Human internal mammary artery produces more prostacyclin than saphenous vein.

The patency rate of internal mammary artery grafts is reported to be better than that of saphenous vein grafts in myocardial revascularization operations. To identify a possible biochemical explanation for this phenomenon, we studied the production of prostacyclin by the internal mammary artery and saphenous vein in 11 patients. Segments of internal mammary artery and saphenous vein from each patient were incubated in Krebs-Henseleit buffer at 37 degrees C. After 15 minutes, the basal production of 6-keto-prostaglandin F1 alpha (prostacyclin metabolite) by the internal mammary artery was 152 +/- 39 pg/mg wet weight (mean +/- standard error of the mean), whereas the saphenous vein produced only 68 +/- 17 pg/mg (p less than 0.001). After 30 minutes, the internal mammary artery produced 179 +/- 42 pg/mg, whereas the saphenous vein produced 75 +/- 18 pg/mg (p less than 0.001). After the basal incubation period, the vessels were incubated with arachidonic acid (prostaglandin substrate) for 15 minutes. The internal mammary artery produced 49.4 +/- 9.9 pg/mg, whereas the saphenous vein produced only 22.6 +/- 9.8 pg/mg (p less than 0.01). These observations suggest that the capacity of the internal mammary artery to produce prostacyclin in both a basal and a stimulated state is greater than that of the saphenous vein. Since prostacyclin is a potent vasodilator and inhibitor of platelet function, these results provide a possible biochemical explanation for the clinically observed better patency rate of internal mammary artery grafts.

Chemoradiation therapy and resection for carcinoma of the esophagus: short-term results.

The purpose of this report is to record the results of a treatment protocol for patients with carcinoma of the esophagus. In May, 1980, we initiated a program of chemoradiation therapy preliminary to resection in patients in whom the protocol was applicable. The chemotherapy consisted of mitomycin-C, 10 mg as a bolus intravenous injection on day 1, and 5-fluorouracil, 1,000 mg per square meter of body surface area in 1,000 ml of 5% glucose solution in distilled water given intravenously on each of days 1 through 4. The radiation therapy consisted of 3,000 rads in three weeks using cobalt 60 or 6 MeV or greater, with ports to cover the tumor and mediastinum. This protocol was given to patients with primary carcinoma of the esophagus whose disease remained or became operable during or following the course of the chemoradiation. Among the patients treated according to the protocol, the operability rate was increased. The resectability rate remained about the same as in our previous experience. The operative mortality was lessened appreciably. The percentage of resected specimens of the esophagus showing residual tumor decreased. However, the absence of any residual tumor in the surgical specimen has not conferred any improved chance of long-term survival to date. There has been a two-year survival of 33% (7/21) among the small group having chemoradiation therapy prior to resection, and this figure is roughly the same as that in our previously reported series of patients treated by preoperative irradiation (4,500 rads in three weeks) and resection without the chemotherapeutic adjunct.(ABSTRACT TRUNCATED AT 250 WORDS)

Aberrant systemic artery-pulmonary venous fistula: diagnosis with Doppler imaging.

A 6-year-old asymptomatic girl presented with a continuous murmur at two different locations. Using Doppler imaging modalities, a small patent arterial duct and an aberrant systemic artery arising near the coeliac axis, piercing the right hemidiaphragm, and connecting to the right lower pulmonary vein were identified. Angiography confirmed the diagnosis and revealed additional pulmonary abnormalities. Doppler examination helped in planning appropriate angiographic projections and sites of the contrast medium injection.

Foreign bodies of the esophagus.

The incidence of esophageal foreign bodies is probably declining. The majority of patients are still in the pediatric age group. Clinical history and radiologic studies usually establish the diagnosis. Rigid esophagoscopy is still the standard method of therapy, but alternative methods can be employed with proper patient selection. The practicing physician must be familiar with the advantages and disadvantages of available methods of therapy. Observation for up to 24 hours is probably safe, and the proper method of therapy must be carefully selected according to the age of the patient, the type of the impacted foreign body, the location of impaction, the duration of impaction, and the available medical resources and skills. Major complications are to be expected with prolonged or missed impaction of foreign bodies in the esophagus. Prevention, high index of suspicion, and early treatment are important factors that can decrease the possible complications of impacted foreign bodies in the esophagus.

