Atherosclerotic disease of the aortic arch and the risk of ischemic stroke

BACKGROUND

Atherosclerotic disease of the aortic arch has been suspected to be a potential source of cerebral emboli. We conducted a study to quantify the risk of ischemic stroke associated with atherosclerotic disease of the aortic arch.

METHODS

Using transesophageal echocardiography, we performed a prospective case-control study of the frequency and thickness of atherosclerotic plaques in the ascending aorta and proximal arch in 250 consecutive patients admitted to the hospital with ischemic stroke and 250 consecutive controls, all over the age of 60 years.

RESULTS

Atherosclerotic plaques > or = mm in thickness were found in 14.4 percent of the patients but in only 2 percent of the controls. After adjustment for atherosclerotic risk factors, the odds ratio for ischemic stroke among patients with such plaques was 9.1 (95 percent confidence interval, 3.3 to 25.2; P < 0.001). Among the 78 patients who had brain infarcts with no obvious cause, 28.2 percent had plaques > or = 4 mm in thickness, as compared with 8.1 percent of the 172 patients who had infarcts whose possible or likely causes were known (odds ratio, 4.7; 95 percent confidence interval, 2.2 to 10.1; P < 0.001). Plaques of > or = 4 mm in the aortic arch were not associated with the presence of atrial fibrillation or stenosis of the extracranial internal carotid artery. In contrast, plaques that were 1 to 3.9 mm thick were frequently associated with carotid stenosis of > or = 70 percent.

CONCLUSIONS

These results indicate a strong, independent association between atherosclerotic disease of the aortic arch and the risk of ischemic stroke. The association was particularly strong with thick plaques. Atherosclerotic disease of the aortic arch should be regarded as a risk factor for ischemic stroke and as a possible source of cerebral emboli.

Carotid artery dissection with renal infarcts. Two cases

BACKGROUND

Clinical features of carotid artery dissection include ipsilateral local signs, contralateral ischemic stroke, or both. We observed two patients in whom these features were associated with renal infarcts.

CASE DESCRIPTIONS

A 57-year-old woman had painful Horner's syndrome caused by a right internal carotid artery dissection. On days 3 and 4 she had acute abdominal pain, first on the right side and later on the left. The computed tomographic (CT) scan showed a left renal infarct. No aortic dissection or cardiac source of embolism was found. Transesophageal echocardiography showed a mild dystrophy of the ascending aorta and of the mitral valve. Cerebral angiography showed irregularities of the V3 segment of the left vertebral artery compatible with fibromuscular dysplasia. Erythrocyte sedimentation rate was 100 mm/h, and she complained of intense fatigue. She fully recovered within 3 months. A 53-year-old man had sudden severe abdominal pain followed by headache and difficulty in swallowing. He had 9th, 10th, 11th, and 12th cranial nerve involvement on both sides due to bilateral internal carotid artery dissections and pseudoaneurysms. CT scan showed a left renal infarct. Angiography showed extensive signs of fibromuscular dysplasia involving carotid, vertebral, renal, iliac, and mesenteric arteries as well as a dissection of the left renal artery. Erythrocyte sedimentation rate was 65 mm/h, and he complained of severe fatigue. His neurological signs returned to normal in 6 months.

CONCLUSIONS

Renal infarct due to renal artery dissection may occur together with cerebral artery dissection. Acute abdominal pain, increased erythrocyte sedimentation rate, and intense fatigue are the warning symptoms.

Phase II study of hepatic arterial floxuridine, leucovorin, and dexamethasone for unresectable liver metastases from colorectal carcinoma

PURPOSE

To determine the toxicity, response rate, and survival of a regimen of hepatic arterial floxuridine (FUDR) with leucovorin (LV) and dexamethasone (Dec) for the treatment of unresectable hepatic metastases from colorectal carcinoma.

PATIENTS AND METHODS

Sixty-two patients with hepatic metastases (33 previously untreated with chemotherapy) were treated with FUDR (0.30 mg/kg/d) and LV (15 mg/m2/d) and Dec (20 mg total dose) as a 14-day hepatic arterial infusion via an implantable pump alternating with 2 weeks of saline.

