Effects of Premature Ventricular Complex Burden on Left Ventricular Global Longitudinal Strain in Patients without Structural Heart Disease.

Background: Evaluation of left ventricular (LV) function in patients with idiopathic premature ventricular contraction (PVC) with preserved LV ejection fraction (LVEF), especially in the subclinical stage, may be of great importance in terms of directing early treatment. Methods: A total of 122 patients, retrospectively recruited, were divided into three groups according to PVC burden: Group 1; 5% ≤ PVC < 10%, Group 2; 10% ≤ PVC < 15%, and Group 3; 15% ≤ PVC. Transthoracic echocardiography (TTE) was performed to evaluate LV parameters. Results: LV-GLS (Global longitudinal strain) was found to be significantly lower in groups 2 and 3 with high PVC burden (18.9% ± 1.4, 17.5% ± 2.1, 16.3% ± 1.3; p < 0.001, respectively). Correlation analysis revealed a positive and significant correlation between PVC burden and deterioration in LV-GLS (r: 0.536; p < 0.001). In addition, PVC burden was found to be an independent predictor of LV-GLS deterioration in multiple linear regression analysis (ß: 0.525, p < 0.001). The ROC curve analysis demonstrated that a PVC burden cut-off value of 8.4% was associated with a LV-GLS deterioration greater than -18, with a specificity of 75.4% and a sensitivity of 75.4% (AUC: 0.81 [0.73-0.88] 95% CI; p < 0.001). Conclusions: PVC burden was an independent predictor of deterioration in LV-GLS. The presence of LV-GLS deterioration due to PVC burden emphasizes the necessity for closer patient monitoring, observation of the response to pharmacological treatment, and evaluation of early invasive treatment strategies in selected patient groups.

An association between vertebral artery dominance and steno-occlusion of the vertebral artery segments: A retrospective angiographic study.

OBJECTIVES: This study investigated whether there was a relationship between steno-occlusion of the vertebral artery (VA) segments and the dominant VA side. MATERIALS AND METHODS: Angiography results of 215 patients (146 men; 69 women) were retrospectively analyzed in this study. The patients were divided into three groups: dominant, non-dominant and co-dominant. These groups were compared according to the presence of steno-occlusion in the vertebral artery segments. The results were evaluatedusing X2, Mann-Whitney U and Kruskal-Wallis tests. For correlation analysis, Spearman's Rho test was used. RESULTS: The findings showed that 55 of 215 patients (25.6%) had a right dominant VA, and 103 (47.9%) had left dominant VA. There was no significant relationship between dominance and age or gender (p > 0.05). More vertebral artery stenosis (VAS) was found on the dominant side. However, a significant relationship only in the right dominant V1 segment (p = 0.044) was noticed. Hypoplastic VA was detected in 13 patients (6%). Most of the VAs (98.4%, n = 423) arose from the subclavian artery. CONCLUSIONS: In conclusion, we found more vertebral artery stenosis on the dominant side than the co-dominant side, especially on the origin of the vertebral arteries. However, it was only significant on the right dominant V1 segment, regardless of age and gender of the patients (p > 0.05).

Central Macular Thickness in Diabetic Macular Edema.

CONTEXT: Retinal microvascular dysfunction differs in macular edema lesions in the two eyes of the same patient with diabetic retinopathy. OBJECTIVE: To evaluate the relationship between central macular thickness (CMT) and metabolic/systemic factors including anthropometric and laboratory findings, in patients with regressed diabetic retinopathy and a history of pars plana vitrectomy (PPV) combined with internal limiting membrane peeling in one eye. SUBJECTS AND METHODS: Forty-two eyes with PPV and the same patients' fellow 42 eyes (without PPV) included this study. Fasting blood samples of these 42 diabetics were collected to study adiponectin levels and other routine parameters. RESULTS: The average hemoglobinA1c value was 7.3±1.3%. CMT of the vitrectomized eyes were significantly correlated with atherogenic index of plasma, total cholesterol, low density lipoprotein cholesterol and uric acid (UA). On the other hand, CMT of the nonvitrectomized fellow eyes significantly correlated with glucose levels and diabetes duration. Adiponectin, adiponectin/body mass index, adiponectin/fibrinogen were found significantly higher in the subgroup with CMT≥300µm in the vitrectomized eyes (P<0.05). UA levels were higher in the subgroup with CMT≥300µm in the fellow (nonvitrectomized) eyes (P<0.05). CONCLUSIONS: Although there was no relationship between CMT and hemoglobinA1c values, CMT seemed to be affected by atherogenicity, prooxidant chemical alterations in the course of inflammation, so determination of adiponectin and UA levels may be suggested before surgery to predict the atherosclerotic damage and the postoperative CMT value. Vitrectomy performed at the proper time may be helpful in metabolic remodeling process of the retinal tissue along with life style changes, well control of diabetes, and intraocular treatments.

