Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: Frequent and dangerous

Purpose: The pathophysiology of acute coronary syndromes (ACS) after noncardiac surgery is not established yet. Thrombosis over a vulnerable plaque or decreased oxygen supply secondary to anemia or hypotension may be involved. The purpose of this study was to investigate the pathophysiology of ACS complicating noncardiac surgery. Methods: Clinical and angiographic data were prospectively recorded into a database for 120 consecutive patients that had an ACS after noncardiac surgery (PACS), for 120 patients with spontaneous ACS (SACS), and 240 patients with stable coronary artery disease (CAD). Coronary lesions with obstructions greater than 50% were classified based on two criteria: Ambrose's classification and complex morphology. The presence of Ambrose's type II or complex lesions were compared between the three groups. Results: We analyzed 1470 lesions in 480 patients. In PACS group, 45% of patients had Ambrose's type II lesions vs. 56.7% in SACS group and 16.4% in stable CAD group (P < 0.001). Both PACS and SACS patients had more complex lesions than patients in stable CAD group (56.7% vs. 79.2% vs. 31.8%, respectively; P < 0.001). Overall, the independent predictors of plaque rupture were being in the group PACS (P < 0.001, OR 2.86; CI, 1.82-4.52 for complex lesions and P < 0.001, OR 3.43; CI, 2.1-5.6 for Ambrose's type II lesions) or SACS (P < 0.001, OR 8.71; CI, 5.15-14.73 for complex lesions and P < 0.001, OR 5.99; CI, 3.66-9.81 for Ambrose's type II lesions). Conclusions: Nearly 50% of patients with perioperative ACS have evidence of coronary plaque rupture, characterizing a type 1 myocardial infarction. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Left ventricular free wall impeding rupture in post-myocardial infarction period diagnosed by myocardial contrast echocardiography: Case report

Abstract Background: Left ventricular free wall rupture occurs in up to 10% of the in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction and its antemortem diagnosis is rarely made. Contrast echocardiography has been increasingly used for the evaluation of myocardial perfusion in patients with acute myocardial infarction, with important prognostic implications. In this case, we reported its use for the detection of a mechanical complication following myocardial infarction. Case presentation: A 50-year-old man with acute myocardial infarction in the lateral wall underwent myocardial contrast echocardiography for the evaluation of myocardial perfusion in the third day post-infarction. A perfusion defect was detected in lateral and inferior walls as well as the presence of contrast extrusion from the left ventricular cavity into the myocardium, forming a serpiginous duct extending from the endocardium to the epicardial region of the lateral wall, without communication with the pericardial space. Magnetic resonance imaging confirmed the diagnosis of impending rupture of the left ventricular free wall. While waiting for cardiac surgery, patient presented with cardiogenic shock and died. Anatomopathological findings were consistent with acute myocardial infarction in the lateral wall and a left ventricular free wall rupture at the infarct site. Conclusion: This case illustrates the early diagnosis of left ventricular free wall rupture by contrast echocardiography. Due to its ability to be performed at bedside this modality of imaging has the potential to identify this catastrophic condition in patients with acute myocardial infarction and help to treat these patients with emergent surgery.

Isolated right atrial appendage (RAA) rupture in blunt trauma – a case report and an anatomic study comparing RAA and right atrium (RA) wall thickness

Abstract Background Heart chambers rupture in blunt trauma is uncommon and is associated with a high mortality. The determinant factors, and the incidence of isolated heart chambers rupture remains undetermined. Isolated rupture of the right atrium appendage (RAA) is very rare, with 8 cases reported in the reviewed literature. The thin wall of the RAA has been presumed to render this chamber more prone to rupture in blunt trauma. Objective To report a case of isolated RAA rupture in blunt trauma, and to compare right atrium (RA) and RAA wall thickness in a necropsy study. Methods The thickness of RA and RAA wall of hearts from cadavers of fatal penetrating head trauma victims was measured. Our case of isolated RAA rupture is presented. The main findings of the 8 cases reported in the literature, and the findings of our case, were organized in a table. Result The comparison of the data showed that wall thickness of the RAA (0.53 ± 0.33 mm) was significantly thinner than that of RA (1.11 ± 0.42 mm) (p < 0.05). Comments In all these 9 cases of isolated RAA rupture, cardiac tamponade occurred, RAA rupture was diagnosed intraoperatively and sutured, and the patients survived. Main mechanisms hypothesized for heart chamber rupture include mechanical compression coincident with phases of cardiac cycle, leading to high hydrostatic pressure inside the chamber. Published series include numerous cases of RA rupture, and only a few cases of RAA rupture. Conclusion Thus, our data suggests that wall thickness is not a determinant factor for RA or RAA rupture in blunt trauma.

