Synchronous gist,colon and breast adenocarcinoma with double colonic polyp metastases

INTRODUCTION

Long term survivors of breast cancer are at risk of developing distant metastasis years after the initial treatment. We report a case of breast adenocarcinoma with colonic polyp metastases, as well as synchronous primary colonic adenocarcinoma and a gastric GIST.

PRESENTATION OF CASE

An 83 year old female underwent colonoscopy for rectal bleeding. This showed a primary colonic adenocarcinoma, a pedunculated polyp in the ascending colon and two polyps in the sigmoid colon. A staging CT scan did not show distant metastasis, but revealed a small gastric GIST which was managed conservatively. A right hemicolectomy showed a T3N0 colonic adenocarcinoma and a polyp contained metastatic adenocarcinoma from a breast primary. The patient had undergone surgery 30 years ago for an invasive lobular carcinoma. Further clinical assessment demonstrated an impalpable grade II Invasive ductal carcinoma in the contralateral breast. She was started on hormonal treatment and at 18 months follow-up, she was well with stable disease.

DISCUSSION

Invasive lobular cancer is the most common histological type of breast cancer that metastasizes to the colon. There is no consensus on the management of breast cancer metastasis to the gastrointestinal tract. Co-existence of a GIST and an adenocarcinoma at two separate locations is uncommon. These are two different cancer entities and it is unclear whether these two are related by as causal relationship.

CONCLUSION

This is a rare case of three distinct tumours; association between them is unlikely. However, the case highlights the importance of a multidisciplinary approach to cancer treatment.     

The evolving risk of sudden cardiac death after heart transplant. An analysis of the ISHLT Thoracic Transplant Registry

Sudden cardiac death (SCD) is responsible for ~10% of post‐heart transplant deaths. We conducted a retrospective analysis of the ISHLT registry evaluating the risk of post‐transplant SCD. Adult heart transplant recipients (2004‐2014) surviving the first year were included. We used multivariable multistate competing risk survival analysis to evaluate the impact of history of treated rejection and cardiac allograft vasculopathy (CAV) on SCD risk. We used a probabilistic analytical model and Monte Carlo simulation to estimate the impact of CAV severity and graft dysfunction on SCD. We included 25 242 recipients. During a median follow‐up of 4.7 (2.3‐7.0) years, 582 patients died suddenly. Treated rejection (HR 1.76, 95% CI 1.36‐2.31) and CAV (HR 3.32, 95% CI 2.73‐4.03) were important risk factors for SCD. The estimated SCD risk in patients with severe CAV without and with graft dysfunction was 3.2% (95% CI 2.0‐4.6) and 5.4% (95% CI 3.8‐7.0), respectively, at 2 years from the CAV diagnosis, and 4.9% (95% CI 3.4‐6.5) and 8.0% (95% CI 6.1‐10.0), respectively, in those who also had treated rejection. These results provide evidence that recipients with severe CAV and graft dysfunction or treated rejection are at clinically significant increased SCD risk. The benefit of ICD post‐transplant remains uncertain.     

Sexual activity and function in women with and without pelvic floor disorders

Introduction and hypothesis

We describe differences in sexual activity and function in women with and without pelvic floor disorders (PFDs).

Methods

Heterosexual women ≥40 years of age who presented to either urogynecology or general gynecology clinics at 11 clinical sites were recruited. Women were asked if they were sexually active with a male partner. Validated questionnaires and Pelvic Organ Prolapse Quantification (POP-Q) examinations assessed urinary incontinence (UI), fecal incontinence (FI), and/or pelvic organ prolapse (POP). Sexual activity and function was measured by the Female Sexual Function Index (FSFI). Student’s t test was used to assess continuous variables; categorical variables were assessed with Fisher’s exact test and logistic regression. Univariate and multivariate analyses were used to assess the impact of pelvic floor disorders (PFDs) on FSFI total and domain scores.

Results

Five hundred and five women met eligibility requirements and gave consent for participation. Women with and without PFDs did not differ in race, body mass index (BMI), comorbid medical conditions, or hormone use. Women with PFDs were slightly older than women without PFDs (55.6?+?10.8 vs. 51.6?+?8.3 years, P <0.001); all analyses were controlled for age. Women with PFDs were as likely to be sexually active as women without PFDs (61.6 vs. 75.5 %, P?=?0.09). There was no difference in total FSFI scores between cohorts (23.2?+?8.5 vs. 24.4?+?9.2, P?=?0.23) or FSFI domain scores (all P?=?NS).