Discrete subaortic stenosis.

From 1971-1981, 18 patients with discrete subaortic stenosis were treated surgically at the Medical University of South Carolina. Echocardiography was diagnostic in 10 of 11 patients in whom it was used. Preoperative cardiac catheterization was performed in all patients. The preoperative left ventricular outflow systolic pressure gradient was 82.0 +/- 27.2 mmHg (mean +/- SD) (range 30-145). In 16 (88.8%) patients excision of the subaortic membrane was complete, and relief of left ventricular outflow obstruction was good. The excision was incomplete in 2 patients; one required reoperation for residual gradient and developed complete heart block, and the other had a residual gradient of 60 mmHg and was in New York Heart Association functional class II when lost to follow-up. These data suggest that complete excision of the discrete subaortic stenosis is important to achieve good relief of left ventricular outflow obstruction.

Myocardial infarction in Qatar: the first 2515 patients.

The data registry of all patients admitted between 1982 and 1990 to the Coronary Care Unit at Hamad General Hospital with the diagnosis of documented acute myocardial infarction is reviewed. We report a total of 2,515 patients (86.6% men and 13.4% women) with a mean age of 51 years (range 18-99). Of these, 62% were smokers, 29% had diabetes, and 20% had hypertension. The hospital mortality rate was 10%. The most significant factors associated with higher mortality were older age, female gender, and anteroseptal infarction. The age of 23% of the patients was 40 years or younger. Comparison between these younger patients (Group I) and those over 40 years (Group II) demonstrated that Group I had lower mortality (3.6%) than Group II (12%) (p < 0.001). Group I patients were predominantly men (96.8%), of Asian nationalities (71%), and usually smokers (78%). The observation that myocardial infarction occurs frequently in young Asian men needs further evaluation to identify specific risk factors.

Coronary angiography in Qatar: the first ten years.

Cardiac catheterization in Qatar was initiated in July 1982. In ten years, a total of 3900 procedures were performed at Hamad General Hospital. Computerized data registry has been maintained since 1982. Isolated coronary angiography was done in 2911 patients; of these, 2635 (90.5%) were men, and 276 (9.5%) were women, the average age of the patients was 47+/-9.2 years (range, twenty-five to eighty-eight). Patients' nationality was Qatari in 492 (17%), and other Arabs in 610 (21%), and 1512 (52%) were from the Asian subcontinent. Myocardial infarction was the most common indication (43%). Single-vessel disease was found in 638 (22%), two-vessel disease in 630 (22%), three-vessel disease in 950 (33%), and nonsignificant coronary artery disease in 693 (24%) patients. Morbidity related to the coronary angiography was reported in 147 (5%) patients, but there was no mortality related to the procedure. In 822 (28%) patients, the age was forty years or younger. The angiographic findings of these younger patients were compared with those of the older ones. Younger patients were usually men of Asian subcontinental origin with a recent myocardial infarction (MI). Often, they had normal coronary arteries or single-vessel disease. Patients of Asian subcontinent origin were usually young male patients with a recent MI, who receive streptokinase, and have single-vessel disease.

Self-inflicted transanal stripping of colorectal mucosa: report of an unusual case.

A young mentally retarded patient with self-abusive behavior managed to dissect between the mucosa and muscularis layers of the anal canal, through the anus, using his fingers; he managed then to strip the mucosal-submucosal layers of his rectum and colon all the way up to the splenic flexure and presented with an unusual two-yard long "rectal prolapse" which was actually stripped colorectal mucosal-submucosal tube. Diagnosis and management of this unusual patient are discussed. The authors could not find any similar case report in the English Medical literature.

Adenocarcinoma in perineal fistulas of Crohn's disease.

Until recently, Crohn's disease has not been regarded as a premalignant lesion, but the increasing number of patients with Crohn's disease in whom adenocarcinoma of the gastrointestinal tract develops strongly suggests that these patients are indeed at a higher risk for carcinoma. These patients are usually young and tend to develop a malignancy in the bypassed ileum or right colon. Patients with such lesions usually have a poor prognosis. Adenocarcinoma arising in perineal fistulas secondary to Crohn's disease has not been reported in English medical literature except for one case published in 1975. In this article, the authors report a second, similar case of Crohn's disease with recurrent perineal fistulas. An infiltrating adenocarcinoma developed in these fistulas, in the anorectal region, and in the left labia. The risk of malignancy should be seriously considered in the management of Crohn's disease, especially in young patients. Because of the risk of adenocarcinoma in these patients, resection rather than bypass is recommended in the surgical management.

