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Potential role of the tissue renin-angiotensin system in the pathophysiology of congestive heart failure. The circulating renin-angiotensin system (RAS) plays an important role in the maintenance of cardiovascular homeostasis. It has recently been demonstrated that endogenous RAS exist in target tissues that are important in cardiovascular regulation. This article reviews the multiple effects of angiotensin II in target tissues, the evidence for the presence of functional tissue RAS and the data that suggest a role for these tissue RAS in the pathophysiology of heart failure. Activation of circulating neurohormones is predictive of worsened survival in heart failure; however, cardiac and renal tissue RAS activities are also increased in the compensated stage of heart failure, when plasma renin-angiotensin activity is normal. It is hypothesized that the plasma RAS maintains circulatory homeostasis during acute cardiac decompensation, while changes in tissue RAS contribute to homeostatic responses during chronic sustained cardiac impairment. This concept of different functions of circulating and tissue RAS in the pathophysiology of heart failure may have important pharmacologic implications. | 3 |
Nontraumatic coma. Glasgow coma score and coma etiology as predictors of 2-week outcome. In 1987 and 1988, we carried out a prospective study of patients older than 10 years with nontraumatic coma in the intensive care units of Columbia-Presbyterian Medical Center, New York, NY. Of 188 patients with Glasgow Coma Scale (GCS) determinations within 72 hours, 61% were dead or in persistent coma by 2 weeks from onset. Age, sex, and ethnicity did not influence outcome. The 2-week outcome for patients with initial GCS of 3 to 5 was 14.8% awake; 85.2% were dead or in persistent coma. For the GCS 6 to 8 group, 53.1% were awake and 46.9% were dead or in persistent coma. Hypoxic or ischemic coma had the worst 2-week outcome (79% dead or comatose); coma caused by metabolic disease or sepsis (68%), focal cerebral lesions (66%), and general cerebral diseases (55%) were intermediate, while drug-induced coma had a favorable outcome (27% dead or comatose). The independent predictors of 2-week outcome were the first GCS and drug-induced coma. The predicted probability of waking at 2 weeks was eight times better for drug-induced coma than other causes when GCS was held constant. Patients with an initial GCS score of 6 to 8 were seven times more likely to waken than those with a score of 3 to 5. The motor subscore alone was a significant independent predictor of 2-week outcome. Modification of coma score to include etiology may give more accurate predictions of 2-week outcome after nontraumatic coma. | 4 |
Etiology and pathophysiology of pyelonephritis. Escherichia coli is the most frequent cause of pyelonephritis. Its possible virulence factors include the ability to adhere and colonize the urinary tract, an important initiating factor in all urinary tract infections (UTIs). The importance of P fimbriae in this adhesion is stressed and the evidence for its importance in pyelonephritis is presented in epidemiologic studies of patients, as well as in animal studies. It appears that both host receptor density and the nonsecretor state is responsible for susceptibility to urinary tract infection. Vesicoureteral reflux can be responsible for ascending upper tract infection, but infection with P-fimbriated E coli may lead to ascending pyelonephritis without reflux because of the paralytic effect of lipid A on ureteral peristaltic activity. Renal ischemia leads to renal damage following infection by reperfusion damage due to the release of superoxide. Experimentally, this ischemic damage can be prevented by allopurinol, a xanthine oxidase inhibitor. The acute inflammatory response can produce renal damage because of the respiratory burst of phagocytosis, which while killing phagocytosed bacteria also damages renal tubules. An amelioration of the inflammatory response by treatment with superoxide dismutase or corticosteroids has been shown to modulate renal damage. Vaccination with P fimbriae has been shown experimentally to prevent the initiation of the disease. However, since vaccines are not clinically available, the clinical and animal studies on therapy of acute disease are stressed. Acute pyelonephritis during the first 3 years of life more often produced the renal damage that could lead to end-stage renal disease. | 3 |
Tumor necrosis factor and severe malaria. To investigate the relation of tumor necrosis factor-alpha (TNF alpha) to Plasmodium falciparum infection, plasma TNF alpha concentrations were measured in Zairian children with severe malaria, mild malaria, or other illnesses. The initial geometric mean plasma concentration of TNF alpha among 61 children with P. falciparum infection, (71 pg/ml) was higher than the level in 26 severely ill, aparasitemic children (10 pg/ml; P less than .001). Among 29 parasitemic children, initial geometric mean TNF alpha levels decreased from 77 to 5 pg/ml (P less than .001) at day 7. TNF alpha levels increased with parasite density and were associated with hyperparasitemia, severe anemia, hypoglycemia, and young age but not with cerebral malaria or fatal outcome. However, TNF alpha levels were elevated equally in children with cerebral malaria and with other signs of severe malaria. With multiple linear regression, TNF alpha levels were elevated independently in children with hyperparasitemia (P = .001) and severe anemia (P = .04). In this study, high TNF alpha levels were associated with several manifestations of severe malaria and were not specific to cerebral malaria. | 2 |
Renal abscess in children. Three cases of renal abscesses in children are described to illustrate the variable presenting features. An additional 23 pediatric cases, reported over the past ten years, were reviewed for clinical features and therapy. Fever, loin pain, and leukocytosis were common presenting features, but less than half of all abscesses were associated with either an abnormal urinalysis or a positive urine culture. The presenting features were sometimes confused with appendicitis, peritonitis, or a Wilms tumor. An organism was identified in 17 cases--Escherichia coli in 9 children and Staphylococcus aureus in 8 children. The majority of E. coli infections occurred in girls and the majority of S. aureus infections occurred in boys. Reflux was documented in 5 patients, and 2 children had a possible extrarenal source of infection. Antibiotics alone produced a cure in 10 children (38%), but 16 children (62%) required a surgical procedure. | 4 |
Mitral valve prolapse. When is it serious? Mitral valve prolapse can best be diagnosed with careful clinical evaluation, including dynamic auscultation. Treatment consists of reassurance, pharmacotherapy for troublesome symptoms, and careful monitoring for signs of complications. Most complications can be either prevented or treated. | 4 |
A predominantly adrenaline-secreting phaeochromocytoma. A 61-year-old woman who presented with diabetes, nausea, weight loss and sweating was found to have a phaeochromocytoma secreting adrenaline, with a small amount of N-methyladrenaline. There was no significant increase in noradrenaline secretion. She was normotensive, and developed profound hypotension in response to the alpha-adrenergic antagonist phenoxybenzamine. These features are unusual in phaeochromocytoma, but similar features occurred in the very few previous reported cases of pure adrenaline-secreting phaeochromocytoma. We conclude that it is important to identify such patients, so that they should not be given alpha-adrenergic antagonist drugs. | 0 |
Vascular abnormalities in epidermal nevus syndrome. We report a patient with epidermal nevus syndrome and right hemispheric infarct and review 3 others with neurologic manifestations best explained by ischemia or hemorrhage. Each had a significant vascular abnormality such as occlusion or blood vessel dysplasia. None had hemimegalencephaly. We hypothesize that underlying vascular dysplasia is the cause of the neurologic lesions in these patients. | 0 |
Driving and epilepsy. A review and reappraisal Driving and epilepsy is a problem that involves physicians as both care providers to patients and consultants to regulatory authorities. Driving restrictions for people with seizure disorders are intended to ensure the public's safety, but such restrictions may unduly harm the welfare of many people with seizures. In the United States, all states now permit some people with epilepsy to drive. In general, only people whose seizures are adequately controlled are licensed to drive. Adequate control has been judged principally by the seizure-free interval, but individual state standards widely vary. There is a trend toward greater liberalization of driving standards for people with seizure disorders, but the appropriateness and application of these standards continue to raise questions, as does the role physicians should have in the licensing process. Our responsibilities to persons with disabilities and advances in our understanding of seizures and the nature of driving risks warrant a reappraisal of the current medical, legal, and social implications of driving and epilepsy. | 2 |
Electrophysiologic findings after Fontan repair of functional single ventricle. Cardiac arrhythmias are well recognized sequelae of the Fontan operation for complex congenital anomalies. In this study the electrophysiologic effects of the Fontan procedure were evaluated in 30 patients who underwent cardiac catheterization with electrophysiologic study 1.9 +/- 1.3 years (mean +/- SD) after modified Fontan repair for functional single ventricle. Abnormalities of sinus node or ectopic pacemaker automaticity were detected in 50% (15 patients) by determination of a prolonged corrected sinus node or pacemaker recovery time. Total sinoatrial conduction time was prolonged in 50% of the patients with normal sinus rhythm. Sinus node or ectopic atrial pacemaker function was entirely normal in only 43% of patients. The predominant atrial rhythm was normal sinus in 70% and ectopic atrial or junctional in 30%. Abnormalities of atrial effective and functional refractory periods were noted in 43% of patients and were most pronounced at faster paced cycle lengths. Atrial endocardial catheter mapping revealed intraatrial conduction delays between adjacent sites in 76% of the patients tested and in eight of nine patients with inducible intraatrial reentry. Programmed atrial stimulation induced nonsustained supraventricular arrhythmias in 10% of the 30 patients and sustained arrhythmias in 27%. Intraatrial reentry was the most common inducible arrhythmia and was present in seven of the eight patients with sustained and two of the three patients with nonsustained atrial arrhythmias. Atrioventricular conduction abnormalities were noted in 10% (three patients). No patient had inducible ventricular arrhythmias with programmed ventricular stimulation. The electrophysiologic findings after Fontan repair include abnormal sinus node function, prolonged atrial refractoriness, delayed intraatrial conduction and inducible atrial arrhythmias. | 4 |
Treatment of severe peptic esophageal stricture with Roux-en-Y partial gastrectomy, vagotomy, and endoscopic dilation. A follow-up study Eleven patients with dysphagia caused by severe esophageal stricture (length 2 to 10 cm) resulting from reflux esophagitis were treated with fibroendoscopic dilation (Eder-Puestow) and Roux-en-Y partial gastrectomy with vagotomy during 10 years (1979 to 1988). There was no operative mortality, but complications developed in three patients: One patient had a mediastinal abscess demanding thoracotomy as a result of esophageal perforation after dilatation; one had postoperative pneumonia; and one patient had ileus. After a mean follow-up of 4 years (range 1 to 10 years) esophagitis healed in all cases, as judged by endoscopy. Eight patients were asymptomatic, but three had slight transient dysphagia. Postoperatively one to eight dilations (average three to four) were needed to relieve dysphagia in the first postoperative year, but later the stricture healed in every case. Postoperative pH measurement was performed in six latest patients and showed complete absence of reflux in all cases. It is concluded that Roux-en-Y partial gastrectomy with vagotomy and endoscopic dilation is an effective, simple, and safe procedure in the management of severe peptic esophageal (acid or alkaline esophagitis) stricture. However, occasional postoperative dilations at the outpatient clinic are often needed in severe cases in the first postoperative year. | 1 |
Assessment and counseling of coronary risk factors by family practice residents. A study was undertaken to determine (1) the likelihood that patients seen for episodic health care in a family medical center have been assessed and counseled for coronary heart disease (CHD) risk factors, and (2) the likelihood that patients having an identified risk factor have been assessed and counseled regarding other CHD risk factors. One thousand five hundred twenty-eight medical records were randomly selected from all visits occurring over two periods in 1986 and 1987 to 122 residents in an eight-site family medicine residency network. Patients with cardiovascular disease and those younger than 20 or older than 65 years of age were excluded. Assessments were made of (1) smoking history, blood pressure, weight, physical activity, and dietary content during the previous 12 months; (2) family history of cardiovascular disease during the previous 12 months and in the initial patient history; (3) and blood cholesterol during the prior 5 years. Risk-factor counseling practices were examined for the previous 12 months. Blood pressure was assessed in 96% of patients, smoking in 40%, cholesterol in 26%, and family history in 52%. Ninety-six percent of hypertensive patients were counseled for hypertension, but only 45% of smokers and 20% of patients with hypercholesterolemia were counseled for those risk factors. Of patients having a given risk factor, assessment for any other risk factor occurred in fewer than 60% of cases. Patients having a documented positive family history were only slightly more likely than other patients to be assessed for additional risk factors. There is continued need for enhancing coronary risk-factor assessment and counseling by resident physicians. | 3 |
Cerebellopontine angle lipoma in a teenager. Lipomas of the cerebellopontine angle are very rare lesions. To date, 18 patients have been reported, 17 of whom were adults. A second child is described with cerebellopontine angle lipoma. | 0 |
Analysis of programmed stimulation methods in the evaluation of ventricular arrhythmias in patients 20 years old and younger. The purpose of this study was to systematically evaluate programmed ventricular stimulation in patients less than 21 years of age undergoing electrophysiologic testing. A standardized protocol was applied in 55 consecutive patients (mean age 14 years) with the following clinical presentations: sustained ventricular tachycardia (VT) (n = 17); ventricular fibrillation (VF) (n = 7); syncope with heart disease (n = 10); nonsustained VT (n = 6); and syncope with an ostensibly normal heart (n = 15). The stimulation protocol consisted of 1 and 2 ventricular extrastimuli during sinus rhythm, followed by 1 to 4 (S2, S3, S4, S5) extrastimuli during pacing at 2 ventricular sites. Of the 17 patients with sustained VT, 12 had induction of the arrhythmia (sensitivity = 71%). Overall, 18 of 55 patients had inducible sustained VT, with this response significantly enhanced by use of S4 or S5 protocols (p = 0.02). Although no syncope patients with an ostensibly normal heart had inducible sustained VT, 7 had polymorphic nonsustained VT in response to ventricular stimulation. The mean number of extra-stimuli preceding the induction of nonsustained or sustained VT or VF did not differ. The induction of VF in 5 cases during this study was preceded in each case by extrastimuli intervals less than or equal to 190 ms. Thus, data indicate that aggressive stimulation protocols appear to be required for induction of sustained VT in most young patients, nonsustained polymorphic VT as a response to aggressive programmed stimulation is of uncertain significance, and that coupling intervals less than or equal to 190 ms may correlate with the induction of VF. | 3 |
