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Isolated ventral pancreatitis in a patient with pancreas divisum. A previously healthy 22-yr-old woman was found to have chronic pancreatitis restricted to the ventral pancreas in association with pancreas divisum. When conservative treatment failed, sphincteroplasty of both papillae was performed with good results. This well-documented case represents a clear exception to the commonly held concept that obstruction of the dorsal duct is the essential pathogenic factor in the development of pancreatitis associated with pancreas divisum. The importance of visualizing both the dorsal and ventral pancreatic ducts to direct therapy for patients with idiopathic pancreatitis is discussed. Theories of the pathogenesis of concomitant pancreatitis and pancreas divisum are reviewed. | 4 |
Rehabilitation in brain disorders. 3. Intervention strategies. This self-directed learning module highlights advances in the principles of management of brain disorders. It is part of the chapter on rehabilitation in brain disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. The chapter is composed of four articles, and each builds on principles established in the others. This article covers rehabilitation philosophy, management of cognitive remediation, and behavioral management, with attention to communication disorders, social factors, vocational/educational/avocational issues, treatment of motor deficits, dysphagia, sensory dysfunction, sexual dysfunction, and substance abuse. Advances that are covered in this section include pharmacologic and rehabilitative interventions for acute, chronic, and progressive brain injuries and diseases. The learner is directed to articles 1, 2, and 4 in this chapter for supporting information. | 2 |
The effect of long-acting somatostatin analogue on enzyme changes after endoscopic pancreatography. The effect of the long-acting somatostatin analogue, octreotide acetate (Sandostatin) on enzyme elevation after endoscopic pancreatography was studied in a prospective, randomized, double-blind trial. Sixty-three consecutive patients undergoing ERCP were randomly allocated to two group. In the control group, 34 patients received isotonic sodium-chloride, and in the treated group 29 patients received 0.1 mg of octreotide acetate subcutaneously before the pancreatography. After the endoscopy, amylase levels increased to pathological range in 15 of the controls and in 3 of the treated patients, whereas lipase levels showed a pathological rise in 17 of the controls and in 5 of the treated patients. A significant difference (p less than 0.01) was observed in the amylase and lipase changes between the two groups at 90 and 180 min after pancreatography. The enzyme levels showed at 90 min, mean +/- SD amylase: controls 540 +/- 185 units/liter, treated patients 261 +/- 108 units/liter; lipase: controls 304 +/- 98 units/liter, treated patients 198 +/- 88 units/liter. These findings suggest that the use of long-acting somatostatin analogue ameliorates the enzyme increases in the serum after endoscopic pancreatography. | 4 |
Electrocorticographic confirmation of focal positron emission tomographic abnormalities in children with intractable epilepsy. The relationship between focal disturbances of glucose utilization demonstrated by positron emission tomography (PET) and electrophysiologic abnormalities defined by intraoperative electrocorticography (ECoG) was studied in eight children (aged 13 months to 12 years) who underwent cortical resection because of intractable seizures. None of the children had pure temporal lobe epilepsy. Computed tomography (CT) and/or magnetic resonance imaging (MRI) were normal in four of the eight children. The scalp electroencephalogram (EEG) showed lateralized interictal epileptiform abnormalities in all eight and lateralized ictal onset in five of eight. In seven children, interictal PET showed focal hypometabolism; the eighth child had focal, ictal hypermetabolism. ECoG at the time of surgery showed epileptiform spiking, slowing, and/or suppression of normal background activity that in every case corresponded to the focus on PET scan. The ECoG findings support the notion that in children with epilepsy focal metabolic abnormalities on PET correspond to electrophysiologically abnormal areas of cortex, which are presumably also the epileptogenic regions. Such areas can appear normal on anatomic imaging studies (CT and MRI). When ictal scalp EEG data are ambiguous or contradictory, PET provides a less invasive means than chronic grid or depth electrode recording for evaluating whether a localized epileptogenic area exists. | 2 |
Mistaken diagnoses in continuous muscle fiber activity of peripheral nerve origin. The syndrome of continuous muscle fiber activity of peripheral nerve origin has manifestations that resemble those of many other more common neurologic disorders during childhood and infancy. This similarity often leads to misdiagnosis when an adequate index of suspicion is not entertained and a comprehensive electromyographic examination is not performed. Two affected patients from 1 family are reported to illustrate the type of diagnostic errors that were made before the establishment of the correct diagnosis. | 2 |
Eosinophilia-myalgia syndrome. A clinical case series of 21 patients. New Mexico Eosinophilia-Myalgia Syndrome Study Group. We reviewed 21 cases of eosinophilia-myalgia syndrome to describe the range of clinical findings in these patients. Most patients were women (20 [95%]) and middle-aged (mean, 46 years) and had taken the food supplement L-tryptophan (95%). All cases involved eosinophilia (eosinophil count, greater than or equal to 2.0 x 10(9)/L) and incapacitating myalgias. Fourteen (88%) of the 16 patients tested had mild liver function abnormalities. Aldolase levels were abnormal in all patients tested. Muscle biopsies were done in five patients; four showed eosinophilic perimyositis, and one had interstitial inflammation. No physical finding was pathognomonic or universal, but muscle tenderness, tachycardia, and rash were the most common signs found during physical examinations. Seven patients were treated with prednisone, and six showed improvement in muscle pain and a decrease in eosinophilia. The cause of this disorder is still unknown. | 4 |
Volvulus of the colon. The charts of all patients with colonic volvulus at the University of Louisville Hospitals between 1983 and 1988 were reviewed. A total of 45 patients were identified, and there were 17 with cecal volvulus and 29 with sigmoid volvulus (1 had both). Two-thirds of the patients were either demented, bedridden, or used constipating drugs. Initial nonoperative decompression was achieved in 26 of 29 patients with sigmoid volvulus but in only three of nine patients in which it was attempted with cecal volvulus. Two of these recurred, and 16 of the 17 cecal volvulus patients underwent operation. One-third of the sigmoid volvulus patients had at least one recurrent episode on the index admission. Fourteen of the 29 had an operation, and half of these patients died following surgery. Fifteen sigmoid volvulus patients chosen to be treated with successive nonoperative treatment had no mortality. Mortality was higher following emergent (4 of 5) than elective (2 of 9) operation for sigmoid volvulus, and one of three died after operation for a successfully decompressed first episode. Mortality for nonoperative reduction of an early recurrence was zero of four patients, while operative mortality for recurrence was two of seven (all had successful preoperative deflation). There was no mortality or recurrence in four patients with cecal volvulus treated by cecopexy alone, but all three patients died in whom tube cecostomy was performed. Two of nine patients died following right hemicolectomy. These data suggest that if an elective operation is to be performed for sigmoid volvulus, it should be done following one or more recurrences and that nonoperative decompression can be safely performed on successive occasions. | 1 |
Effect of atopy on the natural history of symptoms, peak expiratory flow, and bronchial responsiveness in 7- and 8-year-old children with cough and wheeze. A 12-month longitudinal study. Recurrent lower respiratory tract symptoms are common and disabling in childhood, but little is known of their natural history and relationship to asthma. We report a 12-month longitudinal study designed to determine the influence of atopy on respiratory symptoms and bronchial responsiveness in 7- and 8-yr-old children. A postal questionnaire inquiring into the presence of respiratory symptoms was sent to 3,698 children aged 7 and 8 yr. Those reporting either current wheeze (14.8%) or current cough in the absence of wheeze (12.8%) were randomized, and a sample was invited to attend for skin testing. The following groups of symptomatic children entered the longitudinal study: 48 atopic children with cough, 48 atopic children with wheeze, 48 nonatopic children with cough, and 48 nonatopic children with wheeze. All children recorded twice daily the best of three peak expiratory flow (PEF) measurements and completed a 10-point symptom score card, each day for 1 yr. They also recorded all treatment taken and made a note of relevant life events. Each child was seen monthly for general assessment and for measurement of methacholine bronchial responsiveness. Despite the arduous nature of the study 183 of the 192 children (95.3%) successfully completed the 12 months of observation. Symptom groups were compared with regard to FEV1, bronchial responsiveness, symptom chronicity and severity, and diurnal and day-to-day variation in PEF. Atopy was associated with a lower FEV1, increased prevalence of bronchial hyperresponsiveness, greater within-day and between-day variation in PEF, and greater severity of respiratory symptoms compared with the absence of atopy. | 4 |
Stercoral perforation of the colon. Stercoral perforation of the colon is rare. The 64 reported cases are reviewed to define the syndrome of stercoral perforation, and to facilitate accurate diagnosis and treatment. Features of localized or generalized peritonitis were universal; however, only 11 per cent were correctly diagnosed before operation. Recognition that the disease involves a segment of colon rather than only the focal point of perforation is essential to adequate surgical treatment. It is postulated that this is the reason for the higher postoperative mortality following closure of the perforation and proximal colostomy (57 per cent) or exteriorization alone (43 per cent), compared with resection of the diseased segment and exteriorization (32 per cent). Resection and exteriorization is therefore the treatment of choice is most situations. | 1 |
Visual illusions in a patient with lateral medullary syndrome. The disturbance of visual perception associated with nystagmus is a rare phenomenon. This is a case of a 61-year-old woman who developed progressive right hemisensory deficit, left facial sensory deficit, vertigo, staggering to the left, left ptosis, vertical diplopia, and ataxia of the left upper extremity. She had rotatory nystagmus in primary position, which increased in amplitude with left gaze. The above signs and symptoms were consistent with lateral medullary syndrome. During her rehabilitation, the patient complained of visual disturbances typical of oscillopsia. These disturbances, or illusions, are compensatory mechanisms for nystagmus and its resultant retinal error. The purpose of this case presentation was to study the pathophysiology underlying oscillopsia in patients with nystagmus and to stimulate awareness of such visual disturbances in stroke patients. | 2 |
Relationship of uptake of technetium-99m(Sn)-N-pyridoxyl-5-methyltryptophan by hepatocellular carcinoma to prognosis The relationship of technetium-99m(Sn)-N-pyridoxyl-5-methyltryptophan (99mTc-PMT) uptake by hepatic tumors to survival was studied in 162 cases of hepatocellular carcinoma (HCC). The median survival of 82 patients in whom hepatic tumors showed increased uptake in delayed 99mTc-PMT imaging was 1013 days, which was significantly longer than the survival time of 398.5 days of 80 patients in whom hepatic tumors did not show increased uptake of radioactivity (p less than 0.002). The relationship between the ability of hepatic tumors to take up 99mTc-PMT and survival was also analyzed in patients with HCC showing filling defects in 99mTc-colloid liver images and, in relation to the therapy, serum values of bilirubin and alpha-fetoprotein. Results indicated that the degree of 99mTc-PMT uptake by hepatic tumors is closely correlated with the prognosis of patients with HCC. | 0 |
Immunohistochemical demonstration of pancreatic secretory trypsin inhibitor in normal and neoplastic colonic mucosa. Specimens of normal and neoplastic colonic mucosa from 52 patients were analysed by immunohistochemistry using a monospecific polyclonal antiserum against human pancreatic secretory trypsin inhibitor (PSTI). In normal colonic mucosa PSTI was found in the goblet cells in the basal parts of the crypts. In adenomas of tubular, villous, and tubulo-villous types PSTI was also found in the upper parts of the polyps, usually occurring in the regeneration zone. There was a more intense staining reaction in polyps with increased atypia. Carcinomas of different types and of various grades of differentiation and of in situ type did not contain PSTI. These findings indicate that PSTI could be a marker for adenomatous rather than carcinomatous epithelium in the colon. Furthermore, the absence of the inhibitor in malignant cells might facilitate tissue invasion by malignant cells because of deficient protease inhibition. | 0 |
Lipids, vascular disease, and dementia with advancing age. Epidemiologic considerations. Elevated plasma lipid and lipoprotein levels are associated with an increased risk of cardiovascular disease in middle-aged men and women. It is still not clear, however, whether lipid and lipoprotein abnormalities continue to be risk factors for cardiovascular disease in the elderly population. It is not even clear what normal lipid values are in the elderly, and whether diet or drug therapy should be advised on the basis of lipid values established in middle-aged populations. Ischemic heart disease does remain the leading cause of death in the elderly, and there is now preliminary evidence from epidemiologic studies that relative elevations of levels of lipid and lipoprotein fractions in an elderly population might be associated with an independent and increased risk of coronary heart disease, stroke, and possibly dementia. Intervention studies are about to begin that will assess various lipid-and lipoprotein-modifying therapies and their ability to reduce vascular disease risk in the elderly. | 3 |
