Use of CT Angiogram in Interventions Involving Coronary Artery Anomalies: A Case Series

BACKGROUND

Coronary artery anomalies are rare, accounting for about 0.3-1.3% of patients undergoing diagnostic coronary angiography. Interventions in these cases are still rare, and therefore pose technical challenges during intervention. CT Angiography provides a non-invasive means of assessment of coronary artery disease and also shows the anatomy of the coronary tree. This helps in knowing the origin of the coronaries and also to plan selection of hardware. There are no specific guidelines for use of guiding catheters and guide wires in anomalous coronary artery intervention.

CASE REPORT

We report a series of 5 patients presenting with effort angina who had anomalous coronary arteries with coronary stenosis diagnosed by CT angiography. Three patients received percutaneous intervention, 1 patient underwent CABG, and 1 patient received medical management.

CONCLUSIONS

CT Angiography provides a useful tool for showing the coronary anatomy and for selecting the guiding catheter and the guide wire that remain the mainstay of interventions in coronary artery anomalies.

A Rare Case of Pneumoureter: Emphysematous Pyelitis versus Emphysematous Pyelonephritis

Emphysematous pyelitis is a rare benign entity which is defined as isolated gas production in the pelvicalyceal system, ureters or in the urinary bladder as a consequence of acute bacterial renal infection. In this case report we present a case with no prior medical history of diabetes or urinary obstruction who presented with uncontrolled hyperglycaemia for the first time associated with emphysematous pyelonephritis. Further, the imaging differences between emphysematous pyelonephritis (EPN) and emphysematous pyelitis (EP) has been discussed along with the approach and their management.

Characterization of Hemorrhagic Complications after Surgery for Temporal Lobe Epilepsy

OBJECTIVES

To assess the significance of symptomatic hemorrhagic complications occurring after different temporal resections for temporal lobe epilepsy (TLE) and to compare this data to findings with postoperative hematomas after temporal surgery for mostly glial or metastatic tumors.

PATIENTS AND METHODS

Patient charts were retrospectively reviewed for 442 patients who underwent surgery for refractory TLE between 1995 and 2000. Procedures were 247 transsylvian amygdalohippocampectomies (AH), 40 transcortical AH, 57 anterior temporal lobectomies (ATL), 23 lesionectomies plus AH, and 75 lesionectomies without AH. All patients with delayed awakening or new neurological deficits due to hemorrhages were included in the study. An identical procedure was performed to detect symptomatic hemorrhages after 208 procedures for temporal tumor resection during the same time period.

RESULTS

Symptomatic postoperative hemorrhages were found in 17 patients (3.8 %) undergoing epilepsy surgery, while the incidence was 3.0 % in a group with space-occupying temporal tumors (six patients). Hemorrhages showed a characteristic distribution after epilepsy surgery: in eight patients they were located remote from the site of surgery in the upper cerebellar vermis and foliae. Five typical hemorrhages associated with dysphasia were found in the left frontal operculum, only three patients had hematomas in the resection cavity, and one was located epidurally. Two patients had more than one location of hemorrhage. Transsylvian AH and ATL had a similar risk for postoperative hemorrhage, whereas none was found after lateral lesionectomies or transcortical AH. Intraoperative manipulations were associated with opercular hemorrhages; the only predisposing factor for resection site hematomas was older age, whereas cerebellar hemorrhages were associated with cerebrospinal fluid (CSF) loss during AH and ATL. There was no mortality in the TLE group, and 0.75 % permanent mild deficits. Seizure outcome did not differ from the rest of the group (82.5 % satisfactory seizure control). In contrast, all intraaxial hematomas after tumor surgery (N = 4, incidence 1.9 %) were located in or adjacent to the resection cavity. Prognosis was much worse with parenchymal hemorrhages after tumor surgery: three of four patients died, one survived with a severe hemiparesis, only two patients with extraaxial hematomas (incidence 1 %) had a complete recovery. The 3 % incidence of symptomatic hemorrhages was only insignificantly lower compared to the TLE group, patients with tumor surgery were older than TLE patients (49 versus 33 years), and in five of six patients only incomplete tumor resection was achieved.

