Preoperative embolization of hypervascular head and neck tumours

The embolization of vascular tumours of the head and neck has become an important adjunct to the surgical treatment of these tumours. A vascular tumour in the head and neck region in a surgically treatable patient may be a candidate for embolization. Palliative embolization may be the sole treatment for high risk patients. Reducing intraoperative bleeding may shorten surgery time thus decreasing morbidity and mortality. The purpose of this study is to assess the efficacy of embolization as an adjunct to surgery or as a curative measure in the management of hypervascular head and neck tumours. We retrospectively reviewed the records of 46 consecutive patients (27 men and 16 women; mean age, 37.8 years) with 48 hypervascular head and neck tumours that had undergone preoperative transarterial, direct puncture or combined mode of embolization. Diagnosis of tumours was made on the basis of findings of imaging studies. The 46 patients underwent embolization either through transarterial route, by direct puncture technique or both direct puncture and arterial route. The devascularization reached 90–95% with the use of NBCA. The amount of devascularization reached by transarterial particle embolization is a little lesser. One patient (carotid body tumour) developed mild unilateral seventh, ninth and 10th cranial nerve palsy after transarterial embolization, transient hemiparesis was seen in another patient (nasopharyngeal angiofibroma). Both patients improved completely with steroids and had no deficit on follow up. One patient developed delayed glue migration into the middle cerebral artery territory 6 h after the procedure with no reported increase in size of the lesion in the following 5 years. Preoperative embolization of hypervascular tumour of head and neck region appears to be safe and improves the chance of complete removal during surgery with minimal blood loss.     

Massive cardiac thrombosis in a patient with Sheehan's syndrome

Growth hormone deficiency (GHD) is a risk factor for increased cardiovascular disease, and it has been recently demonstrated that abnormalities in coagulation system might contribute to the increased cardiovascular morbidity and mortality. However, there is not enough data related to the major thrombotic events in GH-deficient patients. We describe the case of a 62-year-old woman with Sheehan's syndrome who developed massive cardiac thrombosis. She was hospitalized with acute pulmonary edema. ECG revealed high ventricular responsive atrial fibrillation (AF) and T-wave inversion on precordial leads. The ejection fraction of left ventricle (LVEF) was measured as 60% by transthoracic echocardiography (TTE) and there was 2nd degree mitral regurgitation with concentric hypertrophic LV walls. Transesophagial echocardiography (TEE) established thrombi both at right atrium and left atrial appendix. Before anticoagulant therapy several hemostatic and fibrinolytic markers were measured. Except increased D-dimer concentration (763.14 mug/L (0-325)) we did not observe any pathological finding in these parameters. After 14 days of discharge, the patient was admitted to the intensive care unit with upper gastrointestinal bleeding. The warfarin and salicylate were stopped for two months. At the end of two months, the patient was again hospitalized with congestive heart failure and there was a high ventricular responsive AF on ECG. TEE was performed and three thrombi were demonstrated at right atrium (RA), left atrium (LA) and left ventricle (LV). There was no active bleeding on upper GIS endoscopy and anticoagulant therapy was restarted. In this particular case massive cardiac thrombi involving three chambers (LA, RA, LV) were more extensive than expected in AF. Moreover, there was a 2nd degree mitral regurgitation in the patient, and based on previous studies mitral regurgitation has been associated with less prevalent LA spontaneous echo contrast and fewer thromboembolic events. Therefore we hypothesized that severe GHD in the present case might be the major contributing factor in massive cardiac thrombosis. In summary, based on previous data there is increased risk of thromboembolic events in GHD although the mechanism is unclear yet. Our case is the first case showing massive cardiac thrombosis in a severe GH-deficient patient with Sheehan's syndrome. Therefore, patients with GHD should be screened carefully for thrombus in clinical practice, and further studies need to be done to understand the relation between GHD and coagulation system.     

