Extra-cardiac and complex Fontan baffle fenestration using radio frequency current via surgical electrocautery

BACKGROUND

Fontan baffle punctures and creation of Fontan fenestration for cardiac catheterisation procedures remain challenging especially due to the heavy calcification of prosthetic material and complex anatomy.

OBJECTIVES

We sought to evaluate our experience using radiofrequency current via surgical electrocautery needle for Fontan baffle puncture to facilitate diagnostic, electrophysiology, and interventional procedures.

METHODS

A retrospective chart review of all Fontan patients (pts) who underwent Fontan baffle puncture using radiofrequency energy via surgical electrocautery from three centres were performed from January 2011 to July 2021.

RESULTS

A total of 19 pts underwent 22 successful Fontan baffle puncture. The median age and weight were 17 (3-36 years) and 55 (14-88) kg, respectively. The procedural indications for Fontan fenestration creation included: diagnostic study (n = 1), atrial septostomy and stenting (n = 1), electrophysiology study and ablation procedures (n = 8), Fontan baffle stenting for Fontan failure including protein-losing enteropathy (n = 7), and occlusion of veno-venous collaterals (n = 2) for cyanosis. The type of Fontan baffles included: extra-cardiac conduits (n = 12), lateral tunnel (n = 5), classic atrio-pulmonary connection (n = 1), and intra-cardiac baffle (n = 1). A Fontan baffle puncture was initially attempted using traditional method in 6 pts and Baylis radiofrequency trans-septal system in 2 pts unsuccessfully. In all pts, Fontan baffle puncture using radiofrequency energy via electrocautery needle was successful. The radiofrequency energy utilised was (10-50 W) and required 1-5 attempts for 2-5 seconds. There were no vascular or neurological complications.

CONCLUSIONS

Radiofrequency current delivery using surgical electrocautery facilitates Fontan baffle puncture in patients with complex and calcified Fontan baffles for diagnostic, interventional, and electrophysiology procedures.

Patterns of Electrocardiographic Abnormalities in Children with Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM), a common cardiomyopathy in children, is an important cause of morbidity and mortality. Early recognition and appropriate management are important. An electrocardiogram (ECG) is often used as a screening tool in children to detect heart disease. The ECG patterns in children with HCM are not well described.ECGs collected from an international cohort of children, and adolescents (≤ 21 years) with HCM were reviewed. 482 ECGs met inclusion criteria. Age ranged from 1 day to 21 years, median 13 years. Of the 482 ECGs, 57 (12%) were normal. The most common abnormalities noted were left ventricular hypertrophy (LVH) in 108/482 (22%) and biventricular hypertrophy (BVH) in 116/482 (24%) Of the patients with LVH/BVH (n = 224), 135 (60%) also had a strain pattern (LVH in 83, BVH in 52). Isolated strain pattern (in the absence of criteria for hypertrophy) was seen in 43/482 (9%). Isolated pathologic Q waves were seen in 71/482 (15%). Pediatric HCM, 88% have an abnormal ECG. The most common ECG abnormalities were LVH or BVH with or without strain. Strain pattern without hypertrophy and a pathologic Q wave were present in a significant proportion (24%) of patients. Thus, a significant number of children with HCM have ECG abnormalities that are not typical for "hypertrophy". The presence of the ECG abnormalities described above in a child should prompt further examination with an echocardiogram to rule out HCM.

ALARA in Pediatric Electrophysiology Laboratory

The effects of radiation on patients and the providers are dose-dependent and cumulative. Pediatric patients are not only more sensitive to radiation but also may undergo more procedures and diagnostic tests throughout their lifetime. As providers, the endeavor is to cause no harm and it behooves us to either eliminate or minimize the radiation exposure to patients without affecting the efficacy and outcomes of the diagnostic or therapeutic modalities. Pediatric electrophysiologists have taken the lead in attempting to minimize the radiation exposure to patients and staff with innovative and advanced techniques. The techniques range from minimizing the exposure to radiation with better understanding and applications of the physics associated with fluoroscopic imaging to using alternative imaging modalities that do not use radiation.

