Percutaneous stenting of the superior vena cava syndrome in a patient with cystic fibrosis

Superior vena cava (SVC) obstruction commonly occurs in the setting of malignancy. Cases of benign SVC obstruction are being seen more frequently with the use of long-term central venous lines. This is the case particularly in Cystic Fibrosis (CF). We describe in this report the successful use of intravascular stenting to treat this distressing condition in the setting of thrombotic occlusion of the SVC in a patient with CF.     

Identification of a high risk subgroup of patients with silent ischaemia after myocardial infarction: a group for early therapeutic revascularisation?

Asymptomatic ("silent") ischaemia has been shown to be of prognostic significance in patients with stable and unstable angina and more recently in patients recovering after myocardial infarction. No therapeutic regimen has yet been shown to improve the prognosis of patients with silent ischaemia after infarction, which can be found in as many as a third of these patients. Attempts to achieve therapeutic revascularisation in all these patients may be undesirable, but early revascularisation could be especially beneficial in some selected high risk patients. Two hundred and fifty consecutive clinically stable survivors of myocardial infarction who had predischarge submaximal exercise tests were followed up for a year. Silent ischaemia was found in 27% of these patients; 15% had symptomatic ischaemia. Patients with a positive exercise test were prescribed a beta blocker before discharge. Mortality in patients with silent (9.4%) and symptomatic (5.4%) ischaemia in the first year after infarction was not significantly different. Patients with symptomatic ischaemia were more likely to have undergone coronary artery bypass grafting in the first year. Patients with silent ischaemia were, however, significantly more likely to die than patients with a negative exercise test (relative odds 12:1). Patients with silent ischaemia and an abnormal blood pressure response or who could not complete a submaximal exercise protocol were at particularly high risk, being 32 times more likely to die than those with a negative test (95% confidence interval from 3.3 to 307 times more likely). First year mortality in this group was 22%. The benefits of therapeutic revascularisation in this high risk group need to be studied.     

Normal coronary angiograms: financial victory from the brink of clinical defeat?

OBJECTIVE: To examine the hypothesis that, in patients undergoing coronary angiography for suspected ischaemic heart disease, a normal angiographic result is associated with a fall in consumption of health care resources following the angiogram. DESIGN: Retrospective cost-benefit analysis comparing the 12 month periods before and after coronary angiography. SETTING: Tertiary cardiac referral centre. SUBJECTS: 69 consecutive patients investigated in the financial year 1991-92 whose angiograms were normal. MAIN OUTCOME MEASURES: Drug and hospital admission costs in the 12 month periods before and after angiography; urgent and elective consultations with general practitioner in that time. RESULTS: The mean cost of care per patient in the year before investigation was 656.89 pounds. A highly significant fall in all indices of resource consumption was observed in the year following investigation, the mean resulting difference in the cost of care being 35.15 pounds per month. The cost of coronary angiography would, if this fall were maintained, be recouped in a mean time of 18 months. CONCLUSIONS: Patients suspected on clinical grounds to have coronary atherosclerosis who are found at angiography to have normal coronary arteries are heavy consumers of health care resources. Early investigation for these patients is safe and has beneficial resource consequences in the medium term.     

Effect of sequential radiofrequency ablation lesions at fast and slow atrioventricular nodal pathway positions in patients with paroxysmal atrial fibrillation.

