Pituitary Dysfunction as a Cause of Cardiovascular Disease.

The hypothalamic-pituitary axis is responsible for the neuroendocrine control of several organ systems. The anterior pituitary directly affects the functions of the thyroid gland, the adrenal glands, and gonads, and regulates growth and milk production. The posterior hypophysis, through nerve connections with the hypothalamic nuclei, releases vasopressin and oxytocin responsible for water balance and social bonding, sexual reproduction and childbirth, respectively. Pituitary gland hormonal excess or deficiency results in dysregulation of metabolic pathways and mechanisms that are important for the homeostasis of the organism and are associated with increased morbidity and mortality. Cardiovascular (CV) disorders are common in pituitary disease and have a significant impact on survival. Hormonal imbalance is associated with CV complications either through direct effects on the heart structure and function and vasculature or indirectly by altering the metabolic profile. Optimal endocrine control can prevent or reverse CV defects and preserve survival and quality of life. In this review, we discuss the effects of pituitary hormone excess and deficiency on the CV system. Specifically, we assess the impact of Somatotroph, Corticotroph, Gonadotroph, and Lactotroph anterior pituitary axes on the CV system. The effect of posterior pituitary function on the CV system is also explored.

Noninvasive Ventilation to Treat Respiratory Failure After Cardiac Surgery: Predictors of Application and Outcome.

BACKGROUND: Respiratory complications remain a major cause of morbidity in cardiac surgery patients. This study aimed to determine the prognostic parameters associated with the application of noninvasive ventilation (NIV) for the treatment of acute respiratory failure, along with the possible predictors associated with NIV failure, among the subjects who underwent cardiac surgery. METHODS: This was a retrospective cohort study. Data on all adult patients who underwent cardiac surgery in a single center between May 2012 and December 2016 were analyzed. Multivariate regression analysis with bootstrapping was used to identify which baseline and intraoperative parameters were associated with the application of NIV to treat acute postoperative respiratory failure. A univariate analysis was also applied to identify potential variables associated with NIV failure. P < .05 was considered significant. RESULTS: A total of 1,657 subjects (mean ± SD age 65.2 ± 10.7 y; 21.7% females) constituted the study population, 145 (8.8%) of whom were treated with NIV due to acute postoperative respiratory failure. Body mass index adjusted odds ratio 1.02, bias-corrected 95% CI 1.01-1.04), EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (adjusted odds ratio 1.11, bias-corrected 95% CI 1.02-1.32), COPD (adjusted odds ratio 4.004, bias-corrected 95% CI 2.53-8.93), and preoperative estimated glomerular filtration rate (adjusted odds ratio 0.99, bias-corrected 95% CI 0.98-0.99) independently predicted NIV application. NIV treatment failed in 16 of the 145 subjects (11%) and age, EuroSCORE II, COPD, heart failure, renal replacement therapy, and postoperative stroke were all univariately associated with the outcome. CONCLUSIONS: NIV successfully treated acute respiratory failure in the vast majority of cardiac surgery subjects and COPD, EuroSCORE II, body mass index, and preoperative renal function were independently associated with its application.

Lung cancer induced from chemotherapy a 20 years old case.

Lung cancer is diagnosed at a late stage although we have novel diagnostic tools. The association of smoking and other environmental factors are well known. However; there are cases where a malignancy is associated with previous radiation treatment. There is an association between radiotherapy treatment and cancer incidence. We present a case where lung cancer and laryngeal cancer was induced 20 years after radiation therapy of a hogkin lymphoma.

Beware of hemopneumothorax following core needle breast biopsy.

Minimal diagnostic procedures are conducted regularly by the radiologists for several lesions within the body. The usual methodology is biopsy with a needle, either fine needle aspiration or core biopsy. The guidance is under CT or U/S. Fine needle aspiration has usually small diameter in comparison to the core biopsy. In any case the radiologist will choose the appropriate method based on the site of the lesion and safety of the patient. Pneumothorax and hemothorax are adverse effects that can be managed either on site with the help of a small catheter, however; there are cases where video-assisted thoracic surgery is needed in order to manage a more severe case. In the current study we present such a case where video-assisted surgery was necessary.

