Live/Real time three-dimensional transthoracic echocardiographic assessment of the involvement of cardiac valves and chambers in carcinoid disease

We present an adult with metastatic carcinoid disease affecting the heart, in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over two-dimensional transthoracic echocardiography (2DTTE). Initial 2DTTE was able to demonstrate severe pulmonic and tricuspid regurgitation, but was unable to visualize the posterior leaflet of the tricuspid valve or the right (right anterior) leaflet of the pulmonic valve. Further analysis with 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of both the tricuspid and the pulmonary valves. En face viewing of tricuspid and pulmonary regurgitation vena contractas permitted more reliable quantification of regurgitation severity. In addition, localized, linear, echogenic areas consistent with carcinoid deposits were noted along the inner walls of the right atrium, atrial septum, and inferior vena cava. To the best of our knowledge, endocardial carcinoid deposits have never been reported by 2D or 3D echocardiography. En face viewing of these deposits by 3DTTE enabled measurement of their dimensions and areas. Subcostal examination also identified large circumscribed hepatic lesions consistent with metastatic disease. Neither the carcinoid deposits nor the metastatic lesions were detected by 2DTTE. This case demonstrates the usefulness of 3DTTE as a supplement to 2DTTE in more comprehensively assessing carcinoid involvement of the heart.     

Surgical management of glomus tympanicum tumor

Glomus tympanicum tumor (also known as paraganglioma or chemodectoma) is the most benign tumor of temporal bone. Treatment may be palliative or curative. Palliative therapy includes watchful observation or radiotherapy and curative treatment is surgical. During 1995 to 2005, 18 cases of glomus tympanicum were managed at Basavanagudi ENT Care Centre Bangalore. We review retrospectively the diagnosis and surgical management of these cases. Advances in the imaging and refinements in traditional surgery have made correct diagnosis and complete excision of these tumors possible in most of the cases.     

Atrial Septal Occluder Device Embolization to an Iliac Artery: A Case Highlighting the Utility of Three‐Dimensional Transesophageal Echocardiography during Percutaneous Closure

Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three‐dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.     

Surgical Options for Patients with Neurogenic Bladder

Neurogenic bladder encompasses many conditions that affect the bladder in patients with neurologic disease. Although there is no standard definition for neurogenic bladder, for the intent and purpose of this review, it is defined as any pathologic process affecting the central and/or peripheral nervous systems that results in urine storage or emptying dysfunction. It often presents clinically as varying degrees of urinary incontinence and/or retention but can present with urinary tract infections, urinary tract stones, or upper urinary tract deterioration. It is up to the clinician to identify wherein the problem lies—is it an outlet problem, bladder problem, or both? What is affected: storage, emptying, or both? These factors should be considered together to identify patients who may benefit from surgical intervention. This review focuses on patient evaluation and surgical interventions for adult patients with neurogenic bladder. Surgical interventions for problems with emptying due to detrusor external sphincter dyssynergia include surgical external sphincterotomy, chemical external sphincterotomy, urethral stent, and sphincter dilation. For detrusor underactivity, detrusor myoplasty and neuromodulation are discussed. For neurogenic detrusor overactivity and impaired compliance and capacity, botulinum toxin injection, sacral neuromodulation, and patch enterocystoplasty are discussed. For decreased compliance/capacity, detrusorotomy is also discussed. For combined problems, urinary diversions are also discussed.     

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia?

Background

Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair.

Methods

We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors.

Results

Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain (P = .05), feeling of lump (P = .02), and foreign body perception (P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group (P = .26).

Conclusions

A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.     

Posterior Beta and anterior gamma oscillations predict cognitive insight

Pioneering neuroimaging studies on insight have revealed neural correlates of the emotional "Aha!" component of the insight process, but neural substrates of the cognitive component, such as problem restructuring (a key to transformative reasoning), remain a mystery. Here, multivariate electroencephalogram signals were recorded from human participants while they solved verbal puzzles that could create a small-scale experience of cognitive insight. Individuals responded as soon as they reached a solution and provided a rating of subjective insight. For unsolved puzzles, hints were provided after 60 to 90 sec. Spatio-temporal signatures of brain oscillations were analyzed using Morlet wavelet transform followed by exploratory parallel-factor analysis. A consistent reduction in beta power (15-25 Hz) was found over the parieto-occipital and centro-temporal electrode regions on all four conditions-(a) correct (vs. incorrect) solutions, (b) solutions without (vs. with) external hint, (c) successful (vs. unsuccessful) utilization of the external hint, and d) self-reported high (vs. low) insight. Gamma band (30-70 Hz) power was increased in right fronto-central and frontal electrode regions for conditions (a) and (c). The effects occurred several (up to 8) seconds before the behavioral response. Our findings indicate that insight is represented by distinct spectral, spatial, and temporal patterns of neural activity related to presolution cognitive processes that are intrinsic to the problem itself but not exclusively to one's subjective assessment of insight.     