Multiple adenomas of the human pituitary. A retrospective autopsy study with clinical implications. In a review of autopsy material from two centers, 20 pituitary glands were found containing multiple adenomas. In total, 44 adenomas were identified histologically; 16 glands contained double tumors and in four glands triple adenomas were found. Size was measured in 30 tumors, all of which were microadenomas. Thirty-four adenomas were located in the lateral wings and 10 lay in the median wedge. Forty-one tumors were chromophobic and three were basophilic. Immunocytochemical analysis of the 44 tumors demonstrated the presence of prolactin in 11, adrenocorticotropic hormone in three, growth hormone in one, and alpha-subunit as well as follicle-stimulating hormone and luteinizing hormone in one. Of the 20 patients studied, there were 11 men and nine women, with an average age of 69 years. All patients died from various nonendocrine causes. With the exception of one patient who appeared mildly acromegalic, no correlation was observed between pituitary morphology and clinical data. This study found a 10.4% frequency of adenomas in pituitaries studied randomly at autopsy. Multiple tumors were encountered in 0.9% of cases. Despite its low frequency, adenoma multiplicity may underlie surgical failure in cases in which one adenoma is removed and the other is left behind. | 0 |
Hemodynamic effects of partial correction of chronic anemia by recombinant human erythropoietin in patients on dialysis. Eighteen patients on chronic hemodialysis with renal anemia were treated with recombinant human erythropoietin (r-HuEPO). Hemodynamic parameters in the resting state were determined before and after successful treatment. Posttreatment cardiac index was decreased (3.3 v 2.8 L/min/m2), whereas diastolic blood pressure (72 v 79 mm Hg) and calculated peripheral resistance (2,230 v 2,860 dyne.cm.s-5) were increased significantly when compared with the pretreatment period. We conclude from our study that the increase of blood pressure as seen in patients on dialysis, who are effectively treated with r-HuEPO, is due to an increase in peripheral resistance. This increase overrules the decrease of cardiac index and might well be a result of peripheral vasoconstriction due to improved oxygen availability. | 4 |
Causes and consequences of blood pressure alterations in obstructive sleep apnea. The obstructive sleep apnea (OSA) syndrome has been considered to be a cause of both transient blood pressure elevations during sleep and sustained hypertension during the awake state. The purpose of this review was to examine critically the existing literature regarding (1) the blood pressure alterations associated with OSA, (2) causal mechanisms relating specific blood pressure alterations to OSA, and (3) potential consequences of the systemic circulatory abnormalities associated with OSA. Particular attention was directed at studies that assessed the prevalence of OSA in patients with hypertension and that examined the effects on blood pressure of treatment of OSA. We conclude that patients with OSA have abnormal sleep blood pressure patterns, manifested most frequently by apnea-associated blood pressure elevations. Confounding factors such as obesity and antihypertensive drug therapy, and conflicting evidence regarding changes in daytime blood pressure after therapy for OSA, make it premature to conclude that OSA and daytime hypertension are directly associated. Circumstantial evidence suggests that the blood pressure alterations that occur during sleep could contribute to the high cardiovascular morbidity in patients with OSA. Further research into the relationship between OSA and hypertension should improve the future care of patients with these conditions and enhance our understanding of cardiopulmonary pathophysiology. | 3 |
Radiotherapy alone versus combined chemotherapy and radiotherapy in nonresectable non-small-cell lung cancer: first analysis of a randomized trial in 353 patients. We report the results observed in a large, randomized study that compared the effects of radiotherapy alone (the standard therapy) with those of a combination of radiotherapy and chemotherapy in nonresectable squamous cell and large-cell lung carcinoma. The radiation dose was 65 Gy in each group, and chemotherapy included vindesine, cyclophosphamide, cisplatin, and lomustine. In this study, 177 patients received radiotherapy alone (group A), and 176 patients received the combined treatment (group B). The 2-year survival rate was 14% in group A and 21% in group B (P = .08). The distant metastasis rate was significantly lower in group B (P less than .001). Local control was poor in both groups (17% and 15%, respectively) and remained the major problem. | 0 |
Decline in the prevalence of childhood deafness in the Jewish population of Jerusalem: ethnic and genetic aspects. A longitudinal study was performed on 147 Jewish children with bilaterally sensorineural hearing loss of moderately severe to profound degree, born in Jerusalem during the eighteen years 1968-85. The prevalence rate of these children declined during the years 1977-85, and at the same time the rate of consanguinity of their parents decreased; this decline was more evident in the genetic group among children with non-Ashkenazi ethnic origin. No such decline was found among the Ashkenazi children and no consanguinity among parents of these children was recorded. Our study supports the assumption that restriction of consanguineous matings may affect the prevalence of genetic deafness in children in a well-defined population. We have tried to remain unbiased and concede certain shortcomings in our present study. | 2 |
Angiographic demonstration of acute phase of intracranial arterial spasm following aneurysm rupture. Case report. A case documenting the acute phase of intracranial arterial spasm following rupture of an aneurysm arising from the left internal carotid artery is reported. The patient deteriorated due to recurrent hemorrhage while undergoing angiography 12 hours after the initial aneurysm rupture. The acute deterioration was accompanied by dilatation of the ipsilateral pupil and occurred during injection of contrast material. There was delayed filling of the middle cerebral artery complex along with this narrowing. The arterial narrowing was confirmed to have completely disappeared on an angiographic series performed 14 minutes after the first series of films. The etiology of the acute vasospasm is discussed. | 3 |
Regional differences in the intranodal distribution of tumor cells. The intranodal distribution of tumor cells was examined in 103 mesenteric and 135 axillary nodes to determine the frequency of a circumferential type of distribution and its relationship, if any, to central necrosis. Eighteen percent of the mesenteric nodes removed at surgery from patients with colon cancer contained a circumferential rim of viable tumor cells in an area corresponding wholly or in part to the normal location of the marginal sinus. In each case this rim of tumor cells surrounded a large central area of necrosis. In contrast, only one of the 135 axillary nodes removed from patients with breast cancer demonstrated this pattern. These findings suggest that by interrupting blood and lymph vessels, the circumferential spread of tumor cells underlies development of central necrosis. Previously described structural dissimilarities between mesenteric and axillary nodes may explain the striking difference in incidence of this pattern in these nodes. | 4 |
Intravenous diclofenac sodium. Does its administration before operation suppress postoperative pain? Intravenous diclofenac sodium was evaluated in a double-blind randomised trial relative to intramuscular diclofenac, intravenous fentanyl, and intramuscular placebo in 160 patients undergoing extraction of impacted lower third molar teeth. The test drug was administered before operation in an attempt to alleviate postoperative pain. A 10-cm visual analogue scale was used to assess pain at 30 minutes and one day after surgery, if the patients stayed overnight. Patients who received intravenous diclofenac had significantly less pain than the other groups 30 minutes after operation. They also had significantly less pain one day after surgery than the placebo or opioid groups, but not less than the intramuscular diclofenac group. Capillary bleeding time, in comparison with placebo, was significantly prolonged after the use of intramuscular diclofenac, and a similar but nonsignificant trend was observed in the intravenous diclofenac group. No problems were encountered with excessive bleeding in any group. | 4 |
Compliance, reliability, and validity of self-monitoring for physical disturbances of Parkinson's disease. The Parkinson's Symptom Diary. Previous clinical research in Parkinson's disease has recognized the value of self-monitoring procedures in which patients observe and record the frequency and severity of their own symptoms as these occur within the patient's social and work environment. We discuss issues of methodology and report a study of compliance, test-retest reliability, and validity with a new self-monitoring instrument, the Parkinson's Symptom Diary. Two recordings of frequency (loss of balance, hesitation-freezing) and two ratings of severity (tremor, difficulty walking) were made four times daily for one week by patients (N = 73) who were without apparent loss of cognitive or memory functions. A total of 91% of the diaries received (97% of requested) met strict compliance criteria so that independent sampling over days could be assumed. Test-retest stability over one month was demonstrated for each score (all Spearman rho greater than .85) in a representative subsample of 28 patients. Criterion validity was demonstrated for each score by an expected pattern of correlations with independently obtained observer ratings of the same or related indices of disease, and by comparison with Hoehn and Yahr disability stages. By its simplicity, this self-assessment device can be an invaluable complement to traditional methods of clinical and laboratory assessment in the care and evaluation of Parkinson patients. | 2 |
Long-term results following surgical management of aortic graft infection. Between January 1970 and June 1988, a total of 45 patients with aortic prosthetic graft infection underwent removal of the infected aortic prosthesis. In addition, 36 of these patients also underwent revascularization via an extra-anatomic bypass. We analyzed the early and long-term results with respect to survival, limb salvage, freedom from infection, and extra-anatomic graft patency. The 30-day mortality was 24% (11/45), and the amputation rate was 11% (8/73). During a mean follow-up of 36 months (range, 2 to 144 months), 80% (24/30) of the patients remained free of infection and are considered cured. Infection in the extra-anatomic bypass graft was the most common cause of recurrent sepsis and the leading cause of late amputations (four of seven). By life-table methods, 1-year survival was 63% and 5-year survival was 49%. Limb salvage rates at 1 and 5 years were 79% and 66%, respectively. The primary patency rate of extra-anatomic bypass was 43% at 3 years, with the secondary patency rate improved to 65%. These early and late results are in marked contrast to the natural history of untreated aortic graft infection. Nonetheless, a perioperative mortality rate of 24%, a 5-year limb loss rate of 33%, and 3-year graft thrombosis rate of 35% are testimony to the serious nature of aortic graft infection and the need to develop better methods to prevent this complication. | 4 |
Probability of rupture of an abdominal aortic aneurysm after an unrelated operative procedure: a prospective study. It has been assumed by some authors that patients with abdominal aortic aneurysms may be at increased risk of rupture after unrelated operations. From July 1986 to December 1989, 33 patients (29 men, 4 women) with a known abdominal aortic aneurysm underwent 45 operations. Twenty-eight patients had an infrarenal abdominal aortic aneurysm, and five patients had a thoracoabdominal aneurysm. The abdominal aortic aneurysm ranged in transverse diameter from 3.0 to 8.5 cm (average 5.6 cm). Twenty-seven patients underwent a single operation, and six patients had two or more (range of 1 to 6). Operations performed were abdominal (13); cardiothoracic (9); head/neck (2); other vascular (11); urologic (7); amputation (2); breast (1). General anesthesia was used in 29 procedures, spinal/epidural in 6, and regional/local in 10. One postoperative death occurred from cardiopulmonary failure. One patient died of a ruptured abdominal aortic aneurysm at 20 days after coronary artery bypass (1/33 patients [3%]; 1/45 operations [2%]). Fourteen patients had repair of their abdominal aortic aneurysm at a later date, an average of 18 weeks after operation. Four patients had abdominal aortic aneurysm considered too small to warrant resection (average 3.6 cm). Four patients were considered at excessive risk for elective repair. The five thoracoabdominal aneurysm were not repaired. Four patients are awaiting repair. During this same 40-month period, two other patients, not known to have an abdominal aortic aneurysm, died of a ruptured abdominal aortic aneurysm after another operative procedure, at 21 days and 77 days. All three ruptured abdominal aortic aneurysms were 5.0 cm or greater in transverse diameter. | 3 |
The surgical management of chronic parotitis. Chronic parotitis is a disorder characterized by recurrent painful swelling of the gland with purulent sialorrhea. Occasionally, the condition fails to respond to medical management and definitive surgical therapy is necessary. Sialolithiasis is the usual etiology in cases of parotitis, although occasionally severe recurrent parotid infections are superimposed on underlying Sjogren's disease. Total parotidectomy with facial nerve dissection has been used in such cases in our department and has proved to be an excellent way to manage this disease. A summary of our results indicate that the recurring infections were eradicated and that the complication rate is tolerable, considering the magnitude of the problem. We feel that it is better to use surgical management early rather than wait for the formation of fistulae or abscesses. | 4 |
Nicardipine reduces the cardio-respiratory toxicity of intravenously administered bupivacaine in rats. The purpose of our study was to examine the effect of intravenous (IV) nicardipine pretreatment (30 micrograms.kg-1), given three minutes before an IV bolus of bupivacaine to determine its effect on the incidence of fatal bupivacaine cardio-respiratory toxicity in adult male Sprague Dawley rats anaesthetized with intraperitoneal pentobarbital. Fifty rats were divided into four groups. Groups I and II (n = 10 each) received 3.5 mg.kg-1 0.5 per cent bupivacaine and Groups III and IV (n = 15 each) received 5.0 mg.kg-1, 0.5 per cent bupivacaine. Groups I and III received pretreatment with normal saline before bupivacaine, whereas Groups II and IV were given pretreatment with nicardipine, 30 mg.kg-1. There was no difference in the incidence of survival between the nicardipine pretreatment group and the saline placebo pretreatment group given 3.5 mg.kg-1, 0.5 per cent bupivacaine (no fatalities in either group). However, there was significant protection by nicardipine pretreatment in the group given 5 mg.kg-1, 0.5 per cent bupivacaine (13 of 15 survived, compared with only 4 of 15 in the saline pretreatment group, P less than 0.001). In conclusion, our data demonstrate that in rats given 0.5 per cent bupivacaine, 5 mg.kg-1, nicardipine pretreatment protected against fatal cardio-respiratory toxicity. | 4 |
