Long-term results of percutaneous transluminal angioplasty in renovascular hypertension.

PURPOSE: The long-term effect of percutaneous transluminal renal angioplasty (PTRA) was assessed in 50 patients with renovascular hypertension. MATERIAL AND METHODS: Thirty-eight of the patients had atherosclerotic disease and 12 patients fibromuscular dysplasia (FMD). Dilatation with a balloon catheter were performed at 6 to 8 atm for 15 to 30 s. RESULTS: PTRA was technically successful in 46 (92%) patients. Three of the failures underwent surgical revascularization. There was no mortality connected with PTRA. Minor complications occurred in 6 (12%) patients, and surgical intervention was required in 1. In 4 patients with restenosis, repeated PTRA was performed in 2, and surgery in the other 2 patients. Bilateral disease occurred in 12 patients, and 3 had sequential bilateral PTRA. In 9 patients with atherosclerotic ostial stenosis, PTRA was technically successful in 8 (89%). Thirty-eight patients were re-examined with a mean follow-up of 4 years. At follow-up, 5 (45%) of the patients with FMD were classified as cured, 6 (55%) as improved, and none as failed. In the 27 patients with atherosclerotic disease, 23 (85%) had long-term benefit, 3 (11%) were cured, 20 (74%) were improved, and 4 (15%) were failures. In the 8 patients with ostial atherosclerotic lesions and successful PTRA, there was a 75% long-term benefit. Two patients died during follow-up, both from myocardial infarction. CONCLUSION: The result suggest that PTRA is effective in long-term management of renovascular hypertension, not only in patients with fibromuscular stenosis, but also in patients with atherosclerotic disease, even when ostial lesions are present.

Predicting of postoperative cardiac events using ambulatory ECG monitoring prior to abdominal aortic surgery.

OBJECTIVES: The purpose of this study was to estimate the value of preoperative electrocardiographic (ECG) monitoring in predicting postoperative cardiac events in patients undergoing abdominal aortic surgery. DESIGN: A prospective open study. SETTING: University Hospital. MATERIALS: One hundred consecutive patients were studied before aortic or aortofemoral surgery by ambulatory ECG monitoring for 24 hours. CHIEF OUTCOME MEASURES: An ischaemic episode by ECG criteria was defined as a > or = 1 mm horizontal or downsloping ST segment depression measured 60 msec after the J point and persisting for at least 40 sec. MAIN RESULTS: Twenty-four patients had preoperative ambulatory ischaemia. Twenty patients had postoperative cardiac events including three with fatal myocardial infarction, one with a nonfatal infarction, eight with unstable angina, three with pulmonary oedema and five with atrial fibrillation. Sixteen out of 24 (67%) patients with ambulatory ischaemia had postoperative cardiac events (p < 0.01). Only four events occurred among 76 patients without ischaemia (p < 0.005). The sensitivity of ambulatory ischaemia predicting cardiac events was 80% with a specificity of 90%, the predictive value of ischaemia was 67% and the predictive value of a negative result was 95%. CONCLUSIONS: Preoperative ECG monitoring for myocardial ischaemia could non-invasively identify patients at high risk for postoperative cardiac morbidity and mortality after vascular surgery.

Cardiac arrhythmias and myocardial ischemia after thoracotomy for lung cancer.

The records of 598 patients undergoing a thoracic surgical procedure for lung cancer from 1975 through 1989 were reviewed for occurrence of cardiac arrhythmias and myocardial ischemic events. Atrial tachycardias occurred in 16% (94/598); atrial fibrillation was preponderant (87%), followed by supraventricular tachycardia and atrial flutter. Patients with recurrent episodes of dysrhythmias had a significantly higher mortality rate than those without episodes or with a single episode only (17% versus 2.4%; p less than 0.01). Transient ischemic electrocardiographic changes were documented in 23 patients (3.8%) and myocardial infarction in 7 (1.2%). An abnormal preoperative exercise test result and intraoperative hypotension were strongly associated with both dysrhythmia and ischemia (p less than 0.01). Pneumonectomy, ischemic changes on the electrocardiogram, and cardiac enlargement were also associated with arrhythmias (p less than 0.01). A weaker association (p less than 0.05) was found between postoperative arrhythmias and old myocardial infarction (greater than 6 months), arterial hypertension, and heart failure. Pulmonary function had no predictive value in this respect. A history of angina or old myocardial infarction was predictive of transient postoperative myocardial ischemia but not myocardial infarction. Despite improved anesthetic and monitoring techniques and more frequent use of the intensive care unit postoperatively in the last decade, the incidence of arrhythmias after thoracotomy has not decreased. More effective prevention is needed, particularly for patients with defined preoperative and perioperative risk factors.

