MR angiography of the peripheral vasculature

MR angiography (MRA) for the evaluation of peripheral arterial occlusive disease is a rapidly evolving technique. Recent prospective clinical trials have indicated that MRA may play an important role in the evaluation of patients with peripheral arterial disease. This article discusses the pertinent technical aspects and limitations of peripheral MRA as well as some of the clinical data available.     

Regulation of pyruvate dehydrogenase activity and glucose metabolism in post-ischaemic myocardium

The realm of laparoscopic surgery has extended to include the neonate as well as the pediatric patient. The advent of new and smaller instrumentation has facilitated this goal. Previous procedures exclusively relegated to laparotomy can now be accomplished as outpatient procedures. Removal of the acute appendix, correction of torsion of an adnexa, as well as the appropriate diagnosis and initial treatment of acute pelvic inflammatory disease are now well established laparoscopic procedures. This article provides insight into the laparoscopic evaluation and management of a number of challenging clinical problems for the endoscopic surgeon, thus providing a minimally invasive approach for patients ranging from neonates to adults.     

Availability of health data: requirements and solutions

Cardiovascular stress testing remains the mainstay of provocative evaluation for patients with known or suspected coronary artery disease. Stress echocardiography has become a valuable means of cardiovascular stress testing. It plays a crucial role in the initial detection of coronary disease, in determining prognosis, and in therapeutic decision making. The purpose of this document is to outline the recommended methodology for stress echocardiography with respect to personnel and equipment as well as the clinical use of this recently developed technique. Specific limitations will also be discussed.     

Diagnosis and management of ischemic heart disease in the patient scheduled to undergo electroconvulsive therapy

The cardiovascular risk of electroconvulsive therapy (ECT) is a product of the stress of ECT itself and the severity and stability of coronary artery disease (CAD), as well as other cardiovascular factors. ECT itself represents a relatively low-risk procedure. Patient-specific risk can be defined by a combination of clinical evaluation and noninvasive testing, much of which is aimed at detecting the presence and staging the severity and stability of CAD. Patients at high risk of a cardiac complication include those with severe or unstable symptoms of CAD, and they should undergo extensive cardiac evaluation before ECT Patients at low risk likely need no further evaluation and can undergo ECT. Patients at intermediate risk should have careful clinical evaluation, and most likely noninvasive evaluation, which should include some form of stress testing. Medical therapy should be continued and/or maximized in all patients with CAD. It is expected that with careful screening, patients with established CAD can undergo ECT safely.     

Multiple system atrophy: clinical presentation and diagnosis

Multiple system atrophy (MSA) describes a relatively uncommon, debilitating disorder that is frequently misdiagnosed as Parkinson's disease. Patients with MSA show various combinations of parkinsonism, cerebellar ataxia, pyramidal signs and progressive autonomic failure, especially cardiovascular and urologic autonomic dysfunction. Few treatment options exist. Although some patients initially respond well to dopaminergic treatment for their parkinsonian symptoms, striatal degeneration occurs, and levodopa often becomes ineffective. Thus, physicians may provide only symptomatic treatment and support for patients with MSA. In this paper, we present a case study of a 68-year-old woman who came to the Vanderbilt Movement Disorders Clinic with severe autonomic dysfunction and parkinsonism, previously diagnosed as Parkinson's disease. Following autonomic function tests as well as clinical evaluation, she was diagnosed with MSA and began treatment for orthostatic hypotension and micturition dysfunction.     

