Pseudoangiomatous stromal hyperplasia of the breast, imaging and clinical perspective: A review

Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast pathology, which most commonly presents incidentally along with other breast pathologies. The etiology and pathogenesis of PASH are still unknown; however, there is some evidence suggesting PASH is hormone dependent. The clinical history, presentation, and imaging appearance of PASH are variable. Clinically, PASH has a wide spectrum of presentations, from being silent to gigantomastia. On imaging, PASH demonstrates various benign to suspicious features. Here we summarize PASH's clinical presentation, histopathology, imaging features, and management.

[Safety and efficacy of transcatheter tricuspid valve replacement with LuX-Valve in patients with severe tricuspid regurgitation]

Objectives: To evaluate the safety and efficacy of LuX-Valve on the treatment of severe tricuspid regurgitation (TR). Methods: This is a prospective observational study. From September 2018 to March 2019, 12 patients with severe TR, who were not suitable for surgery, received LuX-Valve implantation in Changhai Hospital. LuX-Valve was implanted under general anesthesia and the guidance of transesophageal echocardiography and X-ray fluoroscopy. Access to the tricuspid valve was achieved via a minimally invasive thoracotomy and transatrial approach. Main endpoints were surgery success and device success. Surgery success was defined as successful implanting the device and withdrawing the delivery system, positioning the valve correctly and stably without severe or life-threatening adverse events. Device success was defined as satisfied valve function (TR severity reduction ≥ 2 grades, tricuspid gradient ≤ 6 mmHg (1 mmHg=0.133 kPa)), absence of malposition, valve failure and reintervention, major adverse events including device related mortality, embolization, conduction system disturbances and new onset shunt across ventricular septum at day 30 post implantation. Results: A total of 12 patients with severe to torrential TR were included in this study. The age was (68.5±6.9) years and 7 were female. All patients had typical right heart failure symptoms. Procedural success was achieved in all cases, there was no intraprocedural mortality or transfer to open surgery. TR significantly improved after LuX-Valve implantation (none/trivial in 8 patients, mild in 3 patients and moderate in 1 patient). The average device time was (9.2±4.2) minutes. Intensive care unit duration was 3.0 (2.0, 4.8) days. One patient died at postoperative day 18 due to non-surgery and device reasons. Transthoracic echocardiography at 30 days after operation showed that TR was significantly reduced (none/trivial in 8 patients, mild in 2 patients and moderate in 1 patient) and device success was achieved in 11 cases. All survived patients experienced a significant improvement in life quality with significantly improvement in New York Heart Association (NYHA) classification (Ⅰ and Ⅱ: 6/11 post operation vs. 0/11 before operation, P=0.012) and there were no device related complications in this patient cohort. Conclusions: LuX-Valve implantation is feasible, safe and effective for the treatment of patients with severe TR.

[The multicenter study on the registration and follow-up of low anticoagulation therapy for the heart valve operation in China]

OBJECTIVE

To investigate the optimal anticoagulation methods and monitoring strategy for Chinese patients undergoing heart valve replacement, which is potentially quite different from western populations.

METHODS

In this multicenter prospective cohort study, the anticoagulation and monitoring strategy data was acquired from 25 773 in-hospital patients in 35 medical centers and 20 519 patients in outpatient clinic in 11 medical centers from January 1st, 2011 to December 31th, 2015.

RESULTS

As for in-hospital patients, mean age of study population was (48.6±11.2) years old; main etiology of valve pathology was rheumatic (87.5%) origin among study cohort; 94.8% of study population received mechanical valve implantation; international normalized ratio (INR) monitoring (in all the study centers) and low-intensity anticoagulation strategy (31 hospitals chose target INR range of 1.5-2.5, and actual values of INR among 89.2% of 100 069 in-hospital monitoring samples were 1.5-2.5), with mean actual INR values of 1.84±0.53, and warfarin dosage of (2.82±0.93) mg/d were widely adopted among the study centers; strategies of in-hospital warfarin administration were similar in all the study centers; complication rates of low-intensity anticoagulation strategy were low in severe hemorrhage (0.02%), thrombosis (0.05%), and thromboembolism (0.05%) events, without anticoagulation-related death.As for 18 974 outpatient clinic patients, the follow-up rate was 92.47%, with a total of 30 012 patient-years (Pty). Anticoagulation-related morbidity and mortality rates were 0.67% and 0.15% Pty; major hemorrhage morbidity and mortality rates were 0.25% and 0.13% Pty; thromboembolism morbidity and mortality rates were 0.45% and 0.03% Pty.The mean dosage of warfarin daily dosage was (2.85±1.23) mg/d and INR value was 1.82±0.57.No significant regional difference in the intensity of anticoagulation therapy was noted during the study.

