A solitary chest wall metastasis from unknown primary hepatocellular carcinoma

We report a 61-year-old male smoker who was admitted to our hospital for treatment of a moderately growing tumour on the right anterolateral chest wall causing chest pain during coughing. Chest computed tomography and magnetic resonance imaging showed a 55 x 50 mm inhomogeneous mass around the 4th rib but not penetrating the subcutis and lung. Neither a preoperative technetium scintigraphy nor a needle biopsy revealed the primary nature of the tumour. The patient was treated with en bloc resection and partial resection of the adjacent 3rd and 4th rib. The frozen section diagnosis confirmed a metastasis from a primary hepatocellular carcinoma.     

The IST registry

Intracoronary brachytherapy has been established in Europe and the US as an evidence-based treatment of in-stent restenoses. The objective of the IST Registry is to register all patients treated in Germany with intracoronary radiation and to observe the clinical outcome for a duration of 5 years. The required set of data for each patient is kept to a minimum to encourage participation. All data are entered online. In the internet, each participating site can, at any time, check their most important parameters and compare them with those of other sites. Presently, the Novoste System is used in 58 catheter labs and the Guidant System in 16, while several sites use both. The requirements regarding radiation safety in intracoronary application of gamma radiation are very strict in Germany, so the Cordis-Gamma System is used in only one German lab. In a first analysis of 332 radiated stenoses, it was observed that late vessel occlusion could occur even after 6-month administration of clopidogrel (in addition to ASA)--without new stents being implanted within the brachytherapy session. Clopidogrel should thus be administered in addition to aspirin for at least a year. Ca. 270 patients per month receive intracoronary radiation in Germany, so the IST Registry will provide important data regarding long-term observation and a foundation for future negotiations with insurance companies potentially bearing the costs. At present, neither the physician's service nor the material costs are reimbursed. The IST Registry can furthermore be used as a comparative database regarding long-term outcome following implantation of antiproliferative-coated stents.     

Endoscopic sphincterotomy in patients with "acalculus" cholangitis associated with juxtapapillary diverticula

BACKGROUND/AIMS: The aim of this study was to investigate patients who underwent endoscopic sphincterotomy for "acalculus" cholangitis associated with juxtapapillary diverticula. METHODOLOGY: In a retrospective study we analyzed 87 patients who underwent endoscopic sphincterotomy for cholangitis; the cholangitis considered "acalculus", when outlining the extra- and intrahepatic bile ducts, we could not observe any intraluminal defect or stricture, and during the clearing of the bile ducts with the balloon, after endoscopic sphincterotomy, there was no evidence of stones, fragments of stones or sludge. Patients who had undergone previous endoscopic sphincterotomy, or who had additional pancreatobiliary diseases were excluded from this study. There were 11 patients with "acalculus" cholangitis associated with juxtapapillary diverticula, and sufficient clinical data available for this study. RESULTS: Nine patients presented pain, fever, and jaundice. In two patients diagnosis was established via the test of abnormal liver biochemistry. Seven patients had positive blood cultures and three of them developed confusion and hypotension. Endoscopic sphincterotomy succeeded in all cases; no evidence of stones, fragments of stones or sludge was recorded during the clearing of bile ducts, after endoscopic sphincterotomy, with the balloon. Five patients presented mild post-endoscopic sphincterotomy complications successfully treated. In the follow-up period, from 4 months to 7 years after endoscopic sphincterotomy, none of the patients developed symptoms of cholangitis. CONCLUSIONS: We recommend endoscopic sphincterotomy in patients with "acalculus" cholangitis associated with juxtapapillary diverticula, despite the absence of obvious obstruction, and the possible morbidity which is inherent with an invasive procedure like endoscopic sphincterotomy.     

A point mutation in the γ2 subunit of γ-aminobutyric acid type A receptors results in altered benzodiazepine binding site specificity

