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Ultrasonography in patients with suspected acute appendicitis: a prospective study. The diagnostic accuracy of high-resolution real-time ultrasonography was prospectively studied in 240 patients admitted to the hospital with suspected acute appendicitis. The criteria for ultrasound diagnosis of appendicitis included a sausage-shaped, aperistaltic, hypoechoic structure when imaged along its longitudinal axis, with a target-like appearance on transverse section. The ultrasonographic findings were correlated with surgical-pathological outcome in 82 cases with proven appendicitis, with laparotomy findings in another 21 patients and with clinical follow-up in the remainder. The overall sensitivity, specificity and accuracy of ultrasonography in the diagnosis of acute appendicitis were 78%, 92% and 87%, respectively. The positive predictive value was 84% and the negative predictive value was 88%. Ultrasonography may significantly improve the diagnostic accuracy in patients with suspected acute appendicitis and should be performed in all patients in whom the clinical diagnosis is equivocal. The ultrasonographic findings must be interpreted in light of the clinical findings. | 4 |
Endoscopic palliative intubation of the esophagus invaded by lung cancer. Thirty-two patients with esophageal involvement by lung cancer were managed by endoscopic intubation. In 22 patients with extrinsic esophageal strictures, the success rate of intubation was 91%, and 82% were discharged with their dysphagia relieved and esophageal patency restored. The mean survival rate was 4.4 months. In 10 patients with esophago-bronchial fistulas, 3 had the fistulous tract obliterated and lived a mean of 5 months. This low success rate of closing fistulas is due to failure to seal off the space between the stent and the fistula because of absence of tumor-associated stenosis. The overall morbidity rate was 28.1% (18.8% perforation, 6.3% hemorrhage, and 3.1% tracheal obstruction). The overall mortality rate was 18.8%. Although complications were more frequent than in primary esophageal tumors, endoscopic intubation was the only way to palliate this desperate condition and provided 66.6% of patients with relief of symptoms, nutritional improvement, and a mean survival time of 4.5 months. | 4 |
Mucosal intussusception to avoid ascending cholangitis. Many methods have been devised to prevent ascending cholangitis following Kasai's hepatic portoenterostomy for biliary atresia. To investigate the effectiveness of mucosal intussusception in preventing ascending cholangitis, 20 mongrel dogs were randomized to undergo Roux-en-Y cholecystjejunostomy and common bile duct ligation with or without mucosal intussusception. Aeromonas hydrophila was instilled into the gastrointestinal tract. Bacterial cultures were grown from samples taken from the gallbladders and lower jejunum, and blood chemistry and barium studies were performed. The barium studies showed satisfactory lack of reflux in all ten dogs with mucosal intussusception. Only two of them had positive cultures for Aeromonas from the gallbladder 3 days after bacterial instillation into the jejunum. All ten dogs in the control group had positive cultures for Aeromonas from the gallbladder. Our results showed that the mucosal intussusception group had a significantly lower rate of recovery of organisms from the gallbladder compared with the control group when the organisms were instilled into distal intestine (P less than 0.05). The method is worthy of clinical trial as a means of preventing or treating ascending cholangitis. | 1 |
Microsurgical epididymovasostomy by tubule intussusception: a new technique in rat model. This experimental study on 15 adult male rats with bilateral epididymovasostomies evaluates a new technique of tubule intussusception as an improved form of end-to-end anastomosis. This paper describes in detail the steps in this technique and offers physiological, anatomical, and histological follow-up after 3 months. With this technique there is a 97% patency rate and a 23.3% incidence of macroscopic spermatic granuloma. Complications are discussed in detail. | 1 |
Prognostic factors in craniofacial surgery. From 1979 to 1989, 21 patients underwent craniofacial resection for malignancies involving the anterior skull base. Histologic types included 8 squamous cell carcinomas, 3 chondrosarcomas, 2 melanomas, 2 basal cell carcinomas, 2 adenocarcinomas, 2 poorly differentiated carcinomas, 1 malignant schwannoma, and 1 malignant hemangiopericytoma. Survival was 57%, with follow-up of 41 months. A 50% complication rate included osteomyelitis, cerebrospinal fluid rhinorrhea, meningitis, brain abscess, epidural abscess, and syndrome of inappropriate antidiuretic hormone. Recurrent disease occurred in 9 patients (41%), the most reliable predictor being dural invasion indicated preoperatively by CT scan or at operation. Patients demonstrating dural involvement (N = 9) had a 22% survival rate, while patients without (N = 12) had a survival rate of 83%. The impact of dural invasion on long-term survival is emphasized. Though complications were frequent, long-term results were favorable. | 0 |
Biphasic effects of doxorubicin on the calcium release channel from sarcoplasmic reticulum of cardiac muscle. To define the mechanism of doxorubicin cardiotoxicity, the effects of doxorubicin and caffeine were examined on calcium release channels from cardiac sarcoplasmic reticulum. We found that calcium release from cardiac sarcoplasmic reticulum vesicles was induced by both compounds. When sarcoplasmic reticulum vesicles were incorporated into planar lipid bilayers, calcium-permeable channels were observed. Addition of caffeine (2.5-10 mM) increased channel open probability from less than 0.1% to 40%, and this effect persisted for a mean of 44 minutes. In contrast, doxorubicin (2.5-10 microM) had a biphasic effect; initially, doxorubicin activated the channel, whereas after a mean of 8 minutes, the channel became irreversibly inhibited. Although the degree of channel activation by doxorubicin was concentration dependent, the time needed to inactivate the channel was concentration independent. Pretreatment with dithiothreitol (0.2 mM) prevented doxorubicin-induced channel inactivation, and channel activity persisted for an average of 58 minutes. Dithiothreitol alone did not alter channel open probability. Our results support the hypotheses that 1) the integrity of sulfhydryl groups is important for some aspects of calcium release channel function and 2) activation and inactivation of the channel are separable processes. The biphasic effect of doxorubicin on channel function may also correspond to the clinically observed adverse effects of doxorubicin, a widely used chemotherapeutic agent that, after prolonged usage, causes a dilated cardiomyopathy. | 3 |
Mapping the distribution of amobarbital sodium in the intracarotid Wada test by use of Tc-99m HMPAO with SPECT. The intracarotid amobarbital sodium, or Wada, test has been used to localize speech and memory function prior to surgical treatment of temporal lobe seizures. The authors mixed technetium-99m hexamethyl-propyleneamine oxime (HMPAO) with amobarbital sodium and injected the mixture in 25 patients with epilepsy. Single photon emission computed tomography (SPECT) of the brain was then performed to determine intracerebral distribution of the amobarbital sodium. Results of SPECT were compared with those of conventional and digital subtraction angiography (DSA). The distribution of Tc-99m HMPAO and, presumably, amobarbital sodium varied from patient to patient. SPECT revealed a statistically different distribution from that predicted with conventional angiography. The distribution also often differed from that of DSA, although the difference was not significant. SPECT revealed infrequent delivery to mesial temporal lobe structures. This emphasizes the need for caution in the use of the intracarotid amobarbital sodium test to predict the outcome of removal of these areas. | 2 |
Muscle fibre type and habitual snoring. Although anatomical abnormalities of the upper airway have been recorded in some patients with obstructive sleep apnoea (OSA), a muscle tone dysregulation also seems to have an important role in this disorder. Since habitual snoring is the initial stage of OSA, the structural characteristics of upper airway muscles (medium pharyngeal constrictor muscle [MPCM]) from 13 men (9 non-snorers and 4 habitual snorers) were studied. MPCM fibre structure in non-snorers was broadly similar to that in normal limb muscles, with the exception that fibre diameters were smaller for all fibre types. Compared with limb muscles, MPCM had a smaller proportion of type IIb fibres and a higher proportion of types I and IIa fibres. MPCM in habitual snorers had an abnormal distribution of fibre types (low percentage of type I and type IIb fibres and high percentage of type IIa fibres) compared with non-snorers (p less than 0.001) and the type IIa fibres were hypertrophic. No myopathic or neurogenic changes were seen. Two possible hypotheses explain the abnormal distribution of fibre types in snorers. First, a constitutionally determined reduction of slow alpha-motor neurons induces an adaptive transformation of type IIb to type IIa fibres and a hypertrophy of type IIa fibres; or, second, motor neurons change their patterns of discharge and, hence, of activation, and modify fibre-type distribution of MPCM as an adaptation to the anatomical characteristic of upper airway and habitual snoring. | 4 |
Prognosis of Wilsonian chronic active hepatitis. Twenty of 320 patients with Wilson's disease initially presented with chemical and laboratory features of chronic active hepatitis, confirmed histologically in 17. When first seen, cirrhosis was present in all 20 and was complicated by ascites and/or jaundice in 11. Within 1 week to 8 years of the onset of over liver disease the diagnosis of Wilson's disease was established, and treatment with D-penicillamine was promptly initiated in 19 patients. One man refused treatment and died 4 months later. Treated patients received D-penicillamine or trientine for a total of 264 patient-years (median, 14 patient-years). Abnormal water retention, for which salt restriction and diuretics were added to penicillamine or trientine, disappeared in all but 1 of the patients so affected. Symptomatic improvement and virtually normal levels of serum albumin, bilirubin, aspartate aminotransferase, and alanine aminotransferase followed within 1 year in the majority of subjects. One woman died after 9 months of treatment. Two patients, who became noncompliant with the therapeutic regimen after 9 and 17 years of successful pharmacological treatment, required liver transplants. These results indicate that the prognosis of specifically treated Wilsonian chronic active hepatitis is very good in spite of the presence of cirrhosis. | 1 |
Rectal bleeding. Patient delay in presentation. Patient delay in presentation of rectal bleeding has been identified as a factor in delayed diagnosis among patients with colorectal cancer. The aim of this study was to identify demographic or psychological factors, or beliefs or behaviors related to delay in presentation of rectal bleeding. In 93 patients presenting with this symptom to their general practitioner, delay ranged from 0 to 249 days with a median of 7 days; 27 (29 percent) delayed more than 14 days. Delay was unrelated to age, sex, ethnic origin, competence in English, length of schooling, social status, availability of social support, measured psychologic traits, and to the belief that the cause might be cancer. The proportions delaying more than 14 days were statistically significantly elevated among those who were not worried by the bleeding (47 percent delayed); those who did not regularly look at their feces or the toilet paper after use (37 percent); and those who took some other action before presenting to their general practitioner (43 percent). | 4 |
Microalbuminuria in essential hypertension. Clinically apparent proteinuria in essential hypertension is associated with increased cardiovascular and total mortality and is an independent risk factor for cardiovascular and cerebrovascular disease. Subclinical elevation of urinary albumin excretion is seen more frequently than clinical proteinuria in essential hypertension and the levels of microalbuminuria (excretions of 30 to 300 mg/24 h) correlate with blood pressure. The increased urinary albumin excretion in hypertension may be explained by several factors such as renal hemodynamic changes, permselectivity changes of the glomerular filter, and structural arteriolar and glomerular changes due to nephrosclerosis. It has been clearly demonstrated that microalbuminuria is a risk factor for the development of clinical proteinuria, renal failure and increased cardiovascular mortality in insulin-dependent diabetes mellitus. It is still not known whether microalbuminuria also predicts development of proteinuria and decline in renal function in hypertension but there is some evidence indicating that microalbuminuria may be a marker of increased cardiovascular risk in hypertensives. | 3 |
Childhood stroke after minor neck trauma: case report. Cerebral infarction after minor trauma to the neck has rarely been reported. A case is presented of a child with trauma to the vertebrobasilar artery resulting in stroke. Computerized tomography scan and angiography results are presented. Despite two subsequent, separate transient episodes of vertigo, the child had good functional recovery with complete restoration of language and cognitive function. After 28 months, residual impairments identified were a mild right-sided ataxia and hemiparesis. | 2 |
Pancreatic duct abnormalities in gall stone disease: an endoscopic retrograde cholangiopancreatographic study. This study was carried out to assess pancreatic duct abnormalities in gall stone disease. Endoscopic retrograde cholangiopancreatograms of 50 patients with gall stone disease were analysed and the results compared with those obtained in 33 patients investigated for cholestatic jaundice who were found to have a normal biliary tree (control group). Abnormal pancreatograms were obtained in 24 (48%) patients with gall stone disease and in only two (6%) in the control group; the differences were statistically significant (chi 2 = 14.3; p less than 0.001). The patients in the control group showed mild abnormalities as did those in the gall stone group. The frequency of various abnormalities were: mild 16 (32%), moderate five (10%), and severe three (6%). Pancreatic duct abnormalities were more severe and occurred more frequently in patients with gall stones who had stones in the biliary tree than in patients with a normal biliary tree (postcholecystectomy patients, 55% v 25%) but the difference between the two groups just failed to be significant (chi 2 = 3.34). In conclusion, nearly half of all patients with gall stone disease have pancreatic duct abnormalities and in 16% these were severe enough to be labelled as chronic pancreatitis. | 1 |
