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Nd:YAG-laser in the microsurgery of frontobasal meningiomas. Forty-three patients with big frontobasal meningiomas underwent a microsurgical removal of the tumor. The 1.32 microns Nd:YAG-laser has proved useful in this prospective series particularly with the contactless shrinkage of the tumors and the necrotization of the dural and bony attachments. Tumor shrinkage was achieved by radiating the tumor surface with the Nd:YAG-laser. This technique facilitated the microsurgical dissection and reduced the blood loss by half. The Nd:YAG-laser necrotization of the dural and bony attachments reduced the recurrence rate following grade two resections from 20% to zero. The postoperative quality of life was excellent with a complete rehabilitation in 76% of the patients. The use of the 1.32 microns Nd:YAG-laser improved significantly the results of microsurgery for frontobasal meningioma. | 2 |
Quantitative proton magnetic resonance imaging in focal cerebral ischemia in rat brain. Proton magnetic resonance (MR) imaging has been recommended as a diagnostic tool for the detection of focal cerebral ischemia. We compared microscopic MR images of rat brains after focal cerebral ischemia with evidence of histological damage found on corresponding silver-impregnated or cresyl violet-stained brain sections. Ten male Wistar rats were subjected to permanent unilateral occlusions of the right middle cerebral and common carotid arteries under halothane anesthesia. Twenty-four hours later the area of injury on MR images amounted to 26% of the total slice area, whereas only 9% of the total slice area was necrotic on histological sections from the same animals. The infarcted areas on tissue sections were surrounded by regions of selective neuronal injury in the cerebral cortex and occasionally in the hippocampus. The area of injury on MR images was larger than the combined areas of infarction and selective neuronal injury on histological sections. Areas of increased T2 values on MR images extended medially into noninfarcted striatum and laterally and dorsally into noninfarcted cortex. The lateral and dorsal areas on MR images frequently coincided with cortical areas in which considerable selective neuronal injury was present in the upper cortical layers. We hypothesize that the abnormal areas on MR images above histologically normal brain tissue represent the ischemic penumbra. If true, this is the first demonstration of the ischemic penumbra by MR imaging and may reflect our use of Wistar rats, a new image analysis technique, and ultra-high resolution MR imaging. | 4 |
Midterm surgical results of arterial switch operation for transposition of the great arteries with intact septum. Between April 4, 1984, and December 31, 1987, 156 consecutive neonates with simple transposition of the great arteries underwent an arterial switch operation (ASO) at our institution. Surgery was performed before the age of 15 days in 96%, and patient weight was less than 3 kg in 28%. Seventeen patients (10.9%) died after surgery. One patient was lost to follow-up. Of the 138 survivors, two died of myocardial infarction 35 and 40 days, respectively, after surgery. They were the only late deaths, and actuarial survival rates were 87% (70% confidence level [CL], 83-89%) at 45 days and 87% (70% CL, 68-95%) at 52 months. Another patient had a myocardial infarction 50 days after surgery and is well 50 months later. Pulmonary stenosis was observed in 14 patients (10.3%) during the first year after surgery; two patients were reoperated on 10 and 12 months, respectively, after ASO. Aortic regurgitation was observed in 17 patients: two had grades II and III, respectively, aortic regurgitation on aortography; in 15 patients, it was detected only by Doppler examination. At the last follow-up (2-52 months after ASO; mean, 27.3 +/- 11.3 months), all patients were asymptomatic and taking no medication. On bidimensional echocardiography, left ventricular fractional shortening was normal at rest in all survivors but one. One patient had junctional rhythm, and one had Wenckebach periods; the remainder were in sinus rhythm. For as long as 5 years after ASO, late death and reintervention were rare; 99% of the survivors were asymptomatic and had sinus rhythm and good systemic ventricular function. | 4 |
Thrombotic vasculopathy associated with cryofibrinogenemia. Cryofibrinogenemia refers to the presence of cold-precipitable plasma proteins associated with a variety of disorders, including malignancies, inflammatory processes, and thrombohemorrhagic phenomena. Few cases of essential or primary cryofibrinogenemia are reported. We report a case in a 48-year-old man of essential cryofibrinogenemia and hemorrhagic necrosis of the ears and of the upper and lower extremities. Histopathologic studies demonstrated extensive eosinophilic thrombi in the dermal vasculature, with minimal inflammation and no vasculitis. Cryofibrinogenemia should be considered in the investigation of patients with otherwise unexplained cold intolerance and dermal thrombosis associated with minimal or no inflammation. | 3 |
Long-term follow-up of patients after transcatheter direct current ablation of the atrioventricular junction. The long-term follow-up study (41 +/- 23 months) of 47 patients undergoing direct current ablation because of drug-resistant supraventricular arrhythmias is reported. Significant early complications occurred in four patients and included hypotension, pericarditis, nonsustained polymorphic ventricular tachycardia and one sudden death. In 42 patients (86%), complete atrioventricular (AV) block was initially achieved. During the follow-up period, AV conduction resumed in 2 of these 42 patients. Of the seven patients in whom ablation was unsuccessful, two developed late complete AV block and three had symptomatic improvement. An improved activity level was reported among 83% of the patients with successful ablation. Health care utilization manifest as the number of hospital admissions per year before and after ablation decreased significantly after ablation (2.4 +/- 2.0 versus 0.3 +/- 0.5, p less than 0.001). Echocardiographic evaluation in five patients with a depressed left ventricular ejection fraction (27 +/- 7%) before ablation showed a significant increase (45 +/- 14%, p less than 0.05) after an average follow-up period of 31 months. New onset of congestive heart failure occurred after ablation in four patients, of whom two had no structural heart disease. The total mortality rate, including the one patient with sudden death, was 17% and was significantly higher among patients with underlying structural heart disease. Transcatheter direct current ablation is an effective treatment in patients with drug-resistant supraventricular tachycardia, providing a beneficial long-term outcome including an improved quality of life and a decrease in health care utilization. | 3 |
Ascending cholangitis: surgery versus endoscopic or percutaneous drainage. A retrospective review of 61 patients with calculous cholangitis was carried out. There were 31 men and 30 women and their mean age was 75.8 years. All patients had abdominal pain, 87% had chills and fever, 65% had clinical jaundice, 23% were in shock, and 54% had positive blood cultures. Because intravenous hydration and antibiotics did not help, 33 patients underwent surgery, 25 patients underwent endoscopic papillotomy (EP), and three patients underwent percutaneous transhepatic drainage of the common bile duct (PTD). Morbidity in the surgery group included two wound infections, one respiratory failure, and one renal failure. Morbidity in the EP-PTD group was one case of arterial bleeding requiring surgery and one of pancreatitis treated conservatively. Two patients (6%) died in the surgery group, one of sepsis and the other of cardiorespiratory arrest. In the EP-PTD group nine patients (32%) died of sepsis and multisystem organ failure. These patients were considered too ill to undergo surgery and thus repeat EP-PTD was carried out. Cholangitis persisted, and retained common bile duct stones with sepsis was the cause of death. Thus when initial EP or PTD is unsuccessful, surgical exploration of the common bile duct should be carried out to control sepsis. | 4 |
Scleroderma and central nervous system vasculitis. We describe a patient with scleroderma (CREST syndrome) and central nervous system vasculitis. While angiography demonstrated segmental symmetrical arterial narrowing characteristic of vasculitis, results of leptomeningeal biopsy were normal. There was no evidence of systemic vasculitis, renal failure, or malignant hypertension previously thought to be required to explain central nervous system dysfunction in patients with scleroderma. Signs and symptoms attributable to vasculitis were reversible with aggressive immunosuppressive therapy. | 3 |
A severe multisystem reaction to sulindac. We present a case of a severe reaction to sulindac. A 30-year-old woman with quiescent systemic lupus erythematosus received sulindac for nonspecific migrating chest pain. An initial course of therapy produced an unrecognized sensitization to the drug with a febrile illness and rash. Readministration of the drug caused an anaphylactoid reaction as well as evidence of cardiovascular, hepatic, pulmonary, and hematologic dysfunction. The patient's illness had evidence of types I, II, and III hypersensitivity reactions. | 4 |
Tracheotomy in the first year of life. Much has been written concerning complications of pediatric tracheotomies, but few studies have reviewed the complication rates of tracheotomies performed in the first 12 months of life. We reviewed the records of 60 patients who underwent tracheotomy in the first year of life between 1976 and 1988. This study includes 30 full-term infants and 30 premature infants, 16 of whom were very low birth weight preterm infants (less than or equal to 32 weeks' gestation and less than 1,500 g birth weight). Overall complication rates were 3% intraoperative, 13% early postoperative, and 38% late postoperative. The early postoperative complication rate in preterm infants was nearly double that of full-term infants. The late postoperative complication rate of patients undergoing tracheotomy for airway obstruction was more than double that of patients requiring tracheotomy for pulmonary indications. Duration of tracheotomy, however, was felt to be the most important factor in the development of a late postoperative complication. | 4 |
Total knee arthroplasty in patients after patellectomy. Twenty-six total knee arthroplasties (TKAs) were evaluated in 22 patients who had had a patellectomy. Fourteen knees (12 patients) had a primary TKA, and 12 patients had a revision TKA. Two patients in the revision group, whose prostheses failed, were from the primary TKA group. The mean follow-up time was 8.5 years in the primary TKA group and 7.6 years in the revision TKA group. A group of 14 control knees with patellae was randomly generated but matched for prosthesis, diagnosis, surgeon, age, and time of surgery. This group was similarly evaluated with an average follow-up time of 6.9 years. The primary TKA group had seven knees that were rated as good or excellent, two as fair, and three as poor. The control group had a significantly higher average rating than the primary TKA group. In this group, there were 12 good or excellent knees, three fair, and none poor. Postoperative pain, flexion contracture, extension lag, and range of motion all contributed significant information to the final score, whereas other variables (walking, function, strength, and instability) did not contribute any additional information. Although higher overall scores may have been expected if the patients had patellae, the results during the follow-up examination were satisfactory and justified TKA in these patients. In general, however, patients without patellae may be at a higher risk for failure of the prosthesis, as seen in five patients having primary TKA and another ten patients with failed TKA requiring revision. | 4 |
The cholecystokinin receptor antagonist devazepide enhances morphine-induced analgesia but not morphine-induced respiratory depression in the squirrel monkey. The effects of the cholecystokinin antagonist devazepide on analgesia and respiratory depression induced by morphine in squirrel monkeys were examined. Pain thresholds were determined using the tail withdrawal procedure, in which monkeys restrained in chairs kept their tails in cool (35 degrees C) water for at least 20 sec, but withdrew them from warm (55 degrees C) water in less than 4 sec. Morphine produced a dose-related increase in tail withdrawal latencies from warm water. Devazepide (injected i.p. or p.o.) had no effect on tail withdrawal latencies when given alone but enhanced the analgesic effects of morphine. The devazepide dose-response curve for morphine enhancement was bell-shaped with doses of 3, 10, 30 and 100 micrograms/kg injected i.p. increasing morphine analgesia whereas higher and lower dose did not. In a separate group of monkeys, morphine produced dose-dependent decreases in respiratory rate and oxygen tension and increases in carbon dioxide tension. In contrast to its effects on morphine analgesia, devazepide had no effect on the various indices of morphine-induced respiratory depression. These data suggest that devazepide may have therapeutic utility as an adjuvant to morphine analgesia allowing lower dose of the opiate to be used to relieve pain and reducing the risk of opiate-induced respiratory depression. | 2 |
