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Modulatory action of adenosine on gastric function and ethanol-induced mucosal damage in rats. This study examines the gastric effects of adenosine and its antagonist, theophylline, on secretory function, mucosal blood flow, and on ethanol-induced glandular mucosal damage in rats that were fasted for 24 hr before experimentation. The animals were anesthetized with sodium pentobarbitone (50 mg/kg intraperitoneal) and their tracheae cannulated. An ex vivo stomach chamber then was prepared. The luminal bathing solution was collected every 15 min and the concentrations of H+ and Na+ were determined by a pH autotitrator and an ionmeter, respectively. The glandular mucosal blood flow was measured by a laser Doppler flowmeter and the severity of lesions was determined by measuring the hemorrhagic areas. Adenosine administration (2.5 or 7.5 mg/kg, subcutaneous) markedly lowered the H+ and Na+ output but increased the secretory volume and mucosal blood flow in a dose-dependent manner. The same doses of the nucleoside also prevented ethanol-induced mucosal damage. These effects were prevented by pretreatment with theophylline (30 or 60 mg/kg, subcutaneous). Ethanol given alone significantly depressed the H+ and Na+ secretion. Both effects were not modified by adenosine treatment. However, the depressive action of ethanol on mucosal blood flow was prevented by adenosine. These findings indicate that adenosine modulates the physiological function of the stomach. It also directly activates the defensive mechanism of the stomach, which is partially mediated by the improvement of the gastric mucosal blood flow and an increase in the nonacid component of gastric secretion. | 4 |
Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers. A prospective, randomized trial. This study prospectively compares multipolar electrocoagulation and injection therapy in high-risk patients with bleeding ulcers. Patients were considered for entry if they had a bloody nasogastric aspirate, melena, or hematochezia and unstable vital signs, transfusion of greater than or equal to 2 U of blood in 12 hours, or a decrease in hematocrit of greater than or equal to 6% in 12 hours. Sixty patients with endoscopic evidence of an ulcer with active bleeding (n = 26) or a nonbleeding visible vessel (n = 34) were randomly assigned to receive multipolar electrocoagulation or injection with absolute ethanol. Hemostasis was achieved in 14 of 14 actively bleeding patients with multipolar electrocoagulation vs. 10 of 12 (83%) treated with injection. No significant differences were observed between electrocoagulation and injection therapy in any parameter assessed during the hospitalization: incidence of further bleeding (6% vs. 10%), units of blood transfused after treatment (1.8 +/- 0.6 vs. 1.3 +/- 0.4), incidence of surgery for bleeding (6% vs. 7%), length of hospital stay in days (5.8 +/- 0.9 vs. 7.2 +/- 2.5), cost of hospitalization (+7160 +/- +1630 vs. +8520 +/- +2960), or mortality rate (3% vs. 3%). Treatment induced bleeding in nonbleeding visible vessels in 35% of subjects in each group, but this was controlled with continued treatment in all patients. One delayed perforation occurred 9 days after multipolar electrocoagulation. Multipolar electrocoagulation and injection therapy are of comparable efficacy in the treatment of patients with clinical evidence of a major upper gastrointestinal bleed and endoscopic evidence of an ulcer with active bleeding or a nonbleeding visible vessel. | 1 |
Dietary fats and cancer. Evidence relating dietary fat to cancer at sites such as the breast and colon is provided by experiments showing that animals fed high-fat diets develop cancer at these sites more readily than do animals fed low-fat diets and by epidemiological data from different countries showing strong positive correlations between cancer incidence and mortality, and level of dietary fat. Experiments on animals have indicated that polyunsaturated vegetable oils promote cancer more effectively than do saturated fats or polyunsaturated fish oils, whereas in the epidemiological data, total dietary fat correlates with cancer incidence and mortality at least as well as does any particular type of fat. Case-control and cohort studies have not shown strong indications of a relationship between dietary fat and cancer, perhaps because of methodological difficulties inherent in such studies. The weight of evidence continues to indicate that long-term adherence to a low-fat diet can reduce the risk of some common types of cancer. | 0 |
The painful shoulder: Part I. Extrinsic disorders. Shoulder disorders are most commonly manifested by pain and limited function. Careful history and examination help the physician localize the problem to the shoulder joint, the surrounding tissues or adjacent sites that can cause referred pain to the shoulder. Common extrinsic causes of shoulder pain include postural problems and cervical spine disorders. | 2 |
Schindler disease: the molecular lesion in the alpha-N-acetylgalactosaminidase gene that causes an infantile neuroaxonal dystrophy. Schindler disease is a recently recognized infantile neuroaxonal dystrophy resulting from the deficient activity of the lysosomal hydrolase, alpha-N-acetylgalctosaminidase (alpha-GalNAc). The recent isolation and expression of the full-length cDNA encoding alpha-GalNAc facilitated the identification of the molecular lesions in the affected brothers from family D, the first cases described with this autosomal recessive disease. Southern and Northern hybridization analyses of DNA and RNA from the affected homozygotes revealed a grossly normal alpha-GalNAc gene structure and normal transcript sizes and amounts. Therefore, the alpha-GalNAc transcript from an affected homozygote was reverse-transcribed, amplified by the polymerase chain reaction (PCR), and sequenced. A single G to A transition at nucleotide 973 was detected in multiple subclones containing the PCR products. This point mutation resulted in a glutamic acid to lysine substitution in residue 325 (E325K) of the alpha-GalNAc polypeptide. The base substitution was confirmed by dot blot hybridization analyses of PCR-amplified genomic DNA from family members with allele-specific oligonucleotides. Furthermore, transient expression of an alpha-GalNAc construct containing the E325K mutation resulted in the expression of an immunoreactive polypeptide which had no detectable alpha-GalNAc activity. | 2 |
Magnitude and time course of extracellular potassium inhomogeneities during acute ischemia in pigs. Effect of verapamil. Prior studies have demonstrated the presence of inhomogeneities in myocardial [K+]e after serial 10-minute occlusions of the left anterior descending coronary artery in the pig, even within restricted locations of an ischemic zone. These inhomogeneities are thought to underlie the electrophysiological abnormalities responsible for lethal ventricular arrhythmias through reentrant and nonreentrant pathways, but a clear association has not been demonstrated. As a prerequisite to establishing this association, these studies were performed to establish measurement standards for [K+]e inhomogeneity, to quantify the magnitude and time course of these inhomogeneities, to determine whether the inhomogeneities are greater in the ischemic border where lethal ventricular arrhythmias are known to originate, and to assess the effect of a known antifibrillatory drug on [K+]e inhomogeneities. [K+]e (expressed as the change in potassium equilibrium potential, dEK [mV]) was measured in 15 preparations using an average of 17 closely spaced, critically calibrated K(+)-sensitive electrodes having stable response characteristics. A series of four 10-minute occlusions each separated by a 50-minute reperfusion period were performed in each study. In half of the studies, intravenous verapamil (0.2 mg/kg bolus followed by 0.0065 mg/kg/hr) was administered before the fourth occlusion. In nine studies (five control and four verapamil), electrodes were placed in the marginal ischemic zone (from 2 mm outside to 5 mm inside the visible cyanotic border). In six other studies (three control and three verapamil), electrodes were placed in the central ischemic zone (10-20 mm within the ischemic region). We determined that the standard deviation is the best measure of inhomogeneity and that 12 equivalent measurement sites are required to estimate it with a satisfactory degree of statistical confidence. We found that after 10 minutes of ischemia, mean dEK was 1.6 times greater in the central than in the marginal ischemic zone, whereas mean standard deviation at the same time was 1.5 times greater in the marginal than in the central ischemic zone. Verapamil reduced mean dEK and mean standard deviation in both ischemic zones for most of the occlusion by delaying the rise in [K+]e and the inhomogeneity of that rise by 3-5 minutes. Comparisons of mean dEK with mean standard deviation revealed a steep linear relation in the marginal zone and a curvilinear relation in the central zone where higher mean dEK values were not accompanied by higher values for mean standard deviation. Furthermore, we determined that these relations were not altered by verapamil.(ABSTRACT TRUNCATED AT 400 WORDS). | 4 |
Beta-carotene and cancer prevention: the Basel Study. In 1971-1973 at the third examination of the Basel Study started in 1959, the major antioxidant vitamins and carotene were measured in the plasma of 2974 men. A subsample and their families were reinvestigated in 1977-79. During the 12-y observation period (1973-85) 553 men died, 204 of cancer (lung cancer 68, stomach cancer 20; colon cancer 17, all other malignancies 99). We found significantly lower mean carotene levels for all cancer, bronchus cancer, and stomach cancer (all P less than 0.01) compared with the 2421 survivors. The relative risk of subjects with low carotene (less than 0.23 mumol/L) was significantly elevated (P less than 0.05) for lung cancer (Cox's model). Higher risks were noted for all cancer (P less than 0.01) if both carotene and retinol were low. Low plasma carotene which is known to reflect carotene intake is in our study associated with increased cancer risk. | 0 |
Immunohistochemical demonstration of acetaldehyde-modified epitopes in human liver after alcohol consumption. Acetaldehyde, the toxic product of ethanol metabolism in the liver, covalently binds to a variety of proteins. Recent studies indicate that such binding can stimulate the production of antibodies against the acetaldehyde adducts. We raised rabbit antibodies which recognized various protein-acetaldehyde conjugates but not the corresponding control proteins. Such antibodies were used in immunohistochemical studies to find out whether acetaldehyde-generated epitopes can be detected from liver specimens of 13 human subjects with different degrees of alcohol consumption. While the specimens obtained from alcohol abusers (n = 4) and alcoholics (n = 3) exhibited marked positive staining for acetaldehyde adducts inside the hepatocytes in a granular uneven pattern, the control samples (n = 6) were almost devoid of immunoreactivity. In the alcohol abusers with an early stage of alcohol-induced liver damage, staining was detected exclusively around the central veins. The data indicate that intracellular acetaldehyde adducts occur in the centrilobular region of the liver of individuals consuming excessive amounts of alcohol. Immunohistochemical detection of such adducts may prove to be of value in the early identification of alcohol abuse and in elucidating the mechanisms of alcohol-induced organ damage. | 1 |
Synovial membrane histology and immunopathology in rheumatoid arthritis and osteoarthritis. In vivo effects of antirheumatic drugs. We examined the histologic and immunopathologic features of the synovial membrane of 18 patients with rheumatoid arthritis (RA) and 12 patients with osteoarthritis (OA) who had undergone total knee arthroplasty. Patients were classified into 5 groups according to therapeutic regimen and disease: RA treated with nonsteroidal antiinflammatory drugs (NSAIDs), RA treated with NSAIDs and prednisone, RA treated with NSAIDs and methotrexate (MTX), OA treated with analgesics, and OA treated with NSAIDs. There were no significant between-group differences in the percentages or the distribution pattern of the infiltrating T cell subsets (CD4, CD8), HLA-DR, or interleukin-2 receptor-bearing cells. However, inflammatory indices, which included the thickness of the lining cell layer and the density of the mononuclear cell infiltrate, were significantly higher in the RA patients treated with prednisone and those treated with MTX (P less than 0.05). Similarly, fibrosis was markedly reduced in these 2 groups. The RA patients treated with NSAIDs alone and the 2 groups of patients with OA demonstrated similar profiles. These data suggest that prednisone and MTX may inhibit the development of fibrosis without altering the subsets of the inflammatory cell population. This observation raises the possibility that the action of these 2 drugs may be partly mediated by the suppression of inflammatory mediators that are responsible for fibroblast activation. | 4 |
Articulatory impairment associated with tardive dyskinesia. The speech of two patients with tardive dyskinesia was studied, and one neuroleptic-treated patient having no signs of overt tardive dyskinesia served as control. A structured interview, including reading, repetition of sentences, and spontaneous conversation, was performed. A phonetic transcription and analysis of abnormal phonemes was done by a linguist under blind conditions. Both patients with tardive dyskinesia had abnormal phonemes whereas the control patient had none. These differences could not be explained by age, direct neuroleptic effect, or neuroleptic exposure time. The abnormal phonemes were all consonants. The authors conclude that tardive dyskinesia may cause articulatory communication problems. | 2 |
The Hastings bipolar hemiarthroplasty for subcapital fractures of the femoral neck. A 10-year prospective study. In a 10-year prospective study, 561 displaced subcapital fractures of the femoral neck in 546 patients were treated with the Hastings bipolar hemiarthroplasty. Within six months of their operations, 148 patients had died. In 322 hips followed up, 243 with adequate serial radiographs separated by more than one year, only 14 (5.6%) showed acetabular erosion. A group of 91 had been reviewed for between three and nine years (mean, 4 years 10 months) and of these, 95% had no pain or slight pain only. Comparison with an earlier series of conventional hemiarthroplasties reported from this institution showed that the clinical results were similar, but that the erosion rate had been halved. | 4 |