Giant cell arteritis and polymyalgia rheumatica in a region of Finland: an epidemiologic, clinical and pathologic study, 1984-1988.

The occurrence of giant cell arteritis (GCA) (considering temporal arteritis and polymyalgia rheumatica as its manifestations) was investigated in Western Nyland, Finland. Between 1984 and 1988 54 patients were diagnosed in a population of about 44,500. Fourteen patients (26%) had biopsy proven arteritis at the initial evaluation, and 2 patients became biopsy positive during followup. The retrospectively determined annual incidence of GCA in a 44 month period was 22.5/10(5) in the whole population, and 69.8/10(5) in residents aged 50 years or older. The corresponding figures of a prospective 16 month study were 30.4/10(5) and 94.4/10(5). The incidence rates of the prospective study are higher than those reported in comparable studies. Polymyalgia rheumatica, occurring alone or combined with cranial symptoms, was the most frequent manifestation of GCA, being present in 87% of patients.

Effect of verapamil on right ventricular pressure and atrial tachyarrhythmia after thoracotomy.

We have studied the effect of verapamil on the incidence of ECG changes and right ventricular pressures (RVP) in 25 male patients (aged 62 (SD 9) yr) undergoing thoracotomy in a placebo-controlled double-blind trial. Verapamil 0.01 mg kg-1 h-1 (n = 12) or saline (n = 13) i.v. was started after surgery and continued on the first day after operation with oral verapamil 80 mg or placebo, 8-hourly. Haemodynamic data were collected before operation and on three days after operation with the patients breathing air and then 60% oxygen (FIO2 0.60) for 10 min. Atrial tachyarrhythmia (AT) (4/13) and new ischaemic ECG changes (3/13) occurred only in the control group (P less than 0.05). With an FI02 of 0.21, systolic RVP increased by 54% on the first two days after operation in the control group and by 13% in the verapamil group (P less than 0.02). With an FIO2 of 0.60 for 10 min, systolic RVP decreased more in the control than in the verapamil group (P less than 0.01). In the control group, an increase in end-diastolic RVP (P less than 0.001) and central venous pressure (P less than 0.05) on the first day after operation was predictive of AT occurring on the second day.

Development of acute myelocytic leukemia in patients with Crohn's disease.

In our hospital within one year two patients with Crohn's disease were seen who developed an acute myelocytic leukemia. A review of the literature reveals eight previously reported patients with both Crohn's disease and leukemia. Six of the reported 10 patients have had acute myelocytic leukemia and, interestingly, three of them, including our two patients, have shown monocytic differentiation (FAB type M4). It has been suggested that the relative risk of leukemia, especially acute myelocytic leukemia, is increased in patients suffering from ulcerative colitis. More data of patients with Crohn's disease and acute leukemia are needed to evaluate the possible association between these diseases.

Long-term prognosis of surgical treatment of renovascular hypertension.

During the period 1974-1986, 71 patients were operated on for renovascular hypertension. Forty-eight patients had atherosclerotic disease and 23 patients had fibromuscular dysplasia. There was no operative mortality. Fourteen patients died during the follow-up, 12 of them from cardiovascular causes. The 57 surviving patients were reexamined with a mean follow-up of 7 years. The relative cumulative 5- and 10-year survival rates in all patients were 79% and 55%, respectively. At follow-up, seven (19%) of the atherosclerotic patients were classified as cured, 22 (59%) as improved and eight (22%) as failures. In the patients with fibromuscular dysplasia, 12 (60%) were normotensive without medication, and six (30%) were improved. The relative 5-year survival rates in these aetiological groups were 73% and 90%, respectively. Only complete cure of hypertension by surgery predicted a good outcome, whereas very similar survival curves were found in the improved and failed groups. This could be due to a higher incidence of target organ changes before surgery in the latter groups. A positive blood pressure response to long-term converting-enzyme inhibition correlated well with the response to surgery. Renal venous renin studies correctly predicted long-term outcome of surgery in 78% of the patients studied, but require careful preparation of the patients and interpretation of results.

