Echinococcal cyst of the right ventricle: diagnostic role of 2-dimensional echocardiography

A case of cardiac echinococcosis in a 22 year-old woman is reported. Clinical findings and cardiac catheterization data offered only presumptive evidence of an intraventricular mass but failed to make a positive diagnosis of cardiac involvement by hydatid disease. Using Two-Dimensional Echocardiography (2-DE) we were able to identify a rounded structure with multiple loculation into the right ventricle, highly suggestive of a hydatid cyst. Surgery confirmed our findings. We confirm the ability of 2-DE to detect and characterise intracardiac masses and we suggest that 2-DE could be considered the procedure of choice in the diagnosis of cardiac hydatid disease.     

Different patterns of technetium-99m sestamibi uptake in multiple myeloma

Technetium-99m 2-methoxyisobutylisonitrile (^99mTc-MIBI) has been proposed as a potential tracer in patients with multiple myeloma (MM). The aims of this study were to evaluate the incidence of various patterns of diffuse ^99mTc-MIBI uptake in patients with MM, to assess their relationship with clinical status and stage of disease, and to try to clarify the meaning of the diffuse bone marrow uptake of ^99mTc-MIBI. Thirty-nine consecutive patients with MM were studied. Twenty-nine of these patients had active disease (13 in stage I, ten in stage II, and six in stage III) and ten were in remission after chemotherapy. Anterior and posterior whole-body scans were obtained 10 min after i.v. injection of 555 MBq of ^99mTc-MIBI. The scans were classified as showing: pattern N, when only physiological uptake was present; pattern D, when diffuse bone marrow uptake was observed; pattern F, when areas of focal uptake of the radiotracer were evident; or pattern D+F, when both D and F patterns were observed. Diffuse bone marrow uptake was scored according to extension and intensity. Seven of the 39 patients (18%) showed pattern N, 18 (46%) pattern D, 2 (5%) pattern F, and 12 (31%) pattern D+F. Of the 32 patients with a positive ^99mTc-MIBI scan (i.e. showing pattern D, F or D+F), 29 (91%) had active disease. Only three patients in remission showed pattern D, but with a very low bone marrow uptake score. Both extension and intensity of diffuse bone marrow uptake correlated with the amount of the monoclonal component and the percentage of bone marrow plasma cells. The distribution of the ^99mTc-MIBI uptake patterns differed among patients in different stages of disease. Using as criteria for advanced stage the presence of either focal uptake (pattern F or D+F) or pattern D with a high score, high (90%) diagnostic accuracy was obtained. In conclusion, the patterns of ^99mTc-MIBI uptake in patients with MM are related to both the clinical status and the stage of disease. The presence of focal uptake or of intense diffuse bone marrow uptake suggests that the patient has active and advanced stage disease, while a negative scan in a patient with MM clearly indicates remission. Received 12 February and in revised form 16 April 1998     

Sodium removal and sodium concentration during peritoneal dialysis: effects of three methods of sodium measurement.

BACKGROUND: Sodium removal (NaR) may have a major impact on the survival of peritoneal dialysis patients. The dialysate/plasma sodium concentration ratio (D/P(Na)) is an indirect index of transcellular water transport by aquaporin channels, and thus of ultrafiltration. Sodium concentration can be assessed by means of flame photometry (F), and direct (D-ISE) or indirect ion-selective electrodes (I-ISE), but these methods have different properties. I-ISE is being used increasingly in clinical laboratories. The aim of this study was to evaluate NaR and D/P(Na) using the three different measurement methods. METHODS: We performed peritoneal equilibration tests (PETs) in 44 peritoneal dialysis patients and calculated the NaR. We also calculated D/P(Na) during the test; plasma and dialysate sodium concentrations were measured by F, D-ISE and I-ISE. RESULTS: NaR was lower (P<0.001) with D-ISE (69+/-29 mmol) than with F (81+/-29 mmol) or I-ISE (79+/-28 mmol). D/P(Na) was also lower at baseline (0.92+/-0.02 vs 0.95+/-0.02 and 0.95+/-0.02; P<0.001), after 60 min (0.87+/-0.03 vs 0.90+/-0.03 and 0.90+/-0.03; P<0.001) and at the end of PET (0.88+/-0.04 vs 0.92+/-0.04 and 0.92+/-0.04; P<0.001) when measured by D-ISE in comparison with F and I-ISE, respectively. CONCLUSIONS: NaR and D/P(Na) were lower when measured by the D-ISE method compared with the F and I-ISE methods. NaR and D/P(Na) were similar when measured by F or I-ISE. I-ISE can be used reliably in the evaluation of NaR and D/P(Na) in everyday clinical practice of peritoneal dialysis.     

