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Pancreatic pseudocysts. When to drain, when to wait. Acute pain in the upper abdomen in a patient recovering from pancreatitis or abdominal trauma may herald a pancreatic pseudocyst. Although small cysts resolve spontaneously, those larger than 6 cm across usually require treatment to prevent such complications as rupture into adjacent structures and infection. The authors describe operative and nonoperative treatment methods and the success reported with each. | 1 |
Fine-needle aspiration for diagnosis of intranodal squamous-cell carcinoma metastatic from the skin. Fine-needle aspiration is a useful way to determine the presence of squamous-cell carcinoma in enlarged lymph nodes of patients at high risk for metastases. Advantages include a high degree of accuracy, outpatient as well as inpatient availability, and negligible potential for seeding of malignant cells. Cutaneous oncologists should consider using this technique in patients with lymphadenopathy and a previous history of cutaneous squamous cell carcinoma. | 0 |
Predictors of cardiac survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction. To assess the outcome of percutaneous transluminal coronary angioplasty (PTCA) in patients with severe left ventricular (LV) dysfunction and to determine the predictors of mortality, 73 patients with LV ejection fraction less than or equal to 40% who underwent initial PTCA were analyzed. The majority of patients had prior (greater than 1 week) myocardial infarction (62 patients, 85%). Congestive heart failure and unstable angina were present in 24 (45%) and 49 (67%) patients, respectively. Multivessel coronary artery disease was present in 60 (83%). The LV ejection fraction ranged from 14 to 40% (mean 34%). Intraaortic balloon pump (15%) and percutaneous cardiopulmonary bypass support (4%) was used infrequently. Angiographic success was obtained in 109 of 128 lesions (85%) attempted. Complete revascularization was obtained in 16 of 60 patients with clinical success. Procedure-related mortality was 5% (4 patients). All patients were followed from greater than or equal to 6 to less than or equal to 71 months (average 26). The estimated survival was 79 +/- 5%, 74 +/- 6%, 66 +/- 7% and 57 +/- 8% at 1, 2, 3 and 4 years, respectively. A Cox regression analysis revealed that the presence of congestive heart failure, a lower LV ejection fraction and a higher myocardial jeopardy score for contractile myocardium were independent predictors of survival after PTCA in patients with LV dysfunction. In conclusion, a high-risk subset can be identified among patients with severe LV dysfunction who undergo PTCA. | 3 |
Quantification of vascular stenosis with color Doppler flow imaging: in vitro investigations. The accuracy of quantifying the degree of vascular stenosis with color Doppler flow imaging (7.5-MHz, linear array system) was determined in an experimental study carried out on six concentric and five eccentric model stenoses (cross-sectional area reduction, 13.4%-93.8%). The measurements were made with use of pulsatile flow at four different flow rates (70.8-339.0 mL/min). The degree of stenosis was calculated from the ratio of prestenotic to intrastenotic flow velocity. The most exact measurement of the degree of stenosis could be achieved with Doppler spectral analysis by determining the maximum peak systolic velocity (r = .994, y = 0.98x - 3.2). With the velocity values derived only from the color-coded image, it was also possible to find the most exact degree of stenosis (r = .995, y = 0.99x - 2.9). For quantification of stenosis, pre- and intrastenotic Doppler spectral analysis is no longer necessary if the stenosis can be imaged sufficiently with color Doppler. | 4 |
Blood pressure reactivity predicts myocardial infarction among treated hypertensive patients. High blood pressure (BP) defines a prognostically heterogeneous group. Because BP varies according to time, setting and means of observation, it has been postulated that BP reactivity might better predict cardiovascular disease (CVD) than does unidimensional measurements. To assess BP reactivity, the difference between pretreatment nurse (RN) and physician (MD) diastolic BP (DBP)--systematically recorded in that order--or MD-RN DBP, was obtained in 1737 previously untreated patients with sustained, RN BP greater than or equal to 160 and/or 95 mmHg. Patients stratified by tertiles of MD-RN DBP [(I) less than or equal to - 3, (II) -2 to 3 and (III) greater than or equal to 4 mmHg] were similar by sex, race, age, body mass index, cholesterol, electrocardiography, prior CVD, smoking and pretreatment or attained in-treatment BPs. During 14 years of followup, myocardial infarction (MI) incidence per 1000/year were, tertile I (3.2), II (3.7), III (7.6) (relative risk = 2.4, III vs I + II, p less than 0.05), whereas stroke incidence and non-CVD mortality were evenly distributed. By Cox survival analysis, controlling for other entry characteristics only age, sex and DBP reactivity remained predictive (p less than or equal to 0.03) of MI or total CVD. Thus, BP reactivity, probably a centrally-mediated phenomenon, identifies a subgroup of hypertensives with an increased propensity for MI despite successful BP control. | 2 |
Differential reading recovery in patients with severe to moderate closed head injury. A differential recovery was seen when alternate forms of a nationally standardized test of Reading Vocabulary, Literal Reading Comprehension and Inferential Reading Comprehension was administered serially to 10 consecutive closed head injury admissions to a university rehabilitation hospital. Inferential Reading Comprehension was the most impaired and had the fastest recovery rate. Subtle cognitive deficits in Inferential Reading Comprehension were detected when Reading Vocabulary was at or better than a twelfth grade level. Maximal recovery of all three reading functions occurred within 4 months after trauma, with most occurring in the first 3 months. The reading recovery pattern parallels the recovery of intelligence scores in the literature. | 2 |
Premorphological metabolic changes in human breast carcinogenesis. Malignant breast tissue is characterized by morphological and metabolic changes when compared with normal breast tissue. In this study, the cytochemical measurement of glucose-6-phosphate dehydrogenase (G6PD) activity was used to detect abnormal metabolism in breast tissue and to determine whether abnormal metabolic activity precedes morphological change during human breast carcinogenesis. Normal and benign breast tissue, morphologically normal tissue from cancer-containing breasts, and malignant breast tissue were studied. In malignant tissue, mean(s.e.m.) G6PD activity was significantly increased when compared with normal and benign tissue (9.69(2.3) versus 27.02(1.7) mean integrated extinction (MIE) x 100, P less than 0.01). G6PD activity was increased in morphologically normal tissue from cancer-containing breasts when compared with normal and benign breast tissue from breasts with no known cancer (27.02(1.7) versus 18.42(2.6) MIE x 100, P less than 0.05). These findings suggest that metabolic abnormalities precede morphological changes in breast carcinogenesis. Abnormal metabolism can be detected widely within a cancer-containing breast. The detection of such abnormality may prove helpful in identifying patients at high risk of developing breast cancer. | 0 |
Modified Van Nes rotationplasty in the treatment of malignant neoplasms in the lower extremities of children. A technique of modified Van Nes rotationplasty has been used since 1981 for limb salvage surgery in children and adolescents with malignant sarcoma of the lower extremity. The original procedure for lesions of the distal femur was further modified and adopted for selected lesions of the proximal femur and tibia. Sixteen skeletally immature children form the base of this report. The tumors were located in the distal femur in ten children, the proximal tibia in five and the proximal femur in one. There were no intraoperative complications and postoperative complications included one infection requiring debridement and three minor healing delays. There were no local recurrences, neurovascular compromises, late derotations, or psychologic decompensations. One patient died of metastatic disease and another died of a second malignancy (leukemia). The remaining patients are good, functional, below-knee prosthesis users who participate in a number of sporting and athletic activities. The procedure is safe, has a relatively low complication rate, allows for the functional demands of an active, growing child, and accommodates for the future growth of extremities. | 0 |
Squamous carcinoma of the posterior pharyngeal wall. We have reviewed a 12-year experience with 295 patients treated for squamous carcinoma of the pharynx in order to focus on 78 patients whose lesions arose in the posterior wall. Surgery was the definitive therapy for the primary tumor in 57 (73%), including 3 treatment groups. Thirty-two patients had limited resections that preserved the larynx, involving local excision (7 patients), anterior pharyngotomy (7 patients), lateral pharyngotomy (6 patients), median labiomandibular glossotomy (6 patients), or median mandibulotomy with paralingual extension (6 patients). The second group consisted of 21 patients with more extensive tumors who required a laryngectomy and complex reconstruction, often with postoperative radiotherapy. Finally, there were four patients who developed metachronous second primaries in the pharynx subsequent to a laryngectomy. All required flap reconstruction. Of the 21 patients whose primary treatment was radiotherapy, 5 had lesions that were implanted after access was provided by a mandibulotomy. Cumulative 5-year survival was 32% and ranged from 44% in those with favorable lesions to 15% in those with extensive tumors. Our experience highlights the variety of treatment approaches available in patients with pharyngeal carcinomas confined to the posterior wall. Surgery in this setting carries acceptable morbidity and yields survival rates that compare favorably with those achieved by external radiation therapy alone. Results in patients with extensive lesions still leave much to be desired, despite radical surgery and aggressive radiotherapy. Innovative brachytherapy techniques using surgery for access deserve further investigation. | 0 |
Microangiopathy in the eosinophilia-myalgia syndrome. The eosinophilia-myalgia syndrome associated with the ingestion of L-tryptophan was recognized in late 1989. We describe our pathologic study of skin, fascial, and muscle biopsies from 21 patients evaluated by light microscopy, histochemistry, and electron microscopy. A perivascular, lymphocytic infiltrate with eosinophils was present in the dermis, fascia, and skeletal muscle. Lymphocytic infiltration of arteries and arterioles was seen. Ultrastructurally, capillary and arteriolar endothelial cell thickening and necrosis was present. This microangiopathy suggests that ischemia may be a contributing factor to the findings in this syndrome. | 3 |
Aortic dissection with the entrance tear in transverse aorta: analysis of 12 autopsy patients. Clinical and autopsy findings are described in 12 patients who had fatal aortic dissection with the entrance tear in the transverse aorta. The 12 patients represent 7% of 182 autopsies of spontaneous aortic dissection studied by us. The ages of the 12 patients at death ranged from 37 to 87 years (mean, 67 years). Eight were men; 8 had a history of systemic hypertension, and 10 had hearts of increased weight. Diagnosis of aortic dissection was made during life in only 4 of the 12 patients. All 12 patients died of rupture of the false channel within 2 weeks of onset of signs or symptoms compatible with dissection. The direction of aortic dissection from the entrance tear was entirely retrograde in 4 patients, entirely anterograde in 4 patients, and in both directions in 4 patients. Hemopericardium occurred in the first group, left hemothorax in the second group, and either in the last group. Of the 8 patients in whom the ascending aorta was involved, the retrograde dissection in each extended to the aortic root, 6 had pulmonary adventitial hemorrhage, and 4 had involvement of the arch arteries by dissection. In the 4 patients with strictly anterograde dissection, none had dissection in the arch arteries. Thus, tear in the transverse aorta causes a dissection that is usually fata, that often dissects retrogradely, and that may mimic dissection from a tear in ascending aorta. Aortic dissection from a tear in transverse aorta requires early operative intervention. | 4 |
Coronary angioplasty following cardiac transplantation: a case report and review of the literature. A 23-year-old man underwent successful percutaneous transluminal coronary angioplasty of a severe stenosis of the left anterior descending artery 25 months after orthotopic heart transplantation. Four months later restenosis of the same lesion was treated by repeat PTCA. Angiography 11 months later showed no restenosis. In selected cases, PTCA may be useful in treating allograft coronary disease. | 3 |
Thrombin stimulates tumor-platelet adhesion in vitro and metastasis in vivo. Recent studies have revealed a role for platelets and the platelet-adhesive proteins, fibronectin and von Willebrand factor (vWF) in platelet-tumor cell interaction in vitro and metastasis in vivo. The present report documents the effect of thrombin treatment of platelets on this interaction in vitro and in vivo. In vitro, thrombin at 100-1,000 mU/ml maximally stimulated the adhesion of six different tumor cell lines from three different species two- to fivefold. As little as 1-10 mU/ml was effective. The effect of thrombin was specific (inhibitable by hirudin, dansyl-arginine N-(3-ethyl-1,5 pentanediyl) amide and unreactive with the inactive thrombin analogue N-P-tosyl-L-phenylchloromethylketone-thrombin and D-phenylalanyl-L-propyl-L-arginine chloromethylketone-thrombin (PPACK-thrombin), and required high-affinity thrombin receptors (competition with PPACK-thrombin but not with N-P-tosyl-L-lysine-chloromethyl-ketone-thrombin). Functionally active thrombin was required on the platelet surface. Binding of tumor cells to thrombin-activated platelets was inhibitable by agents known to interfere with the platelet GPIIb-GPIIIa integrin: monoclonal antibody 10E5, tetrapeptide RGDS and gamma chain fibrinogen decapeptide LGGAKQAGDV, as well as polyclonal antibodies against the platelet adhesive ligands, fibronectin and vWF. In vivo, thrombin at 250-500 mU per animal increased murine pulmonary metastases fourfold with CT26 colon carcinoma cells and 68-413-fold with B16 amelanotic melanoma cells. Thus, thrombin amplifies tumor-platelet adhesion in vitro two- to fivefold via occupancy of high-affinity platelet thrombin receptors, and modulation of GPIIb-GPIIIa adhesion via an RGD-dependent mechanism. In vivo, thrombin enhances tumor metastases 4-413-fold with two different tumor cell lines. | 0 |