Conclusion

Rates of sexual activity and function are not different between women with and without PFDs.     

Transumbilical single-port sleeve gastrectomy: initial experience and comparative study

Background  

Sleeve gastrectomy is gaining relevance in the surgical armamentarium against obesity. The transumbilical single port has proved to be an attractive and safe alternative for a variety of minimally invasive abdominal surgeries. The purpose of this study is to evaluate the initial results of a group of patients operated by single-port sleeve gastrectomy compared with a group operated by conventional laparoscopic technique.     

Higher Cardiorespiratory Fitness in Older Trained Women is Due to Preserved Stroke Volume

Previous literature has shown that sedentary older women rely on peripheral adaptations to improve cardiorespiratory fitness with endurance training i.e. they show minimal increases in central parameters (cardiac output, Q) in response to endurance training. The purpose of this study therefore was to determine whether endurance trained older women were able to preserve maximal exercise Q and were characterized by a high stroke volume (SV) when compared to physically inactive older women. Trained (n = 7) and untrained (n = 1 0) women attended two maximal and one submaximal laboratory session. Breath-by-breath analysis was conducted using mass spectrometry and Q was assessed using acetylene open circuit inert gas wash-in. Multivariate analysis of variance and paired samples t-tests were used to determine between and within group differences. Trained women had a significantly higher VO_2max (37.5 vs. 24.1 ml^-1·kg·min^-1) compared to untrained women. There were no differences for peripheral oxygen extraction (VO₂/Q) at either submaximal or maximal work rates; however trained women had a significantly higher SV at maximal (119.3 vs. 94.6 ml) exercise compared to untrained women. In both trained and untrained women, SV did not rise significantly between submaximal and maximal exercise. Conclusion: Highly fit, endurance trained older women are able to preserve central parameters of VO_2max. Peripheral oxygen extraction is similar between older trained and untrained women.

Key points

• Older women are able to preserve stroke volume with high volumes of endurance training.
• Stroke volume of endurance trained older women does not continue to rise until maximal exercise, as is the case in young endurance trained adults.
• Peripheral oxygen extraction does not differ between endurance trained and physically inactive older women.

Key words: cardiac output, aging, exercise, running, VO_2max     

Phrenic nerve injury associated with high free right internal mammary artery harvesting

BACKGROUND: The right phrenic nerve is at risk of injury during high mobilization of the right internal mammary artery (RIMA). The incidence and implications of this injury have not been previously defined. METHODS: Prospectively collected data on all patients who underwent RIMA harvesting between January 1995 and February 2002 were analyzed. Thirty-one patients with right phrenic nerve injury were identified and the medical charts reviewed. Phrenic nerve injury was diagnosed when a postoperative chest roentgenogram showed the right hemidiaphragm to be two or more intercostal spaces higher than the left, or transection of the nerve was seen intraoperatively. Investigations included fluoroscopy and spirometry in upright and supine positions. Diaphragm plication was offered for symptom control. Subsequent follow-up was undertaken to determine the incidence of spontaneous recovery of diaphragm function and the benefits of diaphragm plication. RESULTS: Seven hundred and eighty-three patients underwent high mobilization of the RIMA with proximal detachment for use as a free graft. Thirty-one patients with right hemidiaphragm dysfunction were identified in the postoperative period providing an injury incidence of 4% (confidence interval, 2.6% to 5.3%). Of these, 12 patients underwent diaphragm plication (4 early and 8 late), 14 patients achieved spontaneous recovery, and 5 patients were lost to follow-up. The supine to upright forced vital capacity ratios at the time of phrenic nerve dysfunction, after diaphragm plication, and after spontaneous recovery were 0.79, 0.90, and 0.96 respectively. CONCLUSIONS: The incidence of phrenic nerve injury associated with high RIMA harvesting was 4% but spontaneous recovery may be anticipated in two thirds (14 of 22) of patients in whom the injury is identified postoperatively. High RIMA harvesting should be used with caution in patients with preoperative pulmonary dysfunction in whom phrenic nerve injury would be poorly tolerated.     

