Postcardiotomy extracorporeal life support

The need for postcardiotomy mechanical support is uncommon and likely to decline. A mixture of options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. Between January 1997 and December 2000, 29 adult, neonate, and infant cardiac surgical patients were supported on an extracorporeal life support system. Indications for cardiac assist included post-cardiotomy low cardiac output syndrome, and hyperacute rejection after cardiac transplantation. Data for analysis were collected prospectively. Survival on the life support system was 20/29 (69%) and 12 patients (41%) survived to discharge. The mean time to starting extracorporeal life support was longer in survivors than non-survivors. The extracorporeal life support system provides effective cardiopulmonary and end-organ support.     

Alveolar soft part sarcoma of the extremities: an evaluation of four cases

We presented four patients (3 women, 1 man; mean age 40 years; range 20 to 56 years) who had alveolar soft part sarcoma in the left arm, right elbow, right tibia, and left thigh, respectively. All the patients presented with a mass. Two patients had lung metastasis at the time of diagnosis. T1- and T2-weighted magnetic resonance images of all the patients showed a soft tissue lesion with hyperintense signal changes and heterogeneous contrast enhancement. Diagnoses were made by histopathologic examination of biopsy samples. All the patients received chemotherapy. Surgical resection was performed in three patients. Two patients with involvement of the left arm and right elbow died within three years after diagnosis. One patient with involvement of the left thigh developed lung and brain metastases at the end of postoperative eight years. One patient with tibial involvement remained disease-free during 10 months of follow-up.     

Aneurysmal bone cyst recurrence in children: a review of 56 patients

BACKGROUND: Aneurysmal bone cysts (ABCs) are benign lesions that are usually treated with intralesional procedures. The clinical behavior of ABCs is reported to be more aggressive in younger patients, with high recurrence rates after surgical treatment by several authors. The purpose of this study was to review longitudinally the demographic data and outcome of current surgical techniques in children with ABC treated at a single institution and to determine the possible risk factors for recurrence, which may be detected at initial examination, including age, presenting complaint, and radiological characteristics. METHODS: The authors performed a retrospective, pediatric population-based (< or =16 years) analysis of 56 cases of ABCs with more than 2 years' follow-up. The subjects were studied and classified on the basis of their age group (< or =5, 5-10, and >10 years of age). The possible risk factors for recurrence were analyzed initially with Student t test and Pearson chi2 test, then a logistic regression analysis model was used for multivariate analysis. RESULTS: Nine patients were younger than 5 years, 17 were between 5 and 10 years old, and 30 were older than 10 years. The most frequent location of the lesion was the humerus (11 cases) followed by proximal femur and fibula. Curettage was the most common treatment modality followed by resection. Recurrence of the lesion occurred in 5 children in the younger age group and in 4 children in the older age group. The difference in persistence or recurrence rates based on age (< or =5 years) and previous surgery was statistically significant. In addition, we have found no significant implication of physeal contact and size of the lesion on recurrence. CONCLUSIONS: The recurrence rates of primary ABC seemed to be higher in younger children. Considering the high cure rates with intralesional procedures even after recurrence, we suggest less aggressive intralesional procedures even in patients with mentioned risk factors; however, the patients' family should be informed about the high probability of recurrence.     

Carotid intima media thickness is increased and associated with morning cortisol in subjects with non-functioning adrenal incidentaloma

Data regarding cardiovascular risk in subjects with non-functioning adrenal adenoma are limited. The objectives of this study are to investigate carotid intima media thickness (IMT) as an indicator of atherosclerosis in subjects with non-functioning adrenal incidentaloma (AI) and to evaluate the factors that could be associated with IMT. Forty-nine subjects without findings of hypercortisolism or other adrenal gland disorders, 34 body mass index (BMI)-unmatched controls (C) and 18 BMI-matched controls (BC) were enrolled. Participants underwent hormonal evaluation including morning cortisol, adrenocorticotrophic hormone (ACTH), post dexamethasone suppression test cortisol (DST), dehydroepiandrosterone sulfate (DHEAS), and urinary free cortisol. Anthropometric and metabolic parameters and carotid IMT were measured. AI group had increased BMI, blood pressure, waist circumference, post DST cortisol, uric acid, and homeostasis model assessment (HOMA) levels when compared with C. Blood pressure, uric acid and, post DST cortisol remained significantly elevated in AI versus BC. Average IMT was increased significantly in AI versus C (0.74 mm vs. 0.68 mm, P = 0.029) and insignificantly elevated in AI versus BC (0.74 mm vs. 0.67 mm, P = 0.086). In all participants, IMT was correlated with age, BMI, HOMA, waist circumference, morning cortisol, and uric acid. Morning cortisol was independently associated with HOMA levels in both AI group and all participants. Increased IMT in non-functioning AI was a consequence of insulin resistant state associated with subtle cortisol autonomy rather than a direct effect of cortisol. The correlation between morning cortisol and IMT may be associated with the effect of hypothalamus–pituitary–adrenal axis disturbances on vasculature.     

