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Obesity, body fat distribution, and sex hormones in breast cancer patients. This study addresses the relationship between female sex hormones, obesity, body fat distribution, and breast cancer. Increasing obesity correlated with a progressive fall in sex hormone-binding globulin (SHBG) level and an increase in testosterone level. Premenopausal breast cancer patients were found to have significantly lower levels of SHBG compared with age-matched and weight-matched controls. This difference in SHBG level was not noted in postmenopausal breast cancer patients. The SHBG level decreased with increasing upper body fat localization in breast cancer patients and controls. This effect was more marked in breast cancer patients which may explain our earlier finding that women with upper body fat localization are at increased risk for developing breast cancer. | 0 |
Surgical epicardial ablation of left ventricular pathway using sling exposure We report our experience with 43 consecutive patients with left free wall pathways operated on since December 1988 using a modified direct epicardial approach through a medial sternotomy, without the adjunct of normothermic cardiopulmonary bypass. The left atrioventricular sulcus is exposed by dislocating the heart cephalad and to the right using a sling made of a large sponge passed around the ventricle through the transverse sinus. While the arterial pressure is monitored, the heart is positioned to obtain adequate exposure without compromising the ventricular function. The left atrioventricular junction is exposed using a direct approach. The epicardium is incised along the ventricular edge and a plane of dissection is identified and opened using blunt dissection over the ventricular wall. The entire left atrioventricular junction can be exposed. After dissection, electrophysiological testing is repeated to assess accessory pathway conduction. Epicardial cryoablation was used when accessory pathway conduction was not present (42 patients). Transmural cryoablation was used under normothermic cardiopulmonary bypass when accessory pathway conduction persisted after dissection (subendocardial pathway). In all, cardiopulmonary bypass was not used in 41 patients. There was one early relapse that required transmural cryoablation. There were no complications. | 4 |
Cytologic identification of clinically occult proliferative breast disease in women with a family history of breast cancer. A cytologic method for sampling the normal breast by fine-needle aspiration (FNA) was used to determine the frequency of clinically inapparent proliferative breast disease (PBD) in women with family histories of breast cancer. The authors attempted to obtain specimens from each quadrant of both breasts in 51 female first-degree relatives of breast cancer patients. The study group had no detectable masses by physical examination or mammography. Samples were prepared on membrane filters, Papanicolaou stained, and evaluated cytomorphologically. Three hundred seventy-eight of 408 (92.6%) possible quadrants were sampled; cellular material was obtained from 290 (76.7%) quadrants. PBD was identified in 20 of the 51 women (39.2%). When epithelium was obtained, nuclear area, perimeter, and diameter were measured with the use of computerized image analysis. Nuclei in samples containing atypical hyperplasia showed significant differences in these parameters when compared with cells from samples containing normal epithelium or benign hyperplasia. The authors' findings indicate that FNA sampling and computerized image analysis are useful in the detection and characterization of clinically inapparent PBD. | 4 |
Echocardiographic measurement of left ventricular mass and volume in normotensive and hypertensive rats. Necropsy validation. Although rats are commonly used to study left ventricular (LV) hypertrophy, measurement of LV mass and dimensions has required killing the rat. To determine the accuracy of echocardiography in rats, blinded crossectional area (CSA) and LV mass measurements using either the cube function (LVM) or an elliptical model (LVMel) from high resolution M-mode echocardiograms were compared to necropsy LV weight (0.28 to 1.5 g), in 41 normotensive (body weight 116 to 762 g) and 17 hypertensive rats (350 to 560 g). Postmortem chamber volumes in 28 normal rats (0.02 to 0.19 mL) were also compared to echocardiographic volumes derived from the elliptical model. Correlation with LV weight was r = 0.87 for LVM, 0.90 for CSA and 0.93 for LVMel (all P less than .00001). Comparison of hypertensive and body-weight-matched normotensive rats revealed the upper normal limit for both LVMel and CSA to have 89% sensitivity and 100% specificity for detection of post mortem LV hypertrophy. Necropsy LV volumes were more closely related to systolic echocardiographic volumes than to diastolic volumes (r = 0.78 v 0.71, both P less than .00001), compatible with the effects of post mortem contracture. Stroke volume determined invasively in 5 Wistar rats by thermodilution was similar to that obtained using elliptical model echo volumes in 5 rats of the same body size (0.35 +/- 0.05 v 0.30 +/- 0.06 mL/beat). Echocardiography can be used to evaluate LV structure and function in rats and to detect in vivo LV anatomic differences induced by hypertension. | 3 |
Hypertension and acculturation in elderly Mexican Americans: results from 1982-84 Hispanic HANES. The purpose of our study was to describe the relationship between acculturation and hypertension in elderly Mexican Americans. Two age groups, 55-64 and 65-74, were examined from data provided in the Hispanic Health and Nutrition Examination Survey (HHANES). The prevalence of hypertension among subgroups of different acculturation was ascertained based on the modified Cuellar Acculturation Scale. Each age group was also stratified using the HHANES poverty index, with those above the index compared to those below. A stepwise logistic regression was performed among the variables of poverty, gender, age, and acculturation in relation to hypertension. The results indicate that acculturation and age are stronger predictors of hypertension than poverty in elderly Mexican Americans, with acculturation being a stronger predictor among those age 55-64. Factors related to acculturation may have a stronger influence on the prevalence of hypertension in older Mexican Americans than differences related to socioeconomic status. | 3 |
Intracerebral hematoma complicating split calvarial bone-graft harvesting. A case is reported of an intracerebral hematoma following the harvest of split calvarial bone. Full recovery by the patient occurred. Complications following calvarial bone graft harvest are reviewed. Potential devastating complications warrant serious consideration of alternative sources of bone, especially in the purely elective surgical candidate. | 4 |
Serum erythropoietin levels in patients receiving intensive chemotherapy and radiotherapy. To investigate the potential role of recombinant human erythropoietin (rhEpo) in patients receiving intensive cytotoxic therapy, we measured the endogenous levels of Epo in 31 patients undergoing bone marrow transplantation (BMT). Seventeen patients underwent allogeneic BMT and 14 underwent autologous BMT. On average, 10 +/- 4 units of red blood cells (RBCs) were transfused per patient. The mean RBC transfusion requirement of the autologous BMT patients was significantly greater than that of the allogeneic recipients (12 +/- 3 v 8 +/- 4, P less than .01), although both groups were maintained at comparable hematocrits. Epo levels were measured by radioimmunoassay (RIA). For each patient, baseline serum Epo levels were determined at time of admission to the hospital. Subsequent samples were collected within 24 hours of completing chemotherapy and/or radiotherapy, and on days 7, 14, and 28, after BMT. Hematocrits (Hcts) were measured daily. All patients had an initial serum creatinine less than or equal to 1.5 mg/dL. Despite considerable differences in absolute Epo levels among individuals, a characteristic pattern was observed. Following admission to the hospital and initiation of cytotoxic therapy, the average Hct decreased and the average Epo level initially increased. The mean serum Epo levels peaked on day 7 post-BMT (284 +/- 190 mU/mL) and fell steadily thereafter. While the average Hcts on day 7 and on day 28 post-BMT were not significantly different (28 +/- 4.6% v 29 +/- 3.3%, respectively), the average serum Epo levels decreased fourfold (P less than .01) during this same period. Moreover, day 28 post-BMT mean Epo levels were inappropriately low (P less than .05) when compared with a reference population with bone marrow failure and normal controls who had not received cytotoxic therapy. We conclude that the endogenous Epo response appears to be blunted during the 3 to 4 weeks immediately post-BMT. Therefore, clinical trials assessing the efficacy of the administration of rhEpo in the treatment of anemias associated with cytotoxic therapy are warranted. | 0 |
Bleeding from duodenal lymphangiectasia. An 8 year old girl with recurrent upper gastrointestinal bleeding was found to have localised duodenal lymphangiectasia by fibreoptic endoscopy. She did not show physical signs or laboratory evidence of significant enteric protein loss. A low fat diet seemed to prevent further bleeding. Duodenal lymphangiectasia may be associated with gastrointestinal bleeding in children. | 4 |
Hormonal and enzymatic parameters of hepatic regeneration in patients undergoing major liver resections. Thirteen patients who underwent 40% to 80% removal of their livers had blood samples drawn initially and daily on postoperative days 1 to 7. The enzyme marker of heightened polyamine metabolism, ornithine decarboxylase, and the indicator of DNA synthesis, thymidine kinase, were measured. In addition, the hormones (insulin, glucagon, estradiol and androgen), which in animals are known to reflect and possibly modulate regeneration, were measured. Changes in all these indices followed the same pattern as in rats, dogs and swine but at a slower rate. Ornithine decarboxylase and estradiol increased within 24 hr, but thymidine kinase and insulin rises did not become statistically significant until 3 to 5 days. Using these plasma or serum indices as surrogate measures of biochemical events in the liver itself, regeneration reached a maximum after 4 or 5 days. By computed tomography scan analysis, restoration of hepatic cell mass was not complete until 3 wk. | 1 |
Differences in glycolytic capacity and hypoxia tolerance between hepatoma cells and hepatocytes. Viability, glycolytic capacity and energy metabolism under anaerobic conditions were studied in the hepatoma cell lines HTC, FU5 and HepG2 and in rat and human hepatocytes using glucose and fructose as glycolytic precursors. During 6 hr of anaerobic incubation without additional substrate, viability decreased rapidly in FU5 and HTC cells, whereas viability of HepG2 cells was not significantly affected. In all tumor cells, 10 mmol/L glucose prevented hypoxic cell injury almost completely. Lactate formation from glucose was about five times higher than in hepatocytes under these circumstances. ATP content of the tumor cells remained almost constant under anaerobic conditions in the presence of glucose. Ten millimoles per liter of fructose diminished glycolysis in the hepatoma cells compared with glucose, ranging from 87% reduction in HTC cells to 43% reduction in HepG2 cells. Accordingly, ATP content decreased rapidly in the FU5 and slowly in the HepG2 cells. Viability was strongly diminished in the HTC and FU5 cells in the presence of fructose, whereas in the HepG2 cells no effect of fructose on viability was detectable. In contrast to the hepatoma cells, rat and human hepatocytes exhibited higher rates of anaerobic glycolysis in the presence of fructose and thus were able to maintain their viability under these conditions. These differences in glycolytic capacity, energy metabolism and hypoxia tolerance of hepatoma cells compared with hepatocytes may be used for the treatment of liver cancer by isolated liver perfusion and ex situ revision of the organ. | 0 |
Expression of blood-group antigen A--a favorable prognostic factor in non-small-cell lung cancer. BACKGROUND. New prognostic factors are needed to guide the treatment of patients with non-small-cell lung cancer. We evaluated the prognostic value of altered expression of ABH blood-group antigens, which has been implicated in the multistep process of carcinogenesis and tumor progression. METHODS. The presence of blood-group antigens was assessed immunohistochemically in paraffin-embedded tumor samples from 164 patients who underwent curative surgery for non-small-cell lung cancer from 1980 through 1982. Monoclonal antibodies were used to detect the A and B antigens, and Ulex europaeus agglutinin I to detect H antigen. RESULTS. Survival of the 28 patients with blood type A or AB who had primary tumors negative for blood-group antigen A was significantly shorter than that of the 43 patients with antigen A-positive tumors (P less than 0.001) and of the 93 patients with blood type B or O (P = 0.002). The respective median survival times were 15, 71, and 39 months. Disease progressed significantly earlier in the 28 patients with tumors negative for blood-group antigen A than in the antigen A-positive patients (P less than 0.001). Expression of blood-group antigen B or H in tumor cells did not correlate with survival. Cox proportional-hazards regression analysis showed that expression of blood-group antigen A in tumor cells added significantly to the prediction of overall survival provided by other known prognostic factors among the patients with blood type A or AB (P = 0.004). CONCLUSIONS. Expression of blood-group antigen A in tumor cells is an important favorable prognostic factor in patients with non-small-cell lung cancer. This variable needs to be considered in the design of future trials of therapy. | 0 |
Tryptophan-induced eosinophilia-myalgia syndrome Eight patients who became ill while taking tryptophan had myalgia, fatigue, rash, fever, edema, alopecia, arthralgias, diminished joint motion, skin tightening, muscle cramping, and distal paresthesias. Three had shortness of breath, and one had pulmonary hypertension. Laboratory abnormalities included peripheral eosinophilia, leukocytosis, thrombocytosis, raised erythrocyte sedimentation rate, and elevated serum levels of aldolase, lactate dehydrogenase, and liver enzymes. Of 4 chest radiographs, 3 were abnormal. Of 5 skin and muscle biopsies, 4 showed sclerosis or mixed inflammatory cell infiltration of the dermis, subcutis, and fascia. Eosinophils were often present, but vasculitis was absent. Muscle inflammation was minimal. We conclude that the "eosinophilia-myalgia syndrome" is related to the ingestion of tryptophan and that abnormalities in the secretion of lymphokines may be important in its pathogenesis. | 4 |
