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Dislocation after primary arthroplasty for subcapital fracture of the hip. Wide range of movement is a risk factor. Dislocation is the most frequent serious complication following total hip replacement for subcapital femoral fracture. We report a prospective study, using matched groups, which compared the range of hip movement following hip replacement for arthritis and for fracture. The range of movement was significantly greater in the fracture group. We suggest that this is a predisposing factor for dislocation. | 4 |
Rheumatoid arthritis and comorbidity. Data collected from 288 patients with rheumatoid arthritis (RA) indicated that 54% of respondents also reported other chronic conditions, and that 20% rated at least one of these other conditions as severe. Both the frequency and severity of these comorbidities affected scores on measures of depressive symptoms, social connectedness and on the Arthritis Impact Measurement Scales. These findings suggest that the absence of controls for comorbidity may bias measures of functional status among patients with RA. | 2 |
Patient profiling: individualization of hypertension therapy. Although the stepped-care approach remains the cornerstone of antihypertensive therapy, the patient's profile must also be considered. Important issues include the patient's age, race and activity level, potential for hypertensive complications, presence of other diseases, cost of medications and probability of adherence to the recommended drug regimen. Nonpharmacologic treatment based on lifestyle changes is a useful adjunct to drug therapy, but it is not sufficient to control hypertension in most patients. Selection of pharmacologic therapy must be based on a knowledge of each drug's mode of action and side effects, as well as the characteristics of special patient populations. | 3 |
Short-term course of corticosteroids in the treatment of resistant ascites complicating schistosomal liver disease. The aim of this work was to evaluate the effect of short-term corticosteroids in resistant ascites complicating schistosomal liver disease after 4 wk or more on standard treatment. Thirty-seven patients were randomly allocated to two groups: Group I (18 patients) was put on 40 mg furosemide and 200 mg spironolactone, in addition to a 15-day, tapering dose of prednisone (15, 10, 5 mg). Group II (19) patients received the same diuretics without steroids, and served as controls. At the end of a 2-wk course of therapy, the mean variations were as follows: body weight in patients in Group I ("cases") decreased by 9.8 kg, compared with 4.3 kg in controls; abdominal girth decreased by 7.4 cm in cases, compared with 3.6 cm in controls; urine output increased by 635.9 ml in cases, compared with 364.6 ml in controls; urinary sodium excretion increased by 16.5 mEq/day in cases, compared with 4.1 mEq/day in controls. These differences between cases and controls were found to be statistically significant (p less than 0.01). On the other hand, there were insignificant differences as regards decrease in blood urea (3.2 g/dl for cases and 2.7 g/dl for controls), decrease in serum creatinine (0.2 mg/dl for both cases and controls), increase in serum albumin (0.3 g/dl in cases and 0.2 g/dl in controls), increase in serum sodium (3.2 mEq/L in cases and 2.7 mEq/L in controls), and increase in serum potassium (0.2 mEq/L in cases and 0.4 mEq/L in controls). We conclude that a short-term course of corticosteroids in conjunction with standard diuretics has proved to be an effective, safe, and economical modality to relieve resistant hepatic ascites. It can be considered a temporary alternative to paracentesis with albumin infusion. | 1 |
Surgical strategy in thyroid disease. Over the past 8 years, 311 patients have undergone surgical treatment by the senior authors for thyroid disease. Over 80% of the cases were performed by the head and neck surgical service at Olive View County Hospital, Sylmar, Calif, with the remainder performed at UCLA-affiliated institutions. This service is an important source of thyroid surgical training for UCLA head and neck residents who rotate through this major affiliate. The purpose of this communication is to review our experience with these cases; to describe our overall surgical strategy; and to detail the specifics of our surgical procedure, which we have developed to safely train residents in the treatment of these challenging cases. This article deals with the specific problems of preservation of the recurrent nerve, the parathyroid glands, and the techniques for reimplantation of injured parathyroid glands; the management of larger, substernal thyroid glands; and our techniques for partial thyroid surgery. In addition, the difficult decisions in the management of thyroid cancer, such as completion thyroidectomy; the management of lymph node mestastases; and how tracheal, esophageal, or laryngeal invasion should be managed are discussed. An initial section describing the general preoperative examination of these patients is also included, so that the proper surgical strategy can be developed prior to entering the operating room. | 0 |
Isolated trigeminal sensory loss secondary to a distal anterior inferior cerebellar artery aneurysm: case report. A previously healthy 25-year-old woman suddenly developed right-sided facial numbness and a headache. The neurological examination was within normal limits with the exception of meningismus and right-sided facial sensory loss. A computed tomographic scan and a magnetic resonance imaging study demonstrated an acute hematoma in the right cerebellopontine angle. A 4-vessel cerebral angiogram revealed no abnormalities. Posterior fossa exploration disclosed a large, partially thrombosed, fusiform anterior inferior cerebellar artery aneurysm, which indented the pons at the trigeminal root entry zone. The aneurysm was excised, and the patient made an excellent recovery. She was left with a persistent trigeminal sensory deficit. Anterior inferior cerebellar artery aneurysms are rare lesions that generally present with a cerebellopontine angle syndrome; occasionally, facial sensory loss is also a feature. Isolated trigeminal sensory findings, as illustrated in this case, are extremely unusual in posterior fossa vascular lesions. | 2 |
Correlation of ultrasound guided and digitally directed transrectal biopsies of palpable prostatic abnormalities. The authors evaluated 51 patients with palpable prostatic abnormalities detected during digital rectal examination. These findings consisted of a nodule or an area of induration. Each palpable abnormality was confined to 1 prostatic lobe and there was no suggestion of extracapsular extension of neoplasm or systemic metastatic disease. All patients underwent 7.0 MHz. sagittal ultrasound guided transrectal biopsy followed by digitally directed transrectal biopsy. Biopsies were obtained only from the area of interest. The procedure was performed in the outpatient clinic without use of sedation or anesthesia. Digitally directed biopsies were positive for adenocarcinoma in 9 lesions. Ultrasound guided biopsies detected adenocarcinoma in 23 lesions, including all those detected by the blind digitally directed technique. This study demonstrates greater diagnostic accuracy using 7.0 MHz. ultrasound guided techniques and its routine use is warranted in the evaluation of palpable prostatic abnormalities. | 0 |
Randomised single blind trial to compare the toxicity of subconjunctival gentamicin and cefuroxime in cataract surgery. Comparatively little attention has been paid to the conjunctival toxicity of antibiotics administered at the time of cataract surgery. We have observed the effect of subconjunctival gentamicin and cefuroxime injection, using colour photography in a randomised single blind trial of 121 patients undergoing routine cataract surgery. Our results suggest that a hyperaemic eye is likely to occur about twice as often in patients injected with gentamicin (p less than 0.001). Gentamicin is associated with more pain postoperatively (p less than 0.05). Significant manifestations of gentamicin toxicity are conjunctival oedema and capillary closure. Cefuroxime has some theoretical advantages over gentamicin in its antibacterial spectrum. | 4 |
A standard dose of radiation for "microscopic disease" is not appropriate. Elective irradiation of sites of potential occult tumor spread is often part of a patient's radiation therapy program. The required radiation dose (D) depends on the probability that occult disease exists (P(occ)), the number of sites at risk (A), the number of tumor clonogens present (Ni), their radiation sensitivity, and the desired control rate. An exponential model of cell survival is used to quantify the importance of these factors. Control Probability = [1 - Pocc x (1 - e-Ni x (SF2)D/2)]A; SF2 = surviving fraction after 2 Gy. Implications for clinical radiation therapy include: 1. Since the number of clonogens in an occult site may vary from 10 degrees to 10(8), Ni is the major determinant of the required dose. The intrinsic radiation sensitivity of the clonogens (SF2) is also extremely important in determining the dose. Other factors are less influential since they vary less. 2. The variability of Ni (8 logs) is larger than the variation in cell number seen with gross disease (1 cm3 versus 1000 cm3, 3 logs). When Ni approximately 10(8), the required dose approaches that needed for small volume gross disease (10(9) cells, 1 cm3). 3. The dose prescribed to elective sites should reflect the risk of occult disease based on the primary tumor site, stage, and grade. 4. Regions where clinicoradiologic evaluation is difficult (e.g., pelvis and obese neck) require higher doses because macroscopic tumor deposits may exist. 5. Relatively low doses (10 to 30 Gy) are often thought to be inadequate for microscopic tumor. However, similar doses have been reported to sterilize microscopic tumor in ovarian, rectal, bladder, breast, and head and neck carcinomas. Relatively low doses should not be discounted since they may be useful in select cases when normal tissue tolerances and/or previous irradiation treatment limit the radiation dose. | 0 |
Subarachnoid hemorrhage of unknown etiology: early prognostic factors for long-term functional capacity. Forty-one patients suffering subarachnoid hemorrhage (SAH) of unknown etiology were re-investigated at an average of 91 months after the bleed to determine functional capacity. Nineteen patients were performing at their previous level of work, five were employed part-time, and four could not work due to the SAH. Five patients showed a moderate disability in activities of daily living but were not dependent on help, one patient was severely disabled, and two had died. There was one rebleed. Early prognosis of an unfavorable outcome was possible on the basis of three clinical variables on admission: a history of hypertension, a Hunt and Hess grade of greater than II, and the presence of focal neurological deficits. In addition, the presence of an organic mental syndrome at discharge was identified as a predictive factor for reduced functional capacity later on. Other clinical variables in the acute stage, including sex, age, history of headache, interval between SAH and admission, impaired consciousness, and cognitive deficits, were not related to a limited functional level. Residual neurological deficits and the Glasgow Outcome Scale score on discharge were also not predictive of restrictions in global functions evaluated by means of the Karnofsky Performance Scale status at follow-up review. | 4 |
Efficacy of recombinant-derived human superoxide dismutase on porcine left ventricular contractility after normothermic global myocardial ischemia and hypothermic cardioplegic arrest. A porcine model of normothermic global ischemia (40 minutes) followed by systemic cooling to 25 degrees C with 4 degrees C crystalloid cardioplegic arrest (90 minutes) was used to assess the efficacy of recombinant-derived human superoxide dismutase (r-HSOD) on postreperfusion left ventricular function while on cardiopulmonary bypass. Isovolumic hemodynamic function was monitored, and adenine nucleotide pool was measured in myocardial biopsy specimens and coronary sinus effluent. The treatment group of pigs (n = 7) received 15 mg/kg r-HSOD immediately before warm reperfusion, both left ventricular peak systolic pressure and developed pressure were significantly better in the r-HSOD group of pigs (p less than 0.05 vs. placebo). This improvement persisted at 60 minutes of reperfusion (p less than 0.05 vs. placebo). Myocardial ATP and total adenine nucleotides did not differ, nor did adenine nucleotide catabolites in the coronary sinus effluent differ between treatment groups of pigs. The exception to this was the nucleotide catabolite inosine, which was significantly elevated in coronary sinus effluent of pigs treated with r-HSOD at 30 minutes of reperfusion (p less than 0.05 vs. placebo). In this model of global ischemia and reperfusion, a recombinant-derived human free-radical scavenger provides significant protection of systolic but not diastolic function. Values for myocardial ATP and total adenine nucleotide content suggest that the improvement in mechanical function during reperfusion is not due to enhanced preservation of myocardial bioenergetics. | 3 |
Chronic anaemia, hyperbaric oxygen and tumour radiosensitivity. Anaemia is an important factor in the response of some human tumours to radiotherapy. The outcome is also influenced by whether the treatment is given in air or high pressure oxygen (HPO). The present study examined the relationship between anaemia and tumour response to radiation given in air or HPO in C3H mice transplanted with a mammary adenocarcinoma using a growth delay assay to assess the radiation response. Chronic anaemia was induced by the use of a low iron diet and was characterized by a significant reduction in host haematocrit and whole blood viscosity. In addition, anaemia was associated with a right shift in the oxyhaemoglobin dissociation curve and an increase in the volume doubling time of the tumour; but there was no change in the concentration of 2,3-diphosphoglycerate in the red cells. Radiation studies with these anaemic mice demonstrated that the tumour radiosensitivity was decreased when treatment was given in air. HPO was successful in overcoming the increased radioresistance associated with anaemia. This result suggested that tumours grown in anaemic mice have a higher hypoxic fraction than those grown in control mice. Changes in host physiology with chronic anaemia may contribute to the benefit seen with HPO but such alterations per se may be inadequate to maintain tumour oxygenation when treatment is given in air. | 0 |