Thyroid Hormone Receptor Beta in the Ventromedial Hypothalamus Is Essential for the Physiological Regulation of Food Intake and Body Weight.

The obesity epidemic is a significant global health issue. Improved understanding of the mechanisms that regulate appetite and body weight will provide the rationale for the design of anti-obesity therapies. Thyroid hormones play a key role in metabolic homeostasis through their interaction with thyroid hormone receptors (TRs), which function as ligand-inducible transcription factors. The TR-beta isoform (TRß) is expressed in the ventromedial hypothalamus (VMH), a brain area important for control of energy homeostasis. Here, we report that selective knockdown of TRß in the VMH of adult mice results in severe obesity due to hyperphagia and reduced energy expenditure. The observed increase in body weight is of a similar magnitude to murine models of the most extreme forms of monogenic obesity. These data identify TRß in the VMH as a major physiological regulator of food intake and energy homeostasis.

Thyroid Function Tests in the Reference Range and Fracture: Individual Participant Analysis of Prospective Cohorts.

Context: Hyperthyroidism is associated with increased fracture risk, but it is not clear if lower thyroid-stimulating hormone (TSH) and higher free thyroxine (FT4) in euthyroid individuals are associated with fracture risk. Objective: To evaluate the association of TSH and FT4 with incident fractures in euthyroid individuals. Design: Individual participant data analysis. Setting: Thirteen prospective cohort studies with baseline examinations between 1981 and 2002. Participants: Adults with baseline TSH 0.45 to 4.49 mIU/L. Main Outcome Measures: Primary outcome was incident hip fracture. Secondary outcomes were any, nonvertebral, and vertebral fractures. Results were presented as hazard ratios (HRs) with 95% confidence interval (CI) adjusted for age and sex. For clinical relevance, we studied TSH according to five categories: 0.45 to 0.99 mIU/L; 1.00 to 1.49 mIU/L; 1.50 to 2.49 mIU/L; 2.50 to 3.49 mIU/L; and 3.50 to 4.49 mIU/L (reference). FT4 was assessed as study-specific standard deviation increase, because assays varied between cohorts. Results: During 659,059 person-years, 2,565 out of 56,835 participants had hip fracture (4.5%; 12 studies with data on hip fracture). The pooled adjusted HR (95% CI) for hip fracture was 1.25 (1.05 to 1.49) for TSH 0.45 to 0.99 mIU/L, 1.19 (1.01 to 1.41) for TSH 1.00 to 1.49 mIU/L, 1.09 (0.93 to 1.28) for TSH 1.50 to 2.49 mIU/L, and 1.12 (0.94 to 1.33) for TSH 2.50 to 3.49 mIU/L (P for trend = 0.004). Hip fracture was also associated with FT4 [HR (95% CI) 1.22 (1.11 to 1.35) per one standard deviation increase in FT4]. FT4 only was associated with any and nonvertebral fractures. Results remained similar in sensitivity analyses. Conclusions: Among euthyroid adults, lower TSH and higher FT4 are associated with an increased risk of hip fracture. These findings may help refine the definition of optimal ranges of thyroid function tests.

Burnout syndrome and job satisfaction in Greek residents: exploring differences between trainees inside and outside the country.

BACKGROUND: The purpose of this study is to investigate the levels of burnout among Greek residents, highlighting potential differences between those practicing at home and abroad, as well as to investigate correlations with demographic, individual and labor factors. METHODS: The research was conducted on a sample of 131 residents, using an anonymous questionnaire which included demographic, individual and labor characteristics, Maslach's Burnout Inventory, questions regarding job and life satisfaction levels, working conditions and the impacts of the economic recession. RESULTS: Fifty two point seven percent of the sample were training in the Greek National Health Service (N.H.S.), 27.5% in Germany and 19.8% in the United Kingdom. One out of three residents in the Greek system showed high levels of burnout in all three dimensions of the syndrome, while 51.1%, 72.2% and 30.8% of the Greek, British and German team, respectively, appeared burnt out simultaneously in two dimensions. Levels of job and life satisfactions ranged on average, while workload appeared heavy. CONCLUSIONS: The occurrence of burnout was associated with gender, specialty, employment characteristics (working hours, autonomy, support etc.), proneness to accidents, country, job satisfaction and quality of life, but was not associated with age or marital status. No correlation was found with susceptibility to medical errors.

