Effect of casting on forearm resistance vessels in young men

The aim of this study was to determine whether physical deconditioning, induced by 6 wk of forearm casting, and the conditioning effects of recovery from casting would elicit changes in the response of forearm resistance vessels to substances that modulate vascular resistance. Forearm blood flow (FBF) responses to intrabrachial infusion of NGmonomethyl-L-arginine (LNMMA) and norepinephrine (NE) were examined in six subjects recovering from Colles', scaphoid, or metacarpal fractures within 72 h of cast removal and again after a 6-wk recovery period. Vascular responses were also examined in six noncasted controls. The FBF responses of casted and control subjects did not differ, and no changes occurred over the 6-wk study period. These results suggest that the effect of forearm casting and recovery from casting do not greatly influence control of vascular tone, including the basal activity of the NO dilator system in vivo.

Analysis of Ki-ras, p53, and MDM2 genes in uterine leiomyomas and leiomyosarcomas

Uterine sarcomas are unusual neoplasms of the female genital tract whose molecular etiology is largely unknown. We examined 20 leiomyomas as well as 23 uterine leiomyosarcomas for the presence of mutations in the Ki-ras and p53 genes, and overexpression of the MDM2 gene. Codons 12, 13, and 61 from the Ki-ras gene were characterized for the presence of mutations by restriction enzyme polymorphisms using mismatched primers and nucleic acid sequencing as appropriate. Activated Ki-ras genes were identified in 3/20 leiomyomas and 0/23 leiomyosarcomas. The p53 gene was analyzed by SSCP, nucleic acid sequencing, and immunohistochemical staining. None of 20 leiomyomas and 6/23 leiomyosarcomas exhibited p53 abnormalities. The SSCP/sequencing results did not consistently correlate with the IHC staining. MDM2 overexpression occurred in 0/20 leiomyomas and 3/23 sarcomas. Clinical correlation suggested that tumors with p53 mutations have a higher histologic grade or stage at presentation. We conclude that leiomyomas and leiomyosarcomas have different patterns of molecular alterations and are separate biologic entities. In addition, p53 and MDM2 overexpression may play a role in the development of a subset of leiomyosarcomas.

Simvastatin, an HMG-coenzyme A reductase inhibitor, improves endothelial function within 1 month

BACKGROUND

Cholesterol-lowering therapy can improve cardiovascular morbidity and mortality in patients with atherosclerosis. Although the mechanisms responsible are unclear, these benefits precede macroscopic changes in the vasculature. Emerging evidence that improvement in endothelial function may occur requires substantiation; in particular, it is unclear how early any such improvement would be detectable after initiation of therapy.

METHODS AND RESULTS

This randomized, double-blind, placebo-controlled crossover study evaluated the effect of simvastatin (20 mg daily for 4 weeks) on endothelium-dependent and endothelium-independent vasodilation and on the response to the inhibitor of nitric oxide synthesis, NG-monomethyl-L-arginine (L-NMMA), in the forearm vasculature of subjects with moderate elevation of total serum cholesterol (6.0 to 10.0 mmol/L) by use of strain-gauge plethysmography. Studies were repeated after 3 more months of open therapy. When the results are expressed as percentage changes in flow in the infused arm relative to the noninfused arm, the vasodilator response to acetylcholine was significantly increased after 4 weeks of treatment with simvastatin (P < .0005), and this improvement was further enhanced after 3 months (P < .005). Concurrently, simvastatin augmented the vasoconstrictor response to L-NMMA, an effect that was maintained at 3 months (P < .0005). The response to the endothelium-independent vasodilator sodium nitroprusside was unaltered.

CONCLUSIONS

These observations indicate that within 1 month of treatment with simvastatin, both the stimulated and basal nitric oxide dilator functions of the endothelium are augmented, and the benefits of this HMG-coenzyme A reductase inhibitor persist with continued therapy.

