Penetrating missile embolisation

The present case report is that of a 13-year-old boy, who was admitted to the Emergency Unit at the American University of Beirut Medical Center (AUBMC), with a bullet injury to the right upper quadrant with no exist. Chest X-ray and KUB failed to reveal the bullet and there was no evidence of haemo- or pneumothorax. X-ray of both thighs showed the bullet at the level of the right groin. The bullet penetrated the liver, diaphragm and pericardium. It entered through the left ventricle and embolised through the arterial circulation to the right superficial femoral artery. Included in this report is a review and analysis of patients with missile embolisation, who were treated at the AUBMC over the last 10 years.     

Impaired temporal resolution of vision after acute retrobulbar neuritis

Following retrobulbar neuritis patients need a greater interval between two flashes of light in order to see them as double. The abnormality is large and easily detectable; the values lie well outside the normal 99 per cent tolerance limits. The abnormality sometimes occurs in localized retinal areas but can cover the whole visual field. The abnormality is a persistent one, remaining up to five years after visual acuity has returned to normal. It can occur in the absence of optic atrophy and with normal visual fields. There is also a delay in visual perception following retrobulbar neuritis but when this and double flash discrimination are both measured at the same retinal sites, the areas of abnormality do not correlate for the two tests. This indicates that the two tests monitor different aspects of visual damage. Double flash threshold can be a more sensitive indication of visual damage due to demyelination than conventional clinical tests including critical flicker fusion frequency. It provides an absolute measurement of local damage in the visual field and has advantages over the recording of perceptual delay and of evoked potentials.     

The physicochemical properties of hair in the BIDS syndrome

The physicochemical properties of hair from a new recessive syndrome associated with brittle hair, intellectual impairment, decreased fertility, and short stature have been studied. Electrophoresis of the SCM-structural proteins showed that the alpha polypeptides appeared normal, but the matrix component was markedly reduced. This was confirmed by finding a normal alpha X-ray diffraction pattern but a reduced 1/2 cystine content of hair and an abnormal stress-strain curve. Electron-microscopic studies revealed extreme disorganization of the filaments which most likely resulted from the absence of normal cross-linking. Nails, which contain structural proteins similar to hair, also showed the abnormality. Since the matrix component seen by electrophoresis consists of more than one component the defect cannot be explained as a single structural gene abnormality.     

Chronic liver disease in Peru: role of viral hepatitis

Autologous or glutaraldehyde treated bovine pericardial valved patch was utilized for widening of the right ventricular outflow tract in 20 patients with tetralogy of Fallot (autologous pericardium group in 10 patients and bovine pericardium group in 10). Pericardial valve function of the both materials was evaluated by postoperative cardiac catheterization performed 1 year after the operation. There were no significant differences in pulmonary arterial and right ventricular pressures, and right ventricular ejection fraction and end-diastolic volume between the 2 groups. Pulmonary angiogram in the autologous pericardium group patients demonstrated the pulmonary regurgitation (PR) of grade 1 in 5 patients, grade 2 in 4 and grade 3 in 1. On the other hand, 1, 3 and 6 patients in the bovine pericardium group demonstrated no-PR, grade 1 PR and grade 2 PR, respectively. It was concluded that there were no significant differences between autologous and glutaraldehyde treated bovine pericardium as a material of valved patch for widening of the right ventricular outflow tract of tetralogy of Fallot.     

Use of transesophageal echocardiography in the detection and consequences of an intracardiac bullet

A 17-year-old male sustained a gunshot injury to the chest. Transesophageal echocardiography showed the presence of a retained bullet in the pericardium and the absence of an intracardiac shunt, which provided important information for the treatment of the patient.     

Pseudohypoaldosteronism: options for consideration

Pseudohypoaldosteronism (PHA), or mineralocorticoid resistance, displays several features which distinguish it from other steroid resistance syndromes: while at presentation the clinical manifestations may be severe, patients almost invariably survive into adulthood without ill effects in the absence of ongoing treatment; patterns of inheritance are very variable; and, in addition to the more common primary form, it may develop secondary to a variety of conditions. Although the clinical presentation and the finding of absent or greatly diminished binding of aldosterone by peripheral blood leukocytes strongly suggest an underlying abnormality involving the mineralocorticoid receptor (MR), no abnormality in the MR has been identified, unlike other forms of resistance to hormones in the steroid superfamily, in which the underlying abnormality has been traced to a defect in the gene encoding the receptor protein. Molecular studies of the index case have excluded a major cytogenetic abnormality and major deletions or rearrangements of the MR gene. They have also shown that the cDNA sequence corresponding to the open reading frame of the mineralocorticoid receptor molecule is normal, compared with the published human MR cDNA sequence, and that MR mRNA is expressed in apparently normal quantities in peripheral blood mononuclear leukocytes. These findings raise a number of questions about the underlying mechanism for PHA and the mechanisms by which homeostasis is achieved in the absence of effective aldosterone action. With respect to the mechanism(s) of PHA, several possibilities can be envisaged. It is possible, albeit unlikely, that by unfortunate chance small mutations have been missed as a result of cloning only normal alleles in heterozygous patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Congenital absence of the pericardium: displacement of the heart associated with tricuspid insufficiency

