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Intraocular pressure increases with fenoldopam, but not nitroprusside, in hypertensive humans. Fenoldopam mesylate stimulates adenyl cyclase in porcine ocular trabecular meshwork and raises intraocular pressure in humans. To clarify whether this results from direct activation of the dopamine-1 receptor or indirectly from baroreflex sympathetic stimulation after blood pressure reduction, intraocular pressure was measured in 14 patients with accelerated/malignant hypertension, randomized between intravenous fenoldopam or sodium nitroprusside. Intraocular pressure was measured with a Perkins tonometer, before and at the twentieth minute of each dose increment. In seven patients with a mean blood pressure of 232/131 mm Hg treated with fenoldopam, intraocular pressure increased in a dose-dependent fashion, from 16 +/- 1 to 20 +/- 2 mm Hg (p less than 0.005). In contrast, seven patients with a mean blood pressure of 225/134 mm Hg treated with sodium nitroprusside exhibited no change in intraocular pressure (15 +/- 1 versus 14 +/- 1 mm Hg) despite similar blood pressure reduction. Increases in heart rate were not significantly different. Rates of urinary excretion of norepinephrine plus epinephrine increased significantly relative to baseline (p less than 0.05) but were not different between groups. These data suggest that the increase in intraocular pressure with fenoldopam results from specific activation of the dopamine-1 receptor and is not caused by baroreflex sympathetic stimulation. Because dopamine-1 receptors may modulate intraocular pressure, dopamine-1 receptor blockers might be useful therapy for glaucoma. | 3 |
Primary varicose veins: topographic and hemodynamic correlations. This study was conducted to correlate the clinical presentations of uncomplicated primary varicose veins with the topographic and anatomic source of reflux (escape points). One-hundred sixty-three patients with primary varicose veins (144 females, 19 males; 96 unilateral, 67 bilateral) in 230 involved limbs were examined. The origin and extent of venous reflux was traced with Doppler ultrasound. Three distinct groups were recognized. Group I. Typical saphenous varicosities with junctional escapes occurred in 164 (71.3%). Sapheno-femoral junction (SFJ) incompetence in 147, and sapheno-popliteal junction (SPJ) incompetence in 17 limbs. Group II. Atypical saphenous varicosities with non-junctional escapes occurred in 51 (22.17%) limbs. In 5 limbs, no escape was detected. Twenty-two limbs had escapes localized in the main perforators: mid-thigh perforator 17, upper calf 2, distal ankle in 3. Twenty-four limbs had their escapes in the auxiliary perforators: abdomino-pelvic 17, and circumflex iliac/external epigastric, 7 limbs. Group III. Non saphenous (lateral venous system) varicosities occurred in 15 (6.52%) limbs. Based on physical examination alone, 55 limbs would possibly have undergone unnecessary ankle to groin stripping and 83 limbs an unnecessary SFJ ligation. Doppler US is an essential diagnostic tool that can accurately map the origin and extent of the venous reflux. The obtained hemodynamic information will permit more selective, multimodal therapy and avoid the indiscriminate, often unnecessary stripping of the entire saphenous system in all cases of primary varicose veins. | 3 |
Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. We report the improving surgical results in a consecutive series of 690 patients referred to one of us (E.S.C.) for aortic dissection between December 1956 and September 1989, a substantial portion of whom had dissection as a complication of either previous aortic (n = 113, 16) or previous cardiac (n = 54, 8%) operation. Our initial operation of choice in patients requiring multiple operations in this group of 690 patients was based on the most life-threatening or symptomatic aortic segment involved, which was ascending aorta and/or aortic arch (Asc/Arch) in 301 (44%) patients, descending thoracic aorta (Desc) in 195 (28%) patients, and thoracoabdominal aorta (TaA) in 194 (28%) patients. As detailed below, considerable improvement occurred in the 30-day survival rates over time, particularly for acute dissection: [table; see text] The independent determinants of both early and long-term mortality were identified. Independent determinants of late fatal rupture, reoperation, and neuromuscular dysfunction for distal dissectors were also identified. In our experience, continued aggressive surgical intervention for aortic dissection with modern operative techniques has resulted in markedly improved 30-day operative survival (approaching 95% including those patients with acute dissection) and significant improvement in late results. | 4 |
Fibrillation potential amplitude and muscle atrophy following peripheral nerve injury. Maximum peak-to-peak fibrillation potential amplitude was measured in 69 subjects between 7 days and 10 1/2 years post complete or partial peripheral nerve injury. Mean amplitude during the first 2 months was 612 muV; third and fourth months 512 muV, fifth and sixth months 320 muV. After the first year, no population of fibrillation potentials greater than 100 muV was recorded. The sciatic nerve was sectioned in 13 guinea pigs and animals studied up to 17 weeks. Fibrillation potential amplitude in gastrocnemius muscles declined paralleling that in humans. By the end of the study, type I fibers had lost almost half of their initial diameter and type II fibers had atrophied more than twice this amount. Fibrillation potential amplitude may be useful in estimating the time post nerve injury and appears to correlate with the surface area and fiber diameter of a type I muscle fiber. | 2 |
Effect of bleomycin on hematoporphyrin derivative phototherapy of solid tumors. Hematoporphyrin derivative phototherapy (HpD-PT) has been successfully used to localize and treat superficial squamous cell cancers. Bleomycin sulfate is a glycopeptide antibiotic that has antineoplastic properties against squamous cell cancers. Because both HpD-PT and bleomycin chemotherapy are accepted forms of treatment for squamous cell cancer and their cytotoxicity is mediated by singlet oxygen and oxygen radicals, we studied the possibility of enhancing the response of solid tumors to HpD-PT by combining this modality with systemic bleomycin chemotherapy in a murine tumor model. Bleomycin did not enhance HpD-PT significantly. Also, we are not confident that HpD-PT alone or in combination with other agents can eradicate solid tumors; it certainly did not in this syngeneic murine tumor model. | 0 |
Pneumococcal pneumonia in a rat model of cirrhosis: effects of cirrhosis on pulmonary defense mechanisms against Streptococcus pneumoniae. To study alterations in host defense mechanisms that enhance pneumococcal virulence, a model of Streptococcus pneumoniae pneumonia was developed in cirrhotic rats. Cirrhosis, with or without ascites, was produced in rats by intragastric administration of carbon tetrachloride (CCl4). Histopathologic and laboratory studies demonstrated that CCl4-induced cirrhosis was similar to alcoholic cirrhosis in humans. Cirrhotic rats were more susceptible to type 3 pneumococcal pneumonia induced by intratracheal challenge than controls, and the presence of ascites was associated with the lowest LD50. More cirrhotic rats with ascites had bacteremia and elevated levels of circulating capsular antigen after challenge compared with cirrhotic rats without ascites or controls. Pulmonary clearance of pneumococci was markedly reduced in rats with cirrhosis and ascites and was associated with reduced serum complement levels. This model may be useful in further studies of the pathogenesis and therapy of pneumococcal infections in the compromised host. | 1 |
Atrial fibrillation after stroke in the elderly. To examine the relationship between atrial fibrillation and mortality after stroke, we studied 186 men and 167 women from the Waikato Stroke Registry whose mean age was 75.2 +/- 7.5 years. Twenty-three percent (82 of 353) had atrial fibrillation or flutter on their admission electrocardiogram. This group differed significantly from that with sinus rhythm in three respects: 1) They were older (p less than 0.01); 2) they had more severe current stroke deficit as evidenced by lower limb power (p less than 0.05) and Mini-Mental State Score (p less than 0.001), higher incidence of homonomous hemianopia (p less than 0.05), and lower incidence of lacunar syndrome stroke (p less than 0.001); and 3) they had a significantly higher incidence of cardiomegaly and congestive heart failure (p less than 0.01). Functional outcome was insignificantly better in the group with sinus rhythm. During a mean follow-up period of 18 months, mortality was significantly higher in the group with atrial fibrillation (p = 0.001). Proportional hazards modeling, however, showed that the apparently poorer survival in those patients with atrial fibrillation could be explained by factors other than cardiac rhythm, such as age, Mini-Mental State Score, level of consciousness, and interstitial edema on admission chest radiograph. Thus, atrial fibrillation was not an independent predictor of survival after stroke. | 3 |
Comparison of vastus medialis obliquus: vastus lateralis muscle integrated electromyographic ratios between healthy subjects and patients with patellofemoral pain. The purpose of this study was to compare vastus medialis obliquus:vastus lateralis muscle (VMO:VL) integrated electromyographic (IEMG) ratios of healthy subjects and patients with unilateral patellofemoral pain (PFP) under isotonic and isometric quadriceps femoris muscle contraction conditions. Subjects ranging in age from 18 to 35 years (mean = 28.06, SD = 5.97) were assigned to one of three groups on the basis of type of knee condition. In group 1, which consisted of seven healthy control subjects with no history of knee pathology, both knees were tested. In group 2, which consisted of nine patients with unilateral PFP, only the painful knee was tested. In group 3, which consisted of the same nine patients who comprised group 2, only the nonpainful knee was tested. Nonnormalized and normalized VMO:VL IEMG ratios were computed for ascending stairs, descending stairs, submaximal isometric contraction, and maximal isometric contraction (nonnormalized only). A two-way analysis of variance for repeated measures indicated VMO:VL ratios for isotonic stair-climbing activities were significantly greater than VMO:VL ratios for isometric contractions. Nonnormalized VMO:VL ratios in group 1 were significantly greater than nonnormalized VMO:VL ratios in the other two groups. Patients with PFP may have abnormal VMO:VL activation patterns, and isotonic quadriceps femoris muscle exercise may elicit more favorable muscle activation patterns than isometric exercise for patients with PFP. | 2 |
West syndrome associated with hyperlexia. Two patients are reported with West syndrome associated with hyperlexia. They had peculiar linguistic and psychosocial development and autistic behavior, yet began to read Japanese and Chinese characters, numbers, Roman alphabet letters, and trademark letters at 3 years of age. Neuropsychologic, electroencephalographic, and radiologic studies were performed at 11 years of age in Patient 1 and at 10 years of age in Patient 2. Although they were able to read fluently with correct intonation, their comprehension was significantly impaired. The neuropsychologic evaluation of both patients demonstrated selective, excellent ability in auditory memory in contrast to impairment of associational abilities, visual retention, and visual constructional abilities. These findings suggest that the functions in the nondominant hemisphere were also impaired. Although children with West syndrome frequently have associated mental retardation, patients with West syndrome associated with hyperlexia have never been reported. A neuropsychologic investigation of epileptic children with mental retardation is necessary for the detection of hyperlexia. | 4 |
Selective peripheral denervation for torticollis: preliminary results Herein we report the preliminary results in nine patients who have undergone selective peripheral denervation for spasmodic torticollis and have been followed up for at least 13 months. All patients had improvement immediately after surgical intervention, and the results have been maintained in five patients. In one patient who had recurrent torticollis, a second procedure in conjunction with injection of botulinum toxin has produced substantial improvement; however, follow-up was brief (6 months). No surgical complications occurred. We believe that selective peripheral denervation is safe and that it can benefit patients with torticollis who have not responded to other types of therapy. These favorable results confirm other published reports on the efficacy of selective peripheral denervation. Long-term follow-up, however, is necessary for determining the role of this procedure in the management of torticollis. | 4 |
Meropenem pharmacokinetics and penetration into an inflammatory exudate. The pharmacokinetics and penetration into a cantharidine-induced inflammatory exudate of meropenem was studied in six volunteers following a single 1-g intravenous dose. Concentrations in plasma, urine, and the inflammatory exudate were determined by a microbiological assay. The mean elimination half-life of meropenem in plasma was 1.1 h, with the concentration in plasma declining from a mean of 23.6 micrograms/ml at 1 h to 0.7 micrograms/ml at 6 h. The inflammatory fluid penetration was rapid (time to maximum concentration of drug in serum, 0.75 h), and the penetration was 111%. The recovery of meropenem in urine at 24 h was 65.4% of the administered dose. | 4 |
Effects of ischemia and hemoglobin on vascular function in isolated rabbit aortas. The vascular endothelium is important in the modulation of vascular tone via production of endothelium-derived relaxing and contracting factors. The abdominal aortas of five groups of rabbits were subjected to varying lengths of ischemia (0, 1, 2, 3, or 4 hours), removed, sectioned into transverse rings, and placed in tissue baths containing Krebs' buffer at 37 degrees C and aerated with 95% O2/5% CO2. After equilibration the rings were tested for endothelium-dependent vasodilation with methacholine and nonendothelium-dependent vasodilation with nitroprusside. Endothelium-dependent relaxation as elicited by methacholine was impaired at 3 and 4 hours of ischemia but was not significantly different at 1 and 2 hours as compared to control, whereas endothelium-independent vasodilation remained normal throughout the different periods of ischemia. The addition of 1 x 10(-6) mol/L rabbit hemoglobin reduced the time needed to demonstrate significant impairment of endothelial function to 2 hours. Endothelium-independent vasodilation was not affected by hemoglobin. We conclude that hemoglobin exacerbates ischemia vascular dysfunction in the rabbit aorta. | 3 |
