Post-infarct left ventricular free wall rupture and ventricular septal defect managed by pericardial aspiration during transport to referral hospital

Although left ventricular free wall rupture is a comparatively common cause of death in acute myocardial infarction survival is infrequently reported. However, even in cases where surgical expertise is not immediately available the condition can be temporarily controlled by judicious pericardial aspiration and blood transfusion until definitive repair can be undertaken. Here we report the successful management of a patient sustaining combined left ventricular free wall rupture and ventricular septal rupture in a community hospital 130 km from the referral center.     

Effects of ejaculation by penile vibratory stimulation on bladder capacity in men with spinal cord lesions

PURPOSE: We examined the effects of ejaculation by penile vibratory stimulation on bladder capacity in men with spinal cord lesions. MATERIAL AND METHODS: Included in our study were 14 men with spinal cord lesions from C4 to T7 with detrusor hyperreflexia. Cystometry was performed before and immediately after ejaculation by penile vibratory stimulation to establish baseline conditions and repeated after 1 month of ejaculation by penile vibratory stimulation every third day. The third cystometry study was done after 1 month of ejaculation by penile vibratory stimulation every third day at home to determine any long-term effects of treatment. This third cystometry was performed 72 hours after the last ejaculation to exclude any acute effects of ejaculation by penile vibratory stimulation on detrusor hyperreflexia. In addition, 1 to 3 days later ejaculation was induced by penile vibratory stimulation and immediately followed by cystometry to examine whether it was possible to achieve an acute effect as well as a potential long-term effect. RESULTS: Baseline urodynamic investigations revealed bladder hyperreflexia and external sphincter dyssynergia in all individuals. There was no statistically significant difference in bladder capacity at leak point before and immediately after ejaculation by penile vibratory stimulation. However, after 4 weeks of frequent penile vibratory stimulation treatment bladder capacity at leak point increased significantly from a median of 190 ml. (range 17 to 700) at baseline to 293 (range 30 to 700) (Wilcoxon signed rank test p = 0.03). Furthermore, there was a trend toward decreased intravesical pressure during the filling phase. CONCLUSIONS: Ejaculation by penile vibratory stimulation was associated with a significant increase in bladder capacity at leak point after 4 weeks of frequent treatment. This finding may have implications in the management of incontinence in men with spinal cord lesions.     

Prevention of Secondary Insults in Neurointensive Care of Traumatic Brain Injury

Background: Secondary insults/complications have a major impact on the prognosis after traumatic brain injury (TBI). The aim was to study the occurrence and prognostic value of secondary insults occurring in TBI patients, during standardized neurointensive care (NIC) dedicated to avoiding secondary insults. Material and Methods: 154 patients, 17-79 years, with acute head trauma and pathologic CT, treated during a 2-year period at the NIC unit were studied. The occurrence of defined secondary insults (standard and severe) was recorded during the 1st week of NIC from bedside surveillance charts containing one value per hour and parameter (intracranial pressure, cerebral perfusion pressure, systolic blood pressure, PaO₂, temperature, and blood glucose). The data set was analyzed using univariate and multivariate logistic regression with favorable outcome as the response variable. Both admission variables (Glasgow Coma Scale Motor Score [GCS M], CT class, Injury Severity Score [ISS], age, and gender) and secondary insult variables were included as explanatory variables. Results: In total, 1,570 insults were identified (320 severe). In the univariate analysis, the sum of all insults, blood glucose, GCS M, CT class, and ISS showed significant effects on outcome (p < 0.05). In the multiple regression analysis, GCS M was the only significant explanatory variable. Conclusions: The occurrence of secondary insults in the NIC unit was not negligible, despite the fact that major efforts were made to avoid them. The sum score of all insult categories and high blood glucose had a statistically significant effect on favorable outcome in the univariate analysis, but secondary insults did not add any prognostic information to the neurologic grade in the multivariate analysis. This finding indicates that the insults that occurred were related to the degree of primary injury/neurologic grade.     

Anxiety, Depression and Health-Related Quality of Life after Jejunoileal Bypass: A 25-Year Follow-up Study of 20 Female Patients

Background: Jejunoileal (JI) bypass was a widely performed operation for morbid obesity in the 1970s.The aim of this study was to investigate the long-term status for mental and physical health after weight loss induced by this operation. Methods: 20 female patients (age 48-80 y, BMI 23-75 kg/m²) were interviewed 25 years after JI bypass. The Hospital Anxiety and Depression Scale (HAD) and Short Form 36 (SF-36) were used. Scores from the Norwegian female population, and published scores for morbidly obese patients were used for comparison. An assessment was made on whether present demographic and clinical factors influenced the scores. Results: Anxiety and depression scores, and scores for physical functioning, bodily pain, vitality and mental health on the SF-36 were similar to scores in the Norwegian female population used for comparison. The scores from the patient sample were much better than scores published for morbidly obese patients, and implies that weight loss induced by the operation has been of great benefit on mental health and health-related quality of life. Anxiety and depression symptoms improved; however, being socially handicapped by the stools had a negative impact on HAD and SF-36 scores. Conclusion: These results suggest that 25 years after the JI bypass most of these patients have a similar level of mental and physical health as the general Norwegian female population. For individuals with bothersome side-effect(s) of the operation, a negative impact is seen.     