CONCLUSION

Although associated with a low permanent morbidity, features of postoperative hemorrhages after TLE surgery are characteristically different to complications after surgery for other indications, which has to be kept in mind for patient counseling and obtaining informed consent.

Role of red cell selenium in recurrent pregnancy loss

Selenium is an essential trace mineral required for normal human health and reproduction. In recent years selenium deficiency in humans has been implicated as a risk factor for recurrent pregnancy loss. So far the selenium status in recurrent pregnancy loss (RPL) has been evaluated only in plasma and serum samples showing discrepancies of selenium deficiency as a cause for RPL. The present pilot study from India has evaluated selenium status in red cells (as they are the better indicators of selenium levels) in 20 women with three or more unexplained recurrent pregnancy losses compared to similar number of controls. The mean+/-SD red cell selenium levels in the study group was found to be 119.55+/-32.94 ng/ml (range 55-170 ng/ml), which was significantly lower compared to the control group with a mean+/-SD of 150.85+/-37.63 ng/ml (range 87-225 ng/ml). The difference was statistically significant at the 1% level ( P <0.01). Since selenium supplementation resulted in successful pregnancy outcome in veterinary practice, we conclude that large randomised studies are needed to assess the contribution of selenium in the aetiology of RPL and the potential benefits of its supplementation.

Charge-density waves in self-assembled halogen-bridged metal chains

Self-assembled growth of an ordered layer of Pt-Br-Pt chains on a Pt(110) surface is demonstrated. Upon slight doping with excess bromine, charge-density wave (CDW) domains separated by well-localized solutions are observed in the Br/Pt layer by scanning tunneling microscopy. Depending on annealing and adatom concentration, a global, long-range-ordered CDW ground state can be established. Angle-resolved UV photoemission data reveal the corresponding Fermi surface and its removal upon the Peierls transition. The CDW phase is stable to well above room temperature.

Role of electron beam treatment in postoperative management of carcinoma of the breast

The aim of post operative radiotherapy to chest wall and drainage areas in advanced breast cancer is to sterilize the possible microscopic disease. Fifty cases of post surgical breast cancers were evaluated in a prospective study of chest wall radiation therapy by electrons. Fifty women of histologically proved post operative invasive breast cancers underwent simple mastectomy with axillary dissection followed by post-operative radiotherapy (Electron) to chest wall +/- drainage area. The chest wall and IMC was treated by a direct electron beam (9/12 MeV and 12 MeV) at fixed angle. 6 MV X-ray beam was used to treat axillary apex and supraclavicular area. In some cases, supplement RT was given by 6 MV X-rays through small posterior axillary portal. The energy of electron beam was 9 MeV or 12 MeV depending on the thickness of treated area. The supraclavicular and axillary lymphatic regions were treated, by direct custom shaped anterior portal. The dose delivered was 50 Gy over 5 weeks at 2 Gy per fraction. Adjuvant chemotherapy was given to patients who were pre-menopausal with histologically proved axillary node involvement as Cyclophosphamide, Methotrexate and 5-Fluorouracil (CMF) after radiotherapy. Post menopausal patients received adjuvant tamoxifen 10 mg.bid. The overall time varied from 26 to 87 days with a median of 41.5 days (SD 11.7). The followup period varied from 4-32 months with a mean of 22 months (SD 6.4). All the fifty patients developed dense pigmentation towards the end of radiation therapy, along with patchy dry desquamation. Moist desquamation occurred in 6 patients. The median OTT in the patients who developed moist desquamation was 34.5 days. The moist reaction healed over 10-15 days after completion of radiotherapy. Lung Fibrosis (Apical lobe) occurred in four patients. The fibrosis was evident at a median of 12 months of follow up. Lymphoedema of the ipsilateral arm occurred in six patients. None of 50 patients developed late sequalae like Cardiac effects, Rib fracture, Brachial Plexopathy, Shoulder joint impairement and Soft tissue effects. Local control in this study was 96% (48 patients). The two year actuarial overall survival was 80%. In early stages survival was significantly better compared to late stages. The actuarial two year DFS was 72%. In early stages DFS was significantly better compared to late stages.

