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Primary carcinoma of the gallbladder. Seventy-four patients with primary carcinoma of the gallbladder, diagnosed over 18 years from 1969 to 1987, were studied retrospectively. The most common presenting complaint was abdominal pain, followed by jaundice and weight loss. Surgery was performed in 61 patients and of these patients, only two had accurate preoperative diagnosis which was made by ultrasonography. Twelve of the 13 patients who were treated medically had the disease diagnosed at autopsy. One of the 13 patients had the diagnosis of gallbladder cancer by the findings of ultrasonography and abdominal computed tomography (CT) scanning. The resectability of the surgically managed group was 36.1%, and the majority of patients with advanced tumors (82.2%) were deemed unresectable. The most common histologic type was adenocarcinoma. Liver was the organ most commonly invaded (76.5%) by direct extension and/or metastases, followed by regional lymph nodes (52.9%). The overall 5-year survival rate was 5.4%. A high index of suspicion of the disease, intraoperative examination of gallbladder specimen, and earlier, more aggressive surgical treatment may improve patient survival. | 1 |
Late relapse with nodular lymphoma after treatment for diffuse non-Hodgkin's lymphoma. Histologic conversion from a low-grade non-Hodgkin's lymphoma (NHL) into a more aggressive histologic pattern is a common, well-documented event in NHL. The converse phenomenon, appearance of a low-grade, follicular NHL after treatment for diffuse, intermediate, or high-grade NHL, has only recently been recognized. The clinical, morphologic, and immunologic features of a patient in whom relapse with an indolent nodular lymphoma was noticed after combination chemotherapy for diffuse lymphoma are presented. Immunologic markers at presentation and relapse were similar. Other previously reported cases are reviewed. Implications for diagnosis and therapy as well as the pathogenesis of this unique form of conversion are discussed. | 4 |
Absence of acetylcholine-induced current in epithelial cells from thymus glands and thymomas of myasthenia gravis patients. We investigated the activity of ion channels in epithelial cells from human thymus glands and thymomas kept in short-term cell culture by clamping the membrane potential of the cells at -85 mV and determining the membrane current flowing on application of acetylcholine, glycine, or gamma-aminobutyric acid. In concentrations of up to 10(-3) M, none of the neurotransmitters induced any detectable current. This suggests (1) that there are no acetylcholine receptors (AChRs) or other products of the AChR gene family having ion-channel properties in the membranes of these epithelial cells, and (2) that the alpha-bungarotoxin-binding protein of thymus and thymoma has no AChR-like ion-channel property. These results support the hypothesis that the cross-reacting structures that elicit the anti-AChR autoimmune response in thymoma-associated myasthenia gravis are antigens having only limited homology with the AChR. Myasthenia gravis not associated with thymoma might have a different pathogenesis. | 2 |
Quantification of the reversibility of stress-induced thallium-201 myocardial perfusion defects: a multicenter trial using bull's-eye polar maps and standard normal limits A multicenter trial was performed on 140 patients from four centers to determine the accuracy of quantitative analysis of stress/delayed thallium-201 myocardial tomograms using normal limits to assess the relative amount of reversibility of stress-induced defects. The patients were found to have 85 fixed and 124 reversible defects, as determined by visual interpretation. Reversibility bull's-eye polar maps were compared to gender-matched normal limits from 36 normals. Regions were identified as reversible if their normalized difference between stress and 4 hr greater than 1.5 s.d.s. from the mean normal limits. Overall agreement between experts at multicenter sites and reversibility maps was 73% for reversible defects and 80% of fixed defects. Sensitivity in detecting reversibility was highest for the left circumflex (88%) and lowest for the right coronary (60%). These results indicate that reversibility polar maps and normal limits offer an objective, accurate technique for determining the reversibility of stress-induced perfusion defects. | 3 |
Fresnel prisms improve visual perception in stroke patients with homonymous hemianopia or unilateral visual neglect. We randomly assigned 39 patients with stroke and homonymous hemianopia or unilateral visual neglect to treatment with 15-diopter plastic press-on Fresnel prisms (n = 18) or to serve as controls (n = 21). Baseline evaluations of visual perception and activities-of-daily-living (ADL) function were similar for both groups. After 4 weeks, the prism-treated group performed significantly better than controls on the following: (1) Motor Free Visual Perception Test; (2) Line Bisection Task; (3) Line Cancellation Task; (4) Harrington Flocks Visual Field Screener; and (5) Tangent Screen Examination. There was no significant difference in Barthel ADL assessment at 4 weeks. Thus, treatment with 15-diopter Fresnel prisms improves visual perception test scores but not ADL function in stroke patients with homonymous hemianopia or unilateral visual neglect. | 4 |
A study of cyproheptadine in the treatment of metastatic carcinoid tumor and the malignant carcinoid syndrome. Sixteen patients with metastatic neuroendocrine tumors and the malignant carcinoid syndrome were treated with cyproheptadine (Periactin, Merck, Sharp & Dohme, West Point, PA) at maximum tolerable doses that ranged from 12 to 48 mg daily. Usual side effects were mild sedation and dry mouth, but three patients found it impossible to sustain treatment due to nausea and vomiting. Most patients had significant relief of diarrhea, frequently associated with weight gain. Relief of flushing was uncommon. The therapeutic benefit produced by cyproheptadine would appear to be a peripheral effect because 5-hydroxyindoleacetic acid (5-HIAA) excretion in these patients was not reduced. Although there have been case reports of objective tumor regression with cyproheptadine therapy, this was not observed in any of these 16 patients. Cyproheptadine would appear to be a useful therapeutic tool for the management of diarrhea associated with the malignant carcinoid syndrome. An appropriate initial total daily dose is 0.4 mg/kg divided in three fractions with prompt modification to produce minimal and tolerable side effects. | 0 |
Pinch-off syndrome: a complication of implantable subclavian venous access devices. Implantable central venous access devices placed via the subclavian vein may become obstructed by thrombosis, impingement against a vein wall, or compression between the clavicle and first rib. The latter has been termed pinch-off syndrome (POS). Eleven patients with POS were studied, including one whose catheter had fractured and one whose catheter had fragmented. They were compared with 22 matched control patients and 100 consecutive routine clinic patients. Each catheter was graded: 0 = normal, 1 = abrupt change in course with no luminal narrowing, 2 = luminal narrowing, and 3 = complete catheter fracture. POS was present in most (eight of 11) cases within 3 weeks after placement. A grade 1 catheter was common (33%) among control subjects, but grades 2 and 3 were uncommon (1%). Catheter fracture or fragmentation was seen in two of five cases with long-term (greater than 3 weeks) pinching (grade 2 catheter). The following conclusions were reached: Grade 2 represents significant catheter compression and the potential for serious complications. Grade 1 is of uncertain clinical significance, due to its high prevalence in control subjects. | 4 |
Technique of photodynamic therapy for disseminated intraperitoneal malignant neoplasms. Phase I study. Patients with disseminated intraperitoneal malignant neoplasms were given intra-abdominal photodynamic therapy. Patients received dihematoporphyrin ethers intravenously 48 to 72 hours before laparotomy at doses of 1.5 to 3.0 mg/kg. At operation, as much tumor as possible was resected. Red light (630 nm) was delivered to all peritoneal surfaces from an argon-pumped dye laser at doses ranging from 0.2 to 3.0 J/cm2 in an escalating fashion. Viscera and peritoneal surfaces were anatomically isolated and exposed to light for intervals calculated to deliver the prescribed energy. Light was delivered to mesentery and bowel by a flat-cut optical fiber, while other areas, including diaphragm, viscera, omental bursa, gutters, and pelvis, were delivered light through a diffusing wand. Twenty-three patients (13 with ovarian cancer, eight with sarcoma, and two with pseudomyxoma peritoneii) underwent photodynamic therapy. Five of eight patients cleared positive peritoneal cytologies after treatment. Six patients remained clinically free of disease for up to 18 months, and five patients had treatment-related complications. Intraperitoneal phototherapy is technically feasible and deserving of clinical evaluation. | 1 |
Femur fracture with limb shortening causing occlusion of a polytetrafluoroethylene femoral popliteal graft. Traumatic occlusion of lower extremity polytetrafluoroethylene arterial grafts is exceedingly rare. We report a patient who suffered a supracondylar femur fracture resulting in shortening of her right lower extremity with kinking and thrombosis of her above-knee polytetrafluoroethylene arterial graft. This is the first report in the English language of prosthetic graft occlusion as a result of traumatic limb shortening. The graft thrombus was successfully lysed by use of intraarterial urokinase, and the kink was repaired by graft resection and reanastomosis. The mechanism of injury and treatment are discussed. | 4 |
Gastrointestinal complications after cardiac transplantation: a spectrum of diseases. Cardiac transplantation has become an accepted treatment modality for end-stage cardiac failure. The gastrointestinal (GI) tract represents a potential source of posttransplant morbidity and mortality. To define the scope of this problem, records of all patients undergoing cardiac transplantation at UCLA between January 1984 and July 1989 were reviewed. In all, there were 120 patients (90 males and 30 females) with a mean age of 45.4 yr. Among them, there were 61 patients (51%) who developed a total of 112 posttransplant GI complications. Of the entire 120 patients, 41 (34%) developed minor complications and 20 (17%) sustained major GI morbidity. Eighteen patients (15%) underwent either endoscopy or surgical intervention. These data suggest that most cardiac transplant recipients will experience some form of GI complication, although most are minor and can be managed conservatively. However, when major, life-threatening complications occur, evaluation and intervention should proceed expeditiously. The gastroenterologist and GI surgeon should play complimentary roles in the care of these complicated patients. | 1 |
Ganglioneuroma of the spinal cord. This report describes a 2-year-old boy who harbored an intramedullary ganglioneuroma involving almost the entire length of the spinal cord. The terminology, pathology, and neurobiological behavior of this tumor is discussed. | 0 |
Low-dose heparin. A cause of hematoma of rectus abdominis. Although hematomas of the rectus abdominis muscle are commonly reported complications of systemic anticoagulation treatment, they are a rare complication of prophylactic administration of low-dose heparin. The occurrence of a massive hematoma of the rectus sheath is reported in a woman with chronic obstructive pulmonary disease and acute respiratory failure who was receiving low doses of heparin for the prevention of deep venous thrombosis. Three other cases of hematoma of the rectus sheath resulting from prophylactic use of heparin are reviewed. The development of hematoma in these patients may have resulted from intramuscular abdominal injection of heparin and from strain of the rectus abdominis muscle caused by coughing. When prophylactic administration of heparin is necessary in patients with a tendency to paroxysmal cough, subcutaneous injections of heparin in the thigh may be preferable to subcutaneous injections in the abdomen. | 3 |
Regurgitation of fat and marrow emboli into coronary veins during resuscitation. Three groups of patients were examined at autopsy for the presence of fat and marrow emboli in the lungs, heart, and other organs. Group 1 was composed of patients with massive pulmonary thromboembolism and attempted cardiopulmonary resuscitation; group 2, patients with pulmonary thromboembolism and without attempted cardiopulmonary resuscitation; and group 3, patients without pulmonary thromboembolism and with attempted cardiopulmonary resuscitation. The results confirm that pulmonary fat and marrow emboli are frequent in those patients who are resuscitated. A novel observation is the finding of multiple coexistent cardiac venous emboli in those resuscitated patients who have pulmonary artery obstruction with pulmonary thromboemboli. These findings suggest that these emboli regurgitate from the right side of the heart to the coronary sinus and cardiac veins in cases of pulmonary artery hypertension. | 3 |
Jejunal-rectal fistula as a complication of postoperative radiotherapy. We present the case of a patient with an unusual, complex enteric fistula with multiple tracts and associated abscesses. The fistula was a late complication of radiotherapy, administered three years earlier, after resection for carcinoma of the sigmoid colon. Most of the small bowel was involved in the radiation-induced disease. A wide resection was performed successfully. This report reviews current literature on intra-abdominal postradiotherapy injuries, particularly intestinal fistulae. | 4 |
Buffered versus plain lidocaine as a local anesthetic for simple laceration repair. STUDY OBJECTIVE: Buffered lidocaine was compared with plain lidocaine as a local anesthetic for simple lacerations. DESIGN: Randomized, double-blind, prospective clinical trial. SETTING: Urban emergency department. TYPE OF PARTICIPANTS: Ninety-one adult patients with simple linear lacerations were enrolled. Patients with allergy to lidocaine and patients with an abnormal mental status were excluded. INTERVENTIONS: Each wound edge was anesthetized with either plain or buffered lidocaine using a randomized, double-blind protocol. The pain of infiltration was measured with a previously validated visual analog pain scale. MEASUREMENTS AND MAIN RESULTS: Analysis of pooled data and paired data (using patients as their own controls) revealed that infiltrating buffered lidocaine was significantly less painful than plain lidocaine (P = .03 and P = .02, respectively). There was no significant difference in the anesthetic effectiveness of the two agents during suturing. CONCLUSION: Buffered lidocaine is preferable to plain lidocaine as a local anesthetic agent for the repair of simple lacerations. | 2 |