Axial myoclonus of propriospinal origin. Three patients are described with nonrhythmic repetitive axial myoclonic jerks causing symmetric flexion of the neck, trunk, hips and knees. No electrophysiological evidence of a cortical or brainstem reticular origin for the myoclonus was found. In the first patient the axial jerks only occurred spontaneously. The latencies of recruitment of spinal segments during a jerk indicated that the discharge arose in the mid thoracic cord and then slowly spread at about 5 ms-1 up and down the cord to involve rostral and caudal segments. No structural lesion was identified in this patient. In the second patient spontaneous and reflex axial jerks developed following the excision of a cervical haemangioblastoma. In the stimulus-induced jerks the relative latencies of muscles innervated by rostral and caudal spinal segments suggested that the myoclonus originated between the upper cervical and midthoracic cord. In the final patient, EMG activity during spontaneous and stimulus-induced jerks commenced in the rectus abdominis, and was followed by later activity in muscles innervated by rostral spinal segments, suggesting that the myoclonus originated in the midthoracic cord. No structural lesion was identified in this patient. Electrophysiological evidence is used to argue a spinal origin for these axial jerks in all 3 cases. There are striking features common both to this form of human myoclonus and to long propriospinal pathways identified in animals. The new concept of propriospinal myoclonus is suggested. | 4 |
Helicobacter pylori and gastric carcinoma. Serum antibody prevalence in populations with contrasting cancer risks. This investigation examined the correlation between Helicobacter pylori (HP) infection, as reflected in immunoglobulin G serum antibodies, and the risk of gastric cancer. Serum samples were obtained from populations with contrasting gastric cancer risks. The highest prevalence of HP infection, 93%, was observed in the adult population at highest gastric cancer risk, the residents of Pasto, Colombia. In the lower risk Colombian city of Cali, a 63% overall prevalence rate was found. Both children and adults were sampled in New Orleans, Louisiana, where gastric cancer rates are high for blacks but not for whites. The prevalence of HP infection was significantly higher in black than in white adults, 70% versus 43%, P = 0.0001. A higher prevalence was also detected in black compared with white children, 49% versus 32%, P = 0.01; however, an even greater disparity was noted when comparing children from two hospitals, regardless of race, which serve different socioeconomic groups. A prevalence rate of 54% was found at Charity Hospital compared with 24% (P = 0.0001) at Children's Hospital. Our findings indicate that socioeconomic conditions, known to influence gastric cancer risk, are also important determinants of HP infection. | 0 |
Long-term treatment of Crohn's disease with cyclosporine: the effect of a very low dose on maintenance of remission. Low-dose oral cyclosporine was used to maintain remission in patients with Crohn's disease. In seven patients, cyclosporine was used as a steroid-sparing agent; in 14 it was given for refractory active disease as an adjunct to conventional treatment, and then continued as maintenance treatment. Cyclosporine was given at an initial dose of 5 mg/kg reduced by 1 mg/kg at 2-month intervals until a maintenance dose of 2 mg/kg was reached. Of the seven patients in whom cyclosporine was used as a steroid-sparing agent, six had a relapse. Remission was achieved in seven of the refractory active group, but cyclosporine was withdrawn because of side effects in six of the patients in this group. Of the seven patients who had achieved remission, six subsequently had a relapse. Therefore, 12 of 14 patients (86%) in remission had a relapse despite cyclosporine maintenance. Ten of these (83%) had a relapse at a cyclosporine dose of 2 or 3 mg/kg. Cyclosporine levels at relapse (median, 74 ng/ml) were lower than the mean levels over the first 6 weeks of treatment (median, 130 ng/ml; p = 0.02). Our data do not support the use of cyclosporine to maintain remission in Crohn's disease. | 1 |
Elevated expression of the genes for transforming growth factor-beta 1 and type VI collagen in diffuse fasciitis associated with the eosinophilia-myalgia syndrome. Full-thickness skin biopsies obtained from four patients with rapidly progressive diffuse fasciitis associated with the Eosinophilia-Myalgia syndrome (EMS) were examined for the expression of transforming growth factor-beta 1 (TGF-beta 1), type VI collagen, and fibronectin genes employing immunohistochemistry and in situ hybridizations. The immunohistochemical studies demonstrated increased deposition of TGF-beta, type VI collagen, and fibronectin epitopes in the extracellular matrix of the fascia in comparison to the adjacent dermis in the same specimens. Increased levels of type VI collagen mRNA, as evidenced by positive in situ hybridization signals with an alpha 2(VI) collagen cDNA, were also found in the fascia in comparison with the dermis. In situ hybridizations of affected fascia with a human sequence-specific TGF-beta 1 cDNA demonstrated numerous fibroblasts displaying positive hybridization signals indicative of high levels of transcripts for this cytokine. In contrast, no hybridization signal for TGF-beta 1 was detected in fibroblasts in the adjacent dermis. These findings suggest that TGF-beta 1 may play an important role in the development of the connective tissue alterations present in EMS-associated diffuse fasciitis. | 2 |
The effect of abdominal surgery on the serum concentration of the tumour-associated antigen CA 125. The CA 125 assay is used to monitor the course of disease in women with adenocarcinoma of the genital tract. We measured serum CA 125 levels longitudinally in three different groups of patients who had normal serum CA 125 levels (less than or equal to 16 U/ml) before extensive intraperitoneal abdominal surgery (group 1, second-look laparotomy in 28 women with ovarian cancer; group 2, radical hysterectomy in 42 patients with cervical cancer; group 3, 13 men and one woman who had aortic surgery for atherosclerotic occlusive disease or aneurysm formation). Following surgery, rising serum CA 125 levels were observed in 69 out of the 84 patients (82%), irrespective of the primary diagnosis, type of operation or sex. The highest levels were found during the second week after the operation (range 3-336 U/ml) and decreased gradually thereafter, to become normal at 8 weeks after surgery. It was concluded that abdominal surgery interferes with the specificity of CA 125 as a tumour marker during the early postoperative period. | 0 |
Fatal pulmonary embolism caused by streptokinase treatment of deep venous thrombosis of the leg? During the last 10 years, four of 150 (2.7%) patients with deep venous thrombosis (DVT) treated with streptokinase (SK) at our department have died of pulmonary embolism (PE). A retrospective study of 1393 DVT patients treated with heparin during the period 1973-1986 showed that five (0.36%) of these patients died of PE while still on heparin. In this paper we describe the four patients treated with SK who developed fatal PE. In our opinion this increase in mortality does not warrant the use of SK in routine treatment of DVT of the leg before a proper trial has been conducted to compare the frequencies of pulmonary embolism after both treatments. | 3 |
The cardiovascular effects of cocaine. Cocaine use and abuse continue to overwhelm urban economic, social, and health care systems. Patients frequently present to the emergency department with life-threatening manifestations of cocaine use, including trauma, acquired immune deficiency syndrome, psychomotor agitation, and cardiovascular collapse. Adequate treatment of the cocaine-intoxicated patient requires a critical understanding of the risk-to-benefit ratios for pharmacologic, toxicologic, and surgical or obstetric interventions. The pharmacologic and physiologic bases for the vascular manifestations of cocaine toxicity and experimental evidence for treatment strategies are reviewed. | 3 |
Eosinophilia-myalgia syndrome (L-tryptophan-associated neuromyopathy). Histopathologic study of skeletal muscle biopsy in a patient with eosinophilia-myalgia syndrome following L-tryptophan use showed prominent lymphocytic perineuritis, neuritis, and perimysial fasciitis. The presence of perineuritis and neuritis provides a histopathologic basis for clinical features of neuropathy in eosinophilia-myalgia syndrome and occurred in conjunction with a fasciitis or interstitial myositis that was predominantly perimysial and focally endomysial. | 2 |
The frequency-dependent behavior of cerebral autoregulation. Cerebral autoregulation is a complex physiological process composed of both fast and slow components that may respond differently to different rates and patterns of blood pressure variation. To assess the temporal nature of autoregulation, transcranial Doppler velocity recordings of the middle cerebral artery obtained over prolonged periods were compared with blood pressure recordings in 5 patients without cerebral disease and in 13 patients with intracranial pathological changes. Correlations between the velocity and pressure wave forms at various frequencies of variation were measured with systems analysis techniques. Patients with aneurysmal subarachnoid hemorrhage had high correlations indicating pressure-dependent flow and impaired autoregulation. Patients without cerebral disease had significantly lower correlations (P less than 0.01), indicating intact autoregulation. Examples of increasing correlations and correlations at new frequencies emerging as the clinical condition worsened are given. These preliminary examples suggest that the application of systems analysis techniques to velocity and pressure data allow measurement of the temporal nature of cerebral autoregulation. | 3 |
Spinal cord hemangioblastoma with subarachnoid hemorrhage. A case of subarachnoid hemorrhage caused by a cervical hemangioblastoma is presented. The clinical picture was indistinguishable from that of a subarachnoid hemorrhage from an intracranial lesion. The diagnosis was established by angiography and water-soluble contrast myelography followed by cervical computed tomographic scan. At surgery, the tumor was completely removed, and no neurological deficit was observed after the operation. | 3 |
Reoperation for intra-abdominal abscess. Reoperative procedures for patients with abscess and other septic complications remain among the most difficult management problems in general surgery. The diagnosis of intra-abdominal septic complications has been greatly enhanced within the last 10 years but remains imperfect and requires clinical judgment that transcends objective methods. Surgical drainage remains the mainstay of care for patients with postoperative intraabdominal abscess. | 4 |
Segmented turboFLASH: method for breath-hold MR imaging of the liver with flexible contrast. A method called segmented turboFLASH imaging allows high-resolution, multisection, short-inversion-time (TI) inversion-recovery (STIR), T1- or T2-weighted magnetic resonance (MR) studies of the liver to be completed within a breath-hold interval. The method was applied in a phantom and in 19 patients with hepatic lesions. Sequence comparisons were performed among segmented turboFLASH, single-shot turboFLASH, T1-weighted gradient-echo with ultrashort echo time, and T2-weighted spin-echo (SE) techniques. Signal from fat and liver could be nulled with the segmented turboFLASH method, with TIs of 10 and 300 msec, respectively; signal from these tissues could not be eliminated with the single-shot approach. Signal-difference-to-noise ratios and contrast for the best segmented sequences were comparable with those of the best T2-weighted SE and T1-weighted gradient-echo techniques. It is concluded that it is feasible to obtain breath-hold images with arbitrary tissue contrast by means of segmented turboFLASH imaging. The method may prove helpful for the detection and characterization of hepatic lesions and will likely have applications to other anatomic regions such as the chest and pelvis. | 0 |
Normalization of ventilation/perfusion relationships after liver transplantation in patients with decompensated cirrhosis: evidence for a hepatopulmonary syndrome. To examine the effect of liver transplantation on the respiratory and cardiovascular functions, ventilation/perfusion relationships were determined by multiple inert gas elimination technique in six patients with end-stage liver disease 1 to 19 mo before and 2 to 6 mo after liver transplantation. Cardiac output and pulmonary vascular pressures were measured after catheterization of the pulmonary artery. All patients had normal spirometry and chest x-ray films before transplantation. PaO2 before transplantation was 78.8 +/- 7.4 mm Hg (range = 51.8 to 102.8 mm Hg). All patients had perfusion of poorly ventilated lung regions (low ventilation/perfusion relationships) varying from 3% to 19% of cardiac output (mean = 8.5% +/- 2.4% of cardiac output) and two patients had intrapulmonary shunting (3% and 20% of cardiac output). Measured and calculated PaO2 agreed closely, indicating absence of pulmonary diffusion abnormality, as well as of extrapulmonary shunting. After transplantation, PaO2 normalized in all patients, and both shunting and low ventilation/perfusion relationships disappeared. Cardiac output decreased from 9.1 +/- 1.4 to 6.6 +/- 0.5 L/min (p less than 0.05), and the pulmonary vascular resistance increased from 0.69 +/- 0.14 to 1.64 +/- 0.43 mm Hg/L/min (p less than 0.05). The systemic vascular resistance also increased (before = 8.7 +/- 1.0; after = 15.3 +/- 1.1 mm Hg/L/min; p less than 0.001). Normalization of respiratory and cardiovascular alterations, after liver transplantation, in patients with end-stage liver disease indicates that these changes have a direct functional relationship to the diseased liver. It is hypothesized that this is part of a "hepatopulmonary syndrome,' which in similarity to the hepatorenal syndrome disappears with improved liver function. | 4 |
Acute compartment syndrome. Effect of dermotomy on fascial decompression in the leg. Prompt surgical decompression is the only means of preventing the late sequelae of ischaemic contracture in post-traumatic compartment syndromes. However, controversy exists regarding the length of dermotomy required for adequate decompression in the lower extremity. This study investigated the skin envelope as a potential contributing factor. Wide fascial releases were performed through limited 8 cm incisions in eight cases of post-traumatic lower extremity compartment syndrome. In nine of 29 compartments the pressure remained greater than 30 mmHg. Lengthening the skin incisions to an average of 16 cm decreased intracompartmental pressures significantly. This study documents the skin envelope as a contributing factor in acute compartment syndromes of the leg. The use of generous skin incisions is supported and the need for intra-operative compartment pressure measurements in the treatment of this condition is emphasised. | 4 |