Successful surgical treatment of a complicated esophageal perforation, by use of primary closure and lung parenchyma reinforcement.

Esophageal perforation (EP) is a medical condition which demands urgent confrontation with significant complications. The cause of the perforation may be common, spontaneous or iatrogenic, with conservative or surgical therapeutic strategy, which is needed in the majority of incidents, depending on the characteristics of the lesion. We report a case of a 68-year-old man, with the existence of an ulcerative lesion 31 cm approximately from the dental barrier, and a coexistent stenosis, diagnosed through esophagogastroduodenoscopy, which evolved to an extensive purulent necrotic mediastinitis, diagnosed through a thorax CT scan after the patient began to complain of asphyxiation during eating. A right posterolateral thoracotomy was performed along with intensive wide spectrum antibiotic therapy. Primary closure of the perforation as well as pulmonary tenting was used with satisfactory results. There was no evidence of leakage after a 12-month "follow-up" period. The early diagnosis of an EP combined with immediate surgical procedure and frequent "follow-up" of the patient, eliminate the risks for the patient's life and ensure a satisfactory outcome.

Percutaneous tracheostomy-beware of the thyroidea-ima artery.

Percutaneous tracheostomy is a minimally invasive operation performed in patients, in order to provide an air passage through the windpipe. A rare cause of severe bleeding during such operation is the injury of the thyroidea-ima artery. This case report presents a patient with hemorrhage after thyroidea-ima injury during percutaneous dilatational tracheostomy. Surgeons should always be aware of such anatomic variation, in order to prevent urgent sternotomy.

A patient with situs inversus totalis and lung cancer-a rare combination.

Situs inversus totalis (SIT) is a rare clinical entity which is characterized by a complete reverse anatomy of the thoracic cage and abdomen. There are a few reports of patients with SIT and lung cancer. The number of the cases that have been treated surgically is also very small. We report a case of an 80 years old patient who underwent left lower lobectomy after staging with uniportal video-assisted thoracoscopic surgery (VATS) and mediastinoscopy.

Fast-track rehabilitation following video-assisted pulmonary sublobar wedge resection: A prospective randomized study.

BACKGROUND: Postoperative morbidity and inhospital length of stay are considered major determinants of total health care expenditure associated with thoracic operations. The aim of this study was to prospectively evaluate the role of video-assisted thoracic surgery (VATS) compared to mini-muscle-sparing thoracotomy in facilitating early recovery and hospital discharge after pulmonary sublobar wedge resections. PATIENTS AND METHODS: A total number of 120 patients undergoing elective pulmonary sublobar wedge resection were randomly assigned to VATS (n = 60) or mini-muscle-sparing thoracotomy (n = 60). The primary endpoint was time to hospital discharge. Postoperative complications, cardiopulmonary morbidity and 30-day mortality served as secondary endpoints. RESULTS: Patients' baseline demographic and clinical data did not differ among study arms as well as the number of pulmonary segments resected and the morphology of the nodular lesions. Total hospital stay was significantly shorter in patients assigned to the thoracoscopic technique as opposed to those who were operated using the mini-muscle-sparing thoracotomy approach (4 ± 0.6 versus 4.4 ± 0.6 days respectively, P = 0.006). Multivariate analysis revealed that VATS approach was inversely associated with longer inhospital stay whereas the number of resected segments was positively associated with an increased duration of hospitalization. Patients in the VATS group were less likely to develop atelectasis (≥1 lobe) compared to those who underwent thoracotomy (0% versus 6.7% respectively, P = 0.042). Kaplan-Meier analysis revealed similar 30-day mortality rates in both study arms (Log-rank P = 0.560). CONCLUSION: VATS was associated with shorter duration of hospitalization positively affecting the patients' quality of life and satisfaction. Significant suppression of the total cost of recovery after thoracoscopic pulmonary resections is expected.

Video-assisted thoracic surgery reduces early postoperative stress. A single-institutional prospective randomized study.