Deoxypyridinoline and other biochemical markers of bone resorption in distinct pathologies

Collagen type 1 represents more than 90% of bone matrix. Therefore, quantitation of collagen crosslinks, such as deoxypyridinoline, can provide information on bone resorption degree. An evaluation was made of deoxypyridinoline as well as other bone markets, such as alkaline phosphatase, tartrate resistant acid phosphatase, and hydroxyproline in patients with the diagnosis of osteoporosis. Paget's disease, hyperthyroidism, and chronic renal failure on haemodialysis or not. Deoxypyridinoline levels were significantly increased in patients with osteoporosis, Paget's disease, and hyperthyroidism. Hydroxyproline levels were increased in patients with Paget's disease, and tartrate resistant acid phosphatase was increased in all the entities studied. Deoxypyridinoline can be a more sensitive marker than hydroxyproline, with some advantages, such as its quantitation in a urine specimen and its high bone specificity. In patients with renal failure, tartrate resistant acid phosphatase was the only biochemical marker of bone resorption with increased levels.     

What help and what confusion can imaging provide?

Low back pain is a very common but benign and, in general, self-limiting disease indicating that only a small proportion of patients will require sophisticated imaging studies. Recent studies have highlighted the fact that a simple relationship of structural abnormalities to low back pain is impossible because similar alterations can be found in symptomatic as well as in asymptomatic individuals. these findings question our current criteria for the diagnosis of low back pain disorders with regard to their discriminative power in differentiating diseased and non-diseased individuals. Structural abnormalities demonstrated by imaging studies should therefore only be interpreted in the light of the clinical findings. This review shows that only a few studies contribute to our understanding of the clinical efficacy of imaging studies in the evaluation of low back pain disorders. There is an absolute need for comprehensive, well conducted studies on the impact of specific imaging modalities on diagnosis and treatment of lumbar spinal disease.     

Pathogenesis of abnormal keratinization in ichthyosiform cetrimide dermatitis: an ultrastructural study

OBJECTIVE AND BACKGROUND: Orthotopic liver transplantation is both a difficult and a demanding surgical procedure. It is not unexpected that cardiovascular dysfunction is present in some individuals being evaluated for liver transplantation. Thus, all potential liver transplant recipients seen at this center undergo a full cardiac evaluation prior to being accepted for transplantation. The goal of this report was to review the components of the cardiovascular evaluation utilized at the Oklahoma Transplantation Institute and to determine their overall usefulness as well as the ability of the process to identify individuals at high risk for a cardiac misadventure during liver transplantation. MATERIALS AND METHODS: Between June 25, 1993 and June 30, 1995, a total of 154 consecutive patients with chronic liver disease were evaluated. The primary liver disease of each was established utilizing specific serologic and biochemical tests, ultrasonographic and abdominal tomographic findings, as well as hepatic histology results and hepatic iron and copper level determinations. Each liver transplant candidate underwent a full cardiac evaluation consisting of the following: nuclear ventriculography to estimate the left ventricular ejection fraction (at rest and during exercise), right ventricular ejection fraction, cardiac output, stroke volume and cardiac index; uptake images using thallium and adenosine to identify foci of cardiac ischemic or fixed defects; echocardiography to define the dimensions of the various cardiac chambers, wall thicknesses, cardiac contractility and morphology of the cardiac valves. Finally, coronary arteriography was performed in 26 patients (16.9%) who were suspected of having clinically important coronary artery disease. It should be noted that all of the cardiac evaluations were performed by a single cardiologist. RESULTS: Eight of the 154 potential liver transplant candidates (5.2%) were determined as not being eligible for liver transplantation because of an inadequate cardiac status based upon an initial history and physical examination. Forty-one of the remaining 146 patients (28.1%) underwent liver transplantation. The remaining 105 subjects have not been transplanted for reasons not related to the cardiac status. Eight of the 41 (19.5%) transplanted patients had a clinically advanced cardiac problem recognized prior to liver transplantation. Four of these eight required a specific cardiac intervention prior to liver transplantation consisting of coronary bypass surgery (n = 1), coronary artery balloon dilation (n = 2) or pericardiectomy (n = 1). The remaining four patients required no pretransplant cardiac intervention and were transplanted. None of these experienced any cardiac complications during, or in the 3 months following, the liver transplant procedure. Only one patient experienced a specific postoperative cardiac complication, consisting of an episode of high grave A-V block requiring transplant placement of a cardiac pacing device. This patient had hemochromatosis. CONCLUSIONS: Based upon this experience, it can be concluded that coronary artery disease per se is not an absolute contraindication for liver transplantation. With appropriate treatment, liver transplantation can be performed safely in individuals with confounding cardiac disease. Nuclear ventriculography and echocardiography are essential procedures in evaluating potential liver transplant recipients in an effort to exclude those with occult cardiomyopathy. Coronary arteriography is indicated only in selected cases with evidence of cardiac ischemia or infarction.     

