Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography

The effect of medium pH on the activity of cultured human osteoblasts was investigated in this study. Osteoblasts derived from explants of human trabecular bone were grown to confluence and subcultured. The first-pass cells were incubated in Hepes-buffered media at initial pHs adjusted from 7.0 to 7.8. Osteoblast function was evaluated by measuring lactate production, alkaline phosphatase activity, proline hydroxylation, DNA content, and thymidine incorporation. Changes in medium pH were determined from media pHs recorded at the beginning and end of the final 48 h incubation period. As medium pH increased through pH 7.6, collagen synthesis, alkaline phosphatase activity, and thymidine incorporation increased. DNA content increased from pH 7.0 to 7.2, plateaued from pH 7.2 to 7.6, and increased again from pH 7.6 to 7.8. The changes in the medium pH were greatest at pHs 7.0 and 7.8, modest at pHs 7.4 and 7.6, and did not change at 7.2, suggesting that the pHs are migrating towards pH 7.2. Lactate production increased at pH 7.0 but remained constant from 7.2 to 7.8. These results suggest that in the pH range from 7.0-7.6 the activity of human osteoblasts increases with increasing pH, that this increase in activity does not require an increase in glycolytic activity, and that pH 7.2 may be the optimal pH for these cells.     

Intermediate syndrome: electrocardiographic, angiographic and clinical characteristics and their development under medical treatment

Diffuse interstitial pulmonary fibrosis was detected in 64 patients (33 males and 31 females). The diagnosis was obtained in each case from the anamnesis, the clinical findings, the chest X-ray, disturbances of the respiratory function, and from the progress of the disease. The analysis of the material produced the following parameters ranging from indicative to typical: Dry cough was reported by 70% of the patients as being trouble-some. Dyspnoea on exertion and at rest existed in 95%, and gradually increased during the progress of the disease in 76,5% of these cases. On auscultation ear-near crepitant rale was heard in 78% above the affected pulmonary parts. In 62 patients (96,5%) the radiogram showed disseminated streaky-reticular as well as finely to coarsely mottled infiltrations. In more than half of these cases (53%) an increase in severity was observed during the follow-up. A predominantly restrictive disturbance of ventilation existed in 85,5%. Exclusive restriction was found in 65,5%. Effort hypoxemia was detected in 92% of our cases which was especially impressive when the arterial oxygen pressure at rest was within the normal range. The electrocardiographic findings seemed to be less unequivocal. All in all it can be stated that in the synopsis of its manifestation DIPF can be positively identified by clinical means. This fact as well as therapeutical problems are discussed taking available publications into consideration, and respective conclusions are drawn for the clinician.     

Transjugular intrahepatic portosystemic shunt: midterm clinical and angiographic follow-up

The synthesis of a series of azabicyclic indole esters is described and their potency reported as 5-HT4 receptor antagonists. Optimization of the most potent compound (19) by preparing the corresponding oxazino[3,2-a]indole ester afforded 34, which had a pIC50 of 9.5 in the guinea pig distal colon longitudinal muscle myenteric plexus preparation.     

The impact of balloon material and lesion characteristics on the incidence of angiographic and clinical complications of coronary angioplasty

To assess the importance of balloon material used for percutaneous transluminal coronary angioplasty (PTCA), we compared the complication rates observed with low complaint plastomer (PM 300), intermediately compliant polyethylene (PE 600), and highly compliant polyolefin copolymer (POC) balloons. In a total of 1,650 procedures, one of these balloon materials was used to dilate 2,040 lesions. The dissection rate tended to be slightly lower with the use of more compliant balloon material. The total clinical complication rate (death, emergency coronary surgery, myocardial infarction, need for bail-out stenting or for prolonged heparin treatment, abrupt out-of-laboratory vessel closure) was 8.1%, 7.4%, and 4.2% in the procedures exclusively performed with PM 300 (N = 653), PE 600 (N = 543) and POC (N = 454) balloons, respectively (P = 0.03). In multivariate analysis, the use of less compliant balloon material emerged as an independent correlate of clinical complications (P = 0.007). However, the predictive power of the lesion complexity (B2, C versus A, B1) was four times stronger. In contrast to current concerns, the use of compliant balloon material seems at least as safe as the use of less compliant material.     