Vitamin D status and concentrations of serum vitamin D metabolites and osteocalcin in elderly patients with femoral neck fracture: a follow-up study.

Vitamin D status and the serum osteocalcin concentration in patients with femoral neck fractures were studied as follows. Thirty-seven elderly patients (P) with fracture of the femoral neck were studied, whereas 24 age-matched persons (C) seen at the out-patient department for non-orthopaedic reasons served as controls. The dietary intake of vitamin D, estimated using a vitamin D score based on food items known to be the main sources of vitamin D, was significantly lower in the patients than in the controls. There was no difference in the serum 25-hydroxy-vitamin D (25-OH-D) (P: 22.3 +/- 7.5 nmol/l; C: 27.5 +/- 13.5) or the serum 1,25-dihydroxy-vitamin D3 concentration (P: 86 +/- 43 pmol/l; 31) C: 85 +/- 31) between the groups. The 25-OH-D concentration was, however, low as compared to reference values, suggesting vitamin D deficiency in both groups. There was no difference in the serum osteocalcin concentration between the groups (P: 3.1 +/- 1.7 micrograms/l; C: 3.4 +/- 1.5). One year later the serum osteocalcin concentrations (5.9 +/- 2.2 micrograms/l, n = 11) was significantly higher (P less than 0.005) in the patients than at the time of the fracture (3.2 +/- 2.2 micrograms/l), indicating an active bone turnover in the patients still present 1 year after the fracture.

Late results and prognosis after carotid artery surgery.

Carotid reconstruction was performed on 75 patients (84 operations) mainly because of transient ischemic attacks (TIA) and/or amaurosis fugax (67%) or TIA with incomplete recovery (20%). The operative mortality was 2.4%. The incidence of permanent postoperative neurologic deficit was 6.0%. The postoperative observation time was 1 year to 13 years 5 months (mean 66 months). At follow-up 87% of the survivors were symptom-free. Three new strokes, one of them not related to the operated side, occurred follow-up, and 26 more patients died. The relative cumulative 5-year survival was 87.3%. Of the total 28 deaths, 16 were due to myocardial infarction. Mortality was significantly heightened and cumulative 5-year survival reduced when preoperative ECG had indicated coronary heart disease. The high incidence of deaths from myocardial disease during long-term follow-up was directly related to preoperative presence of coronary heart disease.

Prediction of perioperative cardiac complications by electrocardiographic monitoring during treadmill exercise testing before peripheral vascular surgery.

ECG monitoring during treadmill exercise testing was performed in a prospective series of 105 consecutive patients with intermittent claudication scheduled for peripheral vascular surgery. ECG monitoring during the exercise test was useful in predicting perioperative cardiac complications. In 55 patients with evidence of coronary artery disease by history and ECG obtained at rest, a strong association (p less than 0.001) between an ischemic response to exercise testing and the occurrence of perioperative cardiac events was observed. ECG monitoring during the exercise test also revealed previously unsuspected ischemia or arrhythmias in six of the remaining 50 patients and predicted perioperative cardiac problems in four of these six. An ischemic response to low-level treadmill exercise testing probably indicates advanced coronary artery disease and offers valuable predictive information when a revascularization procedure is considered for the relief of intermittent claudication.

Postoperative myocardial infarction: a prospective study in a risk group of surgical patients.

