Cardiac Computed Tomography

Computed tomography (CT) has emerged in the past decade as an important tool in the evaluation of cardiac pathology, specifically in the diagnosis of coronary artery disease (CAD). This article will review the technique and role of CT and CT angiography (CTA) in modern cardiovascular care. CT techniques are described, as are the applications of CT in the assessment of CAD including both calcium scoring and CTA. Although CAD is the mainstay of cardiac CT, important noncoronary cardiac applications including the evaluation of cardiac function, masses, valvular disease, and pericardial disease, are reviewed as well. The nursing care of the patient undergoing CTA is reviewed as are future developments within this field.     

Postoperative Hormonal Suppression for Prevention of Deeply Infiltrative Endometriosis Recurrence After Surgery

Purpose of Review

The long-term management of deeply infiltrative endometriosis (DIE) remains debatable. Surgical excision improves pain and fertility in patients with endometriosis, however recurrence is common. In this article, we present an evidence-based approach of recurrence and postoperative hormonal suppression in DIE.

Recent Findings

A clear understanding of recurrence patterns and methods for prevention of DIE are lacking. Repeat surgery in DIE patients is associated with increased morbidity. Older data has suggested the limited utility of short-term postoperative hormonal suppression for the prevention of pain or disease recurrence for patients with endometriosis (Yap et al., Cochrane Database Syst Rev. (3):CD003678, 2004). More recent studies suggest that long-term medical therapy with oral contraceptive pills (OCPs) or progesterone only pills (POPs) reduces recurrence of superficial disease and endometriomas. Limited data, however, exists for DIE.

Summary

This article reviews the literature of hormonal suppression for the prevention of postoperative recurrence of DIE. Despite the dearth of data, the current evidence suggests the utility of long-term postoperative hormonal suppression after surgery especially in those who underwent incomplete excision of DIE. Longer follow-up studies are greatly needed.

     

Prolonged cholestasis after troleandomycin-induced acute hepatitis

We report the case of a patient in whom troleandomycin-induced hepatitis was followed by prolonged anicteric cholestasis. Jaundice occurred after administration of troleandomycin for 7 days and was associated with hypereosinophilia. Jaundice disappeared within 3 months but was followed by prolonged anicteric cholestasis marked by pruritus and high levels of alkaline phosphatase and gammaglutamyltransferase activities. Finally, pruritus disappeared within 19 months, and liver tests returned to normal 27 months after the onset of hepatitis. This observation demonstrates that prolonged cholestasis can follow troleandomycin-induced acute hepatitis.     

Neurodevelopmental outcome at 6 years of age after intrauterine laser therapy for twin-twin transfusion syndrome

This study was undertaken to evaluate neurodevelopmental outcome of children at 6 years of age after intrauterine laser therapy for Twin-twin transfusion syndrome (TTTS). This is part of a longitudinal study in children after intrauterine laser therapy for TTTS; 190 of 254 (74.8%) children, previously investigated at a median age of 2 years 10 months, were re-evaluated at 6 years 5 months (range 4 years 11 months –10 years 4 months). Sixty-four patients were not examined due to loss of contact. The median gestational age at birth was 34 + 3 weeks. The study included a physical/neurological examination, a standardized neurodevelopmental test (Kaufman-ABC) and/or results from the national screening programme for children as well as questionnaires. Patients were grouped in three outcome categories: group I: normal examination and test result; group II: minor neurological deficiencies and normal test results; group III: major neurological deficiencies and/or test results below minus two standard deviations. The following results were obtained at 6 years 5 months (for comparison, results of the same patients at 2 years 10 months in brackets). Group I: 79.5% (84.2%); group II: 11.6% (8.9%); group III: 8.9% (6.8%). Twenty-one (11%) patients had a worse and 8 (4.2%) an improved classification at 6 years 5 months as compared to 2 years 10 months. Overall, the results with 6 years did not significantly differ from the results with 2 years. Neurodevelopmental outcome at 6 years 5 months was not statistically, significantly different from outcome at 2 years 10 months.     

