Temporal artery biopsy: impact on the clinical management of patients.

OBJECTIVES: Temporal artery biopsy (TAB) is requested in an attempt to confirm the diagnosis of temporal arteritis (TA). Patients symptoms and signs are highly variable and TA is often focal and potentially missed in a small biopsy. The study aimed to determine if TAB helps in the management of patients with suspected TA. METHODS: The case records of sixty-six consecutive patients who had undergone temporal artery biopsy were recalled and examined for presenting symptoms, management, therapy, results and outcome. RESULTS: There were 23 men and 43 women with a mean age of 70.2 and 71.1 years respectively. Presenting symptoms varied with unilateral headache in 53, scalp tenderness in 16, muscle weakness in 10, visual disturbance in 16, jaw claudication in 5 and peri-orbital pain in 1 patient. The temporal artery was tender in 21 patients and thickened in 4 patients. Thirty-eight patients were commenced on steroids prior to biopsy and 6 more before the histology became available. Only 8% of biopsies were positive for TA. Of the patients started on steroids with a negative biopsy, the steroids were continued in 26 and stopped in 9. In the patients not put on steroids [22], biopsy was positive in 2; they were commenced on steroids. Therefore, the histological diagnosis resulted in a change in patient management in only 18% of patients. CONCLUSION: The results of TAB do not appear to affect the clinical management of most patients with suspected temporal arteritis. We must therefore question the routine use of this invasive investigation.

Prognostic significance of raised cardiac troponin T in patients presenting with acute limb ischaemia.

OBJECTIVE: To study the relation between serum cardiac troponin T (cTnT) and mortality in patients presenting with acute limb ischaemia secondary to an embolism. MATERIAL AND METHODS: A two years prospective study of all patients admitted to the vascular unit with a diagnosis of acute limb ischaemia secondary to an embolism. On admission all patients had an ECG. A blood sample was taken for measurement of cTnT, CRP, serum biochemistry, full blood count and clotting. All embolectomies were performed under local anaesthesia. Patients were followed until discharge from hospital and up to twelve months after surgery. RESULTS: There were 37 patients with lower limb and 2 patients with upper limb ischaemia. Twenty four patients were female and fifteen were male, with the mean age of 76 years (50-95) for women and 84 years (77-90) for men. Seventeen patients (44%) had a raised cTnT. The patients with raised cTnT were older than those with normal cTnT [86y (77-92) vs 77y (51-95), p = 0.01, t test]. The mean cTnT was 0.20 microg/L (range: 0.11-0.27). Only two patients with raised cTnT gave a history of chest pains. All of the patients with an elevated cTnT had also raised CRP. There was no significant difference in the serum creatinine in the group of patients with elevated cTnT compared to those with normal cTnT [112 micromol/L (range 98-159) vs 119 micromol/L (range: 47-177), p = ns]. The cumulative survival for cTnT+ patients at 7 days was 53% and that of cTnT- patients was 100%. The cumulative survival for cTnT+ and cTnT- patients was statistically different (p = 0.0000, chi2 = 13.1, Log Rank test). Using regression analysis, an elevated cTnT was found to be an independent predictor of outcome. CONCLUSION: A significant proportion of patients presenting with an acutely ischaemic limb have an elevated cTnT. An elevated cTnT may be an early marker of overall disease severity and a predictor of outcome.

The effects of hydroxyethyl starch compared with gelofusine on activated endothelium and the systemic inflammatory response following aortic aneurysm repair.

OBJECTIVE: To investigate the effect of HES, used as a plasma volume expander, on endothelial cell activation induced by ischaemia-reperfusion in humans. MATERIAL AND METHODS: Forty patients undergoing elective infrarenal aneurysm repair were randomised to receive either gelatine or hydroxyethyl starch solution as plasma expanders. The anaesthetic technique was standardised. All patients received the same crystalloid as per standard protocol. Urine samples and blood samples were collected at various times for assessment of microalbuminuria and von Willebrand factor (vWf) and CRP. RESULTS: The peak C-reactive protein was significantly lower in the patients treated with HES than those treated with gelofusine [142 mg/L (113,196 mg/L) vs 246 mg/L (189,291 mg/L) mg/L, P < 0.01, Mann-Whitney test]. The peak ACR was also significantly lower in the HES treated patients (9.3 mg/mmol vs 23.3 mg/mmol, P < 0.05). The plasma level of vWf was significantly higher in the gelofusine treated patients than those treated with HES [173.5 U/dl Vs 80.5 U/dl, P < 0.001, at 4 hr; 160 U/dl Vs 82.5 U/dl, P < 0.001, at 8 hr; 191 U/dl Vs 100.5 U/dl, P < 0.001, at 12 hr; 209 U/dl Vs 81.0 U/dl, P < 0.001, at 24 hr]. CONCLUSION: HES may damp down the systemic inflammatory response and reduce endothelial cell dysfunction.

