Severe aortic regurgitation from aortic valve perforation in Libman-Sacks endocarditis: Incremental value of 3D TEE.

A 43-year-old woman with stroke and systemic lupus erythematosus was found to have severe eccentric aortic regurgitation. Three-dimensional transesophageal echocardiogram further defined the origin of the regurgitant jet through a perforation in the left coronary cusp next to a mass with a tiny stalk attached to the left coronary cusp.

A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion - Adding QRS amplitude of V2 improves the model.

INTRODUCTION: Precordial normal variant ST elevation (NV-STE), previously often called "early repolarization," may be difficult to differentiate from subtle ischemic STE due to left anterior descending (LAD) occlusion. We previously derived and validated a logistic regression formula that was far superior to STE alone for differentiating the two entities on the ECG. The tool uses R-wave amplitude in lead V4 (RAV4), ST elevation at 60 ms after the J-point in lead V3 (STE60V3) and the computerized Bazett-corrected QT interval (QTc-B). The 3-variable formula is: 1.196 x STE60V3 + 0.059 × QTc-B - 0.326 × RAV4 with a value ≥23.4 likely to be acute myocardial infarction (AMI). HYPOTHESIS: Adding QRS voltage in V2 (QRSV2) would improve the accuracy of the formula. METHODS: 355 consecutive cases of proven LAD occlusion were reviewed, and those that were obvious ST elevation myocardial infarction were excluded. Exclusion was based on one straight or convex ST segment in V2-V6, 1 millimeter of summed inferior ST depression, any anterior ST depression, Q-waves, "terminal QRS distortion," or any ST elevation >5 mm. The NV-STE group comprised emergency department patients with chest pain who ruled out for AMI by serial troponins, had a cardiologist ECG read of "NV-STE," and had at least 1 mm of STE in V2 and V3. R-wave amplitude in lead V4 (RAV4), ST elevation at 60 ms after the J-point in lead V3 (STE60V3) and the computerized Bazett-corrected QT interval (QTc-B) had previously been measured in all ECGs; physicians blinded to outcome then measured QRSV2 in all ECGs. A 4-variable formula was derived to more accurately classify LAD occlusion vs. NV-STE and optimize area under the curve (AUC) and compared with the previous 3-variable formula. RESULTS: There were 143 subtle LAD occlusions and 171 NV-STE. A low QRSV2 added diagnostic utility. The derived 4-variable formula is: 0.052*QTc-B - 0.151*QRSV2 - 0.268*RV4 + 1.062*STE60V3. The 3-variable formula had an AUC of 0.9538 vs. 0.9686 for the 4-variable formula (p = 0.0092). At the same specificity as the 3-variable formula [90.6%, at which cutpoint (≥23.4), 123 of 143 MI were correctly classified for 86% sensitivity], the sensitivity of the new formula at cutpoint ≥17.75 is 90.2%, with 129/143 correctly classified MI, identifying an additional 6 cases. The cutpoint with the highest accuracy (92.0%) was at a cutoff value ≥18.2, with 88.8% sensitivity, 94.7% specificity, and a positive and negative likelihood ratio of 16.9 (95% CI: 8.9-32) and 0.12 (95% CI: 0.07-0.19). At this cutpoint, it correctly classified an additional 11 cases (289 of 315, vs. 278 of 315): 127/143 for MI (an additional 4 cases) and 162/171 for NV-STE (an additional 7 cases). CONCLUSION: On the ECG, a 4-variable formula was derived which adds QRSV2; it differentiates subtle LAD occlusion from NV-STE better than the 3-variable formula. At a value ≥18.2, the formula (0.052*QTc-B - 0.151*QRSV2 - 0.268*RV4 + 1.062*STE60V3) was very accurate, sensitive, and specific, with excellent positive and negative likelihood ratios. This formula needs to be validated.

Role of Intra-articular Piroxicam in the Temporomandibular Joint After Arthrocentesis for Anterior Disc Displacement Without Reduction.