Descriptive epidemiology of childhood cancers in Bangalore, India

While fairly complete and reliable incident data on childhood cancers are available from the registries in India, mortality and survival information is not. Information concerning the latter was obtained by the Bangalore cancer registry through active follow-up involving visits to homes of patients. Between 1982 and 1989, 617 cases of cancers in childhood were registered, giving an age-standardized incidence rate of 84.8 and 48.4 per million in male and female children, respectively. Active follow-up provided mortality/survival information in 532 or 86.2 percent of these cases. Overall, observed five-year survival was 36.8 percent (both genders combined) with a relative survival of 37.5 percent when childhood mortality in the general population was taken into account. The five-year relative survival was best for thyroid carcinoma (100 percent) followed by Hodgkin's disease (73 percent) and retinoblastoma (72.9 percent). Survival was comparatively low, being 9.9 percent in acute nonlymphatic leukemia and less than 20 percent in rhabdomyosarcoma and the category grouped as 'other malignant neoplasms.' Survival in Hodgkin's disease was influenced by clinical stage at presentation, but was not statistically significant possibly due to small numbers.

Primary central nervous system lymphoma a report of nine cases

Primary Central Nervous System Lymphoma (PCNSL) is a rare neoplasm of B cell origin and constitute less than 1% of Non-Hodgkin's lymphoma (NHL). Histology is mainly of high grade and intermediate type. Although NHL is known to be highly sensitive to both irradiation and cytotoxic drugs, being a curable malignancy, the therapeutic results remain disappointing. Clinical observations on nine cases of PCNSL seen in one of the major cancer centres in India is presented in this paper. Radiotherapy combined with Chemotherapy although yielded encouraging initial response in these patients, the long term response was unsatisfactory with median survival for these patients being only 19 months. This warrants an alternative therapeutic approach to improve the dismal prognosis of PCNSL.

Descriptive epidemiology of lymphoid and haemopoietic malignancies in Bangalore, India

Lymphoid and haemopoietic malignancies as a group constitute one of the important cancers in India, as elsewhere in the world. While information on incidence and mortality of these cancers, and that on survival, are available from most developed countries, there are very few reports describing this experience in developing ones. Population-based cancer registration commenced in Bangalore, India, in January 1982, under the auspices of the Indian Council of Medical Research. This source provides fairly complete and reliable incidence data, but, in order to obtain mortality and survival information, active follow-up involving visits of homes of patients was undertaken. Between 1982 and 1989, 1397 cases of lymphoid and haemopoietic malignancies were registered in the Bangalore cancer registry, giving an age-adjusted incidence rate of 7.7 and 4.8 per 100,000 in males and females respectively. Active follow-up provided mortality/survival information in 1267 or 90.7% of these cases. The overall observed 5-year survival for these cancers combined (both sexes) was 26%, and relative survival 28.4%. The 5-year survival rate was lower in all the individual lymphomas and leukaemias as compared with similar reports from the developed countries. Survival in Hodgkin's disease was influenced by clinical stage and age at presentation.

Intraluminal brachytherapy in carcinoma of the oesophagus: comparison of afterloading techniques

For improved local control or palliation of oesophageal cancers, Intra-luminal brachytherapy (ILB) has emerged as an increasingly popular treatment modality of therapy in recent years. In combination with external radiotherapy, afterloaded ILB can increase local control rates and may prolong survival of these patients. In this paper two techniques of ILB viz., manual and low dose-rate remote after loading methods, using Caesium-137 tubes and pellets respectively, are described in detail. On comparison of these two techniques it was found that both of them were similar with respect to their physical characteristics (dose rate, dose fall-off, maximum spinal cord dose, total reference air kerma, etc.). Clinically, the manual afterloaded ILB technique was found to be easier to use when compared with the low-dose rate remote afterloader. In addition, the number of patients with uterine cancers being high in a developing country, it was found that it was inappropriate to use the low dose remote afterloaders, designed for use in gynaecological cancers, for ILB of oesophageal cancers. Therefore, in the absence of high dose rate afterloaders, which can be utilized for intracavitary treatments of both uterine and oesophageal malignancies effectively, the manual after-loading ILB system as described in this paper could be a practical alternative. Cancer Oesophagus, Intraluminal radiotherapy technique.

