Impaired fibrinolysis determines the outcome of percutaneus transluminal coronary angioplasty (PTCA).

BACKGROUND: Coronary artery stenosis lesions dilated by percutaneus transluminal coronary angioplasty (PTCA) show a disappointingly frequent recurrence of stenosis. We have investigated the possible role of fibrinolysis and various platelet-release factors - specifically in the locality of the affected vessel - by following 19 patients for 6 months after PTCA. METHODS: PTCA was performed on 19 patients with a significant primary coronary stenosis, proven by quantitative CAAS analysis. Blood for measurement of local fibrinolysis and platelet activity was drawn from the aortic root and the coronary sinus, at three times: just before PTCA, 10 min after it, and 6 months later. RESULTS: The incidence of restenosis at the 6 months follow-up was 37%. PTCA almost doubled the platelet-derived growth factor level (PDGF) in coronary sinus blood in all patients. The seven restenosis patients had a substantially higher tissue plasminogen activator inhibitor antigen (PAI-1ag) level in the aortic root before PTCA than the 12 who remained stenosis-free (mean 62.4 +/- 31.6 ng mL -1 compared with 33.1 + 25.3; P < 0.04) and a lower tissue plasminogen activator activity (t-PAac) level (mean 0.32 +/- 0.19 IU mL-1 compared with 0.68 +/- 0.34; P < 0.03). This was corroborated by the levels of tissue plasminogen activator inhibitor activity (PAI-1ac). At reassessment after 6 months, the restenosis patients had developed, in coronary sinus blood, a large rise of PAI-1ac (7.7 +/- 4.8 IU mL-1 rising to 15.7 +/- 13.9, P < 0.04) and a large rise of of PAI-1ag (48.8 +/- 31.3 ng mL-1 vs. 72.4 +/- 47.2; P < 0.03). But no such increase occurred in the patients who remained stenosis-free. Conclusion Our results indicate that the minor balloon injury, which is inseparable from PCTA, stimulates the local release of PDGF. We suggest that, in those patients whose fibrinolytic activity is inherently low, this rise of PDGF could be a major causative factor in restenosis. We also discuss the possibility that the preoperative level of PAI-1ac could provide a limited but useful prediction of the outcome of PTCA.

Glucose tolerance status and severity of coronary artery disease in men referred to coronary arteriography.

Increasing attention is being paid to disturbances in glucose metabolism as key explanatory factors for the development of coronary artery disease. We studied the prevalence of impaired glucose tolerance and non-insulin-dependent diabetes and the levels of plasma insulin after an oral glucose tolerance test in 99 men with heart disease but without a history of diabetes referred to coronary arteriography; we also compared the outcome with a matched control group (n = 116). The severity of atherosclerosis in coronary angiograms was evaluated according to glucose tolerance status. Among the 99 patients with coronary artery disease, 37.4% had an abnormal oral glucose tolerance test result, whereas only 18.1% of the control group had an abnormal result (p < 0.01). Moreover, patients with heart disease and normal glucose tolerance were hyperinsulinemic compared with the control group (p < 0.01). By analysis of variance no statistically significant difference in severity of coronary atherosclerosis on coronary angiograms was found. In conclusion, we demonstrated frequent disturbances in glucose metabolism indicating insulin resistance in patients with ischemic heart disease without a history of diabetes, but we could not demonstrate a relation between these disturbances and degree of coronary atherosclerosis.

Triplex US in the diagnosis of asymptomatic deep venous thrombosis.

PURPOSE: To evaluate the accuracy of triplex ultrasound (TUS) compared with venography as a screening test for deep venous thrombosis (DVT), and to evaluate interobserver variation in the interpretation of the venographic studies. MATERIAL AND METHODS: A total of 133 postoperative hip fracture patients, asymptomatic of DVT, were prospectively examined with TUS and venography. All venograms were reviewed blindly and in case of disagreement a consensus was arrived at. RESULTS: The incidence of DVT was 20%, with isolated calf vein thrombi in 63% of the cases. There were 7 false-negative and one false-positive result/s at TUS, with a sensitivity of 74%, specificity of 99% and accuracy of 97%. The kappa values ranged from 0.58 to 0.82. The false-negative results were all caused by missed calf vein thrombi in technically inadequate examinations. At sonography 2% of vein segments were noninterpretable, compared to 29% at venography. CONCLUSION: Venous US is less sensitive as a test for DVT in this study of asymptomatic patients than in earlier studies on symptomatic patients. Still, sonographic screening of high-risk patients would be both effective and cost effective. Fresh thrombi may cause a false-negative compression test.

