Correlation between quantitative severity of stress thallium-201 myocardial perfusion defect and severity of coronary stenosis

The correlation between the quantitative myocardial perfusion defect severity of stress 201Tl single-photon emission computed tomography and the severity of coronary stenosis was investigated in 28 patients with angina pectoris. Among the 28 patients, four had normal or nearly normal coronary angiograms, seven had one-vessel disease, six had two-vessel disease and 11 had three-vessel disease. Seven patients had prior myocardial infarctions and two had collateral flows to the diseased vessels. The quantitative 201Tl defect severity score was obtained by summing the standard deviations of each pixel in which the counts fell > 2.5 SD below the mean normal counts. The severity of coronary stenosis was expressed as the Gensini score. The quantitative 201Tl defect severity score correlated significantly with the Gensini score. In patients without prior myocardial infarction or collateral flow, a more significant correlation between the quantitative 201Tl defect severity score and the Gensini score was found. Quantitative analysis of stress 201Tl defect severity provides a useful, noninvasive assessment of the functional severity of coronary stenosis compared with coronary angiography.

Excessive myocardial contraction in vasovagal syncope demonstrated by echocardiography during head-up tilt test

The purpose of this study was to gain insight into the mechanism of vasovagal syncope and to test the efficacy of theophylline to prevent syncope. Twenty-six patients with vasovagal syncope underwent two-dimensional echocardiography and theophylline test during head-up tilt test. A standard parasternal short-axis view of echocardiography at the level of the papillary muscle was recorded to measure fraction shorting of the left ventricle, and left ventricular end-diastolic and end-systolic dimensions. Heart rate, blood pressure, and symptoms were recorded. There were three groups; Group 1: no syncope with and without isoproterenol (n = 5); Group 2: syncope only after the infusion of isoproterenol (n = 16); Group 3: syncope without isoproterenol (n = 5). Groups 2 and 3 proceeded to theophylline injection (250 mg). The study showed that the 80 degrees tilt induced an increase in heart rate of 6.6 +/- 4.0, 12.4 +/- 6.6, and 25.4 +/- 4.5 beats/min in Groups 1, 2, and 3, respectively (p < 0.05 in Groups 1 and 2, p < 0.05 in Groups 1 and 3). The addition of isoproterenol during posture change from supine to an 80 degrees tilt made the significant change of fractional shortening from 0.4 +/- 5% to 6 +/- 13% in Group 2 (p = 0.05), compared with no significant change in Group 1. There were no significant differences in left ventricular end-diastolic dimension and end-systolic dimension in each group between baseline and isoproterenol infusion during posture change. Vasovagal syncope was associated with vigorous myocardial contraction, rather than with contraction against an empty left ventricle. The acute loading of theophylline was not effective in preventing vasovagal syncope.

Cross-cultural research on euthanasia and abortion

Based on cross-cultural studies of euthanasia and abortion, we hypothesized that attitudes toward euthanasia and abortion were socioculturally determined. Using a 2 x 2 factorial design, we examined the effects of culture (America and China) and type of death (infanticide and geronticide). We found that students from the American culture were less likely to favor infanticide than those from the Chinese culture, and that students from the People's Republic of China believed infanticide to be more common and more prevalent than geronticide in Chinese society. Finally, we found that education, judgment of population density, and traditional family values were related to attitudes toward euthanasia, abortion, and female infanticide in the Chinese, but not in the American, culture.

Infected left atrial myxoma caused by Gemella morbillorum

Gemella morbillorum was isolated from the blood of a 38-year-old woman with a 4-week history of fever. An echocardiogram showed a left atrial tumor. The patient was successfully treated by antibiotic therapy and early surgical excision of the tumor. Histological examination of the excised tumor revealed a typical myxoma with infiltrates of neutrophils and remnants of bacteria. To the best of our knowledge, this is the first reported case of infected left atrial myxoma caused by G. morbillorum.

