Thrombus or tumor? A case report of a rare sarcoma entity: intimal sarcoma of the pulmonary arteries.

BACKGROUND: Tumor embolism is a very rare primary manifestation of cancers and the diagnosis is challenging, especially if located in the pulmonary arteries, where it can mimic nonmalignant pulmonary embolism. Intimal sarcoma is one of the least commonly reported primary tumors of vessels with only a few cases reported worldwide. A typical location of this malignancy is the pulmonary artery. Herein, we present a case report of an intimal sarcoma with primary manifestation in the pulmonary arteries. A 53-year-old male initially presented with dyspnea. On imaging, a pulmonary artery embolism was detected and was followed by thrombectomy of the right ventricular outflow tract, main pulmonary artery trunk, and right pulmonary artery after ineffective lysis therapy. Complementary imaging of the chest and abdomen including a PET-CT scan demonstrated no evidence of a primary tumor. Subsequent pathology assessment suggested an intimal sarcoma further confirmed by DNA methylation based molecular analysis. We initiated adjuvant chemotherapy with doxorubicin. Four months after the completion of adjuvant therapy a follow-up scan revealed a local recurrence without distant metastases. DISCUSSION: Primary pulmonary artery intimal sarcoma (PAS) is an exceedingly rare entity and pathological diagnosis remains challenging. Therefore, the detection of entity-specific molecular alterations is a supporting argument in the diagnostic spectrum. Complete surgical resection is the prognostically most important treatment for intimal cardiac sarcomas. Despite adjuvant chemotherapy, the prognosis of cardiac sarcomas remains very poor. This case of a PAS highlights the difficulty in establishing a diagnosis and the aggressive natural course of the disease. CONCLUSION: In case of atypical presentation of a pulmonary embolism, a tumor originating from the great vessels should be considered. Molecular pathology techniques support in establishing a reliable diagnosis.

Direct comparison between Grade Group assessed on systematic and MRI/ultrasound fusion targeted biopsies correlated to the radical prostatectomy specimens in patients with prostate cancer.

OBJECTIVES: To compare the correlation of Gleason score (GS) and ISUP grade determined by prostate biopsies (PBx) and radical prostatectomy (RP) specimens according to the biopsy technique: ultrasound randomised (RBx) vs. MRI/ultrasound fusion targeted (TBx). MATERIALS AND METHODS: Between March 2013 and June 2018, we retrospectively included patients who underwent RP for prostate cancer (PCa) histopathologically proven by RBx and/or TBx. All patients had a prebiopsy MRI by a single radiologist (using PI-RADS score), then transrectal RBx (12cores, blinded to MRI lesions) and TBx (2-4 cores/target) with elastic MRI/ultrasound fusion (UroStation™, Koelis, Grenoble, France). Histological findings were compared: PBx vs. RP. RESULTS: One hundred and four patients underwent RP after RBx and/or TBx. ISUP concordance rate was better with the association RBx+TBx 49% (51/104) vs. 43.3% with TBx (P=0.07) and 43.3% with RBx (P=0.13). With RBx, 50% of the patients were downgraded (52/104) against 42.3% (44/104) with TBx (P=0.088). The association RBx+TBx significantly decreased the rate of downgrading of the ISUP score compared to the ISUP score of RP 35.6% (37/104) vs. RBx (50%, P=0.0001) and vs. TBx (42.3%, P=0.016). CONCLUSION: In half of cases, the ISUP score was underestimated in RBx compared to RP specimens. Adding TBx to RBx significantly reduced downgrading. The combination of both biopsy techniques appeared to be the best protocol to get closer to ISUP score and GS of the RP specimens. LEVEL OF EVIDENCE: C.

The Effect of Caffeine Ingestion during Evening Exercise on Subsequent Sleep Quality in Females.

In a randomised, double-blind, placebo-controlled crossover design, 10 females taking monophasic oral contraceptives completed 90 min intermittent treadmill-running 45 min after ingestion of 6 mg∙kg(-1) body mass anhydrous caffeine or artificial sweetener (placebo). Water (3 mL∙kg(-1)) was provided every 15 min during exercise. Venous blood samples were taken before, during and after exercise, as well as after sleep (~15 h post-ingestion), and levels of caffeine, paraxanthine, theobromine and theophylline were measured using high-performance liquid chromatography. Sleep quality was assessed using the Leeds Sleep Evaluation Questionnaire. Plasma caffeine concentration peaked 100 min after ingestion. Caffeine clearance was 0.95±0.14 mL·min(-1)·kg(-1) while the elimination half-life of caffeine was 17.63±8.06 h. Paraxanthine and theophylline levels were significantly elevated at 15 h with no significant change in theobromine. Sleep latency and subsequent quality of sleep was impaired following caffeine supplementation (P<0.05); there were no differences between trials for how participants were feeling upon awakening. This is the first controlled study to examine caffeine supplementation on sleep quality in female athletes taking a low-dose monophasic oral contraceptive steroid following an intermittent-exercise running protocol. The data shows that female athletes using monophasic oral contraceptive steroids will have impaired sleep quality following evening caffeine ingestion.

