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PubMed1991

Outcome probabilities and life history after surgical mitral commissurotomy: implications for balloon commissurotomy.

From 1967 to 1988, 339 patients with mitral stenosis underwent surgical commissurotomy, 103 with a closed and 236 with an open technique. The 1 month and 1, 5, 10 and 20 year overall survival rate was 99.7%, 99%, 95%, 87% and 59%, respectively, and the technique (open versus closed) was not a risk factor. Technique was also not a risk factor for a second mitral commissurotomy, subsequent mitral valve replacement, thromboembolism or poor functional status. Risk factors were older age at commissurotomy, black race, higher pulmonary vascular resistance, mitral leaflet calcification, left ventricular enlargement and postcommissurotomy mitral incompetence. The closed technique was a risk factor for mitral incompetence immediately after commissurotomy, but important incompetence developed in only 2 of the 103 patients undergoing closed commissurotomy. Mitral valve replacement was not required within 10 years in 78% of patients and within 20 years in 47%. Despite some increased prevalence of postcommissurotomy mitral incompetence and particularly in view of the considerable long-term likelihood of mitral valve replacement, initial therapy for most patients with mitral stenosis should probably be surgical closed (or percutaneous balloon) mitral commissurotomy. The equations developed in the present study can be used to predict and compare outcome probability after percutaneous balloon commissurotomy with that after surgical commissurotomy and to compare these with outcome probability after mitral valve replacement.

Catheterization↗
PubMed2004

Microarray analysis of proliferative and hypertrophic growth plate zones identifies differentiation markers and signal pathways.

Longitudinal bone growth results from coordination of proliferation and hypertrophy of chondrocytes, calcification of the matrix, vascular invasion, and completion of endochondral bone formation in the growth plate. Although proliferative and hypertrophic chondrocytes are well characterized histomorphologically, the understanding of factors governing this transition is not fully explained. Our hypothesis was that significant differential gene expression exists between proliferative and hypertrophic chondrocytes that may provide clues to the regulation of this transition at the transcriptional level. Normal Sprague-Dawley rat growth plate chondrocytes from the proliferative zone (PZ) and hypertrophic zone (HZ) were isolated by laser capture microdissection and then subjected to microarray analysis. Confirmation of the differential expression of selected genes was done by in situ hybridization and quantitative reverse transcription (RT) polymerase chain reaction (PCR). A total of 40 transcripts showed at least twofold greater expression in the PZ compared to HZ at both 6 and 7 weeks of age, while 52 transcripts showed twofold greater expression in the HZ compared to PZ at these time points. Many of the differentially expressed genes in each zone had very high levels of expression and thus were classified as "enriched transcripts" for that zone. The PZ-enriched transcripts included fibromodulin, proline arginine-rich end leucine-rich repeat protein, lactate dehydrogenase, and enolase 1 alpha. In contrast, HZ-enriched transcripts included collagen I, protein kinase (lysine deficient 4), proteasome (prosome, macropain) activator subunit 4, prostaglandin I2 synthase, and integrin-binding sialoprotein, matrix metalloproteinase 13 (MMP13), and collagen X. Other genes were highly expressed in cells from both zones, including collagen II, aggrecan, cartilage oligomeric protein, cartilage link protein, laminin receptor, and eukaryotic translocation elongation factor. Functional classification of the PZ-enriched transcripts showed an increased percentage of genes expressed in nuclear cell cycle and transcription functions. In contrast, the HZ-enriched transcripts were more involved in extracellular structure and membrane receptor and transporter functions. Pathway analysis indicated that transforming growth factor beta and parathyroid hormone-related protein (PTHrP) pathways were important in both zones, and bone morphogenic protein pathway played a role in the HZ. It is likely that these differentially expressed genes are involved in regulation of the transition from proliferation to differentiation functions in the growth plate.

Animals↗
PubMed2006

Diagnostic value of MRI in a pelvic mass of prostatic origin.

