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Optic nerve gliomas and meningiomas. Optic nerve gliomas are benign astrocytic neoplasms that primarily affect children. The ultimate prognosis for vision is poor. For lesions confined to the optic nerves, long-term survival is excellent, but with involvement of the chiasm and especially of the hypothalamus or third ventricle, prognosis falls significantly. For this group, no form of therapy has proven to be of any benefit. Optic sheath meningiomas are neoplasms arising from arachnoid cap cells. They primarily affect middle-aged adults. Like gliomas, the prognosis for vision is poor, but unlike gliomas, prognosis for life is excellent. | 2 |
Hypertension in African-Americans. A considerable disparity exists between African-Americans and US Caucasians in the incidence, severity, and management of hypertension. As a consequence, overall hypertension-related morbidity and mortality rates are at least threefold to fivefold higher in African-Americans than in Caucasians. Alarmingly high frequencies of stroke, end-stage renal disease, congestive heart failure, and left ventricular hypertrophy occur in African-Americans. To bring this crisis under control will require a renewed commitment to expanded research, improved public health measures, and more effective clinical intervention. Current hypertension control programs must be expanded and adequately funded. In addition, primary prevention of hypertension should be strongly recommended for the US population, especially African-Americans. | 3 |
Coronary angioplasty requiring extraordinarily high balloon inflation pressure. Two cases are presented in which extraordinarily high balloon inflation pressures (20 and 17 atm) were required to successfully dilate a saphenous vein graft stenosis and a right coronary artery stenosis. The clinical application of high balloon inflation pressures and balloon selection is discussed. | 4 |
The electrocardiogram in chronic obstructive pulmonary disease. The electrocardiogram is often abnormal in patients who have chronic obstructive pulmonary disease. The most frequent abnormalities are a rightward P-wave axis (greater than or equal to 70 degrees) and a rightward QRS axis (greater than or equal to 90 degrees). In addition, low voltage in the limb leads, an S1S2S3 pattern, poor R-wave progression, a posterior-superior terminal QRS vector or other changes may be present. Transient atrial and ventricular dysrhythmias are common. Knowledge of the usual electrocardiographic manifestations of chronic obstructive pulmonary disease enables the clinician to recognize uncharacteristic abnormalities, which often represent the effects of superimposed illnesses or drug toxicity. | 3 |
Spongiform encephalopathy transmitted experimentally from Creutzfeldt-Jakob and familial Gerstmann-Straussler-Scheinker diseases. A comparison was made of the effects of experimental intracerebral inoculation into marmosets of brain homogenates from a case of Creutzfeldt-Jakob disease (CJD) and from a member of the Wo. family with cerebral amyloid and spongiform encephalopathy--the Gerstmann-Straussler-Scheinker (GSS) syndrome. All the inoculated marmosets developed spongiform encephalopathy (SE) after incubation times of 20-23 months in the CJD group and 25-32 months in the GSS group. Subsequent passage from 1 affected animal in each group resulted in SE developing after 17 months incubation. In every animal inoculated with CJD or GSS material and in the 2 passage experiments the most severely affected region of the brain was the thalamus which in all cases was almost totally occupied by vacuoles. Other grey matter masses were less severely and less consistently affected. Vacuolation was observed in the cerebellar granule cell layer as well as in the molecular layer and the brain stem was finely vacuolated in all cases. There were only minor and inconsistent differences between the disease transmitted from CJD compared with GSS and some differences between the original transmissions and the SE caused by passaged inocula. Severe astrocytic gliosis accompanied the spongiform changes but no amyloid was identified in any of the marmosets with experimentally transmitted disease. The pathogenesis of the spongiform change in the thalamus was studied in a series of marmosets by light and electron microscopy 3-22 months after the intracerebral inoculation of CJD or GSS homogenates and was compared with controls. Dilated irregularly-shaped cisternae and the large complex vacuoles typical of SE, present in abundance after 18 and 22 months incubation, were considered most probably to be derived from cisternae of neuronal smooth endoplasmic reticulum. | 2 |
Long-term follow-up review of 31 children with severe closed head trauma. Thirty-one children aged 3 to 15 years were followed for 5 to 11 years after suffering severe closed head trauma which caused coma for 1 week or more (median duration of coma 3 weeks). One patient remained in a persistent vegetative state until his death 9 years later. The other 30 recovered consciousness and were discharged. All suffered diminution of their abilities, and 24 of them had major permanent disability. The most common motor disabilities were pure spastic hemiparesis (seven cases), basal ganglia syndromes (four cases), ataxia (three cases), and a combination of hemiparesis and ataxia (five cases). Of the 30 patients, 26 regained independent ambulation, seven were epileptic, and 14 were dysarthric in various degrees. Only 10 had the cognitive ability to profit from the normal educational system, and none had attempted postsecondary education. Social problems were common. The worst outcomes were associated with intracranial bleeding and/or brain contusion seen on computerized tomography (CT) scans at the acute stage; the best were associated with normal CT scans. The degree of residual disability in these children seems no less than that of adults with trauma of similar severity. | 2 |
Effects of vagal stimulation on experimentally induced seizures in rats. Repetitive stimulation of the vagus nerve inhibits chemically induced seizures in dogs. We report here the results and conclusions from studies designed to answer some of the immediate questions raised by this finding. (1) Maximal stimulation of vagal C fibers at frequencies greater than 4 Hz prevents or reduces chemically and electrically induced seizures in young male rats. (2) Antiepileptic potency is directly related to the fraction of vagal C fibers stimulated. (3) Vagal stimulation shortens but does not shut down a chemical seizure once it has begun. (4) In rats, optimal stimulus frequency is approximately 10-20 Hz; duration of stimulus, 0.5-1 ms; and stimulus strength, 0.2-0.5 mA/mm2 of nerve cross-section. These results, when taken together with similar results obtained from dogs, monkeys, and humans, strongly suggest that periodic stimulation of the vagus nerve using appropriate stimulation parameters is a powerful method for preventing seizures. The data from the literature suggest that the antiepileptic actions of vagal stimulation are largely mediated by widespread release of GABA and glycine in the brainstem and cerebral cortex. The probable pathway is via projections from the nucleus of the solitary tract to the reticular formation and thence by diffuse projections to the cortex and other areas. Intermittent vagal stimulation has the potentiality of reducing the number and/or the intensity of seizures in patients with intractable epilepsy. These results indicate that feasibility studies in humans should be continued and expanded. | 2 |
Tricuspid valve papillary fibroelastoma: echocardiographic characterization. We report a tricuspid valve papillary fibroelastoma initially detected by transthoracic two-dimensional echocardiography and subsequently characterized by transesophageal two-dimensional echocardiography. The mass was excised during open heart operation, and the diagnosis was verified grossly and histopathologically. Transesophageal echocardiography usually provides images far superior to those from transthoracic echocardiography and may be a useful adjunct for intraoperative localization of intracardiac tumors for excision. | 3 |
The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula. Complex perineal fistula and persistent perineal sinus are difficult to treat. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal approach. Ten patients were reconstructed by a rectus abdominis myocutaneous flap (n = 7), rectus abdominis muscle flap (n = 2), and omental graft (n = 1). Primary healing was achieved in all cases. A median follow-up of 18 months (range 6-54 months) has shown no recurrence of perineal disease or associated abdominal incisional hernia. There were no perioperative deaths. We propose that the rectus abdominis myocutaneous flap is indicated if large amounts of perineal skin has to be sacrificed. When less skin is removed a repair with greater omentum or rectus muscle alone is adequate. The abdominoperineal approach together with filling the residual pelvic cavity with well-vascularized tissue allows definitive treatment to be carried out in one stage. | 1 |
Ponderal index as a predictor of postoperative complications. Four hundred sixty-eight patients undergoing elective surgery were prospectively followed for the development of postoperative complications. There was a trend toward increasing complication rate with a lower ponderal index. However, lower ponderal indices were associated with increasing rates of diabetes mellitus and hypertension. Of these patients, forty cases with postoperative complications were matched to 40 control cases for sex, age, concomitant illness and operation performed. The cases of postoperative complications had a statistically significantly lower ponderal index than the controls (11.98 versus 12.43). The increased risk of postoperative complications in those patients with a ponderal index of less than 11 was 3.36, and less than 13 was 3.44. Surgeons who treated patients with lower ponderal indices need to have a high index of suspicion for the development of postoperative complications in these patients. | 3 |
Selective G to T mutations of p53 gene in hepatocellular carcinoma from southern Africa Hepatocellular carcinoma (HCC) is a prevalent cancer in sub-Saharan Africa and eastern Asia. Hepatitis B virus and aflatoxins are risk factors for HCC, but the molecular mechanism of human hepatocellular carcinogenesis is largely unknown. Abnormalities in the structure and expression of the tumour-suppressor gene p53 are frequent in HCC cell lines, and allelic losses from chromosome 17p have been found in HCCs from China and Japan. Here we report on allelic deletions from chromosome 17p and mutations of the p53 gene found in 50% of primary HCCs from southern Africa. Four of five mutations detected were G----T substitutions, with clustering at codon 249. This mutation specificity could reflect exposure to a specific carcinogen, one candidate being aflatoxin B1 (ref. 7), a food contaminant in Africa, which is both a mutagen that induces G to T substitution and a liver-specific carcinogen. | 4 |
Are ioxaglate and iopamidol equally safe and well tolerated in cardiac angiography? A randomized, double-blind clinical study. A randomized, double-blind, parallel-group study was performed in 50 patients undergoing left ventriculography and coronary arteriography to evaluate ECG changes and the effects on left ventricular function of a low-osmolar ionic contrast agent, ioxaglate, as compared with a low-osmolar nonionic contrast medium, iopamidol. Twenty-five patients received ioxaglate (group 1) and 25 patients received iopamidol (group 2). All patients underwent 48 hours of continuous ECG recording beginning 24 hours before the cardiac catheterization. Left ventricular systolic and end-diastolic pressure, peak positive dp/dt, and dp/dt/P ratio were measured immediately before and after left ventriculography and 3 minutes later. Left ventricular systolic pressure did not change after injection of either contrast medium. Left ventricular end-diastolic pressure increased by 30% in group 1 (p less than 0.01) and by 22% in group 2 (p less than 0.01) immediately after left ventriculography. A further increase by 45% in group 1 (p less than 0.01) and by 24% in group 2 (p less than 0.01) was observed 3 minutes later. No differences were observed between values obtained in the two groups. Peak positive dp/dt did not change immediately after injection of either contrast medium but decreased by 5% (not significant) in group 1 and by 7% (p less than 0.02) in group 2 three minutes after left ventriculography. There were no significant differences between the two groups. Analysis of continuous 48-hour ECGs showed that both ioxaglate and iopamidol induced a slight increase (by 8% and 7%, respectively; p less than 0.05) in heart rate during injection with early and complete recovery. | 3 |
Contrast venography in patients with very edematous feet: use of transdermal illumination to aid in vein puncture. Contrast venography can be technically difficult or impossible in patients with very edematous feet. The authors report a simple technique that uses transdermal illumination of the edematous subcutaneous tissue to enable visualization of a vein and also guide the needle into the vein. This technique has been used successfully in eight patients in whom conventional attempts at vein puncture had failed. | 4 |
Channel specificity in antiarrhythmic drug action. Mechanism of potassium channel block and its role in suppressing and aggravating cardiac arrhythmias. Although work on class III antiarrhythmics remains at an early stage, these agents still appear to possess greater efficacy and less proarrhythmia than conventional class I agents in those experimental arrhythmia models considered to be most representative of the clinical situation. Although prolongation of repolarization carries with its own tendency for pause-dependent arrhythmogenesis (i.e., torsade de pointes), available data suggest that this may be a function of nonspecificity in potassium channel block rather than a general characteristic of class III activity. The availability of new and more selective blockers of specific cardiac potassium channels under development as class III agents have already helped to clarify basic questions about the ionic mechanism of repolarization in the heart, and one hopes that a growing clinical data base will eventually determine the relative safety and efficacy of these agents in preventing symptomatic and life-threatening arrhythmias. | 4 |