CONCLUSIONS

INR can be used as a normalized indicator for intensity of anticoagulation therapy in China.The optimal anticoagulation intensity with INR range from 1.5 to 2.5 is safe and effective for Chinese patients with heart valve replacement, and there is no significant regional difference in the intensity of anticoagulation therapy.

Congenital diaphragmatic hernia misdiagnosed as pneumothorax in a newborn

Congenital diaphragmatic hernia (CDH) is usually left sided and has a large defect allowing abdominal viscera herniated into thoracic cavity. The chest films usually show air-filled stomach and/or loops of bowel in the ipsilateral hemithorax with mediastinal shift. We report a newborn with CDH, presenting as hyperlucent hemithorax, right-shifted mediastinum, apparently normal pattern of abdominal bowel gas, with the tip of nasogastric tube below the left hemidiaphragm on the radiograph. It was initially misdiagnosed as pneumothorax, and the acute respiratory distress was temporarily relieved by needle aspiration. Hyperlucent hemithorax due to intrathoracic gastric dilatation alone is an unusual presentation of CDH in neonatal period. Absence of stomach bubble in the left upper quadrant of the abdomen, in both radiography and abdominal sonography, is an important clue to make diagnosis of CDH in this misleading condition.

Hypovolemia and hypovolemic shock in children with nephrotic syndrome

Hypovolemic shock is not an uncommon presentation in nephrotic syndrome, yet it is seldom mentioned in the literature. This study was performed to investigate the prevalence of hypovolemia and hypovolemic shock in the acute nephrotic stage, and the association of hemoconcentration and abdominal pain with hypovolemic status. Two hundred and twenty-five patients with a total of 328 admissions to the pediatric ward of our hospital during 1983 to 1996 were retrospectively reviewed for hypovolemic episodes. Clinical presentation and laboratory data including hemoglobin, serum sodium, albumin, cholesterol, and triglyceride levels were investigated. Thirteen patients with 19 episodes (5.8%) of hypovolemic shock were found, and had more severe hemoconcentration (hemoglobin 19.6 +/- 2.2 g/dL) and hyponatremia (127.3 +/- 7.2 mEq/L). Another 33 patients with 41 symptomatic hypovolemic episodes without hypotension (12.5%) were found, and their hemoglobin levels were higher compared to patients without hypovolemic symptoms. Among 61 episodes of abdominal pain and hemoconcentration, 58 were responsive to albumin infusion. This suggested the presence of hypovolemia. Twenty patients had abdominal pain without hemoconcentration, and 18 of them had primary peritonitis. Hypovolemia was found in patients at the acute nephrotic stage, and was usually associated with hemoconcentration and abdominal pain. A combined examination of hemoglobin and serum sodium is the best indicator of hypovolemic status. Both primary peritonitis and hypovolemic episodes should be taken into consideration when managing abdominal pain in children with nephrotic syndrome.

Thyroplasty type I: short- versus long-term results

OBJECTIVE

After thyroplasty type I, significant improvement has been reported in objective measures of vocal function. The purpose of this investigation was to compare the short- and long-term results in patients undergoing thyroplasty type I.

METHODS

Data on 26 patients who had undergone thyroplasty type I for management of unilateral vocal fold paralysis were compared from before surgery to the short-term (1-month) and long-term (>1-year) postoperative assessment points. Statistical analysis included paired tests to assess the significance of between-group differences.

