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Eosinophilia-myalgia syndrome in association with L-tryptophan ingestion. The association between the recently described eosinophilia-myalgia syndrome and L-tryptophan is now well established. We describe a patient with eosinophilia-myalgia syndrome who developed incapacitating myalgias and peripheral eosinophilia responsive only to high dose corticosteroids. When massive upper gastrointestinal hemorrhage developed while receiving corticosteroid therapy, surgery was complicated by striking abdominal wall rigidness. A discussion of this case and of eosinophilia-myalgia syndrome is presented. | 2 |
Identification of three related human GRO genes encoding cytokine functions. The product of the human GRO gene is a cytokine with inflammatory and growth-regulatory properties; GRO is also called MGSA for melanoma growth-stimulatory activity. We have identified two additional genes, GRO beta and GRO gamma, that share 90% and 86% identity at the deduced amino acid level with the original GRO alpha isolate. One amino acid substitution of proline in GRO alpha by leucine in GRO beta and GRO gamma leads to a large predicted change in protein conformation. Significant differences also exist in the 3' untranslated region, including different numbers of ATTTA repeats associated with mRNA instability. A 122-base-pair region in the 3' region is conserved among the three GRO genes, and a part of it is also conserved in the Chinese hamster genome, suggesting a role in regulation. DNA hybridization with oligonucleotide probes and partial sequence analysis of the genomic clones confirm that the three forms are derived from related but different genes. Only one chromosomal locus has been identified, at 4q21, by using a GRO alpha cDNA clone that hybridized to all three genes. Expression studies reveal tissue-specific regulation as well as regulation by specific inducing agents, including interleukin 1, tumor necrosis factor, phorbol 12-myristate 13-acetate, and lipopolysaccharide. | 4 |
Risks factors for cerebral infarction in good-grade patients after aneurysmal subarachnoid hemorrhage and surgery: a prospective study. A prospective series of 265 patients with aneurysmal subarachnoid hemorrhage (SAH) of Grades I to III (Hunt and Hess classification) upon admission were evaluated as to neurological outcome and computerized tomography (CT) findings 1 to 3 years (mean 1.4 years) after the SAH and surgery. A total of 73 patients underwent acute surgery (within 72 hours after the bleed: Days 0 to 3), 86 were operated on subacutely (between Days 4 and 7), and 91 had late surgery (on Day 8 or later). Fifteen patients died before surgery was undertaken and another 20 patients died during the follow-up period. A total of 104 patients received nimodipine and the rest of the patients received either placebo (109 patients) or no medication (52 patients). A logistical regression analysis revealed the following prognostic factors for cerebral infarction, in order of importance: the amount of blood on the primary CT scan; postoperative angiographic vasospasm; the timing of the operation; and a history of hypertension. The use of nimodipine was associated with a significant reduction of cerebral infarcts visualized by CT scanning in patients who received intermediate or late surgery. In patients who underwent acute surgery no significant difference between the incidence of cerebral infarcts was observed. | 2 |
Resolution of inferior vena cava syndrome after embolization of a hepatic adenoma. A 77-year-old man presented with severe pruritus and massive lower body edema. Computerized axial tomography of the abdomen showed a large hepatic mass compressing the inferior vena cava, and a liver biopsy specimen showed hepatic adenoma. Embolization of vessels feeding the hepatic tumor resulted in complete resolution of pruritus and ascites, and clinical remission has persisted for 1 year following partial obliteration of tumor vasculature. Angiographic ablation of tumor blood supply represents a nonoperative means for inducing clinical remission in patients with symptomatic hepatic adenoma who are at high surgical risk. | 0 |
Extradural implantation of sacral anterior root stimulators. A technique for extradural deafferentation of the S2 to S5 segments and extradural implantation of stimulating electrodes is described, and its application to twelve patients with spinal cord lesions is reported. Nine patients use their implants for micturition, and seven are fully continent. The advantages and disadvantages of this technique compared with the more usual intrathecal procedure are discussed. | 2 |
Anti-CD33 monoclonal antibody and etoposide/cytosine arabinoside combinations for the ex vivo purification of bone marrow in acute nonlymphocytic leukemia. Pharmacologic and immunologic methods of ex-vivo bone marrow (BM) purging for acute nonlymphocytic leukemia (ANLL) were combined to augment the effect of either method alone. Etoposide (VP16; 20 to 30 micrograms/mL) with or without cytosine arabinoside (Ara C; 10 mg/mL) was used in tandem with the anti-CD33 monoclonal antibody (MoAb), MY9, chosen because CD33 is found on the stem cell pool in the majority of patients with ANLL. The agents were tested singly or sequentially, with a 1-hour incubation of the drugs preceding complement-mediated lysis using MY9. VP16 combined with Ara C killed up to 3.9 +/- 0.3 and 5.11 +/- 0.4 logs of the human ANLL cell lines HL60 and K562 at drug concentrations that killed only 1.2 +/- 0.1 logs of normal committed granulocyte/macrophage stem cells (CFU-GM). Adding a single exposure of the MY9 and complement (C') to the drug-treated cells, greater than 5.4 logs of HL60 were killed. Similar to other pharmacologic agents, no differential kill for clonagenic leukemic cells (colony-forming unit-leukemia; CFU-L) from patients with ANLL was seen for drug only treated blasts versus normal CFU-granulocyte-macrophage (CFU-GM), with less than 1 log CFU-L kill at drug concentrations that spared 1 log of CFU-GM. Similarly, only 1.1 +/- 0.3 logs of ANLL CFU-L were eliminated using MY9 and C'. However, with the sequential VP16/Ara C----MY9 + C' treatment, synergy was demonstrated and 2.6 +/- 0.3 logs of CFU-L were eliminated. Because CD33 is also found on the normal CFU-GM pool, two-stage long-term BM cultures were performed to determine pluripotent stem cell elimination by the drug/MoAb purging combination. No difference of CFU-GM or BFU-E production at 4 to 6 weeks of culture for VP16/Ara C, MY9 + C', or VP16/AraC----My9 + C' treated cells was seen compared with untreated controls indicating sparing of early progenitor cells. Sequential ex vivo treatment of human ANLL CFU-L with VP16/Ara C followed by complement-mediated lysis using MY9 synergistically kills CFU-L while sparing early normal hematopoietic progenitor cells, and thus may be a more effective way to purge BM than either alone. | 0 |
Anteromedial tibial tubercle transfer without bone graft. We followed 30 patients for more than 2 years after anteromedial tibial tubercle transfer for persistent patellofemoral pain associated with patellar articular degeneration. Twelve of these patients were followed more than 5 years. We report 93% good and excellent results subjectively and 89% good and excellent results objectively. The quality of improvement was sustained in all 12 of the patients who were evaluated again after more than 5 years from surgery. When examined separately, 75% of those patients with advanced patellar arthrosis achieved a good result; none of these patients achieved an excellent result. Postoperative continuous passive motion has markedly reduced the incidence of stiffness. Serious complications such as compartment syndrome, infection, and skin slough were avoided completely in 51 consecutive cases. Patellofemoral contact pressure studies in five cadaver knees have shown that anteromedial tibial tubercle transfer can provide substantial reduction of patellofemoral contact stress while helping to balance medial and lateral facet pressures. This surgical procedure is mechanically and clinically successful for alleviating intractable pain related to patellar malalignment and articular degeneration. This procedure enables the majority of appropriately selected patients with malalignment and patellar articular degeneration to resume increased levels of activity with substantially diminished pain. | 2 |
Stage A adenocarcinoma of the prostate: transrectal US and sonographic-pathologic correlation. Results of transrectal ultrasound (TRUS) of the prostate and pathologic examination of specimens obtained at transurethral resection of the prostate (TURP) were compared in 29 patients with clinical stage A adenocarcinoma. Ten specimens contained no residual tumors larger than 5 mm in diameter; in the remaining 19 glands, 20 discrete cancers were found. At TRUS, 30 peripheral hypoechoic lesions were demonstrated, of which 11 corresponded to carcinoma at pathologic examination. Other hypoechoic peripheral zone lesions included a focal area of dilated acinar glands in 10 cases, post-TURP scarring with fingerlike projections of fibrosis in seven, dysplasia in one, and no correlation in one. Of nine tumors that were not detected prospectively at TRUS, eight were predominantly in the anterior zone and one was in the posterior peripheral zone but was isoechoic. Overall, the sensitivity of TRUS in the evaluation of clinical stage A lesions was 55% and the specificity was 37%. Clinical stage A carcinomas may be difficult to detect at US, and findings are often nonspecific. Any suspicious peripheral zone lesion should undergo biopsy with TRUS guidance before being diagnosed as malignant. | 0 |
A community study of delay in presenting with signs of melanoma to medical practitioners. In the absence of more effective treatment for advanced tumors, early diagnosis and treatment of localized tumors is the most effective way of reducing the burden of illness associated with melanoma. This study examined the following factors: prevalence of signs of melanoma (a mole changing in size, shape, appearance, or color, itching or tingling, bleeding or weeping, becoming raised) in 1344 individuals in a randomly selected sample of 1075 households; the length of delay in seeking medical advice; the factors associated with either going to a medical practitioner or not going/delaying; and the actions of the medical practitioners when first presented with these signs. The results indicate that a large proportion of the sample (11.9%, n = 156) had observed signs of melanoma in the previous 12 months. Of the sample reporting signs that had first appeared in the previous 5 years, only 32% sought medical advice about the signs within the recommended period. Of the sample either not seeking advice at all or delaying, 49% reported that they thought the sign "wasn't serious/would clear up." Furthermore, 30% of the sample either did not known or underrated the importance of early detection and treatment of lesions. These results indicate that there is a deficit in the knowledge of the general public about the signs of melanoma, the severity of the disease, and the possible risks associated with delay. | 0 |
Essential thrombocythemia in young adults. Essential thrombocythemia is typically a disorder of adults in the sixth or seventh decade of life and is characterized by frequent thrombohemorrhagic complications. In young patients, the optimal management of complications is controversial. We studied 56 young adults (33 female and 23 male patients) with a diagnosis of essential thrombocythemia. The mean duration of follow-up was 4.68 years. The mean platelet count at diagnosis was 1,328,000/mm3. Platelet aggregation studies in 21 patients demonstrated hypoaggregation to epinephrine; spontaneous platelet aggregation was present in 4. At diagnosis, 39 patients were asymptomatic, and thrombocytosis was discovered incidentally. Throughout follow-up (up to 20 years), 24 patients remained asymptomatic. Thrombotic complications developed in 24 patients; they were life-threatening in only 3. The most common vaso-occlusive symptoms were migraine headache (in 12 patients) and erythromelalgia (in 3). Minor hemorrhagic complications occurred in six patients, and none was life-threatening. Serious complications (one cerebral and two myocardial infarctions) occurred in three patients, all of whom recovered. Two deaths occurred, neither of which was attributable to essential thrombocythemia. The treatment regimens used were chemotherapy in 9 patients, antiaggregating agents in 7, radioactive phosphorus in 1, the newer platelet-lowering agent anagrelide in 10, and only observation in 29. No treatment-related acute leukemias developed. This series of young patients with essential thrombocythemia, the largest to date, demonstrates a low incidence of life-threatening complications and a favorable long-term prognosis. Therapeutic recommendations should remain conservative, and potential leukemogens should be avoided unless serious complications develop. Anagrelide may be useful in young patients with thrombocythemia who are symptomatic. | 3 |
Stress fractures of the femoral neck in athletes. The consequence of a delay in diagnosis. Twenty-three patients with stress fractures of the femoral neck were followed up at an average of 6.5 years after the injury. There were 16 recreational athletes and seven elite athletes. Most injuries (N = 15) occurred during running. The diagnosis was confirmed within 3 to 104 weeks (mean, 14 weeks) after the initial onset of symptoms. Sixteen of the patients were treated with internal fixation, the remaining seven were treated conservatively. Seven patients (30%) developed complications requiring major surgery. Five of these patients had Type 3 fractures (displaced) and four had been treated with internal fixation initially. The remaining two patients had Type 1 fractures (endosteal or periosteal callus without an overt fracture line); one was treated operatively and the other conservatively. Three patients developed avascular necrosis and two were treated by hip replacement. The third patient was treated with arthrodesis. Three refractures and one pseudarthrosis were treated by osteotomy. At followup, all elite athletes stated that they had to end their career as a result of the injury. Results were rated by the ability of the athlete to return to sports. There were 9 bad or fair results, 13 good, and 1 excellent result. No difference in activity level or subjective rating was observed between the surgically and conservatively treated group either preinjury or postinjury. The most important factor influencing the complication rate seems to be the type of fracture. The high incidence of displaced fractures (Type 3) could speculatively be caused by undiagnosed tension side stress fractures. If so, the delay in correct diagnosis may be disastrous. However, we could only objectively observe this in one of our cases. | 4 |
