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Detrusor hyper-reflexia as a factor in spontaneous perforation of augmentation cystoplasty for neuropathic bladder. In a series of 30 children undergoing cystoplasty for neuropathic bladder, 14 had a combination of a competent sphincteric mechanism and detrusor hyper-reflexia. All 3 cases of spontaneous perforation of the augmentation occurred within this latter group and it is postulated that excessive intravesical pressure due to high pressure hyper-reflexia was the causal factor. Strategies to reduce the risk of perforation are discussed. | 4 |
Pulmonary blastomas. Pulmonary blastoma is a rare lung tumor composed of immature mesenchyme and/or epithelium that morphologically mimics embryonal pulmonary structure. The prognosis of these tumors is poor, and the clinical course is not readily predicted from histologic appearance. In this report, the clinical, gross, microscopic, and immunopathologic features of 52 cases are described, and prognostically important correlates are determined. Twenty-eight patients were women, and 24 were men. There was a unimodal age peak in the fourth decade; only two patients were younger than 10 years old, and both had biphasic blastomas. Forty-one percent of patients were asymptomatic. Chest radiography typically showed a peripheral or midlung mass without predilection for any lobe. Microscopically, tumors could be divided into two classes: those composed solely of malignant glands of embryonal appearance (well-differentiated fetal adenocarcinomas [WDFA], 28 cases) and those with a biphasic appearance (24 cases). The malignant epithelium contained cytokeratin, carcinoembryonic antigen, milk fat globulin, and often chromogranin; vimentin, actin, and less frequently desmin and myoglobin were present in malignant stromal cells. More often WDFA was a smaller tumor (less than 5 cm) than biphasic tumors (P less than or equal to 0.001). It was more likely to be asymptomatic (P less than or equal to 0.001), and it was less likely to show pleural effusion by chest radiography (P less than or equal to 0.01) or giant or bizarre tumor cells (P less than or equal to 0.001) or frequent (greater than or equal to 30 mitoses/10 high-power fields) mitoses in the microscopic sections (P less than or equal to 0.01). Only 14% of patients with WDFA died of their tumor; 52% of patients with biphasic tumors died (mean follow-up, 97 months and 49 months, respectively). For patients with WDFA, the presence of thoracic adenopathy by chest radiography (P less than or equal to 0.001) and metastasis at initial presentation (P less than or equal to 0.001), followed by tumor recurrence (P less than or equal to 0.01), were the factors most highly correlated with poor prognosis. For patients with biphasic tumors, tumor recurrence (P less than or equal to 0.001) was the most significant indicator of poor prognosis, followed by metastasis at initial presentation (P less than or equal to 0.05) and gross size of the tumor (greater than or equal to 5 cm) (P less than or equal to 0.05). These findings support the idea that histologic class and gross and clinical findings can be of prognostic value in pulmonary blastoma. | 4 |
Platelet norepinephrine and epinephrine concentration in patients with pheochromocytoma. Platelet and plasma catecholamine concentrations were determined in 17 patients with surgically proven pheochromocytoma (mean age 42.3 years); in 31 patients with borderline hypertension (mean age 35.3 years) and in 9 healthy controls (mean age 39.3 years). Both platelet norepinephrine and epinephrine were significantly increased in patients with pheochromocytoma when compared with hypertensive and control groups (P less than .001). No correlation between platelet and plasma catecholamines was detected in all studied groups. The diagnostic accuracy of platelet catecholamine in pheochromocytoma is limited since increased platelet norepinephrine was found in 35.5% and increased platelet epinephrine was found in 19.4% of patients with essential hypertension. | 3 |
Radiation therapy of laryngeal cancer: a twenty year experience. This paper reviews a 20 year experience of radiation treatment of 286 laryngeal cancers and presents results with a minimum five year follow-up. All cases presented had glottic or supraglottic squamous cell carcinomas with no clinical evidence of nodal metastasis. A policy of primary radiotherapy with surgery for salvage of treatment failures, produced control of primary disease and prevention of metastases superior to most other regimes documented in the literature. | 0 |
Late recurrence of varus deformity after proximal tibial osteotomy. One hundred thirteen knees with medial gonarthrosis in 95 patients were treated by valgus-producing proximal tibial osteotomy and followed clinically and roentgenographically for a minimum of five years (mean, 6.3 years). Sixty-four knees (57%) were pain free or had only mild discomfort when walking. The standing femorotibial angle decreased from a postoperative average of 9.3 degrees valgus to 7.8 degrees valgus at the final follow-up examination. The tendency for varus recurrence greater than 5 degrees and for medial- or lateral-compartment arthritic progression was evaluated using the Kaplan-Meier survival method. Varus recurred in 18%, lateral-compartment arthritic progression in 60%, and medial-compartment arthritic progression in 83% by nine years after surgery. The probability of arthritic progression is much higher than the probability of significant varus recurrence in long-term roentgenographic follow-up studies of patients with valgus-producing proximal tibial osteotomies. | 4 |
Recurrent thoracic outlet syndrome after first rib resection. Seventy-seven patients with 84 operated limbs participated in a follow-up examination on an average of about six years after the resection of the first rib for thoracic outlet syndrome (TOS). Forty-two limbs (50%) were totally asymptomatic one month after the operation and remained so for at least half a year postoperatively. In the follow-up examination, 31 limbs were still asymptomatic, whereas 11 limbs had the same symptoms as before the operation. Of the nine patients with recurrent TOS (two with bilateral resection), seven were women and two were men. These nine patients were on average 38 years old (range = 19 to 51 years) and their jobs consisted of monotonous desk work. Seven of 11 stumps of the first rib were subluxated disclosed by the cervical rotation-lateral-flexion test. The occurrence of a subluxated stump of the first rib in the group of asymptomatic patients was far lower, only 3% (p less than .001). Of the 42 patients with persistent problems, a subluxated stump was encountered in seven (17%). Results of this follow-up examination suggest that monotonous desk work is an important factor causing kinesiologic abnormalities in the thoracic aperture. This abnormal kinesiology contributes to the recurrence of TOS symptoms even after the resection of the first rib. | 2 |
Therapeutic advantage of hypoxic cells in tumors: a theoretical study The presence of hypoxic cells in solid tumors has long been considered a problem in cancer treatment, particularly for radiation therapy but also for treatment with some anticancer drugs. Three general strategies are being actively explored to overcome the problem: oxygenating the tumor, sensitizing the hypoxic cells to radiation (or chemotherapy), or killing the hypoxic cells (with a hypoxic cell cytotoxin). In the present study, we have examined the impact of each of these three strategies on a standard radiation therapy regimen (30 doses of 2 Gy), using either of two major assumptions: full reoxygenation or no reoxygenation of the tumor cells. We demonstrate that a hypoxic cell cytotoxin can produce a level of tumor cell killing higher (by several orders of magnitude) than that produced by full oxygenation of a tumor or by use of an optimum hypoxic cell radiosensitizer, provided the cytotoxin kills more than approximately 50% of the hypoxic cells each time it is given. The only assumption that makes a difference is whether reoxygenation occurs: In the worst case (ie, no reoxygenation), the hypoxic cell cytotoxin performs only as well as an optimum radiosensitizer. The analysis shows that hypoxic cells in tumors can be a major therapeutic advantage. Therefore, we recommend that research efforts be concentrated on development of superior hypoxic cell cytotoxins rather than improved hypoxic cell radiosensitizers and that, in parallel, emphasis be placed on development of agents to increase hypoxia. | 0 |
High resolution real-time ultrasound for the diagnosis of venous thrombosis in the rehabilitation setting. Accurate, noninvasive testing for deep venous thrombosis (DVT) by conventional methods is often not possible in the rehabilitation patient. Lower extremity amputation, a cast or bandage, or skin problems present obstacles to standard diagnostic methods. This report describes the use of duplex ultrasound (US) scanning for noninvasive diagnosis of DVT in a seventy-year-old man with a below-knee amputation, on whom Doppler and plethysmography examinations could not be performed. As experience is gained with this technique, the use of venography for diagnosis of DVT becomes more difficult to rationalize. | 3 |
Comparison of rectal, axillary, and tympanic membrane temperatures in infants and young children. STUDY OBJECTIVE: To evaluate the reliability of a tympanic membrane thermometer in detecting fever in young children presenting to the emergency department. SETTING: Pediatric emergency department in an urban teaching hospital, DESIGN/MEASUREMENT/PARTICIPANTS: Temperature measurements were obtained sequentially at three body sites in children less than 3 years old presenting to the pediatric ED. Axillary and rectal temperatures were obtained with an electronic thermistor probe (Diatek 500), and tympanic membrane temperatures were obtained with a noncontact, infrared sensing device (First TEMP). Patients were stratified by age, ear canal patency, presence of otitis media, and rectal temperature. RESULTS: Of 224 patients enrolled, 87 (39%) were febrile. Overall correlation of axillary and tympanic membrane measurements to rectal for all strata was .75 (P = .001) and .81 (P = .001), respectively. Sensitivity in detecting fever for axillary and tympanic membrane sites was .48 and .55, respectively. Otitis media and ear patency did not influence correlation of tympanic membrane measurements. Low tympanic membrane temperature sensitivity may be a result of probe configuration. CONCLUSION: Tympanic membrane and axillary temperatures should be viewed with caution in children less than 3 years old as neither can detect fever reliably. | 4 |
Congenital cyst of common bile duct: an unusual cause of obstructive jaundice. Congenital cysts, sometimes referred to as nonparasitic biliary cysts, are not unusual findings in the liver parenchyma, but they have not been previously described in the common bile duct. This clinical report describes a 41-year-old woman with obstructive jaundice that was caused by congenital cysts. The patient had obstruction of the middle portion of the common bile duct; therefore the major differential diagnostic considerations were cholangiocarcinoma, cancer of the pancreas, or true biliary cysts. Congenital cysts, retention cysts, and neoplastic cysts cannot be differentiated from other true cysts preoperatively. Diagnosis can only be established by microscopic examination after surgical excision. | 4 |
Intrathecal baclofen for spasticity in cerebral palsy Seventeen patients with congenital spastic cerebral palsy and six patients with other forms of spasticity were injected intrathecally with doses of placebo or baclofen, 25 micrograms, 50 micrograms, or 100 micrograms, in a randomized, double-blind manner. Muscle tone in the upper and lower extremities was assessed by Ashworth scores both before the injections and every 2 hours afterward for 8 hours. Function of the upper extremities was evaluated before the injections and 4 hours afterward. Muscle tone in the lower extremities was significantly decreased within 2 hours after baclofen injection and remained lower than baseline 8 hours afterward. Upper extremity tone and function were not significantly affected by these single doses. Confusion and drowsiness occurred in two of the youngest children in the study after the 50-micrograms dose, but cleared within 2 hours. Our findings indicate that intrathecal baclofen reduces spasticity in children with cerebral palsy, as it does in adults with spasticity of spinal origin. | 2 |
Pancreatic response to percutaneous biliary drainage: a prospective study. To evaluate the effects of percutaneous biliary drainage (PBD) on the pancreas, serum amylase levels were measured for 7 consecutive days after PBD and compared with baseline values in 50 patients who underwent a total of 53 PBD procedures. Of the 45 patients with normal baseline serum amylase levels, 12 patients (24%) developed postprocedural hyperamylasemia without clinical symptoms and five patients (10%) developed postprocedural hyperamylasemia with clinical signs of pancreatitis. Five patients who presented with elevated baseline serum amylase levels demonstrated decreases into the normal range after placement of stents without initiation of bowel rest or liquid diet. The level of biliary obstruction proved insignificant, as did the nature of the obstructing disease, in determining which patients would experience hyperamylasemia or pancreatitis after PBD. It is concluded that the frequency of pancreatic insult from PBD may be more common than previously reported and that patient susceptibility is not dependent on the level of biliary obstruction or the nature of the disease. | 4 |
Lack of change in neurochemical markers during the postepileptic phase of intrahippocampal tetanus toxin syndrome in rats. The chronic epileptic syndrome induced by injecting tetanus toxin into rat hippocampus causes functional changes that essentially are permanent, outlasting the period of active seizures by at least 1 year. These long-term changes have been characterized by an impaired performance on a range of behavioral tasks, which in turn have been associated with a physiologic depression of hippocampal evoked responses but not with any discernible histopathology. In the present study, we examined the hippocampi of rats in the postseizure phase of the tetanus toxin model and observed no significant changes in the concentration of neurochemical markers for six neurotransmitters. Therefore, the long-term reduction in hippocampal excitability cannot be attributed to any major loss of afferents or hippocampal neurons using aspartate, acetylcholine, gamma-aminobutyric acid (GABA), glutamate, norepinephrine (NE), or serotonin as their transmitters. | 2 |