Preliminary results of a new tool to evaluate cavernous body fibrosis following radical prostatectomy: penile elastography.

Development of cavernous tissue fibrosis due to neurovascular bundle damage during radical prostatectomy has been shown in many trials with invasive methods. In this study, we evaluated the changes in cavernous tissue elasticity by elastography in patients who underwent radical prostatectomy with or without neurovascular bundle preservation. Data from 65 patients underwent open retropubic radical prostatectomy between April 2014 and December 2015 was collected prospectively. Patients were grouped with respect to nerve-sparing status (non-, unilateral, and bilateral nerve sparing). International Index of Erectile Function scores, penile lengths, and elasticity scores were recorded at preoperative and postoperative follow-up visits (at 3rd and 6th months). The primary endpoint of the study was to evaluate the changes of the elasticity scores in all groups. Elasticity scores were measured with real-time elastography by a single experienced radiologist. Mean age, baseline total testosterone level, IIEF-5 score, elasticity scores of the cavernous body, and penile length were comparable in all groups. At postoperative 3rd and 6th months, statistically significant higher (in favor for fibrosis) mean cavernous body elasticity scores (p = 0.0001), lower mean IIEF-5 scores (p = 0.0001), and shorter penile lengths (p < 0.05) were observed in non-nerve-sparing group compared to other groups while there were no statistically significant differences between unilateral and bilateral nerve-sparing groups. Very strong negative correlation was detected between IIEF-5 and elasticity scores (p = 0.0001). According to our results, preservation of the neurovascular bundle in at least one side mediates lower elasticity scores, better International Index of Erectile Function scores, and penile lengths. Preliminary results of the penile elastography studies are promising for prediction of erectile functions and cavernous tissue fibrosis.

Is active surveillance a suitable option for African American men with prostate cancer? A systemic literature review.

BACKGROUND: Certain patients presenting with either low or very-low-risk prostate cancer (PCa) can represent a therapeutic dilemma for physicians. The oncologic outcomes of active surveillance (AS) for men with very-low-risk PCa are overall excellent. However, there are concerns about AS related to the potential for upgrading or upstaging. The African American (AA) population is under-represented in studies evaluating AS outcomes and this is particularly important because of the unique epidemiology of PCa in AA men. METHODS: A literature review through the Medline database published from 1990 until August 2015 was performed to identify studies reporting outcomes of the AA population with low-risk PCa that underwent either AS or treatment. An additional search for studies on genetic mechanisms involved in development of PCa in AA men was also performed. RESULTS: Eleven studies on pathologic results of AA men who would qualify for AS were identified and in eight of these studies AA race was found to be associated with adverse pathological outcomes such as positive surgical margins, upgrading or upstaging. The other three studies reported no significance in these parameters with respect to race. Five more studies reported outcomes of AS in AA men with different study end points. AA men were mainly found to have a higher rate of disease reclassification subsequent to active treatment. The studies on genetic mechanisms also identified different genetic alterations in the AA population. CONCLUSIONS: AA men with clinically defined low-risk PCa may have either a higher grade or volume of cancer that was not detected on routine evaluation. Therefore, AS among such patients should be approached with caution. We recommend discussing such risks with AA patients with an acknowledgement that existing favorable outcomes noted in largely Caucasian populations may not be applicable to AA patients. We propose a modified evaluation plan for AA patients that includes an early confirmatory biopsy preceded by an magnetic resonance imaging to optimally detect occult cancer foci.

Effects of transforming growth factor on the developing embryonic ureter: An in-vitro megaureter model in mice.

