Successful rotational atherectomy and stenting in a situs inversus patient

We describe a case of successful high-speed rotational atherectomy and stenting of a long calcified lesion in a patient with dextrocardia and situs inversus.

Coronary artery disease obscuring giant cell myocarditis--a case report

A case in which the diagnosis of idiopathic giant cell myocarditis was obscured by the presence of severe coronary artery disease is described. A 47-year-old man presented with recurrent inferior myocardial infarction and complete heart block. Cardiac catheterization confirmed severe 2-vessel disease and left ventricular dysfunction. Incessant ventricular arrhythmia rapidly ensued, which did not respond to anti-arrhythmic therapy and overdrive pacing despite complete surgical revascularization. He eventually died. Autopsy revealed giant cell myocarditis superimposed on coronary artery disease. Acute myocarditis masquerading as myocardial infarction has been well known, but virtually all reported cases had normal coronary arteries. This case illustrated the fact that even in the presence of obvious coronary artery disease the remote possibility of myocarditis should not be entirely disregarded. Although giant cell myocarditis is a rare and frequently fatal disorder, recent studies suggest that combined immunosuppressive therapy may improve the prognosis.

Internal cardioversion of chronic atrial fibrillation during percutaneous mitral commissurotomy: insight into reversal of chronic stretch-induced atrial remodeling

BACKGROUND

Mechanoelectrical feedback caused by atrial dilatation plays an important role in atrial fibrillation (AF). To test the hypothesis that remodeling is reversible by reducing atrial stretch, we investigated electrophysiological changes after a reduction of left atrial (LA) pressure in patients undergoing percutaneous balloon mitral commissurotomy (PBMC).

METHODS AND RESULTS

In 22 patients with chronic AF who were undergoing PBMC for mitral stenosis, internal cardioversion was successful in 19 patients (86%). Twelve patients with sinus rhythm acted as controls. Mean LA pressure was significantly reduced after PBMC (18.5+/-5.9 mm Hg versus 10.2+/-4.1 mm Hg; P<0.001). The effective refractory period (ERP), conduction delay (CD), and the index of heterogeneity (CoV) of the ERP and CD were compared. Changes in LA pressure were only significantly correlated with AF vulnerability (r=0.7; P=0.02) and CoV of CD (r=0.3; P=0.03). There were no significant changes in ERP and CD immediately after PBMC in the AF group. However, the overall CoV of ERP was reduced in the AF group after PBMC. There were homogenous, although not significant, increases in regional ERP in the control group immediately after PBMC. Atrial CD and CoV of CD were significantly reduced after PBMC in the control group; this was most prominent within the regions of the LA.

CONCLUSIONS

AF vulnerability and CoV of CD correlated significantly with LA pressure. A homogenous increase in regional ERPs could be demonstrated in the control group after an immediate reduction of atrial stretch, whereas the recovery course of electrical remodeling was prolonged and heterogenous in the AF group. Regional conductions were irreversible in patients with preexisting AF.

Risk of adenocarcinomas of the esophagus and gastric cardia in patients with gastroesophageal reflux diseases and after antireflux surgery

BACKGROUND & AIMS

Gastroesophageal reflux has been proposed as an important risk factor for esophageal and gastric cardia adenocarcinoma, but prospective data are lacking. Furthermore, the effect of antireflux surgery has not yet been studied. We conducted a population-based retrospective cohort study to fill these gaps.

METHODS

A cohort of 35,274 male and 31,691 female patients with a discharge diagnosis of gastroesophageal reflux diseases, and another cohort of 6406 male and 4671 female patients who underwent antireflux surgery, were identified in the Swedish Inpatient Register. Follow-up was attained through record linkage with several nationwide registers. Standardized incidence ratio (SIR) was used to estimate relative risk of upper gastrointestinal cancers, using the general Swedish population as reference.