OBJECTIVE: To examine the hypothesis that the anatomic equivalents of the fast and slow pathways identified in patients with atrioventricular (AV) nodal tachycardia may be universal and represent the principal sites of atrial input into the normal compact AV node. METHODS: 15 patients undergoing complete AV junction ablation for paroxysmal atrial fibrillation were studied. Radiofrequency energy was delivered first in the anterior "fast pathway" position so as to prolong the atrium to bundle of His (AH) interval by over 50% of baseline (protocol 1) and then to the "slow pathway" position using the anatomical technique (protocol 2). RESULTS: Ablation protocol 1 resulted in prolongation of AH interval in all patients. Subsequent lesions at the level of the coronary sinus produced complete heart block in four patients, and in five caused a further increase in AH interval above that produced by protocol 1. Four of these latter patients developed complete block after delivery of RF energy slightly anterior to the level of the coronary sinus os, as did three further patients in whom ablation at the level of the coronary sinus had no effect. In four patients complete heart block could not be achieved by protocol 2. CONCLUSIONS: A discrete anterior "fast" pathway and a posterior "slow" pathway or network of posterior pathways form the principal inputs to the compact AV node in most patients with atrial fibrillation. The absence of dual AV nodal physiology in the majority of these patients may be related to the functional properties of the individual components of this posterior network.     

Long-term monitoring of patients with a syncope of obscure etiology with an implantable monitoring device

INTRODUCTION: Generally available methods for the diagnosis of syncopal conditions such as Holter monitoring, the tilt test and invasive electrophysiological examinations, lead to the assessment of the cause of sporadic syncopes only in some patients. The implantable monitoring device REVEAL protracts significantly the monitoring period. METHODS, RESULTS: The authors implanted the implantable monitoring device REVEAL in the course of 14 months to 19 patients with syncopes of obscure origin. During this period it was possible to prove the cause of the syncope in a total of 10 patients (53%), in 8 patients the cause was arrhythmia, in another two an arrhythmic cause was ruled out. During monitoring the authors did not record any serious undesirable events. CONCLUSION: Implantable monitoring devices are an asset in the diagnosis of sporadic syncopes where currently available invasive and non-invasive methods fail. Its use in patients without obvious structural cardiovascular disorders is safe.     

Positron emission tomography in the investigation of pediatric inflammatory bowel disease

BACKGROUND: Endoscopic and radiologic studies are frequently required in inflammatory bowel disease (IBD) to determine disease activity, extent of disease, and delineating disease type. Positron emission tomography (PET) using fluorine-18-fluoro-deoxyglucose to identify metabolically active tissues may offer a simple noninvasive alternative to conventional studies in identification and localization of active intestinal inflammation in children with IBD. The aim of this study was to assess the value of PET in identifying active intestinal inflammation compared with conventional endoscopic and radiologic studies, including small bowel follow-through and colonoscopy. METHODS: Sixty-five children were enrolled in the study. This included 55 children (mean age, 13.3 yr; range, 7-18 yr; 20 girls) with newly diagnosed IBD (37) or symptoms suggestive of recurrent disease (18) and 10 children with recurrent abdominal pain (mean age, 12.7 yr; range, 8-15 yr; 7 girls) who were studied with PET, and the results were compared with small bowel follow-through with pneumocolon and/or colonoscopy. Thirty-eight patients had Crohn's disease (17 ileal, 12 ileocolic, 5 pancolonic, 3 left-sided disease, 1 right-sided disease), and 17 had ulcerative colitis (15 pan-colitis, 2 left-sided colitis). Mean time interval between PET and other studies was 30 +/- 17.6 days. RESULTS: PET correctly identified active inflammatory disease in 80% of children with IBD (81.5% with Crohn's disease; 76.4% with ulcerative colitis) and correctly showed no evidence of inflammation in children with recurrent abdominal pain. Gluorine-18-fluoro-deoxyglucose accumulated at sites that corresponded with active disease at colonoscopy in 83.8% of patients and with small bowel follow-through with pneumocolon 75.0% of the time. CONCLUSION: This study suggests that PET offers a noninvasive tool for identifying and localizing active intestinal inflammation in children with IBD. PET may not be able to replace conventional studies; however, it may be useful when conventional studies cannot be performed or fail to be completed.     