Splicing defect at the ornithine aminotransferase (OAT) locus in gyrate atrophy. Gyrate atrophy (GA), a recessive eye disease involving progressive vision loss due to chorioretinal degeneration, is associated with the deficiency of the mitochondrial enzyme ornithine aminotransferase (OAT), with consequent hyperornithinemia. We and others have reported a number of missense mutations at the OAT locus which result in GA. Here we report a GA patient of Danish/Swedish ancestry in whom one OAT allele produces an mRNA that is missing a single 96-bp exon relative to the normal mRNA. Polymerase-chain-reaction amplification and sequencing revealed a 9-bp deletion covering the splice acceptor region of exon 5, resulting in the absence of exon 5 sequences from the mRNA with no disruption to the reading frame. This mutation, which was not present in 15 other independent GA patients, adds to the array of allelic heterogeneity observed in GA and represents the first example of a splicing mutation associated with this disorder. | 4 |
Impaired polymorphonuclear leucocyte function in patients undergoing hepatectomy: adenylate energy charge and superoxide anion production in relation to hepatic mitochondrial redox state. Patients undergoing hepatectomy have an increased susceptibility to infection. We therefore studied the energy metabolism of the polymorphonuclear leucocyte (PMN), focusing on energy charge and function, especially superoxide anion (O2-) generation, in relation to the hepatic mitochondrial redox state. By labelling the PMN adenine nucleotide pool with radioactive adenine and by superoxide dismutase-inhibitable reduction of ferricytochrome c, the energy charge and O2- production was measured in 18 patients with hepatoma (non-cirrhotic, seven; cirrhotic, 11) undergoing hepatectomy. Their arterial ketone body ratios (KBRs), reflecting the hepatic mitochondrial redox potential, were above 0.7 before operation. After surgery, the 18 patients were divided into two groups: group A, KBR greater than 0.7, n = 10; and group B, KBR less than 0.7, n = 8. The energy charge and O2- release in group B decreased significantly from preoperative values (P less than 0.001 and P less than 0.01 respectively) and when compared with group A (P less than 0.05 and P less than 0.01 respectively). These results suggest that impaired hepatic energy metabolism (KBR less than 0.7) in hepatectomized patients leads to impaired energy charge and O2- production in the PMNs. | 0 |
A randomized trial of the effect of three non-steroid anti-inflammatory agents in ameliorating cancer-induced fever. Paraneoplastic fever is well known, and is not an uncommon problem in daily practice. In an effort to ameliorate tumour-induced fever we randomized 48 patients to receive three different non-steroid anti-inflammatory drugs: Naproxen (500 mg d-1), Indomethacin (75 mg d-1) or Diclophenac sodium (75 mg d-1). All patients had solid tumours, and microbial infection had been excluded. All three drugs were equally effective in bringing the temperature down to normal for a period of 30-33 d. Naproxen had the most rapid effect. In cases of fever relapse with the first drug, when the other two drugs were given instead, both proved equally effective. No side-effects were observed. We conclude that Naproxen, Indomethacin and Diclophenac sodium are equally effective in ameliorating paraneoplastic fever. In relapse, a second drug given subsequently can be effective as well. | 4 |
Utility of computed tomography for surveillance of small abdominal aortic aneurysms. Preliminary report. To assess the ability of computed tomography to predict the potential for expansion of small abdominal aortic aneurysms, we analyzed the computed tomographic scans of 30 patients who had two or more abdominal computed tomographic scans at least 6 months apart between 1979 and 1989. Clinical variables and 10 defined objective characteristics of computed tomography were evaluated. Twenty-five men and five women with abdominal aortic aneurysms ranging from 30 to 64 mm (mean, 45 mm) were followed up with serial computed tomographic scans for a mean (+/- SE) of 26 +/- 3 months. In 19 patients, enlargement of aneurysm diameter of 3 mm or more on serial computed tomographic scans was noted, whereas in 11, there was little or no expansion. Of the clinical variables studied, only serum cholesterol correlated with an increased risk of expansion. Thrombus area, measured by computed tomography, was 7.3 +/- 0.9 cm2 in enlarging aneurysms vs 4.3 +/- 0.9 cm2 in stable aneurysms. Based on these preliminary data, we conclude that computed tomography may provide valuable information about the likelihood of future expansion of small abdominal aortic aneurysms. | 3 |
Potential value of hormone receptor assay in carcinoma in situ of breast. The estrogen receptor (ER) expression of invasive breast cancer has been extensively studied both biochemically and with specific monoclonal antibodies against ER. Relatively few studies have attempted to characterize ER pattern in breast carcinoma in situ (CIS) and in other premalignant lesions. In the current study, the authors investigated the pattern of ER expression in 62 cases of breast CIS, 30 of which had a component of invasive cancer, and 36 cases of atypical hyperplasia. Paraffin sections of formalin-fixed breast tissue underwent enzyme pretreatment to expose nuclear antigenic sites as previously described. Breast tissues then underwent estrogen immunocytochemical assay using specific monoclonal antibodies (Abbott Laboratory, Chicago, IL). The cases were evaluated for heterogeneity, intensity of staining, and percentage of ER-positive cells. An attempt was made to study the relation between the pattern of ER expression, nuclear pleomorphism, and type of CIS. The results of ER immunocytochemical assay showed positive nuclear staining for ER in 75% of the CIS, 73% of CIS with invasive cancer, and 100% of atypical hyperplasias. ER expression in CIS agreed with that in the invasive carcinoma in 29 of 30 cases. This study also suggests that comedocarcinoma has a higher incidence of negative ER expression than the other types of CIS, particularly when it is associated with significant nuclear pleomorphism. There was no significant difference in ER tumor heterogeneity between premalignant and malignant lesions. | 0 |
Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. The diagnostic yield of transesophageal and transthoracic echocardiography for identifying a cardiac source of embolism was compared in 79 patients presenting with unexplained stroke or transient ischemic attack. There were 35 men and 44 women with a mean age of 59 years (range 17 to 84); 52% had clinical cardiac disease. Both transthoracic and transesophageal echocardiograms were performed using Doppler color flow and contrast imaging. Transesophageal echocardiography identified a potential cardiac source of embolism in 57% of the overall study group compared with only 15% by transthoracic echocardiography (p less than 0.0005). Compared with transthoracic echocardiography, transesophageal echocardiography more frequently identified atrial septal aneurysm associated with a patent foramen ovale (9 versus 1 of 79 patients, p less than 0.005), left atrial thrombus or tumor (6 versus 0 of 79 patients, p less than 0.05) and left atrial spontaneous contrast (13 versus 0 of 79 patients, p less than 0.0005). All cases of left atrial thrombus or spontaneous contrast were identified in patients with clinically identified cardiac disease. In the 38 patients with no cardiac disease, transesophageal echocardiography identified isolated atrial septal aneurysm and atrial septal aneurysm with a patent foramen ovale more frequently than transthoracic echocardiography (8 versus 2 of 38 patients, p less than 0.05). The two techniques had a similar rate of identifying apical thrombus and mitral valve prolapse. Overall, transesophageal echocardiography identified abnormalities in 39% of patients with no cardiac disease versus 19% for transthoracic echocardiography (p less than 0.005). Thus, transesophageal echocardiography identifies potential cardiac sources of embolism in the majority of patients presenting with unexplained stroke. | 2 |
Surgical management of nonparasitic cystic liver disease. We report clinical features, surgical management, recurrences, and follow-up study of 12 patients with simple hepatic cyst, 11 patients with polycystic liver disease, and 19 patients with cystadenoma who were surgically treated over a 25-year period. The median age of patients was 48 years, and 37 women and 5 men were in the series. The most common presenting symptom and physical finding were chronic abdominal pain and tenderness in the right upper quadrant. The most commonly associated disease was polycystic kidney disease, which was an associated finding in 5 of the 11 patients with polycystic liver disease (45%). The most valuable diagnostic studies in all groups were computed tomography and ultrasonography. The location of the disease was bilobar in patients with polycystic liver disease, with a right lobe predominance in 18% of patients. The right lobe was also predominant in 83% of patients with simple hepatic cyst and 58% of patients with cystadenoma. Of all solitary cystic lesions in the left lobe, 75% of them were cystadenomas. Of the 66 surgical procedures performed, aspiration was associated with a failure rate of 100%; partial excision, a failure rate of 61%; and total excision and liver resection, a failure rate of 0%. Orthotopic liver transplantation was performed in three patients and was associated with two early deaths. Partial excision relieved symptoms in three patients (43%) with polycystic liver disease. Total excision, enucleation, or liver resection with cyst(s) is the treatment of choice for non-parasitic cystic lesions of the liver. | 0 |
Primary biliary cirrhosis. Quantitation of autoantibodies to purified mitochondrial enzymes and correlation with disease progression. Primary biliary cirrhosis is characterized by the presence of antimitochondrial antibodies. Recently, six of the autoantigens have been identified as components of the 2-oxo acid dehydrogenase multienzyme complexes located within mammalian mitochondria. Immunoblotting studies have shown that two of these components, namely E2 and protein X of pyruvate dehydrogenase complex, are the major antigenic polypeptides recognized by autoantibodies. This study shows the development of an enzyme-linked immunosorbent assay to detect and quantitate antibodies to these two purified antigens. Coded serum samples from 166 patients with primary biliary cirrhosis, 140 patients with other liver and/or autoimmune disease, and 52 normal women were analyzed for reactivity using this immunoassay. These results indicate that this rapid, simple method has a 93% sensitivity and 96% specificity in the diagnosis of primary biliary cirrhosis. The titer of immunoglobulin G autoantibodies correlated not only with antimitochondrial antibody titer measured by indirect immunofluorescence (P less than 0.0001) but also with histological stage of disease (P less than 0.04) and prognostic biochemical variables such as higher serum bilirubin and lower serum albumin levels (P = 0.038 and 0.028, respectively). There was no significant correlation between titer of autoantibodies and serum globulin or immunoglobulin G levels, indicating that the positive correlation with disease progression was not secondary to hypergammaglobulinemia. | 1 |
Intraoperative ultrasonic imaging of the ascending aorta in ischemic heart disease. In an attempt to locate any atherosclerotic lesion in the ascending aorta and to prevent embolization, intraoperative B-mode ultrasonography was performed in 100 patients with ischemic heart disease (31 women and 69 men). Ultrasonography was carried out with a 10-MHz probe placed directly on the ascending aorta. Ultrasonic imaging demonstrated an atherosclerotic lesion in the lower half of the aorta in 76 patients (76%), a lesion in the upper half of the aorta in 89 patients (89%), and a lesion at the orifice of the innominate artery in 99 patients (99%). Prospective palpation identified an atherosclerotic lesion in 12 (25%) of 48 patients. Thoracic computed tomography in 79 patients showed calcification in the lower half of the aorta in 6 patients (7.6%) and in the upper half of the aorta in 11 (13.9%). Palpation and thoracic computed tomography underestimated the frequency of atherosclerotic lesions. Intraoperative ultrasonography accurately identified atherosclerotic disease. This technique allows the surgeon to modify cannulation, aortic clamping, and operative technique to reduce the risk of perioperative stroke due to embolization of atherosclerotic debris from the ascending aorta. | 2 |
The relationship of "high risk" mammographic patterns to histological risk factors for development of cancer in the human breast. In the UK Trial for the Early Detection of Breast Cancer in Nottingham, 119 women were identified as having fibrocystic change with epithelial hyperplasia or in situ carcinoma. Their mammograms were classified according to Wolfe's criteria and the corresponding histology for each patient was classified for degrees of epithelial hyperplasia, atypia and in situ neoplasia using Page's criteria. A control population of patients presenting for breast screening was used to represent the general population. No correlation was found between the four mammographic Wolfe patterns, N1, P1, P2 and DY and histological evidence of epithelial hyperplasia, atypia or in situ carcinoma. A further study was carried out to determine histological features of Wolfe pattern, using radiological examination of resected breast tissue. The variation in Wolfe pattern was related to the distribution of fibrous and adipose tissue in the breast interlobular stroma and appeared to have no relationship to epithelial parenchymal content. This information does not support the hypothesis that radiographic densities of P2 and DY patterns correspond to high risk epithelial proliferation. | 0 |
Results of the arterial switch operation in patients with transposition of the great arteries and abnormalities of the mitral valve or left ventricular outflow tract. Between January 1983 and October 1989, 290 patients underwent an arterial switch operation for transposition of the great arteries; 30 (10.3%) of the patients had abnormalities of the left ventricular outflow tract or mitral valve, or both. These abnormalities included isolated pulmonary valve stenosis (n = 9), septal (dynamic) subpulmonary stenosis (n = 5), anatomic (fixed) subpulmonary stenosis (n = 7), abnormal mitral chordae attachments (n = 2) or a combination of abnormalities (n = 7). There were two early deaths, one of which was due to previously unrecognized mitral stenosis and a subpulmonary (neo-aortic) membrane and one late death due to presumed coronary obstruction. Of the nine patients with pulmonary valve abnormalities due to either a bicommissural (n = 5) or a thickened tricommissural (n = 4) valve, only one underwent valvotomy. Peak systolic ejection gradients in these nine patients measured preoperatively ranged from 0 to 50 mm Hg. At follow-up study 5 to 30 months postoperatively, the neo-aortic valve gradient was less than or equal to 15 mm Hg in all patients; three patients had mild neo-aortic regurgitation. Preoperative gradients may overestimate the degree of obstruction because of the increased pulmonary blood flow present in transposition. No patient with "dynamic" subpulmonary obstruction before the arterial switch operation had a surgical procedure performed on the left ventricular outflow tract; none had evidence of subaortic obstruction after the arterial switch. | 3 |
