Comparison of a novel rectilinear biphasic waveform with a damped sine wave monophasic waveform for transthoracic ventricular defibrillation. ZOLL Investigators

OBJECTIVES

We compared the efficacy of a novel rectilinear biphasic waveform, consisting of a constant current first phase, with a damped sine wave monophasic waveform during transthoracic defibrillation.

BACKGROUND

Multiple studies have shown that for endocardial defibrillation, biphasic waveforms have a greater efficacy than monophasic waveforms. More recently, a 130-J truncated exponential biphasic waveform was shown to have equivalent efficacy to a 200-J damped sine wave monophasic waveform for transthoracic ventricular defibrillation. However, the optimal type of biphasic waveform is unknown.

METHODS

In this prospective, randomized, multicenter trial, 184 patients who underwent ventricular defibrillation were randomized to receive a 200-J damped sine wave monophasic or 120-J rectilinear biphasic shock.

RESULTS

First-shock efficacy of the biphasic waveform was significantly greater than that of the monophasic waveform (99% vs. 93%, p = 0.05) and was achieved with nearly 60% less delivered current (14 +/- 1 vs. 33 +/- 7 A, p < 0.0001). Although the efficacy of the biphasic and monophasic waveforms was comparable in patients with an impedance < 70 ohms (100% [biphasic] vs. 95% [monophasic], p = NS), the biphasic waveform was significantly more effective in patients with an impedance > or = 70 ohms (99% [biphasic] vs. 86% [monophasic], p = 0.02).

CONCLUSIONS

This study demonstrates a superior efficacy of rectilinear biphasic shocks as compared with monophasic shocks for transthoracic ventricular defibrillation, particularly in patients with a high transthoracic impedance. More important, biphasic shocks defibrillated with nearly 60% less current. The combination of increased efficacy and decreased current requirements suggests that biphasic shocks as compared with monophasic shocks are advantageous for transthoracic ventricular defibrillation.

Long-term outcome of patients with unexplained syncope treated with an electrophysiologic-guided approach in the implantable cardioverter-defibrillator era

OBJECTIVES

We evaluated the long-term outcome of patients with coronary artery disease and unexplained syncope who were treated with an electrophysiologic (EP)-guided approach.

BACKGROUND

Electrophysiologic studies are frequently performed to evaluate unexplained syncope in patients with coronary artery disease. Patients with this profile who have inducible ventricular tachycardia are considered at high risk for sudden death and increased overall mortality, and therefore are often treated with an implantable cardioverter-defibrillator (ICD). The impact of this EP-guided strategy is unknown because there are no data comparing the long-term outcome of ICD recipients with that of noninducible patients.

METHODS

We evaluated 67 consecutive patients with coronary artery disease and unexplained syncope. All patients were treated with an EP-guided approach that included ICD implantation in patients with inducible ventricular tachycardia.

RESULTS

Electrophysiologic testing suggested a plausible diagnosis in 32 (48%) of these patients. Inducible monomorphic ventricular tachycardia was the most common abnormality. Despite frequent appropriate therapy with ICDs, the total mortality for patients with inducible monomorphic ventricular tachycardia was significantly higher than for noninducible patients. The respective one- and two-year survival rates were 94% and 84% in noninducible patients and 77% and 45% in inducible patients (p = 0.02).

CONCLUSIONS

Electrophysiologic testing suggests an etiology for unexplained syncope in approximately 50% of patients and risk stratifies these patients with regard to long-term outcome. Patients who receive an ICD for the management of inducible ventricular tachycardia have a high incidence of spontaneous ventricular arrhythmias requiring ICD therapy. However, despite ICD implantation and frequent appropriate delivery of ICD therapies, patients with inducible ventricular tachycardia have a significantly worse prognosis than do those who are noninducible.

The role of nonlinear dynamics in cardiac arrhythmia control

The field of nonlinear dynamics has made important contributions toward a mechanistic understanding of cardiac arrhythmias. In recent years, many of these advancements have been in the area of arrhythmia control. This paper reviews the literature on analytical, modeling, and experimental nonlinear dynamical arrhythmia control with a focus on stimulation and pharmacologic techniques that have been developed, and in some cases used in experiments, to control reentrant rhythms (including spiral and scroll waves) and fibrillation. Although such approaches currently have practical limitations, they offer hope that nonlinear dynamical control techniques will be clinically useful in the coming years.

Prenatal diagnosis and assessment of fetal malformations by ultrasonography in India

A multicentre study to assess the status of prenatal diagnosis of fetal malformation in India was conducted. Questionnaires were sent to the teaching hospitals and to centres in the private sector involved with ultrasonography in all the four zones. Data were obtained from 13 centres. Basic level I scans were performed on all pregnant women in 64% centres, whereas level II or targeted scans were performed as routine in 42% centres. Obstetricians performed level II scans in only 35% of cases while rest were performed by radiologists. Malformations of the central nervous system were commonest, accounting for 35-69% of all malformations, followed by genitourinary and gastrointestinal malformations. Malformations of the cardiovascular system were detected in 9.3% as abnormal four chamber view and outlet tract abnormalities, subsequently confirmed on fetal echocardiography. Invasive prenatal diagnosis by fetal blood sampling, chorion villus sampling and amniocentesis for chromosomal analysis of malformed fetuses was performed at 40% centres. At the All India Institute of Medical Sciences, approximately 11,042 ultrasound scans were performed by obstetricians as routine in all pregnant women. A total of 543 malformations were detected accounting for a 4.9% incidence of structural anomalies. A total of 98 cardiovascular malformations were detected in high and low risk pregnant women on fetal echocardiography. No database or registry exists in India to give an actual insight into the problem of congenital malformation and their prenatal diagnosis. It is important to train obstetricians in level I and II ultrasonography, to recognise centres and institutions at national and regional level, and to integrate a network of diagnostic testing. Close liaison between geneticists, radiologists, pediatric surgeons, pediatricians and obstetricians is a must for prenatal diagnosis and management of fetal malformations.