Fractures of the scapula.

This paper presents a review of all patients admitted to the orthopedic department of Frederiksberg University Hospital during a period of 10 years with a diagnosis of fracture of the scapula-a total of 18. All medical records and roentgenograms were reviewed retrospectively. We found, in agreement with the literature reviewed, an extremely high frequency-88% in our study-of high-energy trauma as a cause of scapular fractures. In 88% of the cases the scapular fracture was associated with other lesions; fractures of the ipsilateral humerus or ribs were seen with the highest incidences (44%). All patients were treated conservatively, resulting in satisfactory conditions of their scapula and shoulder girdles.

The role of carbon dioxide and atmospheric air in double-contrast barium enema.

BACKGROUND: Patient discomfort 0-24 h after double-contrast barium enema (DCBE) was investigated in two ways. METHODS: In part 1, 139 patients, not previously informed, were contacted by telephone to assess symptom rates without bias. In part 2, designed as a prospective randomized double-blind trial, the effect of carbon dioxide (CO2) as an insufflating gas was compared with conventional atmospheric air (AA). RESULTS: Part 1: 10% experienced severe abdominal pain, and 18% severe abdominal distention. Part 2: Low discomfort rates were found for both severe pain (7% for AA vs. 2% for CO2) and severe distention (13% for AA vs. 8% for CO2); the differences were not significant. In both parts of the study, female patients with a history of abdominal discomfort of "colon irritable" type were significantly overrepresented in the severely symptomatic groups. Equal numbers of patients experiencing severe abdominal distention for the first time were found in both the AA and CO2 groups, ruling out AA as the sole cause of these symptoms. CONCLUSION: Abdominal post-DCBE discomfort seems to be less frequent than previously reported and is not effectively eliminated by CO2. We still find the use of AA in DCBEs justified.

A study of obese cats on a calorie-controlled weight reduction programme.

Twenty-two domestic cats were fed a commercial low calorie diet for the management of obesity for up to 18 weeks and showed an average weight loss of 13.5 per cent of their body-weight. There was no indication that a steady weight loss over the study period had any adverse effect on the hepatic function or general health of the cats. There was an increase in the cats' total serum cholesterol concentration in association with the loss of weight.

Radiographic examination of the acute shoulder.

Since 1988 the routine shoulder examination at our department has consisted of the anteroposterior projection (AP), the transthoracic projection (TT) and the apical oblique projection (AO). To save discomfort to the patients - including unnecessary X-rays - as well as time and money, we wanted to see, whether one of the projections could be omitted from the primary examination without losing diagnostic information. Retrospectively, 125 acute shoulder examinations were reevaluated - each projection separately - and the findings from the three radiographs of each shoulder compared. In 47 patients the examinations were normal. The remaining 78 patients had a total of 112 lesions. The AO alone showed 17 of 112 lesions (15%) of which eight were isolated lesions. The AO together with the AP presented 111 of 112 lesions, and with a supplementary TT obtained in case of fracture, no lesions were overlooked. Based on this present material and the literature, we recommend that the routine radiographic examination of the acute shoulder includes the AO and the AP, to be supplemented with the TT - or another lateral projection - in case of humeral fracture.

Diagnosis of fracture of the carpal scaphoid with 4 oblique projections.

Two hundred and nine consecutive patients who suffered acute trauma had their carpal scaphoids examined by a radiographic method comprising 4 oblique projections with 1.4 x magnification. The method proved to be extremely sensitive in the primary diagnosis of scaphoid fracture, as none of 111 patients with normal primary examinations, but persistent soreness, proved to have fractures on control radiographs. A treatment less rigoristic than the traditional plaster cast is suggested when no fracture is shown on primary radiographs obtained by this method.

The apical oblique radiograph in examination of acute shoulder trauma.

One-hundred and twenty-five patients with acuta trauma to the shoulder were radiographed using anteroposterior and transthoracic views supplemented by an apical oblique projection with the patient seated in posterior oblique position, central beam directed 45 degrees caudad. The two standard views were evaluated prior to the apical oblique view. In 15.2% of the patients lesions were seen only in the apical oblique view, which also provided better examinations in 23.2% of all patients. Mainly dislocations of joints and fractures (in particular posterior glenohumeral dislocations), glenoid fractures, Hill-Sachs lesions and soft tissue calcifications were revealed in this view. Its routine use in acute trauma radiography is recommended.