Frontal assessment battery: A tool for screening minimal hepatic encephalopathy?

AIM To apply the Frontal Assessment Battery to cirrhotic patients with or without overt hepatic encephalopathy(OHE) and controls. METHODS The frontal assessment battery(FAB) was applied to 87 patients with liver cirrhosis(16 with and 71 without OHE) and 40 control subjects without cirrhosis treated at the alcohol and liver outpatient clinics and the gastroenterology ward of the Cassiano Ant?nio de Moraes University Hospital(Hospital Universitário Cassiano Ant?nio de Moraes- HUCAM), Espírito Santo, Brazil.RESULTS The average FAB score was lower for the cirrhotic than for the non-cirrhotic patients(10.6 ± 3.67 vs 12.25 ± 2.72, P = 0.015). The FAB score was lower for the cirrhotic patients with OHE than for the patients without OHE(8.25 ± 4.55 vs 11.14 ± 3.25, P = 0.027). The total FAB score was lower for the cirrhotic patients without OHE than for the non-cirrhotic patients, although this difference was not significant(11.14 ± 3.25 vs 12.25 ± 2.72, P = 0.067). Nevertheless, the difference in the scores on the subtest that assessed the ability to inhibit a response previously conditioned to a stimulus was significant(1.72 ± 0.93 vs 2.2 ± 0.85, P = 0.011).CONCLUSION The present study indicates that the FAB is a promising tool for outpatient minimal HE screening and the assessment of HE severity.     

VEGF-C expression in oral cancer by neurotransmitter-induced activation of beta-adrenergic receptors

The aim of this study was to investigate the expression of vascular endothelial growth factor type C (VEGF-C) in oral squamous cell carcinoma (OSCC) cell lines through norepinephrine-induced activation of beta-adrenergic receptors. Human OSCC cell lines (SCC-9 and SCC-25) expressing beta-adrenergic receptors were stimulated with different concentrations of norepinephrine (0.1, 1, and 10 μM) and 1 μM of propranolol, and analyzed after 1, 6, and 24 h. VEGF-C gene expression and VEGF-C production in the cell supernatant were evaluated by real-time PCR and by ELISA, respectively. The results showed that beta-adrenergic receptor stimulation by different concentrations of norepinephrine or blocking by propranolol did not markedly alter VEGF-C expression by SCC-9 and SCC-25 cells. VEGF-C protein levels produced by oral malignant cell lines after stimulation with different norepinephrine concentrations or blocking with propranolol was statistically similar (p?>?0.05) to those of the control group (nonstimulated OSCC cell lines). Our findings suggest that stimulation of beta-adrenergic receptors by means of norepinephrine does not seem to modulate the VEGF-C expression in OSCC cell lines. These findings reinforce the need for further studies in order to understand the responsiveness of oral cancer to beta-adrenergic receptor stimulation or blockage, especially with regard to VEGF-C production.     

Variability of pulmonary nodule volumetry on coronary CT angiograms

This study aims to investigate the variability of pulmonary nodule (PN) volumetry on multiphase coronary CT angiograms (CCTA).Two radiologists reviewed 5973 CCTA scans in this cross-sectional study to detect incidental solid noncalcified PNs measuring between 5 and 8 mm. Each radiologist measured the nodules’ diameters and volume, in systole and diastole, using 2 commercially available software packages to analyze PNs.Bland-Altman analysis was applied between different observers, software packages, and cardiac phases. Bland-Altman subanalysis for the systolic and diastolic datasets were also performed.A total of 195 PNs were detected within the inclusion criteria and measured in systole and diastole. Bland-Altman analysis was used to test the variability of volumetry between cardiac phases ([−47.0%; 52.3%]), software packages ([−50.2%; 68.2%]), and observers ([−14.5%; 27.8%]). The inter-observer variability of the systolic and diastolic subsets was [−13.6%; 31.4%] and [−13.9%; 19.7%], respectively.Using diastolic volume measurements, the variability of PN volumetry on CCTA scans is similar to the reported variability of volumetry on low-dose CT scans. Therefore, growth estimation of PNs on CCTA scans could be feasible.     

Echocardiographic diagnosis of transposition of the great arteries associated with anomalous pulmonary venous connection

We report 2 cases of transposition of the great arteries associated with anomalous pulmonary venous connection emphasizing the clinical findings, the diagnosis, and the evolution of the association. One of the patients had the anomalous pulmonary venous connection in its total infradiaphragmatic form, in the portal system, and the other patient had a partial form, in which an anomalous connection of the left superior lobar vein with the innominate vein existed. At the time of hospital admission, the patients had cyanosis and respiratory distress with clinical findings suggesting transposition of the great arteries. The diagnosis in 1 of the cases, in which the anomalous connection was partial, was established only with echocardiography, without invasive procedures that would represent risk for the patient; in the other case, in which the anomalous connection was total, the malformation was only evidenced with catheterization. The patients underwent surgery for anatomical correction of the heart disease. Only 1 patient had a good outcome.     

Palliative Senning in the Treatment of Congenital Heart Disease with Severe Pulmonary Hypertension

Background

Transposition of the great arteries (TGA) is the most common cyanotic cardiopathy, with an incidence ranging between 0.2 and 0.4 per 1000 live births. Many patients not treated in the first few months of life may progress with severe pulmonary vascular disease. Treatment of these patients may include palliative surgery to redirect the flow at the atrial level.

