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Congenital tracheoesophageal fistula associated with carcinoma of the lung in an adult. A rare case of adult congenital H-type tracheoesophageal fistula was diagnosed. Subsequently, at operation, large cell, undifferentiated carcinoma of the right middle lobe with extension to the right lobe and adherence to the diaphragm was documented. The diagnosis, surgical intervention, and 4-year follow-up are presented. | 1 |
Stools containing altered blood-plasma urea: creatinine ratio as a simple test for the source of bleeding. The plasma urea:creatinine ratio (U:C ratio) is known to be elevated in cases of upper gastrointestinal bleeding. Almost all patients with haematemesis have upper gastrointestinal (or generalized) bleeding so that in this study we characterized the diagnostic power of the U:C ratio in patients with stools containing altered blood without haematemesis in the hope that this simple laboratory test (used in conjunction, perhaps, with clinical data) might reduce the number of patients subjected to an unrewarding gastroscopy or colonoscopy. Of 76 cases seen in a provincial and a metropolitan hospital, 42 and 34 patients had upper and lower gastrointestinal bleeding, respectively. Fifty-four per cent of those with upper gastrointestinal bleeding and none of those with lower gastrointestinal bleeding had U:C ratios above 110 on admission. However, a discriminating level of 90 is considered to be more suitable, judged by the quadratic uncertainty score. At this level the odds for upper gastrointestinal bleeding were 15:1. | 4 |
Myocardial amiodarone and desethylamiodarone concentrations in patients undergoing cardiac transplantation. Myocardial amiodarone and desethylamiodarone concentrations were measured at multiple sites in the explanted heart in four patients who underwent cardiac transplantation. Patients were taking amiodarone, 200 to 400 mg/day (mean 300 +/- 115), for 88 to 428 days (mean 229 +/- 148). The mean cumulative dose was 58 +/- 21.3 g. Plasma amiodarone concentration in three subjects was 204, 312 and 419 ng/ml and desethylamiodarone concentration was 268, 513 and 880 ng/ml, respectively. Significant interindividual variability in myocardial concentrations of amiodarone and desethylamiodarone was observed (p less than 0.05). Mean myocardial amiodarone concentration ranged from 4 +/- 1.0 to 29 +/- 17.2 micrograms/g (p less than 0.05); mean desethylamiodarone concentration ranged from 22 +/- 8.8 to 141 +/- 102.5 micrograms/g (p less than 0.05). At each site, save for fat, myocardial desethylamiodarone concentration was higher than amiodarone concentration. Greater intraindividual variability was observed in myocardial desethylamiodarone compared with amiodarone concentration particularly in septal and scar tissue (p = NS). No significant relation was found between myocardial concentration and duration of treatment. In patients with significant ventricular disease, usefulness of plasma amiodarone and desethylamiodarone concentration to estimate myocardial concentration is limited by intra- and interindividual variability. | 3 |
Interaction of the v-rel protein with an NF-kappa B DNA binding site. The avian reticuloendotheliosis virus T contains within its genome the oncogene rel. The expression of this gene is responsible for the induction of lymphoid tumors in birds. Recently, the rel gene was shown to be related to the p50 DNA binding subunit of the transcription factor complex NF-kappa B. Binding sites for the NF-kappa B complex are found in the enhancer regions of a number of genes, including the immunoglobulin kappa gene and the human immunodeficiency virus long terminal repeat. In this communication we identify an activity from avian reticuloendotheliosis virus T-transformed avian lymphoid cells that binds in an electrophoretic-mobility-shift assay to an NF-kappa B binding site from the kappa enhancer. This activity contains proteins immunologically related to rel, as detected by polyclonal and monoclonal antibodies directed against v-rel. In a DNA affinity precipitation assay using the NF-kappa B site from the human immunodeficiency virus long terminal repeat, v-rel and several other proteins were identified. These data suggest that oncogenic transformation by v-rel is the result of an altered pattern of gene expression. | 4 |
Pancreatic secretory trypsin inhibitor stimulates the growth of rat pancreatic carcinoma cells. Pancreatic secretory trypsin inhibitor was examined for growth-promoting activity on five cell lines using standard cell culture techniques. One cell line, AR4-2J, derived from a rat pancreatic acinar cell carcinoma, responded with significantly increased incorporation of [3H]thymidine and colony formation. Pancreatic secretory trypsin inhibitor stimulated the incorporation of [3H]thymidine in liquid culture; the maximal increase was 61 +/- 10% above control (P less than 0.001) and was seen at a concentration of 10(-9) mol/L. Using a soft agarose clonogenic assay, pancreatic secretory trypsin inhibitor also consistently stimulated (3 assays) colony formation: the peak activity occurred at a concentration of 10(-10) mol/L which caused a 150 +/- 55% (mean +/- SE, P less than 0.05) increase above control. Aprotinin had no effect on the growth of AR4-2J cells and pancreatic secretory trypsin inhibitor did not bind to the epidermal growth factor receptor. AR4-2J cells were shown to produce pancreatic secretory trypsin inhibitor. The study raises the possibility that pancreatic secretory trypsin inhibitor provides autocrine stimulation of tumor cell growth. | 0 |
Treatment of traumatic rupture of the thoracic aorta. A 15-year experience. Traumatic rupture of the thoracic aorta is increasing in incidence and remains a highly lethal injury. The morbidity associated with this injury also remains high. We retrospectively reviewed the records of all patients admitted to our emergency department with ruptured thoracic aortas during a 15-year period to determine the reason for this persistently high morbidity and mortality and to identify any factors that might improve the outcome. We found that patients who are in unstable condition on arrival in the emergency department or who become unstable before reaching the operating room are not likely to survive. Patients who are injured in automobile accidents have a greater chance of survival than do those injured in motorcycle accidents or car-pedestrian accidents. Patients who are in hemodynamically stable condition after aortic injury survive only if diagnosis and treatment are prompt. Major complications of repair following thoracic aortic injury relate primarily to the length of cross-clamp time, and every effort should be devoted to keeping the cross-clamp time less than 30 minutes. | 4 |
Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care. PURPOSE: Clinical and radiographic examinations are commonly used for estimating severity and titrating therapy of chronic congestive heart failure. The purpose of this study was to establish the relationship between findings on history, physical examination, chest roentgenogram, and pulmonary capillary wedge pressure (PCWP). PATIENTS AND METHODS: Fifty-two consecutive patients with chronic congestive heart failure, referred for evaluation for heart transplantation, were studied; all patients underwent history, physical examination, upright chest roentgenogram, and cardiac catheterization. The mean left ventricular ejection fraction was 0.19 +/- 0.06. Patients were divided into three groups according to their PCWP: Group 1, normal PCWP (less than or equal to 15 mm Hg, n = 19); Group 2, mild to moderately elevated PCWP (16 to 29 mm Hg, n = 15); Group 3, markedly elevated PCWP (greater than or equal to 30 mm Hg, n = 18). RESULTS: Physical and radiographic signs of congestion were more common in the groups with higher PCWP, but they could not be used to reliably separate patients with different filling pressures. Physical findings (orthopnea, edema, rales, third heart sound, elevated jugular venous pressure) or radiographic signs (cardiomegaly, vascular redistribution, and interstitial and alveolar edema) had poor predictive value for identifying patients with PCWP values greater than or equal to 30 mm Hg. These findings had poor negative predictive value to exclude significantly elevated PCWP (greater than 20 mm Hg). Radiographic pulmonary congestion was absent in eight (53%) patients in Group 2 and seven (39%) in Group 3. In patients in Group 2 and 3, those without radiographic congestion were in a better New York Heart Association functional class (3.5 +/- 0.5 versus 2.8 +/- 0.6, p less than 0.01). There was good correlation between right atrial pressure and PCWP (r = 0.64, p less than 0.001). A normal right atrial pressure had no predictive value, but a pressure greater than 10 mm Hg was seen in all but one patient with a PCWP value greater than 20 mm Hg. CONCLUSION: Clinical, radiographic, and hemodynamic evaluations of chronic congestive heart failure yield conflicting results. Absence of radiographic or physical signs of congestion does not ensure normal PCWP values and may lead to inaccurate diagnosis and inadequate therapy. It is not known whether therapy aimed at normalizing PCWP is superior to relieving clinical and radiographic signs of congestion. | 3 |
Surgical management of exophytic chiasmatic-hypothalamic tumors of childhood. Sixteen children underwent 18 operations for radical resection of chiasmatic-hypothalamic tumors. The clinical presentation correlated with age: infants under 1 year of age presented with macrocephaly, failure to thrive, and severe visual failure; children aged 1 to 5 years predominantly had precocious puberty with mild visual deficits; and older children (greater than 5 years old) had slowly progressive loss of vision. All three infants had biologically aggressive tumors in spite of low-grade histology, and died from progressive tumor growth. Eleven of the 13 children aged 1 year or over are alive and well, without clinical or radiographic evidence of disease progression, 4 months to 4 1/2 years following surgery. Six of these patients, with a follow-up period of 10 months to 4 1/2 years (mean 27 months), have had no adjuvant therapy following radical surgical resection. The authors conclude that: 1) radical surgical resection of chiasmatic-hypothalamic tumors can be performed with minimal morbidity; 2) radical resection may delay the time to disease progression in older children and postpone the need for irradiation; 3) resection of postirradiation recurrent tumors may provide neurological improvement and long-lasting clinical remission; and 4) chiasmatic-hypothalamic tumors of infancy are aggressive neoplasms that require multimodality therapy. | 2 |
Calcifications in breast biopsy specimens: discrepancies in radiologic-pathologic identification. To analyze the effectiveness and accuracy of the diagnostic process from screening mammography to final diagnosis at pathologic examination, the authors conducted a prospective study of 277 consecutive patients who underwent 291 mammographically directed biopsies of nonpalpable lesions. Of the 170 lesions that demonstrated findings consistent with calcification on preoperative mammograms and radiographs of specimens, 12 (7.1%) were not described by the pathologist as being calcified. These discrepancies were due to inadequate sampling in three cases (25%), lack of explicit description by the pathologist in four (33%), presence of oxalate crystals that required examination with polarizing lenses in two (17%), and unexplained loss of tissue probably related to processing in three (25%). Of the 121 lesions that did not demonstrate findings consistent with calcification at radiography, eight (6.6%) were described as calcified by the pathologist. The authors recommend a protocol for avoiding these discrepancies that involves performance of a more comprehensive examination of histologic sections by the pathologist, including the use of polarizing lenses, if necessary, and radiographic reexamination of paraffin-embedded tissue blocks with subsequent step sectioning by the pathologist when results are positive. | 0 |
Neuropsychological performance in patients with mild multiple sclerosis. Although changes in cognitive function in patients with multiple sclerosis (MS) have been reported, these changes have been traditionally associated with the later stages of the disease. In the current study, a comprehensive neuropsychological battery was administered to MS patients (N = 86) in whom the disease progression was relatively mild and in remission and a demographically well-matched control group (N = 46). Besides the expected differences in tests of motor function, the two groups also differed on a number of cognitive tests with no motor demands. The two cognitive functions that appear impaired were learning and memory. Given that similar deficits have been found in MS patients with more severe symptoms, it is argued that changes in cognitive function can occur in the mild stages of the disease. | 4 |
Endodermal sinus tumor of the ovary during pregnancy: a case report. Serum alpha-fetoprotein screening led to the detection of an endodermal sinus tumor of the ovary in a 24-year-old female in week 17 of pregnancy. After surgery, chemotherapy was postponed. In week 28 levels of serum alpha-fetoprotein increased, but delivery was delayed until 33 weeks' gestation. After delivery, the patient received four chemotherapy courses (cisplatin, etoposide, and bleomycin). Mother (24 months after last chemotherapy) and child are doing well. | 0 |
Brain microemboli during cardiac surgery or aortography We have observed many focal dilatations or very small aneurysms in terminal arterioles and capillaries of 4 of 5 patients and 6 dogs who had recently undergone cardiopulmonary bypass. A smaller number of sausagelike dilatations distended medium-sized arterioles. Two other patients had a small number of the same microvascular changes following proximal aortography. Thirty-four patients and 6 dogs not undergoing cardiopulmonary bypass had none. (A 35th patient who had not undergone cardiopulmonary bypass or aortography showed a small number of dilatations; mediastinal air was a suggested source.) Some of the dilatations exhibited various forms of birefringence. Because most of the dilatations appear empty, we speculate that they are the sites of gas bubbles or fat emboli that have been removed by the solvents used in processing. These microvascular events, occurring only in conjunction with major arterial interventions, may be the anatomical correlate of the neurological deficits or moderate to severe intellectual dysfunction seen in at least 24% of patients after cardiac surgical procedures assisted by cardiopulmonary bypass. | 2 |
