Surgical outcomes of total duct excision in the diagnosis and management of nipple discharge.

INTRODUCTION: Total duct excision (TDE) is performed for the diagnosis and management of nipple discharge. The Association of Breast Surgery's recent guidelines recommend considering diagnostic surgery for single-duct, blood-stained or clear nipple discharge, and for symptomatic management. METHODS: We retrospectively reviewed the diagnostic and surgical outcomes of all cases of TDE between January 2013 and November 2019. RESULTS: In total, 259 TDEs were carried out: 219 for nipple discharge, 29 for recurrent mastitis, 3 for screening abnormalities and 8 for breast lumps. Of the nipple discharge group, 121 had blood-stained discharge. Mean patient age was 52 years (range 19-81). Median follow-up time was 45 months (interquartile range 24-63). The following cases were identified on histopathology: 236 benign breast changes, 10 atypical ductal hyperplasia, 4 lobular carcinoma in situ, 2 low-grade ductal carcinoma in situ (DCIS), 3 intermediate-grade DCIS, 2 high-grade DCIS and 2 invasive ductal carcinomas. In total, 3.5% of patients who underwent TDE had a diagnosis of DCIS or invasive carcinoma. Blood-stained discharge was associated with a significant increase in risk of DCIS or carcinoma compared with other nipple discharge colours (p = 0.043). The most common complications of TDE were infection, poor wound healing and haematoma. Nipple discharge recurred in 14.2% of cases. CONCLUSIONS: TDE can be considered for the diagnostics and management of nipple discharge. Blood-stained nipple discharge increases the risk of DCIS or malignancy, but the majority of the time TDE reveals benign breast pathology.

Transplantation Using Renal Grafts With Multiple Renal Arteries: A Putative Study on the Impact of Arterial Reconstruction Technique and Site of Implantation on Outcomes.

BACKGROUND: In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs). PATIENTS AND METHODS: In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated. RESULTS: The mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P < .05). The best survival was found for anastomosis to the internal iliac artery (P < .05). CONCLUSION: MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.

European Chlamydia abortus livestock isolate genomes reveal unusual stability and limited diversity, reflected in geographical signatures.

BACKGROUND: Chlamydia abortus (formerly Chlamydophila abortus) is an economically important livestock pathogen, causing ovine enzootic abortion (OEA), and can also cause zoonotic infections in humans affecting pregnancy outcome. Large-scale genomic studies on other chlamydial species are giving insights into the biology of these organisms but have not yet been performed on C. abortus. Our aim was to investigate a broad collection of European isolates of C. abortus, using next generation sequencing methods, looking at diversity, geographic distribution and genome dynamics. RESULTS: Whole genome sequencing was performed on our collection of 57 C. abortus isolates originating primarily from the UK, Germany, France and Greece, but also from Tunisia, Namibia and the USA. Phylogenetic analysis of a total of 64 genomes shows a deep structural division within the C. abortus species with a major clade displaying limited diversity, in addition to a branch carrying two more distantly related Greek isolates, LLG and POS. Within the major clade, seven further phylogenetic groups can be identified, demonstrating geographical associations. The number of variable nucleotide positions across the sampled isolates is significantly lower than those published for C. trachomatis and C. psittaci. No recombination was identified within C. abortus, and no plasmid was found. Analysis of pseudogenes showed lineage specific loss of some functions, notably with several Pmp and TMH/Inc proteins predicted to be inactivated in many of the isolates studied. CONCLUSIONS: The diversity within C. abortus appears to be much lower compared to other species within the genus. There are strong geographical signatures within the phylogeny, indicating clonal expansion within areas of limited livestock transport. No recombination has been identified within this species, showing that different species of Chlamydia may demonstrate different evolutionary dynamics, and that the genome of C. abortus is highly stable.

Longitudinal study of Salmonella 1,4,[5],12:i:- shedding in five Australian pig herds.