Successful open reduction of a 5-month-old hip dislocation associated with a femoral head fracture

The long-term prognosis after open reduction of neglected posterior hip dislocations is poor; as such, primary arthroplasty is recommended by a number of authors. We present a patient with a 5-month-old posterior hip dislocation with concomitant paralysis of the sciatic nerve who had an open reduction. At a follow-up of 3.5 years, the patient has normal function with no signs of arthrosis. Magnetic resonance imaging scans, however, revealed partial avascular necrosis of the femoral head. A discussion based on the literature shows the uniqueness of this case.     

Effects of immediate switch from cyclosporine microemulsion to tacrolimus at first acute rejection in renal allograft recipients

BACKGROUND: A number of institutions have reported favorable results in renal transplant patients after conversion from cyclosporine (CsA) to tacrolimus at the time of acute rejection, but no prospective, controlled study has been performed to date. Here, we report the first randomized study comparing patients whose therapy was changed at a first episode of acute rejection to tacrolimus with those who were maintained on CsA microemulsion (ME). METHODS: This 3-month, prospective, open, multicenter, parallel-group study was conducted at 15 centers in seven European countries. In total, 119 renal graft recipients experiencing a first biopsy-proven acute rejection episode while receiving CsA-ME were randomized (1:1) to start tacrolimus-based therapy (n=61) or to continue CsA-ME-based therapy (n=58). RESULTS: Baseline characteristics were comparable for both groups. The initial rejection episode responded to steroid treatment in 93.4% (tacrolimus) and 63.8% (CsA-ME) (P=0.001), respectively. In patients at risk, the incidence of recurrent rejection events within 3 months was significantly lower with tacrolimus therapy (5/57, 8.8%) compared with CsA-ME therapy (15/44, 34.1%) (P=0.002). Patient and graft survival were similar in both study groups 3 months after randomization. The most frequently reported adverse events were increased serum creatinine (29.5% vs. 22.4%), hypertension (24.6% vs. 22.4%), and urinary tract infection (18.0% vs. 20.7%) for tacrolimus versus CsA-ME. Tremor was more common in tacrolimus treated-patients (17.4% vs. 2.1%, P=0.011). CONCLUSIONS: Early conversion to tacrolimus therapy benefited the resolution of acute rejection episodes and significantly reduced the risk of recurrent rejection compared with continuation of CsA-ME.     

Cardiac metabolism measured noninvasively by hyperpolarized 13C MRI.

Pyruvate is included in the energy production of the heart muscle and is metabolized into lactate, alanine, and CO(2) in equilibrium with HCO(3) (-). The aim of this study was to evaluate the feasibility of using (13)C hyperpolarization enhanced MRI to monitor pyruvate metabolism in the heart during an ischemic episode. The left circumflex artery of pigs (4 months, male, 29-34 kg) was occluded for 15 or 45 min followed by 2 hr of reperfusion. Pigs were examined by (13)C chemical shift imaging following intravenous injection of 1-(13)C pyruvate. (13)C chemical shift MR imaging was used in order to visualize the local concentrations of the metabolites. After a 15-min occlusion (no infarct) the bicarbonate signal level in the affected area was reduced (25-44%) compared with the normal myocardium. Alanine signal level was normal. After a 45-min occlusion (infarction) the bicarbonate signal was almost absent (0.2-11%) and the alanine signal was reduced (27-51%). Due to image-folding artifacts the data obtained for lactate were inconclusive. These studies demonstrate that cardiac metabolic imaging with hyperpolarized 1-(13)C-pyruvate is feasible. The changes in concentrations of the metabolites within a minute after injection can be detected and metabolic maps constructed.     