Computed tomographic angiographic imaging of abdominal aortic aneurysms: implications for transfemoral endovascular aneurysm management

Guinea pig pancreatic segments were superfused during 10 min with physiological saline solutions containing 10(-6) M acetylcholine (ACh) or histamine (10(-3)-10(-6) M) and the potassium concentration in the effluent [K+]o) was measured by flame photometry. Histamine evoked a transient increase in [K/]o. The removal of calcium from the superfusing solution and addition of 10(-4) M EGTA caused a significant reduction in the histamine-evoked potassium outflow. Replacement of chloride (Cl-) in the physiological salt solution by nitrate (NO3-) caused a significant reduction in the histamine-evoked potassium release. However, when Cl- was replaced by bromide (Br-) the response to histamine was unaffected. Pre-treatment of pancreatic segments with furosemide (10(-4 M) or ouabain (10(-3) M) caused a marked reduction in the histamine-induced potassium release. The results suggest that ionic requirements in histamine-evoked potassium release are the same as those in acetylcholine-evoked potassium efflux.     

Penetrating atheromatous ulcer of the thoracic aorta. Apropos of a case]

The authors report a case of penetrating atheromatous ulceration of the descending thoracic aorta complicated by a haemothorax. Atheromatous ulceration of the aorta is usually observed in elderly hypertensives. It is caused by rupture of the internal elastic layer under an atheromatous plaque extending into the media and resulting in a parietal haematoma of the aorta. Clinically, the differential diagnosis is that of a dissection of the aorta or of fissuration of an atheromatous aneurysm. Nowadays, the investigations of choice are a chest CT scan with injection of contrast and MRI. Transoesophageal echocardiography excludes dissection of the aorta but may miss a direct image of penetrating ulcer when the latter is of small size. The treatment of choice is not established because the natural history of the condition is not well known. Penetrating ulcer would seem to progress slowly to development of an aortic aneurysm. Surgery is mainly reserved for forms complicated by painful recurrences or rupture and for cases involving the ascending aorta.     

Orthostatic tremor: clinical and electrophysiologic characteristics

Orthostatic tremor, sometimes known as "shaky legs syndrome," is a disorder of middle-aged or elderly people characterized by feelings of unsteadiness in the legs and a fear of falling when standing. Patients stand on a wide base but walk normally. These symptoms are due to high-frequency (13-18 Hz) burst firing in weight-bearing muscles. They are attenuated by walking and are abolished immediately by sitting. Some authors believe that the disorder is a variant of essential tremor. This study reports the clinical and electrophysiologic features of orthostatic tremor in 30 patients. The findings indicate that orthostatic tremor is distinct from essential tremor, both clinically and electrophysiologically. The major differences are the frequency of electromyographic burst firing, the invariable involvement of lower limb and paraspinal muscles, and the task-specific nature of the tremor in orthostatic tremor. The study shows that the diagnosis can be established rapidly with surface electromyographic recordings.     

Intracoronary artery thrombus formation in unstable angina: a clinical, biochemical and angiographic correlation

OBJECTIVES: We examined the relation between the level of urinary fibrinopeptide A and the presence of angiographic intracoronary thrombus in patients with unstable angina to determine whether this marker predicts active thrombus formation. BACKGROUND: Although it is known that thrombus plays a role in acute ischemic syndromes, a noninvasive method to predict its presence in individual patients with unstable angina has not been determined. Fibrinopeptide A is a polypeptide cleaved from fibrinogen by thrombin and thus is a sensitive marker of thrombin activity and fibrin generation. METHODS: Angiographic thrombus, graded 0 to 4, and the presence of ST segment depression or T wave inversions, or both, on the electrocardiogram (ECG) were related to fibrinopeptide A levels in 24 patients with rest angina of new onset, 18 with crescendo angina, 19 with stable angina and 9 with chest pain but without coronary artery disease. All patients had chest pain within the 24 h of sample acquisition. RESULTS: The angiographic incidence of thrombus was significantly higher in patients with new onset of rest angina (67%, p < 0.001) and crescendo angina (50%, p < 0.001) as were fibrinopeptide A levels (p = 0.002). Fibrinopeptide A levels correlated significantly (p < 0.001) with the presence of a filling defect (grade 4 intracoronary thrombus) or contrast staining (grade 3). All patients with fibrinopeptide A > or = 8 ng/mg creatinine showed grade 3 to 4 thrombus and 15 of 16 patients with levels > or = 6.0 ng/mg creatinine exhibited angiographic evidence of thrombus (13 with grades 3 to 4). Patients with reversible ST changes on the ECG had significantly higher levels of fibrinopeptide A (p < 0.001), and ST changes correlated significantly with the presence of angiographic thrombus (p < 0.001). Nonetheless, a significant minority of patients with unstable angina had neither angiographic nor biochemical evidence of thrombus. CONCLUSIONS: Elevated fibrinopeptide A levels in unstable angina reflected active intracoronary thrombus formation and were present in patients with angina of new onset as well as crescendo angina. Reversible ST changes are accompanied by thrombin activity and angiographic thrombus formation. However, a sizable percentage of patients with unstable angina had no evidence of thrombus and these patients may have had transient platelet aggregation without fibrin thrombus formation.     