Physicians' perspectives on cholesterol and heart disease. In early spring of 1988, questionnaires were mailed to 4,000 Midwestern physicians to survey their attitudes and practices regarding elevated serum cholesterol and their use of referrals for nutrition counseling; 633 physicians responded. Sixty-eight percent of the physicians thought that reducing high serum cholesterol levels would substantially affect heart disease; however, physicians attributed considerably less preventive value to reducing the cholesterol level than to reducing blood pressure (80.3%) or ceasing smoking (90.0%). The range of serum cholesterol for which diet therapy was most frequently initiated was 5.70 to 6.20 mmol/L. The most frequent range for initiation of drug therapy was 7.80 to 8.25 mmol/L. The physicians reported that although their medical school training did not prepare them adequately for providing diet counseling, they did feel prepared to provide, and were successful in, counseling on diet modifications for reducing serum cholesterol. Few (10%) of the total sample reported having registered dietitians available for dietary counseling, and most (88.8%) believed that it is the physician's responsibility to provide such counseling. Although the low response rate limits the conclusions of the survey, it is likely that those physicians most interested in the topic responded. We conclude that registered dietitians should explore the need for their special services further. More aggressive marketing of dietetic services could benefit both physicians and patients in the campaign to reduce serum cholesterol. | 3 |
Results of repeat percutaneous balloon valvuloplasty for pulmonary valvar restenosis. Follow-up cardiac catheterization studies were used to evaluate 105 patients who had undergone percutaneous balloon pulmonary valvuloplasty. Fifteen of those patients who had peak systolic pulmonary valve gradients greater than = 40 mm Hg at follow-up underwent repeat balloon valvuloplasty. For the initial balloon pulmonary valvuloplasty, the mean ratio of the balloon diameter to pulmonary valve annulus diameter was 0.98 +/- 0.2; at repeat valvuloplasty the mean was 1.19 +/- 0.12. The immediate post-repeat balloon valvuloplasty results showed a reduction in the peak systolic gradient from a mean of 70.2 +/- 17.8 to 29.1 +/- 19.0 mm Hg (p less than 0.001). This reduction in the gradient was maintained at a mean of 14.3 +/- 5.0 mm Hg in 8 of the 10 patients who underwent further follow-up studies. We conclude that successful repeat balloon pulmonary valvuloplasty with the use of larger sized balloons is feasible in patients who have restenosis after the initial percutaneous balloon valvuloplasty--including partial but not complete dysplasia of the pulmonary valve. | 4 |
The radiologic morphology of painful temporomandibular joints. A high frequency of remodeling changes was demonstrated radiographically in a series of patients having pain in the temporomandibular joint region. Radiologic morphologic differences between painful and asymptomatic temporomandibular joints were in frequency rather than type. Caution should be taken not to overestimate the significance of radiologic abnormality in patients with pain in the temporomandibular joint region. | 4 |
Intracranial hypertension in relation to memory functioning during the first year after severe head injury. The relationship between intracranial hypertension and residual memory deficit after closed head injury was evaluated using the 6-month and 1-year neurobehavioral outcome data obtained by the Traumatic Coma Data Bank. Intracranial pressure was analyzed using the percentage of time that it exceeded 20 mm Hg and the maximum value recorded during the first 72 hours after injury. Memory measures included recall of word lists, prose recall, and visual memory for designs that were obtained 6 months (n = 149) and 1 year (n = 132) after injury. Intracranial hypertension occurred in more than half of the Traumatic Coma Data Bank cohort who met the criteria for the neurobehavioral follow-up study. Linear regression analysis disclosed an effect of elevated intracranial pressure on some, but not all, measures of memory at 6 months, whereas the results were negative for the 1-year follow-up examination. We conclude that the elevation of intracranial pressure exerts little if any effect on later memory functioning, and that any effect it does have diminishes over 1 year in survivors of severe head injury. | 2 |
Reflex sympathetic dystrophy after clavicle fracture: case report. Reflex sympathetic dystrophy (RSD) of the anterior chest wall is a rare entity. A MEDLINE search in all languages of the world's literature from 1966 to the present yielded no report of the association of clavicle fracture with this pain syndrome. Two cases are presented and the anatomic variations of the supraclavicular nerves in relation to the clavicle are discussed. | 2 |
Optic nerve gliomas and meningiomas. Optic nerve gliomas are benign astrocytic neoplasms that primarily affect children. The ultimate prognosis for vision is poor. For lesions confined to the optic nerves, long-term survival is excellent, but with involvement of the chiasm and especially of the hypothalamus or third ventricle, prognosis falls significantly. For this group, no form of therapy has proven to be of any benefit. Optic sheath meningiomas are neoplasms arising from arachnoid cap cells. They primarily affect middle-aged adults. Like gliomas, the prognosis for vision is poor, but unlike gliomas, prognosis for life is excellent. | 0 |
Immunoglobulins A, G, and M to cytomegalovirus during recurrent infection in recipients of allogeneic bone marrow transplantation. Occurrence and significance of specific IgA and IgM to cytomegalovirus (CMV) in recurrent CMV infection was evaluated in 21 allogeneic T lymphocyte-depleted bone marrow transplantation (BMT) recipients who had been previously CMV seropositive. Of 17 patients with CMV infection, viruria was detected in 94%, CMV-specific IgA in 88% and IgM in 76%, and a fourfold rise in IgG in 65%. The median time between BMT and detection of viruria was 69 days, of IgA 70, of IgM 62, and of IgG 88 days. The IgM and IgA responses lasted for 14 and 30 days (median time), whereas high IgG titers persisted. Twelve patients developed CMV disease; in these the appearance of viruria, IgA, and IgM preceded the rise of IgG (P less than .02). CMV-specific IgA and IgM are valuable diagnostic tools in BMT recipients with recurrent CMV infection. | 4 |
Hypocalcemia and hypercalcitoninemia in critically ill children. To study Ca metabolism in critically ill children, we measured ionized Ca (Ca2+), parathyroid hormone (PTH), calcitonin, 25 hydroxycholecalciferol (25[OH] D3), 1-25 dihydroxycholecalciferol (1-25[OH]2D3, and gastrin levels in critically ill children and in healthy controls. Patients were considered hypocalcemic if Ca2+ was less than 1.1 mmol/L. Six (14%) of 45 patients were hypocalcemic. Five hypocalcemic patients were studied and were found to have higher calcitonin levels than normocalcemic patients and healthy controls and higher PTH levels than healthy controls. 25(OH)D3 and 1-25(OH)2D3 were not significantly different in the three groups of patients. Gastrin levels were low in critically ill patients, whether or not they were hypocalcemic. We conclude that hypocalcemia occurs frequently in critically ill children. It is associated with raised levels of calcitonin and PTH. The mechanism for the increase in calcitonin is unknown. | 4 |
Stroke rehabilitation: a geropsychological perspective. Rehabilitation medicine and geriatric medicine are similar in their concern for functional improvement in the face of chronic medical conditions. Although many patients served by rehabilitation medicine fall within the geriatric age range, a knowledge of normal aging does not necessarily inform clinical decision making or research practices in rehabilitation. Using stroke as an example of a disorder affecting primarily geriatric patients and requiring the technology of rehabilitation, ways in which age might affect assessment of outcome are examined. Three areas dealing with conceptual and methodologic issues--depression, neurochemical interventions, and family--are highlighted. The final section outlines recommendations for research on rehabilitation outcome of geriatric stroke patients. | 2 |
The natural history of peripheral vascular disease. Implications for its management. The durability and the eventual complication rate of endovascular therapy (percutaneous transluminal angioplasty, laser-assisted angioplasty, and atherectomy) are not yet entirely clear, especially with respect to the treatment of atherosclerotic lesions in the femoropopliteal or distal arterial segments. Therefore, the indications for its use have not been firmly established and must take into consideration the natural history of the occlusive disease itself. Although some type of procedural intervention clearly is warranted in the presence of ischemic rest pain or tissue necrosis, intermittent claudication is the only complaint in approximately 70% of patients who present with either aortoiliac or femoropopliteal involvement. Most nondiabetic patients experience substantial symptomatic improvement with a daily exercise program, and their long-term risks for either abrupt deterioration (20-25%) or amputation (less than 10%) are relatively low. In comparison, the 5-year mortality rate ranges from 20-40% even in claudicants, and as many as 40% of those with clinical indications of associated coronary artery disease have been shown angiographically to be candidates for myocardial revascularization. These observations suggest that traditional indications for surgical treatment (truly disabling claudication and/or limb salvage) also should be applied to endovascular therapy until its success is confirmed beyond speculation, and that incidental coronary disease deserves particular attention in patients with lower extremity ischemia. | 3 |
Response of the Lambert-Eaton myasthenic syndrome to treatment of associated small-cell lung carcinoma. We evaluated the outcome in 16 patients with Lambert-Eaton myasthenic syndrome (LEMS) associated with histologically verified small-cell carcinoma (SCC). Thirteen patients received specific tumor therapy (chemotherapy, radiation therapy, or resection) and most also received pharmacologic and immunologic treatment for LEMS. Seven of 11 patients surviving for more than 2 months after tumor therapy showed substantial neurologic improvement (1 patient being in complete remission at 7 years); in 3 of 11 improvement was transient. An EMG index of disease severity (compound muscle action potential amplitude in abductor digiti minimi) was significantly increased at final follow-up (p less than 0.01; n = 11). A pretreatment amplitude greater than 3.0 mV was a good prognostic sign. We conclude that a combined treatment approach in SCC-LEMS usually results in neurologic improvement. | 4 |
Skeletal muscle following tonic overload: functional and structural analysis. Functional overloading of skeletal muscle induces a compensatory hypertrophy as an adaptive response to increased functional demand. Overload of the extensor digitorum longus (EDL) muscle (129 ReJ strain male mouse) was induced by unilateral surgical removal of a synergistic muscle, tibialis anterior (TA). Response of the EDL to overload for 7, 21, and 42 d was analyzed for changes in 1) muscle weight, 2) myofiber type distribution, 3) myofiber cross-sectional area by fiber type, 4) speed of contraction and relaxation of the muscle, 5) force of contraction, and 6) myofiber morphologic integrity. The weight of the EDL significantly increased. The overload caused no impairment of muscle contractility and did not have a significant effect on isometric twitch contraction time to peak tension or the time to one-half relaxation of the twitch. Overloaded muscles demonstrated a transient shift in fiber type profile with preferential hypertrophy of Type IIA fibers that occurred in the early phase of overload while type IIB fibers were recruited by 42 d. No significant increase in myofiber number in overloaded muscles occurred. Some morphologic changes in over-loaded muscles parallel those found in patients with neurogenic muscular disorders. However, overloaded muscle did not exhibit a significant occurrence of fiber branching from controls in the midbelly region of the muscle. | 4 |
An analysis of randomized trials evaluating the effect of cholesterol reduction on total mortality and coronary heart disease incidence. The primary aim of this study was to estimate the relation between cholesterol reduction and total mortality and coronary heart disease (CHD) incidence. Secondarily, the clinical issues of whether the efficacy of cholesterol lowering is dependent on the treatment modality, presence of CHD at baseline, or the simultaneous introduction of other interventions was explored. All randomized clinical intervention trials of cholesterol reduction were used in an overview analysis of total mortality rate and CHD incidence; analysis was performed with weighted linear regression. The trials include those that used primary and secondary intervention, diet and drugs, and single or multifactor design. Nineteen trials were analyzed for total mortality, and of the 19, 16 were analyzed for CHD incidence rate. Net difference in cholesterol change between study groups was used as the independent variable, and the three previously mentioned dichotomous design characteristics were used as additional independent variables. For every 1% reduction in cholesterol, an estimated 2.5% reduction in CHD incidence is indicated (95% CL: 1.1, 3.9). With regard to CHD drug trials tended toward better efficiency in cholesterol lowering than did dietary trials. With regard to total mortality, this efficiency was higher in secondary than in primary preventive trials. The efficiency was also somewhat dependent on the baseline cholesterol level. This study shows that cholesterol reduction is effective in lowering CHD incidence, but cholesterol reduction must be at least 8-9% to be effective in lowering total mortality. | 3 |
Coracoclavicular screw fixation for unstable fractures of the distal clavicle. A report of five cases. Five consecutive unstable fractures of the distal third of the clavicle were treated by indirect open reduction and internal fixation using a temporary Bosworth-type screw. Coracoclavicular fixation provided and maintained reduction of the fracture. Healing occurred uneventfully within nine weeks in all cases. The screw was removed under local anaesthesia after healing of the fracture and there were no surgical complications. Shoulder function was restored to the pre-injury level. Temporary coracoclavicular screw fixation appears to be a valuable alternative for the treatment of type II fractures of the distal third of the clavicle. | 4 |
Eosinophil infiltration and degranulation in Helicobacter pylori-associated chronic gastritis. Eosinophil granules contain cationic proteins, including the major basic protein, which are toxic to mammalian tissue. While eosinophils have been observed to comprise part of the inflammatory reaction in acute Helicobacter pylori gastritis, the role of the eosinophil in the pathogenesis of chronic gastritis is unknown. We evaluated whether eosinophil infiltration and degranulation are associated with chronic gastritis and H. pylori infection. We studied eight patients with chronic H. pylori antral gastritis, three with chronic antral gastritis in the absence of H. pylori, 11 healthy age-matched volunteers without antral gastritis, and eight patients with H. pylori-negative chronic specific gastritis (three Crohn's antral gastritis and five Menetrier's disease). Serial sections were stained with hematoxylin and eosin, with Giemsa, and by a specific indirect immunofluorescence technique for eosinophil granule major basic protein. Specimens were graded independently by three observers and scores of 0-3 were given for eosinophil infiltration and degranulation (0 = none to 3 = confluent infiltration and/or degranulation). In H. pylori antral gastritis, significantly greater eosinophil infiltration and degranulation were found compared to the normal group, Menetrier's disease, and chronic H. pylori-negative gastritis. There was no significant difference between gastric Crohn's disease and H. pylori gastritis. The severity of chronic gastritis was significantly correlated with the eosinophil score. Eosinophil degranulation did not appear to be greater at or near sites of bacterial colonization in the H. pylori gastritis specimens. The results suggest that eosinophil infiltration and degranulation may be associated with H. pylori gastritis. We postulate that the release of toxic cationic proteins from eosinophils contributes to the inflammatory changes present in H. pylori gastritis. | 1 |
