Pulmonary arterial hypertension and left-sided heart disease in sickle cell disease: clinical characteristics and association with soluble adhesion molecule expression

Pulmonary hypertension (PH), a risk factor for mortality in sickle cell disease (SCD), has pathologic features of both pulmonary arterial hypertension (PAH) and PH related to left-sided heart disease (LHD) suggesting a link between these two entities. We hypothesized that both are characterized by endothelial dysfunction and increased adhesion molecule expression. SCD patients and normal volunteers underwent a screening questionnaire, echocardiogram, and blood donation for preparation of platelet-poor plasma. PAH was defined as a tricuspid regurgitant jet (TRJ) velocity > or =2.5 m/sec and/or the presence of isolated right ventricular hypertrophy or decreased systolic function. LHD was defined as either left-sided systolic/diastolic dysfunction or significant valvular disease. Plasma vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), P- and E-selectin, nitric oxide (NO(x)), erythropoietin, and vascular endothelial growth factor (VEGF) levels were assayed by enzyme-linked immunoassay. Forty-three percent of sickle cell anemia (HbSS) and 28% of hemoglobin SC disease (HbSC) disease patients had PAH. Additionally, 10-15% of SCD patients had LHD. VCAM-1 levels were significantly increased in HbSS patients compared with HbSC patients and normal volunteers. VCAM-1 and P-selectin levels correlated positively with TRJ velocity in HbSS patients (r = 0.45, P = 0.03, r = 0.2, P = 0.05, respectively). ICAM-1, E-selectin, NO(x), erythropoietin, and VEGF levels were similar across subject groups. PH is common in SCD and, at times, due to LHD. Increased VCAM-1 and P-selectin expression was associated with TRJ elevation regardless of etiology suggesting a similar effect on endothelial gene expression and possibly providing a pathologic link between PAH and PH related to LHD in SCD.

Neutrophil VCS Parameters Are Superior Indicators for Acute Infection

A reliable and cost-effective laboratory method for diagnosing early bacterial infection is needed. The purpose of this study is to compare the sensitivity and specificity of the mean neutrophil volume (MNV) and neutrophil volume distribution width (NDW) parameters with manual band counts, as well as absolute neutrophil count (ANC) and Creactive protein (CRP). We analyzed the clinical history and laboratory data from 242 adult patients with subsequent randomization into 3 groups: patients with no apparent clinical evidence of infection (group 1), localized infection (group 2), and severe infection (group 3). Total white blood cell counts, percentage of neutrophils, ANC, band counts, MNV, and NDW were progressively elevated from group 1 to group 3. There were good correlations between MNV and ANC (P < .05) or band counts (P < .001). Similarly, the NDW correlated well with ANC (P < .001) and band counts (P < .05). Statistical analyses further confirmed that the MNV and NDW were better parameters, with larger areas under the curve than those of CRP, band count, and ANC. The neutrophil VCS parameters, MNV and NDW, have superior sensitivity and specificity compared to manual band count, ANC, and CRP. MNV and NDW are useful indicators in diagnosing acute infectious processes.

Strangulation of the umbilical cord due to combined amniotic band and true knot

A case of fetal death due to an amniotic band and an umbilical cord true knot is presented. To the best of our knowledge the simultaneous occurrence of true knot of cord and amniotic band has never been previously reported and may shed light on the possible time of true knot formation in this case.

Complementary medicine and psoriasis: linking the patient's outlook with evidence-based medicine

BACKGROUND

There is increasing evidence for the extensive use of complementary and alternative medicine (CAM) by patients with psoriasis. Clinical research in the arena of CAM and psoriasis treatment is evolving and includes some randomized controlled trials.

OBJECTIVE

To study CAM use among patients with psoriasis attending a dermatology clinic in a major university hospital in northern Israel. Prevalence, reasons for CAM use and its relevance to doctor-patient communication were emphasized.

METHODS

Semistructured interviews were conducted with psoriasis patients in a dermatology clinic. Consent was obtained for 78 patients. Post-visit questionnaires were given to 5 physicians.

RESULTS

Seventy-eight patients with psoriasis were interviewed and 77 were studied. Sixty-two percent used CAM. Fifty-eight percent of users had seen a CAM practitioner. The study found a trend of CAM use among patients with psoriasis from Arab compared to Jewish descent (p=0.087). CAM users reported on average 2 different CAM modalities. Herbal medicine and nutritional treatments ranked first, followed by homeopathy, traditional Chinese medicine and nutritional supplements. The main reason for CAM use was stated to be to do everything to heal the disease, followed by a quest for improved quality of life. Others mentioned an interest in a less toxic treatment, disappointment with conventional treatment and stress reduction. Well over half of the study participants and their dermatologists did not initiate a discussion about CAM use. The dermatologists' ability to predict CAM use in their patients was relatively low.