Apical hypertrophic cardiomyopathy in a non-Oriental man. Japanese investigators first described apical HCM in 2.9% of patients who had diagnostic left ventricular catheterization for suspected ischemic heart disease or cardiomyopathy. This entity was initially thought to be limited to individuals of Asian origin and has been uncommonly described in patients of Western origin. Patients of Western origin differ in several ways from those in the original description of Yamaguchi et al, but they both share the same classic criterion of hypertrophy of the left ventricular apex. The major differences probably relate to the anatomic variation in the distribution of the left ventricular hypertrophy as described by Maron et al. It is not known whether racial, genetic, or environmental factors account for the variation of disease expression in Asian and Western patients. Our case illustrates that this diagnosis should be considered in patients who have chest pain (anginal or atypical) and markedly abnormal findings on electrocardiograms in the absence of hypertension or significant coronary artery disease. | 3 |
Clinical trials. A family physician's perspective. Primary care specialists diagnose and manage a wide variety of problems. Cancer is one relatively small part of the practice of these clinicians. Patients with newly diagnosed cancer usually are referred to surgical specialists. Primary care physicians often determine future events after surgical care. Oncologists may or may not be consulted depending on tumor type and past experiences of the physician, patient, and patient's family. Many primary care physicians think that chemotherapy regimens given empirically have little if any scientific evidence to support their use. Side effects of cancer treatment regimens often cause suffering and profoundly effect quality of life. There is a lack of communication between oncologists and primary care physicians. Dialogue between oncologists and primary care doctors may help solve communication problems. Clinical trials help determine which treatments are effective. Many clinical trials are conducted at the community hospital level. Most primary care physicians support clinical trials once they know about them. Education activities should be directed at promoting patient referral for participation in clinical trials. | 0 |
Growth factor expression after stroke. Fibroblast growth factors are polypeptides with potent trophic effects on central nervous system cells. Both acidic and basic forms of fibroblast growth factor are found in the mammalian brain. We have examined the expression of these factors after focal brain injury or stroke. After infarction of the lateral cerebral cortex in the mature rat brain, we found a twofold to threefold increase during the first 3 weeks after stroke in levels of fibroblast growth factors in tissue surrounding infarcts. This increase persisted for at least 2 months and appeared mainly to be due to increased levels of basic, but not acidic, fibroblast growth factor. Because of its gliotrophic, angiogenic, and neuronotrophic properties, basic fibroblast growth factor may play an important role in the cascade of cellular reactions that contributes to wound healing and functional recovery after stroke. | 2 |
Endosalpingosis as a cause of chronic pelvic pain. Endosalpingosis, a condition characterized by ectopic oviduct epithelium, is diagnosed histologically by the appearance of benign ciliated and nonciliated columnar cells in an abnormal location. Endosalpingosis is typically without symptoms. Our unusual case report shows symptomatic endosalpingosis first seen with chronic pelvic pain. Various aspects of this disease will also be discussed. | 4 |
The role of beta-blockade therapy for ventricular tachycardia induced with isoproterenol: a prospective analysis. Isoproterenol is sometimes required for ventricular tachycardia (VT) induction. However, the role of beta-blockade for treatment of such VT has not been critically assessed. The use of beta-blockade was evaluated prospectively in 14 consecutive patients who required isoproterenol 2.4 +/- 1.3 (+/- S.D.) micrograms/min to induce sustained monomorphic VT (greater than 30 seconds, or requiring termination due to hemodynamic collapse) after a negative baseline study. The VT mechanisms were enhanced automaticity (group A, six patients), triggered automaticity (group B, three patients), and reentry (group C, five patients). Groups A and B had serial intravenous electropharmacologic tests with propranolol alone (0.2 mg/kg), verapamil alone (0.15 mg/kg), and propranolol plus verapamil, and group C had serial tests with propranolol alone, procainamide or quinidine (class Ia drug) alone, and propranolol plus a class Ia drug until VT could no longer be induced. All six patients in group A responded to propranolol alone. In group B, one patient responded to verapamil alone, and two patients responded to propranolol plus verapamil. In group C, three patients responded to propranolol alone, one patient responded to a class Ia drug alone, and one patient responded to propranolol plus a class Ia drug. During a follow-up of 7 to 37 (17.9 +/- 10.7) (+/- S.D.) months, VT has not recurred in any patient. Three patients treated initially with propranolol alone have required substitution of amiodarone due to refractory congestive heart failure. In patients requiring isoproterenol for VT induction, beta-blockade alone appears to be effective in preventing reinduction of VT caused by enhanced automaticity. A heterogeneous response occurs when the VT mechanisms are triggered automaticity or reentry. | 3 |
Effects of supplemental oxygen administration in an infant with pulmonary artery hypertension. In patients with pulmonary disease, pulmonary artery hypertension often occurs as a result of pulmonary artery vasoconstriction, primarily from hypoxia and alveolar hypotension. In this report we describe the hemodynamic effects of breathing supplemental oxygen in a child with bronchopulmonary dysplasia and pulmonary artery hypertension. These hemodynamic effects include an improvement in oxygenation, an increase in systemic vascular resistance, and a decrease in the pulmonary vascular resistance. As a direct result of these changes in vascular resistances, alterations of heart rate, cardiac index, stroke volume, aortic pressure, oxygen consumption, and pulmonary artery pressure have been shown to occur. Oxygen is widely used to treat many physiologic conditions. However, during the administration of supplemental oxygen, rarely do we recognize the hemodynamic changes associated with its use. These hemodynamic effects must be clearly understood and appreciated before oxygen administration in any clinical situation. | 3 |
Depressed adenoma of the stomach, revisited. Histologic, histochemical, and immunohistochemical profiles. For 52 patients with depressed adenomas of the stomach, histopathologic studies were done on 56 tumors and for 43 of them, histochemical and immunohistochemical features were examined. In addition, nondepressed adenomas (n = 57) and the depressed type of early gastric adenocarcinomas of the well-differentiated variety (n = 44) were studied as the controls. Depressed adenomas in the majority (73%) involved the entire thickness of the mucous membrane of the stomach with tubules of atypical epithelium, presenting a severe grade in many of the cases (41%). Paneth's cells were found in cases of a depressed adenoma, in significantly higher percentages (61%) than in those with a nondepressed adenoma (P less than 0.01). The frequency of cases with argyrophil cells was also higher in depressed adenoma (63%) than in nondepressed adenoma (36%) or in cases of early gastric carcinoma (32%). Carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 were noticed in tumor cells, immunohistochemically in 28% of the cases with depressed adenoma, the frequency being intermediate between cases of a benign nondepressed adenoma (6% for both CEA and CA 19-9) and cases of early gastric carcinoma (71% for CEA and 66% for CA 19-9). No difference was noticed in lectin reactivity and mucin content between depressed and nondepressed adenomas, whereas tumor cells in the early depressed carcinoma had a higher lectin reactivity and less mucin content than those seen in the adenomas. It would thus appear that depressed adenoma is a benign neoplastic lesion; however, the malignant potential of this lesion is somewhat higher than the nondepressed counterpart, as indicated by the immunoreactivity to tumor markers and follow-up results reported by colleagues previously. | 0 |
Empiric treatment of fungal infections in the neutropenic host. Review of the literature and guidelines for use. Persistent fever that is refractory to broad-spectrum antibacterials is common in neutropenic patients undergoing induction chemotherapy of acute leukemia. Clinical experience suggests that many of these patients are infected with fungi. Until recently, data supporting the role of empiric antifungal therapy in this setting were limited to small groups of patients or postmortem reports. Evolving evidence in larger patient populations supports data from smaller series: febrile neutropenic patients who have failed to respond to a 4- to 7-day course of broad-spectrum antibacterials may benefit from the early initiation of antifungal therapy. Patients with fungal colonization or pulmonary infiltrates and adult patients who have not received previous fungal prophylaxis may especially benefit from the early use of antifungal drugs. Amphotericin B has been the "gold standard" for empiric antifungal therapy, although the newer azoles may be useful in certain situations. | 4 |
Augmentation mentoplasty using Mersilene mesh. Many different materials are available for augmentation mentoplasty. However, the optimal implant material for chin implantation has yet to be found. During the past several years, a number of experienced surgeons have turned to the use of Mersilene mesh. Mersilene mesh is a non-absorbable Dacron polyester fiber that can be conformed easily into layers to achieve tailored dimensions and shape. At the McCollough Plastic Surgery Clinic PA, Birmingham, Ala, 277 patients over a 10-year period underwent chin augmentation with Mersilene mesh implants. The material provides excellent tensile strength, durability, and surgical adaptability. The overall complication rate was 3.2% (nine patients); infection rate, 2.5% (seven patients); and removal secondary to infection, 1.7% (five patients). Based on this 10-year experience, Mersilene mesh remains our material of choice for chin augmentation. | 4 |
Role of percutaneous fine-needle aspiration biopsy in suspected intrathoracic malignancy. Percutaneous fine-needle aspiration (PFNA) biopsy is an accepted technique for the diagnosis of suspected intrathoracic malignancy, but the appropriate indications for its use have not been clearly defined. To help establish guidelines, we performed a retrospective analysis of 188 patients who underwent PFNA biopsy for suspected intrathoracic malignancy. Biopsy led to a diagnosis in 72% (135/188) of the patients, but in 27% (50/188) samples were inadequate for cytological diagnosis, and in 2% (3/188) samples were adequate but failed to yield a diagnosis. Fifty-three patients underwent surgical intervention, thus allowing histological confirmation of the cytological diagnosis. In patients with a diagnosis from PFNA biopsy, operation confirmed malignancy in 97% (37/38) and a specific cell type in 79% (30/38). In patients without a diagnosis after biopsy, a malignancy was found in 73% (11/15) at the time of operation. This suggests a high rate of accuracy when PFNA biopsy provides a diagnosis. However, it also illustrates that a substantial percentage of PFNA biopsy attempts fail to yield a diagnosis in patients ultimately found to have malignancies. This implies that PFNA biopsy might best be reserved for patients who are not surgical candidates. | 0 |
Intra-abdominal abscess in regional enteritis. Intra-abdominal abscess (IAA) developed in 129 of 610 patients (21.2%) with Crohn's disease confined to the small bowel. The location of the abscess was intraperitoneal (IPA) in 109 (17.9%) and retroperitoneal (RPA) in 20 (3.3%). There was a marked preponderance of male patients in the retroperitoneal group (ratio, 18:2) (p less than 0.0001). All 129 patients were operated on. Thirteen of one hundred nine patients (12%) with IPA were reoperated on for recurrent abscess, and nine (8.2%) for other reasons. External fistula developed in 24 patients (22%) after simple incision and drainage. Four (3.7%) died; one from hepatitis, and three from sepsis 5, 14, and 90 days after surgery. Of the 20 patients with RPA, two (10%) were reoperated on for recurrent abscess and four (20%) for other reasons. External fistula developed in two patients (10%). There were no deaths in this group. A small number of patients with IAA complicating regional enteritis had persistent sepsis causing postoperative death, which is, however, six times lower than in our comparable series of Crohn's (ileo)colitis. | 1 |
Transient left ventricular filling abnormalities (diastolic stunning) after acute myocardial infarction. A variety of experimental studies suggest that diastolic left ventricular (LV) function changes after acute myocardial infarction (AMI), but limited data exist on these changes in humans. To assess diastolic filling after AMI, 60 patients underwent Doppler echocardiographic examination within 24 hours of AMI. Of 54 patients who also underwent catheterization, 45 (83%) were successfully reperfused. A subgroup of 17 patients underwent a follow-up Doppler examination at 7 days after infarction, whereas 15 patients with stable exertional angina served as control subjects. There was no significant difference in age, gender, incidence of systemic hypertension or diabetes mellitus, heart rate, mean arterial pressure or severity of coronary artery disease between the infarct and control groups. The infarct group had a lower velocity time integral total (9.9 +/- 0.4 cm vs 12.0 +/- 0.9 cm, p less than 0.001), a lower velocity time integral E (5.8 +/- 0.3 cm vs 6.8 +/- 0.5 cm, p less than 0.01) and a lower velocity time integral 0.333 (3.5 +/- 0.4 cm vs 6.1 +/- 0.5 cm, p less than 0.01) than the control group. In addition, velocity time integral A/total was significantly greater in the infarction group (0.44 +/- 0.03 vs 0.35 +/- 0.04, p less than 0.01) compared to the control group. The follow-up subgroup showed an increase in velocity time integral total (p less than 0.01), velocity time integral E (p less than 0.05) and velocity time integral 0.333/total (p less than 0.05) over the first 7 days after infarction. The final recovery values at 7 days were not significantly different from those of the coronary artery disease group. | 3 |
Common nonvenereal genital lesions. There are a wide variety of local and systemic skin diseases that produce lesions in the genitoanal region. These lesions may resemble those produced by sexually transmitted microorganisms. The purpose of this article is to make physicians aware of the common skin diseases that produce lesions on the genitalia to avoid the inappropriate diagnosis of a sexually transmitted disease. | 0 |
