Family relations and eating disorders. The effectiveness of an integrated approach in the treatment of anorexia and bulimia in teenagers: results of a case-control systemic research.

This article presents the results of a broader clinical research into the effectiveness of integrated treatments in teenage eating disorders, carried out at the Complex Operative Unit of Psychotherapy (Unità Operativa Complessa or U.O.C.) of the Department of Psychiatric Sciences and Psychological Medicine in collaboration with the Department of Neuropsychiatric Science for Child Development (Dipartimento di Scienze Neuropsichiatriche dell'Età Evolutiva), both at the "La Sapienza" University of Rome. The hypothesis of this research project is that in diagnosticable situations such as anorexia or bulimia, an integrated and multidisciplinary treatment, which combines medical-nutritional interventions and family psychotherapy, allows better results than a single kind of treatment, which is the usual medical- nutritional intervention supported by psychiatric counselling. Twenty-eight cases (16 of bulimia and 12 of anorexia) were selected and then subdivided, with a randomized distribution, into two (experimental and control) homogeneous groups of 14 patients. The grouping variables were the diagnosis, the disorder's seriousness and duration, BMI, gender, age, family composition and social status. The variables which have been examined in this article are the clinical parameters, which were valuated in accordance with the DSM IV-TR criteria, and relational parameters which were explored through the use of the W.F.T. Test (Wiltwyck Family Tasks). These parameters were tested at beginning as well as at the end of the therapies, in both the experimental group and the control group. Statistical analysis has shown that the experimental group, which was followed with the integrated treatment, experienced a significant improvement of the parameters as related to dysfunctional family interaction modalities, and that this improvement was correlated to the positive evolution of the clinical parameters. This improvement was not present or not of the same degree in the control group. The results, moreover, demonstrate the effectiveness of an integrated systemic treatment based on a complex approach compared to a reductionist approach.

Acute and nine-month clinical outcomes after "suboptimal" coronary stenting: results from the STent Anti-thrombotic Regimen Study (STARS) registry.

OBJECTIVES: This registry collected the 30-day and 9-month clinical outcomes of patients whose coronary stent implantation was suboptimal, and compared them with the cohort of patients with "optimal" stenting in the randomized portion of the STent Anti-thrombotic Regimen Study (STARS) trial. BACKGROUND: Although "optimal" stenting combined with an aspirin and ticlopidine regimen carries a low (0.5%) incidence of subacute stent thrombosis, only limited data are available for patients in whom stents are deployed suboptimally. METHODS: In the STARS, 312 (15.9%) of 1,965 patients enrolled were excluded from participation in the randomized trial based on a perceived "suboptimal" result of coronary stenting. Of these, 265 patients met prespecified criteria for suboptimal stenting, and were followed in a parallel registry, which was compared with the randomized STARS optimal stenting cohort. The primary end point was a 30-day composite of death, emergent target lesion revascularization, angiographic thrombosis of the target vessel without revascularization and nonfatal myocardial infarction (MI) unrelated to direct procedural complications. RESULTS: Registry patients had a similar frequency of the primary end point compared with the overall randomized cohort (3.0% vs. 2.2%), with this end point correlating to use of multiple stents, smaller final lumen diameter and absence of ticlopidine from the poststent regimen. Overall 30-day mortality (1.1% vs. 0.06%, p = 0.009) and periprocedural non-Q wave MI (8.7% vs. 4.2%, p = 0.003) were more frequent in registry patients, and appeared to be related to acute procedural complications. Clinical restenosis was significantly higher for registry patients (26.8% vs. 16.0%, p = 0.001), relating to greater prevalence of independent predictors such as smaller final lumen diameter and multiple stent use. CONCLUSIONS: In the STARS registry, the inability to perform optimal stenting correlated with smaller final lumen diameter and longer stent length. With ticlopidine-containing regimens, the acute clinical results of "suboptimal" stent deployment are clinically acceptable, although they are not quite as good as those of optimal stenting using similar drug therapy.

Coronary reperfusion and Bezold-Jarisch reflex (bradycardia and hypotension).