We report on the case of a 55-year-old male with acute urinary retention, caused by a large pelvic mass. Contrast enhanced computed tomography showed a vascularized prostatic mass with calcifications. To rule out potential bladder and rectum infiltration and to optimize imaging prior to surgical exploration, an MRI examination including MR angiography and spectroscopy was performed. Clinical findings including intraoperative results are presented in this report in detail and correlated to the results of the state of the art magnetic resonance imaging.

Calcinosis↗
PubMed1983

Spontaneously regressing retinoblastomas, retinoma, or retinoblastoma group 0.

A 5-year-old boy had a gray, translucent retinal mass containing calcified nodules and surrounded by retinal pigment clumping and atrophy. The eye was enucleated and the patient has remained well for seven years. Microscopic examination disclosed an intraretinal tumor composed of benign-appearing cells in a bed of well-vascularized ground substance with calcific foci. There was surrounding retinal pigment epithelial hyperplasia but no peripheral necrosis or signs of tumor regression. There were no mitoses, cellular pleomorphism, nuclear atypia, rosettes, or other characteristics of malignancy. Tumors with this typical fundus appearance have been termed spontaneously regressing retinoblastoma or retinoma. Although the tumor in this patient was histopathologically benign, it carries the same genetic risk as a retinoblastoma. A better term for this lesion, therefore, is retinoblastoma group 0.

Child, Preschool↗
PubMed1988

Critical analysis of the use of skeletal surveys in patients with chronic renal failure.

Skeletal radiology and bone histopathology were compared in 82 patients with renal failure. The performance of radiology in detecting lesions was assessed using interobserver studies which showed disappointing levels of agreement probably reflecting the subjective nature of the radiological signs. Radiology was very insensitive in detecting and grading hyperparathyroidism even when histology and serum biochemistry were floridly abnormal. The most useful radiographs for monitoring subperiosteal erosions and vascular and soft tissue calcification are identified.

Adolescent↗
PubMed1977

Chronic viral funisitis.

Four cases chronic funisitis, a rare variant of umbilical cord inflammation, are presented and compared with the acute and subacute forms. The distinctive findings are a predominantly lymphoplasmocytic infiltration, coagulative necorsis of the vascular media with secondary calcification, and the unusual association of chronic funisitis with chronic chorioamnionitis and chronic villitis. One fetus was stillborn, another was aborted, and two were live-born. Two fetuses were growth retarded and three had evidence of infection. Viral inclusions were identified in three placentas. The data strongly suggest that lymphoplasmocytic funisitis in these cases is the result of chronic intrauterine viral infection.

Amnion↗
PubMed2006

[Cutaneous calciphylaxis treated by autologous keratinocytes graft and subtotal parathyroidectomy].

BACKGROUND: Cutaneous calciphylaxis, seen most often in dialysis patients, is characterised by skin necrosis, and is a disabling and lifethreatening disease. Despite intensive topical treatment, recourse to parathyroidectomy is often necessary. We report the case of a female patient with skin necrosis due to calciphylaxis: pain and necrotic lesions were controlled by grafting of cultured autologous keratinocytes (Epibase). CASE REPORT: A 75-year-old woman with a 5-year history of dialysis-dependent chronic renal failure secondary to nephroangiosclerosis presented a very painful necrotic ulceration on her left leg. In spite of an autologous patch grafts, the lesions rapidly deteriorated. Laboratory data showed high levels of calcium, phosphate and parathyroid hormone and imaging suggested parathyroidal adenoma. Although cutaneous biopsy was not performed, the diagnosis of cutaneous necrosis due to calciphylaxis with tertiary hyperparathyroidism was established. Treatment consisted of a low-calcium and low-phosphorus diet with autologous keratinocytes grafts (Epibase). After the third application of keratinocytes, the pain disappeared, necrosis ceased and wound healing began. Subtotal parathyroidectomy was performed two months after the start of grafts. At three months, the patient was cured. DISCUSSION: . Calciphylaxis is an obstructive vascular disease secondary to calcification of the arterioles leading to ischemic tissue necrosis. Prompt diagnosis is essential since this disease is disabling and life-threatening due to sepsis and ischemic complications. In our case, autologous keratinocyte grafts allowed pain relief to be achieved within large expanses of cutaneous necrosis after correction of calcium and phosphorus levels, thereby allowing parathyroidectomy to be performed under optimal conditions.

