Transthoracic Echocardiographic Documentation of Disappearance of Massive Pulmonary Artery Thromboemboli after Fibrinolytic Therapy

In this paper, we report two cases of acute massive pulmonary thromboemboli with pulmonary artery thrombus, in which disappearance of thrombus followed fibrinolytic therapy were documented at transthoracic echocardiographic follow-up. Data from these limited experiences suggest that, transthoracic echocardiography might be useful as a first diagnostic screening in cases of suspect pulmonary thromboembolism and thrombolytic therapy might be considered in patients with pulmonary artery thrombus with pulmonary embolism.     

An unusual pulsed-wave tissue Doppler pattern in mitral valve prolapse: spikes on systolic velocities

BACKGROUND: Mitral valve prolapse (MVP) can be associated with wall-motion abnormalities. Pulsed-wave Doppler tissue imaging (DTI) has been proposed as a method to obtain myocardial velocities with a high spatial and temporal resolution. Our aim was to investigate whether a specific DTI pattern exists in myocardial segments of patients with MVP. METHODS AND RESULTS: We studied 49 consecutive patients with clinically suspected MVP. MVP was diagnosed in 35 patients. After recording the conventional echocardiographic variables, apical-directed left ventricular (LV) segmental myocardial velocities were obtained by DTI. The DTI analysis of myocardial segments revealed a distinct spectral Doppler pattern of mid- and basal posterior and lateral walls consistent with spikes on systolic velocities. These spikes were noticed in 23 (65%) patients with MVP but in none of the 14 subjects without MVP (P = 0.002). The MVP patients with spikes had larger mitral annulus diameters and higher amounts of maximal leaflet displacement when compared with those without spikes (34.8 +/- 5 mm vs 31.2 +/- 4 mm, P = 0.03 and 4.1 +/- 1 ms vs 3.1 +/- 1 mm, P = 0.01, respectively). CONCLUSION: This newly described unique DTI pattern, which may be observed in the majority of patients with MVP, may contribute to the diagnosis of disease. However, future studies are required to evaluate the clinical significance and pathophysiology of the spikes on systolic velocities of posterior and lateral walls in patients with MVP.     

Successful medical treatment of intracranial abscess caused by Brucella spp

An unusual presentation of unilateral cerebellar abscesses due to neurobrucellosis observed in a patient is reported. He gave a history of fever, headache, vomiting and had unilateral cerebellar signs. The abscess was detected on magnetic resonance imaging (MRI) and analysis of cerebrospinal fluid revealed neurobrucellosis. Patient treated by only antibiotics therapy, evolving to complete clinical and radiological resolution, without neurosurgical intervention. We are presenting a case of cerebellar abscess due to neurobrucellosis diagnosed by MRI, treated medically, and had both radiologic and clinical follow-up. We also made a review of the literature concerning the cerebellar abscess due to neurobrucellosis.     

Will a second biopsy sample affect treatment decisions in patients with chronic hepatitis B?

Background and aim

Liver biopsy is the gold standard for assessment of fibrosis in patients with hepatitis B. However, it has some disadvantages, including inter-observer and intra-observer variability in biopsy interpretation and specimen variation. A standard biopsy specimen represents only about 0.0002 % of the whole liver. It has been shown that two biopsy samples collected during a procedure have significant influence on the diagnostic performance of interpretation in patients with hepatitis C or non-alcoholic steatohepatitis. Therefore, we aimed to assess the influence of collecting two liver biopsy samples during a single procedure for staging and grading chronic hepatitis B.

Patients and methods

27 patients were included in the study. The median age of the patients was 43.51 ± 11.69. Fifteen patients were female, 12 patients were male. In the biopsy procedure, two samples of liver lobes were obtained. Grade and stage scores were compared between the two samples. Fibrosis staging and grading were assessed according to the Ishak scoring system.

Results

Numbers of portal tract and biopsy size were equal in the two samples. There was a significant difference between the samples in terms of histological activity index (p value = 0.04). However, the difference was not enough to distinguish the mild and moderate stages. On the other hand, no significant difference in fibrosis staging between the two samples was found.

Conclusions

With this relatively small size of patients, in this study, we showed that a proper liver biopsy size is sufficient to predict treatment decisions in chronic hepatitis B patients. However, further studies are needed to show the association of sampling variability in patients with hepatitis B.

     

Small bowel transplantation

Thirty-seven patients were listed for small bowel transplantation; 16 were transplanted and 15 died while waiting for a donor. Cyclosporine (N=6) or tacrolimus (N=10) were used for immune suppression. Graft rejection rates were lower in the combined liver/small bowel grafts than the isolated intestinal transplants (1/7 vs 5/7;P<0.01) All of the cyclosporine group have died; the median survival was 25.7 months with two patients living more than five years. The tacrolimus group had fewer infections and a shorter hospital stay. All but two are alive with a median survival of 13 months. Seven of eight long-term survivors are off intravenous feedings. We conclude that small bowel transplantation is a life-saving option for patients with intestinal failure who cannot be maintained on total parenteral nutrition.     

