Coronary Atherosclerosis in Valvular Heart Disease

To evaluate the usefulness of routine coronary arteriography in patients undergoing cardiac catheterization for the evaluation of valvular heart disease, we performed coronary arteriographic studies routinely in a series of 201 patients primarily catheterized for such evaluation. Coronary artery obstructive lesions in excess of 50% of the lumen were present in 45 of the 201 patients. In 18 of the 45 there was no history of chest pain. Three of the 18 had three vessels involved while 2 had two vessels involved. A total of 27 patients (13.4%) had luminal obstruction greater than 70%, and 9 of these had no pain. In 35 of the 201 patients, classic angina pectoris existed in the absence of radiographically significant disease.Severe coronary disease was found to coexist with hemodynamically severe valvular heart disease and was not predictable noninvasively.     

Spontaneous retropharyngeal and cervical emphysema: a rare singer's injury

Spontaneous retropharyngeal and cervical emphysema is rare. We describe a case that was unusual in its etiology: the result of singing. Although this condition is usually benign, hospital admission for close observation and supportive therapy is prudent.     

The association between narcolepsy and REM behavior disorder (RBD)

BACKGROUND AND PURPOSE: Rapid eye movement (REM) sleep Behavior Disorder (RBD) is a movement disorder associated with loss of REM-related muscle atonia and is characterized by complex, vigorous and frequently violent dream-enacting behavior during REM sleep. RBD is usually idiopathic or secondary to neurological problems such as Parkinson's disease. This study looked at the association of RBD with another sleep disorder, narcolepsy. PATIENTS AND METHODS: Seventy-eight questionnaires were sent to known narcoleptics chosen at random from those with contact details available at the center. The questionnaire addressed current narcolepsy symptoms, medication use and symptoms of RBD. Positive questionnaire results were followed up with a telephone interview. Limited polysomnography (PSG) data was also analyzed. RESULTS: Fifty-five patients responded (response rate 71%). Of these, 20 (36%) had symptoms suggestive of RBD. The typical RBD patient is an older male (mean age of onset 60.9 years, 87% male); however, in this study, females were as likely to have RBD as males, and the mean age was 41 years. Sixty-eight percent of patients who regularly experienced cataplexy and the associated symptoms of narcolepsy (sleep paralysis, hypnogogic hallucinations and automatic behavior) had RBD, compared to 14% of those who never or rarely experienced these symptoms. CONCLUSION: This study implies a stronger relationship between these disorders than a previously published figure of 7-12% This is clinically significant as RBD is a potentially distressing but readily treatable disorder. It follows that narcoleptics, especially those with cataplexy and other associated symptoms, should be questioned about symptoms of RBD and treated accordingly. Similarly, anyone presenting with RBD should be assessed for symptoms of narcolepsy, particularly if female or of a younger age group than would otherwise be expected.     

Influence of progestin bioactivity on cutaneous vascular responses to passive heating

PURPOSE: Oral contraceptives influence the regulation of cutaneous vascular tone, and both estrogen and progesterone have been shown to affect nitric oxide (NO)-mediated vasodilation. We tested the hypothesis that cutaneous vascular conductance (CVC) during passive heating would be lower in women taking oral contraceptives with higher progestational bioactivity compared with those taking oral contraceptives with lower progestational bioactivity. We further hypothesized that this difference could be attributed to the relative degree of NO-dependent vasodilation. METHODS: Fourteen women (20.3 +/- 0.3 yr) taking combined oral contraceptives (low progestin: 6 subjects, high progestin: 8 subjects) participated in a whole-body heating protocol and were tested during the end of active and placebo pill phases. Red blood cell (RBC) flux was measured by laser-Doppler flowmetry at a control microdialysis site (Ringer's solution) and an experimental site where NO-synthase (NOS) was inhibited (10 mM L-NAME). CVC was calculated as RBC flux/MAP. RESULTS: Baseline oral temperature (Tor) was significantly higher during the active pill phase for all subjects (active: 36.8 +/- 0.1 degrees C; placebo: 36.6 +/- 0.1 degrees C) (P = 0.02) but was not affected by progestational bioactivity. CVC at the control site during heating did not differ between low and high progestin users during either phase of oral contraceptive use. However, CVC in the NOS inhibited site was diminished during both phases of oral contraceptive use in the low progestin group at a given change in Tor (active: DeltaT(or) of 0.6-1.0 degrees C, placebo: DeltaT(or) of 0.8-1.0 degrees C) (P < 0.05). (DeltaT(or) 1.0 degree C: active: 30.86 vs 46.56%CVC(max); placebo: 26.29 vs 49.22% CVC(max)) (P < 0.05). CONCLUSION: Progestational activity in oral contraceptives may alter the mechanisms by which skin blood flow increases during passive heating via NO-dependent cutaneous active vasodilation.     