Hypertension after operative correction of club-foot deformity. Severe hypertension occurred as a postoperative complication after correction of a club-foot deformity in four children (seven feet) who were between the ages of two and three years and had no history of hypertension. The hypertension subsided slowly after administration of antihypertensive medications or more rapidly after release of the correction that had been obtained operatively. | 4 |
Effects of occupied and unoccupied bed making on myocardial work in healthy subjects. Strict bed rest prescribed after acute myocardial infarction provides rest for the heart in an effort to lessen myocardial work. However, bed rest has been implicated as a threat to physical and psychosocial well-being. Nurses must question whether activities associated with bed rest, such as bed making by hospital personnel while the patient is occupying the bed, actually require less myocardial work than out-of-bed activities. In this study we examined cardiovascular function of 22 healthy individuals, 10 (45.5%) men and 12 (54.5%) women ranging in age from 34 to 69 years (mean 48 years), during occupied (side to side method) and unoccupied (patient up to chair) bed making. Cardiac output, heart rate, stroke volume, systolic blood pressure, diastolic blood pressure, mean arterial pressure, total peripheral resistance, and the ratio of preejection period to left ventricular ejection time were measured by using an impedance cardiograph and vital signs monitor. Although differences between these measurements during the two bed making procedures were statistically significant (p less than 0.001), they were not deemed clinically significant for healthy subjects because they represent transient reflexive responses to posturally induced changes in venous return rather than substantial increases in myocardial work. When the goal is minimal myocardial energy expenditure, making the bed when it is unoccupied may offer a sound alternative to making an occupied bed. | 3 |
Electrophysiologic characteristics of manifest and latent retrograde conduction in dogs. Atrioventricular (AV) nodal reentry requires intact retrograde ventriculoatrial (VA) conduction. The purpose of this study was to assess the contribution of various pacing and pharmacologic techniques to uncover VA conduction during apparent unidirectional VA block, and to evaluate the role of several biologic and electrophysiologic factors in concealment of retrograde conduction. Forty healthy dogs underwent catheter-electrophysiologic studies of AV and VA conduction. Group I (20 animals) had intact VA conduction. Group II (six animals) had VA dissociation with ventricular pacing initiated during sinus rhythm, but the presence of VA conduction was confirmed by isoproterenol infusion or by premature ventricular stimulation. In group III (14 animals), the above techniques failed to uncover VA conduction. Eight of 14 group III animals underwent thoracotomy and crushing or freezing of the sinoatrial (SA) node. Ventricular pacing initiated during sinus standstill was associated with 1:1 VA conduction in each experiment. VA conduction time and retrograde Wenckebach cycle length, both in the baseline state and during isoproterenol infusion, were significantly longer in the eight animals in group III than in those in group I. Age, gender, weight, breed, sinus cycle length, and anterograde AV conduction properties were not significantly different between groups I, II, and III. The data suggest that (1) in normal dogs, complete unidirectional VA block probably does not exist; (2) in the presence of anterograde input to the AV node, even sophisticated pacing and pharmacologic maneuvers may fail to uncover the presence of VA conduction; (3) although anterograde input is essential for concealment of VA conduction, the phenomenon is more closely associated with depressed retrograde than with anterograde AV nodal characteristics. | 3 |
Postural studies in pulsatile ocular blood flow: II. Chronic open angle glaucoma. The pulsatile ocular blood flow (POBF) has been recorded in 15 patients with chronic open angle glaucoma. Measurements were performed during regular treatment with timolol 0.25% eyedrops, two weeks after withdrawal of this treatment, and then a further two weeks after its reinstitution. Readings were taken with subjects in both the erect and supine positions by means of a pneumotonometric probe to measure intraocular pressure (IOP), linked to a Langham ocular blood flow system. Assumption of the supine posture was associated with a significant increase in IOP in all phases of the study. Treatment with timolol lowered the mean IOP in comparison with the untreated phase (-4.4 (SEM 0.6) mmHg, p less than 0.001) but had no effect on the postural change. A significant reduction in POBF was recorded on assumption of the supine posture (-66 (SEM 18) microliters/min, p less than 0.001), representing a mean decrement of 19%. However, there were no significant differences in POBF between treated and untreated phases of the study. Comparison of the values obtained in patients with glaucoma (COAG) after withdrawal of treatment with those in subjects with ocular hypertension revealed that there was no significant difference in intraocular pressure between the two groups. However, both POBF (-68 (SEM 29) microliters/min) and the pulse amplitude of the intraocular pressure (ocular pulse: -0.45 (SEM) 0.14 mmHg) were significantly lower in the COAG patients. Pulsatile ocular blood flow is significantly lower in patients with chronic open angle glaucoma. Furthermore, the POBF and the postural response of these patients is not improved by the use of topical timolol therapy. | 4 |
Tonic contraversive ocular tilt reaction due to unilateral meso-diencephalic lesion. We studied 4 patients with tonic contraversive ocular tilt reactions due to unilateral, paramedian, mesodiencephalic lesions. This is in contrast to the only 2 previously reported patients with ocular tilt reactions due to unilateral mesodiencephalic lesions, each of whom had a paroxysmal ipsiversive ocular tilt reaction. This new finding is considered in the context of previous clinical and experimental data on the various types of ocular tilt reactions that follow stimulation or destruction of the peripheral and central vestibular system. Otolithic inputs to the interstitial nucleus of Cajal from the contralateral vestibular nucleus and motor outputs from the interstitial nucleus of Cajal to cervical and ocular motoneurons could be involved in the ocular tilt reaction. We propose that in patients with unilateral meso-diencephalic lesions, a tonic contraversive ocular tilt reaction could be due to persistently decreased resting activity of ipsilateral interstitial nucleus neurons, whereas a paroxysmal ipsiversive ocular tilt reaction could be due to transiently increased activity of the same interstitial nucleus neurons. Cases of ocular tilt reaction due to unilateral meso-diencephalic lesion point to the existence of a crossed graviceptive pathway between the vestibular nucleus and the contralateral interstitial nucleus of Cajal. | 2 |
Erythrocyte stearic acid desaturation in patients with colorectal carcinoma. The erythrocyte stearic:oleic acid ratio (saturation index) was investigated as a means of differentiating between control subjects (n = 146) and patients with benign (n = 48) and malignant (n = 117) colorectal disease and patients undergoing postoperative follow-up after curative resection (n = 49). Erythrocyte fatty acid profiles were determined by gas liquid chromatography. Neither age, sex, Dukes' stage, nor degree of differentiation of the tumors had a significant effect on the erythrocyte saturation index. The erythrocyte saturation index was lower in patients with primary and recurrent colorectal cancer compared with control subjects and patients with inflammatory bowel disease or benign colonic polyps (P less than 0.0001). The erythrocyte saturation index was not found to be useful in the postoperative follow-up of these patients. Using both saturation index and age as a means of differentiating between patients with primary colorectal cancer and control subjects gave a sensitivity of 67 percent and a specificity of 81 percent. | 0 |
Pedunculated soft-tissue mass on the alveolar gingiva [clinical conference] A case of peripheral ameloblastoma, a rare intraoral neoplasm, has been presented. The lesion appears most commonly as a mass on the mandibular lingual gingiva of patients in their fifth and sixth decades of life. The peripheral ameloblastoma does not share the aggressive nature of the intraosseous variant. The lesion has been overtreated in the past and warrants only a local supraperiosteal excision. | 0 |
Access to cancer prevention, detection, and treatment. The American Cancer Society Hearings on Cancer and the Poor made visible to the nation the harsh realities and consequences of lack of access to health care among the poor and uninsured in America. Access to care is more than mere availability; it is also financial accessibility, effectiveness, acceptability, appropriateness, and comprehensiveness of care. The problems and consequences of lack of health care access and its impact on the cancer problem among poor Americans are explored, and ways practitioners and public advocates can improve access are suggested. Local communities have risen to action to make health care more accessible. Successful programs have done their research to document access problems; then they have taken their findings to county governments to request additional funding and to health care institutions to request institutional policy and service changes to make health care more available and accessible. | 0 |
Successful hyperlipemic pregnancy. Women with hypertriglyceridemia are prone to gestational pancreatitis, a condition carrying substantial maternal and fetal risk. We describe a 33-year-old woman with familial hypertriglyceridemia who had recurrent hyperlipidemic abdominal crises during previous pregnancies despite dietary fat restrictions. A fifth pregnancy was carried to term without complications after aggressive dietary therapy and intermittent intravenous feeding, administered whenever her triglyceride levels exceeded an arbitrarily selected threshold concentration of 28 mmol/L. The efficacy of this approach may be explained by the published observation that low-fat (high-carbohydrate) isocaloric diets elevate serum triglyceride levels by the oral, but not the intravenous, route in normal individuals. Reduction of this patient's serum triglyceride concentrations by interrupting oral intake and administering intravenous glucose appeared to prevent late-pregnancy pancreatitis and culminated in uncomplicated full-term delivery. | 1 |
Interleukin-2 therapy in patients with metastatic malignant melanoma: a phase II study. Forty-seven patients with metastatic malignant melanoma were treated with two 5-day cycles of 100,000 U/kg recombinant interleukin-2 (IL-2) intravenously (IV) every 4 hours separated by 1 week. This dose and schedule of IL-2 were identical to those used in a previous combined IL-2 and lymphokine-activated killer (LAK) cell phase II clinical trial of the IL-2/LAK Working Group. Patient eligibility criteria, and clinical management guidelines were similar to those used in the previous trial. Forty-six patients were assessable for response. Objective responses were observed in 10 of 46 patients (two complete responses [CRs], eight partial responses [PRs]) or 22% with responses occurring in lung and liver as well as lymph nodes and subcutaneous sites. The median response duration was 8 months. Toxicity was significant; three patients developed myocardial infarction, and one patient died during therapy. Overall the toxicity and response rate for single-agent IL-2 are similar to that observed with IL-2 administered in combination with LAK cells in the previous trial. These results suggest that single-agent therapy with IL-2 when administered in this schedule has significant antimelanoma activity in humans, and that LAK cells generated from peripheral blood add little to the antimelanoma activity of this dose and schedule of IL-2. | 0 |
Unusual variants of adrenal pseudocysts with intracystic fat, myelolipomatous metaplasia, and metastatic carcinoma. Five previously unreported cases of adrenal pseudocysts are described that demonstrate a wider range of histologic appearances than has been previously recognized in these lesions. One pseudocyst removed from an asymptomatic 59-year-old female contained intracystic nests of cytologically malignant cells of unknown origin. Workup revealed a left breast mass, which on biopsy showed an infiltrating ductal carcinoma with neoplastic cells that were cytologically similar to those found within the cyst contents. Four other pseudocysts are described with variable numbers of intracystic vascular structures and benign adrenal cortical cells. In addition, intracystic mature adipose tissue was observed in all four cases, with myelolipomatous metaplasia found in one. Awareness of the wide histologic variability of these lesions should improve diagnostic accuracy and allow distinction from adrenocortical neoplasia and myelolipoma. | 4 |
Pregnancy outcome in hematologic malignancies. By means of a mail questionnaire, information on a series of 56 pregnancies i in 48 women diagnosed with leukemia or lymphoma was collected from ten hospitals. Seven patients conceived while receiving treatment for their neoplasms; in 22 patients, the hematologic disease was diagnosed during pregnancy, and the remaining 27 patients became pregnant after completion of the antineoplastic treatment. When a comparison was made of the evolution of these pregnancies to that of pregnancies in a healthy population, no increase in the incidence of complications was observed: 64% of the pregnancies went to term, 9% resulted in spontaneous abortion, and 5% resulted in premature births. The observed incidence of one major malformation in 56 pregnancies did not differ from the frequency of malformations in the offspring of healthy individuals. There were no fetal losses in six pregnancies in which conception occurred during the first year after chemotherapy. In spite of the inherent limitations derived from the design of this type of study and the type of subject analyzed, the data here support the hypothesis that the cytostatic treatment of hematologic malignancies, if deemed necessary, should not be postponed because of pregnancy. Moreover, the authors agree with advice recommending that no antifolic or alkylating agents be used for prolonged periods and that radiotherapy be avoided, especially to those fields involving the pelvic area. | 0 |
Intraoperative dexamethasone irrigation in lumbar microdiskectomy. In 45 lumbar hemilaminectomy/microdiskectomy patients, a control group of 23 patients had the standard operative procedure. The remaining 22 patients were treated with intraoperative irrigation of long-acting dexamethasone before incision closure. Age, weight, gender ratio, mean postoperative hospital stay, mean in-hospital narcotics usage, and incidence of perioperative complications among the two groups were compared. Age and gender ratios were comparable, although the control group was significantly heavier in body weight than the steroid-irrigated group. The steroid-irrigated group had a significant reduction in hospitalization and a marked reduction in narcotics usage compared with the control group. Postoperative fever occurred in one patient in the steroid group. The control group had three postoperative complications. These preliminary observations suggest that dexamethasone irrigation during lumbar diskectomy is a safe and effective adjunct to surgical management. | 2 |
