Feasibility of arthroscopic 3-dimensional, purely autologous chondrocyte transplantation for chondral defects of the hip: a case series.

INTRODUCTION: The purpose of this retrospective study was to describe technical aspects of arthroscopic, purely autologous chondrocyte transplantation of the hip and to report short-term data of the postoperative outcome in a consecutive series of patients. MATERIALS AND METHODS: We retrospectively analyzed six patients with a full-thickness chondral defect of the hip joint. The defect was treated with an arthroscopically applicable 3-dimensional purely autologous chondrocyte transplant product (chondrosphere(®); co.don(®) AG, Berlin, Germany) in a two-step surgical procedure. Patient-administered scores were assessed at baseline (day before transplantation) and at 6 weeks, 3, 6 and 12 months. RESULTS: Six out of six initially included patients (five males, one female) with a median age of 32.5 years and an average defect size of 3.5 cm(2) were available for follow-up after a mean of 11.2 months. Five acetabular and one femoral defect were treated. An overall statistically significant improvement was observed for all assessment scores (NHS, mHHS and SF 36). CONCLUSION: In this study, we displayed the feasibility and technical aspects of arthroscopic matrix-associated, purely autologous chondrocyte transplantation as a treatment option for full-thickness cartilage defects of the hip. The patient-administered assessment scores demonstrated an increase in activity level and quality of life after a 1-year follow-up. LEVEL OF EVIDENCE: Level IV, retrospective study.

Impact on pulmonary function after lobectomy in patients with chronic obstructive pulmonary disease.

OBJECTIVE: The purpose of this study was to evaluate the operative outcome and pulmonary function after lobectomy; this included systematic mediastinal and hilar lymph node dissection for primary non-small cell lung cancer or pulmonary metastases of extrapulmonary origin in patients with chronic obstructive pulmonary disease (COPD) and a preoperative FEV (1) of less than 1.5 l (< 80 % of predicted value) and FEV (1)/FVC < 70 % (COPD II degrees ). METHODS: A retrospective analysis was undertaken in 79 patients who had consecutively undergone lobectomy with a preoperative FEV (1) < 1.5 l (< 80 %) and FEV (1)/FVC < 70 % (COPD II degrees ). Inclusion criteria were the ability to complete pulmonary function tests and lobectomy for malignancy. Patients with small cell lung cancer and unable to quit smoking less than 6 months prior to surgery were excluded. In 38 cases, pulmonary function tests were performed at 3 months after surgery, and 16 patients had tests at 3 and 6 months. RESULTS: A total of 79 patients were included in this study, with a median age of 70 years (range: 45 - 85 years). The median preoperative FEV (1) was 1.3 l (range: 0.8 - 1.5 l), and patients underwent assisted ventilation for less than 1 hour after surgery (range: 0 - 214 h), and stayed for less than 24 h in the intensive care unit (range: 1 h-56 d). Three patients (3.8 %) died within 30 days after lobectomy. In 14 patients, additional treatment for surgical complications was performed (17.7 %). Follow-up after surgery revealed a significant decrease in FVC and FEV (1) (- 17 % and - 8 %, P < 0.005), but function had improved again (+ 10 % and + 11 %, P < 0.05) at 3 months after surgery and remained stable at 6 months after lobectomy. No statistically significant changes were noticed for paO (2) and paCO (2) values after surgical treatment. CONCLUSIONS: It appears that surgical resection of malignant lung tumours by lobectomy can also be performed successfully in selected patients with low FEV (1) and COPD II degrees without significant loss of pulmonary function.

Bilateral surgical resection in pulmonary epitheloid hemangioendothelioma.

Epitheloid hemangioendothelioma is a vascular tumour with an epitheloid appearance, originating from endothelial cells. Although it is a slow growing tumour, extensive pulmonary involvement, intrathoracic spread, and systemic spread have been documented. We present a case of epitheloid hemangioendothelioma of the lung in a patient with an initial diagnosis made by transthoracic biopsy. The prognosis is unpredictable, with life expectancy ranging from 1 to 20 years. There is no single effective treatment, though spontaneous regression and response to chemotherapy and interferon are reported. Our patient underwent pulmonary lobectomy of the right lower lobe and pulmonary wedge resection of the nodule located in the left lower lobe.

