Balloon mitral valvotomy: comparison between antegrade Inoue and retrograde non-transseptal techniques

AIMS: The results of percutaneous mitral valvotomy performed by theantegrade transseptal method using the Inoue balloon (n=1000;group 1) and by the retrograde non-transseptal technique usinga polyethylene balloon (n=100; group 2) were compared in a retrospective,non-randomized study. METHODS AND RESULTS: Both the groups were similar with respect to baseline characteristics.The success rate was 95% in group 1 and 93% in group 2. Therewas a significant increase in mitral valve area estimated byGorlin's equation (Group 1: from 0·8 ± 0·5to 2·1 ± 0·8 cm²; Group 2: from 0·8± 0·3 to 1·9 ± 0·8 cm², bothP<0·001) and by Doppler echocardiography using thepressure half-time method (Group 1: from 0·9 ±0·4 to 2·2 ± 0·6 cm²; Group 2: from0·9 ± 0·3 to 2·0 ± 0·7cm², both P<0·001). However, the calculated immediatepost-valvotomy mitral valve area was larger with the Inoue technique(2·1 ± 0·8 vs 1·9 ± 0·8cm²; P<0·02). Results were considered optimal whenthe mitral valve area increased to 1·5 cm², the percentageincrease was 50, and mitral regurgitation was 2/4. Out of thetotal successful procedures, optimal results were obtained in95% patients in Group 1 and 94% in Group 2. Incidence of significantmitral regurgitation (grade 3/4) was similar in two groups (Group1: 4% vs Group 2: 5%, P=ns). A significant left to right atrialshunt (Qp/Qs 1·5:1) in 2·5% and tamponade in2% of cases occurred exclusively with the Inoue technique, whileconduction disturbances, such as transient (<24 h) left bundlebranch block (28%) and complete heart block (2%) were notedwith the retrograde technique (Group 2). Local complicationswere significantly higher in Group 2 (3% vs 0·5%, P<0·01).The procedure time with the Inoue technique was shorter thanwith the retrograde (Group 1: 15 ± 8, range 10 to 35min; Group 2: 22 ± 14, range 15 to 45 min, P=0·05).Echocardiographic follow-up at 1 year showed no significantdifference in mitral valve area between the two groups (Group1 (n=300): 1·8 ± 0·8 vs Group 2 (n=60):1·9 ± 0·9 cm²; P=0·3). CONCLUSION: Balloon mitral valvotomy using the Inoue balloon and the retrogradenon-transseptal technique results in significant immediate haemodynamicand symptomatic improvement. The Inoue technique achieved alarger immediate post-valvotomy mitral valve area, but the differencewas not apparent at 1 year follow-up. Incidence of significantmitral regurgitation was similar with both the techniques; however,local complications occurred more frequently with the retrogradetechnique. Both techniques may complement each other in technicallydifficult cases.     

Role of FNAC in palpable chest wall lesions in developing country

Palpable chest wall lesions are unusual manifestation of an underlying thoracic pathology and it is difficult to diagnose them with their diverse spectrum ranging from benign to malignant. Considering the exposure of patient to invasive biopsy/excision and the risk of local complications, FNAC is now being increasingly used in the primary assessment of these lesions. Objectives of this study were to report the spectrum of chest wall lesions in the population of a developing country and evaluating the diagnostic role of FNAC. All the patients who presented with palpable cutaneous or subcutaneous chest wall swelling during a period of January 2003 to August 2010 were reviewed retrospectively. May Grunwald Giemsa and Papanicolaou stained aspirates were examined, along with special stains. Seven hundred seventy‐three cases were subjected to chest wall FNAC, of which 726 (93.9%) cases were satisfactory. Age ranged from 1 to 93 years with M:F = 0.92:1. 358 (49.3%) were diagnosed as inflammatory and 368 (50.7%) were neoplastic lesions. Two‐hundred thirty four cases (32.2%) were diagnosed as mycobacterial abscess (likely tuberculous). Of the neoplastic lesions, 153 were malignant with carcinomas being predominant (88.2%). Malignant cases comprised of scar site recurrence in breast carcinoma (73 cases), metastatic carcinomas (62 cases), primary sarcomas (eight cases), hematological neoplasms (six cases), and miscellaneous group (four cases). Overall malignant lesions accounted for 21.1% (153/726) of satisfactory chest wall aspirates. FNAC is very useful and simple investigation for early diagnosis of chest wall abscesses, cutaneous metastases from visceral malignancies, and scar site recurrence in breast carcinoma. Diagn. Cytopathol. 2014;42:653–659. © 2014 Wiley Periodicals, Inc.     

Balloon dilation of subaortic stenosis due to a thick fibrous shelf

A young patient with discrete subaortic stenosis due to a thick fibrous shelf was subjected to transcatheter balloon dilation. The outcome of the procedure and its probable mechanism is discussed.     