Characterization of distal bronchial microflora during acute exacerbation of chronic bronchitis. Use of the protected specimen brush technique in 54 mechanically ventilated patients. To obtain accurate information on distal bronchial microflora during acute exacerbation in patients with chronic bronchitis, we prospectively studied 54 such patients who had been receiving mechanical ventilation because of hypercapnic respiratory failure. Fiberoptic bronchoscopy using a protected specimen brush (PSB) was performed on each patient within the first 24 h after admission. Cultures of protected brush specimens demonstrated no growth in 27 patients (50%). With the exception of fever (38.2 +/- 0.8 versus 37.7 +/- 0.6 degrees C; p less than 0.05), the initial severity of the episode of exacerbation was similar in patients with and without infection. A total of 44 organisms were isolated in the 27 patients with positive cultures; the predominant pathogens were Hemophilus spp. and Streptococcus spp. (involved in 74% of cases), but other organisms were isolated in 12 of 27 patients. Mortality rates, duration of mechanical ventilation, and duration of hospitalization were not significantly different between patients with bronchial microflora treated with appropriate antimicrobial therapy (n = 27) and patients without bronchial microflora either receiving empirical antibiotic therapy (n = 18) or not (n = 9). These data suggest that distal bronchial infection due to the usual pathogens, as far as shown by protected specimen brush cultures, may not be the sole or even the predominant cause of acute exacerbation of chronic bronchitis in patients requiring mechanical ventilation. | 4 |
Natural history and prognostic factors for chronic hepatitis type B. One hundred and five hepatitis B surface antigen (HBsAg) positive patients presenting with chronic persistent hepatitis (n = 46) or chronic active hepatitis without cirrhosis (n = 59) were followed longitudinally for one to 16 years (mean 5.5 years) and underwent follow up biopsy. During a mean histological follow up of 3.7 years, active cirrhosis developed in 21 (20%) patients one to 13 years after entry to the study with a calculated annual incidence of 5.9%. The probability of evolution to cirrhosis was significantly higher in patients with chronic active hepatitis and bridging hepatic necrosis than in those with moderate chronic active hepatitis or chronic persistent hepatitis (p less than 0.0001). Cox multiple regression analysis showed that the following three variables independently implied poor prognosis: older age, presence of bridging hepatic necrosis, and persistence of hepatitis B virus DNA in serum (p less than 0.0001). These findings indicate that patients with severe chronic active hepatitis and persistent hepatitis B virus replication are at very high risk of rapid progression to cirrhosis. | 4 |
The effect of adjunctive arteriovenous fistula on prosthetic graft patency: a controlled study in a canine model. Bilateral 6 mm PTFE grafts were placed from the external iliac artery to the femoral artery with ligation of the intervening segment of the iliofemoral artery in 14 dogs. An arteriovenous fistula was constructed at the distal anastomosis on one randomly selected side in each animal while the contralateral graft served as a control. Graft follow-up ranged between 8 and 12 months in all animals. Serial arteriography was performed to confirm graft and fistula patency and demonstrated persistence of antegrade flow into the arterial tree distal to all patent bypasses. Femoral intraarterial pressures distal to patent grafts were identical on both sides in each animal throughout the study. Cumulative life-table patency rates showed higher patency for the arteriovenous fistula bypasses than the control grafts at all time intervals: 71% vs. 57% at 3 months, 48% vs. 25% at 6 months, and 40% vs. 22% at 12 months, respectively. This is the first controlled study that provides experimental evidence suggesting that these bypasses may produce increased patency of prosthetic arterial grafts and lends support to their use in a clinical, prospective, randomized study. | 4 |
Prognostic value of electrophysiology testing in asymptomatic patients with Wolff-Parkinson-White pattern [published erratum appears in Circulation 1991 Mar;83(3):1124] The prognostic value of electrophysiology testing was studied in 75 asymptomatic patients with the Wolff-Parkinson-White electrocardiographic pattern. All patients underwent electrophysiology testing at entry to the study and were followed up annually for a total of 348 patient-years (median, 4.3 years). There were 44 male and 31 female patients, and age at enrollment ranged from 7 to 77 years (mean, 34 +/- 14 years). The median effective refractory period of the accessory pathway was 293 msec (interquartile range, 280-310 msec), and the median shortest RR interval between preexcited beats during atrial fibrillation (SRR) [corrected] was 274 msec (240-320 msec). Twenty-three patients had an SRR of 250 msec or less and eight patients had a median shortest SRR interval of 200 msec or less. Twelve patients had inducible sustained reciprocating tachycardia, 10 patients had inducible nonsustained reciprocating tachycardia, and 23 patients had inducible sustained atrial fibrillation. Twenty patients (27%) lacked retrograde conduction over the accessory pathway. No patient died suddenly during a median follow-up of 4.3 years. Six patients (8%) became symptomatic with documented supraventricular tachycardia, of whom two underwent operative ablation of their accessory pathways. No patient with absent retrograde accessory pathway conduction during the electrophysiology study became symptomatic. Inducible sustained or nonsustained reciprocating tachycardia at electrophysiology study did not predict the development of subsequent symptomatic supraventricular tachycardia. Nine patients lost preexcitation during follow-up. Age at enrollment (relative risk/decade, 1.4; 95% confidence interval, 1.0-1.8) and anterograde accessory pathway refractory period (relative risk, 1.06/10 msec; 95% confidence interval, 1.0-1.12) were independent predictors of loss of preexcitation. | 3 |
The significance of low-grade prostate cancer on needle biopsy. A radical prostatectomy study of tumor grade, volume, and stage of the biopsied and multifocal tumor. Twenty-one cases showing only low Gleason grade prostate carcinoma on needle biopsy were identified. In 15 cases radical prostatectomy was performed with the entire prostate embedded for thorough evaluation of grade, volume, and stage of tumor at the needle biopsy site as well as of multifocal tumor. Eight specimens had solitary low grade and low volume tumor, with only one of these cases showing minimal capsular penetration and the others confined to the prostate. Four cases had low-grade tumor at the biopsy site, yet multifocal higher grade tumor. All of these tumor nodules were low volume and confined to the prostate. In three cases there was both low-grade and high-grade tumor in the nodule sampled by needle biopsy. In two of these cases the tumor was large and in the third it was small but mostly higher grade, with two of these cases showing capsular penetration. Although transrectal ultrasound and repeat needle biopsy would most likely have identified either the tumors' large size or high-grade component in these latter three cases, it is unlikely that these techniques would have identified the cases of multifocal higher grade tumor because of their relatively small size. Furthermore, preoperative serum prostate specific antigen levels and clinical stage failed to distinguish those cases with higher grade tumor. Because of the difficulty in identifying these areas of high-grade tumor preoperatively, it is uncertain whether expectant therapy could be recommended even for patients with very low-grade cancer on needle biopsy. | 0 |
Arterial abnormalities of the hand in athletes. Vascular lesions of the hand may be seen in athletes exposed to repetitive blunt trauma. Thirteen athletes seen from 1983 to 1988 experienced symptoms related to hand ischemia. Nine were professional baseball catchers. The majority of patients complained of chronic symptoms, including cold hypersensitivity (four patients), finger numbness (one), finger coolness (three), and finger blanching (three). Two patients had acute symptoms with sudden posttraumatic hand ischemia with finger and palmar pain. Diagnosis was established by history and physical examination and confirmed by noninvasive testing. Testing included use of Doppler examination and cold tolerance examination with thermistors. Two athletes required angiographic evaluation because of severe ischemia and continuous pain. All patients in this group were managed nonoperatively. Those with chronic complaints were counseled regarding cold avoidance and instructed to increase their glove padding. The two patients with acute symptoms required vasodilator (papaverine chloride) infusion, followed by intravenous heparin and dextran. All baseball catchers returned to their sport with dissipation of symptoms. | 2 |
Evaluation of metastatic cardiac calcification in a model of chronic primary hyperparathyroidism. Recent reports have fueled an interest in the prevalence and significance of metastatic calcium deposition in patients with chronic hyperparathyroidism. Experimental data are limited by the lack of suitable in vivo animal models. We have developed a model of marked hypercalcemia and overproduction of parathyroid hormone using somatic gene transfer. Briefly, the process involves infection of cultured rodent fibroblasts (RAT-1 cells) with a retroviral expression vector that contains the gene encoding human parathyroid hormone. Fibroblasts are grown to confluence on collagen-coated dextran microcarrier beads and are injected into the peritoneal cavities of syngeneic Fisher rats. Human parathyroid hormone production in rat serum is quantified by an immunoradiometric assay for human parathyroid hormone (1-84), which does not recognize rat parathyroid hormone. These rats consistently show production of human hormone within a week. Levels increase progressively, often to 1 ng/ml within 60 days of injection. Serum calcium showed a concomitant rise to an average of 15.5 mg/dl. In this study, 13 rats that had been transplanted with parathyroid hormone-producing fibroblasts were killed 80 days after injection. Examination of the skeleton revealed demineralization and histopathologic sequelae of parathyroid hormone excess with extensive osteoclastic bone resorption. Examination of the hearts revealed calcification in five of 13 hearts. There was no involvement of major coronary arteries or conducting systems, but there was calcification of cardiac myocytes, primarily in subepicardial region. This model may permit an understanding of the mechanisms for sudden cardiac death in severe hypercalcemia. | 3 |
Duplex ultrasonography for persistent gestational trophoblastic tumor. Duplex ultrasonography was performed on 17 consecutive patients being evaluated for persistent gestational trophoblastic tumor (GTT). All patients had had a prior molar pregnancy evacuated and presented with a rise or plateau in their beta-human chorionic gonadotropin levels. The ultrasonography was considered to be abnormal if the image demonstrated a focal area of altered echogenicity within the uterus or if Doppler scanning revealed a focal area of detectable intrauterine blood flow. The ultrasound findings were compared with the pathologic results from dilation and curettage specimens. Ten of the 17 patients had pathologically proven macroscopic tumor. Of those 10, 7 had an abnormal sonographic image (sensitivity, 70%), and 9 had an abnormal Doppler examination (sensitivity, 90%). In all 10 patients the image and/or Doppler examination was abnormal. Among four patients with microscopic disease, imaging was positive in one case, and the Doppler examination was positive in three. Imaging and Doppler ultrasonography are complementary modalities that can reliably detect persistent uterine GTT, and Doppler ultrasonography appears to be more sensitive than imaging in making this diagnosis. | 0 |
The efficacy of methylprednisolone in reducing flap edema. It has been suggested that systemic steroids reduce postoperative flap edema. This has been poorly documented by several reports based on subjective clinical observations. In an effort to provide quantitative data on methylprednisolone and edema, a flap edema model in the rat was developed based on the inferior epigastric vessels. Significant edema developed after 48 hours. Differing intraoperative doses of methylprednisolone were studied, producing a dose-response curve. A single low dose of intraoperative steroid is effective in reducing flap edema; previously recommended doses are probably excessive. | 4 |
Hypoglycemia, hypotonia, and cardiomyopathy: the evolving clinical picture of long-chain acyl-CoA dehydrogenase deficiency. Inherited defects in fatty acid oxidation, which have been described and diagnosed with increasing frequency in the last decade, are most commonly attributed to a deficiency in the activity of medium-chain acyl-CoA dehydrogenase. Few cases of the related enzyme defect of long-chain acyl-CoA dehydrogenase activity have been reported. An infant with documented long-chain acyl-CoA dehydrogenase deficiency is described with a detailed metabolic profile, long-term clinical follow-up, and response to treatment. This patient is compared with the seven previously published cases of this disorder in order to stress the unique features of the initial presentation, more subtle late manifestations of the disease, and clinical and biochemical differentiation from the more common medium-chain acyl-CoA dehydrogenase deficiency. This report stresses the enlarging spectrum of the clinical presentation and natural history of this defect in fatty acid oxidation. | 2 |
Skin reflectance pulse oximetry: in vivo measurements from the forearm and calf. This study describes the results from a series of human experiments demonstrating the ability to measure arterial hemoglobin oxygen saturation (SaO2) from the forearm and calf using a reflectance pulse oximeter sensor. A special optical reflectance sensor that includes a heating element was interfaced to a temperature controller and a commercial Data-scope ACCUSAT pulse oximeter that was adapted for this study to perform as a reflectance pulse oximeter. The reflectance pulse oximeter sensor was evaluated in a group of 10 healthy adult volunteers during steady-state hypoxia. Hypoxia was induced by gradually lowering the inspired fraction of oxygen in the breathing gas mixture from 100 to 12%. Simultaneous SaO2 measurements obtained from the forearm and calf with two identical reflectance pulse oximeters were compared with SaO2 values measured by a finger sensor that was interfaced to a standard Datascope ACCUSAT transmittance pulse oximeter. The equations for the best-fitted linear regression lines between the percent reflectance, SpO2(r), and transmittance, SpO2(t), values in the range between 73 and 100% were SpO2(r) = -7.06 + 1.09 SpO2(t) for the forearm (n = 91, r = 0.95) and SpO2(r) = 7.78 + 0.93 SpO2(t) for the calf (n = 93, r = 0.88). The regression analysis of the forearm data revealed a mean +/- SD error of 2.47 +/- 1.66% (SaO2 = 90-100%), 2.35 +/- 2.45% (SaO2 = 80-89%), and 2.42 +/- 1.20% (SaO2 = 70-79%). The corresponding regression analysis of the calf data revealed a mean +/- SD error of 3.36 +/- 3.06% (SaO2 = 90-100%), 3.45 +/- 4.12% (SaO2 = 80-89%), and 2.97 +/- 2.75% (SaO2 = 70-79%). | 4 |
Placebo controlled trial of xamoterol versus digoxin in chronic atrial fibrillation. Thirteen patients in chronic atrial fibrillation with a normal resting heart rate but with exercise tachycardia and episodes of bradycardia were randomised to treatment periods of two weeks on xamoterol (200 mg twice daily), low dose digoxin, or placebo, in a blind crossover study. The results (mean SEM) of symptom scores, a treadmill exercise test, and 24 hour ambulatory electrocardiographic monitoring were obtained. Xamoterol improved symptom scores and controlled exercise heart rate better than digoxin. Xamoterol was better than digoxin or placebo in reducing the heart rate response to exercise and tended to improve exercise duration. Xamoterol, by reducing the daytime maximum hourly heart rate and increasing the night time minimum hourly heart rate, significantly reduced the difference between the two compared with placebo. In contrast, digoxin tended to reduce both the maximum and minimum hourly heart rates through day and night. Both the frequency and duration of ventricular pauses were reduced by xamoterol but tended to increase with digoxin. Xamoterol reduced both the circadian variation in ventricular response to atrial fibrillation and exercise tachycardia by modulating the heart rate according to the prevailing level of sympathetic activity. These changes were translated into symptomatic benefit for the patients studied. | 3 |
