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Effects of n-3 fatty acids in essential hypertension. We examined the effects on blood pressure, plasma lipoproteins, and platelet function when marine oil supplements (rich in n-3 fatty acids) or vegetable oil supplements (rich in n-6 fatty acids) were added to the usual diets of patients with mild essential hypertension. In a randomized, double-blind, parallel-group study, patients received 50 g of either marine oil (n = 8) or vegetable oil (n = 8) daily for 6 weeks following a baseline observation period. Diastolic blood pressure declined during treatment with fish oil (mean +/- SEM, 96 +/- 2 v 89 +/- 2 mm Hg, P = .02), but did not change with vegetable oil (92 +/- 1 v 94 +/- 1 mm Hg). Systolic blood pressure did not change significantly during either treatment. Serum triglycerides declined (by approximately 30%) in patients receiving only marine oil, but total cholesterol, LDL-, HDL-, HDL2-, and HDL3-cholesterol-subfractions and apolipoproteins A-I and B were unchanged in both treatment groups. Bleeding time increased by 33% during treatment with marine oil but did not change with vegetable oil supplements. Marine oil did not alter in vitro platelet aggregation thresholds. The lack of a significant correlation between blood pressure changes and platelet membrane fluidity, plasma renin activity, aldosterone, norepinephrine, or epinephrine suggests that these variables did not mediate the antihypertensive effect of the marine oil. We conclude that large doses of marine oil reduce diastolic blood pressure, lower triglycerides, and increase bleeding time in patients with mild hypertension. | 3 |
Lyme disease: neurologic and ophthalmic manifestations. Lyme disease is tick-borne infection which produces early and late manifestations in many organ systems. Prominent symptoms and signs occur in skin, heart, joints and nervous system. Many ocular and neuro-ophthalmic abnormalities recently have been attributed to Lyme disease, but some cases have not been well established as direct sequelae. This review of the contemporary state of knowledge about Lyme disease was undertaken so that more rigorous criteria can be applied in future diagnosis. | 2 |
Semantic deterioration in Alzheimer's: the patterns to expect. Differentiating language changes between the normal aged and those in the early stages of dementia is never simple. Knowing the differences and what to expect can aid in making this diagnosis. | 2 |
Iron and the liver. Iron is essential for life, but iron overload is toxic and potentially fatal. The liver is a major site of iron storage and is particularly susceptible to injury from iron overload, especially when (as in primary hemochromatosis) the iron accumulates in hepatocytes. Iron can be taken up by the liver in several forms and by several pathways including: (1) receptor-mediated endocytosis of diferric or monoferric transferrin or ferritin, (2) reduction and carrier-facilitated internalization of iron from transferrin without internalization of the protein moiety of transferrin, (3) electrogenic uptake of low molecular weight, non-protein bound forms of iron, and (4) uptake of heme from heme-albumin, heme-hemopexin, or hemoglobin-haptoglobin complexes. Normally, pathway 2 is probably the major one for uptake of iron by hepatocytes. Iron is stored in the liver in the cores of ferritin shells and as hemosiderin, an insoluble product derived from iron-rich ferritin. Iron in hepatocytes stimulates translation of ferritin mRNA and represses transcription of DNA for transferrin and transferrin receptors. The major pathologic effects of chronic hepatic iron overload are: (1) fibrosis and cirrhosis, (2) porphyria cutanea tarda, and (3) hepatocellular carcinoma. Although precise pathogenetic mechanisms remain unknown, iron probably produces these and other toxic effects by increasing oxidative stress and lysosomal lability. Vigorous efforts at diagnosis and treatment of iron overload are essential since the pathologic effects of iron are totally preventable by early vigorous iron removal and prevention of iron re-accumulation. | 1 |
Adrenal insufficiency in the cancer patient: implications for the surgeon. Aspects of acute and chronic adrenal insufficiency of interest to surgeons who treat cancer patients are reviewed. Clinical features and the management of both primary and secondary types are considered with reference to classification, aetiology, diagnosis and treatment. Specifically considered are the management of patients with Addison's disease and metastases. Prompt recognition and treatment of adrenal insufficiency can avert potentially life-threatening situations. | 0 |
Arteriovenous fistula as a complication of temporary pacemaker insertion: treatment with percutaneous embolization. Arteriovenous fistula is a rare complication of central venous catheterization. We present a case of right internal mammary artery-to-right innominate vein fistula resulting from emergent insertion of a temporary pacemaker. Percutaneous management is discussed and the literature is reviewed. | 3 |
The operative management of coexisting thyroid and parathyroid disease. Three hundred eight patients who underwent operation for hyperparathyroidism were studied. Fifty-two (17%) were identified who had a concomitant thyroid nodule. All 52 underwent parathyroidectomy and thyroid resection in a single operation. Eleven of these patients (21% of those with a thyroid nodule) had differentiated thyroid cancer. One patient with parathyroid hyperplasia developed permanent hypocalcemia. None had permanent vocal cord paralysis and none required tracheostomy. Thorough visual inspection and palpation of the entire thyroid gland should be performed during operations for hyperparathyroidism. Incidentally discovered thyroid nodules should prompt formal lobectomy with frozen section diagnosis; unanticipated thyroid malignancies should then be treated as independent entities. Treating simultaneous hyperparathyroidism and nodular thyroid disease with a single operation can be done safely; it avoids the expense and risk associated with neck reexploration and can detect unsuspected cancers. | 0 |
Adverse haemodynamic effects of high-dose aprotinin in a paediatric cardiac surgical patient. High-dose aprotinin for reduction of intra- and postoperative blood loss was associated with profound hypotension and flushing in a 3.5-year-old child who underwent cardiac surgery. Treatment with noradrenaline and intravenous fluid was required. Cardiovascular stability was restored after 10 minutes. | 3 |
Impact of anatomical radical prostatectomy on urinary continence. Urinary continence following an anatomical approach to radical prostatectomy was evaluated in 593 consecutive patients, 547 (92%) of whom achieved complete urinary control. Stress incontinence was present in 46 patients (8%), of whom 34 (6%) wore 1 or fewer pads per day and 2 (0.3%) required placement of an artificial sphincter. No patient was totally incontinent. Age, weight of the prostate, prior transurethral resection of the prostate, pathological stage and preservation or wide excision of the neurovascular bundles had no significant influence on preservation of urinary control. These data suggest that anatomical factors rather than preservation of autonomic innervation may be responsible for the improved urinary control associated with an anatomical approach to radical prostatectomy. | 0 |
The effects of tartar-control toothpaste on the oral soft tissues. Ninety-two dental and dental hygiene students completed a double-blind, controlled clinical trial. The purpose of the trial was to evaluate the effects of toothpastes, in varying concentrations of flavor and tartar-control agents. Four formulations of toothpastes were assessed: (A) control-low flavor with no tartar control; (B) medium flavoring with medium tartar control; (C) high flavoring with medium tartar control; and (D) medium flavoring with no tartar control. Soft tissue reactions were assessed objectively and independently by three examiners. Subjective perceptions about each toothpaste were gathered by a structured, open-ended questionnaire. The "tartar control" toothpastes, B and C, resulted in statistically significant (p less than 0.005) higher rates of mucosal reactions (e.g., ulceration, sloughing, erythema, migratory glossitis) than the "non-tartar control" toothpastes A and D. When the oral mucosal reaction rates were adjusted for multiple clinical observations within each subject at the same point in time there was no statistically significant (p greater than 0.05) difference between male (0.25) and female (0.28) subjects. In this study population, the order of preference was observed as toothpaste A greater than D greater than B greater than C. The major reasons for disfavor were burning sensation in toothpastes C (2.4%) and B (4%). | 4 |
Why is diabetes mellitus a stronger risk factor for fatal ischemic heart disease in women than in men? The Rancho Bernardo Study [published erratum appears in JAMA 1991 Jun 26;265(24):3249] We report here the 14-year sex-specific effect of non-insulin-dependent diabetes mellitus on the risk of fatal ischemic heart disease in a geographically defined population of men and women aged 40 through 79 years. There were 207 men and 127 women who had diabetes at baseline based on medical history or fasting hyperglycemia. They were compared with 2137 adults who had fasting euglycemia and a negative personal and family history of diabetes. The relative hazard of ischemic heart disease death in diabetics vs nondiabetics was 1.8 in men and 3.3 in women, after adjusting for age, and 1.9 and 3.3, respectively, after adjusting for age, systolic blood pressure, cholesterol, body mass index, and cigarette smoking using the Cox regression model. The sex difference in the independent contribution of diabetes to fatal heart disease was largely explained by the persistently more favorable survival rate of women (than men) without diabetes. | 3 |
Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: early and late clinical results. The results of pharmacomechanical thrombolysis and angioplasty of 121 thrombosed hemodialysis grafts were reviewed. The initial pharmacomechanical method (used in 65 cases) employed clot maceration with hook-shaped catheters and clot lacing with highly concentrated urokinase. The current technique (used in 56 cases) consisted of pulsed-spray injection of urokinase into the clot. All fully treated grafts (117 cases) underwent complete or near-complete thrombolysis, and 93% remained patent after 1 day. Mean time for pulsed-spray lysis was 46 minutes +/- 21. One patient (less than 1%) had gastrointestinal bleeding and received a transfusion; minor complications occurred in 3% of patients. Primary and secondary graft patency rates for both methods at 1 year were 26% and 51%, respectively. While graft age and results of angioplasty did not influence future graft patency, shorter intervals between graft thromboses was predictive of earlier subsequent graft failure. Results suggest that pharmacomechanical thrombolysis and angioplasty provide rapid, consistent, and safe recanalization of clotted hemodialysis grafts and represent a promising additional therapeutic approach to long-term graft management. | 4 |
Submandibular cystic hygroma resembling a plunging ranula in a neonate. Review and report of a case. Cystic hygromas are large lymphangiomas that are most often found in the posterior triangle of the neck and the axilla in children. They are most frequently found before age 2 and may be massive. After upper respiratory infection, they may become infected and enlarged, causing dysphagia and toxemia. The diagnosis can usually be made by history and physical examination and confirmed by biopsy. Treatment is by surgical excision of small lesions and staged debulking excisions in more severe cases. A patient with a cystic hygroma having many clinical characteristics of a plunging ranula is presented. The cyst fluid was aspirated and analyzed for its amylase, sodium, potassium, chloride, urea nitrogen, glucose, and total protein content. The characteristics of the fluid were also compared with those of lymph and saliva. This report demonstrates the difficulty in determining the diagnosis of a tumor that has the clinical features of a cystic hygroma, as well as a plunging ranula. The necessity of a proper presurgical diagnosis is essential since the form of therapy for each is different and conflicting. A method that distinguishes between the cervical cystic hygroma and a plunging ranula by means of aspirated fluid is discussed. | 0 |
Value of electrophysiologic studies in hypertrophic cardiomyopathy treated with amiodarone. The relation of electrophysiologic effects of amiodarone to long-term outcome was studied in 35 patients with hypertrophic cardiomyopathy (HC). Indications for electrophysiologic studies were: cardiac arrest (n = 3), syncope/presyncope (n = 27) and asymptomatic ventricular tachycardia (VT) (n = 5). Twenty-eight patients (80%) had VT, 3 (9%) atrial tachycardia and 3 (9%) paroxysmal atrial fibrillation during 24-hour Holter monitoring. The studies were repeated after a total amiodarone dose of 58 +/- 122 g and during a maintenance median daily dose of 400 mg. Amiodarone abolished paroxysmal atrial arrhythmias in all 6 patients. However, it caused marked atrioventricular nodal conduction abnormality in 3 patients and heart block or marked HV interval prolongation (to greater than or equal to 100 ms) in 4 patients. Sustained VT was induced in 26 patients (74%) at baseline study and in 23 patients (66%) taking amiodarone therapy. With amiodarone, VT was no longer inducible or was more difficult to induce in 11 patients (31%), and the drug abolished VT during Holter monitoring in all patients. However, VT was easier to induce with amiodarone or was induced only with amiodarone in 18 (51%) patients. Amiodarone significantly slowed the rate of induced VT (from 248 +/- 29 to 214 +/- 37 beats/min, p less than 0.001). This was associated with a change in its morphology from polymorphic to monomorphic VT in 7 patients. During a follow up of 18 +/- 14 months (range 2 to 56), amiodarone was discontinued because of adverse effects in 8 patients (23%). | 3 |
Spinal cord injury after subclavian flap aortoplasty. An experimental study in piglets. Paraplegia is a rare but much feared complication of corrective surgery for coarctation of the aorta. The problem was studied in 31 newborn pigs submitted to subclavian flap aortoplasty. The aortic cross-clamping time ranged from 9-25 min. Twenty-three piglets with clamping times 9-18 min were neurologically intact, whereas eight with aortic clamping for 18-25 min became paraplegic. The clinical implications for newborn children with symptomatic aortic coarctation are discussed with regard to these experimental findings. | 2 |