Changes in physician practice for the prevention of cardiovascular disease. To determine recent changes in physicians' practices for cardiovascular disease risk reduction, a randomly selected sample of practicing primary care physicians in the upper Midwest was interviewed by telephone in 1987 and again in 1989 (response rates, greater than 90%; N = 241). The reported mean cutoff levels for labeling a total serum cholesterol level as abnormal dropped from 5.84 to 5.43 mmol/L (226 to 210 mg/dL) and for initiating medication, from 7.34 to 6.54 mmol/L (284 to 253 mg/dL). The proportion of physicians using diuretics as preferred step 1 antihypertensive agents dropped from 60% to 32%. Preferences became evenly divided among diuretics, angiotensin-converting enzyme inhibitors, and beta-blockers. Advice about physical exercise changed little, but consensus among practicing physicians was high. Substantial improvements were found in smoking cessation activities. Practicing physicians are proving to be responsive to new scientific evidence and education in the prevention of cardiovascular disease. | 3 |
Reappraisal of the mechanism for cerebrospinal fluid hypertension during aortic surgery. Cerebrospinal fluid (CSF) hypertension during aortic surgery is a poorly understood, multifactorial event that may increase the risk of spinal cord injury. To assess the factors that may contribute to changes in CSF pressure during aortic surgery, measurements of ascending arterial and CSF pressures were made in 17 anesthetized mongrel dogs. Changes in CSF patterns were monitored under several conditions tested in random sequence. These included systemic hypertension produced by an infusion of phenylephrine, cross-clamping of the descending thoracic aorta, and manual, superior displacement of the transverse aortic arch (arch elevation), either alone or in conjunction with the cross-clamp. Hypertension, cross-clamping, and cross-clamping combined with arch elevation all produced significant increases in ascending mean arterial pressure (204 +/- 20, 170 +/- 8, and 158 +/- 11 mm Hg, respectively, vs. 117 +/- 8 mm Hg [control]; (p less than 0.01). Small, nonsignificant increases in CSF pressure were detected in the cross-clamp group, but none were detected with hypertension alone, despite significant increases in ascending arterial blood pressure in both groups. Thus, neither arterial hypertension nor cross-clamping alone could be demonstrated directly to cause significant CSF hypertension. However, when aortic elevation (displacement) was combined with cross-clamping, the rise in CSF pressure increased to significant levels, even though the ascending arterial hypertension was least severe in this group. In contrast, arch elevation alone did not produce any significant increase in ascending arterial pressure but did produce an approximately 114% increase in CSF pressure (15.2 +/- mm Hg vs. 7.7 +/- 1 mm Hg [control]; p less than 0.01. | 3 |
Altered expression of the retinoblastoma gene product in human sarcomas. BACKGROUND. The retinoblastoma-susceptibility (Rb) gene is a prototype tumor-suppressor gene originally isolated from patients with heritable retinoblastoma. This gene encodes a nuclear phosphoprotein whose expression is altered in several types of human tumors. METHODS. We studied the expression of the Rb protein in 44 primary and 12 metastatic high-grade human sarcomas by means of immunohistochemical methods and Western blotting. Computerized image analysis was used to quantify the level of Rb gene product in individual tumor cells. The expression of the Rb gene was then correlated with clinical outcome in the patients with primary tumors. RESULTS. Of the 44 patients with primary sarcomas, 13 (30 percent) had tumors with normal, homogeneous expression of the Rb protein in essentially all tumor cells. Thirty-one patients with primary tumors (70 percent) had altered Rb expression; in 18 (40 percent) the Rb protein was heterogeneously expressed, and in 13 (30 percent) it was detected in fewer than 20 percent of the tumor cells. All 12 of the patients with metastatic sarcomas had altered expression of the Rb protein. When the findings in the patients with primary tumors were correlated with clinical outcome, survival was found to be significantly increased in the patients whose tumors had homogeneous Rb expression, as compared with those with either heterogeneous expression (P = 0.026) or no expression (P = 0.012). CONCLUSIONS. Tumors in which the expression of Rb gene product was decreased were more aggressive than tumors in which this protein was expressed by nearly all cells. The Rb gene product may be an important prognostic variable in patients with these tumors. | 4 |
Treatment selection for carcinoma of the base of the tongue. Between 1974 and 1984, 173 patients were treated for squamous cell carcinoma of the tongue base. Fifty-four patients had T1 or T2 primaries, while 115 patients had T3 or T4 tumors (4 were not staged). Lymph node metastasis was present in 120 patients. Early primary tumors treated with surgery or radiotherapy had a control rate of 83% (5 of 6 tumors) and 89% (40 of 45 tumors), respectively. For advanced primary tumors, definitive radiotherapy produced a local control rate of 55% (42 of 76 tumors), compared with 79% (23 of 29 tumors) for surgery and postoperative radiotherapy. If primary control was obtained, the regional failure rate was less than 10%. Tumor growth patterns were predictive of the response to radiotherapy. The primary control rate at 2 years for 21 patients with exophytic tumors was 84% as opposed to 58% for 62 patients with ulcerative-infiltrative tumors (p = 0.04). Radiotherapy is effective for early stage or exophytic tumors, whereas for advanced or deeply invasive tumors combined therapy enhances local control. | 0 |
Isolation of measles virus in primary rhesus monkey cells from a child with acute interstitial pneumonia who cytologically had giant-cell pneumonia without a rash. The isolation of measles virus in primary Rhesus monkey kidney cells (PRMK) in patients with documented giant-cell pneumonia who have presented without a rash is limited. The diagnosis usually is made by cytologic examination of nasal or bronchial secretions in which characteristic multinucleated giant cells with intranuclear and intracytoplasmic inclusion bodies are observed. The diagnosis of giant-cell pneumonia has been associated with measles virus but not exclusively. Canine distemper, herpes group viruses, and parainfluenza infections have been associated with these cells. In addition, vitamin A deficiency also has been cytologically associated with multinucleated giant cells. The authors describe the isolation of measles virus from bronchial washing and sputum in PRMK cells at 4 days from an 11-year-old child with acute interstitial pneumonia who was in remission for acute lymphocytic leukemia. Classic cytopathologic effect (CPE) consisting of syncytial and hole formation on the PRMK monolayer was apparent. In addition, a foamy appearance of the monolayer was noted in an otherwise clean lot of monkey cells. Confirmatory testing with measles antibody of the infected areas of the monolayer by indirect immunofluorescence (IFA) was positive for measles antigen and negative for mumps, parainfluenza (types I, II, and III) and influenza A and B virus. Serologic studies for measles antibody revealed an IFA IgG titer of greater than 1:10,240, and an IgM titer of 1:128. Cytologic examination of the same bronchial fluid revealed the typical giant cells with characteristic inclusions associated with measles virus. Because this disease usually is severe, and often fatal, prompt recognition of this virus is essential, not only to the patient, who can be treated with immunoglobulin and/or antiviral therapy, but also to prevent the spread of the virus to other patients and medical personnel. These findings also support direct evidence for the etiologic role of measles virus in giant-cell pneumonia that has been detected either histologically or cytologically and in tissue culture at autopsy. | 0 |
Immunological studies before and during interferon therapy in chronic HBV infection: identification of factors predicting response. Lymphoblastoid interferon is effective therapy in some but not all patients with chronic hepatitis B virus infection. To assess whether immunological parameters were predictive of response to interferon therapy, we determined the human leukocyte antigen type, CD4/CD8 ratio, natural killer cell activity, IgM anti-HBc antibody levels and concanavalin A-induced lymphocyte proliferative response in 30 patients before treatment. In addition, to investigate the mechanisms of action of interferon in promoting hepatitis B virus clearance, we serially measured the CD4/CD8 ratios, natural killer activity and lymphocyte proliferative response at wk 4, 8 and 12 of treatment. A beneficial response to therapy was defined as the sustained clearance of HBeAg and serum hepatitis B virus DNA within 1 yr of commencing therapy. Elevated IgM anti-HBc levels were associated with a beneficial response to therapy, but there was no correlation observed between response and pretreatment CD4/CD8 ratio, natural killer activity or lymphocyte proliferative response. Six of seven human leukocyte antigen DR3-positive patients responded. No measurable changes in the immunological parameters studied were observed in the nonresponder group, whereas a significant rise in CD4/CD8 ratio, associated with a fall in peripheral CD8 number and a decline in measurable NK activity, was seen in the responder group. These changes were maximal at the time of hepatitis B virus DNA clearance, which was associated with a transient increase in hepatic inflammation. | 1 |
Hemodynamic status in critically ill patients with and without acute heart disease. Physicians have been urged to reduce the use of the pulmonary artery catheter. However, there are no guidelines to help the clinician make the decision to use or withhold invasive monitoring in the individual patient. This study was designed to examine the accuracy of physician estimates of cardiac function in a spectrum of patients with hemodynamic instability to determine whether differences in accuracy among subgroups would suggest subgroups of patients who could be managed without invasive measurements. Physician estimates of cardiac index were found to be sufficiently accurate in patients without acute heart disease that initial management without invasive monitoring may be appropriate in selected cases. However, due to the general inaccuracy of physician estimates, efforts to improve the accuracy of clinical judgments of cardiac function and hemodynamic status should be pursued with vigor in patients both with and without acute cardiac dysfunction. | 3 |
Monosomy 22 in rhabdoid or atypical tumors of the brain. Cytogenetic studies of three rare childhood brain tumors were performed. Two children presented with pure rhabdoid tumors. The third child had a tumor composed of a mixture of rhabdoid elements with neuroepithelial, epithelial, and mesenchymal tissue - an atypical teratoid tumor. All three tumors demonstrated monosomy 22 as the only cytogenetic abnormality. The cytogenetic findings suggest that loss of a gene or genes on chromosome 22 may be involved in the initiation or progression of these malignant tumors. Further studies on additional fresh tumor specimens are warranted; however, it is possible that cytogenetic studies may be used as an additional means of diagnosing rhabdoid or atypical teratoid tumors of the brain. | 4 |
Capillary prolactin measurement for diagnosis of seizures. Measurement of serum prolactin levels can be useful in the diagnosis of epilepsy, since prolactin levels often rise after seizures, but not after most imitators of epilepsy. Utility of the test is limited by the need to obtain blood 10 to 20 minutes after the episode. The present study documents the validity of prolactin measurements using capillary blood, which was obtained by the finger-stick method after a possible seizure and then applied to filter paper. Venous and capillary prolactin levels were determined 10 to 20 minutes after seizure-like episodes in 20 patients who were studied in an epilepsy monitoring unit. Venous and capillary prolactin values correlated, with a Pearson coefficient of 0.90. Using a criteria of any elevation above the laboratory upper limit of normal, capillary prolactin values correctly identified seizure versus pseudoseizure in 9 (100%) of 9 patients with generalized tonic-clonic seizures, in 5 (71%) of 7 patients with complex partial seizures, and 4 (100%) of 4 patients with pseudoseizures. Prolactin values were unaffected by leaving filter paper samples at room temperature for up to 1 week. This study suggests the utility of diagnostic capillary blood collection kits to assist in the diagnosis of epilepsy in outpatients. | 2 |
Progression through the cell cycle: an overview. Tissues in adults can be maintained at constant mass or they can increase or decrease in size because of imbalances of synthetic and degradative processes acting at the cellular and molecular levels. Some size changes are caused by physiologic conditions to which the tissue must adjust. Alternatively, the balance may be distorted in favor of net tissue increase in pathologic situations such as cancer. Strict regulatory mechanisms are required to keep proliferation responsive to the organism's needs; these mechanisms may be defective in disease. Net tissue proliferation requires repeated rounds of cell duplication in excess of that necessary to counterbalance cell death. Duplication of a cell requires a net doubling of its every molecule and structure. The myriad of molecular events required for cell proliferation such as DNA duplication and its partitioning at mitosis are tightly regulated in normal cells. One may conceive of two classes of molecules: those required for "housekeeping," which constitute the cell's structural and functional machinery, and those such as growth factors, their receptors, and second messengers involved in signal transduction responsible for regulating the activities of the housekeeping molecules. These molecular events and the cascade of processes that control them can be organized within the sequence of the cell cycle. In this brief overview, we illustrate these issues with a few examples taken from very recent discoveries of novel proteins that appear to have major regulatory roles. Most of these results have been obtained with mammalian fibroblasts, but some have originated with discoveries made using two very different yeasts. | 4 |
The use of the Jarvik-7 total artificial heart and the Symbion ventricular assist device as a bridge to transplantation. The proliferation of transplantation programs has not been paralleled by a similar increase in the availability of organ donors. Between 1984 and 1987, 104 orthotopic heart transplantations were performed at Loyola University Medical Center. During the same period, 25 patients died while awaiting a donor organ. To reduce the mortality, we began using the total artificial heart (TAH) and a ventricular assist device (VAD) as a bridge to transplantation in 1988. Of 29 patients who underwent transplantation, 15 patients required a TAH and three patients required a VAD as a bridge. The underlying heart conditions were ischemic cardiomyopathy (11 patients), dilated cardiomyopathy (5 patients), giant cell myocarditis (1 patient), and allograft failure (1 patient). The average duration of mechanical support was 10 days (range, 1 to 35 days). Of the 17 patients who successfully underwent transplantation, 1 patient died at 17 days because of acute rejection of the transplanted heart, and another patient died at 14 days because of a cerebral vascular event. Fifteen patients (83%) were long-term survivors. Nine patients required reoperation for bleeding. While the mechanical device was in place, the activated clotting time was maintained between 170 and 200 seconds with heparin. Dipyridamole was given. We conclude that the TAH and VAD are excellent mechanical bridges to transplantation. | 4 |
