Atrial masses post cardiac transplantation: diagnostic and treatment dilemmas

Atrial masses postcardiac transplant are not well reported and their diagnosis and treatment can be challenging. In the asymptomatic patient, differentiating thrombus from cardiac tumor can sometimes be difficult and the use of multiple imaging modalities is recommended. Accurate diagnosis is imperative to inform a treatment plan that balances the benefits and risks of a medical versus surgical approach. We present three cases of atrial masses postcardiac transplant to illustrate this clinical dilemma.

Spontaneous gastro-pancreatic fistula - a hitherto unknown natural history of IPMN?

Intraductal papillary mucinous neoplasm (IPMN) is a distinct group of benign pancreatic neoplasms often discovered incidentally on imaging. Apart from their malignant potential, little is known about their natural history as most are surgically resected. We report an unusual presentation and possible natural history of IPMN in a patient who refused surgery and hence was on regular follow up.

Utilization rates of neuroradiology across neuroscience specialties in the private office setting: who owns or leases the scanners on which studies are performed?

BACKGROUND AND PURPOSE

Recent literature shows an increasing portion of imaging studies being conducted and interpreted by nonradiologists, especially across the modalities with the highest RVUs. We examined the trends in the Medicare technical charges for private office neuroradiology studies submitted by subspecialists to identify utilization trends among MR and CT scanner owners or lessees over the last decade.

MATERIALS AND METHODS

The number of neuroradiology studies performed on MR and CT machines owned or leased in private offices was determined from the CMS PSPSMF for 1998-2008. Studies billed through technical and global charges were aggregated. Utilization rates and utilization rate CAGRs were computed by specialty and by imaging study.

RESULTS

Between 1998 and 2008, MR studies grew by a factor of 2.5 and CT studies grew by 2.1. In 2008, radiologists charged the technical/global fee in 1,386,669 (56.6%), neurologists in 82,360 (3.4%), neurosurgeons in 29,218 (1.2%), multi/IDTF in 617,933 (25.2%), and other specialists in 334,843 (13.7%) of neuroradiology cases. Changes from the 1998 base rate to the 2008 rate per 1000 Medicare beneficiaries were 24.1 to 39.7 for radiologists, 1.03 to 2.4 for neurologists, 0.15 to 0.84 for neurosurgeons, 2.2 to 17.7 for multi/IDTF, and 1.3 to 9.6 for other specialists. All specialties, except for multi/IDTF, showed greater MR utilization increases than CT. Neurology (CAGR of 10.6%), neurosurgery (22.1%), multi/IDTF (23.2%), and other specialists' (24.6%) MR growth outpaced that of radiology's (5.3%).

CONCLUSIONS

All nonradiologists showed greater overall utilization growth in private office neuroradiology than did radiology. Also, nonradiologists generally showed greater utilization increases in MR than CT. Radiologists' private office neuroradiology technical fee share shrank from 83.6% to 56.6% between 1998 and 2008.

Percutaneous endovascular abdominal aortic aneurysm repair: methods and initial outcomes from the first prospective, multicenter trial

AIM

A totally percutaneous approach to endovascular abdominal aortic aneurysm repair (PEVAR) has been shown in multiple single center reports to be feasible. Nonetheless, questions regarding the broader applicability of the approach remain due to the lack of a randomized multicenter trial, thus preventing more widespread adoption. We report the methods and outcomes from the roll-in phase of the first prospective, multicenter trial of PEVAR.

METHODS

Among 19 institutions participating in the PEVAR Trial (NCT01070069), 38 consecutive patients with abdominal aortic aneurysm were enrolled in a roll-in phase between April 2010 and May 2011. PEVAR procedures with adjunctive "pre-close" of the common femoral arteries (CFAs) targeted for large sheath access using the ProGlide or Prostar XL closure devices were performed using the Endologix IntuiTrak System. All patients were followed periprocedurally and to 30 days for major adverse events and access-related vascular complications.