The development of laparoscopic surgery in Spain

AIM: To assess degree of development and level of acceptance of laparoscopic surgery in Spain. METHOD: A questionnaire was sent to all members of the Spanish Association of Surgeons in April 2003. It included 32 questions, 9 of which were general, and 23 referred to specific clinical situations, techniques, and standard practice. RESULTS: Eight hundred and fifty-eight (33.1%) surgeons replied. Only 211 (25%) surgeons reported performing advanced laparoscopic procedures. Four hundred and twenty (49%) surgeons believed that the results obtained with laparoscopic surgery were better than those obtained with conventional surgery, and 325 (40%) surgeons believed that laparoscopy would become a superspecialty. Laparoscopic surgery was considered the method of choice in the treatment of gallbladder stones (99%), gastroesophageal reflux disease (94%), acute cholecystitis (81%), in selected cases of inguinal hernia repair, and in procedures to be performed in spleen and adrenals, benign colon disease, and obesity. Three hundred and ninety-eight (47%) surgeons considered laparoscopic surgery the preferred approach for colon cancer, 292 (34%) for appendicitis, and 155 (18%) for incisional hernia. Five hundred and five (59%) surgeons considered that the use of laparoscopic surgery had grown less than expected. CONCLUSIONS: The vast majority of surgeons advocated laparoscopic surgery for the treatment of gallbladder stones and gastroesophageal reflux disease. Although most hospitals had the appropriate technical facilities for performing advanced laparoscopic procedures, few surgeons actually did so.     

Exercise-induced changes in insulin and glucagon are not required for enhanced hepatic glucose uptake after exercise but influence the fate of glucose within the liver

To test whether pancreatic hormonal changes that occur during exercise are necessary for the postexercise enhancement of insulin-stimulated net hepatic glucose uptake, chronically catheterized dogs were exercised on a treadmill or rested for 150 min. At the onset of exercise, somatostatin was infused into a peripheral vein, and insulin and glucagon were infused in the portal vein to maintain basal levels (EX-Basal) or simulate the response to exercise (EX-Sim). Glucose was infused as needed to maintain euglycemia during exercise. After exercise or rest, somatostatin infusion was continued in exercised dogs and initiated in dogs that had remained sedentary. In addition, basal glucagon, glucose, and insulin were infused in the portal vein for 150 min to create a hyperinsulinemic-hyperglycemic clamp in EX-Basal, EX-Sim, and sedentary dogs. Steady-state measurements were made during the final 50 min of the clamp. During exercise, net hepatic glucose output (mg x kg(-1) x min(-1)) rose in EX-Sim (7.6 +/- 2.8) but not EX-Basal (1.9 +/- 0.3) dogs. During the hyperinsulinemic-hyperglycemic clamp that followed either exercise or rest, net hepatic glucose uptake (mg x kg(-1) x min(-1)) was elevated in both EX-Basal (4.0 +/- 0.7) and EX-Sim (4.6 +/- 0.5) dogs compared with sedentary dogs (2.0 +/- 0.3). Despite this elevation in net hepatic glucose uptake after exercise, glucose incorporation into hepatic glycogen, determined using [3-3H]glucose, was not different in EX-Basal and sedentary dogs, but was 50 +/- 30% greater in EX-Sim dogs. Exercise-induced changes in insulin and glucagon, and consequent glycogen depletion, are not required for the increase in net hepatic glucose uptake after exercise but result in a greater fraction of the glucose consumed by the liver being directed to glycogen.     

Laparoscopic-assisted approach in rectal cancer patients: lessons learned from >200 patients

Background The applicability of laparoscopic surgery in the treatment of colorectal diseases is still controversial. Early reports on laparoscopic-assisted colectomy in patients with colon cancer suggested that it minimizes surgical trauma, decreases perioperative complications, and leads to a more rapid recovery. To our knowledge, no previous studies have compared the laparoscopic vs the open approach in rectal cancer. The aim of this paper was to assess the results of laparoscopic techniques in patients with rectal cancer.Methods From March 1998 to February 2003, all patients admitted to our unit with adenocarcinoma of the rectum were evaluated for surgery by the laparoscopic approach.Results A total of 220 patients with a mean age of 67.3 years were included in the study. One hundred thirty patients (59%) were treated with neoadjuvant chemoradiotherapy. In >75% of the patients, a surgical procedure with sphincter preservation was perfomed. The rate of conversion to the open approach was 20%. Ten patients had intraoperative complications. Fifty-eight patients (26.3%) developed postoperative complications. The length of hospital stay was 6.8 days. The distribution of tumor stages was as follows: stage I, 16.81%; stage II, 33.6%; stage III, 26.36%; stage IV, 19.09%. The mean number of lymph nodes was 13.8. The incidence of local relapse was 5.3%, with a follow-up of 18 months.Conclusion Laparoscopic surgery can be safely performed in patients with adenocarcinoma of the rectum with good short-term results. Randomized controlled trials are needed to confirm these results.     

Laparoscopic resection of colon Cancer: Consensus of the European Association of Endoscopic Surgery (EAES)

Background The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.Methods A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.Results Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.Conclusion Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.