Nasal polyps, bronchial asthma and aspirin sensitivity.

The ASA triad comprises bronchial asthma, acetylsalicylic acid (ASA) sensitivity and nasal polyps. It presents as chronic rhinitis followed by bronchial asthma and ASA sensitivity, and later nasal polyps. The pathogenesis of the ASA triad may involve interrelationships between disease in the upper and lower airway and hypersensitivity to cyclo-oxygenase inhibiting medications. Treatment of the nasal polyps has been shown to improve the patients' asthma.     

The Effects of Menstrual Cycle Phase on Cardiovascular and Pulmonary Responses to Behavioral and Exercise Stress

The present study was designed to compare the differential cardiopulmonary and hemodynamic responses of Type A and B women to an exercise and a psychological stressor. In addition, the effects of menstrual cycle phase on the resting and response levels of a wide range of physiological variables were explored. Thirty-two women participated in a progressive exercise stress test and a threat of shock video game during both the luteal and follicular phases of the menstrual cycle. Half of these subjects expressed the coronary-prone behavior pattern referred to as Type A, as assessed by the Jenkins Activity Survey. The remaining women were relatively free of these behaviors (Type B). Heart rate, oxygen consumption, carbon dioxide production, minute ventilation, and end-tidal carbon dioxide were monitored and recorded on a breath-by-breath basis. Systolic and diastolic blood pressure measures were taken at 2-min intervals. Results indicated similar baseline, exercise, and behavioral stress responses among Type A and B women. The stress responses were also the same between the follicular and luteal phases for all measured physiological variables. However, resting levels of heart rate, metabolism, and ventilation were all elevated at rest during the luteal phase. A regression analysis based on the exercise heart rate and oxygen consumption data demonstrated that a majority of subjects exhibited heart rate responses in excess of that expected during the psychological stressor. These data are discussed with special reference to possible mechanisms of the pathophysiology of cardiovascular disease.     

Common brachiocephalic trunk: strategies for revascularization

BACKGROUND: A common brachiocephalic trunk, in which both common carotid arteries and the right subclavian artery arise from a single trunk off the arch, is a normal variant of aortic arch branching that occurs in approximately 10% of the population. Because three of the four primary sources of cerebral blood flow arise from a single aortic branch, stenosis or occlusion of a common trunk can cause severe ischemic consequences. Common trunk revascularization has been described, but there have been no reports focusing on the management options for occlusive disease of this vascular anatomy. METHODS: A retrospective review of our experience with innominate artery revascularization identified 6 patients who underwent revascularization of a common brachiocephalic trunk between 1977 and 1997. All patients were symptomatic, with either total occlusion (n = 3) or critical stenosis (n = 3) caused by atherosclerosis (n = 5) or Takayasu's arteritis (n = 1). Revascularization was achieved by a prosthetic bypass graft from the ascending aorta to the innominate or left common carotid arteries or both (n = 5); or transarterial endarterectomy (n = 1). Concomitant endarterectomy of branch vessels was performed in 3 patients. RESULTS: There was one perioperative death from myocardial infarction, and one perioperative stroke, with death occurring 1 month after hospital discharge. One patient developed cerebral hyperperfusion syndrome 1 week after endarterectomy that resolved without sequelae with antihypertensive medications. During a follow-up period ranging from 1 to 20 years, there was one late death from congestive heart failure 5 years after operation. All surviving patients are alive and free from symptomatic recurrence. CONCLUSIONS: Revascularization for occlusive disease of a common brachiocephalic trunk can be achieved with effective and durable relief of symptoms using either a prosthetic bypass graft or endarterectomy. However, neurologic complications in 2 patients, which were fatal in 1, attest to the potential cerebral ischemic threat posed by occlusive disease of a common brachiocephalic trunk.     

Surgical recanalization of occluded peripheral arteries.

This article, reflecting on the surgical recanalization of occluded peripheral arteries, has exposed the very essence of vascular surgery. Only the pioneering cardiac anomalies repaired by Gross (patent duct arteriosus, 1938), Blalock and Taussig (tetralogy of Fallot, 1944), and Crafoord and Nylin (coarctation, 1945) and the legendary aortic grafting operations of Oudot (occlusion, 1950) and Dubost and coworkers (aneurysm, 1951) are not a part of this article. The contributions to surgical recanalization of the occluded peripheral arteries are numerous. Some are well conceived, and others are innovative. Perhaps the most significant technique of all, endarterectomy itself, began purely as a serendipitous event. The startling impact of dos Santos' revolutionaly "disobliteration" was realized at once. Intimal injury during the operation did not cause inevitable thrombosis, as historically taught. Thus, all vascular interventions, either endarterectomy, graft repair, or the newer endovascular techniques discussed in this issue, would not have been developed without the understanding of the tolerance of the human intima to injury. Thromboendarterectomy, the basis of surgical recanalization of occluded arteries, unlocked the mystery of arterial rethrombosis after intervention. Recognizing these crucial facts, it will have a lasting place in the expanded discipline of vascular disease and its treatment. Dos Santos, the European founder of endarterectomy, and Wylie, the American pioneer and proponent of endarterectomy, were great friends in life (Fig. 4) and would certainly be pleased to see the further development of technology aimed at the treatment of atherosclerotic obstruction of the peripheral arteries.     