This study reports the occurrence of bradycardia and hypotension (Bezold-Jarisch reflex) induced by myocardial reperfusion. Among 92 patients undergoing interventional catheterization for intracoronary thrombolysis in an early phase of acute myocardial infarction, left anterior descending, right coronary, and left circumflex (LC) arteries were identified as the "infarct vessel" in 44, 41, and 7 cases, respectively. The Bezold-Jarisch reflex occurred in 15 of 23 patients (65%) after right coronary recanalization and in 1 of 34 patients after left anterior descending recanalization. The reflex also was observed in 4 (22%) of 18 patients with nonoccluded or nonrecanalized right coronary arteries. The average time from onset of symptoms to right recanalization was significantly shorter (p less than 0.01) among patients in whom the reflex did not develop. Atropine, postural changes, or temporary pacing, or all 3, were generally sufficient to control symptoms. The findings of this study are substantially parallel to those reported by others and confirm that reperfusion of the inferoposterior myocardium is capable of stimulating a cardioinhibitory reflex. Follow-up data available in 15 patients with occluded and recanalized right coronary arteries indicate that the occurrence of the Bezold-Jarisch reflex after reperfusion is not a reliable predictor of myocardial salvage.

Final results of a randomized trial comparing the NIR stent to the Palmaz-Schatz stent for narrowings in native coronary arteries.

The NIR stent is a novel second generation tubular stent that was designed to overcome some of the limitations of the earlier Palmaz-Schatz (PS) stent design. The NIR Vascular Advanced North American (NIRVANA) trial randomized 849 patients with single coronary lesions to treatment with the NIR stent or the PS stent. The study was an "equivalency" trial, designed to demonstrate that the NIR stent was not inferior to (i.e., equivalent or better than) the PS stent, for the primary end point of target vessel failure (defined as death, myocardial infarction, or target vessel revascularization) by 9 months. Successful stent delivery was achieved in 100% versus 98.8%, respectively, with a slightly lower postprocedural diameter stenosis (7% vs. 9%, p = 0.04) after NIR and PS stent placement, respectively. Major adverse cardiac events (death, myocardial infarction, repeat target lesion revascularization) were not different at 30 days (4.3% vs. 4.4%). The primary end point of target vessel failure at 9 months was seen in 16.0% of NIR versus 17.2% of PS patients, with the NIR proving to be equal or superior to the PS stent (p <0.001 by test for equivalency). Angiographic restudy in 71% of a prespecified cohort showed no significant difference in restenosis (19.3% vs 22.4%). Thus, the NIR stent showed excellent deliverability with slightly better acute angiographic results and equivalent or better 9-month target vessel failure rate when compared with the PS stent.

A systemic hemodynamic evaluation of indapamide.

The hemodynamic effects of indapamide were evaluated in an open clinical trial of nine patients with mild to moderate hypertension. Hemodynamic and echocardiographic measurements were made before and after six weeks of treatment with single daily doses of 2.5 mg of indapamide. Indapamide significantly reduced the mean standing systolic blood pressure (P less than 0.025), the mean standing diastolic blood pressure (P less than 0.01), the mean arterial blood pressure (P less than 0.001), and the mean total peripheral vascular resistance (P less than 0.01). Cardiac output increased 12% (P less than 0.05) during treatment. The heart rate, left ventricular end-diastolic and end-systolic volumes, systolic volume, and ejection fraction were not markedly altered after treatment with indapamide, although the systolic wall stress index fell slightly. Six weeks of indapamide administration was well tolerated with no notable adverse effects of the drug. The results suggest that indapamide reduces arterial blood pressure in hypertensive patients by decreasing total peripheral resistance.

Adjunctive therapies in the cath lab. Use of combination glycoprotein IIb/IIIa inhibitor and direct thrombin inhibitor drugs to support percutaneous coronary stent placement in a patient with renal insufficiency and heparin-induced thrombocytopenia.

An 81-year-old woman with a history of prior coronary artery bypass surgery, heparin-induced thrombocytopenia with "white clot" syndrome, and renal insufficiency presented with unstable angina. She was referred for cardiac catheterization. Complex percutaneous revascularization of the native circumflex coronary artery was performed using stents. A combination of tirofiban and lepirudin was used with dosing adjusted for renal insufficiency. The hospital course was uncomplicated and the patient was discharged on the fourth hospital day. This is only the second report of the combination use of direct thrombin inhibitor and glycoprotein IIb/IIIa receptor inhibitor.