Limitation of transcatheter arterial chemoembolization using iodized oil for small hepatocellular carcinoma. A study in resected cases. The radiologic and histologic findings are presented of the resection of 14 small hepatocellular carcinomas (HCC), less than 2 cm in maximum diameter, after transcatheter arterial chemoembolization (TCE) using iodized oil. The effect of TCE on small HCC depended on the morphologic type of the tumors. When no extracapsular invasion of tumor cells occurred, TCE was extremely effective against encapsulated tumors. However, in nine of the 14 resected specimens, viable tumor cells remained in or around the tumor. The authors suggest that small HCC are not always curable with TCE alone and that a multi-disciplinary approach is necessary for patients with small HCC. | 1 |
Vasoactive peptide release in the extracerebral circulation of humans during migraine headache. The innervation of the cranial vessels by the trigeminal nerve, the trigeminovascular system, has recently been the subject of study in view of its possible role in the mediation of some aspects of migraine. Since stimulation of the trigeminal ganglion in humans leads to facial pain and flushing and associated release of powerful neuropeptide vasodilator substances, their local release into the extracerebral circulation of humans was determined in patients who had either common or classic migraine. Venous blood was sampled from both the external jugular and cubital fossa ipsilateral to the side of headache. Plasma levels of neuropeptide Y, vasoactive intestinal polypeptide, substance P, and calcitonin gene-related peptide were determined using sensitive radioimmunoassays for each peptide, and values for the cubital fossa and external jugular and a control population were compared. A substantial elevation of the calcitonin gene-related peptide level in the external jugular but not the cubital fossa blood was seen in both classic and common migraine. The increase seen in classic migraine was greater than that seen with common migraine. The other peptides measured were unaltered. This finding may have importance in the pathophysiology of migraine. | 2 |
Peptic ulcer surgery during the H2-receptor antagonist era: a population-based epidemiological study of ulcer surgery in Helsinki from 1972 to 1987. To evaluate the effects of improvements in medical therapy on the incidence of, indications for and operative methods used in peptic ulcer surgery, all cases of primary peptic ulcer surgery among adults in the city of Helsinki in the years 1972, 1977, 1982 and 1987 were analysed. There was a total of 565 such cases in a population which consisted of 5.2 X 10(5) individuals in 1972 and 4.8 X 10(5) individuals in 1987. The introduction of H2-receptor antagonists in 1979 was associated with a fall in the annual incidence of elective duodenal ulcer operations, from 15.5 to 6.7 per 10(5) individuals, and a fall in the annual incidence of elective gastric ulcer operations, from 9.4 to 3.1 per 10(5) individuals (P less than 0.05). The decrease was greatest among males with duodenal ulcer. In contrast, the annual incidence of emergency surgery for ulcer haemorrhage and perforation (all types of ulcers) remained relatively stable, varying from 7.2 to 10.2 per 10(5) inhabitants over the observation period (n.s.). The mean age of patients undergoing elective surgery remained essentially unchanged. The mean age of patients undergoing emergency surgery increased. The decrease in the annual incidence of elective duodenal ulcer surgery occurred mainly in relation to proximal gastric vagotomy. There was a concomitant relative increase in the incidence of gastric resection. The types of operative procedures used in cases of pyloric, prepyloric and gastric ulcer remained unchanged over the years 1972 to 1987. | 1 |
Pelvic pain: lessons from anatomy and physiology. Pelvic pain is often a difficult differential diagnosis in the emergency department. For physiologic reasons, pain in the pelvis is difficult to localize to a specific organ, and pelvic peritonitis is hard to recognize. On the other hand, differences in types of pain can be very useful in arriving at a correct diagnosis. The clinician must learn to recognize superficial and deep somatic pain, and differentiate between various types of visceral pain which originate from inflammation, ischemia, or colic. A review of the anatomy and physiology of pelvic pain helps identify some of the problems as well as potential aids in approaching the patient with pelvic pain. | 4 |
Neisseria mucosa endocarditis. A case of Neisseria mucosa tricuspid valve endocarditis in an intravenous drug abuser is described. The patient was treated initially with intravenous penicillin G followed by oral penicillin VK but relapsed. He was cured after 4 weeks of combined therapy with penicillin G and gentamicin. In vitro synergy studies performed on the patient's and two other isolates revealed synergy in all three. Thus, combination therapy is recommended for treatment of recalcitrant cases of bacterial endocarditis caused by N. mucosa. | 3 |
Dose-response evaluation of oral labetalol in patients presenting to the emergency department with accelerated hypertension. STUDY OBJECTIVE: Dose-response evaluation of oral labetalol (100, 200, or 300 mg) on heart rate and systemic blood pressure in emergency department patients with hypertensive urgency (diastolic blood pressure, 110 to 140 mm Hg, and no end-organ evidence of hypertensive emergency). METHODS: This acute-treatment, dose-ranging study used a randomized, double-blind, parallel design. Patients with supine diastolic blood pressure of 110 to 140 mm Hg after 30 minutes of bedrest received an oral dose of labetalol. Supine blood pressure and heart rate were measured manually and recorded hourly for four hours after dose. Diastolic blood pressure of 100 mm Hg or less or a 30-mm Hg reduction in diastolic blood pressure was considered a treatment success. RESULTS: Two hundred fifty-five patients were evaluated for inclusion, and 36 patients (19 women and 17 men; mean age, 44 years; age range, 23 to 67 years) were studied. The most frequent reason for exclusion was a spontaneous decrease in diastolic blood pressure to less than 110 mm Hg (31%) with bedrest. There were 12 patients in each treatment group. Compared with baseline, the 100-mg dose significantly (P less than .05) reduced heart rate at three and four hours after dose, and the 300-mg dose significantly (P less than .05) reduced heart rate at one, two, and three hours after dose; the 200-mg dose did not significantly affect heart rate. All doses produced a significant decrease in systolic and diastolic blood pressures at one, two, three, and four hours after dose compared with baseline. There were no statistically significant differences between treatment groups with regard to systolic or diastolic blood pressure or heart rate at baseline or one, two, three, or four hours after dose. At two hours after dose, diastolic blood pressure control was observed in 75%, 58%, and 67% of patients receiving 100, 200, and 300 mg, respectively (P = .903). At four hours after dose, diastolic blood pressure control was observed in 50%, 64%, and 67% of patients receiving 100, 200, and 300 mg, respectively (P = .755). A comparison of treatment success rates between the two time periods showed a waning of response with the 100-mg dose of labetalol at hour 4 compared with hour 2 (P less than .05). No adverse effects were observed. CONCLUSION: Labetalol provides safe and effective treatment for hypertensive urgencies when administered orally in doses of 100 to 300 mg. | 3 |
Treatment of patients with aortic dissection presenting with peripheral vascular complications. The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients. | 2 |
Osteoma of the middle ear. Osteomas involving the middle ear and causing a functional disturbance are rare. We report a case of a patient with an osteoma arising from the lateral semicircular canal. The main symptom was vertigo and to halt this the defect of the canal was obliterated with a bone chip and fibrin glue after removal of the tumour. | 0 |
Mutations in the K-ras oncogene induced by 1,2-dimethylhydrazine in preneoplastic and neoplastic rat colonic mucosa. These experiments were conducted to determine whether point mutations activating K-ras or H-ras oncogenes, induced by the procarcinogen 1,2-dimethylhydrazine (DMH), were detectable in preneoplastic or neoplastic rat colonic mucosa. Rats were injected weekly with diluent or DMH at 20 mg/kg body wt for 5, 10, 15, or 25 wk, killed, and their colons dissected. DNA was extracted from diluent-injected control animals, histologically normal colonic mucosa from carcinogen-treated animals, and from carcinomas. Ras mutations were characterized by differential hybridization using allele-specific oligonucleotide probes to polymerase chain reaction--amplified DNA, and confirmed by DNA sequencing. While no H-ras mutations were detectable in any group, K-ras (G to A) mutations were found in 66% of DMH-induced colon carcinomas. These mutations were at the second nucleotide of codons 12 or 13 or the first nucleotide of codon 59 of the K-ras gene. The same type of K-ras mutations were observed in premalignant colonic mucosa from 2 out of 11 rats as early as 15 wk after beginning carcinogen injections when no dysplasia, adenomas, or carcinomas were histologically evident, suggesting that ras mutation may be an early event in colon carcinogenesis. | 0 |
Prognosticators of second-look laparotomy findings in patients with epithelial ovarian cancer. Prognosticators of outcome at second-look laparotomy (SLL) were evaluated in 49 patients with epithelial ovarian carcinoma undergoing SLL. Residual tumor volume was found to be the most significant prognosticator of outcome, with initial tumor stage being of secondary importance. Grade of tumor played no role in outcome at SLL. The results of the study led us to the conclusion that the second-look procedure may be safely omitted in stage I patients. The importance of optimal cytoreduction during primary surgery was stressed. | 0 |
Transmission of Rift Valley fever virus by adult mosquitoes after ingestion of virus as larvae [published erratum appears in Am J Trop Med Hyg 1991 Jun;44(6):580] We studied the ability of Culex pipiens, Aedes circumluteolus, and Ae. mcintoshi, exposed as larvae to liver tissue from a Rift Valley fever (RVF) virus-infected hamster, to become infected and transstadially transmit virus to the adult and for the adults to transmit virus by bite to hamsters. After exposure as larvae, 9% (5/54) of adult Cx. pipiens and 8% (38/505) of the adult Ae. (Neomelaniconion) species were infected. All of the infected Cx. pipiens and about half of the infected Ae. circumluteolus and Ae. mcintoshi tested transmitted RVF virus by bite to hamsters. Transmission rates for mosquitoes orally infected as larvae were higher than those for mosquitoes orally infected as adults. Animals infected with RVF virus may abort or die in the vicinity of mosquito larvae breeding habitats and infected tissue from these animals may contaminate the water. | 1 |
Pressure-length loop area: its components analyzed during graded myocardial ischemia. The changes in total pressure-length loop area were compared with changes in effective shortening area, systolic lengthening area and postsystolic shortening area (defined with respect to end-diastolic and end-systolic lengths) of the pressure-length loop during myocardial ischemia in seven anesthetized dogs instrumented for measurement of left ventricular pressure and regional segmental wall motion (sonomicrometry) in the minor axis of the apical region of the left ventricle. Ischemia was induced by gradual tightening of a micrometer-controlled snare around the left anterior descending coronary artery, which supplied the apical myocardium. Data were obtained at normal flow, after critical constriction (loss of pulsatile coronary flow), mild ischemia (ischemia 1: onset of regional dysfunction, i.e., postsystolic shortening and mild hypokinesia) and moderate ischemia (ischemia 2: marked hypokinesia). At each stage, acute afterloading was performed by partially occluding the descending thoracic aorta. The pressure-length loops were analyzed in terms of four areas: total loop area, effective shortening area, postsystolic shortening area and systolic lengthening area. Total loop area decreased only when marked hypokinesia was present (176 +/- 18.3 mm Hg x mm at ischemia 2 versus 245.1 +/- 26.9 mm Hg x mm at ischemia 1, p less than 0.05). However, effective shortening area (98.2 +/- 0.8% of total loop area at baseline; 93.8 +/- 2.4% at critical constriction; 76.3 +/- 7.2% at ischemia 1; 51.9 +/- 12.2% at ischemia 2) and postsystolic shortening area (1.8 +/- 0.8% of total loop area at baseline; 5.2 +/- 1.9% at critical constriction; 14.3 +/- 3/4% at ischemia 1; 23.8 +/- 5.1% at ischemia 2) changed significantly with each progressive stage of ischemia. | 3 |
Advances in the treatment of complex cerebrovascular disorders by interventional neurovascular techniques. Treatment of complex cerebrovascular disorders, including intracranial aneurysms, carotid cavernous sinus fistulas, vertebral fistulas, arteriovenous malformations, atherosclerosis of brachiocephalic vessels, and arterial vasospasm, is being performed in selected cases by interventional neurovascular techniques. Recent advances in microballoon technology, permanent solidifying polymers, newer embolic agents, high-resolution digital subtraction angiography with road-mapping technique, and steerable micro-guide wires and catheters have greatly improved access in the distal intracranial circulation and markedly reduced the morbidity associated with these procedures. Interventional neuroradiology is emerging as an important adjunct to neurosurgery for selected cerebrovascular disorders. | 2 |