High ethanol consumption as risk factor for intracerebral hemorrhage in young and middle-aged people. We examined the prevalence of high ethanol intake, hypertension, and other risk factors for intracerebral hemorrhage in a case-control study of 24 young and middle-aged patients with intracerebral hemorrhage. We recorded ethanol consumption, history of hypertension, liver disease, cigarette smoking, and mild or severe coagulation disorder in each case of intracerebral hemorrhage and in 48 control patients matched by sex and age. In univariate matched analyses, the frequencies of high ethanol intake (p = 0.009), hypertension (p = 0.05), and coagulation disorder (p = 0.05) were higher in the cases than in the controls. After controlling for possible confounding factors, we found that high ethanol intake and hypertension were the only independent risk factors for intracerebral hemorrhage (p = 0.02 and p = 0.05, respectively). The hemorrhagic lesion found in cases with a high ethanol intake tended to be located in the cerebral lobes (p = 0.01), contrasting with the typical basal ganglia location of hypertensive hematomas (p = 0.009). We conclude that chronic, high ethanol intake should be considered as an important risk factor for lobar hematomas in young and middle-aged people. | 3 |
Rehabilitation in brain disorders. 2. Clinical manifestations and medical issues. This self-directed learning module highlights advances in clinical manifestations of brain disorders. It is part of the chapter on rehabilitation in brain disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This chapter is composed of four articles, and each builds on principles established in the others. This article covers medical complications, neurobehavioral aspects, and cognitive deficits seen in patients with brain disorders, specifically seizures, hydrocephalus, heterotopic ossification, and cardiovascular/pulmonary, neuroendocrine, gastrointestinal, genitourinary, communication, motoric, and visual/spatial/sensory disorders. Advances that are covered in this section are neuroendocrine complications, seizure prophylaxis, and coma treatment. The learner is directed to articles 1, 3, and 4 in this chapter for supporting information. | 2 |
Effect of cardiac output reduction on rate of desaturation in obstructive apnea. The nadir of SaO2 during an obstructive apnea is dependent upon the apnea's duration and the rate of fall of saturation (dSaO2/dt). We postulated that a low Q, such as in patients with congestive heart failure with sleep apnea, or a reduction in Q, as seen in some humans during obstructive sleep apnea, might steepen dSaO2/dt. The mechanism postulated was lowering of SvO2 with increased pulmonary capillary blood oxygen uptake and faster depletion of alveolar oxygen. This study examines dSaO2/dt following the onset of apnea in eight spontaneously breathing adult baboons. Nonrepetitive obstructive apneas (30, 45, and 60 seconds) were created by clamping an indwelling cuffed endotracheal tube at the end of expiration. Following baseline measurements, the animals were given a bolus of a rapid-acting beta-adrenergic blocker followed by continuous infusion to reduce cardiac output and to limit the cardiovascular response to obstructive asphyxia. Fiberoptic catheters were used for continuous monitoring of SaO2, SvO2, and cardiac output. Esophageal pressure and relative thoracic gas volume (Respitrace) were monitored to insure equivalence of lung volume at the onset of apnea. Beta-adrenergic blockade reduced resting Q by a mean of 25 percent. The blocked vs unblocked dSaO2/dt was 0.73 vs 0.72 percent/s, 0.76 vs 0.73 percent/s, and 0.70 vs 0.71 percent/s for 30-second, 45-second, and 60-second apneas, respectively. Thus, mean dSaO2/dt for all durations of apneas was unaffected by beta-adrenergic blockade. We concluded that dSaO2/dt is not influenced by limited Q preceding or induced by obstructive asphyxia. | 2 |
A clinicopathological study of the paraneoplastic neuromuscular syndromes associated with lung cancer. The highest incidence of remote neuromuscular disorders in cancer has previously been reported in lung carcinoma. The clinical incidence of neuromuscular disorder was estimated and correlated with muscle histology and the histological type of lung tumour in 100 patients with lung carcinoma who were studied prospectively. Thirty-five patients had small cell carcinoma and 65 patients non-small cell lung cancer. Clinically, 33 patients had a polymyopathy, of whom 18 had a cachectic myopathy and 15 had a proximal myopathy (two patients had Lambert-Eaton myasthenic syndrome, one presented with dermatomyositis and one had evidence of ectopic ACTH production). Cachexia was more common in non-small cell cancer; proximal myopathy was more common in small cell cancer. Ninety-nine patients had abnormal muscle histology; 74 had type II atrophy, 12 had type I and II atrophy, one had type I atrophy and 12 had necrosis. The majority of patients were affected sub-clinically and the clinical entities of cachectic and proximal myopathy did not correspond to previous pathological classifications. Atrophy was not related to the duration of tumour symptoms, ageing, clinical type of myopathy or histological type of lung tumour, and was statistically different from that seen in controls. Qualitatively, the presence of weight loss, muscle wasting and metastatic disease were not factors in the development of atrophy. Similarly, necrosis was not related to the type of lung tumour, the presence of metastases, ageing, weight loss, muscle wasting, duration of tumour symptoms or the clinical form of myopathy. This study demonstrates that lung carcinoma has a direct effect on the motor unit, including atrophy, a necrobiotic myopathy and Lambert-Eaton myasthenic syndrome. Clinical assessment does not accurately assess the 'remote' neuromuscular effects of cancer on the motor unit. | 4 |
Fibrinopeptide A is released into the coronary circulation after coronary spasm. To examine whether acute myocardial ischemia activates the coagulation system and platelet activation in the coronary circulation, we measured plasma levels of fibrinopeptide A and beta-thromboglobulin in the coronary sinus and the aortic root simultaneously in 15 patients with coronary spastic angina before and after the left coronary spasm induced by intracoronary injection of acetylcholine and in 15 patients with stable exertional angina before and after acute myocardial ischemia induced by rapid atrial pacing. Fifteen patients with chest pain but normal coronary arteries and no coronary spasm served as controls. The coronary sinus-arterial difference of fibrinopeptide A increased markedly (p less than 0.001) from 0.1 +/- 0.2 to 4.3 +/- 0.7 ng/ml after the anginal attacks in the coronary spastic angina group. However, fibrinopeptide A levels remained unchanged after the attacks in the stable exertional angina group and after intracoronary injection of acetylcholine in the control group. Plasma beta-thromboglobulin levels remained unchanged after the attacks in both patient groups and after acetylcholine in the control group. Our data indicate that coronary spasm induces thrombin generation and may lead to thrombus formation in the coronary artery involved, but pacing-induced ischemia does not activate the coagulation system. | 3 |
Widespread inflammatory response to osteoblastoma: the flare phenomenon. A case of vertebral osteoblastoma caused a diffuse, reactive inflammatory infiltrate in two vertebrae, adjacent ribs, and the paraspinous soft tissues. The authors call this the flare phenomenon. On magnetic resonance images the diffuse inflammatory response caused a misleading appearance that simulated a malignant process (lymphoma or Ewing sarcoma). A computed tomographic myelogram was diagnostic. | 0 |
Intrapericardial infusion of 5-fluorouracil. An unusual complication of a Hickman catheter. Venous access devices (VAD) have become an important tool in the management of patients with cancer. Multiple complications can occur as a consequence of insertion of a VAD. The authors report a case of a Hickman catheter perforating the wall of the superior vena cava into the pericardium, resulting in accidental intrapericardial infusion of 5-fluorouracil (5-FU). Pericarditis and cardiac arrhythmias developed, but the patient did not have cardiac tamponade. She recovered from the event without apparent chronic cardiac dysfunction. | 3 |
Significance of positive margins in oral cavity squamous carcinoma. Three hundred ninety-eight consecutive, previously untreated patients undergoing surgery for epidermoid carcinoma of the oral cavity from 1979 to 1983 were reviewed. One hundred twenty-nine patients were classified as having positive surgical margins. Of these, 83 patients had tumor within 0.5 mm of the surgical margin, 9 had premalignant changes at the margin, 9 had in situ carcinoma at the margin, and 28 had invasive cancer at the margin. The remaining 269 patients had uninvolved margins. The significance of positive margins relating to survival, subsequent clinical course, local recurrence, and patterns of treatment failure was examined, along with the impact of adjuvant postoperative radiotherapy on positive margins. The percentage of patients having positive margins progressively increased with increasing T stage: 21% in T1 versus 55% in T4 primary cancer. The overall 5-year survival for patients with negative margins was 60%. For patients with positive margins, 5-year survival was 52%. This difference was statistically significant. The incidence of local recurrence in patients having positive surgical margins was twice as much as in those with negative margins (36% versus 18%). Metastasis rates in the neck and at distant sites were not significantly influenced by the status of the surgical margin. Of the 129 patients with positive margins, 49 received postoperative radiotherapy. In those patients so treated, a trend toward lower recurrence rates was noted. Differences were not statistically significant. This retrospective review confirms the importance of adequate resection of the primary tumor as well as the relative ineffectiveness of adjuvant postoperative radiotherapy in the improvement of local control in patients with positive surgical margins. | 0 |
Cells secreting antibodies to myelin basic protein in cerebrospinal fluid of patients with Lyme neuroborreliosis. An autoimmune response to myelin basic protein (MBP) has been proposed to participate in the development of the chronic neurologic manifestations that may accompany Borrelia burgdorferi-induced Lyme disease. Using an immunospot assay, we counted cells secreting antibodies to MBP. Anti-MBP IgG antibody-secreting cells were detected in CSF from eight of 13 consecutive patients with Lyme neuroborreliosis irrespective of stage of disease. The numbers were between 1/370 and 1/5,000 CSF cells (mean, 1/1,250 in the 13 patients). The highest numbers were encountered in two patients with severe signs of CNS involvement. The numbers decreased in parallel with clinical improvement after treatment. Anti-MBP IgG antibody-secreting cells were also observed in the CSF from patients with a variety of other inflammatory diseases of the nervous system, and their role in the development of tissue damage remains unsettled. Anti-MBP IgG antibody-secreting cells were not detected in the patients' blood, reflecting accumulation of this autoantibody response to CSF. | 2 |
Neurotoxic action of veratridine in rat brain neuronal cultures: mechanism of neuroprotection by Ca++ antagonists nonselective for slow Ca++ channels. The effect of various Ca++ antagonists and local anesthetics on neuronal cell degeneration induced by veratridine was studied in primary rat brain neuronal cultures. Cell death was quantified by measuring lactate dehydrogenase (LDH) released in the culture medium. The neuronal cell degeneration was Ca+(+)-dependent because, in the absence of extracellular Ca++, 16 hr of exposure to 30 microM veratridine failed to produce release of LDH. Ca++ antagonists, nonselective for slow Ca++ channels (flunarizine, cinnarizine, lidoflazine, prenylamine and bepridil) inhibited veratridine-induced release of LDH with IC50 values between 0.11 and 0.47 microM. Ca++ antagonists selective for slow Ca++ channels were less potent and inhibited veratridine-induced release of LDH at concentrations in the following order of potency: nicardipine greater than gallopamil and verapamil greater than niludipine greater than nitrendipine greater than nifedipine greater than nimodipine greater than diltiazem. Tested local anesthetics were incomplete inhibitors of veratridine-induced release of LDH. A good correlation was found between the potency of the drugs to inhibit released LDH induced by 30 microM veratridine in neuronal cultures and their binding affinity for the batrachotoxin binding site of Na+ channels in rat cortex synaptosomal preparation. It is concluded that protection against veratridine-induced neurotoxicity can be mediated by blocking a veratridine-sensitive Na+ channel. It is a property of certain nonselective Ca++ antagonists. There is apparently no direct relationship with Ca++ antagonistic activity. The effect is unrelated to local anesthetic activity. | 2 |
Heterotopic supradiaphragmatic liver formation in association with congenital cardiac anomalies. Heterotopic supradiaphragmatic liver formation is extremely rare. We studied a case of heterotopic liver in a 26-week fetus with severe cardiac and conotruncal anomalies. The cardiac anomalies are strikingly similar to those of a previously described patient with heterotopic supradiaphragmatic liver. The cardiac anomalies and heterotopic supradiaphragmatic liver formation may be mechanistically related. | 4 |
Controlled trial of antimycobacterial therapy in Crohn's disease. Clofazimine versus placebo. In order to study the effect of clofazimine, a powerful antimycobacterial and antiinflammatory agent, 49 patients with active Crohn's disease were randomized to either corticosteroids plus clofazimine 100 mg daily (N = 25) or to steroids and matching placebo (N = 24). A total of 28 patients (58%) went into disease remission (clofazimine 16, placebo 12; P = NS) with a fall in disease activity score from 10.5 +/- 4.4 to 3.3 +/- 3.5. Patients were treated for a further eight months with clofazimine or placebo and 18 of 28 maintained their remission and completed the study (clofazimine 12, placebo 6; P = NS). Side effects were minor and consisted of skin rash and increased pigmentation. Clofazimine as a solitary antimycobacterial agent appears ineffective in inducing remission in Crohn's disease but may have a role in either disease maintenance or combination chemotherapy. | 4 |
