Asthma-chronic obstructive pulmonary disease overlap and cost-related medication non-adherence among older adults in the United States

BACKGROUND

Cost-related medication non-adherence (CRN) can negatively impact health outcomes in older adults with asthma and chronic obstructive pulmonary disease (COPD) overlap (ACO) by reducing access and adherence to essential medications. The objective of this study is to examine the association of ACO to any CRN and specific forms of CRN among a nationally representative sample of older (age ≥ 65 years) adults.

METHODS

We adopted a cross-sectional study design using data from pooled cross-sectional Medicare Current Beneficiary Surveys (MCBS) (2006-2013) and linked fee-for-service Medicare claims. Unadjusted and adjusted logistic regressions that accounted for the complex survey design examined the association of ACO to any CRN and specific forms of CRN.

RESULTS

Among older adults with ACO, 16% reported any CRN. The most common form of CRN was "failing to get prescription". As compared to older adults with no asthma and no COPD, those with ACO were more likely to report any CRN (adjusted odds ratios [AOR] = 1.50, 95%CI = [1.14, 1.96]) and all forms of CRN. However, when the number of unique medications was added to the model, there were no statistically significant differences in CRN between the two groups.

CONCLUSIONS

Older adults with ACO represent a vulnerable population with increased risk for CRN. Multiple factors can contribute to CRN including: a higher number of prescribed medications, multiple co-morbidities, and cost of therapies. Medication comprehensive review interventions have the potential of reducing the risk of CRN among the older Medicare beneficiaries with ACO.

Occupational musculoskeletal disorders management using Fuzzy TOPSIS Assessment of Repetitive Tasks (ART)

BACKGROUND

In order to evaluate occupational disorders and ergonomic problems in a workplace, Multiple Criteria Decision Making (MCDM) problem solving methods such as Fuzzy Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) can be utilized.

OBJECTIVE

In this paper, Musculoskeletal Disorder (MSD) risk factors were evaluated in a manufacturing company in Iran by a method called Assessment of Repetitive Tasks (ART) of the upper limbs integrated with Fuzzy TOPSIS in order to prioritize the corrective actions.

METHODS

This study was done with a descriptive-analytical approach. The company under study had 240 employees who were working in seven different shops. Out of all tasks, 13 tasks were included in the study. Required information was gathered by a demographic questionnaire and ART method. Also, Fuzzy TOPSIS was utilized for the prioritization of the company shops based on the ergonomic control needs.

RESULTS

Data analysis from ART indicated that 74.6% of the reviewed tasks were high risk. Based on the F- TOPSIS-ART results, Production shop prioritized as the highest need for MSD control.

CONCLUSIONS

Because there is time and financial resources limit in ergonomic control activities, a fuzzy prioritization approach such as Fuzzy TOPSIS ART can be used to take advantage of the available resources and control risks to as low as reasonably practicable (ALARP) level.

Integrating the Ergonomics Techniques with Multi Criteria Decision Making as a New Approach for Risk Management: An Assessment of Repetitive Tasks -Entropy Case Study

BACKGROUND

Nowadays, the health work decision makers need to analyze a huge amount of data and consider many conflicting evaluation criteria and sub-criteria. Therefore, an ergonomic evaluation in the work environment in order to the control occupational disorders is considered as the Multi Criteria Decision Making (MCDM) problem. In this study, the ergonomic risks factors, which may influence health, were evaluated in a manufacturing company in 2014. Then entropy method was applied to prioritize the different risk factors.

METHODS

This study was done with a descriptive-analytical approach and 13 tasks were included from total number of employees who were working in the seven halls of an ark opal manufacturing (240). Required information was gathered by the demographic questionnaire and Assessment of Repetitive Tasks (ART) method for repetitive task assessment. In addition, entropy was used to prioritize the risk factors based on the ergonomic control needs.