The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators BACKGROUND. Nonrheumatic atrial fibrillation increases the risk of stroke, presumably from atrial thromboemboli. There is uncertainty about the efficacy and risks of long-term warfarin therapy to prevent stroke. METHODS. We conducted an unblinded, randomized, controlled trial of long-term, low-dose warfarin therapy (target prothrombin-time ratio, 1.2 to 1.5) in patients with nonrheumatic atrial fibrillation. The control group was not given warfarin but could choose to take aspirin. RESULTS. A total of 420 patients entered the trial (212 in the warfarin group and 208 in the control group) and were followed for an average of 2.2 years. Prothrombin times in the warfarin group were in the target range 83 percent of the time. Only 10 percent of the patients assigned to receive warfarin discontinued the drug permanently. There were 2 strokes in the warfarin group (incidence, 0.41 percent per year) as compared with 13 strokes in the control group (incidence, 2.98 percent per year), for a reduction of 86 percent in the risk of stroke (warfarin:control incidence ratio = 0.14; 95 percent confidence interval, 0.04 to 0.49; P = 0.0022). There were 37 deaths altogether. The death rate was markedly lower in the warfarin group than in the control group: 2.25 percent as compared with 5.97 percent per year, for an incidence ratio of 0.38 (95 percent confidence interval, 0.17 to 0.82; P = 0.005). There was one fatal hemorrhage in each group. The frequency of bleeding events that led to hospitalization or transfusion was essentially the same in both groups. The warfarin group had a higher rate of minor hemorrhage than the control group (38 vs. 21 patients). CONCLUSIONS. Long-term low-dose warfarin therapy is highly effective in preventing stroke in patients with non-rheumatic atrial fibrillation, and can be quite safe with careful monitoring. | 2 |
Stress-related mucosal damage: review of drug therapy. The increased awareness of stress-related mucosal damage (SRMD) that accompanied the widespread use of fiberoptic endoscopy and the increased incidence of SRMD that accompanied the advances in caring for critically ill patients resulted in the recognition that the majority of patients in the intensive care unit (ICU) setting wil develop mucosal damage. Complications of gastrointestinal hemorrhage in these patients may contribute significantly to their morbidity and mortality, and the consequences of this bleeding may be more severe than the underlying predisposing conditions. Because of the importance of gastric acid in the pathogenesis of SRMD, therapy has focused on reduction of the intraluminal acid concentration. Acid neutralization, while effective, is laborious and associated with side effects. H2-receptor antagonists have been used successfully in the prophylaxis and treatment of SRMD and offer the potential for an effective parenteral as well as oral agent. They obviate the need for frequent antacid administration and eliminate some of the troubles and side effects that accompany an intensive antacid regimen. Of the available H2-receptor antagonists, cimetidine has been the most thoroughly evaluated. It is equivalent to antacids in the prevention of overt bleeding and offers the advantage of dosing flexibility, ease of administration, and a remarkable safety profile. Cimetidine has also been shown to be effective when administered by intermittent bolus infusions given every 8, 6, or 4 h or by primed continuous infusion, which has proven to be the most successful method of controlling intragastric pH. | 4 |
Pharmacology of angiotensin-converting enzyme inhibitors as a guide to their use in congestive heart failure. The pharmacokinetics of the angiotensin-converting enzyme (ACE) inhibitors are difficult to assess for several reasons. First, these compounds exert their influence by inhibiting an intermediary enzyme of a cascade of enzymatic events, whose rate-limiting enzyme (renin) is not directly affected by ACE inhibition. Second, renin and angiotensin I accumulate during ACE inhibition and a change in the dose of an ACE inhibitor could produce sudden shifts of angiotensin I to angiotensin II. Third, components of the circulating renin system require the interaction of several organ systems and effector sites. Fourth, the kinetics of ACE inhibitors can be influenced by the organ systems responsible for drug absorption, metabolism and excretion, and the functional status of these systems can be affected by the heart failure process. Fifth, at least some portion of the cardiovascular effects of ACE inhibitors is influenced by the contributions of other systems whose physiologic effects may be of importance in some patients with congestive heart failure. Sixth, the potential impact of tissue-bound ACE is not yet fully understood. Finally, for appropriate drug dosing, the effects of aging on the heart failure process, the extent of renin system activity, and the disposition of ACE inhibitors need to be considered. Because of their complex pharmacokinetics, treatment with ACE inhibitors has been guided by their pharmacodynamic and clinical characteristics. | 3 |
Cardiac arrhythmias in critically ill patients: epidemiologic study The general prevalence of cardiac arrhythmias in 2,820 consecutive patients was 78%, ranging from 44% in multiple trauma patients to 90% in primary cardiovascular patients. Patients without recorded arrhythmias (22%, n = 621) were used as control subjects. No clinical group was free from cardiac arrhythmias. Atrial tachyarrhythmias had the highest prevalence in the population as a whole (28%) and in all clinical groups except multiple trauma. Atrial fibrillation was the most common atrial arrhythmia (52%); ventricular arrhythmias followed. Patients with atrial tachyarrhythmias, nodal rhythm ventricular bradyarrhythmias, and ventricular rapid rhythms had significantly (p less than .01) increased mortality rates (40%, 44%, 77%, and 51%, respectively) when compared with patients without arrhythmias (35%). The relative risk of dying (RRD) of these clinical groups was increased by 1.16, 1.27, 2.20, and 1.47, respectively. Patients with cardiorespiratory precipitating disease and any arrhythmia except atrial bradyarrhythmia had a mortality rate between 32% and 74%, significantly (p less than .05) different from that of patients within the same clinical groups without arrhythmias. The RRD was increased by 1.67 to 3.40. Septic patients with atrial tachyarrhythmia or nodal rhythm and neurologic patients with nodal or ventricular arrhythmias also had significantly (p less than .01 and .05, respectively) increased mortality and were at higher RRD (1.53 to 2.81). Our data suggest that severe illness may be present in some clinical groups of critically ill patients with cardiac arrhythmias. | 4 |
Differential diagnosis of sclerosing cholangiocarcinomas of the common hepatic duct (Klatskin tumors). Although it is recognized that some other lesion may be the cause, a presumptive diagnosis of Klatskin tumor is usually made when a focal stenotic lesion of the common hepatic duct is seen on a cholangiogram of a jaundiced patient. Biopsy is so often nondiagnostic that decisions about therapy are usually made on the basis of the imaging tests and lack of evidence for some other disease. Because the accuracy and consequences of this strategy have never been tested, we contrasted the preoperative diagnosis of Klatskin tumor with the final diagnosis in 98 consecutive patients treated from 1985 to 1990. Preoperative investigations included ultrasound and computed tomographic scans, percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, and angiography. Sclerosing cholangiocarcinomas of the bile duct were correctly diagnosed in 68 cases. The final diagnosis was other than a sclerosing adenocarcinoma in 30 (31%) cases. There were 5 papillary bile duct carcinomas, 12 gallbladder carcinomas invading the bile duct, 5 metastatic tumors to the bile duct, 2 cases of Mirizzi syndrome, 3 granulomas, and 3 cases of idiopathic benign focal stenosis. Patients with papillary adenocarcinomas had an extensive filling defect of the duct, which was often thought to be unresectable. However, four of these five lesions could be completely excised, and the tumor was confined to the duct wall in all four. The outcome of surgical treatment of the other eight patients with benign lesions was good in most cases. These findings demonstrate the pitfalls of assuming that a focal stenosis of the hepatic duct represents a sclerosing adenocarcinoma. The diagnosis is much less specific than is generally thought, so there is considerable opportunity for mismanaging such patients. | 0 |
Deteriorating ischemic stroke: risk factors and prognosis. To determine a risk profile of deterioration in cerebral infarction of less than 8 hours' duration, we studied prospectively a series of clinical and radiologic data in 98 patients. We evaluated the Canadian Neurological Scale Score and Barthel index during a follow-up period of 3 months. There was deterioration in the 1st 48 hours in 40.8% of the patients. High systolic blood pressure, elevated blood sugar concentration at admission, and carotid territory involvement were independently related with deterioration in the logistic regression analysis. Death occurred in 35% of the patients with deteriorating infarcts and in 8.6% of those with stable infarcts. At the end of the study, functional capacity was lower in those with deteriorating infarcts, but the 2 groups improved in parallel from the 4th day onward. | 2 |
Participation of serotonergic mechanisms in the pathophysiology of experimental neoplastic spinal cord compression. We evaluated the role of serotonin (5-HT) in neoplastic cord compression in paraplegic rats harboring a thoracolumbar epidural tumor. We measured serotonin and its major metabolite, 5-hydroxyindole-3-acetic acid (5-HIAA), in the C-1 to C-7, T-1 to T-6, T-7 to T-12, and T-13 to L-3 spinal segments of tumor-free and tumor-bearing rats. In normal controls, a consistent rostral-to-caudal gradient for 5-HT and 5-HIAA was evident, but the 5-HIAA/5-HT ratio remained constant. In paralyzed rats, 5-HT levels were unchanged, but the 5-HIAA/5-HT ratio was elevated, especially in the compressed segments. Treatment with either dexamethasone or indomethacin delayed onset of paraplegia but had no effect on 5-HT metabolism. Blocking 5-HT receptors by cyproheptadine, evaluated 30 hours after onset of paralysis and treatment, resulted in a reduction in the high water content, vascular permeability, and prostaglandin E2 synthesis in the compressed cord. Early administration of cyproheptadine effectively delayed the onset of paraplegia. These data indicate that receptor-activated serotonergic mechanisms participate in the disruption of the blood-spinal cord barrier and that these effects can be manipulated pharmacologically. | 2 |
Flow cytometric DNA analysis of hepatocellular carcinoma. The prognostic value of nuclear DNA content was studied retrospectively using flow cytometry in 203 cases of resected hepatocellular carcinoma. The occurrence of DNA aneuploidy, which was detected in 50% of patients, correlated significantly with tumor size and the presence of vascular invasion or intrahepatic metastasis. Overall, patients with DNA aneuploid tumors had a significantly worse prognosis than those with DNA diploid tumors (P less than 0.001) and, also in subdivided groups by tumor size (P less than 0.01). Among DNA aneuploid patients, the survival times were significantly shorter for patients with a low DNA index (less than 1.5) than for those with a high DNA index (greater than or equal to 1.5) (P less than 0.05). In a Cox multivariate analysis, nuclear DNA content provided significant prognostic value (P = 0.008), as did vascular invasion (P = 0.001) and intrahepatic metastasis (P = 0.005). These results indicated that nuclear DNA content has an important prognostic value in hepatocellular carcinoma. | 0 |
When do optic disc edema and peripheral neuropathy constitute poetry? [clinical conference] A patient with chronic, bilateral optic disc edema developed multiple systemic manifestations of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes). A serum immunoelectrophoresis showed an abnormal serum IgG lambda protein, and urine immunoelectrophoresis revealed a monoclonal lambda protein plus an IgG lambda fragment. Bone survey and MRI scan revealed a sclerotic lesion of the first lumbar vertebra, and lymph node biopsy showed changes consistent with Castleman's disease. Thus, his optic disc edema was the presenting feature of the POEMS syndrome and osteosclerotic myeloma. | 4 |
Histopathologic grading of salivary gland neoplasms: I. Mucoepidermoid carcinomas. Histopathologic grading of salivary gland neoplasms has been done with various degrees of success and hence various degrees of acceptance among pathologists and otolaryngologists-head and neck surgeons. Given their histopathologic diversity, three carcinomas--mucoepidermoid, adenoid cystic, and acinic cell--would seem to be suitable candidates for grading. In this, the first of a three-part series, the authors present a three-level grading scheme for mucoepidermoid carcinomas. It combines histocytologic and growth features of the carcinomas that independently or together, in other grading proposals, have shown prognostic value. | 0 |
Somatostatin analogue, octreotide, reduces increased glomerular filtration rate and kidney size in insulin-dependent diabetes. To determine whether treatment with a somatostatin analogue can reduce kidney hyperfiltration and hypertrophy in insulin-dependent diabetes mellitus, we studied 11 patients with insulin-dependent diabetes mellitus and glomerular hyperfiltration. The patients were assigned randomly to receive continuous subcutaneous infusion of either octreotide, 300 micrograms/24 h (five patients) or placebo (six patients) for 12 weeks. At baseline, mean glomerular filtration rate and mean total kidney volume were not significantly different in the two groups. However, after 12 weeks of treatment, the mean glomerular filtration rate was significantly lower in the octreotide group (136 mL/min per 1.73 m2; range, 91 to 158 mL/min per 1.73 m2) than in the placebo group (157 mL/min per 1.73 m2; range, 138 to 184 mL/min per 1.73 m2). Furthermore, the mean total kidney volume was significantly lower after treatment in the octreotide group (379 mL/1.73 m2; range, 307 to 454 mL/1.73 m2) than in the placebo group (389 mL/1.73 m2; range, 347 to 465 mL/1.73 m2). Glycemic control did not change significantly in either group. We conclude that subcutaneous infusion of octreotide for 12 weeks reduces increased glomerular filtration rate and kidney size in patients with insulin-dependent diabetes mellitus despite the fact that glycemic control remains unchanged. | 4 |