Measuring health status in patients with skeletal metastases treated by surgery

Since the introduction of the Functional Living Index-Cancer (FLIC) > 10 years ago, a variety of general as well as disease-specific quality of life (QOL) instruments have been developed and used as a means of assessing the success of clinical interventions. Clinicians faced with selecting an appropriate QOL measurement tool will need guidance in both the selection of the instrument and its evaluation for applicability to the patient group under study. In our examination of this issue, we analyzed the results of administering the FLIC and the more general SF-36 questionnaire to a group of 17 patients who had undergone orthopaedic surgery to correct problems associated with bone metastatic cancer. Because the SF-36 has been widely adopted as a general Health Status evaluation tool and because of its extensive validation it may be considered a gold standard providing a means of assessing the validity of disease-specific instruments such as the FLIC. Using multivariate regression, we built a model in which five of the eight health status dimensions of the SF-36 account for 77% of the variation in the FLIC scores for this group of patients (R2 = 0.77). The implication of this result is that most of the information (i.e., 77%) provided by the FLIC could be equivalently obtained using the more general, more widely validated SF-36. Despite the small sample size, half of the regression coefficients in this model achieved a high level of statistical significance (p < 0.001). In addition, when applied to new patients, the model showed good predictive capability with relative error 2-20%. If these results can be replicated for other patient disease groups and in larger study populations, it may be possible to use the SF-36 as the primary QOL evaluation tool for cancer patients. The burden of this disease could then be more easily compared with that of other disease groups and the resulting standardization of QOL analysis would be simpler and more cost effective.     

Cholangiocarcinoma

Resection is indisputably associated with prolongation of survival in patients with cholangiocarcinoma and provides the only chance for cure. Equally as important is the ability to achieve microscopically clean margins at the time of resection. Liberal use of hepatic resection in conjunction with hilar vascular skeletonization may improve the ability to achieve disease-free margins and can be performed with little additional morbidity. Optimal treatment for the patient with unresectable disease is currently still debatable. Our experience, as well as others, suggests that patients who have unresectable disease by radiologic or laparoscopic evaluation are better served by nonsurgical internal biliary decompression. We currently favor nonoperative treatment with self-expandable wire mesh stents over operative biliary enteric bypass for nonresectional candidates. Patients who underwent resection who develop local recurrence with biliary obstruction also can be managed with metallic stents across the obstructed hepaticojejunostony to provide an additional period of symptomatic palliation.     

Case management study: polyarthritis with fever

In most cases, a thorough initial evaluation will reveal the cause of fever and polyarthritis. However, in some patients the initial diagnosis may be unclear and, as time passes, the characteristic clinical patterns emerge. Recurrent attacks are suggestive of other conditions such as crystal-induced arthritis, Lyme disease, and Mediterranean fever. In rheumatoid arthritis and Reiter's syndrome, the fever resolves and the articular findings predominate with the passage of time. Similarly, Still's disease is initially diagnosed on the basis of clinical criteria, and later confirmed by the evolution of chronic polyarthritis. Diagnostic approaches for the evaluation of patients presenting with acute arthritis have been published and are readily available (2,8,9). The most reliable way to establish the diagnosis for a rheumatic disease is thoughtful and thorough evaluation by an experienced clinician (3,10). Certain discriminating features and confirmatory tests can aid in the diagnosis of polyarthritis with fever (Tables 2 and 3).     

