Characterization of Pediatric Breast Abscesses and Optimal Treatment: A Retrospective Analysis

BACKGROUND

Literature on pediatric breast abscesses is sparse; therefore, treatment is based on adult literature which has shifted from incision and drainage (I&D) to needle aspiration. However, children may require different treatment due to different risk factors and the presence of a developing breast bud. We sought to characterize pediatric breast abscesses and compare outcomes.

MATERIALS AND METHODS

A retrospective review of patients presenting with a primary breast abscess from January 2008 to December 2018 was conducted. Primary outcome was persistent disease. Antibiotic utilization, treatment required, and risk factors for abscess and recurrence were also assessed. A follow-up survey regarding scarring, deformity, and further procedures was administered. Fisher's exact and Kruskal-Wallis tests for group comparisons and multivariable regression to determine associations with recurrence were performed.

RESULTS

Ninety-six patients were included. The median age was 12.8 y [IQR 4.9, 14.3], 81% were women, and 51% were African-American. Most commonly, patients were treated with antibiotics alone (47%), followed by I&D (27%), and aspiration (26%). Twelve patients (13%) had persistent disease. There was no difference in demographic or clinical characteristics between those with persistent disease and those who responded to initial treatment. The success rates of primary treatment were 80% with antibiotics alone, 90% with aspiration, and 96% with I&D (P = 0.35). The median time to follow-up survey was 6.5 y [IQR 4.4, 8.5]. Four patients who underwent I&D initially reported significant scarring.

CONCLUSIONS

Treatment modality was not associated with persistent disease. A trial of antibiotics alone may be considered to minimize the risk of breast bud damage and adverse cosmetic outcomes with invasive intervention.

Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome

BACKGROUND

Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS.

MATERIALS AND METHODS

We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages.

RESULTS

Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery.

CONCLUSIONS

Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.

Laparoscopic Ladd Procedure for the Management of Malrotation and Volvulus

Introduction: While laparoscopic Ladd procedure is commonly performed in patients with asymptomatic malrotation, a paucity of data exists on children with volvulus or with low weight (≤3 kg). Our purpose was to evaluate the safety and efficacy of the laparoscopic Ladd procedure in these complex patient populations. Methods: A retrospective review of patients undergoing operation for malrotation from 2008 to 2018 was performed. Specific subgroup analysis was performed comparing outcomes after open and laparoscopic approaches in patients presenting with acute volvulus or in low-weight (<3 kg) patients. Results: Out of 110 patients, 38 (35%) presented with volvulus and 72 (65%) without volvulus. In patients with volvulus, 16 (42%) underwent laparoscopy and 22 (58%) had an open procedure. More patients in the open group had a preoperative diagnosis of volvulus (63.6% vs. 12.5%, P = .002). Operative time was longer in the laparoscopic group (87 vs. 61 minutes, P = .029), with 7 patients being converted to an open procedure (44%). Days to regular diet, hospital length of stay, and recurrent volvulus were similar between groups. In patients weighting <3 kg, 10 patients underwent laparoscopy and 10 patients had an open procedure. Demographics, operative time, postoperative outcomes, and complications were similar between groups. One person in the laparoscopic group was converted to open. Conclusion: Laparoscopic management of malrotation, even in the presence of volvulus and low patient weight, is safe and effective, with low rates of recurrent volvulus. If exposure is suboptimal, conversion to open in patients with volvulus should be considered.

Withholding Urinary Catheters in Children Receiving Patient-Controlled Analgesia for Appendicitis

BACKGROUND

In some institutions, urinary catheters (UCs) have been placed in all patients receiving opioid patient-controlled analgesia (PCA) because of the increased incidence of urinary retention. Our institutional data demonstrated no UC replacements in 48 children who had PCA for perforated appendicitis who had their catheters removed before discontinuation of the PCA. As part of a quality improvement initiative, we discontinued the practice of requiring UC with PCA for perforated appendicitis.

MATERIALS AND METHODS

A prospective list of patients with perforated appendicitis was maintained. Data were gathered regarding 60 consecutive patients. UC placement was allowed for specific indications including urinary retention and surgeon discretion.

RESULTS

Sixteen patients (27%) received a UC with 14 of these being placed in the operating room (OR). Two UCs were placed outside the OR for urinary retention. Patients who underwent UC placement in the OR weighed significantly more than those who did not (33 versus 42 kg, P = 0.05). No patients required replacement of the catheter once removed. There were no postoperative urinary tract infections. Median PCA duration was 68 h (50, 98) for patients with UC placed in the OR compared with 60 h (47, 78) (P = 0.42). Median postoperative length of stay for patients with UC placed in the OR was 95 h (76, 140) compared with 90 h (70, 113) (P = 0.09).

CONCLUSIONS

UC can be withheld from patients with perforated appendicitis who are placed on PCA with a very low placement rate. UC placement at time of operation did not lengthen time receiving PCA or length of stay.

The Laparoscopic Versus Open Approach for Reduction of Intussusception in Infants and Children: An Updated Institutional Experience

PURPOSE

We have previously demonstrated successful laparoscopic management after failed enema reduction of children with intussusception. The purpose of this study is to assess the effectiveness of our mature experience with laparoscopic reduction by evaluating operative success, duration of hospital stay, postoperative complications, and hospital readmission rates.

