Original Article--Predictors of Persistent Functional Tricuspid Regurgitation After Transcatheter Closure of Atrial Septal Defect and its Relationship to Tricuspid Valve Remodeling

ObjectivesThe aim of this study is assessment of persistent functional tricuspid regurgitation in patients with atrial septal defect before and after successful device closure and its relationship to tricuspid valve remodeling.MethodsThe current study was conducted on 60 patients referred to Tanta University Hospital Cardiology Department with the provisional diagnosis of atrial septal defect secundum type for transcatheter closure from December 2017 to December 2019. All patients were subjected to history taking, clinical examination, 12 lead electrocardiography, plain chest X-ray, full two dimension transthoracic echocardiography (for assessment of tricuspid regurgitation severity) before and at 3, 6 months after transcatheter closure.ResultsTricuspid regurgitation was decreased significantly after atrial septal defect closure due to remodeling in the right side. Age, estimated systolic pulmonary artery pressure, right atrium end systolic area, right ventricular end diastolic area, tricuspid valve tenting area and height, tricuspid septal leaflet angle and tricuspid annular diameter were predictors of persistent tricuspid regurgitation after 3 and 6 months of closure. Only estimated systolic pulmonary artery pressure, tricuspid septal leaflet angle and tricuspid annular diameter were independent predictors of persistent tricuspid regurgitation after 3, and 6 months of closure.ConclusionTricuspid regurgitation significantly improved after transcatheter atrial septal defect closure despite its significance at baseline due to remodeling in right side and tricuspid valve.     

Improved antigens for IgG-ELISA diagnosis of strongyloidiasis

Two preparations of antigens for the diagnosis of strongyloidiasis were prepared from an extract of the infective larvae of Strongyloides stercoralis: a crude antigen (CA) and a molecular weight cut-off antigen (MWCOA). Both antigens were analysed by indirect ELISA against the sera of strongyloidiasis (26 cases), other helminthiases (167) and normal controls (30). The larvae were obtained from fecal culture by a modified polyethylene tube technique after screening tests by triple simple smears per case. The larvae were extracted with distilled water and further sonicated to obtain a supernatant, the CA. A part of the CA was separated for an antigen containing molecules of lower than 30 kDa by an ultrafree-MC centrifugal filter tube (PLTK): this was designed as the MWCOA. The CA gave 96.15% sensitivity and 40.12% (67/167) specificity at a cut-off value of 0.980 (5SD); false positives were produced by 19 of 20 different helminthiases. The MWCOA produced 96.15% sensitivity at cut-off value of 0.71 (4SD); the specificity of the test was 78.44% (131/167), higher than that of CA. False positives also appeared with 15 other helminthic infections. This study suggests that MWCOA is more specific than CA. A purified MWCOA will be necessary in order to reduce cross-reactivity and provide the suitable diagnosis of strongyloidiasis.     

JK1 (FAM134B) gene and colorectal cancer: A pilot study on the gene copy number alterations and correlations with clinicopathological parameters

Aims

The aims of the study are to characterize changes in JK-1 (FAM134B) at the DNA level in colorectal adenocarcinoma and adenoma and exploring the possible correlations with clinical and pathological features.

Method

JK-1 gene DNA copy number changes were studied in 211 colorectal carcinomas, 32 colorectal adenoma and 20 colorectal non-cancer colorectal tissue samples by real-time quantitative polymerase chain reaction. The results were correlated with clinical and pathological parameters.

Results

Colorectal adenomas were more likely to be amplified than deleted with regard to JK-1 (FAM134B) DNA copy number change. The copy number level of JK-1 (FAM134B) DNA in colorectal adenocarcinomas was significantly lower in comparison to colorectal adenomas. Changes in JK-1 (FAM134B) DNA copy number were associated with histological subtypes, and cancer stage. Lower copy numbers were associated with higher tumor stage, lymph node stage and overall pathological stage of cancer. Conversely, higher DNA copy numbers were detected more often in the mucinous adenocarcinoma.