RESULTS

Patients presented at a mean age of 71 years with mean aneurysm sac diameter of 5.6cm. Technical success of the pre-close procedure was 97% (37/38 patients). In one patient, ProGlide devices failed to achieve ipsilateral CFA hemostasis, leading to bleeding requiring transfusion and surgical vascular repair. All endovascular repairs were successful. No mortality or major adverse events occurred. Other pre-close related complications occurring within 30 days included pseudoaneurysm, lower extremity ischemia, and blood transfusion.

CONCLUSION

PEVAR with adjunctive 'pre-close' techniques using the ProGlide or Prostar XL devices is safe and feasible as applied in this multicenter experience. Continued evaluation in the prospective, randomized trial is warranted.

Tuberculosis infection of the talonavicular joint

Isolated tuberculosis osteomyelitis affecting the foot is extremely rare. Symptoms are nonspecific and haematological investigations are often unhelpful making diagnosis difficult. We report the case of a 41-year-old female who presented with a 7-month history of a painful hindfoot following a minor ankle sprain. Inflammatory markers were mildly raised and initial radiographs showed only some mild narrowing of the talonavicular joint. MRI scanning suggested osteomyelitis centred over the talonavicular joint. Open biopsy confirmed areas of caseous necrosis but no acid-fast bacilli were seen. The final diagnosis was confirmed with culture of mycobacterium tuberculosis. A good recovery was seen following debridement and commencement of anti-tuberculosis chemotherapy. Unless an awareness of this condition exists, the diagnosis and therefore the appropriate treatment can often be delayed which may lead to significant consequences for the patient.

Tobacco and health in India

Tobacco is a well-acknowledged social and health evil. The history of tobacco use traces back to the dawn of human civilization and has been deeply entrenched into the human society since time immemorial. The social, economic, and health impact of tobacco has been a subject of intense debate over the recent decades. For India, this problem has been a unique one, with the consumption patterns either largely influenced by the socioeconomic backgrounds or dictated by the cultural diversity. With more than 200 million tobacco consumers in the country at present, it becomes imperative to address this health hazard and stir up strong measures toward damage control. This article addresses the tobacco problem, its evolution, and the factors that have affected the growth of Indian tobacco industry. It also highlights the current legislative measures against tobacco, fiscal gains to the government, and the serious health and economic impact to the consumer, compounded by the increasing cost of private health care in the present era of consumerism.

Analysis of major complications associated with arterial catheterisation

INTRODUCTION

Arterial catheterisation is used for continuous haemodynamic monitoring in patients undergoing surgery and in critical care units. Although it is considered a safe procedure, a major complication such as arterial occlusion and limb gangrene can occur.

OBJECTIVE

To determine the incidence, outcome and potential to avoid complications associated with arterial catheterisation.

METHODS

The number of arterial catheterisation was determined using an anaesthesiology and critical care medicine billing database over a period of 4 years (1 January 2003 to 31 December 2006). Possible major complications were identified from two hospital databases; all identified charts were screened and then reviewed by an expert panel that determined causation. A major complication was defined as requiring operative intervention and/or resulting in permanent harm.

RESULTS

15 (0.084%) major complications were identified among 17 840 instances of arterial catheterisation insertions. Of 15 arterial catheterisations, nine were performed in the operating room and six in the intensive care unit. Nine patients suffered ischaemic injury, which progressed to gangrene in three patients. Three patients developed haematoma that required surgical evacuation; two of these required vascular repair. One patient had compartment syndrome requiring fasciotomy and two patients had sheared catheter fragments that needed to be removed. All 15 patients had multiple comorbidities, and those in the operating room had an American Society of Anesthesiologists score of >or=3. Seven (46.6%) had arterial catheterisation done under emergent circumstances. Six (40%) died during hospitalisation because of complications unrelated to arterial catheterisation.

CONCLUSION

Arterial catheterisation had a very low rate of major complications. They seem associated with high severity of illness and emergency surgery.