RESULTS

Significant differences were found between the preoperative and both postoperative evaluations for the measures of mean glottal flow rate, maximum phonation time, jitter, shimmer, and harmonic-to-noise ratio. However, no significant differences were found between the 1-month and >1-year assessment points.

CONCLUSIONS

The results for the parameters studied appeared to reach maximum improvement within 1 month after surgery. It is possible that the effects of time, including the normal aging process, hormonal changes, or other alterations in general health, may require longer follow-up to better address these issues.

Longitudinal study of serum free thyroxine and thyrotropin levels by chemiluminescent immunoassay during infancy

From October 1996 to December 1997, ninety normal infants born at full-term were enrolled in this study. There were 59 female infants and 31 male infants. Both serum free thyroxine and thyrotropin levels were measured by chemiluminescent immunoassay in the first week (n = 75), 3 months (n = 66), 6 months (n = 79), and 12 months (n = 77) of age. Serum free thyroxine levels (ng/dL) (mean +/- standard deviation) were 2.2 +/- 0.5, 1.3 +/- 0.2, 1.2 +/- 0.2, 1.0 +/- 0.2 for each age group, respectively. Serum thyrotropin levels (mIU/L) (mean +/- standard deviation) were 9.7 +/- 6.7, 3.0 +/- 1.6, 2.7 +/- 1.3, 2.5 +/- 1.2 for each age group, respectively. There was no significant difference between the levels of these two parameters between male and female. The present study provides the reference data for the normal range of thyroid function during infancy. Our results also show that the serum free T4 and TSH levels tend to decline during the first year of life.

Neonatal type of nonketotic hyperglycinemia

Two infants with the neonatal type of nonketotic hyperglycinemia that had manifested as early neonatal consciousness disturbance are presented. Transient hyperammonemia had been detected in both initially. High levels of glycine in plasma and cerebrospinal fluid disturb the nervous system, causing variable manifestations of this disease. Both cases were complicated by intracranial hemorrhage, which has never before been reported. After treatment with sodium benzoate and dextromethorphan, some neurologic improvement was observed, although the glycine levels did not lower. Recent clinical trials are reviewed, and because of the unfavorable outcomes, the special need for prenatal diagnosis is highlighted.

Nephrocalcinosis in childhood

Charts of 16 children with nephrocalcinosis between 1990 and 1997 were reviewed. The cause of nephrocalcinosis was believed to be iatrogenic in 7 patients (43.8%) and non-iatrogenic in 9 (56.2%). Vitamin D therapy was responsible for 5 patients of iatrogenic nephrocalcinosis, and furosemide therapy for the remaining iatrogenic patients. Non-iatrogenic cases consisted of 3 patients with renal tubular acidosis, 3 patients with idiopathic hypercalciuria, and the 3 other patients with rare underlying conditions. Abdominal X-ray detected nephrocalcinosis in only 2 (12.5%) of the total 16 patients. None showed resolution of nephrocalcinosis during these years of follow-up.

The effect of patient factors on response outcomes to Botox treatment of spasmodic dysphonia

Injection of botulinum toxin (Botox) into the laryngeal muscles has become the treatment of choice for controlling the symptoms of spasmodic dysphonia (SD). Currently, no specific battery of objective tests to assess the outcome is universally accepted. The purpose of this study was to investigate demographic, clinical, and treatment factors with voice outcome following Botox injection. Sixty-eight patients with adductor SD who underwent at least one Botox injection during a 5-year period were studied. Voice outcome measures were made from patient self-reporting scales and included overall vocal quality, length of response, and duration of breathiness. Vocal quality was significantly correlated with the underlying severity of vocal symptoms prior to treatment, incidence of breathiness and unilateral versus bilateral injection. The length of response was greater in males and following bilateral injections. An increased period of breathiness significantly correlated with bilateral injections.