Fetal choroid plexus cysts: a prospective study and review of the literature. To determine the incidence and significance of fetal choroid plexus cysts, a prospective study was carried out at Queen's Medical Centre, Nottingham. The incidence of cysts was found to be 0.42% and the size of cysts varied from 3 to 13 mm with a mean diameter of 6.2 mm. Choroid plexus cysts were associated with other fetal abnormalities in three cases, two of which were subsequently found to have a chromosomal abnormality, one Trisomy 18 and one Trisomy 21. A review of the reported cases of choroid plexus cysts reveals an overall incidence of 5.8% for Trisomy 18. We therefore recommend that in patients with choroid plexus cysts a detailed scan should be carried out to look for the ultrasound markers of Trisomy 18. If there is an associated abnormality or cysts are large (13 mm or greater in diameter) and bilateral then a karyotyping should be carried out. | 4 |
Decollateralization with silicone rubber sheeting for advanced hepatocellular carcinoma: a preliminary report. A new treatment method, interception of collaterals with a silicone rubber sheet, was applied to three patients with advanced hepatocellular carcinoma in whom arterial chemoembolization was assessed as ineffective because of the developed collateral feeding arteries. This procedure was followed by arterial chemoembolization or intraportal infusion chemotherapy or both. Follow-up celiac angiography confirmed that the long-term decollateralization was achieved by shielding the liver with silicone rubber sheeting. This technique resulted in partial responses without serious complications in all the patients including two who had no responses to chemoembolization before the procedure. The response durations were 5, 21, and 27, months, respectively. One patient died of gastrointestinal bleeding 7 months after the decollateralization. The other two patients are still alive, and the survivals after the procedure are 28 and 30 months, respectively. This therapy is considered promising and may be worth choosing as an adjuvant treatment for advanced hepatic malignancies uncontrolled by arterial chemotherapy or chemoembolization. | 0 |
Allograft tympanoplasty: predictive value of preoperative status. The functional and anatomical results of a series of 181 consecutive allograft tympanoplasties for ears with drum perforation and an intact ossicular chain were retrospectively reviewed and related to preoperative factors. Drum closure was realized in 92% (166 of 181 cases evaluated 1 year after surgery), and 96.6% of the reconstructed drums were still intact 3 years after surgery (118 cases evaluated). An air-bone gap of less than 21 dB was reached in 79.6% (of a total of 162 cases) 1 year after surgery, and in 78% (of a total of 118 cases) 3 years after surgery. Age, contralateral pathology, the wet or dry status of the ear preoperatively, and the preoperative air-bone gap had no influence on anatomical results. The preoperative air-bone gap did not predict the postoperative air-bone gap. The influence of age and existence of contralateral pathology on hearing gain was only visible in some of the strictly defined patient groups. The wet preoperative status of the ear generally predicted lower functional gain. | 4 |
Group B streptococcus: an unusual cause of severe peritonitis in young children treated with continuous ambulatory peritoneal dialysis. Peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients is only rarely caused by beta-hemolytical streptococci species. We describe two young children, aged 15 months and 5 years, respectively, who presented an unusually severe course of peritonitis due to group B beta-hemolytical streptococci. This course of the disease showed a strong similarity with neonatal streptococcal septicemia. In neonates, IgG2 deficiency is thought to be partly responsible for the severity of this condition. This may also be true for young children treated with CAPD, since IgG2 deficiency has been established for children. | 1 |
Vitamin B6 in the treatment of the premenstrual syndrome--a review [published erratum appears in Br J Obstet Gynaecol 1991 Mar;98(3):329-30] A search of the literature yielded 12 controlled trials on vitamin B6 in the treatment of the premenstrual syndrome. These are discussed with emphasis on methodological aspects. A major drawback of the trials is the limited number of patients included. The existing evidence of positive effects of vitamin B6 is weak, and some well-designed trials with positive results would be needed to change this view. | 4 |
Glomerular IgA deposits in patients with celiac disease. Glomerular immunopathology was studied in 25 patients with newly diagnosed celiac disease. None had clinical signs of renal disease. Glomeruli were obtained by fine-needle aspiration biopsy. The specimens were processed and studied by indirect immunofluorescence for immunoglobulins and complement. Mesangial IgA was found in 8 of the patients. It occurred occasionally together with slight IgG or IgM, but C3 was not seen in these patients. IgA-class circulating immune complexes (CIC), antireticulin antibodies (ARA), antigliadin antibodies (AGA), and rheumatoid factor (RF) occurred significantly more often in the patients with mesangial IgA than in the 17 patients having no mesangial IgA. The patients with mesangial IgA also had significantly higher mean levels of serum IgA, IgA-ARA and IgA-AGA than those without. The results suggest that glomerular mesangial deposits of IgA occur frequently in untreated celiac disease and that they are in some way associated with circulating IgA-class antibodies and immune complexes. In this situation IgA seems to be deposited without being able to induce clinically overt glomerulonephritis, a circumstance that may be related to the lack of complement in the deposits. | 1 |
Detection and typing of human papillomavirus using the Vira Type "in situ" kit: comparison with a conventional dot blot technique. A new commercial kit (Vira Type "in situ", Life Technologies, Inc., Molecular Diagnostics Division, Guithersburg, Maryland, USA) for the detection of human papillomavirus (HPV) types 6, 11, 16, 18, 31, 33 and 35 in routinely processed human anogenital tissue was compared with a conventional dot blot assay for HPV 6, 11, 16 and 18. Both systems use double-stranded genomic DNA probes for the detection of type specific HPV DNA. The probes used on the dot blots were labelled with 32P and visualised autoradiographically. The Vira Type probes were labelled with biotin and visualised using a streptavidin-alkaline phosphatase conjugate with NBT-BCIP substrate. Biopsy specimens from the cervix, vagina, and vulva of 46 women were processed by both methods and compared. The histological diagnoses ranged from benign changes, to dysplasia, and invasive carcinoma. Overall, 50% of biopsy specimens were positive for HPV DNA by dot blot hybridisation; only 39% were positive by Vira Type in situ hybridisation. Three of the specimens positive by the Vira Type "in situ" kit showed no cross hybridisation and were the same HPV type as the dot blot. A further 13 showed hybridisation, but the showed cross hybridisation, but the to the dot blot results. One biopsy specimen was positive for different HPV types by the two tests and one was positive by Vira Type and negative by dot blot. Six biopsy specimens were negative by Vira Type but positive by dot blot. It is concluded that the Vira Type "in situ" kit has a similar specificity but lower sensitivity than the dot blot hybridisation method for the detection of HPV DNA. | 0 |
Prevalence of acute mountain sickness in the Swiss Alps. OBJECTIVE--To assess the prevalence of symptoms and signs of acute mountain sickness of the Swiss Alps. DESIGN--A study using an interview and clinical examination in a representative population of mountaineers. Positive symptoms and signs were assigned scores to quantify the severity of acute mountain sickness. SETTING--Four huts in the Swiss Alps at 2850 m, 3050 m, 3650 m, and 4559 m. SUBJECTS--466 Climbers, mostly recreational: 47 at 2850 m, 128 at 3050 m, 82 at 3650, and 209 at 4559 m. RESULTS--In all, 117 of the subjects were entirely free of symptoms and clinical signs of acute mountain sickness; 191 had one or two symptoms and signs; and 158 had more than two. Those with more than two symptoms and signs were defined as suffering from acute mountain sickness. At 4559 m 11 climbers presented with high altitude pulmonary oedema or cerebral oedema, or both. Men and women were equally affected. The prevalence of acute mountain sickness correlated with altitude: it was 9% at 2850 m, 13% at 3050 m, 34% at 3650 m, and 53% at 4559 m. The most frequent symptoms and signs were insomnia, headache, peripheral oedema, and scanty pulmonary rales. Severe headache, vomiting, dizziness, tachypnoea, and pronounced pulmonary rales were associated with other symptoms and signs and therefore characteristic of acute mountain sickness. CONCLUSION--Acute mountain sickness is not an uncommon disease at moderately high altitude--that is, above 2800 m. Severe headache, vomiting, dizziness, tachypnoea, and pronounced pulmonary rales indicate severe acute mountain sickness, and subjects who suffer these should immediately descend to lower altitudes. | 2 |
Extracapsular cataract extraction with intraocular lens implantation after scleral buckling surgery. We reviewed the records of 28 patients who had undergone successful scleral buckling surgery followed by extracapsular cataract extraction with implantation of an intraocular lens. Posterior chamber intraocular lenses were inserted in 27 eyes, and anterior chamber intraocular lenses were inserted in two eyes with posterior capsule rupture at the time of surgery. The mean follow-up period was 44 months. Final visual acuity was 20/40 or better in 15 of 29 eyes (52%). One eye (3.4%) developed a recurrent retinal detachment 15 months after cataract surgery. Two eyes (6.9%) developed angiographically proven cystoid macular edema. The outcome for extracapsular cataract extraction with intraocular lens implantation in eyes that had previously undergone successful scleral buckling for retinal detachment is favorable. | 4 |
Oncologic imaging. Staging and follow-up of renal and adrenal carcinoma. Computed tomography (CT) has emerged from the 1980s to play a dominant role in the pretreatment staging of renal and adrenal carcinomas. For detection, definition (staging), and determination of resectability or recurrence, CT with intravenous contrast enhancement, and more recently, magnetic resonance imaging (MRI) with gadolinium-DTPA, may be the only cross-sectional imaging studies required before institution of appropriate therapy. Carcinoma of the kidney is frequently diagnosed by serendipity or detected on incidental ultrasound or CT examinations. Real-time ultrasound and color flow Doppler offer unique information on tumor vascularity and major venous vascular involvement. Positive predictive values of 96% can be achieved for the diagnosis of renal cell carcinoma using contrast-enhanced CT scanning. For follow-up CT and MRI are the best imaging techniques for evaluation of the retroperitoneum. MRI may distinguish tumor recurrence from fibrosis in selected cases. Because primary neoplasms of the adrenal gland are rare and often exceed 10 cm at the time of initial diagnosis, the functional nature (endocrine) of adrenal carcinoma may be part of the clinical presentation. Because initial stage is critical to survival and extent of surgical therapy, a knowledge of tumor classification is essential to the optimal diagnostic evaluation. Newer imaging tests, CT and MRI, have superseded conventional urography, ultrasound, and radionuclide studies for the diagnosis and staging of adrenal cancer. Early diagnosis and low stage at presentation are critical to survival in patients with adrenal carcinoma. The current concepts for pretreatment imaging evaluation and the role of CT, MRI, and ultrasound are outlined. An oncologic imaging approach based on tumor staging and classification for patients with real or suspected renal cell carcinoma and adrenal carcinoma is essential to optimal patient care. | 0 |
Disorders of esophageal motility. Patients with esophageal motility disorders usually have dysphagia and many also have chest pain similar to angina. The diagnosis is suggested by the clinical presentation, and supporting evidence is often provided by contrast roentgenography. Esophageal manometry is usually necessary to confirm the diagnosis. Conservative therapy using pharmacologic agents is often useful as an initial trial, although many patients who continue to be symptomatic ultimately require surgical intervention. | 1 |
Usefulness of fecal alpha 1-antitrypsin clearance and fecal concentration as early indicator of postoperative asymptomatic recurrence in Crohn's disease. The aim of this study was to evaluate in Crohn's disease the possible usefulness of alpha 1-antitrypsin clearance and fecal concentration in the early detection of postoperative asymptomatic recurrence. Eleven adult patients with small bowel Crohn's disease undergoing elective resection were enrolled in the study and prospectively followed for one year. Three, six, and 12 months after surgery the alpha 1-antitrypsin clearance and fecal concentration were measured, and the disease activity was assessed. All patients were free of active symptoms throughout the study. One year after surgery small bowel radiology was performed in all patients. Radiographic evidence of recurrent macroscopic disease was found in five of the 11 patients. Three months after surgery both alpha 1-antitrypsin clearance and fecal concentration were significantly lower (P less than 0.01) than before surgery. There was no difference at this time between patients with recurrence and those with no recurrence. In patients with recurrence both alpha 1-antitrypsin clearance and fecal concentration significantly increased at six months in comparison with the values at three months (P less than 0.02). Both measurements were significantly higher at six and 12 months in this group of patients than in those with no recurrence and in normal controls (P less than 0.01). At six and 12 months alpha 1-antitrypsin clearance was above the upper normal limit in all patients with recurrence. We conclude that fecal alpha 1-antitrypsin clearance is a noninvasive, inexpensive, sensitive marker of asymptomatic recurrence in CD patients who are under regular supervision after surgery. | 4 |
Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies. A randomized, single-blind clinical trial. Sublingual captopril (25 mg) was compared with sublingual nifedipine (10 mg) to determine their effectiveness and safety in the treatment of hypertensive emergencies. In nine of 10 patients who received sublingual captopril, mean (+/- SD) systolic blood pressure and diastolic blood pressure dropped from 245 +/- 39 to 190 +/- 25 mm Hg (P less than .0025) and from 144 +/- 8 to 115 +/- 8 mm Hg (P less than .001) at 50 minutes, respectively. The hypotensive effect of the drug was maintained for a mean of 4 hours. In six of nine responders to sublingual captopril, blood pressure-lowering effect was associated with a clear improvement of end-organ failure within 60 minutes. There were no side effects, including a dangerous fall in blood pressure or reflex tachycardia. Sublingual nifedipine lowered diastolic blood pressure and systolic blood pressure in eight of 10 patients. The hypotensive effect of nifedipine was more rapid than that of captopril (10 vs 20 minutes for diastolic blood pressure and 20 vs 30 minutes for systolic blood pressure, respectively), but no difference was observed in the time or in the magnitude of peak hypotensive effect between the two treatments, nor was a difference observed in the duration of hypotensive effect. In six of eight responders to nifedipine therapy, a clear improvement of symptoms and signs of end-organ failure was observed within 60 minutes. In three patients, minor side effects were observed. We conclude that sublingual captopril effectively and safely lowers arterial blood pressure in patients with hypertensive emergencies. | 4 |
Autosomal recessive chronic granulomatous disease caused by deletion at a dinucleotide repeat. Chronic granulomatous disease (CGD) is a rare inherited condition rendering neutrophils incapable of killing invading pathogens. This condition is due to the failure of a multicomponent microbicidal oxidase that normally yields a low-midpoint-potential b cytochrome (cytochrome b245). Although defects in the X chromosome-linked cytochrome account for the majority of CGD patients, as many as 30% of CGD cases are due to an autosomal recessive disease. Of these, greater than 90% have been shown to be defective in the synthesis of a 47-kDa cytosolic component of the oxidase. We demonstrate here in three unrelated cases of autosomal recessive CGD that the identical underlying molecular lesion is a dinucleotide deletion at a GTGT tandem repeat, corresponding to the acceptor site of the first intron-exon junction. Slippage of the DNA duplex at this site may contribute to the high frequency of defects in this gene. | 4 |
Cheilitis granulomatosa: report of six cases and review of the literature. Six cases of cheilitis granulomatosa, a rare inflammatory disorder of unknown origin, are reported. The condition produces nontender, persistent swelling of one or both lips and affects primarily young adults. Histologically, nonnecrotizing granulomatous inflammation is seen. The clinical findings and results of therapy in these six cases are presented. One patient was treated with hydroxychloroquine sulfate (Plaquenil) that stabilized the process. One of our patients had vesicular-appearing lesions. Microscopic examination showed the lesions to be dilated superficial lymphatic channels, a finding that to our knowledge has not been previously described. | 2 |
The association of selected cancers with service in the US military in Vietnam. III. Hodgkin's disease, nasal cancer, nasopharyngeal cancer, and primary liver cancer. The Selected Cancers Cooperative Study Group As part of a series of investigations into the health of Vietnam veterans, we conducted case-control studies involving 310 men with Hodgkin's disease, 48 with nasal carcinoma, 80 with nasopharyngeal carcinoma, 130 with primary liver cancer, and 1776 controls between 1984 and 1988. All men born between 1929 and 1953 and diagnosed in an area covered by eight cancer registries were considered eligible as cases; controls were recruited by random-digit dialing. Whereas the study had excellent power (96%) to detect a twofold increase in risk for Hodgkin's disease among Vietnam veterans, its ability to detect a similarly elevated risk in the other cancers was limited, ranging from 38% (nasal carcinoma) to 75% (primary liver cancer). Analyses showed that risks among Vietnam veterans relative to other men were 1.1 (Hodgkin's disease), 0.7 (nasal carcinoma), 0.5 (nasopharyngeal carcinoma), and 1.2 (primary liver cancer). None of these relative risks was significantly different from 1.0. Similar results were obtained if Vietnam veterans were compared with (1) other veterans or (2) men who never served in the military. An examination of several attributes of military service in Vietnam (eg, branch, duration of service, and other characteristics that may have been associated with the use of Agent Orange) failed to identify any groups of veterans who were at increased risk for Hodgkin's disease. Small numbers limited further analyses of nasal, nasopharyngeal, and liver cancer. These results provide no evidence that, 15 to 25 years following service in Vietnam, the risk of these malignant neoplasms is higher among veterans. | 0 |
Evidence of serum-protein leakage across the blood-brain barrier in the acquired immunodeficiency syndrome. Lesions of the central nervous system (CNS) in 23 patients with the acquired immunodeficiency syndrome (AIDS) were compared with control cases for the presence of serum protein by immunoperoxidase staining. A sensitive immunostaining kit in conjunction with rabbit antisera to human serum, albumin, immunoglobulins and complement component 3c was used to demonstrate specific immunoreactivity in paraffin-embedded sections. Most AIDS patients with CNS lesions had serum protein immunoreactivity in some neurons, glial cells (including astrocytes), gliomesenchymal cell nodules, vascular endothelial cells, inflammatory cells or microvascular walls. Cases with the most necrosis tended to have the least immunostaining. Immunoreactivity for IgG and fixed complement in anatomically intact or morphologically altered neural cells may indicate cellular lesions and potential cellular necrosis beyond the damage indicated by routine studies alone. Part of this immunoreactivity might represent a humoral autoimmune response. | 2 |
Progressive coma after the transsphenoidal decompression of a pituitary adenoma with marked suprasellar extension: report of two cases. Two cases of neurological deterioration and coma after the transsphenoidal decompression of a pituitary adenoma with marked suprasellar extension and invasion of the 3rd ventricle are presented. Emergency ventricular shunting led to prompt neurological improvement, which, supplemented by radiation therapy, allowed long-term amelioration of symptoms. Three possible explanations for this complication are offered: 1) traction of the attached 3rd ventricle into the decompression site, causing increased obstructive hydrocephalus, 2) vasopressin release by surgical manipulation of the pituitary stalk and circumventricular organs causing cerebral edema, and 3) edema in the residual tumor secondary to surgical manipulation causing further hydrocephalus. Subsequent patients with similar clinical and imaging criteria will have a planned perioperative ventricular shunting procedure performed. | 4 |
Endoprosthetic reconstruction after bone tumor resections of the proximal tibia. The advent of successful adjuvant chemotherapy and radiation therapy protocols for primary malignant tumors and the development of custom-designed metallic endoprostheses has now made possible a successful limb salvage procedure for malignancies of the proximal tibia. Use of the transposed medial gastrocnemius flap, as proposed by Dr. Jean Duboussett of Paris, has been critical to the soft-tissue reconstruction that routinely permits an excellent active and passive range of motion for these patients. This article describes the operative techniques and technical considerations necessary for a successful proximal tibial endoprosthesis reconstruction. | 0 |
Numb chin syndrome secondary to Burkitt's cell acute leukemia. We describe a case of Burkitt's cell acute lymphoblastic leukemia presenting with the bilateral numb chin syndrome as the initial symptom of the disease. Postmortem study of the trigeminal nerve showed heavy infiltrations of leukemic cells and destruction of axon and myelin by leukemic cells in the mandibular nerve. | 0 |
Chronic blood hyperviscosity in subjects with acute stroke, transient ischemic attack, and risk factors for stroke. The origin and significance of blood hyperviscosity in subjects with acute stroke has been controversial. It has been argued that viscous abnormalities simply reflect either elevated hematocrit or an acute-phase response to the stroke itself. To address these issues, we measured the factors that determine blood viscosity in a cross-sectional study of 430 subjects, including 135 with acute stroke, 89 with acute transient ischemic attacks of the brain, 115 with recognized risk factors for stroke, and 91 healthy controls. The at-risk group was balanced with the acute stroke group for types of risk factors and medication usage, and all four groups were balanced for age. The viscosity of whole blood at low rates of shear and the plasma viscosity were significantly elevated in both groups with cerebrovascular symptoms and in the at-risk group compared with the healthy controls. The severity of hyperviscosity was stroke group greater than transient ischemic attack group greater than at-risk group greater than healthy controls. Increased viscosity of whole blood was associated with an elevated plasma fibrinogen concentration and with a decreased albumin/globulin ratio. This study provides evidence that blood hyperviscosity is present not only in subjects with acute brain infarction, but also in those with risk factors for stroke, and that these abnormalities are, to a considerable degree, chronic. | 2 |
Computerized tomography in acute gastrointestinal disorders. In recent years, computerized tomography (CT) has become one of the most important imaging modalities in evaluation of patients with acute gastrointestinal disorders. Its role, diagnostic accuracy, indications, and limitations in some of the most commonly encountered acute abdominal conditions are succinctly presented and reviewed. CT should not be used indiscriminantly, but is best considered a valuable primary or complimentary diagnostic tool in critically ill patients. Its selective use in a variety of emergency abdominal diseases will significantly improve accuracy of clinical diagnoses, leading to a prompt and adequate medical or surgical management. | 4 |
Clinical value of magnetic resonance imaging for cervical myelopathy. The magnetic resonance imaging (MRI) findings in 115 cases of cervical myelopathy, 121 cases of cervical radiculopathy, and 64 cases of neck pain with no neurologic deficit were prospectively studied to investigate the clinical value of MRI for cervical myelopathy. The MRI findings in the T1-weighted sagittal projection were classified into four groups according to the degree of the compressed deformities of the cervical cord. The degree of compression of the cervical cord on MRI findings showed a significant correlation with the severity of myelopathy, the anteroposterior diameter of the spinal column, and the degree of compression of the dural tube in the myelograms (P less than 0.01). Fifty-one patients of cervical myelopathy had undergone both preoperative and postoperative MRI. Of these, the spinal canal of 47 patients that was well decompressed was recognized according to plain computed tomography (CT). However, 24 (51%) of these 47 patients showed on MRI a deformity in the spinal cord amounting to cord atrophy. The correlation between the clinical function of the spinal cord and the recovery of the cord deformity on MRI at the operative levels was accurately investigated in 34 patients who had no cord deformities in the adjacent intervertebral levels. Twenty patients with cord atrophy had slightly poor clinical results, although no significant difference was found between these 20 and 14 patients with recovery in the cord deformities. From these results, it was evident that T1-weighted MRI is useful in the accurate diagnosis of compression myelopathy, in accurately deciding the level of the disease focus, and in the accurate assessment of the surgical results. | 2 |
Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs. OBJECTIVE: To estimate the relative risk for peptic ulcer disease that is associated with the use of oral corticosteroids. DESIGN: A nested case-control study. SETTING: Tennessee Medicaid program. PARTICIPANTS: The case patients (n = 1415) were hospitalized between 1984 and 1986 for gastric or duodenal ulcer or for upper gastrointestinal hemorrhage of unknown cause. The controls (n = 7063) were randomly selected from Medicaid enrollees not meeting the study criteria for inclusion as case patients. MEASUREMENTS AND MAIN RESULTS: The estimated relative risk for the development of peptic ulcer disease among current users of oral corticosteroids was 2.0 (95% CI, 1.3 to 3.0). However, the risk was increased only in those who concurrently received nonsteroidal anti-inflammatory drugs (NSAIDs); these persons had an estimated relative risk associated with current corticosteroid use of 4.4 (CI, 2.0 to 9.7). In contrast, the estimated relative risk for those corticosteroid users not receiving NSAIDs was 1.1 (CI, 0.5 to 2.1). Persons concurrently receiving corticosteroids and NSAIDs had a risk for peptic ulcer disease that was 15 times greater than that of nonusers of either drug. CONCLUSION: Discrepant findings among earlier studies regarding steroids and the risk for peptic ulcer disease could in part be due to differences in the use of NSAIDs among study participants. The high risk for peptic ulcer disease associated with combined use of NSAIDs and corticosteroids indicates the need to prescribe this drug combination cautiously. | 1 |
Dexamethasone as an adjunct in oropharyngeal obstruction in a patient with leukemia. Incipient airway obstruction due to fulminating bacterial infection of pharyngeal tissues requires prompt and definitive intervention. A case is presented in which dexamethasone was a key adjunct to antibiotic therapy in averting this problem in a severely neutropenic patient with acute leukemia. | 4 |