Correlation between estrogen receptor status and histological malignancy in human breast cancer. Sixty-two breast carcinoma patients underwent mastectomy and were analyzed for correlations between estrogen receptor (ER) status of the tumor and the histological findings of tumor, age, nodal status, and tumor size. An immunocytochemical assay for the detection of ER in breast carcinomas was used to evaluate the staining intensity index (SII) of the ER level of the tumors, which was calculated from the staining intensity of cancer cells and the percentage of ER-positive cancer cells. The histological differentiation of carcinomas showed a strong correlation with the SII. A statistically significant (F = 10.580, P less than 0.0005) negative correlation was found between the grade of malignancy and the SII. Patients under 50 years of age tended to have a lower SII, whereas patients over 49 years of age tended to have a higher SII. The tumor size, and nodal status showed no correlations with the SII in any of the patients. The histological differentiation of the tumor cells showed a strong correlation with the heterogeneity of the distribution of ER-positive cells in breast cancers. | 0 |
Obstructing carcinoma of the cecum. Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The mean age of the patients was 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. There was no operative mortality or significant morbidity. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment. | 0 |
Parietal cell vagotomy and dilatation for peptic duodenal stricture. Gastric outlet obstruction due to peptic duodenal stricture (pyloric stenosis) was treated with parietal cell vagotomy and dilatation of the stricture in 32 patients. Follow-up is in the range of 5 years in 37.4% of the patients, while 6 to 10 years follow-up is available in 62.4% of the patients. At their last follow-up, 74.9% of the patients were in either Visick 1 or 2 clinical status. Recurrence rates have been 3.1% at 1 year, 9.3% at 5 years, and 21.8% after 6 to 10 years follow-up. There has been only one instance (3.1%) of restenosis. Two patients required reoperation because of recurrence and one of them died. | 4 |
Activation and in vitro expansion of tumor-reactive T lymphocytes from lymph nodes draining human primary breast cancers. The feasibility of in vitro activation of lymphocytes from the draining lymph nodes (DLN) of breast cancer patients was examined. Lymphocytes isolated from 48 DLN from 12 patients were examined for their proliferative responses to rIL-2, autologous tumor cells, or rIL-2 plus tumor cells. Three general patterns of cellular responses were observed. Cells from some DLN (17%) were unresponsive to any stimuli. Lymphocytes from 52% of the DLN responded moderately to rIL-2 alone. The combination of rIL-2 and tumor antigen had a synergistic effect on the proliferation of cells from 31% of the DLN assayed. Phorbol dibutyrate and ionomycin plus rIL-2 stimulated expansion of DLN lymphocytes by up to 850-fold after 35 days. These expanded cell populations, as well as those stimulated with antigen plus rIL-2, were predominantly CD3+ and CD16- cells, varying in proportions of CD4+ and CD8+ subsets. Both populations were cytotoxic against autologous tumor, MCF-7, and K562 target cells. | 0 |
Role of tolerance in cloxacillin treatment of experimental Staphylococcus aureus endocarditis. The role of Staphylococcus aureus tolerance was investigated in endocarditis in rats. The efficacies of cloxacillin, gentamicin, and a combination of the two were compared for animals infected with a tolerant strain, its kill-sensitive variant, or a nonisogenic nontolerant strain of S. aureus. Cloxacillin was significantly less effective for treating the tolerant than for the nontolerant strains. The addition of gentamicin to cloxacillin reduced bacterial numbers in endocardial vegetations for the tolerant strain comparable to the reduction by cloxacillin alone for the nontolerant strains, but had no additional effect for the nontolerant strains. Isolates from animals infected with the tolerant or nontolerant strains during antibiotic treatment remained tolerant or nontolerant. These results show that the in vitro phenomenon of tolerance is relevant in vivo. | 3 |
Acute syphilitic posterior placoid chorioretinitis. Six patients with evidence of secondary syphilis presented with visual loss in both eyes caused by large, placoid, yellowish lesions with faded centers at the level of the pigment epithelium in the macula and juxtapapillary areas. All eyes had vitreitis. All of the lesions showed a similar fluorescein angiographic pattern of early hypofluorescence and late staining. Five patients had mucocutaneous lesions typical of secondary syphilis. All five patients treated with antibiotics had prompt improvement in visual function and resolution of the fundus lesions. The ophthalmoscopic and angiographic appearance of these posterior fundus lesions was sufficiently characteristic to suggest a diagnosis of secondary syphilis. Modification of the host response to syphilis by human immune deficiency virus (HIV) infection may be partly responsible for this peculiar fundus picture. Three of the four patients tested positive for HIV. | 4 |
Can the blood urea nitrogen/creatinine ratio distinguish upper from lower gastrointestinal bleeding? We wanted to know if the blood urea nitrogen to creatinine (BUN/Cr) ratio could help distinguish upper from lower gastrointestinal bleeding. We analyzed retrospectively patients admitted to our hospital for gastrointestinal bleeding over the past 5 years. A total of 126 patients represented 74 upper bleeds and 52 lower bleeds. The mean BUN/Cr ratio was significantly higher in upper than lower bleeders, 34.8 and 17.8 respectively (p less than 0.001). No lower bleeder had a ratio of greater than or equal to 36, whereas 38% of upper bleeders had a ratio of greater than or equal to 36. The BUN/Cr ratio may be an easy, cheap method of distinguishing upper from lower gastrointestinal bleeding in some cases. A BUN/Cr ratio of greater than or equal to 36 suggests upper gastrointestinal bleeding, whereas a ratio of less than 36 is not helpful in locating the source of bleeding. | 1 |
Quantification of midline shift as a predictor of poor outcome following head injury. A retrospective study of patient outcome, based on admission computed tomography, was carried out in 75 consecutive patients with head injury. Computed tomography data collected included the type and extent of intracranial hemorrhage, the extent of midline shift, and the ratio of midline shift compared with the extent of intracranial hemorrhage. Midline shift was considered to be out of proportion to intracranial hemorrhage when the midline shift of the septum pellucidum exceeded the extent of the hemorrhage as measured radially from the inner table of the skull. When computed tomography data were analyzed by logistic regression, significant predictive factors for poor outcome were intracranial hemorrhage (34%), intracranial hemorrhage with midline shift (61%), and midline shift out of proportion to the extent of intracranial hemorrhage (88%). When patient outcome and mortality rates are considered, our study indicates that midline shift out of proportion to the extent of intracranial hemorrhage is a highly useful predictor of poor patient outcome following head injury. | 4 |
Endometriosis of the abdominal wall. Endometriosis of the abdominal wall typically occurs as a painful mass in a lower abdominal incision from previous cesarean section or hysterectomy. Most patients are young and in their active reproductive years. The histologic diagnosis requires a combination of either endometrial-like glands, endometrial stroma, or hemosiderin pigment. The diagnosis must be considered in any woman with an abdominal wall mass and a history of transabdominal gynecologic surgery. Wide excision offers the best chance to prevent recurrence. | 4 |
Prognostic factors for outcome of and survival after second-look laparotomy in patients with advanced ovarian carcinoma. In ovarian cancer stages IIB-IV, pre-treatment variables and variables obtained intraoperatively at second-look laparotomy were investigated for their prognostic influence on the outcome of 109 patients and survival after second-look laparotomy in 131 patients. The subjects came from a randomized trial of sequential versus alternating combination chemotherapy. The overall median survival after second-look laparotomy was 62 months. Logistic regression analysis identified stage and hysterectomy plus bilateral salpingo-oophorectomy and omentectomy as significant prognostic covariates for second-look laparotomy outcome. Based on a Cox multivariate stepwise analysis, independent prognostic factors for survival after second-look laparotomy were secondary residual tumor size, pre-treatment histologic differentiation grade, and performance status. A high differentiation grade and a good performance status at the start of therapy thus still had a prolonging effect on survival after second-look laparotomy. The prognostic power of these pre-treatment variables was increased substantially by the addition of the secondary residual tumor size variable. The 3-year survival rate after second-look laparotomy for high- and low-risk patients was 15 and 87%, respectively. Second-look laparotomy thus provides prognostic information in patients with advanced ovarian carcinoma, but the benefit in terms of survival is still unclear. | 0 |
Relationship between duration of spinal cord ischemia and postoperative neurologic deficits in animals. Twenty hogs were administered the following procedures before, during, and after overdistraction of the spinal column at T5-T6: somatosensory (SEP) and neurogenic-motor evoked potentials (NMEPs), hydrogen clearance procedures, Stagnara wake-up tests, and aortic-injection of silastic plastic. To ensure that overdistraction was possible, a nonosseous, circumferential osteotomy was made at T5-T6 and distraction applied in one-ratchet increments using Harrington instrumentation. Overdistraction was maintained for 3, 5, 6, 10, 15, 20, 25, or 30 minutes. Results indicated that the duration of overdistraction, as represented by lost NMEPs, was always correlated with the animal's clinical status on wake-up test. If overdistraction was maintained more than 6 minutes, 100% of the animals demonstrated positive wake-up results; if maintained between 5 and 6 minutes, 75% demonstrated positive wake-up results; and if maintained less than 5 minutes, only 25% demonstrated positive wake-up results. Time-to-loss of the NMEPs and SEPs, after onset of overdistraction, fell within two groups: slow and fast. In the slow group, it required slightly more than 20 minutes (mean = 20.6) for the potentials to be lost, while in the fast-loss group data were lost in slightly less than 4 minutes (mean = 3.6). Blood flow studies and inspection of the spinal cord revealed that the mechanism of action for the slow group appeared to be ischemia of the spinal cord that extended several centimeters above and below the site of maximum distraction. In the fast-loss group, it appeared that gross structural damage, with some very localized ischemia, were the mechanisms of actions influencing the integrity of the spinal cord. | 2 |
Polyglucosan body disease. Adult polyglucosan disease has been described in 15 cases. All had signs of peripheral neuropathy, upper motor neuron signs, and 12 of the 15 had sphincter problems. Dementia was prominent in 8 of 15 cases. We reported 2 cases that contained these clinical features. Electrophysiological studies showed axonal neuropathy. Somatosensory evoked potentials on the second patient were abnormal. Sural nerve biopsy showed clusters of polyglucosan bodies. Although the presence of polyglucosan bodies in biopsy is nonspecific, the number as well as the clinical features are necessary to make the diagnosis. Branching enzyme activity in muscle extracts of the muscles were normal. Hence, a specific enzyme abnormality is not yet known. | 2 |
Emergency department approach to managing seizures in pregnancy. Seizures in pregnancy pose risks for both the mother and the fetus and must be managed aggressively. Antiepileptic drugs have some teratogenic potential, but the risks are not as profound as reported in earlier literature. There is definitely less risk to the fetus from anticonvulsant exposure than from uncontrolled seizures. The evaluation of a pregnant woman with new-onset seizures is the same as for the nonpregnant patient, including head computed tomography with appropriate abdominal shielding. Status epilepticus management is based on IV benzodiazepines, phenytoin, or phenobarbital. Good fetal outcome is dependent on rapid seizure control. Management of eclampsia is controversial. There is little evidence that magnesium sulfate has anticonvulsant properties, and its use as such will probably decline steadily in the future. At present, it is reasonable to manage eclamptic seizures in the same way that status epilepticus is managed. | 2 |