Scatter photocoagulation restores tissue hypoxia in experimental vasoproliferative microangiopathy in miniature pigs. Experimental retinal branch vein occlusion using argon laser photocoagulation in miniature pigs induced the development of ischemic retinal territories associated with preretinal neovascularization. Preretinal partial pressure of oxygen (PO2) measurements on the ischemic territories, using O2-sensitive microelectrodes, established that the ischemic retinal areas were hypoxic. Scatter photocoagulation of these ischemic hypoxic territories restores the local PO2 to the normal values within 2 weeks. Hence, the reported inhibitory effect of photocoagulation on the development of retinal neovascularization could be due to a reversal effect on tissue hypoxia. | 4 |
Traumatic retinal detachment. Seventy-seven patients developed retinal breaks following an episode of ocular contusion, and 65 (84.4%) of these developed rhegmatogenous retinal detachment. Surgical treatment successfully restored or maintained retinal apposition in 74 (96.1%) of the eyes. Thirty-six (46.8%) eyes recovered visual acuity of 6/9 or better. Of the retinal breaks recognised dialysis at the ora serrata was observed in 49 eyes, of which 28 were situated at the lower temporal quadrant. Seventeen eyes had irregular breaks arising within necrotic retina at the site of scleral impact. Twenty-four (31.2%) patients had retinal break or retinal detachment diagnosed within 24 hours of injury and 49 (63.6%) within six weeks. Immediate retinal detachment was a feature of necrotic retinal breaks, while inferior oral dialyses led to a slow accumulation of subretinal fluid. Delayed diagnosis of retinal detachment was due either to opaque media or to failure to examine the retina after injury. Visual prognosis was good when retinal break or detachment were diagnosed within six weeks of injury. However, those patients who escaped initial retinal examination and were lost to follow-up had a less favourable visual outcome. | 2 |
Flow cytometric determination of breast tumor heterogeneity. Flow cytometric analysis was done on the DNA content of nuclei obtained from different sites of small breast tumors. Although specimens for analysis were obtained within a few millimeters of each other, dramatic differences were occasionally observed in the DNA histograms. In a limited study involving 141 consecutive breast specimens submitted for flow cytometry, 52% (74) were found to have at least one DNA aneuploid population. In 18% of DNA aneuploid tumors, one or more specimens from areas grossly identified as tumor had no DNA aneuploid population. Because of the proposed correlation of aneuploidy with a poorer prognosis and possible responsiveness to chemotherapy, multiple sites should be assayed when flow cytometric DNA analysis is done. | 4 |
Expression of placental alkaline phosphatase in gastric and colorectal cancers. An immunohistochemical study using the prepared monoclonal antibody. The authors developed monoclonal antibodies (MoAb) against human placental alkaline phosphatase (PLAP). Four specific MoAb reacting only with PLAP and two nonspecific MoAb reacting equally with isozymes of alkaline phosphatase (hepatic, intestinal, and placental) were obtained. Immunohistochemical staining with the specific MoAb showed that the cell membrane and cytoplasm of cancer cells were stained in gastric and colorectal carcinoma. The incidence of PLAP positivity was 23% (25 of 107) of all gastric carcinomas. Among gastric carcinomas, the 42% (13 of 31) positivity of highly differentiated carcinoma (papillary adenocarcinoma and well-differentiated tubular adenocarcinoma) was a significantly higher rate than that found in poorly differentiated carcinoma (poorly differentiated adenocarcinoma and signet-ring cell carcinoma, five of 41, 12%). The incidence of PLAP positivity was 11% (four of 35) in colorectal carcinoma. In contrast, gastric adenoma, intestinal metaplasia, and noncancerous tissue adjacent to cancer did not show staining. These results indicated that expression of PLAP was apt to occur in more highly differentiated gastric carcinoma and was highly specific for carcinoma in the gastrointestinal tract, although its incidence was not high. | 0 |
Rehabilitation in brain disorders. 4. Specific disorders. This self-directed learning module highlights important aspects of medical rehabilitation of patients with brain disorders. The specific disorders reviewed in this module are traumatic brain injury, stroke, multiple sclerosis, Parkinson's disease, and other degenerative disorders. This module is a section of the chapter on rehabilitation of brain disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. The chapter is composed of four articles, and each builds on principles established in the others. Emphasis is given in this section on key elements of current medical practice, including epidemiology, pathophysiology, prognosis, and outcome. Neurologic assessment and management is highlighted for coma, amnesia, cranial nerve and late intracranial complications, postacute management, and postconcussive syndromes. The learner is directed to articles 1, 2, and 3 in this chapter for supporting information. | 2 |
Cardiac conducting tissue. A simplified technique for examination of the SA and AV nodes. We describe a modified method for examination of the atrioventricular and sinoatrial nodes that displays the major elements of the cardiac conducting system, yet is not time-consuming for the technician. We examined 31 cases in three categories: cases with previous cardiac history, sudden deaths from no known cause, and cases where death was sudden and accidental. All cases showed histologic abnormalities in the cardiac tissue. We contend that our method would permit such examination to be routinely used in the pathology laboratory. | 3 |
Significance of anti-HBx antibodies in hepatitis B virus infection. Serological responses to hepatitis B virus-X determinants have been noted in human sera, but conflicting findings concerning the correlation of anti-HBx antibodies with different stages of hepatitis B virus infection or pathological sequelae have been reported. Using an adenovirus-based eukaryotic vector, the 17 kD X protein was efficiently expressed in 293 cells. Cellular extracts containing the eukaryotic X protein have been used to screen for anti-HBx antibodies by immunoblot analysis in a large panel of sera from patients affected by hepatitis B virus chronic hepatitis, hepatocellular carcinoma and acute viral hepatitis. Sera from 32 of 171 (19%) chronic hepatitis B virus patients were positive for anti-HBx antibodies. Only one of thirty-two (3%) HBsAg-negative, anti-HBs/anti-HBc-positive chronic hepatitis serum was anti-HBx positive. Very few sera from primary hepatocellular carcinoma patients showed positivity for anti-HBx (8 of 149 or 5%). Anti-HBx were also detected in 8 of 48 (17%) acute viral hepatitis patients. In the four cases that were followed up weekly, anti-HBx antibodies appeared 3 to 4 wk after the onset of the clinical signs. To compare the X protein expressed in eukaryotic and prokaryotic cells as a substrate for anti-HBx antibody detection, 171 sera were screened with HBx fusion proteins expressed in Escherichia coli. The prokaryotic cell extract test seems to be more sensitive. During the chronic phase of hepatitis B virus infection, the presence of anti-HBx antibodies detected with the eukaryotic cell extract correlates with the presence of well-established markers of ongoing viral replication: serum hepatitis B virus-DNA (p less than 0.001) and intrahepatic HBcAg expression (p less than 0.001). | 0 |
A novel treatment for ischemic intracranial hypertension in cats. There is no accepted efficacious treatment for ischemic cerebral edema. We show in a cat model of focal cerebral ischemia that infarct volume can be reduced (p less than 0.05) by ventriculocisternal perfusion with an oxygenated fluorochemical emulsion (bis-perfluorobutylethylene). An accompanying effect of such ventriculocisternal perfusion is a reduction in intracranial pressure. At 18 hours following the start of the perfusion, there was a significant (p less than 0.05) difference in intracranial pressure between nonperfused controls (mean 11.4 [range 2.3-23.0] torr, n = 6) and cats perfused with an oxygenated nutrient solution not containing fluorochemical (mean 11.3 [range 3.0-29.0] torr, n = 8) or animals perfused with the oxygenated fluorochemical emulsion (mean 2.21 [range 0-3.5] torr, n = 7). Perfusion with this oxygenated fluorochemical emulsion warrants further study as a treatment for elevated intracranial pressure. | 2 |
Primary care patients who refuse specialized mental health services. The charts of 65 patients who completed mental health care referrals were compared with those of 65 patients who failed to complete such referrals. In the year before referral, the noncompliant patients made 37% more medical visits than the compliant patients. As compared with the compliant patients, a significantly greater proportion of the noncompliant patients' medical visits were for difficult-to-explain somatic symptoms. Mental health referrals from some physicians were much more successful than referrals from other physicians. By attending to their patients' pattern of health care utilization, primary care physicians may be able to identify patients at high risk for noncompliance with mental health referrals. | 4 |
The effect of improved cementing techniques on component loosening in total hip replacement. An 11-year radiographic review. Improved cementing techniques have been shown to decrease the rate of aseptic loosening of femoral components of cemented total hip replacements at five to seven years. We now report our results in 105 hips in 93 patients at 10 to 12.7 years (mean 11.2). The improved techniques included use of a medullary plug, a cement gun, a doughy mix of Simplex P and a collared stem of chrome cobalt. Only three femoral components had definitely loosened, none were probably loose and 24 were graded as possibly loose. In contrast, the incidence of radiographic loosening on the acetabular side was 42%. Improved cementing techniques have produced a marked reduction in the rate of aseptic loosening of the femoral component, but the incidence of acetabular loosening is unchanged. | 4 |
Bronchiolar inflammation and fibrosis associated with smoking. A morphologic cross-sectional population analysis. The lungs of 42 smokers and 13 nonsmoking males of various ages who died suddenly and unexpectedly were examined grossly using Gough-Wentworth whole-lung sections and by microscopic planimetry to assess the severity and prevalence of emphysema. The bronchioles in representative histologic sections were evaluated for inflammation and epithelial metaplasia as well as for fibrosis and muscular hypertrophy. Postmortem interviews with next of kin established a history of cigarette smoking and excluded possible occupational exposures to toxic or particulate inhalants. Emphysematous changes were not prominent in members of the study group, but they tended to be more severe in smokers (p = 0.059) and increased in severity with age (p less than 0.001). Inflammatory changes (so-called smoker's bronchiolitis) were evident in smokers of all ages, although they were significantly less prominent in the lungs of older smokers. On the other hand, respiratory and membranous bronchiolar wall fibrosis was increasingly evident in older smokers (p less than 0.05). Muscular hypertrophy in the bronchiolar walls was significantly greater in smokers, but a change with age was not observed. These findings strongly suggest that bronchiolar fibrosis is associated with chronic cigarette use. These lesions occur independently of emphysema and may account for some of the subtle physiologic alterations observed in smokers. | 4 |
High signal intensity in MR images of calcified brain tissue. Calcified lesions of the brain occasionally appear bright on T1-weighted MR images. This report shows that particulate calcium can reduce T1 relaxation times by a surface relaxation mechanism. Calcium particles with greater surface area show greater T1 relaxivity. Reduced proton density and reduced T2 tend to diminish signal intensity, but reduced T1 increases signal intensity. Thus, for concentrations of calcium particulate of up to 30% by weight, the signal intensity on standard T1-weighted images increases but subsequently decreases. | 2 |
The incidence of deep vein thrombosis after cementless and cemented knee replacement. The incidence of deep vein thrombosis in 244 patients who had total knee replacement has been studied. In 120 the prosthesis was cemented and in 124 it was cementless. In all cases the replacement was primary and a porous-coated prosthesis with a porous-coated central tibial stem was used. Deep vein thrombosis was diagnosed by venography, and pulmonary embolism by perfusion scanning. The incidence of deep vein thrombosis in the cementless knees (23.8%) and in the cemented (25%) was approximately the same. The only significant predisposing factors for deep vein thrombosis in both groups were obesity, prolonged postoperative immobilisation, previous venous disease and hyperlipidaemia. | 3 |
Diffuse esophageal leiomyomatosis in a patient with Alport syndrome: CT demonstration. In a patient with progressive dysphagia, postprandial vomiting, and a history of Alport syndrome, barium and manometric studies had been interpreted as consistent with achalasia, but a subsequent computed tomographic (CT) scan of the thorax was suggestive of a lower esophageal intramural mass. Multiple leiomyomas of the esophagus were later proved at thoracotomy. Differences between adult and pediatric leiomyomas and the association of leiomyomas with Alport syndrome are discussed. | 0 |
Lip paresthesia associated with a jaw mass. A case is reported in which mandibular swelling and lower lip numbness were the first signs of a metastatic adenocarcinoma of the lung. The development of paresthesia, with or without other oral symptoms, requires that a diagnosis of malignancy be considered until confirmed or ruled out by tissue biopsy. A thorough head and neck examination in all patients, especially in those whose history or habits may indicate increased risk of malignancy is necessary. | 2 |