Qualitative analysis by interviews and video recordings to establish the components of a skilled low-cavity non-rotational vacuum delivery

Objectives  The objectives of this study were to define the components of a skilled low-cavity non-rotational vacuum delivery (occiput anterior, vertex at station +2 or below and less than 45-degree rotation from midline) and to facilitate the transfer of skills from expert to trainee obstetricians.
Design  Qualitative study using interviews and video recordings.
Setting  Two university teaching hospitals (St Michael's Hospital, Bristol, and Ninewell's Hospital, Dundee).
Participants  Ten obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries.
Methods  Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low-cavity vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and compared for consistency of interpretation. The experts reviewed the coded interviews and video data for respondent validation and clarification. The themes that emerged following the final coding were used to formulate a list of skills.
Main outcome measures  Key technical skills of a low-cavity non-rotational delivery.
Results  The final list included detailed technical skills required for conducting a low-cavity vacuum delivery. The combination of semi-structured interviews and simulation videos allowed the formulation of a comprehensive skills tool for future evaluation.
Conclusion  This explicitly defined skills list could aid trainees understanding of the technique of low-cavity vacuum delivery. This is an important first step in evaluating clinical competence in intrapartum procedures.     

Peripheral blood stem cell recovery following early termination of apheresis due to hypotension in a 4.8‐kg infant

We report a case in which peripheral blood stem cells (PBSC) were successfully recovered following early termination of a collection procedure due to hypotension in a 7‐month‐old patient. The patient was diagnosed at 4 months of age with neuroblastoma stage IV‐S with favorable Shimada histology. She had completed two cycles of chemotherapy before the PBSC collection (PSCC). The procedure was performed on the Cobe Spectra in manual mode, and terminated after 35 min due to severe hypotension. Etiologies considered for the hypotensive episode included a transfusion reaction to the unit of red blood cells (RBC) used for priming the Spectra, citrate reaction, and hypovolemia due to blood drawn for laboratory testing and fluid shifts at the beginning of the procedure. Hypovolemia was ultimately determined to be the most likely etiology. A rinseback was performed into a transfer bag, and the cells were sent to the laboratory for analysis of CD34+ cell yield, volume reduction, and cryopreservation. An adequate number of PBSC were recovered to permit successful autologous transplantation. The ability to recover PBSC from the Spectra white blood cell collection set allowed the patient to avoid undergoing another PSCC. In procedures involving small children, the blood volume drawn for preprocedure testing should be limited to less than 10% of the patient's total blood volume, and the RBC prime should at a minimum replace the entire extracorporeal volume. If the procedure must be terminated early, sufficient PBSC may be recoverable from the blood in the apheresis instrument. J. Clin. Apheresis 2009. © 2009 Wiley‐Liss, Inc.     

Beyond phonotactic frequency: Presentation frequency effects word productions in specific language impairment

Phonotactic frequency effects on word production are thought to reflect accumulated experience with a language. Here we demonstrate that frequency effects can also be obtained through short-term manipulations of the input to children. We presented children with nonwords in an experiment that systematically manipulated English phonotactic frequency and the frequency of presentation within the experiment. Both of these manipulations affected the accuracy and time-to-response for nonword production both for typically developing and children with specific language impairment. Children with SLI were less accurate in their productions overall, but still exhibited an effect of the short-term frequency manipulation. Children with SLI differed significantly from their typical peers in terms of time-to-response only when both English and Experimental frequency were low. The results indicate that simple manipulations of the input can affect children's representation of word forms, and this can facilitate word production without the need for long term exposure or articulatory practice.Learning outcomes: The reader will learn that sound frequency affects the production of new words. This includes not only the frequency with which sound sequences are represented in the speaker's native language, but the frequency with which they are heard within a single session.     

Children with specific language impairment show rapid,implicit learning of stress assignment rules

An implicit learning paradigm was used to assess children's sensitivity to syllable stress information in an artificial language. Study 1 demonstrated that preschool children, with and without specific language impairment (SLI), can generalize patterns of stress heard during a brief period of familiarization, and can also abstract underlying ordered rules by which stress patterns were assigned to syllables. In Study 2, the salience of stressed elements was acoustically enhanced. Counter to expectations, there was no evidence of learning with this manipulation for either the typically developing children or children with SLI. The results suggest that children with SLI and their typically developing peers are sensitive to syllable stress cues to language structure. However, attempts to draw attention to these patterns by making them more salient may prompt children to use alternate learning strategies that do not lead to an implicit understanding of how stress contributes to the structure of language.Learning outcomes: The reader will be able to understand: (1) that children with SLI can learn and generalize the rules for assigning word-level stress patterns within minutes of hearing examples, but (2) strategies to enhance learning may actually have the opposite effect for these children.