Clinical features of adenovirus enteritis: a review of 127 cases. We retrospectively analyzed the clinical features of 127 hospitalized pediatric patients whose fecal samples were positive for adenovirus (Ad) by electron microscopy during an 18-month period. Serotyping results obtained by microneutralization tests and restriction endonuclease analysis were available for 105 of 127 cases. There were 69 males and 58 females and 94% of patients were less than 4 years of age. The average body temperature was 38 degrees C rectal (range, 36.2-40.8 degrees C) with an average duration of fever of 1.6 days. The average duration of clinical illness was 8.8 days (range, 1 to 32 days). Although Ad 40 and Ad 41 were isolated in the majority of cases (59 of 105 (56%], Ad 31 was associated with 18 of 105 cases (17%). Of the 18 cases associated with Ad 31, 14 were nosocomial and associated with diarrhea. Our survey confirms the importance of fastidious enteric Ad in infantile diarrhea (Ad 40, Ad 41) and suggests that Ad 31 produces a clinical syndrome indistinguishable from that caused by Ad 40 and Ad 41. The occurrence of Ad enteritis in patients admitted for unrelated illnesses well after initial hospitalization suggests that Ad is also an important cause of nosocomial enteritis in our hospital. | 4 |
The neuromuscular pathology of the Eosinophilia-Myalgia syndrome. The Eosinophilia-Myalgia Syndrome (EMS) is a recently reorganized disorder in patients ingesting pharmacologic doses of L-tryptophan. We studied the lesions of skeletal muscle, peripheral nerve and skin in 12 cases of EMS. Perimyositis was severe in four, moderate in two, mild in three and absent in three cases. The lesions contained many eosinophils, T-helper cells, mast cells and activated macrophages. Type 2 myofiber atrophy was present in five cases and in one, this was the only pathologic finding. Severe epineurial inflammation was seen in the three sural nerve biopsies. Indirect evidence for peripheral neurologic involvement in three other cases consisted of inflammation surrounding intramuscular nerve twigs (two cases) and neurogenic atrophy (one case). Phlebitis accompanied the connective tissue inflammation in five cases and endarteritis in one. Fasciitis was present in three of four skin biopsies and dermal fibrosis in one. | 2 |
A simple method to improve the accuracy of non-invasive ultrasound in selecting TIA patients for cerebral angiography. A prospective study is reported of the ability of B mode ultrasound imaging and continuous wave Doppler flow studies to detect different degrees of stenosis of the extracranial internal carotid artery (ICA) in 186 arteries in 99 patients with transient ischaemic attacks (TIA) and minor ischaemic stroke. A simple mathematical equation has been developed which combines the image and flow data to provide a single predictor of the degree of angiographic stenosis which has advantages over either ultrasonic modality used alone. The sensitivity and specificity of the predictive model in the detection of stenosis greater than or equal to 25% was 73% and 98%, of stenosis greater than or equal to 50% was 90% and 93%, of stenosis greater than or equal to 75%, 65% and 99% and occlusion 100% and 94% respectively. The principal clinical value of ultrasound screening is to spare patients with "non-significant" stenosis the risk of unnecessary angiography. Thus a simple measure of the Duplex screening tests' performance is the proportion of all strokes occurring as a complication of angiography that are avoided by changing the investigation policy from "angiograms for all carotid TIA and minor ischaemic stroke patients" to "angiograms for all patients with abnormal ultrasound results". If Duplex scanning were used to select patients most likely to have a significant abnormality on angiography, depending on the degree of stenosis to be detected, 52-85% of angiographic strokes might be avoided. If the predictive equation were used 62-88% of angiographic strokes might be avoided. | 4 |
Abdominal sparganosis in Ecuador: a case report. Sparganosis, infection with plerocercoids of the pseudophyllidean tapeworm Spirometra, rarely has been described in Ecuador. We report the details of a human case of sparganosis identified serendipitously in the course of an abdominal hernia repair. The parasite was found moving freely upon the external oblique fascia adjacent to the site of a direct abdominal hernia. The organism was recovered intact, photographed while alive and preserved for subsequent detailed morphological studies. The presumed route of entry into this patient was percutaneous, after application of a poultice of snake flesh to the site of a painful abdominal hernia. The literature on sparganosis in South America is reviewed. This is the second case of human sparganosis reported from Ecuador. | 1 |
Work and power in gait of stroke patients. Biomechanical analysis of the work and power patterns involved in gait provides insight into the nature of gait deficits and suggests methods for improvement. The purpose of this study was to describe the work and power characteristics during gait for both limbs of hemiplegic patients, and to determine the work and power variables related to self-selected speeds of walking. The gait of 30 ambulatory adults between the ages of 47 and 79 years was studied using two-dimensional cinematography and force-plate data in a link-segment model. About 40% of the positive work required for walking was performed by the muscles of the affected side. Major contributors were the ankle plantar flexors, hip flexors, and hip extensors. The results suggest interdependence between the limbs and between muscle groups of the same limb; a need for further research is indicated. | 4 |
Causes of death in the elderly and their changing pattern in Hisayama, a Japanese community. Results from a long-term and autopsy-based study. The causes of death for the elderly were prospectively studied in Hisayama, Japan, a rural community. We compared 1,621 subjects, aged 40 years or over, recruited in 1961, and 2,053 subjects recruited in 1974. Each cohort was studied in a follow-up that lasted 10 years; they had autopsy rates of 82.1% and 86.1% during each 10-year period, respectively. The most common causes of death for those aged 70 years or over were cerebrovascular disease, malignant neoplasms, and pneumonia. Deaths due to cerebrovascular disease tended to decrease in the recent cohort, but the proportion of decline was more prominent in cases aged 40 to 69 years. There was a sex difference in the changing pattern of mortality from heart diseases including ischemic heart disease. Deaths by both heart diseases and ischemic heart disease increased in the more recent cohort of aged women, whereas they decreased in the aged men. Pneumonia was an important cause of death for the elderly in both cohorts. Deaths due to "senility" were rare, being only 1% of the deceased aged 70 or over. With prolonged lifespan, especially for women, the impact of atherosclerosis and its related disorders on the recent Japanese aged population appears to have increased. | 0 |
A detachable balloon procedure for a traumatic internal carotid-internal jugular fistula: report of a case A case of a traumatic fistula between the internal carotid artery and the internal jugular vein is reported. The fistula was treated by detachable balloon occlusion and clipping of the internal carotid artery. | 3 |
Long-term medical consequences of incest, rape, and molestation. One hundred thirty-one patients who gave a history of childhood sexual abuse were seen in a general medical practice decades after the event and were compared with a control group. The subject patients were found to be distinct for chronic depression, morbid obesity, marital instability, high utilization of medical care, and certain psychosomatic symptoms, particularly chronic gastrointestinal distress and recurrent headaches. It is clear that these remote events can underlie difficult chronic medical problems. Questions about childhood sexual abuse must become part of the practitioner's review of systems in these difficult cases, if not routinely. | 4 |
Leiomyosarcoma of the larynx: emergency laryngectomy. Leiomyosarcoma of the larynx is extremely rare. A patient with respiratory obstruction due to such a tumour is presented. This was originally misdiagnosed as hysteria. The treatment of choice was an emergency laryngectomy. | 4 |
Clinicopathologic features of hepatocellular carcinoma in young patients. To investigate clinicopathologic characteristics of hepatocellular carcinoma (HCC) in young adults, excised tumors from 21 patients younger than 45 years (young group) were compared with findings in tumors from 204 patients older than 45 (old group). In the young group HCC showed (1) a high incidence of positive hepatitis B virus surface antigen (HBsAg) (young 71.4% versus old 20.1%); (2) relatively well-preserved hepatocellular function (indocyanine green test; young 10.7 +/- 8.8% versus old 20.6 +/- 10.8%); (3) low incidence of histologically verified concomitant cirrhosis (young 52.4% versus old 78.4%); and (4) a more advanced stage of the disease in TNM classification (Stage III; young 52.4% versus old 18.1%). With respect to survival rates achieved by surgery, there was no statistically significant difference between the two groups. Thus, hepatitis B virus may relate to the occurrence of HCC in the young patients. Despite the advanced stage in the young group, survival rate after surgery was comparable with that achieved in the old group. These observations mean that a close periodic surveillance of young adults with a positive HBsAg is required to detect HCC at an early stage. Treatment of patients with HBsAg using interferon or vidarabine and hepatitis B vaccine should be made to convert HBsAg to negative in these individuals. | 0 |
Demonstration of two distinct subsets of gastric varices. Observations during a seven-year study of endoscopic sclerotherapy. Over a seven-year period, assessment of gastric varices was made on 225 patients receiving endoscopic sclerotherapy for variceal hemorrhage. Of 170 patients with complete data, gastric varices were observed in 26 (15.3%). Importantly, two distinct subsets of gastric varices were identified: varices distal to the gastroesophageal junction without extension into the fundus, termed "junctional varices," occurred in 11.2%, and varices that were confined only to the fundus, termed "fundal varices," occurred less frequently in 4.1%. Although rebleeding was increased in both subsets of gastric varices, junctional varices were more amenable to sclerotherapy. Patients with fundal varices (N = 7) had a significantly higher rebleeding rate, increased complications with sclerotherapy, and significantly decreased survival (P less than 0.005) when compared to patients with esophageal varices alone (N = 87) who were followed for more than three months. Cumulative survival was not significantly different (P less than 0.08) in patients with junctional varices (N = 19) when compared with patients with esophageal varices alone. We conclude that not all patients with gastric varices have a poor result with sclerotherapy. Recognition of these subsets may improve treatment strategies in patients with gastric varices. | 1 |
An epitope on the transferrin receptor preferentially exposed during tumor progression in human lymphoma is close to the ligand binding site. We have previously reported an anti-transferrin receptor antibody, Trump, which was originally selected for its ability to discriminate low- and high-grade lymphomas. This feature was distinct from the other anti-transferrin receptor antibodies such as OKT9. In the present study, further immunochemical analysis was performed to define the nature of the antigenic site recognized by the Trump antibody. Trump was found to block the binding of transferrin both to solubilized and to surface transferrin receptors; conversely, transferrin could block the binding of Trump only to surface transferrin receptors. Therefore, the epitope recognized by Trump is near but not identical to the transferrin binding site. Stimulation of peripheral blood lymphocytes with phytohemagglutinin induced both the OKT9 epitope and the Trump epitope, but 12-phorbol 13 myristate acetate induced only the OKT9 epitope. Growth of some cell lines was inhibited by Trump but not by OKT9. No structural difference was found between transferrin receptor molecules reactive with Trump and those reactive with OKT9. In support of these results, Trump was able to immunoprecipitate transferrin receptor molecules solubilized from low-grade follicular lymphoma cells even though it did not bind to the receptors exposed on the surface of these cells. These findings imply that low-grade lymphoma cells differ from high-grade lymphoma cells not in the structures of their transferrin receptors but in their exposure of the molecule on the cell surface. | 0 |
Endoscopic retrograde brush cytology. A new technique. Endoscopic retrograde cholangiopancreatography has been shown to be a very valuable adjunct in the diagnosis of malignancy involving the biliary and/or pancreatic ductal system. However, characteristic endoscopic retrograde cholangiopancreatography radiographic findings associated with malignant strictures are frequently not specific and cytological confirmation becomes essential for the diagnosis. Unfortunately, the current overall diagnostic yield of positive cytology in such circumstances ranges from 18%-56% depending on the technique. A new brush device has been designed which is uniquely adapted to pancreaticobiliary strictures of varying anatomical configurations. This study shows results using this new cytology brush in a series of 53 patients with pancreaticobiliary malignancy. A significant improvement in the cytological yield of tumor confirmation was obtained with a diagnostic sensitivity of 70% and specificity of 100% using the new brush technique. | 1 |
An in vitro evaluation of an artificial heart. Interactions between human blood and the Penn State Artificial Heart were examined in vitro to study the effects of various operating conditions on the hematologic response. A dual-loop recirculating flow system that accommodated human blood was developed and blood was subjected for 3 hr to various operating conditions known to alter fluid mechanics in the artificial ventricle. The operating conditions investigated were: 60 beats/min at 50% systolic duration, 60 beats/min at 30% systolic duration, and 90 beats/min at 50% systolic duration. Quantification of plasma free hemoglobin provided a direct indicator of hemolysis in the flow system. Platelet number and beta-thromboglobulin levels were monitored to investigate thrombotic activity, and levels of complement 3a were measured to examine complement system activation. The system was effective in demonstrating the relative hemolytic properties of the operating conditions. Ninety beats/min induced 37% more hemolysis than 60 beats/min at 50% systolic duration, and 50% systolic duration induced 32% more hemolysis than 30% systolic duration at 60 beats/min. There were no statistically significant changes in either platelet number or beta-thromboglobulin levels during the 3 hr recirculation period. Increases were seen in complement 3a levels, but these appeared to be surface-induced and not sensitive to the different operating conditions. These studies demonstrate the usefulness of the flow system in examining the relative hemolytic properties of the artificial ventricle, and suggest that bulk turbulent stresses may play a more important role than laminar wall shear stresses in mediating blood damage in this artificial ventricle. | 4 |
