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Comparison of clinical and electrophysiologic features of preexcitation syndromes in patients presenting initially after age 50 years with those presenting at younger ages. Although patients may develop arrhythmias due to preexcitation syndromes at any time from the prenatal period to late adulthood, presentation in late adulthood is considered uncommon and has not been well studied. From June 1981 to June 1989, 73 patients were documented to have preexcitation syndromes on the basis of electrophysiologic studies. Those whose initial arrhythmias appeared at an age greater than 50 years (group 1, n = 13) were compared with the remaining 60 patients (group 2). All group 1 patients presented in the setting of acute medical or surgical diseases (n = 7), or chronic cardiac disease (n = 6) commonly associated with middle age and often with atrial arrhythmias; only 13 group 2 patients had underlying illnesses (p = 0.0001). Almost two-thirds of group 2 patients were evaluated because of narrow complex orthodromic tachycardia or palpitations and electrocardiographic evidence of preexcitation. Wide complex tachycardia was more often a reason for referral of older patients (7 of 13 vs 11 of 60, p less than 0.05), among whom atrial fibrillation/flutter also tended to be more frequent (4 of 13 vs 11 of 60, difference not significant). The PR and QRS intervals of group 1 patients were within the normal range and differed significantly from those of group 2 patients (PR, 0.15 +/- 0.04 vs 0.11 +/- 0.03 second, p less than 0.001; QRS, 0.09 +/- 0.01 vs 0.12 +/- 0.03 second, p less than 0.001), making electrocardiographic identification of preexcitation more difficult in group 1. Several factors likely contributed. | 4 |
Myelopathic neurosarcoidosis: diagnostic value of enhanced MRI. Neurosarcoidosis is an underdiagnosed variant of the systemic disease. We report a case of myelopathic neurosarcoidosis, noting the contribution made by MRI in establishing the diagnosis, and we discuss the possibility that the disease is differentially responsive to various steroid formulations. | 2 |
Safety and efficacy of urokinase during elective coronary angioplasty. Eighty-nine of 462 patients were treated with adjunctive urokinase during elective percutaneous transluminal coronary angioplasty (PTCA), 26% for unstable angina, 34% for intracoronary thrombus, 27% for intimal dissection, 10% for abrupt closure, and 3% for saphenous vein graft embolism. The 80 patients treated before abrupt closure (group A) were compared with 167 patients with similar profiles who did not receive urokinase (group B). Procedural success rates were similar. Adverse cardiac events (abrupt closure, myocardial infarction, emergency coronary artery bypass, or death) in group A versus group B occurred in: 1 of 30 (3%) versus 5 of 27 (18.5%) (p = 0.07) with intracoronary thrombus, 5 of 45 (9%) versus 18 of 110 (16.3%) with unstable angina, 1 of 12 (8%) versus 4 of 13 (31%) with unstable angina with intracoronary thrombus, 4 of 33 (12%) versus 14 of 97 (14.4%) with unstable angina without intracoronary thrombus, and 5 of 24 (20.8%) versus 6 of 66 (9%) with intimal dissection. Hemorrhagic complications occurred in 11% of patients who were treated with urokinase versus 9% of patients who were not (p = NS). No difference in blood transfusions existed. Thus urokinase was found to be safe during elective PTCA. In patients with intracoronary thrombus, urokinase appears to decrease the incidence of new adverse cardiac events, whereas in patients with intimal dissection it might have an adverse effect. | 4 |
Expression of blood group antigens by normal bronchopulmonary tissues and common forms of pulmonary carcinomas. The expression of ABH and Lewis antigens has been studied in a series of pulmonary carcinomas, in areas of squamous metaplasia, and in normal adjacent bronchopulmonary tissues by means of a panel of lectins and monoclonal antibodies. All respiratory epithelial cells can express antigens, with the exception of glandular serous cells. The expression of AB antigens is rather homogeneous, while Lewis antigens are expressed in a more irregular pattern, alternating positively stained cells with negatively stained cells in the same microscopic field. The expression of blood group antigens allows the identification of residual pneumocytes inside the tumor and the proper classification of some neoplasms. Metaplastic areas show a variation in the staining profile when compared with normal tissues and pulmonary carcinomas. The most significant findings are the deletion of A antigen and the strong expression of Le antigen. Pulmonary carcinomas are composed by a heterogeneous population and tend to express antigens in the more differentiated cases or areas. The most important findings are the deletion of AB antigens and the strong expression of Le(y) antigen. | 0 |
Survey of the use of thrombolysis for acute limb ischaemia in the UK and Ireland. A total of 156 vascular surgeons from the UK and Ireland responded to a postal questionnaire on the use of thrombolysis in acute limb ischaemia. Almost half had used thrombolysis in the previous 12 months. Low dose intra-arterial streptokinase (89 per cent) was the regimen most frequently used, but 33 per cent had used intravenous streptokinase. Detailed results for 103 patients (limb salvage rate 60 per cent, amputation rate 35 per cent, mortality rate 5 per cent) were similar to those of previously published reports. Complications in most series were infrequent, but in the entire survey there were six bleeding-related deaths and one death from anaphylaxis. A total of 67 per cent of surgeons with working experience indicated that selected patients with acute arterial thromboses were most suitable for thrombolysis, particularly if there was no neurological deficit and no run-off for surgical bypass. Distal or late emboli and graft occlusions were regarded as appropriate by some surgeons. This study demonstrated that many vascular surgeons currently use thrombolysis, although sparingly and in selected cases. Patients with acute limb ischaemia should be managed by experienced vascular surgeons who are aware of the new therapeutic alternatives, an ideal supported by almost three-quarters of respondents to this survey. | 3 |
Deficiency of complex III of the mitochondrial respiratory chain in a patient with facioscapulohumeral disease. Facioscapulohumeral disease (FSHD), an inherited neuromuscular disorder, is characterized by progressive wasting of specific muscle groups, particularly the proximal musculature of the upper limbs; the primary defect in this disorder is unknown. We studied a patient with FSHD to determine whether the mitochondrial respiratory chain was functionally abnormal. Muscle biopsy revealed fiber atrophy with patchy staining for oxidative enzymes. Electron microscopy of a liver section showed many enlarged mitochondria with paracrystalline inclusions. Decreased oxidation of the respiratory substrates-alanine and succinate-in skin fibroblasts suggested a deficiency of complex III of the electron-transport chain; cytochrome c oxidase activity (complex IV) was in the normal range. Biochemical analysis of liver supported the fibroblast data, since succinate oxidase activity (electron-transport activity through complexes II-IV) was reduced, whereas complex IV activity was normal. Furthermore, analysis of the cytochrome spectrum in liver revealed typical peaks for cytochromes cc1 and aa3, whereas cytochrome b (a component of complex III) was undetectable. Southern blot analysis of fibroblast mtDNA revealed no major deletions or rearrangements. Our study provides the first documentation of a specific enzyme-complex deficiency associated with FSHD. | 2 |
Benign parotid tumour enucleation--a reliable operation in selected cases. The method of surgical treatment for benign tumours of the parotid gland had not yet been rationalized, but many authors recommend parotidectomy as the most appropriate procedure. A series of 289 operations for parotid swelling is reported; the majority of mixed and Warthin's tumours underwent enucleation without either complications or recurrence. The rationale of parotidectomy versus enucleation is discussed but in fast growing, deeply infiltrating and recurrent tumours, parotidectomy appears to be the best choice. In the other group of more commonly occurring tumours, enucleation represents a reliable time saving option. | 4 |
Infarct of the conus medullaris simulating a spinal cord tumor: case report. A 71-year-old woman had the sudden onset of a neurogenic bladder and a stepwise increase in paraparesis that left her unable to stand or walk. Magnetic resonance imaging showed what appeared to be a tumor in the conus medullaris. After laminectomy, the lesion was localized by ultrasound examination, and a biopsy was performed. The deficits remained unchanged postoperatively. Microscopic examination of the biopsy specimen showed necrosis and pathologic changes consistent with infarction of the conus medullaris. An anomalous arterial supply of the conus medullaris is the most likely cause of this unusual problem. The patient gradually regained her ability to walk, but the neurogenic bladder persists. | 4 |
Hydrocephalus: overdrainage by ventricular shunts. A review and recommendations. Selected literature review of the clinical course of patients with ventricular shunts for hydrocephalus shows that the effects of cerebrospinal fluid overdrainage are subdural hematoma, craniosynostosis, slit ventricle syndrome, and low intracranial pressure syndrome. These occur sequentially at different age groups, but approximate averages of incidence and time of occurrence after first shunt reveal an overall incidence of 10%-12% for at least one of these appearing at 6.5 years after shunting. The basic etiology, diagnosis, and variety of treatment modalities available are reviewed, including the need for shunt closing intracranial pressure control. Included is a hydrocephalus program designed to minimize the need for long-term extracranial shunts and to maximize therapeutic intracranial procedures for hydrocephalus. | 4 |
Acute pulmonary embolism triggered by the act of defecation. Pulmonary embolism associated with the act of defecation has not been previously well described. Recently, we reported our experience with four patients who presented to us over a 12-month period with syncope, near syncope, or sudden death following the act of defecation. In all four cases, acute pulmonary embolism was shown to be the etiology of the defecation-associated events. A retrospective chart review of all patients with the diagnosis of pulmonary embolism at our institution over a three-year period yielded five additional patients with the diagnosis of defecation-associated pulmonary embolism. These nine patients accounted for 6.8 percent of all patients with a discharge diagnosis of pulmonary embolism seen at our institution during the three-year study period. Six of the nine patients died from their defecation-associated pulmonary embolism. These six deaths accounted for 25 percent of all deaths from pulmonary embolism seen at our institution during the study period. Based on our experience, we suggest that the act of defecation may trigger the development of acute pulmonary embolism in some patients with deep vein thrombosis. | 4 |
Myocardial infarction in Mexican-Americans and non-Hispanic whites. The San Antonio Heart Study. Mexican-American men experience reduced cardiovascular mortality compared with non-Hispanic white men. There is no corresponding ethnic difference in cardiovascular mortality in women. The difference in men could result either from a lower incidence of cardiovascular disease or a lower case fatality rate among Mexican-Americans. Although the incidence of cardiovascular disease in Mexican-Americans is unknown, we have collected data on prevalence of myocardial infarction in 5,148 individuals examined in the San Antonio Heart Study, a population-based survey of cardiovascular disease conducted between 1979 and 1988 in Mexican-Americans and non-Hispanic whites aged 25-64 years. Myocardial infarction was assessed by Minnesota-coded electrocardiograms and by a self-reported history of a physician-diagnosed heart attack. For both end points, the age-adjusted prevalence of myocardial infarction was lower in Mexican-American men than in non-Hispanic white men. After adjustment for age and diabetes status (present/absent), the odds of a myocardial infarction, as defined by either criterion, was approximately one third lower in Mexican-American men than in non-Hispanic white men (p = 0.06). In women, the prevalence of both myocardial infarction end points was slightly higher in Mexican-Americans than in non-Hispanic whites, although neither of these differences was significant. Although the ethnic differences in prevalence in this study were not statistically significant, their pattern parallels the pattern in the mortality due to cardiovascular diseases. Therefore, the results support the hypothesis that the reduced cardiovascular mortality rate observed in Mexican-American men reflects a lower incidence of myocardial infarction rather than a reduced case fatality rate because the latter would result in a higher prevalence. | 3 |
Continued need for pneumococcal prophylaxis after splenectomy Two children died from pneumococcal infection five and eight years after splenectomy. Pneumococcal vaccination had not been given to either child. When the infection developed both children were not taking prophylactic penicillin. Vaccination and daily penicillin reduce the incidence of this complication and therefore we strongly recommend that both of these measures are continued indefinitely. | 4 |
Mohs micrographic surgery. Mohs micrographic surgery is a versatile technique for the treatment of nonmelanoma skin cancers, especially recurrent, invasive, or infiltrating basal cell carcinomas. It provides unsurpassed cure rates by using 100% surgical margin control, and it achieves maximal preservation of normal tissue. At the conclusion of tumor extirpation, the defect is ready for immediate reconstruction. With better understanding of the Mohs micrographic surgery technique, it can be more effectively used as part of a coordinated multidisciplinary approach to the treatment of patients with difficult cutaneous and paracutaneous neoplasms. | 0 |