Chronic Lyme disease with an expansive granulomatous lesion in the cerebellopontine angle. Expansive granulomatous lesions in the posterior cranial fossa are rare and have not been reported in conjunction with Lyme disease. We report a patient with verified Borrelia burgdorferi infection who developed a tumor in the cerebellopontine angle. Rapid growth of the tumor led to signs of cerebral compression and to hydrocephalus. Surgical intervention was required despite florid meningitis. The histological examination showed inflammatory, nonspecific granulation tissue. The origin of this tissue is almost certainly causally related to the B. burgdorferi infection. Signs of inflammation resolved rapidly after subtotal resection. The clinical, radiological, and biochemical course is documented. This is the first report of an expansive cerebral lesion in the chronic phase of Lyme disease. | 4 |
Gadolinium-enhanced magnetic resonance imaging in Bell's palsy. Inflammation of the facial nerve in Bell's palsy can be demonstrated on gadolinium-enhanced magnetic resonance imaging. We have studied a series of 17 Bell's palsy patients with gadolinium-enhanced magnetic resonance imaging, and the purpose of this paper is to report our findings and discuss their significance. Most acute Bell's palsy cases demonstrate facial nerve enhancement, usually in the distal internal auditory canal and labyrinthine/geniculate segments. Other segments demonstrate enhancement less often. Gadolinium enhancement occurs regardless of the severity of the paralysis and can persist after clinical improvement of the paralysis. The findings of this study corroborate other evidence that the segments of the facial nerve most often involved in Bell's palsy are the only segments that are most often enhanced with gadolinium-enhanced magnetic resonance imaging. The role of gadolinium-enhanced magnetic resonance imaging in the management of Bell's palsy patients is discussed. | 4 |
Selective myectomy for postparetic facial synkinesis. Synkinetic movements are secondary to facial palsy because they appear like a late sequela to spontaneously healing facial nerve injury. They are produced by an involuntary contraction of a muscle group simultaneous with contraction of other homologous muscle groups. The disorderly regeneration of severed axons is responsible for these movements. According to the Lippschitz theory, the regenerating nerve fibers sprout into the wrong peripheral branches. Between 1975 and 1986, 71 patients with facial paralysis were evaluated. Spontaneous recovery from the facial paralysis occurred in 28 of these patients; 14 (50 percent) developed synkinetic movements, and surgical treatment was sought by only 6 patients. In all patients, the lesion of the facial nerve was in the trunk, proximal to the principal ramification. The most frequent clinical finding was simultaneous activation between the orbicularis oculi and the elevators of the corner of the mouth (12 patients) or the elevators of the upper lip (2 patients). In 8 patients, in whom the slight synkinesis was not noticed by the patients, surgical correction was not necessary, but in the other 6 patients with severe aesthetic disturbances, surgical treatment for "disconnection" of the wrong impulses was realized. I obtained this "disconnection" through resection of the involved perioral muscle groups instead of paralysis of the orbicularis oculi. Follow-up of the 6 patients operated with the surgical treatment proposed herein for between 4 and 8 years has shown good aesthetic results without functional or aesthetic sequelae. | 2 |
Immunohistochemical interpretation of early epithelial disorders of pyriform sinus. Expression of cytokeratins (CKs) was investigated immunohistochemically by use of monospecific monoclonal anti-CK antibodies in normal epithelia of pyriform sinus and epithelial lesions such as simple hyperplasia, different degrees of dysplasia, in situ carcinoma, and invasive carcinoma. In normal epithelium, strong expression of CK-19 was consistently observed only in the basal layer as basic CK, while expression of CK-13 showed a completely reverse pattern, being expressed only in suprabasal layers as stratification-related CK. Characteristic changes in expression pattern of these two CKs were observed in accordance with the degree of epithelial disorders and differentiation of carcinoma. Cytokeratin 1, as keratinization-associated CK, was observed only in keratinized cells of hyperplastic epithelia and well-differentiated carcinomas. These findings may be useful in evaluating epithelial disorders and classifying carcinomas more objectively, and may assist earlier detection of carcinoma when used with standard histologic techniques. | 4 |
Coronary artery aneurysm without stenosis in association with Osler-Weber-Rendu disease--a case report. A fifty-three-year-old woman presented with coronary artery aneurysm in association with Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia) manifested also by large pulmonary arteriovenous fistulas. The arterial dye dilution curves were unusually distorted owing to the right-to-left shunts. The coronary artery aneurysm was located in multiple sites but was not accompanied by stenotic lesions. Coronary artery aneurysm without stenosis is a rare pathologic state and has not been previously reported in association with hereditary telangiectasia. | 3 |
Systemic amyloidosis in transgenic mice carrying the human mutant transthyretin (Met30) gene. Pathologic similarity to human familial amyloidotic polyneuropathy, type I. To analyze the pathologic processes of amyloid deposition in type I familial amyloidotic polyneuropathy (FAP), mice were made transgenic by introducing the human mutant transthyretin (TTR) gene. In these transgenic mice, amyloid deposition started in the gastrointestinal tract, cardiovascular system, and kidneys 6 months after birth and extended to various other organs and tissues with advancing age. At age 24 months, the pattern of amyloid deposition was similar to that observed in human autopsy cases of FAP, except for its absence in the choroid plexus and in the peripheral and autonomic nervous systems. Amyloid deposition was shown to be composed of human mutant TTR and, in addition, mouse serum amyloid P component. These results clearly indicate that human variant TTR produced in transgenic mice deposits is a major component of amyloid fibrils in various organs and tissues. Thus this animal model is useful for analyzing how amyloid deposition initiates and proceeds in FAP. | 2 |
Induction of donor-type chimerism in murine recipients of bone marrow allografts by different radiation regimens currently used in treatment of leukemia patients. Three radiation protocols currently used in treatment of leukemia patients before bone marrow transplantation (BMT) were investigated in a murine model (C57BL/6----C3H/HeJ) for BM allograft rejection. These include (a) a single dose of total body irradiation (8.5 Gy TBI delivered at a dose rate of 0.2 Gy/min), (b) fractionated TBI (12 Gy administered in six fractions, 2 Gy twice a day in 3 days, delivered at a dose rate of 0.1 Gy/min, and (c) hyperfractionated TBI (14.4 Gy administered in 12 fractions, 1.2 Gy three times a day in 3 days, delivered at a dose rate of 0.1 Gy/min). Donor-type chimerism 6 to 8 weeks after BMT and hematologic reconstitution on day 12 after BMT found in these groups were compared with results obtained in mice conditioned with 8 Gy TBI delivered at a dose rate of 0.67 Gy/min, routinely used in this murine model. The results in both parameters showed a marked advantage for the single dose 8.5 Gy TBI over all the other treatments. This advantage was found to be equivalent to three- to fourfold increment in the BM inoculum when compared with hyperfractionated radiation, which afforded the least favorable conditions for development of donor-type chimerism. The fractionated radiation protocol was equivalent in its efficacy to results obtained in mice irradiated by single-dose 8 Gy TBI, both of which afforded a smaller but not significant advantage over the hyperfractionated protocol. This model was also used to test the effect of radiation dose rate on the development of donor-type chimerism. A significant enhancement was found after an increase in dose rate from 0.1 to 0.7 Gy/min. Further enhancement could be achieved when the dose rate was increased to 1.3 Gy/min, but survival at this high dose rate was reduced. These results demonstrated indirectly that dose rate affects the expression of host-type pluripotent stem cells, the progeny of which appear 3 to 6 weeks after treatment with 8 Gy TBI delivered at a dose rate of 0.1 Gy/min, but which are eradicated if radiation is delivered at a dose rate of 1.3 Gy/min. | 0 |
Molecular basis of the activation of the tumorigenic potential of Gag-insulin receptor chimeras. A previous study showed that the human insulin receptor (IR) could be activated by insertion of a 3' portion of the cDNA encoding the beta subunit into a retrovirus genome to form a Gag-IR fusion protein. While capable of transforming cells in culture, this IR cDNA-containing virus, called UIR, was not able to induce tumors in animals. Subsequently, we isolated a spontaneous sarcomagenic variant called UIR19t from the parental UIR. UIR19t was molecularly cloned, sequenced, and found to harbor two mutations. A 44-amino acid deletion immediately upstream from the transmembrane domain of the Gag-IR fusion protein removes all the extracellular sequence of the IR remaining in the original UIR construct. In addition, a single nucleotide deletion at the 3' end results in truncation and replacement of the carboxyl-terminal 12 amino acids by 4 new amino acids. The specific kinase activity of UIR19t is 4- to 5-fold higher than that of the parental UIR. However, no new cellular substrates were detected in UIR19t-transformed cells as compared to UIR cells. Viruses containing either the 5' or the 3' deletion mutation were constructed and assessed for their biological function. Our data indicate that the 5' deletion alone is sufficient to confer tumorigenic ability. We conclude that sequence immediately upstream from the transmembrane domain imposes a negative effect on the transforming and tumorigenic potential of the Gag-IR fusion protein. | 4 |
Effects of calcium on vascular smooth muscle tone. It is generally acknowledged that calcium plays a major role in the generation of vascular tone. However, in recent years it has become increasingly evident that relatively calcium-insensitive pathways of excitation-contraction coupling also exist in the vascular smooth muscle cell. Possible mechanisms of vascular smooth muscle contraction and their possible role in the pathophysiology of hypertension are reviewed. The rationale for the use of calcium channel blockers in the treatment of hypertension is discussed. | 3 |
Prolonged indomethacin therapy for the prevention of recurrences of patent ductus arteriosus. We tested the hypothesis that prolonged maintenance indomethacin therapy would allow more effective closure of patent ductus arteriosus (PDA) and thereby decrease the recurrence rate. Thirty-nine low birthweight neonates (less than 1500 gm) with confirmed PDA were randomly assigned in a double-blind fashion to receive standard indomethacin therapy (three doses), followed either by maintenance indomethacin therapy (0.2 mg/kg/day) for 5 days or by an equivalent volume of placebo for 5 days. Of the 20 infants who received maintenance indomethacin therapy, two (10%) required additional therapy and one of these required surgical ligation. Of the 19 infants who received only the first three indomethacin doses, nine (47%) required additional therapy for PDA (p less than 0.05) and seven of these had a ligation (p less than 0.05). We conclude that maintenance indomethacin therapy, in comparison with short-term indomethacin therapy, decreases the incidence of surgical PDA ligations, eliminates most PDA recurrences, and does not increase toxic effects of indomethacin in the low birth weight infant with PDA. | 4 |
Adoptive immunotherapy with high-dose interleukin-2: kinetics of circulating progenitors correlate with interleukin-6, granulocyte colony-stimulating factor level. Immunotherapy with interleukin-2 (IL-2) and lymphokine-activated killer (LAK) cells results in significant tumor regression in patients with advanced cancer. We have investigated the kinetics of circulating erythroid (BFU-E) and granulocytic-macrophage (CFU-GM) progenitors after IL-2 therapy in 11 cancer patients, mainly affected by metastatic melanoma and renal cell carcinoma. Administration of IL-2 from day 1 through day 5 constantly induced a dramatic decrease of the number of circulating BFU-E and CFU-GM, which then showed a striking rebound (up to values fourfold and sevenfold higher, respectively, than the pretherapy levels) on discontinuation of IL-2, ie, from day 5 through day 10. A similar kinetic pattern was observed during and after the second cycle of IL-2 administration. 3[H]-thymidine killing experiments showed that the cycling activity of the progenitors was virtually unmodified in the rebound phases. To explore the mechanism(s) underlying this kinetic pattern, we have analyzed the plasma concentration of several hematopoietic growth factors, including IL-1 beta, IL-3, IL-4, IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), G-CSF, and erythropoietin (Ep). No modifications in the levels of IL-3, GM-CSF, or IL-1 beta were observed, whereas a pronounced increase of IL-6 and G-CSF concentration was monitored, starting at day 3 and peaking at day 5 of treatment (a parallel, but modest, increase of Ep level was also observed). The elevation of IL-6 and G-CSF concentration is directly correlated with and may, at least in part, underlie the subsequent rebound of circulating hematopoietic progenitors. Furthermore, the increase in IL-4 level observed at day 10 of therapy may mediate the eosinophilia gradually starting at this stage of treatment. | 0 |
Effect of a leukocyte-platelet removal filter on ischemia induced reperfusion injury. The effect of leukocyte and platelet depletion on reperfusion injury using a leukocyte-platelet removal filter (LRF) in intracoronary thrombolysis is reported. To better define the usefulness of LRF in evaluating the effectiveness of intracoronary thrombolysis with this device, several cardiovascular variables were examined in rabbits during ischemia followed by reperfusion. The rabbits underwent cytoapheresis with LRF (n = 5) and were compared with controls without LRF (n = 5). LRF was composed of a nonwoven polyester fabric (1.8 microns, 4.6 gm). Removal of leukocytes and platelets by LRF was 98% for both. A period of 30 min equilibration was allowed before any experimental intervention, at which time the diagonal artery was occluded for 20 min and then reperfused. All arrhythmias were defined and quantified in accordance with the Lambeth Convention. Regional wall thickening was examined by a pulsed Doppler dimension system. No significant differences were observed in hemodynamic variables between the two groups; however, rabbits treated with a LRF demonstrated greater regional wall thickening (LRF group: 17 +/- 0.9%, control group: 11 +/- 0.3%, p less than 0.01), as well as significant improvement in the frequency of ventricular arrhythmias (LRF group: 12.5%, control group: 47.2%, p less than 0.01). The data suggest that LRF may help prevent arrhythmias, and preserve left ventricular contraction, during and after intracoronary thrombolysis. | 3 |