High-throughput library screening identifies two novel NQO1 inducers in human lung cells

Many phytochemicals possess antioxidant and cancer-preventive properties, some putatively through antioxidant response element-mediated phase II metabolism, entailing mutagen/oxidant quenching. In our recent studies, however, most candidate phytochemical agents were not potent in inducing phase II genes in normal human lung cells. In this study, we applied a messenger RNA (mRNA)-specific gene expression-based high throughput in vitro screening approach to discover new, potent plant-derived phase II inducing chemopreventive agents. Primary normal human bronchial epithelial (NHBE) cells and immortalized human bronchial epithelial cells (HBECs) were exposed to 800 individual compounds in the MicroSource Natural Products Library. At a level achievable in humans by diet (1.0 μM), 2,3-dihydroxy-4-methoxy-4'-ethoxybenzophenone (DMEBP), triacetylresveratrol (TRES), ivermectin, sanguinarine sulfate, and daunorubicin induced reduced nicotinamide adenine dinucleotide phosphate:quinone oxidoreductase 1 (NQO1) mRNA and protein expression in NHBE cells. DMEBP and TRES were the most attractive agents as coupling potency and low toxicity for induction of NQO1 (mRNA level, ≥3- to 10.8-fold that of control; protein level, ≥ two- to fourfold that of control). Induction of glutathione S-transferase pi mRNA expression was modest, and none was apparent for glutathione S-transferase pi protein expression. Measurements of reactive oxygen species and glutathione/oxidized glutathione ratio showed an antioxidant effect for DMEBP, but no definite effect was found for TRES in NHBE cells. Exposure of NHBE cells to H(2)O(2) induced nuclear translocation of nuclear factor erythroid 2-related factor 2, but this translocation was not significantly inhibited by TRES and DMEBP. These studies show that potency and low toxicity may align for two potential NQO1-inducing agents, DMEBP and TRES.     

Mice lacking brain-type creatine kinase activity show defective thermoregulation

The cytosolic brain-type creatine kinase and mitochondrial ubiquitous creatine kinase (CK-B and UbCKmit) are expressed during the prepubescent and adult period of mammalian life. These creatine kinase (CK) isoforms are present in neural cell types throughout the central and peripheral nervous system and in smooth muscle containing tissues, where they have an important role in cellular energy homeostasis.Here, we report on the coupling of CK activity to body temperature rhythm and adaptive thermoregulation in mice. With both brain-type CK isoforms being absent, the body temperature reproducibly drops ~ 1.0 °C below normal during every morning (inactive) period in the daily cycle. Facultative non-shivering thermogenesis is also impaired, since CK- -/- - mice develop severe hypothermia during 24 h cold exposure.A relationship with fat metabolism was suggested because comparison of CK- -/- - mice with wildtype controls revealed decreased weight gain associated with less white and brown fat accumulation and smaller brown adipocytes. Also, circulating levels of glucose, triglycerides and leptin are reduced. Extensive physiological testing and uncoupling protein1 analysis showed, however, that the thermogenic problems are not due to abnormal responsiveness of brown adipocytes, since noradrenaline infusion produced a normal increase of body temperature. Moreover, we demonstrate that the cyclic drop in morning temperature is also not related to altered rhythmicity with reduced locomotion, diminished food intake or increased torpor sensitivity. Although several integral functions appear altered when CK is absent in the brain, combined findings point into the direction of inefficient neuronal transmission as the dominant factor in the thermoregulatory defect.     

