Upward subluxation of the axis in ankylosing spondylitis. A clinical pathologic report.

Upward subluxation of the axis associated with cord compression and death was noted in a patient with a long history of idiopathic ankylosing spondylitis. Upward subluxation of the axis has been recognized in up to 8 per cent of patients with rheumatoid arthritis but it is an exceedingly rare complication of ankylosing spondylitis. In this patient psoriasis and then psoriatic dactylitis developed 26 years after the onset of his ankylosing spondylitis. It is tempting to speculate that the unusual destruction of the joints around the atlas might be due to an added effect of psoriasis on idiopathic ankylosing spondylitis.     

Propranolol withdrawal in angina pectoris: a prospective study.

In a prospective study, 100 consecutive patients (mean age 51.3 years) with angina pectoris had propranolol abruptly discontinued 24 to 144 hours (mean 39.0 hours) prior to elective coronary arteriography. The mean duration of therapy was 8.2 months and the mean daily propranolol dose was 216.1 mg. New York Heart Association Class II, III and IV symptoms were present in 30, 41, and 29 patients and one, two, or three coronary arteries were more than 50 per cent narrowed in 37, 29, and 34 cases, respectively. Three patients experienced minor increases in chest pain and two suffered non-transmural myocardial infarctions prior to the time of scheduled cessation of therapy. The same number of minor and major complications occurred in the post-withdrawal period. All four patients who developed non-transmural myocardial infarction in this study had pre-existing Class IV symptoms. The course of the remaining 90 patients was uneventful. These findings do not support the concept of a rebound propranolol withdrawal reaction.     

Coronary artery spasm and mitral valve prolapse

Ten patients, representing 1.34 per cent of those patients undergoing selective coronary arteriography, were found to have unequivocal evidence of coronary artery spasm. This involved the proximal right coronary artery in eight patients, the mid-left anterior descending branch in one, and the left main coronary artery in one. Eight of these 10 patients had otherwise normal coronary arteries.Of these 10 patients with coronary artery spasm, nine had evidence of mitral valve prolapse. This involved the posteromedial scallop in six patients; the anterolateral and posteromedial scallops in one; the middle and posteromedial scallops in one; and the anterolateral, middle, and posteromedial scallops in one.These data suggest an association between coronary artery spasm and mitral valve prolapse. Coronary artery spasm may thus be an important factor in the pathogenesis of the chest pain, arrhythmias, electrocardiographic abnormalities, and sudden death, that have already been described in some patients with mitral valve prolapse.     

Mechanism of acquired right ventricular outflow tract obstruction in patients with ventricular septal defect: an angiocardiographic study

Right ventricular outflow tract obstruction can complicate the natural history of patients with isolated ventricular septal defect. Although numerous pathologic mechanisms may be responsible for this phenomenon, it is less clear what the frequency is of each of these mechanisms in any cohort of patients studied in a single institution. We identified 20 patients with isolated ventricular septal defect from 1970 to 1981 who acquired a right ventricular outflow tract gradient of 25 mm Hg or more. They ranged in age at the initial catheterization investigation from 4 days to 23 months and at the subsequent study from 13 months to 8 years. Angiographically, 2 mechanisms were implicated in the 20 patients. Hypertrophy of right ventricular anomalous muscle bundles was identified in 19 of the 20 while hypertrophy of a malaligned infundibular septum (that is, classic tetralogy type) was identified in only 1 patient. These data indicate that acquired right ventricular outflow tract obstruction is rarely of the classic tetralogy type.     

Truncal or aortic valve stenosis in functionally single arterial trunk: A clinical,hemodynamic and pathologic study of six cases

Stenosis of the semilunar valve in the presence of a functionally single arterial trunk is uncommon. Three patients with truncus arteriosus, two with tetralogy of Fallot and pulmonary atresia and one with pulmonary atresia and intact septum were diagnosed as having stenosis of the truncal or aortic valve on the basis of clinical, echocardiographic, hemodynamic and angiocardiographic findings. Echocardiograms consistently showed multiple diastolic closure lines and abnormal semilunar valves in addition to the aortic override in five patients and hypoplastic right ventricle in the patient with pulmonary atresia and intact septum. Peak systolic gradients between the left ventricle and truncus (or aorta) at cardiac catheterization ranged from 20 to 47 mm Hg. Retrograde aortography confirmed a domed and stenotic semilunar valve. Cyanosis was progressive in the three patients with pulmonary atresia. Two patients had arterial anastomosis, and one had a right ventricle-pulmonary arterial graft in addition to aortic valvotomy. One of the three patients with truncus arteriosus underwent complete repair in addition to truncal valvotomy but he died in the postoperative period. The other two patients with truncus arteriosus died of intractable congestive cardiac failure before surgical intervention.It is suggested that the presence of semilunar valve stenosis in these patients adversely affects the prognosis. The myocardium is already jeopardized as a result of hypoxia in pulmonary atresia and left ventricular diastolic overload in patients with truncus arteriosus. The added burden of semilunar valve stenosis may further compromise the functional status of the myocardium.     

Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP)

Background

Risk of red blood cell transfusion (RBCT) in partial hepatectomy is 17–27%; strategies to reduce transfusions can be targeted in patients at increased risk. A Three Point Transfusion Risk Score (TRS) was previously developed to predict patients' risk of transfusion during and following hepatectomy. Here, it was subject to external validation using the ACS-NSQIP database.

Reducing repeat imaging in hepato-pancreatico-biliary surgical cancer care through shared diagnostic imaging repositories

Background

With regionalization of care, patients often undergo treatment in institutions other than where the initial investigation is conducted. This study assessed the impact of a shared diagnostic imaging repository (SDIR) on processes of care and outcomes in hepato-pancreatico-biliary (HPB) cancer surgery.

Kaposi's sarcoma complicating corticosteroid therapy for temporal arteritis

Combination immunosuppressive therapy, particularly in renal transplant recipients, is associated with a higher than expected risk of development of Kaposi's sarcoma. In this report, cutaneous dissemination of Kaposi's sarcoma occurred in a patient with temporal arteritis who was treated with corticosteroids. Reduction of the steroid dosage was followed by regression of the tumor. This sequence of events suggests a causal relationship between the evolution of the sarcoma and corticosteroid therapy. Although Kaposi's sarcoma may complicate corticosteroid therapy alone, the incidence is considerably lower than in renal transplant recipients receiving combination immunosuppressive therapy. Considering the large number of patients with temporal arteritis who are treated with steroids and that this is the first report of its association with Kaposi's sarcoma, it seems that other factors, perhaps genetic, might be important in the development of this neoplasm.     

The criss-cross and superoinferior ventricular heart: an angiocardiographic study

The angiocardiographic features of 11 patients with superoinferior and criss-cross type of atrioventricular (A-V) connections are presented. These unusual ventricular relations are thought to result from postseptation disturbances of ventricular looping. The angiocardiographic appearance of criss-cross is really an illusion, and the A-V connections among these patients are either concordant, discordant or straddling. The often small right A-V valve inflow and sinus portion of the ventricle, combind with the ventricular rotational anomaly, combine to give the angiocardiographic perception of criss-cross. A review of the 11 patients from this institution and those previously reported on suggests that most patients have a transposition of malposition of the great arteries; many have a small right ventricle, and about half have pulmonary outflow tract obstruction. In addition to the obvious embryologic, morphologic and clinical implications of these distorted ventricular loops, the criss-cross A-V hearts raise questions about the various segmental nomenclatures applied to these types of congenital heart disease.     

Optimistic honesty: understanding surgeon and patient perspectives on hopeful communication in pancreatic cancer care

Background

Prognosis conversations between surgical oncologists and patients with pancreatic cancer are critically important and challenging. Surgeons and their patients often have discrepant understandings of prognosis despite extensive conversations. Little is known about how surgeons approach prognosis conversations with these patients; patients' experiences with these conversations are also not well understood. This qualitative study sought to better understand surgeon and patient perspectives on communication in pancreatic cancer care with a view toward improvement.

Management of intractable ventricular tachyarrhythmias after myocardial infarction.

Twenty-five patients with recent or old myocardial infarction were studied because they had life-threatening ventricular arrhythmias that required repeated cardioversions and were intractable to medical management. All patients had had a large anterior infarction a mean of 4.6 weeks before the emergence of the arrhythmias and all had severe left ventricular dysfunction. Cardiac catheterization or autopsy revealed a left ventricular aneurysm in 18 of 18 patients and obstruction of the left anterior descending coronary artery in 20 of 20 patients. Of 16 patients treated surgically with aneurysm resection or coronary bypass grafting, or both, 10 (62 percent) were alive after 3 to 39 (mean 26) months of follow-up. The perioperative mortality rate was 31 percent and only one patient died during the postoperative follow-up period 4 months after discharge from the hospital. By contrast, all nine medically treated patients died either in the hospital (four patients) or suddenly within 2 months of discharge (five patients). Ventricular fibrillation was documented as the cause of death in five of these patients. Surgical intervention was found to improve significantly the survival of these patients (P less than 0.02). The perioperative mortality rate was lower when at least 4 weeks had elapsed from acute infarction to surgery (10 versus 67 percent) and when the procedure included coronary bypass grafting (13 versus 50 percent), although these differences were not statistically significant (P greater than 0.05).     

Relative insesitivity of isovolumic phase indices in the assessment of left ventricular function.

1. The authors compared the sensitivity of the isovolumic phase indices (contractility indices) against LV function curves ("pump-function" indices) in assessing ventricular performance. 2. Certain modifications of the usual isovolumic phase indices, especially those introducing the concept of comparison of exercise with rest, seemed to us to be slightly more helpful in separating normal subjects from the patient with coronary artery disease or cardiomyopathies, but these differences were not striking when statistically evaluated, and could not be utilized in assessment of left ventricular function in individual patients. 3. The construction of left ventricular function curves, in our hands, yielded equally as satisfactory information and, in addition, was much simpler to perform. 4. It is concluded that contractility indices are relatively insensitive in the assessment of left ventricular function, and that they offer little advantage over "pump-function" indices for this purpose.     

