A systematic review of Pilomatrix carcinoma arising from the previous scar site of Pilomatrixoma.

Pilomatrix carcinoma is a rare tumor arising from the hair follicle matrix cells most commonly seen in the head and neck region. Also known as "calcified epithelial carcinoma of Melherbe," it was first reported in 1980 by Lopansri and Mihm. Since then till date to the best of our knowledge only around 125 cases were reported in literature, of which only 11 cases were reported to arise from histologically proven areas of previous pilomatrixoma which is the benign variant. One such case is being reported here along with the review of literature. A 50-year-old man presented with a swelling in the nape of his neck since 6 months, which was gradually increasing in size. He had a history of similar swelling at the same site 18 months back for which he underwent a surgery at a center outside. Final histopathology report was suggestive of pilomatrixoma with negative margin. Wide local excision of the tumor with 3 cm margin, placement of surgical clips followed by a primary closure was done. The final histopathology report is suggestive of pilomatrix carcinoma. The patient has no recurrence in 6 months follow-up. The differential diagnosis of pilomatrix carcinoma should be considered in cases of recurrent skin tumors. Wide local excision is the preferred treatment. Re-excision should be done in margin positive cases and cases where simple excision was done due to improper preoperative diagnosis. Due to the rarity of the disease, adjuvant treatment is not properly defined.

Evolution of treatment in gastric cancer- a systematic review.

Multimodality is the standard of care in gastric cancer but surgery remains the mainstay of curative treatment. As we are heading towards a more conservative approach for functional preservation without compromising oncological outcomes in all malignancies, the guidelines keeps changing based on various studies.The extent of surgery used to vary between the east and west, with the east performing more radical surgery and the west more reliant on multimodality therapy. This practice has been changing in the recent times.In this article we have reviewed how the treatment protocols of gastric cancer has evolved and modified, highlighting the practice changing trials.

A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFE-II Study).

BACKGROUND: Atrial fibrillation (AF) and heart failure (HF) often coexist. The aim was to investigate whether restoring sinus rhythm (SR) could improve cardiac function, symptoms, exercise capacity and quality of life (QoL) in patients with chronic heart failure. METHODS: Patients with HF and persistent AF receiving guideline-recommended treatments, including anticoagulants, were eligible for the study. Patients were randomised to either rhythm (treated with amiodarone for at least 3 months prior to attempting biphasic external cardioversion and continued amiodarone long-term if SR was restored) or rate control. Anticoagulants were continued throughout the study regardless of rhythm, unless contraindications developed. Both groups were treated with beta blockers and/or digoxin to reduce the heart rate to <80 bpm at rest and <110 bpm after walking. Symptoms, walk distance (6-minute corridor walk test, 6MWT), QoL and cardiac function were assessed at baseline and 1 year. RESULTS: 61 patients with HF and persistent AF (median duration 14 months (IQR 5 to 32)) were randomly assigned to a rate or rhythm control strategy. Of patients assigned to rhythm control (n = 30), 66% were in SR at 1 year, and 90% of those assigned to rate control (n = 31) achieved the heart rate target. At 1 year, NYHA class (p = 0.424) and 6MWT distance (p = 0.342) were similar between groups but patients assigned to rhythm control had improved LV function (p = 0.014), NT-proBNP concentration (p = 0.046) and QoL (p = 0.019) compared with those assigned to rate control. Greatest improvement was seen in patients in whom SR was maintained. CONCLUSION: Restoring SR in patients with AF and heart failure may improve QoL and LV function when compared with a strategy of rate control.

Palliative care for patients with heart failure: description of a service.

Over the past 10 years, there has been an increasing demand for heart failure patients to have access to palliative care services. The concerns of this group have been highlighted and there is growing recognition in national palliative care and cardiology bodies that these concerns should be addressed. In spite of this, there is little improvement. There are concerns about the acceptability of hospice services to heart failure patients, worries about service overload, lack of appropriate knowledge and skills and difficulty in knowing when to refer a heart failure patient for palliative care. In Scarborough, a joint approach by a cardiologist and palliative care physician was set up in September 2000. This paper describes the service so far in an attempt to address some of the above reservations and to provide a catalyst and encouragement to others beginning a similar venture.

Giant right coronary artery aneurysm presenting as a mediastinal mass.

Coronary artery aneurysms are commonly of atherosclerotic origin and are frequently asymptomatic. However, they may have varied presentations including angina, myocardial infarction, and sudden death. A case of a giant right coronary artery aneurysm presenting with acute myocardial infarction is presented, where the aneurysm appeared to be a mediastinal mass on transthoracic and transoesophageal echocardiography. Although computed tomography and magnetic resonance imaging of the heart suggested the correct diagnosis, definitive proof came from coronary angiography. Coronary artery aneurysms should be considered in the differential diagnosis of mediastinal masses.