Integrated regional bioengagement framework to combat brucellosis

AIM

To evaluate the current practices in laboratory disease detection, biosafety and biosecurity measures and information-sharing systems available to the public health systems in R. Macedonia and the Balkan region.

METHODS

Epidemiological studies were reviewed from the region to examine the high incidence of localized forms of human brucellosis.

RESULTS

There is clearly a need for the development of a South Eastern European regional network for sharing information aimed at disease surveillance, early reporting and efficient containment of human brucellosis. Given the zoonotic nature of the disease's onset and progression, public health strategies aimed at containing and eventually eliminating human brucellosis require a broader national and regional bioengagement framework that involves human and veterinary diseases detection systems, deployment of medical countermeasures, epidemiology and a supportive laboratory infrastructure, strategic stockpiles and information sharing.

CONCLUSIONS

A systems-centric framework for a national and regional strategy to combat human brucellosis is essential, and should be comprised of: a) a disease threat and surveillance framework at the national and broader regional level, b) laboratory performance evaluation metrics, c) best practices for information-sharing and regional coordination, and d) a coordinated regional strategy to improve biosafety and biosecurity.

Comparison of the effectiveness of music and progressive muscle relaxation for anxiety in COPD—A randomized controlled pilot study

Acute effects of music and relaxation have not been evaluated in hospitalized subjects with chronic obstructive pulmonary disease (COPD). This study aims to evaluate the acute effects of music and progressive muscle relaxation (PMR) in hospitalized COPD subjects after a recent episode of exacerbation. A Randomized controlled study was performed of pre-test post-test design after recruiting 82 COPD subjects from K.M.C hospitals. All patients were admitted for acute exacerbation and were medically stabilized. After being screened for the inclusion and exclusion criteria, 72 subjects were selected for the study. Demographic and baseline data was taken on the day subjects were screened. Music group listened to a self selected music of 60-80 beats per minute for 30 minutes. PMR group practiced relaxation through a pre-recorded audio of instructions of 16 muscle groups. Outcome variables were Spielberger’s state anxiety inventory (SSAI), Spielberger’s trait anxiety inventory (STAI), dyspnea, systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse rate (PR) and respiratory rate (RR). There was statistically significant main effect across the sessions for state anxiety (F = 62.621, p = 0.000), trait anxiety (F = 19.528, p = 0.000), dyspnea ( F = 122.227, p = 0.000), SBP ( F = 63.885, p = 0.000), PR ( F = 115.780, p = 0.000) and RR ( F = 202.977, p = 0.000). There was statistically significant interaction effect between the two groups for state anxiety ( F = 6.024, p = 0.003), trait anxiety ( F = 8.222, p = 0.000), dyspnea ( F = 10.659, p = 0.000), SBP ( F = 12.889, p = 0.000), PR ( F = 4.746, p = 0.008) and RR ( F = 12.078, p = 0.000). There were greater changes observed after the second session in both groups however, change in DBP was not significant in either group. Music and PMR are effective in reducing anxiety and dyspnoea along with physiologic measures such as SBP, PR and RR in two sessions in COPD patients hospitalized with exacerbation. However, reductions in the music group were greater compared to the PMR group.

Mitral valve-sparing procedures and prosthetic heart valve failure: a case report

Prosthetic heart valve dysfunction due to thrombus or pannus formation can be a life-threatening complication. The present report describes a 47-year-old woman who developed valvular cardiomyopathy after chorda-sparing mitral valve replacement, and subsequently underwent heart transplantation for progressive heart failure. The explanted mitral valve prosthesis showed significant thrombus and pannus leading to reduced leaflet mobility and valvular stenosis. The present report illustrates the role of the subvalvular apparatus and pannus in prosthesis dysfunction.

Preconception counseling in the prevention of fetal alcohol syndrome: a unique window of opportunity

The role of alcohol in the causation of Fetal Alcohol Syndrome (FAS) has been firmly established. In most cases events leading to its occurrence have been set into motion prior to conception. Alcohol consumption during pregnancy, the sole causative agent of FAS, can therefore be prevented even prior to conception by implementation of preconception counseling (PCC). The present review examines the important issues involved in the implementation of PCC for the prevention of FAS which can be of immense help to the affected population.

