Is a strategy of intended incomplete percutaneous transluminal coronary angioplasty revascularization acceptable in nondiabetic patients who are candidates for coronary artery bypass graft surgery? The Bypass Angioplasty Revascularization Investigation (BARI)

OBJECTIVES

Our objective was to determine whether a strategy of intended incomplete percutaneous transluminal coronary angioplasty revascularization (IR) compromises long-term patient outcome.

BACKGROUND

Complete angioplasty revascularization (CR) is often not planned nor attempted in patients with multivessel coronary disease, and the extent to which this influences outcome is unclear.

METHODS

Before randomization, in the Bypass Angioplasty Revascularization Investigation, all angiograms were assessed for intended CR or IR via angioplasty. Outcomes were compared among patients with IR intended if assigned to angioplasty, randomized to coronary artery bypass graft surgery (CABG) versus angioplasty; and within angioplasty patients only, among patients with IR versus CR intended.

RESULTS

At 5 years, there was a trend for higher overall (88.6% vs. 84.0%) and cardiac survival (94.5% vs. 92.1%) in CABG versus angioplasty patients with IR intended. The excess mortality in angioplasty patients occurred solely in diabetic subjects; overall and cardiac survival were similar among nondiabetic CABG and angioplasty patients. Freedom from myocardial infarction (MI) at 5 years was higher in nondiabetic CABG versus angioplasty patients (92.4% vs. 85.2%, p = 0.02), vet was similar to the rate observed (85%) in nondiabetic CABG and angioplasty patients with CR intended. Five-year rates of death, cardiac death, repeat revascularization and angina were similar in all angioplasty patients with IR versus CR intended. However, a trend for greater freedom from subsequent CABG was seen in CR patients (70.3% vs. 64.0%, p = 0.08).

CONCLUSIONS

Intended incomplete angioplasty revascularization in nondiabetic patients with multivessel disease who are candidates for both angioplasty and CABG does not compromise long-term survival; however, subsequent need for CABG may be increased with this strategy. Whether the risk of long-term MI is also increased remains uncertain.

Short- and long-term outcome of balloon angioplasty for compromised side branches after intracoronary stent deployment

During coronary stent deployment there is a risk of compromising side branches, which can result in chest pain. Compromised side branches can be reopened by balloon angioplasty through the side of the stent. In a consecutive series of 10 patients with side-branch compromise and chest pain, balloon angioplasty through the side of the stent resolved the ischemia in all cases. The stented segment showed no deterioration following side-branch angioplasty. Six-month follow-up angiography showed a restenosis in the branch vessel of eight patients. The stented parent vessel restenosed in four patients. Therefore, side-branch balloon angioplasty after coronary stenting for ongoing ischemia is technically feasible and immediately effective. Restenosis of the branch occurs in most cases.

The transcription factor HNF3beta is required in visceral endoderm for normal primitive streak morphogenesis

During early embryogenesis, the transcription factor HNF3beta is expressed in visceral and definitive endoderm, node, notochord and floorplate. A targeted mutation in the HNF3β gene results in the lack of a definitive node and notochord. Furthermore, lack of HNF3beta results in failure of proper primitive streak elongation. To address whether HNF3beta is required in visceral endoderm, we have used tetraploid embryo-ES cell aggregations to generate chimeric mouse embryos with wild-type visceral endoderm and homozygous mutant HNF3beta embryonic ectoderm or vice versa. Replacing the visceral endoderm of mutant HNF3beta embryos rescued proper primitive streak elongation and, conversely, mutant visceral endoderm imposed a severe embryonic-extraembryonic constriction on wild-type embryonic ectoderm. Restoration of normal streak morphogenesis was not sufficient to allow formation of the node and notochord in HNF3beta mutant embryos. Thus, our results demonstrate that HNF3beta has two separate roles in primitive streak formation. One is to act within the visceral endoderm to promote proper streak morphogenesis. The second is autonomous to the node and its precursors and involves specification of node and notochord cell fates. HNF3beta mutant embryos rescued for the embryonic-extraembryonic constriction developed further than mutant embryos, allowing examination of later roles for HNF3beta. We show that such mutant embryos lack foregut and midgut endoderm. In addition, left-right asymmetry is affected in the mutant embryos.