Symptomatic hypomagnesemia in children

Between January 1996 and June 1998, 24 children with symptomatic hypomagnesemia were enrolled for analysis of their symptomatology, causes, and treatment outcome. Hypocalcemia and hyperphosphatemia suggesting impaired parathyroid function were the most common electrolyte disorders. Hypokalemia was also frequently noted. The related symptoms including seizure, tetany, and weakness were common. Drug-induced renal magnesium wasting was the most common cause of symptomatic hypomagnesemia, and tended to occur in older children using aminoglycoside, furosemide, and amphotericin-B. The associated gastrointestinal causes might add a minor contribution to the development of hypomagnesemia. Analyses of PTH levels in 13 children suggested that inhibition of PTH synthesis or secretion was responsible for hypomagnesemic hypocalcemia in most patients. However, peripheral PTH resistance might also account for the mechanism in a few patients. In most patients, symptomatic hypomagnesemia was transient, and improved after magnesium provision. Only one child with congenital renal magnesium wasting and two with primary hypomagnesemia needed long-term magnesium treatment.

The human tail

The human tail is a congenital anomaly with a protruding lesion from the lumbosacrococcygeal region. A newborn with a tail-like structure over the coccygeal area observed since birth is presented. Lipoma accompanied by tethered spinal cord were found. In reviewing the literature from 1960 to 1997, 59 cases were described. Higher incidences of spinal dysraphism (49.15%) and tethered spinal cord (20.34%) compared with previous reports were evident. This fact plays an important role in understanding the disturbance of development and regression of human tails. A new classification according to whether the anomaly appears in combination with spinal dysraphism is proposed for clinical usage. Preoperative detailed image studies are needed to clarify the possibility of tethered spinal cord syndrome developing in the future and thus prevent it. Magnetic resonance imaging is the modality of choice if available. Long-term follow-up for possible sequelae after operation, especially in cases with spinal dysraphism, is necessary.

Cause of hoarseness in elderly patients

Hoarseness is a common symptom in older individuals and may reflect a wide variety of pathologic, medical, physiologic, and/or functional causes. Although vocal fold atrophy is one of the more common reported findings in the elderly, inconclusive information is known about the differential diagnosis and cause of dysphonia in older individuals. The purpose of this investigation was to review the cause of hoarseness in all patients older than 65 years and to determine any correlation with advancing age and other demographic factors. Additionally, we wanted to determine the effect vocal pathology has on objective voice measures with advancing age. The two most common causes of hoarseness found in 393 patients older than 65 years were vocal fold bowing and unilateral vocal fold paralysis, followed by benign vocal fold lesions, voice tremor, and spasmodic dysphonia. Although objective measures of vocal function were abnormal compared with reported normative data, they did not increase in severity with advancing age. Apparently, the compounding effect of age on underlying vocal pathology does not increase the severity of the vocal disturbance, at least as represented by objective voice measures. The high incidence of medical illnesses seen in this population also needs to be kept in mind because it may further affect the underlying voice disturbance. It might be interesting to compare data on the patients' perceptions of their vocal disturbance for each disorder as a function of age. It would also be helpful to know whether patients responded to treatment differentially based on age.

Vocal evaluation of thyroplasty type I in the treatment of nonparalytic glottic incompetence

This study investigated the prethyroplasty and postthyroplasty voices of patients with glottic incompetence of mobile vocal folds related to vocal fold bowing and scarring. Seventeen patients underwent vocal function evaluation preoperatively and 1 month postoperatively with videostrobolaryngoscopic examination, acoustic and aerodynamic analysis, and perceptual judgment of voice characteristics. The postoperative voice outcome in this group of patients was compared to that of a group of patients with unilateral vocal fold paralysis. Patients with vocal fold bowing showed significant improvement in glottic gap size and hoarseness after the surgery. There was minimal improvement on other test measures. Patients with vocal fold scarring exhibited worse preoperative and postoperative vocal functions, with little voice improvement after surgery. The outcome of thyroplasty type I in cases of vocal fold bowing or scarring is not as good as that in unilateral vocal fold paralysis.

Lateral arm microvascular flap in head and neck reconstruction

OBJECTIVES

To report our results of a study of 28 patients who underwent sequential reconstructions of the head and neck using the lateral arm flap. To discuss the situations where we have found the procedure useful, report the complication rates, and delineate the advantages and disadvantages of using this flap.

