Pulmonary Embolism as Manifestation of Right Atrial Myxoma

Pulmonary Embolism as Manifestation of Right Atrial Myxoma A  case report and review of literature Abstract We present a case of a 55-year-old man who suffered from shortness of breath and syncope; he was sent to our department for suspecting pulmonary embolism. We proceeded Computed tomography pulmonary angiography (CTPA) and Transthoracic echocardiogram (TTE) , confirmed the diagnosis which was caused by right atrial mass. After the surgery the patient was diagnosed as right atrial myoma (RAM) with pulmonary myoma emboli without no adverse event. The residual emboli were partially improved after one month anticoagulation. We reported this case and review of the relevent literature to help clinicians improve the understanding of diagnosis and treatment of pulmonary embolism caused by RAM. Key words: pulmonary embolism, right atrial myxoma, treatment Pulmonary embolism, most commonly originating from deep venous thrombosis (DVT) of the legs, ranges from asymptomatic, incidentally discovered emboli to massive thromboembolism causing immediate death. PTE is a life-threatening disease with a high morbidity. Annually, as many as 300,000 people in the United States die from acute PTE, which is much more common in China at present than 10 years ago (1). About 50-70% emboli of pulmonary embolism originated from deep venous thrombosis (DVT), most of which in lower extremities. Such patients without DVT should screen occult cancer. Although cancer associated venous thrombosis was widespread described, the emboli from benign tumor are less mentioned (2). Majority of the atrial myxoma complicated pulmonary emboli are tumoral, thrombotic emboli were less reported (3,4). We report a rare case of RAM with a pulmonary localization mimicking pulmonary emboli. Case presentation A 55-year-old man was admitted to emergency room with gradually increased shortness of breath for 2 months, syncope and right chest pain for 6 hours. He had a habit of long time sitting and a history of 20 pack-year smoking, and stopped smoking 10 years prior to admission. Initial assessment revealed cyanosis and right breath sound decreased. No pitting edema in lower extremities. Laboratory tests showed ALT 52IU/liter; 93IU/liter; D-Dimer >10ÃŽ ¼g/ml; NT-proBNP 3544 Ñâ‚ ¬g/ml; Troponin I 0.49 ng/ml. Arterial blood gases revealed severe hypoxemia, oxygenation index was 89mmHg; Electrocardiogram showed Sà ¢Ã¢â‚¬ ¦Ã‚  Qà ¢Ã¢â‚¬ ¦Ã‚ ¢Tà ¢Ã¢â‚¬ ¦Ã‚ ¢. CTPA revealed right main (Figure 1a), both lobar(Figure 1b,1c) and segmental (Figure 1d) pulmonary arteries(PA) multiple filling defects; right atrium irregular mass(Figure 1d). TTE showed enlargement of right chambers and a right atrial 54*47mm mass attached to the top wall, clear margin, irregular and partial rough on surface, l oose in internal structure, moving along with cardiac cycle, mild prolapse through the leaflets of the tricuspid valve and orifice of inferior vena cava, moderate regurgitation of tricuspid valves with mild pulmonary hypertension. Compressed venous ultrasonography showed negative in both lower limbs. The surgical approach was through a medial sternotomy under extracorporeal circulation. The right atrium wall was opened and a gelatinous consistency tumor with necrosis, fragile, measuring 40*50mm, adhering to the inter-atrial septum (Figure 2), a 30*20*70mm tumor embolus in the right main PA, the distal end was near right upper PA. The tumor cells expressed CD34 and calretinin, and were negative for CK and SMA. The histopathological examination confirmed myxoma (Figure 3) in right atrium and right pulmonary artery. The patient was treated warfarin (target INR, 2-3) for 1 month. Repeated CTPA showed left lower PA filling defect with no improvement after 2 months (Figure 4c), right and other left PA filling defect resolved (Figure 4a, 4b). 2 years follow-up he was asymptomatic. Discussion Cardiac tumors are less common, most of which are from metastasis. The incidence rate of primary cardiac tumors (PCTs) in autopsy ranges from 0.02 to 2.8†°. 30-50% of PCTs are myomas, 75% in the left atrium and only 10-20% arising in the right atrium, which may developing from embryonic or primitive gut rests (5,6,7). Histologically, they consist of an acid-mucopolysaccharide rich stroma. Polygonal cells arranged in single or small clusters are scattered among the matrix. The clinical manifestations of RAM may remain asymptomatic or appear with constitutional, obstructive or embolic symptoms according to the size, fragility, mobility, location of the tumor as well as body position and activity (5,8). Nonspecific constitutional signs, which present in 10-45% of patients with myxoma, are fatigue, fever, dyspnea, chronic anemia, weight loss, general arthralgia, and increase of IL-6, ESR, and CRP (8). Therefore the results of laboratory tests may mimic those for rheumatic disorders. These signs are more common for patients with large, multiple, or recurrent tumors, and usually recovered after resection (9). Pulmonary embolism of RAM fragments or thrombi from the surface may also occur, resulting in dyspnea, pleuritic chest pain, hemoptysis, syncope, pulmonary