingotomy with the discharge of the
Analysis of postoperative analgesia efficiency At the patients in the study group it was found a good postoperative analgesia, evidenced by lower pain scores, almost absent, on VAS, at rest and during mobilization. No patient required supplementation of analgesia. (Table 4) Table 4. Pain scores of both groups.
At the control group, 22 patients with intravenous analgesia, "analgesia on request", the average postoperative pain recorded at 4 hours after admission in _____________________________ Laura Gavril et al
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intensive care unit was static 1.13 ± 3.81 and dynamic 5.86 ± 1.28, average values of pain score very high compared with multimodal analgesia group. (Table 4) They show the presence of moderate to high postoperative pain, all the 22 patients (100%) requiring supplementation by administering an opioid, titrated intravenous morphine, at rest and during moderate mobilization. The evaluation at 8 and 12 hours postoperatively indicates the presence of moderate-high pain, which require further analgesia supplementation. A significant reduction in pain score was observed in measurements performed at 24 hours postoperatively. On visual analogue scale, postoperative pain score at rest was 1.68 ± 1.08 and at mobilization: 3.27 ± 1.07. This determined us to continue evaluating postoperative pain up to 48 hours postoperatively, when we found the net reduction at mobilization score on visual analogue scale: 0.49 ± 0.33. Analgesic administration could be discontinued at 48 hours postoperatively, but further oral analgesic (per os) was recommended (the resumption of bowel movements was present), using a modest association of an opioid (codeine) with an NSAID, paracetamol, for another 24-48 hours until discharge. Comparative analysis of the two methods of analgesia, multimodal and traditional, classical, “on request”, at the two groups of patients operated by laparoscopic surgery, points out that the advantages of multimodal analgesia is not limited only to the absence or reduction of postoperative pain score in the first 24 hours postoperatively in the study group, but also that once this protocol is established, may result an improvement of postoperative evolution of patients. The mobilisation of patients in the study group could be achieved much earlier, even at 4 hours postoperatively; that it is not passive mobilisation (respiratory gymnastics), but the active mobilisation of all patients in the study group. (Table 5) Table 5. Mobilisation time (hours).
Regarding the incidence of nausea and / or vomiting, it is in the control group of 72.72% (16 patients). They appear, although we given to all patients prophylactic antiemetic premedication (Dexamethasone 8 mg i.v). _____________________________
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Another crucial element is represented from a statistical point of view (p <0.001) between the two groups (16 patients in the control group versus one patient in the study group) in the incidence of nausea and/or vomiting. Note however, that medication includes a steroid (a derivative of corticosteroid - anti-inflammatory and immunosuppressive) with strong antiemetic effects - Dexamethasone 8 mg (2 ml), intravenous, with 4560 minutes before induction. In this context, oral rehydration was possible much earlier, at 24 hours postoperatively. Later, at 16-20 hours after surgery, they could eat: soups, juices, low-fat yogurt. The presence of bowel movements was delayed at patients in the control group up to 36-48 hours. One possible explanation for the appearance of nausea and vomiting and for postoperative ileus up to 48 hours, can be the administration of an opioid, morphine. (Table 6) Table 6. Bowel movement recovery time (hours).
Time to discharge from intensive care unit and during hospitalization was significantly shorter in the study group, compared with the control group (Table 7). Table 7. Influence of analgesia on the duration of hospitalization of patients.
We made an analysis of physical and psychoemotional comfort of all patients, expressed through satisfaction score after surgery. Of the 22 patients of the study group, 90.9% (N = 20), have given "excellent", while for 2 patients (9.1%) the score was "good". For the control group, postoperative satisfaction score was reported as "good" by 4 patients, a total of 7 patients gave the score “satisfactory” (31.81%), while 11 patients appreciate the confort as "bad" - 50% A comparative presentation of the postoperative evolution in the two groups of patients with gynecological laparoscopic surgery is shown in Table 8.
Table 8. Comparative presentation of postoperative evolution of patients. Postoperative evolution
Study group
Control group
Mobilisation time (hours) – mean values Incidence of nausea / vomiting (%) Bowel movement recovery time (hours) – mean values Surgical morbidity ICU stay (hours) – mean values Discharge from hospital after surgery (days) – mean values Postoperative morbidity Postoperative mortality Postoperative satisfaction score (no. patients) Excellent Good Satisfactory Bad
4,22 4,54% 19,09
21,95 72,72% 41,45
0 23,36 3,22
0 49,81 6,22
0 0
0 0
20 2 -
4 7 11
DISCUSSION Although laparoscopic surgery is less painful than the classic one, postoperative pain in the first 24 hours is intense and enough to justify the interest for many scheme of perioperative analgesia. Hohlrieder et al. found that the worst pain after gynecological laparoscopic surgery was felt in the shoulder in 1% of the patients, two hours after surgery, but in 70% of the patients 24 hours after surgery.6 The mechanism responsible for postoperative pain after laparoscopy still remains unclear.7 In this study, for multimodal postoperative analgesia we associated a COX2-selective NSAID i.v. and a local anesthetic, instilled intraperitoneally. The mechanism of action of NSAIDs is the inhibition of the enzyme cyclooxygenase, which catalyzes arachidonic acid to prostaglandins and leukotrienes. Arachidonic acid is released from membrane phospholipids as a response to inflammatory stimuli. Prostaglandins establish the inflammatory response.8 Of selective NSAIDs, in this study was used Parecoxib sodium (Dynastat) 40 mg i.v.9 Being a selective COX2 inhibitor in usual doses is lacking COX1 enzyme inhibition. Recently, it has been suggested that COX1 enzyme plays an important role in spinal cord pain processing and sensitization after surgery.10 In contrast, paracetamol inhibits COX1 enzyme activity in the central nervous system and might exert an analgesic effect via NMDA (N-methyl d-aspartate) receptors in the spinal cord.11 Part of its effect is thought to be mediated via a central serotonergic mechanism as has been shown in vivo. However, 5-hydroxytryptamine 3 receptor antagonists (5-HT3 receptor antagonists) did not directly antagonize paracetamol in vitro, and thus an indirect mechanism has been postulated12.
Parecoxib, the first injectable COX-2 inhibitor, was introduced into clinical practice in 2001. It was found that preoperative administration of parecoxib was more effective than postoperative administration for postoperative pain relief in patients undergoing elective general surgical procedures such as appendicectomy, open cholecystectomy and hernioplasty.13 Parecoxib can be injected intravenously or intramuscularly with good patient tolerance. The lack of platelet inhibition allows COX-2 inhibitors such as parecoxib to be administered preoperatively. Parecoxib is now increasingly used in ambulatory or day-case surgery because it reduces opioid consumption, improves pain scores, and results in earlier hospital discharge and return to normal function.14 In a recent study from Finland, the γ-aminobutyric acid (GABA) analog pregabalin was used for postoperative pain relief in day-case laparoscopic gynecological surgery. However, it failed to demonstrate any advantage over diazepam 5 mg (active control) in reducing postoperative morphine usage.15 Intra-abdominal administration of local anesthetics (in combination with opioids to enhance their action) subscribes, with wound infiltration, among the analgesic methods used in laparoscopic gynecological surgery.16 Local anesthetic used was bupivacaine stereoisomers L-levobupivacaine (chirocaine), which blocks the transmission of painful stimulus by phrenic nerve fibers and also has in addition to bupivacaine (racemic mixture of stereoisomers L and D) a safer pharmaceutical and pharmacodynamic profile with lower neuro- and cardiovascular toxicity, meaning with a high safety and very good profile (stereoisomer D responsible for toxicity).17,18 The mechanism of action is the interaction of levobupivacaine with cardiac ion channels Na+, K+, Ca++, leading to selective blocking of these channels, preventing the nerve cell membrane depolarization and preventing the transmission of nervous influx. Levobupivacaine binds to specific receptors of Na+ (sodium channels remain inactive in the closed position) blocking external pore of Na+ channels. It results the impossibility of impulse propagation, due to not reaching action potential threshold.19 A comparison of our results concerning the analgesic efficacy with the results of previous studies is difficult because of different application times, routes, and dosages used. A study has compared ropivacaine 150 mg and bupivacaine 100 mg intraperitoneally (the maximum dose of ropivacaine is higher than that of bupivacaine, due to its reduced cardiac toxicity). The team found that ropivacaine reduced morphine usage _____________________________ Laura Gavril et al
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in the first 24 hours approximately four-fold. Both the local anesthetics reduced PONV.20 Jabbour-Khoury et al. reported that intraperitoneal spray of an aliquot of bupivacaine and NSAIDs, or intraperitoneal spray of local anesthetics following by intravenous NSAIDs resulted in significantly lower abdominal pain scores and incidence of vomiting after laparoscopic cholecystectomy, compared to the nontreatment group.21 Meanwhile, Elhakim et al. revealed that a combination of intraperitoneal lidocaine and tenoxicam provided better analgesia on movement, and faster return of bowel function compared with intraperitoneal lidocaine and intravenous tenoxicam after laparoscopic cholecystectomy.22 Patients undergoing total abdominal hysterectomy under general anesthesia were randomized to receive a bilateral block of the abdominal wall with 1.5 mg/ kg ropivacaine or placebo on each side just before incision.23 PCA morphine use over the 48 h period after surgery was less in the ropivacaine group (27 mg) than in the placebo group (55 mg). Pain scores at rest and with movement were reduced in the ropivacaine group. The incidence of PONV did not differ between groups, but the incidence of sedation was reduced in the ropivacaine group. Patients undergoing total abdominal hysterectomy under general anesthesia were randomized into four groups and in whom a local anesthetic mixture (1% lidocaine, 0.25% bupivacaine, 2mg/ml adrenaline) was infiltrated under the skin: preoperative and postoperative; preoperative alone; postoperative alone; or placebo.24 In this study, PCA Morphine consumption over 0–24 h and pain scores did not differ among the four groups. Perhaps the block of the abdominal wall (musculature and skin) is a more effective approach than skin infiltration. The evaluation of pain intensity was achieved using visual analogue scale. VAS is considered to be quite accurate, reproducible and easy to use, although postoperative pain has an important subjective component.
CONCLUSIONS Postoperative evolution of patients in the study group, with multimodal analgesia, is obviously better than patients with classical analgesia, reducing complications resulting from prolonged immobilization, postoperative ileus duration and decreasing the incidence of postoperative nausea and vomiting. These aspects contribute to a net improvement of postoperative evolution, increase satisfaction of patients and not least, decrease the overall cost. _____________________________
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Modern therapy of postoperative pain may be included in the so-called Fast Track Rehabilitation, next to early enteral nutrition and mobilisation, strategy which contributes essentially to improve postoperative evolution.
REFERENCES 1. Baldini G, Carli F. Anesthetic and adjunctive drugs for fast-track surgery. Current Drug Targets, 2009;10:667–86. 2. Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Current Opinion in Anaesthesiology, 2009;22:588-3. 3. Clarke R, Derry S, Moore RA et al. Single dose oral etoricoxib for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD004309. 4. Savoia G, Alampi D, Amantea B. et al. Postoperative pain treatment SIAARTI Recommendations 2010. Short version. Minerva Anestesiologica, 2010;76(8):657-67. 5. Bonnet F, Marret E. Postoperative pain management and outcome after surgery. Best Practice & Research Clinical Anaesthesiology 2007;21(1):99–107. 6. Hohlrieder M, Brimacombe J, Eschertzhuber S. et al. A study of airway management using the ProSeal LMA compared with the tracheal tube on postoperative analgesia requirements following gynecological laparoscopic surgery. Anesthesia. 2007;62:913–8. 7. Grond S, Hall J, Spacek A. et al. Iontophoretic transdermal system using fentanyl compared with patient-controlled intravenous analgesia using morphine for postoperative pain management. British Journal of Anaesthesia 2007;98(6):806-15. 8. Flower RJ. The development of COX-2 inhibitors. Nature Reviews Drug Discovery 2003;2:179–91 . 9. Adverse drug reactions advisory committee (ADRAC). Parecoxib - one shot only. Australian Adverse Drug Reactions Bulletin 2004;23:10-1. 10. Zhu X, Conklin D, Eisenach J. Preoperative inhibition of cyclooxygenase-1 in the spinal cord reduces postoperative pain. Anaesthesia & Analgesia 2005;100:1390–3. 11. Bonnefont J, Courade JP, Lloui A et al. Anti-noceceptive effect of paracetamol. In Drug-Special Issue, Walter Kluwer Company; 2003;63:1-51. 12. Gibbison B, Kinsella SM. Postoperative analgesia for gynecological laparoscopy. Saudi Journal of Anaesthesia 2009;3:70–6. 13. Bajaj P, Ballary CC, Dongre NA et al. Role of parecoxib in preemptive analgesia: comparison of the efficacy and safety of pre- and postoperative parecoxib in patients undergoing general surgery. Journal of the Indian Medical Association 2004;102:272-8. 14. Elvir-Lazo OL, White PF. Postoperative pain management after ambulatory surgery: role of multimodal analgesia. Anesthesiology Clinics 2010;28:217–24. 15. Jokela R, Ahonen J, Tallgren M et al. Premedication with pregabalin 75 or 150 mg with ibuprofen to control pain after day-case gynecological laparoscopic surgery. British Journal of Anaesthesia 2008;100:834–40. 16. Malhotra N, Chanana C, Roy KK et al. To compare the efficacy of two doses of intraperitoneal bupivacaine for pain relief after operative laparoscopy in gynecology. Archives of Gynecology and Obstetrics 2007;276(4):323-6. 17. Lyons GR, Kocarev MG, Wilson RC et al. A comparison of minimum local anesthetic volumes and doses of epidural bupivacaine (0.125% w/v and 0.25% w/v) for analgesia in labor. Anaesthesia & Analgesia 2007;104(2):412-5. 18. Lui KC, Chow YF. Safe use of local anaesthetics: prevention and management of systemic toxicity; Hong Kong Medical Journal 2010;16:470-5. 19. Polley LS, Columb MO, Naughton NN et al. Relative analgesic potencies of levobupivacaine and ropivacaine for epidural analgesia in labor. Anesthesiology. 2003;99(6):1354-8.
20. Goldstein A, Grimault P, Henique A et al. Preventing postoperative pain by local anesthetic infiltration after laparoscopic gynecologic surgery: A placebo controlled comparison of bupivacaine and ropivacaine. Anaesthesia & Analgesia. 2000;91:403–7. 21. Jabbour-Khoury SI, Dabbous AS, Gerges FJ et al. Intraperitoneal and intravenous routes for pain relief in laparoscopic cholecystectomy. Journal of the Society of Laparoendoscopic Surgeons 2005;9:316-21. 22. Elhakim M, Amine H, Kamel S et al. Effects of intraperitoneal lidocaine combined with intravenous or intraperitoneal tenoxicam on
pain relief and bowel recovery after laparoscopic cholecystectomy. Acta Anaesthesiologica Scandinavica Journal 2000;44:929-33. 23. Carney J, McDonnell JG, Ochana A et al. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anaesthesia & Analgesia 2008;107:2056–60. 24. Hariharan S, Moseley H, Kumar A et al. The effect of preemptive analgesia in postoperative pain relief: a prospective double-blind randomized study. Pain Medicine 2009;10:49-53.
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ORIGINAL ARTICLES
THE ANALYSIS OF ATHEROSCLEROTIC CAROTID INVOLVEMENT IN SYMPTOMATIC CORONARY PATIENTS WITH MITRAL/AORTIC ANNULUS CALCIFICATION Silvia Georgiana Ionescu1, Irina Popescu2, Adina Ionac1, Sorin Pescariu1, Stefan Iosif Dragulescu1 REZUMAT Introducere: Markerii preclinici de ateroscleroza sunt considerati a fi implicati si in calcificarea de inel mitral/aortic, caracterizata prin depunere de calciu si lipide la nivelul scheletului fibros. Scop: Sa determinam daca prezenta calcificarii de inel mitral/aortic (studiu ecocardiografic) se asociaza cu boala coronariana (studiu angiografic) si/sau boala carotidiana (studiu ecografic). Material si metode: Am inclus 123 pacienti coronarieni (66,20 ± 8,11 ani) cu indicatie de evaluare angiocoronarografica (angina, modificari ECG sau test de stres pozitiv), care au fost evaluati ecocardiografic si eco carotidian. Cuantificarea leziunilor coronariene s-a facut prin scorul Gensini, a leziunilor caortidiene folosind un scor de placa, iar pentru calcificarile de inel valvular s-au utilizat definitiile din guideline. Rezultate: Intregul lot analizat se caracterizeaza printr-un profil de risc cardiometabolic ridicat. Prevalenta bolii coronariene a fost de 72,4%, cu o mediana a scorului Gensini de 26. Pacientii cu stenoza carotidiana semnificativa (peste 50%) si calcificare de inel mitral/aortic au avut scoruri Gensini mai mari decat cei fara calcificare: 43,17 ± 33,96 vs. 26,62 ± 38,06, p < 0,05; respectiv 43,08 ± 38,04 vs. 26.69 ± 32,17, p < 0.01. Pacientii cu ocluzie carotidiana, indiferent de localizarea calcificarii inelului valvular, au avut un scor Gensini mai mic decat cei cu stenoza carotidiana severa, p < 0,01. In randul subiectilor cu ocluzie carotidiana, numai cei cu calcificare de inel aortic au avut valori crescute ale presiunii pulsate: 85,63 ± 17,61 mmHg vs. 62,50 ± 3,53 mmHg, p < 0,01. Nu am gasit corelatii semnificative statistic intre scorul de carotida-scorul Gensini-calcificarile de inel, in functie de prezenta sindromului metabolic sau a factorilor de risc cardiometabolic. Concluzii: Studiul nostru dovedeste asocierea intre calcificarea de inel mitral/aortic cu leziunile aterosclerotice coronariene si carotidiene, in randul unei populatii selectate. Identificarea stenozei carotidiene la pacientii coronarieni cu calcificare de inel mitral/aortic ar putea sa ofere o mai buna stratificare a riscului, si implicit o mai buna conduita terapeutica. Cuvinte cheie: calcificare de inel mitral/aortic, boala coronariana, ateroscleroza carotidiana
ABSTRACT Introduction: Preclinical atherosclerotic markers are also risk factors for mitral/aortic annulus calcification, characterized by lipid and calcium deposits within its fibrous skeleton. Aims: To determine if the presence of mitral/aortic annulus calcification (echocardiographic study) is associated with significant coronary artery disease (angiographic study) and/or carotid artery disease (echographic study). Material and methods: We included 123 coronary patients (66.20 ± 8.11 years) with indication for angiography (angina pectoris or ECG changes or positive stress testing) that were also evaluated by using echocardiography and carotid ultrasonography. The quantification of coronary lesions was made using the Gensini score, for the carotid lesions we used a plaque score and the calcific annulus lesions were defined according to the Guidelines. Results: The entire population analyzed was characterized by the presence of pro-atherogenic cardio metabolic profile. The prevalence of coronary artery disease was 72.4%, with a median of the Gensini Score of 26. Patients with significant carotid stenosis (>50%) and mitral/aortic annulus calcification had higher Gensini scores vs those without annulus lesions: 43.17 ± 33.96 vs. 26.62 ± 38.06, p < 0.05; respectively 43.08 ± 38.04 vs 26.69 ± 32.17, p < 0.01. Subjects with carotid occlusion, mo matter the site of annulus calcification, had a Gensini score lower than those with significant carotid stenosis: p < 0.01. Among people with carotid occlusion, only those with aortic annulus calcification had high value of the pulsed pressure: 85.63 ± 17.61mmHg vs. 62.50 ± 3.53 mmHg, p < 0.01. There were no significant correlations between the carotid score-the Gensini score and annulus calcification based on the metabolic syndrome or on the cardiometabolic risk components. Conclusions: our study proves the association between mitral/aortic annulus calcification with atherosclerotic lesions at the coronary and carotid site, in a group of selected patients. Identification of carotid stenosis among coronary patients with annulus calcification might allow a more accurate risk stratification with better therapeutical decisions. Key Words: mitral/aortic annulus calcification, coronary artery disease, carotid atherosclerosis
Department of Cardiology, Victor Babes University of Medicine and Pharmacy, Timisoara, 2 Institute of Cardiovascular Disease, Timisoara 1
Correspondence to: Silvia Georgiana Ionescu, Department of Cardiology, Victor Babes University of Medicine and Pharmacy, 2 E. Murgu Sq., Timisoara, Tel. +40-729-095765 Email: m_horheta@yahoo.com Received for publication: Mar. 11, 2011. Revised: Jun. 14, 2011. _____________________________
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INTRODUCTION Preclinical atherosclerotic markers are also risk factors for mitral/aortic annulus calcification, characterized by lipid and calcium deposits within its fibrous skeleton. Framingham Heart Study has proven that those with echocardiografic evidence of mitral annulus calcification have had higher Odds ratio for cerebral stroke (2.10), cardiovascular event-
fatal coronary event, non fatal coronary event requiring hospitalization or revascularization procedure (1.5), overall cardiac death after 16 years follow up (1.6).1 The nature of these vascular events has proven to be embolic. A question arises: could mitral annulus calcification be a direct source of embolism or is it a marker of a clinical status associated with thrombembolism: age, arterial hypertension, hypercholesterolemia, diabetes mellitus, chronic peripheral arterial disease, atrial fibrillation and heart failure? Cardiovascular Health Study showed that the severity of annulus calcification had a direct correlation with the presence of cerebral infarction (MRI study): OR=1.24.2 Future studies will have to clarify the underlying mechanisms and, if we can slow the process of annulus calcification, would we be able to reduce the incidence of stroke? In the ARIC (Atherosclerosis Risk in Communities Study) cohort, carotid atherosclerotic plaque detection was a marker of advanced atherosclerosis and had a strong predictive value for cerebral stroke.3 In light of this evidence, we made the following hypothesis: the presence of mitral annulus calcification could be a sign of high susceptibility for the development of atherogenic vascular processes, due to similar aggregation of cardiovascular risk factors.
AIM Our study aims to determine whether the presence of mitral/aortic annulus calcification is associated with significant coronary or carotid artery disease.
MATERIAL AND METHODS Patient selection: we enrolled 792 patients at high cardiovascular risk, which were evaluated using the echographic method, prior to angiography. The inclusion criteria were as follows: all patients were admitted to the Institute of Cardiovascular Disease, Timisoara, with indication of angiography for signs and symptoms suggestive for coronary artery disease; coronary artery disease diagnosed by ECG changes or positive exercise stress testing; preserved left ventricular ejection fraction; sinus rhythm. Exclusion criteria: acute myocardial infarction (defined by creatin-kinase and troponin elevation), congenital heart disease, heart failure NYHA III, IV. We thus included 123 coronary patients with indication for angiography. All patients have signed the informed consent. The study was approved by the Ethic Committee at The Institute of Cardiovascular Disease Timisoara.
Data collection: we have used the clinical charts for data collection: demographic data, anthropometric data, anamnesis, clinical examination and paraclinical data: metabolic profile, hemodynamic profile: systolic and diastolic blood pressure, pulsed pressure. The echocardiographic evaluation was made using a General Electrics Vingmed Ultrasound System, a Vivid 7 and a Vivid 9 machine, with MS4 and MS5 transducers. Annulus calcifications were analyzed by 2D transthoracic echo, parasternal long axis and short axis view and apical views. They were defined according to the ACC/AHA guidelines 2006 and EAE/ASE guidelines.4,5 In view of the recommendations of The American Society of Echocardiography 2006, we performed the measurements for the evaluation of the carotid intimae-media thickness and we defined carotid atherosclerosis through the plaque score: 0=no calcific lesions; 1 = calcific. atherosclerotic plaques, no stenosis; 2 = stenosis < 50%; 3 = stenosis > 50%; 4 = carotid occlusion.6 The angiography was done using a Siemens Coroskop standard machine, in order to detect coronary atherosclerotic lesions. We calculated the Gensini Score for each enrolled patient, and we applied this score in relationship with the coronary lumen narrowing, according to the reference.7 Statistical analysis The data were collected and electronically depositated using The Epiinfo Program, 2001, version 6. The statistical analysis was done with The SPSS program, 2010, version 18. Results were considered statistically significant for p < 0.05; strong statistical significance was considered for a p < 0.01. For parametric data we applied the t student test; for the non-parametrical data we applied the Mann-Whitney test and the Kruskal-Wallis test; and for the categorical data we used the chi squared test.
RESULTS Mitral annulus calcification was detected in 71 cases out of the 123. The proportion of aortic annulus calcification was 56.1%. (Table 1) The prevalence of mitral and aortic annulus calcification was maximum, 70% respectively 80% among patients with carotid score of 4. Carotid stenosis higher than 50% was present in 25 patients out of 50 with annular calcification (50%). 5 out of 20 patients with annulus calcification had a carotid score of 4 (25%). The variation of the Gensini score in the presence of aortic or mitral annulus calcification in patients with a carotid score of 3 and 4: the prevalence of coronary artery disease defined by the angiographic criteria was _____________________________ Silvia Georgiana Ionescu et alâ&#x20AC;&#x192;
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maximă, 70%, respectiv 80% la nivelul inelului aortic în rândul celor cu scor 4 carotidă. Scorul carotidian și frecvența calcificării de inel valvular sunt redate în tabelul nr.I. Stenoza carotidiană ≥ 50% s‐a întâlnit la 25 din 50 subiecți cu calcificare de inel valvular (50%). La 5 din 20 subiecți cu calcificare de inel valvular, scorul carotidian a fost 4 (25%). Table 1. The frequency of annulus calcification and the carotid plaque score. atherogenic cardio metabolic profile: total cholesterol= 209.75 ± 53.97 mg/dl, LDLc = 137.5 ± 55. 56 mg/dl, Carotid score Annulus calcification Total triglycerides = 147.88 ± 41.97 mg/dl, HDLc = 37.00 Absent Present ± 9.20 mg/dl, fasting plasma glucose = 159.38 ± 74.58 Ao Mi Ao Mi mg/dl. We found no statisticaly significant diferences between those with carotid score 4 and 0, p > 0.05. 28 9 5 7 7 0 furthermore, there was no significant relationship 144 39 33 48 24 1 between the metabolic syndrome and aortic or mitral 3 1 1 0 1 2 annulus calcification, p>0.05. 50 12 13 13 12 3 b. Hemodynamic profile: the subjects 20 2 8 3 7 4 with carotid occlusion had a hypertensive profile 245 63 60 71 51 Total characterized by a mean SBP of 175 mm Hg ± 22.67 mmHg, and a mean DBP of 89.38 mm Hg ± 15.22 72.4%. The Gensini score had a median of 26. mmHg. The entire group was characterized by a mean Tabel nr.I. Frecvența calcificării de inel valvular și scorul lezional carotidian Relation between the Gensini score and the value of the pulsed pressure of 68.38 ± 19.73 mm Hg. S carotid score The histogram of frequency distribution showed a Variația scorului Gensini în prezența calcificării de inel MI sau Ao la subiecții cu scor carotidă 3 și 4. The mean Gensini Score was significantly higher high prevalence of the pulsed pressure above 60mm Prevalența bolii coronariene definită după criteriul angiocoronarografic a fost 72,4%. Scorul Gensini a among those with carotid artery occlusion (score 4) Hg: 90 out of 123 cases. The behaviour of mean inregistrat o mediană de 26. compared to those without carotid lesions (score 0): pulsed pressure among the subgroups of subjects with a. Relația scor Gensini – scor lezional carotidă. Media scorului Gensini a fost semnificativ mai mare la cei 36.13 ± 31.13 vs 19.11 ± 21.31, p < 0.01. (Fig. 1) degenerative annulus lesons was higher among those cu ocluzie carotidiană (scor 4) comparativ cu cei fără calcificări carotidiene (scor 0): 36,13 ± 31,13 with aortic annulus calcification: vs.19,11 ± 21,31 , p < 0,01(fig.nr.1). - aortic valve sclerosis: mean PP = 57.12 ± 17.91 mm Hg; b. Relația scor Gensini – scor lezional carotidă – calcificare inel Ao, Mi. La subiecții cu stenoză carotidiană mitral valve fibrosis: mean PP = mitral 61.72 ± 3.53 ≥ 50%, media scorului Gensini a fost semnificativ mai mare la - cei cu calcificare de inel valvular mm Hg; (43,08 ± 38,04 vs. 26,69 ± 32,17, p < 0,01) sau aortic ( 43,17 ± 33,96 vs. 26,62 ± 36,08, p < 0,05) - mitral annulus calcification: mean PP = 56.35 ± comparativ cu cei fără leziuni degenerative la nivel de inel valvular (fig.nr.2). 20.43 mm Hg; - aortic annulus calcification: mean PP = 66.36 ± 15.10 mm Hg; - atherosclerotic plaques on the ascending aorta mean PP = 49.12 ± 18.68 mm Hg. The variation analysis of the mean PP value in patients with annulus calcification and carotid lesions has found statistically signifficant differences only in Figure 1. The Gensini score and carotid plaque score. the group with carotid score of 4 and aortic annulus calcification: 85.63 ± 17.61 mm Hg vs. 62.50 ± 3.53 Relation between the Gensini score - the carotid mm Hg, p < 0.01. (Tables 2,3) score - aortic and mitral annulus calcification In subjects with carotid stenosis higher than 50%, DISCUSSION the mean Gensini score was significantly higher in those with mitral annulus calcification (43.08 ± 38.04 vs 26.29 Our study clearly proves the association between ± 32.17, p < 0.01) or aortic annulus calcification (43.17 vascular atherosclerosis and degenerative lesions ± 33.96 vs 26.62 ± 36.08, p < 0.05) compared to those found at the mitral/aortic annulus site. The prevalence without degenerative annular lesions. (Fig. 2) of annulus calcification was maxim among patients No matter the site of the annulus calcification (aortic with more severe coronary lesions. Furthermore, in or mitral), subjects with carotid occlusion (score 4) have the presence of significant carotid artery stenosis, the had a significantly lower Gensini score compared to those coronary lesions were more severe in patients with with carotid score of 3: 36.13 ± 31.14 vs. 43.17 ± 33.96, p annulus calcification vs those without. < 0.01; 36.14 ± 32.85 vs. 43.08 ± 38.04, p < 0.05. An interesting observation refers to the quantitative The cardiovascular profile in the presence of analysis of the coronary lesions, expressed as the Gensini carotid occlusion and annulus calcification score: in patients with carotid stenosis higher than 50% a. Metabolic profile: the entire population and annulus calcification, the coronary lesions were analyzed was characterized by the presence of promore severe than in patients with carotid stenosis only. _____________________________
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Table 2. The behaviour of pulsed pressure in the presence of mitral annulus calciciation Carotid Score
PP (M+/-DS) Mitral annulus calcification +
Mitral annulus calcification -
p
0
62.14+/-9.94
67.86+/-23.78
>0.05
1
66.52+/-18.98
66.88+/-17.05
>0.05
2
0+/-0
55.00+/-21.21
>0.05
3
71.67+/-27.57
70.77+/-21.19
>0.05
4
81.43+/-20.14
80.00+/-17.32
>0.05
Table 3. The behaviour of pulsed pressure in the presence of aortic annulus calciciation Carotid score
PP (M+/-DS)
Tabel nr.3 A și B : Comportamentul PP în calcificarea de inel Ao (A) și Mi (B) Ao annulus calcification + Ao annulus calcification p Analiza variației valorilor medii ale PP la subiecții cu calcificare de inel valvular și leziuni concomitente la +/- 15.00 56.00+/-20.43 >0.05 cu scor carotidă 4 și 0 nivel carotidian 70.00 a evidențiat diferențe semnificative statistic numai la subgrupul 65.77+/-29.69 67.67+/-15.10 >0.05 1 calcificare de inel Ao: 85,63 ± 17,61 mmHg vs. 62,50 ± 3,53 mmHg, p < 0,01 (Tabel 3 A si B) 70.00+/-0 >0.05 2 DISCUȚII 40.,00+/- 0 70.42+/-17.38 71.92+/-29.47 >0.05 3Studiul nostru demonstrează clar relația de asociere dintre ateroscleroza vasculară și cea la nivel de inel valvular mitral și/sau aortic. Prevalența calcificării de inel valvular a fost maximă în rândul celor cu leziuni 85.63+/-17.61 62.50+/-3.53 <0.01 4 severe la nivel coronarian. Mai mult, în prezența stenozei carotidiene semnificative, leziunea coronariană a fost mai severă la cei cu calcificare de inel valvular comparativ cu cei fără această determinare. First of interesantă all, the coexistence carotid Study, mitral annulus calcification was ca statistically O observație se referă la of analiza cantitativă a leziunilor coronariene, exprimate scor atherosclerosis and mitral annulus calcification could significant associated with atherosclerosis risk factors: Gensini, în raport cu gradul de severitate al afectării carotidiene: subiecții cu stenoză carotidiană peste bring to light new regard the coronariene age, diabetes mellitus, mass especially in 50% și calcificare de information inel valvular inau avut to leziuni mai severe body decât cei index, cu obstrucție incidence and severity of coronary artery disease.8 women and independently of etnic origins.13 carotidiană. Conssiderăm că aceste date dezvoltă implicații practice deosebite. It seems of intrest the fact that we found a Second of all, atherosclerosis is a systemic disease: În primul rând, ofcoexistența aterosclerozei carotidiene cu calcificarea de inel between mitral ar putea furniza and the distribution the atherosclerotic lesions is most signifficant association pulsed pressure informații suplimentare privind incidența și severitatea bolii coronariene (8). defiantly heterogeneous. A question arises at this point: aortic annulus calcification. It is well known and În al doilea rînd, ateroscleroza este o boală sistemică: distribuția lezională este clar heterogenă. Se pune which site is more protected from atherosclerosis? proven the value of pulsed pressure as a marker întrebarea: ce teritoriu este mai protejat de ischemie: cel coronarian sau cel cerebral? Rosengarten B. și The brain or the myocardium? Rosengarten B. et al, of cardiovascular risk, along with aortic annulus 14-16 by corelating the stenosis of each coronary artery calcification. colab., corelând stenoza fiecărei coronare ca leziune uni‐bi‐sau tri‐vasculară cu stenoza carotidiană nu (as a uni-/bi-/tri- vessel disease) with carotid artery As cerebral represents 15% of the găsește nicio asociere cu parametri cerebrovasculari analizați(9). Numai hemoragy severitatea bolii coronariene 9 stenosis, found no association whatsoever. Only total number of cerebral strokes in Europa, Safar’s exprimată ca scor Gensini s‐a asociat cu modificări ale reactivității cerebrovasculare. the severity of coronary artery disease assese as the conclusion remains valid: independently of systolic În al treilea rând, subiecții cu calcificare de inel mitral au un risc înalt de calcificare în alte teritorii Gensini score has been proven to correlate with blood pressure, diastolic blood pressure and mean vasculare, și deci un risc înalt de eveniment cardiovascular fatal/nonfatal (10;11). Cercetarea cerebravascular disease. blood pressure, pulsed pressure is an important fundamentală privind patobiologia calcificărilor vasculare și/sau valvulare putea furniza soluții into cardiovascular risk ar factor needed to noi be taken Third of all, the patients with mitral annulus privind intervenții de for reducere riscului cardiovascular. J.M.Rennenberg colab. Privesc calcification are atțintite high risk arterial a calciffications accountRoger especially in hypertensiveși patients undegoing 17 acest fenomen de calcificare ca și o rezultantă a interacțiunii complexe dintre proteinele in other vascular teritories, vasculară and are therefore at treatment. stimulatoare ‐ și cele inhibitorii matrixGla Agmon protein, BMP‐7, fetuin‐A ‐ și avansează noi high risk for– BMP‐2,RANKL fatal/nonfatal cardiovascular event.– 10,11 et colab. underline the pathognetic Further research in the field of calcification, both similarities between atherosclerosis and pulsed perspective terapeutice (12). vascular and valvular, could offer new solutions for pressure; he is also the one to issue the hypothesys În al patrulea rând, relația dintre calcificarea de inel valvular și boala cardiovasculară aterotrombotică nu cardiovascular risk stratification and management. that aortic(MESA) valve sclerosis and annulus este încă clar definită. În Multi‐Ethnic Study of Atherosclerosis calcificarea inelului calcification mitral s‐a are Roger J.M.Rennenberg consider vascular calcification atherosclerotic-like processes.18,19 asociat semnificativ cu factorii de risc ai aterosclerozei: vârstă, diabet zaharat, indice de masă corporală as Althoug our study can not prove the implication the result of a complex interaction between cresut, mai ales la femei și indiferent de etnie (13). stimulating proteins-BMP-2, RANKL and inhibiting of traditional cardiovascular risk factors in the genesis Considerăm de interes observația noastră cu privire la relația de asociere semnificativă între presiunea ones-matrixGlc proteins, BMP-7, A-fetuin, thus of mitral/aortic annulus calcification, the metabolic 12 pulsului,PPși calcificarea de inel aortic. Este cunoscută și demonstrată valoarea PP the ca marker risc an launching new therapeutic insights. and hemodynamic profile of patients de justifies cardiovascular hemoragia cerebrală din totalul vasculare Fourth of (14;15;16).Cum all, the relation between valvular annulus reprezintă agressive15% management of accidentelor modifiable risk factors, in cerebrale în Europa, concluzia lui Safar asupra PP rămâne actuală: ‚‚ ...independent de TAS, TAD,TAM, PP calcification and atherothrombotic cardiovascular order to reduce the global cardiovascular risk and, disease has not been well established. In MESA obviously, the number of cardiovascular events. este un important factor de risc cardiovascular, de luat în considerare mai ales în HTA tratată, cu profil de HTA sistolică izolată’’(17). _____________________________ Silvia Georgiana Ionescu et al
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CONCLUSIONS Our study proves the association between mitral/ aortic annulus calcification with atherosclerotic lesions at the coronary and carotid site, in a group of selected patients. The echografic detection of annulus calcification might improve the algorhythm for the evaluation of the arterial function and therefore, the management of the cardiovascular risk. Identification of carotid stenosi among coronary patients with annulus calcification might allow a more accurate risk stratification with better therapeutical decisions. The limitations of our study regard the selection criteria. Our results should be interpreted in a given context: we included in our study only high risk patients, that were evaluated ECHO before the angiography. Itâ&#x20AC;&#x2122;s highly possible for the prevalence data to be overestimated; but our proven associations reflect once again the natural history of atherosclerosis.
REFERENCES 1. Singh JP, Evans GC, Levy D et al. Prevalence and clinical determinants of mitral, tricuspid and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999;83(6):897-902. 2. Rodriguez CJ, Bartz TM, Longstreth WT et al. Association of annular calcification and aortic valve sclerosis with brain findings on magnetic resonance imaging in community dwelling older adults. The Cardiovascular Health Study. J Am Coll Cardiol 2011;57:2172-2180. 3. Burke GL, Evans GW, Riley WA et al. Arterial wall thickness is associated with prevalent cardiovascular disease in middle-aged adults. The Atherosclerosis Risk in Communities (ARIC) Study. Stroke 1995;26:386-391 4. Bonow RO, Carabello BA, Chatterjee K et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006;48;e1-e148.