An unusual case of infective endocarditis.

A rare case of Corynebacterium striatum endocarditis on a bioprosthetic aortic valve replacement, treated medically, is reported. The presentation was subacute, and initially endocarditis screening was negative. Because of the failure of symptoms to settle further screening was performed which confirmed the organism in several sets of blood cultures. This emphasises the importance of persistent screening for endocarditis if the history raises any suspicion of this potentially serious infection, especially in the presence of prosthetic valves.

Efficient assembly of the phomactin core via two different macrocyclization protocols.

[reaction--see text] The core structure of phomactins C and D was assembled by an efficient strategy starting from 3,4-dimethylcyclohexen-2-one. Key reactions include (1) a high yielding and highly diastereoselective Michael addition of a mixed cuprate, (2) a carbonylative alkyne-enoltriflate coupling or an intramolecular addition of an acetylide onto an aldehyde to form the macrocycle, (3) chemoselective Michael addition of a cuprate to an enynone, to give the carbon framework of desformyl phomactin C or D, and finally (4) regioselective addition of a thia-nucleophile to the more reactive beta-position of the resulting dienone.

Validation of electrode placement in neonatal electrogastrography.

Electrogastrography (EGG) is the transcutaneous measurement of gastric electrical activity. The aims of this study were to validate the electrode placement position in neonatal electrogastrography using ultrasonography to localise the stomach, and to describe the observed EGG frequency characteristics. Fifteen neonates with no known abdominal disorder were studied. Two bipolar EGG recordings were obtained from each subject, the first from electrodes placed at sites localized by ultrasound and the second from electrodes placed at the currently recommended sites. Paired sample t tests were used to compare electrode positioning and electrogastrographic data. There were 15 subjects with a mean age of 36 days (range 1-95). While there was a significant difference in the position of electrodes at each site, the EGG recordings did not differ. The 3-cycle/minute (2.6-3.7cpm) activity ranged from 30% to 84% of recorded time (mean at sites localized with ultrasound was 53%, and at currently recommended sites it was 50%; difference not significant, P = 0.155). Bradygastria (<2.6 cpm) was observed in the range of 2-29% of recorded time (mean at sites localised with ultrasound was 12.9%, and at currently recommended sites it was 11.7%; difference not significant, P = 0.40). Tachygastria (3.2-10 cpm) was shown to be in the range of 10-58% of recorded time (mean at sites localized with ultrasound was 33.3%, and at currently recommended sites it was 38.7%; difference not significant; P = 0.044). In conclusion, there was no significant difference between EGG recordings taken from electrode sites localized by ultrasound and those recommended by manufacturers of the electrogastrogram, thus confirming the validity of the manufacturer's recommended electrode positioning. The pattern of electrical control activity in the normal neonatal stomach appears to be different from that demonstrated in adults. Bradygastria and tachygastria are seen more frequently, with fewer periods of 3 cpm activity.

Does aspirin attenuate the effect of angiotensin-converting enzyme inhibitors in hypertension or heart failure?

There is a wealth of data that suggests an important interaction between aspirin and angiotensin-converting enzyme inhibitors in patients with chronic stable cardiovascular disease. The interaction is less obvious in the postinfarction setting, possibly reflecting the fact that many patients stop their aspirin therapy within a few months of such an event. An interaction is biologically plausible, because there is considerable evidence that angiotensin-converting enzyme inhibitors exert important effects through increasing the production of vasodilator prostaglandins, whereas aspirin blocks their production through inhibition of cyclooxygenase, even at low doses. There is some evidence that low-dose aspirin may raise systolic and diastolic blood pressure. There is also considerable evidence that aspirin may entirely neutralize the clinical benefits of angiotensin-converting enzyme inhibitors in patients with heart failure. In addition, aspirin may have an adverse effect on outcome in patients with heart failure that is independent of any interaction with angiotensin-converting enzyme inhibitors, possibly by blocking endogenous vasodilator prostaglandin production and enhancing the vasoconstrictor potential of endothelin. The evidence is not sufficient to justify advising long-term aspirin therapy for patients with cardiovascular disease in general, and for those with heart failure in particular. Thus, the lack of evidence of benefit with aspirin in patients with heart failure and coronary disease, along with growing evidence that aspirin is directly harmful in patients with heart failure and that aspirin may negate the benefits of angiotensin-converting enzyme inhibitors suggest that, unless there is an opportunity to randomize the patient into a study of antithrombotic strategies, then aspirin should be withdrawn or possibly substituted with an anticoagulant or an antiplatelet agent that does not block cyclooxygenase. In contrast, there is fairly robust evidence for a benefit of both aspirin and angiotensin-converting enzyme inhibitors during the first 5 weeks after a myocardial infarction, with little evidence of an interaction. The combination of aspirin and angiotensin-converting enzyme inhibitors is warranted during this period, after which discontinuation or substitution of aspirin with another agent should be considered.

