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Hematoporphyrin photodynamic therapy: is there truly a future in head and neck oncology? Reflections on a 5-year experience. Photodynamic therapy, which consists of the selective destruction of tumors using a combination of a photosensitizer administered systemically (dihematoporphyrin ether) and an argon dye-pumped laser, has provoked profound interest amongst oncologists and has particularly titillated head and neck oncologists with its potential. Unfortunately, no multi-institutional trials for head and neck tumors have been introduced, and the literature is replete with anecdotal reports from individual researchers on the management of advanced cancers for palliation, superficial early cancers, and field cancerization of the mucosa ("condemned mucosa"). A personal 5-year experience with 41 head and neck cancers was reviewed, as was the current literature. An attempt was made to place in perspective the true role and future direction of this technology. | 0 |
Alpha 1-antitrypsin granules in the liver--always important? We have studied the clinical histories and liver biopsy findings in 1951 consecutive adult patients with suspected chronic liver disease, and in four known PiZ-homozygous alpha 1-antitrypsin-deficient patients with emphysema (candidates for lung transplant) and no known liver disease, in order to assess the importance of periportal alpha 1-antitrypsin granules in the liver and their possible causal role in liver disease, and to assess the value of possible screening tests. Periportal granules were found in 30 (1.5 per cent) of the 1951 liver biopsies and in all four known PiZ-homozygous subjects. They were the sole putative aetiological agent in eight of 85 patients (9.4 per cent) with otherwise cryptogenic cirrhosis and present in 2.5 per cent of patients with cirrhosis of known aetiology (alcohol, autoimmune etc.). All but one were Z phenotype (seven homozygotes, 22 heterozygotes). alpha 1-Antitrypsin granules were seen in 12 patients (including three of four lung transplant candidates) with no histological chronic liver disease. Determination of serum alpha 1-antitrypsin levels was quite unhelpful in identifying these patients. This study does not support the concept that periportal alpha 1-antitrypsin granules are necessarily pathogenic, but in some cases they may be causally related to otherwise cryptogenic liver disease. The presence of granules gave no important diagnostic, therapeutic or prognostic information. | 1 |
Sympathovagal interaction during mental stress. A study using spectral analysis of heart rate variability in healthy control subjects and patients with a prior myocardial infarction. We tested the hypothesis that psychological stress testing in the clinical laboratory provokes changes in the sympathetic and vagal activities regulating heart rate that can be assessed noninvasively using spectral analysis of RR variability. To account for the effects on respiration produced by talking, this study was performed with two different procedures: the I.K.T. (i.e., a computer-controlled mental task that is performed in silence and does not entail human confrontation) and a stressful interview. Finally, we assessed whether ischemic heart disease modifies the spectral changes induced by psychological stress by comparing a group of healthy subjects (age, 38 +/- 2 years) with a group of patients (age, 52 +/- 3 years) recovering from 1-month-old myocardial infarctions. The findings indicate that psychological stress induced marked changes in the sympathovagal balance, which moved toward sympathetic predominance. The low-frequency component of RR variability, a marker of sympathetic activity, increased from 58 +/- 5 normalized units (NU) to 68 +/- 3 NU with the I.K.T. and to 76 +/- 3 NU with the interview. This increase was absent in the group of post-myocardial infarction patients. However, arterial pressure increased significantly in both groups of subjects. The possibility of age playing an important role in determining the differences observed was disproved by the findings of a marked increase in low frequency with mental stimuli in an additional group of borderline hypertensive subjects with ages (55 +/- 2 years) comparable to those of post-myocardial infarction patients. | 3 |
Recurrent tension headache in adolescents treated with self-help relaxation training and a muscle relaxant drug. Forty-eight adolescents suffering from recurrent tension headache participated in a controlled trial conducted in a high school setting. During the first treatment phase self-help relaxation training was compared with a waiting-list group. Following this phase a pharmacological regimen consisting of a muscle relaxant (chlormezanone) and placebo was superimposed on relaxation therapy in a double-blind crossover design. Each treatment phase encompassed a 5-week period. In addition to the evaluation of headache complaints, psychological distress among students was measured with respect to their experience of somatic complaints, depressive, anxiety and stress symptoms. Although self-help relaxation training significantly decreased the severity and annoyance of adolescents' headache besides their somatic complaints, the clinical improvement of headache was modest. The addition of chlormezanone did not help those who were nonresponders to self-help relaxation training. Finally, a set of pretreatment variables consisting of baseline headache severity and annoyance, experience of anxiety and daily life stress among adolescents could predict outcome of self-help relaxation therapy. | 2 |
Supraclavicular lymph node metastases in carcinoma of the esophagus and gastroesophageal junction: assessment with CT, US, and US-guided fine-needle aspiration biopsy. The preoperative assessment of supraclavicular lymph node metastases was prospectively studied in 100 patients with carcinoma of the esophagus and gastroesophageal junction. Findings at computed tomography (CT), ultrasound (US), and palpation were compared, and US-guided fine-needle aspiration biopsy of nodes with a small axis of 5 mm or greater was performed. Supraclavicular metastases were detected on CT scans in 11 of 13 patients (85%) and on US scans in 14 of 16 patients (88%) but were palpable in only three of the 16 patients (19%). The predictive value of a supraclavicular node indicating metastases was .74 at US and .85 at CT. Metastases were diagnosed in 10 of 46 patients with squamous cell carcinoma (22%) and five of 50 patients (10%) with adenocarcinoma. Nodes with metastases had a round configuration, with a statistically significant greater short-axis to long-axis ratio than that of benign nodes (0.89 vs 0.54; P = .05). In four of 16 patients (25%) with supraclavicular metastases proved with cytologic examination, neither CT nor US of the mediastinum and abdomen showed enlarged nodes. | 0 |
Diffuse alveolar haemorrhage associated with progressive systemic sclerosis. A 41 year old man with an eight year history of progressive systemic sclerosis developed severe diffuse alveolar haemorrhage and died. The importance of diffuse alveolar haemorrhage as a rare but potentially serious complication of connective tissue disease should not be overlooked. | 4 |
Borderzone hemodynamics in cerebrovascular disease. To investigate the possible existence of chronic selective hemodynamic impairment in the arterial borderzone regions of the brain, we used positron emission tomography (PET) to measure regional mean vascular transit time (rt, equal to the ratio of regional cerebral blood volume to cerebral blood flow) and regional oxygen extraction fraction (rOEF) in 32 patients with either severe internal carotid artery stenosis or occlusion and 11 normal controls. Twenty-four of the patients had had TIAs or amaurosis fugax from 1 to 60 days before PET; all had normal brain CT. We used a stereotactic localization method to locate the anterior and posterior borderzone regions of the middle cerebral artery (MCA) territory. We then calculated ratios of each borderzone to the ipsilateral MCA territory for both rt and rOEF. There was no significant difference from control ratios in any patient subgroup including those with greater than or equal to 75% stenosis or occlusion, those with or without contralateral greater than or equal to 50% stenosis, or those with abnormal hemodynamics in the MCA territory. We therefore found no evidence for selective borderzone hemodynamic impairment in this group of patients with severe carotid artery disease. | 2 |
Benign and malignant nodules in cirrhotic livers: distinction based on blood supply. The blood supplies of nodular lesions associated with liver cirrhosis were analyzed in vivo with various imaging modalities. The portal blood supply was evaluated with computed tomography (CT) during arterial portography (CTAP); the arterial blood supply was evaluated with hepatic angiography, CT angiography, CT following intraarterial injection of iodized oil, or ultrasound following intraarterial injection of carbon dioxide microbubbles. A total of 84 surgically confirmed hepatocellular carcinomas (HCCs) (less than or equal to 3 cm) and 25 areas of adenomatous hyperplasia (AH) were included in the study. At CTAP, a portal blood supply was seen in 96% of cases of AH and only 6% of HCCs (chi 2, P less than .005). In contrast, an arterial supply greater than that of the surrounding liver was verified in 94% of the HCCs and only 4% of the cases of AH (chi 2, P less than .005). The blood supply of areas of AH with atypical hepatocytes and the blood supply of well-differentiated HCCs (Edmondson grade 1) tended to be intermediate between that of AH without atypia and that of HCC that was Edmondson and Steiner grade 2 or greater. Evaluation of the blood supply of the nodular lesions associated with liver cirrhosis is considered to be useful in the differential diagnosis and treatment of early-stage HCC. | 0 |
Aortic regurgitation after left ventricular myotomy and myectomy. Five hundred twenty-five patients with hypertrophic cardiomyopathy underwent left ventricular myotomy and myectomy (LVMM) from 1960 to 1990. Four hundred ninety-six had nonregurgitant trileaflet aortic valves before LVMM. In 19 (4%) of these patients, aortic regurgitation developed after LVMM. Age of the 19 patients ranged from 10 to 58 years (mean age, 35 +/- 3 [+/- standard error of the mean]]. Seven were male and 12, female. Five patients underwent LVMM followed immediately by aortic valve replacement or valvuloplasty. Aortic regurgitation developed in 14 patients at a later date. The average New York Heart Association functional class improved from 3.2 +/- 0.1 to 1.3 +/- 0.1 (p less than 0.05, Student's t test) after operation. The average peak systolic left ventricular outflow tract gradient at rest and with provocation decreased from 65 +/- 8 to 14 +/- 5 mm Hg (p less than 0.05) and 108 +/- 9 to 45 +/- 7 mm Hg (p less than 0.05), respectively, 6 to 8 months after operation. Aortic regurgitation occurred in 7 of the 14 patients at 6 months or less after operation, and 3 required operative repair. In the other 7 patients, aortic regurgitation developed 3 years or more after LVMM, and 3 of them also required operative repair. All 12 patients in whom aortic regurgitation developed at operation or within 6 months postoperatively had either a very small aortic annulus (less than or equal to 21 mm, 5 patients), a low mitral-septal contact lesion (greater than or equal to 35 mm below the aortic annulus, 3 patients), or both (4 patients). | 4 |
Tryptophan-induced eosinophilia-myalgia syndrome Eight patients who became ill while taking tryptophan had myalgia, fatigue, rash, fever, edema, alopecia, arthralgias, diminished joint motion, skin tightening, muscle cramping, and distal paresthesias. Three had shortness of breath, and one had pulmonary hypertension. Laboratory abnormalities included peripheral eosinophilia, leukocytosis, thrombocytosis, raised erythrocyte sedimentation rate, and elevated serum levels of aldolase, lactate dehydrogenase, and liver enzymes. Of 4 chest radiographs, 3 were abnormal. Of 5 skin and muscle biopsies, 4 showed sclerosis or mixed inflammatory cell infiltration of the dermis, subcutis, and fascia. Eosinophils were often present, but vasculitis was absent. Muscle inflammation was minimal. We conclude that the "eosinophilia-myalgia syndrome" is related to the ingestion of tryptophan and that abnormalities in the secretion of lymphokines may be important in its pathogenesis. | 2 |
Endocardial resection in the treatment of ventricular tachycardia secondary to cardiac trauma. Sustained ventricular tachycardia with left ventricular aneurysm formation is a rare complication following penetrating cardiac trauma. We present an unusual case of serious ventricular tachycardia which developed 35 years after a World War II injury and was successfully treated with aneurysmectomy, map-guided subendocardial resection, and cryoablation. | 3 |
No effect of experimental noise exposure on human pregnancy. The effect of experimental noise exposure (15 minutes of 90-dB white noise via headphones) was examined on systolic, diastolic, and mean arterial pressures; heart rate; and stress hormones (ACTH, cortisol, prolactin, epinephrine, and norepinephrine) in normotensive and hypertensive pregnant women. No significant effects induced by noise exposure could be registered in these variables. Fetal and uterine blood circulation was also examined with a duplex pulsed Doppler system. No changes were seen on the fetal side as measured from the descending aorta in blood flow velocity (cm/second) or pulsatility or resistance indexes in either normotensive or hypertensive pregnancy. The only change observed was an increase in fetal heart rate in normotensive pregnancy. However, this increase could not be confirmed by cardiotocographic registration and is not clinically important. Uterine blood circulation was recorded from the proximal uterine artery on the placental side, and no effect of exposure was seen on pulsatility or resistance indexes. | 3 |