Biplane transesophageal echocardiography: technique, image orientation, and preliminary experience in 131 patients. Transesophageal echocardiography with use of a uniplane phased-array transducer with a transverse or horizontal scanning plane has become a well-established tool for evaluating cardiovascular diseases. Recent introduction of biplane probes has enhanced the diagnostic capability of this imaging technique. This article discusses the technique of biplane transesophageal echocardiographic examination and image orientation. The diagnostic value and advantages of various biplane transesophageal images of the heart, aorta, and aortic arch from various esophageal positions are described. | 3 |
Voltage criteria of left ventricular hypertrophy in sudden and nonsudden coronary artery disease mortality: the Italian section of the Seven Countries Study. It is unclear whether sudden or nonsudden death can be predicted independently from other risk factors for coronary artery disease (CAD). Therefore, this investigation was undertaken to measure 12-lead QRS voltage sum, a recently proposed (Am J Cardiol 1985;55:485-494) index of left ventricular (LV) hypertrophy, and its ability to predict either subsequent sudden (less than 2 hours) or nonsudden CAD death during 20 to 23 years of follow-up in 1,588 middle aged men (40 to 61 years old) from 2 cohorts of the Italian section of the Seven Countries Study who were free of demonstrable CAD (at entry examination in 1962). The Sokolow-Lyon and the modified Sokolow-Lyon indexes, 2 standard electrocardiographic methods to detect LV hypertrophy were also measured and compared. During follow-up, 67 patients died suddenly and 87 died a nonsudden CAD death. In the Cox proportional-hazards model, age, mean blood pressure, heart rate, body mass index, cholesterol, physical activity, smoking habit, ST-T alterations (Minnesota codes 4.1 to 4.3 together with 5.1 to 5.3) and the 3 electrocardiographic indexes, all measured at the time of enrollment into the study, were included. The 12-lead QRS voltage sum retained significant and independent relation to sudden death (t = 2.00); Sokolow-Lyon index entered the Cox solution for nonsudden CAD death but the association was inverse (t = -2.10). ST-T alterations were significantly associated only with nonsudden CAD death (t = 2.19). Thus, in addition to several known risk factors, measurement of 12-lead QRS voltage sum in middle-aged men without clinical evidence of heart disease may help identify subjects at an increased risk of sudden death; nonsudden CAD death is predicted by Sokolow-Lyon index and by ST-T alterations. The usefulness of these indexes needs to be tested in different populations. | 3 |
Gaze-evoked visual seizures in nonketotic hyperglycemia. Focal motor seizures are commonly a symptom of nonketotic hyperglycemia (NKH). Posture-induced motor seizures are less common but have been reported in some patients with this disorder. We report the first case of gaze-evoked sensory (visual) seizures in nonketotic hyperglycemia. Both seizures and ictal EEG findings disappeared shortly after hyperglycemia was corrected. | 2 |
Multiple myeloma and bullous lichenoid lesions: an unusual association. Many associations of lichenoid reactions have been described but this case appears to be a previously unreported association--with multiple myeloma. This case also demonstrates the necessity of a mucosal biopsy with adequate hematologic and serologic investigations to obtain a definitive diagnosis. | 4 |
Angiographic follow-up after placement of a self-expanding coronary-artery stent BACKGROUND. The placement of stents in coronary arteries after coronary angioplasty has been investigated as a way of treating abrupt coronary-artery occlusion related to the angioplasty and of reducing the late intimal hyperplasia responsible for gradual restenosis of the dilated lesion. METHODS. From March 1986 to January 1988, we implanted 117 self-expanding, stainless-steel endovascular stents (Wallstent) in the native coronary arteries (94 stents) or saphenous-vein bypass grafts (23 stents) of 105 patients. Angiograms were obtained immediately before and after placement of the stent and at follow-up at least one month later (unless symptoms required angiography sooner). The mortality after one year was 7.6 percent (8 patients). Follow-up angiograms (after a mean [+/- SD] of 5.7 +/- 4.4 months) were obtained in 95 patients with 105 stents and were analyzed quantitatively by a computer-assisted system of cardiovascular angiographic analysis. The 10 patients without follow-up angiograms included 4 who died. RESULTS. Complete occlusion occurred in 27 stents in 25 patients (24 percent); 21 occlusions were documented within the first 14 days after implantation. Overall, immediately after placement of the stent there was a significant increase in the minimal luminal diameter and a significant decrease in the percentage of the diameter with stenosis (changing from a mean [+/- SD] of 1.88 +/- 0.43 to 2.48 +/- 0.51 mm and from 37 +/- 12 to 21 +/- 10 percent, respectively; P less than 0.0001). Later, however, there was a significant decrease in the minimal luminal diameter and a significant increase in the stenosis of the segment with the stent (1.68 +/- 1.78 mm and 48 +/- 34 percent at follow-up). Significant restenosis, as indicated by a reduction of 0.72 mm in the minimal luminal diameter or by an increase in the percentage of stenosis to greater than or equal to 50 percent, occurred in 32 percent and 14 percent of patent stents, respectively. CONCLUSIONS. Early occlusion remains an important limitation of this coronary-artery stent. Even when the early effects are beneficial, there are frequently late occlusions or restenosis. The place of this form of treatment for coronary artery disease remains to be determined. | 4 |
Distribution of bony metastases in prostatic carcinoma. Fifty-five prostate cancer and 55 breast cancer patients with positive bone scintigrams were studied. The pattern of spread in the axial skeleton and pelvis showed differences between the 2 groups. This difference was not related primarily to bone volume at the site of metastasis. The difference in distribution of bony metastases between breast and prostate is explained by our knowledge of Batson's vertebral venous plexus. | 0 |
Expression of a soluble and functional form of the human beta 2 integrin CD11b/CD18. Polymorphonuclear cells and monocytes (phagocytes) are a critical component of host defense against infections. However, these cells also play a significant role in host tissue damage in many noninfectious diseases, such as ischemia-reperfusion injury syndromes and rejection of transplanted organs. The leukocyte adhesion molecule family CD11/CD18 (beta 2 integrins) is critical to the function of polymorphonuclear cells and monocytes in inflammation and injury. Inherited deficiency of CD11/CD18 impairs phagocyte chemotaxis, adhesion and transmigration across endothelium, and clearance of invading microorganisms through phagocytosis and cell-mediated killing. Furthermore, murine monoclonal antibodies directed against the CD11b/CD18 (CR3) heterodimer have been shown to reduce, by 50%-80%, phagocyte-mediated ischemia-reperfusion injury in several organ systems, such as the myocardium, liver, and gastrointestinal tract and to inhibit development of insulin-dependent diabetes mellitus in nonobese diabetic (NOD) mice. Expression of CD11b/CD18 in a soluble and functional form might therefore be potentially useful as an anti-inflammatory agent. We have now expressed a recombinant soluble heterodimeric form of this human beta 2 integrin, normally expressed as two noncovalently associated membrane-bound subunits. The secreted receptor exhibited direct and specific binding to its ligand, iC3b, the major complement C3 opsonin, and inhibited binding of polymorphonuclear cells to recombinant interleukin 1-activated endothelium. | 4 |
The legal implications of dietary fats: risks of cardiovascular disease and the duty of food manufacturers. The arguments for a warning on foodstuffs open new ground in product liability. Some of the dangers of fat-laden foods have been apparent for many years and are widely known to the public. Other aspects of fat consumption, specifically hidden fats, such as saturated fats, have only recently been explored, and are known to a limited segment of the population at risk. Negligence and warranty theories are too narrow to encompass this situation, wherein the benefits and risks of a product are not well defined and not easily separable. Some warning about the dangers resulting from fat ingestion is necessary, but may be adequately dispensed by ingredient labeling. If consumers are aware of the potential for harm, then they are assuming a substantial portion of the risk. How risk-free can we, or should we, make our society? The marketplace is the appropriate venue for determining the acceptance of saturated-fat-containing products by our society. Clear and open labeling policies will allow consumers to weigh the relative advantages and disadvantages of lower fat intake. Warnings of fat content need not be extreme, but should disclose the possible physiological outcome of the heavy ingestion of saturated fat. | 3 |
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. | 4 |
Unconjugated bilirubin and cholesterol gallstone formation. Cholesterol gallstones usually have small amounts of pigment at their centers and often have diffuse pigmentation or pigmented layers alternating with cholesterol layers and/or pigmented rims associated with calcium carbonate (eggshell calcification). The pigments are primarily monomeric calcium salts of unconjugated bilirubin anions and/or an insoluble, black, network polymer of tetrapyrroles. Bilirubin presumably can precipitate only if bile is supersaturated with calcium bilirubinates. Among various in vitro model systems, the aqueous solubilities and pK'a values for unconjugated bilirubin differ greatly. It is therefore not known whether normal bile is saturated with unconjugated bilirubin. However, all systems indicate that unconjugated bilirubin is solubilized by binding to bile salt monomers and oligomers, as well as micelles; marked metastable supersaturation of unconjugated bilirubin can occur in the presence of bile salt micelles, and both pK'a values of unconjugated bilirubin are greater than 6.0, probably because of internal hydrogen-bonding of the--COOH groups. Lecithin decreases equilibrium solubilization of unconjugated bilirubin crystals but enhances metastable supersaturation of unconjugated bilirubin. Calcium ions form insoluble salts with unconjugated bilirubin monoanions and dianions but soluble complexes with bilirubin conjugates. The solubility products of the calcium bilirubinate salts suggest that normal hepatic bile is not saturated with CaB or Ca(HB)2 but that gallbladder bile may be supersaturated with Ca(HB)2. | 1 |
Outcome of renal replacement treatment in patients with diabetes mellitus. OBJECTIVE--To compare the outcome of renal replacement treatment in patients with diabetes mellitus and in non-diabetic patients with end stage renal failure. DESIGN--Retrospective comparison of cases and matched controls. SETTING--Renal unit, Western Infirmary, Glasgow, providing both dialysis and renal transplantation. PATIENTS--82 Diabetic patients starting renal replacement treatment between 1979 and 1988, compared with 82 matched non-diabetic controls with renal failure and 39 different matched controls undergoing renal transplantation. MAIN OUTCOME MEASURES--Patient characteristics, history of smoking, prevalence of left ventricular hypertrophy and myocardial ischaemia at start of renal replacement treatment; survival of patients with renal replacement treatment and of patients and allografts with renal transplantation. RESULTS--The overall survival of the diabetic patients during the treatment was 83%, 59%, and 50% at one, three, and five years. Survival was significantly poorer in the diabetic patients than the controls (p less than 0.001). Particularly adverse features for outcome at the start of treatment were increasing age (p less than 0.01) and current cigarette smoking (relative risk (95% confidence interval) 2.28 (0.93 to 4.84), p less than 0.05). Deaths were mainly from cardiac and vascular causes. The incidence of peritonitis in patients on continuous ambulatory peritoneal dialysis was the same in diabetic patients and controls (49% in each group remained free of peritonitis after one year), and the survival of renal allografts was not significantly worse in diabetic patients (p less than 0.5). CONCLUSIONS--Renal replacement treatment may give good results in diabetic patients, although the outlook remains less favourable than for non-diabetic patients because of coexistent, progressive vascular disease, which is more severe in older patients. | 3 |
Detection of gastric erosions: comparison of biphasic radiography with fiberoptic endoscopy. Biphasic radiography was compared with fiberoptic endoscopy in detecting gastric erosions in a prospective, blinded study of 385 patients with dyspepsia. Because no absolute standard was available for the comparison, since histologic confirmation of all erosions was not possible, the kappa statistic was used to compare results from both modalities. Flat (incomplete) erosions were detected with endoscopy only and were considered to be present in 42 patients (11.2%). Varioliform (complete) erosions were identified with both radiography and endoscopy in 12 patients (3.2%). For the detection of varioliform erosions, a substantial agreement beyond chance between both modalities was found (kappa = 0.73; standard error, 0.12). Thus, flat erosions were detected with endoscopy only, whereas state-of-the-art radiography and endoscopy were equally sensitive for detecting varioliform erosions. Histologic confirmation of erosions was obtained in only 75% of the patients. It is unknown whether the demonstration of erosions with radiography and/or endoscopy correlates with dyspepsia. | 4 |
Reconstructions after resections of tumors involving the proximal femur. Advances in prosthesis design, the use of allografts, and a systematic approach to the staging and surgical treatment of musculoskeletal tumors have made limb salvage possible in the proximal femoral region. With the use of effective adjuvant therapy, limb salvage is now an option for the majority of patients presenting with locally invasive neoplasms in this area. The increase in functional outcome is sufficient to warrant serious consideration of limb salvage over the corresponding amputation. Preoperative planning is discussed along with surgical techniques. | 0 |