Recurrence of duodenal ulcer and elevated serum pepsinogen I levels in smokers and nonsmokers. We determined serum pepsinogen I (PG I) levels by radioimmunoassay in 472 patients with duodenal ulcer and 141 normal subjects to investigate whether serum PG I levels were related to cigarette smoking, and in 225 patients to determine whether the recurrence of duodenal ulcer was related to serum PG I levels or cigarette smoking. Serum PG I levels were not influenced by cigarette smoking in either patients with duodenal ulcer or normal subjects. The recurrence rate of duodenal ulcer not under maintenance therapy was significantly higher in hyperPG I patients than in normoPG I patients, regardless of their smoking habits. Only in hyperPG I patients was the recurrence rate in smokers higher than in nonsmokers. Patients under maintenance therapy showed similar results. Multilogistic regression indicated that hyperPG I had a greater effect than cigarette smoking on ulcer recurrence. These findings indicate that serum PG I levels are not influenced by smoking, and the important characteristic in patients with recurrent duodenal ulcers is the increased serum PG I levels. | 4 |
Extracorporeal shock wave lithotripsy for biliary stones. Extracorporeal shock wave lithotripsy is a noninvasive technique for treatment of patients with gallbladder and bile duct stones. Selected patients with gallbladder stones can be treated on an outpatient basis without general anesthesia and may return to full activity within 1 or 2 days. Stone-free rates of 40% to 60% at 6 months have been achieved in most reported series with minimal morbidity. Bile duct stone lithotripsy has achieved stone clearance in 80% of patients in whom conventional methods were unsuccessful and therefore constitutes a valuable second-line treatment for these patients. | 1 |
Papillary adenocarcinoma of the middle ear. A case of papillary adenocarcinoma of the middle ear is presented. The patient had an unusually short history of otalgia, aural discharge and facial palsy, and, at presentation the tumour was too large for surgical resection to be a feasible option. The management of this rare tumour is discussed and the relevant literature reviewed. | 0 |
Cardiac arrest due to spontaneous coronary artery dissection in a patient with coronary ectasia--a case report. Spontaneous coronary artery dissection is a rare event and only in a few patients has the diagnosis been angiographically confirmed during life. A spontaneous dissection of the right coronary artery was detected as a cause of out-of-hospital cardiac arrest in a patient with coronary artery ectasia. | 3 |
Hepatic histological findings after transplantation for chronic hepatitis B virus infection, including a unique pattern of fibrosing cholestatic hepatitis. Long-term follow-up of 27 patients with hepatitis B virus-related chronic liver disease treated by transplantation showed that 23 had hepatitis B virus recurrence. In 13 patients late changes in the grafts were similar to those described in other series: minor abnormalities in five cases, chronic active hepatitis in five cases and non-hepatitis B virus-related graft dysfunction in three cases. Three patients had incomplete histological follow-up. Analysis of the histological changes and viral antigen expression in six cases revealed a distinct and novel pattern termed fibrosing cholestatic hepatitis. Development of fibrosing cholestatic hepatitis was associated with rapidly progressive graft dysfunction. It is postulated that this pattern of fibrosing cholestatic hepatitis develops because of a high cytoplasmic expression of viral antigens, including HBsAg. The remaining case had some features of fibrosing cholestatic hepatitis. The main histological features of this unique syndrome include thin, perisinusoidal bands of fibrosis extending from portal tracts to surround plates of ductular-type epithelium; prominent cholestasis; ground-glass transformation; and ballooning of hepatocytes with cell loss and mild mixed inflammatory reaction. | 4 |
Frequency of low-grade residual coronary stenosis after thrombolysis during acute myocardial infarction. The clinical, angiographic and demographic characteristics of 42 patients with low-grade (less than 50%) residual stenosis at the infarct lesion after thrombolysis for acute myocardial infarction (MI) were assessed. The study group (group I) represented 21% of 198 consecutive patients receiving thrombolytic therapy over a 59-month period. Data on the 156 remaining patients were pooled for comparison (group II). Group I patients were predominantly men (86%) who were cigarette smokers (81%). Group II patients were predominantly men (75%, p greater than 0.10) but were significantly older (52 +/- 12 vs 56 +/- 10 years, p = 0.02). Prior acute MI or angina was unusual in group I. Sixty percent had no significant (greater than 50%) residual coronary artery disease while 25% had residual single artery disease. Average significant (greater than 50% diameter stenosis) residual vessel disease was 0.6 +/- 1.0 for group I and 1.9 +/- 0.9 for group II (p less than 0.001). In group I, average residual infarct lesion diameter stenosis was 36 +/- 7% in the right anterior oblique and 34 +/- 8% in the left anterior oblique views. Thirty-nine group I patients were discharged with medical therapy and 100% follow-up was obtained over a mean interval of 18 +/- 17 months. Fifteen patients experienced chest pain after acute MI accounting for 17 discrete events. Fifty-nine percent of group I had a benign course on follow-up. Eight events were classified as unstable angina, 4 as acute MI and 5 as atypical angina. Documented coronary vasospasm occurred in 3. | 4 |
Avoiding interpretive pitfalls when assessing arrhythmia suppression after myocardial infarction: insights from the long-term observations of the placebo-treated patients in the Cardiac Arrhythmia Pilot Study (CAPS) The Cardiac Arrhythmia Pilot Study (CAPS) was a 1 year trial that analyzed the safety and effectiveness of arrhythmia suppression in 502 patients surviving acute myocardial infarction who had greater than or equal to 10 ventricular premature depolarizations/h or greater than or equal to 5 runs of ventricular tachycardia on a Holter recording obtained 6 to 60 days after the acute infarction. Because 100 of these patients received placebo in a double-blind fashion for 1 year, a comprehensive objective analysis was performed of spontaneous arrhythmia changes based on real data rather than statistical estimates. In the CAPS placebo group, 19% developed some serious clinical event in 1 year (death, heart failure, proarrhythmia) that could likely be attributable to antiarrhythmic drug toxicity. A significant reduction in the frequency of ventricular premature depolarizations (p = 0.004) occurred in the first few weeks of "therapy" with a further significant (p less than 0.04) decrease between 3 to 12 months. After initiation of placebo antiarrhythmic therapy, 27% had "apparent ventricular premature depolarization suppression" (greater than or equal to 70% reduction) after one Holter recording evaluation and nearly half (48%) after six Holter recordings to assess suppression were performed. | 3 |
Role of granulocyte elastase in tissue injury in patients with septic shock complicated by multiple-organ failure. To better understand the role of granulocyte elastase (GE) in mediating tissue injury during sepsis, GE levels were measured in plasma and bronchoalveolar lavage fluid (BALF) in patients with septic shock (n = 16) and hemorrhagic shock (n = 30). Granulocyte elastase levels were compared to levels of alpha 1-protease inhibitor (alpha 1-PI). Results show that although plasma GE-alpha 1-PI complex was initially elevated in patients with hemorrhagic and septic shock, elevations in plasma GE-alpha 1-PI complex (831 +/- 241 micrograms/L) persisted in septic shock patients. alpha 1-Protease inhibitor levels in serum were increased, resulting in an inhibition of serum GE activity. Granulocyte elastase activity in BALF, however, was significantly higher in those patients with septic, as compared to hemorrhagic shock (31.4 +/- 25.8 versus 3.7 +/- 4.0 U/L, respectively). In addition GE levels were compared to other parameters, including respiratory index, blood neutrophil count, and plasma levels of endotoxin, fibronectin, and coagulation factor XIII. Significant correlations were observed between GE-alpha 1-PI and increased endotoxin concentration and decreased fibronectin and coagulation factor XIII levels. Significant correlation was found also between GE activity in BALF and respiratory index. These findings suggest that severe tissue damage occurred in patients with septic shock complicated by multiple-organ failure. Although GE activity appeared to be adequately inhibited by alpha 1-PI in blood, increased GE activity in local tissues, such as lung alveoli, may be responsible for significant local tissue injury during septic shock. | 4 |
Cobb's collar--a forgotten entity. Cobb's collar or Moormann's ring is a stricture of the bulbar urethra which is largely unrecognised but has considerable relevance urologically as the site of congenital or post-instrumental strictures. The history, anatomy, embryology and surgical importance are reported. | 4 |
Association between primary pulmonary hypertension and portal hypertension: analysis of its pathophysiology and clinical, laboratory and hemodynamic manifestations. To determine the clinical, laboratory and hemodynamic profile in patients with primary pulmonary hypertension and associated portal hypertension, 7 new cases and 71 previously reported cases were analyzed. There was no gender predilection and the average age at diagnosis was 41 years. Liver cirrhosis was the most frequent cause of hypertension (82%) and a surgical portosystemic shunt was present in 29%. Almost invariably, portal hypertension either preceded or was diagnosed concurrently with pulmonary hypertension, favoring the hypothesis that in portal hypertension, the pulmonary vasculature may be exposed to vasoactive substances normally metabolized or produced by the diseased liver, possibly inducing vasoconstriction or direct toxic damage to the pulmonary arteries. Clinically, exertional dyspnea was the most frequent presenting symptom (81%); other symptoms, such as syncope, chest pain and fatigue, were present in less than 33%. An accentuated pulmonary component of the second heart sound (82%) and a systolic murmur (69%) were the most common physical findings. At least 75% of these patients had evidence of pulmonary hypertension on electrocardiography (right ventricular hypertrophy) or roentgenography (cardiomegaly or dilated main pulmonary arteries, or both). Hemodynamic findings included severe pulmonary hypertension (mean pulmonary artery pressure 59 +/- 19 mm Hg) with normal pulmonary capillary wedge pressure and cardiac output. Treatment was basically palliative and the mean and median survival times were 15 and 6 months, respectively. In brief, on the basis of clinical presentation and laboratory features, patients with combined primary pulmonary hypertension and portal hypertension seldom represent a diagnostic challenge. Further research is needed on treatment, which remains palliative. The survival rate is poor and worse than that seen in isolated primary pulmonary hypertension. | 3 |
Ten-year prospective study on the development of renal cell carcinoma in dialysis patients. A prospective study was undertaken to investigate the development of renal cell carcinoma in dialysis patients. Three renal cell carcinomas were detected among 96 hemodialysis patients in 1979, and screening by computed tomographic (CT) scan was continued yearly until 1989. During this 10-year period, one renal cell carcinoma was found in the second year and another in the ninth year. Autopsy performed on seven of 19 patients who died showed one case of small clear cell carcinoma accompanying acquired cystic disease. In 33 males, kidneys were found to have enlarged 2.7 +/- 1.7 times over the 10-year follow-up due to acquired cysts, while no change in kidney volume was noted in 24 females. Native kidneys in nine of 12 patients who maintained functioning grafts were reduced in size. The patient with the largest kidney enlargement (11.5 times) died from retroperitoneal bleeding in 1989. These prospective study results suggest that both the incidence and prevalence of renal cell carcinoma in dialysis patients is high. Furthermore, major complications of acquired renal cystic disease seem to occur predominantly in males. | 0 |
Molecular evolution of inversions in Drosophila pseudoobscura: the amylase gene region. The amylase region of the third chromosome of Drosophila pseudoobscura has been cloned and localized to cytological band 73A. It is contained within a series of highly polymorphic inversions and serves as a convenient tool for a molecular evolutionary analysis of the inverted gene arrangements. Amylase in D. pseudoobscura is a family of three genes, and some chromosomes have deletions for one or two of them. Two overlapping clones covering 26 kilobases were isolated and used as probes to survey DNA restriction map polymorphism among 28 lines, representing five of the major inversion types found in natural populations, as well as single chromosomes from the closely related species Drosophila persimilis and Drosophila miranda. Restriction-site differences are considerably greater among the various gene arrangements than among chromosomes with the same gene arrangement. Clustering the restriction map haplotypes yielded a dendrogram concordant with the phylogeny generated independently from cytogenetic considerations. The inversion polymorphism is estimated to be about 2 million years old. | 4 |
Treatment of status migrainosus: the American experience. Dependence upon a variety of drugs--ergotamine, analgesics, benzodiazepines, corticosteroids--is a major reason for patients to enter an intractable phase of their migrainous disorders. Repeated dosing of dihydroergotamine has proven to be remarkably effective in stabilizing the mechanism of migraine, allowing these patients to make the transition to a more reasonable as well as more specific form of therapy. | 2 |