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5. Baumgartner H, Hung J, Bermejo J et al. EAE/ASE RECOMMENDATIONS Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr 2009;10,1-25. 6. Roman MJ, Naqvi TZ, Gardin JM et al. American Society Echocardiography Report. Clinical application of noninvasive vascular ultrasound in cardiovascular risk stratification: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology. Vasc Med 2006;11(3):201-11. 7. Gensini GG. A more meaningful scoring system for determining the severity of coronary heart disease. Am J Cardiol 1983;51(3):606-10. 8. Amasyali B, Kose S, Aytemir K et al. Is carotid atherosclerosis more important in patients with mitral annular calcification than in those without? Jpn Heart J 2004; 45(4):603-611. 9. Rosengarten B, Grebe M, Muller A et al. Severity of coronary artery disease but not degree of coronary stenosis is correlated to cerebrovascular reactivity. Cerebrovasc Dis 2009;28(3):290-297. 10. Movahed MR, Saito Y, Ahmadi-Kashani M et al. Mitral annulus calcification is associated with valvular and cardiac structural anormalities. Cardiovasc Ultrasound 2007;5:114-126 11. Jassal DS, Tam JW, Bhagirath KM et al. Association of mitral annular calcification and aortic valve morphology: a substudy of the aortic stenosis progression observation measuring effects of rosuvastatin (ASTRONOMER) study. Europ Heart J 2008; 29(12):1542-1547. 12. Rennenberg JM, Schurgers LJ, Kroon AA et al. Arterial calcifications. J Cell Mol Med 2010; 14(9):2203-2210. 13. Kanjanauthai S, Nasir K, Katz R et al. Relationship of mitral annular calcification to cardovascular risk factors: the Multi-Ethnic Study of Atherosclerosis(MESA). Atherosclerosis 2010;213(2):558-62. 14. Darne B, Girerd X, Safar M et al. Pulsatile versus steady component of blood pressure:a cross-sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension 1989;13(4):392-400. 15. Benetos A, Safar M, Rudnichi A et al. Pulse pressure: a predictor of long term cardiovascular mortality in a French male population. Hypertension 1997;30(6):1410-15. 16. Millar JA, Lever AF, Burke V et al. Pulse pressure as a risk factor for cardiovascular events in the MRC mild hypertension trial. J Hypertens 1999,17(8):1065-72. 17. Safar ME. The arterial system in human hypertension. In: Swales JD Editor. Textbook of hypertension 1994. London: Wiley-Blackwell Scientific, 85-102. 18. Agmon Y, Khandheria BK, Meissner I et al. Independent association of high blood pressure and aortic atherosclerosis: a population based study. Circulation 2000,102(17):2087-93 19. Agmon y, Khandheria BK, Meissner I et al. Aortic valve sclerosis and aortic atherosclerosis: different manifestations of the same disease? Insights from a population-based study. J Am Coll Cardiol 2001;38(3):827-34.
ORIGINAL ARTICLES
MULTIPLE ELECTRODES AGGREGOMETRY - A NEW METHOD TO ASSESS THE PLATELET REACTIVITY IN NON-ST ELEVATION ACUTE CORONARY SYNDROME PATIENTS Daniela Maximov1, Adina Ionac2, Alina Lupu1, Cristian Mornos2, Stefan I. Dragulescu2 REZUMAT Introducere: Pacienţii cu sindroame coronariene acute fără supradenivelarea segmentului ST au risc înalt pentru apariţia de noi evenimente cardiovasculare (CV) ischemice. Determinarea statusului de “low-“ sau “non-responder” la terapia antiplachetară duală poststentare poate fi folosită pentru depistarea pacienţilor cu risc crescut. Material și metode: Studiul s-a efectuat prospectiv la un lot de 100 pacienţi internaţi la Institutul de Boli Cardiovasculare Timişoara cu diagnosticul de sindrom coronarian acut fără supradenivelarea segmentului ST, la care s-a practicat angioplastie transluminală percutanată (PTCA) cu plasare de stent; a fost determinată agregarea plachetară postadministrare de clopidogrel şi aspirină. O probă de sânge integral recoltată înainte de PTCA a fost analizată prin agregometrie cu electrozi multipli (AEM), folosind agonişti ADP şi respectiv acid arahidonic (AA) pentru a detecta statusul de “responder” sau “non-responder” la clopidogrel, respectiv aspirină. Analiza, efectuată cu Multiplate® (Dynabyte, Germania), a evaluat reactivitatea plachetară postterapie cu antiagregantele uzuale. Lotul a fost impărţit în quartile în funcţie de valoarea agregării plachetare induse de ADP. Pacienţii din quartila 4 (Q4) au fost consideraţi “low-responderi.” Rezultate: Au fost diagnosticate 10 noi evenimente CV survenite în intervalul de 1 lună poststentare. Apariţia acestora s-a corelat semnificativ cu răspunsul plachetar la clopidogrel [Q4 vs. 1, 2, 3: OR (95% CI) 19.8 (4,4-90,8; P<0,001)]. Concluzii: Determinarea agregării plachetare ADP- şi AA-induse prin AEM este utilă pentru identificarea statusului de non-responder la terapia antiplachetară duală. Agregarea plachetară, exprimată prin valoarea ariei de sub curbă (AUC) obţinută prin AEM, se corelează cu statusul de low-responder la clopidogrel, respectiv aspirină şi cu un risc crescut de recurenţă a evenimentelor CV la 1 lună poststentare la aceşti pacienţi. Cuvinte cheie: agregometrie cu electrozi multipli, low-responder, clopidogrel
ABSTRACT Introduction: Non-ST segment elevation acute coronary syndrome (NSTE ACS) patients are at high risk for development of new cardiovascular (CV) ischemic events. Determination of low- or non-responder status to dual antiplatelet therapy in patients undergoing coronary stenting for NSTE ACS may be a useful method to detect the high- risk patients of this category. Material and methods: We prospectively studied the platelet response to clopidogrel and aspirin in 100 patients admitted in Timisoara Institute of Cardiovascular Diseases undergoing percutaneous coronary intervention (PCI) with stenting for NSTE ACS. A sample of whole blood was obtained before PCI and analyzed by multiple electrodes aggregometry (MEA), using ADP and arachidonic acid (AA) agonists to detect the non-responder status to clopidogrel and aspirin. We used MEA performed with Multiplate® (Dynabyte, Germany) to assess the posttreatment platelet reactivity. Patients were stratified into quartiles according to the ADP-induced platelet aggregation. Patients of the highest quartile (Q 4) were defined as the “low-responders”. Results: Ten recurrent CV events occurred during the 1-month follow-up. Clinical CV events were significantly associated with platelet response to clopidogrel [Q4 vs. 1, 2, 3: OR (95% CI) 19.8 (4.4-90.8; P<0.001)]. Conclusions: The MEA assessment of ADP and AA- induced platelet aggregation is a valuable method to identify the low-responders to dual antiplatelet therapy. The results correlated the values of the area under curve (AUC) determined by MEA with the clopidogrel low-responder status and with an increased risk of recurrent CV ischemic events 1-month follow-up post PCI + stent in NSTE ACS patients. Key Words: multiple electrodes aggregation, low-responder, clopidogrel
INTRODUCTION
Institute of Cardiovascular Diseases, Timisoara, 2 Victor Babes University of Medicine and Pharmacy, Timisoara 1
Correspondence to: Daniela Maximov, Institute of Cardiovascular Diseases, 13A, PP Carp Str., 300310 Timisoara, Tel. +40-723-558475. Email: danielamaximov@yahoo.com Received for publication: May 17, 2011. Revised: Jul. 22, 2011.
Dual antiplatelet therapy with clopidogrel and aspirin is the actual “gold standard” of treatment to prevent stent thrombosis in patients undergoing percutaneous coronary intervention (PCI) and to reduce major adverse cardiovascular events (MACE) in patients with non-ST segment elevation acute coronary syndrome (NSTA ACS).1-3 Despite this data, a lot of studies have reported individual variability platelet response to aspirin _____________________________ Daniela Maximov et al
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and clopidogrel in atherothrombotic disease, and identified patients who did not achieve an appropriate platelet inhibition or with high on-treatment residual platelet reactivity as “low- responders” or “nonresponders”.4-10 The term of “aspirin resistance” should be limited to situations in which failure of the drug to reach its pharmacological target has been documented with specific laboratory tests. The concept of “clinical resistance” to aspirin should not be used to detect situations in which aspirin is unable to prevent atherothrombotic events. Although global tests assessing platelet activation in vitro may identify patients with high residual platelet reactivity, they do not necessarily detect patients who are resistant to aspirin.11,12 The term of “clopidogrel resistance” has increasingly emerged in the literature and its clinical relevance, as a risk factor for cardiovascular ischemic events, has been explored in a few studies.13,14 In the majority of these studies, response to clopidogrel was defined as the difference between baseline and posttreatment maximal intensity of platelet aggregation.4-10 This approach can be criticized because of not taking into account the absolute level of pre- and posttreatment platelet activity. Other issues are represented by the facts that the determination is not suitable for routine clinical practice as the majority of ACS patients need urgently percutaneous coronary stenting and many others are already on chronic clopidogrel or aspirin therapy at the admission to the hospital. On the other hand, recent studies support that post-platelet reactivity is a better estimate of thrombotic risk rather than clopidogrel responsiveness.5,15 Accordingly, we analyzed the inter-individual variability in platelet response to clopidogrel and aspirin based on a single whole blood sample using multiple electrodes aggregation testing just before the PCI procedure in 100 patients admitted for NSTE ACS. We considered the maximal intensity of platelet aggregation using multiple electrode aggregometry (MEA) as a parameter for the antiplatelet responder status. We hypothesized that high level of posttreatment platelet reactivity predicts recurrent ischemic cardiovascular events at 30 days follow-up.
MATERIAL AND METHODS Study patients The study lot consisted of 100 consecutive patients admitted to the Institute of Cardiovascular Diseases Timisoara between January and October _____________________________
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2010. Percutaneous coronary interventions (PCI) with stent implantation were performed in the CathLab of the Institute of Cardiovascular Diseases Timisoara in all study patients. They were eligible for this prospective study if they had presented clinical symptoms defined as acute myocardial ischemia within 12 hours before admission and at least one of the following criteria: transient (<20 min) ST-segment elevation >0.1 mV, a new finding of ST-segment depression >0.05 mV, T-wave inversion in at least two contiguous leads, increased level of cardiac ischemic biomarkers or coronary disease documented by a previous coronary angiography, coronary revascularization or myocardial infarction. The exclusion criteria were: ST elevation ACS, NYHA class IV, PCI or coronary artery by-pass grafting (CABG) in the last 3 months, use of anti GP IIb/IIIa therapy before the PCI procedure, history of bleeding diathesis, contraindication to antiplatelet therapy, platelet count <100x106/L, creatinine clearance <30 mL/min. Patients on chronic clopidogrel therapy with a daily dose of 75 mg > 5 days did not receive a loading dose of clopidogrel. Other patients received a loading dose of 300 mg clopidogrel at least 12 hours before the PCI. All patients received aspirin doses (75-300 mg) daily administered at least 12 hours before stenting procedure. The study protocol was approved by the Institutional Ethics Committee of the Institute of Cardiovascular Diseases Timisoara, and patients gave informed consent for participation. PCI was performed within 48-72 hours after hospital admission. Blood samples Blood samples for testing the platelet activity by multiple electrodes aggregometry method were drawn after admission in the CathLab, before PCI, at least 12 h after the loading dose of clopidogrel and aspirin administration and before administration of anti GP IIb/IIIa therapy if needed. The blood was collected in special vacutainer tubes provided by the Multiplate® analyzer manufacturer, usually containing hirudin, filled to capacity, and then inverted three to five times for gentle mixing before the laboratory analysis testing. Laboratory method The aggregation testing was performed in Timisoara Institute of Cardiovascular Diseases Laboratory. We used the multiple electrodes aggregometry method performed with the Multiplate® analyzer, produced by Dynabyte Medical, Munich. Multiplate® reagents are also provided by the manufacturer, as reconstitute
solutions called ASPItest and ADPtest. In all patients we determined: - Inhibition of arachidonic-acid-induced aggregation (ASPItest), which is in accordance with an adequate aspirin effect; - Inhibition of ADP-induced aggregation (ADPtest), which is in accordance with an adequate clopidogrel effect. The method is a fast and easy one, comprising a few specific steps, and allows obtaining the printed result in a short time (10 minutes). The results are represented by a graphic curve of aggregation (AU)/ time (minutes).The parameters of the results are: the velocity (AU/min), the aggregation (AU), and the most important is the area under the curve (AUC) expressed in AU*min or U (10 AU*min= 1U). Clinical endpoint The clinical endpoint included all following major cardiovascular events (MACE): cardiovascular (CV) death, acute or subacute stent thrombosis, recurrent ACS and ischemic stroke. Follow-up events were assessed by regular clinical 1-month follow-up after PCI:15 ACS was defined by the presence of symptoms compatible with recurrent ischemia needing new hospitalization and angiocoronarography, ischemic stroke was defined as a new focal neurological deficit without bleeding on computer tomodensitometry (CT) and confirmed by a neurologist. Statistical analysis was performed with the SAS Software (v 8.01; SPSS Inc., Chicago, IL, USA). Continuous variables are expressed as mean ± SD. Categorical variables are expressed as frequencies and percentages. The Wilcoxon rank-sum test was used to compare continuous variables in individuals with and without CV events. We used the Fischer’s exact test when frequencies were below five and the χ2- test to compare the categorical variables. P for trend between quartiles of AUC values of AA- or ADP-induced aggregation and other variables was studied using a general linear model with AA- or ADP- induced aggregation as dependent variable. Comparison between individuals with maximal intensity of AAor ADP-induced aggregation in the top vs. the three bottom quartiles were performed using logistic regression after adjustment for conventional CV risk factors, treatment and inflammatory parameters. ADP and AA-induced maximal intensity of platelet aggregation expressed as AUC value /patient were analyzed as potential predictors of the clinical endpoint both univariably and after adjustment for other baseline confounding variables. The value of P<0.05 was considered significant.
RESULTS Patient characteristics One hundred patients were included in our prospective study. Twenty one patients (20%) were on chronic clopidogrel therapy. Demographic and biological baseline data of the studied population are summarized in Table 1. The mean age was 63.2 ± 12 years, and 77% of the patients were males. Multiple CV risk factors were frequent (27% of patients were with diabetes mellitus, 57% were hypertensive, 64% presented dyslipidemia). For the patients who did not receive clopidogrel prior to the current admission, the mean time between the clopidogrel loading dose and blood sampling was 16 ± 2.5 hours. All patients received a daily 75 mg clopidogrel dose and a daily aspirin dose of 100 mg during the 1 month follow-up period. The mean time between angina symptoms and PCI was similar in patients with or without recurrent ischemic CV events (mean ± SD = 20 ± 4.63 vs. 20.24 ± 3.97, P = 0.78). Platelet response to clopidogrel We analyzed platelet response to clopidogrel using the multiple electrodes aggregometry performed with Multiplate® analyzer. In all patients we determined inhibition of ADP induced aggregation (ADPtest). The result of the test is represented by a curve of aggregation (AU)/time (minutes). The most important parameter is the area under the curve (AUC) expressed in AU*min or U (10 AU*min= 1U), which is in accordance with an adequate clopidogrel effect. Other important parameters assessed in the study population were the velocity (AU/min) and the aggregation (AU). We observed that the distribution of the AUC values representing the ADP-induced platelet response intensity was consistent with a normal, bell-shaped distribution. We classified the entire study group into four quartiles according to their ADP-induced platelet aggregation response, assessed by the AUC values, respectively. We considered the first quartile (Q1) of patients “clopidogrel high-responders” (AUC < 200 AU*min), the second quartile of patients (Q2) “clopidogrel responders” (200 AU*min < AUC < 500 AU*min), the third quartile (Q3) “clopidogrel intermediate responders” (500 AU*min < AUC < 700 AU*min) and the patients from the fourth quartile (Q4) were “clopidogrel low responders” (AUC > 700 AU*min). The mean ADP-induced intensity of platelet aggregation response (represented by mean AUC value) in the described quartiles was: 155.5 ± 22.6 _____________________________ Daniela Maximov et al
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Table 1. Baseline characteristics of the patients with and without cardiovascular events
Table 1. Baseline characteristics of the patients with and without cardiovascular events.
AU*min (Q1), 386.7 86.13 AU*min (Q2), 599.3 number of CV events were observed from the first Platelet response to ±clopidogrel ± AU*minplatelet (Q3) and 819 ± 49.1 AU*min (Q4). to the fourth electrodes quartile (0, 0,aggregometry 2, and 8 respectively). In We61.4 analyzed response to clopidogrel using the multiple ® intensity of platelet The range of ADP-induced addition, quartile 4 was associated with a higher risk of performed with Multiplate analyzer. In all patients we determined inhibition of ADP aggregation (AUC) in (ADPtest). the fourth The quartile (lowevents as compared with others: of the odds ratio induced aggregation result of theCV test is represented by the a curve responders) was 701 940 AU*min, determining a cut(OR) associated with the top versus lower aggregation (AU)/time (minutes). The most important parameter is the area under the quartiles off value of 700 AU*min; inthis value is or alsoU present was 1U), 19.8 (95% P <with 0.001 and this curve (AUC) expressed AU*min (10 AU*min= whichCIis =in 4.4-90.8), accordance in few numberclopidogrel of studies available far regarding remains significant adjustment for ana adequate effect.soOther important difference parameters assessed in after the the study this new method multiple electrodes aggregometry. age, sex, CV factors, and treatment: OR 35 (95% CI = population were the velocity (AU/min) and the aggregation (AU). There were no that significant differences between the values 4.85-246), P<0.001. the ADP-induced We observed the distribution of the AUC representing quartiles one and four, excepting a significant increase platelet response intensity was consistent with a normal, bell-shaped distribution. of DISCUSSION We intensity classifiedoftheAA-induced entire studyplatelet group aggregation into four quartiles according to their ADP-induced (AUC) for trend <0.01). No significant relation wasAUC values, respectively. We considered platelet(Paggregation response, assessed by the found between ADP-induced platelet aggregation andhigh-responders” So far, a large number studies were focused the first quartile (Q1) of patients “clopidogrel (AUC < 200ofAU*min), cardiac biomarkers (the percent of troponin positive on individual variability of platelet response to the second quartile of patients (Q2) “clopidogrel responders” (200 AU*min < AUC < 500 patients P =1.1), the presence of ST-shift (P=0.42) or clopidogrel and the term of “clopidogrel resistance” AU*min), the third quartile (Q3) “clopidogrel intermediate4-10 responders” (500 AU*min < the number of stents (P = 0.2). is usual. Despite this facts, its definition is still AUC < 700 AU*min) and the patients from the fourth quartile (Q4) were “clopidogrel controversial and mainly based on the percentage of low responders” (AUC > 700 AU*min). Clinical outcomes changes in ADP-induced maximal intensity of platelet The mean ADP-induced intensity of platelet aggregation response (represented by mean All the study patients were followed at 1 month post aggregation before and after initiation of clopidogrel AUC value) in the described quartiles was: 155.5 ± 22.6 AU*min (Q1), 386.7 ± 86.13 PCI. Recurrences in ischemic events were evaluated as treatment (clopidogrel responsiveness). In addition, follows: ten patients (10%) with angina episodes, one the cut-off value to identify the low responders varied patient hospitalized for recurrent ACS because of an in large ranges (from <10% to 40%).4-10 acute stent thrombosis, one CV death and no ischemic Our study demonstrates that, among a high risk stroke. Patients which presented CV events at 1 month category of CV patients, admitted for NSTE ACS follow-up had a significantly increased ADP-induced treated by PCI with stenting, the single measurement platelet aggregation (P <0.0001). A gradually increasing of ADP-induced platelet aggregation using multiple _____________________________
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electrodes aggregometry (MEA) was associated with the subsequent occurrence of major adverse CV events (MACE). Light transmittance aggregometry (turbidimetric method, LTA) has been the most widely used technique to monitor the effect of antiplatelet drugs, including aspirin, clopidogrel, other P2Y12 inhibitors, and platelet glycoprotein (GP) IIb/IIIa inhibitors.16,17 In the studies using LTA, the historical “gold standard” test, based on the stimulation of plateletplatelet aggregation in platelet-rich plasma after stimulation with various agonists, we identified disadvantages related to the laboratory employees’ workload. They include the need for immediate processing, variable reproducibility, large volume samples required, lengthy processing time, and expenses of the aggregometer and trained operators. LTA has also been the most widely investigated method to predict clinical outcomes.18 Impedance aggregometry is conceptually similar to LTA, but it uses whole blood instead of plateletrich plasma and platelet aggregation is measured by impedance, not by light transmittance.19 Platelet function analysis using multiple electrode aggregometry (Multiplate®)-Dynabyte, Munich, Germany is a recent method which allows an easy and rapid assessment of platelet function, with the possibility to decide on treatment regimens when the patient is still in the CathLab (results in 10 minutes). In present, Multiplate is used in many expert centres and pharmaceutical companies throughout Europe. This method is also suitable for daily clinical practice for many reasons; time consuming stages related to rich platelet plasma preparation or light transmittance aggregometer manipulation were eliminated. This new method of aggregometry allows rapid and reliable results, and could be used also in the Coronary Unit or CathLab. In our study, a baseline aggregation assessment could not be obtained because of certain factors: previous chronic clopidogrel therapy, patients’ admission through the Emergency Department. But recent studies demonstrated that pretreatment platelet activity did not predict the clopidogrel responsiveness.9,14 These trials have also shown the correlation between a low response to clopidogrel (difference between pre- and posttreatment values) and a high posttreatment platelet activity, which was proposed as a better estimate of thrombotic risk.9,14,16-19 Therefore we performed one test per patient to assess the clopidogrel effect with ADP-induced platelet aggregation, from one single blood sample just before PCI, without baseline determination. Patients were stratified into quartiles according to their post therapy
ADP induced platelet aggregation represented by the AUC value obtained with the ADPtest using multiple electrode aggregometry performed with the Multiplate® analyzer. The patients of the fourth quartile were characterized as “clopidogrel low responders” (AUC > 700 AU*min). In addition, we considered the first quartile (Q1) of patients “clopidogrel high-responders” (AUC < 200 AU*min), the second quartile of patients (Q2) “clopidogrel responders” (200 AU*min < AUC < 500 AU*min), the third quartile (Q3) “clopidogrel intermediate responders” (500 AU*min < AUC < 700 AU*min). Similarly, in other studies the patients from the fourth quartile were defined as low responders and were characterized by a maximal intensity of ADPinduced platelet aggregation > 70% (Gurbel et al,16 Cuisset et al).20 A relation between clopidogrel resistance and recurrence of clinical CV ischemic events is emerging. Correlation of ADP-induced platelet aggregation with clinical outcomes was showed for the first time in ST elevation ACS by Mateszky et al.14 These data and a lot of results from clinical trials strongly suggested that the clopidogrel resistance might be associated with increased risk of recurrent CV events.21-28 In this study, a number of 10 CV ischemic events occurred in the 1-month post PCI follow-up period. We demonstrated a correlation between clopidogrel response defined on a single blood sample before the PCI and the recurrence of CV ischemic events for NSTE ACS patients undergoing coronary stenting; in addition, according with the quartile stratification, a number of 8 events (80%) occurred in the 4th quartile patients, characterized as “clopidogrel lowresponders”, and 2 events (20%) in the third quartile patients - “clopidogrel intermediate responders”. No CV events were registered to the patients from the first and second quartile, characterized as “clopidogrel high-responders” and “clopidogrel responders”.
CONCLUSION The results of the present study are encouraging. We found out a correlation between clopidogrel platelet response and a subgroup of patients at higher risk of recurrent ischemic CV events after stenting for NSTE ACS. In addition, we used a single blood sample per patient for testing posttreatment ADPinduced platelet aggregation and a new, faster, simple and accurate method to assess the platelet aggregation. The cut-off value of AUC using multiple electrodes aggregation (MEA) was useful to identify the “clopidogrel low-responders.” _____________________________ Daniela Maximov et al
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PERSPECTIVES MEA seems to be a non-complex method to identify the clopidogrel low responders. These highrisk patients may potentially benefit from a more aggressive antithrombotic therapy (higher clopidogrel doses, alternative molecules, combined antiplatelet therapy).29
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by monitoring of vasodilator-stimulated phosphoprotein phosphorylation. Catheter Cardiovasc Interv 2003;59:295- 302. 14. Matetzsky S, Shenkmann B, Guetta V, et al. Clopidogrel resistance is associated with increased risk of recurrent atherothrombotic events in patients with acute myocardial infarction. Circulation 2004;109:3171-5. 15. Samara WM, Bliden KP, Tantry US, et al. The difference between clopidogrel responsiveness and posttreatment platelet reactivity. Thromb Res 2005;115:89-94. 16. Gurbel PA, Becker CR, Kenneth GM, et al. Platelet function monitoring in patients with coronary artery disease. J Am Coll Cardiol 2007;50:1901-20. 17. Michelson AD. Platelet function testing in cardiovascular diseases. Circulation 2004;110:e489-e493. 18. Gum PA, Kottke-Marchant K, Poggio ED, et al. Profile and prevalence of aspirin resistance in patients with cardiovascular disease. Am J Cardiol 2001;88:230-5. 19. Gurbel PA, Bliden KP, Hayes KM, et al. The relation of dosing to clopidogrel responsiveness and the incidence of high posttreatment platelet aggregation in patients undergoing coronary stenting. J Am Coll Cardiol 2005;116:491-7. 20. Cuisset T, Frere C, Quilici J, et al. High posttreatment platelet reactivity identified low-responders to dual antiplatelet therapy at increased risk of recurrent cardiovascular events after stenting for acute coronary syndrome. J Thromb Haemost 2007;4:542-9. 21. Gum PA, Kottke-Marchant K, Welsh PA, et al. A prospective, blinded determination of the natural history of aspirin resistance among stable patients with cardiovascular disease. J Am Coll Cardiol 2003;41:961-5. 22. Davis CJ, Gurbel PA, Gattis WA, et al. Hemostatic abnormalities in patients with congestive heart failure: diagnostic significance and clinical challenge. Int J Cardiol 2000;75:15-21. 23. Gurbel PA, Bliden KP, Di Chiara J, et al. Evaluation of dose-related effects of aspirin on platelet function: results from the AspirinInduced Platelet Effect (ASPECT) study. Circulation 2007;115:315664. 24. Vinholt P, Poulsen TS, Korsholm L, et al. The antiplatelet effect of clopidogrel is not attenuated by statin treatment in stable patients with ischemic heart disease. Thromb Haemost 2005;94:438-43. 25. Muller I, Seyfarth M, Rudiger S, et al. Effect of a high loading dose of clopidogrel on platelet function in patients undergoing coronary stent placement. Heart 2001;85:92-3. 26. Kastrati A, von Beckerath N, Joost A, et al. Loading with 600 mg clopidogrel in patients with coronary artery disease with and without chronic clopidogrel therapy. Circulation 2004;110:1916-9. 27. Angiolillo DJ, Fernandez-Ortiz A, Bernardo E, et al. High clopidogrel loading dose during coronary stenting: effects on drug response and interindividual variability. Eur Heart J 2004;25:1903-10. 28. Patti G, Colonna G, Pasceri V, et al. Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention. Results from ARMYDA-2 (Antiplatelet therapy for Reduction of Myocardial Damage during Angioplasty) study. Circulation 2005;111:2099-106. 29. Storey RF. The P2Y12 receptor as a therapeutic target in cardiovascular disease. Platelets 2001;12:197-209.
ORIGINAL ARTICLES
ROLE OF CAROTID INTIMA-MEDIA THICKNESS FOR CARDIOVASCULAR RISK EVALUATION Cristina Florea1, Sorin Ursoniu2, Daniela Gurgus1, Adrian Gruici1, Dacian Purcarita1, Jurgen Jahraus1, Raul B. Suciu1, Stelian Siminoc1, Alina Koussini1, Elena A. Ardeleanu1 REZUMAT Introducere: Riscul cardiovascular (RCV) este subestimat la un procent important din populaţie atunci când este evaluat apelând la metode convenţionale de estimare cum este riscul SCORE. Ecografia carotidiană, prin măsurarea grosimii intimă-medie (GIM) carotidiană, este utilă în identificarea aterosclerozei subclinice şi încadrarea astfel în clasa de RCV înalt. Obiectivul studiului: A fost evaluarea contribuţiei screening-ului grosimii intimă-medie carotidiană în redefinirea RCV la o populaţie de studiu asimptomatică încadrată în risc CV intermediar sau scăzut (risc SCORE 3-4% sau sub 3%). Material şi metode: Ecografia carotidiană s-a efectuat la 142 subiecţi cu risc CV SCORE mic sau intermediar. Depistarea la ecografia carotidiană a unei GIM crescute a permis reclasficarea pacienţilor în clasa de RCV înalt. Rezultate: RCV la lotul de studiu a fost mic la 40 (28,2 %) din pacienţi şi intermediar la 102 (71,8 %). GIM medie a fost de 0,65±0,14 mm. Rezultatele ecografiei carotidiene au reclasificat RCV la 39 (27,4%) pacienţi. Reclasificarea s-a produs la 34 (33,3 %) subiecţi cu RCV intermediar şi la 5 (12,5%) subiecţi din grupul cu RCV mic (p<0,05). Reclasificarea s-a asociat cu istoricul de hipertensiune arterială (p<0.001), tensiunea arterială sistolică crescută (p=0,001), vârsta (p<0,05), colesterolemia (p<0,05) şi fumatul (p<0,05). Concluzii: Ecografia carotidiană este deosebit de utilă în medicina preventivă. GIM carotidiană îmbunătăţeşte evaluarea RCV, identificând subiecţii cu risc crescut, nedepistaţi prin evaluarea SCORE şi contribuie astfel la instituirea unor strategii preventive mai agresive. Cuvinte cheie: ateroscleroza subclinică, grosime intimă-medie carotidiană, reclasificarea riscului cardiovascular
ABSTRACT Background: Conventional risk evaluation as SCORE underestimates the cardiovascular risk (CVR) in a significant proportion of population. Carotid artery ultrasonography, by measurement of carotid intima-media thickness (IMT) is useful in identifying subclinical atherosclerosis and placing an individual into high CVR class. The objective of the study was to establish the contribution of IMT screening to the improvement of CVR in a study population of asymptomatic adults at intermediate ore low CHD risk (SCORE risk 3-4% or under 3%). Material and methods: Carotid artery ultrasonography was effectuated in 142 subjects, with low or intermediate SCORE risk class. The detection of abnormal IMT reclassified the subjects to high CVR class. Results: The calculated CVR of the study population by SCORE charts was low risk in 40 (28.2%) patients and intermediate in 102 (71.8 %) individuals. Mean IMT was 0.65±0.14 mm. The results of the ultrasonography reclassified the risk class in 39 patients (27.4%). Reclassification occurred in 34 (33.3 %) patients of the intermediate CVR group and 5 (12.5%) patients of the low CVR group (p<0.05). Reclassification was connected to history of arterial hypertension (p<0.001), increased systolic blood pressure (p=0.001), age (p<0.05), cholesterol levels (p<0.05) and smoking (p<0.05). Conclusions: Carotid ultrasonography is an important investigation in preventive medicine. IMT improves risk classification, identifying high risk individuals, not detected by SCORE function and contributes to establish earlier and more aggressive CV preventive strategies. Key Words: subclinical atherosclerosis, carotid intima-media thickness, cardiovascular risk reclassification
INTRODUCTION Atherosclerosis and its complications are an important cause of morbidity and mortality in Romania and Europe. Cardiovascular risk (CVR) factors influences direct the atherosclerotic process. Department of Family Medicine, 2 Department of Health Management, Victor Babes University of Medicine and Pharmacy, Timisoara 1
Correspondence to: Prof. Elena Aurora Ardeleanu, MD, PhD, Department of Family Medicine, Victor Babes University of Medicine and Pharmacy, 14 T. Vladimirescu Str., Timisoara, Tel. +40-256-492919 Email: ardeleanu.elena@clicknet.ro Received for publication: Oct. 11, 2011. Revised: Nov. 14, 2011.
The evaluation and stratification of the cardiovascular risk is a daily clinical practice, based mainly on Framingham risk function and the European SCORE function, which integrates a part of the CVR factors of individuals, establishes the cardiovascular risk (low, intermediate and high) and the necessary preventive strategies. Conventional scores as SCORE function underestimate the cardiovascular risk in a significant proportion of population.1 Traditional coronary heart disease risk prediction schemes such as the Framingham risk although useful, do not adequately identify all individuals who experience an adverse coronary heart disease event. Therefore, additional tools, including biomarkers, genetic markers, and imaging markers, are being evaluated for their _____________________________ Cristina Florea et al
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value in improving cardiovascular risk assessment. Carotid artery ultrasonography, by measurement of carotid intima-media thickness and detection of carotid plaques, is useful in identifying subclinical atherosclerosis and placing an individual into high CVR class.2,3 Carotid intima-media thickness represents the sum of the thickness of the intima and media layers of the carotid artery. Because atherosclerosis is a subintimal process, IMT has become recognized as a surrogate imaging marker for assessing subclinical atherosclerosis. However, it must be noted that hypertension associated medial hypertrophy may be reflected in the IMT measurement as well. Up to one third of the European adult population are subjects with an intermediate CVR, in whom the preventive measures are based on life style changes. But some of the subjects classified as low or intermediate risk present subclinical atherosclerosis, which detected in this stage, introduce the patients in the high CVR group that needs to benefit from a more aggressive management.1 A direct evaluation of the atherosclerotic carotid artery lesions, to identify high risk individuals, not detected by the CVR functions, can easily be made by high resolution B-mode ultrasonography. Ultrasound based IMT measurement is safe but has several challenges, including reproducibility and operator dependency. Quantifying the carotid IMT and by identification of carotid plaques, subclinical atherosclerosis can be detected and CVR stratification can be improved.1 The actual guidelines for the use of IMT are determined by Mannheim Carotid IMT Consensus and the ASE Consensus Statement.3,4 Many studies have demonstrated that increased IMT is associated with risk of myocardial infarction, stroke and death.5-8 The meta-analysis performed by Lorenz et al. and Roman et al. concluded that IMT is an important predictor of cardiovascular events.8,9 Abnormal values of IMT, that indicate subclinical atherosclerosis, are considered those greater or equal to 75th percentile of the reference population, or values greater than 0.9 mm. By measurement of IMT carotid artery ultrasonography is useful in identifying subclinical atherosclerosis and placing an individual into a high CVR class.
MATERIAL AND METHODS Data were obtained from an ambulatory population sample of 526 patients, who voluntarily enrolled in the CVR screening at 12 general practitioners offices in Timis County, between 2010 and 2012. Ten year risk for cardiovascular disease (CVD) was obtained according to the SCORE charts for populations at high CVR, the cardiovascular risk recommended for Romania. (Fig. 1) The SCORE function classified the participants in low, intermediate and high risk classes, if their calculated risk was < 3%, 3-4% and respectively >5%. Patients with diabetes or cardiovascular disease (CVD) as coronary heart disease, revascularization procedures, stroke and peripheral arterial disease were classified as high risk.
Figure 1. SCORE charts for high CVR countries, indicated for Romania.
three hundred seventy seven patients, 181(34.4%) were in the low CVR class and 196 (37.2%) in the intermediate CVR class. (Fig. 2) We excluded 149 (28.4%) patients of the total number of initial 526 enrolled subjects, because they were assessed in the high CVR class.
OBJECTIVE The aim of the study was to establish the contribution of IMT screening to the refining of CVR in a study population of asymptomatic adults at intermediate ore low CHD risk (SCORE risk 3-4%, or under 3%). _____________________________
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Figure 2. CV SCORE risk classes of the study population.
Three hundred fifty two patients (93.3%) answered a questionnaire, performed according to the European Guidelines of Cardiovascular Disease Prevention,
by which we obtained data about family history of cardiovascular disease, history of hypertension, hypercholesterolemia and smoking habits.10-13 Blood pressure was measured with a calibrated mercury sphygmomanometer according to the JNC-7.14 Laboratory data with total cholesterol and triglycerides were obtained from 285 patients (75.5%) of the low and intermediate CVR study groups. Of the 285 eligible participants (low and intermediate risk) with laboratory data, only 142 (37.6%) underwent the carotid ultrasonography for IMT measurement and carotid plaque assessment. (Fig. 3) Figure 4. B-mode ultrasound scan of CCA. IMT is seen as a double echogenic line in the far wall.
Figure 3. Evaluation methods of the low and intermediate CVR groups.
Carotid arteries were imaged with an ultrasound equipment Sonoscape SSI 8000 with high-resolution B-mode system and linear ultrasound transducer at frequencies of 7-13 MHz. Ultrasonography of the right and the left common carotid artery (CCA) was effectuated with the patient supine and with slight hyperextension of the neck (Mannheim Consensus).3 The inner and outer walls of the carotid artery were scanned longitudinally to obtain a clear horizontal image. We examined a minimum of 10 mm length of both common carotids, 5 mm below the carotid bulb. (Fig. 4) The IMT was calculated as the distance from the leading edge of the first echogenic line to the leading edge of the second echogenic line of the CCA. The system was equipped with software that automatically identified the borders of the CCA and calculated IMT. (Fig. 5) The IMT value was defined as the average of the right and left CCA. Proper measurement of IMT was critical to its clinical use. Plaque was defined as a focal wall thickening > 50% than the surrounding vessel wall or a focal region with the IMT >1.5 mm, protruding into the lumen, distinct from the adjacent boundary. As reference values for IMT, we used the value < and ≥ 0.9 mm. Subjects with a mean IMT ≥ 0.9 mm were considered as having subclinical atherosclerosis and reclassified to high CVR.
Figure 5. IMT automatic measurement.
Statistical analysis The study data were expressed as mean ± (SD) for continuous variables and as frequencies or percentages for categorical variables. Differences in mean values were assessed using t-test. Categorical variables were compared using chi-square tests. Linear regression analysis was used to determine the relationships between continuous variables Comparisons were considered significant in the presence of a P value < 0.05. All statistical analyses were performed using the Software Stata 9.2.
RESULTS One hundred forty two patients, aged between 40 and 72 years, with low or intermediate CVR underwent carotid ultrasonography for IMT assessment and carotid plaques detection. The study population characteristics are described in Table 1. The mean age of the study group was 55.8 ± 9.6 years, the minimum age was 40 years and the oldest patient had 72 years. The mean height was 166.1 ± 11.6 cm, with a minimum of 152 cm and a maximum _____________________________ Cristina Florea et al
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of 198 cm. The mean weight was 75.9 ± 12.8 kg, with a minimum of 45 kg and a maximum of 112 kg. The mean systolic blood pressure was 142.1 ± 12.3 mm Hg, with a minimum of 65 mm Hg and a maximum of 108 mm Hg. The mean diastolic blood pressure was 84.75 ± 7.5 mm Hg with a minimum of 65 mm Hg and a maximum of 115 mm Hg. Mean total cholesterol level was 230.5 ± 42.1 mg/dl, with a minimum of 160 mg/dl and a maximum of 335 mg/dl. The mean triglycerides values were 186.4 ± 60.9 mg/dl, with a minimum of 90 mg/dl and a maximum of 428 mg/ dl. Fifty two patients of the study group (36.6%) were smokers. A history of hypertension was present at 49 (34.5%) and a history of hypercholesterolemia at 52 (36.6%) patients.
General baseline characteristics of the study population (n = 142)
The calculated CVR class of the study population using SCORE charts was low risk class in 40 (28.2%) patients and intermediate risk class in 102 (71.8%). Depending on the values of IMT, the study population was divided into two groups. Group 1 included subjects with IMT < 0.9 mm, not reclassified by carotid ultrasonography. Group 2 included subjects with IMT ≥ 0.9, reclassified into high CVR class by carotid ultrasonography. Baseline characteristics of the two study groups are presented in Table 2. (Figs. 6,7) Mean IMT was 0.65 ± 0.14 mm. Intermediate CVR subjects had higher values of IMT than subjects with low CVR (0.77 ± 0.14 mm vs. 0.59 ± 0.11 mm. Carotid plaque was found in 15 (10.5%) patients, being more frequent in the intermediate CVR group than in the low CVR group: 13 (12.7%) vs. 2 (5%). (Fig. 8)
Table 1. General baseline characteristics of the study population (n = 142).
Figure 8. Mean IMT and presence of plaques in the study groups.
The results of the ultrasonography reclassified the risk of 39 patients (27.4%). Reclassification occurred in 34 (33.3 %) patients of the intermediate CVR group and in 5 (12.5%) patients of the low CVR group. (Table 3) Reclassification was connected to history of arterial hypertension (p<0.001), increased systolic blood pressure (p=0.001), age (p<0.005), cholesterol levels (p<0.05) and smoking (p<0.05). Table III. Cardiovascular reclassification distribution (n = 142)
Table 3. Cardiovascular reclassification distribution (n = 142).
Figure 6. Comparison of the two study groups general characteristics.
Exemplifications of cases in which IMT measurement reclassified the cardiovascular risk of patients and in which normal IMT at ultrasonographic examination maintained the patient in the SCORE risk class, are presented in Figures 9-14. Figure 7. Comparison of the two study groups risk factors. _____________________________
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Table II. Baseline characteristics of the study groups
Table 2. Baseline characteristics of the study groups.
Figure 9. Carotid ultrasound in patient with intermediate SCORE risk, normal IMT, not reclassified.