Objective

Report our institutional experience with the palliative Senning procedure in children diagnosed with TGA and double outlet right ventricle with severe pulmonary vascular disease, and to evaluate the early and late clinical progression of the palliative Senning procedure.

Methods

Retrospective study based on the evaluation of medical records in the period of 1991 to 2014. Only patients without an indication for definitive surgical treatment of the cardiopathy due to elevated pulmonary pressure were included.

Results

After one year of follow-up there was a mean increase in arterial oxygen saturation from 62.1% to 92.5% and a mean decrease in hematocrit from 49.4% to 36.3%. Lung histological analysis was feasible in 16 patients. In 8 patients, pulmonary biopsy grades 3 and 4 were evidenced.

Conclusion

The palliative Senning procedure improved arterial oxygen saturation, reduced polycythemia, and provided a better quality of life for patients with TGA with ventricular septal defect, severe pulmonary hypertension, and poor prognosis.     

Prediction of Pulmonary Arterial Pressure Level after Repair of Congenital Cardiac Communications and Discharge from the Hospital: Role of Down Syndrome and Early Postoperative Hemodynamics

Background: Postoperative pulmonary hypertension limits the success of surgical treatment in some patients with unrestrictive congenital cardiac communications. Identifying patients at risk of developing postoperative pulmonary hypertension is important to individualize follow-up strategies. Methods: We analyzed a prospective cohort of 52 pediatric patients (age 3 to 35 months) looking for perioperative predictors of mildly elevated pulmonary arterial pressure 6 months after surgery, defined as a systolic pressure greater than 30 mmHg by transthoracic echocardiography. This corresponds to a mean pulmonary arterial pressure of >20 mmHg. Clinical, echocardiographic and hemodynamic parameters were investigated. Perioperative hemodynamics was assessed by directly measuring pulmonary and systemic arterial pressures using indwelling catheters. Early postoperative pulmonary hemodynamics was defined as the mean pulmonary/systemic mean arterial pressure ratio (PAP/SAP) obtained per patient during the first 6 h of postoperative care. Results: Among the factors that were investigated as possible predictors, perioperative hemodynamics and the presence of Down syndrome were initially selected using univariate analysis (p < 0.030). Early postoperative PAP/SAP was correlated with PAP/SAP obtained in the operating room just after cardiopulmonary bypass (r = 0.70, p < 0.001), and it was higher in subjects with Down syndrome than in nonsyndromic individuals (p = 0.003). Early postoperative PAP/SAP was the only predictor selected using multivariate analysis. It was characterized as an independent predictor after adjustments for possible confounders. An early postoperative PAP/SAP of >0.35 was 76% sensitive and 74% specific at predicting a systolic pulmonary arterial pressure of >30 mmHg 6 months after surgery (hazard ratio with 95% CI 8.972 [2.428–33.158], p = 0.002). Conclusion: The hypertensive early postoperative behavior of the pulmonary circulation was strongly but not exclusively associated with Down syndrome, and it was characterized as an independent predictor of altered pulmonary arterial pressure after discharge from the hospital.     

Morphodynamic interpretation of acute coronary thrombosis, with special reference to volcano-like eruption of atheromatous plaque caused by coronary artery spasm

Routine autopsy studies of hearts with coronary thrombosis, collected over a period of eleven years, showed unique morphologic features of rupture of soft atheromatous plaques. These features include: (1) irregular luminar outline: angulation, invagination, upheaval, and/or wrinkles, (2) wavy outline of atheromatous cavity, (3) volcano-like rupture with seepage or gushing of semiliquid atheromatous contents into lumen, (4) cholesterol crystals arranged in rheologic vector direction, (5) rupture of deeper intimal fibrous tissue, (6) one or multiple intimal upheavals, (7) focal thickening of contracted media, (8) vestige of volcano-like eruption with organized thrombus, and (9) old thrombotic occlusion with wavy appearance of thick intimal fibrous tissue. The authors present a dynamic model of vasoconstriction or artery spasm that accounts for these features and the rupture of soft atheromatous plaques.     

Ultrastructural aspects of the microvasculature of the cochlea: the internal spiral network.

We performed a study of the microvasculature of the cochlea with scanning electron microscopy on corrosion casts in the guinea pig. This study was performed in 140 cochleas from healthy adult guinea pigs. Different microvascular techniques were used, including injection-microdissection in 53 cases, injection-diaphanization in 27 cases, a histologic technique in 34 cases, injection-microdissection-diaphanization in 32 cases, and scanning electron microscopy on corrosion casts in 14 cases. The internal radiating arterioles branch off as collateral branches of the spiral modiolar artery, as first-order collateral branches. We detail the morphology, caliber, trajectory, and collateral branches. Among their collateral branches, are third-order arterioles, the arterioles to the spiral ganglia, and the arterioles of the tympanic lip. The arterioles of the tympanic lip form, through their anastomosis, a rich capillary network at the edge of the spiral lamina, called the internal spiral network. We emphasize the glomeruli of Schwalbe, which arise near the scala tympani as third-order arterioles with a medium caliber of 14 microm. The upper glomeruli, situated in the bony wall, and the lower glomeruli, situated in the width of the osseous spiral lamina, form vascular loops made of anastomosed capillaries with a caliber of less than 10 microm. These loops play an important role as efficient devices, or "relay stations," for regulation of cochlear blood flow. The comparison of results obtained with each technique gave the perspective of the cochlear microvasculature with great accuracy.