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Hypersensitivity pneumonitis versus invasive pulmonary aspergillosis: two cases with unusual pathologic findings and review of the literature. Two brothers simultaneously exposed to moldy hay, who developed differing forms of Aspergillus-related lung disease, are presented. Patient 1 developed a true case of hypersensitivity lung disease, whereas his brother developed invasive aspergillosis with bronchoalveolar lavage eosinophilia and unusual pathologic features including tissue eosinophilia. The possible overlap between hypersensitivity pneumonitis and invasive aspergillosis in the immunocompetent host is discussed. | 4 |
Influence of catheter technology and adjuvant medication on acute complications in percutaneous coronary angioplasty. We report on the complication rates in 660 consecutive coronary angioplasties (725 lesions) performed using four procedures that differed with respect to catheter technology and adjuvant medication. After the PTCA regimen in our laboratory had been changed from conventional steerable systems to the monorail technique, we observed a significant increase in the incidence of transient vessel occlusions from 2.6% to 7.7%, of permanent occlusions from 3.6% to 8.8%, and of intracoronary thrombus-formation from 2.6% to 5.5%. This was associated with the frequent observation of thrombotic material on the partially Teflon-coated guidewires. Coronary perfusion with urokinase (1,670-6,670 U/min) lead to a further increase in the complication rates (10.4%/10.3%/6.5%). Our present percutaneous transluminal coronary angioplasty (PTCA)-regimen (monorail technique with P.E.T. balloons, fully silicon-coated guidewires, no urokinase) shows an incidence of 3.8% for intermittent and recurrent coronary occlusions and 1.9% for permanent occlusions. Urokinase did not prevent intracoronary thrombus formation with the monorail technique. Furthermore, we suspect that in the case of PTCA-induced regional intimal dissection, fibrinolysis can prevent reestablishment of intima adherence to the vessel wall. Because five procedural deaths were observed in the 212 patients treated with i.c. urokinase as opposed to three deaths in the 448 procedures without urokinase, we feel that i.c. urokinase in PTCA is a potentially harmful regimen. We suggest that the monorail technique should be performed with fully silicon-coated guidewires and without urokinase. | 4 |
Effects of dietary calcium on nimodipine-sensitive calcium channel function in stroke-prone spontaneously hypertensive rats. We studied the effects of dietary Ca2+ on blood pressure, survival, and calcium channel function to investigate cardiovascular disease mechanisms in stroke-prone spontaneously hypertensive rats. Beginning at 3 weeks of age, rats were fed high sodium chloride diets (8.0%) in combination with either high (2.0%) or low (0.2%) Ca2+ diets for 8 weeks. At 12 weeks of age, survival was 90% in the high Ca2+ group and 30% in the low Ca2+ group. The higher blood pressure and lower survival in the low Ca2+ group suggest an intensification of altered vascular muscle cell mechanisms by a dietary Ca2+ deficit. Nimodipine (1-10 nM) effectively blocked L-type Ca2+ currents in isolated vascular muscle cells from both groups. Contraction of isolated cells that were not patch clamped to high potassium solutions were also blocked by 1 nM nimodipine. Disappearance of the L-type Ca2+ channel current was accelerated by holding at depolarizing potentials (positive to -50 mV) and by depolarizing steps to 0 mV. Nimodipine block of the L-type Ca2+ currents in vascular muscle is believed to contribute substantially to antihypertensive properties and stroke prevention, actions that may develop fully only in stroke-prone spontaneously hypertensive rats on a diet of at least normal Ca2+. | 3 |
Crohn's disease and retinal vascular disease. Patients with Crohn's disease may manifest extraintestinal findings including ocular involvement. We treated two patients with Crohn's disease who manifested retinal vascular disease that may have been related to the immune nature of the underlying disease or possibly to changes in the vasculature or coagulation system. One patient had a central retinal vein occlusion and the other had retinal vasculitis involving retinal arteries and veins with an apparent branch retinal artery occlusion. Both patients were in excellent health except for Crohn's disease, which was confirmed by a biopsy specimen. In one patient, the diagnosis of retinal vasculitis preceded the clinical diagnosis of Crohn's disease, whereas for the second patient the symptomatology of the intestinal disease preceded the ocular manifestations. We suggest that inflammatory bowel disease should be considered in the differential diagnosis of retinal vascular occlusive disease, especially in a young patient. | 1 |
Characterization of preneoplastic and neoplastic lesions in the rat pancreas. Nodules of acinar cells with increased proliferative potential develop in the pancreas of carcinogen-treated rats and in untreated aged rats. Large nodules are classed as adenomas. Phenotypic and genotypic characteristics of nodule cells were compared with normal pancreas and transplantable acinar cell carcinomas by several methods. Nuclei of acinar cells from normal pancreas, adenomas, and three carcinomas in situ had normal diploid DNA content as determined by flow cytometry. One of two primary carcinomas had a hypodiploid DNA content. Two of three transplantable carcinomas were aneuploid with a DNA content in the tetraploid range. Explants from nodules and adenomas failed to grow in soft agar, whereas several carcinomas were positive in this assay. A primary carcinoma was serially transplanted, but transplantation of nodules or adenomas failed. Transfection of DNA from carcinomas in situ yielded a higher frequency of NIH 3T3 transformants than DNA from adenomas. DNAs from the transformants did not contain ras sequences. These studies indicate that cells from nodules and adenomas have low growth potential and lack critical phenotypic and genotypic characteristics of transformed malignant cells that were present in some primary and transplanted carcinomas. | 0 |
Cessation of treatment in advanced cancer. A major responsibility for all physicians, but particularly for oncologists, is to recognize the time when active antitumor treatment ceases to have a rational basis. The decision to treat or not to treat at any stage of disease requires an analysis of "the legitimate aims of therapy." We have acquired the ability to cure or prolong survival in an increasing proportion of patients with several types of cancer. For patients who fail to achieve those results and for those with tumors that are rarely amenable to specific therapy, the choice of less surely effective therapy is an option; the patient must participate in the decision, armed with as much information and insight as possible, for conventional and experimental treatment. A distinction must be made between specific antitumor therapy and palliative measures for which cessation is never an option. Happily, cessation of treatment must also be considered when therapy has been so successful that the patient has achieved complete remission. At what point may treatment be discontinued without the danger of relapse? These issues are rarely crisply defined, but primary concern for the patient and careful analysis of the available data can lead to appropriate value judgements. | 0 |
Value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation: case report. A case of spinal cord compression due to spontaneous extradural spinal hematoma is reported. A spinal arteriovenous malformation was suspected on the basis of magnetic resonance imaging. Early surgical exploration allowed a complete neurological recovery. The vascular malformation was histopathologically confirmed. The role of magnetic resonance imaging in the evaluation of acute spinal cord compression syndromes is stressed. | 2 |
Brain potentials associated with movement in traumatic brain injury. Brain potentials may be used to assess the functional abnormalities that underlie impairments of movement. The purpose of this article is to illustrate the usefulness of examining these potentials. In addition to an overview of the topic, the article includes a report of a study demonstrating that there were differences between the brain potentials of five patients with traumatic brain injury and those of four healthy control subjects. All five patients were in the postacute phase of hemiplegia. Slow cortical potentials associated with simple goal-directed forearm and finger movements were recorded from frontal and parietal electrodes. Two seconds of movement-related electroencephalographic activity (movement-related potential) were recorded. The patients showed reduced brain potentials for movements associated with their paretic limb and, to a lesser extent, reduced brain potentials for movements associated with their nonparetic limb. The waveforms obtained from the patients were unusual, with uncharacteristic cross-cortical movement-related potential correlations associated with specific electrode configurations, as well as with specific movement conditions. Brain potentials associated with the fore-period interval of a simple reaction time paradigm were later recorded in two of the patients with traumatic brain injury and in a control subject to help determine the functional significance of the relative positivity apparent in their movement-related potential data. This preliminary study indicates that electroencephalographic potentials obtained during the preparation for and execution of movement can provide information regarding the basis for motor dysfunction. | 2 |
Femoral noninfected anastomotic aneurysms. A report of 56 cases. Fifty-six femoral non infected anastomotic false aneurysms (FAAs) were observed in 49 patients admitted to the Institute of Vascular Surgery, University of Milan, from 1975 to 1988; in 6 patients they were bilateral. These aneurysms developed after primary revascularization procedures at a mean interval of 66 months (range 12 to 156 months); one recurred after reparative surgery. Forty-four FAAs (78.6%) were asymptomatic, whereas 3 (5.3%) were complicated by acute expansion and 9 (16.1%) by thrombosis. Host vessel degeneration was the cause of aneurysm formation in most cases. A history of hypertension was present in 30% of the patients. All anastomotic aneurysms were operated upon except for one small aneurysm that was asymptomatic. In 5 patients aneurysm resection was carried out on both sides. The surgical technique was endoaneurysmectomy in all the cases with insertion of an interposition graft in 48 cases, a fabric patch in 2 cases and prosthesis re-anastomosis in 5 cases. One case of peripheral embolization occurring in the early postoperative period was successfully treated and there was no operative mortality. In our opinion elective repair of these aneurysms should be recommended whenever possible because of their propensity to develop serious complications and the operative morbidity is low. | 4 |
Postauricular cerebellar encephalocoele secondary to chronic suppurative otitis media and mastoid surgery. Cerebellar herniation into the mastoid through the posterior aspect of the temporal bone as a result of chronic suppurative otitis media and mastoid surgery is a rare event. A case is reported in which such a hernia presented subcutaneously behind the pinna; its repair is discussed. | 4 |
Anorectal malignant melanoma in Sweden. Report of 49 patients. Clinicopathologic features and prognosis of 49 patients with anal malignant melanoma were investigated in the total Swedish population between 1970 and 1984. Median age was 71 years (range, 50 to 87 years), and there was a female predominance (31 females, 18 males). The most common symptom at presentation was bleeding. The majority of tumors ranged between 2 and 5 cm in diameter and all invaded at least into the submucosa and/or the lamina propria. At diagnosis, one third of the patients had either regional or distant metastasis with a median survival of 5 months. The remaining patients were surgically treated with curative intent, either by abdominoperineal resection (APR) or local excision. Median survival was poor in both treatment groups (APR, 12 months; local excision, 13 months). Most patients died with distant metastasis. Our results confirm the opinion that APR offers no more curative potential than a more conservative surgical approach. However, tumor sizes were on average smaller in the group treated by local excision. This could indicate that, in the absence of known distant metastasis, radical surgery should be performed, particularly since local recurrences tended to be more common after a local excision. | 4 |
Role of experience in the response to simulated critical incidents. Eight experienced anesthesiologists (faculty or private practitioners) were presented with the same simulated critical incidents that had previously been presented to 19 anesthesia trainees. The detection and correction times for these incidents were measured, as was compliance with Advanced Cardiac Life Support (ACLS) guidelines during cardiac arrest, and the occurrence of unplanned incidents. Experienced personnel tended to react more rapidly than did trainees, but differences between second-year anesthesia residents (CA2) and experienced anesthesiologists were not statistically significant. There was a high variability in performance between incidents and within each group. Unplanned errors and management flaws still occurred with experience subjects. The response to incidents during anesthesia is a complex process that involves multiple levels of cognitive activity and is vulnerable to error regardless of experience. Most trainees seemed to acquire adequate response routines by the end of the CA2 year. Formal reasoning appeared to play a minor role in responding to intraoperative events, but the exact nature of the anesthesiologist's cognition remains to be thoroughly investigated. | 4 |