Methodology of mental stress testing in cardiovascular research. Many issues related to the selection, reliability, and validity of mental stress testing in cardiovascular research are discussed. Five categories of mental stress testing are distinguished: problem-solving tasks, information-processing tasks, psychomotor tasks, affective conditions, and aversive or painful conditions. A series of practical and theoretical criteria are outlined for the selection of appropriate tests, and the measurement of a range of dependent variables is emphasized. The temporal stability of cardiovascular responses to mental stress tests is examined through an analysis of test-retest correlations (weighted for sample size) in 28 comparisons with intervals between sessions varying from 1 day to more than 1 year. Heart rate reactions to tasks show an average-weighted Z of 0.732 +/- 0.031 (r = 0.62), with Z = 0.575 +/- 0.034 (r = 0.52) for systolic blood pressure and Z = 0.313 +/- 0.035 (r = 0.30) for diastolic blood pressure. It is argued that the validity of mental stress tests can be judged in relation to several different aspects, specifically, methodological, ecological, diagnostic, prognostic, and therapeutic validities. The nature of these standards is described, and pertinent literature is presented. | 3 |
An operative complication in a patient with a true posterior communicating artery aneurysm: case report and review of the literature. Intraoperative oculomotor nerve injury in a patient with a true posterior communicating artery aneurysm is reported in detail. A comparison of internal carotid artery aneurysms at the posterior communicating artery junction with true posterior communicating artery aneurysms deserves special attention, because the vascular relationships of the aneurysm are more complex. A clip along the internal carotid artery does not occlude blood flow to the aneurysm, and the aneurysmal neck and the distal posterior communicating artery are closer to the oculomotor nerve. This is the 27th reported case of a true posterior communicating artery aneurysm. The incidence of true posterior communicating artery aneurysms ranges from 0.1 to 2.8% of all aneurysm patients. Such aneurysms constitute 4.6 and 11% of so-called posterior communicating aneurysms in two series. Difficulty associated with a preoperative diagnosis has been documented in at least 4 cases. An awareness of this rare aneurysm is stressed in order to avoid operative complications. | 4 |
Surgical experience with cerebral amyloid angiopathy. Cerebral amyloid angiopathy can present as lobar intracerebral hemorrhage in an elderly person, presumably due to increased fragility of the vessels affected by amyloid deposition. For this reason, patients presenting with intracerebral hemorrhage and suspected of having cerebral amyloid angiopathy have often been treated nonsurgically. Since 1983 we have evaluated 11 patients with cerebral amyloid angiopathy (nine women and two men, mean age 73 years) who have undergone either intracerebral hematoma evacuation or brain biopsy. Nine of the 11 patients presented with intracerebral hemorrhage, which was unilobar in three patients and multilobar in six and involved the parietal lobes seven times, the frontal lobes four times, the temporal lobes four times, and the occipital lobes twice. These nine patients underwent hematoma removal, with no cases of abnormal intraoperative bleeding or recurrent hemorrhage. Six patients improved neurologically, and two were unchanged after hematoma evacuation; the remaining patient had a fatal cardiopulmonary arrest during the immediate postoperative period. During follow-up in seven patients (median 11 months, range 1 week to 74 months) none experienced a recurrent intracerebral hemorrhage and four continued to improve. Two of the 11 patients had cerebral amyloid angiopathy diagnosed by brain biopsy as part of an evaluation for dementia, also without surgical complications. This series suggests that patients with cerebral amyloid angiopathy may safely undergo operative procedures, and patients presenting with intracerebral hemorrhage may show neurologic improvement following evacuation of the hematoma. | 4 |
Transcranial Doppler ultrasonography: clinical applications in cerebrovascular disease. Transcranial Doppler ultrasonography was introduced in 1982 as a noninvasive procedure for assessment of the intracranial cerebral circulation. The lightweight and portable equipment used for transcranial Doppler examination facilitates its use in the bedside assessment of critically ill hospitalized patients and outpatients. Clinical applications include the diagnosis of vasospasm in patients with subarachnoid hemorrhage, assessment of intracranial collateral flow in patients with extracranial arterial occlusive disease, detection of intracranial arterial stenosis, identification of the feeding arteries of arteriovenous malformations and monitoring the hemodynamic effects of their treatment, confirmation of the clinical diagnosis of brain death, intensive-care unit monitoring of brain-injured patients, and intraoperative and postoperative monitoring of neurosurgical patients. Transcranial Doppler technology is also providing new insights into the pathophysiologic mechanisms of a variety of cerebrovascular conditions. Clinicians will find transcranial Doppler technology most helpful if they have a specific question about the status of the intracranial circulation. Further investigations may expand the clinical and research utility of this technology. | 2 |
Testicular relapse in children with acute nonlymphoblastic leukemia. The clinical course and other distinctive features of five children who developed a testicular relapse 4 months to 25 months after the diagnosis of acute nonlymphoblastic leukemia (ANLL) are described. The chief presenting feature at relapse was painless testicular enlargement, as is also seen in children with acute lymphoblastic leukemia who relapse in the testes. By French-American-British convention, the malignant cells were classified as M4 (myelomonoblastic) in four cases and M2 (myeloblastic) in one. All children received a course of multiagent reinduction chemotherapy and all but one received local irradiation to the testes. Only one of these children, whose relapse was a late event after elective cessation of therapy, is a long-term survivor. A comparison with six previously published cases shows similar clinical characteristics and outcome. Given the poor responses of such patients to conventional treatment, it seems worthwhile to consider the use of intensive reinduction chemotherapy with concomitant bilateral testicular irradiation followed by remission intensification and an autologous or allogenic marrow transplant. | 0 |
Complications of nasotracheal intubation in neonates, infants and children: a review of 4 years' experience in a children's hospital. A computerized database was set up to study the incidence and outcome of complications of nasotracheal intubation in a paediatric hospital. We studied 2953 intensive care admissions over a 4-yr period. The overall complication rate was 8%. Accidental extubation and tube blockage were the most frequent events, accounting for a mean of 3.5% and 2.6% of the complications per year, respectively. Complications were more common in smaller children and there were differences between fields of intensive care. None of the complications was fatal or resulted in serious sequelae. None of the children in the study showed clinical symptoms of acquired subglottic stenosis before discharge from hospital, and none has been readmitted for this condition subsequently. | 4 |
The site of recurrent duodenal ulcer. The aim of this retrospective study was to determine the site of recurrent duodenal ulcer in relation to the site of the index ulcer. One hundred and thirty-five patients who had recurrent duodenal ulcer after documented healing of an index ulcer were studied. The recurrent ulcer was more likely to occur in the anterior bulb if the index ulcer was anterior (35 of 58 = 60%) than if the index ulcer was not anterior (29 of 77 = 38%, p less than 0.01). However, the likelihood of a recurrent ulcer on the posterior wall of the bulb was not significantly different whether the index ulcer was posterior (11 of 36 = 31%) or not (22 of 99 = 22%, p less than 0.24). Three of 20 patients (15%) who initially presented with bleeding bled again with their recurrent ulcers, compared with eight of 115 patients (7%) who first presented with dyspepsia only (p = 0.39). Thirteen patients were assessed independently by two endoscopists to determine ulcer site. Their assessments concurred for 12 (92%). | 4 |
Pulse oximetry: a new non-invasive assessment of peripheral arterial occlusive disease. Peripheral skin perfusion reflects the level of vascularity and viability of a limb and may help in planning the site of amputation or bypass surgery in patients with vascular disease. This study used peripheral pulse oximetry in 20 healthy volunteers and in 20 patients with limb ischaemia. Pulse oximetry saturation levels (Psa,O2) were compared with ankle artery Doppler pressures and transcutaneous oxygen measurements (Ptc,O2). Recordings were taken at two standard sites distally and referenced to finger and forearm to calculate an index. A significant correlation was found between Ptc,O2 and Psa,O2 in patients with ischaemia (r = 0.68, P less than 0.01). A further group of 12 patients with acute limb ischaemia was similarly assessed before and after revascularization. After revascularization mean(s.d.) Ptc,O2 increased from 38(13) to 44(1) mmHg (P greater than 0.05) and mean(s.d.) Psa,O2 increased from 86(3) to 90(4) per cent (P less than 0.01). These data suggest that pulse oximetry is a more sensitive index of peripheral perfusion than Ptc,O2 or ankle artery Doppler pressure and that, because of its accuracy and simplicity, it merits further use. | 3 |
Left atrial bacterial mural endocarditis. An unusual case of Staphylococcus aureus endocarditis confined to the mural left atrium is presented. Echocardiographic studies revealed a 1.5 x 2.0-cm vegetation mimicking a myxoma situated in the path of a mitral regurgitant jet on a color Doppler test. Emboli to upper and lower extremities and brain complicated the patient's preoperative course. Surgical excision and pathologic examination confirmed this rare occurrence. | 0 |
Respiratory muscle strength in congestive heart failure. In experimental animals, conditions which drastically decrease cardiac output may reduce the strength and endurance of respiratory muscles leading to hypercapnic respiratory failure. Because patients with chronic CHF have reduced cardiac output and vital capacity (FVC), we measured PImax and PEmax and maximal handgrip force in 16 patients with CHF and 18 AMNs. The patients with CHF had a mean left ventricular ejection fraction of 26 +/- 7 percent. Maximal respiratory pressures were significantly reduced; group mean values (+/- SD) for PImax at FRC were 41.4 +/- 5.6 cm H2O (CHF) and 102.1 +/- 27.4 cm H2O (AMN) (p less than 0.001), with PImax values in five patients with CHF as low as 20 to 30 cm H2O. In most patients, PEmax was comparably reduced. Handgrip force was less dramatically reduced, suggesting selective respiratory muscle weakness. Possible explanations include reduction in respiratory muscle blood flow or generalized muscular atrophy and weakness related to cardiac cachexia. | 3 |
Effects of a multidisciplinary management program on neurologically impaired patients with dysphagia. Dysphagia is a major problem in patients with neurologic disorders. Aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates. Assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively. This prospective study was conducted to determine if a dysphagia program would improve patients' caloric intake and body weight, decrease the instances of aspiration pneumonia, or improve patients' feeding ability. Patients were referred from a 26 bed neurology/neurosurgery unit. A time series design was utilized. The control group consisted of 15 patients (mean age = 46.1 years), managed according to the existing ward routine. Subsequently, nursing staff attended a dysphagia training program. Following this, the treated group of 16 patients, (mean age = 49.3 years) was assessed by the dysphagia team, using bedside and videofluoroscopic examinations to determine the specific swallowing disorder. An individualized treatment program was designed for each patient. The groups were compared on the basis of deviation from their baseline weight, deviation from ideal energy intake, and the incidence of aspiration pneumonia. Statistical analysis revealed that the groups were comparable in age, number of days on the study, and Glasgow Coma Scale score; and that a significant weight gain and increase in caloric intake occurred in the treated group. No incidence of aspiration pneumonia was reported in either group. We speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups. | 2 |