BACKGROUND: Video-assisted thoracic surgery (VATS) has been shown to effectively reduce postoperative pain, enhance mobilization of the patients, shorten in-hospital length of stay, and minimize postoperative morbidity rates. The aim of this prospective study is to evaluate neuroendocrine and respiratory parameters as stress markers in cancer patients who underwent lung wedge resections, using both mini muscle-sparing thoracotomy and VATS approach. METHODS: The patients were randomly allocated into two groups: Group A (n=30) involved patients who were operated on using the VATS approach, while in group B (n=30), the mini muscle-sparing thoracotomy approach was used. Neuroendocrine and biological variables assessed included blood glucose levels, C-reactive protein (CRP) levels, cortisol, epinephrine, and adrenocorticotropic hormone (ACTH) levels. Arterial oxygen (PaO2) and carbon dioxide (PaCO2) partial pressure were also evaluated. All parameters were measured at the following time points: 24 hours preoperatively (T1), 4 hours (T2), 24 hours (T3), 48 hours (T4), and 72 hours (T5), after the procedure. RESULTS: PaO2 levels were significantly higher 4 and 24 hours postoperatively in group A vs group B, respectively (T2: 94.3 vs 77.9 mmHg, P=0.015, T3: 96.4 vs 88.7 mmHg, P=0.034). Blood glucose (T2: 148 vs 163 mg/dL, P=0.045, T3: 133 vs 159 mg/dL, P=0.009) and CRP values (T2: 1.6 vs 2.5 mg/dL, P=0.024, T3: 1.5 vs 2.1 mg/dL, P=0.044) were found increased in both groups 4 and 24 hours after the procedure. However, their levels were significantly lower in the VATS group of patients. ACTH and cortisol values were elevated immediately after the operation and became normal after 48 hours in both groups, without significant difference. Postoperative epinephrine levels measured in group A vs group B, respectively, (T2: 78.9 vs 115.6 ng/L, P=0.007, T3: 83.4 vs 122.5 ng/L, P=0.012, T4: 67.4 vs 102.6 ng/L, P=0.021). The levels were significantly higher in group B. CONCLUSION: This study confirmed that minimally invasive thoracic surgery, by means of VATS, significantly reduces the acute-phase response and surgical stress, while enables better postoperative oxygenation.

Single sternal metastasis due to malignant melanoma with unexpected long-term survival: a case report.

Metastases from melanoma have a very poor prognosis for the patient. Single metastatic lesions in the sternum due to melanoma are extremely rare. A rare case of a presternal mass in a 56-year-old patient who had undergone excision for malignant melanoma is presented. Review of the patient's history and surgical resection of a single metastatic soft tissue lesion offer the best chance of long-term survival.

Massive ovarian oedema: a misleading clinical entity.

BACKGROUND: Massive ovarian oedema is a rare non-neoplastic clinicopathologic entity has a higher incidence in women during their second and third life decade. The oedema can be presented in one or both ovaries as a result of partial intermittent torsion of the ovarian pedicle that interferes to the venal and lymphatic drainage of the ovary. CASE PRESENTATION: We present a clinical case of a 16 year old with massive ovarian oedema and we performed a review of the literature. The pathophysiology of this entity is very complex. We tried to perform a complete review of the literature and focus on the complexity of this entity as far as its pathophysiological backround is concerned and as far as its clinical presentation is concerned. CONCLUSIONS: In conclusion, massive ovarian oedema is a rare, multi disease mimicking clinical entity, with an acute or progressive clinical presentation. It has also to be a part of our differential diagnosis in cases of acute abdominal pain and we have to try to treat her conservatively, in order to preserve fertility.

Coexistence of squamous cell tracheal papilloma and carcinoma treated with chemotherapy and radiotherapy: a case report.