RESULTS

The total exposure score based on the ART method calculated was equal to 30.07 ±12.43. Data analysis illustrated that 179 cases (74.6% of tasks) were in the high level of risk area and 13.8% were in the medium level of risk. ART- entropy results revealed that based on the weighted factors, higher value belongs to grip factor and the lowest value was related to neck and hand posture and duration.

CONCLUSIONS

Based on the limited financial resources, it seems that MCDM in many challenging situations such as control procedures and priority approaches could be used successfully. Other MCDM methods for evaluating and prioritizing the ergonomic problems are recommended.

Operationalizing Cognitive Science and Technologies' Research and Development; the "Brain and Cognition Study Group (BCSG)" Initiative from Shiraz, Iran

Recent advances in brain and cognitive science studies have revolutionized concepts in neural dynamics, regulating mechanisms, coding systems and information processing networks which govern our function and behavior. Hidden aspects of neurological and psychiatric diseases are being understood and hopes for their treatment are emerging. Although the two comprehensive mega-projects on brain mapping are in place in the United States and Europe; the proportion of science contributed by the developing countries should not be downsized. With the granted supports from the Cognitive Sciences and Technologies Council (CSTC), Iran can take its role in research on brain and cognition further. The idea of research and development in Cognitive Sciences and Technologies (CST) is being disseminated across the country by CSTC. Towards this goal, the first Shiraz interdisciplinary meeting on CST was held on 9 January 2014 in Namazi hospital, Shiraz. CST research priorities, infrastructure development, education and promotion were among the main topics discussed during this interactive meeting. The steering committee of the first CST meeting in Shiraz decided to frame future research works within the "Brain and Cognition Study Group-Shiraz" (BCSG-Shiraz). The study group comprises scientific leaders from various allied disciplines including neuroscience, neurosurgery, neurology, psychiatry, psychology, radiology, physiology, bioengineering, biophysics, applied physics and telecommunication. As the headquarter for CST in the southern Iran, BCSG-Shiraz is determined to advocate "brain and cognition" awareness, education and research in close collaboration with CSTC. Together with CSTC, Shiraz Neuroscience Research center (SNRC) will take the initiative to cross boundaries in interdisciplinary works and multi-centric research projects within the study group.

Mixed infection with intestinal tape worms in sheep

In a survey carried out during the period April 2001 to November 2002, the intestines of 3165 slaughtered sheep in the Fars province of Iran were examined for mixed infection with intestinal tape worms. Four point sixty eight percent of animals were found to be infected with one or more than one species of tape worms. The identified species included: Moniezia expansa, Moniezia benedeni, Thysaniezia giardi, Avitellina centripunctata and Stilesia globipunctata. Of all 148 infected sheep, 104 animals (70.3%) were infected with one species, 38 animals (25.7%) were infected with two species and 5 animals (3.4%) were infected with three species of tape worms. No animal was found to be infected with four species but one sheep (0.7%) was found to be infected with all five species of tape worms.

Regulatory proteins alter nucleotide binding to acto-myosin of sliding filaments in motility assays

The sliding speed of unregulated thin filaments in motility assays is only about half that of the unloaded shortening velocity of muscle fibers. The addition of regulatory proteins, troponin and tropomyosin, is known to increase the sliding speed of thin filaments in the in vitro motility assay. To learn if this effect is related to the rate of MgADP dissociation from the acto-S1 cross-bridge head, the effects of regulatory proteins on nucleotide binding and release in motility assays were measured in the presence and absence of regulatory proteins. The apparent affinity of acto-heavy meromyosin (acto-HMM) for MgATP was reduced by the presence of regulatory proteins. Similarly, the regulatory proteins increase the concentration of MgADP required to inhibit sliding. These results suggest that regulatory proteins either accelerate the rate of MgADP release from acto-HMM-MgADP or slow its binding to acto-HMM. The reduction of temperature also altered the relationship between thin filament sliding speed and the regulatory proteins. At lower temperatures, the regulatory proteins lost their ability to increase thin filament sliding speed above that of unregulated thin filaments. It is hypothesized that structural changes in the actin portion of the acto-myosin interface are induced by regulatory protein binding to actin.