Multiple spinal epidural metastases; an unexpectedly frequent finding. In a prospective study, patients with known malignant disease who were suspected of having a spinal epidural metastasis, had myelography which was not confined to the clinically suspected site, but included at least the whole lumbar and thoracic spinal canal. Fifty four of the 106 myelograms revealed at least one epidural metastasis. Twelve of these 54 myelograms showed two separate lesions, and four myelograms showed three separate lesions. In all 16 cases with multiple lesions at least one of the lesions was asymptomatic at the time of the diagnosis. It is concluded that multiple spinal epidural metastases are of common occurrence and occur in about one third of the cases. This finding may have important clinical implications. Examination of the spinal canal for epidural metastases should not be confined to the clinically suspected site, but should include as extensive an area as possible of the spinal canal, whatever technique is to be used. | 0 |
Prevalence and determinants of estrogen replacement therapy in elderly women. To better understand which women use estrogen replacement therapy, we examined the prevalence and determinants of estrogen replacement therapy in 9704 nonblack women, age greater than or equal to 65 years, who participated in the multicenter prospective Study of Osteoporotic Fractures. Overall, 13.7% of women reported current use of oral estrogen; 10.9% took estrogen alone and 2.8% took estrogen opposed by progestin. Four percent currently used parenteral estrogen compounds. Current use declined sharply with age from 17% at age 65 to 4% at age greater than or equal to 85. The primary determinant of estrogen replacement therapy was the type of menopause; the odds of using estrogen replacement therapy in current users compared with never users were approximately five times higher in women with a surgical menopause. Estrogen use was more common among women who had higher levels of education and were less obese. Furthermore, estrogen replacement therapy users were more likely to drink alcohol and to participate in sports and recreation. A diagnosis of osteoporosis was the major determinant of continued estrogen use, but only 24% of women with a diagnosis of osteoporosis used estrogen replacement therapy. We conclude that only a small proportion of elderly women in the United States use estrogen replacement therapy. Selection factors for use of estrogen are evident and may introduce bias in studies of estrogen and disease. In consideration of the distribution of these selection factors, estrogen users will tend to be at lower risk of coronary disease and possibly breast cancer but at greater risk for hip fractures. | 3 |
Diffuse intermediate lymphocytic lymphoma. A clinicopathologic study and comparison with small lymphocytic lymphoma and diffuse small cleaved cell lymphoma. Controversy has recently arisen as to whether diffuse intermediate lymphocytic lymphoma (ILL) should be considered a low-grade or an intermediate-grade non-Hodgkin's lymphoma for clinical purposes. Therefore, the authors performed a clinicopathologic study to determine the biologic course of diffuse ILL (40 cases) and compared it with small lymphocytic lymphoma (SLL; 51 cases) and diffuse small cleaved cell lymphoma (DSCCL; 14 cases). They found that patients with diffuse ILL having pseudofollicular proliferation centers (PC) had a significantly longer median survival (84 months) than those without PC (46.5 months; P = 0.03). The median survival of patients with SLL was 72 months, whereas those with DSCCL had a median survival of only 18 months. Based on these findings, the authors conclude that diffuse ILL with PC should be included in the low-grade category of SLL for clinical purposes, whereas diffuse ILL without PC (true diffuse ILL) should be considered an intermediate-grade non-Hodgkin's lymphoma. True diffuse ILL is similar to centrocytic lymphoma in the Kiel classification and should be accorded a similar status in a modified Working Formulation. | 0 |
Radiation therapy in metastatic spinal cord compression. A prospective analysis of 105 consecutive patients. One hundred thirty consecutive patients with metastatic spinal cord compression (MSCC) were entered in a therapeutic protocol in which radiation therapy (RT) played the main role. When MSCC is diagnosed by clinical-radiologic methods such as myelography with or without computed tomography (CT) or magnetic resonance imaging (MRI), steroids are given and RT treatment started within 24 hours. When diagnostic doubts exist or stabilization is necessary, surgery precedes RT. Chemohormonal potentially responsive tumors are also treated with chemotherapy or hormonal therapy. Twelve patients (9.2%) underwent surgery plus RT, and 118 (90.8%) received RT alone. Thirteen (11%) early death patients were not evaluable. The 105 evaluable cases that received RT alone were analyzed. Median follow-up was 15 months (range, 4 to 38 months). Response among patients with back pain was 80%. In cases with motor dysfunction, 48.6% improved, and in 33 of 105 patients (31.4%) without motor disability there was no deterioration. Forty percent of patients with autonomic dysfunction responded to RT. Median survival time was 7 months with a 36% probability of survival for 1 year. The median duration of improvement was 8 months. The most important prognostic factor was early diagnosis. Radiosensitivity of tumor was only important in paraparetic patients in predicting response to RT. Complete myelographic block significantly diminished response to RT. Vertebral collapse did not influence response or survival. | 0 |
Leukaemia complicating treatment for Hodgkin's disease: the experience of the British National Lymphoma Investigation. OBJECTIVE--To determine the incidence of and risk factors for the development of secondary acute leukaemia and myelodysplasia in patients treated in British National Lymphoma Investigation's studies of Hodgkin's disease since 1970. PATIENTS--2676 Patients entered into Hodgkin's disease studies between February 1970 and November 1986. Data accrued up to November 1988 were analysed, ensuring a minimum follow up period of two years. DESIGN--Retrospective analysis of multicentre trial data by case-control and life table methods. RESULTS--17 Cases of secondary leukaemia were recorded in this group of 2676 patients, giving an overall risk at 15 years of 1.7%. The risks of leukaemia after chemotherapy alone and chemotherapy with radiotherapy were not significantly different. The risk of leukaemia increased sharply with the amount of treatment given as measured by the number of attempts at treatment. The 15 year risks of leukaemia were 0.2%, 2.3%, and 8.1% for patients receiving one, two, or three or more attempts at treatment. The highest risk, 22.8% at 15 years, was observed in patients treated with lomustine (CCNU), and a case-control study suggested that this was an independent risk factor. The risk of secondary leukaemia was largely related to the overall quantity of treatment, although exposure to lomustine seemed to be an important risk factor. Treatment with both drugs and radiation was not more leukaemogenic than treatment with drugs alone. The greatest risk of secondary leukaemia was seen in multiply treated patients who were unlikely to be cured of Hodgkin's disease. CONCLUSIONS--Avoidance of secondary leukaemia should be a minor factor in the choice of treatment for Hodgkin's disease. | 0 |
Light scattering detection of microemboli in an extracorporeal LVAD bovine model. Thromboembolization studies were performed on two calves supported by extracorporeal left ventricular assist devices (LVAD) using a light scattering (He Ne Laser) microemboli detector (LSMD). The LSMD system was placed on the outflow cannula of the LVAD in the extracorporeal loop of each animal. The measurements included the size, number, and rate of production of circulating microemboli in the range 20 microns less than microemboli diameter less than 1,000 microns. These data were compared to independently and concurrently obtained measurements of emboli shear rate (CPF), platelet count, red blood count (RBC), leukocyte count (WBC), plasma free hemoglobin, factors XIII, X, and V, and sorbitol dehydrogenase. Embolic number and volume were seen to be most dynamic in the very early phases of acute thromboembolization (0-40 minutes) with a peak embolic response within the first 30 minutes. The dynamics of reduced emboli volume, rather than number, may be implicated in the later stages of the thromboembolic passivation of these ventricles. The LSMD results generally showed an inverse correlation of microemboli volume rate with CPF measurements for each ventricle. LSMD, CPF, and leukocyte and platelet counts, showed a direct correlation with reduced counts for each additional ventricle for both calves. Factor XII was seen to have a more direct correlation in time with LSMD measurements for each ventricle than other parameters under investigation. This study represents the first time laser scattering and filtration methods have been applied simultaneously with hematologic assays in order to study the dynamics of device associated thrombogenesis. | 3 |
Radiographic techniques and efficacy in evaluating esophageal dysphagia. The radiographic examination of the esophagus to determine structural and/or functional causes of dysphagia is best performed with multiple techniques. These include full-column studies to produce distended films with or without the use of a solid bolus, mucosal relief films to identify mucosal defects such as esophagitis or the presence of varices, double-contrast films, and motion recording (fluoroscopy). The efficacy of each technique depends on the quality of the study and the specific disorder to be detected. Esophageal lesions producing dysphagia are classified into extrinsic structural lesions, intrinsic structural lesions, and esophageal motility disorders. Radiographic studies are the preferred screening techniques for patients with dysphagia. Although not as sensitive for the evaluation of mucosal lesions, radiographic studies are superior to endoscopy for the detection of abnormal motility, esophageal rings, and strictures. | 1 |
Salvage of branch vessels during bifurcation lesion angioplasty: acute and long-term follow-up. To evaluate angiographic success, frequency of branch vessel loss and salvage, and long-term outcome, we studied the early and late outcomes of 56 consecutive patients who underwent PTCA of bifurcation lesions, which involved the left anterior descending or left circumflex coronary artery, with stenoses greater than 70% in both the parent and an involved branch vessel. In 35 patients (63%), the PTCA strategy was attempted dilation of both the main vessel and the involved branch vessels using predominantly a double-wire, sequential balloon technique; in 21 (27%) the PTCA attempt was confined to the main vessel alone. Transient angiographic occlusion of the branch vessel occurred in 32% of patients in whom dilation of both vessels was attempted, and in 38% in whom the main vessel alone was dilated (p = NS); 91% of the occluded branch vessels were the salvaged when sequential angioplasty of both vessels had been initially planned, compared to only 38% when the initial strategy had been dilation of the main vessel alone (p less than .05). Predischarge exercise testing showed residual ischemia in 6% of patients who had both vessels successfully dilated, versus 37% in those in whom dilatation was confined to the main vessels (p less than .01). Clinical restenosis, defined as late (greater than 6 weeks) recurrence of angina or a positive exercise test, occurred in 42% of patients who had both vessels successfully dilated. Thus although bifurcation lesion angioplasty frequently results in transient branch vessel loss, these branches can usually be salvaged using a double-wire technique but tend to have a higher late restenosis than conventional single vessel PTCA. | 4 |
Identification of pre- and postcentral gyri on CT and MR images on the basis of the medullary pattern of cerebral white matter. The authors illustrate a new method to identify the pre- and postcentral gyri on computed tomographic (CT) and magnetic resonance (MR) images of the brain on the basis of the pattern of the medullary branches of the cerebral white matter. The most commonly used method to identify the gyri depends on recognition of the central sulcus by surface arrangement of the sulci. The two methods were compared by analysis of CT images of 104 subjects who had normal findings (age range, newborn to 60 years; 57 males and 47 females). The usefulness of the new method was also determined in angiographic studies of nine patients with space-occupying lesions. The method is especially helpful for identification of gyri on the lower level of the centrum semiovale and if space-occupying lesions are present that may result in a blurred depiction of sulci. Since MR imaging depicts the medullary branches more clearly than does CT, this new method should facilitate identification of the gyri with either modality. | 2 |
Treatment of severe acne with isotretinoin in patients with inflammatory bowel disease. Four patients with inflammatory bowel disease and severe cystic acne were treated with isotretinoin. Two patients had a successful course of treatment without any gastrointestinal side-effects. One patient had two episodes of profuse rectal bleeding that were probably related to pre-existing haemorrhoids. The fourth patient had a flare-up of his Crohn's disease after starting isotretinoin. | 1 |
Response to suxamethonium in a myasthenic patient during remission. A cumulative dose followed by an infusion was used to determine the dose response to suxamethonium in a patient with diagnosed myasthenia gravis who was in true remission (asymptomatic while receiving no therapy). The ED50 and ED90 values for suxamethonium were 0.08 mg/kg and 0.20 mg/kg, and an infusion rate of 3.2 mg/kg/hour was required to maintain a 90-95% depression of the single twitch response as monitored by integrated electromyography. These values are within the range for normal patients, and we conclude that myasthenic patients during a true remission may not demonstrate resistance to suxamethonium. | 2 |
