Citations

Background— Sirolimus-eluting stents (SESs) reduce angiographic restenosis in patients with focal, native coronary artery stenoses. This study evaluated the usefulness of SESs in complex native-vessel lesions at high risk for restenosis. Methods and Results— Angiographic follow-up at 240 days was obtained in 701 patients with long (15- to 25-mm) lesions in small-diameter (2.5- to 3.5-mm) native vessels who were randomly assigned to treatment with SESs or bare-metal stents (BMSs) in the SIRIUS trial. Quantitative angiographic measurements of minimal lumen diameter and percent diameter stenosis were obtained within the treated segment, within the stent, and within its 5-mm proximal and distal edges. Patients treated with SESs had lower rates of binary (>50% diameter stenosis) angiographic restenosis within the segment (8.9% versus 36.3% with the BMS; P <0.001) and within the stent (3.2% versus 35.4% with the BMS; P <0.001). SESs were associated with significantly less late lumen loss within the treated segment, within the stent, and within its 5-mm proximal and distal edges (all P <0.001). The reduction of restenosis with the SES was consistent in patients at risk for restenosis, including those with small vessels, long lesions, and diabetes mellitus. The frequency of late aneurysms was similar in the 2 groups. Conclusions— Compared with BMSs, SESs reduced angiographic late lumen loss within the stent and its adjacent 5-mm margins in patients with complex native-vessel lesions.

Background The diagnosis of a painful partial tear of the medial collateral ligament in overhead-throwing athletes is challenging, even for experienced elbow surgeons and despite the use of sophisticated imaging techniques. Hypothesis The “moving valgus stress test” is an accurate physical examination technique for diagnosis of medial collateral ligament attenuation in the elbow. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Twenty-one patients underwent surgical intervention for medial elbow pain due to medial collateral ligament insufficiency or other abnormality of chronic valgus overload, and they were assessed preoperatively with an examination called the moving valgus stress test. To perform the moving valgus stress test, the examiner applies and maintains a constant moderate valgus torque to the fully flexed elbow and then quickly extends the elbow. The test is positive if the medial elbow pain is reproduced at the medial collateral ligament and is at maximum between 120 ° and 70 °. Results The moving valgus stress test was highly sensitive (100%, 17 of 17 patients) and specific (75%, 3 of 4 patients) when compared to assessment of the medial collateral ligament by surgical exploration or arthroscopic valgus stress testing. The mean shear range (ie, the arc within which pain was produced with the moving valgus stress test) was 120 ° to 70 °. The mean angle at which pain was at a maximum was 90 ° of elbow flexion. Conclusions The moving valgus stress test is an accurate physical examination technique that, when performed and interpreted correctly, is highly sensitive for medial elbow pain arising from the medial collateral ligament.

Objective— Vascular endothelial growth factor (VEGF) is one of the most important pro-angiogenic cytokines. Ability of VEGF to stimulate formation of superoxide anion in vivo has not been studied. We hypothesized that in vivo expression of recombinant VEGF in the rabbit carotid artery increases production of superoxide anion. Methods and Results— Plaque-forming units (10 9 ) of adenovirus-encoding human VEGF 165 (AdVEGF) or β-galactosidase (AdLacZ) were delivered into the lumen of rabbit carotid arteries. Three days after gene delivery, expression of recombinant proteins was detected in endothelium and smooth muscle cells. Endothelium-dependent relaxations to acetylcholine were impaired in AdVEGF-transduced arteries ( P <0.01; n=5). Treatment with superoxide dismutase mimetic, Mn(III) tetra(4-benzoic acid) porphyrin chloride (10 −5 mol/L), improved relaxations to acetylcholine ( P <0.01; n=5). Western blot analysis demonstrated increased expression of p47 phox in AdVEGF-transduced arteries ( P <0.05; n=8). Lucigenin chemiluminescence showed significantly higher production of superoxide anion in AdVEGF-transduced arteries ( P <0.05; n=5 to 10). Conclusions— Our results suggest that in vivo expression of recombinant VEGF in the vascular endothelium increases local production of superoxide anion. Superoxide anion appears to be an important mediator of vascular effects of VEGF in vivo.