Hemodynamic benefit of maintaining atrioventricular synchrony during cardiac pacing in critically ill patients. OBJECTIVE: To determine the hemodynamic effects of maintaining atrioventricular synchrony during emergency cardiac pacing in critically ill patients. DESIGN: Prospective, within patient double-blind study. SETTING: ICU or coronary care unit patients in a university hospital. PATIENTS: Forty (23 cardiac surgery, ten acute myocardial infarction, and seven general intensive care) seriously ill patients with severe symptomatic bradycardia. INTERVENTION: Initial randomization of patients to receive either a pacing mode where atrioventricular synchronization was maintained (atrioventricular pacing: atrial demand, atrioventricular sequential, atrioventricular universal) or a mode of pacing where atrioventricular synchrony was not preserved (ventricular demand pacing). MEASUREMENTS and MAIN RESULTS: The cardiac output increased from a mean of 4.5 +/- 1.7 L/min (95% confidence intervals: 4.0 to 5.0 L/min) during ventricular demand pacing to 5.3 +/- 1.7 L/min (95% confidence intervals: 4.9 to 5.9 L/min) during atrioventricular pacing (p less than .0001) despite trivial decreases in CVP from 14 +/- 4 mm Hg (95% confidence intervals: 13 to 15 mm Hg) to 13 +/- 5 mm Hg (95% confidence intervals: 12 to 15 mm Hg) and pulmonary artery occlusion pressure from 18 +/- 5 mm Hg (95% confidence intervals: 16 to 20 mm Hg) to 17 +/- 5 mm Hg (95% confidence intervals: 15 to 18 mm Hg). At the same time, mean arterial pressure (MAP) increased from 74 +/- 15 mm Hg (95% confidence intervals: 64 to 79 mm Hg) to 83 +/- 15 mm Hg (95% confidence intervals: 80 to 88 mm Hg) and left ventricular stroke work index from 22 +/- 10 g.m/m2 (95% confidence intervals: 19 to 25 g.m/m2) to 30 +/- 11 g.m/m2 (95% confidence intervals: 26 to 33 g.m/m2). There was no significant change in mean pulmonary artery pressure, pulmonary vascular resistance index, or systemic vascular resistance index. CONCLUSION: When cardiac pacing is required in critically ill patients, maintaining atrioventricular synchrony increases stroke volume, cardiac output, and MAP apparently with minimal effects on preload and afterload. | 4 |
HTLV-I-associated leukemia/lymphoma in south Florida. We report here 10 cases of adult T-cell leukemia/lymphoma (ATL) seen in South Florida between February 1988 and July 1989. All were seropositive for human T-lymphotropic virus type I (HTLV-I) and seronegative for human immunodeficiency virus type 1 (HIV-1). DNA extracted from tumor biopsies/peripheral blood lymphocytes of nine patients was shown by the polymerase chain reaction (PCR) to contain HTLV-I proviral DNA. Blot hybridization of DNA extracted from seven patients with an HTLV-I cDNA probe revealed a monoclonal pattern of proviral integration consistent with a diagnosis of ATL. Eight of the 10 patients were women. Six patients were from Haiti, three from Jamaica, and one from the Bahamas. All patients had very aggressive non-Hodgkin's lymphoma. Two patients presented with sinus and retro-orbital involvement; another had gastric lymphoma that perforated. Nine patients developed hypercalcemia. Eight patients died within 1 year of diagnosis. Two were lost to follow-up. During the course of this study, 66 new cases of non-Hodgkin's lymphoma were diagnosed at this hospital. Ten of these cases were ATL. The prevalence of HTLV-I-related lymphoma in this sample was 15%. Since tissue from all patients was not available for HTLV-I screening, however, it is possible that other cases of ATL went undetected. We conclude from this initial survey that a retroviral etiology should be considered in patients from populations known to be at risk for HTLV-I infection who present with non-Hodgkin's lymphoma. | 0 |
Reduced atrial contribution to left ventricular filling in patients with severe tricuspid regurgitation after tricuspid valvulectomy: a Doppler echocardiographic study. Patients undergoing valvulectomy for isolated tricuspid valve endocarditis offer the unique opportunity to study the effects of acquired right ventricular volume overload on left ventricular filling in persons free of pulmonary hypertension and preexisting left heart disease. Eleven patients who had undergone total or partial removal of the tricuspid valve were compared with 11 age-matched control subjects; Doppler echocardiographic techniques were used to quantify changes in left ventricular filling and to relate them to changes in left ventricular and left atrial geometry caused by right ventricular and right atrial distension. The late diastolic fractional transmitral flow velocity integral, a measure of the left atrial contribution to left ventricular filling, was significantly decreased in patients undergoing tricuspid valvulectomy compared with control subjects (0.22 +/- 0.11 versus 0.32 +/- 0.09; p less than 0.04). Severe tricuspid regurgitation in these patients resulted in marked right atrial distension, reversal of the normal interatrial septal curvature and compression of the left atrium such that left atrial area was significantly smaller than in control subjects (5.9 +/- 2.2 versus 8.6 +/- 1.2 cm2/m2; p less than 0.005). Acting as a receiving chamber, the left ventricle was maximally compressed by the volume-overloaded right ventricle in late diastole, coincident with the timing of atrial systole, resulting in a significant increase in the left ventricular eccentricity index compared with that in control subjects (1.35 +/- 0.14 versus 1.03 +/- 0.1; p less than 0.001). Thus, right ventricular volume overload due to severe tricuspid regurgitation results in left heart geometric alterations that decrease left atrial preload, impair left ventricular receiving chamber characteristics and reduce the atrial contribution to total left ventricular filling. | 3 |
Long-term sequelae of conservative treatment by surgery, brachytherapy, and chemotherapy for vulval and vaginal rhabdomyosarcoma in children. Between 1970 and 1978, 17 girls with rhabdomyosarcoma (RMS) of the vulva or vagina were treated at the Institut Gustave-Roussy (IGR) by conservative treatment including surgery, brachytherapy, and chemotherapy. Twelve pubescent or postpubescent girls were studied for long-term sequelae. Eleven of 12 patients have had a normal puberty, two have a total of three healthy children, 11 have normal menses, and 10 normal menarche (one after hormonal replacement). Only one patient underwent hysterectomy following low-dose brachytherapy. Five girls have no vaginal complications, and three are sexually active. Three have had minimal vaginal sequelae, which required surgical correction to permit sexual intercourse. Four girls sustained serious sequelae (colorectal, vaginal, urethral, and ureteral stenosis). These sequelae, secondary to irradiation, are potentially avoidable in the future given the current advances in brachytherapy and improvements in dosimetry. This conservative treatment is useful and appropriate for girls with RMS of vulvar or vaginal origin when complete remission cannot be obtained with chemotherapy and partial colpectomy. | 0 |
Dissection of the aorta associated with congenital malformation of the aortic valve. The association of congenital aortic valve malformation and aortic dissection is analyzed. Over a 30 year period, 186 patients with non-iatrogenic aortic dissection were studied at necropsy. The aortic valve was tricuspid in 170 (91.4%), bicuspid in 14 (7.5%) and unicuspid in 2 (1.1%). Among the 16 patients with aortic dissection and a congenitally malformed valve, the age at death ranged from 17 to 82 years (mean 52) and 13 (81%) were men. The entrance tear of the aortic dissection was located in the ascending aorta in all 16 patients with a malformed valve but in only 68% of those with a tricuspid aortic valve. The aortic valve was stenotic in 6 of the 16 patients with a congenitally malformed valve. Fatal rupture of the false channel occurred after acute ascending aortic dissection in each of the 11 patients (none with healed dissection) who did not have operative therapy for the dissection. Two of the 16 patients with a malformed valve compared with no patient with a tricuspid aortic valve had aortic isthmic coarctation. Histologic sections of aorta from 10 patients disclosed severe degeneration of the elastic fibers of the media in 9 patients. Thus, a congenitally malformed aortic valve appears to be present at least 5 times more frequently in adults with than in those without aortic dissection, and in our patients the entrance tear was always in the ascending aorta, which usually had severe loss of elastic fibers in its media. | 3 |
Adverse treatment effects in the trial of the European Working Party on High Blood Pressure in the Elderly. Adverse treatment effects were assessed in 840 elderly hypertensive patients randomly assigned to active treatment (a combination of triamterene and hydrochlorothiazide) or placebo; methyldopa was added to the regimen in one third of the treated patients. Symptoms of dry mouth, nasal stuffiness, and diarrhea were reported by significantly more treated patients than placebo control subjects. More patients receiving diuretics plus methyldopa than diuretics alone reported dry mouth and diarrhea. Significantly more treated patients than control subjects showed evidence of a high serum creatinine level, mild hypokalemia, and gout. More treated patients tended to have diabetes. The benefits of treatment outweighed these adverse treatment effects. | 3 |
Influence of postmortem time and temperature on osteoinductive activity of demineralized microperforated ethylene oxide-sterilized syngeneic bone implant in the rat. Bone morphogenetic protein is labile and easily inactivated by many extracorporeal factors. It is crucial to establish whether delay in retrieval of donor bone and ambient holding temperature of the donor body influence osteoinductivity of bone left in situ. Of ten adult rats that were killed, five were kept at 4 degrees and five at room temperature. Femurs were harvested at 24, 36, 48, 72, and 168 hours. After processing, segments were implanted in 20 four-week-old syngeneic rats for 14 days. The level of osteoinduction was evaluated histologically. It was excellent in the 4 degrees group in the 24-, 36-, and 48-hour specimens but less advanced at 72 hours. Bone taken from the room temperature group showed findings identical to those kept at 4 degrees through 36 hours, but osteoinduction was less advanced at 48 hours and absent at 72 hours. No bone formed at 168 hours in either temperature group. The following observations were made. (1) Osteoinductivity of demineralized bone left in situ after death was unexpectedly stable. (2) Retrieval time was extended by donor cooling. (3) Microperforated demineralized bone actively induced new bone formation. (4) Ethylene oxide does not inhibit osteoinduction when correctly applied for sterilization. If confirmed in humans, retrieval of bone to be used for osteoinduction could be delayed for some hours, particularly if the donor was immediately refrigerated. This would increase the effective number of bone tissue donors and utilize an undeveloped resource. | 4 |
Persistent ectopic pregnancy following laparoscopic linear salpingostomy. As the surgical approach for ectopic pregnancies evolves from radical to conservative procedures, the potential hazard of persistent ectopic pregnancy has become increasingly pertinent. From September 1, 1986 to August 31, 1989, 11 women with persistent ectopic pregnancy after laparoscopic salpingostomy were diagnosed and treated at Yale-New Haven Hospital. Persistent ectopic pregnancy was suspected in nine cases because of symptoms and in two because of plateauing beta-hCG titers. Ten of 11 patients underwent repeat surgery. Eight had partial or complete salpingectomy of the involved ipsilateral tube, two had repeat salpingostomies, and one was treated with methotrexate. When the 11 women with persistent ectopic pregnancies were compared with 70 patients treated successfully by laparoscopic salpingostomy using multivariate stepwise logistic regression, smaller size of the ectopic (P less than .01) and fewer days of amenorrhea (P less than .05) predicted persistent ectopic pregnancy after laparoscopic salpingostomy. Based upon our experience, we believe that earlier-treated ectopic pregnancies (ie, fewer than 42 days of amenorrhea) and/or smaller ectopics (ie, 2.0 cm or less in diameter) require treatment with particular caution and close postoperative surveillance. | 4 |
Prognostic value of histopathology in Ewing's sarcoma. Long-term follow-up of distal extremity primary tumors. The pathologic material from 56 patients diagnosed initially as Ewing's sarcoma of the distal extremity and treated on National Cancer Institute protocols between 1968 and 1984 was reviewed and correlated with clinical outcome. Histologically, the tumors were categorized, based on recent pathologic criteria, into three diagnostic groups: (1) typical Ewing's sarcoma, (2) atypical Ewing's sarcoma, and (3) other (predominantly peripheral neuroepithelioma [PN]). Thirty-two patients (57%) had typical Ewing's, 13 (23%) were atypical, and 11 (20%) were in the "other" diagnostic category (seven [13%] PN, two primitive rhabdomyosarcoma, one primitive sarcoma of bone, and one synovial cell sarcoma). No cases of metastatic neuroblastoma, osteosarcoma, or lymphoma were found. Forty-five patients had localized disease at diagnosis; 11 had metastases. Patients with typical Ewing's sarcoma were less likely to have metastatic disease at the time of diagnosis. Only two of 32 patients with typical Ewing's sarcoma had metastases compared with nine of 24 patients in the two other groups. The pattern of relapse was also different in these other groups compared with typical Ewing's patients; five patients developed lymph node metastases and two patients developed brain metastases. Although the presence of metastatic disease at diagnosis was a strong negative prognostic factor, our histologic grouping was independently prognostic of clinical outcome in patients with localized disease. Patients with typical osseous Ewing's sarcoma had an improved overall survival (P2 = 0.03) and patients with other tumors (neither typical nor atypical Ewing's sarcoma) had a poorer disease-free survival (P2 = 0.02). Since no generally accepted histopathologic prognostic criteria exist for Ewing's sarcoma, the potential value of our proposed classification should be evaluated in a larger retrospective and a prospective study. | 0 |
Complications after cardiac operations in patients with severe pulmonary impairment. The postoperative courses of 39 patients with severe lung disease (31 with obstructive disease and 8 restrictive) who underwent a cardiac operation were retrospectively reviewed. The stay in the intensive care unit of the study group was 7.9 +/- 10.3 days (mean +/- standard deviation) compared with 2.4 +/- 3.9 days for the control group (100 patients with less impaired pulmonary function) (p less than 0.001). The study group also had a greater number of valve replacements than did the control group (p less than 0.01). Patients with obstructive disease had more respiratory complications than did patients with restrictive disease (p less than 0.05). There were 21 cases of atelectasis. Effusions were noted in 11 patients. Ten patients had bronchospasm. Bronchial secretions were a major problem in 6 patients. Pneumonia developed in 4 patients, and pneumothorax occurred in 3 others. The two in-hospital deaths were not directly related to pulmonary complications. Our findings indicate that (1) patients with severe lung impairment generally do well after a cardiac operation but have more postoperative pulmonary complications than patients with less impairment; (2) patients with restrictive pulmonary disease appear to fare better than those with obstructive disease; (3) pulmonary function tests can alert the clinician to the possible risk of postoperative complications, but they cannot, by themselves, be used to exclude patients from operation; and (4) patients with severe pulmonary impairment facing valve replacement are at greater risk of pulmonary complications than patients having other types of cardiac surgical intervention. | 4 |