Left atrial to femoral arterial bypass using the biomedicus pump for operations of the thoracic aorta. Left atrial to left femoral arterial bypass is an approach to operations of the thoracic aorta dating back to the late 1950s. Since that time, various modifications of the basic bypass circuit have evolved. In addition, temporary bypass shunts have also been described in a variety of positions. The goals of bypass of the thoracic aorta regardless of the technique include prevention of distal hypoperfusion, which can lead to paraplegia, limb loss, multiple organ failure, and sometimes death. Recently, there have been reports of the use of the biomedicus centrifugal pump in bypass circuits of the thoracic aorta. Our series, as well as the success of others, using this variation of a traditional bypass circuit of the thoracic aorta, establishes the biopump's capability of minimizing inherent complications in the bypass circuit. | 3 |
US-assisted aspiration thrombectomy: in vitro investigations. The authors describe the use of a new ultrasound (US)-aspiration thrombectomy technique. An oscillating US probe was inserted into a thin-walled, large-bore aspiration catheter. Experiments tested the ability of the new device and other catheter combinations to remove clot material from a Petri dish, as well as from small and large vessel models made of silicone and glass tubes, respectively. Results of the experiments demonstrated that an oscillating 1.0-mm US probe inserted into an aspiration catheter (7-9 F in diameter) promoted clot fragmentation and allowed continuous aspiration of thrombi of any size. When compared with simple large-bore catheter aspiration and with mechanical fragmentation by means of a US probe within a catheter that was flushed to cool the probe, US-assisted aspiration thrombectomy demonstrated significantly better results for percutaneous transcatheter removal of fresh thrombi. | 3 |
Cardiac echinococcosis with fatal intracerebral embolism. A previously well 7 year old boy presented with sudden loss of consciousness and fitting. No evidence of trauma or space occupying lesion was identified. Death occurred the next day due to cerebral infarction caused by embolised fragments from a ruptured left ventricular hydatid cyst that was found at necropsy. | 3 |
Poisoning with equine phenylbutazone in a racetrack worker. Phenylbutazone is a potent nonsteroidal, anti-inflammatory drug often used by veterinarians to treat racetrack animals. Its use in human beings is limited because of significant adverse effects and the availability of newer, safer drugs. We report the case of a 24-year-old man who ingested 17 g of equine phenylbutazone over a 24-hour period to treat the pain of a toothache. He developed grand mal seizures, coma, hypotension, respiratory and renal failure, and hepatic injury. Serum phenylbutazone concentration obtained approximately eight hours after presentation was 900 micrograms/mL. The patient recovered during six weeks of intensive supportive care and repeated hemodialysis. | 2 |
Effect of hypoxia on cerebral metabolites measured by proton nuclear magnetic resonance spectroscopy in rats. Proton nuclear magnetic resonance spectroscopy is a unique method to monitor noninvasively the concentrations of cerebral metabolites. N-Acetyl-L-aspartate, the concentration of which is assumed to be stable during hypoxia, has been used to form ratios with lactate. To determine the stability of the signal from N-acetyl-L-aspartate, we used a model of graded hypoxia in rats to monitor the percentage changes from baseline of the peak heights for lactate, lipids, and N-acetyl-L-aspartate. Anesthetized adult rats were exposed sequentially to 15% and 10% O2 while proton nuclear magnetic resonance spectra were collected with a surface coil in a 7-T 89-mm-bore spectrometer. Brain lactate concentration was either increased by feeding or infusion of glucose (n = 9) or lowered by fasting (n = 7). After death the brains were removed and frozen, and the water- and lipid-soluble compounds were extracted to identify the origin of the signals. We analyzed the data both as the percentage change from baseline for heights of the lactate (1.33 ppm), lipids (1.5 ppm), and N-acetyl-L-aspartate (2.02 ppm) peaks and as the ratios of heights of the 1.33 and 2.02 and the 1.5 and 2.02 ppm peaks. Both hypoxic episodes caused a 45% decrease from baseline in the 2.02 ppm peak. During the second hypoxic episode, the 1.33:2.02 ppm peak height ratio increased significantly in hyperglycemic rats (p less than 0.05) but was unchanged in hypoglycemic rats. | 4 |
Rupture of atheromatous plaque as a cause of thrombotic occlusion of stenotic internal carotid artery. We analyzed the clinical profiles and autopsy findings of five patients who died shortly after developing cerebral infarction following thrombotic occlusion of the internal carotid artery. In all five cases, thrombotic occlusion was caused by rupture of the fibrous lining over the gruel of atheroma at the origin of the internal carotid artery showing tight stenosis of the lumen. The mean +/- SD shorter diameter of the lumen at the site of occlusion was 1.5 +/- 0.4 mm. Our results show that an internal carotid artery with tight stenosis of the lumen by atheroma containing gruel harbors a risk of thrombotic occlusion, which may give rise to cerebral infarction by artery-to-artery embolism or by reduced cerebral perfusion. | 3 |
Portacaval shunt versus endoscopic sclerotherapy in the elective treatment of variceal hemorrhage. Eighty-two consecutive Child-Campbell class A and B cirrhotic patients were included in a prospective controlled trial to assess the efficacy and safety of portacaval anastomosis vs. endoscopic sclerotherapy as elective treatment of variceal hemorrhage. Forty-one patients were randomized to portacaval anastomosis and 41 to sclerotherapy. After excluding dropouts, 34 patients were treated with portacaval anastomosis and 35 with sclerotherapy. The incidence of variceal rebleeding during follow-up (mean +/- SD, 20.6 +/- 14.2 months) was significantly higher in the sclerotherapy than in the portacaval groups, either considering the overall treated group or only patients completing sclerotherapy (40% and 25% vs. 2.9%; P = 0.0002 and P = 0.01, respectively). The 2-year probability of suffering from at least one episode of hepatic encephalopathy was significantly higher in patients submitted to portacaval anastomosis than in those treated with endoscopic sclerotherapy (40% vs. 12%; P = 0.04). However, disabling encephalopathy only appeared in 3 of 34 patients who underwent surgery (8.8%). Early and long-term mortality did not differ between the therapeutic groups; 2-year survival rates were 83% for portacaval anastomosis and 79% for sclerotherapy. It is concluded that portacaval anastomosis is more effective than endoscopic sclerotherapy in preventing variceal rebleeding in spite of the greater incidence of hepatic encephalopathy. The role of portacaval anastomosis in the elective treatment of variceal rebleeding should be reassessed. | 2 |
Extracorporeal shock wave lithotripsy in combination with transurethral surgery for management of large bladder calculi and moderate outlet obstruction. In 5 men evaluated for symptoms of obstructive voiding flexible cystoscopy revealed large or multiple bladder calculi along with small to moderate prostatic enlargement. All patients had successful localization and fragmentation of calculi with the Dornier HM3 lithotriptor. Of these patients 4 underwent transurethral resection or incision of the prostate under the same epidural anesthesia for moderate prostatic obstruction without complication and 1 subsequently required suprapubic prostatectomy of a gland with a large middle lobe that made a transurethral operation difficult. Extracorporeal shock wave lithotripsy should be considered for the primary management of large or hard bladder calculi and it is of particular value in combination with a transurethral operation for patients with small to moderate prostatic obstruction. | 4 |
Vitamin C and cancer prevention: the epidemiologic evidence. Epidemiologic evidence of a protective effect of vitamin C for non-hormone-dependent cancers is strong. Of the 46 such studies in which a dietary vitamin C index was calculated, 33 found statistically significant protection, with high intake conferring approximately a twofold protective effect compared with low intake. Of 29 additional studies that assessed fruit intake, 21 found significant protection. For cancers of the esophagus, larynx, oral cavity, and pancreas, evidence for a protective effect of vitamin C or some component in fruit is strong and consistent. For cancers of the stomach, rectum, breast, and cervix there is also strong evidence. Several recent lung cancer studies found significant protective effects of vitamin C or of foods that are better sources of vitamin C than of beta-carotene. It is likely that ascorbic acid, carotenoids, and other factors in fruits and vegetables act jointly. Increased consumption of fruits and vegetables in general should be encouraged. | 0 |
Intraoperative transesophageal color-coded Doppler echocardiography for evaluation of residual regurgitation after mitral valve repair. Because mitral valve competence after mitral valve reconstruction is awkward to assess during this procedure, we evaluated in this respect transesophageal color-coded Doppler echocardiography in 23 patients undergoing mitral valve reconstruction for severe mitral regurgitation. Transesophageal echocardiographic examinations were performed after induction of anesthesia but before sternotomy (baseline), after mitral valve repair before decannulation, and at sternal closure, all at similar mean aortic pressure and echocardiographic instrument settings. The degree of mitral regurgitation by transesophageal color Doppler flow mapping was visually quantified on a 5-point scale (0 to 4), pending the left atrial extent of the regurgitant jet. This was compared with the degree of mitral regurgitation by left ventricular cineangiography performed within several weeks after operation and also visually quantified on a 5-point scale (0 to 4), with use of the right anterior oblique projection. There was good correlation between the two methods (r = 0.83; p less than 0.001). We conclude that residual mitral regurgitation, as assessed by transesophageal color flow mapping in the operating room, highly correlates with the ultimate mitral regurgitation by cineangiography. Therefore transesophageal echocardiography can be helpful for evaluation of mitral valve competence during mitral valve reconstruction, and hence, in case of repair failure, allow valve replacement in the same surgical session, thus avoiding reoperation. | 3 |
A simple and sensitive microtiter plate estrogen bioassay based on stimulation of alkaline phosphatase in Ishikawa cells: estrogenic action of delta 5 adrenal steroids. We have developed an estrogen bioassay using the Ishikawa human endometrial adenocarcinoma cell line growing in 96-well microtiter plates. Alkaline phosphatase enzyme activity (AlkP) in these cells is markedly stimulated by estrogens, and this enzyme can be easily quantified in situ using a chromogenic substrate. These cells are very sensitive to estrogens; estradiol induces AlkP at levels as low as 10(-12) M. Antiestrogens completely block the action of estradiol. Various estrogens stimulate AlkP with potencies comparable to those achieved in vivo. The induction of AlkP is specific for estrogens; no other type of steroid, including androgens, progestins, mineralocorticoids, or glucocorticoids produce this effect. The stimulation of AlkP in Ishikawa cells is specific for estrogens, is highly reproducible and sensitive, and permits large numbers of samples to be assayed with ease. We have used this assay to investigate the estrogenic action of the adrenal delta 5-3 beta-hydroxysteroids. While pregnenolone is inactive, dehydroepiandrosterone and its sulfate ester induce AlkP slightly. However, the C19 steroid, 5-androstene-3 beta, 17 beta-diol is considerably more estrogenic in this assay, although it stimulates Ishikawa AlkP with a potency of 1/30,000 that of estradiol. The stimulation by 5-androstene-3 beta,17 beta-diol is inhibited by antiestrogens, but it is not blocked by the delta 5-3 beta-hydroxysteroid isomerase/dehydrogenase inhibitor, cyanoketone, or by the aromatase inhibitor, 4-hydroxy-androstenedione. Thus, neither conversion to a delta 4-3-ketone nor aromatization is required for the action of this unusual estrogen. | 0 |
The diagnosis and management of aortic dissection. Aortic dissection is a severe disease. Most untreated patients with types I and II (proximal) dissection and over half of those with type III (distal) dissection die within 1 year. Most of the deaths occur within 2 weeks and are caused by rupture, aortic insufficiency, and branch vessel obstruction. Aortic dissection is suspected in patients with anterior chest and back pain that progresses downward. Diagnosis is confirmed by computed tomography, aortography, or echocardiography. Appropriate medical treatment and corrective surgery, including total aortic replacement, performed in the acute and chronic stages, are now successful in over 90% of the cases; long-term results of treatment are steadily improving and are expected to exceed 50% at 10 years. The keys to a successful outcome are being aware of the symptoms of dissection, early diagnosis, and prompt application of appropriate treatment; diligent follow-up includes controlling blood pressure, decreasing the velocity of left ventricular contraction, monitoring the size of the residual aorta, and taking appropriate action if redissection, aneurysmal formation, or rupture occurs. | 3 |
Clinical nuclear magnetic resonance spectroscopy: insight into metabolism. Nuclear magnetic resonance (NMR) spectroscopy can nondestructively evaluate changes in metabolites with different disease states, as well as with therapeutic interventions. Animal studies have provided the basis for understanding changes in high-energy phosphates with myocardial ischemia. Studies of graded ischemia due to partial coronary stenosis have shown the sensitivity of the ratio of phosphocreatinine to inorganic phosphate to small reductions in myocardial blood flow and its relation to myocardial function. The application of NMR spectroscopy to humans requires precise localization techniques to avoid acquiring contaminating information from structures around the heart, such as the chest wall and diaphragm. With these localization techniques, metabolic evidence of ischemia has been demonstrated in patients with myocardial infarction and patients with known coronary disease, although the sensitivity of this technique for the diagnosis of inducible ischemia is unknown. At rest, patients with dilated and hypertrophic cardiomyopathies often have an elevated phosphodiester resonance, possibly signifying abnormal breakdown of membrane phospholipids. Increasing oxygen demand in these patients does not usually alter high-energy phosphates, suggesting that oxidative energy metabolism is preserved under these conditions. NMR spectroscopy is a powerful tool to increase understanding of metabolic changes in a variety of pathologic conditions. | 3 |