Clinical evaluation of a side entry access port: a novel dual-lumen venous access device. The initial clinical experience with a low-profile side entry access (SEA) dual-lumen implantable venous access port for cancer chemotherapy administration is summarized in this report. The catheter material is polyurethane. The overall experience in 35 patients in this study was a total of 6,224 patient days, with a mean of 178 days per patient. A variety of chemotherapeutic agents, biologic response modifiers, and antibiotics were administered. In 26% of the patients, the device chambers were in simultaneous use during the treatment period. A 6% incidence of clinical subclavian vein thrombosis was noted. There was no infectious complications. Inconsistencies in blood withdrawal and temporary catheter dysfunction were comparable to other access ports in clinical use. The novel design of this side entry port and the catheter material of low thrombogenicity make this device a good option in patients requiring a low-profile system and dual access. Nursing staff should be made aware of the side entry design and that in-service training for accessing the septum is required in centers where such devices are not routinely used. | 0 |
Systemic alpha-adrenergic blockade with phentolamine: a diagnostic test for sympathetically maintained pain. The diagnosis of sympathetically maintained pain (SMP) is typically established by assessment of pain relief during local anesthetic blockade of the sympathetic ganglia that innervate the painful body part. To determine if systemic alpha-adrenergic blockade with phentolamine can be used to diagnose SMP, we compared the effects on pain of local anesthetic sympathetic ganglion blocks (LASB) and phentolamine blocks (PhB) in 20 patients with chronic pain and hyperalgesia that were suspected to be sympathetically maintained. The blocks were done in random order on separate days. Patients rated the intensity of ongoing and stimulus-evoked pain every 5 min before, during, and after the LASB and PhB. Patients and the investigator assessing pain levels were blinded to the time of intravenous administration of phentolamine (total dose 25-35 mg). The pain relief achieved by LASB and PhB correlated closely (r = 0.84), and there was no significant difference in the maximum pain relief achieved with the two blocks (t = 0.19, P greater than 0.8). Nine patients experienced a greater than 50% relief of pain and hyperalgesia from both LASB and PhB and were considered to have a clinically significant component of SMP. We conclude that alpha-adrenergic blockade with intravenous phentolamine is a sensitive alternative test to identify patients with SMP. | 2 |
Cerebrospinal norepinephrine concentrations and the duration of epidural analgesia This study was performed to determine whether the addition of norepinephrine to local anaesthetics prolongs epidural analgesia in man. In addition, cerebrospinal fluid norepinephrine (NE) concentrations were measured. In the first part of the study, epidural catheters were inserted in 14 patients before herniotomy. Mepivacaine, 1.5 per cent (0.35 ml.kg-1), was administered and norepinephrine (5 micrograms.ml-1) was added in seven patients. The duration of anaesthesia was prolonged from 54 +/- 11 min to 83 +/- 12 min (P less than 0.05) and CSF NE concentrations increased from 68 +/- 12 pg.ml-1 to 336 +/- 85 pg.ml-1 in the NE group (P less than 0.01). In the second part, eight patients with herpetic neuralgia received epidural analgesia at the fourth to eighth thoracic interspace, using bupivacaine 0.25 per cent, with and without NE. The CSF NE concentrations in this group were greater than in the surgical patients before operation and increased from 254 +/- 58 to 406 +/- 58 pg.ml-1 30 min after administration of bupivacaine with NE. The duration of pain relief was prolonged with NE. These results suggest that adding NE to local anaesthetics prolongs epidural analgesia. Moreover, NE concentrations in surgical patients increased to levels similar to those found in patients suffering from herpetic analgesia. This suggests that the increase of CSF NE in chronic pain states has an antinociceptive effect. | 4 |
Reversal of cardiac and vascular hypertrophy by antihypertensive therapy. Cardiovascular hypertrophy, such as left ventricular hypertrophy, and arteriolar hypertrophic changes are common in established hypertension. Left ventricular hypertrophy, in particular, markedly increases the risk of cardiovascular complications and death. The ability of an antihypertensive agent to reverse hypertrophic changes could, therefore, be greatly advantageous. Clinical studies with beta-blockers have shown them able to substantially reduce left ventricular hypertrophy. For reversal of arteriolar hypertrophy, vasodilatory beta-blockers have been shown to be preferable to ordinary beta-blockers, possibly because vasodilation reduces vascular smooth-muscle tone, which may facilitate reversal of hypertrophy. Theoretically, a vasodilatory beta-blocker, such as celiprolol, would therefore appear to offer advantages because of its ability to reverse left ventricular and arteriolar hypertrophy in addition to its antihypertensive action. The practical and clinical effects of cardiovascular hypertrophy reversal remain to be fully evaluated; however, it is logical to assume that they would be of considerable benefit to the hypertensive patient. | 3 |
Absorption of carbon 13-labeled rice in milk by infants during acute gastroenteritis. To determine whether rice cereal could be used to complement a cow milk-based diet in the nutritional management of infants with acute diarrhea, we assessed its digestion and absorption in eight affected male infants, 69 to 131 days of age. They received cow milk formula with 5.4% lactose (diluted 1:1 with water and precooked rice cereal) 5 to 22 hours after admission and rehydration. The first feeding consisted of milk diluted with carbon 13-enriched rice cereal. A 48-hour fecal collection and balance study was performed. Rice cereal was reasonably well absorbed (84.0% to 95.8%) by seven of the eight infants. The study was repeated in seven of the infants after they had recovered. Our results indicated that rice cereal is well absorbed by young infants with acute diarrhea and that it is an adequate nutrient supplement for this patient population. | 1 |
Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Massive transfusion may cause abnormalities of electrolytes, clotting factors, pH, and temperature and may occur in a scenario of refractory coagulopathy and irreversible shock. Identification of correctable variables to improve survival is complicated by the interplay of this pathophysiology. Temperature may be an under-appreciated problem in the genesis of coagulopathy. In vitro studies have demonstrated that platelet function and vascular response are critically temperature-dependent. We reviewed the records of 45 trauma patients without head injury or co-morbid medical illness who required massive transfusions. The mean Injury Severity Score was 55 +/- 6, a mean of 22.5 +/- 5 units of blood was transfused, and mortality was 33%. Nonsurvivors were more likely to have had penetrating injury (88% versus 55%), received more transfusions (26.5 +/- 9 versus 18.6 +/- 1, p less than 0.05), had lower pH (pH 7.04 +/- 0.06 versus 7.18 +/- 0.02, p less than 0.05), had lower core temperature (31 +/- 1 degree C versus 34 +/- 1 degree C, p less than 0.01), and had a higher incidence of clinical coagulopathy (73% versus 23%). Severe hypothermia (temperature less than 34 degrees C) occurred in 80% of the nonsurvivors and in 36% of survivors. Patients who were hypothermic and acidotic developed clinically significant bleeding despite adequate blood, plasma, and platelet replacement. Avoidance or correction of hypothermia may be critical in preventing or correcting coagulopathy in the patient receiving massive transfusion. | 4 |
Postoperative myocardial ischemia in patients undergoing coronary artery bypass graft surgery. S.P.I. Research Group. Cardiac morbidity and mortality after coronary artery bypass graft (CABG) surgery continue to be significant problems. To determine the prevalence, characteristics, and prognostic importance of postoperative myocardial ischemia after CABG surgery, the authors monitored 50 patients continuously for 10 perioperative days with the use of two-lead electrocardiography (ECG). ECG changes consistent with ischemia were defined as a reversible ST depression of 1 mm or greater or an elevation of 2 mm or greater from baseline, lasting at least 1 min. Baseline was adjusted for positional changes and temporal drift. All episodes were verified, with the use of the ECG monitor printout (ECG complexes), by two independent blinded investigators. Clinical care was not controlled by study protocol, and clinicians were unaware of the research data collected. Twenty-six of 50 patients (52%) had 207 episodes of perioperative ischemia (3,409 ischemic minutes). Postoperatively, ischemia developed in 48% of patients, compared with 12% preoperatively and 10% intraoperatively before bypass. Postoperative ischemia was most common in the early period (postoperative days [PODs] 0-2; 38% of patients), peaking during the first 2 h after revascularization, and less common during the late postoperative period (PODs 3-7; 24% of patients). Almost all (120 of 122; 98%) postoperative episodes (after tracheal extubation) were asymptomatic: only 9 of 70 (13%) early episodes were detected by clinical ECG monitoring. Postoperative ischemia did not appear to be related to acute changes in myocardial oxygen demand: only 39% of the postoperative episodes were preceded by a greater than 20% increase in heart rate. However, tachycardia persisted throughout the postoperative week (22-33% of all heart rates greater than 100 beats per min), and patients with postoperative ischemia (POD 0) more frequently had tachycardia (median 43% vs. 12% of the time; P less than 0.01). Five adverse cardiac outcomes occurred on the day of surgery; all five were preceded by postoperative ischemia, three by intraoperative ischemia before bypass, and none by preoperative ischemia. Patients with late postoperative ischemia did not have an adverse cardiac outcome. The authors conclude the following: 1) ischemia is more prevalent postoperatively than preoperatively or intraoperatively before bypass; 2) the incidence of postoperative ischemia peaks shortly after revascularization, during which time it is symptomatically silent, difficult to detect, and related to adverse cardiac outcome; 3) late postoperative ischemia also is silent, but it is less prevalent and not associated with in-hospital adverse cardiac outcome; and 4) a relationship between ischemia and persistently elevated postoperative heart rate may exist and warrants additional investigation. | 4 |
Senescence of nickel-transformed cells by an X chromosome: possible epigenetic control. Transfer of a normal Chinese hamster X chromosome (carried in a mouse A9 donor cell line) to a nickel-transformed Chinese hamster cell line with an Xq chromosome deletion resulted in senescense of these previously immortal cells. At early passages of the A9/CX donor cells, the hamster X chromosome was highly active, inducing senescence in 100% of the colonies obtained after its transfer into the nickel-transformed cells. However, senescence was reduced to 50% when Chinese hamster X chromosomes were transferred from later passage A9 cells. Full senescing activity of the intact hamster X chromosome was restored by treatment of the donor mouse cells with 5-azacytidine, which induced demethylation of DNA. These results suggest that a senescence gene or genes, which may be located on the Chinese hamster X chromosome, can be regulated by DNA methylation, and that escape from senescence and possibly loss of tumor suppressor gene activity can occur by epigenetic mechanisms. | 4 |
Nasal midline masses in infants and children. Dermoids, encephaloceles, and gliomas. Nasal dermoids, gliomas, and encephaloceles are uncommon congenital lesions that result from aberrant embryologic development. We have treated 46 children with these nasal lesions. In view of the potential intracranial connection, patients are at risk for intracranial infection, and early surgical correction is thus imperative. Neuroimaging studies may help to predict intracranial involvement. | 0 |
End-stage renal disease--is infrainguinal limb revascularization justified? Reports of reconstructive surgery for peripheral vascular disease have been relatively uncommon in patients with end-stage renal disease. Between 1980 and 1989, 39 patients with end-stage renal disease underwent revascularization of 56 limbs. Fifty-two primary infrainguinal and four secondary infrainguinal bypass grafts were performed. In addition, nine thrombectomies were performed. At the time of surgery 37 patients were on dialysis; three had functioning kidney transplants. The indications for revascularization were gangrene, rest pain, or ulceration in all except three limbs with disabling claudication. Reversed, nonreversed, or in situ vein was used in 25 of the 52 primary infrainguinal revascularizations performed. Polytetrafluoroethylene was used in 25. Two procedures used a combination of polytetrafluoroethylene and vein. The primary patencies for all infrainguinal procedures at 1 and 2 years were 77% and 68%, respectively. Four perioperative deaths occurred in the infrainguinal group (7.7%). An additional death occurred after thrombectomy for late graft closure. Three deaths were a result of myocardial infarction. One patient on peritoneal dialysis developed uncontrolled sepsis. At 3 years 39% of patients were alive, and 84% of the limbs were salvaged. Among the cases studied no group was identified that represented unacceptable operative risk. Results compared well with reported patencies for patients subjected to infrainguinal revascularization procedures. Limb revascularization in patients with end-stage renal disease may be performed by use of similar criteria to those used for other patients with peripheral vascular disease. | 4 |
Misperceptions of comprehension difficulties of stroke patients by doctors, nurses and relatives. Doctors, nurses and relatives involved with 30 recently aphasic stroke patients were asked to predict how the patient would perform on a comprehension test. Results show that not only do doctors, nurses and relatives underestimate the receptive disability of these patients, but they also illustrate a lack of agreement between health professionals. Implications for management are considered. | 2 |
