Surgical management of coronary malperfusion due to type a aortic dissection

BACKGROUND: Acute aortic dissection coexisting with coronary malperfusion is a relatively rare but fatal condition. Surgical treatment of these patients is to perform early coronary revascularization concomitant with aortic repair. We review our surgical results of a selected group of 14 patients with type A acute aortic dissection and coronary artery dissection. METHODS: Between January 1993 and March 2005, 14 patients (10.2%) from a total of 136 consecutive patients with acute type A aortic dissection concomitant coronary dissection were treated by performing aortic repair and coronary artery bypass grafting. There were 11 men and 3 women (mean age, 56.7 +/- 8.4 years). The right coronary artery was involved in eight patients, the left in two patients, and both coronary arteries in four patients. At admission, nine patients had Q waves (64.2%), inferior in seven (50%) and anterior or lateral in two (14.2%). RESULTS: Hospital mortality rate was 21.4% (3 of 14 patients). Of these, two patients could not be weaned from cardiopulmonary bypass, and one patient died of multiorgan failure in the intensive care unit. CONCLUSIONS: Since acute type A aortic dissection with coronary involvement is associated with high mortality rate, immediate coronary artery bypass grafting and aortic repair is a safe and reliable approach to these challenging group of patients.     

The Sealing Effect of a Fibrin Tissue Patch on the Esophageal Perforation Area in Primary Repair

Background The aim of this study was to investigate the efficacy of the fibrin tissue patch and to analyze its use in patients with esophageal perforation. Methods We studied 28 patients who were diagnosed with esophageal perforation between January 1990 and January 2006 at Akdeniz University Hospital. Sixteen (57.14%) were male. The average age was 59 ± 9 years. We performed surgery and primary repair reinforcement even if the diagnosis of esophageal perforation was late. Results Twenty-three (82.14%) perforations were the result of endoscopic instruments; spontaneous perforations occurred in three (10.71%) patients. Postoperative complication (Heller myotomy) caused perforation in one patient (3.57%) and blunt trauma in one patient (3.57%). Three (10.71%) patients had cervical perforation, and 25 (89.29%) patients had thoracic esophageal perforation. Twelve (42.86%) patients underwent emergency surgery (within the first 24 h). Ten (35.71%) patients underwent surgery within 48 h, and the remaining 6 (21.43%) underwent surgery after 48 h. Nine (32.14%) patients had primary repair, 7 (25%) had reinforcement of the primary repair with fibrin tissue patch, 7 (25%) had esophagectomy and gastric pull-up, and 2 (7.14%) had drainage and placement of metallic stents. In four patients of the nine who had primary repair, fistula complication was detected, whereas in only one of the seven who had reinforcement of the primary repair with fibrin tissue patch was a fistula detected. Three patients (10.71%), two of whom had Boerhaave’s syndrome, died. Conclusions Surgical primary repair with fibrin tissue patch is the most successful treatment option in the management of esophageal perforation.     

Sleep Deprivation Induced Anxiety and Anaerobic Performance

The aim of this study was to investigate the effects of sleep deprivation induced anxiety on anaerobic performance. Thirteen volunteer male physical education students completed the Turkish version of State Anxiety Inventory and performed Wingate anaerobic test for three times: (1) following a full-night of habitual sleep (baseline measurements), (2) following 30 hours of sleep deprivation, and (3) following partial-night sleep deprivation. Baseline measurements were performed the day before total sleep deprivation. Measurements following partial sleep deprivation were made 2 weeks later than total sleep deprivation measurements. State anxiety was measured prior to each Wingate test. The mean state anxiety following total sleep deprivation was higher than the baseline measurement (44.9 ± 12.9 vs. 27.6 ± 4.2, respectively, p = 0.02) whereas anaerobic performance parameters remained unchanged. Neither anaerobic parameters nor state anxiety levels were affected by one night partial sleep deprivation. Our results suggest that 30 hours continuous wakefulness may increase anxiety level without impairing anaerobic performance, whereas one night of partial sleep deprivation was ineffective on both state anxiety and anaerobic performance.