Adult T-cell leukaemia/lymphoma in Brazil and its relation to HTLV-I In a series of fourteen patients with adult T-cell lymphoma-leukaemia (ATLL) in Brazil the main features were lymphadenopathy, hepatosplenomegaly, hypercalcaemia, and high leucocyte counts, with abnormal lymphoid cells which had irregular nuclei. The series included the youngest patient with ATLL so far (18 months). Analysis with monoclonal antibodies showed a mature T-cell phenotype (CD4+, CD8-). Antibodies to HTLV-I and/or integration of HTLV-I proviral DNA were found in eleven patients. In the other three HTLV-I DNA could not be demonstrated even by means of the polymerase chain reaction; they therefore had HTLV-I-negative ATLL. This report of ATLL in Brazil corroborates serological reports that HTLV-I may be endemic in some parts of that country. Follow-up studies are required to identify precisely the main route of transmission of HTLV-I in South America and the risk factors for the development of ATLL in carriers. | 0 |
Deep venous thrombosis: longitudinal study with duplex US. Forty-nine patients with deep venous thrombosis (DVT) of the lower limb were studied with repeated duplex ultrasound (US) for at least 1 year or until the vein became normal at US. Standard anticoagulant therapy was given for 3 months. In 36 patients, the veins became normal within 1 year. The likelihood of normalization increased if the lesion was located in only one site, if the pelvic veins were unaffected, if the affected leg was the left one, if the initial clot was nonocclusive, if there was no history of DVT, and if the symptoms had lasted less than than 24 hours. The average time before normalization was shorter if the symptoms had lasted less than 24 hours, that is, 11 weeks versus 25 weeks (P less than .02). The rate of sequelae at 1 year was lower if the US scan was normal or showed regression at 3 months, 6% versus 83% (P less than .00005). | 3 |
Management of infants at risk for occult bacteremia: a decision analysis. Because febrile infants with no obvious source of bacterial infection may have bacteremia, and because bacteremia is difficult to diagnose on clinical grounds, we used decision analysis to evaluate whether such infants should be treated with antibiotics, tested further, or sent home. Using a simple decision tree, we found that the decision to give empiric antibiotic treatment is the decision of choice. The difference in quality-adjusted life expectancy between the "best" and "worst" decisions was only 11 days. However, this difference translated to prevention of death or permanent disability in 60 cases per 100,000 febrile children. Further, empiric treatment remained the best management alternative unless the probability of bacteremia was less than 1.4% (less than any published prevalence), or the efficacy of treatment was less than 21%. Our analysis demonstrated that a test with far greater sensitivity than leukocyte count or other tests currently in use is needed to justify testing rather than treating empirically. Further, an enormous patient population would be needed to find a difference of both clinical and statistical significance between treated and untreated patients in a controlled trial. In the absence of such trials, we recommend blood culture and empiric antibiotic treatment of all infants at risk for occult bacteremia. | 4 |
Airway luminal liquid. Sources and role as an amplifier of bronchoconstriction. The release of mediators from inflammatory cells into the airway lumen can initiate a series of events leading to airway obstruction, particularly smooth muscle contraction and alteration of endothelial and epithelial permeability leading to mucosal edema and subsequent influx of liquid into the airway lumen. In this report we briefly review the effects of several inflammatory mediators, including eicosanoids, platelet-activating factor, and histamine, as well as the effects of plasma proteins and tachykinins that may be secondarily released because of the presence of inflammatory mediators on endothelial and epithelial permeability. We then consider physical mechanisms whereby the resulting airway luminal liquid could amplify the response of an airway previously constricted because of smooth muscle contraction. Specifically, liquid in the interstices between epithelial projections that are formed during muscular contraction could amplify the degree of luminal compromise by (1) further decreasing luminal cross-sectional area by occupying space, and (2) providing an additional source of inward recoil because of the surface tension of the air-liquid interface. | 4 |
Defective oral tolerance promotes nephritogenesis in experimental IgA nephropathy induced by oral immunization. Oral tolerance, an important feature of the mucosal immune system, appears to protect against immune-mediated disease by blunting production of systemic IgG and IgM antibody directed toward immunogens chronically present at mucosal surfaces. In this study, we explored the role of oral tolerance and mucosal immunoregulation in an experimental model of IgA nephropathy (IgAN), an important form of nephritis in humans. Cyclophosphamide and estradiol were used to inhibit the expression of oral tolerance, which otherwise develops after chronic oral presentation of Ag. BALB/c mice given drinking water containing 0.1% bovine gamma globulin (BGG) continuously for 14 wk were randomly assigned to groups given either 2 mg of cyclophosphamide i.p., 2 mg of estradiol s.c. or both drugs. Groups of control mice received neither BGG nor drugs. In three separate experiments, a low percentage of saline-treated orally immunized mice had microscopic hematuria (0 to 20%), as did nonimmunized controls (0 to 20%). However, 58 to 83% of mice given estradiol and/or cyclophosphamide at appropriate times developed significant hematuria. If drugs were given at suboptimal times, only 25 to 56% of mice developed hematuria. Drug-treated immunized mice also had more serum IgG and IgM anti-BGG antibodies than control and saline groups. Immunofluorescence showed significantly more glomerular deposits of IgG, IgM, and C3 in drug-treated immunized mice compared to saline-treated immunized and normal untreated control mice. Hematuria and glomerular deposits of IgG, IgM, and C3 paralleled serum IgG and IgM antibody. All immunized mice showed significant mesangial IgA and BGG deposits and there were no differences in such deposits between saline- and drug-treated immunized mice. We suggest that blunting of oral tolerance with promotion of systemic IgG and IgM antibody production leads to nephritis in chronically orally immunized mice and that glomerular immune complexes containing IgG and/or IgM promote complement deposition and hematuria in IgAN. Analogous defects in oral (or more generally mucosal) tolerance could play a role in the genesis of symptomatic human IgAN. | 4 |
Clinical significance of colonic fermentation. Recent evidence of the potential benefits of short chain fatty acids has prompted renewed interest in the area of human colonic fermentation. This paper reviews the clinical and metabolic consequences of colonic fermentation. | 0 |
Alcohol consumption--a risk factor for hemorrhagic and non-hemorrhagic stroke. PURPOSE: The risks of alcohol consumption and its association with stroke were studied in 621 patients with stroke and 573 control subjects using case-control methods. PATIENTS AND METHODS: Patients with stroke were subdivided into 193 with subarachnoid hemorrhage, 91 with intracerebral hemorrhage, and 337 with cerebral infarction. Data on recent alcohol consumption were obtained by questionnaire in patients with stroke and compared with data from an occupational screening survey in control subjects. RESULTS: Relative risks, adjusted for confounding variables, exhibited J-shaped associations with increasing levels of alcohol consumption classified into four categories--abstainer, 1 to 90 g, 100 to 390 g, and greater than or equal to 400 g weekly). The individual risks were 1, 0.7, 0.5, and 1.3 for subarachnoid hemorrhage; 1.0, 0.6, 0.5., and 2.5 for intracerebral hemorrhage, and 1.0, 0.6, 0.7, and 2.4 for cerebral infarction for men and women combined. CONCLUSIONS: The results suggest that low levels of alcohol consumption may have some protective effect upon the cerebral vasculature, whereas heavy consumption predisposes to both hemorrhagic and non-hemorrhagic stroke. | 4 |
Renal cell carcinoma vs. renal oncocytoma. Report of a case with overlap features and review of the literature Although the salient features of renal oncocytomas and renal cell carcinomas have been discussed in the recent literature, renal masses with features of both entities will present diagnostic difficulty, especially when the cells are diffusely eosinophilic on microscopic examination. A case of a firm, tan, rounded mass replacing the lower pole of the kidney is discussed. The final diagnosis of renal cell carcinoma, granular cell type, was made after multiple sections of the tumor were examined, and after electron microscopy was performed. A thorough search by light microscopy should be made for clear cell foci, necrosis, mitotic activity, and vascular or capsular invasion, features generally accepted as pathognomonic for renal cell carcinoma. Cellular and especially nuclear pleomorphism is typically focal or mild in renal oncocytomas. True oncocytic tumors will be packed with mitochondria on electron microscopy; however, granular renal cell carcinomas will contain mitochondria as well as other cellular organelles, lipid, and glycogen. Electron microscopy should be performed on tumors suspected of being oncocytomas because eosinophilia on hematoxylin and eosin stain, as demonstrated by this case, is not a predictable measure of mitochondria content. Immunoperoxidase staining for vimentin in oncocytomas has recently been shown to be negative, and may offer a method of ruling out oncocytoma in vimentin-positive tumors, pending further studies. | 0 |
Clinical prognostic factors in patients with posterior uveal malignant melanoma. The authors evaluated the prognostic value of clinically assessed variables for predicting length of survival until death from metastatic disease in 237 patient with a primary choroidal or ciliary body melanoma. Using multivariate Cox proportional hazards modeling, the authors identified the largest linear basal tumor diameter (mm), estimated by indirect ophthalmoscopy and fundus drawing, the location of the anterior margin of the tumor relative to the ocular equator and ora serrata, and the age of the patient at the time of treatment as the best combination of the clinically assessed variables for predicting survival. For each patient in this group, the authors computed a prognostic index based on the best multivariate Cox model. They showed that patients with low, intermediate, and high values of prognostic index had low, intermediate, and high melanoma-related mortality rates, respectively, during the first 5 to 8 posttreatment years. These results suggest that: (1) clinically assessed variables evaluated according to a standardized protocol are useful for predicting the survival of treated patients with posterior uveal melanoma and (2) ophthalmologists who assess potential clinical prognostic variables consistently may identify subgroups of patients with comparable mortality risk on the basis of noninvasive testing. | 0 |
Hypothalamic or central obesity is associated with an early rise in plasma insulin concentration. Insulin levels in a 7-year-old boy with hyperphagia and obesity following an episode of meningoencephalitis were studied sequentially during the course of progressive weight gain. High fasting insulin levels (1183 pmol/L) and strikingly high insulin release in response to glucose (7892 pmol/L) were found within weeks of the onset of the illness. The abnormality in insulin secretion occurred prior to the marked weight gain. Hyperinsulinemia was not accompanied by hypoglycemia. Early hyperinsulinemia may be a primary event in the development of hyperphagia and obesity following hypothalamic injury. | 4 |
Longitudinal dissociation of atrioventricular accessory pathways. Unusual properties of atrioventricular (AV) accessory pathways were found during electrophysiologic investigations in four patients (three men and one woman). Anterograde longitudinal dissociation of the accessory pathway was observed in two patients and retrograde longitudinal dissociation in two others. Two patients had an accessory pathway with a slow conduction time, one in anterograde direction and one in retrograde direction. These observations further expand our knowledge of the spectrum of electrophysiologic properties of accessory AV pathways. | 3 |
Decreased ventilation and hypoxic ventilatory responsiveness are not reversed by naloxone in Lhasa residents with chronic mountain sickness. Persons with chronic mountain sickness (CMS) hypoventilate and are more hypoxemic than normal individuals, but the cause of the hypoventilation is unclear. Studies of 14 patients with CMS and 11 healthy age-matched control subjects residing in Lhasa, Tibet, China (3,658 m) were conducted to test the hypothesis that hypoventilation, blunted hypoxic ventilatory responsiveness (HVR), and hypoxic ventilatory depression of CMS were due to increased endogenous opioid production. Patients with CMS compared with control subjects exhibited hypoventilation (end-tidal carbon dioxide pressure [PETCO2] = 36.6 +/- 1.0 versus 31.5 +/- 0.5 mm Hg, p less than 0.05), lower tidal volume (VT = 0.54 +/- 0.02 versus 0.61 +/- 0.02 ml BTPS, p less than 0.05), blunted HVR (shape parameter A = 17 +/- 8 versus 114 +/- 22 mm Hg/L BTPS/min, p less than 0.05), and a depressant effect of ambient hypoxia on ventilation (delta PETCO2 with acute hyperoxia = -3.5 +/- 0.5 versus -1.0 +/- 0.6 mm Hg, p less than 0.05). Reduced forced expiratory volume in 1 s to vital capacity ratios (FEV1/VC) and a higher proportion of cigarette smokers in the group of patients with CMS compared with control subjects suggested that at least some patients with CMS had mild airway obstructive lung disease. Naloxone infusion (0.14 mg/kg) to six patients with CMS did not change resting VT, PETCO2, HVR, or SaO2. | 4 |