Phase I trial of piritrexim capsules using prolonged, low-dose oral administration for the treatment of advanced malignancies. A phase I trial of piritrexim was conducted by use of a prolonged, low-dose oral schedule. A number of different regimens were tested, including daily dosing for 21 days followed by 7 days of no drug therapy; continuous dosing; and daily dosing for 5 of 7 days for 3 consecutive weeks followed by a week of rest. Dose escalation was accomplished by increasing the dosing frequency from once a day to twice a day and then to three times a day and by increasing the number of days of administration. Fifty-one patients with advanced cancer were entered in the study. One hundred twenty-four (96%) of 129 courses were considered assessable. Myelosuppression proved to be the dose-limiting toxic effect. Other toxic effects included stomatitis, nausea and vomiting, anorexia, diarrhea, skin rash, fatigue, and elevation of liver transaminase levels. Antitumor activity was observed in patients with melanoma and bladder cancer, and disease stabilization occurred in those with sarcoma and pheochromocytoma. The recommended dosing schedule for phase II clinical trials is 25 mg three times a day for 5 days for 3 consecutive weeks followed by 1 week of no drug therapy. | 0 |
Esophageal adenocarcinoma in a patient with surgically treated achalasia. Although squamous cell carcinoma of the esophagus occurs with increased incidence in primary achalasia, esophageal adenocarcinoma has been considered rare in this condition. We report a patient with long-standing achalasia in whom adenocarcinoma of the esophagus occurred many years after Heller esophagomyotomy, presumably related to Barrett's esophagus complicating gastro-esophageal reflux disease. | 4 |
Prevalence of acute mountain sickness in the Swiss Alps. OBJECTIVE--To assess the prevalence of symptoms and signs of acute mountain sickness of the Swiss Alps. DESIGN--A study using an interview and clinical examination in a representative population of mountaineers. Positive symptoms and signs were assigned scores to quantify the severity of acute mountain sickness. SETTING--Four huts in the Swiss Alps at 2850 m, 3050 m, 3650 m, and 4559 m. SUBJECTS--466 Climbers, mostly recreational: 47 at 2850 m, 128 at 3050 m, 82 at 3650, and 209 at 4559 m. RESULTS--In all, 117 of the subjects were entirely free of symptoms and clinical signs of acute mountain sickness; 191 had one or two symptoms and signs; and 158 had more than two. Those with more than two symptoms and signs were defined as suffering from acute mountain sickness. At 4559 m 11 climbers presented with high altitude pulmonary oedema or cerebral oedema, or both. Men and women were equally affected. The prevalence of acute mountain sickness correlated with altitude: it was 9% at 2850 m, 13% at 3050 m, 34% at 3650 m, and 53% at 4559 m. The most frequent symptoms and signs were insomnia, headache, peripheral oedema, and scanty pulmonary rales. Severe headache, vomiting, dizziness, tachypnoea, and pronounced pulmonary rales were associated with other symptoms and signs and therefore characteristic of acute mountain sickness. CONCLUSION--Acute mountain sickness is not an uncommon disease at moderately high altitude--that is, above 2800 m. Severe headache, vomiting, dizziness, tachypnoea, and pronounced pulmonary rales indicate severe acute mountain sickness, and subjects who suffer these should immediately descend to lower altitudes. | 4 |
A clinically applicable method for long-term salvage of postischemic skeletal muscle. The clinical significance and applicability of interventions aimed at reducing reperfusion injury in postischemic skeletal muscle remain unproven, since long-term muscle salvage has not been demonstrated by most treatment protocols that attenuate early reperfusion injury. We have shown that reperfusion of ischemic skeletal muscle results in an early and prolonged sequestration of white blood cells and activation of the alternative complement cascade. The purpose of this study was to determine if 40 minutes of reperfusion with blood depleted of white blood cells and complement proteins, followed by 2 days of normal perfusion, would reduce muscle necrosis after 5 hours of ischemia. The isolated paired canine gracilis muscle model was used. The treatment muscle was initially reperfused with arterial blood that had been spun, washed, passed through a leukocyte removal filter, and resuspended in hydroxyethyl starch (greater than 99.9% removal of white blood cells and the complement proteins factor B and C4). The contralateral control muscle was subjected to unaltered reperfusion. Blood flow (ml/min/100 gm) was measured by timed collection of gracilis venous blood. Myeloperoxidase activity (absorbance at 655 nm/min/mg tissue protein) in muscle biopsies was used to monitor white blood cell sequestration. After 48 hours of reperfusion in vivo, necrosis was quantified by nitroblue tetrazolium staining. Initial reperfusion with white blood cell and complement depleted blood significantly reduced muscle necrosis (53% +/- 3% vs 29% +/- 8%, p less than 0.0025, paired t test). Early blood flow was improved, (p = 0.0025, repeated measure-ANOVA), but subsequent white blood cell sequestration was not altered (p = 0.33, repeated measure-ANOVA). This suggests that a significant amount of white blood cell mediated injury occurs during the first 40 minutes of reperfusion. Preventing early complement activation and white blood cell mediated reperfusion injury is an intervention that is feasible during surgery and may result in clinically significant salvage of postischemic skeletal muscle. | 3 |
Mast cell heterogeneity in chronic idiopathic urticaria. Patients with chronic urticaria are more sensitive to codeine skin testing than other allergic individuals. Nonlesional skin in most patients with chronic urticaria was found to contain increased numbers of both total and atypical mast cells. The presence of increased mast cell density was found to correlate with the degree of clinical (dermatographism) and functional (codeine skin test) skin sensitivity. | 4 |
Night waking during infancy: role of parental presence at bedtime. Night waking occurs commonly in infants and young children. The goal of this study is to determine whether parents who report being present when their infant falls asleep at bedtime are more likely to report increased frequency of night waking by the infant. Mothers were consecutively recruited when they brought their infants to the clinic for their 9-month well-child visit. A total of 122 mothers agreed to participate and completed a questionnaire consisting of closed-ended, forced choice questions about their infant's feeding and sleeping behavior, and demographic and psychosocial characteristics. For 33% of the mothers, a parent was routinely present when the infant went to sleep. The entire sample of infants averaged 4.1 night wakings during the week prior to questionnaire completion. Infants whose parents were present at bedtime were significantly more likely to wake at night than infants whose parents were not present (6.2 vs 3.1, P = .01). Frequent night waking (seven or more wakings in the prior week) occurred in 28% of the sample. More of the infants whose parents were present experienced frequent night waking compared with infants whose parents were not present (40% vs 22%, P less than .04). When potential confounding variables were controlled by multivariate analysis, parents being present when the child went to sleep was independently associated with night waking (P less than .03). The association of parental presence at bedtime and night waking has implications for preventing and managing disruptive night waking in infancy. | 2 |
Etiology of acute lower respiratory tract infections in Gambian children: I. Acute lower respiratory tract infections in infants presenting at the hospital. Ninety infants less than 1 year of age with pneumonia and 43 control infants were investigated for viral and chlamydial infection with the use of culture and serology and for bacterial infection with the use of blood cultures, lung aspirates, antibody assays and antigen detection procedures. One or more potential pathogens were identified in 62 (69%) cases with pneumonia and in 12 (28%) controls. Infection by respiratory viruses was identified in 42 (49%) cases and in 8 (19%) controls. Respiratory syncytial virus was the commonest pathogen identified and was found in 32 cases (37%). Bacterial infections were also common, being found in 27 (30%) cases and 3 (7%) controls, and predominantly involved Streptococcus pneumoniae (20%) or Haemophilus influenzae (11%). Bacterial infections were associated with raised white blood cell counts and were identified more often by antigen detection procedures (68%) than by culture of blood or lung aspirates (34%) or by serology (33%). Mixed viral-bacterial infections were identified in 13 cases (15%). Infection with Chlamydia trachomatis was diagnosed in 2 infants with acute lower respiratory tract infection and in 1 control infant. | 4 |
v-Ha-ras transgene abrogates the initiation step in mouse skin tumorigenesis: effects of phorbol esters and retinoic acid. Experimental carcinogenesis has led to a concept that defines two discrete stages in the development of skin tumors: (i) initiation, which is accomplished by using a mutagen that presumably activates a protooncogene, and (ii) promotion, which is a reversible process brought about most commonly by repeated application of phorbol esters. We have created a transgenic mouse strain that carries the activated v-Ha-ras oncogene fused to the promoter of the mouse embryonic alpha-like, zeta-globin gene. Unexpectedly, these animals developed papillomas at areas of epidermal abrasion and, because abrasion can also serve as a tumor-promoting event in mutagen-treated mouse skin, we tested these mice for their ability to respond to phorbol ester application. Within 6 weeks virtually all treated carrier mice had developed multiple papillomas, some of which went on to develop squamous cell carcinomas and, more frequently, underlying sarcomas. We conclude that the oncogene "preinitiates" carrier mice, replacing the initiation/mutagenesis step and immediately sensitizing them to the action of tumor promoters. In addition, treatment of the mice with retinoic acid dramatically delays, reduces, and often completely inhibits the appearance of promoter-induced papillomas. This strain has use in screening tumor promoters and for assessing antitumor and antiproliferative agents. | 4 |
Rectal mucosal dysplasia in Crohn's disease. Serial sections of 812 rectal biopsy specimens from 356 Crohn's disease patients were analysed for mucosal epithelial dysplasia. Dysplasia was found in 18 patients (5%), with four showing dysplasia on repeat biopsy specimen. In these 22 biopsy specimens the dysplasia was mild in 13, moderate in nine, and severe in none. Subsequently, three patients (17%) developed neoplasms including carcinoma in two and an adenomatous polyp in one. In colectomy specimens which showed dysplasia, significantly more dysplastic changes were found in seven patients who underwent colonic resection than in 10 others who underwent operation but had no prior dysplasia (p less than 0.001). Thirteen patients still have their rectum in situ and remain at risk of developing colonic cancer. Four carcinomas developed in patients with Crohn's disease who did not have dysplasia on rectal biopsy specimen. | 0 |
Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II--DAVIT II) The effect of verapamil on death and major events (i.e., death or reinfarction) after an acute myocardial infarction was studied in a double-blind, randomized, placebo-controlled multicenter trial. Eight hundred seventy-eight patients started treatment with verapamil, 360 mg/day, and 897 patients with placebo. Treatment started in the second week after admission and continued for up to 18 months (mean 16 months). Ninety-five deaths and 146 major events occurred in the verapamil group and 119 deaths and 180 major events in the placebo group. The 18-month mortality rates were 11.1 and 13.8% (p = 0.11, hazard ratio, 0.80; 95% confidence limits, 0.61 to 1.05), and major event rates 18.0 and 21.6% (p = 0.03, hazard ratio, 0.80; 95% confidence limits, 0.64 to 0.99) in the verapamil and placebo groups, respectively. In patients without heart failure in the coronary care unit the mortality rates were 7.7% in the verapamil group and 11.8% in the placebo group (p = 0.02, hazard ratio, 0.64; 95% confidence limits, 0.44 to 0.94), and major event rates 14.6 and 19.7% (p = 0.01, hazard ratio 0.70; 95% confidence limits (0.52 to 0.93). In patients with heart failure the mortality rates were 17.9 and 17.5% (p = 0.79, hazard ratio, 1.05; 95% confidence limits, 0.72 to 1.54), and major event rates 24.9 and 24.9% (p = 1.0, hazard ratio 0.98; 95% confidence limits 0.72 to 1.39). Long-term treatment with verapamil after an acute myocardial infarction caused a significant reduction in major events, and the positive effect was found in patients without heart failure. | 3 |
Absorbable mesh splenorrhaphy for severe splenic injuries: functional studies in an animal model and an additional patient series. Polyglycolic acid mesh has been introduced as a method of controlling hemorrhage in severely damaged spleens. This study examines the effect of splenic wrapping on the immune function of the spleen, and also on its ability to control splenic bleeding in trauma patients. Thirty purebred beagle dogs were divided into three groups and subjected to sham operation (Group 1), splenectomy (Group 2), and splenic wrap (Group 3). Immunologic studies showed no difference between the wrapped group (Group 3) and those with their spleens intact (Group 1) in the induction of specific antibody-producing lymphocytes in splenic tissue after the injection of attenuated Pneumococci. All splenic injuries treated at Cook County Hospital between January 1985 and May 1988 were retrospectively analyzed. Of 60 patients with splenic injuries, 14 underwent mesh splenorrhaphy without mortality or serious complications. This study demonstrates that the immune function of spleen is preserved following mesh splenorrhapy, and that this technique can be used in a clinical setting with safe and efficacious results. | 4 |
Fetal abdominal abnormalities associated with genetic syndromes. Sonographic technology has given the prenatal diagnostician the ability to accurately visualize fetal malformations. This article demonstrates the currently available capability of applying sonographically derived information concerning fetal dysmorphology to our knowledge of genetic disorders and syndromes. As a result, there can be a significant improvement in the management and counseling of these patients. After an initial discussion of normal embryology, principles of abdominal ultrasonography are discussed and applied to the following anomalies: omphalocele, gastroschisis, diaphragmatic hernia, duodenal atresia, other intestinal atresias and stenoses, renal anomalies, and obstructive uropathies. | 4 |