CONCLUSION

There is growing evidence of extensive CAM use among patients with psoriasis. Most patients use CAM as a complementary treatment, rather than an alternative to conventional treatment. Teaching CAM should be integrated into the dermatology residency curriculum. Dermatologists need to increase their awareness of CAM use by their patients in order to improve therapeutic communication.

Abnormalities in the expression of cell cycle-related proteins in tumors of the small bowel

Tumors of the small bowel are quite rare for unknown reasons, although they resemble colorectal tumors in many respects. The purpose of this study was to determine whether abnormalities in the expression of several cell cycle control genes are of importance in small bowel tumorigenesis by comparing a series of samples of normal mucosa, adenomatous polyps, and adenocarcinomas. The levels of cyclin D1, cyclin E, p16, p21, p27, and p53 proteins were determined by immunohistochemistry in samples of normal small bowel (n = 16), small bowel adenomas (n = 20), and small bowel adenocarcinomas (n = 24). Normal small bowel mucosa expressed p27 protein, but not the other cell cycle-related proteins. About 20% of the tumors displayed a decrease in the expression of this protein. The most frequent alteration in the tumors was an increase in the p16 protein. Increased expression of p53 was associated with tumor progression because it was overexpressed in 45% of the adenomas and 65% of the adenocarcinomas (P<0.05). Advanced age and increased detection of cyclin D1 and p53 were associated with a decreased 3-year survival (P<0.05). Cell cycle abnormalities are early and important events in the multistep process of small bowel tumorigenesis, thus resembling colorectal carcinogenesis. As in colon cancer, deregulated expression of G1 proteins may perturb cell cycle control in benign adenomas of the small bowel and thereby enhance tumor progression. Increased expression of cell cycle inhibitors in tumors may serve as a defense mechanism for tumor progression.

The importance of the endopelvic fascia repair during vaginal hysterectomy

During 1985 to 1989, 177 vaginal hysterectomies were performed in the Department of Gynecology, Kaplan Hospital, Rehovot, Israel, using the Porges technique with some modifications. Ninety patients had some degree of loss of the pelvic support--anterior or posterior wall relaxation, enterocele or uterine prolapse in various degrees. The patients were allocated to two groups, in which two different techniques were compared: group 1, with repair of the pubocervical and pararectal fascia and group 2 without the repair. The repair of the pubocervical and pararectal fascia after vaginal hysterectomy prevented vaginal vault prolapse (zero versus 15 percent, p < 0.01) and reduced the incidence of recurrent rectocele (23 versus 55 percent, p < 0.05) and recurrent cystocele (14 versus 45 percent, p < 0.005). Recurrent genuine stress incontinence was found in 9 percent of patients in group 1 and 18 percent of patients in group 2 (not statistically significant; p = 0.163). Optimal management of relaxation of the vaginal wall during vaginal hysterectomy requires clinical suspicion and precise preoperative diagnosis and therapeutic plan. In the present study, the need for careful repair of the pubocervical and pararectal fascia during vaginal hysterectomy to prevent vaginal vault prolapse is emphasized. This procedure does not prolong the operation significantly (92 +/- 15 versus 84 +/- 17 minutes) and has no deleterious postoperative complications.

[Tuberculosis of the middle ear]

Tuberculosis is rare in Israel, especially that of the middle ear. Its rarity leads to both underdiagnosis and misdiagnosis. Since tuberculosis is treatable, diagnosis is of the utmost importance. The recent wave of immigration from countries in which tuberculosis is endemic may confront us with more cases of tuberculosis of this type.

Serum, lymphocyte, and erythrocyte potassium, magnesium, and calcium concentrations and their relation to tachyarrhythmias in patients with acute myocardial infarction

Serum, lymphocyte, and erythrocyte potassium, magnesium, and calcium levels were measured in 215 patients during the five days following acute myocardial infarction. Serum potassium fell from 4.25 +/- 0.05 to 4.08 +/- 0.06 mmol/liter (p less than 0.001), magnesium from 0.93 +/- 0.01 to 0.85 +/- 0.01 mmol/liter (p less than 0.001), and calcium from 2.4 +/- 0.02 to 2.2 +/- 0.08 mmol/liter (p less than 0.001). Lymphocyte potassium increased from 18.1 +/- 1.5 to 51.6 +/- 4.3 pmol/100 cells (p less than 0.001) and magnesium from 2.0 +/- 0.1 to 8.2 +/- 0.8 pmol/100 cells (p less than 0.001), whereas calcium decreased from 2.9 +/- 0.27 to 1.4 +/- 0.25 pmol/100 cells (p less than 0.001). Erythrocyte cations remained constant. There was a larger increase in lymphocyte potassium in patients with tachyarrhythmias than in patients without (70.4 and 46.9 pmol/100 cells, respectively, p less than 0.001), whereas the presence of a high lymphocyte magnesium level was associated with a significant decrease in the development of tachyarrhythmias, despite high potassium concentrations. It is suggested that lymphocyte cation concentrations mirror myocardial interstitial concentrations and that a high interstitial magnesium level has a protective effect on the increased cell excitability due to, and despite, a high interstitial potassium level.

