Surgical excision of papillary fibroelastoma for known or potential embolization

BACKGROUND AND AIM OF THE STUDY: Papillary fibroelastoma (PFE) is a rare and histologically benign tumor, but it may have malignant propensity for life-threatening complications. Herein are described four cases of PFE which reflect the clinical diversity of this lesion. The diagnostic and surgical approach utilized is also briefly reviewed. METHODS: The files of four patients with cardiac valvular PFE treated at the authors' center between January 2002 and November 2003 were reviewed. The diagnosis was strongly suggested by echocardiography. Tumors were noted in aortic (n = 2), mitral (n = 1) and tricuspid (n = 1) sites. Indications for surgery were myocardial infarction (both aortic tumors), previous stroke (mitral tumor), and preventive (tricuspid tumor). RESULTS: Surgical excision with a conservative, valve-sparing approach was performed in all cases. For the first aortic tumor, the aortic valve was reconstructed with a patch of autologous pericardium. None of the patients had evidence of valvular regurgitation after excision on intraoperative transesophageal echocardiography, and all had an uneventful recovery. There were no cases of recurrence or regurgitation on follow up echocardiography. CONCLUSION: PFE is an uncommon but increasingly recognized cause of embolic phenomena. Prompt identification allows for surgical excision, which seems to be curative, safe and well-tolerated. A conservative valve-sparing approach is recommended because of the absence of recurrence after total excision.     

Transient decrease of neutrophil chemotaxis following aerobic exercise

PURPOSE: Intense exercise affects the immune system, increasing the susceptibility of athletes to viral and bacterial infections. We have previously shown a significant decrease of fMLP-neutrophil migration 24 h after aerobic exercise. In this study we aimed to look at the differential effect of different chemoattractants on neutrophil migration following aerobic exercise, to determine the recovery time, and to better understand the role of the cell skeleton behind the impaired chemotaxis. METHODS: Sixteen female volunteers aged 22-30 yr were tested before, 24, and 48 h after aerobic exercise (30 min running at 70% (.)VO(2max). The submaximal exercise test was conducted a week after the (.)VO(2max) test.We studied the membrane cell receptor response to fMLP, IL-8, and C5a, which have specific ligand-receptor pathways. Further, we studied the cytoskeletal response by investigating the cell polarization and the F-actin polymerization. RESULTS: Significant decrease of the neutrophil net chemotaxis was detected with fMLP, IL-8 and C5a, 24 h after exercise (50 +/- 5%, P = 0.0001; 48 +/- 12%, P = 0.0015; and 32 +/- 11%, P = 0.011, respectively). Complete recovery was observed within 48 h with all chemoattractants. Normal neutrophil random migration and F-actin polymerization were found. Decreased neutrophil polarization was detected (46 +/- 6% vs 22 +/- 8% of polarized cells, before and after effort, respectively; P = 0.004). Correlation between polarization and chemotactic migration was found (r = 0.945; P = 0.001). CONCLUSIONS: The impaired chemotactic response, observed 24 h after exercise, was similar using different chemoattractants. This finding indicates a possible exercise-induced effect on a common factor at the ligand-receptor level. The abnormal cell polarization indicates skeletal dysfunction that should be further investigated and elucidated. The normal fMLP-stimulated-F-actin polymerization reflects an adequate pathway of signal transduction for the formyl peptide.     