Vegetables, fruits, and carotenoids and the risk of cancer. Low intake of vegetables, fruits, and carotenoids is consistently associated with increased risk of lung cancer in both prospective and retrospective studies. In addition, low levels of beta-carotene in serum or plasma are consistently associated with the subsequent development of lung cancer. The simplest explanation is that beta-carotene is protective. Since retinol (preformed vitamin A) is not related in a similar manner to lung cancer risk, beta-carotene appears to function through a mechanism that does not require conversion into vitamin A. However, the importance of other carotenoids and other constituents of vegetables and fruit has not been adequately explored. Both prospective and retrospective studies suggest that vegetable and fruit intake may reduce the risk of cancers of the mouth, pharynx, larynx, esophagus, stomach, colon, rectum, bladder, and cervix. But because of fewer studies and less consistency among studies, the epidemiologic evidence is at present less persuasive than for lung cancer. | 0 |
The use of flow cytometry for the prognosis of stage II adjuvant treated breast cancer patients. Characterization of breast cancer cells by histology, flow cytometry, and steroid receptors was performed on 197 Stage II breast node positive cancer patients given adjuvant chemotherapy, plus tamoxifen for patients with positive hormone receptors. Histologic and steroid receptor assays were performed using standard techniques; flow cytometric analysis was performed from paraffin-embedded blocks obtained from the primary tumor. Quality control studies on reproducibility, tissue heterogeneity, and analysis procedures have been included. Of the 197 patients studied, aneuploidy was found in 102 (52%); the median %S value was 8% with a range of 0.4% to 38%. Our results demonstrated that number of positive nodes, receptor status, and grade were of prognostic value. Cell cycle kinetic data were not of independent prognostic value in this series. However, ploidy could differentiate in prognosis in the receptor-negative subgroup. Patients with receptor-negative tumors had a significantly better overall survival if the tumor was diploid in nature. Cell kinetics was not significantly prognostic for either receptor subgroup, although patients with higher %S tended to have better relapse-free and overall survival. This is in disagreement with other studies and may demonstrate that treatment has confounded our results and diminished the ability of flow cytometry data to help predict outcome. | 0 |
The South Karelia Air Pollution Study. The effects of malodorous sulfur compounds from pulp mills on respiratory and other symptoms. The paper mills in South Karelia, the southeast part of Finland, are responsible for releasing a substantial amount of malodorous sulfur compounds such as hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and methyl sulfides [(CH3)2S and (CH3)2S2], into ambient air. In the most polluted residential area the annual mean concentrations of hydrogen sulfide and methyl mercaptan are estimated to be 8 and 2 to 5 micrograms/m3 and the highest daily average concentration 100 and 50 micrograms/m3. The annual mean and highest daily concentrations of sulfur dioxide (SO2) are very low. We studied the effects of malodorous sulfur compounds on eye, nasal and respiratory symptoms, and headache in adults. A cross-sectional self-administered questionnaire was distributed in February 1987 and responded to by 488 adults living in a severely (n = 198), a moderately (n = 204), and a nonpolluted community (n = 86). This included questions about occurrence of the symptoms of interest during the previous 4 wk and 12 months and individual, behavioral, and other environmental determinants of the symptoms. The response rate was 83%. The odds ratios (OR) for symptoms experienced often or constantly in severely versus nonpolluted and moderately versus nonpolluted communities were estimated in logistic regression analysis controlling potential confounders. The odds ratios for eye (moderate exposure OR 11.70, Cl95% 2.33 to 58.65; severe exposure OR 11.78, Cl95% 2.35 to 59.09) and nasal symptoms (OR 2.01, Cl95% 0.97 to 4.15; OR 2.19, Cl95% 1.06 to 4.55) and cough (OR 1.89, Cl95% 0.61 to 5.86; OR 3.06, Cl95% 1.02 to 9.29) during the previous 12 months were increased, with a dose-response pattern. | 2 |
Total hip arthroplasty after fracture of the acetabulum. Long-term results. We made a retrospective study of 55 primary total hip arthroplasties in 53 patients with a history of previous acetabular fracture. The mean follow-up was 7.5 years and the average age at fracture was 48.7 years. The incidence of radiographic femoral loosening (29.4%), symptomatic loosening (15.7%), and femoral revision (7.8%) were similar to those previously reported at 10 years for routine arthroplasties by Stauffer (1982). On the acetabular side, the incidence of radiographic loosening (52.9%), symptomatic loosening (27.5%), and revision (13.7%) were four to five times higher. We conclude that a history of prior acetabular fracture has a significant adverse impact on the long-term outcome of any subsequent total hip arthroplasty. | 4 |
Epidermodysplasia verruciformis-associated papillomavirus infection complicating human immunodeficiency virus disease. Three males infected with the human immunodeficiency virus (HIV) were noted to have extensive flat warts of the face and/or body. In two there were also pityriasis versicolor-like lesions. Biopsies showed foamy, basophilic, distended cytoplasm in granular layer keratinocytes, characteristic of the human papillomavirus types seen in epidermodysplasia verruciformis. DNA hybridization techniques demonstrated the presence of HPV-type 8 in one patient and HPV 5 and 8 in another. Patients with immune suppression due to HIV infection may demonstrate the clinical features of epidermodysplasia verruciformis with the same potentially oncogenic HPV types. | 0 |
Pigmented Bowen's disease arising from pigmented seborrheic keratoses. We report three cases of pigmented Bowen's disease that clinically and histologically had features of seborrheic keratoses. We speculate about the mechanism of pigmentation in these lesions and suggest that they arise from pigmented seborrheic keratoses. | 0 |
Incisional parapubic hernias. A parapubic hernia, distinct from other lower abdominal wall hernias, is identified as a particular type of incisional hernia. This hernia results from the disruption of the musculotendinous elements of the abdominal wall as they insert into the pubis. This disruption is brought about by either the destruction of these musculotendinous tissues at their lower end or the resection of portions of the pubic bone as is sometimes done in suprapubic radical prostatectomies for easier access to the prostate. Seven cases have been identified and reported. Men and women were seen to make up a clinical picture that is suggestive of the diagnosis, namely, multiple previous operations through the lower abdominal wall, procedures of a gynecologic or urologic nature, a herniation that mimics an incisional or inguinal hernia, and a defect that cannot possibly be corrected without the use of a prosthesis. When the diagnosis is accurately established, the polypropylene mesh is inserted in the preperitoneal space and anchored laterally to the ligaments of Cooper and in between to the arcuate pubic ligament and the periosteum of the posterior aspect of the pubis. Excellent results have been obtained, and the success must be ascribed to the recognition of the parapubic hernia as a distinct entity. | 4 |
The risk of lymph node metastasis in colorectal polyps with invasive adenocarcinoma. One hundred fifty-one patients with colorectal polyps containing invasive adenocarcinoma treated by resection were studied to determine the incidence of lymph node metastasis and whether lymph node metastasis was related to the depth of invasion. Other variables evaluated included size and configuration of the polyp, grade of adenocarcinoma, presence or absence of lymphovascular invasion, and degree of differentiation. In patients with sessile polyps, the incidence of lymph node metastasis was 10 percent. Eighty percent of these lesions had lymphovascular invasion. For pedunculated polyps, the overall incidence of lymph node metastasis was 6 percent. However, there was no incidence of lymph node metastasis when the depth of invasion was limited to the head, neck, and stalk of the polyp (Levels 1, 2, and 3). Only when the depth of invasion reached to the base of the stalk (Level 4) was the risk of lymph node metastasis high (27 percent). The other risk factors were not associated with lymph node metastasis. We concluded that the most significant risk factor for lymph node metastasis in patients with invasive carcinoma in a polyp was invasion into the submucosa of the bowel wall (Level 4). | 0 |
Relative effects of brain and non-brain injuries on neuropsychological and psychosocial outcome. Based on the 242 consecutive surviving head injury cases and 132 general trauma cases, this study examined the contribution of brain and non-brain injuries to cognitive and psychosocial outcome 1 month postinjury. The study also examined the relationships among various head injury severity indices. The head injury severity indices were all correlated but patients with Glasgow Coma Scale scores in the mild range had broadly ranging scores on the other head injury severity indices (Abbreviated Injury Scale and time to follow commands). Neuropsychological outcome was related to brain injury severity, but was not independently influenced by severity of other systems injuries. Psychosocial outcome related to both brain and non-brain injuries independently. When evaluating trauma outcome, it is important to consider the contributions of both brain and other system injuries. | 2 |
Acute syphilitic posterior placoid chorioretinitis. Six patients with evidence of secondary syphilis presented with visual loss in both eyes caused by large, placoid, yellowish lesions with faded centers at the level of the pigment epithelium in the macula and juxtapapillary areas. All eyes had vitreitis. All of the lesions showed a similar fluorescein angiographic pattern of early hypofluorescence and late staining. Five patients had mucocutaneous lesions typical of secondary syphilis. All five patients treated with antibiotics had prompt improvement in visual function and resolution of the fundus lesions. The ophthalmoscopic and angiographic appearance of these posterior fundus lesions was sufficiently characteristic to suggest a diagnosis of secondary syphilis. Modification of the host response to syphilis by human immune deficiency virus (HIV) infection may be partly responsible for this peculiar fundus picture. Three of the four patients tested positive for HIV. | 2 |
Differential memory and executive functions in demented patients with Parkinson's and Alzheimer's disease. Selected aspects of verbal memory and executive function were compared in 11 demented Parkinson's disease (PD) patients and 11 Alzheimer's disease (AD) patients with equally severe dementia, with 11 healthy controls matched for age and education. Semantic and episodic memory were impared in all patients compared with controls, but to a relatively greater degree in AD patients than in those with PD. In contrast, demented PD patients were relatively more compromised on executive tasks. These findings, taken in the context of the neuropathological and neurochemical overlap between demented PD and AD patients, suggest that differences in neurobehavioural patterns in patients with these diseases are relative, rather than absolute. | 2 |
Mediastinitis following nasal intubation in the emergency department. A patient who developed a retropharyngeal abscess and fatal mediastinitis following emergent nasal intubation is described. Despite aggressive surgical therapy the patient died of mediastinitis. Although mediastinitis as a complication of oral intubation has been described, mediastinitis following nasal intubation has not previously been reported. | 4 |
Deletion of chromosome 4: 46,XY, del(4) (q31.3) after gamete intrafallopian transfer and in vitro fertilization-embryo transfer. It seems that assisted reproduction technology does not increase the rate of chromosome abnormalities, and up to now, a few cases have been reported. The case we describe here is the first one of monosomy 4q31 in a full-term liveborn after a combined GIFT-IVF procedure. Once more, this case raises the question of whether pregnancies resulting from IVF should be monitored for chromosome abnormalities or not. | 4 |
Neurogenic control of the cerebral circulation during global ischemia. The influence of the trigeminal nerve on the cerebral circulation was investigated in chronically denervated cats during and after reversible four-vessel occlusion for 10 minutes combined with controlled hypotension (50 mm Hg). Postocclusive hyperemia 30 minutes after reperfusion was attenuated by up to 48% in cortical gray matter of the anterior, middle, and posterior cerebral artery territories on the side of trigeminal ganglionectomy. Similar results were observed for denervation accomplished by direct surgical ablation and by the topical application of capsaicin to a cortical branch of the middle cerebral artery. Denervation did not alter basal cerebral blood flow or the duration of hyperemia, nor did it impair the cerebrovascular response to hypercapnia. These data demonstrate the importance of neurogenic mechanisms in the development of postischemic hyperperfusion and suggest that strategies directed at blocking axon reflex-like mechanisms may be beneficial in reducing the morbidity that follows severe cortical hyperemia. | 4 |
Experience with photocoagulation in Behcet's disease. Between 1973 and 1987 we examined both eyes of 300 patients with the uveoretinitis-type lesions characteristic of Behcet's disease. Of the 556 eyes whose fundus could be examined, 38 eyes (6.8%) in 33 patients (11%) had developed retinal capillary nonperfusion, branch retinal vein occlusion, or retinal or disc neovascularization. These eyes were treated by photocoagulation, primarily to forestall vitreous hemorrhage and the development of neovascular glaucoma, as well as to decrease the macular edema resulting from vein occlusion. The treatment, which was well tolerated, was successful in closing retinal capillary nonperfusion areas and eliminating retinal neovascularization. Disc neovascularization was resolved completely in some cases, and partially in others. | 0 |