Caspase 9 is decreased in psoriatic epidermis

Psoriasis is a proliferative and inflammatory disease of the skin. Caspase 9 is responsible for initiating the caspase activation cascade during apoptosis. Apoptosis is a physiological mechanism of homeostasis and development, and caspases are the executioners of apoptosis. This study reports the immunohistochemical localisation of caspase 9 in psoriatic skin and compares it with that seen in normal, healthy control skin. Skin biopsy specimens of lesions were obtained from 15 patients with plaque type psoriasis vulgaris. The specimens were labelled immunohistochemically for binding of an anti-caspase 9 primary antibody. Biopsies of healthy skin from 10 age-matched and sex-matched healthy control individuals were also analysed. The caspase 9 positive cell fraction was calculated for both epidermal and dermal cells in psoriatic lesions and healthy control skin. Counts of caspase 9 positive cells from the epidermis of psoriatic skin lesions were significantly lower than those seen in healthy skin (p<0.05). The caspase 9 immunolabelled perivascular cell counts in the dermis were not statistically significantly different in psoriatic lesions versus normal skin (p>0.05). Psoriatic epidermis contains little of the apoptotic marker, caspase 9. The results of this study are indicative of decreased apoptosis in psoriatic epidermis, and no change in the perivascular area in psoriatic lesions. These findings support the idea that decreased apoptosis is seen in psoriatic epidermal cells. Greater understanding of the nature of the disease may open new avenues for further therapeutic modalities.     

A case of recurrent and migratory complex regional pain syndrome type I: prevention by gabapentin

Complex regional pain syndrome type I (CRPS I) or reflex sympathetic dystrophy (RSD) is a painful and disabling neuropathic pain syndrome. We report a case of a patient who has experienced CRPS I four times with an unidentified cause for all recurrences. The patient responded well to a combination of physiotherapy and intravenous regional sympathetic block in the first two attacks, but not in the fourth one. Gabapentin was effective in the last two attacks. Gabapentin was gradually discontinued 12 months after the last attack and no other recurrence was observed for a follow-up period of 9 months. This case suggests that gabapentin might be considered in the treatment and prevention of CRPS I.     

Bilateral tibialis anterior muscle herniation simulating a soft tissue tumour in a young amateur football player

Muscle herniation is a focal protrusion of muscle tissue through a defect in the deep fascial layer. Anterior tibial muscle is the most commonly affected muscle of the lower extremities because its fascia is the most vulnerable to trauma. Clinically it is characterized by asymptomatic or painful, skin‐coloured, soft, subcutaneous nodules of various size depending on the position. The diagnosis is usually made clinically based on its typical manifestations, but ultrasonographic examination is useful for detecting the fascial defect and excluding other conditions caused by soft tissue tumours such as lipomas, angiolipomas, fibromas, scwhannomas or varicosities. Although this entity is not rare, it has been less well documented in the dermatological literature. We report a case of bilateral tibialis anterior muscle herniation mimicking a soft tissue tumour in a young amateur football player.     

Immunolocalization of VEGF, VEGFR-1 and VEGFR-2 in lung tissues after acute hemorrhage in rats