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. | 1 |
Emergency aortocoronary bypass after failed angioplasty. One thousand two hundred fourteen percutaneous transluminal coronary angioplasties were performed over a 38-month period. Sixty patients required immediate emergency coronary artery bypass grafting after angioplasty failure; 7 of these had evidence of acute myocardial infarction before angioplasty and were excluded from the study. Of the 53 patients remaining, 27 (51%) had electrocardiographic and enzyme evidence of postoperative myocardial infarction. Two patients died (4%), and 10 had postoperative complications (19%). No statistical significance was noted comparing age, sex, incidence of prior myocardial infarction or myocardial dysfunction, time for revascularization, or average number of grafts completed in those with single-vessel (n = 21) versus multiple-vessel (n = 32) coronary artery disease. Postoperatively, those with multiple-vessel disease required intraaortic balloon pump support (p = 0.06) and antiarrhythmic medications more frequently than single-vessel patients (p less than 0.01) and had a higher complication rate (p less than 0.05). Although not reaching statistical significance, the data also suggest a higher death and postoperative myocardial infarction rate in patients with multiple-vessel disease. Emergency coronary artery bypass grafting after failed percutaneous transluminal coronary angioplasty carries a higher morbidity and mortality than elective coronary artery bypass grafting, particularly for patients with multiple-vessel coronary artery disease. | 3 |
The axilla: not a no-go zone Many surgeons, particularly in the UK, give inadequate primary treatment to patients with operable breast cancer. For spurious reasons they regard axillary clearance as unnecessarily extensive surgery and rely instead upon total mastectomy or tumour excision and node sampling, with or without postoperative radiotherapy. But it is now clear that relapse-free and overall survival can be improved by appropriate adjuvant therapy. Thus inadequate exploration of the axilla is doubly unjustified. Not only is there the obvious risk of failure to remove nodes that contain metastases--so that some patients are deprived of cure by primary treatment--but the extent of tumour spread will be inadequately assessed in many more patients, with the risk that they may not receive appropriate adjuvant treatment. | 0 |
Results of a multicenter trial comparing imipenem/cilastatin to tobramycin/clindamycin for intra-abdominal infections. We designed a multicenter study to compare tobramycin/clindamycin to imipenem/cilastatin for intra-abdominal infections. We included the Acute Physiology and Chronic Health Evaluation (APACHE II) index of severity and excluded patients without established infection. Two hundred ninety patients were enrolled, of whom 162 were evaluable. Using logistic regression to analyze both outcome at the abdominal site of infection and outcome as mortality, we found a significant correlation for both with APACHE II score (p less than 0.0001 for both). Next we analyzed the residual effect of treatment assignment and found a significant improvement in outcome for imipenem/cilastatin-treated patients (p = 0.043). The differences in outcome were explained by a higher failure rate for patients with gram-negative organisms for tobramycin/clindamycin-treated patients (p = 0.018). This was reflected in a significantly higher incidence of fasciitis requiring reoperation and prosthetic fascial replacement. Maximum peak tobramycin levels were analyzed for 63 tobramycin/clindamycin patients harboring gram-negative organisms. For failures the maximum peak was 6.4 +/- 1.9 micrograms/mL, and time to maximum peak was 4.6 +/- 5.2 days. For successes the maximum peak was 6.1 +/- 1.7 micrograms/mL, occurring at 3.8 +/- 2.6 days. This study supports inclusion of severity scoring in statistical analyses of outcome results and supports the notion that imipenem/cilastatin therapy improves outcome at the intra-abdominal site of infection as compared to a conventionally prescribed amino-glycoside-based regimen. | 4 |
Serum trace elements and Cu/Zn ratio in breast cancer patients. Serum copper, zinc, and the Cu/Zn ratio were measured in 55 patients with breast disease (20 with benign breast diseases and 35 patients with breast cancer) and 30 controls. The mean serum copper levels were higher in breast cancer than in benign breast diseases (167.3 micrograms/dl vs. 117.6 micrograms/dl) (P less than 0.001) and controls (167.3 micrograms/dl vs. 98.8 micrograms/dl) (P less than 0.001). Patients with advanced breast cancer had higher serum copper levels than did patients with early breast cancer (177.9 micrograms/dl vs. 130.4 micrograms/dl) (P less than 0.001). The mean serum zinc levels were lowered only in patients with advanced breast cancer as compared with controls (88.6 micrograms/dl vs. 115.1 micrograms/dl) (P less than 0.001). Serum zinc levels were not decreased in patients with early breast cancer and benign breast diseases. The Cu/Zn ratio was increased in breast cancer patients (1.91 vs. 0.86) (P less than 0.001) but not in patients with benign breast diseases. The precise mechanisms responsible for the alterations in trace element levels in breast cancer patients are still unclear and require further evaluation. However, the serum copper levels and the Cu/Zn ratio may be used as biochemical markers in these patients. | 0 |
Splenic septic emboli in endocarditis. The significance of septic emboli to the spleen is inferred by the frequency of septic emboli in general seen in patients with left-sided infective endocarditis who are referred for valve replacement. To determine the proper management of splenic infarcts and abscess due to septic emboli, we retrospectively reviewed the records of 108 patients with left-sided endocarditis who underwent valvular surgery at the University of Illinois Hospital from 1980 through 1988. Intravenous drug abuse was the etiology in 68% (n = 73). The incidence of splenic infarcts and abscess was 19% (n = 20), but an incidental finding of splenic infarcts was found in 38% (n = 11) of 29 asymptomatic patients who had computed tomograms. Streptococci and staphylococci were the causative organisms in 85% (n = 17). Localized findings were absent in 90% of splenic infarcts and abscesses. Abdominal computed tomograms were diagnostic of the sequelae of splenic septic emboli in 100%. No patient had intra-abdominal bleeding complications associated with cardiopulmonary bypass. Splenectomy was performed in 50% (n = 10) of patients 3-24 days (mean, 11.2 days) after valve replacement. Indications for splenectomy included persistent sepsis in 60% (n = 6), large (greater than 2 cm) and peripheral lesions in 30% (n = 3), and splenic rupture in 10% (n = 1). Perioperative mortality of patients who underwent splenectomy was 30% (n = 3). The following conclusions can be drawn: 1) Splenic septic embolus is common in endocarditis. 2) Abdominal computed tomography should be performed for all patients. | 3 |
The mechanism of spastic muscle hypertonus. Variation in reflex gain over the time course of spasticity. The electromyographic (EMG) response of the initially passive biceps brachii muscle to imposed extension applied at the elbow was studied in 19 hemiparetic and 12 normal subjects. In relaxed normal subjects, the biceps muscle was found to respond only at displacement velocities above 175 deg/s, with a single early burst of activity in the biceps EMG. In contrast, the hemiparetic subjects, in addition to the early EMG activity, also showed considerable late activity, which persisted even with stretch velocities as low as 35 deg/s. This late activity is a stretch reflex, present in fully plegic arms. It was seen in all spastic subjects in whom the tone of the biceps had been clinically assessed to be raised, but was never observed in subjects with normal muscle tone. The mean level of this EMG response was highly correlated with displacement velocity and its duration to the duration of the applied displacement. It is suggested that this reflex EMG activity is the major factor in the genesis of spastic hypertonus in the arm and that it arises not from a reduction in the threshold of the stretch reflexes of the muscle, but from a pathological increase in stretch reflex gain. It is further shown that this activity is at a high level between the first and third months after the onset of spasticity and that the reflex gain is significantly reduced when spasticity is established for a year or more. It is concluded that, while changes in passive mechanical properties may play a role when spasticity has been established for more than a year, the major cause of spastic muscle hypertonus is a pathological increase in stretch reflex activity. | 4 |
Elective resection of 332 abdominal aortic aneurysms in a southern West Virginia community during a recent five-year period. This study analyzed 33 variables that might potentially affect outcome in a series of 332 consecutive elective abdominal aortic aneurysm repairs in a southern West Virginia community. One of the interesting features of this series was that the repairs were done by 22 surgeons with varying degrees of experience. The mortality and complication rates were compared for various potential risk factors by both univariant methods (chi 2, Fisher's exact, and Student t tests) and multivariant methods of analysis. Our early mortality (2.1%) and postoperative complication rates were consistent with those of other series. With multiple linear regression models, five factors were selected as significant independent risk factors associated with an increasing number of postoperative complications: the number of blood transfusions (p less than 0.0001), left renal vein ligation (p less than 0.0001), the presence of greater than 50% renal artery stenosis (p = 0.0012), the lesser experience of the surgeon (p = 0.0203), and the history of prior cardiac catheterization (p = 0.0245). The only factor statistically correlated with mortality rate was an increased number of postoperative complications (p less than 0.0001). Neither postoperative complications nor mortality rate was found to be significant and independently influenced by other demographic, clinical, or operative factors. It is tempting to speculate that surgeons with less experience might be well served to refer patients with significant renal artery stenosis and coronary artery disease. Our mortality and complication rates were not increased by performing preoperative angiography and therefore prudent surgeons may find this helpful in selecting patients for safer repair. | 3 |
Massive hepatic infarction in systemic lupus erythematosus. Liver disease in systemic lupus erythematosus, as demonstrated by abnormal histopathology, is rare and usually mild; typically, this hepatic disease is of chronic nature and not related to a hypercoagulable state. A patient is described in whom life-threatening hypercoagulability in association with systemic lupus erythematosus resulted in extensive liver infarction. Follow-up radionuclide liver scintigraphy suggested that regenerative recovery in the infarcted areas of the liver may be delayed or absent, but there was no evident functional hepatic impairment. | 4 |
Cytologic criteria to distinguish hepatocellular carcinoma from nonneoplastic liver. The authors reviewed a series of fine-needle aspiration biopsy (FNAB) specimens of the liver to identify useful cytologic criteria to distinguish hepatocellular carcinoma (HCC) from nonneoplastic liver. Ten cytologic features were examined in this study: high cellularity, acinar pattern, trabecular pattern, hyperchromasia, pleomorphism, irregularly granular chromatin, uniformly prominent nucleoli, multiple nucleoli, increased nuclear/cytoplasmic ratio, and atypical naked hepatocytic nuclei. These features were examined in a series of 82 FNAB specimens from 52 patients with HCC and 30 patients with nonneoplastic lesions. With the use of a step-wise logistic regression analysis, three features were identified as predictive of HCC: increased nuclear/cytoplasmic ratio (P = 0.001), trabecular pattern (P = 0.002), and atypical naked hepatocytic nuclei (P = 0.03). When these three criteria were used, the sensitivity of diagnosing HCC by FNAB was 100%, and the specificity was 87%. | 1 |
Chronic alcoholic gastritis. Roles of alcohol and Helicobacter pylori. We assessed the relative roles of alcohol and infection with Helicobacter pylori in the pathogenesis of chronic gastritis in alcoholic patients. Helicobacter pylori was found in 14 of 18 alcoholics with dyspepsia and was associated with chronic antral gastritis. Gastric biopsy specimens were normal in four H pylori-negative alcoholics. Studies were repeated 3 to 4 weeks after controlled abstinence. There was no change in histologic findings during this period, indicating that alcohol itself was not the major causative agent. We then eliminated H pylori in 10 subjects by giving triple therapy (bismuth subsalicylate, amoxicillin, and metronidazole). Treatment for H pylori was associated with almost complete normalization of histologic findings. Four control subjects who received antacids alone showed no improvement. Dyspeptic symptoms in H pylori-positive patients significantly improved after elimination of this organism, whereas there was no change with antacid treatment. | 1 |
Is urethral sparing at cystectomy a safe procedure? Urethrectomy is performed with cystectomy when the neoplasm is multifocal, at the bladder neck, or associated with carcinoma in situ (CIS). The records of the most recent 20 patients treated by radical cystectomy at our institution were reviewed. In 50 percent of the cases, the extent of disease within the bladder was found to have been underestimated to the point that a urethral sparing operation (i.e., to maintain urinary continence with an intestinal segment and an intact urethra) might have been dangerous. | 0 |