Beneficial effect of atrial pacing in severe acute aortic regurgitation and role of M-mode echocardiography in determining the optimal pacing interval. The effect of atrial pacing on cardiac performance was assessed in 11 men (aged 20 to 64 years) with recent-onset severe aortic regurgitation (AR), all of whom had diastolic closure of the mitral valve on the echocardiogram. Thermodilution cardiac outputs were determined, and aortic, left ventricular and pulmonary arterial wedge pressures recorded. Once baseline recordings were completed, the pacing rate was increased by increments of 10 beats/min (70, 80, 90...) to a maximal rate of 140 beats/min. The optimal pacing interval, obtained from hemodynamic data, was defined as that at which the lowest filling pressure was associated with the highest cardiac index. This was then compared with a pacing interval derived from the R wave of the electrocardiogram to the diastolic mitral closing point on the M-mode echocardiogram. Such an interval would shorten diastole without affecting forward mitral flow. Atrial pacing improved the overall hemodynamic state in all patients; the most favorable hemodynamics were achieved at heart rates between 110 and 130 beats/min (mean: 120 +/- 8). At the optimal rate, left ventricular end-diastolic pressure decreased from 46 +/- 7 to 23 +/- 12 mm Hg (p less than 0.001), and the pulmonary arterial wedge pressure from 28 +/- 8 to 16 +/- 7 mm Hg (p less than 0.001), while the cardiac index increased from 2.34 +/- 0.46 to 2.63 +/- 0.49 liters/min/m2 (p less than 0.01). The mean difference between the optimal pacing interval determined from the hemodynamic data and the interval derived from the echocardiogram was 18 +/- 21 ms. | 4 |
Single polypoid cystitis cystica and glandularis presenting as benign bladder tumor. A case report of a ten-year-old boy with a benign polypoid bladder tumor is presented. The rarity of benign or malignant bladder tumors in children is reviewed, as well as the possible etiology of this unique lesion. | 0 |
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. | 1 |
Vertical partial laryngectomy: a critical analysis of local recurrence. The purpose of this study was to evaluate local recurrence following vertical partial laryngectomies in 416 patients with either T1N0M0 or T2N0M0 glottic carcinoma. Local failure was reported according to the T stage, the precise tumor location within each stage, the true vocal cord mobility, and the surgical procedure performed. No local recurrences were observed among 42 patients who underwent thyrotomy and cordectomy when the tumor was confined to the middle third of the mobile true vocal cord. Local failure occurred in 8 of 111 (7.2%) patients in whom hemilaryngectomy was performed for tumors confined to one mobile true vocal cord. There was a diverse group of lesions within each T stage that responded differently to the surgical approaches. The differences in the initial recurrence rates are discussed in terms of careful preoperative assessment and choice of surgical technique for early glottic carcinoma. | 0 |
Correlation between bromodeoxyuridine-labeling indices and patient prognosis in cerebral astrocytic tumors of adults. Bromodeoxyuridine (BUdR), a nonradioactive thymidine analogue, is taken up by cells in S-phase, and the ratio of BUdR-positive nuclei to the total number of cells counted is defined as the labeling index (LI). In this study, BUdR LI and the clinical course of 50 cerebral astrocytic tumors in adults were analyzed. The obtained LI distributed continuously in a broad range from 0% to 19%. The mean LI of 28 glioblastomas, 12 anaplastic astrocytomas, and ten astrocytomas were 8.5%, 4.2%, and 1.2%, respectively, and these differences were statistically significant (P = 0.05). In the analysis of LI and the recurrence-free period (RFP), regardless of the histologic findings, 23 patients with LI more than 5% had a median RFP of 9.0 months; the median RFP of nine patients with LI of 3% to 5% was 14.7 months. Nine of 13 patients with LI less than 3% have not yet recurred after a median follow-up of 36 months. These differences were also statistically significant by the generalized Wilcoxon test (P = 0.05). The proliferative potential reflected by the BUdR LI is a good clinical indicator for predicting the rate of tumor growth in cerebral astrocytic tumors. In combination with histologic diagnosis, BUdR LI could help in determining a patient's prognosis more precisely. | 0 |
The role of sphincteroplasty for fecal incontinence reevaluated: a prospective physiologic and functional review. Sixteen female patients (mean age 54.1 years; range 34-74 years) with a 9.8-year (range 1-25 years) history of incontinence to solid stool underwent overlapping sphincteroplasty with internal sphincter imbrication without fecal diversion. All patients were prospectively evaluated with preoperative anorectal manometry, electromyography, and pudendal nerve motor latency assessment, postoperative anorectal manometry, and preoperative and postoperative functional evaluation. Mean and maximal resting pressures increased from 30 mm Hg and 49 mm Hg preoperatively to 40 mm Hg and 57 mm Hg, respectively, postoperatively. Likewise, mean and maximal squeeze pressures increased from 27 mm Hg and 48 mm Hg preoperatively to 39 mm Hg and 73 mm Hg, respectively, postoperatively (P less than 0.01). Furthermore, anal canal high pressure zone length was increased by sphincteroplasty from a mean of 0.9 cm (range 0-3 cm) to a mean of 2.1 cm (range 1-4 cm). These objective physiologic improvements correlated well with subjective functional improvement. Subjectively, functional outcome was rated by patients as excellent in 38 percent, good in 38 percent, fair in 19 percent, and poor in only 5 percent of cases. Overlapping sphincteroplasty with internal sphincter imbrication improves both the anal sphincter physiologic profile and fecal continence. | 1 |
Effects of tracheal irritation and hypercapnia on tracheal smooth muscle in humans. Both hypercapnia and tracheal irritation are known to constrict the airways in animals. To see whether similar responses occur in humans, we investigated tracheal smooth muscle (TSM) responses to hypercapnia and tracheal irritation with water in 14 paralyzed and anesthetized humans. TSM tone was monitored by measuring the pressure in the saline-filled cuff of the endotracheal tube. Although, tracheal irritation caused TSM constriction in 10 of 14 patients, 4 patients showed no TSM response. Administration of intravenous atropine attenuated the TSM constriction response. Hypercapnia did not cause any change in TSM tone in any of the 14 patients. These results indicate that in paralyzed and anesthetized humans, there exist interindividual differences in the TSM responses to tracheal irritation and that hypercapnia cannot be an effective stimulus for the TSM constriction. | 4 |
Outcome of patients with chronic affective disorder: a five-year follow-up. Patients with major depression, mania, or schizo-affective disorder that had been present without remission for 2 years or more at intake (N = 129) were followed prospectively for 5 years, as were 580 patients who had been ill for shorter periods at intake. Despite very substantial durations of episode, three-quarters of the chronic patients recovered, although recovery occurred much later in the follow-up period than it did among the nonchronic patients. Factors associated with recovery were less severe illness at intake, lack of psychotic features, good friendship patterns in adolescence, and, most important, a relatively high maximum level of functioning in the 5 years preceding intake. | 4 |
Stunned myocardium during extracorporeal membrane oxygenation. The "stunned myocardium" is a syndrome of reversible myocardial dysfunction that may be mediated by oxygen-derived free radicals. This phenomenon has been seen in some neonates undergoing extracorporeal membrane oxygenation. We performed echocardiograms and measured creatine phosphokinase isoenzymes and lipid peroxide levels in 16 neonates before, during, and after extracorporeal membrane oxygenation. Infants who developed stunned myocardia by echocardiography did so shortly after initiation of bypass and exhibited concurrent elevations of the MB fraction of creatine phosphokinase. Lipid peroxide levels did not simultaneously rise. These data suggest that oxygen-derived free radicals may not cause the stunned myocardium seen in neonates undergoing extracorporeal membrane oxygenation. | 3 |
A randomized, controlled trial of the use of music during laceration repair. STUDY OBJECTIVES: To determine whether music significantly reduces the pain and anxiety associated with laceration repair in the emergency department. PARTICIPANTS AND SETTING: Adult patients presenting to the ED at an urban teaching hospital for laceration repair. Exclusion criteria included patients less than 18 years old, having received analgesics, with suspected alcohol or substance intoxication, and in whom laceration repair was complicated by treatment of a more serious medical condition. DESIGN AND INTERVENTIONS: This was a randomized, controlled trial. After giving informed consent, patients were randomly assigned to receive standard laceration repair without music (control) or standard laceration repair with music. Patients assigned to the music group chose an audio tape from 50 available styles and artists. Patients received the music through a headset, and they controlled the volume. Intradermal lidocaine was used in all patients. Data were collected on heart rate, blood pressure, and respirations just before and immediately after wound repair. Psychological variables included the state subscale of the Spielberger State Trait Anxiety Inventory (STAI), a visual analog pain scale rating, and a brief questionnaire. STAI and pain scale ratings were analyzed with Wilcoxon's rank-sum test with an alpha error of .05. RESULTS: Thirty-eight patients (19 per group) completed the protocol. Pain scores were significantly (P less than .05) lower in the music group (mean, 2.09) than in controls (mean, 3.31). Anxiety after the procedure was reduced in both groups, but STAI reduction scores were not significantly different between groups (music, 17.7; control, 18.5). Seventeen of 19 patients (89%) rated music "very beneficial," and 100% said they would use music again. CONCLUSION: Music provides a safe, inexpensive, and effective adjunct for the management of pain in the ED but does not significantly affect anxiety. | 2 |
Small bowel enteroscopy: an early experience in gastrointestinal bleeding of unknown origin. Peroral small intestinal enteroscopy was performed in 35 consecutive patients with gastrointestinal bleeding of unknown origin by using a prototypic Sonde-type enteroscope. The median value for patient age was 69 years; duration of bleeding, 2 years (range, 2 months to 9 years); and transfusion requirements, 9 units. Bleeding was occult in 54% of these patients. Placement and passage of the enteroscope was performed by a gastrointestinal endoscopy assistant. Mean passage time was 4.3 hours. Complete passage was obtained in 14% of the patients, passage into the mid-distal ileum in 69%, and passage only into the jejunum in 17%. The diagnostic yield was 26%, with the majority of lesions encountered being mucosal vascular malformations. Small intestinal enteroscopy is a reasonable diagnostic procedure before embarking on visceral angiography and surgical exploration when standard endoscopic and radiologic methods fail to disclose a diagnosis. | 4 |
Use of magnetic resonance imaging in the diagnosis of cortical blindness in pregnancy. Magnetic resonance imaging (MRI) may be helpful in the assessment of eclampsia and preeclampsia with central nervous system symptomatology such as cortical blindness. We describe a rare case of complete binocular blindness postpartum with no other neurologic deficits, in which MRI abnormalities were undetected on computed tomography. The better soft-tissue discrimination of MRI may visualize important but subtle lesions which ultimately may help to explain the underlying pathophysiologic mechanism in such cases. | 4 |
Technetium-99m sestamibi in chronic coronary artery disease: the European experience. Since the introduction of technetium-99m methoxy-isobutyl isonitrile (Tc-99m sestamibi) in Europe, there has been a growing interest in its use. Several European multicenter trials have been conducted to evaluate this new agent in relation to the traditional perfusion marker thallium-201, and other studies are in progress to understand the use of this perfusion marker for the diagnosis of coronary disease, for use in conjunction with pharmacologic vasodilation, for use in the assessment of ventricular function and wall motion and for the assessment of interventions. | 3 |
Toxoplasmosis of the conus medullaris in a patient with hemophilia A-associated AIDS. Case report. Toxoplasma gondii has been reported to be the most common cause of focal brain lesions in patients with acquired immunodeficiency syndrome (AIDS). A case of intramedullary toxoplasmosis of the conus medullaris is reported in a patient with hemophilia A-associated AIDS. The diagnosis is discussed, with particular emphasis on the magnetic resonance imaging appearance. | 2 |
Narrow excision (1-cm margin). A safe procedure for thin cutaneous melanoma. We analyzed the results at 8 years of an international, randomized, prospective study carried out by the World Health Organization Melanoma Programme aimed at evaluating the efficacy of 1-cm-margin excision of primary melanomas not thicker than 2 mm. Data for 612 patients were assessable; 305 were randomized to receive 1-cm-margin excision and 307 to receive wide excision (margins of greater than or equal to 3 cm). The major prognostic criteria were similar in the two groups. Breslow thickness was 0.99 mm in the narrow excision group and 1.02 mm in the wide excision group. Disease-free and overall survival rates (mean follow-up period, 90 months) were similar in the two groups. Only four patients had a local recurrence as a first relapse. All underwent narrow excision, and each had primary melanomas thicker than 1 mm. | 4 |
