Is autonomic function associated with left ventricular systolic function in Chagas heart disease patients undergoing treatment for heart failure?

Introduction The association between cardiac autonomic and left ventricular (LV) dysfunction in Chagas disease (ChD) is controversial. Methods A standardized protocol that includes the Valsalva maneuver, a respiratory sinus arrhythmia (RSA) test, and an echocardiographic examination was used. Spearman correlation coefficients (rho) were used to investigate associations. Results The study population consisted of 118 ChD patients undergoing current medical treatment, with an average LV ejection fraction of 51.4±2.6%. The LV ejection fraction and diastolic dimension were correlated with the Valsalva index (rho=0.358, p<0.001 and rho=-0.266, p=0.004, respectively) and the RSA (rho=0.391, p<0.001 and rho=-0.311, p<0.001, respectively). Conclusions The impairment of LV function is directly associated with a reduction of cardiac autonomic modulation in ChD.

Exercise-induced ventricular arrhythmias and vagal dysfunction in Chagas disease patients with no apparent cardiac involvement

INTRODUCTION : Exercise-induced ventricular arrhythmia (EIVA) and autonomic imbalance are considered as early markers of heart disease in Chagas disease (ChD) patients. The objective of the present study was to verify the differences in the occurrence of EIVA and autonomic maneuver indexes between healthy individuals and ChD patients with no apparent cardiac involvement. METHODS : A total of 75 ChD patients with no apparent cardiac involvement, aged 44.7 (8.5) years, and 38 healthy individuals, aged 44.0 (9.2) years, were evaluated using echocardiography, symptom-limited treadmill exercise testing and autonomic function tests. RESULTS : The occurrence of EIVA was higher in the chagasic group (48%) than in the control group (23.7%) during both the effort and the recovery phases. Frequent ventricular contractions occurred only in the patient group. Additionally, the respiratory sinus arrhythmia index was significantly lower in the chagasic individuals compared with the control group. CONCLUSIONS : ChD patients with no apparent cardiac involvement had a higher frequency of EIVA as well as more vagal dysfunction by respiratory sinus arrhythmia. These results suggest that even when asymptomatic, ChD patients possess important arrhythmogenic substrates and subclinical disease.

Epstein-Barr virus-positive gastric cancer: a distinct molecular subtype of the disease?

Abstract: Approximately 90% of the world population is infected by Epstein-Barr virus (EBV). Usually, it infects B lymphocytes, predisposing them to malignant transformation. Infection of epithelial cells occurs rarely, and it is estimated that about to 10% of gastric cancer patients harbor EBV in their malignant cells. Given that gastric cancer is the third leading cause of cancer-related mortality worldwide, with a global annual incidence of over 950,000 cases, EBV-positive gastric cancer is the largest group of EBV-associated malignancies. Based on gene expression profile studies, gastric cancer was recently categorized into four subtypes; EBV-positive, microsatellite unstable, genomically stable and chromosomal instability. Together with previous studies, this report provided a more detailed molecular characterization of gastric cancer, demonstrating that EBV-positive gastric cancer is a distinct molecular subtype of the disease, with unique genetic and epigenetic abnormalities, reflected in a specific phenotype. The recognition of characteristic molecular alterations in gastric cancer allows the identification of molecular pathways involved in cell proliferation and survival, with the potential to identify therapeutic targets. These findings highlight the enormous heterogeneity of gastric cancer, and the complex interplay between genetic and epigenetic alterations in the disease, and provide a roadmap to implementation of genome-guided personalized therapy in gastric cancer. The present review discusses the initial studies describing EBV-positive gastric cancer as a distinct clinical entity, presents recently described genetic and epigenetic alterations, and considers potential therapeutic insights derived from the recognition of this new molecular subtype of gastric adenocarcinoma.

Unusual abdominal tumors with intracardiac extension. Two cases with successful surgical resection

Abdominal tumors that can grow through vascular lumen and spread to the right heart are rare. Although these tumors have different histologic aspects, they may cause similar abdominal and cardiac symptoms and are a serious risk factor for pulmonary embolism and sudden death when they reach the right atrium and tricuspid valve. The best treatment is radical surgical resection of the entire tumor using cardiopulmonary bypass with or without deep hypothermia and total circulatory arrest. We report the cases of two patients, the first with leiomyosarcoma of the inferior vena cava and the other with intravenous leiomyomatosis of the uterus that showed intravascular growth up to right atrium and ventricle, who underwent successful radical resection in a one-stage procedure with the use of cardiopulmonary bypass. We discuss the clinical and histologic aspects and imaging diagnosis and review the literature.

