Noncontact mapping for radiofrequency ablation of complex cardiac arrhythmias

Radiofrequency (RF) catheter ablation is the current treatment of choice for several cardiac arrhythmias. The conventional approach utilizing intracardiac electrograms during sinus rhythm and during tachycardia has inherent limitations, including limited two-dimensional fluoroscopic imaging and limited ability to evaluate several potential sites for ablation then go precisely to the most suitable site. Recently, a noncontact mapping system has been developed that can be used to perform single beat high resolution mapping of cardiac arrhythmias. In this report, we describe the advantage of utilizing the system in facilitating a successful outcome in 5 patients with different complex arrhythmias.

Fine needle aspiration cytology of sclerosing lobular hyperplasia of the breast: a case report

BACKGROUND

Sclerosing lobular hyperplasia presenting as a palpable, circumscribed nodular mass in a young female's breast is characterized histologically by prominent hyperplasia of the lobules and sclerosis of the intralobular connective tissue. The cytomorphologic features and differential diagnosis of the lesion are presented.

CASE

A 14-year-old female presented with a painless, progressively increasing, nodular, firm, mobile lump measuring 5 x 5 cm in the right breast. The clinical and radiologic diagnosis was fibroadenoma. Fine needle aspiration smears showed a clean background with uniform, round to oval epithelial cells in flat sheets, round clusters and rosettelike (acinar) arrangements. A few naked nuclei were present, while stromal fragments were not seen.

CONCLUSION

When analyzed in the context of the clinical findings, the cytologic features of sclerosing lobular hyperplasia help to differentiate it from other benign palpable nodular lesions of the juvenile breast.

Effect of prophylactic ondansetron on postoperative nausea and vomiting after elective craniotomy

This prospective, randomized, placebo-controlled, double-blind study was designed to evaluate the efficacy of ondansetron, a 5-HT3 antagonist, in preventing postoperative nausea and vomiting (PONV) after elective craniotomy in adult patients. The authors also tried to discover certain predictors for postcraniotomy nausea and vomiting. We studied 170 ASA physical status I and II patients, aged 15 to 70 years, undergoing elective craniotomy for resecting various intracranial tumors and vascular lesions. A standardized anesthesia technique and postoperative analgesia were used for all patients. Patients were divided into two groups and received either saline placebo (Group 1) or ondansetron 4 mg (Group 2) intravenously at the time of dural closure. Patients were extubated at the end of surgery and episodes of nausea and vomiting were noted for 24 hours postoperatively in the neurosurgical intensive care unit. Demographic data, duration of surgery, and anesthesia and analgesic requirements were comparable in both groups. Overall, a 24-hour incidence of postoperative emesis was significantly reduced in patients who received ondansetron compared with those who received a saline placebo (39% in Group 1 and 11% in Group 2, P = .001). There was a significant reduction in the frequency of emetic episodes and rescue antiemetic requirement in patients treated with ondansetron; however, ondansetron did not significantly reduce the incidence of nausea alone (14% in Group 2 vs 5% in Group 1, P = .065). Prophylactic ondansetron had a favorable influence on PONV outcome measures such as patient satisfaction and number needed to prevent emesis (3.5). Side effects were similar in both groups. We conclude that ondansetron 4 mg given at the time of dural closure is safe and effective in preventing emetic episodes after elective craniotomy in adult patients.

Extraocular muscle cysticercosis presenting as Brown syndrome

PURPOSE

Report of a case of acquired Brown syndrome caused by infestation of the superior oblique muscle by Cysticercus cellulosae.

METHOD

Case seen in a referral practice. A 20-year-old man presented with recurrent attacks of conjunctivitis and diplopia in upgaze. Clinical examination of ocular motility established a diagnosis of acquired Brown syndrome of the right eye. Computed tomography of the right orbit unequivocally established the diagnosis of superior oblique muscle cysticercosis. The patient was started on systemic steroids and albendazole in the prescribed doses for a month.

RESULT

Serial computed tomography scans of the orbit revealed resolution of the cystic lesion after a month. Clinically, although there was restoration of ocular motility in upgaze, mild restriction of movement of the right eye in levoelevation persisted. However, the patient was symptomatically better with amelioration of the recurrent conjunctivitis and diplopia in primary gaze.

CONCLUSION

Extraocular muscle cysticercosis should be considered in the differential diagnosis of acquired motility disorder. The presentation of extraocular muscle cysticercosis as an acquired Brown syndrome is unusual. Response to medical therapy was satisfactory.

Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.