The shedding patterns of Salmonella spp. and MLVA profiles of Salmonella enterica subspecies enterica (I) serotype 1,4,[5],12:i:- were monitored in a 12-month longitudinal observational study of five pig herds to inform management; provide indications of potential hazard load at slaughter; and assist evaluation of MLVA for use by animal and public health practitioners. Twenty pooled faecal samples, stratified by age group, were collected quarterly. When Salmonella was cultured, multiple colonies were characterized by serotyping and where S. Typhimurium-like serovars were confirmed, isolates were further characterized by phage typing and multiple locus variable number tandem repeat analysis (MLVA). Salmonella was detected in 43% of samples. Salmonella 1,4,[5],12:i- was one of several serovars that persisted within the herds and was found among colonies from each production stage. Virtually all Salmonella 1,4,[5],12:i:- isolates were phage type 193, but exhibited 12 different, closely-related MLVA profiles. Salmonella 1,4,[5],12:i:- diversity within herds was low and MLVA profiles were stable indicating colonization throughout the herds and suggesting each farm had an endemic strain. High prevalence of S. 1,4,[5],12:i:- specific shedding among terminal animals indicated high hazard load at slaughter, suggesting that primary production may be an important pathway of S. 1,4,[5],12:i:- into the human food chain, this has implications for on-farm management and the application and targeting control measures and further evidence of the need for effective process control procedures to be in place during slaughter and in pork boning rooms. These findings have implications for animal health and food safety risk mitigation and risk management.

The value of the Clinical SYNTAX Score in predicting long-term prognosis in patients with ST-segment elevation myocardial infarction who have undergone primary percutaneous coronary intervention.

BACKGROUND: The Clinical SYNTAX Score (CSS) combines anatomical and clinical risk assessment. OBJECTIVES: This study was designed to evaluate CSS as a predictor of prognosis in patients with ST-elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (p-PCI). METHODS: We evaluated 433 patients who were diagnosed with STEMI and underwent p-PCI. CSS was calculated by multiplying the anatomically derived SYNTAX score (Sx) by the modified age, creatinine, and ejection fraction score. Patients were divided into tertiles according to the CSS: CSS(Low)≤14 (n=141), 1426 (n=148). The primary endpoints were defined as all-cause mortality, myocardial infarction, and cerebrovascular events over 15 months' follow-up. RESULTS: Primary endpoints were achieved in 9.2% of patients with CSS≤14, 12.5% of those with 1426 (P<0.001). Kaplan-Meier analysis showed that the CSS>26 group had a significantly higher incidence of primary endpoints [P (log-rank)<0.001]. CSS>26 was identified as an independent predictor for all-cause mortality, myocardial infarction, and cerebrovascular events (hazard ratio 3.58, 95% confidence interval 1.68-7.60, P=0.001). Receiver operating characteristic analysis found areas under the curve of 0.66, 0.59, and 0.64 for CSS, Sx score, and age, creatinine, and ejection fraction score (P<0.001, P=0.01, P<0.001, respectively). CONCLUSION: CSS may be better than the Sx score for predicting long-term prognosis in patients with STEMI undergoing p-PCI.

A retrospective analysis of long-term graft survival in 61 pediatric renal transplant recipients: a single-center experience.

BACKGROUND: Although short-term renal allograft survival in children has improved over the years, long-term graft outcomes remain unclear. In this study we report the characteristics and other variables that impact long-term kidney graft survival in children. MATERIAL AND METHODS: Records of 61 pediatric kidney transplant recipients (mean age: 14±3 years) performed at our institution between 1995 and 2011 were evaluated. Patients were divided into 2 groups (functional and non-functional grafts) to investigate the factors that impact graft survival. The groups were compared in terms of recipient characteristics, underlying disease, HLA status, immunosuppressive therapy, donor characteristics, acute rejection, and delayed graft function (DGF). Statistical significance was detected with the t and chi-squared tests (Pearson and Fisher's exact tests). Kaplan-Meier analysis was performed for graft survival. RESULTS: Overall graft survival at 1, 5, 10, and 15 years were 93%, 66%, 46%, and 41%, respectively. The median graft survival was 128.4 months (range: 3-188 months). Donor age, acute rejection, and DGF strongly predicted the chance of graft survival (p<0.05). CONCLUSIONS: It appears that several modifiable risk factors can partially account for poorer graft survival in pediatric kidney transplant recipients.