An immunofluorescence study of cerebral malaria. A correlation with histopathology. Histopathologic and immunopathologic features of cerebral malaria have been defined in a study of six autopsy cases with severe Plasmodium falciparum infection. In five cases, immunofluorescent studies demonstrated intense deposition of P falciparum antigen, IgG, and fibrin in cerebral vessels associated with the histopathologic finding of hemorrhage in the white matter of cerebrum and cerebellum regardless of the presence of parasitized erythrocytes in the cerebral vessels. Immunofluorescent study also demonstrated the extravascular deposits of P falciparum granular antigen associated with acute inflammatory lesion in cerebral tissue in one case. These findings suggested that the immunopathogenic mechanism may in some way play a role in the pathogenesis of cerebral malaria. | 2 |
GI symptoms, function, and psychophysiological arousal in dysmenorrheic women. In a previous study, gastrointestinal (GI) symptoms and stool characteristics were found to be influenced by menstrual cycle phase. The current study was designed to replicate initial work regarding GI symptoms and stool characteristics and to explore the relationships between GI symptoms, stool characteristics, ovarian hormone levels, and indicators of psychophysiological arousal. Fifty women (dysmenorrheic, N = 22; nondysmenorrheic, N = 28) maintained a daily dairy for recording stool characteristics, GI symptoms, and daily anxiety level. First morning void urine specimens for catecholamine assays and serum samples for ovarian hormone and cortisol determinations were obtained at menses, follicular, and luteal phases. Results showed menstrual cycle-related differences in stool characteristics and report of GI symptoms, with the greatest changes occurring at menses in the total sample. Dysmenorrheic women reported higher levels of all GI symptoms at menses as compared to nondysmenorrheic women. In addition, cycle-related differences in serum cortisol, urine catecholamines, and report of anxiety were also noted, particularly in dysmenorrheic women. However, looser stools and GI symptoms at menses were not correlated with absolute levels of ovarian hormones or indicators of psychophysiological arousal. | 1 |
Modification of stroke susceptibility by genotype-dependent maternal influences. The influence of the prenatal and postnatal maternal environment on stroke susceptibility was evaluated by reciprocally crossing the spontaneously hypertensive (SHR) and the Dahl salt-sensitive (SS/Jr) inbred rat strains to produce reciprocal F1 hybrids that were nurtured, respectively, during prenatal and postnatal life by SHR or SS/Jr mothers. Following placement on a high-salt diet containing 8% NaCl at 35 days of age, F1 rats reared by SHR mothers had shorter survival times and were more likely to die with cerebral hemorrhage than F1s reared by SS/Jrs. Across reciprocal F1 female groups, enhanced susceptibility to stroke was associated with greater elevations of systolic blood pressure, but this association was not seen across reciprocal F1 male groups. There was also an association between blood pressure and stroke within each F1/gender subgroup: Rats eventually suffering strokes developed higher blood pressure after placement on the high-salt diet than rats that did not suffer stroke. Lower day 35 body weights (before exposure to the high-salt diet) were associated with greater likelihood of stroke both across the reciprocal F1 groups, and within three of the four F1/gender subgroups. The differences in stroke susceptibility between the reciprocal F1 groupings may be due to systematic differences in the prenatal and/or postnatal environments of SHR and SS/Jr mothers and may be mediated by variations in the nutritive capacity of the two inbred mothers. | 3 |
Hot-tip laser. Results and complications. The hot tip laser system for atheroablation has been used since mid-1984 as a device for broadening the indications for and extending the applicability of angioplasty in the management of lower-extremity atherosclerosis. It has been a controversial device. Although the system demonstrates that it can occasionally be useful for the management of occlusive as opposed to stenotic disease of the infrainguinal arteries, a close examination of the published data fails to demonstrate a consistent improvement in either the primary success or long-term patency rates for thermal energy applied to atheroma for recanalization of the lower extremity arteries. | 3 |
The De Vega tricuspid annuloplasty. Perioperative mortality and long term follow-up. One hundred and fifty-three patients undergoing De Vega tricuspid annuloplasty, with or without other associated cardiac procedures between January, 1979, and June, 1987, were evaluated. There were 136 hospital survivors. The follow-up was 98.1% complete for a mean of 3.7 years/patient. Operative mortality was 11.1%; preoperative NYHA class and length of CPB were significant risk factors of perioperative mortality. The actuarial survival of operative survivors at 9 years was 73.5 +/- 11.8%. There were 7 late cardiac deaths among a total of 12 late deaths. Eleven patients required reoperation (2.1 +/- 0.6% patient-year). In seven patients it was necessary for recurrence of tricuspid regurgitation; six of these had also a mitral prosthesis malfunction or a periprosthetic leak. Residual tricuspid regurgitation was judged as mild, moderate or severe in 29.9%, 11.9% and 4.3% of the patients respectively. De Vega tricuspid annuloplasty is the method of choice for mild and moderate tricuspid insufficiency; in selected cases, with a more severe degree of regurgitation, better results could be achieved with a different surgical approach. | 4 |
Pharmacologic stress imaging. Pharmacologic stress imaging has increasingly been employed as an alternative to exercise imaging for detection of coronary artery disease and risk stratification particularly in patients who are unable to perform adequate exercise. Sensitivity and specificity of thallium 201 scintigraphy using intravenous dipyridamole infusion as a stress for coronary artery disease detection average 85% and 91%, respectively. Dipyridamole imaging is also useful for differentiating between ischemia and scar and identifying patients who have an increased risk for subsequent cardiac events. Dipyridamole imaging is particularly useful for preoperative risk stratification in patients undergoing surgery for peripheral vascular or aortic disease. Dipyridamole imaging is also useful for identifying residual myocardial ischemia after myocardial infarction and detecting restenosis after coronary angioplasty. Adverse side effects of dipyridamole are promptly reversed by aminophylline. Dipyridamole stress can also be employed in association with echocardiography for detection of ischemia-induced regional wall motion abnormalities. | 4 |
Improved silver staining of nucleolar organiser regions in paraffin wax sections using an inverted incubation technique [published erratum appears in J Clin Pathol 1991 Jun;44(6):528] A new simple modification to the silver staining of nucleolar organiser regions (AgNORs) was devised which, by performing the incubation with the slide inverted, results in minimal undesirable background staining, a persistent problem. Inverted incubation is facilitated by the use of a commercially available plastic coverplate. This technique has several additional advantages over other published staining protocols. In particular, the method is straightforward, fast, and maintains a high degree of contrast between the background and the AgNORs. | 0 |
Corneal sensitivity and correlations between decreased sensitivity and anterior segment pathology in ocular leprosy. Leprosy is one of the leading causes of corneal hyposensitivity. In this article the corneal sensitivity of 143 leprosy patients was examined, and correlations between corneal hyposensitivity and anterior segment pathology were detected. Twenty four healthy volunteers were examined as controls. Various degrees of corneal loss of sensitivity were found in 46.2% of leprosy patients. Lagophthalmos, chronic lepromatous granulomatous uveitis, iris atrophy, and social blindness were found 4.5-16.6 times more frequently in eyes which developed severe corneal hyposensitivity. | 2 |
Does carotid restenosis predict an increased risk of late symptoms, stroke, or death? The identification of carotid restenosis as an unexpected late complication of carotid endarterectomy has prompted concerns regarding its importance as a source of new cerebral symptoms, stroke, and death. To investigate these concerns, we analyzed a consecutive series of 507 patients undergoing 566 carotid endarterectomies, each documented as technically satisfactory. Post-operative duplex Doppler examination data at 3 days, 1, 3, 6, 12 months, and annually thereafter in 484 arteries (85.5%) permitted classification of these arteries according to the most severe degree of postoperative stenosis: normal (n = 306); 1% to 19% (n = 89); 20% to 50% (n = 40); more than 50% (n = 49, including 8 occluded). The incidence of more than 50% restenosis was 14.5% in female and 7.7% in male patients (p = 0.003). Life table analyses to 10 years revealed a significantly greater life expectancy among those with restenosis (p = 0.05). Stroke was also less likely in patients with restenosis, although this difference did not reach statistical significance. When survival and stroke were both endpoints, the likelihood of patients with more than 50% restenosis remaining alive and stroke free was also greater than the less than 20% stenotic group (p = 0.03). Thus patients with carotid restenosis were less likely than patients with normal postoperative scans to have late symptoms, stroke, or early death. | 3 |
Results of a multicenter trial comparing imipenem/cilastatin to tobramycin/clindamycin for intra-abdominal infections. We designed a multicenter study to compare tobramycin/clindamycin to imipenem/cilastatin for intra-abdominal infections. We included the Acute Physiology and Chronic Health Evaluation (APACHE II) index of severity and excluded patients without established infection. Two hundred ninety patients were enrolled, of whom 162 were evaluable. Using logistic regression to analyze both outcome at the abdominal site of infection and outcome as mortality, we found a significant correlation for both with APACHE II score (p less than 0.0001 for both). Next we analyzed the residual effect of treatment assignment and found a significant improvement in outcome for imipenem/cilastatin-treated patients (p = 0.043). The differences in outcome were explained by a higher failure rate for patients with gram-negative organisms for tobramycin/clindamycin-treated patients (p = 0.018). This was reflected in a significantly higher incidence of fasciitis requiring reoperation and prosthetic fascial replacement. Maximum peak tobramycin levels were analyzed for 63 tobramycin/clindamycin patients harboring gram-negative organisms. For failures the maximum peak was 6.4 +/- 1.9 micrograms/mL, and time to maximum peak was 4.6 +/- 5.2 days. For successes the maximum peak was 6.1 +/- 1.7 micrograms/mL, occurring at 3.8 +/- 2.6 days. This study supports inclusion of severity scoring in statistical analyses of outcome results and supports the notion that imipenem/cilastatin therapy improves outcome at the intra-abdominal site of infection as compared to a conventionally prescribed amino-glycoside-based regimen. | 1 |
Oral zidovudine, continuous-infusion fluorouracil, and oral leucovorin calcium: a phase I study. A phase I clinical, pharmacologic, and biochemical evaluation of escalating oral zidovudine (AZT) given over 2 days with a fixed dose of continuous-infusion fluorouracil (800 mg/m2 per day X 3 days) and oral leucovorin calcium was performed. Eighteen patients were treated with doses of AZT ranging from 1.0 to 9.0 g/m2 per day. Nausea and vomiting were dose limiting, with a maximally tolerated dose of 7.5 g/m2 per day. Rash and mucositis occurred but were not dose limiting. A dose-related increase in peak plasma levels of AZT was observed, and the alpha half-life of AZT in plasma (75 min) was unaffected by these high doses. At doses above 4.0 g/m2 per day, trough levels significantly increased, perhaps reflecting prolonged absorption from the gut. No responses were observed; however, a significant increase in DNA single-strand breaks was observed in peripheral blood cells after a threshold dose of 4.0 g/m2 per day, confirming a biological effect of AZT in this regimen. Further trials with an intravenous formulation capable of maintaining plasma levels and circumventing dose-limiting toxicity are warranted. | 0 |
A videofluoroscopy chair for the evaluation of dysphagia in patients with severe neuromotor disease. Due to the difficulties encountered in positioning severely neurologically impaired individuals for videofluoroscopic studies, the Rehab Tech Video FluoroChair was developed. The purpose of the chair is to provide the severely disabled patient with safe, stable postural support in an upright position for videofluoroscopic studies, with anterior-posterior, lateral, and rotational views easily performed. The chair features a removable headrest, a full back support, armrests, lateral truncal supports, and a patented base which is clamped to the footboard of the radiology table and allows for 200 degrees rotation of the patient. Two case studies illustrate the practical use and versatility of the Rehab Tech Video FluoroChair. | 2 |
Local-regional breast cancer recurrence following mastectomy. Local-regional recurrence patterns were investigated in 1392 patients with breast cancer. Primary treatment for all patients included a mastectomy. Nine hundred seventeen patients had negative nodes and did not receive systemic therapy. Four hundred seventy-five patients had node metastases and were randomized to receive different combinations of chemoendocrine therapy. Follow-up ranged between 5 and 16 years. Two hundred thirty (25.8%) node-negative patients have had recurrences, with the initial recurrence being local-regional in 9.2%. Two hundred forty-two (50.9%) node-positive patients have had recurrences, with the initial recurrence being local-regional in 17.1%. Larger tumors and more extensive node involvement were associated with more first local-regional recurrences. The relative percent of first local-regional recurrence among patients in whom cancer recurred was similar for node-negative and node-positive patients (35.4% and 33.5%, respectively). In 63.6% of patients in whom cancer recurred, first local-regional recurrence were distant. Larger tumors, more extensive node involvement, and a shorter disease-free interval after mastectomy were associated with more rapid appearance of distant recurrence among these patients. | 4 |