Blindness due to firearm eye injuries in rural western Uttar Pradesh

In a retrospective analysis of 440 cases of firearm injuries, 104 patients had ocular injuries. Following treatment only 14 patients (13.5%) could regain visual acuity of > or = 6/60.

Etiology and outcome of chronic renal failure in Indian children

A prospective analysis of all new pediatric cases of chronic renal failure (CRF) was performed at our hospital over a 1-year period. The diagnosis of CRF was based on serum creatinine >2 mg/dl with supportive clinical, laboratory, and radiological findings. There were a total of 48 patients with CRF with a median age of 13 years (range 10 days to 16 years). The causes of CRF included glomerulonephritis (37.5%), obstruction and interstitial (52%), hereditary (6.3%), and undetermined (4.2%). Patients were symptomatic for a mean of 33.2 months (range 10 days to 11 years) at presentation. Eight patients (16.7%) had acute reversible deterioration of renal function at presentation. This was due to accelerated hypertension in 2, infection in 3, volume depletion in 2, and nonsteroidal antiinflammatory drugs in 1 patient. At presentation, 22 (46%) children had mild to moderate renal failure and 26 (54%) had end-stage renal disease. Twenty-one children (43. 7%) had associated illness at presentation. Mean follow-up was 22.9 weeks (range 2-126 weeks). At the end of the study period, 10 (21%) patients were on conservative treatment, 7 (14.6%) on maintenance dialysis, 8 (16.7%) patients had functioning allografts, 4 (8.3%) patients had died, and 19 (39.6%) opted against further therapy. We conclude that CRF in Indian children carries a poor prognosis due to late referral and the limited availability and high cost of renal replacement therapy.

Mononuclear cell-modulation of granulosa cell steroidogenesis in rat: influence of ovarian cycle

The mononuclear cells exert a paracrine influence on the ovarian function, including steroidogenesis. This study examines the ability of the conditioned medium from the cultures of splenic mononuclear cells, obtained during various phases of the ovarian cycle, on progesterone accumulation by the granulosa cells in the culture medium. Female Wistar rats, aged twenty-five days, were made pseudopregnant by an injection of pregnant mare's serum gonadotropin. The splenic mononuclear cells were isolated at follicular phase, early luteal phase, mid luteal phase and late luteal phase and cultured for 48 h. The ammonium sulphate precipitated fraction of the conditioned medium was added to the granulosa cells obtained from immature rats treated with diethylstillboestrol. The granulosa cells were cultured for 48 h, and the progesterone accumulated in the medium was assayed. The conditioned medium from the cultures of the mononuclear cells obtained during follicular phase and late luteal phase inhibited FSH-induced progesterone secretion, whereas conditioned medium obtained from mid luteal phase mononuclear cells enhanced the effect of FSH. The stimulatory effect of db-cAMP on progesterone accumulation in the culture medium is inhibited by conditioned medium obtained from all the phases of the ovarian cycle. This study demonstrates a cyclicity in the behaviour of the splenic mononuclear cells on ovarian steroidogenesis, suggesting a bi-directional paracrine and/or endocrine relationship between ovary and the mononuclear cells.

A combined laparoscopic-endoscopic method of assessment to prevent the complications of short esophagus

As antireflux surgery has been used increasingly for gastroesophageal reflux disease (GERD), a need has arisen for an accurate method to assess esophageal length. There are a number of preoperative tests that can help surgeons to establish the presence of a short esophagus, but intraoperative assessment after esophageal mobilization is the standard method. In this era of laparoscopic surgery, the surgeon mobilizes the esophagus extensively from the abdomen and then determines if mobilization is sufficient. We report an intraoperative technique that combines laparoscopic with endoscopic methods to determine the position of the gastroesophageal junction. Because two physicians are required, there is additional operating room time, resulting in increased costs. However, these costs are offset by the assurance that the complications of the short esophagus can be avoided. With experience, modifications were made, resulting in the technique described herein.

Ultrasound guided aspiration of endometrioma--a new therapeutic modality to improve reproductive outcome

OBJECTIVE

To evaluate the therapeutic efficacy and reproductive outcome following ultrasound guided aspiration (UGA) of endometrioma in infertile patients.

METHOD

This is a prospective non-randomized clinical report of UGA in 22 infertile patients with endometrioma. The aspiration of endometriotic cysts was carried out transvaginally in nine and transabdominally in 13 patients. Following aspiration intranasal buserilin was given to eight and danazol to 14 patients. In the case of recurrence a reaspiration was done. Patients were allowed to conceive following medical therapy. Recurrence of endometrioma and conception rate was recorded and correlated with endometrioma size and volume aspirated.

RESULT

A total of 47 aspirations were done. There were no procedure related complications. Reaspiration was required in six patients and one was operated (total recurrence 7/22--31.8%). During a mean follow-up of 20+/-8.4 months nine patients (40.9%) conceived and eight have already delivered at term. The recurrence risk and the conception rate was not affected by the cyst size or volume aspirated.