MATERIALS AND METHODS

After IRB approval, a retrospective review was conducted on children (age 0-18 years) who failed enema reduction of intussusception between 2008 and 2017. Cases were classified as either open or laparoscopic. Demographic data, incidence of bowel resection, postoperative length of stay, complications, and hospital readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA with a P value <.05 determined as significant.

RESULTS

A total of 81 children were included in our study with 63 patients (78%) undergoing a laparoscopic reduction and 18 patients (22%) undergoing an open operation. Laparoscopic reduction carried similar complication rates (11%) when compared with children undergoing an open reduction (11%, P = 1.00). Furthermore, both hospital readmission rates and returns to the operating room were similar between the two groups (P = .345 and P = .672, respectively). The median postoperative length of stay was shorter for patients undergoing a laparoscopic reduction (4 days, interquartile range [IQR], 2-5 days) than for patients undergoing an open reduction (5 days, IQR, 4-6 days, P = .001). Children undergoing a laparoscopic reduction had a decreased rate of bowel resection (43% versus 50%, P = .591) despite similar rate of pathological lead points (21% versus 22%, P = .884).

CONCLUSION

Laparoscopic management of intussusception after failed radiographic reduction yields a reduced hospital length of stay with no increase in hospital readmission rates and reoperations.

National study of emergency department visits for acute exacerbation of chronic obstructive pulmonary disease, 1993-2005

OBJECTIVES

Little is known about recent trends in U.S. emergency department (ED) visits for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or about ED management of AECOPD. This study aimed to describe the epidemiology of ED visits for AECOPD and to evaluate concordance with guideline-recommended care.

METHODS

Data were obtained from National Hospital Ambulatory Medical Care Survey (NHAMCS). ED visits for AECOPD, during 1993 to 2005, were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Concordance with guideline recommendations was evaluated using process measures.

RESULTS

Over the 13-year study period, there was an average annual 0.6 million ED visits for AECOPD, and the visit rates for AECOPD were consistently high (3.2 per 1,000 U.S. population; P(trend) = 0.13). The trends in the use of chest radiograph, pulse oximetry, or bronchodilator remained stable (all P(trend) > 0.5). By contrast, the use of systemic corticosteroids increased from 29% in 1993-1994 to 60% in 2005, antibiotics increased from 14% to 42%, and methylxanthines decreased from 15% to <1% (all P(trend) < 0.001). Multivariable analysis showed patients in the South (vs. the Northeast) were less likely to receive systemic corticosteroids (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.9).

CONCLUSIONS

The high burden of ED visits for AECOPD persisted. Overall concordance with guideline-recommended care for AECOPD was moderate, and some emergency treatments had improved over time.

Determination of apurinic/apyrimidinic lesions in DNA with high-performance liquid chromatography and tandem mass spectrometry

A new method has been developed to accurately measure apurinic and apyrimidinic (AP) DNA damage sites, which are lesions in DNA formed by loss of a nucleobase from oxidative stress or carcinogen adducts. If AP sites are left unrepaired (or if improperly repaired), these sites can lead to DNA mutations that may ultimately result in the formation of cancer. Hence, detection of AP sites may provide a useful indicator of exposure and susceptibility to chemical carcinogens and oxidative stress. AP detection is currently accomplished by immunodetection methods using an aldehyde reactive probe [Nakamura, J., Walker, V. E., Upton, P. B., Chiang, S.-Y., Kow, Y. W., and Swenberg, J. A. (1998) Cancer Res. 58, 222-225; Atamna, H., Cheung, I., and Ames, B. N. (2000) Proc. Natl. Acad. Sci. U.S.A. 97, 686-691]; however, these approaches lack the specificity required for unequivocal identification of the AP site. Therefore, we have developed an accurate method based on mass spectrometry detection of AP sites from AP DNA that have been prelabeled with O-4-nitrobenzylhydroxylamine (NBHA). Once labeled and once the excess labeling agent has been removed, enzymatic digestion of DNA to monomeric subunits can be accomplished, followed by isolation and detection with high-performance liquid chromatography coupled to electrospray ionization tandem mass spectrometry (HPLC-ESI-MS/MS). Optimization and validation of the experimental procedures and detection limits have been established using a model DNA oligomer (11-mer) containing uracil. Enzymatic removal of uracil with uracil glycosylase generates well-defined AP sites in both single- and double-stranded DNA. The addition of NBHA labels the AP site in the oligomer, creating a labeled 11-mer. HPLC-ESI-MS/MS in the negative ionization mode was used to monitor and confirm binding of NBHA to the AP oligomer. The NBHA-tagged oligomer underwent endo- and exonuclease digestion to the 5'-deoxyribose monophosphate (5'-dRp) level, thereby releasing free 5'-dRp-NBHA. The 5'-dRp-NBHA product was partially purified by solid phase extraction and quantified by LC-MS/MS using several transitions of the deprotonated molecule ([M - H]- at m/z 363) and isotopically labeled 5'-dRp-NBHA as an internal standard. Further experiments with 5',3'-bisphosphate-deoxyribose and heat/acid-treated calf thymus DNA showed similar labeling, digestion, and detection results. Initial results show a quantification limit with 100 mug of DNA to be 100 fmol (three abasic sites per 10(7) bases).