Modulation of myosin function by isoform-specific properties of Saccharomyces cerevisiae and muscle tropomyosins

Tropomyosin is an extended coiled-coil protein that influences actin function by binding longitudinally along thin filaments. The present work compares cardiac tropomyosin and the two tropomyosins from Saccharomyces cerevisiae, TPM1 and TPM2, that are much shorter than vertebrate tropomyosins. Unlike cardiac tropomyosin, the phase of the coiled-coil-forming heptad repeat of TPM2 is discontinuous; it is interrupted by a 4-residue deletion. TPM1 has two such deletions, which flank the 38-residue partial gene duplication that causes TPM1 to span five actins instead of the four of TPM2. Each of the three tropomyosin isoforms modulates actin-myosin interactions, with isoform-specific effects on cooperativity and strength of myosin binding. These different properties can be explained by a model that combines opposite effects, steric hindrance between myosin and tropomyosin when the latter is bound to a subset of its sites on actin, and also indirect, favorable interactions between tropomyosin and myosin, mediated by mutually promoted changes in actin. Both of these effects are influenced by which tropomyosin isoform is present. Finally, the tropomyosins have isoform-specific effects on in vitro sliding speed and on the myosin concentration dependence of this movement, suggesting that non-muscle tropomyosin isoforms exist, at least in part, to modulate myosin function.

Kinetic differences in cardiac myosins with identical loop 1 sequences

The kinetics of nucleotide turnover vary considerably among isoforms of vertebrate type II myosin, possibly due to differences in the rate of ADP release from the nucleotide binding pocket. Current ideas about likely mechanisms by which ADP release is regulated have focused on the hyperflexible surface loops of myosin, i.e. loop 1 (ATPase loop) and loop 2 (actin binding loop). In the present study, we investigated the kinetic properties of rat and pig beta-myosin heavy chains (beta-MHC) in which we have found the sequences of loop 1 (residues 204-216) to be virtually identical, i.e. DQSKKDSQTPKG, with a single conservative substitution (rat E210D pig). Pig myocardium normally expresses 100% beta-MHC, whereas rat myocardium was induced to express 100% beta-MHC by surgical thyroidectomy and subsequent treatment with propylthiouracil. Slack test measurements at 15 degrees C yielded unloaded shortening velocities of 1.1 +/- 0.8 muscle lengths/s in rat skinned ventricular myocytes and 0.35 +/- 0.05 muscle lengths/s in pig skinned myocytes. Similarly, solution measurements at the same temperature showed that actin-activated ATPase activity was 2.9-fold greater for rat beta-myosin than for pig beta-myosin. Stopped-flow methods were then used to assess the rates of acto-myosin dissociation by MgATP both in the presence and absence of MgADP. Although the rates of MgATP-induced dissociation of acto-heavy meromyosin (acto-HMM) were virtually identical for the two myosins, the rate of ADP dissociation was approximately 3.8-fold faster for rat beta-myosin (135 s(-)(1)) than for pig beta-myosin (35 s(-)(1)). ATP cleavage rates were nearly 30% faster for rat beta-myosin. Thus, whereas loop 1 appears from other studies to be involved in nucleotide turnover in the pocket, our results show that loop 1 does not account for large differences in turnover kinetics in these two myosin isoforms. Instead, the differences appear to be due to sequence differences in other parts of the MHC backbone.

Mid-term clinical and echocardiographic follow up of patients with CarboMedics valves in the tricuspid position

BACKGROUND AND AIM OF THE STUDY

Debate continues regarding tricuspid valve replacement (TVR) with a mechanical prosthesis. Experience with bileaflet prostheses is limited; hence the study aim was to explore early and mid-term outcome and hemodynamic data in patients with bileaflet CarboMedics prosthetic valves in the tricuspid position.