Prevalence of ulcerative colitis in the Israeli kibbutz population. We carried out an epidemiological study of ulcerative colitis in 279 Israeli kibbutzim (121,403 population). The prevalence on December 31, 1987 was 121.08 per 100,000 population. When the data were stratified according to ethnic groups, the highest point prevalence was found in Israeli-born Jews (220.56 per 100,000 population), more than in Asian-African-born, or European-American-born kibbutz members (139.20 and 78.73 cases per 100,000 population, respectively). There were 68 men and 78 women (ratio of 0.87). The average age of the patients in the year of this survey was 46 years; it was 35 years at the time of diagnosis. Proctitis was found in 57%, left-sided colitis in 12%, and substantial or total colitis in 31%. Relapse at pregnancy was demonstrated in seven patients, and remission in one. Family history of a first-degree relative with inflammatory bowel disease was documented in three patients (2%). Probable complications of ulcerative colitis were observed in 38 (26%), anemia in 13 (9%). One patient (0.7%) with rectal cancer, also had breast cancer. We suggest that the impressive increase in ulcerative colitis prevalence among Israeli and Asian-African-born, in comparison with European-American-born kibbutz members, points toward a role of environmental factors in the etiology of this disease. | 1 |
Myosin heavy chain turnover during cardiac mass changes by glucocorticoids. One aim of this investigation was to determine whether the cardiac enlargement observed with glucocorticoid treatment is temporary or remains a permanent adaptation if steroid treatment is prolonged. A second aim was to study whether myosin heavy chain (MHC) synthesis rates are coordinated with the cardiac mass responses. Female rats received either a vehicle (1% aqueous carboxymethyl cellulose in saline) or hydrocortisone 21-acetate for 1, 3, 7, 11, and 15 days. Peak cardiac enlargement (10-15%) was observed after 7 days of hormone treatment in two separate series of experiments. The enlargement was maintained through 11 days of steroid injections but by 15 days had declined toward control levels. MHC synthesis measurements were performed by constant infusion of [3H]leucine. Leucine specific activities were similar among precursor pools (intracellular, extracellular, and leucyl-tRNA) and did not vary with steroid treatments. Fractional synthesis rates of ventricular MHC (%/day) did not change during the period of increase in ventricular mass but were reduced to 56-59% of controls (-11/19.5) at 7 and 11 days of treatment, when ventricular mass increases were highest. MHC breakdown (%/day) was reduced to approximately 60% (-11.5/18.7) of controls at 7 and 11 days. Changes in total protein synthesis, which was measured in isolated perfused hearts, were similar to the MHC responses and indicated that the alterations in MHC synthesis are synchronized with the hormonal effects on total protein metabolism. These results demonstrate that peak cardiac enlargement is not maintained with long-term glucocorticoid treatment. | 4 |
Spontaneous dural carotid-cavernous fistula with central retinal vein occlusion and iris neovascularization. Spontaneous dural carotid-cavernous fistulas are dural vascular malformations that usually run a benign course. We present a case of a spontaneously occurring dural carotid-cavernous fistula complicated by central retinal vein occlusion and iris neovascularization that led to progressive visual failure. | 3 |
Vitamin E supplementation and periventricular hemorrhage in the newborn. In a randomized controlled trial preterm babies received 20 mg vitamin E/kg im soon after birth (day 0) and at 24 and 48 h. The mean +/- SD plasma vitamin E level on day 0 was identical in supplemented and control groups (9.98 +/- 4.88 mumol/L) and rose progressively only in supplemented babies reaching a peak of 69.2 +/- 21.36 mumol/L at 72 h. Supplemented babies had a lower incidence of intraventricular hemorrhage (IVH) diagnosed by ultrasound (9/102, 8.8%) than the control group (37/108, 34.3%; 95% CI for difference in incidence, 15-36%). In a subsequent uncontrolled study using the same vitamin E preparation, a single dose of 20 mg/kg was given soon after birth to preterm babies. The peak mean +/- SD plasma level was 32.97 +/- 13.47 mumol/L at 48 h. The incidence of IVH (16/121, 13.2%) was lower than in historical control from the randomized trial (95% CI for difference; 10.2-31.8%) in spite of the single-dose group having more clinical risk factors for IVH. We conclude that vitamin E protects against IVH in preterm babies. | 4 |
Warning: fatal reaction to the use of fibrin glue in deep hepatic wounds. Case reports. Two cases of severe hypotension following the use of fibrin glue for hemostasis in hepatic injuries are reported. A systemic reaction to bovine thrombin via large venous lacerations is suspected. A preliminary animal study supports this hypothesis. Caution is advised in the use of fibrin glue for hemostasis in deep hepatic wounds. | 3 |
Long-term follow-up of the ileoanal anastomosis in children and young adults. The purpose of this study was to carry out a long-term study of the ileoanal anastomosis (IAA) in children and young adults, comparing the straight IAA to the J pouch. One hundred twenty-one young people who had undergone IAA were studied, with 114 available for long-term follow-up. One hundred one were 18 years and under. Forty-nine patients had a straight IAA and 72 had a J-pouch reservoir. There were no deaths. After surgery, three children had intraabdominal sepsis and one had pelvic sepsis, but it did not lead to excision of the IAA. The mean stool frequency in all 114 patients was 5.0 +/- 2.5 per day and 1.2 +/- 1.1 at night. The mean number of stools for the straight IAA was 6 per day and 2.1 at night. The mean number of stools for the straight IAA with balloon dilations was 5.8 per day and 1.2 at night, and for the J pouch it was 4 per day and 1 at night. Patients with both the J pouch and straight IAA had good to excellent sensation, with patients with the J pouch always able to distinguish flatus from stool in 87% of patients and almost always in 13%. Daytime continence was very good in both groups. Moderate nighttime loss of stool occurred in 10 patients, 6 with a straight IAA and 4 with a J pouch. Ninety-five percent of the 114 patients were satisfied or very satisfied, with most children with a J pouch very satisfied. The J pouch remains the procedure of choice in young people. | 4 |
Epidural morphine with butorphanol for postoperative analgesia after cesarean delivery. Epidural morphine has been used more and more to provide long-lasting postoperative analgesia after cesarean delivery. However, the incidence of pruritus (20%-93%) and nausea (17%-60%) detract from the usefulness of epidural morphine. The purpose of this study was to evaluate, in 30 patients having epidural anesthesia for cesarean delivery, the analgesic efficacy and side effects when a combination of epidural morphine, a mu-receptor agonist, and butorphanol, a mu-receptor antagonist and kappa-receptor agonist, was administered. After clamping of the umbilical cord, patients received 4 mg epidural morphine with 3 mL of normal saline (group 1), 4 mg epidural morphine with 1 mg butorphanol and 2 mL of normal saline (group 2), or 4 mg epidural morphine with 3 mg butorphanol (group 3). Patients were monitored for 24 h after administration of the study medications. There were no significant differences between the groups in visual analogue pain scores, time to first analgesic request, respiratory rate, or Trieger dot test performance in the 24 h immediately after these epidural injections. There were three patients in group 1 and one patient in group 2 who experienced oxygen saturations less than 90%. (No patients in group 3 developed an oxygen saturation less than 92%.) The patients in group 3 did not require treatment for pruritus or nausea, a response significantly different (P less than 0.001 and P less than 0.05, respectively) from group 1 or group 2. | 4 |
Mediastinal tracheostomy using a pectoralis major myocutaneous flap after resection of carcinoma of the esophagus involving the proximal part of the trachea. An operative procedure of mediastinal tracheostomy using a pectoralis major myocutaneous flap is presented. In this procedure, the terminal portion of the trachea penetrates through the center of a pectoralis major myocutaneous flap and the tracheal wall is completely wrapped with the muscular portion of the flap. Between 1981 and 1988, eight patients with carcinoma in the cervicothoracic segment of the esophagus underwent mediastinal tracheostomy after laryngoesophagectomy and extended resection of the proximal part of the trachea through sternal manubrectomy, because of invasion into the trachea. In five of eight patients, a pectoralis major myocutaneous flap was used to construct a tracheal stoma. A skin flap only, or both a skin flap and a muscle flap, was used in the other three. In four of eight patients, tracheal necrosis occurred, and rupture of the brachiocephalic artery occurred in one patient when the tracheal stoma had been constructed using both a skin flap and a muscle flap. However, neither skin breakdown nor bleeding from the major vessels occurred when using the myocutaneous flap. Therefore, it is concluded that the construction of the tracheal stoma using a pectoralis major myocutaneous flap is recommended for mediastinal tracheostomy after laryngoesophagectomy with extended resection of the proximal part of the trachea. | 4 |
Hyposensitivity to vasopressin in patients with hepatitis B-related cirrhosis during acute variceal hemorrhage. It has been suggested that vasopressin given during hemorrhage may be less effective than when given during a stable state in a portal-hypertensive rat model. This study was designed to evaluate the hemodynamic response to vasopressin infusion in 25 HBsAg-positive cirrhotic patients. Nine patients had active variceal hemorrhage before vasopressin infusion, and the other 16 patients were in a stable condition at the time of infusion. The two groups of patients were similar in baseline values except that a higher heart rate was found in patients with hemorrhage (96 +/- 20 vs. 73 +/- 10 beats/min, mean +/- S.D., p less than 0.01). Thirty minutes after vasopressin infusion (0.66 units/min), hepatic venous pressure gradient significantly decreased in both bleeding and stable patients (from 21 +/- 9 to 18 +/- 9 mm Hg, p less than 0.05; and from 18 +/- 4 to 8 +/- 3 mm Hg, p less than 0.0001, respectively). However, the decrease of hepatic venous pressure gradient was less obvious in bleeding patients as compared with stable patients (4 +/- 3 vs. 9 +/- 2 mm Hg, p less than 0.0001). A significant reduction of hepatic venous pressure gradient after vasopressin infusion was found in five bleeding patients without shock (from a median of 16 mm Hg [range = 12 to 26] to 11 mm Hg [range = 6 to 18], p less than 0.05), but not in four bleeding patients with shock (from 28 [range = 15 to 36] to 25 [range = 18 to 33] mm Hg, p greater than 0.05). | 1 |
Selective dopamine DA1 stimulation with fenoldopam in cirrhotic patients with ascites: a systemic, splanchnic and renal hemodynamic study. We studied the effects of fenoldopam, a selective dopamine DA1 agonist on systemic and splanchnic hemodynamics, renal blood flow and sodium excretion in 12 patients with alcoholic cirrhosis and ascites. Hepatic, azygos and renal veins were catheterized before and after intravenous administration of fenoldopam, 0.05 micrograms/kg/min for 1 hr and increased to 0.1 micrograms/kg/min for another hour. Mean arterial pressure progressively decreased (from 83 +/- 7 to a minimum of 77 +/- 8 mm Hg 100 min after starting the infusion) but returned to baseline level at 120 min. Plasma norepinephrine and renin activity increased (respectively from 567 +/- 297 to 919 +/- 375 pg/ml, p less than 0.05, and from 17 +/- 14 to 23 +/- 15 ng/ml/hr, p less than 0.05). Renal blood flow, urine output or sodium excretion did not change. Sodium output decreased at 1 hr from 6.9 mumol/min to 4.0 mumol/min, p less than 0.05. Both hepatic venous pressure gradient and azygos blood flow significantly increased by 21%. We conclude that the acute administration of fenoldopam did not improve renal hemodynamics or function in patients with cirrhosis and ascites. In addition, dopamine DA1 agonism caused further increases in norepinephrine concentration and plasma renin activity. Portal pressure also increased, probably because of an increase in mesenteric blood flow. These results question the renal benefit and raise concern about the use of dopamine agonists in patients with cirrhosis and ascites. | 1 |
The role of attitudes, beliefs, and personal characteristics of Italian physicians in the surgical treatment of early breast cancer. The influence of Italian physicians' attitudes, beliefs, and personal characteristics on medical decision making is examined in the case of surgical treatment of early breast cancer. Responses to a mail survey of 657 physicians from different specialties were analyzed comparing doctors recommending a radical procedure (9%) to those preferring a conservative procedure for younger patients only (25%), and those considering conservative surgery the treatment of choice regardless of patients' age (66%). The findings suggest that the likelihood of physicians' preferring a conservative procedure is influenced by their specialty and the extent to which they feel that a patient should have a role in the treatment decision more than by differences in the beliefs of treatment outcomes. Only preferences of the small group indicating radical surgery as the sole admissible treatment can be accounted for by ignorance or distrust of results of recent trials. These findings suggest that other than scientific factors guide many doctors in their decision making; they may help to explain why the diffusion of research results into clinical practice is often disappointingly slow. | 0 |
Brain death and organ donation in a neurosurgical unit: audit of recent practice OBJECTIVE--To assess the potential for increasing the yield of donors by comparing the current pattern of brain death and organ donation in a neurosurgical unit with that reported in 1981 and with a recent national audit. DESIGN--Retrospective review of all deaths for 1986, 1987, and 1988 and prospective data for 1989. SETTING--A regional neurosurgical unit serving 2.7 million population. RESULTS--Of 553 deaths, 35% (191) patients died while on a ventilator and 17% (92) after discontinuation of ventilation. Medical contraindications to donation were found in 23% (32) of 141 patients tested for brain death, in 38% (19) of 50 patients who died while being ventilated who were not tested, and in 12% (11) of 92 patients no longer being ventilated. Consent for donation was sought in 88% (96) of 109 medically suitable brain dead patients and granted in 70% (67) of these. Half those with permission for multiorgan donation had only the kidneys removed. CONCLUSIONS--More organs may be lost owing to transplant team logistics than by failure to seek consent from relatives of brain dead patients. The estimated size of the pool of potential donors depends on what types of patients might be considered. Ensuring that all who die while being ventilated are tested for brain death and considering the potential for donation before withdrawing ventilation could yield more donors. Ventilating more patients who are hopelessly brain damaged to secure more donors raises ethical and economic issues. | 2 |
Fatal disseminated mycobacterial infection following intravesical bacillus Calmette-Guerin. We describe a fatal case of disseminated mycobacteriosis after intravesical bacillus Calmette-Guerin immunotherapy. We summarize the prior safety record of this therapeutic modality, discuss local and systemic pathophysiological mechanisms by which dissemination might have occurred, and review the reported clinical experience with antituberculous chemotherapy for significant bacillus Calmette-Guerin infection. Finally, we offer suggestions for prophylaxis of certain patients with a history of exposure to intravesical bacillus Calmette-Guerin. | 0 |