Benzodiazepines allosterically modulate γ-aminobutyric acid (GABA) evoked chloride currents of γ-aminobutyric acid type A (GABA_A) receptors. Coexpression of either rat γ₂ or γ₃, in combination with α₁ and β₂ subunits, results both in receptors displaying high [³H]Ro 15-1788 affinity. However, receptors containing a γ₃ subunit display a 178-fold reduced affinity to zolpidem as compared with γ₂-containing receptors. Eight chimeras between γ₂ and γ₃ were constructed followed by nine different point mutations in γ₂, each to the homologous amino acid residue found in γ₃. Chimeric or mutant γ subunits were coexpressed with α₁ and β₂ in human embryonic kidney 293 cells to localize amino acid residues responsible for the reduced zolpidem affinity. Substitution of a methionine-to-leucine at position 130 of γ₂ (γ₂M130L) resulted in a 51-fold reduction in zolpidem affinity whereas the affinity to [³H]Ro 15-1788 remained unchanged. The affinity for diazepam was only decreased by about 2-fold. The same mutation resulted in a 9-fold increase in Cl 218872 affinity. A second mutation (γ₂M57I) was found to reduce zolpidem affinity by about 4-fold. Wild-type and γ₂M130L-containing receptors were functionally expressed in Xenopus oocytes. Upon mutation allosteric coupling between agonist and modulatory sites is preserved. Dose–response curves for zolpidem and for diazepam showed that the zolpidem but not the diazepam apparent affinity is drastically reduced. The apparent GABA affinity is not significantly affected by the γ₂M130L mutation. The identified amino acid residues may define part of the benzodiazepine binding pocket of GABA_A receptors. As the modulatory site in the GABA_A receptor is homologous to the GABA site, and to all agonist sites of related receptors, γ₂M130 may either point to a homologous region important for agonist binding in all receptors or define a new region not underlying this principle.     

Changes of Heart Rate Variability After Coronary Bypass Grafting

Background: Heart rate variability (HRV) may serve as a follow-up parameter in patients with coronary artery disease undergoing percutaneous transluminal angioplasty. Several studies have shown significant changes of HRV parameters in the case of restenosis. The value of this method as a prognostic parameter in patients following coronary artery bypass grafting (CABG) is unknown. Methods: In the present study we investigated changes of HRV parameters in patients undergoing CABG to prove whether this method would predict the outcome in these patients. Twenty patients (six female, 14 male, age 51–75 years, mean 62 years) with angiographically documented coronary artery disease (1 × 1-vessel disease, 10 × 2-vessel disease, 9 × 3-vessel disease) were investigated. Eight patients had previous myocardial infarction: 3 × anterior infarction and 5 × inferior infarction. Before and after CABG 24-hour measurement of HRV was performed using Holler monitoring (elapsed time between the two measurements 218 ± 92 days). All patients underwent successful CABG with complete revascularization. The following time domain parameters were calculated: SDNN, SDNN index, SDANN, r-MSSD and pNN50. Results: These parameters showed a significant decrease after CABG (P < 0.05) except rMSSD, which was below the statistic level. The results of the patients without previous myocardial infarction suggested that the parasympathetically influenced paramenters r-MSSD and pNN50 were mainly involved, while in the subgroup with previous myocardial infarction the sympathetically influenced parameters (SDNN, SDANN) were significantly changed. Other variables such as ejection fraction or severity of coronary artery disease did not influence the HRV results. Conclusions: In contratst to patients with revascularization by PTCA, HRV does not seem to be a suitable predictive parameter in patients after successful CABG. Intrinsic operative alterations with injury of cardiac nerves may be responsible for this observation.     

Pre-Dilatation Versus No Pre-Dilatation for Implantation of a Self-Expanding Valve in All Comers Undergoing TAVR: The DIRECT Trial

Objectives

The aim of this study was to compare the implantation of a self-expanding valve with or without balloon aortic valvuloplasty (BAV) in an open-label, noninferiority, randomized trial.

Plasma Levels of Nitrites/Nitrates in Patients with Chronic Atrial Fibrillation are Increased after Electrical Restoration of Sinus Rhythm

Introduction: Patients with persistent atrial fibrillation (AF) have hemodynamic changes, which impair endothelial cell function resulting in decreased nitric oxide (NO) production. The aim of this work was to assess endothelial function in AF patients before and at various time points after cardioversion. Methods: Forty-two patients with AF and 21 normal and age-adjusted healthy controls were studied. Nitrites and nitrates (NO _x ) and von Willebrand factor (vWf) concentrations were measured on blood samples taken just before cardioversion and over a 30 day period after the procedure. Results: Plasma levels of NO _x in AF were significantly lower compared to healthy controls (p < 0.001), but after cardioversion gradually increased to approach to those of the healthy controls by the end of the first month of sustained sinus rhythm (p = 0.004). Interestingly plasma levels of NO _x were negatively correlated to left atrial volume measured by ultrasonography (r = –0.34, p < 0.05). Plasma levels of vWf in AF patients were significantly higher compared to the healthy controls (p < 0.01) but with sustained sinus rhythm decreased (p = 0.02). Conclusion: The parallel normalization of the NO _x titers and vWf levels suggests that vascular endothelial function improves after 30 days of normal sinus rhythm.