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A new syndrome: hearing loss and familial salivary gland insensitivity to aldosterone in two brothers. Two male siblings presented in infancy with hyponatremia. The levels of plasma renin activity and aldosterone were elevated. Sodium supplement was necessary to maintain normal sodium balance. The salivary sodium concentrations were markedly elevated, with sweat sodium levels being in the upper normal range. Urinary sodium concentration and renal epithelial exchange between sodium and potassium were normal. This was felt to be due to an autosomal recessive disorder. Both siblings were later diagnosed as having a bilateral moderate to severe sensorineural hearing loss with intermittent conductive overlay due to middle ear fluid. The sensorineural loss was also felt to be autosomal recessive in origin, but the possibility of a disturbance of sodium balance in the inner ear has been questioned. | 4 |
Complement activation is a secondary rather than a causative factor in rabbit pulmonary artery ischemia/reperfusion injury. We have previously demonstrated that reperfusion of a rabbit lung in vivo after 24 h of unilateral pulmonary artery occlusion results in edema, transient leukopenia, and intravascular leukocyte aggregation. We hypothesized that complement was activated by reperfusion and that this in turn contributed to lung injury. In the preliminary phase of the study, we found that ischemia followed by reperfusion resulted in a drop in C3 to 15 +/- 10% (mean +/- SEM) of the prereperfusion value as compared with no change in a group of control animals that had undergone an identical thoracotomy but without pulmonary artery occlusion and reperfusion (p less than 0.05). We then studied three groups of animals to determine if complement depletion with cobra venom factor (CVF) prior to ischemia and reperfusion would prevent the injury. Rabbits treated with CVF but without occlusion and reperfusion did not develop significant lung edema, with left and right lung wet/dry ratios of 5.32 +/- 0.11 and 5.26 +/- 0.12, respectively. For rabbits that were not treated with CVF but underwent ischemia and reperfusion, the comparable numbers were 6.15 +/- 0.36 and 5.19 +/- 0.32 (p less than 0.05 for right versus left). For CVF-treated rabbits that underwent ischemia and reperfusion, the right/left difference persisted (6.77 +/- 0.48 versus 5.35 +/- 0.14, p less than 0.01). Immunocytochemistry documented C3 deposition in non-CVF rabbits that underwent ischemia and reperfusion but not in CVF-treated rabbits. We conclude that ischemia/reperfusion of the lung results in complement activation, but it is not a complement-dependent injury. | 3 |
Muscle biopsy for diagnosis of malignant hyperthermia susceptibility in two patients with severe exercise-induced myolysis. Muscle biopsy and in vitro contracture tests for diagnosis of susceptibility to malignant hyperthermia (MH) were performed in two patients who had developed fever and severe myolysis during exercise. MH susceptibility was confirmed in one patient, but in the other, exercise-induced heat stroke proved to be the correct diagnosis. Clinical presentation and epidemiology of exercise-induced MH and its relation to the heat stroke syndrome are discussed. | 2 |
Differentiation in embryonal neuroepithelial tumors of the central nervous system. Ninety-six embryonal neuroectodermal tumors were studied histologically and immunohistologically with a panel of antibodies including glial, neuronal, epithelial, mesodermal, and myelin markers. In 71 tumors there was glial and neuronal differentiation and expression both of an S (photoreceptor) antigen and vimentin. In five tumors there was only glial differentiation and in 20 tumors only neuronal differentiation. No reactivity for myelin and epithelial markers was found. Histologic and immunohistologic findings identified various degrees of differentiation in different tumors, which was bipolar (glial and neuronal) in most tumors and unipolar in the remainder. The authors suggest that their findings may be the result of normal or aberrant oncogenic differentiation, agreeing with the nomenclature of the World Health Organization classification for these tumors with and the inclusion of a category for ependymoblastoma. | 2 |
Arrhythmias in patients with CHF. Should they be treated? Ventricular arrhythmias are a major cause of death in patients with congestive heart failure. Dr Ellenbogen and his associates discuss the current thinking, based on recent studies, concerning use of antiarrhythmic agents to prevent sudden cardiac death in these patients. As they point out, the proper antiarrhythmic therapy may be crucial to long-term survival. | 4 |
Identification, prevention, and treatment of silicone oil pupillary block after an inferior iridectomy. We treated two patients in whom silicone oil pupillary block developed despite a patent inferior iridectomy. The clinical characteristics of this complication were a deep anterior chamber, specular reflexes from the iris surface, identification by biomicroscopy of aqueous trapped inferiorly in the vitreous cavity, and no convection currents in the anterior chamber. This complication may be prevented by early face-down positioning of the patient after the operation, and the avoidance of large, centrally located, inferior iridectomies. We recommend that the iridectomy be placed peripherally no larger than 2 mm and propose a new technique for breaking the silicone oil block, which was clearly successful in one of the patients. | 4 |
Traumatic aneurysm of the superior cerebellar artery: case report and review of the literature. Less than 10% of the 250 reported cases of traumatic intracranial aneurysms have involved the posterior circulation. Traumatic aneurysms of the superior cerebellar artery are extremely rare, with only three cases previously reported. This is the first report of a traumatic superior cerebellar artery aneurysm in which the diagnosis was suggested by computed tomographic scan. The potential for a good outcome suggests the value of early angiography when the history and diagnostic imaging studies suggest the possibility of a traumatic aneurysm. | 4 |
Rectal strictures: treatment with fluoroscopically guided balloon dilation. The authors performed 25 fluoroscopically guided balloon dilation procedures in nine patients with rectal strictures. In all cases, the stricture developed after rectal surgery. Four patients underwent ileoanal anastomosis after total colectomy for various conditions; five patients underwent rectosigmoid end-to-end anastomosis after resection of a tumor or as treatment for diverticulitis. Maximal stricture dilatation was attained in 20 instances with a single 15-30-mm balloon. In five procedures, two balloons (20 or 15 mm) were inflated simultaneously ("kissing balloons" technique) to dilate the strictures. In five patients, only one dilation procedure was required for effective treatment of the strictures, with no clinical evidence of strictures after follow-up of 1.5-56 months (mean, 29.5 months). In the other four patients, multiple procedures were performed: nine in one patient, five in one patient, and three in two patients. In these patients, no recurrent symptoms developed during follow-up of 1.25-18 months (mean, 8.1 months) after the last dilation. Complicating leaks, infection, or hemorrhage did not occur after any of the procedures. Fluoroscopically guided balloon dilation is a safe and effective procedure for the treatment of rectal strictures. | 1 |
Femoral saphenous vein bypass in a newborn. This is believed to be the youngest patient to undergo a saphenous vein bypass for iatrogenic trauma of the right superficial femoral artery. The infant had emergency right heart catheterisation and Rashkind septostomy for severe desaturation due to transposition of the great arteries. During the exposure of the saphenous vein, the superficial femoral artery was accidentally severed at it's origin. An attempt to restore the circulation by end-to-end anastomosis failed and resulted in persistent limb ischemia for over 4 hours. The baby was reoperated upon, the damaged part of the superficial femoral artery was resected and a saphenous vein graft interposed between the common and the distal superficial femoral artery. | 3 |
Loss of nocturnal decline of blood pressure in hypertension due to chronic renal failure. The aim of this study was to assess the blood pressure profile of chronic renal failure in comparison with essential hypertension. Thirty hypertensive patients with chronic renal failure due to non-vascular nephropathies were matched by age, sex, and mean 24 h blood pressure, with 30 patients affected by uncomplicated mild-to-moderate essential hypertension. They were studied in an open hospital ward. Diet, meal times, sleep times, and activity schedules were standardized. Noninvasive, automatic, blood pressure recordings were performed for 48 h at sampling intervals of 15 min. The mean 24 h blood pressure almost coincided in the two groups. However, in essential hypertension a mean (+/- SD) nocturnal fall of systolic and diastolic blood pressure was found (12.7 +/- 3.8 and 12.9 +/- 4.8 mm Hg, respectively), while renal patients displayed an average nocturnal increase of 2.7 +/- 8.9 mm Hg and 3.7 +/- 7.8 (P less than .001). The renal patients had also higher heart rates, with a significantly blunted nocturnal fall (4.4 +/- 4.5 beats/min as compared to 9.3 +/- 3.1 beats/min of essential hypertension; P less than .001). Among the renal patients, the day-night blood pressure changes showed no significant correlation with age, creatinine clearance, hematocrit, nocturnal change in heart rate, or day or night mean blood pressure levels. These data suggest that an abnormal day-night pattern of blood pressure is present in chronic renal failure patients independently from external interfering factors. Hence, casual measurements of blood pressure confined to daytime may underestimate a hypertensive condition associated with chronic renal failure. | 3 |
Postoperative complications in patients with disabling psychiatric illnesses or intellectual handicaps. A case-controlled, retrospective analysis. The purpose of this study was to quantitate the operative risk and costs encountered in the surgical treatment of institutionalized patients. Operative complications and duration of hospitalization for 200 institutionalized patients were compared with those in a control group of patients matched for age, sex, and type of operation drawn from the general hospital population. Postoperative complications occurred in 53 (26.5%) of the patients in the study group compared with 15 (7.5%) of the patients in the control group. Elective laparotomy was followed by a complication in 48% of institutionalized patients compared with 11.6% of matched controls. Emergency celiotomy carried a 75% complication rate in the study group. Atelectasis and pneumonia accounted for 50% of the postoperative complications and occurred with greatest frequency following intra-abdominal procedures. The median hospital stay for all institutionalized patients was 3 days more than for matched controls. A strategy for postoperative treatment is presented, with particular emphasis on prevention of pulmonary complications. | 2 |
A report on radiation-induced gliomas. Radiation-induced gliomas are uncommon, with only 73 cases on record to date. The disease that most frequently occasioned radiation therapy has been acute lymphoblastic leukemia (ALL). Three more cases are added here, two after irradiation for ALL and one after irradiation for tinea capitis. In a review of the relevant literature, the authors stress the possibility that the ALL-glioma and the retinoblastoma-glioma links point to syndromes in their own right that may occur without radiation therapy. | 0 |
Buschke-Loewenstein tumor: verrucous carcinoma of the penis. The Buschke-Loewenstein tumor is an anogenital tumor of characteristic clinical and histologic pattern best considered as a low-grade, well-differentiated squamous cell carcinoma. This remarkable neoplasm and its features are reviewed in detail, stressing salient advances in our understanding of it. | 0 |
Cytostatic and cytotoxic effects of recombinant tumor necrosis factor-alpha on sensitive human melanoma cells in vitro may result in selection of cells with enhanced markers of malignancy. Monolayer cultures of the human melanoma cell lines StML-12, StML-11, StML-14 (third, respectively, twenty-fifth subculture), and SKMel-28 derived from specimens representing different stages of tumor progression were treated with 10-10,000 U/ml rTNF-alpha applied for 72 h. The effects of rTNF-alpha on cell proliferation, DNA synthesis, cell viability, cloning efficiency, cell division, cell morphology, and the immunophenotype were studied in triplicate experiments. The cell line StML-14(3) revealed a significantly dose-dependent reduction of growth due to both cytostatic and cytotoxic activities of rTNF-alpha as well as a decrease of CE. Increased numbers of cells in prophase were observed 24 h after addition of r-TNF-alpha. In addition, dislocation of chromosomes in the metaphase, formation of micronuclei, and dose-dependent increases of cells exhibiting micronuclei and the DNA amount per cell were detected at the end of treatment. On the other hand, only a slight sensitivity to the anti-proliferative effect of rTNF-alpha was observed with StML-14(25) and SKMel-28, whereas StML-12 and StML-11 were significantly resistant. The last four cell lines were serially subcultivated and presented common phenotypic patterns with more malignant characteristics than the cell line StML-14(3) before treatment. Overall, rTNF-alpha enhanced the malignant immunophenotype of the cell lines tested. It increased the expression of the "late" melanoma progression markers A.10.33 and A.1.43, and Ki67, and it decreased the expression of the "early" progression marker K.1.2. The expression of HLA-I, HLA-DR, and ICAM-1 was also enhanced after rTNF-alpha treatment, whereas in contrast to other cytokines, rTNF-alpha did not induce the de novo expression of HLA-DR in HLA-DR-negative melanoma cell lines. These findings indicate that rTNF-alpha induces cytostasis and decreases cell viability of certain rTNF-alpha-sensitive melanoma cells. These effects may result in selection of rTNF-alpha-non-sensitive human melanoma cell populations with higher proliferation rates and a more aggressive immunophenotype in vitro. | 0 |
Neurodevelopmental performance of very-low-birth-weight infants with mild periventricular, intraventricular hemorrhage. Outcome at 5 to 6 years of age. The neurodevelopmental outcome of 38 very-low-birth-weight neonates (birth weight, less than 1501 g) was followed up prospectively from birth to 5 to 6 years of age to assess the neurodevelopmental sequelae of mild periventricular, intraventricular hemorrhage (grades I and II). All neonates were screened for periventricular, intraventricular hemorrhage at 5 to 10 days of age. Eleven incurred a mild periventricular, intraventricular hemorrhage (group 1) and 27 had no periventricular, intraventricular hemorrhage (group 2). Each of the infants was neurodevelopmentally normal at 1 to 2 years of age. The 38 children were matched by race, age, sex, and socioeconomic status with control children (group 3) who had been born at term. On outcome measurements at 5 to 6 years of age, groups 1 and 2 scored significantly lower than group 3 on the combined test measurements and on three of the four individual measurements. Group 1 scored significantly lower than group 2 on the combined test measurements only. These data indicate that very-low-birth-weight infants are at risk for learning problems. Although children with mild periventricular, intraventricular hemorrhage did not demonstrate a significant deficit on individual test scores, the significant difference on the combined battery suggests that mild periventricular, intraventricular hemorrhage has an adverse effect on global performance. | 4 |