Assessment of left atrial mechanical functions in thyroid dysfunction.

INTRODUCTION:  Thyroid hormone deficiency can lead to the impairment of cardiac function. OBJECTIVES:  The aim of the study was to determine the left atrial (LA) mechanical function in patients with subclinical hypothyroidism (SHT) and overt hypothyroidism (OHT) and investigate associations of LA mechanical function with diastolic function.  PATIENTS AND METHODS:  Twenty­six patients with newly diagnosed SHT (mean age, 42.2 ±12.5 years), 21 patients with OHT (40.2 ±8.5 years) and 28 healthy volunteers (42.4 ±11.2 years) were enrolled in this study. Patients were evaluated by standard M­mode echocardiographic measurements, mitral Doppler flow analysis, and tissue Doppler parameters at the lateral, septal, and right ventricular annuli. LA volumes were measured using the disc method, and the parameters of LA mechanical function were calculated.  RESULTS:  The active emptying volume (AEV) and active emptying fraction (AEF) were significantly higher in the OHT and SHT groups compared with controls. The passive emptying volume and passive emptying fraction were lower in the OHT and SHT groups compared with controls, but the differences were not significant. The conduit volume and the E/A ratio were significantly lower in the OHT and SHT groups compared with controls. The lateral and septal E/Em were significantly higher in the OHT and SHT groups than in the control group, but the septal Em/Am was significantly lower. Diastolic function parameters showed significant associations with AEV and AEF.  CONCLUSIONS:  LA mechanical function is impaired in patients with thyroid dysfunction. Our findings suggest that this impairment is secondary to that of the left ventricular diastolic function.

Risk factors associated with Lawsonia intracellularis in English pig farms.

Porcine proliferative enteropathy (PPE) caused by the bacterium Lawsonia intracellularis causes considerable economic loss to the pig industry. The objective of this study was to evaluate the seroprevalence of L. intracellularis exposure in different age groups of pigs (growers to finishers) within English farms and to identify potential risk factors. Samples were obtained in a cross-sectional study of 147 farms between 2008 and 2009. Twelve samples (six growers and six finishers) from each farm were tested for L. intracellularis by antibody ELISA. At animal level there was a significant positive linear trend between seroprevalence and age in weeks (r(2)=2.65, P<0.001), with seroprevalence lowest (24.73%) at 11 weeks and highest (93.33%) at 24 weeks. At farm level, seroprevalence was significantly lower in growers than finishers (56.80% vs. 94.26%, P<0.001). Farms reporting minor Salmonella problems and those that brought boars onto the farm had higher odds of testing positive in growers (OR 5.69 and 4.31, respectively. On the other hand, farms where producers considered temperature as an important stress factor (OR=0.3) and which had more than two sites on which pigs are kept (OR=0.16) were less likely to test positive in growers. The current study confirmed the high prevalence of L. intracellularis in English pig farms. The potential risk factors and further information of the disease impact on the farm productivity will aid the development of appropriate control strategies through better understanding of the disease.

Differences in sex, angiographic frequency, and parameters in patients with coronary artery anomalies: single-center screening of 25 368 patients by coronary angiography.