Urogenital dysfunction after abdominoperineal resection for carcinoma of the rectum. The long-term urogenital dysfunctions in 46 of 104 surviving patients submitted to abdominoperineal resection for rectal carcinoma between 1972 and 1986 were collected and assessed. Urinary retention was present in 41 percent of the men and 35 percent of women, while incontinence was present in 10 percent of men and 29 percent of women. Impotence was reported by 59 percent of the males, all sexually active before surgery. Dyspareunia was present in 50 percent of the women in the study. The possibility of treating prostatic hypertrophy concurrently with abdominoperineal resection in selected cases to avoid urinary retention is discussed. The limited number of responders to the survey may interfere with the global statistical significance. | 0 |
Rett syndrome: findings suggesting axonopathy and mitochondrial abnormalities. We report the histopathologic findings of 3 sural nerve biopsies and 1 muscle biopsy from 3 patients with Rett syndrome. The 3 sural nerve biopsies demonstrated a few ultrastructural abnormalities, including the presence of many Pi-granules and mitochondrial changes in the cytoplasm of Schwann cells, occasional bands of Bungner and onion-bulb formations, and mitochondrial alterations in myelinated axons. Morphometric analysis disclosed reduction in the number of large myelinated fibers with normal densities in comparison to those of an age-matched normal control. Light microscopic examination of the biopsied muscle from a 6-year-old patient with Rett syndrome revealed the existence of many small, dark, angulated fibers with NADH-TR staining. Ultrastructural investigation of the muscle confirmed the presence of the dumbbell-shaped mitochondria. Peripheral nerve involvement and the possibility of mitochondrial abnormalities in Rett syndrome were suggested by the results. | 2 |
Respiratory muscle involvement in nemaline myopathy. A boy who had experienced generalized muscle weakness and hypotonia since early infancy was diagnosed as having nemaline myopathy on the basis of muscle biopsy at 3 years of age. At 8 years of age, he developed severe respiratory failure and required respiratory support during sleep. Because of recurrent pneumothorax, he underwent thoracic surgery, at which time biopsy specimens were obtained from the respiratory and truncal muscles. The histologic findings of the respiratory muscles included marked variation in fiber size with a notable increase in fibrous tissue, type 2 fiber deficiency, elevated acid phosphatase activity, and a disorganized intermyofibrillar network. The findings from the truncal muscles were similar to those of the biceps brachii muscle: little variation in fiber size, numerous nemaline bodies in all fibers, and type 1 fiber predominance. The preferential damage to the respiratory muscles was probably responsible for the sudden onset of severe respiratory failure. | 2 |
Iatrogenic saphenous neuralgia: successful therapy with neuroma resection. We report the case of a patient with saphenous neuralgia secondary to iatrogenic trauma resulting from bypass surgery in the femoral-popliteal region. Early symptoms of this condition were medial calf and ankle pain, with no findings of motor and reflex abnormalities. Exploration of the thigh 2 years later revealed a neuroma of the nerve in the distal dissection site, medial to the knee. Resection of the neuroma alleviated this condition. It is noted that saphenous neuropathy is seen as a spontaneous entrapment syndrome as well as a complication of orthopedic and vascular procedures performed on the medial area of the knee. Saphenous neuralgia is often not recognized by neurosurgeons. If the condition is intractable, it does respond to surgical therapy. | 2 |
Failure of nutritional recovery after total gastrectomy. Malnutrition is reported to be an inevitable consequence of total gastrectomy, although there are few data to support this contention. Six patients of median age 63 years underwent total gastrectomy for malignancy. At follow-up (median 45 months, range 25-60 months) each patient was clinically tumour-free and underwent dietary assessment, faecal fat and nitrogen measurement and routine haematological testing. Protein and fat stores, measured by neutron activation analysis and the tritiated water dilution technique, were compared with the same measurements made before operation and with predicted values. Mean (s.d.) dietary intake (2224(381) kcal day-1 and 81(15)g protein day-1) met the patients' estimated requirements. Mean(s.d.) serum albumin and faecal nitrogen values were normal but there was notable steatorrhoea (21(17) g day-1). Body composition measurements revealed profound deficiencies of body-weight (P less than 0.02), protein (P less than 0.01) and fat (P less than 0.02) before operation which were not corrected by an apparently curative total gastrectomy (P less than 0.05), although further deterioration was prevented. | 0 |
Surgical management of islet cell dysmaturation syndrome in young children. Islet cell dysmaturation syndrome (ICDS) encompasses the causes of infantile hyperinsulinemic hypoglycemia histologically described as islet cell hyperplasia, pancreatic adenomatosis and nesidioblastosis. Eleven infants underwent 14 pancreatic resections for ICDS from 1965 to 1990 at the University of California at Los Angeles Medical Center for severe hypoglycemia unresponsive to medical therapy. Seizures were the presenting symptoms of hypoglycemia in eight infants. Six patients had nesidioblastosis, four had islet cell hyperplasia and one patient had an adenoma with histologically normal pancreatic islet cells. Four neonates underwent 80 per cent pancreatic resection; three with nesidioblastosis required reoperation (90 to 95 per cent resection). Four older infants underwent 80 per cent pancreatic resection but required diazoxide for less than six months postoperatively. Three infants underwent 90 to 95 per cent pancreatic resection. None have required reoperation or postoperative medications. All infants are normoglycemic without pancreatic exocrine insufficiency and none had postoperative complications. Five infants had preoperative neurologic impairment, with three having severe retardation; all showed some improvement postoperatively, but only one infant now has normal findings on neurologic examination. Early diagnosis and aggressive surgical resection should minimize neurologic complications of the ICDS. | 1 |
Neurologic abnormalities in a patient with human ehrlichiosis. Human ehrlichiosis is a tick-borne rickettsial disease characterized by fever, headache, myalgias, anorexia, and occasionally rash. In our patient, changes in mental status, upper motor neuron signs, cerebrospinal fluid pleocytosis, and increased serum protein levels were found in association with serologically confirmed ehrlichiosis and were most likely due to vasculitis involving the central nervous system. Intraleukocytic inclusions, although observed in our case, have been infrequently found in other reported cases of ehrlichiosis. | 2 |
Ventricular arrhythmias in ischemic heart disease. Ventricular arrhythmias remain the leading cause of death from coronary artery disease. This review summarizes current thinking in several areas relating to the pathophysiology, prognosis, and therapy of ventricular arrhythmias associated with acute and chronic coronary artery disease syndromes. The experimental basis of arrhythmias in the setting of acute myocardial ischemia and chronic myocardial infarction is described, stressing the important pathophysiologic differences between these two conditions. The effects of the autonomic nervous system as a key modulator of ischemic arrhythmogenesis are discussed. Insights, derived from endocardial mapping studies, into the nature of ventricular tachycardia in humans with chronic myocardial infarction are described, including implications for risk stratification and therapy to prevent arrhythmia recurrence. Current therapeutic principles are discussed in the management of ventricular arrhythmias associated with coronary artery disease, including pharmacologic approaches, surgical and catheter ablation, and automatic implantable cardioverting and defibrillating devices. | 4 |
Penetrating aortic ulcers: diagnosis with MR imaging. The authors studied seven patients with penetrating aortic ulcers with use of magnetic resonance (MR) imaging. All patients were evaluated for acute chest symptoms, and the presence of aortic ulcers was confirmed by means of angiography in all seven patients. Five patients also underwent computed tomography (CT). Three patients underwent surgical repair of the thoracic aorta. MR findings included intramural hematoma and focal aortic wall ulceration in four patients, focal ulceration in one, focal intramural hematoma in one, and focal intramural hematoma with rupture in one. The diagnosis of intramural hematoma was made by the detection of increased signal intensity on T1- and T2-weighted MR images. MR imaging was superior to angiography in depicting the extent of intramural thrombus, although one ulceration diagnosed at angiography was missed at MR imaging. MR imaging was superior to CT in differentiating acute intramural hematoma from atherosclerotic plaque and chronic intraluminal thrombus, although it did not depict displaced intimal calcification in one patient with extensive intramural hematoma. | 3 |
The prognostic value of image analysis in ovarian cancer. Histologic grading is very important for treatment decisions in ovarian cancer. All grading systems contain a significant subjective component, which could be reduced by including objective measurements into the diagnostic decision. Image analysis was used to determine nuclear area and ploidy distributions in 42 patients with epithelial ovarian cancer, and the results were related to tumor grade and clinical outcome. The mean nuclear area, mean optical density, number of hyperploid cells, and the standard deviation between measurements were significantly higher in Grade 2 and 3 tumors compared with Grade 1 tumors, in rapidly progressive tumors compared with less aggressive malignancies, and in recurrent tumors compared with primary lesions. The number of nuclei with very high DNA content was found to be of prognostic importance. Image analysis thus provides additional prognostic information in epithelial ovarian cancer. | 0 |
The prognostic significance of CA 125 half-life in patients with ovarian cancer who have received primary chemotherapy after surgical cytoreduction. Fifty-four patients with advanced epithelial ovarian cancer were monitored with serial serum CA 125 levels after surgical cytoreduction and during multi-agent chemotherapy with cisplatin-containing regimens. CA 125 half-life of less than 20 days was associated with prolonged overall survival (p less than 0.015). In those patients who eventually were found to be disease-free at surgical surveillance procedures, normalization of serum CA 125 levels to less than 35 U/ml within 65 days of primary operation also suggested an improved survival (p less than 0.059). | 0 |
Eosinophilia-myalgia syndrome associated with L-tryptophan use. The eosinophilia-myalgia syndrome associated with the use of oral preparations of the amino acid L-tryptophan was recognized in late 1989. We describe the clinical and laboratory manifestations, pathological findings and early clinical course of 20 patients with the eosinophilia-myalgia syndrome. Prominent clinical findings included severe myalgias limiting function, fatigue, rashes, edema and weight gain, weight loss, muscle weakness and shortness of breath. Laboratory findings included eosinophilia (often marked), normal erythrocyte sedimentation rate, and elevated aldolase with normal or low creatine kinase values. On biopsy fascial inflammation was always seen consisting of lymphocytes, histiocytes and eosinophils in a perivascular distribution. Invasion of the vascular wall by lymphocytes was seen in 20%. Capillary and arteriolar endothelial cell thickening was found in most cases on electron microscopy and endothelial cell necrosis or mural invasion by lymphocytes was seen in 25% of cases. Two patients improved with no therapy. Ten patients responded to therapy with prednisone alone. Three patients have had progressive disease and one of these died. The relationship of this syndrome to previously described disease entities associated with eosinophilia is discussed. | 2 |
How American oncologists treat breast cancer: an assessment of the influence of clinical trials. The present study was designed to assess the preferred methods of treatment of breast cancer by American oncologists, and the impact of clinical trials on their practice. We mailed 465 questionnaires to surgical, radiation, or medical oncologists. The questionnaire described five hypothetic patients with breast cancer, and respondents were asked to select their preferred treatment for each patient. For primary breast cancer, most physicians would offer the choice of local excision followed by radiation therapy or modified radical mastectomy. About 80% of physicians would prescribe adjuvant chemotherapy for a premenopausal woman with estrogen receptor-negative, axillary node negative breast cancer, and for a postmenopausal woman with estrogen receptor-negative, node-positive disease. This policy was favored by male and female physicians of each specialty. Almost all respondents would treat a young woman with inflammatory breast cancer with initial chemotherapy followed by radiation and/or surgery, and about 60% would recommend chemotherapy to a postmenopausal patient with estrogen receptor-negative disease and minimally symptomatic bone metastases. Clinical trials have compared treatment strategies that could be applied to patients described in our questionnaire. Preferred treatments for primary breast cancer, and for inflammatory breast cancer are supported by the results of clinical trials. Recommendation of adjuvant chemotherapy for node-negative breast cancer is not based on a consistent demonstration of improvement in survival, although randomized trials with short follow-up have shown delay to recurrence. Recommendation of adjuvant chemotherapy for a postmenopausal woman with node-positive breast cancer is contrary to the results of large randomized controlled trials (and to a meta-analysis), which have shown that this policy does not lead to improved survival. Our report suggests that even large randomized clinical trials may have a minimal impact on practice if their results run counter to belief in the value of the treatment. | 0 |