Prospective randomised study of effect of octreotide on rebleeding from oesophageal varices after endoscopic ligation

Up to a third of patients have early rebleeding from oesophageal varices after endoscopic variceal ligation. Octreotide infusion is effective for control of variceal bleeding. We investigated the efficacy of octreotide infusion as an adjunct to endoscopic variceal ligation to prevent early rebleeding from varices. 100 consecutive patients admitted with endoscopically confirmed oesophageal varices and active bleeding or signs of recent haemorrhage were randomly assigned endoscopic variceal ligation alone or octreotide (50 micrograms intravenous bolus injection followed by intravenous infusion at 50 micrograms per h for 5 days) plus endoscopic variceal ligation. Three patients in each group were excluded. Bleeding was controlled in 44 of 47 patients who received variceal ligation alone and in 45 of 47 who received combined treatment (p = 1.0). Recurrent bleeding was documented in 18 (38% [24-52]) patients who received variceal ligation alone and in four (9% [3-21] who received combined treatment (p = 0.0007). The relative risk of rebleeding was lower (0.22 [0.08-0.60]) in the combined therapy group. Ten patients in the variceal ligation group and one in the combined therapy group required balloon tamponade for massive haematesis and haemodynamic instability (p = 0.0039). The in-hospital and 30-day mortality rates were higher in the variceal ligation group than in the combined therapy group (19 vs 9% and 23 vs 11%), but the differences did not reach significance. The relative risks of in-hospital (0.5 [0.04=5.3]) and 30-day (0.45 [0.17-1.2]) mortality were lower in the combined therapy group. Octreotide significantly reduces recurrent bleeding and the need for balloon tamponade in patients with variceal haemorrhage treated by endoscopic variceal ligation.

Local and regional recurrence of carcinoma of the colon and rectum: I. Tumour-host factors and adjuvant therapy

A review of 13 studies (published from 1976 to 1991) shows that the mean loco-regional recurrence rate after resection of colorectal carcinoma is 17%, and nearly one-third of these had only a loco-regional relapse. Approximately half of the pelvic recurrences of rectal cancer appeared within 1 year, and half of the colonic loco-regional recurrences within 2 years. Among 5336 patients studied, there was a progressively higher loco-regional recurrence rate with increased pathological stages: the medians were 2%, 7%, 19%, 21% and 32%, respectively, for Dukes A, B1, B2, C1 and C2 lesions. Other significant prognostic factors include the age of the patient, site of the primary tumour, mucinous subtype, degree of differentiation and vascular or lymphatic invasion. For resected rectal cancers, adjuvant radiotherapy has decreased loco-regional recurrence by 20-30%, especially when it is given preoperatively and/or with added systemic chemotherapy. These quantitative loco-regional recurrence data were collected before systemic adjuvant chemotherapy and radiotherapy were popularized, and before laparoscopic minimal invasive surgery was widely practiced. Thus, they are a useful baseline of information to study the changes in rates and types of relapse in the future.

Severe aplastic anemia induced by ticlopidine: report of a case

Ticlopidine is a powerful antiplatelet activator that inhibits adenosine diphosphate (ADP)-induced platelet aggregation. Its most common side-effects are skin rashes, diarrhea and neutropenia. Aplastic anemia is rare. This paper reports a patient with severe aplastic anemia that developed after the use of ticlopidine. The 85-year-old woman developed fever, chills and chest pain 5 weeks after starting ticlopidine 250 mg twice daily. Severe aplastic anemia was proved by blood examination, bone marrow aspiration and biopsy. In spite of the recovery of absolute neutrophil count to more than 1,000/mm3, 16 days after ticlopidine was stopped and administration of strong antibiotics, the patient died from candidal sepsis.

Effects of fish oil supplementation on atherosclerosis in different regions of the aorta of rabbits with diet-induced hypercholesterolaemia