Figure 12. Detection of pathological IMT and carotid bulbus atherosclerotic plaques.
Figure 10. Carotid ultrasound in a case reclassified to high CVR by thickened IMT.
Figure 13. Detection of carotid plaque at a case classified at intermediate risk with SCORE.
Figure 11. Average IMT of 1.09 mm changed SCORE risk (from intermediate to high CVR).
Figure 14. Carotid atherosclerotic plaques and IMT over 0.9 mm at a reclassified case. _____________________________ Cristina Florea et alâ&#x20AC;&#x192;
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DISCUSSIONS Normal values of IMT are considered 0.4 – 0.89 mm. IMT increases with age with 0.01 mm/ year. Values are greater in man than women and in the left common carotid artery (LCCA) than in the right common carotid artery (RCCA). IMT is related to classical risk factors of atherosclerosis as hyperlipidemia, diabetes, hypertension and smoking. IMT has also non atherosclerotic mediators as age related sclerosis and pressure overload. IMT and Cardiovascular Risk Factors IMT values and progression has been associated with age (linear increasing), gender, race (blacks have greater IMT than whites, who in turn have greater IMT than Hispanics), hypertension, smoking, diabetes in longitudinal studies, SBP, body mass index, waistto-hip ratio, fasting glucose, insulin, mean hemoglobin A1C levels (supporting a link between diabetes and arterial wall thickening). The association of IMT with lipid parameters: HDL-cholesterol levels have an inverse association with IMT. Elevated LDL-cholesterol, lipoprotein(a) levels are associated with thicker IMT and its progression. Lovastatin, atorvastatin and rosuvastatin therapy were shown to reverse IMT progression, being associated with LDL-C reduction and with decreased CVD events. Homocysteine and C-reactive protein have been found to be weakly linked with IMT. IMT and Incidence of CVD Events Several large epidemiologic studies have examined the association between cardiovascular events and IMT measures. For an absolute carotid IMT difference of 0.1 mm, the future risk of myocardial infarction (MI) increases by 10% to 15% and stroke risk by 13% to 18%. In the Atherosclerosis Risk in Communities Study (ARIC), increased IMT was prospectively associated with increased risk of CHD, respectively with a 13% increase of hazard ratio for MI per 0.1 mm increase IMT of CCA, adjusted for age and gender.11 In the Kuospio Ischemic Heart Disease (KIHD) Risk Factor Study made on 1288 finish men, IMT≥1 mm at baseline was associated with increased risk of MI.8 In the study of Matthias W. Lorenz et al., the authors pointed out that IMT is a strong predictor for father CV events.8 The relative risk per IMT difference was slightly higher for the endpoints of stroke than MI. An important percentage of subjects who present subclinical atherosclerosis are not detected by the actual CVR functions, as SCORE charts.8-10 By detecting subclinical atherosclerosis, the risk _____________________________
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evaluation and stratification can be improved by high-resolution B-mode carotid ultrasonography, particularly in patients having an intermediate or low SCORE CVR. The literature review presents studies that mainly used the IMT in the assessment of the Framingham risk function, rather than that of the SCORE function.2,12,14,15 Bard et al. selected from a sample of 200 subjects 95 individuals with intermediate CVR and measured the IMT.16 Of these subjects, 22% presented an abnormal IMT and were so reclassified as having a high CVR. In the study of Stein et al., the IMT was calculated in 82 individuals with no diabetes or CVD.15 Of the study patients, 35.7% with intermediate CVR, according to Framingham function, were reclassified to high CVR. Reclassification was associated with increased SBP, cholesterol levels and smoking. Baldassarre et al. made a 5-year prospective study on dyslipidemic subjects.10 At the beginning of the study IMT was performed. The study group was divided in two groups: the first with low or intermediate CV risk consisted of 242 subjects and the second group with high Framingham CVR class consisting of 44 subjects. The study demonstrated that subjects with an abnormal IMT and intermediate Framingham risk had a CVR similar to those subjects with high Framingham CVR class. In the study of Wyman et al., made on 327 individuals with no diabetes or CVD, 41.6% individuals presented abnormal IMT and 58% carotid plaques. The abnormal IMT was associated to age, male gender and carotid plaque. The high percentage of abnormal IMT detected in this study is explained by the fact that high-risk subjects were not excluded, as CVR stratification was not made. Grewal et al. found that 23% of 752 low-risk individuals had an abnormal IMT, that was associated to high SBP, female gender and apolipoprotein B.17 To explain that female gender is a factor associated to abnormal IMT, we must take in consideration that in this study participated more than twice as many women as men. According to the Framingham scores, most of the young females are considered at low CV risk. Lester et al. determined IMT in 86 low-risk individuals, according to Framingham.18 Abnormal IMT was found in 13% of the study population. Juvent et al., in a study on 409 subjects with dyslipidemia, classified according to the Framingham function into low or intermediate CVR three hundred and sixty seven individuals.19 After IMT determination, 193 (52.5%) were reclassified into high CVR group. This study presents the highest percentage of reclassification that is explained by the
use of abnormal IMT or carotid plaque presence as reclassifying criteria. It is recognized that the presence of carotid plaques is associated with higher values of IMT and higher incidence of cardiovascular events.15-18 In our study, we found more carotid plaques in the intermediate CVR group than in the low CVR group. Many studies demonstrated discordance between the CVR detected by SCORE or Framingham functions and the direct demonstration by ultrasonography of an advanced subclinical atherosclerosis. This discordance can be explained by the fact that the CVR functions do not include all the risk factors involved in atherosclerosis. By means of carotid ultrasound and calculating IMT, we can observe the consequences of all the factors involved in atherogenesis, those included by the CVR functions and not, as individual CVR factors that have a genetic base, those that are dependent on environmental factors, homocysteine levels and so on. Recommendations for IMT measurement from Current Guidelines The ASE Consensus Statement, the National Cholesterol Education Program, the Screening for Heart Attack Prevention , the Education Task Force and the International Panel on Man-agement of Familial Hypercholesterolemia recommend for a better cardiovascular stratification the use of IMT in individuals with intermediate CVR.2,4,12 The ASE task force recommend IMT screening as class IIA level (a reasonable or probably recommended strategy) based on B level evidence (ie, studies on limited populations). American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines on assessment of cardiovascular risk in adults recommend IMT: - In patients who may benefit from the screening (asymptomatic adults, classified as intermediate CHD risk, without CHD or CHD equivalent); - In patients with following features (ASE Consensus Statement): - Family history of premature CHD in a firstdegree relative (men < 55 years old, women < 65 years old); - Age < 60 years with a severe single risk factor, not otherwise on pharmacotherapy; - Women < 60 years old with two or more CHD risk factors. Detection of abnormal IMT by ultrasound determines often a change in treatment plans, by initiation of early and a more aggressive CV preventive strategies, with additional aspirin therapy and increase of statins, until LDL cholesterol is below targets. The adherence of the patient to changes in lifestyle, weight
control, BP control and statin therapy is better after the identification and communication of data about an abnormal IMT and presence of atherosclerotic plaques. Limitations The findings of the study are observational, prospective, that include IMT as part of the CVR evaluation. Another limitation of the study is that we had no IMT reference values for Romanian population, for reclassification we didn’t the recommended IMT values greater than 75 percentiles of the reference values, but the IMT < or ≥ than 0.9 mm. The main purpose of this study was to evaluate the use of IMT in CVR assessment and for this reason we did not reclassify subjects with carotid plaques. Future studies, that evaluate the preventive interventions of reclassified individuals, in order to decrease in evolution future cardiovascular events, needs to be conducted.
CONCLUSIONS Carotid ultrasonography has become useful for monitoring carotid atherosclerosis, prediction of CVD risk and management of preventive strategies. IMT has the potential to be widely adopted as a clinical tool for physician offices, as it is a quick, safe, non invasive, cost effective and a reliable screening tool for subclinical atherosclerosis. In our study the values of IMT measurements were directly associated with history of hypertension, increased SPB, cholesterol, age and smoking. IMT improves CV risk assessment in patients at intermediate or low CVD risk, identifying high risk individuals that are not detected by the SCORE function and contributes to the establishment of earlier and more aggressive CV preventive strategies.
REFERENCES 1. Greenland P, Smith SC, Grundy SM. Improving coronary heart disease risk assessment in asymptomatic people: role of traditional risk factors and noninvasive cardiovascular tests. Circulation 2001; 104:1863-7. 2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood cholesterol in Adults (Adult Treatment Panel III) Final report. Circulation 2002; 106:3143-421. 3. Touboul PJ, Hennerici MG, Meairs S. Mannheim Carotid Intima-Media Thickness Consensus (2004-2006). Cerebrovasc Dis 2007; 23:75-80. 4. Naghavi M, Falk E, Hecht HS. From vulnerable plaque to vulnerable patient. Part III. Executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force report. Am J Cardiol 2006; 98:2-15. 5. Sharma K, Blaha MJ, Blumenthal RS, Clinical and research applications of carotid intima-media thickness. Am J Cardiol 2009; 103:1316-20. 6. O’Leary DH, Polak JF, Kronmal RA. Carotid-artery intima and media _____________________________ Cristina Florea et al
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thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaborative Research Group. N Engl J Med 1999; 340:14-22. 7. Heuten H, Goovaerts I, Ennekens G. Carotid artery intima-media thickness is associated with coronary artery disease. Acta Cardiol 2008; 63:309-13. 8. Lorenz MW, Markus HS, Bots ML. Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation 2007; 115:459-67. 9. Roman M, Naqvi T, Gardin J. Clinical application of noninvasive vascular ultrasound in cardiovascular risk stratification: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology. Vasc Med 2006; 11:201-11. 10. Baldassarre D, Amato M, Pustina L. Measurement of carotid artery intima-media thickness in dyslipidemic patients increases the power of traditional risk factors to predict cardiovascular events. Atherosclerosis 2007; 191:403-8. 11. Chambless LE, Heiss G, Folsom AR. Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atheroscle-rosis Risk in Communities (ARIC) Study, 1987-1993. Am J Epidemiol 1997;146:483-94. 12. Stein JH, Korcarz CE, Hurst RT. Consensus Statement. Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American
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Society of Echocardiography Carotid Intima-Media Thickness Task Force. J Am Soc Echocardiogr 2008; 21:93-111. 13. Conroy RM, Pyorala K, Fitzgerald AP. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003; 24:987-1003. 14. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-71. 15. Stein JH, Fraizer MC, Aeschlimann SE. Vascular age: integrating carotid intima-media thickness measurements with global coronary risk assessment. Clin Cardiol 2004; 27:388-92. 16. Bard RL, Kalsi H, Rubenfire M. Effect of carotid atherosclerosis screening on risk stratification during primary cardiovascular disease prevention. Am J Cardiol 2004; 93:1030-2. 17. Grewal J, Anand S, Islam S. Prevalence and predictors of subclinical atherosclerosis among asymptomatic ‘’low risk’’ individuals in a multiethnic population. Atherosclerosis. 2008;197:435-42. 18. Lester SJ, Eleid MF, Khandheria BK. Carotid intima-media thickness and coronary artery calcium score as indications of subclinical atherosclerosis. Mayo Clin Proc 2009;84:229-33. 19. Junyent M, Zambcon D, Gilabert R Carotid atherosclerosis and vascular age in the assessment of coronary heart disease risk beyond the Framingham Risk Score. Atherosclerosis 2008; 196:803-9.
ORIGINAL ARTICLES
TRENDS IN BACTERIAL PATHOGENS OF LOWER RESPIRATORY TRACT INFECTIONS IN CHILDREN Giorgiana F. Brad1, Ioan Sabau2, Marioara Boia2, Tamara Marcovici2, Adrian Craciun2, Kundnani Nilima1, Calin M. Popoiu2 REZUMAT Introducere: Infecţiile tractului respirator inferior (ITRI) la copii sunt o problemă de sănătate publică, uneori cu o evoluţie mortală. Obiective: Obiectivele acestui studiu au fost identificarea agenţilor patogeni responsabili de apariţia ITRI la copii şi determinarea sensibilităţii bacteriilor izolate la diferite antibiotice. Material şi metode: S-au analizat foile de observaţie şi antibiogramele copiilor (0-18 ani) internaţi în Spitalul de Copii Louis Turcanu, Timisoara, în perioada decembrie 2007 - martie 2009. Identificarea bacterilor s-a făcut din spută, aspirat traheal sau bronşic şi lichid pleural, iar testarea sensibilităţii la antibiotice s-a realizat conform metodelor standard. Rezultate: S-au izolat 120 de tulpini bacteriene de la 69 de copii (43 băieţi şi 26 fete). Au fost 22 (31,88%) nou-născuţi, 18 (26,08%) copii mici (<3 ani), iar restul copii (>3 ani) şi adolescenţi. S-au izolat 77,5% bacterii Gram negative, 20% bacterii Gram pozitive, iar restul tulpini Gram negative non-fermentative. Majoritatea bacteriilor Gram negative izolate au fost Pseudomonas aeruginosa (31,11%), Klebsiella pneumoniae (23,65%) şi Enterobacter (12,90%), pe când Staphylococcus aureus (79,1%) şi Stafilococcus CoagulazoNegativ (12,5%) au fost cele mai frecvente bacterii Gram pozitive identificate. Colistin a fost cel mai eficient antibiotic asupra bacteriilor Gram negative, urmat de Levofloxacin şi Imipenem. Toate tulpinile Gram pozitive au fost sensibile la Vancomicină şi Linezolid. Concluzii: Diagnosticul bacteriologic şi supravegherea rezistenţei bacteriilor la antibiotice sunt indispensabile pentru un management eficient al ITRI. Cuvinte cheie: infecţii ale tractului respirator inferior, copii, sensibilitate la antibiotice
ABSTRACT Introduction: Lower respiratory tract infections (LRTIs) in children remain an important public health problem, with potential life-threatening complications. Objectives: The objectives of this study were to identify bacterial pathogens of LRTIs in children and to study their antibiotic susceptibility. Material and methods: We reviewed the medical charts and microbiological reports of children (0-18 years) with LRTIs admitted to Louis Turcanu Children Emergency Hospital Timişoara from December 2007 to March 2009. Bacterial pathogens were isolated from sputum, tracheal or bronchial aspirates and pleural effusion, and their susceptibility was tested using standard bacteriological techniques. Results: One hundred twenty bacterial strains were isolated from 69 children (43 males and 26 females). There were 22 (31.88%) newborns, 18 (26.08%) toddlers, and the rest children and adolescents. Gram-negative bacteria represented 77.5% of isolates, 20% were Gram-positive and the rest were Non-fermenting Gram-negative strains. From Gram-negative strains, Pseudomonas aeruginosa (31.11%), Klebsiella pneumoniae (23.65%) and Enterobacter (12.90%) were the majority. Staphylococcus aureus (79.1%) and Coagulase negative Staphylococci (12.5%) were the dominants from Gram-positive cocci. Colistin was the most efficient antibiotic active on Gramnegative bacteria, followed by Levofloxacin and Imipenem. All Gram-positive isolates were susceptible to Vancomycin and Linezolid. Conclusions: Bacteriological diagnosis and antibiotic resistance surveillance are indispensable in the effective management of LRTIs. Key Words: lower respiratory tract infections, children, antibiotic susceptibility
INTRODUCTION Respiratory tract infections are one of the major public health problems, affecting both children and adults; it proves to be more serious when located in the lower respiratory tract. Just 5% of respiratory infections involve the lower respiratory tract, while the rest are limited to the upper respiratory tract. Louis Turcanu Children Emergency Hospital, Timisoara, 2 Department of Pediatrics, Victor Babes University of Medicine and Pharmacy, Timisoara 1
Correspondence to: Giorgiana-Flavia Brad, MD, Louis Turcanu Children Emergency Hospital, 1-3 Dr. Iosif Nemoianu Str., 300011, Timisoara, Tel. +40-256-201975 Email: giorgiana.brad@gmail.com Received for publication: Oct. 11, 2010. Revised: Apr. 14, 2011.
A variety of microorganisms can cause lower respiratory tract infections (LRTIs) in children, including bacteria, viruses, parasites, or fungi. Streptococcus pneumoniae is by far the most common bacterial cause of pneumonia in young children, while Mycoplasma pneumoniae and Chlamydia pneumoniae are frequently encountered among older children and adolescents. Group A streptococcus, Staphylococcus aureus, Haemophilus influenzae type B and Moraxella catarrhalis are less frequently seen. In young children, most of LRTIs occur during the seasonal respiratory viral epidemics, generally caused by parainfluenza virus, influenza virus, adenovirus, metapneumovirus or respiratory syncytial virus. Viral pneumonia with cytomegalovirus and herpes simplex virus should be considered even without a suspicion of maternal history. Pneumocystis pneumonia is _____________________________ Giorgiana F. Brad et al
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generally limited to immunocompromised infants while Cryptococcus neoformans may be found in patients with HIV infections. In infants, LRTIs can be also caused by milk aspiration or by a foreign body. In North America, the annual incidence of pneumonia in children <5 years is 30-45 cases per 1,000, while in children aged 5 years and older, the annual incidence is 16-22 cases per 1,000.1 Despite advances in the development of strategies to prevent LRTIs, the availability of newer, safer and more potent antimicrobials and effective vaccines, LRTIs continues to be a leading cause of morbidity and mortality for children of all age groups.2 Children with LRTIs may present life-threatening complications, such as massive parapneumonic or pleural effusion, sepsis, empyema, pericarditis with cardiac tamponade and venous thromboembolism.3-7 Many of these deaths and complications can be prevented by simple inexpensive measures such as early diagnosis and institution of appropriate antimicrobial therapy. The management of pneumonia mainly consists in eradicating the responsible culprits. Antibiotics are not needed to treat pneumonia of viral etiology; sometimes they are used due to the potential for secondary bacterial infection, or when one cannot discriminate between viruses and bacteria. Therefore, antibiotics are administered if the patient is positive for pneumonia. Therefore, empirical antibiotic treatment of LRTIs is important and instituted before the etiology is known, based on the pathogens that commonly cause pneumonia in the local area as per past medical records. This fact could lead to an increase in antibiotic resistance of the common LRTIs pathogens. Nowadays, antimicrobial resistance is a recognized problem all over the world, due to excessive use of antibiotics and frequent prescription of antibiotics in outpatient settings for each and every minor health problem.8 In order to select the optimal antibiotics for the initiation of the empirical treatment, studies are critical to identify the current microorganisms found in the hospital and to determine their antibiotic resistance/ susceptibility.
OBJECTIVES The main objectives of our study were to identify bacterial pathogens of LRTIs in children and to study their antibiotic susceptibility. This report is an update for clinicians in the various antibiotic alternatives available in the treatment of LRTIs in children. _____________________________
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MATERIALS AND METHODS We analyzed the medical charts and microbiology data of children with LRTIs admitted in “Louis Turcanu” Children Emergency Hospital Timisoara from December 2007 to March 2009. Children (age 0-18 years) with clinical, laboratory and radiological signs of LRTIs were eligible for inclusions in our study. Three or more of the following signs and symptoms of LRTIs were found in children: fever, cough, tachypnea (increased respiratory rate >60breaths/ min in infants 0-2 months; >50/min in infants 2-12 months; >40/min in children 1-5 years and >20/min in children aged 5 years and older), signs of respiratory distress (wheezing, expiratory grunting, cyanosis, chest retraction or nasal flaring), refusal of feeding or inability to drink.9 Leukocytosis with neutropenia/ netrophilia, raised erythrocyte sedimentation rate and C-reactive protein were indicative for bacterial infections.10 Radiological diagnosis of LRTIs was based on the presence of either consolidated lobar infiltrate, or large pleural effusion, or parenchymal necrosis. Positive cultures from sputum, tracheal aspirate or pleural effusion were of great diagnostic help. Blood agar medium and MacConkey agar medium were used, and then specimens were incubated at 37°C overnight. Specimens consisting in saliva were examined by microscopy, and Gram staining was then performed only if <10 squamous epithelial cells and >25 polymorphonuclear neutrophils (PMNs) per low power field were found.11 The colony that grew on the medium was identified to species, using several tests: for Gram-positive cocci – catalase, coagulase and optochin; for Gram-negative rods – KIA, MIU and Citrate test. For sensitivity testing, we used the diffusion method on Mueller Hinton medium, with the following antibiotic disks: Ciprofloxacin, Levofloxacin, Ticarcillin/ Clavulanate, Amoxicillin/ Clavulanate, Trimethoprim/Sulfamethoxazole, Amikacin, Gentamicin, Meronem, Imipenem, Ceftriaxone, Ceftazidime, Colistin, Vancomycin, Linezolid, Oxacillin, Erythromycin, and Clindamicyn. For quality control, strains of Escherichia coli ATCC 25922, Pseudomonas aeruginosa ATCC 27853, Klebsiella pneumoniae ATCC 700603 and Staphylococcus aureus ATCC 25923 were used. Results reading and interpreting was done following the current NCCLS standards. Selected demographic characteristics, such as the age and sex of the patients included in the study were also taken into consideration. Our study complied with the Declaration of Helsinki and has been approved by our institutional Ethics Committee.
RESULTS From December 2007 to March 2009, 638 lower respiratory tract specimens (sputum, tracheal or bronchial aspirate and pleural effusion) were cultured in the Microbiology Department; 112 specimens were positive for different bacteria (10.52% sputum, 83.33% bronchial aspirates and 6.14% pleural effusions). A total of 120 bacterial strains were found in these 112 samples, and antibiotic sensitivity testing was performed. These 120 isolates were collected from 69 children aged between newborn and adolescent. Out of these, 22 (31.88%) were newborns and preterm babies, 18 (26.08%) toddlers and the rest children and adolescents, Pictures as presented in Figure 1. Male children were prevalent Figure 1. Distribution of children with LRTIs by age group (62.31% versus 37.68%).
Figure 1. Distribution of children with LRTIs by age group.
Eight children (11.59%) had LRTIs with mixed bacterial etiology and one child had two bacteria and fungi (Klebsiella pneumoniae, Pseudomonas aeruginosa and Candida albicans) in his culture. From the rest, 14.16% of bacterial isolates were mixed with Candida albicans. Gram-negative bacteria were more frequent (77.5%) than Gram-positive (20%). Non-fermenting Figure 2. Distribution of culprits isolated in LRTIs Gram-negative bacilli (other than Pseudomonas species) represented 2.5%, as shown in Figure 2.
Figure 2. Distribution of culprits isolated in LRTIs.
Out of the Gram-negative, Pseudomonas aeruginosa was the most common culprit isolated (31.11%), followed by Klebsiella pneumoniae (23.65%), Enterobacter (12.90%) and E. coli (11.82%).
Other rare bacteria encountered were Citrobacter, Stenotrophomonas maltophilia or Acinetobacter baumannii. Staphylococcus aureus was the dominant Gram-positive coccus (79.1%), followed by Coagulase negative Staphylococci (12.5%), while Enterococcus faecium and Streptococcus pneumoniae were identified in small percentage. The majority of patients were admitted in Intensive Care Units. Some of them had underlying conditions, such as Ducheneâ&#x20AC;&#x2122;s muscular dystrophy, lung agenesia, congenital heart disease, hydrocephaly, meningitis, peritonitis, immunocompromised status or cerebral palsy and spastic tetraparesis. Two children had multiple episodes (four, respectively five) of LRTIs during the study period, because they had underlying conditions that can easily favor this disease: Ducheneâ&#x20AC;&#x2122;s muscular dystrophy and tracheotomy in one child, and Goldenhar disease (cleft lip, palate, and lung agenesia) in the other. A percentage of 23.18 of children had positive bacterial cultures due to life saving procedures, such as endotracheal intubation with mechanical ventilation or tracheotomy. Eight children (11.59%) developed pleural effusions, Staphylococcus aureus being the most often identified germ in these cultures (62.5%), followed by Streptococcus pneumoniae, Coagulase negative Staphylococci and Pseudomonas aeruginosa. Mortality rate in our study was 11.59%. When analyzing the results of our study, it is easy to note that Gram-negative bacteria are sensitive to Colistin, followed by Fluoroquinolones and Carbapenems. In addition, there is a high resistance rate to the 3rd generation Cephalosporins. The antibiotic sensibility testing results are documented in Table 1. Pseudomonas aeruginosa isolates were highly resistant to almost all antibiotics tested, Colistin being the only exception. Both Enterobacter and Klebsiella pneumoniae isolates were 100% susceptible 21 to Levofloxacin, and E. coli was sensible to Colistin, Carbapenems, Levofloxacin and Amikacin. Citrobacter rods were resistant to Aminoglycosides and Cephalosporins, while Proteus isolates were sensible to Trimethoprim/Sulfamethoxazole, Aminoglycosides and Carbapenems. All Gram-positive bacteria were 100% sensible to Vancomycin and Linezolid, as presented in Table 2, while to Oxacillin and Erythromycin they were highly resistant. Multidrug resistance bacteria (MDRB) were also found. Extended spectrum beta-lactamase (ESBL) producing strains were encountered in E. coli and Klebsiella pneumoniae isolates, and phenotypes resistant to Carbapenems were found in Pseudomonas aeruginosa and Acinetobacter baumannii strains, _____________________________ Giorgiana F. Brad et alâ&#x20AC;&#x192;
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Table1. IAntimicrobial Antimicrobial sensibility among Gram-negative isolatedtract from lower respiratory tract specimens Table sensibility among Gram-negative strains isolated fromstrains lower respiratory specimens.
Table II Antimicrobial sensibilities among Gram-positive strains isolated from lower respiratory tract specimens
Table 2. Antimicrobial sensibility among Gram-positive strains isolated from lower respiratory tract specimens.
while Stenotrophomonas maltophilia was resistant to Fluoroquinolones, Cephalosporins and Aminoglycosides. No Methicillin-resistant Staphylococcus aureus and Coagulase negative Staphylococci or Vancomycin-resistant Enterococcus were present in our study group.
DISCUSSIONS In the medical literature it is stated that Grampositive bacteria are the major culprits causing LRTIs in children.12 Streptococcus pneumoniae continues to be a major threat and an important cause of invasive pneumonia in children less then 2 years.13 Cases of highly lethal necrotizing pneumonia in young immunocompetent patients caused by PantonValentine leukocidin-producing Staphylococcus aureus (a citotoxin which increases the virulence of S. aureus) have been reported all over the world.14,15 Our results pointed out only a small percentage of Gram-positive bacteria, which caused pneumonia with less complications and no mortality, while Gramnegative bacteria were most often isolated, almost ¼ of them being associated with life saving maneuvers. Pseudomonas aeruginosa was the most frequent isolate, and not Streptococcus pneumoniae, Haemophilus _____________________________
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influenzae, or atypical bacteria as documented in the medical literature. Most serious cases were younger than 3 years, and males were predominant. Similar results were found in other medical reports.16 The isolation of MDRB is an increasing phenomenon observed in different hospitals all over the world. In recent years, strains of Acinetobacter baumannii and Pseudomonas aeruginosa causing LRTIs in children became resistant to nearly all classes of drugs, including Carbapenems.17,18 Colistin appears as an appropriate therapeutic alternative. Stenotrophomonas maltophilia is resistant to most of the available antibiotics such as β-lactam, Quinolones and Aminoglycosides. In our study, we found S. maltophilia to be 100% sensible to Trimethoprim/ Sulfamethoxazole and highly sensible to Levofloxacin, similar to other study.19 The presence of E. coli and Klebsiella pneumoniae resistant to 3rd and 4th generations of Cephalosporins and Aztreonam (ESBL producing strains), can be explained through the frequent use of Cephalosporins for both prophylactic and therapeutic treatment in our hospital. This fact may have exerted selective pressures leading to the emergence of MDR strains.20 Further, discussing about treatment, what we can observe from our study is that Colistin, Carbapenems
or Fluoroquinolones can be used as first choice empirical treatment of LRTIs in children. Colistin was found to be the most effective drug against all types of Gram-negative bacteria, followed by Levofloxacin and Imipenem. Clinical studies showed the efficacy of inhaled Colistin in treating LRTIs caused by MDR bacteria.21,22 There is a great deal of evidence suggesting that Levofloxacin has low resistance rate, good activity levels, high respiratory penetration and is well tolerated, with good adherence.23 It is particularly well suited for shorter courses of therapy at higher doses.24 Previous studies already showed the efficiency of Imipenem in the treatment of LRTIs in children, alone or in association with other antibiotics (Linezolid or Ciprofloxacin).25,26 Vancomycin and Linezolid were the drugs of choice, fully efficient, against Grampositive bacteria. Hence, these drugs should be spared for serious cases, to avoid MDR bacteria. After identifying the etiological agent, specific antibiotics should be prescribed according to the antibiotic sensibility testing reports.
CONCLUSIONS 1. LRTIs still prevails to be a major health threat in children of all ages. 2. Our study totally contradicted the assertion that Gram-positive cocci are the dominant cause of LRTIs, as we found a majority of Gram-negative bacteria causing LRTIs in our group. Epidemiological studies should be performed more often, in order to find out the changes of culprits responsible for LRTIs in a specific area. 3. Increasing multidrug resistance of Gramnegative bacteria, in particular Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae, explains the reappraisal of the clinical use of Colistin, an antibiotic discovered more than 50 years ago. Carbapenems and Fluoroquinolones are other options. Vancomycin and Linezolid are the best choice for treating Gram-positive infections. 4. Parental awareness and support can further help in preventing heath problems related to aspiration syndromes of liquids, foods and foreign bodies. Vaccinations and avoidance of community gatherings can further help decrease the incidence of LRTIs at the time of seasonal epidemics. Family physicians should be cautious against prescribing antibiotics unnecessarily. Hospital based antibiotic usage should further be limited to special cases, in order to avoid multidrug resistant strains in the future. 5. A little awareness, joint efforts and precautions can help us all tremendously to secure a healthy future.
REFERENCES 1. Sadeli M. Pattern of Bacteria Causing Pneumonia in Children and Its Sensitivity to Some Antibiotics. Proc ASEAN Congr Trop Med Parasitol 2008;3:121-4. 2. Baqui AH, Rahman M, Zaman K, et al. A population–based study of hospital admission incidence rate and bacterial etiology of acute lower respiratory infections in children aged less than five years in Bangladesh. J Health Pop Nutr 2007;25:179-88. 3. Aydemir C, Ustundag GH, Eldes N, et al. Massive parapneumonic effusion caused by Mycoplasma pneumoniae in a child: a case report. Tuberk Toraks 2008;56(3):310-4. 4. Espínola Docio B, Casado Flores J, de la Calle Cabrera T, et al. Pleural effusion in children with pneumonia: a study of 63 cases. An Pediatr (Barc) 2008;69(3):210-4. 5. Pirez MC, Martinez O, Ferrari AM, et al. Pneumonia: standard case management in hospitalized children. Uruguay 1997–1998. Pediatr Infect Dis J 2001;20:283–9. 6. Langley JM, Kellner JD, Solomon N, et al. Empyema associated with community-acquired pneumonia: a Pediatric Investigator’s Collaborative Network on Infections in Canada (PICNIC) study. BMC Infect Dis 2008;8:129. 7. Al-Sabbagh A, Catford K, Evans I, et al. Severe cardiovascular and thromboembolic consequences of pneumococcal infection in a child. Pediatrics 2008;122(4):e945-7. 8. Moore M, Little P, Rumsby K, et al. Effect of antibiotic prescribing strategies and an information leaflet on longer-term reconsultation for acute lower respiratory tract infection. Br J Gen Pract. 2009;59(567):728-34. 9. World Health Organization. Technical bases for the WHO recommendations in the management of pneumonia in children at first-level health facilities: programmer for the control of acute respiratory infections. Geneva: World Health Organization; 1991. Available on internet at http://whqlibdoc.who.int/hq/1991/WHO_ ARI_91.20.pdf. 10. Don M, Valent F, Korppi M, et al. Differentiation of bacterial and viral community-acquired pneumonia in children. Pediatr Int 2009;51(1):91-6. 11. Seo KW, Hwang SJ, Sung SJ, et al. Bacteriologic Analysis of Expectorated Sputum in Patient with Bronchiectasis. Tuberc Respir Dis 2009;67(6):517-27. 12. Farha T, Thomson AH. The burden of pneumonia in children in the developed world. Paediatr Respir Rev 2005;6(2):76-82. 13. Pírez García MC, Giachetto Larraz G, Romero Rostagno C, et al. Invasive pneumococcal pneumonia in children 0-24 months old: does bacterial resistance affect outcome. An Pediatr (Barc) 2008;69(3):205-9. 14. Dubrous P, Cuguillère A, Gendrot A, et al. Panton-Valentine leukocidinproducing Staphylococcus aureus responsible for necrotizing pneumonia. Ann Biol Clin (Paris) 2007;65(3):277-81. 15. Saïdani M, Mesrati I, Benzarti A, et al. Community-acquired pneumonia due to Panton-Valentine producing Staphylococcus aureus: first description in Tunisia. Tunis Med 2008;86(10):924-7. 16. Zar HJ, Madhi SA. Childhood pneumonia - progress and challenges. S Afr Med J 2006;96 :890-900. 17. Gales AC, Jones RN, Forward KR, et al. Emerging importance of multi-drug resistant Acinetobacter species and Stenotrophomonas maltophilia as pathogens in seriously ill patients: geographic patterns, epidemiological features, and trends in the SENTRY Antimicrobial Surveillance Program (1997–1999). Clin Infect Dis 2001;32(2):104–13. 18. Gales AC, Jones RN, Turnidge J, et al. Characterization of Pseudomonas aeruginosa isolates: occurrence rates, antimicrobial susceptibility patterns, and molecular typing in the global SENTRY Antimicrobial Surveillance Program, 1997–1999. Clin Infect Dis 2001;32(2);146–55. 19. Sanchez MB, Hernandez A, Martinez JL. Stenotrophomonas maltophilia drug resistance. Future Microbiol 2009;4:655-60. 20. Duttaroy B, Mehta S. Extended spectrum b lactamases (ESBL) in clinical isolates of Klebsiella pneumoniae and Escherichia coli. Indian _____________________________ Giorgiana F. Brad et al
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J Pathol Microbiol 2005;48(1):45-8. 21. Falagasabc ME, Siemposa II, Rafailidisab PI, et al. Inhaled colistin as monotherapy for multidrug - resistant gram(-) nosocomial pneumonia: A case series. Respir Med 2009;103(5):707-13. 22. Michalopoulos A, Kasiakou SK, Mastora Z, et al. Aerosolized colistin for the treatment of nosocomial pneumonia due to multidrugresistant Gram-negative bacteria in patients without cystic fibrosis. Crit Care 2005;9(1): 53–9. 23. Boselli E, Breilh D, Rimmelé T, et al. Pharmacokinetics and intrapulmonary diffusion of levofloxacin in critically ill patients with severe community-acquired pneumonia. Crit Care Med
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2005;33(1):104-9. 24. Anderson VR, Perry CM. Levofloxacin: a review of its use as a high-dose, short-course treatment for bacterial infection. Drugs 2008;68(4):535-65. 25. Godon N, Denizot S, Podevin G, et al. Effectiveness of Linezolid and Imipenem association in the treatment of severe communityacquired pneumonia in children: two case reports. Scand J Infect Dis 2006;38(5):381-3. 26. Torres A, Bauer TT, León-Gil C, et al. Treatment of severe nosocomial pneumonia: a prospective randomised comparison of intravenous ciprofloxacin with imipenem/cilastatin. Thorax 2000;55:1033-9.
ORIGINAL ARTICLES
CONSIDERATIONS ON JUVENILE IDIOPATHIC ARTHRITIS Dalia Dop, Dumitru Bulucea, Carmen Elena Niculescu REZUMAT Obiective: Obiectivele studiului nostru au fost analiza aspectelor clinice, biologice şi radiologice în artrita idiopatică juvenilă (AIJ). Material şi metodă: Studiu comparativ, retrospectiv, de tip cohortă, în perioada ianuarie 2000-decembrie 2008, pe două loturi de pacienţi: lotul A (66 copii cu AIJ) şi lotul B (258 copii fără AIJ, dar cu afectare articulară) internaţi în Clinicile de Pediatrie din municipiul Craiova. Diagnosticul de AIJ a fost stabilit conform criteriilor ILAR (International League Against Rheumatism) revizuite în anul 2001 la Edmonton. Rezultate: În lotul A, cele mai frecvente forme de AIJ au fost forma oligoarticulară persistentă 56,06% şi forma poliarticulară FR-negativă 24,24%. În lotul B, cele mai frecvente boli cu afectare articulară au fost artrita virală 30,23% şi reumatismul articular acut (RAA) 19,37%. Efectuând analiza afectării articulare în lotul A am constatat că articulaţiile mari sunt cele mai frecvent afectate în AIJ 87,87% versus 30,3% articulaţii mici. Articulaţiile genunchilor sunt cele mai frecvente articulaţii afectate (68,18%), urmate de articulaţiile gleznei (48,38%) şi radiocarpiene (22,72%). Manifestările extra-articulare reprezentate de febră, rash, adenopatii au fost prezente îm 100% din cazuri în forma sistemică. În lotul A, anemia a fost prezentă la 38 de cazuri (54,4%), VSH a fost crescut în 57 din cazuri (86,36%), iar proteina C reactivă în 39 de cazuri (59,09%). Concluzii: 1. Cea mai frecventă formă de AIJ este forma oligoarticulară persistentă. 2. Efectuînd analiza afectării articulare am constatat că sunt afectate toate articulaţiile, cu o preponderenţă mai mare a articulţiilor mari şi în special a genunchilor şi a articulaţiilor gleznei. 3. Analizele de laborator reflectă prezenţa anemiei şi a sindromului inflamator articular. Cuvinte cheie: artrită juvenilă idiopatică (AJI), aspecte clinice, aspecte biologice
ABSTRACT
Objective: The objective of our study was to analyze the clinical, biological and radiological aspects in JIA (juvenile idiopathic arthritis). Materials and method: Comparative, retrospective, cohort study for the period between January 2000 and December 2008, developed on two groups of patients hospitalized in the Pediatrics Clinics of Craiova: group A (66 children with JIA) and group B (258 children without JIA, but with articular impairment). The JIA diagnosis was established according to the ILAR (International League against Rheumatism) criteria revised in 2001 at Edmonton. Results: In group A, the most common forms of JIA were the persistent oligoarticular form (56.06%) and the RF-negative polyarticular form (24.24%). In group B, the most common diseases involving joints were viral arthritis (30.23%) and rheumatic fever (RF) (19.37%). Analyzing joint involvement in group A, we found that large joints are most frequently affected in JIA (87.87% as opposed to 30.3% for small joints). Knee joints are the most affected (68.18%), followed by the ankles (48.38%) and wrists (22.72%). Extra-articular manifestations such as fever, rash and adenopathies were present in 100% of the cases with systemic JIA. In group A, anemia was present in 38 cases (54.4%), ESR (Erythrocyte Sedimentation Rate) was elevated in 57 cases (86.36%), while the C-reactive protein (CRP) was elevated in 39 cases (59.09%). Conclusions: 1. The most common form of JIA is the persistent oligoarticular form. 2. Analyzing joint involvement, we found that all joints are affected, with a higher frequency in the case of large joints, especially knees and ankles. 3. Laboratory analyses reflect the presence of anemia and of the inflammatory articular syndrome. Key Words: juvenile idiopathic arthritis (JIA), clinical aspects, biological aspects
INTRODUCTION Juvenile Idiopathic Arthritis (JIA) represents the most frequent inflammatory rheumatic disease in childhood, as well as a significant cause of short- and long-term disabilities. The clinical aspects of JIA are polymorphous, mimicking in its early stages other diseases that are more or less serious; thus, there is the risk that a certain diagnosis be established later on, at times even years after the onset of the disease. Furthermore, the criteria for the classification of JIA taken into account when establishing the diagnosis are frequently insufficient in the early stages. Department of Infant Care - Pediatrics - Neonatology, University of Medicine and Pharmacy, Craiova Correspondence to: Dop Dalia, 7 I. D. Sîrbu Str., Bl. A, Apt. 5, Craiova, Dolj County, Romania, Tel. +40724531522 Email:dalia_tastea@yahoo.com Received for publication: Oct. 22, 2010. Revised: Aug. 14, 2011.