Abstract Background Heart failure with preserved left ventricular ejection fraction (LVEF) suggests isolated diastolic dysfunction. Aim The purpose of this study was to determine if systolic and diastolic dysfunction occurred with preserved LVEF. Methods Equilibrium resting radionuclide ventriculograms from 439 patients with an LVEF ≥0.50 were used to determine LV peak filling rate (PFR) and peak ejection rate (PER) in end-diastolic volumes per second and LV end-systolic volume (ml). Patients with low-normal (n=147; range, 0.50−0.58; mean±S.D., 0.53±0.02), intermediate-normal (161, 0.59−0.64, 0.61±0.02), and high-normal (131, 0.65−0.94, 0.72±0.06) LVEF were compared. Results From low-normal to intermediate-normal to high-normal LVEF, LV end-systolic volume decreased (93±36, 71±33, 43±26, respectively, P&lt;0.0001), PFR increased (2.31±0.74, 2.58±0.74, 3.15±0.94, P&lt;0.0001), PER increased (−2.78±0.50, −3.13±0.47, −3.83±0.84, P&lt;0.0001), the percentages of patients with abnormal PFR decreased (66, 56, 40, P&lt;.0001), and the percentage with abnormal PER decreased (47, 14, 5, P&lt;0.0001). Of 193 patients with preserved LVEF and abnormally low PFR, 65 (34%) had abnormally low PER. Conclusions The results indicate that a preserved LVEF was often associated with LV systolic dysfunction (enlarged LV end-systolic volume and low PER) and LV diastolic dysfunction (decreased PFR).

Estrogens play a crucial role in the causation and development of sporadic human breast cancer (BC). Chromosomal instability (CIN) is a defining trait of early human ductal carcinoma in situ (DCIS) and is believed to precipitate breast oncogenesis. We reported earlier that 100% of female ACI (August/Copenhagen/Irish) rats treated with essentially physiological serum levels of 17β-estradiol lead to mammary gland tumors with histopathologic, cellular, molecular, and ploidy changes remarkably similar to those seen in human DCIS and invasive sporadic ductal BC. Aurora-A (Aur-A), a centrosome kinase, and centrosome amplification have been implicated in the origin of aneuploidy via CIN. After 4 mo of estradiol treatment, levels of Aur-A and centrosomal proteins, γ-tubulin and centrin, rose significantly in female ACI rat mammary glands and remained elevated in mammary tumors at 5–6 mo of estrogen treatment. Centrosome amplification was initially detected at 3 mo of treatment in focal dysplasias, before DCIS. At 5–6 mo, 90% of the mammary tumor centrosomes were amplified. Comparative genomic hybridization revealed nonrandom amplified chromosome regions in seven chromosomes with a frequency of 55–82% in 11 primary tumors each from individual rats. Thus, we report that estrogen is causally linked via estrogen receptor α to Aur-A overexpression, centrosome amplification, CIN, and aneuploidy leading to BC in susceptible mammary gland cells.