Mucocele of the cystic duct remnant in eight liver transplant recipients: findings at cholangiography, CT, and US. The case histories and radiologic studies of eight liver transplant recipients who developed a mucocele of the allograft cystic duct remnant were retrospectively evaluated. All patients had clinical and/or laboratory evidence of biliary obstruction or cholangitis from 2 weeks to 3.3 years following transplantation. Cholangiographic, ultrasound (US), and computed tomography (CT) images were available for review in eight, five, and four patients, respectively. Cholangiograms demonstrated an extrinsic mass compressing the common hepatic duct in seven of eight patients. US and CT showed fairly well- to well-defined round fluid collections adjacent to the common hepatic duct in three and two patients, respectively. The findings of this study suggest that the detection at cholangiography of an extrinsic mass compressing the common hepatic duct appears to be specific for a mucocele of the allograft cystic duct remnant. CT and US images may offer confirmatory evidence. | 1 |
Premalignant lesions: role of antioxidant vitamins and beta-carotene in risk reduction and prevention of malignant transformation. Epidemiological studies have shown that diets rich in one or more antioxidant nutrients may reduce the risk of cancers of the lung, uterine cervix, mouth, and gastrointestinal tract. Study of premalignant lesions offers a comparatively expedient approach to identifying and evaluating the efficacy of the cancer chemopreventive components of foods. Some recent findings suggest roles for beta-carotene and/or vitamin C in reversing or reducing the risk of cervical dysplasia and oral leukoplakia. There are some indications that vitamin C and beta-carotene may reduce the risk of atrophic gastritis and gastric cancer. Additional epidemiological and molecular biology studies and clinical intervention trials using premalignant lesions as the marker of specific cancer risks should become an important component of future research in the area of cancer chemoprevention. | 4 |
Femorofemoral bypass: a profile of graft failure. We have reviewed our experience with 71 patients who had a femorofemoral bypass for unilateral iliac artery occlusion or stenosis. We analyzed morbidity, mortality, initial relief of symptoms, early patency, and long-term primary and secondary patency; and we attempted to identify the cause of graft failure. The overall hospital mortality after operative repair was 4%. One-year survival was 84% and 2-year survival was 81%. Early patency was 98.5% at 1 month, late patency was 91% at 1 year and 82% at 5 years. The major cause of graft failure was inadequate run-off and outflow disease progression. | 3 |
Influence of bone mineral density on the fixation of thoracolumbar implants. A comparative study of transpedicular screws, laminar hooks, and spinous process wires. Posteriorly directed load to failure testing of four different types of spinal implants was performed in individual T5 to S1 vertebra harvested from seven fresh-frozen human cadaveric spines. The implants tested were: 1) Drummond spinous process wires, 2) Harrington laminar hooks, 3) Cotrel-Dubousset transpedicular screws, and 4) Steffee VSP transpedicular screws. The ultimate failure of each implant was compared with the bone mineral density of each vertebra to determine which implants, if any, were particularly advantageous in osteoporotic vertebrae. Before biomechanical testing, the spines were analyzed in vitro by dual photon absorptiometry to determine the bone mineral densities (gm/cm2) of each vertebra. The mean tensile loads to failure for each of the implants tested were as follows: Cotrel-Dubousset transpedicular screws: 345 Newtons; spinous process wire/button: 382 Newtons; Steffee transpedicular screws: 430 Newtons; and laminar hooks: 646 Newtons. The difference between the loads to failure for laminar hooks and the other implants was significant (P less than 0.05) using one-way analysis of variance. The overall correlation coefficient for bone mineral density with ultimate load to failure was 0.30 (P less than 0.001). The correlation coefficients were 0.47 (P less than 0.001) for spinous process wires alone; 0.096 (not significant) for laminar hooks alone; 0.37 (P less than 0.001) for Cotrel-Dubousset pedicle screws; and 0.48 (P less than 0.001) for Steffee pedicle screws. Of the four different implants tested, laminar hooks were most resistant to failure from posteriorly directed forces. | 4 |
Epidemiologic and immunogenetic aspects of polymyalgia rheumatica and giant cell arteritis in northern Italy. We studied the epidemiology of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) in a Mediterranean population. Ninety-nine patients with PMR and/or GCA were identified over a 9-year period (1980-1988) in Reggio Emilia, Italy. The average annual incidence of PMR and GCA was 12.7/100,000 and 6.9/100,000, respectively, in a population aged 50 years or older. Frequencies of HLA antigens were determined in 49 patients with PMR and/or GCA who were followed by staff at our rheumatology unit during the 1980-1988 period. When compared with HLA findings in 242 healthy controls, DR4 was not found to be significantly associated with PMR (24% in PMR patients versus 14% in controls). Patients with GCA also showed an increased frequency of DR4 compared with controls (36% versus 14%), but this difference was also not statistically significant. The immunogenetic features of PMR and GCA and the relationship between the immunogenetic and epidemiologic patterns in different populations are discussed. | 3 |
A critical review of chemical lymph node clearance and staging of colon and rectal cancer at Ferguson Hospital, 1977 to 1982 A unique opportunity to evaluate the method of chemical lymph node clearance for colorectal cancer exists at Ferguson Hospital. Lymph node clearance has been used at the institution since 1977, and this retrospective analysis was undertaken to ascertain its validity there. Furthermore, the node positive group was evaluated to ascertain if the current staging system (Turnbull, 1967) is prognostically accurate for the Dukes' C group. Specifically evaluated for possible prognostic variance was the survival of those patients whose tumors demonstrated partial bowel wall penetration and only one to four positive nodes, a "C1 subset," previously reported to have favorable prognosis. Eight hundred sixty-four cases of colon and rectal cancer treated surgically from 1977 to 1982 were analyzed. There was a mean of 27 lymph nodes retrieved per specimen and a mean of 4.5 positive nodes per Dukes' C specimen. There were 43 C1 and 201 C2 cases with five-year survival rates of 73 and 38 percent, respectively. The results of chemical clearance at Ferguson Hospital were found to be comparable with that of other centers using chemical clearance and superior to hand dissection. The C1 subset clearly is noted to have prognostic advantage and should occupy a separate designation in any staging system. | 0 |
Amyloidosis associated bleeding diatheses in the surgical patient. The coagulopathies associated with amyloidosis have not been widely appreciated. We encountered a patient with amyloidosis and mildly abnormal coagulation studies who presented for an emergency laparotomy for acute bowel obstruction. Upon gentle manipulation of the bowel, an unexpected bleeding diathesis was manifested by the formation of several large haematomas resulting in a large amount of blood loss (approximately 800 ml). Numerous defects of platelet function and coagulation have been associated with amyloidosis, including abnormal platelet aggregation, increased vascular fragility, factor IX and X deficiencies, decreased levels of alpha-2-plasmin inhibitor, and increased levels of plasminogen. Intraoperative therapy for our patient included the rapid administration of four units of fresh frozen plasma and ten units of platelet concentrate. A review of the pathology and therapeutic modalities for this potentially life-threatening complication is presented. | 1 |
Slowly progressive aphasia: three cases with language, memory, CT and PET data. Three cases of slowly progressive speech and language disturbance were studied at various points post onset (three, five and 15 years respectively). Language, neuropsychological and brain imaging (computer tomography and positron emission tomography) evaluations were completed on all three patients. The data suggest that the syndrome of "progressive aphasia": 1) does not involve a uniform symptom complex; 2) does not necessarily develop into a full blown dementia syndrome; 3) varies greatly in rate of progression from case to case; 4) is associated with normal brain structure (on computer tomography); and 5) is associated with abnormal left temporal lobe metabolism as measured by fluorodeoxyglucose (FDG) positron emission tomography (PET). One patient had histological findings consistent with Alzheimer's disease at necropsy. | 4 |
Coronary artery dilatation requiring high inflation pressure. A patient with rigid coronary lesions refractory to balloon dilatation is described. A Cordis Orion fixed wire balloon able to withstand 20 bar was required for successful dilatation. | 3 |
Congenital myasthenia associated with facial malformations in Iraqi and Iranian Jews. A new genetic syndrome. Fourteen Jewish patients from 10 families of either Iraqi or Iranian origin with congenital myasthenia had associated facial malformations which included an elongated face, mandibular prognathism with class III malocclusion and a high-arched palate. Other common features were muscle weakness restricted predominantly to ptosis, weakness of facial and masticatory muscles, and fatigable speech; mild and nonprogressive course; response to cholinesterase inhibitors; absence of antibodies to acetylcholine receptor; decremental response on repetitive stimulation at 3 Hz but no repetitive compound muscle action potential in response to a single nerve stimulus. This newly recognized form of congenital myasthenia with distinctive ethnic clustering and associated facial malformations is transmitted as an autosomal recessive disorder. The facial abnormalities may be secondary to the neuromuscular defect or may be primary and unrelated. Further studies are needed to elucidate the defect in neuromuscular transmission responsible for the pathogenesis of this syndrome. | 2 |
Elevated serum concentrations of IgE antibodies to environmental antigens in HIV-seropositive male homosexuals. Forty-five homosexual male subjects with human immunodeficiency virus (HIV) infection, who received care during a 4-month period in an ambulatory center for acquired immunodeficiency syndrome (AIDS), were classified according to their principal presentation with characteristic secondary infections (CDC group IV C, N = 28), cancers (IV D, N = 10), or limited or no symptoms (groups II, III, IV A, or IV B, N = 7). The incidence of allergic rhinitis and conjunctivitis increased after HIV seroconversion by approximately twofold in patients of groups IV C and IV D. The mean serum concentration of IgE was significantly higher for group IV C than for the other HIV-seropositive groups and for a control group of 45 HIV-seronegative homosexual male subjects from the same community who were studied concurrently. More patients in groups IV C and IV D had positive RASTs for a panel of environmental antigens than patients in the other HIV-seropositive groups and the HIV-seronegative control group. Patients with AIDS presenting with typical secondary infections thus have a high frequency of some clinical and laboratory manifestations of allergic diseases. | 0 |
Mandibular reconstruction with composite microvascular tissue transfer. Microvascular free tissue transfer has provided a variety of methods of restoring vascularized bone and soft tissue to difficult defects created by tumor resection and trauma. Over 7 years, 26 patients have undergone 28 free flaps for mandibular reconstruction, 15 for primary squamous cell carcinoma of the floor of the mouth or tongue, 7 for recurrent tumor, and 6 for other reasons [lymphangioma (1), infection (1), gunshot wound (1), and osteoradionecrosis (3)]. Primary reconstruction was performed in 19 cases and secondary in 9. All repairs were composite flaps including 12 scapula, 5 radial forearm, 3 fibula, 2 serratus, and 6 deep circumflex iliac artery. Mandibular defects included the symphysis alone (7), symphysis and body (5), symphysis-body-ramus condyle (2), body or ramus (13), and bilateral body (1). Fourteen patients had received prior radiotherapy to adjuvant or curative doses. Eight received postoperative radiotherapy. All patients had initially successful vascularized reconstruction by clinical examination (28) and positive radionuclide scan (22 of 22). Bony stability was achieved in 25 of 26 patients and oral continence in 24 of 26. One complete flap loss occurred at 14 days. Complications of some degree developed in 22 patients including partial skin necrosis (3), orocutaneous fistula (3), plate exposure (1), donor site infection (3), fracture of reconstruction (1), and fracture of the radius (1). Microvascular transfer of bone and soft tissue allows a reliable reconstruction--despite previous radiotherapy, infection, foreign body, or surgery--in almost every situation in which mandible and soft tissue are absent. Bony union, a healed wound, and reasonable function and appearance are likely despite early fistula, skin loss, or metal plate or bone exposure. | 0 |
Hypersensitivity reactions to epipodophyllotoxins in children with acute lymphoblastic leukemia. The incidence, clinical characteristics, and outcome of hypersensitivity reactions to teniposide (VM-26), etoposide (VP-16), or both were determined in 108 children with acute lymphoblastic leukemia (ALL) treated with a contemporary regimen of intensive multiagent chemotherapy. Fifty (46%) of the 108 patients had one or more hypersensitivity reactions. The risk of any child having an initial reaction over the cumulative dose range studied was 52% (95% confidence limits, 41% and 63%) for VM-26, compared with 34% (95% confidence limits, 24% and 44%) for VP-16. The risk of having an initial reaction to VM-26 or VP-16 was clearly related to the cumulative dose. This risk peaked at 1500 to 2000 mg/m2 for VM-26 and at 2000-3000 mg/m2 for VP-16. All reactions were Type 1 reactions according to the Gell and Coombs classification, characterized by urticaria, angioedema, flushing, rashes, or hypotension, and 86% of reactions were of Grade 1 or 2 severity according to standard criteria. There was no evidence of increasing clinical severity on repeated rechallenge with premedication, and no deaths occurred. The findings suggested that hypersensitivity reactions to epipodophyllotoxins in children with ALL are more common than previously reported, but only rarely constitute dose-limiting toxicity. | 3 |