Bilateral renal calculi: assessment of staged v synchronous percutaneous nephrolithotomy

BACKGROUND AND PURPOSE: Percutaneous stone removal has replaced open renal surgery and has become the treatment of choice for large or complex renal calculi. However, patients with large bilateral stone burdens still present a challenge. Simultaneous bilateral percutaneous nephrolithotomy (PCNL) has been demonstrated to be a well-tolerated, safe, cost-effective, and expeditious treatment. We present what is, to our knowledge, the first large retrospective series comparing synchronous and asynchronous bilateral PCNL. PATIENTS AND METHODS: A chart review was performed on 26 patients undergoing 57 PCNLs for bilateral renal calculi over a 7-year period. Seven patients received synchronous PCNL (same anesthesia; Group 1), and 19 patients underwent asynchronous PNL (procedures separated by 1-3 months; Group 2). Complete surgical and hospital records were available on all patients. The average stone burden for Group 1 was 8.03 cm(2) on the left and 9.18 cm(2) on the right v 10.1 cm(2) on the left and 14.23 cm(2) on the right for Group 2 (P> 0.05). Variables of interest included anesthesia time, operative time, blood loss, transfusion rates, length of hospital stay, and complication rates. Each variable was evaluated per operation and per renal unit. Follow-up imaging with stone assessment was available on 20 patients. RESULTS: Group 1 required 1.14 access tracts per renal unit to attempt complete clearance of the targeted stones v 1.88 tracts per renal unit in Group 2 (P> 0.05). The average operative time per renal unit was significantly less in Group 1 (83 minutes) than in Group 2 (168.5 minutes) (P< 0.0001), as was blood loss (178.5 mL v 307.4 mL, respectively; P= 0.02). However, blood loss per operation was similar at 357 mL in Group 1 and 282 mL in Group 2. Comparable transfusion rates of 28.6% and 36.8%, respectively, were noted. Forty percent of the patients in Group 1 were completely stone free compared with 36% of the patients in Group 2; however, an additional 50% and 57%, respectively, had residual stone burden <4 mm (P> 0.05). Complications occurred in 2 of 7 operations (28%) in Group 1 and 8 of 42 operations (19%) in Group 2. The total length of hospital stay was nearly doubled for patients undergoing staged PCNL (P= 0.0005). CONCLUSIONS: These results demonstrate similar stone-free rates, blood loss per operation, and transfusion rates for simultaneous and staged bilateral PCNL. The reduced total operative time, hospital stay, and total blood loss, along with the requirement for only one anesthesia, makes synchronous bilateral PCNL an attractive option for select individuals. However, in patients with larger, less easily accessible stones, excessive bleeding may be encountered more frequently on the first side, thereby delaying management of the second side to a later date. Synchronous bilateral PCNL should be considered in patients in whom the first stage of stone removal is accomplished quickly and safely.     

Clinical and radiographic features mimicking pulmonary embolism as the first manifestation of Takayasu’s arteritis

The current report describes a female patient with Takayasus arteritis who was hospitalized because of respiratory complaints and a ventilation-perfusion (V/P) scan demonstrating severe perfusion defects with normal ventilation. Her symptoms and V/P scan results were initially interpreted as massive pulmonary embolism, but a spiral computed tomography (CT) of the chest and a repeated lung scan indicated inflammatory involvement of the pulmonary artery accounting for the positive lung scan study. Review of her medical records from 17 years ago revealed that similar symptoms and a positive V/P scan were the initial features of her disease.     

Deep brain stimulation for movement disorders

Movement disorders remain the primary indication for the use of intracranial neurostimulation techniques. This review will discuss the history of this technology as well as the mechanisms of action, current clinical indications, and future prospects for the treatment of movement disorders.     