Opposite phenotypes of hypomorphic and Y766 phosphorylation site mutations reveal a function for Fgfr1 in anteroposterior patterning of mouse embryos

Intercellular communication is needed for both the generation of the mesodermal germ layer and its division into distinct subpopulations. To dissect the functions of fibroblast growth factor receptor-1 (FGFR1) during mouse gastrulation as well as to gain insights into its possible roles during later embryonic development, we have introduced specific mutations into the Fgfr1 locus by gene targeting. Our results show functional dominance of one of the receptor isoforms and suggest a function for the autophosphorylation of site Y766 in the negative regulation of FGFR1 activity. Y766F and hypomorphic mutations in Fgfr1 generate opposite phenotypes in terms of homeotic vertebral transformations, suggesting a role for FGFR1 in patterning the embryonic anteriorposterior axis by way of regulation of Hox gene activity.

[Caruncular melanoma. Apropos of clinical case]

The clinicopathologic case of a 69-year-old-female patient with a big caruncular melanoma is reported. Tumor was excised surgically and underwent external conventional radiation therapy with no recurrence two years later. Histopathology endorsed the clinical diagnosis and thickness of the tumor measured 5.5 mm. The bad prognosis of the caruncular location was reinforced by the tumor thickness. A better knowledge of conjunctival melanomas characteristics might allow an earlier diagnosis and a better prognosis as irradiation following surgical treatment appears efficient on unifocal limited melanomas.

[Pigmented basal cell carcinoma of the eyelid. Apropos of a clinical case]

A clinico-pathologic case of a 83-year-old female patient with a deeply pigmented inferior lid tumor is reported. The histopathological study of the tumor demonstrated a pigmented basal cell carcinoma. Numerous different tumors may affect the eyelids, melanocytic or not in nature. True melanomas are infrequent compared with the numerous other pigmented tumors, which always need a histological analysis.

Family systems therapy after Operation Desert Storm with European-theater veterans

We describe a quasi-experimental trial of time-limited family therapy with veterans and families of veterans who served in Europe, outside the war zone, during Operation Desert Storm (ODS). Family systems therapy was provided both to individuals and conjointly to couples or families during the acute postwar readjustment period. The intervention adapted strategies from structural, strategic, intergenerational, and behavioral family therapies in a brief-treatment protocol for systemic stressor resolution. Veterans given family system therapy were able to resume functional levels of psychosocial adjustment and reduce the risk of long-term (chronic or delayed) psychosocial impairment. Based on these preliminary findings, controlled evaluation of family systems therapy appears warranted for individuals and families exposed to subtraumatic stressors such as wartime non-war-zone military deployment.

Acute coronary artery occlusion likely due to thrombus occurring during coronary angiography: report of a case

Twenty-five years ago, fatalities due to acute thrombotic coronary occlusion occurring during coronary angiography were reported not infrequently, but are thought to have been eliminated by changes in technique and equipment. We present a case with documentation of a normal coronary arterial tree just before the time of an abrupt occlusion, which had the angiographic features of clot. The likely source of the thrombus was the arterial sheath. Measures for prevention of this complication are discussed.

A preliminary comparative treatment planning study for radiotherapy of age-related maculopathy

PURPOSE

We present a comparative planning of different approaches for external radiotherapy in age-related maculopathies.

MATERIALS AND METHODS

Calculated dose distributions and dose-volume histograms for (a) bilateral irradiation with 6 MV photons, (b) a single lateral-oblique beam using either photons, electrons or protons and (c) an anterior circular proton beam.

