Coronary artery calcium scoring: an evidence-based guide for primary care physicians.

Primary care physicians often must decide whether statin therapy would be appropriate (in addition to lifestyle modification) for managing asymptomatic individuals with borderline or intermediate risk for developing atherosclerotic cardiovascular disease (ASCVD), as assessed on the basis of traditional risk factors. In appropriate subjects, a simple, noninvasive measurement of coronary artery calcium can help clarify risk. Coronary atherosclerosis is a chronic inflammatory disease, with atherosclerotic plaque formation involving intimal inflammation and repeated cycles of erosion and fibrosis, healing and calcification. Atherosclerotic plaque formation represents the prognostic link between risk factors and future clinical events. The presence of coronary artery calcification is almost exclusively an indication of coronary artery disease, except in certain metabolic conditions. Coronary artery calcification can be detected and quantified in a matter of seconds by noncontrast electrocardiogram-gated low-dose X-ray computed tomography (coronary artery calcium scoring [CACS]). Since the publication of the seminal work by Dr. Arthur Agatston in 1990, a wealth of CACS-based prognostic data has been reported. In addition, recent guidelines from various professional societies conclude that CACS may be considered as a tool for reclassifying risk for atherosclerotic cardiovascular disease in patients otherwise assessed to have intermediate risk, so as to more accurately inform decisions about possible statin therapy in addition to lifestyle modification as primary preventive therapy. In this review, we provide an overview of CACS, from acquisition to interpretation, and summarize the scientific evidence for and the appropriate use of CACS as put forth in current clinical guidelines.

Interferon alpha2b inhibits the murine melanoma cell line Cloudman S91 in vivo but not in vitro: a model for studying tumor cell-cytokine interactions.

Interferon alpha2b has recently been shown to improve outcome in patients with metastatic malignant melanoma. The high-dose interferon therapy used is however associated with significant systemic adverse effects. These adverse effects are likely related to the multitude of actions of interferon which in addition to its antineoplastic effects also possesses antiviral and immunomodulating properties. Elucidation of the mechanism of the antiproliferative effects of interferon may allow for the development of agents that possess the antineoplastic properties while being devoid of the other effects that make interferon toxic. In the animal model developed for this study tumors in mice receiving interferon alpha2b grew at a slower rate and achieved a small final tumor volume (3040 +/- 690 vs 1400 +/- 314 mm3 for the control and treated groups respectively, P < 0.05). Furthermore the final tumor weight in the treated group was significantly smaller (1.50 +/- 0.21 g vs 2.76 +/- 0.46 g for the treated and control groups respectively; P = 0.036). The (3-[4,5-Dimethylthiazol-2-y]-2,5-diphenyltetrazolium bromide) (MTT) colorimetric assay failed to reveal any direct effects of interferon alpha2b on this murine melanoma cell line. This antiproliferative effect of interferon alpha2b was in addition found to be independent of alterations in the expression of the angiogenic cytokines vascular endothelial growth factor, basic fibroblast growth factor, and transforming growth factor beta.