Increased survival of ARDS patients with severe hypoxemia (ECMO criteria). The adult respiratory distress syndrome (ARDS) is a form of diffuse lung injury associated with multiple risk factors. Patients with severe hypoxemia who meet blood gas criteria defined by the extracorporeal membrane oxygenation trial (ECMO) of 1974 to 1977 have a reported survival of 11 percent. The reported survival has remained unchanged for 15 years despite numerous technologic advances. We prospectively studied ARDS patients who met ECMO blood gas criteria. One hundred seventy-eight ARDS patients were prospectively screened over a 30-month period. Fifty-one of these patients met ECMO blood gas criteria and 23 (45 percent) survived (p less than 0.001 vs ECMO trial). No obvious differences in etiology, APACHE II score, organ system failure, or the incidence of sepsis was found between survivors and nonsurvivors. We conclude that survival of ARDS patients who met ECMO blood gas criteria in our institution is higher than that previously reported from both other centers and our own hospital. | 4 |
Ultra short-acting intravenous beta-adrenergic blockade as add-on therapy in acute unstable angina. To assess the efficacy and safety of the ultra short-acting beta-blocking agent, esmolol, in acute unstable angina, we administered esmolol to 21 patients who had persistent angina despite conventional medical therapy. Following a baseline Doppler echocardiographic examination, esmolol was titrated to reduce the rate-pressure product by at least 20%. Once the patients had been receiving a maintenance dosage for 30 minutes, Doppler echocardiographic studies were repeated. Mean esmolol dose at target response was 17 +/- 16 mg/min, with the dosage range of 8 to 24 mg/min. Esmolol was effective in alleviating anginal chest pain in 18 of the 21 patients. Seven patients eventually underwent percutaneous transluminal coronary angioplasty (PTCA) and eight had coronary bypass surgery. The remainder were discharged receiving medical therapy including oral beta-blockade. During esmolol therapy, heart rate and blood pressure decreased significantly (86 +/- 14 to 68 +/- 12 beats/min and 125 +/- 16 to 103 +/- 20 mm Hg, both p less than 0.001). Cardiac output decreased from 5.4 +/- 1.3 to 4.5 +/- 1.1 L/min (p less than 0.001) secondary to a decrease in heart rate as stroke volume remained unchanged. Left ventricular ejection fraction increased from 47 +/- 12 to 49 +/- 13 with esmolol therapy, although this change was not statistically significant. Both the one third filling fraction as well as E/A ratio (ratio of early-to-late diastolic filling velocities) increased with esmolol therapy (35 +/- 8% to 38 +/- 8% and 0.73 +/- 0.2 to 0.85 +/- 0.23, both p less than 0.005), indicating improvement in left ventricular diastolic function. | 3 |
A prospective assessment of the Garren-Edwards Gastric Bubble and bariatric surgery in the treatment of morbid obesity. Morbid obesity is a serious medical hazard, and effective alternatives to surgery have been unsuccessful. In 1985, the Garren-Edwards Gastric Bubble (GEGB) was offered as an adjunct to dietary and behavioral therapy for weight loss treatment. The safety and efficacy of the GEGB were compared with bariatric surgery, the current standard for the treatment of morbid obesity. Fifty-seven patients received GEGB and 77 underwent bariatric surgery. GEGB patients were divided into two groups: those who attended group therapy and those who did not. This study showed that bariatric surgery was far more effective in reducing excess body weight during a 12-month period compared with the GEGB plus group therapy and the GEGB alone. The morbidity from bariatric surgery was greater than in the GEGB-treated groups, while the cost for uncomplicated cases for a year's treatment was comparable. It is concluded that the GEGB does not offer an effective alternative to bariatric surgery in the treatment of morbid obesity. | 4 |
Bacterial meningitis in the United States, 1986: report of a multistate surveillance study. The Bacterial Meningitis Study Group. A prospective, laboratory-based surveillance project obtained accurate data on meningitis in a population of 34 million people during 1986. Haemophilus influenzae was the most common cause of bacterial meningitis (45%), followed by Streptococcus pneumoniae (18%), and Neisseria meningitidis (14%). Rates of H. influenzae meningitis varied significantly by region, from 1.9/100,000 in New Jersey to 4.0/100,000 in Washington state. The overall case fatality rates for meningitis were lower than those reported in several studies from the early 1970s, suggesting that improvements in early detection and antibiotic treatment may have occurred since that time. Concurrent surveillance was also performed for all invasive disease due to the five most common causes of bacterial meningitis. Serotypes of group B streptococcus other than type III caused more than half of neonatal group B streptococcal disease and mortality, suggesting that an optimal vaccine preparation must be multivalent. Of the organisms evaluated, group B streptococcus was the second most common cause of invasive disease in persons greater than 5 years old. | 2 |
A community-based study of acute respiratory tract infections in children in Uruguay. Acute respiratory tract infection (ARI) was investigated in children less than 5 years old in a longitudinal community-based study of 166 families living in a socioeconomically depressed area in Montevideo, Uruguay. Pediatricians made home visits every 10 days from May 1985 to December 1987, and symptoms and signs of ARI were recorded. The incidence of ARI was 5.8 episodes per child-year during the first 12 months of life and decreased with increasing age of the index children; the rate was highest in children 1-5 months old. Children observed from birth were ill during 21% of the visits. According to the definitions of the study, the incidence of lower respiratory tract infection was 11.6% higher than the incidence of upper respiratory tract infections. The rates of ARI were higher during the colder months. Most risk factors for ARI were only marginally statistically significant. | 4 |
Synthesis of platelet activating factor by ocular tissue from inflamed eyes. Platelet activating factors (PAFs) are a family of ether lipids with properties that suggest a major role in inflammation. We have previously implicated PAFs in ocular inflammation based on the inhibition of several rabbit models of iritis with a specific PAF receptor antagonist. We have tested ocular tissues for the ability to synthesize PAF. Iris, ciliary body, cornea, and/or retina were carefully dissected from New Zealand white rabbits, and tissue from four eyes was pooled. Tissues were stimulated with calcium ionophore (10 mumol/L), and supernatants were extracted with chloroform-methanol. Platelet-aggregating activity was found in the chloroform phase in 2 of 9, 1 of 8, 0 of 9, and 3 of 9 studies involving iris, retina, ciliary body, or cornea, respectively. Twenty-four hours after the intravitreal injection of 125 ng of endotoxin, aggregating activity was consistently detectable from supernatants of stimulated iris and ciliary body, occasionally present from stimulated retina but not detectable from cornea. The shape of the aggregation curve resembled that produced by 0.5 to 2.0 ng of authentic PAF. Moreover, the aggregation could be completely inhibited by a PAF receptor antagonist and the aggregating activity chromatographed identically on high-performance liquid chromatography to a PAF standard. These studies indicate that PAF-like activity could be detected from several ocular tissues subsequent to inflammation. Iris, ciliary body, retina, vascular endothelium, and/or leukocytes could each contribute to the presence of this inflammatory mediator. | 4 |
Hemicorporectomy: a collective review. Hemicorporectomy or translumbar amputation has been described as the most revolutionary of all operative procedures. Frederick E. Kredel, who first voiced the concept of the operation in 1950, referred to it as halfectomy. Demonstration of his cadaver studies established the feasibility of the operation. Amputation is effected through the lower lumbar area of the body. Necessary life functions are preserved in the upper torso. Kredel envisioned hemicorporectomy as a curative operation for locally advanced cancer, limited to the pelvis, not encompassable by standard operative intervention. Additional indications are intractable decubitus ulcers with malignant change, particularly in paraplegics; pelvic organs, and bone infection with nonhealing fistulae; and crushing trauma to the pelvis. The first hemicorporectomy operation was reported in 1960. Thirty-four operations have been recorded in the world literature. Two heretofore unreported cases are added, raising the total to 36. Review of these 36 cases confirms the conviction that hemicorporectomy is a humane and ethical alternative to the suffering encumbered by advancing, painful, malodorous malignant disease not treatable by conventional means. While cure rates are not substantial, the best results are reported in paraplegics with intractable decubitus ulcers with or without malignancy. Rehabilitation is prolonged and costly. Most survivors have been restored to preoperative occupations or other gainful employment. | 4 |
Scientific inquiry in childhood cancer psychosocial research. Theoretical, conceptual, and methodologic issues in the investigation and behavioral treatment of procedure-related distress. This paper discusses the current status of scientific inquiry in childhood cancer psychosocial research. The investigation and behavioral treatment of procedure-related distress serves as a model for illustrating and outlining some of the theoretical, conceptual, and methodologic issues and problems that exist in the area of childhood cancer psychosocial research. Specifically, issues related to the process of scientific inquiry, theoretical/conceptual modeling, measurement and assessment, and behavioral treatment strategies are discussed. Examples of how these issues have been addressed in our investigations of procedure-related distress are presented and recommendations for facilitating growth and development in the field of childhood cancer psychosocial research are offered. | 0 |
Spontaneous infarction of placental chorioangioma and associated regression of hydrops fetalis. We report a case of a large chorioangioma diagnosed prenatally with concomitant meconium peritonitis and hydrops fetalis in the second trimester. Spontaneous regression of the tumor occurred, associated with some resolution of the fetal hydrops and delivery near term with good neonatal outcome. | 4 |
Growth abnormalities in children with juvenile rheumatoid arthritis. Growth abnormalities in juvenile rheumatoid arthritis can be divided into two groups: local and systemic. Local disorders of growth often result in increased bone length and bone age or in marked decreases in longitudinal growth due to immobilization, premature epiphyseal closure, or fusion. Common growth defects seen in the knee, hand, wrist, hip, spine, and jaw are discussed. Systemic growth delay is most commonly secondary to active disease or treatment with corticosteroids. Nutritional aspects such as decreased appetite, reduced caloric intake, metabolic caloric requirements greater than available intake, or lack of essential vitamins could be the cause for decreased weight and stature. | 4 |
Tissue preparation for simultaneous flow cytometric quantitation of tumour associated antigens and DNA in solid tumours. A multiparameter flow cytometric assay for the simultaneous study of tumour associated antigens (TAA) and DNA in fresh solid tumours was devised. Cell suspensions were prepared by disaggregating unfixed solid tumour samples mechanically over a stainless steel mesh. Indirect immunofluorescence was used to identify the TAA, and DNA was stained with propidium iodide. Cell morphology was well preserved, cell clumping was negligible, and high quality indirect immunofluorescence quality indirect immunofluorescence and DNA staining were obtained. The technique is simple, rapid, and reproducible. Multiparameter assays can be developed to study prognostic indicators such as membrane oncoproteins, receptors, and multidrug resistance in solid tumours. With a suitable panel of antibodies the technique might become an aid in the differential diagnosis and biochemical diagnosis of some solid tumours. | 0 |
Sexual and physical abuse in women with functional or organic gastrointestinal disorders. STUDY OBJECTIVES: To determine the prevalence of a history of sexual and physical abuse in women seen in a referral-based gastroenterology practice, to determine whether patients with functional gastrointestinal disorders report greater frequencies of abuse than do patients with organic gastrointestinal diseases, and to determine whether a history of abuse is associated with more symptom reporting and health care utilization. DESIGN: A consecutive sample of women seen in a university-based gastroenterology practice over a 2-month period was asked to complete a brief questionnaire. MEASUREMENTS: The self-administered questionnaire requested information about demographics, symptoms, health care utilization, and history of abuse. Physicians indicated the primary diagnosis for each patient and whether she had ever discussed having been sexually or physically abused. RESULTS: Of 206 patients, 89 (44%) reported a history of sexual or physical abuse in childhood or later in life; all but 1 of the physically abused patients had been sexually abused. Almost one third of the abused patients had never discussed their experiences with anyone; only 17% had informed their doctors. Patients with functional disorders were more likely than those with organic disease diagnoses to report a history of forced intercourse (odds ratio, 2.08; 95% CI, 1.03 to 4.21) and frequent physical abuse (odds ratio, 11.39; CI, 2.22 to 58.48), chronic or recurrent abdominal pain (odds ratio, 2.06; CI, 1.03 to 4.12), and more lifetime surgeries (2.7 compared with 2.0 surgeries; P less than 0.03). Abused patients were more likely than nonabused patients to report pelvic pain (odds ratio, 4.05; CI, 1.41 to 11.69), multiple somatic symptoms (7.1 compared with 5.8 symptoms; P less than 0.001), and more lifetime surgeries (2.8 compared with 2.0 surgeries; P less than 0.01). CONCLUSIONS: We found that a history of sexual and physical abuse is a frequent, yet hidden, experience in women seen in referral-based gastroenterology practice and is particularly common in those with functional gastrointestinal disorders. A history of abuse, regardless of diagnosis, is associated with greater risk for symptom reporting and lifetime surgeries. | 1 |
