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PubMed2003

Combating high-priority biological agents: What to do with drug-allergic patients and those for whom vaccination is contraindicated?

The threat of bioterrorism continues to be a very real one. Regularly, there are news stories on bioterrorism-related topics: What biologic weapons will our enemies likely use to attack the United States? How prepared is our country to successfully counter such attacks? Although these critical questions are being addressed by the leaders of our country, allergists-immunologists, too, will have to grapple with difficult questions during these uncertain and frightening times. We care for a special group of patients with various allergic and immunologic disorders. Some of our patients have immunodeficiency disorders that might preclude them from receiving life-saving vaccines. Our patients with drug allergies are fearful that should they become infected with a biologic agent, they will not be able to receive appropriate treatment. In this article we focus on the various vaccine-related and antibiotic-related adverse effects that the allergist-immunologist might see during treatment of infections caused by Category A agents. Where possible, potential management approaches are outlined.

Anti-Bacterial Agents↗
PubMed2005

A case of abnormal findings in the course of the vertebral artery associated with an ossified hyoid apparatus. A contraindication for manipulation of the cervical spine?

OBJECTIVE: To describe a case of a simultaneous occurrence of an ossified stylohyoid ligament in a 56-year-old male cadaver and anomalies of the vertebral artery, and to consider the clinical implications for manipulative therapists. INTERVENTION AND OUTCOME: Dissection showed a simultaneous occurrence of complete developmental ossification of the left hyoid apparatus, variants of the vertebral artery, and a left superior vena cava in a 56-year-old male cadaver. DISCUSSION: Developmental variants, posttraumatic and degenerative changes of the hyoid apparatus may result in variable degrees of ossification or calcification. CONCLUSION: This unusual disorder should be considered in the differential diagnosis of facial and neck pain especially within the scope of manipulation of the upper cervical spine. Cervical spine manipulation may exacerbate existing pathological conditions of the stylohyoid apparatus, thereby irritating neurovascular structures, and induce a fracture. Developmental ossification of this apparatus might be associated with anomalies in the atlantic section of the vertebral artery which make the patient more susceptible to vertebrobasilar insufficiency. We conclude that extreme care should be taken in the presence of such an ossification to avoid trauma to the stylohyoid apparatus and maybe even because of increased vertebrobasilar risk.

Cadaver↗
PubMed2007

Radiation arteritis: a contraindication to carotid stenting?

BACKGROUND: Carotid artery stenting (CAS) for high-risk anatomic lesions is accepted practice. Neck irradiation and radiotherapy-induced arteritis are common indications. The clinical outcomes of CAS for radiation arteritis have been poorly defined. METHODS: A prospective database of patients undergoing CAS at a tertiary referral academic medical center was maintained from 1999 to 2006. Patients undergoing primary carotid artery stenting for significant atherosclerotic (ASOD) and radiotherapy (XRT)-induced occlusive disease were analyzed. Life-table analyses were performed to assess time-dependent outcomes. Cox proportional hazard analysis or Fisher's exact test was performed to identify factors associated with outcomes. Data are presented as the mean +/- SEM unless otherwise indicated. RESULTS: During the study period, 150 patients underwent primary CAS, 75% with embolic protection. Fifty-eight percent were symptomatic. One hundred twenty-seven (85%) were treated for ASOD, and 23 (15%) had XRT. The 30-day all-cause mortality rate was 1% for ASOD and 0% for XRT (P = NS); overall survival at 3 years was equivalent. There was no significant difference in major adverse event rates as defined by the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial between the groups. The 3-year neurologic event-free rate was 85% for ASOD and 87% for XRT (P = NS). Late asymptomatic occlusions were seen only in XRT patients. The 3-year freedom from restenosis rate was significantly worse for the XRT group, at 20%, vs 74% for the ASOD group (P < .05). Likewise, the 3-year patency rate was also worse for the XRT group, at 91%, vs 100% for ASOD by Kaplan-Meier analysis (P < .05). No factor was predictive of occlusion or stenosis by Cox proportional hazards analysis. CONCLUSION: CAS for radiation arteritis has poor long-term anatomic outcome and can present with late asymptomatic occlusions. These findings suggest that these patients require closer postoperative surveillance and raise the question of whether CAS is appropriate for carotid occlusive lesions caused by radiation arteritis.