Key points

• Short time total sleep deprivation (30 hours) increases state anxiety without any competition stress.
• Anaerobic performance parameters such as peak power, mean power and minimum power may not show a distinctive difference from anaerobic performance in a normal sleep day despite the high anxiety level induced by short time sleep deprivation.
• Partial sleep deprivation does not affect anxiety level and anaerobic performance of the next day.

Key words: Psychophysiological disorders, mood, insufficient sleep, muscle fatique     

Malignant myoepithelioma of cranial dura

Malignant tumors of myoepithelial origin have been increasingly recognized at a variety of sites. Herein, we describe an example of malignant myoepithelioma arising in intracranial dura. The patient is a 47-year-old woman who presented with intracranial hemorrhage and on magnetic resonance imaging was found to have an enhancing tumor. No extracranial primary tumor was identified. A gross total resection was performed. Histologically, it varied in pattern from diffuse to focally (<10%) ductular and consisted of epitheloid to spindle cells showing marked mitotic activity. Prominent infiltration of the dura was noted. Immunohistochemical stains showed convincing expression of cytokeratins (AE1/AE3 and CAM 5.2), S-100 protein, smooth muscle actin, and glial fibrillary acidic protein. Electron microscopy performed on formalin-fixed, paraffin-embedded tissue demonstrated cohesive cells with focal intermediate filament content and surface basal lamina formation at stromal interfaces. Occasional desmosomes with tonofilaments surrounded intercellular lumina containing masses of filamentous material. This example of malignant myoepithelioma is the first convincing primary salivary gland type tumor to arise in an intracranial location outside the sellar region or ear. Intracranial dura should be added to various sites at which this morphologically heterogenous tumor may arise.     

Relationship between aortic stiffness and the development of coronary collateral in patients with coronary artery disease

Large artery stiffness is an independent predictor of cardiovascular mortality and a major determinant of pulse pressure. The stiff aorta may result in greater systolic, lower diastolic, and wider pulse pressures, which may decrease coronary artery perfusion. Shear stress has been implicated in the development of coronary collateral. Decreased coronary perfusion may reduce shear stress and thus collateral formation. The goal of this study was to assess the relationship between the development of coronary collateral and aortic stiffness in patients with coronary artery disease. In 106 patients with at least one coronary artery stenosis of 90% or greater, collateral vessels were assessed angiographically by the Rentrop grading (grade 0-3), establishing two groups: 50 patients with poor collateral vessels (Rentrop grade 0 or 1), and 56 patients with good collateral vessels (Rentrop grade 2 or 3). Internal aortic root diameters were measured at 3 cm above the aortic valve by use of two-dimensional guided M-mode transthoracic echocardiography, and arterial pressure was measured simultaneously at the brachial artery by sphygmomanometry. Two indexes of the aortic elastic properties were measured: aortic distensibility index was calculated by use of the formula: 2 x (systolic diameter - diastolic diameter)/(diastolic diameter) x (pulse pressure) in cm(- 2)dyn(-1)10(-6). The aortic stiffness index was calculated by: (systolic blood pressure/diastolic blood pressure)/pulsatile change in diameter/diastolic diameter. The aortic distensibility index and the aortic stiffness index were not significantly different between the patients with poor collateral vessels and those with good collateral vessels (5.1 +/-2.3 vs 5.7 +/-3.3 cm(-2)dyn( -1)10(-6), p = 0.31; 4.02 +/-2.3 vs 4.43 +/-3.7, p = 0.49, respectively). There were no significant differences regarding the aortic elastic properties between the patients with poor collateral vessels and those with good collateral vessels, suggesting that collateral formation is a complex phenomenon consisting of several distinct processes.     