A controlled trial of nebulized isoetharine in the prehospital treatment of acute asthma. Acute asthma is a potentially life-threatening disorder, recognizable to the prehospital care provider. While therapies are available to the prehospital care provider for treating acute asthma, no previous controlled studies have been performed demonstrating the treatment in the field is efficacious and safe. The authors conducted a controlled trial of the prehospital use of nebulized isoetharine in an urban emergency medical services system. Fifty-two patients with acute asthma were studied. Patients were initially evaluated with a peak flow meter. Half of the patients received isoetharine, while the control group received basic life support only. There was no difference in baseline values. Peak expiratory flow increased from 138 L/min to 148 L/min in the control group, while it increased from 149 L/min to 218 L/min in the treatment group (P less than .001). The authors conclude that paramedic treatment of acute asthma with nebulized isoetharine is effective in improving pulmonary function and clinical status during transport. | 4 |
Intracardiac shunting in children with ventricular septal defect: evaluation with Doppler color flow mapping In children with a ventricular septal defect, transseptal blood flow has been demonstrated angiographically to be bidirectional in all but the smallest defects. To investigate this phenomenon noninvasively, two-dimensional Doppler color flow echocardiography was used in 77 patients (aged 1 day to 15.5 years, mean 24 months). During isovolumetric contraction, flow was seen from the left to the right ventricle in 82 (98%) of 84 studies. During isovolumetric relaxation, right to left flow was noted in 72 (96%) of 75 studies. During early diastole in patients with an isolated defect, flow was initially from the right to the left ventricle and subsequently reversed to become left to right in 29 (91%) of 32 studies. In patients with concomitant right ventricular volume overload, flow across the ventricular defect was from the right to the left ventricle throughout diastole in 30 (86%) of 35 studies. In each of four patients with d-transposition of the great vessels and each of two patients with 1-transposition of the great vessels, blood flow was from the morphologic left ventricle to the morphologic right ventricle during isovolumetric contraction and from the morphologic right ventricle to the morphologic left ventricle during isovolumetric relaxation. These results demonstrate 1) the complex nature of intracardiac shunting in children with ventricular septal defect as previously shown by angiography; 2) an intrinsic functional difference in the contractile and relaxation properties of the morphologic left and right ventricles; and 3) differences in diastolic blood flow patterns between children with an isolated defect and those with a ventricular septal defect and right ventricular volume overload (p = 0.0001). | 3 |
Prediction of variceal hemorrhage in cirrhosis: a prospective follow-up study. Endoscopic, clinical, and laboratory parameters including presence of varices in the gastric fundus, red color sign, diameter and number of variceal columns, platelet count, and the Child status were assessed in 109 patients with cirrhosis and esophageal varices without previous variceal bleeding. During a mean follow-up period of 21 months, the predictive values of these parameters with regard to first bleeding incidence and mortality rate were studied. The incidence of bleeding was 29%, and the mortality rate 46%. Endoscopic criteria (presence of varices in the gastric fundus, presence of the red color sign, and size of the largest varix) as well as alcoholic etiology of cirrhosis showed a significant positive correlation with the bleeding incidence but not with mortality. Contrary to this, two factors of the Child classification (encephalopathy and ascites) and age positively correlated with mortality but not with the bleeding incidence. | 4 |
mtDNA depletion with variable tissue expression: a novel genetic abnormality in mitochondrial diseases. We studied two related infants with a fatal mitochondrial disease, affecting muscle in one and liver in the other. Quantitative analysis revealed a severe depletion of mtDNA in affected tissues. This genetic abnormality was also observed in muscle of an unrelated infant with myopathy and in muscle and kidney of a fourth child with myopathy and nephropathy. Biochemistry, immunohistochemistry, and in situ hybridization showed that the depletion of mtDNA in muscle fibers was correlated with a respiratory chain defect and with lack of mitochondrially translated proteins. Although the differential tissue involvement in these infants suggests mtDNA heteroplasmy, sequence analysis of mtDNA replication origins did not reveal any abnormality that could account for the low copy number. | 2 |
Oral manifestations of HIV infection and their management. II. Less common lesions. This second of two articles reviews the many uncommon and rare oral lesions that have arisen in persons infected with human immunodeficiency virus (HIV). The various drug-related oral disorders of HIV disease are also considered. | 0 |
Chromosome 15 uniparental disomy is not frequent in Angelman syndrome. Genetic imprinting has been implicated in the etiology of two clinically distinct but cytogenetically indistinguishable disorders--Angelman syndrome (AS) and Prader-Willi syndrome (PWS). This hypothesis is derived from two lines of evidence. First, while the molecular extents of de novo cytogenetic deletions of chromosome 15q11q13 in AS and PWS patients are the same, the deletions originate from different parental chromosomes. In AS, the deletion occurs in the maternally inherited chromosome 15, while in PWS the deletion is found in the paternally inherited chromosome 15. The second line of evidence comes from the deletion of an abnormal parental contribution of 15q11q13 in PWS patients without a cytogenetic and molecular deletion. These patients have two maternal copies and no paternal copy of 15q11q13 (maternal uniparental disomy) instead of one copy from each parent. By qualitative hybridization with chromosome 15q11q13 specific DNA markers, we have now examined DNA samples from 10 AS patients (at least seven of which are familial cases) with no cytogenetic or molecular deletion of chromosome 15q11q13. Inheritance of one maternal copy and one paternal copy of 15q11q13 was observed in each family, suggesting that paternal uniparental disomy of 15q11q13 is not responsible for expression of the AS phenotype in these patients. | 2 |
Systemic mast cell disease associated with primary mediastinal germ cell tumor. The first known case of systemic mast cell disease associated with a germ cell tumor is reported. Six months after the complete remission of a primary mediastinal germ cell tumor treated by chemotherapy and resection, a young man had a series of episodes of hypotension and syncope and, a few months later, a gastric hemorrhage and coagulation disorder. The diagnosis of systemic mast cell disease was made in view of bone marrow and liver biopsies. A transient circulating heparin-like anticoagulant was noted. The occurrence in a short period of these two unusual conditions, given previous knowledge of hematologic disorders associated with germ cell tumors, suggests that the present association is not a coincidence. Systemic mast cell disease should be considered among the hematologic disorders associated with a germ cell tumor. | 0 |
Anal sphincter function after intersphincteric resection and stapled ileal pouch-anal anastomosis. This study was done to determine the effect of the direct ileal pouch-anal anastomosis upon pressure and sensory components of the anal canal and ileal pouch. These findings were related to postoperative continence. Thirty-three patients with ileal pouch-anal anastomosis (25 continent, eight with episodic minor incontinence) were studied 3 +/- 0.3 and 25 +/- 5 months after ileostomy takedown. The maximum resting pressure in the anal canal was significantly lower in patients with an imperfect result (35 +/- 5 mm Hg) than in continent patients (44 +/- 5 mm Hg) (P less than 0.05). Postoperatively the maximum squeeze anal pressure was slightly greater in continent than in incontinent patients (99 +/- 8 mm Hg vs. 87 +/- 7 mm Hg) (P greater than 0.05). The postoperative recto-(ileo-)anal inhibitory reflex was present in 27 percent. The linear correlation between strength of rectal (ileal) distension and depth resp. duration of internal sphincter relaxation as preoperatively observed disappeared postoperatively in every group of patients. Simultaneous measurements of pouch and anal pressure in patients with imperfect results revealed a reduced positive pouch anal pressure gradient compared to the continent group. This low pouch-anal pressure gradient is thought to be responsible for the increased incidence of soiling in some of our patients. | 1 |
Delayed subcapsular hematoma after percutaneous liver biopsy as a manifestation of warfarin toxicity. Guidelines for the management of patients receiving chronic anticoagulation therapy who require liver biopsy are not clearly defined. In patients with normal coagulation, liver biopsy is a relatively safe procedure with a morbidity of less than 0.1% and a mortality of less than 0.01%. We report a patient with a prosthetic aortic valve who developed a large subcapsular hematoma 12 days after a percutaneous liver biopsy as a consequence of warfarin toxicity. Based on the experience with this patient, reinstitution of anticoagulant therapy should be avoided for at least 72 h after a percutaneous liver biopsy. Intravenous heparin should be resumed first, and warfarin added if no bleeding has occurred after an additional 48-72 h. The prothrombin time should be maintained at 1.5 times the baseline. | 1 |
Socioeconomic factors and cancer incidence among blacks and whites Findings from previous studies suggest that differences in socioeconomic status may be responsible for some, if not all, of the elevated incidence of cancer among blacks as compared with whites. Using incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, we tested this hypothesis by correlating black and white cancer incidence rates in three US metropolitan areas between 1978 and 1982 with data from the 1980 census on socioeconomic status within individual census tracts. The study analyzed data on the incidence of cancer at all sites combined (greater than 100 cancer sites) and at seven major sites separately. As in other studies, income and educational levels served as surrogates for socioeconomic status. The present study also used census-tract data on population density as a surrogate factor. Each of these measures of socioeconomic status was analyzed independently. Before correlation with census-tract data, age-adjusted data on cancer incidence showed statistically significant elevated risks among blacks for cancer at all sites combined and at four of the seven separate sites; whites showed an elevated risk for cancer at two sites. Cancer at only one site, the colon, showed no significant association with race. When age-adjusted incidence data were correlated with socioeconomic status, the comparative black-white risks changed: Whites showed an elevated risk of cancer at all sites combined and at three of the seven separate sites; blacks maintained their elevated risk at three sites. These findings suggest that the disproportionate distribution of blacks at lower socioeconomic levels accounts for much of the excess cancer burden among blacks. They also suggest that for both blacks and whites unidentified racial factors, which may be either cultural or genetic and which are not closely linked to socioeconomic status, may play a role in the incidence of some cancers. | 0 |
Efficacy of fludarabine, a new adenine nucleoside analogue, in patients with prolymphocytic leukemia and the prolymphocytoid variant of chronic lymphocytic leukemia. PURPOSE: To describe the results of fludarabine therapy in patients with prolymphocytic leukemia (PLL) and the prolymphocytoid variant of chronic lymphocytic leukemia (CLL-Pro). PATIENTS AND METHODS: Seventeen patients with a diagnosis of PLL or CLL-Pro received fludarabine 30 mg/m2 over 30 minutes daily for 5 days every 4 weeks alone (12 patients), or with prednisone (five patients). Previously defined criteria for response were used. Differences in response rates according to various characteristics were evaluated by chi-square test. RESULTS: Three patients (18%) achieved complete remission, and three (18%) had a partial remission, for an overall response rate of 35%. Responses were durable and occurred in all involved organ sites. Lower response rates were observed in patients with anemia, thrombocytopenia, advanced Rai stages, and primary resistance to prior therapy. Toxicities were minimal except for febrile episodes associated with therapy. CONCLUSION: Fludarabine has shown encouraging results in these patients and deserves further investigation in combination with other active agents, and in the setting of front-line therapy. | 0 |
Nephron-sparing surgery for renal cell carcinoma with venous involvement. A nephron-sparing operation recently has been shown to provide extended survival free of disease in selected patients with localized renal cell carcinoma, particularly for tumors of lower stage. To define better the role of conservative surgical treatment in more locally advanced renal cell carcinoma we reviewed 9 patients with venous tumor involvement in solitary functioning kidneys who underwent a nephron-sparing operation. Complete tumor resection with adequate preservation of renal function was accomplished in all cases. Of the 9 patients 5 had no evidence of disease 7 to 93 months (mean 33.2 months) postoperatively. The remaining 4 patients died of metastatic renal cell carcinoma 17 to 47 months (mean 35.5 months) postoperatively, 2 of whom had concomitant local recurrences in the renal remnant. Based on previously reported results of total nephrectomy for renal cell carcinoma with venous involvement and the morbidity associated with renal replacement therapy, we believe that a nephron-sparing operation is a viable option in the management of these patients. | 0 |
Evaluation of 13C-urea breath test in the detection of Helicobacter pylori and in monitoring the effect of tripotassium dicitratobismuthate in non-ulcer dyspepsia Sixty nine patients with non-ulcer dyspepsia have been studied with endoscopy, biopsy, quick urease (CLO) test, Helicobacter pylori culture, and the 13C-urea breath test before and after treatment with tripotassium dicitratobismuthane (DeNol) two tablets twice daily for four weeks. Symptoms of non-ulcer dyspepsia were recorded using a standard questionnaire. Using H pylori culture as the gold standard, the sensitivity of the 13C-urea breath test was 90%, the specificity 98.6%, and the accuracy 94.8% with a positive predictive value of 98.2% and a negative predictive value of 92.5%. Conversion rate from H pylori positive to negative status after treatment with tripotassium dicitratobismuthate was 17.9%. Symptoms of non-ulcer dyspepsia improved appreciably after treatment irrespective of H pylori status. The 13C-urea breath test is an accurate research tool suitable for serial testing and population surveys. | 4 |