Pharmacokinetics of famotidine after intravenous administration in liver disease. The pharmacokinetics of famotidine were studied after the administration of a single intravenous dose of 20-mg to seven normal volunteers, six patients with chronic hepatitis, 14 patients with compensated cirrhosis, and seven patients with decompensated cirrhosis. The plasma terminal elimination half-life of famotidine was significantly prolonged and famotidine total body clearance was significantly reduced in patients with decompensated cirrhosis, whose creatinine clearance was 57.2 +/- 6.7 ml/min/1.48 m2, but these changes were not significant in patients with chronic hepatitis (creatinine clearance: 109.2 +/- 10.5 ml/min/1.48 m2) or in patients with compensated cirrhosis (creatinine clearance: 72.2 +/- 26.5 ml/min/1.48 m2 in comparison with normal volunteers. The total volume of distribution at steady state was not significantly different between the normal volunteers and the three groups of patients. Famotidine total body clearance showed a weak but significant correlation with the creatinine clearance (r = 0.66, p less than 0.001), serum albumin level (r = 0.51, p less than 0.01), and serum total bilirubin level (r = 0.36, p less than 0.05), which suggested that the reduction in clearance was due in part to the concomitant renal impairment, as well as hepatic dysfunction in these patients. In conclusion, famotidine total body clearance was reduced in decompensated cirrhosis, indicating that the dose schedule requires modification in patients with this condition. | 1 |
Fluorescein angiography in ciliary body melanomas. We retrospectively studied the value of iris fluorescein angiography in predicitng benignity or malignancy in 10 cases of ciliary body melanoma with iris extension. No correlation between fluorescein-angiographic appearance and histopathologic features was observed. Fluorescein angiography adds little to the management of ciliary body melanomas with iris extension. | 0 |
Mastectomy following preoperative chemotherapy. Strict operative criteria control operative morbidity. The surgical morbidity associated with aggressive preoperative chemotherapy in 106 patients with advanced primary breast cancer who had chemotherapy followed by mastectomy was examined. These patients were compared with a group of 91 consecutive patients who had mastectomy without preoperative chemotherapy. Strict operative criteria were used to determine the timing of mastectomy following chemotherapy. Wound infection rates were no different in the preoperative chemotherapy group compared to the mastectomy-alone groups (7% versus 4%; p = 0.62). The incidence of wound necrosis was similar (11% versus 6%; p = 0.29). Seroma formation was decreased significantly in the preoperative chemotherapy group compared to the mastectomy-alone group (15% versus 28%; p = 0.04). Intensive preoperative chemotherapy did not delay the reinstitution of postoperative treatment (30% versus 20%; p = 0.27). However, when delay in instituting postoperative chemotherapy was more than 30 days, there was a significant decrease in overall survival rate (p = 0.04). This study provides evidence that intensive preoperative chemotherapy and mastectomy can be performed without increased morbidity. Furthermore it is important to institute systemic chemotherapy within 30 days of mastectomy to achieve maximum survival. | 4 |
Improved biocompatibility by postfixation treatment of aldehyde fixed bovine pericardium. Long-standing release of locally cytotoxic aldehyde concentrations is responsible for lack of spontaneous endothelialization and increased calcification of glutaraldehyde fixed bovine pericardium. Postfixation treatment with amino acids made in vitro endothelialization of bioprosthetic heart valves possible. Such treated pericardium calcified significantly less (13 +/- 4 micrograms/mg dry weight) than did conventionally processed pericardium (114 +/- 25 micrograms/mg) after 63 days of subcutaneous implantation in rats. To test the ability for spontaneous in vivo endothelialization, 5 sheep had 6 mm grafts made from postfixation treated pericardium (PTP) implanted into the carotid artery, compared to PTFE grafts on the contralateral side, which spontaneously endothelialize in animal models. In a pregnant animal, both grafts occluded. All remaining pericardial grafts remained patent, but one additional PTFE graft occluded and another one was stenosed. The area covered with red thrombus was significantly smaller in the PTP grafts (3.05 +/- 3.9%) than in the PTFE grafts 42 +/- 14% (p = 0.0036); TEM and SEM showed endothelial cells growing directly on the PTP, but only on myofibroblasts in PTFE grafts. Postfixation treatment of glutaraldehyde fixed pericardium aids spontaneous endothelialization and decreases tissue calcification. | 4 |
Insulin-like growth factor-I receptors in nonfunctioning thyroid nodules. We have recently demonstrated the production of insulin-like growth factor-I (IGF-I) as well as the presence of type I IGF receptors in human thyroid cells in primary culture. The role of IGF-I in the control of thyroid cell growth has been well established. In order to investigate the involvement of IGF-I in abnormal thyroid growth, the density of IGF-I receptors in solitary, cold, micro- and macro-follicular thyroid adenomas, and in extranodular histological normal tissue was studied. Forty-three euthyroid patients with isolated cold nodules were selected for the study. In 30 patients the presence of IGF-I receptors was evaluated by using quantitative immunohistochemistry; in 10 patients by using radioligand binding studies, and in 3 patients by using affinity labeling. Cross-linking and binding studies clearly demonstrated the presence of a homogeneous class of binding sites for type I IGF receptors. Furthermore, radioligand studies did not show any significant differences in receptor density between the 2 types of thyroidal tissues. Conversely, the computerized analysis of 900 fields of nodular and normal thyroid tissues immunostained with the monoclonal antibody alpha-IR3, strongly indicated that higher concentrations of IGF-I receptors were present in the epithelial cells of non-functioning thyroid nodules than in the adjacent extranodular thyroid tissues. These studies strongly suggest that the same type I IGF receptor is present in thyroid follicular adenomas as in histological normal thyroid tissue removed from the same patient. The higher concentration of IGF-I receptors as documented by immunostaining in the adenomas suggests that IGF-I may contribute to the abnormal growth of the neoplasms. | 0 |
Nonpropulsive esophageal contractions and gastroesophageal reflux. Nonpropulsive esophageal contractions radiologically described as tertiary contractions or "corkscrew" esophagus suggest the presence of an underlying motility disorder and may lead to impaired acid clearance. The goals of this study were to determine the prevalence and role of gastroesophageal reflux (GER) in patients with tertiary contractions. Thirty-five consecutive patients with spontaneous, repetitive, nonpropulsive esophageal contractions noted on esophagography were studied with endoscopy, infusion esophageal manometry, and 24-h ambulatory pH monitoring. All patients had esophageal symptoms, mainly dysphagia, heartburn, and chest pain, but only three were found to have esophagitis by endoscopy and biopsy. Nineteen patients had repetitive, nonlumen-obliterating, nonperistaltic (tertiary) contractions, six had corkscrew esophagus, and 10 had forceful, lumen-obliterating simultaneous contractions (rosary bead esophagus). Twenty patients (58%) had GER by pH criteria with mean values: % time pH less than 4, 40.9; %upright pH less than 4, 41; %supine pH less than 4, 44.3%; number of episodes with greater than 5 min of pH less than 4, 12. Esophageal motility revealed "nutcracker" esophagus in eight, low LESP in two, and nonspecific esophageal motility disorder in 10. Symptoms or severity of nonperistaltic contractions did not correlate with GER. Radiologically demonstrable free reflux or the presence of heartburn did not predict GER. We conclude that 1) GER occurs in up to 58% of patients with nonpropulsive (tertiary) esophageal contractions on esophagography, and may play a role in the induction of abnormal peristaltic activity of the esophageal body; 2) GER is usually not associated with endoscopic evidence of esophagitis or characteristic symptoms, and is recognized by 24-h pH monitoring. We speculate that detection and treatment of GER may improve the symptomatic management of patients with nonpropulsive esophageal contractions. | 1 |
Vagal schwannoma. A patient with a benign encapsulated intrathoracic vagal schwannoma is presented and the literature is reviewed. The right paratracheal tumor was identified incidentally on a chest film and excised using a right thoracotomy. Although rare, vagal schwannomas should be considered for any mediastinal mass along the vagus nerves especially when the paratracheal tumor produces minimal or no respiratory symptoms suggesting a slow-growing, encapsulated process. | 0 |
Intraoperative ultrasonography: an important surgical adjunct for intramedullary tumors. The echographic characteristics of 186 suspected intramedullary spinal cord tumors were reviewed. Ultrasonography was found to be specific in distinguishing the tumor type, the extent of the lesion, and the presence and type of associated cysts. Ultrasonography greatly facilitates the selection of respective sites for the placement of a myelotomy, and for initiation of the resection. Additionally, this indispensable adjunct provides ongoing images that allow the preoperative plan to be precisely followed in a surgical field where anatomical landmarks are limited and the margin for error is minimal. | 2 |
Effects of inflammation and copper intake on rat liver and erythrocyte Cu-Zn superoxide dismutase activity levels. Stress such as inflammation produces an acute phase response that includes elevated levels of ceruloplasmin, the main copper component of plasma. Inflammatory effects on cellular copper enzyme activity levels are largely unknown. Cu-Zn superoxide dismutase (SOD) activities in liver, the main site of ceruloplasmin secretion, decreased with turpentine-induced inflammation (0.1 mL, intramuscular, leg) in rats fed any of three copper levels (adequate = 6 mg/kg, marginal = 2.5 mg/kg and deficient less than 0.5 mg/kg). Ceruloplasmin activities rose significantly with inflammation in the adequate and marginal groups but not in the deficient animals. Hepatic Cu-Zn SOD immunoreactive protein levels were unaffected by copper status or inflammatory state. Erythrocyte Cu-Zn SOD activities were influenced by dietary copper but not inflammation. An additional group of rats fed 15 mg copper/kg did not show a turpentine-induced decrease in liver Cu-Zn activity levels. Inflammatory effects on other copper enzyme activities did occur as evidenced by increases in ceruloplasmin and decreases in serum extracellular SOD. In conclusion, an acute phase response in rats increased the amount of dietary copper required to maintain hepatic Cu-Zn SOD activity at levels equal to those of nonstressed, copper-adequate rats. Rat erythrocyte Cu-Zn SOD activities provided a blood measurement reflective of copper intake with or without stress, but these values did not reflect decreases in liver Cu-Zn SOD activities after 3 d of inflammation. | 4 |
Functional chiral asymmetry in descending thoracic aorta To determine whether rotational blood flow or chiral asymmetry exists in the human descending thoracic aorta, we established the ability of color Doppler ultrasound to detect rotational flow in a tornado tube model of a vortex descending fluid column. In a model of the human aortic arch with a pulse duplicator, color Doppler was then used to demonstrate that rotational flow occurs first in the transverse arch and then in the proximal descending thoracic aorta. With the use of color Doppler esophageal echocardiography, 53 patients (age range, 25-78 years; mean age, 56.4 years) were prospectively examined for rotational flow in the descending thoracic aorta. At 10 cm superior to retro-left ventricular position, 22 of 38 patients (58%) revealed rotational flow with obvious diastolic counterclockwise rotation but less obvious systolic clockwise rotation. At 5 cm superior to retro-left ventricular position, 29 of 46 patients (63%) revealed rotational flow with a tendency toward systolic clockwise and diastolic counterclockwise rotation. At the retro-left ventricular position, 47 of 53 patients (89%) revealed rotational flow, usually of a clockwise direction, occurring in systole. Our data suggest that aortic flow is not purely pulsatile and axial but has a rotational component. Rotational flow begins in the aortic arch and is carried through to the descending thoracic aorta, where flow is chirally asymmetric with systolic clockwise and diastolic counterclockwise components. These data demonstrate an aortic rotational flow component that may have physiological implications for organ perfusion. | 3 |
Optimizing the exercise test for pharmacological investigations Exercise trials in cardiology are often hindered by inconsistent approaches to exercise testing. These inconsistencies include the choice of exercise protocol, exercise end points, points of analysis, and absence or misuse of gas exchange data. Gas exchange techniques greatly enhance the accuracy with which cardiopulmonary function is assessed by exercise. Commonly used protocols are not always appropriate for all patients or all studies. Both cardiovascular disease and the exercise protocol can have an important impact on the relation between changes in work rate and oxygen uptake. Ramp protocols appear to offer the greatest promise for assessing cardiopulmonary function. Analyzing hemodynamic and gas exchange responses at several points submaximally, in addition to those at peak exercise, can add important information concerning the efficacy of a drug. A great deal of confusion continues to hinder the application of the gas exchange anaerobic threshold, and many of the commonly used testing end points are not reliable. | 3 |
Neodymium: YAG laser hysteroscopy in large submucous fibroids. The preoperative use of a potent, subcutaneously injected gonadotropin-releasing hormone agonist (GnRH-a) was evaluated in a series of 60 women with large submucosal fibroids. Myomectomy by hysteroscopy and Nd:YAG laser was easily performed. In 12 cases, the largest portion of the myoma was not inside the uterine cavity and myomectomy was carried by a two-step hysteroscopy. In women who wished to become pregnant, a pregnancy rate of 66% was achieved. Advantages of preoperative use of a GnRH-a are (1) the significant decrease of the fibroid size, (2) a lower fluid absorption, and (3) the restoration of a normal hemoglobin concentration. | 0 |