RESULTS

The complete response (CR) plus partial response (PR) rate was 78% in previously untreated patients, with a median survival duration of 24.8 months; 1- and 2-year survival rates were 91% and 57%, respectively. In the previously treated group, the response rate was 52%, with a median survival duration of 13.5 months. Only 3% of patients (two of 62) developed biliary sclerosis; this was significantly lower than the 21% biliary sclerosis rate observed in our previous trial of hepatic arterial FUDR and LV without Dec (P = .002).

CONCLUSION

The addition of Dec to hepatic arterial FUDR and LV reduces biliary toxicity while maintaining an excellent response rate and survival. We recommend that this treatment be studied further.

Repeat hepatic resections for metastatic colorectal cancer

OBJECTIVE

The authors weighed the risks and benefits of repeat liver resections for colorectal metastatic disease.

METHOD

In the 6-year period between January 1985 and June 1991, 499 patients underwent liver resections for colorectal metastases at the Memorial Sloan-Kettering Cancer Center. Of these, 25 patients had repeat surgical resections for isolated recurrent disease to the liver. The clinical data for these patients were reviewed.

RESULTS

The median interval between the two resections was 11 months. There were no perioperative deaths, and the complication rate was 28%. Median follow-up after the second liver resection is 19 months, with median survival of 17 months for nonsurvivors. Although the median survival after the second resection is 30 months, 20 of the 25 patients have had recurrences with a median disease-free interval of only 9 months. No characteristic of primary or metastatic disease predicted outcome, including time between presentation of the primary and development of liver metastases, disease-free interval after the first liver resection, and bilobar liver involvement.

CONCLUSIONS

Although repeat liver resections can be performed safely and improves survival, the likelihood of cure from such resection therapy is low. This likelihood of further recurrences encourage studies of adjuvant or alternative treatments of this population.

A randomized trial of early hospital discharge and home follow-up of women having cesarean birth

OBJECTIVE

To determine the safety, efficacy, and cost savings of early hospital discharge of women delivered by unplanned cesarean delivery.

METHODS

Using randomized assignment, 61 postpartum women were discharged from the hospital at the usual time, and 61 were discharged early and had nurse specialist home follow-up care. The latter group received comprehensive discharge planning, instruction, counseling, home visits, and daily on-call availability from the nurse specialists. Both groups were followed from delivery to 8 weeks postpartum.

RESULTS

Women who were discharged early and received transitional home care services by clinical nurse specialists were sent home a mean of 30.3 hours earlier than the control group (P < .001). They had significantly greater satisfaction with care, more of their infants had timely immunizations at the end of follow-up, and they had a 29% reduction in health care charges compared to the control group receiving routine care. Although there were no statistically significant differences in maternal and infant rehospitalizations and acute-care visits, there were more maternal rehospitalizations in the control group than in the nurse specialist-followed group (three versus zero). No statistically significant differences were found between the groups in the outcomes of maternal affect and overall functional status.

CONCLUSION

Early hospital discharge of women after unplanned cesarean birth, using the model of nurse specialist transitional home care, is safe, feasible, and cost-effective.

Hemodynamics of cough cardiopulmonary resuscitation in a patient with sustained torsades de pointes/ventricular flutter

A 43-year-old female with old myocardial infarction and stenosed bypass grafts developed sustained Torsades de Pointes/ventricular flutter (rate = 300-400 beats per minute) during coronary arteriography after contrast injection to the diagonal graft. Cough-CPR (rate = 37/min) was started within 5 s of dysrhythmia initiation and continued through two defibrillation attempts (200 and 360 joules), and IV lidocaine was administered until return of spontaneous circulation 62 s later. The patient never lost consciousness during this very rapid dysrhythmia. Certain cardiac arrest resuscitation measures (namely, initial defibrillation attemps, IV lidocaine administration) can thus be initiated in a patient while performing cough-CPR and maintaining adequate cerebral perfusion. During the dysrhythmia with Cough-CPR: (a) aortic systolic pressures averaged 100 mmHg--this has commonly been observed in other reports, and (b) aortic diastolic pressures were always > or = 50 mmHg and averaged 63 mmHg, which has seldom been this high during cough-CPR. Dysrhythmia reversion occurred 4 s after the second defibrillation attempt and 80 msec after the peak of the highest cough-generated aortic pressure pulse (128 mmHg). Cough-induced ventricular tachycardia reversion has previously been reported; this may have acted in concert with electrical defibrillation to facilitate dysrhythmia reversion. The patient recovered without incident.