Aged↗
PubMed1994

Hypocalcemia in end-stage renal disease: a consequence of spontaneous parathyroid gland infarction.

Advances over the last several years have led to a better understanding of the etiology of hyperparathyroidism in renal disease and to more effective means of medical prevention and therapy. Thus, in most dialysis populations, many of the serious complications, such as bone fractures, refractory hypercalcemia, and hyperphosphatemia with vascular and other extraskeletal calcifications, have diminished. Furthermore, more aggressive medical management has decreased the requirement for parathyroidectomy. Unfortunately, not all patients respond to medical management and few still develop refractory hyperparathyroidism with associated morbidity. Of the many complications of refractory hyperparathyroidism in dialysis patients, the development of life-threatening hypocalcemia has not been described. We describe a patient with severe secondary hyperparathyroidism who presented with the acute development of hypocalcemia. To our knowledge, this represents the fourth case, the first reported in a patient with end-stage renal disease, of parathyroid autoinfarction presenting as acute hypocalcemia.

Adult↗
PubMed1992

Initiation of bone regeneration in adult baboons by osteogenin, a bone morphogenetic protein.

Osteogenin, and related bone morphogenetic proteins, induce endochondral bone differentiation through a cascade of events which include formation of cartilage, hypertrophy and calcification of the cartilage, vascular invasion, differentiation of osteoblasts, and formation of bone. These events have been studied in a postnatal model of bone development in rodents. Information concerning the morphogenetic potential of osteogenin in primates is a prerequisite for potential clinical application in man. The efficacy of allogeneic osteogenin in primates was investigated in both extraskeletal and skeletal sites in 19-Chacma baboons (Papio ursinus). Osteogenin was isolated from demineralized baboon bone matrix and purified by chromatography on heparin-Sepharose, hydroxyapatite, and Sephacryl S-200. Protein fractions with a molecular mass range of 26-42 kDa induced cartilage and bone differentiation in the subcutaneous space of rats. Final purification to homogeneity was obtained by electroendosmotic elution from a preparative sodium dodecyl sulphate (SDS) polyacrylamide gel, resulting in a single band on a SDS-polyacrylamide gel with an apparent molecular mass of 30-34 kDa, with biological activity in rats. The osteoinductive potential of osteogenin in primates was tested first in intramuscular sites in baboons and found to be active. The bone regeneration potential was investigated in nonhealing calvarial defects surgically prepared in adult male baboons. Baboon osteogenin induced complete regeneration of the cranial wound. These findings in adult primates establish a primary role for osteogenin in initiation and promotion of osteogenesis, and imply a potential therapeutic application based on cell biology of extracellular matrix-cell interactions.

Animals↗
PubMed2003

Use of active vitamin D sterols in patients with chronic kidney disease, stages 3 and 4.

This paper reviews randomized controlled trials and other reported data on the use of the active vitamin D sterols, such as calcitriol, alfacalcidol, and doxercalciferol, in the management of secondary hyperparathyroidism in patients with mild-to-moderate renal insufficiency (stage 3 or 4 chronic kidney disease). Data on potential benefits, including improved histologic abnormalities of bone from secondary hyperparathyroidism, increased bone mineral density, and a reduction of elevated parathyroid hormone levels, are documented. Consideration is given to the risks of such therapy, which include the production of hypercalcemia, more rapid progression of renal insufficiency, the induction of adynamic bone "disease," and accelerated vascular and soft tissue calcification. The low therapeutic index, or "benefit/risk ratio" of calcitriol and alfacalcidol, the sterols currently licensed for such treatment, is recognized. It is recommended that phosphate-restricted diets, phosphate-binding agents, and oral calcium supplements be given adequate trials before starting calcitriol or alfacalcidol. If PTH levels cannot be controlled by these measures, initial doses of these sterols and the proper surveillance during treatment are given. It is emphasized that the risks of hypercalcemia are likely to increase as the degree of kidney failure worsens. Further research using the "less calcemic" vitamin D sterols is clearly needed.