Tumor lysis syndrome in a patient with metastatic Merkel cell carcinoma. A first course of combination chemotherapy for large volume metastatic disease in a patient with Merkel cell carcinoma resulted in a tumor lysis syndrome. After this course a nearly complete response was documented. This case report extends further the chemosensitivity of Merkel cell carcinoma and demonstrates the need for tumor lysis syndrome prophylaxis in patients with bulky disease or fast-growing tumors. | 0 |
Altered protein tyrosine kinase levels in human colon carcinoma. To further understand the molecular mechanisms and the biological indicators of colonic tumorigenesis, the authors examined tyrosine kinase activity in the cytosol and in the particulate fraction of the homogenates of specimens from 20 human colonic carcinomas and compared them with the adjacent normal mucosal tissues. Total protein tyrosine kinase activity could be precisely detected using miniphosphocellulose column purification and a synthetic peptide, Glu-asparagine (Asp)-alanine (Ala)-Glu-tyrosine (Tyr)-Ala-Ala-arginine (Arg)-Arg-Arg-glycine (Gly) (E11-G1), as an artificial substrate. Tyrosine kinase activity of colonic carcinoma and normal mucosa was reduced in the cytosol fraction whereas activity in the particulate fraction was elevated with respect to protein concentration. The average specific activity ratios were 1.95 +/- 0.27 (normal cytosolic/carcinoma cytosolic) and 0.57 +/- 0.01 (normal particulate/carcinoma particulate) for tyrosine kinase activity. Cellular distribution (% cytosol) of tyrosine kinase activity in normal mucosa and in carcinoma varied from 21.0% to 91.2% and from 7.0% to 61.4%, respectively. In nearly all cases the percentage of cytosolic tyrosine kinase activity in carcinoma tissues was lower than in normal tissues. There was no difference due to histologic type or the presence of adenomatous components. A significant decrease of cytosolic tyrosine kinases was correlated with Dukes' Stage A. With advancing Dukes' stage, the average specific activity ratios (normal cytosol/carcinoma cytosol) were decreased. This study indicates that colonic carcinogenesis might be associated with alterations in cellular levels of tyrosine kinase activity and that the average specific activity ratio (normal cytosol/carcinoma cytosol) had a possible correlation with colonic tumor growth. | 0 |
Posterior interosseous nerve palsies. One hundred seventy patients with radial nerve disorders were reviewed at the Louisiana State University Medical Center over a 15-year period. Of these, 32 had involvement of the posterior interosseous nerve exclusively. Findings included weak wrist extension with a radial drift, inability to extend the fingers, paralysis of thumb extension, and weak thumb abduction. Causes included entrapment at the arcade of Froshe (14 patients), laceration (6 patients), fracture (6 patients), compression or contusion (3 patients), and loss associated with tumor (3 patients). The ratio of men to women was 2:1, and the right arm was involved twice as often as the left. Preoperative evaluation included physical examination, electrophysiological testing (electromyogram/nerve conduction velocity), and roentgenograms of the elbow and forearm. Of the 30 patients (2 patients had bilateral lesions), 26 underwent operation. In the operative series, all 28 nerves had a function of Grade 3 or more of a possible 5 after 4 years of follow-up. Seventeen had achieved Grade 4/5, and 7 had obtained Grade 5/5. At operation, 23 nerves were found to be in continuity. Fourteen lesions of nerves in continuity were associated with entrapment and, not unexpectedly, transmitted a nerve action potential with slowed conduction and low amplitude across the lesion. Four nerves in continuity that had lesions caused by injury had nerve action potentials and were treated by neurolysis, and another 4 had no nerve action potentials and were treated by graft or suture repair. Five injured nerves were not in continuity. Two could be repaired by end-to-end suture, and 3 required graft repair. A large ganglion cyst involving the posterior interosseous nerve was also resected. | 2 |
Leukocyte counts and activation in spontaneously hypertensive and normotensive rats The etiology for the progressive organ injury in hypertension is largely speculative. Recent studies have shown that leukocytes play a key role in several cardiovascular diseases. As an initial step toward investigating the role of leukocytes in hypertension, we measured leukocyte counts and spontaneous activation of granulocytes of freshly drawn unseparated blood samples in spontaneously hypertensive rats and in their normotensive counterpart, Wistar-Kyoto rats. The animals were derived from one breeder in the United States and from two breeders in Europe. Total leukocyte counts in young, mature, and old hypertensive rats were 50-100% above the controls. The number of granulocytes in mature and old spontaneously hypertensive rats in more than 100% elevated compared with control rats. In young hypertensive rats the mean granulocyte count was only slightly elevated. The number of spontaneously activated granulocytes, as detected by the nitroblue tetrazolium reduction, increases with age in both species; in mature spontaneously hypertensive rats, it is more than 300% above the values in the controls. Furthermore, in mature hypertensive rats the number of monocytes, activated monocytes, and the lymphocyte count are also significantly elevated over the values in the normotensive controls. It is proposed that these elevated leukocyte counts may constitute an enhanced risk for organ injury in the spontaneously hypertensive rat. | 3 |
Natural history of cardiac rhabdomyoma in infancy and childhood. Although spontaneous regression of cardiac rhabdomyoma has been reported, prognosis is still considered to be poor and surgery continues to be indicated. The experience with rhabdomyoma diagnosed in live infants over a 20-year period was reviewed. Diagnosis by angiography or echocardiography was accepted only if multiple tumors were present or if tuberous sclerosis was also diagnosed. Nine patients (3 diagnosed prenatally and the remaining 6 at age less than 8 months) were identified as having a total of 24 tumors. Measurements in 2 planes demonstrated at least some evidence of regression in 24 patients (100%), with 20 of 24 having complete resolution. One patient required delayed surgery for excision of a subaortic ridge that appeared at the site of a resolved tumor. Our findings suggest that pediatric cardiac rhabdomyoma is most often a benign condition in which spontaneous regression is the rule. Surgery is recommended only for patients with refractory dysrhythmias or severe hemodynamic compromise. | 0 |
Urinary tissue factor activity in colorectal disease. Procoagulant activity (PCA) in normal urine has been recognized for over 50 years. Although tissue factor (TF) is produced by certain tumours, and is increased in both tumour-associated macrophages and blood monocytes, the possibility that it might also be increased in urine has not been studied in patients with cancer. We have measured urinary PCA in hospital controls without inflammatory or neoplastic disease (n = 79), in patients with rheumatoid arthritis (n = 8), inflammatory bowel disease (n = 19), colorectal cancer (n = 70) and in patients undergoing colonoscopy (n = 50). Urinary PCA was higher (P less than 0.001) in patients with colorectal cancer and inflammatory bowel disease than controls or patients with rheumatoid arthritis. Fourteen (88 per cent) out of 16 colonoscopy patients subsequently found to have carcinoma or inflammatory bowel disease had levels above the control upper quartile, compared with 8 (24 per cent) out of 34 with normal colonoscopy (P less than 0.001). TF inhibitors confirmed the nature of the PCA and Western blotting studies indicated a urinary TF molecular weight of approximately 38,000. These studies provide further evidence of abnormal haemostasis in malignancy and suggest that determination of urinary TF may provide a useful screening test in patients undergoing colonoscopy. | 1 |
Significance of discordant ST alternans in ventricular fibrillation. With the use of epicardial mapping, we investigated the electrical alternans of the ST segment during acute myocardial ischemia and studied the difference in ST alternans between dogs with resultant ventricular fibrillation and those without it. During the 7-minute occlusion of the left anterior descending coronary artery below its first diagonal branch, 60 epicardial unipolar electrograms were recorded simultaneously at 1-minute intervals by a computerized mapping system. ST alternans was found in the eight dogs we observed. The amplitude of ST alternans (difference in the ST segment elevation of two consecutive electrograms) was greater in dogs with ventricular fibrillation (n = 4) than in those without it (n = 4) (3.92 +/- 1.24 versus 0.58 +/- 0.49 mV, p less than 0.05). Three of the four dogs with ventricular fibrillation demonstrated discordant ST alternans (i.e., adjacent leads were out of phase). Results from the present study indicate that an increased amplitude and discordance of ST alternans during acute myocardial ischemia are related to ventricular fibrillation and act as indicators of time and spatial unevenness of ventricular repolarization. | 3 |
Role of nerve-sparing radical prostatectomy for clinical stage B2 prostate cancer. To examine the role of nerve-sparing radical prostatectomy in patients with clinical stage B2 prostate cancer we reviewed the first 77 such patients in our series since we adopted the nerve-sparing technique. A total of 47 patients (61%) underwent bilateral and 26 (34%) underwent unilateral nerve-sparing prostatectomy, while in 4 (5%) both neurovascular bundles were resected. Among the patients followed for 12 months 27 of 41 (66%) treated with bilateral and 7 of 19 (37%) treated with unilateral nerve-sparing prostatectomy had potency preserved. With the strict clinicopathological criteria of organ-confined tumor, that is intracapsular tumor with negative surgical margins and undetectable postoperative prostate specific antigen levels, complete tumor excision was achieved in 17 patients (36%) treated with bilateral and 7 of 26 (27%) treated with unilateral nerve-sparing prostatectomy. All patients in whom both neurovascular bundles were resected had pathological stage C or D1 disease. Of the 24 patients who had complete tumor excision by the strict criteria only 15 (19.5% of the 77 preoperatively potent patients) had potency preserved. Of these patients 19 had microscopically positive margins without seminal vesicle invasion (pathological stage C1) with undetectable postoperative prostate specific antigen levels. In addition, 4 patients had seminal vesicle involvement with negative surgical margins and undetectable postoperative prostate specific antigen levels. If these patients also are considered as having complete tumor excision, there was an over-all complete tumor excision rate of 61% (47 of 77), of whom 25 (32% of the 77 patients) had preservation of potency. Ten patients with clinical stage B2 tumor whose potency was preserved had histological and serological evidence of incomplete tumor excision. Of 53 patients with pathological stage C1 disease 9 (17%) had margins positive only in the regions of the neurovascular bundles. Preoperative prostate specific antigen and acid phosphatase levels, and findings on transrectal ultrasonography failed to predict accurately which patients had extracapsular tumor extension. Patients with poorly differentiated tumors and/or bulky disease on rectal examination had a higher incidence of extracapsular extension and positive margins. We conclude that in the majority of potent patients with clinical stage B2 prostate cancer not all of the goals of nerve-sparing radical prostatectomy are realized.(ABSTRACT TRUNCATED AT 400 WORDS). | 4 |
Immunohistochemical study of erythropoietin in cerebellar hemangioblastomas associated with secondary polycythemia. Although cerebellar hemangioblastomas are known to be associated with secondary polycythemia, the cellular derivation of erythropoietin (EPO) in hemangioblastomas still remains obscure. Specimens from 18 patients with cerebellar hemangioblastomas were immunohistochemically studied using anti-EPO monoclonal antibody. Eight cases of brain tumors, including 2 meningiomas, 2 medulloblastomas, 2 glioblastomas, and 2 metastatic brain tumors were studied as controls. In 9 of 18 cases, EPO-positive cells were scattered around the capillaries and were ultrastructurally shown to be mast cells. These cases were not, however, associated with secondary polycythemia. In contrast, the stromal cells were positive for EPO in 3 cases. Among them, one was associated with secondary polycythemia. Furthermore, one-half of the control cases of brain tumor contained EPO-positive mast cells. Accordingly, it was suggested that mast cells (or small granulocytes) have little relationship to the release of EPO; however, some stromal cells might release EPO with a resultant polycythemia. | 0 |
Accumulation and pepsin solubility of collagens in the bowel of patients with Crohn's disease. The collagen content of resected strictured intestine, with and without fistulas, from patients with Crohn's disease has been compared with that in macroscopically normal intestine removed from the same patients and from others without inflammatory bowel disease. Collagen content per unit wet or dry weight of tissue was significantly increased in all grossly diseased tissue whether fistulated or not. Although there was a significant increase in collagen types I, III, and V in diseased tissue, the relative proportions of major collagen types extracted by limited pepsin digestion were similar for both Crohn's and non-Crohn's intestine (type I, 65 to 70 percent; type III, 25 to 30 percent; type IV, 2 to 3 percent; and type V, 2.5 to 3 percent). CNBr digestion of pepsin insoluble material showed a similar relative abundance of types I and III, indicating no major change in collagen type distribution between older (insoluble) and more newly synthesized collagen. There was no evidence of the presence of type I trimer collagen. Type VI collagen, although not quantitated, was observed in 70 percent of intestinal specimens. The proportion of total collagen solubilized by pepsin treatment was significantly greater in both grossly diseased and macroscopically normal Crohn's bowel compared with non-inflammatory bowel disease bowel. These findings suggest that there are disturbances of collagen metabolism in Crohn's intestine, which account for the stricturing process and which may predate gross pathologic changes. | 1 |