Influence of intraluminal brachytherapy dose on complications in the treatment of esophageal cancer

PURPOSE

Demonstration of the influence of intraluminal brachytherapy dose on complications in the treatment of esophageal carcinoma.

METHODS AND MATERIALS

Between January 1990 and June 1991, 75 patients with esophageal cancer were treated with external radiotherapy followed by intraluminal brachytherapy. Patients had a Karnofsky score of over 70, with no supra-clavicular nodal or distant disease. An external radiotherapy dose between 40 and 55 Gy (mean 52 Gy), 5 times a week, 2 to 2.06 Gy/fraction, followed by a single session of Intraluminal brachytherapy using a locally developed, manual, afterloading applicator with Cs-137 sources with dose ranges of 8-10 Gy (Group 1: 42 patients), 10-12 Gy (Group 2: 11 patients), and 12-15 Gy (Group 3: 22 patients) at a mean dose rate of 2.09 Gy/hr was delivered.

RESULTS

The actuarial figures at 1 year were 39% for overall survival, 29% for disease-free survival, and 38% for local control. Fourteen patients (18.6%) developed complications of either an esophageal stricture or fistula. These were dependent on intra-luminal brachytherapy dose, whereas external radiotherapy and intra-luminal brachytherapy doses did not contribute significantly to local control. For Groups 1, 2, and 3, actuarial local control were 28%, 45%, and 63% (p < 0.1) and of complications were 6%, 20%, and 70% (p < 0.001), respectively. Also, on applying the Time/Dose/Fractionation formula on brachytherapy doses, it was found that the complication rate was 6% for TDF of < 31, 25% for TDF of 32-37, and 70% for TDF of > 38 (p < 0.001).

CONCLUSION

External radiotherapy doses in the range of 50 to 55 Gy followed by a dose of 10-12 Gy of intraluminal brachytherapy was found optimal with respect to complications and local control in the radiotherapeutic management of esophageal cancer.

The dose time relationship in the radiotherapy of carcinoma of the cervix--application of CRE formalism

A retrospective analysis of 291 patients with cancer of the uterine cervix treated with a combination of external and intracavitary radiotherapy was carried out. Patients were either treated with 45 Gy in 20 fractions by five fractions per week or with 42 Gy in 14 fractions by three fractions per week or with 42 Gy in 14 fractions by three fraction per week schedule by external radiotherapy. For brachytherapy the total dose was 24 to 32 Gy at a dose rate of 1.4 to 2.2 Gy per hour. Complication were correlated with total CRE values for point A (CRE TA) and for rectum CRE TR. Correlations of CRE TA with overall complication rate (p value < 0.05) and rectal complication rate (p value < 0.01) were excellent. Lack of correlation was observed between CRETR and overall complication rate (p value > 0.1) as well as rectal complication rate (p value > 0.1). In order to limit Grade II and III rectal and bladder complications to acceptable level, in combined external and intracavitary treatments, CRETA value of less than 2500 reu is suggested.

Intraluminal brachytherapy in oesophageal cancer: a simple afterloading technique

Carcinoma of the oesophagus occurs in a good number of patients in any oncology department. Management is either by surgery or radiotherapy. In view of the proximity of the oesophagus to the critical organs in the thorax, effective external beam radiotherapy becomes difficult. A possible solution could be the use of intraluminal brachytherapy (ILB) in addition to external radiotherapy. In this paper a simple and locally developed method of ILB is described which delivers an effective boost to the oesophageal lesion in radical treatments and gives good palliation in advanced cases. Also, this system takes the load off the low dose rate afterloading machines used for intracavitary therapy in gynaecological cancers which otherwise would have also been used for the ILB treatment of oesophageal cancers. A description of the manual afterloading ILB applicator, the technique of its application, and a review of literature, is presented.