Methotrexate therapy for persistent ectopic pregnancy after conservative laparoscopic management. Persistent ectopic pregnancy is a recognized complication of conservative laparoscopic surgery. Three such cases were treated successfully with methotrexate and citrovorum factor rescue. All three patients experienced mild lower abdominal pain for a maximum of 36 hours; no other adverse effects were noted. More experience with this therapy will be necessary before subsequent fertility rates can be determined. | 1 |
Characterization of a rat pancreatic secretory protein associated with pancreatitis. A new protein was purified from the pancreatic juice of rats with acute pancreatitis. That protein, not detectable in control animals, was called "pancreatitis-associated protein." It was first observed 6 hours after induction of experimental pancreatitis with taurocholate or cerulein, reached maximal levels of 45 micrograms/mg protein in zymogen granules and 1.8 micrograms/mg protein in pancreatic tissue during the acute phase (48 hours), and disappeared during recovery (day 5). It was never detected in spleen, liver, kidney, heart, or lung. The detection limit of the assay system was 12 ng/mg protein, so that pancreatitis-associated protein levels increased at least 100-fold in pancreatic tissue during the acute phase. The molecular weight (12,000) and isoelectric point (8.2) were determined by two-dimensional gel electrophoresis. Subcellular fractionation and immunoelectron microscopy showed that the protein was synthesized on the rough endoplasmic reticulum and stored in zymogen granules before being secreted, similar to other pancreatic secretory proteins. Immunoblotting and two-dimensional gel electrophoresis revealed that the same protein was synthesized upon induction of pancreatitis by cerulein infusion, by retrograde injection of bile acids, or pancreatitis induced by pancreatic surgery. The pancreatitis-associated protein is therefore an acute-phase protein that differs from other proteins of that family because of its exocrine nature. | 1 |
Adenocarcinoma arising in Barrett's esophagus after total gastrectomy A 64-yr-old Japanese male who underwent a partial gastrectomy for a duodenal ulcer at the age of 21, a total resection of the remnant stomach for a stomal ulcer at age 25, and in whom Barrett's esophagus was diagnosed at age 47, was found to have a tumor at the distal esophagus and was operated on by thoracic esophagectomy. The tumor was a well to moderately differentiated adenocarcinoma invading down to the muscularis propria. The entire esophageal mucosa in the resected specimen was lined by columnar epithelium. This tumor was thought to derive from the Barrett's esophageal epithelium. | 0 |
Microinvasive carcinoma of the uterine cervix (International Federation of Gynecology and Obstetrics Stage IA). In 1985 the International Federation of Gynecology and Obstetrics (FIGO) subdivided Stage IA cervical cancer and specified metric criteria to demarcate Stage IA from Stage IB. Early stromal invasion (Stage IA1) denotes the first invasive protrusions of a carcinoma in situ into the stroma. Microcarcinomas (Stage IA2) are small cancers a number of orders of magnitude larger than Stage IA1 lesions and with a maximum depth of invasion of 5 mm and a maximum horizontal spread of 7 mm; larger lesions are classified as Stage IB. This study reviews 486 patients previously classified as having Stage IA disease. This yielded 344 Stage IA1 and 101 Stage IA2 lesions; 41 cancers were reclassified as Stage IB. Three hundred nine, 89, and 38 patients were followed for greater than or equal to 5 years. One (0.3%) patient with Stage IA1 disease re-presented with Stage IIB disease 12 years after conization. Five (5.6%) patients with Stage IA2 lesions developed invasive recurrences; three died. None of the 38 patients reclassified as having a Stage IB lesion, including 16 who were treated conservatively, developed a recurrence. The FIGO classification is not a guideline for treatment. Stage IA1 lesions can be treated conservatively, but treatment in Stage IA2 must be individualized. Risk factors such as vascular space involvement and confluency are of high sensitivity but low specificity. | 0 |
Reduced platelet aggregability and thromboxane release after rebleeding in patients with subarachnoid hemorrhage. Serial blood samples were obtained from 80 patients with subarachnoid hemorrhage (SAH) to study adenosine diphosphate-induced platelet aggregation and associated thromboxane B2 release. The goal of the investigation was to detect whether reduced platelet function is involved in rebleeds. Seventeen patients (21%) suffered a rebleed, six of those experiencing their first rebleed within 24 hours after SAH. Therefore, most platelet function studies were performed after rebleeds. Thromboxane release was lower in patients with rebleeds than in the others, both before and after rebleeding, although statistical significance was reached only in samples collected after rebleeds. Patients rebleeding within 24 hours after SAH had lower platelet aggregability (p = 0.037) than patients without a rebleed in the samples taken within 3 days after SAH. The results suggest that reduced platelet aggregability and thromboxane release are involved in rebleeds following primary SAH. | 4 |
Torulopsis glabrata vaginitis: clinical aspects and susceptibility to antifungal agents. Torulopsis glabrata is second only to Candida albicans in frequency of isolation from the vagina in both asymptomatic women and patients with yeast vaginitis. We retrospectively studied 33 patients from whom vaginal isolates of T glabrata were obtained. Torulopsis glabrata caused symptomatic vaginitis in 42% of the patients but was unassociated with symptoms in 30%; in 27% of patients, its importance was uncertain because of concomitant pathology. Antifungal susceptibility testing was performed on 39 T glabrata strains isolated from 39 patients. The minimal inhibitory concentrations (MICs) of the majority of T glabrata isolates fell within the sensitive range of the antimycotic drugs tested; however, no correlation was found between in vitro antifungal MICs and the response to azole drug therapy. Clinical success was achieved in 67% of the patients although mycologic cure occurred in only 33%. A small number of patients developed recurrent and often chronic Torulopsis vaginitis unresponsive to conventional therapy. Limited experience suggests that vaginal boric acid therapy may be of value in these recalcitrant cases. | 4 |
Acute T-cell leukemia/lymphoma mimicking Hodgkin's disease with secondary HTLV I seroconversion. The authors observed a pleiomorphic lymphoma mimicking Hodgkin's lymphoma in a French Guyana black woman lacking antibodies for human T-cell lymphoma/leukemia virus type I (HTLV I). After two courses of chemotherapy with either mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) or doxorubicin, bleomycin, vincaleukoblastine, and dacarbazine (ABVD), a typical acute T-cell leukemia/lymphoma developed with HTLV I seroconversion. Specific HTLV I DNA sequences were detected using the polymerase chain reaction (PCR) on a lymph node biopsy obtained before chemotherapy. The mechanisms of the seroconversion are discussed. | 0 |
Microscopic Wegener's disease: a particular form of Wegener's granulomatosis. We describe a case of Wegener's granulomatosis in which the disease was manifested with crescentic glomerulonephritis, upper airway ulcerations, and microangiopathic hemolytic anemia with consumptive coagulopathy. No granuloma was identified but antibodies to cytoplasmic components of neutrophils were strongly positive with a diffuse pattern. Because microscopic vessels were predominantly involved (capillaritis), and granuloma were absent, were refer to this particular form of the disease as "microscopic Wegener's disease.". | 4 |
Gastric juice ascorbic acid: effects of disease and implications for gastric carcinogenesis. N-nitroso compounds (NOC) are strongly implicated in the causation of cancer of the stomach and it has been suggested that ascorbic acid might reduce the risk of gastric cancer by preventing their formation within gastric juice. However, until recently there have been no measurements of gastric juice ascorbic acid concentrations. We have measured both gastric juice ascorbic and total vitamin C (ascorbic acid and dehydroascorbic acid). Our findings suggest that ascorbic acid is secreted into the gastric lumen so that gastric juice concentrations are often greater than those in plasma. Gastric pathology affects this secretion, leading to values in gastric juice that are lower than plasma levels. Stimulation of gastric secretion does not raise vitamin C concentrations in individuals whose values are initially low. The role of ascorbic acid in preventing formation of NOC and protecting against gastric cancer is discussed in the light of these findings. | 0 |
Elapsed time from symptom onset and acute myocardial infarction in a community hospital. STUDY OBJECTIVE: Previous reports have emphasized that thrombolytic therapy for acute myocardial infarction should be initiated within three or four hours of symptom onset to obtain the best clinical outcomes. However, our clinical impression was that late arrivers, who often do not receive thrombolytic therapy, have a good short-term prognosis. Therefore, we investigated the relationships among the elapsed time from symptom onset, thrombolytic therapy, and short-term prognosis in acute myocardial infarction patients. The research hypothesis was that late arrivers have a better in-hospital prognosis because they have less severe disease that may involve spontaneous thrombolysis. DESIGN: Observational cohort study based on reviewing medical records and emergency department service logs. SETTING: 500-bed teaching hospital with medical school affiliation in northeastern Ohio. TYPE OF PARTICIPANTS: Four hundred consecutive patients with acute infarction confirmed by chest pain and positive ECGs or elevated cardiac enzymes. MEASUREMENTS AND MAIN RESULTS: Patients arriving early (elapsed time less than or equal to 1.5 hours) were more likely to be in Killip class III or IV (P = .04) or to have hypotension (P = .0004); and they experienced twofold increased odds of ventricular tachycardia (P = .007), cardiac arrest (P = .03), or death (P = .01). Patients arriving late (elapsed time greater than 3.5 hours) were more likely to have a history of angina (P = .002) and had a better short-term prognosis. CONCLUSIONS: Time of ED arrival after onset of acute myocardial infarction symptoms distinguishes two patient groups that differ in their risk of in-hospital complications. Late arrivers have better short-term prognoses and less (acutely) severe disease, and may have less need for thrombolytic therapy because of possible spontaneous thrombolysis. Patients with prior angina may need education on seeking care if their symptoms change. | 4 |
Enteric neuronal autoantibodies in pseudoobstruction with small-cell lung carcinoma. Severe gastrointestinal dysmotility is a newly recognized paraneoplastic syndrome that occurs with small-cell lung carcinoma. Thirty-four patients with small-cell carcinoma, of whom 5 had chronic intestinal pseudoobstruction and 29 had no digestive symptoms, were studied serologically. Four of the 5 patients with gut dysmotility had immunoglobulin G antibodies reactive with neurons of the myenteric and submucosal plexuses of jejunum and stomach in an indirect immunofluorescence assay. Antibodies of this type were not found in any of the 29 patients who had no gut dysmotility, nor were they found in patients with chronic idiopathic intestinal pseudoobstruction (n = 8), ovarian cancer (n = 20), or epilepsy (n = 4) or in normal subjects (n = 9). In 4 of the patients with paraneoplastic pseudoobstruction, antibodies in highly diluted serum (1:4000-1:8000) bound selectively to nuclei and cytoplasm of neuronal elements in the gut. This novel autoantibody activity suggests that intestinal pseudoobstruction occurring in patients with small-cell carcinoma may have an autoimmune basis. From a clinical standpoint, serological testing offers a simple means for determining which patients with gut dysmotility syndromes may have associated small-cell carcinoma, thereby enabling earlier diagnosis and treatment of the tumor. | 4 |
Cerebral palsy and rhizotomy. A 3-year follow-up evaluation with gait analysis. A recent increase in the popularity of selective rhizotomy for reduction of spasticity in cerebral palsy has led to a demand for more objective studies of outcome and long-term follow-up results. The authors present the results of gait analysis on 14 children with spastic cerebral palsy, who underwent selective posterior rhizotomy in 1985. Sagittal plane gait patterns were studied before surgery and at 1 and 3 years after surgery using a digital camera system. The parameters measured included the range of motion at the knee and thigh, stride length, speed of walking, and cadence. The range of motion at the knee was significantly increased at 1 year after surgery and further improved to a nearly normal range at 3 years after surgery. In contrast, postoperative measurements of thigh range exceeded normal values at 1 year, but decreased toward normal range at 3 years. While improvements in range of motion continued between Years 1 and 3, the children developed a more extended thigh and knee position, which indicated a more upright walking posture. Stride length and speed of walking also improved, while cadence remained essentially unchanged. This 3-year follow-up study, the first to examine rhizotomy using an objective approach, has provided some encouraging results regarding early functional outcome. | 2 |
The cellular composition of basal cell adenoma of the parotid gland: an immunohistochemical analysis. Four cases of basal cell adenoma of the parotid gland were examined immunohistochemically to characterize their cellular composition. In all cases epithelial membrane antigen and keratin were detected in the inner luminal cells; some cells also showed positive staining for secretory functional markers, indicating their differentiation toward secretory epithelium. In tubular and trabecular types the outer cells consistently displayed an intense staining for vimentin and some were also positive for actin, indicating their myoepithelial nature. In the solid type, most tumor cells resembled the ductal cells or basal cells of larger ducts in normal gland with regard to their immunoreactivity. Our results may suggest that the proportion and arrangement of heterogeneous tumor cells are responsible for different histologic patterns of the salivary basal cell adenoma. | 0 |
