SURFBOARD-RELATED OCULAR INJURIES

Three cases of ocular trauma caused by surfboards are reported. The severe nature of the injuries is discussed and the prevalence of this type of injury is reviewed.     

Improved Short-Term Outcomes of Primary Coronary Stenting Compared to Primary Balloon Angioplasty in Acute Myocardial Infarction at Experienced Centers: The PAMI Study Group Experience

To study the additive benefits of routine stent implantation in patients undergoing primary percutaneous transluminal coronary angioplasty (PTCA) at experienced centers, we compared the outcomes of the 982 patients undergoing PTCA for acute myocardial infarction (AMI) in the Primary Angioplasty in Myocardial Infarction-2 (PAMI-2) trial (only 1% of whom were stented) to the 312 patients in the PAMI Stent Pilot Trial (236 [76%] of whom were stented). The inclusion and exclusion criteria, PTCA methodology, and definitions used were prespecified to be identical between the two trials. Compared to the primary PTCA approach in PAMI-2, the strategy of stenting all eligible lesions in the PAMI Stent Pilot Trial was associated with reduced rates of in-hospital death (0.6% vs 2.7%, P = 0.03), reinfarction (1.3% vs 4.6%, P = 0.008), recurrent ischemia (3.5% vs 11.6%, P < 0.0001), target vessel revascularization (7.3% vs 11.4%, P = 0.04), and a shorter hospital stay (6.4 ± 4.4 vs 7.1 ± 6.2 days, P = 0.01). By multiple logistic regression analysis in 1,294 patients, stent implantation versus PTCA only was the strongest predictor of freedom from the composite in-hospital end point of death, reinfarction, or target vessel revascularization (TVR) (8.3% vs 15.0%, multivariate odds ratio = 0.4, P < 0.0001). These data strongly suggest that despite the excellent results achieved when primary PTCA is performed by experienced operators, the short-term outcomes of mechanical reperfusion can be further improved by a primary stent strategy.     

Design and Objectives of the Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) Study

Clinical trials have demonstrated the efficacy of glycoprotein (GP) IIb/IIIa antagonists in preventing the thrombotic end points of death, myocardial infarction, and urgent revascularization when they are administered at the time of percutaneous coronary revascularization (PTCR). It has been postulated that prolongation of receptor blockade beyond acute intervention would extend the clinical benefit of these agents. The Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) study was a multicenter, international, randomized placebo-controlled trial of the oral GP IIb/IIIa antagonist Xemilofiban administered prior to and after PTCR. The study was designed to assess the efficacy and safety of continuing oral xemilofiban for 6 months to prevent these primary thrombotic end points. More than 7,200 patients were randomized in 29 countries to receive placebo or one of two doses of xemilofiban. Stenting was performed at the discretion of the operator. All patients received aspirin and periprocedural heparin; all stented patients received continuous xemilofiban, or ticlopidine for 2–4 weeks followed by xemilofiban-placebo. Most patients were also evaluated 1 month after conclusion of the study drug treatment. Clinical data from up to 6 months of drug treatment and 1 month posttreatment were used to evaluate the acute and long-term efficacy and safety of xemilofiban. Secondary end points included the need for any revascularization, repeat hospitalization for unstable angina, and nonhemorrhagic stroke. The cumulative incidence of bleeding events and effects of xemilofiban in stented and nonstented patients were evaluated. The efficacy of continuing xemilofiban and aspirin therapy as the sole antithrombotic medications following stent deployment was assessed against a ticlopidine and aspirin control group. The incremental clinical benefit of long-term receptor blockade over acute receptor antagonism was evaluated.     

Experimental Results with 90Yttrium Beta-Particle Emitting Radioactive Stents in a Porcine Model of Restenosis

Background: Radioactive stents have been proposed as a means to prevent restenosis. The ideal radioisotope to deliver endovascular irradiation via a radioactive stent is unknown. Objectives: To evaluate the dose response effects of “high” dose rate irradiation delivered by a high energy, short half-life, beta-particle emitting ⁹⁰yttrium (⁹⁰Y) radioactive stent on neointimal formation in a porcine coronary model of restenosis. Methods: Fifty-two 0–16.0 μCi ⁹⁰y radioactive stents were implanted in the coronary arteries of 19 swine. Stents were oversized 10% to 20% greater than the baseline angiographic lumen diameter. After 28 days, quantitative histological analysis was completed to determine neointimal area and percent in-stent stenosis. Results: The mean vessel injury scores were similar for the control and each of the ⁹⁰Y radioactive stent groups. Neointimal area correlated with vessel injury for the control (r =0.54, P < 0.0001) stents. The percent in-stent stenosis was similar for the nonradioactive control and the 0.25, 0.5, 1.0, 1.25, 2.0, 8.0, and 16.0 μCi ⁹⁰Y radioactive stents. The neointimal area was greater for the 4.0 μCi (3.95 ± 1.16 mm²) and 8.0 μCi (3.55 ± 1.09 mm²) ⁹⁰Y stents as compared with the nonradioactive control stents (2.40 ± 7.72 mm², P ≤ 0.03). The increased neointimal area for the 4.0 μ⁹⁰Y stents resulted in significantly greater percent in-stent stenosis (55 ± 12) versus control nonradioactive stents (36 ± 18, P < 0.05). Conclusions: A radioactive stent manufactured with the short half-life beta-particle emitting radioisotope ⁹⁰Y, designed to deliver a higher dose rate at implant than a ³²P radioactive stent, is ineffective in reducing neointimal formation in the porcine coronary model of restenosis. Further study is required to define effective cumulative dose and dose rate delivery for radioactive stents.     