DESIGN

A clinical series of patients was followed up prospectively. The swallowing function of a subgroup that underwent oropharyngeal reconstruction was compared with that of a simultaneous control group that underwent reconstruction with the pectoralis major flap.

SETTING

University medical center.

PARTICIPANTS

Patients with malignant neoplasms of the head and neck who underwent resections and reconstruction with the lateral arm flap.

INTERVENTIONS

Twenty-eight patients underwent head and neck reconstruction using lateral arm flaps. In 17 patients, the lateral arm flaps were used for pharyngeal and posterior oral cavity defects. Thirteen of these patients underwent reinnervation. Nine combined palatal and midfacial defects were reconstructed, and 1 lateral facial defect was reconstructed. Most cases were advanced malignant neoplasms and represented a selected minority of similar resections performed at our institutions. Three maxillary reconstructions were performed secondarily. All other reconstructions were performed at the time of tumor ablation.

MAIN OUTCOME MEASURES

Data were collected regarding flap survival, return of sensation in flaps, complication rates, and the ability to feed orally.

RESULTS

All flaps survived in their entirety. Of 7.5 tested flaps acquired sensation. Of 14 patients with large oropharyngeal defects, 8 resumed early oral feeding and all survivors eventually obtained nutrition orally. The ability to swallow was superior to the results obtained in a retrospective analysis of a group reconstructed using pectoralis major flaps.

CONCLUSIONS

A unique feature of this flap is that it incorporates both thin skin from the proximal forearm and thicker skin from the upper arm. This is ideal for an oropharyngeal defect, where the thin malleable portion can be used in the posterior oral cavity or pharyngeal wall and the thicker portion in the tongue base. Either portion can be used alone as well. The availability of intermediate tissue bulk can also be advantageous for midfacial reconstruction. Sensation can be reliably reconstituted with this flap. We think that the lateral arm flap is versatile and has particularly low donor-site morbidity.

Tricho-rhino-phalangeal syndrome type II associated with epiglottic aplasia and congenital nephrotic syndrome

A male neonate with tricho-rhino-phalangeal syndrome type II (Langer-Giedion syndrome) and interstitial deletion of chromosome 8 with karyotype 46, XY, del (8) (q24.11-->q24.13) is reported. In addition to hypotrichosis of the scalp hair, abnormally bulbous nose and redundant skin, which are usually found in this syndrome, aplasia of the epiglottis and non-Finnish type congenital nephrotic syndrome were also present. He died of renal failure and respiratory failure at 11 days of age. Electron microscopy of renal necropsy showed foot process loss, focal thickening and splitting of the glomerular basement membrane and mesangial expansion. These have never been reported and could be new associations in this disease that may serve to support the concept of contiguous gene syndrome in patients with tricho-rhino-phalangeal syndrome.

Abnormal soft palate posturing in patients with laryngeal movement disorders

Laryngeal movement disorders (LMDs), including spasmodic dysphonia and essential voice tremor, have been described as focal disorders affecting the muscles of the larynx. Little reference has been made to possible hyperfunction of supralaryngeal structures and/or palatal involvement. Videonasolaryngoscopic examinations of 83 patients with LMDs revealed a significantly high incidence of abnormal soft palate posturing (84%). Further associations and implications are presented.

Longitudinal evaluation of vocal function after thyroplasty type I in the treatment of unilateral vocal paralysis

This study investigated longitudinal changes of vocal efficiency and stability after primary thyroplasty type 1. Fifty-three patients with unilateral vocal-fold paralysis underwent vocal-function evaluation preoperatively and at periodic intervals of 1, 3, and 6 months postoperatively. Vocal-function assessment included videostrobolaryngoscopic examination, acoustical and aerodynamic analysis, and perceptual judgment of voice characteristics. Parameters that included glottic-gap size, maximum phonation time, glottic-flow rate, jitter, harmonic/noise ratio, breathiness, hoarseness, loudness, and phrasing showed significant improvement after thyroplasty and remained stable as early as 1 month postoperatively, with only slight fluctuations over a 6-month period. Postoperative voice outcome was not affected by age, sex, duration of vocal symptoms, cause of paralysis, or preoperative pulmonary function.