Gene amplification in human lung cancer. The myc family genes and other proto-oncogenes and growth factor genes. The development of human lung cancer may require multiple genetic deletions affecting a number of chromosomes, e.g., 1, 3, 11, 13, and 17. These genetic aberrations may induce the activation of proto-oncogenes (c-jun, ras, c-raf1) and the loss of tumor suppressor genes (p53). Some of the activated proto-oncogenes and tumor suppressor genes are more selectively expressed or absent in small-cell lung cancer (L-myc, c-myb, c-scr, Rb gene) or non-small-cell lung cancer (c-erbB-2, c-sis, c-fes). These genes may thus be of importance for selection of differentiation pathway. The c-myc oncogene is frequently amplified in small-cell lung cancer cell lines in a much higher frequency than in vivo. This indicates that c-myc seems to be related to tumor progression and a relatively late event in the lung cancer development. The uncontrolled production of multiple growth factors has been identified in human lung cancer cell lines. These factors can promote and inhibit the proliferation via paracrine and autocrine loops via specific receptors. The products from some of the activated proto-oncogenes (c-sis, c-erbB-2) are sequences homologous to a certain growth factor (PDGF) and a receptor (EGF) identified in lung cancer. The production and action of these growth factors may be of major importance for further activation of proto-oncogenes via intracellular signal transduction and specific oncogenic activation leading to further tumor progression. | 0 |
Evidence that a receptor-operated event on the neutrophil mediates neutrophil accumulation in vivo. Pretreatment of 111In-neutrophils with pertussis toxin in vitro inhibits their accumulation in vivo. The role of neutrophil chemoattractant receptors in neutrophil stimulation in vitro is well established, however, the precise mechanisms underlying local neutrophil accumulation at inflammatory sites in vivo have not been defined. A fundamental question that remains open is whether chemoattractants act on the endothelial cell or the neutrophil to initiate the process of neutrophil migration in vivo. To address this question we have investigated whether neutrophil accumulation in vivo can occur if chemoattractant receptor occupancy is uncoupled from neutrophil stimulation. For this purpose we have used pertussis toxin (PT) as the pharmacologic tool. We have investigated the effect of in vitro pretreatment of rabbit neutrophils with PT on their responses in vitro and on their accumulation in vivo. Pretreatment of rabbit neutrophils with PT inhibited FMLP- and C5a-, but not PMA- induced increases in CD18 expression, neutrophil adherence, and degranulation in vitro. This pretreatment procedure with PT inhibited the accumulation of radiolabeled neutrophils in vivo in response to intradermally injected FMLP, C5a, C5a des Arg, leukotriene B4, IL-8, and zymosan in rabbit skin. Further, in contrast to the in vitro results, PT inhibited the PMA-induced 111In-neutrophil accumulation in vivo. Interestingly, pretreatment of neutrophils with PT also inhibited accumulation in response to intradermally injected IL-1, despite the reports that IL-1 lacks neutrophil chemoattractant activity in vitro. Although the experimental techniques used cannot distinguish the different stages of neutrophil migration involved, these results suggest that the accumulation of neutrophils induced by local extravascular chemoattractants in vivo depends on a pertussis toxin-sensitive receptor operated event on the neutrophil itself. Further, PMA and IL-1 may release secondary chemoattractants in vivo. | 4 |
Correlation of common carotid flow volume measured by ultrasonic quantitative flowmeter with pathological findings. To evaluate the possibility of quantitatively diagnosing carotid and cerebral atherosclerosis noninvasively, we measured common carotid flow volume in 60 sides (30 patients), using an ultrasonic quantitative flowmeter, and then compared these findings to the severity score of carotid and cerebral atherosclerosis as determined at autopsy. Stenosis decreased common carotid flow volume in the carotid and cerebral arteries. Increases in the severity score varied inversely with reduced flow volume, which was high in inverse correlation (r = -0.696). Patients with flow volumes of 8.5 ml/sec or greater did not have stenosis greater than or equal to 75%, whereas all patients with flow volumes of 6.4 ml/sec or less had stenosis greater than or equal to 50%, with 45% of these having stenosis greater than or equal to 75%. These pathological findings confirm that the common carotid flow volume reflects the degree of carotid and cerebral atherosclerosis present and that the lower limit of common carotid flow volume in healthy subjects is 6.5 ml/sec. | 3 |
The relationship of headache symptoms with severity and duration of attacks. Efforts to develop clinically useful headache classification schemes have generally focused on linking specific symptom groupings with specific headache subtypes. An alternative conceptual approach, the "severity model" of headache, considers a continuum of headache ranging from mild to severe forms with specific headache subtypes distinguished by level of severity rather than unique constellations of symptoms. A population-based telephone interview was carried out among 10,169 subjects aged 12-29 to estimate the prevalence of serious headaches and better characterize symptoms that accompany headache attacks. In an analysis of frequency of occurrence, pain and duration of recent (within 4 weeks prior to interview) headache attacks, the data revealed that common symptoms (such as forehead pain and pain in the back of the head, neck and shoulders) were reported frequently, but headaches with these symptoms were generally characterized by low levels of pain and short duration. Although not an original study objective, the data were analyzed to determine whether distinct symptom constellations could be identified or whether symptoms overlapped between headache types. Symptoms of migraine were frequently experienced concomitant with tension-type symptoms; the resultant headaches were usually characterized as moderate in intensity. In contrast, symptoms usually associated with migraine in the absence of concomitant tension-type symptoms were infrequently experienced, but resulted in headaches causing the greatest disability. The data provide some support for the severity model of headache. | 1 |
Dietary management of acute childhood diarrhea: optimal timing of feeding and appropriate use of milks and mixed diets. Several recent clinical trials have examined the optimal timing of feeding and the appropriate foods for use in the dietary management of acute childhood diarrhea. Important methodologic issues relevant to these trials, such as the composition and masking of study diets, measurement of outcome variables, and assessment of nutritional status, are discussed. Available data suggest that feeding should be continued during diarrhea, although a small subgroup of patients receiving nonhuman milk exclusively may have an excess rate of complications. These children should be closely supervised or provided with alternative diets. By contrast, children receiving human milk, nonmilk formulas, and mixed diets are generally able to tolerate these foods and to benefit nutritionally from continued feeding. | 1 |
Role of serum prolactin determination in evaluation of impotent patient. Hyperprolactinemia is a recognized cause of impotence. The discovery of elevated prolactin levels in impotent men is very important since pharmacotherapy in this instance is highly successful. We review our experience with prolactin determinations in impotent men, and a population is defined that may benefit from routine prolactin determination. In our experience, the predominant symptom associated with hyperprolactinemia in men is loss of libido. | 2 |
Comparison of levels of several human microsomal cytochrome P-450 enzymes and epoxide hydrolase in normal and disease states using immunochemical analysis of surgical liver samples. A group of 100 human liver samples obtained from three different network sources was divided into groups of normal, cirrhotic, metastatic cancer and other disease groups. These samples were analyzed for amounts of cytochrome P-450 IA2, IIC, IIE1 and IIIA and epoxide hydrolase per unit of microsomal protein using sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunochemical staining. For each enzyme the amount of protein detected varied by two orders of magnitude, even within the set of normal liver samples. With respect to the liver samples judged to be normal, the cirrhotic samples showed decreased levels of P-450 IA2 and IIE1 and epoxide hydrolase (P less than .05). The level of P-450 IIIA proteins also appeared lower but the high variance did not allow such a statistically valid conclusion. The liver samples obtained from metastatic cancer patients did not show decreased levels of any of the proteins examined, and levels of P-450 IIC proteins were enhanced in this group compared to the controls. In the samples obtained from patients with other liver diseases, the only major change was a decrease in the level of P-450 IA2. These findings are of use in explaining some of the known effects of hepatic disease on the in vitro and in vivo metabolism of certain drugs. | 1 |
Gunshot wounds to the cervical spine. A retrospective review was performed on 28 patients with low-velocity gunshot wounds to the cervical spine. These composed 31% of all spinal gunshot wounds seen during the study period between 1979 and 1988. Surgical decompression did not seem to improve neurologic recovery in either the incomplete or complete patients. Neurologic recovery also appeared to be unaffected by the presence of retained intracanal bullet fragments. The authors found no advantage to routine neck exploration of this penetrating injury. Complications were seen in 93% of the patients. Most complications were thromboembolic, pulmonary, and urinary tract infections. No cases of instability occurred as a direct result of the gunshot wound. No deaths occurred in this series. Two cases of posttraumatic syrinxes were diagnosed. The authors' current treatment recommendations for these patients include selective wound management and observation of retained intracanal bullet fragments in patients with complete lesions. Surgical decompression after this injury is not recommended. | 2 |
Pituitary hemorrhage into a Rathke's cleft cyst This report describes a case of symptomatic pituitary hemorrhage into a Rathke's cleft cyst in a 25-year-old woman. The literature on pituitary hemorrhage in nonadenomatous sellar tumors is reviewed. | 0 |
Brush cytology in the diagnosis of colonic neoplasms. During a three-year period (1986-1988), 234 colonic brush specimens were received in the authors' laboratory. Nine samples (4%) were deemed unsatisfactory for evaluation because of inadequate cellularity and/or poor fixation. In 11 cases concomitant or follow-up histologic specimens were not available. The remaining 214 specimens included 82 malignant neoplasms, 88 neoplastic polyps (adenomas), and 44 nonneoplastic lesions. Sixty-seven (82%) of malignant neoplasms were correctly diagnosed by brush cytology. Three cases of adenoma with severe dysplasia or in situ carcinoma were diagnosed as adenocarcinoma by cytology. No false-positive diagnoses were made of nonneoplastic lesions. Brush cytology was found to be a more sensitive technique in the diagnosis of colon cancer than endoscopic biopsy (82% and 74% sensitivity, respectively). The combination of the two techniques increased the sensitivity to 90% and improved the overall accuracy of the test. Seventy-one (82%) of the colonic adenomas were correctly diagnosed by cytology. Brush cytology is a convenient, safe, and accurate technique which should be used concurrently with endoscopic biopsy or polypectomy. | 0 |
Third ventricle cavernous angioma: report of two cases. Cavernous angioma arising in the third ventricle is an extremely rare disease. We have reviewed five cases previously reported, as well as our own two cases, and discuss the clinical characteristics of and surgical approach to cavernous angioma at this site. The bifrontal craniotomy and interhemispheric translamina terminalis approach minimize the damage to the brain and allow for an approach to the third ventricle in a wide operative field with minimal compression of the brain itself. We have found this approach to be suitable for surgery on angiomas of the anterior half of the third ventricle. | 0 |
6-[18F]fluoro-L-fucose: a possible tracer for assessing glycoconjugate synthesis in tumors with positron emission tomography. The potential of 6-[18F]fluoro-L-fucose (6-[18F]FFuc) for assessing glycoconjugate synthesis in tumors with positron emission tomography (PET) was investigated. Using the tissue sampling method with five tumor models, different time-radioactivity profiles were found: a nearly constant level in Lewis lung carcinoma (3LL) and different clearance patterns in others. Rapid clearance in normal tissues resulted in preferable uptake ratios for tumor imaging of brain and pancreas. Metabolic studies and the L-fucose loading effects on the tissue uptake proved the tracer to be a biochemically active L-fucose analog. Imaging of the intracranial rat glioma and 3LL in lungs or hepatomas in mice by autoradiography (ARG) and intramuscular VX-2 carcinoma in rabbits by PET was demonstrated. Using double-radionuclide ARG, similar distribution images of 6-[18F]FFuc and 14C-L-fucose but different tumor-to-liver uptake ratios were found. A metastasis model seemed to show a higher uptake of both tracers as compared to a primary tumor model. | 0 |
Outpatient orthognathic surgery: criteria and a review of cases. Over a 9-year period, 87 orthognathic procedures were performed in an outpatient environment. Procedures performed included horizontal mandibular osteotomies, rapid palatal expansions, bilateral sagittal split osteotomies, posterior and anterior maxillary osteotomies, and Le Fort I osteotomies. Fourteen of these patients were subsequently admitted to a hospital for either observation or full inpatient care. The rates of admission varied for each of the procedures, with length of anesthesia statistically related to the frequency of admission. Patient selection criteria and facilities used are reviewed. | 4 |
