Right atrial angiosarcoma: a case report

A 32-year-old female patient presented with dyspnea and palpitation, and transthoracic echocardiography revealed the presence of pericardial effusion. Pericardiosynthesis was performed for drainage. Because of the rapid accumulation of effusion and the presence of a right atrial mass on follow-up echocardiography, a computed tomography scan was done that revealed a right atrial defect and the presence of advanced pericardial effusion. The patient was prepared for an emergency operation. The mass on the right atrial wall was approached via a midsternal incision with cardiopulmonary bypass. The tumor filled the right atrial cavity, compressed vital structures, extended to the right ventricle, and had local metastases. As the tumor did not appear to be curable with surgery, a palliative approach was adopted. The right atrial free wall and tissues causing cardiac obstruction were totally removed, the tumor itself was partially excised, and local metastases were sampled. The resulting right atrial wall defect was closed with a Dacron patch. The operation ended uneventfully, and the clinical status and vital and hemodynamic findings of the patient returned to normal. The pathological diagnosis based on the samples obtained during the operation was angiosarcoma. The patient had an uneventful postoperative period and was then referred to an oncology center for clinical recovery. No findings of local recurrence or metastases were observed during the postoperative follow-up. The patient completed her combination therapy and currently is free of any clinical problems at her 13th postoperative month. We believe that advancements in radiotherapy and chemotherapy regimes combined with surgery (radical, if possible) for the treatment of cardiac angiosarcomas may provide better survival and quality-of-life results.     

Oral flurbiprofen spray for mucosal graft harvesting at the palatal area: A randomized placebo‐controlled study

1 Background

Flurbiprofen which is a non‐steroidal anti‐inflammatory drug (NSAID), has been safely used for the control of postoperative patient's morbidity after periodontal plastic surgeries requiring palatal graft harvesting, but there is little information on the efficacy of topical use. The aim of the study was to evaluate whether patient pain perception was reduced and patient morbidity was improved by using oral spray of flurbiprofen after palatal graft harvesting.

2 Methods

Forty‐eight patients (21 males and 27 females), scheduled for subepithelial connective tissue graft (SCTG) and free gingival graft (FGG) requiring periodontal plastic surgeries were selected. The patients were randomly assigned to each group and used oral spray of flurbiprofen or placebo three times a day for a week. The palatal donor area was evaluated at 1, 3, 7, 14, 21, 28, 42, and 56‐day follow‐up after the surgery for postoperative pain, patients’ discomfort, complete epithelialization, changes in dietary habits, burning sensation, color match, the amount of systemic analgesic consumption and the presence of delayed bleeding. Wound healing scores were recorded at 14‐day follow up.

3 Results

The prevalance of complete epithelialization was significantly higher in the placebo‐FGG group than flurbiprofen‐FGG group at 21 days postoperatively (P < 0.05), while there was no significant alteration for both flurbiprofen‐SCTG and placebo‐SCTG groups at any follow‐up periods. In flurbiprofen‐FGG group, significant improvements were observed for postoperative pain, patients’ discomfort and burning sensation at 14 days postoperatively (P < 0.05).

4 Conclusion

Oral flurbiprofen spray reduces patient's morbidity, however it might have negative effects on epithelialization of secondary wound healing after FGG operations.     

Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing

This study is a case report of a meningomyelocele patient with congenital kyphosis who was treated with kyphectomy and a special approach to soft tissue healing. The objective of this study is to show a step by step approach to surgical treatment and postoperative care of a meningomyelocele patient with congenital kyphosis. In meningomyelocele the incidence of kyphosis is around 12-20%. It may cause recurrent skin ulcerations, impaired sitting balance and respiratory compromise. Kyphectomy has first been described by Sharrard. This surgery is prone to complications including pseudoarthrosis, skin healing problems, recurrence of deformity and deep infections. A 15-year-old male presented with congenital kyphosis due to meningomyelocele. He had back pain, deformity and bedsores at the apex of the deformity. The wound cultures showed Staphylococcus epidermidis colonisation at the apex. He was given appropriate antibiotic prophylaxis. During surgery, the apex of the deformity was exposed through a spindle-shaped incision. After instrumentation and excision of the apex, correction was carried out by cantilever technique. Two screws were inserted to the bodies of L3 and T11. After the operation, the skin was closed in a reverse cross fashion. He was sent to hyperbaric oxygen treatment for prevention of a subsequent skin infection and for rapid healing of skin flaps post operation. The patient's deformity was corrected from a preoperative Cobb angle of 135°-15° postoperative. The skin healed without any problems. Preoperative culture and appropriate antibiotic prophylaxis, spindle-shaped incision, reverse cross-skin closure and postoperative hyperbaric oxygen treatment can be useful adjuncts to treatment in congenital kyphosis patients with myelomeningocele to prevent postoperative wound healing and infection problems. Reduction screws and intracorporeal compression screws help to reduce the amount of screws and aid in corection of the deformity.     

Chronic unpredictable stress disturbs the blood–testis barrier affecting sperm parameters in mice

Research questionDoes chronic stress affect the key proteins and sperm parameters of the blood–testis barrier (BTB)?DesignC57Bl/6 mice were divided into two groups: a non-treated control group and a chronic unpredictable stress (CUS) applied group. The stress status of the animals was confirmed with behavioural tests. Histopathologic evaluation was conducted by haematoxylin and eosin staining and electron microscope. Malondialdehyde, corticosterone and testosterone levels were evaluated in peripheral blood. Expression levels of BTB proteins, namely zonula occludens-1 (ZO-1), claudin-11 (CLDN11) and clathrin in Sertoli cells, were assessed by Western blotting and immunofluorescence techniques. Sperm samples were collected from cauda epididymis, and sperm parameters analysed.ResultsThe stress model was confirmed by behavioural tests. Histopathological evaluation of the testes demonstrated a mild degeneration in seminiferous tubules. Malondialdehyde (P = 0.008) and corticosterone levels increased (P = 0.004) and testosterone levels decreased (P = 0.005) in the CUS group. Electron microscopic evaluation confirmed the damage in BTB integrity in the CUS group. Western blot analysis showed that ZO-1 and CLDN11 levels were significantly decreased, although clathrin levels were unchanged. Although sperm concentration and total motility rate were not significantly different between the groups, progressive motility (P = 0.03), normal sperm morphology (P = 0.04), chromatin integrity (toluidine blue) (P = 0.002) and the acrosomal reaction rate (P = 0.002) were significantly decreased, and acrosomal abnormality rate was dramatically increased (P = 0.04) in the CUS group.ConclusionsIn mice, CUS disrupted BTB integrity and impaired sperm parameters. A decrease in ZO-1 and CLDN11 expression levels may be proposed as the causative factor.     

Giant right atrial myxoma leading to cardiac arrest in an infant

We present the case of a three-month-old infant with a giant right atrial myxoma obstructing the tricuspid valve, who following haemodynamic deterioration and cardiac arrest, was operated upon as an emergency. On echocardiogram, there was a mass attached to the tricuspid annulus, in close proximity to the septal leaflet, with dimensions of 16.6 × 12.5 mm. The mass was prolapsing through the tricuspid valve into the right ventricle and obstructing the inflow. While preparing for surgery, cardiac arrest occurred, so the patient underwent an emergency operation under cardiopulmonary resuscitation. The mass was excised without damaging the tricuspid valve and the conduction system. Histologically, the mass consisted of a myxoid matrix with scatted globoid and star-shaped myxoma cells. The patient stayed 15 days in the intensive care unit and was discharged home on the 20th day postoperatively. Although accepted as a benign tumour, a myxoma can display an aggressive clinical course in infants. In centres where cardiac operations cannot be performed, these patients need to be transferred to cardiac centres as soon as possible. Whatever the clinical presentation, we advocate immediate surgical extirpation of the tumour in order to avoid any unpredictable consequences in its clinical course.     