Empirical and subsequent use of antibacterial agents in the febrile neutropenic patient.

UNLABELLED: The objective of this analysis were an assessment of the feasibility of a more individually tailored approach of empirical antibiotic therapy in febrile neutropenia and an exploration of the reasons to modify the initial regimen. DESIGN, SETTING AND SUBJECTS: The main source was a database on febrile neutropenic cancer patients from an unblinded large trial conducted in 35 centres world-wide. This was supplemented by data from patients enrolled in a consecutive series of randomized trials at the Department of Haematology, University Hospital Nijmegen. INTERVENTIONS: Diagnostic procedures were standardized, types of possible infections defined and the reasons for modifying an empirical regimen were recorded. MAIN OUTCOME MEASURES: Survival of the febrile neutropenic episode, development of microbiologically and clinically defined infection in relation to causative organisms, and results of modification. RESULTS: Monotherapy was as effective as combination therapy with an overall mortality of < or = 7%, with 21% of neutropenic episodes accompanied by a clinically defined infection proving fatal compared with only 4% of episodes without a focus. At the end of treatment the empirical regimen had been added to in 60% of cases in the multicentre trial, in contrast to 39% in our own institution, in many cases simply because of continuing fever. CONCLUSION: The development of local guidelines for individually tailoring antibiotic therapy by complementing the empirical regimen is a feasible option for achieving an optimal anti-infective strategy for febrile neutropenic cancer patients.

Congenital absence of the pericardium: echocardiography as a diagnostic tool.

Between 1982 and 1992, 10 patients who underwent echocardiography at the Mayo Clinic were found to have congenital absence of the pericardium. Clinical, electrocardiographic, chest roentgenographic, echocardiographic, computed tomographic, and magnetic resonance imaging features were reviewed in this patient group. The characteristic features of this entity are reviewed. The echocardiographic features in order of frequency are (1) unusual echocardiographic windows, seen in all 10 patients, (2) cardiac hypermobility in nine patients, (3) abnormal ventricular septal motion in eight patients, and (4) abnormal swinging motion of the heart in seven patients.

Primary cardiac tumors: experience with 30 consecutive patients since the introduction of two-dimensional echocardiography.

Experience with 30 consecutive patients who had a total of 32 primary cardiac tumors and who underwent two-dimensional echocardiographic examinations between January 1977 and June 1983 was reviewed. Most of the tumors were atrial myxomas (20 left and 4 right), and 30 were identified on echocardiography. Twenty-five patients, including 21 of 22 with atrial myxoma, underwent surgical resection on the basis of the echocardiographic examination, without preoperative angiocardiography. When the morphologic characteristics of the left atrial myxomas were studied statistically in relation to clinical abnormalities, large tumor size was most closely related to the number and type of associated clinical and laboratory abnormalities. The single exception was embolization, which correlated with echocardiographic tumor consistency. Since the introduction of two-dimensional echocardiography, the yearly incidence of cardiac tumor diagnosis at this clinic has increased several fold and the incidence of unexpected intraoperative diagnosis has been very low (one case). Echocardiography is the method of choice for clinical diagnosis. It has replaced angiocardiography for routine preoperative assessment, permits early diagnosis of cardiac neoplasms and provides insight into the pathophysiology of primary cardiac tumors.

Diaphragmatic hernia mimicking an atrial mass: a two-dimensional echocardiographic pitfall.

Two-dimensional echocardiography has become the diagnostic method of choice for identifying intracardiac masses. However, adjacent extracardiac structures may closely mimic intracardiac masses on the two-dimensional echocardiogram. Five cases of a previously unrecognized phenomenon in which a diaphragmatic hernia mimicked an intraatrial mass are reported. Techniques to identify a diaphragmatic hernia properly on two-dimensional echocardiographic examination and distinguish it from intracardiac masses are discussed.

Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients.