Hyaluronan in pleural effusions and in serum. It has been suggested that a high level of hyaluronan (hyaluronic acid, HYA) in pleural fluid is an indicator of malignant mesothelioma. In 78 consecutive patients with pleural effusion of various causes the HYA concentration was measured in pleural fluid samples and in serum. Nine patients had malignant pleural mesothelioma, and in three of them the HYA level in pleural fluid was 100 mg/l or more. In 42 patients with effusions due to metastatic malignancy, the mean HYA in the pleural fluid was 75 mg/l, and in five the HYA level was above 100 mg/l. Cardiac insufficiency caused the effusion in 11 patients, of whom two had a level above 100 mg/l in pleural fluid. Four patients had a serologically confirmed viral infection and had HYA levels in pleural fluid of 8, 157, 335, and 554 mg/l, respectively. One patient had postinfectious effusion with an HYA level in pleural exudate of 748 mg/l, the highest in this investigation. Two patients had benign asbestos pleural effusions, and both had high pleural HYA levels (256 and 490 mg/l, respectively). The serum HYA values were much lower than in the pleural fluid, namely from 15 to 480 micrograms/l; the levels were independent of the levels in the pleural fluid. Thus, a high level of HYA in pleural fluid is not specific for mesothelioma but can occur in other malignant or benign diseases, and a low level does not exclude mesothelioma. | 0 |
Rate-related left bundle branch block as a cause of non-ischemic chest pain. A case is presented of rate-dependent left bundle branch block associated with chest pain in a patient with angiographically normal coronary arteries. Lactate extraction showed no evidence of myocardial ischemia. It appears that in this case, chest pain was associated with sudden ventricular asynergy rather than myocardial ischemia. | 3 |
Autosomal dominant neovascular inflammatory vitreoretinopathy. Twenty-eight of 61 members of a six-generation family are affected by an autosomal dominant eye disease which has not been described previously. Affected patients are asymptomatic in early adulthood, but have vitreous cells and the selective loss of the b-wave on the electroretinogram. Later, peripheral retinal scarring and pigmentation, peripheral arteriolar closure, and neovascularization of the peripheral retina at the ora serrata or occasionally neovascularization of the optic disc develop. Cystoid macular edema, vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma can cause profound visual loss. Vitrectomy reduces traction on the retina and allows for retinal reattachment. The role of argon laser photocoagulation or cryopexy in reducing the neovascular complications remains uncertain. | 4 |
Forty years of neuroglycopenia: neuropsychiatry for the internist. The case of a 65-year-old patient with an insulin-secreting pancreatic tumour and a 40-year history of neuropsychiatric disease is reported. The physiopathology and clinical features of acute, subacute, and chronic neuroglycopenia in patients with endogenous insulin hypersecretion are discussed. | 0 |
Spinal catheter anaesthesia for caesarean section in a patient with spina bifida. A patient with grossly deformed vertebral anatomy, scheduled for elective Caesarean section, expressed her wish to stay fully awake during the procedure. Epidural anaesthesia was considered to be impracticable, while dural puncture appeared possible only at thoracic level. Spinal anaesthesia using a subarachnoid catheter placed at T7-8 was employed successfully. | 2 |
Heffalumps, jagulars, and cheshire cats. A commentary on cytokeratins and soft tissue sarcomas. Historically, antibodies to cytokeratin intermediate filaments have been models of target specificity. In most diagnostic settings, the utility of these antibodies was unquestioned; reactivity for cytokeratin was dogmatically equated with epithelial differentiation. Recently, however, the diagnostic importance of these antibodies has been challenged, prompted by the demonstration of cytokeratin reactivity in a variety of "nonepithelial" neoplasms. In this review, the evolving literature on this topic is explored, and the practical implications of these findings are discussed. | 0 |
Two distinct loci on the short arm of chromosome 16 are involved in myeloid leukemia. We report a case of acute nonlymphocytic leukemia (ANLL) M5 with the characteristic t(8;16)(p11;p13). The breakpoint in the short arm was regionally localized using nonradioactive in situ hybridization with a series of cosmids of chromosome 16. The results show that a difference exists between the breakpoint in chromosome 16(p13) in this t(8;16) and the breakpoint involved in the short arm in the characteristic inversion 16 (p13;q22)) that occurs in ANLL M4eo. Two different loci appear to be involved in these chromosomal rearrangements. | 4 |
Clinicopathologic features and long-term results of alpha-fetoprotein-producing gastric cancer. During a 10-yr-period, 24 cases of alpha-fetoprotein-producing gastric cancer were experienced in our department. The mean age was 62.5 yr, and the sex ratio of males to females was 3:1. Borrmann II and III types of gastric cancer were predominant (83.3%). The prognosis was dismal. Most of the patients, including three radically operated cases of early gastric cancer, died from liver metastasis within 2 yr. The 1-, 3-, and 6-yr survival rates were 37.5%, 8.3%, and 8.3%, respectively, for all cases and 75.0%, 25.0%, and 25.0% for radically operated cases. The incidences of synchronous and metachronous liver metastasis were 31.8% and 40.9%, significantly higher than the incidences of AFP-negative gastric cancer (p less than 0.91). Despite radical gastrectomy, metachronous liver metastasis occurred in 75.0% of the cases. Two radical hepatic resections, including extended right lobectomy, were performed in one patient with early gastric cancer who had repeated metachronous liver metastasis. However, the tumor recurred immediately. Apparently, radical gastrectomy or hepatic resection alone may not suffice for this particular type of cancer. The methods of treatment and follow-up considered should be different from that for other types of gastric cancer. | 0 |
Prognosis of hospital survivors after salvage from cardiopulmonary bypass with centrifugal cardiac assist. Since October 1986, 6 hospital survivors who were salvaged from cardiopulmonary bypass (CPB) with the Sarns centrifugal pump were observed. Centrifugal assist was employed only after failure to wean with usual resuscitative measures, including multiple high dose inotropes and intraaortic balloon pumping. There were five men and one woman, 46-59 years of age (mean 61 years). All patients had undergone coronary artery bypass grafting, with two patients having had concomitant left ventricular aneurysmectomy and two aortic valve replacement. Five patients had left ventricular assist only and one had biventricular assist. Duration of assist ranged from 26 to 72 hr (mean 48 hr). Complications were ubiquitous, and the resultant prolonged hospitalization was resource intensive. All hospital survivors remain alive and are in New York Heart Association functional Class II, with an average follow-up of 24 months, (6-41 months). Compared with preoperative values, current left ventricular function is improved in 2 patients, has deteriorated in 3, and is unchanged in 1. Thus, the Sarns centrifugal pump will allow salvage of some patients who otherwise are not weanable from CPB. Survivors can expect a reasonable functional capacity as reflected by this experience. | 4 |
Quantitative structural analysis of peripheral airways and arteries in sudden fatal asthma. The peripheral airways and the adjacent muscular pulmonary arteries were studied by morphometric methods in the autopsy lungs of six asthmatic subjects who died suddenly during an asthma attack, and they were compared with those of six control subjects who died of other causes and had no history of respiratory diseases. Bronchioles of asthmatic subjects had an increased amount of lumen occlusion (p less than 0.01), smooth muscle thickness (p less than 0.001), and inflammatory infiltrate (p less than 0.001), and both mononuclear cells and eosinophils contributed to this increased inflammation. The muscular pulmonary arteries adjacent to occluded and inflamed bronchioles did not have the morphologic features of chronic hypoxia, as shown by the normal medial and intimal thickness, but they had an important inflammatory process in their walls that was particularly marked at sites adjacent to airways. Although the functional significance of these findings is unknown, they may be responsible in part for the gas exchange abnormalities observed in acute severe asthma. | 4 |
Technetium-99m (v) dimercaptosuccinic acid: a clinical and scintigraphic study in an animal tumour model. Technetium-99m (99mTc) (v) dimercaptosuccinic acid (DMSA) is a new tumour-imaging agent which has been used to image head and neck squamous carcinoma. This study used an established rabbit tumour model to compare palpation versus planar scintigraphy in the detection of superficially transplanted cancers. Palpation detected 83% of tumours measuring less than 2 cm compared with 58% for scintigraphy. Overall, the sensitivity for palpation was 88% (77% specificity) compared with 50% (63% specificity) for scintigraphy. | 0 |
South American blastomycosis: ophthalmic and oculomotor nerve lesions. A case of South American blastomycosis began with an oropharyngeal lesion which was followed by a granulomatous uveitis. The patient was treated with Amphotericin B and showed a clinical regression. Four months later, he developed a right 3rd cranial nerve palsy, aggravating the clinical aspect with a severe generalized involvement of the central nervous system and death. Necropsy showed blastomycotic meningoencephalitis. | 2 |
A placebo-controlled, double-blind, randomized, two-center, pilot trial of Cop 1 in chronic progressive multiple sclerosis. We found Cop 1 to be effective and relatively safe in a previous (exacerbating-remitting) clinical trial. This current trial involves 106 chronic-progressive patients. The major end point, confirmed progression of 1.0 or 1.5 units (depending on baseline disability) on the Kurtzke Expanded Disability Status Scale, was observed in nine (17.6%) treated and 14 (25.5%) control patients. The differences between the overall survival curves were not significant. Progression rates at 12 and 24 months were higher for the placebo group (p = 0.088) with 2-year probabilities of progressing of 20.4% for Cop 1 and 29.5% for placebo. We found a significant difference at 24 months between placebo and Cop 1 at one but not the other center. Two-year progression rates for two secondary end points, unconfirmed progression, and progression of 0.5 EDSS units, (p = 0.03) are significant. | 4 |
Presentation and management of an acute caffeine overdose. A one-year-old white female ingested approximately two to three grams of caffeine (200-300 mg/kg). The patient survived the ingestion with a maximum caffeine concentration of 385 micrograms/ml four hours postingestion. The child developed ventricular arrhythmias, seizures, metabolic disturbances, and severe pulmonary edema. She survived without apparent long-term sequelae despite having reached a serum caffeine concentration that is the second highest reported level in a survivor. | 2 |
Use of ektacytometry to determine red cell susceptibility to oxidative stress. To define a more sensitive and reliable method to determine changes in the overall cellular characteristics of erythrocytes after oxidative damage, we used a viscodiffractometric method (ektacytometry) to measure the effect of oxidative stress. Erythrocytes were incubated in the presence of hydrogen peroxide, t-butyl hydroperoxide, or cumene hydroperoxide in phosphate buffer. This treatment resulted in decreased cellular deformability of the intact erythrocytes. In addition, deformability and fragility measurements of the erythrocyte ghost membranes indicated an increased membrane dynamic rigidity and altered-mechanical stability as a consequence of oxidant stress. These changes were observed before the onset of hemolysis. The observed decrease in deformability was accompanied by oxidation of hemoglobin, alterations of membrane proteins, and lipid peroxidation. To continuously measure the time course of the decrease in deformability in intact erythrocytes under oxidative stress, a new ektacytometric method was developed. Erythrocytes were oxidatively challenged within the viscometer at a constant osmolality and shear stress. The change in deformability was monitored and a typical range was defined for erythrocytes from normal individuals. Comparison of erythrocytes from patients with sickle cell disease with those from normal individuals demonstrated a higher susceptibility of sickle red cells toward oxidative stress. | 4 |
Expression of the human papillomavirus E7 oncogene during cell transformation is sufficient to induce susceptibility to lysis by activated macrophages. Human papillomaviruses (HPV), and in particular HPV type 16, are etiologic agents in the development of cervical cancer, which is the second most common form of cancer in women worldwide. Mammalian cells are susceptible to transformation in vitro by the E6 and E7 oncogenes derived from the HPV-16 genome. NIH-3T3 cells transfected with the HPV-16 E7 oncogene were found to exhibit cytolytic susceptibility to murine-activated macrophages. In comparison, E6 oncogene-expressing cells were not susceptible to lysis by activated macrophages. The E7 oncoprotein is multifunctional, being capable of complexing with the retinoblastoma tumor suppressor gene (anti-oncogene) product, stimulating DNA synthesis, and causing cell transformation in vitro. Macrophage killing assays performed on cell lines expressing E7 mutants revealed that the ability to complex the retinoblastoma tumor suppressor gene product and stimulate DNA synthesis did not induce susceptibility to activated macrophages, whereas the ability of E7 to cause transformation was required to induce susceptibility to activated macrophages. These data suggest that cell transformation is a more important prerequisite for inducing susceptibility to activated macrophages than is the loss of tumor suppressor gene function. This study also provides an initial link between HPV-16 oncogene expression and the ability of activated macrophages to selectively recognize and destroy HPV-16-associated neoplastic cells. | 0 |