Transaortic endarterectomy of renal visceral artery lesions in association with infrarenal aortic surgery. The complexity of infrarenal aortic reconstruction increases when bypass grafts to revascularize associated renal and visceral arteries are needed. Lesions in these vessels, however, are usually limited to their aortic orifices and therefore are amenable to retroperitoneal transaortic endarterectomy. A combined infrarenal aortic reconstruction and transaortic endarterectomy of the renal/visceral vessels was used in 18 (16%) of 120 patients undergoing elective infrarenal aortic reconstruction over a 2-year-period. Transaortic endarterectomy was performed primarily for renal preservation in 11 patients with bilateral, high-grade renal artery stenoses and abnormal renal function (serum creatinine greater than or equal to 1.9 mg/dl). In seven patients transaortic endarterectomy was performed as a secondary procedure during the course of complex reconstruction of aneurysmal or occlusive aortic disease. Mean serum creatinine, which was elevated preoperatively in 14 (78%) patients (3.3 mg/dl), decreased significantly after the operation (2.0 mg/dl, p less than 0.01). A single death occurred in the 18 patients undergoing transaortic endarterectomy. Renal function preservation can be achieved by renal revascularization in patients with bilateral renal artery stenoses and decreased renal function. The retroperitoneal approach to aortic reconstruction and the use of transaortic endarterectomy allows correction of most renal/visceral vessel involvement in complex aortic revascularization procedures. | 3 |
Quality control practices in centralized tumor registries in North America. A survey of quality control practices was mailed to 73 central registries in the U.S. and Canada. The response rate was 88%, with respondents representing a wide range of registry characteristics and reporting strategies. While registries expressed different priorities in data use, 80% of respondents felt quality control data were important in the identification of problems. The most common method of quality control was acceptance sampling (used by 97% of respondents), and took the form of visual review, recoding and edit checking. Computer-based edit checks were almost universally used (95%). Process control methods of any sort were used by only 22% of respondents with less than 4% of registries reporting formal quantitative criteria. Sixty-one percent of respondents reported conducting one or more designed studies (e.g. reabstracting or casefinding studies) but only 20% of those made the results public. Greater emphasis should be placed on development of quantitative process controls, experimental design of quality control studies, and formal analyses and reporting of study results. | 0 |
Differential effect of oncotic pressure on cerebral and extracerebral water content during cardiopulmonary bypass in rabbits. To study the effect of oncotic pressure on brain water content during cardiopulmonary bypass (CPB), 14 anesthetized New Zealand White rabbits underwent 60 min of nonpulsatile CPB at normothermia. Animals were grouped according to the composition of the circuit priming fluid. Group 1 animals (n = 7) received a priming fluid (6.5% hydroxyethyl starch in 0.72 N NaCl; 323 +/- 13 mOsm/kg [mean +/- SD]) that maintained normal colloid oncotic pressure (COP) during CPB (19.0 +/- 1.5 mmHg). Group 2 animals (n = 7) received a priming fluid (0.9 N NaCl; 324 +/- 23 mOsm/kg) that led to a hypooncotic state (COP = 6.2 +/- 1.2 mmHg). Blood chemistries and hemodynamics were recorded every 15 min during CPB. Animals were given additional priming fluid and sodium bicarbonate during CPB to maintain a circuit flow of 85 ml.kg-1.min-1 and arterial pH greater than 7.35. There were no significant differences between groups 1 and 2 with respect to temperature, central venous pressure, mean arterial pressure, PaO2, PaCO2, plasma sodium concentration, or osmolality at any time during CPB, although osmolality increased in both groups. After 60 min of bypass, animals were killed and organ water contents were determined by wet/dry weight ratios. A separate group of nine similarly prepared and anesthetized animals that did not undergo cannulation or CPB also underwent measurement of plasma chemistries and tissue water contents and served as nonbypass controls (group 3). Brain and kidney water contents were unaffected by oncotic pressure, whereas duodenum and skeletal muscle had significantly greater water content (P = 0.003 and P = 0.008, respectively) after hypooncotic CPB. | 2 |
Fresnel prisms improve visual perception in stroke patients with homonymous hemianopia or unilateral visual neglect. We randomly assigned 39 patients with stroke and homonymous hemianopia or unilateral visual neglect to treatment with 15-diopter plastic press-on Fresnel prisms (n = 18) or to serve as controls (n = 21). Baseline evaluations of visual perception and activities-of-daily-living (ADL) function were similar for both groups. After 4 weeks, the prism-treated group performed significantly better than controls on the following: (1) Motor Free Visual Perception Test; (2) Line Bisection Task; (3) Line Cancellation Task; (4) Harrington Flocks Visual Field Screener; and (5) Tangent Screen Examination. There was no significant difference in Barthel ADL assessment at 4 weeks. Thus, treatment with 15-diopter Fresnel prisms improves visual perception test scores but not ADL function in stroke patients with homonymous hemianopia or unilateral visual neglect. | 2 |
Deformities of the hip in adults who have sickle-cell disease and had avascular necrosis in childhood. A natural history of fifty-two patients. We report the natural course of the hip in fifty-two patients (ninety-five hips) who had sickle-cell disease and had had avascular necrosis in childhood. There were twenty-one African, twenty-one West Indian, and ten Mediterranean patients. At the most recent follow-up examination (at an average duration of nineteen years after the onset of the disease), 80 per cent of the hips that had been affected by avascular necrosis during childhood were painful and had permanent damage with regard to decreased mobility, limb-length discrepancy, and an abnormal gait. When the patients were evaluated, at an average age of thirty-one years, fifteen hips (16 per cent) had had an operation for progressive disability and sixty (63 per cent) had major problems because of pain. Of the twenty hips (21 per cent) that were not painful, five were in patients who had an abnormal gait, with decreased agility. The mean Iowa hip-rating score at the most recent follow-up examination was 73 points (range, 30 to 100 points). Correlations were found between the hip score and the patient's age at the onset of the disease and at the latest follow-up, between the hip score and degenerative changes in the hip, and between degenerative changes and radiographic evidence of deformity of the hip. | 2 |
Contraceptive effects of extended lactational amenorrhoea: beyond the Bellagio Consensus. We have recorded the duration of lactational anovulation and amenorrhoea in a well-nourished group of Australian women who breastfed their babies throughout the study. The data enabled us to compare the theoretical cumulative probability of conception among breastfeeding women who had unprotected intercourse irrespective of their menstrual status with that of those who had unprotected intercourse only during lactational amenorrhoea. Breastfeeding alone is not an effective form of contraception, since all the women in our study resumed normal ovulation while still breastfeeding. However, among women who have unprotected intercourse only during lactational amenorrhoea but adopt other contraceptive measures when they resume menstruation, only 1.7% would have become pregnant during the first 6 months of amenorrhoea, only 7% after 12 months, and only 13% after 24 months. Thus for our women it would be possible to extend the Bellagio Consensus Conference guidelines which stated that lactational amenorrhoea can only be relied on as a contraceptive for the first 6 months post-partum in women who are fully or almost fully breastfeeding. The lactational amenorrhoea method can be relied on for excellent contraceptive protection in the first 6 months of breastfeeding, irrespective of when supplements are introduced into the baby's diet; for women who continue to breastfeed the method can also give good protection for up to 12 months post partum. Once menstruation has returned, other forms of contraception are essential to prevent pregnancy. | 4 |
Skin blisters as a manifestation of oxazepam toxicity. A 75 year-old comatous patient was admitted after ingestion of 200 mg oxazepam. Skin blisters, attributed to oxazepam toxicity, appeared on the left forearm the following day and regressed spontaneously nine days later. | 4 |
Prolapse of a neovagina created by self-dilatation. In patients with congenital absence of the vagina, a neovagina may be created by either operative or nonoperative techniques. A 25-year-old patient with a neovagina created by self-dilatation developed complete prolapse of the neovagina with an enterocele. A transabdominal sacral colpopexy successfully suspended the vaginal vault and allowed the patient to resume sexual function. | 4 |
The accuracy of predictions about progress of patients on a stroke unit. The aim of the study was to check the accuracy of predictions about the factors which affect the progress, in physical abilities and activities of daily living, of patients admitted to a stroke unit. A series of 60 patients admitted consecutively to a stroke unit were assessed on tests of motor, functional and cognitive abilities at admission. On the basis of these assessments predictions were made about the abilities of the patients at discharge. Patients were assessed for level of motor abilities and activities of daily living at discharge and the accuracy of the predictions checked. Predictions were found to be significantly correlated with outcome but the relationships were not so close as to be useful for the clinical management of individual patients. | 2 |
Use of pulmonary artery catheters in patients with acute myocardial infarction. Analysis of experience in 5,841 patients in the SPRINT Registry. SPRINT Study Group This study analyzes the use of PAC in a registry comprising 5,841 hospitalized patients with AMI. A total of 371 patients received PAC. In-hospital mortality was higher in patients with CHF who received PAC, while there was no difference in patients with cardiogenic shock or persistent hypotension. Mortality in patients receiving PAC was higher irrespective of the presence or absence of "pump failure." A separate analysis of discharge summaries of 364 patients with CHF showed that PAC was used more frequently in sicker patients and that when severity of CHF was assessed, no difference in mortality was found in patients with mild or moderate CHF. We conclude that while a higher in-hospital mortality is found in patients receiving PAC, this excess is likely related to difference in severity of CHF, which had not been assessed in every individual. It is unlikely that PAC increases mortality. | 3 |
Use of immunoglobulin gene rearrangements to show clonal lymphoproliferation in hyper-reactive malarial splenomegaly In Africa, hyper-reactive malarial splenomegaly (HMS), which is also known as tropical splenomegaly syndrome, can be associated with a prominent lymphocytosis in blood and bone marrow that is difficult to distinguish clinically from chronic lymphocytic leukaemia (CLL). The observation that some patients with HMS become resistant to treatment with anti-malarial drugs has led to the suggestion that HMS may evolve into a malignant lymphoproliferative disorder. To test this hypothesis, 22 Ghanaian patients with HMS and/or lymphocytosis were categorised by degree of response to proguanil according to standard clinical criteria, and DNA was extracted from peripheral blood cells and screened for rearrangements of the Jh region of the immunoglobulin gene with a DNA probe. Clonal rearrangements of the Jh region were found in all 3 patients with no response, in none of 13 patients with sustained response, and in 2 of 6 patients with moderate response or relapse on proguanil therapy. The detection of such rearrangements, and hence clonal lymphoproliferation in individuals with clinical features intermediate between HMS and CLL, supports the hypothesis that HMS may evolve into a malignant lymphoproliferative disorder. | 4 |
Bile duct emptying in response to fat: a validation study. Fatty meal sonography has been suggested to assess patients with biliary pain after cholecystectomy, but the effects of gallbladder removal on biliary dynamics has not been studied prospectively. Before elective cholecystectomy, 25 patients had their common hepatic ducts' diameter measured by ultrasonography before and after a fat stimulus. In 23, tests were repeated 1 month, 1 year, and 5 years after surgery. In preoperative studies, 5 patients showed dilatation after fat and 2 of these had stones in the common bile duct. However, another 4 patients with stones or sludge in the duct did not show dilatation, so that the response to fat was a poor indicator of patients requiring common bile duct exploration. No patient had major symptoms after surgery. At 1 month and 12 months, the response to fat was variable with more than half of those tested showing no decrease in duct size. A more consistent pattern emerged at 5 years, when 14 of 18 patients tested showed a decrease in common hepatic duct after fat; 3 were unchanged and 1 increased by 1 mm. The response to fat was less consistent and more difficult to measure in the common bile duct, even 5 years after operation. It was concluded that not all patients with indications for exploration of the common bile duct on operative cholangiography show a dilatation response to fat on preoperative testing. Also, fatty meal sonography should be used with caution because the response to fat in asymptomatic patients soon after operation is unpredictable, with occasional patients showing dilation without apparent obstruction. Measurement of common hepatic duct is preferred to common bile duct and increases in diameter of 1 mm are probably not significant. | 1 |