Elective resection of 332 abdominal aortic aneurysms in a southern West Virginia community during a recent five-year period. This study analyzed 33 variables that might potentially affect outcome in a series of 332 consecutive elective abdominal aortic aneurysm repairs in a southern West Virginia community. One of the interesting features of this series was that the repairs were done by 22 surgeons with varying degrees of experience. The mortality and complication rates were compared for various potential risk factors by both univariant methods (chi 2, Fisher's exact, and Student t tests) and multivariant methods of analysis. Our early mortality (2.1%) and postoperative complication rates were consistent with those of other series. With multiple linear regression models, five factors were selected as significant independent risk factors associated with an increasing number of postoperative complications: the number of blood transfusions (p less than 0.0001), left renal vein ligation (p less than 0.0001), the presence of greater than 50% renal artery stenosis (p = 0.0012), the lesser experience of the surgeon (p = 0.0203), and the history of prior cardiac catheterization (p = 0.0245). The only factor statistically correlated with mortality rate was an increased number of postoperative complications (p less than 0.0001). Neither postoperative complications nor mortality rate was found to be significant and independently influenced by other demographic, clinical, or operative factors. It is tempting to speculate that surgeons with less experience might be well served to refer patients with significant renal artery stenosis and coronary artery disease. Our mortality and complication rates were not increased by performing preoperative angiography and therefore prudent surgeons may find this helpful in selecting patients for safer repair. | 4 |
A controlled trial of psychological treatment for the irritable bowel syndrome. One hundred two patients with irritable bowel syndrome were studied in a controlled trial of psychological treatment involving psychotherapy, relaxation, and standard medical treatment compared with standard medical treatment alone. Patients were only selected if their symptoms had not improved with standard medical treatment over the previous 6 months. At 3 months, the treatment group showed significantly greater improvement than the controls on both gastroenterologists' and patients' ratings of diarrhea and abdominal pain, but constipation changed little. Good prognostic factors included overt psychiatric symptoms and intermittent pain exacerbated by stress, whereas those with constant abdominal pain were helped little by this treatment. This study has demonstrated that psychological treatment is feasible and effective in two thirds of those patients with irritable bowel syndrome who do not respond to standard medical treatment. | 1 |
Metabolic bone disease in lumbar pseudarthrosis. Pseudarthrosis occurs in many patients who undergo lumbar spine fusion and it has been suggested that abnormalities of bone metabolism contribute to it. The authors evaluated 47 patients with pseudarthrosis for metabolic bone disease. Symptomatic patients with pseudarthrosis underwent metabolic bone evaluation. Abnormal results of laboratory tests were found in 7 patients (14.9%): 3 low or borderline 1,25 dihydroxy vitamin D3, 2 elevated 24-hour urine calcium, and 2 low serum testosterone. None of these abnormalities correlated with other clinical findings. Bone density was low in 14 of 24 patients in whom it was measured. Low values did not correlate with smoking or abnormal laboratory values. Metabolic bone abnormalities do not appear to play a frequent or significant role in pseudarthrosis after attempted lumbar spine fusion. | 4 |
Comparison of coronary angiographic features and oral dipyridamole thallium 201 tomography. Coronary angiography and left ventriculography is commonly used to identify those patients with incomplete infarctions and therefore, a need for revascularization. The authors compared coronary angiography and left ventriculography with thallium 201 tomography using oral dipyridamole to identify patients with potential ischemia in the infarct zone indicating viable tissue. Forty-five patients (37 men, 8 women) with acute myocardial infarctions (29 anterior, 16 inferior) who received intravenous thrombolytic therapy were studied. On the basis of the left ventriculograms, only 16 patients were judged to have residual function in the infarct zone. Six of these patients had no thallium redistribution in the infarct zone, indicating lack of residual ischemia. Of the 29 patients with no residual function in the infarct zone, 18 had redistribution in the infarct zone, suggesting residual ischemic myocardium and thus viable tissue. Among the 32 patients with open infarct vessels, 15 had no redistribution in the infarct zone, but of the remaining 13 patients with occluded infarct vessels, 9 had redistribution in the infarct zone indicating residual ischemia and thus viable tissue. The authors' data suggest that neither wall motion analysis by left ventriculography nor the angiographic status of the infarct vessel identifies those patients with residual ischemia as evidenced by thallium tomography using oral dipyridamole. | 3 |
Age-related spontaneous intracerebral hematoma in a German community. We investigated incidence, age distribution in relation to etiology, and localization of spontaneous intracerebral hematoma in 100 consecutive cases. Incidence in the total population of the Giessen area was estimated to be greater than 11/100,000 inhabitants/yr and increased with age. There was a trend toward higher incidence in males. Overall mortality was 27%, 22% of 58 patients aged less than 70 years and 33% of 42 patients aged greater than or equal to 70 years. Hypertensive putaminal hematoma showed the highest mortality rate (42%, 10 of 24 cases). Chronic alcoholism and anticoagulant medication influenced the mortality rate unfavourably. We found the following localizations and etiologies to have a specific relation with age: 1) lobar hematomas from vascular malformations, group aged less than 40 years; 2) hypertensive putaminal hematomas and hypertensive thalamic hematomas, group aged 40-69 years; and 3) lobar hematomas, group aged greater than or equal to 70 years. Alcoholism was an additional factor in 38% of the 13 middle-aged men with hypertensive putaminal hematomas. Fourteen cases of spontaneous intracerebral hematoma were possibly due to cerebral amyloid angiopathy. Six of these 14 patients had recurrent lobar hematomas, but only three of the six could be histologically investigated. In these three cases, cerebral amyloid angiopathy was proven. | 3 |
Ultrasound and ultrasound-guided fine needle aspiration biopsy of supraclavicular lymph nodes in patients with esophageal carcinoma. The use of ultrasound combined with ultrasound-guided fine-needle aspiration biopsy (UGFAB) of supraclavicular lymph nodes in the pretreatment staging of 37 patients with squamous cell carcinoma of the esophagus is described. All patients underwent computed tomography (CT) scans of the chest and the abdomen and ultrasound of the abdomen and supraclavicular regions. Supraclavicular lymph node metastases (Stage IV disease according to the tumor nodes metastasis [TNM] classification) were cytologically diagnosed in seven (18.9%) of the 37 patients. In two of these patients, no other metastases were found. In the other five patients, UGFAB replaced more invasive diagnostic procedures. Due to their superficial location, ultrasound and UGFAB of the supraclavicular lymph nodes was relatively simple to perform, and contributed to an improved staging of squamous cell carcinoma of the esophagus. | 0 |
Reversal of colchicine-induced mitotic arrest in Chinese hamster cells with a colchicine-specific monoclonal antibody. The ability of a high-affinity colchicine-binding monoclonal antibody to reverse the effects of colchicine on Chinese hamster ovary cells was investigated. Using flow cytometry, a complete mitotic blockade was demonstrated after 16 hours with 2.5 x 10(-7) mol/l (molar) colchicine. Colchicine-induced changes were reversible when equimolar antibody was added simultaneously with or up to 6 hours after colchicine. With further delay in addition of antibody, a progressive irreversible increase in mitotic blockade and increase in mean cell size was observed. Prolonged colchicine exposure, without antibody reversal, led to polyploidy and structural chromosome breakage. Early antibody reversal restored cells to the diploid state, whereas delayed reversal resulted in a time-dependent increase in polyploidy. Colchicine-induced polyploidy and chromosomal aberrations may be the basis for both colchicine toxicity and the time-dependent increase in irreversibility of colchicine effects. | 4 |
In vivo biological effects of stereotactic radiosurgery: a primate model. Single-fraction, closed skull, small-volume irradiation (radiosurgery) of intact intracranial structures requires accurate knowledge of radiation tolerance. We have developed a baboon model to assess the in vivo destructive radiobiological effects of stereotactic radiosurgery. Three baboons received a single-fraction, 150-Gy lesion of the caudate nucleus, the thalamus, or the pons using the 8-mm diameter collimator of the gamma unit. Serial standard neurodiagnostic tests (neurological examination, computed tomographic scan, magnetic resonance imaging, stable xenon-enhanced computed tomographic scan of cerebral blood flow, somatosensory and brain stem evoked potentials, and myelin basic protein levels of cerebrospinal fluid) were compared with preoperative studies. Magnetic resonance imaging revealed the development of a lesion at the target site between 45 and 60 days after irradiation. Deterioration of the brain stem evoked potentials preceded imaging changes when the lesion encroached on auditory pathways. Myelin basic protein levels increased subsequent to imaging changes. Postmortem neuropathological examination confirmed a well-demarcated radionecrosis of the target volume. The baboon model appears to be an excellent method to study the in vivo biological effects of radiosurgery. | 4 |
Hazards of internal fixation in the treatment of slipped capital femoral epiphysis. We reviewed the records of 202 patients (308 hips) in whom a slipped capital femoral epiphysis had been fixed with pins or screws. A serious complication that was directly related to the use of internal fixation developed in eighty hips (26 per cent). The rate of complications in the 202 patients was 40 per cent. In thirty-six (18 per cent) of the 202 patients, an additional procedure was done to correct a pin-related complication. Forty-one hip joints had been penetrated by a pin. Other complications included avascular necrosis (fourteen hips), chondrolysis (nine), fracture (one), infection (one), further slippage (one), sciatic-nerve injury (one), and breakage of a screw (eight). Ways of decreasing the incidence of complications of fixation were explored. | 4 |
Laryngeal metastasis from colonic adenocarcinoma. Metastases to the larynx from distant primaries are very rare. Usually the secondary lesion comes from an hypernephroma or malignant melanoma. A case of metastatic laryngeal tumour from a colonic adenocarcinoma, occurring in a 59-year-old woman, is presented and the routes for laryngeal spread are discussed. The poor survival-rate of these patients justified only conservative surgery. | 0 |
Respiratory epithelium in a cystic choristoma of the limbus. A female newborn had a cystic, whitish gray mass at the inferotemporal limbus of the left eye. At age 3 weeks, the newborn underwent excision of the tumor, corneal patch grafting, and superior sector optical iridectomy. Histopathologic and electron microscopic examination of the excised tissue revealed a choristoma consisting of cysts lined with respiratory epithelium. To our knowledge, respiratory epithelium in a limbal choristoma has not been previously reported. | 4 |
Acceleration of scrapie in trisomy 16----diploid aggregation chimeras. We studied the susceptibility to prion infection of the trisomy 16----diploid chimeric mouse, a putative model of Down syndrome. When weanling chimeras were inoculated intracerebrally with scrapie prions, the time until appearance of the first symptoms of scrapie was reduced by 17 days (from a mean control time of 153 days) and the time to death was reduced by 30 days (from control time of 170 days). Our results with trisomy 16 chimeras argue that the susceptibility to central nervous system degeneration caused by prions can be modulated by chromosome imbalance. | 2 |
Pathogenesis of gallstones. The many developments in nonoperative methods for the treatment of gallstone disease underscore the importance of understanding the pathogenesis of these stones. Elucidation of the factors responsible for nucleation of crystals and the mechanism by which it occurs would appear to be the challenge if we are to define the cascade of events that results in gallstone formation. | 1 |
Water and electrolyte balance after ileoanal anastomosis. Water and electrolyte balance was studied in 30 patients with ileoanal anastomosis and J pouch, 10 patients with conventional ileostomy, and nine nonoperated patients with quiescent ulcerative colitis. Serum electrolyte concentrations, daily urinary volume, and daily losses of sodium, potassium, and chloride were measured in all patients. Daily fecal weight and daily losses of sodium and potassium were analyzed in patients with ileoanal anastomosis or conventional ileostomy. Serum chloride in patients with ileoanal anastomosis was significantly lower (P less than 0.05) than in those with conventional ileostomy or in nonoperated patients. Daily urinary loss of sodium in nonoperated patients was significantly higher than in patients with ileoanal anastomosis (P less than 0.01) or conventional ileostomy (P less than 0.05). Daily urinary loss of chloride in patients with ileoanal anastomosis was significantly lower (P less than 0.05) than in nonoperated patients. Daily fecal loss of potassium in patients with ileoanal anastomosis was significantly higher (P less than 0.05) than in those with conventional ileostomy. Daily urinary volume and fecal weight did not differ significantly in patients with ileoanal anastomosis or conventional ileostomy. The present study indicates that changes in water and sodium balance after ileoanal anastomosis are similar to those after conventional ileostomy but chloride balance is more altered after ileoanal anastomosis. | 1 |