Clinical Trials Update: CAPRICORN, COPERNICUS, MIRACLE, STAF, RITZ-2, RECOVER and RENAISSANCE and cachexia and cholesterol in heart failure. Highlights of the Scientific Sessions of the American College of Cardiology, 2001.

This is a synopsis of presentations made at the American College of Cardiology (ACC) in 2001 summarising recent research developments relating to heart failure. Clinical studies of particular interest to physicians with an interest in heart failure and its prevention are reviewed. The COPERNICUS trial lends further support to the use of the beta-blocker, carvedilol, in severe heart failure and the CAPRICORN trial to its use in patients with post-infarction left ventricular systolic dysfunction. The MIRACLE study reinforces the evidence from three smaller trials that cardiac resynchronisation therapy is an effective treatment for the relief of symptoms in patients with severe heart failure and cardiac dyssynchrony. The STAF trial casts further doubt on the wisdom of cardioversion as a routine strategy for the management of chronic atrial fibrillation. The RITZ-2 trial suggests that an intravenous, non-selective endothelin antagonist is effective in improving haemodynamics and symptoms and possibly in reducing morbidity in severe heart failure. Observational studies in heart failure suggest that a moderate excess of body fat and elevated blood cholesterol may be desirable in patients with heart failure, challenging the current non-evidenced-based vogue for cholesterol lowering therapy in heart failure. The RENAISSANCE and RECOVER outcome studies of etanercept, a tumour necrosis factor (TNF) receptor analogue that blocks the effect of TNF, were stopped because of lack of evidence of benefit shortly after the ACC.

Are beta-blockers effective in patients who develop heart failure soon after myocardial infarction? A meta-regression analysis of randomised trials.

BACKGROUND: The great majority of post-infarction studies of beta-blockers were conducted in an era when these agents were widely held to be contra-indicated for the management of heart failure. We now know that beta-blockers are highly effective for the management of patients with chronic stable heart failure. However, there remains uncertainty about their role in the setting of post-infarction heart failure and ventricular dysfunction. AIM: the primary objective in this paper, was to investigate the extent to which heart failure or evidence of major cardiac dysfunction influenced outcome in previous trials of beta-blockers in heart failure after myocardial infarction. METHODS: We assessed the extent to which the inclusion of patients with heart failure or major cardiac dysfunction influenced outcome in randomised trials of long-term use of beta-blockade after myocardial infarction. The primary analysis was to assess the extent to which the proportion of patients included in each trial with heart failure influenced the relative odds of all-cause mortality in the trials. All randomised trials without crossover with treatment lasting more than one month and with 50 or more patients were considered. All those that provided information on the proportion of patients with heart failure or major cardiac dysfunction in the original or subsequent articles were included in the analysis. RESULTS: Overall treatment with a beta-blocker was associated with a 22.6% reduction in the odds of death (95% C1 11-32.3%). There were very few data on the effects of beta-blockers after myocardial infarction in patients with documented left ventricular systolic dysfunction. In the analysis that included heart failure as a factor, treatment with a beta-blocker was associated with a non-significant interaction with the presence of heart failure. However, because the group including heart failure patients were at higher risk, the absolute benefit of treatment with beta-blockers appeared greater in this group. CONCLUSIONS: This analysis suggests that the relative benefit of beta-blockers on mortality after a myocardial infarction is similar in the presence or absence of heart failure but that the absolute benefit may be greater in the former. However, as current clinical practice has changed radically from the time when the majority of these trials were conducted, further trial evidence would be desirable.

Carcinoid disease: review of the literature.

Carcinoid syndrome is the product of a rare but fascinating malignant neoplasm. Carcinoid syndrome was described more than 100 years ago, and recent advances in diagnostic localization, elucidation of the mechanisms of oncogenesis, treatment options, and, consequently, patient prognosis have been made. Current modalities of treatment, possible therapeutic implications of new avenues of research, and current literature on the chemotherapeutic combinations used are reviewed.

Meningismus, fever and macular rash as presenting features of the primary antiphospholipid syndrome?

We report here, we believe for the first time, the primary antiphospholipid syndrome, presenting with fever, meningismus and skin rash. Serology was positive for antiphospholipid antibodies but negative for antinuclear factor. Such presentations, once meningitis has been excluded, should be screened for antiphospholipid antibodies. If serology proves to be positive, anticoagulation for life should be considered to avoid thrombotic episodes and death due to pulmonary embolism.