Intravenous administration of recombinant human granulocyte-macrophage colony-stimulating factor causes a cutaneous eruption The intravenous administration of recombinant human granulocyte-macrophage colony-stimulating factor to three patients with leukemia who were receiving marrow aplasia-inducing chemotherapy resulted in the development of wide-spread erythematous macules and papules. The course of the eruption paralleled the time of infusion of the granulocyte-macrophage colony-stimulating factor. Skin biopsy specimens taken from two of the eruptions displayed characteristic changes consisting of a variable mixture of granulocytes and lymphocytes, increased number and size of dermal macrophages, mild to moderate epidermal exocytosis, intercellular edema, and rare dyskeratotic keratinocytes. Immunophenotypic analysis of one specimen was notable for keratinocyte intercellular adhesion molecule-1 expression. Administration of the recombinant human cytokine in pharmacologic doses is postulated to induce changes in the immunologic status of the skin, resulting in the expression of a cutaneous eruption. | 0 |
Oculo-bulbar myasthenic symptoms as the sole sign of tumour involving or compressing the brain stem. Four patients with tumours involving or compressing the brain stem are described whose initial clinical symptoms of fluctuating paresis of the external ocular muscles and/or the pharyngeal muscles without other neurological deficits led to the primary diagnosis of focal myasthenia. The combination of an unusual clinical pattern, involvement of muscles of only one ocular nerve or severe dysphagia/dysarthria without extension of the myasthenic symptoms, should lead to further investigation to exclude other reasons of a focal myasthenic syndrome such as a brain-stem tumour. | 2 |
Synergistic effect of murine cytomegalovirus on the induction of acute graft-vs-host disease involving MHC class I differences only. Analysis of in vitro T cell function. The development of acute graft-vs-host disease (GVHD) is a common outcome after the injection of fully MHC disparate parental T cells into unirradiated F1 mice. Murine cytomegalovirus (MCMV) infection has been previously shown to augment the development of acute GVHD in the parent-into-F1 (P----F1) model, such that 10-fold fewer parental cells are required. In the present study, we have investigated the effect of MCMV infection on the induction of non-lethal GVHD that occurs in P----F1 combinations involving MHC class I only or class II only differences. Using P----F1 combinations involving either an H-2K only difference or an H-2D only difference, MCMV infection of F1 mice 3 days before the injection of parental spleen cells led to a profound T cell immunodeficiency that strongly resembled that observed in acute GVHD. Further studies examining the H-2K disparate P----F1 combination, C57Bl/6---- (C57Bl/6xB6.C-H-2bm1) F1 and combined MCMV infection showed that the immunodeficiency is characterized by a profound loss of in vitro Th cell production of IL-2 and an intrinsic defect in T effector function as shown by an inability of rIL-2 to restore defective CTL responses. Additional experiments in these mice revealed the presence of suppressor cells as well as significant parent-anti-F1 CTL activity possibly accounting for the suppressor effect. This pattern of immunodeficiency was not seen after the administration of either MCMV or MHC class I disparate parental cells alone. MCMV infection did not detectably alter the immunodeficiency observed in a P----F1 combination involving a MHC class II difference only. These results indicate that MCMV infection can alter the pattern of GVHD in the setting of an MHC class I disparity, but not in the setting of class II disparity, such that it resembles acute GVHD. These results may have relevance to the human transplant setting where intercurrent CMV infection has been associated with an adverse clinical outcome. | 4 |
Treatment of decompensated chronic obstructive pulmonary disease in the emergency department--correlation between clinical features and prognosis. STUDY OBJECTIVE: Patients with decompensated chronic obstructive pulmonary disease (COPD) are at high risk of relapse after treatment in an emergency department. The purpose of this study was to determine if the risk of relapse correlates with the clinical features of the disease. PATIENTS: Three hundred fifty-two patients with documented COPD who were treated for dyspnea in the ED of the Albuquerque Veterans Administration Medical Center over a three-year period. METHODS: We reviewed the clinical features and pulmonary function tests of the patients, who were considered to have COPD if the baseline prebronchodilator one-second forced expiratory volume (FEV1) was less than 80% predicted, and less than 80% of the forced vital capacity and inhaled bronchodilators failed to increase the FEV1 to levels of more than 80% predicted. Visits for pneumonia, pneumothorax, pleural effusion, or pulmonary emboli were excluded. A relapse was defined as an unscheduled revisit to the ED within 14 days of initial treatment. Data were entered into a microcomputer data base and analyzed by a commercial statistical package. RESULTS: Of 877 visits in which the patient was treated and released from the ED, 281 (32.0%) resulted in relapse and were considered unsuccessful Compared with successful visits, unsuccessful visits were characterized by a shorter duration of dyspnea (P = .002), a lower entry FEV1 (P = .027), a lower discharge FEV1 (P = .040), a greater number of treatments with nebulized bronchodilators (P = .009), more frequent use of parenteral adrenergic drugs (P = .006), and less frequent use of oral prednisone on discharge (P = .016). Patients with one or more relapse visits during the study period (relapsers) differed from nonrelapsers in several respects. Relapsers had a greater bronchodilator response on baseline FEV1 than nonrelapsers (P = .047). Nevertheless, relapsers required more bronchodilator treatments in the ED (P less than .001); were treated more frequently with parenteral adrenergic drugs (P less than .001), IV glucocorticoids (P less than .001), and oral prednisone (P less than .001); and recovered less of their baseline FEV1 (P less than .014). CONCLUSION: Bronchodilator response on baseline pulmonary function testing appears to identify patients with COPD who have a poor prognosis after emergency treatment. Their poor response to intensive bronchodilator treatment suggests that loss of bronchodilator response may be involved in the pathogenesis of respiratory decompensation. | 4 |
Treatment of chronic relapsing inflammatory demyelinating polyneuropathy by cyclosporin A and plasma exchange. A case report. A patient with chronic relapsing inflammatory demyelinating polyneuropathy was successfully treated with plasma exchanges and cyclosporin A (CsA). Dynamometric measurements of hand force during the time of CsA treatment showed a highly significant correlation between hand force and CsA blood levels. The largest influence of CsA on hand force occurred 11-13 days after CsA uptake. | 4 |
Sudden death due to delayed rupture of hepatic subcapsular hematoma following blunt abdominal trauma. Blunt abdominal trauma can cause sudden, unexpected death due to injuries to internal organs. Rupture of a hepatic subcapsular hematoma is a relatively rare cause of sudden death following minor blunt abdominal trauma. Death may be delayed several days to weeks. The autopsy is an invaluable diagnostic tool that can be utilized to uncover sudden deaths due to abdominal trauma. The case of an alcoholic who died of a ruptured hepatic subcapsular hematoma is presented. The death investigation revealed that the victim had sustained blunt abdominal trauma during a fall a few days prior to death. | 4 |
Acute abdominal pain in the elderly. STUDY OBJECTIVES: To determine the incidences of both specific diagnosis and surgical diseases in patients more than 65 years old who present to the emergency department with nontraumatic abdominal pain of less than one week's duration, and to determine the ED staff's ability to diagnose and triage elderly patients with acute abdominal pain. DESIGN: A 12-month retrospective review of all elderly patients who presented to the ED with acute, nontraumatic abdominal pain. SETTING: A regional trauma center serving a predominately rural population in the Midwest. The ED has 55,000 patient visits yearly. MEASUREMENTS AND MAIN RESULTS: Of the 127 patients enrolled, 30 (24%) had no specific diagnosis made in the ED. Biliary tract disease (12%) and small bowel obstruction (12%) were the two most common specific diagnoses. Overall, 53 patients (42%) required surgery, usually during the initial hospitalization. In four cases, the postoperative diagnosis differed significantly from the ED diagnosis. Of the 74 patients (58%) who did not undergo surgery, 51 had follow-up information available. In 14 patients, the follow-up diagnosis differed from the original diagnosis, but most of these changes did not appreciably alter the treatment and outcome. CONCLUSIONS: The incidence of surgical disease is high in elderly patients with acute abdominal pain, and ED staff are able to diagnose and triage these patients accurately. | 4 |
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). | 4 |
Efficacy of interferons on bowenoid papulosis and other precancerous lesions. Preliminary results of an open randomized trial of recombinant interferon gamma in patients suffering from bowenoid papulosis are described. Recombinant interferon gamma was given subcutaneously to 12 patients at a daily dose of 4 X 10(6) I.U. by injection. Four patients each were assigned to one of three treatment groups consisting of continuous therapy (group A) with three subcutaneous injections per week for 13 weeks; intermittent block therapy (group B) with four six-week cycles consisting of five injections on days 1, 3, 5, 7, and 9 of each cycle; and intermittent single-dose therapy (group C) with six four-week cycles consisting of only one subcutaneous injection on day one of each cycle. At the twenty-sixth week after onset of therapy, complete responses were seen in three of four patients of treatment group A, whereas in the treatment groups B and C only one patient, respectively, responded partially. These results suggest that in contrast to condylomata acuminata bowenoid papulosis lesions respond better to continuous than to intermittent interferon gamma injections. | 0 |
Paralysis of saccades and pursuit: clinicopathologic study. We report a 73-year-old patient with an eye movement disorder characterized by paralysis of saccades and pursuit. At autopsy, there were small cortical lesions in the middle frontal gyrus immediately anterior to the precentral gyrus and in the inferior parietal lobule on both sides. | 4 |
Prevalence of hemodynamically significant stenosis of the carotid artery in an asymptomatic veteran population. The results of previous studies have suggested that significant stenosis of the carotid artery occurs in less than 6 per cent of asymptomatic patients. However, some populations studied were not representative of those seen by most vascular surgeons. Accordingly, we examined two cohorts of patients at the Veterans Administration Medical Center using Duplex scanning. There were 153 volunteers in group 1, all more than 50 years of age, who were being treated at our outpatient department for nonvascular problems. There were 116 patients of similar age in group 2 but who were known to have significant arterial occlusive disease of the lower extremity. The majority of patients were men with a mean age of 64.4 years. Risk factors in the total population included hypertension, diabetes mellitus, coronary arterial disease, peripheral vascular disease and smoking. Over-all, significant (greater than 50 per cent diameter) stenosis of the carotid artery was discovered in 25 of 269 patients. The prevalence for those in group 1 was 6.5 per cent versus 12.9 per cent for those in group 2 (p = 0.058). The prevalence in patients with cardiac disease was 15.2 per cent compared with 6.8 per cent in those without cardiac disease (p = 0.032). Smoking was associated with a 10.6 per cent rate of significant disease compared with a 2.3 per cent rate in nonsmokers (p = 0.065). Hypertension and diabetes were not significant risk factors. Significant stenosis of the carotid artery was found in seven of 40 patients in whom coronary arterial disease, peripheral vascular disease and smoking were all present. | 3 |
Epidemiologic risk factors for children with acute lower respiratory tract infection in Buenos Aires, Argentina: a matched case-control study. The risk factors that predisposed 516 hospitalized and 154 ambulatory patients to acute lower respiratory tract infection (ALRI) are examined in a matched case-control study. The control group was selected from children attending immunization and well-baby clinics at the same institution that was treating the children with ALRI. Sex, age, nutritional status, socioeconomic level, as well as season and place of residence were used as matching criteria. Because of their distinct profiles, hospitalized and outpatient groups were analyzed separately. However, the four variables with the highest odds ratios (incidence ratios or relative risk) were found to be the same for both groups. These variables were related to the host's condition (bronchial hyperreactivity, presence of persistent symptoms of the upper respiratory tract), family (presence of acute respiratory tract disease in household members), and environment (indoor contaminants). | 4 |
Atheroemboli to the lower urinary tract: a marker of atherosclerotic vascular disease--a case report. Atheroemboli to the lower genitourinary tract may serve as a marker for disseminated atheroembolic disease, a highly lethal condition. A case presentation and review of our institional experience is presented. | 0 |
Protective role of vitamin E in biological systems. Vitamin E is well accepted as nature's most effective lipid-soluble, chain-breaking antioxidant, protecting cell membranes from peroxidative damage. Free-radical-mediated pathology has been implicated in the development over time of degenerative diseases and conditions. This paper reviews the current research on the protective role and requirements for vitamin E and the other antioxidants in preventing or minimizing free-radical damage associated with specific diseases and lifestyle patterns and processes, including cancer, aging, circulatory conditions, arthritis, cataract, pollution, and strenuous exercise. While awaiting results of further human studies, research evidence suggests that an adequate intake of vitamin E and the other antioxidants can provide protection from the increasingly high free-radical concentrations caused by air pollutants and current lifestyle patterns. | 0 |