RESULTS

After exclusion of the first year follow-up, 37 esophageal and 36 gastric cardia adenocarcinomas were observed among male patients who did not have surgery (SIR, 6.3, 95% confidence interval [CI], 4.5-8.7; SIR, 2.4, 95% CI, 1.7-3.3, respectively). SIR for esophageal adenocarcinoma increased with follow-up time (P = 0.03 for trend). Among male patients who had undergone antireflux surgeries, risks were also elevated (16 esophageal adenocarcinoma, SIR, 14.1, 95% CI, 8.0-22.8; 15 gastric cardia adenocarcinomas, SIR, 5.3, 95% CI, 3.0-8.7) and remained elevated with time after surgery. The cancer risk pattern in women was similar to that for men, but the number of cases were much smaller.

CONCLUSIONS

Gastroesophageal reflux is strongly associated with the risk of esophageal adenocarcinoma, and to a lesser extent, with gastric cardia adenocarcinoma. The risk of developing adenocarcinomas of the esophagus and gastric cardia remains increased after antireflux surgery.

Risk of adenocarcinomas of the oesophagus and gastric cardia in patients hospitalized for asthma

In the first cohort study of the question we followed 92 986 (42 663 men and 50 323 women) adult patients hospitalized for asthma in Sweden from 1965 to 1994 for an average of 8.5 years to evaluate their risk of oesophageal and gastric cardia adenocarcinoma. Standardized incidence ratio (SIR) adjusted for gender, age and calendar year was used to estimate relative risk, using the Swedish nationwide cancer incidence rates as reference. Asthmatic patients overall had a moderately elevated risk for oesophageal adenocarcinoma (SIR = 1.5, 95% confidence interval CI, 0.9-2.5) and gastric cardia cancer (SIR = 1.4, 95% CI, 1.0-1.9). However, the excess risks were largely confined to asthmatic patients who also had a discharge record of gastro-oesophageal reflux (SIR = 7.5, 95% CI, 1.6-22.0 and SIR = 7.1, 95% CI, 3.1-14.0, respectively). No significant excess risk for oesophageal squamous-cell carcinoma or distal stomach cancer was observed. In conclusion, asthma is associated with a moderately elevated risk of developing oesophageal or gastric cardia adenocarcinoma. Special clinical vigilance vis-à-vis gastro-esophageal cancers seems unwarranted in asthmatic patients, but may be appropriate in those with clinically manifest gastro-oesophageal reflux.

Glutathione S-transferase genotypes and stomach cancer in a population-based case-control study in Warsaw, Poland

Glutathione S-transferases are important in the detoxification of a wide range of human carcinogens. Previous studies have shown inconsistent associations between the GSTT1 and GSTM1 null genotypes and stomach cancer risk. We investigated the relationship between these and related genotypes and stomach cancer risk in a population-based case-control study in Warsaw, Poland, where stomach cancer incidence and mortality rates are among the highest in Europe. DNA from blood samples was available for 304 stomach cancer patients and 427 control subjects. We observed a 1.48-fold increased risk for stomach cancer (95% confidence interval 0.97-2.25) in patients with the GSTT1 null genotype but no evidence of increased risk associated with the GSTM1, GSTM3 or GSTP1 genotypes. Furthermore, the stomach cancer risk associated with the GSTT1 null genotype varied by age at diagnosis, with odds ratios of 3.85, 1.91, 1.78 and 0.59 for those diagnosed at ages less than 50, 50-59, 60-69 and 70 years or older, respectively (P trend = 0.01). This was due to a shift in the GSTT1 genotype distribution across age groups among stomach cancer patients only. These results suggest that the GSTT1 null genotype may be associated with increased risk of stomach cancer.

Genetic polymorphism in exon 4 of cytochrome P450 CYP2C9 may be associated with warfarin sensitivity in Chinese patients