Effect of V1-vasopressin receptor blockade on arterial pressure in conscious rats with cirrhosis and ascites. Angiotensin II blockade with saralasin in human cirrhosis with ascites is associated with a significant reduction in arterial pressure, indicating that endogenous angiotensin II plays an important role in the maintenance of systemic hemodynamics in this condition. The aim of the current study was to investigate whether vasopressin also contributes to the maintenance of arterial pressure in cirrhosis with ascites. The study was performed using three groups of cirrhotic rats with ascites and three groups of control animals. The administration of d(CH2)5Tyr(Me)AVP, a selective antagonist of the vascular effect of vasopressin, to 10 cirrhotic rats induced a significant reduction in mean arterial pressure (from 94 +/- 4 to 85 +/- 4 mm Hg; P less than 0.001) and a significant increase in plasma renin activity (from 24.3 +/- 4.9 to 34.3 +/- 5.9 ng/mL.h; P less than 0.02) and plasma norepinephrine concentration (from 1474 +/- 133 to 2433 +/- 253 pg/mL; P less than 0.01). Similar results were observed following saralasin administration in a second group of 5 cirrhotic rats [mean arterial pressure decreased from 97 +/- 4 to 85 +/- 5 mm Hg (P less than 0.0001); and plasma renin activity and norepinephrine concentration increased from 18.4 +/- 5.8 to 40.3 +/- 5.7 ng/mL.h (P less than 0.02) and from 1383 +/- 70 to 2312 +/- 334 pg/mL (P less than 0.05), respectively]. The simultaneous blockade of angiotensin II and vasopressin in a third group of cirrhotic rats resulted in a significantly greater reduction of mean arterial pressure (from 97 +/- 6 to 74 +/- 6 mm Hg; P less than 0.05). No changes in arterial pressure were observed in the three groups of control rats. These findings indicate that endogenous vasopressin is as important as angiotensin II in the maintenance of arterial pressure in cirrhotic rats with ascites and support the contention that arterial hypotension is the initial event leading to the stimulation of the renin-angiotensin system and vasopressin in this animal model of cirrhosis. | 1 |
Visceral protothecosis mimicking sclerosing cholangitis in an immunocompetent host: successful antifungal therapy. A healthy 39-year-old man who had clinical findings consistent with sclerosing cholangitis was found to have systemic protothecosis at surgery. Severe granulomatous inflammation and palpable nodules were found in the gallbladder, on the surface of the liver, and in the duodenum. Prototheca wickerhamii was detected in biopsied specimens and stool; the titer of indirect fluorescent antibody to this organism was 1:2,000. The patient recovered after a short course of treatment with amphotericin B and 3 months of oral therapy with ketoconazole. He had no other concurrent illness and had no abnormality in his immune system. This is the second reported human case of systemic protothecosis. An elevated IgG level, an elevated erythrocyte sedimentation rate, eosinophilia, and abnormal levels of enzymes in the liver were found in both cases. Protothecosis should be considered in the differential diagnosis of hepatic and biliary inflammatory diseases of uncertain etiology. | 1 |
Extrageniculate vision in hemianopic humans: saccade inhibition by signals in the blind field. The functional competence of extrageniculate visual pathways in hemianopic humans was demonstrated by showing that distractor signals in the blind half of the visual field could inhibit saccades toward targets in the intact visual field. This inhibitory effect of unseen distractors in patients occurred only when distractors were presented in the temporal half of the visual field, was specific to oculomotor responses, and did not occur in normal subjects. These results show that a peripheral visual signal activates retinotectal pathways to prime the oculomotor system and that these pathways can mediate orienting behavior in hemianopic humans. | 4 |
Biologically inert synthetic dural substitutes. Appraisal of a medical-grade aliphatic polyurethane and a polysiloxane-carbonate block copolymer. Two types of artificial membranes, a medical-grade aliphatic polyurethane and a polysiloxane-carbonate block copolymer, were tested as substitutes for dura in 24 and 12 rabbits, respectively. The films were placed either epidurally, subdurally, or as dural grafts in equal subgroups of animals. The postoperative course was uneventful with no manifestations of convulsive disorder or cerebrospinal fluid leak. The animals were sacrificed 3, 6, or 9 months after implantation of the artificial membranes. Both types of artificial membranes were easily removed from the underlying nervous and the other surrounding tissues. The histological examination failed to reveal adhesions, neomembrane formations, or any type of foreign body reactions to the polyurethane film. The implantation of the polysiloxane-carbonate film caused no reaction when it was applied epidurally. As a dural graft, the polysiloxane-carbonate copolymer induced the formation of a thin neomembrane of one to two layers of fibroblasts which formed a watertight seal of the dural defect. A similar thin neomembrane was found to encase this artificial membrane in the group of animals in which it was implanted subdurally. There was no foreign body reaction to the polysiloxane-carbonate film. The authors conclude that these materials hold promise as dural substitutes or in the prevention of spinal dural scarring, and should be evaluated clinically. | 4 |
Sensory ataxic hemiparesis in thalamic hemorrhage. Ataxic hemiparesis with cerebellar-like features has been reported following infarction or hemorrhage of the thalamus. We describe five patients with incoordination and corticospinal tract signs in the limbs opposite a dorsolateral thalamic hemorrhage. In four patients the hemorrhage extended superiorly into the lateral ventricle, the adjacent paraventricular region, and the upper and medial parts of the posterior limb of the internal capsule. Instead of cerebellar dysfunction, these patients exhibited directional errors of movement that improved distinctly when performed under visual guidance. We explain the incoordination on the basis of conscious deep sensory loss in the involved limbs. Perception of light touch, painful pinprick, and temperature were preserved in all patients. We use the term "sensory ataxic hemiparesis" to distinguish these patients from those with "classic" ataxic hemiparesis and cerebellar-like features, a distinction that may be important when planning functional rehabilitation. | 2 |
Stomatococcus mucilaginosus catheter-related infection in an adolescent with osteosarcoma. Ours is apparently the first reported pediatric case of Stomatococcus mucilaginosus bacteremia. It is the second reported case of S mucilaginosus catheter-associated infection, but the first case successfully treated without removing the central venous catheter. This unusual organism should be added to the list of opportunistic pathogens that can be isolated from immunocompromised pediatric patients. | 0 |
New approaches in the rehabilitation of the traumatic high level quadriplegic. The use of noninvasive alternatives to tracheostomy for ventilatory support have been described in the patient management of various neuromuscular disorders. The use of these techniques for patients with traumatic high level quadriplegia, however, is hampered by the resort to tracheostomy in the acute hospital setting. Twenty traumatic high level quadriplegic patients on intermittent positive pressure ventilation (IPPV) via tracheostomy with little or no ability for unassisted breathing were converted to noninvasive ventilatory support methods and had their tracheostomy sites closed. Four additional patients were ventilated by noninvasive methods without tracheostomy. These methods included the use of body ventilators and the noninvasive intermittent positive airway pressure alternatives of IPPV via the mouth, nose, or custom acrylic strapless oral-nasal interface (SONI). Overnight end-tidal pCO2 studies and monitoring of oxyhemoglobin saturation (SaO2) were used to adjust ventilator volumes and to document effective ventilation during sleep. No significant complications have resulted from the use of these methods over a period of 45 patient-years. Elimination of the tracheostomy permitted significant free time by glossopharyngeal breathing for four patients, two of whom had no measurable vital capacity. We conclude that noninvasive ventilatory support alternatives can be effective and deserve further study in this patient population. | 4 |
Effects of fish oil supplements in NIDDM subjects. Controlled study. The aim of this study was to evaluate the effects of a fish oil preparation (MaxEPA) on hemostatic function and fasting lipid and glucose levels in non-insulin-dependent diabetic (NIDDM) subjects. Eighty NIDDM outpatients aged 55.9 yr (mean SD 11.5 yr) participated in a prospective double-blind placebo-controlled study of MaxEPA capsules (10 g/day) or olive oil (control) treatment over 6 wk. Patients received either MaxEPA or olive oil in addition to preexisting therapy. Metabolic and hemostatic variables were measured before treatment and after 3 and 6 wk. Platelet membrane eicosapentaenoic acid (EPA) content increased in the treatment group (P less than 0.001). MaxEPA supplementation was associated with a significant fall in total triglycerides (P less than 0.001) but did not affect total cholesterol (P = 0.7) compared with control treatment. Fasting plasma glucose increased after 3 wk (P = 0.01) but not after 6 wk (P = 0.17) treatment with MaxEPA. Spontaneous platelet aggregation in whole blood fell in the MaxEPA group (P less than 0.02) after 6 wk, but there were no changes in agonist-induced platelet aggregation, thromboxane generation in platelet-rich plasma, or plasma beta-thromboglobulin and platelet factor IV levels. An increase in clotting factor VII (P = 0.02), without changes in fibrinogen or factor X levels, occurred in the MaxEPA group. Similar reductions in blood pressure were observed in both groups. Dietary supplementation with MaxEPA capsules (10 g/day) in NIDDM subjects is associated with improvement in hypertriglyceridemia but with deleterious effects in factor VII and blood glucose levels. Most indices of platelet function are unaffected by this therapy. | 3 |
Comparison of clinical and electrophysiologic features of preexcitation syndromes in patients presenting initially after age 50 years with those presenting at younger ages. Although patients may develop arrhythmias due to preexcitation syndromes at any time from the prenatal period to late adulthood, presentation in late adulthood is considered uncommon and has not been well studied. From June 1981 to June 1989, 73 patients were documented to have preexcitation syndromes on the basis of electrophysiologic studies. Those whose initial arrhythmias appeared at an age greater than 50 years (group 1, n = 13) were compared with the remaining 60 patients (group 2). All group 1 patients presented in the setting of acute medical or surgical diseases (n = 7), or chronic cardiac disease (n = 6) commonly associated with middle age and often with atrial arrhythmias; only 13 group 2 patients had underlying illnesses (p = 0.0001). Almost two-thirds of group 2 patients were evaluated because of narrow complex orthodromic tachycardia or palpitations and electrocardiographic evidence of preexcitation. Wide complex tachycardia was more often a reason for referral of older patients (7 of 13 vs 11 of 60, p less than 0.05), among whom atrial fibrillation/flutter also tended to be more frequent (4 of 13 vs 11 of 60, difference not significant). The PR and QRS intervals of group 1 patients were within the normal range and differed significantly from those of group 2 patients (PR, 0.15 +/- 0.04 vs 0.11 +/- 0.03 second, p less than 0.001; QRS, 0.09 +/- 0.01 vs 0.12 +/- 0.03 second, p less than 0.001), making electrocardiographic identification of preexcitation more difficult in group 1. Several factors likely contributed. | 3 |
Prospective study of early detection of hepatocellular carcinoma in patients with cirrhosis. We prospectively monitored 140 cirrhotic patients for the development of hepatocellular carcinoma for 6 yr, using periodical screening by high-resolution convex-array ultrasonography and alpha-fetoprotein. Twenty-eight patients were positive for HBs antigen, 26 patients had received blood transfusions and were negative for HBs antigen and 26 patients had a history of heavy drinking. We detected hepatocellular carcinoma in 40 patients during this period. The overall cumulative incidence of hepatocellular carcinoma in the 6 yr was 39%; the cumulative incidence was 59% in patients with HBsAg, 53% in patients who had had blood transfusions and were negative for HBsAg and 22% in patients who had a history of heavy drinking and who were without HBsAg. Detection of the carcinoma in 85% of these 40 patients was based on results of ultrasonography. Twenty-six of the patients (65%) had a small hepatocellular carcinoma of 2 cm or less. alpha-Fetoprotein levels were lower than 100 ng/ml in 56% of these 40 patients. Patients with cirrhosis are at high risk of developing hepatocellular carcinoma, especially patients with HBsAg or with a history of blood transfusion who are negative for HBsAg. Periodic monitoring by use of ultrasonography in particular is recommended for early detection of hepatocellular carcinoma. | 1 |
Long-term results of the Belsey Mark IV antireflux operation in relation to the severity of esophagitis A retrospective analysis of the results of the Belsey Mark IV operation has been conducted, relating these to the degree of esophagitis present preoperatively. Analysis of 89 patients showed a 91.7% success rate in patients without esophagitis. Good results diminished steadily as the severity of esophagitis increased, giving 76.5%, 75%, 66.7%, and 50% success rates for first-, second-, third-, and fourth-degree esophagitis, respectively. We believe that shortening of the esophagus is an important factor in this. Shortening is obvious in third- and fourth-degree esophagitis but subtle in first- and second-degree esophagitis. We conclude that the Belsey operation is adequate for patients without esophagitis, but for patients with any degree of esophagitis more effective reflux control is needed. | 1 |