During the last decade, the therapeutic paradigm in JIA has changed significantly. The evidence of the presence of articular erosions during the first months of evolution of JIA has lead to the recognition of the importance of early introduction of disease-modifying antirheumatic drugs (DMARDs) that can stop the progression towards the emergence of disabilities.1-4 Thus, a better assessment starting with the first signs of the disease, which can be obtained when the patient is initially hospitalized, will lead to a correct and complete diagnosis, allowing the introduction of the treatment best suited for each specific form of JIA. Objectives: to analyze the clinical, biological and radiological aspects in JIA.
MATERIALS AND METHOD We have carried out a comparative, retrospective, cohort study for the period between January 2000 and December 2008, that included two groups of patients hospitalized in the Pediatrics Clinics of Craiova, group A (66 children with JIA) and group B (258 children without JIA). _____________________________ Dalia Dop et al
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The JIA diagnosis was established according to the ILAR criteria revised in 2001 at Edmonton. The assessment of the patients was complex and was aimed at evaluating the characteristics of the articular syndrome in each of the two groups. The statistical analysis of the data was done with Microsoft Excel, while the significance of the correlations was evaluated by calculating the threshold of statistical significance, using the Fischer test and calculating the relative risk.
RESULTS
Figure 2. Diseases with articular involvement in Group B.
According to the classification of JIA, in group A the systemic form represents 9.09%, the RF (rheumatoid factor)-positive polyarticular form represents 3.03%, the RF-negative polyarticular form represents 24.24%, the persistent oligoarticular form accounts for 56.06%, the extensive oligoarticular form is found in 6.06%, while spondyloarthropathies represent 1.51%. (Fig. 1)
Regarding the sex distribution, 34 of the patients were boys (51.51%) and 32 were girls (48.48%), while the ratio related to the background of the patients is Urban/Rural = 35/31. Analyzing the age of onset of the various forms of JIA, we can conclude that the onset is possible at any age but the highest incidence is between the ages of 10 and 15. (Table 1) Significant family history was present in 9 cases (13.63%) in group A and in 12 cases (4.65%) in group B (1.29 < RR = 2.93 < 6.66; p < 0.013). The factor that triggered JIA was trauma in 12.12% of the cases, respiratory infections in 4.54%, and physical exercise in 1.51% of the cases. Infections contacted in the first years of life were noticed in 48.48% of the children with JIA, with a difference between the oligoarticular form (58.53%) and the polyarticular form (38.88%). Analyzing the absence of the protective factor represented by breast feeding for a minimum of 6 months and comparing between the 2 groups, we discovered that 42 children (63.63%) in group A were breast-fed for less than 6 months, as opposed to 77 children (29.84%) in group B (1.46 < RR = 1.93 < 2.55; p < 0.001). Following the analysis of joint involvement in group A, we have noticed that large joints are most frequently affected in JIA (87.87% as opposed to 30.3% for small joints); this is in fact correlated to the high frequency of the oligoarticular type. Knee joints are the most affected (68.18%), followed by the ankles (48.38%) and wrists (22.72%). The analysis of joint involvement in relation to the form of JIA has revealed that in most patients (83.33%) with the systemic form, it is the knees that are affected. It has also revealed that in 50% of the patients the joints involved are the ankles, the elbows, the wrists, as well as the metatarsal joints. The metacarpal joints, the proximal interphalangeal joints, the scapulohumeral joints, the coxofemoral joints and the spine are involved in 33.33% of the cases.
Figure 1. Types of JIA according to the ILAR criteria revised in 2001 at Edmonton.
In group B, the children were diagnosed with various diseases with joint involvement: 13.67% presented reactive arthritis, 5.32% presented hemarthrosis, 30.23% presented viral arthritis, 6.2% presented physical trauma, 19.37% presented rheumatic fever, 17.82% presented osteoarthritis, 3.48% presented diseases of the connective tissue and 3.87% presented other joint impairments. (Fig. 2) In group A, the average age for hospitalization is 11.93 years, ranging from 2 to 16 years. There is a difference between the average age at the onset of JIA, which is 10.71 years, and the average age at the moment of diagnosis, which is 11.24 years. In 18 cases (27.27%) the JIA diagnosis was established longer after the onset of the disease (an average of 6.22 months), while in 13 cases (19.69%) one joint was immobilized in cast. _____________________________
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Table 1. Forms of JIA in relation to age. Form of Arthritis
< 5 years
5-10 years
10-15 years
15-16 years
Oligoarthritis extensive
-
2(50%)
2(50%)
-
Oligoarthritis persistent
4(10.81%)
7(18.91%)
19(51.35%)
7(18.91%)
RF+ Polyarticular
-
-
2(100%)
-
RF- Polyarticular
1(6.25%)
5(31.25%)
8(50%)
2(12.5%)
Systemic
2(33.33%)
-
4(66.66%)
-
Spondyloarthropathy
-
-
-
1(100%)
Articular involvement in the polyarticular form has its particular characteristics. Thus, all joints are affected with a higher or lower frequency; the highest incidence is at the level of the metacarpal joints (50%), followed by the proximal interphalangeal joints and knees in 44.44% of the cases. (Fig. 3)
Figure 3. Articular involvement in polyarticular JIA.
In the oligoarticular form, knees are affected with the highest frequency (75.6%), followed at great distance by the ankles (26.82%), the coxofemoral joints (17.07%) and the wrists (7.31%). Scapulohumeral and vertebral column involvement is also present, in 4.87% and respectively 2.43% of the cases. The great majority of the children in group A (78.78%) presented morning stiffness, as opposed to 1.03% in group B (3.08 < RR= 4.07 < 5.37; p < 0.001). Thus, morning stiffness was unanimously present in all forms of JIA, except for the persistent oligoarticular form (78.37%). Systemic manifestations are those that confer particular characteristics to certain JIA forms. Thus fever, rash, and lymph node enlargement were present in 100% of the cases with systemic JIA. Muscular weakness, asthenia and muscular impairment (atrophy, myalgias) were present in 100% of the cases with the RF-positive polyarticular form and in 84.33% of the cases affected by the systemic form. Hepatomegaly and splenomegaly were present in 66.66% of the cases with systemic JIA, in 25% of
the cases with the RF-positive polyarticular form and in 9.75% of the cases with the oligoarticular form. Physical debility represented by joint deformations or muscular atrophy was recorded in 7 cases (10.6%) after 2 years of evolution of the JIA. (Table 2) In group A, anemia was present in 38 cases (54.4%); the highest incidence was recorded in the systemic form (83.33%). ESR was elevated in 57 cases (86.36%), especially in the polyarticular and systemic forms, while the C-reactive protein was elevated in 39 cases (59.09%). Leukocytes count wa on average 13900/mm3 and was associated with various degrees of neutrophilia and left shift of the leukocyte formula. The IgM concentration was significantly higher in the oligoarticular form, while the IgG concentration had elevated values in the systemic and polyarticular forms. The concentration of circulating immune complexes (CIC) was higher in the systemic form as compared to the oligoarticular and polyarticular forms. Hypocalcaemia has a high incidence especially in the systemic and polyarticular forms, being present in 14 patients (21.21%). The rheumatoid factor (RF) was positive in 8 cases (12.12%), while antinuclear antibodies (ANAs) were present in 4 patients (6.06%). Radiographic examinations of the bones also revealed the presence of articular involvement in 13 cases (19.69%), with a significantly higher frequency in the systemic and polyarticular forms. Lung involvement demonstrated by radiographic examinations was present in 16 cases (24.24%).
DISCUSSIONS JIA includes a series of pathological processes that have one common characteristic: inflammatory arthritis of unknown origin that persists for a minimum of 6 weeks.5,6 The results of our study with regard to the various types of JIA are similar to the results of other studies. Thus, the systemic form was certified in 9.09% of the cases, the polyarticular form _____________________________ Dalia Dop et alâ&#x20AC;&#x192;
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Table 2. Extra-articular manifestations in JIA. Systemic
RF+ Polyarticular
RFPolyarticular
Oligoarticular
Spondyloarthropathy
Total
Fever
6 100%
1 50%
10 62.55
22 53.65%
1 100%
40 60.6%
Rash
6 100%
-
2 12.5%
1 2.43%
-
9 13.6%
Adenopathies
6 100%
2 100%
12 75%
27 65.85%
1 100%
48 72.72%
HM/SM
4 66.66%
-
4 25%
4 9.75%
-
12 18.18%
Asthenia
5 83.33%
2 100%
10 62.55%
20 48.78%
-
37 56.06%
Muscular weakness
5 83.33%
2 100%
5
2 4.87%
-
14 21.21%
1 2.43%
-
10 15.15%
31.25% Muscular impairment
5 83.33%
2 100%
2 12,5%
HM/SM = hepatomegaly / splenomegaly
in 27.27% of the cases and the oligoarticular form in 62.12% of the cases. Reviewing the studies in the field, the systemic form is present in 10-20% of the cases, the polyarticular form in 15-30% of the cases, while the oligoarticular form is present in 40-70% of the cases.5,7,8 In group A, in 18 cases (27.27%), mostly with pauciarticular form, the JIA diagnosis was established long after the onset of the disease.9 Also, according to other studies, a significant number of cases (19.69%) were misdiagnosed and incorrectly treated by an orthopedic surgeon.10 The onset of JIA is possible at any age, but there are certain characteristics related to the type of arthritis: the systemic form has two incidence peaks, one at the age of 2 to 3 years and one between the ages of 11 and 12 years; the oligoarticular form is frequent at the age of 1 to 4 years; the seronegative polyarticular form is frequent in preadolescence, while the seropositive form is frequent after the age of 8.5,6 JIA affects mostly females. This, however, is not consistent with the results of our study, which shows more cases of male patients: M/F=34/32. Besides the genetic predisposition that has an important role in JIA pathogenesis, there are discussions in the specialized literature about a series of environmental factors that trigger the disease.11,12 The results of our study show that the most frequent triggering factor was trauma in 12.12% of the cases, _____________________________
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followed by respiratory infections in 4.54% of the cases and physical effort in 1.51% of the cases, while in other cases the triggering factor remained unidentified. The study also demonstrates that infections of the upper airways in the first years of life play a role of predisposing factor in the onset of JIA; this is consistent with other research studies.12,13 There is a lot of controversy regarding the role played by breast feeding in the development of JIA. Most researchers are in favor of the protective role of motherâ&#x20AC;&#x2122;s milk, as we also have shown in our study. 12,14-16 Analyzing joint involvement, we found that all joints are affected, with a higher frequency in the case of large joints, especially knees and ankles. We also have to emphasize the impairment of the spine in 13.77% of the patients with JIA. The frequency of joint involvement depends on the type of arthritis. Thus, in the oligoarticular forms large joints are predominantly affected (knees, ankles), while in the polyarticular forms there is a predominance of small joints involvement (metacarpophalangeal, proximal interphalangeal). Simultaneously with joint involvement, extraarticular manifestations play an important role in JIA, characterizing certain forms of the disease. The systemic form always associates these manifestations, while the polyarticular form does that less frequently. Thus, according to data in the literature, pseudoseptic fever, evanescent rash, adenopathies, hepatomegaly and
splenomegaly consolidate the clinical diagnosis in the systemic form. 5 In the polyarticular forms we notice, besides the polyarthritis, the presence of adenopathies, asthenia, muscular weakness, fever and sometimes rash, hepatomegaly and splenomegaly. Extra-articular manifestations can also be present in the oligoarticular form, but the frequency and degree of manifestation are reduced. Laboratory anomalies reflect the degree of systemic or articular inflammation: anemia characteristic for inflammatory diseases, leukocytosis, elevated acute phase-reactants (ESR, CRP), and elevated seric immunoglobulins.5 JIA can cause an important physical handicap that is present in our study in 10.65% of the cases. Irreversible joint lesions are not characteristic only for long-term evolution of JIA; they can develop within the first months or years from the onset of the disease.17,18 In our study, 19.69% of the children affected by JIA showed articular lesions within the first months from the onset of the disease.
CONCLUSIONS 1. The most common form of JIA is the persistent oligoarticular form. 2. Analyzing joint involvement, we found that all joints are affected, with a higher frequency in the case of large joints, especially knees and ankles. 3. The articular syndrome is associated with various general manifestations present in all forms of JIA, with a higher frequency in the systemic forms. 4. Laboratory analyses reflect the presence of anemia and of the inflammatory articular syndrome.
REFERENCES 1. Ravelli A, Martini A. Juvenile 2007;369(9563):767-78.
idiopathic
arthritis.
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2. Martini A, Lovell D. Juvenile idiopathic arthritis: state of the art and future perspectives. Annals of the Rheumatic Diseases 2010;69(7):1260-3. 3. Finckh A, Liang M,et al. Long-term impact of early treatment on radiographic progression in rheumatoid arthritis: a aeta-analysis. Arthritis and Rheumatism 2006;55(6):864-72. 4. Magni-Manzoni S, Rossi F, Pistorio A, et al.Prognostic factors for radiographic progression, radiographic damage, and disability in juvenile idiopathic arthritis. Arthritis and Rheumatism 2003,48(12):3509-17. 5. Iagaru N. Artrita Idiopatică Juvenila.In Reumatologie Pediatrica. Ed. Amaltea, 2003:121-65. 6. Poduval M, Bhaskar A. Juvenile Rheumatoid Arthritis. www.emedicine. medscape.com 2009 April 20. 7. Minden K, Niewerth M, Listing L, et al Long-term outcome in patients with juvenile idiopathic arthritis. Arthritis and Rheumatism 2002, 46(9):2392-401. 8. Harris EDJr, Budd RC, Firestein GS, et al Kelley’s Textbook of Rheumatology, 2nd volume, Elsevier Saunders 2005, pages 1579-95. 9. Adib N, Hyrich K, Thorton J, et al Association between duration of symptoms and severity of disease at first presentation to Pediatric Rheumatology: results from the Childhood Arthritis Prospective Study. Rheumatology 2008; 47(7):991-5. 10. Cuesta IA, Kerr K, Simpson P, Jarvis JN. Subspecialty referrals for pauciarticular juvenile rheumatoid arthritis. Arch Pediatr Adolesc Med 2000;154(2):122-5. 11. Zeft A, Shear ES, et al. Familial autoimmunity: maternal parent-oforigin effect in juvenile idiopathic arthritis. Clinical Rheumatology 2008;27(2):241-4. 12. Ellis JA, Munro JA, Ponsonby AL. Possible environmental determinants of juvenile idiopathic arthritis. Arthritis and Rheumatism 2008;59(9):1314-21. 13. Carlens C, Jacobsson LT, Brandt L, et al. Perinatal characteristics, early life infections, and later risk of rheumatoid arthritis and juvenile idiopathic arthritis. Ann Rheum Dis 2009;68:1159-64. 14. Mason T, Rabinovich CE, Fredrickson DD, et al. Breast feeding and the development of juvenile rheumatoid arthritis. J Rheumatol 1995;22:1166–70. 15. Rosenberg AM. Evaluation of associations between breast feeding and subsequent development of juvenile rheumatoid arthritis. J Rheumatol 1996;23:1080–2. 16. Kasapcopur O, Tasdan Y, Apelyan M, et al. Does breast feeding prevent the development of juvenile rheumatoid arthritis? J Rheumatol 1998;25:2286-7. 17. Kimme H, Sham LD, Foster HE, et al. Disease activity and disability in children with juvenile idiopathic arthritis one year following presentation to Pediatric Rheumatology. Results from the Childhood Arthritis Prospective Study. Rheumatology 2010;49(1):116-22. 18. Bowyer SL, Roettcher PA, Higgins GC, et al. Health status of patients with juvenile rheumatoid arthritis at 1 and 5 years after diagnosis. J Rheumatol 2003;30(2):394-400.
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ORIGINAL ARTICLES
CORRELATIONS BETWEEN CLINICAL FORMS AND BIOMARKERS IN JUVENILE IDIOPATHIC ARTHRITIS Andrea Somogyi Militaru, Ioan Sabau REZUMAT Introducere: Artrita juvenilă idiopatică este cea mai importantă boală reumatologică a copilăriei. Obiective: Studiul corelaţiilor dintre semnele clinice şi markerii inflamatori în AJI. Material și metode: 58 de copii diagnosticaţi şi clasificaţi conform criteriilor ILAR, au fost evaluaţi clinic şi biologic. Rezultate: Distribuţia pacienţilor a fost următoarea: 17 poliartrite, 18 oligoartrite, 1 AJI sistemică, 22 spondiloartropatii (SpA). În lotul studiat, am observat o corelaţie bună între valorile VSH, CRP şi scorurile funcţionale. Anticorpii anti-CCP (ACPA) au fost pozitivi în doar 6 cazuri, dar în titru scăzut, toate cazurile asociind sindrom inflamator important la debutul bolii, dar nu am găsit corelaţie cu indicii funcţionali. Nivelul plasmatic al interleukinelor pro-inflamtorii IL-1alfa, IL-beta, IL-6 a fost determinat în 8 cazuri. Ambele fracţiuni de IL-1 au avut nivele crescute în 3 cazuri de SpA (cu nivele normale de IL-6). Creşterea concentraţiei plasmatice a IL-6 a fost înregistrată în 3 poliartrite (valori normale ale IL-1). Concluzii: În lotul studiat nu am găsit corelaţie între ACPA şi forma clinică de AJI. IL ar putea fi corelate cu forma clinică de AJI (Il-1 cu spondilopatii, IL-6 cu poliartrite). Studii ulterioare trebuie să confirme observaţiile acestui studiu. Cuvinte cheie: artrită juvenilă idiopatică, anticorpi anti-CCP, interleukine proinflamatorii
ABSTRACT Introduction: Juvenile idiopathic arthritis (JIA) is the most important rheumatic disease of childhood. Aim: To study the correlations between clinical signs and inflammatory biomarkers in JIA. Material and methods: In 58 children, diagnosed and classified according to ILAR (International League of Associations for Rheumatology), evaluation consisted in clinical and laboratory examination (ESR, CRP, RF-rheumatoid factor, anticyclic citrullinated peptide antibody- ACPA, interleukins - ILs). Results: The distribution of patients was: 1 systemic JIA, 17 polyarthritis, 18 oligoarthritis, 22 spondyloarthropathies. There was a good correlation between the ESR, CRP values and the functional scores. ACPA was found positive in 6 cases, but borderline levels, all associating important inflammation at the onset, but no correlations with functional indexes. Plasma levels of IL-1alpha, IL-1betha, IL-6 pro-inflammatory interleukins was determined in 8 cases. Both fractions of IL-1 were increased in two cases of reactive arthritis and one juvenile spondylitis (with normal IL-6 levels). Enhancement of IL-6 (and normal IL-1 values) was observed in 3 children with polyarthritis. Conclusions: In the studied group, we found no correlations between clinical form of JIA and ACPA titre. Interleukins could be correlated with clinical form of JIA (IL-1 with spondyloarthropaty, IL-6 with polyarthritis). Further studies need to sustain these observations. Key Words: juvenile idiopathic arthritis, ACPA, pro-inflammatory interleukins
INTRODUCTION Juvenile idiopathic arthritis (JIA), previously called juvenile chronic arthritis or juvenile rheumatoid arthritis, is the most common chronic autoimmune disease of childhood. It is defined as an inflammatory arthritis of unknown origin in at least one joint persisting for more than 6 weeks in children younger than 16 years of age, and it affects 1 in 1000 children worldwide. This autoimmune disorder is a major cause of chronic disability in children. First Pediatrics Clinic, Victor Babes University of Medicine and Pharmacy, Timisoara Correspondence to: Andrea Somogyi Militaru, First Pediatrics Clinic, Louis Turcanu Clinical Emergency Hospital, 2 Iosif Nemoianu Str., 300011 Timisoara, Romania, Tel. +40-730-618838. Email: andreamilitaru@yahoo.com Received for publication: Oct. 11, 2011. Revised: Nov. 14, 2011. _____________________________
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Juvenile idiopathic arthritis consists of a heterogeneous group of disorders with unknown etiology, and a lack of reliable biomarkers complicates diagnosis. The disease course is unpredictable, with no single marker able to monitor disease. Biomarkers with the potential to differentiate those patients with aggressive JIA early in their disease have recently included anticyclic citrullinated peptide antibodies (ACPA). Although ACPA have been studied extensively in rheumatoid arthritis (RA), their significance in JIA has been evaluated only recently. Anti-CCP antibodies have a specificity of 98% and a sensitivity of 48% for RA, providing a useful diagnostic tool in RA.1 They seem to play an important role in the pathogenesis of RA inflammation, because RA patients with ACPA have a more aggressive disease course with joint erosion and damage.2,3 Citrullinated proteins may be targets of the local immune response in patients with RA and perpetuate a persistent state of synovitis leading to joint destruction. The role of ACPA in JIA remain controversial. Several
studies have generated varying results regarding their significance in the disease process. There was studies in which no statistically significant correlation between ACPA positivity and ESR or radiographic damage was detected.4 Other study suggested that anti-CCP antibodies in JIA were not as prevalent as in adult RA, but could be useful in predicting joint damage.5,6 Although onset and disease course may differ, the subtypes of JIA share the occurrence of chronic inflammation of the joints. Monocytes, macrophages, fibroblasts and T cells within the inflamed microenvironment secrete many mediators that interact directly with the surrounding tissue and tend to have a pro-inflammatory character.7-9 The produced interleukins (IL) regulate the production of inflammatory mediators from the surrounding tissue, whereas secreted chemotactic cytokines (chemokines) function as regulatory molecules that attract and direct the differentiation of new potent inflammatory cells to the site of inflammation.4,9,10 Evidence of an imbalance of pro-inflammatory cytokines in patients with inflammatory diseases includes the positive correlation of serum and synovial cytokine concentrations with JIA disease activity, an increase in antagonists or soluble receptors with a flare of arthritis and the effectiveness of JIA therapies that involve cytokine modulation.9,11 The pro-inflammatory cytokines that have been reported to play a major role in JIA include interleukin 1-beta (IL-1β), tumor necrosis factor alpha and interleukin 6.12,13 (Fig. 1)
IL‐1ra
Adhesion chemokines
IL‐1
IL‐6 TIMPs
IL‐10
TNFα
MMPs sTNFRs
Figure 1. Positive and negative cytokine feedback. IL- interleukin; – matrix metaloproteinase; sTNFR – soluble tumor necrosis factor receptor; TIMPs – tissue inhibitor of matrix metalloproteinase; TNF-alpha – tumor necrosis factor-alpha. Figure 1 MMP
Circulating cytokines correspond to the activation status of immune-competent cells, and could be instrumental to monitor changes in this profile during treatment. Evaluating cytokines in plasma might help in identifying surrogate parameters for disease activity, disease severity, risk of side effects and treatment outcome.11,12
OBJECTIVES The main goals of this study are to analyze certain biomarkers in a pediatric cohort with chronic arthritis, to investigate the interrelation between the inflammatory and immunologic biomarkers, and their correlations with the clinical form and the functional indexes of JIA.
MATERIAL AND METHODS This study was initially retrospective, and then became prospective. We enrolled 58 children with chronic arthritis, assessed in the First Pediatric Clinic from “Louis Turcanu” Emergency Hospital for Children, Timisoara during the period of May 2005 – May 2011. All the patients were diagnosed and classified according to ILAR (International League of Associations for Rheumatology) criteria. The study had full ethical approval of the Department. Informed consent was obtained either from parents or from the individuals directly if they were older than 12 years. Evaluation of the patients consisted in medical history data collection, complete clinical assessment, functional evaluation and lab tests. Demographic and clinical characteristics of the patients included: age at the onset of JIA, sex, body weight, duration of JIA prior diagnosis. Clinical parameters involved: number of swollen joints, of tender joints and of joints with limitation on passive motion. Presence of non-osteoarticular symptoms and signs (ophthalmological, gastrointestinal, dermatological, cardiovascular etc.) was assessed. Functional assessment included: physician’s and parent’s global assessment of disease activity (with a 100-mm visual analogue scale -VAS, in which higher scores indicated more active disease); Disability Index score in Childhood Health Assessment Questionnaire –CHAQ, in which scores range from 0 (best) to 3 (worst) and parent’s or patient’s assessment of pain (through a 100-mm visual analogue scale in which higher scores indicated more severe pain). All patients were assessed through laboratory exams, consisting in evaluation of: 1) inflammatory syndrome (blood cells count, ESR, CRP, plasma alpha2- and gamma-globulin levels, IgG levels); and 2) immunologic assessment (RF, and, just in a part of the cohort, was evaluated presence of anti-CCP antibody, plasma levels of certain pro-inflammatory interleukins: IL-1alpha, IL-1beta, IL-6). Routine assay, consisting in latex agglutination, _____________________________ Andrea Somogyi Militaru et al
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measured 19S IgM RFs, but enzyme-linked immunosorbent assays (ELISAs) have been provided significantly more positive results than the routine ones. This is the reason why in our study we performed the measurement of IgM RF by ELISA. IL-1alpha, IL-1beta and IL-6 plasma levels were determined by ELISA also. Imagistic evaluation was performed in every long lasting form of JIA and included x-ray and, in some cases, magnetic resonance investigation. Genetic assessment included HLA-B27 gene testing in the spondyloarthropathy group. Active disease was defined by the presence of joint swelling or limitation of movement with either pain on movement or tenderness. Non-active disease (remission) was defined by the absence of joint swelling or limitation of movement with no pain on movement or tenderness. Analysis of the results was performed with SPSS16 statistics program. The correlations were estimated using linear regression models.
Female patients were predominant both in oligoarticular and polyarticular JIA, but in the spondyloarthropathy group were more boys than girls. In our studied group, the highest medium age was found in spondyloarthropathy (12.4 years). The ESR and CRP values presented an excellent correlation (p<0.005) with the disability index score, obtaining a R Sq Linear of 0.853 in ESR and CHAQ correlation, respectively 0.741 in CRP and CHAQ interrelation. (Fig. 2) VAS score had an even better statistic correlation both with ESR (R Sq Linear = 0.893) and CRP (R Sq Linear= 0.805) with p<0.005. (Fig. 3)
RESULTS Characteristics of the cohort Clinical data permitted the division of the cohort into four major subgroups: (persistent) oligoarthritis, polyarthritis (including three extended oligoarticular JIA), systemic JIA and spondyloarthropaty (or enthesitisrelated arthritis- ERA). Distribution of the patients is summarized in table I. Spondyloarthropathy group included: 4 cases of arthropathies associated with Crohn disease, 4 juvenile ankylosing spondylitis, 5 reactive arthritis and 9 patients with undifferentiated arthritis. Table 1 summarizes the characteristics and descriptive statistics of our cohort.
Figure Figure 2
2. Correlation between CRP and CHAQ.
Table Characteristics ofand thesubgroups. cohort and subgroups Table 1.1. Characteristics of the cohort Figure 3. Correlation between CRP and VAS. Figure 3 Characteristics
Cohort
Oligo JIA
Poly JIA
Systemic JIA
SpA
Patients number
58
18
17
1
22
Gender ratio F:M
32:26
12:6
10:7
1:0
10:12
Mean Age (years)
8.9
6.8
8.6
5.8
12.4
Mean ESR (mm/1h)
54.64±30.6
33.4±18.6
68.3±21
110
28.6±24.3
Mean CRP (mg/dl)
18.1±14.74
12.8±8.7
24.8±12.6
48
18.3±10.5
Mean VAS score
5.61±1.85
4.43±1.56
6.8±2.2
7
5.3±2.7
Mean CHAQ score
10.73±5.23
6.56±2.87
14.86±4.6
16
8.2±4.64
IgM RF positive (no)
4
0
4
0
0
Anti-CCP ab (no)
6
1
3
0
2
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IgM RF detection IgM RF has been evaluated in all 58 cases. In 4 patients, meaning 6.9% of the entire cohort, elevated IgM RF levels are determined by ELISA. All these cases belonged to polyarticular JIA and had important inflammation with severe functional disability at the onset of the disease. Two of them reached clinical remission on treatment, with excellent improvement of CHAQ, VAS scores, and the decreasing of ESR, CRP values, but without any change in IgM RF titre. This explains the absence of correlation between IgM RF titre and CHAQ, respectively VAS indexes (p > 0.1 in both). All three patients had radiographic evidence of joint damage at the onset of the disease, including joint space narrowing and joint erosion. Anti-CCP antibody detection Thirty-three cases were checked for anti-CCP antibodies. Positive, but very low levels were found, in just 6 children, with the following distribution: 3 polyarticular JIA (1 RF-positive and 2 RF-negative polyarthritis), 1 oligoarticular JIA, 1 case with ankylosing spondylitis and 1 patient with Crohn disease associating arthritis. We found no correlation of ACPA positivity and the clinical form of JIA. We found no correlation between ACPA titre and functional indexes (CHAQ, VAS) and inflammatory biomarkers (p>0.05). 100% of anti-CCP positive cases had important inflammatory syndrome (more than five times normal levels of CRP, ESR) at the onset of JIA. The cases that reached clinical and biological remission on treatment (with the improvement of CHAQ, VAS, ESR, CRP) presented no decreasing in ACPA titer. Furthermore, the only one patient who had significantly high levels of anti-CCP (200UI/ml) was at the time of determination in clinical remission. All other children had ACPA titreâ&#x2030;¤0.8UI/ml, regardless of clinical, functional or inflammatory parameters. In five cases from the six patients with borderline positive ACPA, radiographic evidence of joint damage was found on disease onset. The exception was the patient with arthropathy associated to Crohn disease, with an aggressive evolution of the intestinal inflammation, but no joint damage. Interleukin plasma level evaluation Plasma levels of IL-1alpha, IL-1betha, IL-6 proinflammatory interleukins was determined by ELISA in 8 cases. We studied the correlation of interleukin levels to inflammatory syndrome, immunologic biomarkers and functional indexes. We found no statistically significant correlations between IL plasma levels and ESR, CRP levels, IgM RF, ACPA titer, VAS and CHAQ scores (p>0.05; R Sq Linear < 0.1). This lack of correlation between pro-inflammatory
interleukins and functional indexes could be explained by the different disease activity status of the patients. (Fig. 4)
active polyJIA
polyJIA in remission
high IL-1 high IL-6 normal IL
active SpA
SpA in remission
Figure 4. Interrelation between disease activity and ILs. Figure 4
We observed a possible interrelation between IL type elevation and clinical form of JIA. Both fractions of IL-1, with normal IL-6 levels, were increased in spondyloarthropathies: two cases with reactive arthritis and one juvenile ankylosing spondylitis. Enhancement of IL-6 (and normal IL-1 values) was observed in 3 children with polyarthritis: 2 with clinical active disease, one in clinical remission on treatment, but high ACPA level and positive RF.
DISCUSSIONS In diagnostic of rheumatoid arthritis, ACPA is an important biomarker, with higher specificity than RF and may better predict erosive disease.4,14 Because of this diagnostic and prognostic value of ACPA, recently, RA is reported to be sub-classified into two subsets by ACPA positivity, sub-division which could be useful in JIA as well.14-18 Though, in JIA significance of ACPA remains to be determined. The low prevalence of ACPA in our cohort of JIA is in concordance with the result of other studies.7,10,18,19 This point could support the supposition of the similarity between JIA and the ACPA negative RA, assumption with therapeutic and predictive implications in the management of JIA. Numerous studies have shown that IgM RFpositive polyarthritis patients have a higher prevalence of anti-CCP antibodies, observation which was not _____________________________ Andrea Somogyi Militaru et alâ&#x20AC;&#x192;
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confirmed in our cohort. Limitation of the present study consists in the relative low number of cases.5,6,10 Another issue linked to the low prevalence of ACPA in JIA is the necessity of expanding the diagnostic tools in JIA with other biomarkers from the ACPAs family (anti-mutated-citrullinated-vimentin, anti-Sa antibody), similar to the tendency from rheumatoid arthritis.20,21 The pathogenic pathways of different subtypes of JIA are still up to debate. The correlation between IL and the form of JIA in our cohort is in concordance with the results of some studies, but in discordance with the outcome of others.22-26 Once again, the low number of assessed cases represents an important limitation of our study. The elevated level of pro-inflammatory interleukins in clinical remission JIA cases could support the concept of a sub-clinical, immunological disease activity.27-31 This observation could have a practical importance in answering the question: “When to stop biotherapy in clinical remission JIA”. Normal values of plasma interleukins could be markers for the treatment cut-off, in contrary high levels of IL could suggest the continuation of the anti-TNF therapy. Though, high levels of pro-inflammatory interleukins could be the result of other inflammatory condition out of articular area.
CONCLUSIONS ESR and CRP are important biomarkers in assessment of disease activity and response to treatment, with good correlation with functional indexes. IgM RF and anti-CCP antibody are not reliable markers in appreciation of disease activity or treatment response. However, the measurement of the mentioned biomarkers early in the course of JIA may be beneficial to distinguish aggressive disease and possibly initiate more aggressive treatment earlier in those patients. Interleukins could be correlated with clinical form of JIA (IL-1 with spondyloarthropaty, IL-6 with polyarthritis). The interleukins could be more sensitive markers of the disease activity than the routine inflammatory markers or the functional indexes.
ACKNOWLEDGEMENT During the research described in this paper, the first author Andrea Somogyi Militaru benefitted by a grant from the PhD programme POSDRU/88/1.5/S/63117. _____________________________
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REFERENCES 1. Avcin T, Cimaz R, Falcini F, et al. Prevalence and clinical significance of cyclic-citrullinated peptide antibodies in juvenile idiopathic arthritis. Ann Rheum Dis 2002;61:608-611. 2. Hromadnikova I, Stechova K, Pavla V, et al. Anti-cyclic citrullinated peptide antibodies in patients with juvenile idiopathic arthritis. Autoimmunity 2002, 35:397-401. 3. Kasapcour O, Altun S, Aslan M, et al.: Diagnostic accuracy of anti-cyclic citrullinated peptide antibodies in juvenile idiopathic arthritis. Ann Rheum Dis 2004;63:1687-1689. 4. Berglin E, Johansson T, Sundin U, et al. Radiological outcome in rheumatoid arthritis is predicted by presence of antibodies against cyclic citrullinated peptide before and at disease onset, and by IgA-RF at disease onset.Ann Rhem Dis. 2006 Apr;65(4):453-8. 5. van Jaarsveld CH, ter Borg EJ, Jacobs JW, et al. The prognostic value of the perinuclear factor, anti-cyclic citrullinated peptide antibodies and rheumatoid factor in early rheumatoid arthritis. Clin Exp Rheumatol 2000;17:689-697. 6. van Rossum M, van Soesbergen R, de Kort S, et al. Anti-cyclic citrullinated peptide (anti-CCP) antibodies in children with juvenile idiopathic arthritis. J Rheumatol 2003, 30:825-828. 7. Gilliam BE, Chauchan AK, Low JM, et al. Measurement of biomarkers in juvenile idiopathic arthritis patients and their significant association with disease severity: a compared study. Clin Exp Rheumatol 2008; 11:158-162. 8. Gilliam BE, Low JM, Chauhan AK, et al. Biomarkers associated with joint damage in juvenile idiopathic arthritis. Arthritis Rheum 2006;54:S697. 9. Rooney M, Varsani H, Martin K, et al. Tumour necrosis factor alpha and its soluble receptors in juvenile chronic arthritis. Rheumatology 2000;39:432-8. 10. Syed R, Gilliam B, Moore TL. Rheumatoid factors and anticyclic citrullinated peptide antibodies in paediatric rheumatology. Curr Rheumatol 2008; 10:156-163. 11. Yilmaz M, Kendirli SG, Altintas D, et al. Cytokine levels in serum of patients with juvenile rheumatoid arthritis. Clin Rheumatol 2001;20:30-5. 12. Wilkinson N, Jackson G, Gardner-Medwin J. Biologic therapies for juvenile arthritis. Arch Dis Child 2003;88:186-91. 13. Ferreira RA, Silva CH, Silva DA, et al. Is measurement of IgM and IgA rheumatoid factors in juvenile rheumatoid arthritis clinically useful? Rheumatol Int 2007, 27:345-349. 14. Farragher TM, Lunt M, Plant D, et al. Benefit of early treatment in inflammatory polyarthritis patients with anti-cyclic citrullinated peptide antibodies versus those without antibodies. Arthritis Care Res (Hoboken). 2010 May;62(5):664-75. 15. Ohmura K, Is rheumatoid arthritis without anti-citrullinated peptide antibody a genetically distinct subset? Japanese Journal of Clinical Immunology 2009;32(6):484-91. 16. Kurreman F, Liao K, Chibnik L, et al. Genetic basis of autoantibody positive and negative rheumatoid arthritis risk in a multi-ethnic cohort derived from electronic health records. Am J Hum Genet. 2011 Jan 7;88(1):57-69. 17. Van der Woude D, Houwing-Duistermaat JJ, Toes RE, et al. Ouantitative heritability of anti-citrullinated protein antibody-positive and anticitrullinated protein antibody-negative rheumatoid arthritis. Arthritis Rheum. 2009;60(4):916-23. 18. Dewint P, Hoffman IE, Rogge S, et al. Effect of age on prevalence of anticitrullinated protein/peptide antibodies in polyarticular juvenile idiopathic arthritis. Rheumatology (Oxford) 2006;45(2):204-8. 19. Nishimura K, Kogata Y, Tsuji G, et al. Meta-analysis: diagnostic accuracy of anti-cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis.Ann Intern Med 2007;146(11):797-808. 20. Szekanecz Z, Soos L, Szabo Z, et al. Anti-citrullinated protein antibodies in rheumatoid arthritis: as good as it gets? Clin Rev Allergy Immunol. 2008 Feb;34(1):26-31. 21. Szodoray P, Szabo Z, Kapitany A, et al. Anti-citrullinated protein/
peptide autoantibodies in association with genetic and environmental factors as indicators of disease outcome in rheumatoid arthritis. Autoimmun Rev 2010; 9(3):140-3. 22. Macaubas C, Nguyen K, Milojevic D, et al. Oligoarticular and polyarticular JIA: epidemiology and pathogenesis. Nat Rev Rheumatol 2009 Nov;5(11):616-26. 23. Barnes MG, Grom AA, Thompson SD, et al. Biologic similarities based on age at onset in oligoarticular and polyarticular subtypes of juvenile idiopathic arthritis. Arthritis Rheum.2010; 62, 3249–3258. 24. Lin YT, Wang CT, Gershwin ME, et al. The pathogenesis of oligoarticular/polyarticular vs systemic juvenile idiopathic arthritis. Autoimmun Rev 2011 Jun;10(8):482-9. 25. Saxena N, Aggarwal A, Misra R. Elevated concentrations of monocyte derived cytokines in synovial fluid of children with enthesitis related arthritis and polyarticular types of juvenile idiopathic arthritis.J Rheumatol 2005 Jul;32(7):1349-53. 26. Aggarwal A, Srivastava R, Singh S, et al. IL1 gene polymorphisms in enthesitis related arthritis category of juvenile idiopathic arthritis (ERA-JIA). Clin Rheumatol. 2011 Nov
27. Ringold S, Seidel KD, Koepsell TD, et al. Inactive disease in polyarticular juvenile idiopathic arthritis: current patterns and associations. Rheumatology (Oxford) 2009;48, 972–977. 28. Ruperto N, Lovell DJ, Quartier P, et al. Paediatric Rheumatology International Trials Organization and Pediatric Rheumatology Collaborative Study Group. Abatacept in children with juvenile idiopathic arthritis: a randomised, double-blind, placebo-controlled withdrawal trial. Lancet 2008;372, 383–391. 29. Susic GZ, Stojanovic RM, Pejnovic NN, et al. Analysis of disease activity, functional disability and articular damage in patients with juvenile idiopathic arthritis: a prospective outcome study. Clin. Exp. Rheumatol. 2011;29, 337–344. 30. Wallace CA, Ruperto N, Giannini E. Childhood Arthritis and Rheumatology Research Alliance, Pediatric Rheumatology International Trials Organization. Preliminary criteria for clinical remission for select categories of juvenile idiopathic arthritis. J. Rheumatol. 2004;31, 2290–2294. 31. Martini A, Lovell DJ. Juvenile idiopathic arthritis: state of the art and future perspectives. Ann Rheum Dis 2010 Jul;69(7):1260-3.