CONCLUSION

UGA of endometrioma can be an effective and safe alternative therapeutic procedure in infertile patients with endometrioma to improve their reproductive outcome.

Differential effects of adenosine on focal and macroreentrant atrial tachycardia

INTRODUCTION

The effects of adenosine on atrial tachycardia (AT) remain controversial, and the mechanistic implications of adenosine termination have not been fully established. The purpose of this study was to elucidate the differential effects of adenosine on focal and macroreentrant AT and describe the characteristics of adenosine-sensitive AT.

METHODS AND RESULTS

Thirty patients received adenosine during AT. Tachycardia origins were identified as focal or macroreentrant during invasive electrophysiologic studies. Responses to adenosine were analyzed and characterized as tachycardia termination, transient suppression, or no effect. Electrophysiologic studies demonstrated a focal origin of tachycardia in 17 patients. Adenosine terminated focal tachycardias in 14 patients (dose 7.3 +/- 4.0 mg) and transiently suppressed the arrhythmias in three others (dose 10.0 +/- 6.9 mg). A macroreentrant mechanism was demonstrated in 13 patients; adenosine terminated only one of these tachycardias and had no effect on the remaining 12 patients (dose 10.2 +/- 2.9 mg). Four classes of adenosine-sensitive AT were identified. Class I consisted of nine patients with tachycardia arising from the crista terminalis; these tachycardias also terminated with verapamil (4/4). Class II consisted of four patients with repetitive monomorphic AT arising from diverse sites in the right atrium; these either slowed or terminated in response to verapamil (2/2). Class III consisted of the three patients with transient suppression and demonstrated electropharmacologic characteristics consistent with an automatic mechanism, including insensitivity to verapamil (2/2). In the one patient with macroreentrant AT that was comprised of decremental atrial tissue, adenosine terminated tachycardia in a zone of decremental slow conduction (Class IV); this tachycardia slowed with verapamil.

CONCLUSIONS

Adenosine-sensitive AT is usually focal in origin and arises either from the region of the crista terminalis (inclusive of the sinus node) or from diverse atrial sites with an incessant nonsustained repetitive pattern. Although most forms of macroreentrant AT are insensitive to adenosine, rarely macroreentrant AT with zones of decremental slow conduction can demonstrate adenosine sensitivity.

Induction of neurally mediated syncope with adenosine

BACKGROUND

Tilt testing is used to establish the diagnosis of neurally mediated syncope. However, applicability of the tilt test is limited by test sensitivity and length of time required to perform the test. We hypothesized that adenosine could facilitate the induction of neurally mediated syncope through its sympathomimetic effects and therefore could be used as an alternative to routine tilt testing.

METHODS AND RESULTS

In protocol 1, the yield of adenosine tilt testing (12 mg while upright, followed by 60 degrees tilt for 5 minutes) and a 15-minute isoproterenol tilt test were compared in 84 patients with a negative 30-minute drug-free tilt test. In protocol 2, 100 patients underwent an initial adenosine tilt test followed by our routine tilt test (30-minute drug-free tilt followed by a 15-minute isoproterenol tilt). Six additional control patients underwent microneurography of the peroneal nerve to compare the sympathomimetic effects during bolus administration of adenosine and continuous infusion of isoproterenol. In protocol 1, the yields of adenosine (8 of 84, 10%) and isoproterenol (7 of 84, 8%) tilt testing were comparable (P=NS). In protocol 2, the yields of adenosine (19 of 100, 19%) and routine (22 of 100, 22%) tilt testing were also comparable (P=NS). Although the yield of adenosine tilt testing was comparable in both protocols, patients with a negative adenosine tilt test but a positive routine tilt test usually required isoproterenol to elicit the positive response. Microneurography confirmed discordant sympathetic activation after adenosine and isoproterenol administration.

CONCLUSIONS

Adenosine is effective for the induction of neurally mediated syncope, with a diagnostic yield comparable to routine tilt testing. However, the discordant results obtained with adenosine and the isoproterenol phase of routine tilt testing suggest that adenosine and isoproterenol tilt testing may have complementary roles in eliciting a positive response. Therefore, a tilt protocol that uses an initial adenosine tilt followed, if necessary, by an isoproterenol tilt would be expected to increase the overall yield and reduce the duration of tilt testing.

Catecholamine facilitated reentrant ventricular tachycardia: uncoupling of adenosine's antiadrenergic effects

INTRODUCTION

Adenosine has no direct electrophysiologic function in ventricular tissue, but in the presence of cyclic adenosine monophosphate (cAMP), stimulation exerts a potent antiadrenergic effect. This effect has been exploited in the recognition and treatment of ventricular tachycardia (VT) due to cAMP-mediated triggered activity and automaticity, which are respectively terminated and suppressed by adenosine. However, the effects of adenosine on catecholamine-facilitated reentrant VT are unknown. A pivotal issue is whether termination of VT with adenosine is mechanism specific, or whether it represents a nonspecific antiadrenergic effect. The purpose of this study, therefore, was to define the effects of adenosine in a well-characterized group of patients with catecholamine-facilitated reentrant VT.