Effect of direct intracoronary administration of methylergonovine in patients with and without variant angina. The effects of intracoronary administration of methylergonovine were studied in 21 patients with variant angina and 22 patients with atypical chest pain and in others without angina pectoris (control group). Methylergonovine was administered continuously at a rate of 10 micrograms/min up to 50 micrograms. In all patients with variant angina, coronary spasm was provoked at a mean dose of 28 +/- 13 micrograms (mean +/- SD). In the control group neither ischemic ST change nor localized spasm occurred. The basal tone of the right coronary artery was significantly lower than that of the left coronary artery. The percentage of vasoconstriction of the right coronary artery was significantly higher than that of the left coronary artery. These results suggest that spasm provocation tests, which use an intracoronary injection of a relatively low dose of methylergonovine, have a high sensitivity in variant angina and the vasoreactivity of the right coronary artery may be greater than that of the other coronary arteries. | 3 |
Sensitivity to titanium. A cause of implant failure? Tissues from five patients who underwent revision operations for failed total hip replacements were found to contain large quantities of particulate titanium. In four cases this metal must have come from titanium alloy screws used to fix the acetabular component; in the fifth case it may also have originated from a titanium alloy femoral head. Monoclonal antibody labelling showed abundant macrophages and T-lymphocytes, in the absence of B-lymphocytes, suggesting sensitisation to titanium. Skin patch testing with dilute solutions of titanium salts gave negative results in all five patients. However, two of them had a positive skin test to a titanium-containing ointment. | 4 |
Underlying illness associated with failure to thrive in breastfed infants. Over a four-year period in a suburban pediatric practice, 38 infants aged six months or less were identified with failure to thrive (FTT) while breast-feeding. In seven cases (18.4%), an associated organic illness was diagnosed. Only 2 of 28 breast-fed neonates (8%) were found to have FTT associated with another illness, as compared to 5 of 10 older infants (50%). Breast-fed infants with FTT, particularly those presenting after the first month of life, should be considered high risk for having other disease. Their clinical evaluation should include an appropriate search for organic illnesses. | 4 |
Post-cannulation radial artery aneurysm--a rare complication. The following case report describes an expanding aneurysmal dilatation of the radial artery which developed 17 days following cannulation. Possible causes of this complication are: abnormal state of the vessel wall, multiple attempts at cannulation, and haematoma or infection at cannulation site. Other major and minor sequelae following arterial cannulation are reviewed. | 3 |
Stress echocardiography and the human factor: the importance of being expert. The aim of this study was to evaluate how the diagnostic accuracy of a stress echocardiographic procedure, such as a dipyridamole echocardiography test, depends on the specific experience of the physician interpreting the test. Recordings of 50 consecutive dipyridamole echocardiographic tests were selected for the first part of the study. They were analyzed by 20 experienced echocardiographers with different backgrounds in stress echocardiography: 10 beginners (less than 20 stress studies interpreted with trained staff) and 10 experienced observers (greater than or equal to 100 stress studies performed). Diagnostic accuracy (true positive + true negative/total number of tests) versus the angiographic reference standard (greater than 70% coronary stenosis of at least one major coronary artery) was 62 +/- 6% for beginners and 85 +/- 3% for experienced observers (p less than 0.0001). In the second part of the study, 10 observers (5 beginners and 5 experienced observers) evaluated 2 different sets of 50 dipyridamole echocardiographic test studies before and after the training of the beginners. Before training, the accuracy of beginners was lower than that of experienced observers (61 +/- 7% versus 85 +/- 3%; p less than 0.001). After training, the accuracy gap was closed (83 +/- 3% versus 86 +/- 2%; p = NS). Therefore, interpretation of stress echocardiographic tests by an echocardiographer without specific training severely underestimates the diagnostic potential of this technique. One hundred stress echocardiographic studies are more than adequate to build the individual learning curve and reach the plateau of diagnostic accuracy that the test can yield. | 4 |
Role of endogenous angiotensin II in the control of vasopressin secretion during hypovolemia and hypotension in conscious rabbits. In order to investigate the physiological role of angiotensin II (ANG II) in the control of vasopressin (VP) secretion, the VP responses to hypotension induced by hemorrhage (20 ml/kg, n = 10) or nitroprusside infusion (1-10 micrograms/kg.min, n = 9) were studied with or without blockade of ANG II formation by the converting enzyme inhibitor captopril in conscious rabbits. Administration of captopril (5 mg/kg, iv) caused a small decrease in mean arterial pressure but did not enhance the hypotensive response to subsequent hemorrhage or nitroprusside infusion. The renin response to both stimuli was enhanced by captopril, whereas the increase in plasma ANG II concentration was attenuated. Plasma VP (PAVP) concentration increased during hemorrhage (2.0 +/- 0.2-113.6 +/- 47.7 pg/ml, P less than 0.01) and nitroprusside infusion (2.1 +/- 0.3-5.1 +/- 1.0 pg/ml, P less than 0.01). Captopril did not change basal plasma PAVP, nor did it attenuate the VP responses to hemorrhage or nitroprusside. Indeed, captopril tended to enhance the VP responses to hemorrhage (2.3 +/- 0.3-147.1 +/- 65.9 pg/ml) and nitroprusside infusion (1.9 +/- 0.2-15.4 +/- 6.0 pg/ml). The relationship between log PAVP and mean arterial pressure during hemorrhage and nitroprusside infusion in the presence of captopril was not different than in the absence of captopril. These results indicate that in conscious rabbits, the renin-angiotensin system does not contribute to the increase in VP secretion during hypotension induced by hemorrhage or nitroprusside infusion. | 4 |
Hiccups and breathing in human fetuses. Serial recording in 45 low risk fetuses throughout the second and third trimesters showed that hiccups were the predominant diaphragmatic movement before 26 weeks' gestational age and that there was a significant negative correlation with gestational age. There was a pronounced reduction between 24 and 26 weeks, which was the result of a decrease in the number of episodes of hiccups rather than a change in the duration of episodes. In contrast, fetal breathing was positively correlated with gestational age, the greatest increase in breathing occurring between 26 and 32 weeks' gestation. This was the result of both an increase in the number and duration of episodes. From the time that rest-activity cycles of behaviour could be determined in recordings, both breathing and hiccups were dependent on behavioural state or cycle, occurring predominantly during active episodes. This association between quiet and active behaviour and breathing did not alter with increasing gestational age, and the variables in fetal behavioural state became increasingly closely linked. The importance of prolonged and repeated recording, and also the need to take account of other variables in fetal behaviour, before any sinister conclusions can be drawn about the absence of fetal breathing is emphasised. | 4 |
Epstein-Barr virus transformation of B lymphocytes from IgA nephropathy patients and first-degree relatives results in increased immunoglobulin synthesis not restricted to IgA. In order to study B-cell activation patterns independent of T-cell regulation in patients with IgA nephropathy (IgAN), peripheral blood mononuclear cells from 67 patients with IgAN, 15 first-degree relatives of patients with familial disease, and 13 normal controls were transformed with Epstein-Barr virus (EBV). Culture supernatants of these transformed cells were assayed for levels of IgG, IgA, and IgM, and results obtained on the three populations were compared. EBV-transformed cells of IgAN patients, as well as the population of first-degree relatives, secreted significantly elevated levels of all three isotypes as compared with the normal controls. However, in comparing ratios of secreted isotypes, it was determined that more IgA relative to IgG and IgM was synthesized by cells of these two populations as compared with the normal controls. Our results imply that (1) the population of B cells susceptible to EBV activation is increased in IgAN patients; (2) this population of "activatable" B lymphocytes is polyclonal and not restricted to the IgA class; and (3) even though there may be a primary B-cell abnormality in IgAN, an additional defect(s) is probably operative in the pathogenesis, since cells of clinically unaffected relatives behaved in a pattern similar to that of patients. | 0 |
Studies of controlled reperfusion after ischemia. XXII. Reperfusate composition: effects of leukocyte depletion of blood and blood cardioplegic reperfusates after acute coronary occlusion. OBJECTIVES: This study evaluates the role of leukocyte depletion during initial reoxygenation with normal blood and blood cardioplegic reperfusates in limiting reperfusion damage. METHODS: Twenty-eight dogs underwent 2 hours of ligation of the left anterior descending coronary artery. The initial reperfusate (37 degrees C) was delivered on total vented bypass to the left anterior descending artery by a calibrated pump via an internal mammary artery graft at 50 mm Hg for 20 minutes. Eight dogs received normal (normokalemic, nonenriched) blood reperfusion (leukocyte count 8000/mm3) and six were reperfused with leukocyte-depleted normal blood (leukocyte count less than 100/mm3). Of 14 dogs reperfused with substrate-enriched (hyperkalemic) blood cardioplegic solution, six received a cardioplegic solution with a leukocyte count less than 100/mm3. RESULTS: Leukocyte depletion of normal blood reduced reperfusion-induced arrhythmias from 63% to 17% (p less than 0.05). Coronary vascular resistance at initial reperfusion was low and remained low during substrate-enriched blood cardioplegic reperfusion with both normal and reduced leukocyte counts. In contrast, coronary vascular resistance rose 63% with normal blood reperfusion, and this increase was avoided by leukocyte depletion (2.6 versus 4.0 mm Hg x ml/min, p less than 0.05). Coronary vascular resistance after 20 minutes was, however, higher than that with blood cardioplegia with normal or decreased leukocyte counts. Negligible functional recovery followed reperfusion with normal blood and leukocyte-depleted blood (12% and 6% of control systolic shortening). In contrast, substantial segmental recovery followed blood cardioplegic reperfusion (73% systolic shortening, p less than 0.05) but was not improved by leukopheresis (81% systolic shortening). Leukocyte depletion of normal blood reperfusate reduced histochemical damage from 53% to 38% (p less than 0.05), but the least histochemical damage followed blood cardioplegic reperfusion with a normal or reduced leukocyte count (8% or 11%, p less than 0.05). CONCLUSIONS: These findings suggest an important role for leukocytes in reperfusion damage, but reperfusate leukocyte filtration alone is inferior to blood cardioplegic reperfusion. Leukocyte depletion of blood cardioplegic solutions seems unnecessary after only 2 hours of ischemia. | 4 |
Acute and chronic stress in duodenal ulcer disease. Acute and chronic life event stressors were objectively assessed in a sample of duodenal ulcer patients and community controls. Stress was assessed on two dimensions, "personal threat" and "goal frustration." Chronic stressors (those of 6 months' duration or more) involving high goal frustration were significantly and independently associated with the onset and relapse of duodenal ulcers, as were acute events of high immediate but transient personal threat. | 1 |
The headache-specific locus of control scale: adaptation to recurrent headaches. This paper describes the development, psychometric properties, and construct and incremental validity of a Headache-Specific Locus of Control Scale (HSLC). The HSLC is a 33 item scale designed specifically for recurrent headache sufferers. It assesses the individual's perceptions that headache problems and headache relief are determined primarily by: the individual's behavior (Internal factors), Health Care Professionals, or Chance factors. The psychometric properties of the HSLC were satisfactory. Among our findings were that: (1) the belief that headache problems and relief are determined by chance factors was associated with higher levels of depression, physical complaints, reliance on maladaptive pain coping strategies (p less than .001), and greater headache-related disability (p less than .01); (2) the belief that headache problems and relief are influenced primarily by the ministrations of health care professionals was associated with higher levels of medication use (p less than .01) and preference for medical treatment (p less than .001); and (3) the belief that headache problems are determined by the individual's responses and behaviors was associated with a preference for self-regulation treatment (p less than .01). These findings suggest adaptation to headache problems is influenced not only by the frequency and severity of the headache episodes, but by locus of control beliefs. The assessment of locus of control beliefs may provide useful information not typically obtained from standard medical evaluations. | 2 |
Flow cytometric determination of breast tumor heterogeneity. Flow cytometric analysis was done on the DNA content of nuclei obtained from different sites of small breast tumors. Although specimens for analysis were obtained within a few millimeters of each other, dramatic differences were occasionally observed in the DNA histograms. In a limited study involving 141 consecutive breast specimens submitted for flow cytometry, 52% (74) were found to have at least one DNA aneuploid population. In 18% of DNA aneuploid tumors, one or more specimens from areas grossly identified as tumor had no DNA aneuploid population. Because of the proposed correlation of aneuploidy with a poorer prognosis and possible responsiveness to chemotherapy, multiple sites should be assayed when flow cytometric DNA analysis is done. | 0 |
