Assessment of atherosclerosis by carotid intimomedial thickness in patients with rheumatoid arthritis

OBJECTIVES

To determine the prevalence of subclinical (asymptomatic) atherosclerosis in patients with rheumatoid arthritis (RA) and to study the variables affecting such an occurrence.

METHODS

Case control study which included 100 patients with RA having disease duration more than 5 years and 100 healthy age and sex matched controls. Cases and controls symptomatic for atherosclerosis or having traditional risk factors for atherosclerosis were excluded. Both cases and controls were subjected to carotid ultrasound examination in addition to detailed history and physical examination.

RESULTS

The study population (both cases and controls) included 94 females and 6 males. The mean age of cases and controls was similar (44.06 +/- 11.32 years and 44.1 +/- 11.52 years). The mean disease duration was 155.04 +/- 48.8 months. The mean carotid intimo-medial thickness (CIMT) of the RA patients (0.519 +/- 0.18 mm) was significantly greater than the controls (0.387 +/- 0.085). Age and disease duration were the only factors found to significantly affect CCIMT. RA patients had higher prevalence of carotid plaques (21%) compared to controls (1%). Erosions on hand radiographs were the only significant predictor of plaques in patients with RA.

CONCLUSION

Patients with RA exhibit premature atherosclerosis by way of increased CIMT and carotid plaques when compared to age and sex matched controls.

Eye position information on CT increases the identification of acute ischemic hypoattenuation

BACKGROUND AND PURPOSE

It is possible that identification of eye deviation may sensitize a scan reader to early brain hypodensity associated with an arterial occlusive process. Our aim was to investigate the value of observing eye deviation on blinded CT identification of early hypoattenuation following ischemic infarct.

MATERIALS AND METHODS

Two staff and 2 fellow neuroradiologists reviewed 75 brain CT scans obtained within 3 hours of acute ischemia from subjects in the Interventional Management of Stroke Study. Films were reviewed 3 months apart, the first time with tape over the eyes on the images, the second with the eyes visible. Readers were asked if early hypoattenuation in the middle cerebral artery (MCA) distribution or if a hyperattenuated MCA was present. kappa statistics were calculated to determine agreement among the 4 readers and between each of the 2 readings by the same reader, not only for the original interpretation of the blinded study neuroradiologist but also for the Alberta Stroke Program Early CT Score (ASPECTS) for each subject assigned by an unblinded expert panel. A generalized estimating equations modeling approach was used to look at the overall effect of including eye information for agreement between interpretations.

RESULTS

Eye information availability was associated with improved agreement for detection of early ischemic hypoattenuation not only among the 4 readers but also between the 4 readers and both the blinded study neuroradiologist (P = .02) and the unblinded expert ASPECTS panel. When comparing first and second readings for hypoattenuation, we also noted increased mean values for sensitivity (46.8% first, 56.5% second), specificity (78.2%, 80.2%), positive predictive value (72.0%, 80.7%), negative predictive value (55.5%, 61.0%), and percentage agreement (61.0%, 67.5%).

CONCLUSION

Observation of CT eye deviation significantly improves reader identification of acute ischemic hypoattenuation.

Lymphadenectomy in carcinoma stomach: Experience from a regional cancer centre

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Background: Carcinoma stomach is the most common cancer in males in chennai city. Lot of controversy exists regarding the need for extended lymphadenectomy because of the morbidity and mortality associated. Methods: A retrospective analysis was done to assess the benefit of extended lymphadenectomy. The records of all the patients operated at Cancer Institute from 1991 to 2004 were analysed. Out of 5050 cases of carcinoma stomach seen, only 570 cases were taken up for some form of treatment. 400 cases underwent resection, of which 366 patients records were retreived from the tumor registry for analysis. Followup ranged from 1 year to 10 years. Results: Male to female ratio was 3:1, most patients were in 40 - 60 year age group (60%). 60% patients had antral tumors and the rest were evenly distributed. 79 patients (21%) underwent conventional gastrectomy (D1), 243 patients (66%) underwent extended lymphadenectomy and 44 patients (12%)underwent palliative gastrectomy. 280 patients underwent subtotal gastrectomy, 54 patients total gastrectomy, 28 esophago gastrectomy and 5 had transhiatal esophagectomies. Stage wise distribution was IA 4.9%, IB 9.8%, II 21%, IIIA 29.4%, IIIB 12.8%, IV 22.1%. The total number of nodes dissected in the Extended nodal dissection group was less than or equal to 15 in 12% patients, 15 to 30 nodes in 48% patients and >30 nodes in 40% patients. 72% patients had node positive disease. Overall Survival at 5years was 38.9% for all the cases. 5year ovarall survival for conventional gastrectomy group was 37% and was 48% for the extended lymphadenectomy group which was statistically significant(p =0.06) .On substratification for T status and stage, the difference in survival between conventional and extended lymphadenectomy arms was not found to be significant.However,there was a trend towards improved survival in the lymphadenectomy arm.There were 7 post operative deaths in the lymphadenectomy arm,5 of which were in the first year of starting extended lymphadenectomies, which points to the learning curve for these procedures. Conclusions: Larger trials may be required to prove the advantage of extended lymphadenectomies in Gastric cancer. In addition neoadjuvant chemotherapy and Intraoperative radiotherapy may need to be studied to improve survival in gastric cancer.