This report describes a patient with congenital absence of the left pericardium with displacement of the heart into the left pleural space and associated tricuspid insufficiency. Excision of the ruptured chordae, plication of the flail anterior leaflet, and tricuspid annuloplasty rendered a competent tricuspid valve.     

Apical filling abnormality in patients with heart failure assessed with contrast echocardiography using venous injection of Albunex

Contrast echocardiography by venous injection of Albunex was used to visualize apical filling abnormality in patients with heart failure. 1. Contrast echocardiography was serially performed in 24 patients with acute anterior myocardial infarction. Wall motion of the infarct region was better at any stage in patients without apical filling abnormality than in patients with that. Improvement of filling abnormality was observed prior to that of wall motion abnormality. 2. Influence of tachycardia was assessed on apical filling in 20 patients with old myocardial infarction during rapid atrial pacing. Stress contrast echocardiography evidenced that tachycardia deteriorates apical filling abnormality in patients with chronic heart failure. 3. The effect of amrinone on apical filling was assessed in 60 patients with chronic anterior myocardial infarction. Apical filling abnormality improved in 46% of patients after amrinone infusion. The improvement of apical filling abnormality was closely related to the reduction of preload and improvement of asynergy in the infarct area after amrinone. Both adjunctive therapy and anticoagulant therapy should be considered if apical filling abnormalities are observed by contrast echocardiography.     

Enhanced detection of proximal right coronary artery stenosis with the additional analysis of right ventricular thallium-201 uptake in stress scintigrams

The value of right ventricular thallium-201 analysis in detecting proximal right coronary artery stenosis in exercise myocardial scintigraphy was analyzed in 52 patients, 27 with and 25 without proximal right coronary artery stenosis. For the detection of proximal right coronary artery stenosis, the sensitivity and specificity of thallium scintigraphic analysis were 59 and 88% for a right ventricular abnormality, 67 and 68% for a left ventricular inferior wall abnormality, and 93 and 56% for an abnormality of either. When both right and left ventricular thallium images were abnormal, all 9 patients had proximal right coronary artery stenoses, and when both were normal, 26 of 28 patients had a normal proximal right coronary artery. The sensitivity and specificity of blood pool scintigraphic variables during exercise (right ventricular ejection fraction and left ventricular inferior wall motion) were not significantly different for detection of proximal right coronary artery stenosis. Thus, the additional analysis of the right ventricle on thallium-201 stress scintigrams can improve the detection of proximal right coronary artery stenosis. When both right ventricular and left ventricular thallium scintigrams are abnormal (or normal), the ability to predict the presence (or absence) of proximal right coronary artery stenosis is very high.     

Combined elevation of IgM and IgA rheumatoid factor has high diagnostic specificity for rheumatoid arthritis

An annual check by chest roentgenogram is very important for the early detection of lung cancer. We present three cases of primary lung cancer which were not detected by the double check system or previous examination. The three patients visited our hospital for evaluation of an ill-defined opacity in the upper lobe of the lung. In the three cases, no abnormality had been reported in the previous year's annual chest X-ray, and we concurred in the decisions. The correct diagnoses of the three cases were well or poorly differentiated adenocarcinoma, and were still amenable for surgical therapy. A poorly defined tumor in this region is very difficult to detect because of superimposed opacities of other anatomical structures. When a questionable shadow in this region is found but without the typical radiological features of lung cancer, it is important to search for indirect indications of adenocarcinoma. These may include fibrotic changes and absence of inflammation. In our cases, the increased number of normal-size bronchi penetrating the ill-defined tumor, seem to have diagnostic significance.     