An objective score to predict upper tract deterioration in myelodysplasia. Bladder dysfunction in myelodysplasia may present a significant hazard to the upper tract and a threat to kidney function. Urodynamic features of high leak pressure and detrusor-sphincter dyssynergia have been associated with an increased risk. We have developed an objective score to describe urodynamic findings in myelodysplasia. The score includes consideration of bladder compliance, detrusor contractility and reflux, in addition to leak pressure and sphincter behavior. In 171 myelodysplastic patients a significant correlation was demonstrated between the score and upper tract studies at the time of urodynamics and the score and the management decision. Of 73 myelodysplasia patients with normal upper tracts at the first urodynamics study hydronephrosis later developed in 14. The score was a potent predictor of outcome (p = 0.0006). | 2 |
Surgical correction of the snapping iliopsoas tendon. Eighteen patients with 20 symptomatic hips underwent lengthening of the iliopsoas tendon for persistent painful snapping of this "internal" variety of snapping hip. We referred to the pathologic, painful snapping of the iliopsoas in the deep anterior groin as the "internal" snapping hip. This is in contrast to the more common and better-known "external" snapping that involves the greater trochanter and its overlying soft tissues. The results of our iliopsoas lengthening procedure are presented here. Lengthening of the iliopsoas tendon was accomplished by step cutting of the tendinous portion of the iliopsoas. The pathoanatomy of this poorly understood symptom complex was described in 1984 paper from this institution and is reviewed here. Iliopsoas bursography demonstrated a sudden jerking movement of the iliopsoas tendon between the anterior inferior iliac spine and iliopectineal eminence, synchronous with the patient's pain and often accompanied by an audible snap. The average preoperative duration of symptoms was 2.9 years, and the average length of postoperative followup was 25 months. All patients, except one, had a marked reduction in the frequency of snapping after tendon lengthening, and 14 of 20 hips had no snapping postoperatively. Of the six patients who had recurrence of snapping, all but one stated that this occurred much less frequently and was much less painful compared to the preoperative state. Two hips required reoperation. Postoperatively, only three patients complained of subjective weakness, and most patients were unlimited in physical activity with return to activities such as competitive football, pole vaulting, and long-distance running. | 4 |
Spontaneous necrosis in osteosarcoma. The percentage of necrosis in a primary osteosarcoma after the patient has received preoperative chemotherapy is prognostic and is usually used to select subsequent chemotherapy. However, the percentage of necrosis that occurs spontaneously, without preoperative chemotherapy, has not been adequately studied. The examination of histologic macrosections of 76 osteosarcomas from patients who had not received preoperative treatment and of 20 patients who had received preoperative chemotherapy revealed a significant difference in the percentage of necrosis. There was minimal spontaneous necrosis, but necrosis after preoperative chemotherapy was usually extensive. The larger the tumor, the greater the percentage of spontaneous necrosis; however, size did not correlate with the percentage of necrosis with preoperative chemotherapy. Survival among those patients who did not receive preoperative treatment correlated with the size and percentage of necrosis. Necrosis in an osteosarcoma in a patient who has received preoperative chemotherapy can be considered the result of chemotherapy and not a spontaneous event. | 4 |
Nodular regenerative hyperplasia: a cause of ascites and hepatomegaly after chemotherapy for leukemia. Tender hepatomegaly and ascites occurred in a young woman receiving cytosine arabinoside and daunorubicin for acute myelogenous leukemia. Whereas veno-occlusive disease was suspected clinically, liver biopsy showed nodular regenerative hyperplasia with no evidence of hepatic vein abnormalities. It is postulated that nodular regenerative hyperplasia can be initiated by hepatotoxicity of chemotherapy agents used to treat leukemia and/or that these agents exacerbate clinical manifestations of this histological abnormality. Nodular regenerative hyperplasia should be added to the list of liver problems occurring in patients with leukemia. | 4 |
Chondrosarcoma of bone in children. Chondrosarcoma of bone rarely occurs in children. This report analyzes the clinicopathologic features in a series of 47 patients with conventional chondrosarcoma who were less than 17 years of age. Of the 47 cases, 14 were from the Mayo Clinic files, and 33 were from our consultation files. Most of the lesions occurred in the trunk and upper ends of the long bones, with the humerus being the most frequent skeletal site. Twelve of the 47 tumors were secondary. The radiographic findings were the same as those seen in adult chondrosarcoma. Pathologically, the tumors were low grade. En bloc resection is the treatment of choice because of the high incidence of local recurrence with lesser surgical margins. Prognosis in childhood chondrosarcoma is no different from that in adult chondrosarcoma. None of the patients with follow-up data had metastasis. | 0 |
A6--a new 45RO monoclonal antibody for immunostaining of paraffin-embedded tissues. The authors report on the extensive characterization, on normal and pathologic tissues, of the T-cell-specific monoclonal antibody (MoAb) A6, which the authors previously found to identify a fixation- and paraffin-embedding-resistant epitope. A6 reacted with most T lymphocytes, macrophages, and Langerhans' cells of normal tissues and with peripheral T-cell lymphomas (31 of 34), Ki-1+ lymphomas (12 of 18), and T-cell leukemias (1 of 5). All cases of X and non-X histiocytosis examined and monocytic leukemias with mature phenotype only were A6 positive. Three of 47 cases of B-cell lymphoma and leukemia were labeled. Hairy cell leukemias, multiple myelomas, and Hodgkin's and Reed-Sternberg cells were negative. The A6 reactivity was preserved with different fixatives (formalin, Bouin's fluid, Carnoy's fixative, and B5) and decalcification procedures and was slightly enhanced by trypsin digestion. The pattern of reactivity of A6 was similar to that obtained with MoAb UCHL-1, recognizing the CD45RO determinant of leukocyte common antigen; however, in pathologic tissues, A6 labeled a higher percentage of cells than UCHL-1. Cross-blocking and enzyme digestion studies (Pronase E [Sigma Chemical, St. Louis, MO] and neuraminidase [Sigma Chemical]) indicated that the two MoAbs may identify close epitopes on the same molecule. In conclusion, the authors' study indicates that A6 is an excellent reagent for detection of the CD45RO molecule on paraffin-embedded normal and pathologic tissues. | 0 |
Serum creatinine: an independent predictor of survival after stroke. We prospectively studied the relationship between serum creatinine and survival among 492 elderly subjects admitted for stroke and monitored for a mean period of 18 months post-stroke. In multivariate proportional hazards models, serum creatinine remained an independent predictor of mortality (P = 0.0001) after accounting for other important predictors such as level of consciousness. Mini-Mental State Score, age, leucocyte count, presence of heart disease, diabetes, heart failure, atrial fibrillation and use of cardiovascular medication. This association between elevated serum creatinine and mortality was also found in patient subgroups with CT-proven infarction and intracerebral haematoma. It is concluded that serum creatinine is an independent predictor of survival after stroke. Further studies are required to confirm this relationship and to elucidate the underlying mechanism. | 2 |
Somatostatin analogue treatment inhibits post-resectional adaptation of the small bowel in rats. Post-resectional hyperplasia is the phenomenon in which residual small bowel increases in size and absorptive capacity after segmental enterectomy. This experiment studied the effect of somatostatin analogue therapy on the development of two structural parameters of post-resectional hyperplasia in rats subjected to 40% proximal small bowel resection. Octreotide acetate-treated rats failed to develop increased villus height (902 +/- 50 microns) relative to saline-treated rats (1,103 +/- 98 microns). Augmentation of residual intestinal weight was also significantly impaired in analogue-treated rats (92 +/- 3 versus 118 +/- 5 mg/cm). We conclude that somatostatin analogue treatment during the early postoperative period does impair the growth of residual bowel in rats. These findings raise concern regarding the use of this drug for postoperative patients who have undergone massive small bowel resection in whom the process of post-resectional adaptation may be critical to allow sustenance with enteral nutrition. | 4 |
Annular pancreas as a cause of extrahepatic biliary obstruction. Annular pancreas is a rare congenital abnormality that is increasingly diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) in the adult. In this population, it can present with duodenal or gastric ulceration, duodenal obstruction, pancreatitis, and, rarely, with associated congenital abnormalities. Although it has been suggested that biliary obstruction may result from associated pancreatitis, such cases have not been reported; primary extrahepatic biliary obstruction from a constricting annulus also has not been reported. We report such a case, and describe resolution of symptoms and a return to normal biochemical tests in a patient. The literature and embryology of annular pancreas are reviewed. We suggest that this entity be added to the differential diagnosis of extrahepatic biliary obstruction. | 1 |
Topical calcipotriol treatment in advanced breast cancer [published erratum appears in Lancet 1991 Jun 29;337(8757):1618] 19 patients with locally advanced or cutaneous metastatic breast cancer were treated with the topical vitamin D analogue calcipotriol 100 micrograms daily. 14 patients completed 6 weeks' treatment; 3 showed a 50% reduction in the bidimensional diameter of treated lesions and 1 other patient showed a minimal response. 2 patients became hypercalcaemic during treatment. In all patients who responded the tumours contained receptors for 1,25-dihydroxyvitamin D3, shown by immunocytochemistry. | 0 |
Aortic regurgitation after left ventricular myotomy and myectomy. Five hundred twenty-five patients with hypertrophic cardiomyopathy underwent left ventricular myotomy and myectomy (LVMM) from 1960 to 1990. Four hundred ninety-six had nonregurgitant trileaflet aortic valves before LVMM. In 19 (4%) of these patients, aortic regurgitation developed after LVMM. Age of the 19 patients ranged from 10 to 58 years (mean age, 35 +/- 3 [+/- standard error of the mean]]. Seven were male and 12, female. Five patients underwent LVMM followed immediately by aortic valve replacement or valvuloplasty. Aortic regurgitation developed in 14 patients at a later date. The average New York Heart Association functional class improved from 3.2 +/- 0.1 to 1.3 +/- 0.1 (p less than 0.05, Student's t test) after operation. The average peak systolic left ventricular outflow tract gradient at rest and with provocation decreased from 65 +/- 8 to 14 +/- 5 mm Hg (p less than 0.05) and 108 +/- 9 to 45 +/- 7 mm Hg (p less than 0.05), respectively, 6 to 8 months after operation. Aortic regurgitation occurred in 7 of the 14 patients at 6 months or less after operation, and 3 required operative repair. In the other 7 patients, aortic regurgitation developed 3 years or more after LVMM, and 3 of them also required operative repair. All 12 patients in whom aortic regurgitation developed at operation or within 6 months postoperatively had either a very small aortic annulus (less than or equal to 21 mm, 5 patients), a low mitral-septal contact lesion (greater than or equal to 35 mm below the aortic annulus, 3 patients), or both (4 patients). | 3 |
Botulinum vs adjustable suture surgery in the treatment of horizontal misalignment in adult patients lacking fusion. Thirty patients were treated with either botulinum toxin or adjustable suture surgery in a prospective, randomized clinical trial. All patients had horizontal deviations greater than 10 prism diopters and absent fusion. Seventeen patients were assigned to toxin treatment, and 13 were assigned to surgical treatment. Follow-up at 6 months after either procedure indicated that surgery was superior, with patient alignment showing a 92.7% average net change, compared with a 50.50% net change in the botulinum-treated group. There was no difference in response between those patients with a starting deviation of 20 PD or less and greater than 20 PD in the surgery group. However, in the botulinum-treated group, those patients with a starting deviation of 20 PD or less seemed to show better responses than those patients with greater than 20 PD. Patients with esotropia showed an 88.89% change with surgery and a 51.55% change with toxin treatment. Patients with exotropia had a 95.83% change with surgery but a 50.3% change with toxin treatment. Since we had 20 patients with exotropia and 10 patients with esotropia, a more formal comparison would require larger numbers. | 2 |
Left ventricular aneurysm secondary to Behcet's disease. A 16-year-old boy with Behcet's disease who was seen with thrombophlebitis of the leg was found to have coronary artery occlusion with postinfarction left ventricular aneurysm. Recurrent femoral artery aneurysms and orogenital ulceration developed in him. The diagnostic features together with successful treatment of this patient and a discussion of Behcet's syndrome are presented. | 4 |