Intracellular cations and diuretic therapy following acute myocardial infarction

In a controlled, prospective, randomized study of the effects of diuretic therapy on serum, lymphocyte, and erythrocyte potassium, magnesium, and calcium concentrations, 155 patients were followed up for six months after experiencing acute myocardial infarction. Of these, 48 patients received furosemide and potassium; 37 patients received hydrochlorothiazide and amiloride hydrochloride; and 70 patients did not require diuretics. Lymphocyte and erythrocyte cation concentrations were all statistically significantly lower in the furosemide-treated patients when compared with the patients in the nondiuretic-therapy group or the hydrochlorothiazide-amiloride-treated group, with no change in serum levels. Since the combination of low intracellular potassium and magnesium concentrations in patients with recent myocardial infarction may be of importance in the cause of arrhythmias, we suggest that potassium- (and magnesium-) sparing diuretics be used in the treatment of patients, when necessary, unless their diuretic needs cannot be met by such agents.

Rhabdomyoma of the larynx

Since 1897 a total of 37 cases of extracardiac rhabdomyomas of the fetal type have been reported in the literature. Only two of these were localized in the larynx. We report an additional case of extracardiac rhabdomyoma localized in the larynx, and the pertinent literature is discussed. Although rare, its existence should be kept in mind in the differential diagnosis of laryngeal tumours.

Anomalous origin of the left coronary artery from the pulmonary artery: new electrocardiographic, echocardiographic and surgical observations

The case of a two year old girl with anomalous origin of the left coronary artery from the pulmonary artery is described. She was never in heart failure but had cardiomegaly and anginal pain. The ECG showed a typical infarct pattern with left ventricular hypertrophy. An unusual finding was a prolonged QTc of 0.52. During cardiac catheterization and twice 24 hours later she developed ventricular fibrillation treated with electroshock and prevented later with propranolol. The QTc returned to normal after surgery. Echocardiography showed diastolic flutter and early systolic closure of the pulmonary valve. This disappeared after surgical correction. Transverse 2D echo of the aortic root showed a large right coronary artery which decreased in size after surgery. The left coronary artery was not seen on echocardiography. At cardiac catheterization the diagnosis of an anomalous origin of the left coronary artery from the pulmonary artery was established, with a large shunt to the pulmonary artery through the anomalous artery. Mild pulmonary hypertension and mild mitral regurgitation were present. At surgery, since direct implantation was technically impossible, the left coronary artery was successfully connected to the aorta via a 6 mm expanded Poly-Tetra-Fluoro-Ethylene (P.T.F.E.) graft.

Ovarian carcinoma masquerading as ovarian hyperstimulation syndrome

Two patients receiving ovulation-inducing drugs were found to have ovarian carcinoma. Since patients receiving such medication are prone to develop enlarged ovaries with or without the fully developed hyperstimulation syndrome, the diagnosis of ovarian tumors in such patients may be delayed or missed. It is therefore being suggested that an ovarian enlargement persisting for more than 4 weeks, or the finding of ovarian solid masses by sonography in patients receiving ovulation-inducing drugs, should lead to a thorough work-up for neoplasia, sometimes including even laparotomy.

Spatial and temporal variations in regional left ventricular function in isolated disease of the left anterior descending coronary artery

The temporal and spatial pattern of left ventricular (LV) contraction and relaxation in 34 patients with isolated lesions of the left anterior descending artery (LAD) were studied from the LV cineangiogram in the right anterior oblique position using a computer interactive technique. The LV outline was divided into 100 equiangular radii from the center of the enddiastolic silhouette and the trajectory of contraction and relaxation of each radius measured and displayed. Patients were divided into different subsets. Classical anterior wall infarction caused impaired contraction of the distal two thirds of the anterior wall, the apex and the distal quarter of the inferior wall, with marked delay in contraction and relaxation of the border zones and hyperkinesis of the inferior wall. Spatial and temporal disturbances (akinesis and asynchrony) were marked in the other subsets. Left bundle branch block caused profound temporal delay particularly during relaxation.

Complete atrioventricular canal with survival to the eighth decade

Survival to the eighth decade of patients with atrioventricular canal is extremely rare. A patient is presented with such survival of the complete form of the defect. This possibly represents the first such report in the medical literature. The value of 2-dimensional echocardiography, particularly with venous contrast studies, in establishing the diagnosis, is shown.

An unusual case of double-outlet left ventricle

The first case of a double-outlet anterior left ventricle with normal relationships of the great vessels is reported (S.L.D.). This case is associated with a chromosomal trisomy--the exact nature of which is not yet clear. The clinical, electrocardiographic, echocardiographic and angiographic features are described.