BACKGROUND: Although the prevalence of coronary artery anomalies varies in different series, the precise population frequency is unknown. MATERIALS AND METHODS: The medical records of all patients who underwent coronary angiography between January 2002 and August 2012 were retrieved, and 238 cases with coronary anomalies were evaluated. Unlike other studies, we compared several angiographic parameters (fluoroscopy time, number of images, and catheters used) in addition to frequency and sex data. RESULTS: The angiographic frequency of coronary artery anomalies was 0.94%. The most common coronary anomaly was a left anterior descending-circumflex artery originating from separate ostia (0.29%). The second most common anomaly was a right coronary artery (RCA) originating from the left sinus of Valsalva (sV) (0.23%). Overall, coronary artery anomalies (1.28 vs. 0.80%; P<0.001) and a left anterior descending-circumflex artery originating from separate ostia (41.3 vs. 25.3%, P=0.010) were more frequent in women than in men. The percentage of patients requiring more than two catheters during the procedure was significantly higher for an RCA originating from the left sV (45.7 vs. 16.7%, P<0.001) and in hypertensive patients (85.7 vs. 70.8%, P=0.015). On comparing the three most common coronary anomalies, an anomalous RCA originating from the left sV had a significantly higher value for at least one angiographic parameter. CONCLUSION: An anomalous RCA originating from the left sV is the most difficult type of anomaly to perform the ostial coronary cannulation during procedure. The results of this study may lead to the development of more suitable diagnostic catheters for an anomalous RCA originating from the left sV.

A novel method of forming micro- and macroporous monetite cements.

Second to autologous bone grafts are the calcium phosphate cements (CPCs) used as synthetic bone substitutes due to their chemical similarity to the mineral component of bone. Their ability to conform to complex bone defects and excellent osteoconductivity also render them excellent scaffolds for bone tissue engineering, although they do have their own limitations. Calcium phosphates can be divided into two main categories, namely apatite and brushite. Apatites exhibit low solubility, whereas, calcium phosphates that set to form brushite, are metastable, which degrade rapidly, but do subsequently form hydroxyapatite that retards the rate. In contrast dicalcium phosphate anhydrous (monetite) has a higher solubility than octacalcium phosphate and does not transform to an apatite; thus, it is able to continue to degrade with time. Herein, a new method was used via the addition of sodium chloride to ß-tricalcium phosphate and monocalcium phosphate monohydrate to form micro- and macroporous monetite (DCPA). The X-ray diffraction and FTIR spectra confirmed the formation of monetite in the presence of both, 6.2 M NaCl solution or 60% of solid sodium chloride. The maximum compressive strength (σc = 12.3 ± 1.8 MPa) and the Young's modulus (E = 1.0 ± 0.1 GPa) of the monetite cements obtained were comparable to the upper limits of the values reported for cancellous bone and also higher than that reported by other routes used to form monetite. The porous cements analysed by microCT revealed an interconnected porosity with the preliminary in vitro biological evaluation indicating favourable osteoblast cell attachment and growth.

Can aortic elastic parameters be used for the diagnosis of volume overload in patients with end stage renal disease.

BACKGROUND: We aimed here to investigate hydration status by echocardiography in end stage renal disease (ESRD) patients. METHODS: 25 ESRD patients [15 males; mean age: 54.0±16.6 years; 13 hemodialysis; 12 peritoneal dialysis] were considered eligible for this study. We also examined 29 healthy volunteers as a control group (17 males; mean age: 46.5±12.8 years). Body composition analysis using the bioimpedance spectroscopy technique was performed for volume overload diagnosis. The ratio of extracellular water (ECW) to height was used as volume indices. The aortic elastic parameters were calculated by echocardiography. A correlation analyses was performed between the ratio of ECW to height indicating the volume overload and the aortic elastic parameters e.g. Aortic strain (AS), Aortic distensibility (AD) and Aortic stiffness index (ASI). RESULTS: The ratio of ECW to height that indicates volume overload in ESRD patients was considerably higher than that in the control group (10.25±1.98 L/m vs. 8.66±1.22 L/m, p=0.001). There was a negative correlation between the ratio of ECW to height and AS and AD and a positive correlation between the ratio of ECW to height and ASI. CONCLUSION: Given the importance of the diagnosis and follow up of volume overload, the results show that aortic elasticity measurements, being easy to perform and replicate, can be used for this purpose.

Left main coronary artery thrombus resulting from combined protein C and S deficiency.

Inherited hypercoagulopathies such as protein C and S deficiency usually lead to the formation of venous thrombi in clinical practice; however, they rarely lead to arterial thrombosis. It has been demonstrated that both protein C and S deficiency may lead to myocardial infarctions. However, our literature review revealed no reports of left main coronary artery thrombi caused by protein C and S deficiency. This paper presents a case of a left main coronary artery thrombus resulting from protein C and S deficiency in a young patient with normal coronary arteries.