Immunochemical studies on some spermatozoal antigens

The authors report therapeutic results obtained in 190 patients with sciatic pains (110 men and 80 women). In 115 cases discopathy was the cause of sciatica, in 75 degenerative vertebral disease was present. The duration of the disease ranged from 6 months to 36 years. Four sets of procedures were used depending on the manifestations of the disease. In evaluation of therapeutic effects the mobility range of the spine, the tone of paravertebral muscles and disappearance of pain were taken into account. Complete improvement was obtained in 76% of cases on the average. It was observed that radon baths had mainly an analgesic effect, peat or paraffin poultices as well as diadynamics were particularly useful in cases with increased tonus of paravertebral muscles. Massage was contraindicated in these cases. Therapeutic exercises were useful in this disease, increasing significantly the mobility range of the spine.     

Complications of gastroesophageal reflux disease. Esophagitis, acid laryngitis, and beyond

Gastroesophageal reflux disease is a common disorder that can result in various esophageal and extraesophageal complications. Reflux of gastric contents can cause esophageal mucosal abnormalities, such as ulcers and peptic strictures, as well as pulmonary and otolaryngologic symptoms, including reflux-induced asthma and acid laryngitis. Left untreated, some complications can lead to more severe disorders, such as esophageal adenocarcinoma that develops in patients with Barrett's esophagus. Accurate recognition of these diverse manifestations allows improved identification of patients at risk for reflux-related disorders and aids in proper evaluation and treatment.     

Immunohistochemical evaluations of ultrashort-segment Hirschsprung's disease. Report of three cases

PURPOSE: Unlike classic Hirschsprung's disease, short-segment and ultrashort-segment varieties are usually found to be latent and milder. Ultrashort-segment Hirschsprung's disease may present as intractable chronic constipation in children over one year of age, adolescents, and adults. Anorectal myectomy has been shown in many instances to provide effective long-term treatment for certain patients with ultrashort-segment Hirschsprung's disease. Histologically, the affected segment in Hirschsprung's disease has been shown to have increased cholinergic nerves, lack of nitric oxide synthase-containing neuronal elements, and show moderate to severe loss of myenteric neurons. METHODS: Here, we report three cases that showed clinical and manometric evidence of ultrashort-segment Hirschsprung's disease. Two of the three patients responded well to myectomy. RESULTS: Detailed histologic and immunohistochemical evaluation of the internal anal sphincter and a comparison with three normal controls revealed absence of nitric oxide synthase-containing neurons in both cases that responded well to surgery and continued presence of these neurons in the patient who did not respond. A review of the current literature on various treatment modalities is included. CONCLUSIONS: Anorectal myectomy provides long-term relief of this chronic problem in a subgroup of patients with ultrashort-segment Hirschsprung's disease who lack nitrinergic neurons at the internal anal sphincter.     

Postexercise systolic blood pressure response: clinical application to the assessment of ischemic heart disease

Stress test parameters indicating the presence and extent of coronary artery disease have traditionally included such variables as exercise duration, and the blood pressure and ST-segment responses to exercise. The three-minute systolic blood pressure ratio, another important indicator of significant coronary artery disease, is a useful and readily obtainable measure that can be applied in all patients who are undergoing stress testing for the evaluation of known or suspected ischemic heart disease. The ratio is calculated by dividing the systolic blood pressure three minutes into the recovery phase of a treadmill exercise test by the systolic blood pressure at peak exercise. A three-minute systolic blood pressure ratio greater than 0.90 is considered abnormal and has a diagnostic accuracy of approximately 75 percent for the detection of coronary artery disease (i.e., an accuracy comparable to that of ST-segment depression). Higher values for the ratio are associated with more extensive coronary artery disease, as well as an adverse prognosis after myocardial infarction. Thus, the three-minute systolic blood pressure ratio provides information that is complementary to the traditional exercise test parameters for identifying high-risk ischemic heart disease.     

