Reoperative Intervention in Patients with Mesh at the Hiatus is Associated with High Incidence of Esophageal Resection—A Single-Center Experience

Background

Mesh hiatoplasty is a widely debated topic among foregut surgeons. While short-term outcomes tout decreased recurrence rates, an increase in mesh-related complications has been reported. The aim of this study is to present a single-center experience with reoperative intervention in patients with previous mesh at the hiatus.

Methods

After institutional review board approval, a prospectively maintained database was retrospectively queried to identify patients who underwent reoperative intervention between 2003 and spring of 2013 and had mesh placed at a previous hiatal hernia procedure. Patient charts were reviewed and data variables collected.

Results

Twenty-six patients (mean age of 56.7?±?18.3; 19 females) who underwent 27 procedures met the inclusion criteria. Synthetic mesh was placed in 15 (56 %) procedures, while the remaining 12 had biologic mesh. The mean interval between reoperative intervention and previous surgery was 33 months. Dysphagia (56 %) was the most common presentation, while three patients had mesh erosion. Recurrent hiatus hernia (2 to 7 cm) was noted in 19 (70 %) patients. Eight patients (30 %) underwent redo fundoplication, six patients (22 %) were converted to Roux-en-Y gastrojejunostomy, two patients (7.4 %) underwent distal esophagectomy with esophagojejunostomy, five patients (19 %) had subtotal esophagectomy with gastric pull-up, and one patient underwent substernal gastric pull-up for esophageal bypass with interval esophagectomy. The mean operative time was 252?±?71.7 min, and the median blood loss was 150 ml (range, 50–1,650 ml). There was no postoperative mortality.

Conclusion

Reoperative intervention in patients with mesh at the hiatus is associated with a high need for esophageal resection. More than two thirds of the patients also had a recurrent hiatal hernia.     

A case of rhabdomyosarcoma masquerading as acute leukemia at presentation: a case report

Non-hematopoietic malignancies infiltrating bone marrow have always been a source of erroneous diagnosis. Among these, the small round cell tumors like neuroblastomas and rhabdomyosarcomas mimick the hematopoietic blasts. Several case reports of rhabdomyosarcoma mimicking acute leukemia, clinically and morphologically at presentation have been reported in the literature. To the best of our knowledge such an entity has not been reported in Indian literature. We report here one such case of alveolar rhabdomyosarcoma masquerading as acute leukemia. A thorough clinical examination with high degree of suspicion on bone marrow morphology and judicious use of appropriate immunohistochemistry markers will solve many of these cases.     

Gingival enlargement in Niemann-Pick disease: a coincidence or link? Report of a unique case

A case of a 25-year-old man appearing with generalized gingival enlargement is reported here. Niemann-Pick disease (NPD) was provisionally diagnosed by histopathologic analysis of tissue excised by gingivectomy and later confirmed by quantitative enzyme assay. Correlation between clinical features and histopathologic and biochemical analysis enabled the diagnosis of NPD type C.     

Hypertonic saline with furosemide for the treatment of acute congestive heart failure: A systematic review and meta-analysis

Background

Advanced congestive heart failure (CHF) therapies include intravenous inotropic agents, change in class of diuretics, and venous ultrafiltration or hemodialysis. These modalities have not been associated with improved prognosis and are limited by availability and cost. Compared to high-dose furosemide alone, concomitant hypertonic saline solution (HSS) administration has demonstrated improved clinical outcomes with good safety profile.

Methods

A literature search was conducted for randomized controlled trials that investigated the use of HSS in patients admitted to hospital with acute CHF.

Results

1032 patients treated with HSS and 1032 controls, demonstrated decreased all-cause mortality in patients treat with HSS with RR of 0.56 (95% CI 0.41–0.76,p = 0.0003). 1012 patients treated with HSS and 1020 controls, demonstrated decreased heart failure hospital readmission with RR of 0.50 (95% CI 0.33–0.76,p = 0.001). Patients treated with HSS also demonstrated decreased hospital length of stay (p = 0.0002), greater weight loss (p < 0.00001), and preservation of renal function (p < 0.00001).

Conclusion

The results of this meta-analysis demonstrate that in patients with advanced CHF concomitant hypertonic saline administration improved weight loss, preserved renal function, and decreased length of hospitalization, mortality and heart failure rehospitalization. A future adequately powered, multi-centre, placebo controlled, randomized, double dummy, blinded trial is needed to assess the benefit of hypertonic saline in patients with renal dysfunction, in diverse patient populations, as well using a patient population on optimal current heart failure treatment. Pending further validation, there is promise for hypertonic saline as an advanced therapy for the management of acute advanced CHF.     

Role of “Ischemia Modified Albumin” (IMA) in acute coronary syndromes

Background

Diagnosis of acute coronary syndrome (ACS) is important, due to the associated very high mortality. Failure to diagnose ACS is a problem both for the patients and the clinicians. Ischemia modified albumin (IMA) has already been licensed by the US Food and Drug Administration for the diagnosis of suspected myocardial ischemia.

Methods

Patients attending the emergency department (ED) within 6 h after having features of ACS were selected. IMA was done on admission. Blinded to the IMA results patients were fully evaluated and a diagnosis of non-ischemic chest pain (NICP), unstable angina (UA) or myocardial infarction (MI) was made. Later IMA results were correlated in each group.