No significant financial relationships to disclose.

Visualization of a stationary CPG-revealing spinal wave

Central Pattern Generator (CPG) is still an elusive concept that has a visual manifestation as a rhythmic oscillation commanded from the spine, but that also has another manifestation as a train of bursts in the surface electromyographic (sEMG) signals recorded on the para-spinal muscles. This leads to the challenging problem of correlating the visually observed spinal wave with the sEMG signals recorded during the session. This paper develops a mathematical model of the spinal wave phenomenon, which, when driven by the sEMG data, yields such visually observable features as wave nodes.

Organization and running of the first comprehensive hereditary cancer clinic in India

Hereditary cancers are thought to account for around 5% of cancers, particularly breast/ovarian and colorectal cancers. In India there is a paucity of data on hereditary cancers and the mutations in some of the common genes linked to hereditary cancers, such as BRCA1, BRCA2, hMSH2 and hMLH1. The country's first comprehensive hereditary cancer clinic was established in February 2002. The article describes the organization and running of the Clinic. It also discusses some of the social issues relevant to the given population in running the Hereditary Cancer Clinic.

ChiroSensor -- an array of non-invasive sEMG electrodes

It is shown that the statistical analysis of the sEMG signals recorded by the ChiroSensors along the paraspinal muscles during Network Spinal Analysis (NSA) provides objective confirmation of the physiological reality as perceived by the practitioner as it relates to levels of care and spinal injury recovery.

Repair of Double Coaraction or Aorta with Associated Anomalies

An 8-year-old boy who had coarctation of the aorta with two stenotic ridges, a stenotic left subclavian artery, and absence of collaterals, underwent successful surgical repair. Both ridges showed histopathological features of true coarctation.

Management of chyle fistulae following surgery in the neck

Chyle fistulae are seen in less than twenty percent of cases following head and neck surgery. At the Cancer Institute, Madras, India, chyle leaks were seen in 19 patients between 1990 and 1999. The leak subsided spontaneously in sixteen patients on conservative management. The neck was re-explored in three patient. The thoracic duct was ligated in one and the wound packed in two. Conservative management in the form of aspirations and strapping is more likely to succeed when the volume of drainage is low or decresing over time and the surgical incision and skin flaps remain healthy. Rightsided leaks and late appearing fistulae are also likely to close on conservative management. Dietary modifications may help in this process. Re-exploration of the neck would be required when conservative management fails. Early exploration would be advised when the drainage is large or does not decrease over a few days or if there is a tendency to wound breakdown. A thorough knowledge of the anatomy of lymphatic pathways from the thorax and abdomen, identification of the thoracic duct during surgery and detection and ligature of all lymphatic leaks intraoperatively using a trendelenburg position and valsalva maneuver will help reduce the occurrence of this problem.

Voiding cystourethrograms and urinary tract infections: how long to wait?

OBJECTIVES

Many authorities recommend an interval of at least 3 to 6 weeks after a urinary tract infection (UTI) before performing a voiding cystourethrogram (VCUG). However, such an interval may reduce the likelihood of completing the procedure. This study was performed to investigate whether the length of the interval between a UTI and the performance of the VCUG influences the presence or severity of reflux, and whether it influences the likelihood of actually having the study performed.

DESIGN

We reviewed 352 admissions of children under 10 years old whose discharge diagnoses indicated UTIs. These admissions occurred over a 27-month period between October 1994 and December 1996 at the Children's Hospital of Austin, Texas. We identified 213 patients with confirmed UTIs and no other previously defined urinary tract pathology. These patients were divided into 2 groups according to whether they had a VCUG scheduled to be performed either within 1 week after the diagnosis of a UTI (the early group), or later than 1 week after the diagnosis (the late group). We compared the presence and severity of reflux in the 2 groups as well as the proportion of scheduled VCUGs that were actually performed.