Spontaneous combined rupture of a pelvicalyceal cyst into the collector system and retroperitoneal space during the acquisition of computed tomography scan images: a case report

Abstract Introduction Pelvicalyceal cysts are common findings in autopsies and can manifest with a variety of patterns. These cystic lesions are usually a benign entity with no clinical significance unless they enlarge enough to cause compression of the adjacent collecting system and consequently obstructive uropathy. Few cases of the spontaneous rupture of pelvicalyceal renal cysts have been published and to the best of our knowledge there is no report of a combined rupture to collector system and retroperitoneal space documented during a multiphase computed tomography. Case presentation We report a case of a ‘real-time’ spontaneous rupture of a pelvicalyceal cyst into the collecting system with fistulization into the retroperitoneum. The patient was a 78-year-old Caucasian man with a previous history of renal stones and a large pelvicalyceal renal cyst who was admitted to our Emergency department with acute right flank pain. A multiphase computed tomography was performed and the pre-contrast images demonstrated a right pelvicalyceal renal cyst measuring 12.0 × 6.1cm in the lower pole causing moderate dilation of the upper right renal collection system. In addition, a partially obstructive stone on the left distal ureter with mild left hydronephrosis was noted. The nephrographic phase did not add any new information. The excretory phase (10-minute delay) demonstrated a spontaneous rupture of the cyst into the pelvicalyceal system with posterior fistulization into the retroperitoneal space. Conclusion In this case study we present time-related changes of a rare pelvicalyceal cyst complication, which to the best of our knowledge has fortunately not been previously documented. Analysis of the sequential images and comparison with an earlier scan allowed us to better understand the physiopathological process of the rupture, the clinical presentation and to elaborate hypotheses for its etiopathogenesis.

Evaluation of vertical forces in the pads of Pitbulls with cranial cruciate ligament rupture

Background: Cranial cruciate ligament rupture (CCLR) is one of the most important stifle injuries and a common cause of lameness in dogs. Our objective was to measure the vertical forces in the pads of Pitbulls with cranial cruciate ligament rupture (CCLR) using a pressure sensitive walkway. A pressure sensitive walkway was used to collect vertical force data from the pads of 10 Pitbulls affected with unilateral CCLR. Ten healthy Pitbulls were included in the study as controls. Velocity varied between 1.3 and 1.6 m/s and acceleration was kept below ± 0.1 m/s2. Differences between groups and between pads in the same limb within groups were investigated using ANOVA and the Tukey test. The paired Student t-test was employed to assess gait symmetry (p < 0.05). Results: Peak vertical forces (PVF) were lower in the affected limb, particularly in the metatarsal pad. Increased PVF values in the forelimb and the contralateral hind limb pads of affected dogs suggest a compensatory effect. Conclusions: A consistent pattern of vertical force distribution was observed in the pads of dogs with CCLR. These data are important for increased understanding of vertical force distribution in the limb of dogs with CCLR disease. Kinetic analysis using pressure sensitive walkways can be useful in follow-up assessment of surgically treated dogs regardless of the surgical technique employed.

A comprehensive study of the 26th December 2004 Sumatra earthquake: possible implications on Earth rotation and investigations on the coseismic and postseismic stress diffusion associated with the seismic rupture

