Henoch-Schönlein purpura in a chronic hemodialysis patient.

We describe a patient on maintenance hemodialysis who developed purpura, abdominal pain with bloody stool, and gross hematuria. A skin biopsy revealed leukocytoclastic vasculitis with IgA deposits. This is the first report of Henoch-Schönlein purpura in a hemodialysis patient.

Prognostic value of the admission electrocardiogram in acute coronary syndromes.

CONTEXT: The presence of ischemic changes on electrocardiogram (ECG) correlates with poorer outcomes in patients with acute chest pain. OBJECTIVE: To determine the prognostic value of various ECG presentations of acute myocardial ischemia. DESIGN: Retrospective analysis of the presenting ECGs of patients enrolled in Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb). SETTING: Three hundred seventy-three hospitals in 13 countries in North America, Europe, Australia, and New Zealand. PATIENTS: A total of 12142 patients who reported symptoms of cardiac ischemia at rest within 12 hours of admission and had signs of myocardial ischemia confirmed by ECG. On presenting ECG, 22% of patients had T-wave inversion, 28% had ST-segment elevation, 35% had ST-segment depression, and 15% had a combination of ST-segment elevation and depression. MAIN OUTCOME MEASURE: Ability of presenting ECG to predict death or myocardial reinfarction during the first 30 days of follow-up. RESULTS: The 30-day incidence of death or myocardial reinfarction was 5.5% in patients with T-wave inversion, 9.4% in those with ST-segment elevation, 10.5% in those with ST-segment depression, and 12.4% in those with ST-segment elevation and depression (P<.001). After adjusting for factors associated with an increased risk of 30-day death or reinfarction, compared with those who had T-wave inversion only, the odds of 30-day death or reinfarction were 1.68 (95% confidence interval [CI], 1.36-2.08) in those with ST-segment elevation, 1.62 (95% CI, 1.32-1.98) for those with ST-segment depression, and 2.27 (95% CI, 1.80-2.86) for those with combined elevation and depression. An elevated creatine kinase level at admission correlated with a higher risk of death (odds ratio [OR], 2.36; 95% CI, 1.92-2.91) and death or reinfarction (OR, 1.56; 95% CI, 1.32-1.85). The ECG category and creatine kinase level at admission remained highly predictive of death and myocardial infarction after multivariate adjustment for the significant baseline predictors of events. CONCLUSIONS: The ECG at presentation allows immediate risk stratification across the spectrum of acute coronary syndromes. An elevated creatine kinase level at admission is associated with worse outcomes.

Measurement of hydrostatic pressures during simulated post cementation.

Tooth sensitivity and fracture after cementation of posts for endodontically treated teeth have been a problem. This investigation developed an in vitro method of measuring intraradicular hydrostatic pressures created during simulated post cementation. The testing apparatus consisted of a pressure transducer and brush recorder connected to precision milled post spaces in a Plexiglas block. Cast post and cores were fabricated and cemented with three different luting agents: resinous cement, glass ionomer cement, and zinc phosphate cement. Mean hydrostatic pressures (psi) recorded during post cementation were zinc phosphate cement, 22.67; resinous cement, 19.77; and glass ionomer cement, 17.66. Zinc phosphate cement created substantially greater hydrostatic pressures than either the resinous or glass ionomer cements. This in vitro system was capable of discriminating intraradicular hydrostatic pressures among different classes of luting agents.

Primary leiomyosarcoma of the pulmonary artery: diagnostic and surgical implications.

Primary pulmonary trunk sarcoma is a rare and highly lethal disease. A case of multicentric pulmonary trunk leiomyosarcoma with right and left main pulmonary artery involvement, mimicking massive pulmonary embolism, is described. The importance of a timely diagnosis and of radical surgical excision is discussed.

[Angina due to anatomical anomalies and to functional changes in the epicardial coronary vessels]. / Angina da anomalie anatomiche e da alterazioni funzionali dei vasi coronarici di conduttanza.

Myocardial ischemia with normal coronary arteries can be due to anatomic or functional reasons. The more severe congenital coronary anomalies in the adulthood are the origin of the left main of the left coronary artery from the right aortic sinus, with a course between the aorta and the pulmonary trunk, and the origin of the left main from the pulmonary trunk. Both these anomalies can cause sudden death, usually associated with physical exertion. The coronary vasomotion of epicardial vessels depends on the interaction of several neurohumoral substances. We report the hemodynamic, angiographic and stress test data of 30 patients affected by chest pain, with myocardial ischemia and normal coronary arteries. In 8 patients the response of epicardial coronary arteries to intracoronary infusion of acetylcholine was evaluated.

[Myocardial infarct and angiographically normal coronary arteries]. / L'infarto miocardico a coronarie angiograficamente normali.

Myocardial infarction and normal coronary arteries is not a rare event in the ischemic heart disease. Even if the patients with acute myocardial infarction and angiographically normal coronary arteries represent a small percentage (reported incidence varies from 1% to 12%) of all patients with acute ischemic attacks, they might be useful to highlight the pathogenetic mechanisms of this syndrome. To improve the understanding of this clinical entity, we reviewed our experience of 18 patients with myocardial infarction and normal coronary arteries. They were compared with a control group of patients with similar clinical characteristics (gender, age, infarct location) and residual coronary artery stenosis. The myocardial damage was less extensive in patients without residual stenosis (peak CK-MB: 56.1 +/- 71.9 vs 126.5 +/- 87.9 IU/I, p < 0.05), with a better left ventricular function either global (ejection fraction: 64 +/- 11 vs 55 +/- 13%, p < 0.05) and regional (SD/chord: -1.36 +/- 1.20 vs -2.42 +/- 1.04, p < 0.02). These findings probably reflect a more prompt and complete reperfusion of the infarct related artery. Myocardial necrosis may occur without obstructive coronary artery disease by the interaction of multiple factors such as abnormal platelet aggregation, thrombus formation and localized or diffuse changes of coronary vascular tone.