[Variable response to the biological inhibition of platelets by abciximab in patients subjected to percutaneous coronary angioplasty]

INTRODUCTION AND OBJECTIVES

Abciximab has been shown to reduce the risk of thrombotic complications during coronary angioplasty, however there are still many aspects to be resolved. The aim of this study was to investigate the various biological effects of abciximab on platelets during coronary angioplasty.

METHODS

The degree of platelet inhibition (with 5 and 20 mol/l concentrations of ADP), occlusion time (measurement of platelet haemostatic capacity, PFA-100), and the platelet activation markers were determined in 15 patients who underwent basal coronary angioplasty and abciximab treatment. Determinations were obtained before, 15 minutes after procedure initiation, at procedure termination, and 24 hours after procedure termination.

RESULTS

More than 80% platelet aggregation inhibition was observed in 13 patients during the procedure, but after 24 hours (p < 0.05) was only detected in two. The occlusion time during the procedure was > 300 sec. in 13 patients, 6 of whom evolved to normal values after 24 hours (p < 0.05). A high correlation (p = 0.02) was found between these two parameters during the intervention, but not after 24 hours. No platelet inhibition or occlusion time changes were observed in 2 patients during the study. The expression of p-selectin increased significantly during the procedure (p < 0.05).

CONCLUSIONS

The variability of platelet function inhibition and existence of circulating activation during coronary angioplasty following the administration of abciximab support the use of early analytical controls with the objective of modifying guidelines for use in order to optimize its effect or to combine it with other antithrombotic agents.

Bundle-branch reentry and the postpacing interval after entrainment by right ventricular apex stimulation: a new approach to elucidate the mechanism of wide-QRS-complex tachycardia with atrioventricular dissociation

BACKGROUND

Diagnosis of bundle-branch reentry ventricular tachycardia (BBR-VT) by the standard approach is challenging, and this may lead to nonrecognition of this tachycardia mechanism. Because the postpacing interval (PPI) after entrainment has been correlated with the distance from the pacing site to the reentrant circuit, BBR-VT entrainment by pacing from the right ventricular apex (RVA) should result in a PPI similar to the tachycardia cycle length (TCL). This factor may differentiate BBR-VT from other mechanisms of wide-QRS-complex tachycardia with AV dissociation, such as myocardial reentrant VT (MR-VT) or AV nodal reentrant tachycardia (AVNRT), in which the circuit is usually located away from the RVA.

METHODS AND RESULTS

Transient entrainment by RVA pacing was attempted in 18 consecutive BBR-VTs and finally achieved in 13. Results were compared with those found in 59 consecutive MR-VTs and 50 consecutive AVNRTs. The mean PPI-TCL difference was significantly (P:<0.0001) shorter in the BBR-VT group (9+/-11 ms) than in the MR-VT (109+/-48 ms) and the AVNRT (150+/-29 ms) groups. No BBR-VT showed a PPI-TCL >30 ms (range -12 to 24 ms). Except for 2 MR-VTs, no MR-VT (range 21 to 211 ms) or AVNRT (range 100 to 215 ms) showed a PPI-TCL <30 ms.

CONCLUSIONS

A PPI-TCL >30 ms, after entrainment by RVA stimulation, makes BBR-VT unlikely. Conversely, a PPI-TCL <30 ms is suggestive of BBR-VT but should lead to further investigation by use of conventional criteria.

Ablation of idiopathic ventricular tachycardia by bipolar radiofrequency current application between the left aortic sinus and the left ventricle

BACKGROUND

Failure to ablate idiopathic ventricular outflow tract tachycardia by radiofrequency current is not uncommon and suggests that non-standard approaches may be required to map and suppress idiopathic ventricular tachyarrhythmias in some patients.

METHODS AND RESULTS

Left and right ventricular activation and pace mapping proved inadequate for radiofrequency application in a patient with idiopathic ventricular outflow tract tachycardia. Presystolic activity was recorded at the left aortic sinus of Valsalva, and the QRS complex recorded at this location during pacing showed few differences compared with that recorded during tachycardia. Radiofrequency current application at this site transiently suppressed the tachycardia. Following new mapping of the left ventricle outflow tract, radiofrequency application just below the aortic valve in close proximity to the previous aortic application site transiently abolished the arrhythmia. Finally, bipolar radiofrequency application between the distal electrode of the aortic catheter and the distal electrode of a second catheter placed in the left ventricular subaortic area permanently suppressed the tachycardia.

CONCLUSION

Bipolar radiofrequency application between the aortic sinus of Valsalva and the left ventricle could be an alternative approach in occasional patients with idiopathic ventricular outflow tract tachycardia resistant to conventional left ventricular and aortic root unipolar radiofrequency application.

