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The role of the endothelium in vascular tone is well established. New physiopathological concepts were brought about by the discovery of endothelium derived vasoactive substances such as the vasodilators prostacyclin and endothelium-derived relaxing factor (EDRF) or the vasocontrictors endothelin and other putative endothelium-derived contracting factors (EDCF). Their discovery led to new therapeutic concepts in vascular, respiratory and infectious diseases. Prostacyclin is a prostaglandin derived from arachidonic acid which has an inhibitor effect on platelet aggregation. It also has a vasodilator effect on vascular smooth muscles cells. Prostacyclin analogues are choice vasculoactive pharmacological agents for patients with thromboangiitis obliterans or severe peripheral vascular disease, whether arteriosclerotic or not. The effect of EDRF is vascular dilatation, predominately in the arteries but also in the veins, including vessels in grafted tissues. EDRF also inhibits platelet aggregation and adhesion. Inversely, the endothelium can also release EDCF which has a vasoconstrictor effect. Endothelin, a recently identified 2429 kD EDCF is active in both arteries and veins and is implicated in physiologic regulation of vasomotricity.

The existence of vasoconstrictive factors originating from the endothelium was confirmed by the description of endothelin, a 21-amino-acid peptide derived from a series of precursors, preproendothelin and a 38-amino-acid big endothelin. Three isoforms of endothelin, endothelin-1, -2 and -3, and 3 receptors (ETA, ETB and ETC) have been described and cloned. The cellular mode of action of endothelin seems to involve the modulation of intracellular calcium (through inositol trisphosphate, diacylglycerol and phospholipase C) and activation of calcium channels. The effects of endothelin are predominantly on the cardiovascular system. Its major effect is vasoconstriction, both systemic and pulmonary, with additional positive chronotropic and inotropic effects on the heart. It has also been implicated in homeostatic regulation of kidney microcirculation, and has powerful mitogenic effects on fibroblasts and smooth muscle cells. Many additional effects have been described on the endocrine system and on other systems. However, the clinical relevance of such effects is uncertain. Increased plasma endothelin levels have been reported in many diseases, but as yet it is not certain whether they are a cause or a consequence of the pathology. Pathologies most probably related to endothelin dysfunction are the vasospastic diseases, especially vasospasm after subarachnoid haemorrhage. Endothelin could be implicated to a lesser measure in diseases typical of the elderly population, such as hypertension or atherosclerosis. Drugs are being developed which act on endothelin metabolism, the most promising of which appear to be the inhibitors of endothelin converting enzyme and endothelin receptor antagonists. Some already existing drugs, such as calcium channel blockers or angiotensin converting enzyme inhibitors, probably act at least in part by interfering with endothelin metabolism or effects.

For curative treatment of deep vein thrombosis, all trials have shown that twice a day low molecular weight heparin were at least as efficacious as unfractionated heparin on clot reduction or stabilisation. Through the unit cost of low molecular weight heparin is higher, the real cost of treatment should take into account not only the cost of the drug, but also the cost of materials used and lab tests as well as the time necessary. We have therefore prospectively compared the operating and overall costs of nadroparin and intravenous heparin treatment of deep vein thrombosis in hospitalised patients (21 with unfractionated heparin and 19 with nadroparin). The results show that low molecular weight heparin is no more expensive than treatment with unfractionated heparin (336 +/- 74.9 F for unfractionated heparin and 344.9 +/- 44.05 F for nadroparin). In addition, using nadroparin rather than heparin saves approximately one hour per patient per week nursing time (42 +/- 7 minutes vs 104.0 +/- 10.7 minutes, p < 0.05). The methodology of this study should be repeated with other low molecular weight heparin and low molecular weight heparin compare not only to standard i.v. heparin, but also to standard SC heparin.

Objective: Laparoscopic cholecystectomy is becoming a popular alternative to open cholecystectomy. However, the technical aspects of this new procedure increase the risk of injuring the bile ducts. The purpose of this study was to determine the feasibility and value of performing cholangiography during laparoscopic cholecystectomy., Materials and Methods: We retrospectively reviewed the clinical and operative cholangiographic findings of the first 107 patients undergoing laparoscopic cholecystectomy at Hôtel-Dieu de Montréal between August 1990 and August 1991., Results: Operative cholangiography was attempted in 98% of patients; the success rate was 71%. Eight anatomic anomalies of the biliary tract that were of surgical importance were found as well as 10 cases of stones in the common bile duct, eight of which were unsuspected. No biliary tract injuries occurred. With experience, surgical cannulation of the cystic duct for injection of contrast material can be done quickly without major difficulty, and cholangiograms of excellent diagnostic quality can be obtained., Conclusion: Our results show that operative cholangiography is feasible and useful in patients undergoing laparoscopic cholecystectomy.

The case of 87-old year woman with necrolytic migratory erythematosus rash without elevated plasma enteroglucagon is discribed. Decreased serum zinc level, response to oral zinc substitution and follow up proved the zinc deficiency.

In order to assess the prevalence of cardiac involvement in the primary antiphospholipid syndrome (PAS), a syndrome which associates thromboembolism, recurrent abortion, the presence of antiphospholipid antibodies and thrombocytopenia, transthoracic (TTE) and trans-esophageal echocardiography (TEE) was performed in 15 patients, 10 women and 5 men with a mean age of 38.8 +/- 11 years, with the PAS but without systemic lupus erythematosus. The presentation of the PAS was a thrombotic event (6 arterial and 7 venous) in 13 cases, and recurrent abortion in 3 cases. Twelve patients had high anticardiolipin antibody levels (> or = 15 U GPL) and 12 had a raised anti-prothrombinase antibody title. Valvular heart disease was detected in 9 patients (60%) as a valve thickening (> or = 5 mm for the mitral and > or = 3 mm for the aortic valve) or nodule. Mitral regurgitation was observed in 4 cases both on TTE and TEE and was mild in 3 cases and severe in 1 case. Aortic regurgitation was diagnosed in 6 patients, in 3 cases by TTE and in 6 cases by TEE. It was mild in 5 cases and moderate in the other cases. Pericardial effusion was observed in 3 patients (20%), alone in 1 case and associated with valvular disease in the other two cases. No abnormality of left ventricular systolic or diastolic function could be demonstrated. In conclusion, cardiac involvement seems to be common in the PAS, and TEE is a sensitive and accurate method for describing the valvular, especially aortic valve, abnormalities.

