MR breast screening in patients with genetic mutation

PURPOSE: To compare screening breast MRI with conventional screening techniques in high-risk patients with genetic mutation. MATERIALS AND METHODS: Prospective study of 85 patients (mean age of 43 years) with genetic mutation and screening > or = 2 years (mean of 2.7 years, 231 screening examinations). BI-RADS lesions 3-5 were biopsied; isolated BI-RADS 3 lesions on MRI were followed. Results from both techniques were compared. The number of short interval follow-up examinations and biopsy results were reviewed. RESULTS: Eight cancers were diagnosed (3 in situ, 5 invasive carcinomas including an interval cancer, mean size of 14 mm). The sensitivity values for mammography, US and MRI were 12.5%, 50% and 95%, and specificity values were 98.7%, 97.3% and 94.8% respectively. Nineteen short interval follow-up MRI examinations were performed (19%): 14% of patients at initial screening and 5% and 6% at the the second and third screenings. Thirty-two biopsies were performed in 17 patients, including 18 after MRI (PPV of cytology: 30%, and biopsy: 58%). CONCLUSION: Our results confirm the value of MRI for screening of high-risk patients with genetic mutation.     

Surgical repair for degenerative and rheumatic mitral valve disease. Operative and mid-term results

BACKGROUND: Non randomized studies suggest that mitral valve repair for rheumatic disease is technically more difficult than repair for degenerative disease, and that operative and late results are worse. New surgical techniques have been developed in our and other institutes during the last 5 years, and this moved us to review the experience with these two pathologies and to compare the operative and mid-term RESULTS: METHODS: From March 1996 to September 1997, 66 patients underwent primary mitral valve repair for treatment of degenerative or rheumatic disease. Fifty-two patients (79%) were in the former group (group A) and 14 in the latter (group B). Surgery was performed by 2 experienced cardiac surgeons. A new technique to calculate the exact artificial chordae length was introduced. In 2 cases, tricuspid autografts were transposed to mitral position and reinforced with artificial chordae. Patients were followed both clinically and echocardiographically. The follow-up data were collected in a 1-month period (May 2000). The average clinical follow-up was 3.1+/-0.9 years (range 1.7 to 4.2 years) while the average echocardiographic follow-up was 2.7+/-0.7 years (range 9 months to 4 years). All values were expressed by means of the average and standard deviation. chi(2) and Student's "t"-test were used to analyze the significance between variables. The Kaplan-Meyer method was used for actuarial statistics. RESULTS: There were no operative deaths in either group. In group A, 1 patient underwent a second surgical repair 1 week later, successfully. In group B no patients underwent reoperation within 30 days or during the initial hospitalization. At follow-up of group A there were the following events: deaths from cancer (n=2), endocarditis (n=1), aortic dissection (n=1). At follow-up of group B there were mitral valve replacement (1 year after first operation, n=1), Ross procedure (n=1), ischemic heart failure (n=1). Among the remaining 62 patients followed, 32 were in NYHA class I, 15 in class II, 3 in class III, and none in class IV, in group A. In group B, 7 patients were in class I, 4 in class II, 1 in class III and none in class IV (p=ns). In group A mitral regurgitation was absent in 23 patients, mild in 21, moderate in 6, while in group B it was absent in 4, mild in 6, and moderate in 2 (p=ns). In both groups there were no cases of severe insufficiency. The mean gradient was 1.1+/-1.7 mmHg in group A (median=0), and 2.4+/-3.1 mmHg in group B (median=0), (p=ns). No case of systolic anterior movement was seen at mid-term. The event free-survival rate was 92.8% in group A and 92.3% in B. CONCLUSIONS: Perfecting and innovation of surgical techniques make possible nowadays to reach good and equivalent operative and mid-term results in both pathologies.     

Minimally invasive approach to Boerhaave’s syndrome

Background: Boerhaave's syndrome requires urgent thoracotomy, laparotomy, or both for esophageal repair and pleuromediastinal debridement. Minimally invasive techniques may be suitable alternatives. Material and methods: Over a period of 12 months, three patients with spontaneous esophageal perforations after forceful vomiting were treated by a combination of minimally invasive techniques including laparoscopy, thoracoscopy, mediastinoscopy, and endoscopic stenting. Results: Esophageal repair was performed transhiatally via laparoscopy using primary suture, primary suture reinforced by a fundic patch, and fundic patch alone in one patient each. One patient had a second perforation of the proximal esophagus, which was sutured through a cervical incision. This patient successfully underwent secondary endoscopic stenting for a persistent esophageal fistula. Mediastinal debridement was performed transhiatally and also by means of a mediastinoscope introduced via the cervical incision in one patient. One patient required secondary thoracoscopic debridement of a pleural empyema but died of sepsis after 1 month. The two other patients recovered and were discharged from the hospital after 2 and 8 weeks, respectively. Conlusions: Boerhaave's syndrome is amenable to minimally invasive techniques. Avoidance of a formal thoracotomy with its resulting morbidity could be of considerable benefit to these critically ill patients.     

