[Endocarditis caused by Candida parapsilosis after total correction of tetralogy of Fallot. Medico-surgical treatment]

Three children with Candida Parapsilosis endocarditis after total surgical correction for Tetralogy of Fallot, are reported. Blood cultures became negative in one child with amphotericin-B and in the other two with Ketoconazole, before reoperation for septal patch replacement. Oral therapy with Ketoconazole continued for a total of 24 months, and during a mean follow-up of 36 months no side effects or reinfection occurred. Medical and surgical conjoined therapy, with surgical timing decided on clinical and laboratorial grounds, were important for good results and cure.

[Percutaneous transluminal pulmonary valvuloplasty in children --5 years' experience]

OBJECTIVE

Assessment of the results of percutaneous transluminal balloon pulmonary valvuloplasty (BPV) in children.

DESIGN OF THE STUDY

Retrospective analysis of the methodology and results between October 1985 and October 1990. SITE OF THE STUDY: Pediatric Cardiology Service, Santa Marta Hospital, Lisbon.

PATIENTS

43 consecutive children with pulmonary valve stenosis. 4 children with Noonan's Syndrome were excluded from the study and the results of 45 valvuloplasties in 39 patients are analysed.

METHODS

Full diagnostic catheterization and right ventricular cineangiography were performed. One or two balloon dilatation catheters were inserted percutaneously in one or both femoral veins and positioned across the pulmonary valve under fluoroscopic control. The balloons were then inflated to their maximum pressure with diluted contrast medium. In 18 children follow up cardiac catheterization was performed 3 to 12 months after valvuloplasty (mean 6.7 /+- 2.7).

RESULTS

A satisfactory dilatation was achieved in 35 patients (89%) with a substantial decrease in right ventricular systolic pressure (RVP) and in transvalvar peak systolic gradient (GR) (p less than 0.0001). A further significant spontaneous reduction in RVP and GR was recorded on follow up catheterization (p less than 0.01). A repeat BVP was performed in 6 children and was successful in 5. In cases a satisfactory relief of the stenosis was not achieved and 3 of them were submitted to surgery. There were no deaths. One child had cardiac arrest leading to successful surgical valvotomy and with no sequelae. Another child had cerebral embolism with hemiparesis. Ligation of a femoral vein was required in one case for haemorrhage. Mild pulmonary insufficiency resulted in 15 children.

CONCLUSIONS

Our experience confirms that BPV is the method of choice for the treatment of children with pulmonary valve stenosis either isolated or associated to small ventricular septal defect. It proved to be a safe and effective technique for reduction of GR. Mortality, morbidity, costs of the treatment and hospitalisation time are lower for BPV than for surgery with comparable short term results.

Effect of nicergoline on platelet aggregation, plasma viscosity and erythrocyte deformability in geriatric patients with cerebral infarction. Preliminary report

The effects of nicergoline (Sermion) on platelet aggregation, plasma viscosity and erythrocyte deformability were evaluated in 11 geriatric patients with cerebral infarction, 2 men and 9 women (ages 61-78, mean age 71.6). Nicergoline was given orally at a dose of 5 mg 3 times daily after meals for 8 weeks. Hematological variables were determined twice prior to the administration and at 4 and 8 weeks after the administration. The platelet aggregation in vitro was determined by the turbidimetric method and the level of circulating platelet aggregates was determined according to the method of Wu-Hoak. Erythrocyte deformability was determined according to the method based on the examination of passing erythrocytes through a filter containing pores smaller than the undeformed cells. Collagen-, arachidonic acid- and PAF-induced platelet aggregation was decreased after nicergoline administration. Erythrocyte deformability was increased and plasma viscosity was also decreased after the administration. Thus the improvement of platelet aggregation, plasma viscosity and erythrocyte deformability in cerebral infarction may prevent disturbing blood flow and may contribute to prevention of formation and progression of thrombosis and atherosclerosis in geriatric patients with cerebral infarction.

Clinical study of primary carcinoma of the fallopian tube: experience with 15 cases

Between 1950 and 1986, fifteen cases of primary carcinoma of the fallopian tube were diagnosed and treated at the Cancer Institute Hospital, Tokyo. These cases constituted 0.14% of the total number of gynecologic malignancies at the hospital during that period. The average age of the 15 patients was 55.7 years. The most frequent symptom was atypical genital bleeding, seen in 12 cases (80%). Massive watery discharge was seen in 4 cases (27%). In preoperative cytologic examination, 6 cases (40%) were positive for cancer. All cases underwent operation as therapy. Postoperative irradiation, adjuvant chemotherapy, and/or second- or third-look operations were also performed. Histopathologically, all materials were found to be adenocarcinoma. Four cases were well differentiated, eight were moderately differentiated, and three were poorly differentiated. As for the prognosis, 7 patients were followed more than 5 years postoperatively. The 5-year survival rate was 57% (4/7). In stage I cancers, the 5-year survival rate was 80% (4/5). The prognosis of stage I cancer patients was estimated to be rather good.