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ORIGINAL ARTICLES
A COMPARISON OF THE EVALUATION SCALES FOR DISEASE ACTIVITY USED IN ANKYLOSING SPONDYLITIS: WHICH ONE IS MORE RELIABLE? Razvan G. Dragoi1, Claudiu Avram2, Radu Petroman1, Oana Suciu1, Elena Amaricai1, Dan A. Nemes1, Mihai Dragoi1 REZUMAT Obiective: Ne-am propus compararea şi evaluarea capacităţii discriminative şi corelarea Indexului Functional Bath pentru Spondilita Anchilozanta (BASFI), cu alţi indici de evaluare a activităţii bolii utilizaţi în spondilita anchilozantă (AS), împreună cu alte variabile corespunzătoare pacienţilor (vârstă, sex, etc), în scopul de a identifica factorii relevanți pentru pacienţi şi medici. Material si metode: Pe durata unei perioade de trei luni, am studiat 31 de pacienţi, toţi diagnosticaţi cu AS în diferite stadii evolutive, în conformitate cu criteriile Grupul European de Studiu al Spondilartropatiilor şi cu criteriile New York pentru AS, modificate. Datele au fost analizate statistic prin metoda corelaţiei. Rezultate: Iniţial am constatat o corelaţie semnificativă între starea funcţională a pacienţilor evaluaţi prin scorul BASFI şi ASDAS ESR (r2=0,19, p=0,016), dar nu si cu ASDAS CRP, scorurile BASDAI sau markerii inflamtori. Dupa trei luni de tratament cu medicamente anti-TNF-alfa, am observat o corelaţie semnificativă între scorurile BASFI şi ASDAS ESR (r2=0,20, p=0,014), ASDAS CRP (r2=0,21, p=0,01), BASDAI (r2=0,16, p=0,026), ESR și CRP (r2=0,17, p=0,023). Concluzii: Am ajuns la concluzia că este fezabil şi relevant ca evaluarea activitatii bolii sa se faca utilizând scala ASDAS ESR in cazul tratamentului clasic, în timp ce pentru pacienţii aflaţi sub medicație anti-TNF-alfa toate scalele evaluate şi markerii biologici sunt corelate cu starea funcţională. Avantajul de a folosi scala ASDAS ESR în practica clinică derivă din uşurinţa în aplicare şi în evaluarea progreselor pacienţilor după iniţierea tratamentului biologic. Cuvinte cheie: spondilită anchilozantă, scale de evaluare, activitatea bolii, dizabilitate
ABSTRACT Objective: We aimed at comparing and assessing the discriminative ability and correlation of the Bath Ankylosing Spondylitis (AS) Functional Index (BASFI) with several disease activity indexes used in ankylosing spondylitis (AS), together with other variables related to the patients (age, gender, etc.), in order to identify the relevant ones for patients and doctors. Material and methods: During a three-month period, we studied 31 patients, all diagnosed with AS at different stages with respect to the European Spondylarthropathy Study Group criteria and the Modified New York criteria for AS. The data were analyzed by statistical correlation. Results: At the baseline we found significant correlation between the functional status of the patients evaluated by the BASFI score and ASDAS ESR (r2=0.19, p=0.016), but not vith ASDAS CRP, BASDAI scores or inflammatory markers. After three months of treatment with anti-TNF-alpha medication, we noticed a significant correlation between BASFI score and ASDAS ESR (r2=0.20, p=0.014), ASDAS CRP (r2=0.21, p=0.01), BASDAI (r2=0.16, p=0.026), ESR and CRP (r2=0.17, p=0.023). Conclusions: We concluded that in patients following classical treatment there is feasible and relevant to assess the disease activity of patients using the ASDAS ESR scale, while in patient under anti-TNF-alpha medication all the evaluated scales and biological markers are correlated with the functional status. The advantage of using ASDAS ESR scale in clinical practice results from the easiness in application and progress assessment of the patients after initiating the biological therapy. Key Words: ankylosing spondylitis, evaluation scales, disease activity, disability
BACKGROUND Ankylosing spondylitis (AS) is a chronic inflammatory disease of unknown cause associated with human leukocyte antigen (HLA)-B27. It usually affects the sacroiliac joints at early stages and may involve the axial skeleton at later stages of the disease.
Victor Babes University of Medicine and Pharmacy Timisoara, 2 Faculty of Sports and Kinetotherapy, West University, Timisoara 1
Correspondence to: Razvan G. Dragoi, Victor Babes University of Medicine and Pharmacy, 2A E. Murgu Sq., 300041 Timisoara Email: rdragoi@gmail.com Received for publication: Oct. 11, 2011. Revised: Nov. 14, 2011. _____________________________
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Peripheral joint involvement may also be an important feature. The disease can be accompanied by extraskeletal manifestations such as acute anterior uveitis, aortic incompetence, cardiac conduction defects, fibrosis of the upper lobes of the lungs, neurologic involvement, or renal (secondary) amyloidosis. AS causes significant pain, disability, and social burden around the world. Favorable results of treating AS with anti–tumor necrosis factor (TNF) agents have largely redefined the entire therapeutic approach to this disease.1 (Figs.1-3) When assessing patients with AS, it is useful to think of measuring disease activity, physical function and structural damage as separate facets of the AS process.2 Correct assesment is imperative for keeping the disease under control because mortality is increased in patients with AS. Parameters reflecting the duration and intensity of inflammation are associated
with reduced survival. These results indicate that, to improve long-term survival in AS, there is a need for early detection and antiinflammatory treatment.3 For this assesments several evaluation scales have been developed and validated in the past several years.
Figure 1. A 54 years old pacient diagnosed with ankylosing spondylitis, central form Bechterew, stage IV. It is 1. to remark the cervical ghibus, Figure lombar rectitude and protuberant abdomen. The movement of the spine is restricted in all movement plans (personal collection).
in AS (Bath Ankylosing Spondylitis Disease Activity Index -BASDAI, Ankylosing Spondylitis Disease Activity Score – ASDAS ESR and ASDAS CRP) and other variables of patients (age, gender, etc), in order to establish which scale is feasible and relevant for patients and doctors.
Figure 3. Radiographic image of the spine in a pacient diagnosed with ankylosing spondylitis, central Figure form Bechterew, stage IV. It is to remark 3. the square vertebras, the anterior sindesmofitis and the characteristic “bamboo spine” (personal collection).
MATERIAL AND METHODS
Figure 2. Radiographic image of sacroileitis grade 4, of a pacient with 2. ankylosing spondylitis, central Figure form Bechterew, stage IV. The sacroiliac joints are no longer visible (personal collection).
OBJECTIVE The purpose of our study is to compare and assess the discriminative ability and correlation of the Bath Ankylosing Spondylitis Functional Index (BASFI) with several disease activity indexes used
The gold standard for measuring and evaluating disease activity in Ankylosing Spondylitis is the BASDAI, or the Bath Ankylosing Spondylitis Disease Activity Index. The BASDAI is the result of the work of a research team consisting of rheumatologists, physiotherapists, and research associates with a special interest in AS who developed the index in Bath, England. The BASDAI consists of a one through 10 scale (one being no problem and 10 being the worst problem) which is used to answer 6 questions pertaining to the 5 major symptoms of AS: Fatigue, spinal pain, joint pain / swelling, areas of localized tenderness (also called enthesitis, or inflammation of tendons and ligaments), morning stiffness duration, morning stiffness severity. To give each symptom equal weighting, the mean (average) of the two scores relating to morning stiffness is taken. The resulting 0 to 50 score is divided _____________________________ Razvan Dragoi et al
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BASFI:
by 5 to give a final 0 – 10 BASDAI score. Scores of 4 or greater suggest suboptimal control of disease, and patients with scores of 4 or greater are usually good candidates for either a change in their medical therapy or for enrollment in clinical trials evaluating new drug therapies directed at Ankylosing Spondylitis. When evaluated using strict clinical paramaters, the BASDAI wasBath validated. The Ankylosing Spondylitis Disease Activity Index
1. Putting on your socks or tights without help or aids (e.g. sock aids)? 2. Bending forward from the waist to pick up a pen from the floor without a aid? 3. Reaching up to a high shelf without help or aids (e.g. helping hand)? 4. Getting up out of an armless dining room chair without using your hand or any other help?
Please place a mark on each line below to indicate your answer to each question
5. Getting up off the floor without any help from lying on your back?
relating to the past week
6. Standing unsupported for 10 minutes without discomfort?
1. How would you describe the overall level of fatigue/tiredness you have
7. Climbing 12-15 steps without using a handrail or walking aid (one foot on each step)?
experienced? NONE _____________________________________________ VERY SEVERE
8. Looking over your shoulder without turning your body?
2. How would you describe the overall level of neck, back or hip pain you have had?
9. Doing physically demanding activities (e.g. physiotherapy exercises, gardening or sports)?
NONE _____________________________________________ VERY SEVERE 3. How would you describe the overall level of pain/swelling in joints other than neck, back, hips you have had? NONE _____________________________________________ VERY SEVERE 4. How would you describe the overall level of discomfort you have had from any are as tender to touch or pressure? NONE _____________________________________________ VERY SEVERE 5. How would you describe the overall level of morning stiffness you have had from the time you wake up? NONE _____________________________________________ VERY SEVERE 6. How long does your morning stiffness last from the time you wake up? ___________________________________________________________ 1
1½
2 or more hours4
The BASFI scale reffers to disability. After pain and stiffness, one of the most important complaints of patients with ankylosing spondylitis (AS) is disability. The main aims of treatment are to control pain but also to improve function. Various methods of assessing function exist but are either not specific for the disease or have not been adequately validated. As a result of this deficiency was developed the Bath Ankylosing Spondylitis Functional Index (BASFI) as a new approach to defining and monitoring functional ability in patients with AS.5 Each of the questions is assigned a score from 1 to 10 where 1 is easy and 10 is impossible difficulty on a ten point scale. The Ankylosing Spondylitis Disease Activity Score (ASDAS) is a new composite index to assess disease activity in ankylosing spondylitis (AS). It combines five disease activity variables with only partial overlap, resulting in one single score with better truth (validity), enhanced discriminative capacity and improved sensitivity to change as compared to singleitem variables.6,7 The two ASDAS formulas are: ASDAS-CRP (preferred) and ASDAS-ESR (alternative). _____________________________
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Please draw a mark on each line below to indicate your ability with each of the following activities, during the past week:
Table 1. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI).
½
Ankylosing
Date_______________ Patient Name________________________
(BASDAI)
0 hrs
Bath
Table 2. The Bath Index Ankylosing Spondylitis Functional Index (BASFI). Functional
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10. Doing a full day activities whether it be at home or work?
ASDAS-CRP=0.12 x Back Pain + 0.06 x Duration of Morning Stiffness + 0.11 x Patient Global + 0.07 x Peripheral Pain/Swelling + 0.58 x Ln(CRP+1) ASDAS-ESR=0.08 x Back Pain + 0.07 x Duration of Morning Stiffness + 0.11 x Patient Global + 0.09 x Peripheral Pain/Swelling + 0.29 x √(ESR) ASDAS, Ankylosing Spondylitis Disease Activity Score; √(ESR), square root of the erythrocyte sedimentation rate (mm/h); Ln(CRP+1), natural logarithm of the C-reactive protein (mg/L) + 1. Back pain, patient global, duration of morning stiffness and peripheral pain/swelling are all assessed on a visual analogue scale (from 0 to 10cm) or on a numerical rating scale (from 0 to 10). Back pain, BASDAI question 2: “How would you describe the overall level of neck, back or hip pain you have had?”. Duration of morning stiffness, BASDAI question 6: “How long does your morning stiffness last from the time you wake up?”. Patient global: “How active was your spondylitis on average during the last week?” Peripheral pain/swelling, BASDAI question 3: “How would you describe the overall level of pain/ swelling in joints other than neck, back or hips you have had?” The Assessment of SpondyloArthritis international Society (ASAS) membership has selected the ASDAS containing C-reactive protein (CRP, mg/l) as acute phase reactant as the preferred version, and the one with erythrocyte sedimentation rate (ESR, mm/hr) as the alternative version. Apart from the value of CRP or ESR, the four additional self-reported items
Table 1. Linear regression between BASFI score (BASFI_0) and all other inv parameters at baseline.
Table 3. Linear regression between BASFI score (BASFI_0) and all other included in this index are back pain (0-10cm, visual investigated parameters at baseline. analogue scale [VAS] or 0-10, numerical rating scale [NRS]), duration of morning stiffness (VAS/NRS), Liniar Regression r2 P value peripheral pain/swelling (VAS/NRS) and patient global assessment of disease activity (VAS/NRS).6,7 BASFI_1 0.4672 < 0.0001 The next step to consolidate the ASDAS as an ASDAS-ESR_0 0.1988 0.0135 instrument to measure disease activity in AS. The ASDAS-CRP_0 0.02080 0.4471 methodology and the results were debated by ASAS BASDAI_0 0.1172 0.0640 members and four disease activity states were chosen by ESR_0 (mm/h) 0.1056 0.0797 CRP_0 (mg/dL) consensus: “inactive disease”, “moderate disease activity”, 0.000001262 0.9953 ASDAS-ESR_1 0.04443 0.2635 “high disease activity” and “very high disease activity”. ASDAS-CRP_1 0.03776 0.3035 The 3 cut-offs selected to separate these states BASDAI_1 0.008669 0.6246 were: <1.3 between “inactive disease” and “moderate ESR_1 (mm/h) 0.07618 0.1398 disease activity”, <2.1 between “moderate disease CRP_1 (mg/dL) 0.06593 0.1708 activity” and “high disease activity”, and >3.5 between “high disease activity” and “very high disease activity”. BASFI: Bath Ankylosing Spondylitis Functional Index score at baseline (BSAFI_0) and after 3 months o Selected cut-offs for improvement scores (BASFI_1); ASDAS_ESR: The Ankylosing Spondylitis Disease Activity Score_ESR at baseline (ASDAS_ were: a change ≥1.1 units for “clinically important after 3 monts of treatment (ASDAS_ESR_1); ASDAS_CRP: The Ankylosing Spondylitis Disease Activity Sc improvement” and a change ≥2.0 units for (ASDAS_CRP_0) “major baseline and after 3 monts of treatment (ASDAS_CRP_1); BASDAI: Bath Ankylosing 8 improvement”. Disease Activity Index at baseline (BASDAI_0) and after 3 months of treatment (BASDAI_1); ESR an At the Outcome Measures in inflammatory markers at baseline (ESR_0; CRP_0) and after 3 months of treatment (ESR_1; CRP_1). Rheumatology (OMERACT) 10 Conference, in Malaysia, the ASDAS disease activity states and response criteria also obtained the endorsement from OMERACT.9 During 3 months period we took in our study 30 patients from the evidences of the Rehabilitation, Physical Medicine and Rheumatology Clinic in Timisoara, all diagnosed with AS with different Figure 4. Correllation between BASFI score and ASDAS_ESR score at Figure 4. stages (1, 2, 3 and 4), respecting the European baseline. Spondylarthropathy Study Group criteria and the After 3 months of a complex rehabilitation modified New York Criteria for AS. All patients were treatment with anti-TNFα medication, physiotherapy evaluated on all of these validated assessment scales procedures, and a change of life style, we noticed at the beginning of the treatment, and after 3 month. significant correlation between BASFI score and In this 3 months period all of them followed complex ASDAS ESR (r2=0.20, p=0.014), ASDAS CRP therapeutical approach consisting in a individualized (r2=0.21, p=0.01), BASDAI (r2=0.16, p=0.026), ESR rehabilitation programme for A.S. and medication and CRP (r2=0.17, p=0.023). (Table 4, Figs. 5-8) with anti-TNF inhibitors following the Romanian Table 2. Linear regression between BASFI score (BASFI_1) and all other inv protocol for A.S. Tableof 4. Linear regression between BASFI score (BASFI_1) and all other parameters at the end intervention. We analyzed the data using statistical correlations. investigated parameters at the end of intervention. Statistical evaluation was performed using GraphPad Prism v. 5.0 software. Linear regression between Liniar Regression r2 P value BASFI score and all other investigated parameters was BASFI_0 0.4672 < 0.0001 used in order to calculate the regression coefficient ASDAS_ESR_0 0.06865 0.1619 (r2) and p value. A value of p <0.05 was considered ASDAS_CRP_0 0.0005617 0.9011 statistically significant.
RESULTS AND DISCUSSION At baseline we found significant correlations between functional status of the patients evaluated using BASFI score and ASDAS ESR (r2=0.19, P=0.016), but not with ASDAS CRP, BASDAI scores, and inflammatory markers. (Table 3, Fig. 4)
BASDAI_0 ESR_0 (mm/h) CRP_0 (mg/dL) ASDAS_ESR_1 ASDAS_CRP_1 BASDAI_1 ESR_1 (mm/h) CRP_1 (mg/dL)
0.007552 0.09968 0.001030 0.1971 0.2310 0.2264 0.2894 0.2418
0.6480 0.0892 0.8663 0.0140 0.0072 0.0079 0.0022 0.0058
_____________________________
BASFI: Bath Ankylosing Spondylitis Functional Index score at baseline (B Razvan Dragoi et al 213 and after 3 months of treatment (BASFI_1); ASDAS_ESR: The An Spondylitis Disease Activity Score_ESR at baseline (ASDAS_ESR_0) and monts of treatment (ASDAS_ESR_1); ASDAS_CRP: The Ankylosing Sp
Figure 5. Correllation between BASFI score Figure 6. and ASDAS_ESR score after 3 months of complex treatment. Figure 5.
Figure 6. Correllation between BASFI score and ASDAS_CRP score after 3 months of complex treatment.
The results of this study shows good correlations between evaluation scales used, as well as good correlations between evaluation scales and biological markers, as showed in other studies.8-12 Moreover, having better correlations after the initiation of complex therapy, demonstrates the efficiency of biological therapy against all factors that leads to complications, deficiencies and handicaps that can affect one of this patients.12-15 The two ASDAS scales not correlating in the first can be explained by other studies showing that it should be clearly understood that these ASDAS versions with CRP or with ESR are not interchangeable. One version should be used consistently within patients or within a study.7 The limits of this study are so much the small cohort that have been identified, as much as the lack of a regional or national electronically database of this population, as happened in other European countries such as Austria, Germany, Norway, Sweden, Great Britain, etc. Other limits of the study we consider to be that we evaluated a population from the West side of Romania. Studies for the population from different regions of Romania should be conducted having in mind the cultural, traditional and climatologically diversities of our country.
CONCLUSIONS
Figure 7. Correllation between BASFI score and BASDAI score after 3 months of complex treatment. Figure 7.
We conclude that in patients following classical treatment there is feasible and relevant to assess the disease activity of patients using ASDAS ESR scale, while in patient under anti-TNFÎą medication, all evaluated scales and biological markers are correlated with functional status. The overall quality of life in patients with AS is independently determined both by disease activity measured by ASDAS and BASDAI and by physical function measured by BASFI.
Figure 8. Correllations between BASFI score and the inflammatory markers CRP and ESR after 3 months of complex treatment. _____________________________
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Figure 8.
The correlations between these scales offers us a prediction model on how the patient will evolve in outcomming period. Functional status of the patient and disease activity are the most important domains in the treatment of AS in order to maximize benefits in quality of life of the patient. The ASDAS are more sensitive in discriminating the disease activity and the efficacy of TNF-α blocker treatment at 3 months in AS patients. The advantages of using ASDAS ESR scale in clinical practice results from quickness and easiness in application, and progress assessment of patient after initiating the biological therapy, so we propose this scale to be also validated in Romania. Both ASDAS versions, consisting of both patientreported data and acute-phase reactants, performed well in discriminating low and high disease activity.
ACKNOWLEDGEMENT During the research described in this paper, the first author, Razvan G. Dragoi, benefitted by a grant from the PhD programme POSDRU/88/1.5/S/63117.
REFERENCES 1. van der Linden SM, van der Heijde D, Maksymowych WP. In: Kelley`s Textbook of Rheumatology. 8th Ed. Philadelphia: Saunders (Elsevier), 2008, Vol I, Chapter 70. 2. Zochling J, Braun J. Assessment of ankylosing spondylitis. Clin Experim Rheum 2005;23(Suppl. 39):S133-S141. 3. Bakland G, Gran JT, Nossent JC. Increased mortality in ankylosing spondylitis is related to disease activity. Ann Rheum Dis 2011;70:1921-25.
4. http://basdai.com (Accessed on 8th Sep. 2011). 5. Calin A, Garrett S, Whitelock H, et al. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. Journal of Rheumatology, 1994;21(12):2281-5. 6. Lukas C, Landewé R, Sieper J, et al. Development of an ASAS-endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:18-24. 7. van der Heijde D, Lie E, Kvien TK, et al. ASDAS, a highly discriminatory ASAS-endorsed disease activity score in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:1811-8. 8. Machado P, Landewé R, Lie E, et al. Ankylosing Spondylitis Disease Activity Score (ASDAS): defining cut-off values for disease activity states and improvement scores. Ann Rheum Dis (In Press) 2010. 9. Machado P, Landewé R, van der Heijde D. Endorsement of the definitions of disease activity states and improvement scores for the Ankylosing Spondylitis Disease Activity Score (ASDAS): results from the Outcome Measures in Rheumatology (OMERACT) 10 conference. J Rheumatol (Submitted) 2010. 10. Nemeş IDA. Metode de explorare şi evaluare în kinetoterapie (in Romanian). Timişoara: Orizonturi Universitare, 2001. 11. Song IH, Rudwaleit M, Listing J, et al. Comparison of the Bath Ankylosing Spondylitis Disease Activity Index and a modified version of the index in assessing disease activity in patients with ankylosing spondylitis without peripheral manifestations. Ann Rheum Dis 2009;68:1701–1707. 12. Wagner C, Visvanathan S, Braun J, et al. Serum markers associated with clinical improvement in patients with ankylosing spondylitis treated with golimumab. Ann Rheum Dis (2011). doi: 10.1136ard.2010.148890 13. Vastesaeger N, van der Heijde D, Inman RD, et al. Predicting the outcome of ankylosing spondylitis therapy. Ann Rheum Dis 2011;70:973–981. 14. Rudwaleit M, Listing J, Brandt J, et al. Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor a blockers in ankylosing spondylitis. Ann Rheum Dis 2004;63:665–670. 15. Pedersen SJ, Sørensen IJ, Garnero P, et al. ASDAS, BASDAI and different treatment responses and their relation to biomarkers of infl ammation, cartilage and bone turnover in patients with axial spondyloarthritis treated with TNFα inhibitors. Ann Rheum Dis 2011;70:1375–1381.
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CLINICAL DIFFERENCES IN SEASONAL AND NONSEASONAL DEPRESSION Radu Romosan1, Tiberiu Mircea1, Felicia Romosan1,2,3, Monica Ienciu1,2, Lucian Ile2,3, Cristina Bredicean1,2,3, Ion Papava1,2,3, M. Milin4 REZUMAT Obiective: Compararea profilului simptomatologic al episoadelor depresive sezoniere şi non-sezoniere. Material si metode: Au fost selecţionaţi 15 pacienţi cu episoade depresive sezoniere şi 22 de pacienţi cu episoade depresive non-sezoniere, aparţinând categoriilor diagnostice de tulburare afectivă bipolară tip I şi tip II şi tulburare depresivă majoră, după criteriile DSM-IV TR, internaţi în Clinica de Psihiatrie Timişoara în perioada 2007-2011. Evaluarea a fost retrospectivă, realizată pe baza documentaţiei medicale. Ca instrumente de lucru s-au folosit scala de evaluare a depresiei Hamilton (HDRS), înregistrarea greutăţii, calitatea somnului, apetitul alimentar, documentate în foaia de observaţie. Rezultate: La grupul de pacienţi cu episoade depresive sezoniere au fost găsite mai frecvent simptome vegetative atipice cu hipersomnie, creştere ponderală şi a apetitului alimentar, iar la grupul de pacienţi cu episoade depresive non-sezoniere simptome vegetative tipice, cu insomnie, scăderea apetitului alimentar şi a greutăţii corporale. Concluzii: Episoadele depresive sezoniere au fost mai frecvente la pacienţii cu diagnosticul de depresie majoră recurentă şi la pacienţii cu tulburare afectivă bipolară de tip II. Simptomele vegetative tipice au fost prezente preponderent la lotul de pacienţi cu depresie non-sezonieră, cele atipice fiind mai frecvente la lotul de pacienţi cu depresie de model sezonier. Cuvinte cheie: tulburare afectivă sezonieră, tulburare depresivă majoră, tulburare afectivă bipolară
ABSTRACT Objectives: Comparison of the symptomatic profile of seasonal and non-seasonal depressive episodes. Material and methods: Fifteen in-patients with seasonal depressive episodes and 22 in-patients with non-seasonal depressive episodes, admitted in the Timisoara Psychiatric Clinic between 2007 and 2011 were selected in this study. The diagnoses of the patients were bipolar affective disorder type I, II or major depressive disorder, according to DSM-IV-TR criteria. Retrospective evaluation was based on medical documentation. Methods used were the Hamilton Depression Rating Scale (HDRS), recording of weight, quality of sleep, appetite and the patient’s chart. Results: In the group of patients with seasonal depressive episodes we more frequently found atypical vegetative symptoms such as hypersomnia, increased appetite and weight gain, and in the group of patients with non-seasonal depressive episodes we found typical vegetative symptoms, with insomnia, decreased appetite and weight loss. Conclusions: Seasonal depressive episodes were more common in patients diagnosed with recurrent major depression and type II bipolar affective disorder. Typical vegetative symptoms were mainly present in the group of patients with non-seasonal depression, whilst atypical symptoms were more frequent in the group of patients with a seasonal depressive pattern. Key Words: seasonal affective disorder, major depressive disorder, bipolar affective disorder
INTRODUCTION During the course of evolution, most organisms have adapted to the geophysical cycle of day and night and their modulation across the length of the year.
1 Department of Psychiatry, Victor Babes University of Medicine and Pharmacy, Timisoara, 2 Eduard Pamfil Psychiatric Clinic, Timisoara, 3 Mara Institute, Timisoara, 4 Clinical Municipal Hospital, Timisoara Correspondence to: Dr. Radu-Stefan Romosan, Department of Psychiatry, Victor Babes University of Medicine and Pharmacy, 2A Eftimie Murgu Sq., 300041 Timisoara, Romania, Tel. +40.724.981.888 Received for publication: Oct. 11, 2011. Revised: Nov. 14, 2011. _____________________________
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Man also has a physiological and behavioral circadian rhythm, led by the biological clock, which depends on the time schedule of seasonal changes in day length. Seasonal vulnerability is a feature of several psychological disorders and this type of environmental influence has been studied for several centuries, especially regarding depression. Longitudinal studies of patients suffering from recurrent major depressive episodes have shown the existence of a particular relationship with the seasonal changes in temperate regions. Seasonal depression was first described by Rosenthal and is characterized by recurrent depressive episodes whose onset is during winter-time and which are responsive to light-therapy.1 Wehr later described the summer depression that was supposed
to be responsive to external temperature handling. 2 Community epidemiological studies indicate a lifetime prevalence for seasonal affective disorder estimated between 1.4 and 9.7% in North America and between 1.3 and 3.0 % in Europe.3-8 Seasonal pattern can be applied, according to the diagnostic criteria of DSM-IV-TR to major depressive episodes in BD I, BD II (Bipolar Affective Disorder type I, II) or MDD (Major Depressive Disorder).9 A seasonal pattern in depressive episodes is present when we can detect a regular temporal relationship between the onset of major depressive episodes and a particular time of the year (e.g. the onset of a major depressive episode during autumn or winter) for at least two years in a row without psycho-social stressors in relation to season. Also, a full remission (or change from depression to mania or hypomania) must occur in the same season or time of the year (e.g. a remission of depressive symptoms during spring). The number of seasonal major depressive episodes must substantially exceed non-seasonal major depressive episodes that occurred during the lifetime of the individual. Characteristic of patients with seasonal depression, in addition to the criteria of major depression is the presence of a higher frequency of atypical symptoms such as increased duration of sleep, increased appetite and weight gain.1,2 The purpose of this study was to identify cases with seasonal depressive episodes and to compare the profile of symptoms between seasonal and nonseasonal depressive episodes.
MATERIALS AND METHOD Subjects Fifteen in-patients, with seasonal depressive episodes and 22 in-patients with non-seasonal depressive episodes, admitted in the Timisoara Psychiatric Clinic between 2007 and 2011, aged 18 to 65 were selected in this study. The diagnoses of the patients were BD I, II or MDD, according to DSMIV-TR criteria.9 The inclusion criteria for cases with seasonal depression were: a history of at least two main episodes with onset during the same time of the year, two years consecutively and remission not later than six months after the onset of symptoms. The inclusion criteria for patients with non-seasonal depressive episodes were: a history of at least two main depressive episodes, spaced at least one year apart. Patients with an age below 18 or over 65 years, cases of abuse or addiction to alcohol or drugs and
those with a limited capacity to give valid consent were excluded from the study. There were nine female subjects in the seasonal group and 12 in the non-seasonal group. Patients received information regarding study design and were asked to give an informed consent to participate in the study. As the study interferes very little with the follow-up treatment, all subjects who were invited agreed to participate. At the time of enrollment all subjects were in a depressive episode. Anamnestic data was evaluated retrospectively via the observation sheet and direct interview. Measurements Several clinical and demographical variables have been comparatively analyzed (both in term of numbers and percentages) such as : sex, age at onset, duration of the depressive episode, duration of the disorder, evaluation of depression severity using the HDRS (Hamilton Depression Rating Scale) and vegetative symptoms (weight, appetite, sleep quality). Statistical analysis was performed using SPSS v. 15.0 and the graphical charts were made with Microsoft Excel 2007. The results for continuous variables were expressed as mean values and standard deviations, while those for categorical data were expressed as counts and percentages. Depending on the type of the variables, either the t-test for independent samples or the Pearson chi-square test was applied to test the statistical significance of the differences observed between the two groups, i.e. with seasonal or nonseasonal depression.
RESULTS The distribution of cases in the two distinct groups (seasonal and non-seasonal) can be observed in Figure 1. In the group with seasonal depressive episodes, 11 subjects (73.33 %) had been diagnosed with MDD, three (20 %) with BD II and one (6.67 %) with BD I. In the non-seasonal depression group 13 subjects (59.1 %) had been diagnosed with MDD, six (27.27%) with BD II and three (13.63 %) with BD I. Table 1 presents demographic and clinical data of patients with seasonal and non-seasonal depressive episodes. Mean age at onset stood at 26.60±4.45 years in the seasonal group, whilst in the non-seasonal group it was 29.82±5.16. Mean disorder duration (years) and mean episode duration (months) were 16.53±10.83 / 4.60±2.32 in the seasonal group and 16.64±6.81 / 4.00±1.98 in the non-seasonal group. Mean HDRS17 scores in the seasonal group were 22.20±4.87 and 20.41±4.13 in the non-seasonal group. _____________________________ Radu Romosan et al
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Table 1. Demographical and clinical characteristics of the two patient groups Table 1. Demographical and clinical characteristics of the two patient groups Seasonal (n=15)
Non-seasonal (n=22)
Comparison between the two groups (seasonal vs non-seasonal)
Male/Female
6/9
10/12
p=0.742 (Pearson chi-square test)
BP/MDD
4/11
9/13
p=0.373(Pearson chi-square test)
Age in years (ms)
43.1313.33
46.459.20
p=0.375 (t-test); p=0.083 (Levene’s test for variances)
Age at onset (ms)
26.604.45
29.825.16
p=0.057 (t-test); p=0.529 (Levene’s test for variances)
Disorder duration (ms)
16.5310.83
16.646.81
p=0.974 (t-test); p=0.024* (Levene’s test for variances)
Episode duration (ms)
4.602.32
4.001.98
p=0.404 (t-test); p=0.452 (Levene’s test for variances)
HDRS-17 score (ms)
22.204.87
20.414.13
p=0.236 (t-test); p=0.497 (Levene’s test for variances)
There is a marginally significant difference between the two groups regarding the age at onset (marked by the index ms next to the corresponding p-value); there is also a statistically significant difference between the variability of the disorder duration for the two groups (marked by * next to the corresponding p-value).
Figure 1.
Figure 1. Distribution of the distinct diagnoses in the two patient groups (%).
Figure Figure 2. 2. Typical and atypical symptoms in seasonal and non-seasonal depression.
The subjects in the seasonal group were more likely to exhibit atypical vegetative symptoms: increased appetite (80% vs. 36.37%, p=0.009), weight gain (73.34% vs. 27.27%, p=0.006), hypersomnia (86.67% vs. 40.9%, p=0.005). Patients with non seasonal depressive episodes were more likely to exhibit frequent typical vegetative symptoms: loss of appetite (59.1% vs. 6.67%, p=0.001), weight loss (59.1% vs. 6.67%, p=0.001), insomnia (59.1% vs. 6.67%, p=0.001). (Fig. 2, Table 2)
There were no significant statistical differences regarding disorder duration within the two groups, still, the high variability (p=0.024) in the seasonal group may have affected this result. In the future, a comparison of more homogenous samples would yield better results. There was a marginally significant statistic difference regarding age at onset between the two groups, with a higher mean value in the nonseasonal group. Highly significant statistical differences were found for all the six symptoms considered (three typical and three atypical depressive symptoms). DISCUSSIONS Our results are consistent with other studies that have shown increased prevalence of atypical vegetative No statistically significant differences were found symptoms in patients with seasonal depressive between the two groups regarding most demographical episodes.1,10-14 and clinical characteristics. According to the literature, data regarding the Table 2. The presence of symptoms (both typical and atypical) in seasonal and non-seasonal prevalence of seasonal depression differs, some authors depression. statistical differences (markedreported with **)a were for all for the six Table 2. The Highly presence ofsignificant symptoms (both typical and atypical) in seasonal higherfound prevalence seasonal depression and non-seasonal depression. Highly significant statistical differences symptoms considered. in bipolar patients and other authors reported an (marked with **) were found for all the six symptoms considered. Seasonal (n=15)
Non-seasonal (n=22)
p-values (Pearson chi-square test)
Loss of appetite
1 (7%)
13(59%)
0.001**
Increased-appetite
12 (80%)
8 (36%)
0.009**
Weight loss
1 (7%)
13(59%)
0.001**
Weight gain
11(73%)
6 (27%)
0.006**
Insomnia
1 (7%)
13(59%)
0.001**
Hypersomnia
13 (87%)
9 (41%)
0.005**
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increased prevalence for seasonal depression in patients with MDD. In our study, subjects with bipolar disorder type I and II tend to be non-seasonal.14-22 Other studies have showed a higher prevalence of seasonal and non-seasonal depression in women.23-28 Evaluating a larger nation-wide sample of seasonal and non-seasonal subjects in the future study might confirm the findings of other studies. The limits of this preliminary study are the relatively small number of cases investigated and the retrospective evaluation method which allows only an indirect assessment of seasonal patterns. A larger number of cases (nation-wide), a prospective study design, the inclusion of subjects with schizo-affective disorder or other mood disorders and a wider set of data could provide additional information on the effect of seasonal affective disorder. Detecting the evolutionary model of seasonal affective disorder in patients may be important in terms of differentiated therapeutic approach using lighttherapy in cases with seasonal depression.1,6,16,22,27-31
CONCLUSIONS The evolutionary pattern of seasonal depression was found more frequently in patients with recurrent major depressive disorder and in those with bipolar affective disorder type II. Typical vegetative symptoms were mainly present in the group of patients with non-seasonal depression, whilst atypical symptoms were more frequent in the group of patients with a seasonal depressive pattern. These results may help facilitate the preparedness of mental health services at different times during the year and possibly a different therapeutic approach.
ACKNOWLEDGEMENT During the research described in this paper, the first author, Radu Romosan, benefitted by a grant from the PhD programme POSDRU/88/1.5/S/63117.
REFERENCES 1. Rosenthal NE, Sack DA, Gillin JC et al. Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy. Arch. Gen. Psychiatry 1984; 41: 72-80. 2. Wehr TA, Sack DA & Rosenthal NE. Seasonal affective disorder with summer depression and winter hypomania. Am. J. Psychiatry 1987; 144: 1602-1603. 3. Sherman JA. Evolutionary origin of bipolar disorder-revised: EOBD-R. Med Hypotheses 2012; 78(1): 113-122. 4. Rodin I, Thompson C. Seasonal affective disorder. Adv. Psychiatric Treatment 1997; 3: 352-359. 5. McClung CA. Circadian rythms and mood regulation: insights from preclinical models. Eur Neuropsychopharmacol. 2011. 21 Suppl 4:
S683-693. 6. Michalak EE, Wilkinson C, Dowrick G et al. Seasonal affective disorder: prevalence, detection and current treatment. British Journal of Psychiatry 2001; 179: 31-34. 7. Westrich L, Sprouse J. Circadian rhythm dysregulation in bipolar disorder. Curr Opin Investig Drugs 2010; 11(7): 779-787. 8. Wirz-Justice A, Graw P, Krauchi K et al. Seasonality in affective disorders in Switzerland. Acta Psychiatr. Scand. 2003; 108 (Suppl. 418): 92-95. 9. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. 10. Avery DH, Khan A, Dager SR et al. Morning or evening bright light treatment of winter depression ? The significance of hypersomnia. Biol. Psychiatry 1991; 29: 117-129. 11. Takahashi K, Asano Y, Kohsaka M et al. J. Multi-center study of seasonal affective disorder in Japan. A preliminary report. Affect. Disord.1991; 21: 57-65. 12. Reeves GM, Nijjar GV, Langenberg P et al. Improvement in Depression Scores After 1 Hour of Light Therapy Treatment in Patients With Seasonal Affective Disorder. J Nerv Ment Dis.; 200(1): 51-55. 13. Roecklein KA, Rohan KJ, Postolache TT. Is seasonal affective disorder a bipolar variant ? Curr Psychiatr. 2010; 9(2): 42-54. 14. Lam RW. Seasonal affective disorder. Diagnosis and management. Primary Care Psychiatry 1998; Vol. 4: 63-67. 15. Virk G, Reeves G, Rosenthal NE et al. Short exposure to light treatment improves depression scores in patients with seasonal affective disorder: A brief report. Int J Disabil Hum Dev. 2009; 8(3): 283-286. 16. Wirz-Justice A, Graw P, Krauchi K et al. Light therapy in seasonal affective disorder is independent of time of day or circadian phase. Arch. Gen. Psychiatry 1993; 50: 929-937. 17. Gordijn MC, Mannetje D, Meesters Y. The effects of blue-enriched light treatment compared to standard light treatment in seasonal affective disorder. J Affect Disord. 2012; 136(1-2): 72-80. 18. Pail G, Huf W, Pjrek E et al. Bright-light therapy in the treatment of mood disorders. Neuropsychobiology 2011; 64(3): 152-162. 19. Faedda GL, Tondo L, Teicher MH. Seasonal mood disorder: patterns of seasonal recurrence in mania and depression. Arch. Gen. Psychiatry 1993; 50: 17-23. 20. Friedman E, Gyulai L, Bhargava M et al. Seasonal changes in clinical status in bipolar disorder: a prospective study in 1000 STEP-BD patients. Acta. Psychiatr. Scandinavica 2006; 113: 510-517. 21. Thompson C, Isaacs G. Seasonal affective disorder in a british sample: symptomatology in relation to mode of referral and diagnostic subtype. J. Affect. Disord. 1998; 14: 1-11. 22. Murray G, Lam RW, Beaulieu S et al. Do symptoms of bipolar disorder exhibit seasonal variation? A multisite prospective investigation. Bipolar Disord. 2011; 13(7-8): 687-695. 23. Enggasser JL, Young MH. Cognitive vulnerability to depression in seasonal affective disorder. Predicting mood and cognitive symptoms in individuals with seasonal vegetative changes. Cogn. Ther. Res. 2007; 31: 3-21. 24. Quera Salva MA, Hartley S, Barbot F et al. Circadian rhythms, melatonin and depression. Curr Pharm Des. 2011; 17(15): 1459-1470. 25. Lucht MJ, Kasper S. Gender differences in seasonal affective disorder (SAD). Arch. Womens Mental Health. 1999; 2: 83-89. 26. Rastad C, Sjoden PO, Ulfberg J et al. High prevalence of self-reported winter depression in a Swedish County. Psychiatry and Clinical Neurosciences 2005; 59: 666-675. 27. Thorn L, Evans P, Cannon A et al. Seasonal differences in the diurnal pattern of cortisol secretion in healthy participants and those with self-assessed seasonal affective disorder. Psychoneuroendocrinology 2011; 36(6): 816-823. 28. Hallam KT, Berk M, Kader LF et al. Seasonal influences on firstepisode admission in affective and non-affective psychosis. Blackwell Munksgaard 2006; 18: 154-161. 29. Winthorst WH, Post WJ, Meesters Y et al. Seasonality in depressive and anxiety symptoms among primary care patients and in patients with depressive and anxiety disorders; results from the Netherlands Study _____________________________ Radu Romosan et alâ&#x20AC;&#x192;
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of Depression and Anxiety. BMC Psychiatry 2011; 11(1): 198. 30. Simonsen H, Shand AJ, Scott NW et al. Seasonal symptoms in bipolar and primary care patients. J Affect Disord 2011; 132(1-2): 200-208. 31. Rohan KJ, Nillni YI, Mahon JN et al. Cognitive vulnerability in moderate,
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mild, and low seasonality. J Nerv Ment Dis. 2011; 199(12): 961-970. 32. Lee HJ, Rex KM, Nievergelt CM et al. Delayed sleep phase syndrome is related to seasonal affective disorder. J Affect Disord. 2011;133(3):573-579.