Left alien hand sign and mirror writing after left anterior cerebral artery infarction. A 43-year-old, right-handed man was admitted complaining of peculiar movements of his left hand. Computed tomography scan and magnetic resonance imaging showed an infarct area in the territory of the left anterior cerebral artery. The abnormal movements of the left hand were diagnosed as so-called alien hand sign. This patient also exhibited mirror writing with his left hand. The clinical manifestations and neuroradiological findings of this case are described in detail, and the possible mechanisms of these extremely rare combinations of alien hand sign and mirror writing are discussed. | 2 |
Adult respiratory distress syndrome after limited resection of adenocarcinoma of the lung. Two cases of the adult respiratory distress syndrome developed after limited resection for lung carcinoma. No other known precipitants were evident. The adult respiratory distress syndrome is a clinical expression of acute lung injury that may arise from various insults and include air and blood borne factors. Tumour related blood borne factors may have contributed to lung injury in these cases. | 4 |
All-trans retinoic acid in acute promyelocytic leukemias. II. In vitro studies: structure-function relationship. All-trans retinoic acid induces leukemic cells from patients with acute promyelocytic leukemia (M3) to differentiate in vitro to mature granulocytes which express the CD15 antigen and are capable of respiratory burst function. Of 35 M3 samples, only one failed to respond. In eight cases, we compared the efficacy of two naturally occurring isomers of retinoic acid, all-trans RA and 13-cis RA. Both isomers induce maximal differentiation at 10(-6) mol/L. The maximal response was maintained at 10(-7) mol/L for the all-trans but not for the 13-cis RA. We also observed that the metabolites 4-oxo-all-trans and 4-oxo-13-cis were effective at 10(-6) mol/L. This 1 order of magnitude difference in the in vitro differentiating potencies of all-trans RA and 13-cis RA in the blasts of promyelocytic leukemias predicts a difference in the clinical efficacy of the two drugs. | 0 |
Histopathologic evidence of fibrovascular ingrowth four weeks after placement of the hydroxyapatite orbital implant. We studied the histopathologic findings after placement of an orbital hydroxyapatite implant in a patient. The implant was placed after enucleation for a choroidal melanoma and was removed four weeks later because histopathologic examination of the enucleated globe disclosed tumor invasion of the optic nerve that necessitated further orbital tissue removal. Our histopathologic findings confirm that there is significant ingrowth of fibrovascular tissue in these implants, even within weeks of implantation. | 0 |
Translocation breakpoint of acute promyelocytic leukemia lies within the retinoic acid receptor alpha locus. Acute promyelocytic leukemias (APLs) are characterized by a reciprocal balanced translocation that involves chromosomes 15 and 17 [t(15;17)]. We report the isolation and characterization of one of the two reciprocal break sites and demonstrate that the chromosome 17 breakpoint lies within the retinoic acid receptor alpha locus. Nucleotide sequencing of the 15;17 cross-over junction on 15q+ showed that the retinoic acid receptor alpha gene is truncated within its first intron, 370 base pairs upstream from the splicing donor site of exon II. Such a recombination would be expected to generate abnormal RAR alpha mRNA and protein. Southern blot analysis of a number of APLs with chromosome 15- and 17-derived DNA probes revealed similar 15;17 recombinations in the majority of other APLs. Our data are strong evidence that the retinoic acid receptor alpha gene plays a crucial role in the leukemogenesis of APL. | 4 |
Gonadoblastoma in an anatomically normal man: a case report and literature review. Gonadoblastoma, a rare gonadal neoplasm, presents most frequently in phenotypic female or phenotypically male patients with dysgenetic gonads or undescended testes. To date, only 2 cases of gonadoblastoma have been reported in anatomically normal male patients with scrotal testes. Both of these patients presented with testicular masses and germ cell tumors. We report a case of a genotypically and phenotypically normal, fertile man with descended testes who on evaluation for chronic orchialgia had a gonadoblastoma unaccompanied by a germ cell neoplasm. The tumor was nonpalpable and was initially discovered on scrotal ultrasound. | 0 |
Lung lobe torsion following lobectomy. Three cases of postoperative pulmonary lobe torsion were reported. Two of three showed hemorrhagic infarctions, and as a result underwent rethoracotomies and removal of the affected lobes. From these experiences, we consider that computed tomography (CT) and bronchofiberscopic examinations are useful for the diagnosis of advanced torsion. | 4 |
The effect of screws and pegs on the initial fixation stability of an uncemented unicondylar knee replacement. Two uncemented unicompartmental tibial components were examined for initial fixation stability. A conventional design that employed a single posteriorly angled peg was compared with a new design that was held in place by cancellous bone screws. The components were implanted into the medial condyles of 12 preserved human tibiae, and a cyclic load was first applied anteromedially and then posteromedially. The screwed implants failed at significantly higher loads (1634.8 +/- 121.6 N, mean +/- standard error of the mean) than the pegged implants (1103.3 +/- 152.0 N). On application of a 19.6-N preload, the screwed implants moved significantly less than the pegged implants. Although the differences in micromotion and subsidence were not always significant, there were definite trends. The screwed implants had much lower levels of temporary and permanent displacement compared with the pegged implants for all load levels from the initial load of 245.2 N up to and including the failure load. When the motion that resulted from moving the load from the anterior position to the posterior position was examined, the screwed implant's average total motion was less than 10 microns compared with almost 135 microns for the pegged implant after the 245.2-N load cycle. For the cycle before failure, the screwed implant's average motion increased to less than 29 microns, whereas the pegged implant's average total motion was almost 354 microns. From this information it appears clear that screws provide better initial fixation stability than angled pegs for uncemented unicondylar tibial components. | 4 |
Brake mechanics, asbestos, and disease risk. Health risks posed by inhalable asbestos fibers are known to exist in a variety of industrial and nonindustrial settings. Although early studies described an increased risk of asbestosis, lung cancer, and mesothelioma in asbestos-industry workers, subsequent research revealed the existence of a potential asbestos-related health hazard in nonasbestos industries such as the textile and railroad industries. Brake mechanics and garage workers constitute a large work force with potential exposures to levels of asbestos capable of producing disease. Unfortunately, the health risk faced by these workers has received little attention. This article briefly discusses currently available information on the asbestos health risks of workers in this setting, and highlights the need for further investigations of this occupational group. | 0 |
Congenital duodenal diaphragm: conversion of stable chronic symptoms to subacute gastric outlet obstruction by penetrating foreign body. Congenital duodenal diaphragms (CDD) are rare lesions that usually become symptomatic and require surgery in childhood. We report a patient, who, although symptomatic since early childhood, had accommodated to the condition and finally required surgical correction in late life after an ingested foreign body traumatized the diaphragm, producing subacute gastric outlet obstruction. The condition, including the reconstruction of the precipitating event, was diagnosed endoscopically prior to surgery. | 4 |
Prospective randomized study on the effect of ranitidine against injection ulcer after endoscopic injection sclerotherapy for esophageal varices. Thirty-five consecutive patients undergoing endoscopic injection sclerotherapy for esophageal varices were randomly allocated to either ranitidine-administered group (18 patients) or ranitidine-nonadministered group (17 patients), in an attempt to evaluate the efficacy of ranitidine for prevention and healing of postinjection ulcer with a prospective randomized trial. Two of seventeen patients in the nonadministered group dropped out of this trial because of development of gastric ulcer, so 18 patients in the first group were evaluated and compared with the 15 remaining patients in the second group. Sclerotherapy was performed with 5% ethanolamine oleate and 0.6% polydocanol; the mean number of injection courses and the mean amount of sclerosant were the same in both groups. Moreover, there was no significant difference between the two groups in either the occurrence rate or the size of injection ulcer 1 wk after the last session. However, the persistence rate of ulcer 1 month after last injection in the ranitidine-administered group was significantly lower than that in the ranitidine-nonadministered group (6.3% vs. 38.5%, p less than 0.05). Our study demonstrated that ranitidine administration will help to hasten healing of postinjection ulcer, although it was not effective for prevention of injection ulcer. | 1 |
rCBF-SPECT in brain infarction: when does it predict outcome? We prospectively studied 26 patients with ischemic stroke within 24 hr, after 2 wk, and after 6 mo with thallium-201-diethyldithiocarbamate single-photon emission computed tomography (SPECT) and neurologic and functional assessments. The admission flow deficits correlated with outcome. The admission and 6-mo scores correlated with clinical conditions at each time. At 2 wk, the flow deficits were smaller and did not correlate with clinical parameters. Nor did the presence or absence of hyperfixation of the radiopharmaceutical. Six months after the infarct, the flow defect had decreased in 9 of 15 patients in whom three serial scans were available, with better clinical improvement than in the remaining six whose flow deficits increased. More patients in the first group had been treated randomly with the calcium-entry blocker flunarizine. SPECT imaging of rCBF within 24 hr after stroke correlates with clinical outcome and condition, whereas rCBF imaging at 2 wk after the stroke shows no clinical correlation. | 2 |
The effect of quinidine and mexiletine on the adaptation of ventricular refractoriness to an increase in rate. The purpose of this study was to determine the effects of quinidine and mexiletine on the adaptation of ventricular refractoriness to a change in heart rate. The ventricular effective refractory period was measured at a basic drive cycle length of 500 msec with basic drive train durations of two beats, eight beats, 20 beats and 3 minutes. The ventricular refractory periods were measured in the baseline state and after oral treatment with quinidine or mexiletine in 20 subjects each. In the baseline state, there was progressive shortening of the ventricular refractory period as the drive train duration increased from two beats to 3 minutes. Quinidine prolonged refractoriness by 5% (p less than 0.001) at each drive train duration. Mexiletine did not affect the ventricular effective refractory period at any of the drive train durations. In a control group of 20 subjects, there were no significant differences between two determinations of refractoriness at each basic drive train duration. In conclusion, neither quinidine nor mexiletine affect the adaptation of ventricular refractoriness to an increase in rate. Although the ventricular effective refractory period measured with a conventional basic drive train duration of eight beats is often more than 20 msec longer than the actual ventricular effective refractory period measured with a drive train duration of 3 minutes, the effects of quinidine and mexiletine on the conventionally measured ventricular effective refractory period accurately reflect the effects of these drugs on the actual ventricular effective refractory period. | 3 |
The recalcitrant perineal wound after rectal extirpation. Applications of muscle flap closure. Perineal wounds developing after abdominoperineal resection result in chronic purulent drainage and intermittent episodes of sepsis and are generally unresponsive to conservative medical and surgical treatment. Thirteen consecutive patients (aged 27 to 74 years; mean, 48 years) who underwent debridement and immediate muscle flap closure of these wounds were analyzed to identify risk factors for delayed healing and to evaluate the effectiveness of muscle flap coverage. Three risk factors were identified: preoperative or postoperative radiation therapy, resection for recurrent carcinoma, and inflammatory bowel disease. A total of 19 muscle flaps (11 gracilis, five gluteal thigh, two gluteus maximus, and one rectus abdominis) were used to close these wounds. During an average 3.5-year follow-up, four (31%) minor complications and one (8%) recurrence were noted to occur. Muscle flaps provide safe, effective, single-stage procedures for the closure of chronic perineal wounds. | 4 |
Pulmonary metastases and bone sarcomas. Surgical removal of lesions appearing after adjuvant chemotherapy. Pulmonary metastasis is the leading cause of death in pediatric patients with bone tumors. Multiple thoracotomies for surgical removal of individual lesions are performed at many centers. To explore the efficacy of this procedure and establish guidelines for an appropriate choice of patients, the experience with 43 thoracotomies in 24 children was reviewed. The appearance of first metastasis later than one year after diagnosis, presence of fewer than five nodules, and completeness of surgical resection were favorable predictors of postthoractomy survival. Early or multiple metastases, unresectable disease, and hilar, nodal, or pleural lesions conferred an unfavorable prognosis. With careful patient selection, pulmonary metastecotomy is a safe procedure that has few operative or long-term complications. It must be emphasized that although surgical removal of pulmonary metastases prolongs survival with good quality of life, the majority of patients with bone sarcomas ultimately succumb to their disease after thoracotomy. Follow-up time of greater than eight years is necessary to adequately assess the effectiveness of pulmonary resection in eradicating all disease in these patients. | 0 |