Pneumonia complicating abdominal sepsis. An independent risk factor for mortality. Nosocomial pneumonia (NP) is associated with a significant mortality, 66% in a previous retrospective study of NP complicating intra-abdominal sepsis (IAS). We prospectively compared the outcome of NP complicating IAS with that of recurrent IAS (R-IAS) in the absence of NP. Data were collected prospectively on 300 patients with IAS; 34 patients who presented with pneumonia were excluded from the analysis (44% mortality). One hundred seventy-one patients with no NP and no R-IAS (group 1) had a hospital mortality of 20% (34 patients); 36 without NP in whom R-IAS developed (group 2) had a 17% mortality (six patients); and 47 with NP but no R-IAS (group 3) had a 53% mortality (25 patients). Finally, 12 patients who had both NP and R-IAS suffered a 75% mortality (nine patients). We examined the relationships among the following putative risk factors and mortality: APACHE (acute physiology and chronic health evaluation) II score (at initial presentation with IAS), the need for mechanical ventilatory assistance following initial treatment for peritonitis, steroid requirement, generalized peritonitis vs abscess, and the need for surgical as opposed to percutaneous treatment. Using mortality as the dependent variable, group 2 vs 3 as the explanatory variable, and the risk factors as confounders, logistic regression analysis indicated that the group difference was significant after controlling for confounders. We conclude that NP complicating IAS is an independent risk factor associated with a significant mortality compared with R-IAS. These data challenge the notion that death in IAS is usually due to recurrent or persistent intra-abdominal infection. | 4 |
Attenuation of suxamethonium myalgias. Effect of midazolam and vecuronium. We studied the incidence of fasciculations and postoperative myalgias in 100 female outpatients who had laparoscopy under thiopentone, N2O, isoflurane anaesthesia. Four groups of 20 patients each were pretreated with saline (group 1), tubocurarine 0.05 mg/kg (group 2), vecuronium 0.006 mg/kg (group 3), or midazolam 0.025 mg/kg (group 4), followed by suxamethonium 1.5 mg/kg. Group 5 received only vecuronium 0.1 mg/kg as relaxant (no suxamethonium). Fasciculations were graded, and postoperative myalgias rated on the first and third postoperative days. In groups 1-5 the incidence of fasciculations was 95, 15, 25, 95 and 0%; the incidence of myalgias on the first day after operation was 70, 45, 65, 75 and 60%, and on the third day after operation 20, 5, 20, 20, and 5%, respectively. We conclude that pretreatment with vecuronium, but not midazolam, decreases the incidence of fasciculations after suxamethonium (p less than 0.05) and that in this patient population, postoperative myalgias appear to be unrelated to the use of suxamethonium. | 4 |
Trial of brief intermittent neuroleptic prophylaxis for selected schizophrenic outpatients: clinical and social outcome at two years. OBJECTIVE--To evaluate a novel approach to the prophylaxis of schizophrenic relapse characterised by administration of brief courses of neuroleptic for the earliest non-psychotic signs of relapse (prodromal symptoms). DESIGN--Two year follow up of subjects randomised, double blind, to receive either active (control group) or placebo (intermittent group) depot neuroleptic medication. Both groups received brief courses of oral neuroleptic when prodromal symptoms or relapse occurred. SETTING--Psychiatric outpatient department, Charing Cross Hospital, London. SUBJECTS--54 Stable patients in remission who met the American Psychiatric Association's DSM-III criteria for schizophrenia on the basis of case notes. MAIN OUTCOME MEASURES--Survival without relapse, survival without hospitalisation, point prevalence of extrapyramidal side effects and tardive dyskinesia, structured assessment of social functioning (social adjustment scale II), and frequency of prodromal symptoms. RESULTS--Of 19 relapses recorded over two years, 10 (53%) were preceded by non-psychotic prodromal signs. Survival rates for both relapse and hospitalisation were worse with intermittent treatment than continuous treatment over the two year follow up: 92% of controls and only 54% of patients given intermittent treatment survived the two year period without hospitalisation. Prolonged or frequent relapses as well as episodes of prodromal symptoms were more frequent with intermittent treatment. Lower scores for extrapyramidal side effects were recorded in the intermittent treatment group, but periodic assessments of social functioning failed to show any social advantages from this. CONCLUSION--The findings are at variance with a previous report of one year follow up in this cohort and attest to the superiority of continuous depot neuroleptic prophylaxis in preventing both psychotic and neurotic or dysphoric morbidity in schizophrenia. | 2 |
Putative mechanism of blood pressure reduction induced by increases in dietary calcium intake. An increase in dietary calcium intake lowers blood pressure in spontaneously hypertensive rats and in some patients with arterial hypertension. The mechanisms by which this decrease come about are not clear. A membrane-stabilizing effect wrought by an increase in extracellular calcium would appear unlikely, since the increases in extracellular calcium concentration with increased dietary intake are minimal. Calcium regulatory hormones may be the mediators, and a cybernetic framework has been suggested. Striking defects have been reported in the calcium handling and hormonal household of the spontaneously hypertensive rat. However, a clear cut relationship in terms of a hormonal "template" has not yet been identified in prospective experiments. Data have been presented to show that increased calcium intake has a direct effect on regulatory areas in the brain. However, the mechanisms by which such a response would be mediated are entirely unknown. Increased calcium intake may induce natriuresis. It has been suggested that increased calcium intake helps the "salt sensitive"; however, prospective studies to this effect have not been presented. Increased calcium intake may induce phosphaturia. However, the evidence that blood pressure lowering effects are mediated by phosphate depletion are unconvincing. Some evidence suggests that increased calcium intake may influence local regulatory processes which in turn influences cell integrity and growth. At this point, a unifying hypothesis is not available. However, the clues to various possibilities are intriguing. | 3 |
Fatal sepsis following intravesical bacillus Calmette-Guerin administration for bladder cancer. Intravesical administration of bacillus Calmette-Guerin has been shown to be highly effective treatment of superficial bladder cancer. Complications from bacillus Calmette-Guerin therapy are usually minor but serious and even fatal reactions can occur. Five recent cases illustrate the gravity of bacillus Calmette-Guerin sepsis. One man with severe debility and the organic brain syndrome died acutely with a fever of 40 C. Two men had frank sepsis that progressed to multiorgan failure and death. Sepsis progressed despite the use of isoniazid, rifampin and streptomycin. Two men who had equally progressive sepsis with intravesical bacillus Calmette-Guerin survived with the use of cycloserine for the first 72 hours of treatment. Triple antituberculous antibiotics, including cycloserine, may be lifesaving. Sepsis resulted from intravenous absorption through inflamed or disrupted urothelium. Bacillus Calmette-Guerin treatment should not be administered in the presence of severe cystitis or after grossly traumatic catheterization. | 4 |
Infrarenal abdominal aortic disease: a review of the retroperitoneal approach. Transabdominal exposure is the most widely used surgical approach to the infrarenal aorta. Over the last 30 years a number of surgeons have championed the retroperitoneal approach for repair of abdominal aortic aneurysms and aortoiliac occlusive disease using a variety of incisions. Several studies attest to the clinical superiority of this approach over the transabdominal route and recent evidence demonstrates reduced physiological disturbance with this technique. The retroperitoneal approach is suitable for all elective operations on the abdominal aorta, particularly in patients with high-risk aneurysms and in selected patients with symptomatic and ruptured aneurysms. | 4 |
Audiometric and subjective assessment of hearing handicap. This study compares self-perceived assessment of hearing handicap with audiometrically derived measures of hearing handicap in a sample of elderly persons. Subjects were evaluated by traditional audiometric tests, the Speech Perception in Noise test, and the Hearing Handicap Inventory for the Elderly, a self-assessment questionnaire. Hearing handicap was also calculated by the audiometrically derived American Academy of Otolaryngology (1979) method. Our results are consistent with other studies that indicate a low correspondence between audiometric measures of hearing handicap and self-assessment of hearing handicap. Furthermore, if the Hearing Handicap Inventory for the Elderly is considered the true measure of hearing handicap, our data indicate that the American Academy of Otolaryngology method tends to overestimate handicap among persons with no self-perceived hearing handicap and underestimates handicap among persons with significant self-perceived hearing handicap. | 4 |
Relation between beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure. The Multicenter Diltiazem Post-Infarction Research Group. This study examined the relations among beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure in patients after myocardial infarction. The study was performed with the placebo group of the Multicenter Diltiazem Post-Infarction Trial. Ejection fraction data were available in 1,084 patients; of these, 557 were receiving a beta-blocker and 527 were not. In addition to ejection fraction, other correlates of left ventricular function included the presence or absence of pulmonary rales, chest X-ray film evidence of pulmonary congestion and the presence of an S3 gallop. Beta-blocker use was less frequent in patients with an ejection fraction less than 30%, rales, an S3 gallop and pulmonary congestion on chest X-ray film. Twenty-one percent of patients with an ejection fraction less than 30%, 42% of patients with rales, 28% of patients with an S3 gallop and 28% of patients with pulmonary congestion were receiving beta-blocker therapy. For every correlate of left ventricular function, the chance of developing congestive heart failure was greater in patients with diminished left ventricular function than in those without. For each level of left ventricular function, the chance of developing congestive heart failure requiring treatment was greater in patients not taking a beta-blocker. | 3 |
Prostaglandin modulation of early afterdepolarizations and ventricular tachyarrhythmias induced by cesium chloride combined with efferent cardiac sympathetic stimulation in dogs. Prostaglandins inhibit efferent cardiac sympathetic nerve effects by acting at presynaptic sites and may act to suppress some arrhythmias. In the present study, the effects of intravenous administration of prostacyclin (PGI2) and prostaglandin E2 (PGE2) on early afterdepolarizations and ventricular tachycardia induced by cesium chloride (0.5 mmol/liter per kg body weight intravenously) combined with stimulation of bilateral ansae subclaviae in anesthetized dogs were examined. The right atrium was paced at a constant cycle length of 600 ms. A left ventricular endocardial monophasic action potential catheter was used to detect early afterdepolarizations. Prostacyclin (0.2 microgram/kg per min) reduced the amplitude of the early afterdepolarizations (39.2 +/- 8.4% of the monophasic action potential amplitude during control study to 28.7 +/- 5.5%, n = 10; p less than 0.001) as well as the prevalence of ventricular tachycardia (11 of 14 dogs during control study to 5 of 14 dogs; p = 0.031). Prostaglandin E2 (0.2 to 0.6 microgram/kg per min) did not significantly reduce the early afterdepolarization amplitude (34.7 +/- 8.9% to 25.1 +/- 10.7%, n = 8; p = 0.085) or the prevalence of ventricular tachycardia (8 of 10 versus 6 of 10 dogs; p = 0.50). Alpha- and beta-adrenoceptor blockade with combined intravenous administration of propranolol (0.5 mg/kg) and phentolamine (0.3 mg/kg) decreased the amplitude of the early afterdepolarizations induced by cesium chloride and bilateral ansae subclaviae stimulation from 38.6 +/- 11.2% to 18.8 +/- 3.3% (n = 6; p = 0.005). Additional administration of PGI2 further reduced the early afterdepolarization amplitude from 18.8 +/- 3.3% to 9.8 +/- 4.8% (n = 6; p = 0.001). | 3 |
Beta blockers and the primary prevention of nonfatal myocardial infarction in patients with high blood pressure. A population-based, case-control study was conducted to determine whether beta blockers, used for the treatment of high blood pressure, prevent first events of coronary heart disease. All study subjects were health-maintenance organization enrollees with pharmacologically treated hypertension. Patients presented in 1982 to 1984 with new coronary heart disease, and control subjects were a probability sample of eligible hypertensive enrollees free of coronary heart disease. With the investigators blind to case-control status, the subjects' medical records were reviewed for other coronary risk factors, and the health-maintenance organization's computerized pharmacy database was used to ascertain the use of beta blockers. A larger proportion of controls than cases were using beta blockers. This difference was confined to the subgroup with nonfatal myocardial infarctions. For current use, the estimated relative risk for nonfatal myocardial infarction was 0.62 (95% confidence interval, 0.39 to 0.99). Among current users of beta blockers, higher doses conferred greater protection. Past use and total lifetime intake of beta blockers were only weakly associated with case-control status. The current use of beta blockers may prevent first events of nonfatal myocardial infarction in patients with high blood pressure. | 3 |
Acute porphyria presenting with hyperamylasemia. An elevation of serum amylase and lipase has not been reported previously to occur with porphyria. In this report, we describe a patient who presented with the clinical and laboratory picture of pancreatitis: elevated amylase, lipase, amylase-creatinine clearance ratio, and with abdominal pain. Only after extensive evaluation, was the patient found to have porphyria. On two separate occasions, with hematin therapy, her serum amylase decreased, as did her clinical symptoms of porphyria and her urinary quantitative porphyrins. This suggests an association between elevation of the serum amylase and lipase with acute porphyria. Moreover, this association can lead to delay in establishing the diagnosis of acute porphyria. | 1 |
Delayed rupture of a pseudoaneurysm of the costocervical trunk: treatment with therapeutic embolization. Fourteen days after removal of an internal jugular catheter inserted prior to renal transplantation, a patient presented with brisk arterial hemorrhage from the insertion site. The hemorrhage, caused by a ruptured pseudoaneurysm of the costocervical trunk, was controlled by transcatheter embolization with gelatin particles. One year later the patient reported no problems related to the pseudoaneurysm or its management. | 3 |