Successful treatment of an excimer laser-associated coronary artery perforation with the Stack perfusion catheter. A 64-year-old woman underwent excimer laser angioplasty of the right coronary artery. The procedure was complicated by perforation, which was successfully managed without complication with a Stack perfusion catheter. This report describes successful nonsurgical treatment of laser-induced coronary perforation and makes recommendations for avoiding this complication in other patients. | 4 |
Flow cytometric evaluation of chemosensitive and chemoresistant head and neck tumors. For patients with head and neck squamous carcinoma, a clinical response to induction chemotherapy has correlated with a survival advantage. Similarly, patients with diploid tumors have displayed a survival advantage when compared with patients with aneuploid tumors. This study examined DNA content in 33 patients who had undergone induction chemotherapy as part of two clinical protocols to determine if there was a correlation between the patients with diploid tumors and the patients with a clinical response to chemotherapy. Although patients with stage III tumors had a longer disease-free survival than stage IV patients (p less than 0.0002), the addition of DNA content information did not improve the ability to predict response. Specifically, there was no correlation between DNA content and the response to chemotherapy. In addition, for this group of patients, a diploid DNA content was not correlated with a survival advantage. We conclude that DNA content information did not add significantly to the prediction of clinical outcome in these patients who received induction chemotherapy. | 0 |
Anterior segment ischemia: a complication of retinal detachment repair in a patient with sickle cell trait. Anterior segment ischemia (ASI) is a dreaded complication of retinal detachment surgery particularly in patients with predisposing factors such as sickle cell disease. We report a case of ASI after scleral buckling in an otherwise healthy black patient with sickle cell trait. Conditions of relative hypoxia intraoperatively from either anesthesia or surgical manipulation may precipitate vasoocclusive phenomena in these normally asymptomatic patients. Since the incidence of sickle cell trait in the black population in the United States is 8.5%, we recommend these patients have a preoperative sickle test followed by hemoglobin electrophoresis with quantification if positive. The presence of sickle cell trait should alert the surgeon to the risk of ASI, and factors predisposing to hypoxia should be minimized when possible. | 3 |
Transesophageal echocardiography during percutaneous balloon mitral valvuloplasty. To ascertain the value of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty, the present study was undertaken in 26 anesthesized patients (21 women and 5 men; mean age, 47 years) with symptomatic rheumatic mitral valve stenosis. In all but one patient the balloon dilation of the mitral valve was successful and Doppler-derived valve area increased (0.9 +/- 0.3 to 1.9 +/- 0.4 cm2). Transesophageal echocardiography provides continuous monitoring, as well as guidance of the procedure. Crossing the arterial septum, as well as delivery of the sheath through the mitral valve orifice and correct positioning of the balloon, was highly facilitated and reduced x-ray exposure time. The degree of mitral regurgitation and the presence of interatrial shunting at the end of the procedure could be readily assessed, making cineangiography not necessary. Complications of the procedure, such as pericardial effusion, could be detected before hemodynamic deterioration had occurred (one patient). The advantages of transesophageal echocardiography for routine monitoring of percutaneous mitral valvuloplasty, however, should be weighted against the added risk and expense of this support. | 3 |
Chronic posterior subluxation and dislocation of the radial head. The clinical and radiographic features of chronic posterior subluxation or dislocation of the radial head were studied in thirty-four elbows of twenty-seven patients. Three characteristic radiographic types were noted: Type I, subluxation; Type II, posterior dislocation with minimum displacement; and Type III, posterior dislocation with substantial proximal migration of the radius. Follow-up of eighteen patients (twenty-one elbows) revealed that posterior displacement did not usually cause serious functional impairment except for loss of rotation of the forearm. The least common presentation, Type-I subluxation, caused pain and clicking and was associated with late degenerative arthritis. Cosmetic deformity due to prominence of the radial head was also a cosmetic problem, particularly with Type-III dislocation. | 4 |
An improved photochemical model of embolic cerebral infarction in rats. To provide further evidence that the multiple cerebral infarcts found in rats following photochemical damage to the carotid artery are caused by emboli and to eliminate the systemic hypotension and heating of the blood reported with the previous photochemical embolic stroke model (rose bengal and a green laser), I have modified the photochemical technique. Brain pathology was studied in 18 Wistar rats following carotid artery irradiation with a red laser (632 nm) at powers ranging from 100 to 800 mW/cm2 for 10 or 20 minutes following the injection of the photosensitizing dye Photofrin II. Multiple cerebral arterioles were occluded by platelet aggregates containing frequent erythrocytes and leukocytes, identical to the thrombotic material in the carotid artery but different from the platelet aggregates seen in the carotid artery and the brain in the rose bengal model. Eighty infarcts were distributed randomly throughout the brain ipsilateral to the nonocclusive carotid thrombus. Significant heating (0.5 degree C or more) of the blood occurred only with laser powers higher (1,600 mW/cm2) or laser irradiations longer (25 minutes) than those used in the improved model of embolic stroke. This model mimics one mechanism of stroke in humans and provides a means to study systematically the morphological evolution of small cerebral infarcts. | 3 |
Human basophils express interleukin-4 receptors. Interleukin-4 (IL-4), a multipotential lymphokine reputed to play an important role in the regulation of immune responses, interacts with a variety of hemopoietic target cells through specific cell surface membrane receptors. The present study was designed to investigate whether human basophils express IL-4 binding sites. For this purpose, basophils were enriched to homogeneity (93% and 98% purity, respectively) from the peripheral blood of two chronic granulocytic leukemia (CGL) donors using a cocktail of monoclonal antibodies (MoAbs) and complement. Purified basophils bound 125I-radiolabeled recombinant human (rh) IL-4 in a specific manner. Quantitative binding studies and Scatchard plot analysis revealed the presence of a single class of high affinity IL-4 binding sites (280 +/- 40 sites per cell in donor 1 and 640 +/- 45 sites per cell in donor 2) with an apparent dissociation constant, kd, of 7.12 x 10(-11) +/- 2.29 x 10(-11) and 9.55 +/- 3.5 x 10(-11) mol/L, respectively. KU812-F, a human basophil precursor cell line, was found to express a single class of 810 to 1,500 high affinity IL-4 binding sites with a kd of 2.63 to 5.54 x 10(-10) mol/L. No change in the numbers or binding constants of IL-4 receptors was found after exposure of KU812-F cells to rhIL-3 (a potent activator of basophils) for 60 minutes. No effect of rhIL-4 on 3H-thymidine uptake, release or synthesis of histamine, or expression of basophil differentiation antigens (Bsp-1, CD11b, CD25, CD40, CD54) on primary human CGL basophils or KU812-F cells was observed. | 0 |
Comparison of pump-driven and spontaneous continuous haemofiltration in postoperative acute renal failure. In a comparison of spontaneous continuous arteriovenous haemofiltration (CAVH) and pump-driven haemofiltration (PDHF) for acute renal failure after surgery, 116 patients admitted to a surgical intensive care unit were assigned CAVH (48) or PDHF (68). The method of assignment was that a patient was treated by PDHF if he or she was the only patient requiring treatment at that time (only one pump was available); any other patient coming to the unit would be treated by CAVH. The groups were slightly unbalanced because there were fewer simultaneous cases than expected. The main endpoints were survival rate, control of uraemia, and additional application of haemodialysis. There were no differences between the patient groups in age, duration of treatment, severity of illness, serum creatinine concentration at the start of treatment, or cause of acute renal failure. Both treatments adequately controlled uraemia and fluid overload. However, the survival rate was significantly higher with PDHF than with CAVH (6 [12.5%] vs 20 [29.4%]; p less than 0.05). The daily ultrafiltrate volume was significantly higher with PDHF than with CAVH (15.7 [95% confidence interval 13.6-17.8] vs 7.0 [6.6-7.4] l/day; p less than 0.05). The volume of ultrafiltrate in patients with ischaemic or sepsis-induced acute renal failure was correlated with the survival rate. This finding suggests that the better survival rate in the PDHF group was due to faster elimination of toxic mediators (of molecular weight 800-1000 daltons) through the filter membrane by high-volume haemofiltration. | 4 |
Colorectal cancer: differences between community and geographically distant patients seen at an urban medical center. Many studies in clinical oncology rely on hospital-derived patients. Hospitals vary in the proportions of patients from the local catchment area vs. those from more distant places, of whom a larger proportion are presumably referrals. To study the differences between these two types of patients, we analyzed 1,245 colorectal cancer patients seen at a large urban medical center over a seven-year period. Three hundred ninety-eight patients were from the local community (32 percent), 489 were from the extended community (39.3 percent), and 358 from more distant communities (28.8 percent). The patients from the local community tended to be older and from minority ethnic groups. In addition, the local community patients were more likely to have advanced disease at the time of presentation. The grade of the tumor and its site distribution within the large bowel were similar for the three groups. After adjusting for age, sex, race, and stage of disease, the survival was somewhat better for the distant community patients as compared with the local and extended communities (P less than 0.02). Overall, in our patient population, the distant patients tended to have more favorable socioeconomic factors and less advanced disease, and these differences may account, in large part, for a better prognosis for these patients. Particularly in large cooperative trials, studies may need to take into account the respective proportions of local community and geographically distant patients in analyzing and generalizing treatment outcomes. | 0 |
Cyclosporin-associated akinetic mutism and extrapyramidal syndrome after liver transplantation. Three patients developed akinetic mutism on the third day after the introduction of intravenous cyclosporin A, given for immunosuppression after liver transplantation. One patient in addition developed a florid orofacial dyskinesia, which resolved completely, as did the akinetic mutism, after withdrawal of cyclosporin. In these patients the time course of the akinetic mutism and extrapyramidal syndrome, which developed in the absence of any other identifiable cause, suggests cyclosporin A was the precipitating factor. Subsequently, two of the patients showed signs of pseudobulbar palsy with abnormalities in the pons on MRI scanning, suggesting central pontine myelinolysis (CPM). None of the patients had experienced significant fluctuations in serum sodium or other risk factors for central pontine myelinolysis and the exact relationship to the earlier cyclosporin related mutism was not clear. | 2 |
The mutation for medullary thyroid carcinoma with parathyroid tumors (MTC with PTs) is closely linked to the centromeric region of chromosome 10. Two new morphs (F and G) detected by the centromeric alpha satellite probe p alpha 10RP8 and D10Z1 in HinfI digests are linked to the PstI polymorphisms of D10Z1, confirming their chromosome 10 location. The F and G morphs were in strong linkage disequilibrium with each other but were in weak linkage disequilibrium with the A and B morphs defined in PstI digests. Data for haplotypes formed by using the A and F morphs improved the lod score for linkage between the disease locus for multiple endocrine neoplasia type 2A (MEN2A) and D10Z1 (Z = 14.06 at theta = 0) in the six large families studied by Wu et al. Furthermore, the locus that codes for a distinct phenotype, medullary thyroid carcinoma (MTC) with parathyroid tumors (PTs) and no pheochromocytomas (PHEOs) (referred to as MTC with PTs), in one of the families was closely linked to two markers, D10Z1 and RBP3, with lodscores of 2.86 and 3.54, respectively, at theta = 0. A possible allelic association was noted between disease phenotypes and centromeric haplotypes. The phenotype MTC and PHEOs with and without PTs was associated with the same relatively common centromeric haplotype (A + B-F-G-) in the four families in which all four morphs could be determined, while the phenotype MTC with PTs was associated with the rare centromeric haplotype (A-B-F-G+) in one family. | 0 |
Exposure of the intracavernous carotid artery in aneurysm surgery. The pterional intradural approach was used in five cases of large and giant carotid-ophthalmic aneurysms and in two cases of intracavernous aneurysms that arose from the anterior siphon knee in the cavernous sinus (CS) and extended into the carotid cistern. In four cases of large carotid-ophthalmic aneurysms removal of the anterior clinoid process and the roof of the optic canal gave easy access to the pericarotid ring. The anteromedial part of the pericarotid ring was dissected to expose the extradural portion of the internal carotid artery (ICA) proximal to the neck and to make enough room between the wall of the CS and the extradural portion of the ICA, thus allowing easy clipping of the neck. In one case of a giant carotid-ophthalmic aneurysm extending into the CS with an extradural origin of the ophthalmic artery and in two cases of an intracavernous aneurysm arising from the siphon knee, neck clipping was performed by opening the lateral wall and roof of the CS after removal of the optic strut. The opening of the lateral wall anterior to the 3rd nerve facilitated wide exposure of the anterior siphon knee. The horizontal portion of the intracavernous ICA as well as the whole aspect of the aneurysm could be exposed as a result of the extended opening of the cavernous roof anterior to the posterior clinoid process. Successful operative results were obtained in all seven patients. A visual field detect as an operative complication was noted in one patient. No disturbance of ocular movements was noted. | 3 |