Decreased growth velocity before IDDM onset. Diabetes can retard growth. Growth was studied prospectively in 12 nondiabetic identical twins aged less than 14 yr and in their co-twins with insulin-dependent diabetes mellitus (IDDM) to determine whether changes in growth occur before the onset of IDDM. Seven of the 12 nondiabetic twins subsequently developed IDDM; the remainder are now unlikely to become diabetic. A significantly reduced growth velocity was observed more frequently in the nondiabetic twins (7 of 12) than in their diabetic co-twins (1 of 12; P = 0.03). Of the 7 nondiabetic twins who were prediabetic, 6 had a reduction in growth velocity to below the 3rd percentile before the onset of diabetes compared with 1 of their diabetic co-twins (P = 0.03). However, only 1 of the 5 nondiabetic twins who did not develop diabetes showed a reduction in growth velocity. The nadir of growth in the twins who developed diabetes occurred a mean of 1.2 yr before diagnosis (range 0.3-2.3 yr). All 7 of the prediabetic twins had islet cell antibodies when first seen, and 3 had them before they showed either decreased growth velocity or impaired glucose tolerance. In 4 prediabetic twins, the decreased growth preceded impaired glucose tolerance. The prediabetic twins tested had lower testosterone or estradiol levels at the time they showed decreased growth than their diabetic twins. We conclude that decreased growth velocity is an early sensitive marker of IDDM. | 4 |
1990 Ogura memorial lecture: moral dilemmas in head and neck cancer. Neither morality nor dilemma can be defined meaningfully in the concept of the practical management of head and neck cancer. Although both have important implications, particularly with regard to ethnic and social factors, they play a relatively minor role in determining management policy. With little knowledge of the intrinsic causes of cancer and with a treatment strategy limited to radiotherapy and surgery, our desire for cure must be tempered by concern to avoid any increase in patient privations. My philosophy, based upon the care of more than 3500 patients over almost 30 years, reflects some of the difficulties of applying the concept "do nothing that may cause harm," while offering each patient the opportunity for long-term cure. | 0 |
Proximal gastric vagotomy in the emergency treatment of bleeding duodenal ulcer. Proximal gastric vagotomy for bleeding duodenal ulcer was performed in 52 low-risk patients between 1973 and 1986. Duodenotomy without violation of the pylorus was done in all patients to allow inspection and control of the bleeding site. The median duration of operation was 3 hours and 20 minutes, although 25% of the procedures required 4 or more hours. There was no postoperative mortality and no early reoperations. Among the six patients with postoperative complications, one rebled from the ulcer and two developed prolonged gastric atony. At the time of follow-up (median, 2.9 years), 48 of the patients were alive and 4 had died of non-ulcer causes. No patient had significant postvagotomy sequelae. Ulcer recurrence was documented in six patients, and three required reoperation. Proximal gastric vagotomy is a safe, effective therapy for bleeding duodenal ulcer. Because of the length of the operation, it should be restricted to low-risk patients who are hemodynamically stable at the time of operation. | 4 |
Hyperplastic gastric polyps associated with persistent Helicobacter pylori infection and active gastritis. We report two cases of patients with 3-yr histories of upper gastrointestinal symptoms, hyperplastic gastric polyps, and active chronic gastritis. Biopsies retrospectively stained with Giemsa revealed the persistent presence of Helicobacter pylori (HP) in gastric biopsies of both patients throughout the 3 yr. After treatment with amoxicillin and bismuth subsalicylate, both became asymptomatic, one demonstrating disappearance and recurrence of the gastric polyps in conjunction with the HP. These cases demonstrate 3 yr of hyperplastic gastric polyps associated with HP and active gastritis. | 1 |
Comparison of right ventricular and biventricular circulatory support in a porcine model of right heart failure. The effects of right ventricular (RVAD) and biventricular assist devices (BVAD) in an acute porcine model of right heart ischemic failure produced by occluding the right coronary artery for 2 min (RCAO) were compared. Right and left ventricular pressures were measured with Millar transducers and respective septal-to-free wall dimensions (RVSFWD, LVSFWD) with ultrasonic crystals. RCAO alone resulted in significant right heart failure, marked by a 36 +/- 5% reduction in cardiac output (pulmonary artery flow) and a 54 +/- 16% reduction in RV stroke work. Isolated RVAD significantly improved the hemodynamic conditions by restoring pulmonary blood flow and left heart filling to control levels. RVAD also resulted in reduced RVSFWD to control levels and increased LVSFWD via a rightward septal shift due to right heart unloading. Biventricular support resulted in the same hemodynamic improvement, but estimated LV peak systolic wall stress was reduced by 65 +/- 15% compared with control, due to concomitant LV unloading and reductions in LVSFWD. Therefore, either right or biventricular devices are effective in treating RV failure. The advantage of biventricular support is that the left ventricle is also unloaded, thus allowing improved circulatory support with minimal LV wall stress. | 3 |
Interferon activation of latent natural killer cells and alteration in kinetics of target cell lysis: clinical implications for oral precancerous lesions. Reduced natural killer cell activity was observed in patients with oral leukoplakia and submucous fibrosis compared with normal control subjects. However, the number of target binding lymphocytes was found to be normal in these precancers. Treatment of effector cells with interferon-alpha resulted in highly elevated active killer cell activity, although no change was observed in target binding lymphocyte counts. This finding could imply that precytotoxic cells that are activated by interferon exist in peripheral blood or that direct recruitment of a new cell population takes place. In addition, altered target lysis kinetics was observed, with interferon-activated killer cells demonstrating a tremendous lytic activation that is completed so quickly that a statistical kinetic analysis could not be accurately done. Because natural killer cell activity is an important effector system in immunosurveillance against tumors, its modulation with interferon may be an exciting clinical possibility in the control of malignant transformation or oral precancers. | 4 |
Long-term effects of radiotherapy in childhood and adolescence. The records of 50 selected pediatric patients who were treated and followed at M. D. Anderson Cancer Center were reviewed to study the late effects of nonsurgical treatment of cancer in children. There were 26 girls and 24 boys ranging in age between 2 months and 16 years. Patients with head and neck cancer received chemotherapy and radiotherapy for rhabdomyosarcoma (n = 27), retinoblastoma (n = 8), or nasopharynx cancer (n = 2). Median follow-up was 13 years. The most severe side effects were noted in the fields of radiation and included hypoplasia of the jaw, orbit, or hemi-face with varying degrees of atrophy of the overlying soft tissues. A wide range of endocrine, dental, and psychologic abnormalities was also documented. Since 1 in every 1,000 adults older than 20 years today is likely to be a survivor of childhood cancer, recommendations are made for this "new" class of patients whom the head and neck surgeon will be seeing in the future. | 0 |
Clinical study of intracranial nongerminomatous germ cell tumors producing alpha-fetoprotein. We present six patients with intracranial nongerminomatous germ cell tumors that produced alpha-fetoprotein (AFP). Their ages ranged from 8 to 20 years (average, 11.5 years old); two were male and four were female. Four of the tumors originated in the pineal region and two in the suprachiasmatic region. One patient treated with only radiation therapy died within 3 months of admission as a result of intraperitoneal metastasis via a ventriculoperitoneal shunt. Another patient, treated with radiation therapy and intrathecal administration of neocarzinostatin, died after 12 months because of tumor progression and subarachnoid dissemination. Two patients who received radiation and combination therapy with cisplatin, vinblastine, and bleomycin died after 13 and 25 months. The remaining two patients treated with radiation therapy and adjuvant chemotherapy (cisplatin and etoposide) are now alive without recurrence after 16 and 19 months from admission. Adjuvant chemotherapy with cisplatin and etoposide appears to be efficacious in the treatment of intracranial nongerminomatous germ cell tumor. | 2 |
From chimney sweeps to oncogenes: the quest for the causes of cancer. Over the past 200 years, a bewildering array of chemical, physical, and viral agents has been identified that can cause cancer, but the mechanisms involved are only now becoming clear. In the leukemias and lymphomas, it appears that the activation of cellular oncogenes is important. The genes involved are present in all normal cells and are often associated with cell growth and regulation. When activated, they act in a dominant fashion to cause a cell to express the malignant phenotype. There is increasing evidence that in solid tumors, a more important mechanism may be the loss of a suppressor gene. The classic example is retinoblastoma, in which the retinoblastoma gene has been cloned and is also found to be associated with several other common cancers including sarcomas and small cell lung cancer. It is likely to be one of a family of such genes. It may well be that the activation of one or more oncogenes or the loss of one or more suppressor genes, or both, is required for a tumor to progress from initiation through promotion to a metastasizing malignancy. | 4 |
Eosinophilia-myalgia syndrome in association with L-tryptophan ingestion. The association between the recently described eosinophilia-myalgia syndrome and L-tryptophan is now well established. We describe a patient with eosinophilia-myalgia syndrome who developed incapacitating myalgias and peripheral eosinophilia responsive only to high dose corticosteroids. When massive upper gastrointestinal hemorrhage developed while receiving corticosteroid therapy, surgery was complicated by striking abdominal wall rigidness. A discussion of this case and of eosinophilia-myalgia syndrome is presented. | 4 |
Adverse mortality experience of a southwestern American Indian community: overall death rates and underlying causes of death in Pima Indians. As part of an ongoing epidemiologic study, the death rate and causes of death during 1975 through 1984 were determined in Pima Indians who resided in the Gila River Indian Community (GRIC) in 1965 and later. Death certificates were available for 677 of the 681 deaths. In 78% of the deaths, the underlying cause recorded on the death certificate agreed with the cause determined after review of all available relevant records. The age- and sex-adjusted average annual death rate for the GRIC population (1639/100,000) was 1.9 times (95% CI 1.7-2.0) the 1980 rate for the U.S. all races (878/100,000). In Pima males, whose death rate was substantially higher than that of Pima females, the age-adjusted death rate was 2.3 times that in U.S. males, all races. Moreover among males 25-34 years of age, the Pima death rate was 6.6 times that for the U.S. all races. Diseases of the heart and malignant neoplasms caused 59% of U.S. deaths in 1980, but only 19% of GRIC deaths. By contrast, the age- and sex-adjusted mortality rate in the GRIC Pima was 5.9 times the rate of the U.S. all races for accidents, 6.5 times for cirrhosis, 7.4 times for homicide, 4.3 times for suicide, and 11.9 times for diabetes. Tuberculosis and coccidioidomycosis were important causes of death in the Pima, for whom infectious diseases was the tenth leading cause of death. The findings indicate that programs to improve the adverse mortality experience of the GRIC population should emphasize factors related to fatal accidents, alcoholic cirrhosis, homicide, suicide, diabetes mellitus, and infectious diseases. Young Pimas, especially the males, should be the primary focus of such preventive efforts. These findings and recommendations probably apply to many Native American populations. | 3 |
A randomized trial comparing direct current therapy and bipolar diathermy in the outpatient treatment of third-degree hemorrhoids. Fifty patients with third-degree hemorrhoids were randomized to receive outpatient treatment with either bipolar diathermy or direct current therapy. Direct current therapy was used to treat 26 patients and bipolar diathermy was used to treat 24 patients. Twenty patients in each group were successfully treated as judged by resolution of symptoms and shrinkage of hemorrhoidal tissue. Both treatments are effective in the outpatient management of large, prolapsing hemorrhoids. Bipolar diathermy is less time consuming and better tolerated. | 3 |
Quantitative assessment of ultrasonic myocardial reflectivity in hypertrophic cardiomyopathy The purpose of this study was to investigate the relation between acoustic properties of the myocardium and magnitude of left ventricular hypertrophy in patients with hypertrophic cardiomyopathy. An on-line radio frequency analysis system was used to obtain quantitative operator-independent measurements of the integrated backscatter signal of the ventricular septum and posterior free wall in 25 patients with hypertrophic cardiomyopathy and 25 normal age-matched control subjects. The integrated values of the radio frequency signal were normalized for the pericardial interface and expressed in percent. Tissue reflectivity was significantly increased in the hypertrophied ventricular septum, as well as in the nonhypertrophied posterior free wall, in patients with hypertrophic cardiomyopathy (58 +/- 15% and 37 +/- 12%, respectively) compared with values in normal subjects (33 +/- 10% and 18 +/- 5%, respectively; p less than 0.001). Furthermore, measurements of reflectivity of the septum or posterior free wall, or both, were beyond 2 SD of normal values in greater than 90% of the patients and were also abnormal in each of the five study patients who had only mild and localized left ventricular hypertrophy. No correlation was identified between myocardial tissue reflectivity and left ventricular wall thickness in the patients with hypertrophic cardiomyopathy (correlation coefficient r = 0.4; p = NS). These findings demonstrate that myocardial reflectivity is abnormal in most patients with hypertrophic cardiomyopathy and is largely independent of the magnitude of left ventricular hypertrophy. Moreover, quantitative analysis of ultrasonic reflectivity can differentiate patients with hypertrophic cardiomyopathy from normal subjects independently of clinical features and conventional echocardiographic measurements. | 3 |