Diurnal fluctuations of arterial ketone body ratio in normal subjects and patients with liver dysfunction. To explore the metabolic aspects of chronic liver disease, diurnal changes of arterial ketone body ratio (acetoacetate/3-hydroxybutyrate), reflecting hepatic mitochondrial redox potential, were investigated in normal subjects, patients with chronic liver disease (Child's class A or B), and patients with hepatic failure (Child's class C). Ketone body ratio in normal subjects increased after breakfast from 0.96 to 2.00, after lunch from 2.17 to 2.38, and after dinner from 1.23 to 2.55 with blood glucose level ranging from 103 to 141 mg/dL (5.7 to 7.8 mmol/L). By contrast, the ketone body ratio in the Child A or B group changed little and remained within a range of 0.70-1.35 despite a large change in blood glucose level from 102 to 176 mg/dL (5.7 to 9.8 mmol/L). Ketone body ratio in Child's class C remained near or below 0.4 with no response to glucose administration, despite a marked elevation in blood glucose level. These results indicate that hepatic mitochondrial redox potential undergoes diurnal changes in sharp response to meals in normal liver function but that these fluctuations are absent in patients with liver damage (Child's class A, B, and C). Furthermore, it remains at low levels in severe liver failure (Child's class C). It is also suggested that hepatic mitochondrial redox potential plays an important role in the regulation of blood glucose levels. | 4 |
Black-white differences in cancer prevention knowledge and behavior. Data from the 1987 National Health Interview Survey Cancer Control Supplement were used to estimate multivariate logistic regression models of diet change, mammography utilization, stool blood test utilization, and smoking. Predictor variables included race, sex, age, income, dietary concerns, and four knowledge-related variables: education and three measures of cancer prevention knowledge. When knowledge variables were included in the models, race was not a significant predictor of behavior, with one exception: among women, Blacks were found to smoke less than Whites. | 0 |
Severity of coronary atherosclerosis correlates with the respiratory component of heart rate variability. Decreased vagal activity is frequently observed in coronary artery disease, but the mechanism of this association is unknown. We investigated cardiac autonomic function by relating heart rate spectral components to clinical and angiographic findings in 80 patients who were undergoing coronary angiography. The age- and sex-adjusted magnitude of the respiratory spectral component, which is an index of cardiac vagal tone, showed a significant negative correlation with the extent of coronary atheromatosis (r = -0.43, p less than 0.0001) and a less significant negative correlation with the severity of coronary stenosis (r = -0.30, p = 0.0070). These relationships were independent of previous myocardial infarction and of left ventricular function. Stepwise regression analysis showed that the respiratory spectral component contributed to atheromatosis independently of established coronary risk factors (partial R2 = 9.4%, p = 0.002), but not to stenosis. Our results support the hypothesis that decreased cardiac vagal activity is associated with an increased risk of coronary atherosclerosis. | 3 |
Relationship between duration of spinal cord ischemia and postoperative neurologic deficits in animals. Stagnara wake-up tests, blood flow measures, somatosensory evoked potentials (SEPs), and neurogenic-motor evoked potentials (NMEPs) were elicited from 20 hogs before and after spinal cord overdistraction at L3-L4. Overdistraction was maintained from 5 to 30 minutes after loss of NMEPs. Results suggest that the longer the duration of overdistraction the greater the likelihood of paraplegia. Blood flow measures indicated that reduced perfusion was greatest at the distraction site but extended proximally and distally. Finally, NMEPs were more sensitive to onset of overdistraction and a more valid indicator of paraplegia than SEPs. NMEPs should provide the surgeon with more time for initiation of intervention techniques than SEPs. Because NMEPs and SEPs provide information regarding different spinal cord tracts, the authors continue to use both methods for monitoring the functional integrity of the human spinal cord during corrective spine surgery. | 3 |
Diffusing capacity of the lung and nifedipine in systemic sclerosis. Lung involvement in systemic sclerosis may be due in part to a functional abnormality of the pulmonary vasculature. To investigate the possible role of a pulmonary vasospastic process in this disorder, 21 non-smoking patients who had no evidence of cardiac disease or pulmonary hypertension were evaluated with pulmonary function tests prior to administration of nifedipine, 30 minutes after a single oral dose of nifedipine (20 mg), and after 4 weeks of treatment with nifedipine (10 mg 3 times daily). Treatment with nifedipine did not significantly change any of the pulmonary function values, except for the carbon monoxide diffusing capacity (DLCO). The linear trend between the individual DLCO values at baseline and their changes immediately following the initial 20-mg dose of nifedipine (r = -0.603, P = 0.02) and after 4 weeks of treatment (r = -0.636, P = 0.01) showed that the lower the DLCO value at baseline, the greater the improvement caused by nifedipine. These findings support the hypothesis of a potentially reversible pulmonary vasospasm in systemic sclerosis and suggest that nifedipine may be useful in the treatment of lung disease in these patients; however, further studies are needed. | 4 |
Suppression of mouse mammary tumorigenesis by long-term tamoxifen therapy. A sustained release of tamoxifen, which produced decreasing serum levels of this drug (24 to 4 ng/mL) over 6 months, suppressed mammary tumorigenesis in virgin or once pregnant C3H/OUJ female mice. Tamoxifen was consistently more effective than early ovariectomy, which only delayed tumorigenesis. Tamoxifen prevented the stimulatory action of cyclical (alternate-month) progesterone administration on mouse mammary tumorigenesis. However, when tamoxifen treatment (12 months) was stopped, progesterone treatment initiated tumorigenesis. In contrast, when long-term tamoxifen treatment was stopped in mice that had not undergone ovariectomy, and estrous cycle returned, the majority of these mice remained tumor free. A comparison of different durations (3, 6, and 12 months) of tamoxifen treatment of virgin mice, starting at approximately 4 months of age, showed an equivalent effect on mammary tumorigenesis. All virgin mice developed tumors by 18 months of age, whereas 80% of the tamoxifen-treated mice were tumor free. Nevertheless, cyclical progesterone administration caused rapid development of tumors after 3 months of tamoxifen treatment; only 15% of these mice were tumor free at 18 months. Cyclical progesterone administration caused an increase in tumorigenesis after 6 months of tamoxifen treatment; 50% of these mice were tumor free at 18 months of age. These data demonstrate the efficacy of tamoxifen to suppress mouse mammary tumorigenesis and demonstrate that continuous tamoxifen therapy is necessary to prevent the development of tumors by progesterone, a stimulatory hormone. | 0 |
The standardized assessment of argyrophilic nucleolar organizer regions in meningeal tumors. Tissue markers of cellular proliferation have been recently utilized as prognostic indicators in tumors of the central nervous system. Nucleolar organizer regions represent transcriptionally active sites of ribosomal deoxyribonucleic acid (DNA) and can be identified by a simple argyrophilic technique. The authors describe a standardized approach to the assessment of these argyrophilic nucleolar organizer regions in meningeal tumors. Twenty-five meningiomas were classified histologically into benign, atypical, or malignant groups. In addition, two hemangiopericytomas and one leptomeningeal melanoma were examined. Appropriate sections were silver stained and argyrophilic nucleolar organizer regions were counted in 200 nuclei. The mean argyrophilic nucleolar organizer region count was statistically different (p less than 0.001) between benign tumors (245 +/- 156, 1.23/cell), atypical tumors (497 +/- 135, 2.49/cell), and malignant tumors (921 +/- 59, 4.61/cell). The count for recurrent meningiomas (544 +/- 76) was also statistically different (p less than 0.02) from non-recurrent tumors (329 +/- 183). The standardized assessment of argyrophilic nucleolar organizer regions can be easily performed by any surgical pathology laboratory without specialized equipment and, in meningeal tumors, may be useful as an independent indicator of biological behavior. | 2 |
Peroxisomal disorders. Although peroxisomes were once considered a vestige, their importance in cellular metabolism is clearly established by the many inherited diseases that have been described in the past two decades. Unfortunately there is no definitive treatment for the various disorders, but based on the recognition of the biochemical abnormalities, prenatal testing and appropriate genetic counseling can be provided. It is essential for clinicians to be aware of this group of diseases, as diagnosis and further study of these patients are essential in understanding the basic etiologic mechanisms underlying these complex groups of disorders. Clearly, there is much to be learned about the relationship between biochemical abnormalities and the phenotypic variability of the peroxisomal disorders. | 4 |
Atrial fibrillation after stroke in the elderly. To examine the relationship between atrial fibrillation and mortality after stroke, we studied 186 men and 167 women from the Waikato Stroke Registry whose mean age was 75.2 +/- 7.5 years. Twenty-three percent (82 of 353) had atrial fibrillation or flutter on their admission electrocardiogram. This group differed significantly from that with sinus rhythm in three respects: 1) They were older (p less than 0.01); 2) they had more severe current stroke deficit as evidenced by lower limb power (p less than 0.05) and Mini-Mental State Score (p less than 0.001), higher incidence of homonomous hemianopia (p less than 0.05), and lower incidence of lacunar syndrome stroke (p less than 0.001); and 3) they had a significantly higher incidence of cardiomegaly and congestive heart failure (p less than 0.01). Functional outcome was insignificantly better in the group with sinus rhythm. During a mean follow-up period of 18 months, mortality was significantly higher in the group with atrial fibrillation (p = 0.001). Proportional hazards modeling, however, showed that the apparently poorer survival in those patients with atrial fibrillation could be explained by factors other than cardiac rhythm, such as age, Mini-Mental State Score, level of consciousness, and interstitial edema on admission chest radiograph. Thus, atrial fibrillation was not an independent predictor of survival after stroke. | 2 |
Retained intrahepatic stones: treatment with piezoelectric lithotripsy combined with stone extraction. Extracorporeal shock wave lithotripsy (ESWL) was performed in 11 patients with oriental cholangiohepatitis and intrahepatic stones associated with segmented strictures of intrahepatic ducts. All patients had previously undergone biliary surgery and basket extraction via a T-tube tract at the time of lithotripsy. The indication for ESWL was failure of, or anticipated difficulty with, basket extraction of the stones via a T-tube tract. A piezoelectric lithotriptor was used in all procedures. The average total number of shock waves administered was 29,756 (range, 10,000-61,395). The average number of treatment sessions was 3.1 (range, 1-6); the number of shock waves used in a single session ranged from 10,000 to 15,000 with a frequency of five shots per second and 30%-50% power. In six patients, the stones were successfully fragmented and completely removed; in three of the others of the stones were fragmented and removed. The overall success rate, including complete (54%) and incomplete (27%) success, was 82%. Difficulty in targeting stones, and severe strictures and deformities of intrahepatic ducts, were the factors responsible for failure. No significant complications were observed. | 1 |
Lack of correlation of clinical breast examination with high-risk histopathology. PURPOSE: Routine breast examination frequently finds differences in palpable density and palpable nodularity, but it is not known if these differences correlate with the presence of high-risk histopathology. PATIENTS AND METHODS: To test for a relationship between clinical breast examination and histopathology, we devised separate, 4-point scales of clinical density and nodularity and validated these scales by repeat examinations 4 or more months apart in 199 separate breasts (the scale was the same or within 1 point on repeat examination 87% of the time for density and 90% for nodularity). We then used these two clinical scales to compare density and nodularity to histopathology of breast tissue at the margins of segmental resections in 60 women undergoing breast-conserving treatment of primary breast cancer. In cases such as these, a large sample of "normal" tissue is intentionally removed when the wide excision is done to obtain negative margins. Histopathology at the margins was graded according to the consensus panel of the American College of Pathology; as might be expected in women with previous cancer, some higher-risk histopathology was found in 37% of cases. A relationship was sought using Spearman's rank correlation coefficient. RESULTS: Neither clinical breast density (rho = 0.16) nor clinical breast nodularity (rho = 0.01) related to the presence of high-risk histopathology in the underlying tissue. Interestingly, breast nodularity increased with age (rho = 0.28), and clinical density and nodularity were inversely related (rho = -0.28). CONCLUSION: We conclude that neither clinical breast density nor nodularity correlates with histopathology and that it is unlikely that a larger study would find a clinically useful correlation. Therefore, a clinical examination should not be used to decide that high-risk histopathology is likely to be present in an individual woman's breast. | 4 |
Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. The effect of cardiac sympathetic blockade by high thoracic epidural anesthesia (TEA) (T1-T6, bupivacaine) on the luminal diameter of normal and diseased portions of epicardial coronary arteries was determined by quantitative coronary angiography in patients (n = 27) with severe coronary artery disease (CAD). In a separate group of patients (n = 9) with severe CAD, the effects of TEA on coronary arterioles (resistance vessels) were studied, by measuring total and regional myocardial blood flow and metabolism with the retrograde coronary sinus thermodilution technique. At the stenotic segments, TEA induced an increase in luminal diameter from 1.34 +/- 0.11 to 1.56 +/- 0.13 mm (P less than 0.002), but did not change the diameter of the nonstenotic segments (3.07 +/- 0.13 to 2.99 +/- 0.13 mm). In the second group of patients, TEA induced no changes in coronary perfusion pressure, total or regional myocardial blood flow, coronary venous oxygen content, coronary blood flow distribution, regional myocardial oxygen consumption, or lactate extraction or uptake. Two patients had chest pain in the control situation and had regional myocardial lactate production that was attenuated by TEA. We conclude that TEA may increase the diameter of stenotic epicardial coronary artery segments in patients with CAD without causing a dilation of coronary arterioles. These effects may be beneficial when high TEA is used to treat severe ischemic chest pain in patients at rest. | 3 |