1. The effects of fish oil supplementation on atherosclerosis in different regions of the aorta in rabbits with diet-induced hypercholesterolaemia were studied. Control and experimental rabbits were fed a 1% cholesterol-enriched diet with or without 10% fish oil supplementation (seven in each group), and were killed after 2 weeks of feeding. The ascending, descending and abdominal aortas as well as the pulmonary artery were harvested for analyses of prostanoid production, malondialdehyde, superoxide dismutase activity and cholesterol levels. The tissues from the other seven rabbits of each group were obtained after 6 weeks of feeding for the identification of atherosclerotic lesions by a Sudan IV stain. 2. The cholesterol-fed rabbits had a significantly higher thromboxane B2 production, a lower 6-keto-prostaglandin1 alpha/thromboxane B2 ratio and a higher malondialdehyde level than the other two groups in the ascending and abdominal aortas as well as the pulmonary artery; this finding paralleled the severity of atherosclerotic lesions. These manifestations were most prominent in the ascending aorta. The fish oil-supplemented rabbits had the most beneficial aortic prostanoid production, attenuated lipid peroxidation and significantly suppressed atherosclerosis. 3. These results suggest that a high-cholesterol diet induces more atherosclerotic lesions, especially on the ascending aorta, in rabbits. A fish oil supplement favours prostanoid production and attenuates lipid peroxidation on all four regions of the great arteries, thus suppressing atherosclerosis in diet-induced hypercholesterolaemic rabbits.

Flow pattern of four pulmonary veins in a case with prolapsing left atrial myxoma. A case report

The authors report the flow pattern of the four pulmonary veins in a case with prolapsing left atrial myxoma. The early systolic flow was reversed, midsystolic forward flow was diminished, and diastolic forward flow was augmented and decelerated rapidly in all four pulmonary veins. This phenomenon is attributed to the dynamic movement of the myxoma.

Migration of a fractured retention wire in the pulmonary artery from an active fixation atrial lead

A fragment of fractured retention wire of an atrial J lead (Accufix) was found in the pulmonary artery in an asymptomatic patient by routine chest X ray, fluoroscopy, and pulmonary angiography. The lead itself looked normal in these imaging studies. Results after successful surgical removal was reported.

Monitoring of two hearts in one chest

A 32 year old patient with end-stage cardiomyopathy underwent heterotopic heart transplantation with a small donor heart. Monitoring of this unusual clinical setting of two hearts beating independently in one chest required special technique and scrutinous interpretation so one can differentiate donor heart from recipient heart immediately.

Anomalous origin of left circumflex artery in a scimitar syndrome. A case report

This report concerns a twenty-seven-year-old woman with scimitar syndrome of abnormal origin of the left circumflex artery from the pulmonary artery. Operation was performed to redirect the abnormal venous return to the left atrium and abnormal origin of the left circumflex artery to the aorta. Unfortunately, pulmonary hypertension with hemoptysis occurred nineteen months after the operation. A second angiogram showed total occlusion of the graft to the left circumflex artery and impaired left ventricle function, rather than thrombosis of the anastomosis to the scimitar vein, as the cause of pulmonary hypertension.

Dobutamine stress echocardiography predicts early wall motion improvement after elective percutaneous transluminal coronary angioplasty

In 24 patients with chronic coronary artery disease, dobutamine stress echocardiography (DSE) was performed within 2 days before and after successful elective percutaneous transluminal coronary angioplasty (PTCA) in a blinded fashion. Patients with ischemic response on DSE before PTCA had significant improvement in the global peak-dose DSE score index after PTCA (1.62 +/- 0.35 to 1.40 +/- 0.29, p < 0.001), whereas patients without ischemic response had no improvement. The positive and negative predictive values of pre-PTCA DSE on early myocardial ischemia relief after angioplasty were 93% and 80%, respectively. In patients showing contractility recruitment during low-dose dobutamine infusion in the DSE before PTCA, there was significant improvement in the global resting wall motion score index in the DSE after PTCA (1.48 +/- 0.43 to 1.34 +/- 0.33, p = 0.004), while patients without contractility recruitment showed no improvement. Again, the positive and negative predictive values of pre-PTCA DSE on early hibernation recovery following angioplasty were 80% and 89%, respectively. In conclusion, DSE in patients with chronic, stable coronary artery disease accurately predicts wall motion improvement after successful angioplasty, and the expected improvement is safely demonstrated early after the procedure.

Torsade de pointes and T-wave alternans in a patient with brainstem hemorrhage

Torsade de pointes, a form of life-threatening ventricular arrhythmia associated with QT prolongation, is rarely reported in intracranial hemorrhage. T-wave alternans is recently considered a risk marker for ventricular arrhythmias. To our knowledge, we report the first case of brainstem hemorrhage in which the patient presented with torsade de pointes and T-wave alternans. The implication of this association is discussed.