Immunochemical characterization and quantitative distribution of pancreatic stone protein in sera and pancreatic secretions in pancreatic disorders. A fluorometric immunoassay has been established to quantitate pancreatic stone protein providing a sensitivity for concentrations from 0.015 to 0.5 micrograms/mL. When concentrations of pancreatic stone protein were determined from pancreatic secretions obtained either from patients suffering from chronic pancreatitis (n = 31) [including the calcifying forms (n = 10)], pancreatic cancer (n = 22), or nonpancreatic diseases (n = 17), no significant differences were found. In contrast, increased concentrations were found in serum samples from patients with chronic (39/66) and acute pancreatitis (16/20) compared with control patients. The differences between these diagnostic groups and controls were highly significant (P less than 0.0001) and independent of pancreatic enzyme activity. Immunochemical analyses of serum pancreatic stone protein showed an isoelectric point (pH 9) similar to that reported for the pancreatic thread protein. With respect to recent communications, these data do not support the etiopathogenic role postulated for pancreatic stone protein in chronic pancreatitis and chronic calcifying pancreatitis by other investigators. | 0 |
Treatment of human melanoma hepatic metastases in nude mice with human cytotoxic T lymphocytes. We investigated the effects of human melanoma-specific cytotoxic T lymphocytes in treating experimental human melanoma hepatic metastases in a nude mouse model of adoptive immunotherapy. Hepatic metastases were generated by intrasplenic injection of 1.5 x 10(6) human melanoma cells. Three days after injection, animals received salt solution and interleukin 2 or interleukin 2 and cytotoxic T lymphocytes. Twenty-four of 25 control animals had developed multiple tumor nodules in the liver; 11 of 13 animals receiving only interleukin 2 also had significant tumor burdens. In striking contrast, 17 of 18 animals receiving cytotoxic T lymphocytes and interleukin 2 had no gross or histologic evidence of tumors. The remaining animal had a 2-mm nodule. Human tumor-specific cytotoxic T lymphocytes are effective in vivo in a model of adoptive immunotherapy and may prove useful in adoptive immunotherapy of humans with metastatic melanoma. | 0 |
Iron chelation by deferoxamine inhibits lipid peroxidation during cardiopulmonary bypass in humans. Iron catalysis is involved in oxygen-derived free radical generation and subsequent lipid peroxidation, which have been reported to occur during cardiopulmonary bypass in humans. We assessed the effects of the iron chelator deferoxamine on the susceptibility of circulating low density lipoproteins (LDLs) to induced peroxidation in 20 adult patients (10 controls and 10 treated) undergoing cardiopulmonary bypass for coronary or valve procedures. Deferoxamine was given both intravenously (30 mg/kg body wt, starting 30 minutes before bypass and extending for the next 4 hours) and as an additive to the cardioplegic solution (250 mg/l). Blood samples were taken from both atria before and immediately after the end of cardiopulmonary bypass. Plasma lipid peroxidation was assessed by measuring spectrophotometrically the thiobarbituric acid reactive substances (TBARS) content of selectively isolated LDLs after their exposure to a peroxidizing agent. Before cardiopulmonary bypass, the right and left atrial blood values of LDL-TBARS were not significantly different between the two groups. Cardiopulmonary bypass resulted in a lipid peroxidation of significantly greater magnitude in control than in treated patients. Postbypass right atrial values for LDL-TBARS (expressed in mumol/mmol LDL-phospholipids) were 45.7 +/- 17.2 (mean +/- SEM) in control patients and 6.9 +/- 2.9 in treated patients (p less than 0.02), whereas in the left atrial blood, LDL-TBARS yielded values of 62.7 +/- 20.5 and 10.3 +/- 3.9, respectively (p less than 0.01). | 4 |
China White epidemic: an eastern United States emergency department experience. STUDY OBJECTIVE: The purpose of this study was to isolate significant clinical or demographic findings concerning overdose patients treated during a China White (3-methyl fentanyl) epidemic and compare them with data for all unintentional narcotic overdose patients during a 24-month period. DESIGN: We reviewed charts from 85,246 patient visits to our emergency department during the 24-month period of January 1987 through December 1988 to study this narcotic epidemic. Data from the Allegheny County Coroner's Office pertaining to unintentional drug overdose deaths that occurred during this same period also were reviewed. SETTING: The first outbreak of narcotic overdoses in the eastern United States involving China White occurred in Allegheny County, Pennsylvania, in 1988. TYPE OF PARTICIPANTS: Patients were included if they met the criteria of a suspected unintentional narcotic overdose, but excluded if they were not given naloxone. INTERVENTIONS: Emergency physicians became suspicious of China White use after an unusual increase in narcotic overdoses presenting to the ED coupled with "routine drug of abuse" screens negative for opiates despite dramatic patient responses to naloxone. In most of the cases in which specific testing was done, there were positive indicators of fentanyl derivatives. Investigations found China White present in street drugs and paraphernalia. MEASUREMENTS AND MAIN RESULTS: A cluster was defined as a time period with a statistically significant increase in overdoses over the expected number for an interval of equal length. Although there were no significant clinical differences in case presentation during the 24-month period, there was a statistically significant 13-fold increase in overdoses during the September through November 1988 cluster (mean, 13 vs 0.95 per month, P less than .001 by Wilcoxon rank-sum test). A dramatic increase in unintentional drug overdose deaths occurred in the county during this cluster. A total of 18 fentanyl-positive unintentional drug overdose deaths, predominantly male (89%) and black (56%), with an age range of 19 to 44 years (mean, 34.9 years), were reported by the county coroner (13 during the cluster). Narcotic overdoses and unintentional drug overdose deaths declined sharply with confiscation of a clandestine China White laboratory. CONCLUSIONS: China White was responsible for a dramatic rise in unintentional drug overdose deaths in Allegheny County in 1988. There were no significant clinical differences between China White overdose survivors and other unintentional narcotic overdose victims. Overdoses responsive to naloxone with inconsistent routine toxicologic screens may be due to a fentanyl analogue. | 4 |
The anatomical basis of the caecocentral scotoma. New observations and a review. It is shown that the 'papillomacular bundle' of optic nerve fibres, although a concept discussed frequently in the clinical literature, lacks a clear anatomical definition. It is suggested that the explanation for this is that the 'bundle' was originally described in autopsy studies of toxic amblyopia, not normal anatomy. The optic nerve fibre projection and vascular architecture of the caecocentral region of the retina is described. These anatomical features are discussed in relation to a number of possible anatomical explanations for the fact that a caecocentral scotoma is the characteristic field defect found in toxic amblyopia. We have been unable to identify a distinct anatomical feature which might explain this vulnerability but suggest that the problem has not as yet been clearly addressed by anatomists. | 2 |
Multiple representations of pain in human cerebral cortex. The representation of pain in the cerebral cortex is less well understood than that of any other sensory system. However, with the use of magnetic resonance imaging and positron emission tomography in humans, it has now been demonstrated that painful heat causes significant activation of the contralateral anterior cingulate, secondary somatosensory, and primary somatosensory cortices. This contrasts with the predominant activation of primary somatosensory cortex caused by vibrotactile stimuli in similar experiments. Furthermore, the unilateral cingulate activation indicates that this forebrain area, thought to regulate emotions, contains an unexpectedly specific representation of pain. | 2 |
Surgical resection of cor triatriatum in a 74-year-old man. Review of echocardiographic findings with emphasis on Doppler and transesophageal echocardiography. A 74-year-old man was admitted to the hospital with congestive heart failure secondary to cor triatriatum. He also had sick sinus syndrome with complete heart block and syncope that had been treated with a permanent pacemaker 20 years earlier. The patient underwent successful surgical resection of the atrial membrane with closure of an atrial septal defect. M-mode, two-dimensional, Doppler, and transesophageal echocardiographic findings are reviewed. A unique "spike and dome" pattern on continuous-wave Doppler echocardiography is described that may suggest diagnosis of cor triatriatum. | 3 |
Hypertrophic pyloric stenosis: volumetric measurement of nasogastric aspirate to determine the imaging modality The authors postulated that volumetric measurement of residual gastric aspirate in neonates and infants with nonbilious projectile vomiting could enable differentiation between patients with hypertrophic pyloric stenosis (HPS) and those with gastroesophageal reflux (GER) and help to determine whether ultrasound (US) or fluoroscopy of the upper gastrointestinal tract would best confirm the diagnosis. In the 38 patients (all but two of whom had been fasting for 3-4 hours), 10 mL or more of nasogastric aspirate was considered indicative of obstruction. HPS occurred in 91.7% of patients with 10 mL of aspirate or more, whereas GER occurred in 85.7% of patients with less than 10 mL. The differences between the two groups were statistically significant. Solely on the basis of residual volume (greater than or equal to 10 mL), the cause of vomiting could be differentiated, prior to standard radiologic studies, 89.4% of the time. It is concluded that patients with projectile vomiting who have 10 mL or more of residual aspirate in the stomach should undergo US for confirmation of HPS; those with less than 10 mL should undergo fluoroscopy for confirmation of GER. | 1 |
Vertigo after epidural morphine. Severe complications from the use of epidural morphine for analgesia after Caesarean section are rare. A case is reported of extreme prostrating vertigo several hours after epidural morphine injection, where the time of onset of the symptom coincided with the expected time of arrival of the morphine within intra-cerebral cerebro-spinal fluid. | 4 |
Effect of thiazide on rates of bone mineral loss: a longitudinal study [published erratum appears in BMJ 1991 Jan 26;302(6770):18] OBJECTIVE--To determine the effect of thiazide diuretic drugs on rates of bone mineral loss. DESIGN--Longitudinal, observational study with a mean follow up of five years. SETTING--Hawaii Osteoporosis Center, Honolulu. SUBJECTS--1017 Japanese-American men born between 1900 and 1920, of whom 378 were treated for hypertension (study group) and 639 did not have hypertension (control group). INTERVENTION--Thiazide diuretics were taken by 325 men for a mean of 11.9 years; 53 men took antihypertensive drugs other than thiazides. MAIN OUTCOME MEASURE--Rate of bone loss estimated from serial photon absorptiometric scanning at three skeletal sites (calcaneus, distal radius, and proximal radius). RESULTS--Rates of bone loss at all three sites were significantly reduced among thiazide users when compared with controls. The reductions in loss rate ranged from 28.8% (p = 0.02) (distal radius) to 49.2% (p = 0.0005) (calcaneus) relative to the controls. At all three sites the men taking other antihypertensive drugs had faster loss rates (22.6-43.1%) than those of the controls but the difference was significant only for the distal radius. CONCLUSION--Thiazide diuretics slow the rate of bone loss in elderly men. | 3 |
Natural history of congestive gastropathy in cirrhosis. The Liver Study Group of V. Cervello Hospital. In a prospective study of the natural history of congestive gastropathy, 212 consecutive cirrhotic patients (75 treated with sclerotherapy) were included. Mean follow-up was 46 months. Mild gastropathy (mosaiclike pattern) was found in 110 patients and severe gastropathy (granular mucosa with cherry spots) was found in 20. Prevalence of Helicobacter pylori, formerly Campylobacter pylori, was 50% in patients without, 43% in those with mild, and 28% in those with severe gastropathy. Congestive gastropathy was significantly more frequent in patients treated with sclerotherapy (83% vs. 50%, P less than 10(-5)). Sixty-month actuarial proportions of patients free of anemia (in the absence of hematemesis or melena), were 17% with severe, 62% with mild, and 93% without gastropathy (P less than 10(-8]. Corresponding figures for overt bleeding were 25%, 73%, and 87% (P less than 10(-7], whereas those for survival were 46%, 72%, and 85% (P = 0.0005), respectively. A multivariate regression analysis supported the following conclusions: (a) sclerotherapy and the presence of large esophageal varices significantly increase the risk of congestive gastropathy, which (b) is a significant risk indicator of both chronic and overt bleeding but does not independently affect survival. | 1 |
Percutaneous popliteal approach for angioplasty of superficial femoral artery occlusions. Angioplasty using the percutaneous popliteal approach was utilized in 50 patients (PTS) to recanalize 59 occluded superficial femoral arteries which had been unsuccessfully canalized by using the antegrade approach because of either a flush origin occlusion or inability to maintain the guide wire in the true lumen. All PTS had claudication; 8 had rest pain; 3 had non-healing ulcers. The laser Probe was used in 17 cases and the Rotablator in 3 cases. Occlusion length varied between 1 and 40 cm: 7 lesions were less than 10 cm (group 1); 9 were between 10 and 20 cm (group 2); and 43 were greater than 20 cm (group 3). An angiographic success was obtained in 48/59 lesions (81%): 14/16 (87%) in groups 1 and 2 and 34/43 (79%) in group 3. Three PTS needed complementary common femoral endarterectomy and one required percutaneous aspiration of a thromboembolus. Complications included: arterial perforation and/or dissection (without clinical sequelae) in 11 and a popliteal hematoma in 1 PT. One patient with a severely ischemic leg underwent successful emergency vascular surgery, while another limb salvage patient required below-knee amputation. There was no worsening of limb ischemia from any popliteal approach attempt. At discharge, 39 patients (78%) whose outcome would have been unsuccessful with the traditional antegrade approach were clinically improved after utilizing the popliteal approach to achieve a successful angioplasty procedure. | 3 |