Application of radiation effect models in combined external and intracavitary radiotherapy of carcinoma of the uterine cervix

A retrospective analysis of 291 patients with cancer of the uterine cervix treated with a combination of external and intracavitary radiotherapy was carried out. Patients were treated with an external radiotherapy dose of 45 Gy in 20 fractions, 5 fractions per week, or 42 Gy in 14 fractions, 3 fractions per week. For brachytherapy the total dose was 24 to 32 Gy at a dose rate of 1.4 to 2.2 Gy per hour. Treatment results in terms of survival, local disease-free survival and complication rates were compared with cumulative radiation effect (CRE) and extrapolated response dose (ERD) values for point A (CRETA and ERDTA respectively) and for rectum (CRETr and ERDTr respectively). CRETA and ERDTA values did not significantly correlate with local disease-free and survival rates. Correlations of CRETA and ERDTA with overall complication rate and with rectal complication rate (p-value less than 0.025) were good. No significant correlation was observed between CRETr or ERDTr and overall complication rate and rectal complication rate. In order to limit grades II and III rectal complications to acceptable level, in combined external and intracavitary treatment, CRETA and ERDTA values of less than 2,500 and 93 respectively are suggested.

The time dose fractionation (TDF) relationship in the radiotherapy of carcinoma of the cervix

A retrospective analysis of 291 patients with cancer of the uterine cervix treated with a combination of external and intracavitary radiotherapy was carried out. Patients were either treated with 45 Gy in 20 fractions by five fractions per week or with 42 Gy in 14 fractions by three fractions per week schedule by external radiotherapy. For brachytherapy the total dose was 24 to 32 Gy at a dose rate of 1.4 to 2.2 Gy per hour. Treatment results in terms of response, survival, recurrence and complication were correlated with total TDF values for point A (TDFTA) and for rectum TDFTR. Correlations of TDFTA with overall complication rate (p value less than 0.05) and rectal complications rate (p value less than 0.01) were excellent. TDFTA values did not correlate with response, recurrence and survival rates (p value greater than 0.1). Lack of correlation was observed between TDFTR and overall complication rate (p value greater than 0.1) as well as rectal complication rate (p value greater than 0.1). In order to limit grade II and III rectal and bladder complications to acceptable level, in combined external and intracavitary treatments, TDFTA value of less than 150 is suggested.

cAMP-activated C1 conductance is expressed in Xenopus oocytes by injection of shark rectal gland mRNA

Development of reliable expression systems for use in identification and functional characterization of proteins required for secretory Cl channel activity is key to understanding the molecular basis of cystic fibrosis (CF). Until now, heterologous expression of epithelial Cl channels had not been accomplished. We show here that Xenopus oocytes express an adenosine 3',5'-cyclic monophosphate (cAMP)-activated Cl conductance after injection of mRNA from shark rectal gland. Current through this conductance was rapidly activated by intracellular application of cAMP, reversed near the chloride equilibrium potential (ECl), blocked by the Cl channel inhibitor 5-nitro-2-(3-phenylpropylamino) benzoate, and was not affected by preincubation with the intracellular calcium buffer bis-(2-amino-5-methylphenoxy)-ethane-N,N,N',N'-tetraacetic acid tetraacetoxymethyl ester, a condition that prohibits activation of the endogenous Ca-activated Cl conductance.

Epithelial K channel expressed in Xenopus oocytes is inactivated by protein kinase C

K homeostasis is maintained in higher animals by epithelia of the kidney and intestine. Little is known regarding the molecular regulation of K secretion. We injected Xenopus oocytes with mRNA from teleost intestine, a K-secreting epithelium with apical membrane K channels. Oocytes expressed a conductance that displayed whole-cell current properties with the following characteristics: marked selectivity for K over Na and Cl, voltage-independent kinetics, Ca insensitivity, tonic activation, and inward rectification in symmetrical K. Barium, quinine, and tetraethylammonium blocked the conductance, whereas apamin, charybdotoxin, and 4-aminopyridine did not. The K conductance was rapidly (t1/2 = 10 min) and completely inactivated by 4 beta-phorbol 12-myristate 13-acetate but not by 4 alpha-phorbol 12,13-didecanoate. Sucrose density gradient fractionation revealed that mRNA required for expression is in the 1- to 2-kilobase size range, suggesting the possibility that a single subunit encodes the channel. The K conductance expressed from injection of size-fractionated mRNA was identical in all respects to that seen using unfractionated mRNA, including response to 4 beta-phorbol 12-myristate 13-acetate. The results suggest that protein kinase C regulates K secretion in epithelia by modulation of apical K channels.