Brucella endocarditis: the role of combined medical and surgical treatment. Brucella endocarditis, although a rare complication of brucellosis, is the main cause of death related to this disease. This report describes a case of aortic endocarditis due to Brucella abortus in an elderly farmer with known aortic stenosis. Urgent valve replacement was performed because of progressive heart failure despite appropriate antimicrobial treatment. The infection was cured with trimethoprim-sulfamethoxazole and rifampin given for 3 months after surgery. A review of the literature reports on the 38 other cases of cured brucella endocarditis made clear the need for combined antimicrobial treatment and surgical valve replacement. | 3 |
The validity of canine platelet aggregometry in predicting vascular graft patency. Several laboratories have found canine platelet aggregometry predictive of thrombotic potential in vascular grafts. Adenosine diphosphate (ADP) is a frequently used agonist, often at unspecified or differing concentrations. This study was designed to evaluate the predictive value of ADP-induced platelet aggregometry and the validity of the methodology. Platelet aggregometry in response to 2 x 10(-5) M ADP was assayed in 70 dogs. Twenty-six percent were aggregators, 51% were non-aggregators, and 20% were indeterminant. All dogs were then treated with aspirin and dipyridamole. Vascular prostheses were implanted bilaterally (aorto-iliac) and anti-platelet therapy continued for two weeks. Dose-response to ADP was studied at three concentrations in 20 dogs. At 2 x 10(-5) 1/20 aggregated, at 4 x 10(-5) 3/19 aggregated and at 2 x 10(-4) 15/20 aggregated. Time between samples and study was evaluated in 11 dogs, with 2/11 changing from non-aggregator to aggregator at two or three hours. Daily reproducibility was studied in 70 dogs, 14 of which changed aggregation status between days. Patency was 58/68 (85%) for non-aggregators, 23/34 (68%) for aggregators (p = 0.038). Platelet aggregometry has significant predictive value for graft patency but methodology must be specified and standardized. | 4 |
Osteoma of the middle ear. Report of a case. Osteomas of the middle ear are rare. We report a case of a 7-year-old boy with osteoma originating from the pyramidal eminence, combined with congenital cholesteatoma. The osteoma and cholesteatoma were successfully removed by tympanomastoidectomy. The long process of the incus and the superstructure of the stapes disappeared. The body of the incus was sculpted and used as a columella. Histopathologically, the osteoma was much the same as an external auditory canal osteoma. The possibility of a primary congenital origin of this neoplasm is suggested. | 0 |
Orthotopic liver transplantation for patients with hepatitis B virus-related liver disease Fifty-nine patients with prior hepatitis B virus infection underwent orthotopic liver transplantation. During the first 2 mo, mortality was not significantly different in the hepatitis B virus-infected group (25.5%) vs. a hepatitis B virus-immune control group (21%). Beyond 2 mo, the mortality, rate of graft loss, need for retransplantation and incidence of abnormal liver function were significantly higher in the hepatitis B virus-infected group. Treatment of the hepatitis B virus infection was attempted with passive immunization, combined active and passive immunization, alpha-interferon or nothing. The clinical outcome was not significantly influenced by any of these therapies. However, of the patients who lived more than 60 days, 6 of 22 treated with active plus passive immunization were cleared of HBsAg, something achieved once in 16 patients treated with alpha-interferon, never in 3 patients with passive immunization only and once in 4 patients with no therapy. In patients with recurrent hepatitis B virus infection, the pace of hepatitis development in the graft appeared to be accelerated, and this was particularly striking in patients who underwent multiple retransplantations at progressively shorter intervals. None of the patients who became HBsAg-negative had HBeAg preoperatively. | 1 |
Positive selection of candidate tumor-suppressor genes by subtractive hybridization. A positive selection system designed to identify and recover candidate tumor-suppressor genes is described. The system compares mRNA expression of genes from normal and tumor-derived human mammary epithelial cells grown in a special medium that supports similar growth rates of the two cell types. mRNAs uniquely expressed in normal cells are recovered as cDNAs after subtraction with mRNA from tumor cells. Seven different clones, from 0.6 to 4.8 kilobases in transcript size and including both rare and abundunt transcripts, were recovered in the first 23 clones analyzed. Among the isolated clones were genes encoding the gap-junction protein connexin 26, two different keratins, and glutathione-S-transferase pi, as well as an unknown gene in the S100 family of small calcium-binding proteins. In principle, tumor-suppressor genes include two classes: class I, in which loss of function results from mutation or deletion of DNA and class II, in which loss of function is from a regulatory block to expression. A class II suppressor gene is assumed to be regulated by a different suppressor gene that lost its function by mutation or deletion. Both classes of tumor-suppressor genes may provide valuable proteins with clinical applications in cancer diagnosis or therapy. Class II suppressors may be especially useful because the normal genes are present and their reexpression may be inducible by drugs or other treatments. | 0 |
Recurrent pain, illness intrusiveness, and quality of life in end-stage renal disease. Repeated episodes of headache and muscle cramp were hypothesized to contribute to increased patient perceptions of illness intrusiveness and to compromised quality of life. Standard measures of pain, illness intrusiveness, and quality of life were obtained on 2 occasions, each 6 weeks apart, from 100 end-stage renal disease patients. The impact of recurrent muscle cramps on perceptions of illness intrusiveness was conditional upon the occurrence of headache symptoms. Perceptions of illness intrusiveness were significantly higher when both muscle cramp and headache symptoms occurred during one or more assessment intervals as compared to when muscle cramps or headaches, only, occurred. Illness-related concerns and general feelings of pessimism were also significantly higher among patients who experienced recurrent episodes of muscle cramp. Although no direct relations were observed between pain and other quality of life indicators, previous research has documented a relation between illness intrusiveness and quality of life. Recurrent pain problems, thus, appear to contribute to increased illness intrusiveness and to reduced quality of life in end-stage renal disease patients. | 4 |
Transcranial Doppler determination of cerebral perfusion in patients undergoing CPR: methodology and preliminary findings. STUDY OBJECTIVES: To correlate cerebral arterial blood velocity measurements as determined by transcranial Doppler ultrasound with various resuscitation maneuvers performed in an uncontrolled manner in a series of cardiac arrest patients undergoing standard resuscitation. TYPE OF PARTICIPANTS: Any patient undergoing resuscitation for a nontraumatic cardiac arrest was eligible for the study. INTERVENTIONS: Resuscitation was carried out while flow velocities were monitored in various intracranial arteries by transcranial Doppler ultrasound. Vessel identification was based on the angle and depth of insonation. MEASUREMENTS AND MAIN RESULTS: The internal carotid artery was located more consistently than either middle cerebral or ophthalmic arteries and provided superior waveforms for analysis. Alterations in flow velocity were noted and correlated to various therapeutic interventions. Flow velocities were 70% of normal during the early phase of resuscitation but deteriorated over time until there was no evidence of net forward flow. Even early in CPR, flow was demonstrated only during systole. CONCLUSION: Transcranial Doppler ultrasound appears to be a potentially promising means of determining cerebral flow in patients undergoing CPR. | 3 |
Clinical recognition and evaluation of peptic ulcer disease. When a patient has epigastric pain that worsens 1 to 3 hours after meals, the possibility of peptic ulcer disease should be considered. Completely typical clinical presentations in patients younger than age 50 justify empirical therapy when no physical or laboratory findings suggest a mimicking disorder. Esophagogastroduodenoscopy should be undertaken when response to therapy is incomplete, symptoms recur quickly, or dyspeptic symptoms present for the first time in a patient older than age 50. When gastric ulcers are diagnosed radiographically, endoscopy and biopsy at multiple sites should be done to exclude malignant disease. Intractable duodenal ulcers may necessitate endoscopic biopsy of antral and duodenal mucosa to rule out an associated Helicobacter pylori infection, which may modify therapeutic approaches. Zollinger-Ellison syndrome is rare but should be suspected when ulcer disease presents atypically or aggressively or in families. Diagnosis is not difficult to confirm. | 0 |
Leukocyte larceny: spurious hypoxemia confirmed with pulse oximetry Leukemic patients with extremely high white blood counts may exhibit the phenomenon of leukocyte larceny, in which white blood cells metabolize plasma oxygen in arterial blood gas samples (ABG) producing a spuriously low oxygen tension. We report the case of a leukemic patient with a white blood count in excess of 500,000 in whom multiple ABGs documented hypoxemia out of proportion to his clinical picture. Pulse oximetry was used to confirm higher hemoglobin oxygen saturation to establish the leukocyte larceny. | 4 |
Resting and total energy expenditure in patients with inflammatory bowel disease. Patients with inflammatory bowel disease often present with weight loss. Among possible causes, an elevated energy expenditure has frequently been suggested but is the least documented. In this study resting metabolic rate (RMR) and total daily energy expenditure (TDEE) were measured in 15 outpatients with inflammatory bowel diseases and in eight healthy control subjects. Measured RMR as a percentage of that predicted from fat-free mass was not significantly different for control subjects (102 +/- 9.8%, mean +/- SD) and patients (100 +/- 13.3%). TDEE, expressed as a multiple of RMR, was 1.70 +/- 0.31 for control subjects and 1.78 +/- 0.24 for patients. When patients were subgrouped as greater than or equal to 90% or less than 90% desirable body weight, a mean increase over RMR predicted from fat-free mass was seen in the underweight patients (106 +/- 9.3%) but not in normal-weight patients (99.0 +/- 15.6%). Mean TDEE/RMR values for the patient subgroups were 1.70 +/- 0.30 and 1.88 +/- 0.08, respectively. We conclude that stable outpatients with inflammatory bowel disease have only a minimal increase in energy needs. | 1 |
Elevated prostaglandin E2 levels in bronchoalveolar lavage fluid of patients with bronchogenic carcinoma. Understanding local pulmonary immunoregulatory mechanism(s) in patients with carcinoma of the lung is an important step towards the development of innovative methods of treatment. Prostaglandin E2 plays an integral role in immunoregulation. Therefore, we evaluated PGE2 concentrations in BALF from 18 patients with bronchogenic carcinoma, compared to that from six patients with pulmonary diseases other than carcinoma and ten normal smokers of similar age. The level of PGE2 in patients with lung carcinoma (158.1 +/- 88.7 pg/ml) was significantly (p less than 0.001) higher than the other two groups (16.2 +/- 6.9 and 4.4 +/- 3.4 pg/ml). Levels of PGE2 also varied among patients with carcinoma of different cell types. Patients with SQCA had significantly (p less than 0.001) higher levels of PGE2 (242.7 +/- 29.4 pg/ml) than patients with ADCA or SCCA (82.3 +/- 27.9 and 66.3 +/- 15.2 pg/ml, respectively). Furthermore, there was a marked difference in PGE2 concentration between carcinomatous lung and clinically noninvolved lung in patients with SQCA and ADCA. Further study is warranted to determine the interactions between PGE2 and other cytokines (interleukin-1, IL-2, and tumor necrosis factor), as well as the activity of cytolytic lymphocytes (LAK cells) in the lungs of patients with bronchogenic carcinoma. | 0 |
Intracranial chordoma in a preadolescent. Case report. Chordomas are rare tumors derived from notochord remnants occurring primarily in the sacrum, clivus, and cervical regions. Exceptionally, these tumors occur in children, though usually in the sacrum. Eight cases of clivus chordoma have been described in preteenagers. In this report, a clival chordoma with unusual radiologic features is described in an 11-year-old boy. The literature regarding this entity is reviewed. | 0 |
Changes in the clearance of total and unbound etoposide in patients with liver dysfunction. The disposition of total and non-protein-bound etoposide was investigated in 21 cancer patients receiving etoposide and cisplatin combination chemotherapy. Etoposide plasma concentrations were determined using a specific high-performance liquid chromatography (HPLC) method, and etoposide plasma protein binding was determined by equilibrium dialysis. The patients had a wide range of renal function (creatinine clearance, 32 to 159 mL/min/m2) and hepatic function (total bilirubin range, 0.3 to 21.5 mg/dL; aspartate aminotransferase [AST] range, 14 to 415 IU/L; serum albumin range, 2.7 to 4.1 g/dL). The mean etoposide total systemic clearance was not different in 15 patients with total bilirubin less than 1.0 mg/dL versus six patients with total bilirubin 1.1 to 21.5 mg/dL (18.7 +/- 5.9 mL/min/m2 v 26.4 +/- 10.7 mL/min/m2; t-test P = .06), with a trend toward higher total clearance in the patients with abnormal bilirubin values. However, the mean clearance of unbound etoposide was significantly lower in patients with increased total bilirubin (220 +/- 90 mL/min/m2 v 135 +/- 61 mL/min/m2; t-test P = .027). The fraction of etoposide unbound (fu) in plasma was significantly higher in patients with increased bilirubin (9% +/- 3% v 27% +/- 15%; t-test P = .002), explaining the trend toward higher total clearance in these patients. Etoposide clearance (total or unbound) in the 14 patients with measurable hepatic metastases was not different from the clearance in the seven patients without hepatic metastases. This study provides an explanation for why patients with increased bilirubin do not have lower total systemic clearance of etoposide, and indicates that such patients have a higher exposure to unbound etoposide. The results of ongoing pharmacodynamic studies of total and unbound etoposide in patients with increased bilirubin will determine the clinical relevance of altered etoposide protein binding. | 0 |
