Hiatal hernia with upside-down stomach. Management of acute incarceration: case presentation and review of literature

Upside-down stomach (UDS) represents the rarest type of hiatal hernia (<5%) and is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. We present here a very rare complication of such a condition which is incarceration of upside-down stomach. A 54 year-old female was admitted to the emergency department presenting signs of acute epigastric pain radiating into thorax. Computed tomography revealed a giant hiatal hernia with incarceration of the gastric trunk. Immediate operation for reduction of the incarcerated stomach and repair of the hiatal defect was performed. The patient was discharged without any complication and was followed up at the surgical outpatient department. The presented case confirms that differentiation of an acute epigastric or intrathoracic pain in adults should always exclude presence of hiatal hernia which in case of incarceration should be treated by prompt surgical management.

Transportation with very long transfer delays (>90 min) for facilitated PCI with reduced-dose fibrinolysis in patients with ST-segment elevation myocardial infarction: the Krakow Network

BACKGROUND

The majority of ST-segment elevation myocardial infarction (STEMI) patients are admitted to centers without primary percutaneous coronary intervention (PCI) facilities. Purpose of the study was to determine safety and outcomes in STEMI patients with transfer delay to PCI>90 min receiving half-dose alteplase and abciximab before PCI (facilitated PCI with reduced-dose fibrinolysis).

METHODS AND RESULTS

Outcomes of 669 STEMI patients (<12 h chest pain, non shock, fibrinolysis eligible, <75 years) with transfer delay to PCI>90 min who received half-dose alteplase and full-dose abciximab and were immediately transferred for PCI were compared with primary PCI effects in 1311 patients with transfer delay <90 min. Mean time from symptom-onset to PCI was longer (357 ± 145 min vs. 201 ± 177; P<0.001) in facilitated PCI with reduced-dose fibrinolysis group. In-hospital and 12-month outcomes were similar in both groups, however bleeding events were more frequent in facilitated PCI group (hemorrhagic stroke 0.9% vs. 0%; P<0.001; severe+moderate 5.5% vs. 2.3%; P<0.001).

CONCLUSIONS

This is the first large report showing the safety and benefits of transportation with very long transfer delay (>90 min) for facilitated PCI with reduced-dose fibrinolysis in STEMI patients. In fact, pharmacological treatment (combotherapy) was effective in overcoming the deleterious effects of long time-delay on outcome, with similar survival as compared to short-time transportation, despite higher risk of major bleeding complication.

Management of myocardial infarction with ST-segment elevation in district hospitals without catheterisation laboratory--Acute Coronary Syndromes Registry of Małopolska 2002-2003

INTRODUCTION

Early reperfusion therapy significantly reduces mortality and improves outcome in ST-elevation myocardial infarction (STEMI). Primary percutaneous intervention has been proven to be a better therapeutic option than fibrinolysis when it can be performed by an experienced team of interventional cardiologists, within 90 minutes from the first medical contact. Despite the publication of guidelines of the European and American Scientific Societies (ESC and ACC/AHA), treatment of patients with STEMI is far from the optimum. The registry is an effective and reliable method to estimate the quality of treatment and demographic and epidemiologic characteristics of the population of a given region.

AIM

To evaluate the therapeutic strategies of treatment of STEMI in district hospitals without a catheterisation laboratory in Małopolska.

METHODS

29 district hospitals from Cracow and Małopolska province participated in the Registry of Acute Coronary Syndromes in Małopolska. Finally, 2382 patients with an initial diagnosis of acute coronary syndrome were included. In 867 of them, STEMI was finally diagnosed.

RESULTS

In district hospitals, most patients with STEMI (63%) did not receive any reperfusion therapy (25% of them were >75 years old, in 20% chest pain lasted longer than 12 hours, in 7% cardiogenic shock was diagnosed and 12% had contraindications for thrombolysis or were at increased risk of haemorrhagic complications). Fifteen percent of all 867 patients were transferred to the interventional cardiology centre (63% for primary PCI, 20% for facilitated PCI and the remaining 17% for rescue PCI). Fibrinolysis was applied in 21% of all patients with STEMI. In-hospital mortality rate was 14.3% in patients treated with fibrinolysis as compared to 15.9% in those treated conservatively. Multivariate logistic regression revealed that younger age (OR 0.93; 95% CI 0.91-0.95; p <0.0001), lack of diabetes (OR 0.54; 95% CI 0.30-0.98; p=0.04) and higher systolic blood pressure (OR 0.93; 95% CI 1.00-1.02; p=0.006) were independent factors predicting the referral of patients with STEMI for PCI. GP IIb/IIIa inhibitors were used in 5% of all patients and in 30% of those referred for PCI.