Velocity, stroke rate, and distance per stroke during elite swimming competition

The mean velocity of 9 out of 10 women's events during the U.S. Olympic Swimming Trials was greater in 1984 as compared to 1976. Three of the 10 men's events showed improvement. In 9 out of these 12 events, the increased velocity was accounted for by increased distance per stroke (range, -3 to -13%). In the women's 100-m butterfly and 100-m backstroke, increased velocity was due solely to faster stroke rates. The finalists in each event were compared to those whose velocities were 3-7% slower. In almost all events and stroke styles, the finalists achieved greater distances per stroke than did the slower group. In the men's events increased distance per stroke was associated with decreased stroke rate, except in the backstroke, in which both were increased for the finalists. Although the faster women swimmers generally had greater distances per stroke, they were more dependent than men on faster stroke rates to achieve superiority. The profile of velocity for races of 200 m and longer indicated that as fatigue developed the distance per stroke decreased. The faster swimmers compensated for this change by maintaining or increasing stroke rate more than did their slower competitors. This study indicates that improvements and superiority in stroke mechanics are reflected in the stroke rate and distance per stroke used to swim a race.     

Focal thyroid incidentalomas identified with whole-body FDG-PET warrant further investigation

Fluorodeoxyglucose (FDG) whole body positron emission computed tomography (PET-CT) detects clinically occult malignancy. The aim of this study was to assess the prevalence and significance of focal thyroid 18F - fluorodeoxyglucose uptake. A retrospective review of all patients who had FDG PET-CT examinations, in a single tertiary referral centre was performed. PET scan findings and the final pathological diagnosis were collated. 2105 scans were reviewed. Focal uptake was identified in 35 (1.66%) patients. Final surgical histology was available on eight patients, which confirmed papillary carcinoma in four (20%) patients and lymphoma and metastatic disease in two patients respectively. This gave an overall malignancy rate in focal thyroid uptake of at least 33%. Thyroid incidentalomas occurred with a frequency of 2.13%, with an associated malignancy rate of at least 33% in focal thyroid uptake. The high malignancy rate associated with focal thyroid uptake mandates further investigation in medically fit patients.     

A real-life multicentre clinical practice study to evaluate the efficacy and safety of intravesical chondroitin sulphate for the treatment of interstitial cystitis

OBJECTIVE

To report a multicentre, community based open‐label study designed to assess the efficacy and safety of intravesical sodium chondroitin sulphate in the treatment of patients with the clinical diagnosis of interstitial cystitis (IC). Chondroitin sulphate is a naturally occurring glycosaminoglycan (GAG) in the bladder mucus layer and changes in this GAG have been implicated in the pathogenesis of IC, and small single‐centre studies have suggested that intravesical chondroitin sulphate may have efficacy in IC.

PATIENTS AND METHODS

Patients with IC were treated with sodium chondroitin sulphate (Uracyst®, Stellar Pharmaceuticals Inc., London ON, Canada) solution 2.0% via urinary catheter weekly for 6 weeks and then monthly for 16 weeks for a total of 10 treatments. The primary efficacy endpoint was the percentage of responders to treatment as indicated by a marked or moderate improvement on a seven‐point patient Global Response Assessment (GRA) scale at week 10 (4 weeks after the initial six treatments) compared with baseline. A major secondary efficacy endpoint (durability) was the percentage of responders on the GRA scale after 10 treatments. Additional secondary efficacy objectives were differences from baseline in Patient Symptom/Problem Index scores over the course of the treatment compared with baseline.

RESULTS

In all, 47% of the 53 enrolled patients with long standing moderately severe IC (mean [sd , range] diagnosis of IC 3.0 [3.4, 0.1–16] years; duration of symptoms 9.2 [9.2, 1–39] years; baseline symptom score 14.2 [3.2]) were responders at week 10. At 24 weeks, 60% were responders. There was a statistically and clinically significant decrease in the mean (sd ) symptom and bother scores from baseline at 10 weeks and 24 weeks, at 9.0 (4.3) and 8.1 (5.0), respectively (P < 0.001). There were no significant safety issues during the study.

CONCLUSIONS

This multicentre community based real‐life clinical practice study suggests that intravesical chondroitin sulphate may have an important role in the treatment of IC and validates the rationale for a randomized placebo‐controlled trial.