Open-ended guidewire: new technique for balloon angioplasty of chronically occluded coronary arteries.

Chronic total coronary occlusion is a growing indication to percutaneous transluminal coronary angioplasty. Since primary success of balloon angioplasty in this condition is usually limited by the difficulty of crossing the occlusion, different techniques have been described for this purpose, such as use of stiff guidewires, coronary infusion catheters, guidewires with an olive-shaped tip, or new developing methods (atherectomy, laser), in association with balloon dilatation. Here, we describe our initial experience with a thick (0.035 in) and relatively stiff open-ended guidewire, which has an inner (0.018 in diameter) lumen provided with a core wire. Several advantages are considered. The core wire yields a perfect means of steerability of the whole system, while pushability of a thicker guidewire is much greater. Moreover, the core wire can be removed, and contrast injections beyond the occlusion through the inner lumen can assure proper intraluminal location. Finally, position across the occlusion can be kept easily, since an exchange wire for conventional balloon catheters can be inserted in the inner lumen of the open-ended guidewire.

Single coronary artery from the left sinus of Valsalva.

A patient with chronic exertional angina and electrocardiographic signs of myocardial ischemia at exercise stress test had recent onset of rest chest pain and underwent coronary arteriography. Besides severe atherosclerotic coronary disease (which was probably responsible for clinical presentation), a single coronary artery arising from the left sinus of Valsalva was discovered. This is an exceptional finding, and its in-life diagnosis may be relevant for surgical treatment.

[Correlation between coronary angiographic and ergometric studies after coronary angioplasty]. / Correlazioni coronarografiche ed ergometriche dopo angioplastica coronarica.

In 35 patients with effort angina exercise tests before and after coronary angioplasty (PTCA) were compared, aimed at evaluating functional improvement and at correlating some ergometric parameters with angiographic results. All tests were performed during therapy with verapamil 360 mg/die. After PTCA mean diameter of the stenosis was reduced from 68 +/- 11% to 19 +/- 12%. Duration of exercise and rate-pressure product (RPP) were significantly greater in the test after PTCA. While all tests before PTCA were positive, after PTCA ST segment depression occurred in 9 patients (26%). In 7 of these patients it was less than 1 mm. In 26 patients (74%) tests were negative after PTCA. In patients with ST segment depression, ischemia threshold significantly rose from 5.2 +/- 1.5 min (RPP 15,875 +/- 3,253 to 7.6 +/- 1.2 min (RPP 20,157 +/- 3143). Maximal ST segment depression and ST/HR slope were significantly reduced. In negative stress tests the time free from ischemia significantly rose from 6.5 +/- 2.6 min (RPP 18,872 +/- 3,861) to 10.5 +/- 2.3 min (RPP 28,476 +/- 4,289). In patients with positive tests stenosis after PTCA was more severe than in patients without ST segment depression (29 +/- 13% vs 17 +/- 13%). In patients with ST segment depression improvement of ischemia threshold and of stenosis were correlated. In these patients improvement of ischemia threshold is the ergometric parameter more useful to evaluate the angiographic result of PTCA.

Coronary arterial aneurysms after percutaneous transluminal coronary angioplasty--a not uncommon finding at elective follow-up angiography.

Five coronary arterial aneurysms were found in 4 of 80 (5%) patients who underwent elective coronary arteriography 6 months after successful percutaneous transluminal coronary angioplasty. None of them was present immediately after dilatation. All patients had been suffering from stable angina before angioplasty, while no case had recurrent angina or definite angiographic restenosis at the 6-month follow-up. Quantitative coronary angiography was performed in all angiograms. The coronary aneurysms only developed in the dilated portions (4 in left anterior descending and 1 in an intermediate branch of the left coronary artery): their diameter ranged from 3.1 to 4.4 mm, and their length from 2.2 to 4.9 mm. The ratio between the aneurysm diameter and the coronary arterial diameter (aneurysm: artery ratio) varied from 1.15 to 1.91 (mean 1.47). No significant clinical or technical differences were found between patients who developed aneurysm after angioplasty, and patients who did not. On the other hand, 4 of the 5 patients who developed aneurysm had angiographic evidence of "non-pathologic" dissection immediately after balloon dilatation. Moreover, the ratio between the measured angiographic diameters of the balloon (at maximal inflating pressure) and of the coronary artery selected for the procedure showed that the balloon was mildly oversized (balloon: artery ratio ranging from 1.10 to 1.37, mean 1.28) in all cases with aneurysm except the only 1 in whom dissection did not occur. In conclusion, aneurysm formation after coronary angioplasty is not infrequent in our experience: balloon size and wall dissection seem to be the major factors related to this event.

[Our experience with fundoplication according to Nissen in the treatment of hiatal hernia]. / Nostra esperienza con la fundusplicatio secondo Nissen nel trattamento dell'ernia iatale.

The authors illustrate their experience with the fundoplication according to Nissen in the treatment of hiatal hernia and gastroesophageal reflux, and appraise its effectiveness in the light of the most modern diagnostical methods, among which chiefly the monitored pH-metry of distal oesophagus.