Diagnosis and laparoscopic management of a fallopian tube torsion following Irving tubal sterilization: a case report.

Tubal torsion is a very rare but serious clinical entity. Its occurrence has been reported following Pomeroy tubal ligation and laparoscopic tubal cauterization. The following case report will be the first one describing a tubal torsion after an Irving tubal ligation in a patient who also had a history of pelvic inflammatory disease (PID). This study includes the presentation of a case of tubal torsion that is diagnosed and managed laparoscopically and the review of the literature through a computerized search of MEDLINE for relevant cases in the English literature published between January 1966 and July 1999. The patient is a 26-year-old woman with a history of PID and Irving tubal ligation. She presented with a second episode of acute right lower quadrant pain. The patient underwent a diagnostic laparoscopy and was found to have a 6 x 5 cm hemorrhagic and necrotic fallopian tube consistent with torsion of the right tube. A right salipingectomy was done laparoscopically. Combination of PID and tubal sterilization in the medical history of a patient presenting with acute or intermittent pelvic pain may suggest tubal torsion.

Radiofrequency multielectrode catheter ablation in the atrium.

We developed a temperature-controlled radiofrequency (RF) system which can ablate by delivering energy to up to six 12.5 mm long coil electrodes simultaneously. Temperature feedback was obtained from temperature sensors placed at each end of coil electrodes, in diametrically opposite positions. The coil electrodes were connected in parallel, via a set of electronic switches, to a 150 W 500 kHz temperature-controlled RF generator. Temperatures measured at all user-selected coil electrodes were processed by a microcontroller which sent the maximum value to the temperature input of the generator. The generator adjusted the delivered power to regulate the temperature at its input within a 5 degrees C interval about a user-defined set point. The microcontroller also activated the corresponding electronic switches so that temperatures at all selected electrodes were controlled within a 5 degrees C interval with respect to each other. Physical aspects of tissue heating were first analysed using finite element models and current density measurements. Results from these analyses also constituted design input. The performance of this system was studied in vitro and in vivo. In vitro, at set temperatures of 70 degrees C, 85% of the lesions were contiguous. All lesions created at set temperatures of 80 and 90 degrees C were contiguous. The lesion length increased almost linearly with the number of electrodes. Power requirements to reach a set temperature were larger as more electrodes were driven by the generator. The system impedance decreased as more electrodes were connected in the ablation circuit and reached a low of 45.5 ohms with five coil electrodes in the circuit. In vivo, right atrial lesions were created in eight mongrel canines. The power needed to reach 70 degrees C set temperature varied between 15 and 114 W. The system impedance was 105+/-16 ohms, with one coil electrode in the circuit, and dropped to 75+/-12 ohms when two coil electrodes were simultaneously powered. The length and the width of the lesion set varied between 17.6+/-6.1 and 59.2+/-11.7 mm and 5.9+/-0.7 and 7.1+/-1.2 mm respectively. No sudden impedance rises occurred and 75% of the lesions were contiguous. From the set of contiguous lesions, 90% were potentially therapeutic as they were transmural and extended over the entire target region. The average total procedure and fluoroscopy times were 83.4 and 5.9 min respectively. We concluded that the system can safely perform long and contiguous lesions in canine right atria.

Serous adenocarcinoma of the uterus presenting as paraneoplastic cerebellar degeneration.

Paraneoplastic cerebellar degeneration is a rare complication of cancer and is most frequently associated with lung, ovary, and breast cancers as well as Hodgkins lymphoma. A 74-year-old female with a past history of breast cancer presented with vomiting, ataxia, slurred speech, and dizziness. Her serum chemistry, thyroid and liver function tests, acetylcholine antibodies, serum cortisol, CT, and MRI imaging were all normal. Serum testing for anti-YO antibodies was positive. Further evaluation including CT of the abdomen and pelvis revealed endometrial thickening. Subsequently, an endometrial biopsy showed a poorly differentiated serous adenocarcinoma. Surgical staging was consistent with a stage IIIc serous adenocarcinoma of the uterus. The risk factors, symptoms, signs, differential diagnosis, and clinical and antibody associations of the paraneoplastic cerebellar degeneration syndrome are reviewed. In addition, an efficient approach to the diagnostic evaluation of such patients is proposed.