Conclusions

This is the first study showing significant correlations of the JK-1 (FAM134B) gene copy number alterations with clinical and pathological features in a large cohort of pre-invasive and invasive colorectal malignancies. The changes in DNA copy number associated with progression of colorectal malignancies reflect that JK-1 (FAM134B) gene could play a role in controlling some steps in development of the invasive phenotypes.     

UK national survey of management of breast lobular carcinoma in situ

Introduction

There is no national standard treatment for patients with breast lobular carcinoma in situ (LCIS). Association of Breast Surgery guidelines for the management of breast cancer suggest that lesions containing LCIS should be excised for definitive diagnosis and recommend close surveillance after excision biopsy. The aim of this study was to form a picture of the current management of LCIS by UK breast surgeons.

Methods

A questionnaire about the management of LCIS was sent to 490 UK breast surgeons.

Results

Of 490 questionnaires sent out, 173 (35%) were returned. When LCIS is present in a core biopsy, 61% of breast surgeons perform surgical excision, 22% would not excise but would continue follow-up and the remainder perform neither or set no clear management plan. Over half (54%) follow patients up with five years of annual mammography. If classic LCIS were found at the margins of wide local excision, 92% would not re-excise. Conversely, if pleomorphic LCIS were found, 71% would achieve clear margins. Respondents were split evenly regarding management of classic LCIS with a family history as 54% would not alter management whereas 43% would treat the disease more aggressively.

Conclusions

Our survey has shown that in cases where LCIS is found at core biopsy, most surgeons follow Association of Breast Surgery guidance, obtaining further histological samples to exclude pleomorphic LCIS, ductal carcinoma in situ or invasive cancer, whereas others opt for annual surveillance and some discharge the patient. This study highlighted the huge variability in LCIS management, and the need for randomised controlled trials and input into national audits such as the Sloane Project to establish evidence-based national standard guidelines.     

Successful closure of gastrocutaneous fistulas using the Surgisis? anal fistula plug

Introduction

Gastrocutaneous fistulas remain an uncommon complication of upper gastrointestinal surgery. Less common but equally problematic are gastrocutaneous fistulas secondary to non-healing gastrostomies. Both are associated with considerable morbidity and mortality. Surgical repair remains the gold standard of care. For those unfit for surgical intervention, results from conservative management can be disappointing. We describe a case series of seven patients with gastrocutaneous fistulas who were unfit for surgical intervention. These patients were managed successfully in a minimally invasive manner using the Surgisis^® (Cook Surgical, Bloomington, IN, US) anal fistula plug.

Methods

Between September 2008 and January 2009, seven patients with gastrocutaneous fistulas presented to Wishaw General Hospital. Four gastrocutaneous fistulas represented non-healing gastrostomies, two followed an anastomotic leak after an oesophagectomy and one following an anastomotic leak after a distal gastrectomy. All patients had poor nutritional reserve with no other identifiable reason for failure to heal. All were deemed unfit for surgical intervention. Five gastrocutaneous fistulas were closed successfully using the Surgisis^® anal fistula plug positioned directly into the fistula tract under local anaesthesia and two gastrocutaneous fistulas were closed successfully using the Surgisis^® anal fistula positioned endoscopically using a rendezvous technique.

Results

For the five patients with gastrocutaneous fistulas closed directly under local anaesthesia, oral alimentation was reinstated immediately. Fistula output ceased on day 12 with complete epithelialisation occurring at a median of day 26. For the two gastrocutaneous fistulas closed endoscopically using the rendezvous technique, oral alimentation was reinstated on day 5 with immediate cessation of fistula output. Follow-up upper gastrointestinal endoscopy confirmed re-epithelialisation at eight weeks. In none of the cases has there been fistula recurrence (range of follow-up duration: 30–59 months).

Conclusions

Surgisis^® anal fistula plugs can be used safely and effectively to close gastrocutaneous fistulas in a minimally invasive manner in patients unfit for surgical intervention.     