METHODS AND RESULTS

Fourteen patients with catecholamine-facilitated reentry were studied. In the 12 patients with structural heart disease (including two with arrhythmogenic right ventricular dysplasia), adenosine (260 to 550 microg/kg) failed to slow or terminate VT. Two patients without structural heart disease had intrafascicular tachycardia confined to the left posterior fascicle, a calcium-dependent, verapamil-sensitive arrhythmia. In the absence of isoproterenol, verapamil terminated VT but adenosine did not. However, when isoproterenol was subsequently required for facilitation of tachycardia, adenosine terminated VT in both patients.

CONCLUSION

Adenosine has no antiadrenergic (antiarrhythmic) effect in patients with catecholamine-facilitated VT due to structural heart disease. Patients with verapamil-sensitive, left posterior intrafascicular reentry have an unusual dual response to adenosine. In the unstimulated state, adenosine has no effect on basal inward calcium current and, therefore, no effect on VT. However, when induction of VT requires amplification of the inward calcium current through stimulation of cAMP, adenosine sensitivity of VT becomes manifest. These results indicate that with few exceptions, termination of VT with adenosine is strongly suggestive of a cAMP-mediated triggered mechanism rather than reentry.

Cytological study of serous effusions with the aid of tumour markers

Clinicocytological evaluation with the help of tumour markers was done in 25 cases presenting with serous effusions. The main aim was to differentiate between reactive mesothelial cells and malignant cells, type the tumour cells in effusions with the aid of tumour markers--carcino-embryonic antigen (CEA), epithelial membrane antigen (EMA), cytokeratin and vimentin. It was observed that immunocytochemistry has complemented conventional cytology in diagnosis of carcinoma specially in cases labelled as suspicious of malignancy. EMA was found to be the most reliable epithelial marker and very useful in differentiating carcinoma cells from reactive mesothelial cells.

Posterior scleritis: clinical profile and imaging characteristics

Posterior scleritis is relatively uncommon and is often misdiagnosed due to its protean manifestations. We report eight cases of posterior scleritis to analyse the clinical profile, ultrasonographic and computed tomography (CT) scan features of this rare disorder. Fundus findings included serous retinal detachment, choroidal folds, retinal folds, subretinal mass, choroidal detachment, disc edema, and macular edema. There was associated anterior scleritis and anterior uveitis in the majority of the cases. In all cases ultrasound with or without CT scan confirmed the clinical diagnosis. All patients responded to systemic steroids except one who required immunosuppressive therapy. This paper describes the clinical profile of a series of posterior scleritis cases highlighting varied clinical presentation, and the role of ultrasound and CT scan findings in the diagnosis.

Mammary coronary artery anastomosis without cardiopulmonary bypass through minithoracotomy: one year clinical experience

OBJECTIVE

The recent concept of minimally invasive coronary artery surgery in selected patients has dramatically affected surgical management of coronary artery disease. We explored the possibility of coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy on beating heart.

METHOD

Minithoracotomy and direct coronary artery surgery without cardiopulmonary bypass (CPB) was attempted in 116 patients. The procedure was completed in 108 cases while in eight cases minithoracotomy was converted to mid sternotomy. In 107 cases, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery anastomosis was done through left anterior minithoracotomy and in one case LIMA to LAD and right internal mammary artery (RIMA) to right coronary artery (RCA) anastomosis was done through bilateral minithoracotomy. Left anterior minithoracotomy through 4th intercostal space and right anterior minithoracotomy through 5th intercostal space was used for left and right internal mammary artery dissection respectively. With this approach 4-8 cm length of mammary artery was easily dissected. Mammary coronary artery anastomosis were performed on a beating heart without CPB through window pericardiotomy. Two patients also underwent left carotid endarterectomy along with LIMA to LAD anastomosis. In two patients complementary percutaneous transluminal coronary angioplasty (PTCA) to circumflex artery was done 5 days after minithoracotomy and LIMA to LAD anastomosis.

RESULTS

Forty-two patients were extubated in the operating room and 66 in the intensive care unit 2-10 h after surgery. Blood transfusion was used in one case who was reexplored for postoperative bleeding due to a displaced hemoclip from the internal mammary artery branch. None of these patients required inotropic support. Postoperative predischarge check angiogram in 53 cases revealed adequate mammary coronary flow in 51 cases, the remaining two had anastomotic problems, one was subjected to PTCA and the other for redo coronary bypass grafting through mid sternotomy. Doppler flow assessment of anastomosis was done in 102 cases, of which two showed problems which was confirmed on check angiography. One-hundred and six patients are in our regular follow-up (mean follow-up 10+/-1.5 months), 98 of them are in functional class I.

CONCLUSION

In our experience mammary coronary artery anastomosis without CPB through minithoracotomy is a safe, simple and minimally invasive procedure. Favorable cost/benefit ratio, has been achieved due to no early/late mortality and minimal early morbidity. Postoperative check angiogram and Doppler flow study revealed excellent mid term results.

Evaluation of endothelial function in postkeratoplasty eyes

BACKGROUND AND OBJECTIVE

To evaluate corneal endothelium function in postkeratoplasty eyes.

PATIENTS AND METHODS

Endothelial function was assessed in 23 clear corneal grafts. After a measurable corneal edema was induced by soft contact lens wear, serial pachometric readings were taken for 3 hours to arrive at the percentage recovery per hour (PRPH) index.

RESULTS

The assessed PRPH values of the clear corneal grafts ranged from 24.6% to 73.0%, with a mean value of 51.8% +/- 12.2%. Of the six corneal grafts that demonstrated an initial PRPH value of less than 47.5%, four became edematous within 6 months of follow-up.