Tuberculous peritonitis: a study comparing cirrhotic and noncirrhotic patients. Tuberculous peritonitis is a rare disease, which often goes unrecognized because of the subtle clinical clues and its insidous onset. We retrospectively analyzed the records of 37 cases of tuberculous peritonitis diagnosed over a 15-year period, and compared the clinical and diagnostic features of cirrhotic and noncirrhotic patients. In cirrhotic patients, tuberculous peritonitis can simulate ascites from liver disease or spontaneous bacterial peritonitis. The diagnosis is difficult in these patients because the ascitic fluid may not be of the exudative type as a result of the low albumin level in serum, and lymphocytes do not predominate in all cases. Adenosine deaminase (ADA) activity in ascitic fluid was elevated (higher than 40 U/L) in all 11 patients (four patients with hepatic cirrhosis). The time required to achieve a correct diagnosis was significantly longer in cirrhotic than in noncirrhotic patients. The overall mortality was 13%, with deaths occurring exclusively among cirrhotic patients. We emphasize that tuberculous peritonitis in cirrhotic patients can present an atypical picture. A considerable element of suspicion is necessary. | 1 |
Chilaiditi's syndrome. A diagnostic challenge. Chilaiditi's syndrome should be considered in the differential diagnosis of abdominal and chest pain. Although interposition of the right colon is a relatively common radiologic finding, there is a distinct paucity of information in the medical literature. Chilaiditi's syndrome is usually asymptomatic, but when symptoms occur, conservative treatment is usually effective. Recognition is important because this syndrome can be mistaken for more serious abnormalities, which may lead to unnecessary surgical intervention. | 1 |
Fungal pseudomeningitis superimposed on Escherichia coli meningitis. Pseudomeningitis is the demonstration of microorganisms from the cerebrospinal fluid by stain or culture in a patient with symptoms suggesting meningitis. This is a report of fungal pseudomeningitis superimposed on a case of nosocomial Escherichia coli meningitis resulting from a neurosurgical procedure. Critical care personnel need to be aware of the possibility of pseudomeningitis with or without associated meningitis in the appropriate setting. | 2 |
Immunohistochemical evaluation of seven monoclonal antibodies for differentiation of pleural mesothelioma from lung adenocarcinoma. A panel of seven monoclonal antibodies including anti-vimentin, anti-keratin markers AE1/AE3 and EAB902, human milk fat globule (HMFG-2), B72.3, anti-carcinoembryonic antigen (CEA), and anti-Leu-M1 were used for an immunoperoxidase staining assay to determine their value in the differentiation of pleural mesothelioma from lung adenocarcinoma. Anti-vimentin positively identified 86% of the mesotheliomas and none of the adenocarcinomas. AE1/AE3, EAB902, and B72.3 reacted with a high percentage of both mesothelioma and adenocarcinoma specimens. With HMFG-2, both membrane and cytoplasmic staining was observed in 92% of the adenocarcinomas and in 14% of the mesotheliomas, whereas 26% of the mesotheliomas only exhibited membrane staining. Eighty percent of the adenocarcinomas and 8% of the mesothelioma tissues stained with anti-Leu-M1. Anti-CEA did not react with any of the 50 mesotheliomas tested but did react with 95% of the lung adenocarcinomas tested. From this study, it was concluded that anti-CEA and anti-Leu-M1 were the most effective of the seven tumor markers evaluated; and that 100% of the pleural mesothelioma tissues could be correctly differentiated from lung adenocarcinomas using a panel consisting of anti-vimentin, HMFG-2, anti-CEA and anti-Leu-M1 monoclonal antibodies. | 0 |
Studies of myocardial protection in the immature heart. II. Evidence for importance of amino acid metabolism in tolerance to ischemia. This study tests the importance of amino acid transamination in determining the tolerance of immature hearts to ischemic damage. Amino acid transamination was inhibited metabolically by pretreatment with aminooxyacetic acid. The aminooxyacetic acid dose and duration were determined by incubating in vitro tissue homogenate and showing that an 8 mmol/L AOA dose for 5 minutes blocked 90% of alanine aminotransferase and aspartate aminotransferase activity. Control studies in nonischemic hearts showed that coronary perfusion with aminooxyacetic acid for 5 minutes did not impair myocardial performance. In contrast, pretreatment of immature puppies with aminooxyacetic acid severely impaired recovery after 45 minutes of normothermic global ischemia (30% versus 85% recovery in untreated hearts, p less than 0.05). Biochemical analyses of hearts undergoing ischemia showed aminooxyacetic acid to limit lactate production, impair glutamate utilization, prevent alanine production, and limit succinate accumulation (p less than 0.05). These data suggest that amino acid transamination is an important adaptive process in the immature heart that improves its resistance to ischemic damage. | 3 |
Carotid artery resection and replacement in patients with head and neck malignant tumors. Tumor involvement of the carotid artery with head and neck cancers may be present either simultaneously with the primary lesion or more often appears at a later date following resection of the primary tumor. Management of the secondary tumor consists of its resection together with the involved carotid artery with or without carotid artery reconstruction. The Authors are convinced that the best chance for cure of patients with advanced head and neck squamous cell cancers involving the carotid artery is radical extirpation with ablative surgery in the form of en block resection of the primary lesion, the secondary tumor, and the involved carotid artery followed by immediate revascularization. This bold approach was carried out in two male patients, 48 and 61 years of age, followed by chemotherapy and radiation therapy in one and radiation therapy alone in the other, with excellent results. Dermal grafts were placed over the entire length of the arterialized veins to protect them from radiation injury. Based on this limited experience and excellent results, we recommend this one-stage surgical ablative procedure in well selected patients. However, cooperation between the ENT and vascular surgeons, strict adherence to the principles and techniques of vascular surgery, and coverage of the arterialized vein with a dermal graft is absolutely essential. | 0 |
Stressful experience and cardiorespiratory disorders. Ever since Selye's time, the belief has persisted that the outcome of stressful experience is disease. The likelihood of this eventuality is increased when the experience is damaging, unavoidable, or uncontrollable. However, in most stressful instances, these conditions do not occur. The experience either is overcome or produces disturbances in physiological functions without structural change. The prevalence of "functional" disorders are far more common in medical practice than is disease. Among the most interesting of these is the hyperventilation syndrome, which may mimic or be confused with ischemic heart disease. Its symptomatology and physiology are complex. The syndrome may produce coronary vasospasm, but it may also complicate ischemic heart disease. It is even believed that chronic hyperventilation may be a risk factor for ischemic heart disease. Stressful experience consisting of various tasks and challenges may also produce myocardial perfusion deficits in ischemic heart disease, presumably secondary to vasospasm. These deficits are in turn considerably more frequent in any one patient than ST segment changes in the electrocardiogram or the incidence of angina pectoris. Vasospasm is in turn related to cardiac arrhythmias, which may occur with ischemic heart disease during a variety of stressful experiences and during outbursts of anger. Finally, the role of stressful experience in inciting ischemic heart disease and its complications remains moot. | 3 |
A kallikrein-like enzyme in blood vessels of one-kidney, one clip hypertensive rats. Active and inactive kallikrein or a kallikrein-like enzyme are found in the aorta, vena cava, and tail artery and veins of the rat. We studied the concentration of vascular kininogenase in rats with one-kidney, one clip renovascular hypertension and in unilaterally nephrectomized normotensive rats. Six weeks after surgery, active and total vascular kininogenase activity (active plus trypsin-activated) was measured. Blood pressure was 212 +/- 4 mm Hg in the hypertensive rats (n = 33) and 120 +/- 1 mm Hg in the normotensive rats (n = 32) (p less than 0.001). Active kininogenase was lower in the hypertensive rats; although the difference was not significant in the thoracic aorta (56 +/- 8 versus 77 +/- 15), it was highly significant in the abdominal aorta (63 +/- 13 versus 167 +/- 17, p less than 0.001) and tail artery (48 +/- 8 versus 197 +/- 31, p less than 0.003). Total vascular kininogenase activity (active plus trypsin-activated) was lower in the hypertensive rats in all arteries examined: thoracic aorta (183 +/- 16 versus 380 +/- 38, p less than 0.003), abdominal aorta (565 +/- 61 versus 1,093 +/- 74, p less than 0.001), and tail artery (532 +/- 112 versus 1,243 +/- 135, p less than 0.003). Active kininogenase in the vena cava was higher in the hypertensive rats (213 +/- 56 versus 131 +/- 31); however, this difference was not statistically significant, whereas in the tail veins it was highly significant (1,803 +/- 221 versus 771 +/- 79, p less than 0.003). | 3 |
Small bowel obstruction associated with a leiomyomatous uterus. A case report and review of the literature. A 38-year-old woman developed small bowel obstruction shortly after a cholecystectomy because of a massively enlarged leiomyomatous uterus. Small bowel obstruction is a relatively rare complication from fibroid tumors and results from entrapment of the bowel between serosal pedunculated fibroids (as in this patient), adhesions to infarcted leiomyomas, or from compression of the small bowel by the large mass. Large uterine leiomyomas clearly must be considered in the etiology of intestinal obstruction. | 1 |
Late outcome of survivors of out-of-hospital cardiac arrest with left ventricular ejection fractions greater than or equal to 50% and without significant coronary arterial narrowing. In a retrospective survey of 1,195 survivors of out-of-hospital ventricular fibrillation, 43 patients were identified in whom left ventricular ejection fraction was greater than or equal to 0.50 and in whom no coronary artery stenosis of greater than or equal to 50% luminal diameter were present. Thirteen (30%) of these patients had hypokinesia on left ventriculography, and 20 patients (47%) had a persistently abnormal electrocardiogram. Seven patients (16%) had recurrent out-of-hospital cardiac arrest during an average follow-up of 86 +/- 54 months. The presence of either wall motion or electrocardiographic abnormalities defined patients with a several-fold higher risk of recurrent cardiac arrest than those without such abnormalities. The risk for recurrent cardiac arrest within 5 years was 30% in those with abnormal electrocardiograms versus 5% in the others (p less than 0.03). Age was an independent predictor of recurrent cardiac arrest in this group (p less than 0.01); surprisingly, recurrent cardiac arrest was occurring more often among younger patients. Although cardiac arrest is unusual in patients without major structural heart disease, its recurrence in such survivors is common. Patients at relatively high risk for recurrent ventricular fibrillation can be identified by their youth and by abnormalities detected on the surface 12-lead electrocardiogram or by contrast left ventriculography. | 4 |
Changes in the relative frequency of gastric adenocarcinoma in southern California. The incidence of gastric cancer is decreasing in most counties of the developed world, but at the Los Angeles County-University of Southern California Medical Center, we diagnosed 99.8 cases of gastric adenocarcinoma per 10(5) discharges in the period 1982 to 1986 as opposed to 62.2 per 10(5) discharges in 1972 to 1976 (P less than .0001). This change involved primarily Hispanics younger than 30 years of age with 30 cases per 10(5) vs 4.2 cases per 10(5) (P less than .0001) and whites older than 30 years: 87 cases per 10(5) vs 54 cases per 10(5) (P less than .05) during 1982 to 1986 and 1972 to 1976, respectively. There was no change in the relative frequency rates of gastric adenocarcinoma among African Americans and Asians. Although these changes do not seem important enough to make the detection of gastric cancer a high-priority public health problem, they should alert physicians working in areas with high Hispanic populations of the relative possibility of the occurrence of gastric malignancy even in young patients. Also, we have found that gastric cancer is still prevalent in whites of low socioeconomic class. | 0 |
High-normal blood pressure progression to hypertension in the Framingham Heart Study. This study sought to determine if individuals with high-normal blood pressure (diastolic blood pressure of 85-89 mm Hg) progress to hypertension more frequently than those with normal blood pressure (diastolic blood pressure less than 85 mm Hg), thus advancing to a higher cardiovascular risk category. Individuals from the Framingham Heart Study were placed in normal and high-normal blood pressure categories and followed for 26 years for the development of hypertension. With hypertension defined as a diastolic blood pressure of 95 mm Hg or greater or the initiation of antihypertensive therapy, 23.6% of men and 36.2% of women with normal blood pressure developed hypertension compared with 54.2% of men and 60.6% of women with high-normal blood pressure. The relative risk for the development of hypertension associated with high-normal blood pressure was 2.25 for men (95% confidence interval [CI], 1.8-2.8; p less than 0.0001) and 1.89 for women (95% CI, 1.5-2.3; p less than 0.0001). The age-adjusted relative risks estimated by the proportional hazards model were 3.36 for men and 3.37 for women (p less than 0.001). Among those risk factors examined, baseline systolic and diastolic blood pressure, Metropolitan relative weight, and change in weight over time were significant predictors of future hypertension in men and women whose initial blood pressure was normal. For men with high-normal blood pressure, systolic blood pressure and change in weight were identified as risk factors for future hypertension. These results indicate that the probability of individuals with blood pressure in the high-normal range developing hypertension is twofold to threefold higher than in those with normal blood pressure. | 3 |