Role of Three-Dimensional Visualization Modalities in Medical Education

For the past two decades, slide-based presentation has been the method of content delivery in medical education. In recent years, other teaching modalities involving three-dimensional (3D) visualization such as 3D printed anatomical models, virtual reality (VR), and augmented reality (AR) have been explored to augment the education experience. This review article will analyze the use of slide-based presentation, 3D printed anatomical models, AR, and VR technologies in medical education, including their benefits and limitations.

Impact of Obesity on Left Ventricular Thickness in Children with Hypertrophic Cardiomyopathy

Obesity is associated with additional left ventricular hypertrophy (LVH) in adults with hypertrophic cardiomyopathy (HCM). It is not known whether obesity can lead to further LVH in children with HCM. Echocardiographic LV dimensions were determined in 504 children with HCM. Measurements of interventricular septal thickness (IVST) and posterior wall thickness (PWT), and patients' weight and height were recorded. Obesity was defined as a body mass index (BMI) ≥ 99th percentile for age and sex. IVST data was available for 498 and PWT data for 484 patients. Patient age ranged from 2 to 20 years (mean ± SD, 12.5 ± 3.9) and 340 (68%) were males. Overall, patient BMI ranged from 7 to 50 (22.7 ± 6.1). Obesity (BMI 18-50, mean 29.1) was present in 140 children aged 2-19.6 (11.3 ± 4.1). The overall mean IVST was 20.5 ± 9.6 mm and the overall mean PWT was 11.0 ± 8.4 mm. The mean IVST in the obese patients was 21.6 ± 10.0 mm and mean PWT was 13.3 ± 14.7 mm. The mean IVST in the non-obese patients was 20.1 ± 9.5 mm and mean PWT was 10.4 ± 4.3 mm. Obesity was not significantly associated with IVST (p = 0.12), but was associated with increased PWT (0.0011). Obesity is associated with increased PWT but not IVST in children with HCM. Whether obesity and its impact on LVH influences clinical outcomes in children with HCM needs to be studied.

Transseptal puncture using surgical electrocautery in children and adults with and without complex congenital heart disease

BACKGROUND

Atrial transseptal puncture (TSP) for cardiac catheterization procedures remain challenging in children and adults with complex congenital heart disease (CHD).

OBJECTIVES

We sought to evaluate our experience using radiofrequency (RF) current via surgical electrocautery needle for TSP to facilitate diagnostic and interventional procedures.

METHODS

Retrospective chart review of all patients (pts) who underwent TSP using RF energy (10-25 W) via surgical electrocautery from three centers from January 2011 to January 2017 were evaluated. Echocardiograms were reviewed to define the atrial septum as normal and complex (thin aneurysmal, thick/fibrotic, synthetic patch material, and extra cardiac conduit).

RESULTS

A total of 54 pts underwent 55 successful TSP. Median age was 12.5 years (1 day-54 years) and weight was 52.7 kg (2-162). Indications for TSP included; EP study and ablation procedures in structurally normal hearts (n = 24) and in complex atrial septum/CHD and structural heart disease pts (n = 30): Electrophysiology study and ablation in 4, diagnostic catheterization in 9, and interventional procedures in 17 pts were performed. Atrial TSP was successful in 54/55 (98%). Atrial perforation with tiny-small pericardial effusion not requiring intervention was noted in 2 pts. TSP was unsuccessful in one critically ill neonate with unobstructed TAPVR and restricted atrial septum who experienced cardiac arrest requiring CPR, ECMO, and emergent surgery.

CONCLUSIONS

RF current delivery using surgical electrocautery for TSP is a feasible and an effective option in patients with complex CHD for diagnostic, interventional, and electrophysiology procedures.

Is Interarterial Course a Requisite for Ischemia in Anomalous Origin of Coronary Arteries?

Anomalous origin of the left main coronary artery from the noncoronary sinus (LCANS) is a rare variant of anomalous aortic origin of a coronary artery that is not characterized by an interarterial course. Despite the absence of an interarterial course, there are rare reports of LCANS presenting with sudden death, life-threatening arrhythmia, exercise-induced myocardial ischemia, premature ventricular contractions, and syncope. We report a patient with LCANS presenting with acute myocardial infarction who recovered completely with emergent surgical unroofing of the coronary artery.

Feasibility, accuracy, and safety of 3-dimensional electroanatomic mapping without fluoroscopy in patients with congenital heart defects

BACKGROUND

Use of nonfluoroscopic 3-dimensional electroanatomic mapping (NF-3DEAM) in patients with congenital heart defects (CHDs) is not well reported.