CONCLUSIONS

Assessed PRPH, as an in vivo-measured index of endothelial function, is a valuable method for monitoring endothelial function in postkeratoplasty eyes. The low PRPH index identifies eyes at risk of spontaneous nonimmunologic failures.

Primary amenorrhoea: analysis of 48 cases

The clinical analysis of 48 patients of primary amenorrhoea seen at All India Institute of Medical Sciences, New Delhi for a period of 3 years, was performed. Twenty-six patients (54.2%) had muellerian anomalies, 11 (22.9%) had hypogonadotropic hypogonadism, 8 (16.6%) had hypergonadotropic hypogonadism and 3 (6.3%) had genital tuberculosis. The study highlights the role of transabdominal sonography in the work up of these cases. It suggests the reproductive potential of these cases by visualising the genital organs and makes laparoscopy and intravenous pyelography obsolete and selects the cases who deserve to be further investigated.

Correlation of radiological and pathological assessment of tumour volume with lymph node involvement in cancer cervix

The present study was carried out in 18 patients with carcinoma cervix stage IB through early IIB-Preoperative computerised tomography (C.T.) was done within seven days before surgery. Volume of tumour was determined from the C. T. films. Radical hysterectomy Type-III was performed in all 18 patients and specimens of cervix, parametrium and lymph nodes subjected to histopathological examination. Each specimen of cervix was cut into 4 to 12 equal sections depending on the size of the tumour mass. Cervical tumour volume was measured. Correlation of radiological with pathological tumour volume and of tumour volume with lymph node involvement was done. C. T. Scan was able to detect tumour mass accurately only four patients (Sensitivity 40%, Specificity 28.5%). In the Indian setting the conventional surgical approach appears to be the more appropriate.

Chronic renal failure in India

A prospective study of all new cases of chronic renal failure (CRF) including inservice referrals was done at our hospital over a period of 1 year from May 1994 to April 1995. The diagnosis of CRF was based on clinical, laboratory, and radiological features. Kidney biopsies were done when indicated. The patients were subdivided into various etiologic groups of primary renal disease according to standard criteria. There were a total of 835 cases of CRF with a median age of 43 years (range 10 days to 90 years); 67.8% of them were men. Glomerulonephritis (28.6%), diabetic nephropathy (23.2%), and interstitial nephritis (16.5%) were the most common causes of CRF, followed by obstructive nephropathy (6.4%), benign nephrosclerosis (4.1%), and polycystic kidney disease (2%). However, in patients more than 40 years of age, diabetic nephropathy was the most common cause (36.8%). The cause of CRF was unknown in 16.2% of the cases. One hundred twenty-one patients (14.5%) had an acute deterioration of their underlying renal dysfunction at presentation. This was most commonly due to accelerated hypertension (26.1%), infection (22.4%), volume depletion (20.1%), and drugs (14.9%). Anti-inflammatory drugs were the most common drugs responsible for the acute decline in renal function. One year after their initial presentation, of the 512 patients (61.3%) with end stage renal disease, 12.5% had died, 17% had received a kidney allograft, 12.7% were on some form of maintenance dialysis, and 295 patients were lost to follow-up. Of the 323 patients with less severe illness, 7 died, 209 were on outpatient treatment, and 107 patients were lost to follow-up. We conclude that the pattern of CRF in India does not differ greatly from that in the developed countries. However, it carries a poorer prognosis due to late referral and limited availability and affordability of renal replacement therapy in India.

Comparison of outcome after stenting for de novo versus restenotic narrowings in native coronary arteries

Intracoronary stenting of de novo narrowings results in a lower restenosis rate when compared with percutaneous transluminal coronary angioplasty. We sought to determine whether intracoronary stenting for restenotic narrowings is associated with a worse outcome when compared with stenting for de novo narrowings. A total of 114 consecutive patients with 124 narrowings were retrospectively identified. Stents were deployed in 46 de novo (37%) and in 78 restenotic (63%) narrowings. The 2 groups were similar with respect to variables known to affect restenosis. Follow-up angiograms were available in 88% of patients at a mean of 6.3 +/- 3.3 months after stent implantation. At follow-up angiography, a significantly higher restenosis rate in the restenotic group was observed (p = 0.05). Restenosis risk could not be predicted from variables known at the time of stent implantation. However, the presence of angina at the time of follow-up was significantly associated with restenosis (p = 0.01). Kaplan-Meier survival curves for freedom from repeat target-site revascularization demonstrated a significant difference in the need for target-site revascularization between the de novo and restenotic groups over the first-year post-stent implantation (p = 0.01; relative risk = 1.94). Multivariate analysis identified restenosis as the indication for stenting (p <0.01), postprocedure percent stenosis (p = 0.01), and narrowing length (p = 0.01) as independent predictors for repeat target-site revascularization. When compared with de novo narrowings, restenotic narrowings have a worse outcome after stenting. A prospective, randomized trial comparing outcome after percutaneous transluminal coronary angioplasty and stents for restenotic narrowings would be useful.

Congenital megalourethra

Congenital non-obstructive dilatation of penile urethra (megalourethra) can result from absence of corpus spongiosum alone (scaphoid) or along with the absence of corpora cavernosa (fusiform). Associated urogenital or other systemic anomalies are usually present and require detection and appropriate management. Urethroplasty (Nesbitt) gives desirable results. Condition has been reviewed with report of a case.