METHODS

The study population included 25 patients (21 females, four males; mean age 50.5 +/- 13.4 years) who underwent TVR with a CarboMedics valve over a six-year period. Routine clinical examinations and details of transthoracic echocardiography (TTE) were reviewed. Additional TTE, transesophageal echocardiography (TEE) and fluoroscopy were performed as indicated. The number of previous cardiac operations was zero, one and two in 36%, 32% and 32% of patients, respectively. Previous tricuspid surgery was performed in eight cases (32%); concurrent mitral valve replacement was performed in 17 (68%). The hospital mortality rate was 24% and late mortality rate 12%. Seventeen early survivors (13 females, four males) were followed up for 46 +/- 28 months (range: 4-96 months).

RESULTS

Among early survivors, the mean and peak transvalvular gradients were 4.0 +/- 1.7 and 7.9 +/- 3.3 mmHg, respectively. Commonly observed INR levels were >2.5 in seven patients (41%), and >3.0 in only three (18%). Five patients (29% of mid-term survivors) experienced a total of 13 episodes of obstructive valve thrombosis, mostly with inappropriate anticoagulation. One patient required emergency re-do surgery; the others responded initially to thrombolysis or intensified antithrombotic treatment, but experienced at least two additional relapses. Aside from thrombotic episodes, all patients but two were in NYHA functional class II-III, and all but four required diuretics.

CONCLUSION

TVR with bileaflet mechanical valves carries a high perioperative mortality and mid-term morbidity. Among patients with poor or fair anticoagulation, these valves were associated with a high incidence of obstructive valve thrombosis. If poor patient compliance is anticipated, insertion of a bioprosthesis should be encouraged.

Preparation of the internal thoracic artery by vasodilator drugs: is it really necessary? A randomized double-blind placebo-controlled clinical study

OBJECTIVE

The internal thoracic artery has become the conduit of choice for coronary artery bypass grafting. To avoid spasm of the artery, and increases in its diameter and flow, various vasodilators have been used either intraluminally or by topical application by different surgeons. In order to define the best vasodilating agent for preparation of the internal thoracic artery, a randomized double-blind placebo-controlled clinical study was performed in a group of patients submitted for elective coronary artery bypass grafting.

METHODS AND RESULTS

Eighty (80) consecutive patients submitted for elective first time coronary artery bypass grafting were randomly subdivided into five treatment groups. Free flow of the left internal thoracic artery was measured using an electromagnetic flow meter. The first measurement was performed shortly after the internal thoracic artery was dissected from the chest wall and the second just prior to performing distal anastomosis to the left anterior descending coronary artery. During the time interval between the two measurements the internal thoracic artery was immersed in a special applicator tube containing 20 ml solution of one of the following drugs: papaverin 2 mg/ml, nitroglycerin 1 mg/ml, verapamil 0.5 mg/ml, nitroprusside 0.5 mg/ml, normal saline 0.9%.

RESULTS

No statistically significant differences were found between the groups in respect to age, body surface area, bypass time, cross clamping time, and time interval between the two flow measurements. Mean arterial pressure at the time of the first and second internal thoracic artery flow measurements did not show statistically significant differences either within or between the groups. In all five groups, the free flow of the internal thoracic artery increased significantly with time. However, no statistically significant differences were shown between the five groups with respect to second flow (P = 0.2).

CONCLUSIONS

Within the limits of our study design, we suggest that preparation of the LITA by topical vasodilator drugs using a special applicator tube does not result in a significantly superior free flow than placebo.

Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial

OBJECTIVE

We examined the effects of aprotinin on graft patency, prevalence of myocardial infarction, and blood loss in patients undergoing primary coronary surgery with cardiopulmonary bypass.