Urological complications in 350 consecutive renal transplants. Ten urological complications (2.9%) were found in 350 kidney transplants performed in this centre. These included obstructive uropathy (20%), urinary leaks (40%), distal uretic fistulas (necrosis) (30%) and renal calculi (10%). Two grafts were lost due to chronic rejection 9 and 30 months post-operatively. The remaining 8 patients have stable renal function (mean creatinine 1.5 mg%). It was concluded that meticulous surgical technique may reduce the number of urological complications and early diagnosis and prompt surgical treatment may help to save the grafts. | 4 |
Follicular neoplasms of the thyroid in men older than 50 years of age. A DNA flow cytometric study The clinical behavior of follicular neoplasms of the thyroid in elderly men can be difficult to predict on histologic grounds alone. To assess the usefulness of DNA flow cytometry in predicting the metastatic potential of these tumors, the authors studied 44 primary and metastatic follicular neoplasms of the thyroid by DNA flow cytometry of paraffin-embedded tissue. The neoplasms were obtained from 44 men ranging in age from 50 to 79 years (mean, 60). There were 29 follicular adenomas, 11 primary follicular carcinomas (neoplasms with capsular and/or vascular invasion), and 4 metastatic follicular carcinomas. Follow-up information was available on 40 of the 44 patients. The mean follow-up was 114 months. Twenty-five of the 29 follicular adenomas had a diploid DNA content, 2 (7%) were tetraploid, and the DNA histograms on 2 were not interpretable. All patients with follicular adenomas had no evidence of disease (NED) at last follow-up. Eight of the 11 primary follicular carcinomas were diploid. Six of these patients had NED, one died with carcinoma at 82 months, and no follow-up was available on one. Three (27%) of the primary follicular carcinomas were aneuploid or tetraploid. Two of these patients had NED, and the third died with carcinoma 84 months after diagnosis. Two of the four metastatic follicular carcinomas were diploid and two (50%) were aneuploid or tetraploid. One of the two patients with diploid metastatic follicular carcinomas died with carcinoma, as did one of the two patients with aneuploid metastatic follicular carcinomas. These results suggest the following: (1) follicular carcinomas are more likely to be aneuploid or tetraploid than are follicular adenomas; (2) follicular neoplasms without capsular or vascular invasion may include a small number of aneuploid or tetraploid tumors; and (3) DNA ploidy does not add to the prognostic value of histologic studies alone. | 4 |
Osteomalacia in hereditary hypophosphatemic rickets with hypercalciuria: a correlative clinical-histomorphometric study. We characterized the bone disease of transilial biopsy specimens from children with hereditary hypophosphatemic rickets with hypercalciuria (HHRH) and genetically related asymptomatic hypercalciuric subjects. All HHRH patients showed irregular mineralization fronts, markedly elevated osteoid surface and seam width, increased number of osteoid lamellae, and prolonged mineralization lag time. These findings are consistent with a mineralization defect and indicate unambiguously that the bone disease in HHRH is osteomalacia. The only abnormality seen in the asymptomatic hypercalciuric subjects was slightly extended osteoid surface. Parametric and nonparametric statistical analyses performed on a pooled sample of HHRH patients and asymptomatic hypercalciuric subjects revealed a very high inverse correlation and a tight linear relationship between serum phosphorus and osteoid parameters. Serum 1,25-dihydroxyvitamin D, which is low in other forms of hereditary hypophosphatemia and osteomalacia, is elevated in HHRH and correlated positively with osteoid parameters and the mineralization lag time. Serum alkaline phosphatase showed similar relationships. These results as well as the clinical, biochemical, and radiological remission of bone disease consequent to phosphate therapy strongly suggest that in HHRH 1) hypophosphatemia alone is sufficient to cause osteomalacia; and 2) the elevation of 1,25-dihydroxyvitamin D reflects the degree of the primary renal phosphate leak, but is not involved in the pathogenesis of the bone disease. | 4 |
A videofluoroscopy chair for the evaluation of dysphagia in patients with severe neuromotor disease. Due to the difficulties encountered in positioning severely neurologically impaired individuals for videofluoroscopic studies, the Rehab Tech Video FluoroChair was developed. The purpose of the chair is to provide the severely disabled patient with safe, stable postural support in an upright position for videofluoroscopic studies, with anterior-posterior, lateral, and rotational views easily performed. The chair features a removable headrest, a full back support, armrests, lateral truncal supports, and a patented base which is clamped to the footboard of the radiology table and allows for 200 degrees rotation of the patient. Two case studies illustrate the practical use and versatility of the Rehab Tech Video FluoroChair. | 1 |
The pharmacokinetics of plasminogen activator inhibitor-1 in the rabbit. The pharmacokinetics of the activated and latent forms of plasminogen activator inhibitor-1 (PAI-1) isolated from HT1080 fibrosarcoma cells (HT1080 PAI-1) and a nonglycosylated form of human PAI-1 isolated from a yeast expression system (rPAI-1) were followed in the rabbit. As assessed by an immunologic assay specific for human PAI-1, guanidine HCI activated HT1080 PAI-1 and rPAI-1 entered the total plasma volume following intravenous bolus administration and exhibited a biphasic clearance pattern. The t1/2s of HT1080 PAI-1 for the initial and beta phases equalled 6.0 and 24.8 minutes, respectively. The t1/2s of rPAI-1 for the initial and beta phases equalled 8.8 and 34.0 minutes, respectively. Similar results were obtained by measuring PAI-1 activity in plasma and with trace amounts of 125I-rPAI-1, suggesting that the above pharmacokinetic behavior could also apply to endogenous PAI-1. The liver was the main site of rPAI-1 clearance. Unactivated, latent PAI-1 exhibited a very different pharmacokinetic profile. Over 80% of latent rPAI-1 cleared from the circulation within 10 minutes (t1/2 = 1.7 minutes). The difference in clearance behavior between activated and latent PAI-1 may be related to the ability of activated PAI-1, but not latent PAI-1, to rapidly form high-molecular-weight complexes with plasma binding factors which were observed in vitro and in vivo. Because PAI-1 could potentially tilt the fibrinolytic balance toward a prothrombotic state, its rapid clearance may represent an important control mechanism governing the circulating levels of this key component of the fibrinolytic pathway. | 0 |
Treatable complications in undiagnosed cases of autosomal dominant polycystic kidney disease. In a study to determine the proportion of unrecognised cases and the prevalence of treatable complications of autosomal dominant polycystic kidney disease (ADPKD), 46 probands were identified through genetics and renal clinics in Melbourne, Australia. 321 offspring of the probands who were older than 15 years and had not been previously diagnosed as having ADPKD were identified. 68 (21%) had ultrasound evidence of polycystic kidney disease. Of this previously undiagnosed group, 25 (37%) had one or more treatable complications at the time of diagnosis. The complications included 20 cases of hypertension (diastolic blood pressure 95 mm Hg or above), 7 cases of impaired renal function (serum creatinine 0.12 mmol/l or above), and 4 cases of bacterial urinary tract infection. 8 people had several complications. ADPKD has an important treatable component which is not being treated in a substantial proportion of affected individuals, because the disease is not being diagnosed despite the presence of a positive family history. | 3 |
Histologic evaluation of the larynx in sudden infant death syndrome. Seventy-four larynges removed at death from children who died of sudden infant death syndrome (SIDS) have been studied by serial sectioning in the transverse plane. An increase in subepithelial glandular tissue is seen in many specimens, and the reduction in the available subglottic area has been measured with the Measuremouse Image Intensifying system. This preliminary report confirms that in some of these children with SIDS, particularly around the age of 3 months, there is a potentially lethal reduction in subglottic airway secondary to an increase in mucus-secreting glands, possibly from an associated mild upper respiratory tract infection. Accepting that adequate control infants within this age group who have not had any trauma to the laryngotracheal area are not available, these findings offer a possible explanation for what are always tragic events. | 4 |
The Madigan prostatectomy. A total of 59 patients with bladder outflow obstruction underwent the Madigan prostatectomy. The method, results and complications are described. For select patients with large benign adenomas without a median lobe or hematuria we believe the technique to be the operation of choice, particularly in younger patients. Advantages include absence of postoperative hematuria and clot retention, a decreased requirement for blood transfusions, a 16F postoperative catheter with early removal, avoidance of post-catheter stricture, a low rate of postoperative urinary infection, a short comfortable period of hospitalization and, in the long term (median followup 6 years), preservation of potency and antegrade ejaculation. | 4 |
Chondrosarcoma of the larynx. Diagnosis with magnetic resonance imaging and computed tomography. Chondrosarcomas are the most common sarcomas of the larynx. They are generally slow-growing lesions with insidious onset of symptoms. We are presenting a case of chondrosarcoma that recurred 10 years after excision of a presumed chondroma. Computed tomographic and magnetic resonance imaging (MRI) scans were performed. Both studies delineated the lesion nicely. To the best of our knowledge, this is the first report on MRI characteristics of chondrosarcoma of the larynx. A review of the literature regarding the use of computed tomography in the management of chondrosarcoma is presented. The MRI characteristics are discussed and the two scanning modalities are compared. Computed tomography is an excellent study in its ability to demonstrate the extent of the lesion within the laryngeal skeleton. Furthermore, it is more highly sensitive than plain roentgenograms in the detection of calcifications that are highly suggestive of chondrosarcoma. Alternatively, MRI can also demonstrate the lesion within the larynx but it has the added advantage of superior contrast resolution of the tumor and paralaryngeal tissues. When the three-dimensional imaging capacity of MRI is considered as well, MRI seems to be the superior study. | 0 |
Malignant potential of juvenile polyposis coli. Report of a case and review of the literature. Juvenile polyps of the colon and rectum traditionally have been viewed as being benign inflammatory or harmartomatous lesions without potential for malignant change. The authors report a case of adenocarcinoma developing in a patient with sporadic juvenile polyposis. Juvenile polyposis was diagnosed in the patient at age 4 years. He underwent subtotal colectomy at age 6 years. At age 12, he underwent a proctectomy and a Swenson pull-through because of adenomatous changes in the rectal stump. At age 19 surveillance endoscopy revealed invasive cancer in a juvenile polyp. | 0 |
Specific binding sites for insulin-like growth factor I in the ovarian stroma of women with polycystic ovarian disease and stromal hyperthecosis. Women with polycystic ovarian disease and hyperthecosis have hyperinsulinemia and insulin resistance. It is possible that insulin in supraphysiologic concentration exerts its steroidogenic action on ovarian stromal cells through insulin-like growth factor I receptors. We undertook this study to investigate whether the ovarian stroma of women with hyperthecosis has specific binding sites for insulin or insulin-like growth factor I. Ovarian stromal tissue was obtained from seven women with normal ovulatory cycles and from five women with hyperthecosis of the ovaries. Binding studies with insulin tagged with iodine 125 and insulin-like growth factor I tagged with iodine 125 revealed specific binding sites both for insulin and insulin-like growth factor I in the ovarian stroma. The binding of insulin tagged with iodine 125 in the ovarian stroma of women with hyperthecosis (3.4% +/- 1.1% (+/- SE) per 100 micrograms protein) was significantly (p less than 0.04) lower than that observed in normal premenopausal women (8.3% +/- 1.6% per 100 micrograms protein). By contrast, the specific binding of insulin-like growth factor I tagged with iodine 125 in the ovarian stroma of women with hyperthecosis (7.1% +/- 1.7% per 100 micrograms protein) was higher than that observed in the ovarian stroma from normal women (4.5% +/- 1.7% per 100 micrograms protein), although the difference was not statistically significant. The affinity constants for these high-affinity receptors were similar (1.2 to 3.6 x 10(9) L/mol) in the two groups of women. These results indicate that (1) the ovarian stroma has specific binding sites both for insulin and for insulin-like growth factor I; (2) in women with hyperthecosis, the ovarian stroma has decreased binding sites for insulin but has normal concentrations of insulin-like growth factor I receptors; and (3) in women with hyperthecosis, stimulation of ovarian androgen synthesis by insulin may be mediated through the insulin-like growth factor I receptors. | 4 |
Balloon dilatation versus surgical revision of infra-inguinal autogenous vein graft stenoses: long-term follow-up. Although infra-inguinal autogenous vein graft stenoses may be treated by balloon dilatation (PTA) or surgical revision, the optimal approach is undefined. Over the last 7 years 24 PTA procedures were performed on 37 vein graft stenoses in 19 grafts. Graft stenoses were diagnosed from 2 to 72 (mean = 17.3) months after implantation. PTA was successfully completed in 23 (96%) of the 24 procedures including 18 (95%) of the primary, and 5 (100%) of the secondary procedures. Recurrent vein graft stenosis or graft thrombosis developed in 12 (67%) grafts from 3 to 47 (mean = 12.5) months after primary PTA. Long-term patency after primary PTA was 69% at 6, 29% at 12, and 22% at 36 months; secondary patency was 81% at 6, 45% at 12, and 27% at 36 months. During the same period vein graft stenosis in 7 fem-pop and 2 fem-tib grafts were surgically revised with an initial success rate of 100%, and 2 (22%) complications. Four (44%) of these grafts occluded from 1-17 (mean 6.2) months after repair, yielding a primary 5-year patency of 62%. Although vein graft stenosis may be safely, effectively, and repeatedly treated with PTA, long-term durability appears to be superior after surgical revision. | 4 |