OBJECTIVE

The purpose of this study was to evaluate the feasibility, accuracy, and safety of NF-3DEAM in patients with CHDs.

METHODS

Retrospective review of electrophysiologic study (EPS) in patients with CHD from 2009 to 2013 was conducted. Patients undergoing EPS with NF-3DEAM using the EnSite NavX system (St. Jude Medical) were included and those with fluoroscopy were excluded. Cardiac angiography performed in close proximity was matched with 3DEAM by proper aspect ratio using manual alignment by overlay images and comparing distances between cardiac landmarks using Pearson correlation coefficient and intraclass correlation. Success and complications were reviewed.

RESULTS

Three-dimensional electroanatomic mapping and angiograms were compared in 48 EPS (45 patients); 13 patients with intracardiac leads, quiescent chambers indicating significant scarring, and who required transseptal puncture were excluded. Indications for EPS included documented tachyarrhythmia and preoperative mapping. Mean age was 25.3 ± 9.8 years. Simple CHDs (isolated shunt lesions or valvular lesions) were identified in 13 studies (27%) and complex CHDs (others) were identified in 35 studies (73%). Ablations were performed in 25 studies (52%). Average time to obtain right atrial geometry was 25.3 minutes (range 14-47 minutes) and right ventricular geometry was 22.8 minutes (range 12-35 minutes). Pearson correlation coefficient and intraclass correlation of cardiac landmarks were 0.90 and 0.80, respectively. Anatomic landmarks, mapping, and ablation were accurate in all 3DEAMs. No complications were recorded.

CONCLUSION

NF-3DEAM is feasible, safe, and accurate in CHD patients without extensive scarring, intracardiac leads, and need for transseptal puncture.

Primary hip spica with crossed retrograde intramedullary rush pins for the management of diaphyseal femur fractures in children: A prospective, randomized study

Background:

Femoral fractures are common in children aged between 2 and 12 yearsand 75% of the lesions affect the femoral shaft. Traction followed by a plaster cast is universally accepted as a conservative treatment. We compared primary hip spica or traction followed by hip spica with closed reduction and fixation with retrogradely passed crossed Rush pins for diaphyseal femur fracture in 25 children of the age group 3-12 years, randomly distributed in each group.

Materials and Methods:

Fifty children (age: 3-13 years, mean; 9 years) with femoral fractures were evaluated; 25 of them underwent the conservative treatment using immediate hip spica (group A) and 25 underwent treatment with crossed retrograde Rush pins (group B).

Results:

Mean duration of fracture union was within 15 weeks in group A and 12 weeks in group B. Mean duration of weight bearing was 14weeks in group A and 7 weeks in group A. Mean hospital stay were 4 days in group A and 8days in group B. The man follow-up period was 16 months in group A and 17 months in group B. Complications like angulation, shortening and infection were compared. Bursitis and penetration of pins at the site of Rush pin insertion is a complication associated with this method of treatment.

Conclusion:

Closed reduction and internal fixation with crossed Rush pins was a superior treatment method in terms of early weight bearing and restoration of normal anatomy.

The asymptomatic teenager with an abnormal electrocardiogram

Use of medications for attention-deficit hyperkinetic disorder and preparticipation sports physical examination has led to an increase in number of electrocardiograms (ECG) performed during adolescence. Interpreting ECGs in children and young adults must take into account the evolutionary changes with age and the benign variants, which are usually not associated with heart disease. It is crucial for primary-care providers to recognize the changes on ECG associated with heart disease and risk of sudden death. In this article, the significance, sensitivity, specificity, and the diagnostic workup of these findings in the asymptomatic teenager are discussed.

Antitubercular drug-induced violent suicide of a hospitalised patient

We present a case where a young adult male, on treatment for multidrug-resistance tuberculosis (MDR-TB), developed drug-induced psychosis. The psychiatric symptoms were ascribed to the anti-TB drug and were duly withdrawn by the treating doctors and supplemented with other drugs. However, the victim continued to have psychiatric symptoms and committed suicide in the hospital. He ended his life in a violent manner by stabbing and cutting himself with a kitchen knife. The case is briefly reported in this paper with a discussion on anti-TB drug-induced psychiatric effects leading to suicide.