Testing of susceptibility of Mycobacterium tuberculosis to pyrazinamide with the nonradiometric BACTEC MGIT 960 system

The reliability of the novel BACTEC MGIT 960 pyrazinamide (PZA) kit (Becton Dickinson Microbiology Systems, Sparks, Md.) was assessed for testing of susceptibility of Mycobacterium tuberculosis to PZA. Results generated by the BACTEC MGIT 960 system (Becton Dickinson) were compared with those obtained with the BACTEC 460TB system. Extensive proficiency testing (phase I) and reproducibility testing (phase II) as well as susceptibility testing of blinded strains of M. tuberculosis from the Centers for Disease Control and Prevention (phase III) were performed prior to testing 58 strains isolated from clinical specimens (phase IV). After resolution of discrepant results obtained by the two BACTEC methods by two other laboratories which acted as independent arbiters (phase V), overall agreement of the BACTEC MGIT 960 system with the BACTEC 460TB system for PZA testing of phase IV strains was 96.6%. Between the two systems there was no statistically significant difference in time until results were obtained, i.e., 6.8 days (BACTEC MGIT 960) versus 5.4 days (BACTEC 460TB), the latter not counting the time required for a subculture with a growth index of 200, however. The new BACTEC MGIT PZA susceptibility testing procedure works equally well for inocula prepared from liquid (MGIT) and solid (L?wenstein-Jensen) cultures. PZA MGIT medium in plastic tubes yielded results equivalent to medium dispensed in glass tubes.     

Th1-like Cytokine Production Profile and Individual Specific Alterations in TCRBV-gene Usage of T Cells from Newly Diagnosed Type 1 Diabetes Patients after Stimulation with β-cell Antigens

In order to study cytokine production profile (IFN-γ, IL-4 and TNF-α) and TCRBV-gene usage of peripheral autoreactive T cells from IDDM patients, we have generated antigen-specific T cell lines with either tetanus toxoid, insulinoma membranes or a single β-cell protein, recombinant ICA69, which has been shown to be a target of both autoantibodies and T cells in IDDM. By semi-quantitative polymerase chain reaction (PCR) analysis, we have determined the composition of the T cell receptor repertoire of these T cell lines and compared this with the general peripheral repertoire.T cell responses against β-cell antigens and tetanus toxoid (TT) were shown to be associated with IFN-γ and TNF-α production, suggestive of a Th1-like phenotype of the T-cell lines. The production of IFN-γ was significantly higher in T-cell lines generated with ISG compared to those generated with TT. The cytokine production profiles of the T-cell lines generated with ICA69 did not provide an obvious explanation for the inverse relation between cellular and humoral responses to this protein observed earlier. Upon stimulation with β-cell antigens, outgrowth of T cells using a restricted set of TCRBV elements was observed in newly diagnosed IDDM patients. However, this skewing in TCRBV-gene expression was patient-specific rather than antigen-associated, since the T-cell repertoire that is used for the recognition of these antigens was, overall, heterogeneous.     

Emergence of SCCmec Type IV and SCCmec Type V Methicillin-Resistant Staphylococcus aureus Containing the Panton-Valentine Leukocidin Genes in a Large Academic Teaching Hospital in Central Switzerland: External Invaders or Persisting Circulators?

