Dilation of the ascending aorta after balloon valvuloplasty for aortic stenosis during infancy and childhood

Dilation of the ascending aorta (AA) is common in patients with a bicuspid aortic valve. The natural history of the aortic root and AA and the risk factors for dilation have not been characterized in patients with congenital aortic stenosis (AS) treated with balloon valvuloplasty during childhood. The present study was performed to determine the prevalence of aortic dilation in patients with congenital AS before and up to 20 years after balloon valvuloplasty performed during childhood. In patients who underwent balloon valvuloplasty for AS at age ≤18 years from 1984 to 2005, the aortic diameter measurements before intervention and at 5-year intervals afterward were recorded and the Z scores calculated. Among 156 patients (median age 1.5 years at valvuloplasty), the AA Z scores were significantly larger than normal before intervention (median Z score 1.5) and at all follow-up points (all p <0.001). Using mixed modeling, with time as a categorical variable (before intervention, 5-year window, 10-year window, and so forth), the mean AA Z score was greater at all postvalvuloplasty points than before the intervention, with mean Z score increases of 1.20 at 5 years and 2.11 at 20 years (p <0.001). Moderate or greater aortic regurgitation early after valvuloplasty was associated with greater AA Z scores than mild or less aortic regurgitation, with a progressive difference over time. More significant residual AS after valvuloplasty was associated with lower AA Z scores over time. In conclusion, AA dilation is common in children with congenital AS and continues to progress over many years after balloon valvuloplasty.     

Relation between NT-proBNP levels, iron overload, and early stage of myocardial dysfunction in β-thalassemia major patients

Background: Heart failure (HF) secondary to myocardial iron loading remains the leading cause of death in β‐thalassemia major (β‐TM) patients. The early diagnosis and treatment of HF in these patients is related to survival. We aimed to evaluate myocardial performance using conventional and tissue Doppler echocardiography and its relation to plasma NT‐proBNP levels and iron overload indices in β‐TM patients with preserved systolic function. Methods: The study population included 49 β‐TM patients (24.0 ± 4.2 years) and 48 age‐matched healthy controls. Doppler‐echocardiographic study was performed and blood samples for NT‐proBNP measurements were drawn on the third day following blood transfusion. Patients were divided as group‐1, without diastolic dysfunction: E/E′ ratio < 9 and group‐2, with suspected diastolic dysfunction: E/E′ ratio ≥ 9. Results: NT‐proBNP levels and E/E′ ratio were increased in patients compared with controls (P < 0.001 and P < 0.001) but did not correlate with each other. A strong positive correlation was detected between NT‐proBNP levels and mean ferritin levels in β‐TM patients (r_s= 0.939; P < 0.001). Median NT‐proBNP levels were significantly higher in group‐1 in comparison to controls [51.2 (41.51–113.5) vs 30.1 (17.97–68.16) ng/mL, P < 0.01]. NT‐proBNP levels were also increased in group‐2 in comparison to group‐1 but this increase was not statistically significant. Conclusion: NT‐proBNP secretion begins in the early phase of the disease before the increase in diastolic pressure becomes overt. While there was a strong correlation between the plasma NT‐proBNP levels and iron overload, there was no correlation between NT‐proBNP levels and diastolic dysfunction parameters in patients in the third decade of life. (Echocardiography 2012;29:318‐325)     

Cystic and hemorrhagic giant left atrial myxoma in a patient presenting with exertional angina and dyspnea

Myxomas are the most common type of primary cardiac tumors and are usually localized in the atrium. The clinical features of the disease depend on the size, location, mobility, and fragility of the mass. In our case report, we present a 38-year-old female patient admitted to our hospital with typical exertional angina and dyspnea. Diagnosis of giant cystic/hemorrhagic atrial myxoma was established after imaging modalities including echocardiography, angiography, and radiology and the pathological evaluation of the mass. On the coronary angiography, a significant feeding artery of the tumor originating from the right coronary artery and the cystic/hemorrhagic appearance all raised the suspicion for the presence of other cardiac masses. However, the pathological evaluation of the mass was reported as consistent with myxoma, with many prominent cystic and hemorrhagic fields and no evidence of malignancy. Since large intratumoral hemorrhagic fields and the presence of a significant feeding artery secondary to tumor neovascularization were observed, we hypothesized that the remarkable amount of blood flow from the coronary artery to the giant myxoma may result in a kind of coronary steal phenomenon and typical anginal symptoms of the patient.     

Analysis of Isokinetic Knee Extension / Flexion in Male Elite Adolescent Wrestlers

