Rheologic genesis of discrete subvalvular aortic stenosis: A Doppler echocardiographic study

AbstractTo determine whether morphologic structures or abnormal flow patterns predispose to pathologic proliferation or subvalvular tissue, 26 patients (mean age 19.8 ± 10.3 years) were studied ≥6 months after operation for isolated discrete subvalvular aortic stenosis. The aortic root diameter and the mitral-aortic separation were measured with sector echocardiography. Flow patterns in the left ventricular outflow tract of these patients and control subjects were evaluated with a color flow mapping system optimized for the detection of turbulence.All control subjects had laminar flow throughout systole in the left ventricular outflow tract. By contrast, turbulence originating well below the site where the shelf had previously been resected was observed in 20 (77%) of the 26 patients. In 16 of these 20 patients turbulence was caused by a ridge, which in 13 patients could be identified as the offshoot of a ventricular band. In four patients the turbulence was caused by malalignment of the muscular and membranous septum, resulting in protrusion of the muscular septum into the outflow tract. Except for the latter four patients, the aortic root diameter was 84 ± 10% of values predicted by body surface area, with values in six patients falling below the third percentile (p < 0.01). The mitral-aortic separation was 9.7 ± 3.5 mm, values in 21 patients falling above the 97th percentile (p < 0.001).These data support the theory that discrete subvalvular aortic stenosis may be caused by a chronic flow disturbance, preferably in a small and long outflow tract. Left ventricular bands, if reaching the outflow tract, may be a factor. Because recurrence of subaortic stenosis is a frequent problem, these findings argue for careful echocardiographic and surgical exploration of the outflow tract well below the subvalvular stenosis to detect and resect structures that cause turbulence

Physical status, symptoms and health-related quality of life during a severe exacerbation of COPD: Recovery and discriminative capacity for future events

Objective: Severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) can have a negative impact on functional capacity, symptoms and health-related quality of life (HRQOL). This study aimed to i) investigate the recovery of muscle strength, functional capacity, symptoms, and HRQOL in patients after a severe AECOPD; ii) compare with matched patients with stable COPD (SCOPD); and iii) assess whether these assessments at hospital discharge could discriminate patients’ risk for future events. Methods: This observational study assessed patients with AECOPD during hospital discharge (T1) and one month after discharge (T2). Patients with SCOPD were assessed once. Quadriceps force, handgrip strength, short physical performance battery (SPPB), 6-min walk distance (6 MWD), COPD assessment test (CAT), London chest activity of daily living (LCADL), modified medical research council, checklist individual strength-fatigue, patient health questionnaire, and physical activity (Actigraph) were measured. Exacerbation-related readmission and mortality within six months and 1-year were collected. Results: Forty-four patients with AECOPD were matched with 44 patients with SCOPD. At T2, a significant improvement was found for the SPPB total score, 6 MWD, CAT score, and LCADL score. Compared to patients with SCOPD, a worse LCADL score was found at T2 in patients with AECOPD. Patients with AECOPD that were readmitted or died had a worse SPPB classification and five-repetition sit-to-stand test at T1. Conclusion: Patients after severe AECOPD improved in functional capacity and HRQOL one month after hospital discharge, but ADL performance was still worse compared to SCOPD. Patients who were readmitted or died had significantly worse scores on functional tests at hospital dischargepublishe

A giant phyllodes tumor of the breast

Phyllodes tumors of the breast are rare, accounting for less than 1% of the breast tumors. They are mostly seen in women between 45 and 49 years old. These are fast growing tumors with a large spectrum of behavior (from benign to metastatic) and can resemble fibroadenomas. Correct diagnosis mostly through core needle biopsy is important to decide whether a surgical excision has to be done. Here we report a case of a 57-year-old woman with a fast growing, ulcerated tumor in the left breast. Core needle biopsy suggested a malignant phyllodes tumor with heterologous liposarcomatous differentiation. Treatment with total mastectomy and adjuvant radiotherapy followed. Primary treatment is always surgery, whether radiotherapy or chemotherapy has to follow remains uncertain. There is a high-recurrence rate, especially when the surgical margins are narrow