Beta-lactam resistance mechanisms of methicillin-resistant Staphylococcus aureus. In vitro and in vivo activity of amoxicillin and penicillin G alone or combined with a penicillinase inhibitor (clavulanate) were tested against five isogenic pairs of methicillin-resistant Staphylococcus aureus (MRSA) producing or not producing penicillinase. Loss of the penicillinase plasmid caused an eight times or greater reduction in the MICs of amoxicillin and penicillin G (from greater than or equal to 64 to 8 micrograms/ml), but not of the penicillinase-resistant drugs methicillin and cloxacillin (greater than or equal to 64 micrograms/ml). This difference in antibacterial effectiveness correlated with a more than 10 times greater penicillin-binding protein 2a affinity of amoxicillin and penicillin G than of methicillin and a greater than or equal to 90% successful amoxicillin treatment of experimental endocarditis due to penicillinase-negative MRSA compared with cloxacillin, which was totally ineffective (P less than .001). Amoxicillin was also effective against penicillinase-producing parent MRSA, provided it was combined with clavulanate. Penicillinase-sensitive beta-lactam antibiotics plus penicillinase inhibitors might offer a rational alternative treatment for MRSA infections. | 3 |
Hepatic giant cavernous hemangioma with microangiopathic hemolytic anemia and consumption coagulopathy. We describe a case of hepatic giant cavernous hemangioma with both microangiopathic hemolytic anemia (MAHA) and consumption coagulopathy, but without thrombocytopenia, which was completely cured by surgical resection of the tumor. The patient was a 54-yr-old Japanese woman whose chief complaint was right upper abdominal discomfort. Angiography and dynamic computed tomography revealed typical findings of hepatic cavernous hemangioma. The patient also had hematological disorders. At surgery, we performed an atypical right lobectomy to preserve as much normal liver tissue as possible. The patient has been well, with no related complaints or abnormal laboratory findings, 5 yr since her operation. This case indicates that giant cavernous hemangioma of the liver should be considered in the differential diagnosis of MAHA, and if surgical treatment is adequate, hematological abnormalities may be eliminated. | 0 |
Effects of indomethacin on hepatogenic pulmonary angiodysplasia. A patient had liver cirrhosis associated with marked hypoxemia. With administration of indomethacin (75 mg/day for six days), PaO2 was elevated up to 50 mm Hg from 44 mm Hg. At that time, dynamic pulmonary perfusion imaging revealed a plateau time course curve of MAA uptake in the lungs, as compared with findings obtained during the state of severe hypoxemia without indomethacin. These observations suggest that part of hepatogenic pulmonary angiodysplasia is a functional vasodilatation that is presumably modulated by vasoactive substances, such as prostaglandins and/or other eicosanoids. | 1 |
Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group BACKGROUND. Adverse cardiac events are a major cause of morbidity and mortality after noncardiac surgery. It is necessary to determine the predictors of these outcomes in order to focus efforts on prevention and treatment. Patients undergoing noncardiac surgery sometimes have postoperative cardiac events. It would be helpful to know which patients are at highest risk. METHODS. We prospectively studied 474 men with coronary artery disease (243) or at high risk for it (231) who were undergoing elective noncardiac surgery. We gathered historical, clinical, laboratory, and physiologic data during hospitalization and for 6 to 24 months after surgery. Myocardial ischemia was assessed by continuous electrocardiographic monitoring, beginning two days before surgery and continuing for two days after. RESULTS. Eighty-three patients (18 percent) had postoperative cardiac events in the hospital that were classified as ischemic events (cardiac death, myocardial infarction, or unstable angina) (15 patients), congestive heart failure (30), or ventricular tachycardia (38). Postoperative myocardial ischemia occurred in 41 percent of the monitored patients and was associated with a 2.8-fold increase in the odds of all adverse cardiac outcomes (95 percent confidence interval, 1.6 to 4.9; P less than 0.0002) and a 9.2-fold increase in the odds of an ischemic event (95 percent confidence interval, 2.0 to 42.0; P less than 0.004). Multivariate analysis showed no other clinical, historical, or perioperative variable to be independently associated with ischemic events, including cardiac-risk index, a history of previous myocardial infarction or congestive heart failure, or the occurrence of ischemia before or during surgery. CONCLUSIONS. In high-risk patients undergoing noncardiac surgery, early postoperative myocardial ischemia is an important correlate of adverse cardiac outcomes. | 4 |
Myocarditis or acute myocardial infarction associated with interleukin-2 therapy for cancer. The hearts of eight patients aged 22 to 67 years (mean, 41 years) who died during or within 4 days of interleukin-2 (IL-2) based immunotherapy for treatment of renal cell carcinoma or melanoma were studied at necropsy. Death resulted from combined cardiorespiratory failure in two patients, sepsis in four patients, acute myocardial infarction in one patient, and myocarditis in one patient. Transmural left ventricular necrosis was present in one of the two patients with significant atherosclerotic coronary artery narrowing. Noninfectious myocarditis was present in five patients: the inflammatory infiltrate was lymphocytic in four and composed of a mixture of eosinophils and lymphocytes in one. Although treatment-related deaths associated with high-dose IL-2 therapy are uncommon (1.5% in 652 consecutive patients), the potential for significant myocardial ischemia or myocarditis exists, and careful monitoring for arrhythmias or myocardial failure is warranted. | 3 |
Complications of extracorporeal membrane oxygenation in neonates. In cases of severe respiratory failure, cardiopulmonary bypass has been used as support until cardiac and pulmonary recovery occurs. We report the Wilford Hall USAF Medical Center experience with extracorporeal membrane oxygenation (ECMO) and its associated complications. From July 1985 to March 1989, 57 neonates were placed on membrane oxygenators. The overall survival was 79%. Technical complications encountered included catheter-related problems, mechanical complications of the pump apparatus, and hemorrhage. Hemorrhagic complications were the most frequent and devastating complications encountered. Intracranial hemorrhage accounted for six deaths associated with bypass. Extracorporeal membrane oxygenation is successful in significantly improving survival of neonates whose predicted mortality approaches 100% with conventional treatment. The rate of infant mortality using the membrane oxygenator is not affected by technical complications related to catheter position, mechanical problems with the circuit, or hemorrhage, excluding intracranial hemorrhage. The major cause of death of infants receiving extracorporeal membrane oxygenation is the underlying disease process leading to cardiopulmonary failure. | 4 |
Follow-up recatheterization after balloon aortic valvuloplasty. Mansfield Scientific Aortic Valvuloplasty Registry Investigators. The results of recatheterization were assessed in a select group of 95 patients enrolled in the Mansfield Scientific Aortic Valvuloplasty Registry to determine whether any procedural or patient-related variables at baseline predicted either initial immediate or follow-up (6.2 +/- 3.3 months) results. At the follow-up catheterization, 39 (41%) of the patients were in improved condition and 56 patients (59%) had recurrence of symptoms, allowing for analysis of the effect of the procedure in two symptomatic patient subsets. In the total group the aortic valve area increased initially from 0.56 +/- 0.16 to 0.87 +/- 0.27 cm2 but partial return to the baseline valve area was evident at follow-up (0.63 +/- 0.25 cm2). Similarly, the mean aortic gradient initially decreased from 72 +/- 30 to 35 +/- 16 mm Hg but then increased to 55 +/- 25 mm Hg at follow-up. Neither the initial nor the late hemodynamic results appeared affected by any definable procedural variable at the time of valvuloplasty, including the maximal diameter of balloons, number of balloons simultaneously used, mean inflation time or total number of inflations. Such technical concerns also did not seem to affect short- or long-term outcome. Similarly, no baseline hemodynamic variable clearly separated those who became increasingly symptomatic from those whose condition was improved at the 6 month interval. At recatheterization, a reduction in the aortic valve area toward baseline was observed in 24 (62%) of the 39 improved patients and in 45 (80%) of the 56 who were symptomatic. | 3 |
Structural alterations of nerve during cuff compression. Whether compression nerve injury is due to ischemia, direct mechanical injury, or both remains unsettled. To assess structural changes of nerve during compression, peroneal nerves of rats were compressed at various pressures for different times, and the structural alterations were stopped by simultaneous in situ and perfusion fixation. The structural changes observed during a few minutes of compression cannot be explained by ischemic injury because the pathologic alterations characteristic of ischemia take many hours to develop and in any case are different from the ones found here. The pressure- and time-related structural changes observed in the present study under the cuff were (i) decrease in fascicular area and increase in fiber density due to expression of endoneurial fluid; (ii) compression and expression of axoplasm, sometimes to the point of fiber transection; (iii) lengthening of internodes; and (iv) obscuration of nodes of Ranvier due to cleavage and displacement of myelin and overlapping of nodes by displaced loops of myelin. At the edges of the cuff the changes were (i) increase of fascicular area probably from expressed endoneurial fluid; (ii) widening of nodal gaps, perhaps mainly from translocated axonal fluid; and (iii) disordered structure of axoplasm. We suggest that the process of paranodal demyelination and axonal transection are linked, occur during the act of compression, and are due to shear forces. The initial event is expression of endoneurial fluid, followed by compression and expression of axoplasm and cleavage and displacement of layers of myelin. Conceivably, with prolonged cuff compression ischemic injury might be found to be superimposed on mechanical injury. | 2 |
Laparoscopic ventrosuspensions. A review of 72 cases. Laparoscopic ventrosuspension is simple to perform after diagnostic laparoscopy. Serious postoperative complication is unlikely. However, patient follow-up over 6 months has not confirmed the usefulness of laparoscopic ventrosuspension in the management of deep dyspareunia or pelvic pain in association with a retroverted uterus. The success rate of laparoscopic ventrosuspension at 6 months varies from 18.6% to 46.5%. The prior use of a Hodge pessary does not predict the success of laparoscopic ventrosuspension. | 2 |
Human hepatic regenerative stimulator substance: partial purification and biological characterization of hepatic stimulator substance from human fetal liver cells. Current support or replacement therapies for fulminant acute hepatic failure are frequently very disappointing. In this study, human hepatic stimulator substance--a liver-specific growth factor--was partially purified from human fetal liver cells and characterized by its biological effects. Almost 70-fold protein content was purified with an approximately 80-fold increase in specific growth stimulator activity. Human hepatic stimulator substance proved to be heat-stable, protease-sensitive, organ-specific and species-nonspecific. Human hepatic stimulator substance produced a two- to threefold increase of 3H-thymidine incorporation into hepatic DNA when injected intraperitoneally into growing weanling mice (nonhepatectomized) or regenerating rats (34% hepatectomy). The effects of hHSS in reversing the lethality of D-galactosamine (1.6 gm/kg body weight)-induced hepatic necrosis in rats were further evaluated. A survival rate of 4% (n = 24), 41% (n = 12, p less than 0.05), 33% (n = 12, p less than 0.05), 31% (n = 13, p less than 0.05) and 18% (n = 11, p greater than 0.05) was observed when the rats were injected with 4 ml of saline intraperitoneally, 4 ml of human intact fetal hepatocytes (2.4 x 10(8] intraperitoneally, 4 ml of human hepatic stimulator substance intraperitoneally, 2 ml of twofold concentrated human hepatic stimulator substance intravenously and 1 ml of fourfold human hepatic stimulator substance intramuscularly, respectively, 20 hr after poisoning. | 1 |
Ileal pouch-anal anastomosis. Reoperation for pouch-related complications. The aim was to assess the value of reoperative surgery for pouch-related complications after ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis and familial adenomatous polyposis. Between January 1981 and August 1989, 114 of 982 IPAA patients (12%) seen at the Mayo Clinic had complications directly related to IPAA that required reoperation. Among the 114 patients, the complications prevented initial ileostomy closure in 33 patients (25%), occurred after ileostomy closure in 68 patients (60%), and delayed ileostomy closure in the remaining patients. The salvage procedures performed included anal dilatation under anesthesia for anastomotic strictures, placement of setons and/or fistulotomy for perianal fistulae, unroofing of anastomotic sinuses, simple drainage and antibiotics for perianal abscesses, abdominal exploration with drainage of intra-abdominal abscesses with or without establishment of ileostomy, and complete or partial reconstruction of the reservoir for patients with inadequate emptying. None of the reoperated patients died. Reoperation led to restoration of pouch function in two thirds of patients and, of these, 70% had an excellent clinical outcome. However approximately 20% of the 114 pouches required excision. Excision was common, especially among patients who had pelvic sepsis. Salvage procedures for pouch-specific complications can be done safely and will restore pouch function in two thirds of patients. Complications after reoperation, however, may ultimately lead to loss of the reservoir in one in five patients. | 4 |