In treatment of hypovolemia it is important to reestablish normal tissue hemodynamics after fluid resuscitation. Vascular endothelial growth factor (VEGF) and VEGF receptors (VEGFR) have been identified as important in many physiological and pathological processes. In this study, we aimed to investigate the histo-physiological effects of VEGF, VEGFR-1 (flt-1) and VEGFR-2 (KDR/flk-1) in resuscitation with different plasma substitutes on lung tissues after acute hemorrhage in rats. Male Sprague-Dawley rats (n=25) were used in this study. The left femoral vein and artery were cannulated for the administration of volume expanders and for direct measurement of mean arterial blood pressure (MAP) (Power-Lab) and heart rate (HR). Fifteen rats were bled (5 ml/10 min) and infused (5 ml/5 min) with one of three randomly selected fluids: (a) dextran-70 (Macrodex); (b) gelatin (Gelofusine); or (c) physiological saline (PS, 0.9% isotonic saline) solutions. Five rats were bled and none were infused (hypovolemia group) and five rats were untreated as the control group. At the end of the experiment, rats were sacrificed and lung tissues were removed for routine processing and paraffin wax embedding. Sections of tissue were stained with hematoxylin and eosin (H&E) and selected blocks were then prepared for indirect immunohistochemical labeling for anti-VEGF, anti-VEGFR-1 and anti-VEGFR-2 primary antibodies. It was observed that both MAP and HR decreased parallel to blood withdrawn in this time interval. The MAP and HR were restored in the following periods. In the control rats, positive immunoreactivity of VEGF and its receptors (VEGFR-1 and VEGFR-2) were detected in respiratory epithelial cells, respiratory and vascular smooth muscle cells, alveolar cells and endothelial cells. While strong immunoreactivities of VEGF and VEGFR-1 were observed in the hypovolemia group, only moderate immunoreactivity of VEGFR-2 was seen in this group. Moderately strong immunolabeling of VEGF and VEGFR-1 were observed in the dextran-70, gelatin and PS resuscitated groups, whereas only weak immunolabeling of VEGFR-2 was observed in these groups. In summary, the vascular protecting effects of these factors were observed with fluid resuscitation, contributing to the pathophysiological changes seen in hypovolemia.     

Rubella revisited: where are we on the road to disease elimination in Central Europe?

Rubella is a contagious viral disease with few complications except when contracted by pregnant women. Rubella infection in pregnancy can result in miscarriage, stillbirth or an infant born with congenital rubella syndrome (CRS) which comprises deafness, heart disease, cataracts and other permanent congenital manifestations. Clinical diagnosis of rubella is difficult due to overlapping symptoms with many other diseases and confirmation of rubella is not possible without laboratory testing.Effective vaccination programmes are critical to the elimination of rubella and prevention of CRS. Such programmes have been successful in several countries in Europe and around the world. However, rubella outbreaks still occur due to suboptimal vaccine coverage and in the past 10 years rubella has been reported in Central European countries such as Romania and Poland. Over the past decade the elimination of rubella and prevention of congenital rubella infection in Europe has been a high priority for the WHO European Regional Office. In 2010 the WHO regional committee for Europe renewed its commitment to the elimination of rubella and prevention of CRS with a new target of 2015.This paper examines the current situation for rubella and CRS in Central Europe and describes the different rubella vaccination programmes in the region. The Central European Vaccination Advisory Group (CEVAG) recommends that two doses of measles, mumps and rubella vaccine, MMR, should be given to all children. The first dose should be given between 12 and 15 months of age. The second dose can be given between the ages of 21 months and 13 years with the exact age of administration of the second dose depending on the situation specific to each country. All suspected rubella cases should be laboratory-confirmed and monitoring systems to detect and investigate cases of CRS should be strengthened.     

Comparison of epicardial adipose tissue (EAT) thickness and anthropometric measurements in metabolic syndrome (MS) cases above and under the age of 65

EAT is a new index of cardiac and visceral obesity. Waist circumference (WC) measurement is not fully reliable in the determination of visceral adipose tissue (VAT), especially in elderly individuals. Studies on the reflection of the intra-abdominal fat mass by the EAT mass surrounding the heart were performed. Our purpose in this study was to determine the relation between the MS criteria and EAT in MS cases and especially to compare anthropometric measures between non-geriatric patients under the age of 65, and geriatric ones over the age of 65 years. The study was performed during the years 2008 and 2009 on 120 cases; 66.7% of them were under the age of 65 and 33.3% of the cases were 65-year old or older. All of the patients were diagnosed as MS by the International Diabetes Federation (IDF) criteria. They were randomized as per the application order and included to the study. Each subject underwent transthoracic two-dimensional (2D) guided M-mode echocardiogram. We measured epicardial fat thickness on the 1/3 section close to the ventricle basis adjacent to the free wall of right ventricle from both the parasternal long axis (LA) and parasternal short axis (SA) views. Multiple regression analysis showed that WC, systolic blood pressure (SBP) and age were the strongest independent variables correlated with EAT (p < 0.001). We also determined a significant correlation between low-density lipoprotein-cholesterol (LDL-C) and EAT (p < 0.05). Our data show that EAT-measurement by echocardiography is an efficient method in determination of visceral adiposity and shall be taken into consideration especially when advanced age groups are in question.