Bilateral ureteral fibroepithelial polyps and review of the literature

Despite being the most common forms of benign ureteral neoplasms, ureteral fibroepithelial polyps are rare and their etiology is still unknown. To our knowledge, we report the fourth case of bilateral fibroepithelial polyps in the English literature with a discussion of clinical features and etiology.     

Interrelations Between QRS Morphology, Duration, and HV Interval Changes Following Right Bundle Branch Radiofrequency Catheter Ablation

Interrelations between QRS morphology, duration, and HV interval changes in a model of “complete” bundle branch block following right bundle branch radiofrequency ablation have not been subjected to systematic study. This article describes these interrelations in patients who underwent right bundle ablation. Over a period of 42 months, 16 patients underwent radiofrequency ablation of the right bundle for treatment of bundle branch reentrant tachycardia. AH 16 patients had prolonged HV interval at baseline (minimum = 60 ms; mean = 68 ± 8 ms). After ablation, one patient developed complete heart block; the remaining 15 patients developed complete right bundle branch block (RBBB) and further prolongation of the HV interval (increment = 24 ± 16 ms). In 14 of these 15 patients, QRS duration was 138 ± 26 ms before ablation and increased to 168 ± 13 ms after ablation. In the remaining patient, the QRS duration was 160 ms before ablation and shortened to 144 ms following ablation despite further HV prolongation. Larger increases of HV interval after ablation were associated with smaller or negative changes in QRS duration (r = -0.77). There was a direct relationship between QRS duration at baseline and the increment in HV interval after ablation (r = 0.70), and an inverse relationship between QRS duration before and after ablation (r = -0.84). Radiofrequency ablation of right bundle may he associated with an increase in HV interval and QRS duration. However, HV interval prolongation is not necessarily associated with QRS duration widening. A large change in HV interval is more likely to be associated with an already prolonged QRS duration before ablation and a lesser increase or even decrease in QRS duration after ablation. A shorter QRS duration before ablation is associated with a smaller HV interval increase following ablation but a greater increment in QRS duration. These findings are consistent with the concept that narrowness of QRS duration is due to synchronized activation of ventricular endocardium; whereas, QRS duration widening seen with His Purkinje damage is due to reduced synchronization of endocardial activation.     

Increased Neurotoxicity Following Concurrent Exposure to Pyridostigmine Bromide, DEET, and Chlorpyrifos

The operating environment of the service personnel during thePersian Gulf War involved psychological, biological, and chemicalelements including exposure to pesticides such as the insectrepellent DEET (N,N-diethyl-m-toluamide) and the insecticidechlorpyrifos (O,O-diethyl O-3,5,6-trichloropyridinyl phosphorothioate)and to pyridostigmine bromide (PB, 3-dimethylaminocarbonyloxy-N-methylpyridiniumbromide) that was administered as a prophylactic agent againstpossible nerve gas attack. The present study was designed todetermine the toxicity produced by individual or coexposureof hens 5 days/week for 2 months to 5 mg PB/kg/day in water,by gavage; 500 mg DEET/kg/day, neat, sc; and 10 mg chlorpyrifoskg/day in corn oil, sc. Coexposure to various binary treatmentsproduced greater neurotoxicity than that caused by individualexposures and was characterized by severe neurologic deficitand neuropathological alterations. Also, neurotoxicity was furtherenhanced following concurrent administration of the three chemicals.Severe inhibition of plasma butyrylcholinesterase (BuChE) activitywas produced in hens treated with PB (activity 17% of control)compared to those treated with chlorpyrifos (activity 51% ofcontrol) or DEET (activity 83% of control). BuChE inhibitionwas further increased in binary and tertiary treatment groupscompared to individual treatment groups. In contrast, a significantinhibition of brain acetylcholinesterase (AChE) was producedin hens administered chlorpyrifos alone (activity 67% of control),while those given chlorpyrifos in combination with other compoundsexhibited a significant inhibition of brain AChE activity rangingfrom 43 to 76%. Brain neurotoxicity target esterase (NTE) wasnot inhibited in any of the individual treatment groups or PBIDEET,but was significantly inhibited and had activity expressed asa percentage of control in groups administered combined chlorpyrifoswith PB of 73% or DEET of 74% and in the tertiary treatmentgroup of 71%. We hypothesize that test compounds may competefor xenobiotic metabolizing enzymes in the liver and blood andmay also compromise the integrity of the blood-brain barrier,leading to an increase in their "effective con centrations"in the nervous system to levels equivalent to the toxic dosesof individual compounds. This is consistent with the presentobservation of increases in (1) the inhibition of brain AChEand NTE, (2) the extent of neurologic dysfunction, and (3) theseverity and frequency of neuropathologic lesions in the combinedtreat ment groups compared to those administered individualcompounds.     