[Clinicopathological study on clear cell carcinoma of the ovary]

The clinical and pathological findings in 23 cases of clear cell carcinoma of the ovary treated at Cancer Institute Hospital from January 1951 to September 1987 are discussed. Clear cell carcinoma accounted for 7.1% of all malignant tumors of the ovary. In the last 21 months of the study, the incidence of clear cell carcinoma increased to 23.7 at the institute. This tumor was frequently associated with endometriosis, and the ratio of nulliparous women was as high as 47.8%. Operative findings revealed adhesion of the tumor to surrounding tissues in more than half of the cases. Moreover, rupture of the tumor capsule during operation occurred in 42.1% of the cases. Incidences of clear cell carcinoma by clinical stage were 82.6% for stage I, 8.7% for stage II, 8.7% for stage III, and 0% for stage IV. The incidences of serous carcinoma were 20.8%, 24.2%, 45.8%, and 9.2%, respectively. Histologically, clear cell carcinoma could be divided into solid and tubular types, with the solid type being slightly more frequent. The three-year survival rate for stage I cases was 95.2% for serous carcinoma and 54.5% for clear cell carcinoma, showing a poor prognosis for clear cell carcinoma. When classified by the histologic type of clear cell carcinoma, the three-year survival rate was 50.0% for solid type and 60.0% for tubular type, with no significant difference. For clear cell carcinoma, the prognosis was poor despite even though most cases were stage I.

Cheiro-oral syndrome with bilateral oral involvement: a study of pontine lesions by high-resolution magnetic resonance imaging

Two cases of unusual cheiro-oral syndrome due to small pontine haemorrhage are described, in which both sides of the mouth were involved in the initial stage. High resolution magnetic resonance imaging revealed a small lesion at the paramedian pontine tegmentum in both cases and suggested involvement of the medial portion of the medial lemniscus.

Use of angio computed tomography to evaluate extent of endometrial carcinoma

Patients with endometrial carcinoma underwent angio computed tomography (CT) prior to surgery to evaluate the extent of the carcinoma. The subjects of the study were 87 patients operated on at the Cancer Institute Hospital during the period 1983 to 1986. After preoperative bilateral internal iliac angiography, angio CT was performed using the already inserted catheters. Although the intact uterine wall was enhanced by the angio CT, the cancerous lesion was not, which permitted easy recognition of the cancerous lesion as a low-density area. To evaluate the degree of myometrial invasion, the minimal thickness of intact uterine wall was measured in the CT image, and was compared later with findings from the operative materials. The comparison showed that for all the patients, the minimal thickness of the intact uterine wall as shown in the CT image was comparable to the actual minimal thickness of the operative materials. Because depth of myometrial invasion is known as an important prognostic factor, measurement of the minimal thickness of the intact uterine wall as shown in the CT image is useful as an objective prognostic factor. Angio CT facilitates recognition of myometrial invasion preoperatively.

[Rheumatic cardiopathy in children. A comparative study in 2 consecutive 9-year periods]

The case rate of children observed with rheumatic carditis or rheumatic heart disease during two consecutive periods of nine years are compared. The first was from October 1969 to September 1978, with previously published data, and the present study from October 1978 to September 1987. During the second period there were 38 cases, 26 of which had the first attack in Portugal, with isolated carditis in 18 (69%), associated with polyarthritis in 5 (20%) and associated with chorea in 3 (11%). Isolated mitral insufficiency was the most frequent valve lesion (80%) and 84% of the children were in NYHA class I and II when first seen. Eighteen children were followed during an average of 2.7 years and there was good compliance of secondary prevention in 78% of them with improvement of the valve lesion. The 12 cases referred from the african countries of portuguese language were more severe, and studied separately. Comparing with the first 9 years period, the case rate of rheumatic carditis, per year decreased from 12.5 to 2.3, the mortality was reduced and the clinical presentation was different, with earlier detection, milder forms and better compliance to secondary prevention.