Role of laparoscopic cholecystectomy in the management of gangrenous cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy is increasingly being employed as the initial surgical approach in patients with acute cholecystitis. Gangrenous cholecystitis will be unexpectedly encountered in a proportion of these patients. The applicability of laparoscopic techniques and its outcome in this group of patients remain poorly defined. This paper presents our experience with laparoscopic cholecystectomy in the treatment of patients with gangrenous cholecystitis. METHODS: From January 1994 to March 1999, 281 patients underwent laparoscopic cholecystectomy for acute cholecystitis. Operative and histopathologic data were obtained and the subgroup with gangrenous cholecystitis identified (53 of 281, 18.8%). Laparoscopic cholecystectomy was the initial surgical approach in 44 (83%) and was successfully completed in 30 of 44 (68%) patients. Conversion to an open cholecystectomy became necessary in 14 of 44 (32%). A retrospective review comparing these two groups of patients was performed. RESULTS: Of the 44 patients, there were 25 males and 19 females, with a mean age of 64.6 years. Mean duration of symptoms prior to presentation was 2.3 and 2.9 days in the laparoscopic and conversion groups, respectively. Clinical presentation included the presence of right upper quadrant pain (98%), leukocytosis (91%), fever (16.3%), and jaundice (9%). Liver function test abnormalities included elevations of alkaline phosphatase (25%), aspartate aminotransferase (20.4%), alanine aminotransferase (22.7%), and total bilirubin (18.1%). Ultrasonography revealed the presence of gallstones (88.6%), gallbladder wall thickening (52.3%), and pericholecystic fluid (20.5%). Air in the gallbladder wall and intraluminal membranes were present in 2 patients and 1 patient, respectively. Nuclear scans performed in 29 patients revealed cystic duct obstruction in all 29. The rim sign was present in 1 patient. A laparoscopic cholecystectomy was attempted in 44 of 53 patients and was successfully completed in 30 (68%). Conversion to an open procedure became necessary in 14 of 44 (32%). No difference in preoperative factors was noted among the two groups. The mean duration of surgery in patients undergoing a successful laparoscopic cholecystectomy was 107 minutes versus 110 minutes when conversion was necessary. There were no deaths in the study population. Morbidity occurred in 40% of the laparoscopic group and 71% of the conversion group. No patient in the laparoscopic group required admission to the intensive care unit. In contrast, 4 of 14 patients in the conversion group required a mean of 2.6 days in the intensive care unit. Postoperative hospital stay was 3.3 versus 5.5 days in the two groups, respectively. CONCLUSIONS: Preoperative factors did not predict conversion in patients undergoing laparoscopic cholecystectomy for presumed acute cholecystitis who are found to have gangrenous cholecystitis. Duration of surgery is not significantly prolonged and outcome in terms of morbidity, admission to the intensive care unit, and hospital stay are significantly better in patients in whom laparoscopic cholecystectomy is successful.

Ischemic colitis in young adults: a single-institution experience.

Ischemic colitis is not well characterized in the young adult population, despite its commonness in older patients. The aim of this study was to investigate the demographics, etiology, clinical features, and prognosis of ischemic colitis in young adults. We conducted a retrospective study of 39 young adults (<50 years of age) diagnosed with ischemic colitis over a period of 9 years (1990 to 1998). The mean age at diagnosis was 38 +/- 2 years (range 18 to 49 years); the female:male ratio was 1.8. Fifty-two percent (13 of 25) of women were using oral contraceptives at the time of diagnosis. Other potential associations identified were vascular thromboembolism (4 of 39), vasoactive drugs (4 of 39), hypovolemia (4 of 39), and vasculitis (2 of 39); 19 patients (49%) had no identifiable predisposing factors. Dominant presenting symptoms were abdominal pain (77%), bloody diarrhea (54%), and hematochezia (51%). Most patients were diagnosed at colonoscopy, and most disease was left sided. Twenty-nine patients were successfully managed with intravenous fluids, broad-spectrum antibiotics, and bowel rest; 10 patients required surgery. There was one disease-related death in the operative group. We found a strong female predominance and an association with oral contraceptive use, but almost half of the patients did not have an identifiable etiology. Mortality from ischemic colitis in this patient population is low.

Pre-operative ultrasonography guiding minimal, selective surgical approach in primary hyperparathyroidism.

BACKGROUND: The traditional surgical approach for the treatment of primary hyperparathyroidism (HPT) has been routine bilateral surgical exploration. Our aim was to evaluate pre-operative ultrasonography (U/S) in altering our practice to selective unilateral neck exploration. PATIENTS AND METHODS: A retrospective study was conducted involving 53 patients who had parathyroidectomy over a 5-year period (1989-1994), 41 of whom with the diagnosis of HPT had pre-operative neck U/S. RESULTS: Thirty-eight patients had a single adenoma, one had parathyroid cancer, and two had multiple adenomas. Thirty-six of 41 (88%) patients were true positives, two (5%) false positives, two (5%) false negatives and one (2%) was true negative. Based on the surgeon's personal preference and U/S results, 21/41 (51%) of patients had bilateral and 20/41 (49%) had unilateral neck exploration. All the 41 patients had resolution of the hypercalcemia postoperatively. Eighteen of 38 (47%) patients with a single adenoma had bilateral neck exploration and only in two patients was this necessary. CONCLUSIONS: Patients undergoing parathyroid surgery for HPT should have preoperative U/S and, if a single enlarged parathyroid gland is found, unilateral U/S guided neck exploration is safe and economical. In all the other patients, bilateral exploration is the preferred approach.