Hilar-lymphadenopathy predictive of cutaneous sarcoid

A case of hilar lymphadenopathy, a cardinal sign of extra-cutaneous sarcoidosis, is being described in detail. It continued to be a diagnostic dilemma until the appearance of several papules and/or nodules over the face, front and back of the upper chest. The diagnosis was clinched by demonstration of non-caseating, epithelioid naked granuloma and affirmative response to oral administration of prednisolone in dosage of 40 mg a day.     

Comparison of continuous, stat, and intermittent cardiac output measurements in patients undergoing minimally invasive direct coronary artery bypass surgery

OBJECTIVE: To compare intermittent cardiac output (ICO) with continuous cardiac output (CCO) and stat cardiac output (SCO) measurements in patients undergoing minimally invasive direct coronary artery bypass (MIDCAB) surgery. DESIGN: Prospective, clinical study. SETTING: Single, tertiary referral center. PARTICIPANTS: Twenty adult patients undergoing off-pump MIDCAB surgery from January through June 2000. INTERVENTIONS: Each patient had a 7.5F 5-lumen pulmonary artery thermodilution catheter (CCO catheter, Baxter Healthcare Corporation, Irvine, CA) inserted for measurement of cardiac output (CO). ICO, CCO, and SCO were compared at 10 predefined time points. RESULTS: A total of 400 data pairs for CO were obtained. ICO values ranged from 1.8 to 8.4 L/min; CCO, 1.9 to 7.5 L/min; and SCO, 2.25 to 6.35 L/min. Correlation between ICO and CCO was significant (correlation coefficient, r = 0.78, p < 0.001), accompanied by a bias of -0.095 L/min and precision of 0.729 L/min. Similarly, the correlation between ICO and SCO was significant (r = 0.79, p < 0.001), accompanied by good accuracy (bias, 0.084 L/min) and precision (0.843 L/min). There were statistically significant decreases in mean arterial pressure, CO, cardiac index, stroke volume, stroke volume index, and left and right ventricular stroke work indices during anastomosis of the left internal mammary artery to left anterior descending artery. These parameters returned to baseline preinduction values 1 minute after completion of the anastomosis. CONCLUSION: Excellent correlation, accuracy, and precision were found among the 3 methods of measuring CO in patients undergoing MIDCAB surgery. Further studies are needed to assess their accuracy in multivessel off-pump coronary artery bypass graft surgery and in patients with poor left ventricular function.     

Hormone receptor status of breast cancer in India: a study of 798 tumours

The objectives of this study were to document the oestrogen and progesterone receptor (ER & PR) status of breast cancer in the Indian population (as done by immunohistochemistry on paraffin blocks), and correlate the steroid receptor status of breast cancer with all relevant patient and tumour characteristics. Our current data have been compared with previously published data from other centres. In contrast to the higher rates reported in the Western literature, only 32.6% of our tumours were ER positive and 46.1% were PR positive. Tumours were separated into four categories: ER+PR+ (25%), ER+PR- (7.4%), ER-PR+ (21.1%) and ER-PR- (46.5%). ER and PR immunoreactivity increased with advancing age, and correlated with the presence of elastosis. Infiltrating lobular carcinoma, mucinous carcinoma, and mixed tumours were more frequently ER & PR positive. High-grade infiltrating duct carcinomas, pure comedo ductal carcinoma in situ, and medullary carcinoma were predominantly ER & PR negative. The presence of necrosis and lymphovascular invasion showed an inverse relationship with ER and PR reactivity.     

Muscular sufficiency, serum protein, enzymes and bioenergetic studies (31-phosphorus magnetic resonance spectroscopy) in chronic malnutrition

Muscle sufficiency was significantly lower in 1336 children with chronic malnutrition of moderate to severe degree. Eighteen children with a chronic moderate degree of malnutrition and 8 well-nourished, age-matched controls were selected for biochemical and 31-phosphorus magnetic resonance spectroscopy (31 -P MRS) studies. The results showed that: (a) serum total protein, albumin, iron, calcium and inorganic phosphate were similar in both groups; (b) serum enzyme levels were significantly increased in the malnourished group; (c) 31-P MRS showed significantly higher means for total ATP, β-ATP, a-ATP and inorganic phosphate for the malnourished compared to the control group. In chronic malnutrition, proteins are maintained by degradation in muscle resulting in release of amino acids and enzymes. 31-P MRS studies showing increases in total ATP, β-ATP and inorganic phosphate and a decrease in phosphocreatine suggest that ATP is maintained at the cost of phosphocreatine.     