Endocardial noncontact activation mapping of idiopathic left ventricular tachycardia

Idiopathic left ventricular tachycardia with a right bundle, left-axis deviation is thought to originate from posterior fascicles. Recently, there has been considerable interest in the anatomic and mechanistic basis of this arrhythmia. We report our experience with a 26-year-old man in whom new noncontact mapping technology was used to acquire detailed data from the left ventricle, identify the mid-diastolic potential and part of the ventricular tachycardia circuit, and perform successful ablation. This information helped define the physiologic aspects of this unique tachycardia.

Malakoplakia of the appendix. An unusual association with eggs of Taenia species

Malakoplakia of the appendix is an unusual condition that has been reported to occur in association with tumors, infections, and immunocompromised states. We describe a case of appendicular malakoplakia associated with eggs of Taenia species. The diagnosis was made on histopathologic examination of surgically resected tissue from an appendicular mass. To the best of our knowledge, this is the first time that helminths have been documented to be associated with malakoplakia. We also discuss the implications of helminthic infestation in the pathogenesis of the lesion.

Sonographic diagnosis of congenital tuberculosis: an experience with four cases

Abdominal sonography of four infants with pyrexia and hepatomegaly demonstrated multiple hypoechoeic hepatic and splenic foci, guided biopsies of which showed caseating granulomas with acid-fast bacilli. Evidence of tuberculosis in maternal endometrium and its exclusion in the contacts further confirmed a diagnosis of congenital tuberculosis. Clinical suspicion supplemented by careful sonography facilitated early detection and antemortem diagnosis of this potentially fatal disease.

Dobutamine-atropine stress echocardiography and dipyridamole sestamibi scintigraphy for the detection of coronary artery disease: limitations and concordance

OBJECTIVES

We sought to compare dobutamine-atropine stress echocardiography (DASE) and dipyridamole Technetium 99-m (Tc-99m) sestamibi single photon emission computed tomography (SPECT) scintigraphy (DMIBI) for detecting coronary artery disease (CAD).

BACKGROUND

Both DASE and DMIBI are effective for evaluating patients for CAD, but their concordance and limitations have not been directly compared.

METHODS

To investigate these aims, patients underwent multistage DASE, DMIBI and coronary angiography within three months. Dobutamine-atropine stress echocardiography and stress-rest DMIBI were performed according to standard techniques and analyzed for their accuracy in predicting the extent of CAD. Segments were assigned to vascular territories according to standard models. Angiography was performed using the Judkin's technique.

RESULTS

The 183 patients (mean age: 60 +/- 11 years, including 50 women) consisted of 64 patients with no coronary disease and 61 with single-, 40 with two- and 18 with three-vessel coronary disease. Dobutamine-atropine stress echocardiography and DMIBI were similarly sensitive (87%, 104/119 and 80%, 95/119, respectively) for the detection of CAD, but DASE was more specific (91%, 58/64 vs. 73%, 47/64, p < 0.01). Sensitivity was similar for the detection of CAD in patients with single-vessel disease (84%, 51/61 vs. 74%, 45/61, respectively) and multivessel disease (91%, 53/58 vs. 86%, 50/58, respectively). Multiple wall motion abnormalities and perfusion defects were similarly sensitive for multivessel disease (72%, 42/58 vs. 66%, 38/53, respectively), but, again, DASE was more specific than DMIBI (95%, 119/125 vs. 76%, 95/125, respectively, p < 0.01). Dobutamine-atropine stress echocardiography and DMIBI were moderately concordant for the detection and extent of CAD (Kappa 0.47, p < 0.0001) but were only fairly (Kappa 0.35, p < 0.001) concordant for the type of abnormalities (normal, fixed, ischemia or mixed).

CONCLUSIONS

Dobutamine-atropine stress echocardiography and DMIBI were comparable tests for the detection of CAD. Both were very sensitive for the detection of CAD and moderately sensitive for the extent of disease. The only advantage of DASE was greater specificity, especially for multivessel disease. Dobutamine-atropine stress echocardiography may be advantageous in patients with lower probabilities of CAD.

