Surgical Management of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection, which causes acute coronary syndrome and can result in sudden death, is rare; but its true incidence is underestimated, since most patients die suddenly, without diagnosis. The aim of this study was to show the importance of prompt diagnosis and treatment.In reviewing the records of 5,000 consecutive patients who underwent coronary angiography between January 2001 and August 2006, we found 6 cases of spontaneous coronary artery dissection (an incidence rate of 0.12%). Five patients presented with left main coronary artery dissection and 1 patient, with right coronary artery dissection.Angioplasty with stenting failed in the patient with right coronary artery dissection. Coronary artery bypass surgery was performed in all patients. The patient with right coronary artery dissection died of sepsis on the 30th postoperative day. The other 5 patients (83.3%) are still free of symptoms, and they had negative results on stress tests at the 6- and 12-month follow-up visits after coronary artery bypass surgery.The clinical presentation of spontaneous left main coronary artery dissection was similar to that of atherosclerotic disease. However, early diagnosis of spontaneous coronary artery dissection by means of coronary angiography is of paramount importance, because urgent coronary artery bypass grafting can be lifesaving.Key words: Aneurysm, dissecting/diagnosis/therapy; death, sudden, cardiac/etiology; myocardial ischemia/etiology; pregnancy complications, cardiovascular; puerperal disorders; rupture, spontaneousSpontaneous coronary artery dissection (CAD), which causes acute coronary syndrome and can result in sudden death, is a rare event. Spontaneous coronary artery dissection has been observed in 3 groups of patients: patients with coronary artery disease, young women during peripartum, and patients with idiopathic disease and no obvious associated factors. The pathogenesis of spontaneous CAD is still unclear.^1,2The clinical presentation of left main coronary artery (LMCA) dissection may be similar to that of a patient with atherosclerotic disease of the LMCA. Early diagnosis and urgent coronary artery bypass grafting (CABG) is lifesaving in patients with LMCA dissection. In this retrospective study, we present an account of our management of spontaneous CAD, and we review the medical literature in order to investigate the potential causes and optimal treatments of this condition.     

Agenesis of the gallbladder as a rare misdiagnosis

Anatomic anomalies of the biliary tract are not uncommon, but gallbladder and cystic duct agenesis is rare, with an incidence of 0.01% to 0.04% and a frequency of 0.016% at autopsy. It is usually asymptomatic and discovered incidentally. Although this congenital anomaly is infrequent, it may be encountered in clinical practice; thus, the surgeon should be aware of the associated problems. A correct preoperative diagnosis of this congenital anomaly is difficult to establish because of the nonspecific nature of the symptoms and the relative inaccuracy of the currently available diagnostic tests. Here we report a patient with a preoperative false diagnosis of cholelithiasis that was found on laparoscopy and open surgery to be agenesis of the gallbladder.     

The importance of IRS-1 Gly972Arg polymorphism in evaluating the response to metformin treatment in polycystic ovary syndrome

BACKGROUND: Recent evidence suggests that one of the modes of action of metformin may be through phosphorylation of the insulin receptor and insulin receptor substrates. With this in mind, we supposed that the G972A variant of insulin receptor substrate-1 (IRS-1) may modulate the response to metformin treatment in women with polycystic ovary syndrome (PCOS). METHODS: This preliminary study involved 60 randomly selected women with PCOS. All patients received dietary instructions and metformin 500 mg three times daily for 6 months. Main outcome measures were androgen levels, parameters of glucose and insulin metabolism and anthropometric variables. After a second evaluation of the patients at 6 months, they were genotyped for the Gly972Arg variant of the IRS-1 gene. RESULTS: Metformin had differential effects on fasting insulin levels, insulin resistance as demonstrated by homeostasis model assessment (HOMA), LH, total testosterone, dehydroepiandrosterone sulphate and free testosterone index on the basis of IRS genotype. The response to metformin therapy in other parameters was not different according to IRS genotype. CONCLUSION: There was a differential effect of metformin therapy in PCOS women on the basis of IRS genotype. This study may call attention to the importance of molecular markers in the management of women with PCOS.     

Mechanisms of nerve growth factor mRNA regulation by interleukin-1 beta in hippocampal cultures: role of second messengers.