Granulocytic sarcoma of uterine cervix as presentation of acute myeloid leukemia: a case report and review of literature

Localized extramedullary collection of leukemic cells is termed as granulocytic sarcoma. Incidences of 2-8% in acute myeloid leukemia have been reported in various autopsy studies. In female it usually involves ovary. Since most of such tumors are asymptomatic, they are detected only at autopsy. We report here a case who manifested as abnormal vaginal bleeding, large cervical mass, renal failure, and aspergillous fungaemia. The patient died before she could be treated. From the present report it would appear that granulocytic sarcoma at times may precede other manifestations of leukemia.

Diagnosis of a persistent coronary fistula after ventricular septal defect patch closure

Penetrating chest trauma can result in multiple clinical syndromes depending on the structures involved. Tamponade, valvular regurgitation, ventricular septal defect (VSD), conduction system abnormalities, and coronary lacerations have been reported. We report a case of right ventricular free wall laceration, VSD, and coronary artery fistula involving a septal perforator.

Mammary-coronary artery anastomosis without cardiopulmonary bypass through a minithoracotomy

BACKGROUND

Coronary artery bypass grafting has been based on cardiopulmonary bypass, myocardial protection, and the median sternotomy. The recent concept of minimally invasive coronary artery bypass grafting in selected patients has dramatically affected surgical management of coronary artery disease. Coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy is a procedure that is gaining acceptance.

METHODS

Fifty-one patients were operated on by minithoracotomy and direct coronary artery bypass grafting without cardiopulmonary bypass. Left internal mammary artery-to-left anterior descending coronary artery anastomosis was done in 50 patients, and in 1 patient, left internal mammary artery-to-left anterior descending artery and right internal mammary artery-to-right coronary artery anastomoses were constructed through bilateral minithoracotomies. Left anterior minithoracotomy through the fourth intercostal space and right anterior minithoracotomy through the fifth intercostal space were used for left internal mammary artery and right internal mammary artery dissection, respectively. With this approach, a 4- to 6-cm length of mammary artery was easily dissected. Mammary-to-coronary anastomosis was performed on a beating heart without cardiopulmonary bypass through window pericardiotomy.

RESULTS

Twenty-five patients were extubated in the operating room and 26 in the intensive care unit 4 to 6 hours after operation. None of these patients required blood transfusion or inotropic support. Postoperative predischarge angiography in 42 patients revealed adequate mammary-to-coronary flow in 40 patients. Doppler flow studies were also in accordance with angiographic findings. Forty-five patients are in our regular follow-up (mean follow-up, 6.23 +/- 1.34 months); 44 of them are in functional class I.

CONCLUSION

In our experience minithoracotomy is a safe, simple, and minimally invasive procedure. Favorable cost/benefit ratio has been achieved owing to no early or late mortality and minimal early morbidity. Postoperative angiography and Doppler flow study revealed excellent predictive long-term results.

Cornea stress test--evaluation of corneal endothelial function in vivo by contact lens induced stress

Reliable and valid assessment of corneal endothelial function is a critical input for diagnosing, prognosticating and monitoring progression of disorders affecting corneal endothelium. In 123 eyes, corneal endothelial function was assessed employing data from the corneal hydration recovery dynamics. Serial pachometric readings were recorded on Haag-Striet pachometer with Mishima-Hedbys modification before and after two hours of thick soft contact lens wear. Percentage Recovery Per Hour (PRPH) was derived from raw data as an index of endothelial function. Assessed PRPH in pseudophakic corneal oedema and Fuchs' endothelial dystrophy eyes (35.9 +/- 9.8%) was significantly lower than normal controls (61.9 +/- 10.5%). On employing receiver operation characteristics curve analysis the tested results demonstrated high sensitivity (87%) and specificity (92%) for detection of low endothelial function at PRPH cut off of 47.5%. Using this PRPH cut off, 80% of Fuchs' endothelial dystrophy and 93.3% of pseudophakic corneal oedema eyes could be demonstrated to have low endothelial function. A total of 66.7% of diabetic eyes also demonstrated PRPH of lower than 47.5%. Clear corneal grafts demonstrated PRPH values of 24.6% to 73.0%. Of 6 corneal grafts that demonstrated initial PRPH of lower than 47.5%, 4 failed within 4 to 6 months. Our data demonstrated high sensitivity and specificity of this corneal stress test. PRPH index was useful in quantifying endothelial function in clinical disorders including diabetes mellitus. The index PRPH was demonstrated to be useful in monitoring and prognosticating outcome of corneal grafts.

Sustained bundle branch reentry in a patient with hypertrophic cardiomyopathy and nondilated left ventricle

Ventricular tachycardia is a well-known complication in patients with hypertrophic cardiomyopathy. We report the case of a patient with hypertrophic cardiomyopathy with easily inducible monomorphic ventricular tachycardia. Electrophysiology study demonstrated that bundle branch reentry was the mechanism of the tachycardia. The tachycardia was rendered non-inducible by radiofrequency ablation of the right bundle branch.

An interesting unusual case of endometrial stromal sarcoma

An interesting case with an unusual presentation of endometrial sarcoma is described. This patient presented with a history of continuous vaginal bleeding 3 months following a full term caesarean section and perception of an enlarging abdominal mass. The physical examination revealed an enlarged uterus with a leiomyoma though there was no evidence of the same at the time of the caesarean section. A laparotomy was undertaken and the patient was found to have a large tumor with multiple polypoidal growths invading the myometrium through to the serosa. This was proven to be an endometrial stromal sarcoma on histopathology.