Molecular characterization of adenocarcinoma of the cervix

In an attempt to characterize the molecular alterations of cervical adenocarcinoma, we analyzed 32 paraffin-embedded specimens for the presence of K-ras mutations, p53 overexpression, p16 and Rb protein expression, and the presence of HPV 16 and 18 DNA. Overall 25/32 (78%) of the tumors displayed an abnormality in at least one of these analyses. K-ras mutations were detected by PCR amplification and RFLP analysis in 3 tumors, including 2 at codon 12 and 1 at codon 61. p53 overexpression determined by immunohistochemistry was demonstrated with > 80% of tumor nuclei staining in 4 cases, 10-15% of nuclei staining in 3 cases, and < 1% of nuclei staining in 5 cases. The pattern of staining was diffuse in 6 cases, focal in 1 case, and scattered in 5 cases. Analysis of p16 protein expression in 23 specimens revealed 1 tumor with abnormal staining, while Rb protein expression was determined to be normal in all 25 tumors tested. HPV DNA, detected by PCR with type-specific primers, was found in 16 tumors (50%), including 7 (22%) with HPV 16 and 9 (28%) with HPV 18. There was no correlation among these abnormalities except that the presence of HPV and strong p53 overexpression (> 80% tumor nuclei staining) were mutually exclusive events. Clinical correlation demonstrated that p53 overexpression involving the majority of tumor cell nuclei is characteristic of advanced stage disease, while HPV positivity and activated ras genes are associated with early stage disease.

Methylenetetrahydrofolate reductase gene and coronary artery disease

BACKGROUND

Hypermocysteinemia has been substantiated as a risk factor for occlusive vascular disease. A common mutation (nucleotide 677 C-->T) has been described recently in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, which results in a valine for alanine substitution, a thermolabile enzyme, and a tendency to elevate plasma homocysteine levels and which has been proposed to contribute importantly to coronary artery disease.

METHODS AND RESULTS

To study the potential influence of the mutation on ischemic heart disease, we screened 555 whites with angiographically documented coronary artery disease and 143 unrelated control subjects without a history of angina or myocardial infarction randomly selected from the community. The patients were in two groups: group 1 comprised 358 prospectively recruited individuals younger than 50 years, and group 2, 197 patients investigated prospectively for restenosis 6 months after coronary angioplasty. The frequency of homozygosity for the mutation was 10.5% in control subjects, 10.6% in group 1, and 9.1% in group 2 patients. There was no relationship between MTHFR genotype and number of coronary vessels with > 50% diameter obstruction, prior myocardial infarction, or restenosis after coronary angioplasty. Plasma folate concentrations in control subjects (n = 90) and patients (n = 208) showed closely similar distributions.

CONCLUSIONS

Although it is accepted that moderate hyperhomocysteinemia significantly increases the risk for coronary, cerebrovascular, and peripheral vascular diseases, our data suggest that a mutation of the MTHFR gene, which has been associated with a thermolabile form of the enzyme and with hyperhomocysteinemia in subjects with plasma folate below the median, does not appear to be significantly associated with risk for premature coronary artery disease or for restenosis after coronary angioplasty.

Familial defective apolipoprotein B-100 (FDB): effect of simvastatin therapy on LDL-receptor binding

Heterozygotes for familial defective apolipoprotein B-100 (FDB) have two populations of low density lipoprotein (LDL), one bearing normal apolipoprotein B-100 (apo B) and the other bearing defective apo B which exhibits a much lower affinity for the LDL-receptor. If HMGCoA reductase inhibitors such as simvastatin lowered LDL mainly by up-regulating LDL-receptor mediated clearance, they should decrease the overall binding affinity of LDL from an FDB heterozygote by selectively decreasing LDL bearing normal apo B. We compared how LDL from FDB heterozygotes competed with normal 125I-labelled LDL for binding to LDL-receptors while on and off therapy with simvastatin. The LDL of FDB heterozygotes had 40% (n = 10) the affinity of normal LDL (n = 12) for the LDL receptor on cultured fibroblasts, and 55% (n = 6) of normal LDL (n = 6) for that on HepG2 cells. Treatment of FDB subjects with simvastatin (n = 10) decreased serum LDL by 22% but had no effect on its binding affinity for LDL receptors, indicative of lowering of LDL containing both normal and defective apo B. This is consistent with the major LDL lowering effect being associated with decreased synthesis of LDL, rather than enhanced LDL-receptor clearance.