Reducing unnecessary coronary care unit admissions: a comparison of three decision aids OBJECTIVE: To determine whether published decision rules for ischemic heart disease have practical value in reducing unnecessary admissions to coronary care units. DESIGN: Prospective cohort study. SETTING: A community hospital emergency room. PATIENTS: 235 consecutive patients presenting to an emergency room with a chief complaint of chest pain. MEASUREMENTS: Clinical information, including observations needed to use previously published decision aids, was collected on special forms at the time of the emergency room visit. Follow-up information was obtained from the medical records of patients who were admitted and by telephone interviews with patients who were discharged. The authors compared the residents' actual decisions with the predictions of the decision aids regarding their ability to predict complications (that is, to identify patients who needed admission or intensive care). MAIN RESULTS AND CONCLUSIONS: None of the decision aids could reduce unnecessary admissions without seriously increasing the rate of inappropriate discharges. However, within the clinically relevant subgroup of patients for whom the decision to admit or discharge was not obvious on clinical grounds (those without complications on presentation whom the residents chose not to discharge), the decision aids examined, used in combination to verify the need for admission, might have safely averted some unnecessary admissions. | 3 |
Efficacy of percutaneous mitral balloon valvuloplasty with the inoue balloon. Percutaneous mitral balloon valvuloplasty has become an accepted technique for use in selected patients with severe, symptomatic mitral stenosis. Recently, a new balloon catheter with an "hourglass" shape and specially designed guidewires and dilators has become available (Inoue balloon). The design of this balloon provides ease of manipulation and self-stabilization across the mitral valve during inflation. These features should decrease the incidence of complications associated with the procedure. Preliminary results in 12 consecutive patients who underwent percutaneous mitral balloon valvuloplasty with the Inoue balloon are presented. The mitral valve area increased from 0.92 +/- 0.21 cm2 before the procedure to 1.75 +/- 0.40 cm2 after the procedure. No complications occurred from the procedure, including no increase in severity of mitral regurgitation or creation of an atrial septal defect. Further follow-up is necessary to determine the long-term efficacy with this new balloon. Nonetheless, the preliminary results are encouraging. | 3 |
Lung cancer histology in Jews and Arabs in Israel, 1962-1982. Lung cancer rates in Israel are lower than in Western countries, not explainable by smoking habits. Because of the different relations of squamous cell carcinoma and adenocarcinoma to smoking it was of interest to study the histologic distribution in Israel. A total of 7,871 histologically confirmed lung cancer cases were studied in the period 1962-1982. Squamous cell carcinoma was the leading tumor type in Jewish men and adenocarcinoma in Jewish women. Rates of both adenocarcinoma and squamous cell carcinoma increased throughout the period in both Jewish men and women, but the increase in adenocarcinoma was more pronounced in the last study period than that in squamous cell carcinoma. In 1977-1982 the rate ratio of squamous cell carcinoma to adenocarcinoma among Jewish men was 1.7. In Arab men it was 2.9, and in Jewish women 0.57. The Kreyberg I/II ratio among Jewish men was about 2.7 with no clear trend throughout the study period, and among Arab men this gradually decreased from 8.1 to 3.5. Jewish women had a constant Kreyberg I/II ratio of about 1 through the whole study period, but the ratio in Arab women was significantly higher than 1, with a mean overall ratio of 3.2. Jews and Arabs in Israel are different from each other in their patterns of lung cancer histology and are different to some extent from other populations in the Western world. | 0 |
Epidermoid cysts of the brain stem. Report of three cases. The authors report the cases of three patients with epidermoid cysts which insinuated themselves into the brain stem. In all three patients, the tumor occupied the pons, although in one it was predominantly located in the medulla. The cyst contents and nonadherent tumor capsule were removed in all three patients, but no attempt was made to remove tumor densely adherent to the brain stem. One patient's cyst was removed in one operation, but maximal resection in the other two required two operations. After surgery, sixth nerve function completely returned in one patient; another patient had a stable pontine gaze palsy but developed new facial weakness; and the third patient had stable cranial nerve deficits with a diminished hemiparesis. The last patient developed a pseudomeningocele and communicating hydrocephalus, and required a lumboperitoneal shunt. In all three patients, computerized tomography scans demonstrated hypodense tumors not enhanced by contrast material. Magnetic resonance imaging was performed on two patients; in both, the tumors showed increased signal intensity relative to brain on T1-weighted images and decreased signal intensity relative to brain on T2-weighted studies. Magnetic resonance imaging, the most accurate modality for localizing these lesions and determining their extent, was also invaluable for postoperative monitoring and follow-up evaluation. Safe and adequate resection includes decompression of cyst contents and removal of nonadherent portions of the cyst capsule. Cyst wall adherent to the brain stem, however, should not be removed. | 0 |
Hemangioma of the temporalis muscle. A rare case of an intramuscular hemangioma of the temporalis muscle is reported. The clinical examination, carotid arteriogram, computed tomographic scan, and aspiration cytology suggested the vascular nature of the tumor, but an exact diagnosis could only be made after histopathologic examination. Temporary occlusion of the ipsilateral external carotid artery and subperiosteal dissection permitted complete, wide excision without much bleeding. | 0 |
An evaluation of the Level 1 blood warmer series The Level 1 blood warmer series comprises three infusion sets and two blood warmers of different power outputs. All systems were found to be extremely efficient, with the larger 500 series capable of warming the equivalent of 80 units of blood an hour almost to body temperature. | 4 |
Atrioventricular plane displacement in severe congestive heart failure following dilated cardiomyopathy or myocardial infarction. Echocardiographic recording of the atrioventricular (AV) plane displacement during the cardiac cycle was used to assess left ventricular (LV) global function in patients with congestive heart failure (CHF). The study population consisted of 70 patients with chronic CHF (NYHA functional groups III and IV) following dilated cardiomyopathy (DCM) or myocardial infarction (MI), and 35 age-matched healthy subjects. The AV plane displacement was recorded from the apical 4- and 2-chamber views at four LV sites located about 90 degrees apart and representing the septal, anterior, lateral and posterior parts of the LV wall. A mean value was calculated from the above sites (AV-mean). Patients with CHF showed a significant generalized reduction of AV plane displacement compared to healthy subjects (5.6 mm vs. 14.5 mm, P less than 0.001). Thirty CHF patients also underwent radionuclide angiography in order to determine the ejection fraction (EF). The correlation between AV-mean and EF was good (r = 0.82, P less than 0.001). The selection of an AV-mean of less than 7 mm to define a severely depressed LV function (EF less than 30%) gave a sensitivity of 92% and a specificity of 67%. It is concluded that the AV plane displacement can be used to estimate LV systolic function in patients with CHF. | 3 |
The beta-type transforming growth factor. Mediators of cell regulation in the lung. An increased interest in the role of growth factors in the regulation of processes concerning normal and pathologic lung physiology has spurred a flurry of research in this area. Peptide growth factors are known to control not only cell proliferation but other events such as differentiation, chemotaxis, and matrix deposition as well. The transforming growth factor beta (TGF beta) family of regulatory peptides serves as a prime example to illustrate the multiplicity of effects elicited by peptide growth factors in various lung-derived cell types. At present, the TGF beta family consists of at least 17 proteins and, based on sequence analysis, they can be divided into two groups: a cluster that shows very high sequence similarity to TGF beta 1, the closely related group, and a cluster that shows weaker sequence similarity to TGF beta 1, the distantly related group. The purpose of this brief review is to summarize the salient features of TGF beta structure and regulatory abilities of the closely related group. In addition, we will outline the evidence suggesting a role for TGF beta in normal lung development and physiology. Emphasis will be placed on studies with the closely related members TGF beta 1 and TGF beta 2 because, until recently, purified protein was available only for these two proteins. | 0 |
Meta-analysis of sulfasalazine in ankylosing spondylitis. At present there is no widely accepted therapy for ankylosing spondylitis (AS), a progressive debilitating disease. The effectiveness of sulfasalazine in AS still lacks strong evidence, as well, the magnitude of its benefit is unknown. A meta-analysis was carried out to assess the effectiveness of sulfasalazine in AS. A search of the literature was done using Medline, Index Medicus, the reference lists of articles located and contacting content experts to reveal unpublished studies. Five randomized controlled trials (RCT) comparing sulfasalazine to placebo were located and assessed methodologically. The methodologic quality of all 5 RCT was considered satisfactory and consequently these studies were included in the meta-analysis. The pooled estimate of clinical benefit (and its 95% confidence interval) favoring sulfasalazine, over and above that observed in the placebo group was as follows: Duration of morning stiffness -28.2% (-54.6 to -1.8%); severity of morning stiffness -30.6% (-52.5 to -8.7%); severity of pain -26.7% (-44.3 to -9.1%); general well being -7.1% (-24.3 to 10.0%); erythrocyte sedimentation rate -9.2% (-24.8 to 6.4%); and IgA -11.7% (-18.8 to -4.7%). Adverse effects, mostly mild, were more frequently observed in the sulfasalazine group (odds ratio [OR] = 1.5746, p = 0.1082). The occurrence of dropouts (OR = 1.1554, p = 0.6119) was similar in both groups. Sulfasalazine is a safe and effective drug in the short term treatment of AS. | 2 |
Role of the protease-antiprotease balance in peritoneal exudate during acute pancreatitis. The peritoneal exudate formed during experimental pancreatitis is toxic when administered intraperitoneally or intravenously to other animals. Overwhelming of the peritoneal antiprotease defences by proteolytic enzymes released from the pancreas may be a key factor responsible for this toxicity and is examined in the current study. Human pancreatitis exudates possessed tryptic amidase activity indicating trypsinogen activation. The trypsin inhibitory capacities of exudates were reduced indicating a degree of consumption of the peritoneal antiproteases. Of 21 exudates examined, three showed marked reduction of their trypsin inhibitory capacity indicating almost complete consumption of their antiproteases. All three patients were shocked at the time of sampling, two dying of fulminant pancreatitis within 24 h. Overwhelming of the peritoneal antiproteases was not confirmed, but may occur in a few instances where proteolytic enzyme release or zymogen activation continues. Intraperitoneal administration of exogenous antiproteases prolongs survival in rats with pancreatitis and has been suggested as a therapy in man. The current data suggests that few patients are likely to benefit from such an approach. | 4 |
Endothelialization of vascular prostheses by transplantation of venous tissue fragments. A method to accelerate the endothelialization of vascular prostheses by seeding venous tissue fragments was developed. A piece of peripheral vein was obtained, chopped into small fragments, and stirred into 20 ml of saline, making a tissue suspension. This suspension was sieved through the wall of a highly porous vascular prosthesis (water porosity: 3,600-4,000). The prostheses, (7 mm ID and 5.7 cm in length) seeded with tissue fragments, were implanted into the thoracic descending aortae of 20 dogs, and were removed from 1 to 371 days after implantation. Ten prostheses, preclotted with fresh blood, were used as controls. In the seeded grafts, an infinite number of endothelial cells migrated and proliferated from the fragments. These had produced numerous capillaries by 5 days after implantation that had reached and opened onto the luminal surface of the prosthesis. From these openings, numerous endothelial cells spread out and formed colonies. With the increase in the size of the colonies, the inner surface was completely endothelialized within 5 weeks. This quick neointimal formation by seeding venous tissue fragments might be applicable to several artificial organs. | 4 |
Pathophysiological insights into the cardiomyopathy of Chagas' disease. The evidence gained from both human and animal studies of chronic chagasic cardiomyopathy suggests that the disease occurs as a consequence of several discrete and progressive pathophysiological processes occurring after infection, the ultimate expression of which depends on a host of unidentified factors. Collectively, the infection-associated events compromise microvasculature function and result in hypoperfusion, with consequences indistinguishable from those observed in other, nonparasitological cardiomyopathic diseases secondary to hypoperfusion. Therefore, chronic chagasic cardiomyopathy may share similar pathophysiological abnormalities with other chronic congestive cardiomyopathic states. | 4 |