Bronchopulmonary dysplasia: correlation of radiographic and clinical findings

BACKGROUND AND PURPOSE: Abnormalities of the chest wall have been described in bronchopulmonary dysplasia (BPD). Clinical, radiographic and pulmonary function variables were evaluated in 1-year-old children ventilated because of neonatal lung disease in order to quantify these thoracic changes and to evaluate the lung disease. METHODS: The pulmonary status of 51 infants with neonatal lung disease requiring artificial ventilation was reevaluated clinically and radiographically at the age of 1 year. Twenty-two of these infants had developed BPD. Thoracic depth and width were measured clinically and on chest X-ray. The Toce score evaluated the presence of cardiomegaly, hyperinflation, emphysema and interstitial lung disease. Lung function was measured after sedation using previously reported methods. In BPD patients, Toce score and lung function were determined and compared at 1 month and at 1 year of age. RESULTS: In BPD patients, chest depth was significantly smaller when measured clinically as well as on chest radiograph (P < 0.05; Mann-Whitney U-test). There was a statistically significant correlation between chest depth measured clinically and on chest X-ray. Toce score was significantly higher in BPD patients (P < 0.05). In BPD patients intersitial abnormalities and decreased lung compliance were more frequent at the age of 1 month than at the age of 1 year. At the age of 1 year, hyperinflation was more frequent and at that time increased airway resistance was still noted. Thus the type of X-ray abnormality reflects the type of lung function disturbance. CONCLUSION: The flatness of the chest is most likely a consequence of the long-standing lung function abnormalities.     

Integrity of the pericardium. Its beneficial effects on the protection of the right ventricle in the presence of acute pulmonary hypertension

After cardiac transplant (CT), the right ventricle can be subject to an acute pressure overload, especially in cases where there is a pre-existing severe pulmonary hypertension. Objectives: To determine the maximum tolerance of the right ventricle (MxTRV) when faced with acute pressure overload. To study the function of both ventricles of the healthy heart (donor) when faced with different degrees of pulmonary hypertension. To detect possible interactions between the ventricles in the absence of the pericardium to approximate the experimental model to the clinical model of CT. Methods: The pulmonary artery is progressively constrained in an experimental model until biventricular failure is detected. This experiment is performed in two different situations: with and without pericardial integrity. Results: When pericardial integrity is maintained the MxTRV faced with a pressure overload is 73.2+/-8.56 mmHg. When this pressure is exceeded there is a circulatory collapse with a sharp fall in the cardiac output and in the aortic pressure. However, when pericardectomy is performed (model similar to CT), only 52+/-6.71 mmHg is tolerated (p< 0.001). Conclusions: With the pericardium open, as in CT, the maximum pressure that the right ventricle can support is significantly less than with the pericardium closed. The pericardium has a positive effect in protecting the systolic ventricular interaction.     

Myoclonic absence-like seizures and chromosome abnormality syndromes

PURPOSE: We explored the relationship between myoclonic absence seizures (MAS) and underlying chromosome disorders. METHODS: Among 14 patients with MAS observed in three centers, 5 had typical cryptogenic myoclonic absence epilepsy (MAE), 2 had MAS associated with other seizure types (1 with signs of a neuronal migration abnormality and 1 with signs of a metabolic disorder), and 7 had MAS, with or without other seizure types, complicating a chromosome abnormality syndrome-2 with trisomy 12p, 4 with Angelman syndrome, and 1 with inv dup (15). RESULTS: In the 7 patients with chromosomopathy, MAS appeared at a mean age of 2.9 years (range 4 months to 6 years 6 months), had a duration of 4-20 s, and were accompanied by reduced awareness and rhythmic myoclonic jerks involving proximal limb muscles. Ictal EEG showed 2- to 3-Hz generalized spike-and-wave discharges. CONCLUSIONS: In these patients, MAS differed slightly from those of typical MAE: age of onset was earlier, absences were of shorter duration, and no clear increase in muscular tone was noted. Abnormal expression of genes codifying for the subfamily of K+ channels and for gamma-aminobutyric acid-3 subunit receptors (GABRB3), both located in the chromosome segments involved in the chromosomopathies presented by our patients, could be responsible for the same generalized seizure type. Chromosome analysis should be performed in patients with mental retardation and MAS, especially when the ictal pattern does not completely overlap that observed in MAE.     

Proof of the primacy of prion protein

This paper presents a case of a 5-year old girl with a congenital absence of the nose. Congenital arrhinia is a very rare malformation of the midfacial bones. The difficulties of treating a child with this abnormality are discussed.     

Levels of immunoglobulin E (IgE) in paired examinations of serum and synovial fluid in rheumatoid arthritis and reactive synovitis of local origin

Twenty-eight pregnant patients exhibiting subnormal fetal growth patterns by serial ultrasonic cephalometry were studied. Only 12 (43%) delivered small-for-gestational-age (SGA) infants indicating a poor correlation between the prenatal assessment of intrauterine growth retardation (IUGR) by ultrasonic cephalometry and the neonatal evaluation of the newborn as SGA. The most important factors in the evaluation of the fetus with subnormal serial ultrasonic cephalometry were: 1) the type of ultrasonic growth pattern ("late flattening" vs "low growth profile"), 2) the presence or absence of maternal high-risk factors, and 3) the gestational age of the fetus at the time of detection of the growth abnormality. A pregnancy showing a late flattening type of growth pattern by serial ultrasound in the presence of maternal high-risk factors and with the growth abnormality being detected before 35 weeks of gestation, almost certainly will terminate with the birth of a SGA infant. On the contrary, serial plasma free estriol determinations were not useful in predicting the fetal status at birth. All but 4 of these patients were delivered at term and there was neither perinatal mortality nor significant morbidity. It is suggested that the existence of an abnormal cephalometric pattern is not an indication for early delivery unless fetal distress is detected by means of an oxytocin challenge test.     