Papillary thyroid carcinoma after total body irradiation

Two children developed papillary thyroid carcinoma after allogeneic bone marrow transplantation (BMT) probably due to radiotherapy during remission and pretransplantation conditioning. Establishing a relationship between the cellular thyroid stimulating hormone (TSH) effect and development of carcinoma in cases with high serum TSH concentrations is difficult. After BMT, patients should be regularly followed up with thyroid ultrasound and, when nodularity is found, fine needle aspiration and/or open biopsy are recommended.

Three additional linkage groups that repress transcription and meiotic recombination in the mating-type region of Schizosaccharomyces pombe

The mating-type genes of Schizosaccharomyces pombe are found at three locations in the same chromosomal region. These genes are in an active configuration at the mat1 locus and in an inactive configuration at the mat2 and mat3 loci. The mechanism that represses transcription of mat2 and mat3 also inactivates other promoters introduced nearby and is accompanied by a block to meiotic recombination in the mat2-mat3 interval, suggesting that this mechanism involves a particular chromatin structure. We present evidence that the transcription and recombination blocks require three newly defined trans-acting loci, clr2, clr3 and clr4, in addition to the previously identified clr1, rik1 and swi6 loci. We also investigated the role of mat2 cis-acting sequences in silencing. Four cis-acting elements that repress mat2 in a plasmid context were previously identified. Deletion of two of these elements proved to have little effect in a chromosomal context. However, when combined with mutations in trans-acting genes, deletion of the same two elements greatly enhanced mat2 expression. The observed cumulative effects suggest a redundancy in the silencing mechanism.

Hemimegalencephaly: a longitudinal MR study

An infant with hemimegalencephaly was studied with MR at 5 days and again at 10 months of age. The initial scan showed an abnormally large left cerebral hemisphere. At the age of 10 months, the left cerebral hemisphere was smaller than the right--an apparent left-sided micrencephaly caused by normal growth of the right hemisphere and arrested growth of the left. The age of imaging of a patient with hemimegalencephaly can be important if the correct diagnosis is to be made.

[Relationship between plasma antioxidants and coronary artery disease]

Plasma concentrations of the antioxidants, vitamin E, beta-carotene and vitamin A were studied. 29 patients in whom at least 70% obstruction of 1 coronary artery was found, and 73 who were normal according to noninvasive tests were compared using multivariable, logistic, regression analysis. The group with coronary disease had significantly lower plasma vitamin E and beta-carotene concentrations as compared with the normal group (means +/- SD: 44.2 +/- 18.3 micrograms/ml vs 50.6 +/- 22.4 and 1.0 +/- 0.5 micrograms/ml vs 1.1, respectively) but plasma vitamin A concentration was not reduced. Decrease in plasma antioxidant vitamin concentrations may be linked to atherogenesis by LDL oxidative modification, which explains the inverse relationship found between the risk of coronary artery disease and plasma antioxidant vitamins.

Disorders of the central nervous system

In this article, we have reviewed the most common CNS abnormalities seen in perinatal medicine. The prognosis in ventriculomegaly is most closely related to the presence or absence of associated anomalies. The current treatment for DWM consists of shunting of either the posterior fossa cyst or lateral ventricles. Facial abnormalities can frequently aid in distinguishing holoprosencephaly from other CNS lesions. Anencephaly is one of the most severe fetal anomalies and is incompatible with life. Spina bifida represents a spectrum of NTDs with a variable outcome depending on the size and location of the defect, as well as the presence of other anomalies.