Profound hypothermia protects neurons and astrocytes, and preserves cognitive functions in a Swine model of lethal hemorrhage

BACKGROUND: Lethal injuries can be repaired under asanguineous hypothermic arrest (suspended animation) with excellent survival. This experiment was designed to test the impact of this strategy on neuronal and astroglial damage in a swine model of lethal hemorrhage. Furthermore, our goal was to correlate the histological changes in the brain with neurological outcome, and the levels of circulating brain specific markers. MATERIALS AND METHODS: Uncontrolled hemorrhage was induced in 32 female swine (80-120 lbs) by creating an iliac artery and vein injury, followed 30 min later by laceration of the thoracic aorta. Through a thoracotomy approach, organ preservation fluid was infused into the aorta using a roller pump. Experimental groups included normothermic controls (no cooling, NC), and groups where hypothermia was induced at three different rates: 0.5 degrees C/min (slow, SC), 1 degrees C/min (medium, MC), or 2 degrees C/min (fast, FC). Profound hypothermia (core temperature of 10 degrees C) was maintained for 60 min for repair of vascular injuries, after which the animals were re-warmed (0.5 degrees C/min) and resuscitated on cardiopulmonary bypass (CPB). Circulating levels of neuron specific enolase (NSE) and S-100beta were serially measured as markers of damage to neurons and astrocytes, respectively. Light microscopy and quantitative immunohistochemical techniques were used to evaluate hippocampal CA1 area and caudate putamen for neuronal injury and astrogliosis (astrocyte hyperplasia/hypertrophy). Surviving animals were observed for 6 weeks and neurological status was documented on an objective scale, and cognitive functions were evaluated using a technique based upon the concept of operant conditioning. RESULTS: Normothermic arrest resulted in clinical brain death in all of the animals. None of the surviving hypothermic animals displayed any neurological deficits or cognitive impairment. On histological examination, normothermic animals were found to have ischemic changes in the neurons and astrocytes (hypertrophy). In contrast, all of the hypothermic animals had histologically normal brains. The circulating levels of brain specific proteins did not correlate with the degree of brain damage. The changes in NSE levels were not statistically significant, whereas S-100beta increased in the circulation after CPB, largely independent of the temperature modulation. CONCLUSIONS: Profound hypothermia can preserve viability of neurons and astrocytes during prolonged periods of cerebral hypoxia. This approach is associated with excellent cognitive and neurological outcome following severe shock. Circulating markers of central nervous system injury did not correlate with the actual degree of brain damage in this model.     

Experience of sentinel node biopsy alone in early breast cancer without further axillary dissection in patients with negative sentinel node

AIMS: The aims of surgical therapy of breast cancer are loco-regional tumour control and staging. Axillary staging is still considered the single most important prognostic indicator in breast cancer. Surgical removal of axillary nodes remains the standard way to assess their involvement in most centres. The morbidity associated with axillary dissection (AD) is well recognized. In recent years sentinel node biopsy (SNB) has evolved. Multiple studies suggest it has the same accuracy as AD in axillary staging and less morbidity in early breast cancer (EBC). SNB has become the standard of practice in EBC in many parts of the world. In Australia, the preference has been to wait for the results of the Sentinel Node versus Axillary Clearance (SNAC) trial as well as other international trials before accepting SNB as a standard of care. The experience of a single surgeon with SNB alone in EBC without further completion axillary dissection (CAD) in negative sentinel node (SLN) is described in the present paper. METHODS: An audit was done of the senior author's prospective data from the Royal Australasian College of Surgeons database. Other information was added retrospectively from case notes. RESULTS: Between December 2000 and December 2003, 154 EBC cases (153 patients) underwent SNB alone. An average of four SLN was removed. Of these cases, 31.8% had positive SLNs (excluding 2.6% cases that had isolated tumour cells), of these, 93.9% had metastases (39.1% micro- and 60.9% macro-metastases) in axillary-SLN (ASLN) and almost all of these had CAD. ASLNs were the only positive nodes in 73.9%. Extra-ASLN retrieved in 68.8% of 34% demonstrated on lymphoscintigraphy. Of these, 12.1% were positive (6.1% micro- and macro-metastases each), all internal mammary. Mean follow up was 22.1 months. There was one local-regional-systemic and one systemic recurrence over this time. CONCLUSION: SNB has a valid role in staging of the axilla particularly in low-risk patients. After adequate self audit, SNB offers a minimal morbidity and reliable method of axillary staging. Patients choosing SNB alone must understand that the long-term results of the randomized controlled trial are still pending for level I evidence of long-term efficacy.     