The effects of age and peripheral vascular disease on the circulatory and mechanical response of skin to loading. The skin and subcutaneous soft tissues of amputation residual limbs are required to withstand externally applied loads of greater magnitude than similar tissues of the intact lower limb. Increased age and poor circulatory status may contribute to the increased risk of tissue injury seen in this population. This study evaluates the effects of age and circulatory status as risk factors for skin injury resulting from externally applied forces. Twelve young control (YC), six elderly control (OC) and 11 subjects with peripheral vascular disease (PVD) were studied. After base-line ankle arm index (AAI) measurements, TcPO2 electrodes were applied 10 cm below the knee over the medial surface of the tibia and the muscle belly of tibialis anterior. TcPO2 measurements and tissue displacements were obtained under the influence of incremented, normally oriented, external loads. The sensitivity of the tissues to applied loads was determined by calculating the load at which the TcPO2 reached zero. The stiffness of the tissues (displacement/load) was calculated under high (greater than 40 mm Hg) and low (less than 20 mm Hg) loading conditions. No difference was noted in tissue sensitivity to applied loads between the OC and YC populations. The TcPO2 decreased to zero in the PVD population at significantly lower applied loads than both the OC and YC populations. The tissue stiffness of the PVD and the OC populations over bone was greater than the YC population, but no significant differences were noted between the PVD and the OC populations. In summary, increased age does not result in a greater tissue sensitivity to externally applied loads, in spite of the demonstrated increased tissue stiffness. | 3 |
Prognostic value of radionuclide angiography in medically treated patients with coronary artery disease. A comparison with clinical and catheterization variables. To evaluate the usefulness of multiple measures from rest and exercise radionuclide angiography (RNA) in predicting cardiovascular death and cardiovascular events (death or nonfatal myocardial infarction) and to assess the prognostic usefulness of the RNA relative to clinical and catheterization data, we studied 571 stable patients with symptomatic coronary artery disease who had upright rest/exercise first-pass RNA within 3 months of catheterization and were medically treated. With a median follow-up of 5.4 years, 90 patients have died from cardiovascular causes, and 147 patients have either died or suffered a nonfatal myocardial infarction. Using the Cox regression model and a preselected group of RNA variables, the most important RNA predictor of mortality was exercise ejection fraction (chi 2 = 81, p less than 0.00001). Neither rest ejection fraction nor the change in ejection fraction from rest to exercise contributed additional predictive information. Two other RNA study variables, the change in heart rate from rest to exercise and rest end-diastolic volume index, did contribute additional prognostic information to the exercise ejection fraction (chi 2 = 23, p less than 0.0001). Compared with noninvasive clinical data (history, physical examination, electrocardiogram, and chest radiograph), RNA variables were considerably more predictive of mortality (chi 2 = 71 [clinical variables] versus chi 2 = 104 [RNA]). Remarkably, the strength of the relation of RNA variables with mortality was equivalent to that of the set of catheterization variables previously demonstrated in our large angiographic population to be prognostically important (chi 2 = 104 [RNA] versus chi 2 = 102 [catheterization variables]). The RNA contained 84% of the information provided by clinical and catheterization descriptors combined. Furthermore, the RNA contributed significant additional prognostic information to the clinical and catheterization data (chi 2 = 13.6, p = 0.0035). For cardiovascular events, the relative prognostic usefulness of the RNA was similar, although relations with this outcome were generally weaker. Descriptors from the rest/exercise RNA exhibit a powerful relation with long-term outcomes and can be useful in defining risk, even when clinical and catheterization data are available. | 3 |
Corneal sensitivity and correlations between decreased sensitivity and anterior segment pathology in ocular leprosy. Leprosy is one of the leading causes of corneal hyposensitivity. In this article the corneal sensitivity of 143 leprosy patients was examined, and correlations between corneal hyposensitivity and anterior segment pathology were detected. Twenty four healthy volunteers were examined as controls. Various degrees of corneal loss of sensitivity were found in 46.2% of leprosy patients. Lagophthalmos, chronic lepromatous granulomatous uveitis, iris atrophy, and social blindness were found 4.5-16.6 times more frequently in eyes which developed severe corneal hyposensitivity. | 4 |
Large diameter expanded polytetrafluoroethylene grafts for infrarenal aortic aneurysm surgery. The performance of an expanded polytetrafluoroethylene (ePTFE) graft used for aortic aneurysm replacement was evaluated. ePTFE grafts were implanted in 241 patients undergoing infrarenal abdominal aortic aneurysm (AAA) repair. Sixty patients were operated as emergencies for aneurysm rupture and 181 electively. One hundred and fourteen bifurcated and 127 tube grafts were inserted. The transperitoneal approach was used in 64 cases and the remainder were placed using a retroperitoneal approach. There was a one-month mortality of 2.8% in elective and 20% in emergency cases. Median follow-up was 26 months. Specific graft complications included one infected graft resulting in a graft-enteric fistula. No graft rupture, degeneration, dilatation, pseudoaneurysm or late graft limb thromboses were observed in up to 7 years of follow-up. The aortic ePTFE prosthesis demonstrated satisfactory performance over the period studied. | 4 |
Radical prostatectomy and adjuvant radioactive gold seed placement: results of treatment at 5 and 10 years for clinical stages A2, B1 and B2 cancer of the prostate. Between 1977 and 1988, 131 patients with adenocarcinoma of the prostate underwent combined radical prostatectomy and intraoperative radioactive gold seed placement. Of these 131 patients 80 were clinically assessed as having stage A2 (12), B1 (43) or B2 (25) cancer and they are the subject of this review. The average dose of radioactivity administered to each patient was 96.6 mCi, and mean followup was 65 months (median 64 months). No patient in this series received any other form of adjuvant therapy until disease recurrence was demonstrated. Local recurrences were observed in 2 patients (2.5%) in this series while distant recurrences were observed in 10 (12.5%). Cancer specific survival free of disease at 5 years was 100% for clinical stage A2, 91% for B1 and 75% for B2 cancers. The 10-year survival free of disease was 100% for clinical stage A2, 82% for B1 and 68% for B2 cancers. Covariants of clinical stage and seminal vesicle involvement influenced survival free of disease in a statistically significant manner (p less than 0.05) while pathological stage and degree of tumor differentiation did not. Mild to severe complications were observed in 12 patients (15%). Intraoperative placement of radioactive gold seeds into unresected pelvic tissues surrounding the site of prostatectomy offers a theoretical advantage in treatment by delivering tumoricidal levels of irradiation to residual foci of cancer not appreciated at the time of surgery. Our results suggest that increases in cancer specific survival free of disease over that previously reported for prostatectomy alone may be achieved through this combined treatment regimen. Furthermore, it is our opinion that therapeutic gains can be achieved without the attendant increases in morbidity and treatment delay often associated with adjuvant external beam radiotherapy. | 0 |
Delayed subcapsular hematoma after percutaneous liver biopsy as a manifestation of warfarin toxicity. Guidelines for the management of patients receiving chronic anticoagulation therapy who require liver biopsy are not clearly defined. In patients with normal coagulation, liver biopsy is a relatively safe procedure with a morbidity of less than 0.1% and a mortality of less than 0.01%. We report a patient with a prosthetic aortic valve who developed a large subcapsular hematoma 12 days after a percutaneous liver biopsy as a consequence of warfarin toxicity. Based on the experience with this patient, reinstitution of anticoagulant therapy should be avoided for at least 72 h after a percutaneous liver biopsy. Intravenous heparin should be resumed first, and warfarin added if no bleeding has occurred after an additional 48-72 h. The prothrombin time should be maintained at 1.5 times the baseline. | 4 |
Serum and CSF levels of IL-2, sIL-2R, TNF-alpha, and IL-1 beta in chronic progressive multiple sclerosis: expected lack of clinical utility. We measured interleukin-2 (IL-2), soluble IL-2 receptor (sIL-2R), tumor necrosis factor-alpha (TNF-alpha), and interleukin-1 beta (IL-1 beta) by ELISA in paired sera and CSF from 50 chronic progressive multiple sclerosis (CPMS) patients during worsening disability, 19 patients with other neurologic diseases (OND), and in sera from 40 healthy volunteers. In the CPMS patients, 28% (14/50), 10% (5/50), 16% (8/50), and 6% (3/50) had elevated serum levels of IL-2, sIL-2R, TNF-alpha and IL-1 beta, respectively, compared with healthy controls. The only analyte we detected in the CSF was IL-2 in 1 CPMS patient (1/50, 2%). We also saw elevated serum sIL-2R in 16% (3/19) of OND patients. We found no significant difference in mean levels of serum sIL-2R between the 3 groups. Our study, the largest to date of CPMS patients, shows that serum and CSF levels of IL-2, sIL-2R, TNF-alpha, or IL-1 beta are not sensitive for, and the serum sIL-2R level is not specific for, CPMS. Therefore, measurement of these analytes will not be clinically useful for therapeutic or prognostic purposes in the majority of CPMS patients. | 4 |
Postoperative urinary tract infection in gynecology: implications for an antibiotic prophylaxis policy. A prospective observational study of postoperative infection after gynecologic surgery assessed the need for antibiotic prophylaxis with special reference to the urinary tract. Catheterization requirements in the postoperative period were compared with the development of urinary tract infection after excluding both preoperative and postoperative bacteriuria. Forty-six of 115 patients (40%) developed a urinary tract infection in the postoperative period. Furthermore, this was not clearly related to the need for postoperative catheterization. Significant wound and vaginal vault infections were uncommon, indicating that antibiotic prophylaxis should be directed specifically at the urinary tract. | 4 |
Case-control study of Cryptosporidium parvum infection in Peruvian children hospitalized for diarrhea: possible association with malnutrition and nosocomial infection. A retrospective, hospital-based case-control study was used to investigate whether there were any clinical characteristics that could distinguish Cryptosporidium parvum-infected children with diarrhea from other non-C. parvum-infected children with diarrhea. Ten percent (24 of 248) of children admitted to a rehydration ward at Cayetano Heredia University Hospital, Lima, Peru, were infected with C. parvum. The 24 patients infected with C. parvum (cases) were matched to an equal number of noninfected patients (controls). C. parvum-infected patients were more likely to be malnourished than were children without this infection (P less than 0.05). Also nosocomial infection caused by C. parvum occurred in three severely malnourished patients, two of whom died. No other clinical or laboratory characteristics were found that would distinguish children with diarrhea caused by C. parvum from other children with diarrhea. In children hospitalized for diarrhea C. parvum infection occurs most frequently in malnourished children. | 1 |
The use of a biodegradable mesh to prevent radiation-associated small-bowel injury. Radiation-associated small bowel injury occurs in up to 50% of patients receiving postoperative radiotherapy following pelvic cancer surgery. We describe our experience using a biodegradable mesh that allows the small bowel to be supported above the pelvic inlet and is totally absorbed following radiation therapy. Between 1985 and 1989, 45 procedures were performed in patients with carcinoma of the rectum (anterior resection in 15 patients, abdominoperineal resection in 23 patients, pelvic exenteration in six patients, and proctocolectomy in one patient). In 30 patients a polyglycolic acid (Dexon) mesh was used, and in 15 patients a polyglactin 910 (Vicryl) mesh was used. Forty-four patients received postoperative radiotherapy. The mean (+/- SEM) dose was 56.8 +/- 18.4 Gy. There were no immediate complications related to the mesh. Follow-up ranged from 12 to 53 months (median follow-up, 34 months). With the exception of two patients who had a polyglactin 910 mesh and who developed bowel obstruction due to adhesions under the anterior abdominal wall, there has been no documented incidence of clinical radiation-associated small bowel injury. The use of the absorbable mesh may permit us to use higher doses of postoperative radiotherapy without the associated hazard of radiation-associated small bowel injury. | 0 |