Papanicolaou smear cell recovery techniques used by primary care physicians. Nine hundred Tennessee-based internists, family physicians, and obstetrician-gynecologists were randomly selected and surveyed to identify Papanicolaou smear cell recovery methods used in their practices. This 16-item survey also requested typical laboratory reporting procedures on Papanicolaous smears. The most frequently reported cell sampling technique was the combination cotton-tipped applicator and spatula, which was used by 47 percent of all physicians. Use of the cervical cytobrush for Papanicolaou smears, which has been shown to improve the detection of cervical dysplasia, was used alone or in combination by 19 percent of those surveyed, of whom 72 percent were gynecologists. Cervical sampling should contain cells from the transformation zone as evidenced by an adequate number of endocervical cells on the smear. Laboratories reporting the presence of endocervical cells were significantly different (P less than 0.05) among the specialties, with 26 percent of the internists', 18 percent of the family physicians', and 15 percent of the obstetricians' laboratories not providing this information in their reports. Reporting inadequate smears is a necessary first step toward improved sampling technique. Without this information, physicians risk missing pathology through reports of false-negative Papanicolaou smears. | 0 |
Practical aspects of pulsatile gonadotropin-releasing hormone administration. Pulsatile administration of gonadotropin-releasing hormone represents a major advance in the treatment of anovulation in women who fail to ovulate with clomiphene citrate and is an alternative for many women who currently receive human menopausal gonadotropin. Four issues must be addressed before administering pulsatile gonadotropin-releasing hormone: (1) safety, (2) efficacy, (3) convenience, and (4) cost. Each of these issues will be affected by the three major decisions a physician makes with gonadotropin-releasing hormone therapy: (1) patient selection, (2) route of administration, and (3) dose of gonadotropin-releasing hormone. The ideal candidate for gonadotropin-releasing hormone therapy is a patient with an absence of endogenous pulsatile gonadotropin-releasing hormone, as seen in hypothalamic amenorrhea. Although women with polycystic ovarian disease can be treated with pulsatile gonadotropin-releasing hormone, a decreased ovulation rate should be expected. The route of administration, intravenous or subcutaneous, and the degree of monitoring can be tailored by the physician to fit each patient's needs. Pulsatile gonadotropin-releasing hormone therapy is a safe, effective, convenient, and economical alternative to human menopausal gonadotropin for ovulation induction in women resistant to clomiphene. | 0 |
Uneventful delivery following series of successive treatments for virilized Cushing syndrome due to adrenocortical carcinoma. A twenty-one-year-old virilized woman with Cushing syndrome due to a huge adrenocortical carcinoma was successively treated with trilostane (3 beta-hydroxysteroid dehydrogenase inhibitor), subsequent adrenalectomy, and postoperative cis-platinum. Clinical or biochemical abnormalities peculiar to Cushing syndrome gradually subsided, and three and one-half years after the adrenal surgery, the patient delivered a normal female infant. This study points out some of the clinical and biochemical responses of each treatment. | 0 |
Results of vein graft reconstruction of the lower extremity in diabetic and nondiabetic patients. The results of 171 vein grafts of the lower extremity were evaluated. These were placed between January 1981 and December 1987 in 150 patients, 75 diabetic and 75 nondiabetic, to determine the influence of diabetes on the outcome of the procedure. One and four year patency rates were determined by a life table analysis. No statistical differences in primary patency were found between the patients with diabetes and those without diabetes for all indications of operations (one year, diabetic patients 95 +/- 3 per cent, nondiabetic patients 85 +/- 3 per cent; four years, diabetic patients 89 +/- 11 per cent and nondiabetic patients 80 +/- 12 per cent; p = n.s.). For those operated upon for salvage of the limb because of rest pain, ulceration or gangrene, patency in diabetic patients at one year approached a statistically significant advantage (diabetic patients 94 +/- 4 per cent versus nondiabetic patients 79 +/- 8 per cent; p = 0.056). We believe that arterial reconstruction of the lower extremity can be performed upon patients with diabetes with the same high degree of success for revascularization and salvage of the limb as can be accomplished in nondiabetic patients. This is true even though those with diabetes present with necrosis of the tissue and more often require bypass to distal tibial arteries. | 4 |
Recurrent wheezy bronchitis and viral respiratory infections Fifty four patients aged from 1 to 6 years who had had recurrent attacks of wheezy bronchitis were prospectively followed up for three months to find out if there was an association between different viral respiratory infections and episodes of wheezing. Of the 115 episodes of upper or lower respiratory tract symptoms, virus or Mycoplasma pneumoniae infection were diagnosed in 52 (45%). Thirty four of rhinoviruses. The patients had an average of 2.1 episodes of respiratory tract symptoms the total mean (SD) duration of which was 30 (2) days of the 92 days that followed. Wheezing occurred during 76 (66%) of the 115 episodes and during a third of these the patient was admitted to hospital because of severe dyspnoea. Wheezing started a mean (SD) of 43 (7) hours after the first symptoms of respiratory infection and persisted for 3.8 (4.2) days in patients in whom virus infection was diagnosed. The incidence of wheezing was not associated with IgE mediated atopy, with positive virological tests, or with fever during virus infection, but was associated with parental smoking and more than one sibling. | 4 |
Biological correlates of mental activity studied with PET. The development of newer imaging techniques that allow direct investigation of the function of the human brain under normal and pathological conditions has affected the way in which we conceive of the mind/brain relation. In this report the authors use examples from findings obtained with positron emission tomography (PET) to illustrate the highly interactive organization of the brain. Because operations in the brain require the participation of various brain areas, a model that does not require a one-to-one relationship between the physical and mental, but rather allows an association between clusters of physical processes and one or more mental phenomena, may reflect better the relation between physical brain phenomena and mental activities. | 2 |
Dipyridamole perfusion scintigraphy: the experience with its application in one hundred seventy patients with known or suspected unstable angina. We evaluated the safety, accuracy, and potential clinical utility of intravenous dipyridamole perfusion scintigraphy with thallium-201 in 170 patients, 78 with suspected and 92 with known unstable angina. All had coronary angiography. Noncardiac side effects (26%), induced chest discomfort (44%), and ST segment changes (12%) were similar in the two groups. No significant arrhythmias occurred. Two patients had prolonged chest pain, both with extensive reversible image abnormalities and associated creatinine kinase-MB release. Both had elective bypass surgery. Twenty-eight patients had normal coronary arteries, and 35 had single-vessel disease. Scintigraphic per patient sensitivity and specificity were 91% and 79% with a per vessel sensitivity of 74% and a per vessel specificity of 78% without between-group differences. During a brief follow-up period, 62 patients with image abnormalities had coronary revascularization, and there were seven deaths without intergroup differences. In a similar patient group that did not have angiography, scintigraphic defects were less frequent and less extensive, revascularization was not performed, and subsequent deaths occurred less often. Dipyridamole perfusion scintigraphy is an accurate alternative to exercise testing in the evaluation of patients with unstable angina pectoris. Although not without risk, the method appears relatively safe and should be considered as a guide to diagnosis, and probably to prognosis and management. | 3 |
Syphilitic meningomyelitis. A 28-year-old nonimmunocompromised man developed secondary syphilis confirmed by serum and CSF findings. His course was complicated by chorioretinitis, extensive skin lesions, and spastic paraparesis secondary to syphilitic meningomyelitis. MRI of the spinal cord was strikingly abnormal. | 2 |
Nonsquamous tumors of the head and neck in the geriatric population. Thyroid tumors, salivary gland tumors, and non-Hodgkin's lymphoma are described. Psychosocial issues involving the geriatric patient are discussed. Case reports of a number of geriatric tumor patients are included. | 0 |
Evaluation of WC3 rotavirus vaccine and correlates of protection in healthy infants. The safety, immunogenicity, and efficacy of WC3 rotavirus vaccine was evaluated in a double-blind, placebo-controlled trial of healthy infants 2-12 months of age; 103 received one dose of vaccine and 103 received placebo. Vaccination appeared to be safe and induced an antibody response (WC3 neutralizing antibody) in 97% of vaccinees. Only 9 (9%) of these, however, produced antibody to human rotavirus serotypes; at least 7 of the 9 were naturally infected before vaccination. Neither the number of symptomatic episodes of rotavirus diarrhea (21 vs 25) nor the number of moderate to severe rotavirus illnesses (9 vs. 15) was significantly different in vaccine or placebo recipients, respectively, during a predominantly serotype 1 rotavirus season. A slight but significant decrease in mean symptom score was detected in vaccine recipients. Despite an overall lack of efficacy, protection could be correlated to previous rotavirus infection, high levels of WC3 neutralizing antibody, and preexisting (maternal) serotype 1 neutralizing antibody with a titer greater than or equal to 30. | 1 |
Evolution of human cardiac myocyte dimension during prolonged mechanical support. In animal models using left ventricular assist systems over long time periods, myocardial cellular atrophy has been reported, raising concern that prolonged clinical use of such systems might lead to deterioration in left ventricular function. At the University of Pittsburgh, long-term clinical use of the Novacor (Baxter Healthcare Corp., Novacor Div., Oakland, Calif.) left ventricular support system for patients awaiting heart transplants has allowed study of the effects of long-term mechanical support on human subjects. This study determined that cardiac myocyte dimension is initially greater in patients with end-stage cardiac disease who require support rather than in patients with the same disease who do not require such support. Although myocyte dimension does decrease within a few days of the inception of support, this decrease merely brings cell size closer to the values usual in patients with chronic end-stage cardiac disease, and no further shrinkage is observed. Thus the Novacor left ventricular assist system does not appear associated with left ventricular atrophy, and its long-term use may not be detrimental to left ventricular function. | 3 |
Caffeine and ventricular arrhythmias. An electrophysiological approach. Little information is known regarding caffeine's effect on the substrate supporting sustained ventricular arrhythmias. This prospective study evaluated the effect of coffee (275 mg of caffeine) on this substrate with programmed ventricular stimulation in 22 patients with a history of symptomatic nonsustained ventricular tachycardia, ventricular tachycardia, or ventricular fibrillation. Patients underwent electrophysiological testing before and 1 hour after coffee ingestion. Mean (+/- SEM) plasma caffeine level achieved after coffee consumption was 6.2 +/- 0.5 mg/L. Mean plasma catecholamine and potassium values were not altered significantly 1 hour following caffeine ingestion. The number of extrastimuli required to induce an arrhythmia was unchanged in 10 patients (46%), increased in six (27%), and decreased in six (27%). Rhythm severity was unchanged in 17 patients (77%), more severe in two (9%), and less severe in three (14%). In those patients with clinical ventricular arrhythmias, caffeine did not significantly alter inducibility or severity of arrhythmias, suggesting little effect on the substrate supporting ventricular arrhythmias. | 4 |
Recurrent peripheral facial nerve palsy after dental procedures. Peripheral facial palsy is an uncommon complication of dental procedures. Most cases begin immediately after dental anesthesia and resolve within 12 hours. No report of recurrent facial palsy with dental manipulations has previously been described. We report a patient with two episodes of peripheral facial palsy, 2 years apart, developing within 24 hours of dental procedures. A third episode of contralateral facial weakness developed 3 years after the second event. This event was not related to dental manipulations. Although the exact mechanism is not known, dental manipulations may rarely result in precipitation of recurrent Bell's palsy. | 4 |
The relationship between bone morphogenetic protein and neoplastic bone diseases. The monoclonal antibody against bovine bone morphogenetic protein was used for demonstration of bone morphogenetic protein (BMP) in neoplastic bone diseases. The avidin-biotin-peroxidase complex method demonstrated that BMP mainly exists in the cytoplasm of tumor cells of osteosarcoma and chondrosarcoma. Immunostaining showed that a majority of osteosarcomas and all of the chondrosarcoma cells contained a large quantity of BMP. Conversely, none of the fibrosarcomas showed positive staining. Thus, it was possible to differentiate osteosarcomas from fibrosarcomas by immunostaining. In fibrous dysplasia of bone, BMP was abundant in the fibrocellular tissue that had osteogenic activity. In contrast, fibrous tissue of ossifying fibroma showed weak positive staining; only the osteoblasts rimming the bone showed a positive reaction. Immunostaining showed that BMP was also detected in other neoplastic bone diseases such as osteoma, chondroma, and other tumors. | 0 |