Catheterization-based intervention in low birth weight infants less than 2.5 kg with acute and long-term outcome

BACKGROUND

The number of low birth weight infants with congenital heart disease is increasing and catheterizations may have an increased risk for mortality and morbidity.

OBJECTIVES

We investigate the outcome and complications of cardiac catheterizations in infants weighing < 2.5 kg.

METHODS

Retrospective review of catheterization records from 1995 to 2010 in infants weighing < 2.5 kg. The demographics, procedure, outcome, and follow-up data were collected.

RESULTS

Of 101 catheterizations performed in 88 patients, 45 (45%) catheterizations were interventional. Balloon atrial septostomy (n = 23), pulmonary valvuloplasty (14), aortic valvuloplasty (4), stent placement (3), balloon angioplasty (2), and temporary pacemaker insertion (1) were successfully performed. Balloon atrial septostomy was performed with pulmonary or aortic valvuloplasty in two catheterizations. Infants < 2.5 kg had higher significant adverse event rate that those 2.5-3.5 kg (13% versus 6.6%, P < 0.05). No procedural death was noted. Significant adverse events (n = 13) included cardiopulmonary resuscitation three, vascular six, arrhythmia three, and apnea requiring intubation one. On median follow-up of 3 years (0.03 to 14), n = 69, mortality rate was 36%. In six patients with valvar pulmonary stenosis with median follow-up of 6 years (0.75-13), four (67%) did not require re-intervention. Of two patients with aortic stenosis, one did not require repeat intervention for 6 years (last follow-up).

CONCLUSION

Interventional catheterization is feasible with low procedural morbidity and mortality in high risk infants < 2.5 kg. Catheterization primarily serves as a palliative procedure to stabilize infants for definitive treatment. Balloon valvuloplasty may be effective for isolated valvar pulmonary stenosis in infants < 2.5 kg.

Pacing in children

The implantation of cardiac pacing devices in children and young adults can be challenging and different from the adult population due to their smaller size, their longer life expectancy, and anatomical variations associated with congenital heart defects. A knowledge of indications, pacing leads and devices, anatomical variations, and the technical skills are important for those who implant and care for children with pacemakers. In this review we attempt to discuss these specific points of cardiac pacing in children and young adults.

Cardiac pacing and defibrillation in children and young adults

The population of children and young adults requiring a cardiac pacing device has been consistently increasing. The current generation of devices are small with a longer battery life, programming capabilities that can cater to the demands of the young patients and ability to treat brady and tachyarrhythmias as well as heart failure. This has increased the scope and clinical indications of using these devices. As patients with congenital heart disease (CHD) comprise majority of these patients requiring devices, the knowledge of indications, pacing leads and devices, anatomical variations and the technical skills required are different than that required in the adult population. In this review we attempt to discuss these specific points in detail to improve the understanding of cardiac pacing in children and young adults.

The Study of Antiarrhythmic Medications in Infancy (SAMIS)

Background—

Supraventricular tachycardia (SVT) is one of the most common conditions requiring emergent cardiac care in children, yet its management has never been subjected to a randomized controlled clinical trial. The purpose of this study was to compare the efficacy and safety of the 2 most commonly used medications for antiarrhythmic prophylaxis of SVT in infants: digoxin and propranolol.

Methods and Results—

This was a randomized, double-blind, multicenter study of infants <4 months with SVT (atrioventricular reciprocating tachycardia or atrioventricular nodal reentrant tachycardia), excluding Wolff-Parkinson-White, comparing digoxin with propranolol. The primary end point was recurrence of SVT requiring medical intervention. Time to recurrence and adverse events were secondary outcomes. Sixty-one patients completed the study, 27 randomized to digoxin and 34 to propranolol. SVT recurred in 19% of patients on digoxin and 31% of patients on propranolol ( P =0.25). No first recurrence occurred after 110 days of treatment. The 6-month recurrence-free status was 79% for patients on digoxin and 67% for patients on propranolol ( P =0.34), and there were no first recurrences in either group between 6 and 12 months. There were no deaths and no serious adverse events related to study medication.

Conclusions—

There was no difference in SVT recurrence in infants treated with digoxin versus propranolol. The current standard practice may be treating infants longer than required and indicates the need for a placebo-controlled trial.