Treatment of alopecia areata with diphenylcyclopropenone. One hundred thirty-nine patients with severe alopecia areata (the majority with the subtotal, total, or universalis type) were treated with topical immunotherapy (diphenylcyclopropenone). Patients were initially treated unilaterally; the other side of the scalp served as a control. In 50.4% of the patients the response was either excellent (total regrowth) or satisfactory (subtotal regrowth with only a few remaining bald patches). The most frequent side effects were eczematous reactions with blistering, spreading of the induced contact eczema, and sleep disturbances. | 4 |
High- versus standard-dose megestrol acetate in women with advanced breast cancer: a phase III trial of the Piedmont Oncology Association. One hundred seventy-two patients with advanced breast cancer were randomized to receive oral standard-dose megestrol acetate (MA), 160 mg/d or high-dose MA, 800 mg/d. All but two patients had one prior trial of tamoxifen therapy for either metastatic disease (74%) or as adjuvant treatment (26%). Pretreatment characteristics were similar for both arms. High-dose MA resulted in a superior complete plus partial response rate (27% v 10%, P = .005), time to treatment failure (median, 8.0 v 3.2 months, P = .019), and survival (median, 22.4 v 16.5 months, P = .04) when compared with standard-dose therapy. These differences remained significant after adjustment for other covariates. Thirty-four patients were given high-dose MA after failure of standard-dose MA treatment, and none responded. Weight gain was the most distressing side effect, with 13% of standard-dose and 43% of high-dose patients gaining more than 20 lbs. Four major cardiovascular events occurred in patients receiving high-dose treatment and one in patients given standard doses. Other toxicity was modest. High-dose MA may represent a significant improvement in secondary endocrine therapy for advanced breast cancer patients refractory to initial endocrine treatment, but its use on a regular basis should be reserved until these results are confirmed by other clinical trials. | 3 |
Prognostic factors and value of adjunctive nephrectomy in patients with stage IV renal cell carcinoma. We reviewed 57 cases of Stage IV renal cell carcinoma to clarify the factors influencing prognosis and to evaluate the value of nephrectomy. Cumulative survival from the initial diagnosis was analyzed with respect to the patients' age, sex, side of primary tumor, initial performance status (PS), site of metastasis, and nephrectomy. Overall survival for the patients was 51 percent at one year, 22 percent at three years, and 11 percent at five years. Age, sex, and side of primary tumor had no influence on survival. Improved survival was correlated with good PS, metastases limited to single organ, and removal of the primary tumor. With regard to histopathologic features in nephrectomized patients, low grade and stage were correlated with longer survival. These factors should be considered in the analysis of results of future clinical trials of metastatic renal cell carcinoma. | 0 |
Bilateral infrapatellar tendon rupture in a patient with jumper's knee. This is the fourth case report of bilateral infrapatellar tendon rupture as a result of indirect trauma in a patient without systemic disease. This is the only report we have found of jumper's knee leading to simultaneous infrapatellar tendon ruptures. | 3 |
Percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections. Operative drainage is the cornerstone of therapy for pancreatic abscess. Recently it has been suggested that successful percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections may serve as definitive therapy. We undertook therapeutic, computed tomography-directed percutaneous drainage in a selected group of 29 patients with infected pancreatic and peripancreatic fluid collections. Twenty-three patients (79%) were successfully treated with percutaneous drainage. Of six patients (21%) representing failures of percutaneous drainage, four died and two recovered after operative drainage. The four patients who died had a mean APACHE (acute physiology and chronic health evaluation) II score of 23 and five of Ranson's prognostic signs. Ranson's signs and APACHE II scores were predictive of success and mortality. We conclude that in selected patients, infected pancreatic and peripancreatic fluid collections can be treated definitively with therapeutic percutaneous catheter drainage. Based on this experience, recommendations regarding patient selection are included. | 4 |
Plaque and structural characteristics of the descending thoracic aorta using transesophageal echocardiography. The in vivo acoustic and structural characteristics of atherosclerosis in the descending thoracic aorta have not been well delineated. We prospectively evaluated the descending thoracic aorta of 147 patients (35 women and 112 men; age, 61 +/- 14 years) who underwent clinically indicated transesophageal echocardiography. Patients with suspected disease of the aorta were excluded. Thirty-eight patients (26%) had protruding plaques (men, 25%; women, 29%). Six patients had mobile intimal densities with the mobile area ranging up to 1 cm2. As expected, aortic lumen area was decreased (plaque-free, 3.53 cm2; plaque, 3.19 cm2; p less than 0.05) and wall area was increased (plaque-free, 1.51 cm2; plaque, 1.92 cm2; p less than 0.05) in the regions of the plaque. However, total arterial area was not increased (plaque-free, 5.04 cm2; plaque, 5.09 cm2; difference not significant) in a compensatory manner as observed in other arterial beds. Plaque gray scale was less than the gray scale of plaque-free wall (plaque-free, 141.2; plaque, 122.7; p less than 0.05) when compared at the same level of the descending thoracic aorta or with a second aortic plaque-free level (plaque-free, 150.4; plaque, 122.7; p less than 0.05). Standard deviation of gray scale level was similar between plaque and normal regions. Unsuspected protruding plaques in the descending thoracic aorta occurred in one quarter of the patients referred for routine transesophageal examination. Plaques tended to have lower echogenicity and were differentiated from plaque-free walls within patients. Plaque formation did not result in increased total arterial area. These data suggest that the degree or character of compensatory atherosclerotic remodeling in the highly elastic descending thoracic aorta may differ from other arterial beds. | 3 |
Treatment of complicated prosthetic aortic valve endocarditis with annular abscess formation by homograft aortic root replacement. The outcome of 30 consecutive patients with active aortic prosthetic valve endocarditis and root abscesses treated by the technique of homograft aortic root replacement with reimplantation of the coronary arteries is detailed. The principles of this technique are the removal of all abscesses and infected areas likely to drain into the infected mediastinum, excision of infected tissues down to healthy noninfected tissue and replacement with an antibiotic-impregnated homograft aortic root. All patients had evidence of progressive cardiac failure and ongoing sepsis. Mean patient age (+/- SD) at the time of operation was 42 +/- 18 years. The mean number of previous aortic valve replacements per patient was 1.6 +/- 0.7; 14 patients (47%) had undergone greater than or equal to 2 previous replacements. At operation, aortic root abscesses were found in all patients; abscess extension to adjacent structures and partial valve dehiscence had occurred in 23. In-hospital death occurred in 9 (30%) of the 30 patients. The 21 hospital survivors have been followed up for a mean of 66 +/- 42 months (range 9 to 144). Overall, 17 (81%) of the 21 hospital survivors have remained free of major adverse events (recurrence of endocarditis, need for reoperation or death). The results of our study suggest that homograft aortic root replacement should be considered favorably in the treatment of patients with aortic prosthetic valve endocarditis and root abscesses. | 3 |
Small bowel phytobezoar mimicking presentation of Crohn's disease. A case of small bowel phytobezoar formed from unusual ingested vegetation is described. The patient presented with recurrent subacute obstruction and a right iliac fossa mass mimicking the presentation of Crohn's disease. None of the usual gastrointestinal disorders that predispose to bezoar formation were present. The phytobezoar passed spontaneously following small bowel enema and colonoscopy. It is possible that relaxation of the gut secondary to the antispasmodics administered at investigation or the physical disturbance during these procedures enabled migration through the ileocecal valve. Antispasmodics may be of use in the conservative management of bezoars obstructing otherwise normal bowel. | 1 |
Squamous cell carcinoma of prostate. A primary squamous cell carcinoma occurring in the prostate of a sixty-nine-year-old man is described. A radical excision that included cystoprostatectomy, total penectomy, scrotectomy, pubic symphysiectomy, and abdominoperineal resection of rectum was done. The patient died of systemic metastases six months after diagnosis. Review of the literature suggests that such a cancer of the prostate is rare, highly aggressive, and responds poorly to any mode of therapy. Histogenesis of this tumor remains controversial; however, it probably does not originate from the prostatic acinar cells. | 0 |
Intratumoral oxygen pressure in malignant brain tumor. Oxygen pressure (pO2) in brain tumors, pO2 in brain cortex surrounding the tumors, and PaO2 were measured simultaneously during total resection in 16 patients with previously untreated brain tumors in order to detect hypoxic regions within the tumors. When the inhaled O2:N2O ratio was 1:3 under enflurane anesthesia, mean PaO2 was 109.2 +/- 5.8 mm Hg, a rather high value when compared with that obtained when air is inhaled under atmospheric pressure. The simultaneously measured intratumoral pO2 and pO2 in brain cortex surrounding the tumor were 15.3 +/- 2.3 and 59.8 +/- 6.5 mm Hg, respectively. Each intratumoral pO2 value was significantly lower than that of pO2 in brain cortex surrounding the tumor (mean less than 30 mm Hg, Wilcoxon signed rank test, p less than 0.005) and influenced the oxygen effects on radiation. These results appear to confirm that there are hypoxic regions within human brain tumors. A comparison between intratumoral pO2 and either the angiographic or contrast-enhanced computerized tomography scans of the tumor vasculature disclosed no correlation. | 0 |
Safe performance of difficult laparoscopic cholecystectomies. Laparoscopic cholecystectomy has been advocated for the treatment of uncomplicated symptomatic gallstone disease, but has not been widely advocated for the management of more complicated gallbladder disease such as acute cholecystitis, previous surgery, or common duct stones. During the last 9 months, 360 patients underwent laparoscopic removal of their gallbladder. A total of 138 had a complicated presentation, making surgery more difficult. This article discusses the management of these patients with acute cholecystitis, previous surgery, or common duct disease. Using the described techniques, there were no complications or mortality. Laparoscopic management of difficult gallbladder problems is safe and effective. | 1 |
Antinuclear antibodies in sera of patients with recurrent pregnancy wastage. Four groups of women were studied to determine whether low-level antinuclear antibody titers are associated with a higher risk for pregnancy loss. Group A consisted of 30 patients with a history of unexplained fetal losses. Group B consisted of 30 women with "explained" fetal losses (e.g., uterine septum or luteal phase defect). Ages and number of losses were comparable between the women in groups A and B. Group C consisted of 61 healthy pregnant women. Group D involved 61 healthy nonpregnant women of reproductive age. In groups A and B, 40% and 53.3% of the respective patients had antinuclear antibody titers greater than or equal to 1:40. In groups C and D the frequencies of positive antinuclear antibody titers were 8.2% and 5.6%, respectively. This study demonstrates a high prevalence of low-titer antinuclear antibody-positive serum in patients with explained and unexplained pregnancy losses. | 4 |
Primary adrenal insufficiency: a new cause of reversible gastric stasis. Primary adrenal insufficiency is known to cause a wide spectrum of sometimes severe upper gastrointestinal symptoms; however, it has not previously been shown to be the cause of reversible gastric stasis. We have documented such a case in which the symptoms and physiologic abnormalities associated with gastric stasis were reversed by steroid replacement. A follow-up radionuclide gastric-emptying study after physiologic steroid replacement showed complete normalization of gastric emptying. Although gastric stasis has long been suspected of being present with primary adrenal insufficiency, this represents the first case in which it has been documented, and so should be included in the differential diagnosis of patients presenting with chronic nausea and vomiting. | 1 |
Sumatriptan in acute migraine: pharmacology and review of world experience. The introduction of sumatriptan, a novel abortive antimigraine agent, has generated a significant amount of preclinical and clinical interest during the past few years. At the scientific level, sumatriptan is unique in terms of its selective pharmacological properties. The effects of sumatriptan in various experimental paradigms have led to new insights into the pathophysiology of migraine. At the clinical level, sumatriptan appears to be an effective abortive anti-migraine agent with minimal side effects. Its ability to decrease, rather than exacerbate, the nausea and vomiting of migraine appears to be an important advance in the treatment of migraine. | 2 |