Intra-arterial urokinase as the initial therapy for acutely ischemic lower limbs Acute ischemia of the lower limb remains a significant risk to both life and limb. Mortality rates of approximately 10-30% and amputation rates of the same magnitude in the survivors are repeatedly reported despite advances in medical and surgical techniques. Our experience, which utilized percutaneous intra-arterial thrombolysis as the initial treatment in 72 instances (63 patients), has resulted in a markedly lower mortality rate of 1.6% and a lower amputation rate of 8.5% in the survivors. Careful categorization by clinical degree of ischemia indicates that 82% of the cases were either threatened or irreversible limb ischemia. The initial treatment with thrombolysis did not preclude subsequent prompt surgical treatment when necessary; in these cases, thrombolysis promoted improved surgical results (100%) when it was successful. It markedly reduced the need for urgent surgery, usually simplified the subsequent surgical approach, diminished the overall need for surgery, and often accomplished a successful outcome alone (31%). Significant bleeding was not noted during subsequent surgical procedures and was noted in only 2.8% of the cases. Confirmation of these results and further improvements in technique might justify the use of an initially high-dose urokinase transcatheter infusion regimen as the initial treatment of choice for acute lower-limb ischemia. | 4 |
Limitation of transcatheter arterial chemoembolization using iodized oil for small hepatocellular carcinoma. A study in resected cases. The radiologic and histologic findings are presented of the resection of 14 small hepatocellular carcinomas (HCC), less than 2 cm in maximum diameter, after transcatheter arterial chemoembolization (TCE) using iodized oil. The effect of TCE on small HCC depended on the morphologic type of the tumors. When no extracapsular invasion of tumor cells occurred, TCE was extremely effective against encapsulated tumors. However, in nine of the 14 resected specimens, viable tumor cells remained in or around the tumor. The authors suggest that small HCC are not always curable with TCE alone and that a multi-disciplinary approach is necessary for patients with small HCC. | 0 |
Angioplasty of coronary bifurcation stenoses: immediate and long-term results of the protecting branch technique. Percutaneous transluminal angioplasty (PTCA) of coronary stenoses involving major bifurcations carries a small but significant risk of side branch occlusion which can be avoided by simultaneously using multiple dilatation systems. Among 1,275 PTCA procedures performed between 1984 and 1988 in 1,035 consecutive patients, 42 double wire procedures were applied (4%) to protect and/or dilate major coronary side branches. A total of 80 coronary stenoses were attempted of which 76 were located on a bifurcation and 4 on other segments. In the first 11 patients (group A), 2 guiding catheters were used and PTCA of each vessel was successfully performed by means of separate double lumen over-the-wire balloon catheters. In the next 31 patients (group B), 2 guidewires were advanced through a single guiding catheter and PTCA was attempted using "Monorail" balloon catheters sequentially advanced over the wires. In group B, a successful PTCA was obtained in 29 patients (93%) but twisting of the wires hampered balloon progression in 5 cases, such that dilatation could only be performed by stepping back to a single wire technique. The procedure time in group B was significantly shorter than in group A: 144 +/- 30 versus 230 +/- 52 minutes (p = .01). Repeat angiography was performed in 35 out of 40 patients (87%) after a mean of 180 +/- 46 days following successful PTCA. Angiographic restenosis was present in 37% (24/65) of bifurcation segments which, in our experience, is not significantly different from the angiographic restenosis rate in less complex lesions (248/740; 34%; NS). | 3 |
Short course chemotherapy for childhood tuberculosis A prospective study, with an attempted 24-month-post-treatment follow-up, of children with tuberculosis (TB) treated with short course chemotherapy (SCC) for 6 months was carried out because published experience of SCC in childhood TB was limited. All children in Port Moresby diagnosed as having TB between November, 1984, and November, 1986, entered the trial. Of the 639 children 165 (26%) were younger than 2 years old. Of these, 227 (35%) had extrapulmonary TB (peripheral lymph node, 110; central nervous system, 43; abdominal, 27; miliary, 16; bone and joint, 11; pleural, 11; polyserositis, 9). Clinical response to SCC was rapid. Adverse drug reactions occurred in 15 (2%), mainly to streptomycin. Twelve (2%) died, 38 (6%) transferred out and 145 (28% of the 518 who did not die, transfer or live too far from a treatment centre) defaulted. Three hundred seventy-three (58%) completed a 2-month course of daily rifampin, isoniazid, pyrazinamide and streptomycin followed by a 4-month course of twice weekly rifampin and isoniazid. A further 71 (11%) had their treatment modified because of their distance from a treatment center. Only 70 (19%) of the 373 children available for post-treatment follow-up attended the every-3-month follow-up visits for 24 months, although 223 (60%) attended one or more of the follow-up visits. Seven of the 373 children relapsed, mostly within 3 months. Five of these children had been irregular with their treatment. SCC for childhood TB is safe and effective for pulmonary and extrapulmonary disease. | 4 |
Evaluation and management of supraventricular tachycardia in children. Emergency physicians may be called on to resuscitate acute complications in pediatric patients with congenital heart disease. Supraventricular tachycardia, with or without hemodynamic decompensation, is one of the most serious complications. We present the case of a 22-month-old boy with a history of single ventricle who presented to our institution with a history of syncope and hemodynamically stable supraventricular tachycardia. Initial attempts at pharmacologic conversion with propranolol and verapamil failed. The arrhythmia was terminated in response to an IV fluid bolus and dopamine infusion and probably resulted from a combination of anemia, hypovolemia, and impaired contractility. Appropriate evaluation and management relating to the cre of acute supraventricular tachycardia in children are discussed. | 3 |
Prospective payment system and impairment at discharge. The 'quicker-and-sicker' story revisited Since the introduction of the prospective payment system (PPS), anecdotal evidence has accumulated that patients are leaving the hospital "quicker and sicker." We developed valid measures of discharge impairment and measured these levels in a nationally representative sample of patients with one of five conditions prior to and following the PPS implementation. Instability at discharge (important clinical problems usually first occurring prior to discharge) predicted the likelihood of postdischarge deaths. At 90 days postdischarge, 16% of patients discharged unstable were dead vs 10% of patients discharged stable. After the PPS introduction, instability increased primarily among patients discharged home. Prior to the PPS, 10% of patients discharged home were unstable; after the PPS was implemented, 15% were discharged unstable, a 43% relative change. Efforts to monitor the effect of this increase in discharge instability on health should be implemented. | 2 |
External ear resonance in children with otitis media with effusion. A middle ear effusion has been shown, in KEMAR, to increase the height of the resonant peak of the external auditory canal by 6 dB SPL. It has also been shown that the hearing impairment due to otitis media with effusion is related to the volume of middle ear fluid. Therefore, it was hypothesized that measurement of the height of the resonant peak of the external auditory canal could be used as a method of assessing the magnitude of any hearing impairment due to otitis media with effusion. 182 ears from 182 children aged 3-12 (mean 6.3) years were studied. Pure-tone audiometry and impedance tympanometry were performed, and the acoustics of the external auditory canal were measured using the Rastronics CC1-10 frequency response analyser. The mean height of the resonant peak (17.9 dB SPL) of children with a type A tympanogram was significantly different from the mean value (23.6 dB SPL) of those with a type B tympanogram. There was a significant correlation between the height of the resonant peak and the speech frequency average of the pure-tone thresholds. The sensitivity and specificity of using the height of the resonant peak to detect hearing impairments in different age groups were calculated and compared with the sensitivity and specificity of tympanometry. The test did not provide the same degree of sensitivity as tympanometry but was more specific. The additional advantages of the test are that it is quick, taking less than 1 min per ear, and is well tolerated by children in whom there was a 99% compliance. | 4 |
Characterization of a factor-dependent acute leukemia cell line with translocation (3;3)(q21;q26). A strictly factor-dependent cell line (UCSD/AML1) was established from a patient with the syndrome of multilineage acute leukemia with high platelets. The patient's cells and the cell line karyotype were 45,XX,-7,t(3;3)(q21;q26), typical of the syndrome of acute leukemia with high platelets. The cell line expresses CD34, CD7, TdT, and myeloid (CD13, CD14, CD33) and megakaryocyte/platelet (CD36, CD41, CD42b, CDw49b) antigens. In short-term culture, UCSD/AML1 cells proliferate in response to interleukin-3 (IL-3), IL-4, IL-6, macrophage colony-stimulating factor (M-CSF), and granulocyte-macrophage CSF (GM-CSF), but not IL-1, IL-2, IL-5, or G-CSF. In long-term culture, proliferation can be sustained by GM-CSF, IL-6, or M-CSF. When maintained in GM-CSF, a small percentage of cells form multinucleated megakaryocyte-like giant cells. Culture with GM-CSF combined with IL-6, but not with IL-6 alone, increased giant cell formation fourfold to sevenfold. IL-6 alone or in combination with GM-CSF increased expression of platelet-related antigens. In contrast, culture with phorbol ester induced formation of macrophage-like cells. UCSD/AML1 is the first human acute nonlymphocytic leukemia cell line established from a patient with an acute leukemia syndrome associated with a specific chromosome abnormality. | 0 |
Calcium channel blockers in geriatric hypertension. Though the calcium channel blockers have been used to treat angina pectoris for almost a decade, the long-acting forms of these agents that have become available in the last few years have made them practical for use as antihypertensive agents as well. They are becoming increasingly popular in this role, especially to treat elderly hypertensive patients. Because they are vasodilators with a mild diuretic action, they are logical treatment choices for the majority of hypertensive patients who have increased peripheral vascular resistance. They offer the advantage of a dual benefit for hypertensive patients with angina, and they have no effect on carbohydrate or lipid metabolism. Disadvantages include cost and a side effect profile that includes headaches, palpitations, ankle edema, and constipation. | 3 |
Infectious intracranial aneurysms: comparison of groups with and without endocarditis. A series of 12 patients with infectious intracranial aneurysms is presented, and a number of unusual features of the disorder are emphasized. A comparison of characteristics of the aneurysms and clinical course is made between patients with and without infective endocarditis. Most of the unusual characteristics of infectious aneurysms, including rare locations, causative organisms, and predisposing medical conditions, occurred in the group without endocarditis. The relationship of atypical features of infectious aneurysms to the etiology of aneurysm formation is discussed, and an approach to treatment is presented. | 3 |
Regional wall thickening of left ventricle evaluated by gated positron emission tomography in relation to myocardial perfusion and glucose metabolism. Regional wall thickening was assessed by electrocardiographically gated positron emission tomography (ECG-gated PET) in 26 patients with coronary artery disease. The standardized percent count increase from end-diastole to end-systole (S-percent Cl) was calculated as an index of wall thickening. The S-percent Cl was 77.8% +/- 28.9% in the segments with normal perfusion at rest, 51.9% +/- 29.5% in those with mild hypoperfusion, and 32.8% +/- 30.9% in those with severe hypoperfusion (p less than 0.001, each). Among the segments with resting hypoperfusion, the S-percent Cl was 38.9% +/- 31.5% in those without stress-induced ischemia and 48.7% +/- 30.9% in those with ischemia (p less than 0.05). Furthermore, among resting severe hypoperfusion, the S-percent Cl was 23.0% +/- 23.9% in the segments without fluorine-18-fluorodeoxyglucose (FDG) uptake and 37.8 +/- 32.9% in those with FDG uptake (p less than 0.05). These results suggest that stress-induced ischemia and FDG accumulation correlated with wall thickening. Thus, quantitative analysis of regional wall thickening seems to be useful for combined analysis of regional function, perfusion and metabolism in coronary patients. | 3 |