Chemical synthesis of a neurotoxic polypeptide from the sea anemone Stichodactyla helianthus+

The sea anemone Stichodactyla helianthus neurotoxin I, a 48-residue polypeptide, was synthesized by automated solid phase methodology. The fully reduced polypeptide was subsequently refolded in the presence of a glutathione oxidoreduction buffer to the biologically active species containing three disulfide bonds. The overall yield after rigorous purification was 12.5%. The circular dichroism (CD), and proton nuclear magnetic resonance (¹ H NMR) spectra of the HPLC-purified synthetic toxin were indistinguishable from those obtained concurrently with the natural toxin. A subtilisin digest of the synthetic neurotoxin generated peptide fragments identical to that of a sample of the natural toxin subjected to the same treatment. The toxicity of the synthetic polypeptide was identical to that of the natural toxin (crab LD₅₀, 3.1μg/kg). The equilibrium dissociation constant (28 nM) for interaction of the synthetic toxin with crab axolemma vesicles was nearly identical to that of the natural toxin (25 nM).     

The Surgical Anatomy of Tetralogy of Fallot with Pulmonary Atresia Rather than Pulmonary Stenosis

We examined the pertinent surgical features of the anatomy of 56 hearts having tetralogy of Fallot with pulmonary atresia instead of stenosis, or malformations with pulmonary atresia closely related to tetralogy. We took particular cognizance of the pulmonary arterial supply in 15 hearts in which this was derived through systemic-to-pulmonary collateral arteries, dissecting, as far as possible, the bronchopulmonary segmental distribution of the collateral arteries compared to the intrapericardial pulmonary arteries in 11 of these hearts. Two of the hearts had absence of intrapericardial pulmonary arteries, so that a solitary arterial trunk left the base of the heart. Evidence of an atretic subpulmonary infundibulum was found in 40 of the hearts, while such an infundibulum was lacking in the remainder. The pulmonary atresia was muscular in 43 hearts, valvar in 11, while the pulmonary trunk was absent in the other two hearts. In the hearts with collateral arteries, on average 2.6 collaterals were found in each case, varying from two to five per case. Only one of these arose from a brachiocephalic artery, the others all arising from the descending aorta. The distribution of collateral arteries in two cases was remarkably reminiscent of the arrangement of bronchial arteries. As far as could be judged, 16.5 bronchopulmonary segments on average were supplied in each heart, 5.1 exclusively by collateral arteries, 11.8 by intrapericardial pulmonary arteries and an average of 0.64 segments per case having a shared supply.     

Simultaneous, Multiple Point Mapping During Surgery for Wolff-Parkinson-White Syndrome Without the Use of a Computer

Epicardial mapping of patients undergoing surgical correction of the Wolff-Parkinson-White syndrome is usually accomplished by using a single point probe. This somewhat tedious and time consuming method has been streamlined by computer-based systems allowing multiple simultaneous point maps to be developed either by electrodes applied as a band around the atrioventricular groove or a sock over the ventricle. Because the computer technology required to access, analyze, and display this data is not widely available, a system was devised to display ten simultaneous electrograms from a wrap of ten electrodes placed about the atrial or ventricular side of the atrioventricular groove. Using this technique three patients undergoing surgery for accessory pathway removal were accurately and quickly mapped allowing surgical cure of the preexcitation in each case.     

Complementary and alternative methods in cerebral palsy

There are no published studies specifically addressing complementary and alternative treatments in adults with cerebral palsy (CP). However, national surveys of adults with chronic disabilities document that a majority of them use such treatments, that they are willing to pay out of pocket, if necessary, and that they believe that pursuing such treatment relieves pain, reduces stress and anxiety, and leads to improved feelings of fitness and well-being. Individuals enjoy taking charge of their own health care decisions, and frequently feel more in control with these therapies than with more traditional methods. In contrast to adults, there is some information on complementary and alternative methods (CAM) in children with CP. This article discusses some of the CAM used in children that may be carried over into adulthood, as well as the pitfalls for patients and conventional physicians as they try to sort out what might be helpful and what might be harmful in this arena. Practitioners of both conventional and CAM therapies believe that exercise can be beneficial; accordingly, activities such as recreational sports, yoga, and hippotherapy may be continued from childhood into adulthood. General treatments for stress and anxiety, through such activities as yoga and meditation, though not directed at CP per se, may be more popular for adults than children. Research in this area should first identify what methods are being utilized and then subject these methods to well-designed outcome studies that take into account any associated risks.