Effect of I-deprenyl and gliclazide on oxidant stress/antioxidant status and dna damage in a diabetic rat model

BACKGROUND: This study investigates the possible effect of monoamine oxidase inhibitor (MAOI), selegyline (l-deprenyl), in combination with oral antidiabetic-gliclazide (OAD), in preventing oxidative stress in streptozotocin-induced diabetes model in male Swiss Albino rats by measuring oxidant stress/ DNA damage and antioxidant levels. METHODS: Diabetic rats were divided into four groups (n = 10) as (1) diabetic untreated (DM), (2) deprenyl treated (DM + D), (3) gliclazide treated (DM + O), and (4) gliclazide and deprenyl treated (DM + O + D). Controls were divided into two groups (n = 8) (1) untreated (C), and (2) deprenyl treated (C + D). Gliclazide 5 mg/kg and/or MAOI 0.25 mg/kg daily were given orally by gavage for 4 weeks. At the end of the 12th week, catalase and superoxide dismutase (SOD) levels in erythrocyte lysates (EL); total antioxidant status (TAS), 8-hydroxy-deoxyguanosine (8-OHdG), malondialdehyde (MDA), and vitamin A and E levels in plasma, MDA, and MAO in liver homogenates were determined. RESULTS: Diabetic rats showed a decrease in EL-SOD, plasma TAS, and vitamin E, and an increase in plasma 8-OHdG, plasma, and liver MDA levels (p < 0.05). Gliclazide and/or deprenyl decreased 8OHdG levels and increased antioxidant levels and survival when compared with untreated diabetic rats (p < 0.05). The lowest 8-OHdG levels were determined in the DM +O + D group. CONCLUSIONS: The combined treatment of deprenyl and gliclazide may contribute to the control of the physiopathological mechanisms underlying both the process of aging and type 2 diabetes by reducing oxidant stress and DNA damage, improving antioxidant status, and increasing survival, and may have implications for further clinical studies.     

Impact of prior malignancy on outcomes of stage IV esophageal carcinoma: SEER based study

Introduction: Usually, clinical trials on esophageal cancer exclude patients with a prior malignancy, assuming that this may influence survival outcomes. However, little is known about the impact of a prior malignancy on its prognosis.

Methodology: The Surveillance, Epidemiology, and End Results database (SEER) was used to review patients with stage IV squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the esophagus during 1973–2014. We calculated overall and esophageal cancer-specific survival using unadjusted Kaplan-Meier and multivariable covariate-adjusted Cox models.

Results: A total of 7,807 patients with stage IV SCC, and 11,238 patients with stage IV AC were reviewed, of which 652 and 840 patients, respectively, had a prior malignancy. Kaplan-Meier curves did not show difference in overall survival of SCC or AC in patients with prior malignancy. Stage IV AC patients with prior malignancy did not show different esophageal cancer-specific survival. However, esophageal cancer-specific survival was better among stage IV SCC patients with prior malignancy. Similar results were observed in Cox models after adjustment for: age, sex, race, marital status, grade, site in esophagus, and undergoing surgery.

Conclusion: Prior malignancy does not adversely impact survival of stage IV esophageal cancer. These results should be taken into consideration when designing clinical trials.     

Giant substernal goiter with chylothorax

A 60-year-old woman presented with a huge goiter extending from the lower jaw to the diaphragm. Right pleurocentesis produced chylous fluid. A cervicothoracic incision was used to totally excise the substernal goiter, with near-total excision of the cervical goiter, and repair of the lymphatic leakage.     

Comparison of management patterns and clinical outcomes in patients with atrial fibrillation in Canada and the United States (from the analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management [AFFIRM] database)

Little is known about differences in practice patterns or outcomes in the management of patients who have atrial fibrillation in Canada compared with those in the United States (US). We evaluated the effect that the country of enrollment may have on the management patterns and clinical outcomes in patients who participated in the AFFIRM study. Three thousand four hundred patients came from the US and 660 from Canada. In the US, patients were more likely to have a history of coronary artery disease (39% vs 35%, p = 0.03), hypertension (72% vs 67%, p = 0.01), or congestive heart failure (24% vs 18%, p = 0.0002). More US participants were <65 years of age (25% vs 19%, p = 0.003). Although at randomization the use of warfarin was comparable, during follow-up Canadians were more likely to be treated with warfarin and to be therapeutically anticoagulated. Mortality rate at 5 years was higher in US patients (24% vs 16%, p = 0.001), and the composite end point (death, disabling stroke, major bleeding, cardiac arrest, or anoxic encephalopathy) was also higher in US patients (30% vs 22%, p = 0.0005). Even after adjusting for known differences in baseline characteristics, the risk of death was lower in Canada (hazard ratio 0.70, p = 0.02). In conclusion, in the AFFIRM study, US subjects were more likely to have preexisting cardiovascular diseases despite being younger (<65 years old) than those in Canada. Effective warfarin therapy was more commonly employed in Canada. After correcting for the known differences in baseline characteristics, Canadian patients who had atrial fibrillation had a lower mortality risk.