BACKGROUND: Papillomatosis presents, most frequently, as multiple lesions of the respiratory tract, which are usually considered benign. Malignant degeneration into squamous cell carcinoma is quite common, although curative approaches vary a lot in modern literature. CASE REPORT: We report a case of a 66-year-old male patient with the coexistence of multiple squamous cell papilloma and carcinoma in the upper trachea with severe airway obstruction that was diagnosed through bronchoscopy and treated by performing an urgent tracheostomy, followed by concurrent chemotherapy and radiotherapy. There was no evidence of recurrence after a 12-month follow-up period. CONCLUSION: This study underlines the diagnostic and therapeutic value of bronchoscopy as well as multimodality palliative treatment in such cases. To the best of our knowledge, this is the first study to describe an immediate treatment protocol with tracheostomy and concurrent chemotherapy/radiotherapy in a patient with squamous cell tracheal papilloma and carcinoma.

Surgical anatomy of the internal thoracic arteries and their branching pattern: a cadaveric study.

BACKGROUND: The purpose of this study is to review the anatomic characteristics of internal thoracic artery (ITA) and its branches, in order to pursue the extension of its utilization and avoid intraoperative and postoperative complications. METHODS: The study was carried out on anterior chest walls obtained during routine autopsies of 50 specimens (30 male, 20 female). Macroscopic and microscopic dissection was performed and the following were studied: origin, length and termination of ITA, size and distance from the sternum, and types of branches. RESULTS: From the origin to the termination point, the length of the left internal thoracic artery (LITA) varied from 159 to 220 mm; with a mean of 182.60 mm. The length of the right internal thoracic artery (RITA) varied from 150 to 231 mm; with a mean of 185 mm. Four types of branches were distinguished. The RITA mean diameter was 2.31 mm, measured at the 2(nd) intercostal space, while the distance from the sternum was 12.77 mm, measured at the 3(rd) intercostal space. The LITA mean diameter was 1.98 mm with the distance from the sternum measured at 12.01 mm. CONCLUSIONS: ITA has become the primary conduit for cardiac bypass surgery; many studies have generated fundamental anatomical knowledge for its clinical utilization, which is always useful in order to avoid intraoperative and postoperative complications.

Double primary non-small cell lung cancer with synchronous small cell lung cancer N2 nodes: a case report.

Synchronous multiple primary lung cancer (SMPLC) is rare and very hard to distinguish from metastatic disease. Recent studies indicate the presence of this entity in the lung, with no mention to the involvement of the mediastinum. An extremely rare case of a 68-year-old male with double primary non-small cell lung cancer (NSCLC) in the left upper lobe and N2 positive nodes for small cell lung cancer (SCLC) is presented. Modern diagnostic criteria as well as aggressive curative strategies are encouraged, in order to achieve better survival rates for such patients.

Subclinical thyroid dysfunction and fracture risk: a meta-analysis.

IMPORTANCE: Associations between subclinical thyroid dysfunction and fractures are unclear and clinical trials are lacking. OBJECTIVE: To assess the association of subclinical thyroid dysfunction with hip, nonspine, spine, or any fractures. DATA SOURCES AND STUDY SELECTION: The databases of MEDLINE and EMBASE (inception to March 26, 2015) were searched without language restrictions for prospective cohort studies with thyroid function data and subsequent fractures. DATA EXTRACTION: Individual participant data were obtained from 13 prospective cohorts in the United States, Europe, Australia, and Japan. Levels of thyroid function were defined as euthyroidism (thyroid-stimulating hormone [TSH], 0.45-4.49 mIU/L), subclinical hyperthyroidism (TSH <0.45 mIU/L), and subclinical hypothyroidism (TSH ≥4.50-19.99 mIU/L) with normal thyroxine concentrations. MAIN OUTCOME AND MEASURES: The primary outcome was hip fracture. Any fractures, nonspine fractures, and clinical spine fractures were secondary outcomes. RESULTS: Among 70,298 participants, 4092 (5.8%) had subclinical hypothyroidism and 2219 (3.2%) had subclinical hyperthyroidism. During 762,401 person-years of follow-up, hip fracture occurred in 2975 participants (4.6%; 12 studies), any fracture in 2528 participants (9.0%; 8 studies), nonspine fracture in 2018 participants (8.4%; 8 studies), and spine fracture in 296 participants (1.3%; 6 studies). In age- and sex-adjusted analyses, the hazard ratio (HR) for subclinical hyperthyroidism vs euthyroidism was 1.36 for hip fracture (95% CI, 1.13-1.64; 146 events in 2082 participants vs 2534 in 56,471); for any fracture, HR was 1.28 (95% CI, 1.06-1.53; 121 events in 888 participants vs 2203 in 25,901); for nonspine fracture, HR was 1.16 (95% CI, 0.95-1.41; 107 events in 946 participants vs 1745 in 21,722); and for spine fracture, HR was 1.51 (95% CI, 0.93-2.45; 17 events in 732 participants vs 255 in 20,328). Lower TSH was associated with higher fracture rates: for TSH of less than 0.10 mIU/L, HR was 1.61 for hip fracture (95% CI, 1.21-2.15; 47 events in 510 participants); for any fracture, HR was 1.98 (95% CI, 1.41-2.78; 44 events in 212 participants); for nonspine fracture, HR was 1.61 (95% CI, 0.96-2.71; 32 events in 185 participants); and for spine fracture, HR was 3.57 (95% CI, 1.88-6.78; 8 events in 162 participants). Risks were similar after adjustment for other fracture risk factors. Endogenous subclinical hyperthyroidism (excluding thyroid medication users) was associated with HRs of 1.52 (95% CI, 1.19-1.93) for hip fracture, 1.42 (95% CI, 1.16-1.74) for any fracture, and 1.74 (95% CI, 1.01-2.99) for spine fracture. No association was found between subclinical hypothyroidism and fracture risk. CONCLUSIONS AND RELEVANCE: Subclinical hyperthyroidism was associated with an increased risk of hip and other fractures, particularly among those with TSH levels of less than 0.10 mIU/L and those with endogenous subclinical hyperthyroidism. Further study is needed to determine whether treating subclinical hyperthyroidism can prevent fractures.