Effects of glucose on hypoxic vasoconstriction in isolated ferret lungs. To characterize the effects of glucose on the pulmonary vascular response to anoxia and hypoxia, isolated ferret lungs were ventilated with 28% O2 and 5% CO2 and perfused at constant flow (100 ml.kg-1.min-1). Perfusate glucose concentrations were allowed to fall spontaneously to less than 1 mM (low glucose) or were controlled at 5-6 mM (normal glucose) or 12-17 mM (high glucose). At 60, 120, and 180 min of perfusion, the inspired O2 tension (PIO2) was reduced to 0, 10, or 30 Torr for 30 min, and vasomotor responses were quantified by continuous measurement of pulmonary arterial pressure. At PIO2 of 0 Torr, the response consisted of an early phase of transient intense vasoconstriction and a late phase of sustained slight vasoconstriction. High glucose markedly potentiated the magnitude of late-phase vasoconstriction with each successive anoxic exposure. This effect was not reproduced in normal glucose lungs and was not caused by a change in perfusate osmolarity, an action on blood cells, or an altered ability of pulmonary vascular smooth muscle to contract. At PIO2 of 10 Torr, high glucose not only potentiated late-phase vasoconstriction but also slowed the onset of early-phase vasoconstriction. At PIO2 of 30 Torr, high glucose had no effect on vasomotor responses, which were characterized by a slowly developing sustained vasoconstriction. Our results suggest that the vascular response of isolated ferret lungs to severe hypoxia consisted of separate early and late phases of vasoconstriction. This biphasic response may have resulted from two distinct vasoconstrictor mechanisms or from modulation of a single vasoconstrictor mechanism by a secondary vasodilator influence. | 4 |
Molecular biology of atherothrombotic brain infarction. Because reduced high density lipoproteins may contribute to atherothrombotic brain infarction, we performed molecular biologic and metabolic studies to characterize high density lipoprotein metabolism with respect to its role in reverse cholesterol transport, to clone the high density lipoprotein receptor, and to determine gene polymorphism for apolipoprotein A-I, the major protein of high density lipoprotein, because altered structure may impair reverse cholesterol transport. For high density lipoprotein metabolism measurements, high density lipoprotein 3 was isolated, purified, and labeled with iodine-125. The radiolabeled high density lipoprotein 3 was reinjected, and daily blood samples were taken for 10 days. Synthesis rates and fractional catabolic rates were determined from the specific activities and daily decrements. Preliminary data indicate that stroke-prone individuals' fractional catabolic rates for high density lipoprotein 3 are twice those of normal individuals. Also, the conversion of high density lipoprotein 3 to high density lipoprotein 2 is reduced in these individuals, suggesting that high density lipoprotein may be abnormally processed in individuals prone to atherothrombic brain infarctions. We surveyed more than 100 patients with carotid stenosis using a 2.2-kb probe for the apolipoprotein A-I gene. A subset of these patients displays polymorphism with restriction enzymes SacI or PstI. These preliminary findings suggest that gene polymorphism for apolipoprotein A-I may provide a molecular clue of atherothrombic brain infarction. | 2 |
Evaluation of ketotifen in corticosteroid-dependent idiopathic anaphylaxis. To study the possible efficacy of ketotifen (K) in the treatment of idiopathic anaphylaxis (IA), K was administered in an open-label trial to six patients with IA who required corticosteroids at doses below which their disease could not be controlled. During the study, patients continued to receive noncorticosteroid medications (eg, antihistamines, oral adrenergic agents) that had been used on a regular basis for treatment of IA before study, but periodic attempts to reduce corticosteroid doses were made. A reduction of prednisone dose with continued control of disease was judged to be evidence for a beneficial effect of K. After 7 to 16 months of K administration, three patients were judged to have had probable benefits from K (reductions in alternate day prednisone dose requirement from 40 mg to none, 35 mg to 15 mg, and 30 mg to none), and one patient had a possible benefit from K (dose reduction from 100 to 120 mg to 77 mg). Two other patients were unable to tolerate major decreases in prednisone without developing symptoms or signs of IA. Within the limitations of this study design, we conclude that K may be efficacious in the treatment of some patients with IA, and that further trials of K in the treatment of IA are indicated. | 3 |
Silent myocardial ischemia: dilemma or blessing? Developing an optimal strategy for the evaluation and management of patients with silent myocardial ischemia is extremely difficult. Although otherwise healthy, asymptomatic individuals may be at risk of dying suddenly during exercise, neither exercise testing nor Holter monitoring reliably identifies those at greatest risk. In patients with underlying coronary artery disease, silent ischemia increases the risk of an adverse outcome. | 3 |
The frequency, causes and timing of death within 30 days of a first stroke: the Oxfordshire Community Stroke Project. In a prospective, community-based study of 675 consecutive patients with a first-ever stroke, of whom over 90% had computed tomography (CT) and/or necropsy examinations, 129 deaths occurred within 30 days of the onset of symptoms, a case fatality rate (CFR) of 19%. The 30 day CFR for patients with cerebral infarction was 10% (57 of 545, for primary intracerebral haemorrhage 52% (34 of 66), for subarachnoid haemorrhage 45% (15 of 33) and for those of uncertain pathological type 74% (23 of 31). The CFR for patients who had been functionally dependent pre-stroke was 33% compared with 17% for those who had been independent pre-stroke. The age-adjusted relative risk of death for patients who had been functionally dependent pre-stroke was not significantly greater (1.8, 95% confidence interval 0 to 4.3). There was a significant trend for CFR to increase with age (Chi square for trend = 4.0, p less than 0.05). This relationship was found in those patients who had been functionally independent prestroke (Chi square for trend = 7.9, p less than 0.005) but not in those who had been dependent pre-stroke (Chi square for trend = 0.5, NS). The pattern of increasing CFR with increasing age amongst those who had been independent prestroke was seen particularly in patients with cerebral infarction (Chi square for trend = 8.6, p less than 0.005). The age-adjusted relative risk of death for patients with cerebral infarction who had been functionally dependent pre-stroke was 2.2 (95% confidence interval 1.2 to 4.1). Fifty three percent of all deaths within 30 days of stroke were due to the direct neurological sequelae of the stroke. | 3 |
Isolated lung transplantation for pulmonary fibrosis. The peri-operative anaesthetic management of 11 patients with pulmonary fibrosis undergoing single-lung transplantation is presented. Intra-operative problems, the early postoperative phase of recovery and intensive care, and other incidents in which general anaesthesia was required for the management of complications, are featured. Results, both short- and long-term, are mentioned. Major intra-operative events that cause concern appear to be related to the severity of the presenting illness and the development of respiratory failure. Others have reported the development of intra-operative cardiac failure. All cases were successfully managed operatively using conventional one-lung anaesthesia, although resort to partial cardiopulmonary bypass may have been indicated in some. The indications and attitudes to utilising cardiopulmonary bypass in the evolution of techniques for facilitating single-lung transplantation are reviewed. | 4 |
Role of ultrasound guided fine needle aspiration biopsy in the diagnosis of hepatocellular carcinoma. In 170 cases of hepatocellular carcinoma, ultrasound showed a high sensitivity in identifying focal liver lesions. Fine needle aspiration biopsy guided by ultrasound yielded a pathological diagnosis in the majority of cases. The advantages of this technique, its high diagnostic yield and low cost, render the older technique of blind percutaneous biopsy using a coarse needle obsolete. Laparoscopy retains its essential role in selected cases. Complementary use of fine needle aspiration biopsy under ultrasound guidance and laparoscopy assures the highest rate of diagnostic accuracy in hepatocellular carcinoma. We confirm the poor sensitivity of alpha fetoprotein. | 0 |
Plasma thrombomodulin in health and diseases. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis followed by immunoblot analysis of plasma thrombomodulin concentrate revealed that four degraded forms of thrombomodulin with different molecular weights are present in plasma. Plasma concentrations of thrombomodulin in patients with various diseases were measured by two methods of enzyme-linked immunosorbent assay using monoclonal antibodies. One method measures intact thrombomodulin and degraded forms of thrombomodulin; the other does not detect the two smaller degraded forms of thrombomodulin present in plasma. The results indicated that thrombomodulin was increased in the circulating blood of patients with disseminated intravascular coagulation syndrome, pulmonary thromboembolism, adult respiratory distress syndrome, chronic renal failure, or acute hepatic failure. The different values obtained by the two methods indicate that the increase of plasma thrombomodulin found in these patients was mainly due to an increase of the smaller fragments of degraded forms, suggesting that the release of thrombomodulin from endothelial cells was accelerated in various disease states by proteolytic activity generated on the surface of the endothelium and may be removed from the circulation mostly by the kidneys and liver. | 1 |
Color Doppler imaging. A new noninvasive technique to diagnose and monitor carotid cavernous sinus fistulas. Color Doppler imaging is a recent development in ultrasonography that allows for simultaneous two-dimensional structural imaging and Doppler evaluation of blood flow. With this technique, one patient with a traumatic carotid cavernous sinus fistula and two patients with spontaneous dural cavernous arteriovenous malformations were evaluated. Color Doppler imaging demonstrated a dilated superior ophthalmic vein with arterialized blood flow in all three patients. In two cases the diagnosis was confirmed by angiography, and in one of these cases the fistula was occluded with a detachable balloon catheter. Postembolization color Doppler imaging revealed return of normal venous flow in the superior ophthalmic vein. This technique offers a noninvasive means to confirm the clinical diagnosis and to track the hemodynamics of these arteriovenous fistulas. In certain cases, color Doppler imaging may eliminate the need for computed tomography and magnetic resonance imaging in the evaluation of suspected arteriovenous malformations of the orbit. | 3 |
Anti-tumor X anti-lymphocyte heteroconjugates augment colon tumor cell lysis in vitro and prevent tumor growth in vivo. Cross-linking an anti-tumor antibody, specific for tumor cell surface antigens, and an anti-lymphocyte antibody, specific for the T lymphocyte receptor complex (TCR/CD3), produces a heteroconjugate that can direct T cells to lyse tumor cells. We tested the ability of anti-tumor X anti-lymphocyte (CD3) heteroconjugates to redirect human peripheral blood lymphocytes (PBLs) to lyse human colon cancer cells in cytotoxicity assays and in a murine colon tumor model. We demonstrated in vitro, that cultured human PBLs alone produced low levels of tumor lysis, but PBLs treated with anti-tumor X anti-CD3 heteroconjugates produced significantly greater tumor cell lysis (P less than 0.0025). Similarly, nude mice injected with LS174T human colon cancer cells and treated with cultured human PBLs and anti-tumor X anti-CD3 heteroconjugates survived significantly longer than saline control mice (P less than 0.01), or mice treated with PBLs alone (P less than 0.01), or heteroconjugates alone (P less than 0.05). F(ab')2 heteroconjugates were equally as effective in prolonging animal survival, but irrelevant heteroconjugates and monoclonal anti-tumor antibodies showed no therapeutic benefit. Anti-tumor X anti-CD3 heteroconjugates may represent an effective approach to tumor-specific cellular immunotherapy. | 0 |
Relief of injection pain in adults. EMLA cream for 5 minutes before venepuncture. The effectiveness of skin anaesthesia after 5 minutes' topical application of a lignocaine-prilocaine cream was evaluated. One hundred and twenty patients estimated the pain of antecubital venepuncture both on a linear scale and verbally after use of the cream for either 5 or 60 minutes, a placebo cream or no treatment. Reported pain was significantly less after only 5 minutes of the lignocaine-prilocaine cream (p = 0.002). The cream can be used to relieve the pain of all routine injections. | 2 |
Clinical characteristics and coronary angiographic findings of patients with unstable angina, acute myocardial infarction, and survivors of sudden ischemic death occurring during and after sport. The clinical characteristics and coronary angiographic findings of 42 well-conditioned subjects with an acute ischemic event related to sport are reported. Five patients had unstable angina, 25 had acute myocardial infarction (AMI), and 12 were resuscitated victims of sudden ischemic death. Twenty-two events occurred during sport (group A) and 20 after sport (group B). There were two women and 40 men. The mean age was 46 years (range 25 to 65). Twelve out of 30 patients who smoked cigarettes had an adjunctive risk factor for coronary artery disease. Twelve others (28%) had no identifiable risk factor. Prodromal cardiac symptoms were detected in three patients (group A). Two patients had previous myocardial infarction (group B). Coronary angiography was performed acutely in 39 patients. The distribution of the ischemia-related coronary artery was comparable in both groups. The lesion morphology of 35 culprit coronary arteries was described as concentric in six patients and eccentric with regular borders (type I lesion) in 11 and irregular borders (type II lesion) in 18. Eccentric lesions consistent with ruptured plaques prevailed in both groups. Associated coronary artery disease was present in 10 patients. There was no relationship between the number of risk factors and the extent of diseased coronary arteries. Clinical characteristics and coronary angiographic findings of patients with unstable angina, AMI, and sudden death either during or after sport are similar and indicate a common pathogenesis. The probable mechanism of a coronary event related to sport is exercise-induced plaque rupture. In most instances such an event is unexpected and unpredictable. Identification of some subjects at risk is possible. | 3 |
