Pregnancy and delivery in patient after Fontan's operation due to common ventricle of left ventricular morphology

A 53-year-old male presented to our emergency department with a sudden onset of ventricular tachycardia with left bundle branch block and right axis deviation. After the tachyarrhythmia converting to sinus rhythm, the ECG displayed sinus rhythm with a typical epsilon wave in leads V1 and V2. Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) was suspected. The epsilon wave is the most specific hallmark for the diagnosis of ARVD/C, although it is insensitive. For the management of these patients, antiarrhythmic medications appear to be effective. However, implantable cardioverter defibrillators are the only reliable treatment to prevent sudden cardiac death.     

Bone mineral density and hip structural analysis in type 1 diabetic men

OBJECTIVE: The risk of non-vertebral fractures is increased in men with type 1 diabetes (DM1) but studies have shown only moderately decreased or normal bone mineral density (BMD) in these patients. No previous studies have evaluated hip strength and geometry indices in DM1 patients. This study was therefore designed to characterize associations between BMD, dual X-ray absorptiometry (DXA)-based hip strength indices, metabolic control, and DM1chronic complications. DESIGN AND METHODS: The study was performed on 36 males aged 43.6 +/- 5.1 years with long-lasting DM1 and 36 healthy males matched for age, weight, and height. BMD in lumbar spine, total hip, upper and lower part of the femoral neck, hip axis length, cross-sectional area and moment of inertia (CSMI), and glycated hemoglobin (HbA1c) were measured. RESULTS: DM1 men had decreased spine BMD (P < 0.05) and normal total hip BMD in comparison with controls. Hip geometry and strength indices were comparable in both groups. However, M1 men had decreased CSMI and upper femur BMD but these differences did not reach statistical significance (P = 0.06). BMD changes and hip strength parameters did not correlate with HbA1c. CONCLUSIONS: Middle-aged DM1 men have decreased lumbar spine BMD, normal hip BMD and normal hip strength indices. These changes are not influenced by metabolic control and presence of chronic microvascular complications.     

A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents

BACKGROUND: Robotic surgery offers all the advantages of laparoscopy with additional increased accuracy. The use of robotic surgery has increased in the past 5 years. It has proven particularly useful in complex surgical procedures such as intracorporeal intestinal anastomosis. As the prevalence of robotic surgery increases, so will the need for residents to be able to perform surgery using the robotic system. Our goal was to compare hand-sewn, laparoscopic, and robotic suturing techniques performed by midlevel residents using a porcine intestinal model. METHODS: Fifteen residents unfamiliar with the robotic suturing technique participated in performing an initial hand-sewn suture line and then were randomized with cross-over to laparoscopic or robotic suturing. Completion time, leak pressure, number of sutures per cm, and difficulty level were assessed. RESULTS: The mean leak pressure for hand-sewn, laparoscopic, and robotic suturing was 9.5, 3.2, and 11.4 mm Hg, respectively. The laparoscopic group had 6 and the robotic group had 1 suture line that was inadequate for testing. Suture breakage was common in the robotic group. The anastomosis was considered hard by 92% in the laparoscopic group versus 17% in the robotic group. The time it took to complete 1 cm of anastomosis was .9, 8.7, and 8.3 minutes for hand-sewn, laparoscopic, and robotic suturing, respectively. CONCLUSION: The robotic suture line performed by midlevel residents was superior to laparoscopy, although the time for anastomosis was equivalent.     

Single-stapled double-pursestring anastomosis after anterior resection of the rectum

BACKGROUND: Single-stapled double-pursestring technique for colorectal anastomosis to the mid-rectum or upper rectum is the most commonly used technique in the single institution reported here. The investigators evaluate single-stapled double-pursestring anastomosis after anterior resection of the rectum performed at a single institution. METHODS: Medical records of patients who underwent single-stapled double-pursestring anastomosis between January 2000 and May 2005 were analyzed to identify postoperative anastomotic complications. Patients with previous radiation, diverting stoma, coloanal, and hand-sewn and double-stapled anastomoses were excluded. The primary goal was to identify postoperative anastomotic complications. RESULTS: Of 160 patients, 153 (96%) no septic complications. One patient (.6%) developed anastomotic leak requiring diversion. Of the 4 patients with pelvic abscesses (2.5%), 2 were treated with antibiotics and 2 with computed axial tomography-guided drainage. CONCLUSIONS: Single-stapled double-pursestring anastomosis is reliable, with very low rates of leak, subsequent diversion, and pelvic abscess (.6%, .6%, and 2.5% respectively).     