Long-term angiographic and clinical outcome of patients undergoing multivessel coronary stenting

BACKGROUND: Randomized clinical trials have shown that multivessel coronary angioplasty is feasible and provides similar long-term survival as bypass surgery in selected patients. However, the higher need for repeat intervention, in particular, coronary artery bypass graft surgery, remains a problem. The objective of this study was to test the hypothesis that multivessel stenting is safe and effective in reducing the need for repeat interventions, in particular, the need for bypass surgery. METHODS AND RESULTS: Between March 1993 and June 1995, 100 consecutive patients (243 lesions) had multivessel coronary stenting. High-pressure stent optimization was used in all patients. Procedural success was achieved in 97% of lesions; 2 patients (2%) required emergency bypass surgery. Angiographic follow-up was obtained in 89% of patients at 5.2+/-2.5 months. Angiographic restenosis occurred in 22% of the lesions, but 37% of patients had > or = 1 lesion with restenosis. Clinical follow-up was obtained in all patients at 21 +/- 10 months: target lesion revascularization was needed in 30 patients (30%), repeat angioplasty in 28 patients (28%) and coronary bypass surgery in 2 patients (2%); the overall survival rate was 96% (2% noncardiac death). CONCLUSIONS: Multivessel coronary stenting can be performed with high success rate and low need for emergency bypass surgery. Compared with historical results with multivessel percutaneous transluminal coronary angioplasty, patients who undergo multivessel stenting need less repeat interventions, in particular, less coronary bypass surgery and have similar long-term survival.     

Renal artery angioplasty for renovascular hypertension and preservation of renal function: long-term angiographic and clinical follow-up

OBJECTIVE: Percutaneous transluminal angioplasty of stenoses of the renal artery can be used to treat hypertension and renal insufficiency. Although many studies have been published on the short-term results of this procedure, few long-term studies are available. SUBJECTS AND METHODS: One hundred ninety-five patients (123 men and 72 women 19-79 years old; mean age, 56 years) with stenosis of the renal artery and hypertension underwent renal percutaneous transluminal angioplasty at our institution. The stenosis was unilateral in 66% of patients, bilateral in 26%, and in a solitary functioning kidney in 8%. Renal insufficiency was present in 31% of patients. After renal percutaneous transluminal angioplasty, long-term clinical and angiographic follow-up was evaluated by life-table analysis. RESULTS: In patients with fibromuscular disease, blood pressure returned to normal in 57%, improved in 21%, and was unchanged in 21%. In patients with atherosclerotic stenosis, blood pressure returned to normal in 12%, improved in 51%, and was unchanged in 37%. After percutaneous transluminal angioplasty, renal function improved in 48% of patients with renal insufficiency due to bilateral stenosis or stenosis in the single functioning kidney, whereas none of the patients with unilateral stenosis of renal artery and renal insufficiency had any notable improvement. Long-term follow-up showed a high rate (82%) of patency of revascularized arteries and a low rate (21%) of hypertension recurrence at 5 years. CONCLUSION: Renal percutaneous transluminal angioplasty is useful for treating hypertension and for reestablishing renal function. Its effects on blood pressure and renal function are long-lasting in the large majority of patients.     

Long-term clinical angiographic follow-up undergoing PTCA more than 10 years

Previously, it has been shown that human immunodeficiency virus (HIV)-1 envelope proteins gp160 and gp41 bind to Candida albicans. Whether this interaction affects candidal virulence in vitro was investigated. HIV-1 gp160 or gp120 treatment of C. albicans significantly altered neither growth nor phospholipase activity of the fungus. However, treatment of C. albicans with gp160, but not with gp120, led to an elevation of free and cell-bound aspartate proteinase. In addition, culture supernatants obtained from C. albicans treated with gp160 or gp41, but not with gp120, showed a strong increase in proteinase activity. Finally, C. albicans viable yeast cells treated with gp160 or gp41 and serum were phagocytosed by polymorphonuclear leukocytes to a lesser extent than was C. albicans treated with gp120 and serum or serum alone. These findings suggest that the interaction between HIV-1 gp160 and C. albicans may promote the virulence of C. albicans in HIV-1-positive patients.     