Neurogenic control of the cerebral circulation during global ischemia. The influence of the trigeminal nerve on the cerebral circulation was investigated in chronically denervated cats during and after reversible four-vessel occlusion for 10 minutes combined with controlled hypotension (50 mm Hg). Postocclusive hyperemia 30 minutes after reperfusion was attenuated by up to 48% in cortical gray matter of the anterior, middle, and posterior cerebral artery territories on the side of trigeminal ganglionectomy. Similar results were observed for denervation accomplished by direct surgical ablation and by the topical application of capsaicin to a cortical branch of the middle cerebral artery. Denervation did not alter basal cerebral blood flow or the duration of hyperemia, nor did it impair the cerebrovascular response to hypercapnia. These data demonstrate the importance of neurogenic mechanisms in the development of postischemic hyperperfusion and suggest that strategies directed at blocking axon reflex-like mechanisms may be beneficial in reducing the morbidity that follows severe cortical hyperemia. | 3 |
A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. We performed truncal posterior right vagotomy with lesser curve anterior gastric myotomy by videocoelioscopy on 10 patients (5 men and 5 women, ranging in age from 19 and 54 years, with a mean age of 32 years). All had a long history of chronic duodenal ulcer with a mean duration of symptoms of 3.8 years. The mean length of the operation was 60 minutes (range: 55 to 110 minutes). There was no morbidity, and all patients were discharged after 5 days. The acid secretion tests under basal conditions and under insulin stimulation preoperatively and 1 month postoperatively showed a mean decrease in the basal output of 79.3% and a mean decrease of 83.04% in the maximal output. The fibroscopic control at the second postoperative month showed a complete healing of the ulcer in nine patients and a residual ulcer scar in one. No patients had any abdominal complaints. Right truncal vagotomy and anterior lesser curve seromyotomy by videocoelioscopy is an efficient and elegant method of treating chronic duodenal ulcer, but it needs thorough experimental practice. | 1 |
Causes of death in hospitalized intravenous drug abusers. The authors reviewed at autopsy the causes of death of 274 patients with evidence of intravenous drug abuse who had been admitted to a large public hospital. There were 127 who died from diseases unrelated to intravenous drug abuse, and in 41% of these, chronic alcoholism was implicated. Deaths from overdose syndromes and drug-related organ pathology comprised only 11% of all cases. The mean age at death was 39 years. There was a male/female ratio of 3.6:1. Half of all patients died from infection--72 from acquired immunodeficiency syndrome (AIDS) alone. These findings indicate that persons hospitalized with a history of intravenous drug abuse usually die from causes other than overdose and that AIDS and chronic alcoholism are significant problems. Emphasis should be placed upon detecting "hidden" intravenous drug deaths to provide more accurate statistical information. | 0 |
Coronary artery pattern and outcome of arterial switch operation for transposition of the great arteries. A successful outcome of an arterial switch operation (ASO) for dextro-transposition of the great arteries (D-TGA) depends in large part on the transfer of the coronary arteries to the neoaorta without distortion or narrowing. However, the origins and distribution of the coronary arteries are quite variable in D-TGA; therefore, the entire experience with ASO at the Children's Hospital in Boston was reviewed. From 1983 through November 1989, 314 patients underwent surgery for D-TGA with the intent to perform an ASO. An ASO was actually performed in 290 patients, and 20 patients died, with 12 deaths (4.2%) clearly related to problems with the coronary arteries (CA deaths). The ASO was aborted to a Senning operation in 24 patients (7.6%), primarily due to coronary anatomy. Eight coronary patterns were identified and related to the outcome of the ASO. In 182 patients with the "usual" coronary pattern for D-TGA (i.e., anterior descending and circumflex arteries from the left sinus and right coronary artery from the right sinus), five CA deaths occurred, and two patients had Senning operations. Sixty-seven patients had right coronary and circumflex arteries from the right sinus and anterior descending arteries from the left sinus. Three CA deaths occurred, and one patient had a Senning operation. Single right coronary artery was found in 14; 12 had ASOs with three CA deaths (25%); and two had Senning operations. One late death was due to diffuse narrowing of the single right coronary artery. Single left coronary artery occurred in 11 patients, and seven had ASO with no early but one late "sudden" death, whereas four had Senning operations. | 3 |
The role of antihistamines in the treatment of chronic urticaria. For many years, H1 antihistamines have been the primary management option for urticaria. However, undesirable side effects, particularly daytime sedation, have limited the usefulness of these classic antihistamines. A new class of peripherally acting, nonsedating antihistamines (e.g., terfenadine, astemizole, loratadine, and cetirizine) has proved to have clinical efficacy comparable with the classic antihistamines. In comparative trials between the various nonsedating agents, no significant difference in efficacy has been noted. All these agents have good safety profiles, although astemizole use has been correlated with increased appetite and weight gain in some patients, and cetirizine has caused slightly increased sedative effects compared with placebo. Although H1/H2 antihistamine combinations have been proposed as possible treatments for urticaria, studies have produced mixed results. | 4 |
Cells secreting anti-MAG antibody occur in cerebrospinal fluid and bone marrow in patients with polyneuropathy associated with M component. Occurrence and distribution of cells secreting antibodies against myelin associated glycoprotein (MAG) were studied in 9 patients with polyneuropathy associated with the monoclonal (M) component in serum. Utilizing an immunospot assay, we found that 4 of 7 patients with polyneuropathy associated with an IgM M component had cells secreting anti-MAG IgM antibody in cerebrospinal fluid (CSF) numbering between 1 per 212 and 1 per 3333 mononuclear cells. All 7 patients had cells secreting anti-MAG IgM antibody in bone marrow (median value 1 per 2000 cells). In contrast, peripheral blood from only 2 of these patients contained low numbers of such cells. One patient with polyneuropathy associated with an IgA M component had cells secreting anti-MAG IgA antibody in CSF, and 1 with an IgG M component had cells secreting anti-MAG IgG antibody in CSF; both patients also had anti-MAG IgM antibodies detectable in CSF only by ELISA. These 2 patients may thus have concurrent intrathecal production of antibodies of 2 different isotypes which are directed against the same or different epitopes of MAG. The production of antibodies directed against a component of myelin occurring in the immediate vicinity of the peripheral nervous system might be involved in the pathogenesis of the polyneuropathy. | 2 |
Clinical and biologic effects of granulocyte colony stimulating factor in the treatment of myelokathexis. Successful treatment of a patient with myelokathexis, a rare form of chronic neutropenia associated with recurrent infections, is described. Rapid mobilization of bone marrow neutrophils and improved myeloid morphologic features were observed after treatment with human granulocyte colony stimulating factor. Transient thrombocytopenia and bone pain were observed during treatment. Although neutrophil chemotaxis, superoxide production, and FcRIII surface expression were reduced, the patient improved clinically after restoration of a normal neutrophil count. | 4 |
Catheter-based intravascular ultrasound imaging of chronic thromboembolic pulmonary disease. Pulmonary thromboendarterectomy is now the treatment of choice for pulmonary hypertension due to chronic pulmonary thromboemboli. A precise assessment of location and extension of these thrombi is important because only proximal chronic pulmonary thromboemboli are accessible to surgery. Because intravascular ultrasound imaging can assess not only arterial luminal size, but also wall thickness, its value as a complement to angiography was assessed in 11 patients aged 35 to 64 years with severe pulmonary hypertension (systolic pulmonary artery pressure, mean +/- standard deviation 70 +/- 19 mm Hg; pulmonary artery resistance, 609 +/- 297 dynes.s.cm-5). Intravascular ultrasound was obtained in 10 of 11 patients and no complication occurred. Intravascular ultrasound identified 10 segments with suspected chronic pulmonary thromboemboli in 7 patients, all confirmed at operation. Nine segments were considered normal, all of which (except 1) were free of chronic pulmonary thromboemboli at operation. Image quality was highly dependent on pulmonary artery size and position of the catheter. Therefore, intravascular ultrasound of pulmonary arteries is feasible and safe in patients with pulmonary hypertension. It may help to assess the location and extension of the pathologic process involving pulmonary arteries. | 3 |
IgD immune complex vasculitis in a patient with hyperimmunoglobulinemia D and periodic fever. We describe a 27-year-old Dutch woman with the hyperimmunoglobulinemia D and periodic fever syndrome. During febrile attacks she occasionally presented with skin lesions on the distal parts of her upper and lower extremities, with the histologic picture of a leukocytoclastic vasculitis. Clear perivascular deposits of IgD and C3 were presented in early lesional skin on immunofluorescence investigation. Circulating IgD immune complexes were demonstrated on several occasions, both during and in between clinical attacks. These findings are consistent with an IgD immune complex-mediated pathogenesis for the skin lesions. In 10 patients with other forms of immune complex vasculitis of the skin, minimal perivascular deposits of IgD were found in four cases. In these cases, however, IgD was never found as the solitary immunoglobulin class. | 3 |
The impact of right ventricular infarction on the prevalence of ventricular arrhythmias during acute inferior myocardial infarction. To determine the impact of RV infarction on the prevalence and complexity of ventricular arrhythmias during inferior AMI, 57 patients with no prior MI were studied by 24-hour Holter monitoring on the first and tenth days of AMI. Based on radionuclear studies, patients were allocated into two groups: (1) group A, 21 patients (37 percent) with normal RVEF (greater than or equal to 40 percent); and (2) group B, 36 patients (63 percent) with depressed RVEF (less than 40 percent). There were no significant differences between the groups regarding age and LVEF. Values of RVEF were 47 +/- 6 percent and 31 +/- 6 percent, respectively (p less than 0.05). The RVEF had no influence on the prevalence and complexity of early and late arrhythmias. Stratification of patients in group B into two subgroups based on the extent of RV dysfunction did not reveal any differences in the occurrence of all forms of ectopy (when both groups were matched to group A). Therefore, patients with inferior AMI, with or without RV infarction, have a similar prevalence of arrhythmias. Ventricular ectopic beats may be related to the severity and spread of LV involvement, rather than to RV dysfunction. | 4 |
Primary adenocarcinoma of the temporal bone. A case with 40-year follow-up. Adenomatous tumors of the temporal bone are rare neoplasms. This article records the 40-year course of a patient with adenocarcinoma of the temporal bone and reviews the literature pertinent to the biologic behavior, histologic appearance, prognosis, and treatment of this group of tumors. | 0 |
Pharmacokinetics of tiaprofenic acid after oral administration in fasting patients during and between migraine attacks. This study examined the pharmacokinetics of 300 mg of tiaprofenic acid, a NSAID belonging to the 2-arylpropionic class, as a single oral dose, in 10 migraine patients during and out of migraine attacks. Plasma concentration of tiaprofenic acid was determined by HPLC analysis. Drug absorption appeared to be the same during and out of migraine attacks (absorption half life: during attack, 0.249 +/- 0.122 hr; out of attack, 0.249 +/- 0.105 hr; maximum plasma concentration: during attack, 37.8 +/- 9.8 ug/ml; out of attack, 40.1 +/- 13.2 ug/ml). The other pharmacokinetic parameters evaluated were not affected by headache attacks as well. We conclude that tiaprofenic acid absorption and metabolism are not affected by migraine attacks. Also, our data suggest that tiaprofenic acid might be useful in the treatment of migraine. | 2 |
How stressful is retirement? Findings from the Normative Aging Study. The stressfulness of retirement both as a transitional event experienced during the past year and as a life stage was investigated. Transitional stress was assessed using a life events approach, and stage stress using a "hassles" approach. Respondents were 1,516 male participants in the Normative Aging Study, 45% of whom were retired. Among those retiring in the past year, respondents' own and spouse's retirement were rated the least stressful from a list of 31 possible events. Only 30% found retirement stressful. Retirement hassles were also less frequently reported and were rated less stressful than the work hassles of men still in the labor force. The only consistent predictors of both transitional and stage retirement stress were poor health and family finances; personality did not predict retirement stress. | 4 |
Levels of disability among U.S. adults with arthritis. This article studies the excess levels of disability experienced by persons with arthritis, compared to persons without the disease. The data set is the Supplement on Aging (1984 National Health Interview Survey); it has information for a national probability sample of community-dwelling persons ages 55 + (N = 16,148). (1) Arthritis people have more difficulty in physical functions, personal care, and household care than do nonarthritis persons. The excess disability is greatest for physical functions (walking, reaching, stooping, etc.). Disabled arthritis people have especially high degrees of difficulty in physical activities that require endurance and strength. (2) Various models are tested for walking, grasping, shopping, and light housework to show how comorbidity propels disability for arthritis people and to show arthritis' own contribution to disability in the presence of other chronic conditions. Difficulties escalate for arthritis people when they have other concurrent conditions. These models affirm that arthritis has a pronounced effect on physical dysfunctions, but these are not readily translated into personal and household care problems. Apparently, arthritis people often make successful accommodations so their roles and daily activities are not seriously affected by the disease. | 4 |