Daytime hypertension in obstructive sleep apnea. Prevalence and contributing risk factors. We examined the prevalence of daytime hypertension in a modern sample of patients with obstructive sleep apnea (OSA) and assessed the relative risk factors contributing to the development of hypertension in this disorder. Daytime hypertension was present in 92 (45 percent) of 206 male and female patients with OSA. Stepwise logistic regression revealed that only age and body mass index (BMI) were predictors of hypertension in this population. A subsample of 152 male patients with OSA was then compared to 904 men identified from a geographically and ethnically similar general population. When one controlled for age and BMI, the prevalence of hypertension in the two groups was the same except for those aged 25 to 44 years who were markedly obese (BMI greater than 31 kg/m2). In this group, 47 percent of the patients with OSA were hypertensive vs 26 percent of control subjects (p less than 0.05). Our data suggest that the high prevalence of hypertension in OSA is primarily related to age and the excess obesity seen in these patients. In morbidly obese young patients with OSA, factors directly related to OSA may also be contributing to the development of hypertension. With increasing age, other competitive risks may obscure any independent effect that OSA may exert. | 3 |
In vitro and in vivo evaluation of a right ventricular assist device. A simple right ventricular assist device (RVAD) has been developed. This device will be useful in situations where biventricular failure has been partially treated by placement of a left ventricular assist device, or when right ventricular failure occurs in isolation. This pneumatically actuated, R-wave synchronized, sac type pump contains no valves, and is connected by a graft to the pulmonary artery. The RVAD was tested in a circulation simulator to verify its hemodynamic efficacy and then implanted in six calves for 2-4 weeks to evaluate its biocompatibility. In vitro testing of the RVAD demonstrated that it restored normal hemodynamics in the presence of severe simulated RVF. In six animal implantations, a small amount of thrombus was found in one pump. No anticoagulants were employed. Thrombus was present in the connecting graft in three animals; in two this was clearly related to technical implant errors. No evidence of significant hemolysis was found. This simple RVAD has been found to be hemodynamically effective, is simple to use, and is well tolerated. Refinements in the interconnection graft between the pulmonary artery and the device are necessary. | 3 |
Bone marrow stromal cell changes in haematological malignancies. Stromal cell numbers from subjects with no haematological disease and those with acute myeloid leukaemia (AML), chronic granulocytic leukaemia (CGL), acute lymphatic leukaemia (ALL) and non-Hodgkin's lymphoma (NHL) were compared to determine their role in malignancy. Frozen sections of trephine biopsy specimens from iliac crests were stained for endogenous alkaline phosphatase activity, endogenous acid phosphatase activity, and, using immunocytochemical methods, for endothelial cells (anti-factor-VIII related antigen) and macrophages and related cells (EBM/11). In granulocytic malignancies, whether acute or chronic, alkaline phosphatase positive reticulum cells (AL-RC) and vascular endothelial cells were generally increased. In lymphoid malignancies, the numbers of AL-RC were generally reduced. Numbers of vascular endothelial cells seemed to be normal in ALL but reduced in foci of NHL. Macrophages are numerous in normal marrow, and their numbers seemed to be normal in granulocytic lesions but were more variable and sometimes reduced in ALL and NHL. Lymphoid malignancies, therefore, have a destructive effect on some stromal elements; granulocytic malignancies are associated with normal or increased numbers of stromal cells. A possible consequence of depleted stromal cells might be slower reconstitution of normal haemopoiesis after treatment. The large numbers in granulocytic malignancies raises the possibility of synergistic stimulation between stromal and neoplastic cells. | 0 |
Carbon tetrachloride-induced alterations of hepatic calmodulin and free calcium levels in rats pretreated with chlordecone. Calmodulin, a low molecular weight Ca2+ binding protein, regulates a large number of cell activities including cell division. Previous studies from our laboratory indicated excessive accumulation of Ca2+ in hepatocytes succeeded by rapid glycogen breakdown and suppressed cell division in rats receiving CCl4 after previous dietary exposure to 10 ppm chlordecone. Since calmodulin plays a major role in Ca2(+)-regulated events and has been reported to be localized in mitotic apparatus during cell division, we have assessed subcellular distribution of calmodulin and estimated cytosolic phosphorylase a to indicate cytosolic free Ca2+ levels in livers of rats fed 0 ppm or 10 ppm (chlordecone) in the diet for 15 days before CCl4 (100 microliters/kg) administration to understand the role of Ca2(+)-calmodulin in chlordecone + CCl4 toxicity. Hepatotoxicity was assessed by determining serum AST and ALT succeeded by histopathological observations of liver sections. Serum aminotransferases were significantly elevated 6 hr after CCl4 administration to normal rats and returned to control level by 24 hr. However, serum AST and ALT elevations were severalfold higher, and progressive increase was observed starting 4 hr after CCl4 administration to chlordecone rats. Histopathological observations of liver sections for necrotic, swollen and lipid-laden cells provided findings commensurate with the serum enzyme data. These data indicate that normal rats do recover from CCl4 hepatotoxicity. However, the CCl4 hepatotoxicity is progressive in chlordecone rats without recovery. In normal rats, CCl4 administration resulted in a slight increase in phosphorylase a starting at 6 hr. | 1 |
A new DNA marker (D10S94) very tightly linked to the multiple endocrine neoplasia type 2A (MEN2A) locus. Combined somatic cell hybrid and linkage studies between D10S94 and five pericentromeric loci (FNRB, D10Z1, MEN2A, RBP3, and D10S15) have localized the new DNA sequence pcl1/A1S-6-c23 at D10S94 to 10q11.2. No recombinants were observed between D10S94 and D10Z1 or MEN2A. D10S94 maps in proximal 10q11.2 very near to MEN2A. There are three possible orders for the six loci that we investigated from the centromeric region of chromosome 10. At present the genetic data do not allow us to order MEN2A with respect to D10Z1 and D10S94. The three possible orders are FNRB-D10Z1-D10S94-MEN2A-RBP3-D10S15, FNRB-D10Z1-MEN2A-D10S94-RBP3-D10S15, and FNRB-MEN2A-D10Z1-D10S94-RBP3-D10S15. In view of the fact that no recombinants between D10S94 and MEN2A or between D10S94 and D10Z1 were observed, the combined haplotypes formed from RFLPs and D10Z1 and D10S94 will increase the informativeness and accuracy of genotype prediction for at-risk members of the families having the MEN 2A syndrome, particularly when the affected parent is female. The localization of D10S94 with respect to MEN2A will prove valuable in experiments directed toward cloning the MEN2A locus. | 0 |
Acquired childhood aphasia. Outcome 1 year after onset. The effects of the variables age at onset, cause, severity and bilaterality of lesion, and type of aphasia on course and outcome were investigated in a group of 28 aphasic children. Analysis of spontaneous speech and tests of auditory verbal comprehension were used to determine the presence of aphasia. The severity of the cerebral lesion was assessed using a rating scale for computed tomographic scans. Most of the children had not recovered completely 1 year after onset. Recovery was significantly different according to etiological categories. Complete recovery was seen in the majority of traumatic cases. | 0 |
Colon carcinoma associated with ureterosigmoidostomy. A patient developing a colonic adenoma 38 years following ureterosigmoidostomy is presented. The mechanisms of neoplastic transformation associated with ureterosigmoidostomy is now better understood. This knowledge is being applied to develop modifications both of the surgical technique and the management of patients with this form of urinary diversion, and is a subject of discussion. | 0 |
Duodenogastric reflux and gastric histology after cholecystectomy with or without sphincteroplasty. Sixteen patients who had undergone cholecystectomy plus sphincteroplasty, 14 cholecystectomized patients and ten control patients were studied to evaluate whether differences existed in duodenogastric reflux and whether these were related to morphological damage of the gastric mucosa. Duodenogastric bile reflux during fasting was evaluated by measuring the concentration of total bile acids (by an enzymatic method) and single bile acids in the gastric juice by high performance liquid chromatography. The damage was evaluated histologically by systematic endoscopic biopsy of the antrum and body of the stomach. There was a statistically significant difference in fasting bile reflux between the three groups (Kruskal-Wallis test, P less than 0.001), and the group that underwent cholecystectomy plus sphincteroplasty had a significantly higher median value than the cholecystectomized group (P less than 0.05) and the control group (P less than 0.01). The distribution of chronic antral atrophic and superficial gastritis was different in the three groups (chi 2 test, P less than 0.005). Chronic atrophic gastritis was associated with cholecystectomy plus sphincteroplasty (P less than 0.01), while chronic superficial gastritis was more frequent in cholecystectomized patients. These results suggest that there may be more duodenogastric reflux after cholecystectomy plus sphincteroplasty than after cholecystectomy alone, and that there may be a correlation between the amount of duodenogastric reflux and the severity of mucosal damage. | 4 |
Tuberculous tenosynovitis of the wrist. Two case reports. Tuberculosis was first described in 1756 by Acrel in a case report. Subsequent reports of musculoskeletal tuberculosis documented the uncommon occurrence of hand and wrist involvement. The two cases presented here demonstrate the difficulty in eradicating the organism even with modern regimens of chemotherapy. Intraoperative Gram's stain and frozen sections were useful to rule out other etiologies. Firm diagnosis must be established by tissue culture. The first case appeared cured after thorough initial debridement and had no recurrence for 36 years. While recurrences are common in patients treated with debridement alone, most appear within one year after the index procedure. The amount of time that elapsed in this case is unusual and serves as a sobering reminder that tuberculosis may recur at a time distant from the initial procedure. The second patient had tuberculosis diagnosed elsewhere and was treated twice with antituberculous chemotherapy. Although the first course of therapy for six months may have been inadequate, the second course with multiple drugs for 18 months would certainly be considered adequate; yet he had a recurrence in his wrist eight months after completing treatment. These two cases illustrate the fastidious nature of the Mycobacterium tuberculosis organism and the need for a combined treatment protocol of meticulous surgical debridement and combined chemotherapy. | 4 |
The papillary-cystic neoplasm of the pancreas. An increasingly recognized clinicopathologic entity. The clinical course of the papillary-cystic neoplasm of the pancreas is contrasted with that of the pancreatic ductal adenocarcinoma. The former occurs predominantly in young women, has a low malignant potential, and is highly curable with surgical treatment. Three cases are reported that illustrate the typical clinical features and the indolent nature of the tumor. One case was discovered after blunt abdominal trauma resulted in rupture of the tumor and hemoperitoneum. All cases were treated by pancreatic resection with preservation of the spleen, an important consideration in younger patients. All patients were free of disease at long-term follow-up. Increasing awareness of this tumor has resulted in the reclassification of several tumors and should lead to better recognition by surgeons caring for patients with pancreatic diseases. | 0 |
Reduced psychological morbidity after breast conservation. Psychological morbidity was compared in 52 patients treated by mastectomy and 67 patients treated by lumpectomy for early breast cancer. An informal counselling service was provided for all patients. Morbidity was measured at 6, 9 and 12 months after surgery with two self-rating scales: the general health questionnaire and the Leeds depression and anxiety scales. There was a significant excess of severe depression in the mastectomy group. In contrast to the findings of previous research, this result suggests that breast conservation reduces psychological morbidity. | 4 |