Penetrating iliac vascular injuries: recent experience with 233 consecutive patients. During a recent 11-year period, 233 consecutive patients with 358 penetrating iliac vascular injuries were treated at our institution. Injuries of the common and external iliac arteries were most often repaired with lateral suture (31%) although several other techniques were also employed. Lateral suture and ligation were used with nearly equal frequency in the management of venous injuries. The hospital mortality rate for the series was 28%, and 56/66 deaths (85%) were due to exsanguination or shock. One patient, initially treated with an end-to-end anastomosis of the iliac artery, died a year after discharge from a ruptured false aneurysm. Two patients treated with lateral suture of venous injuries died of pulmonary embolism. Arterial complications occurred in 15% of patients with arterial injuries and three patients required amputation. No graft infections occurred in 16 patients treated with PTFE interpositions, including four with associated colorectal injuries. Venous complications occurred in 12% of patients with venous injuries, and most were noted in those treated with ligation. Four patients treated by venous ligation developed chronic venous insufficiency. The prevention of death from exsanguination is the greatest problem in the management of patients with iliac vascular injuries. Although some late deaths and many complications may be related to the technique of vascular repair, circumstances often prohibit alternative methods. Despite two deaths from pulmonary embolism, insufficient data exist to condemn lateral suture of venous injuries. | 4 |
Subrenal capsule assay as a chemosensitivity test for primary esophageal squamous cell carcinoma. The efficiency of the subrenal capsule assay (SRCA) was studied with fresh tissue of esophageal squamous cell carcinoma. The day-to-day changes in 10 carcinoma cases were evaluated for 9 days. The cancer cells continued to proliferate from the 3rd to the 7th day after the implantation and then decreased. The host reaction was recognized histologically from the 3rd or 4th day to the 9th day. However, the immune reaction did not significantly influence the evaluation of SRCA until the 7th day. The immunohistochemical staining with anti-bromodeoxyuridine monoclonal antibody revealed the existence of cancer cells at the DNA synthesizing stage (S stage) in the graft until the 7th day. In chemosensitivity test by SRCA, 21 patients were studied, and all were evaluable. 5-FU administration produced a response in 8/21 cases (38.1%), VDS in 8/21 (38.1%), and CDDP in 3/21 (14.3%). Used in combination, CDDP + VDS was effective in 7/18 cases (38.9%) and CDDP + BLM in 6/18 cases (33.3%). | 0 |
Phenytoin administration by constant intravenous infusion: selective rates of administration. STUDY OBJECTIVES: To determine the adequacy of seizure control and the adverse effects of administering an IV loading dose of phenytoin by constant infusion pump. DESIGN: A prospective study of patients presenting with acute onset of seizures. Patients were divided into two groups. Group 1 comprised all patients 50 years of age or younger without a history of atherosclerotic cardiovascular disease (ASCVD). Group 2 comprised all patients older than 50 years or with a history of ASCVD. SETTING: A rural community hospital emergency department. TYPE OF PARTICIPANTS: Forty-two adult patients. INTERVENTIONS: Both groups received an IV loading dose of phenytoin at 15 mg/kg. Infusion rates were 50 mg/min and 25 mg/min for groups 1 and 2, respectively. Cardiac rhythm and vital signs were monitored throughout and after infusion. MEASURES AND MAIN RESULTS: Group 2 demonstrated significantly more cardiovascular side effects (hypotension and bradycardia) than did group 1 (Fisher's exact test, P less than .05). CONCLUSION: Phenytoin provided adequate seizure control in both groups. For individuals with ASCVD, IV phenytoin administration rates should not exceed 25 mg/min. For individuals without ASCVD, phenytoin administration at 50 mg/min appears safe and without significant cardiovascular side effects. | 3 |
Measles-associated diarrhea in hospitalized children in Lima, Peru: pathogenic agents and impact on growth. Because the causes of measles-associated diarrhea are not well known, 0- to 5-year-old children presenting to the hospital with measles-associated diarrhea (cases, n = 77) or acute diarrhea only (controls, n = 77) were compared. Growth and diarrheal morbidity were evaluated for 1 month after acute illness. Campylobacter jejuni was more frequently isolated from cases (31%) than controls (16%; P = .03). Rotavirus was absent in all cases versus 28% of controls (P less than .001). Incidence density for new episodes of diarrhea was significantly greater in cases (6.5 vs. 4.1; odds ratio, 1.6; confidence intervals, 1.09-2.34; P = .01), as was duration of episodes (3 vs. 2 days, P = .02). Both groups showed similar positive cumulative percentage weight gains throughout follow-up. These data support the theory of measles as a risk factor for developing diarrhea. The bacteriologic and virologic findings may reflect the immunologic response of the host to measles infection. | 1 |
Long-term follow-up in patients who have undergone balloon dilation for gastric outlet obstruction. Although balloon dilation for gastric outlet obstruction has supplanted vagotomy plus drainage or resective therapy in some institutions, there are no long-term data which demonstrate what percentage of patients ultimately requires surgical intervention. Of 23 evaluable patients treated with hydrostatic balloon dilation in our institution, 70% were asymptomatic at a mean follow-up of 2.5 years. Five patients required surgery--one for acute perforation and the other four for symptoms of continued obstruction, despite one to three additional attempts at dilation. Only three of seven patients with previous gastric resection had a satisfactory long-term result. Whereas endoscopic therapy initially cost one tenth to one fifth that of surgical intervention, such figures do not factor for loss of productivity, on the one hand, or potential need for chronic H2 blockade, on the other. Despite instruction to the contrary, only 6 of 15 (40%) active patients continue acid-suppressive therapy. We conclude that balloon dilation remains a viable alternative for selected patients with gastric outlet obstruction. | 1 |
Validation of a surveillance case definition of carpal tunnel syndrome The National Institute for Occupational Safety and Health (NIOSH) has proposed a surveillance case definition for work-related carpal tunnel syndrome (CTS). The case definition requires the presence of median nerve symptoms; one or more occupational risk factors; and objective evidence of CTS including one of three physical examination findings or nerve conduction tests diagnostic of CTS. We evaluated the performance of the NIOSH case definition, restricting our analysis to cases in which physical examination findings served as the objective criterion. Nerve conduction studies were used as the gold standard. Seventy-eight workers were studied; 38 percent had CTS. The NIOSH case definition had sensitivity of 0.67 (95% CI = 0.57, 0.77), specificity of 0.58 (95% CI = 0.47, 0.69), and positive and negative predictive values of 0.50 (95% CI = 0.39, 0.61) and 0.74 (95% CI = 0.64, 0.84), respectively. Overall 38 percent of subjects were classified incorrectly. In a sample with a prevalence of 15 percent, as might be encountered in high risk workplaces, the positive predictive value would be 0.22. In conclusion, when physical examination findings serve as the objective criterion the performance of the case definition is modest reflecting the limited diagnostic value of its component tests and indicating that effective screening for CTS awaits improved diagnostic techniques. | 2 |
Operative choledochoscopy: common bile duct exploration is incomplete without it. This paper reviews the reported experience of operative choledochoscopy. Development of choledochoscopes to the currently available rigid and flexible instruments is described. The collected results of both rigid and flexible choledochoscopy are reported. Retained stones occurred in 97 of 2712 stone-positive explorations with the rigid choledochoscope (3.6 per cent) and in 35 of 1726 stone-positive explorations with the flexible choledochoscope (2.0 per cent). Choledochoscopy should now be a mandatory part of common bile duct exploration. | 4 |
Juvenile (embryonal and alveolar) rhabdomyosarcoma of the head and neck in adults. A clinical, pathologic, and immunohistochemical study of 12 cases. Sites in the head and neck region (orbit, nasopharynx, nasal cavity, etc.) are among the most frequent locations for juvenile (embryonal and alveolar) rhabdomyosarcomas in patients younger than 15 years; however, comparable neoplasms in adults are very uncommon. A clinicopathologic and immunohistochemical study of 12 juvenile rhabdomyosarcomas in patients between the ages of 18 and 36 years is presented. There was a female:male ratio of 2:1. The orbit with or without contiguous paranasal sinus involvement, nasal cavity, sphenoid sinus, middle ear, and soft tissues of the neck and preauricular region were the primary sites. Seven tumors involved a parameningeal site and eight cases were alveolar rhabdomyosarcomas which together contributed to the adverse outcome. Only two patients were long-term, disease-free survivors. Six patients have died of tumor and two others are alive with persistent disease. Immunohistochemical study in 11 cases demonstrated reactivity for vimentin and muscle-specific actin (HHF-35) and desmin in ten cases. Juvenile rhabdomyosarcoma rarely presents in the head and neck of adults but should be considered in the differential diagnosis of a small cell neoplasm in patients during the third and fourth decades of life. | 0 |
Four chromosomal breakpoints and four new probes mark out a 10-cM region encompassing the fragile-X locus (FRAXA). We report the validation and use of a cell hybrid panel which allowed us a rapid physical localization of new DNA probes in the vicinity of the fragile-X locus (FRAXA). Seven regions are defined by this panel, two of which lie between DXS369 and DXS296, until now the closest genetic markers that flank FRAXA. Of those two interesting regions, one is just distal to DXS369 and defined by probe 2-71 (DXS476), which is not polymorphic. The next one contains probes St677 (DXS463) and 2-34 (DXS477), which are within 130 kb and both detect TaqI RFLPs. The combined informativeness of these two probes is 30%. We cloned from an irradiation-reduced hybrid line another new polymorphic probe, Do33 (DXS465; 42% heterozygosity). This probe maps to the DXS296 region, proximal to a chromosomal breakpoint that corresponds to the Hunter syndrome locus (IDS). The physical order is thus Cen-DXS369-DXS476-(DXS463,DXS477)-(DXS296, DXS465)-IDS-DXS304-tel. We performed a linkage analysis for five of these markers in both the Centre d'Etude du Polymorphisme Humain families and in a large set of fragile-X families. This establishes that DXS296 is distal to FRAXA. The relative position of DXS463 and DXS477 with respect to FRAXA remains uncertain, but our results place them genetically halfway between DXS369 and DXS304. Thus the DXS463-DXS477 cluster defines presently either the closest proximal or the closest distal polymorphic marker with respect to FRAXA. The three new polymorphic probes described here have a combined heterozygosity of 60% and represent a major improvement for genetic analysis of fragile-X families, in particular for diagnostic applications. | 2 |
Identification of patients at greatest risk for developing major complications at cardiac surgery [published erratum appears in Circulation 1991 Jul;84(1):446] As part of a prospective program to use risk-adjusted outcome (operative mortality and morbidity) as a measure of quality of care, we have analyzed perioperative complication data in 10,634 patients representing 73% of all patients undergoing cardiac surgery requiring cardiopulmonary bypass at Veterans Administration medical centers between April 1, 1987, and March 31, 1989. One or more complications occurred in 15% of patients undergoing coronary artery bypass grafting, and in 24% of patients undergoing valve and other cardiac surgery. Patients experiencing one or more complications had an eightfold to 10-fold increase in operative mortality compared with patients with no perioperative complications. The most frequent complication was requirement for mechanical ventilation for at least 48 hours occurring in 8% of patients undergoing coronary artery bypass and in 15% of patients undergoing valve and other cardiac surgery; 24-25% of these patients died within 30 days of surgery or as a direct result of a surgical complication. Previous heart surgery was a strong predictor of development of one or more complications in both groups of patients, being associated with an adjusted relative risk of 1.6-2.0. Other important predictors in both surgical groups were surgical priority, older age, peripheral vascular disease, and higher serum creatinine. Although a number of preoperative risk factors could be identified for the development of renal failure, low cardiac output, and requirement for prolonged mechanical support, few risk factors could be identified for the development of mediastinitis and reoperation for bleeding. This observation suggests that mediastinitis and reoperation for bleeding are more likely the result of technical factors rather than patient-related risk factors. | 4 |
Gallbladder perforation and bile leakage: percutaneous treatment. Three patients with spontaneous gallbladder perforation and one with an iatrogenic bile leak causing bile peritonitis were treated successfully by means of percutaneous catheter drainage. Three patients had cholelithiasis as the cause of perforation; the fourth patient had previously undergone gallstone dissolution with methyl tert-butyl ether lavage and developed bile peritonitis a few hours after removal of the catheter. In three patients, a percutaneous cholecystostomy catheter provided successful decompression; in the fourth patient, drainage was performed with a percutaneous sump catheter in the subhepatic space adjacent to the gallbladder. No specific complications occurred. Follow-up was performed at 1, 12, 22, and 59 months, respectively. To date, one of the four patients has undergone elective cholecystectomy (1 month after drainage). The remainder of the patients are asymptomatic. This preliminary experience suggests that the severe complication of gallbladder perforation and bile leakage may be treated, at least temporarily, by means of percutaneous drainage. | 1 |
Ischemic colitis in a crack abuser. We report a case of acute colitis temporally associated with smoking crack. Colonoscopy revealed a patchy left-sided hemorrhagic inflammation from the rectosigmoid colon to the splenic flexure. Biopsy specimens were consistent with resolving ischemic colitis. This entity should be considered in the differential diagnosis of acute bloody diarrhea in recreational drug users. | 3 |