Peritoneal tuberculosis mimicking advanced ovarian cancer: a retrospective review of 22 cases

OBJECTIVE: To evaluate the clinical, laboratory and diagnostic features in women with peritoneal tuberculosis that resembled advanced ovarian malignancy. METHODS: A retrospective review of women with peritoneal tuberculosis who were managed at TCSB Ankara Etlik Maternity and Women's Health Teaching and Research Hospital from July 1992 to November 2004 was undertaken. RESULTS: Among the 1,826 women treated during the study period, 22 women with peritoneal tuberculosis (1.2%) were identified. The mean age was 36.9 years (range 21-68 years); the mean Ca125 level was 564.95 U/ml (3-2021 U/ml). All patients with peritoneal tuberculosis had ascites, 20 patients (90.91%) had elevated CA125 levels and 17 patients (77.27%) had detectable pelvic masses in the preoperative period. During preoperative diagnostic work-up, pulmonary tuberculosis was diagnosed and antituberculosis therapy had begun in two of 22 patients (9.09%). Among 20 patients, 11 (55%), 8 (40%) and 1 (5%) underwent exploratory laparotomy, diagnostic laparoscopy and laparoscopy converted to laparotomy due to dense pelvic adhesions, respectively. Since frozen section was not available during the surgery in 5 of 20, 3 patients (10%) underwent extended surgery. Frozen section was performed in 15 patients and revealed chronic granulomatous changes and final pathological examination confirmed the diagnosis. CONCLUSION: Our data indicate that the majority of the cases with peritoneal tuberculosis can be diagnosed intraoperatively through the use of frozen section in conjunction with clinical features. Ascites and high levels of Ca125 do not necessarily indicate that the clinical picture is malignant in reproductive women. Laparoscopic tissue biopsy may be a fundamental tool in the management of such cases to avoid extended surgery.     

Chromosome aberrations involving 10q22: report of three overlapping interstitial deletions and a balanced translocation disrupting C10orf11

Interstitial deletions of chromosome band 10q22 are rare. We report on the characterization of three overlapping de novo 10q22 deletions by high-resolution array comparative genomic hybridization in three unrelated patients. Patient 1 had a 7.9 Mb deletion in 10q21.3–q22.2 and suffered from severe feeding problems, facial dysmorphisms and profound mental retardation. Patients 2 and 3 had nearly identical deletions of 3.2 and 3.6 Mb, the proximal breakpoints of which were located at an identical low-copy repeat. Both patients were mentally retarded; patient 3 also suffered from growth retardation and hypotonia. We also report on the results of breakpoint analysis by array painting in a mentally retarded patient with a balanced chromosome translocation 46,XY,t(10;13)(q22;p13)dn. The breakpoint in 10q22 was found to disrupt C10orf11, a brain-expressed gene in the common deleted interval of patients 1–3. This finding suggests that haploinsufficiency of C10orf11 contributes to the cognitive defects in 10q22 deletion patients.     

Chromosome deletions in 13q33-34: report of four patients and review of the literature

Deletions of chromosome bands 13q33-34 are rare. Patients with such deletions have mental retardation, microcephaly, and distinct facial features. Male patients frequently also have genital malformations. We report on four patients with three overlapping deletions of 13q33-34 that have been characterized by tiling-path array-CGH. Patient 1 had mental retardation and microcephaly with an interstitial 4.7 Mb deletion and a translocation t(12;13)(q13.3;q32.3). His mother (Patient 2), who also had mental retardation and microcephaly, carried the identical chromosome aberration. Patient 3 was a girl with a de novo insertion ins(7;13)(p15.1;q22q31) and interstitial 4.5 Mb deletion in 13q33-34. She had mental retardation and microcephaly. Patient 4 was a newborn boy with severe genital malformation (penoscrotal transposition and hypospadias) and microcephaly. He had a de novo ring chromosome 13 lacking the terminal 9.3 Mb of 13q. Karyotype-phenotype comparisons of these and eight previously published del13q33-34 patients suggest EFNB2 as a candidate gene for genital malformations in males. Molecular cytogenetic definition of a common deleted region in all patients suggests ARHGEF7 as a candidate gene for mental retardation and microcephaly.     

Atrial fibrillation due to oral methylprednisolone in a patient with membranoproliferative glomerulonephritis

Cardiac adverse effects of intravenous pulse methylprednisolone administration are well known, but there is little information about the cardiac side effects of oral methylprednisolone in the literature. We present a 41 year-old man with membranoproliferative glomerulonephritis in whom developed atrial fibrillation after oral methylprednisolone therapy.