Autoradiographic evaluation of monoclonal antibodies' access to melanoma-associated antigens in melanoma xenografts. Autoradiography of nude mice bearing human malignant melanoma xenografts was performed to characterize the distribution pattern of radioiodinated anti-melanoma monoclonal antibodies (MoAb) and fragments in macroscopic tumor nodules. Non-uniformity of radioactivity distribution was seen in all MoAb-xenograft combinations. The predominant patterns were marked deposition of radioactivity either in the periphery of nodules or in sharply delimited intra-tumoral foci. These patterns were generated by limitations in the accessibility of melanoma tissue rather than gross necrosis or heterogeneity of antigen expression. Computer-aided densitometry of autoradiograms was used to elaborate the difference of accumulation in intra-tumoral hot spots versus cold areas. It was found that increasing uniformity was achieved by increasing the dose of MoAb (i.e., intact IgG) injected, whereas a reduction in the size of MoAb (IgG greater than F(ab')2 greater than Fab) showed no such effect. | 0 |
Recovery of CD3+ and CD5- lymphocyte subpopulation after autologous bone marrow transplantation and chemotherapy. Although most circulating T cells in normal subjects express both CD3 and CD5 antigens on the cell surface, a small number lack the CD5 antigen. Recipients of allogeneic bone marrow transplants develop increased numbers of CD3+ CD5- cells, particularly those who develop graft versus host disease (GVHD). This CD3+ CD5- population may rise transiently in patients who have received an autologous bone marrow transplant (BMT) and in patients following completion of intensive chemotherapy for acute myeloid leukaemia (AML). These findings suggest that these CD3+ CD5- cells are a normal component of the regenerating lymphoid system after BMT or chemotherapy. | 4 |
Gastric adaptive relaxation and symptoms after vagotomy. Gastric adaptive relaxation is reported to be impaired after vagotomy. This abnormality has been implicated in the pathogenesis of postvagotomy symptoms, but no association has previously been demonstrated between the two. Gastric adaptive relaxation was measured in 15 healthy volunteers and 33 patients more than 1 year after highly selective vagotomy or truncal vagotomy and drainage. Seventeen patients were asymptomatic. The remainder were symptomatic including seven patients with persistent diarrhoea. Fasted subjects were intubated with a Ryle's tube containing a pressure microtransducer within a flaccid (800 ml) plastic bag. Gastric corpus-fundus pressure was recorded during distension of the bag with air (15 ml/s) over 30 s. Pressure indices were derived from the areas under the pressure curves. Median (range) pressure indices were: healthy volunteers 12.7 (7.5-17.1) cmH2O, highly selective vagotomy 14.0 (9.8-15.9) cmH2O (n.s.), truncal vagotomy and drainage 14.5 (8.6-26.8) cmH2O (P = 0.04). All patients with diarrhoea had abnormally high pressure indices (P less than 0.001). Pressure indices in all other patient groups were within the normal range. We conclude that gastric adaptive relaxation remains abnormal in patients with postvagotomy diarrhoea but not in those who are asymptomatic or who have other symptoms. | 1 |
Plasma concentrations of bupivacaine and two of its metabolites during continuous interscalene brachial plexus block. An interscalene brachial plexus block was performed via a catheter with 20-28 ml of 0.75% bupivacaine plus adrenaline for surgery of the shoulder region in 12 patients. Constant infusion of 0.25% bupivacaine 0.25 mg kg-1 h-1 was continued for 24 h. During surgery light general anaesthesia, without analgesics, was maintained. Plasma concentrations of total and unbound (free fraction) bupivacaine, desbutylbupivacaine (DBB), 4-hydroxybupivacaine (4-OHB) and alpha 1-acid glycoprotein (AAG) were measured at predetermined intervals during the continuous block. The greatest mean plasma concentrations of bupivacaine were measured at 30 min (1.63 (SD 0.55) micrograms ml-1) and 60 min (1.38 (0.48) micrograms ml-1). There was a small but statistically significant increase in the plasma concentration of bupivacaine between 12 and 24 h of infusion. The mean unbound concentration of bupivacaine in plasma decreased from 0.044 (0.015) microgram ml-1 (3.6 (1.1)% of total bupivacaine concentration) at 3 h to 0.023 (0.011) micrograms ml-1 (2.1 (1.0)%) at 24 h. The AAG concentration in plasma increased by 38% in 24 h. The metabolites DBB and 4-OHB were detectable in plasma from 30 min, with a gradual increase during infusion. At 24 h the mean concentrations of DBB and 4-OHB were 0.33 (0.22) micrograms ml-1 and 0.13 (0.04) micrograms ml-1, respectively. There were no toxic reactions during the blocks. | 4 |
The comportmental learning disabilities of early frontal lobe damage. Two adult patients are described who suffered bilateral prefrontal damage early in life and who subsequently came to psychiatric attention because of severely aberrant behaviour. A battery of developmental psychology paradigms (not previously used to assess neurologically impaired individuals) showed that social and moral development of these 2 patients was arrested at an immature stage. In comparison with other types of brain damage which disrupt cognitive development, frontal damage acquired early in life appears to provide the neurological substrate for a special type of learning disability in the realms of insight, foresight, social judgement, empathy, and complex reasoning. | 2 |
Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality. We analyzed the outcome of 202 percutaneous transluminal angioplasty (PTA) procedures performed between 1983 and 1989 to quantitate procedural risks and define factors associated with suboptimal results or immediate clinical failure. Premorbid factors studied included age, sex, treatment of single versus multiple lesions, stenoses versus occlusions, premorbid status of the limb (claudication vs limb threat), and most distal level of PTA. Adverse outcomes included complications (hematoma, acute occlusion, or thrombosis of PTA site, distal embolization, failure to dilate or cross, arterial dissection, rupture, and significant systemic derangement), major amputations (below knee and above knee), and deaths. There were 66 complications (32.7%), 22 amputations (10.9%), and 12 deaths (5.9%) in our series. Logistic regression analysis revealed that the major predictive variable for the occurrence of a complication (p = 0.002), and the only predictive variable for the outcomes of amputation and death (p = 0.0001 and p = 0.0139, respectively), was the premorbid clinical status of the limb. Lower extremity PTA is not an intrinsically benign procedure and is associated with a significant risk of complication, amputation, and procedure-associated death. These adverse outcomes cluster in patients with limb threat. Therefore it may be reasonable to restrict the use of PTA to patients with claudication and strictly selected cases of limb threat. | 3 |
Secretory carcinoma of the breast. Most studies of secretory carcinoma of the breast have been single case reports or separate analyses of the problem in either children or adults. We studied 10 female patients, aged 5 to 87 years. Most patients presented with a palpable mass, often near the areola. Five of six tumors were estrogen receptor negative; three analyzed for progesterone receptor were positive. Histologic patterns present in varying proportions were "classic" secretory carcinoma with microacini, abundant secretion with papillary features, and with prominent solid and papillary apocrine features. The tumors had strong reactivity for alpha-lactalbumin, S100, and carcinoembryonic antigen (polyclonal) and were negative for gross cystic disease fluid protein and anti-carcinoembryonic antigen (monoclonal). Six patients had mastectomy; four had local excision; none had axillary nodal metastases initially. With follow-up of 3 to 72 months (mean, 47 months; median, 48 months), two patients treated by local excision had local recurrences, one patient had axillary nodal metastases. All patients are alive. Comparison of patients under and over 30 years of age revealed one important difference: younger patients had a longer interval between detection and biopsy-30 vs 2 months. Treatment recommendations are initial wide excision or quadrantectomy with low axillary dissection in most cases and, in premenarchal patients, strong effort to preserve the breast bud without jeopardizing local control. | 0 |
Efficacy of transesophageal echocardiography as a perioperative monitor in patients undergoing cardiovascular surgery. Analysis of 149 consecutive studies. To evaluate the usefulness of transesophageal echocardiography as a perioperative monitor in patients undergoing cardiovascular surgery, 149 consecutive patients were studied since 1985. Left ventricular function was assessed by measurement of left ventricular dimension and ejection fraction in patients with valvular disease. This monitoring was useful in detecting the changes in left ventricular performance in patients with volume overload and in managing patients in the early postoperative period. Cardiac tamponade was clearly demonstrated before changes in electrocardiogram and hemodynamic data. In 27 patients, transesophageal color Doppler echocardiography was used to confirm that there was no residual regurgitation immediately after valvular reconstructive surgery. Transesophageal color Doppler echocardiography was also useful in detecting the entry of false lumen before surgery in 7 patients with dissecting aortic aneurysm. There were no unsuccessful introductions, no traumatic or thermal injuries, 18 patients (12.1%) with hoarseness and 5 patients (3.4%) with transient arrhythmia. In conclusion, transesophageal echocardiography provides a good imaging window to the heart and great vessels perioperatively. This expedient, safe informative imaging method can be used more routinely in patients during surgery. | 3 |
Long-term results after atrial correction of complete transposition of the great arteries. This study presents the late results for the first 104 consecutive patients surviving and atrial repair for transposition of the great arteries (TGA) between January 1971 and December 1978 (group 1). Mean follow-up was 12 years (range, 0.1 to 17.7 years). The actuarial survival rate at 18 years was 84.2% (70% confidence limits, 79% to 88%) for simple TGA and 93.7% (70% confidence limits, 84% to 97%) for complex TGA. Nine of the 11 deaths were sudden. Two (2.6%) of the 78 late survivors operated on for simple TGA are in New York Heart Association functional class III or IV versus 4 (26.7%) of the 15 survivors with complex TGA; the other patients are doing very well. To better assess long-term results, we report the findings for randomly obtained electrocardiograms, Holter monitor recordings, radionuclide angiographic studies, and cardiac catheterizations performed in 1987 in a larger group of 159 long-term survivors of atrial repair operated on at Ospedale Riuniti di Bergamo from January 1971 to December 1984 (group 2), which includes all of group 1. The findings confirm that the arterial switch repair is the procedure of choice for complex TGA and that there is a major incidence (approximately 10%) of systemic right ventricular dysfunction and rhythm disturbances after the atrial repair. On the other hand, our late survival rate at 18 years of 84% for simple TGA with 97.5% of the patients in functional class I is a result that should be kept in mind, especially in institutions where the arterial switch is a relatively new approach and presumably is a higher risk to cause early death. | 4 |
In-hospital symptoms of psychological stress as predictors of long-term outcome after acute myocardial infarction in men. The impact of high levels of psychological stress symptoms in the hospital after an acute myocardial infarction (AMI) was examined over 5 years among 461 men who took part in a trial of psychological stress monitoring and intervention. Psychological stress was assessed using the 20-item General Health Questionnaire (GHQ) 1 to 2 days before hospital discharge. Once discharged, patients in the treatment group responded to the GHQ by telephone on a monthly basis and, when they reported high levels of stress symptoms (GHQ greater than or equal to 5), received visits from nurses to help them deal with their life problems. Control patients received routine medical care after discharge. Post-hoc subgroup analyses based on life-table methods showed that, for patients receiving routine care after discharge, high stress (GHQ greater than or equal to 5) was associated with a close to threefold increase in risk of cardiac mortality over 5 years (p = 0.0003) and an approximately 1.5-fold increase in risk of reinfarction over the same period (p = 0.09). In contrast, highly stressed patients who took part in the 1-year program of stress monitoring and intervention did not experience any significant long-term increase in risk. Although program impact was significant in terms of reduction of both cardiac mortality (p = 0.006) and AMI recurrences (p = 0.004) among highly stressed patients, there was little evidence of impact among patients with low levels of stress in the hospital. | 4 |
Tracheal extubation in children: halothane versus isoflurane, anesthetized versus awake. The authors compared the incidence of respiratory complications and arterial hemoglobin desaturation during emergence from anesthesia in children whose tracheas were extubated while they were anesthetized or after they were awake and to whom halothane or isoflurane had been administered. One hundred children 1-4 yr of age undergoing minor urologic surgery were studied. After a standard induction technique, patients were randomized to receive either isoflurane or halothane. In 50 patients tracheal extubation was performed while they were breathing 2 MAC of either halothane or isoflurane in 100% oxygen. The remaining 50 patients received 2 MAC (volatile agent plus nitrous oxide) during the operation, but tracheal extubation was delayed until they were awake. A blinded observer recorded the incidence of respiratory complications and continuously measured hemoglobin saturation for 15 min after extubation. When tracheal extubation occurred in deeply anesthetized patients, no differences were found between the two volatile agents. When tracheal extubation of awake patients was performed, the use of isoflurane was associated with more episodes of coughing and airway obstruction than was halothane (P less than 0.05). Awake tracheal extubation following either agent was associated with significantly more episodes of hemoglobin desaturation than was tracheal extubation while anesthetized. | 4 |
Sarcoid reaction mimicking intrathoracic dissemination of testicular cancer. The close observation of patients treated for testicular cancer led to the suspicion of intrathoracic and/or mediastinal metastases on radiologic examination in a number of patients without other evidence of relapse. This report presents two patients with combined seminomatous and nonseminomatous germ cell tumors with isolated sarcoid reactions of hilar and interlobular lymph nodes, detected concomitant with diagnosis and 12 months after diagnosis, respectively. Histologic examination appears to be imperative in these cases to avoid unnecessary chemotherapy. | 0 |