Unconsciousness associated with midazolam and erythromycin. An 8-yr-old boy suffering from an asymptomatic ventricular septal defect was given erythromycin for antibiotic prophylaxis before adenoidectomy. Sixty minutes after premedication with oral midazolam 0.5 mg kg-1 and oral atropine 0.03 mg kg-1, an infusion of erythromycin 400 mg was started. When 200 mg of erythromycin had been infused, the patient lost consciousness, but other vital functions remained normal. After 45 min, he awakened spontaneously. At the time the plasma concentration of midazolam was 134 ng ml-1. In order to investigate possible interactions between midazolam and erythromycin, we studied the pharmacokinetics of midazolam in six children of the same age undergoing minor otolaryngological surgery. The plasma concentration of midazolam in the patient who lost consciousness was significantly greater than in six other children without concomitant administration of erythromycin. The altered pharmacokinetics of midazolam may result from reduced hepatic clearance of midazolam caused by an enzyme inhibiting drug, erythromycin. | 2 |
The role of pain in the last year of life of older persons. A random sample of 200 decreased older community residents was studied with a focus on the role of pain in the last year of life. Interviews with a surviving close person elicited retrospective reports. Pain increased over the final year; one month before death 66% felt pain frequently or all of the time, substantially higher than a matched comparison group of living persons (24%). For both groups across the year, pain was associated with most measures of behavioral competence, perceived quality of life, and psychological well-being. Hierarchical multiple regressions indicated that background and health variables explained 28% to 32% of the variance of pain over the year. Controlling for background variables and health, pain contributed significantly to lowered happiness and to depression, but had no independent impact on hope and interest in the world. After controlling for physical health, the older old were judged to have less pain than the younger old. | 4 |
Tachycardia during reversal of one-kidney, one-clip hypertension in conscious rats. The efferent sympathetic activity of the heart was investigated during reversal of one-kidney, one-clip (1K,1C) hypertension in conscious, freely moving rats using changes in heart rate as an index. One-kidney, one-clip hypertensive rats presented marked tachycardia during the first 8 h after unclipping. Mean arterial pressure fell 28% 3 h after unclipping and 37% 8 h after unclipping. In a separate experiment, short term infusion (15 min) of sodium nitroprusside in conscious freely moving rats produced similar tachycardia in hypertensive and sham-operated rats. The present results indicate that the baroreceptor reflex of the heart was operating normally during the prompt reversal of hypertension after unclipping. | 3 |
Limits of brain tolerance to daily increments in serum sodium in chronically hyponatraemic rats treated with hypertonic saline or urea: advantages of urea. 1. At present there is no consensus about the optimal management of hyponatraemia to prevent demyelinating brain lesions. We have evaluated in a large series of rats (n = 136) the protective role of urea for the brain in the treatment of severe chronic hyponatraemia. Urea (group I, n = 51) was compared with hypertonic saline in boluses (group II, n = 46) and with hypertonic saline in divided doses (group III, n = 39). Treatment was administered intraperitoneally over 48 h. The severity of brain lesions was assessed by histological scoring. 2. For 95% of the injured animals treated with hypertonic saline, brain lesions appeared for an absolute increment in serum Na+ concentration (delta SNa+) of 20 mmol day-1 l-1. Above this limit neurological injuries gradually worsened, and beyond a transition zone (delta SNa+ greater than or equal to 20 less than or equal to 23 mmol day-1 l-1) 89% (group III) to 100% (group II) of the animals were injured. This limit can be reached rapidly, as attested by the comparable severity of brain lesions observed in group II (mean delta SNa+ 1 h after a bolus injection, 19 mmol/l) and in group III (mean delta SNa+ 1 h after an injection, 2 mmol/l), both groups achieving similar daily delta SNa+. 3. A correction above the threshold of 20 mmol day-1 l-1 is as toxic during the first 24 h as during the second day of the treatment. | 4 |
Pneumocystis carinii pneumonia complicating multiple myeloma. Pneumocystis carinii pneumonia complicated the course of two patients with multiple myeloma. The diagnosis was established in both cases by bronchoalveolar lavage, which demonstrated the typical pneumocysts. Clinical and roentgenographic improvement in both patients was observed following a course of trimethoprim-sulfamethoxazole. One patient had lymphocyte subsets performed with a CD4/CD8 ratio of 0.8; both patients were HIV antibody-negative by ELISA. Both patients tolerated prophylactic TMP-SMX given concurrently with the subsequent chemotherapy for myeloma. We suggest that the immune defect seen in multiple myeloma may have placed these patients at risk for opportunistic infections such as P carinii pneumonia; however, as opposed to patients with AIDS, our patients tolerated therapy with TMP-SMZ quite well. | 0 |
Deterioration following delay in performing femoral angioplasty. It is not uncommon for a delay to occur between assessment arteriography and angioplasty attempt. We reviewed retrospectively the arteriograms of 61 patients where such a delay occurred to assess progression of superficial femoral artery (SFA) disease in this interval. A mean delay of 14.6 days (range 2-60 days) occurred between arteriogram and angioplasty attempt. Arteriographic deterioration was found in six of 61 patients (9.8%) and in three this precluded angioplasty. Of the six patients four had initial arteriography via the same side as the SFA disease whilst two had arteriography via the contralateral femoral approach. We discuss the aetiology of this phenomenon and suggestions are made to reduce its incidence. | 3 |
Glomerular hyperfiltration indicates early target organ damage in essential hypertension In 111 patients with essential hypertension (World Health Organization stage I or II), we examined the relationship between renal hemodynamics and left ventricular hypertrophy. Left ventricular structure was determined by two-dimensional guided M-mode echocardiography, renal blood flow by iodine I 131 aminohippuric acid clearance, and glomerular filtration rate by creatinine clearance. The glomerular filtration rate correlated with left ventricular mass (r = .52) and left ventricular cross-sectional area (r = .21). Conversely, at a similar age, body mass index, body surface area, and arterial pressure, hypertensive patients with left ventricular hypertrophy disclosed a higher glomerular filtration rate and filtration fraction than those without left ventricular hypertrophy, whereas renal blood flow and renal vascular resistance measurements were not significantly different. Thus, at similar levels of arterial pressure and renal blood flow, glomerular hyperfiltration was linked to early cardiac structural changes in essential hypertension. We conclude that, in a hypertensive patient with normal renal function, a high glomerular filtration rate may be an indicator for early target organ damage in essential hypertension. | 3 |
Functional significance of myocardial perfusion defects induced by dipyridamole using thallium-201 single-photon emission computed tomography and two-dimensional echocardiography. The mechanisms responsible for inhomogeneous myocardial blood flow after oral administration of a large dose (300 mg) of dipyridamole were assessed in 27 patients with serial thallium-201 single-photon emission computed tomography (SPECT) and simultaneous 2-dimensional echocardiograms. Myocardial tomographic images were obtained 50 minutes and 3 to 4 hours after administration of dipyridamole. Two-dimensional echocardiograms were recorded at baseline and then every 15 minutes for 60 minutes. Dipyridamole caused only a mild reduction in blood pressure (from 129 +/- 18 to 126 +/- 16 mm Hg) and a mild increase in heart rate (from 69 +/- 15 to 73 +/- 4 beats/min). Sixteen patients had perfusion defects after dipyridamole by SPECT, which underwent partial or total filling-in. Fourteen of these patients (87.5%) had either a new abnormality or further deterioration of a preexisting wall motion abnormality by 2-dimensional echocardiography, and thus were considered to have developed transient ischemia during dipyridamole administration. Ten of 11 patients (91%) with normal perfusion or fixed defects by SPECT had no further deterioration in wall motion after oral dipyridamole, and were thus considered to have no evidence of myocardial ischemia. In conclusion, most patients with transient thallium-201 defects after dipyridamole develop transient worsening of resting wall motion by 2-dimensional echocardiography, suggestive of true myocardial ischemia. Because myocardial oxygen demand, as indicated by the heart rate-blood pressure product, did not change significantly, the mechanism of myocardial ischemia in these patients is likely to be diminished regional blood flow related to a "subendocardial steal" induced by dipyridamole. | 3 |
Role of leukotriene C4 in mucosal damage caused by necrotizing agents and indomethacin in the rat stomach. Intragastric ethanol stimulates mucosal formation of leukotriene C4 in the rat stomach. The present study demonstrates that the increase in leukotriene C4 formation begins within 30 seconds and is maximal within 5 minutes, closely paralleled by the appearance of hemorrhagic lesions. Leukotriene C4 formation returns to prechallenge levels within 3 hours, although erosions still persist. Intragastric 0.2N NaOH, acidified 100 mmol/L taurocholate, 25% NaCl, or 0.6N HCl did not consistently increase leukotriene C4 formation despite severe mucosal injury. A number of sulfhydryl-containing or sulfhydryl-blocking agents as well as metals protected against mucosal damage and simultaneously prevented the stimulation of leukotriene C4 formation induced by ethanol. None of the agents increased and some virtually abolished mucosal formation of prostaglandin E2, indicating that gastroprotection can occur completely independently of the endogenous prostaglandin system. The leukotriene biosynthesis inhibitor MK-886 markedly suppressed gastric leukotriene C4 formation but did not protect against damage caused by ethanol, NaOH, NaCl, or acidified taurocholate. Oral indomethacin reduced the ex vivo formation of both prostaglandin E2 and, to a lesser extent, leukotriene C4 in the gastric mucosa, inducing a shift in the balance from protective prostaglandins to proulcerogenic leukotriene C4. Pretreatment with MK-886, however, did not significantly diminish indomethacin-induced lesions. These data suggest that leukotriene C4 is not the exclusive mediator of gastric injury caused by necrotizing agents or indomethacin. On the other hand, certain protective compounds exhibit a striking parallelism between protection and inhibition of ethanol-induced leukotriene C4 formation, suggesting that they may affect a target crucial for both mucosal injury and stimulation of 5-lipoxygenase. | 1 |
Thrombolytic therapy for noncoronary diseases. Thrombolytic therapy has been used fairly extensively in the management of acute proximal deep-vein thrombophlebitis of the extremities, acute pulmonary embolism, and acute peripheral arterial thrombosis and embolism in addition to acute thrombotic coronary events. In the presence of acceptable indications and a favorable benefit to risk ratio, this form of therapy, when successful, has served as a useful adjunct in the management of these disorders. In deep-vein thrombophlebitis, lysis of the thrombus before permanent pathological changes (eg, organization, scarring) have occurred can prevent venous valvular dysfunction and postural venous hypertension and its complications, especially the postphlebitic syndrome. In the more severe forms of acute pulmonary embolism, thrombolytic therapy, when applied early after symptom onset, decreases morbidity and is likely to prevent a chronic increase in pulmonary vascular resistance and persistent pulmonary hypertension. In peripheral arterial thrombo-occlusive events, early restoration of flow through thrombolysis has been shown to limit ischemic damage and serve as a useful supplement to angioplasty or surgery. Thrombolytic therapy has been used less extensively in acute strokes. Here the danger of reperfusion causing bleeding into a softened area of brain undergoing infarction has slowed its evaluation for this disorder; its application to stroke remains experimental. | 3 |
Recurrent transient ischemic attacks and stroke in association with an internal carotid artery web Fibromuscular dysplasia is a nonatherosclerotic vascular disease that most commonly affects cervical carotid arteries at the C1-C2 level when cephalic arteries are involved. Several histopathologic and angiographic subtypes of fibromuscular dysplasia exist; most have a benign natural history. We describe the third reported case of a pathologically proven, symptomatic proximal internal carotid artery web and suggest that patients with this lesion are at a higher risk for stroke. | 2 |
Patterns of epidermal growth factor receptors in basal and squamous cell carcinoma. The presence of immunoreactive epidermal growth factor receptors in human skin tumors was investigated using the indirect immunoperoxidase technique. Sixteen basal cell carcinomas and 11 squamous cell carcinomas were evaluated. All of the specimens studied were receptor positive. In 70% of the specimens there was prominent staining of the cell membranes. In 54% of the nodular basal cell carcinoma specimens there was increased staining at the periphery of the tumor cell masses. | 0 |
Corpus callosotomy for intractable seizures in the pediatric age group. The results of corpus callosotomy in 18 patients 16 years old and younger are presented. Eighty-three percent of our patients have had a significant improvement from the surgery (a decrease in seizure frequency of greater than 80% or no longer having generalized atonic, tonic, or tonic-clonic seizures). The procedure seems to be well tolerated in young patients, and we have not noted a postoperative deterioration in behavior, memory, or language function in our patients. One of our patients died in status epilepticus 3 months after surgery. Nevertheless, we have not encountered any serious morbidity in our other patients. Corpus callosotomy can be considered for children with intractable seizures, especially when generalized atonic, tonic, or tonic-clonic (whether primary or secondary) seizures are the major seizure type. | 4 |