Aged↗
PubMed2006

Evolving techniques in the treatment of liver colorectal metastases: role of laparoscopy, radiofrequency ablation, microwave coagulation, hepatic arterial chemotherapy, indications and contraindications for resection, role of transplantation, and timing of chemotherapy.

The management of patients who have hepatic metastases from CRC has become increasingly complex as the number of modalities that is available to treat these tumors has increased. Surgical resection remains the mainstay of treatment, when possible, and may become an option in an increasing proportion of patients that has advanced disease and previously were considered unresectable when treated with a combination of neoadjuvant systemic or hepatic arterial chemotherapy. The role of microwave coagulation and RFA can be considered only complementary to surgical resection at this point, but they may represent the best option in highly selected patients, such as those who are at high risk for extrahepatic recurrence or who are poor surgical candidates.

Antineoplastic Agents↗
PubMed2005

Renal transplantation in patients over 65 years of age: no more a contraindication but a growing indication.

INTRODUCTION: Worldwide organ shortage and the increasing age of end-stage renal disease patients demanding a graft have prompted extensive use of marginal donors. The "old-for-old" allocation has been proposed for the elderly. The aim of this study was to evaluate the results of a policy of free acceptance into the waiting list of recipients older than 65 years. METHODS: From 1987 to 2004 70 patients whose mean age was 67.4 +/- 2.8 years, underwent an extensive pretransplant evaluation including cardiac studies. Immunosuppression was based upon low-dose steroids, and cyclosporine (50%) or tacrolimus (44%). RESULTS: Patient and graft survival at 1, 3, 5, and 10 years were 85%, 78.5%, 75%, 50%, and 80%, 74%, 70%, 36%, respectively. Death occurred in 17/70 (24%), 14 of whom had a functioning graft. The causes of death were 30% cancer, 23% cardiovascular, 23% sepsis, 12% cerebrovascular hemorrhage, 12% meningitis. The acute rejection (AR) rate was 18.6%. The causes of graft loss were: 71% patient death, 4% irreversible AR, 4% vascular thrombosis, and 21% chronic allograft dysfunction. The main complications were: 52% prostatic hypertrophy, 40% urinary tract infections, 8.6% diabetes, 11% pneumonia, 10% cardiovascular diseases, 7% urological complications, 8% abdominal pathology, 6% acute pyelonephritis, 8% non-skin cancer. CONCLUSIONS: Despite the increased vulnerability of the elderly, they should not be excluded a priori from renal transplantation. Extensive pretransplant screening, mainly cardiovascular, and a tailored immunosuppression are two crucial issues. The moderate rate of AR suggests that these patients do not have an impaired immunocompetence as far as acute rejection is concerned.

Adult↗
PubMed2006

Contraindications of VEGF-based therapeutic angiogenesis: effects on macrophage density and histology of normal and ischemic brains.

Therapeutic angiogenesis by vascular endothelial growth factor (VEGF) is advocated as a promising treatment strategy for brain ischemic stroke. However, data in the literature demonstrating the benefit of therapeutic angiogenesis are contradictory. In this paper, we describe the effects of non-angiogenic and angiogenic doses of VEGF165 on macrophage density and histology of normal and ischemic brains of adult rats. VEGF165 was administered intra-arterially for 7 days following temporary occlusion of the middle cerebral artery. In contrast to ischemic brains treated with non-angiogenic doses of VEGF165 which showed preserved neuropil and reduced numbers of macrophages, ischemic brains treated by an angiogenic dose showed phagocytized neuropil and high macrophage density. Though neither non-angiogenic nor angiogenic doses caused macrophage infiltration in normal brains, damage of the brain matrix occurred with the angiogenic dose. These results suggest an angiogenic dose of VEGF165 injures the nervous tissue rather than promote recovery. Angiogenesis by VEGF monotherapy for ischemic stroke should be viewed with caution, or avoided. Since our data show intravascular administration of VEGF165 does not cause macrophage inflammation, in contrast to reports in the literature whereby VEGF165 was applied directly to the brain, our findings also indicate the relationships between VEGF, angiogenesis, and macrophage inflammation are governed by the route VEGF is administered to the brain.