Neutrophil cytoplasmic antibodies: a link between primary sclerosing cholangitis and ulcerative colitis. Whether serum autoantibodies to neutrophil cytoplasmic components, previously found in ulcerative colitis, are also associated with primary sclerosing cholangitis was determined. In an enzyme-linked immunosorbent assay for immunoglobulin G neutrophil antibodies, neutrophil binding by primary sclerosing cholangitis sera was significantly greater than that for primary biliary cirrhosis, chronic hepatitis B, and chronic non-A, non-B hepatitis. Similar differences were seen when sera from patients with primary sclerosing cholangitis without evidence for ulcerative colitis were compared with sera from liver disease controls. Perinuclear immunofluorescence staining of neutrophils was exhibited by the majority of ulcerative colitis, primary sclerosing cholangitis, and primary sclerosing cholangitis without ulcerative colitis sera. The combination of elevated immunoglobulin G neutrophil antibodies and a perinuclear pattern was 65% sensitive and 100% specific for primary sclerosing cholangitis compared with the liver disease control sera. It is concluded that neutrophil cytoplasmic antibodies in ulcerative colitis and primary sclerosing cholangitis may be markers of shared underlying immunopathogenic mechanisms. Identification of the target antigen(s) may facilitate understanding of the underlying immune response and development of an improved disease marker assay. | 1 |
Role of histamine in natural killer cell-mediated resistance against tumor cells. The formation of lung metastases by i.v.-injected B16 melanoma (F1 and F10 strain) cells in Swiss albino, C57BL/6, and BALB/c mice was reduced by a single dose of histamine given 24 h before tumor cell inoculation. The antimetastatic effect of histamine was specifically mediated by histamine H2-receptors (H2R): it was blocked by the H2R antagonist ranitidine and mimicked by dimaprit, a specific H2R agonist but not by an H2R-inactive structural analog of this compound, nor-dimaprit, or the H1R agonist 2-thiazolyl-ethylamide. A single dose of any of the H2R antagonists ranitidine, tiotidine, famotidine, or cimetidine drastically augmented metastasis. Effects of H2R-interactive compounds on B16 metastasis required intact NK cells, as judged by the inability of histamine or ranitidine to affect B16 metastasis after NK cell depletion in vivo using antibodies to asialo-GM1. NK-cell-mediated lysis of YAC-1 lymphoma cells in vivo was enhanced by histamine and reduced by ranitidine within 4 h after inoculation of tumor cells. The antimetastatic effect of IL-2 was potentiated by histamine; in some experiments, combined treatment with a low dose of IL-2 (6000 U/kg) and histamine completely eliminated metastasis, whereas concomitant treatment with ranitidine abrogated antimetastatic effects of IL-2; animals treated with ranitidine and IL-2 displayed the same level of enhanced metastasis as those treated with ranitidine alone. The presented data are suggestive of an earlier unrecognized role for histamine in NK cell-mediated resistance against metastatic tumor cells. | 0 |
Pediatric spinal epidural metastases. A total of 2259 children with solid malignant tumors were treated at St. Jude Children's Research Hospital between the years 1962 and 1987. Of these, 112 (5%) developed spinal epidural metastasis with spinal cord compression during the course of their disease process. Metastatic epidural spinal cord compression was caused most commonly by Ewing's sarcoma and neuroblastoma, followed by osteogenic sarcoma, rhabdomyosarcoma, Hodgkin's disease, soft-tissue sarcoma, germ-cell tumor, Wilm's tumor, and (rarely) hepatoma. There was no significant difference in outcome between patients with small-cell tumors (neuroblastoma, Hodgkin's disease, and germ-cell tumors) who received only chemotherapy and/or radiation therapy and the patients with similar lesions who received a decompressive laminectomy alone or prior to chemotherapy and/or radiation therapy. Patients with spinal cord compression from metastatic sarcoma (Ewing's sarcoma, soft-tissue sarcoma, osteogenic sarcoma, and rhabdomyosarcoma) showed a significant improvement with decompressive laminectomy alone or before medical therapy, compared to those who received radiation therapy and/or chemotherapy without posterior decompression. Pediatric tumors invade the spinal canal via the neural foramen, compressing the spinal cord in a circumferential manner, allowing decompressive laminectomy (posterior approach) to be an effective surgical approach. Sixty-six percent of children who had no evidence of motor or sensory function below the level of the compression became ambulatory after surgical decompression and medical treatment, regardless of tumor type. | 0 |
Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain STUDY OBJECTIVE: To determine whether information from a prior electrocardiogram (ECG) improves diagnostic accuracy in the emergency department (ED) evaluation of patients with acute chest pain. DESIGN: Analysis of prospectively collected data from a cohort study. SETTING: Emergency departments of four community and three university hospitals. PATIENTS: 5,673 patients aged greater than or equal to 30 years who presented to the EDs of participating hospitals for evaluation of acute chest pain, including 772 (14%) with acute myocardial infarction (AMI). MEASUREMENTS AND MAIN RESULTS: After adjusting for clinical characteristics, no significant difference was found in the sensitivities of admission to the hospital or to the coronary care unit (CCU) between AMI patients with and without prior ECGs available for review. However, non-AMI patients with prior ECGs available for review were more likely to avoid CCU admission than were non-AMI patients without prior ECGs. This improvement in specificity was most marked in the 2,024 patients whose current ED ECGs had changes consistent with ischemia or infarction: when a prior ECG was available, non-AMI patients were more than twice as likely to be discharged (26% vs. 12%) and about 1.5 times as likely to avoid CCU admission (39% vs. 27%) (both p less than 0.0001). Admission rates of AMI patients with and without prior ECGs were similar. CONCLUSION: When the current ECG is consistent with ischemia or infarction, the availability of a prior ECG for comparison to determine whether the ECG changes are old or new improves diagnostic accuracy and triage decisions by reducing the admission of patients without AMI or acute ischemic heart disease (increased specificity) without reducing the admission of patients with these diagnoses (unchanged sensitivity). | 3 |
Senile dementia and healthy aging: a longitudinal CT study. Volumetric indexes of cerebral atrophy obtained by using computed tomography (CT) were measured longitudinally in patients with senile dementia of the Alzheimer type (SDAT) and in healthy elderly control subjects. Measurements were made three times over a 51-month period. Of the original 44 patients with SDAT, five were available for CT examination at the last time of assessment (51 months); in contrast, 41 of the original 58 control subjects were still available for study at 51 months. As a group, scans of SDAT subjects showed greater atrophy than those of control subjects in all volumetric indexes at each time of testing and demonstrated greater progression of atrophy during the study period. However, the overlap of indexes between the patients with SDAT and the control subjects indicates that CT data cannot be used alone to predict the presence or progression of dementia in individual cases. | 4 |
Tropical neuromyelopathies and retroviruses: a review. Debilitating disorders of the nervous system have a relatively high prevalence in the tropics, a geographic region that is often deficient in specialists in the fields of neurology and epidemiology. During World War II, attention was called to a possible nutritional origin for most of these diseases. Recently, however, human T lymphotropic virus type I (HTLV-I), formerly linked only to a rare form of leukemia (adult T cell leukemia), has been associated with a spastic paraplegia observed mostly in tropical areas and referred to as tropical spastic paraparesis. This entity is also observed in nontropical areas endemic for HTLV-I, including Japan, South America, and the southern United States. Viruses of the HTLV family are being associated increasingly with pathology in humans. The pathogenesis of HTLV-I-associated tropical spastic paraparesis remains to be understood. However, future research is expected to favor a multidisciplinary approach, with exciting potential insights derived from the fields of neurology, immunology, and infectious diseases. The aim of this review is to summarize contemporary research related to the viral etiology of this clinical entity. | 2 |
Neurovascular mechanisms and sodium balance in the pathogenesis of hypertension. Physiological studies have clarified the role that the brain has in the interplay between salt balance and hypertension. Neural mechanisms and endocrine secretions play a pivotal role in the adaptation of mammals to changes in the intake and excretion of sodium. Maneuvers that alter the concentration of sodium in the plasma modify the sensitivity of baroreceptor reflexes and alter vascular reactivity. These changes may be mediated in part by the release of vasopressin. The research also suggests that the brain indirectly modulates the ability of the vascular endothelium to release vasoactive factors. Collectively, these studies illustrate the multiple effects of the sodium ion on the peripheral neural and central endocrine mechanisms that participate in the regulation of arterial pressure. | 3 |
A T-cell neoplasia showing clinicopathologic features of malignant histiocytosis with novel chromosomal abnormalities and N-ras mutation. Malignant histiocytosis (MH) is a distinct disease entity defined clinically and morphologically. However, the neoplastic origin of MH is not well established. The authors report a 26-year-old woman who showed the typical clinicopathologic features of so-called MH. Cytogenetic and molecular genetic examinations were performed in addition to the morphologic and immunologic approach. The expression of CD2 and T-cell receptor gene rearrangements indicated the T-cell origin of this case. CD30, which is positive for anaplastic large cell lymphoma (Ki-1 lymphoma), was not expressed. The cytogenetic study revealed a clonal chromosome abnormality involving 3q25, 6p21, 11p15, and 11q21. An N-ras point mutation within codon 12 (GGT----GCT) was also detected. These finding indicate that MH defined clinically and morphologically is not a tumor of true histiocytic origin and that it should be reclassified on the basis of immunologic, cytogenetic, and molecular genetic data. | 0 |
The Cancer Prevention Reminder System. The Cancer Prevention Reminder System is a computer-based system designed to increase the delivery of periodic health maintenance procedures. The program provides printed reminders that identify patients' overdue procedures, prints summary reports of the percentage of patients who are eligible and overdue for a procedure, and prints mailing labels for patients. We performed a randomized, controlled trial in which the effects of computer-based reminders were compared with those of two other interventions among residents in a university-based group practice. | 0 |
Repeat operation for failure of antireflux procedures. The majority of patients who receive modern antireflux operations obtain substantial long-term relief of their symptoms. About 10% to 15% will have persistent or recurrent problems, some severe enough to warrant reoperation for correction. With careful symptom review, barium study, endoscopy, and manometry, the mechanism of failure becomes evident, and remedial surgical treatment may proceed. The results at reoperation are not as good as those of the primary procedure, which emphasizes the need for proper diagnosis and choice of procedure and for reliable execution of technique at the initial treatment. | 4 |
Variations in sensitivity after sectioning the intercostobrachial nerve. The authors present a prospective study of the variations in sensitivity that appear in the armpit and arm after the intercostobrachial nerve has been sectioned in a modified radical mastectomy. Of a total of 208 patients studied between 1978 and 1987, the intercostobrachial nerve was sectioned in 139 patients, whereas in 30 it remained intact; in 39 patients only peripheral branches of the nerve were sectioned. The patients were examined at regular postoperative intervals in order to evaluate their sensitivity both to touch and to pain in the axilla and arm. Four hundred thirty-three examinations were carried out and the 3 operative groups were assessed accordingly. After the nerve was sectioned, there was increasing anesthesia in the armpit and hypoesthesia on the posterointernal face of the arm, while for the patients in whom the intercostobrachial nerve remained intact, these alterations were less intense and long-lasting. Significant statistical differences between the two groups also exist. In the absence of axillary lymphatic ganglia infiltrated by the tumor, the conservation of the intercostobrachial nerve is recommended. | 0 |
Patterns of growth and metastases of induced pancreatic cancer in relation to the prognosis and its clinical implications. To understand high malignancy of pancreatic cancer, the growth and metastatic patterns of pancreatic cancer induced in Syrian hamsters were examined. In this model, induced tumors resemble the human disease morphologically, clinically, biologically, and immunologically. In the current study, primary-induced cancer and transplants of pancreatic cancer cell line (PC-1) into the SC tissue or pancreas of homologous hosts were used. In the primary-induced pancreatic cancer, perineural invasion was the most common path (88%), followed by lymphogenic (31%) or vascular (2%) metastases. Inoculation of PC-1 cells into the pancreas resulted in 100% tumor take within 3 weeks. Of 19 intrapancreatic allografts, all showed peritoneal invasion, 5 (26%) liver metastases, 3 (16%) lymph node metastases, 17 (89%) perineural invasion, and none vascular invasion. Even microscopic tumors were found to metastasize primarily via perineural spaces. It was also demonstrated, for the first time, that cancer cells take this route to reach distant tissues, including the lymph nodes. Intraductal spreading occurred in both primary cancers and intrapancreatic allografts either continuously or discontinuously. The patterns of discontinuous intraductal tumor expansion imitated tumor multicentricity. Although perineural invasion was the most common feature of primary cancer and intrapancreatic allografts, lymphatic, hepatic, and vascular invasion and metastases usually occurred in advanced cases. Environmental factors seem to influence expansion and metastases, as evidenced by differences in growth and in metastatic patterns between SC and intrapancreatic allografts. | 4 |