New approaches to the diagnosis, prevention, and treatment of cytomegalovirus infection after transplantation. Infection occurring after solid organ transplantation continues to exert a considerable detrimental effect upon patient and allograft survival. While the search for better targeted immunosuppressive regimens continues, we must seek to improve our ability to both diagnose and treat those infections that do occur after transplantation. Viral infections in general, and cytomegalovirus (CMV) infections in particular, represent an area in which substantial progress is being made. Improvement in diagnostic modalities has allowed more rapid and precise identification of CMV infection and disease, and the use of antiviral agents that possess activity against CMV has allowed both prophylaxis and treatment of this frequently life-threatening disease. The prophylactic use of presently available agents in combination and the development of less toxic, more potent anti-CMV agents should serve to further lessen the impact of CMV disease upon the field of solid organ transplantation. | 4 |
Alcohol consumption--a risk factor for hemorrhagic and non-hemorrhagic stroke. PURPOSE: The risks of alcohol consumption and its association with stroke were studied in 621 patients with stroke and 573 control subjects using case-control methods. PATIENTS AND METHODS: Patients with stroke were subdivided into 193 with subarachnoid hemorrhage, 91 with intracerebral hemorrhage, and 337 with cerebral infarction. Data on recent alcohol consumption were obtained by questionnaire in patients with stroke and compared with data from an occupational screening survey in control subjects. RESULTS: Relative risks, adjusted for confounding variables, exhibited J-shaped associations with increasing levels of alcohol consumption classified into four categories--abstainer, 1 to 90 g, 100 to 390 g, and greater than or equal to 400 g weekly). The individual risks were 1, 0.7, 0.5, and 1.3 for subarachnoid hemorrhage; 1.0, 0.6, 0.5., and 2.5 for intracerebral hemorrhage, and 1.0, 0.6, 0.7, and 2.4 for cerebral infarction for men and women combined. CONCLUSIONS: The results suggest that low levels of alcohol consumption may have some protective effect upon the cerebral vasculature, whereas heavy consumption predisposes to both hemorrhagic and non-hemorrhagic stroke. | 3 |
Carotid-subclavian bypass--a decade of experience. From August 1979 to August 1989, carotid-subclavian bypass or transposition procedures were performed on 18 women and 13 men ranging in age from 19 to 75 (mean, 58.2) years. Indications for surgery included symptoms of vertebrobasilar insufficiency in 16 (52%), upper extremity ischemia in six (19%), both vertebrobasilar insufficiency and extremity ischemia in four (13%), and stroke and/or hemispheric transient ischemic attacks in four (13%) patients. One patient (3%) had angina pectoris caused by "coronary-subclavian steal." Formal bypass grafts were performed in 28 (90%) cases by means of polyterafluoroethylene (24), Dacron (2), or saphenous vein (2), and carotid-subclavian transposition was performed in three (10%) cases. Synchronous procedures included carotid endarterectomy (4), carotid-carotid bypass (1), and axillobrachial bypass (1). There was no operative mortality. Thirty-day primary patency was 97%. Follow-up has ranged from 1 to 121 (mean, 42) months. Three grafts (polytetrafluoroethylene) have occluded during follow-up yielding long-term primary patency of 92% at 5 years and 83% at 8 years. Relief of symptoms was initially achieved in 30 (97%) patients. Recurrent symptoms have developed in six (20%) patients from 2 to 55 (mean, 26) months after surgery, including two with occluded and four with patent grafts. Symptom-free survival is 89% at 1 year, 84% at 2 years, and 71% at 7 years of follow-up. Six patients have died during follow-up yielding overall survival of 88% at 5 years, and 48% at 10 years. | 4 |
Clinical evaluation of plasma abnormal prothrombin (des-gamma-carboxy prothrombin) in hepatobiliary malignancies and other diseases. Des-gamma-carboxy prothrombin (DCP), a protein induced by vitamin K absence or antagonist-II (PIVKA-II) was measured in the plasma of patients with primary hepatocellular carcinoma and those with various other hepatobiliary and pancreatic diseases. DCP levels were determined by enzyme immunoassay (E-1023), using an anti-DCP monoclonal antibody. Forty-two of the 91 patients (46.2%) with hepatocellular carcinoma had abnormally elevated levels of DCP, whereas only one of the 24 patients with hepatic cirrhosis showed a slight increase. An increase was also observed in some patients with obstructive jaundice. There was no correlation between plasma levels of DCP and those of serum alpha-fetoprotein (AFP). In most patients with hepatocellular carcinoma, plasma DCP levels normalized after curative surgical resection. Plasma DCP levels were not related to the plasma concentration of vitamin K in the patients with hepatocellular carcinoma. Plasma DCP determination may be useful in the diagnosis and postoperative monitoring of the response of hepatocellular carcinoma. | 0 |
Was CEPOD right? This retrospective study found that the long-term (greater than 6 months) postoperative survival in ASA 4E and 5E patients was 41% and 21% respectively, in 1986. This supports the Confidential Enquiry into Peri-operative Deaths' recommendation that life-saving surgery should not be withheld from patients who present in so serious a condition that they are unlikely to survive surgery. | 4 |
Sudden blindness after thermocoagulation of the trigeminal ganglion. Sudden blindness during percutaneous thermocoagulation of the gasserian ganglion occurred in a 72-year-old woman with trigeminal neuralgia. Considered a safe procedure, we highlight the possibility of this serious complication which was probably due to direct damage of the optic nerve. | 2 |
Coronary pathology predicts conduction disturbances after coronary artery bypass grafting. Conduction disturbances after coronary artery bypass grafting may result from compromised septal blood flow. To examine this hypothesis we reviewed the preoperative coronary angiography of 55 consecutive patients undergoing coronary artery bypass grafting. Thirty-five patients had either no lesion or a discrete lesion in the left anterior descending coronary artery that did not include the septal perforator (type I anatomy). Twenty patients had a lesion of the left anterior descending coronary artery at the origin of the first septal branch, a lesion of the first septal artery, or a pair of lesions in the left anterior descending coronary artery that straddled the origin of the first septal artery; all lesions were proximal to the graft site (type II anatomy). None of the patients with type I anatomy had a major conduction disturbance after coronary artery bypass grafting. Eleven of the patients with type II anatomy had major conduction disturbances after coronary artery bypass grafting; right bundle-branch block in 1, right bundle-branch block and left anterior hemiblock in 2, left bundle-branch block in 5, and complete atrioventricular block that required pacemaker implantation in 3 (p less than 0.001). In the 20 patients with type II anatomy, the appearance of conduction disturbances correlated well with the absence of retrograde flow to the septal branches from the right coronary artery (p less than 0.01). Pathological lesions in the left anterior descending coronary artery that compromise flow in the first perforator and that do not provide an adequate circulation produce localized damage and conduction disturbances after coronary artery bypass grafting. This can be predicted from the preoperative angiographic anatomy. | 3 |
Suboptimal response to hepatitis B vaccine in drug users. Fifty-five drug users institutionalized in a community for drug detoxification were vaccinated against hepatitis B virus (HBV) with a recombinant yeast-derived vaccine (Engerix B, Smith Kline Biologicals, Belgium). At 0, 1, and 6 months, 20 micrograms of vaccine was given in the deltoid to these patients, of whom 17 had no serum HBV markers, 15 had only the antibody to core antigen (anti-HBc), and 23 had anti-HBc and antibody to the surface antigen (anti-HBs) values lower than the allegedly "protective" value of 10 mIU/mL. Forty-one healthy controls were vaccinated in parallel. At month 7 (ie, 1 month after the third dose of vaccine), in 76% (13/17) of drug users with no HBV markers, 6% (1/15) of those with isolated anti-HBc, and 69% (16/23) of those with anti-HBc and nonprotective anti-HBs, protective anti-HBs titers (greater than or equal to 10 mIU/mL) developed, compared with 97% (40/41) of controls. At month 24, these rates fell to 43% for drug users with no HBV marker, 0% for those with anti-HBc, 31% for those with anti-HBc and anti-HBs, and 86% for controls. The drug users who did not respond to vaccination were more likely to be those with evidence of prior HBV infection and anergy to skin tests. This indicates that unresponsiveness to hepatitis B vaccine in drug users may be due to altered immunity. | 1 |
Early hospital discharge of children with cancer treated for fever and neutropenia: identification and management of the low-risk patient. Children with leukemia and solid tumors are often hospitalized for empiric broad-spectrum antibiotic therapy because of fever during periods of chemotherapy-induced neutropenia. Conventional practice dictates that parenteral antibiotics be continued until the patient is afebrile and has recovered from neutropenia, ie, until the absolute neutrophil count (ANC) exceeds 500 cells per cubic millimeter. However, the practice in our center has been to discontinue parenteral antibiotic therapy and discharge many such patients before resolution of neutropenia. Since the feasibility and safety of this approach has not been studied, we reviewed the records of 114 consecutive hospitalizations for fever and neutropenia in 61 patients during a 13-month period. Seventy-seven children (68%) were discharged to their homes while still neutropenic after they had been afebrile for 1 to 2 days on parenteral antibiotics, had negative blood cultures, appeared well, and usually had some evidence of bone marrow recovery. Five patients (4.4%) developed recurrent fever and required rehospitalization within 7 days of discharge. Only three of the 77 patients (3.9%) who were sent home with neutropenia had recurrent fever. Each had a brief and uneventful second hospitalization. Two of the 37 children discharged with an ANC over 500 cells per cubic millimeter required rehospitalization. A declining ANC and advanced malignancy were risk factors in predicting recurrence of fever following discharge. A rising monocyte count was a predictor of imminent recovery from neutropenia. These results suggest that "early" discharge of an afebrile yet still neutropenic patient is safe when the patient is in remission, has no evidence of serious infection, appears clinically stable, and has indications of bone marrow recovery. The conventional approach of routinely continuing the hospitalization until resolution of neutropenia may be unnecessary in such low-risk patients. | 4 |
Use of Mohs micrographic surgery to establish quantitative proof of heightened tumor spread in basal cell carcinoma recurrent following radiotherapy. We compared 27 basal-cell carcinomas (BCCs) recurrent following radiotherapy and subsequently excised by Mohs micrographic surgery to a control group of BCCs recurrent following other treatment modalities and similarly excised. Mohs technique permitted precise, quantitative tumor assessment, obtained via a novel method utilizing three parameters: the number of surgical stages required for complete excision, the percentage increase between clinical preoperative tumor area and final postoperative defect area, and the presence of deep subcutaneous tissue invasion. Figures for the postradiation group were larger in all three categories, with the latter two revealing statistically significant differences versus the nonradiation group. This study gives strong, direct quantitative support to the clinical impression that BCC recurrent following radiotherapy is a uniquely aggressive, invasive subset of recurrent BCC. | 0 |
Neuroacanthocytosis. A clinical, haematological and pathological study of 19 cases. Nineteen cases are described, including 12 cases from three different families and 7 nonfamilial cases, in which multisystem neurological disease was associated with acanthocytosis in peripheral blood and normal plasma lipoproteins. Mild acanthocytosis can easily be overlooked, and scanning electron microscopy may be helpful. Some neurologically asymptomatic relatives with significant acanthocytosis were identified during family screening, including some who were clinically affected. The mean age of onset was 32 (range 8-62) yrs and the clinical course was usually progressive but there was marked phenotypic variation. Cognitive impairment, psychiatric features and organic personality change occurred in over half the cases, and more than one-third had seizures. Orofaciolingual involuntary movements and pseudobulbar disturbance commonly caused dysphagia and dysarthria that was sometimes severe, but biting of the lips or tongue was rarely seen. Chorea was seen in almost all symptomatic cases but dystonia, tics, involuntary vocalizations and akinetic-rigid features also occurred. Two cases had no movement disorder at all. Computerized tomography often demonstrated cerebral atrophy. Caudate atrophy was seen less commonly, and nonspecific focal and symmetric signal abnormalities from the caudate or lentiform nuclei were seen by magnetic resonance imaging in 3 out of 4 cases. Depression or absence of tendon reflexes was noted in 13 cases and neurophysiological abnormalities often indicated an axonal neuropathy. Sural nerve biopsies from 3 cases showed evidence of a chronic axonal neuropathy with prominent regenerative activity, predominantly affecting the large diameter myelinated fibres. Serum creatine kinase activity was increased in 11 cases but without clinical evidence of a myopathy. Postmortem neuropathological examination in 1 case revealed extensive neuronal loss and gliosis affecting the corpus striatum, pallidum, and the substantia nigra, especially the pars reticulata. The cerebral cortex appeared spared and the spinal cord showed no evidence of anterior horn cell loss. Two examples of the McLeod phenotype, an X-linked abnormality of expression of Kell blood group antigens, were identified in a single family and included 1 female. The genetics of neuroacanthocytosis are unclear and probably heterogeneous, but the available pedigree data and the association with the McLeod phenotype suggest that there may be a locus for this disorder on the short arm of the X chromosome. | 2 |