Late luteal phase dysphoric disorder in young women. The authors determined the prevalence of late luteal phase dysphoric disorder in 217 university women aged 17-29 years. Unaware of the focus on premenstrual syndrome (PMS), the participants rated DSM-III-R symptoms of late luteal phase dysphoric disorder over 90 days. Using a 30% or greater premenstrual change as an index of luteal variation, the authors found that 10 women (4.6%) met the symptom criteria during two menstrual cycles. Compared to 25 young women seeking treatment for PMS who met the same diagnostic criteria, the 10 women from the university sample reported significantly less fatigue and impaired concentration and somewhat less severe depression and overall symptoms. | 4 |
Marker profile of different phases in the transition of normal human ovarian epithelium to ovarian carcinomas. To investigate whether early changes in the transformation of normal ovarian epithelial cells into tumor cells can be detected with monoclonal antibodies, a comparative immunohistochemical study was performed on normal human ovarian mesothelial cells, cystomas, cystadenomas, ovarian carcinomas, as well as granulosa cell tumor. Using monoclonal antibodies against different keratin subtypes, it was shown that mesothelial cells, ovarian cysts, cystadenomas, and carcinomas all reacted positively with broad-spectrum anti-keratin monoclonal antibodies (MAbs), as well as with MAbs to keratins 7, 8, 18, and 19. Keratins 4 and 13 were not found in mesothelial cells, but positive groups of cells were identified in several cystomas, adenomas, and carcinomas. While mesothelial cells did not react with the pan-epithelial marker BW495/36, invaginating metaplastic mesothelial cells, inclusion cysts, cystomas, adenomas, and carcinomas showed an increasing reactivity with BW495/36, with an increasing degree of malignancy. The reactivity of MAbs against ovarian carcinoma-associated antigens (OV-TL 3, OC 125, MOv 18, and OV-TL 10) was limited to weak staining reaction in some mesothelial cells but were found to be positive on more than 50% of the ovarian cystadenomas and more than 90% of the ovarian carcinomas. Thecal and granulosa cells of primordial, primary, and secondary follicles all reacted positively with antibodies to the broad-spectrum keratins OV-TL 12/5 and RCK 102, and to keratins 8 and 18, but not with keratins 4, 7, 13, and 19. These keratins decreased or disappeared in granulosa cells of mature follicles (Graafian follicles), whereas granulosa cell tumors did not react with anti-keratin antibodies. The reactivity of BW 495/36 was negative or limited to traces in some granulosa cells. Ovarian carcinoma-associated antigens were not expressed in granulosa cells or granulosa cell tumors. The data indicate that mesothelial cells undergoing metaplastic changes finally resulting in ovarian cystadenomas (and carcinomas) initiate the synthesis of a 200-kd glycoprotein recognized by MAb (BW 495/36), the production of ovarian carcinoma associated antigens, in addition to focal production of keratin 4 and/or 13, as seen in several samples. The granulosa cell tumors decrease or switch off their keratin production and remain negative for the 200-kd glycoprotein and the ovarian carcinoma-associated antigens. | 0 |
Pharmacological reversibility of experimental cerebral vasospasm. Using a morphometric technique, the pharmacological reversibility of luminal narrowing after experimental subarachnoid hemorrhage (SAH) was investigated. For vasodilation, a "cocktail" consisting of 10(-4) M papaverine, 2 x 10(-4) M sodium nitroprusside, and 10(-5) M adenosine was administered intra-arterially. Forty-two rabbits were divided into six groups: control (normal animals); control plus cocktail (normal animals perfused with the cocktail before fixation); SAH (animals sacrificed 48 hours subsequent to intracisternal injection of 1.5 ml/kg of arterial blood); SAH plus cocktail (SAH plus perfusion with the cocktail); BaCl2 (animals sacrificed 10 minutes after intracisternal injection of 2 ml of 3 x 10(-3) M BaCl2); and BaCl2 plus cocktail (BaCl2 animals perfused with the cocktail). The diameter of the basilar arteries in the control and the control plus cocktail groups was not significantly different. BaCl2 reduced the diameter 44% and SAH reduced the diameter 27%. There were no significant differences between the diameter of the BaCl2 plus cocktail group and SAH plus cocktail group when compared with the control or the control plus cocktail group. Morphological examination by light and transmission electron microscopy showed luminal narrowing and corrugation of the elastic lamina with few degenerative or proliferative changes of the vessel wall in animals with SAH. These results suggest that cerebral vasospasm is caused initially by smooth muscle contraction rather than by proliferative vasculopathy and that it is not an irreversible process. | 3 |
Relationship of laparoscopic findings to self-report of pelvic pain. An assessment battery including standardized measures of behavioral and psychosocial factors associated with other chronic pain conditions was administered to 102 women scheduled for laparoscopic surgery. Surgeons who were blinded to the patient's self-reported pain data completed the American Fertility Society classification for endometriosis and adhesions on the basis of observed physical disease. Although American Fertility Society classification scores were significantly related to self-assignment into pain or no-pain groups, the extent of physical disease evaluated by this procedure was not significantly correlated with ratings of pain levels or a number of indexes of impairment. The group of patients with laparoscopically diagnosed pathologic conditions reported higher pain levels and greater interference than the group who reported pain and had negative laparoscopic results; however, some women with observable pathologic conditions reported no pain symptoms. | 2 |
Acute psychosis. Functional versus organic. Acute psychosis is a true emergency and is a manifestation of multiple organic and functional disorders. The emergency medicine physician's role in dealing with the acutely psychotic patient is to control the patient's behavior, to delineate the etiology of the psychosis, and to provide appropriate initial treatment and disposition. When making initial contact with the psychotic patient, behavioral control can be accomplished through supportive, physical, or pharmacologic interventions. Judicious use of rapid tranquilization permits rapid control of these patients when supportive and other nonpharmacologic therapies fail. Initial examination is directed at identifying immediate life-threatening organic disorders and promptly treating them. Historical data, mental status examination, physical examination, and appropriate radiologic and laboratory investigations give information that assist in delineating functional from organic psychosis. Most acute organic psychoses, with the exception of some drug intoxications that clear in the Emergency Department, require medical or surgical admission. Acute functional psychotic patients who are a danger to themselves or others, who are without a reliable social support system, or who present with their first psychotic episode require admission to the psychiatric service for further evaluation and treatment. | 4 |
Sustained improvement in left ventricular function after successful coronary angioplasty. The short and long term effects of successful percutaneous transluminal coronary angioplasty on left ventricular function, at rest and on exercise were investigated in 49 patients. Thirty-four had had no previous infarction (group 1) and 15 had (group 2). Technetium-99m gated blood pool images were obtained at rest and during exercise before, six weeks after, and a mean of fifteen months after successful angioplasty. Before angioplasty the mean (SD) ejection fraction fell significantly on exercise in both groups from 58 (10)% to 53 (13)% in group 1 and from 48 (10)% to 40 (16)% in group 2. This change was paralleled by a worsening wall motion score (from 0.6 (0.4) to 1.6 (1.2) in group 1 and from 2.3 (1.9) to 3.3 (2.4) in group 2). Six weeks after the procedure there was little change in resting ejection fraction but it increased significantly on exercise (to 62 (11)% in group 1 and to 53 (13)% in group 2). There was a concomitant significant improvement in the exercise wall motion score (to 0.4 (0.6) in group 1 and to 1.8 (1.1) in group 2). This improvement in exercise ejection fraction and wall motion was maintained at later follow up with no significant deterioration in either variable and a clearly sustained improvement in ejection fraction (60 (10)% in group 1 and 51 (10)% in group 2) and wall motion score (0.2 (0.2) in group 1 and 1.3 (0.8) in group 2) compared with values before angioplasty. | 3 |
A double-masked evaluation of lignocaine-prilocaine cream (EMLA) used to alleviate the pain of retrobulbar injection A randomised, placebo controlled, double-masked study was undertaken in 115 patients undergoing cataract surgery to assess the efficacy of the anaesthetic cream EMLA (eutetic mixture of local anaesthetic, lignocaine-prilocaine) in alleviating the pain of retrobulbar injection. Sixty three patients received the EMLA cream and 52 the placebo cream. The pain was assessed objectively by the anaesthetist, who observed the reaction of the patient on needle insertion, and subjectively by the patient. Significantly lower pain scores were recorded in patients treated with EMLA cream (anaesthetist's observation: p less than 0.01, patient's assessment: p less than 0.006). No patients experienced serious side effects in either treatment group. | 2 |
Carotid endarterectomy for elderly patients: predicting complications OBJECTIVE: To determine whether the complication or death rate from carotid endarterectomy can be predicted from hospital and physician structural variables, such as the hospital's teaching status or the number of endarterectomies done by the surgeon per year. DESIGN: Survey of medical records. After controlling for the severity of the patient's condition on the basis of data in the medical record at the time of the endarterectomy, regression analyses were used to predict the postoperative stroke, heart attack, and 30-day death rate as a function of patient, physician, and hospital characteristics. SETTING: Three geographic areas (states or large parts of states; average population, 3 million) in the United States. PATIENTS: Random sample of 1302 patients 65 years of age or older having carotid endarterectomy in 1981. INTERVENTION: Carotid endarterectomy. MEASUREMENTS AND MAIN RESULTS: Of 1302 patients, 11.3% had a postoperative stroke or heart attack or died within 30 days of the operation. Patient age, race, income, and gender; physician volume, board certification status, and age; and hospital size, for-profit status, ownership, and teaching status were not significantly related to the postoperative complication or death rate. If the surgeon was a graduate of a foreign, but not a Western European or Canadian, medical school, however, the average complication or death rate rose from 10.4% to 19.6% (P less than 0.05). CONCLUSIONS: The effectiveness of carotid endarterectomy depends heavily on its complication rate. Because complications after surgery cannot, in general, be predicted from structural variables, referring physicians cannot rely solely on the surgeon's experience and qualifications when recommending a carotid endarterectomy. The surgeon's and the hospital's actual postoperative complication and death rate should be considered. | 3 |
Influence of otitis media on the correlation between rectal and auditory canal temperatures. In a noninterventional, controlled, single-blinded trial, 251 children were examined in a university hospital emergency department setting to study the influence of acute otitis media on the relationship between rectal and auditory canal temperatures. Bilateral auditory canal temperatures were measured using an infrared detection probe and microprocessor by nursing staff blinded to the presence of acute otitis media. Correlation between rectal and auditory canal temperatures in children with (r = .81) and without (r = .75) acute otitis media were not significantly different. There was no significant difference between infected (38.1 degrees C +/- 1.0 degree C) and uninfected ears (38.0 degrees C +/- 1.0 degree C) with unilateral otitis (n = 75). Although significantly higher than in uninfected children, auditory canal temperatures of children with acute otitis media reflected elevated rectal temperatures and not differences in auditory canal temperatures between ears. | 4 |
Influence of organ environment on extracellular matrix degradative activity and metastasis of human colon carcinoma cells Orthotopic implantation of human colon carcinoma cells is useful for studying the behavior of metastatic subpopulations. We observed that the parental line and variants of human colon carcinoma KM12 cells were all tumorigenic following implantation into the subcutis or cecal wall of BALB/c nude mice. Their ability to metastasize to distant organ sites varied, however, with the site of growth. Subcutaneous (SC) tumors did not produce visceral metastases, whereas cecal tumors metastasized to the regional mesenteric lymph nodes and to the liver. To examine the influence of organ environment on the extracellular matrix-degrading activity of the tumors, we inoculated human colon carcinoma cells into the subcutis or cecal wall and after 7 weeks isolated and cultured the tumors in serum-free medium. The conditioned media of SC tumors contained very low levels of type IV collagenase (gelatinase) and heparanase (heparan sulfate-specific endo-beta-D-glucuronidase), whereas the media of the cecal wall tumors contained high levels of both. Zymograms of the media revealed that the intracecal human colon carcinomas secreted more than three times the amount of latent and active forms of 92-kd type IV collagenase than did the SC tumors. Moreover, only the conditioned media of intracecal tumors contained latent and active forms of 64-kd type IV collagenase. Histochemical analysis using rabbit antiserum raised against the synthetic peptides of 72-kd procollagenase type IV showed type IV collagenase in the intracecal tumors; human colon carcinoma growing SC, however, were not stained significantly. These results suggest that factors in the organ environment may affect production and secretion of tumor extracellular matrix-degrading enzymes, and these factors may modify the metastatic behavior of human colon carcinoma cells in nude mice. | 0 |
Orbital volume augmentation with adjustable prefabricated methylmethacrylate subperiosteal implants. Prefabricated right and left subperiosteal implants were used in nine anophthalmic sockets to correct superior sulcus deformities. The advantages of these implants include increased stability, easy insertion under direct visualization and the possibility of easy retrieval if necessary, and custom modification for volume and shape intraoperatively, with the addition of methylmethacrylate. There were no extrusions, implant migrations, or infections. Complications included mild undercorrection, upper eyelid blepharoptosis, and transient ectropion. | 4 |