Use of a guiding catheter for contralateral femoral artery angioplasty. We describe a unique method employing a transseptal sheath as a "guiding catheter" that allows contralateral retrograde femoral artery access to perform balloon angioplasty of proximal superficial femoral artery lesions. This technique simplifies arterial access, provides support for crossing lesions, and allows angiographic visualization of target lesions during the procedure. | 3 |
Late results of the left subcostal approach for automatic implantable cardioverter defibrillator implantation. A left subcostal surgical approach was used to implant an automatic implantable cardioverter defibrillator (AICD) in 48 patients with a history of nonfatal cardiac arrest or documented ventricular tachycardia/fibrillation. Electrophysiologic studies before surgery yielded induction of monomorphic or polymorphic ventricular tachycardia in 40 patients, whereas 8 were noninducible. Mean (+/- standard deviation) age was 58 +/- 12 years. Mean ejection fraction was 33 +/- 16%. Thirty patients (63%) had documented coronary artery disease; 14 patients (29%) had previous coronary bypass surgery. The mean intraoperative defibrillation threshold was 13.8 +/- 6.6 J. In 6 patients, an adjunctive right minithoracotomy was used to position 1 patch over the right atrium and thus optimize the defibrillation threshold. Patients with prior exposure to amiodarone and previous coronary bypass surgery had higher defibrillation thresholds at implantation. Two perioperative deaths occurred. There were no infections. Long-term follow-up yielded a 1- and 5-year survival of 0.88 and 0.58, respectively, and a freedom from sudden cardiac death of 1.0 and 0.97, respectively. The nonthoracotomy, left subcostal surgical approach is safe and effective, provides adequate defibrillation thresholds in most patients, and yields long-term survival comparable to other implantation techniques. | 4 |
Impaired pressor reactivity in cirrhosis: evidence for a peripheral vascular defect. The blood pressure responses to intravenous infusions of norepinephrine and angiotensin II, sympathetic and nonsympathetic vasoconstricting agents, respectively, were measured in 20 patients with cirrhosis (10 Child-Pugh grade A and 10 Child-Pugh grades B or C) and in 20 healthy subjects. The log PD20 (dose of agonist required to raise blood pressure by 20 mm Hg) for norepinephrine was 4.78 +/- 0.36 (mean +/- S.D.) in patients with severe cirrhosis and 4.36 +/- 0.37 in controls, p less than 0.01. Log PD20 for angiotensin II was 3.16 +/- 1.06 in patients with severe cirrhosis and 1.97 +/- 0.74 in controls, p less than 0.01. Cardiovascular responses to selective sympathetic agonists were measured in 10 other cirrhotic patients (all Child-Pugh grades B or C) and in 10 healthy controls. Log PD20s for phenylephrine, an alpha-1 adrenoceptor agonist, and for alphamethylnorepinephrine; an alpha-2 adrenoceptor agonist, were increased in cirrhosis (phenylephrine = 5.35 +/- 0.49 vs. 4.95 +/- 0.35, p less than 0.05; alphamethylnorepinephrine = 4.05 +/- 0.26 vs. 3.44 +/- 0.55, p less than 0.001). In contrast, log CD20 (dose of agonist required to raise the heart rate by 20 beats/min) for isoproterenol, a beta-adrenoceptor agonist, was similar in cirrhotic patients and controls (2.81 +/- 0.38 vs. 2.94 +/- 0.45, p = 0.49). These studies demonstrate that pressor reactivity to both sympathetic and nonsympathetic agonists is impaired in severe cirrhosis, that the impaired sympathetic responses are not caused by generalized sympathetic desensitization and that the site common to the four agonists with impaired responses is the peripheral vascular smooth muscle. | 1 |
Stroke in pediatric acquired immunodeficiency syndrome. In a 4 1/2-year period, 4 of 68 children in a longitudinal study of neurological complications of human immunodeficiency virus (HIV) infection had clinical and/or neuroradiological evidence of stroke, yielding a clinical incidence of stroke in this population of 1.3% per year. During this period, 32 subjects died, and permission for autopsy was granted in 18 of the patients, including 3 of 4 who had clinical evidence of stroke. The prevalence of cerebrovascular pathological features in our consecutive autopsy series was higher than the clinical incidence. At autopsy cerebrovascular disease was documented in 6 (24%) of 25 children with HIV infection, including all 3 children who had clinical evidence of stroke. Four patients had intracerebral hemorrhages, 6 patients had nonhemorrhagic infarcts, and 3 had both. Hemorrhage was catastrophic in 1 child and clinically silent in 3 children, all of whom had immune thrombocytopenia. One child had an arteriopathy that affected meningocerebral arteries. In another child, the arteries of the circle of Willis were aneurysmally dilated. Two children had coexisting cardiomyopathy and subacute necrotizing encephalomyelopathy with vascular proliferation. These results suggest that stroke should be considered when children with HIV infection develop focal neurological signs. | 2 |
Evaluating oxygen delivery and oxygen utilization with mixed venous oxygen saturation monitoring: a case study approach. Three cases studies are presented to demonstrate clinical application of mixed venous oxygen saturation (SvO2) monitoring in critical care nursing practice. Examples of critically ill patients are used to demonstrate how SvO2 monitoring can be used in clinical practice to reflect an imbalance between oxygen delivery and oxygen utilization. In the first case, the patient had a problem with oxygen delivery. Continuous SvO2 data aided nurses in guiding, adjusting, and assessing therapy. The second case demonstrates how SvO2 monitoring can provide an early sign of a life-threatening complication. The final case is one in which the patient had a problem with oxygen utilization. In all the cases, continuous SvO2 data provided important information about the balance between oxygen delivery and oxygen utilization. | 4 |
Microdochectomy for discharge from a single lactiferous duct. Microdochectomy for persistent discharge from a single lactiferous duct was performed in 162 women. Invasive or in situ ductal carcinoma was diagnosed in 16 patients (10 per cent), none of whom had a palpable lump. The discharge was blood-stained in 14 of these women and in two it was clear. Mammography was performed in 15 of these 16 patients and was abnormal in only five. Three patients had atypical ductal hyperplasia, one of whom subsequently developed an invasive ductal carcinoma. Microdochectomy for persistent discharge from a single lactiferous duct is curative and gives a diagnosis of the cause. It remains the treatment of choice whether the discharge is blood-stained or clear. | 0 |
Doxorubicin for unresectable hepatocellular carcinoma. A prospective study on the addition of verapamil. A prospective study was conducted to assess the safety and efficacy of the addition of oral verapamil to intravenous Adriamycin (doxorubicin) for the management of patients with unresectable hepatocellular carcinoma (HCC). All 28 patients studied had histologically verified disease, and cirrhosis was present in 20 of the 21 patients with adequate tissue sampling. The overall median survival was 57 days. Chemotherapy was terminated in seven patients after one course of treatment. Partial response and complete response were noted in four patients (19%) and one patient (4.8%), respectively, among the 21 patients evaluated. Side effects related to the chemotherapy were present in all patients studied. Death from fulminating sepsis occurred in three of the 13 patients with leukopenia. Symptomatic myocardial dysfunction developed in one patient. The addition of verapamil apparently did not potentiate the tumoricidal effect of systemic Adriamycin on HCC but probably did increase its complications. | 0 |
Flow-volume characteristics in the pulmonary circulation. Isolated ferret and canine lungs were used to validate a method for assessing determinants of vascular volume in the pulmonary circulation. With left atrial pressure (Pla) constant at 5 mmHg, flow (Q) was raised in steps over a physiological range. Changes in vascular volume (delta V) with each increment in Q were determined as the opposite of changes in perfusion system reservoir weight or from the increase in lung weight. At each level of Q, the pulmonary arterial and left atrial cannulas were simultaneously occluded, allowing all vascular pressures to equilibrate at the same static pressure (Ps), which was equal to the compliance-weighted average pressure in the circulation before occlusion. Hypoxia (inspired PO2 25 Torr) in ferret lungs, which causes intense constriction in arterial extra-alveolar vessels, had no effect on the slope of the Ps-Q relationship, interpreted to represent the resistance downstream from compliance (control 0.025 +/- 0.006 mmHg.ml-1.min, hypoxia 0.030 +/- 0.013). The Ps-axis intercept increased from 8.94 +/- 0.50 to 13.43 +/- 1.52 mmHg, indicating a modest increase in the effective back-pressure to flow downstream from compliant regions. The compliance of the circulation, obtained from the slope of the relationship between delta V and Ps, was unaffected by hypoxia (control 0.52 +/- 0.08 ml/mmHg, hypoxia 0.56 +/- 0.08). In contrast, histamine in canine lungs, which causes constriction in veins, caused the slope of the Ps-Q relationship to increase from 0.013 +/- 0.007 to 0.032 +/- 0.006 mmHg.ml-1.min (P less than 0.05) and the compliance to decrease from 3.51 +/- 0.56 to 1.68 +/- 0.37 ml/mmHg (P less than 0.05). | 4 |
Abnormal hemodynamic response to Valsalva maneuver in patients with atrial septal defect evaluated by Doppler echocardiography. Hemodynamic responses to the Valsalva maneuver were studied in eight healthy subjects (group 1) and eight patients with ASD (group 2) using Doppler echocardiography. The acute changes of aortic blood flow profiles during the Valsalva maneuver were investigated on a basis of beat-to-beat estimation. During the active strain phase (phase 2), group 1 showed a significant decrease in systolic blood pressure, SV and CO with reflex tachycardia; in group 2, there was a significant decrease in SV and CO with reflex tachycardia, but not systolic blood pressure. The percentage decreases in SV and CO in group 2 were significantly less than those in group 1 (23 +/- 16 percent vs 48 +/- 10 percent for SV, p less than 0.01; 17 +/- 12 percent vs 40 +/- 13 percent for CO, p less than 0.05). After release of strain phase (phase 4), group 1 showed significant reversed changes in systolic blood pressure, SV and heart rate, indicating an overshoot effect which was, however, not observed in group 2. Thus, patients with ASD presented abnormal Valsalva response which was characterized by the absence of phase 4 overshoot and a less marked phase 2 change. The findings suggest that the decremental effect of impaired venous return on stroke output during active strain may be attenuated by the increased pulmonary blood volume due to left-to-right shunt. In patients with ASD, the lesser decrement of CO during phase 2 may not provoke sufficient sympathetic activity to induce overshoot response in phase 4. | 3 |
Noncardiogenic pulmonary edema complicating massive diltiazem overdose. Non-cardiogenic pulmonary edema has not been previously described in calcium channel blocker overdose. We describe a case of non-cardiogenic pulmonary edema occurring during the course of therapy for massive diltiazem overdose in a young patient with anorexia nervosa. Review of the current literature suggests that major and minor pulmonary complications occur with some frequency in the setting of calcium channel blocker overdose although their exact incidence remains unclear. | 2 |
Puppet-like syndrome of Angelman: a pathologic and neurochemical study. We present the first pathologic descriptions of the puppet-like syndrome of Angelman based on autopsy studies of a 21-year-old woman. The noteworthy findings were a small brain with mild cerebral atrophy but normal gyral development. There was marked cerebellar atrophy with loss of Purkinje and granule cells and extensive Bergmann's gliosis. Study of dendrite morphology using Golgi impregnations of the visual cortex revealed a prominent decrease in dendritic arborization of layer 3 and layer 5 pyramidal neurons. Quantitative Golgi analysis also revealed a significant decrease in the numbers of dendritic spines in apical layer 3 dendrites and both apical and basal layer 5 dendrites. Neurochemical studies of frozen brain tissue demonstrated markedly reduced gamma-aminobutyric acid content in the cerebellar cortex, as well as elevated glutamate content in the frontal and occipital cortices. Although there are no definite morphologic correlates of many of the clinical signs, the pronounced dendritic pathology and neurochemical abnormalities in cerebral cortex may provide a physiologic basis for mental retardation. | 2 |
Gastrointestinal dysfunction and disaccharide intolerance in children infected with human immunodeficiency virus. Because gastrointestinal dysfunction is a major problem in children with human immunodeficiency virus (HIV) infection, we utilized breath hydrogen measurements to determine the relationship between disaccharide malabsorption and gastrointestinal dysfunction in HIV-infected children. We found a strong association between lactose intolerance and persistent diarrheal disease in this population (p less than 0.007, Mann-Whitney U test). We also found evidence of sucrose malabsorption and persistent diarrheal disease in three of the children. Extensive microbiologic evaluations failed to reveal an etiologic agent related to the occurrence of gastrointestinal symptoms. Our findings indicate that disaccharide intolerance is a common occurrence in HIV-infected children with persistent diarrheal disease. Careful attention to dietary intake may be required to ameliorate clinical symptoms and to maintain adequate nutrition. | 1 |