Short- and long-term clinical and quantitative angiographic results with the new, less shortening Wallstent for vessel reconstruction in chronic total occlusion: a quantitative angiographic study

OBJECTIVES: This study was designed to examine whether oversized implantation of the new, less shortening Wallstent provides a more favorable long-term clinical and angiographic outcome in chronic total occlusions than does conventional coronary balloon angioplasty. BACKGROUND: Restenosis and reocclusion remain major limitations of balloon angioplasty for chronic total occlusions. Enforced mechanical remodeling by implantation of the oversized Wallstent may prevent elastic recoil and improve accommodation of intimal hyperplasia. METHODS: Lumen dimension was measured by a computer-based quantitative coronary angiography system (CAAS II). These measurements (before and after intervention and at 6-month follow-up) were compared between the groups with Wallstent implantation (20 lesions, 20 patients) and conventional balloon angioplasty (266 lesions, 249 patients) for treatment of chronic total occlusion. Acute gain (minimal lumen diameter after intervention minus that before intervention), late loss (minimal lumen diameter after intervention minus that at follow-up) and net gain (acute gain minus late loss) were examined. RESULTS: Wallstent deployment was successful in all patients. High pressure intra-Wallstent balloon inflation (mean +/- SD 14 +/- 3 atm) was performed in all lesions. Although vessel size did not differ between the Wallstent and balloon angioplasty groups, acute gain was significantly greater in the Wallstent group (2.96 +/- 0.55 vs. 1.61 +/- 0.34 mm, p < 0.0001). Although late loss was also significantly larger in the Wallstent group (0.81 +/- 0.95 vs. 0.43 +/- 0.68 mm, p < 0.05), net gain was still significantly greater in this group (2.27 +/- 1.00 vs. 1.18 +/- 0.69 mm, p < 0.0001). Angiographic restenosis (> or = 50% diameter stenosis) occurred at 6 months in 29% of lesions in the Wallstent group and in 45% of those in the balloon angioplasty group (p = 0.5150). CONCLUSIONS: Implantation of the oversized Wallstent, with full coverage of the lesion length, ensures resetting of the vessel size to its original caliber before disease and allows greater accommodation of intimal hyperplasia and chronic vessel recoil. Wallstent implantation provides a more favorable short- and long-term clinical and angiographic outcome than does conventional balloon angioplasty for chronic total occlusions.     

Causes and clinical aspects of postoperative recurrent peptic ulcer

General practitioners as well as surgeons should be aware that there is a high recurrence rate after the "standard" operation (vagotomy and pyloroplasty) for duodenal ulcer. Recognition of recurrence is much delayed. The much lower recurrence rate, with similar morbidity and mortality rates, after vagotomy and antrectomy, make this the operation of choice at present. The high overall recurrence rate, the not inconsiderable operative morbidity and occasional mortality, and the high postoperative morbidity rate for peptic ulcer surgery indicate that such surgery is not to be undertaken without positive indications, such as the presence of complications. An operation undertaken solely because an ulcer recurs within, say, two years can no longer be justified.     

Systematic clinical and angiographic follow-up of patients undergoing minimally invasive coronary artery bypass

Acute HIV infection is associated with a vigorous immune response characterized by the proliferation of selected T cell receptor V beta (BV)-expressing CD8(+) T cells. These 'expansions', which are commonly detected in the peripheral blood, can persist during chronic HIV infection and may result in the dominance of particular clones. Such clonal populations are most consistent with antigen-driven expansions of CD8(+) T cells. However, due to the difficulties in studying antigen-specific T cells in vivo, it has been hard to prove that oligoclonal BV expansions are actually HIV specific. The use of tetrameric major histocompatibility complex-peptide complexes has recently enabled direct visualization of antigen-specific T cells ex vivo but has not provided information on their clonal composition. We have now made use of these tetrameric complexes in conjunction with anti-BV chain-specific monoclonal antibodies and analysis of cytotoxic T lymphocyte lines/clones to show that chronically clonally expanded CD8(+) T cells are HIV specific in vivo.     

The etiological and pathogenetic characteristics of duodenal peptic ulcer in adolescents

Studied by endoscopy were 100 adolescents with diagnosed duodenal ulcer, as were 100 essentially healthy subjects and 90 ones of the same age presenting with primary chronic gastroduodenitis together with 60 adults who had duodenal ulcer. The following items were etiologic risk factors for duodenal ulcer, if combined, in the above adolescent series: Frequent episodes nervous of tension, hereditary predisposition and helicobacteriosis. In juveniles with duodenal ulcer, secretion and motility of the stomach appeared to be subjected to changes to a higher degree than it was in adult subjects with duodenal ulcer, while functions of the psychovegetative and immune systems were found to be less changeable in the former. In adolescents presenting with duodenal ulcer and primary chronic gastroduodenitis, the etiologic risk factors and pathogenetic changes were found out to be identical.     