Echocardiographic evaluation of right ventricular function in complete transposition of the great arteries: angiographic correlates.

Right ventricular function of patients with complete transposition of the great arteries may be impaired. To assess whether the M mode echocardiogram could predict right ventricular function 64 echocardiograms and ventricular angiograms of 62 patients were studied, 33 obtained before repair of the defect (group I) and 31 (including 2 from patients in group I) obtained after the Mustard procedure (group II). Each group was subdivided according to whether a ventricular septal defect or patent ductus arterposus was or had been present preoperatively.The right ventricular preejection period was expressed as the ratio of the observed to the predicted value for a systemic left ventricle. This value was above normal In all groups and was not significantly different in the 13 patients with right bundle branch block. The observed ejection time expressed as a percent of that predicted for a systemic left ventricle correlated with right ventricular ejection fraction (r = 0.47). The ratio of the observed preejection period/ejection time had a higher correlation with right ventricular ejection fraction (r = ? 0.70). Nine patients had a low right ventricular ejection fraction (an ejection fraction of 0.55 or less was considered indicative of poor right ventricular function). These nine patients were all in group II and all had right bundle branch block.Most patients with poor right ventricular function had had a ventricular septal defect or patent ductus arteriosus before repair of the transposition, and postoperatively had angiographic tricuspld regurgitation, right bundle branch block, a preejection period/ejection time ratio greater than 0.55 and a percent predicted ejection time of 96 percent or less. Most patients who had good right ventricular function (ejection fraction greater than 0.55) had none of these findings. Systolic time intervals obtained with M mode echocardiography can be used for the assessment and longitudinal follow-up of right ventricular function in patients with transposition.     

Chronic effects of myocardial infarction on right ventricular function: a noninvasive assessment

To assess the chronic effects of myocardial infarction on right ventricular function, 48 subjects were studied utilizing radionuclide angiography and two-dimensional echocardiography. Ten were normal subjects (group I), 11 had previous inferior wall myocardial infarction (group II), 10 had previous anteroseptal infarction (group III), 11 had combined anteroseptal and inferior infarction (group IV) and 6 had extensive anterolateral infarction (group V). The mean (+/- standard deviation) left ventricular ejection fraction was 0.66 +/- 0.03 in group I, 0.58 +/- 0.02 in group II, 0.52 +/- 0.02 in group III, 0.33 +/- 0.03 in group IV and 0.33 +/- 0.01 in group V. No systematic correlation between left and right ventricular ejection fraction was observed among the groups. The mean right ventricular ejection fraction was significantly reduced in the presence of inferior myocardial infarction (0.30 +/- 0.03 in group II and 0.29 +/- 0.03 in group IV compared with 0.43 +/- 0.02 in group I [p less than 0.001]). The group II and IV patients also had increased (p less than 0.001) right ventricular end-diastolic area and decreased (p less than 0.001) right ventricular free wall motion by two-dimensional echocardiography. In the presence of anteroseptal infarction (group III), right ventricular free wall motion was increased (p less than 0.05) compared with normal subjects (group I). Thus, the effects of prior myocardial infarction on right ventricular function depend more on the location of infarction than on the extent of left ventricular dysfunction. Inferior infarction was commonly associated with reduced right ventricular ejection fraction and increased right ventricular end-diastolic area. The right ventricular free wall excursion was increased in the presence of anteroseptal infarction, suggested loss of contribution of interventricular septal contraction to right ventricular ejection.     

Stroke Prevention for High-Risk Atrial Fibrillation in the Emergency Setting: The Emergency Physician Perspective

Atrial fibrillation is a frequent reason for presentation to an emergency department (ED), and the number of these visits are increasing. This creates an opportunity to improve the suboptimal rate of oral anticoagulation (OAC) use in patients with atrial fibrillation who are at high risk of stroke. However, there are very few data on whether OAC initiation in the ED, compared with referral to the longitudinal health care provider to initiate it, results in better long-term use. Moreover, for ethical and medicolegal reasons, physicians who initiate a chronic medication are obliged to reassess the patient at a later date, to check for medication side effects and the need for dose adjustment. More research is needed to determine whether OAC should be prescribed in the ED, by a physician who will never see the patient again. Patients who are cardioverted in the ED might be an exception, secondary to the increased risk of stroke after cardioversion. If ED OAC prescribing is associated with better outcomes, these results must be placed into context with the care and outcomes of the other patients in the ED. If there is a net benefit, the findings should be disseminated to practicing emergency physicians, preferably via emergency physician opinion leaders. An implementation science-based approach, which addresses the barriers to ED OAC prescribing (eg, the competing demands of running an ED and lack of guaranteed follow-up care after discharge from an ED), should be used to support prescribing of OAC in the ED. Potential solutions are described.