Immediate reproducibility of electrically induced sustained monomorphic ventricular tachycardia before and during antiarrhythmic therapy The immediate reproducibility of sustained ventricular tachycardia induction was evaluated prospectively during 106 studies performed in 53 patients with clinical sustained monomorphic ventricular tachycardia. Programmed electrical stimulation was performed twice, using the same protocol during 53 drug-free studies and 53 subsequent studies on antiarrhythmic therapy. Sustained monomorphic ventricular tachycardia was reproduced in 104 (98%) of the 106 studies. There was no significant difference in the incidence of reproducible tachycardia in the drug-free state compared with that observed during treatment with different classes of antiarrhythmic drugs. An increase in the number of extrastimuli was required to reinitiate the tachycardia in 9 (11%) of 83 studies in which single or double extrastimuli were initially required to induce the tachycardia. In 39 (37%) of 104 studies with reproducible tachycardia induction, the two tachycardias significantly differed in electrocardiographic (ECG) configuration and cycle length. These observations suggest that the overall reproducibility of ventricular tachycardia induction is sufficiently high to provide a reliable marker for evaluating the efficacy of therapeutic interventions. However, specific tachycardia characteristics such as cycle length and ECG configuration are more variable even within the same study and may be less useful in assessing the effects of subsequent interventions. | 3 |
Immediate breast reconstruction following mastectomy is as safe as mastectomy alone. We evaluated wound complications and potential risk factors after mastectomy with immediate breast reconstruction and compared them with similar data after modified radical mastectomy. The incidences of infection, seroma, hematoma, and epidermolysis were compared among 395 patients (305 with modified radical mastectomies and 90 with mastectomy with immediate breast reconstruction) from Virginia Mason Medical Center, Seattle, Wash, between 1983 and 1989. Obesity, age (60 years or older), smoking, antibiotics, and wound drainage were examined as possible risk factors. There were more wound complications in the modified radical mastectomy group (48% vs 31%), and specifically, more seromas (30% vs 13%). In the modified radical mastectomy group, age of 60 years or older was associated with seroma and infection, drainage greater than 30 mL per day (at time of drain removal) with seroma, and smoking with epidermolysis. In the mastectomy with immediate breast reconstruction group, obesity was associated with seroma and epidermolysis. We conclude that mastectomy with immediate breast reconstruction appears to be as safe as modified radical mastectomy alone with respect to wound complications. | 4 |
A bleeding risk index for estimating the probability of major bleeding in hospitalized patients starting anticoagulant therapy. PURPOSE: To construct and test prospectively a bleeding risk index for estimating the probability of major bleeding in hospitalized patients starting long-term anticoagulant therapy. PATIENTS AND METHODS: In an inception cohort of 617 patients starting long-term anticoagulant therapy in one hospital, data were gathered retrospectively and bleeding was classified using reliable explicit criteria. We constructed a bleeding risk index by identifying and weighting independent predictors of major bleeding using a multivariate proportional-hazards model. The bleeding risk index was tested in 394 other patients prospectively identified in a second hospital. The index was compared to physicians' predictions. RESULTS: Major bleeding developed before discharge in 61 of all 1,011 patients (6%). The bleeding risk index included four independent risk factors for major in-hospital bleeding: the number of specific comorbid conditions; heparin use in patients aged 60 years or older; maximal prothrombin or partial thromboplastin time 2.0 or more times control; liver dysfunction worsening during therapy. In the testing group, the index predicted major bleeding, which occurred in 3% of 235 low-risk patients, 16% of 96 middle-risk patients, and 19% of 63 high-risk patients (p less than 0.001). The bleeding risk index performed as well as physicians' predictions, and integration of the bleeding risk index with physicians' predictions led to a classification system that was more sensitive (p = 0.03) than physicians' predictions alone. In 86% of patients with a high risk of major bleeding, we identified specific ways of improving therapy, e.g., avoiding overanticoagulation and nonsteroidal anti-inflammatory agents. CONCLUSION: The bleeding risk index provides valid estimates of the probability of major bleeding in hospitalized patients starting long-term anticoagulant therapy and complements physicians' predictions. The possibility that bleeding can be prevented in high-risk patients warrants prospective evaluation. | 4 |
Exocrine pancreatic function in chronic liver diseases. To confirm the respective influence of chronic alcoholism and liver disease on exocrine pancreatic function in cholecystokinin secretin (CS), tests were performed on patients with chronic liver cirrhosis (LC) and non-cirrhotic (nLC) disease of alcoholic (A) and nonalcoholic (nA) etiology. Results were compared in four subgroups (ALC, N = 26; AnLC, N = 45; nALC, N = 18; and nAnLC, N = 43). Volume of duodenal juice and bicarbonate output (BO) were increased and maximal bicarbonate concentration was decreased in ALC, compared with those in normal controls. Comparison of LC and nLC indicated that the volume, BO, and amylase output (AO) were greater in LC than in nLC of alcoholic etiology, but not in those of nonalcoholic etiology. The initial disappearance rate (KICG) of indocyanine green (ICG) excretion correlated with a parameter of CS test in alcoholic liver disease (vs. volume: r = -0.51, p less than 0.01 vs BO: r = -0.40, p less than 0.01), but not in nonalcoholic liver disease. Concurrent chronic pancreatitis with pain and definite exocrine insufficiency was observed in only one ALC patient and in four AnLC patients, but in none of the nonalcoholics. In alcoholic liver disease, exocrine pancreatic secretion tends to increase with severity of liver damage, but concurrence of definite chronic pancreatitis is not correlated with the severity. | 4 |
Duodenal ulcer is associated with low dietary linoleic acid intake. It has been suggested that the falling incidence and virulence of duodenal ulcer is related to increased dietary polyunsaturated essential fatty acid intake. The adipose fatty acid profile, which closely reflects dietary intake, was measured in 35 men with chronic duodenal ulcer and 35 matched control men. The mean percentage of linoleic acid in adipose tissue was significantly lower in the ulcer group (10.0 (0.7) v 12.3 (0.7)%, p less than 0.01) and this difference was found in both smokers and non-smokers. This finding suggests that the diets of duodenal ulcer patients are deficient in linoleic acid and this could be of aetiological importance. | 1 |
Hepatic vascular disease and portal hypertension in polycythemia vera and agnogenic myeloid metaplasia: a clinicopathological study of 145 patients examined at autopsy. The pathogenesis of portal hypertension arising in patients with myeloproliferative disorders has been difficult to understand because liver biopsy findings often show minimal changes. It has been suggested that increased splenic blood flow, hepatic infiltration with hematopoietic cells or sinusoidal fibrosis may be important. We have reviewed the autopsy findings and clinical histories of 97 patients with polycythemia vera and 48 patients with agnogenic myeloid metaplasia collected from three institutions and from the Polycythemia Vera Study Group. Cirrhosis was present in seven patients, one of whom had bleeding varices. Esophageal varices were present clinically in 10 patients without cirrhosis (seven polycythemia and three agnogenic myeloid metaplasia). All of these patients had lesions in small or medium-sized portal veins and four had stenosis of the extrahepatic portal vein with histology compatible with organized thrombi. Nodular regenerative hyperplasia occurred in 14.6% and correlated closely with the presence of portal vein lesions. Thirty patients had greater than 500 ml of ascites, seven of these patients also had varices and six of them had hepatic vein thrombosis. Ascites also correlated with hepatic vein disease confined to small intrahepatic branches. No correlation was seen between hepatic hematopoietic infiltration and signs of portal hypertension. We conclude that esophageal varices are common and are almost always associated with portal vein lesions visible by light microscopy. These portal vein lesions, and the secondary effects of nodular regenerative hyperplasia and portal hypertension, are most likely a result of portal vein thrombosis in patients with myeloproliferative disorders. | 1 |
The use of gadolinium-enhanced magnetic resonance imaging to determine lesion site in traumatic facial paralysis. Gadolinium-enhanced magnetic resonance imaging has been used to evaluate 20 patients with surgically confirmed facial nerve lesions. When the nerve could be seen, gadolinium-enhanced magnetic resonance imaging accurately revealed the lesion site as well as the known extent, which in some cases was not predicted by topognostic testing. This technique appears to provide accurate lesion-site testing and may have importance in surgical planning. Currently used topognostic tests of facial nerve function are frequently inaccurate and can only determine the most proximal lesion site when there are multiple or extensive lesions. The focal nerve enhancement seen in nerve injury, globally increased signal intensity within the temporal bone after trauma, and increased signal intensity within the dura after surgery can occasionally mask nerve lesions and may be confused with tumors. | 4 |
Toxic epidermal necrolysis after bone marrow transplantation: study of nine cases. Acute graft-versus-host reaction after allogeneic bone marrow transplantation has been reported to induce toxic epidermal necrolysis. To assess the respective role of acute graft-versus-host disease and of drug reaction in this setting, we retrospectively reviewed nine cases of toxic epidermal necrolysis that occurred in a series of 152 allogenic bone marrow recipients. In five cases visceral involvement was suggestive of acute graft-versus-host disease without any drug more than "doubtfully" suspected. In four cases extracutaneous symptoms were absent or mild and suspect drugs (mainly sulfonamides) had been administered with a timing suggestive of "possible" causality. All nine patients died, mainly from infection possibly aggravated by high doses of corticosteroids. We conclude that toxic epidermal necrolysis may be more frequent than generally thought after bone marrow transplantation and has a poor prognosis. It seems to be related to a drug reaction to sulfonamides as often as to acute graft-versus-host disease. | 4 |
Increased arterial adrenaline is related to pain in uncomplicated myocardial infarction. Plasma levels of catecholamines, beta-thromboglobulin (BTG) and arginine vasopressin (AVP), and degree of pain were examined in 22 patients with suspected uncomplicated myocardial infarction within 24 h following onset of chest pain. Sixteen patients developed infarction with peak creatine phosphokinase at 1280 Ul-1 (range 293-3770 Ul-1). Fifteen healthy men served as controls (C). Arterial adrenaline levels were significantly higher in patients with pain (1.15 +/- 0.23 nmol l-1, n = 8, mean value +/- SEM) than in those without pain (0.60 +/- 0.10 nmol l-1, n = 14, P less than 0.05). Plasma catecholamines were moderately but significantly elevated in myocardial infarction; the concentration of arterial adrenaline was 0.83 +/- 0.14 nmol l-1 and that of arterial noradrenaline was 2.70 +/- 0.28 nmol l-1 compared with 0.44 +/- 0.04 nmol l-1 (P less than 0.025) and 1.47 +/- 0.05 nmol l-1 (P less than 0.0005), respectively, in C. One week later, plasma catecholamines had returned to baseline levels. Plasma BTG showed borderline elevation (1.0 +/- 0.1 pmol l-1) compared with C (0.6 +/- 0.1 pmol l-1, P = 0.04), and remained unchanged 1 week later. Plasma AVP was at baseline level. Uncomplicated myocardial infarction, regardless of size, was associated with only moderately increased sympathetic tone. Plasma adrenaline was related more to the degree of pain than to the presence of acute myocardial infarction. Arterial adrenaline may be a sensitive marker of sympatho-adrenal activity related to pain. | 2 |
Streptokinase treatment for femoral artery thrombosis after arterial cardiac catheterisation in infants and children. Data on 205 children who underwent retrograde arterial catheterisation were studied to assess the frequency of femoral artery thrombosis and the safety and efficacy of systemic streptokinase treatment for this complication. In 29 (14%) a transarterial balloon dilatation was performed. In 15 (7.3%) patients impaired arterial perfusion due to vascular spasm with or without thrombus formation was seen in the cannulated leg after catheterisation. Despite heparinisation, signs of impaired arterial circulation persisted in nine patients (4.4% of the total). In these patients femoral artery thrombosis was strongly suspected. Six (53%) of these had undergone a balloon dilatation. Therefore in this study the risk of femoral artery thrombosis developing was 12 times greater after transarterial balloon dilatation than after arterial catheterisation without dilatation (20.6% v 1.7%). Systemic infusion of streptokinase was started in all patients with femoral artery thrombosis. Arterial perfusion became normal in all patients, though in one this was delayed. Haematological monitoring showed lengthening of the thrombin time and a decrease of the fibrinogen concentration during streptokinase treatment. There were no serious complications. Systemic infusion of streptokinase is a safe and useful treatment in children with persistent femoral artery thrombosis after arterial cardiac catheterisation. | 3 |