METHODS

Patients from 13 international sites were randomized to receive intraoperative aprotinin (n = 436) or placebo (n = 434). Graft angiography was obtained a mean of 10.8 days after the operation. Electrocardiograms, cardiac enzymes, and blood loss and replacement were evaluated.

RESULTS

In 796 assessable patients, aprotinin reduced thoracic drainage volume by 43% (P < .0001) and requirement for red blood cell administration by 49% (P < .0001). Among 703 patients with assessable saphenous vein grafts, occlusions occurred in 15.4% of aprotinin-treated patients and 10.9% of patients receiving placebo (P = .03). After we had adjusted for risk factors associated with vein graft occlusion, the aprotinin versus placebo risk ratio decreased from 1.7 to 1.05 (90% confidence interval, 0.6 to 1.8). These factors included female gender, lack of prior aspirin therapy, small and poor distal vessel quality, and possibly use of aprotinin-treated blood as excised vein perfusate. At United States sites, patients had characteristics more favorable for graft patency, and occlusions occurred in 9.4% of the aprotinin group and 9.5% of the placebo group (P = .72). At Danish and Israeli sites, where patients had more adverse characteristics, occlusions occurred in 23.0% of aprotinin- and 12.4% of placebo-treated patients (P = .01). Aprotinin did not affect the occurrence of myocardial infarction (aprotinin: 2.9%; placebo: 3.8%) or mortality (aprotinin: 1.4%; placebo: 1.6%).

CONCLUSIONS

In this study, the probability of early vein graft occlusion was increased by aprotinin, but this outcome was promoted by multiple risk factors for graft occlusion.

Massive spontaneous hemothorax as a presenting sign of aneurysmal rupture of the internal thoracic artery. A case report

Massive spontaneous hemothorax is a very uncommon, life-threatening situation. Acute dissection and ruptured aorta can be one of the differential diagnoses, but usually the clinical feature is completely different, and very few patients have survived this event and received medical attention. Among other causes of spontaneous bleeding, some are extremely rare, demanding precise diagnosis and judicial and immediate intervention. We describe a patient who presented with a massive hemothorax. There was no immediately apparent cause. Emergent angiography revealed active bleeding from an extremely unusual source: aneurysmal dilatation of the internal thoracic artery.

Echocardiography can detect cloth cover tears in fully covered Starr-Edwards valves: a long-term clinical and echocardiographic study

The incidence of cloth cover tears in fully covered Starr-Edwards valves, as assessed by autopsy or repeat surgery, is approximately 1% per patient-year. However, no echocardiographic study has explored this phenomenon. This study was designed as a one-time observational study and aimed to explore the ability of two-dimensional transthoracic echocardiography to identify cloth cover tears in 35 late survivors with 38 fully covered Starr-Edwards valves who had been operated on 20 to 24 years earlier. The hemodynamic profile, clinical status, and valve-related complications in this highly selected group of late survivors were also studied. Five patients also underwent transesophageal echocardiography. An elongated echogenic mass attached to the prosthetic valve cage and floating downstream was considered indicative of cloth tear. There were 16 patients with aortic valve prostheses, 16 with mitral valve prostheses, and three with double prosthetic valves. In six (17.1%) patients (four with aortic valve prostheses, two with mitral valve prostheses), an echogenic mass suggestive of cloth cover tear was detected, which was confirmed by transesophageal echocardiography in three patients. In two patients the echocardiographic finding was confirmed at surgery. The initial presentation of these six patients was endocarditis, possible embolism, unexplained dyspnea, and weakness in one patient each. Two patients were asymptomatic. There was no evidence of significant prosthetic valve malfunction in any patient. The transvalvular gradients were similar in patients with and without cloth cover tears. Echocardiographic findings highly suggestive of cloth cover tears are not uncommon and can be detected in the third postoperative decade in patients with fully covered Starr-Edwards valves. A prospective study to evaluate the clinical significance of an incidental echocardiographic finding suggestive of cloth cover tears in asymptomatic patients with these valve models is warranted.