RESULTS

For lateral photon or electron beams the dose to the lens is usually lower than 10% of the dose to the macula. The entrance doses for bilateral photon beams are about 50% which increase up to 100% at the orbital bone. About 5 mm of optic nerves are irradiated at the maximal dose while the optic chiasma is spared. A single photon beam gives 50% of the dose to the fellow eye. The electron beam spares the fellow eye but gives a rather inhomogeneous dose to the target volume. For a lateral proton beam, 4 mm of optic nerve receives 90% of the dose, the skin dose is at least 70% of the dose to the macula and the lens and the fellow eye are spared. An anterior proton beam gives 90% of the dose to 1 mm of optic nerve and the 50% isodose approaches the periphery of the lens.

CONCLUSION

Doses to the critical structures can be dramatically diminished for all the techniques by reducing the beam size, but only if very precise set-up techniques are used. Proton beams are an attractive solution, but the impact of such a choice on the use of proton facilities and on the national health system should be carefully evaluated, as well as the risk of radio-induced secondary neoplasias.

The tumor suppressor gene Smad4/Dpc4 is required for gastrulation and later for anterior development of the mouse embryo

Mutations in the SMAD4/DPC4 tumor suppressor gene, a key signal transducer in most TGFbeta-related pathways, are involved in 50% of pancreatic cancers. Homozygous Smad4 mutant mice die before day 7.5 of embryogenesis. Mutant embryos have reduced size, fail to gastrulate or express a mesodermal marker, and show abnormal visceral endoderm development. Growth retardation of the Smad4-deficient embryos results from reduced cell proliferation rather than increased apoptosis. Aggregation of mutant Smad4 ES cells with wild-type tetraploid morulae rescues the gastrulation defect. These results indicate that Smad4 is initially required for the differentiation of the visceral endoderm and that the gastrulation defect in the epiblast is secondary and non-cell autonomous. Rescued embryos show severe anterior truncations, indicating a second important role for Smad4 in anterior patterning during embryogenesis.

Do patient and physician expectations predict response to pain-relieving procedures?

OBJECTIVE

To evaluate the relationships between patient and physician pretreatment expectations of pain relief and subsequent pain relief reported by chronic pain patients immediately after treatment.

DESIGN

Prospective study of consecutive patients undergoing a procedure in a pain clinic for treatment of chronic pain. Patients rated their current pain level and their expectation of pain relief immediately prior to undergoing a procedure (e.g., intravenous drug infusion, nerve block) for the treatment of chronic pain. Simultaneously and independently, the treating physician completed a similar questionnaire. At completion of the procedure, patients rated their current pain level and degree of pain relief.

SETTING

University of Washington Multidisciplinary Pain Center procedure suite.

PATIENTS

Forty-six consecutive chronic pain patients.

INTERVENTION

Intravenous drug infusions and nerve blocks.

OUTCOME MEASURES

Current pain and pain relief ratings.

RESULTS

Patients' pain relief expectation ratings were not correlated significantly with their postprocedure pain relief ratings or pre-post procedure changes in pain ratings. However, a statistically significant correlation was found between physician expectations of pain relief and patient pain relief ratings and patient pre-post procedure changes in pain.

CONCLUSIONS

The results of this study suggest that physicians are better predictors than are patients of patients responses to these procedures and/or that physicians may somehow subtly communicate their expectations to patients during the procedure, and these expectations then influence patient response. Patient pretreatment expectations may not always play a significant role in nonspecific treatment effects.