Electroanatomic mapping to identify breakthrough sites in recurrent typical human flutter

The accuracy of conventional techniques in localizing previous radiofrequency (RF) ablation sites and thus breakthrough sites of recurrent atrial flutter is somewhat limited. We investigated the role of electroanatomic mapping for identifying breakthrough sites or "gaps" at the tricuspid annulus and inferior vena cava (IVC)/eustachian ridge isthmus to help RF ablation in patients with recurrent typical flutter. Twelve patients (8 men, 4 women, age 63 +/- 10 years) with recurrent typical atrial flutter were included in the study. An electroanatomic mapping system (CARTO) was used to create a voltage map and activation and propagation patterns in the right atrium. Detailed voltage, activation, and propagation mapping of the tricuspid annulus and IVC/eustachian ridge isthmus allowed precise identification of gaps in all 12 patients at the tricuspid annulus (eight sites), IVC ridges (two sites), mid-isthmus region (one site), and tricuspid annulus and IVC ridges (one site). Radiofrequency energy directed at these sites eliminated atrial flutter in all 12 patients, confirmed by noninducibility of atrial flutter and demonstration of conduction block during atrial pacing on either side of the lesion lines. During a mean follow-up of 14.8 +/- 3.5 months (range 8-19 months), paroxysmal atrial flutter recurred in only one patient and was subsequently treated with amiodarone, although this had been ineffective prior to ablation. Electroanatomic mapping can precisely identify gaps in the lesion line responsible for breakthrough of recurrent typical atrial flutter at the tricuspid annulus and at the IVC/eustachian ridge isthmus. These sites can be targeted with RF ablation with a high degree of success.

Histological assessment of dermal nerve damage occurring during multidrug therapy for leprosy

This is a prospective histomorphological assessment of dermal innervation in biopsies taken before and after multidrug therapy (MDT) from 41 leprosy patients: 35 borderline tuberculoid (BT), 3 borderline lepromatous (BL), 3 lepromatous (LL). Biopsies of the same lesions taken before commencement (diagnostic therapy) and at the end of therapy (check biopsy) were compared. Hematoxylin and eosin, immunoperoxidase stain for S-100 protein, and the Holmes' silver impregnation method for nerve cells and fibers were used. Skin biopsies were classified as having detectable or undetectable nerves. Of 35 patients with BT leprosy, 17 had no detectable nerves in their diagnostic biopsies; in the check biopsies of 13 of these 17, dermal nerves remained undetectable, in 2 they were S-100 positive but were Holmes negative. Identifiable dermal nerves were present in diagnostic biopsies from 18 patients; in the check biopsies 5 of these 18 had no detectable nerves while in the remaining 13 nerve branches could be detected. The study provides histological documentation of complete damage to dermal innervation in 62.85% (22/35) of patients with BT leprosy, of which 14.28% (5/35) occurred during MDT. Of the patients with detectable dermal innervation at the onset of MDT, 27.7% (5/18) suffered continuing damage during MDT.

Carotid stenting in patients older than 65 years with inoperable carotid artery disease: a single-center experience

Carotid angioplasty and stenting to treat extracranial carotid stenosis is an alternative (as yet not widely accepted) to high-risk surgery, but its safety and efficacy are little known, especially in elderly patients. We reviewed our 3-year experience of treating 100 elderly patients (> 65 years old) considered to be inoperable (76 men, 24 women, mean age 76+/-10 years, mean follow-up 18+/-9.2 months) and present two case histories. Most (85%) were symptomatic (transient ischemic attacks in 60, stroke in 25); 80 had concomitant coronary artery disease (severe in 30 [defined by > 70% stenosis in two or more epicardial coronary arteries or the left main coronary artery]) and 25 had severe left ventricular dysfunction (ejection fraction < or =20%). The procedure was technically successful in all patients; there was one major stroke and no patient died. Postprocedure, 15% had minor complications: reversible neurological deficit (5%), pulmonary edema (3%), prolonged hypotension (3%), vascular access complications (3%), and neck hematoma (1%). Over 90% of patients were discharged home within 24 hr.

Fine needle aspiration cytology of primary extraskeletal myxoid chondrosarcoma. A case report

BACKGROUND

Extraskeletal myxoid chondrosarcoma is a rare soft tissue tumor of the extremities. Since it usually lacks obvious chondroid differentiation on light microscopy, it needs to be distinguished from other myxoid soft tissue sarcomas.

CASE REPORT

The diagnosis of extraskeletal myxoid chondrosarcoma was made on fine needle aspiration in a patient with a swelling in the right calf. Cellular myxoid fragments having round to oval cells with grooved nuclei arranged in a cordlike pattern suggested chondroid differentiation. The diagnosis was confirmed by histopathology.

CONCLUSION

Fine needle aspiration cytology can be diagnostic of extraskeletal myxoid chondrosarcoma even in the absence of obvious chondroid differentiation.