Neurotrophin-4/5 (NT-4/5) increases adult rat retinal ganglion cell survival and neurite outgrowth in vitro

Retinal ganglion cell (RGC) survival and neurite outgrowth were investigated in retinal explants from adult rats. Neurotrophin-4/5 (NT-4/5) caused dose-dependent increases in neurite outgrowth with one-half maximal effects at approximately 0.5 ng/ml and maximal effects at 5 ng/ml. In explants treated for 7 days, the actions of NT-4/5 were similar to those of brain-derived neurotrophic factor (BDNF); with either neurotrophin, nearly twice as many RGCs survived and there was a two- to threefold increase in the number of neurites formed by RGCs. Combinations of saturating concentrations of NT-4/5 and BDNF did not enhance these in vitro effects, implying that both neurotrophins share a common signaling pathway. In contrast, nerve growth factor (NGF), neurotrophin-3 (NT-3), or ciliary neurotrophic factor (CNTF) appeared to exert minimal influences on RGC survival or neurite outgrowth.

Msx1 is close but not allelic to either Hm or Hx on mouse chromosome 5

The Msx1 homeobox locus has been mapped in relation to the mutations hammer-toe (Hm) and hemimelic extra toes (Hx). Msx1 is expressed in the developing limb, while limb development is affected by the Hm and Hx mutations. Hm and Hx are very tightly linked loci. In interspecific crosses, the segregation of either mutation was followed in relation to polymorphic alleles of Msx1, Il6, and En2, to give a fine map around the mutant loci. Our results show that Msx1 is not allelic to either of the mutations, but is located about 3 cM from them. Il6 did not recombine with either Hm or Hx and, therefore, provides a point of access for the analysis of these mutations at the molecular level.

Aortic dissection and cardiovascular syphilis: report of an observation with transesophageal echocardiography and anatomopathologic findings

We report the case of a man who had thoracic pain and stroke. Transesophageal echocardiography enabled us to diagnose an intramural hematoma and a saccular aneurysm of the thoracic aorta before he died. Autopsy showed lesions compatible with syphilitic aortitis in the aortic wall. Transesophageal echocardiography and anatomopathologic findings are correlated, and the role of syphilis as a causal factor is discussed.

Relationship between the parachute reactions and standing and walking in normal infants

Assumption of the vertical position and independent walking are potentially hazardous motor milestones in the developing infant. It has been presumed that the parachute reactions evolved to protect infants from injury during this developmental stage. To determine the relationship between the appearance of the upper and lower parachute reactions and the developmental milestones of unsupported standing and independent walking, 190 normal infants were prospectively studied. The upper parachute reaction was found to precede the lower by less than a month (mean age of appearance: 8.9 and 9.2 months, respectively). More than one-half of the cohort achieved standing without either the upper (49%) or lower parachute reaction (57%); however, no independent walking occurred without the upper parachute reaction, and only 2 of 190 infants (1%) walked independently without the lower parachute reaction. Onset of walking occurred about 4 months after the appearance of the upper parachute reaction. The significance of these findings is discussed.

[Guidelines of the French Society of Cardiology on the training of echocardiographers and the performing of echocardiography]

The considerable advances achieved in the field of echocardiography have made this investigation an essential diagnostic tool. Under the auspices of the French Society of Cardiology, the Working group on Echocardiography publishes its practical recommendations for optimising the training of echocardiographers (theoretical instruction and practical courses) and for performing echocardiography (understanding the clinical problem, referral to previous examinations, necessary recordings and measurements, and appropriate equipment). In the future, these recommendations should be updated to take into account continuing technical improvements and changes in methods of studying cardiac disease by echocardiography.

Antibody targeting in metastatic colon cancer: a phase I study of monoclonal antibody F19 against a cell-surface protein of reactive tumor stromal fibroblasts

PURPOSE

To define the toxicity, imaging, and biodistribution characteristics of iodine 131-labeled monoclonal antibody F19 (131I-mAbF19). MAbF19 recognizes the fibroblast activation protein (FAP), a cell-surface glycoprotein not present in most normal tissues, but abundantly expressed by reactive stromal fibroblasts of epithelial cancers, including more than 95% of primary and metastatic colorectal carcinomas.