A double-blind, randomized study of three antimicrobial regimens in the prevention of infections after elective colorectal surgery

The objective of this study was to assess the prophylactic efficacy of cefoxitin, ceftizoxime, and metronidazole-gentamicin in colorectal surgery. A double-blind, randomized prospective clinical trial design was used in a Canadian tertiary care teaching hospital. Patients were randomized to one of three treatment groups and received three doses of a study drug (30 min preoperative and 2 postoperative doses at 12 and 24 h). Cefoxitin and ceftizoxime were given as 1000-mg doses. Metronidazole-gentamicin was given as 500 mg of metronidazole plus 120 mg of gentamicin in a minibag. High-risk patients (bowel ischemia, diabetic, current steroid use, etc.) received 10 postoperative doses. Patients with infections, prior antibiotics, or study drug allergies were excluded. Over 30 months, 153 patients were enrolled. Thirty-one patients were excluded for protocol violations. Of the 122 evaluable patients (38 ceftizoxime, 45 metronidazole-gentamicin, 39 cefoxitin), there was no difference across groups regarding sex, age, weight, preoperative Apache II score, and prior history of bowel surgery. Groups were equivalent regarding surgeon, nursing unit, high-risk status (six ceftizoxime, seven metronidazole-gentamicin, seven cefoxitin), bowel preparation, and procedure (including blood loss, drains, organ injury, intraoperative complications). Clinically significant infection requiring systemic antibiotics (7-day hospital and 30-day follow-up) was identified in 0% of ceftizoxime, 15% of metronidazole-gentamicin, and 26% of cefoxitin receiving patients (p = 0.005). Mean ASEPSIS scores for each group were 2.3 (range 0-15) for ceftizoxime, 9.2 (range 0-45) for metronidazole-gentamicin, and 10.4 (range 0-75) for cefoxitin (p = 0.01). Ceftizoxime patients tended to have a shorter total hospital stay (12.2 days versus 19.7 days for cefoxitin versus 13.9 days for metronidazole-gentamicin; p = 0.04), although the procedure to discharge interval was not significantly different (p = 0.09). There was no difference in clinical outcome according to risk status. Anaerobic bacteria were observed more commonly in the ceftizoxime and cefoxitin groups, whereas enteric Gram-negative aerobes were observed most often in the metronidazole-gentamicin group. The study regimens were generally well tolerated. Drug costs were equivalent between ceftizoxime and cefoxitin and lowest with the metronidazole-gentamicin regimen. Ceftizoxime appears to be more effective for the prevention of infection in colorectal surgery than either cefoxitin or metronidazole-gentamicin in the dosage regimens studied.

Mortality related to diagnostic cardiac catheterization. The importance of left main coronary disease and catheter induced trauma

BACKGROUND

The mortality of diagnostic catheterization is very low but still exists. Large series have documented left main disease as the most important anatomical risk factor but have not clarified the mechanism.

OBJECTIVES

To determine the mortality of diagnostic catheterization in a single high volume centre over a 9 year period and assess any change during this period; to compare this experience with that of larger multicentre surveys; to identify the clinical and anatomical risk factors; to investigate the mechanism of the event; to develop guidelines for prevention

METHODS

Cardiac catheterization records were reviewed over a 9 year period and patients dying during or within 24 hours were identified. The clinical and anatomical profile of the patients who died were compared with the overall group to search for independent risk factors. The angiograms of the deaths were reviewed for a mechanism.

RESULTS

There were 30 deaths in 42,345 procedures (0.071%). There was no change in the incidence over the 9 years. Left main coronary disease was an overwhelming risk factor (incidence 0.7%, p < .002 compared to all other subgroups) and no other anatomical subgroup including triple vessel disease was at greater risk than the overall group. Dissection of the left main coronary artery by the diagnostic catheter was the mechanism of death in 20 cases (67%)

CONCLUSIONS

Left main disease and catheter induced trauma are the most important risk factor for and mechanism of death during diagnostic catheterization and may account for the unchanging incidence. Technical guidelines are described which may reduce this risk.