Massive left atrial thrombus: a possible paraneoplastic complication of breast carcinoma.

We describe a patient with long-standing rheumatic mitral valve disease, left atrial dilatation, and a precommissurotomy history of left atrial thrombus. Following operation she was maintained on daily aspirin as an antithrombotic measure. For 6 years she had no evidence, echocardiographically, of left atrial thrombus. She underwent surgery for apparently nonmetastatic breast cancer in early 1986. In May 1986 the left atrium was echocardiographically clear. At approximately the same time, recurrence was found at the suture line. In October 1987, two metastatic lung lesions and a very large left atrial mass were detected by computed tomography. The atrial mass was surgically removed and found to be a thrombus. There was a striking temporal correlation between dissemination of carcinoma and development of a massive atrial thrombus.

The use of injectable nitroglycerin in the cardiac catheterization laboratory. Nitroglycerin in cardiac catheterization.

At our institution, injectable nitroglycerin (TNG) has been employed during cardiac catheterization since 1976. Initially, it was primarily used in patients undergoing a provocative test for coronary spasm with ergonovine maleate. After the initial favorable experience, the use of injectable TNG became routine.

Left atrial ball thrombus: review of clinical and echocardiographic manifestations with suggestions for management.

Left atrial ball thrombus is an infrequent clinical syndrome, which can have a catastrophic outcome but can be readily treated when recognized. It is usually a complication of long-standing rheumatic mitral stenosis. Symptomatic presentation is variable: fragmentation of the thrombus followed by peripheral embolization will produce ischemia or infarction of myocardium, brain, viscera, or extremities; random, intermittent, partial, or total occlusion of the mitral valve orifice may cause syncope, pulmonary congestion, and occasionally sudden death in other patients. Embolic and obstructive phenomena may also occur together. Cardiac physical findings usually suggest mitral stenosis; variability in the intensity of the diastolic rumble is common. Two-dimensional echocardiography is the gold standard for identifying ball thrombus. Cardiac catheterization provides assessment of coronary artery status when needed. The outcome of untreated ball thrombus is unlikely to be favorable. The results of anticoagulation and thrombolysis are unpredictable and potentially as harmful as no treatment at all. Current evidence although scant suggests that prompt surgical removal of the free thrombus, often in conjunction with mitral valve repair or replacement, is the appropriate therapeutic course in most patients.

Myocardial ischemia resulting from spontaneous dissection in a patient with massive bilateral sinus of valsalva aneurysms.

We describe a patient with large sinus of Valsalva aneurysms involving both the left and right coronary sinuses. Spontaneous dissection of the left coronary artery occurred, causing unstable angina, a complication heretofore not associated with this disease. Successful surgical reconstruction of the aortic root, aortic valve replacement, and coronary bypass grafting were performed. Pathology revealed cystic medial necrosis.

A comparative study of cephapirin, cephalothin, and methicillin in cardiovascular surgery.

An open, randomized study involving 217 patients undergoing elective cardiovascular surgery was undertaken to compare the effectiveness of cephapirin, cephalothin, and methicillin in preventing postoperative infections. One of the three antibiotics was assigned randomly to each patient and administered beginning 2 h before operation and continuing every 6 h for 5 days. There was no significant difference between the three study groups with respect to the incidence of infection (p = 0.9913). In both the cephalothin and methicillin groups, seven patients developed adverse reactions as compared with two patients in the cephapirin group. However, the difference was not statistically significant (p = 0.0788). The results from the investigation indicate that cephapirin, cephalothin, and methicillin are equally effective as prophylactic antibiotics when used perioperatively for cardiovascular surgery.

Transradial cardiac catheterization in patients with prior brachial artery cutdown.