Ondansetron: a new entity in emesis control. Nausea and vomiting are serious problems for patients receiving cancer chemotherapy. Dopamine receptor and cholinergic receptor antagonism have been the target mechanism for agents used to combat drug-induced nausea and vomiting; more recently, blockade of serotonin receptors has been used for this indication. Current therapies are limited by extrapyramidal adverse effects, as well as drowsiness, sedation, respiratory depression, and cardiac effects. Ondansetron is an investigational serotonin antagonist that has documented effectiveness for cancer chemotherapy-induced emesis. Ondansetron appears to be well tolerated, with the possible exception of headaches and transient increases in liver enzymes. No extrapyramidal toxicities have been reported with this agent. While ondansetron looks promising, further studies are needed to fully define its role as an antiemetic. | 1 |
Advances in data assessment. Application to the etiology of nausea reported during chemotherapy, concerns about significance testing, and opportunities in clinical trials. Typical inferential statistical procedures, such as the t-test and analysis of variance, compare differences in mean values of variables. This approach can sometimes obscure rather than illuminate research data. Here we present and discuss alternative data analytic techniques. Potential advantages of box plots over conventional t-tests for understanding data are shown by comparing the area under high and low frequencies from spectral curves of autonomic changes following chemotherapy treatment. Typical t-tests provide information regarding statistical significance in terms of the differences in group means; box plots and related exploratory techniques provide information regarding the characteristics of the distributions within the groups as well as examination of potential outliers. Multivariate analysis of variance (MANOVA) and other multivariate techniques are commonly used to deal with potentially complex data sets with multiple outcome measures. The potential advantages of visual clustering techniques such as star plots, Chernoff faces, and Andrew's Function Plots are demonstrated by examining changes in facial pallor caused by chemotherapy-induced nausea and vomiting. Typical MANOVA approaches can identify potential differences in mean values between groups; visual clustering approaches do this by graphically presenting complex interrelationships for individual cases. This approach enhances the visual interpretation of potential interactions that would be obscured by simply focusing on overall mean values. Preliminary data from a meta-analysis on the effect of metoclopramide on chemotherapy-induced vomiting demonstrates the potential uses and advantages of this summary technique over simple tabular summaries. We found significant relationships between the effect size of the drug and variables such as the year of study publication and whether the publication was an article or an abstract. While none of these techniques are meant to replace traditional inferential statistics, they offer advantages in terms of data exploration and understanding relationships within data sets that are not clearly addressed by other methods. They are potentially valuable alternatives worthy of exploration. Finally, we discuss issues of interim analyses and multiple endpoint assessment for clinical trials. | 0 |
Surgical and prosthesis-related complications using the Groningen button voice prosthesis. Prosthesis-assisted tracheoesophageal speech has advanced speech rehabilitation appreciably. However, the surgical technique and the use of a prosthesis may give rise to complications. In a retrospective study on 132 consecutive patients rehabilitated with a Groningen button voice prosthesis, the complications were assessed, the average follow-up being 21 months. Surgical complications were not observed. Prosthesis-related complications, which were encountered in 28%, were all of a minor nature and mainly consisted of granulation formation and hypertrophic scarring; these appeared to be easily treatable. The complications found were few and insignificant in comparison with reports in the literature. This may be attributed to the uncomplicated surgical procedure for the insertion of the Groningen button. Moreover, the prosthesis is self-retaining and requires hardly any care from the patient. Permanent removal of the prosthesis usually requires surgical closure, which is a simple procedure performed under local anaesthesia. | 4 |
Chylothorax as presenting manifestation of adenocarcinoma with probable gastric primary. Chylothorax is an unusual complication of various malignant neoplasms, generally lymphomas. The few reported cases of chylothorax with gastric and other abdominal malignancies have involved large abdominal masses with prominent adenopathy and chylous ascites. We describe a patient in whom chylothorax was the presenting manifestation of an adenocarcinoma with probable gastric primary, developing prior to any clinical or radiologic evidence of tumor. | 0 |
Human breast milk contains bovine IgG. Relationship to infant colic? Previous studies have suggested that an unidentified cow's milk protein, other than beta-lactoglobulin and casein, might play a pathogenetic role in infant colic. Therefore, a radioimmunoassay was used to analyze human breast milk and infant formula samples for the presence of bovine IgG. Milk samples from 88 of the 97 mothers tested contained greater than 0.1 micrograms/mL of bovine IgG. In a study group of 59 mothers with infants in the colic-prone 2- to 17-week age group, the 29 mothers of colicky infants had higher levels of bovine IgG in their breast milk (median 0.42 micrograms/mL) than the 30 mothers of noncolicky infants (median 0.32 micrograms/mL) (P less than .02). The highest concentrations of bovine IgG observed in human milk were 8.5 and 8.2 micrograms/mL. Most cow's milk-based infant formulas contained 0.6 to 6.4 micrograms/mL of bovine IgG, a concentration comparable with levels found in many human milk samples. The results suggest that appreciable quantities of bovine IgG are commonly present in human milk, that significantly higher levels are present in milk from mothers of colicky infants, and that bovine IgG may possibly be involved in the pathogenesis of infant colic. | 1 |
Uses and complications of uvulopalatopharyngoplasty. Uvulopalatopharygoplasty has become widely performed for chronic snoring and for cases of obstructive sleep apnoea. Unfortunately this operation is not without morbidity and complications. We report our results of a prospective series of 50 patients undergoing uvulopalatopharyngoplasty with a minimum follow-up of one year. Snoring was abolished in 18 (36 per cent) and substantially reduced in the remainder. Obstructive sleep apnoea syndrome, identified in 11 patients pre-operatively, was reduced in severity in all but three. Troublesome complications were seen in 18 (36 per cent) patients, namely intermittent velopharyngeal incompetence in five (10 per cent), pharyngeal dryness in 11 (22 per cent) and loss of taste in five (10 per cent). One patient had nasopharyngeal stenosis requiring correction. A cautious approach to this operation is required with rigorous case selection. The importance of full assessment and careful follow-up should not be underestimated. | 4 |
Substance abuse-related spontaneous bladder rupture: report of 2 cases and review of the literature. Spontaneous rupture of the normal bladder associated with alcohol abuse is rare, with only 20 cases reported in the English literature to which we add 2 cases. Heavy alcohol ingestion predisposes the bladder to rupture by the large volume of fluid intake, its diuretic effect and the mental obtusion it produces, clouding sensory cues to void. alpha-Sympathomimetic drugs, such as cocaine and methamphetamine, increase the resistance at the urethral sphincter and exacerbate the effects of alcohol. Cystography will be diagnostic, and prompt operative repair of intraperitoneal rupture is mandatory. Complete evaluation of the bladder, including urodynamic study, is important to eliminate underlying bladder pathological conditions. Substance abuse-related rupture demonstrates a typical constellation of clinical features that necessitate considering it a syndrome separate from other causes of spontaneous bladder rupture. | 4 |
Effects of intravenous verapamil on left ventricular relaxation and filling in stable angina pectoris. Left ventricular (LV) diastolic function is often impaired in coronary artery disease (CAD). To assess whether verapamil could improve LV diastolic properties, 12 patients with CAD undergoing right- and left-sided cardiac catheterization, as well as simultaneous radionuclide angiography, were studied before and during intravenous administration of verapamil (0.1 mg/kg as a bolus followed by 0.007 mg/kg/min). The heart rate was kept constant by atrial pacing in both studies. LV pressure-volume relations were obtained. Verapamil decreased LV systolic pressure (130 +/- 22 to 117 +/- 16 mm Hg, p less than 0.01) and the end-systolic pressure/volume ratio (2.4 +/- 1.3 to 1.6 +/- 0.5 mm Hg/ml, p less than 0.05), and increased LV end-diastolic (13 +/- 4 to 16 +/- 4 mm Hg, p less than 0.02) and pulmonary capillary pressures (10 +/- 5 to 12 +/- 5 mm Hg, p less than 0.005). Despite such negative inotropic effects, cardiac index increased (3.4 +/- 0.7 to 3.9 +/- 0.6 liters/min/m2, p less than 0.02). The time constant of isovolumic relaxation shortened (63 +/- 14 to 47 +/- 9 ms, p less than 0.02); peak filling rate increased (370 +/- 155 to 519 +/- 184 ml/s, p less than 0.001; 2.6 +/- 1.1 to 3.3 +/- 0.9 end-diastolic counts/s, p less than 0.02; and 4.1 +/- 1.6 to 5.5 +/- 1.5 stroke counts/s, p less than 0.001). | 3 |
Tilt test for diagnosis of unexplained syncope in pediatric patients. Thirty-five teenage patients with a history of presyncope or syncope underwent a passive head-up tilting to reproduce symptoms of syncope. If tilting alone did not induce syncope, isoproterenol infusion was given to increase heart rate to 150 to 160 beats per minute. In 80% of patients with a history of syncope, identical symptoms could be reproduced during tilting: an abrupt fall in blood pressure combined with profound nodal bradycardia, ranging from 32 to 86 beats per minute. These symptoms were quickly reversed by returning the patient to the supine position. For patients with frequent occurrences of syncope, especially when there was a history of trauma sustained during these episodes, a therapeutic regimen of either beta blockers or 9 alpha-fluorocortisol was begun. The mechanisms of this common cause of syncope in childhood is neurocardiogenic in response to venous pooling and catecholamine-induced tachycardia. The tilt test is an excellent and cost-effective test for the workup of unexplained syncope in childhood. | 3 |
Assessment of the critical level of androgen for growth response of transplantable human prostatic carcinoma (PC-82) in nude mice. The androgen dependent prostatic carcinoma of human origin, PC-82, was used as a model system to investigate the effect of various levels of androgen on the growth of prostatic tumor tissue. Plasma testosterone levels in mice were correlated to tumor growth and intratumor concentrations of testosterone and 5 alpha-dihydrotestosterone. PC-82 tumor burden remained stable at plasma testosterone levels of 0.8 nmol/l., whereas tumor growth occurred at higher levels and tumor regression was observed at lower plasma levels. This critical level of testosterone corresponded with intratumor testosterone and 5 alpha-dihydrotestosterone concentrations of six to 10 and three to four pmol/gm. tissue, respectively, which are significantly above the levels found in castrated non-supplemented animals (3.1 and 1.4 pmol/gm. respectively). This indicates that remaining concentrations of dihydrotestosterone, which amount to two to three times the castrate level, are not stimulatory for tumor growth in the model of the androgen dependent PC-82 tumor. | 0 |
Functional outcome measures in stroke rehabilitation. I examine statistical considerations in the analysis of functional outcome following stroke and discuss the mathematical relation between improvement in function and discharge functional score. I demonstrate mathematically that the predictor variables of improvement and discharge functional score are the same and that the regression coefficients for improvement and discharge functional score will be equal, except for the admission functional score, for which a mathematically defined relation exists. I argue that the relation between admission functional score and discharge functional score must be positive and strong and that the relation between admission functional score and improvement must be negative for the stroke population. I believe that an ignorance of statistical concepts, especially confounding, and of the differences between raw correlations, partial correlations, and predictors have led to much confusion in functional outcome research. | 2 |
Effects of physostigmine on spatial attention in patients with progressive supranuclear palsy. We tested patients with progressive supranuclear palsy and control subjects on a task of visuopatial attention. Targets preceded by cues on the same side were termed validly cued; and those on the opposite side, invalidly cued. For all subjects, validly cued targets were responded to faster than those that were invalidly cued. The difference between reaction times for invalidly and validly cued targets, which is hypothesized to measure attentional movement, was significantly increased for the patients. The performance of the controls on certain neuropsychological tests was correlated with their attentional ability. These correlations were altered by progressive supranuclear palsy. Physostigmine treatment of the patients induced a speeding of responses to invalidly cued targets as a function of the duration of the disease. These studies show defects in cognition and attention in patients with progressive supranuclear palsy and demonstrate that physostigmine reduces some of the abnormal visual attentional performance. | 2 |
Latissimus dorsi cardiomyoplasty in the treatment of patients with dilated cardiomyopathy. Stimulated skeletal muscle grafts have been proposed as a means to reinforce ventricular wall in the treatment of severe myocardial failure. Latissimus dorsi cardiomyoplasty was performed in 11 patients with advanced heart failure due to cardiomyopathy who were in New York Heart Association (NYHA) class III or IV despite maximal medical therapy. There were no operative deaths. Eight patients were followed for a mean of 10.8 months. Two patients remain in muscle conditioning protocol. One patient died with latissimus dorsi ischemia and congestive heart failure. Four of the eight patients in long-term follow-up are in NYHA class I, three in class II, and one in class III. At 3 months of follow-up, rest radioisotopic left ventricular ejection fraction increased from 20.5 +/- 3.6% to 26.8 +/- 8.1% (p less than 0.01). Doppler-echocardiography demonstrated that left ventricular segmental wall shortening improved from 11.3 +/- 2.5% to 16.5 +/- 3.9% (p less than 0.01) and left ventricular stroke volume from 22.9 +/- 4.6 to 33.1 +/- 10 ml (p less than 0.01). Cardiopulmonary exercise test showed that maximal oxygen consumption during treadmill test increased from 14.8 +/- 3.7 to 18.2 +/- 3.3 ml/kg.min (p less than 0.05). At 6 months of follow-up, all the above values remained essentially unchanged. Furthermore, nonsustained ventricular tachycardia was abolished without specific medical therapy in four patients. Thus, cardiomyoplasty improves left ventricular function, reverses congestive heart failure, and may improve long-term survival in severe cardiomyopathies. | 3 |