Oncogene amplification in breast cancer. To refine the analysis of gene amplification in breast cancer, the authors have developed sensitive methods that can be used to screen nucleic acid prepared from a variety of sources. In their analysis, Southern hybridization and DNA dot-blot analysis were used to screen 49 breast cancer DNAs for Myc, Neu, and Int-2 gene amplification. The analysis detected minimal one extra gene copy) as well as expanded (two or more extra gene copies) gene amplifications, and in addition, distinguished between gene amplification and aneuploidy as the cause of extra gene copies. These quantitative methods were adapted to patient specimens routinely available in the anatomic pathology laboratory, including fresh tumor tissue, tumor nuclei discarded during estrogen receptor analysis, and paraffin blocks. One minimal gene amplification was found in three cases of intraductal cancer. Of 25 cases of nonmetastatic invasive cancer, 28% had at least one extra Myc gene, whereas 24% had Neu, and 21% had Int-2 gene amplification. Of 21 cases of metastatic invasive cancer, 43% had Myc, 43% had Neu, and 40% had Int-2 gene amplification. Among the nonmetastatic cancers, 47% had one, 12% had two, and 4% had three amplified genes. Within the metastatic cancers, 48% had one, 28% had two, and 5% had three amplified genes. Our data suggest relationships between tumor progression and both incidence and size of Myc, Neu, and Int-2 gene amplification. | 0 |
The relation of pain to depression among institutionalized aged. Nursing home and congregate apartment residents (N = 598) were classified on the basis of a DSM-IIIR symptom checklist as suffering possible major, minor, or no depression; they also completed the Geriatric Depression Scale (GDS) and the Profile of Mood States (POMS). Possible major depressives reported more intense pain and a greater number of localized pain complaints than did minor depressives; nondepressed individuals reported the least intense pain and fewest localized complaints. The effect remained strong even when functional disability and health status were controlled statistically. Both pain intensity and number of localized complaints were correlated with GDS and POMS factor scores, but strength and direction of associations varied with level of depression. Item-by-item examination of localized complaints again indicated that more depressed individuals were more likely to report pain, particularly where physicians had identified a physical problem that might account for the pain. Results are compared with previous research on pain among younger individuals. Implications for treatment of depressed elderly are discussed. | 2 |
Digital cutaneous vascular responses to histamine and neuropeptides in Raynaud's phenomenon. The pathophysiology of Raynaud's phenomenon is not well defined, but active cutaneous microvascular vasoconstriction and emptying must occur to account for the pallor and are reasons for studying the microvasculature. It has been proposed that there may be a defect in a local histamine vasodilator mechanism. The role of the peptidergic nervous system in Raynaud's phenomenon has not been previously investigated. To study the histaminergic and peptidergic axes in Raynaud's phenomenon, we measured the cutaneous microvascular responses of patients with Raynaud's phenomenon to digital intradermal injections of saline, histamine, the histamine-releasing agent, compound 48/80, substance P, and calcitonin gene-related peptide. We compared these results with those obtained in normal subjects. Intradermal cutaneous microvascular blood flow responses were quantified by planimetry and laser Doppler flowmetry. The results show: a) that in primary Raynaud's phenomenon there is no evidence of local deficiency in histamine release or insensitivity to histamine in the cutaneous microvasculature; and b) that patients with Raynaud's phenomenon react normally to the neuropeptides calcitonin gene-related peptide and substance P, providing a rationale for treating Raynaud's phenomenon with vasoactive peptides. | 3 |
Adenocarcinoma of the colon and rectum in patients less than 40 years of age. From 1962 to 1988, 50 of 801 patients with adenocarcinoma of the colon and rectum treated at the National Naval Medical Center were less than 40 years old. Symptoms were present in 47 of the younger patients at presentation. The mean duration of time from the onset of symptoms to diagnosis in this group was 4.9 months. Risk factors for carcinoma of the colon and rectum were identified in 14 of 50 patients less than 40 years old. A significantly greater proportion of patients less than 40 years old had Stage C disease compared with the older group of patients (42 versus 22 per cent, p = 0.014). Stage B disease was more common in patients more than 40 years of age (44.8 versus 26.0 per cent, p = 0.014). The proportion of patients with Stages A and D disease was similar in both age groups. The cumulative survival rate in this group at five and ten years was 43 and 34 per cent, respectively. The five year survival rate in patients less than 40 years old with Stage B disease was 76 per cent and with Stage C disease, 37 per cent. All young patients with Stage D disease were dead at 28 months. Synchronous and metachronous carcinomas of the colon and rectum were uncommon in patients less than 40 years old. Patients less than 40 years of age with carcinoma of the colon and rectum are usually symptomatic and have advanced disease at the time of presentation. Survival time for these patients for each stage of disease is similar to the over-all population of patients with carcinoma of the colon and rectum. | 0 |
Magnetic resonance imaging contrast agents: theory and application to the central nervous system. The theoretical aspects of magnetic resonance (MR) imaging contrast agents are reviewed, and their current applications to the central nervous system (CNS) and their future applications are discussed. Profound differences exist between contrast agents used for MR imaging and computerized tomography (CT). In MR imaging, the contrast agents are not imaged directly but rather act on adjacent protons to shorten T1 and T2 relaxation times. This in turn results in signal intensity changes. The lanthanide metal, gadolinium, in the form of gadopentetate dimeglumine, has been found to be both safe and efficacious as the only currently approved contrast agent for MR imaging. Magnetic resonance imaging revolutionized the detection and treatment of disease affecting the brain and spine. Initially, it was thought that signal characteristics on MR imaging would allow differentiation of specific pathology. It was soon found that MR studies were able to detect more abnormalities but were less able to characterize them. The recent development of contrast agents for MR imaging has allowed this modality to surpass CT for the evaluation of most CNS lesions. At present, contrast-enhanced MR imaging is generally accepted as the study of choice for evaluating acoustic neurinomas, pituitary lesions, meningeal disease, primary and secondary brain tumors, active multiple sclerosis, intradural spinal neoplasms, intramedullary spinal disease, and postoperative states in both the spine and brain. Even when contrast-enhanced CT can detect the same abnormalities, evaluation of the lesions in multiple planes on MR imaging can sometimes yield invaluable information, especially prior to surgery. Future developments of contrast material for MR imaging include non-gadolinium compounds, intrathecal contrast media, cerebral blood flow and volume evaluation, and, possibly, antibody-labeled contrast agents. | 2 |
Orbital inflammatory disease associated with systemic lupus erythematosus. Orbital inflammatory disease in a patient with systemic lupus erythematosus is rare and presents a diagnostic dilemma as well as a therapeutic challenge. Ours appears to be the sixth such case reported in the literature. | 4 |
Effacement of glomerular foot processes in kwashiorkor. In a study of the pathogenesis of the oedema of kwashiorkor the ultrastructure of the kidneys from 6 children was examined shortly after they died from oedematous malnutrition. There was a generalised effacement of the glomerular epithelial cells onto the basement membrane. The filtration slits that remained were narrowed. The picture was similar to that seen in minimal-change nephrotic syndrome--but none of the children had albuminuria. The degree of effacement was statistically related to treatment with gentamicin. The findings suggest that there is a defect in the anionic charge of the glomerular basement membrane in oedematous malnutrition, that the membrane charge is more easily neutralised by cations such as gentamicin, and that, because proteinuria is not a feature of oedematous malnutrition, the proteinuria in other conditions associated with glomerular epithelial cell effacement (eg, minimal-change nephrotic syndrome) is due to something more complex than simple loss of charge. | 4 |
Effect of indecainide in patients with left ventricular dysfunction. Indecainide, a new antiarrhythmic agent classified as type Ic was evaluated in 11 patients with heart disease who had greater than or equal to 30 ventricular premature complexes/hour, moderate-to-marked left ventricular dysfunction, and mean ejection fraction 34% +/- 8%. Patients received indecainide, 50 mg by mouth, every 6 hours and the dose was increased until greater than or equal to 80% suppression was noted, adverse effects occurred, or a maximum dose of 100 mg indecainide was given every 6 hours. Ventricular premature complexes were suppressed greater than or equal to 80% in nine patients (p less than 0.05) and ventricular tachycardia episodes were completely suppressed in five of eight patients. The effective or maximal mean daily indecainide dose was 191 +/- 32 mg; half of the responders achieved achieved efficacy at serum drug concentration greater than or equal to 600 ng/ml. Serum drug concentration was directly related to gender (r = 0.78, p less than 0.04) and inversely related to creatinine clearance (r = 0.74, p less than 0.05) and ejection fraction (r = 0.71, p less than 0.02). Indecainide prolonged mean PR and QRS intervals (p less than 0.05) but not QT or QTc. There was a linear relation between percent change in PR (r = 0.80, p less than 0.001) and QRS (r = 0.66, p less than 0.001) intervals and serum drug concentration. After starting or increasing the dose, careful observation of patients with decreased renal function or reduced ejection fraction should be exercised because they attain higher drug concentration than normal subjects. | 4 |
Carcinoma of the breast: measurement and the management of treatment. II. The regression of tumours. Regression slopes fitted in 238 new cases of primary breast cancer submitted to a variety of managements are analysed. Contrary to the original hypothesis that slopes would primarily reflect the composition of the tumours, the steepness of resorption slopes is found also to be treatment dependent. Investigation of other factors influencing slopes is confined to radiotherapy where the expectation that the prescribed dose will be delivered is high. A large cumulative radiation effect before the start of shrinkage is associated with steeper slopes. A small correlation between slope and both menopausal status and starting diameter has been found, with premenopausal patients and small tumours producing the steepest slopes. The full range of slopes has been seen in postmenopausal patients. The data has been fitted to a linear model to evaluate the relative importance of these associations. Illustrative cases support the hypothesis that resorption slopes are a product of tumour architecture and histology but we conclude that the maximum possible steepness of slope is not always achieved in the clinic, even when radiation is used. A combination of histological and regression data is therefore required to characterize a tumour for predictive purposes. | 0 |
When epilepsy masquerades as heart disease. Awareness is key to avoiding misdiagnosis. Autonomic neural impulses that accompany discharges during a seizure can cause a variety of cardiac manifestations, including cardiac arrhythmias, sudden death, anginal chest pain, neurogenic pulmonary edema, and symptoms of pheochromocytoma. Either generalized or focal seizures may generate such signs and symptoms. A better appreciation of cardiac problems caused by epilepsy is helpful in preventing misdiagnosis, because the clinical picture in such a patient may be confusing. | 0 |
Evolution of in vitro transformation and tumorigenesis of HPV16 and HPV18 immortalized primary cervical epithelial cells. Cervical carcinoma develops through a progressive spectrum of premalignant intraepithelial lesions (CIN I-III), the majority of which are associated with human papillomavirus (HPV) types 16 and 18. We established HPV16 and HPV18 immortalized human cervical epithelial cell lines and used them as a model to investigate the genesis and progression of cervical malignancy. The cell lines when cultured in vitro in a system mimicking their in vivo environment exhibit cytologic atypia and a variety of defects in morphologic differentiation at early passage compared to their normal counterparts. With increased passage, these alterations progress to more severe grades, histologically similar to CIN III; however only a limited number of the cell lines are tumorigenic, mimicking the epidemiologic evidence on the rate of conversion from premalignant to invasive carcinoma. The observed changes are not associated with alterations of viral DNA integration or expression and may reflect specific cellular events or changes in virus-host interactions associated with malignant progression. | 0 |
Circadian esophageal motor function in patients with gastroesophageal reflux disease. Effective esophageal peristalsis is a major determinant of esophageal clearance function and may contribute to the development of complications in gastroesophageal reflux disease. Using 24-hour ambulatory esophageal manometry, we compared the circadian esophageal motor activity of normal volunteers to that of patients with increased esophageal exposure to gastric juice and various grades of mucosal injury (no mucosal injury, esophagitis, stricture, or Barrett's esophagus). The prevalence of a mechanically defective lower esophageal sphincter, esophageal acid exposure time, and the frequency of nonperistaltic esophageal contractions during the supine, upright, and meal periods increased with increasing severity of mucosal injury. The median amplitude of esophageal contractions was compromised only in patients with a mechanically defective sphincter. This was particularly so in patients with stricture or Barrett's esophagus and was associated with an increased frequency of ineffective contractions (less than 30 mm Hg). These data show that esophageal motor function deteriorates with increasing severity of mucosal injury. This appears to be caused by persistent reflux of gastric juice across a mechanically defective lower esophageal sphincter. The need for surgical correction of a mechanically defective sphincter before the loss of esophageal body function is implicated. | 1 |