Analysis of nm23 expression as a prognostic parameter in renal cell carcinoma

To identify the clinicopathological events including nm23 expression that underlies progression in renal cell carcinoma, a retrospective analysis of patients with renal cell carcinoma was performed. Ninety-eight cases of radical nephrectomies with extensive regional or para-aortic lymph node dissection were assessed for clinicopathological variables, and eighty-five cases underwent nm23/NDPK-A protein immunohistochemical staining. Significant parameters in survival were tumor size, histologic pattern, Fuhrman's nuclear grade, pathologic T(pT) stage, pathologic N stage, M stage, tumor thrombi, location of metastasis, and nm23 staining intensity. To assess the relationship with survival, the tumors with low and high nm23 expressions were compared. The fifty-nine patients with a high staining intensity had a significantly worse survival than did the twenty-six with a low staining intensity (p = 0.0015). Additionally nm23 staining intensity was correlated with tumor size, Fuhrman's nuclear grade, pT, and distant metastasis. Therefore, the immunostaining intensity of nm23 protein could be used as a prognostic parameter with an inverse correlation.

Dynamics of Carbonium Ions Solvated by Molecular Hydrogen: CH 5 + (H 2 ) n ( n = 1, 2, 3)

The dynamics of the carbonium ion (CH(5)(+)), a highly reactive intermediate with no equilibrium structure, was studied by measuring the infrared spectra for internally cold CH(5)(+)(H(2))n(n = 1, 2, 3) stored in an ion trap. First-principle molecular dynamics methods were used to directly simulate the internal motion for these ionic complexes. The combined experimental and theoretical efforts substantiated the anticipated scrambling motion in the CH(5)(+) core and revealed the effect of the solvent molecular hydrogen in slowing down the scrambling. The results indicate the feasibility of using solvent molecules to stabilize the floppy CH(5)(+) ion in order to make it amenable to spectroscopic study.

A double-blind comparison of once-daily metoprolol controlled-release and atenolol in the treatment of Chinese patients with mild to moderate hypertension

The efficacy and tolerability of controlled-release metoprolol (metoprolol CR/ZOK), 100-200 mg, and atenolol, 50-100 mg, once daily was compared in Chinese patients with mild to moderate essential hypertension. The study was of a randomized, double-blind, two-way crossover design. The active treatment periods lasted 4 weeks each and were preceded by a 4-week placebo run-in period. The two double-blind phases were separated by a 2-week washout period on placebo. Blood pressures and heart rates were measured at rest in each 2-week visit and during exercise at the end of each treatment period. Twenty-four patients (M/F = 14/10) were valid for efficacy analysis. Their ages ranged from 39 to 68, with a mean of 53.5 years. The rest supine blood pressure and heart rate before active treatment was 160 +/- 15/106 +/- 6 mmHg and 75 +/- 14 beats/min (mean +/- SD), respectively. A responder was defined as exhibiting a supine diastolic blood pressure < or = 90 mmHg or a supine diastolic blood pressure reduction of at least 10% of the baseline level. Both agents had high response rate: 88% and 92% of all patients responded to metoprolol CR/ZOK and atenolol, respectively. Both active treatments considerably reduced resting systolic and diastolic blood pressures and heart rates as compared with baseline (p < 0.001), respectively. With controlled-release metoprolol, a more pronounced beta 1 blockade was obtained than with atenolol, which was expressed as a significant reduction in exercise-induced heart rate at the highest comparable workload compared with placebo (p < 0.05). These findings are compatible with those reported from western populations.