Predicting severe angiographic coronary artery disease using computerization of clinical and exercise test data

Currently the standard exercise test is shifting from being a tool for the cardiologist to utilization by the nonspecialist. This change could be facilitated by computerization similar to the interpretation programs available for the resting ECG. Therefore, we sought to determine if computerization of both exercise ECG measurements and prediction equations can substitute for visual analysis performed by cardiologists to predict which patients have severe angiographic coronary artery disease. We performed a retrospective analysis of consecutive patients referred for evaluation of possible or known coronary artery disease who underwent both exercise testing with digital recording of their exercise ECGs and coronary angiography at two university-affiliated Veteran's Affairs medical centers and a Hungarian hospital. There were 2,385 consecutive male patients with complete data who had exercise tests between 1987 and 1997. Measurements included clinical and exercise test data, and visual interpretation of the ECG paper tracings and > 100 computed measurements from the digitized ECG recordings and compilation of angiographic data from clinical reports. The computer measurements had similar diagnostic power compared with visual interpretation. Computerized ECG measurements from maximal exercise or recovery were equivalent or superior to all other measurements. Prediction equations applied by computer were only able to correctly classify two or three more patients out of 100 tested than ECG measurements alone. beta-Blockers had no effect on test characteristics while ST depression on the resting ECG decreased specificity. By setting probability limits using the scores from the equations, the population was divided into high-, intermediate-, and low-probability groups. A strategy using further testing in the intermediate group resulted in 86% sensitivity and 85% specificity for identifying patients with severe coronary disease. We conclude that computerized exercise ST measurements are comparable to visual ST measurements by a cardiologist and computerized scores only minimally improved the discriminatory power of the test. However, using these scores in a stratification algorithm allows the nonspecialist physician to improve the discriminatory characteristics of the standard exercise test even when resting ST depression is present. Computerization permitted accurate identification of patients with severe coronary disease who require referral.     

Spontaneous intracranial hypotension: clinical and magnetic resonance imaging characteristics

OBJECTIVE: To evaluate the antimicrobial susceptibility pattern of oxacillin susceptible (OSSA) and resistant Staphylococcus aureus (ORSA) isolates to other antimicrobial agents that can be used for the treatment of staphylococcal infections. MATERIAL AND METHOD: We evaluated 117 clinical S. aureus isolates from several S?o Paulo hospitals. Clinical isolates from Campinas, SP and from Jo?o Pessoa, PB, were also included. The in vitro susceptibility testing was performed by broth microdilution as described by the National Committee for Clinical Laboratory Standards (NCCLS). The minimum inhibitory concentration (MIC) was evaluated for 24 antimicrobial agents, including beta-lactams, fluoroquinolones, aminoglycosides, glycopeptides, macrolides, lincosamides and streptogramins. Both commercially available and experimental drugs were included in the study. Cross-resistance among fluoroquinolones was evaluated by susceptibility testing 24 isolates to 10 fluoroquinolones. RESULTS: The antimicrobial agents that showed the highest in vitro activity were the glycopeptides, the streptogramin RP-59.500, and the mupirocin (100% susceptibility). Eighty-seven percent of the OSSA and only 38% of the ORSA isolates were susceptible to ciprofloxacin (MIC50 0.25 microgram/mL and > 4 micrograms/mL, respectively). Cross-resistance among fluoroquinolones were noted even for the experimental drugs. Two fluoroquinolones remained active against ciprofloxacin-resistant isolates, clinafloxacin and WIN-57.273. However, the ciprofloxacin-resistant isolates had MICs eight-to 64-fold higher than the ciprofloxacin-susceptible isolates, suggesting that the MICs may continue to increase when these fluoroquinolones become commercially available. CONCLUSION: Our results showed a high rate of antimicrobial resistance among S. aureus from the Brazilian hospitals. Very few drugs can still be used for the treatment of staphylococcal infections.     

Penetrating ocular injuries: an epidemiologic and retrospective study

Penetrating injuries of the eye are an important cause of unilateral visual loss. We studied a series of 82 cases of penetrating injuries treated here from 1987 through 1993. The injuries were caused by sharp objects in 66% and blunt trauma in 6%. The prognosis after a penetrating injury is greatly influenced by the nature of the injury and the extent of the initial drainage. Among factors associated with an unfavorable visual outcome were diminished preoperative visual acuity and scleral wounds with dense vitreous hemorrhage.