Significance of U wave polarity in patients with a prior inferior myocardial infarction. Sixty consecutive patients who underwent coronary angiography and left ventriculography from six to eight weeks after the onset of definite inferior myocardial infarction were divided into three groups according to the polarity of U waves in (1) leads II, III, a VF and (2) in leads V4 to V6 (positive = Group P, flat or isoelectric = Group F, and negative = Group N). The following parameters were analyzed: (1) ECG score; (2) global ejection fraction: (3) regional area change: (4) number of asynergic, and akinetic segmental radii; (5) number of asynergic and akinetic areas: and (6) number of diseased coronary arteries and the incidence of left anterior descending artery (LAD) disease. There were no significant differences among the three groups according to the polarity of U waves in two subgroups by the site of U waves in age, gender, systemic blood pressure, and ECG scores. The polarity of U waves in leads II.III.a VF (subgroup 1) correlated with the size of myocardial infarction; regional area changes in inferior segment (Area 2) were 64.1 +/- 8.2 in group P1, 31.8 +/- 14.7 in group F1, and 21.0 +/- 15.8 in group N1 (p less than 0.01, F = 32.8). The polarity of U waves in leads V4-6 (subgroup2) correlated with anterolateral wall motion; regional area changes in anterolateral segments (Area 5) were 76.8 +/- 11.6 in group P, 66.5 +/- 18.5 in group F, and 48.9 +/- 17.1 in group N (p less than 0.01, F = 18.6). The incidence of multivessel disease increased from group P2 (36.4%), to group F2 (54.5%), to group N2 (75.0%), and the incidence of LAD disease increased from 27.3%, to 45.5%, to 68.8%, respectively. A negative U wave in either location suggested severely decreased apical wall motion, and there was a tendency for global ejection fractions to decrease in the following order: group P, group F, and group N. From these results, the authors conclude that the polarity of U waves may be one of the parameters correlating with the wall motion and left ventricular function in prior inferior myocardial infarction. | 3 |
Surgical correction of recurrent venous ulcer. Seventy-six limbs from 46 patients with comparable superficial and deep venous valve incompetence underwent surgical correction for recurrent venous ulcers of the leg that were refractory to various modes of nonsurgical and surgical treatments. A follow-up of 10 to 73 months (mean = 37 months), revealed the venous ulcer healed with perforator ligation and saphenous vein stripping in 14 of 33 (44%), stripping plus valvuloplasty 17 of 21 (80%), stripping plus vein transposition 11 of 14 (78%) and stripping plus valve transplantation 6 of 8 (75%). In patients with incompetent deep venous valve and perforators, the disassociation of the superficial from the deep venous system (stripping) plus correction of the deep venous valvular incompetence (valvuloplasty, transposition or valve transplant) produced superior results in the treatment of recurrent venous ulcer when compared to perforator ligation and saphenous vein stripping alone (p less than 0.005). Adjunctive usage of elastic stockings and intermittent compression pneumatic boots in the perioperative period was helpful in controlling leg swelling and promoting wound healing. | 4 |
Apparent reduction in the size of one side of the face associated with a small retrosplenial haemorrhage. A 68 year old Japanese female with unilateral metamorphopsia of the face that developed after a small haemorrhage in the contralateral retrosplenial region, is described. The patient claimed that the right side of a face, that is, the left side when looked at by the patient, appeared smaller than the left. In addition, her drawings of the face showed some distortions. Objects other than the face were perceived normally. Cranial CT scan revealed a small high density area in the right retrosplenial region. The face appears to have a special representation in the posterior hemisphere. | 4 |
Complete jejunoileal necrosis due to torsion of the superior mesenteric artery. We have reported a case of small-bowel volvulus in which complete jejunoileal necrosis resulted from torsion of the superior mesenteric artery. This case was unusual not only because of the extent of necrosis but also because primary small-bowel volvulus is rare in adults. Despite nearly total small-bowel resection, the patient continues to do well 6 months postoperatively. | 4 |
Genetic diagnosis of Lynch syndrome II in an extended colorectal cancer-prone family. Knowledge of colon cancer genetics, with particular attention to precision in hereditary cancer syndrome diagnosis, can often enable highly targeted surveillance and management strategies for patients at high genetic risk. Unfortunately, the patient's family history of cancer is often given minimal attention, and knowledge of hereditary cancer syndromes is frequently limited. Indeed, many physicians still consider familial adenomatous polyposis (FAP) as the only genetic risk factor for colorectal cancer. This concern with FAP was noted in a colorectal cancer-prone kindred which for decades had been thought to manifest that syndrome. However, after meticulous genetic, medical, and pathologic studies, the cardinal phenotypic characteristics of Lynch syndrome II were observed. The potential for cancer control in current and future generations of families like this one clearly mandates the need for computerized registries which could transmit current information about hereditary colon cancer syndrome diagnosis, surveillance, and management. | 4 |
Recent changes in the treatment of aortoiliac occlusive disease by the Oxford Regional Vascular Service. Over the four years from 1 January 1985 to 31 December 1988, 192 patients were treated for aortoiliac occlusive disease by the Oxford Regional Vascular Service. The number of patients treated by percutaneous transluminal angioplasty increased from two in the first year of the study to 34 in the third year of the study. This increase was accompanied by a decrease in the proportion of patients treated by aortobifemoral bypass but the proportion of patients treated by extra-anatomic bypass remained constant at around 30 per cent. Twice as many patients were treated in the fourth year as in the first year of the study so that the number of surgical operations increased despite many patients being treated exclusively by percutaneous transluminal angioplasty. The number of patients requiring mandatory treatment for limb salvage increased by 109 per cent and optional treatment for intermittent claudication by 85 per cent. The introduction of percutaneous transluminal angioplasty in Oxford has coincided with an increase in the number of patients presenting with symptomatic aortoiliac occlusive disease and has allowed twice as many people to be treated while the number of aortobifemoral bypass operations has remained unchanged. It is concluded that the introduction of percutaneous transluminal angioplasty has not only generated its own workload but has also led to an increased demand for surgical reconstruction for aortoiliac occlusive disease. | 3 |
Why do lean hypertensives have higher mortality rates than other hypertensives? Findings of the Hypertension Detection and Follow-up Program. Specific causes of death were analyzed for 10,908 participants in the Hypertension Detection and Follow-up Program, to explore possible explanations for the observed excess 8.3-year mortality from all causes in hypertensives with low body mass. Although the cardiovascular mortality rate among men in the lowest decile of body mass (body mass index 21.96 or less) was 50% higher than that of men in the median class (body mass index 26.4-28.8), death rate for noncardiovascular deaths was more than 2 1/2 times higher in men with lean versus median body mass. The pattern was similar among women. Among noncardiovascular causes, striking differences in mortality rates between lean hypertensives and those of average body mass were observed for cirrhotic death (relative risk of 12+ in men and 11+ in women), for nonmalignant respiratory disease in men (relative risk of 7+), for violent death (both sexes), and for malignant neoplasms in men. Prevalence of smoking was almost twice as high in the lowest compared with the median body mass group; among the lean, excess deaths, particularly noncardiovascular deaths, were concentrated among smokers. Thus, male smokers in the lowest decile of body mass constituted only 3% of the study population, but contributed 8% of all deaths, 11% of all noncardiovascular deaths, and 22% of all cirrhotic deaths. A larger proportion of deaths occurred early in follow-up in the lean versus other hypertensives, suggesting occult disease among the lean at baseline. There was no evidence that more severe or treatment-resistant hypertension was present in or could explain excess mortality among the hypertensives with low body mass. The inference from the findings is not that overweight is protective for hypertensives nor that excess risk is due to leanness per se. Rather, a reasonable hypothesis, particularly from findings on specific causes of death, is that excess mortality in lean hypertensives is due to deleterious lifestyles, particularly smoking and excess alcohol intake, contributing to both leanness and risk of death. | 3 |
Thoracoplasty: current application to the infected pleural space Thoracoplasty, once commonly used in the management of cavitary pulmonary disease, continues to find application in the obliteration of infected pleural spaces. This study reports a series of 13 patients receiving thoracoplasty between 1976 and 1989. Five patients had chronic apical empyema spaces without prior resection of lung tissue. Two of the empyemas were due to tuberculosis, two were due to atypical mycobacteria, and one was due to postpneumonic empyema. All patients had extensive destruction of upper lobe tissue. Eight patients had undergone prior pulmonary resection; 3 had persistent infected spaces in the early postoperative period, 3 had development of empyemas and bronchopleural fistulas late (5 to 19 years) after pulmonary resection, and 2 had postpneumonectomy empyema. All patients had rigid cavity walls preventing space obliteration by rib removal alone and required concomitant resection of the thickened pleura and intercostal muscle tissues. Bronchopleural fistulas were present in 11 patients and were closed with adjacent nonintercostal muscle. All patients survived and had successful obliteration of the infected spaces with acceptable physiological and cosmetic results. We conclude that thoracoplasty remains a useful procedure in the management of the infected pleural space in select patients. | 4 |
A prognostic system for transient ischemia or minor stroke. OBJECTIVE: To build a prognostic system for patients with carotid transient ischemic attack or minor stroke. DESIGN: Inception cohort study with 2-year follow-up. SETTING: Urban community teaching hospital. PATIENTS: Eligible patients (n = 142), identified on a carotid ultrasound roster, had been hospitalized between 1984 and 1987 within 30 days of a first carotid transient ischemic attack or minor stroke. MEASUREMENTS: Stroke or death within 2 years. MAIN RESULTS: Three factors were associated with stroke or death: age of more than 65 years, diabetes, and hypertension. Based on regression coefficients, age of more than 65 years was assigned 3 points; diabetes, 3 points; and hypertension, 2 points. An initial prognostic system comprised risk groups 1 (0 points), 2 (1 to 5 points), and 3 (6 to 8 points). Outcome rates in the three groups were 2%, 31%, and 54% (P less than 0.0001), respectively. In an independent test sample, the corresponding outcome rates for the initial system were 12%, 21%, and 31% (P = 0.04). A final prognostic system, including two additional predictors (coronary heart disease [1 point] and the distinction between stroke and transient ischemic attack for the baseline event [2 points]), comprised risk groups 1 (0 to 2 points), 2 (3 to 6 points), and 3 (7 to 11 points). Corresponding outcome rates were 3%, 27%, and 48% (P less than 0.001) in the original cohort and 10%, 21%, and 59% (P less than 0.001) in the test cohort. CONCLUSION: For selected patients with carotid transient ischemia or minor stroke, five clinical features can be combined to stratify effectively the risk for a subsequent stroke or death. | 4 |
The renally compromised older hypertensive: therapeutic considerations. Although the slow progression of renal insufficiency caused by aging does not usually reach the clinical disease level, nephron loss may be accelerated by the concomitant presence of hypertension and renal artery atherosclerosis. Treatment of hypertension and correction of other risk factors promoting atherosclerosis is appropriate in the elderly. Consideration should be given to a search for reversible causes of renal functional deterioration in elderly patients, particularly in those with increasingly refractory hypertension. In the uncomplicated elderly hypertensive, renal function appears to be adequately preserved if blood pressure is well controlled, although there may be a subset in whom factors other than blood pressure itself, such as glomerular hemodynamic disturbances, promote progressive renal dysfunction. | 3 |
Continuous muscle fiber activity, peripheral neuropathy, and thymoma. Two patients, one of them with myasthenia gravis, presented symptoms of continuous muscle fiber activity syndrome before discovery of a thymoma. Peripheral neuropathy was present in both patients, with axonal and demyelinating lesions in sural nerve biopsy. The syndrome remained unchanged or worse after thymectomy. Both patients died of associated complications. | 0 |
Immunohistochemical demonstration of the placental form of glutathione S-transferase, a detoxifying enzyme in human gliomas. Expression of the human placental form of glutathion S-transferase (GST-pi) in human gliomas was investigated by immunohistochemical methods, and the result was compared with that of normal human glial cells. The gliomas in this study were composed of five benign astrocytomas (Grade 2), ten anaplastic astrocytomas (Grade 3), and 16 glioblastomas (Grade 4). Normal human glial cells showed only a weak immunostaining response for GST-pi in the cytoplasm or some nuclear membranes. All of benign astrocytomas had diffusely weak GST-pi immunostaining, resembling that of normal glial cells. With increasing grade, gliomas showed a strongly positive reaction for GST-pi. The positive reactions were remarkable especially in the gemistocytes and giant cells in the high-grade gliomas. These results suggest that cells of gliomas have some detoxifying function and the expression of this detoxifying enzyme, GST-pi, is related to the degree of malignancy of the gliomas. | 0 |
Long-term echocardiographic follow-up of patients with a tricuspid bioprosthesis. To clarify the long-term results of bioprosthetic valve function in the tricuspid position, 29 consecutive patients who underwent tricuspid valve replacement (TVR) were evaluated. There were 20 girls/women and 9 boys/men, with ages ranging from 6 to 61 years (mean 41.4 years). The bioprosthetic valves included Hancock in 2, and Carpentier-Edwards in 27. The follow-up period ranged from 32 to 145 months (mean 89 months). Regurgitant flow of the tricuspid bioprosthesis was studied by color Doppler echocardiography. Peak velocity (Vp) and pressure half time (PHT) were measured by continuous wave Doppler echocardiography. Operative mortality was 13.7% (4/29), with the actuarial survival rate, including operative deaths, 75% at 10 years. Valve thrombosis developed in one patient 4 years after TVR. Color Doppler showed regurgitation in 7 of the 20 patients who were completely followed up, but they were all asymptomatic and required no special intervention. Cusp tear or calcification requiring reoperation was not observed in this study, including 8 patients younger than 35 years of age. The Vp was significantly slower, and PHT was significantly prolonged, in the tricuspid rather than the mitral position. These data demonstrate that bioprosthetic valves in the tricuspid position can be used safely. Doppler examination should be performed taking these different flow dynamics into account. | 4 |