[Cardioinhibitory vagal response not related to pain, and induced by radiofrequency application during ablation of right posteroseptal accessory pathway]

Inappropriate sinus tachycardia is the most common arrhythmia induced by radiofrequency energy delivery in the posteroseptal area. It has been suggested that this could be secondary to parasymphathetic nerve injury. We report a patient with extreme sinus bradycardia and PR interval prolongation induced by radiofrequency energy delivered in the coronary sinus ostium area, but not related to any other stimulus. The most probable mechanism of the disorder was transient stimulation of the vagal afferent nerve fibers located in this anatomical area.

[Oblique orientation of the accessory pathway demonstrated by radiofrequency application]

Activation mapping of atrial and ventricular insertion has suggested an oblique orientation of some accessory pathways. However, this aspect has not been demonstrated by radiofrequency application. This report presents two patients with Wolff-Parkinson-White syndrome and an accessory pathway with bidirectional conduction and oblique orientation. The accessory pathway oblique orientation was demonstrated by transient and permanent conduction abolition following radiofrequency application in two separate ventricular and atrial sites. These findings may explain the failure to ablate accessory pathway by radiofrequency application in the ventricular side of the mitral annulus guided by retrograde atrial activation occasionally observed in patients with a concealed accessory pathway.

Quantitative study of metals in bile from patients with cholelithiasis

OBJECTIVE

Biliary lithiasis is a multifactorial phenomenon that is decisively influenced by the composition of bile. We analyzed the presence of eight metals in bile and compared their concentrations in healthy persons and patients with cholelithiasis.

METHODS

We studied bile from 119 patients who underwent cholecystectomy because of symptomatic cholelithiasis, and from 25 control subjects in whom the gallbladder was removed for reasons other than cholelithiasis. Metal concentrations were analyzed by atomic absorption spectrophotometry. The subjects were divided into subgroups according to age, sex and type of stone.

RESULTS

Bile from patients with cholelithiasis contained significantly less of the essential element magnesium (Mg) and the toxic element lead (Pb) than bile from control subjects. Calcium (Ca) and strontium (Sr) concentrations were also lower in patients with gallstones than in the control group, although the differences were not significant.

CONCLUSIONS

Biliary concentrations of Mg and Pb were significantly lower in patients with cholelithiasis than in the control group. The biliary excretion of Ca and Sr was lower in patients than in controls, although the differences were not statistically significant.

[Coxiella burnetii endocarditis: long-term clinical course in 20 patients]

INTRODUCTION AND OBJECTIVES

Coxiella burnetii is a causative agent of increasingly frequent subacute infective endocarditis, and is associated with elevated morbimortality. Our aim in the present study was to assess the clinical, serological and therapeutic long-term evolution of 20 patients with Coxiella burnetii endocarditis.

METHODS

Twenty patients (13 male and 7 female, age 42 +/- 10 years) admitted between 1982 and 1996 were retrospectively studied. All of them fulfilled the Duke criteria modified by Raoult for Q fever endocarditis.

RESULTS

Endocarditis involved prosthetic and native valves in 14 and 6 patients, respectively. All patients except one received antibiotic treatment. Patients treated with doxycycline in monotherapy showed worse evolution than those treated with doxycycline in combination with other antibiotics. Valve replacement was performed in 15 patients, due to prosthetic dysfunction in most of them. The overall mortality was 40% (8 patients). At follow-up of 74 months (range 19-156) (mean 74 +/- 47) all patients showed persistent high levels of phase I antibodies. At follow-up of 15 to 65 months (32 +/- 30) antibiotic treatment was suspended in five patients because they were asymptomatic and without microbiologic findings of valvular endocarditis.

CONCLUSIONS

Q fever endocarditis was associated with severe complications, which often required valve replacement. All patients showed persistent high serological titers of Coxiella burnetii endocarditis without other signs of active infection. This finding raises the issue of suspending antibiotic treatment in patients with negative microbiologic findings and questions the persistence of abnormal serology as a monitor of treatment efficacy.

[Demonstration of accelerated growth of heart sarcoma using imaging techniques]

We report the case of a patient presenting a sarcoma of interatrial septum with an accelerated growth and a fulminate clinical course documented by non-invasive image diagnostic techniques, habitual in the cardiologic practice. The natural history of some cardiac malignant tumours, as aggressive as in this case, explains the diagnostic delay, the difficulty to establish a curative treatment such as surgery and/or chemotherapy/radiotherapy and the awful short-term prognosis.

[Aortic pseudocoarctation complicated by a giant pseudoaneurysm]

Pseudocoarctation of the aorta is an infrequent anomaly caused by the elongation and the congenital kinking of the aorta. We present a case of pseudocoarctation of the aorta with saccular aneurysm complicated with a large pseudoaneurysm. Both, magnetic resonance and aortography showed an aneurysm of the aortic isthmus that extended/progressed as pseudoaneurysm towards the neck. The patient was asymptomatic but due to the high risk of rupture, she underwent surgical reparation. The revision of the literature and our experience with this case show that pseudocoarctation of the aorta is not always a benign pathology and that surgical reparation should be performed in all those cases that are complicated by aneurysm.