Surgical results of T3 lung cancer with combined resection

Forty six patients with T3 lung cancer underwent pulmonary resection in our institutes. The actual survival rate of lung cancer patients with invasion in pericardium at five years is significantly higher than that in parietal pleura and chest wall (63.5% vs 13.2%, 11.1%). The survival rate of patients with large cell lung cancer is significantly lower than that with squamous cell lung cancer and small cell lung cancer (0.0% vs 39.9%, 16.7%). It is suggested that T3 large cell lung cancer patients might be contraindication of pulmonary resection. The five-year survival rate of patients with n0, n1, n2 disease are 35.5%, 66.7%, 6.7% respectively. There are significant differences in survival rate between patients with n0 + n1 and n2 disease.     

Effects of dilute acetic acid on the cervical smear

BACKGROUND: Mesothelial integrity is essential for the prevention of pericardial adhesions. This study was performed to determine the effect of physical protection of the pericardium on mesothelial integrity. METHODS: A pericardial biopsy specimen was obtained at the time of pericardiotomy (0 minutes) in 10 patients undergoing a cardiac operation for the first time. The left free edge of the pericardiotomy was plicated inward to protect the mesothelium. Biopsy specimens were obtained from the protected and unprotected pericardium at 45 and 90 minutes after the start of extracorporeal circulation. Mesothelial integrity and the local inflammatory response were then assessed and graded histologically. RESULTS: The mesothelium was found to be present in the protected specimens at 0, 45, and 90 minutes, but it was found to be denuded in the unprotected specimens (p = 0.003 at 45 minutes; p = 0.004 at 90 minutes). Local inflammation was totally established in both the protected and unprotected specimens at 45 minutes. CONCLUSIONS: Physical agents appear to be the main factor that is damaging to the pericardial mesothelium, and this is an important concept to be taken into consideration when designing a method to prevent pericardial adhesions.     

Anatomy and histotopography of human pericardial lymphoid tissue

Data concerning microscopic structure of the layers of human serous pericardium, localization of lymphoid structures as related to them and their interrelations with connective tissue elements and vessels are represented. Findings on the thickness of serous pericardium in different layers are also given.     

Analysis of IMP-SPECT in cerebral infarcts

We performed single photon emission computed tomography with N-isopropyl[123I]-p-iodoamphetamine in 22 normal volunteers (mean age, 68.3 +/- 9.5 years) and 190 patients with unilateral cerebral infarcts (66.1 +/- 11.4 years). We then compared visual and semiquantitative assessment of the left/right ratio of the early images. Cerebral blood flow in the patients with cerebral infarcts was compared with data from normal volunteers. An abnormal left/right ratio was recognized in 110 of 136 (81%) patients in whom X-ray computed tomography (CT) showed an abnormality, while visual inspection revealed abnormalities in only 99 (73%). In 54 patients no abnormality on CT, an abnormal left/right ratio was found in 28 (52%), and visual abnormalities in only 9 (17%). Altogether, the left/right ratio was abnormal in 138 of 190 (73%) patients, and abnormalities were detected visually in 108 (57%). Of 95 patients, 56 (59%) showed markedly larger lesions using the left/right ratio method than with the visual method.     

Epidemiology and therapy of malignant hemopathies in Senegal

Rupture of the pericardium due to blunt thoracic trauma is a rare pathology with a range of mortality between 30 and 64% according to different authors. We review 40 cases which have been reported in the literature in the last decade and report a case of our own. We have found that 82% of the patients with traumatic rupture of the pericardium were men with a mean age of 45 years. In 80% of the cases the cause was a motor vehicle accident, 17% were due to falls and only 1 case was associated with a crush. The commonest location of the tear was the left pleuropericardium (62%) followed by the diaphragmatic portion of the pericardium (22%). In 80% of the cases the diagnosis was achieved in the course of a surgery performed for associated lesions. None of the cases was diagnosed in a post-mortem study. The traumatic rupture of the pericardium is a disease which often remains undiagnosed, especially when one does not have a high index of suspicion. Nevertheless, this is a disease which can threaten the life of the patient and we should keep it in mind to diagnose and treat it as soon as possible. It is known that an early and aggressive management of these patients implies a much better prognosis with a significant reduction of the mortality. In this article we want to give useful clues to allow a preoperative diagnosis and an early and adequate management.