Plasma dehydroepiandrosterone and dehydroepiandrosterone sulfate in patients undergoing diagnostic coronary angiography [corrected and republished with original paging, article originally printed in J Am Coll Cardiol 1990 Oct;16(4):862-70] Serum levels of DHEA sulfate are inversely associated with cardiovascular death in men, and urinary dehydroepiandrosterone (DHEA) levels are inversely associated with clinical manifestations of coronary artery disease. These observations may be related to the antiproliferative effects of DHEA, resulting in inhibition of atherosclerotic intimal hyperplasia. To examine the relation between these steroids and a direct measure of coronary atherosclerosis, plasma DHEA and DHEA sulfate levels were determined in 206 middle-aged patients (103 men, 103 women) undergoing elective coronary angiography. Plasma DHEA sulfate levels were lower in men with at least one stenosis greater than or equal to 50% compared with those without any stenosis greater than or equal to 50% (4.9 +/- 2.7 versus 6.1 +/- 3.5 nmol/ml, p = 0.05). Levels of DHEA sulfate were also inversely related to the number of diseased coronary vessels (r = -0.20, p = 0.05) and a continuous measure of the extent of coronary atherosclerosis (r = -0.25, p = 0.01) in men. The association between DHEA sulfate levels and extent of coronary artery disease was independent of age and other conventional risk factors for coronary disease. In women, there was no association between plasma DHEA or DHEA sulfate levels and coronary disease. These data demonstrate a consistent, independent, inverse, dose-response relation between plasma DHEA sulfate levels and angiographically defined coronary atherosclerosis in men. Plasma DHEA sulfate may be another important and potentially modifiable risk factor for the development and progression of coronary atherosclerosis. | 3 |
Potent selective inhibition of 7-O-methyl UCN-01 against protein kinase C. UCN-01 is a staurosporine-related compound that was isolated from the culture broth of Streptomyces sp. and shows potent and selective inhibitory activity against protein kinase C. Cellular inhibitory activity of UCN-01 against protein kinase C and cytotoxicity of UCN-01 were compared with those of staurosporine. When the mechanism of inhibitory activity was investigated in vitro, UCN-01 as well as staurosporine inhibited the activity of the catalytic domain of protein kinase C. In spite of direct inhibition against the catalytic domain of protein kinase C, cytotoxicity of UCN-01 was much lower than that of staurosporine. In addition, UCN-01 showed more selective inhibitory activity against protein kinase C than did staurosporine because of the sole structural difference at C-7. Therefore, a series of 7-O-alkyl derivatives of UCN-01 was synthesized and investigated. Interestingly, one of the compounds, the beta-methoxy derivative, showed 3-fold greater potency and 17-fold more selective inhibitory activity against protein kinase C than did UCN-01. | 0 |
Relationship of 4F2 antigen with local growth and metastatic potential of squamous cell carcinoma of the larynx. The 4F2 antigen is a cell-membrane glycoprotein which arises early in the G0-G1 phases of the cell cycle. This molecule is present in all established human cell lines and most malignant human cells. The authors used an indirect immunophosphatase method to study 50 squamous cell carcinomas of the larynx and ten lymph-node metastases, corresponding to six primary tumors, for 4F2 expression. The tumors showed several patterns of 4F2 staining which were correlated with different behaviors and prognoses of the neoplasms. Three different patterns (no staining, peripheral staining, and diffuse 4F2 expression) are described as are their relationships with metastatic behavior of the carcinomas. Tumors with metastases were found only in the third group (P = 0.0001). These results led to the following conclusions: (1) the 4F2 antigen is present in squamous cell carcinomas; (2) its distribution reflects the tumor-spreading pattern; and (3) it correlates with differentiation and metastatic behavior. | 0 |
Allelic variants at insulin-receptor and insulin gene loci and susceptibility to NIDDM in Welsh population. A cohort of 132 well-documented White Welsh non-insulin-dependent diabetic (NIDDM) subjects were genotyped for 5 restriction-fragment-length polymorphisms (RFLPs) at the insulin-receptor gene (IRG) locus and a polymorphic locus 5' to the insulin gene. There was no significant difference in RFLP frequencies between the NIDDM subjects and a group of 87 matched White control subjects. Paired haplotype analysis of the IRG RFLPs suggested a difference between NIDDM and control groups for the endonuclease combinations Bgl II-Rsa I and Bgl II-Xba I. Analysis of implied haplotypes defined by the endonucleases Bgl II, Rsa I, and Xba I revealed one haplotype to be more prevalent in the NIDDM group; whereas, another haplotype was associated with the control group (P less than 0.02). Subset analysis within the NIDDM cohort compared the metabolic response of NIDDM subjects with the differing IRG haplotypes to a standard meal tolerance test. Both groups showed equivalent basal and postprandial glucose excursions, but one group revealed a significantly exaggerated plasma insulin response compared with the other (P less than 0.05). This may reflect the influence of genetic variation at the IRG locus on insulin sensitivity in patients with NIDDM. | 4 |
Iatrogenic illness in pediatric critical care. Iatrogenic illness may be an important determinant of the need for pediatric intensive care. We prospectively evaluated consecutive admissions to a pediatric ICU (PICU) over two time periods totaling 6 months. Twenty-five (4.6%) admissions were necessitated by iatrogenic illnesses. Drug-induced conditions accounted for eight (32%) of the iatrogenic patients, and complications of medical-surgical acts accounted for 17 (68%). Diagnoses included six respiratory failures due to seizure medications, six chronic upper airway complications of neonatal intensive care, four posttonsillectomy and postadenoidectomy complications, two chronic postcardiac surgery complications, two cardiac catheterization complications, and five miscellaneous conditions. One (3.7%) patient with iatrogenic illness died. As a group, patients with iatrogenic illness were at a risk of dying similar to other patients. We conclude that iatrogenic illness is a significant cause of PICU admission. | 4 |
Fine needle aspiration biopsy in the diagnosis and management of fibroadenoma of the breast. Cytological and histological biopsies were obtained on 75 breast lumps clinically diagnosed as fibroadenomas. Of these, 95 per cent of lesions were benign. In 51 (68 per cent) confirmed as fibroadenomas histologically, cytology was benign in 78 per cent, but inadequate for diagnosis in 16 per cent. The remaining 24 lesions included three breast cancers and one lymph node with Hodgkin's disease. In this group cytology was inadequate for diagnosis in 54 per cent, including one breast cancer. No lesion with benign cytology was subsequently shown to be malignant. The study supports the view that clinical diagnosis and cytology are accurate in the diagnosis of benign breast disease of this type. Breast cancer may rarely present with the clinical features of a fibroadenoma and too few lesions have been studied to assess fully the performance of cytological biopsy in detecting these small mobile lesions. A non-excisional policy should therefore include prolonged follow-up and repeat biopsy. | 0 |
Usefulness of the automatic implantable cardioverter defibrillator in improving survival of patients with severely depressed left ventricular function associated with coronary artery disease. Clinical outcome was analyzed among a group of 39 consecutive patients with coronary artery disease, left ventricular (LV) ejection fractions less than 30% and arrhythmias that required an automatic implantable cardioverter defibrillator (AICD) in an attempt to better define the role of the device in patients with severely depressed LV function. Twenty-nine (74%) were survivors of out-of-hospital cardiac arrest and 10 (26%) had ventricular tachycardia that was refractory to electrophysiologically guided antiarrhythmic therapy. The study group had the following demographic characteristics: 90% were men, mean age was 64 years (range 41 to 79) and mean LV ejection fraction was 21 +/- 4%. Concomitant pharmacotherapy included antiarrhythmic drugs 31 (79%), vasodilators in 22 (56%) and digoxin in 20 (51%). There was no statistical difference in baseline characteristics between survivors and nonsurvivors. Patients were followed for a mean of 24 months (range 2 to 72) from implantation. The difference between actuarial survival--77% at 1 year and 72% at 2 years--and projected survival without the AICD (patients who survive without appropriate device discharge)--30% at 1 year and 21% at 2 years--was significant (p less than 0.01 and less than 0.05 at 1 and 2 years, respectively). This study suggests that the AICD improves survival in patients with coronary artery disease despite severely depressed LV function. | 3 |
Pulmonary hypertension five years after left pneumonectomy for adenoid cystic carcinoma. We report the findings in a patient with shortness of breath due to pulmonary hypertension five years after left pneumonectomy. Mediastinal recurrence of an incompletely resected and slowly growing adenoid cystic carcinoma of the left main bronchus had encased the right main pulmonary artery. | 0 |
Choroid plexus tumors in the breast cancer-sarcoma syndrome. Choroid plexus neoplasms are rare epithelial tumors of the central nervous system. A carcinoma of the choroid plexus occurred in a child from a family with the breast cancer-sarcoma syndrome (Li-Fraumeni or SBLA syndrome), an inherited condition characterized by the development of diverse neoplasms (sarcoma, breast cancer, brain tumors, leukemia, adrenal cortical carcinoma, and others). Choroid plexus carcinomas were identified in two kindreds previously reported with the syndrome. The literature contains reports of choroid plexus neoplasms occurring in families and in individuals with multiple primary tumors. Choroid plexus neoplasm may be a manifestation of the inherited proclivity to tumor development in the breast cancer-sarcoma syndrome. | 2 |
CV 205-502--effectiveness, tolerability, and safety over 24-month study. Twenty hyperprolactinemic women (median prolactin [PRL] 2,989 mU/L, range 1,149 to 11,910 mU/L), previously unsuccessfully treated with bromocriptine, were treated in a prospective study, for 3 to 24 months with the new, nonergot, long-acting, dopamine agonist, CV 205-502. Treatment resulted in normalization of PRL in 14 patients, in one daily dose of 0.075 to 0.150 mg of the drug. Three patients were treated in doses above 0.150 mg up to 0.300 mg, but PRL was not normalized during the study. Menstrual function was restored in 15 of 18 amenorrheic patients. Galactorrhea, present in 7 patients, disappeared in 5. Four patients became pregnant and gave birth to healthy children. In conclusion, we found CV 205-502 effective in one daily dose, with good tolerability; it is safe and provides a valuable alternative to the dopamine agonist drugs in use today. | 2 |
Asymptomatic ulnar neuropathy in carpal tunnel syndrome. Quantitative assessment of the vibration threshold of the second and fifth fingertips at 125Hz was performed on 28 affected limbs of 17 patients with carpal tunnel syndrome (CTS) together with a median and ulnar sensory nerve conduction velocity (SNCV) study. Twenty-six limbs of 26 age-matched healthy subjects were used as controls. Both the vibration threshold elevation of the second finger and the delay of median SNCV were significant in CTS patients as compared with controls (p less than .001). Although the ulnar SNCVs of all affected limbs were within the normal range, ten affected limbs (36%) were found to have a concomitant vibration threshold elevation of the fifth finger, and eight of those limbs were found to be exposed to chronic occupational mechanical stimulation at the wrist. These findings appear to support the presence of subclinical traumatic damage to the ulnar nerve at the wrist. In summary, digital vibration measurement can elucidate subclinical ulnar neuropathy in CTS which cannot be detected by SNCV studies. | 2 |
Titrated intravenous barbiturates in the control of symptoms in patients with terminal cancer. Patients with terminal cancer may have a series of severe and dehumanizing physical and psychologic symptoms. To improve symptom control in the final days and hours of life, we administer intravenous barbiturates continuously to provide heavy sedation or continuous somnolence. Titrated dosage is then reduced to a minimum, after a desired steady-state has been achieved. Improved symptom control is provided, and the patient's dignity is maintained until death. | 0 |
Sexual behavior before AIDS: the hepatitis B studies of homosexual and bisexual men. Data on sexual practices, collected during studies of hepatitis B virus (HBV) infection in 1978 and 1979, were analyzed for 4910 homosexual and bisexual men from Chicago, Denver, Los Angeles, San Francisco, and St Louis. Data on sexual practices in 1978 showed that white participants had larger numbers of non-steady male sexual partners and engaged in oral-genital activities more frequently but were equally likely to engage in anal intercourse as black and Hispanic participants. San Francisco participants had more non-steady sex partners and were more likely to engage in receptive anal intercourse with non-steady partners than participants from all other sites. Analysis of data on 606 HBV-antibody-negative men interviewed on three occasions in 1978 and 1979 showed no changes in risk indices for insertive and receptive anal intercourse between these years, except in San Francisco where significant declines occurred in insertive anal intercourse and receptive anal intercourse without ejacultion in a small, highly select group of participants. | 1 |