Aspiration in bilateral stroke patients. Seventy patients with bilateral strokes underwent neurologic and videofluoroscopic barium swallowing examinations; 34 (48.6%) aspirated. Patients with aspiration were more likely to have posterior circulation strokes, abnormal cough, abnormal gag, and dysphonia. However, patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough, an abnormal gag reflex, or both. The prediction of patients at risk for aspiration was not improved by additional clinical information (ie, presence of dysphonia or bilateral neurologic signs). | 4 |
Cor triatriatum dexter: antemortem diagnosis in an adult by cross sectional echocardiography. Cor triatriatum dexter is a rare cardiac abnormality in which the right atrium is subdivided into two distinct chambers. This anomaly is generally attributed to the persistence of the right sinus venosus valve and it is frequently associated with severe malformations of other right heart structures. The antemortem diagnosis of the membrane may be difficult and its presence is often only established at necropsy. In a woman of 56 with Ebstein's anomaly the echocardiographic features of cor triatriatum dexter were examined before and during cardiac catheterisation. These investigations showed the position of the membrane, that there was no gradient between the two atrial chambers, and that there were perforations in the centre of the membrane. | 3 |
Techniques of adjustable suture strabismus surgery. Adjustable sutures allow eye muscle positions to be changed following strabismus surgery, when the patient is awake and able to cooperate in muscle balance testing. Bow-tie-knot and sliding-handle sutures can be adjusted within 24 hours after surgery. Scleral traction sutures, which can be used to fix the globe to periorbital tissues during postoperative healing, can be adjusted for up to 14 days after surgery. We describe these techniques as well as an adjustable loop suture for conjunctival closure. | 4 |
The dynamics of platelet thrombus formation rate, thrombus retention time, and rate of embolization on a control and heparin bonded polyurethane angio-catheter. The dynamics of platelet deposition and embolization from control and heparin bonded polyurethane catheters (CPC and HBPC) was evaluated with In-111 labeled autologous platelets (IN-PLT) and a computerized gamma camera (CGC). Ten non-heparinized dogs (18-25 kg) were catheterized in both femoral arteries with 10 cm of CPC and HBPC (5 Fr., Cordis) 24 hr after injection of 300-420 microCi of In-PLT, and imaged for 3 hr with the computerized gamma camera. The regional platelet deposition curves (RPDC) indicated multiple peaks and valleys; the curves were analyzed for early rate of thrombus formation (upswing), thrombus retention time (full width at half maxima of the RPDC-peak), and rate of embolization (downswing) on both catheters. The four parameters (mean +/- SD) of thrombosis on catheters and integral of the radioactivity time curve for the 3 hr duration of imaging were calculated from normalized counts/sec. The rate of thrombus formation and rate of embolization are higher for the control than HBPC, suggesting that heparin-bonding decreases the early rate of thrombosis and embolization. The thrombus adhesivity and retention time appear shorter for the control catheter, indicating that the control thrombogenic catheter forms multiple thrombi and emboli than HBPC. The integral appears larger for the control catheter than HBPC. In vivo (dynamic) studies, in vitro studies, and critical analyses of the radioactivity time curve were essential for complete evaluation of thrombogenicity of catheters and other cardiovascular prostheses. | 3 |
Hypertension as a risk factor for epilepsy after aneurysmal subarachnoid hemorrhage and surgery. A prospective, consecutive series of 307 patients with aneurysmal subarachnoid hemorrhage ranging from Grades 1 to V according to the classification of Hunt and Hess on admission were evaluated to determine the incidence of epilepsy 1 to 3 years (mean, 1.4 years) after aneurysmal subarachnoid hemorrhage (SAH) and surgery. Sixty-three patients had died and one patient was lost to follow-up. Twenty-nine patients developed epileptic seizures after the SAH and surgery. The mean time from the SAH to epileptic seizure varied from 0 days (day of the SAH) to 2 years (mean, 6.7 months). The seizures were classified as focal in 9 patients (31%) and as generalized in 20 patients (69%). All patients received anticonvulsant medication after more than one seizure. The risk factors for development of posthemorrhagic/postoperative epilepsy were, in order of importance: a history of hypertension; an infarct on late computed tomographic scan; and the duration of coma after the ictus. Of the 85 patients with histories of hypertension, 17 (20.0%) developed epilepsy. Only 12 (5.4%) of the 222 nonhypertensive patients developed epileptic seizures. The difference between the groups was significant (P = 0.0001). Computed tomographic scans were undertaken in 237 patients 1 to 3 years (mean, 1.4 years) after the SAH and surgery. Postoperative epilepsy was significantly associated with infarcts visualized on computed tomographic scan (P = 0.0005). | 3 |
Coronary angioplasty in symptomatic patients after bypass surgery. With the availability of percutaneous transluminal coronary angioplasty (PTCA), the management of patients who present with recurrent angina following coronary artery bypass surgery (CABG) has changed. From January 1987 to December 1988, 149 symptomatic post CABG patients underwent coronary angiography at our institution. Ninety were treated with medical antianginal therapy, 14 had repeat surgery, and 45 underwent PTCA. Complications of repeat CABG included one death, two perioperative myocardial infarctions, and four patients with postoperative supraventricular arrhythmia. PTCA was performed on 42 lesions in 37 native vessels (88% success rate), and on 24 lesions in 23 vein grafts (91.7% success rate). Complications included acute reocclusion (one patient), peripheral artery occlusion (one patient), hematoma formation (one patient), and periprocedure myocardial infarction (one patient). No deaths occurred. At a mean follow-up of 5.9 +/- 3.8 months, 10 patients had recurrent symptoms, six of whom were found to have restenosis. Repeat PTCA was successfully accomplished in four patients; the other two were treated medically. It is concluded that PTCA is a feasible alternative to repeat CABG in selected patients and can be achieved with a high success rate and minimal complications. | 4 |
Malignant fibrous histiocytoma of soft tissue. A population-based epidemiologic and prognostic study of 137 patients. Epidemiology and prognosis were analyzed in a consecutive, population-based series of 137 patients with malignant fibrous histiocytoma of soft tissue in the extremities and trunk wall, with a complete follow-up of minimum 3 years. All but one patient were treated by surgery in 28 cases combined with adjuvant radiotherapy or chemotherapy. The annual incidence was 0.42/10(5). The ratio men to women was 1.1. The median age was 64 years (range, 22 to 87 years). The thigh was the most common location. The median size was 6 cm. Superficial tumors constituted 43% and were smaller than deep-seated tumors. Eighty-three tumors were storiform-pleomorphic, 53 were myxoid, and one was of inflammatory type. The myxoid tumors were smaller and more often superficial. The cumulative 5-year survival rate for all patients was 0.7, but differed markedly between the histologic types; it was 1.0 in patients with myxoid tumors and 0.5 in patients with storiform-pleomorphic tumors. In the 77 patients with storiform-pleomorphic tumors without metastases at presentation, only tumor size larger than 10 cm and tumor necrosis independently impaired survival. The 23 patients who had none of these risk factors had a 5-year survival rate of 0.8. | 0 |
Selenium in forage crops and cancer mortality in U.S. counties. The potential protective effect of selenium status on the risk of developing cancer has been examined in animal and epidemiologic studies. This ecological study investigated the association between U.S. county forage selenium status and site- and sex-specific county cancer mortality rates (1950-1969) using weighted least squares regression. Consistent, significant (p less than .01) inverse associations were observed for cancers of the lung, rectum, bladder, esophagus, and cervix in a model limited to rural counties and for cancers of the lung, breast, rectum, bladder, esophagus, and corpus uteri in a model of all counties. No consistent significant positive associations were observed in the rural county models. This remarkable degree of consistency for the inverse associations strengthens the likelihood of a causal relationship between low selenium status and an increased risk of cancer mortality. | 0 |
Myasthenic thymus and thymoma are selectively enriched in acetylcholine receptor-reactive T cells. We compared T-cell proliferative responses to acetylcholine receptor (AChR) and to purified protein derivative (PPD) (of tuberculin) of hyperplastic thymus, thymoma, and blood cells from patients with myasthenia gravis (MG). Hyperplastic MG thymus cells gave significantly higher and more consistent responses to AChR than parallel cultures of autologous blood cells, whereas responses to PPD showed an opposite trend. Thus there was a preferential localization of AChR-reactive T cells in the hyperplastic MG thymus. Furthermore, there was a strong correlation between blood and thymus cell responses to PPD (but not to AChR), arguing that the hyperplastic MG thymus contains a sample of sensitized peripheral T cells. By contrast, both AChR- and PPD-responsive T cells were almost undetectable in thymus from nonmyasthenic patients, which is evidently much less receptive to circulating T cells. Cells from MG thymomas showed the highest stimulations by AChR but did not consistently react to PPD. However, the uninvolved thymus adjacent to these thymomas behaved almost identically to the hyperplastic samples described above. Our interpretation is that AChR-specific T cells are initially sensitized in the MG thymoma but are selectively trapped in the hyperplastic thymus after being primed elsewhere. | 4 |
Decreased toxicity of polymorphonuclear neutrophils toward hepatocytes isolated from rats with acute inflammatory reaction. We have recently demonstrated that polymorphonuclear neutrophils were toxic to hepatocytes through a protease-mediated mechanism. Since synthesis of antiproteases is markedly increased during acute inflammatory reaction, the aim of this work was to investigate the toxicity of neutrophils against normal vs. inflammatory rat hepatocytes. Acute inflammatory reaction was induced by subcutaneous injection of turpentine 24 hr before the experiments. Hepatocytes from normal and turpentine-treated rats were isolated by collagenase digestion. They were incubated with human neutrophils stimulated by 1 mg/ml opsonized zymosan. Cytotoxicity was quantified by the percentage of alanine aminotransferase activity released by hepatocytes in culture medium after an 18-hr incubation period. By comparison to normal hepatocytes, inflammatory hepatocytes were more resistant to the toxicity of neutrophils. At a neutrophil/hepatocyte ratio of 20:1, the alanine aminotransferase activity releases were 53.7% +/- 5.4% (mean +/- 1 S.E.) and 27.4% +/- 4.8% for normal and inflammatory hepatocytes, respectively. Similarly, inflammatory hepatocytes were found to be less sensitive than normal hepatocytes to the toxic effect of purified neutrophil cathepsin G. In contrast, both types of hepatocytes exhibited the same sensitivity to H2O2 generated by a system consisting of glucose and glucose oxidase. Two arguments suggested that the resistance of inflammatory hepatocytes to protease toxicity was explained by an increased production of antiproteases by these cells: (a) when tested against cathepsin G and porcine pancreatic elastase activities, the protease inhibitory capacity of conditioned medium from inflammatory hepatocytes was higher than that of conditioned medium from normal hepatocytes; (b) conditioned medium from inflammatory hepatocytes markedly reduced the toxicity of stimulated neutrophils as that of cathepsin G. | 4 |
Right ventricular function and metabolism. Right ventricular protection may be limited with current methods of cardioplegic delivery. Sensitive measurements of right and left ventricular function and metabolism were made in 30 patients undergoing elective coronary artery bypass surgery with cold cardioplegic arrest. Myocardial adenine nucleotide concentrations decreased with cardioplegia and reperfusion in both the right and left ventricles despite adequate levels of precursors, suggesting perioperative mitochondrial dysfunction. Postoperatively, right and left ventricular pressures were measured with micromanometer catheters and volumes were measured by nuclear ventriculography. Right and left ventricular systolic elastance was calculated by the isochronic method and by the end-systolic method. Both methods provided sensitive indexes of end-systolic elastance. This study demonstrated that right ventricular function and metabolism can be evaluated by methods analogous to methods used in the left ventricle. These results suggest that right ventricular functional and metabolic recovery are delayed despite apparently adequate myocardial protection. Sensitive measurements may permit improved assessment of alternative methods of right ventricular protection. | 3 |
Evaluation of the pre-S (pre-S(1)Ag/pre-S(2)Ab) system in hepatitis B virus infection. The diagnostic and prognostic value of pre-S(1)Ag and pre-S(2)Ab was investigated in 69 HBsAg surface antigen positive patients--14 with acute hepatitis B, 30 with chronic liver disease (six chronic persistent hepatitis, 14 chronic active hepatitis, 10 with cirrhosis) and in 25 asymptomatic carriers. Pre-S(1)Ag was found in all patients with chronic hepatitis B virus (HBV) infection regardless of viral replication. In contrast, pre-S(2)Ab was not detected in any patients. Acute hepatitis was studied sequentially with periodic controls at 20 day intervals. Pre-S(1)Ag cleared before HBsAg in six of 14 (43%) patients who progressed favourably, and the two antigens cleared simultaneously in eight of 14 (57%) cases. Patients with early clearance of pre-S(1)Ag progressed favourably, thus indicating the prognostic value of this test, which, however, is still of limited practical application given the small temporal difference between the moment of clearance of the two antigens. The first markers to clear, however, were HBeAg and DNA-HBV, which showed significant differences with respect to the clearance of HBsAg. Moreover, pre-S(2)Ab appeared before HBsAb in 57.1% of our patients and was found in some patients before pre-S(1)Ag and HBsAg had cleared (42.8%), thus allowing complete viral clearance and acute HBV infection to be predicted earlier. | 4 |
Scintigraphic evaluation of aggressive fibromatosis. Despite its benign microscopic appearance, aggressive fibromatosis has potential to recur and infiltrate neighboring tissues. Therefore, it is necessary to determine the exact extent before therapy. In the present study, 11 cases of aggressive fibromatosis were examined scintigraphically using [99mTc(V)]dimercaptosuccinic acid (11 cases) and 67Ga-citrate (7 cases). Technetium-99m-(V)-dimercaptosuccinic acid demonstrated all lesions, while 67Ga-citrate detected 57% of the cases. | 0 |