Animals↗
PubMed1997

Hyperfluorescent plaque lesions in the late phases of indocyanine green angiography: a possible contraindication to the laser treatment of drusen.

PURPOSE: To highlight the possible role of indocyanine green angiography in predicting future exudative changes in eyes that are candidates for drusen laser treatment. METHODS: In a 56-year-old woman, fluorescein and indocyanine green angiography were performed before drusen laser treatment. RESULTS: The treated eye had a suspicious lesion at baseline indocyanine green angiography and a nonsuspicious fluoroangiographic pattern. Seven months after treatment, the patient developed choroidal neovascularization and pigment epithelial detachment in the treated eye. CONCLUSION: To decrease the risk of macular exudative changes that may be related to laser treatment, eyes that are candidates for drusen laser treatment should be examined before treatment, not only by fluorescein angiography, but also by indocyanine green angiography.

Angiography↗
PubMed2001

Aortopulmonary size discrepancy is not a contraindication to the pediatric Ross operation.

BACKGROUND: Modification of the aortic annulus or the ascending aorta, or both, may be required in pediatric patients undergoing the Ross operation. The fate of these autografts remains uncertain. METHODS: Retrospective review of 15 patients undergoing Ross operation without aortic annular modification (group 1), 11 patients requiring annular reduction (group 2, n = 11), and 8 patients requiring annular enlargement (group 3, n = 8). Autograft function and dimensions were evaluated by echocardiography. RESULTS: Autograft insufficiency was less than or equal to mild in 33 patients and moderate in 1 patient. The annulus body surface area ratio increased in group 1 from 19.7 +/- 5 to 20.3 +/- 5 mm/M2 (p = 0.8). The average annular reduction in group 2 was 5 +/- 1.5 mm, and 10 of 11 patients required reduction of the ascending aorta (mean 11 +/- 5 mm). The annulus body surface area ratio increased from 18.6 +/- 7 to 20.5 +/- 9 mm/M2 (p = 0.2). The mean augmentation in annulus diameter in group 3 was 6 +/- 4 mm; the annulus body surface area ratio decreased from 23.7 +/- 14 to 20.3 +/- 8 mm/M2 (p = 0.5). CONCLUSIONS: We continue to offer the Ross operation to pediatric patients even when aortic annular or ascending aortic size discrepancies mandate surgical modifications.

Adolescent↗
PubMed2002

Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated?

BACKGROUND: The use of prosthetic material (rather than a homograft) for ascending aorta/aortic valve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval. METHODS: Twenty-eight patients (55 +/- 14 years; 22 male) underwent a Bentall procedure for acute prosthetic valve endocarditis between 1988 and 2000. Twenty-five patients had undergone previous aortic valve replacement (1 with concomitant mitral valve replacement, 4 with coronary artery bypass grafting), and 3 had had a previous Bentall operation. The median interval between initial surgery and reoperation was 13 months (range, 1 to 106). Sixty-eight percent of operations were urgent or emergencies. Ninety-three percent of patients had significant aortic regurgitation; complete annuloaortic dehiscence occurred in 71%, and in 57%, an abscess was found. Causative organisms were identified in 25 of 28 patients: Staphylococcus epidermidis (9), Staphylococcus aureus (7), Streptococcus viridans (6), Pseudomonas (2), and Legionella (1). RESULTS: Twenty-three patients had mechanical and 5 had biological valves implanted during the Bentall procedure. Hypothermic circulatory arrest was used in 64%. Hospital mortality was 11%: there was one intraoperative death, and two before discharge (one cardiac, one sepsis). Eighty-nine percent survived without stroke. During follow-up (median, 44.5 months; complete in 92%), 1 patient died of recurrent endocarditis at 4 months. CONCLUSIONS: These results indicate that prosthetic root replacement may be superior to use of a homograft for acute aortic prosthetic valve endocarditis, with only a 4% incidence of recurrent endocarditis and reoperation.

Adult↗