Troponin T: how high is high? Relationship and differences between serum cardiac markers according to level of creatine kinase and type of myocardial infarction.

Cardiac troponins have emerged over recent years as the "gold standard" serum biochemical marker for the diagnosis and management for patients with acute myocardial infarction (MI). The relationship between old (creatine kinase; CK) and new (troponin T; TT) markers of myocardial injury were examined in this study of 392 consecutive patients admitted to a district hospital with a diagnosis of an acute MI. Significant correlation of serum TT and peak CK levels were seen (R = 0.58, p<0.0001) in all types of MI. A significant relationship was also seen according to type of MI (Q wave or non-Q wave MI) or peak CK level. The regression equation (TT (microg/l) = 0.0027 (peak CK) + 1.1160 (IU/l)) may be used by clinicians to estimate TT release from a known peak CK result and thus provide some guidance on equivalence between the two tests. Our findings provide physicians with a benchmark reference range between the two cardiac markers, according to level of peak CK.

Randomized study comparing the effects of hydroxyethyl starch solution with Gelofusine on pulmonary function in patients undergoing abdominal aortic aneurysm surgery.

BACKGROUND: Restoring blood flow to ischaemic tissue can cause lung damage with pulmonary oedema. Hydroxyethyl starch (HES) solution, when used for volume replacement, may modify and reduce the degree of ischaemia-reperfusion injury. We compared the effects of HES solution with those of Gelofusine solution on pulmonary function, microvascular permeability and neutrophil activation in patients undergoing elective infrarenal abdominal aortic aneurysm surgery. METHODS: Forty patients were randomized into two groups. The anaesthetic technique was standardized. Lung function was assessed with the PO(2)/FI(O(2)) ratio, respiratory compliance, chest x-ray and a score for lung injury. Microvascular permeability was determined by measuring microalbuminuria. Neutrophil activation was determined by measurement of plasma elastase. RESULTS: Four hours after surgery, the median (quartile values) PO(2)/FI(O(2)) ratio was 40.3 (37.8, 53.1) kPa for the HES-treated patients compared with 33.9 (31.2, 40.9) kPa for the Gelofusine-treated patients (P<0.01, Mann-Whitney test). The respiratory compliance was 80 (73.5, 80) ml cm(-1) H(2)O in the HES-treated patients compared with 60.1 (50.8, 73.3) ml cm(-1) H(2)O in the Gelofusine-treated patients (P<0.01, Mann-Whitney test). The lung injury score 4 h after surgery was less for the patients treated with HES compared with the patients treated with Gelofusine (0.33 vs 0.71, P=0.01, Wilcoxon rank sum test). Mean (SD) plasma elastase was less in the HES-treated patients on the first postoperative day (1.96 (0.17) vs 2.08 (0.24), P<0.05). The log mean microalbuminuria was less in the HES-treated patients (0.41 vs 0.91 mg mmol(-1), P<0.05). This difference in microvascular permeability was associated with different volumes of colloid required to maintain stable cardiovascular measurements in the two groups of patients studied (3000 vs 3500 ml, P<0.01, Mann-Whitney test). CONCLUSION: Compared with Gelofusine, the perioperative pulmonary function of patients treated with HES after abdominal aortic aneurysm surgery was better.

Splanchnic oxygenation in patients undergoing abdominal aortic aneurysm repair and volume expansion with eloHAES.

BACKGROUND: Gastric intramucosal pH (pHi), a surrogate marker of splanchnic oxygenation, falls following abdominal aortic aneurysm surgery. AIM: To investigate the effects of volume expansion with hydroxyethyl starch (eloHAES) on splanchnic perfusion compared to another colloid such as gelofusine. PATIENTS AND METHODS: Twenty-two consecutive patients undergoing AAA repair were randomised to receive either eloHAES or gelofusine as plasma expanders. Tissue oxygenation was monitored (10 gelofusine and 12 eloHAES) indirectly by measuring pHi using a nasogastric tonometer. RESULTS: Compared to the eloHAES group, the fall in pHi was significantly greater in the gelofusine group at clamp release (7.29 vs 7.33, P=0.003) and at 4 h following clamp release (7.29 vs 7.33, P=0.03). There was a good inverse correlation between the lowest pHi and the peak serum interleukin-6 (r(s)= -0.47, P=0.03). By multivariate analysis, the only factor that influenced the pHi was the type of colloid used (F=5.54, P=0.005). The eloHAES treated patients required significantly less colloid on the first postoperative day (3175 +/- 175 vs 4065 +/- 269 ml, P=0.01). CONCLUSION: In patients undergoing abdominal aortic aneurysm repair, plasma expansion with eloHAES improves microvascular perfusion and splanchnic oxygenation.