Identification of transforming growth factor beta family members present in bone-inductive protein purified from bovine bone. Characterization of the polypeptides present in bone-inductive protein extracts from bovine bone has led to the cloning of seven regulatory molecules, six of which are distantly related to transforming growth factor beta. The three human bone morphogenetic proteins (BMPs) we describe herein, BMP-5, BMP-6, and BMP-7, show extensive sequence similarity to BMP-2, a molecule that by itself is sufficient to induce de novo bone formation in vivo. The additive or synergistic contribution of these BMP-2-related molecules to the osteogenic activity associated with demineralized bone is strongly implicated by the presence of these growth factors in the most active fractions of highly purified bone extract. | 0 |
Effect of granulocyte colony-stimulating factor on neutropenia due to chemotherapy for non-Hodgkin's lymphoma. The authors administered recombinant human granulocyte colony-stimulating factor (rhG-CSF) to 16 patients with advanced non-Hodgkin's lymphoma treated with combination chemotherapy. Groups of three to five patients were treated with 50, 100, 200, and 400 micrograms/m2 per day of rhG-CSF by intravenous infusion for 14 days, beginning 3 days after chemotherapy. There was a strong linear relationship between the dose and the area under the curve over this dose range. The rhG-CSF was rapidly cleared from serum, with a mean half-life of 5.97 hours for the second phase (t1/2). In patients treated with a dose of more than 100 micrograms/m2 per day, the duration of neutropenia (P less than 0.01) and the duration of fever (P less than 0.05) were significantly decreased. The rhG-CSF was well tolerated and the only clinical observation that appeared relating to rhG-CSF administration was slight bone pain. This study strongly suggests that an optimum dose of rhG-CSF in patients after chemotherapy is 100 to 200 micrograms/m2. Our study shows that rhG-CSF is a clinically useful drug for patients treated with myelosuppressive chemotherapy. | 4 |
Ultrastructural evidence for differentiation in a human glioblastoma cell line treated with inhibitors of eicosanoid metabolism. Human glioblastoma cells incubated in the presence of inhibitors of eicosanoid biosynthesis show decreased cellular proliferation without cytotoxicity. We studied the ultrastructural morphology of a human glioblastoma cell line cultured with nordihydroguaiaretic acid (NDGA), a lipoxygenase inhibitor, or 5,8,11,14-eicosatetraynoic acid, a cyclooxygenase and lipoxygenase inhibitor. When glioblastoma cells were treated for 3 days with antiproliferative concentrations of either agent, they shared many morphological characteristics, including evidence for increased astrocytic differentiation with only limited signs of toxicity. The inhibited glioma cells demonstrated an increase in the number and length of astrocytic processes containing greater numbers of glial filaments, and the NDGA-treated cells also demonstrated extensive lateral pseudopod formation along the processes. The glioblastoma cell shape also became more elongated, losing the usual nuclear lobularity and nuclear inclusions, especially in NDGA-treated cells. Many cytoplasmic organelles packed the cytosol of the inhibited glioma cells, including prominent Golgi apparatus, dilated smooth endoplasmic reticulum evolving into dilated vesicles, cytoplasmic vacuoles, and numerous concentric laminations. There was limited evidence for toxicity, however, as the mitochondria were more pleomorphic with some mitochondrial distention and disruption of the cristae along with an increase in cytoplasmic vacuolization. We conclude that the inhibitors of eicosanoid biosynthesis, NDGA and 5,8,11,14-eicosatetraynoic acid, not only suppress glioblastoma cell proliferation, but also induce increased astrocytic differentiation. | 0 |
Diagnostic value of DNA analysis in effusions by flow cytometry and image analysis. A prospective study on 102 patients as compared with cytologic examination One hundred twenty-six effusion samples from 102 patients were examined by cytology and flow cytometry (FCM). Overall, there was an 84% correlation between cytologic and FCM results. Of the 36 malignant cases determined by cytologic examination, FCM revealed an aneuploid peak in 20 (56%). Image analysis (IA) performed on the malignant cytologic cases with a diploid flow pattern detected two additional aneuploid peaks. In addition, FCM indicated three aneuploid cases in which cytologic characteristics were initially interpreted as benign (false negative). Aneuploidy was therefore detected in 64% of the malignant effusion specimens by FCM and IA. Twenty-three of the total of 24 aneuploid cases detected by FCM were associated with malignancy (predictive value = 96%). The one nonmalignant case was that of hemorrhagic pancreatitis with infected pseudocyst. FCM is an excellent tool when moderate to large numbers of tumor cells are present, whereas use of IA is advantageous for specimens containing smaller numbers of malignant cells because these can be directly analyzed. When an aneuploid peak is present, a diagnosis of malignancy must be suspected, and, if the initial cytologic screen is negative, a critical review of the cytology slides is justified. In those cases with an equivocal atypical cytology report and an abnormal cytometric histogram, additional investigation is warranted. In some malignancies the tumor cells will be diploid (in this study 36%) and neither FCM nor IA will add to tumor detection, leaving cytologic examination as the definitive technique. | 0 |
Human atherosclerotic coronary artery xenografts: a model for investigation of transluminal recanalization. A model for testing transluminal recanalization techniques was developed. Fragments of human atherosclerotic coronary arteries were transplanted into carotid arteries of dogs and evaluated by angiographic, angioscopic, and histologic study within a three-month period. An inflammatory response was most intense within the first week. By two weeks no inflammation was noted. Total occlusion (n = 13) and stenosis (n = 11) of the carotid arteries were achieved without complications. The model is easy to produce within a short period and the arterial occlusion resembles human vascular disease. This model has been used to evaluate laser recanalization of vascular obstructions. | 4 |
Restenosis after directional coronary atherectomy: differences between primary atheromatous and restenosis lesions and influence of subintimal tissue resection. Rates of restenosis were evaluated in 70 patients (74 lesions) after successful directional coronary atherectomy. The extent of vascular tissue resection was correlated with restenosis rates for coronary (n = 59) and vein bypass graft (n = 15) lesions. After 6 months, the overall restenosis rate was 50% (37 of 74 lesions); it was 42% (15 of 36 lesions) when intima alone was resected, 50% (7 of 14 lesions) when media was resected and 63% (15 of 24 lesions) when adventitia was resected. Subintimal tissue resection increased the restenosis rate for vein grafts (43% with intimal resection versus 100% with subintimal resection, p = 0.01) but not for coronary arteries (50% versus 48%). There was no overall difference in restenosis rates after atherectomy between primary lesions and restenosis lesions that occurred after balloon angioplasty (46% versus 54%). Among postballoon angioplasty restenosis lesions, a higher rate of restenosis after atherectomy was found with subintimal than with intimal resection (78% versus 32%, p = 0.01). Tissues from patients undergoing a second atherectomy for restenosis after initial atherectomy (n = 8) demonstrated neointimal hyperplasia that appeared histologically identical to restenotic tissue developing after balloon angioplasty (n = 37). These data suggest that the cellular response to directional coronary atherectomy is characterized by neointimal proliferation similar to that which may develop after balloon angioplasty. The extent of fibrous hyperplasia appears to be related to the depth of tissue resection in vein graft lesions and coronary artery restenosis lesions that occur after balloon angioplasty but not in primary atheromatous coronary artery lesions. | 3 |
Eleven years' experience with retinopathy of prematurity: visual results and contribution of cryoablation. We report our 11 years' experience of cryotherapy for retinopathy of prematurity (ROP). Charts of 624 infants weighing under 1250 g who were admitted to our Neonatal Intensive Care Unit during 1977-87 were reviewed. Three hundred and eighty nine babies survived, and the total ROP prevalence was 57.5%. Cryotherapy was applied to 35%. Only one case (0.25%) of blindness was detected, and four babies (1%) had a final visual acuity of less than 20/200 in one eye. The complication rate following cryoablation was very low. | 4 |
Placement of esophageal stethoscope by acoustic criteria does not consistently yield an optimal location for the monitoring of core temperature. The esophageal stethoscope has evolved into a device for both acoustic and core temperature monitoring. To test whether routine placement according to acoustic criteria results in placement of the core temperature sensor in the region of contiguity between the esophagus and the heart, we determined the depth of placement electrocardiographically. All patients were undergoing nonthoracic elective operations requiring general anesthesia and tracheal intubation. First, we established that different observers selected the same esophageal depth within +/- 1 cm electrocardiographically, using the criterion of a symmetric biphasic P wave of maximal amplitude (7 patients). Then, in 30 more patients, we compared routine acoustic placements with the depths of the maximal-amplitude biphasic P wave. Stethoscopes placed according to acoustic criteria were within +/- 3 cm of P-wave depths in 15 of 30 patients. In the remaining patients, measured discrepancies ranged up to 13.5 cm. We conclude that the prevailing stethoscope design, with a thermistor at the tip, below the acoustic window, does not ensure placement of the thermistor within the optimal region for monitoring of core temperature. A modification in design that would take advantage of the reliability of electrocardiographic positioning is suggested. | 4 |
Plasma tumour necrosis factor alpha in cystic fibrosis. Plasma tumour necrosis factor alpha (alpha) concentration is increased in acute Gram negative sepsis, but the effect of chronic infection on plasma concentrations is unknown. A study was carried out in patients with cystic fibrosis to determine the effect of chronic lung infection with Pseudomonas aeruginosa on the plasma concentration of tumour necrosis factor and two other indicators of the inflammatory response, circulating C reactive protein and neutrophil elastase-alpha 1 antiproteinase complex (elastase complex). The concentration of immunoreactive tumour necrosis factor in plasma was greater than the upper 95% confidence interval for healthy subjects (2.6 U/ml) on 129 out of 189 occasions in 14 patients observed for about a year. The increase in tumour necrosis factor was associated with increased circulating C reactive protein and elastase complex. Twelve patients with an exacerbation of respiratory symptoms were studied before and after two weeks' treatment with anti-pseudomonal antibiotics. All three indicators of the inflammatory response fell after treatment, though median tumour necrosis factor (4.8 U/ml) and elastase complex (0.41 microgram/ml) concentrations remained above the upper limits for healthy subjects. During a period of clinical stability plasma tumour necrosis factor was increased in 10 of the 12 patients, elastase complex was increased in 10 of the 12, and C reactive protein was increased in seven. Increased plasma immunoreactive tumour necrosis factor was a feature of the near continuous inflammatory response to chronic P aeruginosa infection in cystic fibrosis and may be a factor contributing to the progressive lung destruction seen in this disease. | 4 |
The "stuck twin" phenomenon: ultrasonographic findings, pregnancy outcome, and management with serial amniocenteses. Thirteen consecutive twin pregnancies affected by the "stuck twin" phenomenon were reviewed to determine the potential benefit of serial amniocenteses. The fetal survival rate for the eight pregnancies that underwent serial amniocenteses was 69% (11 of 16 fetuses). This is significantly improved compared with a fetal survival rate of 20% among the five preceding pregnancies managed without serial amniocenteses at the same institution (p = 0.01). It is also markedly improved compared with a combined fetal survival rate of 16% among 48 previously reported pregnancies with the stuck twin phenomenon managed without serial amniocenteses (p less than 0.0001). Survival correlated with the absence of concomitant pregnancy complications (i.e., maternal hypertension or intractable labor) and with the absence of severe fetal structural abnormalities. Procedural complications occurred in three of eight pregnancies (37.5%) managed with serial amniocenteses and was attributed as a cause of fetal death in one case. Two of 11 survivors (18%) had complications after serial amniocenteses including brain infarction and renal tubular necrosis. Serial amniocenteses may significantly improve the survival rate of twin gestations affected by the stuck twin phenomenon but may be associated with complications among survivors. | 4 |
Peripheral neuropathy associated with eosinophilia-myalgia syndrome. In 1989, the Centers for Disease Control recognized the existence of an epidemic illness characterized by myalgia and eosinophilia in individuals taking preparations containing L-tryptophan. We evaluated 3 patients with eosinophilia-myalgia syndrome who presented with subacute progressive neuropathies. The neuropathies were predominantly motor and maximal in the lower extremities. Two patients were confined to a wheelchair and one was ventilator-dependent and bedridden. Sensory loss predominantly involved small fiber modalities. Electrophysiological studies showed multifocal marked conduction slowing and conduction block indicating segmental demyelination, with associated axonal degeneration that was accentuated distally. Examination of sural nerve biopsy specimens demonstrated axonal degeneration in all 3 patients and perivascular infiltrates in 2. Levels of quinolinic acid, a neurotoxic metabolite of L-tryptophan, were elevated in the cerebrospinal fluid in the 2 patients in whom it was measured. The cause of the neuropathy is unknown but may include immune mechanisms or toxicity of eosinophils, L-tryptophan, its metabolic products, or contaminants within L-tryptophan preparations. | 4 |
