Large Lipomatous Hypertrophy of the Interventricular Septum

We present the case of a 58-year-old woman who had large lipomatous hypertrophy of the interventricular septum, a condition that is reported very infrequently. Preoperative cardiac magnetic resonance images revealed an inhomogeneous, infiltrating mass that was suppressed in fat-suppression mode. The extensive mass was causing right ventricular dysfunction, so we excised it through a right ventricular approach. The findings on histologic analysis of the mass were consistent with lipomatous hypertrophy. The patient died of septic shock on the 28th postoperative day. In addition to the patient''s case, we discuss the characteristics and diagnosis of this rare entity.     

Experimental Obstructive Jaundice Results in Oxidized Low-Density-Lipoprotein Accumulation in Surgical Wound of Rats

Introduction : Mounting evidence suggests that impaired wound healing is a well-defined consequence in obstructive jaundice and, as redox-regulated processes are relevant to wound healing, it is not unreasonable to suppose that oxidative stress associated with lipid peroxidation in cholestasis might be a systemic phenomenon probably comprising all tissues and organs, including wounds. The aim of the present investigation was to analyse the lipid peroxidation status of surgical wounds, in terms of oxidized low-density-lipoprotein (oxLDL) accumulation in experimental obstructive jaundice.

Methods : Sixteen Wistar-Albino rats weighing 200–230 gr were randomly divided into two groups. Group I (n = 8) was designed as the prolonged obstructive jaundice group and was subjected to bile duct ligation. Group II (Sham-control, n = 8) rats underwent laparotomy alone and bile duct was just dissected from the surrounding tissue. Histopathological evaluation, immunohistochemical screening and immunoflourescent staining of the surgical wound was conducted to the bile-duct ligated rats and control group on the 21^st postoperative day.

Results : Wound healing was found to be impaired in jaundiced rats histopathologically. When compared with the control group, significant positive oxLDL staining and intracellular accumulation of TNF-a, IL-2 and iL-6 was detected in the wound sections of the prolonged obstructive jaundice group.

Conclusion : Our present data is the first in the literature, indicating significant oxLDL accumulation in surgical wounds of cholestatic rats, which might be one of the results of systemic oxidative stress leading to deficient healing capacity as a consequence of persistent inflammation.     

Antisynthetase syndrome with refractory lung involvement and myositis successfully treated with double filtration plasmapheresis

Antisynthetase syndrome (ASS) is characterized by inflammatory muscle disease, pulmonary and joint involvement, and antisynthetase autoantibodies, with anti‐Jo‐1 antibody being the most common. Despite the use of immunosuppressive drugs, the prognosis of lung involvement seems poor. Herein, we report a case of refractory ASS, which maintained long‐term remission by double filtration plasmapheresis (DFPP) combined with immunosuppressive therapy. For a 65‐year‐old woman, who was diagnosed with ASS, immunosuppressive therapy was initiated and plasmapheresis (PP) was performed five times due to acute interstitial pulmonary disease and inflammatory myopathy. She remained in remission for eight months following PP. Increase in interstitial involvement was identified by lung tomography when the patient presented again with complaint of progressive increase in dyspnea and muscle pain. Although the immunosuppressive therapy was increased for the patient with elevated creatine phosphokinase (CPK) (2776 IU/mL), a rapid decrease in diffusion capacity of the lung for carbon monoxide (DLCO) was observed and the patient underwent PP. After four sessions of therapy, insufficient clinical and laboratory response was obtained (control CPK 1797 IU/mL) and because of that issue DFPP using a 2A filter was performed to the patient. There was a marked improvement in complaints of the patient, DLCO, and laboratory findings (control CPK 508 IU/mL) after three sessions of DFPP. The patient, who continued the immunosuppressive therapy after DFPP procedure, is being followed for 12 months in remission. Although our experience is limited with only one patient, DFPP seems promising as a treatment option for ASS with severe lung involvement. J. Clin. Apheresis, 28:422–425, 2013. © 2013 Wiley Periodicals, Inc.     

Evaluation of prostate volume in mpMRI: comparison of the recommendations of PI-RADS v2 and PI-RADS v2.1

PURPOSEWe aimed to evaluate the prostate volumes calculated as recommended in the PI-RADS v2 and PI-RADS v2.1 guidelines, intraobserver and interobserver variability, and the agreement between the two measurement methods.METHODSProstate mpMRI examinations of 114 patients were evaluated retrospectively. T2-weighted sequences in the axial and sagittal planes were used for the measurement of the prostate volume. The measurements were performed by two independent observers as recommended in the PI-RADS v2 and PI-RADS v2.1 guidelines. Both observers conducted the measurements twice and the average values were obtained. In order to prevent bias, the observers carried out measurements at one-week intervals. In order to assess intraobserver variability, observers repeated the measurements again at one-week intervals. The prostate volume was calculated using the ellipsoid formula (W×H×L×0.52).RESULTSIntraclass correlation coefficient (ICC) revealed almost perfect agreement between the first and second observers for the measurements according to both PI-RADS v2 (0.93) and PI-RADS v2.1 (0.96) guidelines. The measurements were repeated by both observers. According to the ICC values, there was excellent agreement between the first and second measurements with respect to both PI-RADS v2 and PI-RADS v2.1 for first (0.94 and 0.96, respectively) and second observer (0.94 and 0.97, respectively). For both observers, the differences had a random, homogeneous distribution, and there was no clear relationship between the differences and mean values.CONCLUSIONThe ellipsoid formula is a reliable method for rapid assessment of prostate volume, with excellent intra- and interobserver agreement and no need for expert training. For the height measurement, the recommendations of the PIRADS v2.1 guideline seem to provide more consistently reproducible results.