An ultra-sensitive DeltaR/R measurement system for biochemical sensors using piezoresistive micro-cantilevers

Piezoresistive micro-cantilevers are interesting bio-sensing tool whose base resistance value (R) changes by a few parts per million (DeltaR) in deflected conditions. Measuring such a small deviation is always being a challenge due to noise. An advanced and reliable DeltaR/R measurement scheme is presented in this paper which can sense resistance changes down to 6 parts per million. The measurement scheme includes the half-bridge connected micro-cantilevers with mismatch compensation, precision op-amp based filters and amplifiers, and a lock-in amplifier based detector. The input actuating sine wave is applied from a function generator and the output dc voltage is displayed on a digital multimeter. The calibration is performed and instrument sensitivity is calculated. An experimental set-up using a probe station is discussed that demonstrates a combined performance of the measurement system and SU8-polysilicon cantilevers. The deflection sensitivity of such polymeric cantilevers is calculated. The system will be highly useful to detect bio-markers such as myoglobin and troponin that are released in blood during or after heart attacks.

In vitro experiments demonstrate that monocytes and dendritic cells are rendered apoptotic by extracorporeal photochemotherapy, but exhibit unaffected surviving and maturing capacity after 30 Gy gamma irradiation

Extracorporeal photochemotherapy (ECP) has been shown to induce apoptosis in lymphocytes. Until recently the prevailing opinion has been that the monocytes were mainly not affected by this treatment. This study has investigated the effect of ECP and gamma irradiation on monocytes and immature dendritic cells (DC) in vitro and followed the ability of the cells to differentiate and survive post treatment. ECP induced apoptosis in lymphocytes, monocytes and immature DC within 72 h following treatment, in contrast to 30 Gy gamma irradiation, which seemed mainly to affect lymphocytes. The minority of the surviving ECP-treated monocytes presented a reduced ability to differentiate into immature DC within this time frame. We also demonstrated that immature DC after ECP-treatment lost their normal ability to mature on stimulation with lipopolysaccharide. As monocytes and immature DC seem to have a reduced ability to differentiate after ECP-treatment, it is suggested that the therapeutic effect of ECP is caused by in vivo effects of reinfused apoptotic cells, rather than by infusion of monocytes induced to differentiate into immature DC.

Return of Memory and Sleep Efficiency Following Moderate to Severe Closed Head Injury

Objective. Sleep disturbance is common in the subacute recovery phase following brain injury. A previous study from the authors' group found 68% of patients with closed head injury (CHI) had disrupted sleep on a rehabilitation unit. In the present study, the authors investigated whether improvement in sleep efficiency correlates with duration of posttraumatic amnesia (PTA) after CHI. Methods. Fourteen CHI patients were enrolled and followed prospectively. Mechanism of injury included motor vehicle accident, fall, and blunt assault. An actigraph was placed on each subject's wrist within 72 hours of admission to the rehabilitation unit and recorded data for the duration of their stay. A minimum of 7 days of continuous actigraphy data was obtained on all subjects. PTA was measured daily using the Orientation Log (O-LOG). Results. Seventy-eight percent of subjects had mean week-1 sleep efficiency scores of ≤63%. Patients admitted having already cleared PTA had significantly better week-1 sleep efficiency scores than those with ongoing amnesia ( P = .032). For those patients admitted with ongoing PTA, each 10-unit increase in sleep efficiency score correlated with 1 unit increase in O-LOG score ( P = .056). Conclusions. Disrupted sleep is common in the postacute stage following CHI. Improved sleep efficiency correlates with resolution of PTA. Decreased sleep efficiency may negatively affect memory return after traumatic brain injury. Actigraphy is uniquely suited to study the sleep patterns of these patients.