Primary hydatid cyst of the retroperitoneum

Retroperitoneal contamination may occur during the natural history of hydatid disease. Primary hydatid cyst of the retroperitoneum is extremely rare. The authors report a case of a giant retroperitoneal hydatid cyst. Clinicians and surgeons must be aware of this possibility and follow a policy of nonsystematic puncture of an abdominal cyst and avoid spillage during surgery. Symptoms are related to the size, location, or ensuing complications of a cyst. Its occurrence should be strongly suspected ahead of any abdominal cyst, especially in an endemic area, where it may act as a parasite. Total and careful surgical excision is the gold-standard therapy.     

Activity of fin muscles and fin motoneurons during swimming motor pattern in the lamprey

Coordination of motoneuron activity is a fundamental prerequisite for the generation of functional locomotor patterns. We investigate the neural mechanisms that coordinate activity of motoneuron pools in the vertebrate spinal cord with differing phases of activity in the locomotor cycle in a simple motor system, the lamprey swimming network. In the region of dorsal fins the lamprey spinal cord contains two groups of motoneurons: the myotomal motoneurons that innervate the trunk muscles; and the fin motoneurons controlling muscle fibres of the dorsal fins. We investigated the activity of fin muscles during swimming in vivo and that of fin motoneurons during fictive swimming in vitro. During swimming in vivo with cycle periods of 4-8 Hz, fin muscle activity covered a broad portion of the cycle, with the peak of activity out-of-phase to the ipsilateral myotomal muscles. During fictive swimming evoked by N-methyl-d-aspartate in the isolated spinal cord, fin motoneurons expressed similar out-of-phase activity. The phase relationship of the synaptic drive to fin motoneurons was examined by recording their activity intracellular during fictive swimming. Three different forms of membrane potential oscillation with different time courses in the locomotor cycle could be distinguished. Sagittal lesions of the spinal cord in the segment where fin motoneurons are recorded and up to one segment rostral and caudal from it did not influence the out-of-phase activity pattern of the motoneurons. Our results indicate that coordination of fin motoneuron activity with the locomotor activity of myotomal motoneurons does not depend on intrasegmental contralateral premotor elements.     

Adult spinal cord injury with no radiographic bone lesion: analysis of nine consecutive patients

Background

Spinal cord injury with no radiographic bone lesion described as spinal cord injury without radiographic abnormality (SCIWORA) in childhood is less often reported in adults than in children. This study was undertaken to report our experience in the management of nine cases over 25 years.

Patients and methods

This was a retrospective study from 1985 to 2009 concerning nine adult patients who sustained spinal cord injury with no radiographic abnormality. The ratio among all cervical spine traumas for the same period was 2.21%. Magnetic resonance imaging (MRI) was performed in all the patients. The patients’ clinical status at the time of admission and discharge was evaluated using the Frankel's grading system. We report the results based on the clinical, epidemiologic and radiological findings and outcomes.

Results

The mean age of our population was 37.43 years, ranging from 18 to 60 years. All the patients were men. The main etiology was falls (5/9) followed by road traffic accidents (4/9). According to the Frankel's grading system, four patients (44.45%) were grade A, four were grade B (44.45%), and one was grade C (11.11%). On MRI, medullar lesions were: contusion, non-compressive cervical disc herniation, cervical spine stenosis, and two cases of normal cervical spine. Four patients were operated on via the posterior cervical spine approach (laminectomy, C3-C7 in three cases and C1-C3 in one case). The other five patients were treated orthopaedically for 6 to 8 weeks. Three patients (3/9), who were Frankel's grade B and C with no demonstrable injury on MRI, improved to Frankel a useful neurological grade (Frankel's grades D or E) at the time of discharge. One patient evaluated as Frankel's grade A died from cardiovascular disturbance.

Conclusion

Spinal cord injury with no radiographic abnormality accounted for 2.21% of cases of spinal cord injury in our series. MRI is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to identify surgically correctable abnormalities.     

Aesthetic vermilion reconstruction of a post-involuted hemangioma scar

The author describes a technique for vermilion reconstruction after excision of an involuted hemangioma scar in the upper lip in an adult female patient. Reconstruction was achieved by making use of all the available vermilion tissue remaining after a triangular excision of the scar. The incision is in the form of a horizontal “K” with extended limbs and repair by advancing and interdigitating the two medial and lateral triangular vermilion flaps with a final Z-shaped suture line. The advancement is like a modified double opposing Y–V plasty. This was complemented by a simple Z-plasty of the labial mucosa to correct an existing notch and deficiency of the free mucosal border. The aesthetic result was excellent; thus, its use can be considered when closing any similar defects resulting from scars or small benign lesion excisions.     