Exercise thallium-201 imaging in complete left bundle branch block and the prevalence of septal perfusion defects. To determine the prevalence of septal defects in a generalized referral population, the records of 93 consecutive patients with complete left bundle branch block (BBB) who underwent symptom-limited treadmill exercise testing with thallium-201 myocardial imaging over a 3-year period were reviewed. Segmental analysis of the planar thallium-201 images was performed in a blinded fashion with agreement by consensus. Computerized quantitative analysis of the images also was independently performed, and was correlated with the visual interpretations. Forty-seven patients (51%) had normal images, and 46 (49%) had defects of greater than or equal to 2 segments. In the abnormal studies, only 13 patients (14% of the total population) had septal defects, while a much higher number of patients, 33 (39%), had inferior or apical defects, or both. Coronary angiography was performed in 6 patients with septal defects: Significant narrowing of the left anterior descending coronary artery was found in 4 patients, a narrowed right coronary artery was found in 1, and normal coronary arteries were seen in the other patient. In conclusion, whereas previous studies have suggested a high percentage of false-positive septal defects in patients with left BBB, this study demonstrates a low prevalence (14%) of septal defects in a large population of unselected patients presenting for exercise thallium-201 imaging. Therefore, exercise thallium-201 imaging remains a useful procedure for evaluating patients with complete left BBB. | 4 |
Surgery for acute and chronic cholecystitis. Cholecystostomy and cholecystectomy remain appropriate and effective therapy for acute and chronic cholecystitis. Cholecystectomy is the gold standard against which all alternative methods of treatment of inflammatory biliary stone disease should be judged. The pathogenesis, diagnosis, and surgical treatment of acute and chronic cholecystitis have been described. Techniques of cholecystostomy, cholecystectomy, and intraoperative cholangiography used by the author have been given. Our results and those generally described in the literature indicate that the overall mortality rate for cholecystectomy, in all age groups, is approximately 0.5%. This rate increases slightly in patients with acute cholecystitis and in those over the age of 65 years. Cholecystectomy remains the most effective and the definitive treatment for acute and chronic cholecystitis. | 4 |
Elective resection for diverticular disease of the sigmoid colon. From 1966 to 1987, 177 consecutive patients were operated on electively for diverticular disease of the sigmoid colon. The indications for surgery were: colovesical fistula (n = 12), suspicion of residual abscess (n = 39), two or more previous attacks of acute inflammation (n = 52), chronic symptoms (n = 72) and suspicion of carcinoma (n = 2). An abscess was found at operation in 76 patients (43 per cent) and this was extracolic with local peritonitis in 52 patients (29 per cent). An unsuspected abscess was found in 25 of the 72 patients operated on for chronic symptoms. Colonic resection with primary anastomosis was performed in 95 per cent of the 177 patients and in 94 per cent of those 52 patients with an extracolic abscess. There were no postoperative deaths and no clinical anastomotic leakages. Long-term results were very good in 85 per cent of the 177 patients and in 82 per cent of the 72 patients operated on for chronic symptoms. The results of this series suggest that a one-stage procedure can be safely performed with some technical precautions in most patients operated on electively for diverticular disease, even if an extracolic abscess is found. The good long-term results in patients operated on for chronic symptoms suggest that such symptoms should be taken into account with respect to surgical indications. | 4 |
Treatment with deferoxamine during ischemia improves functional and metabolic recovery and reduces reperfusion-induced oxygen radical generation in rabbit hearts BACKGROUND. Iron may play a central role in oxygen radical generation during myocardial ischemia and after reperfusion. Because conditions during ischemia may also liberate iron, we hypothesized that administration of the iron chelator deferoxamine during ischemia would result in improved functional and metabolic recovery after postischemic reperfusion. METHODS AND RESULTS. Isolated, perfused rabbit hearts were studied by phosphorus-31 nuclear magnetic resonance spectroscopy. The hearts received one of three treatments: deferoxamine at the onset of 30 minutes of global ischemia (n = 9), deferoxamine as a bolus followed by a continuous 15-minute infusion begun at reflow (n = 9), or standard perfusate (n = 7). Hearts treated with deferoxamine during ischemia showed better recovery of developed pressure than did control hearts (63.2 +/- 7.5% versus 41.2 +/- 2.9% of baseline) (p = 0.02) and better recovery of myocardial phosphocreatine content (92.4 +/- 10.3% versus 68.2 +/- 4.5% of baseline, p less than 0.05). These functional and metabolic benefits were comparable to those obtained with deferoxamine treatment during early reperfusion. In 15 additional hearts, intraischemic treatment with deferoxamine resulted in no reduction in oxygen radical concentrations as measured on frozen tissue by electron paramagnetic resonance spectroscopy at end ischemia, but the treatment eliminated the reperfusion-induced increase of free radical generation observed in control hearts (2.9 +/- 0.01 versus 7.0 +/- 0.07 microM, p less than 0.001). The magnitude of reduction was similar to that when deferoxamine was given at the onset of reflow (2.4 +/- 0.02 microM, p less than 0.001 versus control). CONCLUSIONS. These results demonstrate improved functional and metabolic recovery of myocardium treated with deferoxamine during ischemia, accompanied by a reduction in reperfusion-induced oxygen free-radical generation to the same degree as reflow treatment, confirming the importance of iron in the pathogenesis of myocardial reperfusion injury. | 3 |
Transesophageal echocardiography in evaluation and management after a Fontan procedure. Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to assess the immediate (5 patients) or intermediate (13 patients) results after a Fontan-type procedure. The findings were correlated with precordial echocardiographic (all patients) and cardiac catheterization (11 patients) data. Atrial shunting was documented by transesophageal studies in three patients (precordial in one patient). In two patients it was confirmed by cardiac catheterization; the third underwent reoperation based on the transesophageal study alone. Pulmonary artery obstruction was documented in three patients (precordial in one patient) and was confirmed by subsequent cardiac catheterization in all. Evaluation of anterior Fontan connections was successful in 5 of 8 patients (precordial in 6 of 8), and posterior connections in 10 of 10 patients (precordial in 5 of 10). A Glenn shunt could be evaluated in eight of nine patients (precordial in three of nine). Thrombus formation was detected by transesophageal studies in three patients (precordial in one patient); repeat studies were used to evaluate thrombolytic therapy in two. Atrioventricular valvular regurgitation (11 of 18 patients) was better defined by transesophageal than by precordial studies (5 of 18). A coronary artery fistula was identified in two cases (precordial in none). Transesophageal pulsed Doppler interrogation of pulmonary artery and pulmonary vein flow patterns consistently allowed a detailed evaluation of the Fontan circulation. Transesophageal echocardiography is an important diagnostic and monitoring technique after the Fontan procedure. In this series, it was far superior to precordial ultrasound evaluation and of substantial additional value to cardiac catheterization. | 3 |
Neoplastic changes in the stomach after gastrectomy. Partial gastric resection for benign ulcer disease has been associated with an increased incidence of mucosal dysplasia and invasive adenocarcinoma, particularly 15 to 20 years after resection. These remnant carcinomas are particularly virulent with little hope of resection or cure once symptoms occur. Using a planned protocol of routine endoscopic surveillance with biopsy, the goal was to identify early markers of neoplasia, that is, dysplasia, and a diagnosis of adenocarcinoma of the gastric remnant, while both resection and cure were possible. Between July 1980 and August 1988, yearly flexible gastroscopic examination and random biopsy have been performed on 163 patients at least ten years after gastrectomy for benign ulcer disease. All biopsy results were interpreted for findings of dysplasia and early gastric adenocarcinoma. Results of this ongoing screening program revealed dysplasia of the gastric remnant in nine patients with eventual findings of adenocarcinoma in four of this group. These patients underwent total gastrectomy with findings of limited disease. Five patients with mucosal dysplasia continue to be observed at six month intervals. Three additional gastric carcinomas were found on initial gastroscopic screening, while one patient had adenocarcinoma diagnosed during a third yearly gastroscopic examination. These eight asymptomatic patients with adenocarcinoma in the gastric remnant had a postgastrectomy interval which ranged from 15 to 29 years (mean of 26.5 years). The results of this study support the concept of neoplastic change in the gastric remnant as a function of time from initial gastric resection. Findings of dysplasia on random biopsy indicate a greater likelihood of development of carcinoma of the gastric remnant and identify a subset of patients requiring aggressive endoscopic surveillance. | 1 |
Secondary deposition of beta amyloid within extracellular neurofibrillary tangles in Alzheimer-type dementia. The hippocampal areas of 34 autopsy specimen brains from aged demented and nondemented subjects were examined using double staining of Bodian and beta protein. In 18 cases (75.5 +/- 7.4 years old), none of the extracellular neurofibrillary tangles (E-NFTs) were immunoreactive with beta protein. In 16 cases (82.9 +/- 5.4 years old), the minority of E-NFTs were immunoreactive with beta-protein antiserum. These beta-immunoreactive E-NFTs frequently appeared in the areas having senile plaques, while they were not observed in the area lacking beta-immunoreactive senile plaques. The ultrastructure of beta-immunoreactive E-NFTs revealed that they consisted of extracellular amyloid fibrils, extracellularly located bundles of paired helical filaments, astroglial processes and degenerating neurites. These findings suggest that the beta immunoreactivity of E-NFTs comes from secondary deposition of amyloid fibrils. | 2 |
A composite driving system for LVAS and IABP: practical and effective driving and weaning. We have devised a new method, termed alternate synchronous driving (ASD), to wean patients from a left ventricular assist system (LVAS) to a pressure assist intraaortic balloon pump (IABP). We have built a new drive unit, VCT200, to apply ASD easily and automatically. After IABP insertion in the final weaning stage, this method drives the LVAS and IABP alternately, with electrocardiogram (ECG) synchronization. The pumping ratio of IABP increases while that of LVAS decreases according to recovery of natural heart function. In in vitro studies, ASD was effective when bypass flow (BF) was less than 50% of total flow (TF) (TF:BF + cardiac output [CO]), and its advantages increased under lower BF conditions. Mean aortic pressure (mAP) and CO increased 10 mmHg and 15%, respectively, with this method (IABP:LVAS = 1:1) when BF was 30% of TF. During in vivo studies, mAP increased 75.7 +/- 6.7 mmHg to 80.1 +/- 3.6 mmHg (p less than 0.001), and the CO increased from 3.1 +/- 0.5 L/min to 3.3 +/- 0.5 L/min (p less than 0.001), while the endocardial viability ratio (DPTI/TTI) increased 20-30%. This method was used in a 62-year-old man in which LVAS was applied after ventricular aneurysmectomy, BF was reduced from 2.2 L/min to 1.1 L/min by using ASD without any change in systemic perfusion. This reduction of BF could not be achieved with LVAS alone. From these data, this system could wean patients from LVAS and then switch to IABP smoothly, easily, and automatically, without hemodynamic instability. | 4 |
Treatment of metastatic melanoma with an autologous tumor-cell vaccine: clinical and immunologic results in 64 patients. We treated 64 patients with metastatic melanoma using a melanoma vaccine preceded by low-dose cyclophosphamide (CY), and monitored immunologic effects and antitumor activity. On day 0, the patients were given CY 300 mg/m2 intravenously. Three days later, they were injected intradermally with vaccine consisting of 10 to 25 x 10(6) autologous, enzymatically dissociated, cryopreserved, irradiated (25 Gy) tumor cells mixed with bacillus Calmette-Guerin (BCG). This treatment sequence was repeated every 28 days. Of 40 assessable patients with measurable metastases, five had responses, four complete and one partial, with a median duration of 10 months (7 to 84+ months). In six additional patients, we observed an antitumor response that seems to be peculiar to this vaccine therapy: the regression of metastatic lesions that appeared after the immunotherapy was begun. Delayed-type hypersensitivity (DTH) to autologous, mechanically dissociated melanoma cells that had not been exposed to extraneous antigens, such as enzymes or fetal calf serum, increased significantly following immunotherapy (day 0 v day 49, P less than .001; day 0 v day 161, P less than .001; day 0 v day 217, P = .021). Antitumor responses to the vaccine were strongly associated with DTH, as indicated by three observations: (1) eight of 10 patients who exhibited tumor regression had positive DTH, (2) in postsurgical adjuvant patients, there was a highly significant linear relationship (P less than .001) between the intensity of DTH to autologous melanoma cells and the time to recurrence of tumor, and (3) nine patients who developed DTH to the autologous melanoma cells in their original vaccine developed new metastases that failed to elicit DTH or elicited a much smaller response. In three cases, we were able to excise regressing tumors for histologic examination; such tumors were characterized by an intense infiltration of lymphocytes. This demonstration that an immune response to melanoma-associated antigens can be elicited in cancer-bearing patients provides some basis for optimism about the prospects for developing active immunotherapy that has practical therapeutic value. | 0 |