Asymptomatic rhabdomyolysis of unknown etiology. A 7-year-old boy developed rhabdomyolysis with a peak creatine phosphokinase level of 261,400 IU/L after his appendectomy. These abnormalities occurred following a 2-3-day illness consisting of upper respiratory tract symptoms, fever, and abdominal pain mimicking acute appendicitis. At the time of operation, a normal appendix was removed, and mesenteric lymphadenitis was noted. The myoglobinuria and elevation of creatine phosphokinase were transient, and the patient remained asymptomatic. We review various causes of right lower quadrant pain and rhabdomyolysis and address the roles of malignant hyperthermia and infectious agents. The possible cause of the phenomena observed in this patient is discussed. | 1 |
Nitrous oxide antagonizes CNS stimulation by laudanosine in mice. We have investigated whether nitrous oxide antagonizes or augments the CNS stimulant action of laudanosine in mice by comparing the mean convulsive doses (CD50 (SE] of a control group and those following pretreatment with 65% nitrous oxide in oxygen for 20 and 180 min. Nitrous oxide significantly increased CD50 from 46.8 (1.4) mg kg-1 of control to 57.3 (1.3) mg kg-1 at 20 min and 53.5 (1.7) mg kg-1 at 180 min. The attenuation of the effect of nitrous oxide at 180 min, suggestive of possible partial drug tolerance, was not statistically significant. These findings indicate that nitrous oxide antagonizes the CNS stimulating action of laudanosine. | 4 |
Renal angiomyolipoma: report of 24 cases. A series of 24 patients with renal angiomyolipoma was reviewed. Their ages ranged from 10 to 70 years (average 41). Four cases were associated with tuberous sclerosis, 1 with spinal neurilemmoma, 1 with transitional cell carcinoma and another with renal tuberculosis. The presenting symptoms in decreasing frequencies were flank pain, mass, haematuria, fever, syncope and respiratory distress. Although it has often been said that angiomyolipomas associated with tuberous sclerosis are small and asymptomatic, all 4 such patients in this study had large symptomatic tumours. Before the advent of CT scan and ultrasonography, the pre-operative diagnostic rate for cases unassociated with tuberous sclerosis was 10% (1/10). With the combined use of these 2 modalities, the diagnostic rate increased to 60% (6/10). Most patients in this series were treated with nephrectomy. However, equally good outcomes occurred in 2 patients who received partial nephrectomies. Pre-operative diagnosis now makes it possible to consider more conservative management. | 0 |
Catheterization laboratory events and hospital outcome with direct angioplasty for acute myocardial infarction To assess the safety of direct infarct angioplasty without antecedent thrombolytic therapy, catheterization laboratory and hospital events were assessed in consecutively treated patients with infarctions involving the left anterior descending (n = 100 patients), right (n = 100), and circumflex (n = 50) coronary arteries. The groups of patients were similar for age (left anterior descending coronary artery, 59 years; right coronary artery, 58 years; circumflex coronary artery, 62 years), patients with multivessel disease (left anterior descending coronary artery, 55%; right coronary artery, 55%; circumflex coronary artery, 64%), and patients with initial grade 0/1 antegrade flow (left anterior descending coronary artery, 79%; right coronary artery, 84%; circumflex coronary artery, 90%). Cardiogenic shock was present in eight patients with infarction of the left anterior descending coronary artery, four with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery. Major catheterization laboratory events (cardioversion, cardiopulmonary resuscitation, dopamine or intra-aortic balloon pump support for hypotension, and urgent surgery) occurred in 10 patients with infarction of the left anterior descending coronary artery, eight with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery (16 of 16 shock and six of 234 nonshock patients, p less than 0.001). There was one in-laboratory death (shock patient with infarction of the left anterior descending coronary artery). | 3 |
Surgical management of pheochromocytoma with the use of metyrosine. Despite recommended preoperative preparation with alpha-adrenergic blockers, severe hemodynamic instability may occur during operations to resect pheochromocytoma. We combined the alpha-blocker phenoxybenzamine with the tyrosine hydroxylase inhibitor metyrosine in an attempt to better manage the hypertension of patients with pheochromocytoma undergoing surgical resection. This report reviews the cases of 25 consecutive patients undergoing surgery for known intra-abdominal pheochromocytoma. Each patient had elevated serum or urine levels of catecholamines or their metabolites. Nineteen patients were prepared before operation with phenoxybenzamine and metyrosine and six patients were given phenoxybenzamine alone. There were no significant differences in maximum, minimum, or mean blood pressure before or after tumor resection between patients who received metyrosine and those who did not. However careful review suggested that those who received metyrosine had more severe disease as judged by biochemical criteria. Study of selected patients matched for age and severity of disease suggested that the intraoperative blood pressure management of patients prepared with phenoxybenzamine and metyrosine was facilitated. In addition metyrosine-prepared patients lost less blood and required less volume replacement during surgery than did non-metyrosine-prepared patients. There were no apparent differences in postoperative fluid requirements. Although the study is not a prospective randomized trial, a retrospective review of patients managed with the combination of phenoxybenzamine and metyrosine suggests that surgery to resect pheochromocytoma can be better performed with both drugs than with phenoxybenzamine alone. The combination regimen appears to result in better blood pressure control, less blood loss, and the need for less intraoperative fluid replacement than does the traditional method of single-agent alpha-adrenergic blockade. | 3 |
The role of endoscopic injection sclerotherapy in the management of bleeding peristomal varices. Peristomal varices usually occur in patients with enterostomies who develop portal hypertension, and represent a cause of recurrent or intractable gastrointestinal bleeding. Treatment options for such bleeding include surgical ligation of varices, stoma revision with devascularization, injection sclerotherapy, portacaval shunt, or liver transplantation. We reviewed the records of seven patients with peristomal varices, who were followed for a mean of 17 months after diagnosis. Fourteen episodes of clinically significant peristomal bleeding occurred in six patients. Surgical ligation of varices was ineffective in controlling bleeding in two of three patients, although stoma revision with devascularization was temporarily effective in two other patients. Injection sclerotherapy, used in three patients, effectively controlled acute bleeding without serious complications or need for surgery. Definitive treatment for peristomal bleeding (portacaval shunt or liver transplantation) has prevented any further bleeding in three patients for a mean of 8 months after surgery. | 1 |
Studies of controlled reperfusion after ischemia. XVIII. Reperfusion conditions: attenuation of the regional ischemic effect by temporary total vented bypass before controlled reperfusion. This study tests the hypothesis that total vented bypass can attenuate the regional ischemic effect during a defined time interval before controlled blood cardioplegic reperfusion. Thirty-three dogs underwent 2 or 4 hours of occlusion of the left anterior descending coronary artery and then received a regional blood cardioplegic reperfusate on total vented bypass. Cardiopulmonary bypass and reperfusion were started after 2 hours of ischemia in eight dogs, and after 4 hours of ischemia in 25 others. Among the 25 dogs, seven had total vented bypass started after the first 2 hours of the 4 hours of regional ischemia. Segmental shortening (ultrasonic crystals), tissue water content (wet/dry weight), and histochemical damage (triphenyltetrazolium chloride stain) were assessed 2 hours after reperfusion. Dogs reperfused after 2 hours of ischemia recovered 73% +/- 8% of control systolic shortening and sustained only 11% triphenyltetrazolium chloride nonstaining. Dogs undergoing 4 hours of regional ischemia, but with total vented bypass 2 hours before reperfusion had improved recovery of systolic shortening (49% versus 31%, p less than 0.05), limited epicardial edema (79.6% versus 81.1% water content, p less than 0.05), and reduced histochemical damage (24% versus 39% triphenyltetrazolium chloride nonstaining, p less than 0.05). These findings imply that institution of total vented bypass during ischemia attenuates the infarct process, increases regional recovery of contractility, limits edema and restricts histochemical damage, and may be a useful adjunct to myocardial salvage when controlled reperfusion can be provided. | 3 |
Perioperative arrhythmias after Fontan repair. Arrhythmias are well-recognized sequelae of the Fontan repair. A prospective analysis of perioperative arrhythmias after Fontan repair was performed. Thirty-three patients had 24-hour ambulatory monitoring on the day before surgery and for 24 hours immediately after surgery; the 27 surviving patients had an additional 24-hour study on the seventh postoperative day. The most common preoperative rhythm was normal sinus, which was present in 79%. Hemodynamically significant preoperative arrhythmias were present in only two patients-atrial flutter (n = 1) and complete heart block (n = 1). Other asymptomatic preoperative arrhythmias included ectopic atrial rhythm (n = 2), supraventricular tachycardia (n = 1), accelerated junctional rhythm (n = 1), and frequent ventricular premature beats (n = 1). On the first postoperative day, the most common rhythm was accelerated junctional rhythm, which was present in 48%. Hemodynamically significant arrhythmias were present in nine patients (27%) -rapid accelerated junctional rhythm (rate, greater than 190 beats/min) (n = 3), complete heart block (n = 2), atrial flutter (n = 2), supraventricular tachycardia (n = 1), and ventricular tachycardia (n = 1). Three of six deaths occurring between postoperative days 2 and 7 were in patients with rapid accelerated junctional rhythm and associated low cardiac output. On the seventh postoperative day, the most common rhythm was normal sinus, which was present in 41%. Nine of the 27 surviving patients had complete resolution of their arrhythmias between postoperative days 2 and 7. On postoperative day 7, hemodynamically significant arrhythmias were present in four patients-atrial flutter (n = 2) and complete heart block (n = 2). | 4 |
Liver and pancreas: improved spin-echo T1 contrast by shorter echo time and fat suppression at 1.5 T. T1-weighted spin-echo magnetic resonance (MR) images have had limited soft-tissue contrast at 1.5 T. The authors investigated the effects of echo-time (TE) minimization and fat suppression on MR images of the liver and pancreas. Two sets of MR images were obtained with identical repetition times and other parameters. In 10 subjects with seven liver lesions, images with TEs of 20 and 12 msec were compared. In 18 additional subjects with seven liver lesions and five pancreatic carcinomas, images with identical TEs but with and without fat suppression were compared. Contrast-to-noise ratios (CNRs) were greater with a TE of 12 msec than with a TE of 20 msec for liver versus spleen (7.6 vs 4.9, P = .014) and liver versus lesion (6.9 vs 3.9, P = .031). In patients without fatty liver, CNR for six lesions versus liver was greater (9.5 vs 6.0, P = .014) with fat suppression. CNR between glandular pancreas and cancer was most conspicuous with fat suppression, but fat planes were less distinct. Minimization of TE improves T1-weighted images significantly. Fat suppression also improves CNR, but the disadvantages of fat suppression do not allow elimination of conventional T1-weighted images. | 0 |
Magnetic resonance imaging of facial nerve neuromas. Facial nerve neuromas are uncommon tumors often confused with other tumors of the temporal bone and cerebellopontine angle. Radiologically, it may be impossible to differentiate an intracanalicular facial nerve neuroma from an acoustic neuroma. We present three case reports of facial nerve neuromas arising within the internal auditory canal to show the important magnetic resonance imaging features of these tumors. One tumor extended into the cerebellopontine angle, middle cranial fossa, and middle ear. Another filled the internal auditory canal and extended through the cerebellopontine angle to the brain stem. The third occurred in a patient who had neurofibromatosis as well as numerous other intracranial tumors. We feel that gadolinium-enhanced magnetic resonance imaging provides the most useful information in the preoperative assessment of this disorder. | 2 |
Total knee arthroplasty in diabetes mellitus. A retrospective study was done of 59 total knee arthroplasties (TKAs) in 40 patients diagnosed with diabetes mellitus. The overall infection rate was 7%, with an overall revision rate of 10% and an average follow-up period of 4.3 years. Wound complications were present in 12% of the TKAs. The rate of deep joint infections in diabetic patients was statistically higher than the reported incidence of sepsis in nondiabetic patients. Therefore, maximum precautions should be taken for diabetic patients having TKA to minimize both wound complications and joint sepsis. | 3 |
Frequency and severity of mitral regurgitation one year after balloon mitral valvuloplasty. Mitral regurgitation (MR) was evaluated by Doppler echocardiography in 59 patients with mitral stenosis before, immediately after and 1 year after balloon mitral valvuloplasty (BMV). The severity of MR was graded on a scale from 1+ to 4+. Echocardiographic and hemodynamic variables were analyzed to study the potential factor(s) that might predict the long-term persistence of MR. Echocardiographic variables were mitral valve thickness and motion, subvalvular change, left atrial dimension, commissural calcification and effective balloon/mitral anular diameters. Hemodynamic variables were mitral pressure gradient, pulmonary arterial pressure, ejection fraction, mitral valve area index, age, gender and cardiac rhythm. Mitral valve area index increased from 0.9 +/- 0.5 to 1.5 +/- 0.8 cm2/m2 immediately after BMW, and to 1.4 +/- 0.3 cm2/m2 at 1 year follow-up (p less than 0.01). Immediately after BMV, MR grading did not change in 30 patients (51%), increased by 1+ in 23 patients (39%), by 2+ in 2 patients (3.3%) and by 3+ in 2 patients (3.3%), and decreased by 1+ in 2 others. At 1-year follow-up, only 1 patient with severe MR required valve replacement. Fifty-one patients (88%) had no change in the extent of MR (less than or equal to 1+) and 6 patients (10%) had a 1-grade decrease in their MR; only 1 patient had a 1-grade increase in MR. No clinical or hemodynamic variables or morphologic characteristics of the mitral valve could predict the development of significant MR after BMV. It is concluded that an increment in MR severity less than or equal to 2+ is frequently seen after BMV. | 3 |