INTRODUCTION: It is generally agreed that the cause of a megaureter is narrowing at the vesicoureteral junction, with a functional obstruction arising from an aperistaltic, juxtavesical segment that is unable to transport urine at an acceptable rate. Histological examinations of megaureter specimens have reported several histological analyses, and the pathogenic role of transforming growth factor is still a matter of speculation. OBJECTIVE: To evaluate whether transforming growth factor-beta (TGF-ß) and its receptors (TGFRs) are expressed during ureterovesical junction (UVJ) and lower ureter development in mice, and whether exogenous TGF-ß might postpone the maturation of smooth muscle cells, in the pathogenesis of megaureter using an embryonic organ-culture model. METHODS: Expression of TGF-ß and TGFRs on the lower ureter and UVJ were determined at different embryonic days (E) (E16, 18, 20 and postnatal day 1). The functional studies were performed by harvesting ureters from wild-type mice at embryonic day 16 (E16), which were grown in serum-free organ-culture; some cultures were supplemented with TGF-ß (2 and 20 ng/ml) and/or with soluble TGFR, which blocks bioactivity. Organs were harvested after 6 days and the expression of CD31 and Ki67 were assessed using immunohistochemistry. The muscle content of the UVJ and ureter were analyzed by flowcytometry. RESULTS: The TGF-ß and TGFR positive cells were immune detected in embryonic ureters. The TGF-ß expression was highest on E18 and decreased postnatally. Exogenous TGF-ß decreased ureterovesical (UV) muscle differentiation and proliferation. The longitudinal muscle fibers were significantly less in TGF-ß explants. The TGF-ß also decreased the proportions of cells expressing α smooth muscle actin (α-SMA). Soluble TGFR blocked the effects of exogenous TGF-ß. CONCLUSIONS: In organ culture, exogenous TGF-ß postpones the UV smooth muscle proliferation and affects the muscular structure. Whether the effects of TGF-ß are direct or indirect, these form an in-vitro megaureter model. The finding that TGF-ß is highest in embryonic ureters in vivo and decreased postnatally suggests that a pathological persistence might potentially explain the pathogenesis of primary megaureters.

Chronic botulism in a Saxony dairy farm: sources, predisposing factors, development of the disease and treatment possibilities.

The aim of this study is to investigate Clostridium botulinum at a Saxony dairy farm with 159 cows and 18 heifers. The animals exhibited clinical symptoms of chronic botulism. To determine the source of the infection, feces, blood, organs, and gastrointestinal fluids of dead or euthanized cows; as well as soil, water, silage and manure were tested for C. botulinum spores and BoNTs using ELISA. BoNT/C and C. botulinum type C were detected in 53% and 3% of tested animals, respectively, while BoNT/D and C. botulinum type D were detected in 18% of the animals. C. botulinum also was detected in organs, gastrointestinal fluids, drinking water and manure. To evaluate possible treatments, animals were given Jerusalem artichoke syrup (JAS), Botulism vaccine (formalinised aluminum hydroxide gel adsorbed toxoid of C. botulinum types C and D) or a suspension of Enterococcus faecalis. After four weeks treatment with JAS, BoNT/C and C. botulinum type C were not detected in feces. In contrast, BoNT/D and C. botulinum type D were not significantly influenced by the JAS treatment. Vaccination with botulism vaccine and the E. faecalis suspension significantly decreased BoNT/D and C. botulinum type D. A significant increase of Enterococci was detected in animals treated with E. faecalis. Interestingly, there was a negative correlation between the detection of both BoNT and C. botulinum with the concentration of Enterococci in feces. Although C. botulinum C and D antibodies increased significantly (p < 0.0001) after vaccination with the botulism vaccine, the reduction of C. botulinum and BoNT in feces did not result in recovery of the animals because they were deficient of trace elements [manganese (Mn), cobalt (Co), copper (Cu) and selenium (Se)]. Animals treated with trace elements recovered. It appears that intestinal microbiota dysbiosis and trace element deficiency could explain the extensive emergence of chronic Botulism.

Cilostazol and diltiazem attenuate cyclosporine-induced nephrotoxicity in rats.

AIM: Cyclosporine (CsA), an important agent used in organ transplantation to prevent rejection, displays nephrotoxicity as the most important side effect limiting usage. In this study, we sought to evaluate the effects of cilostazol and diltiazem to counter the nephrotoxicity induced by the calcineurin inhibitor CsA. MATERIALS AND METHODS: Animals were randomly divided into seven groups, each consisting of eight animals: sham, controls, cilostazol, diltiazem, CsA, CsA plus diltiazem, and CsA plus cilostazol treatment. At the end of a 60-minute ischemic period, we administered the drugs after reperfusion for 7 days thereafter. CsA (10 mg/kg/d) was intraperitoneally for 7 days; cilostazol (10 mg/kg/d) orally by catheter for 7 days; diltiazem (5 mg/kg/d) intraperitoneally for 7 days. At the end of the 7-day treatment period, blood and tissue samples were harvested for biochemical, and serological evaluation. RESULTS: Ischemia-reperfusion injury significantly increased malondialdehyde (MDA) levels as well as decreased catalase (CAT) activities and superoxide dysmutase (SOD) content. The lowest MDA mean level was observed in the diltiazem and, the highest in the control group. The lowest CAT mean levels were noted in the CsA and diltiazem groups with highest CAT content was in the CsA and cilostazol groups. The lowest SOD mean level occurred in the sham group; the highest, in the CsA group. CONCLUSION: Cilostazol and especially diltiazem were effective to mitigate renal ischemia-reperfusion injury.