Testicular fine needle aspiration cytology for the diagnosis of azoospermia and oligospermia

OBJECTIVE

To evaluate qualitative and quantitative cytologic features on testicular fine needle aspiration biopsy in the diagnosis of azoospermia and oligospermia and to correlate cytologic and histologic diagnoses.

STUDY DESIGN

In this prospective study, 50 infertile males selected from the infertility clinic of Guru Tegh Bahadur Hospital were studied. Fine needle aspiration cytology (FNAC) smears from both testes of 27 azoospermic and 23 oligospermic patients (sperm count < 10 million per milliliter) were stained with May-Grünwald-Giemsa and Papanicolaou stain. Differential counting of 500 spermatogenic cells was done, and the number of Sertoli cells per 500 germ cells was determined for calculating the spermatic index and Sertoli cell index, respectively. FNAC and testicular biopsy were performed under local anesthesia as a minor surgical procedure.

RESULTS

Six groups were identified on FNAC smears from azoospermic patients: I. normal spermatogenesis (8), II. hypospermatogenesis (2), III. maturation arrest (2), IV. Sertoli cells only (6), V. atrophic pattern (7), and VI. Leydig cell predominance (2). In oligospermic patients two groups were identified: I. those with normal spermatogenesis (4), and II. those with subnormal spermatogenesis (19). Correlation with histopathologic examination was seen in 81.5% azoospermic and 65.2% oligospermic patients.

CONCLUSION

Qualitative and quantitative evaluation of testicular FNAC provides useful information on both azoospermic and oligospermic patients. FNAC performed under local anesthesia is an acceptable outpatient procedure that consistently yields sufficient diagnostic material in all patients.

Atrial fibrillation: epidemiology, mechanisms and management

The incidence of AF, the most common sustained arrhythmia in clinical practice, increases with age and coronary artery disease, hypertension and valvular heart disease are common underlying substrates; however, occasionally, AF may occur without any underlying heart disease. The most widely accepted theory of its mechanism is Moe's multiple wavelet hypothesis, although recent studies are helping to shed light on other mechanisms, including the focal origin of AF in some patients. Most patients experience palpitations, but fatigue, dyspnoea, and dizziness may also occur. Therapy includes prevention of thromboembolism, control of rate, and restoration and maintenance of sinus rhythm. The risks and benefits of each treatment modality need to be assessed according to each patient's circumstances. Unlike other arrhythmias, there is still no highly successful therapy for treating AF. However, significant advances are being made using non-pharmacological approaches to either prevent or cure this troublesome arrhythmia.

Driving safety among patients with neurocardiogenic (vasovagal) syncope

Neurocardiogenic syncope is one of the most common causes of syncope. However, the important issue of driving related injury due to syncope in this population is not well defined. Risk of injury due to syncope while driving and driving behavior was evaluated in 155 consecutive patients (92 women and 63 men; mean age 49 +/- 19 years) with history of syncope in whom hypotension and syncope or presyncope could be provoked during head-up tilt testing. Patients with syncope and positive head-up tilt table test were treated with pharmacological therapy. All participants were asked to fill out a detailed questionnaire regarding any driving related injuries and their driving behavior before tilt table testing and during follow-up. Prior to head-up tilt testing two patients had syncope while driving, and one of these patients had syncope related injury during driving. The mean duration of syncopal episodes was 50 +/- 14 months (range 12-72 months). Of the 155 patients, 52 (34%) had no warning prior to syncope, while 103 (6%) had warning symptoms such as dizziness prior to their clinical syncope. Following a diagnosis of neurocardiogenic syncope established by head-up tilt testing, six patients stopped driving on their own. During a median follow-up of 22 months recurrent syncope occurred in five (3.2%) patients. No patient had syncope or injury during driving. In conclusion, syncope and injury while driving in patients with neurocardiogenic syncope is rare. The precise mechanism of this is unclear but may be related to posture during driving. Consensus among the medical community will be needed to provide specific guidelines in these patients.

'Hot tub folliculitis'. Test the waters--and the patient--for Pseudomonas

A healthy 10-year-old boy presented with a widespread, nonpruritic, pustular rash of 3 days' duration. He reported having no fever, chills, or other systemic symptoms. Physical examination revealed perifollicular pustules concentrated in the swimsuit area, with fewer widely scattered lesions on the trunk and extremities (figure 1). His mother reported that he had bathed in a hot tub on the evening before onset of the rash. A similar rash had developed in two other boys who had bathed with the patient. No laboratory tests or cultures were performed. The patient was empirically treated with erythromycin tablets, 250 mg twice daily for 10 days. His mother was instructed to contact the owners of the hot tub so that it could be properly cleaned and maintained. Within 1 week the rash had completely resolved.

