Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction. TAMI Study Group

To determine the clinical consequences of reocclusion of an infarct-related artery after reperfusion therapy, we evaluated 810 patients with acute myocardial infarction. Patients were admitted into four sequential studies with similar entry criteria in which patency of the infarct-related artery was assessed by coronary arteriography 90 minutes after onset of thrombolytic therapy. Successful reperfusion was established acutely in 733 patients. Thrombolytic therapy included tissue-type plasminogen activator (t-PA) in 517, urokinase in 87, and a combination of t-PA and urokinase in 129 patients. All patients received aspirin, intravenous heparin and nitroglycerin, and diltiazem during the recovery phase. A repeat coronary arteriogram was performed in 88% of patients at a median of 7 days after the onset of symptoms. Reocclusion of the infarct-related artery occurred in 91 patients (12.4%), and 58% of these were symptomatic. Angiographic characteristics at 90 minutes after thrombolytic therapy that were associated with reocclusion compared with sustained coronary artery patency were right coronary infarct-related artery (65% versus 44%, respectively) and Thrombolysis in Myocardial Infarction (TIMI) flow 0 or 1 (21% versus 10%, respectively) before further intervention. Median (interquartile value) degree of stenosis in the infarct-related artery at 90 minutes was similar between groups: 99% for reoccluded (value, 90/100%) compared with 95% for patent (value, 80/99%). Patients with reocclusion had similar left ventricular ejection fractions compared with patients with sustained patency at follow-up. However, patients with reocclusion at follow-up had worse infarct-zone function at -2.7 (value, -3.2/-1.8) versus -2.4 (SD/chord) (value, -3.1/-1.3) (p = 0.016). The recovery of both global and infarct-zone function was impaired by reocclusion of the infarct-related artery compared with maintained patency; median delta ejection fraction was -2 compared with 1 (p = 0.006) and median delta infarct-zone wall motion was -0.10 compared with 0.34 SD/chord (p = 0.011), respectively. In addition, patients with reocclusion had more complicated hospital courses and higher in-hospital mortality rates (11.0% versus 4.5%, respectively; p = 0.01). We conclude that reocclusion of the infarct-related artery after successful reperfusion is associated with substantial morbidity and mortality rates. Reocclusion is also detrimental to the functional recovery of both global and infarct-zone regional left ventricular function. Thus, new strategies in the postinfarction period need to be developed to prevent reocclusion of the infarct-related artery.     

Surgical treatment of Basedow's disease: our experience with 424 operations

From February 2002 to December 2005, 424 operations for thyroid disease were performed in our institute. Twenty-two patients were suffering from Basedow's disease, 14 female and 8 male, mean age 36 years (range: 23 to 53 years). In each patient the diagnosis of Basedow's disease was made according to common clinical and laboratory criteria, by evaluation of the thyroid hormones, TSH and TRAB. Before operation all patients were rendered euthyroid with antithyroid drug treatment. Fourteen total thyroidectomies (64%) and 8 near-total thyroidectomies (36%) were performed. Postoperative thyroid function status was evaluated before, 3-4 weeks after the operation and then 3, 6,12 and 24 months postoperatively. The patients were classified as euthyroid (FT3-FT4 and TSH normal), hypothyroid (FT3 and/or FT4 reduced and TSH increased), or hyperthyroid (FT3-FT4 increased). In expert hands, surgical treatment appears to be capable of curing the hyperthyroidism of Basedow's disease effectively, with a very low and largely acceptable risk of complications. Among the different types of surgery, total thyroidectomy and near-total thyroidectomy are equally appropriate to ensure there is no risk of recurrence of hyperthyroidism.     

Complete atrioventricular block induced by rituximab in monotherapy in an aged patient with non-Hodgkin’s diffuse large B-cell lymphoma

Rituximab is a treatment option to non-Hodg kin's diffuse large B-cell lymphoma (NHDLBCL) in advanced stage and comorbility. It is known the cardiotoxicity effect of this drug, but there is no previous report describing a complete atrioventricular block (CAVB) secundary to treatment with Rituximab. We present an elderly woman treated with monotherapy with Rituximab who experienced a CAVB after administration of the fifth dose of this drug.     

Patterns of cervical node metastases from squamous carcinoma of the larynx

We undertook a retrospective review of 247 previously untreated consecutive patients from 1965 to 1986 with primary squamous cell carcinoma of the supraglottic or glottic larynx to ascertain the prevalence of neck node metastases by neck level. The 247 patients underwent a total of 262 radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection in the NO neck; immediate therapeutic dissection in the N+ neck; and subsequent therapeutic dissection in the NO neck that over time converted clinically to N+. Detailed analysis revealed a predominance of neck node metastases in levels II, III, and IV for all clinical neck groups. Level V was rarely involved, but always in conjunction with neck node metastases in levels II, III, or IV (ie, N2 disease). Level I was rarely involved; involvement occurred with neck node metastases in levels II, III, or IV 75% of the time. Level I involvement correlated with T3 or T4 primary tumors exhibiting histologic extralaryngeal spread. These data support the trend toward selective limited neck dissection in both NO and N1 patients.     