Comparison of an antigen capture enzyme-linked assay with reverse transcription--polymerase chain reaction and cell culture immunoperoxidase tests for the diagnosis of ruminant pestivirus infections.

A study to compare the merits of three different tests for the diagnosis of ruminant pestivirus infections was carried out. Sensitivity studies using reference strains of bovine viral diarrhoea virus (BVDV) and buffy coat samples from persistently infected (PI) carriers showed the reverse transcription-polymerase chain reaction (RT-PCR) had a greater sensitivity than the other tests. The antigen capture enzyme-linked immunosorbent assay (ELISA) was least sensitive and could only be used on samples containing cells (tissue or blood). When 169 clinical samples were examined, the RT-PCR detected the most positives (42) compared to the ELISA (32) and the immunoperoxidase test (IPT) (20). The RT-PCR was more successful when specific antibody was also present in the sample. The lower sensitivity of the IPT was related to the use of a 1 passage (4-day) test and the testing of toxic or contaminated samples. The ELISA was found to be most suitable for large-scale testing for the diagnosis and control of pestivirus infections.

Immune function in patients undergoing open vs laparoscopic cholecystectomy.

BACKGROUND: Abnormal release of inflammatory mediators following surgical injury is associated with immunological alteration, which may predispose to sepsis. Laparoscopic surgery is associated with reduced postoperative complications, but mechanisms are unclear. We hypothesized that early recovery following laparoscopic surgery may relate to minimal impairment of immune function. DESIGN: Analysis of the temporal immune responses in two similar groups of patients randomized to open (n = 22) vs laparoscopic (n = 22) cholecystectomy. Patients were matched for age, height, weight, and operation time. Immune parameters, including monocyte superoxide anion (O2-) and tumor necrosis factor release, neutrophil O2- levels and chemotaxis, total white blood cell counts, partial arterial oxygen pressure, and serum cortisol and C-reactive protein levels were assessed preoperatively and on postoperative days 1 and 3. RESULTS: There were significant increases (P < .001) in monocyte release of O2- and tumor necrosis factor, neutrophil release of O2- and chemotaxis, and white blood cell count in the open vs laparoscopic cholecystectomy study groups, with a concommitant decrease in partial arterial oxygen pressure. These findings correlated with significantly higher postoperative septic complications in the open cholecystectomy group (P < .05). There were no significant differences in either plasma cortisol or C-reactive protein levels between groups. All measurements were carried out in a blinded fashion. CONCLUSIONS: This study demonstrates that laparoscopic surgery appears to be associated with similar metabolic responses compared with open surgery, while immune parameters vary greatly between groups. The beneficial effects of laparoscopic surgery may relate, in part, to preservation of immune function in the postoperative period.

Multiparameter flow cytometric analysis of a pH sensitive formyl peptide with application to receptor structure and processing kinetics.

Environmentally sensitive molecules have many potential cellular applications. We have investigated the utility of a pH sensitive ligand for the formyl peptide receptor, CHO-Met-Leu-Phe-Phe-Lys (SNAFL)-OH (SNAFL-seminaphtho-fluorescein), because in previous studies (Fay et al.: Biochemistry 30:5066-5075, 1991) protonation has been used to explain the quenching when the fluoresceinated formyl pentapeptide ligand binds to this receptor. Moreover, acidification in intracellular compartments is a general mechanism occurring in cells during processing of ligand-receptor complexes. Because the protonated form of SNAFL is excited at 488 nm with emission at 530 nm and the unprotonated form is excited at 568 nm with emission at 650 nm, the ratio of protonated and unprotonated forms can be examined by multiparameter flow cytometry. We found that the receptor-bound ligand is sensitive to both the extracellular and intracellular pH. There is a small increase in the pKa of the ligand upon binding to the receptor consistent with protonation in the binding pocket. Once internalized, spectral changes in the probe consistent with acidification and ligand dissociation from the receptor are observed.

Anterior midline or medial parapatellar incision for arthroplasty of the knee. A comparative study.

Early mobilisation after arthroplasty of the knee sometimes results in wound breakdown. The two commonly used incisions, the anterior midline and the medial parapatellar incisions, were compared in order to determine which had the best potential for wound healing. Study of the cleavage lines around the knee demonstrated that the medial parapatellar incision lies parallel to the lines, whilst the anterior midline incision lies perpendicular to them. In addition, the medial parapatellar wound was found to be subjected to significantly less tension during flexion; after arthroplasty it can be expected to heal faster and to be less liable to disruption during early mobilisation.