Practicalities of lipids: ICU patient, autoimmune disease, and vascular disease. Although the use of lipids should be individualized, certain generalizations are appropriate. 1. Lipid infusion should be limited in the fulminately septic patient to 10% of total calories in an effort to reduce immunosuppression. 2. The stressed, nonseptic patient with difficulties in ventilator weaning or TPN-induced hepatic dysfunction may reap benefit from a reduction in dextrose calories and the provision of daily lipids. 3. Patients with severe autoimmune disease have had mild amelioration of symptoms with PUFA supplementation. The relative benefits of omega-6 vs omega-3 continue to be examined. 4. Dietary immunomodulation in transplant and burns remains an area of active investigation. 5. Patients with fat-free TPN show transient declines in serum lipids. The development of a "fat-solubilizer" remains in the experimental realm. 6. The provision of fish oil, high in W-3 EPA, has shown promise in atherosclerosis and immunomodulation. The changes in the relative amounts of each prostaglandin class depend on precursor prevalence. | 3 |
Learning disabilities in epilepsy: neurophysiological aspects. Subclinical generalized spike-wave discharges are often accompanied by transitory cognitive impairment, demonstrable by psychological testing during EEG recording. Transitory cognitive impairment is demonstrated most readily by difficult tasks and during generalized regular spike-wave bursts lasting for more than 3 s, but can also be found during briefer and even focal discharges. That this is not simply a consequence of global inattention is shown by the fact that focal discharges exhibit some specificity: left-sided focal spiking is more likely to produce errors on verbal tasks, for instance, whereas right-sided discharges are more often accompanied by impairment in handling nonverbal material. Both learning difficulties in general and specific abnormal patterns of cognitive functioning are well documented in children with epilepsy and are most pronounced in those with frequent interictal discharges. However, there is now evidence that intermittent cognitive impairment due to the discharges themselves contributes significantly to such neurophysiological abnormalities. The significance of transitory cognitive impairment accompanying subclinical EEG discharges for everyday functioning is uncertain, but there is experimental evidence that subclinical discharges may be accompanied by disruption of educational skills in children or by impairment of driving performance in motorists. In some individuals, suppression of discharges by antiepileptic drugs has demonstrably improved psychological function, but further work is required to determine the indications for such treatment. | 4 |
Bone scans in the diagnosis of bone crisis in patients who have Gaucher disease [published erratum appears in J Bone Joint Surg [Am] 1991 Jun;73(5):791] Of thirty-four occurrences of bone pain in seventeen children and young adults who had type-I Gaucher disease, twenty-five were finally diagnosed as bone crises. On the basis of a bone scan with technetium-99m methylene diphosphonate, a correct diagnosis of bone crisis was made for twenty-three occurrences, with a sensitivity of 0.92. At the onset of a crisis, the bone scan typically showed decreased uptake of radionuclide at the involved site. After six weeks, a repeat bone scan of the long bones showed a ring of increased uptake surrounding an area of decreased uptake. At six months, the appearance of the bones on the radionuclide scan was normal. | 2 |
Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience. During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia. | 4 |
Doppler ultrasonography of malignant melanomas of the uvea. Doppler shifts were detected using duplex and color Doppler scanning in 41 of 42 patients with malignant melanomas of the uvea. Mean maximum tumor systolic velocity was 18.8 +/- 7.6 cm/s. Time-averaged maximum velocity in the tumor vessels was 12.3 +/- 5.3 cm/s. Maximum tumor velocity increased in four of eight tumors and was unchanged or had diminished in the other four 2 to 3 days after ruthenium plaque irradiation. Doppler shifts were undetectable in three tumors, markedly reduced in three tumors, and unchanged in one tumor 1 to 4 months after treatment. We detected minimal non-pulse-synchronized Doppler shifts in one of three tumors, and no shifts in the remaining two tumors 1 1/2 to 4 years after therapy. Color duplex scanning allowed a rapid overview of tumor vasculature and facilitated study of individual vessels. | 0 |
Germ line p53 mutations in a familial syndrome of breast cancer, sarcomas, and other neoplasms Familial cancer syndromes have helped to define the role of tumor suppressor genes in the development of cancer. The dominantly inherited Li-Fraumeni syndrome (LFS) is of particular interest because of the diversity of childhood and adult tumors that occur in affected individuals. The rarity and high mortality of LFS precluded formal linkage analysis. The alternative approach was to select the most plausible candidate gene. The tumor suppressor gene, p53, was studied because of previous indications that this gene is inactivated in the sporadic (nonfamilial) forms of most cancers that are associated with LFS. Germ line p53 mutations have been detected in all five LFS families analyzed. These mutations do not produce amounts of mutant p53 protein expected to exert a trans-dominant loss of function effect on wild-type p53 protein. The frequency of germ line p53 mutations can now be examined in additional families with LFS, and in other cancer patients and families with clinical features that might be attributed to the mutation. | 0 |
Intravascular stents. General principles and status of lower-extremity arterial applications. The two major types of intravascular stents are balloon expandable and self-expanding. Many animal and, more recently, clinical studies have begun to delineate the real and potential roles of stents. Although the ideal intravascular stent does not exist, it is possible to identify characteristics of the hypothetical ideal stent. Iliac and femoropopliteal arterial applications of metallic stents are reviewed. Stents have proved useful in postangioplasty elastic recoil, in some cases of postangioplasty restenosis, and in angioplasty-induced dissection. Their role in primary angioplasty procedures is still uncertain, although in iliac angioplasty the immediate hemodynamic effects of angioplasty plus stenting are superior to those of angioplasty alone. It is clear that metallic stents have not solved the problem of postangioplasty restenosis, as restenosis still occurs in a significant number of cases. This problem is particularly evident in the femoropopliteal stent procedures, in which angiographic restenosis (more than 50% single diameter stenosis) at 6 months after treatment has occurred in approximately 30% of cases. The existence of poststenting restenosis, which often involves the stented segment, underscores the need for better drug regimens in angioplasty and for better understanding of the intimal fibrocellular proliferative response of the vessel wall to injury. Although potentially very useful, biodegradable stents are still a dream whose realization will demand the development of better materials. | 4 |
Umbilical cord ulceration and intestinal atresia: a new association? In three fetuses, congenital intestinal atresia was associated with linear ulcerations of the umbilical cord. In two cases, hemorrhage was seen from the cord ulcer. Both fetuses required emergency cesarean section for fetal distress and were born anemic. The third fetus was mildly hydropic, attributed to hemorrhage, and was stillborn. The mechanism of the association could not be determined. These cases suggest a risk of prenatal umbilical cord hemorrhage in infants with intestinal atresia. | 1 |
Skeletal muscle depressed calcium and phosphofructokinase in chronic heart failure are upregulated by captopril--a double-blind, placebo-controlled study. The effects of the angiotensin converting enzyme inhibitor captopril, after treatment for 5-6 weeks with 25 mg t.i.d., were studied in 12 patients with stable moderate heart failure. Five patients received placebo treatment, and the two groups were comparable at baseline. Angiotensin II levels decreased in response to captopril therapy. Skeletal muscle potassium, magnesium and chloride levels did not differ from reference values. Calcium was subnormal (P less than 0.0001), but increased to the reference range during captopril treatment. Phosphofructokinase, a rate-limiting glycolytic enzyme, was in the lower reference range and increased (P less than 0.04) in response to captopril therapy. In conclusion, stable moderate heart failure is associated with low levels of skeletal muscle calcium and phosphofructokinase activity, these metabolic changes tending to return to normal levels with captopril treatment. | 3 |
Skin conductance and arousal in the newborn. We measured skin conductance continuously from the sole of a foot in babies of different conceptional ages before, during, and for 10 minutes after a 'heel prick' carried out for routine blood sampling. We studied 82 healthy babies whose gestational and postnatal ages ranged from 25-42 weeks, and 1-73 days. The median skin conductance level (preheel prick) in babies of 40-43 weeks' conceptional age was 0.6 microS (microsiemens) and differed significantly between awake babies (1.2 microS) and those who were asleep (0.5 microS). In contrast babies less than 40 weeks had a significantly lower median skin conductive level (0.3 microS) which was identical in awake and asleep babies. In response to the heel prick all babies became aroused and skin conductance rose sharply and immediately in 21 out of 22 (95%) babies 40-43 weeks' conceptional age, and in seven out of 23 (30%) babies 36-39 weeks. The median rise at one minute in babies of 40-43 weeks was significantly higher than those 36-39 weeks (2.7 microS compared with 0.5 microS). No babies less than 36 weeks had a change in their skin conductance after the heel prick. These results are consistent with the notion that 'emotional sweating' is a function of maturity and does not develop until 36 weeks' conceptional age. | 2 |
Primary prevention of coronary artery disease through a family-oriented cardiac risk factor clinic. Primary prevention of coronary artery disease in children and young adults is important and can be instituted through a family-oriented cardiac risk factor clinic. Such a clinic was initiated at the Medical College of Georgia in March 1988. Children whose total cholesterol level (TC) exceeded 200 mg/dL when screened by their primary care physician were referred with their siblings and parents for fasting lipid profile and further evaluation. Data are available for the initial 21 families, including 30 children and 36 adults. The mean TC level was 258 mg/dL for index cases, 195 mg/dL for siblings, and 233 mg/dL for parents. Follow-up data obtained after therapy at a mean of 6 months are available for 12 families, including 14 children and 14 adults. The mean change in TC was from 265 to 246 mg/dL; 82% of the patients had a decrease in TC. Only one index case was documented as having neither a sibling nor a parent with an elevated cholesterol level. Family-oriented cardiac risk factor clinics are important for the identification and treatment of hypercholesterolemia in asymptomatic young people when primary prevention is possible. | 3 |
Multivariate data reduction by principal components, with application to neurological scoring instruments. Principal components analysis is widely used as a practical tool for the analysis of multivariate data. The aim of this analysis is to reduce the dimensionality of a multivariate data set to the smallest number of meaningful and independent dimensions. The analysis can also provide interpretable linear functions of the original measured variables that may serve as valuable indices of variation. A brief introduction to principal components analysis is given herein, followed by an examination of a particular set of multivariate data accruing from a study of acute brain injuries in a pediatric population, in which severity of brain injury had been assessed with the Glasgow Coma Scale (CGS). Principal components analysis reveals that the GCS sum score is a particularly inefficient summarizer of information in this cohort. The determination of an objective weighting of measured variables, as provided through principal components analysis, is essential in the construction of meaningful neurological scoring instruments. | 4 |
A risk of malignancy index incorporating CA 125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer. Age, ultrasound score, menopausal status, a clinical impression score and serum CA 125 level were assessed to see how they could best distinguish between patients with benign (n = 101) and malignant (n = 42) pelvic masses. Each criteria used alone provided statistically significant discrimination. The most useful individual criteria were a serum CA 125 level of 30 U/ml (sensitivity 81%, specificity 75%) and an ultrasound score of 2 (sensitivity 71%, specificity 83%). Three criteria could be combined in a risk of malignancy index (RMI) which is simply calculated using the product of the serum CA 125 level (U/ml), the ultrasound scan result (expressed as a score of 0, 1 or 3) and the menopausal status (1 if premenopausal and 3 if postmenopausal). This index was statistically virtually as effective a discriminant between cancer and benign lesions as more formal methods. Using an RMI cut-off level of 200, the sensitivity was 85% and the specificity was 97%. Patients with an RMI score of greater than 200 had, on average, 42 times the background risk of cancer and those with a lower value 0.15 times the background risk. | 0 |
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