Magnetic resonance imaging of vertebral osteoblastoma: a report of two cases. Two patients with vertebral osteoblastoma evaluated with computed tomography and magnetic resonance imaging are presented. A literature review revealed that cases of osteoblastoma originating within the vertebral body are exceedingly rare. | 0 |
Impact of active immunisation against enteritis necroticans in Papua New Guinea. Enteritis necroticans, known locally as pigbel, has been a major cause of illness and death among children in the highlands of Papua New Guinea. After a successful trial of active immunisation against the beta toxin of the causative organism, Clostridium perfringens type C, immunisation of children was begun in 1980. The effects of the immunisation programme on pigbel admissions in 3 of the 5 major highland hospitals were assessed. In each of the centres studied the proportion of admissions due to enteritis necroticans dropped significantly after immunisation was introduced (p less than 0.001) and hospital admissions for pigbel in 1984-86, when immunisation was well established, were less than one fifth of previous figures. | 4 |
Covalent binding of oxidative biotransformation intermediates is associated with halothane hepatotoxicity in guinea pigs. In vivo covalent binding of halothane biotransformation-reactive intermediates to hepatic protein and lipid was examined in association with the subsequent development of hepatic necrosis in the guinea pig. Oxidative halothane biotransformation was inhibited by the use of deuterated halothane, whereas reductive metabolism was enhanced by low inspired oxygen concentrations. Male outbred Hartley guinea pigs (n = 8) were exposed to either 1% (v/v) halothane or deuterated halothane--with a fractional inspired O2 concentration (FIO2) of 0.40 or 0.10--for 4 h. Livers removed from half of the animals immediately after anesthesia were evaluated for organic fluorine bound to protein and lipid. The remaining animals were evaluated for a hepatotoxic response up to 96 h after exposure. Only guinea pigs that received 1% halothane at an FIO2 of 0.40 had centrilobular necrosis develop with significantly increased plasma alanine aminotransferase activities. All other treatment conditions significantly reduced oxidative halothane biotransformation, as indicated by decreased plasma trifluoroacetic acid concentrations. These reductions were associated with a significant decrease in organic fluorine bound to hepatic proteins. An FIO2 of 0.10 during halothane anesthesia significantly enhanced reductive biotransformation, as indicated by plasma fluoride ion concentrations. This was associated with a significant increase in organic fluoride bound to hepatic lipids. Centrilobular necrosis did not develop under these conditions. Thus, covalent binding to subcellular proteins by the trifluoroacetyl acid chloride intermediate generated by oxidative halothane biotransformation is implicated as a mechanism of centrilobular necrosis in guinea pigs. Binding to lipids by reductive pathway generated free radicals does not appear to be involved in production of the lesion. | 4 |
Litigation and employment status: effects on patients with chronic pain. In order to study the effects of compensation and litigation, 201 chronic pain patients were selected from a sample of 444: 99 were working, 15 were working and litigating, 53 were receiving Worker's Compensation, and 34 were receiving Worker's Compensation and litigating. Employment (working vs. Worker's Compensation) and litigation status (litigating vs. not litigating) were analyzed in a 2 x 2 factorial design with measures of pain, disability, psychological distress, and selected demographics as dependent variables. Compared to Worker's Compensation patients, working patients reported significantly less disability (down-time, days spent in bed, interference of pain in daily activities) and pain of a longer duration. Compared to litigating patients, non-litigating patients reported less pain (on the McGill Pain Questionnaire) and less disability (stopping activity, interference of pain in daily activities). On two measures of psychological distress (depression, anxiety), there were significant interactions: Worker's Compensation patients who were litigating reported less distress than non-litigants, while working patients who were litigating reported more distress than non-litigants. The results indicate clear differences in self-reports of disability associated with both employment and litigation status. They also suggest that litigation may function as a coping response for patients who are distressed by the adversarial nature of the Worker's Compensation system. Limitations of the study as well as suggestions for further research also are discussed. | 4 |
Active specific immunotherapy in patients with melanoma. A clinical trial with mouse antiidiotypic monoclonal antibodies elicited with syngeneic anti-high-molecular-weight-melanoma-associated antigen monoclonal antibodies [published erratum appears in J Clin Invest 1991 Feb;87(2):757] In two clinical trials the mouse antiidiotypic monoclonal antibody (MAb) MF11-30, which bears the internal image of human high-molecular-weight-melanoma-associated antigen (HMW-MAA) was administered by subcutaneous route without adjuvants to patients with stage IV malignant melanoma on day 0, 7, and 28. Additional injections were administered if anti-antiidiotypic antibodies were not found or their titer decreased. In the first phase I trial with 16 patients the initial dose was 0.5 mg per injection and escalated to 4 mg per injection. Neither toxicity nor allergic reactions were observed despite the development of anti-mouse Ig antibodies. Minor responses were observed in three patients. In a second clinical trial MAb MF11-30 was administered to 21 patients at a dose of 2 mg per injection, since this dose had been shown in the initial study to be effective in inducing anti-antiidiotypic antibodies. Two patients were inevaluable; in the remaining 19 patients, the average duration of treatment was 34 wk. In this trial as well, neither toxicity nor allergic reactions were observed. 17 of the 19 immunized patients increased the levels of anti-mouse Ig antibodies and 16 developed antibodies that inhibit the binding of antiidiotypic MAb MF11-30 to the immunizing anti-HMW-MAA MAb 225.28. One patient increased the level of anti-HMW-MAA antibodies. One patient achieved a complete remission with disappearance of multiple abdominal lymph nodes for a duration of 95 wk. Minor responses were observed in three patients. These results suggest that mouse antiidiotypic MAb that bear the internal image of HMW-MAA may be useful reagents to implement active specific immunotherapy in patients with melanoma. | 0 |
Early-onset autosomal dominant retinitis pigmentosa with severe hyperopia. We studied a four-generation family with early-onset autosomal dominant retinitis pigmentosa, severe hyperopia, and axial eye lengths of less than 20 mm. The affected members had decreased vision, night blindness, typical peripheral retinal pigmentary changes, and electroretinographic abnormalities characteristic of retinitis pigmentosa. This pedigree suggests there is another variant of retinitis pigmentosa associated with hyperopia besides Leber's congenital amaurosis and preserved para-arteriole retinal pigment epithelium. | 2 |
Pressure measurements from biliary and pancreatic segments of sphincter of Oddi. Comparison between patients with functional abdominal pain, biliary, or pancreatic disease. Using a minimally compliant infusion system and a triple-lumen pressure recording catheter, we obtained endoscopic manometric measurements from both the common bile duct and pancreatic duct segments of the sphincter of Oddi (SO) in 58 patients. Fifteen patients (ages 27-69) had the diagnosis of functional abdominal pain, 19 patients (ages 30-76) had partial biliary obstruction, and 24 patients (ages 15-80) had idiopathic acute recurrent pancreatitis. Resting ductal pressure was similar in the common bile duct and pancreatic duct in all patient groups. In the group with functional pain, basal SO pressure was similar, whether obtained from the common bile duct or pancreatic duct sphincteric segment. Eight of 19 patients with partial biliary obstruction had elevated basal SO pressure. Five of these eight patients had elevated basal SO pressure confined exclusively to the common bile duct segment of the sphincter, while three patients had elevated basal SO in both segments. Conversely seven of 24 patients with acute recurrent pancreatitis had an elevated basal SO pressure, with five patients having pressure elevation only in the pancreatic duct segment while two patients had abnormal basal SO pressure in both segments. We conclude that selective cannulation of the common bile duct and/or the pancreatic duct during manometric study of the SO is necessary in order to diagnose segmental SO dysfunction responsible for partial biliary obstruction or episodes of acute recurrent pancreatitis. | 1 |
Alcohol-dependent unilateral vestibular impairment persisting after a closed head injury. A 20-year-old man suffered a closed head injury followed by symptoms of right-sided labyrinthine concussion with complete clinical recovery within 3 weeks. Episodic vertigo and ataxic gait occurred after the ingestion of small amounts of alcohol over the next 2 years. Electro-oculography revealed a right-sided peripheral type vestibular lesion, only after taking alcohol. This was interpreted as an alcohol-induced impairment of central compensation following an incomplete recovery from right-sided labyrinthine trauma. | 4 |
Improved water and sodium absorption from oral rehydration solutions based on rice syrup in a rat model of osmotic diarrhea. Rice syrup solids, rice protein, and casein hydrolysate were added to experimental oral rehydration solutions in various combinations and tested in a rat intestinal perfusion system. Chronic osmotic diarrhea was induced in juvenile rats by supplying the cathartic agents, magnesium citrate and phenolphthalein, in their drinking water for 1 week. The experimental oral rehydration solutions were compared with standard oral rehydration solutions containing 20 gm/L or 30 gm/L of glucose and with each other to determine if there were significant differences in net water, sodium, or potassium absorption. An oral rehydration solution containing 30 gm/L of rice syrup solids had a net water absorption rate significantly higher than that of the standard 20 gm/L glucose-based oral rehydration solution (2.1 +/- 0.62 versus 1.5 +/- 0.48 microliters/[min x cm], p less than 0.05). Casein hydrolysate did not significantly affect net water absorption. However, combinations of 30 gm/L rice syrup solids and 5 gm/L casein hydrolysate significantly increased (p less than 0.05) net sodium and potassium absorption compared with the 20 gm/L glucose-based oral rehydration solution but not versus rice syrup solids alone. Oral rehydration solutions containing 30 gm/L rice syrup solids plus 5 gm/L rice protein, and 30 gm/L rice syrup solids plus 5 gm/L casein hydrolysate, had net water absorption rates significantly higher than the rate of a 30 gm/L glucose-based oral rehydration solution (2.5 +/- 0.36 and 2.4 +/- 0.38, respectively, versus 0.87 +/- 0.40 microliters/[min x cm], p less than 0.05). Rice protein and casein hydrolysate, however, did not significantly affect net water, sodium, or potassium absorption when added to rice protein glucose-based oral rehydration solutions. An inverse correlation between osmolality and net water absorption was observed (r = -0.653, p less than 0.02). The data suggest that substitution of rice syrup solids for glucose in oral rehydration solutions will improve water absorption and that rice syrup solids in combination with protein hydrolysates may, in addition, promote better sodium and potassium uptake. | 1 |
Clinical experience with the Nimbus pump. The Nimbus pump is an indwelling, electromagnetic powered left ventricular (LV) assist device inserted transfemorally. The inflow cannula (7 mm) is positioned across the aortic valve and the pump in the descending aorta. Indications for insertion include cardiogenic shock despite maximal medical support and PCWP greater than 18 mmHg, MAP less than 90 mmHg, and Cl less than 2 L/min/m2. Twelve patients underwent the attempt at surgical insertion of the Nimbus pump. Diagnoses included eight acute myocardial infarctions (AMI), two ischemic cardiomyopathy, one postpartum cardiomyopathy, and one transplanted heart rejection. Eight (67%) of twelve patients had successful insertion. One patient had peripheral vascular disease preventing passage, and three had femoral vessels too small for insertion (less than 7.5 Hagar dilator). Five patients with the diagnosis of AMI had successful insertion and three (60%) underwent sufficient LV recovery for removal of the device; the other two patients died of stroke and ventricular arrhythmias, respectively. Three patients with the diagnosis of cardiomyopathy had progression of the disease process, and their needs exceeded the capabilities of the pump and they died of multiorgan failure. The Nimbus pump is an attractive LV assist device because of its pumping capacity (3.5 L/min) and minor surgical procedure for insertion. However, its application is limited because of access route and size. The device appears to work well for patients in cardiogenic shock after AMI (60% recovery) but does not appear indicated for patients with cadiomyopathy. | 3 |
Calcium absorption in bone disease associated with chronic cholestasis during childhood. Fractional absorption of calcium was determined in 9 children aged 4.9 to 16.9 yr with chronic cholestatic liver disease to determine the role of calcium malabsorption in the development of metabolic bone disease. Radiological evidence of rickets was absent in all patients, but bone density, measured by single beam photon absorptiometry of the distal radius, was reduced in eight of nine subjects. Serum calcium and phosphorus concentrations were normal in all except one subject. Serum 25-hydroxyvitamin D concentration was decreased compared with controls in only one of nine patients, but serum 1,25-dihydroxyvitamin D concentrations were diminished in seven of nine subjects. In all subjects, dietary calcium and phosphorus intakes were greater than 80% of the RDA. Fractional absorption of calcium, determined by oral and intravenous administration of stable calcium isotopes, was similar in cholestatic compared with control subjects (37.1% +/- 12.5% vs. 34.0% +/- 16.4%). In the cholestatic subjects, calcium absorption correlated with serum 1,25-dihydroxyvitamin D (r = 0.871, p less than 0.002) but not 25-hydroxyvitamin D concentrations. Calcium balance, assessed by the duplicate diet method, was positive in four of five subjects. Anthropometric measurements were performed to examine the relationship between nutritional status and bone mineral content. Heights of all subjects were less than or equal to the 10th percentile and fat stores and somatic protein stores were less than the 25th percentile in six of nine subjects. We conclude that factors other than calcium malabsorption and decreased serum 25-hydroxyvitamin D concentration contribute to diminished bone mass in children with cholestatic liver disease. | 4 |