Urinary tract infection in very low birth weight preterm infants

BACKGROUND: The prevalence of urinary tract infection (UTI) in preterm neonates ranges between 4 and 25%. The need for a radiologic investigation has not yet been established in very low birth weight premature newborns (<1500 g birth weight). PATIENTS AND METHODS: For an 11-year period (1990 to 2001), medical records of 62 very low birth weight premature infants admitted to a Level III neonatal intensive care unit and who developed UTI were reviewed retrospectively. Results of renal ultrasound and voiding cystourethrograms were compared between extremely low birth weight infants (birth weight, <1000 g) (Group A, Patient 34) and premature infants with birth weight between 1001 and 1500 g (Group B, Patient 28). RESULTS: UTI was more common in Group A (12.2%) than in Group B (5.7%) infants. Renal ultrasound detected mild renal pelvic dilatation (unilateral or bilateral) in 9 infants in Group A (26%) and in 1 infant in Group B (3.5%). Voiding cystourethrograms were performed in 26 of 34 (76%) infants in Group A and in 17 of the 28 (61%) premature infants in Group B. Vesicourethral reflux (VUR) was observed in 6 infants, 2 in group A (7.7%) and 4 in Group B (23%). CONCLUSIONS: We found that the rate of VUR was lower in very low birth weight premature newborns than that reported in the medical literature among term newborns who developed UTI. VUR was less frequent in extremely low birth weight infants who developed UTI than in infants weighing 1001 to 1500 g.     

Quantitative ultrasound of the tibia and radius in prepubertal and early-pubertal female athletes

BACKGROUND: Physical exercise during childhood has been shown to enhance bone mineral density, thus reducing the risk of osteoporosis. OBJECTIVE: To examine bone properties, as measured by quantitative ultrasound, in prepubertal and early-pubertal female athletes engaged in impact and nonimpact sports. DESIGN: Survey. SETTING: General community. PARTICIPANTS: Twenty-five acrobatic gymnasts, 21 swimmers, and 21 control subjects. Athletes had been training for at least 1(1/2) years. MAIN OUTCOME MEASURE: Bone speed of sound (bilateral) at the distal radius and the midtibia. RESULTS: Gymnasts were significantly shorter and lighter than swimmers and control girls (P<.001) but had a body mass index similar to that of swimmers. Adiposity was lower in athletes than in controls. Speed of sound did not correlate with measures of body size. Higher mean +/- SD radial speed of sound values (nondominant side) were observed in gymnasts (3764 +/- 104 m/s; P =.045) than in swimmers and control girls (3732 +/- 99 and 3721 +/- 83 m/s, respectively). Mean +/- SD tibial speed of sound values (nondominant side) were similar in gymnasts and swimmers (3629 +/- 87 and 3619 +/- 78 m/s, respectively) and higher in the athletic groups than in the control group (3516 +/- 127 m/s; P<.001). In all 3 groups, no differences were observed between dominant and nondominant sides in the radii or tibias. CONCLUSIONS: Physical exercise, impact and nonimpact, is related to enhanced bone properties, as measured by quantitative ultrasound. Longitudinal studies using various modes of bone evaluation are necessary to determine the long-term effect of various types of exercise on bone properties.     

Exercise training, menstrual irregularities and bone development in children and adolescents

Weight bearing physical activity plays an important role in bone development. This is particularly important in children and adolescents since bone mineral density reaches about 90% of its peak by the end of the second decade, and because about one quarter of adult bone is accumulated during the two years surrounding the peak bone growth velocity. Recent studies suggested that the exercise-induced increase in bone mineralization is maturity dependent, and that there is a "window of opportunity" and a critical period for bone response to weight bearing exercise during early puberty and premenarchal years. This supports the idea that increase in physical activity during childhood and adolescence can prevent bone disorders (like osteoporosis) later in life. In contrast, strenuous physical activity may affect the female reproductive system and lead to "athletic amenorrhea". The prevalence of "athletic amenorrhea" is 4-20 times higher than the general population. As a consequence, bone demineralization may develop with increased risk of skeletal fragility, fractures, vertebral instability, and curvature. Menstrual abnormalities in the female athlete result from hypothalamic suppression of the spontaneous pulsatile secretion of gonadotropin releasing hormone. Recent studies suggested that reduced energy availability (increased energy expenditure with inadequate caloric intake) is the main cause of the central suppression of the hypothalamic pituitary-gonadal axis. Therefore, effort should be made to optimize the nutritional state of female athletes, and if not successful, to reduce the training load in order to prevent menstrual abnormalities, and deleterious bone effects in particular during the critical period of rapid bone growth.