Warfarin-Induced Skin Necrosis

Warfarin-induced skin necrosis is an infrequent complication occurring in individuals under warfarin treatment who have a thrombophilic history or after administration of large loading doses of warfarin particularly without simultaneous initial use of heparin. A 62-year-old lady developed skin necrosis 4 days after initiating warfarin therapy of 5 mg daily without initial co-administration of heparin. The patient had a normal clotting profile. Skin necrosis progressed to eschar formation after cessation of warfarin and heparinization stopped expanding. Warfarin was reintroduced at 2 mg daily, initially together with low molecular weight heparin. Autolytic debridement of the necrotic tissue was followed by healing of the cutaneous deficit by secondary intention. Prompt diagnosis and discontinuation of warfarin are crucial for the prognosis.     

Percutaneous endovascular treatment of aortic aneurysms: Clinical evaluation and literature results

Abstract In this study we aimed to evaluate the efficiency of percutaneous endovascular aortic aneurysm repair (p-EVAR). Anatomically selected patients treated with a single 10Fr Perclose Prostar XL vascular closure device (VCD) were examined. Primary success rate and common femoral artery (CFA) open conversion (OC) requirement per sheath size used were recorded. A literature review on p-EVAR results was also performed. One-hundred patients were enrolled. Successful p-EVAR was achieved in 183 of the 196 CFA access sites (93.4%), and was specifically 85.9% and 98.3% for sheaths ≥20Fr and ≤18Fr respectively. There were 13 periprocedural complications (bleeding = 10, arterial dissection and thrombosis = 1, pseudoaneurysm = 2) all leading to OC. Use of ≥20Fr sheaths had significantly higher OC rate (P < .05). Reconstruction was achieved with primary repair (N = 11) and patch angioplasty (N = 2). Mean hospital stay was 1.8 days. The literature review (vascular closure of 2921 CFA access sites) revealed an overall technical success rate of 92.3%. Device related- were more common than patient related-OCs (P < .05). p-EVAR procedures are safe and feasible. Sheath size is a significant predictor of OC rate and more OCs might be expected with very large (≥20Fr) sheath sizes.     

Hypoxia inducible factor (HIf1alpha and HIF2alpha) and carbonic anhydrase 9 (CA9) expression and response of head-neck cancer to hypofractionated and accelerated radiotherapy

PURPOSE: Tumor hypoxia and low intrinsic radiosensitivity may counteract the efficacy of standard radiotherapy for locally advanced head and neck cancer (HNC). We investigated the involvement of hypoxia-regulated proteins (Hypoxia inducible factors HIF1alpha, HIF2alpha and carbonic anhydrase CA9) in HNC resistance to accelerated and hypofractionated radiotherapy. MATERIALS AND METHODS: Thirty-nine patients with locally advanced HNC received 15 daily fractions of 3.4 Gy amounting to a total tumor dose of 51 Gy (equivalent to 63 Gy in four weeks--one week split); this was combined with platinum chemotherapy and amifostine cytoprotection administered subcutaneously. Immunohistochemical analysis of hypoxia-regulated proteins, namely HIF1alpha, HIF2alpha and CA9, was performed in formalin-fixed paraffin-embedded tissues obtained prior to radio-chemotherapy. RESULTS: HIF1alpha and HIF2alpha were expressed in the nuclei and cytoplasm of cancer cells, while CA9 had a membrane reactivity. A high expression of HIF1alpha, HIF2alpha and CA9 was noted in 21/39 (53.8%), 20/39 (51.3%) and 23/39 (58.9%) cases, respectively. Complete response was obtained in 85.2% of patients and HIF1alpha was marginally related with persistent disease after RT (p = 0.05). HIF1alpha was significantly associated with poor local relapse free survival (LRFS) (p = 0.006) and overall survival (p = 0.008), whilst HIF2alpha was not. A significant association of CA9 expression with poor LRFS was noted (p = 0.01). CONCLUSION: In accord with previously reported studies, high levels of the hypoxia regulated proteins HIF1alpha and CA9 in HNC predict resistance to platinum based radio-chemotherapy. Whether HIF2alpha expressing tumors are more sensitive to larger radiotherapy fractions, compared to standard radiotherapy fractionation, is an issue that deserves further investigation.     

Myxoid leiomyosarcoma of the uterus: a diagnostic challenge

Myxoid leiomyosarcoma is an extremely rare variant of leiomyosarcoma, masquerading almost to perfection as a benign lesion. For, indeed, the tumor lacks the defining features of high mitotic activity, cellular atypia or necrosis, and the microscopic picture is dominated by abundant myxoid stroma containing sparse spindle cells. We report here such a case occurring in the uterus and discuss the differential diagnosis. The relevant literature is reviewed.     

Intestinal-type metaplasia in the original squamous epithelium of the cervix

There have been a number of reports on cervical carcinomas, both invasive and intraepithelial (CIN III), indicating the presence of intracellular mucins in the absence of glandular differentiation. Yet, the expression of such cells in the normal/original squamous epithelium of the cervix remains unexplored. We investigated the presence of mucin-distended goblet cells at this site, after examining retrospectively normal cervices from 250 hysterectomy specimens. Goblet cells were detected in 3.2% (8/250) of the cervices examined using haematoxylin and eosin stained sections and confirmed by mucin histochemistry: alcian blue (AB) pH 2.5, periodic acid-Schiff reaction with and without diastase digestion (PAS-d, PAS) and the combined AB/PAS. Additional sections were stained with Diazo and Masson-Fontana for argentaffin granules and Grimelius for argyrophil cells, but were all negative and no other cell types were identified. It is believed that this incomplete type of intestinal metaplasia is an acquired change in the cervix, derived from multi-potential stem cells of Müllerian duct origin.     

The Longitudinal Association of Lifestyle with Cognitive Health and Dementia Risk: Findings from the HELIAD Study

The aim of the current study was to investigate whether a Total Lifestyle Index (TLI), including adherence to the Mediterranean diet, sleep duration, physical activity and engagement in activities of daily living, is associated with cognitive health over time and dementia risk, in a representative cohort of older people. A total of 1018 non-demented community-dwelling older adults ≥65 years old (60% women) from the HELIAD study were included. A comprehensive neurological and neuropsychological assessment was conducted at baseline and at the 3-year follow-up evaluating cognitive functioning, and a dementia diagnosis was set. Diet, physical activity, sleep duration and engagement in activities of daily living were assessed using standard, validated questionnaires at baseline. Sixty-one participants developed dementia at follow-up; participants who developed dementia were older and had fewer years of education compared with participants with normal cognition. With the exception of sleep duration, participants with normal cognition at follow-up scored higher in the individual lifestyle factors compared to those who developed dementia. Regarding TLI, values were lower for participants with dementia compared with those with normal cognition. Each additional unit of the TLI was associated with 0.5% of a standard deviation less decline per year of the Global Cognition score, whereas for each additional unit of the TLI, the risk for dementia was reduced by 0.2% per year (p < 0.05). Our results suggest that greater adherence to a healthy lifestyle pattern is associated with a slower decline of cognitive function and reduced dementia risk.