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Side effects of cerebral angiography
354 A dose-gradient effect of the amount of smoking radiation is being investigated in a follow-up
Hamilton,
Diltiazem and prevention transplanted hearts.
of coronary
during study.
G Browman (1) McMaster University, ON L8N 325, Canada
artery
disease in
Cardiac transplant patients were randomly assigned to receive diltiazem 30-90 mg tid (n = 52) or no calcium channel blocker (n = 54) lo- I4 d after transplantation to assess the efficacy of diltiazem in preventing coronary artery disease post-transplantation which affects 50% of all patients by five years post-transplant. All patients were receiving cyclosporine, azathioprine, prednisone, and aspirin. Seventy-five patients completed I or 2 years of the study. Among patients who had three angiograms, average coronary artery diameter decreased in the group not receiving diltiazem (P < 0.001 at I and 2 y), but changed very little in the group receiving diltiazem (P < 0.001). New angiographic evidence of coronary artery disease developed in I4 patients not receiving diltiazem vs five who did receive the drug (P = 0.82); coronary stenoses of > 50% of the luminal diameter developed in seven and two patients, respectively. Death related to coronary artery disease or retransplantation occurred in five patients not receiving diltiazem; no such deaths were noted in the diltiazem group. These findings suggest that diltiazem can prevent the intimal proliferation which occurs in response to immune injury as well as the lipid deposition. This observation is consistent with the reports in non-transplant CAD that calcium channel blockers may prevent new atherosclerotic lesions, and therefore may have a protective effect when used in patients for angina or hypertension. JS Schroeder (2) Stanford University School of Medicine, Stanford, CA 94305, USA
Side effects of cerebral angiography. Cerebral arterial angiography is widely used to investigate cerebrovascular disease. A major problem with this technique is the incidence of neurological side-effects which include both focal symptoms such as stroke and more diffuse symptoms such as confusion. The pathogenesis of these side-effects is unclear; it has been suggested that air embolism may play a role. Doppler ultrasound can be used to detect circulating air emboli. Air results in high intensity signals due to reflection of ultrasound at the air/blood interface. Recently, with the advent of transcranial Doppler ultrasound (TCD) it has been possible to use this technique to monitor for air emboli in the cerebral circulation. (1) N End/ (2) N Engl
J Med J Med
(1993) (1993)
328. 328,
159 164
Using TCD, the middle cerebral arteries of seven patients were monitored during cerebral angiography. In all patients, signals consistent with air emboli were observed. These particularly occurred during injection of the non-ionic contrast medium. This phenomenon was studied further in a sheep model in which a major carotid branch was insonated transorbitally, while contrast was injected into the proximal carotid artery. During all contrast injections, air embolic signals were observed. Allowing the contrast to stand prior to injection, resulted in a marked reduction in air emboli; it is hypothesised that air is introduced when the viscous contrast medium is drawn up, and this diffuses out if the contrast is allowed to stand. These results indicate that air is introduced during routine cerebral angiography. This may account for at least some of the neurological side-effects observed. Simple measures, such as allowing contrast to stand prior to injection, may allow the quantity of air embolism to be reduced. HS Markus (3) St George’s Hospital Medical School, London SW I7 ORE, UK
Leukaemia
and eating disorders.
Eating disorders (anorexia nervosa and bulimia) are common diseases among young women in industrialized countries. These disorders often follow a chronic course. The authors observed three cases who developed leukaemia after a relatively long history of eating disorders. Case I (23 years-old) was diagnosed as having chronic myelocytic leukaemia after a history of considerable body weight fluctuation from the age of I6 and severe vomiting after the age of 20. She died of blastic crisis. Acute promyelocytic leukaemia (FAB classification M3 type) was diagnosed in case 2 (27 years-old) after a 5-year history of anorexia nervosa. Case 3 started dieting when she was I5 and lost 27 kg in two years. The habit of binging and vomiting then developed. At the age of 24, she was found to have acute myeloblastic leukaemia (FAB classification Ml type). Cases I and 2 are among 89 eating disorder patients who were referred to our clinic for research on eating disorders. Although the number of patients observed here is very small, the prevalence of leukaemia among eating disorder patients seems higher than that among the general population. We suggest that protracted malnutrition, hypokalemia etc may affect general systems such as the immune system and make the patients vulnerable to the genesis of leukaemia rather than triggering a specific factor which may lead to one type of leukaemia. A Nishizono-Maher (4) Keio University, Tokyo 160, Japan (3) Lancer (1993) 341, 784 (4) BMJ (1993) 306. 830
Hamilton,
Diltiazem and prevention transplanted hearts.
of coronary
during study.