CONCLUSIONS

Only one in every 7 patients with STEMI is qualified for PCI. Patients transferred to the centre with PCI facilities are younger, have no diabetes or hypotension. The use of GP IIb/IIIa inhibitors is limited. There is a need to establish local networks of hospitals with 24-hour catheterisation laboratory availability to increase frequency and efficacy of reperfusion therapy, especially in regions far from centres of interventional cardiology.

Randomized, double-blind, multicenter trial comparing two doses of arzoxifene (LY353381) in hormone-sensitive advanced or metastatic breast cancer patients

BACKGROUND

This randomized, double-blind, phase II study assessed two doses of the selective estrogen receptor modulator arzoxifene in women with advanced breast cancer. The primary end point was to choose the best of two doses of arzoxifene based on the response rate or the clinical benefit rate (CBR). Pharmacokinetics and toxicities were also assessed.

PATIENTS AND METHODS

Ninety-two patients with advanced breast cancer received arzoxifene 20 or 50 mg/day. Tumor response was assessed using World Health Organization criteria. Toxicities were graded according to the National Cancer Institute Common Toxicity Criteria (NCI-CTC) system. Pharmacokinetic data were analyzed using the NONMEM software program (GloboMax, Hanover, MD, USA).

RESULTS

Response rates in the 20 mg arm were numerically higher than the 50-mg arm according to the investigator (40.5% versus 36.4%) and the independent review panel (42.9% versus 27.3%). CBR was higher in the 20 mg arm according to the investigator (64.3% versus 61.4%) and the independent review panel (59.5% versus 47.7%). Arzoxifene was well tolerated. There were no study drug-related deaths. Mean observed steady-state plasma concentrations of arzoxifene were 3.62 and 7.48 ng/ml for the 20 and 50 mg doses, respectively.

CONCLUSIONS

There were no significant differences in efficacy or safety between 20 and 50 mg of arzoxifene. Accordingly, arzoxifene 20 mg/day was selected for further study in patients with breast cancer.

[Assessment of myocardial reperfusion in patients with acute myocardial infarction treated with combination of fibrinolysis and IIb/IIIa platelet inhibitor]

Facilitated percutaneous coronary intervention (facilitated PCI) in acute myocardial infarction--the use of planned PCI after pharmacological reperfusion therapy, can fuse the best aspects of thrombolysis and primary angioplasty. The aim of the study was to assess microvacular reperfusion in patients with acute myocardial infarction treated with half dose of alteplase and full dose of abciximab followed by primary PCI.

METHODS

The study enrolled 100 patients with myocardial infarction within 12 hrs of chest pain onset in hospitals with at least 90 minutes of transportation time to interventional center. All patients received intravenous boluses of 60 U/kg heparin, 15 mg alteplase (r-tPA) and 0.25 mg/kg abciximab, and then infusions of: alteplase (35 mg/60 min) and abciximab (0.125 micrograms/kg/min for 12 hours) before transportation to interventional facility

RESULTS

Coronary angiography was performed at a mean 123 +/- 38 minutes after lytic therapy administration. In baseline angiography 73% of patients had TIMI 3 flow in infarct related artery. In 88 patients (90%) there was TIMI 2 + 3 flow. In 82 patients PCI was performed immediately after diagnostic catheterization, with angiographic procedural success rate of 92% (TIMI 3). Corrected TIMI frame count was 29.8 +/- 25.9 before and 17.2 +/- 9.5 after PCI. TIMI Myocardial Perfusion Grade 3 and 2 (MPG 3 + 2) was present in 77% of patients before and in 72% after PCI.

CONCLUSIONS

Combination of abciximab and half dose of alteplase was a very effective strategy in restoring flow in infarct related artery and achieving microvascular reperfusion. This model of pharmacological treatment could be utilized as pre-treatment for patients referred for primary PCI from remote hospitals.