STUDY DESIGN: This is comparative experimental research to evaluate the role of piroxicam in the temporomandibular joint (TMJ) after arthrocentesis. OBJECTIVE: To evaluate the role of intra-articular piroxicam in the temporomandibular joint after arthrocentesis for anterior disc displacement without reduction. MATERIAL AND METHODS: Twenty-two individuals (twenty-two TMJs) were evaluated clinically and radiographically for the study, and then they were randomly assigned to one of two groups. As for group I, they were given arthrocentesis using Ringer's solution (100 ml). Group II received an intra-articular injection of 20 mg/mL of piroxicam (in 1 mL of Ringer's solution) after arthrocentesis (100 mL). The same individuals were assessed both before and after surgery to determine the degree to which their symptoms had improved. Patients were seen in the clinic once a week for the first month after surgery, then once a month for the next three months. RESULT:  Group II patients presented with better results when compared with Group I. CONCLUSION: It can be concluded that installing a 1 ml intra-articular injection of piroxicam at a concentration of 20 mg/ml after arthrocentesis improves the relief of symptoms, both qualitatively and quantitatively. Relief of TMJ symptoms reduced the anxiety in the patients as evaluated by the BAIS (Beck's Anxiety Inventory Scale) score.

Association between tumour volume and recurrence of squamous cell carcinoma of the head and neck.

OBJECTIVE: To evaluate the prognostic significance of computerized tomography derived tumour volume for squamous cell cancers of the head and neck, treated primarily by surgery. METHODS: The retrospective review study comprised 72 patients with head and neck malignancies who were treated primarily by surgery at Aga Khan University Hospital, Karachi, with/without adjuvant. It was done from May 2007 to November 2008. Each patient was followed up for a minimum of one year to check for recurrence. For statistical analysis SPSS 17 was used. Frequencies, cross-tabulations with chi square tests to find associations, binary logistic regression analysis, Cox regression analysis and receiver operating characteristic curve tests were run on the data. RESULTS: Overall, the median tumour volume for patients with recurrent disease was 52cm3 compared to 22cm3 for those who did not have a recurrence. It was found that large tumour volume was associated with a significantly higher chance of recurrence (p = 0.009). Laryngeal cancers with volumes greater than 46cm3 and oral cancers with volumes greater than 23.1cm3 were associated with poor prognosis. CONCLUSIONS: The primary tumour volume can represent an important prognostic factor for treatment outcome. Patients with larger primary tumour volumes should be treated more aggressively.

Familial presence of early onset Fuchs' corneal endothelial dystrophy, a report of two rare cases.

A 15-year-old girl presented to our clinic with a history of gradual loss of vision and photosensitivity. She had bilateral corneal haze with stromal oedema. Her best-corrected visual acuity was 20/400 in the right eye and 20/200 in the left. She underwent penetrating keratoplasty in both eyes. Corneal histopathology revealed a pattern similar to Fuchs' endothelial dystrophy. The graft settled well and stayed clear while the vision kept improving. Her brother also presented with similar symptoms.

Endocrine complications in patients of beta thalassemia major in a tertiary care hospital in Pakistan.

OBJECTIVE: To determine the major endocrine complications present in patients of Thalassemia major presenting to a tertiary care center in Karachi, Pakistan. METHODS: Records of all thallasemia major patients at a Haematology Department in a tertiary care hospital of Karachi were retrospectively reviewed from May to August 2009 with specific focus on endocrine data and investigations. The patients' data was recorded in a questionnaire and analyzed using SPSS v.17, frequencies and percentages along with corresponding 95% confidence interval were computed. RESULTS: Our data revealed that a significantly small percentage of those under care received regular endocrine follow-up. Male hypo-gonadal abnormalities had the highest probability; 100% of the tested patients had decreased levels of testosterone, while 95.2% had raised serum creatinine levels. Parathyroid dysfunction was noted in 40% of the patients. Of those screened 29.4% had blood glucose levels in the diabetic range and 11.8% of the tested patients had reduced levels of FT4. CONCLUSION: A high frequency at endocrine dysfunctions seen in thalasaemia patients included: male hypogonadism, parathyroid dysfunction, deranged blood glucose and FT4 levies.