Prostaglandin E2-induced diarrhea in mice: importance of colonic secretion. The present study has investigated the basis for induction of diarrhea by prostaglandin (PG)E2 in mice. When given i.p., PGE2 induced a dose- and time-dependent diarrhea; the shortest post-treatment time for diarrhea onset was approximately 7 min, at a PGE2 dose of 200 micrograms/kg. At this dose, PGE2 also produced accumulation of fluid in the small intestine and in the colon (enteropooling). The enteropooling reached its maximum by 9 min and did not decrease until approximately 11 min (i.e., 2 to 4 min after the mean time for diarrhea onset). PGE2 treatment altered neither gastric emptying nor gastrointestinal propulsion, but strongly enhanced the expulsion of a glass bead from the colon (i.e., decreased the time to bead expulsion). The shortest time to expulsion of the glass bead was observed at 200 micrograms/kg i.p. The induction of diarrhea by PGE2 was unaffected by cecectomy, or sham-cecectomy, but the dose-response curve for time to onset of diarrhea by i.p. PGE2 was displaced to the right in animals with ligations of the ileo-ceco-colonic (ICC) junctions. The intraluminal fluid accumulation in the colon, evaluated in mice with ICC ligations, was increased by PGE2 administration within 2 min and remained greater than in vehicle-treated animals until the onset of diarrhea. The stimulation of colonic bead expulsion produced by i.p. PGE2 in control mice was not observed in animals with acute ICC ligations, even at i.p. doses up to 800 micrograms/kg. | 1 |
ST segment alternans during percutaneous transluminal coronary angioplasty--a case report. The occurrence of electrical alternans of the ST segment has been reported in patients with variant angina. The authors encountered a patient with typical electrical alternans of the ST segment in leads V4 through V6, which developed during percutaneous transluminal coronary angioplasty (PTCA) of the proximal left anterior descending artery. Hemodynamic pulsus alternans of the aortic pressure tracing was not observed during electrical alternans, and a Ca2+ blocker could not prevent this phenomenon during PTCA. | 3 |
Economic barriers to the use of oral rehydration therapy. A case report Diarrheal dehydration is a highly prevalent condition among young children and is readily prevented and treated with oral rehydration therapy. We report a death due to hypernatremic dehydration caused by rotavirus diarrhea of a 9-month-old infant whose mother attempted to purchase oral glucose-electrolyte solution in a pharmacy but was unable to afford it. While efforts such as the National ORT Project should help to promote the proper at-home treatment of this condition, we conclude that oral rehydration therapy will not be used optimally by the parents of children living in poverty until the economic barriers to its use are removed. | 1 |
Refractory hypoglycemia secondary to topical salicylate intoxication. We describe a case of severe refractory hypoglycemia secondary to topical salicylate intoxication. A 72-year-old man with psoriasis and end-stage renal disease was treated with a topical cream containing 10% salicylic acid. The patient presented with encephalopathy and subsequently developed hypoglycemia refractory to infusions of large amounts of glucose. A serum salicylate concentration was elevated at 3.2 mmol/L. Emergent hemodialysis was accompanied by rapid lowering of serum salicylate concentration and resolution of refractory hypoglycemia. Salicylate is well absorbed across normal and diseased skin. Salicylate markedly impairs gluconeogenesis and increases glucose utilization, resulting in hypoglycemia. To our knowledge, this is the first article on hypoglycemia due to the application of topical salicylate. | 2 |
Stroke volume during submaximal exercise in endurance-trained normotensive subjects and in untrained hypertensive subjects with beta blockade (propranolol and pindolol). The effect of beta-adrenergic blockade on stroke volume (SV) at increasing submaximal exercise intensities was studied in 12 endurance-trained normotensive and 12 untrained hypertensive (diastolic blood pressure greater than 95 mm Hg) men, aged 18 to 34 years. Subjects were assigned to each of 3 treatments in a double-blind, randomized order: placebo, propranolol (80 mg twice daily) and pindolol (10 mg twice daily) for 10 days, with a period of 48 to 60 hours from the initial dose to the first treadmill test and a 4-day washout period between drugs. Cardiac output was measured using the carbon dioxide rebreathing method and SV was calculated from cardiac output and heart rate as follows: SV = cardiac output/heart rate. Cardiac outputs were estimated at rest and while walking on a treadmill at 25, 45, 60 and 75% of the subject's previously determined maximal oxygen uptake (VO2max). No significant differences were found in cardiac output between either of the drugs and placebo at rest, or at any of the 4 rates of work. Propranolol significantly increased SV above placebo values (p less than 0.05) for both trained and untrained groups at the intensities of 45, 60 and 75%. Significant differences in SV were found between pindolol and placebo only at the intensities of 60 and 75% in the trained group. Contrary to expectations, SV showed no indication of a plateau with propranolol in the trained subjects throughout the 4 different exercise intensities, whereas a plateau was established under placebo conditions by 45% of VO2max in both trained and untrained subjects. These results suggest that both trained and untrained hypertensive persons can exercise with beta-adrenergic blockade at submaximal levels without compromised cardiac function. | 3 |
The prognostic value of modal deoxyribonucleic acid in low grade, low stage untreated prostate cancer. We selected for a prospective surveillance study 167 patients with untreated grades 1 and 2 prostate cancer. The tumors were classified regarding modal deoxyribonucleic acid value (ploidy) by flow cytometry, cytological grade by transrectal fine needle aspiration biopsy and local tumor stage. Of the patients 146 could be evaluated. Mean followup was 50 months. The initial ploidy was statistically correlated to cytological grade but not to initial local tumor stage, prostatic acid phosphatase activity or patient age. Initial ploidy and cytological grade had a prognostic value regarding local tumor progression when considered as single predictors and in combination. Two patients with diploid and 8 with nondiploid tumors initially had metastases during the surveillance. Five patients (1 with diploid and 4 with nondiploid disease) died of prostatic cancer. Modal deoxyribonucleic acid value and cytological grade were of prognostic value in untreated prostate cancer. | 0 |
Cerebrospinal fluid endothelin-1 and endothelin-3 levels in normal and neurosurgical patients: a clinical study and literature review. Endothelins are a family of structurally related, potent, long-lasting vasoconstrictor peptides. There are no established normal human levels of endothelin-1 or endothelin-3 in the cerebrospinal fluid. We measured cerebrospinal fluid endothelin-1 and endothelin-3 levels in five groups of patients: normal controls, patients with subarachnoid hemorrhage and cerebral vasospasm, patients with severe head injuries, patients undergoing temporal lobectomy for intractable epilepsy, and a patient with a gunshot injury to the thoracic spine. Endothelin-3 levels were significantly elevated in patients with subarachnoid hemorrhage and may participate in cerebral vasospasm and subsequent neurologic deterioration. | 3 |
Pylorus preserving pancreatoduodenectomy: an overview. Pylorus preserving pancreatoduodenectomy (PPPD) was reintroduced 12 years ago. Since that time, over 400 patients have undergone PPPD with approximately 41 per cent having chronic pancreatitis and 54 per cent having pancreatic and other periampullary malignancies. Reported 5-year survivals in this latter group have been comparable to those achieved by the classic Whipple procedure. The postoperative mortality rate in 339 reported patients has been 3.8 per cent. Postoperative morbidity, including delayed gastric emptying, has been similar to that of the classic Whipple operation. However, PPPD has been associated with fewer late problems with dumping, diarrhoea, delayed gastric emptying (8.6 per cent), and marginal ulceration (3.6 per cent). Moreover, most patients undergoing PPPD have been able to return to their preoperative and preillness weight. The additional advantage of decreased operative time makes PPPD an attractive alternative to the classic pancreatoduodenectomy. | 4 |
Clinical features and natural history of von Hippel-Lindau disease The clinical features, age at onset and survival of 152 patients with von Hippel-Lindau disease were studied. Mean age at onset was 26.3 years and 97 per cent of patients had presented by aged 60 years. Retinal angioma was the first manifestation in 65 patients (43 per cent), followed by cerebellar haemangioblastoma (n = 60, 39 per cent) and renal cell carcinoma (n = 15, 10 per cent). Overall, 89 patients (59 per cent) developed a cerebellar haemangioblastoma, 89 (59 per cent) a retinal angioma, 43 (28 per cent) renal cell carcinoma, 20 (13 per cent) spinal haemangioblastoma and 11 (7 per cent) a phaeochromocytoma. Renal, pancreatic and epididymal cysts were frequent findings but their exact incidence was not accurately assessed. Mean age at diagnosis of renal cell carcinoma (44.0 +/- 10.9 years) was significantly older than that for cerebellar haemangioblastoma (29.0 +/- 10.0 years) and retinal angioma (25.4 +/- 12.7 years). The probability of a patient with von Hippel-Lindan disease developing a cerebellar haemangioblastoma, retinal angioma or renal cell carcinoma by age 60 years was 0.84, 0.7 and 0.69, respectively. A comprehensive screening protocol for affected patients and at-risk relatives is presented, based on detailed analysis of age at onset data for each of the major complications. Median actuarial survival was 49 years, with renal cell carcinoma the leading cause of death. | 2 |
Neuropsychological outcome of survivors of out-of-hospital cardiac arrest. Thirty patients resuscitated from out-of-hospital cardiac arrest (15 with and 15 without postanoxic coma on admission) underwent a clinical examination and neuropsychological testing. In order to assess quality of life, they were compared to two matched control groups; 15 patients with previous myocardial infarction and 15 healthy subjects. None of the survivors showed severe neurologic impairment, and all had returned to self-sufficient physical activity. However, the behavior rating scale scores were significantly worse in patients with postanoxic coma. The processing ability linked to memory was significantly worse in the postanoxic coma group. Mood disorders were also observed in this group, but they did not have pathological significance. The remarkably low incidence of neurologic and psychological sequelae in these resuscitated patients, particularly in those with early clinical evidence of severe cerebral damage, is an encouraging result that supports the therapeutic systems development and efforts in the management of out-of-hospital cardiac arrest. | 3 |
Innervation territories for touch and pain afferents of single fascicles of the human ulnar nerve. Mapping through intraneural microrecording and microstimulation. The peripheral distribution of the fibre content of individual ulnar nerve fascicles supplying skin and muscles of the hand in human volunteers was indirectly mapped by tracing the fields of projected sensation evoked by intraneural electrical microstimulation (INMS) and by tracing receptive fields delineated through intraneural recording of afferent impulse activity elicited by natural stimulation of end organs. Moderate intensity suprathreshold INMS, delivered in cutaneous fascicles, induced nonpainful sensations projecting to stereotyped and coherent areas of skin, the fascicular projected fields (FPFs). Fascicular receptive fields (FRFs) were mapped during microneurographic recording by determining the area of skin which, when activated by light tactile stimuli, elicited afferent neural discharges recorded intraneurally. It was found that at a given electrode position in a skin nerve fascicle, moderate intensity INMS induced nonpainful sensations projecting to a cutaneous field (FPF) that coincides with the FRF, while high intensity INMS induced painful sensations projecting within the cutaneous field of nonpainful sensations. Pain induced by INMS in muscle nerve fascicles was projected to the muscles innervated by that fascicle and, in most instances, to areas beyond the muscular receptive field. The study demonstrates that individual ulnar nerve fascicles, at wrist levels, subserve well-defined cutaneous territories in the hand, and that the area of skin covered by the sum of all ulnar fascicular receptive or projected fields matches the maximal possible cutaneous distribution of the ulnar nerve. Insights of practical relevance regarding clinical expression of fascicular nerve injuries are also brought up by this study. | 2 |
Malignant melanoma and pigmented lesions: a diagnostic and management dilemma. We document two cases of malignancy occurring at the site of partially removed benign nevi. Because of the difficulty in clinical diagnosis and the uncertainty in its behavior, we propose that any recurring melanocytic nevus expanding beyond the original surgical scar be re-excised and the specimen carefully analyzed to ensure complete removal. | 0 |
Loss of consciousness after emergence from anaesthesia. A case of suspected micturition syncope. A case of postanaesthesia micturition syncope with respiratory arrest is described. If syncope occurs, the temporary myocardial ischaemia and cerebral hypoperfusion may increase anaesthetic risk in the marginally compensated patient. The loss of airway protection during the syncopal period is also a cause of concern. We recommend the use of an indwelling bladder catheter during any prolonged surgical procedure. | 2 |