hypertension and right heart failure even sudden death. Acute abdominal pain was mentioned in two cases (10). Embolic event in cardiac myxoma is common, with the incidence ranging from 30% to 40% (5) . In the cases of RAM with pulmonary embolism, a smaller size, villous or irregular surface and multi-foci are most common factors associated with embolization (11). The duration period was ranging from 1 day to 3.5 years. The age of patients ranged from 17 to 76 years (mean age 42.8 years), with a higher incidence in women (20/35, 57%). In these cases RAMs are usually attached by a short pedicle to the inter-atrial septum (22/35), mostly in fossa ovalis, others are in free wall, crista terminalis, Koch triangle and multiple origins. Most of the patients were diagnosed with TTE (Transthoracic echocardiography), CT, transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI), others were with angiography and autopsy. In almost all cases treatment was surgical with removal of the intra-atrial myxomas and the pulmonary emboli, which are usually tumoral. Majority of such patients recovered well after surgery. Four preoperative deaths, two postoperative deaths were reported. Right atrial thrombosis, transient ischemic attack (TIA), ischemic hepatitis and renal failure were the rare complication (Table 1). TTE and TEE are the most commonly used diagnostic methods in the detection and initial description of atrial myxomas (23). TTE is nearly 95% sensitive for the confirmation of cardiac myxomas, and TEE reaches nearly 100% sensitivity (45). TTE facilitated bedside test to safely detect myxomas in fatal pulmonary embolism as in our patient. TEE produces explicit images of small tumors (1 to 3 mm in diameter), especially in fat patients with poor TTE images (46). The TEE also permits a clearer picture of the attachment of the tumor and more precise characterization of the size, shape, surface, inner structure and location of the mass (47). Although TEE is a semi-invasive diagnostic test with a very low rate of significant complications, lethal pulmonary embolism during TEE procedure has been reported (22). Superior to echocardiography, multi-detectors spiral computed tomography (MSCT) and cardiac magnetic resonance imaging (CMR) are more accurate in determining the relationship to normal intra-cardiac structures and tumor infiltration into the pericardium, extension to adjacent vasculature and mediastinal structures, pulmonary arteries emboli and surgical planning (48,49). RAMs manifest as a low-attenuation intra-atrium mass with a smooth, irregular or villous surface on MSCT. Calcifications are seen in about 14% and are more common in right side lesions. Arterial-phase contrast enhancement is usually not apparent, but heterogeneous enhancement is reported on studies performed with a longer time delay (50,51). Varying amounts of myxoid, calcified, hemorrhagic, and necrotic tissue gives them heterogeneous appearances on T1 and T2-weighted images. Delayed enhancement is typical and usually patchy in nature. Steady state free preceesion (SSFP) sequences may slow prolapse through the tricu spid valve in diastole phase and can suggest the attachment point of a stalk lesion. Reconstruction of cine gradient recalled echo (GRE) images enables assessment of lesion mobility and attachment (52). 18F-FDG PET/CT can help the noninvasive preoperative confirmation of malignancy (41). Mean SUVmax was 2.8 ±0.6 in benign cardiac tumors and significantly higher in both malignant primary and secondary cases. (8.0 ±2.1 and 10.8 ±4.9). The SUVmax of myxoma is ranging from 1.6 to 4. Malignancy was determined with a sensitivity of 100% and specificity of 86% with a cut-off SUVmax value of 3.5. A weak correlation between the SUVmax and the size of tumors is found due to the partial volume effect, cardiac motion and respirtatory movement (53). Angiography is an invasive investigation that presents an additional risk of inducing migration of the tumor and only suitable for suspected acute coronary heart disease (37). Surgical removal of the RAM with pulmonary embolism is the first treatment of choice and usually curative (44,45). The crucial aspects of surgery are measures for bi-caval cannulation to prevent intra-operative embolism (27), en-bloc excision of the myxoma with a wide cuff of normal tissue, removal of fragments in pulmonary arteries, and conducted under moderate or deep hypothermia, low circulatory flow or total circulatory arrest based on the extent and sites of the emboli (44). Surgical treatment leads to complete resolution with low rates of recurrence and good long-term survival. The overall recurrence rate is about 1–3% for sporadic atrial myxoma (5,54), which grows an average of 0.24–1.6 cm per year. The risk of recurrence pulmonary embolism after resection has been reported to be 0.4% to 5.0% and interval from excision to recurrence is reported ranging from a few months to 8 years (55). The reasons of RAM recurrence include multifocal origin, incomplete surgical resection, familial disposition or abnormal DNA ploidy pattern. Postoperative annual TTE, V/Q scan for long-term observation should be followed up to detect eventual recurrence of new myxoma