The effect of hypercholesterolemia on the sodium inward currents in cardiac myocyte

To determine whether chronic hypercholesterolemia affects sodium inward currents in cardiac myocytes, whole-cell clamp recordings were made in single cardiac myocytes isolated from normo- and hypercholesterolemic rabbits. Modification of the serum cholesterol was accomplished by feeding ten 3-month-old male New Zealand white rabbits with control diet (group I) and ten with 0.5% cholesterol-enriched diet (group II), for 3 months. The serum cholesterol levels of group II were much higher than those of group I (2042 +/- 231 v 82 +/- 9 mg/dl, P < 0.001). The cholesterol-ester and free cholesterol component of cardiac sarcolemma of group II were also significantly higher than those of group I (26.6 +/- 12.4 v 10.8 +/- 4.5 nmole/dl, P < 0.001, and 50.9 +/- 14.8 v 27.5 +/- 6.2 nmole/dl, P < 0.001, respectively). The cell capacitance of hyperlipidemic myocytes seemed larger than that of normolipidemic ones (157.4 +/- 6.4 pF v 103.6 +/- 3.0 pF, P < 0.05). However, the sodium current density on hypercholesterolemic ventricular sarcolemma was significantly lower than that of normolipidemic sarcolemma. This effect was associated with a leftward shift in the inactivation potential and a slowing of the time course of recovery. In conclusion, hypercholesterolemia has important effects on the sodium inward currents in ventricular myocytes, which may be due to a decrease in current density and an alteration in channel functional state.

Fish oil supplementation attenuates myointimal proliferation of the abdominal aorta after balloon injury in diet-induced hypercholesterolemic rabbits

The effects of supplementing with fish oil on the myointimal proliferation of the abdominal aorta after balloon injury were studied in control and in rabbits fed a 1% cholesterol-enriched diet, with and without 10% fish oil supplementation. Twenty-one animals in each group underwent a balloon injury of the abdominal aorta and left common iliac artery after 2 weeks of feeding. The animals remained on their respective diets thereafter. In 7 balloon-injured and 7 sham-operated animals of each group, the abdominal aorta was harvested 3 days later for the analysis of prostanoids, malondialdehyde, superoxide dismutase activity, [3H]thymidine uptake, and cholesterol levels. In the other 7 balloon-injured rabbits of each group, the tissue was harvested 3 weeks later for morphometric study. The fish oil-treated rabbits had the lowest aortic production of thromboxane B2 levels and the highest 6-keto-PGF1 alpha/thromboxane B2 ratios among the three groups after balloon injury. The aortic malondialdehyde levels of the cholesterol-fed rabbits were significantly higher than the other two groups (each P < 0.001) independent of balloon injury. The myointimal proliferation of the abdominal aorta and left common iliac artery in the fish oil-treated rabbits was less severe than in the cholesterol-fed animals (both P < 0.001) and was comparable with the controls. These results suggest that a fish oil supplement changes prostanoid metabolism to a favorable pattern and reduces lipid peroxidation on the abdominal aortic wall, thus attenuating myointimal proliferation after balloon injury in diet-induced hypercholesterolemic rabbits.

Dobutamine stress echocardiography compared with dipyridamole thallium-201 single-photon emission computed tomography in detecting coronary artery disease

To compare the diagnostic value of dobutamine stress echocardiography with dipyridamole thallium-201 single-photon emission computed tomography (SPECT) in detecting coronary artery disease (CAD), we performed both tests on 54 patients who also underwent coronary arteriography. Dobutamine was infused at an incremental regimen of 5, 10, 20, 30 and 40 micrograms.kg-1.min-1. Dipyridamole was infused at a rate of 0.14 mg.kg-1.min-1 over 4 min. Dobutamine stress echocardiography detected 40 (93%) and SPECT 42 (98%, P = ns) of the 43 patients with significant CAD, defined as > or = 50% diameter stenosis. The specificity was 73% (8 of 11) for both tests. The sensitivity for detecting individual coronary artery stenosis with dobutamine stress echocardiography was 81% (30 of 37) for the left anterior descending artery, 75% (24 of 32) for the right coronary artery, and 61% (17 of 28) for the left circumflex artery. For SPECT it was 89%, 97% (P < 0.05 vs dobutamine stress echocardiography) and 75%, respectively. Among the 97 stenotic coronary arteries, 17 had mild to moderate stenosis (50%-69% diameter stenosis) and 80 had severe stenosis (> or = 70% diameter stenosis). With dobutamine stress echocardiography, 53% of the arteries with mild to moderate stenosis were identified vs 78% of those with severe stenosis (P < 0.05). With SPECT, the sensitivity was 82% (14 of 17) in mild to moderate stenosis and 89% (71 of 80) in severe stenosis (P = ns). No major side effects occurred during either test. Thus, both dobutamine stress and SPECT are highly sensitive for detection and localization of CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