Evaluation of ventilating tubes and myringotomy in the treatment of recurrent or persistent otitis media In a prospective controlled study of the efficacy and sequelae of ventilating tubes, 44 children with bilateral recurrent acute otitis media (greater than 6 episodes/year) and 13 children with bilateral persistent middle ear effusion (greater than 3 months) received unilateral ventilating tube insertion in a randomly selected ear. The contralateral ears were randomized to receive either myringotomy alone or no surgery. Clinical, otoscopic, tympanometric and audiologic examinations were performed before the study and 2 to 4 weeks later, then at 3-month intervals for up to 2 years and at 36 months after surgical randomization. Medical therapy and antibiotic prophylaxis were used whenever indicated. While the ventilating tubes remained functional (mean duration, 10 months) the ears with a tube had significantly fewer episodes of otitis media than their contralateral ear (P less than 0.001; 95% confidence intervals -0.7, -1.7) and had more hearing improvement (P = 0.005; 95% confidence intervals, -5.9, -1.2). After tube extrusion there was a tendency for surgically treated ears to have more otitis and worse hearing, but not at a significant level. Tympanosclerosis, retraction and atrophy were more common in ears that received tubes. The majority of ears treated medically also improved. There is need for a more cautious and selective use of ventilating tubes. | 4 |
Predicting failure following shunting of pleural effusions. We placed 43 shunts in 34 patients in five years. Twenty-four had malignant effusions and ten had benign effusions. Thirty-one patients had unilateral shunts, three had bilateral shunts and six required revisions for shunt failure. Two patients died after shunt placement from disease progression. Of the nine patients who experienced poor results, one was noncompliant in operating the shunt and eight had occluded shunts. In the 30 patients, who were compliant and had adequate length of follow-up, five had excellent results, 12 had good results, and five had fair results. Two of the patients with occluded shunts had good results after shunt revision; 24 patients had some symptomatic relief with shunting. Evaluation of factors including a history of prior abdominal surgery, performance status, and pleural fluid cell counts, differential, chemistries, and cytology revealed no significant differences between the patients who experienced shunt failure and those who had patent shunts. Shunting of pleural effusions is well tolerated and has good success rates in properly selected patients. | 4 |
Laparoscopic ventrosuspensions. A review of 72 cases. Laparoscopic ventrosuspension is simple to perform after diagnostic laparoscopy. Serious postoperative complication is unlikely. However, patient follow-up over 6 months has not confirmed the usefulness of laparoscopic ventrosuspension in the management of deep dyspareunia or pelvic pain in association with a retroverted uterus. The success rate of laparoscopic ventrosuspension at 6 months varies from 18.6% to 46.5%. The prior use of a Hodge pessary does not predict the success of laparoscopic ventrosuspension. | 4 |
Femoral mononeuropathy after radical prostatectomy. Femoral mononeuropathy is a recognized complication following abdominal and vaginal hysterectomy. Retractor injury and lithotomy position were postulated mechanisms. We report a femoral nerve lesion following a radical perineal prostatectomy. | 0 |
Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging. Spontaneous osteonecrosis about the knee typically is a disease of the elderly characterized by an acute onset of pain. The exact cause of this condition has long been debated, although a causative relationship between meniscal tears and spontaneous osteonecrosis about the knee has been postulated. Seven patients with knee pain, meniscal tears, and chondromalacia without initial evidence of osteonecrosis at magnetic resonance (MR) imaging underwent arthroscopic surgery with meniscal recontouring or repair and cartilage shaving. These patients returned within 2-14 months with recurrent pain in the treated knee. MR imaging then demonstrated abnormalities consistent with osteonecrosis. Osteonecrosis of the femoral condyle or tibial plateau may be a late sequela of meniscal injury in association with chondromalacia and arthroscopic surgery. This diagnosis should be suspected in patients with recurrent knee pain after arthroscopic repair of meniscal tears. The precise relationship of this pattern of osteonecrosis to that previously described as spontaneous requires further investigation. | 2 |
The effects of smoking on the signal-averaged electrocardiogram in normal subjects. Tobacco smoking increases the risk of sudden cardiac death, possibly by altering the substrate for propagation or sustainment of ventricular tachyarrhythmias. To test this hypothesis, 15 long-term smokers without known coronary artery disease abstained from tobacco smoking for 12 h, after which they underwent SAECG before, 15 min after and 30 min after smoking two cigarettes. Other than minor lengthening of filtered QRS duration, no significant change in time-domain SAECG parameters was noted. We conclude that late potentials are not produced by cigarette smoking and that ventricular arrhythmia substrate as measured by SAECG variables is not worsened in long-term smokers without evidence of coronary artery disease. | 4 |
Long-term results of the Belsey Mark IV antireflux operation in relation to the severity of esophagitis A retrospective analysis of the results of the Belsey Mark IV operation has been conducted, relating these to the degree of esophagitis present preoperatively. Analysis of 89 patients showed a 91.7% success rate in patients without esophagitis. Good results diminished steadily as the severity of esophagitis increased, giving 76.5%, 75%, 66.7%, and 50% success rates for first-, second-, third-, and fourth-degree esophagitis, respectively. We believe that shortening of the esophagus is an important factor in this. Shortening is obvious in third- and fourth-degree esophagitis but subtle in first- and second-degree esophagitis. We conclude that the Belsey operation is adequate for patients without esophagitis, but for patients with any degree of esophagitis more effective reflux control is needed. | 4 |
Reinforcement of incontinent stools in the treatment of encopresis. In this paper, fecal incontinence and constipation were treated in two mentally retarded individuals using a novel intervention wherein incontinent stools were first rewarded in order to increase the frequency of bowel movements. This intervention was implemented only after more traditional pediatric and behavioral treatments were unsuccessful. The reinforcement of incontinent stools procedure resulted in an increase in both the frequency and the number of continent stools for both individuals. Hypotheses regarding the failure of previous treatments and the success of the current treatment are discussed as well as directions for future research. | 4 |
Adult height in boys and girls with untreated short stature and constitutional delay of growth and puberty: accuracy of five different methods of height prediction. To determine how accurately several methods of height prediction estimate adult height, we compared height predictions calculated by the Bayley-Pinneau, Roche-Wainer-Thissen (RWT), target height, and Tanner-Whitehouse Mark I (TW-MI), and Mark II (TW-MII) methods with final adult height in 37 boys and 32 girls with short stature and constitutional delay of growth and puberty. They were first seen at a chronologic age (mean +/- SD) of 14.80 +/- 1.70 years (boys) and 12.87 +/- 2.56 years (girls). Adult height at 23.14 +/- 1.95 years and 21.05 +/- 2.02 years was 170.4 +/- 5.4 cm (boys) and 157.8 +/- 4.2 cm (girls), respectively, and thus within the lower range of normal. Height predictions were calculated for the total group and for patients with parents of normal (group 1) as well as short stature (group 2). For boys, the RWT method gave very accurate results, underestimating adult height by -0.6 cm for the total group. The prediction errors for the other methods were -7.3 cm (TW-MI), -4.2 cm (TW-MII), and +3.1 cm (Bayley-Pinneau method) or +1.7 cm (target height). For girls, no method was superior in estimating adult height. The mean prediction error was -0.8 cm, -2.1 cm, and -1.8 cm with the Bayley-Pinneau, TW-MI, and TW-MII methods, respectively. In contrast, adult height was overpredicted by +2.3 cm and +1.2 cm with the RWT and target height methods. We conclude that patients with short stature and constitutional delay of growth and puberty reach an adult height in the lower range of normal. Height prediction methods differ with respect to their accuracy and their tendency to overestimate or underestimate adult height. | 4 |
Effects of short-term pancreatic duct obstruction in rats. The short-term effects of rat pancreatic duct obstruction were evaluated and compared with those recently reported to follow obstruction of the rabbit pancreatic duct. In both species pancreatic edema and hyperamylasemia are noted, and the lysosomal hydrolase cathepsin B is redistributed from the lysosome-enriched to the zymogen granule-enriched subcellular fraction. Theoretically, this redistribution phenomenon might lead to digestive enzyme activation because cathepsin B is known to be capable of activating trypsinogen. The hyperamylasemia and pancreatic edema (but not the cathepsin B redistribution) that follow rat pancreatic duct obstruction were increased by infusion of a submaximally stimulating dose of the cholecystokinin analogue cerulein. Administration of the cholecystokinin-receptor antagonist L-364,718 reduced the hyperamylasemia but did not alter the pancreatic edema or cathepsin B redistribution. These observations indicate that cholecystokinin may modulate some but not all of the effects of duct obstruction. Secretin administration increased the degree of pancreatic edema and had no demonstrable protective effect. The rat duct-obstruction model described in this report may prove particularly useful in future studies designed to clarify the early events underlying the development of acute pancreatitis. | 1 |
Job dimensions associated with severe disability due to cardiovascular disease. This study explored associations among job activities and disability due to cardiovascular disease by merging national disability data with independently-obtained job activity data. Disability data were taken from a 1978 U.S. health interview survey (n = 9855). Expert ratings of job activities (dimensions) were obtained from a job analysis database (n = 2485 occupations). The two databases were merged such that job dimension data were imputed to each occupation in the disability database. Odds ratios for cardiovascular disability were calculated for scores in the second, third, and fourth quartiles for each of the 32 job dimensions, using scores in the first quartile as the standard. Job dimensions associated with cardiovascular disability were (a) hazardous situations; (b) vigilant work and responsibility for others; (c) exchanging job-related information; and (d) attention to devices. Occupations identified with high scores on these job dimensions included transportation jobs (air traffic controllers, airline pilots and attendants, bus drivers, locomotive engineers, truck drivers), teachers (preschool, adult education), and craftsmen/foremen (machinists, carpenters, and foremen). | 3 |
Effect of age on the efficacy of blood pressure treatment strategies. To study whether the proportion of excess cardiovascular events attributable to various levels of systolic blood pressure varies with age, we calculated the population-attributable risk of all-cause mortality, fatal and nonfatal cardiovascular events (stroke, coronary heart disease, angina, congestive heart failure, and peripheral vascular disease), and stroke incidence due to systolic blood pressure in men and women 45 years of age or older in the United States during 1980. Our estimates are based on US census counts, blood pressure prevalence distributions from the second National Health and Nutrition Examination Survey, and the annual risk of cardiovascular complications during 18 years of follow-up in the Framingham cohort. We then determined the impact of age on the relative efficacy of mass treatment and case-finding strategies in preventing systolic blood pressure-related events. At 45-54 years of age, only 30-40% of systolic blood pressure-related excess events occur in hypertensive individuals (systolic blood pressure greater than or equal to 160 mm Hg). With increasing age, however, the percentage of systolic blood pressure-related events that occur in hypertensive individuals rose substantially; in the older age group (greater than or equal to 75 years), 65-70% of fatal and nonfatal cardiovascular disease events occur in hypertensive persons. The pattern is similar for men and women. The potential impact of a mass treatment strategy designed to shift the distribution of blood pressure downward by a small amount is greater in younger than in older groups, whereas an opposite trend is seen for a high-risk, hypertensive case-finding and treatment approach. | 2 |
Patient compliance--a factor in facial trauma repair. The clinical records of 25 consecutive patients who were treated for facial trauma were reviewed and analyzed to ascertain what effect patient cooperation had on the outcome of facial fracture repair. The study was designed to establish the incidence of complications and to discover what factors contributed to untoward sequela in such patients. Overall, 15 patients (60%) were noncompliant in one or more aspects of their care. Six patients (24%) had significant postoperative complications associated with their facial injuries. Four of these patients were not fully cooperative. | 4 |
A new monoclonal antibody (CH-F42) recognizes a CD7- subset of normal T lymphocytes and circulating malignant cells in adult T-cell lymphoma-leukemia and Sezary syndrome. We describe a new rat immunoglobulin M monoclonal antibody (CH-F42) that recognizes a subset (1.5% to 8%) of normal peripheral blood T lymphocytes. The phenotype of these cells was determined, using dual-color immunofluorescence, to be CD2+, CD3+, CD4+, CD5+, CD7-, CD8-. They do not express T-cell activation markers, and are positive for UCHL1 (CD45RO), but negative for 2H4 (CD45RA). The antigen was expressed on circulating malignant cells in Sezary syndrome (four of four cases) and adult T-cell lymphoma-leukemia (ATLL) (four of six cases) and negative in a variety of other hematologic malignancies tested. These included chronic and acute lymphoid leukemias of B and T lineage, together with chronic and acute myeloid leukemias. However, normal CH-F42+ cells do not display any of the ultrastructural features associated with Sezary or ATLL cells. The marked similarities between these conditions together with the shared expression of an otherwise very restricted surface antigen (CH-F42) provide strong evidence for the existence of a common normal counterpart. Preliminary characterization studies of the antigen, which is also expressed by K562 and Jurkat cells, suggest the CH-F42 antigen is an O-linked, sialated glycan on a glycoprotein. | 4 |