[Porencephaly. Case report]

A case of porencephaly in a 33-year-old male is presented. The patient exhibited right hemiparesis and generalized seizures. Computed tomography and, subsequently, craniotomy revealed a cerebral defect in the left parietal lobe, which communicated with the lateral ventricle. On angiography and at surgery, the cortical branches of the middle cerebral artery were found to be stretched over the surface of the cyst. Histopathological examination showed the outer membrane of the cyst to consist of arachnoid, subarachnoid space, vessels, pia mater, and a layer of degenerative brain tissue on histology. The diagnosis of porencephaly and its differentiation from arachnoid cyst are discussed.

Effect of flunarizine on volume flow of the common carotid artery, peripheral hemodynamics, erythrocyte deformability and platelet function

The Ca2+ antagonist flunarizine (Flunarl) was administered to 14 patients (4 men and 10 women, 70.9 +/- 2.5 years old, mean +/- S.E.), suffering from cerebral atherosclerosis. The dose was 10 mg/day given for 8 weeks and the following results were obtained. The volume flow of the common carotid artery was increased in the 4th week after the administration, and this increase was maintained until the 8th week. Flunarizine caused improvement of peripheral hemodynamics, induced inhibition of platelet aggregation and improvement erythrocyte deformability. These results indicate that the Ca2+ entry blocker flunarizine improves cerebral and peripheral hemodynamics including microcirculation by inhibiting platelet aggregation and erythrocyte deformability.

[Clinical application of MRI for urological malignancy. 2: Usefulness of various imaging modalities for local staging of bladder cancer; a comparison between MRI, CT and transurethral ultrasonography]

MRI of bladder cancer was accomplished in 28 patients. All of the 28 patients were simultaneously studied by CT, and 22 were also studied by transurethral US before operation. MRI is not as useful as US for local staging of bladder cancer. However, MRI is more useful for diagnosing extravesical extension and covers the deficit of the overdiagnosing tendency of US.

[Relationship between peritoneal cytology and prognosis in endometrial carcinomas]

From 1971 to 1985, peritoneal cytologic examination was performed at the time of operation in 235 previously untreated patients with endometrial carcinoma. The relationship between the cytologic findings and prognoses by stage was investigated. The results were as follows: 1. In the peritoneal cytologic examination, 44 (18.7%) out of 235 cases were positive for cancer cells in all stages, 25 (14.5%) out of 173 cases in stage I, 7 (21.2%) out of 33 cases in stage II, and 8 (32.0%) out of 25 cases in stage III. 2. Among the 20 cases of stage I endometrial carcinoma that had no macroscopic metastasis and had positive peritoneal cytologic findings for cancer cells, 5- and 10-year cumulative survival rates were 94.7 and 94.7%, against 92.7% and 90.9% in cases with negative peritoneal cytology respectively. The recurrence rate in the same stage was 12.0% for positive cases, against 9.5% for negative cases. No significant differences between positive and negative cases were found. 3. In stages II and III, the difference between the survival rates for 9 cases which have positive peritoneal cytology without macroscopic peritoneal metastasis and 47 cases with negative peritoneal cytology were not statistically significant. 4. In endometrial carcinoma without macroscopic peritoneal metastasis, the appearance of cancer cells in peritoneal cytologic examination is not correlated with the prognosis.

[Four cases of upper urinary tract transitional cell carcinoma after radical cystectomy in bladder cancer]

One hundred and eighty-six patients with primary transitional cell carcinoma underwent radical cystectomy between 1965 to December, 1986. Four of them (2.2%) had developed upper urinary tract transitional cell carcinoma. Three of the 4 patients had received various transurethral treatments for the primary bladder lesions before radical cystectomy, but one patient had undergone total cystectomy and ileal conduit as primary treatment. All of the upper urinary tract tumors were invasive. Three patients died and one is alive. We consider the following to be high risk patients for the development of upper tract recurrence. 1) patients with carcinoma-in-situ and multicentric tumors in the bladder, 2) patients with recurrent bladder cancer treated with bladder preserving treatment for a long periods, 3) patients with vesicoureteral reflux, and 4) occupational bladder cancer patients.

[Significance of preoperative diagnosis of endometrial carcinoma by angio-CT]

Angio computed tomography (CT) was performed in 87 previously untreated patients with endometrial carcinoma to study its clinical usefulness. All the patients subsequently underwent surgery and the angio CT findings were correlated with the surgical and pathologic findings. The results were as follows: 1. The tumor appeared as areas of low density in comparison with the surrounding myometrium after intraarterial infusion of contrast medium. 2. Angio CT proved to be useful in determining the depth of myometrial invasion. The myometrial invasion measured from the serosal surface in millimeters was assessed on angio CT. The CT findings were correlated well with pathologic findings. 3. Patients with intact myometrium greater than 10mm from the serosal surface assessed by angio CT had no nodal metastases. Angio CT provides a better display of cross-sectional uterine pathology than CT after intravenous infusion of contrast medium. The depth of myometrial invasion measured from the serosa on angio CT seems to be a useful prognostic factor in patients with endometrial carcinoma.