The interaction of fluvastatin and cyclosporin A in renal transplant patients

A possible interaction between fluvastatin, a new HMG CoA reductase inhibitor, and cyclosporin A (CsA) was studied in 16 stable renal transplant patients with dyslipoproteinemia despite dietary control. They entered a 12-week study period: 4-week baseline, 4-week placebo and 4-week fluvastatin treatment (20 mg daily). Weekly trough whole blood CsA concentrations were measured by monoclonal antibody immunoassay. Serial renal and liver function tests and creatine phosphokinase (CPK) were monitored. The mean trough levels of CsA during fluvastatin treatment were 115.6 micrograms/l compared with 114.3 micrograms/l and 113.3 micrograms/l in the baseline and placebo period, respectively. Apart from a small decrease in serum albumin level (from a mean of 38.6 g/l to 37.9 g/l), there were no significant changes in renal and liver functions or CPK levels. No adverse effects were reported. Fluvastatin (20 mg daily) may be used safely without extra monitoring of blood CsA concentrations in renal transplant patients.

Hypovolemic shock and mortality after ingestion of Tripterygium wilfordii hook F.: a case report

Tripterygium wilfordii Hook F (TWHF) is a kind of Chinese herbal medicine used for 2000 years. It was applied externally for treatment of arthritis and inflammatory tissue swelling in early years. Recently, this drug has been found to have immunosuppressive effects which could successfully induce remission of some autoimmune disorders without obvious adverse effects. Although there are side effects of gastrointestinal upset, infertility and suppression of lymphocyte proliferation, little information about lethal toxicities has been reported. A case is presented here of a previously healthy young man who developed profuse vomiting and diarrhea, leukopenia, renal failure, profound hypotension and shock after ingestion of an extract of TWHF. In addition to his hypovolemic shock, serial electrocardiograms (ECG), cardiac enzyme studies, and echocardiography also showed some evidence of coexisting cardiac damage. He died of intractable shock 3 days after the abuse of TWHF. Further studies of the pathogenesis of peripheral collapse and possible cardiac toxicity, and determination of the therapeutic range of this drug are necessary before it is used extensively.

Early change of vascular permeability in hypercholesterolemic rabbits

To study the effect of hyperlipidemia on vascular permeability, serial anterior chamber fluorophotometric examinations were carried out on 33 control rabbits (group 1) and 32 diet-induced hypercholesterolemic (group 2) rabbits. Changes in the blood-aqueous barrier function associated with total serum cholesterol (CHO) and triglyceride (TG) levels were studied at the beginning of the study and every 2 weeks thereafter for up to 16 weeks following 0.5% cholesterol-enriched diet feeding. Concurrently, a slit-lamp biomicroscope was used to examine the iris for evidence of atheromatous plaque. In group 1, the CHO level decreased slightly during the first 6 weeks and remained rather steady thereafter. The status of the blood-aqueous barrier correlated significantly with serum CHO and TG levels (r = .46, P < .001; r = .23, P = .01, respectively). In group 2, CHO and TG levels increased significantly after 2 and 8 weeks of cholesterol-enriched diet feeding, respectively. The blood-aqueous barrier also became more permeable than that in group 1 after 2 weeks' and increased above its baseline level after 6 weeks' feeding. Both CHO and TG levels correlated well with the degree of blood-aqueous barrier breakdown (r = .51, P < .001; r = .25, P < .001, respectively). The first evidence of iridic lipid-streak deposition was noted at 7.6 +/- 0.7 weeks, while definite iridic atheromatous plaque appeared 11.2 +/- 0.7 weeks after feeding. The change in the blood-aqueous barrier also correlated well with the semiquantitative score of iridic plaque (r = .58, P < .001) and usually preceded visual evidence of plaque formation.(ABSTRACT TRUNCATED AT 250 WORDS)