Association of Escherichia coli HEp-2 adherence patterns with type and duration of diarrhoea. 373 (59%) out of 636 faecal specimens obtained during the first 2 years of life of 72 Mexican children yielded adherent Escherichia coli (HEp-2 cells). Strains with localised adherence were significantly associated with acute non-bloody diarrhoea, whereas strains with aggregative adherence were significantly associated with persistent diarrhoea. Half the strains with localised adherence were not enteropathogenic E coli serotypes nor did they hybridise with an enteropathogenic E coli adherence factor DNA probe. All strains with localised adherence gave a positive fluorescent actin staining (FAS) assay, irrespective of serotype. One-third of children colonised by aggregative strains had bloody diarrhoea. Isolation of strains with diffuse adherence was not related to type or duration of diarrhoea but was generally associated with isolation of another pathogenic organism. | 4 |
Do life events or depression exacerbate inflammatory bowel disease? A prospective study. OBJECTIVE: To determine whether depressed mood or life events are associated with an exacerbation of inflammatory bowel disease. DESIGN: A prospective study of a consecutive sample of patients with relapsing inflammatory bowel disease, followed by monthly questionnaires and periodic office visits. SETTING: A referral-based gastroenterology clinic at a medical school. PATIENTS: A consecutive sample of 32 patients with inflammatory bowel disease who had had at least one relapse in a 2-year period after entry into the study. MEASUREMENTS AND MAIN RESULTS: The Social Readjustment Rating Scale (measuring life events), the Beck Depression Inventory (a visual analog scale for depressed mood) and an inventory of intestinal symptoms were completed monthly by each subject with a 78% rate of compliance. A mean of 2.2 exacerbations was seen per subject during the study period. Life events were not temporally associated with changes in intestinal symptoms. Significant associations were found between intestinal symptoms and the two mood scales (P less than 0.05 for each), but no directionality in symptom occurrence could be detected in a time-lagged analysis. The results were similar when the months preceding exacerbations of inflammatory bowel disease were analyzed separately. CONCLUSIONS: Although these findings suggest that mood changed concurrently with exacerbation of inflammatory bowel disease, no evidence indicated that stressful life events or depressed mood precipitated exacerbations in this study group. | 1 |
Studies of controlled reperfusion after ischemia. XXIII. Deleterious effects of simulated thrombolysis preceding simulated coronary artery bypass grafting with controlled blood cardioplegic reperfusion. This study tests whether simulated thrombolysis before controlled reperfusion (i.e., simulated coronary artery bypass) causes reperfusion injury that obviates the benefits of subsequent controlled reperfusion and results in unnecessary ventricular arrhythmias. Fifteen dogs underwent acute occlusion of the left anterior descending coronary artery. In 10 dogs we simulated thrombolysis after 1 hour of ischemia (delivering 10% to 15% of control flow at 5 ml/min), followed 1 hour later by either normal blood reperfusion at systemic pressure (to simulate percutaneous transluminal coronary angioplasty) in five dogs or regionally controlled blood cardioplegic reperfusion on bypass in five others to simulate coronary bypass. In five dogs ischemia was prolonged to 2 hours, and the initial reperfusate was blood cardioplegic solution on total vented bypass (to simulate primary coronary bypass). All hearts receiving simulated thrombolysis (100%) after 1 hour of ischemia had reperfusion-induced ventricular fibrillation. All hearts treated by simulated angioplasty recovered regional contractility (56% of control systolic shortening), whereas there was no (0%) recovery of spontaneous contractility after subsequent blood cardioplegic reperfusion, and only two (40%) dogs had contractile reserve capacity (6% +/- 49%). Conversely, surgically controlled blood cardioplegic reperfusion without preceding low-flow normal blood reperfusion after 2 hours of ischemia resulted in no ventricular arrhythmias (0%; p less than 0.05 versus simulated coronary artery bypass after simulated thrombolysis), 72% +/- 7% (p less than 0.05 versus simulated coronary artery bypass after simulated thrombolysis) recovery of regional contractility (ultrasonic crystals), and 114% +/- 11% (p less than 0.05 versus simulated coronary artery bypass after simulated thrombolysis) recovery of contractile reserve with calcium chloride stimulation. We conclude that controlled reperfusion (simulating coronary artery bypass) with blood cardioplegic solution produces immediate functional recovery and avoids the ventricular fibrillation that follows simulated thrombolysis despite the need for prolonged ischemic time. Preceding controlled reperfusion by normal blood reperfusion (simulated thrombolysis) shortens the ischemic time but nullifies immediate functional recovery possible by simulated coronary bypass and produces unnecessary arrhythmias. | 4 |
Seven-pathogen tricuspid endocarditis in an intravenous drug abuser. Pitfalls in laboratory diagnosis. Polymicrobial endocarditis is being reported with increasing frequency in drug abusers. However, the full extent of infection may be unrecognized with routine blood culture techniques because of the overgrowth of more fastidious organisms by other pathogens. This report documents an intravenous drug abuser with the first reported case of tricuspid valve endocarditis involving seven pathogens, discusses pitfalls of routine blood cultures and examines the role of the laboratory in microbiologic diagnosis. | 3 |
Sympathetic neural adjustments to stress in physically trained and untrained humans. The purpose of this study was to determine if the state of physical training influences sympathetic neural activation during acute stress in humans. We recorded muscle sympathetic nerve activity (microneurography of the peroneal nerve), arterial blood pressure, and heart rate in 12 highly trained, endurance athletes (25 +/- 1 years, mean +/- SEM) and 12 untrained subjects (27 +/- 1 years) before (supine rest control) and during: 1) lower body negative pressure at -5, -10, -15, and -20 mm Hg (orthostatic stress); 2) isometric handgrip at 30% of maximum (exercise stress); and 3) hand immersion in ice water, that is, the cold pressor test (thermal stress). Body weight was not different in the two groups, but the athletes had a lower body fat content (8.9 +/- 1.3% versus 16.1 +/- 2.0%, p less than 0.05). During supine rest, muscle sympathetic nerve burst frequency (24 +/- 3 versus 24 +/- 2 bursts/min, athletes versus untrained subjects) and burst incidence (36 +/- 3 versus 44 +/- 4 bursts/100 heart beats) and arterial blood pressure were not different in the two groups, but heart rate was lower in the athletes (54 +/- 2 versus 67 +/- 3 beats/min, p less than 0.05). | 4 |
Prospective randomized comparison of Brown-McHardy and microvasive balloon dilators in treatment of achalasia. We report the results of a randomized prospective study comparing a standard bougie rubber balloon dilator [Brown-McHardy (BMH)] and a newer polyethylene dilator passed over a guide wire [Microvasive Rigiflex (MVR)]. Twenty achalasia patients (15M, 5F, mean age 45.4 yr) considered candidates for either dilator were randomized. Symptom assessment, body weight, and upright radionuclide solid esophageal emptying study were measured before and 6 months after pneumatic dilatation. All dilatations were performed by one of three experienced gastroenterologists under fluoroscopic guidance. Overall success occurred with 10/10 BMH and 7/10 MVR. One patient not improved with MVR had myotomy; the other two were successfully treated by BMH. No complications occurred with either dilator. | 1 |
Magnetic resonance imaging of facial nerve neuromas. Facial nerve neuromas are uncommon tumors often confused with other tumors of the temporal bone and cerebellopontine angle. Radiologically, it may be impossible to differentiate an intracanalicular facial nerve neuroma from an acoustic neuroma. We present three case reports of facial nerve neuromas arising within the internal auditory canal to show the important magnetic resonance imaging features of these tumors. One tumor extended into the cerebellopontine angle, middle cranial fossa, and middle ear. Another filled the internal auditory canal and extended through the cerebellopontine angle to the brain stem. The third occurred in a patient who had neurofibromatosis as well as numerous other intracranial tumors. We feel that gadolinium-enhanced magnetic resonance imaging provides the most useful information in the preoperative assessment of this disorder. | 0 |
Shared idiotype expression by chronic lymphocytic leukemia and B-cell lymphoma. Antiidiotype (Id) antibodies identify unique determinants within the surface immunoglobulin (Ig) that are present on B-cell tumors. Anti-Ids have been used for diagnosis and therapy of B-cell lymphoma and leukemia. A panel of 29 anti-Id monoclonal antibodies (MoAbs) that recognize shared idiotypes (SIds) on B-cell lymphomas was tested for reactivity with both B-cell leukemias and lymphomas. Ten of 40 (25%) cases of chronic lymphocytic leukemia (CLL) reacted with at least one of the 29 anti-SId MoAbs. Three cases reacted with more than one anti-SId MoAb, but there was no repetitive pattern of a single anti-SId MoAb reacting with a large proportion of CLL cases. In contrast, for B-cell lymphoma, in which 11 of 31 (36%) cases reacted, one anti-SId (B4-1) reacted with five of the positive cases; all were diffuse histology. Restricted anti-SId reactivity may lead to important insights into the etiology of certain B-cell lymphomas. In addition, these anti-SIds may obviate the need to develop "tailor-made" antibodies for individual patients. | 0 |
Myocardial sulfhydryl pool alterations occur during reperfusion after brief and prolonged myocardial ischemia in vivo. Myocardial sulfhydryl (SH)-containing compounds, including reduced glutathione (GSH), are both defenses against and potential markers of reactive oxygen metabolite injury during ischemia and reperfusion. We examined the alterations in GSH and other myocardial SH pools during reperfusion in anesthetized dogs exposed to brief (15 minutes, n = 7) or prolonged (90 minutes, n = 6) regional ischemia caused by occlusion of the left anterior descending artery. Ninety minutes of ischemia followed by 5 hours of reperfusion, which resulted in myocardial necrosis of 43.9 +/- 4.0% of the area at risk, caused a 22% reduction in total myocardial SH groups (p less than 0.01), a 57% decrease in nonprotein myocardial SH groups (p less than 0.01), a 56% decrease in GSH (p less than 0.01), and a 62% decrease in non-GSH, nonprotein SH groups (p less than 0.02). However, protein SH groups were not significantly reduced (12% decrease, p = NS). Also, myocardial release of GSH and oxidized glutathione (GSSG) into the coronary venous effluent occurred during early reperfusion. In contrast, 15 minutes of ischemia, followed by 30 minutes of reperfusion, did not alter myocardial total SH groups, protein SH groups, or GSH (9% decrease, p = NS); nor was there reperfusion release of GSH or GSSG. However, even with brief ischemia, nonprotein SH groups decreased 23% (p less than 0.05), due mainly to a 59% decrease in the non-GSH, nonprotein SH pool (p less than 0.05). These changes after brief ischemia occurred without alterations in myocardial GSSG or the GSH/GSSG ratio. | 3 |
Magnetic resonance angiography of abdominal vessels: early experience using the three-dimensional phase-contrast technique. Based on three-dimensional acquisition of three sequences sensitive to one flow-direction, abdominal magnetic resonance phase-contrast angiography (MRA) was performed in 13 volunteers and 20 patients. The subjects received no antiperistaltic medication and were allowed to breath normally during the three acquisition periods of 11 minutes. The frequency of demonstration of the normal aorta, superior mesenteric and right and left renal arteries was 100%/100%/91%/100%, and of the inferior vena cava, splenic, superior mesenteric and portal veins was 92%/67%/92%/100%, respectively, whereas other abdominal vessels were seen less constantly. In renal artery stenosis or occlusion, MRA detected eight out of nine pathological arteries, missed only a minimal stenosis and was never false positive. In all 10 cases of portal hypertension, MRA demonstrated the venous collaterals detected by conventional angiography and in six cases showed more collaterals, particularly paravertebral vessels. A Budd-Chiari syndrome was investigated as well. If the accuracy of MRA can be proved in larger studies, it may become an important diagnostic tool in evaluating abdominal vascular pathology, such as renal artery stenosis or portal hypertension. | 1 |
Preoperative selection for curable renovascular hypertension. Clinical research has defined the criteria for identifying "curable" renovascular hypertension. The prediction is based on the measurement of plasma renin activity in peripheral veins, renal veins, and the aorta. Renin profiles can be examined with the method of Laragh and coworkers (the so-called incremental method), in which values for plasma renin activity are incorporated into formulas to compute indexed parameters. A score is attributed to each index and the prediction is based on the final score. Because the identification of curable renovascular hypertension is made according to numerical rules, the method is easily transformed into a computer-assisted process. The program is written in BASIC, and it is short enough to run on a personal computer. | 3 |
Survival of premenopausal women with metastatic breast cancer. Long-term follow-up of Eastern Cooperative Group and Cancer and Leukemia Group B studies. In premenopausal women with metastatic breast cancer, differences in survival curves early during follow-up can be misleading. The authors therefore analyzed long-term survival in 378 patients, entered in three randomized trials, started between 1973 and 1978. Combined data from the three trials were used to increase the power for identifying prognostic variables. Cancer and Leukemia Group B (CALGB) trial 7382 randomized patients to oophorectomy plus either cyclophosphamide or combination chemotherapy or observation. Eastern Cooperative Oncology Group (ECOG) 2174 randomized patients who had not progressed 3 months after oophorectomy to combination chemotherapy or combination chemotherapy or observation. Trial ECOG 2177 randomized estrogen receptor (ER) positive or ER-unknown patients to oophorectomy plus combination chemotherapy or immediate combination chemotherapy, and ER-negative patients were directly assigned to combination chemotherapy. Hence ER-negative patients need not have been healthy enough to be randomized to oophorectomy. With only 14% of the patients still alive, median survival on the three studies was 30, 24, and 28 months. The median survival of individual treatments changed noticeably in ECOG 2174 and ECOG 2177 with long-term follow-up. At this time there are no differences in survival between randomized regimens in any of the three trials. In a multivariate model, factors associated with significantly poorer survival were visceral-dominant disease, nodal metastases, breast metastases, age younger than 45 years, ER negativity, and not receiving chemotherapy immediately after oophorectomy. This treatment difference was thus not due to imbalances in the prognostic variables used in the model, but it may be due to imbalances of unknown prognostic factors or differences in patient selection. | 4 |
