Symptomatic vagotonia in young patients. Clinical data and therapeutic approach

Syncope or near-syncope can be the manifestation of a benign problem or a symptom of a life-threatening disease. Vasovagal syncope accounting for almost 70 per cent of cases. We identified 5 young patients who were presented to us with syncope or near-syncope. Diagnostic test, such as electrocardiogram, Holter monitoring and electrophysiological study identified only markers of hypervagotonia. We treated them with oral propantheline. By the time of follow up (20 months) none had recurrent episodes of syncope. Propantheline can be useful in patients with symptomatic vagotonia.     

Impaired endothelium-dependent relaxations in rabbits subjected to aortic coarctation hypertension

Rabbits were rendered hypertensive by suprarenal coarctation of the abdominal aorta. Seven days later, endothelium-dependent and endothelium-independent vascular relaxations were examined in vascular rings taken from hypertensive (thoracic aorta, carotid artery) and normotensive (abdominal aorta) regions. Relaxation of phenylephrine-contracted rings in response to endothelium-dependent agonists (acetylcholine, A23187) was impaired, compared with that in sham-operated and intact controls, in regions exposed to the elevated blood pressure (i.e., above the coarctation). Responses to acetylcholine and A23187 in the abdominal aorta, below the coarctation, were not altered. The diminished endothelium-dependent responses in the thoracic aorta were not affected by pretreatment with the cyclooxygenase inhibitor indomethacin. In contrast to acetylcholine and A23187, responses to the endothelium-independent agonist nitroprusside were not attenuated in vessels from hypertensive regions, indicating that the defect occurred in the endothelium. The EC50 for acetylcholine-induced relaxations of thoracic aorta correlated significantly with mean arterial pressure above the coarctation, indicating that the extent to which endothelium-dependent relaxation is impaired is in proportion to the degree of blood pressure elevation. This study suggests that the diminished relaxations by endothelium-dependent agonists is a local response to the elevation of blood pressure and is not due to a circulating factor.     

Coronary spasm following myocardial revascularization. Clinico-therapeutic considerations in a successfully treated case

A 30-year-old man had a spasm of the anterior descending coronary artery and received a bypass graft. The spasm which caused several cardiac arrests was relieved by intracoronary injection of nitrates and verapamil. The patient was discharged 13 days after surgery, receiving nitrates and calcium antagonists. Four months after operation he remains asymptomatic.     

Intravascular ultrasound imaging of coronary arteries. Is three layers the norm?

BACKGROUND. The purpose of this study was to evaluate the significance of the three-layered appearance of coronary arteries in adolescence and adults from intravascular ultrasound scans and to correlate these observations with histopathology. METHODS AND RESULTS. Sixteen intact hearts were excised at autopsy from patients with no clinical history of coronary artery disease. The patients' ages ranged from 13 to 55 years. A 30-MHz ultrasound imaging catheter was used to obtain images throughout the epicardial coronary vasculature. A total of 72 image cross sections was marked by epivascular sutures, and the corresponding histological sections were examined. Ultrasound images were classified into two groups: images exhibiting three-layered appearance and images without distinct layering. Histological analysis revealed a significantly greater degree of intimal thickening in segments with three layers (243 +/- 105 microns) than in nonlayered segments (112 +/- 55 microns). Discriminant analysis of these data predicted the threshold between the two groups to be 178 microns. Measurements of medial thickness were not different between these two groups (235 +/- 61 versus 210 +/- 76 microns). In the nonlayered group, the average patient age was 27.1 +/- 8.5 years, whereas in the three-layered groups, the average age was 42.8 +/- 9.8 years. CONCLUSIONS. The intracoronary ultrasound image appearance of young, morphologically normal coronary artery walls is homogeneous without layering. A three-layered appearance suggests the presence of at least 178 microns of intimal thickening and is seen more frequently with advancing age.     

ELISA test for the diagnosis of cysticercosis in pigs using antigens of Taenia solium and Taenia crassiceps cysticerci

In the present study ELISA was standardized for the diagnosis of swine cysticercosis based on necropsy parameters and confirmed positive and negative control sera. Serum samples from pigs with other infections were also assayed to determine possible cross-reactions. Four antigens were assayed: from Taenia crassiceps vesicular fluid (VF-Tcra) and crude larvae extract (T-Tcra), and from Taenia solium extracts of scolex (S-Ts) and of larvae (T-Ts). A checkerboard evaluation of antigen, serum and conjugate dilutions, as well as the use of Tween-20 and skim cow milk in wash and blocking solution had a marked effect on improving ELISA performance. All the antigens showed a good performance, but VF-Tcra was the best, with 96.0% and 80.0% sensitivities for cut-offs respectively at 2sd and 3sd, and corresponding specificities of 97.5% and 100.0%. Cross-reactivity was observed only with hydatidosis and ascaridiosis. In view of the high performance observed, the ELISA test should be recommended for the diagnosis of cysticercosis in suspected swine in slaughterhouses and for the screening of cysticercosis in swine production. These results will support integrated measures of cysticercosis control throughout the chain of swine production, effectively contributing to public health.     

