Impact of three or more sirolimus-eluting stents versus paclitaxel-eluting stents on clinical outcomes in patients undergoing percutaneous coronary intervention.

OBJECTIVES: The purpose of this study was to examine the clinical outcomes of patients who underwent stenting with > or =3 sirolimus-eluting stents (SES) when compared with those treated with > or =3 paclitaxel-eluting stents (PES). BACKGROUND: Drug-eluting stent (DES) implantation for single coronary lesions is proven to be effective and durable. METHODS: A total of 126 patients who received DES were identified, of which 66 patients received > or =3 SES (SES group) and 60 patients received > or =3 PES (PES group). RESULTS: The baseline clinical and angiographic characteristics were compatible between the two study groups. During the index hospitalization, all clinical outcomes were similar between the two groups. There were no deaths or Q-wave myocardial infarctions (MIs) in either group. At 30 days' and 6 months' follow-up, all clinical outcomes, including death, Q-wave MI, non-Q-wave MI, target lesion revascularization, target vascular revascularization, and major adverse cardiac events, were compatible between both groups. There were 2 patients (3.0%) with subacute thrombosis in the SES group and 1 patient (1.7%) in the PES group, but there was no statistical significance. There was no late thrombosis from either group. In addition, patients in the SES group had similar event-free survival rates as compared with those in the PES group (P = 0.56). CONCLUSIONS: Patients who require > or =3 DES implantations experienced increased adverse clinical events as compared with historical single stent implantation. However, there were no differences in safety and efficacy among the patients treated with SES as compared with those treated with PES.     

Giant cell tumor of the pancreas arising in the ovarian-like stroma of a mucinous cystadenocarcinoma

Summary We describe a malignant mucinous cystic neoplasm of the pancreas with ovarian-like stroma within which an osteoclast-like giant cell rich tumor arose. This rare tumor had a unique immunohistochemical profile with the giant cells staining for vimentin, leukocyte common antigen, and the monocyte/macrophage marker CD68, whereas the mucinous epithelium stained for epithelial membrane antigen and cytokeratin. The immunohistochemical findings are consistent with two lines of differentiation, one epithelial and the other suggesting mesenchymal differentiation of the giant cell tumor with an immunophenotype similar to giant cell tumor of bone. The coexistence of these two rare tumors suggests that they are histogenetically related. The finding of a giant cell tumor arising in the ovarian stroma indicates that the stroma of mucinous tumors is not always an innocuous component of the tumor.     

Frequency and direction of interatrial shunting in valvular pulmonic stenosis with intact ventricular septum and without left ventricular inflow or outflow obstruction: An analysis of 127 patients treated by valvulotomy

This report summarizes observations in 127 patients who underwent pulmonic valvulotomy for valvular pulmonic stenosis with intact ventricular septum and without obstruction to left ventricular inflow or outflow. Of the 127 patients, 30 (24%) preoperatively by dye dilution curves had shunting at the atrial level: in 19 (63%), the shunt was right-to-left, and in the other 11 (27%), entirely left-to-right. The patients with right-to-left interatrial shunts had severe pulmonic valve stenosis (average peak systolic pressure gradient = 120 ± 11 mm. Hg) and small (average diameter 1.1 ± 0.1 cm.) sized defects in the atrial septum (patent foramen ovale). In contrast, the patients with left-to-right shunts had mild to moderate pulmonic valve stenosis (average peak systolic pressure gradient = 60 ± 5 mm. Hg) and relatively large (average diameter = 2.8 ± 0.1 cm.) defects in the atrial septum (true atrial septal defect). The patients with right-to-left interatrial shunts had no significant differences in right versus left atrial pressures. The patients with left-to-right interatrial shunts, however, had left atrial pressures significantly greater than right atrial pressures (7 ± 0.5 vs 5 ± 0.5, p < 0.05). No significant differences were found in ventricular end-diastolic pressures.     