Differential antibody recognition of FC27-like Plasmodium falciparum merozoite surface protein MSP2 antigens which lack 12 amino acid repeats

Three alleles of the FC27-type allelic family of the MSP2 gene of the malaria parasite Plasmodium falciparum have been sequenced from parasites from the field (The Gambia and Tanzania). These alleles lack the 12 amino acid repeat units which are usual in this family of MSP2 alleles. We have investigated the recognition by sera from an endemic area (The Gambia) of three recombinant MSP2 proteins that have 5, 1 and no copies of this repeat region. Antibody recognition of these recombinant proteins varied according to the number of repeats present. High titre antibody levels were seen with most sera using the recombinant protein with 5 x 12-mer repeats, whereas only low responses were measured using proteins containing 1 or no 12-mer repeats. Several sera entirely failed to recognise the protein which lacked 12-mer repeats. The data suggest that variation in the number of tandem repeat sequences could allow the parasite to avoid high avidity antibody binding and this may allow escape from immune recognition.

Diversity of energy-yielding substrates and metabolism in avian mycoplasmas

The metabolism of organic substrates and production of H2O2, a potential pathogenicity factor, were studied in the type strains of fourteen avian Mycoplasma species, and in low-passage isolates of M. gallinarum, M. gallisepticum, M. iners and M. pullorum. Substrates were added to cell suspensions in Ringer or saline solution and oxygen uptake and/or change in pH monitored. The fermentative species could be sub-divided according to whether O2 uptake did (M. anatis, M. columborale, M. gallisepticum, M. imitans and M. iowae) or did not (M. gallinaceum, M. gallopavonis and M. pullorum) accompany glucose metabolism and the five non-fermentative, arginine-hydrolysing strains according to whether organic acids (lactate, 2-oxobutyrate, pyruvate) were (M. columbinasale, M. columbinum and M. gallinarum) or were not (M. iners and M. meleagridis) oxidized, Lysed cells of strains which consumed O2 during glucose or organic acid metabolism had relatively high NADH oxidase activity (170-950 nmol min-1 mg cell protein-1) and produced 0.02-0.36 mol H2O2 per mol O2 consumed during NADH oxidation. In contrast, strains which did not oxidize organic acids or consume O2 during glucose or organic acid metabolism possessed low NADH oxidase activity (< or = 20 nmol min-1 mg cell protein-1). All arginine-hydrolysing species showed a high affinity (Km value 1-3 microM) towards arginine. The fermentative species similarly showed a high affinity (Km value 2-5 microM) towards glucose, but used only a small number of additional sugars at detectable rates. All M. pullorum strains metabolized sucrose (Km < or = 3 microM). The type-strains of M. gallisepticum and M. imitans were biochemically similar and had high affinities for fructose and mannose. A number of low-passage avain isolates, but none of the type strains, metabolized glycerol and, in lysed cells, oxidized L-alpha-glycerophosphate (GP) with the production of 1 mol H2O2 per mol GP.