[Effect of iron supplementation and its frequency during pregnancy]. / Efecto de la suplementación con hierro y su frecuencia en gestantes.

The iron (Fe) nutritional status of 203 healthy pregnant women was assessed at the first prenatal visit (To) (gestational age: 16.9 weeks +/- 3.81. Women were randomly assigned to one of three groups: G1 and G2 were supplemented with ferrous fumarate (60 mg elemental Fe) daily or intermittently (three times a week), respectively; and GC was the control group, without supplementation. The follow up was carried out until 34-37 weeks of gestational age (Tf), but only 43% of pregnant women completed the trial. At To and Tf fasting blood samples were collected and Hematocrit (Hct), Hemoglobin (Hb), Erythrocyte Protoporphyrin (EP) and Serum Ferritin (FERR) were determined. The percentage of women with abnormal biochemical values at To (n = 203) was: Hb (g/dl) < 10.5: 2.6%; PE (microgram/dl of red blood cells) > 70: 4.8%; FERR (ng/ml) < 10: 4.4%. Results (X +/- DE) of women that completed the follow up were at To and Tf, respectively: Hct (%): GC: 37.7 +/- 3.4 and 36.0 +/- 3.2 (p < 0.05); G1: 38.8 +/- 2.2 and 38.0 +/- 2.6; G2: 39.0 +/- 2.7 and 37.7 +/- 3.7; Hb (g/dl): GC: 12.5 +/- 1.2 and 11.9 +/- 1.3 (p < 0.05); G1: 12.6 +/- 1.1 and 12.8 +/- 1.1; G2: 12.9 +/- 0.9 and 12.2 +/- 1.5; PE (microgram/dl red blood cells): GC: 30 +/- 17 and 43 +/- 22 (p < 0.01); G1: 26 +/- 13 and 38 +/- 21 (p < 0.01); G2: 26 +/- 16 and 31 +/- 26; FERR (ng/ml): GC: 75 +/- 67 and 31 +/- 49 (p < 0.01); G1: 46 +/- 34 and 19 +/- 10 (p < 0.01); G2: 43 +/- 11 and 11 +/- 7 (p < 0.01). These results show: a) Fe administration was efficient to mitigate Hb decrease; b) Fe stores decreased during pregnancy regardless of Fe supplementation and frequency; c) EP values indicate that intermittent Fe administration was more efficient to maintain normal erythropoiesis.

[Biochemical status and iron intake in a population of pregnant women of Buenos Aires, Argentina]. / Indicadores bioquimicos e ingesta de hierro en un grupo de gestantes del gran Buenos Aires.

The iron (Fe) nutritional status was studied in 113 healthy pregnant women, age: 24.8 +/- 6.1 Ys. During the second trimester (gestational age: 16.9 +/- 3.8 weeks), a 24 h dietary recall was carried out and daily Fe intake was calculated, according to Latinoamerican and German Food Composition Tables. On the same day, hematocrit (Hct), hemoglobin (Hb), erythrocyte protoporphyrin (EP) and serum ferritin (SF) were determined in fasting blood samples. Mean daily Fe intake was 10.8 +/- 4.6 mg. The percentage of population with abnormal biochemical values was: Hb (g/dL) < 10.5: 2%; PE > 70 microgram/dL of red blood cells: 6.5%; SF (ng/mL) < 12-20: 16%. According to the new recommendations of the American Institute of Medicine, Fe supplementation would be necessary in women with SF < 20 ng/ml (22%). Therefore, the follow-up of iron stores would be necessary in those with SF > 20 ng/mL before Fe administration.

[Transcatheter subendocardial infusion: a novel technique for ablation of atrial arrhythmias]. / Direkte subendokardiale Katheterinfusion als neues Ablationsverfahren von rechtsatrialen Arrhythmien.