Magnetic resonance imaging--the evaluation of choice in residual shunt after congenital heart disease surgery? Accurate anatomic diagnosis presents a dilemma in patients with residual shunt after corrective surgery for congenital heart disease. We describe a patient who, after atrial septal defect repair, developed dyspnea and central cyanosis despite normal pulmonary arterial pressures and right heart chamber size. A role for early MRI is suggested. | 3 |
Evaluation of women with possible appendicitis using technetium-99m leukocyte scan. The authors evaluated the use of technetium-99m albumin colloid white blood cell (TAC-WBC) scan in women with possible appendicitis. One hundred and nine women underwent 110 TAC-WBC scans. One woman had a second scan on a separate admission and was considered two individual patients in the analysis. Twenty-six women had appendicitis, 10 of whom had a perforated appendix at surgery. The TAC-WBC scan was indeterminate (abnormal but nondiagnostic for appendicitis) in 52 women (47%), nine of whom had appendicitis. Fifty-eight scans were read as positive or negative for appendiceal pathology. There were 16 true positives, 5 false positives, 36 true negatives, and 1 false negative. The predictive value of a positive scan was 76%, and the predictive value of a negative scan was 97%. The TAC-WBC scan was positive in 62% of patients with appendicitis and negative in 43% of the patients without appendicitis resulting in an overall accuracy of 47% in the 109 women. The main value of TAC-WBC scan in women with possible appendicitis is its high negative predictive value and the main problem with the TAC-WBC scan is its high indeterminate rate. | 1 |
Simultaneous operative repair of multilevel lower extremity occlusive disease. Sixty-two patients (39 men (63%), 23 women (27%), mean age 68 years) with multilevel lower extremity arterial occlusive disease underwent simultaneous inflow and outflow operative arterial repair consisting of aortofemoral bypass in 22 (35%), axillofemoral bypass in 17 (28%), femorofemoral bypass in 15 (24%), iliac endarterectomy in 7 (11%), and unilateral aortoiliac bypass in 1 (2%), combined with 69 outflow procedures (unilateral in 55 patients, 89%), including above-knee femoropopliteal in 12 (17%), below-knee femoropopliteal in 35 (51%), femoroinfrapopliteal in 20 (29%), popliteal tibial in 1 (1%), and femoropedal bypass in 1 (1%). Multiple criteria were used to identify patients with multilevel disease likely to benefit from multilevel procedures. The operations were performed by two operating teams in a median time of 240 minutes. Prosthetic grafts were used for eight (13%) distal bypasses, the remainder were autogenous vein. There was one operative death (1.8%). The mortality rate, morbidity rate, and operative time were not significantly different from a group of patients who underwent concurrent, isolated inflow operations (aortofemoral, axillobifemoral, femorofemoral bypass or iliac endarterectomy). Mean follow-up was 14.9 months (range, 0 to 120). The life-table primary patency for the inflow procedures was 92.6% at 24 months, the outflow was 94.9% at 24 months. Cumulative limb salvage was 90.9% at 48-month follow-up. All patients with claudication were relieved of their symptoms. We conclude that complete correction of multilevel disease can be accomplished with operative time, morbidity rate, and patency equal to that of single level repair. Multilevel procedures provide complete relief of symptoms in a higher percentage of patients than has been reported after single level repair. | 3 |
Variants of intestinal metaplasia in the evolution of chronic atrophic gastritis and gastric ulcer. A follow up study. A follow up study with biopsy was initiated in 1982 to define the relations between variants of intestinal metaplasia and the evolution of chronic atrophic gastritis and gastric ulcer. All patients (58 with chronic atrophic gastritis and 66 with gastric ulcer) had intestinal metaplasia at the start of the study. In the six year period to 1988 a total of 241 biopsies were performed on the patients with chronic atrophic gastritis and 243 on the patients with gastric ulcer. Initially, 81% of the patients with chronic atrophic gastritis presented with type I intestinal metaplasia and 14% with type III intestinal metaplasia. During follow up type I was predominant, often associated with grades 2 and 3 active disease (81%) and 45% of these patients reverted to a non-intestinal metaplasia status by the third year of follow up. In contrast, type III metaplasia was more common in the absence of appreciable inflammation (78% of biopsy specimens), being persistent in five of seven patients in the third year of follow up, and was found to be associated with dysplasia in three of these patients. Similarly, the initial biopsy specimen showed type I metaplasia in most patients with gastric ulcer (82%) and type III in only 4%. Type I metaplasia was also predominant in these patients (80%), particularly in active disease (68%), gradually regressing with healing. In contrast, type III was associated with delayed ulcer healing and reactivation (75%; six of eight patients). | 4 |
Clomiphene citrate stimulation as an adjunct in locating ovarian tissue in ovarian remnant syndrome. Ovarian remnant syndrome results from residual ovarian tissue after bilateral oophorectomy. The syndrome is associated with chronic pelvic pain and is suspected when premenopausal levels of FSH and LH are present in a patient with documented bilateral oophorectomy. Histologic demonstration of ovarian tissue at operation confirms the diagnosis. We treated a patient with ovarian remnant syndrome with a 10-day course of clomiphene citrate, 100 mg daily, to stimulate the residual ovarian tissue and facilitate localization. Preoperative ultrasound revealed a 5.0 x 3.5 x 6.2-cm cystic mass in the right adnexal region. Exploratory laparotomy easily localized the mass, and it was removed intact. Histologic slides demonstrated normal ovarian tissue with multiple follicles in various stages of development and a corpus luteum cyst. Clomiphene citrate is capable of stimulating an ovarian remnant, producing an enlarged, cystic structure easily localized by ultrasound. The increased size and preoperative knowledge of the location facilitated surgical removal. | 4 |
Parathyroidectomy in chronic renal failure: a nine-year follow-up study. Seventy-three patients with chronic renal failure who underwent parathyroidectomy between March 1978 and April 1987 were reviewed. Thirty-four patients had undergone sub-total parathyroidectomy, and 39 patients had undergone total parathyroidectomy with parathyroid autograft into the forearm. Eight patients showed persistent hyperparathyroidism requiring a second surgical procedure. In all other patients there was highly statistical improvement in parathyroid hormone, total calcium, ionized calcium, alkaline phosphatase and a significant reduction in calcium x phosphate product. Histological evidence of osteitis fibrosa was present in 21 of 22 patients before surgery. Postoperatively, four showed complete resolution and improvement. Three patients developed histological evidence of osteomalacia during the study period. Only four of the 39 patients who underwent total parathyroidectomy with autograft had true recurrent hyperparathyroidism and only two of the 34 patients who underwent sub-total parathyroidectomy had recurrent disease, indicating that there is little to choose between the two techniques in the control of secondary hyperparathyroidism and its subsequent recurrence. In one patient with recurrence of hyperparathyroidism from a forearm parathyroid graft the histological picture was different from that of normal hyperplastic parathyroid tissue. Although it is probable that abnormal parathyroid tissue had been implanted there was no evidence of invasive growth into the forearm muscle. The most striking feature of long term follow-up was the difference in calcium x phosphate product in patients in whom vascular calcification increased compared to those patients with no change or regression of calcification. Mean calcium phosphate product in those patients with progressive vascular calcification was 4.93 for small and medium size vessels and 5.38 for large vessels compared to 4.10 for small and medium vessels and 4.09 for large vessels. In the former case the serum phosphate was 2.00 and 2.17 as compared to 1.75 or 1.73, suggesting that the aim in patients with end stage renal failure maintained by dialysis should be to control the serum phosphate concentration to 1.8 mmol or less and the calcium x phosphate product to less than 4.2. | 3 |
Comparison of the antihypertensive effects of delapril and enalapril. The angiotensin converting enzyme (ACE) inhibitors delapril and enalapril were compared in a double-blind, randomized, parallel study. The population included 142 patients with essential hypertension who were treated with delapril and 140 treated with enalapril. At the end of a 2 week initial placebo period, the diastolic blood pressure of these patients ranged from 95 to 115 mm Hg in the sitting position. After this placebo period, randomization took place. Patients in the delapril group received 15 mg of the drug twice daily. Treatment with enalapril was started with a daily dose of 10 mg. If the diastolic blood pressure did not fall to less than or equal to 90 mm Hg or at least by 15 mm Hg after 2 weeks of treatment, the doses of the ACE inhibitors were doubled. After another 2 weeks, 25 mg hydrochlorothiazide daily was added if the target level of diastolic blood pressure was not reached. Both drugs caused a similar decrease of systolic and diastolic blood pressure. The antihypertensive effect of both ACE inhibitors was increased by the addition of the diuretic. The frequency and severity of side effects were similar in the two groups of patients. It is concluded from this study that delapril and enalapril do not differ in antihypertensive efficacy nor in safety. | 3 |
Oral or intravesical bacillus Calmette-Guerin immunoprophylaxis in bladder carcinoma. A total of 71 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to 3 treatment groups: control group--transurethral resection discontinued within the study, oral bacillus Calmette-Guerin (BCG) group--transurethral resection of bladder tumor plus BCG (Moreau) and intravesical BCG group--transurethral resection of bladder tumor plus BCG. Of 9 patients in the control group 8 (89%) experienced tumor recurrence during a mean followup of 20 months. Of the 28 patients in the oral BCG group 11 (39.3%) had recurrence during a mean followup of 36 months. Of the 34 patients in the intravesical group 6 (18%) had recurrence in a 24-month mean followup. The incidence of complications was higher in the intravesical (41.2%) than in the oral BCG group (28.5%). These results show that intravesical BCG is a more effective immunotherapy; however, oral BCG can be used in patients who do not accept intravesical BCG administration. | 0 |
Intralaryngotracheal thyroid. A case of intralaryngotracheal thyroid in a 57-year-old man is presented. The treatment modalities are considered and the previous literature is reviewed. | 0 |
Sclerotherapy of varicose and telangiectatic leg veins. Minimal sclerosant concentration of hypertonic saline and its relationship to vessel diameter The author reports the results of a double-blind, paired-comparison study using saline sclerosant plus or minus heparin additive. The study was designed to elucidate the effects of increasing concentrations of hypertonic saline with regard to vessel diameter, clinical efficacy, complications, and discomfort. Six hundred women with bilaterally symmetrical starburst telangiectasias or varicose veins were entered into the study. Sodium chloride 11.7% appeared to be the minimal sclerosant concentration of saline that produced the most effective vein sclerosis of vessels of less than 8 mm in diameter, while producing the least morbidity. The optimal concentration of the sclerosant may vary with the diameter of the vessels under therapeutic consideration. | 3 |
Cytokine regulation of IL-1 beta gene expression in the human polymorphonuclear leukocyte. Although recently polymorphonuclear leukocytes (PMN) have been identified as producers of IL-1 beta in response to LPS and granulocyte/monocyte colony stimulating factor, little is known regarding the ability of other cytokines to induce the production of IL-1 beta in the PMN. Inasmuch as IL-1 and TNF have been shown to be important priming agents, as well as agents that induce migration of PMN, we investigated their effect on IL-1 beta gene expression in human peripheral blood PMN. In the present study, we demonstrate that human peripheral blood PMN produce IL-1 beta in response to IL-1 alpha, IL-1 beta, and TNF-alpha. Control (unstimulated) human PMN had virtually undetectable levels of IL-1 beta mRNA. Either IL-1 beta or TNF, induced PMN to transiently express IL-1 beta mRNA with peak expression at 1 h, returning to untreated levels by 2 h. A dose response indicated that as little as 0.05 ng/ml of IL-1 beta or TNF resulted in IL-1 beta induction, with maximal effects at 1 ng/ml of IL-1 beta and 5 ng/ml of TNF. IL-1 alpha or IL-1 beta exhibited similar dose responses in IL-1 beta mRNA induction. Inasmuch as cytokines have been shown to have synergistic effects in cell function studies, we induced PMN with a combination of maximally effective doses of TNF plus IL-1 beta. They demonstrated a cooperative effect on IL-1 beta gene expression, in that mRNA levels were sustained for three hours. IL-1 beta Ag expression, as measured by ELISA, paralleled IL-1 beta mRNA expression with cell associated peak levels at 2 to 4 h. IL-1 beta Ag levels in PMN lysates and supernatants correlated with IL-1 beta mRNA levels, i.e., TNF + IL-1 greater than TNF greater than IL-1. Thus, these studies represent the first demonstration of IL-1 and TNF induction of IL-1 beta gene expression in the PMN. Furthermore, the time course of induction is unique to the PMN, with peak induction of mRNA at 1 h, which is consistent with the short lived nature of these cells in inflammatory lesions. | 4 |
Use of various epithelial tumor markers and a stromal marker in the assessment of cervical carcinoma. The epithelial cell tumor markers squamous cell carcinoma antigen, CA 125, CA 15-3, and TAG 72, and the aminoterminal propeptide of type III procollagen, an indicator of collagen metabolism, were evaluated in 111 cervical carcinoma patients. Squamous cell carcinoma antigen was pathologic in 47%, aminoterminal propeptide of type III procollagen in 40%, CA 125 in 13%, CA 15-3 in 30%, and TAG 72 in 9% of the 91 patients with squamous cell carcinoma. The squamous cell carcinoma antigen, aminoterminal propeptide of type III procollagen, and CA 125 correlated with the clinical stage. The predictive value of a pathologic squamous cell carcinoma antigen was 78% and that of a negative result 68%. Squamous cell carcinoma antigen and aminoterminal propeptide of type III procollagen further increased the detection rate by approximately 20% from that obtained by squamous cell carcinoma antigen alone. In 16 patients with advanced disease, squamous cell carcinoma antigen correlated with the behavior of the disease in eight, aminoterminal propeptide of type III procollagen in nine, and CA 125 in six patients. Pathologic squamous cell carcinoma antigen, CA 125, CA 15-3, TAG 72, and aminoterminal propeptide of type III procollagen appeared in 11, 32, 31, 31, and 47% of 19 patients with adenocarcinoma, respectively. Squamous cell carcinoma antigen is clinically useful in squamous cell carcinoma but poor in adenocarcinoma, for which the other markers are better. Squamous cell carcinoma antigen, CA 125, and aminoterminal propeptide of type III procollagen may be used for monitoring the behavior of advanced squamous cell carcinoma. | 0 |