Decapitation ischemia-induced release of free fatty acids in mouse brain. Relationship with diacylglycerols and lysophospholipids

In this study, the release of lysophospholipids (to depict phospholipase A2 activity) and diacylglycerols (DG) (to depict stimulated hydrolysis of polyphosphoinositides) was related to the decapitation-induced release of free fatty acid (FFA) in the mouse brain. To assay for lysophospholipids, Balb/c mice were injected intracerebrally with either [3H]choline or [3H]inositol for 16 h in order to label their respective phospholipids. These lipids were examined at various times (30 s to 30.5 min) after decapitation. Between 30 s and 1.5 min after decapitation, the rate of FFA release (3 micrograms FA/mg FA in phospholipids/min) was three times more rapid than that between 10 and 15 min (0.8 microgram FA/mg FA in phospholipids/min). FFA released during the initial phase were enriched in 20:4 and 18:0 whereas those released during the latter phase were nonspecific. The DG fatty acids are enriched in 18:0 and 20:4. Ischemia induced a rapid release of DG as measured by its fatty acid content (3.2 micrograms FA/mg FA in phospholipids/min). Unlike FFA, the level of DG reached a plateau after 1.5 min and remained elevated for the entire 30.5 min. In agreement with previous notions indicating the involvement of phospholipase A2 in ischemic insult, steady increases in radioactivity of both lysophosphatidylcholines and lysophosphatidylinositols were observed with time after decapitation. Based on the preferential increase in both 18:0 and 20:4 during the initial time period, the results suggest that poly-PI hydrolysis coupled to DG-lipase may contribute to the initial release of FFA, whereas the FFA released subsequent to the initial phase may be mainly a result of activation of phospholipase A2 acting on phosphatidylcholines and phosphatidylinositols.

Vowel production in a prelinguistic child following cochlear implantation

Formant frequencies were determined from vocalic utterances of a prelinguistically deafened child implanted with a Nucleus 22-channel device at age 5 years. Speech samples were obtained from recordings of speech made 5 and 2 months prior to implantation and at 6, 12, 18, 24, and 36 months post implantation. Prior to implantation, first formant values showed a greater range than those of normal hearing children of comparable age, and second formant values showed a greatly reduced range and clustered around a mean of 1800 Hz. By 36 months post implantation, first formant values approximated age-matched norms. By 6 months post implantation, higher second formant values were apparent. A progressive shift in second formant values was noted through 36 months post implantation when the vocalic space most closely corresponded to age-matched normative data.

[Microsurgical treatment of trigeminal neuralgia]

129 cases of trigeminal neuralgia were treated microsurgically. The roots of trigeminal nerves were found to be affected by arteries in 96 cases, by veins in 23, and by both arteries and veins in 10. According to these relations, the disease was divided into 3 types: (1) contiguous type (49 cases, 37.9%), vessels 1 mm close to the nerves without any compression; (2) compressive type (42, 32.5%), vessels close to the nerves with compression; (3) adhesive type (38, 29.5%), vessels and nerves adhered to each other. A piece of dacron was used to wrap the nerve root and fixed by gelfoam and silver clip. Pain relieved immediately after operation in 123 cases with an effective rate of 98.4%.

[Mortality rate of malignant tumors in Yangzhong County]

Complete and reliable data of mortality rate of malignant tumors from 1973 to 1982 in Yangzhong County, Jiangsu Province, China are reported. The annual mortality rate was 271.38/100,000 which is the highest of all counties in China. Among the malignant tumors, the mortality rates of esophageal, stomach, liver and intestinal cancers are 100.77/100,000, 90.25/100,000, 31.25/100,000 and 11.95/100,000, respectively. Moreover, the mortality rates of lung, cervical cancers and leukemia are also rather high. The mortality rate of esophageal cancer in the female is higher than that in the male. There have been no obvious changes in the mortality rates of some chief malignant tumors in the past ten years. For the high mortality rates of various malignancies in Yangzhong county, epidemiological factors should be further investigated.