Helicobacter pylori and Zollinger-Ellison syndrome. Helicobacter pylori (previously Campylobacter pylori) is almost invariably associated with chronic duodenal ulcer disease. The relationship between H. pylori infection and duodenal ulcer in Zollinger-Ellison syndrome is unknown. We investigated the frequency of H. pylori infection in Zollinger-Ellison syndrome and also what effect H. pylori infection had on gastric function in patients with Zollinger-Ellison syndrome. H. pylori infection was diagnosed based on a specific serologic (ELISA) assay based on high-molecular-weight cell-associated proteins of H. pylori. We studied 20 patients with Zollinger-Ellison syndrome; 15 men and 5 women ranging in age from 24 to 71 years, median age 51. Six Zollinger-Ellison syndrome patients had H. pylori infection compared to 100 consecutive patients with chronic recurrent duodenal ulcer disease (P less than 0.05). Pretreatment basal acid output in Zollinger-Ellison syndrome patients ranged from 7.9 to 95.0 mmol/hr, median 35.2. Pentagastrin-stimulated maximal acid output ranged from 8.5 to 132 mmol/hr; median 52.7. Acid secretion was lower in the H. pylori-infected patients than the uninfected patients (BAO 24.5 +/- 6.5 vs 45.4 +/- 6.6, and MAO 44.3 +/- 11.8 vs 67.9 +/- 10.7, for H. pylori infected vs uninfected patients, respectively). The difference in BAO was statistically significant (P less than 0.05). The present results indicate that H. pylori is not a major contributing factor in duodenal ulcer associated with Zollinger-Ellison syndrome. The association of a reduced BAO with H. pylori suggests that these findings may be related. | 4 |
Moderate prenatal alcohol exposure: effects on child IQ and learning problems at age 7 1/2 years. This longitudinal, prospective, population-based study examined the long-term effects of moderate prenatal alcohol exposure on 482 school aged children. Maternal reports of alcohol use obtained during pregnancy were significantly related to child IQ, achievement test scores, and classroom behaviors in second grade children, even after statistical adjustment for appropriate covariates. Consumption of two drinks per day or more on the average was related to a 7-point decrement in IQ in 7-year-old children even after statistically adjusting for appropriate covariates. Low paternal education and more children in the household were identified as environmental factors exacerbating the effect of prenatal alcohol exposure on child IQ. Learning problems were associated with the alcohol "BINGE" pattern of five or more drinks on at least one occasion. This study shows that alcohol use patterns within the social drinking range can have long lasting effects on IQ and learning problems in young school aged children. These patterns should not be interpreted as biologic thresholds. It should also be noted that these are group effects of prenatal alcohol exposure, not necessarily predictable in the individual child, and that for the most part these children were functioning within the normal range of intelligence. | 4 |
Regulation of collagen production in freshly isolated cell populations from normal and cirrhotic rat liver: effect of lactate. Previous work has shown that lactic acid, and to a lesser extent pyruvic acid, is able to increase collagen synthesis significantly in liver slices of CCl4-treated rats but not normal rats. The purpose of this report is to document which cells in the cirrhotic liver are responsible for the lactate-stimulated increase in collagen synthesis. It was found that (a) incorporation of 3H-proline into protein-bound 3H-hydroxyproline is increased threefold to fourfold in hepatocytes from CCl4-treated rats as compared with normal rat hepatocytes; (b) neither the hepatocytes from normal nor those from CCl4-treated rats modify their collagen synthesizing capacity when 30 mmol/L lactic acid was added to the incubation medium; (c) nonparenchymal cells obtained from livers of CCl4-treated rats synthesize much less collagen than hepatocytes, but their synthesis is stimulated twofold by lactic acid; (d) from the different nonparenchymal cells, only fat-storing (Ito) cells increase collagen synthesis when lactic acid is present in the incubation medium. These results suggest that the increased lactic acid levels observed in patients with alcoholic hepatic cirrhosis may play an important role in the development of fibrosis by stimulating collagen production by fat-storing (Ito) cells. | 1 |
Trapped-lung syndrome after cardiac surgery: a potentially preventable complication of pleural injury. A case of trapped-lung syndrome after coronary artery bypass grafting (CABG) is presented. A significant pleural injury occurred during the bypass operation resulting in intrapleural hemorrhage, pleural fibrosis, and trapped-lung syndrome. The physicians caring for the patient when she was first seen with the trapped-lung syndrome were unaware of the potential relationship between the two prior bypass surgeries to this pulmonary complication. Recognition of the potential for pleural injury to occur after cardiac operations is important and may allow for earlier diagnosis and institution of appropriate therapeutic interventions. Early recognition and treatment with pleural fluid drainage and reexpansion of the collapsed lung may help prevent this potentially serious pleuropulmonary complication from occurring. In addition, the presentation of this pleuropulmonary complication may be delayed after the cardiac surgery, making early diagnosis more problematic. | 4 |
Relationship between duration of spinal cord ischemia and postoperative neurologic deficits in animals. Stagnara wake-up tests, blood flow measures, somatosensory evoked potentials (SEPs), and neurogenic-motor evoked potentials (NMEPs) were elicited from 20 hogs before and after spinal cord overdistraction at L3-L4. Overdistraction was maintained from 5 to 30 minutes after loss of NMEPs. Results suggest that the longer the duration of overdistraction the greater the likelihood of paraplegia. Blood flow measures indicated that reduced perfusion was greatest at the distraction site but extended proximally and distally. Finally, NMEPs were more sensitive to onset of overdistraction and a more valid indicator of paraplegia than SEPs. NMEPs should provide the surgeon with more time for initiation of intervention techniques than SEPs. Because NMEPs and SEPs provide information regarding different spinal cord tracts, the authors continue to use both methods for monitoring the functional integrity of the human spinal cord during corrective spine surgery. | 2 |
Brain retractor edema during induced hypotension: the effect of the rate of return of blood pressure. This study evaluated the hypothesis that the postoperative formation of cerebral edema may be influenced by the rate of blood pressure return after induced hypotension in a graded brain retractor injury. Nineteen cats underwent unilateral craniotomy, isoflurane-induced hypotension to a mean of 50 mm Hg, and application of a brain retractor at 20 mm Hg of pressure for 1 hour. Blood pressure was returned to normal either within 3 minutes or over 20 minutes. The degree of cerebral edema formation was determined by Evans blue dye and coronal magnetic resonance imaging. All animals showed extravasation of Evans blue dye in the retracted hemisphere that was most marked at the periphery of the retractor. T1 relaxation times were significantly prolonged in the retracted hemispheres of both the fast return and slow return groups (18.8% and 17.8%, respectively) and more so at the Evans blue sites (42.8% and 40.8%), although not so strikingly beneath the retractor itself (6.3% and 7.8%). T2 relaxation times were similarly prolonged but to approximately half the degree of the T1 times. In the nonretracted hemisphere, drug-induced hypotension alone did not result in significant acute cerebral edema or blood-brain barrier alteration. There was no significant difference between the fast and slow groups in Evans blue extravasation or magnetic resonance changes. Thus, in a retractor-induced brain injury, restoration of arterial pressure to normal either gradually or rapidly did not influence the degree or extent of edema formation. | 2 |
Rapid percutaneous tracheostomy We describe a new method of performing percutaneous tracheostomy rapidly and safely using a specialized instrument kit. The technique permits the safe insertion of a full-sized 7.0 (ID) or 7.5 mm (ID) cuffed cannula into the trachea within 1-2 min, through the membranous second intercartilagenous space. Animal studies have demonstrated a superior healing process compared to that seen after conventional tracheostomy techniques. | 4 |
Circumferential quantitative analysis of planar 201T1 myocardial scintigraphy in the diagnosis of coronary artery disease. Methodology for the computer analysis of 201T1 myocardial perfusion images has been developed by several laboratories. Substantial evidence of the advantage of this approach over visual inspection alone has been reported. The currently available computer analyses use different algorithms to analyze 201T1 kinetics in the myocardium. The authors evaluated and compared two widely used software programs, Medical Data System (MDS): a mean-count profile, and the Cedars Sinai (CS): a maximal-count profile, of planar 201T1 scintigraphy for their ability to detect coronary artery disease (CAD). | 3 |
Crohn's disease and adenocarcinoma of the intestinal tract. Report of four cases. Four patients with intestinal adenocarcinoma complicating Crohn's disease are reported. The youngest of the four patients was a 21-year-old female with a 9-year history of Crohn's disease of the terminal ileum as well as of the entire colon. She developed mucus-producing moderately differentiated adenocarcinoma in the cecum. Of the remaining three patients with Crohn's disease, one presented an adenocarcinoma in the ascending colon, one in the rectum and the remaining one in the duodenum. All three colorectal adenocarcinomas originated in areas of high-grade dysplasia and all four in areas with chronic transmural inflammation. The review of the literature indicates that a total of 174 small and large bowel cancers occurring in Crohn's disease have been recorded (including the four reported herein). The vast majority of the reported cases have been found in the North American subcontinent. Only in a few instances were bowel adenocarcinoma and Crohn's disease observed in the European continent. It is therefore remarkable that three of our four cases were seen within a period of 12 months. Interestingly, six patients having colorectal adenocarcinoma in association with Crohn's disease were recently reported from a single hospital in England. The question therefore arises whether our cases and those reported recently from England are unrelated and merely coincidental or whether carcinomas are now also affecting European CD patients. If the latter is the case, the surveillance policy for patients with CD should be reconsidered at this hospital. | 0 |
Experience with childhood urolithiasis. Report of 196 cases. A total of 196 children with urinary calculi were treated surgically. Their ages ranged from 1 to 14 years. The male:female ratio was 3:1. Stones were located in the kidney in 96 patients, in the bladder in 52 and in the ureters in 32. Multiple organ involvement was present in 16 patients and associated urinary tract anomalies were found in 11. Stone analysis revealed calcium oxalate and phosphate stones in 121 patients, struvite stones in 60 and uric acid stones in 15. | 4 |
Peritoneal blastomycosis. Blastomycosis is a systemic fungal infection caused by Blastomyces dermatitidis. Involvement of the peritoneum is unusual, with only two previously reported cases that occurred in association with disseminated disease. A single case of histopathologically proven blastomycosis involving the peritoneum is presented, as well as a short overview of previously published cases on gastrointestinal and peritoneal blastomycosis. The case is unique in that chronic peritonitis was the only manifestation of disease. The diagnosis was made by laparoscopy. | 4 |
Anisocoria in the pigmentary dispersion syndrome We studied four patients with anisocoria and the pigmentary dispersion syndrome. In all patients, the larger pupil was on the side of the greater iris transillumination. The amount of anisocoria was between 0.5 and 1.5 mm and was the same in both the light and dark. There was no blepharoptosis, and all pupils dilated normally with cocaine. All of the patients were young men with myopia, and one patient had increased intraocular pressure. | 2 |
Prediagnostic serum levels of carotenoids and vitamin E as related to subsequent cancer in Washington County, Maryland. In 1974 and 1975, serum specimens were collected from 25,802 volunteers in Washington County, Maryland. The serum was kept frozen at -73 degrees C until the time of assay. Prediagnostic samples from 436 cancer cases and 765 matched control subjects have been assayed. Nine sites have been studied: colon, rectum, pancreas, lung, melanoma, basal cell of skin, breast, prostate, and bladder. Serum beta-carotene levels showed a strong protective association with lung cancer, suggestive protective associations with melanoma and bladder cancer, and a suggestive but nonprotective association with rectal cancer. Serum vitamin E levels had a protective association with lung cancer; none of the other sites showed impressive associations. Low levels of serum lycopene were strongly associated with pancreatic cancer and less strongly associated with cancer of the bladder and rectum. | 0 |
Pregnancy-induced hypertension and acute fatty liver of pregnancy: atypical presentations. Severe pregnancy-induced hypertension and markedly elevated levels of serum alkaline phosphatase developed in a 29-year-old-woman in whom one pregnancy resulted in intrauterine death. Acute fatty liver of pregnancy developed with good fetal outcome in the next pregnancy. This case suggests that pregnancy-induced hypertension and acute fatty liver of pregnancy are part of a clinical spectrum. Moreover, classic abnormalities of liver function tests need not be present in acute fatty liver of pregnancy. | 1 |