PATIENTS AND METHODS

131I-mAbF19 was administered intravenously to 17 patients with hepatic metastases from colorectal carcinoma who were scheduled for resection of localized metastases or insertion of hepatic artery catheter for regional chemotherapy. Seven to 8 days before surgery, patients received 131I-mAbF19 at three dose levels, with at least four patients entered at each level.

RESULTS

No toxicity associated with intravenous 131I-mAbF19 administration was observed. Tumor images were obtained on planar and single-photon emission tomography (SPECT) scans in 15 of 17 patients with hepatic metastases, tumor-infiltrated portal lymph nodes, and/or recurrent pelvic disease. The smallest lesion visualized was 1 cm in diameter. The optimal time for tumor imaging was 3 to 5 days after 131I-mAbF19 administration. The use of image registration techniques allowed precise anatomic localization of 131I-mAbF19 accumulation. Immunohistochemical analysis of biopsy tissues showed expression of FAP in the tumor stroma (but not in normal liver) in all patients studied and confirmed that the FAP-positive tumor stromal fibroblasts were interposed between the tumor capillaries and the malignant colon epithelial cells. At the time of surgery, tumor-to-liver ratios up to 21:1 and tumor-to-serum ratios up to 9:1 were obtained. The fraction of the injected 131I-mAbF19 dose per gram tumor (%ID/g tumor) localized to hepatic metastases at the time of surgery ranged from 0.001% to 0.016%.

CONCLUSION

The FAP tumor fibroblast antigen is highly expressed in primary and metastatic colorectal carcinomas and shows limited expression in normal adult tissues. This highly selective expression pattern allows imaging of colorectal carcinoma lesions as small as 1 cm in diameter on 131I-mAbF19 scans. Because of the consistent presence of FAP in the stroma of epithelial cancers and the accessibility of FAP-positive tumor stromal fibroblasts to circulating monoclonal antibodies (mAbs), this study suggests possible diagnostic and therapeutic applications of humanized mAbF19 and mAbF19 constructs with novel immune and nonimmune effector functions.

Two transthyretin mutations (glu42gly, his90asn) in an Italian family with amyloidosis

A family with familial amyloidotic polyneuropathy (FAP) was previously found to have a substitution of asparagine for histidine at position 90 of transthyretin. Members with his90asn developed FAP. However, close examination of the transthyretin gene revealed that glu42gly is coinherited with his90asn in this family. Since glu42gly has already been seen in Japanese FAP patients, and his90asn has been found in Portuguese and German individuals without FAP, we conclude that his90asn is a nonpathogenic variant.

[Atherosclerosis of the aortic arch: a possible new source of cerebral embolism]

Atherosclerosis of the aortic arch is common in individuals aged over 60. Plaques are very often ulcerated. The normal healing process results in the regular formation of thrombi on these ulcerations. A mural thrombus can thus be the source of systemic or cerebral emboli. Since the advent of transesophageal echocardiography, it has become possible to detect atherosclerotic plaques of the aortic arch. However, a causal relationship has never been demonstrated and it is possible that they may merely be a marker of atherosclerotic disease. Certain arguments suggest that the aortic arch may be a source of cerebral emboli: the high incidence of aortic mural thrombi and atheroma emboli during aortography or coronary arteriography, or cardiac surgery with extracorporeal circulation requiring cannulation of the aorta. Recent studies have also shown that plaques of the aortic arch are commoner in cases of cerebral infarction of unknown origin than when another potential cause is detected. The natural history of this type of lesion must be studied before any management attitude can be defined. In the present state of knowledge, the only possible advice is antiplatelet treatment and case-by-case consideration of anti-coagulant treatment, in particular in the presence of a mobile thrombus of the aortic arch.