CYP2C9 polymorphisms reported in Caucasians (Arg144Cys in exon 3 and Ile359Leu in exon 7) are extremely uncommon in Chinese persons. The genotype of CYP2C9 in this population was characterized to investigate its relation with the interindividual variation in warfarin dosages. Eighty-nine Chinese patients receiving warfarin were recruited. Target sequences in CYP2C9 in exons 1, 4, and 5 were amplified by polymerase chain reaction, followed by direct sequencing. Polymorphisms at 4 positions were demonstrated in exon 4. Heterozygosities for 608TTG>GTG (Leu208Val), 561CAG>CCG (Gln192Pro), 537CAT>CCT (His184Pro), and 527ATT>CTT (Ile181Leu) existed at frequencies 0.75, 0.20, 0.10, and 0.09, respectively. Seventeen patients (frequency, 0.19) were homozygous for Val208. The common genotypic combinations at these loci are Ile181/His184/Gln192/Leu208Val (n = 50), Ile181/His184/Gln192/Val208 (n = 15), Ile181/His184/Gln192/Leu208 (n = 4), Ile181/His184/Gln192Pro/Leu208Val (n = 6), Ile181/His184Pro/Gln192Pro/Leu208Val (n = 4), and Ile181Leu/His184/Gln192Pro/ Leu208Val (n = 4). At codon 208, heterozygous Leu208Val and homozygous Val208 appeared to have a lower warfarin dose requirement than the homozygous Leu208. Patients who are heterozygous for Ile181Leu had a higher warfarin dose requirement than the homozygous Ile181. Amplified sequences in exons 1 and 5 did not exhibit polymorphism. In conclusion, Chinese patients showed genetic polymorphisms of CYP2C9 in exon 4 and at codon 208; most were heterozygous Leu208Val and homozygous Val208. Homozygous Leu208, a common allele in Caucasians, is uncommon in this cohort. The significance of these CYP2C9 polymorphic alleles remains to be determined.

Nutrient intake and risk of subtypes of esophageal and gastric cancer

Incidence rates for adenocarcinoma of the esophagus and gastric cardia have been rising rapidly. We examined nutrient intake as a risk factor for esophageal and gastric cancers in a population-based case-control study in Connecticut, New Jersey, and western Washington state. Interviews were completed for cases with histologically confirmed esophageal adenocarcinoma (n = 282), adenocarcinoma of the gastric cardia (n = 255), esophageal squamous cell carcinoma (n = 206), and noncardia gastric adenocarcinoma (n = 352), along with population controls (n = 687). Associations between nutrient intake and risk of cancer were estimated by adjusted odds ratios (ORs), comparing the 75th versus the 25th percentile of intake. The following nutrients were significantly inversely associated with risk of all four tumor types: fiber, beta-carotene, folate, and vitamins C and B6. In contrast, dietary cholesterol, animal protein, and vitamin B12 were significantly positively associated with risk of all four tumor types. Dietary fat [OR, 2.18; 95% confidence interval (CI), 1.27-3.76] was significantly associated with risk of esophageal adenocarcinoma only. Dietary nitrite (OR, 1.65; 95% CI, 1.26-2.16) was associated with noncardia gastric cancer only. Vitamin C supplement use was associated with a significantly lower risk for noncardia gastric cancer (OR, 0.60; 95% CI, 0.41-0.88). Higher intake of nutrients found primarily in plant-based foods was associated with a reduced risk of adenocarcinomas of the esophagus and gastric cardia, whereas higher intake of nutrients found primarily in foods of animal origin was associated with an increased risk.

Transcatheter closure of atrial septal defect using Amplatzer septal occluder in Chinese adults

Amplatzer septal occluder (AGA Med. Co., USA) is a novel device for occlusion of atrial septal defect. We present our experience of transcatheter closure of atrial septal defects using Amplatzer septal occluder in 45 adult Chinese patients (age range 18-69 years). The size of atrial septal defect varied from 14-28 (23 +/- 4) mm. Cardiac catheterization revealed a pulmonary-to-systemic shunt ratio ranging from 1.4-2.8 (mean 2.0 +/- 0.4). The procedure was successful in 44 (98%) patients. Displacement of the device requiring surgical removal occurred in one (2%) patient and minor wound complication occurred in two (4%) patients. Total procedure time was 67 +/- 16 minutes and the fluoroscopy time was 25 +/- 8 min. Immediate post-procedure and pre-discharge echocardiography revealed complete abolition of shunt in 42 (93%) and trivial residual shunt in 3 (7%) patients. The average follow-up period was 16 +/- 6 months (range 2 months to 3 years) months. None of the patients had developed other major complication at follow-up. Cathet Cardiovasc Intervent 2001;52:373-377.