In this work a multidisciplinary study of the December 26th, 2004 Sumatra earthquake has been carried out. We have investigated both the effect of the earthquake on the Earth rotation and the stress field variations associated with the seismic event. In the first part of the work we have quantified the effects of a water mass redistribution associated with the propagation of a tsunami wave on the Earth’s pole path and on the length-of-day (LOD) and applied our modeling results to the tsunami following the 2004 giant Sumatra earthquake. We compared the result of our simulations on the instantaneous rotational axis variations with some preliminary instrumental evidences on the pole path perturbation (which has not been confirmed yet) registered just after the occurrence of the earthquake, which showed a step-like discontinuity that cannot be attributed to the effect of a seismic dislocation. Our results show that the perturbation induced by the tsunami on the instantaneous rotational pole is characterized by a step-like discontinuity, which is compatible with the observations but its magnitude turns out to be almost one hundred times smaller than the detected one. The LOD variation induced by the water mass redistribution turns out to be not significant because the total effect is smaller than current measurements uncertainties. In the second part of this work of thesis we modeled the coseismic and postseismic stress evolution following the Sumatra earthquake. By means of a semi-analytical, viscoelastic, spherical model of global postseismic deformation and a numerical finite-element approach, we performed an analysis of the stress diffusion following the earthquake in the near and far field of the mainshock source. We evaluated the stress changes due to the Sumatra earthquake by projecting the Coulomb stress over the sequence of aftershocks taken from various catalogues in a time window spanning about two years and finally analyzed the spatio-temporal pattern. The analysis performed with the semi-analytical and the finite-element modeling gives a complex picture of the stress diffusion, in the area under study, after the Sumatra earthquake. We believe that the results obtained with the analytical method suffer heavily for the restrictions imposed, on the hypocentral depths of the aftershocks, in order to obtain the convergence of the harmonic series of the stress components. On the contrary we imposed no constraints on the numerical method so we expect that the results obtained give a more realistic description of the stress variations pattern.

The rupture process of recent tsunamigenic earthquakes by geophysical data inversion

Subduction zones are the favorite places to generate tsunamigenic earthquakes, where friction between oceanic and continental plates causes the occurrence of a strong seismicity. The topics and the methodologies discussed in this thesis are focussed to the understanding of the rupture process of the seismic sources of great earthquakes that generate tsunamis. The tsunamigenesis is controlled by several kinematical characteristic of the parent earthquake, as the focal mechanism, the depth of the rupture, the slip distribution along the fault area and by the mechanical properties of the source zone. Each of these factors plays a fundamental role in the tsunami generation. Therefore, inferring the source parameters of tsunamigenic earthquakes is crucial to understand the generation of the consequent tsunami and so to mitigate the risk along the coasts. The typical way to proceed when we want to gather information regarding the source process is to have recourse to the inversion of geophysical data that are available. Tsunami data, moreover, are useful to constrain the portion of the fault area that extends offshore, generally close to the trench that, on the contrary, other kinds of data are not able to constrain. In this thesis I have discussed the rupture process of some recent tsunamigenic events, as inferred by means of an inverse method. I have presented the 2003 Tokachi-Oki (Japan) earthquake (Mw 8.1). In this study the slip distribution on the fault has been inferred by inverting tsunami waveform, GPS, and bottom-pressure data. The joint inversion of tsunami and geodetic data has revealed a much better constrain for the slip distribution on the fault rather than the separate inversions of single datasets. Then we have studied the earthquake occurred on 2007 in southern Sumatra (Mw 8.4). By inverting several tsunami waveforms, both in the near and in the far field, we have determined the slip distribution and the mean rupture velocity along the causative fault. Since the largest patch of slip was concentrated on the deepest part of the fault, this is the likely reason for the small tsunami waves that followed the earthquake, pointing out how much the depth of the rupture plays a crucial role in controlling the tsunamigenesis. Finally, we have presented a new rupture model for the great 2004 Sumatra earthquake (Mw 9.2). We have performed the joint inversion of tsunami waveform, GPS and satellite altimetry data, to infer the slip distribution, the slip direction, and the rupture velocity on the fault. Furthermore, in this work we have presented a novel method to estimate, in a self-consistent way, the average rigidity of the source zone. The estimation of the source zone rigidity is important since it may play a significant role in the tsunami generation and, particularly for slow earthquakes, a low rigidity value is sometimes necessary to explain how a relatively low seismic moment earthquake may generate significant tsunamis; this latter point may be relevant for explaining the mechanics of the tsunami earthquakes, one of the open issues in present day seismology. The investigation of these tsunamigenic earthquakes has underlined the importance to use a joint inversion of different geophysical data to determine the rupture characteristics. The results shown here have important implications for the implementation of new tsunami warning systems – particularly in the near-field – the improvement of the current ones, and furthermore for the planning of the inundation maps for tsunami-hazard assessment along the coastal area.