Left ventricular passive diastolic properties in chronic mitral regurgitation. BACKGROUND. In chronic mitral regurgitation, the myocardium responds to the increased filling volume by geometric alteration and eccentric hypertrophy. This study was designed to evaluate the effects of a pure volume overload on left ventricular diastolic chamber and myocardial properties and to assess the relation of passive diastolic function to systolic ejection performance. METHODS AND RESULTS. By use of simultaneous cineangiography and left ventricular micromanometry, left ventricular passive diastolic stiffness was evaluated in nine normal controls (group 1), 14 patients with chronic mitral regurgitation and a normal ejection fraction (greater than or equal to 57%, group 2), and 13 patients with mitral regurgitation and a reduced ejection fraction (less than 57%, group 3). Passive diastolic function was evaluated by using a three-constant elastic model. Left ventricular chamber properties were represented by the relation of pressure to volume; myocardial properties were evaluated by relating myocardial midwall stress to midwall strain. The constant of left ventricular chamber stiffness was decreased in group 2 compared with controls (p less than 0.05) but it was normal in group 3. The constant of myocardial stiffness was increased in group 3 compared with groups 1 and 2 (p less than 0.01). Among patients with mitral regurgitation, there was a significant inverse relation between ejection fraction and the constant of myocardial stiffness (r = -0.83). CONCLUSIONS. The chronic adaptation to volume overload in chronic mitral regurgitation tends to decrease left ventricular chamber stiffness. Patients with mitral regurgitation and a depressed ejection fraction demonstrated diastolic myocardial dysfunction. Compromised diastolic function in patients with chronic mitral regurgitation and reduced systolic performance may contribute to the clinical manifestations of congestive heart failure. | 4 |
Role of alcohol in recurrences of atrial fibrillation in persons less than 65 years of age. The role of alcohol in recurrences of atrial fibrillation (AF) was assessed in a consecutive series of 98 patients (75 men) aged less than 65 years. In addition to etiologic assessment using clinical and laboratory methods and echocardiography, the patients' drinking habits were evaluated by recording the amount of alcohol used during the week preceding AF, by responses to the CAGE (Cut, Annoying, Guilt, Eye; see below) questionnaire (a screening test for alcohol abuse) and by selected laboratory tests. Two groups of control subjects were studied: 98 sex- and age-matched patients admitted to the emergency ward for acute illnesses, and 50 subjects selected randomly from the local out-of-hospital population. The mean alcohol consumption among men during the study week was 186 g (median 45 g; range 0 to 2,100 g) among patients, whereas among male hospital and population control subjects it was 86 g (30 g; 0 to 1,050 g) and 94 g (35 g; 0 to 630 g), respectively. When the weekly alcohol consumption was analyzed in 3 categories (0; 1 to 210 g; greater than 210 g), there was a significant difference between AF cases and hospital control patients (p = 0.03), but not between AF cases and population control subjects. Multivariate analysis of data of AF cases and population control subjects showed that alcohol intake and a positive response to 1 or more of the CAGE questions were independently related to AF in men. Other independent risk factors were the presence of heart disease, low serum potassium and lack of sleep or experience of excess psychologic stress, or both. | 4 |
Dystrophin analysis in Duchenne and Becker muscular dystrophy carriers: correlation with intracellular calcium and albumin. Immunocytochemical localization and immunoblot analysis of dystrophin in muscle fibers of 11 obligate and probable, and 7 possible carriers of Duchenne and Becker muscular dystrophy revealed an abnormal expression of the protein in 3 of them. Localization of calcium and albumin, as endogenous markers of extracellular fluid penetration, showed the presence of both molecules inside some fibers lacking dystrophin. Our morphological studies show that the initial stages leading to fiber necrosis in Duchenne muscular dystrophy are present in carriers with mosaicism. Comparison of dystrophin studies with restriction fragment length polymorphism analysis and creatine kinase levels showed that neither immunocytochemical nor immunoblot techniques for dystrophin are sensitive enough to provide a basis for genetic counseling. | 4 |
Aortico-left ventricular tunnel: long-term outcome after surgical repair. Over a 14 year period, four children (three male, one female) underwent surgical correction of an aortico-left ventricular tunnel. All presented in infancy (age range 5 days to 9 months). The presenting feature was a systolic and diastolic murmur in all, one of whom developed heart failure within 2 weeks of presentation. In the first two patients, the echocardiographic findings were inconclusive and the diagnosis was confirmed at cardiac catheterization (at 10 and 23 months of age, respectively); the other two were diagnosed echocardiographically by two-dimensional and Doppler color flow imaging. All four patients underwent surgery by patch closure of the aortic end of the tunnel (three patients) or direct suture closure (one patient) and there were no deaths. The mean age at operation was 11 months. During a mean follow-up period of 71 months (range 2 to 157), three patients have clinical and echocardiographic evidence of trivial aortic valve regurgitation, which was noted in the immediate postoperative period in one and at early (less than 6 months) follow-up study in the other two. All are symptom-free, are taking no medications and are growing and developing normally. Aortico-left ventricular tunnel can be accurately diagnosed by echocardiography. In patients presenting in infancy, echocardiography also provides the necessary morphologic information to enable surgical correction without angiography. Early operation is associated with an excellent outcome, whereas repair at a later age is associated with a high incidence of residual aortic regurgitation requiring further surgery. | 3 |
Effect of ischemia reperfusion or hypoxia reoxygenation on lung vascular permeability and resistance. The effect of ischemia reperfusion or hypoxia reoxygenation on pulmonary vascular permeability and resistance was studied in 25 isolated blood-perfused dog lungs. Vascular permeability, assessed by determining filtration coefficient (Kf), and vascular resistances were measured at the beginning and end of the experiment. Ischemia reperfusion was produced by occluding blood flow to the lung for 3 h and reperfusing for 1 h, whereas hypoxia reoxygenation was obtained by ventilating the lung with 95% N2-5% CO2 for 3 h and then ventilating with 95% O2-5% CO2 for 1 h with no interruption of perfusion. There was a significant increase in Kf in both ischemia reperfusion and hypoxia reoxygenation groups (51 and 85%, respectively), and total vascular resistance increased greatly in both groups (386 and 532%, respectively). Two additional groups were also studied in which the ischemia reperfusion or hypoxia reoxygenation lungs were pretreated with allopurinol (20 micrograms/ml). The Kf did not significantly increase in either the allopurinol ischemia reperfusion or the allopurinol hypoxia reoxygenation groups (22 and 6%, respectively). However, total vascular resistance significantly increased in both groups (239 and 224%, respectively). Although vascular permeability is modestly increased by both ischemia reperfusion and hypoxia reoxygenation, the predominant change in these conditions is the increased vascular resistance, which predominantly affects the postcapillary resistance and would result in a greater tendency for edema to develop in these slightly damaged lungs. Allopurinol, which inhibits xanthine oxidase, attenuated the permeability changes in both groups and may be useful in preventing ischemia reperfusion injury in certain conditions. | 3 |
Syringomyelia as a postoperative sequela of the resection of a chordoma of the clivus: case report. Syringomyelia has been described frequently in association with various abnormalities of the skull base but rarely with tumors of the skull base. Syringomyelia as a postoperative sequela of surgery of the skull base has not been reported. The authors describe a case of cervical syringomyelia developing after the partial resection of a chordoma and combined conventional and proton beam irradiation. The possible mechanisms causing this abnormality are discussed. | 0 |
Standards for analysis of ventricular late potentials using high-resolution or signal-averaged electrocardiography: a statement by a task force committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology. Sufficient data are available to recommend the use of the high-resolution or signal-averaged electrocardiogram in patients recovering from myocardial infarction without bundle branch block to help determine their risk for developing sustained ventricular tachyarrhythmias. However, no data are available about the extent to which pharmacological or nonpharmacological interventions in patients with late potentials have an impact on the incidence of sudden cardiac death. Therefore, controlled, prospective studies are required before this issue can be resolved. As refinements in techniques evolve, it is anticipated that the clinical value of high-resolution or signal-averaged electrocardiography will continue to increase. | 3 |
Chemotherapy for children with aggressive fibromatosis and Langerhans' cell histiocytosis. Two disorders involving histologically benign proliferations of fibrous tissue or of histiocytes occur preferentially in children and often require combined management by an orthopedic surgeon and a pediatric oncologist. Treatment of young people with aggressive fibromatosis usually begins with wide local excision of the lesion. However, some tumors cannot be completely removed either because of their location or because of the risk of subsequent serious dysfunction. Not infrequently, local recurrence supervenes despite previous wide local excision, and sometimes multiple tumors are present. In these situations a trial of multiple-agent chemotherapy incorporating vincristine, actinomycin D, and cyclophosphamide may be indicated in an attempt to control the disease. Radiation therapy may also be useful, but the relatively high dose (5000 cGy or more) needed in a growing child is at times a less attractive alternative. Biopsy of a lytic bone lesion in young patients with Langerhans' cell histiocytosis, formerly known as histiocytosis X, is also indicated for initial diagnosis. Biopsy and curettage are usually curative in the patient with an isolated lesion. Patients with multiple simultaneous or recurrent lesions need chemotherapy if dysfunction of the liver, spleen, or lungs is present. Drug therapy may also be beneficial for children with systemic symptoms. This article outlines suggestions for chemotherapeutic treatment in both diseases. | 0 |
Embolism during caesarean section. We investigated the occurrence of gas embolism during Caesarean section using a Doppler ultrasound probe and found that it occurs between uterine incision and delivery. Embolism is less common during general anaesthesia than has been reported during regional anaesthesia. Both ruptured membranes and a protracted uterine incision to delivery interval predispose to embolism. | 4 |
Management of meralgia paresthetica Meralgia paresthetica is a syndrome of pain or dysesthesia, or both, in the anterolateral thigh caused by entrapment or neurinoma formation of the lateral femoral cutaneous nerve. Conservative treatment was successful in relieving symptoms in 91% of 277 patients with this syndrome; however, 24 patients required surgical treatment for intractable symptoms. Although neurolysis with transposition is the most common procedure, sectioning of the lateral femoral cutaneous nerve was performed in 24 cases and was successful in 23. One patient had early symptomatic relief, but subsequently developed different neurological signs and symptoms because of an undetected pelvic neoplasm. Anatomical variations of the nerve and neurinomas, which occur frequently, are easily handled with sectioning but may lead to recurrence with neurolysis and transposition. | 2 |
Early detection and treatment of hyperlipidemia: physician practices in Canada. We surveyed primary care physicians in Canada to determine their current practices regarding the detection and treatment of hyperlipidemia in asymptomatic adults 20 years of age or more and to determine the role of selected patient characteristics (age, sex and the presence of coronary heart disease [CHD] risk factors) in their management decisions. The self-administered questionnaire was completed by 428 of 804 family physicians and general practitioners. The proportion of physicians who reported having tested at least 50% of their adult patients varied from 29% to 85% and was related to the number of CHD risk factors present and the patient's age. The proportion of respondents who reported starting dietary or drug therapy among patients with a cholesterol level of 6.2 mmol/L or less increased as the number of CHD risk factors increased and was not related to patient age or sex. According to the factors examined our results suggest that primary care physicians in Canada select patients for screening and treatment mainly on the basis of CHD risk factors present and that their approach is more conservative than that recommended by the Canadian and US consensus conferences. | 3 |
Ocular melanoma in families with dysplastic nevus syndrome. Five families with the dysplastic nevus syndrome, in each of which one member had ocular melanoma, are reported. These five families were examined within a 3-year period in one medical center. To date only five other families with such a combination have been reported. We suggest a causal relation between ocular melanoma and the familial dysplastic nevus syndrome. | 0 |
