Coexistence of benign phyllodes tumor and invasive ductal carcinoma in distinct breasts: case report

This report describes a rare case of coexistence of benign phyllodes tumor, which measured 9 cm in the right breast, and invasive ductal carcinoma of 6 cm in the left breast, synchronous and independent, in a 66-year-old patient. The patient underwent a bilateral mastectomy due to the size of both lesions. Such situations are rare and usually refer to the occurrence of ductal or lobular carcinoma in situ when associated with malignant phyllodes tumors, and more often in ipsilateral breast or intra-lesional.     

Do Alterations in the Rate of Gastric Emptying after Injection Sclerotherapy for Oesophageal Varices Play any Role in the Development of Portal Hypertensive Gastropathy?

Bleeding from portal hypertensive gastropathy (PHG) has been estimated to account for upto 30% of all upper gastrointestinal haemorrhage in patients with cirrhosis and portal hypertension. Although portal hypertension seems to be an essential prerequisite, the precise mechanisms responsible for the development of PHG are unknown. The aim of this study was to examine the role of injection sclerotherapy of oesophageal varices in the development of PHG. Gastric emptying was studied using a radionuclide test meal with the emptying characteristics of a slow liquid in 57 patients with cirrhosis and/or portal hypertension (median age 53 yrs), of whom 34 had received injection sclerotherapy for their oesophageal varices and 20 normal healthy volunteers (median age 42 yrs). As vagal damage is associated with more rapid emptying of liquids, despite hold up of solids, this technique might be expected to demonstrate such damage if gastric emptying was accelerated. The results indicated that there was no difference in the rate of gastric emptying between normal healthy volunteers and portal hypertensive patients. However, patients who had received injection sclerotherapy emptied their stomachs faster than those who had not (p<0.05). Furthermore, the speed of gastric emptying correlated directly with the number of injections (r=0.41; p=0.02) and the volume of sclerosant injected (r=0.39; p=0.03). These observations suggest that injection sclerotherapy for oesophageal varices results in disturbances of gastric emptying that may contribute to the pathogenesis of portal hypertensive gastropathy.     

The influence of baricity on the haemodynamic effects of intrathecal bupivacaine 0.5%

This study compared the haemodynamic effects of subarachnoid block with plain bupivacaine 0.5% (dextrose-free), heavy bupivacaine 0.5% (in dextrose 8%) and a mixture of these two solutions, i.e. bupivacaine 0.5% in dextrose 4%. Thirty-six male patients, aged 55-89 years, undergoing transurethral surgery were recruited. Invasive systolic arterial and central venous pressures were recorded at 5-s intervals after the block was initiated using a computerised data-collection system. The height of sensory blockade was recorded at 5-min intervals. No preload was given and episodes of hypotension were treated with colloid (8 ml x kg(-1)) and, if this was ineffective, a metaraminol infusion. Systolic arterial and central venous pressures decreased in all three groups following block (p < 0.05). These decreases were more rapid in onset in the heavy bupivacaine group compared with plain bupivacaine group (p < 0.005). Patients in the heavy bupivacaine group also had a greater requirement for early treatment of hypotension (< 10 min) and treatment with metaraminol (p < 0.05). The onset of sensory blockade was more rapid in the heavy group compared with the mixed group, although final sensory levels were similar. The onset of haemodynamic and sensory changes are more rapid when using heavy bupivacaine intrathecally. This leads to a higher and earlier incidence of hypotension and requirement for treatment.     

Abnormal renal vasodilation to an amino acid infusion in congestive heart failure: normalization by enalapril

In congestive heart failure (CHF), the neurohormonal mechanisms that cause renal vasoconstriction, particularly those depending on the renin-angiotensin system, could interfere with renal vasodilating mechanisms. To elucidate this issue, we studied the kidney response to an amino acid infusion (known to cause renal vasodilation in healthy individuals) in eight patients with CHF. We found that the amino acid infusion (0.7 mL/kg/h of a 10% solution) elicited no renal hemodynamic response, in marked contrast to healthy subjects. We next hypothesized that the renin-angiotensin system (known to be activated in heart failure) has a role in the lack of response to the amino acid infusion. To test this hypothesis, we repeated the study after two 5-mg doses of enalapril, an inhibitor of the angiotensin-converting enzyme, administered 12 hours apart. After enalapril treatment, the amino acid infusion caused a 45% increase in mean renal blood flow (RBF) from 383 +/- 55 to 557 +/- 51 mL/min at the fifth hour (P < 0.05). This normalization of the renal response to the amino acid infusion occurred without changes in cardiac output or in systemic vascular resistance. Hence, the renal fraction of the cardiac output increased during the amino acid infusion. The recovery of the renal vascular response was not accompanied by an increase in glomerular filtration rate (GFR; filtration fraction decreased), suggesting a predominant efferent arteriole dilatation. Our study shows that, in heart failure, the kidney loses its ability to increase RBF in response to an amino acid load. This lack of renal vascular response can be restored by inhibiting the renin-angiotensin system and is unrelated to changes in systemic hemodynamics.     

Altered Immunogenicity of Donor Lungs via Removal of Passenger Leukocytes Using Ex Vivo Lung Perfusion

Passenger leukocyte transfer from the donor lung to the recipient is intrinsically involved in acute rejection. Direct presentation of alloantigen expressed on donor leukocytes is recognized by recipient T cells, promoting acute cellular rejection. We utilized ex vivo lung perfusion (EVLP) to study passenger leukocyte migration from donor lungs into the recipient and to evaluate the effects of donor leukocyte depletion prior to transplantation. For this purpose, female pigs received male left lungs either following 3 h of EVLP or retrieved using standard protocols. Recipients were monitored for 24 h and sequential samples were collected. EVLP‐reduced donor leukocyte transfer into the recipient and migration to recipient lymph nodes was markedly reduced. Recipient T cell infiltration of the donor lung was significantly diminished via EVLP. Donor leukocyte removal during EVLP reduces direct allorecognition and T cell priming, diminishing recipient T cell infiltration, the hallmark of acute rejection.