Is coronary angiography necessary for vascular surgery patients who have positive results of dipyridamole thallium scans?

PURPOSE: Because dipyridamole thallium (DT) scanning is a useful predictor of perioperative cardiac events, a positive results of a DT scan is frequently the basis for performing more invasive cardiac evaluation and for consideration for performing coronary revascularization procedures before performing peripheral vascular surgery. The rationale for this approach has been that the treatment of anatomically significant coronary artery disease would lower the risk of performing a subsequent vascular operation. However, the benefit of performing aggressive diagnostic and therapeutic cardiac procedures in such patients remains unproved. To examine this issue, data from patients who underwent coronary angiography because of thallium redistribution were compared with data from matched control subjects who underwent peripheral vascular operations without further cardiac evaluation. METHODS: The medical records of 70 consecutive patients who underwent coronary angiography because of the presence of two or more segments of redistribution on DT scan were reviewed and compared with 70 other patients matched with respect to age, gender, peripheral vascular operation, and number of segments of redistribution on DT scan who did not undergo additional cardiac evaluation. RESULTS: DT scans were performed on 934 preoperative peripheral vascular surgery patients to help in the assessment of operative risk. Ischemic responses, defined as two or more segments of redistribution, were observed in 297. Of these, 70 underwent cardiac catheterization and 25 underwent coronary revascularization procedures. Adverse outcomes affected 46% of the coronary angiography group and 44% of the control group (p = NS). Patients who underwent coronary angiography and were considered for myocardial revascularization had fewer cardiac events with a subsequent vascular operation than did the control subjects. However, any possible benefit from invasive cardiac evaluation was offset by the three deaths and two myocardial infarctions (MIs) that complicated the cardiac evaluation. There was no significant difference between the angiography group and the matched control subjects with respect to perioperative nonfatal MI (13% vs 9%), fatal MI (4% vs 3%), late nonfatal MI (16% vs 19%), or late cardiac death (10% vs 13%). In long-term follow-up, MIs occurred later in patients who underwent coronary angiography than the control subjects (p = 0.049), but this difference was not associated with an improvement in the overall survival rate. CONCLUSIONS: The risks of extended cardiac evaluation and treatment did not produce any improvement in either the perioperative or the long-term survival rate. For most vascular surgery patients who have a positive result of a DT scan, coronary angiography does not provide any additional useful information.     

Leptin levels do not change acutely with food administration in normal or obese subjects, but are negatively correlated with pituitary-adrenal activity

Modern liver surgery is based upon deep knowledge of the surgical anatomy of the liver and improvements with ultrasounds imaging techniques have provided multidimensional interpretations of the liver anatomy intraoperatively. The technical advances with real-time scanning combined with the pioneering efforts of the Japanese liver surgeons have permitted the dynamic adaptation of the functional liver anatomy to the real anatomy, thus intimately aiding in segment oriented anatomical resection. Intraoperative ultrasound afford several advantages such as viewing the internal anatomy in direct relationship to the surface landmarks under the probe, enabling higher frequencies resulting in greater image resolution. The utilization of intraoperative ultrasound can modify the tactics involved with resection of both primary and metastatic liver tumours. The routine use of intraoperative ultrasound is strongly advocated since more complex procedures can be performed safely since the surgeon proceeds with complete knowledge of the real liver anatomy when deciding the feasibility and extent of liver resection.     

The updated guideline 'Gastric complaints' of the Dutch College of General Practitioners; a reaction from a general practitioner]

Three working diagnoses in gastric complaints are presented: aspecific gastric complaints, ulcer complaints, reflux complaints; these assist the general practitioner in formulating the initial diagnostic and pharmacological interventions and in evaluating the effects of therapy. The guidelines state that eradication treatment of Helicobacter pylori is indicated only in gastritis caused by H. pylori, grade IV bulbitis, a duodenal bulb malformation or peptic ulcers.     

Mutagenic consequences of the incorporation of 6-thioguanine into DNA

The stimulatory effect of phytin added to skim milk on acid production of Lactobacillus casei was examined. Phytin stimulated acid production of L. casei fairly well. The stimulatory effect of phytin on acid production was not shown when phytin was treated with Dowex 50 (H+) and neutralized by NaOH solution. The incinerated product of phytin maintained almost equal stimulatory effect on acid production as that before processing. The addition of Mn2+ in the amount contained in a reagent phytin augmented the stimulatory effect on acid production markedly. The further addition of Fe3+, Ca2+, Mg2+ and PO4(3-) in amounts corresponding to their contents in the preparation of phytin as well as Mn2+ increased the effect slightly. The four preparations of phytin contained 0.045-0.20% of Mn, and the greater the Mn content was, the greater the potentiation of acid production.     

Ornithine decarboxylase transformation of NIH/3T3 cells is mediated by altered epidermal growth factor receptor activity

Ornithine decarboxylase (ODC) has been shown to be oncogenic in transfected NIH/3T3 cells overexpressing the enzyme from a heterologous promoter. These cells, designated as NODC-2 cells, acquire proliferative properties associated with tumorigenic transformation such as loss of contact inhibition, decreased population doubling time, anchorage-independent growth, and tumor production in nude mice. At least one of these parameters, loss of contact inhibition, remains dependent on elevated ODC levels. We have used these cells to investigate the molecular mechanisms by which ODC overexpression drives cell transformation and to examine the involvement of other proto-oncogene products in this process. An interaction between ODC overexpression and the epidermal growth factor receptor (EGF-R) was suggested initially by the elevation of both basal (300%) and ligand-induced (457%) EGF-R tyrosine kinase activities in NODC-2 cells compared to similarly treated control NLK cells. Disruption of EGF-R mediated signal transduction in NODC-2 cells both by treatment with tyrphostin-25 or by transfection with a vector expressing a dominant negative EGF-R mutant resulted in reacquisition of contact-inhibited growth and suppression of anchorage-independent, clonogenic growth in soft agar. We conclude that ODC-induced transformation of NIH/3T3 cells is mediated, at least partly, by alterations in EGF-R signal transduction activity.     

Outcome of rheumatoid arthritis and psoriasis following autologous stem cell transplantation for hematologic malignancy

Based on successful results in animal models, it has been proposed that high-dose myeloablative therapy followed by autologous bone marrow or stem cell transplantation (ABMT/ASCT) may cure autoimmune disease. The coexistence of autoimmune disease and hematologic malignancy provides an opportunity to examine the response of autoimmune disease to ABMT or ASCT. We describe 4 patients with autoimmune disease (3 with psoriasis and 1 with rheumatoid arthritis) and hematologic malignancy. In each patient, the autoimmune disease remitted posttransplantation, but, in 4 patients with long-term followup, it recurred at 8-24 months. The earliest relapse occurred in a patient treated with interferon-alpha. Our experience suggests that a single autograft with unpurged stem cells is unlikely to cure autoimmune disease, but that other strategies building on this approach are worthy of investigation.