Thyrostimulin Regulates Osteoblastic Bone Formation During Early Skeletal Development.

The ancestral glycoprotein hormone thyrostimulin is a heterodimer of unique glycoprotein hormone subunit alpha (GPA)2 and glycoprotein hormone subunit beta (GPB)5 subunits with high affinity for the TSH receptor. Transgenic overexpression of GPB5 in mice results in cranial abnormalities, but the role of thyrostimulin in bone remains unknown. We hypothesized that thyrostimulin exerts paracrine actions in bone and determined: 1) GPA2 and GPB5 expression in osteoblasts and osteoclasts, 2) the skeletal consequences of thyrostimulin deficiency in GPB5 knockout (KO) mice, and 3) osteoblast and osteoclast responses to thyrostimulin treatment. Gpa2 and Gpb5 expression was identified in the newborn skeleton but declined rapidly thereafter. GPA2 and GPB5 mRNAs were also expressed in primary osteoblasts and osteoclasts at varying concentrations. Juvenile thyrostimulin-deficient mice had increased bone volume and mineralization as a result of increased osteoblastic bone formation. However, thyrostimulin failed to induce a canonical cAMP response or activate the noncanonical Akt, ERK, or mitogen-activated protein kinase (P38) signaling pathways in primary calvarial or bone marrow stromal cell-derived osteoblasts. Furthermore, thyrostimulin did not directly inhibit osteoblast proliferation, differentiation or mineralization in vitro. These studies identify thyrostimulin as a negative but indirect regulator of osteoblastic bone formation during skeletal development.

Heimlich valve and pneumothorax.

The Heimlich valve is a small one-way valve used for chest drainage that empties into a flexible collection device and prevents return of gases or fluids into the pleural space. The Heimlich valve is less than 13 cm (5 inches) long and facilitates patient ambulation. Currently there are several systems in the market. It can be used in many patients instead of a traditional water seal drainage system. The Heimlich chest drainage valve was developed so that the process of draining the pleural cavity could be accomplished in a safe, relatively simple, and efficient manner. This valve system has replaced the cumbersome underwater drainage bottle system. Moreover; the Heimlich valve system connects to chest tubing and allows fluid and air to pass in one direction only. This system functions in any position, and it does not ever need to be clamped, a regulated suction can be attached to it if necessary. The valve drains into a plastic bag that can be held at any level, allowing the patient undergoing chest drainage to be ambulatory simply by carrying the bag. In the current mini review we will present the Heimlich valve system and method of insertion.