Initial results of an optimized perfusion system.

BACKGROUND: In order to reduce the negative effects of extracorporeal circulation (ECC), the perfusion system and management were optimized at our institution. The goals of optimization were a reduction in the priming volume, in the foreign surface area and in microbubble activity, as well as optimization of suction blood management. METHODS: Sixty patients were included in this retrospective study. Patients were assigned to two groups, with regard to the use of an optimized perfusion system (OPS-group, n=30) and a standard perfusion system (SPS-group, n=30). All patients underwent elective procedures. RESULTS: There were no significant differences with respect to patient demographics and operation time. ECC time and cross-clamp time were significantly longer in the OPS group. Statistically significant differences in outcome between the two groups were seen with regard to the following variables: effective priming volume (OPS: 775±447ml; SPS: 1610±0ml; p<0.0001), hemoglobin drop after the start of ECC (OPS: 2.7±1.2g/dl; SPS: 4.2±0.8g/dl; p<0.0001), c-reactive protein on postoperative day 2 (OPS: 121.0±59.4 U/l; SPS: 164.0±50.2 U/l; p=0.003). With regard to the use of blood transfusions, a 33% reduction in the overall amount of transfused units was seen. The rate of patients without transfusions during the entire hospital stay increased from 37% (SPS) to 53% (OPS). The mean transfused red blood cell units per patient was lower in the OPS-group (1.6±2.4 units) than in the SPS-group (2.3±3.5 units). CONCLUSION: With the described optimized perfusion system, a significantly lower priming volume, leading to less hemodilution after the onset of CPB, was achieved. The amount of blood transfusions and the inflammatory response were reduced.

Retrospective analysis of outcome data with regards to the use of Phisio®-, Bioline®- or Softline®-coated cardiopulmonary bypass circuits in cardiac surgery.

BACKGROUND: Numerous cardiopulmonary bypass circuits with various coatings designed to reduce the inflammatory response and to provide better hemocompatibility are available. The aim of this study was to compare the effect of phosphorylcholine-coated, albumin-heparin-coated and synthetic polymer-coated perfusion tubing systems on patient outcome. METHODS: We performed a retrospective database review of elective patients between January 1st 2010 and December 31st 2010. Demographics, preoperative, operative, postoperative data and follow-up were collected and statistically analysed. RESULTS: We identified 201 patients and formed three groups: Group 1 with phosphorylcholine coating (n=133), Group 2 with albumin-heparin coating (n=32) and Group 3 synthetic polymer coating (n=36). Mean age was 68 ± 11 years, additive Euroscore 5.8 ± 2.7. In-hospital outcomes were comparable between the groups without statistically significant differences. The overall 30-day and 1-year late survival were 98.5% and 96.7 ± 1.9%, respectively. CONCLUSIONS: Our findings suggest that in-hospital and follow-up outcomes are comparable in cardiac surgery patients after using either phosphorylcholine-coated, albumin-heparin-coated or synthetic polymer-coated circuits during cardiopulmonary bypass.

Defibrillator generator replacements in patients with left ventricular assist device support: The risks of hematoma and infection.

BACKGROUND: The majority (89%) of left ventricular assist device (LVAD) patients have an implantable cardioverter-defibrillator (ICD) in place. Due to the advances of modern-day LVAD therapy, more patients are on support for longer. This inevitably leads to more LVAD patients facing ICD generator battery depletion. Until now, there are insufficient data regarding periprocedural risks of generator replacements in a high-risk group like the LVAD cohort. METHODS: A retrospective, single-center analysis of pocket-related outcomes of all ICD generator replacements in LVAD and Non-LVAD patients between January 2014 and December 2018. The primary outcome was the combined endpoint of clinically significant pocket hematoma and/or cardiac implantable electronic device (CIED) infection in the first 6 months after ICD generator exchange. The clinically significant hematoma was defined as hematoma requiring reoperation, prolongation of hospitalization, or interruption of anticoagulation. The cumulative incidence function was calculated for the primary endpoint. RESULTS: Two hundred seventy-seven patients underwent ICD generator exchange in our clinic in this time. Of these, 251 patients had a complete 6-month follow-up regarding clinically significant pocket hematomas and pocket infections. One hundred ninety patients had no LVAD, and 61 patients were on LVAD support. The rate of the primary combined endpoint clinically significant pocket hematoma and/or CIED infection was 3.5 times higher in LVAD patients compared to the non-LVAD cohort (event rate 39.14 vs 11.07 per 100 patient-years, p = 0.048). Clinically significant pocket hematomas necessitating revision occurred nearly 4 times more often in the LVAD group (p = 0.042). Pocket device infection rates were around 16 times higher in LVAD patients compared to non-LVAD patients (p = 0.002). CONCLUSIONS: Compared to Non-LVAD patients, LVAD patients exhibit a relevant higher rate of clinically significant pocket hematoma and CIED infection after ICD generator exchange. This information should additionally be considered in the decision-making process regarding the indication for ICD generator exchange.