Clustering of atherogenic behaviors in coffee drinkers. We studied the clustering of coffee consumption and selected atherogenic behaviors in older adults living in a southern California community. Men were somewhat more likely to drink caffeinated coffee while women were more likely to drink decaffeinated coffee. In men, but not women, caffeinated coffee drinking decreased with age and decaffeinated coffee drinking increased. Caffeinated coffee drinkers drank more alcohol, consumed more dietary saturated fats and cholesterol, were more likely to be current smokers and less likely to be current exercisers than were non-coffee drinkers. Smoking and exercise also showed a dose-response relationship to the amount of caffeinated coffee consumed. Risk factor levels among drinkers of decaffeinated coffee were more like those of caffeinated coffee than non-drinkers. These data illustrate the clustering of atherogenic behaviors with coffee drinking and highlight their potential importance in interpreting the growing body of literature about coffee and health. | 3 |
Diagnostic value of ventricular stimulation in patients with idiopathic dilated cardiomyopathy. To assess the response to programmed ventricular stimulation and the clinical outcome, we performed a prospective study in 103 patients with idiopathic dilated cardiomyopathy. The protocol used up to three extrastimuli delivered at two right ventricular sites during sinus rhythm and ventricular pacing at 100 and 150 beats/min and was repeated during infusion of 1 to 4 micrograms/min of isoproterenol. Sustained monomorphic ventricular tachycardia (VT) was induced in 8 of 11 patients with spontaneous sustained VT, in none of 35 patients without significant ventricular arrhythmias during Holter monitoring, and in 9 of 56 patients with salvos of ventricular premature beats. Isoproterenol infusion facilitated the induction of two episodes of sustained VT in patients with spontaneous sustained VT; however, in all but one of the remaining patients, induction of ventricular tachyarrhythmias was not impaired. During the follow-up period there were eight sudden deaths among patients who initially had syncope, inducible sustained VT, or both and three episodes of sustained VT in patients who initially had nonsustained VT but inducible sustained VT. Isoproterenol infusion can be used to safely facilitate induction of ventricular tachyarrhythmias in patients with dilated cardiomyopathy. The induction of sustained VT was associated with a poor prognosis. | 4 |
Dysphagia and esophageal motor dysfunction in gastroesophageal reflux are corrected by fundoplication. Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction. | 1 |
Klinefelter's syndrome with anomalous origin of left main coronary artery Klinefelter's syndrome is a rare entity. Even rarer is an anomalous origin of the Left Main Coronary Artery. For both conditions to occur in the same patient is hence exceedingly rare. Reported here is a never previously reported case of a coronary congenital anomaly in a patient with Klinefelter's syndrome together with the proper angiographic approach. | 4 |
Prolonged intermittent clamping of the portal triad during hepatectomy. From 112 consecutive hepatectomies for malignant tumours performed with intermittent portal triad clamping, we have retrospectively selected the 20 cases in which clamping exceeded 90 min. Intermittent portal clamping of prolonged duration was used because of abnormal liver texture in 13 cases (mainly patients who had received intra-arterial chemotherapy) and/or because of technically difficult hepatectomy. The mean(s.d.) duration of intermittent portal clamping was 109(18) min and in two cases it exceeded 140 min (148 and 150 min). There was no postoperative mortality and the rate of postoperative morbidity was 35 per cent. Postoperative changes in biochemical liver tests were not major and transient hepatic failure occurred in only one patient following subtotal resection of the liver. We conclude that intermittent portal clamping is a useful manoeuvre in partial hepatectomy when resection is difficult or prolonged, or when the liver parenchyma is abnormal. Such clamping may be used for longer than 120 min without major complications. | 4 |
Cutaneous vasculitis associated with pheochromocytoma. We describe a patient who presented with constitutional symptoms, severe hypertension, and purpuric lesions over the knees, thighs, and penis. The patient was eventually diagnosed as having multiple endocrine neoplasia type II, with cutaneous leukocytoclastic vasculitis. The cutaneous vasculitis persisted despite treatment with high-dose systemic corticosteroids, but rapidly resolved after the removal of bilateral pheochromocytomas. This case demonstrates cutaneous leukocytoclastic vasculitis in association with pheochromocytoma. | 3 |
The Roux operation for postgastrectomy syndromes. The aim of this paper is to describe the technique, indications, and results of the Roux operation as used in the treatment of postgastrectomy syndromes. A Roux gastrojejunostomy with a 40-cm Roux limb is the procedure of choice for alkaline reflux gastritis, because it virtually eliminates reflux of bile and pancreatic juice into the stomach. The slow transit through a Roux limb can also be used to good advantage to slow gastric emptying in patients with dumping. Patients with delayed gastric emptying respond to the combination of near-total gastric resection, which removes the atonic gastric remnant and speeds emptying, and Roux-Y gastrojejunostomy, which prevents reflux esophagitis and provides a reservoir for ingesta in the upper gut. After all Roux operations, however, the Roux limb may slow emptying so much that pain, fullness, nausea, and food vomiting result, the so-called Roux stasis syndrome. Prevention of the Roux stasis syndrome with an "uncut" Roux limb and the treatment of the syndrome by using electrical pacing to suppress the ectopic pacemakers that emerge in the limb offer possible new solutions to this vexing problem. | 1 |
Anchorage-independent growth and the expression of cellular proto-oncogenes in normal human epidermal keratinocytes and in human squamous cell carcinoma cell lines. The expression of multiple cellular proto-oncogenes and the in vitro anchorage-independent growth of normal human epidermal keratinocytes and several human squamous cell carcinoma cell lines were studied and correlated. Squamous cell carcinoma cell lines KB, Si Ha, HEp-2, and Fa Du showed high anchorage independency, and MS 751 and A-253 cell lines had minimum independency. However, the normal keratinocytes and the A-431 cell line did not show anchorage-independent growth. Both the normal human epidermal keratinocytes and cancer cell lines expressed multiple proto-oncogenes such as src, erb B-1, abl, fos, raf, H-ras, and myc, and the amount of expression of these oncogenes was notably higher in the cancer cell lines than in the normal keratinocytes. The expression of proto-oncogenes from the monolayer cultures of the cancer cell lines is poorly correlated with the anchorage independency of the cells. These data indicate that the anchorage independency is not directly linked to the expression of specific cellular proto-oncogene(s) of the monolayer cancer cell cultures. | 4 |
Migration stimulating activity in serum of breast cancer patients. An assay to measure the ability to stimulate migration of fibroblasts into collagen gel was carried out on serum from treated and untreated breast cancer patients and from healthy controls. Migration stimulating activity was found in the serum of 10 (83%) of 12 untreated breast cancer patients immediately before surgical resection of the primary tumour and in 9 (75%) of them 4 days after resection; in 13 (93%) of 14 patients 1-13 years after tumour resection who had received adjuvant treatment; and in 2 (10%) of 20 healthy women matched for age. The migration stimulating activity in cancer patients' serum was indistinguishable from the migration stimulating factor produced in vitro by fetal and cancer patient skin fibroblasts in its behaviour in various biochemical fractionation procedures. The presence of this activity in the serum of treated breast cancer patients clearly distinguishes it from other oncofetal proteins, which all seem to be produced by tumours. | 0 |
Growth factor-dependent differentiation along the myeloid and lymphoid lineages in an immature acute T lymphocytic leukemia. Bone marrow cells from a child with an immature (CD2+, CD5+, CD7+) acute T lymphocytic leukemia (T-ALL) were cultured in the presence and absence of human rIL-2, IL-3, or granulocyte-macrophage (GM)-CSF. Cells cultured without growth factors failed to divide and those initiated in the presence of IL-2 or GM-CSF underwent maturation and terminal T lymphoid or myelomonocytic differentiation, respectively. In contrast, a permanent growth factor-dependent cell line, designated TALL-103/3, was established upon culture in IL-3. The TALL-103/3 cells gradually lost the T cell-specific markers and acquired a myeloid phenotype (CD15+, CD33+). Switching of the IL-3-dependent cells at an early passage to medium containing only human rIL-2 resulted in the establishment of a subline, named TALL-103/2, with a T lymphoid phenotype (CD3+, CD8+, TCR-gamma delta +, CD7+). The TALL-103/2 cells strictly require IL-2 for growth, are irreversibly committed to the lymphoid lineage, and cannot survive in the presence of any other hemopoietic growth factor tested so far. In contrast, the IL-3-dependent TALL-103/3 cells could be adapted to grow in synthetic (serum-free) medium also in the presence of either GM-CSF or IL-5, in which they retain a myeloid phenotype. Interestingly, after 18 mo in culture in IL-3, the TALL-103/3 cells can still be phenotypically converted to the lymphoid lineage upon addition of IL-2, thus maintaining its bipotentiality. Despite the marked phenotypic differences, the TALL-103/2 and TALL-103/3 cell lines show the same karyotypes with multiple abnormalities present in the primary malignant clone and have identical rearrangements of the TCR-gamma and -delta loci, thus confirming their derivation from a common precursor cell. Together, these findings indicate that the phenotype of immature T-ALL cells can be drastically modified by the presence of specific hemopoietic growth factors in the environment, leading to either lymphoid or myeloid lineage commitment while leaving their karyotype and genotype intact. | 0 |
Miller-Fisher syndrome and pontine abnormalities on MRI: a case report. The authors report a patient with Miller-Fisher syndrome in whom MRI of the brain stem showed increased signal density on T2 sequence anterior to the fourth ventricle, on the right and the left. The authors discuss the relation between these MRI abnormalities and some clinical features of the syndrome. The authors believe that the cardinal features of Miller-Fisher syndrome are due to peripheral nervous system dysfunction, but that this does not preclude a possible central nervous system involvement. | 2 |
Diagnostic value of ventricular stimulation in patients with idiopathic dilated cardiomyopathy. To assess the response to programmed ventricular stimulation and the clinical outcome, we performed a prospective study in 103 patients with idiopathic dilated cardiomyopathy. The protocol used up to three extrastimuli delivered at two right ventricular sites during sinus rhythm and ventricular pacing at 100 and 150 beats/min and was repeated during infusion of 1 to 4 micrograms/min of isoproterenol. Sustained monomorphic ventricular tachycardia (VT) was induced in 8 of 11 patients with spontaneous sustained VT, in none of 35 patients without significant ventricular arrhythmias during Holter monitoring, and in 9 of 56 patients with salvos of ventricular premature beats. Isoproterenol infusion facilitated the induction of two episodes of sustained VT in patients with spontaneous sustained VT; however, in all but one of the remaining patients, induction of ventricular tachyarrhythmias was not impaired. During the follow-up period there were eight sudden deaths among patients who initially had syncope, inducible sustained VT, or both and three episodes of sustained VT in patients who initially had nonsustained VT but inducible sustained VT. Isoproterenol infusion can be used to safely facilitate induction of ventricular tachyarrhythmias in patients with dilated cardiomyopathy. The induction of sustained VT was associated with a poor prognosis. | 3 |
Susceptibility to effects of UVB radiation on induction of contact hypersensitivity as a risk factor for skin cancer in humans. Normal, healthy human volunteers and patients with proved history of non-melanoma skin cancer have been tested for their capacity to develop contact hypersensitivity to dinitrochlorobenzene (DNCB) following exposure of buttock skin to acute, low-dose ultraviolet B (UVB) radiation. Using a radiation protocol that achieves virtually complete depletion of normal-appearing Langerhans cells from irradiated skin, it was learned that approximately 60% of healthy volunteers developed vigorous contact hypersensitivity (CH) when 2000 micrograms DNCB was painted on the irradiated site. These individuals were designated UVB-resistant, and were distinguished from other individuals, designated UVB-susceptible, who failed to develop contact hypersensitivity following an identical treatment protocol. It was then discovered that virtually all (92%) skin cancer patients exposed to UVB and DNCB failed to develop CH, i.e., were UVB-susceptible. In subsequent experiments, epicutaneous application of 2000 micrograms DNCB to unirradiated skin of UVB-susceptible individuals revealed a further distinction between normal persons and skin cancer patients. Approximately 45% of the latter (and none of the former) remained unresponsive (failed to develop contact hypersensitivity following this second attempt at sensitization), implying that they had been rendered immunologically tolerant. These tolerant individuals responded normally to the unrelated hapten, diphencyprone. We conclude that human beings resemble inbred strains of laboratory mice in that some individuals are UVB-susceptible, whereas others are UVB-resistant. Because the incidence of UVB-susceptibility was significantly higher in skin cancer patients, and as specific unresponsiveness could be demonstrated only in these patients, we propose that UVB-susceptibility, as we define it in this hapten system, may be a risk factor for the development of skin cancer. | 4 |