[Cytological study on uterine sarcoma]

Between 1958 and 1985 (28 years), 53 cases of uterine sarcoma were seen at the Cancer Institute Hospital. Their cytological examination produced the following findings: 1) The positive rate in preoperative cytologic diagnostic tests was a low 21.7 percent for pure sarcoma and 70.0 percent for mixed mesodermal tumor. 2) The preoperative cytologic diagnosis and the final histologic diagnosis agreed in only 13.0 percent of pure sarcoma and 16.7 percent of mixed mesodermal tumor cases. 3) About one-half of the cases of mixed mesodermal tumor were diagnosed preoperatively as adenocarcinoma. 4) The positive rate in the cytologic diagnosis and the clinical stage were not correlated. 5) The positive rate in the cytologic diagnosis was high in cases of intracavity growth type sarcoma, but all cases of intramuscular localized type sarcoma were negative.

[Clinical study of primary carcinoma of the fallopian tube: experience with 14 cases]

Between 1950 and 1986, 14 cases of primary carcinoma of the fallopian tube were treated and diagnosed at the Cancer Institute Hospital. These cases constituted 0.13% of the total number of gynecologic malignancies at the hospital during the period. The clinical/pathological findings and prognoses were described. Of the 14 cases, the average age was 56.0 years. The most frequent symptom was atypical genital bleeding, seen in 11 cases (79%). Massive watery discharge was seen in four cases (29%). In preoperative cytologic examination of vaginal smears, six cases (43%) were positive for cancer. All cases underwent operation as therapy. Postoperative irradiation, adjuvant chemotherapy, and/or second-or third- look operation was also used. Histopathologically, all materials were found to be adenocarcinoma. Four cases were well differentiated, seven were moderately differentiated, and three were poorly differentiated. Two patients with stage III and IV cancers died of the disease. Nine patients were still alive at the end of this study. The five-year survival rate was 57% (4/7). In stage I cancers, the five-year survival rate was 80% (4/5). The prognosis of stage I cancer patients was estimated as rather good.

[Optical internal urethrotomy after traumatic disruption of the urethra]

We report 4 cases of complete traumatic disruption of urethra treated by endoscopic management, core-through optical internal urethrotomy. A direct vision urethrotome was used to incise the totally obliterated urethra with transvesical endoscopic guidance and digital rectal or perineal control. Postoperatively, the patients required an average of 1.3 subsequent urethrotomies. The results were satisfactory in three cases and one case was under observation. All patients were continent and three of them were potent. We suggest that the endoscopic approach should be considered as an initial procedure for restoring urethral continuity prior to more extensive surgical repair.

[Clinical studies with a new non-ionic contrast medium (iopamidol) in intravenous pyelography in aged patients]

Iopamidol (IOPAMIRON 300) was examined for excretory urography on 21 patients, between 70 and 94 years old, with reference to visualization, safety and urinary excretion. The results about visualization and safety were compared with those obtained with 60% Urografin. Iopamidol was demonstrated visualization nearly equivalent to that with Urografin, and 19% better pyelogram. Especially, calix showed a clearer contrast than those obtained with Urografin. None of the 21 old patients experienced any side effects or adverse reactions. No abnormalities were noted in serum chemistries. Iopamidol was not quickly excreted into the urine, only 19% during the first 2 hours, in elder patients.

[Clinical statistics on inpatients and operations in the Department of Urology, Toyooka Public Hospital (from January 1982 to December 1985)]

Statistical observations on inpatients and operations in our department from 1982 to 1985 were reviewed in comparison with the statistics for the preceeding three years. More elderly persons comprised the inpatients at our hospital than at other facilities. Urogenital tumors and urolithiasis were the predominant disease of the inpatients, as they were in the preceeding three years. Number of prostatic cancer has remarkably increased. Transurethral operations, TUR-P and TUR-Bt, were the most representative. Operations for the malignant disease, especially for prostatic cancer, were more frequent in this period than in the preceeding three years. As to urinary diversion, ileal conduit was the main procedure used during this four years. Kock continent ileal reservoir was adopted in 1985. In July 1985, open operations for urolithiasis were dramatically replaced by percutaneous and transurethral procedures.