UNLABELLED: Ablation of typical atrial flutter using radiofrequency energy is limitted by difficulties in creating a continuous line of block across the istmus between the tricuspid anulus and the inferior vena cava. Recent studies from our laboratory have shown that a novel infusion ablation technique can create large endocardial lesions in a safe and predictable fashion. The purpose of our study was to assess the feasibility of transcatheter subendocardial infusion of a mixture of 95% enthanol, iodinated contrast and glycerin to create atrial lesions resulting in complete ablation of the critical isthmus mediating typical atrial flutter. METHODS: Seven closed-chest dogs (weight 24+/-1 kg) were studied during general anesthesia with isoflurane. Two transcatheter subendocardial infusions of 0.5 cc of ethanol, contrast medium and glycerin were made over an injection time of 5 s into the posterior right atrial isthmus in each dog. Staining of the target site was monitored on fluoroscopy. Sinus rate, AH interval and AV block cycle length were determined before and after infusion ablation. Arterial blood pressure and right atrial pressure were continuously recorded. Six infusion ablations were also performed in the lateral wall of the right atrium. Lesion dimensions were measured pathologically, thereafter. RESULTS: A total of 14 infusions was made in the isthmus of the right atrium. The mean lesion volume was 0.21+/-0.18 cc. The lesions were 6+/-3 mm in width, the length was 12+/-5 mm and the average deepness was 6+/-4 mm. An ablation of the entire isthmus was, achieved in five dogs. Disturbances in AV conduction were not observed after ablation in any dog. The isthmus lesions were not proarrhythmic during programmed stimulation. 4/6 infusion ablations in the lateral atrial wall caused a penetration of contrast media of the pericardial sac. Hemodynamic deterioration was not seen after any ablation attempt. CONCLUSIONS: Direct subendocardial insusions can be used to create large ablation lesions in the posterior right atrium. The lesion size is predictable and can be directly visualized on fluoroscopy. Infusion ablations into the right atrial isthmus do not cause damage to the AV node or to the right coronary artery. Transcatheter infusions in the posterior right atrium seem to be promising for ablation of the entire isthmus mediating typical atrial flutter. Additional studies of this technique in an arrhythmia model seem warranted.

Transcatheter subendocardial infusion. A novel technique for mapping and ablation of ventricular myocardium.

BACKGROUND: Catheter ablation with radiofrequency energy is feasible in a limited subset of patients with ventricular tachycardia. The purpose of this study was to evaluate a technique for mapping and ablation of ventricular myocardium with the use of transcatheter subendocardial infusion. METHODS AND RESULTS: A needle-tipped deflectable electrode catheter was used to deliver reagents to endocardial target sites. This was equipped with two central lumens to allow sequential administration of mapping and ablation injectants with minimal admixture. The mapping injectant consisted of a mixture of lidocaine, iohexal, and glycerin; the ablation injectant contained ethanol, iohexal, and glycerin. Infusion of the mapping injectant (1 cm3 over 3 or 5 seconds, n = 14) produced a stain on fluoroscopy and increased local capture threshold by 61%. No lesions resulted from mapping infusions. Infusion of the ethanol-containing injectant (n = 48) produced discrete lesions, with a mean volume ranging from 0.6 to 1.5 cm3. There was a direct relationship between infusion volume, infusion duration, and resultant lesion volume. Fibrosis in a region of healed myocardial infarction did not impair diffusion of the injectant or affect lesion dimensions. Microscopic analysis of chronic lesions showed a sharply demarcated border zone between fibrotic and normal myocardium. CONCLUSIONS: Transcatheter subendocardial infusion can be used to reversibly impair local excitability and mark an injection site fluoroscopically. Subendocardial injection of ethanol can predictably ablate a large volume of ventricular myocardium. Additional study of this system in an arrhythmia model will help to define its potential for mapping and ablation of hypotensive ventricular tachycardia.

Blunted catecholamine responses after glucose ingestion in children with attention deficit disorder.