Estimating the age of immature <Emphasis Type="Italic">Chrysomya albiceps</Emphasis> (Diptera: Calliphoridae), correcting for temperature and geographical latitude

Developmental curves for Chrysomya albiceps (Wiedemann) (Diptera: Calliphoridae) were established at 13 different constant temperatures using developmental landmarks and length as measures of age. The thermal summation constants (K) and developmental zeros (D (0)) were calculated for five developmental landmarks using the method described by Ikemoto and Takai (Environ Entomol 29:671-682, 2000). Comparison with the K and D (0) values of our findings to those of three previously published studies of C. albiceps suggests that K is directly proportional to geographic latitude, and D (0) is inversely proportional to both K and geographic latitude. Body size and developmental landmarks have a complex relationship because of trade-offs between mortality risk and female fecundity (as measured by body size) at non-optimal temperatures. This relationship can be summarized using superimposed isomorphen and isomegalen diagrams, which can then be used to make forensic estimates of postmortem intervals from larval body lengths. Finally, we recommend that future studies providing data for precise forensic estimates of postmortem intervals should use a relative temporal precision of about 10% of the total duration being measured. For many blowflies, this translates into a sampling interval of approximately every 2 h before hatching, 3 h before first ecdysis and 6 h before second ecdysis.     

The CAG trinucleotide repeat length in the androgen receptor does not predict the early onset of prostate cancer

OBJECTIVE: To relate the repeat length of the androgen-receptor CAG trinucleotide to the age of onset of prostate cancer, stage and grade of disease. PATIENTS AND METHODS: After obtaining ethical approval, 265 patients with locally confined or locally advanced/metastatic prostate cancer were identified and evaluated for age at diagnosis (< 65 years and > 75 years). DNA was extracted from peripheral blood lymphocytes and 1 micro g aliquots subjected to polymerase chain reaction using fluorescently labelled primers. Samples were then run on an ABI 377 gene scan analysis gel with an internal molecular weight marker. The length of the CAG repeat was determined by comparing the gene scan product size to samples where the CAG repeat length had been quantified using direct sequencing. The Kruskal-Wallis, Mann-Whitney and Wilcoxon two sample tests were used to analyse the data. RESULTS: The mean (range) length of the CAG repeat in the androgen receptor was 22.2 (10-31) in the younger and 22.5 (16-32) in the older group, and was not statistically different. There was no significant association between the CAG repeat length and the age of onset of prostate cancer (P = 0.568) or with stage (P = 0.577) and grade (P = 0.891) of prostate cancer. CONCLUSION: These results suggest that there is no correlation between the androgen receptor CAG repeat length and the age of onset, stage and grade of prostate cancer, confirming recent doubts from other similar studies of a suggested correlation between shorter androgen receptor CAG repeat and early onset and aggressiveness of prostate cancer.     

In vitro susceptibilities of Escherichia coli isolated from patients with intra-abdominal infections worldwide in 2002-2004: results from SMART (Study for Monitoring Antimicrobial Resistance Trends)

BACKGROUND: Since 2002, the worldwide Study for Monitoring Antimicrobial Resistance Trends (SMART) has tracked resistance patterns among aerobic and facultative gram-negative bacilli isolated from patients with intra-abdominal infections. Escherichia coli has been by far the most frequently isolated species. METHODS: Antimicrobial susceptibilities for consecutive non-duplicate isolates of aerobic and facultative gram-negative bacilli recovered from intra-abdominal infections were determined by standard broth microdilution techniques. A subanalysis was performed for E. coli isolates from the first three years of the study. RESULTS: A total of 7,002 E. coli isolates were recovered, most commonly from the peritoneal cavity followed by the biliary tract. Susceptibility rates to the 12 antimicrobial agents tested differed among geographic regions, with isolates from Asia/Pacific generally having the highest resistance rates. Overall, extended-spectrum beta-lactamase (ESBL)-producers had a more antibiotic-resistant profile than non-ESBL-producers but usually were susceptible to the carbapenems and amikacin. Community-acquired E. coli strains comprised slightly more than one-half of the isolates and were susceptible to the agents tested more frequently than were hospital-acquired E. coli. CONCLUSIONS: The prevalence of antimicrobial resistance among E. coli isolated from intraabdominal infections is not inconsequential, especially in the Asia/Pacific region. The carbapenems and amikacin were consistently active in vitro against E. coli isolates worldwide, including ESBL-producers.     

Reimplantation of the aortic valve at 20 years

Objective

To provide additional information on clinical and echocardiographic outcomes after reimplantation of the aortic valve (RAV) in patients with aortic root aneurysm.