Charcoal Heart: Metastatic Melanoma Mimicking Right Atrial Myxoma.

A 59-year-old woman with history of skin melanoma and complete excision presented with palpitations. Transthoracic echocardiogram revealed right atrial mass attached to interatrial septum. Cardiac magnetic resonance was suggestive of metastatic melanoma. Laboratory tests revealed elevated liver enzymes. Liver ultrasonography showed a large mass positive for metastatic melanoma by biopsy. (Level of Difficulty: Intermediate.).

Pleuro pericardial cyst.

A 68-year-old male, presented with exertional dyspnoea and chest pain in his anterior chest wall for 3 months. He had no previous history of cardiac disease. Clinical examination failed to show anything significant. Chest X-ray showed a mass superimposed over the upper cardiac silhouette. He was further evaluated by chest CT, which showed a cystic mass in the anterior mediastinum measuring 9 x 7 cm in its maximum diameter. On surgical excision and histopathological examination, findings were consistent with benign pleuropericardial cyst, confirming the earlier diagnosis.

Doppler derived gradient of St. Jude mechanical prosthesis, early postoperative assessment.

OBJECTIVE: To determine the doppler derived mean gradients of St Jude mechanical prosthesis in early postoperative period in patients undergoing valve replacement at a tertiary care cardiac centre. METHODS: Medical records of 190 consecutive patients who underwent 233 mitral, aortic or dual (mitral and aortic) valve replacement by St Jude bileaflet mechanical prosthesis at Tabba Heart Institute, between March 2006 to December 2008 were reviewed. Doppler derived mean gradients were assessed predischarge and recorded. RESULTS: There were 98 (51.5%) males and 92 (48.5%) females in the study cohort. The mean age was 40 +/- 14 years. Of the total, 101 (53%) had mitral, 46 (24.2%) had aortic and 43 (22.6%) patients had dual valve replacement. Doppler derived mean gradient was assessed across 144 mitral and 89 aortic St Jude mechanical prosthesis. Doppler derived mean gradient for St Jude mitral prosthesis was 3.5 mm Hg and for St Jude aortic prosthesis was 10.2 mm Hg. CONCLUSIONS: The study determines baseline gradients across mitral and aortic St Jude mechanical prosthesis in our population. These can be used as reference gradients to assess St Jude prosthetic valve function in patients who did not have early postoperative doppler assessment.

Familial Mitral Arcade, Tricuspid Dysplasia, Left Ventricular Noncompaction and Short-Chain Acyl-CoA Reductase Deficiency.

Mitral arcade is a rare entity that is mostly reported in pediatric patients. We present the first 2 adult cases of mitral arcade in combination with tricuspid dysplasia, left ventricular noncompaction, and short-chain acyl-CoA deficiency in 2 brothers. We examined clinical and echocardiographic data on 2 brothers with a combination of short-chain acyl-CoA deficiency, mitral arcade, tricuspid dysplasia, and left ventricular noncompaction (LVNC), highlighting their clinical course and outcomes. Two-dimensional and 3-dimensional transthoracic echocardiography revealed direct attachment of the papillary muscles to the mitral leaflets, namely mitral arcade, as well as mild mitral regurgitation along with LVNC and tricuspid dysplasia. Over the past 7 years, both brothers have remained asymptomatic with excellent exercise capacity (13 and 10 metabolic equivalents (METS), respectively). Mitral and tricuspid regurgitation remain mild with unchanged left ventricular function (ejection fraction: 65% and 59%). In conclusion, we highlight 2 cases with a constellation of pathology including short-chain acyl-CoA deficiency, mitral arcade, tricuspid dysplasia, and LVNC, which has never been described before.