Tricuspid insufficiency and interatrial septum rupture: a cause of persistent systemic hypoxemia after blunt chest trauma

The case of a 45-year-old man with severe tricuspid insufficiency and interatrial septum rupture caused by a car accident is described. The patient had a rupture of the anterior papillary muscle of the tricuspid valve and right-to-left shunt through an interatrial defect with severe hypoxemia that was difficult to distinguish from that caused by pulmonary damage. Transesophageal echocardiography was extremely useful for early diagnosis.

[Pulmonary artery primary sarcoma: diagnosis with transthoracic and transesophageal echocardiogram]

Pulmonary artery sarcoma is a rare malignant disease and diagnosis before surgery or autopsy is difficult. We present a case of a pulmonary artery sarcoma diagnosed with transtoracic and transesophagic echocardiogram which was treated surgically.

Successful treatment of prosthetic aortic valve mucormycosis

Mucor endocarditis after cardiovascular surgery is rare and usually fatal. We report the first known case of prosthetic aortic valve mucormycosis in a patient without predisposing risk factors who was successfully treated using a combination of early antifungal drug therapy and surgical removal of infected material.

Transient entrainment of bundle-branch reentry by atrial and ventricular stimulation: elucidation of the tachycardia mechanism through analysis of the surface ECG

BACKGROUND

Different responses to entrainment have been reported in relation to the pacing site of a variety of tachycardias. However, transient entrainment of bundle-branch reentrant tachycardia (BBRT) has not been investigated systematically.

METHODS AND RESULTS

We attempted entrainment of 13 BBRTs in 9 patients by pacing first the right ventricle and then the right atrium. The initial pacing cycle length (CL) was 10 ms faster than the tachycardia CL. Subsequent pacing sequences were performed with 5- to 10-ms CL decrements until tachycardia termination or loss of postatropine 1:1 AV conduction. Both full ventricular-paced and AV-conducted QRS complex references were obtained during sinus rhythm pacing from the same sites and with similar CL as during entrainment. Transient entrainment was achieved by ventricular and atrial stimulation in 11 and 8 tachycardias, respectively. Constant fusion was always present during entrainment by ventricular stimulation. There was no change in the QRS complex (orthodromically concealed fusion) during entrainment by atrial stimulation in 6 of 6 tachycardias with left bundle-branch block morphology and in 1 of 2 tachycardias with right bundle-branch block morphology.

CONCLUSIONS

BBRT, especially if it has a left bundle-branch block morphology, can be differentiated from other wide-QRS-complex tachycardia mechanisms through analysis of the ECGs recorded during tachycardia entrainment by atrial and ventricular stimulation. This diagnostic approach may be especially useful when it is difficult to record a stable or sufficiently sized His bundle electrogram or when spontaneous changes in the ventricular CL precede similar changes in the His bundle CL.

Angular variation of thermal infrared emissivity for some natural surfaces from experimental measurements

Multiangle algorithms for estimating sea and land surface temperature with Along-Track Scanning Radiometer data require a precise knowledge of the angular variation of surface emissivity in the thermal infrared. Currently, few measurements of this variation exist. Here an experimental investigation of the angular variation of the infrared emissivity in the thermal infrared (8-14-microm) band of some representative samples was made at angles of 0 degrees-65 degrees (at 5 degrees increments) to the surface normal. The results show a decrease of the emissivity with increasing viewing angle, with water showing the highest angular dependence (approximately 7% from 0 degrees to 65 degrees views). Clay, sand, slime, and gravel show variations of approximately 1-3% for the same range of views, whereas a homogeneous grass cover does not show angular dependence. Finally, we include an evaluation of the impact that these data can produce on the algorithms for determining land and sea surface temperature from double-angle views.

Mechanisms of sustained ventricular tachycardia in myotonic dystrophy: implications for catheter ablation

BACKGROUND

Ventricular arrhythmias have been documented and linked to the high incidence of sudden death seen in patients with myotonic dystrophy. However, their precise mechanism is unknown, and their definitive therapy remains to be established.

METHODS AND RESULTS

We studied 6 consecutive patients with myotonic dystrophy and sustained ventricular tachycardia by means of cardiac electrophysiological testing. Particular attention was paid to establish whether bundle-branch reentry was the tachycardia mechanism, and when such was the case, radiofrequency catheter ablation of either the right or left bundle branch was performed. Clinical tachycardia was inducible in all patients and had a bundle-branch reentrant mechanism. In 1 patient, 2 other morphologies of sustained tachycardia were also inducible, neither of which had ever been clinically documented, and both had a bundle-branch reentrant mechanism. Ventricular tachycardia was no longer inducible after bundle-branch ablation, except for a nonclinically documented and nonsustained ventricular tachycardia in the only patient who had apparent structural heart disease.

CONCLUSIONS

A high clinical suspicion of bundle-branch reentrant tachycardia is justified in patients with myotonic dystrophy who exhibit wide QRS complex tachycardia or tachycardia-related symptoms. Because catheter ablation will easily and effectively abolish bundle-branch reentrant tachycardia, myotonic dystrophy should always be considered in patients with sustained ventricular tachycardia. This is especially true if no apparent heart disease is found.