Cytokines such as interleukin-1, which are found in the brain after trauma, regulate expression of nerve growth factor (NGF) mRNA and protein in hippocampal cultures. We have investigated possible mechanisms by which Il-1 beta regulates NGF in hippocampal cells. The induction of NGF mRNA by Il-1 beta was blocked by a receptor antagonist indicating that this effect is receptor mediated. Il-1 beta elicited a dramatic induction of c-fos mRNA and a slight elevation of c-jun mRNA in a time dependent manner which may allow for a role in the induction of NGF mRNA expression. We examined whether specific second messenger pathways were involved in mediating the action of Il-1 beta in the hippocampus. Activation of cAMP with forskolin or treatment with 8-Br-cAMP had no effect on NGF mRNA levels. Moreover, exposure of hippocampal cultures to Il-1 beta evoked no change in cAMP levels, indicating that this second messenger system played little or no role in the regulation of NGF expression by Il-1 beta in these cells. Further, interleukin-1 elicited no change in membrane inositol phosphate turnover, nor did it affect intracellular calcium levels. Treatment of cell cultures with the phorbol ester PMA elicited an increase in NGF mRNA, suggesting that activation of protein kinase C (PKC) may mediate NGF mRNA expression. However, prolonged treatment of cultures with PMA to desensitize PKC did not eliminate the Il-1 beta induction of NGF mRNA. Il-1 beta, therefore, did not appear to activate NGF expression via cAMP, Ca2+, or a PKC isoform that is downregulated by prolonged PMA treatment. However, a phosphorylation event may be involved in the signal transduction mechanism, as treatment with okadaic acid to inhibit protein phosphatase 2a potentiated the induction of NGF mRNA by Il-1 beta. The results presented indicate that Il-1 beta acts via its receptor to induce a rise in NGF expression. Identification of the specific second messenger pathway has remained elusive; however, a phosphorylation event appears to be intermediary. Moreover, the induction of c-fos and c-jun may represent a final common path in activation of NGF gene expression by different signals such as Il-1 beta and PMA.     

Maternal cocaine abuse resulting in necrotizing enterocolitis. An experimental study in a rat model. II. Results of perfusion studies

 During the last decade, several publications have appeared associating the maternal use of cocaine and subsequent development of necrotizing enterocolitis (NEC). In 1994, the effects of cocaine in pregnant rats had been reported by this group: a significant decrease in the number of live births, mean birth weight and mean placental weight. In addition, histopathologic examinations revealed severe inflammation and degenerative vascular changes in the uterus and placenta. Severe histopathologic changes resembling NEC such as focal necrosis, necrobiosis, and hemorrhagic inflammatory changes in the gastrointestinal tract of the embryos were also reported. The aim of the second part of this study was to assess the hemodynamic effects of cocaine HCl in pregnant rats and the results of perfusion studies in the uterus, placenta, and fetuses to determine a relation between the dose of drug, hemodynamic changes, and degree of histopathologic findings. Forty-seven Wistar albino rats and 91 rat fetuses were studied: group A (pregnant rats), 16 rats and 91 rat fetuses, group B (non-pregnant rats), 31 rats. Each group was divided into subgroups of cocaine-abused and non-cocaine-abused rats. In each group 2–3 mCi technetium Tc-99m methoxyisobutyl-isonitryl (Sesta MIBI) was injected into the tail vein. Radioactivity counts per g tissue (cps/g) in the uterus, placenta, and fetus were assessed by gamma counter. Cocaine 75 mg/kg per day severely decreased the perfusion of the uterus, placenta, and fetuses. These impairments were statistically significant. In lower doses (30–50 mg/kg per day) no statistically significant changes were observed in the perfusion of the uterus and placenta, but a significant decrease in fetal perfusion was seen. In group B, no significant changes in the perfusion of the uterus due to cocaine were seen. Thus, maternal cocaine abuse results in a reduction in perfusion of the uterus, placenta, and fetus. There was a dose-dependent correlation between the perfusion changes and the development of NEC-like histopathologic changes: the higher the cocaine dose received by the mother, the higher the level of placental and fetal injury. We suggest that perinatal cocaine exposure should be considered a high risk for development of NEC in rat fetuses and embryos. For this reason, infants with a history of possible maternal cocaine abuse or positive urinary cocaine metabolites have to be followed very carefully for NEC. Accepted: 13 December 1999     

Adnexal fascioliasis masquerading as ovarian cancer

BACKGROUND: Preoperative diagnosis of ovarian cancer is still problematic as multiple disease processes may present with pelvic mass. Fascioliasis is a parasitic disease producing unique clinical manifestations. CASE REPORT: A 49-year-old female patient admitted to our hospital with the complaint of occasional abdominal pain. Pelvic examination revealed a right adnexal mass. Serum CA-125 level was elevated. Explorative laparotomy was performed with the initial diagnosis of ovarian tumor. Final diagnosis was adnexal fascioliasis. CONCLUSION: In the setting of a newly diagnosed pelvic mass, care should be taken when interpreting an elevated CA-125 level. While ovarian cancer is high on the list of differential diagnoses, atypical clinical presentation of fasciola may give rise to a misdiagnosis of malignancy.     

Effect of TGF-beta 1 on the EBV-induced transformation of human lymphocyte cultures.

We tested the effect of TGF-beta 1 on the EBV-induced activation and immortalization of human B lymphocytes. In lymphocyte cultures of EBV-seropositive individuals, T cells can inhibit the EBV-induced transformation of B cells. We found that in the presence of TGF-beta 1 the transformation was more efficient, due to the inhibition of this function. TGF-beta 1 inhibited the EBV-induced proliferation of purified B-cell cultures. Its effect was strongest when added at the beginning of the culture. Added later, the inhibition gradually decreased and was lost by the 4th day. After 10 to 14 days, in the cultures initiated with TGF-beta 1, the number of cells was higher and they formed larger aggregates as compared with control cultures. Thus, TGF-beta 1 modifies EBV-induced transformation in a complex way. It inhibits the activation of B cells but does not affect those already activated. Once they acquire the immortalized state, the B cells are even stimulated by TGF-beta 1.