Impact of routine angiographic follow-up on the clinical benefits of paclitaxel-eluting stents: results from the TAXUS-IV trial.

OBJECTIVES: The objectives of the study were to evaluate the effect of angiographic follow-up on revascularization rates in the TAXUS-IV trial and to determine whether the relative benefit of paclitaxel-eluting stent implantation compared with bare metal stent implantation was modified by angiographic follow-up. BACKGROUND: Although several clinical trials have demonstrated that drug-eluting stents (DES) reduce restenosis compared with bare-metal stents (BMS), virtually all of these studies have incorporated angiographic follow-up. METHODS: In the TAXUS-IV trial, 1,314 percutaneous coronary intervention patients were randomized to receive paclitaxel-eluting stents (PES) (n = 662) or identical-appearing BMS (n = 652). Clinical outcomes were compared, stratified by assignment to angiographic follow-up or clinical follow-up alone. RESULTS: Compared with clinical follow-up alone, angiographic follow-up patients had a significantly higher rate of target vessel revascularization (TVR) at 1 year (adjusted hazard ratio [HR] 1.46; p = 0.04), with similar relative increases in PES and BMS patients. Because PES reduced TVR by approximately 60% regardless of type of follow-up, assignment to angiographic follow-up tended to overestimate the absolute benefit of PES relative to clinical follow-up alone. In contrast, assessment of end points immediately before the time of follow-up angiography led to substantial underestimation of the absolute benefit of PES implantation. CONCLUSIONS: Performance of mandatory angiographic follow-up increases rates of TVR among patients receiving both BMS and PES and overestimates the absolute clinical benefits of PES relative to clinical follow-up alone. Nonetheless, PES substantially reduces TVR regardless of assignment to mandatory angiographic follow-up or not. Future studies designed to determine the true clinical benefits of DES should either forgo routine angiographic follow-up or separate the time of repeat angiography from the primary clinical end point by as long as possible.     

Changes in colloido-osmotic pressure in patients on extracorporeal circulation

Changes in colloidosmotic pressure (COP) were observed in 15 patients submitted to hemodilution for extracorporeal circulation. Preoperative laboratory tests were within normal limits. COP before hemodilution was above 15 mmHg in 14 cases and 12.6 mmHg in one 9-month-old patient, the mean CP was 18.17 mmHg. During extracorporeal circulation the mean COP decreased to 55% of its initial value (9.92 mmHg). Within the first 4 hrs of the postoperative recovery 13 had COP over 11 mmHg; the remaining two died of cardiorespiratory failure with a COP of less than 7 mmHg. One patient that recovered 100% of its initial COP value between 20 and 24 hrs of the postoperative period had his COP decreased to 6 mmHg and developed fatal pulmonary edema. One patient -who died acute bleeding did not diminish his COP under 12.5 mm Hg. We can conclude that COP lower than 10 mmHg can produce fatal cardiorespiratory failure. Extracorporeal circulation time does not influence the COP recovery. Acute bleeding does not diminish COP values. Hemodilution significantly reduces COP; its recovery and stabilization over 11 mmHg are of prognostic value. COP monitoring is a simple and useful method.     

Carcinoid tumor of the ampulla of Vater and Recklinghausen's neurofibromatosis

We report the fifth case of carcinoid tumour of Vater ampulla with Von Recklinghausen's neurofibromatosis. We have reviewed the literature and discussed the significance of such an association which seems fortuitous.     

Usefulness of electrophysiologic studies. Report of 224 cases

Two hundred and twenty four electrophysiologic studies were performed in 194 patients during a two-year period. One hundred and six (54.6%) had tachyarrhythmias: 21 had atrial tachycardia, 28 had the Wolff-Parkinson-White syndrome. Of 51 patients with a normal electrocardiogram a concealed left Kent bundle was observed in 21 cases and only one concealed right Kent bundle; functional James fibers were seen in 7 patients and Mahaim fibers in two. In 15 patients A-V nodal reentry was diagnosed and functional ectopy was observed in 5 patients. The sick-sinus-syndrome was seen in 24 patients and atrial arrest in three. Thirty patients underwent a second electrophysiologic study to evaluate proper antiarrhythmic therapy. Atrioventricular conduction was evaluated in 52 patients. A "suprahisian" delay was found in 34%, troncular lesions were diagnosed in 31%, a distal delay in 25% and mixed conduction disturbances in 10%. We conclude that electrophysiologic studies are a useful procedure to: 1) establish the etiologic diagnosis of tachyarrhythmias; 2) evaluate their potential danger; 3) objectively evaluate antiarrythmic therapy; 4) establish the need for surgical treatment; 5) give the topographic diagnosis and severity of A-V conduction disturbances and 6) indicate the need for definitive pacemaker implant.