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ORIGINAL ARTICLES
INCORPORATION OF ISOFLAVONOID GENISTEIN IN BETA RAMIFIED CYCLODEXTRINS - AN OPTION FOR IMPROVING WATER SOLUBILITY Corina Tiulea Danciu1, Cristina Dehelean2, Codruta M. Soica3, Camelia Peev1, Andrei Motoc4 REZUMAT Genistein Isoflavonoid (4 ‘,5,7-trihydroxyisoflavone), aglicon de heteroside genistin, reprezinta compusul activ principal din soia. El este solubil în solvenţi organici, cum ar fi DMSO, dimetil formamidă, acetonă, etanol. Cu toate acestea, datorita structurii sale chimice, prezinta solubilitate slaba în apă, ceea ce desigur că ii reduce in mod drastic biodisponibilitatea. Scopul acestui studiu este de a demonstra că genisteina poate fi încorporata în diferite tipuri de ciclodextrine ramificate, compusi care cresc solubilitatea în apă: hidroxil-propil-beta-ciclodextrina (HPBCD), aleator-metilata-beta-ciclodextrină (RAMEB) şi a 6-O-Maltosil-beta-ciclodextrină (G 2BCD). Imaginile de microscopie electronica de baleiaj arată o diferenţă între structura substanţei pure, genistein si structura genistein după frământare cu cele trei ciclodextrine. O alta analiza care a fost făcută în scopul de a dovedi că procesul a avut loc a fost calorimetria de scanare differentiala. Genisteina are un vârf endoterm care reflectă punctul de topire în jurul valorii de 300 oC. HPBCD, RAMEB şi G 2BCD sunt materiale amorfe; în aceste cazuri, sunt presupuse a exista fenomene de complexare, deoarece punctul de topire a dispărut. Datele prezentate sugerează că încorporarea de genisteina în hidroxi-propil-beta-ciclodextrina, aleator-metilata-beta-ciclodextrina şi 6-O-maltosil-beta-ciclodextrină a avut loc din cauza schimbărilor aparute in proprietăţile fizico-chimice ale compuşilor. Cuvinte cheie: genisteină, hidroxi-propil-beta-ciclodextrina, aleator-metilata-beta-ciclodextrina, 6-O-maltosil-beta-ciclodextrină, SEM, DSC
ABSTRACT Isoflavonoid genistein (4’,5,7-trihydroxyisoflavone), the aglicon of heteroside genistin, represent the major active compound from soybean. It is solubile in organic solvents such as DMSO , dimethyl formamide, acetone, ethanol. Due to its chemical structure it shows, however, poor solubility in water, that of course drastically reduces its bioavailability. The aim of this study is to demonstrate that genistein can be incorporated in different tyes of ramified cyclodextrins, compounds that increase water solubility: hydroxyl-propyl-beta-cyclodextrin (HPBCD) , randomly –metylated- beta-cyclodextrin (RAMEB) and 6-O –Maltosil- beta-cyclodextrin (G 2BCD) . The scanning electron microscopy images show a difference between the structure of the pure substance, genistein and the structure of genistein after the kneading with the three cyclodextrins. Another analyze that was made in order to prove that complexation took place was the differencial scanning calorimetry. Genistein has an endothermic peak which reflect its melting point around 300 oC. HPBCD , RAMEB and G 2BCD are amorphous materials, in these cases complexation phenomena is presumable, because the melting point disappeared. Presented data suggest that incorporation of genistein in hydroxy-propyl- beta-cyclodextrin , randomly –metylated- beta-cyclodextrin and 6-O–maltosil-
INTRODUCTION Isoflavonoid genistein (4’,5,7-trihydroxyisoflavone), the aglicon of heteroside genistin, represent the major active compound from soybean, the vegetal product from Glycine max Fam. Fabaceae. Previous studies have demonstrated that genistein possess many biological functions such as prevention of coronary heart disease, as well as osteoporosis, antioxidant, Department of Pharmacognosy, 2 Department of Toxicology, Faculty of Pharmacy, 3 Department of Pharmaceutical Chemistry, 4 Department of Anatomy, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Timisoara 1
Correspondence to: Corina Tiulea, Victor Babes University of Medicine and Pharmacy, 2A E. Murgu Sq., 300041 Timisoara, Romania, Tel. +40-744-648855. Email: corina_tiulea@yahoo.com Received for publication: Oct. 11, 2011. Revised: Nov. 14, 2011.
anticancerous and anti-inflamatory activity.1-4 Genistein is solubile in organic solvents such as DMSO , dimethyl formamide, acetone, ethanol. Due to its chemical structure it shows, however, poor solubility in water, that of course drastically reduces its bioavailability. Inclusion complexes are now widely used in pharmaceutical industry, for improving the solubility, stability and bioavailability of the guest molecules. Recently, much interest has been focused on cyclodextrins, because of their remarkable ability to form, via noncovalent interactions, “host–guest” inclusion complexes with a wide variety of molecules, altering the physico-chemical characteristics of the guest.5,6 Beta-cyclodextrines are cyclic oligomers formed of seven units of glucose via α-(1,4)-linkages, having a toroidal shape with a non-polar inside and two hydrophilic rings. Due to this specific structure they act as molecular hosts for a large variety of guest molecules, polar and non-polar ones, through noncovalent interactions.7 _____________________________ Corina Tiulea et al
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AIM AND OBJECTIVES The aim of this study is to demonstrate that genistein can be incorporated in different tyes of ramified cyclodextrins, compounds that increase water solubility: hydroxyl-propyl-beta-cyclodextrin (HPBCD), randomly-metylated-beta-cyclodextrin (RAMEB) and 6-O-Maltosil-beta-cyclodextrin (G2BCD).
MATERIAL AND METHODS Reagents Genistein was acquired from Extrasynthese (France), hydroxyl-propyl-beta-cyclodextrin (HPBCD), randomlymetylated-beta-cyclodextrin (RAMEB) and 6-O-Maltosilbeta-cyclodextrin (G2BCD) from Cyclolab Hungary. Scanning electron microscopy (SEM) assay Genistein was prepared in three complex one with hydroxy-propyl-beta-cyclodextrin one with randomly-metylated-beta-cyclodextrin and one with and 6-O-maltosil-beta-cyclodextrin in a molar ratio 1:2 by kneading method. The shape and surface characteristics of genistein and complex were visualized using a scanning electron microscope (Hitachi S4700, Hitachi Scientific Ltd., Japan). The samples were sputter coated with gold–palladium under an argon atmosphere using a gold sputter module in a high vacuum evaporator and the samples were examined using SEM set at 15 kV. Differential scanning calorimetry (DSC) The DSC measurements were made with a Mettler Toledo DSC 821e thermal analysis system with the STARe thermal analysis program V9.1 (Mettler Inc., Schwerzenbach, Switzerland). Approximately 2–5 mg of MEL or its product was examined in the temperature range between 25oC and 300oC. The heating rate was 5 oC min-1. Argon was used as carrier gas, at a flow rate of 10 l h-1 during the DSC investigation.
RESULTS Genistein was incorporated in the three ramyfied beta-cyclodextrins in a molar ratio of 1:2 by kneading method. The scanning electron microscopy images show a difference between the structure of the pure substance, genistein and the structure of genistein after the kneading with the three cyclodextrins, HPBCD , RAMEB and G 2BCD. This analyze confirms the fact that the complexation took place and physical interactions were performed. These preliminary observations are important to establish the solvent and formulation type for active compound application. Results are presented in Figures 1-4. _____________________________
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Figure Figure1 1. SEM
picture of pure genistein.
Figure 2
Figure 2. SEM picture of genistein incorporated in HPBCD.
Figure 3
Figure 3. SEM picture of genistein incorporated in RAMEB.
Figure 4
Figure 4. SEM picture of genistein incorporated in G2BCD.
Figure 1 presents the aspect of genistein: the large, pure crystals have a smooth surface with a regular prismatic form. The size of tetragonal particles is between 5-30 μm. The SEM pictures demonstrate the changes in habit of the crystals after complexation: the regular, smooth surface disappeared. (Figs. 2-4) Because of the interaction between the drug and excipient and the preparation procedure, aggregation can be seen. Presumably the excipient covered the surface of genistein. HPBCD, RAMEB and G 2BCD are amorphous materials and complexing agents, therefore amorphization or inclusion complexation of genistein is presumable. The regular shape of the drug is also splitted. It can be seen the amorphous HPBCD, RAMEB and G 2BCD with irregular shape on the particle surface. (Figs. 2-4) These results suggest that complexation took place. Another analyze that was made in order to prove that complexation took place was the differencial scanning calorimetry. Results can be seen in Figure 5. Genistein has an endothermic peak which reflect its melting point around 300 oC. HPBCD , RAMEB and G 2BCD are amorphous materials, in these cases complexation phenomena is presumable, because the melting point disappeared. These data regarding DSC analysis are preliminary studies. Further studies expanding the range of temperature at 350 degrees for better observing the endothermic pick will be made.
Figure 5
Figure 5. DSC results for genistein and genistein incorporated in the three types of cyclodextrins.
DISCUSSION Recently, one of the most used methods to improve watter solubility, stability, safety and bioavailibility of drug molecules is complexation with cyclodextrins.8,9 Genistein has a poor water solubility, and in order to improove the drug delivery parameters many scientist have resorted this solution.10-12 β-cyclodextrins seem to be the best natural cyclodextrin for complexation because of their cavity size, efficient drug complexation and availability in pure form.13,14 Although inclusion complex formation
of beta-cyclodextrins with drugs have been studied extensively the lower solubility of these complexes to some extent limits their use.15 Therefore in this study we have focused on the preparation of derivates of beta-cyclodextrin with a higher water solubility. Genistein was incorporated in the three ramyfied beta-cyclodextrins, HPBCD, RAMEB and G 2BCD in a molar ratio of 1:2 by kneading method. Scanning electron microscope analyse show physico-chemical changes in the structure of the complexes compared to pure genistein, a proof that complexation took place. Crupi et al also concluded that these type of cyclodextrins are suitable for a myriad of lipophilic substances and Bergonzi et al studied the complex formed by these cyclodextins with other flavonoids. Borghetti et al also studied the formation of the complex between ramyfied beta-cyclodextrins and the second most plentiful isoflavonoid from soybean, daidzein and concluded that the complexation increased water solubility.16-18 Another analyze that was made in order to prove that complexation took place was the differencial scanning calorimetry. This analyse also suport the fact that incorporation took place because the melting point of genistein which it was detected at 300oC disappeared, but in order to explain better the process furtherer studies expanding the range of temperature at 350 degrees for better observation of the endothermic pick will be made. Shuang et al studied the formation of the complex between genistain and beta-cyclodextrin using DSC method and concluded that incorporation took place.19 SEM and DSC analyses confirm that incorporation of genistein in ramyfied beta cyclodextrins took place. This result is of special interest for practical purposes in the pharmaceutical field, since formulations that produce higher drug concentrations in solution may provide improved therapeutic options for patients.
CONCLUSION Presented data suggest that incorporation of genistein in hydroxy-propyl-beta-cyclodextrin, randomlymetylated-beta-cyclodextrin and 6-O-maltosil-betacyclodextrin took place because of the changes in the physico-chemical proprieties of the compounds.
ACKNOWLEDGEMENTS During the research described in this paper, the first author, Corina Tiulea, benefitted by a grant from the PhD programme POSDRU/88/1.5/S/63117. _____________________________ Corina Tiulea et al
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REFERENCES 1. Dalais FS, Ebeling PR, Kotsopoulos D, et al. The effects of soy protein containing isoflavones on lipids and indices of bone resorption in postmenopausal women. Clin. Endocrinol. 2003; 58: 704–70. 2. Wei H, Saladi R, Lu Y, et al. Isoflavone Genistein: Photoprotection and Clinical Implications in Dermatology, J. Nutr. 2003; 133:3811S-3819S. 3. Kao TH, Huang RF, Chen BH. Antiproliferation of hepatoma cell and progression of cell cycle as affected by isoflavone extracts from soybean cake. Int. J. Mol. Sci. 2007; 8: 1095–1110. 4. Bhatia AL , Gaur A, Sharma A. Radiation protection by an isoflavone, genistein: a study on the survivability of mice, Nuclear Technology & Radiation Protection 2007; 22: 34-39. 5. Crupi V, Ficarra R , Guardo M, et al. UV-vis and FTIR-ATR spectroscopic techniques to study the inclusion complexes of genistein with betacyclodextrins, J Pharm Biomed Anal. 2007; 9, 44(1):110-7. 6. Cannavà C, Crupi V, Ficarra P, et al. Physico-chemical characterization of an amphiphilic cyclodextrin/genistein complex, J Pharm Biomed Anal 2010; 6, 51(5):1064-8. 7. Menuel S, Joly JP, Courcot B, et al. Synthesis and inclusion ability of a bis-β-cyclodextrin pseudo-cryptand towards Busulfan anticancer agent. Tetrahedron, 63, 2007; 7:1706-1714. 8. Rasheed A, Kumar A, Sravanthi VV. Cyclodextrins as Drug Carrier Molecule: A Review, Scientia Pharmaceutica, 2008; 76: 567–598. 9. Patil JS, Kadam DV, Marapur SC. Inclusion complex system; a novel technique to improve the solubility and bioavailability of poorly soluble drugs: a review, International Journal of Pharmaceutical Sciences Review and Research ,2010, 2 (2):29-34. 10. Daruházi AE, Szente L, Balogh B, et al. Utility of cyclodextrins in the formulation of genistein part 1. Preparation and physicochemical
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properties of genistein complexes with native cyclodextrins, J Pharm Biomed Anal., 2008, 8(3):636-40. 11. Stancanelli R, Guardo M, Cannavà C et al. Amphiphilic cyclodextrins as nanocarriers of genistein: A spectroscopic investigation pointing out the structural properties of the host/drug complex system, J Pharm Sci., 2010 , 99(7):3141-9. 12. Xavier CR, Silva PC, Schwingel LC et al. Improvement of genistein content in solid genistein/β-cyclodextrin complexes, Quím. Nova , 2011, 34 (9) :1534-1538. 13. Fernandes SA, Cabeca LF, Marsaioli AJ, Eneida P. Investigation of tetracaine complexation with beta-cyclodextrins and p-sulphonic acid calixarenes by nOe and PGSE NMR. J Incl Phenom Macrocycl Chem , 2007, 57:395–401. 14. Crini G. Studies on adsorption of dyes on beta-cyclodextrin polymer. Bioresource Technology, 2003, 90 (2):193-198. 15. Haiyun D, Jianbin C, Guomei Z et al. Preparation and special investigation on inclusion complex of beta-cyclodextrins with rutin Spectrochim Acta A Mol Biomol Spectrosc ,2003, 59(14):3421-9. 16. Crupi V, Majolino D, Paciaroni A, et al., The effect of hydrogen bond on the vibrational dynamics of genistein free and complexed with β-cyclodextrins, Journal of Raman Spectroscopy, 2010, 41(7) :764770. 17. Borghetti GS, Pinto AP, Lula IS, et al. Daidzein/cyclodextrin/ hydrophilic polymer ternary systems, Drug development and industrial pharmacy, 2011, Epub ahead of print 18. Bergonzi MC, Bilia AR, Bari LD et al. Studies on the interactions between some flavonols and cyclodextrins. Bioorg.Med.Chem.Lett 2007, 17(21): 5744-8. 19. Shuang C, Ling-Yun DU, Mei-Ju N et al. Study on inclusion interaction of β-cyclodextrin and genistein. , Food Science, 2006, 27 (2): 94–99.
REVIEW ARTICLES
INFECTIONS, ANTIBIOTICS AND PREGNANCY Simona Sipos1, Mirabela Dima2, Camelia Budisan2, Adina Bucur3, Victor Dumitrascu1 REZUMAT Femeile gravide prezintă deseori în timpul sarcinii infecţii urinare, boli cu transmitere sexuală sau pot fi purtătoare de streptococ beta-hemolitic, motive pentru care este necesară instituirea tratamentului cu antibiotice. De asemenea, se aplică o terapie standard cu antibiotice femeilor cu naşteri premature şi ruptura prematură a membranelor înainte de travaliu (RPM). Antibioticele pentru RPM reduc complicaţiile datorate naşterii premature şi infecţiilor postnatale. Modificările fiziologice survenite în cursul sarcinii determină particularităţi farmacocinetice care pot afecta eficienţa agenţilor antimicrobieni. Un motiv serios de îngrijorare este reprezentat de posibilul risc de producere al efectelor teratogene şi toxice pentru făt. În general, femeile gravide sunt excluse din trialurile clinice, iar informaţiiile farmacocinetice referitoare la administrarea şi dozarea corectă a antimicrobienelor la această populaţie sunt insuficiente. Deşi majoritatea antimicrobienelor pot traversa bariera hemato-placentară, datele referitoare la potenţialele efecte teratogene şi toxicitatea fetală şi neonatală provocată de aceste medicamente sunt limitate şi relativ variabile. Prezentul articol recenzează datele disponibile cu relevanţă clinică semnificativă referitoare la farmacologia antibioticelor celor mai frecvent utilizate în sarcină, cu preponderenţă pe toxicitatea fetală. Cuvinte cheie: sarcină, infecţii, antibiotice, transmitere transplacentară
ABSTRACT Pregnant women often present in the evolution of pregnancy urinary tract infections, sexually transmitted infections and group beta streptococcus carriage requiring treatment with antibiotics. Also, it is standard practice to give antibiotics to women with pre-term, prelabor rupture of membranes (PROM). Antibiotics for PROM reduce complications due to pre-term delivery and post-natal infection. The physiologic changes that occur during pregnancy result in pharmacokinetic changes that can alter the effectiveness of antimicrobial agents. The possible risk of teratogenic and toxic effects of antibiotics on the fetus is an additional cause of concern. In general, pregnant women are excluded from clinical trials and there is little pharmacokinetic information on the use and proper dosing of antimicrobials in this population. Although most antimicrobials can cross the placental blood barrier, data on the potential teratogenic effects, fetal and neonatal toxicity caused by these drugs are also limited and off varying reliability. This article reviews the available evidence with the greatest clinical relevance regarding the pharmacology of different antibiotic agents in pregnancy, with particular focus on data related to fetal toxicity. Key Words: pregnancy, infections, antibiotics, transplacental transmission
INTRODUCTION 1. Drug risks in pregnancy. Reproductive and developmental toxicology Antibiotics are often prescribed during pregnancy by gynecologists and family healthcare providers due to several bacterial infections which occur during the perinatal period.1 Their increased use is correlated with the risk of adverse effects on the fetus.2
Department of Pharmacology, 2 Department of Neonatology, 3 Department of Public Health, Victor Babes University of Medicine and Pharmacy Timisoara 1
Correspondence to: Simona Sipos, Department of Pharmacology, Victor Babes University of Medicine and Pharmacy, 2A E. Murgu Sq., 300041 Timisoara, Tel. +40256204476. Email: simosipos@yahoo.com Received for publication: Oct. 11, 2011. Revised: Nov. 14, 2011.
Certain antibiotics can have varying levels of impact on the fetus based on when they are taken during the pregnancy. During these time periods, one must be conscious of the multiple consequences taking antibiotics can have.3 The care of pregnant women represents one of the paradoxes of modern medicine.4 Practicing clinicians, who prescribe medicinal products, have to evaluate the drug exposure in women who are or may become pregnant.5 Since the recognition of prenatal vulnerability in the early 1960s, after the maternal exposure to the mild sedative thalidomide, much has been accomplished to identify potential developmental toxicants such as medicinal products and to regulate human exposure to them.6 The adverse developmental effects of pharmaceutical products are now recognized to include not only malformations, but also growth restriction, fetal death and functional defects in the newborn.7 Many reviews provide an update of anti-infective drugs used during pregnancy, known to produce fetal _____________________________ Simona Sipos et al
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developmental anomalities.8 In all cases it is essential to critically consider the benefit of the antibiotic therapy for the disease being treated, whether the disease is maternal, fetal or placental.9 1.1. Pharmacokinetics in pregnancy
Pregnancy induces many maternal physiological changes and adaptations, which can lead to clinically important reductions in the blood concentrations of certain medicinal products. The total water increases as much as 81 during pregnancy, which provides a substantially increased volume in which drugs can be distributed.10 Serum proteins relevant to drug binding undergo considerable changes in concentration. Albumin, which binds acidic drugs and chemicals decreases in concentration by up to 10 g/L. The main implication of this change is the interpretation of drug concentrations.11 The increased production of female hormones activates enzymes in the maternal liver, and this may result in a modified drug inactivation. The renal plasma flow will almost doubled by the last trimester of pregnancy, and drugs that are excreted unchanged by the kidney are usually eliminated more rapidly.12 1.2. Fetal kinetics and passage of drugs to the unborn
Most studies of drug transfer across the maternal and embryonic/fetal barrier are concerned with the end of pregnancy; but little is known about the transport of substances in the early phases of pregnancy, in which, morphologically and functionally, both the yolk sac and the placenta develop and change in performance.13,14 The placenta is a lipid barrier between the maternal and the embryonic/fetal circulations, allowing fatsoluble drugs to cross more easily than water-soluble. Drugs cross the placenta by passive diffusion, and a non-ionized drug of low molecular weight will cross more rapidly than a more polar drug. However, most drugs achieve equal concentrations on both sides of the placenta. Most drugs have a lower molecular weight than 600-800 Da, and will therefore be able to cross the placenta. In the third month of pregnancy, the fetal liver is already capable of activating or inactivating chemical substances through oxidation.15 It is very important that, in the fetal compartment, the detoxification of drugs and their metabolites takes place at a low level, certainly in the first half of pregnancy. The excretion in the amniotic fluid explains the accumulation of biological active substances might take place in the fetal compartment. The blood-brain barrier in the fetus is another characteristic that might be important for the possible fetotoxic effects of drugs. Although fetal treatment is still an exception, it is of great interest that in the case of prevention of vertical _____________________________
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infections, at the time of functioning circulation and kidney excretion, antibiotics (penicillins, cephalosporins) concentrate in the fetal compartment. Such depot effects are also enhanced by recirculation through swallowing of the antibiotics in the amniotic fluid, thus contributing to a great extent to the therapeutic effect. Obviously, this effect is lost when an early amniorrhexis (rupture of the membranes) occurs.16
OBJECTIVE To review the current status of antibiotic therapy for pre-term, prelabor rupture of membranes (PROM) cesarean delivery, newly evolving strategies to enhance the effectiveness in reducing post-natal infection, and to monitor the adverse effects on the embryo and fetus.
DATA SOURCES We conducted a full PubMed (January 1976 - August 2011) search using the key words “pregnancy”, “infections”, “antibiotics” and “transplacental transmission”. A total of 355 articles were identified and supplemented by a bibliographic search. Methods of study selection We have selected a total of 59 observational and clinical trials revealing the clinical and biological effects of antimicrobials with transplacentar transmission, administered during different stages of pregnancy.
RESULTS AND DISCUSSIONS We conducted an analytic review of selected studies in order to reveal safety of antibiotic use in pregnancy. Although current guidelines recommend the administration of antibiotics with narrow spectrum to be delayed, only after clamping the neonate’s umbilical cord, previous studies revealed the effectiveness of extended spectrum antibiotics to be used earlier, prior to surgical incision. However, the final goal is to reduce maternal infection up to 50% and to extend beneficial effects on neonatal infection as well. 1. Classification of drugs used in pregnancy Since 1984, classification systems have been introduced in the USA, Sweden and Australia. Some of the frequently prescribed antibiotics are distributed into three groups according to their rational use during pregnancy (categories A,B,C).17,18 Antibiotics belonging to the first group, which should not be administered to pregnant women, are listed in Table 1:19
Table 1. Usual antibiotics not to be used in pregnant women
Table 1. Usual antibiotics not to be used in pregnant women. Class of antibiotics
Representative antibiotics
Phenicols
Cloramphenicol
Aminoglycosides
Gentamycin Streptomycin Tobramycin
Antimycotics
Amphotericin B 5-flucytosine Griseofulvin
Polymyxins
Colistin Polymyxin
Tetracyclines
Doxycicline Minocycline Tetracycline
Classification of antibiotics is general, and these systems allow for a general estimation of the safety of drugs during pregnancy and reproduction. In the European Union, a specification of the medicinal products to be used in pregnancy has to include:20 - Facts regarding human experience and conclusions from preclinical toxicity studies which are of relevance for the assessment of risks associated with exposure during pregnancy; - Recommendations on the use of the medicinal product at different times during pregnancy in respect of gestation; - Recommendations on the management of the situation of an inadvertent exposure. 2. Safety of antibiotic use in pregnancy Among the anti-infective agents, the use of common antibiotics prescribed in therapeutic doses is very important for family healthcare providers. Fetal monitoring is recommended regarding the safety in pregnancy of the following classes of antibiotics: 2.1. Penicillins
Penicillins are widely used during pregnancy, including ampicillin, amoxicillin, azlocillin, mezlocillin, penicillin G, penicillin V, piperacillin, ticarcillin, etc. Many studies have revealed their lack of fetal adverse effects, even if it has been proved that they accumulate in the amniotic fluid.21 Penicillins, belonging to the β-lactam antibiotics, inhibit cell-wall synthesis in bacteria and have bactericidal properties. They have a low toxicity profile for both, the pregnant woman and the fetus, when used in therapeutic doses. Penicillins cross the placenta in low concentrations, and can be detected in amniotic
fluid. Elimination is more rapid in pregnant women and therefore dosage or dosage intervals should be adjusted if necessary.22 There is no evidence that penicillins have teratogenic or embryo/fetotoxic properties.23 A higher prevalence of cleft palate after prenatal exposure to ampicillin in the second and third month of pregnancy was revealed though by Czeizel.24 Recommendation: penicillins are the antibiotics of choice in pregnancy and can be safely recommended in usual doses. 2.2. Cephalosporins
Cephalosporins are the most widely used class of antibiotics. Based on their spectrum of activity against gram-negative bacteria, these antibiotics are classified into four generations. Many of the first and second generation cephalosporins have been studied extensively in pregnant patients.25 Cephalosporins also belong to the β-lactam antibiotics, but their pharmacokinetic and antibacterial properties are different from those of penicillins. Although further research is still needed, the first and second generation cephalosporins can be considered safe, with no side-effects for the fetus if used during pregnancy.26 The third and generation of cephalosporins, however, have not been used extensively during pregnancy; therefore, there is little information known about their effects. Forth generation cephalosporins (cefipime) are useful in in pregnancy, but only for cases of severe bacterial sepsis.27 Cephalosporins cross the placenta, and can reach therapeutic levels in amniotic fluid and fetal tissues. It has been revealed that elimination in pregnant women is faster and it may be necessary to adjust dosage.28 Among the first-generation cephalosporins, cephalotin was widely used before it has been proved that it crosses the placental barrier being bound to plasma proteins in an average of 60-70%; thus, when extended to the fetus, many researchers have revealed cases of neonatal kern icterus produced at decreased bilirubin levels.29 Concerning the use of cephalosporins during the perinatal period, the drug of choice is cefuroxime, because its ability to cross the placenta after the second trimester of pregnancy, without fetal toxic side-effects.30 Second and third generation of cephalosporins, especially cefotetan, are increasingly associated with 23 severe immune hemolytic anemia.31 Recommendation: cephalosporins can be used safely during pregnancy if needed; the older, first generation cephalosporin antibiotics are preferred. _____________________________ Simona Sipos et al
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2.3. Macrolide antibiotics
Erythromycin is the oldest of the macrolides. The most extended and suggestive study included the infants of 398 women who received erythromycin for different infectious diseases during the second and third trimesters of pregnancy; the safety of this common used macrolide antibiotic was proved by the lack of congenital anomalies in the pediatric study group. When considering the different side-effects affecting the neonate’s liver, only the estolate ester of erythromycin was correlated with an increased rate of hepatotoxicity. The levels of serum glutamic oxaloacetic transaminase ranged from 44 to 130 IU/L, but the subclinical and biological changes were reversible.32 Many studies revealed a better understanding of the beneficial effects of erythromycin treatment upon delaying premature rupture of membranes, as well as improving pregnancy evolution in the last trimester with no side-effects on neonatal outcome.33 In a recent study, Källén reported an increased rate of cardiovascular malformations (1.8%), especially ventricular and atrial septal defects; he concluded that even the association is causal, the individual risk for an infant is still low.34 The association between prenatal exposure to erythromycin and infant pyloric stenosis is still controversial; thus, an increased risk (0.2%), was revealed by Cooper.35 Clarithromycin has a similar chemical structure to erythromycin. Relatively few epidemiological studies have examined the congenital anomalies induced in neonates following in utero exposure. There have been often reported cardiovascular abnormalities, and in some cases cleft palate, fetal growth retardation, and embryonic loss, but these results are controversial.36 Even if further research is needed, these data suggest the higher toxicity of clarithromycin during development in comparison with its parent compound, erythromycin.37 The defined underlying relationship between experimental study findings and neonatal risks is still unclear. Recommendation: Erythromycin is still the drug of choice among the macrolides during pregnancy. Erythromycin estolate and troleandomycin should not be given in the second and third trimesters. Newer macrolides such as azithromycin, clarithromycin, josamycyn, and roxithromycin are second-choice macrolides. Spiramycin is the drug of choice for the treatment of toxoplasmosis during the first trimester. 2.4. Lincomycin and clindamycin
These antibiotics are only indicated during pregnancy when penicillins, cephalosporins, erythro_____________________________
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mycin or the other macrolides are not effective. Nor teratogenic or fetotoxic effects have been reported for lincomycin in 302 pregnancies.38 Intravaginal clindamycin is very effective in the treatment of bacterial vaginosis.39 2.5. Tetracyclines
Several clinical reports point out that the exposure to tetracycline after the third trimester (since week 13 following conception) affects the color of deciduous teeth, which appear yellowish and even darker: brown or gray-brown. At the light of Wood lamp they have the typical fluorescence. Alterations arerelated to the type of tetracycline, its dosage, the length of treatment and the stage of teeth calcification at the moment of exposure. In case of exposure to tetracyclines in the last period of pregnancy also the crown of permanent teeth may possibly be stained.40 Most authors agreed the fact that only the deciduous teeth are involved in the staining process. Thus, if the drug administration occurs close to term, the crowns of the permanent teeth are affected by the antibiotic and may be stained. This process has only cosmetic signification, without affecting the development of the enamel, or increasing the caries rate. After in utero exposure to tetracycline were pointed out similar staining affecting the bones of the fetus. Important consequences on bone status during childhood with teeth staining and a 40% depression of bone growth have been revealed after tetracycline, doxycycline, and minocycline administration during the second or third trimester of pregnancy.41 Interesting researches in the field of premature infants have reported the correlation between the use of tetracyclines during pregnancy and decreased rates of bone growth.42 Recommendation: Tetracyclines are contraindicated beyond the fifteenth week of gestation. In the first trimester – they are considered to be second-line therapy. Doxycycline should be preferred in such cases. 2.6. Sulfonamides and trimethoprim
Sulfonamides cross the placenta well and fetal concentrations are 50-90% of maternal plasma concentrations. Due to their bilirubinmobilizing capacity, they may increase the risk of hyperbilirubinemia in the neonate when used near the delivery.43 Very high doses of trimethoprim have produced teratogenic effects (cleft palate) in rats. However, there is no strong evidence to suggest that trimethoprim or co-trimoxazole cause a serious risk of teratogenicity in human.44
Recommendation:
Sulfonamides, trimethoprim, and co-trimoxazole may be safe alternative drugs for antibiotic treatment of urinary tract infections when penicillins and cephalosporins are ineffective. When trimethoprim or co-trimoxazole are needed in the first trimester, folic-acid supplementation (0,5 mg/day) is recommended.45,46 2.7. Quinolones
Quinolones cross the placenta and are found in the amniotic liquid in low concentrations. Umbilical cord concentrations of ciprofloxacin, pefloxacin, and ofloxacin have been found to be lower than maternal blood concentrations.47 The use of quinolones in the first trimester of pregnancy has not been associated with an increased risk of major malformations or other adverse effects on pregnancy outcome.48 The relationship between the prenatal use of fluoroquinolones and the increased risk of bone malformations was studied by Wogelius in 2005; he pointed out that the study on 130 women who redeemed a prescription of fluoroquinolones during the first trimester or 30 days before conception did not find a significant increase of (such) birth defects.49 Recommendation: Quinolones should only be used in case of complicated infections resistant to the antibiotics of choice in pregnancy. Ciprofloxacin and norfloxacin should then be chosen, because of their relatively large documented experience. Even the first-trimester use of a quinolone antibiotic is not an indicator for termination of pregnancy, but detailed ultrasonography is needed.50
first four month of pregnancy after aminoglycoside exposure.53,54 Elevated gentamycin serum levels have been detected in nursing infants one hour after gentamycin administration. It is important to find out if accumulation from chronic drug exposure affects the vital organs of the newborn; several previous studies have suggested that this process may be correlated with the gestational age and with the fetal renal function.55 Recommendation: Aminoglycosides are not recommended for parenteral use during pregnancy. They should only be administered in case of lifethreatening infections; in those cases, maternal serum levels should be carefully monitored and dose should be adjusted if necessary. When higher doses have been used, renal function should be monitored in the neonate and an auditory test should be performed. 2.9. Cloramphenicol
Cloramphenicol is relatively toxic, and can cause severe agranulocytosis. It crosses the placenta well and can reach therapeutic concentrations in the fetus. It should not be used in the last weeks of pregnancy as, owing to inadequate metabolism in the neonate, toxic concentrations can be reached which may cause the â&#x20AC;&#x153;gray baby syndromeâ&#x20AC;? (feeding problems, vomiting, ash-gray skin, respiratory distress, and cardiovascular collapse), which may be fatal in the neonate.56 Recommendation: Cloramphenicol and thiamphenicol are contraindicated during pregnancy unless there is a serious indication. Treatment during the first trimester is not an indication for termination of pregnancy or for massive prenatal diagnostic procedures.
2.8. Aminoglycosides
Currently, there is a lack of epidemiological studies concerning congenital fetal anomalies among pediatric population when mothers received gentamycin during pregnancy. It is well known that gentamycin use is correlated with nephrotoxicity; many researchers tried to understand the mechanisms involved in fetal kidney damage after maternal therapy during pregnancy.51 While maternal gentamycin side-effects, like fetal nephropathy after maternal therapy, are still in debate, severe neonatal renal damages have been revealed. A special concern affects premature infants, and the ability to eliminate gentamycin may be correlated with post-conception age and not with the age from birth.52 The use of gentamycin as an aminoglycoside during pregnancy may be also correlated with an increased risk for fetal auditory nerve damage, as previously reported with streptomycin exposure. The higher incidence of side-effects is considered to be the
2.10. Polypeptide antibiotics
Only few epidemiological studies concerning in utero exposure to colistin and polymyxin B have been reported. In a retrospective clinical survey, there were no adverse effects associated with the use of polymyxin B during pregnancy. However, the safety of using this compound during pregnancy is needed to be evaluated in further longitudinal studies, and therefore these antibiotics have an undetermined risk for use during pregnancy.57 There is a case report of a woman who became hypotensive when vancomycin was infused too rapidly during labor; the fetus exhibited bradycardia during the hypotensive episode.58 Recommendation: Vancomycin should only be used in case of life-threatening bacterial infections.59 Even if the majority of antimicrobial drugs can cross the placental blood barrier, there are few data _____________________________ Simona Sipos et alâ&#x20AC;&#x192;
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Table II. Overview of Published Trials of Transplacental Passage of Antibiotics
Table 2. Overview of published trials of transplacental passage of antibiotics. Study
Design
Sample size
Antibiotic in pregnant women
Study outcome - Fetal risk
Czeizel AE24
RCT
105
Ampicillin
Cleft palate
SumnerJY29
RCT
69
Cephalotin
Kernicterus
RCT
58
Cefazolin
High risk of neonatal kernicterus
RCT
128
Cefotetan
Severe immune hemolytic anemia
RCT
268
Erythromycin estolate
Hepatotoxicity (SGOT – 44-130 IU/L)
RCT
275
Erythromycin
Increased rates of PROM
RCT
1585
Erythromycin
Cardiovascular malformations
RCT
448
Erythromycin estolate
Innfantile hypertrophic pyloric stenosis
RCT
350
Clarithromycin
Mitchell TF
27
31
Garraty G
32
Mc Cormack WM Czeizel AE Källén B
33
34
Cooper WO Einarson A
35
36
Cardiovascular abnormalities, cleft palate, fetal growth retardation
CzeizelAE41
RCT
1247
Oxytetracycline
Decreased rates of bone growth in premature infants
Boskovic R
46
RCT
1336
Cotrimoxazole
Preterm birth reduction
49
RCT
215
Fluoroquinolones
Increased risk of bone malformations
RCT
320
Gentamycin
Nephrotoxicity
RCT
1345
Cloramphenicol
Gray baby syndrome
Wogelius P 55
Jin ZK
56
Basim I
RCT: Randomized Clinical Trial
referring to the teratogenic effects, and toxicity upon fetus and neonate; the clinical experience with these drugs during pregnancy is also limited and of varying reliability. This article reviews the available clinical trials mostly suggestive for the pharmacology of various antibiotic agents administered during pregnancy, with special interest on evidence related to fetal toxicity. (Table 2)
CONCLUSION Even if the use of antibiotics prescribed to pregnant women is a requirement in many infectious conditions, most of the side-effects and mechanisms induced by these drug exposure remain unclear. If in certain situations an antibiotic must be prescribed, it is important to be well informed about the effects of such drug on pregnancy, in order to choose the most appropriate treatment with the lowest risk to the fetus and neonate.
ACKNOWLEDGEMENT During the research described in this paper, the first author, Simona Sipos, benefitted by a grant from the PhD programme POSDRU/88/1.5/S/63117.
1. Sarkar M, Woodland C, Koren G, et al. Pregnancy outcome following gestational exposure to azithromycin. BMC Pregnancy and Childbirth 2006;6:18-22. 2. Lynch CM, Sinnott JT, Holt DA, et al. Use of antibiotics during pregnancy. Am Fam Phys 2007;12:33-7. 3. Meyer JM, Rodyold KA. Safety and toxicity of antimicrobials during pregnancy. Infect Med 2007;22(11):600-12. 4. Rayman D, Phil M, Wijnen H, et al. Maternal selenium status during early gestation and risk of preterm birth. CMAJ 2011;183(5):549-55. 5. Dogaru MT, Vari EV. Medicamentul, sarcina şi alăptarea. Târgu Mureş: University Press, 2007. 6. Teo SK, Denny KH, Stirling DI, et al. Effects of thalidomide on developmental, peri- and postnatal function in female New Zealand white rabbits and offspring. Toxicol Sci 2004;81:379–89. 7. Schaefer C, Peters P, Miller RK. Drugs during pregnancy and lactation. Treatment options and risk assessment. 2nd Ed. Amsterdam, Boston, Heidelberg, London, New York, Oxford, Paris, San Diego, San Francisco, Singapore, Sydney, Tokyo: Academic Press, 2007. 8. Hui I, Bianchi DW. Prenatal pharmacotherapy for fetal anomalies: a 2011 update. Prenat Diagn 2011;31(7):735-43. 9. Blackburn S, Faan RN. Fetal Pharmacotherapy. J Perinat Neonat Nurs 2008;22(4):264-6. 10. Miller RK. Basic principles in drug-induced reproductive and developmental toxicology. In: Schaefer C, Peters P, Miller RK. Drugs during pregnancy and lactation. Treatment options and risk assessment. 2nd Ed. Amsterdam, Boston, Heidelberg, London, New York, Oxford, Paris, San Diego, San Francisco, Singapore, Sydney, Tokyo: Academic Press, 2007, p. 9-12. 11. Morselli I, Franco-Morselli R, Bossi I. Clinical pharmacokinetics in newborns and infants: age-related differences and therapeutic implications. Clin Pharmacokinet 2010;5(11):484-527. 12. Lobstein R, Lalkin A, Koren G. Pharmacokinetic changes during pregnancy and their clinical relevance. Clin Pharmacokinet 1997;33:328-43.