Pericardiocentesis guided by 2-dimensional echocardiography has been used at the Mayo Clinic since April 1980. The 2-dimensional examination localizes the pericardial fluid. Particular note is made of the place on the body wall closest to the fluid. An entry track that permits puncture of the pericardial sac without damage to any vital structure is then selected for the pericardiocentesis needle. Between April 1980 and March 1984, 132 consecutive pericardiocenteses in 117 patients were done by this technique. The volume of fluid obtained ranged from 75 to 1,700 ml (mean 650). Seventy percent of the taps were done for therapy, 21% for diagnosis, and 9% for both therapy and diagnosis. A Teflon-sheathed "intracath" needle was used to complete 80% of the pericardiocenteses. In the other 20%, a large catheter was secondarily introduced and connected to a closed drainage system. There were no deaths related to the procedure. One symptomatic pneumothorax occurred. There were 3 minor complications. Two-dimensional echocardiographic imaging of the heart and pericardial fluid permits a safe and effective means of performing pericardiocentesis.

Sensitivity of two-dimensional echocardiography in the direct visualization of atrial septal defect utilizing the subcostal approach: experience with 154 patients.

In the standard precordial echocardiographic imaging planes, there is frequent dropout of atrial septal echoes in the region of the fossa ovalis that can be minimized by use of the subcostal imaging approach. The diagnostic sensitivity of this approach was reviewed in 154 patients (mean age 31 years, range 2 months to 74 years) with documented atrial septal defect in whom a satisfactory image of the atrial septum could be obtained. Subcostal two-dimensional echocardiography successfully visualized 93 (89%) of the 105 ostium secundum atrial septal defects, all 32 (100%) ostium primum defects and 7 (44%) of the 16 sinus venosus defects. A defect was not visualized (false negative response) in 12 patients (11%) with an ostium secundum defect and in 9 patients (56%) with a sinus venosus defect. In three of the former and five of the latter, a two-dimensional echocardiographic contrast examination established the presence of the interatrial shunt. Twenty-four patients (16%) with clinical findings of uncomplicated atrial septal defect confirmed by two-dimensional echocardiography underwent surgical repair of the defect without preoperative cardiac catheterization. There were no perioperative complications. Two-dimensional echocardiographic examination of the atrial septum utilizing the subcostal approach is the preferred method for the confident, noninvasive diagnosis and categorization of atrial septal defects. Two-dimensional echocardiographic contrast and Doppler examinations complement the technique and enhance diagnostic accuracy.

M-mode and two-dimensional echocardiographic features in cardiac amyloidosis.

Twenty-eight patients with cardiac amyloidosis were studied by echocardiography -- 26 by M-mode and 13 by two-dimensional (2D) studies. All had heart failure and biopsy-proved amyloidosis, M-mode features included (1) normal left ventricular (LV) dimension in all; (2) thickened ventricular septum (88%), LV posterior wall (77%), and right ventricular (RV) anterior wall (79%); (3) decreased thickening of ventricular septum (96%) and of LV posterior wall (65%) and reduced LV global function (62%); (4) left atrial enlargement (50%); and (5) pericardial effusion (58%). Two-dimensional echocardiography provided additional features: (1) thickened papillary muscles (five of 13); (2) thickened valves (four of 13); (3) better appreciation of thickened RV wall; and (4) a characteristic "granular sparkling" appearance of thickened cardiac walls -- presumably secondary to the amyloid deposit -- which was noted in 12 of 13 patients. Thus, M-mode echocardiography is helpful in the recognition of cardiac amyloidosis. However, the better appreciation with 2D echocardiography of thickened cardiac walls with a "granular sparkling" appearance in patients with unexplained cardiac failure is virtually diagnostic of cardiac amyloidosis.

Precordial auscultatory findings in pneumoperitoneum.

A case is reported of a patient in whom a loud precordial click developed postoperatively. The new sound was attributed to pneumoperitoneum. A series of 17 patients is presented who underwent elective surgical procedures that produce pneumoperitoneum. Postoperative precordial auscultation revealed abnormalities in nine which included sounds mimicking clicks or gallops and changes in intensity of previously normal heart sounds. Thus, pneumoperitoneum can produce abnormal precordial auscultatory findings.

