Massive right atrial myxoma presenting as syncope and exertional dyspnea: case report

Primary heart neoplasms are rare occurring with an estimated incidence of 0.0017-0.19%. Myxoma is the most prevalent primary heart tumor. The right atrium is an unusual localization, occurring only in 15-20% of myxoma cases. We report a rare case of a massive right atrial myxoma causing tricuspid valve obstruction and presenting as syncope and exertional dyspnea. This case illustrates the influence of myxoma's size, position and mobility as well as patient's body posture and respiration to the development of signs and symptoms. Three-dimensional echocardiography proved useful in surgery planning, allowing a better definition of the tumor outline and attachment

On the functional overlap between complement and anti-microbial peptides

Intriguingly, activated complement and anti-microbial peptides share certain functionalities; lytic, phagocytic, and chemo-attractant activities and each may, in addition, exert cell instructive roles. Each has been shown to have distinct LPS detoxifying activity and may play a role in the development of endotoxin tolerance. In search of the origin of complement, a functional homolog of complement C₃ involved in opsonization has been identified in horseshoe crabs. Horseshoe crabs possess anti-microbial peptides able to bind to acyl chains or phosphate groups/saccharides of endotoxin, LPS. Complement activity as a whole is detectable in marine invertebrates. These are also a source of anti-microbial peptides with potential pharmaceutical applicability. Investigating the locality for the production of complement pathway proteins and their role in modulating cellular immune responses are emerging fields. The significance of local synthesis of complement components is becoming clearer from in vivo studies of parenchymatous disease involving specifically generated, complement-deficient mouse lines. Complement C₃ is a central component of complement activation. Its provision by cells of the myeloid lineage varies. Their effector functions in turn are increased in the presence of anti-microbial peptides. This may point to a potentiating range of activities, which should serve the maintenance of health but may also cause disease. Because of the therapeutic implications, this review will consider closely studies dealing with complement activation and anti-microbial peptide activity in acute inflammation (e.g., dialysis-related peritonitis, appendicitis, and ischemia)

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast. Cancer Patents. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Phase II Randomised Controlled Trial Of The Effects Of Parenteral Fish Oil Emulsion On Pro And Anti Inflammatory Markers And Clinical Outcome In Critically Ill Septic Patients In Intensive Care Unit

Introduction:Sepsis is a leading cause of mortality in critically ill patients on the intensive care unit (ICU). Death from sepsis in the ICU is frequently preceded by the development of multiple organ failure as a result of uncontrolled inflammation. Treatment with omega- 3 fish oil has been demonstrated to attenuate the effects of uncontrolled inflammation and may be clinically beneficial in reducing morbidity from organ dysfunction.Trial design:A phase 2 randomised controlled trial investigating the effects of parenteral omega-3 on critically ill patients in ICU in a single institution. Methods:Participants: Consecutive patients with sepsis were considered for the trial. Sepsis was defined as the presence of a known or suspected infection and two or more SIRS criteria (Systemic inflammatory response syndrome).Interventions: 60 patients were randomised to receive either parenteral fish oil (FO) and standard medical care or standard medical care only.Hypothesis: Administration of omega 3 fish oil emulsion will not alter the level of proinflammatory and anti-inflammatory markers in critically ill patients with sepsis on Intensive Care Unit as compared to controls.Outcome: The primary outcome measure was the effect of omega-3 on various inflammatory markers including cytokine, complement, resolvins and protectins (measured using ELISA, LC-MS). The secondary outcome measure was clinical benefit measured using SOFA score and 28-day mortality. Cytokines and complement were analysed used ELISA. Resolvins & protectins were analysed using LC-MS. Data was analysed using Strata statistical tool.Results:Sixty patients were included in the study, 30 in the control group and 30 in the treatment group. The baseline demographics were matched for the two cohorts. A significant increase (p=0.001) was detected in the concentration of pro-inflammatory mediators PGE2, PGF2a, TXB2 in the control group while the anti-inflammatory mediators 4HDHA, 17HDHA were significantly higher in the FO group (p=0.01). Omega-3 significantly reduced IL-17 in FO group (p=0.035). Also, the concentration of other pro-inflammatory cytokines (E-selectin, VCAM, ICAM, TNFR1, TNF-α, IL-17, IL-12, IL-6, IL-1b) were reduced in the FO group. Omega-3 improved outcomes in C3 depleted patients by 50%. Patients treated with parenteral fish oil were associated with a significant reduction in new organ dysfunction (delta-SOFA 2.2±2.2 vs. 1.0±1.5, p=0.005 and maximum-SOFA 10.1±4.2 vs. 8.1±3.2, p=0.041). Patients treated with fish oil demonstrated a reduction in 28-day mortality (26% in control vs 13% in FO, p=0.19).Conclusion:This study has demonstrated that omega-3 altered the concentrations of various pro and anti-inflammatory mediators significantly resulting in clinical benefit. It was safe in critically ill septic patients in ICU.</div