Association of sleep time with diabetes mellitus and impaired glucose tolerance

BACKGROUND: Experimental sleep restriction causes impaired glucose tolerance (IGT); however, little is known about the metabolic effects of habitual sleep restriction. We assessed the cross-sectional relation of usual sleep time to diabetes mellitus (DM) and IGT among participants in the Sleep Heart Health Study, a community-based prospective study of the cardiovascular consequences of sleep-disordered breathing. METHODS: Participants were 722 men and 764 women, aged 53 to 93 years. Usual sleep time was obtained by standardized questionnaire. Diabetes mellitus was defined as a serum glucose level of 126 mg/dL or more (> or =7.0 mmol/L) fasting or 200 mg/dL or more (> or =11.1 mmol/L) 2 hours following standard oral glucose challenge or medication use for DM. Impaired glucose tolerance was defined as a 2-hour postchallenge glucose level of 140 mg/dL or more (> or =7.8 mmol/L) and less than 200 mg/dL. The relation of sleep time to DM and IGT was examined using categorical logistic regression with adjustment for age, sex, race, body habitus, and apnea-hypopnea index. RESULTS: The median sleep time was 7 hours per night, with 27.1% of subjects sleeping 6 hours or less per night. Compared with those sleeping 7 to 8 hours per night, subjects sleeping 5 hours or less and 6 hours per night had adjusted odds ratios for DM of 2.51 (95% confidence interval, 1.57-4.02) and 1.66 (95% confidence interval, 1.15-2.39), respectively. Adjusted odds ratios for IGT were 1.33 (95% confidence interval, 0.83-2.15) and 1.58 (95% confidence interval, 1.15-2.18), respectively. Subjects sleeping 9 hours or more per night also had increased odds ratios for DM and IGT. These associations persisted when subjects with insomnia symptoms were excluded. CONCLUSIONS: A sleep duration of 6 hours or less or 9 hours or more is associated with increased prevalence of DM and IGT. Because this effect was present in subjects without insomnia, voluntary sleep restriction may contribute to the large public health burden of DM.     

Particle repositioning manoeuvre in benign paroxysmal positional vertigo: is it really safe?

OBJECTIVE: A prospective study to determine the safety of the particle repositioning manoeuvre (PRM) by analyzing the various complications of the procedure. SETTINGS: Outpatient Department of Otorhinolaryngology, Nehru Hospital, Chandigarh, India. METHODS: Thirty patients with the classic findings of benign paroxysmal positional vertigo (BPPV) were included in the study. Clinical symptoms prior to the procedure were noted. Twenty-nine of them were subjected to PRM, and postprocedural instructions were given to all patients. Various side effects during and following the procedure were recorded. They were classified into early and late based on the period and into major and minor based on severity. All patients were reviewed after 3 days, 7 days, and 1 month. RESULTS: Of the 29 patients, 19 patients (65.52%) had heaviness in the head, with 11 each (37.93%) reporting nausea and imbalance and 9 (31.03%) reporting instability during the procedure. A major complication, asystole, was noted in one patient. The percentage of side effects remained more or less the same in the early phase following the procedure. Only 5 of 29 patients were entirely asymptomatic. Ninety percent were relieved of symptoms by the end of 7 days, with no major complication recorded. CONCLUSIONS: PRM is an easy, effective, and relatively safe procedure. The risk of major complications with PRM, such as arrhythmias and asystole, highlights the need to consider other management modalities for BPPV in certain medically unfit patients.