Heterotopic tissue in lymph nodes. An unrecognized problem. Heterotopic tissue in lymph nodes is both unknown to clinicians and a potential source of confusion with metastatic disease. We reviewed the English literature and found 289 cases of heterotopic tissue in lymph nodes. The majority (84%) of these patients were operated on for malignant neoplasms. The most frequent sites of occurrence was the pelvis (67%), followed by the axilla (14%), neck (14%), groin (3%), abdomen (2%), and mediastinum (less than 1%). The tissue seen is site-specific and frequently resembles a neighboring organ. Three cases have been reported in which heterotopic tissue was mistaken for metastatic disease. These cases illustrate the importance of being familiar with heterotopic tissue in lymph nodes and identifying it when it does occur, to avoid inappropriate therapy. | 4 |
Four-part valgus impacted fractures of the proximal humerus. There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury. | 4 |
Dysgerminoma of the ovary: review of 27 cases. Twenty-seven patients with pure dysgerminoma were seen at the Tata Memorial Hospital, Bombay, between January 1980 and December 1984. Of the 10 patients in stage I, 2 patients underwent a unilateral salpingoophorectomy (USO) and were kept under observation without any adjuvant therapy, while the remaining patients received adjuvant treatment following surgery. All of the 6 patients in stage II and 4 of 7 in stage III had total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) followed by postoperative radiotherapy. One patient presented in stage IV and 3 patients presented with recurrence after previous definitive treatment undertaken at other institutions. The disease free, as well as the overall survival, at 108 months, for the 24 cases primarily treated at this institution, is 81% and 88% respectively, and, for patients in stages I and II, 100% (Kaplan-Meier estimation). The need for controlled clinical trials to devise optimal therapy in the early clinical stages and use of chemotherapy for advanced stages of this highly curable entity are stressed. | 4 |
Cystic dilatation of the cystic duct: a new type of biliary cyst. A case of a patient with a congenital cyst that was localized solely to the cystic duct is presented. We propose including this anomaly in the biliary cyst classifications, which currently include choledochal and intrahepatic and extrahepatic biliary cysts. The diagnosis and management of this new type of cyst in addition to other types of biliary cysts are discussed. | 0 |
Nerve growth factor prevents toxic neuropathy in mice. Taxol is a promising new antitumor drug with therapeutic use that is limited by a toxic sensory neuropathy. Taxol is also cytotoxic to dorsal root ganglion neurons in vitro, but this effect is prevented by cotreatment with the trophic protein, nerve growth factor. We sought to develop an animal model and then to determine whether nerve growth factor can prevent taxol neuropathy in vivo. Administration of taxol to mice resulted in a profound sensory neuropathy characterized by decreases in dorsal root ganglion content of the peptide neurotransmitter, substance P, elevated threshold to thermally induced pain, and diminished amplitude of the compound action potential in the caudal nerve. Coadministration of nerve growth factor prevented all of these signs of neurotoxicity. These findings suggest that administration of nerve growth factor may prevent certain toxic sensory neuropathies. | 2 |
Long-term follow-up in toxic solitary autonomous thyroid nodules treated with radioactive iodine The long-term effects of radioiodine treatment on thyroid function in patients with a toxic solitary autonomous thyroid nodule were evaluated. Fifty-two patients received a therapeutic dose of 20 mCi of iodine-131 (131I). Duration of follow-up was 10 +/- 4 yr. Follow-up data included a biochemical evaluation of thyroid function. The failure rate (recurrent hyperthyroidism) was 2%. The incidence of hypothyroidism was 6% and was not related to the dose per gram of nodular tissue. Oral administration of 20 mCi of radioiodine is a simple and highly effective method for the treatment of patients with a toxic autonomous thyroid nodule. The risk of development of hypothyroidism is low if extranodular uptake of 131I is prevented. This can be achieved by not treating euthyroid patients, by no longer using injections of exogenous thyroid stimulating hormone in the diagnostic work-up of the patients and by always performing radioiodine imaging shortly before treatment. | 4 |
Vaccination against tumor cells expressing breast cancer epithelial tumor antigen. Ninety-one percent of breast tumors aberrantly express an epithelial tumor antigen (ETA) identified by monoclonal antibody H23. Vaccinia virus recombinants expressing tumor antigens have considerable promise in the active immunotherapy of cancer, and we have evaluated the potential of vaccinia recombinants expressing the secreted (S) and cell-associated (transmembrane, T) forms of H23 ETA to elicit immunity to tumor cells expressing ETA. Tumorigenic ras-transformed Fischer rat fibroblast lines FR-S and FR-T, expressing the S or T form of H23 ETA, respectively, were constructed for use in challenge experiments. Expression of H23 ETA in these lines was confirmed by Western blotting and immunofluorescence. When challenged by subcutaneous seeding of tumor cells, 97% (FR-S) and 91% (FR-T) of syngeneic Fischer rats rapidly developed tumors that failed to regress. Vaccination with recombinant vaccinia virus expressing ETA-T prior to challenge prevented tumor development in 82% of animals seeded with FR-T cells but in only 61% of animals seeded with FR-S. The vaccinia recombinant expressing the S form was a less effective immunogen, and vaccination protected only 29-30% of animals from developing tumors upon challenge with either FR-S or -T cells. The increased immunogenicity of the recombinant expressing ETA-T was reflected in elevated levels of ETA-reactive antibody in vaccinated animals, confirming that secreted antigens expressed from vaccinia virus are less effective immunogens than their membrane-associated counterparts. | 0 |
Characteristics of oculomotor disorders of a family with Joseph's disease. The oculomotor abnormalities of 12 patients of a large Japanese family with Joseph's disease were investigated and compared with those of 27 patients with olivopontocerebellar atrophy (OPCA). All 12 patients had limitation of upward gaze, impairment of convergence and horizontal gaze nystagmus. However, none had abnormalities of pupillary shape or light reflexes. Impairments of saccadic and pursuit eye movements were frequently present. Further, difficulty of eyelid opening, bulging eyes, impairment of optokinetic and caloric responses and square wave jerks were seen in some of the patients. The autopsy examination of 1 patient revealed marked neuronal loss in the oculomotor nucleus with preservation of the Edinger-Westphal nucleus and neuronal decrease, myelin loss and gliosis of the dorsal midbrain including superior colliculus, pretectum and posterior commissures. Disturbance of upward gaze, sparing of pupillary light reflexes and horizontal gaze nystagmus were frequent and early symptoms. The pattern of oculomotor disturbances is different from that of OPCA and evaluation of the oculomotor system is useful for clinical diagnosis of the disease. | 4 |
Intraoperative scintigraphy for active small intestinal bleeding. Localizing active sites of bleeding within the small intestine remains a difficult task. Endoscopic, angiographic or scintigraphic studies may point to the small intestine as the site of blood loss, but at operation, without a palpable lesion, the exact site of bleeding remains elusive. Patients are managed at laparotomy with intraoperative endoscopy, angiography, multiple enterotomies, "blind" resections, or placement of an enterostomy. We describe two patients in whom intraoperative scintigraphy accurately identified active sites of bleeding in the small intestine when other modalities failed. Intraoperative scintigraphy is rapid, easy to perform and is an effective means of identifying active sites of bleeding within the small intestine. | 1 |
Venous and arterial thrombosis in patients who received adjuvant therapy for breast cancer. The records of 2,673 patients randomized according to seven consecutive Eastern Cooperative Oncology Group (ECOG) studies of adjuvant therapy for breast cancer were reviewed for the occurrence of vascular complications. All protocols opened and closed between June 1977 and July 1987. The objectives of the present study were (1) to compare the frequency of vascular complications among patients who received adjuvant therapy for breast cancer with patients on observation, and (2) to estimate the contribution of chemotherapy and hormonal therapy to the occurrence of venous and arterial thrombi. The frequency of thrombosis, both venous and arterial combined, was 5.4% among patients who received adjuvant therapy and was 1.6% among patients on observation (P = .0002). Premenopausal patients who received chemotherapy and tamoxifen had significantly more venous complications than those who received chemotherapy without tamoxifen (2.8% v 0.8%, P = .03). Postmenopausal patients who received tamoxifen and chemotherapy had significantly more venous thrombi than those who received tamoxifen alone (8.0% v 2.3%, P = .03) or those who were observed (8.0% v 0.4%, P less than .0001). Premenopausal patients who received tamoxifen and chemotherapy had a 1.6% frequency of arterial thrombosis, significantly more than patients who received chemotherapy alone (1.6% v 0.0%, P = .004). The frequency of arterial thrombosis among postmenopausal patients was not significantly correlated with adjuvant therapy. In conclusion, patients who received adjuvant therapy for breast cancer had a 5.4% frequency of thromboembolic complications, significantly more than those who were observed. The combination of chemotherapy and tamoxifen was associated with more venous and arterial thromboembolic complications than chemotherapy alone in premenopausal patients and with more venous thrombi than tamoxifen alone among postmenopausal patients. | 3 |
Endoscopic ventricular fenestration using a "saline torch". The fiberoptic endoscope has never gained popularity among neurosurgeons although it is ideally suited for navigating within the cerebral ventricles. Recent advances in optics and miniaturization make the application of endoscopy in neurosurgery more practical. The authors report eight children who underwent ventriculoscopic fenestration of symptomatic loculated cerebrospinal fluid (CSF) collections. These CSF collections were either isolated ventricular cysts or trapped lateral ventricles secondary to obstruction at the foramen of Monro. Cyst wall dissection was carried out with a "saline torch" dissector which was introduced through a working channel in the ventriculoscope. The torch was used to coagulate vessels and to sculpt large windows in cyst walls or in the septum pellucidum. Ventriculoscope-guided cyst fenestration can be performed safely and easily under direct vision. The technique may permit simplification of shunt systems in some patients and elimination of shunts in others. | 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. | 3 |
Short-term and long-term changes in renal function after donor nephrectomy. We retrospectively examined the effect of nephrectomy on renal function in 55 living related donors. Renal function was measured with 131iodine-orthoiodohippurate scans. All patients were studied preoperatively, and 1 week and 1 year postoperatively. In 20 patients 10-year followup was available. Compensatory hypertrophy was complete 1 week postoperatively: effective renal plasma flow of the remaining kidney was 32.5% higher than preoperatively. The increase remained stable for at least a year. The degree of compensatory hypertrophy was significantly greater in male patients (46.9% after 1 week) than in female patients (26.7%). Compensatory hypertrophy occurred in all age groups studied and it was most pronounced in patients less than 30 years old. In the patients followed for 10 years effective renal plasma flow decreased from 387.7 ml. per minute 1 week after nephrectomy to 367.4 ml. per minute at 10 years. This result is similar to the decrease seen in the normal population. According to our results, renal donation by living related persons does not lead to long-term decrease in renal function. | 4 |
Spontaneous rupture of liver during pregnancy: current therapy. Spontaneous hepatic rupture secondary to severe pregnancy-induced hypertension is associated with a high rate of maternal and fetal mortality. Numerous types of surgical management have been described, but a uniform surgical approach has not been accepted. The purpose of this review was to examine modes of surgical therapy reported in the literature since 1976, as well as the 11-year experience at our institution. Twenty-eight cases were extracted from the literature and seven more were identified at our institution. The incidence in our population was one per 45,145 live births. Among 27 cases managed by packing and drainage, an 82% overall survival was achieved, whereas only 25% of eight patients undergoing hepatic lobectomy survived (P = .006). Hepatic hemorrhage with persistent hypotension unresponsive to blood products should be managed by evacuating the hematoma, packing the damaged liver, and draining the operative site. More aggressive surgical techniques, such as hepatic artery ligation or hepatic lobectomy, should be reserved for refractory cases. | 4 |
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