Late onset cytomegalovirus disease in liver transplant recipients: de novo reactivation in recurrent hepatitis C virus hepatitis

Late onset cytomegalovirus (CMV) disease (occurring more than 1 year post-transplant] was documented in two liver transplant recipients with recurrent hepatitis C virus hepatitis in the absence of factors known to precipitate CMV disease, i. e., primary acquisition of CMV, allograft rejection, augmented immunosuppression, concomitant infections, or blood transfusions. Both patients had CMV enteritis (with CMV adrenalitis in one case]; however, other symptoms and signs of overt CMV infection, i. e., fever, leukopenia, or atypical lymphocytes, were lacking. Hepatitis C virus is an immunomodulatory virus; impaired CMV-specific T-cell responses may have accounted for the predisposition of our patients to unprovoked, late onset CMV disease. Given the high incidence of hepatitis C virus recurrence after liver transplantation, awareness of the occurrence and recognition of the unusual presentation of CMV disease in this setting is both clinically relevant and significant, particularly since CMV is treatable if recognized promptly. Received: 25 September 1997 Received after revision: 27 January 1998 Accepted: 2 March 1998     

The reduced tolerance of rat fatty liver to ischemia reperfusion is associated with mitochondrial oxidative injury

BACKGROUND: Oxidative stress contributes to the pathogenesis of hepatic ischemia-reperfusion injury. This study aimed to determine whether fatty degeneration affects the oxidative damage during warm ischemia reperfusion and whether mitochondria, the major intracellular site of energy synthesis, represent a preferential target of this injury. MATERIALS AND METHODS: Fed rats with control or fatty liver induced by choline deficiency underwent 60' lobar ischemia and reperfusion. Oxidative damage was assessed by measuring in whole liver tissue and in isolated mitochondria the thiobarbituric acid-reactive substances (TBARs), protein carbonyls (PC), and total and oxidized glutathione (GSH and GSSG) concentrations. The mitochondrial F0-F1-ATPase content and the oxidative phosphorylation activity were also determined. Rat survival and ALT release were assessed as parameters of liver injury. RESULTS: In the whole liver tissue, with the exception of TBARs, no differences were observed for GSH, GSSG, and PC between the two groups throughout all of the experiment. In contrast, in isolated mitochondria, fatty infiltration was associated with a mild oxidative imbalance already under basal conditions. The preischemic differences in the mitochondrial TBARs, PC, and GSSG levels were significantly amplified by reperfusion in the presence of steatosis. The enhanced oxidative damage was associated to a reduced F0-F1-ATPase content and oxidative phosphorylation activity in fatty liver mitochondria. Finally, serum ALT levels were significantly greater and survival significantly lower in rats with steatotic liver. CONCLUSIONS: Fatty infiltration exacerbates mitochondrial oxidative injury during warm ischemia reperfusion. The increased oxidative stress can alter mitochondrial functions, including key processes for ATP synthesis, thus, contributing to the reduced tolerance to reperfusion injury.     

Complete surgical resection of a huge thoracic mass consisting in a localized fibrous tumor simulating a high-grade malignant neoplasm

Solitary fibrous tumour is an infrequent neoplasm generally arising from the parietal and visceral pleura. The diagnosis may be difficult in the presence of a history of malignant disease owing to the different presentations and to radiological findings of evident invasiveness. The authors report the case of a woman with a right giant fibrous solitary tumour of the pleura twenty years after a subcutaneous mastectomy with axillary dissection and radiation therapy for breast cancer. The biopsy diagnosis was consistent with a probable solitary fibrous tumour of the pleura but the discrepancy with the radiological images and the difficult differential diagnosis versus a malignant sarcoma, possibly radio-induced, prompted us to verify the real features of the disease. The patient was submitted to a right anterolateral thoracotomy and partial sternotomy and the giant mass was resected enbloc with the phrenic nerve and diaphragm which proved to be the only structures tightly adhering to the neoplasm. Histological examination confirmed the diagnosis of a solitary fibrous tumour of the pleura. The patient is still alive and disease-free 30 months after the surgical operation. Fibrous solitary tumour is a disease generally characterised by a good prognosis but in particular cases, with unmistakable radiological findings of invasiveness, a precise diagnosis must be obtained in order to choose the most appropriate therapy.     

Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy

BACKGROUND: The incidence of deep vein thrombosis and pulmonary embolism following laparoscopic surgery is unknown and studies on alterations of hemostasis after laparoscopy are inconclusive. METHODS: In this study we prospectively evaluated changes in prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (Fg), antithrombin III (ATIII), prothrombin fragment F 1 + 2, beta-thromboglobulin (betaTG) and D-dimer (D-D), preoperatively and 24 h after laparoscopic surgery in 16 patients. RESULTS: Comparing pre- and postoperative values, no statistical differences were observed in aPTT, F1 + 2, and ATIII measurements. Postoperative PT values increased slightly (p approximately 0.05) after surgery. Conversely, Fg, betaTG, and D-D values were statistically higher in the 24-h evaluation (p = 0.008, 0.01, and 0.045, respectively). CONCLUSIONS: These data suggest that laparoscopic surgery induces activation of coagulation and fibrinolytic pathways and, additionaly, betaTG elevation, which has never been reported and might account for postoperative platelet activation and a greater risk of thrombogenicity. Therefore, routine thromboembolic prophylaxis in patients undergoing laparoscopic surgery is recommended.     

Acute portal vein thrombosis secondary to donor/recipient portal vein diameter mismatch after orthotopic liver transplantation: a case report

The incidence of portal vein thrombosis in end-stage liver disease is estimated as varying between 5% and 21%, whereas in candidates undergoing liver transplantation, this is 3-13%. Portal vein thrombosis occurring after liver transplantation can be managed surgically by thrombectomy, retransplantation, splenorenal shunt, or Wall-stent placement, or nonsurgically by angioplasty, local high-dose infusion of thrombolytic agents, combination of portal thrombolysis, or embolization of a pre-existing spontaneous splenorenal shunt. We report a case of portal vein thrombosis after liver transplantation diagnosed on postoperative day 1 in a 57-year-old patient who received a liver from an 8-year-old donor. The patient was successfully treated surgically with portal vein thrombectomy and systemic anticoagulation. Portal vein thrombosis, in this case, was considered to be secondary to size discrepancy between the donor and the recipient portal veins. Routine use of daily Doppler ultrasound was the key factor in early diagnosis.     

Endoscopy-assisted rhinoplasty

In nasal surgery some surgical steps are done without the aid of direct vision. In these situations, surgeons must use their experience and judgment. I have adapted techniques used in endoscopic sinus surgery to perform some of the surgical steps of functional and aesthetic rhinoplasty. Between September 1999 and February 2000, 11 patients underwent endoscopic-assisted septorhinoplasty, and 18 patients underwent traditional closed rhinoplasty. The following parameters were compared: surgical bleeding, postoperative edema and ecchymosis, dorsum irregularity, and operative time for each technique. The following steps were clearly visualized with the endoscope: raising the periosteum from the nasal bone, resecting the nasal hump, and rasping the nasal bones. The use of endoscopic instruments does not change the surgical steps required. Rather, it allows direct vision of steps previously not viewable.     

Control of aerostasis in pulmonary metastasectomy by precision resection. Standard technique versus fibrin glue modification

The control of aerostasis after performing non-anatomical pulmonary resections constitutes a serious problem. The presence of an air leak in the postoperative period requires a prolonged thoracic drainage and consequently a longer hospital stay. The aim of our study was to evaluate the usefulness of fibrin glue and its effectiveness in the prevention of air leaks. At the Department of Thoracic Surgery of the National Cancer Institute of Milan, we conducted a case-control study in 90 patients submitted to metastasectomy for secondary lung cancer, removing multiple small nodules < or = 1.5 cm using the precision resection technique. We divided the patients into two groups, both of 45 subjects: group 1 treated with fibrin glue and group 2 submitted to cauterization of the pulmonary parenchyma. The patient characteristics were well matched for age, type of approach and operation, number of resections performed and type of pathology. The assessment parameters investigated were the duration of the air leak, expected complications, drainage time and length of hospital stay. In group 1 we performed fewer than 5 precision resections in 21 cases, from 5 to 10 in 16, and more than 10 in 8. In group 2 we executed fewer than precision resections in 21 cases, from 5 to 10 in 17, and more than 10 in 7. In group 1 the duration of the air leak was 2.93 +/- 1.91 days as against 6.95 +/- 7.01 days in group 2 (p = 0.000). In group 1 we had one complication (2%) (a long-term air leak lasting > 10 days), while in group 2 we had a long-term air leak in 11 cases (24%) (p = 0.000). Mean thoracic drainage time was 4.22 +/- 1.43 days in group 1, and 8.13 +/- 7.37 in group 2 (p = 0.000). The mean postoperative hospital stay was 6.22 +/- 1.43 days in group 1 compared to 10.13 +/- 7.37 days in group 2 (p = 0.000). In the group of patients treated with fibrin glue we obtained a significant reduction in drainage time, complications and postoperative hospital stay. The results of our experience show that the use of fibrin glue in non-anatomical resections with a high risk of developing air leakage is effective in reducing the expected complications, with a favourable impact also on the quality of life of patients with metasases.