DNA damage in human leukocytes after ischemia/reperfusion injury.

Leukocytes have been shown to play an important role in the development of tissue injury after ischemia and reperfusion (I/R). In the present study, the effects of tourniquet-ischemia on induction of DNA damage in peripheral leukocytes and on respiratory burst of neutrophils in humans were examined. The DNA damage was measured as increased migration of DNA using the single-cell gel-electrophoresis technique (comet assay). Intracellular production of reactive oxygen species by neutrophils was measured flow-cytometrically using dihydrorhodamine 123 as indicator. Postischemic, significantly increased migration of DNA was found in leukocytes of 20 patients (tourniquet-ischemia of the lower limb for 65-130 min, anterior-cruciate-ligament-reconstruction) and in 10 experiments (1 volunteer, repeated tourniquet-ischemia of the upper limb for 60 min, no operation). DNA effects were most pronounced 5-30 min after tourniquet release, and then declined over a 2 h period, but did not return to preischemic baseline values. A similar time course showed the oxidative status of unstimulated granulocytes during reperfusion. Simultaneously, opposing changes were measured in formyl peptide (f-MLP)- or phorbol ester (PMA)-stimulated granulocytes, which showed a significantly declined respiratory burst reaction after tourniquet-release indicating preactivation of neutrophils by IR. Our data suggest that IR induces genotoxic effects in human leukocytes presumably in response to oxidative stress during reperfusion.

The ross operation in 225 patients: a five-year experience in aortic root replacement.

BACKGROUND AND AIM OF THE STUDY: The Ross operation, introduced more than 30 years ago, has recently undergone several modifications to improve both technical feasibility and results. At the authors' institution, the Ross operation, performed as root replacement in all cases, was commenced in February 1995. METHODS: A total of 225 patients (177 males, 48 females; mean age 39+/-15 years; range: 2 to 67 years) were operated on up to December 2000. Aortic regurgitation was present in 80 patients, stenosis in 69, and combined disease in 73; prostheses were replaced in three patients. Combined procedures were performed in 51 patients. Nine patients had active endocarditis. Follow up was 98% complete and totaled 471 patient-years. RESULTS: There was no early mortality, and no thromboembolic or hemorrhagic events. Complications included prolonged ventilation in two patients, perioperative myocardial infarction in three, pacemaker implants in three and perioperative bleeding in six. One patient died at 25 months from hemoptysis, and one at five months of unknown cause. In the long term, four patients required reoperation due to autograft regurgitation (one autograft repair, three autograft replacements). Routine aortic annulus support, a lowered threshold in replacing all dilated ascending aorta and keeping the autograft short to the level of the sinotubular junction seems to have prevented further autograft failure. Pulmonary homograft stenosis led to reoperation in one patient. Six patients with elevated gradients are currently under observation. Echocardiography revealed autograft median peak gradients of 5.1+/-2.8 mmHg, pulmonary homograft gradients of 14.2+/-11.5 mmHg, and no significant regurgitation, except in one additional patient with recently diagnosed aortic insufficiency (grade >2). CONCLUSION: Mid-term excellent hemodynamic results, low morbidity and reoperation requirement support the evolved root replacement technique and justify its further utilization.

[Psychological effects of embryonal reduction. From the decision making to 4 months after delivery]. / Effets psychologiques des réductions embryonnaires. De la prise de décision à 4 mois après l'accouchement.