Development of language in six hemispherectomized patients. The development of language skills in the isolated right hemisphere was investigated by comparing the performance of 3 left hemispherectomized with that of the 3 right hemispherectomized patients and three groups of control subjects on baseline clinical measures of language and on production and judgement of morphological markers. The initial brain insult in the hemispherectomy patients of each group had occurred either during early, middle or late childhood. The left hemispherectomy patients were severely impaired in language processing across all three stages of language development. The consequences of a right hemisphere insult on language development were more restricted, with deleterious effects being apparent only in the case in which the lesion was acquired during early childhood. | 2 |
Comparison of four pulse oximeters: effects of venous occlusion and cold-induced peripheral vasoconstriction. The ability of four pulse oximeters (the Ohmeda 3700, Nellcor N100 and N200 and the Datex Oscar) to detect hypoxaemia was determined in the presence of venous obstruction and cold-induced peripheral vasoconstriction. Significant increases in detection time for hypoxaemia were found in both cases. There were no significant differences in detection time between the instruments, although the Ohmeda 3700 displayed smaller values of SaO2 under certain conditions. Peripheral vasoconstriction was induced using three differing methods which gave differing results, thus emphasizing the importance of methodology in assessments of pulse oximetry. | 4 |
Cervical lymph nodes from an unknown primary tumor in 190 patients. Over 10 years, 475 patients with isolated lateral neck masses were evaluated: 190 with lymph nodes from an unknown primary tumor (LNUP), 188 with neck lymphomas, 78 with benign tumors, 10 with sarcomas, and 9 with chemodectomas. This study focused on the patients with LNUP. Only 86 patients were treated with surgery (plus radiotherapy). Other patients were treated with radiotherapy (84) or chemotherapy (13) or had no treatment (7). For the overall population, failures in the neck occurred in 51% of the patients and distant metastases in 27%, while primary tumors appeared in 16%. Survival rates at 3, 5, and 10 years were 27%, 19%, and 7%, respectively, for the overall population and 45%, 35%, and 19%, respectively, for the surgical group. The diagnosis and therapeutic approach had a direct effect on neck control; failure in the neck occurred in 7 of 47 patients (15%) when fine needle aspiration and radical neck dissection with radiotherapy were performed, in 5 of 12 patients (42%) when fine needle aspiration and modified neck dissection with radiotherapy were used, in 5 of 12 patients (42%) when adenectomy diagnosis and radiotherapy treatment were performed, and in 6 of 11 patients (54%) when diagnosis by incisional biopsy was performed prior to admission, despite subsequent radical neck dissection and radiotherapy treatment. In our opinion, panendoscopy and fine needle aspiration should be the first-line diagnostic approach. When cytologic diagnosis proves impossible, the second-line approach must consist of cervical exploration with frozen section examination and excisional biopsy, followed by immediate appropriate treatment. In cases of LNUP, radical neck dissection seems to be preferable. | 0 |
Crico-tracheal disruption and common carotid artery occlusion: a case of blunt trauma. A case of blunt trauma to the neck is presented. While driving an all terrain vehicle (ATV), a 20-yr-old male was struck across the anterior neck by a cord suspended between two poles. Initial findings were suggestive of an isolated laryngeal injury; 48 hours later, however, a dense left hemiplegia became manifest. A CT scan demonstrated a large right frontoparietal cerebral infarct, and an angiogram confirmed occlusion of the right common carotid artery. Intractable cerebral oedema developed, and the patient died five days after the initial insult. Such injuries should alert the clinician to the possibility of major vascular injury, and if suspected, angiography is warranted. | 2 |
An early phase II study of CPT-11: a new derivative of camptothecin, for the treatment of leukemia and lymphoma. An early phase II study of a new camptothecin analog and an inhibitor of topoisomerase I, CPT-11, was conducted in 62 patients with refractory leukemia and lymphoma by four different treatment schedules in a multiinstitutional cooperative study. CPT-11 therapy resulted in four complete remissions (CRs) and three partial remissions (PRs) in 29 assessable non-Hodgkin's lymphoma (NHL) patients, one PR in three Hodgkin's disease (HD), one CR and one PR in 11 acute lymphoblastic leukemia (ALL), and one PR in 15 acute myelogenous leukemia (AML) patients. Single infusion of 200 mg/m2 every 3 to 4 weeks produced no response in both leukemia and lymphoma patients. Sixty-minute infusions of 40 mg/m2/d for 5 days every 3 to 4 weeks or for 3 days weekly produced four CRs (17%) and four PRs (17%) in 24 patients with malignant lymphoma. Sixty-minute infusions of 20 mg/m2 twice a day for 7 days every 3 to 4 weeks resulted in one CR and two PRs in 12 patients with acute leukemia. No response was seen in an acute leukemia patient by another treatment schedule. CPT-11 was effective in two (15%) of 13 primarily refractory leukemia and lymphoma cases, in two of four relapsed cases, and in seven (17%) of 41 relapsed and refractory cases. Major side effects were leukopenia (91%) and gastrointestinal (GI) (76%). CPT-11 was shown to be effective against refractory leukemia and lymphoma, and thus deserves further clinical study; the novel antitumor activity mode of this drug predicts no cross-resistance to presently available antitumor drugs. | 0 |
Deposits of crystalline material containing silicon in surgically excised human valves. Ninety-seven surgically excised natural cardiac valves were examined by scanning electron microscopy and x-ray energy spectroscopy to assess the occurrence of crystalline deposits that contain the element silicon. Valves examined included 33 mitral valves, 63 aortic valves, and 1 tricuspid valve. To reduce the possibility of surface contamination, the deep layers of some valves were examined after exposure by fracture of the valve. Crystalline material containing silicon was observed in the deep tissue. Such crystalline material was sometimes entwined within subendothelial fibers. Crystalline deposits that contained silicon were associated with 34 of 97 of these valves (35%). Among the 34 valves that showed silicon, 24 (71%) also showed microdeposits of calcific material. In view of evidence that silicon may participate in the calcification of bone, and is found in the intima of arteries, a role for this element in ectopic calcification of valves may exist. | 3 |
Conjugal temporal arteritis. We report the simultaneous occurrence of biopsy-proven temporal arteritis in husband and wife. Serologic and viral studies were negative, including viral culture of the wife's temporal artery. The concurrent incidence of giant cell arteritis in a married couple would suggest a common exogenous exposure. | 3 |
Differential regulation of human immunodeficiency viruses (HIVs): a specific regulatory element in HIV-2 responds to stimulation of the T-cell antigen receptor. The human immunodeficiency viruses (HIVs) types 1 and 2 have similar genetic organization but differ significantly in nucleic acid sequence. Although infection by either agent leads to symptoms of immunodeficiency, recent studies suggest potential differences in the time course and severity of these diseases. In this report, the transcriptional regulation and induction of these retroviruses were analyzed. We report that the regulation of HIV-2 differs from that of HIV-1: a distinct T-cell activation pathway, triggering of the CD3 component of the T-cell receptor complex, stimulates HIV-2 but not HIV-1 gene expression. The response to T-cell receptor stimulation in HIV-2 is mediated partly by an upstream regulatory element, termed CD3R, which is recognized by a sequence-specific DNA binding protein, NF-CD3R. Jurkat T leukemia cell lines containing HIV-2 provirus also showed increased viral replication after stimulation of the T-cell receptor complex, in contrast to HIV-1. These findings suggest that transcriptional regulation and induction of HIV-2 differ from HIV-1 and raise the possibility that different cofactors contribute to the activation of HIV-1- and HIV-2-associated AIDS. | 4 |
Retrovirus from human T-cell leukemia virus type I-associated myelopathy is the same strain as a prototype human T-cell leukemia virus type I. A retrovirus was isolated from a T-cell line that was established from lymphocytes in the cerebrospinal fluid of a patient with human T-cell leukemia virus type I-associated myelopathy (HAM), and its genome was sequenced. The nucleotide sequence of the 3' half of the total genome was identical in 99.5% of the nucleotides to that of the prototype human T-cell leukemia virus type I that was derived from a patient with adult T-cell leukemia. These results indicate that the same retrovirus human T-cell leukemia virus type I is associated with both a neurological disease, HAM, and a lymphoproliferative disease, adult T-cell leukemia. | 0 |
Adenovirus colitis in the acquired immunodeficiency syndrome. Adenovirus was identified in colonic tissue by transmission electron microscopy or culture in 5 of 67 (7.4%) homosexual men seropositive for human immunodeficiency virus (51 with the acquired immunodeficiency syndrome) with diarrhea. Colonoscopy showed the mucosa to be normal in 3 cases and mildly inflamed in 2. Light microscopy showed foci of mucosal necrosis that contained chronic inflammatory cells and degenerating and necrotic epithelial cells with amphophilic nuclear inclusions. By transmission electron microscopy, hexagonal viral particles characteristic of adenovirus were identified within the inclusions. Only 1 patient was concomitantly infected by a second potential enteric pathogen. It was concluded that adenovirus, an uncommon enteric pathogen in immunocompetent adults, causes intestinal pathology and may be associated with diarrheal illness in persons with the acquired immunodeficiency syndrome. | 1 |
Diagnostic value of a new myocardial perfusion agent, teboroxime (SO 30,217), utilizing a rapid planar imaging protocol: preliminary results [corrected and republished with original paging, article originally printed in J Am Coll Cardiol 1990 Oct;16(4):855-61] Technetium-99m-labeled agents have advantages over thallium-201 in terms of photon statistics, cost and clinical availability. They have been suggested as an alternative to thallium for myocardial perfusion imaging. Teboroxime is a new boronic acid adduct of technetium dioxime (BATO) compound that demonstrates favorable characteristics in preliminary studies. With use of a novel (seated) patient positioning technique and a rapid dynamic acquisition protocol, 30 patients underwent planar imaging with teboroxoime while at rest and after maximal treadmill exercise. Postexercise scans were completed in an average time (mean +/- SD) of 4.4 +/- 1.6 min, with 4.8 +/- 1.5 min for the views at rest. These results were compared with coronary arteriography or thallium scintigraphy after treadmill exercise, or both. Diagnostic agreement (abnormal versus normal) was present in 28 of the 30 patients (p less than 0.001). Regarding physiologic assessment as compared with thallium scintigraphy, the finding of infarction and ischemia was concordant in 89% and 86% of patients, respectively. This report describes the initial use of teboroxime with a rapid dynamic planar imaging technique, resulting in a high correlation with exercise thallium scintigraphy. Delayed postexercise images obtained 5 to 10 min after exercise demonstrated rapid disappearance of exercise-induced defects noted on the initial (0 to 5 min) postexercise views. The rapid differential washout with teboroxime has not been previously described and the possible clinical significance is discussed. | 3 |
Osteosarcoma of the spermatic cord. Malignant tumors of the spermatic cord are rare but the vast majority of these tumors are sarcomas. We report on a patient with osteosarcoma arising in the spermatic cord. Left radical orchiectomy with high dissection of the spermatic cord was performed, and the patient remains free of recurrence 2 years postoperatively. We could find no previous discussion or report of this tumor. | 0 |
Risk of angina pectoris and plasma concentrations of vitamins A, C, and E and carotene The relation between risk of angina pectoris and plasma concentrations of vitamins A, C, and E and carotene was examined in a population case-control study of 110 cases of angina, identified by the Chest Pain Questionnaire, and 394 controls selected from a sample of 6000 men aged 35-54. Plasma concentrations of vitamins C and E and carotene were significantly inversely related to the risk of angina. There was no significant relation with vitamin A. Smoking was a confounding factor. The inverse relation between angina and low plasma carotene disappeared and that with plasma vitamin C was substantially reduced after adjustment for smoking. Vitamin E remained independently and inversely related to the risk of angina after adjustment for age, smoking habit, blood pressure, lipids, and relative weight. The adjusted odds ratio for angina between the lowest and highest quintiles of vitamin E concentrations was 2.68 (95% confidence interval 1.07-6.70; p = 0.02). These findings suggest that some populations with a high incidence of coronary heart disease may benefit from eating diets rich in natural antioxidants, particularly vitamin E. | 3 |
Urologic function after experimental cauda equina compression. Cystometrograms versus cortical-evoked potentials. Twenty female beagle dogs underwent an L6-7 laminectomy and six dogs each had 25, 50 or 75% constriction of the cauda equina and 2 control dogs had laminectomy only. Cystometrograms were performed pre- and post-operatively and three months after constriction. Cortical evoked potentials were monitored pre- and post-operatively and monthly for three months. After three months of constriction, the cauda equina of these dogs in each group was examined histologically and vascular circulation was examined by latex and India ink injection (Spalteholz technique). The control dogs had normal CMGs and CEPs. Twenty-five percent constriction caused no CMG changes and mild CEP changes. Fifty percent constriction caused no statistically significant CMG changes, major CEP changes and venous congestion of the nerve roots and dorsal root ganglia. Seventy-five percent constriction produced severe CMG changes with detrusor areflexia, increased bladder capacity and clinical incontinence. CEPs also had marked deterioration. Vascular analysis revealed severe arterial narrowing at the level of constriction and venous congestion of the nerve roots and dorsal root ganglia. Blockage of axoplasmic flow and nerve root atrophy was seen in all dogs with 75% constriction. Cortical evoked potentials were the most sensitive predictor of neural compression. CMGs were not sensitive until severe compression was achieved. Bladder dysfunction, i.e., detrusor areflexia, appears to occur with blockage of axoplasmic flow and early sensory changes occur with neurovenous congestion. | 2 |