Rupture du silence. L'écriture engagée de Gisèle Pineau

A writer by passion and a psychiatric nurse by profession, Gisèle Pineau is described as the new feminine voice of the literature from the French Antilles (Martinique and Guadeloupe). In all her novels, she explores the human condition and more specifically that of women. Breaking the silence that oppresses Antillean women, Gisèle Pineau delves into the destinies of women from Guadeloupe, scrutinizing the environment of her island and elsewhere, reinventing the French language, and giving voice and identity to all those women who have never had the possibility to express themselves. After having introduced the author in a postcolonial context linked with the theory of the feminine writing and its expressions in Caribbean literature, the plight of women is described through the experience of their bodies in Antillean society and elsewhere. The author focuses on physical and psychological violence denouncing the treatment of women. Escaping from oppression, women look for the space to rebuild a new life and a new identity.

Kinematic description of the rupture from strong motion data: strategies for a robust inversion

We present a non linear technique to invert strong motion records with the aim of obtaining the final slip and rupture velocity distributions on the fault plane. In this thesis, the ground motion simulation is obtained evaluating the representation integral in the frequency. The Green’s tractions are computed using the discrete wave-number integration technique that provides the full wave-field in a 1D layered propagation medium. The representation integral is computed through a finite elements technique, based on a Delaunay’s triangulation on the fault plane. The rupture velocity is defined on a coarser regular grid and rupture times are computed by integration of the eikonal equation. For the inversion, the slip distribution is parameterized by 2D overlapping Gaussian functions, which can easily relate the spectrum of the possible solutions with the minimum resolvable wavelength, related to source-station distribution and data processing. The inverse problem is solved by a two-step procedure aimed at separating the computation of the rupture velocity from the evaluation of the slip distribution, the latter being a linear problem, when the rupture velocity is fixed. The non-linear step is solved by optimization of an L2 misfit function between synthetic and real seismograms, and solution is searched by the use of the Neighbourhood Algorithm. The conjugate gradient method is used to solve the linear step instead. The developed methodology has been applied to the M7.2, Iwate Nairiku Miyagi, Japan, earthquake. The estimated magnitude seismic moment is 2.6326 dyne∙cm that corresponds to a moment magnitude MW 6.9 while the mean the rupture velocity is 2.0 km/s. A large slip patch extends from the hypocenter to the southern shallow part of the fault plane. A second relatively large slip patch is found in the northern shallow part. Finally, we gave a quantitative estimation of errors associates with the parameters.

The vulnerable carotid plaque. Identification of endothelial markers predictive of plaque weakness, rupture predisposition and neoangiogenesis

Background. Neoangiogenesis is crucial in plaque progression and instability. Previous data from our group demonstrated that intra-plaque neovessels show both a Nestin+/WT+ and a Nestin+/WT1- phenotype, the latter being correlated with complications and plaque instability. Aims. The aims of the present thesis are: (i) to confirm our previous results on Nestin/WT1 phenotype in a larger series of carotid atheromatous plaques, (ii) to evaluate the relationship between the Nestin+/WT1- neoangiogenesis phenotype and plaque morphology, (iii) to evaluate the relationship between the immunohistochemical and histopathological characteristics and the clinical instability of the plaques. Materials and Methods. Seventy-three patients (53 males, 20 females, mean age 71 years) were consecutively enrolled. Symptoms, brain CT scan, 14 histological variables, including intraplaque hemorrhage and diffuse calcifications, were collected. Immunohistochemistry for CD34, Nestin and WT1 was performed. RT-PCR was performed to evaluate Nestin and WT1 mRNA (including 5 healthy arteries as controls). Results. Diffusely calcified plaques (13 out of 73) were found predominantly in females (P=0.017), with a significantly lower incidence of symptoms (TIA/stroke) and brain focal lesions (P=0.019 and P=0.013 respectively) than not-calcified plaques, but with the same incidence of intraplaque complications (P=0.156). Accordingly, both calcified and not calcified plaques showed similar mean densities of positivity for CD34, Nestin and WT1. The density of Nestin and WT1 correlated with the occurrence of intra-plaque hemorrhage in all cases, while the density of CD34 correlated only in not-calcified plaques. Conclusions. We confirmed that the Nestin+/WT1- phenotype characterizes the neovessels of instable plaques, regardless the real amount of CD34-positive neoangiogenesis. The calcified plaques show the same incidence of histological complications, albeit they do not influence symptomatology and plaque vulnerability. Female patients show a much higher incidence of not-complicated or calcified plaques, receiving de facto a sort of protection compared to male patients.