Prostacyclin production in myocardial infarction in the acute phase and during follow-up. Twenty-five patients with myocardial infarction were monitored in the acute phase and during follow-up with regard to the in vivo production of prostacyclin (PGI2) and thromboxane (TxA2), by measurement of their major urinary metabolites, 2,3-dinor-6-keto-PGF1 alpha and 2,3-dinor-TxB2, respectively. In 22 of these patients PGI2 and TxA2 production were also assessed before, during and after an exercise test performed 6 weeks after discharge. In approximately 24% of patients the in vivo production of prostacyclin did not increase during the acute phase of the infarction process. This inability was usually associated with a decrease in the release of heart muscle enzymes, and was mostly frequently observed in women. During the exercise tolerance test, none of the patients showed any increase in prostacyclin production, in contrast to healthy volunteers, in whom a significant increase was seen. There were no differences between patients with and without an increase in prostacyclin production during the acute phase. At the follow-up 2 years after the myocardial infarction, eight cardiac events had occurred, all of which were noted among patients who exhibited an expected increase in prostacyclin production in association with the infarction. This would seem reasonable, since most of the patients in this group had larger primary infarctions. | 3 |
Traffic of peripheral B and T lymphocytes to hyperplastic, preneoplastic thymuses of AKR mice. AKR mice develop hyperplasia of the thymus before the development of retrovirus-associated lymphoma at that site. This hyperplasia, first detectable in AKR/J mice by 4 weeks of age and in AKR/C mice by 4 to 5 months of age, is characterized by an enlarged thymic medulla that contains T and B lymphocytes. In contrast to the general population of thymocytes, most of these T and B lymphocytes have a mature immunophenotype that includes expression of high levels of the MEL-14-defined (gp90) 'homing receptor' for peripheral lymph node high endothelial venules. In vivo homing studies reveal a marked increase in traffic of peripheral lymphocytes (T more than B) to the hyperplastic thymuses of old AKR mice as compared to histologically normal thymuses of age-matched BALB/c and C57BL/Ka mice or young AKR mice. These changes correlate chronologically with changes in retrovirus antigen expression in AKR thymuses and suggest a role for the traffic of lymphocytes from the periphery to the thymus in response to local antigenic stimulation in the pathogenesis of thymic hyperplasia in AKR mice. | 4 |
Fatty liver hepatitis (steatohepatitis) and obesity: an autopsy study with analysis of risk factors. Steatohepatitis (fatty liver hepatitis), histologically identical to alcoholic disease, occurs in some obese patients after jejunoileal bypass. A similar lesion occurs rarely in obese patients without bypass surgery, but the risk factors are poorly understood. Hepatic steatosis, steatohepatitis and fibrosis were sought in 351 apparently nonalcoholic patients at autopsy and various risk factors were evaluated. Incidence of steatosis and steatohepatitis correlated with the degree of obesity. Steatohepatitis was found in 18.5% of markedly obese patients and 2.7% of lean patients. Additional risk factors for steatohepatitis were type II diabetes, weight loss in the preterminal period shortly before death and intravenous glucose therapy in the last week of life. Severe fibrosis was found in 13.8% of markedly obese patients and in 6.6% of lean patients; this difference was largely explained by the higher prevalence of diabetes in obese groups. The risk factors defined in this study are known to be associated with abnormalities of free fatty acid metabolism. Obesity, type II diabetes and intravenous glucose therapy are associated with hyperinsulinemia, which may inhibit fatty acid oxidation. Obesity and weight loss increase the presentation of fatty acids to the liver. Similar metabolic changes may occur in obese patients after jejunoileal bypass surgery. Thus this study supports the hypothesis that fatty acids have a role in the hepatocellular necrosis found in some obese individuals. | 4 |
The relationship of nasopharyngeal carcinomas and second independent malignancies based on the Radiation Therapy Oncology Group experience. The authors sought to learn if the incidence of second independent malignancies after the irradiation of carcinomas of the nasopharynx is similar to that observed after treatment of tumors arising in other head and neck sites. One hundred twenty-one patients who had primary carcinomas of the nasopharynx who were treated solely by ionizing radiation (according to the specifications of a Radiation Therapy Oncology Group protocol) were identified and their subsequent well-being was reviewed. Overall there was a 4.1% incidence of second malignancies (2% after 3 years, 5% after 5 years, and 8% after 8 years) with most arising in the upper aerodigestive tract. This rate is significantly less than the rate associated with other head and neck sites. It is not significantly different from the rate of first malignancies observed in an age-matched and sex-matched population. When only those patients who were free of all evidence of neoplastic disease 6 months after the completion of radiotherapy are considered, similar analysis leads to similar outcomes. The authors conclude that the risk of second malignancies after the successful irradiation of carcinomas of the nasopharynx is substantially less than after treatment of tumors at other head and neck sites. | 0 |
Regional myocardial blood flow and left ventricular diastolic properties in pacing-induced ischemia. The relation between left ventricular diastolic abnormalities and myocardial blood flow during ischemia was studied in eight open chest dogs with critical stenoses of the proximal left anterior descending and circumflex coronary arteries. The heart was paced at 1.7 times the heart rate at rest for 3 min. In dogs with coronary stenoses, left ventricular end-diastolic pressure increased from 8 +/- 1 to 14 +/- 2 mm Hg during pacing tachycardia (p less than 0.01) and 16 +/- 3 mm Hg (p less than 0.01) after pacing, with increased end-diastolic and end-systolic segment lengths in the ischemic regions. Left ventricular diastolic pressure-segment length relations for ischemic regions shifted upward during and after pacing tachycardia in dogs with coronary stenoses, indicating decreased regional diastolic distensibility. In dogs without coronary stenoses, the left ventricular diastolic pressure-segment length relation was unaltered. Pacing tachycardia without coronary stenoses induced an increase in anterograde coronary blood flow (assessed by flow meter) in both the left anterior descending and circumflex coronary arteries, and a decrease in regional vascular resistance. In dogs with coronary stenoses, regional vascular resistance before pacing was decreased by 18%; myocardial blood flow (assessed by microspheres) was unchanged in both the left anterior descending and circumflex coronary artery territories. During pacing tachycardia with coronary stenoses, regional coronary vascular resistance did not decrease further; subendocardial myocardial blood flow distal to the left anterior descending coronary artery stenosis decreased (from 1.03 +/- 0.07 to 0.67 +/- 0.12 ml/min per g, p less than 0.01), as did subendocardial to subepicardial blood flow ratio (from 1.04 +/- 0.09 to 0.42 +/- 0.08, p less than 0.01). | 3 |
Bacteriologic quality of intraoperative autotransfusion. Controversies remain about the bacteriologic aspects of intraoperative blood salvage despite the widespread use of this technique. In this prospective study, intraoperative salvaged blood was cultured in 401 patients, according to a direct plating technique. Bacterial growth was detected in 12.7% of cases. These results were compared with those obtained in control studies with sterile water and blood bank units under the same culture conditions. Most microorganisms were coagulase-negative staphylococci, followed by other skin and environmental contaminants. Quantitative estimates of contaminations showed low counts of colony-forming units (CFU/ml): 82% of positive cultures yielded 1 or 2 CFU/ml and 6% had 5 to 20 CFU/ml. Patients were followed up for a minimum of 3 months to detect septic complications. No statistically significant correlation could be found between bacteriologic results of autotransfused blood and infectious complications. This study suggests that bacteriologic monitoring of patients who have undergone autotransfusion may help in detecting surgical field contamination. It also confirms that intraoperative autotransfusion adds little septic risk to cardiac surgery. | 4 |
Glucagonoma syndrome is an underdiagnosed clinical entity. Glucagonomas, considered among the rarest of the islet cell neoplasms, produce a well-defined clinical syndrome characterized by necrolytic migratory erythema, diabetes mellitus, glossitis, anemia, and weight loss. This report describes seven patients with glucagonoma treated at our institution. All seven had the characteristic dermatologic manifestations, present from 1 to 6 years prior to diagnosis. Five patients had extensive disease at the time of initial operation, three of whom underwent aggressive cytoreductive surgery, whereas the other two had biopsy only. The remaining two patients presented with a single nodule each, underwent distal pancreatectomy and splenectomy, and remain free of disease 2 and 6 years postoperatively. Earlier recognition of the distinctive physical findings peculiar to this syndrome should increase survival. Aggressive cytoreductive surgery results in prolonged remission. | 0 |
Deleterious effects of testicular venous occlusion in young rats. To determine the differences between testicular arterial and venous obstruction, the spermatic artery or vein, or both, were occluded for varying periods of time in young rats. Two months later, at the conclusion of the study, the testes were examined. Histologic degeneration after vascular obstruction was graded by a modified Johnsen's tubular biopsy score (TBS). The testicular concentrations of enzymes (lactic dehydrogenase and sorbitol dehydrogenase), known to decrease with testicular injury, were measured. TBS and seminiferous tubule diameter (STD) were found to decrease significantly after two hours of vascular occlusion and were similar regardless of whether the obstruction was produced by occlusion of arterial inflow or venous drainage, or both. Testicular concentration of enzymes decreased significantly after permanent ligation of the spermatic artery and vein, but decreased minimally when the vascular obstruction lasted less than 120 minutes. Testicular injury produced by venous occlusion was equally severe and occurred as rapidly as injury produced by arterial or combined arteriovenous occlusion. No significant injury was noted in the contralateral testes in any group. | 3 |
Preperitoneal herniorrhaphy for the acutely incarcerated groin hernia. Elective preperitoneal or posterior repair for recurrent groin hernias and primary femoral hernias has been shown to be a technically advantageous approach. In addition to the ease of inguinal floor and femoral canal assessment, scar tissue from prior anterior herniorrhaphy can be avoided. The emergency management of the acutely incarcerated or strangulated hernia of the groin using this approach has not been addressed. During a 30-month period, all patients with a diagnosis of acute incarceration of a groin hernia (n = 28) were surgically managed using either the anterior approach (AA) (n = 14) or the preperitoneal approach (PA) (n = 14). Two patients with strangulated intestine in the AA group required an additional midline incision for bowel evaluation and resection. Intestinal evaluation was easily accomplished through the same incision in four patients in the PA group. The preperitoneal approach also allowed proximal control of incarcerated or strangulated viscera, thus avoiding excessive manipulation of gangrenous or necrotic intestine, potential spillage of infected contents into the peritoneal cavity, and entry of bacteria, toxins, potassium, and the metabolic waste products of anaerobic metabolism into the systemic circulation during hernia reduction. There have been no recurrences in either group, and minor complications, such as wound infection and cellulitis, in the two groups are not statistically different. | 4 |
Plasma norepinephrine in chronic schizophrenia. Several lines of evidence indicate altered noradrenergic function in schizophrenia. The authors examined resting, standing, and change (standing minus resting) in plasma norepinephrine levels in 14 drug-free patients with chronic schizophrenia or schizoaffective disorder and in 33 age- and sex-matched healthy volunteers. Schizophrenic patients had significantly higher resting and standing plasma norepinephrine levels and significantly greater change. Resting and standing levels were significantly related to positive and negative symptoms. There was a significant positive correlation between resting plasma and CSF norepinephrine levels and a significant negative correlation between CSF homovanillic acid and resting, standing, and change in plasma norepinephrine levels. | 4 |
Predicting distant metastases in operable breast cancer patients. Risk factors for distant metastases following mastectomy and axillary node dissection for breast cancer were analyzed in a review of 1022 women. From diagnosis until the end of the adjuvant treatment, six stages were identified that corresponded well to patient data acquisition. At each stage, a prognosis study based on the Cox model was carried out using all acquired information from the first stage. The results demonstrated that tumor size, nuclear pleomorphism, mitotic index, and nodal status at the top of axilla were stable independent risk factors in predicting metastasis-free survival (MFS). These analyses also revealed those factors that were significantly related to MFS at one or several stages and losing their significance at a subsequent stage. This was the case with clinical node status, age, and vascular tumor emboli. Other factors such as estrogen, progesterone, histologic grade, and clinical stage were never identified as independent factors at any stage. The four major stable risk factors were used to define a stratification of reference. The results demonstrated that the mere knowledge of clinical information such as tumor size, clinical node status, and age would enable 51% of the patients to be universally well classified according to that stratification. Knowledge of additional factors, such as nuclear pleomorphism and mitotic index, would bring the rate up to 61%, and then to 64% if supplementary information such as vascular tumor emboli were acquired. These percentages did not appear high enough to claim that the physician may make a reliable prognosis of operable breast cancer patients before acquiring information from the axillary node dissection. However, it was proven that there exist some subsets of patients with stable prognosis, i.e., subsets of patients who will belong permanently to the same risk group through the stages. | 0 |