Pregnancy outcome after inadvertent ivermectin treatment during community-based distribution. Ivermectin is the drug of choice for community-based treatment of onchocerciasis. Since pregnancy testing during mass distribution campaigns is not feasible, the safety of ivermectin in pregnancy must be established. During a 3-year study, ivermectin was distributed to the population of a rubber plantation (14,000 people) in Liberia. Only 31% of women were aware of their pregnancy status during the first month; it was calculated that about half of women in the first trimester of pregnancy are likely to be treated inadvertently. 203 children born to women inadvertently treated during pregnancy were identified. In this limited sample, there was no significant difference in birth defects between treated and untreated mothers in the same population or compared with a reference population. Children of treated and untreated mothers showed no difference in developmental status or disease patterns. Further surveillance is necessary; however, since no major effects of ivermectin on pregnancy outcome were detected, there seems no need to change existing strategies of ivermectin distribution. | 4 |
Outcome of cataract surgery in central India: a longitudinal follow-up study. An epidemiological follow-up study of patients who had intracapsular cataract extraction in a voluntary hospital and its associated eye camps in Central India has for the first time evaluated the outcome one year after surgery in terms of visual acuity, use of spectacles, and improvement in income and mobility. The findings indicate that under these fairly typical conditions, 92% of the cases have adequate vision of 6/18 or better one year after surgery. Information on high usage of spectacles and on considerable improvements in income and mobility after cataract surgery is also reported. The outcome for patients operated upon in eye camps was almost as favourable as for those operated upon in hospital. Although the small differences are not statistically significant, the comparative findings require cautious interpretation and give rise to the epidemiological issues which are briefly discussed in this paper. | 2 |
Unusual cerebral manifestations in hereditary fructose intolerance. Five children with hereditary fructose intolerance developed symptoms of neurological impairment. In three of them, neurological involvement was related to the acute hepatic toxicity of fructose (hypoglycemia, abnormal coagulation, cardiovascular collapse); in the other two, such a relationship could not be demonstrated. Neurological impairment is not classic in hereditary fructose intolerance, but its occurrence in the acute phase of the disease is possible and does not constitute an argument against the diagnosis. | 4 |
HTLV-I viral-associated myelopathy after blood transfusion in a multiple trauma patient. This may be the first documented case in the United States and in the orthopedic literature of transfusion-transmitted human T-cell leukemia virus Type I (HTLV-I)-associated myelopathy (HAM). Progressive myelopathy occurred in a 58-year-old white man with serologic and molecular evidence of HTLV-I infection after multiple trauma and subsequent transfusion with multiple units of banked blood products. Symptoms of myelopathy occurred 15 months after the transfusions. Myelopathy from HTLV-I infection simulates a disorder of orthopedic interest. Physicians should be aware of the symptoms of HAM and unexplained myelopathy. | 2 |
Early diagnosis of breast cancer. Universal screening is essential. Breast cancer strikes 1 in 10 women in the United States. Early diagnosis of breast cancer improves chances of survival. With universal screening and expert evaluation of early clinical signs and symptoms of breast cancer, mortality rates can be reduced by 30% to 40%. Physicians can help achieve this goal by taking an active role in patient education and promoting the availability of affordable screening mammography. | 0 |
Effect of dietary alpha-linolenic acid on growth, metastasis, fatty acid profile and prostaglandin production of two murine mammary adenocarcinomas. The purpose of this study was to determine whether dietary (n-3) fatty acids would affect mammary tumor growth and metastasis. Weanling female BALB/c mice were fed diets that contained 10% corn oil (CO), linseed oil (LO) or a fish oil-corn oil mix (FO) for 3-8 wk prior to receiving subcutaneous injections of one of two syngeneic mammary tumor cell types (410 and 410.4). Tumor growth was assessed by monitoring mean tumor diameter and tumor weight upon removal. Feeding LO, but not FO, reduced the growth (p less than 0.05) of 410.4 mammary tumors compared with growth in those fed CO. Metastasis data paralleled the tumor growth rate. Feeding LO and FO enhanced (p less than 0.005) incorporation of (n-3) fatty acids into tumors. Tumor prostaglandin E (PGE) production was reduced (p less than 0.005) by LO and FO, compared with CO. FO feeding reduced 410.4 tumor PGE synthesis more (p less than 0.05) than LO feeding, yet tumor growth was only inhibited by LO. These data suggest an inhibitory effect of dietary linolenic acid [i.e., 18:3 (n-3)] on mammary tumor growth and metastasis. However, this effect did not directly correlate with diet-induced changes in PGE synthesis. | 4 |
The tall cell variant of papillary carcinoma of the thyroid gland. Comparison with the common form of papillary carcinoma by DNA and morphometric analysis. The tall cell variant of papillary carcinoma of the thyroid manifests a more aggressive behavior than the usual form of papillary carcinoma of the thyroid. Morphometric analysis of nuclear features and DNA analysis may yield information predictive of aggressive behavior. Accordingly, the DNA content and morphometric features of the neoplastic cells of the tall cell variant were measured and compared with measurements obtained from neoplastic cells of the usual form of papillary carcinoma. Six of the 11 tall cell neoplasms were aneuploid, as were four of the eight usual papillary neoplasms. Although benign cells were separated from malignant cells in each case, differences between tall and usual papillary carcinoma cells were not observed regarding DNA content, chromatin texture, or nuclear size and shape. Differences in the clinical behavior of these neoplasms will likely need to be explained on the basis of other characteristics. | 0 |
Toxic dermatitis induced by 10-ethyl-10-deaza-aminopterin (10-EdAM), a novel antifolate. A new methotrexate analog, 10-ethyl-10-deaza-aminopterin (10-EdAM), was found to induce a particular form of skin toxicity different than the skin rash reported to result from methotrexate. At histologic examination, it was found to be a toxic dermatitis that clinically most often first appears on the lower legs but can occur anywhere in the body, especially if treatment is continued. Nine cases are reported. A specific risk factor could not yet be identified. Discontinuation of 10-EdAM administration leads to complete healing; concomitant corticosteroid treatment also induces healing. | 0 |
One-stage repair of colovaginal fistula complicating acute diverticulitis. Fourteen patients with colovaginal fistula secondary to sigmoid diverticulitis were seen between 1964 and 1988. Thirteen had undergone prior hysterectomy. Three different operative approaches were used. Three patients were treated with colostomy alone; one died and the fistula persisted in one. Five patients underwent staged procedures. One patient died of complications after the second stage of a planned three-stage procedure. Four patients underwent a two-stage procedure (fistula takedown, colectomy with colostomy and colostomy closure), all with good results. Six patients were treated with one-stage fistula takedown, colectomy and primary anastomosis, without major complication. We advocate this as the procedure of choice and emphasize the following principles of epidemiology and management: 1) colovaginal fistula complicates diverticulitis in elderly women usually following hysterectomy; this association may be a factor in etiology; 2) vaginography is useful in diagnosis; and 3) planned one-stage repair is the best surgical approach. | 4 |
Biomechanics of a double prosthetic ligament in the anterior cruciate deficient knee. We have assessed the biomechanical properties of a 'double-bundle' prosthetic ligament replacing the anterior cruciate in cadaver knees. We compared the results with those of single bundle 'over-the-top' and 'through-the-condyle' techniques, performing anterior drawer tests at 20 degrees and 90 degrees knee flexion. The over-the-top reconstruction gave better anteroposterior stability at 20 degrees, while the through-the-condyle repair was more stable at 90 degrees. The double-bundle reconstruction gave practically normal anterior stability at both 20 degrees and 90 degrees. | 4 |
The severity of coronary atherosclerosis at sites of plaque rupture with occlusive thrombosis. Atherosclerotic plaque rupture with superimposed thrombosis is recognized as the lesion causing greater than 90% of acute myocardial infarctions. To determine the severity of atherosclerosis at the site of plaque rupture, 184 coronary arteries from autopsies of 162 patients who died of acute myocardial infarction were studied. There were 102 men, 72 +/- 10 years old (mean +/- SD), and 60 women, 75 +/- 8 years old. All arteries were dissected from the heart, fixed, decalcified, cut at 2 to 3 mm intervals and processed routinely for histologic examination. A planimeter was used to measure artery, plaque, thrombus and luminal cross-sectional area at the site of plaque rupture with thrombosis in sections projected at x13.8 magnification. At the site of atherosclerotic plaque rupture with superimposed thrombosis, the degree of stenosis due to plaque was: 90 +/- 7% for the right (n = 67), 91 +/- 6% for the left anterior descending (n = 79) and 91 +/- 6% for the left circumflex (n = 38) coronary arteries. Plaque rupture in fatal acute myocardial infarction occurs at sites of severe narrowing (mean 91%, range 67% to 99%). Thus, plaque rupture with thrombosis is unlikely to cause the fatal acute myocardial infarction in patients with mild to moderate coronary stenosis. | 4 |
Elective diagnostic laparoscopy. Laparoscopy developed as a science at the turn of the century, and many scientists assisted in the evolution of this technique. However, it was many years before the multiple trocar system was developed that allowed internal organs to be moved and biopsies to be obtained. This has led to the development of numerous indications for elective diagnostic laparoscopy. Adequate preparation and attention to instrumentation ensure the safety of this operation. Elective diagnostic laparoscopy is a useful adjunct to many other diagnostic modalities such as, for instance, the assessment of abdominal pain, abdominal masses, fever of unknown origin, and gastrointestinal bleeding. In many other circumstances, such as the assessment of oncology cases, this modality is superior to conventional radiology because biopsy specimens may be obtained. If the procedure is correctly performed, the diagnostic yield is extremely high and the morbidity and mortality are low. The role of this important technique should not be underestimated by today's practicing surgeon. | 4 |
Crystal-storing histiocytosis and crystalline tissue deposition in multiple myeloma [published erratum appears in Arch Pathol Lab Med 1991 Aug;115(8):806] Systemic distribution of crystal-storing histiocytes, increasing in number, and widespread crystalline tissue deposition were found in a 75-year-old man with a 5-year history of IgG-kappa-type multiple myeloma associated with corneal opacity and chronic renal failure. Characteristic crystalline inclusions were present not only in myeloma cells but also in cornea, epithelial cells of glomeruli, tubuli, Bowman's capsules, and choroid plexus. Histiocytes had particularly infiltrated the renal interstitium. These inclusions were positive by immunofluorescence for kappa light and gamma heavy chains. By electron microscopy, the inclusions were filled with fine crystalline hexagonal columns, each possessing a core structure. Of various factors generally considered responsible for renal failure in multiple myeloma, marked infiltration of histiocytes and the nephrotoxic effects of light chain appeared most relevant in the present case. | 0 |
Neuropathological changes in transgenic mice carrying copies of a transcriptionally activated Mos protooncogene [published erratum appears in Proc Natl Acad Sci U S A 1991 May 1;88(9):4060] Independent transgenic mouse lines carrying the mouse Mos protooncogene linked to a retroviral transcriptional control sequence display behavioral abnormalities including circling, head tilting, and head bobbing. This dominant phenotype shows various degrees of penetrance in different transgenic founder animals and lines. Neuronal and axonal degeneration, gliosis, and inflammatory infiltrates are found in all transgenic mouse lines in which behavioral traits are present. Recordings of auditory-evoked potentials in mice of one of these lines demonstrate that transgenic mice are deaf; in these mice spiral ganglia degenerate and most of the cochlear hair cells are absent. By using an S1 nuclease protection assay, we have detected RNA expression of the transgene in all tissues examined and, in particular, at high levels in brain. In situ hybridization experiments show that Mos expression can be detected in specific areas of the central nervous system. Lesions are present in areas with demonstrable overexpression of Mos. | 2 |
Seizures in the alcoholic patient. The First International Symposium on Alcohol and Seizures (September 1988, Washington, DC) convened experts from North America and Europe to discuss the basic and clinical research findings in this field. Most of the observations communicated at this symposium are included in this article. Emergency physicians are familiar with the alcoholic patient who presents during or after a seizure(s). This familiarity must not obscure the fact that a significant minority of these patients will have an underlying process that can cause morbidity or mortality if the unsuspecting physician does not have an organized and methodic approach to the evaluation and management of the seizing alcoholic patient. Status epilepticus should be evaluated and treated in a similar fashion, whether or not the patient is an alcoholic. Otherwise, almost without exception, there are nuances and controversies with respect to the evaluation and management of the alcoholic patient with a seizure(s), from the indications for CT scan, to the proper role of sedatives and anticonvulsants, and the need for admission. The emergency physician must remain a patient advocate. The great majority of alcoholic patients with seizures who require admission can be treated satisfactorily at the hospital of presentation. | 2 |