[Prosthetic heart valve thrombosis: a 3-year experience]

A series of 12 patients with 16 episodes of prosthetic heart-valve thrombosis over 3 years is presented. Most episodes affected mitral or tricuspid bileaflet prostheses. All patients were inadequately anticoagulated at the time of thrombosis. The clinical presentation was acute and severe in 6 patients, and subacute or chronic in the rest. Physical examination was suggestive of stuck valves in most cases. Transthoracic echocardiography revealed increased transvalvular gradients in most. However, clearer evidence of valve thrombosis was obtained from transesophageal echocardiography or fluoroscopy. 9 patients eventually had their valves re-replaced successfully, and the preoperative diagnosis was confirmed in all. 5 patients were operated as soon as the diagnosis was established. and an additional 4 were operated after failure of anticoagulation. In 4 patients the valve leaflets became completely mobile after a course of thrombolysis. Prosthetic valve thrombosis is a severe and potentially fatal complication in patients with mechanical heart valves. Alertness of physicians at all levels- the general practitioner, the internist and the cardiologist- to the possibility of valve thrombosis and to its clinical presentation may lead to prompt and earlier diagnosis and to comprehensive therapy.

Suture granuloma simulating lung neoplasm occurring after segmentectomy

A suture granuloma was resected which developed after segmentectomy of a squamous cell carcinoma of the lung and radiologically mimicked a neoplasm. This report emphasises that although the appearance of the lesion may be typical for malignancy, the possibility of a benign suture granuloma should be considered, especially if the lesion appears shortly after surgery.

An unusual cause of recurrent angina two years after coronary artery bypass grafting: fistula between internal mammary artery graft to pulmonary vasculature

A 55-year-old man developed recurrent angina pectoris 2 years after coronary artery bypass grafting. Cardiac catheterization demonstrated that the venous grafts were patent, but selective left internal mammary angiogram showed multiple fistulous connections between the internal mammary artery and the pulmonary vasculature of the left upper lobe. After surgical correction of the fistula, the angina resolved. Only three previous cases of acquired internal mammary artery graft fistulas draining to the pulmonary vasculature have been described. The etiology, clinical presentation, and management of an internal mammary artery fistula to the pulmonary vasculature are discussed.

Recombinant alpha-interferon may be efficacious in acute hepatitis B

Whereas, in chronic type B hepatitis, the therapeutic effect of alpha-interferon has been studied extensively, data on the effect of interferon on the course and prognosis of acute hepatitis B are scarce in the literature. We report a case of acute type B hepatitis complicated by life-threatening extrahepatic manifestations where recombinant alpha-interferon facilitated clinical, biochemical, and serological recovery.

Surgical removal of echocardiographically detected multiple pedunculated and mobile left ventricular thrombi in acute myocardial infarction

Two-dimensional echocardiography revealed at least three left ventricular mural thrombi in a 59-year-old man with acute anterior myocardial infarction. The thrombi, which had highly mobile pedunculated elements, were attached to the septo-apical wall and protruded into the left ventricular cavity. In spite of the lack of a clinical event but in view of the potential risk of embolization, surgical removal of the thrombi was performed on the 16th day of hospitalization.

Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases

During an 11-month period, 4 patients underwent surgical removal of a mobile, pedunculated left ventricular thrombus. All 4 patients had a history of myocardial infarction. Two of the 4 patients had systemic emboli, and in the 2 others, the ventricular thrombi were removed to prevent emboli. The thrombus was removed during the acute phase of myocardial infarction in 2 patients and one and two years, respectively, following the infarct in the remaining 2 patients. Concomitant coronary artery bypass grafting was performed in 3 patients. There were no early or late deaths, and none of the patients had clinical or echocardiographic evidence of recurrent thrombi or emboli at follow-up 3 to 15 months later. These results indicate that left ventricular thrombectomy might be an effective treatment for patients with mobile, pedunculated, left ventricular thrombi. However, additional experience is required to compare surgical and medical treatment.