Pigtail catheter fracture and embolization into the abdominal aorta: an extremely rare angiographic complication.

Coronary angiography is a widely used diagnostic method for coronary artery disease. In clinical practice, although complications of the procedure often involve the vascular access point, there is no previous report of the fracture and embolization of the distal tip of a pigtail catheter. Herein, we present the case of a 51-year-old woman whose left ventriculography was interrupted by fracture of the curved tip of a pigtail catheter, which remained at the renal artery level in the abdominal aorta.

Evaluation of atrial electromechanical delay and left atrial mechanical function in patients with obstructive sleep apnea : Cardiac involvement in patients with OSA.

OBJECTIVE: The aim of this study was to evaluate atrial electromechanical delay measured by tissue Doppler imaging and left atrial mechanical function in patients with obstructive sleep apnea (OSA). MATERIALS AND METHODS: Fourty-seven moderate-to-severe OSA patients who were newly diagnosed by polysomnography (Apnea-hypopnea index ≥ 15 events/h, 32 males, mean age 49.4 ± 11.5) and 30 patients who had no OSA in polysomnography (Apnea-hypopnea index < 5 events/h, 21 males, mean age 45.4 ± 9.1) were included in the study. Using tissue Doppler, diastolic functions, atrial electromechanical coupling were measured from the lateral mitral, septal, and tricuspid annulus. Inter, intra, and left atrial electromechanical delay were calculated (lateral-tricuspid, septum-tricuspid, lateral-septal). Left atrial volumes (maximal, minimal, and presystolic) were measured by the method of discs in the apical four-chamber view and were indexed to body surface area. Mechanical function parameters of the left atrium were also calculated. RESULTS: Interatrial, intraatrial, and left atrial electromechanical delays were significantly higher in the OSA group compared to the control group. Passive emptying fraction was significantly decreased, volume at the beginning of atrial systole and active emptying volume were significantly increased in OSA patients compared to the controls. The apnea-hypopnea index was significantly associated with interatrial and intraatrial electromechanical delay, passive emptying fraction, and conduit volume. CONCLUSIONS: Electromechanical delay was markedly prolonged and left atrial electromechanical function was impaired in untreated OSA patients. These impairments worsen with increasing severity of OSA.

The value of P wave dispersion in predicting reperfusion and infarct related artery patency in acute anterior myocardial infarction.

PURPOSE: The aim of this study is to investigate whether P wave dispersion (PWD), measured before, during and after fibrinolytic therapy (FT,) is able to predict successful reperfusion and infarct related artery (IRA) patency in patients with acute anterior MI who received FT. METHODS: Sixty-eight patients who presented with acute anterior MI were enrolled in the study. An electrocardiogram was performed before and at 30, 60, 90 and 120 minutes after the start of FT. PWD was defined as the difference between maximum and minimum P wave duration on standard 12-lead surface electrocardiogram. A multivariate logistic regression model was used to assess whether PWD was predictor of IRA patency and ST-segment resolution (STR) on electrocardiogram. RESULTS: PWD120 was significantly lower in patients with STR on electrocardiogram (38 patients) compared with those without STR (30 patients) (44.8±11.5 vs. 52.9±10.3 ms; p < 0.001). PWD120 was found to be significantly lower in patients with patent IRA (31 patients) compared to those with occluded IRA (37 patients) (42.3±9.7 vs. 53.5±10.6 ms; p < 0.001). Logistic regression analysis revealed that PWD120 significantly predicted STR and IRA patency. A ≥51.6 ms PWD120 can predict an occluded IRA with a 87% sensitivity, ≥51 ms PWD120 can predict no reperfusion with a 74% sensitivity. CONCLUSION: PWD values, which were higher than 51 ms and 51.6 ms in patients who received fibrinolytic therapy, can serve as a marker of failed reperfusion and occluded IRA. PWD values, in combination with other reperfusion parameters, can contribute to the identification of rescue PCI candidates.