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13. Carney EW, Scialli AR, Watson RE, et al. Mechanisms regulating toxicant disposition of the embryo during early pregnancy: an interspecies comparison. Birth Defects Res C Embryo Today 2004;72:345-60. 14. Miller RK. Does the placenta product against insult or is it the target? Teratology Primer, Reston, VA: Teratology Society, 2005, p. 22-6. 15. Juchau MR. Bioactivation in chemical teratogenesis. Ann Rev Pharmacol Toxicol 2009;29:165-87. 16. Gonser M, Stoll P, Kahle P. Clearance prediction and drug dosage in pregnancy. A clinical study on metildigoxin, and application to other drugs with predominant renal elimination. Clin Drug Invest 2005;9:197-205. 17. Briggs GG, Polifka J; R. Organization of Teratology Information Specialists. Better data needed from pregnancy registries. Birth Defects Res A Clin Mol Teratol 2009;2:109-11. 18. Draper JC, Cox KW, Teratology and Drug Use During Pregnancy. Birth Defects Res A Clin Mol Teratol 2011;2:83-5. 19. Knothe GA, Dette A. Antibiotics in pregnancy. Infection 2005;13:3-7. 20. Briggs GG, Freeman RK, Yaffe SJ. Classification of drugs for teratogenic risk: an anachronistic way of counseling: a reply to Merlob and Stahl. Birth Defects Res 2003;67:207-8. 21. Heinonen OP, Shapiro S. Birth defects and drugs in pregnancy. 3rd ed. Littleton MA: Publishing Sciences Group, 2008, p. 79-81. 22. Heikkla A, Erkkola R. Review of beta-lactam antibiotics in pregnancy. The need for adjustment of dosage schedules. Clin Pharmacokinet 2004;125:50-4. 23. Berkowitch M, Diav-Citrin O, Greenberg R, et al. First-trimester exposure to amoxicillin/clavulanic acid: a prospective cohort study. Br J Clin Pharmacol 2004;58:298-302. 24. Czeizel AE. Teratogenic study of penicillin and doxycycline. Obstet Gynecol 2007;29:324-7. 25. Porter RS, Kaplan JL. The Merck Manual of Diagnosis and Therapy 19th ed. Whitehouse Station: Merck, Sharp & Dhome Corp., 2010, p. 188-95. 26. Cunha BA. Antibiotic Essentials. 5th ed. Royal Oak, Mich: Physicians Press; 2006, p. 92-103. 27. Cunha BA. Current therapy. Infect Dis Clin North Am 2007;283(7):13-7. 28. Mitchell TF, Pearlman MD, Chapman RL, et al. Maternal and transplacental pharmacokinetics of cefazolin. Obst Gynecol 2001;98:1075-9. 29. Sumner JY, Aranda JV. Neonatal and Pediatric Pharmacology. Therapeutic Principles in Practice. 5 ed. New York: Lippincot Williams&Wilkins, 2005, p. 144-7. 30. Berkovitch M, Segal-Socher M, Greenberg R, et al. First trimester exposure to cefuroxime: Br J Clin Pharmacol 2000;50:161-5. 31. Garraty G, Leger RM, Arndt PA. Severe immune hemolytic anemia associated with prophylactic use of cefotetan in obstetric and gynecologic procedures. Am J Obstet Gynecol 1999;181:103-4. 32. Mc Cormack WM, George H, Donner A, et al. Hepatotoxicity of erythromycin estolate during pregnancy. Antimicrob Agents Chemother 1977;12:630-5. 33. Czeizel AE, Rockenbauer M. Use of antibiotics during early pregnancy. Eur J Obst Gynecol 2002;11:1-5. 34. Källén B, Otterblad AJ, Olausson P. Is erythromycin therapy teratogenic in humans? Reprod Toxicol 2005;20:209-14. 35. Cooper WO, Ray WA, Griffin MR. Prenatal description of macrolide antibiotics and infantile hypertrophic pyloric stenosis. Obstet Gynecol 2002;100:101-6. 36. Einarson A. Pregnancy outcome after clarithromycin in pregnancy. Am J Perinatal 2008;9:523-5. 37. Drinkard CR, Shatin D, Clouse J. Postmarketing surveillance of
medications and pregnancy outcomes: clarithromycin and birth malformations. Pharmacoepidemiol Drug Saf 2000;9:549-56. 38. Czeizel AE, Rockenbauer M, Sorensen HT. A teratological study of lincosamides. Scand J Infect Dis 2000;32:579-80. 39. Joesoef MR, Schmid GP, Hillier SL. Bacterial vaginosis: a review of treatment options and potential clinical indications for therapy. Clin Infect Dis 1999;28(Suppl 1):S57-65. 40. Shepard TH, Brentt RL, Friedman JM, et al. Update on new developments in the study of human teratogens. Teratology 2002;65:153-61. 41. Czeizel AE, Rockenbauer M. A population based case-control teratologic study of oral oxytetracycline treatment during pregnancy. Eur J Obstet Gynecol Reprod Biol 2000;88:27-33. 42. Landers DV, Wiesenfeld HC, Heine RP, et al. Predictive value of the clinical diagnosis of lower genital tract infection in women. Am J Obstet Gynecol 2004;190:1004–10. 43. Brumfitt W, Pursell R. Trimethoprim sulfamethoxazole in the treatment of bacteriuria in women. J Infect Dis 1973;128:657-63. 44. Czeizel AE, Fladung B, Vargha P. Preterm birth reduction after cotrimoxazole treatment during pregnancy. Eur J Obstet Gynecol Reprod Biol 2004;116:157-63. 45. Kinzy BJ, Taylor JW. Trimethoprim and folinic acid. Ann Intern Med, 1984;101:565. 46. Boskovic R, Koren G. Placental Transfer of Drugs. In: Sumner JY, Aranda JV. Neonatal and Pediatric Pharmacology. Therapeutic Principles in Practice. 5th ed. New York: Lippincot Williams&Wilkins, 2005, p. 136-46. 47. Giammarellou H, Kolokythas I, Petrikkos G, et al. Pharmacokinetics of three newer quinolones in pregnant and lactating women. Am J Med 1989;87:49-51. 48. Larsen H, Nielsen GL, Schonheyder HC et al. Birth outcome following maternal use of fluoroquinolones.Intl J Antimicrob Agents 2001;18:259-62. 49. Wogelius P, Norgaard M, Gislum M, et al. Further analysis of the risk of adverse birth outcome after maternal use of fluoroquinolones. Intl J Antimicrobial Agents 2008;26:235-7. 50. Loebstein R, Addis A, Ho E, et al. Pregnancy Outcome Following Gestational Exposure to Fluoroquinolones. Antimicrob Agents Chemother 2008;42(6):1336-9. 51. Jolley JA, Wing DA. Pyelonephritis in pregnancy: an update on treatment options for optimal outcomes. Drugs 2010;70(13):1643-55. 52. Yaris F, Kadioglu M. Gentamycin use in pregnancy. A renal anomaly. Saudi Med J, 2004;25:958-9. 53. Hill JB, Sheffield JS, McIntire DD, et al. Acute pyelonephritis in pregnancy. Obstet Gynecol 2007;105(1):18-23. 54. Sanchez-Sainz-Trapaga C, Gutierrez Fonseca R, Ibanez-Ruiz C, et al. Relationship between a case of severe hearing loss and use of gentamycin in the pregnant mother. An Esp Pediatr 1998;49:397-9. 55. Jin ZK. Effects of gentamycin on the fetal kidneys. Chinese J Obstet Gynecol 1992;27:221-2. 56. Basim I, Abdel-Haq NM. Macrolides, Cloramphenicol and Tetracyclines. In: Sumner JY, Aranda JV. Neonatal and Pediatric Pharmacology. Therapeutic Principles in Practice. 5th ed. New York: Lippincot Williams&Wilkins, 2005, p. 402-30. 57. Kazy Z, Puho E, Czeizel AE. Parenteral polymixin B treatment during pregnancy. Reprod Toxicol 2005;20:209-14. 58. Hill LM. Fetal distress secondary to vancomycin-induced maternal hypotension. Am J Obstet Gynecol 1985;153:91-5. 59. Bonow RO. ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease. J Am Coll Cardiol 2006;48:1-148.
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REVIEW ARTICLES
THE PLACE OF ECHOCARDIOGRAPHY IN THE ASSESSEMENT OF PATIENTS RECEIVING CARDIOTOXIC CANCER THERAPIES: NEW HORIZONS Cristian Mornos, Adina Ionac REZUMAT În ultimii ani tratamentul afecțiunilor oncologice a cunoscut progrese importante, ce au condus la o scădere semnificativă a morbidității și mortalității mai multor forme de cancer. Managementul pacienților cu cancer include combinații de chimioterapie, radioterapie și chirurgie, iar acestea pot cauza complicații cardiovasculare. Cea mai eficientă metodă de apreciere a disfuncției ventriculare stângi induse de terapia antineoplazică este ecocardiografia transtoracică. Ecocardiografia convențională prezintă unele limitări privind analiza funcției micoardice, fiind prea puțin sensibilă la modificările subtile ale funcției ventriculare care apar în cardiotoxicitatea timpurie, înaintea scăderii fracției de ejecție ventriculare stângi. Noile tehnici ecocardiografice au ameliorat capacitatea de a detecta modificările cardiotoxice. Scopul acestui review este de a sumariza cunoștiințele actuale cu privire la evaluarea ecocardiografică a complicațiilor cardiovasculare induse de chimioterapie.
ABSTRACT In the last years cancer treatment has shown an important progress leading to an significant reduction of morbidity and mortality of several kinds of cancer. The management of patients with cancer includes combinations of chemotherapy, radiotherapy and surgery, but these can cause cardiovascular complications. The most appropriate method of assessing left ventricular dysfunction induced by antineoplastic therapy is transthoracic echocardiography. Conventional echocardiography has several limitations regarding the analysis of myocardial function and is insensitive in detecting the subtle changes in ventricular function which occur in early cardiotoxicity, before left ventricular ejection fraction decreases. Newer echocardiographic techniques have enhanced the ability to detect cardiotoxicity at an early stage; in this regard, tissue Doppler imaging and bidimensional strain analysis using speckle tracking promises to be particularly useful. The purpose of this review is to summarize the current state of echocardiographic assessement of common cardiovascular complications induced by chemotherapy.
INTRODUCTION In the last years cancer treatment has shown an important progress leading to a significant reduction of morbidity and mortality of several kinds of cancer. The therapeutic management of patients with cancer includes multiple combinations of chemotherapy, radiotherapy, and surgery. However, many of these treatments can cause cardiovascular complications such as heart failure (HF), myocardial ischemia/ infarction, hypertension, thromboembolism, and arrhythmias.1,2
Department of Cardiology, Institute of Cardiovascular Diseases, Victor Babes University of Medicine and Pharmacy, Timisoara Correspondence to: Cristian Mornos, MD, Institute of Cardiovascular Diseases, 13A G.Adam Str., Timisoara, Tel. +40256207355 Email: mornoscristi@yahoo.com Received for publication: Feb. 22, 2011. Revised: Nov. 17, 2011. _____________________________
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This can negatively affect the quality of life as well as the prognosis of oncologic patients. Chemotherapyinduced cardiotoxicity is of rising concern for both cardiologists and oncologists. Therefore, identifying these effects is crucial to the successful management of cancer patients with cardiovascular complications. The traditional screening of patients with cancer includes cardiologic examination, and both electrocardiography and transthoracic echocardiography at rest.3,4 Also biomarkers such as troponine and natriuretic peptides may be useful for early diagnosis of cardiotoxicity.3-8 The most appropriate method of assessing antineoplastic therapy induced cardiotoxicity is transthoracic echocardiography, which can measure cardiotoxicity in a quantitative, non-invasive manner. Standard echocardiography evaluate the global cardiac function. As such, current treatment guidelines emphasize prevention and early intervention for atrisk individuals and individuals with asymptomatic decreased left ventricular ejection fraction (LVEF).9 Doppler measurements require adequate imaging windows and parallel alignment of the Doppler cursor with blood flow to avoid underestimation of
Doppler jet velocity and calculated pressure. These parameters are dependent on heart rate and loading conditions and lack validity in patients with preserved EF and are insensitive in detecting the subtle changes in myocardial function which occur in early cardiotoxicity. Newer echocardiographic techniques have enhanced the capability to detect cardiotoxicity at an early stage; in this regard, tissue Doppler imaging (TDI) and bidimensional (2D) strain analysis promise to be particularly useful.1,4 The purpose of this review is to summarize the current state of echocardiographic assessement of common cardiovascular complications induced by chemotherapy.
CHEMOTHERAPY AGENTS AND CARDIOTOXICITY Several therapies for cancer have been associated with the development of LV dysfunction and/or HF. The cumulative dose, the administration schedule, and the concomitant use of other cardiotoxic therapies determine the likelihood of cardiomyopathy.2 Cardiotoxicity can be divided into four types: acute, subacute, chronic and late-onset10. Acute complications are usually observed after the first administration of high doses, affect elderly patients, and include electrocardiographic abnormalities (atypical ST-T changes, reduced QRS voltages, sinus tachycardia, premature supraventricular and ventricular complexes, QT interval prolongation, or acute myocardial ischemia). These derangements are usually associated with few symptoms, but may be asymptomatic at all, resolving spontaneously several hours or weeks after the completion of chemotherapy in several patients. Sub-acute cardiotoxicity is rare, appears several days or weeks after the last dose of drug and is most frequent manifestated as pericarditis or myocarditis. Chronic cardiotoxicity is observed in patients exposed to repeated doses of chemotherapy, occurs several weeks or months after chemotherapy (within 1 year following treatment) with overt congestive HF due to LV dysfunction, has a poor prognosis and its strictly dependent on the total dose administered. Finally, late cardiotoxicity is diagnosed at >1 year following treatment, may be manifested clinically as congestive HF, arrhythmias and conduction abnormalities, but has a more favorable prognosis, rarely leading to sudden death. Anthracyclines and trastuzumab are the most used antineoplastic drugs with known cardiotoxicity. Anthracyclines (Doxorubicin, Daunorubicin, Epirubicin, Idarubicin), the best studied anticancer drugs, directly damage the myocardium through
production of oxygen free radicals, leading to LV dysfunction and, in some cases, an irreversible cardiomyopathy.1,2 The onset of cardiotoxicity, even asymptomatic, not only negatively impacts the cardiac outcome of cancer patients, but also seriously limits their therapeutic opportunities.11 In adults the incidence of HF induced by anthracycline varies from 4% to 5% at a cumulative dose of 500â&#x20AC;&#x201C;550 mg/m2, to 36% at a cumulative dose 600 mg/m2 or more.2,4,12 Data from oncology literature, however, indicate that more than one-half of all patients exposed to anthracycline will show some degree of cardiac dysfunction 10 to 20 years after chemotherapy, and 5% of them will develop HF.11 On the basis of numerous studies, there is now evidence that many factors predispose to anthracyclineinduced cardiomyopathy.2,10,13 Not only the cumulative dose administered, but also sequence and method of administration, simultaneous administration of other antineoplastic agents and patient related factors (age>70 years, female sex, mediastinum radiotherapy, previous exposure to anthracycline agents, arterial hypertension, prior valvular heart disease and/or cardiomyopathy, electrolytic abnormalities, genetic predisposition) predict cardiotoxicity.2,3,13 Importantly, these early studies focused only on patients in whom symptomatic HF developed. A potentially successful strategy for reducing the cardiotoxicity associated with conventional doxorubicin involves liposomal encapsulation, an advanced and versatile drug delivery system which alters the tissue distribution and pharmacokinetics of these agents while preserving antitumor efficacy (liposomal anthracyclines).13 Monoclonal antibodies (Alemtuzumab, Bevacizumab, Cetuximab, Rituximab, Trastuzumab), modernly applied for treatment of some hematologic malignancies and solid tumors, have toxicity profiles specific to the blocked receptors but all produce arterial hypotension.1,2 Trastuzumab, used to treat breast cancer patients with overexpression of human epidermal growth factor receptor 2, has an unclear mechanism for cardiotoxicity. Most likely trastuzumab interferes with normal growth, repair, and survival of cardiomyocytes.1,2 Anthracycline exposure is clearly important; cardiotoxicity is worse if trastuzumab is administered in parallel with, rather than following anthracyclines.2 Due to the known cardiotoxicity of trastuzumab, the package insert recommends baseline LVEF assessment and reassessment every 3 months during and upon completion of this therapy.14 Alkylators (Busulfan, Cyclophosphamide, Cisplatin, Mytomicin), used for several solid tumors and lymphomas, may induce HF, myocarditis and pericarditis related to endothelial and cardiomyocyte _____________________________ Cristian Mornos et alâ&#x20AC;&#x192;
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injury mediated by a toxic metabolism.1,2 Antimetabolities (5-fluorouacil, Clofarabine) and antimicrotubule agents (Docetaxel, Paclitaxel, Vinca Alkaloids) applied also to the treatment of several solid tumors, may induce ischemic syndrome (angina pectoris and myocardial infarction), arrhythmias and cardiomyopathy.1,2 Most of the other chemotherapeutic agents (Cytokines, Imatinib mesylate, Etoposide, etc.) have also been correlated with cardiotoxicity, but this was generally rare and reversible.1,2 Routine cardiac monitoring is not considered relevant for classes of chemotherapy other than anthracyclines and trastuzumab.
ELECTROCARDIOGRAPHY AND CARDIOTOXICITY Electrocardiography is the traditional support and completion to the clinical examination, but the electrical abnormalities are often non-specific: ST-T changes, decreased QRS voltage and QTinterval prolongation (acute toxicity induced by anthracycline), malignant arrhythmias (cardiotoxicity induced by chronic anthracycline, cyclophosphamide, interferon-α or interleukin-2), or signs of myocardial ischemia (5-Fluorouracil)2.1-3 Increased QT-interval dispersion has been recently found to be a predictor of acute HF after cyclophosphamide therapy and to persist even in late survivors of childhood anthracycline treatment.1,2
BIOMARKERS Natriuretic peptides have been used for the noninvasive assessment of LV function. Increased levels are produced mainly in response to LV wall pressure and volume overload, and are strongly related to symptoms, cardiac events and mortality.3,7,8 In the setting of chemotherapy, however, data regarding the use of natriuretic peptides for monitoring are inconclusive.3,7 Although widely used in current oncology studies, its clinical value remains thus to be proven. Cardiac troponin is a powerful biomarker for the sensitive and specific detection of cardiac injury arising from various causes. Elevations of serum troponin levels have been reported also after anthracycline chemotherapy, indicating myocardial damage and predicting subsequently cardiac morbidity and mortality.3,5,6 The place of troponin and its clinical value on the non-invasive assessement of patients receiving cardiotoxic cancer therapies is also controversed.3 _____________________________
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CONVENTIONAL ECHOCARDIOGRAPHY Current common sense is to assess baseline cardiac function before therapy in order to document normal LV function and schedule further regular evaluations to detect signs or symptoms of cardiac involvement. The most appropriate method of assessing chemotherapy induced cardiotoxicity is conventional echocardiography.4 In these evaluations, a variety of parameters are applied. At present, resting LVEF by 2D-echocardiography is the key parameter used to identify and monitor cardiotoxicity. In clinical oncology practice, asymptomatic decreases in LVEF are the most commonly encountered form of cardiotoxicity.14,15 LVEF has been validated by comparison with a variety of reference standards, and clear guidelines regarding its acquisition and calculation are published.11 However, LVEF presents numerous limitations: it relies on simplified assumptions about cardiac geometry (if the geometry is abnormal, the measurement is open to error), it is dependent on 2D image quality and on the transducer position, is unable to detect subtle regional alterations in myocardial mechanics, and it is influenced by variable preload and afterload conditions.11 In many studies, cardiac toxicity is assumed if (a) LVEF drops more than 10% from baseline to values below 50%, (b) LVEF drops more than 20% from baseline despite still normal function, or (c) LVEF drops below 45%. Early decreases in the LVEF after chemotherapy may be associated with significant cardiotoxicity at a later time; the long-term significance of transient decreases in LVEF during cancer therapy is not well-known, although data suggest that the response to injury of various causes is similar, with negative remodeling leading to progressive LV dysfunction over time.14 A study performed to investigate possible acute effects in patients with Hodgkin’s lymphoma did not show significant changes of M-mode derived LV end-diastolic diameter, end-systolic diameter and EF but identified regional wall motion abnormalities (hypokinesis) by 2D assessment.15 More recently it has been established that HF can result from abnormalities of diastolic function, where LVEF is relatively preserved. Stoddard et al found that prolonged Doppler-derived isovolumetric relaxation time preceded and reliably predicted anthracyclineinduced systolic dysfunction.16 Early peak flow velocity to atrial peak flow velocity (E/A) ratio, deceleration time and isovolumic relaxation time were all in more than 50% of patients treated by anthracyclines, when EF was still normal.17 Parameters of diastolic function (E/A ratio, isovolumic relaxation time, and pulmonary
venous flow pattern) can easily be measured with resonable accuracy, but are highly sensitive to any change in the circulatory system and, thus, rather unspecific for cardiotoxicity evaluation.3 Myocardial performance index (the sum of isovolumic contraction time and isovolumic relaxation time devided by ejection time), accurate marker of global LV function, may be particularly useful since it appeared significantly altered in patients receiving chemotherapy.18-20 Dobutamine stress echocardiography was tested in several studies to detect subclinical abnormalities of LV function induced by anthracycline cardiotoxicity but studies findings appear insufficient or controversial1. Stress echocardiography, an optimal tool to unmask coronary artery disease in the general population, remains important also in patients treated radiation therapy, which is able to provoke accelerated coronary atherosclerosis.1 Conventional echocardiography is useful to document valvular heart disease, coronary artery disease, pericarditis and/or myocarditis, developing during cancer therapy, but is insensitive in detecting the subtle changes in ventricular function which occur in early cardiotoxicity, before decreasing of LVEF.2 Newer echocardiographic techniques have enhanced the capability to detect cardiotoxicity at an early stage; in this regard, myocardial velocity and deformation promises to be particularly useful.
ADVANCED ECHOCARDIOGRAPHIC TOOLS FOR EARLY DETECTION OF CARDIOTOXICITY
Figure 1
Tissue Doppler imaging (TDI) has emerged as a complementary method to standard echocardiography, being able to assess the velocity of myocardial segments and other cardiac structures movement. This new
method allows the quantification of both regional and global myocardial function. Two important changes were needed to get from standard echocardiography to TDI: a change in the settings of the machines, that allows the recording of low velocities, and avoiding the over saturation that occurs due to the fact that the myocardium is significantly more echo dense than the blood; changing the gain (decreasing) and the rejet to shunt the filters of high passage was necessary, so the TDI signal reaches straight to the autocorelator.21,22 The filters can be set, in the last generation echocardiography machines, so they ignore the signal reflected by erythrocytes (having low amplitude and high velocity). During the image acquisition time, it is vital to optimize the frame rate by using a narrow sector and an adequate scale of velocities. It is not possible to modify these parameters during off-line analysis. To avoid a series of inconveniences that may occur while recording or analysing the signal, it is recommended to use a frame rate over 100 Hz or even higher if it comes to strain or strain ratetechniques.21,23 TDI is currently available on all modern echocardiograpic systems, and was proposed by the European Association of Echocardiography to be the standard method of exploring LV function, amongst the EAE guideline recommendations regarding the redaction of the transthoracic echocardiographic result24. There are several methods of measuring myocardial and cardiac structures’ velocities with TDI: Pulsed Doppler, M-Mode Color Doppler or Bidimensional Color Doppler. The ratio between early diastolic transmitral velocity (E) and early mitral annular diastolic velocity (E’) has been demonstrated to correlate with LV filling pressure.25 (Fig. 1) E/E’ is currently used for the non-invasive assessment of LV filling pressure. Several studies showed that TDIderived parameters (E/E’, E’) can detect LV dysfunction prior to alterations in conventional indices like heart
Figure 1. Bedside measurements of spectral Doppler peak early transmitral inflow (E) velocity (panel a) and spectral tissue Doppler peak early diastolic (E’) velocities, respectively peak systolic (S’) velocities, at the septal (panel b) and lateral (panel c) corners of mitral annulus. E/E’ ratio was calculated (E/E’ = 11.45). The average of the velocities from septal and lateral mitral annulus was used. _____________________________ Cristian Mornos et al
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Figure 2
rate, LV end-diastolic pressure, or blood pressure and conventional echocardiography in doxorubicininduced cardiac injury.20-23 Tassan-Mangina et al evaluated the early and late anthracycline effects in adults.26 A few months after chemotherapy TDI parameters that explore diastolic function (E, E’, E/A) changed, while changes in systolic function (S’) occurred later. In a recent report, subclinical systolic and diastolic myocardial abnormalities (S’, E’, E/A) were present in asymptomatic breast cancer survivors up to 6 years after standard chemotherapy; adjuvant trastuzumab treatment did not appear to have an additive adverse impact on myocardial function in Figure 2. Longitudinal regional strain determined by tissue Doppler the medium-long term.27 The superiority of TDI imaging. parameters can be attributed to the capacity of reduced S’ to identify LV dysfunction in subjects with normal The 2D-strain technique can evaluate LV LVEF.23 TDI does not require tracing of endocardial deformation in 3 planes (longitudinal, radial and borders, unlike LV volumes and LVEF. circumferential strain) as opposed to TDI derived strain Similarly to conventional Doppler echothat largely quantifies longitudinal strain.21 (Fig. 3) A cardiography, for an accurate TDI analysis it is recently published work suggests that global 2D strain necessary to make a parallel alignment between the and strain rate are superior predictors of impaired ultrasound wave and the movement direction ofFigure LV 3 filling than the E/E’ ratio (the current standard 22,23 the analyzed structure. Consequently, the angle measurement), highlighting the likely value of strain between the ultrasound wave and the movement imaging in the assessment of diastolic function.31 direction must not exceed 20°. Another issue is the complex rotation and translation movement of the heart inside the thorax, with every cardiac cycle, that distorts the measurements of myocardial velocities.22,23 All these factors make the interpretation of the images recorded with TDI more complicated, thus a good theoretical and practical preparation of the ultrasound cardiologist is mandatory. LV function is the results of the contraction and relaxation of helically oriented myofibres.28 LV torsion and global longitudinal strain are essential components of cardiac performance.28,29 With technical improvements in the temporal and spatial resolutions of two-dimensional echocardiography, the myocardial deformation and rotation can now be measured using the 2D-strain with the speckle tracking method.29,30 Currently, Figure 3. Global longitudinal strain of the left ventricle determined by 2D strain measurement is not always a feature strain imaging. of standard ultrasound equipment and strain analysis algorithms differ amongst manufacturers, Bidimensional strain imaging can measurre also making comparison between measurements on the rotational movement of the LV.28,29 Greyscale different ultrasound systems difficult.4 Most strain digital cine loops triggered to QRS complexes must measurements require off-line analysis, are time be acquired from two LV short-axis planes: at LV consuming and involve additional training and basal level with the cross-section as circular as possible expertise. The strain could be measured using TDI (identified by the mitral valve) and at apical level (distally 21 or speckle tracking (from 2D images). (Fig. 2) The to the papillary muscles with an optimized transducer latter requires lower frame rates (40–70 frames per position to ensure a proper, circular short-axis cut second), is relatively angle independent and appears with no papillary muscles present). In each plane, to be more reproducible.21 three cardiac consecutive cycles are recorded during _____________________________
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breath-hold at a frame rate of 70–100 frames/s and stored on hard disk for subsequent off-line analysis. Counter-clockwise rotation is marked as a positive value and clockwise rotation as a negative value when viewed from the apex. The LV twist curve is generated by calculating the difference between apical and basal rotations at each corresponding time point. The LV twist represents the peak difference between rotation angles at the apex and base. (Fig. 4) The LV torsion Figure 4 is defined as peak LV twist divided by LV diastolic longitudinal length.
LV dysfunction induced by anticancer therapies. The advantage of these new echocardiographic techniques is that it does not require a separate examination. TDI is available in most of the last generation echocardiography machines and data acquisition adds only a few minutes to the conventional echo study. Myocardial deformation (strain and strain rate) identifies preclinical myocardial dysfunction earlier than conventional measurements in patients undergoing treatment with antineoplastic therapy. Speckle-tracking technique (also referred to as twodimensional strain method) with its ability to measure systolic and diastolic function, hold great promise for improving the early detection of subclinical myocardial dysfunction due to chemotherapy, but further research is warranted in order to determine its role in this important clinical setting.
ACKNOWLEDGEMENT Figure 4. Apical and basal left ventricular rotation and left ventricular twist determined by 2D strain imaging.
Myocardial deformation identifyes preclinical myocardial dysfunction earlier than conventional measurements in women undergoing treatment with trastuzumab or epirubicin for breast cancer.32,33 Regional LV systolic strain rate and systolic strain were reduced within 2 h after the first dose of anthracyclines in the longitudinal as well as in the radial direction, as showed a recent study.34 Conventional echocardiography failed to show any decline in LVEF or fractional shortening after the first two cycles of treatment, while myocardial deformation parameters had already changed. These parameters remain reduced at 5 years after the completion of therapy, while EF remained within normal limits.35 In a study of the efficacy of modified anthracyclines, significant reductions were observed in strain and strain rate after six cycles of the pegylated liposomal doxorubicin, without a significant decrease in LVEF. Ho et al reported that longitudinal strain abnormalities were present in asymptomatic breast cancer survivors up to 6 years after standard chemotherapy, while radial strain was not influenced.27 2D-strain echocardiographic parameters provide a more refined tool to evaluate regional and global cardiac function, but their role in clinical practice and their cutoff values must be confirmed in multicenter studies. In summary, transthoracic echocardiography and particularly TDI and 2D-strain echocardiography can be considered valuable for the early detection of
This work was supported by CNCSIS–UEFISCU, project number PN II/RU code PD 526/2010.
REFERENCES 1.Galderisi M, Marra F, Esposito R, Lomoriello VS, Pardo M, de Divitiis O. Cancer therapy and cardiotoxicity: the need of serial Doppler echocardiography. Cardiovasc Ultrasound. 2007;5:4. 2. Yeh ET, Bickford CL.Cardiovascular complications of cancer therapy: incidence, pathogenesis, diagnosis, and management. J Am Coll Cardiol 2009;53(24):2231-47. 3. Jurcut R, Wildiers H, Ganame J, D’hooge J, Paridaens R, Voigt JU. Detection and monitoring of cardiotoxicity-what does modern cardiology offer? Support Care Cancer 2008;16(5):437-45. 4. Stoodley PW, Richards DA, Meikle SR, Clarke J, Hui R, Thomas L. The potential role of echocardiographic strain imaging for evaluating cardiotoxicity due to cancer therapy. Heart Lung Circ 2011;20 (1):3-9. 5. Cardinale D, Sandri MT, Colombo A, Colombo N, Boeri M, Lamantia G, Civelli M, Peccatori F, Martinelli G, Fiorentini C, Cipolla CM: Prognostic value of troponin I in cardiac risk stratification of cancer patients undergoing high-dose chemotherapy. Circulation 2004, 109:2749-2754. 6. Lipshultz SE, Rifai N, Sallan SE, Lipsitz SR, Dalton V, Sacks DB, Ottlinger ME. Predictive value of cardiac troponin T in pediatric patients at risk for myocardial injury. Circulation 1997;96:2641–2648. 7. Daugaard G, Lassen U, Bie P, Pedersen EB, Jensen KT, Abildgaard U, Hesse B, Kjaer A. Natriuretic peptides in the monitoring of anthracycline induced reduction in left ventricular ejection fraction. Eur J Heart Fail 2005;7(1):87–93 8. Okumura H, Iuchi K, Yoshida T, Nakamura S, Takeshima M, Takamatsu H, Ikeno A, Usuda K, Ishikawa T, Ohtake S, Matsuda T. Brain natriuretic peptide is a predictor of anthracyclineinduced cardiotoxicity. Acta Haematol 2000;104:158–163 9. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2009;53:e1–90. 10. Lotrionte M, Palazzoni G, Natali R, Comerci G, Abbate A, Di Persio S, Biondi-Zoccai GG. Appraising cardiotoxicity associated with liposomal doxorubicin by means of tissue Doppler echocardiography _____________________________ Cristian Mornos et al
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end-points Rationale and design of the LITE (Liposomal doxorubicin–Investigational chemotherapy–Tissue Doppler imaging Evaluation) randomized pilot study. Int J Cardiol 2009;135(1):72-7. 11. Cardinale D, Colombo A, Lamantia G, Colombo N, Civelli M, De Giacomi G, Rubino M, Veglia F, Fiorentini C, Cipolla CM. Anthracycline-induced cardiomyopathy: clinical relevance and response to pharmacologic therapy. J Am Coll Cardiol 2010;55(3):213-20. 12. Swain SM, Whaley FS, Ewer MS. Congestive heart failure in patients treated with doxorubicin: a retrospective analysis of three trials. Cancer 2003;97(11):2869–79. 13. Theodoulou M, Hudis C. Cardiac profiles of liposomal anthracyclines: greater cardiac safety versus conventional doxorubicin? Cancer 2004;100:2052–63. 14. Yoon GJ, Telli ML, Kao DP, Matsuda KY, Carlson RW, Witteles RM. Left ventricular dysfunction in patients receiving cardiotoxic cancer therapies are clinicians responding optimally?J Am Coll Cardiol 2010;56(20):1644-50. 15. Krupicka J, Markova J, Pohlreich D, Kozak T, Linkova H, Diehl V: Echocardiographic evaluation of acute cardiotoxicity in the treatment of Hodgkin disease according to the German Hodgkin’s Lymphoma Study Group. Leuk Lymphoma 2002, 43:2325-2329. 16. Stoddard MF, Seeger J, Liddell NE, Hadley TJ, Sullivan DM, Kupersmith J. Prolongation of isovolumetric relaxation time as assessed by Doppler echocardiography predicts doxorubicin-induced systolic dysfunction in humans. J Am Coll Cardiol 1992;20(1):62–9. 17. Tjeerdsma G, Meinardi MT, van Der Graaf WT, van Den Berg MP, Mulder NH, Crijns HJ, de Vries EG, van Veldhuisen DJ: Early detection of anthracycline induced cardiotoxicity in asymptomatic patients with normal left ventricular systolic function: autonomic versus echocardiographic variables. Heart 1999, 81:419-423. 18. Ocal B, Oguz D, Karademir S, Birgen D, Yuksek N, ertem U, Cabuk F: Myocardial performance index combining systolic and diastolic myocardial performance in doxorubicin-treated patients and its correlation to conventional echo/Doppler indices. Pediatr Cardiol 2002, 23:522-527. 19. Karakurt C, Koçak G, Ozgen U. Evaluation of the left ventricular function with tissue tracking and tissue Doppler echocardiography in pediatric malignancy survivors after anthracycline therapy. Echocardiography 2008;25(8):880-7. 20. Baysal T, Koksal Y, Oran B, Sen M, Unal E, Cimen D. Cardiac functions evaluated with tissue Doppler imaging in childhood cancers treated with anthracyclines. Pediatr Hematol Oncol 2010;27(1):13-23. 21. Pellerin D, Sharma R, Elliott P, Veyrat C. Tissue Doppler, strain, and strain rate echocardiography for the assessment of left and right systolic ventricular function. Heart 2003; 89:iii9. 22. Price DJ, Wallbridge DR, Stewart MJ. Tissue Doppler imaging: current and potential clinical applications. Heart 2000; 84 Suppl 2:II11-8. 23. Nikitin NP, Witte KK. Application of tissue Doppler imaging in cardiology. Cardiology 2004; 101(4):170-184.
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24. Evangelista A, Flachskampf F, Lancellotti P, et al. European Association of Echocardiography. European Association of Echocardiography recommendations for standardization of performance, digital storage and reporting of echocardiographic studies. Eur J Echocardiogr 2008;9(4):438-48. 441–58. 25. Nagueh SF, Middleton KJ, Zoghbi WA, Quinones MA. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997; 30:1527–1533. 26. Tassan-Mangina S, Codorean D, Metivier M, Costa B, Himberlin C, Jouannaud C, Blaise AM, Elaert J, Nazeyrollas P. Tissue Doppler imaging and conventional echocardiography after anthracycline treatment in adults: early and late alterations of left ventricular function during a prospective study. Eur J Echocardiogr 2006;7(2):141–146 27. Ho E, Brown A, Barrett P, Morgan RB, King G, Kennedy MJ, Murphy RT. Subclinical anthracycline- and trastuzumab-induced cardiotoxicity in the long-term follow-up of asymptomatic breast cancer survivors: a speckle tracking echocardiographic study. Heart 2010;96(9):701-7. 28. Sengupta PP, Tajik JA, Chandrasekaran K, Khandheria BK. Twist mechanics of the left ventricle: principles and application. J Am Coll Cardiol Img 2008; 1 (3): 366–376. 29. Helle-Valle T, Crosby J, Edvardsen T, Lyseggen E, Amundsen BH, Smith HJ, Rosen BD, Lima JA, Torp H, Ihlen H, Smiseth OA. New noninvasive method for assessment of left ventricular rotation: speckle tracking echocardiography. Circulation 2005; 112 (20): 3149– 3156. 30. Reisner SA, Lysyansky P, Agmon Y, Mutlak D, Lessick J, Friedman Z. Global longitudinal strain: a novel index of left ventricular systolic function. J Am Soc Echocardiogr 2004; 17 (6): 630–633. 31. Dokainish H, Sengupta R, Pillai M, Bobek J, Lakkis N. Usefulness of new diastolic strain and strain rate indexes for the estimation of left ventricular filling pressure. Am J Cardiol 2008;101(10):1504–9. 32. Hare JL, Brown JK, Leano R, Jenkins C, Woodward N, Marwick TH. Use of myocardial deformation imaging to detect preclinical myocardial dysfunction before conventional measures in patients undergoing breast cancer treatment with trastuzumab. Am Heart J 2009;158(2):294-301. 33. Bi X, Deng Y, Zeng F, Zhu Y, Wu Y, Zhao C, Li C.Evaluation of epirubicin-induced cardiotoxicity by two-dimensional strain echocardiography in breast cancer patients. J Huazhong Univ Sci Technolog Med Sci 2009;29(3):391-4. 34. Ganame J, Claus P, Eyskens B, Uyttebroeck A, Renard M, D’hooge J, Gewillig M, Bijnens B, Sutherland GR, Mertens L. Acute cardiac functional and morphological changes after anthracycline infusions in children. Am J Cardiol 2007; 99:974–977 35. Ganame J, Claus P, Uyttebroeck A, Renard M, D’hooge J, Bijnens BH, Sutherland GR, Eyskens B, Mertens L. Myocardial dysfunction late after low dose anthracycline treatment in asymptomatic pediatric patients. J Am Soc Echocardiogr 2007; 20 (12):1351–1358
REVIEW ARTICLES
MINIMAL RESIDUAL DISEASE - GENERALITIES AND PERSPECTIVES Florina Boldeanu1,2, Valentin L. Ordodi2, Alexandra Gruia1, Mirabela Cristea1, Elena Gai1, Margit Serban2 REZUMAT Boala minimă reziduală (Minimal Residual Disease - MRD) reprezintă numărul mic de celule tumorale leucemice care rămân în pacient în timpul tratamentului sau după aceea, atunci când acesta este în remisie (fără simptome sau semne de boală). Dacă, după aproximativ patru săptămâni de chimioterapie, există mai puţin de 5% celule-blast într-un eşantion de măduvă osoasă, pacientul este în remisie clinică. Trei metode sunt disponibile pentru monitorizarea MRD: flux-citometrie immunofenotipică folosind etichetarea dublă sau triplă pentru a detecta immunofenotipurile specifice leucemiei; analiza de tip reactia în lant a polimerazei (polymerase chain reaction (PCR)), a întreruperilor din regiunile de fuziune ale aberatiilor cromozomiale specifice leucemiei; analiza de tip PCR a regiunilor jonctionale de rearanjamente imunoglobuline (Ig) şi receptorilor celulelor T (TCR). Detectia MRD asigură oportunităti unice pentru interventia terapeutică atunci când nici unul sau câtiva blaşti sunt rezistenti la medicamente, în timp ce analiza MRD are câteva roluri importante: să determine daca tratamentul cancerului îndepărtează urmele rămase; comparând eficienta diferitelor tratamente; monitorizarea statusului pacientului, remisia şi recurenta leucemiei; sau personalizarea tratamentului cancerului. Cuvinte cheie: MRD, leucemie
ABSTRACT Minimal residual disease (MRD) is the small number of leukemic tumor cells that remain in the patient during treatment or afterwards, when the patient is in remission (no symptoms or signs of disease). If there are less than 5% blasts in a bone marrow sample, the patient is in clinical remission (CR) after about four weeks of chemotherapy. Three methods are available for MRD monitoring: flow-cytometric immunophenotyping using double or triple labeling to detect leukemia-specific immunophenotypes; polymerase chain reaction (PCR) analysis of breakpoint fusion regions of leukemia-specific chromosome aberations; PCR analysis of the clone-specific junctional regions of immunoglobulin (Ig) and T-cell receptor (TCR) rearrangements. MRD detection provides unique opportunities for therapeutic intervention when none or few blasts are resistant to drugs, while MRD analysis has several important roles: to determine if treatment cancer removes remaining traces; comparing the efficacy of different treatments; monitoring patient status, remission and recurrence of leukemia; or personalizition of the cancer treatment. Key Words: MRD, leukemia
MINIMAL RESIDUAL DISEASE GENERALITIES Minimal residual disease (MRD) is the small numbers of leukemic cells that remain in the patient during treatment, or after treatment, when the patient is in remission.1 Technical approaches for MRD assessment are extensively reviewed.2 Nowadays, there are very sensitive molecular biology tests, based on DNA, RNA or proteins, which can be measured in tissue samples, as low as one cancer cell in million normal cells. Regional Center for Transplant Immunology, Emergency Clinical County Hospital Timisoara, 2 Victor Babes University of Medicine and Pharmacy, Timisoara 1
Correspondence to: Florina Boldeanu, Regional Center for Transplant Immunology, Emergency Clinical County Hospital, 10 Iosif Bulbuca Blvd., 300736 Timisoara Email: boldeanu.florina@yahoo.com Received for publication: Oct. 11, 2011. Revised: Nov. 14, 2011.