A divergent breakdown of neurocognitive networks in Parkinson's Disease mild cognitive impairment

Cognitive decline is a major disabling feature in Parkinson's disease (PD). Multimodal imaging studies have shown functional disruption in neurocognitive networks related to cognitive impairment. However, it remains unknown whether these changes are related to gray matter loss, or whether they outline network vulnerability in the early stages of cognitive impairment. In this work, we intended to assess functional connectivity and graph theoretical measures and their relation to gray matter loss in Parkinson's disease with mild cognitive impairment (PD‐MCI). We recruited 53 Parkinson's disease patients and classified them for cognitive impairment using Level‐1 Movement Disorders Society‐Task Force Criteria. Voxel‐based morphometry, functional connectivity and graph theoretical measures were obtained on a 3‐Tesla MRI scanner. Loss of gray matter was observed in the default mode network (bilateral precuneus), without a corresponding disruption of functional or graph theoretical properties. However, functional and graph theoretical changes appeared in salience network nodes, without evidence of gray matter loss. Global cognition and executive scores showed a correlation with node degree in the right anterior insula. We also found a correlation between visuospatial scores and right supramarginal gyrus node degree. Our findings highlight the loss of functional connectivity and topological features without structural damage in salience network regions in PD‐MCI. They also underline the importance of multimodal hubs in the transition to mild cognitive impairment. This functional disruption in the absence of gray matter atrophy suggests that the salience network is a key vulnerable system at the onset of mild cognitive impairment in PD.     

Pulmonary complications following hematopoietic stem cell transplantation: diagnostic approaches

Pulmonary complications are a significant cause of morbidity and mortality in hematopoietic stem cell transplant recipients. Pulmonary infiltrates in such patients pose a major challenge for clinicians because of the wide differential diagnosis of infectious and noninfectious conditions. It is rare for the diagnosis to be made by chest radiograph, and commonly these patients will need further invasive and noninvasive studies to confirm the etiology of the pulmonary infiltrates. This review describes the role of the different diagnostic tools available to reach a diagnosis in a timely manner in this patient population.     

Bone scan and liver ultrasound scan in the preoperative staging for primary breast cancer

The aim of the present study was to investigate the value of preoperative staging in primary operable breast cancer. This retrospective study included patients presenting between May 1999 and February 2004 with operable primary breast cancer. Of the 221 patients 189 had normal and 32 suspicious or positive bone scans (BS). Of the 189 patients with normal BS 182 had normal liver ultrasound (US), whereas the remaining seven patients underwent computed tomography scan which was normal in five and two confirmed liver metastases (one with abnormal LFTs). Of the 32 patients with suspicious or positive BS 26 were false positive on further investigations and the remaining six patients were confirmed to have bony metastasis (one abnormal bone profile). BS and liver US truly altered treatment in 3% of patients. False-positive results caused delay, psychological upset, and costly investigations in 14% of cases. Preoperative staging with liver US and BS should be reserved for high-risk patients.     

UVB in the management of early stage mycosis fungoides

BACKGROUND: Several options for treatment of early mycosis fungoides (MF) offer similar success rates. Previous small studies have shown UVB to be at least as effective as PUVA. OBJECTIVE: To summarize our experience with UVB treatment of early MF. METHODS: A retrospective analysis of early-stage MF patients treated by narrow band (NB) or broad band (BB) UVB in our institution between 1996 and 2002. Most patients achieving complete response (CR) were put on maintenance until natural sun exposure was possible and followed up every 3-6 months. The results were compared to those previously reported regarding PUVA. RESULTS: Sixty-eight and 43 patients were treated by NB and BB UVB, respectively. Eighty-six per cent (84 and 89% in NB and BB UVB groups, respectively) of IA and 71% (78 and 44% in NB and BB UVB groups, respectively) of IB patients achieved CR within a mean of 12.8 and 10.6 weeks, respectively. When maintenance was stopped, 65 and 30% had not relapsed after an average follow up of 27 and 222 weeks, respectively. Non-relapse rate was 33 and 48% for those having had vs. those not having had maintenance, respectively. CONCLUSIONS: Our results are comparable to all previously reported for skin-targeted treatments, including PUVA and, to our belief, reflect the nature of early MF, in which CR can probably be achieved in most of the patients. Among the responding patients there is no relapse during prolonged follow-up in about one third of the cases. Thus, we believe treatment should be stopped completely following first CR induction and maintenance treatment should be considered for relapsing patients only. Both broad and narrow UVB options are good and future choices should be made on the basis of short- and long-term side-effects.