Out of a total of 12,654 patients who underwent major surgery under general or regional anesthesia during a 3-year period, there were 12 postoperative myocardial infarctions in patients with no evidence of previous heart disease. From the same group of patients, a selected group of 214 patients with preoperative myocardial infarction or with ECG patterns suggesting left ventricular hypertrophy or subendocardial injury were studied preoperatively and reassessed by means of postoperative serial ECGs. Thirty-eight of these patients (17.7%) developed postoperative myocardial infarction, 18 of whom had ECG patterns of transmural and 17 of subendocardial infarction. In three other patients who died from cardiac arrest, transmural infarction was verified at autopsy. Eighty-five percent of all infarctions were detected within the first 3 postoperative days. Sixteen infarctions (32%) were fatal. Excluding three fatal cardiac arrests, 13 (37%) of the other 35 infarctions in the series occurred without clinical symptoms. Risk factors associated with increased infarction rates included intraoperative hypotensive episodes, preoperative hypertension, and previous myocardial infarction within six months. Type of surgery, anesthetic techniques, anesthesia of more than 3 hours' duration, patient factors such as diabetes, a history of chest pain, and age and sex did not significantly affect the rate of infarction. Postoperative myocardial infarction is a rare complication in patients who have no evidence of previous heart disease. Preoperative recognition of ischemic ECG changes and other risk factors demands ECG tracing for at least 3 days after surgery.

Severe gastrointestinal bleeding due to carcinoid tumour of the ileum.

Repeated episodes of severe intestinal bleeding in a 55-year-old male were found to originate from multiple small carcinoid tumours of the ileum. Laparatomy was performed after extensive negative endoscopic and radiological investigation of the bleeding site, and five tumours, 6 to 15 mm in diameter, were found within a 40 cm bowel segment. The most distal tumour was situated 50 cm from the ileocaecal valve. The site of bleeding was erosion of the bowel mucosa at the largest tumour. The affected bowel was excised, including its mesentery with two lymph nodes containing small islands of metastatic carcinoid tumour. Otherwise no metastases were found.

Haematologic findings in patients with renal carcinoma.

Haemoglobin concentration and leukocyte and platelet counts were studied in 122 patients with renal carcinoma, 104 of whom subsequently underwent nephrectomy. In 61 of the operable patients the tumour was located within the renal capsule (group I) and in the other 43 it had invaded the perinephric tissues (group II). Eleven of the group II patients also had distant metastases in one or two sites. Multiple distant metastases precluded renal surgery in 18 patients (group III). Normochromic anaemia (haemoglobin less than 120 micrograms/l) was found in 17% and leukocytosis (greater than 8 x 10(9)/l) in 25% of the group I patients. The corresponding frequencies for group III were 72 and 67%. Severe anaemia was found in patients with localized tumours as well as in patients with extensive metastases. Thrombocytosis (400-800 x 10(9)/l) occurred in less than 20% of the patients in groups I and II, but in 42% in group III. Thrombocytopenia (less than 200 x 10(9)/l), on the other hand, which was present in 31% of the group I patients, was less common in those with metastasizing tumours. Haematologic anomalies in renal carcinoma suggest either bone-marrow metastases of tumour-induced mechanisms such as production of erythropoietin or thrombopoietin and phagocytic and chemotactic effects of tumour cells or auto-immune processes. When uncorrected by nephrectomy in patients without signs of metastases, such haematologic findings suggest concomitant blood disorders.

Late results of surgical treatment for renovascular hypertension.

Over a 4-year period, 32 patients, 11 females and 21 males between 18 to 62 years of age (mean age 39 years) were operated on because of renovascular hypertension. Three patients were operated on bilaterally. The most common type of arterial reconstruction was aortorenal venous bypass. Early nephrectomy was performed in two patients, and secondary nephrectomy due to graft occlusion in four patients. There was no operative mortality. Seven patients died during follow-up, five of them of cardiovascular causes. The proportion of patients who were cured or improved by surgery throughout a follow-up of two to 72 months (mean 24 months) exceeded 87%. Nine of these 28 patients were normotensive, the other 19 were improved with less need of drugs following surgery. Four patients were failures. Lateralizing renal venous renin activity was found to be the best single criterion for prediction of improvement following surgery. In the majority of the patients who were cured after surgery, there was no preoperative heart hypertrophy and fundoscopic findings were normal or mildly pathological. A higher incidence of hypertensive changes in the target organs was observed preoperatively in the improved patients than in the cured ones.

Gonococcal perihepatitis in a surgical ward.