Clinical Trial Registration Information—

http://clinicaltrials.gov ; NCT-00390546.

Successful Ablation of Antero-septal Accessory Pathway in the Non-Coronary Cusp in a Child

A 15-year-old boy with Wolff-Parkinson-White syndrome underwent an electrophysiology study for symptoms of palpitations and persistence of pre-excitation during peak exercise. He was detected to have right antero-septal accessory pathway with relatively long effective refractory period and no inducible tachycardia. He had only transient normalization with cryoablation. Eight months later, he presented again with two episodes of seizures with preceding palpitations. Neurology evaluation was unremarkable with a normal electroencephalogram. In view of his symptoms in association with evidence of pre-excitation, he underwent a second electrophysiology study with ablation. Cryoablation in the anterior septum again achieved only transient normalization. Mapping in the non-coronary cusp identified an earliest accessory pathway potential. RF ablation was performed in the non-coronary cusp with immediate normalization of his electrocardiogram. At 6 month follow-up, he continues to have no pre-excitation on his EKG. Ablation of the anteroseptal accessory pathway in the non-coronary cusp can be safely performed in patients' refractory to conventional ablation sites and techniques.

Primary endocardial fibroelastosis presenting in a young child as incessant ventricular tachycardia and dilated cardiomyopathy

Endocardial fibroelastosis is a cardiomyopathy not commonly seen in the present age. We describe the case of a 4-year-old girl who presented with sustained incessant ventricular tachycardia, a severely dilated left ventricle, and cardiac dysfunction refractory to all medical management and even to ablation; she eventually underwent cardiac transplantation. The diagnosis was made only after histopathologic examination of the explanted heart showed clear evidence of endocardial fibroelastosis. Through this report, we would like to highlight the fact that primary endocardial fibroelastosis can masquerade as idiopathic dilated cardiomyopathy and that associated frequent premature ventricular contractions and nonsustained ventricular tachycardia require close monitoring. Progressive ventricular dilation and ventricular dysfunction can convey a poor prognosis. Sustained recalcitrant ventricular tachycardia in these patients can be a life-threatening event that requires emergent mechanical support and heart transplantation.

Transcatheter retrieval and repositioning of embolized stent from the right ventricle in an infant

Intracardiac stent embolization is a challenging complication in a small infant. A Palmaz stent was placed across the atrial septum in a 3-month-old boy to relieve symptoms of right-side heart failure. On routine chest radiography one week later, the stent was found to have embolized into the right ventricle. The stent was retrieved and repositioned by means of transcatheter technique, without subsequent complications. We found this method to be a viable alternative to surgery in a high-risk infant. To our knowledge, this is the first report of the successful transcatheter retrieval and repositioning of an expandable intravascular stent from an intraventricular position in an infant.

An improved method of measurement of ECG parameters for online medical diagnosis

The accuracy in the online measurement of ECG parameters has a decisive role in the better diagnosis and effective treatment of the diseases. The present paper describes a Lab-VIEW based programming using Pan Tompkins method to extract out QRS complex whereas QT interval measurements were carried out using Mat-lab based math-script module. Hilbert transform has been applied on the ECG signal to convert it into an analytical signal for better peak detection. Peak detection and other parameters like RR interval, HR and several time domain measures of heart rate variability such as RR mean and standard deviations, HR mean and standard deviations, RMSSSD, NN50 count, pNN50 etc were calculated for several other clinical applications apart from online disease diagnosis.

Unusual cause of recurrent syncope in a child

A 5-year-old boy with an unremarkable past medical and family history presented with recurrent syncope precipitated by physical activity. Electrocardiogram performed in the emergency room after one of his episodes revealed atrial flutter. He had a structurally normal heart. Exercise stress test revealed atrial fibrillation with rapid ventricular response immediately on commencement of running. Atrial fibrillation subsequently organized into atrial flutter with variable ventricular response followed by spontaneous conversion to sinus rhythm. This case highlights the use of exercise stress test in a preschool child to elicit an unusual cause of syncope.