In vivo efficacy of SM-20302, a GP IIb/IIIa receptor antagonist, correlates with ex vivo platelet inhibition in heparinized blood but not in citrated blood

This study analyzed temporal changes of striatal dopamine-D2 receptor binding during the course of different extrapyramidal movement disorders using 123I-iodobenzamide (IBZM) SPECT. METHODS: Eighteen patients (9 with Parkinson's disease, 9 with parkinsonian plus syndrome) were followed for 11-53 mo. Dopamine-D2 receptor binding was assessed using 123I-IBZM SPECT at the beginning and at the end of the follow-up period. SPECT data were acquired 120 min postinjection of 3-5 mCi 123I-IBZM. A semiautomated algorithm was applied to the raw data for semiquantitative evaluation of regional cerebral receptor binding. RESULTS: Intraobserver (r = 0.992) and interobserver (r = 0.930) variance was low for the semiautomated interpretation of the SPECT examination of the dopaminergic D2 receptor binding, reflecting a highly reproducible SPECT algorithm. Mean specific dopamine-D2 receptor binding was lower in patients with parkinsonian plus syndrome compared to patients with Parkinson's disease on the initial (p < 0.001) as well as the follow-up study (p < 0.001). In patients with Parkinson's disease, we observed an unaffected receptor binding compared to a reduced binding of radiotracer in patients with parkinsonian plus syndrome during the course of the disease (p < 0.001). CONCLUSION: During the follow-up, patients with Parkinson's disease showed a constant dopamine-D2 receptor binding. In contrast, patients with parkinsonian plus syndrome revealed a decline of the binding of dopamine-D2 receptor. These findings are in agreement with histopathological data that demonstrated a preserved dopamine-D2 receptor status in patients with Parkinson's disease and a decline of the dopamine-D2 receptors in patients with parkinsonian plus syndrome. SPECT examinations using 123I-IBZM are useful for assessing dynamic changes of dopamine-D2 receptors in extrapyramidal movement disorders. Semiquantitative SPECT evaluations may provide valuable information for clinical management and prognosis of the patient with extrapyramidal movement disorders.     

Systematic analytic procedure for identification of unknown medicaments in biological material

Increase in blood pressure and its circadian alterations in Type 1 diabetes are usually associated with diabetic nephropathy. To evaluate if diabetes itself could be responsible for the observed increase in blood pressure levels, we studied a group of 17 normotensive, normoalbuminuric Type 1 diabetic patients with a disease duration more than 15 years, with no clinical evidence of autonomic neuropathy or ischaemic heart disease, and without any known determinant of hypertension, and a control group of 17 normal subjects, normotensive, each matched for sex, age, BMI, albumin excretion rate, and clinical blood pressure to a diabetic subject. In both groups an ambulatory blood pressure monitoring was performed through an oscillometric recorder. The mean systolic and diastolic ambulatory blood pressure values were significantly higher in diabetic patients (p < 0.001) in the 24-h analysis and during waking and sleeping periods. The night/day ratio of systolic and diastolic blood pressure were not significantly different in patients and controls, as well as heart rate values and heart rate variability. We conclude that mechanism(s) inherent to the diabetic condition other than diabetic nephropathy or autonomic neuropathy could be responsible for blood pressure evaluation in normotensive Type 1 diabetes with normoalbuminuria.     