Linking in accessory pathways. Functional loss of antegrade preexcitation. BACKGROUND. Concealed retrograde activation has been proposed as a mechanism for antegrade conduction block in the bundle branches and atrioventricular accessory pathways. We studied this hypothesis (linking) in 10 patients with the Wolff-Parkinson-White syndrome in whom antegrade preexcitation could be persistently blocked by overdrive atrial pacing. METHODS AND RESULTS. An atrial pacing protocol, with a decremental ramp followed by an incremental ramp, defined a range of atrial paced cycle lengths (linking window) associated with both persistent conduction and block in the accessory pathway. Within the limits of the linking window, the ability of an atrial impulse to conduct over the accessory pathway was dependent on the preceding state (i.e., conduction or block). The observed linking window ranged from 70 to 290 msec (mean, 185 +/- 68 msec) and closely approximated the measured delay in retrograde activation of the accessory pathway during persistent antegrade block. The mean antegrade effective refractory period of the accessory pathways was long (486 +/- 156 msec), and in each case, it exceeded the antegrade refractory period of the normal atrioventricular pathway. Critically timed premature ventricular extrastimuli, delivered while linking was maintained in the accessory pathway, were able to interrupt the linking and restore antegrade accessory pathway conduction. CONCLUSIONS. These observations suggest that accessory pathway linking is associated with bidirectional block in the accessory pathway. The ability to initiate linking (and the stability of the phenomenon) depends on a critical relation between antegrade accessory pathway refractoriness and the magnitude of retrograde accessory pathway activation delay. | 4 |
Hypoxic acidemia, hyperviscosity, and maternal hypertension do not affect the umbilical arterial velocity waveform in fetal sheep. The effect of hypoxic acidemia, hyperviscosity, and maternal hypertension on the umbilical arterial velocity waveform was studied in 23 chronically catheterized fetal sheep. Fetal hypoxic acidemia induced by lowering the maternal inspired oxygen concentration (n = 7) caused no change in the ratio of systolic/diastolic blood velocity even when fetal arterial pH was as low as 6.8. Fetal blood hyperviscosity (n = 7) induced by exchange transfusion with packed maternal blood cells increased placental vascular resistance by greater than or equal to 50% but had no significant effect on the systolic/diastolic ratio. Similarly, maternal hypertension induced by intravenous infusion of angiotensin II to the ewe (n = 9) did not affect the systolic/diastolic ratio despite a 50% increase in maternal arterial blood pressure. We conclude that umbilical arterial velocity waveform abnormalities observed in growth-restricted human fetuses are probably not a direct result of fetal hypoxemia or hyperviscosity or maternal hypertension. | 3 |
Radiology for cochlear implants. One fifth of patients selected for cochlear implants have such bony irregularities in the cochlear duct that full insertion of a multichannel electrode array is impossible. Three cases of cochlear deafness are presented where pre- and post-operative radiology played an important part in the management. Standard CT at 2 mm cuts is compared with ultra high resolution CT at 1 mm cuts. The pitfall of poor definition is that the inexperienced surgeon may find himself unexpectedly drilling out an obliterated cochlear duct. Sections 30 degrees caudal to Reid's infra orbito-meatal base line at 1 mm intervals give maximum information for minimum radiation. Plain films show the placement of individual platinum electrode contacts in relation to the spiral 'frequency map' of the cochlea. This is vital information for the audiologist who has to route specific frequencies to specific sites within the ear for a good hearing result. | 2 |
Case finding, data quality aspects and comparability of myocardial infarction registers: results of a south German register study. The population-based Augsburg Coronary Event Register (330,000 residents, age 25-74 years) has registered a total of 1012 cases of acute myocardial infarction (AMI) in 1985 and 1021 AMI in 1986 and categorized them on the basis of the current WHO diagnostic algorithm for AMI. The register is designed for longitudinal comparisons of annual AMI risk (incidence, attack rate, death rate), and the risk to the AMI patients themselves (28-day case fatality). The methodology and specific issues encountered during registration and data evaluation are described. With an estimated 95% completeness of case finding, the quality control data review which the register conducts annually shows a consistency of specific data structures which indicate stable case finding and validation procedures. However, local conditions which affect case finding and data completeness per case are responsible for the creation of subsets of AMI which are in turn distinguished by differences in diagnostic category structures. With regard to the study objectives, the differences among subsets appear to have the least effect on rate calculations if DEFINITE and POSSIBLE AMI are combined. The implications of methodological variations and subset differences within and across registers on annual rate calculations and result comparisons are discussed. | 3 |
The treatment of Gilles de la Tourette syndrome by limbic leucotomy. A patient with Gilles de la Tourette syndrome and severe self-injurious compulsions who had failed to respond to drug treatment and behavioural therapy obtained a complete and sustained resolution of his destructive behaviour and improvement in his tics following bilateral limbic leucotomy. | 2 |
Benign intracranial hypertension after ciprofloxacin administration. Many drugs, including antibiotics, have been implicated in the aetiology of benign intracranial hypertension. We report the development of benign intracranial hypertension after the use of ciprofloxacin in a teenager with cystic fibrosis. | 2 |
The alien hand sign. Localization, lateralization and recovery. The alien hand sign was first described by Brion and Jedynak as a "feeling of estrangement between the patient and one of his hands." The affected hand frequently shows a grasp reflex and an instinctive grasp reaction as well as elements of what Denny-Brown referred to as a "magnetic apraxia" associated with frontal lobe damage. Most notably, however, the affected hand is observed to perform apparently purposive behaviors that are perceived as being outside the volitional control of the patient. The patients interpret the behavior of their own affected limb as being controlled by an external agent. They do not feel that they are initiating or controlling the behavior of the hand and often express dismay at the hand's "extravolitional" activity. The patients attempt to control behavior of the alien hand with the unimpaired hand by forcibly restraining the affected limb, an act that may be termed "self-restriction." In this paper, we report an additional four cases of alien hand sign in right-handed subjects: two involving the right hand and two involving the left hand. In each case, the clinical findings were associated with extensive unilateral damage of the medial frontal cortex of the hemisphere contralateral to the affected hand. Furthermore, the alien movement gradually disappears over the course of 6-12 months after the stroke. These clinical case studies are presented and discussed in the context of the "dual premotoer systems hypothesis," an anatomicophysiological model that proposes that action is organized by two separate but interactive premotor brain systems corresponding to evolutionarily defined medial and lateral cortical moieties. It is hypothesized that the alien mode behavior results from unconstrained activity of the lateral premotor system in the damaged hemisphere. The residual volitional control in the limb occurs through the activity of the intact medial premotor system of the ipsilateral hemisphere. Recovery may occur through extension of these ipsilateral control mechanisms by compensatory changes in subcortical systems controlling hemispheric activation associated with adaptive behavior. This observation may be important in understanding mechanisms involved in motor recovery after stroke. | 4 |
Studies of salt intake in hypertension. What can epidemiology teach us? It has been suggested that small changes in population blood pressure will have a major impact upon the incidence of cardiovascular disease caused by blood pressure elevation. Early reports indicated a close correlation between intercultural differences in salt intake and blood pressure. Before such epidemiological associations can be translated into population advice, certain conditions have to be met. The association has to be validated scientifically, and persuasive evidence has to be produced that the relationship is causal and reversible by changes in salt intake. Further, risk-benefit analysis should indicate that net harm is unlikely. Finally it has to be demonstrated that the population measures being advocated will produce an adequate change in dietary salt intake. The small individual effects upon blood pressure being examined, and the prevailing changes in blood pressure and cardiovascular mortality suggest that data will always fall short of the ideal and therefore that extrapolation will always be necessary. Nevertheless, a review of the present evidence indicates the inadequacies of the available data as a basis for population advice. | 3 |
Five-year experience with triple-drug immunosuppressive therapy in cardiac transplantation. Although triple-drug immunosuppression with a combination of cyclosporine, prednisone, and azathioprine has been shown to improve short-term survival after cardiac transplantation, its long-term effects still are unknown. From December 1983 through December 1988, all patients (N = 139) who underwent orthotopic cardiac transplant at our institution received triple-drug immunosuppressant therapy. Follow-up averaged 32.2 +/- 15.8 months. Twenty-one patients died; 134 survived more than 30 days. Actuarial survival was 92% at 1 year, 85% at 3 years, and 78% at 5 years. Twenty-five episodes of acute graft rejection were diagnosed in 21 of the 139 recipients (0.18 episode per patient). In patients, the incidence of infection was 0.82 episode; 72% of infections were viral, with 10% due to cytomegalovirus. The incidence of coronary artery disease was 10% at 1 year, 25% at 3 years, and 36% at 5 years. Coronary artery disease was responsible for 60% of late deaths. Arterial hypertension developed in 81% of patients, despite relatively well-maintained renal function (serum creatinine, 1.7 +/- 0.3 mg/dl). Skeletal complications occurred in 15.8% and lymphoma in 1.4% of recipients. Complete long-term rehabilitation was achieved in all but two of the surviving patients. These data support the short- and long-term effectiveness of triple-drug therapy. This regimen reduces the incidence of rejection, infection, and lymphoma, as well as the degree of renal failure. However, the incidence of posttransplant coronary artery disease has not been reduced, and graft atherosclerosis represents the major cause of late graft failure and death. | 3 |
Progression through the cell cycle: an overview. Tissues in adults can be maintained at constant mass or they can increase or decrease in size because of imbalances of synthetic and degradative processes acting at the cellular and molecular levels. Some size changes are caused by physiologic conditions to which the tissue must adjust. Alternatively, the balance may be distorted in favor of net tissue increase in pathologic situations such as cancer. Strict regulatory mechanisms are required to keep proliferation responsive to the organism's needs; these mechanisms may be defective in disease. Net tissue proliferation requires repeated rounds of cell duplication in excess of that necessary to counterbalance cell death. Duplication of a cell requires a net doubling of its every molecule and structure. The myriad of molecular events required for cell proliferation such as DNA duplication and its partitioning at mitosis are tightly regulated in normal cells. One may conceive of two classes of molecules: those required for "housekeeping," which constitute the cell's structural and functional machinery, and those such as growth factors, their receptors, and second messengers involved in signal transduction responsible for regulating the activities of the housekeeping molecules. These molecular events and the cascade of processes that control them can be organized within the sequence of the cell cycle. In this brief overview, we illustrate these issues with a few examples taken from very recent discoveries of novel proteins that appear to have major regulatory roles. Most of these results have been obtained with mammalian fibroblasts, but some have originated with discoveries made using two very different yeasts. | 0 |
Growth disturbance in Legg-Calve-Perthes disease and the consequences of surgical treatment. Seventy-two patients with Legg-Calve-Perthes disease were studied to assess the interference with proximal femoral growth as a result of the disease itself and of surgical treatment. Twenty-five patients were treated nonoperatively, 20 were treated by femoral varus derotation osteotomy, and 27 by innominate osteotomy. All patients were studied clinically for evidence of abductor weakness and leg-length discrepancy. They were also studied roentgenographically for evidence of femoral head deformity and trochanteric overgrowth. The overall results showed a 6% incidence of leg-length discrepancy greater than 2 cm after both operative and nonoperative treatment. The articulo-trochanteric distance (ATD) was less than +5 mm in 23% of patients, of which 43% had a positive Trendelenburg sign. A significantly lower mean ATD was found in patients treated by femoral varus osteotomy, which should be avoided in patients over eight years of age. The study also demonstrated a strong association between coxa magna and growth disturbance of the proximal femoral physis manifesting itself as either a leg-length discrepancy or as a low ATD. The significant effects of growth disturbance after treatment must be considered, as well as the sphericity of the healed femoral head, in the final assessment in Legg-Calve-Perthes disease. | 4 |