Endothelium-derived nitric oxide activity in forearm vessels of tennis players

The aim of this study was to determine whether physical conditioning induced by a repetitive exercise stimulus would elicit changes in the response of forearm resistance vessels to an infusion of substances that modulate nitric oxide synthesis. Forearm blood flow responses to a 5-min ischemic stimulus and intrabrachial infusion of acetylcholine, sodium nitroprusside, and NG-monomethyl-L-arginine were examined in the preferred and nonpreferred limbs of eight habitual tennis players. Forearm volume, girth, and grip strength were significantly greater in the preferred limb, indicating a bilateral difference in physical condition. This was associated with an enhanced reactive hyperemic response in the preferred limb (53.5 +/- 9.4 vs. 38.8 +/- 4.7 ml.100 ml-1.min-1; P < 0.05). No differences between the limbs were evident in response to acetylcholine, sodium nitroprusside, or NG-monomethyl-L-arginine. These results suggest that exercise training enhances the peak vasodilator capacity of the vasculature without influencing basal or stimulated activity of the nitric oxide dilator system in vivo.

Selective recognition of malaria antigens by human serum antibodies is not genetically determined but demonstrates some features of clonal imprinting

Malaria infection induces the production of serum antibodies to a variety of malaria antigens but the prevalence of antibodies to any particular antigen is typically much less than 100%. It has been assumed that non-responsiveness to defined antigens in malaria immune subjects is due to HLS-mediated restriction of the immune response. In this study we have investigated the role of HLA and non-HLA genes in the antibody response to two merozoite surface antigens (MSP1 and MSP2) and a sexual stage antigen (Ps260/230) of Plasmodium falciparum, and conclude that host genotype is not a major determinant of responsiveness. Although antibody levels vary in accordance with seasonal variations in malaria transmission in semi-immune children, antibody levels remain stable in clinically immune adults. Antigen recognition is selective with individual donors showing consistent high titre responses to some antigens/epitopes whilst consistently failing to recognize adjacent regions/epitopes of the same protein. An alternative explanation, consistent with the data presented here, is that selective antibody responses to malaria antigens in immune individuals result from a process akin to clonal imprinting (original antigenic sin).

A national assessment of the service, support, and housing preferences by persons with chronic fatigue syndrome. Toward a comprehensive rehabilitation program

Persons with Chronic Fatigue Syndrome (PWCs) completed and returned by mail a brief survey of open- and closed-ended items designed to assess their utilization and preferences for a variety of services. A total of 984 middle-aged adults diagnosed with Chronic Fatique Syndrome (CFS) from across North America returned the survey. During the past 12 months, many of these PWCs reported utilization of a primary care physician, gynecologist, CFS specialist, and self-help group to assist in their recovery from CFS. Most PWCs believed it was important to educate both health-care practitioners and the general public about CFS. In terms of their desire for specific recovery needs, factor analysis of responses indicated that these PWCs preferred self-help/social support services and general advocacy services in the treatment of their illness. The implications of these results for developing rehabilitation programs for PWCs are discussed.

Control of skeletal muscle blood flow during dynamic exercise: contribution of endothelium-derived nitric oxide

Traditional explanations for the hyperaemia which accompanies exercise have invoked the 'metabolic theory' of vasodilation, whereby contractile activity in the active muscle gives rise to metabolic by-products which dilate vessels bathed in interstitial fluid. Whilst metabolites with vasodilator properties have been identified, this theory does not adequately explain the magnitude of hyperaemia observed in active skeletal muscle, principally because large increases in flow are dependent on dilation of 'feed' arteries which lie outside the tissue parenchyma and are not subjected to changes in the interstitial milieu. Coordinated resistance vessel dilation during exercise is therefore dependent on a signal which 'ascends' from the microvessels to the feed arteries located upstream. Recent studies of ascending vasodilation have concentrated on the possible contribution of the endothelium, a monolayer of flattened squamous cells which lie at the interface between the circulating blood and vascular wall. These cells are uniquely positioned to respond to changes in rheological and humoral conditions within the cardiovascular system, and to transduce these changes into vasoactive signals which regulate blood flow, vascular tone and arterial pressure. Endothelial cells produce nitric oxide (NO), a rapidly diffusing labile substance which relaxes adjacent vascular smooth muscle. NO is released basally and contributes to the regulation of vascular tone by acting as a functional antagonist to sympathetic neural constriction. In addition, NO is spontaneously released in response to deformation of the endothelial cell membrane, indicating that changes in pulsatile flow and wall shear stress are likely physiological stimuli. Since the dilation of microvessels in response to exercise increases blood flow through the upstream feed arteries, which subsequently dilate, one explanation for ascending vasodilation is that NO release is stimulated by flow-induced shear stress. Evidence that NO contributes to ascending vasodilation is reviewed, along with studies which indicate that NO mediates exercise hyperaemia, that physical conditioning upregulates NO production and that NO controls blood flow by modifying other physiological mechanisms.