Müllerian adenosarcoma of the uterus with sarcomatous overgrowth following tamoxifen treatment for breast cancer

Müllerian adenosarcoma with sarcomatous overgrowth presented by a 52-year-old female patient after adjuvant tamoxifen treatment for breast carcinoma is described. The diagnosis was made on histological basis after curettage and complementary total hysterectomy with bilateral salpingo-oophorectomy. The immunohistochemical study showed high expression of estrogen receptors in the epithelial component of the lesion and irregularly positive findings in the stroma. The proliferative activity evaluated by Ki-67 immunoexpression was higher in the stroma than the epithelium. Some of the stromal cells showed rhabdomyoblastic differentiation. The association of tamoxifen use and development of mesenchymal neoplasms is discussed.

The use of a modular titanium endoprosthesis in skeletal reconstructions after bone tumor resections: method presentation and analysis of 37 cases

We analyzed 37 patients who underwent segmental wide resection of bone tumors and reconstruction with a modular titanium endoprosthesis at the Orthopaedic Oncology Group, between 1992 and 1998. Twelve patients were male and 25 were female, with a mean age of 30 years (9 - 81). The mean follow-up was 14 months (2 - 48). The diagnoses were: osteosarcoma (14 cases), metastatic carcinoma (10), Ewing's sarcoma (4), giant cell tumor (4), malignant fibrous histiocytoma (3), chondrosarcoma (1), and aneurysmal bone cyst (1). Eleven articulated total knee, 8 partial proximal femur with bipolar acetabulum, 8 partial proximal humerus, 3 total femur, 2 partial proximal tibia, 2 diaphyseal femur, 2 diaphyseal humerus, and 1 total proximal femur with cementless acetabulum endoprosthesis implant procedures were done. The complications related to the procedure included: infection (5 cases), dislocation (3), module loosening (1), and ulnar nerve paresthesia (1). We used the following criteria for the clinical evaluation: presence of pain, range of motion, reconstruction stability, surgical and oncologic complications, and patient acceptance. The results were good in 56.8% of the cases, regular in 32.4% and poor in 10.8%.

Prostate carcinoma with neuroendocrine differentiation: case report and literature review

Neuroendocrine differentiation in prostatic carcinomas generally confers a more aggressive clinical behavior and less favorable prognosis than usual prostatic carcinomas. In this manuscript, we report a case of a 58-year-old man with prostatic carcinoma who died 1 year after initial diagnosis. Autopsy showed a disseminated prostatic carcinoma with neuroendocrine differentiation. There were metastasis to the spleen, an organ infrequently involved by disseminated epithelial neoplasms. Neuroendocrine differentiation was demonstrated by immunohistochemical studies in the biopsy and autopsy material.

Computed tomography-guided cutting needle biopsy of pulmonary lesions

PURPOSE: To report the experience of a radiology department in the use of computed tomography - guided cutting needle biopsy of pulmonary nodules, by evaluating diagnostic yield and incidence of complications. METHODS: This is a retrospective analysis of 52 consecutive patients who underwent lung lesion biopsy guided by computed tomography, performed between May 1997 and May 2000. Thirty-five patients were male and 17 were female, with ages ranging from 5 to 85 years (median, 62 years). The size of the lesions ranged from 1.8 to 15 cm (median, 5.4 cm). RESULTS: In a total of 52 biopsies of lung lesions, 51 biopsies (98.1%) supplied appropriate material for histopathological diagnosis, with 9 diagnosed (17.3%) as benign and 42 (80.8%) as malignant lesions. Specific diagnosis was obtained in 44 (84.6%) biopsies: 4 benign (9.1%) and 40 (90.9%) malignant lesions. The sensitivity, specificity, and accuracy of the cutting needle biopsies for determining presence of malignancy were 96.8%, 100%, and 97.2%, respectively. Complications occurred in 9 cases (17.3%), including 6 cases (11.5%) of small pneumothorax, 1 (1.9%) of hemoptysis, 1 (1.9%) of pulmonary hematoma, and 1 (1.9%) of thoracic wall hematoma. All had spontaneous resolution. There were no complications requiring subsequent intervention. CONCLUSION: The high sensitivity and specificity of the method and the low rate of complications have established cutting needle biopsy as an efficient and safe tool for the diagnosis of lung lesions. In our hospital, cutting needle biopsy is considered a reliable procedure for the evaluation of indeterminate pulmonary nodules.