Instability of leukocyte aggregation: lack of evidence for leukoembolization during various states of inflammation

This study centers on the question of whether the phenomenon of leukocyte aggregation, which is typical to inflammatory conditions, is pathogenic per se. We examined patients and laboratory animals in whom the presence of aggregated leukocytes in the peripheral blood was documented by direct visualization and where, despite the presence of aggregated leukocytes, neither the patients nor the laboratory animals showed clinical or pathological evidence for leukoembolization. Our in vitro findings about the reversibility of the phenomenon of leukocyte aggregation help to explain the above-mentioned observations as well as the well-known daily clinical experience that, despite complement activation and other aggregatory stimuli, there is no clinical or pathological evidence for leukoembolization.

Massive hemoptysis complicating Behçet's syndrome: the importance of early pulmonary angiography and operation

A 16-year-old patient with Behçet's syndrome had massive hemoptysis due to a ruptured aneurysm of a segmental artery of the left lung. Emergency left lower lobectomy was performed. The patient is well 12 months after operation. There have been no further episodes of hemoptysis.

Late partial tamponade of the right atrium. A case report

An unusual case of late partial tamponade of the right atrium is reported in a patient 35 days after aortic valve replacement. Chest x-rays, echocardiograms and ECG were not helpful. The diagnosis was made by emergency bedside right heart catheterization which showed a 7 cm H2O gradient between the junction of the superior vena cava and right atrium and also a 12 cm H2O pressure difference between the femoral vein and the right atrium with a normal capillary wedge pressure. Re-thoracotomy with evacuation of blood clots and control of bleeding points improved the hemodynamics dramatically. However the patient succumbed 3 weeks later due to irreversible brain damage. This is thought to be the first report of a late partial right atrial tamponade in the English medical literature.

Bronchial adenoma: surgical experience with long-term follow-up (4-17 years)

Of 16 patients with bronchial adenoma who were operated on at Beilinson Medical Center from 1967 to 1980, only three presented the "triad" of cough, hemoptysis, and recurrent pulmonary infections. In two patients the tumor was diagnosed incidentally and in five patients histological evidence of adenoma was made during bronchoscopy. One patient died of myocardial infarction following reoperation for bleeding, and one patient was lost to follow-up. The remaining 14 patients were followed for 4 to 17 years without evidence of local recurrence or distant metastases. We conclude that the long-term prognosis of patients with bronchial adenoma is excellent, and limited surgical procedure should be the treatment of choice whenever possible.

Atrial tumors--surgical experience of 9 cases

Nine patients underwent surgical removal of intracardiac tumor during a 12-year period. The mean age of the five women and four men was 57 years (range 40 to 69). Eight of the nine patients were operated on in the last four years of the study period. The interval from onset of symptoms to surgery averaged 18.3 months. Clinical presentation varied significantly, reflecting mechanical, embolic and constitutional effects of the intracardiac mass. Echocardiography was the noninvasive procedure that contributed most to preoperative diagnosis, confirming presence of an intracardiac tumor in seven of the eight examined patients. Of the nine intracardiac tumors, seven were myxomas (6 left atrial and 1 right atrial), one was a primary left atrial liposarcoma and one a right atrial metastasis from an anaplastic carcinoma of the kidney. No patient died during or immediately after the operation. The two patients with malignant tumor died, two months and two years postoperatively, from progression of the basic disease. In neither case, however, was atrial recurrence of tumor found at autopsy. Of the seven surviving patients, five are symptom-free after observation periods averaging 34 months (range 2 months to 12 years). The other two still have signs of mild congestive heart failure. No recurrence of atrial myxoma has so far been detected.