The prostate gland is one of the organs for which the disease incidence and prevalence in men increases with age. Prostate volume (PV) has an important role in the evaluation and management of both malignant and benign prostate diseases (1–3). In benign prostatic hyperplasia (BPH), prostate volume is used to decide upon treatment and evaluate response to medical therapy (3–5). In the diagnosis of prostate cancer, one of the important markers is prostate-specific antigen (PSA), but it has low specificity, and therefore PSA derivatives are used to increase its specificity. One example is PSA density, which is obtained by dividing the PSA value by PV. In the treatment of prostate cancer, PV is important, and the effectiveness of brachytherapy decreases in prostates with a volume greater than 50 mL (6). Furthermore, PV is used to identify appropriate patients for brachytherapy and select the number of radioactive seeds, and also determine fractionation for external beam radiation, radical prostatectomy operating planning and continence rate counseling, and focal therapy candidacy preparation (7, 8). For these reasons, it is vital to accurately calculate PV.There are many methods that can be used to calculate PV, with the ellipsoid formula being one of the most preferred since it is easy to apply and highly time-efficient (1–4, 9). Many studies have shown that this method has high accuracy due to the elliptic shape of the prostate (1, 2, 10–13). The ellipsoid formula is obtained by multiplying the height (anterior-posterior), width (medio-lateral) and length (cranio-caudal) values of the prostate by 0.52. These measurements can be performed by transrectal ultrasonography (TRUS) or magnetic resonance imaging (MRI). TRUS has certain disadvantages, such as being operator-dependent and susceptible to sonographic artifacts (14). MRI, which has become increasingly popular in recent years, allows for an accurate definition of the prostate boundaries and multiplanar measurements through its high contrast resolution of soft tissues (1, 5). It also provides more accurate measurements than TRUS (4, 15, 16).In order to ensure global standardization in the reporting of prostate MRI findings, PI-RADS v2 published in 2015, which is the revised version of PI-RADS 1.0, and the last updated version PI-RADS v2.1 made available in 2019, propose different calculation methods for the measurement of height in obtaining PV (17, 18). The midaxial plane is recommended for this measurement in PI-RADS v2, while the midsagittal plane is recommended in PI-RADS v2.1. This study aimed to evaluate the interobserver and intraobserver variability of PV calculated by both measurement methods and the agreement between the two measurement methods.     

High-thoracic ultrasound-guided erector spinae plane block for acute herpes zoster pain management in emergency department

Herpes zoster is a painful, eruptive, viral condition occurring with reactivation in immunosuppressed individuals. The selection of an effective analgesic method in the acute phase of herpes zoster can decrease the incidence of postherpetic neuralgia by reducing neural sensitization. The erector spinae plane block has been reported to provide diffuse and effective analgesia in the cervical, thoracic, and lumbar regions. We report an effective decrease in pain with the application of the high-thoracic erector spinae plane block in the emergency department in a patient with herpes zoster pain in the cervicothoracic and shoulder region.     

Unusual suspects: Real-time physiological evaluation of stressors during laparoscopic donor nephrectomy

IntroductionThe purpose of this study was to document the variability of faculty surgeon electrodermal activity (EDA) peaks during laparoscopic donor nephrectomy (LDN) to determine the effect of case difficulty and learner expertise on the stress response.MethodsEDA for a single faculty surgeon was captured over 15 LDN cases using an Empatica E4 wristband. During each case, one of three transplant fellows (novice, intermediate, or expert level LDN expertise) participated. Difficulty was rated preoperatively as “low/moderate/high” by the faculty. EDA peaks were collected and analyzed; the frequency and magnitude of EDA peaks, case difficulty, and fellow expertise were compared using a two-way factorial ANOVA.ResultsThe main effects of learner expertise (F[2, 308]=11.27, p<0.001) and difficulty rating (F[2, 414]=15.13, p<0.001) were significant. The interaction between difficulty and expertise on faculty EDA peaks was also significant (F[3, 391]=14.29, p<0.001). The novice fellow resulted in higher faculty EDA levels compared to intermediate and expert fellows on low-difficulty cases, but not moderate- or high-difficulty cases.ConclusionsThis is the first report examining faculty surgeon EDA across cases of varying difficulty and varying learner expertise during a high-stakes operation. EDA levels were inversely proportional to the expertise of the learner and case difficulty, suggestive of a significant impact of learner autonomy on faculty stress response.