Successful prophylaxis for fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: six years' experience [published erratum appears in Am J Kidney Dis 1991 Jun;17(6):726] Fungal peritonitis as a serious complication of continuous ambulatory peritoneal dialysis (CAPD) is often associated with severe morbidity, CAPD "drop-out" and, occasionally, death. Most episodes of fungal peritonitis occur during or after a period of antibiotic treatment of various bacterial infections, usually bacterial peritonitis. From April 1979 to December 1982 (period I), 10 episodes of fungal peritonitis occurred during 415 patient-months, ie, 10.5% of all peritonitis episodes recorded in our CAPD program. After the introduction of oral prophylaxis with 3 x 500,000 IU [corrected] nystatin during every course of antibiotic treatment, only four episodes of fungal peritonitis occurred during 2,102 patient-months, ie, 3.1% of all peritonitis episodes from January 1983 to March 1989 (period II). This difference between the first and second periods is significant (P less than 0.05). Moreover, none of the four patients who contracted fungal peritonitis in the second period received nystatin prophylaxis. Thus, the simple measure of oral prophylaxis using this nonabsorbable antifungal agent in every case of an antibiotic treatment largely eliminates the risk of fungal peritonitis in patients on CAPD. | 1 |
Genotypic characterization of centrocytic lymphoma: frequent rearrangement of the chromosome 11 bcl-1 locus. Centrocytic lymphomas are defined in the Kiel classification as B-cell lymphomas composed exclusively of cells resembling cleaved follicular center cells (FCC). These lymphomas have been shown to be histologically, immunophenotypically, and clinically distinct from other cleaved FCC lymphomas. DNA from 18 centrocytic lymphomas (14 patients) was analyzed using Southern blotting and probes for immunoglobulin heavy (JH) and kappa light chain (JK) joining gene, T-cell receptor beta chain constant gene (CB), bcl-1, bcl-2, and c-myc gene rearrangements. All of the lymphomas had JH and JK rearrangements, confirming their B-cell origin. None of the specimens had detectable CB, bcl-2, or c-myc rearrangements. However, 4 of 14 patients (28.6%) had rearrangement of the chromosome 11 bcl-1 locus. Therefore, centrocytic lymphomas are genotypically distinguishable from the majority of other small cleaved FCC lymphomas by their lack of demonstrable bcl-2 rearrangements. This supports the distinct nature of centrocytic lymphomas and suggests the lack of importance for the putative oncogene bcl-2 in these cases. Furthermore, the frequent rearrangement of bcl-1 suggests a possible role for this locus in the pathogenesis of at least some centrocytic lymphomas. | 0 |
Acoustic schwannoma and epidermoid cyst occurring as a single cerebellopontine angle mass. The case of a 66-year-old man with a 3-year progressive hearing loss and a homogeneous left cerebellopontine angle mass on magnetic resonance imaging scan is described. At surgery, the major portion of the mass was a typical encapsulated, solid, acoustic schwannoma, but the most rostral portion was a distinct, flaky, cystic mass without a well-defined capsule, typical of an epidermoid cyst. The radiographic and operative findings of this unique coexistence of two different benign cerebellopontine angle masses are presented. | 0 |
Intraoperative assessment of cerebral ischemia during carotid surgery. One of the problems in carotid surgery is the intraoperative detection of brain ischemia. None of the methods (EEG; stump pressure) applied so far have been successful. Branston et al. (1974) found a threshold relationship between cortical cerebral blood flow and cortical somatosensory evoked potential (SEP). As the local blood flow fell below about 16 ml/100 g/min a progressive reduction occurred in the amplitude of the cortical evoked potential (N20/P25), implying a fundamental failure of neuronal function in the somatosensory cortex. We have monitored cortical SEP (somatosensory evoked potential) during 734 CEA's (carotid endarterectomies) in order to find an index of risk of incipient cerebral ischemia during carotid cross-clamping, to determine the need for shunting and the causes of early irreversible neurologic deficits. In 59 cases evaluation of SEP was not possible because of technical difficulties. During 586 CEA's no alteration of SEP occurred. However, 4 patients had an immediate postoperative neurologic deficit, while the SEP remained normal. Abnormal SEP occurred in 89 cases and in 6 of these an irreversible loss of SEP was seen. These patients awoke with a new neurologic deficit. We found a reversible abnormal SEP in 83 cases. Reversible changes of SEP occurred mainly during carotid clamping. The diagnostic sensitivity of intraoperative SEP monitoring in predicting neurologic outcome was 60% with a specificity of 100%. | 3 |
Feasibility and safety of vagal stimulation in monkey model. The feasibility, safety, and preliminary effects of chronic vagal stimulation were studied in an aluminagel monkey model. Pilot studies to perfect the equipment, determine stimulation thresholds, and insure the comfort and safety of the animals preceded this study. Four monkeys were equipped with an indwelling, 2-electrode cuff (titanium bands spaced 7 mm apart; silicone encased; 1.5 cm total length) in contact around the right vagus nerve; avoidance of the cardiac branch was confirmed by electrocardiograms. After postsurgical recovery, the intact and awake animals received constant-current stimulation (5 mA; 83 Hz, 143 Hz, or 50-250 Hz randomly; 0.5-ms pulse width) at the onset of every spontaneous seizure for the duration of the seizure or every 3 h for 40 s if stimulation had not occurred in the preceding hour. Stimulation periods of 2-6 weeks, with differing levels of stimulation, were preceded and followed by at least a 2-week baseline period of no stimulation. During the stimulation periods, the seizure rate decreased to zero in two monkeys and the interseizure intervals became invariable in the remaining two monkeys. These effects carried over temporarily into the poststimulation baseline periods. Vagal stimulation had no consistent effects on seizure severity or EEG interictal spikes. Histological studies of six vagus nerves were unable to separate electrode cuff damage from any direct effects stimulation may have had on the nerves. Although it appears that chronic vagal stimulation is feasible and that epileptogenic processes are influenced, the safety and efficacy of the procedure are still in question. | 2 |
Spinal man after declaration of brain death Complex spinal automatism in a patient who was declared brain dead is described. These movements tend to appear once cerebrospinal shock has abated. We postulate that these manifestations are a reflection of the physiological potential of the isolated spinal cord. These spinal movements should be included in the revised guidelines for the determination of cerebral death. | 2 |
Etiology of acute lower respiratory tract infection in children from Alabang, Metro Manila. The etiology of acute lower respiratory tract infection (ALRI) was identified in 235 (43.8%) of 537 hospitalized children less than 5 years of age. Clinical evidence of measles was found in 258 (48.0%) patients, of whom 59 had a second viral infection. A viral agent was identified in an additional 121 patients, so that a total of 379 (70.6%) had viral infections. After measles, respiratory syncytial virus was the most common respiratory virus. Bacteremia was noted in 72 children (13.4%), occurring as frequently in children with measles (14.8%) as in those without (12.1%); Haemophilus influenzae and Salmonella typhi were predominant in the former, and H. influenzae, Staphylococcus aureus, and Streptococcus pneumoniae were prominent in the latter. The presence of bacterial antigen in urine was not helpful in identifying bacterial infection. Extrapulmonary and intrapleural complications, concomitant measles, complicated ALRI, female gender, and malnutrition were associated with increased mortality among children with ALRI. The importance of measles immunization, vitamin A supplementation for alleviation of defects associated with malnutrition, and timely antimicrobial therapy is emphasized. | 4 |
Oral indomethacin for acute renal colic. A number of studies have suggested that nonsteroidal antiinflammatory agents can relieve renal colic by a mechanism of action different from that of narcotics, offering the potential advantage of avoiding narcotic side-effects such as alteration of mental status. The authors prospectively administered oral indomethacin, 50 mg, to 25 nonvomiting patients with acute renal colic due to a documented stone. Eleven patients group (I) received the drug in an unblinded, nonrandomized fashion after failure of oral or parenteral narcotics to provide satisfactory pain relief, either at home or in the emergency department. In 14 additional patients group (II) indomethacin was given as the only initial treatment. Pain intensity before and after treatment was reported using a 1-to-10 scale. In group I, pain decreased from 5.8 +/- 2.7 to 3.6 +/- 3.8 (P less than .02). Six of the 11 patients reported a decrease in pain intensity of 50% or more, which occurred within 25 +/- 11 minutes, and in 5 of these 6, pain decreased to a 0 or 1 level. In group II, pain decreased from 7.6 +/- 1.5 to 4.6 +/- 4.0 (P less than .008). Eight of the 14 patients reported a decrease in pain intensity of 50% or more, which occurred within 40 +/- 14 minutes, and in 5 of these 8 pain decreased to a 0 or 1 level. Among all 25 patients who received indomethacin, pain relief was not significantly associated with the duration of pain before treatment or with patient age or sex. There was a trend for pretreatment pain intensity to be higher among nonresponders (P = .07). | 4 |
Marked cerebrospinal fluid void: indicator of successful shunt in patients with suspected normal-pressure hydrocephalus. The authors blindly reviewed the charts of 20 patients with normal-pressure hydrocephalus (a disease of unknown cause characterized radiologically as chronic communicating hydrocephalus and clinically by gait apraxia, dementia, and incontinence) who had undergone creation of a ventriculoperitoneal shunt. The initial clinical response to surgery was graded excellent, good, fair, or poor; 5-year follow-up was available in 55% of cases. The magnetic resonance (MR) images obtained in these patients were also blindly reviewed for the magnitude of cerebrospinal fluid (CSF) flow void (graded on the basis of extent rather than degree of signal loss) in the cerebral aqueduct. A significant (P less than .003) correlation existed between good or excellent response to surgery and an increased CSF flow void. The presence of associated deep white matter infarction on MR images did not correlate with a poor response to surgery. On the basis of these findings, it is suggested that patients who fulfill the clinical criteria of NPH and have an increased CSF flow void undergo creation of a shunt. | 2 |
High-protein ascites in patients with the acquired immunodeficiency syndrome. Diseases of the liver or peritoneum resulting in ascites have been infrequently reported in patients with the acquired immunodeficiency syndrome. Since 1985, eight noncirrhotic patients with the acquired immunodeficiency syndrome presenting with new onset high-protein ascites have been evaluated. All but one patient had nondiagnostic paracentesis studies. Laparoscopy with biopsy of identified abnormalities or percutaneous omental biopsy were diagnostic in four patients. Non-Hodgkin's lymphoma was the cause in three patients, and disseminated cryptococcosis occurred in one patient. In the four other patients, chronic nonspecific peritonitis was found at laparoscopy; follow-up of these latter patients, including exploratory laparotomy in one patient and autopsy in two patients, disclosed no specific cause. Patients with the acquired immunodeficiency syndrome and high-protein ascites of uncertain etiology should undergo directed peritoneal evaluation as a potentially treatable disorder may be found. However, despite extensive evaluation, a subset of patients in whom no specific cause can be identified still remains. | 1 |
Pelvic resections: the Rizzoli Institute experience. Materials, methods, and techniques of pelvic resections are discussed. Results, including the complications of nerve damage, infection, and vascular, visceral, and reconstructive complications are tabulated. | 4 |
Rectal carcinoma: CT staging with water as contrast medium. Computed tomography (CT) was used to study 42 patients with rectal carcinoma. Water was used as a contrast medium for studying the local extent of tumor in all patients. Scans were read prospectively without knowledge of the histologic staging and then compared with pathologic specimens. CT depicted the tumor in all patients. Comparison of CT and histologic results (following the Dukes classification) showed that disease was correctly staged as A in three of four patients, as B in eight of 12, as C in 15 of 17, and as D in nine of nine. Overall, carcinoma was correctly staged with CT in 35 of 42 patients (diagnostic accuracy, 83.3%). The accuracy in the assessment of local invasion was 97.6% (41 of 42). In the detection of lymph node involvement, the accuracy was 78.6% (sensitivity, 88%; specificity, 64.7%). CT is recommended in the preoperative staging of rectal carcinoma and as an aid in choosing the appropriate therapy. The use of water enema and complete distention of the rectum are reliable techniques for improving the accuracy of CT in the assessment of local invasion by cancer. | 0 |
The surgical treatment of atrial fibrillation. I. Summary of the current concepts of the mechanisms of atrial flutter and atrial fibrillation. Atrial fibrillation is a common arrhythmia that is frequently resistant to medical therapy and has no satisfactory surgical therapy. The development of an effective surgical procedure to treat atrial fibrillation has been hampered by the paucity of clinically relevant information on the basic mechanisms responsible for the arrhythmia. This paper summarizes the current concepts of the electrophysiologic abnormalities in atrial flutter and fibrillation. | 3 |
Genetic strategies of tumor suppression. The evaluation of the cancer cell is a complex multigene process. Tumor suppressor genes that are lost or inactivated, as well as genes that are overexpressed, play key roles in tumor progression. The identification of overexpressed genes has been expedited by the presence of transforming genes in some animal retroviruses. However, tumor suppressor genes have been difficult to identify and isolate because of their loss or inactivation during tumorigenesis. By a variety of methods, summarized in this review, a few tumor suppressors have been cloned and characterized, and many more have been recognized indirectly. The general finding at this time is that the same tumor suppressors (and oncogenes) are found associated with many different tumors, that several different altered genes are found typically in the same tumors, and that other oncogenes and tumor suppressor genes seem to be characteristically altered in particular tumor types as well. Functions of tumor suppressor genes include the control of normal cell activities such as proliferation and differentiation as well as senescence, which is a special kind of differentiation in which cells lose their ability to divide. The genetic basis of senescence and identification of genes involved in overcoming senescence, leading to immortalization (i.e., indefinite growth potential), are important areas of current investigation. Our laboratory is engaged in senescence/immortalization studies as a result of our discovery that normal human mammary epithelial cells can be immortalized by DNA of the human papilloma virus. These new studies are summarized here. | 0 |