Evolution of the Z-score in size-reduced bicuspid homografts

Human homografts are frequently used to establish an anatomic continuity between the right ventricular outflow tract (RVOT) and the pulmonary artery. Their limited availability, especially in small sizes, has encouraged the use of alternative strategies, such as size-reduced bicuspid homografts. The study aim was to analyze the follow up of patients who had received a standard tricuspid or size-reduced bicuspid homograft in the RVOT position, and to investigate modifications of the patients' Z-scores over the years.status: publishe

Behaviour of polyester grafts in adult patients with repaired coarctation of the aorta

AIMS: Whatever the technique used for surgical or endovascular repair of a coarctation of the aorta (CA), long-term complications might occur. Aneurysm formation after patch angioplasty is not uncommon and may lead to a life-threatening condition. Therefore, we were interested in the long-term results of different types of tube grafts, from which a lower degree of dilatation is expected. METHODS AND RESULTS: All patients, currently older than 16 years, who underwent (redo) surgery for CA, and in whom a tube graft was inserted, were selected from the database of congenital heart disease of our hospital. Follow-up data were collected by reviewing the patients' files. The degree of graft dilatation was calculated for each patient. Fifty-three patients (41 males, median age 33.1 years, Q1-Q3 29.9-40.2 years) could be included in the study, in which 20 (38%) 'Gelseal', 12 (23%) 'Gelsoft', 8 (15%) 'Gelweave', and 13 (24%) older types of grafts were used. Twenty patients underwent a primary repair and in all others a tube graft was implanted after a previous patch angioplasty. The median graft diameter (manufacturer size) at implantation was 20 mm (Q1-Q3 16-22 mm). The median follow-up time of the grafts was 13.1 years (Q1-Q3 9.0-17.2 years). The graft size increased to a median value of 26 mm (Q1-Q3 22-30 mm) (median 50% increase in diameter, range 0-271%, P < 0.0001). The diameter of six grafts remained unchanged during follow-up. Three deaths occurred, of whom two were cardiac-related. False aneurysms occurred in four patients, graft aneurysm in two, endarteritis in two, and graft stenosis in one. CONCLUSION: Nearly, all tube grafts dilated up to 50% of the manufacturer diameter during follow-up. Re-interventions were inevitable in more than 10 per cent of the cases, primarily because of (false) aneurysm formation. Our series illustrates that late complications are not uncommon, so that rigorous follow-up of these CA patients remains mandatory.status: publishe

Impact of antipsychotic medication on physical activity and physical fitness in adolescents: an exploratory study

Antipsychotics are used increasingly in adolescents for a range of psychiatric disorders. The aim of the current study was to investigate whether physical activity levels and physical fitness of adolescent inpatients treated with antipsychotic medication, differs from either (i) antipsychotic naïve adolescents with mental health problems and, (ii) healthy controls. All participants completed the Physical Activity Questionnaire for Adolescents, the Positive-and-Negative-Affect-Schedule and performed the Eurofit test battery. Adolescents with mental health problems (irrespective of antipsychotic medication) were significantly (P<0.05) less physically active and had an impaired whole body balance, running speed and cardiovascular endurance compared to healthy controls (n=15, 8♂, 15.9±1.3 years). Adolescents treated with antipsychotic medication (n=15, 8♂, 15.5±1.3 years) were less physically active and had an impaired whole body balance compared with antipsychotic naïve adolescents (n=15, 8♂, 15.7±1.4 years). Given the overwhelming deleterious impact of physical inactivity and low physical fitness on physical and mental health outcomes, interventions specifically targeting physical activity and physical fitness among adolescents experiencing mental illness, both treated with, and not treated with antipsychotic medication are warranted as a priority. Antipsychotic medication should be considered as a risk factor for physical inactivity and poor physical fitness.publisher: Elsevier articletitle: Impact of antipsychotic medication on physical activity and physical fitness in adolescents: An exploratory study journaltitle: Psychiatry Research articlelink: http://dx.doi.org/10.1016/j.psychres.2016.05.042 content_type: article copyright: © 2016 Elsevier Ireland Ltd. All rights reserved.status: publishe