Electrocardiographic J wave as a result of hypercalcemia aggravated by thiazide diuretics in a case of primary hyperparathyroidism

Electrocardiographically, the QT interval is shortened, ST segment is depressed, and T wave becomes negative in hypercalcemia. The use of diuretics in cases with hyperparathyroidism decreases the excretion of calcium, causes changes in bone-calcium turnover and parathyroid hormone activity, and forms hypercalcemia. A 67 year-old Turkish female patient in whom we electrocardiographically observed a J wave is presented as a hypercalcemic case with primary, hyperparathyroidism aggravated by the use of a thiazide diuretic.     

Acute renal failure in early life

Data are presented on 25 children under 2 years of age with acute renal failure treated by peritoneal dialysis. The clinical features, treatment, complications, and outcome of the illnesses are described. 22 (88%) survived, and though the incidence of serious complications during the illness was high most regained full health and normal renal function.     

Fluoroscopic‐guided balloon dilatation and stenting in tracheal stenosis with metallic self‐expandable stents and long‐term follow‐up results

The purpose of this study was to assess the safety and long‐term efficacy of self‐expandable stents in the treatment of benign tracheal stenosis. Nine patients (seven men) with tracheal stenosis (including one with fistula) of varied cause were treated by fluoroscopically guided balloon dilatation and stenting with self‐expandable metallic stents. The procedure was carried out under topical spray in eight patients and under general anaesthesia in one patient. The patients were followed up for a period ranging between 13 and 60 months. In eight of the nine patients, satisfactory positioning of the stent was achieved at the first instance, with immediate relief of dyspnoea. One patient with innominate artery aneurysm died 16 days after the procedure because of renal failure. At 1 month of follow up, six out of eight (75%) of our live patients were without any respiratory embarrassment. This dyspnoea‐free result reached almost 90% by the end of 1 year especially so in the fibrous strictures. Four out of the eight live patients (50%) had cough for 2 months and two (25%) had mild blood‐tinged sputum treated by inhalation and mucolytic agents. Secondary intervention was required in one patient at 1 month because of recurrent symptoms. The patient with tracheo‐oesophageal fistula required surgical intervention because of fracture of the stent. Fluoroscopically guided balloon dilatation and stenting of the tracheal stenosis is an effective non‐surgical therapy resulting in cure of fibrous strictures and palliation in cases of malignancy.     

The effects of growth hormone therapy on heart rate variability in adults with growth hormone deficiency

Background: Growth hormone (GH) deficiency is associated with increased cardiovascular morbidity and mortality. Abnormalities in heart rate variability (HRV) (such as decreased cardiac sympathetic activity), which is a marker of cardiac autonomic tone, have been found in patients with GH deficiency.Objective: The purpose of this study was to investigate the effects of GH therapy on HRV in adults with GH deficiency.Methods: Adult patients with GH deficiency were eligible. HRV measurements were obtained by 24-hour measurements from Holter electrocardiography before and after 6 months of GH therapy in adult patients with GH deficiency. The following time domain parameters of HRV were calculated: the SD of the normal-to-normal (NN) interval (SDNN), the SD of the average NN interval (SDANN), the square root of the mean squared differences (RMSSD), and the proportion derived by dividing the number of interval differences of successive NN intervals >50 ms (NN50) by the total number of NN intervals (PNN50).Results: A total of 21 patients (7 men, 14 women; mean age, 46.0 ± 11.2 years) were enrolled. Thirteen patients had panhypopituitarism and 8 had normal adrenocorticotropic hormone secretion. At the end of 6 months of GH therapy, the mean values of the sympathetically influenced parameters SDNN (before GH treatment, 134.5 ± 6.0 ms; after GH treatment, 118.5 ± 8.0 ms) and SDANN (before GH treatment, 121.2 ± 6.0 ms; after GH treatment, 96.2 ± 9.1 ms) decreased significantly (P < 0.05), but the parasympathetically influenced parameters RMSSD and PNN50 did not differ significantly from baseline. The mean heart rate and ventricular premature beats were not significantly different from baseline after GH therapy.Conclusions: In this patient population, cardiac sympathetic tone was increased, without an obvious arrhythmogenic effect, after 6 months of GH therapy.