Poisoning with equine phenylbutazone in a racetrack worker. Phenylbutazone is a potent nonsteroidal, anti-inflammatory drug often used by veterinarians to treat racetrack animals. Its use in human beings is limited because of significant adverse effects and the availability of newer, safer drugs. We report the case of a 24-year-old man who ingested 17 g of equine phenylbutazone over a 24-hour period to treat the pain of a toothache. He developed grand mal seizures, coma, hypotension, respiratory and renal failure, and hepatic injury. Serum phenylbutazone concentration obtained approximately eight hours after presentation was 900 micrograms/mL. The patient recovered during six weeks of intensive supportive care and repeated hemodialysis. | 1 |
Lateralized effects of subclinical epileptiform EEG discharges on scholastic performance in children. The interaction between lateralization of subclinical epileptiform discharges and cognitive tasks was investigated in 21 children (12 girls and 9 boys, mean age 10.6 years). Seventeen had a diagnosis of epilepsy (partial or secondarily generalized). Testing was by reading, arithmetic, and intelligence subtests during continuous telemetric EEG and video monitoring. Children with left-sided discharges had significantly lower reading performance than children with right-sided discharges. During reading, epileptiform discharges occurred relatively less frequently and with a shorter total duration over the left hemisphere than the right. This supports the view that cognitive tasks suppress epileptiform discharges when they activate a region of the brain within the epileptogenic zone. Discharges from other epileptogenic zones not directly activated by the tasks are increased, however. | 2 |
Defects in the precore region of the HBV genome in patients with chronic hepatitis B after sustained seroconversion from HBeAg to anti-HBe induced spontaneously or with interferon therapy. Hepatitis B virus DNA clones were propagated from sera of six patients with chronic hepatitis B who seroconverted from HBeAg to antibody to HBeAg either spontaneously or after administration of alpha-interferon. Defects in the precore region blocking synthesis and secretion of HBeAg were detected in all 46 hepatitis B virus DNA clones from three patients who remained positive for antibody to HBeAg and in whom hepatitis resolved. Defective clones had point mutations from guanine to adenine at nucleotide 83 in the precore region, converting codon 28 from tryptophan (TGG) to a stop codon (TAG). In contrast, this defect was not found in any of 39 hepatitis B virus DNA clones from three patients who seroconverted to antibody to HBeAg but then redeveloped HBeAg with reactivation of hepatitis. Using these results, the G-to-A point mutation at nucleotide 83 in the precore region would predict sustained positivity for antibody to HBeAg and remission of hepatitis in patients who have seroconverted either spontaneously or with interferon therapy. | 4 |
Digoxin for atrial fibrillation: a drug whose time has gone? For over 200 years digitalis compounds have been used to treat atrial fibrillation. The rapid ventricular response to atrial fibrillation is frequently treated with digoxin to produce a controlled heart rate. Digoxin has also been proposed as a treatment for terminating recent-onset atrial fibrillation, for maintaining sinus rhythm after an episode of atrial fibrillation, and as prophylactic therapy in patients with paroxysmal atrial fibrillation to prevent excessive tachycardia during a paroxysm. Perhaps because it has been used for so long, few of these indications have been studied scientifically until recently. Studies now suggest that in patients with atrial fibrillation, digoxin is a poor drug for controlling heart rate during exertion, has little or no effect in terminating the arrhythmia, and may occasionally aggravate paroxysmal atrial fibrillation. Despite adequate digitalization, the heart rate at the onset of a paroxysm of fibrillation in patients receiving the drug does not differ from the heart rate in patients not receiving it. This article discusses the current role of digoxin in the management of patients with chronic, recent-onset, or paroxysmal atrial fibrillation. | 4 |
Prognostic indicators for acute low-back pain. Chart review was conducted on a 6-month sample of patients with low-back to identify outcome indicators in acute low-back pain. Two hundred seven episodes were identified. Extracted material included the age, sex, past history, time to presentation, occupation, suggested precipitating event of injury, and estimated difficulty of job tasks. Symptoms and findings presentation were also recorded. All cases were work-related, and the outcome indicator was time loss from work. Analysis of variance showed significant associations in time loss from work with factors including the occupation, age, job difficulty, past history, symptoms, examination, and diagnosis on presentation. | 4 |
Carotid-subclavian bypass--a decade of experience. From August 1979 to August 1989, carotid-subclavian bypass or transposition procedures were performed on 18 women and 13 men ranging in age from 19 to 75 (mean, 58.2) years. Indications for surgery included symptoms of vertebrobasilar insufficiency in 16 (52%), upper extremity ischemia in six (19%), both vertebrobasilar insufficiency and extremity ischemia in four (13%), and stroke and/or hemispheric transient ischemic attacks in four (13%) patients. One patient (3%) had angina pectoris caused by "coronary-subclavian steal." Formal bypass grafts were performed in 28 (90%) cases by means of polyterafluoroethylene (24), Dacron (2), or saphenous vein (2), and carotid-subclavian transposition was performed in three (10%) cases. Synchronous procedures included carotid endarterectomy (4), carotid-carotid bypass (1), and axillobrachial bypass (1). There was no operative mortality. Thirty-day primary patency was 97%. Follow-up has ranged from 1 to 121 (mean, 42) months. Three grafts (polytetrafluoroethylene) have occluded during follow-up yielding long-term primary patency of 92% at 5 years and 83% at 8 years. Relief of symptoms was initially achieved in 30 (97%) patients. Recurrent symptoms have developed in six (20%) patients from 2 to 55 (mean, 26) months after surgery, including two with occluded and four with patent grafts. Symptom-free survival is 89% at 1 year, 84% at 2 years, and 71% at 7 years of follow-up. Six patients have died during follow-up yielding overall survival of 88% at 5 years, and 48% at 10 years. | 3 |
Gastrointestinal tuberculosis. Report of four cases. Gastrointestinal tuberculosis is a rare disease in the United States. Correct identification is often delayed because it is not considered early on in the differential diagnosis. Four patients with gastrointestinal tuberculosis and the symptoms, diagnosis, complications, and treatment of the disease are discussed. Gastrointestinal tuberculosis should be considered in Asian immigrant patients who present with symptoms and signs of inflammatory bowel disease. | 1 |
Immunohistochemical differentiation of basal cell epithelioma from cutaneous appendages using monoclonal anti-glycoprotein antibody TNKH1. Its application in Mohs' micrographic surgery. TNKH1, which was primarily developed to detect differentiated melanocytic tumor cells, was found to recognize basal keratinocytes of hair follicle and some basal keratinocytes of human epidermis. Thus, TNKH1 decorated the basal cells of following structures: epidermis (39 of 54, only part of each specimen [OPES]), upper hair follicle (one of 24, OPES), lower hair follicle (21 of 21, very high rate of each specimen [VHES]), sebaceous duct (14 of 15, VHES), sebaceous gland (ten of 14, germinative cells near duct), eccrine duct (three of 19, OPES). Epithelial tumors, considered to be derived from or differentiating toward hair follicle such as trichilemmoma (one of one, VHES) and basal cell epithelioma (BCE) (32 of 32, VHES) were labeled not only in the peripheral cells but in their entirety. On the other hand, epidermal tumors, such as seborrheic keratosis (ten of 11, OPES), actinic keratosis (two of three, OPES), and squamous cell carcinoma (one of two, OPES), showed an irregular peripheral basal cell staining as in normal epidermis. The apocrine sweat apparatus and eccrine secretory portion were negative. Eccrine ductal tumors such as syringoma (two tested), eccrine acrospiroma (one), and eccrine carcinoma (two) were TNKH1 negative. Taking advantage of this total labeling of BCE versus peripheral labeling of the hair follicle, the authors could distinguish BCE tissue from other structures clearly. Among confusing structures the upper hair follicle and the eccrine duct were excluded easily because of their negative staining with TNKH1. The lower hair follicle was TNKH1 positive but only in the outer basal layer, whereas the BCE was TNKH1 positive in its entire basaloid cells. The result indicated that TNKH1 will be a useful antibody in Mohs' micrographic surgery. | 0 |
Intravascular laser therapy of acute myocardial infarction. The efficacy of a new method of treatment, endovascular blood irradiation with He-Ne laser, developed by the authors, was studied in 295 patients with primary acute transmural myocardial infarction (MI). Twenty-four-hour Holter monitoring findings before and after laser irradiation suggested the possibility of preventing sudden death in the acute period of MI owing to the high anti-arrhythmic efficacy of the method with respect to high-grade ventricular arrhythmias. Precodial ECG mapping and serial determination of blood enzyme activities (CPK and MB-CPK) showed that irradiation performed within the first hours of MI development contributed to effective limitation of the infarction area and restricted the spread of the area of myocardial ischemic damage. | 4 |
Antibodies to synthetic peptide (125-148) of the alpha-subunit of human nicotinic acetylcholine receptor in sera from patients with myasthenia gravis. We measured the amount of antibodies to a synthetic peptide that corresponds to the alpha-subunit residues Lys125-Thr148 of human acetylcholine receptor (AChR) in myasthenic sera. We detected anti-peptide antibodies in 52% (89/171) of the patients with myasthenia gravis (MG), but none in any of the healthy controls. Anti-peptide antibodies should provide a valuable immunologic parameter for the clinical evaluation of MG, but no apparent correlation was observed between the titers of anti-peptide and anti-AChR antibodies. | 2 |
New technologies for the treatment of obstructive arterial disease. The well-known limitations of balloon angioplasty include unpredictable abrupt closure, chronic total occlusion, diffuse disease, and restenosis, among other factors. These limitations have prompted the development of new technologic approaches to angioplasty including laser applications for plaque ablation, mechanical device applications for plaque removal/debridement, and stent devices for structural maintenance of vascular lumen patency. Devices which directly apply laser energy for ablation of plaque material include a balloon-centered laser angioplasty system, excimer laser ablation catheter systems, and a fluorescence-guided spectral feedback laser system. Experience with these devices indicates that plaque can be successfully ablated by using laser energy. Vessel perforation and dissection are complications reported with these devices and the effects of laser angioplasty on restenosis remain unclear. Indirect application of laser energy has been tested by using a "hot tip" catheter and a laser balloon angioplasty system. Although the hot tip device has received FDA approval for use in peripheral arteries, it appears to have very limited applications in the coronary arteries. Laser balloon angioplasty appears to be beneficial in the setting of threatened acute closure; the device continues to be evaluated for potential beneficial impact on restenosis. Mechanical atherectomy catheters are designed to remove atherosclerotic plaque from the arterial system and include the AtheroCath, the Transluminal Extraction Catheter (TEC), and the Pullback Atherectomy Catheter (PAC). The Rotablator is an atheroablation device which debrides the obstructing plaque material with distal embolization of the particulate debris. Successful removal/debridement of atherosclerotic plaque has been demonstrated with the AtheroCath, Rotablator, and the TEC device. Pre-clinical studies demonstrate successful removal of plaque material with the PAC device. Despite the theoretic advantage of removing plaque material when performing angioplasty with these devices, there has been little or no reduction in restenosis rates based on a significant experience with the AtheroCath and the Rotablator. Intravascular stent devices including one self-expanding device design and two balloon-expandable device designs have been employed successfully in the elective setting to treat recurrent restenosis lesions. Two of the devices have been successfully tested in the setting of threatened acute closure. Early follow-up studies suggest some improvement in restenosis rates in certain clinical settings following intravascular stenting. Acute and subacute thrombosis remain substantial problems for stent devices and very aggressive anticoagulation regimens are necessary to minimize the adverse events. In summary, a number of a new technologic approaches for treatment of atherosclerotic lesions have been developed and are undergoing significant clinical evaluation.(ABSTRACT TRUNCATED AT 400 WORDS). | 3 |
Apocrine mammary carcinoma. A clinicopathologic study of 72 cases. Apocrine carcinoma (AC) is an uncommon, poorly characterized type of breast tumor. In this review, 55 patients with intraductal (ID) AC and 17 patients with infiltrating (IF) AC were analyzed retrospectively to define the histologic features and clinical course of this neoplasm. Recurrences in the breast occurred in 3 of 20 ID-AC patients treated by biopsy alone, but not in the 2 patients who received local radiation therapy after biopsy. One patient with ID-AC had axillary metastases at the time of treatment by mastectomy and died of disease five years later. The remaining patients with ID-AC treated by mastectomy have remained disease free. One of the three patients with IF-AC treated by biopsy alone died of disease, and one of two patients with IF-AC treated by biopsy and radiotherapy was alive with carcinoma. Twelve patients with IF-AC were treated by mastectomy. Ten of them were recurrence free at the time of last observation. More than one-third of the cases of ID-AC and IF-AC were detected by mammography alone. Survival analysis of IF-AC cases compared with nonapocrine duct carcinoma cases matched for stage revealed no statistical difference in estimated recurrence-free survival or estimated survival probability. AC is a distinct morphologic entity with a natural history similar to that of nonapocrine ductal carcinoma. | 0 |