Hematological features of pediatric systemic lupus erythematosus: suggesting management strategies in children.

AIM: The aim of this study was to analyze the hematological features in children with systemic lupus erythematosus (SLE) and to review our current treatment protocols. METHODS: We evaluated hematological findings of 43 children with SLE diagnosed and followed at the Pediatric Rheumatology Division of Hacettepe University, Turkey. Thirty-seven patients with hematological abnormalities were analyzed in detail. RESULTS: Median age at presentation was 13 years. Hematological involvement was seen in 86% of patients. The most common hematological finding was anemia (n = 30). Anemia was either a Coombs (+) hemolytic one, or was due to other causes. Hemolytic anemia was treated with steroids and intravenous gamma globulin (IVIG). Leucopenia and thrombocytopenia were detected in 35.1 % and 37.8 %, respectively. Bone marrow aspiration was performed in 15, mainly for cytopenia. Secondary dysplastic changes were common. Acute lymphoblastic leukemia (ALL) was diagnosed in one patient. Six patients were diagnosed as having macrophage activation syndrome (MAS). One patient died due to secondary infections and multiorgan failure despite aggressive treatment. In patients diagnosed early, treatment with steroids and cyclosporine resulted in an excellent response. Thrombotic microangiopathy was detected in two patients. Both were treated successfully with steroids and plasma exchange. Antiphospholipid and anticardiolipin antibodies were positive in 12 and 15 of the patients, respectively. Five developed deep vein thrombosis (DVT), one cerebral sinus thrombosis and one presented with purpura fulminans. They were effectively treated with anticoagulation protocol. CONCLUSION: Hematological findings should be carefully assessed and treated vigorously to prevent the morbidity and possible mortality.

Acute lymphoblastic leukaemia in a child with systemic lupus erythematosus.

Haematological involvement of systemic lupus erythematosus (SLE) - which ranges from the well-described haemolytic anaemia to macrophage activation syndrome - has a large impact on both morbidity and mortality. On the other hand, association between haematological malignities and SLE - in terms of pathophysiology and molecular genetics - is an obscure entity which has not been clarified evidently to date. Herein, we present a six-year-old female with the diagnosis of SLE who developed acute lymphoblastic leukaemia following a period of myelodysplasia. It could possibly be coincidental; however, persistent cytopenia, prominent dysplasia on bone marrow smears and azathioprine treatment may be considered as possible triggers for the development of leukaemia in the present case.

Secondary hemophagocytosis in 3 patients with organic acidemia involving propionate metabolism.

Hemophagocytic lymphohistiocytosis (HLH) may develop secondary to infections, malignancies, immune deficiency syndromes, and rheumatologic and metabolic disorders. Associations between HLH and inborn errors of metabolism, including lysinuric protein intolerance, multiple sulfatase deficiency, galactosemia, Gaucher disease, Pearson syndrome, and galactosialidosis, have previously been reported in the literature. In this report the authors present 3 children with disorders of propionate metabolism--1 with methylmalonic acidemia and 2 with propionic acidemia--who developed secondary HLH during their metabolic attacks. All patients fulfilled the 5 HLH criteria of the Histiocyte Society. Familial HLH was ruled out by molecular analysis. Plasma exchange was performed for 2 of them. Unfortunately 1 died of multiorgan failure despite intensive therapy. This is the first report of such an association.

Prophylactic intraoperative pneumoperitoneum decreases pleural space problems after lower lobectomy or bilobectomy of the lung.