Gelatine-resorcine-formol glue as a sealant of ePTFE patch suture lines.

BACKGROUND: ePTFE patch reconstruction has superior flow characteristics in preventing early thrombus formation during carotid endarterectomy. However prolonged bleeding at the suture line of the patch reconstruction is a problem. The aim of this study was to investigate whether the application of gelatine-resorcine-formol (GRF) glue at the suture line can improve local haemostasis. METHODS: A prospective randomised trial of 40 consecutive patients undergoing carotid endarterectomy was undertaken. Patients were randomised to receive GRF glue as a topical haemostatic agent or to act as controls. Statistical analysis was performed using the Mann-Whitney test. RESULTS: Although the patch size was significantly smaller in the control group (3.0 cm2 vs 4.3 cm2, p<0.001), local haemostasis was achieved in half the time when the glue was used (11 min vs 22, p<0.004). In the follow-up period ranging from 12 to 24 months, there have been no adverse effects related to the glue. Two patients died during the follow-up period. These deaths were neither related to the patch nor to the glue. CONCLUSIONS: This study has shown that GRF glue is an effective sealant of ePTFE patch suture line. GRF glue does not compromise the patch's characteristics.

The non-ischaemic blue finger.

Finger discoloration may result from recognized conditions affecting upper limb vasculature. We describe 11 patients who presented with acute pain, swelling and blue/purple discoloration in a finger. This benign condition mimicked digital ischaemia. There were 9 women and 2 men. The episode usually started with an ache/pain in the finger followed 2-3 h later by a blue/purple discoloration primarily on the volar aspect but always sparing the tip. This completely resolved after 4-7 days with no residual deficit. There was no history of trauma. Four patients had had previous episodes--2 had been started on warfarin. There was no family history and only one gave a history of spontaneous bruising of her legs. Examination of all patients--pulse rate, blood pressure, cardiac and subclavian artery auscultation and digital artery Doppler insonation--was normal. All patients had normal full blood counts, CRP, vasculitis screen and clotting (except those on warfarin). Six similar cases, all women, were reported in 1982. There was no common aetiological factor other than sex. Although of no prognostic significance, the condition is likely to concern patients and doctors in primary care. The discoloration is, however, clearly of a different distribution to that in an ischaemic finger where the tip of the digit is involved.

Worsening lipid profile is associated with progression of carotid artery stenosis.

BACKGROUND: To determine if uncontrolled hypercholesterolaemia predisposes to progression of carotid artery stenosis. METHODS: Fasting blood samples were collected from 76 patients referred for carotid duplex ultrasound for investigation of transient ischaemic attacks or recent stroke. Patients were grouped depending on the severity of the stenosis found. Patients on lipid lowering agents were excluded. The data were analysed using one way analysis of variance and the c2 test as appropriate. RESULTS: There were more men in the 70-99% group (15 vs 6, c2 = 10.6, p < 0.001, Table I). The total cholesterol was raised in all three groups. Patients with carotid stenosis of 70-99% had significantly elevated triglycerides (2.4 mmol vs 1.47 mmol and 1.37 mmol, p < 0.003), low HDL (1.14 mmol vs 1.45 mmol and 1.18 mmol, p < 0.003) and a higher cholesterol/HDL ratio (5.56 vs 4.29 and 4.71, p < 0.014) compared with the other two groups. There was no difference in lipoprotein(a) in the three groups. CONCLUSIONS: Increased triglycerides and low HDL cholesterol seen in the 70-99% group suggest that a worsening lipid profile is associated with progression of carotid artery stenosis.

Recurrent prosthetic valve thrombosis: importance of prolonged Doppler echocardiography examination for diagnosis.

In a 9-month period a 52-year-old woman was admitted on 3 occasions with thrombotic obstruction of a Medtronic Hall aortic valve prosthesis. On the first occasion the diagnosis was clinically obvious; on the second occasion prosthetic valve malfunction was detected fortuitously on Doppler echocardiography; on the third occasion the diagnosis was made after prolonged Doppler echocardiographic examination. The patient was treated with thrombolysis, surgical thrombectomy, and aortic valve re-replacement on the 3 occasions, respectively.

A prospective echocardiographic study of the effects of balloon mitral commissurotomy on pre-existing mitral regurgitation in patients with mitral stenosis.