Ethanol septal ablation for hypertrophic obstructive cardiomyopathy in a very old patient

BACKGROUND

A 90-year-old woman who had hypertrophic obstructive cardiomyopathy presented with drug-refractory heart failure.

METHOD

She successfully underwent transcoronary ethanol septal ablation under sedation.

OUTCOME

There was instantaneous improvement in left ventricular outflow tract gradient 6 months after discharge, and the symptoms of heart failure have resolved.

Transcatheter closure of the patent ductus arteriosus using an Amplatzer duct occluder in adults

Patent ductus arteriosus (PDA) is a congenital heart disease that frequently escapes detection until the patient reaches adulthood. Percutaneous closure of the PDA has been established as a safe alternative to surgery, the Amplatzer duct occluder (ADO) is a new device that has been recently reported in paediatric patients. Our initial experience with an of ADO in an adult population appears to be encouraging and as good as in paediatric patients.

Family history of cancer and risk of esophageal and gastric cancers in the United States

The worldwide rates for histology- and subsite-specific types of esophageal and gastric cancer reveal strikingly divergent patterns. The contribution of environmental and genetic factors has been explored in several high-incidence areas, but data on genetic influences are scarce for Western countries. Using data from a multicenter, population-based, case-control study on 1,143 cases and 695 controls in the United States, we evaluated whether a family history of digestive or other cancers was associated with an increased risk of esophageal adenocarcinoma (n = 293), esophageal squamous cell carcinoma (n = 221), gastric cardia adenocarcinoma (n = 261) or non-cardia gastric adenocarcinoma (n = 368). After adjusting for other risk factors, individuals reporting a family history of digestive cancers experienced no increased risk of either type of esophageal cancer but they were prone to adenocarcinomas of the gastric cardia [odds ratio (OR) = 1.34, 95% confidence interval (CI) 0.91-1.97] and non-cardia segments (OR =1.46, 95% CI 1.03-2.08). This familial tendency, particularly for non-cardia gastric tumors, was largely explained by an association with family history of stomach cancer (OR = 2.52, 95% CI 1.50-4.23). In addition, family history of breast cancer was associated with increased risks of esophageal adenocarcinoma (OR = 1.74, 95% CI 1.07-2.83) and non-cardia gastric adenocarcinoma (OR = 1.76, 95% CI 1.09-2.82). Also seen were non-significant familial associations of esophageal squamous-cell cancer with prostate cancer as well as non-cardia gastric cancer with leukemia and brain tumors, though these relationships must be interpreted with caution. Our data point to the role of familial susceptibility to gastric cancer, but not to any form of esophageal cancer, in the United States.

Late stent thrombosis after successful rescue of a major coronary artery rupture with a polytetrafluoroethylene-covered stent

We describe a case in which we successfully treated a major left anterior descending artery rupture with a polytetrafluoroethylene-coated stent. The patient presented with acute antero-apical myocardial infarction 52 days after the initial procedure and cardiac catheterization revealed late stent thrombosis, which was successfully treated by primary angioplasty.

Dietary intake of heterocyclic amines, meat-derived mutagenic activity, and risk of colorectal adenomas