Accuracy of pedicle screw insertion in the cervical spine for internal fixation using frameless stereotactic guidance

OBJECT: Although transpedicular fixation is a biomechanically superior technique, it is not routinely used in the cervical spine. The risk of neurovascular injury in this region is considered high because the diameter of cervical pedicles is very small and their angle of insertion into the vertebral body varies. This study was conducted to analyze the clinical accuracy of stereotactically guided transpedicular screw insertion into the cervical spine. METHODS: Twenty-seven patients underwent posterior stabilization of the cervical spine for degenerative instability resulting from myelopathy, fracture/dislocation, tumor, rheumatoid arthritis, and pyogenic spondylitis. Fixation included 1-6 motion segments (mean 2.2 segments). Transpedicular screws (3.5-mm diameter) were placed using 1 of 2 computer-assisted guidance systems and lateral fluoroscopic control. The intraoperative mean deviation of frameless stereotaxy was < 1.9 mm for all procedures. RESULTS: No neurovascular complications resulted from screw insertion. Postoperative computed tomography (CT) scans revealed satisfactory positioning in 104 (90%) of 116 cervical pedicles and in all 12 thoracic pedicles. A noncritical lateral or inferior cortical breach was seen with 7 screws (6%). Critical malplacement (4%) was always lateral: 5 screws encroached into the vertebral artery foramen by 40-60% of its diameter; Doppler sonographic controls revealed no vascular compromise. Screw malplacement was mostly due to a small pedicle diameter that required a steep trajectory angle, which could not be achieved because of anatomical limitation in the exposure of the surgical field. CONCLUSIONS: Despite the use of frameless stereotaxy, there remains some risk of critical transpedicular screw malpositioning in the subaxial cervical spine. Results may be improved by the use of intraoperative CT scanning and navigated percutaneous screw insertion, which allow optimization of the transpedicular trajectory.     

The effect of chemotherapy on Ki-67, Bcl-2 and Bak expression in primary tumors and lymph node metastases of breast cancer

The aim of this study was the analysis of Ki-67, Bcl-2 and Bak expression in primary tumor and axillary lymph node metastases of breast cancer as well as an attempt to assess preoperative chemotherapy influence on the mentioned markers with regard to changes in the morphological appearance of the primary tumor and its metastases. Immunohistochemical examinations of Ki-67, Bcl-2 and Bak expression were conducted on sections collected from 135 patients treated surgically on invasive ductal breast cancer. Sixty-four of these patients were administered preoperative chemotherapy, whilst on 71 patients the surgery was performed without initial chemotherapy. In the group of patients without preoperative chemotherapy positive correlation in Ki-67 and Bcl-2 expression between primary tumors and lymph node metastases (p<0.0001, r=0.707; p<0.0001, r=0.604, respectively) was observed. In the group of patients after chemotherapy positive correlation between primary tumors and lymph node metastases in case of Bcl-2 and Bak proteins (p<0.04, r=0.424; p<0.02, r=0.478, respectively) was observed. It was also found that preoperative chemotherapy has an influence on the expression of proteins connected with proliferation and apoptosis and thus, it can influence neoplastic process biology. It does not have any significant impact on the proapoptotic Bak protein expression either in primary tumor or in lymph node metastases of breast cancer. However, it is related to lower expression of antiapoptotic Bcl-2 protein (p<0.0005) and of Ki-67 proliferation marker (p<0.03) in primary tumors, which indirectly indicates a beneficial influence of preoperative chemotherapy on the primary tumor. Concurrently, the influence of neoadjuvant therapy on lymph node metastases seems to be relatively small, which can limit its effectiveness.     