Design and development of a knowledge driven web based ECG data monitoring and diagnostic tool in lab-view

Knowledge driven technological developments, the growth and speed of application oriented products in the field of web based services, medical technology and information science, the use of sensor networks for remote patient monitoring is currently playing a major role in quality healthcare delivery to the masses. However, further research need to be done for more effective diagnosis and treatment of diseases remotely. An improved web based, knowledge driven, patient data monitoring and diagnosis system remotely, is developed to acquire, store and process the data using specially developed GUI (Graphical User Interface) on lab-view platform. The GUI displays, communicates and processes vital biomedical parameters such as Heart rate (HR), beat to beat ratio (R-R), QRS and QT intervals etc after acquiring ECG, pulse rate, body temperature etc. from the patient's body sensors. The system detects any emergency condition automatically, if the patient develops any abnormality in his heart rate or irregularity in rhythm heart line and establishes direct connectivity between specialists and patient. The provision to store the online data on remote PC in auto mode is given. The storage of data files on demand on local and remote PC and online data communication between the two is done through shared variables. A case study to evaluate the performance and to verify the experimental implementation is conducted on two patients with varying heart rate (HR) and varying rhythm and the results were found exactly to be in accordance with the expected outcome.

Estimation of CD4+ and CD8+ T-lymphocytes in human immunodeficiency virus infection and acquired immunodeficiency syndrome patients in Manipur

PURPOSE

To estimate and stratify CD4 + and CD8 + T-lymphocyte levels in human immunodeficiency virus (HIV) infected (asymptomatic) and acquired immunodeficiency syndrome (AIDS) patients (symptomatic) and correlate the clinical features of the patients with CD4+ and CD8+ lymphocyte level.

METHODS

Between April 2002 and September 2003, a total of 415 HIV seropositive adult patients (297 males and 118 females) attending Regional Institute of Medical Sciences (RIMS) hospitals were tested for CD4+ and CD8+ T-lymphocytes by fluorescent activated cell sorter (FACS) counter (Becton Dickinson). Symptomatic patients were diagnosed as per NACO clinical case definition.

RESULTS

Ranges of 0-50, 51-100, 101-200, 201-300, 301-400, 401-500 and above 500 CD4+ T-lymphocyte per microlitre were seen in 68, 52, 101, 73, 47, 31 and 43 patients respectively whereas CD8+ T-lymphocyte ranges of 0-300, 301-600, 601-900, 901-1500, 1501-2000, 2001-3500 per microlitre were seen in 29, 84, 92, 145, 40 and 25 patients respectively. One hundred and fifty patients were asymptomatic and 265 were symptomatic. CD4/CD8 ratio in asymptomatics and symptomatics were 0.13-1.69 and 0.01-0.93 respectively. Tuberculosis and candidiasis occurred in CD4+ T-lymphocyte categories between 0-400 cells per mL in symptomatics. However, cryptosporidiosis, toxoplasmosis, herpes zoster, cryptococcal meningitis, Pneumocystis carinii pneumonia, penicilliosis and cytomegalovirus retinitis were seen in patients having CD4+ T-lymphocyte less than 200 per mL.

CONCLUSIONS

CD4+ T-lymphocyte was decreased in both asymptomatic and symptomatic HIV patients, The decrease was greater in symptomatics while CD8+ T-lymphocyte was increased in both except advanced stage symptomatics. CD4:CD8 ratio was reversed in both groups. Opportunistic infections correlated with different CD4+ T-lymphocyte categories.

Atrioventricular septal defect with common atrioventricular junction, common arterial trunk, and severe coarctation of the aorta in a patient with Down's syndrome

Atrioventricular septal defect with common atrioventricular junction is rarely associated with either a common arterial trunk or coarctation of the aorta. We report, as far as we are aware, the first case of Down's syndrome with atrioventricular septal defect with common atrioventricular junction, common arterial trunk, and severe coarctation of the aorta.

Advantage technology, equitable usage of available resources and infrastructure and effective practice management--key to quality healthcare delivery in India

The impact of technological advancement and the widespread availability of resources and their utilization, to meet the health care requirements of the community, an important fundamental need of the human being. After food and shelter is discussed. Some of the most sought criteria relating to the technology selection and the practice management are devised and proposed for their implementation to achieve quality health, particularly in the rural areas. An insight into the government policies, programs and as a result, the impact on the ultimate goal of achieving the desired health care, mainly during the last two decades is covered here. A model of health care for remote areas is proposed here to assist in the improvement of the conditions of better health care and better quality of life of the human being.