BACKGROUND: Following lower lung lobe resection, prolonged air leaks and residual pleural space are common. We investigated whether an artificially induced prophylactic intraoperative pneumoperitoneum would prevent these complications. METHOD: Sixty patients who underwent lower lobectomy or bilobectomy were prospectively randomized into 2 groups according to the use of intraoperative pneumoperitoneum. Air was delivered via a catheter placed under the diaphragm in the pneumoperitoneum group. Parameters related to pleural drainage, complications, and hospital stay were compared. RESULTS: No difference between the preoperative characteristics of both groups was present. The mean duration of chest tube drainage was shorter (3.47 +/- 1.04 days vs. 4.87 +/- 1.43 days, P < 0.001) and the mean amount of chest drainage was lower (305.0 +/- 76.9 ml vs. 488.3 +/- 215.2 ml, P < 0.001) in the pneumoperitoneum group. Residual pleural space was observed in 1 pneumoperitoneum patient (3.3 %) and in 8 controls (26.7 %). Pneumoperitoneum patients were discharged 1.1 days earlier on average than the controls. CONCLUSION: Artificial prophylactic intraoperative pneumoperitoneum is a simple and safe procedure that decreases the postoperative amount of fluid drainage, residual pleural space, duration of chest tube drainage, and hospital stay.

A comparative ID migraine screener study in ophthalmology, ENT and neurology out-patient clinics.

Migraine is more likely to be misdiagnosed in patients with comorbid diseases. Not only primary care physicians, but also specialists might misdiagnose it due to the lack of diagnostic criteria awareness. The ID migraine test is a reliable screening instrument that may facilitate and accelerate migraine recognition. This study aimed to compare the prevalence and characteristics of migraine in a large sample of patients admitted to clinics of ophthalmology (OC), ear, nose and throat diseases (ENTC) and neurology (NC), as well as to validate the use of the ID migraine test in OC and ENTC settings. This was a multicentre (11 cites) study of out-patients admitting either to NC, ENTC or OC of the study sites during five consecutive working days within 1 week. From each of the clinics, 100 patients were planned to be recruited. All recruited patients were interviewed and those having a headache complaint received an ID migraine test and were examined for headache diagnosis by a neurologist, blinded to the ID migraine test result. A total of 2625 subjects were recruited. Only 1.3% of OC patients and 5.4% of ENTC patients have been admitted with a primary complaint of headache, whereas the percentage of NC patients suffering from headache was 37.6%. Whereas 138 patients (19.3%) in OC, 154 (17.3%) in ENTC and 347 (34%) in NC were found to be ID migraine test positive, 149 patients (20.8%) in OC, 142 (16%) in ENTC and 338 (33.1%) in NC were diagnosed with migraine. The sensitivity, specificity, and positive and negative predictive ratios of the ID migraine test were found to be similar in all clinics. An important fraction of the patients admitted to NC, as well as to OC and ENTC, for headache and/or other complaints were found out to have migraine by means of a simple screening test. This study validated the ID migraine test as a sensitive and specific tool in OC and ENTC, encouraging its use as a screening instrument.

Analysis of isolated cranial nerve manifestations in patients with cancer.

The aim of this study was to assess the underlying causes of isolated cranial nerve (CN) manifestations in cancer patients. In a prospective study over a 16 month period, 20 of 242 patients presented with isolated CN manifestations, and were assessed for the following: primary site; CN symptoms and signs; length of time between primary diagnosis and neurological involvement; and survival following the neurological diagnosis. The most frequent primary site was determined as hematological malignancy (9/20). Thirteen of the 20 patients presented with single CN manifestations. Underlying causes of CN manifestations in 16 of the 20 patients were related to metastases. They included meningeal carcinomatosis (10/16), brain stem metastases (3/16), primary brain astrocytomas (1/16), and metastases out of the central nervous system (2/16). The remaining four patients' CN manifestations related to non-metastatic conditions. Although most of the isolated CN manifestations were due to systemic metastasis, in particular to the meninges, up to 20% were related to benign conditions.

Nonalcoholic Wernicke's encephalopathy with prominent astasia and optic neuropathy.

OBJECTIVE: To present a case with nonalcoholic Wernicke's encephalopathy (WE) developing astasia and optic neuropathy as major sequelae. CLINICAL PRESENTATION AND INTERVENTION: A 47-year-old woman developed WE following operation for pyloric stenosis. She received total parenteral nutrition before and after operation, but on the second postoperative day she developed visual hallucination and confusion, followed by nystagmus, ophthalmoplegia, apathy, dysarthria and coma. Although the patient has recovered with thiamine treatment, astasia and optic neuropathy persisted s major morbidities. CONCLUSION: The report shows that astasia and optic neuropathy may be prominent sequelae in some patients with WE.