[Indications and surgical techniques in the acute phase of infective endocarditis]

Infectious endocarditis is increasingly resistant to antibiotic therapy, due to the increasing number of patient with cardiovascular prostheses or those who are severely immunosuppressed. Frequently, this syndrome and its complications can only be solved with surgery. In this article, which is based on the international literature plus own observations in 77 patients, the indications for surgery and the different technical approaches during the acute phase of infectious endocarditis are reviewed. Surgery to control infectious endocarditis is indicated when there is one of the following situations: a) persistence of infection despite an adequate antibiotic treatment, usually due to a specific pathogen (Staphylococcus aureus, fungus, etc.) or to a low antibiotic penetration into the infected issues (abscess); b) progressive hemodynamic deterioration due to tissular destruction and development of valvular incompetence or fistulous communications or c) development of other complications (repetitive embolism, cardiovascular aneurysms, conduction blocks, etc.). Hemodynamic deterioration due to heart failure refractory to medical treatment is the most frequent indication for cardiovascular surgery, and this was present in 61% of our patients. The timing for surgery is still controversial, although scheduling it at an early stage is generally preferred. The specific surgical technique is chosen according to the degree of tissular destruction and is aimed to remove the infected tissue and to repair the damaged structures or, if this is not feasible, to implant cardiovascular prosthesis.

[Study of the secretion of P substance, neurotensin and somatostatin in healthy adults]

OBJECTIVE

A study in humans of the profile of physiologic secretion, basal and postprandial of three gastrointestinal peptides has been carried out.

METHOD

20 healthy subjects were studied (9 women and 11 men); any previous digestive pathology has not been included. The study was carried out by determining P substance, neurotensin and somatostatin in plasma by means of RIA I125. The subjects were studied in basal conditions of fasting and the samples were taken at 30, 60 and 90 minutes intervals after the oral intake of a semi-liquid preparation made up of the three immediate principles.

RESULTS

It shows the secretion curve of the three gastrointestinal peptides, in a global way and also in relation to sex, age and body weight.

[Uncommon atrial flutter related to cicatrix from atriotomy surgery: radiofrequency catheter ablation]

A patient with a complex congenital abnormality required the implantation of an interatrial septum patch through a right lateral atriotomy. Nine years later he developed two different morphologies of an incessant uncommon atrial flutter refractory to antiarrhythmic drug treatment. The electrophysiological study localized a site on the right atrium lateral wall where local activation time was 75 ms earlier than the onset of the P wave, transient entrainment with concealed fusion was obtained, the first postpacing interval after transient entrainment was 5 ms longer than tachycardia cycle length and the stimulus to P wave interval was 50 ms. At this site, radiofrequency delivery terminated the atrial flutter in less than 1 second. No further induction or recurrences of any morphology of the atrial flutter were observed after a four month follow up. These findings suggest the existence of a narrow conduction isthmus amenable to interruption by focal delivery of radiofrequency. The isthmus was most probably located between the atriotomy and the crista terminalis, posterior to the former and anterior to the latter.

Unipolar mapping and magnetic resonance imaging of "idiopathic" right ventricular outflow tract ectopy

Radiofrequency catheter ablation of symptomatic ventricular ectopy guided by unipolar mapping was successfully accomplished at the right ventricular outflow tract in a patient who did not exhibit apparent structural heart disease. A "QS" morphology with a fast slope of the downstroke deflection at the successful ablation site was observed on the unipolar electrogram. Focal thinning of the lateral wall of the right ventricular outflow tract was shown in the magnetic resonance image, similar to that reported in patients with "idiopathic" right ventricular outflow tract tachycardia.

Study of the secretion of substance P, neurotensin and somatostatin in patients with cholelithiasis

A comparative, case-control study on the pre- and postprandial release of three gastrointestinal peptides implicated in gallbladder motility has been carried out in humans in the attempt to determine their possible role in the pathogenesis of cholelithiasis. Fifty-seven adult patients (40 females and 17 males) with an ultrasound diagnosis of gallstones and 20 healthy subjects (9 females and 11 males) without cholelithiasis or other digestive pathology were studied. Plasma substance P, neurotensin and somatostatin were measured by means of RIA-I125 in basal fasting conditions and 30, 60 and 90 minutes after the oral intake of a semiliquid mixed meal. The levels of secretion of each hormone were compared in patients and healthy controls on an overall basis and in terms of sex, age and body weight. We found a basal and postprandial hypersecretion of substance P in patients with gallstones when compared with controls. Individuals with cholelithiasis showed a moderate decrease in neurotensin secretion after the oral meal. Somatostatin release was unchanged. In conclusion, patients with gallstones may present a functional disorder in the secretion of gastrointestinal hormones involved in gallbladder motility.

[Papillary muscle rupture during subaortic membrane balloon dilatation]

A 37 year-old female patient underwent catheter-balloon dilation for discrete subaortic stenosis. During the procedure severe mitral regurgitation was produced requiring emergency surgery. Transesophageal and intraoperative findings were posteriormedial papillary muscle rupture. Retrospective viewing of the cineangiogram during balloon inflation revealed distal balloon indentation, corresponding to the injured papillary muscle. This severe complication of the left ventricular outflow tract angioplasty should be avoided by careful positioning of the guidewire and balloon before inflation.