Myofibroblastoma of the male breast: imaging appearance and ultrasound-guided core biopsy diagnosis

We present the case of a 78-year-old man with the history of a 14-mm, well-circumscribed mass in the retroareolar region of the right breast. An ultrasound-guided core biopsy showed myofibroblastoma. The mammagraphic and sonographic characteristics of this lesion are described.

Effects of estrogen and estrogen-progestin on mammographic parenchymal density. Postmenopausal Estrogen/Progestin Interventions (PEPI) Investigators

BACKGROUND

In longitudinal studies, greater mammographic density is associated with an increased risk for breast cancer.

OBJECTIVE

To assess differences between placebo, estrogen, and three estrogen-progestin regimens on change in mammographic density.

DESIGN

Subset analysis of a 3-year, multicenter, double-blind, randomized, placebo-controlled trial.

SETTING

Seven ambulatory study centers.

PARTICIPANTS

307 of the 875 women in the Postmenopausal Estrogen/Progestin Interventions Trial. Participants had a baseline mammogram and at least one follow-up mammogram available, adhered to treatment, had not taken estrogen for at least 5 years before baseline, and did not have breast implants.

INTERVENTION

Treatments were placebo, conjugated equine estrogens (CEE), CEE plus cyclic medroxyprogesterone acetate (MPA), CEE plus daily MPA, and CEE plus cyclic micronized progesterone (MP).

MEASUREMENTS

Change in radiographic density (according to American College of Radiology Breast Imaging Reporting and Data System grades) on mammography.

RESULTS

Almost all increases in mammographic density occurred within the first year. At 12 months, the percentage of women with density grade increases was 0% (95% CI, 0.0% to 4.6%) in the placebo group, 3.5% (CI, 1.0% to 12.0%) in the CEE group, 23.5% (CI, 11.9% to 35.1%) in the CEE plus cyclic MPA group, 19.4% (CI, 9.9% to 28.9%) in the CEE plus daily MPA group, and 16.4% (CI, 6.6% to 26.2%) in the CEE plus cyclic MP group. At 12 months, the odds of an increase in mammographic density were 13.1 (95% CI, 2.4 to 73.3) with CEE plus cyclic MPA, 9.0 (CI, 1.6 to 50.1) with CEE plus daily MPA, and 7.2 (CI, 1.3 to 40.0) with CEE plus cyclic micronized progesterone compared with CEE alone.

CONCLUSIONS

Further study of the magnitude and meaning of increased mammographic density due to use of estrogen and estrogen-progestins is warranted because mammographic density may be a marker for risk for breast cancer.

Lessons from mammographic-histopathologic correlation of large-core needle breast biopsy

A thorough understanding of the limitations of sampling and histopathologic issues affecting lesion management is critical to successful large-core (14-gauge) needle breast biopsy. The most common problems are differentiating usual hyperplasia, atypical hyperplasia, and carcinoma in situ; satisfactory sampling of microcalcifications, often present in adjacent benign and malignant processes; differentiating phyllodes tumor from cellular fibroadenoma; and assessing the extent of an in situ component in mixed invasive and in situ carcinoma. Equally important is understanding what constitutes an acceptable histopathologic result given the mammographic appearance of the lesion. Mammographers and pathologists need experience in identifying benign processes that can manifest as discrete masses at mammography and core biopsy: focal fibrosis, apocrine metaplasia, sclerosing adenosis, and fat necrosis. When present as discrete histopathologic processes at core biopsy, such diagnoses should be accepted. Nonspecific diagnoses such as "benign breast tissue" should be avoided by pathologists when a discrete process is evident; absence of a discrete finding to explain the mammographic appearance should prompt repeat core or excisional biopsy.

Gross morphology of the alimentary canal and seasonal variation in feeding of Noemacheilus montanus (McClelland)

Noemacheilus montanus (McClelland) is a bottom feeder Omnivorous fish of Garhwal hillstreams. The alimentary canal is short and the stomach consists of a corpus and a pylorus portion. As it consumes more animal food than the vegetable food, it may be better called Carni-omnivore. The study of GSI for different months revealed that the feeding intensity attains 2 peaks during a year, first in December and second in June. The change in feeding intensity may be correlated with the availability of food items in nature.