Coronary angioplasty in symptomatic patients after bypass surgery. With the availability of percutaneous transluminal coronary angioplasty (PTCA), the management of patients who present with recurrent angina following coronary artery bypass surgery (CABG) has changed. From January 1987 to December 1988, 149 symptomatic post CABG patients underwent coronary angiography at our institution. Ninety were treated with medical antianginal therapy, 14 had repeat surgery, and 45 underwent PTCA. Complications of repeat CABG included one death, two perioperative myocardial infarctions, and four patients with postoperative supraventricular arrhythmia. PTCA was performed on 42 lesions in 37 native vessels (88% success rate), and on 24 lesions in 23 vein grafts (91.7% success rate). Complications included acute reocclusion (one patient), peripheral artery occlusion (one patient), hematoma formation (one patient), and periprocedure myocardial infarction (one patient). No deaths occurred. At a mean follow-up of 5.9 +/- 3.8 months, 10 patients had recurrent symptoms, six of whom were found to have restenosis. Repeat PTCA was successfully accomplished in four patients; the other two were treated medically. It is concluded that PTCA is a feasible alternative to repeat CABG in selected patients and can be achieved with a high success rate and minimal complications. | 3 |
Treatment of patients with aortic dissection presenting with peripheral vascular complications. The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients. | 3 |
Reoperation for recurrent peptic ulcer disease. The patient with recurrent peptic ulcer evidences failure of an initial operation to control the ulcer diathesis. A trial of aggressive medical therapy is warranted in elective presentations and has a moderate chance of success. Failing this, we believe that reoperation should be tailored to the patient's physiologic status and previous operation (Table 5). Nevertheless, in most cases, we believe that the second operation should be the final operation and should consist of the procedure with the lowest recurrence rates. Therefore, we believe that the assurance of an adequate antrectomy and complete vagal section is the preferred procedure for most patients with recurrent peptic ulcer. | 4 |
Gastric duplication cyst communicating with the pancreatic duct: a rare cause of recurrent abdominal pain. A 41-year-old woman with recurrent attacks of postprandial abdominal pain was found on endoscopic retrograde cholangiopancreatography and subsequent computed tomographic scan to have an enteric duplication within the substance of the pancreas with communication to the pancreatic duct. Celiotomy demonstrated a noncontiguous gastric duplication cyst. Internal drainage was curative. | 0 |
Sinus node-atrioventricular node isolation: long-term results with the "corridor" operation for atrial fibrillation The "corridor" operation is designed to restore sinus rhythm to patients with atrial fibrillation by electrically isolating the sinus node, a band of atrial tissue and the atrioventricular (AV) node from the remaining atrial tissue. Nine patients with drug-refractory atrial fibrillation underwent this operation; four patients had chronic atrial fibrillation and five had paroxysmal atrial fibrillation; the mean duration of symptoms was 12 +/- 8 years. Patient ages ranged from 25 to 68 years (mean 48 +/- 12). At preoperative electrophysiologic study, no patient had evidence of an accessory AV pathway or AV node reentry. Sinus node recovery time could not be determined in five patients because of recurrent atrial fibrillation during or before programmed stimulation. At operation the corridor of atrial tissue connecting the sinus and AV nodes was successfully isolated from the remaining left and right atrial tissue in all patients. One patient required early reoperation for recurrent atrial fibrillation before hospital discharge. At the predischarge electrophysiologic study, the corridor remained isolated in all patients except for one patient who had intermittent conduction between the corridor and excluded right atrium. One patient had nonsustained atrial fibrillation and one had atrial tachycardia evident in the corridor. Atypical AV node reentry of uncertain significance was induced in one other patient. Over a total follow-up of 191 patient months (mean 21 +/- 20), seven patients remained free of atrial fibrillation. Two patients had recurrent atrial fibrillation, which in one patient was effectively controlled by a single antiarrhythmic agent. A permanent pacemaker was implanted in four patients for sinus node dysfunction. | 3 |
Extracranial metastases of medulloblastoma in adults: literature review. A consecutive series of 30 cases of extracranial medulloblastoma metastases in adults is analysed. The majority of the patients were males with a 3:1 male/female ratio. Bone was the most frequent site of metastases in adults (77%) and children (78%), followed by lymph nodes (33%) in both children and adults. Lung metastases were more common in adults (17%), but liver metastases occurred more frequently in children (15%). Possible routes of spread and development of metastases are discussed, with special emphasis on the role of shunts in tumour seeding. Distant extracranial metastatic spread of medulloblastoma occurs at the rate of 7.1%. Mean interval between operation of the primary tumour and the discovery of metastases was shorter in children (20 months) than in adults (36 months). Survival after the discovery of metastases was also shorter in children (5 months) than in adults (9.5 months). Shunts were associated with an earlier appearance of metastases and with a poorer prognosis. A detailed review of the literature of 119 cases of medulloblastoma with extracranial metastases is provided. | 0 |
Systemic toxic effects associated with high-dose verapamil infusion and chemotherapy administration. Aside from its more conventional uses as a cardiovascular drug, the calcium channel blocker verapamil has recently been added to chemotherapeutic regimens to reduce drug resistance in B-cell and other neoplasms that express the P-glycoprotein. We recently treated patients with continuous-infusion verapamil (0.15 mg/kg per hour to 0.60 mg/kg per hour) over a 5-day period in combination with continuous-infusion vincristine and doxorubicin plus oral dexamethasone. Seventy-one courses involving 35 hospitalized patients were prospectively studied for cardiovascular and other side effects. Cardiovascular side effects were observed most frequently and consisted of first-degree heart block, hypotension, sinus bradycardia, and junctional rhythms. We observed higher degree heart block, but the QRS interval remained narrow and the ventricular escape rate remained relatively normal. Effects on mean arterial pressure, heart rate, and PR interval were both time and dose related. Severe, symptomatic congestive heart failure was rarely observed. The most common noncardiovascular side effects were constipation, peripheral edema, and weight gain. All systemic toxic effects observed were easily treated or disappeared with either temporary or permanent discontinuation of the verapamil infusion or by a decrease in the dose of verapamil. We conclude that the cardiovascular side effects associated with continuous, high-dose intravenous verapamil therapy are significant and dose limiting but are rapidly reversible. Less cardiotoxic chemosensitizers are needed to reverse multidrug resistance in cancer. | 0 |
Introduction to limb-salvage surgery for sarcomas. This article provides a history of limb-salvage surgery and definitions of terms used to describe aspects of the procedure. Staging is also discussed. | 0 |
Endoscopic coagulation of the choroid plexus using the Nd:YAG laser: initial experience and proposal for management. Although most patients with hydrocephalus are treated effectively with ventriculoperitoneal shunts, a small group fails to respond to diversion procedures. In some patients within this group, hydrocephalus may be caused in part by the overproduction of the cerebrospinal fluid (CSF). In other patients, previous shunt infections may limit the ability of the peritoneum to absorb fluid, and patient response to a ventriculoperitoneal shunt may be improved by reducing CSF production. We discuss a case of a 29-month-old hydrocephalic infant with a ventriculoperitoneal shunt who had ascites. Computed tomography showed bilateral symmetrical enlargement of the choroid plexus. Repeated cultures of the CSF and shunt tubing were sterile, and the daily production of the CSF exceeded 1000 ml. Therapy with acetazolamide decreased the CSF output temporarily, but it was discontinued after serious electrolyte abnormalities occurred. The endoscopic coagulation of the choroid plexus with a neodymium:YAG laser transmitted through a flexible quartz fiber decreased CSF production effectively. This procedure may be useful in a variety of clinical conditions associated with hydrocephalus or with other intraventricular lesions. | 2 |
Surgical augmentation of skin blood flow and viability in a pig musculocutaneous flap model. A porcine rectus abdominis musculocutaneous (TRAM) flap model was designed and validated in nine pigs. This TRAM flap was based on the deep inferior epigastric (DIE) vessels with an 8 x 18 cm transverse skin paddle at the superior end of the rectus abdominis muscle. The model was subsequently used to test our hypothesis of surgical augmentation of flap viability by vascular territory expansion. Specifically, we observed that ligation of the superior epigastric (SE) vessels at 4, 7, 14, and 28 days (N = 6 to 8) prior to raising the TRAM flaps significantly increased (p less than 0.05) the length and area of the viable skin in the transverse skin paddles of the treatment flaps compared with the contralateral shammanipulated control flaps. This significant increase in skin viability was seen to be accompanied by a significant increase (p less than 0.05) in skin and muscle capillary blood flow in the treatment TRAM flaps compared with the controls (N = 9). The mechanism of vascular territory expansion is unclear. We postulate that hypoxia resulting from the ligation of the superior epigastric vessels prior to the flap surgery may play a role in the triggering of the deep inferior epigastric artery to take over some of the territory previously perfused by the superior epigastric artery. This would then increase the skin and muscle capillary blood flow in the transverse paddle when the TRAM flap was raised on the deep inferior epigastric vascular pedicle. | 3 |
Hyperkalemia in acute glomerulonephritis due to transient hyporeninemic hypoaldosteronism. Transient hyperkalemia has been reported to occur in patients with acute glomerulonephritis, but the pathogenetic mechanism has not been investigated systematically. We studied the mechanism of hyperkalemia (5.7 to 6.7 mmol/liter) in four men with post-infectious glomerulonephritis. All four patients had clinical findings consistent with acute glomerulonephritis (edema, hypertension, proteinuria, hematuria, and an elevated ASO titer) and a renal biopsy performed in three of the patients confirmed the diagnosis. In comparison to normal subjects (N = 18), plasma aldosterone (5.4 +/- 1.6 vs. 22.8 +/- 2.6 ng/dl, P less than 0.005) and plasma renin activity (0.3 +/- 0.2 vs. 4.3 +/- 0.6 ng/ml/hr, P less than 0.005) were reduced. Hyperkalemia resolved within one to two weeks in two patients as the nephritis resolved and diuresis ensued, and aldosterone and renin levels obtained at follow-up visits were normal. Hyperkalemia persisted despite furosemide-induced diuresis in the other two patients, but resolved with fludrocortisone treatment. Thus, hyperkalemia in patients with acute glomerulonephritis is a manifestation, in part, of hyporeninemic hypoaldosteronism. It is ameliorated by mineralocorticoid therapy and improves spontaneously with resolution of the glomerulonephritis. | 4 |
Pathological changes in levator palpebrae superioris muscle treated with botulinum toxin in a case of carotico-cavernous fistula. We describe the case of a patient with carotico-cavernous fistula who had botulinum toxin A to induce a protective ptosis 4.5 days before death. The levator palpebrae superioris muscle from both sides and the superior rectus muscle from the injected side were obtained for examination. The preserved samples were stained with haematoxylin and eosin, Martius scarlet blue, Glees, S100, dehydrogenase, ATPase, and toluidine blue as well as being examined by electron microscopy. Inflammation and oedema were found that were probably due to the carotico-cavernous fistula. Axonal and some myelin sheath damage were also seen. | 3 |
Rate-related left bundle branch block as a cause of non-ischemic chest pain. A case is presented of rate-dependent left bundle branch block associated with chest pain in a patient with angiographically normal coronary arteries. Lactate extraction showed no evidence of myocardial ischemia. It appears that in this case, chest pain was associated with sudden ventricular asynergy rather than myocardial ischemia. | 4 |
Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. From June 1984 to September 1989, 43 patients with large vena caval tumor thrombi from retroperitoneal malignancies underwent surgical treatment with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The primary malignancies were renal cell carcinoma (RCC) (n = 39), renal pelvic transitional cell carcinoma (n = 1), adrenal pheochromocytoma (n = 1), and renal (n = 1) or retroperitoneal (n = 1) sarcoma. The level of the caval thrombus was either suprahepatic (n = 27), intrahepatic (n = 14), or subhepatic (n = 2). In all cases the primary tumor and caval thrombus were completely removed. Concomitant procedures included coronary artery bypass grafting (n = 5), pulmonary resection (n = 2), and hepatic lobectomy (n = 1). The time of circulatory arrest ranged from 10 to 44 minutes (mean, 23.5 minutes). There were two operative deaths (4.7%), neither of them due to to the use of DHCA. Major postoperative complications occurred in 13 patients (30.2%). There were no ischemic or neurologic complications and no cases of perioperative tumor embolization. The median postoperative hospital stay was 9 days. Twenty-two patients (51%) are alive and enjoying a good quality of life. The 3-year patient survival rates in patients with localized (n = 24) versus metastatic (n = 15) RCC are 63.9% and 10.9%, respectively (p = 0.02). We conclude that CPB with DHCA facilities excision of retroperitoneal malignancies with large caval thrombi and provides the potential for cure with low morbidity and mortality rates. | 0 |
Serum amylase in patients with renal insufficiency and renal failure. Results vary with regard to the upper limits of serum amylase seen in patients with renal failure, and very little has been reported with patients with renal insufficiency not yet requiring dialysis. To determine the level of serum amylase elevation in renal insufficiency and renal failure, we determined serum amylase values in 128 subjects with creatinine clearances less than 90 ml/min. Serum amylase remained in the normal range when creatinine clearance was greater than 50 ml/min, and did not become elevated until creatinine clearance was less than 50 ml/min. The highest serum amylase recorded in the absence of acute pancreatitis was 503 IU/L (normal, less than 128 IU/L). Serum lipase and trypsin values paralleled those for serum amylase; values remained normal when creatinine clearance was greater than 50 ml/min, and were normal or elevated when creatinine clearance was less than 50 ml/min. These results indicate that elevations of serum amylase (i.e., amylase greater than 128 but less than 500 IU/L) in asymptomatic patients with impaired renal function are not evident until creatinine clearances fall below 50 ml/min, and probably do not represent acute pancreatitis. | 1 |
Correlation between essential tremor and migraine headache. The relationship between essential tremor (ET) and migraine was investigated in a prospective study. In a group of 74 ET patients 36.5% had migraine compared with 17.7% of 102 control subjects without tremor. In a group of 58 patients with migraine 17.2% had ET compared with 1.2% of 85 controls without migraine. The prevalence of ET in migraine controls was greater than controls without migraine (22% compared with 1%; p = 0.002). It is concluded that there is an association between essential tremor and migraine. | 4 |
Colonic stenoses: use of oral barium when retrograde flow is completely obstructed on barium enema studies. Forty patients with complete obstruction to retrograde barium flow on barium enema examinations, without clinical or radiographic evidence of obstruction, were studied further with orally administered barium in the same session. All patients had undergone aborted double-contrast barium enema studies and had received antispasmodics intramuscularly before the examination. The authors describe the technique, as well as the clinical and radiologic findings, that allows the safe ingestion of oral barium in patients with stenotic lesions of the colon. In all patients, oral barium passed through the small bowel and the stenotic site in an average of 148 minutes, with no complications. In seven patients, there were synchronous lesions in the colon and small bowel, and the findings were determined better with oral barium studies in 19 patients. If a barium enema study is done and retrograde passage of barium is obstructed by a lesion in the left side of the colon, additional diagnostic information can be obtained by giving the patients oral barium. This practice is safe if precise criteria are applied. | 1 |
Antiepileptic drug monitoring at the epilepsy clinic: a prospective evaluation. To assess the value of on site therapeutic drug monitoring at the epilepsy clinic, management decisions were recorded before and immediately after antiepileptic drug (AED) concentrations became available. In the first year of this prospective study, 632 [277 carbamazepine (CBZ), 170 phenytoin (PHT), 113 valproate (VPA), and 72 phenobarbital (PB)] assays were performed during 488 clinic attendances in 182 actively managed epileptic patients. The results of drug analysis led to alterations in management at 114 patients visits, i.e., 23% of those monitored. Dosage was increased in response to the circulating AED concentration in 12% of consultations and decreased in another 7.5%. Unsuspected poor compliance was uncovered in eight patients, and in three others an AED was added or discontinued on the basis of the assay result. The time of the next appointment was rearranged in 58 attendances. Only 50% of results were in the "therapeutic" ranges for the four major AEDs. Dosage was adjusted (50 up, 16 down) after 54% of low results. "Therapeutic" levels were followed by a change in AED dose (52 up, 31 down) in 26%. Only 29% of concentrations above the "therapeutic" range persuaded the doctor to alter the dosage regimen, and in 20% of these an increase in dose was recommended. On-site AED monitoring had an immediate impact on clinical decision-making in greater than 23% of consultations but in a form more subtle than the simple quest for a therapeutic result. | 2 |
Area of lateral ventricles measured on cranial ultrasonography in preterm infants: association with outcome. The association between measurements of lateral ventricle area (determined by serial ultrasound scans) and outcome was studied in 70 preterm neonates of 33 weeks' gestation or less. The study group was subdivided into four groups according to cranial ultrasonographic findings at 2 weeks postnatal age: group A (n = 15) had isolated periventricular/intraventricular haemorrhage; group B (n = 20) had periventricular/intraventricular haemorrhage and dilated ventricles; group C (n = 24) had periventricular/intraventricular haemorrhage and periventricular leukomalacia with or without dilated ventricles; and group D (n = 11) had isolated periventricular leukomalacia. Eighty seven preterm infants with no evidence of intracranial disease and good neurodevelopmental outcomes at 2 years formed the control group. A poor outcome was observed in infants in group B, C, and D, particularly in those who had persistent dilated ventricles at 6 weeks postnatal age and extensive periventricular leukomalacia. There was no difference in outcome between group A and controls. During the first six weeks of life ventricular area growth velocities were significantly higher in groups B, C, D, compared with normal controls and group A. We suggest that persistent ventricular dilatation at this early stage carries a bad prognosis, which is the result of atrophy of the brain. | 2 |
Cadherin cell adhesion receptors as a morphogenetic regulator. Cadherins are a family of cell adhesion receptors that are crucial for the mutual association of vertebrate cells. Through their homophilic binding interactions, cadherins play a role in cell-sorting mechanisms, conferring adhesion specificities on cells. The regulated expression of cadherins also controls cell polarity and tissue morphology. Cadherins are thus considered to be important regulators of morphogenesis. Moreover, pathological examinations suggest that the down-regulation of cadherin expression is associated with the invasiveness of tumor cells. | 0 |
Leukocyte larceny: spurious hypoxemia confirmed with pulse oximetry Leukemic patients with extremely high white blood counts may exhibit the phenomenon of leukocyte larceny, in which white blood cells metabolize plasma oxygen in arterial blood gas samples (ABG) producing a spuriously low oxygen tension. We report the case of a leukemic patient with a white blood count in excess of 500,000 in whom multiple ABGs documented hypoxemia out of proportion to his clinical picture. Pulse oximetry was used to confirm higher hemoglobin oxygen saturation to establish the leukocyte larceny. | 0 |
Cochlear implants as a contraindication to magnetic resonance imaging. Magnetic resonance imaging poses little risk to the majority of patients undergoing scanning. However, cochlear implantation should pose a contraindication to this imaging process. This conclusion is based on several findings of in vitro testing of three cochlear implants: the 3M/House and 3M/Vienna designs and the Nucleus device. Specifically, tremendous torques are generated by each of these devices when they are introduced into the coil of a magnetic resonance imager; in addition, the 3M products not only were noted to induce an electrical current, but also were significantly magnetized and rendered afunctional. The clinical implications are discussed. | 4 |
Gastric lesions secondary to long-distance running. Gastrointestinal disorders have been reported during long-distance running. The purpose of this study was to evaluate the effects of prolonged exercise on the upper digestive tract. Seven subjects were submitted to a standard endoscopic examination of the upper digestive tract before and after long-distance running (range 18-50 km). Mucosal biopsy specimens were taken during all endoscopies. After running, all runners had histologically pathological features in the stomach. Vascular lesions were present in the chorion in six subjects after running, with the intensity of the lesions ranging from congestion to hemorrhage. Postexercise histological examination also showed a decrease in mucosal secretion. These lesions secondary to prolonged exercise indicate the presence of hemodynamic perturbations in the upper digestive tract. | 1 |
A comparative study of terbinafine versus griseofulvin in 'dry-type' dermatophyte infections. We conducted a double-blind comparative study of terbinafine, 250 mg twice daily, versus griseofulvin, 500 mg twice daily, for 6 weeks in chronic dermatophyte infections of the feet or hands. All but three patients (total 31) had Trichophyton rubrum infection. At 12-week follow-up, 100% of the terbinafine-treated group were free from infection compared with 45% of those treated with griseofulvin. Therapy in 75% of the terbinafine-treated group and in 35% of those given griseofulvin was rated as effective overall at long-term follow-up, although these differences were not statistically significant. Six months after treatment all nine patients whose skin had cleared with terbinafine therapy remained in remission versus only one of seven patients treated with griseofulvin. None of the patients in either group experienced serious adverse effects. | 4 |
Metastatic carcinoma to the retina. Clinicopathologic findings in two cases. Two cases of metastatic carcinoma to the neuroretina are reported. One patient had an oat cell carcinoma of the lung that was metastatic to the brain and retina; this was confirmed postmortem. The other patient had metastatic breast carcinoma with seeding of tumor cells into the vitreous from a focus of retinal embolism. The diagnosis was confirmed from a vitrectomy specimen. | 4 |
Incidence of large oesophageal varices in patients with cirrhosis: application to prophylaxis of first bleeding. Because several studies have suggested that beta blockers are effective in the prophylaxis of first variceal bleeding in cirrhosis, screening for oesophageal varices might be appropriate. We prospectively studied 84 cirrhotic patients without obvious evidence of large oesophageal varices and previous bleeding during a mean follow up of 16 months. At entry to the study 41 patients had no oesophageal varices and in 43 these were grade 1. The subsequent percentages of patients without large oesophageal varices were 74% at one year and 52% at two years. Univariate analysis showed that a longer duration of cirrhosis (p less than 0.05) and grade 1 oesophageal varices at entry (p less than 0.001) were predictive factors for the occurrence of large oesophageal varices, whereas, multivariate analysis showed that the initial size of the oesophageal varices (p less than 0.001), a high initial Child-Pugh score, and a smaller improvement in Child-Pugh score during the study were independent risk factors. Among patients with grades 0 and 1 oesophageal varices at the start of the study the proportions with large oesophageal varices at two years were 31% and 70% respectively. We have calculated that, accepting a maximum risk of first bleeding of 10% without prophylactic treatment, a patient without oesophageal varices should be screened endoscopically every other year, while a patient with grade 1 disease should benefit from one annual upper gastrointestinal endoscopy. | 1 |
Current trends in suture fixation of posterior chamber intraocular lenses. Corneal surgeons were surveyed with regard to their technique of suture fixation of posterior chamber intraocular lenses in the absence of posterior capsular support. Fifty-nine percent of the 260 respondents stated they perform the procedure almost exclusively during penetrating keratoplasty. Scleral fixation was marginally favored over iris fixation by these surgeons. Most intraoperative problems reported were related to the relative technical difficulty of the procedure, although transient hemorrhage from the ciliary body was also mentioned. Postoperative complications cited included mechanical problems involving the lens and iris, cystoid macular edema, glaucoma, and endophthalmitis. | 4 |