Carcinoid tumors. The authors carried out a retrospective study of 32 patients (23 M, 9 F) with carcinoid tumors who were diagnosed and treated at Harlem Hospital Center, New York, from 1967 to 1988. All the patients were black and the commonest sites were the ileum (28.1%), rectosigmoid and rectum (21.9%), and the appendix and lung (15.6% each). Metastasis correlated with site, size, and depth of the primary tumor and occurred in 12 patients (38%), most frequently to the regional lymph nodes and liver. Carcinoid syndrome developed in 12.5% (3 F, 1 M). Surgical resection for cure or palliation was the mainstay of treatment. Overall 5 year survival rate was 66%, and for those with metastases was 0%. The poorer survival rates are probably related to the socioeconomic status of our patient population. The only observed racial difference compared to other series is the preponderance of males, and the disproportionately higher ratio of females with the carcinoid syndrome. | 0 |
Nonhomologous chromatid exchange in hereditary and sporadic renal cell carcinomas. For the development of renal cell carcinomas, it has been suggested that a germ-line or somatic mutation occurs on one of the homologous chromosomes 3p, and subsequently the other 3p segment is lost. We have examined the karyotype and/or the allelic combination on chromosomes 3 and 5 by restriction fragment length polymorphism analysis in normal kidney and tumor samples from 28 renal cell carcinomas that developed in two patients with von Hippel-Lindau disease; we then compared the results to those of sporadic tumors. An unbalanced translocation between chromosome 3p and 5q or other chromosomes was found to be the most common aberration. We developed a model of nonhomologous chromatid exchange involving breakpoint clusters at chromosomes 3p13, 3p11.2, 5q22, and 8q11.2. Subsequent chromatid segregation may result in net loss of the 3p segment either (i) in one step or (ii) after a nondisjunctional loss of the derivative chromosome carrying the 3p segment. This general mechanism could also be implicated to explain genetic changes occurring in other types of solid tumors. | 0 |
Kaposi's sarcoma of the colon in a young HIV-negative woman with Crohn's disease. We report a case of isolated colonic Kaposi's sarcoma in a 36-year-old HIV-negative woman with refractory Crohn's disease of the colon and perineum following 11 months' treatment with azathioprine. The clinical features of this case are quite different from those classically described in Kaposi's sarcoma. Among the known risk factors, iatrogenic immunosuppression would appear to be the most probable. | 0 |
Unknown primary squamous cell carcinoma metastatic to the neck. We analyzed retrospectively 157 cases of metastatic neck squamous cell carcinoma from unknown primary sites, treated with surgery, radiotherapy, excisional biopsy, and combined modalities. Median follow-up was 74 months, and overall actuarial survival was 55% at 5 years. The surgery-treated group, despite a higher rate of manifesting primary tumors, had significantly better survival at 5 years compared with those receiving radiation therapy, of whom 23% had residual disease after treatment. Primary tumors were discovered during follow-up in 16% overall. Different treatments yielded comparable results in lower-staged neck disease (NX, N1, N2a), while surgery appeared more effective in controlling advanced disease (N2b, N3a). Factors that affected survival include neck stage, connective tissue invasion, and presence of recurrent or residual disease after treatment. | 4 |
Role of alcohol in recurrences of atrial fibrillation in persons less than 65 years of age. The role of alcohol in recurrences of atrial fibrillation (AF) was assessed in a consecutive series of 98 patients (75 men) aged less than 65 years. In addition to etiologic assessment using clinical and laboratory methods and echocardiography, the patients' drinking habits were evaluated by recording the amount of alcohol used during the week preceding AF, by responses to the CAGE (Cut, Annoying, Guilt, Eye; see below) questionnaire (a screening test for alcohol abuse) and by selected laboratory tests. Two groups of control subjects were studied: 98 sex- and age-matched patients admitted to the emergency ward for acute illnesses, and 50 subjects selected randomly from the local out-of-hospital population. The mean alcohol consumption among men during the study week was 186 g (median 45 g; range 0 to 2,100 g) among patients, whereas among male hospital and population control subjects it was 86 g (30 g; 0 to 1,050 g) and 94 g (35 g; 0 to 630 g), respectively. When the weekly alcohol consumption was analyzed in 3 categories (0; 1 to 210 g; greater than 210 g), there was a significant difference between AF cases and hospital control patients (p = 0.03), but not between AF cases and population control subjects. Multivariate analysis of data of AF cases and population control subjects showed that alcohol intake and a positive response to 1 or more of the CAGE questions were independently related to AF in men. Other independent risk factors were the presence of heart disease, low serum potassium and lack of sleep or experience of excess psychologic stress, or both. | 3 |
Combined myocardial revascularization and abdominal aortic aneurysm repair. Myocardial infarction remains the leading cause of early and late deaths after abdominal aortic reconstruction in patients with abdominal aortic aneurysm. Our approach for the past 4 years has been combined myocardial revascularization with abdominal aortic aneurysm repair in patients with good left ventricle performance. From July 1984 through June 1989, 128 patients underwent abdominal aortic aneurysm repair. Seventeen patients underwent combined abdominal aortic reconstruction with coronary artery bypass grafting. One patient died (5.9%). The remaining patients are all well at current follow-up. Our experience shows that patients with coronary artery disease and abdominal aortic aneurysm may have both lesions safely repaired as a single operative procedure. | 3 |
Catheter-induced tricuspid regurgitation. Incidence and clinical significance. The incidence and severity of catheter-induced tricuspid regurgitation has not been studied extensively. Given the frequency with which right heart catheters are employed to measure cardiac output, it is important to know whether the severity of catheter-induced tricuspid regurgitation is sufficient to invalidate the measurement of thermodilution cardiac output. Accordingly, the purpose of the present prospective study was to determine the incidence and severity of catheter-induced tricuspid regurgitation in 25 men (mean age, 58.1 +/- 1.4 years) using Doppler ultrasound. The tricuspid valve was interrogated from two orthogonal views using pulsed-wave and color flow Doppler, either in the presence or absence of a 7-French catheter across the tricuspid valve. The severity of catheter-induced tricuspid regurgitation was graded semiquantitatively using a validated scoring system. Pulsed-wave Doppler studies showed that the incidence of catheter-induced tricuspid regurgitation was 48 percent, and that the average tricuspid regurgitation score increased from 0.41 +/- 0.16 to 0.61 +/- 0.17 (p less than 0.01). Color flow Doppler studies showed similar findings. Further, the incidence of catheter-induced tricuspid regurgitation was not related to the patient's underlying hemodynamic status or right ventricular geometry. In conclusion, this study shows for the first time that the quantitative extent of catheter-induced tricuspid regurgitation is small, and is therefore unlikely to be important clinically, particularly with regard to the assessment of thermodilution cardiac output. | 3 |
Syncope of unknown origin: clinical, noninvasive, and electrophysiologic determinants of arrhythmia induction and symptom recurrence during long-term follow-up. Ninety-one consecutive patients with syncope of unknown origin underwent electrophysiologic studies (EPS). Univariate analysis identified the following variables: age, + signal-averaged ECG (SAECG), left ventricular ejection fraction (LVEF), history of myocardial infarction, coronary artery disease, left ventricular aneurysm, and history of sustained monomorphic ventricular tachycardia (SMVT) on Holter; multivariate analysis identified +SAECG, LVEF, and history of SMVT as risk factors for induction of SMVT at EPS. All patients were followed up for 19.0 +/- 8.3 months and 17 had recurrence of syncope. Patients were divided into empiric, EP-guided, and no therapy groups. The EP-guided therapy group included all patients with SMVT at EPS. Recurrence rates among all three groups were similar. We conclude that: (1) Patients who have inducible SMVT at EPS can be identified using certain clinical and noninvasive variables. When these patients undergo EP-guided therapy, their rate of recurrence of syncope becomes compatible with that of patients who had no arrhythmia induced at EPS. (2) Empiric therapy does not offer any benefit over no therapy in reducing the rate of recurrent of scope. | 3 |
Cardiac catheterisation with 5 French catheters. From the beginning of November 1987 to the end of January 1989, 526 coronary arteriograms and left ventricular angiograms were performed with 5 French coronary catheters. In 448 (85%) patients diagnostic pictures were obtained with three standard types of 5 French catheters (No 4 Judkins): that is, left coronary, right coronary, and pigtail catheters. In 60 patients (11.4%) various other 5 French catheters were required to complete the study. In nine patients (1.7%), a 7 or 8 French catheter was used. Major complications causing cardiac arrest or requiring urgent operation developed in five patients. Sixty two patients (11.77%) had minor complications that required sublingual nitrates or a single bolus of atropine, or developed a haematoma that did not need intervention or had a mild reaction to the contrast material. Complications of moderate severity developed in 17 patients (3.2%): severe chest pain, arrhythmia requiring a temporary pacemaker, contrast reaction associated with hypotension, haematoma requiring blood transfusion, or a transient ischaemic episode. There were no deaths. 5 French catheters were used for routine coronary angiography and left ventriculography in 98.3% of patients. There were no major complications related to femoral artery puncture. The routine use of 5 French coronary catheters should increase the feasibility of safe coronary angiography in outpatients and should reduce the cost of this investigation. | 3 |
Colon cancer in pregnancy with elevated maternal serum alpha-fetoprotein level at presentation. A case of colon cancer in pregnancy is presented in which the maternal serum alpha-fetoprotein level was elevated. Failure to evaluate colon cancer as a cause of the elevated maternal serum alpha-fetoprotein may have accounted for the poor outcome. | 4 |
Thymoma: results of 241 operated cases Clinical and histopathological aspects of 241 thymomas were reviewed. One hundred sixty of the patients with thymoma had myasthenia gravis and 15 had other autoimmune diseases; 55% of the thymomas were encapsulated and 45% invasive. Operation was radical resection in 87.5% of the patients, subtotal resection with residual tumor in 8.7%, and simple biopsy in 3.7%. A tumor relapse was observed in 24 patients (10%): 2 (1.5%) of 133 with encapsulated thymomas and 22 (20.4%) of 108 with invasive thymomas; among these patients, a relapse was found in 20.6% of the patients who received radiotherapy postoperatively and in 24.6% who did not. Adverse prognostic factors were clinical stage IVa (multiple pleural nodes), not feasible resection (for technical reasons), inoperable tumor relapse, and association with one of the following autoimmune diseases: pure red cell aplasia, hypogammaglobulinemia, and lupus erythematosus. Conversely, myasthenia gravis is now a curable disease; it contributes to early discovery of associated thymoma, thus allowing a better survival for patients with thymoma who have myasthenia gravis compared with patients with thymoma but without myasthenia gravis (p less than 0.05). Postoperative radiotherapy does not seem necessary after removal of encapsulated thymomas, but it is advisable in case of invasive thymomas, regardless of the extent of the resection. | 2 |
Doxazosin and atenolol as monotherapy in mild and moderate hypertension: a randomized, parallel study with a three-year follow-up. The efficacy and safety of doxazosin (n = 83) and atenolol (n = 81) have been compared during a 3-year period. Doxazosin (mean dose at 3 years, 5.2 mg/day) and atenolol (mean dose, 66.4 mg/day) produced a sustained and overall similar reduction in blood pressure, with no evidence of tolerance. Doxazosin decreased mean blood pressure from 158/104 mm Hg to 146/90 mm Hg; with atenolol the decrease was from 160/103 mm Hg to 144/88 mm Hg. Whereas the reduction in blood pressure with atenolol was paralleled by a significant (p less than 0.05) decrease in heart rate (from a mean of 74 to 60 beats/min), doxazosin produced no clinically meaningful changes in heart rate. In contrast to atenolol, doxazosin reduced triglyceride levels by -5.9% (atenolol +22.5%), increased high-density lipoprotein cholesterol levels by +3.7% (atenolol, -11.2%), and increased the high-density lipoprotein/total cholesterol ratio by +5.9% (atenolol, -10.3%); all of these values were significantly (p less than 0.001) different from those of atenolol-treated patients. Doxazosin also reduced the calculated low-density lipoprotein cholesterol levels by -3.3% (atenolol, unchanged). The adverse effect of atenolol on lipid levels apparently negated any beneficial effect of blood pressure reduction, because the calculated coronary heart disease (CHD) risk actually increased significantly. In contrast, the reduction in calculated CHD risk in the doxazosin group was statistically significant at all points during the study. The safety profile of the drugs was similar. With the added potential of the reduction in the calculated risk of CHD among hypertensive patients,doxazosin represents an appropriate first-line drug for the treatment of essential hypertension. | 3 |