Foreign body in the heart

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In vivo evaluation of corneal endothelial function following cataract surgery

BACKGROUND AND OBJECTIVE

To quantify corneal endothelial function measured in vivo following extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation.

PATIENTS AND METHODS

Endothelial function was assessed in 18 patients using recovery of the corneal hydration rate following induced cornea swelling before and after ECCE and PC IOL implantation.

RESULTS

The mean percentage recovery per hour (PRPH) showed a significant decrease at 12 and 24 weeks after surgery compared with before surgery (P < .01). A decrease in PRPH of more than 5% was observed in 55.6% and 66.7% of the eyes at 12 and 24 weeks after surgery, respectively.

CONCLUSIONS

PRPH measured in vivo demonstrates decreased endothelial function following ECCE and PC IOL implantation. The PRPH measures even slight changes in endothelial function and could be useful in evaluating endothelial damage.

Graded corneal sensitivity for screening of diabetic retinopathy

Several alternative approaches to screen diabetics followed by referral of patients with retinopathy changes, are being investigated. The intent is to demonstrate usefulness of a cost effective, easy and valid screening test. We investigated in this report the efficacy of graded corneal sensitivity for screening presence of diabetic retinopathy. In 105 randomly chosen subjects with (70 subjects) and without (35 subjects) diabetes mellitus, corneal aesthesiometry and status of retinopathy was determined independently. Corneal sensitivity in subjects of diabetes mellitus without retinopathy (1.17 +/- 0.29 gm/mm2) was significantly different when compared to healthy controls (0.99 +/- 0.04 gm/mm2) (p < 0.01). Also corneal sensitivity in eyes with any type of retinopathy was significantly worse (1.94 +/- 1.33 gm/mm2) when compared to eyes without retinopathy. At a cut off value of 1.20 gm/mm2 the sensitivity and specificity of corneal hypoesthesia as a test to detect diabetic retinopathy was 86% and 74%, respectively. For detecting presence of proliferative diabetic retinopathy at a cut off value of 1.49 gm/mm2 the sensitivity and specificity were 89% and 80% respectively. These observations indicate that corneal hypoesthesia may be a reasonable indication of the presence of diabetic retinopathy and could be used to screen diabetic populations for retinopathy, after its validity is confirmed in larger studies.

In vivo quantification of corneal endothelium function

Reliable and valid quantification of functional status of the corneal endothelium is a desirable input to optimize monitoring and intervention strategies in clinical disorders affecting endothelium. We examined the validity and clinical usefulness of an in vivo corneal stress test in an age and sex matched sample of 15 eyes each of normal controls, pseudophakic corneal edema and Fuchs' dystrophy. The test measures Percentage Recovery Per Hour (PRPH) as endothelial function by evaluating the deswelling response of cornea. In pseudophakic corneal edema assessed PRPH is significantly lower than in normal cornea (p < 0.01). At optimum critical cut off PRPH of 47.5%, the test has high specificity and sensitivity (93.3%) in pseudophakic corneal edema eyes, which validates the test. When baseline corneal thickness is more than 0.55 mm, PRPH is determined to be below the cut-off value in 100% of eyes. In eyes where baseline corneal thickness is less than 0.55 mm, PRPH ranges from 26.7% to 76.8%. We conclude that the in vivo corneal stress test quantifies endothelial function reliably and when compared to age specific normal eyes, it helps in identifying and monitoring low endothelial function.

Radiation-induced cardiovascular dysfunction

Coronary artery disease and valvular dysfunction are long-term complications of mediastinal irradiation. We describe 3 patients who underwent successful combined coronary artery bypass grafting and valve replacement for symptoms related to radiation-induced coronary artery and valvular disease.

In vivo assessment of corneal endothelial function in diabetes mellitus

OBJECTIVE

To evaluate in vivo corneal endothelial function in patients with non-insulin-dependent diabetes mellitus with or without diabetic retinopathy.

METHODS

In age-matched samples of 45 eyes of diabetic patients and 15 eyes of healthy control subjects, corneal endothelial function was evaluated by using pachometric measurements of the cornea following hydrophilic contact lens wear of low oxygen transmissibility. Corneal deswelling regression was quantitated to arrive at the percentage recovery per hour as an index of endothelial function. The status of retinopathy was determined in diabetic patients by using standard criteria.

RESULTS

In patients with diabetes mellitus and diabetic retinopathy, the assessed mean (+/- SD) value for the percentage recovery per hour following contact lens-induced edema was 40.03% +/- 7.27%, which was significantly lower than in eyes without changes of diabetic retinopathy (54.31% +/- 6.88%). Also, diabetic patients without retinopathy had a significantly lower percentage recovery per hour than did healthy control subjects (65.27% +/- 12.02%).

CONCLUSIONS

This study demonstrates significantly lower corneal endothelial function in patients with non-insulin-dependent diabetes mellitus and thus suggests a higher potential to decompensate following any deleterious stress.

