Interventionalists beware: the apical thrombus!

Recent myocardial infarction is a recognized risk factor for ischemic stroke. Patients who have a stroke in the peri-infarct period are usually in hospital and therefore well placed to access early cerebral reperfusion therapy. However, due to the risk of myocardial rupture, recent myocardial infarction is considered a contraindication to intravenous thrombolysis, which is usually the first-line therapy for the treatment of ischemic stroke. We report a case in which intravenous thrombolysis was safely and effectively used to treat acute ischemic stroke in a patient who had suffered an acute myocardial infarct within the previous 48 h. We also highlight the lack of evidence-based guidelines for the treatment of stroke in this important subgroup of patients.     

Presence of phthalate derivatives in the essential oils of a medicinal plant Achillea tenuifolia

Background

Phthalate, esters of phthalic acid, are mainly applied as plasticizers and cause several human health and environment hazards. The essential oils of Achillea species have attracted a great concern, since several biological activities have been reported from varieties of these medicinal species. On the other side, due to the problems regarding the waste disposal in developing countries, phthalate derivatives can easily release from waste disposal to the water and soil resulting in probable absorption and accumulation by medicinal and dietary plants. As a matter of fact, although the toxicity of phthalate derivatives in human is well-known, food crops and medicinal plants have been exposing to phthalates that can be detected in their extracts and essential oils. Achillea tenuifolia (Compositea) is one of these herbaceous plants with traditional applications which widely growing in Iran.

Finding

The plant root was subjected to hydro-distillation for 4 h using Clevenger type apparatus to obtain its essential oil before and after acid treatment. Both of the hydro-distilled essential oils were analysed by GC-MS method resulted in recognition of their constituent. Phthalate contamination as (1, 2-benzenedicarboxylic acid, bis (2-methylpropyl) ester (5.4%) and phthalic acid (4.5%), were identified in the first and second extracted oils, respectively.

Conclusion

As a warning, due to the potential role of phthalates to cause reproductive toxicity, disturb of endocrine system and causing cancers, medicinal plants have to be considered through quality control for detection of these compounds.     

Awake endotracheal retrograde intubation in restricted mouth opening: a ‘J’-tipped guide wire technique—a retrospective study

Introduction

Airway management in patient with restricted mouth opening is a great challenge, owing to the difficulty in laryngoscopy and visualisation of the vocal cords during the procedure of intubation. The term retrograde intubation refers to a technique in which a guide wire is passed into the trachea and then into the mouth or nose. A tracheal tube is then passed down over the guide until it enters the trachea.

Material and method

A retrospective audit was undertaken to determine the success and complication associated with retrograde intubation.

Results

The results show that in a sample of 20 patients in which retrograde intubation was done, only three developed sore throat and cough, one had bronchospasm and one developed infection at the site of insertion of a J-tipped catheter.

Conclusion

Retrograde tracheal intubation was easy to perform and had a high success rate and a low incidence of complications.     

Additional stenting promotes intimal proliferation and compromises the results of intravascular radiation therapy: an intravascular ultrasound study

Background

Vascular brachytherapy (VBT) reduces in-stent restenosis (ISR). However, additional stenting at the time of radiation may be associated with a worse outcome.

Methods and results

Intravascular ultrasound (IVUS) was performed after VBT and at 6 months follow-up in 79 native artery ISR patients treated with γ-radiation who participated in the Washington Radiation for In-Stent restenosis Trial (WRIST), Gamma-1, and Angiorad Radiation Technology for In-Stent restenosis Trial in Coronaries (ARTISTIC) trials. Patients were treated with ¹⁹²Ir at 14 or 15 Gy at 2 mm from the source. Additional stents were used to treat the ISR lesions in 45 patients; these patients were then compared with the 34 patients treated without restenting. Paired measurements included stent, lumen, and intimal hyperplasia volumes. After the VBT procedure, intimal hyperplasia volume was smaller in the group treated with additional stents (54 ± 33 mm³ vs 34 ± 33 mm³, P = .012), but minimal lumen area was similar between the 2 groups (4.3 ± 1.5 mm² vs 4.7 ± 1.4 mm² respectively, P = NS). Between the time of the VBT procedure and follow-up, intimal hyperplasia volume increased by 27 ± 19 mm³ in the restented group and by 9 ± 21 mm³ in the group treated without additional stents (P = .014). At 6 months, intimal volume was similar in the 2 groups, but minimal lumen area was slightly smaller in the group treated with additional stents (3.4 ± 1.8 mm² vs 4.2 ± 1.7 mm², P = .053). Patients treated with additional stents had more target lesion revascularizations than the group treated without additional stents (38% vs 15%, P = .02).