Manual stretch: effect on finger movement control and force control in stroke subjects with spastic extrinsic finger flexor muscles. This study evaluated the effects of manual stretch of extrinsic finger flexor muscles on finger extension movement control and force control in 16 spastic hemiparetic subjects. These subjects were randomly divided into a control group and an experimental group. A group of able-bodied subjects also participated. A joint-movement tracking test (JMTT) quantified control of active finger extension movement at the metacarpophalangeal joint of the index finger within the available range of active movement, and a force tracking test (FTT) quantified control of isometric finger extension force at the same joint within the subject's available force range. Electromyographic activity was monitored in the extensor digitorum and flexor digitorum superficialis muscles during both tracking tests. Manual stretch was applied to the extrinsic finger flexor muscles of the experimental group between the pretest and posttest tracking tests. The JMTT performances of both control (p less than .025) and experimental (p less than .05) groups were significantly subnormal on the pretest as were FTT performances of controls (p less than .01) and study subjects (p less than .03). The JMTT improvement on posttest was significantly greater (p less than .05) in subjects than in controls. However, the change in FTT performance was not significantly different between the two groups. Manual stretch treatment, properly applied to extrinsic finger flexor muscles, is an effective method of temporarily improving the control of finger extension movement in spastic hemiparetic subjects. | 2 |
A randomized, double-blind, placebo-controlled trial of oral antibiotic therapy following intravenous antibiotic therapy for postpartum endometritis. One hundred thirty-six patients were enrolled in a randomized, double-blind, placebo-controlled trial of oral antibiotic therapy (amoxicillin) versus placebo following successful intravenous (IV) antibiotic therapy for postpartum endometritis. No subjects were readmitted to the hospital for recurrent endometritis and there were no wound infections or recurrent fevers. Minor side effects were seen in 10% of those taking amoxicillin and 14% of those taking placebo. Compliance was fair; only 52% of those taking amoxicillin and 65% of those taking placebo completed therapy. The lack of infectious complications in this high-risk population suggests that oral antibiotic therapy is unnecessary after successful IV antibiotic therapy for endometritis. | 4 |
Long term survival and severe rebleeding after variceal sclerotherapy. Of 197 consecutive patients with cirrhosis admitted because of bleeding from esophageal varices, 133 were included in a prospective study of elective sclerotherapy. We evaluated the incidence of extensive rebleeding and mortality rate. The period of study was 54 months and the mean follow-up period was 21 months. Forty-one patients had severe rebleeding and a majority of the episodes occurred during the first year. Only four patients had more than five sessions of sclerosis when rebleeding occurred. The probability rate for patients to be free of severe rebleeding after 48 months, according to Pugh's classification, was 88 per cent for those with grade A, 50 percent for grade B and 43 percent for grade C. The over-all mortality rate was 38.8 per cent (53 patients), with the highest rate noted during the first year. The mortality rate of patients with severe rebleeding was much higher than that of those who did not rebleed. Kaplan-Meier survival analysis at four years was 52 per cent, and survival rates in relation to Pugh's classification were 73 per cent for A, 53 per cent for B and 34 per cent for C. Differences between the three groups were statistically significant. Therefore, because of the high mortality rate associated with patients with cirrhosis and extensive rebleeding during the first year, it is important to achieve, as soon as possible, eradication of esophageal varices. | 4 |
Detection of breakpoint cluster region- negative and nonclonal hematopoiesis in vitro and in vivo after transplantation of cells selected in cultures of chronic myeloid leukemia marrow. Philadelphia (Ph1) chromosome-positive clonogenic progenitors usually disappear within 4 to 6 weeks in long-term cultures established from the marrow of patients with chronic myeloid leukemia (CML). In contrast, coexisting chromosomally normal hematopoietic cells are relatively well maintained. Thus, even though normal cells are initially undetectable, they may become the predominant population. Recently, we have begun to explore the potential of such cultures as a strategy for preparing CML marrow for autografting, and based on cytogenetic studies of the differential kinetics of Ph1-positive and Ph1-negative clonogenic cells, have chosen a 10-day period in culture to obtain maximal numbers of selectively enriched normal stem cells. Here we present the results of molecular analyses of the cells regenerated in vivo for the initial three CML patients to be treated using this approach by comparison with the differentiated cells generated by continued maintenance of an aliquot of the autograft in vitro (using a slightly modified culture feeding procedure to enhance the production and release of cells into the nonadherent fraction after 4 weeks) for the one patient whose genotype made molecular analysis of clonality status also possible. These analyses showed that cells with a rearranged breakpoint cluster region (BCR) gene were not detectable by Southern blotting in either in vitro or in vivo populations of mature cells that might be assumed to represent the progeny of primitive cells present at the end of the initial 10 days in culture. Production of BCR-negative cells was also shown to be temporally correlated with the appearance of nonclonal hematopoietic cells both in culture and in vivo. These findings provide support for the view that prolonged maintenance of CML marrow cells in long-term culture may allow molecular characterization of both the BCR-genotype and clonality status of cells with in vivo regenerative potential. | 0 |
Effects of carotenoids in cellular and animal systems. It has been suggested that carotenoid pigments may function as chemopreventive agents for reducing the risk of cancer in humans. Part of this suggestion rests on epidemiological evidence, and part rests on work done in cellular and animal systems. In this article, the experimental evidence for carotenoid inhibition of mutagenicity, malignant transformation, tumor formation, and immunoenhancement is reviewed. Although a mechanism for these effects cannot yet be identified, it is clear that the overwhelming evidence in these systems would indicate that carotenoids exert an important influence in modulating the actions of carcinogens. | 0 |
Ectopic thyroid tissue in the submandibular region. This report describes an unusual location of ectopic thyroid gland tissue. A growth in the left submandibular area was surgically excised, and the microscopic examination of the specimen revealed thyroid tissue with colloid goiter. Because this entity cannot be clinically distinguished from a salivary gland tumor, ectopic thyroid tissue should be considered in the differential diagnosis of swellings involving the submandibular area. | 4 |
Prognostic indicators in invasive breast cancer. Tumor size and axillary lymph node involvement are the primary determinants of clinical course for most patients. Receptors for estrogen and progesterone are important additional prognostic factors for disease-free survival, overall survival, survival time after initial disease recurrence, and the likelihood of response to hormonal therapy. Histologic grading has merit as a prognostic factor, although poor reproducibility limits its broad application. Promising data have been emerging from the use of flow cytometry to analyze DNA content and proliferative rate. Patients with aneuploid tumors are more likely to have a shorter survival time than patients with diploid tumors. A high S-phase fraction also identifies a subset of patients at increased risk for early relapse. A combined index of ploidy and S-phase may be a more useful guide; together, diploidy and low S-phase identify a subgroup of node-negative patients at very low risk for disease recurrence. A number of oncogenes have been identified in breast cancer; amplification of the HER-2/neu gene or overexpression of the gene product may be an important prognostic indicator for node-positive patients. | 0 |
Chronic anal fissure. A new method of treatment by anoplasty. Chronic anal fissure is a common condition usually treated by maximal anal dilatation or lateral subcutaneous sphincterotomy. The following method is based on a common surgical principal; to widen a stenosed tube a longitudinal incision is made across the stenosed area and this is sutured transversely as in pyloroplasty. This method of anoplasty is simple and appears to have no resultant complications. Further studies are necessary before its value can be established compared to the presently accepted methods of treatment. | 1 |
Chest pain in teenagers. When is it significant? Chest pain in teenagers often has no obvious organic cause. Onset of symptoms with an emotionally stressful situation may indicate psychogenic chest pain. The differential diagnosis also includes cardiac, musculoskeletal, gastrointestinal, and respiratory disorders. Routine testing generally does not help to establish a diagnosis and may even do harm by reinforcing a patient's unspoken fear of serious illness. Most teenagers with chest pain have no such illness, and symptoms usually resolve without therapy. An important role for primary care physicians is to provide support during evaluation and follow-up. | 4 |
Spermatic cord for onlay coverage of urethral defect. Segmental urethral necrosis may accompany scrotoperineal gangrene, and primary closure of the urethral defect may unacceptably reduce urethral dimensions. This dilemma has been managed successfully in 5 patients by application of the intact spermatic cord to the urethral defect and approximation to its margins. A representative case is described. | 4 |
A note on the measurement of hypertension in HHANES Using data from the HHANES, we found the rates of elevated blood pressure readings on clinical examination to be extremely low for a sample of Mexican American and Puerto Rican women. The prevalence rates were one-fourth to one-fifth the rates found for a comparable sample of White women from NHANESII. These findings are discrepant with the little that is known about hypertension prevalence among Hispanics and with estimates of hypertension prevalence for Mexican Americans and Puerto Ricans drawn from NHANESII. While our HHANES samples women had much lower rates of clinical high blood pressure than Whites, they reported hypertension histories in excess of Whites. Rates of medicine usage among Hispanics were insufficiently large for effective treatment to explain the disparity. The prevalence estimates increased, but the relative discrepancies remained when we altered our sample specifications and clinical high blood pressure measure. A possible explanation for these discrepancies is that few physicians performed the majority of blood pressure readings in our HHANES sample. This may have been statistically inefficient. The discrepancies noted suggest that HHANES may not be a reliable source of information on hypertension among Hispanic women. | 3 |
Endemic Cryptosporidium and Giardia lamblia infections in a Thai orphanage. We conducted a point prevalence survey for enteric protozoa in 205 institutionalized orphans 1-61 months of age in Bangkok, Thailand. Cryptosporidium was identified in 17 children (8%), Giardia lamblia in 42 (20%), and 3 children (1%) had both parasites. At the time of diagnosis, diarrheal symptoms were present in a minority of subjects: 36% of children with Cryptosporidium alone, 10% with G. lamblia alone, and in 20% of those with neither parasite. Although chronic nutritional status (height/age) was similar in all groups, acute nutritional status (weight/height) was lower only in children with Cryptosporidium (Z score = -1.39 +/- 0.13) compared with children with G. lamblia (mean Z score +/- SEM = -0.56 +/- 0.26) or neither parasite (Z score = -0.78 +/- 0.13; P = 0.05). Detectable levels of Cryptosporidium-specific IgG antibodies by ELISA were identified in 15 of 16 Thai children with Cryptosporidium and in 17 of 19 Thai children without Cryptosporidium (mean OD +/- SEM = 1.27 +/- 0.18 vs. 1.06 +/- 0.13, respectively), but in only 1 of 18 sera from toddlers in day-care centers in Denver, CO (OD = 0.128 +/- 0.03). Although neither infection with Cryptosporidium nor G. lamblia was consistently associated with acute diarrheal symptoms, Cryptosporidium was more often associated with depressed acute nutritional status than G. lamblia. The high prevalence of specific antibodies to Cryptosporidium in Thai orphans suggests an association between high rates of exposure with asymptomatic excretion of the parasites. | 1 |
Pigmented spindle cell naevus. We report 22 cases of pigmented spindle cell naevus (PSCN). The usual appearance of these naevi is that of a heavily pigmented papule found mostly on the legs of young patients. Histologically, PSCN was characterized by symmetrical proliferation of spindle-shaped pigmented melanocytes grouped in large junctional nests. Pagetoid spread of single cells in the overlying epidermis was frequently found. In our opinion, PSCN is a distinctive benign acquired melanocytic naevus that in the past has been frequently misdiagnosed as atypical Spitz naevi or malignant melanoma. | 0 |
Cytomegalovirus infections in bone marrow transplant recipients given intensive cytoreductive therapy. Cytomegalovirus (CMV) infections were studied in 785 bone marrow transplant recipients given intensive cytoreductive therapy. CMV excretion occurred in 24%, viremia in 9%, seroconversion in 40%, and overall active infection in 47%. CMV disease was much less common. Retinitis, enteritis, and pneumonitis occurred in only one, five (less than 1%), and 55 (7%) of the patients, respectively. Allograft recipients were more likely to develop CMV disease than were autograft patients (P = .0001) despite comparable rates of active CMV infection. CMV disease was rare after primary infection in both autograft and allograft recipients (0 and 1%, respectively). In contrast, CMV disease occurred in 16% of seropositive allograft recipients. Among allograft recipients, risk factors for CMV pneumonitis were seropositivity, age greater than 10 years, and acute graft-vs.-host disease, while the use of cyclosporine as prophylaxis against graft-vs.-host disease was protective. Although active infection rates did not decrease, the rates of CMV pneumonitis in allograft recipients during successive years declined significantly (P less than .001). | 0 |