Giant hemangioma of the liver with pain, fever, and abnormal liver tests. Report of two cases. In conclusion, we report the cases of two patients with large hemangiomas of the liver, abdominal pain, increased ESR and fibrinogen, increased serum alkaline phosphatase and gamma-glutamyltransferase activity, and normal white blood cell counts. Clinical and biochemical abnormalities disappeared after surgical resection. Increased ESR and fibrinogen are probably related to thrombosis within the tumor. This mode of presentation may suggest a diagnosis of hepatocellular carcinoma. | 0 |
Redevelopment of hepatitis B surface antigen after renal transplantation. A patient with chronic hepatitis B virus (HBV) and chronic renal failure received a renal transplantation. Hepatitis B surface antigen (HBsAg) disappeared, and antibodies to HBsAg appeared 10 months before transplantation. Liver tests showed no abnormality at transplantation. Six months later, chronic hepatitis reactivated, antibodies to HBsAg disappeared, and HBsAg reappeared. Hepatitis B virus DNA was demonstrated with polymerase chain reaction in the serum collected before transplantation. This observation suggests that low level HBV replication was present before transplantation despite the absence of detectable HBsAg and was reactivated under immunosuppressive therapy after transplantation. | 1 |
Anxiety levels and cancer fear in patients admitted for elective operations. Patients who are to have elective operations project varying degrees of anxiety, and many spontaneously express fear (without basis) that their operation involves a diagnosis of malignancy. To measure total, covert, and overt anxiety objectively, we gave the Institute for Personality and Ability Testing anxiety test to 125 consecutive patients admitted for elective general surgical procedures. A simple survey of cancer fear was also completed. Chi-square and Fisher's exact test were used to compare categoric data, and linear regression and analysis of variance were used where appropriate. Total anxiety scores were in the upper quartile compared to the general population. Scores indicating fear of cancer were elevated in 75% of patients who had no history of or reason to suspect malignancy. Covert anxiety scores correlated with cancer fear scores, and both significantly decreased as age increased (P less than .05). Also, as age increased, the cancer fear scores decreased (P less than .002). Obese patients had higher scores of cancer fear than all other patients (P less than .0001). | 0 |
Patient-controlled analgesic administration. A comparison of steady-state morphine infusions with bolus doses. The authors have shown previously that bone marrow transplant (BMT) patients who self-administered bolus doses of morphine gained equal oral mucositis pain relief while using less drug compared with similar patients receiving morphine by staff-controlled continuous infusion. In a follow-up study they compared the efficacy and side effects of morphine in two groups of marrow transplant patients who controlled their own analgesic administration either by conventional bolus-dose, patient-controlled analgesia (PCA) or by adjusting the rate of continuous morphine infusion to increase or decrease their plasma morphine concentration. Patients controlling their morphine infusion rates (pharmacokinetically based patient-controlled analgesia [PKPCA] group) obtained more relief from oral mucositis pain than did patients using conventional PCA. Patients in the PKPCA group used more morphine than PCA patients and achieved superior pain relief without significant increases in side effects (e.g., nausea, mood changes, sedation). The authors conclude that PKPCA improves the management of prolonged, severe pain in marrow transplant patients and that this approach to patient-controlled analgesia may be useful in other types of persistent pain. | 0 |
Left ventricular remodeling after acute myocardial infarction: clinical course and beneficial effects of angiotensin-converting enzyme inhibition. LV enlargement is an important determinant of survival after AMI. Pathophysiologic mechanisms leading to LV dilatation after an AMI include early thinning and stretching of the infarcted segment (e.g., infarct expansion) and hypertrophy of the noninfarcted myocardium. Such LV dilatation may adversely affect subsequent cardiac function, leading to heart failure and death. Experimental data in animals and preliminary studies in humans have demonstrated that early administration of captopril, an angiotensin-converting enzyme inhibitor, may limit infarct expansion and will attenuate progressive LV dilatation. This article discussed the clinical importance of the dilated left ventricle and reviewed advances and ongoing research in the use of angiotensin-converting enzyme inhibitors in the chronic phase after AMI. | 3 |
Radiotherapy alone versus combined chemotherapy and radiotherapy in nonresectable non-small-cell lung cancer: first analysis of a randomized trial in 353 patients. We report the results observed in a large, randomized study that compared the effects of radiotherapy alone (the standard therapy) with those of a combination of radiotherapy and chemotherapy in nonresectable squamous cell and large-cell lung carcinoma. The radiation dose was 65 Gy in each group, and chemotherapy included vindesine, cyclophosphamide, cisplatin, and lomustine. In this study, 177 patients received radiotherapy alone (group A), and 176 patients received the combined treatment (group B). The 2-year survival rate was 14% in group A and 21% in group B (P = .08). The distant metastasis rate was significantly lower in group B (P less than .001). Local control was poor in both groups (17% and 15%, respectively) and remained the major problem. | 4 |
Localization of trophoblastic disease with vaginal ultrasonography. A report of two cases. Two patients had elevated beta-human chorionic gonadotropin levels and normal abdominal ultrasound examinations. In both instances transvaginal ultrasonography demonstrated a persistent nodule of trophoblastic disease confirmed at the time of hysterectomy. This new imaging modality can assist in the diagnosis of persistent trophoblastic disease in the uterus. | 0 |
Undifferentiated carcinoma of the ovary. Thirty-five cases of ovarian carcinomas, which had as the predominant histologic component solid areas of epithelial cells without differentiation into mullerian carcinomas, were reviewed. The patients' ages ranged from 39 to 72 years (mean age, 54 years). Two patients had clinical stage I disease, one had stage II, 26 had stage III, and six had stage IV. Microscopically, the malignant cells formed large groups or sheets with desmoplastic stroma around them. Foci of papillary serous carcinoma, unclassified adenocarcinoma, or transitional cell carcinoma were seen in 26 tumors, foci of necrosis were seen in 30 tumors, and vascular invasion was seen in seven tumors. Six of 13 carcinomas tested expressed CA125 reactivity, and 12 of 13 carcinomas reacted to B72.3 monoclonal antibody. The primary tumors were treated by aggressive surgical reduction in 32 patients and by multiple biopsy procedures in three patients. After the first operation, 30 patients had residual disease, smaller than 2 cm in five patients and larger than 2 cm in 23 patients. After surgery, 33 patients received chemotherapy; three of these 33 also received radiotherapy. One patient was treated with postsurgical radiotherapy only, and one patient refused further treatment. Thirty-four patients (97%) died of disease between 8 and 108 months (mean, 27 months) after initial surgery, 29 patients died in less than 32 months. Four patients (11%) survived more than 5 years: two patients with stage I disease who died at 82 and 102 months, one patient with stage II who died at 72 months, and one patient with stage III who has no evidence of disease after 116 months. Five-year survival of patients with undifferentiated ovarian carcinoma is worse than the reported survival of patients with serous carcinoma or ovarian carcinoma with a pattern resembling transitional cell carcinoma. The distinction between these three carcinomas that have solid areas carries prognostic significance. | 0 |
Measurement of acute phase proteins for assessing severity of Plasmodium falciparum malaria. Seventeen adult patients with acute Plasmodium falciparum malaria, admitted to the Hospital for Tropical Diseases, were studied. Serial measurements of the serum concentration of C-reactive protein, serum amyloid A protein, and percentage parasitaemia were determined, together with initial measurement of serum electrolytes, liver function, haemoglobin, white cell and platelet counts. Initial C-reactive protein and serum amyloid A concentrations were increased (C-reactive protein mean 49.0 mg/l serum amyloid A 28 mg/l) falling towards the normal range by the seventh day of treatment. There was a significant correlation between the pretreatment parasite count and clinical and laboratory markers of inflammation. C-reactive protein and serum amyloid A concentrations correlated inversely with the serum sodium. These results indicate that measurement of acute phase reactants such as C-reactive protein and serum amyloid A may prove valuable in assessing the severity of P falciparum malaria, and in following the response to antimalarial treatment. | 4 |
Silicone pouch for protection of automatic implantable cardioverter-defibrillator leads. Automatic implantable cardioverter-defibrillator has become routine treatment for recurrent, drug-resistant ventricular tachycardia. Although there is documentation regarding clinical experience and device performance, there is little information on how to avoid complications related to the retrieval of sensing and defibrillation leads from the subcutaneous space. We are reporting our experience with a silicone pouch for protection of automatic implantable cardioverter-defibrillator leads that allows immediate and simple retrieval of the leads in case an automatic implantable cardioverter-defibrillator generator is needed. | 3 |
Lyme disease: recommendations for diagnosis and treatment The incidence and the endemic range of Lyme disease in the United States have increased steadily since the disease was originally recognized in Lyme, Connecticut, in 1975. Because of the varied clinical manifestations of this illness and the use of unstandardized serologic testing methods, diagnosis is often uncertain and treatment outcomes are often difficult to evaluate. The antibiotic regimens that are commonly used in clinical practice have changed rapidly. They show much regional variation with little critical comparison of treatment results. The clinical diagnosis and the literature on the treatment of the various stages of Lyme disease are reviewed. The reported data are supplemented with recommendations based on 15 years of clinical experience with this illness. | 2 |
Utility of surgical margins in the radiotherapeutic management of soft tissue sarcomas. Seventy-four adult patients with localized soft tissue sarcomas were treated with radiation therapy following surgery between 1965 and 1988. Fifty-three were treated after the first excision of their tumor with 6 (11.3%) local recurrences. Twenty-one received radiation after excision of recurrent disease with 11 (52.4%) local failures (P less than .0005). Metastatic disease occurred in 14 (26.4%) of the primary tumors and 8 (38.1%) with multiple previous excisions (P less than .48). Of those patients treated for primary sarcoma, there were no local failures with pathologically wide margins or if a single margin was microscopically positive. Local failure occurred in 4 of 26 (15.4%) if the tumor was merely enucleated and in 2 of 11 (18.2%) who had grossly positive surgical margins (P not significant). Local failure was also more common in truncal locations (33.3%) as compared with extremity locations (8.7%, P = .1359). Additional factors analyzed which adversely affected prognosis included tumor grade, stage, and inadequate radiation dose. | 0 |
Prospective evaluation of a protocol for induction of sustained ventricular tachycardia in patients referred to a tertiary centre. All eight stages of a stimulation protocol that used one then two extrastimuli from the right ventricular apex in sinus rhythm and three ventricular drive rates (100, 120, and 140 beats/min) were performed in 24 patients with recurrent spontaneous sustained ventricular tachycardia despite drug treatment. Twenty two of the patients had sustained a previous myocardial infarct and 18 were on long term treatment with amiodarone. Sustained (greater than 30 s) ventricular tachycardia was induced in all patients. Two extrastimuli were significantly more likely to induce sustained ventricular tachycardia than one extrastimulus, both overall and individually for the three ventricular drive rates. A ventricular drive rate of 140 beats/min was significantly more likely to induce ventricular tachycardia than ventricular drive rates of 100 and 120 beats/min which were significantly more effective than sinus rhythm. A ventricular drive rate of 140 beats/min with one or two extrastimuli induced ventricular tachycardia in 23/24 (95%) of the patients in this study. The full eight stage protocol was progressive separately for both extrastimuli and ventricular drive rate but the last two stages (ventricular drive rate of 140 beats/min with one or two extrastimuli) were as effective as the entire protocol in inducing ventricular tachycardia. | 3 |
Electroencephalography should not be routine in the evaluation of syncope in adults We reviewed the reports of all electroencephalograms obtained at the Nashville (Tenn) Veterans Administration Hospital from September 1987 to August 1989. Seventy-three patients were referred for evaluation of syncope or near syncope. Of these 73 patients, 10 (13.7%) had abnormal findings. Twenty-six patients were referred for other complaints similar to syncope (ie, blackouts, loss of consciousness, falling out, passing out, and fainting). Of these 26 patients, five (19.2%) had abnormal findings. We reviewed the medical records of the patients with abnormal findings and found that the final diagnosis or treatment of the syncope was affected by electroencephalogram in only one patient. These findings suggest that routine electroencephalography is not of significant value in the evaluation of syncope in adults. | 2 |
