Pyoderma gangrenosum mimicking mediastinitis after cardiac surgery: a case study.

UNLABELLED: Pyoderma gangrenosum is a dermatosis which associates both, necrosis and polynuclear infiltration of the skin. While the aetiology is not well understood, the disease is thought to be due to immune system dysfunction and it can occur after minor trauma or surgery. Although it has seldom been reported after cardiac surgery in the literature, it is not exceptional. Here we report a case of pyoderma gangrenosum after coronary artery bypass grafting in a 76-year-old patient with chronic idiopathic myelofibrosis. Diagnosis was clinically made and the patient was treated with systemic steroids. The lesions showed a remarkable improvement with this therapy. In the field of cardiac surgery, physicians of the surgical team and nurses should think about this diagnosis in all rapidly expanding postoperative lesions without improvement after debridement or antibiotics. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

ECMO as a bridge to decision: Recovery, VAD, or heart transplantation?

BACKGROUND: Our 8-year experience with ECMO support as a bridge to decision was reviewed. METHODS: A cohort of 124 consecutive patients received ECMO for refractory cardiogenic shock in our institution. Twenty-six of these were out of hospital cardiac arrests and were excluded from this analysis. The median age was 43 years, in the range of 11 to 73 years. RESULTS: The median duration of ECMO support was 4.5 days. Mortality while supported by ECMO was 50% with a median support time of 2 days. Weaning from ECMO was achieved for 49 patients with the following outcomes: cardiac recovery (60%), heart transplantation (26%), and VAD implantation (14%). Median duration of support before weaning was 8 days. Hospital survival was 83%, 61.5% and 71% for cardiac recovery, heart transplantation and VAD implantation, respectively. ECMO weaning was significantly improved in all patients who had normalized their renal function, and when duration of support>6 days (HR: 4.255 [1.255-14.493], p=0.02 and HR: 2.164 [1.152-4.082], p=0.02, respectively). A creatinine level>14 mg/l the day of weaning was a significant predictor of death (HR: 5.807 [1.089-30.953]; p=0.04). Median follow up was 2.4 years; one-year survival rate was 78%, 51% and 75% for cardiac recovery, heart transplantation and VAD implantation, respectively. CONCLUSION: With at least 6 days of support, ECMO allowed a better patient selection for myocardial recovery, VAD implantation or heart transplantation. Whether VAD implantation or heart transplant in those patients is a better indication remains to be evaluated.

Overexpression and promoter mutation of the TERT gene in malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is a very aggressive tumor with no known curative treatment. Better knowledge of the molecular mechanisms of mesothelial carcinogenesis is required to develop new therapeutic strategies. MPM, like all cancer cells, needs to maintain telomere length to prevent senescence. Previous studies suggested that the telomere lengthening mechanism in MPM is based mainly on telomerase activity. For this reason, we focused on the key catalytic enzyme, TERT (telomerase reverse transcriptase), by analyzing its gene expression in MPM and by studying the mechanism underlying its upregulation. We used our large collection of MPM composed of 61 MPM in culture and 71 frozen MPM tumor samples. Evaluation of TERT mRNA expression by quantitative RT-PCR showed overexpression in MPM in culture compared with normal mesothelial cells, and in MPM tumor samples compared with normal pleura. We identified a 'hot spot' of mutations in the TERT gene core promoter in both MPM in culture and in MPM tumor samples with an overall frequency of 15%. Furthermore, data clearly identified mutation in the TERT promoter as a mechanism of TERT mRNA upregulation in MPM. In contrast, gene copy number amplification was not associated with TERT overexpression. Then, we analyzed the clinicopathological, etiological and genetic characteristics of MPM with mutations in the TERT promoter. TERT promoter mutations were more frequent in MPM with sarcomatoid histologic subtype (P<0.01), and they were frequently associated with CDKN2A gene inactivation (P=0.03). In conclusion, a subgroup of MPM presents TERT promoter mutations, which lead to TERT mRNA upregulation. This is the first recurrent gain-of-function oncogenic mutations identified in MPM.

Posterior intercostal hemorrhage following median sternotomy.

We report two cases of patients who underwent cardiac surgery and suffered from posterior intercostal artery bleeding. Both cases were treated by transcatheter arterial embolization.

Simplified open repair for anterior chest wall deformities. Analysis of results in 205 patients.

INTRODUCTION: Pectus deformities are the most frequently seen congenital thoracic wall anomalies. The cause of these conditions is thought to be abnormal elongation of the rib cartilages. We here report our clinical experience and the results of a sternochondroplasty procedure based on the subperichondrial resection of the elongated cartilages. HYPOTHESIS: This technique is a valuable surgical strategy to treat the wide variety of pectus deformities. PATIENTS AND METHODS: During the period from October 2001 through September 2009, 205 adult patients (171 men and 34 women) underwent pectus excavatum (181), carinatum (19) or arcuatum (5) repair. The patients' pre and postoperative data were collected using a computerized database, and the results were assessed with a minimum 2-year follow-up. RESULTS: The postoperative morbidity rate was minimal and the mortality was nil. The surgeon graded cosmetic results as excellent (72.5%), good (25%) or fair (2.5%), while patients reported better results. Patients with pectus excavatum were found to have much more patent foramen ovale (PFO) than the normal adult population, which occluded after the procedure in 61% of patients, and significant improvement was found in exercise cardiopulmonary function and exercise tolerance at the 1-year follow-up. DISCUSSION: Our sternochondroplasty technique based on the subperichondrial resection of the elongated cartilages allows satisfactory repair of both pectus excavatum and sternal prominence. It is a safe procedure that might improve the effectiveness of surgical therapy in patients with pectus deformities.

[Pleuro-pulmonary metastases from a malignant mesothelioma of the tunica vaginalis]. / Métastases pleuropulmonaires d'un mésothéliome de la vaginale testiculaire.

INTRODUCTION: Mesothelioma is a malignant tumour of the serous membranes that principally affects the pleura. Peritoneal, pericardial and tunica vaginalis mesothelioma are very rare. CASE REPORT: We report the case of a 65-year-old male with malignant mesothelioma of the tunica vaginalis (MTV). He presented with several local recurrences and, five years after the initial surgery, with pulmonary nodules and a pleural effusion. Pleural biopsies confirmed epithelioid mesothelioma. A diagnosis of pleuro-pulmonary metastases from previous malignant MTV was made. CONCLUSIONS: Malignant MTV is a rare and aggressive tumor with frequent local recurrences and, rarely, visceral metastases. This case report emphasizes the difficulties of the differential diagnosis between pleural mesothelioma and pleural metastases from MTV. The lack of any treatment for metastatic malignant MTV is discussed.