Human antibody response to Plasmodium falciparum merozoite surface protein 2 is serogroup specific and predominantly of the immunoglobulin G3 subclass

MSP2 is a merozoite surface protein of Plasmodium falciparum and, as such, is a potential component of a malaria vaccine. In this study, we have used a panel of recombinant MSP2 antigens in enzyme-linked immunosorbent assays to investigate the recognition of MSP2 by antibodies from malaria-immune human serum. These recombinant antigens include full-length proteins of serogroups A and B and fragments representing the conserved, group-specific, or repeat regions of each serogroup. Ninety-five percent of the serum samples tested contained MSP2-specific antibodies: 81% of serum samples tested responded to serogroup A, and 86% responded to serogroup B. The antibody response is directed almost exclusively towards dimorphic and polymorphic regions of MSP2; the conserved regions are rarely recognized, and antibodies to serogroups A and B do not cross-react. Interestingly, the antibody response is predominately of the cytophilic and complement-fixing subclass immunoglobulin G3.

Angiotensin-converting enzyme and apolipoprotein E genotypes and restenosis after coronary angioplasty

BACKGROUND

An insertion/deletion (I/D) polymorphism in the gene for angiotensin-converting enzyme (ACE) has been associated with myocardial infarction and other cardiac pathology. There is evidence for a role of the renin-angiotensin system in cell growth and in the repair of damaged arterial walls, so the ACE gene was postulated to be a candidate gene affecting the important clinical problem of restenosis after percutaneous transluminal balloon coronary angioplasty (PTCA). Because restenosis is influenced by the apolipoprotein E (apoE) genotype, the possibility of a relation between ACE and apoE genotypes and restenosis was also sought.

METHODS AND RESULTS

Subjects (< 70 years of age) were prospectively followed and had coronary angiography 6 months after PTCA to determine the presence or absence of restenosis. Those who had angiography earlier and did not have restenosis (> or = 50% loss of gain at PTCA plus > or = 50% luminal diameter stenosis) also had angiography at 6 months. The whole group (n = 207) had a higher DD genotype frequency than did 136 population control subjects (38% versus 26%, P < .02); in PTCA patients, the frequency was the same in those with and without prior myocardial infarction. The distribution of ACE genotypes was not different in the 88 patients with and 119 patients without restenosis, while the epsilon 4/4 genotype was more frequent in those with restenosis (8 of 88 versus 3 of 118, P < .05). There was no effect of the ACE genotype in noncarriers of the epsilon 4 allele, but there was a significant effect in epsilon 4 carriers (P < .005). The combined D and epsilon 4 carrier state showed a 16-fold increase in the odds ratio for restenosis (P < .02). Multiple linear regression examining the loss of lumen as a continuous variable showed significant independent effects of the ACE and apoE genotypes.

CONCLUSIONS

Overall, the ACE genotype had no clear influence on restenosis, but there was an interaction between ACE and apoE genotypes. The combined carrier state for the D and apoE epsilon 4 alleles substantially increased restenosis. For loss of lumen as a continuous variable, there were significant effects of both ACE and apoE genotypes. While the observations may not affect current management, they no doubt have implications in pathophysiology.