Humans↗
PubMed2002

A prospective study of combination therapy for hyperphosphataemia with calcium-containing phosphate binders and sevelamer in hypercalcaemic haemodialysis patients.

INTRODUCTION: Hyperphosphataemia is predictive of death, in haemodialysis (HD) patients. Sevelamer is a mineral-free phosphate binder not limited by the hypercalcaemia often encountered when utilizing calcium-containing phosphate binders. Highly positive calcium balance is associated with ectopic calcification and potentially accelerated vascular disease. Unfortunately, exclusive use of sevelamer entails a large cost differential, limiting its use in many centres. We report on a strategy of partial replacement of calcium with sevelamer for the management of hyperphosphataemia in hypercalcaemic chronic HD patients. METHODS: We identified 23 HD patients with serum calcium >2.6 mmol/l. Dietary phosphate and calcium intake were assessed and baseline serum calcium, phosphate and 1alpha calcidol and elemental calcium dose recorded. Fifty per cent of this initial calcium dose was exchanged for sevelamer. Vitamin D doses were left unchanged. If serum calcium was still >2.6 mmol/l after 4 weeks a further 50% of calcium was exchanged. If serum phosphate was >2 mmol/l the sevelamer dose was increased by 25%. The patients were followed up for a further 4 weeks. RESULTS: Seven patients complained of gastrointestinal intolerance of sevelamer. Serum calcium fell from a mean value of 2.8+/-0.04 (2.64-3.54) mmol/l to 2.56+/-0.03 (2.4-2.9) mmol/l, P<0.0005. The hypercalcaemic percentage of patients fell from 100 to 26%. Mean serum phosphate was not significantly changed, 1.59+/-0.1 (0.57-2.6) mmol/l to 1.63+/-0.11 (0.55-2.68) mmol/l, 17-22% of patients having serum phosphate >2 mmol/l. Serum intact parathyroid hormone increased from 166+/-47 (12-933) ng/l to 276+/-104 (20-1013) ng/l, P=0.02. Mean sevelamer dose was 2.77+/-0.36 (0-5.6) g per day. Elemental calcium dose fell from 2.05+/-0.23 (0.5-4.5) g to 1.03+/-0.1 (0.5-2.5) g, P<0.0001. CONCLUSION: A regimen based on the combination of sevelamer and calcium is capable of effectively managing hyperphosphataemia, without hypercalcaemia, in the majority of hypercalcaemic HD patients. Such a minimally calcaemic approach might reduce the financial burden of sevelamer therapy, and enable a wider range of patients to be treated.

Calcium↗
PubMed2004

The clinical consequences of secondary hyperparathyroidism: focus on clinical outcomes.

Secondary hyperparathyroidism (SHPT) is a common occurrence in patients with chronic renal failure and is characterized by excessive serum parathyroid hormone (PTH) levels, parathyroid hyperplasia and imbalances in calcium and phosphorus metabolism. PTH acts as a uraemic toxin and it may be responsible for the following long-term consequences: renal osteodystrophy; non-skeletal abnormalities, including severe vascular and heart valve calcification; alterations in cardiovascular structure and function; immune dysfunction; and renal anaemia. The risk of developing SHPT is not the same for all uraemic patients. Black patients appear to have a higher risk of developing SHPT than Caucasian patients, and patients with diabetes have a lower risk than non-diabetic patients. Current treatments include dietary phosphate restriction, oral phosphate binders, vitamin D and its analogues, and, in severe cases, parathyroidectomy. These treatments do not provide optimal treatment for many patients, and compounds that directly inhibit PTH secretion may prove a major step forward in the treatment of SHPT.