Hypergastrinemia, gastric endocrine cell hyperplasia, and intractable diarrhea. A patient with pernicious anemia developed severe intractable diarrhea night and day. Investigation revealed chronic atrophic gastritis and a markedly elevated level of serum gastrin. No obvious explantation for the diarrhea was found, but after antrectomy, the gastrin level returned to normal and the diarrhea subsided. Possible mechanisms for an association between diarrhea and hypergastrinemia include colonic hypermotility secondary to release of acetylcholine and inhibition of fluid and electrolyte reabsorption within the small bowel. | 1 |
Naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal and thoracic aneurysms. Forty-seven patients who were treated for thoracoabdominal or thoracic aneurysms over a 5 1/2-year period were analyzed for neurologic deficit risk. Patients were divided into two groups for analysis. Twenty-four patients, who were treated from January 1984 to December 1986, did not undergo spinal fluid drainage or naloxone administration (group A). Twenty-three patients, who were treated from January 1987 to August 1989, had spinal fluid drainage (group B); 12 patients in this group also received naloxone as an intravenous drip at 1 microgram/kg/hr for 48 hours after surgery. Permanent neurologic deficits occurred in seven (29%) group A patients but in only one (4%) group B patient, who did not receive naloxone (p less than 0.03). The first two group B patients to receive naloxone showed complete reversal of neurologic deficits on waking from anesthesia. This significant reduction in neurologic deficit was associated with an increased 1-year survival rate (72% in group A, 91% in group B). We conclude that the use of naloxone and spinal fluid drainage reduces the incidence of neurologic deficit that is associated with repair of thoracoabdominal and thoracic aortic aneurysms. This reduction in neurologic deficit is associated with improved survival in the long term. The observed reversal of postoperative neurologic deficits with naloxone implicates opiates as a major factor in the pathophysiology of spinal cord ischemia. | 3 |
Dysphagia following fundoplication: "slipped" fundoplication versus achalasia complicated by fundoplication. Failure to obtain preoperative esophageal manometry in patients being considered for antireflux surgery can result in immediate persistent postoperative dysphagia due to a missed diagnosis of achalasia. We describe the clinical assessment and management of a case of delayed postoperative dysphagia due to a "slipped" fundoplication, which is contrasted with three patients with immediate postoperative dysphagia due to a missed diagnosis of achalasia. Surgical revision was required to correct the "slipped" fundoplication, and pneumatic dilatation was successfully used in two of three cases of achalasia complicated by fundoplication. Careful preoperative esophageal evaluation with manometry is essential to rule out the presence of a primary esophageal motor disorder. | 1 |
Effects of nicardipine, a calcium antagonist, on myocardial salvage and high energy phosphate stores in reperfused myocardial injury. The current study determined the effectiveness of nicardipine, a 1,4-dihydropyridine calcium antagonist, in preserving reperfused myocardium in a cat model of temporary coronary occlusion and ascertained if replenishment of myocardial phosphate stores during reperfusion as defined by phosphorus-31 nuclear magnetic resonance (NMR) spectroscopy was indicative of salvage. Twenty open chest, anesthetized cats were studied with use of a snare ligature around the proximal left anterior descending coronary artery, with a coil sutured to the epicardial surface overlying the distribution of the artery. Peak areas of phosphocreatine, inorganic phosphate and adenosine triphosphate (ATP) NMR signals were measured during 1 h of occlusion followed by 1.5 h of reperfusion. Infarct size and jeopardy area were determined in vitro by simultaneous infusion of phthalocyanine blue dye and triphenyltetrazolium chloride into the aorta and the left anterior descending coronary artery, respectively, after 5 h of myocardial reperfusion. Nicardipine-treated and control groups had similar jeopardy area values (41.2 +/- 1.6% versus 47.4 +/- 3.1% of the left ventricle), but infarct area was significantly reduced in the nicardipine-treated group (3.2 +/- 1.1% versus 24.9 +/- 7.5% of jeopardy area, p less than 0.01). High energy phosphate compounds remained markedly altered during reperfusion in both groups. No significant improvement in phosphocreatine or inorganic phosphate recovery was observed in animals pretreated with nicardipine despite an 87% reduction in infarct size. Myocardial ATP was greater during reperfusion in the nicardipine-treated compared with the control group (average over initial 90 min of reperfusion 58 +/- 6% versus 46 +/- 3% of baseline values, p less than 0.05), suggesting improved recovery of ATP. However, the measured levels of high energy phosphate compounds during reperfusion and their ratios did not correlate with infarct size and thus were not predictive of myocardial salvage. | 3 |
Polyamine levels in healthy and tumor tissues of patients with colon adenocarcinoma. Tissue polyamine levels were determined in patients with colon adenocarcinoma to try to identify biochemical indicators able to characterize the growth and the metabolism of human solid tumors. Polyamine content was determined in the tumor and in the "healthy" mucosa sampled at different distances within the resection edges. For each patient the polyamine content in the tumor was compared with that in the mucosa. The results demonstrated that the spermidine concentration was higher in the tumor than in the healthy mucosa; the differences were statistically significant. However, spermine in the tumor increased to a lesser degree. No statistically significant differences were observed among these mucosae at different localizations, but the spermine concentration in the mucosa after the tumor showed values very close to those of the neoplasia. | 0 |
Angiographic follow-up and clinical outcome of 126 patients after percutaneous directional atherectomy (Simpson AtheroCath) for occlusive peripheral vascular disease. Angiographic and clinical follow-up data were obtained in 115/126 patients who underwent directional atherectomy for peripheral vascular disease; of the 126, ten were excluded for appropriate reasons and one was lost to follow-up. Thus, 115/116 successful atherectomy patients (99%) had follow-up of 182/213 lesions (86%): 74 patients (64%) with angiography (mean time 5.4 mon), and 41 patients (36%) clinically. One hundred twenty-eight of 183 lesions (70%) had angiographic follow-up; the lesion recurrence as a stenosis or as an occlusion was 53%. Lesion distribution did not differ between angiography and clinical follow-up groups: nearly 85% were within the superficial femoral or popliteal arteries. Despite data stratification, angiographic follow-up indicated that patients after successful directional atherectomy, at a mean follow-up time of 5 mos, have more than a 50% lesion recurrence rate. Although directional atherectomy (Simpson AtheroCath) utilizing present techniques has excellent primary success and acceptable complication rates, angiographic follow-up statistics are bothersome. | 3 |
Approach to men with urethritis and urologic complications of sexually transmitted diseases. The most important causes of urethritis, and epididymitis in younger men, are C. trachomatis and N. gonorrhoeae. Management of these syndromes requires a thorough sexual history, genital examination, evaluation for objective and laboratory evidence of infection, antimicrobial therapy directed toward the major etiologies, and evaluation and treatment of sexual partners. Treatment of N. gonorrhoeae requires use of a single-dose regimen active against this organism, plus a 7- to 10-day tetracycline regime active against C. trachomatis and nongonococcal urethritis. With recommended regimens, microbiologic failure is infrequent in compliant patients. Recurrent urethritis is frequent, however. The management of patients with persistent or recurrent symptoms requires careful reevaluation of the patient, documentation of urethritis, and re-treatment with antimicrobials if urethritis is documented by positive cultures or increased numbers of polymorphonuclear leukocytes in urethral secretions. Additional treatment beyond this point usually is not indicated, even though a proportion of men will remain symptomatic and some of these will have increased numbers of polymorphonuclear leukocytes in urethral secretions. The most important causes of prostatitis, and epididymitis in older men or men with urethral structural abnormalities, are classical urinary tract pathogens rather than sexually transmitted pathogens. Management of these infections includes documentation of the infection and treatment directed toward the specific pathogen. Men with symptoms of "prostatitis" must be evaluated using both urine and prostatic secretions to document infection and inflammation. The majority of men with such symptoms do not have an infection that can be documented. These men respond poorly to medications. Men with documented chronic bacterial prostatitis require long courses of antimicrobials to effect cure. In some cases, however, the disease is intractable, and chronic suppression with antimicrobials may be necessary. | 4 |
Home treatment for acute psychiatric illness OBJECTIVE--To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. DESIGN--All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. SETTING--Electoral ward of Sparkbrook, Birmingham. SUBJECTS--99 Patients aged 16-65 with severe acute psychiatric illness. RESULTS--65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. CONCLUSIONS--Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service. | 4 |
Spontaneous termination of reentry after one cycle or short nonsustained runs. Role of oscillations and excess dispersion of refractoriness. This study describes factors that contribute to spontaneous termination of reentry lasting one to 10 cycles after induction by a single premature stimulus. Reentry was studied in vitro in rings of canine atrial tissue from around the tricuspid valve orifice. Activation was recorded from a circular array of 10 extracellular bipolar electrodes equally spaced around the ring. In some experiments, transmembrane or monophasic action potential recordings were made near critical sites. Termination of reentry within one cycle after induction was recorded 110 times in 11 of 35 experiments. Important factors contributing to termination were 1) an obligatory reversal of the activation sequence that resulted in a long coupling interval in the critical region beyond the site of unidirectional block after the premature stimulus and 2) much longer refractory periods limited to this critical region, which facilitated unidirectional block but contributed to termination when this region was first activated with a short coupling interval at the end of the first reentrant cycle. Termination of nonsustained reentry lasting longer than one cycle resulted from oscillations of conduction and refractoriness initiated by the abrupt shortening of cycle length after initiation of reentry. Oscillations of conduction resulted from interval-dependent conduction of reentrant impulses that encountered partially refractory tissue. For reentry to become sustained, the oscillations after induction of reentry must dampen. Thus, damped cycle length oscillations after induction may identify clinical tachycardias caused by reentry with a partially excitable gap. | 3 |
The value of symptom directed evaluation in the surveillance for recurrence of carcinoma of the breast. Specific postoperative tests used to diagnose recurrent carcinoma of the breast were evaluated for their ability to have an impact on the over-all course of the disease. Sixty-four patients with recurrent or new contralateral primary disease were divided into two groups based on the method of diagnosis. Those patients with a new complaint at an interval between scheduled follow-up visits and who went on to have tests to document a recurrence were categorized as interval follow-up. Those who were seen at a prearranged regular follow-up period and received tests as recommended by the attending physician or surgeon and had a documented recurrence were classified as routine follow-up. Thirteen patients presented with new contralateral primary disease and 51 with metastatic disease (16, bone; 13, lung; 11, local; three, liver, and eight, multiple). The median time to discovery of recurrence from the primary treatment was 29 and 28 months for the interval and routine groups, respectively. Ninety per cent of the failures occurred by 53 months. The survival time after recurrence was significantly greater in those patients diagnosed routinely (p = 0.003). However, the over-all survival time (from primary therapy to death) was only significantly improved for the routine group when the contralateral new primary diseases were included (p = 0.009). The method of diagnosis of a contralateral primary carcinoma was physical examination and mammogram. Strong recommendations for follow-up testing can be limited to mammogram and physical examination. | 0 |
Quality of life among hypertensive patients with a diuretic background who are taking atenolol and enalapril. The cardioselective beta-blocker atenolol and the angiotensin-converting enzyme inhibitor enalapril were compared for efficacy, safety, and quality-of-life factors in 30 patients with hypertension whose hypertension was inadequately controlled with diuretic alone. Atenolol (50 to 100 mg once a day) and enalapril (2.5 to 40 mg once a day), combined with hydrochlorothiazide (25 mg once a day), had similar levels of efficacy and safety. A comprehensive battery of psychologic assessments for quality of life was administered, including measures of anxiety, depression, psychiatric symptoms, memory, and psychomotor function. These five conceptually based clusters were first analyzed by multivariate analysis of variance procedures, followed by univariate analyses of the individual variables composing each domain. In general, neither atenolol nor enalapril was associated with major changes in psychologic functioning. The only data cluster with a statistically significant change was memory function, primarily as a result of lower scores of the digit span (backward) test, for atenolol relative to enalapril. These preliminary findings suggest that atenolol and enalapril have comparable degrees of efficacy and safety, with no major disparities in quality-of-life effects, for hypertensive patients with a history of taking diuretics and this sort of quality-of-life assessment can be performed during trials of antihypertensive drugs. | 3 |
Carbamazepine overdose: a prospective study of serum levels and toxicity. A cooperative prospective study of consecutive cases of carbamazepine overdose was conducted to determine if serum levels were predictive of toxicity and if risk factors such as age, chronic exposure, or previous disorder or cardiovascular disease could be used as prognostic indicators. Seventy-three consecutive cases were collected from two regional certified poison control centers from January 1989 to August 1989. There were 25 exposures in children less than 6 yrs., 11 exposures in adolescents, and 37 exposures in adults. Ten adult cases and one adolescent case were excluded from the study due to the presence of coingestants or inadequate information. Peak measured serum levels ranged from 0.3 to 56 mcg/ml. Using the presence of coma, seizure activity or respiratory depression requiring mechanical ventilation as measures of toxicity, we found poor correlation between rising serum levels of carbamazepine and toxicity. Increased serum levels of carbamazepine did appear to correlate with increased hospital stay, but not with ICU stay. History of a seizure disorder appears to pose increased risk of a seizure in carbamazepine overdose. In this series chronic exposure to carbamazepine did not appear to increase the risk of coma or respiratory depression for a given toxic serum level and may add some protective effect. Serum levels below 40 mcg/ml do not appear to accurately predict the severity of toxicity. Cardiac conduction defects were rare (one child). Anticholinergic findings, as evidence by decreased bowel motility and sinus tachycardia were common. Previous cardiovascular disease and age did not appear to be important prognostic indicators. | 4 |