Central neurogenic hyperventilation in invasive laryngeal carcinoma. We describe a patient with central neurogenic hyperventilation secondary to extension of a laryngeal tumor into the base of the brain, resulting in extrinsic compression of the medulla. Such an association has not been previously described. Unique features which distinguish this patient from previously reported cases are emphasized. Possible mechanisms involved in pathogenesis, as well as types of therapy, are outlined. | 0 |
Acquired benign esophagorespiratory fistula: report of 16 consecutive cases. Sixteen cases of acquired benign esophagorespiratory fistula were treated in a 20-year period. A delay in diagnosis was usual, and most patients were first seen with a pulmonary infection already developed. Contrast esophageal x-ray studies established the diagnosis in all patients. There were seven esophagotracheal and nine esophagobronchial fistulas. A fistula between the esophageal diverticulum and a bronchus considered to be of inflammatory origin developed in 7 patients. A fistula as the consequence of trauma developed in 9 patients, and these fistulas were situated at a higher level of the respiratory tree. All patients underwent surgical treatment; in 12 it was definitive, and in 4 temporary gastrostomy was performed to improve nutrition before definite repair. The definitive repair consisted of eventual diverticulectomy, division of the fistula, and suture of both esophageal and respiratory defects. Two patients required esophageal resection and later reconstruction with colon interposition. One patient died, creating an operative mortality of 8.3% in the definitive-repair group. The remaining 11 patients had a gratifying long-term result. There were two deaths in the gastrostomy group due to an extremely poor condition of patients and debilitating pulmonary infection. Early diagnosis of this rare condition is necessary if severe pulmonary complications are to be avoided. Early direct repair gives excellent results. | 1 |
Multicenter trial of L-carnitine in maintenance hemodialysis patients. II. Clinical and biochemical effects. Since carnitine deficiency has been reported in some patients undergoing maintenance hemodialysis, we studied the effects of intravenous infusion of L-carnitine or placebo at the end of each dialysis treatment. The trial, which lasted seven months (one month baseline, 6 months treatment) was multicenter, double blind, placebo controlled, and randomized. Eighty-two long-term hemodialysis patients, who were given either carnitine (N = 38) or placebo (N = 44), completed this study. In each group, clinical and biochemical parameters during treatment were compared with baseline values. Intra-dialytic hypotension and muscle cramps were reduced only in the carnitine treated group, while improvement in post-dialysis asthenia was noticed in both carnitine and placebo groups. Maximal oxygen consumption, measured during a progressive work exercise test, improved significantly in the carnitine group (111 +/- 50 ml/min. P less than 0.03) and was unchanged in the placebo group. L-carnitine treatment was associated with a significant drop in pre-dialysis concentrations of serum urea nitrogen, creatinine and phosphorus (means +/- SEM, 101 +/- 4.5 to 84 +/- 3.9, 16.7 +/- 0.67 to 14.7 +/- 0.64, and 6.4 +/- 0.3 to 5.5 +/- 0.4 mg/dl, respectively, P less than 0.004). No significant changes in any of these variables were noticed in the placebo group. Mid-arm circumference and triceps skinfold thickness were measured in 11 carnitine and 13 placebo treated patients. Calculated mid-arm muscle area increased in the carnitine patients (41.37 +/- 2.68 to 45.6 +/- 2.82 cm2, P = 0.05) and remained unchanged in the placebo patients. | 2 |
Cerebellar and frontal hypometabolism in alcoholic cerebellar degeneration studied with positron emission tomography. Local cerebral metabolic rate for glucose was studied utilizing 18F-2-fluoro-2-deoxy-D-glucose and positron emission tomography (PET) in 14 chronically alcohol-dependent patients and 8 normal control subjects of similar age and sex. Nine of the 14 patients (Group A) had clinical signs of alcoholic cerebellar degeneration, and the remaining 5 (Group B) did not have signs of alcoholic cerebellar degeneration. PET studies of Group A revealed significantly decreased local cerebral metabolic rates for glucose in the superior cerebellar vermis in comparison with the normal control subjects. Group B did not show decreased rates in the cerebellum. Both Groups A and B showed decreased local cerebral metabolic rates for glucose bilaterally in the medial frontal area of the cerebral cortex in comparison with the normal control subjects. The severity of the clinical neurological impairment was significantly correlated with the degree of hypometabolism in both the superior cerebellar vermis and the medial frontal region of the cerebral cortex. The degree of atrophy detected in computed tomography scans was significantly correlated with local cerebral metabolic rates in the medial frontal area of the cerebral cortex, but not in the cerebellum. The data indicate that hypometabolism in the superior cerebellar vermis closely follows clinical symptomatology in patients with alcoholic cerebellar degeneration, and does not occur in alcohol-dependent patients without clinical evidence of cerebellar dysfunction. Hypometabolism in the medial frontal region of the cerebral cortex is a prominent finding in alcohol-dependent patients with or without alcoholic cerebellar degeneration. | 2 |
Elevated soluble interleukin-2 receptor levels in patients with active multiple sclerosis. The level of soluble interleukin-2 receptor (sIL-2R) was quantitated with enzyme-linked immunosorbent assay in serum and cerebrospinal fluid obtained from 24 patients with multiple sclerosis and 10 patients with other neurological disorders in whom immunological mechanisms are unlikely to participate. The sIL-2R level in the serum and cerebrospinal fluid of patients with multiple sclerosis in relapse was significantly higher compared with patients with multiple sclerosis in remission and with controls. The sIL-2R level, especially in the cerebrospinal fluid, showed higher sensitivity and specificity than other clinical parameters including the cerebrospinal fluid IgG ratio, peripheral lymphocyte CD4/CD8 ratio, cerebrospinal fluid myelin basic protein and oligoclonal bands. Our data suggest that measurement of the sIL-2R level may be useful in evaluating disease activity in patients with multiple sclerosis. | 4 |
Radiation therapy for intraductal carcinoma. Is it an equal alternative? Of 213 consecutive patients with intraductal carcinoma, 109 were selectively treated with mastectomy and 104 with radiation therapy. There were eight local recurrences, seven in patients treated with radiation therapy and one in a patient treated with mastectomy. Histologically, there were 110 comedocarcinomas and 103 noncomedocarcinomas. Seven local recurrences occurred in patients with comedocarcinomas and one in a patient with a noncomedo tumor. Three (38%) of eight local recurrences (all comedo) were invasive. The 5-year actuarial survival for all subgroups was 100%. The median follow-up was 51 months. Intraductal carcinoma is unlikely to metastasize to axillary lymph nodes, and routine dissection is unnecessary. Ductal carcinoma in situ of the comedo variety is more aggressive and more likely to recur than its noncomedo counterpart. We currently view conservative therapy for patients with intraductal comedocarcinoma with caution. | 0 |
Intramedullary spinal ependymal cyst: case report. A cervical intramedullary spinal ependymal cyst in a 39-year-old man is reported. Diagnosis was made through magnetic resonance imaging. Total enucleation was possible. This is the sixth such reported case. | 0 |
The progression of mild idiopathic dementia in a community population. Thirty-one subjects aged 75 years and over who were identified as suffering from mild, idiopathic dementia in a large community survey were reviewed at annual intervals for 2 years. Diagnoses and severity ratings were based on defined criteria following a mental state examination, a medical and psychiatric history, detailed cognitive testing, and an interview with relatives or other key informants. Fourteen subjects became more severely demented within 2 years. The initial cognitive test battery failed to reveal any differences between respondents whose dementia advanced and those whose condition remained unchanged, but, in the former group, subjects' symptoms had been present for longer, and a greater proportion had been recognised as demented, or possibly demented, by their general practitioners. We suggest that subjects whose dementia progressed had actually been more severely disabled at the time of identification. | 2 |
Effects of mental exercise in patients with dilated cardiomyopathy and congestive heart failure. An echocardiographic Doppler study. To assess the effects of mental stress on left ventricular diastolic function in patients with congestive heart failure, nine patients aged 57 +/- 12 years with dilated cardiomyopathy (end-diastolic volume, more than 110 ml/m2; ejection fraction, less than 40%; mean, 28 +/- 8%) and congestive heart failure in New York Heart Association functional class II or III and 14 normal volunteers (mean age, 49 +/- 8 years) were studied during mental arithmetic lasting 10 minutes with echocardiographic Doppler monitoring of transmitral flow velocity. During mental arithmetic, the ratio of peak flow velocity in early versus late diastole (E/A) and deceleration time of early diastole did not change in normal controls. However, E/A increased significantly (from 1.6 +/- 1.5 to 1.9 +/- 1.7; p less than 0.01) and deceleration time markedly decreased (from 156 +/- 49 to 108 +/- 31 msec; p less than 0.001) in patients with congestive heart failure. In 16 postinfarct patients with ejection fraction of less than 40% studied during mental arithmetic with simultaneous hemodynamics and Doppler recordings, good correlations were found between pulmonary wedge pressure and Doppler parameters (wedge pressure versus E/A, r = 0.89; wedge pressure versus deceleration time, r = -0.87). During mental arithmetic, the pulmonary wedge pressure-E/A correlation was weaker (r = 0.67), whereas the correlation between pulmonary wedge pressure and deceleration time was stronger (r = 0.91). The value of 153 msec in deceleration time was the best cutoff point in predicting 12 mm Hg pulmonary wedge pressure, both at rest and during mental arithmetic: the higher the deceleration time, the lower the pulmonary wedge pressure, and vice versa. Among patients with congestive heart failure, five showed normal baseline deceleration time (195 +/- 21 msec; pattern 1), and the remaining four showed a short (less than 153 msec) deceleration time (108 +/- 13 msec; pattern 2). During mental arithmetic, deceleration time markedly decreased to as short as 119 +/- 20 msec in all patients except one with baseline pattern 1. Deceleration time further decreased to 75 +/- 6 msec in all patients with baseline pattern 2. Mental arithmetic induces changes in left ventricular diastolic function in patients with congestive heart failure. Transmitral echocardiographic Doppler provides a simple noninvasive method of estimating and monitoring pulmonary wedge pressure in patients with severe left ventricular dysfunction. | 3 |
Experience with in situ saphenous vein bypasses during 1981 to 1989: determinant factors of long-term patency. From 1981 to 1989, 361 consecutive in situ saphenous vein bypasses were performed. Indications for revascularization were critical limb ischemia (n = 335, 93%), popliteal aneurysm (n = 15, 4%), and claudication (n = 11, 3%). Outflow tract was the popliteal artery in 116 (32%) and tibial artery in 245 (68%) of bypasses. At 6 years primary patency was 63% and secondary patency was 81%. During the performance of the in situ bypass procedure, 86 (24%) venous conduits were modified because of a technical failure (n = 49, 13%) or an inadequate vein segment (n = 37, 10%). Secondary patency at 4 years for bypasses requiring modification was 72% compared to 84% for bypasses not modified (p less than 0.05). Atherosclerotic disease of the inflow artery necessitating endarterectomy, patch angioplasty, or replacement lowered primary patency at 3 years (69%) compared to the inflow artery not requiring reconstruction (46%, p less than 0.02). In the follow-up period, 95 (26%) bypasses were revised because of thrombosis or hemodynamic failure. Bypasses requiring revision had a 4-year secondary patency of 68% compared to 88% for bypasses not revised (p less than 0.02). The first 179 cases (1981 to 1985) were compared to the subsequent 182 cases (1986 to 1989). The secondary patency at 3 years for the latter half (92%) compared to the first half (80%) of the experience was significantly improved (p less than 0.02). The secondary patency for bypasses not requiring revision was significantly improved (p less than 0.02) for the latter half (n = 142, 97%) compared to the first half (n = 124, 83%) of the series. Long-term patency with the in situ saphenous vein bypass is dependent on surgical experience, quality of the venous conduit, and atherosclerotic disease of the inflow artery that necessitates reconstruction. Meticulous surgical technique and compulsive bypass surveillance results in superior long-term patency. | 4 |
Effects of the phospholipase inhibitor mepacrine on injury in ischemic and metabolically inhibited adult isolated myocytes. The phospholipase inhibitor mepacrine has been shown to delay cell death of metabolically inhibited cultured cardiomyocytes. The present study was initiated to determine if mepacrine also delays cell death and development of osmotic fragility of both metabolically inhibited and ischemic adult rat cardiomyocytes. Isolated myocyte suspensions were incubated with 3 mmol/l (millimolar) iodoacetic acid and 6 mmol/l amytal (inhibited) or were pelleted into a slurry and layered with oil (ischemic) in the presence and absence of 10 or 50 mumol/l (micromolar) mepacrine. Rates of contracture, cell viability as determined by trypan blue permeability, cell viability after osmotic swelling in 170 mOsm media (osmotic fragility), and cell morphology were monitored. Mepacrine had no effects on rates of contracture, but was found to significantly delay cell death during isotonic incubations of both metabolically inhibited and ischemic cells. In contrast, mepacrine had no effect on the development of osmotic fragility. Incubation of metabolically inhibited myocytes in calcium-free media did not delay contracture or cell injury, but did attenuate the protective effects of mepacrine. This study confirms previous reports that mepacrine protects cells from injury, extends the observations of protection to ischemic isolated adult myocytes, but shows that development of osmotic fragility is not inhibited by mepacrine. | 3 |