Multipiece tire rim injuries. Multipiece tire rims can explode during tire change, causing severe injury. Although more than 450 such accidents, with at least 80 deaths, have been recorded by the National Highway Traffic Safety Administration (NHTSA), we found no reports in the surgical literature on such injuries in the United States. This report describes experience with seven patients who sustained injuries in explosions of multipiece tire rims. All victims suffered massive maxillofacial trauma with associated ocular, cranial, intracranial, and extremity injuries. Two patients died, both because of intracerebral hemorrhage. One patient suffered serious long-term disability. All survivors required extensive reconstructive surgery. The design of the multipiece tire rim is inherently hazardous. Since many accidents of this type are not reported to the NHTSA, the incidence of such injuries may be significantly higher. An alternative, nonhazardous tire rim is available. Design modifications or a law restricting use of multipiece tire rims would prevent many accidents. | 2 |
Coronary vascular remodeling and myocardial fibrosis in the rat with renovascular hypertension. Response to captopril. Progressive myocardial fibrosis, including the accumulation of collagen within the adventitia of intramyocardial coronary arteries, is seen in the hypertrophied rat myocardium secondary to renovascular hypertension (RHT) and has been held responsible for alterations in myocardial diastolic stiffness. This study was undertaken to test the hypothesis that this presumptive angiotensin-aldosterone mediated fibrosis and its functional consequences could be favorably altered by an antihypertensive oral dose (50 mg/kg/day) of the angiotensin converting enzyme (ACE) inhibitor captopril. Three groups were studied: control; untreated RHT for 8 weeks; treated RHT, with captopril started 48 h before banding and continued for 8 weeks. Interstitial collagen volume fraction and perivascular collagen area (morphometry), the fibrillar nature of collagen (picrosirius polarization), and the end diastolic stress-strain relation of the intact left ventricle were examined in each group. In comparison to untreated animals with RHT, we found that captopril, begun prior to banding, attenuated interstitial and perivascular fibrosis and prevented hypertrophy and the rise in diastolic stiffness 8 weeks later. Thus, an adverse accumulation of collagen in the interstitium and around intramyocardial coronary arteries, and its functional consequences in the rat with RHT, can be prevented by captopril. Other ACE inhibitors may have similar salutary effects, but remain to be evaluated. The pathogenetic origin of myocardial fibrosis in RHT requires further investigation, but appears to be related to the angiotensin-aldosterone system. | 4 |
Gluten challenge in patients with celiac disease: evaluation of alpha 1-antitrypsin clearance. Our aim in this study was to monitor changes of the intestinal structure by alpha 1-antitrypsin clearance (alpha 1-ATCL) in order to offer an alternative to the gluten challenge biopsy. In addition, we evaluated the possibility of reducing the time of gluten challenge. Twelve patients had a presumptive diagnosis of celiac disease based on clinical and histological grounds. They were studied when the jejunal histology was normal after gluten-free diet and an alpha 1-ATCL was normal. The gluten was introduced by returning to a normal diet. The challenge lasted 4 wk. We measured alpha 1-ATCL at the end of the 1st and 4th wk, and a new jejunal biopsy was obtained at the end of the 4th wk. By wk 1, alpha 1-ATCL was abnormal in 11 patients but normal in one. By wk 4, alpha 1-ATCL was abnormal in 10 patients and still normal in one. The post-challenge biopsies showed atrophy in 11 and was normal only in the patient with normal alpha 1-ATCL at wk 1 and 4. One patient with abnormal alpha 1-ATCL had to stop the challenge at the first week. The patient with normal clearance at wk 1 and 4 and normal biopsy at wk 4 had abnormal results at 6 months. These data support our hypothesis that alpha 1-ATCL can be used as evidence of gluten toxicity after gluten challenge, and that this test can be abnormal as early as 1 wk after gluten is reintroduced. | 1 |
Effects of prostaglandin E1 on collagen diseases with high levels of circulating immune complexes. Prostaglandin E1 (PGE1) was administered to 4 patients with collagen diseases presenting with high levels of circulating immune complexes (CIC) in sera. Our study patients had progressive systemic sclerosis, systemic lupus erythematosus, polyarteritis nodosa, and rheumatoid arthritis. In all 4 patients, CIC levels significantly decreased after administration of PGE1 by continuous infusion at 10/ng/kg/min via central venous catheter for 72 h. In addition, the skin ulcer in a patient with PSS healed completely, and the finger necrosis in a patient with RA improved. These results suggest that PGE1 given by continuous venous infusion is effective in reducing CIC, in addition to improving peripheral vascular disorders. | 3 |
Prevention and changing demographics. The underserved and cancer. This paper illustrates the complexity of the "cancer control in the underserved" problem, especially as it is affected currently, and will be in the future, by the multiple demographic changes in the United States. It does so by extensively quoting from four rather different articles by authors from a variety of backgrounds in health, management, and economics. Another issue is that although the articles quoted refer mainly to secondary and tertiary prevention, they do apply equally to primary prevention and health promotion. Furthermore, the twin issues of priority and ethnic/cultural differences need to be addressed insofar as they affect health risks, risk reduction efforts, early diagnosis, treatment, and rehabilitation/disability reduction. Finally, the point is made that social and structural change of this magnitude cannot occur in the health care system and society at large without the allocation of discrete private and public sector resources. | 0 |
Diagnosis and localization of prostate carcinoma by fine-needle aspiration cytology and correlation with histologic whole-organ sections after radical prostatectomy. Twenty-nine patients with clinical stage T1-2, NO, MO prostate carcinoma were treated by retropubic radical prostatectomy. Diagnosis was made by fine-needle aspiration biopsy from six to eight separate sectors of the prostate. At the time of biopsy, diagrams of the palpated organ were drawn, depicting the location of the lesion and the site of each biopsy. Without the examiners' knowledge of cytologic data, extirpated prostate glands were examined with whole organ histologic sections, and carcinomas were scored according to the method of Gleason. The location and extent of all typical and malignant foci were mapped on a standard diagram. The results of preoperative cytologic examination were compared with postoperative histopathologic findings, showing a tendency toward underestimation of both the extent and degree of differentiation of the carcinomas during cytologic examination. In no case were these parameters overestimated during cytologic examination. The Gleason score correlated well with the presence of capsular and seminal vesicle invasion. | 0 |
Noninvasive cerebral optical spectroscopy for monitoring cerebral oxygen delivery and hemodynamics. OBJECTIVE: To present an algorithm for noninvasive measurement of cerebral oxygen saturation (cerebral oximetry) and cerebral hemodynamics with near infrared spectroscopy. DESIGN: In vitro correlation of oximetry measurements with reference measurements; illustrative cases of hemodynamic and oximetric recordings. SETTING: Tertiary care neuroscience ICU. PATIENTS: Brain-injured patients with a prolonged, decreased level of consciousness chosen as illustrative examples. INTERVENTIONS: Two-channel multiple wavelength diffuse infrared transmission spectroscopy was interfaced with the scalp using adhesive. Transmission data were collected with gross superficial-to-deep spatial resolution. Saturation calculation based on the deep signal was observed longitudinally in the patient. With the same technology, arterial input and cerebral response functions, generated by iv tracer bolus, were deconvoluted to measure mean cerebral transit time. MEASUREMENTS AND MAIN RESULTS: A positive linear regression fit between diffuse transmission oximetry and measured blood oxygen saturation over the range 23% to 99% (r2 = .98, p less than .001) was noted. CONCLUSIONS: The approach used overcomes previously identified difficulties with cerebral oximetry, and demonstrates excellent in vitro correlation. The technique can be performed clinically without difficulty. A simultaneous measure of mean cortical transit time is possible. | 2 |
Evidence for platelet-activating factor as a late-phase mediator of chronic pancreatitis in the rat. The role of platelet-activating factor (PAF) as a mediator of pancreatic inflammation was examined in the rat pancreatic duct ligation model of obstructive pancreatitis. Pancreatic generation of PAF, as measured by bioassay (ie, platelet [3H]serotonin secretion), was determined at various times after induction of inflammation. Tissue levels of PAF in the normal pancreas averaged 600 +/- 49 pg/g, but PAF was not detectable during the initial 24 hours of pancreatitis, a time when the inflammatory reaction would be considered acute, that is, during the period of maximal serum amylase release and the development of interstitial edema. However a substantial increase in pancreatic PAF levels (12 times control levels) was observed 7 to 14 days after duct ligation during the late-phase response interval similar to the situation characteristic of chronic pancreatitis in which parenchymal atrophy, fibrosis, and pancreatic insufficiency evolve. One week after duct ligation when PAF levels peaked, an evaluation was made of the effects of PAF antagonists (BN52021 and WEB2170) on pancreatic lesions using Evan's blue extravasation, pancreatic myeloperoxidase (MPO) activity, and acid phosphatase activity in peritoneal lavage fluid. BN52021 or WEB2170 treatment was shown to reduce pancreatic damage and inflammation significantly. Long-term in vivo administration of exogenous PAF (20 micrograms/kg/hr for 7 days) exhibited a reduction of [3H]thymidine uptake into and amylase release from pancreatic acini in vitro. Our observations 1) that pancreatic PAF levels increased significantly during the chronic phase of obstructive pancreatitis induced by duct ligation; 2) that inhibition of the action of PAF, through specific receptor antagonism, caused an attenuation of pancreatic lesions; and 3) that chronic administration of PAF resulted in decreased pancreatic regeneration and exocrine function are consistent with a pivotal role for PAF as a late-phase inflammatory mediator in chronic pancreatitis in rats. | 4 |
Hepatocyte expression of HBcAg and serum HBeAg in hepatitis B: comparison of polyclonal and monoclonal antibodies during a trial of interferon. The distribution and quantitative expression of HBcAg in relation to serum HBeAg and liver histology before and after a trial of interferon in 50 patients with chronic type B hepatitis were evaluated using polyclonal and monoclonal antibodies. In general, both antisera showed a similar pattern in terms of the distribution of HBcAg, with predominant localisation of HBcAg in the cytoplasm in HBeAg positive patients with chronic active hepatitis. Semiquantitative analysis showed, however, that there was a higher degree of cytoplasmic expression of HBcAg with polyclonal than with monoclonal anti-HBc. Some of the HBeAg positive patients with only a focal expression of HBcAg in the cytoplasm by polyclonal anti-HBc showed no expression of HBcAg with monoclonal anti-HBc. The expression of HBcAg with polyclonal anti-HBc correlated better with the histological features of chronic active hepatitis or the persistence of serum HBeAg on follow up, suggesting that it did not result from non-specific or false positive staining. All of the HBeAg negative patients with minimal histological changes or inactive cirrhosis were HBcAg negative with both antisera. In conclusion, though both polyclonal and monoclonal antibodies produced a quite similar distribution of HBcAg in patients with chronic type B hepatitis, polyclonal antibody seemed to be more sensitive in detecting HBcAg in the cytoplasm than did monoclonal anti-HBc, and the expression of HBcAg with polyclonal anti-HBc correlated better with the clinical and histological outcome. | 4 |
Vagal schwannoma associated with syncopal attacks and postural hypotension: a case report. A case of vagal schwannoma in the cerebellomedullary angle is reported. Preoperatively, the patient had paroxysmal episodes of postural hypotension with syncope. After total removal of the vagal tumor, her systemic blood pressure returned to normal. | 0 |
Intravenous nicardipine: an effective new agent for the treatment of severe hypertension. Fifty-six patients with severe hypertension were treated with intravenous nicardipine for infusion periods of eight to twenty-four hours. Each patient achieved satisfactory blood pressure control during the infusion period with a mean controlling dose of 7.85 mg/hr. The dose of nicardipine needed for sustained blood pressure control correlated with untreated diastolic blood pressure but not with untreated systolic blood pressure. These results demonstrate the potential usefulness of intravenous nicardipine for the treatment of severe hypertension requiring rapid lowering, and they suggest also that the severity of pretreatment diastolic hypertension might be a useful indicator of the dose required for blood pressure control. | 4 |
Ondansetron: a new entity in emesis control. Nausea and vomiting are serious problems for patients receiving cancer chemotherapy. Dopamine receptor and cholinergic receptor antagonism have been the target mechanism for agents used to combat drug-induced nausea and vomiting; more recently, blockade of serotonin receptors has been used for this indication. Current therapies are limited by extrapyramidal adverse effects, as well as drowsiness, sedation, respiratory depression, and cardiac effects. Ondansetron is an investigational serotonin antagonist that has documented effectiveness for cancer chemotherapy-induced emesis. Ondansetron appears to be well tolerated, with the possible exception of headaches and transient increases in liver enzymes. No extrapyramidal toxicities have been reported with this agent. While ondansetron looks promising, further studies are needed to fully define its role as an antiemetic. | 4 |
Laparoscopic management of ovarian cysts. One hundred two women with ovarian cysts were managed laparoscopically over a 13-year period. Thirteen were treated with laparoscopic inspection followed by laparotomy, 6 with laparoscopic fine needle aspiration followed by laparotomy and 83 with laparoscopic fenestration and biopsy, with or without coagulation or removal of the cyst lining. Satisfactory results were noted in patients treated completely with laparoscopy. Only 1 of 56 functional, simple or paraovarian cysts recurred during the study period. Two of the 18 ovarian endometriomas treated with fenestration and coagulation or removal of the lining recurred, whereas 8 of 9 such lesions recurred when treated with fenestration alone. There were no surgical complications. | 0 |
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