Interaction between trimethoprim-sulfamethoxazole and methotrexate in children with leukemia. Because trimethoprim-sulfamethoxazole (TMP-SMX) causes neutropenia in children with leukemia, we investigated the possibility that pharmacokinetic interaction between methotrexate (MTX) and TMP-SMX causes accumulation of the antileukemia agent. We studied the pharmacokinetics of MTX given intravenously or orally to nine children with acute lymphoblastic leukemia, once with and once without TMP-SMX. There was an increase in free MTX fraction during TMP-SMX therapy in all patients, from (mean +/- SD) 37.4 +/- 11% without TMP-SMX to 52.2 +/- 6.4% with TMP-SMX (p less than 0.01). Plasma clearance of total MTX did not change significantly, whereas clearance of free MTX decreased significantly (from 12.5 +/- 4 to 7.6 +/- 1.5 ml/kg/min; p less than 0.05). There was a consistent decrease in the renal clearance of free MTX (from 12.1 +/- 6.8 to 5.6 +/- 2.4 ml/kg/min; p less than 0.05). Elimination half-life of MTX was not affected significantly by TMP-SMX. There was a significant correlation between serum concentrations of TMP-SMX and the percentage of decrease in the renal clearance of free MTX (r = 0.91; p less than 0.05). These changes in protein binding and tubular clearance of MTX, caused by competition with TMP-SMX, result in a mean 66% increase in systemic exposure to MTX and may explain the myelotoxicity often observed with the coadministration of the two drugs. | 0 |
Clinical prediction rule for pulmonary infiltrates OBJECTIVE: To derive and validate a clinical rule for predicting pneumonic infiltrates in adult patients with acute respiratory illness. DESIGN: Prevalence studies in three settings. SETTING: Emergency departments of the University of Illinois Hospital at Chicago, the University of Nebraska Medical Center at Omaha, and the Medical College of Virginia at Richmond. PATIENTS: Symptoms, signs, comorbidity data, and chest roentgenogram results were recorded for 1134 patients from Illinois (the derivation set), 150 patients from Nebraska, and 152 patients from Virginia (the validation sets). All patients presented to the emergency department and had a chest roentgenogram to evaluate fever or respiratory complaints. MEASUREMENTS AND MAIN RESULTS: Within the training set, temperature greater than 37.8 degrees C, pulse greater than 100 beats/min, rales, decreased breath sounds, and the absence of asthma were identified as significant predictors of radiographically proved pneumonia in a stepwise logistic regression model (P = 0.001). The logistic rule discriminated patients with and without pneumonia in the training set with a receiver operating characteristic (ROC) area of 0.82. In the validation sets, the rule discriminated pneumonia and nonpneumonia with ROC areas of 0.82 and 0.76 after adjusting for differences in disease prevalence (P greater than 0.2 compared with the training set). The predicted probability of having pneumonia for patients with different clinical findings corresponded closely with the incidence of pneumonia among patients with such findings in the three settings. CONCLUSIONS: Among adults presenting with acute respiratory illness, a prediction rule based on clinical findings accurately discriminated patients with and without radiographic pneumonia, and was used in two other samples of patients without significant decrement in discriminatory ability. This rule can be used by physicians to develop more effective strategies for detecting pneumonia and for helping to determine the need for radiologic study among patients with acute respiratory disease. | 4 |
Treatment of refractory oral candidiasis with fluconazole. A case report. We describe a patient with the acquired immunodeficiency syndrome who had persistent oral esophageal pseudomembranous candidiasis clinically refractory to nystatin, clotrimazole, and ketoconazole. In vitro resistance to clotrimazole was demonstrated as well. The patient received temporary relief with intravenous amphotericin B therapy, but this was associated with serious adverse effects, including transfusion-requiring anemia, azotemia, and severe thrombophlebitis. Despite two courses of intravenous amphotericin B therapy, the patient's highly symptomatic, recurrent oral and esophageal candidiasis continued. The patient was then treated with fluconazole and obtained immediate relief without associated adverse effects. | 1 |
Annulo-aortic ectasia with DeBakey type II dissecting aneurysm in Gaucher's disease. Annulo-aortic ectasia is an extremely rare complication of Gaucher's disease. We report successful surgery in a patient with Gaucher's disease complicated by annulo-aortic ectasia and aortic dissection. Cabrol's operation was accomplished without bleeding or sternal adaptation problems. | 3 |
Prognostic factors in alcoholic liver disease. VA Cooperative Study Group. Two hundred eighty-one alcoholic patients were prospectively evaluated by clinical, biochemical, and histologic parameters during a 4-yr period to assess their prognosis. They were stratified into four categories of injury: 1) fatty liver (26 patients), 2) acute alcoholic hepatitis (106), 3) cirrhosis (39), and 4) cirrhosis with superimposed alcoholic hepatitis (111). The rate of survival and variables correlating with survival varied according to the group. At 48 months, 70% of the patients with fatty liver were alive, 58% in the alcoholic hepatitis group, 49% in cirrhosis, and 35% in alcoholic hepatitis superimposed upon cirrhosis. Within group one, deaths were due to causes unrelated to liver disease. In the alcoholic hepatitis group, factors significantly correlating with survival were ascites, alanine amino-transferase levels, grams of alcohol consumed, continuation of alcohol intake, and clinical severity of disease. Survival in patients of group three correlated significantly with prothrombin time and histologic severity score. Patients with combined cirrhosis and alcoholic hepatitis exhibited the worst prognosis, with the most significant predictors of survival being age, grams of alcohol consumed, the ratio of serum aminotransferases (AST:ALT) and the histologic and clinical severity of the disease. Although a different pattern of correlates was observed for each pathologic level of injury, knowledge of the various correlates aids in prognostic assessment. | 4 |
Sequential esophageal motility studies after endoscopic injection sclerotherapy: a prospective investigation. To assess prospectively the effects of endoscopic intravariceal sclerosis (EIS) on esophageal function, we performed esophageal manometry on 13 cirrhotic patients before EIS, 24 h after the second session and 4 wk after the fourth session. EIS had no impact on lower esophageal sphincter pressure. However, a significant decrease in the amplitude of peristaltic waves was observed immediately post-EIS in the lower two-thirds of the esophagus. There was no modification of duration or velocity of progression of peristaltic waves. A four-fold increase in simultaneous contractions was observed early after EIS. These changes were reversible, as assessed by late esophageal testing after EIS. No correlations were demonstrated between esophageal motor parameters and doses of sclerosant. We conclude that sclerosant injection into the esophageal wall acutely impairs esophageal motility, but motor function is partially restored 4 wk after completion of EIS, suggesting that dysmotility is reversible. | 1 |
Diltiazem therapy for symptoms associated with nutcracker esophagus. A randomized double-blind, cross-over prospective trial in 22 patients was designed to evaluate possible effect of an oral calcium channel blocker, diltiazem, on symptoms of chest pain and/or dysphagia in patients with nutcracker esophagus. We studied 22 consecutive patients referred to an esophageal diagnostic center for evaluation of noncardiac chest pain or dysphagia having high amplitude esophageal contractions, 14 of whom completed the study. Diltiazem (60-90 mg qid) was compared with placebo, each being administered for 8 wk. Patients were evaluated with esophageal motility pre- and posttreatment periods and with regular symptom assessment throughout each 8-wk treatment. Active diltiazem therapy resulted in significantly lower (p less than 0.05) mean distal esophageal peristaltic pressure (128 +/- 20 mm Hg; +/- SE) than placebo (158 +/- 16 mm Hg). Mean chest pains scores were significantly (p less than 0.05) lower with diltiazem therapy than with placebo. Only nine of the 14 patients fulfilled presently acceptable criteria for diagnosing nutcracker esophagus, and the diltiazem effect was similar, although not significant, because of the smaller sample. Conclusions: In this preliminary study involving 14 patients, the oral calcium channel blocker, diltiazem, appeared to improve noncardiac chest pain associated with strong esophageal contraction, the nutcracker esophagus. These improved symptoms were associated with significant decreases in contraction pressure. | 1 |
Infantile systemic hyalinosis: newly recognized disorder of collagen? Four infants with stiff skin and painful joint contractures in the first few months of life are described. Other features included small papules, particularly on the face and trunk, perianal nodules, hyperpigmentation over the metacarpophalangeal joints and over the malleoli, gingival hyperplasia, persistent diarrhea, and failure to thrive. Two of these infants died before the age of 18 months. In each case hyaline material was found in the papillary dermis. Ultrastructurally, there was a distinctive fibrillogranular appearance in which a banding pattern could be observed. This material was also found within membrane-bound vacuoles in macrophages and fibroblasts. It had an appearance and localization identical with that of collagen type VI. These features are similar to those reported in juvenile hyaline fibromatosis. It is believed that these infants have a closely related, but nonetheless distinctive, inherited disorder of collagen. | 2 |
Survey of adolescents with severe intellectual handicap. A diagnostic survey was undertaken of children aged 11 to 19 years in Tameside with severe learning difficulties (intelligence quotient less than or equal to 50). Eighty-two children were identified and their medical records reviewed. A specific diagnosis for the retardation was documented in 25 (30%) of the children, 18 of whom had Down's syndrome. A probable aetiology or a disorder of unknown aetiology had been identified in a further 21 (26%) children. To confirm the existing diagnosis, identify new diagnoses, and offer genetic counselling, the parents of 63 children were offered detailed reassessment of their child. Fifty three children were reviewed, and a specific disorder identified in 25 out of 31 previously undiagnosed children. The most frequent diagnoses made were fragile X syndrome and Rett's syndrome. On completion of the survey, 61 of the 82 children (74%) had a specific diagnosis or probable aetiology identified, 12 (15%) had associated disorders such as cerebral palsy, and in only nine of the 82 children (11%) were there no clues at all to the cause of their retardation. | 2 |
Repair of cartilage lesions using biological implants. A comparative histological and biomechanical study in goats. We report the experimental use of three different biological implants to restore articular surface defects: glutaraldehyde-fixed bovine meniscal xenograft, glutaraldehyde-fixed bovine costal cartilage xenograft, and viable osteochondral allografts. The grafts were implanted in the knees of 19 goats who were allowed free-field activity and were studied for up to one year. The natural articular surfaces of meniscal fibrocartilage provided excellent articular surfaces at all times. Equally good articular surfaces were restored by host tissue growth covering costal cartilage grafts at six months, but by 12 months this surface had degenerated. The majority of the allografts survived and integrated with the host at six months, but many showed signs of failure at 12 months. Only three out of seven ungrafted defects healed completely at six months and the healed surfaces were degenerating at 12 months. | 4 |
Sudden unexpected nocturnal death syndrome in the Mariana Islands. Sudden unexpected nocturnal death syndrome (SUNDS) is a distinct clinical entity in previously healthy, young, Southeast Asian males. It is well known in the Philippines and more recently recognized in the U.S. by nonspecific autopsy findings, with no evidence of underlying disease and absence of toxic drug or alcohol levels. In 1973-89, 14 cases of apparent SUNDS came to coroner's autopsy in the Commonwealth of the Northern Marianas (CNMI) and Guam. All 14 cases, with the exception of one Yapese, were previously healthy, male Filipinos, aged 23 to 55, who were either found dead in bed, or described by their colleagues as having nocturnal seizure activity consisting of gurgling, frothing, and tongue biting immediately prior to death. Autopsy findings showed no anatomic findings to account for death. Comprehensive serum and urine drug analyses were negative. All decedents showed absence of significant atherosclerosis or grossly detectable structural cardiac anomaly, while four showed cardiomegaly. Migrants from Southeast Asia carry with them a pre-disposition to this syndrome, which appears to decline with longer residence in the new country. The mechanism of death in SUNDS is believed to be ventricular fibrillation, possibly precipitated by sudden sympathetic discharge. Studies suggest at least some deaths may be associated with an abnormal cardiac conduction system. Acute pancreatitis has been a finding in some series, but not our cases. Why the condition is virtually limited to males and seemingly sleep-triggered, has not been adequately explained. Stress and depression are believed to be predisposing factors. | 4 |
Progression of native coronary artery disease at 10 years: insights from a randomized study of medical versus surgical therapy for angina. Repeat coronary angiography was performed in 42 patients 10 years after randomization to medical (n = 21) or surgical (n = 21) therapy for chronic angina. The native coronary arteries were classified into 15 angiographic segments and 3 arterial trunks for analysis of progression of coronary artery disease. The incidence rate of disease progression in coronary segments was 24% and 28% in medically and surgically treated patients, respectively (p = NS). Grafted segments showed a 38% rate of disease progression, which was higher than the 18% rate of for nongrafted segments (p less than 0.001) and the overall rate of 24% for medically treated patients (p less than 0.01). Similarly, 29 (94%) of 31 grafted arteries exhibited disease progression compared with 19 (59%) of 32 nongrafted arteries (p less than 0.01) and 42 (67%) of 63 arteries in medically treated patients (p less than 0.01). In grafted vessels, disease progression occurred more often in arteries proximal (84%) to the anastomosis than in arteries distal (16%) to graft insertion (p less than 0.001). Progression occurred in 46% of proximal segments compared with 23% of distal segments (p less than 0.02). Progression was seen in 23 (55%) of 43 segments with an occluded graft compared with 30 (31%) of 96 segments with a patent graft (p less than 0.02). Ten years after randomization, medically and surgically treated patients showed a comparable rate of disease progression in coronary segments. However, surgical therapy appeared to significantly accelerate atherosclerotic progression in the grafted vessels, especially in the proximal portions. Occluded grafts also correlated with an adverse effect on disease progression. | 3 |