Wrestling requires strength of the upper and lower body musculature which is critical for the athletic performance. Evaluation of the adolescent’s skeletal muscle is important to understand body movement, especially including those involved in sports. Strength, power and endurance capacity are defined as parameters of skeletal muscle biomechanical properties. The isokinetic dynamometer is an important toll for making this type of evaluation. However, load range phase of range of motion has to be considered to interpret the data correctly. With this in mind we aimed to investigate the lover body musculature contractile characteristics of adolescent wrestlers together with detailed analyses of load range phase of motion. Thirteen boys aged 12 - 14 years participated to this study. Concentric load range torque, work and power of knee extension and flexion were measured by a Cybex Norm dynamometer at angular velocities from 450°/sec to 30°/sec with 30°/sec decrements for each set. None of the wrestlers were able to attain load range for angular velocities above 390°/sec and 420°/sec for extension and flexion respectively. Detailed analyses of the load range resulted in statistically significant differences in the normalized load range peak torque for extension at 270°/sec (1.44 ± 0.28 Nm·kg^-1 and 1.14 ± 0.28 Nm·kg^-1 for total and load range peak torque respectively, p < 0.05), and for flexion at 300°/sec (1.26 ± 0.28 Nm·kg^-1 and 1.03 ± 0.23 Nm·kg^-1 for total and load range peak torque respectively, p < 0.05), compared to total peak torque data. Similarly, the significant difference was found for the work values at 90°/sec (1.91 ± 0.23 Nm·kg^-1 and 1.59 ± 0.24 Nm·kg^-1 for total and load range work respectively for extension and 1.73 ± 0.21 Nm·kg^-1 and 1.49 ± 0.19 Nm·kg^-1 for total and load range work respectively for flexion, p < 0.05), and was evident at higher angular velocities (p < 0.001) for both extension and flexion. At extension, load range power values were significantly smaller than total power for all angular velocities except 150°/sec (p < 0.05 for 120 and 180°/sec, p < 0.001 for others). Finally, load range flexion power was found to be higher than total power with statistically significance (p < 0.05 for 60, 120, 150, 180, 210, 270 and 300°/sec, p < 0.001 for 240 °/sec). Extra caution is required for correct interpretation of load range data in terms of considering the load range during limb movement. Evaluation of muscle performance of these adolescent wrestlers at regular intervals may give us an opportunity to obtain a healthy maturation profile of these adolescent wrestlers.

Key Points

• Consideration of load range for peak torque, work and power calculation resulted significant differences in the data presented by isokinetic dynamometer. Therefore evaluation of the dynamometer data required consideration of the load range for correct analysis and interpretation.
• Contraction velocity has critical importance in determining the load range attaining ability for a moving limb during load range evaluation. In fact alterations in contraction speed may be due to a number of changes in muscle morphology, subjects’ age and the ratio between type I and type II muscle fiber area.

Key Words: Wrestling, adolescent, isokinetic dynamometer, muscle, load range     

Elimination of intraluminal colonization by antibiotic lock in catheters

Antibiotic lock (AL) technique for catheter related infection encompasses the filling of a catheter lumen with high concentrations of antibiotics for hours. The goal of AL therapy is to decontaminate the intraluminal surface of the catheter. However the duration of antibiotic therapy is not established. An in vitro model was designed to establish the time needed to eliminate intraluminal microbial colonization and to evaluate the efficacy of vancomycin in comparison with teicoplanin by using laboratory AL model. Human plasma was instilled into the catheters to allow deposition of fibrin and other products on the catheter wall. After 48 hours, the catheters were drained and inoculated with bacteria in tryptic soy broth. The catheters were then drained and filled with either (a) vancomycin saline solution (VSS) lock (b) teicoplanin saline solution (TSS) lock or (c) saline solution (SS) as the control and then incubated for 12 hours. After 12 hours incubation all the catheter were drained and filled with human plasma. Instillation of human plasma and AL was alternated every 12 hours to simulate clinical conditions. For each day three catheters, locked with VSS, TSS and SS were cultured for colony count. Microbial counts were expressed as total colony-forming units per longitudinal centimeters of catheter surface. A significant decrease in intraluminal catheter colonization started as early as day 1. At the end of 7th day catheters treated with VSS and TSS lock were completely sterile. The decrease of intraluminal colonization was similar in catheters treated with VSS and TSS lock. Also the decrease of intraluminal colonization were similar in catheter colonized with slime forming S. epidermidis and nonslime-forming S. epidermidis.     

Nomogram with potential clinical use to predict lymph node metastasis in endometrial cancer patients diagnosed incidentally by postoperative pathological assessment

Purpose

To determine the clinical and pathological risk factors for lymph node metastasis (LNM) in patients with endometrial cancer and to create a nomogram to predict LNM in patients without surgical staging.

Methods

All patients with endometrial adenocarcinoma who were treated surgically at a university based gynecologic oncology clinic between January 2011 and December 2014 were recruited. Women with endometrial adenocarcinoma who were surgically staged including lymphadenectomy were included in the study. Data regarding clinical and pathological risk factors were recorded. The histopathologic slides from the staging surgeries were re-evaluated microscopically by a gynecologic pathologist for all parameters along with lymphovascular space invasion (LVSI).

Results

A total of 279 patients with endometrial cancer were analyzed. Among those, 31 (11.1%) had lymph node metastasis. According to the univariate analyses, elevated CA 125 (>35 U/mL), LVSI, myometrial invasion ≥50%, grade 3 disease, non-endometrioid type, and cervical stromal involvement were significantly associated with LNM. The multivariate logistic regression analysis showed that LVSI, non-endometrioid type, elevated CA 125, and cervical stromal involvement increased the risk of LNM. However, myometrial invasion and grade did not significantly affect the risk of LNM. A nomogram to predict LNM was constructed using these factors (concordance index 0.92).

Conclusions

LVSI is the most important predictor for LNM. The present nomogram can be useful to decide if adjuvant therapy is required for patients who undergo simple hysterectomy for a benign etiology and incidentally diagnosed with endometrial cancer by pathological evaluation.