Transbronchial biopsy in patients with pulmonary eosinophilic granuloma. Comparison with findings on open lung biopsy

We evaluated the findings on transbronchial biopsy specimens in reference to open lung biopsy specimens from 12 patients with pulmonary eosinophilic granuloma. Features in transbronchial biopsy specimens were further contrasted to those of patients with interstitial fibrosis and nondiagnostic biopsy specimens for localized lesions. Transbronchial biopsy specimens were randomized and graded for histologic features and cellularity. Patients with eosinophilic granuloma had more macrophages (P < .05) but equivalent numbers of eosinophils, neutrophils, and Langerhans' cells compared with those of the other two groups. Only two endoscopic biopsy specimens were histologically diagnostic or highly consistent with eosinophilic granuloma. We conclude that the diagnosis of eosinophilic granuloma is possible on transbronchial biopsy but requires a high index of suspicion. The demonstration of Langerhans' cells by immunohistochemical staining for S100 protein is a useful adjunct. The low diagnostic yield for eosinophilic granuloma on transbronchial biopsy results from inadequate sampling and from the nonspecific appearance of discrete lesions in small tissue samples.

Platelet serotonin transporter in drug-naive migrainous children and adolescents

Platelet [3H]imipramine binding was measured in 17 children and adolescents suffering from common (n = 10) and classical (n = 7) migraine and 10 healthy control subjects. All patients had more than a 1-year history of the disease and suffered at least one attack per month. All subjects had been drug-free for at least 4 weeks prior to the study and had never been treated with drugs active at the serotonergic system. An increased density in [3H]imipramine binding sites was detected in the migraine patients (+51%; p < 0.05). The increase in maximal binding was more prominent in the classical migraine group (+63%) than in the common migraine group (+43%). These results disagree with previous studies that reported decreased platelet imipramine binding in adult migraine patients. The discrepancy may be related to chronicity of drug treatment, long-term duration of disease and comorbidity of depression and anxiety disorders in adult migrainous patients.

Hepatic arterial floxuridine and leucovorin for unresectable liver metastases from colorectal carcinoma. New dose schedules and survival update

BACKGROUND

We studied three new dose schedules of hepatic arterial infusion of floxuridine (FUDR) and leucovorin and update survival analysis of a previously reported trial using these drugs by hepatic arterial infusion for patients with hepatic metastases from colorectal carcinoma.

METHODS

Untreated patients with hepatic metastases from colorectal cancer were treated with three dose schedules: Group D, FUDR (0.3 mg/kg/day) and leucovorin (30 mg/m2/day) as a 14-day continuous infusion through an implantable hepatic arterial pump alternating with a 4-week rest period; Group E, a lower dose of FUDR (0.25 mg/kg/day) and leucovorin (30 mg/m2/day) as a 14-day infusion alternating with 2 weeks of saline; and Group F, FUDR (0.3 mg/kg/day) with a lower leucovorin dose (15 mg/m2/day) for 2 weeks followed by a 2-week rest.

RESULTS

In 42 patients with unresectable hepatic metastases, the complete-plus-partial response rate was 56%, with a median survival of 24.2 months. Complete-plus-partial response rates for groups D, E, and F were 30%, 54%, and 75%, respectively. Twelve percent of the 42 patients developed biliary sclerosis; the percentages of patients per group were 17%, 15%, and 6%, respectively. Updated median survival of the original 24 patients treated with FUDR and leucovorin by hepatic arterial infusion and these 42 new patients (66 total) was 28.8 months. One-, two-, three-, four-, and five-year survival rates were 86%, 62%, 31%, 15%, and 7%, respectively.

CONCLUSIONS

Hepatic arterial chemotherapy with FUDR and leucovorin for patients with hepatic metastases from colorectal carcinoma yields a high response rate and 1- and 2-year survivals of 86% and 62%, respectively. Although a lower dose of leucovorin (15 mg/m2) with FUDR produces a high response rate with less toxicity, before larger scale trials are initiated, further investigation is needed to reduce toxicity. A study of hepatic arterial dexamethasone with FUDR and leucovorin has been initiated for this purpose.