Asthma and eczema in children born to women with migraine. Migraine and asthma have been reported to occur in the same person more commonly than would be expected if they are independent. The large Collaborative Perinatal Project provided an opportunity to see if children born to women with migraine or with the group of disorders characterized by asthma and/or allergies were more likely to manifest asthma or eczema in the first 7 years of life. Among children whose mothers had neither migraine nor asthma/allergies, 3.2% had asthma. Of children whose mothers had migraine, but not asthma/allergies, more than 6% had asthma. The risk of asthma among children born to women who had both migraine and asthma/allergies was greater than the risk associated with each maternal disease. The risk of eczema in children was not appreciably influenced by the mother's propensity to migraine or asthma/allergies. The results of this first study of migraine in one generation and asthma in the next lead to the conclusion that the two disorders are probably related. | 2 |
The growing teratoma syndrome. Thirteen patients with metastatic non-seminomatous germ cell tumours and enlarging metastases consisting of teratoma differentiated only were identified. Patients were managed with surgical resection soon after the growing lesions were documented. Surgical morbidity was minimal and 12 patients are alive (10 are disease-free) at a median follow-up of 28 months. | 4 |
Torsade de pointes: a critical care nurse's dilemma. Torsade de pointes is a polymorphous ventricular tachycardia characterized by a gradual change in the direction of the QRS complex. Because critical care nurses are the first to recognize arrhythmias, they require the knowledge and skill to intervene appropriately. This case report focuses on identification of the characteristics, contributing factors, therapeutic modalities, and relevant nursing diagnoses for the patient with torsade de pointes. | 3 |
Spinal epidural abscess: an unusual complication of a duodenal ulcer. A 50-year-old man had several months of progressively worse low-back pain associated with constitutional symptoms and a history of retroperitoneal tumor and bleeding duodenal ulcer. Initial evaluation suggested a lumbar spine tumor, but myelography confirmed the presence of an epidural abscess. Further evaluation revealed a duodeno-spinal fistula at the site of the previous duodenal ulcer, which proved to be the cause of the abscess. | 1 |
Attenuated neuropathology by nilvadipine after middle cerebral artery occlusion in rats. We investigated the effects of nilvadipine, a calcium antagonist, on cerebral ischemia in rats. Under halothane anesthesia, 30 rats had a 3-0 nylon suture introduced through the extracranial internal carotid artery to occlude the left middle cerebral artery. Nilvadipine was dissolved in polyethylene glycol 400. Immediately following occlusion, group 1 rats (n = 10) were treated subcutaneously with vehicle and group 2 and 3 rats were treated with 1.0 (n = 10) and 3.2 (n = 10) mg/kg nilvadipine, respectively. Perfusion fixation was performed 24 hours later, and the histopathologic outcomes were quantified. In group 1 infarct volume was 28.2 +/- 11.4% of the total cerebral volume; in groups 2 and 3 infarct volumes were 25.5 +/- 11.6% (NS) and 13.9 +/- 9.2% (p less than 0.05 different from group 1), respectively. Nilvadipine decreased ischemic neuronal injury in a dose-dependent manner and may be of use in the treatment of cerebral ischemia. | 2 |
Colobronchial fistula: a rare complication of Crohn's colitis. A 29-yr-old white woman presented with chronic pneumonia in the left lower lobe and with left pleural effusion. She was known to have inflammatory bowel disease, but she was asymptomatic under maintenance treatment with 5-ASA. She received numerous antibiotic regimens according to susceptibility testing of microorganisms cultured from sputum and bronchial lavage and on an empiric basis was also given antituberculosis treatment, but there was no clinical improvement or change in the chest radiographic findings. Sputum was repeatedly examined and yielded, among other organisms, Clostridium inocuum, Enterobacter, Klebsiella pneumoniae, Proteus mirabilis, and Staphylococcus aureus. On one microscopic examination of sputum, the presence of feculent material was suspected. A subsequent gastrografin enema revealed a cologastric and colobronchial fistula between the splenic flexture of the colon and the greater curve of the stomach and the bronchial system. Segmental resection of the colon and resection of the lower lobe of the left lung were performed. Histologic findings of the resected colon were consistent with Crohn's disease. After a long period of postoperative recovery, the patient returned to good general health and well-being. To our knowledge, a colobronchial fistula caused by Crohn's colitis has not been previously reported. | 4 |
Association between primary pulmonary hypertension and portal hypertension: analysis of its pathophysiology and clinical, laboratory and hemodynamic manifestations. To determine the clinical, laboratory and hemodynamic profile in patients with primary pulmonary hypertension and associated portal hypertension, 7 new cases and 71 previously reported cases were analyzed. There was no gender predilection and the average age at diagnosis was 41 years. Liver cirrhosis was the most frequent cause of hypertension (82%) and a surgical portosystemic shunt was present in 29%. Almost invariably, portal hypertension either preceded or was diagnosed concurrently with pulmonary hypertension, favoring the hypothesis that in portal hypertension, the pulmonary vasculature may be exposed to vasoactive substances normally metabolized or produced by the diseased liver, possibly inducing vasoconstriction or direct toxic damage to the pulmonary arteries. Clinically, exertional dyspnea was the most frequent presenting symptom (81%); other symptoms, such as syncope, chest pain and fatigue, were present in less than 33%. An accentuated pulmonary component of the second heart sound (82%) and a systolic murmur (69%) were the most common physical findings. At least 75% of these patients had evidence of pulmonary hypertension on electrocardiography (right ventricular hypertrophy) or roentgenography (cardiomegaly or dilated main pulmonary arteries, or both). Hemodynamic findings included severe pulmonary hypertension (mean pulmonary artery pressure 59 +/- 19 mm Hg) with normal pulmonary capillary wedge pressure and cardiac output. Treatment was basically palliative and the mean and median survival times were 15 and 6 months, respectively. In brief, on the basis of clinical presentation and laboratory features, patients with combined primary pulmonary hypertension and portal hypertension seldom represent a diagnostic challenge. Further research is needed on treatment, which remains palliative. The survival rate is poor and worse than that seen in isolated primary pulmonary hypertension. | 1 |
Nutrient modulation of inflammatory and immune function. The metabolic response to injury occurs after a diverse group of surgical injuries including major surgical intervention, shock, infection, and sources of inflammation such as pancreatitis. The response is mediated by the macroendocrine system, the autonomic nervous system, and the cell-cell communication system. The clinical manifestations include now well-described clinical, physiologic, and metabolic characteristics. The approach of aggressive source control, invasive circulatory resuscitation, and nutrition/metabolic support has been associated with an overall reduction in morbidity and mortality. In those patients who do not respond to this approach, the disease process progresses to multiple organ failure syndrome with its associated high mortality. Altering the route of feeding, preventing single nutrient and generalized nutrient deficiency, and reducing nosocomial infections with selective gut decontamination have not significantly altered the course or outcome of the disease process in this latter group of patients with persistent hypermetabolism. The available data support the position that this persistent hypermetabolism represents abnormal metabolic regulation resulting in persistence of the inflammatory response with associated suppression of the immune defenses. A number of research approaches are being taken to understand and modulate this abnormal state of regulation. Because of the role of specific nutrients in these regulatory processes, beyond their role in classic nutrition support, nutrients such as arginine n-3 polyunsaturated fatty acids, and RNA are being evaluated for their ability to modulate inflammation and to improve immune function. Preliminary results are encouraging. | 4 |
Treatment of acute hydrocephalus after subarachnoid hemorrhage with serial lumbar puncture. Computed tomography demonstrated acute hydrocephalus less than or equal to 72 hours after subarachnoid hemorrhage in 24 (23%) of 104 patients. Of these 24 patients, six (25%) had no impairment of consciousness. In nine (11%) of the remaining 80 patients, acute hydrocephalus developed within 1 week after subarachnoid hemorrhage. With the exception of three patients, all 104 patients received antifibrinolytic treatment. Delayed clinical deterioration from acute hydrocephalus occurred in seven (29%) of the 24 patients with acute hydrocephalus on admission and in six (8%) of the remaining 80 patients. Serial lumbar puncture was performed in 17 patients. Twelve (71%) of the 17 patients treated with serial lumbar puncture, including 10 (77%) of the 13 patients with delayed deterioration from acute hydrocephalus after admission, achieved improvement in the level of consciousness. Four of these 17 patients (4% of all 104 patients) required an internal shunt. No patient deteriorated from coning following serial lumbar puncture. The rebleeding rate within 12 days after subarachnoid hemorrhage in hydrocephalic patients with serial lumbar puncture was not higher than the rate in those without hydrocephalus (two [12%] of 17 versus nine [13%] of 71). Neither meningitis nor ventriculitis was observed. We conclude that if neither a hematoma with a mass effect nor an obstructive element exists, cerebrospinal fluid drainage with serial lumbar puncture is a good alternative to ventricular drainage in patients with acute hydrocephalus after subarachnoid hemorrhage. | 3 |
The role of protein kinase C and calcium in the regulation of norepinephrine release from the vascular adrenergic neurons in hypertension. This study was designed to investigate the role of protein kinase C and calcium in vascular adrenergic transmission in hypertension. In perfused mesenteric vasculatures of spontaneously hypertensive rats (SHR, 7 to 10 weeks old) and age-matched Wistar-Kyoto rats (WKY), we have examined the effects of the protein kinase C inhibitor H-7 on endogenous norepinephrine release and vascular responsiveness during nerve stimulation. Endogenous norepinephrine release and pressor responses during periarterial nerve stimulation were significantly greater in SHR than in WKY. The protein kinase C inhibitor H-7 inhibited the stimulation-induced norepinephrine release and pressor responses in a dose-dependent manner. The magnitude of these suppressive responses were more pronounced in SHR than in WKY. Calcium removal from extracellular fluid also reduced the norepinephrine release more strongly in SHR than in WKY. These results demonstrate that the regulation of norepinephrine release might be more dependent on protein kinase C and calcium in the blood vessels of SHR, which could contribute, at least partially, to the pathogenesis of this form of hypertension. | 3 |
Primary cysts and tumors of the mediastinum. A retrospective analysis was performed on 230 patients with primary cysts and tumors of the mediastinum seen at our institution from January 1944 to April 1989. We divided these patients into two groups. Group 1 was seen before 1970 and group 2 was seen from January 1970 to April 1989. There was a significant increase in the prevalence of malignancy in group 2 (47.2% versus 17.1%; p less than 0.0001) due to an increase in the number of lymphomas (22.6% versus 3.5%; p less than 0.001) and malignant neurogenic tumors (6.8% versus 1.1%; p = 0.0528). There was a significant increase in the number of malignant tumors in the anterior (59.5% versus 30.9%; p = 0.0022) and paravertebral (28.5% versus 2.8%; p = 0.0027) compartments in group 2. More patients with these tumors were symptomatic in group 2 (63.6% versus 5%; p = 0.0422). There was an increase of ancillary diagnostic studies performed to evaluate these tumors (76.0% versus 34.5%; p = 0.0422). Logistic regression analysis identified date of presentation (p less than 0.005), symptoms (p less than 0.01), size (p less than 0.005), and the anterior mediastinal compartment (p less than 0.005) as preoperative predictors of malignancy. The surgical approach to these tumors included more median sternotomy (30.1% versus 10.7%; p = 0.0008), anterior mediastinotomy, and cervical mediastinoscopy in group 2 (1.1% versus 17.5%; p = 0.0002). Long-term results support surgical resection in benign lesions and an aggressive multimodality approach to malignant lesions. | 0 |
Electrocardiographic J waves after resuscitation from cardiac arrest. A patient was monitored prior to, during, and after cardiac arrest with a Holter monitor and an electrocardiograph. The arrest occurred without any premonitory signs on the ECG. At the onset of the arrest, torsades de pointes ventricular tachycardia occurred, which quickly degenerated into ventricular fibrillation. After a successful second defibrillation, the patient developed Osborn waves, which subsided within a few minutes. | 4 |
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