Circumferential venolysis and paraclavicular thoracic outlet decompression for "effort thrombosis" of the subclavian vein.

Effort thrombosis of the subclavian vein (Paget-Schroetter syndrome) has long been considered a primary thrombotic process, but recent experience suggests that it may commonly result from repeated mechanical compression. Increased awareness of the pathophysiology of this syndrome can allow timely, improved diagnostic screening and the use of specific surgical intervention to relieve the venous consequences. During the past 15 years we have treated six patients with mechanical compression in the thoracic outlet causing surgically correctable venous occlusive problems. There were four men and two women with an average age of 38 years (range 26 to 53 years). All patients exhibited pain, swelling, and cyanosis of the upper extremity, with worsening venous congestion on abduction of the arm. Five of six patients were originally treated for effort thrombosis of the subclavian vein with arm elevation and anticoagulation; two also underwent immediate thrombolytic therapy with urokinase. Venography was prompted in each case by positional symptoms during follow-up and showed irregular stenosis of the subclavian vein adjacent to the first rib. All patients underwent extended first rib resection and circumferential venolysis (one patient underwent bilateral procedures); one was performed through a transaxillary approach, two through a supraclavicular approach, and four through a new, "paraclavicular" approach. All subclavian veins appeared normal after venolysis. Five of six patients also underwent complete scalenectomy and brachial plexus neurolysis. In each patient, venous and neurogenic symptoms resolved and venography confirmed a patent subclavian vein, with follow-up ranging from 11 months to 13 years (mean 3.8 years).     

The long leg radiograph is a reliable method of assessing alignment when compared to computer-assisted navigation and computer tomography

BackgroundThe mechanical alignment of the knee is an important factor in planning for, and subsequently assessing the success of a knee replacement. It is most commonly measured using a long-leg anteroposterior radiograph (LLR) encompassing the hip, knee and ankle. Other modalities of measuring alignment include computer tomography (CT) and intra-operative computer navigation (Cas). Recent studies comparing LLRs to Cas in measuring alignment have shown significant differences between the two and have hypothesized that Cas is a more accurate modality. This study aims to investigate the accuracy of the above mentioned modalities.MethodologyA prospective study was undertaken comparing alignment as measured by long-leg radiographs and computer tomography to intra-operative navigation measurements in 40 patients undergoing a primary total knee replacement to test this hypothesis. Alignment was measured three times by three observers. Intra- and inter-observer correlation was sought between modalities.ResultsIntra-observer correlation was excellent in all cases (> 0.98) with a coefficient of repeatability < 1.1°. Inter-observer correlation was also excellent measuring > 0.960 using LLRs and > 0.970 using CT with coefficient of repeatability < 2.8°. Inter-modality correlation proved to be higher when comparing LLRs and CT (> 0.893), than when comparing either of these modalities with Cas (> 0.643 and > 0.671 respectively). Pre-operative values had the greatest variability.ConclusionGiven its availability and reduced radiation dose when compared to CT, LLRs should remain the mainstay of measuring the mechanical alignment of the lower limb, especially post-operatively.Level of evidenceII     

Novel erythropoiesis stimulating protein (darbepoetin alfa) alleviates anemia associated with chronic inflammatory disease in a rodent model

OBJECTIVE: We developed a rodent model of noninfectious systemic inflammation to examine the pathogenesis of the associated anemia of chronic disorders (ACD), to evaluate the similarity of this ACD model to human ACD, and to evaluate the potential efficacy of novel erythropoiesis stimulating protein (darbepoetin alfa) as an ACD therapy. METHODS: Lewis rats were immunized with peptidoglycan-polysaccharide polymers (PG-APS), the chronic inflammation and associated ACD were characterized, and the effects of darbepoetin alfa treatment on complete blood counts (CBC), red blood cell (RBC) indices, and iron metabolism were analyzed weekly. RESULTS: Acutely inflamed rats had reduced peripheral blood (PB) RBC counts and hemoglobin (Hb) concentrations and increased reticulocyte counts. PB RBC numbers normalized during chronic inflammation, but RBC remained hypochromic and microcytic. Consequently, the rats remained chronically anemic. Anemic rats had fluctuating serum erythropoietin (EPO) concentrations, but mean EPO concentrations never varied significantly from baseline control levels. Histology of anemic rat spleen sections revealed reticuloendothelial siderosis. Total serum iron concentrations were chronically low. Peritoneal exudate cells (PEC) isolated from anemic rats and stimulated with PG-APS in vitro produced more interleukin (IL)-1alpha and interferon (IFN)-gamma, and significantly more tumor necrosis factor (TNF)-alpha and IL-10 than control cultures. Darbepoetin alfa restored Hb concentrations to baseline levels within 2 to 7 weeks, depending on dosage. A refined treatment strategy restored Hb to baseline and maintained those levels with reduced dosing. CONCLUSION: ACD in this rodent model closely replicates human ACD. Darbepoetin alfa treatment reversed ACD in this model by increasing RBC production and RBC hemoglobinization while reducing siderosis and hypoferremia.