The safety and efficacy of transradial cardiac catheterization in patients with prior ipsilateral brachial cutdown is not known. Using standard techniques we performed transradial catheterization in 278 consecutive patients, of which 63 had prior brachial cutdown. All patients had a strongly palpable radial pulse and a negative Allen's test. Although patients with prior cutdown were older and had a higher incidence of hypertension and prior coronary artery bypass surgery, there was no significant difference in success rates for transradial catheterization (93.6% vs. 95.3%; P = NS). There were no periprocedural complications. Brachial artery occlusion was responsible for only two unsuccessful catheterization attempts. We conclude that, with careful preprocedural screening, ipsilateral transradial cardiac catheterization can be successfully performed in a majority of patients with prior brachial cutdown.

Successful removal of papillary endocardial fibroma.

We report a case of systemic embolization secondary to a small papillary endocardial fibroma, a rare cardiac tumor. It was attached to a chords of the mitral valve by a short stalk. The tumor was successfully excised and the mitral valve was preserved. Two-dimensional echocardiography played the major role in the diagnosis of this small endocardial tumor.

Successful treatment of a saphenous vein graft perforation with an autologous vein-covered stent.

A 52-year-old man with a history of prior coronary bypass surgery suffered recurrent angina and underwent percutaneous placement of a stent within the midportion of the saphenous vein graft to the marginal branch of the left circumflex coronary artery, which was complicated by a significant perforation. The perforation was successfully closed using an NIR stent covered with a segment of autologous antecubital vein. Subsequent surgical exploration confirmed successful closure of the perforation. Cathet. Cardiovasc. Intervent. 48:382-386, 1999.

Angioplasty of a large aortocoronary bypass graft utilizing a single oversized balloon catheter.

Angioplasty of large saphenous vein grafts may present problems because of unavailability of adequately sized balloon dilatation catheters. We report a case of successful PTCA of a left anterior descending graft by using a 5 mm balloon and a standard 8F guiding catheter.

An unusual complication during deployment of a Multi-Link stent.

The use of intracoronary stents has greatly impacted on the practice of interventional cardiology. Complications due to equipment failure during deployment of stents are rare but potentially serious. We report a case of a malfunctioning Multi-Link delivery system and the successful treatment of the resulting complications.

Transradial cardiac catheterization in elderly patients.

The safety and efficacy of transradial cardiac catheterization in elderly patients is unknown. This study examines procedure success rates for transradial catheterization in appropriately selected patients < 70 (n = 195) and >/= 70 (n = 83) years old. Elderly patients were less likely to be selected for the transradial approach (46% vs. 61%; P = 0.05). Although patients >/= 70 years old were more often female (39.7% vs. 24.1%; P = 0.008) and had a smaller body surface area (1.89 +/- 0.18 vs. 2.01 +/- 0.24 m2; P = 0. 001), procedure success rates did not differ (95.1% vs. 94.8%; P = NS). Procedure-related variables including procedure time (15.4 +/- 12.6 vs. 16.1 +/- 11.6 min; P = NS), amount of radiographic contrast (90.1 +/- 31.9 vs. 86.4 +/- 29.8 cc; P = NS), and number of catheters used (1.5 +/- 0.9 vs. 1.5 +/- 0.7; P = NS) were similar between groups. We conclude that transradial catheterization can be safely and effectively performed in selected elderly patients. Cathet. Cardiovasc. Intervent. 51:287-290, 2000.

Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques.

In order to monitor the incidence and types of peripheral vascular complications in a single institution, we prospectively entered 1,579 coronary angioplasty cases into a computer data base during the years 1991 and 1992. Various periprocedural risk factors were analyzed. The patients were followed closely to identify complications that occurred outside the laboratory or after discharge from the hospital. Peripheral vascular complications occurred in 37 patients (2.37%) and included hematoma 20 (1.27%), retroperitoneal bleeding 7 (.44%), false aneurysm 6 (.38%), occlusion 1 (.06%), infection 2 (.13%), and cholesterol emboli 1 (.06%). Risk factors for complications by multivariate analysis were older age, female gender, and clinical evidence of peripheral vascular disease. Other factors potentially related to vascular trauma or bleeding tendency that were not risk factors in this series were clinical presentation, use of heparin or thrombolytic agents, blood clotting parameters, and arterial sheath size. There was no significant difference between the femoral and brachial approaches in frequency of complications (2.5% vs. 1.6%), but femoral complications tended to carry greater morbidity.