Hemiparkinsonism-hemiatrophy syndrome: clinical and neuroradiologic features. We evaluated 11 patients with hemiparkinson-hemiatrophy syndrome, 6 with body and contralateral cerebral hemispheric hemiatrophy, 4 with only body hemiatrophy, and 1 with just brain hemiatrophy. The mean age of symptom onset was 38.1 years (range, 18 to 54) with 5.2 +/- 3.1 (mean +/- SD) years of illness until the last follow-up visit. The presenting symptom was unilateral tremor in 6 patients, hand dystonia in 2, bradykinesia in 2, and abnormal gait in 1 patient. Three patients had a good response to levodopa, 4 had moderate response, and 2 patients had a poor response. During a mean follow-up period of 1.7 years (range, 4 months to 5 years), the Hoehn and Yahr score changed in only 3 patients: 2 gained 1.5 points and 1 gained 3 points over 2.5 years. We discuss the association between hemiparkinsonism-body hemiatrophy and contralateral hemispheric hemiatrophy, and raise the possibility of early childhood brain insult with delayed-onset parkinsonism. | 4 |
Thyroid disease in the elderly. As people in our society live longer, it is important for clinicians to know more about problems commonly seen in the elderly. Thyroid problems are especially important to understand because they do occur with rather high frequency, and their mode of presentation is frequently different from those seen in younger patients. The thyroid gland does undergo certain age-related changes in anatomy and physiology, but overall the thyroid is able to produce a normal amount of thyroid hormone throughout the years. Hypothyroidism is frequently difficult to diagnose in the elderly, because many of the symptoms of hypothyroidism can easily be confused with symptoms of aging. When hypothyroidism is looked for in large population studies of elderly patients, the incidence varies from 1% to as high as 17%, with women being more commonly affected than men, and subclinical hypothyroidism being more common than overt hypothyroidism. Virtually all cases of hypothyroidism are due to autoimmune thyroid disease, with most patients having measurable titers of thyroid autoantibodies. The therapy of hypothyroidism is done with extreme caution, as older patients are frequently very sensitive to the effects of excess thyroid hormone. In addition, the metabolism of thyroid hormone slows down with age, making the full replacement dose much less in an older patient than in a younger one. Hyperthyroidism is also quite common, occurring in from 0.5% to 3% of all elderly patients. The presentation is frequently atypical, as patients often lack the hyperdynamic symptomatology and instead have a more sedated, apathetic presentation. Weight loss and cardiac symptoms frequently predominate, and the presence of a goiter is frequently absent, making the diagnosis less obvious than in a younger patient. Therapy is usually radioactive iodine, after an adequate course of antithyroid drugs, to render the patient euthyroid. Thyroid nodules do occur with increasing frequency in the elderly, but most of them are not malignant. Fine-needle aspiration for cytology is very helpful in determining which patients should be referred for surgery. Well-differentiated cancers do predominate, but their course is frequently less predictable than in younger patients. Lymphoma of the thyroid and undifferentiated cancers do occur with increasing frequency in the elderly. Multinodular goiter, usually of longstanding, is frequently seen in elderly patients, and thyroid hormone suppressive therapy not only is not indicated but may contribute to exogenous hyperthyroidism. | 0 |
Enhanced antitumor reactivity of tumor-sensitized T cells by interferon alfa. Tumor-draining lymph node cells from mice bearing the methylcholanthrene-induced MCA 106 tumors can be sensitized in vitro to acquire antitumor reactivity. We examined the effect of interferon alfa on the function of cells that underwent in vitro sensitization in adoptive immunotherapy. Interferon alfa increased the antitumor reactivity of in vitro sensitized cells in the treatment of MCA 106 pulmonary metastases. This effect was evident in irradiated mice, indicating that a host response to the interferon alfa was not required. Interferon alfa treatment increased class I major histocompatibility complex antigen expression on tumor cells and increased their susceptibility to lysis by in vitro sensitized cells. These results suggest that interferon alfa enhancement of adoptive immunotherapy was mediated by its effect on tumor cells. Interferon alfa may be a useful adjunct to the adoptive immunotherapy of human cancer. | 0 |
Gastric duplication cyst communicating with the pancreatic duct: a rare cause of recurrent abdominal pain. A 41-year-old woman with recurrent attacks of postprandial abdominal pain was found on endoscopic retrograde cholangiopancreatography and subsequent computed tomographic scan to have an enteric duplication within the substance of the pancreas with communication to the pancreatic duct. Celiotomy demonstrated a noncontiguous gastric duplication cyst. Internal drainage was curative. | 4 |
Two distinct loci on the short arm of chromosome 16 are involved in myeloid leukemia. We report a case of acute nonlymphocytic leukemia (ANLL) M5 with the characteristic t(8;16)(p11;p13). The breakpoint in the short arm was regionally localized using nonradioactive in situ hybridization with a series of cosmids of chromosome 16. The results show that a difference exists between the breakpoint in chromosome 16(p13) in this t(8;16) and the breakpoint involved in the short arm in the characteristic inversion 16 (p13;q22)) that occurs in ANLL M4eo. Two different loci appear to be involved in these chromosomal rearrangements. | 0 |
Arsenic poisoning: acute or chronic? Suicide or murder? The case of the death by arsenic poisoning of a 62-year-old white man is presented. One year prior to death, he developed intermittent bouts of severe gastroenteritis with vomiting and diarrhea, hyperpigmentation and keratosis of the skin, neutropenia, and Guillain-Barre-like neuropathy for which he was hospitalized several times. Urine test results 6 months prior to death indicating 36 mg/L arsenic were believed to be in error. At the patient's last admission, he appeared in the emergency room with severe gastroenteritis, hypotension, and dehydration. He died 3 days later. Antemortem as well as autopsy specimens revealed elevated arsenic concentrations. Arsenic micrograms/g analysis by neutron activation of hair pulled from the man's head revealed by centimeter segmental analysis proximal to distal: 226, 104, 28, 56, 41, 40, and 74. The wife of the decedent was charged with murder by arsenic poisoning of this, her fifth, husband. The defense alleged that the decedent had committed suicide. The judge awarded a directed verdict of "not guilty." Particulars of the medical, toxicological, and investigative findings are presented. | 4 |
Omeprazole in the management of intractable esophageal ulceration following injection sclerotherapy. Transient esophageal ulceration is a common finding after sclerotherapy of varices. A small proportion of these ulcers become chronic and resistant to conventional therapy. Such chronic ulcers have been associated with pain, stricture formation, and recurrent hemorrhage. The use of omeprazole, a proton pump inhibitor, was examined in the current study in the treatment of 10 patients (6 women, 4 men; age range, 27-86 years) with cirrhosis (PBC, 4; sclerosing cholangitis, 2; chronic active liver disease, 2; alcohol, 1; and cryptogenic, 1) who developed an esophageal ulcer after a mean of 13 (range, 8-21) sessions of sclerotherapy. The ulcers had been present for 3-54 months despite prolonged treatment with high-dose H2-receptor antagonists and sucralfate. In each case one or more complications had occurred: severe pain in 3, stricture formation in 4, and recurrent hemorrhage in 7 cases. After an 8-week course of omeprazole, 40 mg daily, endoscopy confirmed complete healing of the ulceration in all 10 cases with symptom resolution. In 2 cases the ulcer recurred, with associated bleeding within 6 weeks of discontinuing the treatment in 1 patient. Both cases responded to repeat therapy. These results confirm the efficacy of omeprazole for postsclerotherapy ulceration and imply that acid-pepsin has a role in perpetuating such ulcers. | 3 |
Inflammatory breast cancer. Historically, the prognosis of inflammatory breast cancer has been poor. We conducted a retrospective review to evaluate the recent Memorial Sloan-Kettering Cancer Center experience, to evaluate the role of combination chemotherapy, and to compare the effect of surgery and radiation on local/regional failure. Fifty-six patients with local/regional inflammatory breast cancer diagnosed between 1975 and 1984 were identified. All were treated with combination chemotherapy. Overall 5-year survival was 45% with a 5-year disease-free survival rate of 37%. Twenty-one patients were treated with induction chemotherapy followed by mastectomy and adjuvant chemotherapy. Survival and disease-free survival rates were similar to those achieved in patients treated with mastectomy followed by chemotherapy. Residual cancer was found in all 21 patients treated with induction chemotherapy, with extensive disease present in 18, including six of seven complete responders. The local/regional failure rate was 34%. | 0 |
Factors influencing the results of open reduction and internal fixation of tibial plateau fractures. Forty-three displaced tibial plateau fractures were treated with open reduction and internal fixation. The fractures were classified into four groups, and the clinical results were evaluated using a standard 100-point knee rating system. The average follow-up period after surgery was 2.7 years. Overall there were 35 excellent, five good, three fair, and no poor results. In five of eight knees with a less than excellent score, the results were due to the technique of fracture fixation or the absence of a bone graft. There were ten postoperative complications, but only one ultimately affected the clinical result. Fourteen patients required removal of implants. Roentgenographic analysis showed that six knees had mild degenerative changes, two had moderate, and two had severe degenerative changes. There was no statistically significant association between the fracture type and a less than excellent result. The absence of bone grafting, however, was associated with a less than excellent result. Bicondylar fractures had a mean range of motion of 110 degrees, 18 degrees less than that of all other types of fracture combined. | 4 |
Reversed helper/suppressor T-lymphocyte ratio in bronchoalveolar lavage fluid from patients with breast cancer and Pneumocystis carinii pneumonia. Pneumocystis pneumonia (PCP) usually occurs in patients with hematologic malignancies and acquired immunodeficiency syndrome (AIDS). Patients with solid tumors represent a very small fraction of the reported cases of PCP. Over an 18-month period, PCP was diagnosed in three patients who had received radiation and chemotherapy for breast cancer. In all three patients, there was no serologic or clinical evidence of AIDS. Direct staining of bronchoalveolar lavage fluid (BAL) revealed Pneumocystis carinii, and cellular analysis of BAL revealed an increased percentage of lymphocytes with reversed helper/inducer:suppressor/cytotoxic T-cell (CD4:CD8) ratio. Because decreased CD4:CD8 ratio in BAL is commonly accepted as findings consistent with hypersensitivity pneumonitis and AIDS, we conclude that similar findings in patients without AIDS are not specific for hypersensitivity pneumonitis, and P. carinii should be ruled out in the appropriate clinical setting. | 0 |
Reversal of chronic hepatic encephalopathy by colonic exclusion: poor correlation with blood GABA levels. Previous studies have suggested that the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) is a key factor in the syndrome of portasystemic encephalopathy. We report the case of a patient with medically intractable portasytemic encephalopathy after portacaval shunt who had marked clinical improvement after creation of an end ileostomy. Plasma GABA and serum ammonia levels were measured before and after ileostomy. Although the clinical syndrome and the EEG improved markedly after the ileostomy, the plasma GABA levels remained markedly elevated. Preoperative and postoperative GABA levels were 865 and 633 pmol/ml, respectively (nl = 100-180 pmol/ml). Our findings confirm previous reports of the efficacy of colonic exclusion in patients with intractable portasystemic encephalopathy. However, our results conflict with the hypothesis that GABA itself is the key mediator of the syndrome. | 2 |
Treatment of hepatolithiasis: improvement of result by a systematic approach. In previous decades the result of treatment of hepatolithiasis has been unsatisfactory. The incidence of residual stones after surgery might reach 77%. In the past 6 years we adopted a systematic approach comprised of accurate delineation of disease in the liver and biliary tract by direct cholangiography, ultrasonography, and computed tomography; tailored surgical treatment according to the extent of involvement of the liver and biliary tract; access to the intrahepatic ducts through the left duct or round ligament approach when there was difficulty with common bile duct exposure; routine use of flexible choledochoscopy; and application of electrohydraulic lithotripsy for large and impacted stones. Complete stone clearance was achieved in 114 of 127 patients (89.8%). Of those patients who had incomplete stone clearance, only six cases (4.7%) were related to technical failure of postoperative choledochoscopy. The incidence of stone recurrence was 15.8%, the lowest rate so far reported. It was the same regardless of whether a biliary drainage procedure had been performed, but the treatment for recurrent stones was facilitated by previous hepaticocutaneous jejunostomy. Overall the surgical treatment required for stone recurrence was of a lesser magnitude than that in the past. | 1 |
Magnetic resonance imaging in neurological disorders. To investigate the role of magnetic resonance imaging (MRI) in neurological disorders, 115 children were studied in two groups. Group A (78 patients) was studied by paired computed tomography and MRI cranial scans. Group B (37 patients) was studied by paired computed tomography assisted myelography (CTM) and MRI spinal scans. In group A, the scans were generally equivalent for supratentorial tumours and for investigating fits, hydrocephalus, benign intracranial hypertension, and cerebral atrophies, but MRI scanning was superior for posterior fossa tumours and cysts. In group B, MRI scans were superior for intramedullary spinal tumours, spinal dysraphic problems with tethering or syrinx, and were complementary to CTM in diastematomyelia. | 2 |
The iris in Williams syndrome. Forty three children with Williams syndrome and 124 control subjects had their eyes photographed. The photographs were examined by three ophthalmologists and four geneticists of varying experience. A stellate pattern was noted more often in the irides of patients with Williams syndrome (51%) than in those of the control subjects (12%), and was more difficult to detect, or was absent, in heavily pigmented irides. We conclude that the stellate pattern is of diagnostic importance, particularly if the pattern is carefully defined and the clinician is experienced. | 4 |