Giant left atrial myxoma: case report

This report describes the case of a 40 year old woman with a giant left atrial myxoma. Only a thin path of 9 mm diameter allowed blood flow through the left atrial chamber to the left ventricle. Despite this obstruction, the patient developed only minimal symptoms. Echocardiography, especially transoesophageal mode is the diagnostic procedure of choice to detect these tumours. The giant mass was successfully removed and the patient is doing well two years after surgery.

Unusual expression of Gaucher's disease: cardiovascular calcifications in three sibs homozygous for the D409H mutation

Three sisters suffering from an unusual form of Gaucher's disease are described. These patients had cardiovascular abnormalities consisting of calcification of the ascending aorta and of the aortic and mitral valves. Neurological findings included ophthalmoplegia and saccadic eye movements in two patients, and tonic-clonic seizures in the third. The three patients died, two of them after having undergone aortic valve replacement. Tissue was obtained from one of the sibs and fibroblast and liver beta-glucocerebrosidase activity was reduced to 4% and 11% of mean normal values. Genotype analysis indicated that the patient was homozygous for the D409H mutation. It is tempting to relate the phenotype of severe cardiac involvement to the D409H/D409H genotype, although further cases will be needed before this association can be confirmed.

[Aortic prosthetic endocarditis and periprosthetic abscess caused by Staphylococcus aureus]

Prosthetic endocarditis with annular abscess formation is a severe complication of cardiac valve replacement fortunately uncommon, though highly lethal. Increasing surgical experience and the high mortality with medical management have led to a widespread recommendation for early prosthetic replacement. We report a case of a 49 year old man with infective endocarditis due to Staphylococcus aureus in aortic ascendens prosthetic and aortic valve prosthetic complicated with periaortic abscess which was as successful treatment by drain of abscess without prosthetic replacement.

Percutaneous balloon valvuloplasty for concurrent mitral, aortic and tricuspid rheumatic stenosis

Percutaneous balloon valvuloplasty has been used with good results to treat rheumatic mitral stenosis. However, its use in degenerative aortic stenosis has shown many limitations. There is little information about balloon valvuloplasty in tricuspid and aortic rheumatic stenosis. This article describes two patients with combined rheumatic mitral, aortic and tricuspid stenosis in which triple percutaneous valvuloplasty was performed in a single procedure.

[The return to work after coronary revascularization]

INTRODUCTION

Work resumption after a therapeutical intervention has been considered as a sensitive indicator of its success. There are some reports analyzing working status after coronary artery revascularization in western countries. However, to our knowledge, similar studies have not been published in Spain.

PATIENTS AND METHODS

We studied 210 patients after coronary artery revascularization surgery or percutaneous transluminal coronary angioplasty. Exclusion criteria were age of 65 or more years and female sex gender (n = 64).

RESULTS

Working patient rate before and after coronary revascularization was respectively 63.2% and 28.9% for surgery, and 57.1% and 41.4% for percutaneous angioplasty (p = 0.11). None of the former inactive patients, with the exception of one in the surgery group, went back to work after the revascularization procedure. Asymptomatic patients after percutaneous angioplasty had a higher postprocedure working rate than symptomatic ones (58.1% vs 11.1%, p < 0.0001). Patients in the surgery group did not show this relation (30% vs 25%, p = 0.69).

CONCLUSIONS

Surprisingly, coronary artery revascularization interventions, mainly coronary surgery, seems to behave in our environment as important determinants of working cessation.

[The clinical and echocardiographic factors predictive of bioprosthetic leaflet rupture. The clinical tolerance for prosthetic malfunction]

OBJECTIVE

The objective of this research was to determine the existence of predictors of bioprosthetic valve disruption depending on the echocardiographic characteristic of the biologic prosthesis. It also determines the factors that provoke a need of emergency surgery and a bad clinical tolerance to the prosthetic dysfunction.

METHODS

Clinical and echocardiographic features of two groups of 28 and 21 patients, all of them carrying bioprosthesis, were compared. The groups were homogeneous in sex, age, location and durability of the prosthesis. The first group showed leaflet disruption in a period of 6 months to 1 year after the study, not in the second group. Calcification, thickness and mobility of leaflets, prosthetic function were studied. An echocardiographic score was given between 4 and 10 points. Left ventricular function and pulmonary pressure were also studied.

RESULTS

Valve thickness was statistically different in both groups (95% of the first group vs 71.3% of the second, p = 0.0281). There was no significant difference in calcification (52% vs 38.7%), nor in leaflet mobility (71.5% normal in the first group vs the 80% of the second group), nor in the prosthetic function (52.3% vs 76.6%, respectively). It was not found in the echocardiographic score either. Left ventricular function and pulmonary pressure were 91.6% and 55% normal respectively in the first group. They were 80% and 45.83% normal in the second group. Clinical onset of disruption was: 5 asymptomatic patients, 2 patients noticed a change in prosthetic click, 14 cases with progressive dyspnea, 6 patients with acute pulmonary edema and 1 patient with cardiopulmonary arrest and effective resuscitation. Symptoms were kept under control with medical treatment in 22 patients (78.55%) and 6 patients were referred to surgery. These latter suffered from pulmonary hypertension and two of them had left ventricular dysfunction. Surgical mortality was 3% (1 patient).