The objectives of this study were to determine the effectiveness of a novel, trypsinized density gradient treatment designed to remove viruses from semen and to evaluate sperm viability after treatment. Exp. 1: Cryopreserved human semen (n = 6 donors) was layered on 2-mL columns of 45% Isolate (Irvine Scientific, Santa Ana, CA, USA) with or without 0.25% trypsin (trypsin-exposed and control, respectively), which overlaid 2-mL columns of 90% Isolate with or without 10 µg/mL soy-based trypsin inactivator (Sigma, St. Louis, MO, USA) and centrifuged (700g for 30 min). The layering of multiple density gradients is facilitated by a novel polypropylene tube insert, which also prevents contamination when extracting treated sperm (USA and international patents pending). Pellets were washed and then incubated at room temperature. Sperm were examined (motility and supravital staining) at 0, 2, 24, and 48 h post-treatment and the results evaluated using Wilcoxon Signed Rank and Rank Sum tests. Exp. 2: A cytopathic cell (MT-2) assay was conducted (6 replicates) to determine the effect of trypsin (1-min exposure) on HIV-1 RNA infectivity. Viral replication was assessed by syncytium formation and p24 antigen production. Exp. 3: Two pools of fresh human semen (N1 = 3 and N2 = 8 donors) were inoculated (1:1) with 1 × 108 copies/mL of cultured HIV-1 RNA, and one pool (N2) was inoculated (1:1) with plasma collected from patients infected with either Hepatitis B DNA (HBV) or C (HCV) RNA viruses; spiked and non-spiked aliquots were processed as in Exp. 1. Treated sperm pellets were analyzed for HIV-1 or HBV and HCV concentrations by the Bayer Versant branched DNA (bDNA; version 3.0) and/or the Roche Amplicor quantitative RT-PCR (1.5 ultrasensitive) assays at Toga Laboratories (Pty), Ltd. (Edenvale, South Africa). As a result of Exp. 1, there was significantly (P &lt; 0.05) lower motility (but not supravital staining) between trypsin-treated and control sperm at 0 h (58.0 vs. 69.3%) and 2 h (54.7 vs. 62.9%) post-washing; however, no differences were noted after 24 h (P &gt; 0.05). In Exp. 2, trypsin exposure affected HIV-1 RNA infectivity negatively as compared to controls in terms of MT-2 cell syncytium formation and p24 antigen production. Results of the bDNA and/or RT-PCR assays in Exp. 3 indicated that the procedure effectively reduced HIV-1, HBV, and HCV viral copies in the spiked semen samples to undetectable levels or levels below clinical relevance. In conclusion, the novel trypsin density gradient procedure was effective for removing HIV-1, HBV and HCV from spiked semen without markedly affecting sperm survival. Extrapolation of these results to natural infections may be unfounded for viruses (e.g. HBV) that are thought to integrate into sperm chromatin.

AbstractTherapeutic endoscopy (TE) has provided a new means for treating peptic ulcer disease, prompting a reevaluation of surgery's role. The aim of this study was to determine if surgical therapy of bleeding duodenal ulcers has changed since the advent of TE. This retrospective review involved consecutive time periods during which TE was (1985–1990) and was not (1980–1984) widely available. Exclusion criteria were prior gastric surgery, nonpeptic conditions, and untreated ulcers. Inclusion standards were met by 252 patients (180 men, 72 women) whose mean age was 67 years. Patients were grouped by the initial therapeutic intervention. Groups were similar in age, medical condition (mean APACHE II score 16), and morbidity. Seventy‐five patients had surgery alone during 1980–1984 and 38 during 1985–1990. TE was initially performed on 134 patients during 1985–1990. Bleeding (n=30) and perforation (n=1) prompted emergent operation in 23% of cases following TE. Thus 69 (38+31) patients underwent surgery between 1985 and 1990. Preprocedure transfusions averaged 4.1 units in the endoscopic group and 8.2 units in the operative groups (p<0.0001). Disagreement existed between the endoscopic and surgical descriptions of ulcer location in 53% of cases. Emergent surgery was required in 45% of hemodynamically unstable patients versus 14% of stable patients who initially underwent TE (p<0.0001). Sixty‐one percent of incompletely visualized TE‐treated lesions required operation, and 18% of well visualized ulcers underwent operation (p<0.0001). Hospital mortality was similar (8% versus 16%) in the endoscopic and operated groups (p=0.7). Mean follow‐up was 540 days. The number of operations performed for bleeding duodenal ulcer did not change significantly during the TE era, and a significant subset (23%) of endoscopically treated patients required surgical therapy. TE failure was portended by hemodynamic instability or incomplete endoscopic visualization.

AbstractFocal nodular hyperplasia (FNH) and hepatocellular adenoma (HA) are uncommon benign hepatic tumors that continue to pose diagnostic and therapeutic challenges. An update of a recent Mayo Clinic experience is presented to highlight the management of patients harboring these neoplasms. A marked female predominance was seen. Incidental diagnosis was more prevalent with FNH, whereas symptomatic presentation was typical of HA. The frequency of oral contraceptive steroid use was similar regardless of tumor histology. Preoperative diagnosis remains difficult. Scintigraphy proved most specific, and ultrasonography and computed tomography were equally sensitive. Resection was employed in most patients. There was no mortality and minimal morbidity. Selective observation of FNH was uneventful, but resolution of HA after abstinence of oral contraceptive steroids was uncommon. These findings and data from the literature support selective management of benign liver tumors.