Six physicians with inflammatory bowel disease. This essay tells the stories of six physicians with inflammatory bowel disease (IBD) to emphasize how important denial and control become when a physician is a patient. Guilt at the supposed psychosomatic "origin" of IBD suggests that we as physicians should never blame our patients for getting sick. | 1 |
Role of leukotriene B4 in granulocyte infiltration into the postischemic feline intestine. Several studies have demonstrated that granulocytes accumulate in the intestinal mucosa following ischemia/reperfusion. It has been suggested that leukotriene B4 may be released during ischemia/reperfusion and consequently may promote granulocyte infiltration into the mucosa. The objectives of this study were to determine whether (a) leukotriene B4 is produced in the gut mucosa during ischemia and reperfusion, and (b) inhibition of leukotriene B4 attenuates granulocyte infiltration into the postischemic intestinal mucosa. Isolated segments of cat intestine were subjected to 3 hours of ischemia and 1 hour of reperfusion. Mucosal samples were obtained during baseline, ischemia at 3 hours and reperfusion at 1 hour. Leukotriene B4 production was determined by radioimmunoassay. Tissue-associated myeloperoxidase activity was used to quantitate granulocyte accumulation in the mucosal samples. In untreated animals, mucosal leukotriene B4 concentration was higher at reperfusion compared with baseline levels. The reperfusion-induced increase in mucosal leukotriene B4 was entirely prevented by pretreatment with either nordihydroguaiaretic acid (Sigma Chemical Co., St. Louis, MO) or L663,536 (Merck-Frosst, Montreal, Quebec, Canada), two potent lipoxygenase inhibitors. Both lipoxygenase inhibitors, as well as leukotriene B4 antagonist (SC-41930) significantly attenuated the reperfusion-induced infiltration of granulocytes. These results indicate that leukotriene B4 plays an important role in mediating the granulocyte accumulation elicited by reperfusion of the ischemic bowel. | 4 |
Intrathecal morphine 0.2 mg versus epidural bupivacaine 0.125% or their combination: effects on parturients. To compare the efficacy and side effects of 0.2 mg intrathecal (IT) morphine with 0.125% epidural bupivacaine, 62 women in labor were studied. They were randomly divided into three groups: group 1 (n = 20) received IT morphine; group 2 (n = 22) received epidural bupivacaine; and group 3 (n = 20) received a combination of both using a combined spinal-epidural (CSE) technique. According to a visual analogue scale for assessing analgesia, neither IT 0.2 mg morphine nor 10 ml 0.125% epidural bupivacaine was effective in producing adequate pain relief in labor, whereas the combination produced excellent analgesia. The use of IT morphine significantly reduced the dosage requirement of epidural bupivacaine. The incidence of nausea, vomiting, and pruritus was significantly higher when IT morphine had been administered, whereas that of urinary retention did not differ. No serious respiratory depression occurred in any of the patients. When the course of labor was studied, the prior use of IT morphine significantly prolonged the duration of the first stage of labor and the total duration of labor. We conclude that the administration of 0.2 mg IT morphine in combination with epidural administration of 0.125% bupivacaine provides better analgesia than the administration of either drug alone. | 2 |
Modulation of mediator release from human intestinal mast cells by sulfasalazine and 5-aminosalicylic acid. Intestinal mast cells are thought to contribute to the mucosal inflammation in ulcerative colitis and Crohn's disease through release of inflammatory mediators. Since sulfasalazine and its metabolite 5-aminosalicylic acid are effective therapeutic agents in inflammatory bowel disease and have been shown to inhibit generation of inflammatory products in other cells, we examined the effect of these agents in vitro on human intestinal mast cell mediator release. Sulfasalazine (5 x 10(-4)-10(-3) M) was found to significantly enhance goat anti-human IgE-induced histamine release from intestinal mast cells, which is the same response as seen in human blood basophils, whereas its metabolite 5-aminosalicylic acid was an effective inhibitor of stimulated histamine release in both mast cells and basophils. 5-Aminosalicylic acid also inhibited production of prostaglandin D2 by the stimulated intestinal mast cells. Sulfasalazine alone, without immunologic stimulation, did not induce histamine release from mast cells or basophils, but the enhancement of ongoing mast cell activation by sulfasalazine may explain some cases of adverse reactions to the drug. The inhibition of mast cell histamine release and prostaglandin generation by 5-aminosalicylic acid demonstrates a potential therapeutic modality of this agent. | 1 |
Management of posterior urethral strictures secondary to pelvic fractures in children. Bulboprostatic anastomotic urethroplasty was performed in 20 children with posterior urethral strictures secondary to bony pelvic fractures. The approach was perineal in 4 children and transpubic abdominoperineal in 16, with good postoperative results in 100 and 62.5%, respectively. In some children the urethral disruption occurred within the prostate itself and not at the prostatomembranous junction. In such cases the proximal sphincteric mechanism may be at risk and immediate repair of the injury is advisable. In the case of common prostatomembranous disruption displacement of the urethra may be significant. In such cases a transpubic approach is preferable. If the proximal sphincteric mechanism is deranged, it can be managed at the same time. | 4 |
Failed acromioplasty for impingement syndrome. We evaluated 67 shoulders in 65 patients who had pain and dysfunction for more than two years after an initial acromioplasty for impingement syndrome without a rotator cuff tear. In addition to a thorough history, physical examination, local anaesthesia injection and any other necessary investigations all patients had arthroscopic evaluation of the shoulder. In 27 shoulders there had been diagnostic errors, and in 28 operative errors; only in 12 had the diagnosis and the operative procedure both been correct. Subsequent operative intervention in patients not receiving worker's compensation benefit had a 75% success rate, whereas in those receiving such benefits the success rate was only 46%. | 2 |
Diabetic retinopathy in blacks. Diabetic eye disease, particularly diabetic retinopathy, is the leading cause of new cases of legal blindness in people 20-74 yr of age in the United States. The prevalence and rate of diabetes in this age-group are higher in Blacks than in Whites. The rate of blindness from diabetic eye disease is also higher in Blacks than in Whites. Severe macular edema, the most frequent cause of decreased vision in diabetic retinopathy, appears to be more common in Blacks. Risk factors for developing macular edema include poorly controlled hypertension, hyperglycemia, and duration of disease. The higher prevalence of hypertension in Blacks may contribute to the increased severity of diabetic retinopathy. Further evaluation is necessary to determine the influence of race on the severity of diabetic retinopathy. | 3 |
Differential alpha-fetoprotein lectin binding in hepatocellular carcinoma. Diagnostic utility at low serum levels. The reactivity of serum alpha-fetoprotein (AFP) from 20 patients with hepatocellular carcinoma (HCC) with immobilized lentil lectin was examined and found to be significantly greater (39% +/- 18%) than that of the same protein from seven patients with chronic liver disease (CLD, 11.2% +/- 3.3%), seven with fulminant hepatic failure (FHF, 10% +/- 8.4%), and eight normal pregnant women (4.1% +/- 2.7%). The reactivity with Concanavalin A (Con A) was also significantly greater for AFP from HCC patients (44.5% +/- 12.5%) than that from FHF patients (7.7% +/- 4%) and normal pregnant women (5.3% +/- 3.3%), but not from patients with CLD. The reactivity with lentil lectin permitted distinction between those with HCC (31.3% +/- 14.1%) and those with uncomplicated CLD (11.2% +/- 8.4%) even when the absolute levels of serum AFP were in the same range (80-400 ng/ml). Evaluation of the alterations by lectin binding methodology may be useful in overcoming problems associated with distinguishing between malignant and CLD, particularly at moderate serum AFP elevations. | 0 |
Endosalpingosis as a cause of chronic pelvic pain. Endosalpingosis, a condition characterized by ectopic oviduct epithelium, is diagnosed histologically by the appearance of benign ciliated and nonciliated columnar cells in an abnormal location. Endosalpingosis is typically without symptoms. Our unusual case report shows symptomatic endosalpingosis first seen with chronic pelvic pain. Various aspects of this disease will also be discussed. | 2 |
Trends in primary breast cancer management. Where are we going? The treatment of cancer during any period has been based not on the whim of a clinician but on the therapeutic consequences of the dominant biologic model of the disease. Until the 1960s, the dominant model of breast cancer was of a disease that spread centrifugally along anatomic pathways, with time being the only determinant of prognosis. An alternative model, that of biologic determinism, posits that the outcomes of treatment are determined by the extent of microscopic dissemination that occurred before the tumor became detectable. This model, too, has flaws, and the author suggests that it is time for a Kuhnian paradigm shift. Breast cancer exhibits a heterogeneity of phenotypes resulting from one or perhaps two mutations. The multiple prognostic variables may be epiphenomena, expressing different degrees of amplification of a limited domain of the genome. | 0 |
Effects of diltiazem on the functional recovery of the myocardium at organ and cellular level during prolonged hypothermic ischemic cardiac arrest. The effectiveness of diltiazem on the functional recovery of the heart, calcium (Ca++) uptake and binding, Ca++ ATPase of cardiac sarcoplasmic reticulum (SR), and MB fraction of creatine kinase (MBCK) of coronary sinus blood was investigated after one and a half hours of reperfusion following three hours of ischemic cardiac arrest. The dogs were divided into three groups: group I, sham bypass; group II, cold crystalloid cardioplegia; and group III, cold crystalloid cardioplegia with diltiazem. There was a decrease in aortic pressures left ventricular pressure development (dp/dt), left ventricular work index (LVWI), total systemic vascular resistance (TSVR), and left ventricular systolic pressure (LVSP) in the sham bypass group. There was a decrease in cardiac index (CI), LVWI, and mean right atrial pressure (mRAP) and an increase in TSVR and pulmonary vascular resistance (PVR) in group II as compared with group I. Although there was a tendency for a decrease in the indices of myocardial contractility in group II, they were not significantly different from those in group I. The indices of myocardial contractility, CI, and LVWI in group III were slightly higher than in group II, but they were not significantly different from each other. The values for calcium uptake by SR in groups II and III were similar but significantly lower than those in group I. Calcium binding in group III was significantly lower than that in group I. Calcium ATPase of SR in the three groups were similar. Although MBCK increased in all the groups, the increases were not significantly different among the three groups. The results of this study indicate that cold crystalloid cardioplegia with diltiazem was not better than cold crystalloid alone in preserving the cardiac contractility and cellular function during prolonged ischemic cardiac arrest. However, the cardiac function in terms of cardiac index was better preserved with diltiazem. | 3 |
Laser angioplasty: results of a prospective, multicenter study at 3-year follow-up. A prospective multicenter trial was initiated to evaluate the efficacy and safety of laser angioplasty. Laser recanalization was performed in 338 patients with arteriosclerotic femoropopliteal artery occlusions (average length, 8.5 cm). Neodymium-yttrium-aluminum-garnet lasers were used in combination with sapphire probe catheters. The initial recanalization rate was 85%. Complications were observed in 14% of the patients. Emergency surgery was required in 1.5%. The cumulative long-term patency rate of the successfully recanalized arteries was 80%, 70%, 62%, and 57% at 6 months, 1 year, and 2 and 3 years, respectively. The patency rates were not affected by the length of the occlusion and the long-term medication (platelet inhibition vs anticoagulation), but patients with a normal runoff had significantly better patency rates than those with reduced runoff (63% vs 52%, P less than .01). The study has shown that laser-assisted angioplasty is safe and at least as effective as conventional angioplasty. | 4 |
Widespread functional effects of discrete thalamic infarction. In order to investigate functional effects of various thalamic structures on metabolism in remote, morphologically intact cerebral regions, we used positron emission tomography of (18F)-2-fluoro-2-deoxy-D-glucose to study regional cerebral metabolic rates of glucose (rCMRGlu) in 11 patients with chronic unilateral or bilateral infarcts strictly confined to the thalamus. Patients were grouped according to computed tomographic scans showing anterior (three), medial (four), or posterior (four) lesions. Compared with a matched group of 11 healthy subjects (hemispheric CMRGlu 35.2 +/- 3.49 mumol/100 g per minute), glucose metabolism was significantly lower in the hemisphere ipsilateral to the infarction (31.2 +/- 2.97 mumol/100 g per minute). Patients with bilateral infarcts had lower hemispheric CMRGlu (29.9 +/- 2.74 mumol/100 g per minute) than those with unilateral lesions (32.2 +/- 2.97 mumol/100 g per minute). Depending on infarct location within the thalamus, there was differential depression of rCMRGlu, with the largest effects on frontal and occipital areas in medial infarctions. Except for ipsilateral thalamic deactivation, metabolic patterns with anterior thalamic infarcts were close to normal, while posterior infarcts mostly depressed rCMRGlu in the visual and in the inferior limbic cortex. Cerebellar metabolic rates were within normal limits in most cases. These patterns of regional cerebral deactivation may be related to categories of thalamic projections--intrathalamic, to limbic system and basal ganglia, diffuse to most cortical areas, and specific to defined neocortical areas. Even small brain lesions may have widespread functional sequelae, potentially demonstrable by positron emission tomography. | 2 |