Indications for the surgical treatment of osteomas of the frontal and ethmoid sinuses. Sixty-one patients with an osteoma of the frontal or ethmoid sinuses have been studied. The following indications for surgical removal of these osteomas are suggested: osteomas extending beyond the boundaries of the frontal sinus, if enlarging, if localized in the region adjacent to the nasofrontal duct, if signs of chronic sinusitis are present, osteomas of the ethmoid sinuses, irrespective of their size and if patients with osteomas complain of headache and other causes of headache have been excluded. The operation of choice is the osteoplastic flap operation. | 0 |
Management of soft tissue sarcomas of the extremities. The management of soft tissue sarcomas has undergone and continues to undergo important changes. The purpose of this report is to review the presentation, diagnosis, and natural history of soft tissue sarcomas. In so doing, the importance of a careful and rigorous method of evaluation will be emphasized. Furthermore, the results of multidisciplinary treatment, with a goal towards limb salvage, will be reviewed. With appropriate and timely intervention, selected patients with pulmonary metastases may still experience long-term survival. Throughout this review, the importance of early and continuing multidisciplinary treatment and evaluation will be emphasized. | 0 |
Chest pain in teenagers. When is it significant? Chest pain in teenagers often has no obvious organic cause. Onset of symptoms with an emotionally stressful situation may indicate psychogenic chest pain. The differential diagnosis also includes cardiac, musculoskeletal, gastrointestinal, and respiratory disorders. Routine testing generally does not help to establish a diagnosis and may even do harm by reinforcing a patient's unspoken fear of serious illness. Most teenagers with chest pain have no such illness, and symptoms usually resolve without therapy. An important role for primary care physicians is to provide support during evaluation and follow-up. | 3 |
Maternal and uteroplacental hemodynamic effects of chronic captopril in the hypertensive, term-pregnant rat. The chronic effects of captopril on maternal hemodynamics and organ perfusion were investigated in 10 untreated and 10 captopril-treated pregnant spontaneously hypertensive rats by means of the radioactive-labeled microsphere technique. The normal decrease in blood pressure during gestation was prevented by reduction of litter size to two conceptuses on day 7 of gestation. Captopril (approximately 10 mg/kg/day) or drug vehicle (50% ethyl alcohol) was administered intraperitoneally by an osmotic pump from day 7 to 21. At term mean arterial pressure was 23% lower in the captopril-treated group as the result of a 29% decrease in total peripheral resistance without a significant change in cardiac output. The decrease in total peripheral resistance was primarily caused by a decline in splanchnic and skin resistances. Maternal organ and uteroplacental perfusion were not significantly altered. We conclude that administration of captopril during the last 2 weeks of pregnancy in the hypertensive rat effectively lowers maternal blood pressure without adverse effects on organ and uteroplacental perfusion. | 3 |
Treatment of the acquired immune deficiency syndrome-related Kaposi's sarcoma with bleomycin as a single agent. A nonrandomized trial was conducted to assess the efficiency and toxicity of bleomycin as a single agent in treatment of non-life-threatening AIDS-related Kaposi's sarcoma (KS). Sixty patients were enrolled in this study. They all had a disseminated and progressive non-life-threatening AIDS-related KS associated with systemic symptoms and/or CD4 lymphocyte count less than 400/mm3. Thirty patients were treated with intramuscular bleomycin (5 mg/d for 3 days every 2 or 3 weeks) and 30 others with a slow continuous intravenous infusion of bleomycin (6 mg/m3/d for 4 days every 4 weeks). The mean duration of therapy was 5 months (range, 2 to 24 months). A partial response was observed in 29 patients (48.3%) and the disease was stabilized in 18 additional patients (30%). Bleomycin failed in 21.6% of patients. Therapy had to be discontinued in two patients because of side effects. Thus bleomycin as a single agent is a good alternative therapy for AIDS-related KS. | 0 |
The combined use of apraclonidine and pilocarpine during laser iridotomy in a Hispanic population. Early postoperative intraocular pressure (IOP) rise is a frequent and vision-threatening complication of laser surgery for glaucoma. Recent studies show that apraclonidine, a new alpha-2 adrenergic agonist, can reduce the incidence of this problem. In a randomized, double-masked prospective study, we explored the efficacy of apraclonidine combined with pilocarpine during laser iridotomy in a Hispanic population. A significantly lower early postoperative IOP with less frequent severe pressure spikes occurred in the apraclonidine-treated patients. The addition of pilocarpine did not interfere with the beneficial effect of this medication. Of particular interest was the fact that chronic angle-closure glaucoma was the diagnosis in all patients who had a significant postoperative IOP rise in this study. | 4 |
Atrial fibrillation with cardiac tamponade as the initial manifestation of malignant pericarditis This article describes the case of a 72-year-old woman with cardiac tamponade and atrial fibrillation as the initial manifestation of a lymphoid malignancy. The pathogenesis of cardiac tamponade, various diagnostic modalities, and therapy of this condition are reviewed. | 0 |
Sequential connection of flaps: a logical approach to customized mandibular reconstruction. Microsurgery has improved the success rate for reconstruction of composite defects in the head and neck. Restoration of mandibular continuity alone is not adequate for reconstruction. Replacement of the oral lining with thin tissue is necessary to improve tongue mobility and to set the stage for later dental restoration. There is currently no ideal osteocutaneous free flap that provides unlimited length of bone, can undergo multiple osteotomies to produce the proper curve to the reconstructed mandible, and provides thin skin for oral lining. Combining free flaps can take advantage of the strengths of the individual donor sites and eliminate some of the problems with current osteocutaneous flaps. In six patients, a fibular osseous free flap was combined with either a radial forearm flap or a lateral arm flap to provide bone and oral lining in reconstruction of mandibular composite defects. In these selected patients, the fibula provided the blood supply for the second free flap, which was placed sequentially. The distal peroneal vessels were used to anastomose to the radial forearm vessels or the lateral arm pedicle. This approach allows the surgeon to customize the defect by improving both the functional and aesthetic aspects of reconstruction and is of use in cases where vascular access is limited, such as following head and neck surgery and radiation. | 0 |
Survey of the use of thrombolysis for acute limb ischaemia in the UK and Ireland. A total of 156 vascular surgeons from the UK and Ireland responded to a postal questionnaire on the use of thrombolysis in acute limb ischaemia. Almost half had used thrombolysis in the previous 12 months. Low dose intra-arterial streptokinase (89 per cent) was the regimen most frequently used, but 33 per cent had used intravenous streptokinase. Detailed results for 103 patients (limb salvage rate 60 per cent, amputation rate 35 per cent, mortality rate 5 per cent) were similar to those of previously published reports. Complications in most series were infrequent, but in the entire survey there were six bleeding-related deaths and one death from anaphylaxis. A total of 67 per cent of surgeons with working experience indicated that selected patients with acute arterial thromboses were most suitable for thrombolysis, particularly if there was no neurological deficit and no run-off for surgical bypass. Distal or late emboli and graft occlusions were regarded as appropriate by some surgeons. This study demonstrated that many vascular surgeons currently use thrombolysis, although sparingly and in selected cases. Patients with acute limb ischaemia should be managed by experienced vascular surgeons who are aware of the new therapeutic alternatives, an ideal supported by almost three-quarters of respondents to this survey. | 4 |
Surgical management of nonparasitic cystic liver disease. We report clinical features, surgical management, recurrences, and follow-up study of 12 patients with simple hepatic cyst, 11 patients with polycystic liver disease, and 19 patients with cystadenoma who were surgically treated over a 25-year period. The median age of patients was 48 years, and 37 women and 5 men were in the series. The most common presenting symptom and physical finding were chronic abdominal pain and tenderness in the right upper quadrant. The most commonly associated disease was polycystic kidney disease, which was an associated finding in 5 of the 11 patients with polycystic liver disease (45%). The most valuable diagnostic studies in all groups were computed tomography and ultrasonography. The location of the disease was bilobar in patients with polycystic liver disease, with a right lobe predominance in 18% of patients. The right lobe was also predominant in 83% of patients with simple hepatic cyst and 58% of patients with cystadenoma. Of all solitary cystic lesions in the left lobe, 75% of them were cystadenomas. Of the 66 surgical procedures performed, aspiration was associated with a failure rate of 100%; partial excision, a failure rate of 61%; and total excision and liver resection, a failure rate of 0%. Orthotopic liver transplantation was performed in three patients and was associated with two early deaths. Partial excision relieved symptoms in three patients (43%) with polycystic liver disease. Total excision, enucleation, or liver resection with cyst(s) is the treatment of choice for non-parasitic cystic lesions of the liver. | 4 |
Primary inflammatory reaction in synovial fluid and tissue in rabbit immobilization osteoarthritis. The kinetics and composition of the primary cellular inflammatory process were studied in the synovial fluid (SF) and synovial tissue (ST) compartments of a rabbit knee immobilization osteoarthritis model. Immobilization induced rapid migration of neutrophils (59% +/- 26% of all cells) into SF in three days, which was accompanied by nonspecific esterase-positive monocytes (71% +/- 8% of all mononuclear cells). This finding suggests that non-specific inflammation mediated by phagocytic leukocytes predominates the cellular response in the SF compartment. In contrast, morphometric analysis of ST proper showed an inflammatory mononuclear cell response, the intensity of which diminished over time during the study period from Day 3 (416 +/- 59 cells per 0.049 mm2 ST tissue) through Day 10 (305 +/- 32 cells) to Day 35 (174 +/- 36 cells). A dotlike T-pattern alpha-naphthyl acetate esterase (ANAE) was found in the T-cell-dependent areas of secondary lymphatic tissue in the spleen, enabling immunocytologic ANAE marker studies. The ST response in situ was predominated by tissue macrophage, though infiltrates rich in T lymphocytes were present in the immediate sublining stroma. There was a significant correlation between the intensity of the SF cell response (total recovery) and the percentage of neutrophils, but there was no correlation between the intensity of the ST response and the proportion of T lymphocytes. These T-cell accumulations together with the local proliferation of fibroblastlike lining cells and stromal fibroblasts suggest that the primary inflammatory cell response is not caused by either wear and tear or mechanically by cartilage fragments. | 4 |
Association of Treacher Collins syndrome and translocation 6p21.31/16p13.11: exclusion of the locus from these candidate regions. Treacher Collins syndrome (TCS) is an autosomal dominant defect of craniofacial development which has not been chromosomally localized. We have identified a mother and two children who have TCS and also a balanced translocation t(6;16)(p21.31;p13.11), which suggested the possibility that the TCS locus might be located at one of the translocation breakpoints. These were defined by in-situ hybridization as 6p21.31 (by using loci in the HLA complex defined by the probes p45.1DP beta 003/HLA-DPB2 and pRS5.10/HLA class I chain) and 16p13.11 (by using probes pACHF1.3.2/D16S8 and VK45/D16S131). Pairwise and multipoint linkage analysis using localized chromosome 6 probes and chromosome 16 probes in 12 unrelated TCS families with multiple affected siblings excluded the TCS locus from proximity to both translocation breakpoints. These data were confirmed when a third affected child, who did not exhibit the translocation, was born to the mother. | 4 |
Collagen metabolism in gynecologic patients: changes in the concentration of the aminoterminal propeptide of type III procollagen in serum. We have previously found the serum concentration of the aminoterminal propeptide of type III procollagen, an indicator of collagen metabolism, to be increased in advanced ovarian cancer. In this study we measured the serum aminoterminal propeptide of type III procollagen concentration in healthy women during the menstrual cycle and in patients with salpingo-oophoritis, leiomyomas, endometriosis, and benign ovarian tumors. The concentration was higher in the luteal phase than that in the follicular phase, suggesting an association of collagen metabolism with ovarian steroid hormones. Severe salpingo-oophoritis increased the serum level of the aminoterminal propeptide of type III procollagen with a decrease to normal during recovery. Elevated values were occasionally seen in endometriosis and leiomyomas. These findings indicate that the aminoterminal propeptide of type III procollagen is a relatively unspecific indicator of ovarian carcinoma. | 0 |