Hypothyroidism following struma ovarii tumor resection: a case report

Struma ovarii is an infrequent ovarian tumor, and there are only few reports with detailed data of thyroid function. In several cases, malignant struma ovarii have been shown to produce hyperthyroidism, but there is no reported case of hypothyroidism following struma ovarii tumor resection. A 62-year-old white woman underwent right ovary resection that had a pathologic diagnosis of struma ovarii. After 6 days, she developed weakness, myalgia, somnolence, nausea, and arterial hypotension. Laboratory tests showed a high level of thyroid-stimulating hormone (TSH) and a decreased level thyroxin. Thyroxin replacement therapy was initiated, and the patient became completely asymptomatic. This is the first reported case of a previously asymptomatic woman who developed a definite clinical hypothyroidism after resection of a struma ovarii tumor.

Meningeal carcinomatosis as the initial manifestation of a gallbladder adenocarcinoma associated with a Krukenberg tumor

A case of malignant neoplasm is described in which the initial manifestations were mental dysfunction and meningeal irritation, mimicking chronic or subacute meningitis. Physical examination showed cranial nerve involvement and a pelvic tumor. There was progressive deterioration, and death occurred in 2 weeks. The autopsy revealed a gallbladder adenocarcinoma, meningeal carcinomatosis, and ovarian metastasis presenting as a Krukenberg tumor. The authors emphasize the importance of including meningeal carcinomatosis as a possibility in the differential diagnosis of non-characteristic clinical pictures, as well as the importance of the cerebrospinal fluid cytologic examination, repeated as needed, in order to confirm this diagnosis.

Color Doppler sonography with contrast in the differentiation of ovarian tumors

The objective of this study was to differentiate benign ovarian tumors from malignant ones before surgery using color and pulsed Doppler sonography, and to compare results obtained before and after use of contrast medium, thereby verifying whether contrast results in an improvement in the diagnostic sensitivity. METHODS: Sixty two women (mean age 49.9 years) with ovarian tumors were studied, 45 with benign and 17 with malignant tumors. All women underwent a transvaginal color Doppler ultrasonographic exam. A study of the arterial vascular flow was made in all tumor areas, as well as an impedance evaluation of arterial vascular flow using the resistance index. RESULT: Localization of the vessels in the tumor revealed a greater proportion of malignant tumors with detectable internal vascular flows (64%) than benign tumors with such flows (22%). There was a considerable overlap of these findings. The use of contrast identified a greater number of vessels with confirmation in the totality of tumors, but did not improve the Doppler capacity in tumoral differentiation. Malignant tumors presented lower values of resistance index than the benign ones, whether or not contrast was used. The cutoff value for resistance index that better maximized the Doppler sensitivity and specificity was 0.55. Through this value, an increase of the sensitivity after contrast use was obtained, varying from 47% to 82%, while specificity remained statistically unchanged. CONCLUSION: Although the injection of a microbubble agent improved the sensitivity of the method detecting vascularization of tumors, a positive finding for vascularization by this method was not clinically useful in the differentiation of benign and malignant ovarian tumors.

Adnexal torsion following gonadotropin-releasing hormone analog therapy: a case report

Adnexal torsion may occur in girls and adolescents. Often it is associated with ovarian diseases resulting in ovarian enlargement. Adnexal torsion may involve the ovary, fallopian tube or both, and the main sympton is acute pelvic pain. An 8-year-old girl complaining of acute pelvic and abdominal pain, who was previously diagnosed with precocious puberty and who received treatment with a GnRH analog, is reported. Ultrasound demonstrated a normal-sized uterus and bilaterally enlarged ovaries with multiple internal cysts. At laparotomy, we found a complete torsion in the right adnexa. The histological examination revealed massive edema associated with multiple antral follicles and reduction of the follicular reserve.