Early uptake of 99mTc-C2A in the acute phase of myocardial infarction as a prognostic indicator for follow-up cardiac dysfunction

OBJECTIVE: The C2A domain of Synaptotagmin I is a molecular probe for the specific imaging of cell death. Here we test the hypothesis that the uptake of 99mTc-C2A in the acute phase of an infarction is associated with cardiac dysfunction in follow-ups. METHODS: The left coronary artery was occluded in Sprague-Dawley rats for 0, 10, 20, and 30 min. 99mTc-C2A was injected intravenously at 2 h of reperfusion. Anterior planar images were acquired with one million counts on a gamma camera 3 h after injection. 99mTc-C2A uptake was calculated as the total counts in the left ventricle region minus blood pool signal. The in-vivo signal detected was correlated with wall motion score index at 1 and 3 weeks follow-ups measured by echocardiography. RESULTS: 99mTc-C2A uptake was higher with increased ischemic time (2244+/-852, 4054+/-1223, and 6178+/-1451 for 10, 20, and 30 min ischemia, analysis of variance P<0.001). A significant correlation was found between 99mTc-C2A uptake and wall motion score index at 1 week (R=0.800, P=0.0006) and 3 weeks (R=0.810, P=0.0008). CONCLUSION: In this ischemia/reperfusion model, 99mTc-C2A uptake in the acute phase was associated with functional abnormality at 1 and 3 weeks. This demonstrates the potential diagnostic and prognostic value of 99mTc-C2A as a novel imaging agent.     

Full-field digital mammography compared to screen film mammography in the prevalent round of a population-based screening programme: the Vestfold County Study

The purpose of the study was to compare the performance of full-field digital mammography (FFDM) with soft-copy reading to screen film mammography (SFM) used during the first prevalent 2-year round of population-based screening. A total of 18,239 women aged 50–69 years were screened with FFDM as part of the Norwegian Breast Cancer Screening Programme (NBCSP). Process indicators were compared to data from 324,763 women screened with SFM using the common national database of the NBCSP. The cancer detection rates were 0.77% (140/18,239) for FFDM and 0.65% (2,105/324,763) for SFM (p = 0.058). For ductal carcinoma in situ (DCIS) alone, the results were: FFDM 0.21% (38/18,239) compared to SFM 0.11% (343/324,763) (p < 0.001). Recall rates due to positive mammography were for FFDM 4.09% (746/18,239), while for SFM 4.16% (13,520/324,764) (p = 0.645), due to technically insufficient imaging: FFDM 0.22% (40/18,239) versus SFM 0.61% (1,993/324,763) (p < 0.001). The positive predictive value (PPV) in the FFDM group was 16.6% (140/843), while 13.5% (2,105/15,537) for SFM (p = 0.014). No statistically significant differences were recorded concerning histological morphology, tumour size, or lymph node involvement. In conclusion FFDM had a significantly higher detection rate for DCIS than SFM. For invasive cancers no difference was seen. FFDM also had a significantly higher PPV and a significantly lower technical recall rate.     

Influence of intraluminal thrombus on structural and cellular composition of abdominal aortic aneurysm wall

INTRODUCTION: It has been suggested that the intraluminal thrombus of abdominal aortic aneurysm (AAA) affects the underlying vessel wall. Aneurysm enlargement has been associated with growth of thrombus, and rupture has been proposed to occur after bleeding into the thrombus. To examine how thrombus affects the vessel wall, we compared the morphology of aneurysm wall covered with thrombus with wall segments exposed to flowing blood.Material and methods Sixteen patients (14 men, 2 women; age range, 56-79 years) undergoing elective repair of AAA, where computed tomography scans showed thrombus and segments of the aneurysm wall exposed to flowing blood, were included in the study. Specimens from the aneurysm were taken for light and electron microscopy. Masson trichrome staining was performed for wall thickness determination and demonstration of collagen, and Weigert-van Gieson staining for elastin. The cellular composition was analyzed by immunohistochemistry with antibodies against CD3 for T cells, CD4 for T helper cells, CD8 for T cytotoxic cells, CD20 for B cells, CD68 for macrophages, and smooth muscle alpha-actin for smooth muscle cells (SMCs). Caspase-3 staining and TUNEL analysis were performed to evaluate apoptosis. RESULTS: The aneurysm wall covered with thrombus was thinner and contained fewer elastin fibers, and the few that were found were often fragmented. This part of the wall also contained fewer SMCs and more apoptotic nuclei than the wall exposed to flowing blood. Clusters of inflammatory cells were detected in the media of the aneurysm wall and in higher numbers in the parts covered with thrombus. Electron microscopy showed that the aneurysm wall without thrombus contained a dense collagenous matrix with differentiated SMCs. In the segment covered with thrombus, SMCs were more dedifferentiated (synthetic) and apoptotic or necrotic. There were also an increased number of inflammatory cells located in close contact with SMCs in various stages of apoptosis. CONCLUSION: The aneurysm wall covered with thrombus is thinner and shows more frequent signs of inflammation, apoptosis of SMCs, and degraded extracellular matrix. These findings suggest that thrombus formation and accumulation of inflammatory cells may perturb the structural integrity and stability of the vessel wall and thereby increase the risk for aneurysm rupture.