Colonic fistulization in pancreatitis: case report and literature review.

A case is reported in which pancreatic abscess with erosion into the colon and the splenic artery was treated successfully. The 35 previously reported cases of colonic fistulization in pancreatitis are reviewed, and the pathophysiology, diagnosis, and management of this complication are discussed.

Cultured human vascular smooth muscle cells with functional thromboxane A2 receptors: measurement of U46619-induced 45calcium efflux.

Thromboxane A2 (TXA2)/prostaglandin H2 (PGH2) are potent vasoconstrictors whose contractile effects are mediated by increases in cellular calcium. Stable analogues of these compounds have shown calcium ionophore activity at high concentrations. To determine if effects of TXA2/PGH2 analogues on 45Ca2+ fluxes are receptor mediated, the effects of the stable TXA2/PGH2 mimetic U46619 and the TXA2/PGH2 receptor antagonist I-PTA-OH on 45Ca/+ fluxes in cultured human vascular smooth muscle cells were studied. The smooth muscle cells were cultured from human saphenous vein explants, and they retained the morphologic and immunologic characteristics of vascular smooth muscle cells. U46619 stimulated 45Ca2+ efflux in a dose-dependent manner with an EC50 of 398 +/- 26 nM (n = 4). The maximal 45Ca2+ efflux in response to U46619 (5 microM) was significantly greater (p = 0.006) than the 45Ca2+ efflux induced by KCl (40 mM). I-PTA-OH inhibited the U46619-induced 45Ca2+ efflux but had no effect on KCl-induced 45Ca2+ efflux. These results suggest that the effects of U46619 in increasing vascular smooth muscle cell calcium efflux are receptor mediated. Furthermore, vascular smooth muscle cells with functional TXA2/PGH2 receptors were cultured from human saphenous veins and provide a potentially useful in vitro system for the further study of TXA2/PGH2 receptor-mediated phenomena in human vascular tissue.

Solitary bronchial papilloma presenting with recurrent dyspnea attacks: case report with computed tomography findings.

A case of solitary bronchial papilloma is reported which, because of its unusual location near the carina and marked mobility, presented with attacks of dyspnea that were misdiagnosed as asthma for many years. It caused no abnormality on a plain chest X-ray, but could be visualized on linear and computed tomograms. The computed tomograms further demonstrated the absence of extraluminal extension of the tumor or mediastinal lymphadenopathy which could not be excluded by linear tomography or bronchoscopy. Transbronchial resection resulted in complete relief of symptoms.

Latissimus dorsi free myocutaneous flap.

Microvascular surgery has added new dimensions in reconstructive surgery. The concept of myocutaneous flap improved soft-tissue reconstruction procedures. The latissimus dorsi myocutaneous flap proved to be very reliable in regional reconstruction operations on the chest wall, abdomen, back, head, and neck regions. The use of latissimus dorsi myocutaneous flap as a free flap using microvascular anastomosis paved the way for the use of this flap in distant soft-tissue reconstruction. In this paper we review the literature of latissimus dorsi free myocutaneous flap in clinical application, and added three cases of our own in whom the latissimus dorsi free myocutaneous flap was used for soft-tissue reconstruction in distal leg defects. This flap proved itself again as reliable mainly because of its constant dominant vascular pedicle, its large size, and the minimal functional problems that result from its use.

Congenital absence of superior vena cava: unusual anomaly of superior systemic veins complicating pacemaker placement.

Congenital anomalies of the superior systemic veins can complicate placement of transvenous pacemaker electrode leads. Persistent left superior vena cava is the most common congenital anomaly; in this paper, we describe the case of a patient who had congenital absence of both superior venae cavae, which has not been reported previously. The superior systemic veins drained into persistent double azygos veins subdiaphragmatically. The anomaly was verified by venography. Temporary cardiac pacing was established by passing the electrode lead through the femoral vein, and a permanent epicardial pacemaker lead was placed thereafter. This appears to be the first recorded case of such an anomaly.