The psychological effect of reducing the number of embryons was studied prospectively in two Paris hospitals. All women who had multifetal pregnancy reduction (n = 18) were contacted for interviews just after the operation, during pregnancy, and four months after delivery. The decision to reduce the number of embryons was painful and led to a guilty feeling. After operation, nearly one-half of the women suffered psychologically. To justify their decision, and contain their emotions, the women spoke of the problems related to having triplets and, most importantly, the medical arguements explained by the physician. Medical counselling is thus essential to help this couples at the time of the operation. The pregnancy period is almost always a period of calm for these women. Nevertheless, four months after delivery, 5 women expressed a psychological malaise related to the reduction, and 2 women refused to continue the study because they did not want to revive their suffering. This study shows that psychological problems are of major importance after multifetal pregnancy reduction and can occur several months after delivery. These negative conclusions should however be examined in light of the consequences if reduction had not been performed.

Surgical pacemaker lead extraction: 10 years of experience.

Due to the worldwide increasing number of patients with pacemaker implants, the problem of lead extraction with its potential difficulties and complications has gained enormous importance. Primarily lead extraction should be attempted percutaneously; however, in case of failure or contraindications for percutaneous extraction, such as vegetations with a high risk of embolization (size >10mm), a surgical approach is necessary. From 1991 until 2001 we performed surgical lead extraction in 16 patients (mean age 62.1±15.0 years, male 13, female 3). All patients presented with lead infection and clinical symptoms of septicemia at a rather advanced stage, in average 7.0±8.8 months after the onset of symptoms. In 13 cases we performed an open heart approach with the use of cardiopulmonary bypass, in 3 a closed heart approach. Perioperative mortality was 0%. Pacemaker leads were successfully removed in 100%. No reinfections were reported. Surgical pacemaker lead extraction is a highly effective tool and can be safely performed without significant mortality. If surgery is indicated it should be performed as early as possible.

Initial experience with a modified left atrial maze procedure concomitant to cardiac surgery.

BACKGROUND: The excellent results of the Cox-Maze-III operation showed that a surgical treatment of atrial fibrillation is possible. The maze operation is surgically demanding and time-consuming. This fact led to the development of simplified modifications. Due to the good results of an exclusive left atrial maze procedure in combination with mitral valve surgery and new technologies of ablation, it seems reasonable to perform these techniques concomitant to cardiac surgery on a large number of patients.¶ METHODS: From November 1999 until June 2000 a modified maze procedure concomitant to a cardiac surgical intervention was performed on 42 patients, with a mean age of 62.2 years, suffering from chronic or intermittent atrial fibrillation. Primary cardiac disease was mainly cardiac valve disease (mitral valve disease 19 patients, aortic valve disease 10 patients) or coronary heart disease (8 patients). After left atriotomy and with the use of the Thermaline probe (Boston Scientific, Corporation, San Jose, California, USA) a bilateral pulmonary veins isolation was carried out by radiofrequency ablation. An additional ablation line was directed from the left pulmonary veins to the posterior mitral valve anulus. Finally, the left atrial appendage was resected. An evaluation of the therapeutic success was carried out in the immediate postoperative course and 3 months after surgery, at that point of time operation-related influences on the refractory period of the atrial myocardium were negligible.¶ RESULTS: At the time of discharge 32 patients (76.2%) showed a regular supraventricular rhythm. Twenty-one patients have already undergone the 3-month follow-up examination. At the time of discharge 13 out of these 21 patients (61.9%) were in sinus rhythm and at 3 months after surgery 18 out of these 21 patients (85.7%) showed a sinus rhythm with a restoration of atrial transport function echocardiographically determined. Three patients were still receiving antiarrhythmic medication.¶ CONCLUSION: The modified maze procedure in combination with cardiac surgical interventions proved to be easy, quick and reliable to perform. The early results suggest a high success rate of this technique. The long-term results have to be verified with further, regular follow-up examinations of the patients.

[Moral status of the embryo]. / El estatuto moral del embrión.

Diagnosis for the purposes of embryo selection prior to implantation, research using embryos and the German embryo Protection Act (1991) constitute the starting-point for a discussion of the legal and moral status of embryos. Since the entire genetic programme for a future human being is established at the point of completed union of female egg-cell and male sperm-cell, the embryo conceived in vitro also benefits from the protection of human dignity. It may therefore not be treated exclusively as an object of another's purposes, in other words, it may not be exploited for research or rejected after pre-implantation diagnosis. This conclusion is in accordance with constitutional case-law and international human rights treaties. Research using embryos is permissible in the case of one narrowly circumscribed exception, which will be more closely defined.

Hydrops of the gallbladder in the neonatal period.

A case of hydrops of the gallbladder in the neonatal period in which the diagnosis was made with the help of ultrasonography is described. To our knowledge this is the first case of gallbladder hydrops that has been described in the newborn period.