A recurrent pelvic desmoid tumor successfully treated with tamoxifen. A case of recurrent retroperitoneal desmoid tumor successfully treated with tamoxifen (Nolvadex tablets, ICI Pharma, Division of ICI Americas, Wilmington, DE) is reported. The patient presented late in her second pregnancy with a large retroperitoneal pelvic desmoid tumor that was treated with surgical excision and megestrol acetate. When the tumor recurred 12 months later, it was again treated with surgery, this time followed by radiation therapy. The desmoid tumor quickly recurred. The patient was then treated with tamoxifen, resulting in a complete tumor regression that has remained stable for 27 months. Tamoxifen should be considered as first-line therapy in recurrent desmoid tumors. | 0 |
Reoperation for failed gastric bypass procedures for obesity. Reoperation is worthwhile when there is an obvious defect in the gastric reduction operation that has failed to control weight. Reoperation occasionally is necessary to correct a complication of gastric bypass. Vertical banded gastroplasty is the operation of choice for reoperations, as it provides weight control while eliminating the problems of bypass. Conversion of a horizontal to a vertical pouch is safe but requires careful attention to the technique to avoid injury to the other organs in the area and preservation of blood supply to the stomach. The gastrogastrostomy across the old horizontal staple line in the vertical pouch can be constructed in a way that will minimize the risk of obstruction. Vertical banded gastroplasty is now the only operation in use at UIHC for the treatment of obesity and is used not only as the primary operation but in all reoperations. Bypass of the stomach and duodenum is not necessary for weight control and adds some risk of malabsorption and duodenal and stomal ulcer plus a lifetime of inaccessibility of the excluded areas for diagnostic and therapeutic measures. | 1 |
Electrocardiographic abnormalities in cerebrovascular accidents. The electrocardiographic abnormalities found in 100 patients with acute cerebrovascular disease and previously normal hearts are described. The abnormalities were more often seen in patients with intracerebral and subarachnoid hemorrhages. The most common changes were Q-Tc Prolongation and ST segment and T wave abnormalities. The mechanisms of these electrocardiographic abnormalities appear to be multiple. | 4 |
Williams' vulvovaginoplasty after supralevator total pelvic exenteration. Seven patients had delayed Williams' vulvovaginoplasty after supralevator total pelvic exenteration. Of the three patients who died of carcinoma of the cervix (at 2, 5, and 15 months after vulvovaginoplasty), the first died before having a chance to attempt intercourse, but the other two had reported intercourse on at least two occasions after the reconstruction. One of the patients described the experiences as neither pleasant nor unpleasant but stated that her husband seemed satisfied. The other patient described the experience as satisfactory to both herself and her husband. The remaining four patients are alive with no evidence of recurrent disease at 28, 42, 56, and 106 months after operation. Two of these patients have reported entirely satisfactory sexual relations approximating pre-exenteration frequency, but the remaining two have not had sexual relations since surgery. Both give the main reason for this as lack of opportunity. The Williams' vulvovaginoplasty appears to be a reasonable alternative for vaginal reconstruction in patients who will have and especially who have had exenteration. To improve results, other methods of vaginal reconstruction should continue to be evaluated. | 0 |
Extracorporeal LDL cholesterol removal: role of LDL-pheresis in combination with other hypolipidemic therapy to regress vascular disease. The direct relationship between hypercholesterolemia and atherosclerosis has resulted in formal cholesterol-lowering recommendations for patients at increased risk. The incomplete response to therapy of some forms of hypercholesterolemia as well as not uncommon drug intolerance prompted the development of extracorporeal techniques to reduce serum cholesterol levels. Nonhuman primate data and an analysis of human cholesterol epidemiology and reduction trials were used to establish guidelines that would maximize the likelihood of stabilizing or regressing established coronary artery atherosclerosis. These goals are a total cholesterol (TC) level of less than or equal to 150 mg/dL (3.9 mmol/L) and a ratio of TC to high-density lipoprotein cholesterol (HDL) of less than 2.8. Selective, extracorporeal removal of LDL cholesterol (LDL-pheresis) was combined with diet and hypolipidemic drugs in a pilot study at The Rogosin Institute to achieve these lipid end-points. Technical aspects of LDL-pheresis, the background rationale for its use as part of a combined hypolipidemic therapy, the initial experience at The Rogosin Institute, and plans for future studies and applications are presented. | 3 |
Neonatal intracranial choriocarcinoma. A 1-month-old infant died from extensive intracerebral hemorrhage due to a metastatic choriocarcinoma to the brain that presumably originated in the placenta. The clinical course was characterized by hyperbilirubinemia, repeated episodes of seizures, and intracranial hemorrhage. A computed tomographic scan revealed a large vascular mass in the left parieto-occipital region and a small lesion in the left frontal lobe. The placenta was expelled during the delivery and was not examined. In view of the high level of maternal human chorionic gonadotropic hormone and the autopsy finding of metastasis, we presumed that the mass was a metastatic choriocarcinoma that had originated in the maternal placenta. To our knowledge, only one previous instance of this phenomenon has been reported. | 0 |
Massive allografts in salvage revisions of failed total knee arthroplasties. Ten patients with failed total knee arthroplasties and severe bone loss were treated with massive whole distal femur and proximal tibial allografts in combination with prosthetic implants. Fourteen allografts were inserted either as invaginated or segmental grafts and were rigidly fixed to the host bone. Clinically and roentgenographically, 12 of 14 grafts (86%) seemed to have united to the host bone. The average range of motion was 92 degrees. Five patients developed complications; two of these involved the allograft (nonunion and fracture) and two were caused by inadequate healing at the ligament-allograft junction. One patient had a late infection. With careful planning and improved surgical techniques, these complications can be avoided. The massive allograft-prosthesis composite techniques is a viable reconstructive alternative worthy of further clinical trials. | 4 |
Serial prothrombin time as prognostic indicator in paracetamol induced fulminant hepatic failure. OBJECTIVE--To find out whether changes in the daily prothrombin time are of prognostic importance in patients with paracetamol induced fulminant hepatic failure. DESIGN--Retrospective study. SETTING--The Liver Unit, King's College Hospital, London. PATIENTS--150 Consecutive patients with paracetamol induced fulminant hepatic failure admitted between October 1986 and February 1989. MAIN OUTCOME MEASURE--Death. RESULTS--Of the 150 patients, 72 (48%) died. In all, 34 of the 37 (92%) patients with a peak prothrombin time of greater than or equal to 180 seconds died as did 20 of the 41 (49%) with a time of 130-179 seconds, nine of the 25 (36%) with a time of 90-129 seconds, and nine of the 47 (19%) with a time of less than 90 seconds. Of the 42 patients with a continuing rise in prothrombin time between days 3 and 4 after overdose, 39 died (93%) compared with 21 of the 96 (22%) in whom the prothrombin time fell. CONCLUSIONS--These data indicate that a continued increase in prothrombin time on day 4 after overdose and a peak prothrombin time of greater than or equal to 180 seconds identify at an early stage those patients with a less than 8% chance of survival. Liver transplantation should be considered in patients meeting either of these criteria. | 1 |
Mesenteric blood flow in patients with diabetic neuropathy. We examined flow velocities in the superior mesenteric artery and celiac artery in normal controls (group C, n = 11), diabetic patients (group D, n = 8), and diabetic patients with clinically evident autonomic neuropathy (group DN, n = 6) to further define the usefulness of duplex examination in the evaluation of the mesenteric circulation in normal and disease states. By use of a 3 MHz duplex scanner, peak systolic velocity, peak diastolic forward velocity, end-diastolic forward velocity, and peak diastolic reverse velocity were measured in centimeters per second before and after a standardized meal. The vessels' diameters in centimeters were also measured. After the meal peak diastolic reverse velocity disappeared in all patients. The average vessel diameter in the superior mesenteric artery (0.7 cm) and celiac artery (0.8 cm) did not change. Flow velocities in the celiac artery were not significantly altered by the meal. In the control group, peak systolic velocity in the superior mesenteric artery increased 38%, peak diastolic forward velocity rose 66%, and end-diastolic forward velocity increased by 70%. In the diabetic nonneuropathic group the changes were 15%, 98%, and 100%, respectively. These changes were statistically significant (p less than 0.01). On the other hand, the patients with diabetic autonomic neuropathy presenting a picture of gastroparesis did not exhibit the expected increases in postprandial velocities. Moreover, this alteration in blood flow velocity, although similar to that encountered in patients with intestinal angina, did not appear to be due to occlusive arterial disease on the basis of clinical examination and B-mode scanning. | 2 |
The "stuck twin" phenomenon: ultrasonographic findings, pregnancy outcome, and management with serial amniocenteses. Thirteen consecutive twin pregnancies affected by the "stuck twin" phenomenon were reviewed to determine the potential benefit of serial amniocenteses. The fetal survival rate for the eight pregnancies that underwent serial amniocenteses was 69% (11 of 16 fetuses). This is significantly improved compared with a fetal survival rate of 20% among the five preceding pregnancies managed without serial amniocenteses at the same institution (p = 0.01). It is also markedly improved compared with a combined fetal survival rate of 16% among 48 previously reported pregnancies with the stuck twin phenomenon managed without serial amniocenteses (p less than 0.0001). Survival correlated with the absence of concomitant pregnancy complications (i.e., maternal hypertension or intractable labor) and with the absence of severe fetal structural abnormalities. Procedural complications occurred in three of eight pregnancies (37.5%) managed with serial amniocenteses and was attributed as a cause of fetal death in one case. Two of 11 survivors (18%) had complications after serial amniocenteses including brain infarction and renal tubular necrosis. Serial amniocenteses may significantly improve the survival rate of twin gestations affected by the stuck twin phenomenon but may be associated with complications among survivors. | 2 |
The role of ras gene mutations in myeloproliferative disorders. Mutations in the ras genes frequently are found in myeloproliferative disorders. These abnormalities have prognostic significance in the myelodysplastic syndromes, but their clinical importance in other hematopathic states remains unclear. The study of this gene in leukemic conditions is providing insights into the genetic pathways leading to leukemic progression. | 0 |
Ki67 index and S-phase fraction in human breast carcinomas. Comparison and correlations with prognostic factors. In a prospective study of 148 consecutive breast adenocarcinomas, proliferative indices of the same surgical tumor sample were performed by immunohistologic staining (Ki67 index) with the use of the Ki67 monoclonal antibody, which binds to a nuclear antigen only expressed in cycling cells, and by flow cytometry-derived S-phase fraction (SPF). Measurable Ki67 and SPF indices were obtained in 142 cases and 99 cases, respectively, and in 96 cases by both methods. In aneuploid tumors, a significant but low (P less than 0.05, r = 0.3) relationship was observed between Ki67 index and SPF. When compared with clinical, pathologic, and biochemical parameters these two proliferative indices were shown to be associated with nuclear grading and mitotic index. Additionally, correlations were observed between Ki67 index and node involvement (P less than 0.02) and between SPF and estrogen receptors (P = 0.002). These results show that (1) proliferative indices are obtained in 96% of surgical samples with Ki67 versus 67% with SPF and that (2) Ki67 index and SPF may provide complementary data with respect to prognosis. | 0 |
Circadian variation in onset of acute ischemic stroke. A circadian pattern for the onset of myocardial and cerebral infarction has been identified. To evaluate this phenomenon further, we analyzed prospectively collected data from 151 patients with acute ischemic stroke. The number of strokes per 6-hour period were the following: midnight to 6 AM, 20 (13%); 6 AM to noon, 86 (57%); noon to 6 PM, 21 (14%); and 6 PM to midnight, 24 (16%). This pattern was not affected by previous use of aspirin. The most frequent time of onset was 6 AM to noon for all subgroups of ischemic stroke: small artery, 71%; cardioembolic, 62%; large artery atherothrombotic, 57%; large artery atheroembolic, 46%; and "other" or unknown cause, 40%. We also investigated the time between awakening and stroke onset in 145 patients and found that 24% of ischemic strokes occurred within the first hour after awakening. Our data demonstrate that an early morning peak exists for all subtypes of stroke. Our data also suggest that the most critical period is the first hour after awakening. | 4 |