CONCLUSIONS

No echocardiographic features were found as being predictors of imminent bioprosthetic disruption. However, leaflet thickness is the most common finding. Symptoms of disruption in patients without high surgical risk factors (left ventricular dysfunction or pulmonary hypertension) are kept under control with medical treatment. Therefore, "prophylactic" surgery is not needed in bioprosthesis with signs of degeneration and normal hemodynamic performance.

Complete heart block in an adult with systemic lupus erythematosus

Report of a case of complete heart block in a patient with systemic lupus erythematosus (SLE). The cardiac disturbance presented as repeated syncopal episodes and normal cardiac clinical and electrocardiographic examination between these episodes. Circulating anti-U1RNP antibodies were detected and tests for anti-SSA/Ro, anti-SSB/La and antiphospholipid antibodies were negative. Evidence of myocarditis was not found. The diagnosis was just established when the patient developed a syncopal episode during hospitalization. Only one SLE case with a similar clinical course has been reported previously.

[Acute pericarditis as the initial presentation of a primary cardiac angiosarcoma. The anatomicoclinical correlations]

We report the clinic and postmortem pathologic examination of a 38-years-old man with a primary angiosarcoma of right atrium and many widespread metastatic. Both his presentation, a clinical course of acute pericarditis self-limited, as the negatives complementary examination, give at case unusual characteristics, for his high malignancy.

[Lipomatous hypertrophy of the interauricular septum, fibrosis of the bundle of His and calcification of the mitral annulus associated with multiple rhythm and conduction disorders. The anatomicoclinical correlations]

We present the case of a 72 years old female with multiple episodes of atrial fibrillation, interatrial block and different degrees of atrioventricular block, that died because of stroke. Postmortem pathologic examination showed a lipomatous hypertrophy of the interatrial septum (previously suspected on echocardiogram), his bundle and right branch degeneration as well as mitral annular calcification extended to conduction system. According to these pathologic findings, rhythm and conduction disturbances are correlated with the two levels (atrial and atrioventricular) where anatomic abnormalities were found.

[Acute posttraumatic myocardial infarct: the necessity of an early interventionist posture]

We describe five cases of posttraumatic anterior acute myocardial infarction in young patients, without previous heart disease. One case was treated with intracoronary thrombolysis and angioplasty, 3 cases received systemic thrombolysis, and the last one did not have any re-permeabilization therapy, having arrived to the hospital 72 hours after the episode. The coronary angiograms showed at the left anterior descending artery: thrombosis in 3 cases, coronary dissection in one case, and slow flow with no morphological lesions in the other. The case which not received thrombolytic therapy developed a severe left ventricular dysfunction. In conclusion we emphasize an early angiographic study, in order to decide the re-permeabilization therapy.

[The independent origins of the anterior descending, circumflex and right coronary arteries from the right coronary sinus]

We present a patient with chronic ischaemic cardiac disease and anomalous left anterior descending and circumflex coronary arteries with independent origin from the right Valsalva sinus. Each one had his own ostium and the left anterior descending artery followed an intramyocardial pathway through the interventricular septum whereas the circumflex artery had a retrocardiac pathway. The clinical picture of the patient was related to the presence of atherosclerotic obstructive lesions in right, whose origin and curse were normal, and circumflex coronary arteries. He was treated medically at first but without obtaining complete control therefore he needed surgical treatment which was undertaken without technical difficulties. We reviewed the anomalies of the main coronary arteries, in the origin and course, with its clinical signification, diagnosis and therapeutics topics.

[Left atrial thrombus. Its evolution with oral anticoagulation]

Left ventricular thrombi were found in 25 patients by two-dimensional echocardiography. All patients were in atrial fibrillation, 16 had mitral or mitroaortic valve diseases and nine mitral or mitroaortic bioprosthetic valves. Nine patients (36%) had history of arterial embolism. At diagnostic time, oral anticoagulation with coumadin was instaured in all the patients. Periodic clinic and echocardiography follow-up was performed. Left atrial thrombi either disappeared (18 patients [72%]) or reduced their size (one patient). Six patients with mitral stenosis were considered as candidates to percutaneous mitral valvuloplasty, which was performed in 4 patients whose thrombi disappeared with anticoagulation therapy in 6 months. During the follow-up one patient had cerebral embolism without sequelae.

CONCLUSIONS

1st. Patients with left atrial thrombi have high risk for arterial embolism. 2nd. Left atrial thrombi disappear in a high proportion after prescribing oral anticoagulation, which has some important therapeutic implications.

Acute myocardial infarction after blunt chest trauma in young people: need for prompt intervention

We describe four cases of acute myocardial infarction in young patients, secondary to blunt chest trauma. One case was treated with intracoronary thrombolysis and angioplasty, two cases received systemic thrombolysis, and the last one did not have any reperfusion therapy. The coronary angiograms of the left anterior descending artery showed thrombosis in two cases, coronary dissection in one case, and no morphological lesions in the other. We encourage the early performance of angiographic studies in these patients, adjusting the therapy to their pathophysiologic mechanism.