Lumbosacral neurenteric cyst with associated tethered cord in an adult.

Spinal neurenteric cysts are rare congenital lesions of endodermal origin that lead to spinal cord compression or tethering. These cysts are usually lined by mucus-secreting epithelium resembling that of the gastrointestinal tract. A 31-year-old man presented with low back and bilateral limb pain of three-year duration. Magnetic resonance imaging (MRI) revealed an intradural extramedullary heterogeneous mass lesion at L4 - L5 disc level causing severe compression and displacement of terminal portion of conus medullaris to the left side. Additionally, tethered cord, syringohydromyelia and spina bifida were present. He had also polysyndactyly on the left foot. The patient underwent laminoplasty and partial excision of the lesion through a posterior approach. Neurosurgical exploration revealed a large intradural, extramedullary solid lesion with cystic component, compressing the spinal cord. Histopathology confirmed a neurenteric cyst with mucin-producing cuboidal or columnar epithelium lining the cystic cavity. Clinical suspicion is important for an early diagnosis, and their early preplanned surgical removal should be the goal of treatment, which leads to a better outcome. This case is reported in view of rare congenital abnormality in an adult with peculiar presentation.

Synthesis, in vitro cytotoxic and antiviral activity of cis-[Pt(R(-) and S(+)-2-alpha-hydroxybenzylbenzimidazole)2Cl2] complexes.

A pair of enantiomeric platinum(II) complexes of cis-[Pt(R(-) and S(+)-HBB)2Cl2] (HBB=2-alpha-hydroxybenzylbenzimidazole) was synthesized and evaluated for its preliminary in vitro cytotoxic activity on the human MCF-7 breast cancer and HeLa cervix cancer cell lines and antiherpes virus activity against bovine herpesvirus type 1 (BHV-1). In general, it was found that Pt(II) complexes were less cytotoxic on both cell lines than cisplatin and were comparable to carboplatin. There was no significant difference in cytotoxicity between two enantiomers, and the antiviral test results showed that the Pt(II) complexes and their carrier ligands R(-) and S(+) HBB had no effects inhibiting replication of BHV-1.

Synthesis and analgesic and antiinflammatory activity of methyl 6-substituted-3(2h)-pyridazinone-2-ylacetate derivatives.

A series of methyl 6-substituted-3(2H)-pyridazinone-2-ylacetates 9 were synthesized and their analgesic and anti-inflammatory effects were evaluated in the phenylbenzoquinone-induced writhing test (PBQ test) and carrageenan-induced paw edema method, respectively. Side effects of the compounds were examined on gastric mucosa. None of the compounds showed gastric ulcerogenic effect compared with reference nonsteroidal anti-inflammatory drugs. Methyl 6-(4-(4-fluorophenyl)piperazine)-3(2H)-pyridazinone-2-ylacetate 9e was found to be more active than acetylsalicylic acid (ASA). Methyl 6-(4-(2-ethoxyphenyl)piperazine)-3(2H)-pyridazinone-2-ylacetate 9c has shown an anti-inflammatory activity as compared to the standard compound indometacin at the carrageenan-induced paw edema method.A significant dependence of the anti-inflammatory effect on the substituents has been observed. The pharmacological study of these compounds confirms that modification of the chemical group at the position 6 of the 3(2H)-pyridazinone system influences analgesic and anti-inflammatory activities. The structures of these new pyridazinone derivatives were confirmed by their IR and (1)H-NMR spectra and elemental analysis.

Congestive heart failure associated with chronic venous insufficiency and leg ulcers secondary to an arteriovenous fistula caused by a shotgun wound 15 years ago.

We present a 65-year-old man who had a significant arteriovenous fistula between the right arteria profunda femoralis and vena profunda femoralis. He had evidence of chronic venous insufficiency and chronic leg ulcers on his right leg, and he had clinical findings of congestive heart failure. An arteriovenous fistula was responsible for all of clinical situation that had been caused by a shotgun wound 15 years ago. Using ultrasonography, after palpating a marked thrill and mass during physical examination, established the diagnosis of arteriovenous fistula. Angiography was performed both to delineate the suspected vascular anatomy and to show the coronary arteries. The patient was operated on and no complication was experienced during or after the procedure. Dramatic improvement was seen in the clinical picture just after surgery, and heart size markedly reduced both on chest X-ray and echocardiographic examination.