Time-limited psychotherapy with Operation Desert Storm veterans

Time-limited psychotherapy conducted 2 to 9 months after demobilization was evaluated with Persian Gulf Theater veterans of Operation Desert Storm (ODS). Thirty five treatment-seeking veterans were contrasted with 20 non-treatment-seeking ODS Persian Gulf veterans in a repeated measures design at pretest, posttest, and 6-week followup assessments. In addition, psychotherapy participants at followup were contrasted with 80 non-treatment-seeking ODS Persian Gulf veterans from the same military units who were assessed one time at a comparable time point. Time-limited psychotherapy was associated with sustained improved psychosocial functioning and reduced levels of psychiatric and stress-related symptomatology.

[Initial results of proton therapy in choroidal melanoma at the d'Orsey Center for Proton Therapy; the first 464 cases]

PURPOSE

Retrospective analysis of the treatment of choroidal melanoma with protontherapy at the Centre de protonthérapie d'Orsay, France.

PATIENTS AND METHODS

Between September 1991 and September 1995, 612 patients presenting with choroidal melanoma were treated by protontherapy in Orsay. Following initial management of the first 464 patients, results were analyzed, as were results after a 1-year follow-up for 305 patients, a 2-year follow-up for 169 patients, and a 3-year follow-up for 59 patients.

RESULTS

Univariate analysis showed that the actuarial local recurrence rate was 5%, the 3-year survival rate 88%, and the overall metastasic rate 5%. The initial tumor volume was the most significant predictive factor for visual results and metastases. Multivariate analysis revealed that visual results were significantly related to the initial tumor volume, initial retinal detachment, and total dose delivered to the optic nerve and macula.

CONCLUSION

Protontherapy of choroidal melanoma allows in most cases conservation of the eye without modification of survival. Visual results mainly depend on the site and size of the tumor.

Clinical outcomes of patients more than one year following randomization in the Canadian Coronary Atherectomy Trial (CCAT)

BACKGROUND

The Canadian Coronary Atherectomy Trial (CCAT) assessed, in a randomized comparison, the clinical and angiographic outcomes following atherectomy with those following balloon angioplasty for the treatment of de novo lesions in the proximal one-third of the left anterior descending artery (LAD). Although the procedural success rate was somewhat higher and the postprocedure lumen larger in patients treated with atherectomy, lumen dimensions, restenosis rates and clinical outcomes were similar in the two groups at six months. To determine whether late differences emerged between the groups, clinical follow-up was obtained at a median of 18 (range 10 to 31) months after randomization.

METHODS AND RESULTS

Patients were contacted monthly by telephone for the first six months. Subsequent follow-up information was obtained in 272 (99%) of the 274 randomized patients via a clinic visit or telephone interview with the patient and/or a relative. Additional information was obtained from the referring physician as required. There were no differences in adverse events between the two groups during follow-up. In patients randomized to atherectomy compared with balloon angioplasty, death occurred in 1.5% versus 2.2% (cardiac death 0.7% versus 0.7%); myocardial infarction in 5.1% versus 5.9% (Q wave 1.5% versus 1.5%); coronary bypass surgery in 13.1% versus 12.6%; and repeat target lesion intervention in 22.6% versus 21.5%. Persistent or recurrent Canadian Cardiovascular Society class III/IV angina not treated by a further intervention was present in 1.5% versus 2.2%. The combined end-point of death or nonfatal myocardial infarction occurred in nine (6.6%) versus 11 (8.1%) patients and any adverse cardiac event in 50 (36.5%) versus 53 (39.3%). Multivariate logistic regression indicated that unstable angina, reference vessel size and preprocedure minimum lumen diameter were the only variables independently associated with adverse events.

CONCLUSIONS

The initial choice of directional atherectomy or balloon angioplasty had no impact on clinical outcome over a period of 18 months in this patient population. With either technique, just over 60% of patients with proximal LAD disease experienced sustained symptomatic improvement without an adverse event following a single procedure, and 80% achieved this status following a repeat percutaneous intervention.