G Browman (1) McMaster University, ON L8N 325, Canada
artery
disease in
Cardiac transplant patients were randomly assigned to receive diltiazem 30-90 mg tid (n = 52) or no calcium channel blocker (n = 54) lo- I4 d after transplantation to assess the efficacy of diltiazem in preventing coronary artery disease post-transplantation which affects 50% of all patients by five years post-transplant. All patients were receiving cyclosporine, azathioprine, prednisone, and aspirin. Seventy-five patients completed I or 2 years of the study. Among patients who had three angiograms, average coronary artery diameter decreased in the group not receiving diltiazem (P < 0.001 at I and 2 y), but changed very little in the group receiving diltiazem (P < 0.001). New angiographic evidence of coronary artery disease developed in I4 patients not receiving diltiazem vs five who did receive the drug (P = 0.82); coronary stenoses of > 50% of the luminal diameter developed in seven and two patients, respectively. Death related to coronary artery disease or retransplantation occurred in five patients not receiving diltiazem; no such deaths were noted in the diltiazem group. These findings suggest that diltiazem can prevent the intimal proliferation which occurs in response to immune injury as well as the lipid deposition. This observation is consistent with the reports in non-transplant CAD that calcium channel blockers may prevent new atherosclerotic lesions, and therefore may have a protective effect when used in patients for angina or hypertension. JS Schroeder (2) Stanford University School of Medicine, Stanford, CA 94305, USA
Side effects of cerebral angiography. Cerebral arterial angiography is widely used to investigate cerebrovascular disease. A major problem with this technique is the incidence of neurological side-effects which include both focal symptoms such as stroke and more diffuse symptoms such as confusion. The pathogenesis of these side-effects is unclear; it has been suggested that air embolism may play a role. Doppler ultrasound can be used to detect circulating air emboli. Air results in high intensity signals due to reflection of ultrasound at the air/blood interface. Recently, with the advent of transcranial Doppler ultrasound (TCD) it has been possible to use this technique to monitor for air emboli in the cerebral circulation. (1) N End/ (2) N Engl
J Med J Med
(1993) (1993)
328. 328,
159 164
Using TCD, the middle cerebral arteries of seven patients were monitored during cerebral angiography. In all patients, signals consistent with air emboli were observed. These particularly occurred during injection of the non-ionic contrast medium. This phenomenon was studied further in a sheep model in which a major carotid branch was insonated transorbitally, while contrast was injected into the proximal carotid artery. During all contrast injections, air embolic signals were observed. Allowing the contrast to stand prior to injection, resulted in a marked reduction in air emboli; it is hypothesised that air is introduced when the viscous contrast medium is drawn up, and this diffuses out if the contrast is allowed to stand. These results indicate that air is introduced during routine cerebral angiography. This may account for at least some of the neurological side-effects observed. Simple measures, such as allowing contrast to stand prior to injection, may allow the quantity of air embolism to be reduced. HS Markus (3) St George’s Hospital Medical School, London SW I7 ORE, UK
Leukaemia
and eating disorders.
Eating disorders (anorexia nervosa and bulimia) are common diseases among young women in industrialized countries. These disorders often follow a chronic course. The authors observed three cases who developed leukaemia after a relatively long history of eating disorders. Case I (23 years-old) was diagnosed as having chronic myelocytic leukaemia after a history of considerable body weight fluctuation from the age of I6 and severe vomiting after the age of 20. She died of blastic crisis. Acute promyelocytic leukaemia (FAB classification M3 type) was diagnosed in case 2 (27 years-old) after a 5-year history of anorexia nervosa. Case 3 started dieting when she was I5 and lost 27 kg in two years. The habit of binging and vomiting then developed. At the age of 24, she was found to have acute myeloblastic leukaemia (FAB classification Ml type). Cases I and 2 are among 89 eating disorder patients who were referred to our clinic for research on eating disorders. Although the number of patients observed here is very small, the prevalence of leukaemia among eating disorder patients seems higher than that among the general population. We suggest that protracted malnutrition, hypokalemia etc may affect general systems such as the immune system and make the patients vulnerable to the genesis of leukaemia rather than triggering a specific factor which may lead to one type of leukaemia. A Nishizono-Maher (4) Keio University, Tokyo 160, Japan (3) Lancer (1993) 341, 784 (4) BMJ (1993) 306. 830