Extracorporeal renal artery reconstruction for renovascular hypertension. Extracorporeal reconstruction can be applied to the successful repair of stenoses in the distal renal artery and its hilar branches. This study evaluates the short- and long-term results of extracorporeal renal artery reconstruction in 65 patients, including 5 children, with renovascular hypertension who were treated from 1974 through 1989. The mean age of the patients was 37 years (range, 7 to 67 years). The cause of the stenoses was arteriosclerosis in 8 patients, fibrodysplasia in 54 patients, and miscellaneous in 3. Hypertension was severe before treatment with a mean blood pressure of 187/147 mm Hg that was reduced to a mean of 159/102 mm Hg after medical therapy. Ten patients had renal dysfunction. Results were evaluated both at short-term intervals (mean, 7.9 months; 64 patients) and long-term intervals (mean, 5.9 years; 60 patients), after surgery. Blood pressure responses were classified as beneficial (cured/improved) or failures. Anatomic results were evaluated by angiography in 98% of the patients at the short-term interval and in 77% of the patients at the long-term interval. Extracorporeal renal artery surgery was performed on 78 kidneys among 65 patients (unilateral, 45 patients; bilateral, 13 patients; unilateral extracorporeal and contralateral in situ, 7 patients). In most of the cases autologous arterial graft was used for reconstruction. Early in the series one patient died as a result of the operative procedure (1/65, 1.5%). A beneficial blood pressure response occurred in 53 patients (53/65; 82%) at the short-term interval and in 49 patients (49/61; 80%) at the long-term interval, with the average blood pressure at the short-term interval being 138/85 mm Hg and at the long-term interval being 139/85 mm Hg. Renal function improved in all patients with preoperative renal dysfunction. Graft stenosis or occlusion of the main renal artery was neither observed at the short-term interval nor at the long-term interval. However, residual stenoses were observed in 9 of the 163 reconstructed distal branches (5.5%). Extracorporeal renal artery reconstruction with autologous arterial grafts can be effectively applied to lesions of the distal main renal artery and its hilar branches with durable functional results. | 3 |
Total gastrectomy for gastric cancer in the elderly. Of 1070 patients with gastric cancers, 292 patients underwent total gastrectomy during 13 years. Sixty patients were more than 70 years of age and 232 were under 69 years. The incidence of well-differentiated carcinomas and poorly differentiated carcinomas was the same in the elderly patients, whereas the latter was dominant in the young patients. However, there was no significant difference between the two groups regarding location, size, macroscopic patterns, extent of lymph metastases, or stage classification. The rates of preoperative surgical risk factors were significantly different between the two groups (p less than 0.01): 90.0% for the elderly and 34.9% for the young patients. However, the rates of postoperative morbidity and mortality were 31.7% and 3.3% for the elderly and 24.1% and 1.3% for the young patients, respectively, with no significant difference. The 5- and 10-year survival rates after curative total gastrectomy were 48.6% and 23.2% for the elderly compared with 49.4% and 33.6% for the young patients, respectively, with no significant difference. A 5-year survival rate after noncurative operation was 0% for the elderly and 6.4% for the young patients. These results indicate that, when performed for cure, total gastrectomy with systematic lymphadenectomy can provide good long-term results for elderly, as well as young, patients. | 0 |
Extended neck dissection. From the time Crile described radical neck dissection in 1906, this surgical procedure became popular in the management of metastatic cancer in the neck. Over the past two decades, the modified neck dissection has been effectively utilized for conservation of function and cosmesis while achieving the same oncologic goals. However, there are several instances where the above standard procedures are not adequate for resection of malignant tumors. Although there is a definite trend toward conservation procedures, extended neck dissection is often necessary especially in patients with N2 and N3 disease. Apart from the standard structures removed in radical neck dissection, the other structures removed in extended neck dissection include skin, the digastric muscle, hypoglossal nerve, vagus nerve, sympathetic chain, ramus mandibularis, carotid artery, tracheo-esophageal nodes, etc. Over the past seven years, we have performed 40 extended neck dissections. All the patients had N2 or N3 disease in the neck. Nine patients had unknown primaries. Thirteen patients had their primary tumors in the oral cavity and 11 in the laryngopharynx. Five patients had primary tumor in the salivary glands and two patients had metastatic melanoma. Patients who underwent extensive skin excision had pectoralis myocutaneous flap reconstruction. All patients received postoperative radiation therapy. One patient died of cardiac problems 4 weeks after operation. Local control was achieved in 70%. The most difficult region for local control was the disease behind the mastoid process, and the most difficult problems were patients with involvement of the subdermal lymphatics. Our data suggests that there are definite situations where extended neck dissection is indicated with satisfactory local control of the nodal disease. | 0 |
Intermediate hyperhomocysteinemia resulting from compound heterozygosity of methylenetetrahydrofolate reductase mutations. Four subjects with thermolabile methylenetetrahydrofolate reductase (MTHFR) were discovered among 16 "obligate" heterozygotes for severe MTHFR deficiency and their family members. All four subjects had less than 25% of normal mean MTHFR specific activity in lymphocyte extracts. Three of them with normal serum folate and cyanocobalamin had intermediate hyperhomocysteinemia, and one with high serum folate and cyanocobalamin had no excessive accumulation of serum homocysteine. The biochemical features in these four subjects are distinguishable from subjects homozygous for the thermolabile MTHFR, whose specific activity is approximately 50% of the normal mean, and from heterozygotes for severe MTHFR deficiency, in whom the enzyme is thermostable and has a specific activity of about 50% of the normal mean. We propose that these four subjects are genetic compounds of the allele for the severe mutation and the allele for thermolabile mutation of the MTHFR gene. It is postulated that subjects with this genetic compound are more susceptible to the development of intermediate hyperhomocysteinemia despite normal folate and B12 levels. Nonetheless, hyperhomocysteinemia due to this compound heterozygosity is correctable by oral folic acid therapy. | 2 |
Cardiovascular response of a continuous variable rate alfentanil infusion for abdominal aortic surgery. A prospective study was undertaken to determine the cardiovascular response of a continuous alfentanil infusion during abdominal aortic surgery (AAS). Each subject (n = 20) received a beta-blocking drug preoperatively, and was premedicated with oral lorazepam. Anaesthesia was induced with alfentanil 50 micrograms.kg-1 and thiopentone 3 mg.kg-1, and was maintained with a variable rate infusion of alfentanil and 66 per cent nitrous oxide in oxygen. During the infusion, boluses of alfentanil, 7.5 micrograms.kg-1, were administered to maintain heart rate and blood pressure within 20 per cent of awake baseline values. Haemodynamic stability during surgery was achieved with infusion rates varying between 0.5 and 2.5 micrograms.kg-1, which resulted in mean alfentanil serum concentrations ranging from 186 +/- 53 to 315 +/- 98 ng.ml-1. The mean cumulative alfentanil dose was 15.4 +/- 6.2 mg.patient-1 for surgery which lasted an average of 141 +/- 41 min. Throughout surgery, no patient required inhalational anaesthetic agents or vasoactive drugs. Fifteen of the 20 patients had perioperative Holter monitoring. No myocardial ischaemia was detected during the intraoperative period. However, there was a 33 per cent incidence of myocardial ischaemia on the first postoperative day. There were no myocardial infarcts and no deaths. We conclude that in beta-blocked patients undergoing aortic reconstructive surgery, a variable rate alfentanil infusion administered with 66 per cent nitrous oxide provides anaesthesia characterized by good haemodynamic control without the need for supplemental agents or vasoactive drugs. | 3 |
Saphenous nerve entrapment caused by pes anserine bursitis mimicking stress fracture of the tibia. Numerous studies have addressed saphenous nerve entrapment at the level of the adductor canal. In this case, we report an entrapment syndrome located further distally occurring as part of an athletic overuse injury. Distal tibial pain, initially managed as a stress fracture, resolved when a pes anserine bursitis was treated. This was associated with return of saphenous nerve potentials along the tibia. | 2 |
Jejunal immunoglobulin and antigliadin antibody secretion in adult coeliac disease. We compared the local intestinal immunoglobulin (Ig) secretion in six adult patients with coeliac disease and nine control subjects by perfusion of a small bowel segment under an occluding balloon and analysis of the perfusion fluid for the content of Ig and secretory component. The results were compared to the number of Ig-containing plasma cells in the test segment. There was, respectively, a two-fold and a fivefold increase in jejunal secretion rates of IgA (both monomeric and polymeric) and IgM in patients with coeliac disease compared with control subjects. The high IgA and IgM secretion rates parallel the increase of Ig-containing plasma cells in the lamina propria. In contrast, the IgG plasma cell density increase was barely significant in patients with coeliac disease and did not result in a high IgG secretion rate. The jejunal secretion rate of secretory component was significantly increased in patients with coeliac disease and no free dimeric IgA was present in the jejunal fluid. Antigliadin-IgA was detected in the serum and jejunal fluid of the six patients with coeliac disease. Antigliadin-IgA, however, was almost entirely polymeric IgA linked to secretory component in jejunal fluid, whereas 61% was dimeric IgA not linked to secretory component in serum. This result, combined with a raised secretory component secretion rate with no evidence of secretory component saturation, suggests that serum and intestinal antigliadin IgA might be of different origins in coeliac disease. | 1 |
Mortality among aerial pesticide applicators and flight instructors: a reprint [corrected and republished article originally printed in Arch Environ Health 1990 Sep-Oct;45(5):295-302] A cohort mortality study was conducted of male aerial pesticide applicators and flight instructors identified from computerized Federal Aviation Administration medical examination records from 1965-1979. Vital status of 9,677 applicators and 9,727 instructors was determined through January 1, 1980, and standardized mortality ratios (SMRs) were calculated. The overall SMR was 127 for applicators (699 deaths) and 93 for instructors (454 deaths). Fatalities from nonmotor vehicle accidents, mostly aircraft crashes, were in notable excess (SMR = 1,168 among applicators, 630 among instructors), whereas deaths from most chronic diseases, including all cancer, was below expectation (e.g., for arteriosclerotic heart disease, SMR = 52 among applicators and 50 among instructors). The ability of the study to assess cancer risk among applicators was limited by a relatively brief follow-up period. However, 8 applicators (SMR = 171), but only 1 flight instructor (SMR = 24), died of leukemia, and small, nonsignificant risk elevations for some other cancer sites among applicators were observed and warrant continued follow-up. | 0 |
Ovarian suspension in massive ovarian edema. Massive ovarian edema is an uncommon condition found in young women that is speculated to occur as a result of incomplete ovarian torsion. We present the second patient to our knowledge to undergo ovarian suspension as a treatment for this condition. This approach succeeded after ovarian wedge resection had failed. Our patient remained symptom-free at 1 year of follow-up. Ovarian suspension should be considered when this pathologic entity is diagnosed. | 4 |
The timed "Up & Go": a test of basic functional mobility for frail elderly persons. This study evaluated a modified, timed version of the "Get-Up and Go" Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital (mean age 79.5 years). The patient is observed and timed while he rises from an arm chair, walks 3 meters, turns, walks back, and sits down again. The results indicate that the time score is (1) reliable (inter-rater and intra-rater); (2) correlates well with log-transformed scores on the Berg Balance Scale (r = -0.81), gait speed (r = -0.61) and Barthel Index of ADL (r = -0.78); and (3) appears to predict the patient's ability to go outside alone safely. These data suggest that the timed "Up & Go" test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time. The test is quick, requires no special equipment or training, and is easily included as part of the routine medical examination. | 2 |
Hemorrhoidectomy during pregnancy: risk or relief? Acute hemorrhoidal crisis can occur in the pregnant female. When medical therapy fails to relieve pain, operative intervention may be necessary. The surgeon, however, may be reluctant to operate due to potential complications to the mother and fetus. From July 1983 to July 1989, hemorrhoidectomy was performed in 25 of 12,455 pregnant women (0.2 percent) who delivered in our institution. Twenty-two women were in their third trimester, 80 percent were multiparous, and each had a remote history of hemorrhoidal symptoms, including intermittent pain, bleeding, and protrusion. Closed hemorrhoidectomy was performed under local anesthesia. The surgery was directed at removing only symptomatic disease, which included three quadrants in 14 patients, two quadrants in seven patients, and one quadrant in four patients. All patients experienced relief of intractable pain the day after surgery, except one patient who required a hemostatic packing during the immediate post-operative period. There were no other maternal or fetal complications. Subsequent follow-up for anorectal disease ranged from 6 months to 6 years. Six (24 percent) patients required additional hemorrhoid treatment. Hemorrhoidectomy in selected pregnant patients is safe in our experience. | 3 |