Paraneoplastic pemphigus. An autoimmune mucocutaneous disease associated with neoplasia. BACKGROUND and METHODS. We describe five patients with underlying neoplasms in whom painful mucosal ulcerations and polymorphous skin lesions developed, usually with progression to blistering eruptions on the trunk and extremities. Histologic examination showed vacuolization of epidermal basal cells, keratinocyte necrosis, and acantholysis. Immunofluorescence testing revealed atypical pemphigus-like autoantibodies in perilesional epithelium and serum from all five patients. We studied the antigenic specificities of the autoantibodies by indirect immunofluorescence and immunoprecipitation, using extracts of 14C-labeled human keratinocytes. IgG purified from the serum of one patient was passively transferred to four neonatal mice to test for pathogenicity. RESULTS. Immunofluorescence testing showed that the autoantibodies bound to the surface of tissues containing desmosomes, including complex and simple epithelia, and myocardium. An identical and unique complex of four polypeptides with molecular weights of 250, 230, 210, and 190 was immunoprecipitated by all serum samples. The 250-kd polypeptide comigrated with desmoplakin I (a protein found in the desmosomes of all epithelia), and the 230-kd antigen comigrated with the antigen of bullous pemphigoid. Cutaneous blisters, a positive Nikolsky's sign, and epidermal and esophageal acantholysis developed in all mice into which the autoantibody was injected. Electron microscopy showed epidermal acantholysis similar to lesions of experimentally induced pemphigus vulgaris. CONCLUSION. These five patients with cancer had a novel acantholytic mucocutaneous disease characterized by autoantibodies that were pathogenic after passive transfer. The autoantibodies from these patients reacted with an antigen complex composed of desmoplakin I and the 230-kd antigen of bullous pemphigoid and two as yet unidentified epithelial antigens. We suggest the term "paraneoplastic pemphigus" for this disease. | 0 |
Single lung transplantation for primary pulmonary hypertension. Single lung transplantation has become a therapeutic option for end-stage interstitial lung disease and obstructive lung disease. Our group recently extended this treatment to three patients with primary pulmonary hypertension. All patients had marked decreases in pulmonary artery pressures and pulmonary vascular resistance and increases in cardiac output following single lung transplantation. Spirometry, lung volumes, and diffusion capacity were not different in comparison to preoperative studies. Quantitative ventilation-perfusion scans revealed the majority of perfusion distributed to the transplanted lung, with ventilation approximately equally divided between the native and the transplanted lung. Despite ventilation-perfusion imbalance, there was no resting hypoxemia and there was no arterial oxygen desaturation with exercise. One patient expired on the 30th postoperative day due to cytomegalovirus infection of the lungs. In the remaining two patients, maximum exercise capacity following transplantation was near normal in one recipient and reduced in the second recipient. Of note, there was no evidence of ventilatory limitation or impaired oxygenation during exercise in these two recipients. Although an exaggerated exercise ventilatory response was present, this did not limit exercise performance. This report supports the use of single lung transplantation for the treatment of primary pulmonary hypertension. | 3 |
Herpes zoster ophthalmicus and iris cysts. Herpes zoster ophthalmicus has been associated with numerous complications such as neuropathy, keratitis, anterior uveitis, and neuralgia. To my knowledge, there have been no reports of secondary iris cyst formation. I hereby report the case of a patient who developed an iris cyst during a Herpes zoster ophthalmicus infection. | 0 |
Detecting hypertension: screening versus case finding in Norway. OBJECTIVE--Evaluation of detection of hypertension in adults in the county of Nord-Trondelag, Norway. DESIGN--Cross sectional survey with clinical follow up examinations. SETTING--Health survey by screening teams from the national health screening service, and examinations by all 106 general practitioners in the county. SUBJECTS--During 1984-6, 74,977 persons (88.1% of those aged 20 years and over) participated in the health survey. MAIN OUTCOME MEASURES--Hypertension (when assessed by standardised recording and by questionnaires on drug treatment for hypertension) according to the blood pressure thresholds used in the Norwegian treatment programme. Subjects positive on screening were grouped after clinical examination into treatment groups. RESULTS--In all, 2399 subjects were positive for hypertension. Before screening 6210 (8.3%) patients reported taking antihypertensive drugs and another 3849 (5.1%) had their blood pressure monitored regularly. All who screened positive were referred to their general practitioner and evaluated according to a standard programme. As a result, drug treatment was started in 406 (0.5%) participants screened and blood pressure monitoring in another 1007 (1.3%). Of all patients taking antihypertensive drugs after the screening, 6399 (94.0%) had been diagnosed before screening, and of those whose blood pressure was monitored after the screening, 79.3% had been diagnosed before screening. CONCLUSIONS--At the blood pressure screening thresholds used, and when hypertension is defined by an overall clinical diagnosis, the results indicate that general practitioners can find and diagnose hypertensive patients with the case finding strategy. | 3 |
Treatment strategies in shock: use of oxygen transport measurements. Shock has traditionally been categorized according to its cause. Shock can result from hemorrhage, primary cardiac failure, central nervous system failure, trauma, or sepsis. Therapeutic principles have been developed for each etiologic type. End points for such therapy have included optimization of pulmonary capillary wedge pressure, cardiac output, blood pressure, and urine output. Recent investigators agree that the common denominator in each of the shock syndromes is a reduction in the amount of oxygen consumed by the cell. The logical therapeutic approach would be to increase oxygen delivery to support the increased metabolic demand of the cells. The end point of resuscitation should be optimization of oxygen delivery and oxygen consumption. These variables are easily calculated by using data obtained from pulmonary artery catheter and laboratory measurements. The physician or nurse caring for critical ill patients should have a thorough understanding of the rationale for the use of oxygen transport calculations and the methods of manipulating oxygen delivery. A simple explanation of these principles including the importance of hemoglobin, cardiac index, and percent saturation of hemoglobin and suggested treatment strategies are presented. | 4 |
Hepatic metabolism of cholesterol in Crohn's disease. Effect of partial resection of ileum. To study cholesterol metabolism in Crohn's disease and especially the effect of ileum resection, liver biopsy specimens were obtained from patients undergoing partial ileal resection because of Crohn's disease (n = 17) and patients with Crohn's colitis undergoing colectomy (n = 3). Gallstone-free patients (n = 16) undergoing cholecystectomy because of adenomyomas or polyps of the gallbladder served as controls. The mean levels of cholesterol 7 alpha-hydroxylase activity and 3-hydroxy-3-methylglutaryl coenzyme A reductase activity, rate-determining enzymes in bile acid, and cholesterol synthesis, respectively, were twofold to threefold higher in the ileum-resected patients than in the controls. Significant positive correlations were obtained between length of resected ileum and cholesterol 7 alpha-hydroxylase activity. Provided patients who had received total parenteral nutrition preoperatively were excluded from analysis, a significant correlation was also observed between length of resected ileum and 3-hydroxy-3-methylglutaryl coenzyme A reductase activity. Significant positive correlations were also obtained between length of resected ileum and serum levels of 7 alpha-hydroxycholesterol (a marker for bile acid biosynthesis) and lathosterol (a marker for cholesterol synthesis). The plasma levels of total and low-density lipoprotein cholesterol were negatively correlated to the length of resected ileum. The expression of hepatic low-density lipoprotein-receptor binding activity was determined in five of the patients and in three of the controls. A significant positive correlation was observed between 3-hydroxy-3-methylglutaryl coenzyme A reductase activity and low-density lipoprotein-receptor binding activity. The results show that malabsorption of bile acids leads to parallel stimulation of cholesterol synthesis, cholesterol degradation, and low-density lipoprotein-receptor expression in human liver. The resulting effect in the present patients was a significant reduction in low-density lipoprotein cholesterol. | 1 |
Enhanced reactive oxygen species metabolism of airspace cells and airway inflammation follow antigen challenge in human asthma. Airflow limitation and airway inflammation follow antigen bronchoprovocation in sensitized individuals. Inflammation likely results from the interplay of several previously demonstrated factors, but the participation and persistence of enhanced reactive oxygen species (ROS) metabolism of airspace cells after antigen challenge have received more limited attention. We studied nine subjects with mild asthma by bronchoalveolar lavage before and 48 (one subject) to 72 (eight subjects) hours after antigen bronchoprovocation and compared airspace cell numbers and types, cell function, and bronchoalveolar lavage fluid protein, albumin, and immunoglobulins. Mild, but significant, airflow limitation persisted at the time of the second lavage. Eosinophil influx was a notable component of the increased airspace cells in postchallenge lavages. Airspace cells demonstrated significantly enhanced ROS metabolism, and total protein, albumin, and IgM levels were higher in postchallenge lavage specimens. Antigen bronchial challenge produces airspace inflammation, which may develop, in part, as a consequence of enhanced ROS metabolism of airspace cells. | 4 |
Repetitive intraoperative mapping and cryotherapy improve the results of endocardial resection for ventricular tachycardia. Patients with recurrent ventricular tachycardia or a history of a sudden cardiac death episode and ventricular tachycardia inducible in the electrophysiology laboratory have a high incidence of recurrence and a high mortality despite medical therapy. Map-guided endocardial resection has improved treatment results, but is associated with a 10-30% failure rate. In our initial experience with endocardial resection (Group I) we incurred a 30% treatment failure rate. In the present study we have found the addition of sequential intraoperative mapping and routine use of cryotherapy (Group II) improved our results of ventricular tachycardia control without significant additional morbidity or mortality. | 4 |
Strapless oral-nasal interface for positive-pressure ventilation. A custom-fabricated strapless oral-nasal interface (SONI) is described. It was used in the long-term administration of intermittent positive-pressure ventilation (IPPV) by 18 patients with paralytic or restrictive pulmonary insufficiency. This interface is an acrylic shell which is firmly fixed to an orthodontic bite plate; it is designed to form a seal over the nose and mouth for the entry of IPPV. Eight patients were ventilator dependent 24 hours a day. The ten patients who required only nocturnal aid had improvement in daytime arterial blood gases. Although nine of these patients could manage less than 15 minutes of unassisted breathing (free time) supine, all slept supine on SONI IPPV. The 13 patients who underwent sleep monitoring maintained a mean oxygen saturation of 95.3% +/- 1.7% and acceptable end-tidal pCO2 (30 to 45 mmHg). These 13 patients have used SONI IPPV for an average of 22 months (range = 3 to 63 months). Impediments to successful long-term use of a SONI include the presence of a hyperactive gag reflex or stimulation of excessive oral secretions. When combined with mouth IPPV, glossopharyngeal breathing, the intermittent abdominal pressure ventilator, or the cuirass ventilator for daytime use, SONI IPPV is an option for the patient who prefers total ventilatory support by noninvasive means. | 4 |
A randomized clinical study of a calcium-entry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest. Brain Resuscitation Clinical Trial II Study Group BACKGROUND. Abnormalities of cellular calcium homeostasis have been implicated in the pathophysiology of postischemic encephalopathy. Calcium-entry-blocking drugs inhibit the influx of calcium into cells and have been shown to mitigate postischemic encephalopathy in animal models. METHODS. Five hundred twenty patients with cardiac arrest who remained comatose after the restoration of spontaneous circulation were randomly assigned to receive three doses of lidoflazine, an experimental calcium-entry blocker, or a placebo and were followed for six months. Four patients were lost to follow-up. Treated patients received an intravenous loading dose (1 mg per kilogram of body weight) of lidoflazine and two subsequent doses (0.25 mg per kilogram) 8 and 16 hours after resuscitation. The investigators were blinded to treatment assignment. RESULTS. There was no statistically significant difference between the lidoflazine group (n = 259) and the placebo group (n = 257) in the proportion of patients who died during the six-month follow-up (82 vs. 83 percent), who survived with good cerebral recovery (15 vs. 13 percent), or who survived with severe neurologic deficit (1.2 vs. 1.9 percent). Analysis of the best level of recovery achieved at any time during follow-up also did not show a difference between the treatment groups: 24 percent of those given lidoflazine and 23 percent of those given placebo recovered good cerebral function (normal or only moderately disabled cerebral performance) at some time. CONCLUSIONS. The administration of lidoflazine after cardiac arrest was not found to be beneficial. Our data do not support the routine use of this calcium-entry-blocking drug in comatose survivors of cardiac arrest. | 4 |