Failure of transluminal angioplasty in the treatment of myointimal hyperplasia of the internal carotid artery: case report. Recurrent stenosis of the carotid arteries after a carotid endarterectomy for atherosclerosis can occur as a result of myointimal hyperplasia. This condition was treated by percutaneous transluminal angioplasty. Excellent dilatation of the vessel lumen was documented after balloon dilatation. A 6-month follow-up angiographic study, however, demonstrated recurrent high-grade stenosis at the same level in both carotid arteries. Presumably, the failure of percutaneous transluminal angioplasty and the treatment of myointimal hyperplasia of the internal carotid artery results in the same condition after the original endarterectomy, that is, additional myointimal hyperplasia. | 3 |
Chronic pain--assessment of orthopedic physical therapists' knowledge and attitudes. Orthopedic physical therapists' knowledge of pain mechanisms and methods of pain management and their attitudes toward working with patients with benign chronic pain were studied. A random sample of 500 members of the American Physical Therapy Association's Section on Orthopaedics received by mail a 36-item questionnaire. Statistical analysis of scores, using frequencies, means, and correlations was performed on the 119 (23.8%) usable returns. All but 4% of the respondents preferred to work with patients who are not likely to have chronic pain. Seventy-two percent believed their entry-level education in pain management and theory was very inadequate or less than adequate to deal with an orthopedic patient population. Pain knowledge scores were low (35.8 out of 46 points), and the scores on positive attitudes toward treating patients with benign chronic pain were lower (20.5 out of 36 points). The study suggests specific deficiencies in orthopedic physical therapists' knowledge of clinical pain mechanisms and management and potentially undesirable attitudes toward treating patients with chronic pain. | 4 |
Chylothorax secondary to obstruction of the superior vena cava: a complication of the LeVeen shunt. A case of thrombosis of the superior vena cava was complicated by bilateral chylothoraces and a widened mediastinum. Removal of a clotted LeVeen shunt led to prompt resolution of the obstruction and chylothoraces. | 3 |
Isoenzymes of aldehyde dehydrogenase in human lymphocytes. The types of isozymes of aldehyde dehydrogenase (ALDH) present in human lymphocytes has been investigated using isoelectric focusing of polyacrylamide gels followed by substrate-specific staining. Lymphocytes obtained from most individuals were found to contain both types I and II ALDH. This group of 'typical' individuals reported that they did not develop marked facial flushing or rapid heart rate after drinking alcohol nor did they develop an erythema to cutaneously applied ethanol. Lymphocytes obtained from 'atypical' individuals who do suffer from alcohol-induced flushing and rapid heart rate and who developed erythema to cutaneous ethanol displayed type II, but not type I, ALDH. Lymphocytes thus appear to be an easily accessible and suitable tissue for determining type I ALDH phenotype. | 4 |
Disseminated histoplasmosis with embolic endovascular complications: a case report. A 57-year-old man had subacute embolic ischemia of his right foot and subsequent acute embolic ischemia of his left foot after angiography. Thrombus removed at the time of the left femoral thromboembolectomy grew Histoplasma capsulatum confirming the diagnosis of disseminated histoplasmosis. Surgical revascularization of the right leg and parenteral amphotericin B was followed by chronic ketoconazole therapy for 16 months. The patient has remained asymptomatic at 30 months after operation. Effective treatment of endovascular infection with ischemic complications of Histoplasmosis requires surgical revascularization and intensive chemotherapeutic intervention. Histoplasmosis is a ubiquitous infection in endemic areas that often has an asymptomatic subclinical course. Involvement of the cardiovascular system is rarely reported. Previous case reports have described infected cardiac valves and aortic aneurysms. This report describes the uncommon presentation of disseminated Histoplasma capsulatum infection as a peripheral embolic event and the successful management with revascularization combined with systemic amphotericin B followed by ketoconazole therapy. | 3 |
Improved survival after Hemopump insertion in patients experiencing postcardiotomy cardiogenic shock during cardiopulmonary bypass. Immediate placement of a Hemopump (HP) ventricular assist device was undertaken in nine patients (seven men, two women) after other attempts at weaning from cardiopulmonary bypass (CPB) after coronary bypass surgery had failed. All nine patients (100%) were successfully weaned from CPB, and six (63.3%) gradually improved enough to permit removal of HP support. Five (83.3%) of the six who were weaned from CPB survived beyond hospital discharge. HP support was evaluated in terms of vital organ function, incidence of complications, and clinical outcome. In both survivors (S) and nonsurvivors (NS), serial hemodynamic measurements were taken. Although there were few differences in hemodynamic parameters between groups at 4 hr, by 24 hr the S group had markedly improved cardiac index, Glasgow Coma Scale, urinary output, and pulse pressure and required far less inotropic support than did the NS group. All four patients who required high dose inotropic agents to maintain acceptable end-organ perfusion on HP support died; three were unable to tolerate weaning from the HP, and all died within 72 hr of surgery because of ineffective myocardial recovery. None of the survivors required additional early inotropic augmentation. Renal perfusion appeared to be well maintained, even with mean arterial pressures below 60 mmHg during HP support. There were no episodes of hemolysis, infection, or limb ischemia in either group. Thus, the Hemopump provided excellent circulatory support for those patients who could not be weaned from CPB by traditional methods. | 3 |
False aneurysm of the internal mammary artery. Iatrogenic false aneurysm of a branch of the internal mammary artery after sternal wire closure is a very rare occurrence. We describe a case which appeared in a 62 year old woman operated upon for mitral valve replacement and diagnosed after Digital Subtraction Angiography. | 3 |
Hepatic portal venous gas identified by computed tomography in a patient with blunt abdominal trauma: a case report. An abdominal computed tomographic (CT) scan in a middle-aged man injured in a high-speed motor vehicle accident demonstrated the presence of portal venous gas. Findings on initial peritoneal lavage were entirely negative. Exploratory celiotomy performed because of increasing abdominal pain and leukocytosis revealed gangrene of the cecum. This report illustrates the importance of the finding of portal venous gas on CT scan in patients with blunt abdominal trauma. | 4 |
Epstein-Barr virus small nuclear RNAs are not expressed in permissively infected cells in AIDS-associated leukoplakia. Epstein-Barr virus (EBV) DNA structure and gene expression were analyzed in tissue specimens from oral hairy leukoplakia (HLP), a mucocutaneous lesion that develops in patients infected with human immunodeficiency virus (HIV). The structure of the terminal restriction enzyme fragments of EBV revealed that HLP is a permissive infection without a predominant, detectable population of EBV episomal DNA. In RNA preparations from this uniquely permissive infection, EBV replicative mRNAs could be identified by Northern analysis; however, the virally encoded small nuclear RNAs, the EBERs, were not detected in most HLP RNA preparations. In situ hybridization detected EBER expression in very rare cells. These data indicate that unlike other viral small nuclear RNAs, the EBERs are not expressed during viral replication and must participate in the complex maintenance of latent EBV infection. | 0 |
Ischemic brain damage: reduction by sodium-calcium ion channel modulator RS-87476. A novel sodium-calcium ion channel modulator, RS-87476, reduced cerebral infarct size in cats subjected to permanent unilateral occlusion of the middle cerebral artery. Cerebral injury was assessed in vivo with a combination of magnetic resonance (MR) imaging and spectroscopy for 5-12 hours after occlusion and was compared with the area of histochemically ischemic brain tissue. Compared with infarcts in placebo-treated animals, infarcts in cats given RS-87476 were reduced by an average of 70% at the lowest dose, 75% at the intermediate dose, and 88% at the highest dose. Tissue edema, observed as areas of signal hyperintensity on diffusion- and T2-weighted spin-echo images, was confined to small regions of the parietal cortex and basal ganglia in drug-treated animals. Mean plasma levels of RS-87476 at the lowest dose were 13 ng/mL initially, falling to maintenance levels of 3-5 ng/mL; at the intermediate and highest doses, plasma levels of drug were approximately five- and 20-fold greater. The drug was only slightly hypotensive. At least part of the potent cerebroprotective effects of RS-87476 result from its ability to stabilize metabolic energy reserves, reduce lactate formation in ischemic tissues, and attenuate intracerebral edema. | 2 |
Quantitative angiographic comparison of the immediate success of coronary angioplasty, coronary atherectomy and endoluminal stenting. Coronary atherectomy and coronary stenting effectively reduce the severity of coronary artery stenoses, but direct comparisons of these interventions with conventional balloon angioplasty have not been performed. To compare the immediate efficacy of these 3 interventions, the angiographic morphology and the severity of the residual coronary stenosis were quantitatively evaluated in 18 patients undergoing coronary atherectomy and in 21 patients treated by endoluminal coronary stenting. Each of these groups of patients was compared with a matched group of coronary angioplasty patients selected from a large, computerized data-base. The variables matched included patient age and sex, lesions site and severity, and lesion complexity. Both coronary atherectomy and coronary stenting more effectively reduced the severity of the coronary stenosis when compared with balloon angioplasty. The luminal diameter stenosis was reduced from 69 +/- 10 to 22 +/- 20% in the atherectomy group compared with a reduction from 74 +/- 11 to 44 +/- 14% in the matched coronary angioplasty population (p = 0.008). Similarly, the luminal diameter stenosis was reduced from 77 +/- 11 to 26 +/- 12% in the stented group compared with a reduction from 81 +/- 10 to 42 +/- 14% in the matched coronary angioplasty group (p = 0.014). In addition, moderate or severe coronary dissections were noted more frequently in the coronary angioplasty groups than in their respective atherectomy and stent groups (0 vs 33%, p = 0.008, and 5 vs 19%, p = 0.15, respectively). | 3 |
Clinical characteristics and treatment of isolated inferior rectus paralysis. Isolated inferior rectus paralysis without mechanical restriction of the globe has received only scant attention in the literature. The authors report on 21 patients treated during the past 16 years. The etiology was congenital, traumatic, myasthenic, and vascular. Anomalous head posture, diplopia, or a disfiguring hypertropia were presenting symptoms. Diagnosis was made on the basis of the prism and cover test in the diagnostic positions and on examination of ductions and versions. The direction of the head tilt, the Bielschowsky head tilt test, and tests for cyclotropia are only of secondary diagnostic value since they may give paradoxical results. Surgery consisted of resection of the paralyzed muscle, combined with or without recession of its antagonist and/or recession of the contralateral superior oblique. After a mean follow-up of 17 months, 14 patients were cured, 6 had improved, and 1 remained unchanged. | 4 |
Acute myocardial infarction and chest pain syndromes after cocaine use. Seventy patients hospitalized with chest pain after cocaine use were retrospectively evaluated to define the risk and clinical course of acute myocardial infarction (AMI). AMI developed in 22 patients (31%) and transient myocardial ischemia was seen in an additional 9 patients (13%). Coronary risk factors did not distinguish those who developed AMI from those who did not. The presenting electrocardiogram was abnormal in 20 of 22 patients who evolved AMI and in 19 of 48 of those who did not. Creatine kinase levels were elevated in 75% of the patients, including 65% of those who did not develop AMI, but creatine kinase-MB elevations were only observed in the AMI group. The route of cocaine administration did not predict AMI and there was no predilection for a particular coronary vascular bed. The length of time between drug use and onset of AMI pain was often quite prolonged (median interval, 18 vs 1 hour in the non-AMI group). Eight of the patients with AMI underwent cardiac catheterization and 4 had significant coronary narrowing. | 3 |
Effects of the differentiating agent hexamethylene bisacetamide on normal and myelodysplastic hematopoietic progenitors. Hexamethylene bisacetamide (HMBA; NSC 95580) is a potent polar-planar differentiating agent of leukemia and solid tumor cell lines in vitro at clinically achievable concentrations. HMBA is currently being studied in patients with myelodysplastic syndrome. Previous phase I trials have demonstrated that HMBA produces hematologic toxicity in morphologically normal bone marrows of patients with solid tumors. Because of concern that HMBA may produce more severe myelotoxicity in patients with myelodysplastic syndrome since these patients have limited hematopoietic reserves, we studied the effects of HMBA on myelodysplastic and normal hematopoietic progenitors in vitro. HMBA concentrations that are optimal for differentiation in vitro (2 to 5 mmol/L) and HMBA concentrations that are being achieved in clinical trials (1 to 2 mmol/L) inhibited the growth of granulocyte-macrophage colony-forming units and erythroid burst-forming units from all 15 patients with myelodysplastic syndrome and all 4 normal subjects, HMBA did not induce proliferation of myelodysplastic or normal progenitors at any concentration; rather, it produced nearly identical inhibition of normal and myelodysplastic hematopoietic progenitors. HMBA also produced quantitatively similar inhibition of clonogenic leukemic growth of two myeloid leukemia cell lines. For a differentiating agent to be effective, it will likely have to either produce both differentiation and proliferation of abnormal hematopoietic progenitors or show selective inhibitory effects on abnormal as compared with normal progenitors. Although the mechanisms responsible for the antiproliferative effects of HMBA cannot be determined from this study, similar inhibitory effects of HMBA on normal and abnormal hematopoietic progenitors suggest that HMBA may be of limited utility in producing and sustaining elevations of peripheral blood cell counts in patients with myelodysplastic syndrome. | 4 |