Use of intravenous stilbestrol diphosphate in patients with prostatic carcinoma refractory to conventional hormonal manipulation. The patient presenting with severe bone pain after primary hormonal therapy, with vertebral collapse, or with uremia resulting from ureteric obstruction should be considered for intravenous stilbestrol diphosphate therapy. The urologist can expect early marked improvement in the patients' mobility and pain, with a reduction in analgesic requirements, from a single 7-day course of treatment. In addition, the drug is inexpensive and free of the side effects commonly associated with cytotoxic therapy. Accurate monitoring of the response is possible with serum prostate-specific antigen measurements, which also enable further therapy to be planned efficiently. | 2 |
Whither short-course chemotherapy for tuberculous meningitis? Short-course chemotherapy is well established for the treatment of pulmonary tuberculosis but not for extrapulmonary disease. We present a series of 35 cases in which chemotherapy for tuberculous meningitis was given for a period of less than 2 years. Short-term therapy was associated with recrudescence of tuberculous meningitis and, in some cases, with the development of deep cerebral infarcts and permanent neurological deficits. We think short-term chemotherapy for tuberculosis of the central nervous system is inadequate. | 2 |
Angiodysplasia: characterization, diagnosis, and advances in treatment. Gastrointestinal bleeding accounts for 2% of all adult hospital admissions each year. Angiodysplasia is one of the most frequently reported causes of lower gastrointestinal bleeding. In 80% of patients with bleeding angiodysplasia, the bleeding will stop spontaneously, but will often recur. Although angiography may detect bleeding in 86% of actively bleeding patients, the bleeding rate must be at least 0.5 mL/min. The treatment of choice for control of bleeding has been resection of the suspected segment of bowel, but this procedure is associated with a 10% rebleeding rate and 7% to 8% mortality. Superselective catheterization with infusion of vasoconstrictors has been used to control bleeding, but effects are short-lived. Superselective embolization occludes an offending vessel, but is difficult to perform accurately and is associated with risk of infarction. Laser photocoagulation controls bleeding in 84% of patients, with a 6% complication rate. This method of controlling bleeding offers distinct advantages, especially for the hemodynamically unstable patient. Except for cases in which surgical resection is indicated, Nd:YAG laser photocoagulation is the safest, least invasive, and probably most effective means of treating angiodysplasia. | 3 |
The t(1;19)(q23;p13) results in consistent fusion of E2A and PBX1 coding sequences in acute lymphoblastic leukemias. The t(1;19)(q23;p13) chromosomal translocation is observed cytogenetically in 25% of children with pre-B-cell acute lymphoblastic leukemia (ALL) and is associated with an adverse treatment outcome. The t(1;19) juxtaposes the E2A gene from chromosome 19 with the PBX1 gene on chromosome 1, leading to the production of fusion transcripts and resultant chimeric proteins that contain the transcriptional-activating motif of E2A and the DNA-binding homeodomain of PBX1. To investigate the molecular nature of E2A/PBX1 fusion in patients with t(1;19) ALL we used an RNA-based polymerase chain reaction (PCR) procedure to amplify a portion of the chimeric transcript. We detected E2A/PBX1 fusion transcripts in cells from 97% (37 of 38) of cases in which the t(1;19) had been observed cytogenetically. Molecular evidence of E2A/PBX1 fusion transcripts was also observed in a patient in whom a t(1;19) was not detected cytogenetically and in one patient with subclinical levels of minimal residual disease before overt clinical relapse. In all PCR-positive cases the junction of E2A and PBX1 coding sequences occurred at precisely the same location as demonstrated by hybridization of PCR products with a fusion site-specific detection oligonucleotide. These findings demonstrate the consistent fusion of E2A and PBX1 coding sequences resulting from t(1;19) and suggest that site-specific fusion of E2A and PBX1 is an important pathogenic event in t(1;19) ALL. | 4 |
Plasma cell granuloma of the nasal cavity treated by radiation therapy. Plasma cell granuloma is a rare, benign tumor most commonly found in the lungs in patients younger than 30 years. Although presentation has been reported at a number of other anatomic sites, this report is the first of plasma cell granuloma of the nasal cavity. The tumor was initially resected, but progression was seen at 1-month follow-up. Because further surgery to completely eradicate the tumor would have been extensive and disfiguring, 40-Gy external beam radiation was given in 20 fractions using a three-field wedge technique. Most recent clinical follow-up at 27 months showed local control. Surgery remains the treatment of choice for plasma cell granuloma when the disease can be completely resected. However, irradiation can also be effective in patients with recurrent or inoperable local disease. | 0 |
Clinical spectrum of leber's congenital amaurosis in the second to fourth decades of life. Leber's congenital amaurosis is a type of congenital retinitis pigmentosa in which the fundus abnormalities are extremely variable and to some extent age dependent. Most cases are seen in infancy. The retinal, electroretinogram, and fluorescein angiographic findings are described in ten patients with Leber's congenital amaurosis who ranged in age from 13 to 36 years when first seen. All of the patients were from Honduras and were unrelated except for one pair (a brother and sister). The polymorphic appearance of the fundus is emphasized and is particularly striking in the siblings. A macular lesion (a bull's-eye maculopathy) not previously associated with Leber's congenital amaurosis is reported as a variant fundus appearance in this entity. | 4 |
The pathology of heart allograft rejection. The pathologist plays an important role in the care of cardiac transplant recipients. Day-to-day management of immunosuppression is largely dependent on the diagnosis and grading of acute rejection. While noninvasive methods have been tried experimentally, the endomyocardial biopsy remains the gold standard in monitoring the rejection status of the heart allograft. The diagnosis of rejection, however, is complicated by a variety of other histologic findings, which may be procedural or processing related, due to sampling, or specifically related to transplantation. Failed allografts, whether from autopsy or explantation, provide the opportunity to study short- and long-term changes in the transplanted heart. Allograft arteriopathy, or graft atherosclerosis, is the major limiting factor in long-term recipient survival. While the morphological features of graft arteriopathy have been well described, the mechanism and factors contributing to its development remain unclear. | 4 |
Cadherin cell adhesion receptors as a morphogenetic regulator. Cadherins are a family of cell adhesion receptors that are crucial for the mutual association of vertebrate cells. Through their homophilic binding interactions, cadherins play a role in cell-sorting mechanisms, conferring adhesion specificities on cells. The regulated expression of cadherins also controls cell polarity and tissue morphology. Cadherins are thus considered to be important regulators of morphogenesis. Moreover, pathological examinations suggest that the down-regulation of cadherin expression is associated with the invasiveness of tumor cells. | 4 |
Subcutaneous lisuride infusion in Parkinson's disease. Response to chronic administration in 34 patients. Thirty-eight parkinsonian patients with motor fluctuations and dyskinesias on chronic levodopa therapy were treated with subcutaneous lisuride infusion (SLI). Thirty-six were discharged from hospital on combined treatment with 24 h lisuride infusion (111.3 +/- 29.5 micrograms/h) and oral levodopa plus a decarboxylase inhibitor (729.6 +/- 452 mg/day); all obtained a marked initial improvement in mobility (mean reduction 'off' hours 87.5%); 34 were followed for a mean of 20.85 (range 6-45) months. Most patients continued to show improvement with respect to baseline assessment during chronic treatment but 23 developed dyskinesias, 'off' periods or both, which were difficult to control by changing the levodopa schedule, lisuride dose or both. In only 5 patients was lisuride treatment stopped because of inefficacy. The high incidence of psychiatric side-effects (18/38) was the major limiting factor for continuing lisuride infusion in this population of severe parkinsonian patients. Many complained about the inconvenience of the pump's technical requirements for long-term utilization, but only 4 patients abandoned SLI for this reason. These results indicate that motor function may be substantially improved in severe parkinsonian patients treated with SLI but increased dyskinesia or psychiatric adverse effects limited the long-term usefulness of this approach. It is suggested that continuous dopaminergic stimulation may be a particularly useful therapeutic strategy when applied in earlier stages of the disease. | 2 |
Lipid screening: is it enough to measure total cholesterol concentration? OBJECTIVES--To determine whether measurement of total cholesterol concentration is sufficient to identify most patients at lipoprotein mediated risk of coronary heart disease without measurement of triglyceride and high density lipoprotein (HDL) cholesterol concentrations. DESIGN--Cross sectional screening programme. SETTING--Six general practices in Oxfordshire. PATIENTS--1901 Men and 2068 women aged 25-59. MAIN OUTCOME MEASURE--Cardiovascular risk as assessed by fasting venous plasma concentrations of total cholesterol, triglyceride, and HDL cholesterol. RESULTS--2931 Patients (74% of those screened) had a total cholesterol concentration of less than 6.5 mmol/l. If the triglyceride concentration had not been measured in these patients isolated hypertriglyceridaemia (greater than or equal to 2.3 mmol/l) would have remained undetected in 185. Among these 185 patients, however, 123 were overweight or obese and only 18 (0.6% of those screened) had an increased risk associated with both a raised triglyceride concentration (greater than or equal to 2.3 mmol/l) and a low HDL cholesterol concentration (less than 0.9 mmol/l). Conversely, in the 790 patients with predominant hypercholesterolaemia (cholesterol concentration greater than or equal to 6.5 mmol/l and triglyceride concentration less than 2.3 mmol/l) measurement of HDL cholesterol concentration showed that 348 (9% of those screened) had only a moderately increased risk with a ratio of total to HDL cholesterol of less than 4.5 and 104 had a low risk with a ratio of less than 3.5. CONCLUSIONS--Fasting triglyceride and HDL cholesterol concentrations identify few patients at increased risk of coronary heart disease if the total cholesterol concentration is less than 6.5 mmol/l. HDL cholesterol and triglyceride concentrations should, however, be measured in patients with a total cholesterol concentration exceeding this value. Total cholesterol concentration alone may overestimate risk in a considerable number of these patients, and measurement of HDL cholesterol concentration allows a more precise estimate of risk. Measurement of the triglyceride concentration is required to characterise the lipoprotein abnormality. A patient should not be started on a drug that lowers lipid concentrations without having had a full lipoprotein assessment including measurement of HDL cholesterol concentration. | 3 |
Long-term follow-up of the use of nonporous hydroxyapatite for augmentation of the alveolar ridge. Particulate hydroxyapatite (HA) was used in the augmentation of 18 mandibular and four maxillary ridges in 21 patients whose cases were followed postoperatively for 5 to 7 years. Patients were evaluated clinically, radiographically, and through questionnaires. Prosthodontic assessment of retention and stability of dentures showed improvement 5 years postoperatively. Patients receiving HA rated their dentures favorably using parameters of the Cornell Medical Index. The results of this study show that particulate HA alone can be used as a satisfactory material for augmentation of the alveolar ridge. | 2 |
Dietary Ca2+ prevents NaCl-sensitive hypertension in spontaneously hypertensive rats by a sympatholytic mechanism. The current study tested the hypothesis that dietary Ca2+ supplementation reverses the NaCl-sensitive component of hypertension and the associated neurochemical abnormalities in the NaCl-sensitive spontaneously hypertensive rat (SHR-S). Male SHR-S were begun on one of four diets at 8 weeks of age: control (0.75% NaCl/0.68% Ca2+); high NaCl (8.00% NaCl/0.68% Ca2+); high Ca2+ (0.75% NaCl/2.00% Ca2+); and high NaCl/high Ca2+ (8.00% NaCl/2.00% Ca2+). High NaCl SHR-S (X2 weeks) had higher mean arterial pressure (MAP) (161 +/- 4 mm Hg) than controls (149 +/- 3 mm Hg; P less than .05). Supplementation with Ca2+ prevented the rise in MAP in high NaCl rats, but did not alter MAP in controls. The 8% NaCl diet elevated plasma norepinephrine and reduced anterior hypothalamic (AHA) norepinephrine stores and turnover; concomitant Ca2+ supplementation restored both plasma norepinephrine and AHA norepinephrine turnover to normal. Clonidine was microinjected into the AHA of rats maintained on the four diets for 2 weeks to test the hypothesis that dietary Ca2+ supplementation prevents the previously observed NaCl-induced upregulation of alpha 2-adrenoceptors in AHA. Clonidine caused dose-dependent decreases in MAP that were greater in high NaCl rats than in controls. The Ca2+ supplementation prevented the exaggerated depressor response to clonidine in the high NaCl group, but not in the controls. The Ca2+ supplementation had no effect on pretreatment MAP or on MAP responses to clonidine in control NaCl-resistant SHR (SHR-R) or Wistar-Kyoto (WKY) rats. Thus, dietary Ca2+ supplementation prevents the NaCl-induced exacerbation of hypertension and augmented depressor response to clonidine in SHR-S by increasing noradrenergic input to AHA, thereby preventing the upregulation of AHA alpha 2-adrenoceptors. | 3 |
Recurrence rate after discontinuation of long-term mebendazole therapy in alveolar echinococcosis (preliminary results). The recurrence rate was investigated in 19 patients with non-resectable alveolar echinococcosis after discontinuation of a long-term therapy with mebendazole (average treatment 4.3 years). A control group consisted of 14 patients who underwent radical surgery and finished a course of prophylactic postoperative mebendazole treatment of 2 years. In the controls, no recurrence was observed after a post-therapy period averaging 3.5 years. In contrast, recurrence occurred in 7/19 patients (37%) with non-resectable alveolar echinococcosis an average of 1.6 years after discontinuation of the long-term mebendazole therapy. The absence of clinically detectable recurrence in the remaining 12 patients seems to be due either to spontaneous inactivation of alveolar echinococcosis preceding chemotherapy or too short post-therapy surveillance. The patients with recurrence responded favorably to reintroduction of chemotherapy. The data indicate that mebendazole therapy is parasitostatic rather than parasiticidal. | 4 |
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