Effects of dipyridamole and aminophylline on hemodynamics, regional myocardial blood flow and thallium-201 washout in the setting of a critical coronary stenosis. Experiments were performed to characterize the interaction of intravenous dipyridamole and aminophylline on thallium-201 transport kinetics, regional myocardial blood flow and systemic hemodynamics in the presence of a critical coronary artery stenosis. In 12 dogs with a critical left anterior descending coronary artery stenosis, arterial pressure decreased from a mean value (+/- SEM) of 107 +/- 6 to 94 +/- 3 mm Hg (p less than 0.05) and distal left anterior descending artery pressure decreased from 70 +/- 7 to 55 +/- 4 mm Hg (p less than 0.05) after intravenous administration of dipyridamole (0.25 mg/kg body weight). In the left anterior descending perfusion zone, the endocardial/epicardial flow ratio decreased from 0.70 to 0.36 and the intrinsic thallium washout rate was significantly prolonged. Intravenous aminophylline (5 mg/kg) reversed the dipyridamole-induced systemic hypotension and transmural coronary steal and restored the thallium washout rate to baseline values. In six other dogs, aminophylline alone resulted in no alterations in systemic and coronary hemodynamics or regional myocardial blood flow. As expected, dipyridamole-induced vasodilation and coronary steal were prevented by aminophylline pretreatment. These data show that in a canine model of partial coronary stenosis, systemic hypotension, adverse regional flow effects (coronary steal) and prolonged thallium-201 washout consequent to intravenously administered dipyridamole are promptly reversed by intravenous aminophylline administration. Aminophylline alone had no significant hemodynamic and coronary flow effects. This study provides further insight into the altered thallium kinetics occurring as a consequence of dipyridamole-induced vasodilation and suggests that the prompt reversal of symptoms and signs of ischemia with aminophylline in patients receiving intravenous dipyridamole for clinical imaging studies probably reflects the reversal of transmural coronary steal. | 4 |
Gallbladder perforation and bile leakage: percutaneous treatment. Three patients with spontaneous gallbladder perforation and one with an iatrogenic bile leak causing bile peritonitis were treated successfully by means of percutaneous catheter drainage. Three patients had cholelithiasis as the cause of perforation; the fourth patient had previously undergone gallstone dissolution with methyl tert-butyl ether lavage and developed bile peritonitis a few hours after removal of the catheter. In three patients, a percutaneous cholecystostomy catheter provided successful decompression; in the fourth patient, drainage was performed with a percutaneous sump catheter in the subhepatic space adjacent to the gallbladder. No specific complications occurred. Follow-up was performed at 1, 12, 22, and 59 months, respectively. To date, one of the four patients has undergone elective cholecystectomy (1 month after drainage). The remainder of the patients are asymptomatic. This preliminary experience suggests that the severe complication of gallbladder perforation and bile leakage may be treated, at least temporarily, by means of percutaneous drainage. | 4 |
Dysgeusia, gustatory sweating, and crocodile tears syndrome induced by a cerebellopontine angle meningioma. Facial nerve involvement in cerebellopontine angle tumors, both during their development and after excision, may be expressed in irreversible dysfunction of the parasympathetic pathways. The exact location of the lesion along the efferent nerve fibers can be established through evaluation of the functional level of those organs supplied by the cholinergic motor secretory components. This report deals with a female patient in whom peripheral facial palsy developed shortly after removal of a right cerebellopontine angle meningioma. She had slight facial asymmetry and deafness in the right ear and complained of prandial flush and sweating of the right malar area. Occult ipsilateral hyposalivation and hypolacrimation were diagnosed. In patients with seventh and ninth cranial nerve pathoses, evaluation of the end organs that are supplied by their associated autonomous nerve fibers is mandatory to prevent late ocular and oral sequelae. | 0 |
Study on the genesis of the double potential recorded in the high right atrium in atrial flutter and its role in the reentry circuit of atrial flutter. To investigate the genesis of the double potential (DP), which is two separate waves, and its role in the reentry circuit of atrial flutter (AF), we performed overdrive pacing (ODP) from the high right atrium (HRA) in six cases of spontaneous AF in which the DP was recorded in the HRA. In four of the six cases, when the DP was arbitrarily designated D1 and D2, D1 and D2 showed progressive fusion during ODP. In addition, the D1 return cycle, immediately after the termination of ODP, corresponded to the AF cycle, and the D2 return cycle corresponded to the pacing cycle. This may indicate that the DP is caused by the collision of two directional waves. Furthermore, it is suggested that the HRA plays an important role in preventing a possible shortcutting of reentry waves and in stabilizing the reentry circuit of AF. | 4 |
Effect of propranolol on endothelin-induced increase in cytosolic free calcium. This study was designed to investigate the effect of propranolol on endothelin (ET)-1-induced increase in cytosolic Ca2+ [( CA2+]i) in cultured vascular smooth muscle cells (VSMCs) obtained from rat aorta. Propranolol (0.01 to 1 mmol/L) reduced the changes in the initial transient and the later sustained phase of [Ca2+]i induced by 100 nmol/L ET-1 as well as 10 mmol/L procaine. The inhibitory action of propranolol on the change in [Ca2+]i induced by ET-1 may be involved in one of the mechanisms of propranolol-induced reduction of vasospasms. | 3 |
Delayed facial nerve palsy after temporal lobectomy for epilepsy: report of four cases and discussion of possible mechanisms. Four cases of idiopathic peripheral facial nerve palsy were documented after 110 consecutive resections of the temporal lobe for intractable epilepsy. In 3 of the 4 cases, the palsy was ipsilateral to the side of the temporal lobectomy. The onset of facial weakness was delayed 7 to 13 days after surgery (mean, 9.7 days). One patient underwent facial electroneurography, which documented 17% of normal facial motor function at the height of his weakness and the absence of the acoustic stapedius reflex. All patients were treated with prednisone (60-80 mg per day by mouth for 10-14 days, tapering off throughout the subsequent week). Facial function recovered fully in all patients within 6 to 8 weeks. Possible mechanisms are discussed, including heat and/or mechanical trauma to the facial nerve near the geniculate ganglion during resection of mesial temporal lobe structures. | 4 |
Risk monitoring of randomized trials in emergency medicine: experience of the Brain Resuscitation Clinical Trial II. Risk monitoring for the Brain Resuscitation Clinical Trial II, a multicenter, placebo-controlled trial to evaluate the efficacy of the calcium-entry blocker lidoflazine in the amelioration of brain damage in comatose cardiac-arrest survivors, posed unexpected challenges. Concern arose when monitoring of adverse reactions showed an excess of dangerous cardiac arrhythmias, including rearrest, in the lidoflazine group. To ascertain the cause of this problem and determine whether it was ethical for the trial to continue, an in-depth review of data was conducted, outside experts were consulted, and additional data were collected. These efforts suggested possible causes for the problem. Existing drug administration protocols for blood pressure control were reinforced, resulting in lower subsequent arrhythmia rates. Thus, through an efficient monitoring system, an important problem was uncovered and resolved, allowing the trial to be completed without major changes. | 2 |
Brief intensive chemotherapy for metastatic non-small-cell lung cancer: a phase II study of the weekly CODE regimen. Fifty-three patients, 17 with stage IIIB and 36 with stage IV non-small-cell lung cancer, were given CODE (cisplatin, vincristine, doxorubicin, and etoposide) plus antibiotic prophylaxis and an antiemetic regimen in an intensive chemotherapy program emphasizing weekly treatment and a planned brief duration (9-12 weeks); for 45 of these patients, the CODE program also included antifungal prophylaxis and supportive corticosteroids. Of the total study population, 33 patients (62%) responded to treatment, including five (9%) with complete response. The median survival for the entire group was 42 weeks (55 weeks for those with stage IIIB and 39 weeks for those with stage IV). More than 40% were alive at 1 year. Comparison of granulocyte counts of patients receiving prednisone with those of the subgroup to whom no corticosteroids were given showed less granulocytopenia for those receiving prednisone. Use of prednisone thus allowed improved delivery of myelosuppressive drugs. CODE was halted in nine patients because of disease progression. Although more constitutional side effects are associated with weekly chemotherapy than with standard chemotherapy, only 12 of the remaining 44 patients (27%) failed to receive at least 9 weeks of treatment. Serious toxicity was uncommon: There were no treatment-related deaths and only three episodes of neutropenia with fever. CODE is a novel treatment for non-small-cell lung cancer that this pilot study provided entirely in an outpatient setting over a 9-12 week period with an acceptable incidence of toxicity and a promising level of efficacy. Additional testing and comparison with other regimens or supportive care alone are warranted. | 0 |
Usefulness of combined propranolol and verapamil for evaluation of surgical ablation of accessory atrioventricular connections in patients without structural heart disease. Successful surgical ablation of atrioventricular (AV) accessory connections may be confirmed during postoperative electrophysiologic testing by the absence of accessory connection conduction in both the anterograde and retrograde directions. Whereas the former may be readily apparent by examination of the surface electrocardiogram during sinus rhythm or atrial pacing, assessment of the latter may be complicated by the frequent presence of enhanced retrograde AV nodal conduction in the postoperative period. Consequently, availability of interventions that selectively affect AV nodal conduction and refractoriness without concomitant effects on accessory connections may be helpful for assessing the success of the surgical procedure. In this study the effects of combined propranolol and verapamil administration on electrophysiologic properties of the AV node and the accessory AV connection were assessed both pre- and postoperatively in 17 patients (12 men and 5 women, mean age 33 years) undergoing surgical ablation of accessory connections. Preoperatively, electrophysiologic characteristics of all but 1 of the accessory AV connections were unaffected by propranolol and verapamil administration. Postoperatively, on the other hand, propranolol and verapamil significantly prolonged both the retrograde AV node effective refractory period (baseline: 272 +/- 34 ms vs after drugs: 384 +/- 70 ms [p less than 0.0001]) and the shortest cycle length maintaining 1:1 ventriculoatrial conduction (baseline: 357 +/- 99 ms vs after drugs: 485 +/- 64 ms [p less than 0.0001]). Late postoperative electrophysiologic evaluation (7 +/- 3 weeks) revealed no evidence of residual accessory AV connection conduction, and all patients remain asymptomatic at 21 +/- 10 months follow-up. | 4 |
Cardiac contractility and conduction: a comparison of antihypertensives. The four classes of first-line antihypertensive agents recommended in the 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure are reviewed here. Particular consideration is given to the effects of these agents on heart rate, atrioventricular nodal conduction, and myocardial contractility in patients with other cardiovascular diseases. Diuretics and angiotensin-converting enzyme inhibitors have no significant direct effects on cardiac function. beta-Blockers inhibit catecholamine stimulation of the heart and may be particularly beneficial in treating patients with a history of myocardial infarction. Calcium channel blockers reduce blood pressure by dilating arterial resistance vessels. They are structurally heterogeneous and highly selective in their sites of action. As a consequence, cardiac effects can be minimized by selecting a calcium channel blocker with more potent peripheral vasodilatory effects. A new calcium channel blocker, isradipine, currently undergoing clinical trials, is highly selective for arterial smooth muscle and appears to be a safe and effective antihypertensive agent. | 3 |
Echocardiographic left ventricular mass and electrolyte intake predict arterial hypertension. OBJECTIVE: To identify predictors of arterial hypertension. PATIENTS: One hundred thirty-two normotensive adults from a large employed population. METHODS: Echocardiography, standard blood tests, and 24-hour urine collection, at baseline and after an interval of 3 to 6 years (mean, 4.7 +/- 0.8 years). RESULTS: At follow-up, 15 subjects (11%; 7 men, 8 women) had a systolic blood pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg or both (mean, 143 +/- 7 and 87 +/- 6 mm Hg, respectively). At baseline, subjects who developed hypertension had a greater left ventricular mass index than those who did not (92 +/- 25 compared with 77 +/- 19 g/m2 body surface area; P less than 0.005) and higher 24-hour urinary sodium/potassium excretion ratio (3.6 +/- 1.7 compared with 2.6 +/- 1.4; P less than 0.04); there were no differences in race, initial age, systolic or diastolic blood pressure, coronary risk factors, or plasma renin activity. The likelihood of developing hypertension rose from 3% in the lowest quartile of sex-adjusted left ventricular mass index to 24% in the highest quartile (P less than 0.005); a parallel trend was less regular for quartiles of the sodium/potassium excretion ratio (P less than 0.04). In multivariate analyses, follow-up systolic pressures in all subjects and in the 117 who remained normotensive were predicted by initial age, systolic blood pressure, black race, and sex-adjusted left ventricular mass index; final diastolic blood pressure was predicted by its initial value, plasma triglyceride levels, urinary sodium/potassium ratio, low renin activity, black race, and plasma glucose level. CONCLUSIONS: Echocardiographic left ventricular mass in normotensive adults is directly related to the risk for developing subsequent hypertension. Left ventricular mass improves prediction of future systolic pressure, whereas diastolic pressure is more related to initial metabolic status. Black race is also an independent determinant of higher subsequent blood pressure. | 3 |