Renal transplantation in dialysis patients with the history of coronary artery bypass grafting and cardiac valve replacement

Death with a functioning kidney is the most frequent cause of graft failure. Cardiovascular disease is the most frequent cause of death after renal transplantation. Therefore, prior to grafting, it is mandatory to diagnose and treat coronary artery disease and heart valve impairment. Transplantation is the best option for renal replacement therapy as far as the quality of life and life expectancy are concerned, although patients with such comorbidities may experience a higher short-term mortality risk. The objective for this study was to analyze both short- and long-term results of patients after coronary artery bypass grafting (CABG) or cardiac valve replacement (CVR). The cardiac surgery recipient group (CSR) included 16 patients (15 men, 1 woman) aged from 44 to 73 (mean 54.9 +/- 7.8) years. CABG was performed in 13/16 patients, and CVR in 3/16. The rest of our patients were treated as a comparative noncardiac surgery recipient (non-CSR) group. It consisted of 422 patients (264 men, 158 women) aged from 14 to 68 years (mean 43.2 +/- 12.9). The comparison revealed that graft function estimated at 1 year after transplantation was not different: serum creatinine concentrations of 1.7 +/- 0.2 and 1.6 +/- 0.5 mg/dL in CSR and non-CSR, respectively. One-year patient survival in the CVR group of 93.8% was slightly worse than that in the non-CSR group (97.9%), but death-censored 1-year graft survivals were comparable in both groups (93.8% vs 92%). Urinary tract and cytomegalovirus infections were the most common complications in the CSR group. One patient lost his graft in month 3(rd) due to many serious infectious complications. One patient died at the end of 12 months as a result of a cardiovascular event (1/16). Our single-center results confirm that transplantation in patients after CABG or CVR is a safe procedure; therefore, such patients should be referred into the waiting list.     

Correlation between foveal structure and visual outcome following macular hole surgery: a spectral optical coherence tomography study

PURPOSE: The aim of this paper is to evaluate the retinal structure after macular hole surgery and to study the correlation of structural findings with final functional outcomes, using high-speed, high-resolution spectral optical coherence tomography (SOCT). METHODS: Sixty-eight eyes of 60 patients with full-thickness macular holes were included in the study. All patients underwent pars plana vitrectomy with trypan blue staining and internal limiting membrane (ILM) peeling. Patients were evaluated by SOCT, with 6 mum axial and 12-18 mum transverse resolution and three-dimensional images of the retina. RESULTS: There were four different types of macular hole closure: U-shape, V-shape, irregular and flat/open. The following retinal abnormalities were observed in postoperative scans: photoreceptor irregularities, lack of photoreceptors (photoreceptor defect), cysts in outer retinal layers, nerve fiber layer defects, lesion of all retinal layers, and RPE defects. It was possible to evaluate photoreceptor defects on a three-dimensional image. Retinal thickness in the fovea was also measured. CONCLUSIONS: Because of excellent resolution, SOCT is capable of visualization of retinal defects after macular hole surgery. Three-dimensional examination is adequate for evaluation of photoreceptor defects. Good postoperative visual acuity is correlated with U-shape closure, normal foveal thickness and absence of photoreceptor layer defects.     

Waclaw Blaise Orlowsky and his unacknowledged discovery in neurology

Journal of Neurology -     

Value of the real-time myocardial contrast echocardiography for risk stratification and for the detection of significant coronary stenosis in patients with end-stage renal disease.

Sir, Coronary artery disease (CAD) is common in patients with end-stagerenal disease (ESRD), and is associated with poor clinical outcome.However, routine screening for CAD in asymptomatic ESRD patientsis usually not required, except for renal transplant candidates[1]. Myocardial contrast echocardiography (MCE) is a new bedsidetechnique providing information regarding myocardial tissueperfusion. The assumption that MCE might be useful in patientswith ESRD has not been previously investigated. Moreover, thereare no published data concerning prognostic utility of MCE inpatients with ESRD. The aim of the study was to assess the prognostic significanceof MCE in patients with ESRD, and to