An accurate,rapid and sensitive determination of tramadol and its active metabolite O-desmethyltramadol in human plasma by LC–MS/MS

A rapid, sensitive and accurate liquid chromatography–tandem mass spectrometry (LC–MS/MS) assay for the simultaneous determination of tramadol and its active metabolite, O-desmethyltramadol in human plasma is developed using propranolol as internal standard (IS). The analytes and IS were extracted from 200 μL aliquots of human plasma via protein precipitation using acetonitrile. Chromatographic separation was achieved in a run time of 2.0 min on an Aquasil C18 (100 mm × 2.1 mm, 5 μm) column under isocratic conditions. Detection of analytes and IS was done by tandem mass spectrometry, operating in positive ion and multiple reaction monitoring (MRM) acquisition mode. The method was fully validated for its selectivity, sensitivity, linearity, precision and accuracy, recovery, matrix effect, ion suppression/enhancement, stability and dilution integrity. A linear dynamic range was established from 1.0 to 600.0 ng/mL for tramadol and 0.5–300.0 ng/mL for O-desmethyltramadol. The method was successfully applied to a bioequivalence study of 200 mg tramadol tablet formulation in 27 healthy Indian male subjects under fasting condition.     

Multipurpose surgical robot as a laparoscope assistant

Background

This study demonstrates the effectiveness of a new, compact surgical robot at improving laparoscope guidance. Currently, the assistant guiding the laparoscope camera tends to be less experienced and requires physical and verbal direction from the surgeon. Human guidance has disadvantages of fatigue and shakiness leading to inconsistency in the field of view. This study investigates whether replacing the assistant with a compact robot can improve the stability of the surgeon’s field of view and also reduce crowding at the operating table.

Methods

A compact robot based on a bevel-geared “spherical mechanism” with 4 degrees of freedom and capable of full dexterity through a 15-mm port was designed and built. The robot was mounted on the standard railing of the operating table and used to manipulate a laparoscope through a supraumbilical port in a porcine model via a joystick controlled externally by a surgeon. The process was videotaped externally via digital video recorder and internally via laparoscope. Robot position data were also recorded within the robot’s motion control software.

Results

The robot effectively manipulated the laparoscope in all directions to provide a clear and consistent view of liver, small intestine, and spleen. Its range of motion was commensurate with typical motions executed by a human assistant and was well controlled with the joystick.

Conclusions

Qualitative analysis of the video suggested that this method of laparoscope guidance provides highly stable imaging during laparoscopic surgery, which was confirmed by robot position data. Because the robot was table-mounted and compact in design, it increased standing room around the operation table and did not interfere with the workspace of other surgical instruments. The study results also suggest that this robotic method may be combined with flexible endoscopes for highly dexterous visualization with more degrees of freedom.     

Sudden Sensorineural Hearing Loss: An Otologic Emergency

The study purpose was to determine the efficacy of steroids, volume expanders and antivirals in the management of idiopathic sudden sensory neural hearing loss and to establish importance of early medical intervention. In this prospective study, thirty-four patients presenting with idiopathic sudden hearing loss of 30 db or more were enrolled in study group between 2005 and 2009. Patient variables as they related to recovery were studied and include patient age, time to onset of therapy, status of contralateral ear, presence of diabetes, severity of hearing loss, pattern of hearing loss in audiogram and presence of associated symptoms, (tinnitus, vertigo). Treatment protocol with intravenous hydrocortisone, intravenous dextran and oral anti-viral agent was followed. Pre-treatment and post-treatment pure tone average was analyzed. With combination therapy the overall improvement in pure tone threshold was seen in 27 patients (79.4%). A statistically significant association was found between the time at which medical intervention was started and hearing improvement. Early intervention in patients presenting before 3 days has given 77.8% complete type 1 recovery Idiopathic sudden sensory neural hearing loss is a medical emergency. It should not be misdiagnosed. Early detection and management with volume expanders, steroids and antivirals will improve the chances of complete recovery.