Sumatriptan-associated myocardial infarction: report of case with attention to potential risk factors.

Vascular headaches are a relatively common phenomenon. Increasing numbers of patients with headache are being considered for treatment with the selective serotonin-receptor agonist sumatriptan succinate because of its potential for pronounced therapeutic efficacy in selected patients. Sumatriptan-associated myocardial infarction occurred in a 50-year-old woman with a history of migraine headaches. Cardiac risk factors that must be considered in all patients with migraine before initiation of therapy include concomitant ergotamine use, postmenopausal state, male gender older than 40 years, family history of heart disease, cigarette smoking, hypertension, diabetes mellitus, as reviewed in this report.

Peduncular hallucinosis as a transient ischemic attack.

Peduncular hallucinosis is characterized by vivid hallucinations associated with organic midbrain disease. In the case reported here, the computed tomography brain scan showed basilar arterial atherosclerotic disease with central and cortical atrophy. Carotid imaging revealed bilateral stenosis. The electroencephalogram and magnetic resonance imaging of the midbrain revealed no abnormalities. The patient's symptoms resolved completely in 48 hours. This is believed to be the first report of peduncular hallucinosis as the manifestation of a transient ischemic attack syndrome.

Multiple system organ failure. The role of uncontrolled infection.

Multiple system organ failure (MSOF) remains a principal cause of death after major operative procedures and/or severe trauma. We studied multiple parameters in 553 consecutive emergency surgical patients to determine the incidence of MSOF, the predisposing factors to MSOF, and the sequelae of MSOF. Thirty-eight patients had MSOF; mortality was 74% for these patients. Evaluation of multiple factors demonstrated that (1) MSOF is primarily due to infection, (2) the temporal sequence of organ failure is lung, liver, gastric mucosa, and kidney, and (3) MSOF is the most common fatal expression of uncontrolled infection.

An experimental assessment of esophageal anastomotic integrity.

A series of experiments was designed to establish the role of proximal diversion and perioperative antibiotics in primary healing of experimental esophageal anastomoses designed to stimulate the clinical leak and death rate seen in patients treated for carcinoma of the esophagus. Thirty-four cats underwent partial thoracic esophagectomy with end-to-end anastomosis. Seventeen cats were randomized to complementary proximal esophageal diversion. Postoperative mortality was 38 per cent. The over-all rate of anastomotic leakage was 18 per cent, with 83 per cent of these cats dying as a result of this complication. Proximal esophageal diversion had no demonstrable role in the prevention of anastomotic dehiscence or subsequent mortality. In 22 of 34 cats, systemic perioperative antibiotics were administered. Administration of perioperative antibiotics decreased anastomotic leak significantly, p less than 0.05, and lowered mortality, p less than 0.001, with or without proximal esophageal diversion.

Gastrocutaneous fistula: etiology and treatment.

Gastrocutaneous fistula is an infrequent but serious surgical complication which has received little attention in the recent literature. The current report analyzes 13 patients with this complication. The fistula most commonly occurs in the fundic portion of the greater curvature of the stomach and is usually a result of unrecognized iatrogenic injury or associated with severe left upper quadrant inflammation and external drainage. Clinical recognition occurs when the patient develops left subphrenic sepsis or drains gastric content. The fistula is best documented by upper gastrointestinal contrast studies and usually responds to wide drainage and supportive treatment in the presence of benign disease. Oral alimentation apparently need not be delayed until complete fistula closure.

Post-traumatic intestinal obstruction.

The roentgenographic and pathologic findings in three patients with delayed post-traumatic intestinal obstruction are described. The pertinent literature also is reviewed to delineate the variable pathophysiology of the clinical phenomenon. As a result of the increasing incidence of blunt trauma in our society, the problem of occult intra-abdominal injury resulting in subsequent clinical disease always should be considered in the differential diagnosis of patients presenting later with intestinal complaints. Once considered, routine roentgenologic evaluation usually is diagnostic, and arteriographic evaluation should be considered if the diagnosis is strongly suspected in the face of normal contrast studies. If intestinal obstruction is diagnosed, operative treatment is indicated, simple, and effective.