Clinical significance of simple heart rate-adjusted ST segment depression in supine leg exercise in the diagnosis of coronary artery disease. To evaluate the clinical significance of simple heart rate-adjusted ST segment depression (delta ST/delta HR) in the diagnosis of coronary artery disease, 42 patients with stable exertional angina underwent supine leg exercise testing and cardiac catheterization. During exercise, heart rate, a multilead electrocardiogram, and pulmonary artery wedge pressure were recorded. The sensitivity and accuracy of the delta ST/delta HR criteria (greater than or equal to 3.0 microV/beat/min) were significantly greater than the conventional analysis of ST segment depression criteria (greater than or equal to 0.2 mV) for detecting three-vessel coronary artery disease at a matched specificity of 72% (100% versus 46%, 81% versus 64%, p less than 0.01). A significant linear correlation was found between maximum pulmonary artery wedge pressure increments during exercise (delta PAWP) or Gensini score and the delta ST/delta HR (delta PAWP: r = 0.51, p less than 0.001; Gensini score: r = 0.47, p less than 0.001). There were no statistically significant differences in the delta PAWP or Gensini score between patients with three-vessel disease who had delta ST/delta HR greater than or equal to 3.0 microV/beat/min and those with one- or two-vessel disease who had delta ST/delta HR greater than or equal to 3.0 microV/beat/min (delta PAWP: 18.1 +/- 2.0 versus 21.9 +/- 3.3, p = NS; Gensini score: 68.5 +/- 6.6 versus 66.3 +/- 11.3, p = NS). These findings demonstrate that delta ST/delta HR is more useful than a conventional analysis of ST segment depression for identifying not only anatomically severe coronary artery disease but also functionally severe coronary artery disease. | 3 |
Tumor factors predicting for prognosis in metastatic breast cancer. The presence of P24 predicts for response to treatment and duration of survival. Fifty-one patients with metastatic breast cancer were investigated to determine tumor parameters with prognostic significance. Investigations included determinations of P24 content by immunocytochemical means using a monoclonal antibody to P24 protein; immunocytochemical analysis of estrogen and progesterone receptors; ploidy analysis by flow cytometry, and histologic grading. There were significant correlations between the presence of P24 and estrogen receptor, between histologic grade and P24 expression, and between estrogen and progesterone receptors. Of the tumor factors investigated only P24 protein was, however, of prognostic significance. Patients with P24-positive tumors had a significantly higher rate of response to treatment as well as more prolonged duration of response and duration of survival from diagnosis of metastatic disease. None of the other variables investigated were significantly predictive of outcome. P24 protein may be a useful predictor of prognosis in metastatic breast cancer. | 0 |
Effect of fibrin sealant on the healing colonic anastomosis in the rat. Fibrin adhesives have been advocated as a protective seal in colonic anastomosis to prevent leakage. In order to assess the effect of fibrin glue sealing we compared the healing of sutured colonic anastomosis in the rat (group 1) with the addition of human-derived fibrin sealant (group 2). As a control for a possible reaction to foreign protein, in group 3 the sutured anastomosis was sealed with specially prepared rat fibrin adhesive. On days 2, 4 and 7, ten animals in each group were killed. Adhesion formation was scored and the in situ bursting pressure was measured. The collagen concentration and degradation were estimated by measuring hydroxyproline. Adhesion formation was significantly increased in groups 2 and 3 compared with the control group. On days 2 and 7 the bursting pressure was not different between the groups. On day 4 the bursting pressure in groups 2 and 3 was significantly lower than in group 1 (P less than 0.001). These findings correspond with the results of collagen measurements. On day 4 the concentration of hydroxyproline was significantly reduced in groups 2 and 3. Histological examination showed infiltration of neutrophilic granulocytes into the sealant on days 2 and 4; on day 7 the sealant had vanished. From these results it is concluded that fibrin sealing of the colonic anastomosis in the rat does not improve healing, as demonstrated by bursting pressure and hydroxyproline concentration. On the contrary, it seems to have a negative influence. | 4 |
Outpatient flexible cystoscopy and fulguration of recurrent superficial bladder tumors. Flexible cystoendoscopy and fulguration were used in the outpatient management of 185 patients with superficial bladder tumors followed for 24 months. This method provided optimal surveillance for recurrence and successful tumor control in selected cases. | 0 |
Accelerated non-muscle contraction after subarachnoid hemorrhage: cerebrospinal fluid testing in a culture model. The cause of chronic cerebral vasospasm after subarachnoid hemorrhage has been studied intensively, but it is still controversial whether the observable luminal narrowing should be attributed to the contraction of vascular smooth muscle cells or whether it results from some organic change in the wall. A proliferation of myointimal cells, accompanied by increased deposition of collagen, as well as myonecrosis, have been frequently observed several days after aneurysm rupture. Studies from our laboratory showed that these myointimal cells had characteristics identical to myofibroblasts. In this study, we quantitatively and morphologically examined the effect of cerebrospinal fluid on the ability of myofibroblasts to alter collagen matrices using an in vitro model. Myofibroblasts contract the collagen matrix by rearranging or compacting the framework of collagen fibers. Cerebrospinal fluid obtained from patients with recently ruptured aneurysms significantly accelerated lattice contraction, especially when the patient developed symptomatic vasospasm. This study suggests that myofibroblasts in the spastic artery can produce a contractile force that contributes to chronic vasospasm, tightening the proliferated collagen. Some unknown agent present in bloody cerebrospinal fluid accelerates the rearrangement of the collagen lattice by myofibroblasts, both of which have, until now, been considered non-contractile components. | 4 |
Effects of the novel thromboxane antagonist Bay U 3405 on experimental coronary artery disease. Bay U 3405 is a novel thromboxane receptor blocker. The present investigations describe its effects on experimental canine and porcine cardiac damage. In anesthetized dogs, a coronary artery was occluded for 6 hours and reperfused for 30 minutes. Bay U 3405 was administered intravenously 15 minutes after occlusion (1 mg/kg) followed by infusion of 10 mg/kg/hr from 30 minutes after ligature. In a second study, the effects of Bay U 3405 on endoperoxide analogue U-46619-induced coronary constriction were studied in anesthetized, open-chest pigs. Bay U 3405 reduced myocardial infarct expansion by 65% (p less than 0.01) assessed with biochemical staining. Hemodynamics and collateral blood flow were unaffected. However, reperfusion arrhythmias were suppressed. In porcine experiments, 1 mg/kg Bay U 3405, given intravenously or intraduodenally, antagonized U-46619-induced coronary vasoconstriction over 5 hours. The studies demonstrate anti-ischemic and antivasoconstrictor properties of Bay U 3405 probably due to binding to platelet and smooth muscle thromboxane receptors. This may have clinical relevance in angina pectoris and myocardial infarction. | 3 |
Extracranial metastatic glioblastoma: appearance on thallium-201-chloride/technetium-99m-HMPAO SPECT images. Sequential thallium-201-chloride and technetium-99m-hexamethylpropyleneamine oxime single-photon emission computed tomography (SPECT) images were obtained in a patient with extracranial metastatic glioblastoma multiforme. Thallium-201 uptake was high (three times the scalp background) in all pathologically confirmed extracranial metastases and moderate (1.6 times scalp background) intracranially, where most biopsy specimens showed gliosis with scattered atypical astrocytes. Technetium-99m-HMPAO uptake was decreased intracranially in the right frontal and parietal lobes which had been irradiated. It was also decreased in one well-encapsulated scalp lesion and high in another scalp mass with less defined borders. Possible mechanisms of tumor uptake of these agents are reviewed. | 0 |
Inhibition of angiogenesis and tumor growth in the brain. Suppression of endothelial cell turnover by penicillamine and the depletion of copper, an angiogenic cofactor. Microvascular proliferation, a hallmark of malignant brain tumors, represents an attractive target of anticancer research, especially because of the quiescent nonproliferative endothelium of the normal brain. Cerebral neoplasms sequester copper, a trace metal that modulates angiogenesis. Using a rabbit brain tumor model, normocupremic animals developed large vascularized VX2 carcinomas. By contrast, small, circumscribed, relatively avascular tumors were found in the brains of rabbits copper-depleted by diet and penicillamine treatment (CDPT). The CDPT rabbits showed a significant decrease in serum copper, copper staining of tumor cell nuclei, microvascular density, the tumor volume, endothelial cell turnover, and an increase in the vascular permeability (breakdown of the blood-brain barrier), as well as peritumoral brain edema. In non-tumor-bearing animals, CDPT did not alter the vascular permeability or the brain water content. CDPT also inhibited the intracerebral growth of the 9L gliosarcoma in F-344 rats, with a similar increase of the peritumoral vascular permeability and the brain water content. CDPT failed to inhibit tumor growth and the vascularization of the VX2 carcinoma in the thigh muscle or the metastases to the lung, findings that may reflect regional differences in the responsiveness of the endothelium, the distribution of copper, or the activity of cuproenzymes. Metabolic and pharmacologic withdrawal of copper suppresses intracerebral tumor angiogenesis; angiosuppression is a novel biologic response modifier for the in situ control of tumor growth in the brain. | 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. | 1 |
Healing of experimental intestinal anastomoses. Parameters for repair. Anastomotic dehiscence remains a major complication in surgery of the large bowel, and studies on the healing sequence of experimental anastomoses are necessary to define underlying mechanisms and find ways to improve surgical outcome, particularly in high-risk situations. For the quantitative description of anastomotic repair, both mechanical and biochemical parameters are employed, each with their own limitations. Mechanical parameters, either bursting pressure or breaking strength, only reflect growing anastomotic strength as long as disruption occurs within the anastomotic area, which is less than one week after surgery for the bursting pressure and probably up to two weeks for the breaking strength. The biochemical description of anastomotic repair has been limited to behavior of collagen, as represented by its rather unique constituent amino acid hydroxyproline. Conclusions based on collagen concentrations--per unit weight--should be considered with caution since they may change as a consequence of changes in noncollagenous substances. In this respect, collagen content, per unit length, is probably a better parameter to describe anastomotic collagen levels. Few investigations have addressed the quality of collagen (e.g., crosslinking or type). Since, at this time, no distinct correlations have been demonstrated between development of mechanical strength or occurrence of leakage and collagen levels in the healing anastomosis, attention should not be restricted to a description of the quantity of collagen present: the quality of anastomotic collagen should be investigated, perhaps even more so. | 4 |
Prolonged extracorporeal life support of pediatric and adolescent cardiac transplant patients. Options for mechanical support of pediatric patients with severe heart failure who are awaiting transplantation or have undergone transplantation are limited. This report examines 3 patients placed on extracorporeal life support (ECLS) while awaiting transplantation and 3 patients who underwent transplantation and suffered subsequent heart failure due to rejection or postoperative myocardial dysfunction. The overall survival rate was 2 of 6. The 2 surviving patients had a failing transplanted heart. There were no survivors among the patients placed on ECLS as a bridge to transplantation. In each case a contraindication to transplantation developed before a donor heart could be obtained. The mean time of ECLS support was 147.5 hours (range, 70 to 370 hours). The ECLS circuit did not affect cyclosporin levels or antirejection therapy. Extracorporeal life support can be used to support pediatric cardiac transplant patients with biventricular failure due to acute rejection or postoperative dysfunction. Although the results have been discouraging, ECLS may still have a role as a bridge to transplantation. However, complications can develop during ECLS that may preclude transplantation. | 3 |
A unique indexing splint for use in combined Le Fort and nasal injuries to avoid tracheostomy. Midface fractures with associated displaced and/or comminuted nasal fractures can require tracheostomy for a general anesthetic airway if these fractures are to be reduced simultaneously. We describe a unique indexing splint that allows oral intubation yet also allows simultaneous reduction of midface and nasal fractures under one anesthetic. Furthermore, tracheostomy with its potential complications is avoided. The case report illustrates the technique, and alternative treatments for these injuries are discussed. | 2 |
Low-dose preoperative radiation postpones recurrences in operable rectal cancer. Results of a randomized multicenter trial in western Norway. A randomized, multicenter clinical trial was conducted in Western Norway to study the effectiveness of preoperative radiation therapy in operable rectal cancer, given at a dosage of 3150 cGy in 18 fractions, 2 to 3 weeks before radical surgery. Three hundred nine patients were entered into the trial between May 1976 and December 1985. After radiation no tumor was seen in 4.5% of the patients. There was no increased morbidity or mortality at surgery. The 5-year survival for evaluable patients was 57.5% in the control group and 56.7% in the radiotherapy group. For patients operated on for cure the 5-year survival was 60.9% and 64.2% in the control group and radiotherapy group, respectively. Radiation significantly delayed both local and distant recurrences in patients in the radiation group who had curative resection from 13.3 months in controls to 27.1 months. The local recurrence rate in the corresponding groups was 21.1% and 13.7%, respectively. We conclude that higher preoperative radiation doses should be used in new trials as a higher dosage may transform the observed positive effects into a survival benefit. | 0 |