Prognostic factors in critically ill cancer patients admitted to the intensive care unit

Objective

The objective of this study is to identify factors predicting intensive care unit (ICU) mortality in cancer patients admitted to a medical ICU.

Patients and methods

We conducted a retrospective study in 162 consecutive cancer patients admitted to the medical ICU of a 1000-bed university hospital between January 2009 and June 2012. Medical history, physical and laboratory findings on admission, and therapeutic interventions during ICU stay were recorded. The study end point was ICU mortality. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

Results

The study cohort consisted of 104 (64.2%) patients with solid tumors and 58 patients (35.8%) with hematological malignancies. The major causes of ICU admission were sepsis/septic shock (66.7%) and respiratory failure (63.6%), respectively. Overall ICU mortality rate was 55 % (n = 89). The ICU mortality rates were similar in patients with hematological malignancies and solid tumors (57% vs 53.8%; P = .744). Four variables were independent predictors for ICU mortality in cancer patients: the remission status of the underlying cancer on ICU admission (odds ratio [OR], 0.113; 95% confidence interval [CI], 0.027-0.48; P = .003), Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.032-1.215; P = .007), sepsis/septic shock during ICU stay (OR, 8.94; 95% CI, 2.28-35; P = .002), and vasopressor requirement (OR 16.84; 95% CI, 3.98-71.24; P = .0001). Although Acute Physiology and Chronic Health Evaluation II score (OR, 1.30; 95% CI, 1.054-1.61; P = .014), admission through emergency service (OR, 0.005; 95% CI, 0.00-0.69; P = .035), and vasopressor requirement during ICU stay (OR, 140.64; 95% CI, 3.59-5505.5; P = .008) were independent predictors for ICU mortality in patients with hematological malignancies, Sequential Organ Failure Assessment score (OR, 1.83; 95% CI, 1.29-2.6; P = .001), lactate dehydrogenase level on admission (OR, 1.002; 95% CI, 1-1.005; P = .028), sepsis/septic shock during ICU stay (OR, 138.4; 95% CI, 12.54-1528.4; P = .0001), and complete or partial remission of the underlying cancer (OR, 0.026; 95% CI, 0.002-0.3; P = .004) were the independent risk factors in patients with solid tumors.

Conclusion

Intensive care unit mortality rate was 55% in our cancer patients, which suggests that patients with cancer can benefit from ICU admission. We also found that ICU mortality rates of patients with hematological malignancies and solid tumors were similar.     

Direct and indirect effects of paliperidone extended-release tablets on negative symptoms of schizophrenia

Direct and indirect effects of the new psychotropic paliperidone extended-release (paliperidone ER) tablets on negative symptom improvement in schizophrenia were investigated using path analysis. A post hoc analysis of pooled data from three 6-week, double-blind, placebo-controlled studies of paliperidone ER in patients experiencing acute exacerbation was conducted. Regression analysis explored relationships between baseline/study characteristics and negative symptoms. Change in Positive and Negative Syndrome Scale (PANSS) negative factor score at endpoint was the dependent variable; explanatory variables included demographic and clinical characteristics. Path analysis determined direct and indirect effects of treatment on negative symptom change. Indirect mediators of negative symptom change in the model included changes in positive symptoms, anxiety/depression symptoms and movement disorders. Path analysis indicated that up to 33% of negative symptom improvement was a direct treatment effect. Indirect effects on negative symptoms were mediated through changes in positive symptoms (51%) and anxiety/depression symptoms (18%), whereas changes in movement disorders had a 2.1% inverse effect. Path analysis indicated that paliperidone ER has a direct effect on negative symptoms. Negative symptom improvement also was indirectly mediated via changes in positive and depressive symptoms.