CLINICAL PHARMACOLOGY OF MIVACURIUM CHLORIDE (BW B1090U) INFUSION: COMPARISON WITH VECURONIUM AND ATRACURIUM

Mivacurium chloride (BWB1090U) is a new, short-acting non-depolarizingneuromuscular blocking agent. It is a synthetic bis-benzylisoquinoliniumdiester, which is hydrolysed rapidly by plasma cholinesterase.This study compares mivacurium, atracurium and vecuronium bycontinuous i.v. infusion. The duration of mivacurium infusionranged from 29.5 to 286 min. The steady state infusion ratesnecessary to maintain 95 (SEM 4)% twitch suppression were: mivacurium8.3 (0.7) µg kg^–1 min^–1; atracurium 7.9 (0.4)µg kg^–1 min^–1; vecuronium 1.2 (0.3) µgkg^–1 min^–1. Following infusions of mivacurium, variousrecovery times (for example: 25–75%, 6.9 (0.3) min; 25–95%,11.0 (0.4) min; 5–95% 14.5 (0.4) min) did not differ significantlyfrom those following single bolus doses. Recovery times followingcessation of mivacarium infusions were approximately 50% ofthose for equivalent durations of infusion of atracurium (10.9(0.3) min for 25–75% recovery and 26.6 (0.4) min for 5–95%recovery). For vecuronium, corresponding recovery times were13.8 (0.9) and 32.0 (1.2) min, respectively. Comparative recoverytimes for mivacurium were 40–50% of those for vecuronium.There was a significant correlation between the infusion rateof mivacurium required to maintain 95% twitch depression andthe plasma cholinesterase activity of individual subjects. Presented in part in Abstract form at the Annual Meeting, AmericanSociety of Anesthesiologist, Las Vegas, Nevada, 1986.     

A Distinct Type of Palmoplantar Keratoderma

Abstract:   Palmoplantar keratodermas (PPK) are a diverse group of disorders. We report a boy with PPK, grayish-blue hyperkeratotic lesions on the lips and peri-oral area, opacities on the lower portions of the corneas, mutilation of his right auricle and many other skin lesions.     

Reduced Fluoroscopy During Atrial Fibrillation Ablation: Benefits of Robotic Guided Navigation

Reduced Fluoroscopy in PVI Using RN.   Background: Recently, a nonmagnetic robotic navigation system (RN, Hansen-Sensei™) has been introduced for remote catheter manipulation.
Objective: To investigate the influence of RN combined with intuitive 3-dimensional mapping on the fluoroscopy exposure to operator and patient during pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) in a prospective randomized trial.
Methods: Sixty patients were randomly assigned to undergo PVI either using a RN guided (group 1; n = 30, 20 male, 62 ± 7.7 years) or conventional ablation approach (group 2; n = 30, 14 male, 61 ± 7.6 years). A 3-dimensional mapping system (NavX™) was used in both groups.
Results: Electrical disconnection of the ipsilateral pulmonary veins (PVs) was achieved in all patients. Use of RN significantly lowered the overall fluoroscopy time (9 ± 3.4 vs 22 ± 6.5 minutes; P < 0.001) and reduced the operator's fluoroscopy exposure (7 ± 2.1 vs 22 ± 6.5 minutes; P < 0.001). The difference in fluoroscopy duration between both groups was most pronounced during the ablation part of the procedure (3 ± 2.4 vs 17 ± 6.3 minutes; P < 0.001). The overall procedure duration tended to be prolonged using RN without reaching statistical significance (156 ± 44.4 vs 134 ± 12 minutes, P = 0.099). No difference regarding outcome was found during a midterm follow-up of 6 months (AF freedom group 1 = 73% vs 77% in group 2 [P = 0.345]).
Conclusion: The use of RN for PVI seems to be effective and significantly reduces overall fluoroscopy time and operator's fluoroscopy exposure without affecting mid-term outcome after 6-month follow-up. (J Cardiovasc Electrophysiol, Vol. 21, pp. 6–12, January 2010)     

Improved Clinical Efficacy of External Cardioversion by Fluoroscopic Electrode Positioning and Comparison to Internal Cardioversion in Patients with Atrial Fibrillation

Background: Despite using different electrode positions, “conventional” external DC cardioversion in patients with atrial fibrillation is ineffective in 6%–50% of cases. An alternative when DC cardioversion is not successful is low energy internal cardioversion, which is performed at increased risk. We tested the hypothesis that optimization of electrode pad position under fluoroscopy to encompass as much atrial muscle as possible might improve the success rate of external cardioversion and thus minimize the need for internal cardioversion. Methods: Fifteen (9 males, 6 females) patients (age: 54 ± 15 years, weight: 124 ± 35 kg) with chronic atrial fibrillation (> 8 weeks) who had undergone unsuccessful conventional external cardioversion entered the study. Repeat conventional external cardioversion with electrodes in standard (right anterior and left posterior) positions was followed by “optimized” external cardioversion by positioning electrodes under fluoroscopy (using metallic markers). In case of failure, internal cardioversion was performed. Results: All 15 patients had undergone unsuccessful conventional external cardioversion with 360-J shocks. Eight patients (group A) reverted to sinus rhythm with one or two 360-J shocks using fluoroscopy-guided pad placement (53%). Six of the remaining 7 (86%) patients (group B) had successful internal cardioversion with biphasic shocks (12 ± 3 J). The body weight and body mass index were statistically lower in group A vs group B (106 ± 27 vs 145 ± 33 kg, p = 0.03 and 35 ± 8 vs 45 ± 8 kg/m², P = 0.48, respectively). There was no statistically significant in age, height, body surface area, duration of atrial fibrillation, amiodarone therapy, ejection fraction, or underlying heart disease. Conclusion: Unsuccessful external DC cardioversion, in some patients, is in part due to suboptimal conventional positioning of electrode pads that can be improved under fluoroscopic guidance by achieving the best possible vector encompassing the right and left atria. The optimized external cardioversion technique may minimize the need for internal cardioversion, which remains an effective approach when external cardioversion fails.