Unusual echocardiographic findings in a patient with left atrial myxoma.

A 53-year-old patient is presented who had left atrial myxoma with unusual echocardiographic findings. The patient had been regarded for 10 years as having mitral stenosis. This error in diagnosis was due in part to misinterpretation of his echocardiograms. This report is presented to emphasize not only the unusual echocardiographic findings but also the subtle findings on the phonocardiogram and apexcardiogram which should have led to the correct diagnosis.

Atrial septal defect: echocardiographic observations. Studies in 120 patients.

Previous studies on small numbers of patients have indicated a high incidence of increased right ventricular dimension and abnormal ventricular septal motion in patients with atrial septal defect. However, recent evidence suggests that septal motion may be normal in as many as 46% of patients with atrial septal defect when observed at proper levels. We have analyzed the echocardiograms of 120 patients with sinus venosus or secundum atrial septal defect in an attempt to define sensitivity of the foregoing two echocardiographic abnormalities. Right ventricular dimension index was increased in 98% of patients. When both sides of the ventricular septum were analyzed, abnormal ventricular septal motion was observed in 87% of patients. It is important to observe both right and left septal echoes at all levels. Other measurements and observations were made when possible and are included in the study.

Spectrum of echocardiographic findings in bacterial endocarditis.

Forty-seven echocardiograms were obtained in 32 patients with bacterial endocarditis. Preexistent abnormalities were found in 14 patients. In five of them thought to have bacterial endocarditis on normal valves, echocardiography showed mitral stenosis (one), bicuspid aortic valve (two), and prolapse of mitral valve (two). Definite vegetations were seen in 22 patients--on the aortic valve in seven, the mitral valve in 12, and both valves in three. Ten patients had milder changes suggestive but not diagnostic of vegetations. In 12 patients, surgery confirmed the echocardiographic findings. Fourteen had systemic embolic episodes and all had echocardiographic evidence of vegetations. Abnormalities secondary to bacterial endocarditis, other than vegetations, were common. Twenty-one patients had left ventricular volume overload. Ten had a flail posterior leaflet of the mitral valve, three of which were confirmed surgically. Eight had abnormal coarsely fluttering echoes in the left ventricular outflow tract consistent with a prolapsing aortic valve or underlying aortic vegetations; four were confirmed by surgery. Five had signs of severe aortic regurgitation of recent onset (premature mitral valve closure) and all had confirmation by surgery. Echocardiographic abnormalities persisted after successful medical treatment. We conclude that echocardiography is helpful in patients with bacterial endocarditis. It permits recognition of unsuspected preexistent lesions and the characteristic vegetations, as well as the extent and nature of valvular damage secondary to bacterial endocarditis. However, echocardiography does not differentiate between active and healed lesions.

Further echocardiographic observations in pericardial effusion.

Although the presence of fluid behind the left atrium, on echocardiography, has been used to differentiate pleural from pericardial effusions, five cases are reported showing that pericardial fluid can and does accumulate behind the left atrium. Abnormal valvular motion, as a result of free swinging of the heart in the pericardial sac, was also demonstrated in these patients.

Aorta-coronary artery saphenous vein bypass grafts. Isolated and combined with other procedures.

The results in 578 patients who underwent a saphenous vein bypass graft operation (isolated SVBG) or a SVBG combined with other procedures (combined SVBG) from 1969 through 1972 were analyzed. The operative mortality rate was low (3 percent) for isolated SVBG but increased considerably for combined SVBG. The late mortality rate was also low (4 percent) for isolated SVBG and also increased markedly for combined SVBG. The operative mortality rate did not change in the group undergoing left ventricular aneurysmectomy or mitral valve surgery for postinfarction mitral insufficiency, whether or not SVBG was used; however, late results were better in both groups when SVBG was performed. Among all groups, patients with postinfarction mitral insufficiency or rheumatic mitral incompetence associated with coronary artery disease had the poorest outcome. Despite the operative and late deaths, patients undergoing SVBG with aortic valve replacement showed excellent results in the group of survivors.