Differential therapy with calcium antagonists in pulmonary hypertension secondary to COPD. Hemodynamic effects of nifedipine, diltiazem, and verapamil. In 53 patients with COPD and precapillary pulmonary hypertension, we investigated the effect of three typical calcium antagonists on hemodynamics at rest and during bicycle ergometer exercise. In the responders, the decrease in pulmonary vascular resistance following nifedipine was 23 percent at rest (p less than 0.0005) and 35 percent during exercise (p less than 0.0005); following diltiazem, it was 10 percent at rest (p less than 0.05) and 23 percent during exercise (p less than 0.025); following verapamil, it was 22 percent at rest (p less than 0.005) and 11 percent during exercise (p less than 0.025). The cardiac index rose significantly at rest and under exercise only after the administration of nifedipine (+16 percent and +8 percent, resp). Nifedipine caused the most distinctive peripheral vasodilation. The heart rate increased slightly following nifedipine and decreased slightly following diltiazem and verapamil. After long-term therapy with nifedipine (13 +/- 5 months), the decrease in pulmonary artery pressure and pulmonary vascular resistance was no longer significant. In our opinion, the different hemodynamic action profiles will have consequences for the differential therapy in patients with COPD and pulmonary hypertension. | 3 |
Nd:YAG laser with sapphire tip combined with balloon angioplasty in peripheral arterial occlusions. Long-term results In 167 patients with complete occlusion (greater than 3 cm) of the femoropopliteal artery, percutaneous transluminal laser angioplasty (PTLA) was performed after an unsuccessful attempt at crossing with a guide wire and was immediately followed by balloon dilatation. An Nd-YAG laser and an optical fiber delivery system with a sapphire tip serving as a contact probe were used for PTLA. In 132 of 167 (79%) patients, the occluded segment was successfully reopened. Clinical symptoms improved in 126 of 167 (75%) patients. PTLA was unsuccessful in 35 patients, and in 15 of these, injury of the vessel wall occurred. In one patient, surgical drainage of a large hematoma became necessary. All patients in whom recanalization had been achieved were randomized to receive long-term treatment with either phenprocumarol or acetylsalicylic acid (ASA) plus dipyridamole to prevent rethrombosis. At 36 months of follow-up, the cumulative patency rate (CPR) was 63%. A complete reobstruction in 32 patients (24%) and a partial reobstruction in 15 patients (11%) were found angiographically. The CPR after 36 months was significantly lower (p less than 0.05) in patients younger than 60 years of age (54%) than in patients older than 60 (68%); it was also significantly lower (p less than 0.05) in patients with reduced peripheral runoff (55%) due to obstructed arteries of the lower leg than in patients with unaffected runoff (73%). The CPR was 65% in recanalized segments shorter than 7 cm and was 62% in recanalized segments longer than 7 cm. | 4 |
Blood pressure reactivity predicts myocardial infarction among treated hypertensive patients. High blood pressure (BP) defines a prognostically heterogeneous group. Because BP varies according to time, setting and means of observation, it has been postulated that BP reactivity might better predict cardiovascular disease (CVD) than does unidimensional measurements. To assess BP reactivity, the difference between pretreatment nurse (RN) and physician (MD) diastolic BP (DBP)--systematically recorded in that order--or MD-RN DBP, was obtained in 1737 previously untreated patients with sustained, RN BP greater than or equal to 160 and/or 95 mmHg. Patients stratified by tertiles of MD-RN DBP [(I) less than or equal to - 3, (II) -2 to 3 and (III) greater than or equal to 4 mmHg] were similar by sex, race, age, body mass index, cholesterol, electrocardiography, prior CVD, smoking and pretreatment or attained in-treatment BPs. During 14 years of followup, myocardial infarction (MI) incidence per 1000/year were, tertile I (3.2), II (3.7), III (7.6) (relative risk = 2.4, III vs I + II, p less than 0.05), whereas stroke incidence and non-CVD mortality were evenly distributed. By Cox survival analysis, controlling for other entry characteristics only age, sex and DBP reactivity remained predictive (p less than or equal to 0.03) of MI or total CVD. Thus, BP reactivity, probably a centrally-mediated phenomenon, identifies a subgroup of hypertensives with an increased propensity for MI despite successful BP control. | 3 |
Ondansetron compared with high-dose metoclopramide in prophylaxis of acute and delayed cisplatin-induced nausea and vomiting. A multicenter, randomized, double-blind, crossover study. OBJECTIVE: To compare the efficacy and side effects of ondansetron with those of high-dose metoclopramide in treating acute and delayed cisplatin-induced nausea and vomiting. DESIGN: Randomized, double-blind, crossover trial. SETTING: Conducted at two university hospitals, a cancer institute, and six community hospitals. PATIENTS: Of 125 patients, 95 were evaluable for the acute phase and 79 for the delayed phase. Major reasons for not being evaluable were no second course (14 patients), protocol violation (5 patients), and change in cisplatin dose (3 patients) for the acute phase, and rescue medication on day 1 (7 patients), protocol violation (3 patients), and inadequate data (4 patients) for the delayed phase. INTERVENTIONS: All patients received cisplatin, 50 to 100 mg/m2 body surface area (median, 75 mg/m2); none had previously received chemotherapy. Thirty minutes before the cisplatin administration, ondansetron was given intravenously over 15 minutes, at a loading dose of 8 mg followed by a continuous infusion of 1 mg/h for 24 hours. Metoclopramide was given at a loading dose of 3 mg/kg body weight, followed by a continuous infusion for 8 hours (4 mg/kg). For the delayed phase (days 2 through 6), the first oral dose was given as soon as the infusion was completed; the oral dose consisted of either metoclopramide, 20 mg three times daily, or ondansetron, 8 mg three times daily for another 5 days. MEASUREMENTS AND MAIN RESULTS: In the acute phase, a major or complete response was seen in 72% of the ondansetron-treated and 41% of the metoclopramide-treated patients (P less than 0.001). Nausea was significantly better controlled among the ondansetron-treated patients (P = 0.04). In the delayed phase, no statistically significant difference was seen between ondansetron- and metoclopramide-treated patients. Nausea was significantly better controlled with metoclopramide (P = 0.016). CONCLUSIONS: Ondansetron is significantly more effective than metoclopramide in preventing acute nausea and vomiting. In the delayed phase, the results of both drugs were disappointing, although metoclopramide's effect on delayed nausea was superior. Patients preferred ondansetron. | 1 |
Sensitivity and specificity of various morphological features of cervical condylomas. An in situ hybridization study. Fifty-seven cervical biopsy specimens or endocervical curettings showing condyloma, changes suggestive of condyloma, or no changes of condyloma were analyzed for presence of nuclear atypia (nuclear enlargement and irregularity in superficial epithelium), presence of multinucleated cells, and presence of perinuclear cytoplasmic clearing in superficial squamous epithelium. The findings were correlated with results of in situ hybridization with biotin-labeled human papillomavirus DNA probes. Moderate nuclear atypia was significantly more specific than perinuclear cytoplasmic clearing and 100% sensitive for predicting cases positive for human papillomavirus. Of the various morphological features analyzed, perinuclear cytoplasmic clearing had the lowest specificity for predicting positive results on in situ hybridization. | 0 |
Complications of percutaneous abdominal fine-needle biopsy. Review. To determine whether the increasing use of percutaneous fine-needle biopsy of abdominal lesions is associated with an increase in serious complications, the author updated a literature search and evaluated a questionnaire (distributed among selected hospitals in the United States in 1986 and 1987) that followed up a questionnaire distributed in 1983. The updated literature review revealed a total of 24 deaths and 20 needle tract seedings. The updated questionnaire revealed five deaths after 16,381 biopsies (0.031%), whereas the previous questionnaire had shown four deaths after 63,108 biopsies (0.006%). Two similar European questionnaires revealed mortality rates of 0.008% and 0.018%, respectively. Of the total of 33 deaths, 21 involved biopsies of liver lesions; six involved pancreatic biopsies. Seventeen of the 21 deaths after liver biopsies were secondary to hemorrhage; five of the six deaths after pancreatic biopsies were due to pancreatitis. Of the 23 instances of needle tract seeding, 10 occurred after biopsies of pancreatic malignancies. The frequencies of needle tract seeding in the four questionnaires were 0.005%, 0.006%, 0.003%, and 0.009%, respectively. Although infrequent, serious complications may be associated with this procedure. The author makes suggestions that may help minimize them. | 0 |
Vancomycin pharmacokinetics in hydrocephalic shunt prophylaxis and relationship to ventricular volume. Vancomycin pharmacokinetics were determined in 25 patients receiving ventriculoperitoneal shunts for hydrocephalus. Computed tomography scan-derived ventricular-brain ratio as an expression of hydrocephalus varied between 9.3% and 15.4% (12.9% +/- 1.7%). One hour prior to surgery each patient received 1 g of vancomycin infused intravenously over 60 minutes. Samples of cerebrospinal fluid and venous blood were obtained 1 hour later and vancomycin levels assayed by fluorescence polarization immunoassay. There were 11 females and 14 males, with a mean age of 44.5 +/- 10.3 years and a mean weight of 72.0 +/- 11.4 kg. All had normal renal function. Levels of vancomycin in the cerebrospinal fluid at 1 hour ranged from 0.1 to 1.5 micrograms/mL (0.9 +/- 0.3). Weight did not affect these values (p greater than 0.1). Simultaneous blood vancomycin levels varied between 9.1 and 38.7 micrograms/mL (22.3 +/- 8.3). Ventricular volume, expressed as the ventricular-brain ratio, did not correlate with cerebrospinal fluid vancomycin levels (p greater than 0.5). There was no significant increase in concentrations of vancomycin in CSF as cerebrospinal fluid protein concentration increased, nor when blood vancomycin concentration was greater than 20 mg/dL (therapeutic range) (p greater than 0.1). No patient had evidence of infection at 6 months follow up. These results indicate minimal cerebrospinal fluid penetrance of vancomycin when administered systemically 1 hour prior to shunt surgery. In addition concentrations of vancomycin in cerebrospinal fluid bear no relationship to weight, ventricular volume, meningeal inflammation, or blood levels in the therapeutic range. The minimum inhibitory concentration of vancomycin for staphylococci is 1.5 to 3.1, and as bactericidal levels of 5 to 8 minimum inhibitory concentration are needed to kill organisms, a combination of both systemic and intraventricular vancomycin may be needed to ensure adequate cerebrospinal fluid and tissue concentration of antibiotic during shunt prophylaxis. | 2 |
Pulmonary hypertension complicating portal hypertension: prevalence and relation to splanchnic hemodynamics. The prevalence of pulmonary hypertension in 507 patients hospitalized with portal hypertension but without known pulmonary hypertension who underwent cardiac catheterization was prospectively studied. Ten (2%) of these patients, 6 of whom were clinically asymptomatic, had primary pulmonary hypertension. Second, 26 patients with symptomatic pulmonary hypertension complicating portal hypertension were reviewed. Pulmonary hypertension occurred later after diagnosis of portal hypertension in patients with a surgical shunt (10 patients) than in those without a shunt (147 +/- 49 vs. 44 +/- 27 months; P less than 0.0001). Cardiac index correlated inversely with pulmonary arterial pressure (r = -0.45; P less than 0.01) and was lower in the 5 patients who died of pulmonary hypertension than in the 5 who died of liver failure (1.52 +/- 0.14 vs. 3.69 +/- 1.88 L/min.m2; P less than 0.05). Third, systemic and splanchnic hemodynamics were compared in 285 patients with alcoholic cirrhosis and 29 controls. No significant relation was found between elevated pulmonary vascular resistance and increased portal pressure, zzygos blood flow, or cardiac index. Pulmonary hypertension is considerably more frequent than was previously estimated in patients with portal hypertension. The risk of developing pulmonary hypertension could increase with the duration of portal hypertension without any clear relation to the degree of portal hypertension, hepatic failure, or amount of blood shunted. | 3 |
Liposarcoma arising in the cheek: report of a case and review of the literature. The following points can be made about liposarcoma of the oral cavity: 1) it is rare and slow growing; 2) it is often mistaken for a benign lesion; 3) there is a direct correlation of microscopic appearance with biological behavior and prognosis; 4) treatment is primarily surgical, with radiation used for selected cases; and 5) the better-differentiated tumors seem to respond more favorably to radiation. | 0 |
Correlation dimension of heartbeat intervals is reduced in conscious pigs by myocardial ischemia. A reduced standard deviation of RR intervals (SDRR) predicts increased mortality in groups of survivors of myocardial infarction. Like SDRR, the correlation dimension (D2) describes variation within a sampled time series, but uniquely it reveals 1) the epoch's geometric structure and 2) the degrees of freedom of the generator. These unique features may be more sensitive predictors of mortality than SDRR. We developed a new algorithm for estimating D2 (i.e., the "point-D2"), tested it with known data, and found that it had greater accuracy for finite data than other published algorithms. Analysis of RR intervals from eight conscious pigs undergoing acute occlusion of the left anterior descending coronary artery revealed a drop in the point-D2 from a control mean and standard deviation of 2.50 +/- 0.81 to 1.58 +/- 0.64 during the first minute of ischemia (p less than 0.01) and to 1.07 +/- 0.18 during the last minute preceding ventricular fibrillation (p less than 0.01). Partial occlusions (50-90% reduction of coronary blood flow) evoked point-D2 reductions only 25-30% of control (p less than 0.01). The point-D2 means were correlated between pigs with the magnitude of the respiratory sinus arrhythmia (p less than 0.01), but during ischemia this correlation was replaced by one between the standard deviation of the point-D2s and SDRRs. Because the simultaneous reduction in the mean point-D2 and its standard deviation to 1.07 +/- 0.18 occurred in every case, was unique to the few minutes preceding ventricular fibrillation, and never reached these low values during other conditions in which it was reduced, we conclude that the point-D2 may be an accurate prospective predictor of mortality within the individual subject. | 3 |
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