Results

Mean IMA value was 56.38 ± 23.89 u/ml in NICP group whereas in UA group it was 89.00 ± 7.76 u/ml and MI group was 87.50 ± 9.62 u/ml. This showed a sensitivity of 92% and specificity of 87%. The positive predictive value of the test was 88% and negative predictive value was 94%. In 16 patients an early diagnosis could be made when compared with Trop-T. Of the 89 patients 11 patients died in hospital. The IMA value was compared between this group and the patients who survived. Patients who died had a mean IMA value of 88.5 with a standard deviation of 5.33 whereas in patients who survived the mean value was 78.26 which was not statistically significant.

Conclusion

In conclusion the benefit of the test would be to rule out ACS in patients who present early to ED with inconclusive diagnosis.     

Rapidly Progressive Congenital Rhabdomyosarcoma Presenting with Multiple Cutaneous Lesions: An Uncommon Diagnosis and a Therapeutic Challenge

Congenital rhabdomyosarcomas (RMSs) are rare tumors with variable clinical presentations. A 2 month-old, term male neonate (37 weeks, 4 days), weighing 3.2 kg, born to a 24 year-old primigravida, by simple vaginal delivery presented with multiple erythematous papulonodular lesions over his trunk that progressed to his whole body, on the first day of delivery. Prior to conception, his mother was treated for polycystic ovarian disease. On the tenth day, his chest computed tomogram scans revealed multiple, heterogeneously enhancing, bilateral pleural-based soft tissue density nodular lesions, along with multiple soft tissue density lesions, involving skeletal muscles of all his body parts. Microsections from two biopsies (on 10th day and after 2 months) revealed a malignant round cell tumor with cells arranged in a diffuse, solid pattern, comprising embryonal and solid alveolar components. Immunohistochemically, the tumor cells were diffusely positive for desmin, myoD1 and myogenin. Diagnosis of embryonal and alveolar (mixed type) RMS was offered. Further molecular cytogenetic analysis was negative for PAX3-FKHR and PAX7-FKHR. The patient was induced on chemotherapy as per intergroup rhabdomyosarcoma study IV protocol. There was treatment response with near total remission after 8 weeks of treatment. Thereafter, new lesions started appearing that also disappeared after modification of the chemotherapy drugs. However, after 16 months, the baby died of brain metastasis. The present case forms the fourth case report of an aggressive form of a congenital RMS with extensive cutaneous involvement and brain metastasis. A review of previously diagnosed cases of congenital RMSs is discussed herewith.     

Evaluating Cluster Preservation in Frequent Itemset Integration for Distributed Databases

Medical sciences are rapidly emerging as a data rich discipline where the amount of databases and their dimensionality increases exponentially with time. Data integration algorithms often rely upon discovering embedded, useful, and novel relationships between feature attributes that describe the data. Such algorithms require data integration prior to knowledge discovery, which can lack the timeliness, scalability, robustness, and reliability of discovered knowledge. Knowledge integration algorithms offer pattern discovery on segmented and distributed databases but require sophisticated methods for pattern merging and evaluating integration quality. We propose a unique computational framework for discovering and integrating frequent sets of features from distributed databases and then exploiting them for unsupervised learning from the integrated space. Assorted indices of cluster quality are used to assess the accuracy of knowledge merging. The approach preserves significant cluster quality under various cluster distributions and noise conditions. Exhaustive experimentation is performed to further evaluate the scalability and robustness of the proposed methodology.     

Infantile Salmonella meningitis associated with gecko-keeping

A serotype found mainly in reptiles was isolated from cerebrospinal fluid from a 2 month old baby with meningitis. A related salmonella was isolated from gecko faeces from the floor of the tank in the baby's home, suggesting a possible source of infection, and indicating the need for hygienic precautions in homes where reptiles are kept as pets.     

Genetic basis for chamber-specific ventricular phenotypes in the rat infarct model

BACKGROUND: We, and others, have previously reported a strong correlation between increased inter-ventricular dispersion of repolarization and the occurrence of fatal arrhythmia in animal models of CHF. The existence of this and other such distinct electrophysiologic phenotypes in right (RV) vs. left ventricles (LV) could be explained by chamber-specific patterns of gene expression. METHODS: We employed microarray gene profiling of 13824 sequence-verified, nonredundant rodent cDNAs to compare myocardial gene expression in RV vs. LV of rats with surgically induced myocardial infarction (MI: n=3) and in sham-operated animals (Sham: n=3). RESULTS: Significant LV infarction (32+/-4% LV) and severe CHF were observed in all MI animals at 4 weeks. In Sham animals, 937 genes exhibited significant differential expression in RV vs. LV myocardium. In MI animals, 1158 genes exhibited significant differential expression in RV vs. LV. Of those genes exhibiting significant differential expression, only 241 were common to both Sham and MI animals. Differentially expressed genes included those involved in signal transduction, cell growth and maintenance, and apoptosis. Genes with potential roles in altered dispersion of repolarization included voltage-dependent Ca(2+) channel gamma subunit (MI 8-fold increasing) and K(+) inwardly rectifying channel subfamily J, member 10 (MI 6-fold decreasing). Gap junction membrane channel protein alpha 4 (MI 6-fold decreasing) and cardiac troponin I (MI 8-fold decreasing) were also significantly differentially expressed. Inter-ventricular comparisons revealed significantly greater alterations in gene expression vs. intra-ventricular comparisons. CONCLUSIONS: Microarray gene profiling has revealed candidate genes, some of them novel, which may account for chamber-specific ventricular electrophysiologic phenotypes, both in physiologic as well as in arrhythmogenic states such as CHF.