Tropism of human adenovirus type 5-based vectors in swine and their ability to protect against transmissible gastroenteritis coronavirus

The infection of epithelia] swine testicle and intestinal porcine epithelial (IPEC-1) cell lines by adenovirus type 5 (Ad5) has been studied in vitro by using an Ad5-luciferase recombinant containing the firefly luciferase gene as a reporter. Porcine cell lines supported Ad5 replication, showing virus titers, kinetics of virus production, and luciferase expression levels similar to those obtained in human 293 cells, which constitutively express the 5'-end 11% of the Ad5 genome. The tropism of Ad5-based vectors in swine and its ability to induce an efficient immune response against heterologous antigens expressed by foreign genes inserted in these vectors has been determined. Ad5 vectors replicate and express heterologous antigens in porcine lungs and mediastinal and mesenteric lymph nodes. Significant levels of heterologous antigen expression were also demonstrated in the small intestine (jejunum and ileum), but Ad5 replication in this organ was very poor, suggesting that Ad vectors undergo an abortive replication in the porcine small intestine. The tissues infected by Ad5 were dependent on the inoculation route. The oronasal route appeared to be best for inoculation of bronchus-associated lymphoid tissue infection, while the intraperitoneal route was best for gut-associated lymphoid tissue infection. Epithelial cells of bronchioles, macrophages, type II pneumocytes, and follicular dendritic cells were identified as targets for Ad5, while epithelial cells of the intestine were not infected by Ad5. Viruses with a deletion from 79.5 to 84.8 map units in the E3 region, with or without heterologous inserted genes, replicated to lower levels in porcine tissues than did wild-type Ad5. It was also shown that an Ad5 recombinant expressing the four antigenic sites (A, B, C, and D) of transmissible gastroenteritis coronavirus (TGEV) spike protein induced in swine immune responses which neutralized TGEV infectivity. In addition, porcine serum from Ad-TGEV-immune animals provide passive protection when mixed with fully virulent TGEV and orally administered to highly susceptible newborn piglets. These results taken together indicate that swine may be a good animal model for human Ad5 lung infection to aid in the evaluation of candidate adenovirus vaccines and that Ad5 may be suitable as a recombinant viral vaccine or for other applications in swine.

Plasma platelet aggregating factor and platelet aggregation studies in pre-eclampsia

OBJECTIVE

A plasma platelet aggregation factor (PAF) has been implicated in the pathogenesis of platelet activation in thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Similar mechanism may be operative in pre-eclampsia.

METHODS

Coagulation profile and detailed in vitro platelet aggregation with various agonists were studied. PAF was demonstrated by spontaneous aggregation of normal platelets with test plasma. Non-parametric Wilcoxon's rank sum test and Krauskal Wally's one way analysis of variance were applied.

RESULT

Twenty-two pre-eclamptic patients and 20 normal pregnant controls were studied. Anti-thrombin III levels were within normal range and fibrin degradation products were only border line raised ( > 10 < 40 micrograms/ml) in 14 (65.4%) patients. In vitro platelet aggregation was abnormal in 17 (77.2%) patients. PAF was demonstrable in 10 of 22 (45.5%) patients.

CONCLUSION

Platelet aggregation studies indicated the presence of both activated (hyperaggregable) as well as exhausted (hypoaggregable) platelets in circulation. PAF demonstrable in 45.4% pre-eclampsia patients would suggest its role in the pathogenetic mechanism of platelet activation in this disease.

Fragile 'X' syndrome. A case study

Fragile 'X' syndrome also known as the Martin-Bell syndrome or the marker 'X' syndrome is an 'X'-linked disorder with connective tissue dysplasia and varying degree of mental retardation. A case of this syndrome with characteristic Martin-Bell phenotype is presented. Oral features as yet unmentioned are added.

Sequential external counterpulsation: an adjunctive therapy for patients with chronic coronary artery disease and left ventricular dysfunction

We assessed the clinical and haemodynamic improvement with 3 weeks of sequential external counterpulsation (SECP) therapy in 23 patients with chronic coronary artery disease (CAD) and left ventricular (LV) dysfunction who were refractory to maximal tolerated doses of medical therapy and in whom intervention or surgery was not contemplated. All patients were subjected to one-hour duration of SECP for 3 weeks. SECP is a new noninvasive tool which increases coronary artery filling utilizing external pressure in a sequential manner from calf to thigh. A detailed clinical and echocardiographic evaluation was done before and after the completion of therapy to assess the utility of SECP. There were 18 males and 5 females with a mean age of 53 years. On coronary angiography, 39 percent patients had single, 8.7 percent had double and 48 percent had triple vessel disease. Four patients had coronary artery bypass graft (CABG) surgery in the past. Out of all patients, 48 percent had diffuse or distal coronary artery disease which was considered not suitable for CABG, 22 percent were not willing for intervention and 30 percent had other systemic diseases making them unfit for surgery. After 3 weeks of SECP, the anginal frequency reduced from 9 episodes/week to 1 episode/week. Before SECP, 74 percent patients were in NYHA class III, whereas only 8.7 percent were class III symptomatic after SECP. All patients claimed symptomatic improvement of a mean of 6.8 +/- 1.4 on a visual analog scale of 1-10. After SECP, the LV diastolic dimensions reduced from 54.6 +/- 7 to 51 +/- 7 mm, systolic dimensions reduced from 40 +/- 8 to 36 +/- 8 mm and LVEF increased from 32.7 +/- 9 to 37.4 +/- 8.5 percent. In conclusion, 3 weeks of therapy with SECP produces significant improvement in symptomatic status and cardiac function in patients with chronic CAD and LV dysfunction, refractory to medical therapy.