and pulmonary embolism. Excision of the recurrent lesions may be the only choice of treatment because of the poor role of chemotherapy and radiation (28). Pulmonary emboli from RAM are usually tumoral, although discriminating myxomas from thrombi in pulmonary arteries is difficult. Daniel T et al (56) presented the first case of paradoxical pulmonary embolism in the presence of a left atrial myxoma withouingt intra-cardiac shunting, potentially secondary to a combination of hemolysis, hemeoxygenase-1 up-regulation, systemic hypercoagulability/hypofibrinolysis, and regional venous stasis. Pulmonary thromboembolism complicated to RAM improved by coumadin therapy in a refused surgery patient (40). In our case the surgery do not remove the right side emboli, while anticoagulation was helpful for residue emboli remission, which confirmed coexistence of myxoma and thrombi. We suggest anticoagulation may be the useful in unresectable myxoma with pulmonary embolism. The duration of anticoagulation in pulmonary thromboembolism is at least three months, but the course in patients with RAM is still unknown. Conclusion According to review of the literature, RAM may not be timely diagnosed, or even totally undiagnosed. Because of the fragile consistency of RAM, pulmonary embolism are the most common comorbidity and mortality disease, usually be fatal. Surgical removal of masses from the atrium and pulmonary arteries is almost uneventful. Although the association between right atrial myxoma and pulmonary embolism has been described, the presence of thrombi was less mentioned. We suggest anticoagulation may be a choice of treatment after operation, especially in incomplete resection cases. Annual TTE and V/Q are suggested for a period of 8 years when the risk of recurrence is reported. Competing interests The authors declare that they have no competing interests.

Disco Music

Matt Crane 8-19-06 Music Back in the late 1960s, disco originated as a combination of many instruments played together. It was in 1969 when Jerry Butler released his latest song ‘Only the Strong Survive’ that we got our very first disco song. This was the birth of disco but then it was a form of music which hadn’t been named. Four years and many songs later on the 13th of September 1973, Vince Aletti wrote an article in the Rolling Stone Magazine which gave this music form its name â€Å"DISCO†.This soulful music is based on a number of instruments blended together to get what is known as the disco sound. The vocals are played on a steady four on the floor beat or what is known as a quaver (eighth note) or a semi- quaver (sixteenth note). Many electronic musical gadgets are used to create the background score. This form of music has more of electric bass line and the guitar is seldom used as a lead instrument. Films like Saturday Night Fever and Thank God I ts Friday made disco theque more popular than ever before.It was the Bee Gees who came to represent real Disco theque. The group till then was famous for their ballads and pop songs challenging the supremacy of The Beatles. Their success numbers were released again on the Saturday Night Fever movie soundtrack. Disco was born much earlier in the late 60’s when Jerry Butleras haunting melody was the first case of a combination of music with dance. This particular song brought about the marriage between Philly and New York soul both being evolutions of Motown Sound. The Philly sound is lavish percussion. 972 Soul Makasso is said to be one of the first disco songs. Disco spread to Europe through the jivings of Abba from the mid 70’s. Boney-M was another group of four West Indian singers and dancers who guided by West German record producer Frank Farian, soon became a great hit in Canada and Japan. The latter half of the 70’s saw clubs reverberating with Disco music. The culture centered on discotheques, nightclubs, and private parties where DJ’s played disco hits through power sound systems. Long single records kept people dancing throughout the night.Even some of the most prestigious clubs matched their lighting arrangements to swish to the beat of Disco theque. Dancing schools sprung up in some cities and candidates were taught how to touch dance hustle and cha-cha. Disco fashions then hit the market with Halston dresses for women, shiny Qiana shirts for men pointed collars and open at the chest worn with double knit jacket suits. Disco culture soon became a shelter for those on the fringes of society they found a way to express themselves. Disco managed to fulfill one of the objectives of the Civil Rights movement.It brought the races closer together for the first time where Blacks & Whites â€Å"co-mingled† freely. Although â€Å"disco's† did in fact lead to the downfall of the â€Å"inner city Funk House† a nd while a few of them practiced â€Å"racist door policies†. For the most part you could get in, dance and socialize across racial barriers. Disco was in fact one of the first forms of â€Å"voluntary integration† that American’s have seen. The music was the same & every ones attitude was the same. Different instruments and disco sounds made their way into the hearts of people in a big way.Discos became a place where there