Importance of transesophageal echocardiography in the evaluation of Staphylococcus aureus bacteremia

BACKGROUND AND AIM OF THE STUDY: Staphylococcus aureus is a leading cause of bacteremia and is often associated with endocarditis. The diagnosis of endocarditis may be missed when relying on clinical risk prediction, and this has led others to recommend transesophageal echocardiography (TEE) for diagnosis in most cases of S. aureus bacteremia (SAB). The study aim was to determine the likelihood of finding vegetations on TEE in patients with SAB in a suburban teaching hospital setting, and to identify risk factors predictive of vegetation on TEE. METHODS: All cases of SAB at Walter Reed Army Medical Center between January 2000 and May 2003 were evaluated. The prevalence of vegetations was determined in those cases selected for TEE. Potential risk factors for endocarditis were analyzed by review of medical records. RESULTS: A total of 176 patients had documented SAB during the time frame of the study, and 64 of these had TEE performed. Among the latter patients, 14% had a previously unidentified vegetation discovered by TEE. Patients with vegetation on TEE were as likely as those without vegetation to have nosocomial bacteremia, an alternate source of infection, and lack of valvular disease by prior surface echocardiography. Patients with a vegetation were significantly older (mean age 68.4+/-10.9 versus 54.6+/-19.6 years; p = 0.04). CONCLUSION: TEE identified a significant number of vegetations resulting from SAB. The clinical risk profile and transthoracic echocardiography did not reliably exclude vegetation. These findings support the liberal use of TEE for the diagnosis of SAB.     

Does creatine kinase‐MB (CK‐MB) isoenzyme elevation following percutaneous coronary intervention with drug‐eluting stents impact late clinical outcome?

BACKGROUND: The incidence of postprocedural creatine kinase (CK)-MB elevation to >3x the upper limit of normal after percutaneous coronary intervention (PCI) has been reported at rates of up to 18% in the bare metal stent era and is correlated with higher adverse cardiovascular outcomes. This study examined the incidence and prognostic significance of CK-MB elevations after drug-eluting stent (DES) implantation. METHODS: The records of 2,537 patients who underwent DES implantation and completed > or =6 months' follow-up were evaluated. Patients with acute myocardial infarction and those who presented in cardiogenic shock and had elevated cardiac enzymes at baseline were excluded from the analysis. Of these, 179 patients (7.1%) had > or =3x postprocedural CK-MB and 2,358 patients had <3x CK-MB elevation. The composite end point of target vessel revascularization-major adverse cardiac events (TVR-MACE) at 6 months was compared between groups. Univariate and multivariate regression analyses were performed to identify predictors of adverse cardiac outcomes. RESULTS: The patients with CK-MB > or =3x elevation had a higher number of diseased vessels (2.15 +/- 0.86 vs. 1.81 +/- 0.87; P < 0.001), higher prevalence of type C lesions (29.9% vs. 17.7%; P < 0.001), received a higher average number of stents, and total stented length (1.72 +/- 0.89 vs. 1.49 +/- 0.83; P < 0.001 and 37.4 +/- 23.0 mm vs. 30.8 +/- 20.7 mm; P = 0.0003, respectively), and had lower rates of clinical success (91.9% vs. 99.2%; P < 0.001). The 6-month and 1-year TVR-MACE rates were higher for the elevated CK-MB group (11.9% vs. 7.0%; P = 0.02 and 16.1% vs. 26.6%, respectively; P = 0.005). The rates of subacute thrombosis were also significantly higher in the group with elevated CK-MB (0.4% vs. 3.2%, P < 0.001). Though significant CK-MB release was a predictor of TVR-MACE after univariate analysis, multivessel PCI, subacute stent thrombosis, total stented length, and history of prior PCI were the only predictors after multivariate regression analysis. CONCLUSIONS: Postprocedural CK-MB > or =3x elevation following PCI with DES continues to be a marker for the complexity of coronary disease and lack of clinical success; and correlates with higher rates of subacute thrombosis as well as late adverse events at 6-months and 1-year postprocedure.     

Pharmacokinetic and pharmacodynamic evaluation of intramuscular artesunate in healthy beagle dogs

Pharmacokinetic and pharmacodynamic responses were evaluated after intramuscular (i.m.) injection of artesunate (AS). Twelve dogs were injected with i.m. AS at 2.5, 5, or 10 mg/kg into the left gluteal muscle. A second injection of only diluent was given in the right gluteal muscle. At 24 hours post-injection, plasma creatine kinase (CK) concentrations were elevated above normal. Muscle biopsies showed myocyte necrosis and acute inflammation, which was worse on the treated side. At 7 days after injection, CK concentrations were normal. Muscle biopsies showed mineralization, fibrosis, and chronic inflammation with less difference between sides. Compared with intravenous administration, i.m. AS resulted in a prolonged half-life for both AS and DHA. Intramuscular AS also had a lower mean dose-adjusted C(max) and a higher mean dose-adjusted area under the curve; but produced similar concentrations of dihydroartemisinin. These findings suggest that adverse reactions to i.m. artesunate are minor and temporary which justify further study of this route in treating severe malaria.