Treatment of high-risk solid tumors of childhood with intensive therapy and autologous bone marrow transplantation. Autologous bone marrow transplantation (ABMT) allows delivery of intensive, marrow-ablative chemotherapy or chemoradiotherapy to children with high-risk solid tumors. Results from several studies of neuroblastoma suggest that outcome is improved by ABMT; however, relapses can occur months to years after complete clinical remission. Other high-risk tumors including peripheral neuroepithelioma, Ewing's sarcoma, rhabdomyosarcoma, Wilms' tumor, and brain tumors also appear to be responsive to intensive marrow-ablative therapy, although few studies have been reported. For tumors that can metastasize to marrow, a sensitive method is necessary for detecting tumor cell contamination. Immunocytologic analysis with monoclonal antibodies can identify one neuroblastoma cell per 10(5) normal marrow cells; this method also is applicable to other tumors with appropriate antibodies. Ex vivo removal (purging) of tumor cells decreases the probability of infusing tumorigenic cells with the ABMT. There is considerable experience in tumor detection and purging for neuroblastoma, but little has been done for other childhood solid tumors. Future investigations of ABMT will aim to further increase disease-free survival by intensifying induction and marrow-ablative regimens and by developing therapies to be given after ABMT that are directed at minimal residual disease. As pilot investigations mature, the efficacy of ABMT and conventional chemotherapy will be compared in multi-institution randomized studies. | 0 |
Penetrating trauma involving the innominate artery. Penetrating trauma involving the innominate artery is uncommon. Few surgeons have experience with this injury. A successfully managed case of penetrating innominate artery trauma is summarized and the literature reviewed. | 3 |
Effects of 1.32-micron Nd-YAG laser on brain thermal and histological experimental data. Considering that the 1.32-microns Nd-YAG laser should have physicothermal properties close to those of the CO2 laser, a series of experiments were conducted on rat cortex (N = 51). Three laser wavelengths were compared: CO2 laser (10.6 microns), 1.06-microns Nd-YAG, and 1.32-microns Nd-YAG lasers. For each shot, temperature measurements were recorded with an infrared thermographic videocamera. The digitized signals were figured as thermal profiles and temperature developments. Ninety-five shots were correctly studied and analyzed: CO2, N = 29; 1.06-microns Nd-YAG, N = 20; 1.32-microns Nd-YAG, N = 46. The histological lesions produced by these three lasers were compared on animals killed 24 hours (N = 20), 8 days (N = 20), and 30 days (N = 5) after the laser impacts. For equivalent densities of energy, the depth of cortical necrosis was comparable for the CO2 laser (200-250 microns) and the 1.32-microns Nd-YAG laser (210-260 microns) whatever the date of death; the 1.06-microns Nd-YAG laser shots were responsible for much more important damage (400-550 microns). Because of its important absorption in water and nervous tissue, the authors consider the 1.32-microns Nd-YAG laser most suitable for neurosurgery, particularly because it is conducted through optic fibers, and therefore is easy to handle during neurosurgical procedures. | 4 |
Evaluation of hepatocellular carcinoma aggressiveness by a panel of extracellular matrix antigens. Invasion and metastasis requires a series of interactions between malignant cells and the extracellular matrix (ECM). Antigen markers that relate to these interactions were evaluated for prognostic correlation in human hepatocellular carcinoma. Basement membrane type IV collagen (cIV), type IV collagenase (cIVase), laminin, and laminin receptors (LRs)--all ECM antigens previously proposed to be modulated in association with tumor aggressiveness--were immunohistochemically investigated in 30 cases of hepatocellular carcinomas (HCCs). The pattern of antigen expression was correlated with 1) 36 months' clinical follow-up and 2) the pathologic grade. As a means of estimating the proliferation fraction, an additional antigen, Ki67, was also studied in this series. There were major differences in the distribution of cIV and laminin, and in the quantity of cIVase-, LR-, and Ki67-positive cells associated with grade and prognosis. A smaller quantity of cIV and laminin and a higher number of cIVase-, LR-, and Ki67-positive cells were detected in the poorly differentiated compared with the well-differentiated HCCs. The tumors with lower immunoreactivity for cIV and laminin components accompanied by a higher number of cIVase-, LR-, and Ki67-positive cells fall into a group with the poorest overall survival (P less than 0.006). The panel of antigens is proposed as a useful prognostic tool for evaluating HCC tumor aggressiveness. | 1 |
Unfavorable outcome following early surgical repair of ruptured cerebral aneurysms--a critical review of 238 patients. Among 238 consecutive patients admitted early with ruptured cerebral aneurysms, surgical repair within 48-72 hours was feasible in 200 cases. Unfavorable outcomes among the latter 200 patients are analyzed and discussed in this paper. Preoperatively, 148 patients were in Hunt and Hess grades I-III, 33 were in grade IV, and 19 in grade V. After clipping of the aneurysm, all patients received a regimen of topical intracisternal and intravenous/peroral medication with the calcium antagonist nimodipine. The overall rate of unfavorable outcomes was 25%, ie, outcome with moderate or severe deficit or lethal outcome. The reasons for unfavorable outcomes among these 49 patients were the devastating effect of the bleed (severe subarachnoid hemorrhage or additional intracerebral hemorrhage) in 31 patients (15% of the 200 patients), a surgical complication in 11 (5.5%), preoperative rebleeding in three (1.5%), delayed ischemia from vasospasm in one (0.5%), and various others in three further patients (1.5%). Unfavorable outcome occurred in 11% of patients with preoperative grades I-III, in 52% of patients with grade IV, and in 16 of 19 patients with grade V. Among the 141 patients with subarachnoid hemorrhage but not intracerebral or intraventricular hematoma, 16 made an unfavorable outcome, ie, 11% versus 56% among patients with intracerebral hematoma/intraventricular hematoma on preoperative computed tomography scan. The present data seem to speak in favor of early surgery. Since half of the patients with intracerebral hematoma and poor outcome had suffered previous warning leaks, it appears to be a continuing challenge to diagnose warning leaks before a massive hemorrhage occurs. | 4 |
Screening of nineteen unrelated families with generalized resistance to thyroid hormone for known point mutations in the thyroid hormone receptor beta gene and the detection of a new mutation. Generalized resistance to thyroid hormone (GRTH) is a syndrome characterized by impaired tissue responsiveness to thyroid hormone. Two distinct point mutations in the hormone binding domain of the thyroid hormone receptor (TR) beta have recently been identified in two unrelated families with GRTH. One, Mf, involves a replacement of the normal glycine-345 for arginine in exon 7 and another, Mh, replaces the normal proline-453 for histidine in exon 8. To probe for the presence of the Mf and Mh defect in 19 unrelated families with GRTH, we applied separate polymerase chain reactions using allele-specific oligonucleotide primers containing the normal and each of the two mutant nucleotides at the 3'-position. A total of 24 affected subjects and 13 normal family members were studied. The mode of inheritance was dominant in 13 families, was unknown in 5 families, and was clearly recessive in 1 family in which only the consanguineous subjects were affected. Primers containing the substitutions specific for Mf and Mh amplified exons 7 and 8, respectively, only in affected members of each of the two index families. Primers containing the normal sequences amplified exons 7 and 8 of the TR beta gene in all subjects except affected members of one family. In this family with recessively inherited GRTH, neither exon could be amplified using any combinations of primers and DNA blot revealed absence of all coding exons. These results indicate a major deletion of the TR beta gene, including both DNA and hormone binding domains. Since heterozygous members of this family are not affected, the presence of a single normal allele is sufficient for normal function of the TR beta. These data also support the hypothesis that in the dominant mode of GRTH inheritance the presence of an abnormal TR beta interferes with the function of the normal TR beta. Distinct mutations are probably responsible for GRTH in unrelated families. | 4 |
Stressful events and life satisfaction among elderly men and women. The purpose of this study was to examine the interrelationships among stressful events, domain-specific assessments of life satisfaction, and global evaluations of life satisfaction. This research was guided by two competing theoretical formulations. According to bottom-up theory, older adults first assess feelings of satisfaction within specific life domains that are based in part on the experiences (i.e., stressors) they encounter in these areas. The domain-specific views are subsequently synthesized to form an overall sense of satisfaction with life as a whole. In contrast, the top-down theory suggests that a person's ongoing sense of satisfaction with life as a whole predisposes him or her to assess satisfaction with specific domains in ways that are congruent with his or her initial sense of global life satisfaction. Analysis of data provided by older participants in a nationwide survey tends to support the bottom-up perspective. | 4 |
Intrahepatic cholestasis due to hypersensitivity reaction to procainamide. Hypersensitivity reactions to procainamide involving liver dysfunction are rare. We describe a patient who developed liver dysfunction after procainamide administration, manifested by fever, jaundice, elevated bilirubin concentration, and alkaline phosphatase concentration. Hepatobiliary scintigraphy demonstrated good hepatic uptake of the radionuclide without movement from hepatic parenchyma. To our knowledge, this is the first reported case of procainamide-induced intrahepatic cholestasis as demonstrated by radionuclide hepatobiliary scintigraphy. | 4 |
Local recurrence following abdominoperineal excision and anterior resection for rectal carcinoma. The aim of this retrospective study is to compare the outcome of abdominoperineal excision (APE) and anterior resection (AR) for rectal cancer in terms of local tumor recurrence. A further comparison has been carried out between hand-sewn and stapled anastomosis; 147 patients have been followed for at least 2 years: 69 after APE and 78 after AR, 40 being stapled. The following variables potentially related to the risk of recurrence were evaluated: age, grading, staging, and site of the tumor. An overall 2-year local recurrence rate of 11 percent after APE and 12 percent after AR was observed, whereas it was 13 and 11 percent following stapled and hand-sewn sutures, respectively. Both differences were not statistically significant. A similar local recurrence rate was noted after APE and AR when the patients were matched for Dukes' stage and grading of the lesion. A trend toward an increased risk of recurrence following AR (P = 0.07) was shown when comparing the two procedures if mid and upper rectal cancers were grouped together. In the patients with anastomotic leaks after AR, no increase of local recurrence was observed. In conclusion, AR is unlikely to be followed by an increased risk of local recurrence and, therefore, when oncologically indicated, may be considered the operation of choice in the treatment of rectal cancer, although the possible risk of its overuse should be taken into account. | 0 |
Why does somatostatin cause gallstones? Long-term administration of the somatostatin analogue, octreotide, is complicated by gallstone formation. Somatostatin is known to inhibit hepatic bile secretion and gallbladder emptying. However, the effect of octreotide on gallbladder bile composition remains unknown. Therefore, we tested the hypothesis that octretide would alter hepatic bile composition and cause gallbladder stasis, thereby increasing gallbladder bile solute concentrations. Fourteen control prairie dogs received daily saline injections, whereas 10 animals received 1 micrograms of octreotide subcutaneously three times per day for 5 days. Cholecystectomy and common bile duct cannulation were then performed. Octreotide increased hepatic bile concentrations of bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.05), and total protein (p less than 0.01). Rsa, an index of gallbladder stasis, was decreased (p less than 0.01) in the octreotide group. Gallbladder bile total calcium (p less than 0.05), bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.01), total protein (p less than 0.05), and total lipids (p less than 0.05) were increased in the octreotide group. Animals receiving octreotide also had decreased hepatic (p less than 0.05) and gallbladder (p less than 0.001) bile pH. No differences in cholesterol saturation index were observed. These data suggest that in the prairie dog, octreotide (1) alters hepatic bile composition, (2) causes gallbladder stasis, and (3) increases gallbladder bile calcium, bilirubin, protein, lipid, and hydrogen ion concentrations. We conclude that octreotide causes alterations in gallbladder bile composition that increase the likelihood of cholesterol and calcium bilirubinate precipitation. | 1 |
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