Meats cooked well-done by high temperature techniques produce mutagenic compounds such as heterocyclic amines (HCAs), but the amounts of these compounds vary by cooking techniques, temperature, time, and type of meat. We investigated the role of HCAs in the etiology of colorectal adenomas and the extent to which they may explain the previously observed risk for red meat and meat-cooking methods. In a case-control study of colorectal adenomas, cases (n = 146) were diagnosed with colorectal adenomas at sigmoidoscopy or colonoscopy, and controls (n = 228) were found not to have colorectal adenomas at sigmoidoscopy. Using a meat-derived HCA and mutagen database and responses from a meat-cooking questionnaire module, we estimated intake of 2-amino-3,4,8-trimethylimidazo[4,5-f]quinoxaline (DiMeIQx), 2-amino-3,8-dimethylimidazo[4,5-f]quinoxaline (MeIQx), 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) and mutagenic activity. We calculated odds ratios and 95% confidence intervals using logistic regression adjusting for several established risk factors for colorectal adenomas or cancer. The odds ratios (95% confidence interval; P for trend test) fifth versus first quintiles are: 2.2 (1.2-4.1; P = 0.02) for DiMeIQx; 2.1 (1.0-4.3; P = 0.002) for MeIQx; 2.5(1.1-5.5; P = 0.02) for PhIP; and 3.1 (1.4-6.8; P = 0.001) for mutagenic activity. When the three HCAs were adjusted for the other two, only the trend for MeIQx (P = 0.04) remained statistically significant. When we tried to disentangle the relative contribution of the three HCAs from the meat variables, we found that MeIQx remained significantly associated with risk even when adjusted for red meat but not vice versa. When MeIQx and well-done meat were analyzed in the same model, the risks were attenuated for both. Mutagenic activity from meat remained significantly associated with increased risk even when adjusted for intake of red meat or well-done red meat, whereas the red meat and well-done red meat associations were no longer significant when adjusted for total mutagenic activity. In conclusion, we found an elevated risk of colorectal adenomas associated with high intake of certain HCAS: Further, mutagenic activity from cooked meat consumption, a measure that integrates all of the classes of mutagens, was strongly associated with risk and explained the excess risk with intake of well-done red meat.

Percutaneous balloon mitral valvuloplasty during pregnancy: long-term follow-up of infant growth and development

We have studied the long-term growth and development of seven infants who had been exposed during the foetal stage to ionising irradiation associated with percutaneous balloon mitral valvuloplasty between 1 April 1991 and 30 November 1993. We found that infants of mothers who underwent this procedure during the second and third trimester of pregnancy had normal long-term growth and development. This finding supports the argument that percutaneous balloon mitral valvuloplasty using the Inoue balloon technique should be the procedure of choice for pregnant women who have severe mitral stenosis refractory to medical therapy.

Monostotic fibrous dysplasia of the spine: report of a case involving the lumbar transverse process and review of the literature

Monostotic fibrous dysplasia of the spine is rare. We report its clinical, radiologic and histologic features affecting a 47-year-old housewife. She presented with low-back pain of 1-year's duration, and radiographs showed a diffuse expansile lesion in the left transverse process of the fourth lumbar vertebra. The lesion was excised and histologically confirmed to be fibrous dysplasia. The patient remained well 8 years after operation. Including the present case, a total of 22 cases of monostotic fibrous dysplasia of the spine were found in the literature. Combining these reported cases, we found that the condition affects either sex with equal frequency and presents at any age, the mean being 32 years. There is no predilection for any part of the spinal column, though sacral or coccygeal involvement is distinctly rare. It most commonly involves the body and adjacent pedicle, although no part of the vertebra is spared. It is worth noting that a propensity for progressive enlargement, even to the extent of causing graft destruction, exists if the lesion is left untreated or incompletely treated. Complete removal of all involved bone, together with stabilization, should therefore be the treatment of choice for this condition.

Percutaneous stenting of anomalous coronary arteries

We present a case series of stenting de novo lesions in anomalous coronary arteries. Our experience suggests that appropriate guiding catheter selection would allow diseased anomalous coronary arteries to be amenable to rotational atherectomy, excimer laser coronary angioplasty or brachytherapy.

Comparing odds ratios for nested subsets of dietary components

BACKGROUND

In nutritional epidemiology, it is often of interest to disentangle the risk of disease associated with related foods or nutrients, where the food items are in a nested arrangement within a larger group. To compare odds ratios (OR) derived from a standard quantile-based analysis can be misleading since the amounts consumed may differ substantially for different dietary components.

METHODS

The authors applied different logistic regression models on a case-control study concerning the risk of colorectal adenomas due to meat and its different subsets such as white meat, red meat and well-done red meat.

RESULTS

By calculating OR for a fixed amount of intake, the authors suggest a method for partitioning the risk of one dietary item into that associated with increasingly detailed sub-components. A graph is presented for illustrating such partitions in terms of both addition and substitution effects.