Mitral regurgitation which is more than mild in severity is usually regarded as a relative contraindication to balloon mitral commissurotomy (BMC) because it is commonly believed that it may be worsened by the procedure. The aim of this study was to investigate the effects of BMC on pre-existing mitral regurgitation. Transthoracic and biplane transoesophageal echocardiography (TTE, TEE) combined with colour flow mapping (CFM) were performed prospectively on 50 consecutive patients immediately before and within 24 h after Inoue BMC. Before BMC, mitral regurgitation (MR) was diagnosed by TEE and left ventriculography in 36 and 13 patients respectively. Angiographic MR was mild in all 13 cases. The precise origins of MR jets were carefully sought by scanning in multiple TTE and TEE views. The maximal area of colour flow MR jets detected by TEE was measured by planimetry. After BMC mean mitral valve area increased from 1.0 +/- 0.3 to 1.7 +/- 0.8 cm2, p < 0.0001, mean left atrial pressure and volume decreased from 23.7 +/- 5.6 mm Hg to 21.6 +/- 7.5 ml, p = 0.039, and from 105 +/- 56 to 90 +/- 46 ml, p = 0.002, respectively. MR jets as assessed by TEE CFM disappeared in 12 patients, in all of whom MR had been undetected by angiography. MR jets remained within 20% of their original sizes in 16 (44%) patients and more than doubled in only 3 patients. However, the latter had only mild angiographic MR after BMC. BMC created new MR jets, distinct from pre-existing ones, in 27 (75%) patients. Their aetiologies were commissural splitting in 24, leaflet tears in 2 and chordal rupture in 1 case. New MR jets were co-existent with old jets in 17 (47%) cases and in 10 (28%) cases old jets were replaced by new jets. The severity of angiographic MR was unchanged in 21 (58%) of the 36 patients; new jets, all originating from one or both commissures, were found in 13 (65%) patients on TEE. Angiographic MR increased by 1 grade in 11 (33%) patients; new jets were detected in 9 patients, 8 from the commissures and 1 due to chordal rupture; in only 1 of the 11 patients did the increase in MR appear to be due to a worsening of a pre-existing jet. Angiographic MR increased by 2 grades in 3 (8%) patients; new jets appeared in all 3, arising from the commissures in 2 and from a leaflet tear in 1 case. One patient with a leaflet tear sustained an increase of 3 grades in angiographic MR. The final degree of angiographic MR was nil in 13, mild in 15, moderate in 6 and severe in 2 patients. Leaflet tears were responsible for both cases of severe MR. BMC does not appear to affect pre-existing mitral regurgitation adversely in almost all patients. It may abolish trivial jets but in most cases it creates new jets alongside the old ones. Leaflet tears are responsible for severe mitral regurgitation after BMC and this is independent of pre-existing regurgitant jets.

Detection of a small left atrial myxoma: value and limitations of four imaging modalities.

Coronary angiography in a 52-year-old woman with angina-type chest pain showed tumor circulation with feeding arteries arising from the circumflex artery. Transthoracic echocardiography and magnetic resonance imaging both failed to show any intracardiac masses. A sessile mass measuring 1.5 cm in diameter attached to the atrial septum was readily detected by transesophageal echocardiography. Histologic analysis confirmed the tumor to be a myxoma. Coronary angiography may provide the first clue to the presence of a small myxoma. Transesophageal echocardiography is the imaging modality of choice for further evaluation.

Transseptal mitral balloon valvotomy in patients with atrial septal aneurysms.

Transthoracic and transoesophageal echocardiography (TTE, TEE) were performed in 130 consecutive patients referred for mitral balloon valvotomy. Atrial septal aneurysms were diagnosed by TTE and TEE in 2 and 3 patients, respectively. All 3 patients underwent mitral balloon valvotomy via the transseptal route. The foramen ovale was found to be patent in 2 of these patients, thus rendering puncture of the interatrial septum unnecessary. In the 3rd patient transseptal catheterisation was performed through the wall of the aneurysm itself. There were no significant complications in any of these patients. No left-to-right interatrial shunting could be demonstrated by oximetry in any of the 3 patients. Transoesophageal colour flow imaging showed trivial shunting in 2 patients and none in the 3rd. Transseptal mitral balloon valvotomy can be performed safely in patients with atrial septal aneurysms, especially in those with co-existent patent foramen ovale.

Myocardial infarction with extensive intracoronary thrombus induced by anabolic steroids.

Anabolic steroids have been associated with a variety of adverse reactions, including myocardial infarction. We report two cases of myocardial infarction in young men on anabolic steroids. In both men, extensive intracoronary thrombosis was demonstrated at coronary angiography; this failed to resolve despite anticoagulation.

Tracheal occlusion in the prone position in an intubated patient with Duchenne muscular dystrophy.

A 15-year-old boy with Duchenne muscular dystrophy developed complete airway obstruction under general anaesthesia when positioned prone for spinal surgery. Tracheobronchial compression against vertebral bodies facilitated by a shortened sternovertebral distance due to thoracic lordoscoliosis is suggested as the cause.