Within a three-year period six female patients with gonococcal perihepatitis were encountered. In the acute stage they had clinical symptoms indistinguishable from acute cholecystitis. In all six patients the diagnosis was established by positive growth of Neisseria gonorrhoeae from cervix specimens. Evidence of previous gonococcal pelvic infection was disclosed in three of the patients. In two patients the gonococcal aetiology of the disease was suggested by papular skin lesion and arthritis. Of the annual mean number of patients admitted to the emergency ward with suspicion of acute cholecystitis within the same three year period, 2.6% presented with gonococcal perihepatitis. As the incidence of gonorrhoea is increasing, complications such as perihepatitis are seen more frequently among young female patients admitted to surgical emergency wards because of acute abdominal pains.

Polymyalgia rheumatica and chronic lymphatic leukaemia.

A patient with polymyalgia rheumatica (PMR) is reported in whom, at the time of diagnosis, the number of lymphocytes in peripheral blood and bone marrow was normal. Lymphocytic infiltration typical of PMR was detected in renal and muscle biopsy specimens, and a liver fine-needle aspirate contained an abnormal lymphocytic infiltration, probably leukaemic. The number of lymphocytes gradually increased in bone marrow and peripheral blood until, almost 5 years after PMR had been diagnosed, a typical picture of chronic lymphatic leukaemia (CLL) was observable. The significance of the reported combination is discussed. The possibility is pointed out that a CLL in progress must be suspected when persistent lymphocytosis occurs in a patient with typical PMR, even if initially the response to treatment with corticosteroids suggests that PMR is the sole disorder.

Sarcoidosis with thyroid involvement, polymyalgia rheumatica and breast carcinoma. A case report.

Polymyalgia rheumatica developed in a 71-year-old patient within 2 years of the onset of acute sarcoidosis with biopsy-verified involvement of the thyroid, and concomitant autoimmune thyroiditis with hyperthyroid symptoms. Three years after the onset of muscle symptoms a non-metastasizing breast carcinoma was discovered and treated surgically. Neither the long interval between the onset of polymyalgia rheumatica and the discovery of the breast tumour, nor the good response of muscle symptoms to a one-year maintenance treatment with corticosteroids, was consistent with a paraneoplastic mechanism of the polymyalgia rheumatica syndrome. It was therefore hypothesized that the various disorders suffered by this patient might be related to a partly age-dependent depression of T-lymphocyte function, leading to an altered immunological reactivity to which the various clinical manifestations could be attributed. Such a hypothesis is supported by recent reports showing that in old people and in ageing experimental animals, a decrease in T-lymphocyte function and in the number of circulating T-cells occurs concomitantly with an increase in the incidence of a variety of neoplasms and autoimmune disorders.

Liver involvement in polymyalgia rheumatica.

The incidence of abnormal results in liver function tests was determined in 37 of 51 patients with polymyalgia rheumatica (PMR) or temporal arteritis. Fine-needle biopsies fo the liver were performed on 6 of these patients and the bile canalicular network and liver cytology were studied in the aspirate by enzyme-cytochemical methods. Of the 37 patients in whom it was measured, 23 (62%) had elevated concentrations of serum alkaline phosphatases (AP), mainly of hepatic origin. The concentrations of other serum enzymes associated with hepatic function were normal in all 37 patients. BSP retention was studied in 13 patients and was abnormal in 6 (46%). Three of the 4 patients for whom smears were stained for AP activity had an increase in this activity in their bile canaliculi that corresponded to a rise in the serum concentration of AP. In one of these 3 patients, smears stained for naphthylamidase showed that bile canaliculi had a calibre wider than normal and had granular walls. A second biopsy performed 10 days showed a partial reversal of these changes. Mild fatty infiltration of the liver cells was seen in 2 patients; one patient whose serum concentration of AP was normal also had normal liver cells and bile canaliculi. The structural changes in the bile canaliculi detected in one patient may be evidence of a subclinical hepatic disease associated with PMR. The cholestatic hepatic dysfunction, common in PMR and manifested in over half of our patients by elevated serum AP levels, can easily be confirmed with special staining methods for visualizing the bile canaliculi in cytological liver specimens.