The prophylactic use of octreotide in a patient with ovarian carcinoid and valvular heart disease. This case report describes the use of octreotide, a long-acting somatostatin analogue, in the management of a patient with an ovarian carcinoid tumour and severe cardiac valvular disease. This patient underwent laparotomy and tumour resection without complication. Anaesthesia was induced with midazolam, fentanyl, and vecuronium, and maintained with isoflurane as well as additional fentanyl and vecuronium. However, we feel that it was the use of octreotide that prevented a life-threatening crisis intraoperatively, and recommend its use in patients with carcinoid syndrome undergoing anaesthesia and surgery. | 4 |
Risk factors for metastases in patients with retinoblastoma. The study is based upon a review of data from 583 consecutive patients with retinoblastoma over the years 1956 to 1986. Mean follow-up was 8 years, and median was 5.5 years. In 41 patients, metastases developed within 5 years. The influence of clinical and histopathologic risk factors on the occurrence of metastases was first analyzed by univariate tests. Significant variables were then reevaluated using the Cox proportional hazards method. Four factors were found to be independently associated with the development of metastases: optic nerve invasion with and without involvement of the resection line, choroidal invasion and enucleation of an affected eye more than 120 days after initial diagnosis. The 5-year metastatic risks associated with these factors were 67%, 13%, 8%, and 4%, respectively. The relative risk estimate, calculated from the Cox model, was used for a score classification with groups of low, medium, and high metastatic risk. The 5-year incidence of metastases was 4%, 43%, and 68%, respectively. | 2 |
Myocarditis or acute myocardial infarction associated with interleukin-2 therapy for cancer. The hearts of eight patients aged 22 to 67 years (mean, 41 years) who died during or within 4 days of interleukin-2 (IL-2) based immunotherapy for treatment of renal cell carcinoma or melanoma were studied at necropsy. Death resulted from combined cardiorespiratory failure in two patients, sepsis in four patients, acute myocardial infarction in one patient, and myocarditis in one patient. Transmural left ventricular necrosis was present in one of the two patients with significant atherosclerotic coronary artery narrowing. Noninfectious myocarditis was present in five patients: the inflammatory infiltrate was lymphocytic in four and composed of a mixture of eosinophils and lymphocytes in one. Although treatment-related deaths associated with high-dose IL-2 therapy are uncommon (1.5% in 652 consecutive patients), the potential for significant myocardial ischemia or myocarditis exists, and careful monitoring for arrhythmias or myocardial failure is warranted. | 0 |
Reconstitution of high-affinity opioid agonist binding in brain membranes. In synaptosomal membranes from rat brain cortex, the mu selective agonist [3H]dihydromorphine in the absence of sodium, and the nonselective antagonist [3H]naltrexone in the presence of sodium, bound to two populations of opioid receptor sites with Kd values of 0.69 and 8.7 nM for dihydromorphine, and 0.34 and 5.5 nM for naltrexone. The addition of 5 microM guanosine 5'-[gamma-thio]triphosphate (GTP[gamma S]) strongly reduced high-affinity agonist but not antagonist binding. Exposure of the membranes to high pH reduced the number of GTP[gamma-35S] binding sites by 90% and low Km, opioid-sensitive GTPase activity by 95%. In these membranes, high-affinity agonist binding was abolished and modulation of residual binding by GTP[gamma S] was diminished. High-affinity (Kd, 0.72 nM), guanine nucleotide-sensitive agonist binding was reconstituted by polyethylene glycol-induced fusion of the alkali-treated membranes with (opioid receptor devoid) C6 glioma cell membranes. Also restored was opioid agonist-stimulated, naltrexone-inhibited GTPase activity. In contrast, antagonist binding in the fused membranes was unaltered. Alkali treatment of the glioma cell membranes prior to fusion inhibited most of the low Km GTPase activity and prevented the reconstitution of agonist binding. The results show that high-affinity opioid agonist binding reflects the ligand-occupied receptor-guanine nucleotide binding protein complex. | 0 |
Changes in interferon receptors on peripheral blood mononuclear cells from patients with chronic hepatitis B being treated with interferon. We studied the binding of 125I-labeled human interferon-alpha to peripheral blood mononuclear cells and the activity of 2',5'-oligoadenylate synthetase in peripheral blood mononuclear cells obtained from 21 patients with chronic hepatitis B who were treated with human interferon-alpha or interferon-beta. Fourteen patients were given interferon daily for 4 wk. Interferon receptors per cell decreased to about 50% of baseline but increased to baseline by 2 wk after therapy ended. The activity of 2',5'-oligoadenylate synthetase rose about fivefold during therapy, decreasing to baseline by 1 wk after the end of therapy. The seven other patients were given interferon daily for 2 wk, no interferon for 2 wk and then interferon daily for 2 wk more. During both periods of therapy on this schedule, interferon receptors decreased to about 50% but returned to baseline 1 wk after the interferon was stopped. The activity of 2',5'-oligoadenylate synthetase increased about fivefold during both the first and second periods of therapy and decreased to baseline 1 wk after interferon was stopped. Close negative correlation existed between the number of interferon receptors and the 2',5'-oligoadenylate synthetase activity. The results of interferon therapy could not be predicted by either the numbers of interferon receptors before therapy or by the decrease in this number during therapy. | 4 |
Effects of screws and a sleeve on initial fixation in uncemented total knee tibial components. Aseptic loosening of tibial components remains a serious problem in uncemented total knee arthroplasties. Achieving rigid initial fixation of porous-coated components is one of the most important factors in promoting bone ingrowth. The results of a biomechanical study for micromovement of the tibial component under posteroanterior shear and axial compressive loading are presented. Forty anatomic specimen tibiae were stress tested on a servohydraulic mechanical test machine to evaluate the effects of screws and a sleeve on initial fixation of the uncemented total knee tibial component. Twenty specimens were used for posteroanterior shear loading and 20 for anterolateral axial compressive loading. Four cancellous screws were inserted through holes of the tibial tray to pierce the cortex of the proximal tibia. The methylmethacrylate sleeve was applied to the central stem. Rigidity of fixation was significantly improved by the combination of screws and a sleeve. Bone strength was also an important factor affecting the quality of fixation. | 4 |
When epilepsy masquerades as heart disease. Awareness is key to avoiding misdiagnosis. Autonomic neural impulses that accompany discharges during a seizure can cause a variety of cardiac manifestations, including cardiac arrhythmias, sudden death, anginal chest pain, neurogenic pulmonary edema, and symptoms of pheochromocytoma. Either generalized or focal seizures may generate such signs and symptoms. A better appreciation of cardiac problems caused by epilepsy is helpful in preventing misdiagnosis, because the clinical picture in such a patient may be confusing. | 4 |
All-trans retinoic acid as a differentiation therapy for acute promyelocytic leukemia. I. Clinical results. Twenty-two patients with acute promyelocytic leukemia were treated with all-trans retinoic acid (RA, 45 mg/m2 per day) for 90 days. Of the 22, four patients were previously untreated, two were resistant after conventional chemotherapy, and 16 were in first (n = 11), second (n = 4), or third (n = 1) relapse. We observed 14 complete response, four transient responses, one failure, and three early deaths. Length of hospitalization and number of transfusions were notably reduced in complete responders. Correction of coagulation disorders and an increase of WBCs were the first signs of all-trans RA efficacy. Morphologic analysis performed at days 0, 15, 30, 45, 60, and 90 showed that complete remissions were obtained without bone marrow (BM) hypoplasia. Presence of Auer rods in the maturing cells confirmed the differentiation effect of the treatment. At remission, the t(15;17) initially present in 20 patients was not found. The in vitro studies showed a differentiation in the presence of all-trans RA in 16 of the 18 tested cases. The single nonresponder to all trans RA in vitro did not respond in vivo. Adverse effects of RA therapy--skin and mucosa dryness, hypertriglyceridemia, and increase of hepatic transaminases--were frequently noted. We also observed bone pain in 11 patients and hyperleukocytosis in four patients. Whether maintenance treatment consisted of low-dose chemotherapy or all-trans RA, early relapses were observed. Five patients are still in complete remission (CR) at 4 to 13 months. Our study confirms the major efficacy of all-trans RA in M3, even in relapsing patients. Remissions are obtained by a differentiation process. | 4 |
Demonstration of two distinct subsets of gastric varices. Observations during a seven-year study of endoscopic sclerotherapy. Over a seven-year period, assessment of gastric varices was made on 225 patients receiving endoscopic sclerotherapy for variceal hemorrhage. Of 170 patients with complete data, gastric varices were observed in 26 (15.3%). Importantly, two distinct subsets of gastric varices were identified: varices distal to the gastroesophageal junction without extension into the fundus, termed "junctional varices," occurred in 11.2%, and varices that were confined only to the fundus, termed "fundal varices," occurred less frequently in 4.1%. Although rebleeding was increased in both subsets of gastric varices, junctional varices were more amenable to sclerotherapy. Patients with fundal varices (N = 7) had a significantly higher rebleeding rate, increased complications with sclerotherapy, and significantly decreased survival (P less than 0.005) when compared to patients with esophageal varices alone (N = 87) who were followed for more than three months. Cumulative survival was not significantly different (P less than 0.08) in patients with junctional varices (N = 19) when compared with patients with esophageal varices alone. We conclude that not all patients with gastric varices have a poor result with sclerotherapy. Recognition of these subsets may improve treatment strategies in patients with gastric varices. | 4 |
Abnormal membrane physical properties of red cells in McLeod syndrome. McLeod red cells (RBCs) lack Kx antigens and have weak expression of the Kell antigens. Individuals who carry the McLeod phenotype have acanthocytic RBCs and a compensated hemolytic state. To elucidate the role of the protein on which the Kx antigens reside in maintaining membrane deformability, the rheologic properties of McLeod RBCs were determined by ektacytometry. RBCs were obtained from normal individuals and from four patients with McLeod syndrome. Osmotic gradient deformability profiles of McLeod RBCs showed decreased whole cell deformability. Resealed ghosts from McLeod RBCs also showed decreased deformability, partly because of the decreased cell surface area and partly because of an intrinsic membrane stiffness in this syndrome. For the measurement of membrane mechanical stability, resealed ghosts were subjected to constant high shear stress in the ektacytomer, and deformability was recorded continuously as the deformable ghosts fragmented into rigid spherical vesicles. Membranes from McLeod RBCs showed a noticeable increase in mechanical stability. Acquired causes of acanthocytosis, such as liver disease, did not cause the rheologic abnormalities observed in McLeod cells. Other abnormalities noted in McLeod RBCs were decreased RBC potassium content and an increased number of dense RBCs, as determined by centrifugation on a discontinuous density gradient. The data indicate that McLeod RBCs are rigid and have decreased surface area and that their membranes are intrinsically rigid with increased mechanical stability. These abnormalities may account for the reduced RBC survival observed in McLeod syndrome. The protein that carries the Kx surface antigen seems to be required for the maintenance of the normal physical function of RBC skeletal proteins. | 1 |
An evaluation of cocaine-induced chest pain STUDY OBJECTIVE: To determine if enzymatic evidence of acute myocardial injury is present in patients complaining of chest pain after cocaine use when the ECG is normal or nondiagnostic. DESIGN: Serial ECG and creatinine kinase (CK) and CK isoenzymes (CK-ISO) determinations were performed at time of emergency department presentation and every six hours over 12 hours on individuals complaining of chest pain within six hours of last cocaine use. SETTING: ED of an urban tertiary care center. TYPE OF PARTICIPANTS: Forty-two individuals with a mean age of 28.5 years. INTERVENTIONS: Patients with positive CK-ISOs were admitted immediately to formally rule out myocardial infarction. Patients developing ECG changes during observation period also were admitted even if CK-ISOs were normal. Patients with unchanged ECGs and normal CK-ISOs were discharged after 12 hours of observation. RESULTS: Eight patients (19%) had elevated CK and CK-ISO values at presentation. Two of these patients had elevated values on three sequential determinations and were believed to have sustained acute myocardial infarction. Six patients had elevated CK and CK-ISOs at presentation only. ECGs remained normal or nondiagnostic in all patients. CONCLUSIONS: Enzymatic evidence of acute myocardial injury may occur in patients who develop chest pain after cocaine use and have normal or nondiagnostic ECGs. This injury may reflect acute infarction or transient ischemia. Single or serial normal or nondiagnostic ECGs do not rule out ischemia or injury in this group of patients. | 4 |
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