Evaluation of the heart rate and arrhythmias following the Maze procedure for chronic atrial fibrillation

PURPOSE: To assess the presence and the prevalence of arrhythmias and the variability of the heart rate in the medium-term postoperative period following the maze procedure for chronic atrial fibrillation (AF). METHODS: Seventeen patients with a mean age of 51.7±12.9 years, who previously underwent the maze procedure without cryoablation for chronic atrial fibrillation, were evaluated with the 24 hour electrocardiogram (ECG) - Holter monitoring from the 6th month after the operation. Valvular and coronary procedures were concomitantly performed. RESULTS: The mean heart rate during Holter monitoring was 82±8bpm; the maximal heart rate was 126 ± 23bpm and the minimal heart rate 57±7bpm. Sinus rhythm was found in 10 (59%) patients and atrial rhythm was found in 7 (41%). Supraventricular extrasystoles had a rate of 2.3±5.5% of the total number of heartbeats and occurred in 16 (94%) patients. Six (35%) patients showed nonsustained atrial tachycardia. Ventricular extrasystoles, with a rate of 0.8±0.5% of the total heartbeats, occurred in 14 (82%) patients. The chronotropic competence was normal in 9 (53%) patients and attenuated in 8 (47%). The atrioventricular conduction (AV) was unchanged in 13 (76%) patients and there were 4 (24%) cases of first degree atrioventricular block (AVB). CONCLUSION: After the maze procedure, the values for the mean heart rate, AV conduction and chronotropic competence approach the normal range, although some cases show attenuation of the chronotropic response, first degree AV block or benign arrhythmias.

Aortic valve assessment. Anatomical study of 100 healthy human hearts

PURPOSE: To assess anatomical characteristics of the aortic valve, so that they may be useful in diagnostic situations and surgical treatment. METHODS: The study analyzed 100 healthy fixed human hearts; 84% of them obtained from males, 61% of them from Caucasian individuals. The ages of the individuals ranged from 9 to 86 years (mean 30±15.5 years). The characteristics assessed related to age, sex, and race were the following: number and height of the cusps, size of the lunulae, internal and external intercommissural distance, position of the coronary ostium in relation to the aortic valve, position of the ventricular septum in relation to the aortic valve, thickness of the cusps. RESULTS: All hearts assessed had a tricuspidal aortic valve. In regard to the height of the cusps and size of the lunula, the left coronary cusp was larger, followed by the right coronary cusp and the noncoronary cusp. The internal and external intercommissural distances had mean values of 24.6±5.7mm and 19.7±7mm, respectively. In regard to the position of the coronary ostia, in one heart two ostia emerged from the left coronary sinus, and in another, the ostium was supracommissural. The mean diameter of the aorta was 21.8±3.6mm, and there were no significant sexual or racial differences, but the diameter increased progressively with the increase in age. The thickness of the cusps did not show any significant difference in the 3 points assessed. CONCLUSION: The aortic valve annulus did not show a perfect circumference, with some variations in the measurements of the annulus, in the cusps and in the relation with the ventricular septum.

Results of the surgical treatment of chronic atrial fibrillation

OBJECTIVE: Report clinical experience in surgical treatment of atrial fibrillation (AF) by Cox-maze procedure. METHODS: 61 patients underwent surgical treatment for AF. Two had primary AF and 59 AF secondary to heart disease (2 atrial septal defects, 57 mitral). Ages ranged from 20 to 74 years (mean = 49). There were 44 females (72%). The surgical technique employed was Cox 3 without cryoablation. The patients were follow-up in specific at patient clinics and underwent periodical ECG, exercise tests, echocardiogram and Holter monitoring. RESULTS: In-hospital mortality was 4.9% and late mortality 1.6%. A temporary pacemaker was used in 28 (46%) and a definitive in 7 patients (11.4%). On hospital discharge, AF remained in 17%; 63.9% had sinus rhythm, 6.9% atrial rhythm, 1.7% junctional rhythm, and 10.3% had pacemaker rhythm. In the last evaluation, AF was present in 19.5%; (70.5% sinus rhythm, 4% atrial rhythm, 2% atrial tachycardia, and 4% pacemaker rhythm). There was no report of thromboembolic episodes. Chronotropic response was considered adequate in 19%, intermediate in 29%, and inadequate in 42%. In Holter monitoring, the mean heart rate was 82±8 bpm, with a minimum of 57±7 bpm and maximum of 126±23 bpm, with supraventricular extrasystoles in 2.3±5.5% of the total heartbeats and ventricular extrasystoles in 0.8±0.5%. In the echocardiogram, the A wave was present in the left atrium in 87.5%. CONCLUSION: Maze procedure is effective and has acceptable surgical risk. Atrial or sinus rhythms remain stable with a small but remarkable frequency of atrial and ventricular arrhythmias. Left atrial contraction is present, although attenuated, as well as the chronotropic response to exercise.