RESULTS

Reflux was present in 19% of the patients studied within 1 week after UTI (95% confidence interval [CI]: 12.9-26.4) and in 18% of those studied after 1 week (95% CI: 6. 7-34.5). This difference was not statistically significant (chi(2) =. 034; DF = 1). However there was a substantial difference between the 2 groups with regard to the number of scheduled VCUGs actually performed. Whereas 100% of the scheduled VCUGs in the early group were performed, only 48% (95% CI: 35.9-60.1) of those scheduled in the late group were performed. This difference is statistically significant (chi(2) = 89.6; DF = 1).

CONCLUSIONS

In the hospitalized children who underwent VCUGs within a week after diagnosis of UTI, the presence of reflux is not significantly different from those studied later. Furthermore, late scheduling of VCUGs resulted in failure to perform the procedure in more than half of the patients. Some of the patients who were not evaluated would be expected to have vesicoureteral reflux and thus be at risk for chronic renal disease. Therefore, the traditional recommendation to perform the VCUG at 3 to 6 weeks after the diagnosis of UTI should be reconsidered, especially for hospitalized children.

Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion

BACKGROUND

In off-pump coronary bypass grafting (CABG), invasiveness is reduced but technically perfect anastomosis is jeopardized by cardiac motion and the need to hurry to reduce the time of ischemia. Also, a major cause of postoperative morbidity and mortality is ungrafted circumflex coronary artery disease. We have devised a means of overcoming these shortcomings and performing multivessel CABG. The objective of this study was to assess the safety and efficacy of our technique.

METHODS

One hundred patients with severe triple-vessel disease underwent multivessel off-pump CABG. For cardiac stabilization, a combination of local pericardial stabilization sutures and lifting and rotating the heart by means of posterior pericardial sutures were used. For myocardial perfusion, a technique of retrograde coronary sinus perfusion by arterial blood from the ascending aorta was used.

RESULTS

Each patient received an average of 3.8 grafts (range 3 to 5). Complications included conversion to cardiopulmonary bypass (CPB) in 1 patient and a perioperative myocardial infarction in the same patient. In all other patients we were able to perform a satisfactory grafting in all territories with no operative mortality. Rapid recovery allowed 95% of our patients to resume normal activity within 1 month. A predischarge graft angiogram in 35 patients showed 97.8% patency.

CONCLUSIONS

These results suggest that off-pump CABG with our techniques is effective and safe. Early clinical outcome and excellent patency rates suggest its more widespread use in selected cases.

AgNORs in endometrial lesions

Silver nucleolar organizer region (AgNOR) staining was employed in one hundred specimens of endometrium. These included fifteen normal controls (Proliferative + Secretory endometrium) and eighty five lesions. Endometrial lesions comprised of endometritis (15), endometrial hyperplasia (25) and endometrial carcinoma (45). Three micron thick sections of paraffin embedded tissue were subjected to AgNOR staining as described by Crocker and Smith with a little modification of 0.01% safranin counterstain--The mean AgNOR scores were found to increase steadily from normal to endometritis to endometrial hyperplasia and carcinoma--The observations revealed statistically significant differences in values between atypical hyperplasia and carcinoma also. AgNOR staining and scoring is simple, inexpensive and a useful adjunct to routine histopathology to evaluate endometrial lesions especially to differentiate borderline lesions. Though scores cannot be standardized and fixed for a particular lesion as there are intralaboratory variations.

Tracheal injury during transhiatal mobilization of the esophagus

In 50 transhiatal esophageal mobilizations done from 1988 to 1998 at the Cancer Institute (W.I.A.) in Chennai, India, injuries to the trachea were detected on 3 occasions: 1 in a woman with carcinoma of the hypopharynx and 2 in patients (1 male, 1 female) with squamous cell carcinoma of the esophagus. The incidence of tracheal injuries during esophageal mobilization varies in different series. This is usually on the membranous posterior wall of the trachea. When recognized on the table, repair of the rent must be carried out. Persistent air leak through the intercostal tube or surgical emphysema developing over the face and neck in the postoperative period indicates an injury to the airway. A bronchoscopy will reveal the site of injury. If the lung is fully expanded and the stomach abuts the rent completely, the patient may be observed. However, if the lung is collapsed and does not expand on applying negative suction to the intercostal tube or the injury is in the bronchi, the patient is best reexplored to close the rent. With proper case selection and careful dissection of the esophagus, the problem of tracheal injuries can be avoided.