Fine needle aspiration cytology of reactions in leprosy

OBJECTIVE

To define diagnostic cytomorphologic features of reactions in leprosy.

STUDY DESIGN

Part-retrospective, part-prospective, single-blind, controlled study of the applicability of fine needle aspiration cytology in the diagnosis of reactions in leprosy. Cytomorphologic features were compared in 42 clinically diagnosed patients with reactions in leprosy with those in a control group of patients with nonreactional leprosy. The study groups included type 1 and type 2 reactions in 35 and 9 patients, respectively. May-Grünwald-Giemsa and Ziehl-Neelsen staining methods were employed.

RESULTS

Statistically significant (P < .01) cytomorphologic features of type 1 reaction were the presence of fragments of collagen and elastin; giant cells; giant cells exhibiting elastin phagocytosis; loose, epithelioid cell granulomas; and fibroblasts. Type 2 reaction was characterized in aspirates by the presence of an abundance of neutrophils in a background of lepromatous leprosy (P < .01).

CONCLUSION

Criteria that are used in histopathology for the diagnosis of leprosy reactions can be applied satisfactorily to cytologic smears. A good correlation between clinical diagnosis and cytomorphology can be achieved. Multiple-site aspirates from the skin, nerve and lymph nodes are helpful in substantiating the diagnosis.

Diagnosing granulomatous inflammation of the skin. A cytomorphologic approach based on evaluation of cellular reaction patterns

OBJECTIVE

To determine the applicability of recognizing cellular reaction patterns in the cytologic diagnosis of granulomatous inflammation of the skin.

STUDY DESIGN

Prospective. Two hundred seventeen cases of clinically suspected granulomatous dermatitis formed the data for this study. May-Grünwald-Giemsa, Ziehl-Neelsen, periodic acid-Schiff, silver impregnation and Gram staining methods were employed.

RESULTS

Five cytomorphologic patterns of granulomatous inflammation were identified: epithelioid cell granulomas (77), histiocytic granulomas (20), epithelioid cell granulomas with polymorphous exudate (77), foreign body granulomas (3) and fat necrosis with granulomas (9).

CONCLUSION

Correlating clinical presentation with cytomorphologic patterns often yields diagnostic information in the workup of granulomatous inflammation of the skin and frequently obviates the need for biopsy.

Cloning, characterization and serological evaluation of K9 and K26: two related hydrophilic antigens of Leishmania chagasi

We report here the molecular cloning and characterization of two related hydrophilic antigens of Leishmania chagasi. These two antigens have predicted molecular weights of approximately 9 and 26 kDa and detect antibodies in sera of patients with kala-azar (k). Thus, to maintain consistency with nomenclature of the previously described 39 kDa diagnostic antigen of L. chagasi (k39 [1]), these antigens are being referred to as k9 and k26. A significant difference between k9 and k26 is the presence of 11 copies of a 14 amino acid repeat in the open reading frame of k26. The region flanking the repeats of k26 shares a 69% identity with the open reading frame of k9. The recombinant proteins encoded by both antigens are very hydrophilic and show aberrant migration on SDS PAGE. Results of Southern blot analysis reveal that k9 and k26 are conserved to varying degrees among various Leishmania species. Interestingly, the repeat region of k26 is specific to L. chagasi and L. donovani while the flanking region is conserved among several other species. Transcript levels of k26 are significantly upregulated in the amastigote stage of the parasite. Our results show that recombinant K26 is specific in detecting antibodies in infection sera from visceral leishmaniasis (VL) patients. Thus rK26 may complement rK39 in a more accurate diagnosis of VL in the old and the new world.

Interobserver agreement of the Nottingham histologic grading scheme for infiltrating duct carcinoma breast

Interobserver agreement of the histologic grading scheme for infiltrating duct carcinoma (IDC) of breast was assessed. Three pathologists independently evaluated histologic grade using the modified Bloom and Richardson histological grading system on 40 cases of IDC breast. Pairwise K value for agreement ranged from 0.68-0.83 (median 0.68) for histological grade suggesting substantial agreement. Generalized K values were 0.54, 0.34 and 0.36 for tubule formation, nuclear pleomorphism and mitotic count respectively indicating moderate and fair agreement. Similar levels of agreement were obtained specially in the final histologic grade between pathologists routinely reporting histopathology material and one pathologist who was not. This was achieved by use of precise guidelines. The ease with which this grading system could be applied by pathologists on histopathology material will greatly help its acceptability in routine histopathology.