Earlier age of first diagnosis in schizophrenia is related to impaired motor control

We examined the control of motor behavior in relation to age of first diagnosis (AFD; an approximation of age of onset) in schizophrenia. We hypothesized that earlier AFD reflects increased vulnerability to the disorder, vulnerability that may be indexed by elevated levels of motor abnormality. AFD, symptom and demographic features, motor performance on a line drawing task, and the presence and severity of dyskinesia and extrapyramidal side effects were evaluated in 65 chronic schizophrenia subjects. More severely impaired motor control was significantly related to an earlier age of diagnosis. Potential confounds, including age, gender, education, length of illness, current medication dosage, symptom status, and motor side effects, did not appear to influence this relationship, although greater chronicity appeared to be independently related to more severely impaired motor control. In summary, the data are consistent with the hypothesis that an earlier AFD is associated with more pronounced motor impairment.     

Nasal sinus cancer registry of the province of Brescia

Sinonasal cancers (SNC) are neoplasm uncommon; although strictly related to occupational risk factors, in the Brescia province the professional SNC was unknown to the Occupational Health Service until short time ago. During the first nineties, a retrospective study has carried out to detect SNC and it has showed several occupational SNC cases. A local SNC population based Register was subsequently set up in 1994, covering 1,044,544 inhabitants. Between 1981 and 2000 104 SNC, occurred to 74 men and 30 women, have been collected; 98% of them was histologically diagnosed and 87.4% was of epithelial type. 36% of cases is located on maxillary sinus and the 31.7% on the ethmoidal sinus; 43% is the squamous cell carcinoma and 13.7% is the intestinal adenocarcinoma. The annual standardised incidence rates (on the Italian population, census 1981, x 100,000) on 1990-1995 and 1996-2000 are respectively 1 and 1 in men, 0.3 and 0.4 in women, in accordance with those esteemed in others industrialised provinces. In 1990-1995 the survival observed after 1, 3 and 5 years are respectively 83.8%, 67.7% and 48.3%. Anamneses were collected on 83 SNC cases among the epithelial type cancer. In men the 33% was exposed to occupational risk factors: wood (13 cases), leather (6 cases) and chromium (1 case) dusts. Among works probably related to SNC, agriculture, construction and textile reached respectively the 20.5% for both sex, 16.4% for men and 18% for women. As for non occupational risk factors suggested by literature, smoke appear to be the most relevant, related to the 52% of all cases and reaching the 64% in men. Among the women, polyps and inverted papillomas (31%), and also chronic rhinitis and sinusitis (13.6%) are more frequently observed. Some problems still limiting the work and its usefulness are discussed.     

Functional sequelae of tuberculous pleurisy in patients correctly treated

STUDY OBJECTIVES: To assess the functional sequelae (FS) of patients with tuberculous pleurisy (TP), to analyze the influence of different factors in the occurrence of these FS, and, finally, to evaluate the relationship between the FS and roentgenographic sequelae. DESIGN: An observational, retrospective study. SETTING: A community teaching hospital in Alicante, Spain. PATIENTS AND METHODS: From April 1986 to July 2000, all patients with a firmly established diagnosis of TP, who had been functionally studied at the end of follow-up, were included in the study. A diagnosis of TP was considered to be definitive when the presence of granuloma on a pleural biopsy specimen was demonstrated or when a culture was positive for Mycobacterium tuberculosis in pleural fluid (PF) or tissue. The general characteristics of the study population and PF were compared in patients with or without restrictive FS (ie, FVC or TLC < 80%), looking for risk factors for developing this complication. RESULTS: Eighty-one of 150 patients who had been treated for TP were eligible for the study. At the end of follow-up, eight patients (10%) had a restrictive FS. These patients had a lower PF lactate dehydrogenase concentration (p < 0.001), a higher PF concentration of cholesterol (p < 0.03) and triglycerides (p < 0.03), and a higher percentage of lymphocytes (p < 0.04). A weak correlation was found between the FVC and the intensity of radiographic pleural thickening (r = - 0.298; p < 0.01). CONCLUSIONS: The FS in patients with TP is restrictive in type, infrequent, and usually mild. A higher PF lipid content or a more chronic inflammatory pleural reaction at diagnosis appear to be risk factors for developing a FS. The correlation between FS and roentgenographic sequelae is poor.