Atherosclerotic vascular complications in diabetic transplant candidates

Serious vascular complications limit the success of renal transplantation in diabetic patients. Nearly half of diabetic transplant recipients die within 3 years after transplantation from a vascular complication. However, it has been difficult to determine before transplantation which patients are likely to do poorly. Because atherosclerosis is a systemic disease, we hypothesized that diabetic transplant candidates with pretransplant coronary artery disease would be at high risk for vascular complications even if asymptomatic at the time of pretransplant evaluation. Our hypothesis was that insulin-dependent (IDDM) transplant candidates with coronary artery disease identified with pretransplant coronary angiography would have an increased number of vascular events (amputation, cerebral vascular accident [CVA], or myocardial infarction [MI]) within 3 years of follow-up. We prospectively studied 198 consecutive diabetic transplant candidates grouped on the basis of coronary artery disease. Group 1 patients had no stenosis that was 50% or greater, group 2 patients had one or more stenoses between 50% and 74%, and group 3 patients had one or more stenoses of 75% or greater. During median follow-up of 41 months, 64 patients experienced 98 amputations, 28 MIs, and seven CVAs. At 36 months of follow-up, 55% of group 3 patients, 30% of group 2 patients, and 11% of group 1 patients had experienced a vascular event (P < 0.001). Cox regression confirmed the association of coronary artery disease with subsequent vascular events. Patients with coronary artery disease had a sevenfold increased risk of amputation and a fourfold increased risk of myocardial infarction. Six of seven CVAs occurred in patients with coronary artery disease. We conclude that coronary artery disease identified at pretransplant evaluation is associated with an increased risk of noncoronary vascular complications within 3 years after evaluation.     

The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies

Laparoscopic evaluation of patients with suspected periampullary malignancies has been utilized more frequently in recent years. Its exact role with regard to staging and surgical bypass for palliation have yet to be clearly defined. To better define the role of laparoscopy in the evaluation and palliation of periampullary malignancy, a retrospective review of the Duke experience was carried out. Fifty-three patients with suspected pancreatic or periampullary malignancies were referred for surgical evaluation at Duke University Medical Center between 1993 and 1995. All patients underwent CT scanning and lesions were classified as resectable or unresectable based on previously established criteria. Patients either underwent laparoscopic evaluation (n = 30; 11 with laparoscopic palliation) or proceeded directly to celiotomy (n = 23). Charts were reviewed for postoperative course including complications, length of stay, and hospital costs. Although laparoscopy had a sensitivity of 93.3% for metastatic disease, CT scans accurately staged 86.8% of patients missing only one patient with peritoneal/hepatic disease. Based on these results, laparoscopy may not be beneficial for every patient with a suspected pancreatic malignancy. Retrospectively an attempt was made to determine which patients benefited from laparoscopy and which patients are best served by proceeding directly to open exploration. From these data we devised an algorithm that outlines an efficient and cost-effective approach for this patient population.     

Providing dental treatment for patients with cardiovascular disease

The appropriate management of dental patients with cardiovascular disease is contingent on appropriate assessment and evaluation. Baseline vital signs, a good medical history and medical evaluation are all essential for the safe delivery of care. All patients with cardiovascular disease can be managed using the following guidelines: 1. Properly assess the patient. This should include an assessment by the dentist and also a medical consultation if required. 2. Establish what medications the patient is taking along with the dose and timing and note any potential drug interactions and side effects. 3. Use short appointments (less than one hour), preferably in the morning. 4. Premedication should be considered to alleviate anxiety. The intraoperative use of nitrous oxide and oxygen is also a reasonable strategy for patients with cardiovascular disease, particularly those with ischemic heart disease. 5. Effective local anesthesia is important in order to avoid undue stress during the appointment as long as the guidelines for the administration of epinephrine are followed. The use of epinephrine impregnated gingival displacement cord should be strictly avoided in patients with cardiovascular disease. 6. For patients with angina pectoris, a fresh supply of nitroglycerin should be available at the time of the appointment. Prophylactic nitroglycerin has been shown to be effective in the prevention of both hypertension and angina pectoris during dental treatment. The appointment should be terminated early if the patient becomes overly anxious. In the event of cardiovascular symptoms during dental treatment, all work should be stopped. Emergency measures should be instituted if necessary. Preparations for emergencies should be undertaken by all dentists. The treatment of patients with cardiovascular disease is relatively simple if the proper steps are taken. The use of blood pressure measurements on all patients will help to screen for undiagnosed hypertension and all patients who are potentially hypertensive should be referred for medical evaluation. A preventive approach to the treatment of these patients will serve to prevent untoward outcomes and provide safe and simple delivery of dental care for cardiovascular patients.