Chronic headache associated with a functioning shunt: usefulness of pressure monitoring. Chronic headaches in a shunt-dependent patient with small ventricles has long been treated with little or no regard to intracranial pressure. In this study, pressure monitoring on 12 such patients demonstrated that they fell into three distinct categories: 3 had headaches caused by intracranial hypertension, 2 had headaches from hypotension, and 7 showed no relation of symptoms to pressure. As therapeutic procedures for treating these three categories are entirely different and sometimes opposing, it is clear that intracranial pressure monitoring is essential to successful management of this complaint. | 2 |
Chronic diarrhea in essential mixed cryoglobulinemia: a manifestation of visceral vasculitis? Gastrointestinal involvement occurs frequently in essential mixed cryoglobulinemia, and most often involves the liver and spleen. Intestinal involvement is much less common and is generally felt to be a late and often catastrophic manifestation of the disease due to severe vasculitis. Occasionally, the disorder mimics inflammatory bowel disease, both clinically and radiographically. We recently cared for a patient with essential mixed cryoglobulinemia who developed persistent diarrhea. Endoscopic evaluation revealed scattered petechial lesions in the duodenum and colon as well as prominent lymphoid hyperplasia in the terminal ileum. Mucosal biopsies disclosed the presence of diffuse inflammation. We suggest that this patient's diarrhea was due to intestinal vasculitis and that prominent ileal lymphoid hyperplasia may be a manifestation of essential mixed cryoglobulinemia. | 4 |
Gastric contents retained in rat stomach following mild irritant exposure contribute to adaptive cytoprotection. Fluid retained in the gastric lumen immediately preceding the administration of a damaging product will dilute that product and decrease its injurious capacity. In an attempt to explain the phenomenon of adaptive cytoprotection, we studied the effect of mild irritant exposure on the volume of fluid retained in the gastric lumen. Rats treated with 0.2 N-0.4 N HCl had a larger volume of gastric fluid retained as compared to animals treated with 0.4 N NaCl. Additionally, a mixture of gastric juice derived from rats exposed to 0.4 N HCl with 2 ml ethanol was significantly less damaging to the gastric mucosa than a similar mixture containing an equal volume of gastric juice derived from 0.4 N NaCl-exposed rats. We conclude from our observations that in mild irritant-exposed stomachs, the gastric juice is a main contributor to the protection against ethanol injury. | 1 |
Low plasma iron status and akathisia. Thirty patients were examined to test the hypothesis that a depletion of iron levels is associated with symptoms of akathisia. Fifteen akathisic patients were pair-matched with 15 non-akathisic patients. Plasma ferritin levels were significantly decreased in the akathisic patients, and there was a significant inverse correlation between plasma iron levels and akathisia rating. In addition, akathisia ratings were found to be correlated with a scale measuring symptoms of tardive dyskinesia. | 2 |
Prolonged intermittent clamping of the portal triad during hepatectomy. From 112 consecutive hepatectomies for malignant tumours performed with intermittent portal triad clamping, we have retrospectively selected the 20 cases in which clamping exceeded 90 min. Intermittent portal clamping of prolonged duration was used because of abnormal liver texture in 13 cases (mainly patients who had received intra-arterial chemotherapy) and/or because of technically difficult hepatectomy. The mean(s.d.) duration of intermittent portal clamping was 109(18) min and in two cases it exceeded 140 min (148 and 150 min). There was no postoperative mortality and the rate of postoperative morbidity was 35 per cent. Postoperative changes in biochemical liver tests were not major and transient hepatic failure occurred in only one patient following subtotal resection of the liver. We conclude that intermittent portal clamping is a useful manoeuvre in partial hepatectomy when resection is difficult or prolonged, or when the liver parenchyma is abnormal. Such clamping may be used for longer than 120 min without major complications. | 0 |
DNA ploidy pattern in rectal carcinoid tumors. The nuclear DNA pattern of 22 rectal carcinoids was determined by cytophotometry of paraffin embedded tissues. The results were compared with clinical as well as histopathologic features of the tumor. Three of the carcinoids with synchronous or metachronous metastasis had aneuploid DNA pattern, whereas 19 tumors with no metastasis showed diploid DNA pattern. No other single clinical or pathologic feature of the tumor could predict more accurately the malignant potential and the subsequent course of the rectal carcinoid. It is concluded that DNA aneuploidy in rectal carcinoid tumors is not so rare as indicated by earlier studies and that it is a factor of significant prognostic value. | 4 |
Cyst of the choroid plexus in the lateral ventricle: case report and review of the literature. We report an intraventricular cyst in a 2-year-old boy who had myoclonic jerks of the extremities. The cyst had no communication with the ventricular system or subarachnoid space. Total removal of the cyst adhering to the choroid plexus was accomplished. The glial cyst wall was lined in part by flattened or cuboidal epithelium. The preoperative and postoperative computed tomographic scans and magnetic resonance images are presented, and congenital benign cysts in the lateral ventricle are reviewed and discussed. | 4 |
Surgical staples in cesarean section: a randomized controlled trial. This randomized controlled trial compares the use of the Auto Suture Poly CS 57 disposable surgical stapler (n = 98) with standard hysterectomy (n = 102) in low transverse cesarean sections. Subjective assessment of blood loss by the surgeon resulted in lower mean (+/- SEM) total blood loss estimates in the stapled group (492 +/- 24 ml) than in the nonstapled group (579 +/- 38 ml) (p = 0.05). However, surgeon's estimation of blood loss as a result of the hysterotomy and blood loss estimated by the hemoglobin deficit measured on the second postoperative day did not significantly differ between the two groups. The use of the stapling device tended to lengthen the total operating time, which averaged 42.5 minutes in the group with the staples and 39.2 minutes in the group with the standard hysterotomy (p = 0.05). The risk of febrile morbidity, the frequency of endometritis, and the length of hospitalization were similar in the two groups. Our results do not support the routine use of the Auto Suture Poly CS 57 disposable surgical stapler in low transverse cesarean sections. | 4 |
Imaging of tumor in patients with indium-111-labeled biotin and streptavidin-conjugated antibodies: preliminary communication Tumor localization in patients has been achieved through the in vivo use of streptavidin and biotin. In these preliminary studies, the monoclonal antibody HMFG1 was conjugated with streptavidin and 1 mg was administered intravenously to each of 10 patients with documented squamous cell carcinoma of the lung. Two to 3 days later, 111In-labeled biotin was also administered intravenously. No evidence of toxicity was observed. Background radioactivity levels were reduced in liver (1% ID at 24 hr) and kidneys (2%) and in all other normal tissues and blood. Images of lung tumor were obtained in as little as 2 hr following administration of labeled biotin. In eight patients, tumor was detected with labeled biotin alone without the previous administration of streptavidin-conjugated antibody but in three of these patients, the images were improved with the prior administration of conjugated antibody. These results suggest that this approach may improve the tumor-to-normal tissue radioactivity ratios in radioimmunotargeting. | 0 |
Primary central nervous system lymphoma in a pediatric patient with acquired immune deficiency syndrome. Treatment with radiation therapy. Primary central nervous system (CNS) lymphoma, an otherwise rare pediatric tumor, has been reported with increasing frequency in children with acquired immune deficiency syndrome (AIDS). With current therapy, the outcome of this disease is invariably fatal. The authors present a case of primary CNS lymphoma in a 3.5-year-old girl with AIDS who received treatment with total brain irradiation. After treatment, the patient's mental status improved, the seizures resolved, and she had no further progression of her neurologic symptoms until she died of pneumonia 6 months later. The autopsy revealed a necrotic mass at the site of the original tumor. The brain stem and spinal cord, unirradiated, contained lymphomatous lesions. The patient had extensive fibrinoid necrosis and leukoencephalopathy that were consistent with radiation-induced CNS damage. Coexisting AIDS encephalopathy also contributed to the patient's CNS injury. Effective palliation of CNS lymphoma in children with AIDS may be obtained with cranial irradiation. Pediatric AIDS patients may show more severe tissue effects from irradiation than unaffected children. | 0 |
Endoscopic and radiographic evaluation of the murine colon. Endoscopic and radiographic techniques have not been widely applicable in the evaluation of chemically induced murine colon cancer. The authors investigated methods of cleansing the rat colon and refined endoscopic and radiographic techniques. They compared total colonoscopy (TC) and air-contrast (ACBE) and single-contrast barium enema (SCBE) findings with those obtained at necropsy in rats with 1,2-dimethylhydrazine (DMH)-induced colon cancer. Gastrograffin enemas with bisacodyl suppositiories showed complete evacuation of solid feces. Sprague-Dawley rats treated with DMH had their colons cleansed and then underwent TC (5.0-mm Olympus bronchoscope) and either SCBE or ACBE. Colonoscopy and ACBE were equally sensitive (81.5% and 76.3%, respectively), although SCBE was significantly insensitive in identifying lesions (P less than 0.001). This study demonstrates that: (1) mechanical cleansing of the rat colon is feasible, (2) TC and barium radiology can be done routinely after mechanical cleansing, and (3) TC and double-contrast BE are sensitive in identifying colon lesions. These techniques will provide a means for manipulation of murine tumors and in vivo surveillance. | 0 |
Closed heart cryoablation of the His bundle using an anterior septal approach. His bundle cryosurgical ablation using a closed heart anterior septal approach was used in 6 patients. There were 3 men and 3 women, aged 24 to 73 years. Three patients had atrial fibrillation and 2 patients had atrial flutter (2 with combined episodes of atrial tachycardia). One patient had atrial tachycardia. Five patients had no structural heart disease and 1 patient had left ventricular dilatation (ejection fraction, 0.35). All patients undergoing His bundle cryosurgical ablation had permanent heart block without intraoperative complications (mean follow-up, 25 months). Closed heart anteroseptal cryoablation of the His bundle is effective and is an alternative to attempted catheter ablation. | 3 |
Diagnosing Staphylococcus aureus endocarditis by detecting antibodies against S. aureus capsular polysaccharide types 5 and 8. Consecutive serum samples from patients with Staphylococcus aureus endocarditis or septicemia or non-S. aureus endocarditis and febrile nonsepticemic controls were tested for antibodies against S. aureus capsular polysaccharide (CP) types 5 and 8 by ELISA. The upper normal antibody levels were defined as the upper 99.5% confidence limits of the values from the febrile controls. All available patient isolates were tested for the presence of CP type 5 or 8 (85% of the isolates expressed either serotype), and all five patients with S. aureus endocarditis had positive antibody levels against the corresponding serotype within the first 10 days of infection. Three other endocarditis patients lacked isolates for CP testing but two of these were positive. Positive antibody levels were found in 0 of 28 septicemia patients, in 1 of 12 non-S. aureus endocarditis patients, and in 3 of 37 febrile controls. Thus, testing for anti-CP 5 or 8 antibodies, especially together with CP serotyping of the patient's isolate, seems to provide important information in the differential diagnosis of endocarditis in patients with S. aureus septicemia. | 3 |
Crohn's disease and pregnancy. Seventy-eight pregnancies in 50 patients were reviewed to evaluate the effects of Crohn's disease on the outcome of pregnancy and the influence of the pregnancy on the course of Crohn's disease. Overall, 21 pregnancies (27 percent) had abnormal outcomes including spontaneous abortions (9), infants small for gestational age (6), premature infants (5), and infants who developed respiratory distress (1). Eight (50 percent) patients with active disease compared with 13 (21 percent) patients with inactive disease at conception had abnormal outcomes (P less than 0.05). During pregnancy 15 (55 percent) with active disease and 6 (12 percent) with inactive disease had an abnormal outcome (P less than 0.001). Neither medical nor surgical treatment, independent of disease activity, appeared to affect the outcome adversely. Eighteen of 73 (25 percent) patients with quiescent or mild disease relapsed, and seven of 16 patients with some disease activity improved (44 percent). Of 34 patients on medication, nine relapsed (27 percent), and of 39 patients not on medication, nine relapsed (24 percent) (P = N.S.). These results suggest that the outcome of pregnancy is not adversely affected by Crohn's disease. However, patients with active disease at conception and/or during the pregnancy have poorer outcomes independent of the use of medication or requirement of surgery. Neither pregnancy nor medications taken affect the course of the disease. | 1 |