Hyperthyroidism due to papillary carcinoma of the thyroid--a case report

A rare case of papillary carcinoma of the thyroid producing hyperthyroidism is presented. A young patients presented seven years after a thyroid operation with metastatic disease in the cervical lymph nodes and a history of deteriorating vision in the left eye. He also had a lesion in the base of the skull which could not be established to be metastasis from the thyroid cancer. There was clinical and biochemical evidence of hyperthyroidism. Radionuclide scan revealed uptake in the residual thyroid tissue and patchy uptake by the cervical lymph nodes. The patient underwent a complete thyroidectomy and radical neck dissection of the left side and 'berry-picking' of the lymph nodes on the right side. Although the patient became euthyroid post-operatively, his general condition deteriorated and he rapidly lost vision in both eyes before any ablative therapy could be instituted for the tumour in the base of the skull. The patient was lost to follow-up.

Amebic liver abscess with jaundice

A case of an amebic liver abscess with unusual clinical manifestations is presented. A middle-aged male with an abscess in both lobes of the liver presented with obstructive jaundice due to pressure on the porta hepatis with stasis of the bile in the intrahepatic biliary radicals. The patient did not respond to repeated needle aspirations and thus required open drainage. Subsequently, the patient developed a biliary leak through the drainage sites, and an injection of contrast dye into the cavity revealed a communication between the abscess cavities and the biliary tree. The biliary leak stopped spontaneously, and the large cavities also closed completely during the followup period.

Sudden appearance of a mass on chest X-ray

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Azathioprine in the treatment of Parthenium dermatitis

BACKGROUND

Parthenium dermatitis is a chronic disorder whose management is extremely difficult. Allergen avoidance is almost impossible, topical corticosteroid therapy provides only partial relief, and prolonged systemic corticosteroid therapy has unacceptable side-effects.

METHODS

Twenty patients with chronic Parthenium dermatitis, with relative contraindications to systemic corticosteroids or their side-effects, were treated with oral azathioprine (100-150 mg daily). The severity of dermatitis was assessed at 0, 1, 3, 6, and 12 months using a modified PASI scoring system.

RESULTS

The mean age of the patients was 54 years (range, 40-72 years) and the mean duration of dermatitis was 7.6 years (range, 3 months to 36 years). The mean initial score was 18.9 (range, 3.3-42), which decreased to 8.8 (range, 1.6-18.2) at 3 months, 4.8 (range, 0.6-14.6) at 6 months, and 0.7 (range, 0.2-1.4) at 12 months. Of the 15 patients evaluated at 6 months, all but one showed a response. Ten (66.6%) patients showed near-total clearance, i.e. reduction in score by more than 90%, and three patients (20%) showed more than 50% reduction in score. No significant side-effects were noted.

CONCLUSIONS

Azathioprine is an effective and safe alternative to corticosteroid therapy in the treatment of chronic Parthenium dermatitis. It is especially useful in patients with side-effects or contraindications to corticosteroid therapy.

Isolated involvement of the mandible by non-Hodgkin's lymphoma

A case report of isolated involvement of the mandible by non-Hodgkin lymphoma is presented. The patient presented with a non-healing ulcer following a tooth extraction. Biopsy revealed an undifferentiated cancer. Investigations failed to reveal any involvement of the organs. A hemimandibulectomy was performed followed by radiotherapy on receipt of the histopathological diagnosis of non-Hodgkin lymphoma. The patient is asymptomatic two and a half years after treatment.

Visceral larva migrans

We present a case of visceral larva migrans which came as a complete histologic surprise. The patient was operated as a case of chronic cholecystitis and was found at operation to have multiple hepatic nodules. A cholecystectomy with a biopsy of the liver nodule was performed. Histopathologically a diagnosis of visceral larva migrans was made. To our knowledge this is the first case report of the disorder from India. A discussion based on the review of literature is presented.

Managing respiratory distress syndrome in adults

Respiratory distress syndrome in adults may be produced by any of a number of causes resulting in similar pathophysiologic changes and having identical therapeutic implications. The most important factors in treatment are early recognition and early institution of therapy.

Benign superior vena cava syndrome

Benign superior vena cava (SVC) obstruction is an uncommon entity. However, it is important to recognize that a small percentage of SVC syndromes are due to benign diseases such as mediastinal granulomas. The insidious onset and slow progression of symptoms allow for development of an efficient collateral venous circulation compatible with long-term survival. Surgical intervention to bypass the obstruction is often unsuccessful and should be avoided in most cases. We review the English literature on the subject, classify the various causes of benign SVC syndrome, and report our experience with 16 documented cases.