The fallacy of the screening interval for cervical smears. One hundred seventy-four women with invasive cervical carcinoma were interviewed about their cervical smear histories to assess the accuracy of self-reporting and to relate the smear history with patient and tumor characteristics. Patients reported significantly more frequent, more recent, and more normal smears than were documented in medical records. The interval between onset of cancer symptoms and previous smear correlated directly with advanced stage. Sixteen women with normal smears within 36 months had significantly more advanced cancers than did 25 women with recent abnormal smears. Women with recent normal and abnormal smears had similar sociodemographic and behavioral characteristics. Because of inaccuracies in patients' self-reported smear histories and cancers developing in women with recent normal smears, we conclude that a specific screening interval should not be relied upon. | 0 |
Dialysis arthropathy: a clinical, biochemical, radiological and histological study of 36 patients. Out of a population of 97 haemodialysis patients, 36 patients with dialysis arthropathy were identified. Dialysis arthropathy is a chronic symmetrical polyarthritis which affected 97 per cent of the patients who had been undergoing cuprophane haemodialysis for more than 10 years. It commonly affected the shoulders, hips, hands, knees and wrists, worsening with time and extending to other joints. Fifty-eight per cent of the patients complained of morning stiffness and 47 per cent complained of exacerbation of shoulder pain during or after haemodialysis. Half of the patients also suffered from carpal tunnel syndrome, which recurred and was associated with a long-lasting disability. The most common radiological abnormality was periarticular bone cysts, followed by articular erosions and a destructive spondyloarthropathy, but clinical symptoms were more common than radiological signs. Patients with dialysis arthropathy had a higher C-reactive protein level than patients without arthropathy (18.6 mg/l versus 11.4 mg/l), indicative of an inflammatory process. Some of the clinical manifestations of the disease correlated with levels of C-reactive protein and ferritin. Serum ferritin levels correlated strongly with the units of blood transfused in the past five years (RS = 0.83), and the logarithm of ferritin level correlated weakly with C-reactive protein (r = 0.32). Haemarthroses were documented in 19 per cent of patients. Mean serum beta 2-microglobulin was elevated in the patients with (57.3 mg/l) and without arthropathy (50.7 mg/l), and there was no difference in the parathormone or aluminium levels between these groups. Articular tissue was obtained in 25 patients; beta 2-microglobulin amyloid was present in 24. Larger deposits were present in the capsular tissue, and these appeared to replace collagen bundles in eight cases. Amyloid deposits replaced the lining layer in six cases. It is likely therefore that amyloid disrupts normal joint function by replacing normal joint tissue. Mild chronic synovitis with haemosiderin deposition were found in approximately 60 per cent of cases. These findings suggest that amyloid derived from beta 2-microglobulin has a primary role in the pathogenesis of dialysis arthropathy, but there was also evidence of inflammatory processes. It is suggested that iron overload or haemarthroses might contribute to the inflammation, but other factors, such as dialysis-related bioincompatibility reactions, may also have a role. | 4 |
Bone mineral loss in young women with amenorrhoea. OBJECTIVE--To examine the impact of amenorrhoea on bone mineral density in women of reproductive age. DESIGN--Cross sectional study of 200 amenorrhoeic women compared with normally menstruating controls. SETTING--Teaching hospital outpatient clinic specialising in reproductive medicine. SUBJECTS--200 Women aged 16-40 with a past or current history of amenorrhoea from various causes and of a median duration of three years, and a control group of 57 age matched normal volunteers with no history of menstrual disorder. MAIN OUTCOME MEASURE--Bone mineral density in the lumbar spine (L1-L4) as measured by dual energy x ray absorptiometry. RESULTS--The amenorrhoeic group showed a mean reduction in bone mineral density of 15% (95% confidence interval 12% to 18%) as compared with controls (mean bone mineral density 0.89 (SD 0.12) g/cm2 v 1.05 (0.09) g/cm2 in controls). Bone loss was related to the duration of amenorrhoea and the severity of oestrogen deficiency rather than to the underlying diagnosis. Patients with a history of fracture had significantly lower bone density than those without a history of fracture. Ten patients had suffered an apparently atraumatic fracture. CONCLUSIONS--Amenorrhoea in young women should be investigated and treated to prevent bone mineral loss. Menopausal women with a past history of amenorrhoea should be considered to be at high risk of osteoporosis. | 4 |
Emergency tracheal intubation in the postanesthesia care unit: physician error or patient disease? Inadequate airway maintenance has been a major factor in perioperative morbidity. To determine the incidence and etiology of emergency tracheal intubations in the postanesthesia care unit (PACU), we retrospectively reviewed 13,593 consecutive admissions to our PACU from October 1986 through October 1988. Twenty-six patients (26/13,593 = 0.19%) required the insertion of an endotracheal tube while in the PACU. Seventy-seven percent (20/26) of the intubations occurred within 1 h of extubation and/or admission to the PACU. Intubation was more common at the extremes of age; 54% of those intubated were more than 60 yr old (P = 0.003); 19% were less than 3 yr old (P less than 0.05). Twenty-three percent of the intubated patients had undergone otolaryngologic procedures (P = 0.008). Interestingly, 73% of the intubations occurred during the months of January through June (P = 0.016). Median PACU admission scores were lower for the intubated group (P less than 0.001). There was no association between intubation and gender (P = 0.74), anesthetic technique (P = 0.41), or anesthetic agent (P = 0.49). Of the 26 intubations, 18 (69%) were considered to be directly related to anesthetic management. Despite the extremely low incidence of emergency tracheal intubation in a heterogeneous group of patients admitted to our PACU, preventable anesthesia-related etiologic factors including excessive sedative or anesthetic effect, inappropriate fluid management, persistent muscle relaxant effect, and upper airway obstruction contributed to the majority of these intubations. | 4 |
The effect of intravenous fixed-dose heparin during total hip arthroplasty on the incidence of deep-vein thrombosis. A randomized, double-blind trial in patients operated on with epidural anesthesia and controlled hypotension. Heparin was given in fixed doses intravenously during unilateral primary total hip-replacement operations in a prospective, double-blind trial to assess the effect on the incidence of deep-vein thrombosis. One hundred and fifty patients were randomly assigned to one of two groups before the operation. Twenty-four patients were excluded from the study, leaving 126 patients. Group I consisted of sixty-six patients who received saline solution intravenously, and Group II comprised sixty patients who received heparin. All patients had epidural anesthesia with controlled hypotension. Fixed doses of heparin were administered five minutes before the operative incision was made and every thirty minutes throughout the operation. Mean arterial pressures were maintained at between fifty and sixty millimeters of mercury in all patients. Ascending venography was done on the seventh day after the operation. The incidence of deep-vein thrombosis was 24 per cent (sixteen of sixty-six patients) in Group I and 8 per cent (five of sixty patients) in Group II; the difference is significant (p = 0.03). The intraoperative loss of blood averaged 220 +/- 79 milliliters in Group I compared with 269 +/- 109 milliliters in Group II. An average of less than one unit of blood was transfused for each patient in each group. Postoperatively, there was no difference between the groups with regard to the amount of drainage that was collected in a Hemovac device or the values for hematocrit. | 3 |
Esophageal and gastric endoscopy in critically ill patients. How can it help you? Bleeding from the upper gastrointestinal tract in a critically ill patient is a tough diagnostic situation. Endoscopy can help physicians determine the cause of bleeding and can also provide several therapeutic options. The authors discuss these applications of the current technology. | 4 |
Recreational sun exposure in Puerto Rico: trends and cancer risk awareness. Persons who sunbathe or engage in other activities at the beach are exposed to large amounts of UV radiation. Four hundred seven adults who visited the beaches of Puerto Rico were surveyed to determine their knowledge about the risks of sun exposure and to evaluate sunscreen use. The group consisted of 195 year-round Puerto Rican residents and 212 tourists. Ninety-five percent believed that the sun can cause skin cancer, although only half of the subset who lived all year in Puerto Rico believed that they personally received enough exposure to be at risk. The majority of the group (83%) understood the meaning of the sun protection factor numbers, although 35% used either nothing or a nonscreening oil. Half of Puerto Rican residents rarely or never used sunscreen protection while sunbathing. When sunscreen was used, the most important factor sought was given as sun protection factor (64%), followed by a perceived ability to aid in tanning (26%). | 0 |
Possible role of leukotrienes in gastritis associated with Campylobacter pylori. This study was done to evaluate the role of leukotrienes (LTs) in gastritis associated with Campylobacter pylori. Biopsy specimens of gastric mucosa were obtained endoscopically from 18 patients with nonulcer dyspepsia for bacteriological and histological examination and extraction of LTs. There was correlation between the LTB4 level in the mucosa and the degree of gastritis evaluated histologically. The level was higher when infiltration of neutrophils in the gastric mucosa was more extensive. The LTB4 level in mucosa infected with C. pylori was higher than that in noninfected mucosa. These findings suggest that endogenous LTs may be related to the pathogenesis of gastritis associated with C. pylori. | 1 |
L-tryptophan use and the eosinophilia-myalgia syndrome. We present a case of the eosinophilia-myalgia syndrome in a patient taking large doses of L-tryptophan for sedation. He developed the now-classic findings of myalgias, skin changes, and marked eosinophilia. This syndrome was first recognized in late 1989, and epidemiologic studies have demonstrated an association of the clinical syndrome with ingestion of L-tryptophan. The mechanism of toxicity remains unknown. Casual use of L-tryptophan has been diminished by its rapid removal from the nutrition counter of health food stores. | 4 |
Onset of induced atrial flutter in the canine pericarditis model To test the hypothesis that induced atrial flutter evolves from a transitional rhythm, the onset of 99 episodes of induced atrial flutter (mean cycle length 135 +/- 18 ms) lasting greater than 5 min in 40 dogs with sterile pericarditis was first characterized. In 85 (86%) of the 99 episodes, atrial flutter was preceded by a brief period (mean 1.4 +/- 0.9 s, range 0.4 to 42) of atrial fibrillation. Then, in 11 open chest studies, atrial electrograms were recorded simultaneously from 95 pairs of right atrial electrodes during the onset of 18 episodes of induced atrial flutter (mean cycle length 136 +/- 16 ms). Atrial flutter was induced by a train of eight paced atrial beats, followed by one or two premature atrial beats (7 episodes) or rapid atrial pacing (11 episodes). A short period of atrial fibrillation (mean cycle length 110 +/- 7 ms) induced by atrial pacing activated the right atrium through wave fronts, which produced a localized area of slow conduction. Then unidirectional conduction block of the wave front occurred for one beat in all or a portion of the area of slow conduction. This permitted the unblocked wave front to turn around an area of functional block and return through the area of slow conduction that had developed the unidirectional conduction block, thereby initiating the reentrant circuit. The location of the unidirectional block relative to the direction of the circulating wave fronts determined whether the circus movement was clockwise or counterclockwise. The area of slow conduction and unidirectional conduction block occurred where the wave front crossed perpendicular to the orientation of the atrial muscle fibers, suggesting a role for anisotropic conduction. These areas included the high right atrial portion of the sulcus terminalis (10 episodes), the low right atrial portion of the sulcus terminalis (4 episodes) and the pectinate muscle region (4 episodes). It is concluded that the development of a localized area of slow conduction in the right atrium followed by unidirectional conduction block in this area produced during a short period of atrial fibrillation or rapid atrial pacing is necessary for atrial flutter to occur in this model. | 3 |
Intravenous and oral corticosteroids for the prevention of relapse after treatment of decompensated COPD. Effect on patients with a history of multiple relapses To determine if a regimen of intravenous and oral corticosteroids reduces the relapse rate after treatment of decompensated COPD in the ED, 30 patients were studied. Forty-five visits in which intravenous and oral corticosteroids were given (T visits) were compared with an equal number of matched visits in which they were withheld (N visits). No differences were noted between T and N visits with respect to clinical findings, laboratory results and other forms of therapy. Treatment with corticosteroids reduced the relapse rate within 24 h of discharge. At 48 h, the cumulative relapse rate for T visits (8.9 percent) was significantly lower than for N visits (33.3 percent; p = 0.005). For patients with a history of multiple relapses, a regimen consisting of intravenous and oral corticosteroids reduces the risk of relapse after ED treatment of decompensated COPD. | 4 |
Pressure measurements from biliary and pancreatic segments of sphincter of Oddi. Comparison between patients with functional abdominal pain, biliary, or pancreatic disease. Using a minimally compliant infusion system and a triple-lumen pressure recording catheter, we obtained endoscopic manometric measurements from both the common bile duct and pancreatic duct segments of the sphincter of Oddi (SO) in 58 patients. Fifteen patients (ages 27-69) had the diagnosis of functional abdominal pain, 19 patients (ages 30-76) had partial biliary obstruction, and 24 patients (ages 15-80) had idiopathic acute recurrent pancreatitis. Resting ductal pressure was similar in the common bile duct and pancreatic duct in all patient groups. In the group with functional pain, basal SO pressure was similar, whether obtained from the common bile duct or pancreatic duct sphincteric segment. Eight of 19 patients with partial biliary obstruction had elevated basal SO pressure. Five of these eight patients had elevated basal SO pressure confined exclusively to the common bile duct segment of the sphincter, while three patients had elevated basal SO in both segments. Conversely seven of 24 patients with acute recurrent pancreatitis had an elevated basal SO pressure, with five patients having pressure elevation only in the pancreatic duct segment while two patients had abnormal basal SO pressure in both segments. We conclude that selective cannulation of the common bile duct and/or the pancreatic duct during manometric study of the SO is necessary in order to diagnose segmental SO dysfunction responsible for partial biliary obstruction or episodes of acute recurrent pancreatitis. | 4 |