Myocardial infarction with normal coronary angiography compared with severe coronary artery disease without myocardial infarction: the crucial role of smoking.

BACKGROUND: Why do some patients suffer acute myocardial infarction (MI) despite angiographically normal coronary arteries (NL + MI) whereas others enjoy an acute MI-free life despite extensive three-vessel disease (3VD-MI)? The present study contrasts these two groups to identify some differences in the risk profile. METHODS: In 10,000 patients admitted to the cardiology service, a first MI was confirmed in 2356 patients, of whom 1609 underwent coronary angiography. In 77 patients with MI, coronary angiography was found to be entirely normal (NL + MI, 77/1609, 4.1%). These were contrasted to 123 patients with severe three-vessel coronary disease but no MI (3VD-MI). RESULTS: Patients with NL + MI were 13 years younger (42 +/- 8.3 vs 55 +/- 10.5, P < 0.05), with 33 patients (43%) under the age 40 years, in contrast to only 9 patients (7.3%) in the 3VD group being this age. Patients with NC + MI were more often current smokers (80.5% vs 29% in the 3VD group; P < 0.01). Patients with 3VD-MI were, on the other hand, more often diabetic (54% vs 9% in the NL + MI group; P < 0.01) and had a higher cholesterol level (5.6 +/- 1.1 vs 4.9 +/- 1.0 Mmol/l, P < 0.01) as well as a higher incidence of chronic stable angina (52% vs 22%; P < 0.01) and heart failure (6% compared with 0% in the NL + MI group). Sixty-one out of 77 (79%) NL + MI patients had a single risk factor, and in 87%, this was smoking alone. Diabetes mellitus was rare and never occurred alone in this group. CONCLUSION: In patients who suffer MI despite normal coronary angiography, smoking is a major risk factor: In contrast, in patients with extensive coronary artery disease on angiography but no MI, diabetes rather than smoking is the dominant risk factor. The findings of this study support the view that the risk factors for stable and unstable coronary artery disease are different, as reflected by the contrast of the above groups at the extremes of the spectrum. Smoking appears to be a major risk factor for acute MI (even with normal coronary angiography), whereas diabetes is a major risk factor for more severe but more stable coronary artery disease.

Pharmacologic characterization of human and canine thromboxane A2/prostaglandin H2 receptors in platelets and blood vessels: evidence for different receptors.

The present study was undertaken to characterize thromboxane A2/prostaglandin H2 (TXA2/PGH2) receptors in platelets and blood vessels. Both human and canine platelet aggregation and saphenous vein contractions were induced by the stable TXA2/PGH2 mimetics (15S)-hydroxy-11 alpha,9 alpha-(epoxymethano)prosta-5Z, 13E-dienoic acid (U46619) and 9,11-epithio-11,12-methano-TXA2 (ONO-11113). ONO-11113 was a more potent agonist than U46619 in the human saphenous vein but less potent in the platelet. These agonists were equipotent in the canine platelet but ONO-11113 was more potent in the saphenous vein. Platelet aggregation and saphenous vein contraction induced by U46619 were blocked in a dose-dependent manner by the TXA2/PGH2 receptor agonists 9,11-dimethylmethano-11,12-methano-16-phenyl-13,14-dehydro-13-aza- 15 alpha beta-omega-tetranor-TXA2 (ONO-11120), 9,11-dimethylmethano-11,12-methano-16-(4-hydroxyphenyl)-13,14-d ihy dro-13-aza-15 alpha beta-omega-tetranor-TXA2 (PTA-OH), 9,11-dimethylmethano-11,12-methano-16-(4-methoxyphenyl)-13,14-d ihy dro-13-aza-15 alpha beta-omega-tetranor-TXA2 (PTA-OM), 9,11-dimethylmethano-11,12-methano-16-(3-iodo-4-hydroxyphenyl-13,1 4-dihydro-13- aza-15 alpha beta-omega-tetranor-TXA2 (I-PTA-OH) and 9,11-dimethylmethano-11,12-methano-15-phenyl-13,14-dihydro-13-aza- 15 alpha beta-omega-pentanor-TXA2 [PTA-(omega-1)].(ABSTRACT TRUNCATED AT 250 WORDS)