Simultaneous presentation of adenocarcinoma of prostate and transitional cell carcinoma of bladder. Simultaneous presentation of transitional cell carcinoma of the bladder and adenocarcinoma of the prostate is not uncommon. Twenty-two patients were diagnosed as having simultaneous or concurrent presentation of prostate and bladder carcinomas between January 1970 and July 1986. The overall five-year survival was 40 percent, with patients presenting with prostate cancer doing better (50%) than those with bladder cancer (32%). Retrospective review of these cases suggests that primary therapy should be directed to the most advanced cancer. Incidental prostate cancer may be "cured" with a cystoprostatectomy and, when indicated, radiation therapy added postoperatively for the bladder cancer. Eleven patients presented with Stage A prostate cancer: 10 of the 11 were treated for their bladder cancer. Treatment was usually radical cystoprostatectomy with or without postoperative radiation. None died of prostate cancer. Patients presenting with advanced stage prostate cancer have had recurrence or have died of the cancer. | 0 |
Electrophysiology and colour perimetry in dominant infantile optic atrophy. A typical finding in dominant infantile optic atrophy (DIOA) is the variation of the phenotypic expression of the DIOA gene even within one family. It is of special interest for genetic consultation to evaluate an examination method for detecting subclinically involved patients. Seven patients of two families were examined. Three of them had the typical symptoms of DIOA: reduced visual acuity, tritan defect, temporal pallor of both optic discs, and a relative central scotoma for white test spots. In visual evoked cortical potentials (VECP) the amplitudes were reduced, and in one patient the latencies were slightly delayed and two patients considerably so. The amplitude of the negative component of the PERG was markedly reduced, while the positive component was normal. In the remaining four family members normal retinal and cortical responses were recorded under standard conditions and visual fields and colour vision (FM 100 hue) were also normal. However, static perimetry with blue test spots showed in two family members enlarged central scotomas, thus proving that they had subclinical DIOA. | 2 |
Developmental changes in vascular responses to histamine in normoxic and hypoxic lamb lungs. This study of newborn (3-10 day old) and juvenile (6-8 mo old) in situ isolated lamb lungs was undertaken to determine whether 1) histamine receptor blockade accentuates hypoxic pulmonary vasoconstriction more in newborns than in juveniles, 2) histamine infusion causes a decrease in both normoxic pulmonary vascular resistance and hypoxic pulmonary vasoconstriction in newborns, and 3) the H1-mediated dilator response to infused histamine in newborns is due to enhanced dilator prostaglandin release. Pulmonary arterial pressure (Ppa) was determined at baseline and in response to histamine (infusion rates of 0.1-10.0 micrograms.kg-1 min-1) in control, H1-blocked, H2-blocked, combined H1- and H2-blocked, and cyclooxygenase-inhibited H2-blocked lungs under "normoxic" (inspired O2 fraction 0.28) and hypoxic (inspired O2 fraction 0.04) conditions. In newborns, H1-receptor blockade markedly accentuated baseline hypoxic Ppa, and H2-receptor blockade caused an increase in baseline normoxic Ppa. In juveniles, neither H1 nor H2 blockade altered baseline normoxic or hypoxic Ppa. Histamine infusion caused both H1- and H2-mediated decreases in Ppa in normoxic and hypoxic newborn lungs. In juvenile lungs, histamine infusion also caused H2-mediated decreases in Ppa during both normoxia and hypoxia. During normoxia, histamine infusion caused an H1-mediated increase in normoxic Ppa in juveniles as previously seen in mature animals; however, during hypoxia there was an H1-mediated decrease in Ppa at low doses of histamine followed by an increase in Ppa. Combined histamine-receptor blockade markedly reduced both dilator and pressor responses to histamine infusion. Indomethacin failed to alter the H1-mediated dilator response to histamine in newborns. | 4 |
Coronary collateral recruitment: functional significance and relation to rate of vessel closure. Studies in animals and humans have demonstrated the anatomic presence and functional significance of coronary collaterals. The extent of collateralization varies among species and among individuals. Collateral vessels are usually adequate for preserving resting regional and global ventricular function in the face of coronary obstruction. During stress, however, collateral supply may be inadequate. Collateral development is a time-dependent process during both the initial occlusion and following transient reflow and reclosure. Therefore when a previously collateralized coronary occlusion is recanalized and then recloses, the extent of the resulting collateral recruitment will depend, at least in part, upon the period of reflow between the two occlusions. The longer the reflow period, the less enhanced will be the collateralization. This is illustrated in the cases presented and has also been demonstrated in animal studies. The exact mechanisms for this recurrent collateral recruitment need further study. | 3 |
Reduction in bleeding after heart-lung transplantation. The importance of posterior mediastinal hemostasis. To reduce perioperative hemorrhage following heart-lung transplantation, several technical modifications were introduced in June 1988 to secure better posterior mediastinal hemostasis. The intraoperative and postoperative use of blood and blood products, as well as the chest tube drainage in the first 24 hours postoperatively, were compared in the seven patients operated on since June 1988 with the nine patients operated on before that date. Significant (p less than 0.05) reductions were demonstrated in the intraoperative and postoperative transfusion of packed cells, in the postoperative administration of fresh frozen plasma, and in the chest tube drainage within the first 24 hours postoperatively. The one-month and total hospital mortality rates were 6 percent and 12.5 percent, respectively. It is concluded that newer techniques to obtain optimal posterior mediastinal hemostasis have significantly reduced blood loss following heart-lung transplantation in our experience and have contributed to our excellent early postoperative results. | 4 |
Results of multiple pulmonary resections for metastatic osteogenic sarcoma after two decades. A 20-year follow-up of children who had complete resection of pulmonary metastases from osteogenic sarcoma of the extremities was undertaken. Four of six 10-year survivors survived more than 19 years even with multiple metastases and as many as nine thoracotomies. Fifty percent of the 10-year survivors developed second primary cancers during the second decade of follow-up. | 0 |
Postoperative cerebrospinal fluid leakage after lumbar spine operations. Conservative treatment. Cerebrospinal fluid (CSF) leakage from a postoperative wound after lumbar spine operation is an uncommon complication. It may result from excessive traction of the nerve roots, direct trauma, or laceration at the time of operation, causing the dura to be inadvertently opened. Other reasons for this complication are postlaminectomy residual bone spikes, traumatic myelography puncture, and improper suture of dura defects. Eight patients who had postoperative CSF leakage as the only complication after lumbosacral spine operations were examined. They were all treated conservatively with bed rest in the Trendelenburg position, antibiotic coverage, watertight skin suturing, and daily subcutaneous punctures. No patient was operated on for the same type of complication. | 4 |
Intravascular laser therapy of acute myocardial infarction. The efficacy of a new method of treatment, endovascular blood irradiation with He-Ne laser, developed by the authors, was studied in 295 patients with primary acute transmural myocardial infarction (MI). Twenty-four-hour Holter monitoring findings before and after laser irradiation suggested the possibility of preventing sudden death in the acute period of MI owing to the high anti-arrhythmic efficacy of the method with respect to high-grade ventricular arrhythmias. Precodial ECG mapping and serial determination of blood enzyme activities (CPK and MB-CPK) showed that irradiation performed within the first hours of MI development contributed to effective limitation of the infarction area and restricted the spread of the area of myocardial ischemic damage. | 3 |
Imaging techniques in the diagnosis of carcinoma of the colon. The variability in the published results for colonoscopy and barium enema examinations is confusing. With both, optimum results are dependent on meticulous preparation, technical excellence, and operator proficiency. It is a mistake to place colonoscopy and the barium enema in competitive positions; the two methods ideally complement one another in the evaluation of high risk individuals, including those with positive Hemoccult tests. The exclusion of significant pathology by the double-contrast enema can be relied on and is less costly to the patient. Detection of abnormalities by a barium enema should, when necessary, be followed by colonoscopic verification and/or biopsy. When used in this sequence, the procedures provide a cost-effective approach to the early detection and control of cancer; it is estimated that observance of the ACS guidelines can reduce mortality rates by 30%. | 0 |
Radiographic manifestations of anomalies of the brain. Congenital brain anomalies are classified as developmental anomalies, effects of teratogens, errors of histogenesis, or sequelae of infections. The imaging options for delineation of these anomalies are many; a basic understanding of the disorder is central to the effective choice of imaging modality. This review begins with a brief overview of embryogenesis then reviews the common congenital brain anomalies encountered in infants. | 2 |
Cardiac myosin-induced myocarditis. Heart autoantibodies are not involved in the induction of the disease. We recently demonstrated that cardiac myosin is capable of inducing autoimmune myocarditis in genetically predisposed mice. This disease parallels coxsackievirus B3-induced autoimmune myocarditis in many respects and is associated with high-titer autoantibodies specific for cardiac myosin. The following lines of evidence suggest that these autoantibodies are not involved in the induction of autoimmune myocarditis: 1) immunoperoxidase staining of heart sections from cardiac myosin-immunized A/J and A.SW mice revealed IgG depositions only along damaged muscle fibres in infiltrated areas, but not in intact tissue; 2) myosin autoantibodies did not bind to the surface of viable cardiac myocytes isolated from mice, but only reacted with myocytes permeabilized with detergent; 3) mice treated with a single high dose of cyclophosphamide, which reduces the humoral immune response, still developed severe myocarditis, despite the fact that their autoantibody titers were reduced to the level of adjuvant-injected controls; and 4) passive transfer of high-titer myosin autoantibodies failed to induce myocarditis, although the titers in the recipients were comparable to those found in mice with cardiac myosin-induced disease. Together, the results suggest that high-titer myosin autoantibodies are secondary rather than primary to the disease. | 3 |
A study of the comparative efficacy of four common analgesics in the control of postsurgical dental pain. Four common oral analgesics were tested in a single-blind trial to determine their relative efficacy in the management of postsurgical pain in 103 patients who had their impacted third molars surgically removed under general anesthesia. The analgesics tested were acetylsalicylic acid (26 patients), ibuprofen (26 patients), a paracetamol/codeine/caffeine combination (Solpadeine) (25 patients), and dihydrocodeine (26 patients). The paracetamol/codeine/caffeine combination, ibuprofen, and acetylsalicylic acid preparations produced equally effective analgesia. Dihydrocodeine was found to be a poor analgesic in this pain model. There were no adverse reactions to any of the preparations. | 4 |
A surgical approach to the cervicothoracic spine. We describe a method for approaching the lower cervical and upper thoracic spine, the brachial plexus and related vessels. The method involves the elevation of the medial corner of the manubrium, the sternoclavicular joint, and the medial half of the clavicle on a pedicle of the sternomastoid muscle. We have used this exposure in 17 cases with few complications and good results. Its successful performance requires high standards of anaesthesia, surgical technique and postoperative care. | 4 |
Hole preparation techniques for transpedicle screws. Effect on pull-out strength from human cadaveric vertebrae. In each of eight thoracolumbar human cadaveric vertebrae, a hole was made through one pedicle into the vertebral body with a drill bit and through the contralateral pedicle with a probe. Identical metal screws were implanted into the holes to equal depths, and maximum pull-out force was determined for each screw. Using a paired Student t test, no significant difference (P = 0.87) was found in pull-out strength between the screws implanted into drilled holes and those implanted into probed holes. In fact, the average pull-out strengths for the two groups differed by less than 2%. The pedicular cortex was broken through during hole preparation in 5 of the 16 pedicles: 3 as a result of drilling and 2 secondary to probing. The average pull-out strength of the screws in these five pedicles was 11.0% less than the average pull-out strength of the screws implanted into the contralateral intact pedicles. Although this does not represent a statistically significant difference (P = 0.15), it suggests that damaging the pedicular cortex may weaken pedicle screw fixation. | 4 |
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