would be loud disco music, a dance floor with disco lights and of course you disco lovers dressed in the latest disco outfits having a blast of a life time. Discos have a culture of their own. The music is loud enough to make you and your heart beat a little faster. The lights keep changing colors and also help in changing you moods and shedding any inhibition you have. The clothes too are tight fitting to show off your more of the body. Shirts with slightly long and pointy collars, the Qiana shirts for the gents and the Halston dresses f or women were in fashion.Discos brought in many other cultures too. One of the main addictions that disco brought in was drugs. Cocaine and Quaalude became the main drugs for all disco lovers. While cocaine gave them a high spirit, it helped many to enjoy the loud music better. Quaalude made them feel light like jelly and helped them to move to the groove. The dance lovers enjoyed the discotheques, as there was music, dance, alcohol and fun. Discos became very popular and some of them became as popular as tourist sites too. Manhattans Studio 54 is one such place.You couldn’t miss this hangout, as you would see many celebrities and people who are both rich and famous there. In the 1970s and 80s disco and dance came together and were the craze of the time. Groups like The Jackson Five, ABBA and The BEE GEES are still bands which are famous for their great disco music. Disco, which was performed only by a few bands in the beginning spread like a forest fire. Soon disco became ma instream and all kinds of bands were performing disco numbers. Disco was the in thing and a lot of movies were made on the disco theme too.Saturday night fever starring John Travolta and Thank God It’s Friday were two big hits with disco as its mainstream idea. ABBA was a group, which took Disco beyond the borders of America and right into Europe and Asia. The songs were such big chart busters that all over the world they created many new records. Boney M a group of four West Indian singers were another group, which broke the barriers of caste, color and creed to give pure and outstanding disco music. Dalida released their hit number â€Å"J’attendrai† which topped the charts in Japan, middle and south Asia and Canada These groups made disco very popular in the 70’s.The growing craze for disco angered the fans of rock music. While some just threw out all disco records, a few took drastic steps. DJs of rock music held events like the Disco Demolition night . Many groups came together to stage anti-disco demonstrations. Slowly but steadily in the 1980s disco began to die down. Though disco kind of became obsolete but it was still very much a part of the night life in Europe. With newer forms of music and even newer groups emerging Disco was given a back seat. In 1990s and 2000 once again disco began gaining popularity again.With major singers like Madonna, Kate Ryan and Suzanne Palmer performing Disco. Disco sound is mainly based on strings and horns accompanied by reverberating vocals mixing with electric pianos and chicken-scratch guitars. Dramatic minor and major seventh chords dominate disco music. The other instruments in used are bass guitar, piano, string synth with electrocoustic keyboards. There are drum kits and electronic drums together with harp, violin, viola, trumpet, saxophone, trombone, clarinet, flugelhorn, French horn, tuba, English horn, oboe, flute and piccolo.The songs usually have a steady four-on-the floor beat. It has affinity with Dominican meringue, rumba, samba and cha-cha-cha rhythms. A synthesizer is sometimes used to replace the bass guitar. Disco branched off into regional styles during the mid70’s by many formal musicians. Keeping the same broad traits of disco the new types came to get an individual stamp of the singer and the orchestra. Notable among them were The Philadelphia Symphony Orchestra and New York Philharmonic. Disco thus came to be arranged and composed by experienced arrangers and orchestrators. It required large number of instruments and a eam, which included the conductor, copyists, record producers and mixing engineer. Disco songs used as many as 64 tracks of vocals and instrumentals. Mixing engineers thus had a very important role. They created a distinctive sounding known as disco-mix. DJ’s were important for popularizing disco and consequently its sales. I would say that disco music expresses itself by its fast beats that you dance to. Its music g ets people to be all about partying, loosing yourself to the songs, and feeling good. It lets people â€Å"groove† or â€Å"Boogie down†, just dance the night away.It’s the art of arranging sounds in time so as to produce a continuous, unified, and evocative composition, as through melody, harmony, rhythm, and timbre. To me disco music means, music that consists of several different instruments that make all sorts of rhythms and melodies. It’s a type of music that has a fast beat and just makes you want to dance. With disco music all you want to do is get down on a dance floor with a lot of people and just feeling good. Disco music is a good style of music that puts different sounds in one through the melody and rhythm of the song.