Clear cell adenocarcinoma of the lower genital tract. Correlation of mother's recall of diethylstilbestrol history with obstetrical records. The written obstetric records of maternal exposure to diethylstilbestrol (DES) were used as a criterion standard and compared with the DES exposure history recalled by mothers of women with vaginal, cervical, or indeterminable vaginal/exocervical clear cell adenocarcinoma. Among cervical cases, the sensitivity of maternal recall was 50% (N = 2), and its specificity was 100%. Among vaginal and vaginal/exocervical cases, this sensitivity was 72%; specificity was 60%; and the majority of these mothers who said they did not take DES were DES positive by written records. Thus investigators should avoid using maternal recall alone to measure DES exposure. Among subjects for whom written maternal obstetric records were available, 88% of vaginal cases and 46% of cervical cases were DES positive. The authors conclude that few cases of vaginal clear cell adenocarcinoma should occur in young women as the cohort of women exposed in utero to DES continues to age, whereas cases of cervical origin may continue to occur. | 0 |
Prostacyclin-to-thromboxane A2 ratio in arteriogenic impotence. It has been suggested that penile hypercoagulability predisposes to aging penile vascular changes and impotence, and that elevated thromboxane A2 during erection may contribute to hypercoagulability and atherosclerosis. Since the ratio of the prostacyclin concentration to the thromboxane A2 concentration is constantly maintained in normal hemostatic responses, an imbalance between thromboxane A2 and prostacyclin may be a factor to initiate vascular diseases and decrease blood flow. We assess the usefulness of the prostacyclin-to-thromboxane A2 ratio in penile blood during erection for diagnosis of arteriogenic impotence. The ratio in the arteriogenic impotence group was significantly lower (p less than 0.01) than in the psychogenic and venogenic impotence groups. Therefore, the prostacyclin-to-thromboxane A2 ratio seems to be useful to diagnose arteriogenic impotence. | 3 |
Direct measurement of skeletal muscle fatigue in patients with chronic heart failure. Skeletal muscle function was measured as force production and fatigue in both the quadriceps (a large locomotive muscle) and adductor pollicis (a small intrinsic hand muscle) in five healthy volunteers, five patients with mild chronic heart failure, and five patients with severe chronic heart failure. The quadriceps of patients with chronic heart failure had a reduced muscle cross sectional area, a reduced maximum isometric force production, and an increased tendency to fatigue. Isometric force production and fatigue of the adductor pollicis, however, were not significantly different between the three groups under control conditions. But during circulatory occlusion fatigue in the adductor pollicis increased more in the patients with severe chronic heart failure. These differing findings in quadriceps and adductor pollicis suggest that skeletal muscle atrophy and reduced isometric force production are not a necessary consequence of chronic heart failure per se, because they were only present in the large locomotive muscle. The normal values for muscle fatigue observed in adductor pollicis in patients with chronic heart failure imply that skeletal muscle blood flow must increase normally during muscle activation when only a small muscle mass is used. These results are not compatible with the concept of a generalised impairment of normal vasodilatation within active skeletal muscle. In contrast, activation of a large muscle, such as quadriceps, results in the rapid onset of fatigue in patients with severe chronic heart failure. This fatigue may be related to the inability of the cardiovascular system to provide the required blood flow for the activation of a large muscle mass. | 3 |
Insulin resistance, hyperinsulinemia, and hypertriglyceridemia in the etiology and clinical course of hypertension. Patients with untreated hypertension have been shown to be resistant to insulin-stimulated glucose uptake and are more hyperinsulinemic and hypertriglyceridemic than matched groups of patients with normal blood pressure. In addition, insulin resistance, hyperinsulinemia, and hypertriglyceridemia have been demonstrated in spontaneous hypertensive rats and in Sprague-Dawley rats fed a fructose-enriched diet. The defect in insulin-stimulated glucose uptake in these experimental models can also be shown at the cellular level. Experimental interventions that prevent insulin resistance or hyperinsulinemia from developing in fructose-fed rats also greatly attenuate the increase in blood pressure. Since endogenous hyperinsulinemia and hypertriglyceridemia have been identified as factors that increase the risk of coronary artery disease (CAD), it is likely that they contribute to the increased prevalence of CAD in hypertensive patients. Antihypertensive treatment may have exacerbated these metabolic abnormalities, which could help explain why it has been difficult to show that lowering blood pressure decreases the risk of CAD. These observations raise the possibility that abnormalities of carbohydrate and lipoprotein metabolism may play a role in both the etiology and clinical course of hypertension. | 3 |
Incidence, determinants and significance of delayed clearance of serum HBsAg in chronic hepatitis B virus infection: a prospective study. To investigate the incidence, determinants and significance of delayed clearance of serum HBsAg in chronic hepatitis B virus infection, a prospective follow-up study was conducted in two consecutive groups of patients. Group I consisted of 984 patients (859 men and 125 women) with biopsy-proven chronic type B hepatitis, whereas group II consisted of 1,598 asymptomatic chronic carriers (998 men and 600 women) with normal serum aminotransferase activity. During a mean follow-up period of 4.0 +/- 2.3 yr, 19 patients (1.9%) of group I cleared HBsAg from their serum, whereas 35 patients (2.2%) in group II did so in a mean follow-up period of 2.7 +/- 1.4 yr. The annual incidence of delayed serum HBsAg clearance was 0.5% in group I and 0.8% in group II (p less than 0.02). The cumulative probability of HBsAg clearance was also higher in group II than in group I (p less than 0.007). Antibodies to HBsAg developed in 9 patients (47.4%) with chronic hepatitis and in 11 (31.4%) asymptomatic carriers who cleared serum HBsAg. Those who were HBeAg negative and those older than 40 at entry and those who exhibited cirrhosis during follow-up had a higher incidence of delayed HBsAg clearance. Gender, initial histological changes and hepatitis delta virus infection did not influence the occurrence of HBsAg clearance. Serum HBV DNA was not detectable by slot-blot hybridization but was still detectable by polymerase chain reaction in serum specimens collected within 1 yr of HBsAg clearance. Liver biopsy performed later in 10 patients showed no significant hepatitis activity or tissue HBV DNA, HBsAg or HBcAg. | 1 |
Premature menopause because of an inherited deletion in the long arm of the X-chromosome. A family is described in which both a mother and an infertile daughter had premature menopause at the ages of 31 and 28 years, respectively. Initially, an extensive investigation revealed no apparent cause for their conditions. However, when cytogenetic analysis in the daughter was performed, a terminal deletion in the long arm of one of the X-chromosomes was found. The karyotype was: 46,Xdel(X),(q25-qter). Chromosomal investigation in the mother showed an identical deletion. The karyotype of the patient's 35-year-old sister is normal. She has a normal menstrual cycle and two normal children. The presence of such familial cases suggests that chromosomal investigation should be considered in young women with oligomenorrhea, especially those whose mothers have experienced a premature menopause. | 4 |
Activated protooncogenes in human lung tumors from smokers. Fourteen primary human lung tumor DNAs from smokers were analyzed for transforming activity by two DNA transfection assays. Activated protooncogenes were detected in 3 of 11 tumor DNAs by the NIH 3T3 focus assay, whereas activated protooncogenes were detected in 11 of 13 tumor DNAs by the NIH 3T3 cotransfection-nude mouse tumorigenicity assay. K- or NRAS genes activated by point mutation at codons 12 or 61 were detected in a large cell carcinoma, a squamous cell carcinoma, and 5 adenocarcinomas. An HRAS oncogene activated by a different mechanism was detected in an epidermoid carcinoma. One adenocarcinoma was found to contain an activated RAF gene. Two unidentified transforming genes were detected in a squamous cell carcinoma DNA and two adenocarcinoma DNAs. Eight of 10 lung adenocarcinomas that had formed metastases at the time of surgery were found to contain RAS oncogenes. No significant increase in metastasis was observed in the lung adenocarcinomas that contained one or more 6-kilobase EcoRI alleles of the LMYC gene. Overall, 12 of 14 (86%) of the lung tumor DNAs from smokers were found to contain activated protooncogenes. RAS oncogenes appear to play a role in the development of metastases in lung adenocarcinomas. | 4 |
Physiologic and psychobehavioral research in oncology. A major thrust in research in psychosocial oncology is the study of the interaction of psychologic and physiologic variables. This discussion reviews the current status and future directions of such research. Areas addressed include pain, nausea and vomiting with chemotherapy, sexuality, effects of cancer on psychologic and neuropsychologic function, impact of psychologic factors on cancer and its treatment, and psychoneuroimmunology. In addition, specific recommendations for strategies to facilitate research in these areas of psychosocial oncology are proposed. | 2 |
Superior hypophyseal artery aneurysm. Report of two cases. Two cases of saccular intracranial aneurysms arising from the superior hypophyseal artery take-off from the internal carotid artery are presented. The angiographic findings and technical details of the operative approach are discussed. Particular attention is focused on the use of fenestrated angled clips. | 3 |
Effects of exercise on myocardial catecholamine content and ischemic injury in dogs with gradual coronary occlusion. The effects of exercise on catecholamine content and the extent of myocardial damage in dogs with Ameroid constrictor occlusion of the left circumflex coronary artery were determined. Tissue samples from both the anterior and posterior walls of the left ventricle were obtained for determination of catecholamine content, and the rest of the ventricles were processed for histologic examination. When subjected to treadmill exercise for 40 days after surgery, obstructed animals performed significantly less exercise than sham-operated animals and showed significantly higher percentages of ischemia and necrosis in the left ventricle than sedentary, obstructed, sham-operated, or control dogs. Levels of norepinephrine and epinephrine in the posterior wall of the left ventricle were significantly lower than in the other groups. Our data show that exercise in this well-known model of chronic coronary artery stenosis produced deleterious effects on the myocardium and suggest a marked heterogeneity of catecholamine stores in the myocardium that may have important functional and electrophysiologic consequences. | 3 |
Technetium-99m sestamibi myocardial imaging: same-day rest-stress studies and dipyridamole. Unlike thallium-201, technetium-99m (Tc-99m) sestamibi does not redistribute in the myocardium after injection. Thus, 2 separate injections, 1 at rest and the other at stress (or after dipyridamole), are required to differentiate ischemia from scar. From a physical viewpoint, a 24-hour interval between the 2 injections is preferable for detection of coronary artery disease (CAD) with Tc-99m sestamibi imaging. However, same-day studies are more convenient in clinical practice. Results of studies using different Tc-99m sestamibi injection protocols are presented with emphasis on the advantages of a rest-stress injection sequence with a low dose at rest (7 mCi) followed 2 hours later by a higher dose at stress (25 mCi). A prospective study was conducted in a patient population with proven CAD using same-day studies to compare a rest-stress (7 and 25 mCi, respectively) to a stress-rest (7 and 25 mCi) Tc-99m sestamibi injection sequence. There was an agreement in 87.3% of the analyzed segments between the 2 protocols. However, the largest discordance for type of defect applied to 7.4% of the segments judged ischemic in the rest-stress protocol, which were called scars on stress-rest. This study showed that a rest-stress sequence is preferable when using a same-day protocol with a short time interval (less than 2 hours) between the 2 Tc-99m sestamibi injections because the rest image performed initially represents a "true" rest study, which is not necessarily the case with the stress-rest sequence. Preliminary studies were performed to evaluate dipyridamole with Tc-99m sestamibi imaging in normal subjects and in patients with CAD. These studies showed that treadmill and dipyridamole Tc-99m sestamibi imaging are comparable and the results are similar to those obtained with thallium-201. | 3 |
Primary undifferentiated small cell carcinoma of the esophagus: clinicopathological and flow cytometric evaluation of eight cases. We present a clinicopathological and flow cytometric evaluation of eight primary small cell carcinomas of the esophagus representing 1.5% of all esophageal malignancies diagnosed during a 22-year period (1965-1987) in the Tampere University Central Hospital. The mean age of the patients (four male and four female) was 67 years (range 55-75 years). Five cases had distant metastases at the time of diagnosis. Three patients were treated by esophageal resection, one by laser vaporisation, and four by chemotherapy. The median survival time was 4 months (range 9 days to 8 months). A complete local response to chemotherapy in serial esophagogramms was detected in one patient. All four patients given chemotherapy survived longer than those treated with esophageal resection only. Four (67%) of the six carcinomas analyzed by DNA flow cytometry contained DNA-aneuploid stemlines. The median S-phase fraction of these small cell carcinomas was high (16.3%), reflecting rapid cell proliferation rate, which may be related to their responsiveness to chemotherapy. | 0 |
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