Diffuse arterial involvement in temporal arteritis is well known but the intimate mechanisms of vasculopathy is unknown. Recently the presence of anticardiolipin antibodies (aCL) has been recognized in giant cell arteritis. We report two cases of temporal arteritis with diffuse arterial involvement associated with aCL (axillary arteries in the two cases associated with femoral arteries in one). During corticosteroid and anticoagulant therapy, a rapid improvement was noted with regression of upper-limb ischemia. One month later, the aCL were absent. These cases confirm the presence of aCL in giant cell arteritis with diffuse arterial involvement. These antibodies might imply severe vascular damage and could play a role in pathogenesis of the vasculopathy of temporal arteritis. Their presence suggests the necessity of anticoagulant therapy at the beginning of corticosteroid therapy.

Endothelin (ET) is a novel vasoactive peptide occurring in 3 isoforms (ET1, ET2, ET3) in humans. Derived from vascular endothelium cells, ET arises from a precursor peptide and exerts diverse actions through specific receptors. ET possess a wide spectrum of activities: a potent vasoconstrictor activity but also contraction of nonvascular smooth muscles (air-way, intestinal, urinary) or mitogenic actions, renal and endocrine effects. The physiological and/or physiopathological roles of endothelin is still unclear, but ET may play a part in the genesis of some vascular diseases as atherosclerosis, forms of hypertension or may be implicated in the pathogenesis of vasospasm.

Serum cholesterol was measured in all patients admitted to the Department of Internal Medicine over one year. 6.2 percent had hypocholesterolaemia defined as total serum cholesterol level below 4 mmol/l. Comparison with non-hypocholesterolaemic patients showed male predominance and indirect arguments for increased morbidity: longer duration of hospital stay, greater number of rehospitalizations, greater number of associated diseases. In over a quarter of the cases, hypocholesterolaemia was associated with malignant disease. These results should entice physicians to caution when finding a low serum cholesterol level: this could be a marker of associated disease, especially malignant.

We report the case of a 25 year old man with pituitary carcinoma with Cushing's syndrome. Though the diagnosis was initially proposed, it was only confirmed by the appearance of meningeal and lymphatic metastases. These were secretory, as confirmed by immunocytochemistry and electron microscopy. These tumours are rare, whether they secrete or not, and can be confirmed only by the existence of metastases, most often in the brain or the liver.

A case of an ileal mucosal diaphragm with enteroliths causing obstruction in a 67-year-old man is reported. The distal site of the mucosal diaphragm, its relative patency, and the late formation of enteroliths, are thought to be the reasons for the delayed clinical manifestations of intestinal obstruction leading to the diagnosis of the abnormality.

Notable advances have been made in the investigation of pancreatic disorders. However, many of the diagnostic tests required are still of an invasive nature and are attended by difficulty and risk. The authors have found that the noninvasive method of axial tomography is highly reliable for the evaluation of pancreatic lesions, especially in cases in which a pancreatic mass is present or the duct of Wirsung is dilated. This procedure can also be helpful in the follow-up of patients who have suffered from acute or chronic pancreatitis. The same diagnostic problem is present at operation. To obtain a quick and reliable diagnosis of pancreatic lesions, the authors performed fineneedle aspiration biopsies followed by immediate staining and examination of the specimen. Among 43 patients an accurate diagnosis was obtained in 41 instances and no complication was ascribed to this diagnostic procedure.

Sixteen patients with an established diagnosis of oculopharyngeal muscular dystrophy underwent clinical, radiologic and manometric assessment. Secondary pharyngo-oral and pharyngonasal regurgitations are usually associated with this condition and chronic aspiration with consequent bronchorrhea is common. Such patients may present with marked oropharyngeal dysphagia. Cineradiologic findings correlated well with the mamometric results. The pharynx showed very weak contractions of longer duration than those observed in normal subjects. The proximal esophageal sphincter had a normal resting and closing pressure; however, relaxation and coordination of the sphincter were substantially different from those in a control group. Eleven patients underwent cricopharyngeal myotomy. All had notable improvement of their symptoms. Surgery on the sphincter results in a substantial decrease in its resting pressure; pharyngeal contraction remains unaltered.

On roentgenograms made with the patient supine, the knees flexed 20 to 30 degrees, the x-ray tube between the ankles, and the cassette held proximal to the knees and perpendicular to the x-ray beam, it was found that a line between the femoral condyles and a line between the margins of the lateral facet of the patella formed the lateral patellofemoral angle, an angle that was of diagnostic value in patients with subluxation of the patella. In 100 clinically normal patients, these lines were parallel in three and formed an angle open laterally in ninety-seven. In thirty patients with subluxation of the patella, the lines were parallel in twenty-four and formed an angle open medially in six. In 100 patients with chondromalacia of the patella, however, the roentgenographic study was of no diagnostic value since the lines were parallel in ten and formed an angle open laterally in ninety.

Extrinsic compression of the medial border of the ascending colon and bilateral small bowel displacement at the lumbosacral level were observed in a sportswoman. Psoas muscle hypertrophy was confirmed by computed tomography. This entity should be added to the differential diagnosis of bowel displacement.