U.s. Nsa Program On Surveillance - 1789 Words

Over the last several years, cyber attacks have been continually rising. This is in response to emerging threats from rogue nations and terrorist groups. They are increasing their attacks on government, military and civilian installations. According to James Clapper (the Director of National Intelligence) these threats have become so severe. It is surpassing terrorism as the greatest challenge facing the nation. In response, the National Security Agency (NSA) began conducting surveillance on those who are involved in these activities and others which are threat to US national security interests. This program became so broad; it started continually collecting phone records and emails on ordinary Americans. This angered many, who felt that the US was acting in a way that circumvented established legal guidelines and procedures. To fully understand what is taking place requires focusing on the event, the government s response and the ways it did / did not meet our national security goal s. Together, these different elements will illustrate what occurred and the lasting impacts on everyone. (Greenwald 2014) The NSA program on surveillance began in 2001. This is when Congress authorized government officials to listen in on the phone calls and emails of those individuals suspected of engaging in terrorist activities (via the USA Patriot Act). It is designed to ensure that the intelligence community and law enforcement have the tools they need to track / monitor those suspectedShow MoreRelatedNational Security Agency Is Unconstitutional887 Words   |  4 PagesThe NSA is an unconstitutional Federal government agency established by a failed president. In 1952, the worst president in U.S. History, President Truman, established the National Security Agency (NSA). 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Saadat Hasan Manto, the Controversial Urdu Short Story Writer

PRESENTATION ON SAà DAT HASAN MANTO Of the several hundred stories, the court found only two stories in which he had transgressed the law and was liable for punishment. But his critics and the custodians of society declared Manto to be retrogressive and licentious. Even the so-called progressives betrayed him. At one strike they tarnished his entire writing career with the same dirty brush as the others... To call a writers work nothing on the basis of two stories is crass injustice. We cannot overlook the fact that Mantos masterpieces such as Toba Tek Singh, Mozel, Babu Gopinath have nothing to do with obscenity. (Jagdish Chander) 1948 to 1955 saw Manto writing most of his controversial stories. With the outcome that he†¦show more content†¦Rather they were repelled and attacked in the name of politics and religion. Manto seems to suggest the madness of the Partition and this is reflected in Toba Tek Singh as well. Perhaps even more disturbing is fact that the so-called ‘Razakars’ torment her. It is ironic as the word ‘Razakar’ is a Persian word meaning ‘a volunteer’. These were like social workers who had the reputation of ‘recovering women and children’- missing or abducted- from the other side of the border at their own risk. One realises then that there is no rational or â€Å"political explanation† of what has happened (Shashi Joshi). This also answers the question of success of Manto’s stories that have successfully shocked readers. As Alok Bhalla puts it, â€Å"What is scandalous about Manto’s partition stories is his radical erasure of all social, moral or religious reasons which normally inform civilizations. Manto’s primary argument is not only the Hobbesian one that when men are freed from responsibilities they become predators, but also that in a world which is as heartless and selfish as ours there is no reason for mercy and pity to create a safe ground for the frailty of goodness to survive.† How do we place this cynical world view of Mantos in perspective? Is it just cynical or is he doing more? Is he not reflecting what he has already seen and become aware of during the days of the