Demonstration of Lipiodol in paraffin sections using a modified silver impregnation technique. To demonstrate postangiographic Lipiodol (LIP) in hepatocellular carcinoma (HCC) in paraffin sections, direct impregnation of formalin-fixed tissue blocks with silver nitrate (AgNO3) was followed by routine processing. LIP appeared as black globules in the sinusoids. Ninety-four tissue blocks from 13 postangiographic LIP HCCs and 69 from 8 non-LIP HCCs and 4 fatty livers were studied. Seventy-two of 73 negative controls and all positive blocks as seen on soft tissue radiographs (STRs) were correctly coded (specificity 98.6%, sensitivity 100%). Twenty-six of the 44 LIP-negative areas on STRs from LIP cases contained scanty globules of less than 10 microns in diameter. Fatty change gave no positive readings. Thus, modified AgNO3 impregnation is a simple, accurate means of detecting LIP in high-quality paraffin sections suitable for tumor diagnosis and, if applied to postangiographic LIP, ultrasonographically guided liver biopsy, can verify that a biopsy has reached a suspected tumor focus. | 0 |
Cystocerebral syndrome. Acute urinary retention presenting as confusion in elderly patients. The diagnosis of acute mental status changes in the elderly patient is often very difficult. Many causes are possible, and there is often little history obtainable. The physical examination occasionally provides the essential clues needed to discover the source of the sudden deterioration. We have recently evaluated four episodes of acute delirium in three elderly patients who presented with no readily apparent cause for these changes. On further evaluation, the patients were found to have marked bladder distention associated with acute urinary retention. None of these patients complained of discomfort, and none had any awareness or recollection of their deterioration. Each patient had rapid resolution of symptoms on bladder decompression. To our knowledge, this "cystocerebral syndrome" has not been previously described, and we suggest that it be considered in the evaluation of acute confusional states in elderly men. | 2 |
Mediastinal hibernoma, a rare tumor. Hibernoma is an uncommon soft tissue tumor that is derived from the remnants of fetal brown fat. Review of the world medical literature revealed 90 cases, 6 of which were intrathoracic. We present the seventh case of intrathoracic hibernoma; in this case, the hibernoma was within the mediastinum without direct invasion of other structures. | 0 |
Comparative in situ hybridisation study of juvenile laryngeal papillomatosis in Papua New Guinea and Australia. A comparative study of cases of juvenile laryngeal papillomatosis from Papua New Guinea (n = 3) and Brisbane, Australia (n = 9) was carried out. In situ hybridisation reactions for human papillomavirus (HPV) types 6 and 11 occurred in 11 cases. All three cases from Papua New Guinea and eight from Australia gave positive signals. A negative reaction was observed in one Australian case. The intensity of the reaction was strong in seven cases, moderate in one, and weak in three. An equivocal reaction was also noted with probes for types 16 and 18, and types 31, 33, and 35 in two cases from Australia and one from Papua New Guinea. It is concluded that as similar staining patterns and intensities occurred in cases from both areas, the aetiology is the same. The equivocal reactions noted in three cases were probably due to cross hybridisation rather than multiple infection. | 0 |
AIDS-associated polyclonal lymphoma: identification of a new HIV-associated disease process. High-grade non-Hodgkins B-cell lymphoma is one of the principle malignancies that occurs in individuals infected with the human immunodeficiency virus (HIV-1). Immunoblastic lymphomas that arise in immunosuppressed transplant patients have been described as both monoclonal and polyclonal, and occur in association with Epstein-Barr virus (EBV) infection. To test whether polyclonal lymphoma occurred in patients with AIDS we studied tumors from multiple sites in three patients who died with widespread AIDS-associated large cell or large cell immunoblastic lymphoma. All biopsy specimens contained invasive lymphoma. Tumor cells were mature IgM-positive immunoblasts by immunohistochemical analysis, with the same B-cell phenotype observed in all tumor sites. Only a minority of sites from all patients analyzed were monoclonal as measured by immunoglobulin gene rearrangements, with one case having several foci of monoclonal disease with other histologically identical metastases showing no evidence of monoclonal proliferation. Similar to the transplant-associated polyclonal B-cell proliferations. EBV gene sequences were present in multiple sites from one autopsy. In the other two autopsies, polyclonal B-cell proliferations occurred in the absence of EBV involvement except at one site, where a minor clone of EBV-infected cells was found. In contrast to HIV-associated Burkitt's lymphoma, no c-myc rearrangements were found at any site. These studies describe the occurrence of polyclonal lymphoma in AIDS and suggest that EBV-negative polyclonal lymphoma may be a distinct disease entity unique to HIV-infected individuals. | 0 |
A prognostic system for transient ischemia or minor stroke. OBJECTIVE: To build a prognostic system for patients with carotid transient ischemic attack or minor stroke. DESIGN: Inception cohort study with 2-year follow-up. SETTING: Urban community teaching hospital. PATIENTS: Eligible patients (n = 142), identified on a carotid ultrasound roster, had been hospitalized between 1984 and 1987 within 30 days of a first carotid transient ischemic attack or minor stroke. MEASUREMENTS: Stroke or death within 2 years. MAIN RESULTS: Three factors were associated with stroke or death: age of more than 65 years, diabetes, and hypertension. Based on regression coefficients, age of more than 65 years was assigned 3 points; diabetes, 3 points; and hypertension, 2 points. An initial prognostic system comprised risk groups 1 (0 points), 2 (1 to 5 points), and 3 (6 to 8 points). Outcome rates in the three groups were 2%, 31%, and 54% (P less than 0.0001), respectively. In an independent test sample, the corresponding outcome rates for the initial system were 12%, 21%, and 31% (P = 0.04). A final prognostic system, including two additional predictors (coronary heart disease [1 point] and the distinction between stroke and transient ischemic attack for the baseline event [2 points]), comprised risk groups 1 (0 to 2 points), 2 (3 to 6 points), and 3 (7 to 11 points). Corresponding outcome rates were 3%, 27%, and 48% (P less than 0.001) in the original cohort and 10%, 21%, and 59% (P less than 0.001) in the test cohort. CONCLUSION: For selected patients with carotid transient ischemia or minor stroke, five clinical features can be combined to stratify effectively the risk for a subsequent stroke or death. | 2 |
Epidemiologic features of asymptomatic cerebral infarction in patients with nonvalvular atrial fibrillation. We performed unenhanced computed tomographic scans on 141 asymptomatic patients with nonvalvular atrial fibrillation. Thirty-six patients (26%) had hypodense areas consistent with cerebral infarction. The majority of these were small deep infarcts, seen in 29 patients (21%), but 13 patients (9%) had cortical or large deep infarctions. Twelve patients had more than one infarct on computed tomographic scan. Increasing age and increased left atrial diameter were the only clinical features associated with asymptomatic infarction. Patients older than 65 years with a left atrial diameter greater than 5.0 cm (n = 23) had a 52% prevalence of asymptomatic infarction. Patients younger than 65 years with a left atrial diameter less than 5.0 cm (n = 38) had an 11% prevalence of silent infarction. Patients with only one of these risk factors (n = 72) had a 24% prevalence of silent infarction. Infarction was more common in those with chronic (34%) as opposed to intermittent (22%) nonvalvular atrial fibrillation, but this difference was not significant. Hypertension, diabetes, duration of atrial fibrillation, congestive heart failure, history of myocardial infarction, and echocardiographic evidence of left ventricular dysfunction were not associated with asymptomatic infarction. A history of hypertension was present in only 35% of our patients with small-deep asymptomatic infarction, similar to the percentage in patients without stroke. Asymptomatic cerebral infarction is common in nonvalvular atrial fibrillation. The association with enlarged left atria and the lack of correlation with major cerebrovascular risk factors suggests a cardioembolic mechanism. Further study is needed to determine the functional and prognostic significance of these strokes. | 3 |
Long-term outcome of massive small bowel resection. The long-term outcome for seven patients 4-17 yr (mean 7.1 yr) after massive small bowel resection, leaving 5-160 cm (mean 86.4) of small bowel, was reviewed. Their mean age at the final enterectomy was 40 yr. Adaptation to foodstuffs and the effects of physiologic alterations and complicating diseases on their return to work were emphasized. More than 3.5 yr after surgery, the patients had adapted to many kinds of foodstuffs, but dietary fat could not be tolerated by three patients. Six patients returned to work an average of 2.7 yr after surgery, but four were obliged to discontinue their work because of rehospitalization for long-term complications. In addition, their working hours were limited, and they could not engage in heavy physical work, owing to physiologic alterations, such as a reduced metabolic state, after massive enterectomy. | 1 |
Benefit of bicarbonate dialysis during CAVHD. The effect of bicarbonate dialysate (BD) on acid-base status in six pediatric CAVHD patients was examined during seven episodes of metabolic acidosis. When metabolic acidosis was not corrected with CAVHD, a sterile BD was substituted for either acetate- or lactate-based dialysate. Pre- and post-BD substitution levels of lactate, HCO3, PCO2, anion gap, and pH were recorded, as well as dose of intravenous (i.v.) bicarbonate. Improvements in pH and serum HCO3 were seen in all seven cases. Anion gap decreased in all but one of the patients who were switched from lactate to bicarbonate dialysate, with improvement most marked in those patients with marked elevation of the anion gap. No adverse effect on PCO2 was noted. Lactate dialysate may be less effective when serum lactate levels are high, and may contribute to further elevation of lactate levels and anion gap. These data suggest that bicarbonate dialysate may be preferable to lactate or acetate dialysate in CAVHD patients with persistent metabolic acidosis. | 4 |
A prospective randomized trial comparing epirubicin monochemotherapy to two fluorouracil, cyclophosphamide, and epirubicin regimens differing in epirubicin dose in advanced breast cancer patients. The French Epirubicin Study Group The French Epirubicin Study Group carried out a randomized trial comparing epirubicin alone 75 mg/m2 with fluorouracil (5FU) 500 mg/m2, cyclophosphamide 500 mg/m2, and epirubicin 50 mg/m2 (FEC 50) and 5FU 500 mg/m2, cyclophosphamide 500 mg/m2, and epirubicin 75 mg/m2 (FEC 75) as first treatment for advanced breast cancer patients. Patients were stratified according to whether or not there were bone metastases only. Four hundred twelve patients entered this trial; 378 were assessable for tolerability and 365 for efficacy. The overall response rates were comparable between FEC 50 (44.6%) and FEC 75 (44.7%), but both were better than the epirubicin alone (30.6%) (P = .04 and P = .0006, respectively). The complete response rate was better in FEC 75 (15.5%) than in FEC 50 (7%) (P = .025) or epirubicin (4%) (P = .002). Similar results were obtained in the group of patients without bone-only metastases. No difference in the three treatments was observed in the patients with bone metastases only. Mean durations of response were similar in the three groups, being 412 days, 440 days, and 350 days for FEC 50, FEC 75, and epirubicin, respectively. Patients without previous adjuvant chemotherapy fared better than those with previous treatment (without anthracyclines). Tolerability was fair in the three groups. Overall, the epirubicin-alone group showed better tolerance than the two other groups, which did not differ significantly. Time to progression and survival were not different among the three groups, but more early relapses occurred in the epirubicin and FEC 50 groups; survival seemed to be better during the first 8 months in the FEC 75 group, and the survival difference between the epirubicin group and the FEC 75 group was of borderline significance. No difference in survival was observed between epirubicin- and FEC 50-group patients, even though the response rate was significantly worse in the monochemotherapy group. | 3 |
Erythema infectiosum and pregnancy-related complications Erythema infectiosum, an acute, communicable viral disease with a highly distinctive exanthem, follows the usual course of a self-limiting benign disease. In pregnant women, however, it may be associated with fetal death and nonimmune hydrops fetalis. Because of the association of human parvovirus (HPV) B19 infection with fetal damage we reviewed the current knowledge of the clinical aspects of erythema infectiosum, focusing on pregnancy and fetal outcome, to determine the magnitude of fetal risk and offer recommendations for management. Among 180 infected pregnant women 44 fetal deaths (24%) occurred, 1 to 12 weeks after the infection was noted. Pregnant women should be advised that (a) because of the high prevalence (up to 65%) of anti-HPV B19 IgG antibody among adults most of them are not at risk and (b) if maternal infection does occur therapeutic abortion is not indicated since intrauterine infection causes fetal death more often than abnormal development. Infection should be suspected in pregnant women who exhibit the symptoms of erythema infectiosum with or without arthropathy. They should be monitored for an elevated serum alpha-fetoprotein level (indicating fetal aplastic crisis) and undergo serial ultrasonography for the detection of hydrops fetalis. Although the incidence of congenital malformation is no higher than the expected rate in the general population (3% to 5%), the precise incidence of fetal adverse outcomes remains unknown and requires investigation in larger, prospective studies. | 4 |
Giant-cell arteritis of the uterus with associated temporal arteritis: a case report. Giant-cell arteritis involving the uterus was identified incidentally upon hysterectomy and anterior colporrhaphy for uterine prolapse. Subsequently, the patient was found to have giant-cell temporal arteritis presenting with fever of unknown origin. Fourteen previous cases involving the female genital tract have been reported. There appears to be an association between constitutional symptoms of fever, weight loss, malaise, headache, and polymyalgia rheumatica in elderly women with uterine prolapse and giant-cell arteritis of the genital tract. The rare presentation of giant-cell arteritis in the female genital tract does not support invasive costly evaluation in asymptomatic patients. However, a thorough investigation for involvement of other sites, including appropriate treatment for generalized disease, should be undertaken. | 3 |
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