CONCLUSIONS

Odds ratios based on upper versus lower quantiles or percentiles are useful as they compare the risk between the upper and lower ends of the consumption range. A complimentary set of OR are those based on fixed amounts of consumption. These allow for direct comparisons between nested subgroups of dietary components, in order to disentangle the risk linked to specific groups of foods or nutrients.

Obesity, hypertension, and the risk of kidney cancer in men

BACKGROUND

Obesity and hypertension have been implicated as risk factors for the development of renal-cell cancer.

METHODS

We examined the health records of 363,992 Swedish men who underwent at least one physical examination from 1971 to 1992 and were followed until death or the end of 1995. Men with cancer (renal-cell cancer in 759 and renal-pelvis cancer in 136) were identified by cross-linkage of data with the nationwide Swedish Cancer Registry. Poisson regression analysis was used to estimate relative risks, with adjustments for age, smoking status, body-mass index, and diastolic blood pressure.

RESULTS

As compared with men in the lowest three eighths of the cohort for body-mass index, men in the middle three eighths had a 30 to 60 percent greater risk of renal-cell cancer, and men in the highest two eighths had nearly double the risk (P for trend, <0.001). There was also a direct association between higher blood pressures and a higher risk of renal-cell cancer (P for trend, <0.001 for diastolic pressure; P for trend, 0.007 for systolic pressure). After the first five years of follow-up had been excluded to reduce possible effects of preclinical disease, the risk of renal-cell cancer was still consistently higher in men with a higher body-mass index or higher blood pressure. At the sixth-year follow-up, the risk rose further with increasing blood pressures and decreased with decreasing blood pressures, after adjustment for base-line measurements. Men who were current or former smokers had a greater risk of both renal-cell cancer and renal-pelvis cancer than men who were not smokers. There was no relation between body-mass index or blood pressure and the risk of renal-pelvis cancer.

CONCLUSIONS

Higher body-mass index and elevated blood pressure independently increase the long-term risk of renal-cell cancer in men. A reduction in blood pressure lowers the risk.

Obesity, hypertension, and the risk of kidney cancer in men

BACKGROUND

Obesity and hypertension have been implicated as risk factors for the development of renal-cell cancer.

METHODS

We examined the health records of 363,992 Swedish men who underwent at least one physical examination from 1971 to 1992 and were followed until death or the end of 1995. Men with cancer (renal-cell cancer in 759 and renal-pelvis cancer in 136) were identified by cross-linkage of data with the nationwide Swedish Cancer Registry. Poisson regression analysis was used to estimate relative risks, with adjustments for age, smoking status, body-mass index, and diastolic blood pressure.

RESULTS

As compared with men in the lowest three eighths of the cohort for body-mass index, men in the middle three eighths had a 30 to 60 percent greater risk of renal-cell cancer, and men in the highest two eighths had nearly double the risk (P for trend, <0.001). There was also a direct association between higher blood pressures and a higher risk of renal-cell cancer (P for trend, <0.001 for diastolic pressure; P for trend, 0.007 for systolic pressure). After the first five years of follow-up had been excluded to reduce possible effects of preclinical disease, the risk of renal-cell cancer was still consistently higher in men with a higher body-mass index or higher blood pressure. At the sixth-year follow-up, the risk rose further with increasing blood pressures and decreased with decreasing blood pressures, after adjustment for base-line measurements. Men who were current or former smokers had a greater risk of both renal-cell cancer and renal-pelvis cancer than men who were not smokers. There was no relation between body-mass index or blood pressure and the risk of renal-pelvis cancer.

CONCLUSIONS

Higher body-mass index and elevated blood pressure independently increase the long-term risk of renal-cell cancer in men. A reduction in blood pressure lowers the risk.

Successful angioplasty and stenting of anomalous right coronary artery using a 6 French Left Judkins #5 guide catheter

We describe the case of a 66-year-old female patient in whom percutaneous transluminal coronary angioplasty and stenting was performed in an anomalous right coronary artery arising from the ascending aorta above the non-coronary sinus of Valsalva using a 6 French Judkins JL5 catheter. The patient remained symptom free at 4-months follow-up.