Factor XIIIa in nodular malignant melanoma and Spitz naevi. The distribution of factor XIIIa-positive dermal dendritic cells was studied in a series of nodular malignant melanomas and compared with that seen in Spitz naevi. Two patterns of distribution were recognizable: (a) diffusely spread through the tumour and (b) located mainly at the periphery of the tumour. These did not correlate with the diagnosis of melanoma or Spitz naevus and the distribution appeared to be a function of growth pattern of the tumour. The diffuse pattern was the most common regardless of diagnosis and the distribution of factor XIIIa-positive cells is the same in malignant melanoma and Spitz naevi. | 0 |
Flow cytometric analysis of the mechanism of methylmercury cytotoxicity. Flow cytometric analysis of murine erythroleukemic cells (MELC) exposed in vitro to 2.5 to 7.5 mumol/l (micromolar) methylmercury (MeHg) reveals a dose-dependent decrease in the rate of DNA synthesis (rate of passage through the S phase of the cell cycle), manifested as the accumulation of most of the cells in the S phase, and a modest accumulation of cells in the G2/M phase of the cycle. Light microscopy reveals a progressive increase in chromosomal damage (condensation, pulverization). At or above 10 mumol/l MeHg, progression through all the phases of the cell cycle is blocked and mitotic cells are arrested irreversibly in anaphase, with most exhibiting arrangement of chromosomes in a wreathlike ring formation. Also the cells exhibit both nuclear propidium iodide (PI) fluorescence (indicative of loss of viability) and concurrent cytoplasmic carboxyfluorescein (CF) fluorescence (viable cells exhibit CF fluorescence and exclude PI). In addition, there is a dose-dependent increase in cellular refractive index (90 degrees light scatter), an apparent decrease in cell volume (axial light loss), and progressive resistance to detergent (NP-40)-mediated cytolysis. Resistance to detergent-mediated cytolysis is indicative of fixation (protein denaturation, cross-linking, and so on) of the plasma membrane/cytoplasm complex. Our findings indicate that DNA synthesis is the primary target of MeHg cytotoxicity and that apparent targets and degree of cytotoxicity are a complex function of dose. | 4 |
Differences between florid osseous dysplasia and chronic diffuse sclerosing osteomyelitis. Florid osseous dysplasia (FOD) is confused in the literature with chronic diffuse sclerosing osteomyelitis. Two cases of each condition are presented to demonstrate the differences between them. In FOD, there are multiple lobulated sclerotic masses in several quadrants of the jaws, usually in black females. In some cases, the sclerotic masses are exposed to the oral cavity, resulting in a secondary osteomyelitis. Periapical cemental dysplasia is often found in association with FOD. Chronic diffuse sclerosing osteomyelitis is a primary inflammatory condition of the mandible. Patients have cyclic episodes of unilateral pain and swelling. The affected region of the mandible exhibits a diffuse opacity with poorly defined borders. Although women are affected more often than men, black persons are not particularly susceptible. | 4 |
The modified Schollner costoplasty. The modified Schollner costoplasty is a cosmetic procedure for the correction of rib prominence deformity in scoliosis. We present the results of the procedure in 21 patients who had previously undergone spinal fusion for scoliosis. We found the procedure to be well tolerated without major complications. Objective cosmetic improvement was achieved in all but one case. All but one patient considered the procedure to have been of cosmetic benefit. | 2 |
The hyperimmunoglobulinaemia E and recurrent infections syndrome in an adult [published erratum appears in Thorax 1990 Dec;45(12):984] A 27 year old white woman with a history of chronic eczema and episodes of serious infection of the chest, skin, and bone presented with acute respiratory failure. She was found to have a spontaneous right pneumothorax and a pneumatocele in the left upper lobe. Despite a left upper lobectomy she was left with chronic respiratory failure, bullous lung disease, and bilateral bronchiectasis. The hyperimmunoglobulinaemia E and recurrent infections syndrome was diagnosed only in adult life. | 4 |
Pre-discharge immunization among hospitalized Filipino children. Identifying opportunities to vaccinate eligible children is one way to boost rates of immunization especially in countries with low immunization coverage and where convalescence from infectious illness is a contraindication to vaccination. To determine the safety and immunogenicity of diphtheria-tetanus toxoid-pertussis and oral polio immunization, 210 convalescing infants and children and community controls, comparable image and nutritional status, were studied. Using the pertussis agglutination and poliovirus neutralization tests, quantitative serologic responses were compared in the two study groups. No significant differences in the incidence rates of febrile reactions (23% in controls; 28% in convalescents) of local reactions (92% in controls; 87% in convalescents) and of seroconversion (P greater than 0.05) were noted between the two groups. Our investigation suggests that infants and children convalescing from infectious illnesses can be safely and effectively vaccinated. This study further suggests that hospitalization provides an opportunity to vaccinate such children. | 4 |
Post-transplant hypertension. Post-transplant hypertension remains an important risk factor for cardiovascular mortality and graft function. There are multiple mechanisms responsible for post-transplant hypertension. The details of these mechanisms are poorly understood. Steroids, acute and chronic rejection, recurrent renal disease, native kidney disease, and renal artery stenosis have all been implicated in causing post-transplant hypertension. With the addition of cyclosporine, a known hypertensive agent, to the immunosuppressive armamentarium, the evaluation of post-transplantation hypertension has become difficult. Presently, medical therapy is initially directed toward the complications of cyclosporine nephrotoxicity. Empirically, converting enzyme inhibitors are added to the antihypertensive regimen. Further management is aimed at identification of specific causes of post-transplant hypertension. Unfortunately, because of the multifactorial etiology of post-transplant hypertension and a lack of detailed information about the mechanisms, medical and surgical therapy are often unrewarding. Further study is needed to clarify the mechanisms involved in post-transplant hypertension, and thus direct therapy. | 3 |
Potentiation of the erythropoietin response by dimethyl sulfoxide priming of erythroleukemia cells: evidence for interaction of two signaling pathways. Erythropoietin (Epo) and dimethyl sulfoxide (DMSO) are believed to induce the differentiation of transformed erythroid cells by different signal transduction pathways. We have now obtained evidence for the interaction of these pathways. We used a Rauscher murine erythroleukemia cell line with a relatively low (8% to 10%) hemoglobinization response to Epo alone. Pretreatment of these cells for 1 day with DMSO followed by its removal and the addition of Epo resulted in a marked enhancement of the Epo specific hemoglobinization. We have designated this effect "DMSO priming." This priming effect of DMSO on the Epo response was both time-dependent and DMSO concentration-dependent. DMSO priming potentiated the Epo response in three ways. Firstly, DMSO priming increased the total number of Epo responsive cells from 8% to 10% to 40% to 60%. Secondly, DMSO priming reduced the time required to reach the optimal Epo-induced response from 4 days to 2 days. Thirdly, the Epo dose-response curve was left-shifted approximately 20-fold. DMSO priming was also associated with a marked increase in Epo receptor density characterized by an apparently new receptor population and by the appearance of positive cooperativity between receptors. Our results suggest that the DMSO priming effect is due to potentiation of the Epo signaling pathway, thus resulting in a much more rapid and dramatic Epo-induced hemoglobinization response. | 0 |
Effect of sleep-induced increases in upper airway resistance on respiratory muscle activity. To investigate the response of inspiratory and expiratory muscles to naturally occurring inspiratory resistive loads in the absence of conscious control, five male "snorers" were studied during non-rapid-eye-movement (NREM) sleep with and without continuous positive airway pressure (CPAP). Diaphragm (EMGdi) and scalene (EMGsc) electromyographic activity were monitored with surface electrodes and abdominal EMG activity (EMGab) with wire electrodes. Subjects were studied in the following conditions: 1) awake, 2) stage 2 sleep, 3) stage 3/4 sleep, 4) CPAP during stage 3/4 sleep, 5) CPAP plus end-tidal CO2 pressure (PETCO2) isocapnic to stage 2 sleep, and 6) CPAP plus PETCO2 isocapnic to stage 3/4 sleep. Inspired pulmonary resistance (RL) at peak flow rate and PETCO2 increased in all stages of sleep. Activity of EMGdi, EMGsc, and EMGab increased significantly in stage 3/4 sleep. CPAP reduced RL at peak flow, increased tidal volume and expired ventilation, and reduced PETCO2. EMGdi and EMGsc were reduced, and EMGab was silenced. During CPAP, with CO2 added to make PETCO2 isocapnic to stage 3/4 sleep, EMGsc and EMGab increased, but EMGdi was augmented in only one-half of the trials. EMG activity in this condition, however, was only 75% (EMGsc) and 43% (EMGab) of the activity observed during eupneic breathing in stage 3/4 sleep when PETCO2 was equal but RL was much higher. We conclude that during NREM sleep 1) inspiratory and expiratory muscles respond to internal inspiratory resistive loads and the associated dynamic airway narrowing and turbulent flow developed throughout inspiration, 2) some of the augmentation of respiratory muscle activity is also due to the hypercapnia that accompanies loading, and 3) the abdominal muscles are the most sensitive to load and CO2 and the diaphragm is the least sensitive. | 4 |
Epidemiology of pelvic inflammatory disease in parous women with special reference to intrauterine device use. Up to the end of 1989, 206 parous women in the Oxford Family Planning Association contraceptive study had been referred to hospital with a first episode of pelvic inflammatory disease. Of these, 65 suffered from definite disease described as acute, 81 from definite disease not described as acute and 60 from 'other disease'. Considering all forms of disease together, referral was less common in those aged 25-29 and in those aged 45 or more than in those aged 30-44. Referral was more common in those of low social class, in those who smoked and in those who married young. All these factors were taken into account in analyses considering the effects of contraceptive methods. In these analyses, women currently using the contraceptive pill, the diaphragm, the sheath, female sterilization or an intrauterine device (IUCD) were compared with those currently using other methods or no method of contraception. IUCD ex-users were, however, placed in a separate category, irrespective of their current method of contraception. The relative risks obtained in these analyses, with 95% CI, were as follows: contraceptive pill 0.5 (0.2-0.9), diaphragm 0.6 (0.3-1.2), sheath 1.2 (0.6-2.4), female sterilization 0.7 (0.3-1.5), non-medicated IUCD 3.3 (2.3-5.0), medicated IUCD 1.8 (0.8-4.0), IUCD ex-users 1.3 (0.7-2.3). These data suggest that oral contraceptives, the diaphragm and female sterilization protect against pelvic inflammatory disease and that IUCDs increase the risk. Medicated devices, however, appear to carry only about half the risk of non-medicated devices, and the elevation of risks in IUCD ex-users appears to be small. Special analyses examined the risk associated with use of a Dalkon Shield. Among women currently using an IUCD (of any kind), those who had used a Dalkon Shield (at any time) had nearly five times as great a risk of hospital referral for pelvic inflammatory disease as those who had never used a Dalkon Shield (relative risk 4.7, 95% CI 2.1-9.0). | 4 |
Hereditary ovarian cancer. Heterogeneity in age at diagnosis. An unknown fraction of the ovarian cancer burden occurs in women with a family history indicative of a putative autosomal dominantly inherited cancer susceptibility syndrome. The results from a five-generation, extended, hereditary breast-ovarian cancer kindred are described 10 years after it was initially ascertained. Significantly more cancers were observed in high-risk family members during this decade than were expected (P less than 0.001). The age of ovarian cancer diagnosis was studied in additional ovarian cancer-prone families of three types: site-specific ovarian cancer syndrome, the breast-ovarian cancer syndrome, and Lynch syndrome II. The age of onset in each of the three sets was significantly (P less than 0.001) earlier than the general population mean of 59, and there were significant differences in the age of onset (P = 0.050) among these three cohorts. Ovarian cancer histology was similar to that of patients with negative family histories. There may be clinically significant heterogeneity in the age at diagnosis of ovarian cancer among these ovarian cancer-prone syndromes. This has important implications for understanding its natural history and targeting surveillance-management strategies. | 4 |