Maple syrup urine disease caused by a partial deletion in the inner E2 core domain of the branched chain alpha-keto acid dehydrogenase complex due to aberrant splicing. A single base deletion at a 5'-splice donor site of an intron of the E2 gene disrupts the consensus sequence in this region. We have studied the molecular bases of maple syrup urine disease by analyzing the activity, subunit structure, mRNA sequence, and the genome of the affected enzyme. The branched chain alpha-keto acid dehydrogenase (BCKDH) activity in the patient was 4.2-4.5% of the control level. Immunoblot analysis revealed that the E2 subunit of BCKDH (Mr 52,000) was absent and another protein band with an Mr of 49,000 was present. We amplified the cDNA of the E2 subunit obtained from the patient's cell using the polymerase chain reaction method, then sequenced the amplified cDNA, in which a 78-bp deletion was identified. The consanguineous parents and a sister had two species of mRNA; the one corresponding to the normal E2 subunit and the other with a 78-bp deletion, whereas findings in a brother were normal. The molecular size of the translation products as deduced from the abnormal mRNA sequence was compatible with an abnormal protein band (Mr 49,000) detected in the patient's cells by immunoblot analysis. Analysis of genomic DNA of BCKDH-E2 subunit revealed that the 78-bp deletion in the mRNA was caused by an exon skipping due to a single base deletion in the 5'-splice donor site. As a result of the mutation, part of the inner E2 core domain was omitted. The specified region of the inner E2 core domain was highly homologous to the region of the E2 subunit of pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase. These observations imply the biological importance of the region in the inner E2 core domain of BCKDH to maintain normal function of the activity. | 4 |
Primary carcinoma of the upper urinary tract. Effect of primary and secondary therapy on survival. The pathologic material and medical records of 76 patients with primary upper urinary tract carcinomas were reviewed to identify the role of grade and stage in predicting survival; to determine any differences in survival between ureteral and renal pelvic carcinoma; to understand the role of local therapy in low grade, low stage tumors; and to establish the usefulness of adjuvant therapies in metastatic disease. Kaplan-Meier survival curves with Cox-Mantel analysis for statistical significance revealed both grade and stage to be excellent predictors of survival. No differences in survival were noted between renal pelvic and ureteral carcinomas for equivalent stage tumors. For low grade, low stage tumors, although there was an increased risk of local recurrence with local therapy, there were no differences in survival between patients treated with local therapy or radical surgery. Finally, cisplatin-based chemotherapy seemed to improve survival in patients with metastatic disease. | 0 |
Use of computed tomographic scanning and aortography in the diagnosis of acute dissection of the thoracic aorta. Before the introduction of computed tomographic (CT) scanning, aortography was the investigation of choice for acute aortic dissection. Between 1978 and 1982, 24 patients were referred to the Brompton Hospital with suspected acute thoracic aortic dissection; all had aortography with diagnosis confirmed at surgery (n = 12) or necropsy (n = 2) or supported by clinical outcome (n = 8). One patient in whom aortography was negative had type B dissection at necropsy and another patient was lost to follow up. CT scanning became available in this unit in 1983 and between 1983 and 1987 was used as the only imaging investigation in 32 patients with suspected acute dissection of the thoracic aorta while in a further 22 patients aortography was used alone. Results were confirmed at surgery (n = 18), necropsy (n = 3), or supported by clinical outcome (n = 31). Two patients were lost to follow up. In an additional 16 patients both aortography and CT scanning were performed with concordant findings in 10. In six in whom the results were discordant, aortography was normal in three in whom subsequent CT scanning showed type B dissection and CT scanning was normal in three patients in whom aortography showed type A dissection. Both CT scanning and aortography are reliable techniques for assessment of suspected acute dissection of the thoracic aorta. Both techniques misdiagnose occasionally and the frequency of misdiagnosis will be minimised by performing both investigations in patients where the level of clinical suspicion is high and the initial investigation negative. CT scanning tends to miss type A dissection and in view of the success of surgery in this condition this failing has the more serious clinical consequences. | 3 |
A risk-benefit analysis of elective bilateral oophorectomy: effect of changes in compliance with estrogen therapy on outcome. A bilateral oophorectomy at the time of elective hysterectomy is often performed to prevent ovarian cancer. The assumption that endogenous estrogen can be easily replaced with supplemental medication fosters the decision for routine oophorectomy. Published reports on the use of postmenopausal estrogen indicate that compliance is less than perfect. This fact could affect the overall outcome. Decision analysis techniques with Markov cohort modeling were used to evaluate the policy of elective bilateral oophorectomy. Results from studies judged methodologically sound were combined to determine values representing the influence of estrogen on coronary heart disease, breast cancer, and osteoporotic fracture. The decision tree also explicitly incorporated patient compliance. When compliance with estrogen therapy is assumed to be perfect, oophorectomy yields longer life expectancy than retaining the ovaries. When actual drug-taking behavior is considered, retaining the ovaries results in longer survival. This analysis highlights the importance of including the effects of patient compliance with treatment recommendations when the impact of a health policy decision such as prophylactic surgery is assessed. | 3 |
Impact of echocardiography on the management of patients with mitral valve prolapse OBJECTIVE: To determine whether echocardiography affects the decisions to use beta blockers or to recommend bacterial endocarditis prophylaxis in patients suspected of having mitral valve prolapse (MVP). DESIGN: Retrospective review of echocardiograms and clinical records. SETTING: Military tertiary care hospital. PATIENTS: 127 patients with clinically suspected MVP (105) or incidentally discovered MVP (22). MAIN RESULTS: Beta blockers were used more often in patients with suspected MVP and positive echocardiograms (45%) than in patients with normal echocardiograms (13%, p less than 0.001). Bacterial endocarditis prophylaxis was recommended more often in patients with suspected MVP and positive echocardiograms (65%) than in patients with normal echocardiograms (11%, p less than 0.001). Presence or absence of a murmur did not influence the decision to recommend bacterial endocarditis prophylaxis. Patients in whom MVP was incidentally discovered were unlikely to receive either beta blockers or the recommendation for bacterial endocarditis prophylaxis. CONCLUSIONS: The results of echocardiography affect the decisions to use beta blockers or to recommend bacterial endocarditis prophylaxis in patients with suspected MVP. | 4 |
The surprising kidney-fluid mechanism for pressure control--its infinite gain! In this short paper, I have tried to explain the elation that we felt when we first realized that the kidney-fluid mechanism for controlling the arterial pressure has an infinite feedback gain property. Because of this, all the other pressure control mechanisms, none of which has ever been shown to have a similar infinite gain property, must themselves alter the kidney-fluid mechanism if they are to succeed in causing long-term changes in the arterial pressure. We have not been able to refute this principle despite many experiments over the last 2 decades. For this reason, our first understanding of the infinite gain property of the kidney-fluid mechanism was like a light at the end of the tunnel. I hope that I can explain to the reader the excitement of those few seconds when we first recognized the principle in 1966. | 3 |
A single cholesterol measurement underestimates the risk of coronary heart disease. An empirical example from the Lipid Research Clinics Mortality Follow-up Study. In prospective epidemiologic studies of coronary heart disease, a single measurement of cholesterol is made to assess its relationship to the risk of coronary disease. Statistical theory states that if this measurement is subject to within-individual variability, the strength of the relationship will be underestimated. This is empirically shown for the example of plasma cholesterol. For the Lipid Research Clinics Follow-up Study population (comprising 2170 white men over 30 years of age), the age-adjusted coronary heart disease mortality regression coefficient increases from .453 to .496 if the average of two cholesterol measurements is used instead of a single measurement. Since the correlation between the two repeated cholesterol measurements is .815, an increase in the regression coefficient up to .556 would be expected if the true cholesterol values were available. Thus, epidemiologic studies have substantially underestimated the strength of the relationship between cholesterol levels and the risk of coronary disease by calculating the relationship on the basis of a single cholesterol determination. | 3 |
Crohn's disease: what about the pancreas? [editorial] Crohn's disease (CD) is now accepted as a systemic illness. The importance of extraintestinal manifestations is underlined by the fact that such "complications" can be more prominent and even more difficult to control than the intestinal disease itself. Lately, evidence for a more than accidental association of pancreatitis and exocrine pancreatic insufficiency with CD is growing. This might have a significant impact on the treatment of abdominal pain and diarrhea in CD, symptoms which have so far been attributed exclusively to the intestinal rather than the extraintestinal manifestations of the disease. | 1 |
Toxicity of high-dose cytosine arabinoside in the treatment of advanced childhood tumors resistant to conventional therapy. A Pediatric Oncology Group study. Experience with high-dose cytosine arabinoside (HDAC) in pediatric solid tumors is limited. Sixteen children with solid tumors resistant to conventional therapies were registered in a pilot Pediatric Oncology Group (POG) study that required the administration of HDAC at 3 g/m2 every 12 hours for four doses. There were four cases of rhabdomyosarcoma, two cases of fibrosarcoma, four cases of neuroblastoma, and one case each of germ cell tumor, Wilm's tumor, retinoblastoma, hepatocellular carcinoma, Ewing's sarcoma, and Burkitt's lymphoma. All eligible patients had advanced diseases and had previously received extensive chemotherapy. Thirteen patients received one course of HDAC and three patients received two courses of HDAC. Due to prior treatments, patients had less than normal marrow reserves. Short-term toxicity included nausea, vomiting, suppression of hemopoiesis, drug fever, and increased blood urea nitrogen (BUN), creatinine, and liver enzymes. All evaluable patients recovered from their toxicities. There were no drug-related deaths. None of the patients had neurologic problems, including the only patient with prior irradiation to the skull. With the above schedule, HDAC appears to have manageable toxicity. | 4 |
Molecular analysis of acute promyelocytic leukemia breakpoint cluster region on chromosome 17. Acute promyelocytic leukemia (APL; FAB M3) is characterized by a predominance of malignant promyelocytes that carry a reciprocal translocation between the long arms of chromosomes 15 and 17, t(15;17) (q22;q11.2-q12). This translocation has become diagnostic for APL, as it is present in almost 100 percent of cases. A Not I linking clone was used to detect this translocation initially on pulsed-field gel electrophoresis and subsequently with conventional Southern (DNA) analysis. The breakpoints in ten APL cases examined were shown to cluster in a 12-kb region of chromosome 17, containing two CpG-rich islands. The region is the first intron of the retinoic acid receptor alpha gene (RARA). | 0 |
Progressive coronary luminal narrowing after cardiac transplantation. Accelerated coronary disease is a major factor limiting long-term survival in cardiac transplant recipients. Coronary angiography was obtained a mean of 5.1 weeks posttransplantation and annually thereafter. Replicate projections recorded after nitroglycerine administration were quantitated using computer-assisted edge detection. Five hundred and fifteen coronary segments in 25 patients having 1-year follow-up and 353 segments in 18 patients reaching 2-year follow-up were compared with baseline angiograms. Significant change was defined as +/- 0.10 mm, equal to 3.8% change in diameter based on three standard deviations obtained from estimation of measurement error. Mean coronary diameter fell from 2.44 +/- 0.26 mm at baseline to 2.21 +/- 0.34 mm (p less than 0.001) at 1-year follow-up. This rate of diameter decline was 20-fold more rapid during the initial posttransplantation year than the rate of change of visually normal segments in nontransplant patients with coronary atherosclerosis elsewhere. There was no significant drop in mean diameter between the first and second year in those patients who had second-year studies. Decrease in absolute diameter for vessels greater than 2.9 mm significantly exceeded diameter reduction for smaller vessels but did not differ when considered as a ratio of vessel diameter. In 21 of 25 patients, mean coronary diameter reduction exceeded the three-standard deviation threshold at their last angiogram, but only two of these patients had visually detectable transplant coronary disease. | 3 |
Gynecologic vascular abnormalities: diagnosis with Doppler US. The authors describe the use of duplex and/or color Doppler ultrasonography of the pelvis in three women to demonstrate the presence of venous malformations. One patient with a pulsatile vaginal mass was shown to have an arteriovenous malformation of the vaginal wall. The second patient was shown to have an unsuspected venous angioma in the endometrial cavity. The third patient was shown to have adnexal varices that closely mimicked hydrosalpinx. In the latter two cases, the duplex and color flow capabilities of an endovaginal probe were especially important. | 3 |
Stiff-man syndrome: a GABAergic autoimmune disorder with autoantigenic heterogeneity. Autoantibodies that reacted with cell bodies and axon terminals of gamma-aminobutyric acid (GABA)ergic neurons were present in the serum and cerebrospinal fluid in a patient with stiff-man syndrome with type I diabetes. Immunoblot experiments using this patient's serum and cerebrospinal fluid did not corroborate an earlier observation that these autoantibodies are directed against the GABAergic cytosolic enzyme, L-glutamic acid decarboxylase. While L-glutamic acid decarboxylase autoantibodies may be associated with this syndrome, they do not appear to be easily demonstrated. | 4 |
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