Inflammation of the residual appendix stump: a systematic review.

AIM: A systematic review of the literature was undertaken to examine reported cases of stump appendicitis (SA) to determine the relationship between SA and the original operative strategy (open vs laparoscopic), and to evaluate the clinical features and diagnosis. METHOD: A Pub-med search was conducted to identify cases of appendicitis of a residual stump following appendicectomy. Two original cases of SA following laparoscopic appendicectomy treated in our own hospitals are also included in the analysis. Sixty cases of SA reported in the English medical literature were analysed. RESULTS: The interval from the original appendicectomy ranged from 4 days to 50 years. SA followed appendicectomy in 58% of open and 31.6% of laparoscopic procedures. SA was frequently misdiagnosed as constipation or gastroenteritis, with a significant delay to surgery. Computerized tomography diagnosed SA in 46.6% of cases. Perforation with gangrene of the stump occurred in 40%. CONCLUSION: Stump appendicitis is rare. It may complicate open or laparoscopic appendicectomy. A high level of suspicion should be maintained in any patient with right sided abdominal pain and a history of prior appendicectomy.

A case of spontaneous multivessel coronary artery dissection presenting with acute myocardial infarction and ventricular tachycardia.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia. Multivessel SCAD is much rarer than single vessel involvement and acute coronary syndrome remains the most common clinical presentation of a patient with SCAD. It predominantly occurs in association with atherosclerosis or in the absence of atherosclerosis. We, hereby, present a case of spontaneous multivessel coronary artery dissection in a 35-year-old male patient presenting with chest pain and ventricular tachycardia following emotional stress and discuss the etiology and treatment options.

Investigation of the atrial electromechanical delay duration in Behcet patients by tissue Doppler echocardiography.

AIMS: To investigate the atrial electromechanical delay (EMD) duration that is a non-invasive predictor of atrial fibrillation (AF) in patients with Behcet's disease (BD). METHODS AND RESULTS: Thirty-eight Behcet's patients (24 females, 14 males; mean age: 43.6 ± 10.3 years) who were being followed in the dermatology or internal medicine department and 29 demographically matched controls (13 females, 16 males; mean: age 42.6 ± 11.1 years) were included in the study. The inclusion criteria were recurrent oral ulcerations and two of the following features: recurrent genital ulceration, eye lesions, skin lesions or positive pathergy skin test for Behcet's group. Using tissue Doppler imaging, atrial electromechanical coupling [time interval from the onset of P wave on surface electrocardiogram to the beginning of A wave interval with tissue Doppler echocardiography (PA)] were measured from the lateral mitral annulus (PA lateral), septal mitral annulus (PA septum), and right ventricular tricuspid annulus (PA tricuspid). The mean disease duration was 10.5 ± 7.7 years. The inter-atrial and intra-atrial EMD were significantly higher in the Behcet group than those in the controls (19.8 ± 8.2 vs. 13.1 ± 4.4 ms, P = 0.001; 11.5 ± 7.4 vs. 6.9 ± 3.7 ms, P = 0.02; respectively). The left atrial EMD was similar in both of the groups. However, the P(max) and PWD values were significantly higher in the BD group compared with those in the controls (120.5 ± 10.1 vs. 112.1 ± 5.9 ms, P < 0.0001; 44.9 ± 10.7 vs. 28.4 ± 5.9 ms, P < 0.0001; respectively). CONCLUSION: Atrial electromechanical conduction times were increased in the BD patients compared with those in the controls. The tendency of BD patients to go into AF can be easily and non-invasively detected using tissue Doppler echocardiography. These findings may be indicators for subclinical cardiac involvement.

Extreme QT interval prolongation caused by mad honey consumption.

An unusual type of food poisoning, mad honey poisoning, is a well-known phenomenon in the Black Sea region of Turkey. Mad honey poisoning can result in severe cardiac complications including sinus bradycardia, nodal rhythm, various degrees of atrioventricular blocks, and even asystole. However, no cases of long QT interval have been reported so far. This paper reports the first case of extremely long QT interval to be associated with mad honey consumption.