Symptomatic pericardial effusion in breast cancer patients: the role of fluid cytology. Clinical and cytologic findings in 21 breast cancer patients with symptomatic pericardial effusion are presented. The etiology of the pericardial effusion was definitely malignant, by cytology/histology in 13 patients (62%), and suspected malignant by cytology in 2 patients (9%). One patient (5%) with definitely nonmalignant pericardial effusion by cytology was found to be histologically positive at autopsy. In 5 patients (24%) there was no histological/cytological evidence of malignancy; radiation pericarditis could be the etiology in 4 of these 5 patients. The median time from the diagnosis of breast cancer to the development of symptomatic pericardial effusion was 60 months (range: 1-219 months). Ten patients developed cardiac tamponade; they were treated by either pericardiocentesis or pericardiectomy. The mean survival of patients with negative cytology/histology was 12 months; patients with suspicious cytology had a mean survival of 9 months; patients with malignant effusion, treated by pericardiectomy, had a mean survival of 22.3 months, while patients with malignant pericardial effusion, who were not subjected to surgery, had a mean survival of 4.7 months, only. It is concluded that the etiology of symptomatic pericardial effusion in breast cancer patients is not always malignant, which emphasizes the role of fluid cytology in establishing definite diagnosis. The survival probability is a function of the extent of extracardiac disease; among patients with malignant pericardial effusion those selected for pericardiectomy have a longer than average survival. | 0 |
Cerebral venography with MR. The authors describe a two-dimensional time-of-flight magnetic resonance (MR) angiography technique to create projection venograms of the head. The technique was applied to 27 healthy volunteers and 39 patients. The superior sagittal and straight sinuses, the internal cerebral veins, and the Galen vein were visualized in all the volunteers. Other veins were seen in a high percentage of subjects. Systematic comparison of digital subtraction angiography (DSA) after intraarterial contrast medium injection and MR venography in patients showed good correlation between the two techniques. MR venography proved helpful in identifying thrombosis or patency of cerebral veins and sinuses and showed collateral venous drainage and venous drainage from arteriovenous malformations. There was good correlation between conventional contrast angiography and MR venography. In conclusion, MR venography is considered reliable for showing the cerebral venous system and provides information additional to that of conventional spin-echo imaging. | 2 |
The modified superior based pharyngeal flap. Part III. A retrospective study. A retrospective study of 31 patients who had diagnosed velopharyngeal incompetence and were surgically managed with the modified superior based pharyngeal flap was completed. The following were analyzed: age at time of operation, gender, physical status, diagnostic protocol, length of operation (length of total surgery) and length of superior based pharyngeal flap, length of postoperative hospital stay, length of total hospital stay, length of follow-up, speech results, complications, patient care, and medication. The result showed that the optimal timing for correction of velopharyngeal incompetence was between 3 and 6 years of age. The mean length of total hospital stay was 2.7 days, postoperative complications were minimal, and speech results were generally good. | 2 |
Sixty consecutive breast reconstructions with the inflatable expander: a critical appraisal. Breast reconstruction using inflatable expanders has become an established and preferred technique. Although our knowledge of the biomechanical changes occurring in expanded skin has increased greatly, little information is available regarding average aesthetic results achieved with this technique. In order to eliminate the bias of best case selection reports, this study of 60 consecutive patients undergoing skin-expansion breast reconstruction was undertaken. Results of the study demonstrated a significant frequency and diversity of complications. In particular, immediate breast reconstruction with skin expanders was identified as a high-risk procedure because of its association with skin necrosis and delayed wound healing. Although two procedures--insertion and replacement--had been anticipated, patients from both the Boston and New York groups required approximately three operations to complete the expansion process. Average aesthetic results, often characterized by problems of symmetry, ptosis, and contour, need to be recognized and improved. | 0 |
Long-term efficacy of primary laser trabeculoplasty. Sixty glaucomatous eyes of 60 patients treated with laser trabeculoplasty as primary therapy were reviewed retrospectively. There were 42 eyes with capsular glaucoma and 18 with simple glaucoma. The mean prelaser intraocular pressure (IOP) was 35.2 (SD = 6.5) mmHg. Success was defined as IOP less than or equal to 22 mmHg without medication. The probability of success was 0.73 at 1 year, 0.66 at 2 years, 0.57 at 3 years, and 0.50 at 4 years. Three eyes experienced progressive visual field loss or disc damage in spite of an intraocular pressure below 22 mmHg without medication. High prelaser pressure and the severity of the visual field defects were significant predictors of treatment failure. | 2 |
Audit of results of operations for infantile pyloric stenosis in a district general hospital Because of the proposal that infants with hypertrophic pyloric stenosis should only be treated by surgeons with an interest in paediatric surgery, we carried out a retrospective study to audit our experience in a district general hospital. Forty six infants over a five year period underwent pyloromyotomy. There were no deaths, and 36 infants (78%) made uneventful recoveries. Perforation of the duodenal mucosa occurred during the operation in 11 patients, and eight complications developed in six of these infants. There were seven wound infections, and two patients had vomiting that lasted four days or longer after their operations. There were no long term feeding problems. The results of this study show that such patients can be successfully treated in district general hospitals, and three areas merit special attention: meticulous surgical technique, the use of prophylactic antibiotics, and early graduated feeding. | 1 |
Elevated plasma endothelin-1 concentrations are associated with the severity of illness in patients with sepsis. Plasma immunoreactive endothelin-1 concentrations were determined by radioimmunoassay in 11 septic patients during the first 24 hours after the development of the sepsis syndrome in 15 nonseptic postoperative patients studied 24 hours after open heart surgery and in 14 healthy volunteers. Mean endothelin-1 plasma concentrations were significantly (p less than 0.001) increased in septic patients (19.9 +/- 2.2 pg/mL, mean +/- standard error) compared to concentrations found in postoperative cardiac patients (11.9 +/- 0.7 pg/mL) or in healthy volunteers (6.1 +/- 0.3 pg/mL). In septic patients elevated plasma concentrations of endothelin-1 were inversely correlated with cardiac index (r = -0.80, p less than 0.005) and positively correlated the severity of illness as documented by APACHE II score (r = 0.74, p less than 0.01) and plasma creatinine levels (r = 0.80, p less than 0.005). No such correlations were found in postoperative cardiac patients. These results indicate that endothelin-1 concentrations are correlated with the severity of illness and depression of cardiac output in patients with sepsis. | 4 |
Biliary endoprostheses. Plastic versus metal stents. Plastic biliary endoprostheses relieved malignant obstructive jaundice in 80% to 90% of the patients. The comfort of a completely indwelling endoprosthesis should be offered to all palliatively treated tumor patients, and external-internal catheters should be reserved for the minority of patients who return with reoccluded endoprostheses. These patients have bacterial flora that rapidly contaminates the endoprosthesis and causes encrustations and reocclusions. Thus, a second endoprosthesis also would reocclude quickly. The mechanism of reocclusion of plastic and metal endoprostheses is completely different. In plastic endoprostheses, bacterial contamination causes decomposition of the bile and subsequent encrustation. In metal endoprostheses tumor ingrowths between the struts of the stent cause reocclusion. Tumor ingrowths were observed in only 6.5% of metal prostheses with a narrow woven mesh (Wallstent), whereas prostheses with large distances between the struts (Gianturco stent) had ingrowth rates of 19% to 50%. This fact shows that tumor ingrowths can be reduced by narrowing the spaces between the metallic network, and, therefore, improvements in the design of the metal stents should reduce the occlusion rate to or below that of plastic endoprostheses, which currently have a lower encrustation rate. The major advantages of expandable metal prostheses are the relative ease and the minimal trauma of the implantation procedure. The Wallstent endoprosthesis, in particular, can be inserted through a 7-F introducer sheath and offers the chance of single-step placement. The 30-day mortality rate, therefore, was only 5%. This is significantly lower than the 30-day mortality rate after insertion of plastic prostheses (15% to 24%). Even simple external catheter drainage procedures have a higher reported 30-day mortality rate (27%). Expandable metal endoprostheses would be the most useful device if the occlusion rate could be kept under 10% in large series. Increasing the length of the endoprostheses to 10 cm in the expanded state could also improve the long-term patency rates. | 4 |
Thrombus in a natural left ventricle during left ventricular assist: another thromboembolic risk factor. Systemic thromboembolism is one of the serious complications during use of a left ventricular assist system (LVAS). The authors' original LVAS has excellent antithrombogenicity to reduce this risk, but thrombus formation in a natural left ventricle (LV) is another risk factor for systemic embolization. We used our LVAS in 22 patients. Of these, LV wall motion was studied in 15, and a smoke-like echo disclosed thrombus in the LV in eight. When LVAS sufficiently supported the systemic circulation, LV wall motion was irregular upon closure of the aortic valve. Upon recovery of LV function and decrease of LVAS flow, the smoke-like echo diminished and LV thrombus decreased in one, but LV thrombus remained unchanged or increased in seven. Systemic administration of antithrombotic agents had an unclear effect. Seven of eight patients with LV thrombus on echo died during or after LVAS. In these seven, a high incidence of LV thrombus (71%), and systemic embolism to the brain (29%) or kidney (86%), were revealed at necropsy. We subsequently used local heparinization to prevent LV thrombus formation. One patient with a smoke-like echo had no evidence of LV thrombus or systemic embolism. During LV assist, careful management of the LVAS, and intra-LV heparinization should be considered to reduce the risk of thrombus formation in the natural LV. | 4 |
Timing of operation for aortic regurgitation: relation to postoperative contractile state. With angiography and pressure measurement, we determined left ventricular volume, wall stress, and systolic performance in 30 patients with aortic regurgitation before and after successful aortic valve replacement. End-systolic wall stress was greatly elevated preoperatively and decreased to normal postoperatively. Systolic pump performance assessed as ejection phase indexes was severely depressed preoperatively and improved to normal or near-normal postoperatively in most patients. The ratio of end-systolic wall stress to end-systolic volume index (ESS/ESVI), an index of myocardial contractility, was greatly decreased before operation. Postoperatively, the ratio increased in all patients, becoming normal in 12 of the 13 patients who had a preoperative ESS/ESVI of 2.9 or greater. However, 15 of 17 patients in whom the ESS/ESVI ratio was less than 2.9 still had subnormal ratios, which indicates the presence of irreversible contractile dysfunction. Stepwise multivariate analysis showed that preoperative ESS/ESVI was the only independent discriminator of postoperative normalization of the contractile function as assessed by ESS/ESVI. After aortic valve replacement, myocardial contractile state does not return to normal in a considerable number of patients. It is important to offer aortic valve replacement for aortic regurgitation before the chance for a good functional result is lost. The ESS/ESVI ratio may be a useful index in determining the timing of operation in patients with aortic regurgitation. | 3 |
Verbal memory impairment correlates with hippocampal pyramidal cell density. Thirty-five patients with medically refractory epilepsy localized to the temporal lobe (18 left, 17 right) completed the verbal Selective Reminding Test before surgery. Verbal memory impairments existed before surgery regardless of the lateralization of the seizure focus, but patients with left temporal seizure foci were significantly more impaired. After surgical removal of the mesial temporal lobe structures, 2 blinded observers established volumetric cell densities for hippocampal subfields CA1, CA2, CA3, the hilar area, and the granule cell layer of the area dentata. Statistically significant correlations existed between presurgical memory impairment and cell counts (in CA3 and the hilar area, only) for patients with left temporal seizure foci. These findings support the hippocampal model of memory and complement prior research documenting the memory impairments present after surgical removal of the mesial temporal structures. | 4 |
Susceptibility to thyroid autoimmune disease: molecular analysis of HLA-D region genes identifies new markers for goitrous Hashimoto's thyroiditis. Hashimoto's thyroiditis has been shown to be associated with the HLA-specificities DR4 and DR5. Since former association studies yielded variable results, we used novel molecular typing methods to assess predisposing immunogenetic factors. Gene analysis of the HLA-DR-DQ and tumor necrosis factor region was performed in a group of Hashimoto's thyroiditis patients and randomly chosen controls using standards and nomenclature of the 10th International Histocompatibility Workshop. Genomic DNA of patients and controls was analyzed using a cDNA probe of the DQB1 gene. The resulting restriction fragment patterns allowed the determination of newly defined DQw-types 1-9. We find the strongest relative risk conferred by DQw7 (RR = 4.7), that is observed in 36 of 64 patients (56%) and only 21 of 98 controls (21%) (P corr less than 0.002). Comparison of DNA sequence variation in the DQB1 gene, that is found predominantly in Hashimoto's thyroiditis patients, indicates that codons 45 and 57 are critical features in DQw7 which distinguish it from other DQw specificities. The adjacent DQA1 genes also display a significant association with Hashimoto's thyroiditis (DQA1*0201/*0301 heterozygotes were found in 37% of patients and 15% controls, P less than 0.03). No significant association could be found with polymorphisms of the tumor necrosis factor gene. These results provide a new basis for the concept of genetic susceptibility in Hashimoto's thyroiditis and will help to elucidate the underlying autoimmune mechanisms that lead to disease at the functional level. | 4 |
Nutritional approach to cancer prevention with emphasis on vitamins, antioxidants, and carotenoids. The main human cancers are associated with complex life-style related causative, enhancing, and inhibiting factors. Tobacco smoking or chewing exposes humans to genotoxic carcinogens and to promoting substances. Likewise, Western dietary traditions involve certain carcinogens and promoters, whereas Oriental traditions implicate other carcinogens and promoters. Importantly, in virtually all situations regular intake of fruits and vegetables appreciably lowers the risk of cancer. This paper reviews the causes of the main human cancers and analyzes the mechanisms of the protective effects of fruits and vegetables. Prevention of human cancer requires the definition of optimal levels of recommended daily allowances of micronutrients. | 0 |
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