An all-polyethylene cementless tibial component. A five- to nine-year follow-up study. An all-polyethylene cementless tibial component was used in 221 total knee arthroplasties. With one exception, failures did not occur before three years. Failure was characterized by medial subsidence of the tibial component. There was abrasion of the polyethylene on the undersurface of all components that failed. Survivorship was seven to nine years (87.1%). This study demonstrated that a flexible cementless component can function well when used with any type of bone. However, abrasion of the polyethylene that occurs from shearing forces is a concern. Polyethylene components need adequate provisions to prevent shearing or need surface treatment to prevent abrasion. | 4 |
Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps. Our experience treating perineal wounds secondary to abdominoperineal resection, either for inflammatory bowel disease or cancer, is presented. A total of 16 patients were treated either on a delayed basis or at the same time as the abdominoperineal resection. All wounds were closed using the inferior gluteal myocutaneous flap. Fifteen of 16 patients have achieved healing, eight of whom had no complications. Only minor revisions or local wound care were required in the remaining patients, with only one patient failing to heal. Our results compare favorably with previous reports of treatment of this difficult problem. | 4 |
Cholinergic stimulation of the pons depresses respiration in decerebrate cats. The injection of carbachol into the pontine tegmentum of decerebrate cats evokes a postural motor atonia that has many of the characteristics of the atonia of natural rapid-eye-movement (REM) sleep (Morales et al. J. Neurophysiol. 57: 1118-1129, 1987). We have used the carbachol-injected decerebrate cat to study the changes in respiratory neuronal activity that accompany the atonia. The activities of representative respiratory motor nerves--phrenic, intercostal, and hypoglossal--and that of a motor branch of C4 were recorded in decerebrate, vagotomized, paralyzed, and artificially ventilated cats. After the microinjection of carbachol, there was a profound suppression of activity in all the nerves and a decrease in respiratory rate. This was a consistent stereotyped response in which the magnitude of the suppression of respiratory-related activity was phrenic (to approximately 65% of control) less than inspiratory intercostal (approximately 50%) less than hypoglossal (approximately 10%) less than expiratory intercostal (approximately 5%). The decrease in respiratory rate (to approximately 70% of control) was caused by a prolongation of both inspiratory and expiratory durations. Complete reversal of the carbachol effect was elicited by the microinjection of atropine into the same site as the carbachol injection. This allowed us to produce a second episode of atonia by the injection of carbachol into the contralateral pons. Thus we have demonstrated the existence of neural pathways originating in the cholinoceptive cells of the pons that have the potential to powerfully and differentially depress various respiratory motoneuronal pools and to reduce the respiratory rate. These pathways are likely to be activated along with the atonia of REM sleep. | 2 |
Physical and psychosocial consequences of total laryngectomy. The incidence and severity of respiratory symptoms after total laryngectomy and their influence on daily living were studied in 59 laryngectomized patients. Daily sputum production was the principal complaint of these patients (98%), followed by coughing (64%) and the need for frequent forced expectoration (more than 5 times a day) in order to clear the airway (57%). Frequent stoma cleaning (more than 5 times a day) was required by 37% of the patients. Significant correlation was found between respiratory symptoms, voice rehabilitation and several aspects of daily living, including fatigue, sleep problems, social contacts and psychological distress. These findings indicate that respiratory symptoms after total laryngectomy are both frequent and troublesome. The development of effective methods for minimizing and/or preventing such respiratory problems would contribute significantly to improving the quality of life of laryngectomized patients. | 4 |
Significance of blasts in low-cell-count cerebrospinal fluid specimens from children with acute lymphoblastic leukemia. The purpose of this study was to determine whether the presence of more than 5% blasts in a differential count of cytocentrifuged cerebrospinal fluid (CSF) with less than 6 leukocytes/microliter was predictive of central nervous system (CNS) relapse in children with acute lymphoblastic leukemia (ALL). A double concentrate method of cytocentrifuge preparation was used to analyze 4543 consecutive CSF specimens from 349 children with ALL between January 1, 1982, and September 30, 1988. One hundred nine CSF specimens from 58 evaluable children had less than 6 leukocytes/microliter and more than 5% blasts on cytocentrifuge differential count (low-cell-count specimen with blasts [LCB]). During the study period, 25 of 332 evaluable children (7.5%) had CNS leukemic recurrence. In 22 of 25 (88%), the CNS relapse was preceded by at least one abnormal low-cell-count CSF specimen. One of 34 patients with a single LCB at diagnosis (3%) had subsequent CNS relapse compared with five of eight patients (62.5%) with a single LCB during remission (P = 0.0002). Of 16 children with two or more LCB during remission, nine (56%) had CNS relapse defined by standard criteria, whereas six additional patients in this group were declared to be in CNS relapse on the basis of their repetitive LCB. Whether diagnosing CNS recurrence earlier in its course based on a modification of the definition of CNS leukemia will change the frequency of subsequent adverse events or make possible decreased intensity of CNS retreatment remains to be determined. | 0 |
Treatment of flexor tenosynovitis of the hand ('trigger finger') with corticosteroids. A prospective study of the response to local injection. We developed a protocol to maximize medical therapy for "trigger finger." Fifty-eight patients with 77 episodes of flexor tenosynovitis of the hand that was resistant to rest, therapy with nonsteroidal anti-inflammatory drugs, and/or splinting were treated with single or multiple injections of depo-methylprednisolone acetate or triamcinolone acetonide. Patients were prospectively followed up for an average of 4.6 years. Results showed that symptoms and signs resolved in 61% after a single injection. Recurrent episodes, after prolonged pain-free intervals, occurred in 27% and were effectively re-treated with injection. In 12% of cases, either injection failed or early recurrence required surgical release. Local adverse reactions to injection, including pain at the injection site, stiffness, ecchymosis, or atrophy of subcutaneous fat, were self-limited. No episodes of postinjection infection or tendon rupture occurred. The medical management of flexor tenosynovitis with local corticosteroid injection(s) is effective in nearly 90% of cases and is free from serious adverse reactions. | 4 |
Microvascular right-to-left pulmonary shunt demonstrated by a radionuclide method. A 37-yr-old man with angiolymphoid hyperplasia (Kimura's syndrome), who had been treated unsuccessfully for suspected asthma, was investigated due to a decrease in arterial oxygen saturation (86%). Right heart catheterization and angiography of the pulmonary artery failed to demonstrate any right-to-left shunts. However, simultaneous scintigraphy over the lungs, kidneys, and head after injection of 150 MBq technetium-99m-labeled macroaggregated albumin i.v. and inhalation of 150 MBq krypton-81m demonstrated a right-to-left shunt in the lungs probably caused by precapillary pulmonary arteriovenous shunts. | 4 |
Mandibular osteomyelitis in a patient with sickle cell anemia: report of case. A case is presented in which mandibular osteomyelitis and mental nerve paresthesia developed in a patient with sickle cell anemia. This infection appeared to precipitate a sickle cell crisis. The mechanisms for these patients' propensity to infection and the diagnosis and management of sickle cell osteomyelitis of the jaws are discussed. | 2 |
Microvascular pedal bypass for salvage of the severely ischemic limb Bypass to the pedal arteries was performed with use of the operating microscope and standard microsurgical technique in 37 patients with severe, chronic ischemia of a lower extremity. Twenty-one patients (57%) had three or more cardiovascular risk factors, and 22 (59%) had diabetes. Preoperative arteriography identified a pedal artery suitable for bypass in all but one patient. The greater or lesser saphenous vein was used in all patients, most frequently as a nonreversed, translocated vein graft. An arm vein was used as part of a composite graft in only one patient. No early deaths occurred, and only one patient had a perioperative myocardial infarction. Although five grafts occluded within 30 days, four were successfully revised, and 36 patients had a patent graft at the time of dismissal from the hospital. At 1 year, the primary graft patency rate (patency without revision) was 60.8%, and the secondary patency rate was 68.8%. One early and six late amputations were performed; the cumulative 1-year limb salvage rate was 82.4%. Grafts with an intraoperative flow rate of 50 ml/min or more had a better patency rate than those with a lower flow rate. The presence of diabetes did not adversely affect long-term patency. Of the 34 patients who were alive at the time of this report, 27 (79%) had a functional foot that allowed ambulation, had no rest pain, and had no substantial loss of tissue. Pedal bypass should be considered for critical, chronic ischemia, even if the patient has an increased surgical risk and advanced distal atherosclerotic disease. | 3 |
Functional character and augmentation of lymphocytes in regional lymph nodes of patients with lung cancer. It appears that lymph node metastases are more frequent in lung cancer than in other cancers because of impaired defensive mechanisms in the regional lymph nodes. However, little is known about the immunologic function of regional lymph node lymphocytes (RLNL) in patients with lung cancer. We have studied the immunologic properties of RLNL in comparison with peripheral blood lymphocytes (PBL). We measured the natural killer (NK) cell activity of RLNL and PBL in patients with lung cancer and found that the NK activity was significantly more depressed in the RLNL than in the PBL. In contrast, interleukin-2 (IL-2) production was markedly higher in the RLNL than in the PBL. The cytotoxic effect of RLNL in nonmetastatic lymph nodes on target cells (such as K562 cells) or PC-3 and PC-10 cells (NK-resistant, human lung cancer of adenocarcinoma and epidermoid carcinoma, respectively) was significantly enhanced by in vitro incubation with recombinant IL-2 (rIL-2). Furthermore, we clarified that both rIL-2 and OK-432, which is a biologic response modifier and IL-2 inducer as well, augmented the cytotoxicity of RLNL and that these effector cells were lymphokine-activated killer (LAK) cells. The depletion of lymphocyte subsets by pretreatment with specific monoclonal antibody showed that the LAK activity in RLNL was mediated by CD3+ and CD8+ cells, whereas the lymphocyte subsets contributing the LAK activity in PBL were CD3+ and CD16+ cells. It was concluded that a majority of the effector cells in RLNL were LAK cells of the cytotoxic T cell population. | 0 |
Bleeding gastroesophageal varices: gastric vein embolization after partial portal decompression. Shunts that decompress the portal vein are effective in the treatment of bleeding esophageal varices. Use of large-caliber portacaval shunts, however, results in the complete decompression of the portal system and the risk of subsequent development of hepatic encephalopathy. Use of small-caliber portacaval shunts results in mild portal hypertension and less frequent hepatic encephalopathy but may increase the risk of recurrent bleeding. Thirty-three patients underwent angiography after partial decompression portacaval shunting (median trans-shunt pressures, 8 mm Hg). Embolization of residual varices, noted in 13 patients, was performed. Results included one complication with no sequelae and no bleeding a mean of 13 months after the procedure was performed. Trans-shunt embolization of esophageal varices effectively prevents bleeding varices after partial portal decompression. | 4 |
Surgical resection of intrinsic brain stem lesions: an overview. A major limitation to the effective treatment of intrinsic mass lesions of the brain stem has been the inability to clearly define the pathological anatomy radiographically. The improved soft tissue resolution offered by magnetic resonance imaging, as compared with axial computed tomography, now makes it possible not only to accurately distinguish anatomical relationships, but also to predict the pathological nature of the lesion. Accordingly, we have been encouraged to pursue a more aggressive approach to intrinsic lesions of the brain stem that appear well circumscribed on magnetic resonance imaging scan. The object of this paper is to report the successful treatment of four intrinsic lesions of the brain stem and to present an overview of the relevant published experience. | 0 |
The symptom sensitivity index: a valuable additional parameter in 24-hour esophageal pH recording. Twenty-four-hour esophageal pH monitoring is useful for the quantitative measurement of gastroesophageal reflux and for the demonstration of a temporal relationship between symptoms and reflux. The symptom index, a numerical score, was developed to quantify the association between symptoms and reflux. Because the symptom index primarily assesses the specificity of a patient's reflux symptoms, we propose to refer to this score as the symptom specificity index. Because of certain limitations of this score, we developed and evaluated a new score, the symptom sensitivity index, that quantifies the subject's sensitivity for reflux. Fifty-two consecutive patients, referred to our laboratory for ambulatory 24-h pH recording were studied. Beside the conventional reflux variables, both indexes were calculated. Although a statistically significant correlation between the indexes was found, discordance between the specificity and sensitivity indexes was seen in 17 patients (33%). Based on the findings in this study we advocate that the symptom sensitivity index should be used, in addition to the symptom specificity index, and incorporated in future pH studies to optimalize the interpretation of the results. | 1 |
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