Renal hemodynamics in normal and hypertensive pregnancy: lessons from micropuncture. Rats are an excellent animal model in which to study the changes in renal hemodynamics associated with normal pregnancy. Midterm pregnant rats exhibit a maximal renal vasodilation leading to increases in glomerular filtration rate (GFR) and renal plasma flow (RPF). Micropuncture studies in midterm pregnant Munich-Wistar rats have shown that single-nephron GFR (SNGFR) increases, due entirely to increases in plasma flow and, importantly, glomerular capillary blood pressure (PGC) remains unchanged in normotensive pregnancy, due to parallel and proportionally similar reductions in preglomerular (RA) and efferent (RE) arteriolar resistance. Despite the chronic gestational renal vasodilation, pregnancy in normotensive rats with either normal kidneys or a variety of underlying diseases, causes no adverse changes in renal function, perhaps because the glomeruli are protected from damaging high PGC. In the presence of systemic hypertension, the renal vasodilation of pregnancy could put the maternal kidney at risk of injury due to increases in PGC. There are few renal functional studies in preexisting, essential hypertension, but micropuncture studies in spontaneously hypertensive rats (SHRs) have shown that repetitive pregnancies in SHRs cause no functional impairment. Surprisingly, SHRs demonstrated no gestational renal vasodilation, although gestational decreases in peripheral resistance certainly occur in the SHR. This absence of gestational renal vasodilation may be a protective mechanism; it remains to be determined whether hypertensive states in which renal vasodilation does occur are associated with increased risk to the maternal kidney. | 3 |
Plasma HDL cholesterol concentrations are correlated to bile cholesterol saturation index in the African green monkey. In an attempt to determine if plasma lipoprotein concentrations correlate with the bile cholesterol saturation index in the African green monkey, we have studied a group of adult male animals available from a long-term study investigating the effects of dietary fat and cholesterol on cholesterol metabolism and atherosclerosis. The animals were fed diets containing 0.8 mg cholesterol/kcal or 0.03 mg cholesterol/kcal for five years. Within each dietary cholesterol group, animals received 42% of dietary calories as fat, enriched with either saturated or polyunsaturated fat. Using stepwise multiple linear regression, high density lipoprotein (HDL) cholesterol concentration was found to be the best plasma lipid predictor of the bile cholesterol saturation index. When the cholesterol saturation index of a fasting gallbladder bile specimen was compared to the plasma HDL cholesterol level for individual animals, a significant positive correlation was noted for animals fed polyunsaturated fat, (r = 0.68) and for animals fed saturated fat (r = 0.72). For any value of HDL cholesterol, however, the cholesterol saturation index was higher in animals fed polyunsaturated fat compared to saturated fat. Since plasma HDL cholesterol levels were positively correlated with the bile cholesterol saturation index in adult male African green monkeys, we conclude that a metabolic link exists between plasma HDL cholesterol concentrations and bile cholesterol saturation, perhaps due to enhanced delivery of cholesterol to the liver by HDL. | 1 |
Long-term function of persons with atherosclerotic bilateral below-knee amputation living in the inner city. Long-term function of 24 elderly persons with atherosclerotic bilateral below-knee amputation living in an inner city for at least six months after the second amputation, was determined. Twenty-one (87.6%) subjects were living at home; three were living in nursing homes. Fourteen (70%) of 20 subjects who received bilateral prostheses were ambulators. At interview, the mean age was 75.2 years; 4.87 years was the mean time since the second amputation. Ten (50%) subjects remained ambulatory. Among the other ten who received prosthesis, loss of ambulation occurred mostly due to medical factors, at an average of 3.47 years after the second amputation. Those no longer ambulatory were older and "sicker," and the interval between amputations was shorter. Fifteen (62.5%) subjects were independent in dressing, 14 (58.4%) in toileting, and only nine (33.3%) in bathing. All but one subject required housekeeping assistance. The anticipated effect on function of environmental and socioeconomic factors could not be demonstrated in this sample. Survival time and retention of ambulatory skills for an average of nine years after the second amputation in eight (33.3%) subjects who died before the end of the study was longer than previously described. The high rate of success in rehabilitation and in maintenance of ambulatory skills fully justifies intensive restorative efforts for this group of amputees. | 3 |
Ectopic retinoblastoma within the 3rd ventricle: case report. Ectopic intracranial retinoblastomas are rare. These tumors usually occur in the pineal, parasellar, or suprasellar regions several years after the successful treatment of ocular retinoblastomas with no evidence of direct extension or distant metastasis. We report here a case of ectopic retinoblastoma occurring within the third ventricle. The tumor was surgically excised by the transventricular approach. Ectopic retinoblastomas exhibit greater differentiation than one would expect to observe in a metastatic lesion of this tumor. The distinction of ectopic retinoblastomas and metastasis from ocular retinoblastomas is important, since ectopic retinoblastomas, unlike metastasis, can be successfully managed by intensive therapy including radical excision. | 2 |
Unusually late onset of cerebrospinal fluid rhinorrhea after head trauma. Two cases of acute meningitis and cerebrospinal fluid rhinorrhea, in which the head trauma responsible occurred 10 and 30 years before, are presented. Intraoperatively, the brain parenchyma was found to be plugged into the fractured anterior fossa. By debridement and duraplasty from an intradural approach, both patients were cured. Several precipitating factors could be responsible for this unusually late reopening of the fistula. The possible accidental causes could be coughing or undetected microtraumas, but in the long run, atrophy of tissues and consequent changes in brain compliance with aging may play a role. | 2 |
Mechanisms for left ventricular systolic dysfunction in aortic regurgitation: importance for predicting the functional response to aortic valve replacement To test the hypothesis that the combined use of the time-varying elastance concept and conventional circumferential stress-shortening relations would elucidate differential mechanisms for left ventricular systolic dysfunction in severe, chronic aortic regurgitation and therefore predict the functional responses to aortic valve replacement, 31 control patients and 37 patients with aortic regurgitation were studied. The studies included micromanometer left ventricular pressure determinations, biplane contrast cineangiograms under control conditions and radionuclide angiograms under control conditions and during methoxamine or nitroprusside infusions with right atrial pacing. The patients with aortic regurgitation were classified into three groups: Group I had normal Emax and stress-shortening relations, Group II had abnormal Emax but normal stress-shortening relations and Group III had abnormal Emax and stress-shortening relations. The left ventricular end-diastolic and end-systolic volumes showed a progressive increase and the ejection fraction showed a progressive decrease from Group I to III; these values differed from those in the control patients (p less than 0.001). In Group I, there was a decrease in left ventricular volumes (p less than 0.05) but no significant change in ejection fraction (61 +/- 7% versus 63 +/- 4%) after aortic valve replacement. In contrast, in Group II, reduction in left ventricular volumes (p less than 0.01) was associated with an increase in ejection fraction from 50 +/- 8% to 64 +/- 11% (p less than 0.01). Finally, in Group III, reduction in left ventricular volumes (p less than 0.05) was associated with a further decrement in ejection fraction from 35 +/- 13% to 30 +/- 13%. Group I patients had compensated adequately for chronic volume overload. However, Group II had left ventricular dysfunction that was associated with an increase in the left ventricular volume/mass ratio compared with that in the control patients and Group I (p less than 0.05 for both), suggesting inadequate hypertrophy and assumption of spherical geometry. Finally, irreversible myocardial dysfunction had supervened in Group III. In conclusion, a combined analysis of left ventricular chamber performance using the time-varying elastance concept and myocardial performance using conventional circumferential stress-shortening relations provides complementary information that elucidates differential mechanisms for left ventricular systolic dysfunction and therefore predicts the functional response to aortic valve replacement. | 3 |
Echocardiographic measurement of left ventricular mass and volume in normotensive and hypertensive rats. Necropsy validation. Although rats are commonly used to study left ventricular (LV) hypertrophy, measurement of LV mass and dimensions has required killing the rat. To determine the accuracy of echocardiography in rats, blinded crossectional area (CSA) and LV mass measurements using either the cube function (LVM) or an elliptical model (LVMel) from high resolution M-mode echocardiograms were compared to necropsy LV weight (0.28 to 1.5 g), in 41 normotensive (body weight 116 to 762 g) and 17 hypertensive rats (350 to 560 g). Postmortem chamber volumes in 28 normal rats (0.02 to 0.19 mL) were also compared to echocardiographic volumes derived from the elliptical model. Correlation with LV weight was r = 0.87 for LVM, 0.90 for CSA and 0.93 for LVMel (all P less than .00001). Comparison of hypertensive and body-weight-matched normotensive rats revealed the upper normal limit for both LVMel and CSA to have 89% sensitivity and 100% specificity for detection of post mortem LV hypertrophy. Necropsy LV volumes were more closely related to systolic echocardiographic volumes than to diastolic volumes (r = 0.78 v 0.71, both P less than .00001), compatible with the effects of post mortem contracture. Stroke volume determined invasively in 5 Wistar rats by thermodilution was similar to that obtained using elliptical model echo volumes in 5 rats of the same body size (0.35 +/- 0.05 v 0.30 +/- 0.06 mL/beat). Echocardiography can be used to evaluate LV structure and function in rats and to detect in vivo LV anatomic differences induced by hypertension. | 4 |
Axial rotation of the lumbar spine and the effect of flexion. An in vitro and in vivo biomechanical study. A series of experiments were performed on eight whole, cadaveric lumbar spines and on eight male volunteers to determine whether axial rotation changed with subjects bending forward compared with being in a neutral posture and whether rotation was affected by articular tropism. Kirschner wires were inserted into the spinous processes of the eight cadaveric lumbar spines, and the axial rotation of the wires was measured while the spine was rotated in a torsion apparatus. Similarly, Steinmann pins were inserted into the spinous processes of L3, L4, and L5 of the eight volunteers, and the axial rotation of the pins was measured while the subjects rotated in a torsion apparatus. Axial rotation was found to be less when combined with forward flexion, and articular tropism did not influence the amplitude of rotation. | 4 |
Loss of expression of blood group antigen H is associated with cellular invasion and spread of oral squamous cell carcinomas. Membrane-bound carbohydrates may influence the metastatic behavior of cancer cells. Forty-two squamous cell carcinomas (SCC) of the buccal and maxillary alveolar mucosa were studied retrospectively using a monoclonal antibody (BE2) that reacts with blood group H (type 2 chain) structure and an immunoperoxidase (avidin-biotin peroxidase complex) staining technique. H-antigen staining within the entire tumor did not correlate with the stage of the tumor, i.e., tumor spread. However, loss of staining within the most invasive sites of the tumors correlated significantly with the stage of tumor development and histologic grade of malignancy. These findings support the view that features regarding the cells of deeper parts of the carcinomas are very important for the clinical behavior of the tumors and that loss of H-antigen expression is related to the stage of the tumor and invasion of carcinoma cells. | 0 |
The contribution of median nerve SEPs in the functional assessment of the cervical spinal cord in syringomyelia. A study of 24 patients. Since the early study of Halliday and Wakefield (1963) it has generally been agreed that scalp somatosensory evoked potentials (SEPs) are normal in patients with dissociated loss of pain and temperature sensation. Up to now a few patients with abnormal spinal N13 and preserved scalp P14 and N20 have been reported in the literature, but there is no firm evidence, based on group data, that this dissociation can be related to any form of dissociated sensory loss. We studied median nerve SEPs in 24 patients with syringomyelia documented by CT scan or MRI. For the recording of the cervical N13 we used a Cv6 anterior cervical montage, which cancels the potentials generated above the foramen magnum and enhances the amplitude of N13. Scalp far-field and early cortical SEPs were recorded using a noncephalic reference electrode. Since N13 pathological changes are mainly changes in amplitude we measured the N13/P9 amplitude ratio in normal subjects and patients and found that it was a reliable index to quantify the amplitude decrease of N13. Absent or reduced N13 was observed in 40 median nerve SEPs (83%) in conjunction with normal P14 and N20 in 30 SEPs. Thus the dissociated loss of the cervical N13 was identified as the most conspicuous SEP feature in syringomyelia. A significant correlation was found between abnormal N13 and loss of pain and temperature sensations, whereas P14 abnormalities correlated well only with loss of joint and touch sensations. In the median nerve territory, sensation was either normal (6 cases) or lost only for pain and temperature (24 cases) when SEPs showed abnormal N13 and normal P14. Although it does not directly reflect the postsynaptic activity of spinal cells receiving their inputs from A delta and C fibres the N13 potential proved to be a reliable index of spinal cord grey matter dysfunction in syringomyelia. | 2 |
Synergism of ara-C-imuvert combination in aborting the development of transplanted chloroleukemia in the rat. The development of chloroleukemia in the rat after transplantation of C51 chloroma cells can be aborted by treatment with an exogenous source of differentiating activity (DA) or by stimulation of endogenous DA production by the administration of Imuvert, a biologic response modifier. Success or failure of treatment was determined by the ratio of DA to leukemic cell load. Accordingly, in the present study we examined the hypothesis that treatment with cytosine arabinoside (ARA-C) to reduce the leukemic cell load coupled with Imuvert would be more effective than either given alone. Treatment with ARA-C-Imuvert aborted the development of chloroleukemia in 79% of the animals in contrast to 0%, 9% and 45% in animals treated with buffer, ARA-C, or Imuvert respectively. These results suggest that stimulation of endogenous DA in combination with cytoreductive agents offers a potentially curative treatment for myelogenous leukemia. | 0 |
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