MIB-1 index, S-phase fraction, mitotic figure count, and SBR histologic grading in invasive breast carcinoma: a comparative study

Abstract: Proliferative activity has been proven to be of prognostic significance in breast carcinoma. This study was performed to compare the different proliferative fractions in the Egyptian population and to define the most suitable one for daily routine use in our surgical pathology laboratories. The proliferative activity of 63 invasive ductal carcinomas was evaluated by immunohistochemical staining of paraffin-embedded tissue sections with MIB-1 rabbit polyclonal antibody and the heat-induced epitope retrieval method, flow cytometric determination of the S-phase fraction (SPF) on frozen tissues, and estimation of the Scarff–Bloom–Richardson (SBR) grading and mitotic figure count (MFC) on hematoxylin and eosin-stained tissue sections. Fifty-two percent of invasive ductal carcinoma were aneuploid. The mean values of MIB-1 index, SPF, and MFC were 17.7 ± 12.3, 4.9 ± 3.8, and 5.2 ± 4.5, respectively, for diploid tumors; while for aneuploid tumors, they were 58.6 ± 31.9, 19.9 ± 12.2, and 23.1 ± 16.9, respectively. These values were significantly higher in aneuploid versus diploid tumors (p < 0.0001). A close correlation was found between MIB-1 index, SPF, MFC, and SBR grading (p < 0.0001). In conclusion, in surgical pathology laboratories that cannot afford the costs of flow cytometry and/or immunostaining, proper SBR grading and MFC can provide an estimation of the proliferation fraction similar to the flow cytometric SPF and MIB-1 immunostaining.     

Cortical Na+,K+-ATPase activity, abundance and distribution after in vivo renal ischemia without reperfusion in rats

The aim of our work was to study the changes in activity, abundance and distribution of sodium, potassium-adenosine triphosphatase (Na+,K+-ATPase) in membranes of cortical tubular cells in an in vivo model of ischemic injury without reperfusion. Na+,K+-ATPase, alkaline phosphatase (AP) activities and their distribution in membranes isolated from renal cortex using a Percoll gradient were studied after different ischemic periods. Na+,K+-ATPase alpha-subunit protein abundance was analysed by Western-blot. Plasma urea and cortical adenosine 5' triphosphate (ATP) were also measured. In cortical homogenates 5 min of ischemia promoted a diminution in ATP content. Na+,K+-ATPase activity diminished after 40 min and AP after 100 min of ischemia. Na+,K+-ATPase activity in the Percoll gradient fractions after 5 min peaked at a higher density and was significantly decreased after 40 min. AP activity was decreased in typically enriched apical membranes after both times of ischemia. At each time studied Na+,K+-ATPase abundance was increased in cortical homogenates and membranes. Our results showed opposite effects of ischemia on Na+,K+-ATPase activity and abundance. Increased levels of Na+,K+-ATPase protein were observed. The enzyme would be rapidly delivered to membrane domains and become inactivated as ischemia persists.     

Effects of a new cardiomyoplasty technique on cardiac function

OBJECTIVE: The current cardiomyoplasty technique was modified to maintain the resting tension of the latissimus dorsi muscle and to prevent lateral movement of the heart during muscle stimulation. The aim of this study is to compare the short term hemodynamic effects of the new cardiomyoplasty wrap (W1) with those of the clinically applied cardiomyoplasty wrap (W2). Preliminary indications of the long-term hemodynamic effects of W1 are presented. METHODS: In three acute experiments in sheep mean central venous pressure (MCVP), mean arterial pressure (MAP), mean cardiac output (MCOP), mean left ventricular systolic pressure (MLVSP), and mean left ventricular diastolic pressure (MLVDP) were measured for 30s before and five minutes after applying each procedure with and without stimulation of the muscle graft. The same parameters were also recorded 5min after removing each muscle wrap. Hemodynamic changes associated with unstimulated muscle wraps were compared to the baseline data. Hemodynamic effects of muscle stimulation were determined by comparing the assisted to the preceding unassisted cardiac cycle. The long-term effects of W1 on the hemodynamics of another three sheep were studied at 6-12months after the operation. The viability of the muscles used in the chronic experiments were evaluated by morphometric analysis. RESULTS: Unstimulated W2 significantly increased mean central venous pressure and reduced mean cardiac output. It also increased mean left ventricular diastolic pressure and reduced peak negative dP/dt. Unstimulated W1 had no deleterious effect on mean central venous pressure, mean left ventricular diastolic pressure or peak -dP/dt, but it also reduced mean cardiac output and increased mean left atrial pressure (MLAP). Synchronised muscle stimulation, in both techniques, augmented the mean arterial pressure, mean cardiac output and mean left ventricular systolic pressure. In W2, however, myostimulation was also associated with a significant increase of the mean left ventricular diastolic pressure. In two long-term experiments significant hemodynamic assistance was observed at 6months and at 1yr after W1. In those sheep 68% of the cross-sectional area of the muscle was well preserved. CONCLUSIONS: Unstimulated cardiomyoplasty wraps acutely impair left ventricular function in sheep. The new technique, however, may offer significant long-term hemodynamic assistance and adequate preservation of the structural and functional integrity of the muscle flap for up to 1yr.