Effects of high altitude and cold air exposure on airway inflammation in asthmatics

AIMS: Eighteen patients with asthma were evaluated during preparation to climb to extreme altitude in order to study the effects of low fractional inspired oxygen (FiO(2)), prolonged exposure to cold air and high altitude on lung function, asthma control and airway inflammation. METHODS: Spirometry and airway inflammation (fractional exhaled nitric oxide (FeNO) and induced sputum) were studied under different test conditions: hypoxic (FiO(2)=11%) exercise test, 24-hour cold exposure (-5°C) and before, during and after an expedition that involved climbing the Aconcagua mountain (6965 m). RESULTS: Forced expiratory volume in 1 s (FEV(1)) and FeNO values were slightly lower (p<0.04) after 1 h of normobaric hypoxia. FEV(1) decreased (p=0.009) after 24-hour cold exposure, accompanied by increased sputum neutrophilia (p<0.01). During the expedition FEV(1) and forced vital capacity decreased (maximum FEV(1) decrease of 12.3% at 4300 m) and asthma symptoms slightly increased. After the expedition the Asthma Control Test score and prebronchodilator FEV(1) were reduced (p<0.02), sputum neutrophil count was increased (p=0.04) and sputum myeloperoxidase levels, sputum interleukin 17 mRNA, serum and sputum vascular endothelial growth factor A levels were significantly higher compared with baseline. Patients with asthma with the lowest oxygen saturation during the hypoxic exercise test were more prone to develop acute mountain sickness. CONCLUSIONS: Exposure to environmental conditions at high altitude (hypoxia, exercise, cold) was associated with a moderate loss of asthma control, increased airway obstruction and neutrophilic airway inflammation. The cold temperature is probably the most important contributing factor as 24-hour cold exposure by itself induced similar effects.status: publishe

The Contegra conduit in the right ventricular outflow tract is an independent risk factor for graft replacement

Objective: A large spectrum of congenital heart diseases requires valved conduits to establish an anatomical continuity between the right ventricle outflow tract (RVOT) and the pulmonary artery. The aim of the present study was to compare the incidence of graft replacement in patients receiving the Contegra conduit (bovine jugular vein graft) with that in patients receiving a homograft implanted in the RVOT. Methods: We reviewed a total of 347 conduits (Contegra 54; homografts 293) implanted in the RVOT from 1989 to 2003 in 323 patients (median age 12.7 years, range 4 days-69 years). Indications were Tetralogy of Fallot (n=148), Ross operation (n=89), truncus arteriosus communis (n=47), pulmonary valve atresia (n=30), double-outlet right ventricle (n=15), transposition of the great arteries (n=12), and endocarditis (n=6). Follow-up was 99.4% complete (mean time: 5.9 years; range: 0-14.2 years). Results: Freedom from graft replacement at 1, 5, and 10 years of follow-up in the Contegra and homograft groups were 98.1±1.9%, 78.3±5.8%, and 63.5±7.2% and 99.6±0.4%, 94.0±1.6%, and 81.4±3.4%, respectively (log-rank test, p<0.001). Independent predictors of graft replacement of the whole sample population were: graft size≤20mm (hazard ratio (HR) 3.6), age≤10.4 years (HR 3.0), the non-anatomical position of the graft (HR 2.9), and the use of the Contegra conduit (HR 2.5). The multivariable analysis carried out on the propensity-score-matched population confirmed three independent predictors of graft replacement: graft size≤20mm (HR 8.0), the non-anatomical position of the graft (HR 2.3), and the use of the Contegra conduit (HR 3.7). Conclusions: Besides size of the graft, age of the patients, and the non-anatomical position of the graft, the use of the Contegra conduit was found to be an independent risk factor for graft replacement in the RVOT. Patients receiving this conduit were more than twice as likely to undergo re-operation for graft replacement as those receiving a homograft.status: publishe