Eating simple sugars has been suggested as having adverse behavioral and cognitive effects in children with attention deficit disorder (ADD), but a physiologic mechanism has not been established. To address this issue, metabolic, hormonal, and cognitive responses to a standard oral glucose load (1.75 g/kg) were compared in 17 children with ADD and 11 control children. Baseline and oral glucose-stimulated plasma glucose and insulin levels were similar in both groups, including the nadir glucose level 3-5 h after oral glucose (3.5 +/- 0.2 mmol/L in ADD and 3.3 +/- 0.2 mmol/L in control children). The late glucose fall stimulated a rise in plasma epinephrine that was nearly 50% lower in ADD than in control children (1212 +/- 202 pmol/L versus 2228 +/- 436 pmol/L, p < 0.02). Plasma norepinephrine levels were also lower in ADD than in control children, whereas growth hormone and glucagon concentrations did not differ between the groups. Matching test scores were lower and reaction times faster in ADD than in control children before and after oral glucose, and both groups showed a deterioration on the continuous performance test in association with the late fall in glucose and rise in epinephrine. These data suggest that children with ADD have a general impairment of sympathetic activation involving adrenomedullary as well as well as central catecholamine regulation.

Three-dimensional finite element analysis of current density and temperature distributions during radio-frequency ablation.

This study analyzed the influence of electrode geometry, tissue-electrode angle, and blood flow on current density and temperature distribution, lesion size, and power requirements during radio-frequency ablation. We used validated three-dimensional finite element models to perform these analyses. We found that the use of an electrically insulating layer over the junction between electrode and catheter body reduced the chances of charring and coagulation. The use of a thermistor at the tip of the ablation electrodes did not affect the current density decreased more slowly with distance from the electrode surface. We analyzed the effects of three tissue-electrode angles: 0, 45, and 90 degrees. More power was needed to reach a maximal tissue temperature of 95 degrees C after 120 s when the electrode-tissue angle was 45 degrees. Consequently, the lesions were larger and deeper for a tissue-electrode angle of 45 degrees than for 0 and 90 degrees. The lesion depth, volume, and required power increased with blood flow rate regardless of the tissue-electrode angle. The significant changes in power with the tissue-electrode angle suggest that it is safer and more efficient to ablate using temperature-controlled RF generators. The maximal temperature was reached at locations within the tissue, a fraction of a millimeter away from the electrode surface. These locations did not always coincide with the local current density maxima. The locations of these hottest spots and the difference between their temperature and the temperature read by a sensor placed at the electrode tip changed with blood flow rate and tissue-electrode angle.

Effects of hyperglycemia on memory and hormone levels in dementia of the Alzheimer type: a longitudinal study.

The effect of hyperglycemia on hormone levels, metabolite levels, and memory performance was examined in 22 subjects with very mild and mild probable dementia of the Alzheimer type (DAT) and in 12 normal elderly adults. Subjects were tested in 3 plasma glucose conditions (fasting baseline, 175 mg/dl, and 225 mg/dl) at initial and 18-month follow-up sessions. Initially, adults with very mild DAT showed memory facilitation and elevations in plasma insulin in the 225-mg/dl glucose condition relative to baseline. At follow-up, very mild DAT patients whose dementia had progressed showed significant decreases in insulin and hyperglycemic memory facilitation. Changes in basal insulin and cortisol levels over time were correlated with memory changes for DAT subjects. These results suggest that glucoregulatory abnormalities may contribute to the pathophysiology of DAT.

Protein-drug interactions: characterization of inhibitor binding in complexes of DHFR with trimethoprim and related derivatives.

Structural and thermodynamic interactions for the binding of trimethoprim and related congeners to the binary complex of dihydrofolate reductase (from chicken) and NADPH are explored using free energy simulation methods. Good agreement between structures from experimental X-ray refinement and molecular dynamics simulations is found for the complexes. Agreement with thermodynamic measurements is found as well. Our thermodynamic calculations suggest that entropic contributions and desolvation thermodynamics can play a crucial role in overall binding, and that extreme care must be taken in the use of simple model building to rationalize or predict protein-drug binding.

Autonomic dysreflexia: an unusual radiologic complication.

Two cases of autonomic dysreflexia are reported in which patients with high spinal cord lesions developed untoward effects during a diagnostic radiologic procedure. One patient had a retrograde cystogram and the other had a femoral angiogram. Radiologists should be aware of this potentially hazardous complication which could occur in any patient with a spinal cord lesion at or above T6. It can precipitate severe acute hypertension, acute myocardial failure or intracranial hemorrhage. We reviewed clinical features, etiologies, pathophysiology, treatment and prophylaxis.