Rupture forces of split aptamers

Rupture forces of ligand-receptor interactions, such as proteins-proteins, proteins-cells, and cells-tissues, have been successfully measured by atomic force spectroscopy (AFS). For these measurements, the ligands and receptors were chemically modified so that they can be immobilized on the tip and on a substrate, respectively. The ligand interact the receptor when the tip approaches the substrate. This interaction can be studied by measuring rupture force upon retraction. However, this technique is not feasible for measurements involving small molecules, since they form only few H-bonds with their corresponding receptors. Modifying small molecules for immobilization on surfaces may block or change binding sites. Thus, recorded rupture forces might not reflect the full scope of the involved small ligand-receptor interactions.rnIn my thesis, a novel concept that allows measuring the rupture force of small involved ligand-receptor interactions and does not require molecular modification for immobilization was introduced. The rupture force of small ligand-receptor interaction is not directly measured but it can be determined from measurements in the presence and in the absence of the ligand. As a model system, the adenosine mono phosphate (AMP) and the aptamer that binds AMP were selected. The aptamer (receptor) is a single stranded DNA that can partially self-hybridize and form binding pockets for AMP molecules (ligands). The bonds between AMP and aptamer are provided by several H-bonds and pair stacking.rnIn the novel concept, the aptamer was split into two parts (oligo a and oligo b). One part was immobilized on the tip and the other one on the substrate. Approaching the tip to the substrate, oligo a and oligo b partially hybridized and the binding pockets were formed. After adding AMP into the buffer solution, the AMP bound in the pockets and additional H-bonds were formed. Upon retraction of the tip, the rupture force of the AMP-split aptamer complex was measured. In the presence of excess AMP, the rupture force increased by about 10 pN. rnThe dissociation constant of the AMP-split aptamer complex was measured on a single molecular level (~ 4 µM) by varying the AMP concentrations and measuring the rupture force at each concentration. Furthermore, the rupture force was amplified when more pockets were added to the split aptamer. rnIn the absence of AMP, the thermal off-rate was slightly reduced compared to that in the presence of AMP, indicating that the AMP stabilized the aptamer. The rupture forces at different loading rates did not follow the logarithmic fit which was usually used to describe the dependence of rupture forces at different loading rates of oligonucleotides. Two distinguished regimes at low and high loading rates were obtained. The two regimes were explained by a model in which the oligos located at the pockets were stretched at high loading rates. rnThe contribution of a single H-bond formed between the AMP molecule and the split aptamer was measured by reducing the binding groups of the AMP. The rupture forces reduce corresponding to the reduction of the binding groups. The phosphate group played the most important role in the formation of H-bond network between the AMP molecule and the split aptamer. rn

Postmortem whole-body computed tomography angiography visualizing vascular rupture in a case of fatal car crash

In addition to the increasingly significant role of multislice computed tomography in forensic pathology, the performance of whole-body computed tomography angiography provides outstanding results. In this case, we were able to detect multiple injuries of the parenchymal organs in the upper abdomen as well as lesions of the brain parenchyma and vasculature of the neck. The radiologic findings showed complete concordance with the autopsy and even supplemented the autopsy findings in areas that are difficult to access via a manual dissection (such as the vasculature of the neck). This case shows how minimally invasive computed tomography angiography can serve as an invaluable adjunct to the classic autopsy procedure.

Extra-intracranial blood shunt mimicking aneurysm rupture: intracranial-pressure-controlled rabbit subarachnoid hemorrhage model

The achieved degree of delayed cerebral vasospasm (DCVS) in the rabbits most frequently applied cistern magna blood injection model is often mild. The aim of this study was to characterize and evaluate the feasibility of an experimental SAH technique that mimics pathophysiological mechanisms and triggers higher degrees of DCVS.