Transoesophageal echocardiography in heart disease—old technologies, new tricks

Cardiac ultrasound and upper gastrointestinal endoscopy are relatively old technologies. With the introduction of new ultrasound probes and by incorporating ultrasound technology into conventional endoscopes, ‘new tricks’ in cardiac imaging were discovered. Posterior structures of the heart are now able to be imaged clearly by the ultrasound probe from the oesophagus. Consequently, better resolution of cardiac anatomy allows more accurate diagnosis of cardiac pathologies which is not possible using conventional transthoracic (TT) approach. Over a period of two years, 1200 cases of transoesophageal echocardiography (TOE) were undertaken in our institution. The major indications were diseases of the aorta (10%), source of cardioembolism (28%), assessment of native and prosthetic valve function (20%), suspected endocarditis and its complication (17%), pre and post percutaneous transluminal mitral valvotomy (PTMV [13%], congenital heart disease (2%) and others (10%). The greatest impact with TOE is in the diagnosis of aortic dissection and transection, TOE is superior to conventional TT approach in detecting potential source of embolism, valvular vegetations and its complication, native and prosthetic valve dysfunction and LA thrombus prior to PTMV. Observations by TOE such as spontaneous echo contrast (SEC) in the left atrium open new challenges for further research in its role in the pathogenesis of LA thrombus and its association with cardioembolic event. Other areas of interest include; reclassification of distal aortic dissection and the use of TOE in intra-operative work.     

Giant right atrial diverticulum: an unusual cause of Wolff-Parkinson-White syndrome.

A case of a giant right atrial diverticulum associated with neonatal supraventricular tachycardia is reported. The electrocardiogram in sinus rhythm showed pre-excitation that may have been caused by the right atrial diverticulum adhering to the right ventricle.     

Symptoms of pancreatic cancer

We describe the symptoms, physical findings, treatment interventions, risk factors, and length of survival in persons with pancreatic cancer referred to a palliative care service (PCS) in a tertiary care facility. Data were collected prospectively over a 2-yr period using a standard clinical assessment tool in 39 patients with unresectable pancreatic cancer. Common symptoms include pain (82%), anorexia (64%), early satiety (62%), xerostomia and sleep problems (both 54%), and weight loss (51%). Analyzed retrospectively, 82% had at least one known risk factor for the development of pancreatic cancer. Twenty-five people presented to the PCS within 1 mo of diagnosis; in this group, length of survival was analyzed according to the presence of specific symptoms, and a significant inverse relationship between the presence of dyspnea and length of survival was found. As there is no effective treatment for surgically unresectable pancreatic cancer, palliation of common symptoms should be the primary emphasis of therapy.     

adaptive fourier threshold filtering: A method to reduce noise and incoherent artifacts in high resolution cardiac images

We introduce an image processing method which reduces white noise and random artifacts in sets of high resolution, time resolved images. At each pixel, the processing consists of: (1) the isolation of a time intensity curve (TIC), (2) Fourier transformation of each TIC, (3) application of a threshold to remove low intensity coefficients, (4) inverse transformation to generate noise reduced TICS which are recombined to form images with improved signal-to-noise ratio (SNR). Noise filtering by Fourier thresholding is demonstrated on a set of cardiac images, resulting in a reduction of the noise energy by approximately 90%.     

Interleukin-1-inhibitor activity induced by respiratory syncytial virus: abrogation of virus-specific and alternate human lymphocyte proliferative responses

Respiratory syncytial virus (RSV) infection has been shown to induce human mononuclear leukocyte (MNL) production of net interleukin-1 (IL-1)-inhibitor activity. In the current studies of IL-1-inhibitor effects, RSV-exposed cells were compared with autologous MNL that were sham-exposed or exposed to inactivated RSV or influenza virus (which induces net IL-1 activity and commonly elicits effective homotypic immunity). Exposure of MNL to influenza virus or inactivated RSV resulted in increased expression of human leukocyte antigen-DR, the IL-2 receptor, and the transferrin receptor and increased progression through the cell cycle by 3 days. In contrast, exposure to infectious RSV resulted in decreased marker expression and cell cycle arrest, with abrogation of proliferation in response to the virus or other stimuli. These data raise the possibility that a contributing mechanism for recurrence of RSV infection is early suppression of the clonal expansion of virus-specific lymphocytes due to net IL-1-inhibitor activity.     

An immunohistological demonstration of c-erbB-2 oncoprotein expression in primary urothelial bladder cancer

Summary Sections of formalin-fixed, paraffin-blocked tissue from 116 primary transitional cell carcinomas were stained immunohistochemically using a polyclonal antibody against the c-erbB-2 oncoprotein. Positive staining of cell membranes, known to correlate with gene amplification, was seen in 22 (19%) of the 116, with variable staining from tumour to tumour and within tumours themselves. Consistent with its mooted value as a prognosticator in bladder cancer, the c-erbB-2 oncoprotein was detected in 13 (of 40) grade III and 9 of the 26 muscle-invasive tumours examined compared to 1 (of 25) grade I and 6 (of 66) mucosa only (pTa) lesions. These results support further examination of c-erbB-2 expression in bladder cancer.     

Impact of Induction Chemotherapy and Preoperative Chemoradiotherapy on Operative Morbidity and Mortality in Patients with Locoregional Adenocarcinoma of the Stomach or Gastroesophageal Junction

Background Significant tumor downstaging has been achieved in patients with localized gastric or gastroesophageal adenocarcinoma by induction chemotherapy and preoperative chemoradiotherapy (CTX–CTXRT). However, the influence of CTX–CTXRT on operative morbidity and mortality has not yet been clarified. The aim of the present study was to document the frequency and nature of morbidity and mortality after surgery combined with CTX–CTXRT, and identify factors predictive of postoperative complications in patients with localized gastric or gastroesophageal adenocarcinoma. Methods A prospectively collected database on 71 consecutive patients who underwent CTX–CTXRT at M.D. Anderson Cancer Center between January 1997 and August 2004 was reviewed. Postoperative morbidity and mortality were investigated, and risk factors for overall complications were identified by multivariate logistic regression analysis. Results Overall morbidity and mortality rates were 38.0% (27 patients) and 2.8% (2 patients), respectively. Age greater than 60 years [relative risk 11.3 (95% confidence interval 2.50–50.6)] and body mass index (BMI) of 26 kg/m² or above [relative risk 4.08 (95% confidence interval 1.08–15.4)] were significant risk factors for overall complications. Conclusions CTX–CTXRT can be performed safely with an acceptable operative morbidity and a low operative mortality rate in patients with gastric or gastroesophageal cancer, with careful consideration of added risk associated with age and obesity.