LDH isoenzymes in cerebrospinal fluid in various brain tumours. This study examined the isoenzymatic pattern of LDH in the cerebrospinal fluid (CSF) as well as the ratio between the five fractions of LDH among patients with various brain tumours, carcinomatous meningitis and control groups. LDH 1/LDH 2 less than 1 was found significant for carcinomatous meningitis (p less than 0.001) and brain metastases (p less than 0.001). LDH 1/LDH 2 ratio was found to be significantly lower in carcinomatous meningitis than in brain metastases (p less than 0.05). No LDH 1/LDH 2 ratios smaller than 1 were found in the other groups. The LDH 1/LDH 2 ratio smaller than 1 was found in the early stage of carcinomatous meningitis without other evidences of the involvement of the leptomeninges. Examination of LDH 1/LDH 2 can be found as an adjunctive method to identify brain metastases and carcinomatous meningitis at the initial stage. | 0 |
Orthostatic hypotension after spinal cord injury: treatment with fludrocortisone and ergotamine. We report a case of a 28-year-old woman with C5 quadriplegia, unresponsive to conservative treatment for orthostatic hypotension. Ergotamine, daily combined with fludrocortisone, successfully prevented symptomatic hypotension. In this report, neural, renal, and hormonal blood pressure regulatory mechanisms are described. Experiences obtained from this case and the existing literature suggest that (1) in persons with quadriplegia, plasma catecholamine levels show little increase with sitting, indicating an inability to activate baroreceptor and chemoreceptor reflexes, (2) elevated plasma aldosterone and renin levels indicate a renal compensatory response to decreased renal perfusion secondary to low plasma volume and/or chronic hypotension, and (3) the net effect of ergotamine and fludrocortisone is probably a combination of plasma volume expansion and direct peripheral vasoconstriction. | 3 |
Thyroid cancer. There have been important recent advances in our understanding of the biologic nature of thyroid cancer and in the early diagnosis of the disease. Despite these advances, there is still considerable controversy over the management of thyroid cancer, including the extent of surgery, the indications for the use of iodine-131, the effectiveness of thyroid-stimulating hormone suppression, and the prediction of outcome. In this review, the current status of the diagnosis and management of the various types of thyroid cancer are carefully reviewed and extensively documented. | 0 |
The nature of opioid responsiveness and its implications for neuropathic pain: new hypotheses derived from studies of opioid infusions. In recent years, the observation that the response of patients to opioid drugs may be influenced by properties inherent in the pain or pain syndrome, such as its pathophysiology, has evolved into the belief that certain types of pain, e.g., neuropathic pains, may be unresponsive to these drugs. This concept has important implications for both clinical practice and basic understanding of opioid mechanisms. We critically evaluate opioid responsiveness, particularly as it relates to neuropathic pain, and propose a clinically relevant definition and a paradigm for its investigation. The paradigm is illustrated by analgesic responses to opioid infusion in 28 patients with neuropathic pains and by a detailed presentation of the pharmacokinetic and pharmacodynamic relationships in one of these patients, whose central pain responded promptly to an infusion of hydromorphone. From this analysis, we hypothesize that (1) opioid responsiveness in man can be defined by the degree of analgesia achieved during dose escalation to either intolerable side effects or the occurrence of 'complete' or 'adequate' analgesia; (2) opioid responsiveness is a continuum, rather than a quantal phenomenon; (3) opioid responsiveness is determined by a diverse group of patient characteristics and pain-related factors, as well as drug-selective effects; and (4) a neuropathic mechanism may reduce opioid responsiveness, but does not result in an inherent resistance to these drugs. Given the complexity of factors contributing to opioid responsiveness and the observation that outcome cannot be reliably predicted, opioids should not be withheld on the assumption that pain mechanism, or any other factor, precludes a favorable response. Both the clinical use of opioids and paradigms to investigate opioid responsiveness should include dose escalation to maximally tolerated levels and repeated monitoring of analgesia and other effects. | 2 |
The iris in Williams syndrome. Forty three children with Williams syndrome and 124 control subjects had their eyes photographed. The photographs were examined by three ophthalmologists and four geneticists of varying experience. A stellate pattern was noted more often in the irides of patients with Williams syndrome (51%) than in those of the control subjects (12%), and was more difficult to detect, or was absent, in heavily pigmented irides. We conclude that the stellate pattern is of diagnostic importance, particularly if the pattern is carefully defined and the clinician is experienced. | 3 |
Haemangiosarcoma of the maxillary antrum. Angiosarcomas are extremely rare in the head and neck and the histological diagnosis is often difficult. We present a case of a haemangiosarcoma of the maxillary antrum in a 33 year old male. The histological diagnosis and subsequent management are discussed. | 0 |
Morphometry of the subepithelial circulation in sheep airways. Effect of vascular congestion. In order to quantitate the subepithelial microvascular volume and its relation to the airway lumen, we conducted a morphometric analysis of the vascular compartment in the wall of the trachea (within a 55-microns depth from the epithelial basement membrane) and of 1.0 and 0.5-mm bronchioles of sheep. The lungs were fixed by bronchial and pulmonary artery perfusion with glutaraldehyde under three experimental conditions: (1) bronchial artery pressure, 100 mm Hg pulmonary artery pressure, 20 mm Hg (control); (2) bronchial artery pressure, 100 mm Hg, pulmonary artery pressure, 40 mm Hg (pulmonary hypertension, PH); (3) bronchial artery pressure, 100 mm Hg, pulmonary artery pressure, 40 mm Hg (pharmacologic vasodilation with sodium nitroprusside, PH + V). Venous pressures were atmospheric. Under control conditions, the microvascular volume fraction comprised 12, 16, and 15% of the subepithelial tissue in the trachea and 1-mm and 0.5-mm bronchioles, respectively. PH increased the microvascular volume fraction in the bronchioles (p less than 0.05), but it had no effect on the microvasculature in the trachea. PH + V approximately doubled the microvascular volume fraction in the trachea and the bronchioles. PH increased the mean wall thickness, and PH and PH + V decreased the airway cross-sectional area in the 1-mm bronchioles. These observations demonstrate that the microvasculature constitutes a considerable volume fraction of the subepithelial airway tissue and that vascular congestion can narrow the bronchiolar lumen. | 3 |
Characterization of a large deletion associated with a polymorphic block of repeated dinucleotides in the type III procollagen gene (COL3A1) of a patient with Ehlers-Danlos syndrome type IV. Ehlers-Danlos syndrome type IV (EDS IV) is an autosomal dominant condition characterized by extreme fragility of skin, blood vessels, intestine, gravid uterus, and lungs. The phenotype is accounted for by mutations affecting the integrity and/or synthesis of the precursor procollagen molecules of type III collagen. In this article, we report the elucidation of the molecular defect in an EDS IV patient whose type III collagen was previously found to be structurally abnormal. We utilized PCR in a two-step process involving first the localization of the mutation in the mRNA and then the characterization of the defect in the gene. The results established the patient's heterozygosity for a genomic deletion of about 7.5 kb which eliminates 1,026 nucleotides of coding sequences in the message. The mutation arose as a result of an exon-to-intron recombination. The deleted segment extends from the 13th nucleotide of exon 9 to within a DNA sequence of intron 24, which is composed of a series of dinucleotide repeats. Using PCR, we tested the polymorphic nature of this DNA element on several unrelated individuals. Analysis of amplified genomic products of 45 chromosomes recognized at least four distinct allelic forms that display frequencies ranging from 5% to 61%. Mendelian segregation of three of the four alleles was established by the same method in a 3-generation family. | 4 |
Magnetic resonance imaging in Mayer-Rokitansky-Kuster-Hauser syndrome. Six girls with suspected Rokitansky syndrome underwent magnetic resonance imaging (MRI) and then sonography and laparoscopy to confirm the clinical diagnosis and define the precise characteristics of the malformation. The uterus was missing in all; four had mullerian rudiments in place of the uterus, which were cavitary in two as shown by sonography and in one by MRI. Both ovaries were present in all cases, normally located in four and extrapelvic in two; they were correctly identified by MRI in all cases and by sonography in four. Partially canalized vaginal rudiments were recognized by MRI in two girls and by sonography in one. One patient had unilateral renal agenesis, demonstrated by both MRI and sonography. Magnetic resonance imaging was more precise than laparoscopy and sonography in defining the anatomical characteristics of Rokitansky syndrome, and is less invasive and expensive than laparoscopy. | 4 |
Final height in boys with untreated constitutional delay in growth and puberty. To determine the natural history and psychological impact of the growth pattern in boys with constitutional delay in growth and puberty (CDGP), 43 boys presenting with short stature due to CDGP were followed up to final height. At presentation mean (SD) chronological age was 14.0 (1.9) years, bone age delay 2.7 (1.0) years, standing height standard deviation score (SDS) -3.4 (0.6), and predicted adult height SDS -1.3 (0.7). Final adult height SDS was -1.6 (0.9), measured at 21.2 (2.6) years. There was no significant difference between final height and predicted adult height, but there was a significant difference between final height and measured mid-parental height. Psychological questionnaires showed no significant difference in self esteem, marital, or employment state between the CDGP group and a control group. There was no correlation between self esteem and final height, but 25 felt their growth delay had affected their success either at school, work, or socially and 20 would rather have had treatment to advance their growth spurt. This study supports the more frequent use of active medical treatment to advance growth in boys with CDGP, and shows that although boys with CDGP reach their predicted heights, this is short for their families. | 4 |
Defective jejunal brush border membrane sodium/proton exchange in association with lethal familial protracted diarrhoea. The spectrum of clinical disease associated with specific defects in jejunal brush border membrane sodium/proton exchange is poorly defined and only two patients have been described so far. Jejunal brush border membrane transport studies were performed in a boy who presented with lethal familial protracted diarrhoea in the first few days of life. Using jejunal brush border membrane vesicles prepared from conventional jejunal biopsy specimens, initial sodium uptake under H+ gradient conditions was found to be only 6% of the mean control value. In contrast, sodium stimulated glucose uptake was normal. Our data confirm the importance of a congenital defect in this exchanger as a cause of severe sodium-losing diarrhoea and extend the spectrum of disorders characterised by a specific defect in brush border membrane Na+/H+ exchange to include some forms of lethal familial protracted diarrhoea. | 1 |
Frequency of low-grade residual coronary stenosis after thrombolysis during acute myocardial infarction. The clinical, angiographic and demographic characteristics of 42 patients with low-grade (less than 50%) residual stenosis at the infarct lesion after thrombolysis for acute myocardial infarction (MI) were assessed. The study group (group I) represented 21% of 198 consecutive patients receiving thrombolytic therapy over a 59-month period. Data on the 156 remaining patients were pooled for comparison (group II). Group I patients were predominantly men (86%) who were cigarette smokers (81%). Group II patients were predominantly men (75%, p greater than 0.10) but were significantly older (52 +/- 12 vs 56 +/- 10 years, p = 0.02). Prior acute MI or angina was unusual in group I. Sixty percent had no significant (greater than 50%) residual coronary artery disease while 25% had residual single artery disease. Average significant (greater than 50% diameter stenosis) residual vessel disease was 0.6 +/- 1.0 for group I and 1.9 +/- 0.9 for group II (p less than 0.001). In group I, average residual infarct lesion diameter stenosis was 36 +/- 7% in the right anterior oblique and 34 +/- 8% in the left anterior oblique views. Thirty-nine group I patients were discharged with medical therapy and 100% follow-up was obtained over a mean interval of 18 +/- 17 months. Fifteen patients experienced chest pain after acute MI accounting for 17 discrete events. Fifty-nine percent of group I had a benign course on follow-up. Eight events were classified as unstable angina, 4 as acute MI and 5 as atypical angina. Documented coronary vasospasm occurred in 3. | 3 |
Pseudocyst of the auricle: successful treatment with intracartilaginous trichloroacetic acid and button bolsters. Pseudocyst of the auricle is an asymptomatic, noninflammatory cystic swelling that typically involves the anthelix of the ear and results from an accumulation of fluid within an unlined intracartilaginous cavity. We report a patient with a recurrent pseudocyst of the auricle and describe a new surgical technique for treating this condition by applying 50% trichloroacetic acid to the intracartilaginous cavity and utilizing external button bolsters for compressive therapy. This therapeutic approach is simple to perform in the office, results in permanent resolution of the pseudocyst, preserves the normal architecture of the external ear, and provides excellent postoperative and long-term cosmetic results. | 4 |
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