Streptococcus pneumoniae pelvic inflammatory disease. A case report

BACKGROUND

Single-agent causes of pelvic inflammatory disease (PID) are uncommon. Streptococcus pneumoniae, as the suspected sole causative bacterium, has been reported since the 1800s. In the postantibiotic era, 46 cases have been reported, with a high mortality rate.

CASE

We report a case of S pneumoniae as a single bacterial etiology of PID. This single bacterial species was documented by separate cervicovaginal, culdocentesis and laparoscopic cultures.

CONCLUSION

It is unusual to identify an uncommon, single organism as the causative bacterial species in PID in an immunocompetent patient without evidence of a primary infectious pneumococcal source.

Abnormal expression of the retinoblastoma gene in ovarian neoplasms and correlation to p53 and K-ras mutations

We analyzed the expression of the retinoblastoma (Rb) gene in a group of ovarian neoplasms previously characterized for mutations in the p53 suppressor gene and the Ki-ras oncogene. Using immunohistochemical techniques, a total of 59 ovarian neoplasms spanning the histiologic spectrum from benign to malignant were examined for the expression of the Rb protein. All benign cystic adenomas and low malignant potential tumors exhibited normal expression of the Rb protein. Abnormalities in Rb protein staining were noted in 3 of 22 (14%) ovarian carcinomas. The staining patterns included tumors that were totally or focally negative for Rb protein. One tumor focally expressed Rb. This tumor demonstrated a direct juxtaposition of sections of Rb expressing and nonexpressing malignant epithelial cells. Two of the three tumors with abnormal Rb expression also had p53 mutations and staining on serial sections demonstrated that selected ovarian cancer cells possessed mutations in both oncogenes. These data suggest that the loss of Rb gene expression may play a role in the pathogenesis of a small number of invasive ovarian malignancies, but not in noninvasive ovarian neoplasms.

Late presentation of an alpha-fetoprotein secreting isolated large upper abdominal retroperitoneal Sertoli-Leydig cell tumor recurrence

The following case reports the surgical and adjuvant treatment of a solitary upper abdominal retroperitoneal recurrence of a poorly differentiated Sertoli-Leydig cell tumor (SLCT) which presented 4 years after the original diagnosis. The patient was treated with en bloc resection of the mass, which included her left kidney, adrenal gland, and distal pancreas. She received four courses of adjuvant chemotherapy and remains without evidence of malignancy. Both the primary and recurrent tumor secreted alpha-fetoprotein allowing serologic follow-up. The utility of serum alpha-fetoprotein in disease response to treatment and for surveillance of recurrence is also shown.

Neutrophil platelet-activating factor production and acetyltransferase activity in clinical acute myocardial infarction

1. Neutrophil function was studied in 10 males presenting with acute myocardial infarction (MI) within 6 h of onset and in 10 normal males. Neutrophil production of platelet-activating factor (PAF), determined by bioassay, that of leukotriene B4 by HPLC, and the activity of an enzyme involved in the synthesis of PAF, acetyltransferase (AT), were measured before and after stimulation with opsonized zymosan and calcium ionophore, A23187. 2. The neutrophil count was significantly raised at presentation in those with MI (8.2 +/- 0.8 vs 2.8 +/- 0.3 (s.e.m.) x 10(9) cells/L, P < 0.001; t-test, 18 d.f.). Production of PAF per neutrophil in response to both stimulants was greater than normal in those with MI (zymosan: 21 +/- 4 vs 12 +/- 1 ng/10(7) cells, P < 0.05; ionophore: 174 +/- 18 vs 113 +/- 11 ng/10(7) cells, P < 0.02) despite normal leukotriene B4 production and depressed AT activity. By 7 days, the neutrophil count had significantly fallen but it remained greater than normal as did PAF production. 3. Acute MI is associated with increased potential for production of PAF by neutrophils which may be important in the pathogenesis of MI.