Animals↗
PubMed1977

Xeroradiography of the hand in patients with renal osteodystrophy.

The hands of 40 patients with chronic renal failure and varying degrees of renal osteodystrophy were studied. The xerograph and radiograph of each patient were compared, assessing the degree of subperiosteal erosion, and of vascular, capsular and ectopic calcification. While the changes of osteodystrophy were clearly demonstrated on the xeroradiographs, they were also seen on the radiographs, even when only minor changes were present. The authors prefer the xeroradiograph for the measurement of the metacarpal cortical thickness, because of the sharp medial border of the cortex afforded by the "edge enhancement" of this technique.

Chronic Kidney Disease-Mineral and Bone Disorder↗
PubMed2002

Impact of degenerative radiographic abnormalities and vertebral fractures on spinal bone density of women with osteoporosis.

CONTEXT: Measurements of bone density taken by dual-energy x-ray absorptiometry are the most accurate procedure for the diagnosis of osteoporosis. This procedure has the disadvantage of measuring the density of all mineral components, including osteophytes, vascular and extra vertebral calcifications. These alterations can influence bone density results and densitometry interpretation. OBJECTIVE: To correlate radiography and densitometry findings from women with osteoporosis, analyzing the influence of degenerative processes and vertebral fractures on the evaluation of bone density. DESIGN: Retrospective study. SETTING: Osteoporosis outpatients' clinic at Hospital das Clínicas, Universidade Estadual de Campinas. PARTICIPANTS: Ninety-six postmenopausal women presenting osteoporosis diagnosed by bone density. MAIN MEASUREMENTS: Bone mineral density of the lumbar spine and femoral neck were measured by the technique of dual-energy x-ray absorptiometry, using a LUNAR-DPX densitometer. Fractures, osteophytes and aortic calcifications were evaluated by simple x-rays of the thoracic and lumbar spine. RESULTS: The x-rays confirmed vertebral fractures in 41.6%, osteophytes in 33.3% and calcifications of the aorta in 30.2%. The prevalence of fractures and aortic calcifications increased with age. The mean bone mineral density was 0.783g/cm2 and the mean T-score was - 3.47 DP. Neither fractures nor aortic calcifications had significant influence on bone mineral density (P = 0.36 and P = 0.09, respectively), despite the fractured vertebrae having greater bone mineral density (P < 0.02). Patients with lumbar spine osteophytes showed greater bone mineral density (P = 0.04). Osteophytosis was associated with lumbar spine bone mineral density after adjustment for fractures and aortic calcifications by multiple regression (P = 0.01). CONCLUSION: Osteophytes and lumbar spine fractures can overestimate bone density interpretation. The interpretation of densitometry results should be carried out together with the interpretation of a simple lumbar spine x-ray in elderly women.

Absorptiometry, Photon↗
PubMed1999

Surgical treatment of craniopharyngiomas: experience with 168 patients.

OBJECT: The goal of this study was to assess the outcome of surgical management in 168 consecutive patients harboring craniopharyngiomas treated between January 1983 and April 1997. METHODS: In 148 patients undergoing initial (primary) surgery, the pterional approach was most frequently used (39.2%), followed by the transsphenoidal approach (23.6%). For large retrochiasmatic craniopharyngiomas, the bifrontal interhemispheric approach was used increasingly over the pterional approach and led to improved surgical results. Total tumor removal was accomplished in 45.7% of transcranial and 85.7% of transsphenoidal procedures. The main reasons for incomplete removal were attachment to and/or infiltration of the hypothalamus, major calcifications, and attachment to vascular structures. The success rate in total tumor removal was inferior in the cases of tumor recurrence. The operative mortality rate in transcranial surgery was 1.1% in primary cases and 10.5% in cases of tumor recurrence. No patient died in the group that underwent transsphenoidal surgery. The rate of recurrence-free survival after total removal was 86.9% at 5 years and 81.3% at 10 years. In contrast, the 5-year recurrence-free survival rate was only 48.8% after subtotal removal and 41.5% after partial removal. Following primary surgery, the actuarial survival rate was 92.7% at 10 years, with the best results after complete tumor removal. At last follow up, 117 (79%) of 148 patients who underwent primary surgery were independent and without impairment. CONCLUSIONS: Total tumor removal while avoiding hazardous intraoperative manipulation provides favorable early results and a high rate of long-term control in craniopharyngiomas.