Reversed lateralization of cognitive functions in right handers. Exceptions to classical aphasiology. Most current and past research on the cerebral organization of cognitive functions has presupposed certain specialized hemisphere operations. At least for right handers, language and praxis are to be organized in the left hemisphere, while affective prosody, configurational spatial capacity, and global attention are lateralized in the right hemisphere. Deviations from these presuppositions, as in crossed aphasics and perhaps left handers, are generally considered to be 'exceptions' and either to disprove the rules or to be irrelevant to the rule. We report 4 very 'exceptional' cases, right handers with almost entirely reversed lateralization of functions. Analysis of the intrahemispheric relationships between functions suggests that there may be a specific neurobiology to the interrelationships between and among cognitive functions, handedness, and the intrahemisphere localization of the function. | 4 |
Extracorporeal piezoelectric lithotripsy for complicated bile duct stones. Today, common bile duct stones are extracted endoscopically. After endoscopic sphincterotomy, nearly 90% of all stones can be removed with a Dormia basket or a mechanical lithotripter. Problems are encountered if there are larger stones or a duct stenosis. New conservative therapies do serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. Stone fragmentation can be achieved by extracorporeal shock wave lithotripsy, and remaining fragments can be removed endoscopically. So far, authors of most reports on the successful disintegration of common bile duct stones used the Dornier lithotripter. Stone localization is thus achieved with x-rays, and the shock waves are generated by an underwater spark discharge. We report on our experiences and results with extracorporeal piezoelectric shock wave lithotripsy (EPL) in 19 patients with complicated bile duct stones. With this lithotripter, stones are visualized by ultrasound, and shock waves are produced by a piezoelectric acoustic generator. Fragmentation was achieved in 84.2%, and complete stone removal in 78.9%. These results show that piezoelectric lithotripsy is also a useful method for the treatment of complicated bile duct stones, as has already been proved for the electrohydraulic- and electromagnetic-generated shock waves systems. However, the renunciation of general anesthesia and the need for analgesia or sedation in only 25% of the treatments render this lithotripter system attractive, especially for elderly and frail patients. | 1 |
Glomus tumours of the skin: an immunohistochemical investigation of the expression of marker proteins. Immunohistochemical studies were carried out on cutaneous glomus tumours from 10 patients. The glomus areas in these tumours reacted strongly with anti-smooth muscle (CGA-7), anti-muscle (HHF-35) and anti-vimentin antibodies. Their neural supply was analysed using several nervous tissue markers (anti-neurone specific enolase, anti-S 100, anti-Leu 7, anti-neurofilaments). The results indicate a sprouting and proliferation rather than entrapment of pre-existing nerve fibres. | 0 |
A vascular malformation mimicking an intracanalicular acoustic neurilemoma. Case report. A patient with an enhancing, completely intracanalicular mass on magnetic resonance imaging was operated on for a presumed acoustic neurilemoma, but was found at surgery to have an intracanalicular vascular malformation. This rare lesion should be distinguished from angiomatous change within an acoustic neurilemoma and in the past has been termed "vascular tumor," "hemangioma," or "fibro-angioma." The clinical distinctions between intracanalicular acoustic neurilemomas and intracanalicular vascular malformations and the ability of magnetic resonance imaging to distinguish between the two are discussed. | 2 |
Evidence for decreased coronary flow reserve in viable postischemic myocardium. To try to unravel the complexity and heterogeneity of the "no-reflow" phenomenon and its underlying mechanisms, we studied tissue perfusion in reperfused heart muscle by using tracer microspheres in an anesthetized dog model of 90-minute coronary occlusion followed by reperfusion for 2 1/2 hours, 24 hours, or 1 week. Regional myocardial blood flow was determined both in basal flow conditions and during reactive hyperemia. The effect of intracoronary adenosine administration was examined, and the ultrastructure of postischemic myocardium was analyzed. In viable reperfused tissue (as delineated by triphenyltetrazolium chloride staining), reflow in basal conditions is unimpaired. Coronary flow reserve (as approximated by peak reactive hyperemic flow) is intact at the start of reperfusion, decreases by more than half after 2 1/2 hours, and recovers completely within 1 week. This impairment of coronary reserve can be relieved by intracoronary adenosine administration. On ultrastructural examination, the capillaries are patent. On the other hand, in irreversibly damaged myocardium, both the basal reflow impairment and the decrease in coronary flow reserve are severe and permanent. Coronary flow reserve is already decreased at the start of reperfusion, and the pharmacological intervention has no beneficial effect. Ultrastructurally, extracellular and intracellular edema invariably are present, whereas the vascular endothelium is damaged and the capillaries are packed with red blood cells. We conclude that the no-reflow phenomenon (i.e., mechanical obstruction to blood flow) is limited to infarcted tissue. In viable myocardium, however, coronary flow reserve is transiently diminished, probably because of washout and subsequent insufficient availability of the chemical mediator adenosine after breakdown and slow recovery of the precursor ATP pool. | 3 |
Long-term memory of acute postsurgical pain. The long-term memory of acute postoperative pain intensity was evaluated in a population of patients who had undergone the removal of impacted third molar teeth. The results suggest a positive correlation between experienced and remembered intensities of postsurgical pain for up to 3 years after surgery. They also suggest that males and females do not differ significantly in their reports of postsurgical pain intensity, nor do they differ significantly in their memories of pain intensity. Pain recall using verbal pain descriptors was more reliable than recall with visual analog scales. Patient reports of intensity of past postsurgical acute pain, particularly those reports obtained with verbal descriptors, may be useful in the planning of treatment and in the selection and evaluation of analgesic regimens. | 4 |
Shunt surgery for hydrocephalus in tuberculous meningitis: a long-term follow-up study. Hydrocephalus is a common complication of tuberculous meningitis. Case studies of 114 patients with tuberculous meningitis and hydrocephalus, who underwent shunt surgery between July, 1975, and June, 1986, were reviewed to evaluate the long-term outcome and to outline a management protocol for these patients based on the results. Seven factors were studied in each case: 1) age at admission; 2) grade on admission (I to IV, classified by the authors; Grade I being the best and Grade IV being the worst); 3) duration of alteration of sensorium; 4) cerebrospinal fluid (CSF) cell content at initial examination; 5) CSF protein levels at initial examination; 6) number of shunt revisions required; and 7) the necessity for bilateral shunts. During a long-term follow-up period ranging from 6 months to 13 years (mean 45.6 months), the mortality rate was 20% for patients in Grade I; 34.7% for patients in Grade II; 51.9% for patients in Grade III; and 100% for patients in Grade IV. Only the grade at the time of admission was found to be statistically significant in determining final outcome (p less than 0.001). Based on these results, the authors advocate early shunt surgery for Grade I and II patients. For patients in Grade III, surgery may be performed either if external ventricular drainage causes an improvement in sensorium or without selection. All patients in Grade IV should undergo external ventricular drainage and only those who show a significant change in their neurological status within 24 to 48 hours of drainage, should have shunt surgery. | 2 |
Positive results of combined therapy of surgery and intraperitoneal hyperthermic perfusion for far-advanced gastric cancer. To evaluate the clinical efficacy of intraperitoneal hyperthermic perfusion (IPHP) for far-advanced gastric cancer, particularly with peritoneal seeding, we investigated the survival times of 59 patients who underwent distal subtotal gastrectomy, total gastrectomy, or total gastrectomy combined with concomitant resection of some of the remaining intra-abdominal organs. In all the 30 patients given IPHP, no cancer cells were present posthyperthermically in the lavage from the Douglas pouch. The 30 patients given IPHP lived longer than the 29 patients not given IPHP (p = 0.001), with a 1-year survival rate of 80.4% in the former group compared to 34.2% in the latter. With respect to a comparison of survival time of patients with peritoneal seeding, 7 patients not given IPHP had a 6-month survival rate of 57.1% and did not survive more than 9 months, whereas 20 patients given IPHP had 1- and 2-year survival rates of 78.7% and 45.0%, respectively; here the difference was significant (p = 0.001). The IPHP and control groups without peritoneal metastasis included 10 and 22 patients, respectively, and the 1-year survival rates are 85.4% and 45.3%, respectively. The survival rates of the former exceeded those of the latter, with p = 0.015 by the generalized Wilcoxon test. Thus this combined therapy offers the promise of extended survival for patients with far-advanced gastric cancer. | 0 |
Management of dysphagia in suspected esophageal motor disorders Fifty-three patients suffering from dysphagia because of suspected esophageal motor disorders were treated by pneumatic dilatation using the Rider-Moeller technique. Fifteen had achalasia demonstrated by manometric studies. Forty-nine of them had remarkable clinical improvement after the procedure. During the mean period of follow-up (average 5 years, range 1-11), 75% of the patients needed a new dilatation, with a delay of two years. The results of the dilatation were excellent or good in 80% of the cases. Early complications consisted in two esophageal perforations surgically treated. There was no mortality. We did not observe late complications of the procedure. We conclude that pneumatic dilatation should be the initial procedure in the treatment of dysphagia in suspected esophageal motor disorders. | 1 |
Renal autotransplantation in children: a successful treatment for renovascular hypertension. Renovascular hypertension in children is not a common disease. With improved surgical technique the incidence of nephrectomy has decreased and renovascular reconstruction is currently the preferred method to manage this entity. Between 1977 and 1988, 21 patients with renovascular hypertension were treated at our hospital: 7 patients 6 to 16 years old underwent renal autotransplantation. Of the children 4 had unilateral and 3 had bilateral disease requiring bilateral autotransplantation. Autotransplantation was performed by anastomosis of each renal artery end-to-side to the common iliac artery. The renal veins were anastomosed end-to-side to the common iliac veins. The ureters were left intact in all but 1 patient who required a bench operation. Of the 4 patients who had a unilateral procedure 3 are cured and 1 is improved with a normal blood pressure on a small dose of antihypertensive medication. The 3 patients with bilateral autotransplants are cured. These results, with normalization of the blood pressure in 86% of the patients and improvement in blood pressure in 14% with a patency rate of 87%, are similar to other reported reconstructive modalities in children. | 3 |
Leucine kinetics in patients with benign disease, non-weight-losing cancer, and cancer cachexia: studies at the whole-body and tissue level and the response to nutritional support. We have performed intraoperative isotopic infusions of carbon 14-labeled leucine in 65 patients to define the abnormalities in protein metabolism at both the whole-body and tissue level in patients with weight-losing and non-weight-losing cancer. Eighteen patients had benign disease, 26 had non-weight-losing cancer, and 21 had cancer cachexia. Samples of plasma and expired breath were taken to determine rates of whole-body protein synthesis (WBPS), whole-body protein catabolism (WBPC), net protein catabolism, and albumin fractional synthetic rates. Tissue samples were taken to determine the fractional synthetic rates (FSR) of protein in muscle, liver, cancer, and the tissue in which the cancer arose. In addition, in 14 patients the effect of nutritional support on protein metabolism was assessed. In all parameters examined we were unable to detect any significant differences between patients with no cancer and the patients with non-weight-losing cancer. In contrast, patients with cancer cachexia had a significant elevation (p less than 0.005) in WBPC compared with the other two groups. WBPS was also elevated (to a lesser extent) in the patients with cancer cachexia, and the rate of net protein catabolism was increased significantly (p less than 0.05). Patients with cancer cachexia also had significantly higher values of FSR of protein in muscle (p less than 0.05), liver (p less than 0.05), and albumin (p less than 0.01) compared with the other two groups. In addition, the protein FSR in the cancer rose progressively when the values for the primary cancer were compared with those for nodal and systemic metastases. Further, although nutritional support resulted in an increase in host muscle protein synthesis (p less than 0.04), there was no promotion of FSR of protein in cancer. We conclude that patients with cancer cachexia are actively losing protein as a result of an increase in WBPC that is only partially compensated for by an increase in WBPS. There are compensatory increases in protein synthesis in muscle and liver, but these increases in host protein synthesis are insufficient to keep pace with the combined effect of the accelerated rate of protein synthesis in the cancer per se and the accelerated rate of net protein catabolism at the whole-body level. In response to nutritional support, there is a significant increase in the muscle protein synthesis, but we could not demonstrate any increase in cancer protein synthesis. | 0 |
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