The molecular genetics of gyn malignancies

Gynecologic malignancies, representing 13% of all cancers affecting women, have a major impact on women's health. Cervical, endometrial, and ovarian cancers comprise the majority of these tumors and contribute significant morbidity and mortality to the female population. While cervical and endometrial cancers can be detected early in their development, sadly, many patients present with advanced disease, as do the majority of patients with ovarian cancer. Unfortunately, advanced cases of these malignancies are usually lethal despite modern therapeutic modalities. In order to impact upon these grim statistics, gynecologic researchers have turned to molecular biology in an attempt to elucidate the etiology of these cancers. Recent research describing dominant oncogene and tumor suppressor gene mutations common to these malignancies is providing a basis for the molecular genesis of these cancers. This information should offer new avenues for the development of early detection and chemoprevention, as well as novel treatment strategies.

Modification of forearm resistance vessels by exercise training in young men

The aim of this study was to determine whether a 4-wk handgrip training program would elicit changes in endothelium-dependent and endothelium-independent vasodilatation in resistance vessels of the human forearm. Minimum vascular resistance after a 10-min ischemic stimulus, an index of peak vasodilator capacity, was also determined. Forearm blood flow response to the endothelium-dependent vasodilator methacholine chloride did not change over the 4-wk-intervention period either in the group undertaking training (n = 11) or in control subjects (n = 6). Similarly, the response to sodium nitroprusside was not influenced by the handgrip training program. Peak vasodilator capacity of the trained forearms significantly increased, whereas no change was evident in the untrained limbs. These results suggest that 4 wk of forearm exercise training enhances peak vasodilator capacity of the vasculature without influencing stimulated activity of the nitric oxide dilator system.

Apolipoprotein epsilon 4 homozygosity--a determinant of restenosis after coronary angioplasty

Conventional coronary risk factors have not consistently been found to be related to restenosis after coronary angioplasty. Apolipoprotein E (apo E) gene polymorphism and/or plasma apo(a) levels were determined in 195 subjects undergoing prospective follow up and angiographic study 6 months after elective balloon angioplasty of a previously untreated coronary obstruction. Restenosis (stenosis > or = 50% plus loss of > or = 50% of initial gain) had occurred in 59 of 150 subjects for whom E genotypes were available. The apo epsilon 4 allele frequency in those with restenosis was higher than those without (0.20 vs. 0.10, P < 0.01), attributable to an excess of epsilon 4 homozygotes in the restenosis group (5 of 59 vs. 1 of 91, P < 0.04). Restenosis was not related to plasma apo(a) and the apo epsilon 4 allele was not associated with elevated levels of apo(a) as has been reported elsewhere. No relationship was found between E genotype and serum lipid and lipoprotein levels; paradoxically, LDL cholesterol was significantly lower and HDL cholesterol higher in those with restenosis. In conclusion, homozygosity for apolipoprotein epsilon 4 appears to be an important determinant of restenosis after coronary angioplasty.

Unusual intramural gastric metastasis of recurrent epithelial ovarian carcinoma

Epithelial ovarian carcinoma regularly metastasizes to peritoneal surfaces throughout the abdomen and pelvis. Gastrointestinal involvement is usually limited to seromuscular involvement of the small and large bowel and its mesentery. Gastrointestinal invasion is most often superficial, mesentery is shortened, and intestinal lumens are narrowed. Transmural invasion is less common, as is gastrointestinal hemorrhage. We present a case of life-threatening intralumenal gastric hemorrhage from an intramural gastric metastasis of epithelial ovarian carcinoma effectively palliated with a gastric resection. Intralumenal gastric metastasis represents an unusual trophism of recurrent epithelial ovarian carcinoma. Surgical intervention for life-threatening hemorrhage, while not curative, may provide effective palliation in the otherwise fully functional patient and thereby reducing the need for medical attention and the anxiety assigned to recurrent gastrointestinal hemorrhage. Palliative maneuvers for gastric metastasis may require a multidisciplinary approach.