Adolescent↗
PubMedDate not supplied

Recrudescence of pulmonary tuberculosis: radiological and CT features in an asymptomatic Southern Italian young population.

AIM: The authors report the results observed in apparently healthy young adults undergoing chest radiography for pre-employment screening. MATERIALS AND METHODS: Between July 1996 and December 1997, 2292 young adults underwent conventional chest radiography for pre-employment screening purposes. Of these, 378 subjects (16.4%) in whom the chest X-ray showed alterations indicative for pulmonary parenchymal lesions were selected for the study. The lesions were divided into four groups: 1) single nodular opacity (n=98/378=25.9%); 2) multiple nodular opacities (n=25/378=6.6%); 3) single or multiple parenchymal consolidation(s) (n=203/378= 53.7%); 4) interstitial disease ( %). All subjects received a tuberculin skin test. The subjects in groups 1, 2 and 3 underwent the diagnostic protocol, which consisted of tuberculin skin test (TST) and CT scan for groups 1 and 2, and a repeat chest radiograph at 30 days for group 3. The subjects in group 4 were studied by high-resolution CT (HRCT). RESULTS: In group 1, CT showed nodular opacities with psammomatous calcifications in 13 cases, vascular dilatations in 3, calcified nodule in 7 subjects with positive TST, and uncalcified nodular lesions in 75 subjects (53/75 with positive TST). In group 2, FNAB confirmed the preliminary diagnosis of metastases in 2 cases; CT demonstrated the pleural origin of opacities in 1 patient, and multiple nodular lesions in 12 subjects; it invalidated the radiographic findings in 3 subjects, and demonstrated multiple nodules associated to increased interstitial thickening in 3 subjects. In group 3, the lung alterations had completely disappeared in 106 subjects, whereas in 97 subjects there was reduced extension of the previously observed lesions, but appearance of new sites of parenchymal consolidation. In group 4 CT confirmed the radiographic suspicion in 14 cases. CONCLUSIONS: Tubercular infection is currently increasing in industrialised countries. In our study it showed a relatively high prevalence of about 4.5% in a young asymptomatic population.

Adolescent↗
PubMed1979

Autologous rectus sheath grafts. V. Growth in aortic grafts.

Experiments were designed to test autologous rectus sheath as a replacement for the thoracic aorta in the growing dog. Adequacy of graft function was determined by angiography at 4 month intervals; stress-strain measurements and microscopic examination were made at the time of autopsy. A 3 cm tubular graft of rectus sheath tissue was employed as an aortic graft in 13 mongrel puppies. Nine puppies (70%) were long-term survivors and were put to death between 6 and 22 months postoperatively. No deaths were due to graft failure. Angiographic studies demonstrated patency of the graft without development of pressure gradients. An increase in diameter of the aorta (21.25%) and the rectus sheath graft %22.87%) were demonstrated in all cases. During the time of observation, the compliance of the growing aorta (93,120 dynes/cm2) decreased to one fourth that of the control aortic tissue (24,800 dynes/cm2), whereas the compliance of the rectus sheath graft (547,1000 dynes/cm2) decreased to only one eighth that of the control rectus sheath (47,400 dynes/cm2). Tensile strength is maintained in both the growing aorta (4.5 x 10(7) dynes/cm2) and the rectus sheath graft (4.7 x 10(7) dynes/cm2; p less than 0.05). Microscopic examination showed no calcification, thinning, or weakness. Vascularization of the graft had occurred, with cellular proliferation and development of more than 30 lamellar-like units in the media and an adventitia-like surface.

Abdominal Muscles↗