The influence of warning signal timing and cognitive preparation on the aversiveness of electric shock. Many medical and dental procedures are noxious. Finding an optimal way of warning patients concerning the aversive procedures could help them to cope better. A model for the effective use of a warning signal in coping with pain posited that a person needs enough time to be able to react and should possess the skills necessary to utilize the time effectively. It was felt that a very short warning period, e.g., 5 sec, could not be long enough, while a 180 sec warning period would in and of itself become aversive. Reactions to electric shock were obtained from 36 paid, volunteer subjects who were each tested on a within-subject, counterbalanced order at 4 different warning periods: 5, 30, 60, and 180 sec. The subjects were divided into 3 groups: (1) the experimental group was provided with a pretested self-instructional booklet to learn a variety of pain control techniques; (2) the placebo group was provided with a self-instructional booklet on citizenship; (3) the control group waited quietly for 13 min. No significant results were obtained for the different pain-coping conditions. Significant differences, however, were obtained for the various warning periods. Maximum skin resistance changes, higher ratings of pain and of anxiety were obtained for the 60 and 180 compared to the 5 and 30 sec warning periods. Maximum heart rate was obtained for the 30 sec warning. Results were discussed in terms of the psychological meaning of the various measures as well as their clinical implications. | 2 |
Endothelium-dependent responses in long-term human coronary artery bypass grafts. In the present study, responses of long-term human coronary artery bypass grafts (CABGs) to known endothelium-dependent vasodilators, acetylcholine, calcium ionophore A23187, thrombin, and histamine, as well as authentic nitric oxide, the putative endothelium-derived relaxing factor, were studied. Sixteen CAGBs were isolated within 1-2 hours from hearts of 14 patients receiving a cardiac transplant. A total of 109 ring segments were prepared from these CABGs and studied in vitro. The duration of the CABGs ranged from 7 months to 12 years. Addition of acetylcholine (0.01-10 microM), calcium ionophore A23187 (0.01-1.0 microM), thrombin (0.01-1.0 unit/ml), and histamine (0.01-1.0 microM) consistently produced a dose- and endothelium-dependent relaxation, reaching a maximum of -35.3 +/- 3.3%, -45.3 +/- 5.5%, -26.9 +/- 4.8%, and -17.8 +/- 2.5% (mean +/- SEM), respectively. No significant difference was observed among the CABGs with different duration of transplantation, whereas the relaxant responses of different segments along the entire length of a CABG were markedly different. These latter differences in the endothelium-dependent responses appear to correlate inversely with the development of intimal proliferative lesions in these CABGs. Addition of nitric oxide (0.01-10 microM) produced a potent dose- and endothelium-independent relaxation, which was also slightly depressed in CABGs with severe intimal proliferation. These results demonstrate that long-term transplanted human saphenous vein grafts retain their endothelium-dependent responses and that development of severe intimal proliferative lesions, rather than the duration of the grafts, result in marked alterations in the reactivity of these transplanted CABGs. | 4 |
Comparison of blood flow assessment between laser Doppler velocimetry and the hydrogen gas clearance method in ischemic intestine in dogs. Blood flow of the colon and the ileum was measured before and after intestinal devascularization by laser Doppler velocimetry and the hydrogen gas clearance technique in 10 dogs in order to evaluate the clinical usefulness of laser Doppler velocimetry. The submucosal blood flow of the colon and the ileum measured by the hydrogen gas clearance method was significantly decreased, as was the subserosal blood flow of both sites measured by laser Doppler velocimetry. There was a linear relationship between the flow values using the two methods both in the colon (r = 0.7192, p less than 0.001) and in the ileum (r = 0.7646, p less than 0.001). These data suggested laser Doppler velocimetry may be a useful method to assess the degree of intestinal ischemia because of its noninvasiveness and good correlation with submucosal blood flow by the hydrogen gas clearance technique. | 3 |
Reciprocal inhibition between forearm muscles in spastic hemiplegia. We studied reciprocal inhibition of H-reflexes in the forearm flexor and extensor muscles in 14 patients with spastic hemiplegia secondary to a focal cerebral lesion and 14 normal volunteers. In the spastic limb, the Hmax/Mmax ratio was increased in both flexor and particularly extensor wrist muscles. The 3 normal inhibitory phases of reciprocal inhibition between extensor and flexor forearm muscles were markedly reduced on the spastic side of patients. The early disynaptic phase showed the greatest alteration. Reduced or absent inhibition between forearm muscles associated with increased spinal motoneuron excitability may be typical to spastic hemiplegia. | 2 |
Computerized tomography as an indicator of isolated mesenteric injury. A comparison with peritoneal lavage. This study evaluated 18 patients with blunt abdominal trauma who suffered isolated mesenteric injuries, diagnosed at exploratory laparotomy. Thirteen had diagnostic peritoneal lavage (PL) as their initial diagnostic study, and five had computed tomography (CT). All patients who had positive PL were explored emergently, undergoing repair of mesenteric injuries. Three of the five patients with CT as initial studies had delayed recognition of their injuries due to incorrect initial interpretation of the scan in two, and a false negative scan in one. Two of these patients developed intestinal infarction and required bowel resection. There were no complications in the PL group related to surgery; morbidity was greater in those undergoing CT. We conclude that early laparotomy and repair of significant mesenteric injuries is necessary to reduce morbidity, and that PL is a more sensitive indicator of this injury than CT. | 4 |
A prospective study of double diagnosis of nonpalpable lesions of the breast. Approximately three-fourths of open biopsies of the breast performed for mammographically detected suspicious lesions are shown histologically to be benign. Under the narrow conditions described herein, stereotaxic fine-needle aspiration (FNA) can identify these lesions with an accuracy of more than 90 per cent and a false-negative rate of 5 per cent. In an effort to reduce this failure rate, the mammographic appearance and stereotaxic FNA results of these lesions each were given scores on a scale of zero (benign) to five (malignant), to derive an over-all risk score prospectively applied to 264 suspicious occult lesions of the breast prior to open, biopsy. While all 264 lesions could be assigned a mammographic score, adequate tissue for assignment of a cytologic score could be obtained from 150 lesions. Of the 150 evaluable lesions, 53 were malignant and 97 were benign, historically. With a total score of two as the threshold for open biopsy, 21 of 150 (14 per cent) were proved to be benign, with no false-negative findings. If the total threshold score mandating an open biopsy was raised to four, the comparable figures were 61 of 150 (40 per cent) benign lesions and two false-negative instances of carcinoma in situ. Provided adequate tissue is aspirated for cytologic examination, we conclude that this algorithm has practical value in the management of nonpalpable lesions of the breast in that it can reliably identify a fraction of the benign lesions and spare these patients an operation. | 0 |
Adrenal medullary implants in the rat spinal cord reduce nociception in a chronic pain model. Previous work in this laboratory has indicated that the transplantation of adrenal medullary tissue into the subarachnoid space of the rat spinal cord can reduce pain sensitivity to acute noxious stimuli, particularly following stimulation by nicotine. This most likely results from the stimulated release of opioid peptides and catecholamines from the transplanted chromaffin cells. However, chronic pain models may more closely resemble human clinical pain, and the arthritic rat model has been used for screening potential therapeutic strategies. The purpose of the present study was to assess the potential for adrenal medullary tissue implanted into the spinal subarachnoid space to alleviate chronic pain. Adrenal medullary tissue was implanted into adjuvant-induced arthritic rats, and changes in body weight and vocalization responses were monitored over the 10 week course of the disease. Results indicate that the severe weight reduction normally associated with this inflammatory arthritis was attenuated by adrenal medullary, but not control, implants. In addition, vocalizations were reduced in animals implanted with adrenal medullary, but not control tissue following nicotine stimulation. This reduction was blocked by the opiate antagonist, naloxone, and partially attenuated by the alpha-adrenergic antagonist, phentolamine. Together, these results suggest that the transplantation of adrenal medullary tissue into the subarachnoid space of the spinal cord may provide a local source of opioid peptides and catecholamines for the reduction of chronic pain. | 2 |
Panic disorder and cardiovascular/cerebrovascular problems: results from a community survey. Follow-up studies of psychiatric patients with panic disorder have shown an abnormally high mortality rate in men due to cardiovascular and cerebrovascular events. The authors report that in the New Haven portion of the Epidemiologic Catchment Area program the risk for stroke in persons with lifetime diagnoses of panic disorder was over twice that in persons with other psychiatric disorders or no psychiatric disorder. After adjustments for demographic differences between groups, the risk was even higher. While the results should be interpreted cautiously because of the small sample and absence of medical examinations, these findings are consistent with clinical studies showing an association between panic disorder and cardiovascular/cerebrovascular events. | 3 |
Mixed connective tissue disease with arterial thrombosis, antiphospholipid antibodies and heparin induced thrombocytopenia. We report a patient with mixed connective tissue disease (MCTD) who presented with thrombosis of the right femoral artery in association with antiphospholipid antibodies (aPL). When treated surgically and with heparin prophylaxis, she developed heparin induced thrombocytopenia and thrombosis which necessitated amputation of a lower limb. Thus our patient developed 2 separate groups of autoantibodies associated with thrombotic events. Our case highlights an association between thrombosis, aPL and MCTD. Furthermore, it emphasizes a need for intensive monitoring when hypercoaguable individuals with connective tissue disorders are treated with heparin. | 3 |
Kearns-Sayre syndrome presenting as renal tubular acidosis. Renal tubular acidosis and tetany were the 1st manifestations of Kearns-Sayre syndrome in a 5-year-old child. Subsequently, he developed progressive external ophthalmoplegia, ptosis, retinopathy, heart block, and endocrinopathy. There was a 7.5-kb deletion of mitochondrial DNA documented in muscle, kidney, skin fibroblasts, and leukocytes, providing evidence for a multisystem mitochondrial cytopathy. | 2 |
Results of repeat percutaneous balloon valvuloplasty for pulmonary valvar restenosis. Follow-up cardiac catheterization studies were used to evaluate 105 patients who had undergone percutaneous balloon pulmonary valvuloplasty. Fifteen of those patients who had peak systolic pulmonary valve gradients greater than = 40 mm Hg at follow-up underwent repeat balloon valvuloplasty. For the initial balloon pulmonary valvuloplasty, the mean ratio of the balloon diameter to pulmonary valve annulus diameter was 0.98 +/- 0.2; at repeat valvuloplasty the mean was 1.19 +/- 0.12. The immediate post-repeat balloon valvuloplasty results showed a reduction in the peak systolic gradient from a mean of 70.2 +/- 17.8 to 29.1 +/- 19.0 mm Hg (p less than 0.001). This reduction in the gradient was maintained at a mean of 14.3 +/- 5.0 mm Hg in 8 of the 10 patients who underwent further follow-up studies. We conclude that successful repeat balloon pulmonary valvuloplasty with the use of larger sized balloons is feasible in patients who have restenosis after the initial percutaneous balloon valvuloplasty--including partial but not complete dysplasia of the pulmonary valve. | 3 |
The beta globin 3' enhancer element confers regulated expression on the human gamma globin gene in the human embryonic-fetal erythroleukemia cell line K562. We have constructed fusion genes comprised of gamma and beta globin elements and globin sequences linked to neomycin resistance (neoR) genes to define the cis acting sequences responsible for developmental stage-specific expression and induction of fetal globin genes in embryonic-fetal erythroleukemia K562 cells. The results indicate that the gamma promoter is required for proper initiation of transcription. However, the accumulation of gamma globin transcripts in response to hemin induction requires the additional presence of either gamma intervening sequence 2 or the 3' enhancer element of the beta globin gene. Thus, the gamma promoter may provide the elements for developmental stage-specific gene expression during fetal life. By contrast, the beta 3' enhancer is erythroid-specific but not developmental stage- or gene-specific. | 0 |
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