MRD testing has important roles as determining whether treatment has eradicated the cancer or whether traces remain, comparing the efficacy of different treatments, monitoring patient remission status and recurrence of the leukemia or cancer and choosing the treatment that will best meet those needs.3 Methods for detecting MRD (e.g. submicroscopic), can be 100 times more sensitive than morphologic examination and permit a more objective assessment of treatment response.4-6 Most research on MRD has been done on leukemia, adult chronic myeloid leukemia, and childhood acute lympholblastic leukemia.4 The success of treatment of patients with leukemia is judged by several criteria. For the patient and clinician the most desirable outcome is sustained remission from disease and long-term survival. Unfortunately it is unlikely that complete eradication of leukemic cells is ever achieved. Hematological remission is defined as fewer than 5% blast cells in the bone marrow as determined by morphology.7 When interpreting residual disease one must distinguish between the postinduction situation _____________________________ Florina Boldeanu et al
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when patients enter a morphologically defined, potentially incomplete remission and the time point at which patients have experienced maximal response to therapy and present with true MRD.8 If there are less than 5% blasts in a bone marrow sample, the patient is in “clinical remission”. Although doctors now know that clinical remission does not mean that the disease is eliminated, the term still has value as a prognostic factor in treatment.9 This term came into use in the 1950’s, when this level of sensitivity was the limit of the doctors’ tests. A majority of patients reach complete remission (CR) after about four weeks of chemotherapy. There are techniques utilized to measure MRD in leukemia, such as DNA based tests, RNA based tests, patient specific testing, immunological tests. DNA tests are based on detecting a leukemic specific DNA sequence. These types of tests are achieved through the use of the polymerase chain reaction. The markers used for DNA based testing are often chromosomal translocations such as t(14;18) involving BCL2 and t(11;14) involving BCL1 (CCND1). Other genes utilized for MRD detection include microsatellites, immunoglobulin and T cell receptor.10 RNA tests are based on detecting a leukemic specific RNA sequence. This is achieved through the use of reverse transcription of the RNA followed by polymerase chain reaction. RNA based tests are normally utilized when a DNA test is impractical. For example, the t(9;22) BCR-ABL translocation may occur over a large length of the chromosome which makes DNA based testing difficult and inefficient. The markers used for RNA based testing are almost exclusively chromosomal translocations such as t(9;22) BCR-ABL, t(15;17) PML-RARA and t(12;21) ETV6RUNX1 (TEL-AML1).11 Both the DNA and RNA based tests require that a pathologist examine the bone marrow to determine which leukaemic specific sequence to target. Once the target is determined, a samples of blood or bone marrow is obtained, nucleic acid is extracted, and the sample analyzed for the leukaemic sequence. These tests are very specific, and detect leukaemic cells at levels down to 1 cell in a million, though the limit typically achieved is 1 in 10,000 to 1 in 100,000 cells. For comparison, the limit of what one can detect using traditional morphologic examinations using a microscope is about 1 cell in 100.12 Patient specific MRD detection using immunoglobulin (IG) or T cell receptors (TCR) is gaining popularity as a way of measuring MRD in leukemias that do not contain a chromosomal _____________________________
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translocation or other leukemic specific marker. The leukemic specific IG or TCR clone is amplified using PCR and the variable region of the IG or TCR is sequenced.13 Immunological based testing of leukaemias utilizes proteins on the surface of the cells. White blood cells (WBC) can show a variety of proteins on the surface depending upon the type of WBC. Leukaemic cells often show quite unusual and unique combinations (leukemic phenotype) of these cell surface proteins. The limit of detection of immunological tests is generally about 1 in 10,000 cells and cannot be used on leukaemias that don’t have an identifiable and stable leukaemic phenotype.14
IMMUNOPHENOTYPING VERSUS MOLECULAR MONITORING OF RESIDUAL DISEASE The most problematic aspect in the clinical relevance of a molecularly defined remission remains the small fraction of patients who can actually benefit from molecular evaluation, particularly in acute myeloid leukemia (AML). Immunophenotypic evaluation of response by multiparameter flow cytometry requires that the leukemic cells express an antigen profile, which differs from those observed on normal hematopoietic precursor cells, and are expected to be present in a remission bone marrow. The detection of aberrant markers on leukemic cells is successful in the majority of patients with acute lymphoblastic leukemia (ALL) or AML.15-17 Chemotherapy may affect antigen expression patterns. However, the high incidence of leukemia-associated immunophenotypes (80–85% of cases) stands in contrast to the percentage of patients with AML, who can be followed with cytogenetic markers or their molecular equivalents (e.g. AML1/ ETO, PML/RARα, possibly FLT3 gene mutations). AML subtypes with traceable molecular markers account for approximately 30% of patients in clinical trials. Another fraction demonstrate chromosome abnormalities which may be monitored by fluorescence in situ hybridization (FISH) (e.g. monosomies, deletions, hyperdiploidy), but present a problem when low-level disease, below the level of sensitivity accomplished by FISH, needs to be evaluated by PCR. Although approximately 100 times more sensitive than standard cytogenetics, the sensitivity level achieved by FISH (one cell in 103) is markedly below that desired for MRD detection (one cell in 105). The possibility that genetic defects detected by interphase FISH may not be actually translated and thus reflect ‘silent’ and physiologically potentially meaningless disease adds
a significant complication to the interpretation of FISH data. The best currently known example for this concept stems from the differentiation inducing effect of all-trans retinoic acid (ATRA) therapy in APL which can lead to the finding of t(15;17) in mature granulocytes, destined to die and thus irrelevant in terms of residual disease detection.18 Then there is the rather large portion of AML patients with apparently normal karyotype (30–40% of patients in most large clinical trials). In AML, the advantage offered by FISH is rather small, attributable, for instance, to the rare karyotypically normal patient with clinical and/or morphologic characteristics of APL which prompt the physician to order FISH, leading to the detection of a cryptic t(15;17) in the leukemic cells.19 Of great clinical interest are patients who present with cryptic molecular markers, detected by PCR, which derive from chromosomal translocations with well-defined, prognostic significance, such as AML1/ ETO (in patients lacking t[8;21]), CBFβ/MYH11 (in patients lacking inv[16]) or MLL-AF4 (in patients lacking t[4;11]), as data on their clinical implication in comparison to that of the standard cytogenetic translocations are scarce and controversial.20-24 Chances for molecular monitoring are considerably better in ALL. In pediatric ALL, approximately a quarter of patients express cytogenetically cryptic TEL/AML1 transcripts. In adult ALL, a similar percentage of patients contain BCR/ABL transcripts (resulting from the Philadelphia chromosome). Another sizable fraction of patients contain aberrations of the MLL gene which result from translocations or deletions involving chromosome 11 at q23.2. Most importantly, in ALL there is the possibility to monitor monoclonality based on immunoglobulin or T cell receptor gene rearrangements, although this approach may harbor its own challenges.25,26
CONCLUSIONS AND PERSPECTIVES MRD-detection provides unique opportunities for therapeutic intervention when none or few blasts are resistant to drugs.1 Each method of MRD has specific advantages and potential traps. Immunologic and molecular techniques are equally reliable in detecting clinically significant levels of residual leukemia, and can be applied in tandem for universal monitoring of minimal residual disease.8 Molecular markers can be used by the physician to provide an accurate prognosis and predict response, resistance, or toxicity to therapy they can give new insights into the methodology of investigation and
treatment of disease.1,8 A goal of MRD assays is to guide therapeutic decisions by recognizing patients who responded well to therapy and thus should be spared further therapy and distinguishing them from patients in whom therapy must be continued or intensified to minimize the likelihood of clinical relapse.3 MRD analysis has several important roles: to determine if treatment cancer removes remaining traces comparing the efficacy of different treatments, monitoring patient status, remission and recurrence of leukemia or cancer treatment choice that will best meet these needs (personalization of treatment).1 Important issues in molecular biology are specimen collection, modification, storage, and laboratory staff experience. Establishing a protocol and method to be followed depends on the laboratory equipment.14
ACKNOWLEDGEMENT During the research described in this paper, the first author Florina Boldeanu benefitted by a grant from the PhD programme POSDRU/88/1.5/S/63117.
REFERENCES 1. Frei E, Kufe DW, Holland JK. Section 34: Hematopoietic System: Adult Acute Lymphocytic Leukemia: Evaluation of Minimal Residual Disease. Cancer medicine 6, Hamilton, Ont: Deker, 2003, p. 129. 2. Béné MC, Kaeda JS. How and why minimal residual disease studies are necessary in leukemia: a review from WP10 and WP12 of the European Leukaemia Net. Haematologica 2009;94(8):1135-50. 3. Haferlach T, Bacher U, Kern W, et al. The diagnosis of BCR/ ABL-negative chronic myeloproliferative diseases (CMPD): a comprehensive approach based on morphology, cytogenetics, and molecular markers. Ann Hematol. 2008;87(1):1–10. 4. Campana D, Minimal Residual Disease Studies in Acute Leukemia, Am J Clin Pathol, 2004;122(Suppl 1):S47-S57. 5. Foroni L, Harrison CJ, Hoffbrand AV, et al. Investigation of minimal residual disease in childhood and adult acute lymphoblastic leukaemia by molecular analysis. Br J Haematol 1999;105(1):7-24. 6. Campana D, Pui CH. Detection of minimal residual disease in acute leukemia: methodologic advances and clinical significance. Blood, 1995;85(6):1416-34. 7. Viljoen GJ, Nel LH, Crowther JR. Molecular diagnostic PCR handbook. Dordrecht: Springer, 2005, p. 278-298. 8. Paietta E. Assessing minimal residual disease (MRD) in leukemia: a changing definition and concept? Bone Marrow Transplantation 2002;29:459–65. 9. Van Dogen JJM, Adriaansen HJ. Immunogiology of Leukemia. In Henderson ES, Lister TA, Greaves MF(eds): Leukemia, 6th Ed, Philadelphia:WB Saunders Co 1996,. p. 83-130. 10. Bacher, U., Haferlach, T., Fehse, B., et al. Minimal residual disease diagnostics and chimerism in the post-transplant period in acute myeloid leukemia. The Scientific World Journal 2011;11:310–19. 11. Schmitt C, Balogh B, Grundt A, et al. The bcl-2/IgH rearrangement in a population of 204 healthy individuals: occurrence, age and gender distribution, breakpoints, and detection method validity. Leuk Res. 2006;30(6):745–50. 12. van der Velden VH, Hochhaus A, Cazzaniga G, et al. Detection of minimal residual disease in hematologic malignancies by real-time _____________________________ Florina Boldeanu et al
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quantitative PCR: principles, aproaches, and laboratory aspects. Leukemia 2003;17(6):1013-34. 13. Neale GA, Pui CH, Mahmoud HH, et al. Molecular evidence for miminal residual bone marrow disease in children with isolated extramedullary relapse of T-cell acute lymphoblastic leukemia. Leukemia 1994;8(5):768-75. 14. Pongers-Willemse MJ, Seriu T, Stolz F, det al. Primers and protocols for standarized detection of minimal residual disease in acute lymophoblastic leukemia using immunoglobulin and T cell receptor gene rearrangements and TAL1 deletions as PCR targets. BioTechnical Methods Section. Leukemia 1999;13(1):110-8. 15. Kerst G, Kreyenberg H, Roth C, et al. Concurrent detection of minimal residual disease (MRD) in childhood acute lymphoblastic leukaemia by flow cytometry and real-time PCR. Br J Haematol. 2005;128(6):774-82. 16. Ryan J, Quinn F, Meunier A, et al. Minimal residual disease detection in childhood acute lymphoblastic leukaemia patients at multiple timepoints reveals high levels of concordance between molecular and immunophenotypic approaches. Br J Haematol. 2009;144(1):107-15. 17. Øbro NF, Marquart HV, Madsen HO, et al. Immunophenotypedefined sub-populations are common at diagnosis in childhood B-cell precursor acute lymphoblastic leukemia. Leukemia 2011;25(10):1652-7. 18. Vyas RC, Frankel SR, Agbor P, et al. Probing the pathobiology of response to all-trans retinoic acid in acute promyelocytic leukemia: premature chromosome condensation/fluorescence in situ hybridization analysis. Blood 1996;87:218–26. 19. Hiorns LR, Min T, Swansbury GJ, et al. Interstitial insertion of retinoic acid receptor-alpha gene in acute promyelocytic leukemia with normal chromosomes 15 and 17. Blood 1994;83:2946–51.
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20. Sarriera JE, Albitar M, Estrov Z, et al. Comparison of outcome in acute myelogenous leukemia patients with translocation (8;21) found by standard cytogenetic analysis and patients with AML1/ETO fusion transcript found only by PCR testing. Leukemia 2001;15:57–61. 21. Mrózek K, Prior TW, Edwards C, et al. Comparison of cytogenetic and molecular genetic detection of t(8;21) and inv(16) in a prospective series of adults with de novo acute myeloid leukemia: a Cancer and Leukemia Group B study. J Clin Oncol 2001;19:2482–92. 22. Uckun FM, Herman-Hatten K, Crotty ML, et al. Clinical significance of MLL-AF4 fusion transcript expression in the absence of a cytogenetically detectable t(4;11)(q21;q23) chromosomal translocation. Blood 1998;92:810–21. 24. Yeung DT, Parker WT, Branford S. Molecular methods in diagnosis and monitoring of haematological malignancies. Pathology. 2011;43(6):566-79. 25. Kottaridis P, Gale RE, Frew ME, et al. The presence of a FLT3 internal tandem duplication in patients with acute myeloid leukemia (AML) adds important prognostic information to cytogenetic risk group and response to the first cycle of chemotherapy: analysis of 854 patients from the United Kingdom Medical Research Council AML 10 and 12 trials. Blood 2001;98:1752–9. 26. de Haas V, Verhagen OJ, von dem Borne AE, et al. Quantification of minimal residual disease in children with oligoclonal B-precursor acute lymphoblastic leukemia indicates that the clones that grow out during relapse already have the slowest rate of reduction during induction therapy. Leukemia 2001;15:134–40. 27. Campana D, Neale GAM, Coustan-Smith E, et al. Detection of minimal residual disease in acute lymphoblastic leukemia: the St Jude experience. Leukemia 2001;15:278–9.
CASE REPORTS
REPLACEMENT OF THE ASCENDING AORTA AND THE AORTIC ARCH FOR ACUTE TYPE A AORTIC DISSECTION Dan Bindea, Sigismund Papp, Luminita Slabu, Simona Oprita, Alexandra Todoran, Teodora Mihai, Traian Scridon REZUMAT Pacienta L.M. în vârstă de 53 ani a fost internată de urgenţă în Serviciul nostru cu diagnosticul de disecţie de aortă (Ao) tip A cu interesarea porţiunilor iniţiale a trunchiului arterial brahiocefalic (TABC) şi a arterei carotide comune (ACC) stângi (confirmat prin CT în Spitalul teritorial). Ecografia cardiacă confirmă diagnosticul şi arată prezenţa unei colecţii pericardice cu semne de tamponadă şi a insuficienţei aortice severe. În aceste condiţii, pacienta este supusă de urgenţă unei intervenţii chirurgicale complexe: protezarea valvei aortice, înlocuirea Ao ascendente şi a 2/3 proximale din arcul aortic, reimplantarea arterelor coronare prin interpoziţia a două segmente de proteză scurte şi reimplantarea TABC şi a ACC stângi, de-asemenea prin intermediul unor segmente de proteză. Pentru refacerea porţiunii iniţiale a aortei s-a utilizat procedeul Bentall şi tehnica Mills. Pe perioada arestului cardiocirculator (53 min) perfuzia cerebrală a fost asigurată prin încanularea directă a TABC. Evoluţia postoperatorie a fost marcată de prezenţa unui sindrom de insuficienţă respiratorie acută (ARDS), care a necesitat ventilaţia mecanică prelungită a pacientei. În ziua a 14-a postoperator a fost necesară evacuarea unei colecţii pericardice compresive prin abord chirurgical subxifoidian. Ulterior, evoluţia a fost fără alte evenimente. Considerăm că, chirurgia arcului aortic rămâne o provocare pentru chirurgul cardiac; o tehnică chirurgicală excelentă alături de o protecţie cerebrală bună asigură premisele unei reuşite. Cuvinte cheie: disecţie de Ao tip A, procedeul Bentall, tehnica Mills, protecţie cerebrală
ABSTRACT A 53-year old female patient was admitted in our Service for acute type A aortic dissection (confirmed on a CT scan made at a local hospital). The cardiac echography confirm the diagnostic and showed cardiac effusion with tamponade and severe aortic regurgitation. The patient underwent emergency surgery: replacement of the aortic valve, replacement of the ascending aorta and of the 2/3 of the aortic arch, associated with reconnection of the coronary arteries, the brachiocephalic trunk and the left common carotid artery to the aortic graft using also prosthetic grafts (For the replacement of the ascending aorta we performed Bentall procedure associated with Mills technique). During the cardio-circulatory arrest (53 min), the cerebral perfusion was made possible by cannulation of the brachiocephalic trunk. Surgery of the aortic arch remains a challenge for the cardiac surgeon. A good surgical technique together with a good cerebral perfusion assure the success of the surgical procedure. Key Words: acute type A aortic dissection, Bentall procedure, Mills technique, cerebral protection
INTRODUCTION Acute type A aortic dissection, especially the one interesting the aortic arch, bears a high mortality (1020%) and morbidity.1 The incidence of postoperative neurological complications remains high (5-70%) due to the advanced cerebral protection techniques: deep hypothermia with circulatory arrest, antegrade or retrograde cerebral perfusion.2-5
Clinic of Cardiovascular Surgery, Niculae Stancioiu Heart Institute, ClujNapoca Correspondence to: Dan Bindea, MD, Clinic of Cardiovascular Surgery, Niculae Stancioiu Heart Institute, 19-21 Motilor Str., Cluj-Napoca, Romania, Tel. +40264-591531 Email: bindea_dan_ch@yahoo.com Received for publication: Sep. 11, 2011. Revised: Dec. 14, 2011.
The structure of the aortic wall in the dissected area, the involvement of the coronary arteries, of the aortic arch and its branches represent technical difficulties that impose replacement of the ascending aorta and of the aortic arch, with reconnection of these branches to the aortic graft. We are going to present the case of a female patient with type A aortic dissection involving the brachiocephalic trunk and the origin of the left common carotid artery, who underwent successful surgical correction.
CASE REPORT A 53-year old female patient was admitted in our hospital with shock due to acute type A aortic dissection, diagnosed at a local hospital by CT scan. (Fig. 1) Emergency cardiac echography revealed acute type A dissection that involved the aortic arch, the first 3 cm of the brachiocephalic trunk and of the left _____________________________ Dan Bindea et al
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common carotid artery, severe aortic regurgitation and cardiac tamponade. The patient was obese, diabetic and hypertensive.
left common carotid artery were reconnected to the aortic graft using the interposition of 8 mm Dacron grafts. (Figs. 2,3)
Figure 1. CT Scan: type A aortic dissection.
An emergency operation was undertaken under general anesthesia and through a median sternotomy. Cardiopulmonary bypass was established via cannulation of the right femoral artery and of the right atrium and 500 ml of blood were evacuated from the pericardium; the aortic cross-clamp was applied and the dissected ascending aorta opened. The coronary ostia were also circumferentially dissected. Giving the fact that the aortic root dissection involved also the coronary ostia and was associated with severe aortic regurgitation, Bentall reconstruction of the aorta was chosen (an intraoperatively-made composite valve graft conduct - mechanical 21 Carbomedics bileaflet valve and 26 Dacron graft was used), associated with reimplantation of the coronary arteries by interposing short 8 mm Dacron grafts (Mills technique).6 Using deep hypothermia (150C) and antegrade cerebral perfusion via direct cannulation of the brachiocephalic trunk (at a flow rate of 350-400 ml and a perfusion pressure of 60-70 mm Hg), the aortic arch was opened: an intimal tear was found at the origin of the brachiocephalic trunk, which extend on the 2/3 aortic arch and on the first 3 cm of the brachiocephalic trunk and the origin of the left common carotid artery.4,7 Therefore, the replacement of the aortic arch, up to the origin of the left subclavian artery was necessary (using the same 26 mm Dacron graft) and the distal anastomosis site was reinforced with Teflon felt strips using Prolene 3/0. The brachiocephalic trunk and the _____________________________
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Figure 2. Drawing showing the replacement of the aortic valve, replacement of the ascending aorta and of the 2/3 of the aortic arch, associated with reconnection of the coronary arteries, the brachiocephalic trunk and the left common carotid artery to the aortic graft using also prosthetic grafts. For the replacement of the ascending aorta we performed Bentall procedure associated with Mills technique.
Afterwards, the cardiopulmonary by-pass was reinstituted, the patient rewarmed, and the course of the operation was uneventful. The total extracorporeal circulation time was 4h 58 min, the aortic cross-clamp time was 2h 50min and the cardio-circulatory arrest time was 53 min. Extubation was possible only during the 6th postoperative day, due to an acute respiratory distress syndrome (ARDS), without neurological deficit. Postoperatively, on the 14th day, the patient required evacuation of a sero-sanguinolent pericardic effusion through a subxiphoidal incision. The postoperative course was uneventful and the patient was discharged 19 days after the main surgical procedure. At the 3-month follow-up the angio CT scan shows no obstruction/stenosis of the grafts, and no dissection on the descending aorta; the patient remained free of symptoms. (Fig. 4)
Figure 3. Intraoperative view showing the replacement of the aortic valve, replacement of the ascending aorta and of the 2/3 of the aortic arch, associated with reconnection of the coronary arteries, the brachiocephalic trunk and the left common carotid artery to the aortic graft using also prosthetic grafts.
The success of the surgical intervention depends on a prompt and accurate diagnosis, emergency operation submission together with two extremely important surgical factors: 1. Correct evaluation of the lesion, removal of the entry point of the dissection and an aggressive replacement of as much dissected artery as possible; total arch replacement for acute type A aortic dissection may decrease the risk of late complications related to the false lumen and lead to excellent long term survival.8-11 2. Cerebral protection and a short circulatory arrest time (30-40 min); cerebral blood flow during the period of circulatory arrest may be delivered in either a retrograde or antegrade technique. The antegrade cerebral perfusion is considered more efficient and allows the surgeon a longer â&#x20AC;&#x153;safeâ&#x20AC;? time to complete the anastomosis on the aortic arch.3,4,12 In our case we dealt with a complex lesion: ascending aortic dissection involving the proximal 2/3 of the aortic arch, the origin of the innominate artery, left common carotid artery, coronary ostia and severe aortic regurgitation. This lead to performing the Bentall procedure using the Mills technique: reimplantation of the coronary arteries by interposing short 8 mm Dacron grafts (this allowed for less anastomotic tension, and a more precise suture). We had to prepare the valved tube together with its branches intraoperatively, due to lack of availability of ready-made prostheses for this type of pathology in our hospital. This has obviously prolonged the operative time. Cerebral protection was ensured by direct cannulation of the innominate artery, distally to the dissection area, associated with profound hypothermia during the cardio-circulatory arrest. The efficiency of these methods was verified by cerebral transcranian pulse-oximetry, and by the presence of blood reflow in the left common carotid artery.
CONCLUSIONS
Figure 4. Angio-CT at 3 months follow-up show no obstruction /stenosis of the grafts, and no dissection on the descending aorta.
DISCUSSIONS Despite advances in operative techniques and postoperative care, repair of aortic dissection involving the aortic arch remains a challenging and high-risk procedure.
We chose to present this case in order to describe the successfully used technique for cerebral protection and due to the types of surgical techniques combined (Bentall procedure modified by Mills, aortic arch replacement with brachiocephalic trunk and left common carotid artery implantation using interposition grafts). Although we resolved that case successfully, we must note that the operative mortality for acute aortic dissection in our hospital in 2010 remains high (around 37%). _____________________________ Dan Bindea et alâ&#x20AC;&#x192;
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REFERENCES 1. Reece TB, Green GR, Kron IL. Aortic dissection. In: LW Cohn. Cardiac Surgery in the Adult, Third edition, Ed. McGraw Hill Medical;2008:1195-1222. 2. Hagl C, Khaladj N, Krack M, et al. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection. Eur J Cardiothorac Surg 2003;24:371-378. 3. Okita Y, Minatoya K, Tagusari O, et al. Prospective comparative study of brain protection in total arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg 2001;72(1):72-9 4. Ueda Y, Miki S, Kusuhara K, et al. Deep hypothermic systemic circulatory arrest and continuous retrograde perfusion for surgery of aortic arch aneurysm. Eur J Cardio Thorac Surg 1992;6:36-41. 5. Bachet J, Teodori G, Goudout B, et al. Replacement of the transverse aoric arch during emergency operations for type A acute aortic dissection: report of 26 cases. J Thorac Cardiovasc Surg 1988;96:912-924. 6. Mills NL, Morgenstern DA, Gaudiani VA, Ordoyne F. “Legs” technique
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for management of widely separated coronary arteries during ascending aortic repair. Ann Thorac Surg 1996;61:869-873. 7. Guilmet D, Roux PM, Bachet J, et al. Nouvelle technique de protection cerebrale: Chirurgie de la crosse aortique. Presse Med 1986;15:1096-1098. 8. Ochiai Y, Imoto Y, Sakamoto M, et al. Long-term effectiveness of total arch replacement for type A aortic dissection. Ann Thorac Surg 2005;80:1297-1302. 9. Ando M, Nakajima N, Adachi S, et al. Simultaneous graft replacement of the ascending aorta and total aortic arch for type a aortic dissection. Ann Thorac Surg 1994;57:669-676. 10. Erwin M, Tan SH, Dossche KM, et al. Is extended arch replacement for acute type a aortic dissection an additional risk factor for mortality? Ann Thorac Surg 2003;76:1209-1214. 11. Estrera AL, Miller CC, Huynh TT, et al. Replacement of the ascending and transverse aortic arch: determinants of long-term survival. Ann Thorac Surg 2002;74:1038-1065. 12. Krahenbuhl ES, Immer FF, Stadler M, et al. Technical advances improved outcome in patients undergoing surgery of the ascending aorta and/or aortic arch: ten years experience. Eur J Cardio Thorac Surg 2008;34:595-599.
CASE REPORTS
LEFT VENTRICULAR NON-COMPACTION - CASE REPORT Irina Popescu1, Georgiana Ionescu2, Cristian Mornos2, Dan Gavrilescu1, Dragos Cozma2, Flavia Goanta1, Adina Ionac2 REZUMAT Cardiomiopatia prin non-compactare este o afecţiune congenitală rară a inimii, caracterizată prin prezenţa trabeculaţiilor excesive ale miocardului ce afectează în principal ventriculul stâng. Vom prezenta un caz de cardiomiopatie prin non-compactare a ventriculului stâng la un pacient relativ tânar şi vom sublinia rolul extrem de important al ecocardiografiei transtoracice în diagnosticarea acestei entităţi rare de boală cardiacă. Cuvinte cheie: cardiomiopatie prin non-compactare; cardiomiopatii; trabeculaţii ale miocardului
ABSTRACT Non-compaction of the ventricle is a rare congenital cardiomyopathy characterized by the presence of excessive trabeculation of myocardium which mostly affects the left ventricle. We report a case of non-compaction of the left ventricle in a relatively young patient; this case report proves that transthoracic echocardiography is an important diagnostic tool for this rare cardiomyopathy. Key Words: non-compaction of left ventricle; cardiomyopathy; trabeculation of myocardium
INTRODUCTION Non-compaction of the myocardium (left ventricular non-compaction - LVNC) is a cardiomyopathy characterized by the occurrence of numerous excessive trabeculations and intertrabecular recesses which communicate with the left ventricular (LV) cavity.1 In normal human hearts, the left ventricle has up to 3 prominent trabeculations and is less trabeculated than the right ventricle.2 The clinical presentation of this entity includes depressed systolic and diastolic function, systemic embolism and tachyarrhythmias.3 The mechanisms that lead to LVNC are unclear. It was suggested that the basic morphogenetic anomaly may be an arrest of normal compaction of myocardial fibers in the intrauterine development, resulting in two different myocardial layers (one compacted and one non-compacted, trabeculated).3
Clinic of Cardiology, Institute of Cardiovascular Diseases, Timisoara, Department of Cardiology, Victor Babes University of Medicine and Pharmacy, Timisoara 1 2
Correspondence to: Prof. Adina Ionac, Department of Cardiology, Institute of Cardiovascular Diseases, 13A Gh. Adam Str., 300310 Timisoara, Tel. +40-744-790381 Email: adina_ionac@rdstm.ro Received for publication: Sep. 22, 2011. Revised: Dec. 18, 2011.
Studies in the genetics of LVNC have strongly suggested that the disease has an inheritance pattern (18% to 50% of cases are familial).3 The incidence is noted to be low (from literature review: 0.12/100,000 births).3 Nevertheless, there was a raise of prevalence of LVNC in the last years, which could be explained by better diagnostic due to more performant echocardiographic machines and new techniques.3 Clinical presentation is similar to other cardiomyopathies, and includes systolic and diastolic dysfunction of the LV, tachyarrhythmias and systemic embolism. The main symptom described at first presentation is dyspnea, due to low cardiac output.4,5 Tachyarrhythmias in Wolf-Parkinson-White syndrome, ventricular tachycardias, atrio-ventricular blocks, bundle branch blocks and even sudden cardiac death have also been reported.6 Transthoracic echocardiography (TTE) is the method of choice for the diagnosis of LVNC. Twodimensional TTE, three-dimensional TTE, Doppler color method, and contrast echocardiography are all used for the diagnosis and screening of patients with LVNC. In LVNC, the LV is thickened and has two distinct layers: one compacted, thin, towards the epicardium, and the other thicker, noncompacted, with deep trabeculations towards the endocardium, which communicate directly with the LV cavity. On _____________________________ Irina Popescu et al
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two dimensional TTE, measurements must be done in parasternal short axis view in endsystole, when the myocardium is the thickest. For positive diagnosis, the ratio between non-compacted and compacted myocardium must be above 2 (Jenni Criteria, see Table 1).1
Others present a better prognosis.16 That could be explained by different stages of disease at the moment of diagnosis, by the severity of heart failure and the improvement achieved with invasive and noninvasive treatment methods.15,16
CASE REPORT
Table 1. Jenni Criteria (1999). Absence of any other coexisting cardiac structural abnormality Numerous, excessively prominent trabeculations and deep intertrabecular recesses Views: parasternal short axis, and apical Focus on a 2-layer structure Measured in end-systole Ratio of thick noncompacted layer to thin compacted â&#x2030;Ľ 2 Perfused intertrabecular recesses suplied by intraventricular blood on color Doppler analysis
The apical and midventricular segments of lateral and inferior LV wall are affected in more than 80% of patients.1 Three-dimensional TTE brings us supplementary data, the trabeculations and recesses are better visualized and the distinction between compacted and noncompacted myocardium is easily demarcated.8 Contrast echocardiography is being used successfully in obese patients, in patients with lung disease and poor acoustic window. This method enhances endocardial border delineation and makes the differential diagnosis with prominent normal myocardial trabeculation, hypertrophic cardiomyopathy, dilated cardiomyopathy and left ventricular apical thrombus much easier.9-13 Cardiac magnetic resonance imaging (MRI) is also used in patients with poor acoustic window and applies the same diagnostic criteria as the echocardiography. Genetic tests for identification of specific genes are reserved to research purpose or family screening.7 There is no specific treatment for LVNC at this moment. All patients should receive treatment for heart failure: betablocker, angiotensine converting enzyme inhibitor, diuretic. Heart transplant is the only therapeutic solution in final stages. Aspirin should also be recommended, due to the risk of thromboembolic events. Patients with chronic atrial fibrillation should be orally anticoagulated. Treatment for specific arrhythmias consists of antiarrhythmic drugs and intracardiac defibrillator (ICD) for selected patients. Patients with LVNC have a controversial prognosis. Some studies associate this disease with high mortality due to heart failure and sudden cardiac death.14,15 _____________________________
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We present the case of a 46 years old male, with no previous cardiovascular pathology. For the last 6 months he complained of dyspnea on mild physical exertion and fatigue. On physical examination he showed slightly elevated blood pressure values (BP = 150/90 mmHg); the rest of the examination was normal. Resting electrocardiogram revealed sinus rhythm, HR = 80 b/min, left bundle branch block. TTE was performed and showed a dilated LV with an end diastolic volume (LVEDV) of 216 ml and slightly impaired systolic function (EF = 40%), type 1 diastolic dysfunction, trabecular aspect of the apex and lateral wall. All of these raised the suspicion of LVNC and contrast transthoracic echocardiography was performed using SonoVue contrast agent. Two ml of this agent were injected into a peripheral vein and LV endocardium was accurately delineated. LV apical and medial walls were bold, with deep recesses that communicated freely in color Doppler with the LV cavity. (Figures 1-3)
Figure 1. TTE, apical 4 chambers view. Deep trabeculations can be observed at LV apex and lateral wall.
LV layers ratio was calculated from the parasternal short axis view at papillary muscle level, and the non-compacted/compacted myocardium was about 2. (Fig. 4) The left atrium and right cavities were of normal size. Angiocoronarography was performed to exclude ischemic etiology of the dilated cardiomyopathy and revealed normal coronary arteries. Ventriculography showed clear trabeculations located at the apical and medial segments of LV lateral and inferior walls.
specific medical problems), but the patient failed to return for follow-ups.
CONCLUSION
Figure 2. TTE, apical 4 chambers view with color Doppler. Presence of color Doppler signal deep inside the recesses.
Figure 3. TTE, parasternal short axis view at the site of the papillary muscles. Excessive trabeculations are observed on the infero-lateral walls.
Figure 4. Contrast enhanced echocardiography, parasternal short axis view at the site of papillary muscles. The endocardial border is better visualized and the ratio between noncompacted and compacted myocardium can be calculated.
In this context, our recommendation was for conservative therapy. Treatment with beta blockers, angiotensin converting enzyme inhibitor, diuretic and antiplatelet agents was started, with mild improvement in symptoms and normalization of blood pressure. We tried to make an echocardiographic screening of his family (patient has two male children, with no
In conclusion, complete echocardiographic evaluation in this patient allowed the noninvasive diagnosis of LVNC. Particular echocardiographic appearance demonstrated with standard echocardiography and confirmed with contrast echocardiography completed the diagnosis correctly and accurately for this rare entity of cardiomyopathy.
REFERENCES 1. Jenni R, Oechslin E. Non-compaction of the left ventricular myocardium - from clinical observation to the discovery of a new disease. European Cardiology 2005; 1:1-4. 2. Song ZZ. Echocardiography in the diagnosis of left ventricular noncompaction. Cardiovasc Ultrasound 2008; 6:64. 3. Botto LD. Left ventricular noncompaction. Orphanet Enciclopedia, 2004. http://www.orpha.net/data/patho/GB/uk-LVNC.pdf 4. Pignatelli RH, Mc Mahon CJ, Dreyer WJ et al. Clinical characterization of left ventricular noncompaction in children. Circulation 2003; 25,108:2672-8. 5. Weiford BC, Subbarao VD, Mulhern KM. Noncompaction of ventricular myocardium. Circulation 2004; 109:2965-71. 6. Taniguci M, Hioka T, Maekawa K, et al. Adult case of isolated ventricular non-compaction discovered by complete atrioventricular block. Circulation 2004; 68:873-5. 7. Mc Crohon JA, Richmond DR, Pennel DJ, et al. Isolated noncompaction of the myocardium: a rarity or missed diagnosis? Circulation 2002; 106:e22-23. 8. Baker GH, Pereira NL, Hlavacek AM, et al. Transthoracic real-time three-dimensional echocardiography in the diagnosis and description of noncompaction of ventricular myocardium. Echocardiography 2006; 23:490-4. 9. Main ML, Grayburn PA. Clinical applications of transpulmonary contrast echocardiography. Am Heart J 1999; 137:144-53. 10. Mulvagh SL, DeMaria AN, Feinstein SB, et al. Contrast echocardiography: current and future applications. J Am Soc Echocardiogr 2000; 13:331-42. 11. Koo BK, Choi D, Ha JW, et al. Isolated noncompaction of the ventricular myocardium: contrast echocardiographic findings and review of the literature. Echocardiography 2002; 19:153-6. 12. Hayashi Y, Hamada M, Hiwad K. Characterization of left ventricular opacifiation using sonicated serum albumin in patients with dilated cardiomyopathy and myocardial infarction. Jpn Circ J 1998; 62:91-6. 13. Bednarz JE, Spencer KT, Weinert L,et al. Identification of cardiac masses and abnormal blood flow patterns with harmonic powerDoppler contrast echocardiography. J Am Soc Echcardiogr 1999; 12:871-5. 14. Oechslin EN, Attenhofer Jost CH, Rojas JR, et al. Long-term follow-up of 34 adults with isolated left ventricular noncompaction: a distinct cardiomyopathy with poor prognosis. J Am Coll Cardiol 2000; 36: 493-500. 15. Ichida F, Hamamichi Y, Miyawaki T, et al. Clinical features of isolated noncompaction of the ventricular myocardium. J Am Coll Cardiol 1999; 34:233-40. 16. Murphy RT, Thaman R, Blanes JG et al. Natural history and familial characteristics of isolated left ventricular non-compaction. Eur Heart J 2005; 26:187-92.
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