Tricuspid stenosis due to intravenous leiomyomatosis--a call for caution: case report and review of the literature

Extension of a benign intravenous leiomyomatous tumor from the pelvis into the right atrium resulted in severe tricuspid stenosis in a 28-year-old woman. Absence of the Budd-Chiari syndrome and other abdominal manifestations led to a misdiagnosis of a primary right atrial tumor, with a fatal outcome during operation. In our search of the English literature, this was only the second case found in which extensive intravenous leiomyomatosis interfered with the tricuspid valve mechanism. In this report, the clinical picture, etiology, and treatment are discussed, along with the literature on this rare entity.

Left ventricular rupture after mitral valve replacement. Report of two cases and a review of the literature

Rupture of the left ventricle following mitral valve replacement occurred in 2 women among 520 patients (0.4%) during a 17-year-period at the Beilinson Medical Centre. In one patient, a delayed, type II rupture, followed by immediate exanguination, resulted from a 31 mm cloth-covered Starr-Edwards prosthesis inserted in a normal sized left ventricle. In the second patient, an intra-operative type I rupture occurred as a result of an over-zealous resection of a heavily calcified valve and annulus. Repeated attempts at surgical repair were unsuccessful. A review of 46 previously reported cases revealed several other factors that might be responsible for this complication which carries a 40-100% mortality rte, depending on whether it is diagnosed intra-operatively or in the immediate postoperative period. These factors and the variety of surgical approaches used for the repair of this grave complication are discussed.

Unilateral increased transradiancy of the lung caused by bronchial carcinoid tumour

Two patients with an intraluminal carcinoid tumour obstructing the right main bronchus in one, and the left main bronchus in the other, resulting in unilateral increased transradiancy from hypoperfusion of the lung, are described. Resection of the tumours and reconstruction of bronchial continuity was followed by return of perfusion to normal between three and 18 months after the operation. The patient in whom the diagnosis was delayed showed a much slower rate of return of perfusion and a small lung resulted. The finding of increased transradiancy of lung even in an asymptomatic patient should be an indication for bronchoscopy.

Congenital atresia of the left main coronary artery ostium

Three patients with the rare anomaly of congenital absence of the ostium of the left main coronary artery are presented. In two of the patients, aged 50 and 52 respectively, the diagnosis was established during selective coronary cineangiography for a severe anginal syndrome. The third patient, a 16-year-old-girl, underwent cardiac catheterization for investigation of a congenital heart malformation, when a single right coronary artery was demonstrated with absence of the main coronary artery ostium. Two patients underwent successful aortocoronary bypass grafting. In view of the occurrence of sudden death and massive myocardial infarction in adult patients shown to have severe or complete obstruction of the left main coronary artery, it is suggested that adult patients with this condition, who require open-heart surgery for any other cardiac disorder, should undergo aortocoronary bypass grafting concurrently even prior to the development of anginal symptoms. Children shown to have this anomaly should be subjected to long-term follow-up and have an aortocoronary bypass graft performed when symptoms of coronary insufficiency develop.

Multiple pulmonary hamartomas; a case report and review of the literature

Bilateral multiple hamartomas were found in a woman suspected of having metastatic malignancy of the lung. As extensive investigation for the primary tumour was unrevealing, a left exploratory thoracotomy and histological examination established the diagnosis. In view of the benign character of the tumours, local excision alone was performed. No surgical intervention was performed on the right side. Repeat chest films 12 months after surgery did not show the appearance of new lesions in the left lung or any increase in the size of the nodules in the right lung. This is the 12th case so far reported. The clinical characteristics and surgical management of these tumours are discussed.

Complete occlusion of the left main coronary artery: successful surgical management by myocardial revascularization

Isolated total occlusion of the left main coronary artery was demonstrated on coronary cineangiography in a 50-year-old woman with a progressive anginal syndrome. Aortocoronary saphenous vein graft bypass was performed. Six weeks after operation the patient was free of symptoms and postoperative coronary angiography showed the graft to be patent.