Coronary angioplasty of a posterolateral branch with severe proximal vessel tortuosity

We present a case of a patient who experienced recurrent angina 15 months after coronary bypass surgery. A single lesion distal to a graft anastomosis was identified in the posterolateral coronary artery. There were two severe angulations, each greater than 90 degrees proximal to the lesion, with access possible only through the saphenous vein graft to the posterior descending artery. For ultimate success, such challenging anatomy required a combination of an array of guidewires, secondary support catheters, and a deflecting balloon.

Bicalutamide for advanced prostate cancer: the natural versus treated history of disease

PURPOSE

To determine the therapeutic effects of bicalutamide 200 mg in patients with prostate cancers of different hormone sensitivities.

METHODS

Patients with progressive prostate cancer were treated with bicalutamide 200 mg daily. Before treatment, patients' tumors were classified on the basis of prior hormone exposure and by serum testosterone levels into androgen-dependent and androgen-independent groups. Prior exposure to flutamide and response to flutamide withdrawal was also considered. Outcomes were reported independently on the basis of posttherapy changes in prostate-specific antigen (PSA), measurable disease, and radionuclide bone scans.

RESULTS

Outcomes varied by prior hormone exposure as a higher proportion of patients with progression of androgen-dependent tumors showed posttherapy PSA decreases of more than 50% or more than 80%, measurable disease regression, and improvement on radionuclide bone scans than did patients with androgen-independent progression. Within the category of androgen-independent progression, clinical benefit was observed in patients who had previously progressed on flutamide, independent of the response to flutamide withdrawal. Patients who had progressed on a gonadotropin-releasing hormone (GnRH) analog alone had a low response proportion, whereas those who progressed after two or more hormone therapies did not respond. Overall, the drug was well tolerated. After progression on bicalutamide monotherapy, one third of patients with androgen-dependent progression responded to medical castration with a GnRH analog.

CONCLUSION

Classifying patient tumors on the basis of prior hormone exposure permits a more precise estimate of the potential benefit of a specific hormone therapy for the individual patient. The precision is further increased by reporting the effects of a drug on each parameter of disease independently. The difference in outcomes for patients with androgen-independent progression suggests that the specific hormone therapy administered and the response to that therapy can influence the biology of the relapsing tumor and the sensitivity to subsequent therapies. The sensitivity to bicalutamide after progression on flutamide deserves further study.

Chimeric analysis of fibroblast growth factor receptor-1 (Fgfr1) function: a role for FGFR1 in morphogenetic movement through the primitive streak

Fibroblast growth factor (FGF) signaling has been implicated in the patterning of mesoderm and neural lineages during early vertebrate development. In the mouse, FGF receptor-1 (FGFR1) is expressed in an appropriate spatial and temporal manner to be orchestrating these functions. Mouse embryos homozygous for a mutated Fgfr1 allele (fgfr1(delta tmk)) die early in development, show abnormal growth and aberrant mesodermal patterning. We have performed a chimeric analysis to further study FGFR1 function in the morphogenesis and patterning of the mesodermal germ layer at gastrulation. At E9.5, fgfr1(delta tmk)/fgfr1(delta tmk) cells showed a marked deficiency in their ability to contribute to the extra-embryonic, cephalic, heart, axial and paraxial mesoderm, and to the endoderm of chimeric embryos. Analysis at earlier stages of development revealed that fgfr1(delta tmk)/fgfr1(delta tmk) cells accumulated within the primitive streak of chimeric embryos, and consequently failed to populate the anterior mesoderm and endodermal lineages at their inception. We suggest that the primary defect associated with the fgfr1(delta tmk) mutation is a deficiency in the ability of epiblast cells to traverse the primitive streak. fgfr1(delta tmk)/fgfr1(delta tmk) cells that accumulated within the primitive streak of chimeric embryos tended to form secondary neural tubes. These secondary neural tubes were entirely fgfr1(delta tmk)/fgfr1(delta tmk) cell derived. The adoption of ectopic neural fate suggests that normal morphogenetic movement through the streak is essential not only for proper mesodermal patterning but also for correct determination of mesodermal/neurectodermal cell fates.