Determination of ventricular fluid outflow resistance in patients with ventriculomegaly. Resorption of the ventricular fluid was studied by measuring ventricular fluid outflow resistance during steady state 1.5 and 5.0 ml/min infusions in 26 patients with substantial enlargement of the supratentorial ventricular system. This test may avoid unnecessary use of shunts, but a shunt could be introduced during the same procedure. | 2 |
Perforin-mediated myocardial damage in acute myocarditis. Endomyocardial specimens were obtained from 7 patients with acute myocarditis. Immunohistochemical examination of the mononuclear infiltrate showed mainly cytotoxic T lymphocytes and natural killer cells. Perforin (a pore-forming protein found in cytotoxic lymphocytes) was identified in this myocardial lymphocytic infiltrate and electron microscopy showed myocardial cell damage that may have been associated with these perforin containing lymphocytes. The results indicate that in acute idiopathic and viral myocarditis, myocardial damage may be due to the action of perforin-secreting lymphocytes. | 3 |
Cardiac tamponade and contralateral hemothorax after subclavian vein catheterization. A patient developed life-threatening cardiac tamponade and contralateral hemothorax after insertion of a subclavian catheter in the operating room. Contrast was infused through the catheter, demonstrating its malposition in the pericardial space. Contrast infusion was valuable in evaluating this complication of central line placement. | 3 |
Physicochemical determinants of in vitro shock-wave biliary lithotripsy. Human gallstones were studied by visual inspection, computerized tomographic imaging, and chemical analysis to assess physicochemical characteristics that may determine the outcome of in vitro shock-wave fragmentation. Eighty-five stones (mean diameter: 13.2 +/- 5 mm) were each collected from different patients. Fifty-five (65%) calculi were angular and 30 (35%) round or oval-shaped. Three easily obtained measures were derived from each stone's optimal computerized tomographic image including the mean stone density, a measure corresponding to the standard deviation of the mean stone density value which we termed the stone density distribution index and which may reflect the physicochemical heterogeneity of a given gallstone, as well as the density range. After the administration of 2500 shock waves using an electrohydraulic generator, fragmentation was noted in 68 calculi (80%) and was satisfactory in 27 (32%) (where the largest resulting fragment diameters were all less than or equal to 5 mm). Strong determinants of satisfactory fragmentation on multivariate analysis included a stone diameter of less than or equal to 15 mm, the presence of an angular stone shape, and a stone density distribution index of greater than or equal to 60 Hounsfield units. The other parameters did not independently determine satisfactory fragmentation. Prospective clinical trials are needed to assess whether these findings result in a better prediction of the success of extracorporeal biliary lithotripsy and a broadening of its indications. | 1 |
Unfading acral microlivedo. A discrete marker of thrombotic skin disease associated with antiphospholipid antibody syndrome. Small erythematous or cyanotic lesions on the hands and feet of four patients with antiphospholipid antibodies are described. These discrete lesions outline capillaries and do not disappear when pressure is applied. The histologic features are identical to those described in skin thrombotic syndrome associated with antiphospholipid antibodies, that is, microthrombi in dermal vessels without inflammation. In addition to indicating antiphospholipid antibodies in apparently healthy patients, this sign could be a marker of risk for large-vessel thrombosis. | 4 |
Reperfusion arrhythmias after thrombolysis. Electrophysiologic tempest, or much ado about nothing. Arrhythmias that may accompany myocardial reperfusion have generated significant clinical interest. First, there were concerns, based on animal studies, that high-grade ventricular tachyarrhythmias would pose a serious threat following thrombolytic therapy to treat an evolving myocardial infarction. Second, lower-grade arrhythmias, such as accelerated idioventricular rhythm, were cited as useful, noninvasive markers of successful reperfusion. Critical review of the current data, however, indicates that arrhythmias following thrombolytic therapy for acute myocardial infarction are usually neither dangerous clinical events nor consistent markers of reperfusion. | 3 |
Oxidative damage to lipids within the inflamed human joint provides evidence of radical-mediated hypoxic-reperfusion injury. Previous work has established the existence of a pathophysiological environment within the inflamed human joint, capable of sustaining a hypoxic-reperfusion event. Using four different assay systems (two standard and two novel) applied to synovial fluid for the assessment of lipid peroxidation, a series of studies demonstrate that exercise of the inflamed human knee promotes radical-mediated lipid peroxidation within the joint. The implication for novel antioxidant therapeutic approaches to inflammatory joint disease is discussed. | 4 |
Multiagent chemotherapy in relapsed acute lymphoblastic leukemia in children. Twenty-seven evaluable children with early first bone marrow relapse of acute lymphoblastic leukemia were treated with an intensive induction/consolidation and ongoing maintenance therapy. Induction therapy consisted of a 35-day course of daunomycin, vincristine, and prednisone, immediately followed by teniposide, cytosine arabinoside (Ara-C), and L-asparaginase. Intrathecal methotrexate, hydrocortisone, and Ara-C were given through the induction/consolidation phase. Twenty-three of 27 patients achieved remission by the end of induction/consolidation. Maintenance with the same drugs in a modified dosage schedule continued for approximately 2 years. A small subgroup of patients who were M3 at day 35 but M1 at day 56 (end of induction/consolidation) and had a cumulative event-free survival (EFS) of only 0.40 at 6 months, all had relapsed by 15 months. However, the EFS for M1 patients by day 35 and maintained on chemotherapy was 0.64 at 12 months and 0.32 at 30, 36, and 48 months, respectively. Although good reinduction and remission duration rates at 12 to 24 months were achieved and an apparent plateau in survival occurs at 30 months, fall-off in survival would not be unexpected with probably less than 20% alive after 5 years. | 4 |
Perioperative blood transfusion adversely affects prognosis of patients with stage I non-small-cell lung cancer. It has been speculated that blood transfusion might adversely affect prognosis in cancer patients by immunosuppression. To avoid the confounding affect of advanced disease, we tested this hypothesis in 117 patients with stage I non-small-cell lung cancer. Mean and median follow-up were 49.7 months and 47 months, respectively. Patients who died during the postoperative period were not included. Perioperative transfusion was defined as administration of whole blood or packed cells within 30 days of operation. The overall cumulative 5-year disease-free survival rate was 67%. In patients with transfusion, it was 53% and in patients without transfusion it was 81% (p = 0.0055). A multivariate analysis was performed that included patient age, race, sex, cell type, extent of operation (pneumonectomy versus lobectomy/segmentectomy), operative blood loss, admission hematocrit, discharge hematocrit, and the presence or absence of perioperative transfusion. The only variable that significantly correlated with 5-year disease-free survival was the presence or absence of perioperative transfusion (p = 0.0278), and this effect was not related to the number of transfusions. Retrospective analysis of long-term results of patients surviving curative operation for stage I lung cancer shows that any perioperative transfusion significantly worsens the patient's prognosis and suggests very strongly that this association is due to an adverse effect of the transfusion rather than the transfusion serving as a marker for another risk factor. | 0 |
Significance of magnetic resonance imaging in acute head injury. One hundred seventy-seven patients who had incurred head trauma were studied with magnetic resonance imaging (MRI). Patients varied from those with mild injury without any focal neurological deficit to those with severe injury with post-traumatic coma. Altogether, 177 lesions were demonstrated by MRI in 123 of 177 patients within 3 days of injury using T2-weighted (SE2000/40,2000/111) and T1-weighted (IR1500/500/40) multislice sequences. In contrast, computerized tomography (CT) demonstrated 103 lesions in 90 patients. MRI was superior to CT in the diagnosis of nonhemorrhagic contusions demonstrated as a high-intensity area on T2-weighted imaging. MRI provided some information to evaluate the severity of diffuse axonal injury or to predict delayed traumatic intracerebral hematoma (DTICH). | 2 |
Immunohistologic detection of the epidermal growth factor receptor in human esophageal squamous cell carcinoma. Epidermal growth factor receptor (EGF-R) expression was studied immunohistologically in 38 patients with esophageal squamous cell carcinoma. The EGF-R was faintly expressed in basal and parabasal layers of normal esophageal epithelia and in cancer nests of 20 patients; it was strongly expressed in all areas of dysplastic epithelia and in cancer nests of 18 patients. The patients with strongly expressed EGF-R had lymph node metastases more frequently, and their prognosis was poorer than those with faintly expressed EGF-R. The EGF-R expression showed a mosaic pattern in 17 patients and a diffuse pattern in 21 patients. The patients with a mosaic pattern had lymph node metastases more frequently and a worse prognosis than those with a diffuse pattern. Expression of EGF-R in metastatic lymph nodes was similar to that in strongly expressing areas of primary cancers with a mosaic pattern. Thus EGF-R expression may be an important indicator for malignancies of esophageal squamous cell carcinomas because primary cancer cells with strongly expressed EGF-R metastasize to lymph nodes more frequently. | 0 |
Hepatic resection for advanced hepatocellular carcinoma with removal of portal vein tumor thrombi. In 13 of 398 patients who underwent hepatectomy, tumor thrombi of the remnant portal vein was concomitantly removed by the balloon catheter method in 8, an open method under hepatic vascular exclusion in 1, and resection of the occlusive portal segment followed by portal reconstruction in 4. In 8 of these patients the liver was cirrhotic. The mode of hepatectomy consisted of bisegmetectomy or trisegmentectomy in 11, segmentectomy in one, and partial resection in one patient. Two patients died of portal thrombosis or hepatic failure in the hospital. The mean survival in four patients was 12 months. Seven are still alive (mean, 16 months). In the corresponding period, nine patients with occlusive tumor thrombi of the portal confluence were hospitalized without operation and survived up to 4 months (mean, 64 days) after detection of the tumoral occlusion. The causes of death of the nine patients were bleeding esophageal varices, rupture of the tumor, or hepatic failure. It was revealed that removal of tumor thrombi in the remnant portal vein contributes to (1) portal decompression, (2) feasibility of arterial embolization, and (3) increase in resectability of the main tumor. At present, this procedure might be regarded as an emergency procedure for the avoidance of the above lethal impendence, but it may open the door to an adjuvant therapy. | 3 |
Combined radiologic and retrograde endoscopic and biliary interventions. Methods of treating complex biliary duct problems by a team composed of an endoscopist and interventional radiologist are described. These procedures are of two types: Those in which all manipulations are performed through the endoscope and those in which an antegrade transhepatic and a retrograde endoscopic approach are combined. | 1 |
Systolic wall stress and ventricular arrhythmia: the role of acute change in blood pressure in the isolated working rat heart. 1. The effect of a sudden acute change in blood pressure upon arrhythmia provocation has been studied in an isolated working heart model from the Wistar-Kyoto strain of rat. Twenty-four hearts were studied. 2. They were perfused with two different, modified, Krebs-Henseleit solutions at a fixed left atrial pressure. 3. Acute changes in pressure, both increases and decreases, were arrhythmogenic. Whilst ectopic activity was more predictably produced by pressure reductions, this consisted of simple ventricular ectopics only. Pressure increases, in contrast, were capable of provoking more complex and sustained arrhythmias. 4. The effect of pressure changes were highly dependent upon electrolyte concentrations in the perfusate. Low potassium and magnesium concentrations increased the amount of arrhythmia provoked by pressure increases but tended to reduce that provoked by pressure reductions. 5. We conclude that the direct effect of an acute change in pressure upon the myocardium is arrhythmogenic. However, the myocardial response to a pressure change is interdependent upon prevailing electrolyte concentrations. | 4 |
Increased microvascular permeability in vivo in response to intradermal injection of neutrophil-activating protein (NAP-2) in rabbit skin. Neutrophil-activating protein-2 (NAP-2), an NH2-terminally processed form of the platelet-release product beta thromboglobulin (beta TG), was purified to homogeneity from stimulated human blood leukocytes. In the presence of a vasodilator substance (PGE2, CGRP) picomolar (pmol/l) amounts of NAP-2 induced neutrophil accumulation and plasma leakage on intradermal injection in rabbit skin, whereas the longer forms, beta TG itself and connective tissue-activating peptide III (CTAP-III), had no such effect. NAP-2-induced increased in microvascular permeability was neutrophil dependent and fast in onset, with a half-life of 65 to 75 minutes, comparable to that previously reported for the structural-related neutrophil-activating protein-1/interleukin-8 (NAP-1/IL-8). However NAP-2 showed a lower potency in that more protein was needed to provoke skin reactivity. Nevertheless the finding that a platelet release product can elicit neutrophil-mediated inflammation further narrows the gap between thrombotic events and inflammatory disorders. | 4 |
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