Conclusions

Additional stenting reduces intimal hyperplasia within the stents acutely. However, it compromises the benefit of VBT by promoting higher intimal regrowth within months after radiation.     

Adjuvant and preoperative chemotherapy for gastric cancer

Gastric cancer is the second most frequently diagnosed malignancy worldwide, and the risk of relapse remains high in the majority of patients undergoing resection. Attempts to reduce this risk and prolong survival have led to numerous adjuvant chemotherapy trials that either had no benefit for patients or occasionally had controversial results. The recently reported Intergroup 0116 trial shows conclusive evidence of survival benefit for patients treated with postoperative chemoradiotherapy. In this Intergroup trial, which involves over 600 patients, a regimen of postoperative chemotherapy plus chemoradiotherapy was shown to prolong overall and disease-free survival in gastric cancer patients with stage IB through IV disease following a curative (R0) resection. This approach should be considered the standard of care in patients with gastric cancer who have undergone curative resection. Preoperative chemotherapy shows promise in downstaging tumors and increasing the rate of curative resection, but randomized trials are needed to assess survival benefits. Efforts to combine existing treatment modalities and new agents with novel mechanisms of action hold promise for the future.     

Outcomes after emergency surgery for gastric perforation or severe bleeding in patients with gastric cancer

BACKGROUND AND OBJECTIVES: Free perforation and major bleeding in patients with gastric cancer are rare but serious conditions with potentially dangerous effects. To clarify the clinicopathologic characteristics of patients with these conditions and to determine the optimum management, we reviewed 16 cases of perforation and 13 cases of major bleeding in patients with gastric cancer who required emergency surgery. METHODS: We compared the clinical and histologic features of the patients with perforation and those with bleeding. Cox's multivariate regression analysis was used to compare survival rates between patients who underwent single-step surgery or a two-step radical procedure, between patients with stage I or II and stage III or IV cancer, between patients who underwent complete (R0) and incomplete (R1 or R2) resection, and between patients with bleeding and those with perforation. RESULTS: Many of the patients had advanced disease. There were no significant differences in clinicopathologic findings or survival between patients with gastric perforation and those with major bleeding. Patients who had major bleeding tended to have larger cancers. In the univariate analysis, gastrectomy (vs. no gastrectomy), R0 (vs. R1 or R2) resection, and lower stage (vs. higher stage) were highly correlated with improved survival time. CONCLUSIONS: Overall, patients with gastric cancers who underwent emergency gastrectomy had a poor prognosis, but it was better than that of patients who could not have gastrectomy because of the prXesence of advanced cancer. However, the survival rate was excellent in patients with early-stage cancer who underwent complete (R0) resection. We recommend complete resection when possible.     

Management of perforated gastric carcinoma: a report of 16 cases and review of world literature

Perforated gastric carcinoma is rare; however, it is a serious condition associated with complications. To understand the proper management of this disease and to characterize its clinical course we reviewed available data on 16 patients with perforated gastric carcinoma. We collected data on the age and sex of the patients as well as operative findings and histological features of the primary tumor. The depth of invasion and presence of lymph node metastasis were also recorded. The Union Internationale Contre Cancer stage, extent of resection, and surgical method used were reviewed. We also reviewed published information on the management of perforated gastric carcinoma. The carcinoma was stage I in three cases, stage II in one case, stage III in three cases, and stage IV in nine cases. Many patients had distant metastases. Fourteen patients underwent gastrectomy. Two patients whose preoperative condition was poor died of surgery-related complications, but patients with early-stage carcinoma underwent an R0 resection (resection of the primary tumor with negative margins) and had minimal complications. We conclude that the outcome of patients who were able to undergo radical surgery was good and correlated with the stage of cancer. It is important to perform gastrectomy rather than repair the perforation first, and a proper lymphadenectomy should follow--thus a two-step surgery when necessary.