The hospital epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) has changed in the past few years due to the encroachment of community-associated MRSA (CA-MRSA) strains into health care settings. MRSA strains that were isolated during a 2-year period from patients of the Luzerner Kantonsspital were analyzed to elucidate their epidemiology. Moreover, extended surveillance of individuals who were contacts of those patients was carried out for 6 months to identify the routes of spread and to assess the quality of the infection control measures used in our setting. Patient data were collected to distinguish CA-MRSA strains from health care-associated MRSA (HA-MRSA) strains by epidemiological criteria, as defined by the Centers for Disease Control and Prevention (CDC). On the basis of the CDC definition, the majority of the strains were considered to be HA-MRSA. However, 87% of them belonged to staphylococcal cassette chromosome mec (SCCmec) types IV and V, which are traditionally associated with CA-MRSA. Surprisingly, classical nosocomial SCCmec types I and II represented a minority, whereas SCCmec type III was completely absent. By PFGE analysis, four predominant clonal lineages and 21 highly variable sporadic genotypes were detected. Twenty-eight percent of the MRSA strains studied carried the genes encoding the Panton-Valentine leukocidin (PVL), of which 21% and 83% were associated with SCCmec types IV and V, respectively. Among 289 contact individuals screened for MRSA carriage throughout the extended surveillance, a single secondary patient was discovered. The possibility of nosocomial transmission could be excluded. The high proportions of SCCmec type IV and V strains as well as PVL-positive strains suggest strong infiltration of CA-MRSA into our institution. Moreover, the low endemic prevalence of MRSA demonstrates that current infection control measures are sufficient to limit its spreading and the emergence of large epidemic outbreaks.Methicillin-resistant Staphylococcus aureus (MRSA), one of the most common nosocomial pathogens, usually carries genetic elements that confer resistance to a broad range of antibiotics (2, 25). Methicillin resistance in staphylococci is based on the expression of a modified penicillin-binding protein (PBP), PBP 2a, which is encoded by the mecA gene. This gene is located on the staphylococcal cassette chromosome mec (SCCmec), a mobile genetic element integrated in the chromosome (6, 23) which also carries the genes for specific recombinases (ccr) necessary for its excision and integration (24). On the basis of the mec and ccr complex sequences, SCCmec is classified into types I to VII (1, 25). Previous studies showed that health care-associated (HA) MRSA (HA-MRSA) infections are generally caused by multidrug-resistant strains harboring SCCmec types I, II, and III but rarely SCCmec type IV (26, 38, 47, 52). On the other hand, community-associated (CA) MRSA (CA-MRSA) strains carry SCCmec type IV, V, or VII; are commonly susceptible to the majority of non-β-lactam antibiotics; frequently produce the Panton-Valentine leukocidin (PVL); and differ in their pulsed-field gel electrophoresis (PFGE) patterns (38). Recent studies have reported that CA-MRSA strains are spreading in hospital settings and are replacing traditional HA-MRSA strains (44, 46, 47, 52).Although the average prevalence of MRSA strains in Switzerland has been lower than that in the surrounding countries—between 0 and 6% of the first isolates of S. aureus recovered, except in Geneva, where the rate is 20% (2, 17, 19)—the incidence of MRSA infections is increasing. Even though there are epidemiological data for MRSA in Switzerland (2, 17, 20, 44, 47), the extent of the problem in the central part of Switzerland is unknown. In this study, we aimed at assessing the frequency, diversity, and clonal distribution of MRSA strains that were isolated at the Luzerner Kantonsspital (LUKS) between January 2007 and December 2008, in order to elucidate their origin and ways of circulation within our institution. Moreover, in a 6-month prospective study, we evaluated the effects of extended health care-associated hygienic measures on nosocomial MRSA transmission.     

Pudendal Neurolysis: 6-Step Laparoscopic Approach

ObjectiveTo demonstrate the safety and feasibility of the laparoscopic approach to perform pudendal neurolysis in a case of pudendal nerve entrapment syndrome [1, 2, 3].DesignA video tutorial that highlights the laparoscopic steps to performing pudendal neurolysis, with a focus on the main anatomic landmarks [4,5].SettingA tertiary care regional hospital.InterventionsThis video shows a 6-step approach to laparoscopic pudendal neurolysis for the treatment of pudendal nerve entrapment between the sacrospinous and sacrotuberous ligaments [2,6, 7, 8].Step 1: Identification of the umbilical artery.Step 2: Dissection and development of the lateral paravesical space until the pelvic floor.Step 3: Identification of the arcus tendineus of the endopelvic fascia.Step 4: Identification of the ischial spine and the sacrospinous ligament covered by the coccygeus muscle.Step 5: Coagulation and section of the coccygeus muscle and the sacrospinous ligament.Step 6: Medialization of the pudendal nerve until its entrance into the Alcock canal.ConclusionThis video demonstrates the safety, feasibility, and reproducibility of laparoscopic pudendal neurolysis in 6 steps. A minimally invasive approach is adequate to treat the pudendal compression until the Alcock canal [2].