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3 | The robustness of an empirically derived taxonomy of chronic pain patients. There is currently no classification system for chronic pain patients that has achieved consensus. The lack of a classification that is used consistently across settings has impaired advance of knowledge and treatment of chronic pain patients. Recently, an empirically derived multivariate classification system, the Multiaxial Assessment of Pain (MAP) patients, has been developed. In this paper, the generalizability of the MAP system was evaluated by contrasting the MAP classification of 3 common but diverse chronic pain syndromes, namely, low back pain, headache, and temporomandibular disorders. The results indicate that although the proportion of patients classified into the 3 subgroups of the MAP taxonomy differ, the profiles based on the pattern of interrelationship among the assessment scales were remarkably similar. These data suggest that the psychosocial and behavioral responses associated with chronic pain are common to diverse samples of pain patients despite differences in demographic characteristics and medical diagnosis. The implications of these results for research and clinical practice are discussed. The potential utility of a polydiagnostic approach using more traditional medically based classifications such as proposed by the IASP (Merskey, H., Pain, Suppl. 3 (1986) S1-S225) complemented by classification based on the MAP psychosocial-behaviorally based taxonomy are examined. |
1 | Two-drug therapy in patients with metastatic germ cell tumors. Eighty-two patients with metastatic germ cell tumors (GCT) treated with two-drug therapy consisting of etoposide and cisplatin were evaluated for late relapse. Good-risk GCT was defined using Memorial Sloan-Kettering Cancer Center (MSKCC) criteria. Etoposide was given at 100 mg/m2 on days 1 to 5 and cisplatin was given at 20 mg/m2 on days 1 to 5; therapy was recycled at 21 days with delays up to 7 days for a leukocyte count of less than 3000/microliters or a platelet count of less than 100,000/microliters. Drug doses were not attenuated for myelosuppression. Seventy-six of 82 evaluable patients achieved a complete response (CR). Seventy-two patients had a CR to chemotherapy alone. Forty-six (56%) patients had excision of residual abnormalities: 11 had teratoma in the resected specimen, 31 had necrotic debris or fibrosis, and 4 had a CR after chemotherapy plus complete excision of residual viable GCT. Six patients had an incomplete response to chemotherapy; one of these patients had unresectable mature teratoma and remains progression-free. The median etoposide dose (+/- standard deviation [SD]) was 500 mg/m2/course (+/- 35 mg/m2) and the median cisplatin dose (+/- SD) was 100 mg/m2/course (+/- 6 mg/m2). Nine patients experienced a relapse at 6 to 17.5 months; two patients with nonseminomatous GCT were salvaged by chemotherapy and one patient with seminoma was salvaged by chemotherapy and radiation therapy. The three patients who were salvaged by additional therapy are disease-free at 59 to 63 months. Seventy-one patients (87%) remain disease-free with a median follow-up time of 63 months (range, 33 to 92 months). No relapses have occurred beyond 17.5 months. Etoposide and cisplatin therapy at these doses and schedule results in durable CR without late relapse. |
5 | Skeletal muscle depressed calcium and phosphofructokinase in chronic heart failure are upregulated by captopril--a double-blind, placebo-controlled study. The effects of the angiotensin converting enzyme inhibitor captopril, after treatment for 5-6 weeks with 25 mg t.i.d., were studied in 12 patients with stable moderate heart failure. Five patients received placebo treatment, and the two groups were comparable at baseline. Angiotensin II levels decreased in response to captopril therapy. Skeletal muscle potassium, magnesium and chloride levels did not differ from reference values. Calcium was subnormal (P less than 0.0001), but increased to the reference range during captopril treatment. Phosphofructokinase, a rate-limiting glycolytic enzyme, was in the lower reference range and increased (P less than 0.04) in response to captopril therapy. In conclusion, stable moderate heart failure is associated with low levels of skeletal muscle calcium and phosphofructokinase activity, these metabolic changes tending to return to normal levels with captopril treatment. |
5 | Hemorrhagic pituitary adenomas: clinicopathological features and surgical treatment. Forty-five (9.9%) of 453 pituitary adenomas operated on between January 1973 and November 1988 demonstrated hemorrhagic changes at surgery: 24 had a blood collection, 12 had a blood collection associated with hemorrhagic necrosis, and 9 had hemorrhagic necrosis. Thirteen patients (28.9%) experienced the acute symptoms of pituitary apoplexy, whereas another 32 had an "asymptomatic" hemorrhage, that is, the clinical course was comparable to an uncomplicated adenoma. Nineteen tumors (42.2%) showed marked suprasellar extension, 8 (17.8%) showed moderate extension, and 11 (24.5%) showed slight extension; another 2 (4.4%) were laterosellar and 5 (11.1%) were intrasellar. Invasive behavior was present in 32 cases (71.1%) and this may suggest another hypothesis to explain the pathogenesis of tumoral hemorrhage. The incidence of hemorrhagic complications in invasive adenomas with marked suprasellar extension was particularly impressive; therefore, we do not suggest preoperative bromocriptine treatment in this type of tumor. Two of 14 patients operated on by the transcranial route died after surgery, whereas there was no operative mortality in the 31 patients operated on by the transsphenoidal route. It proved advantageous to operate as early as possible, even during the acute phase of pituitary apoplexy. The transsphenoidal approach gave the best results, but to achieve satisfactory late results multidisciplinary treatment was necessary, namely, postoperative radiotherapy in 23 patients, bromocriptine in 12, and endocrine replacement therapy in almost all. In an average follow-up period of 6.2 years, 5 (11.1%) symptomatic recurrences were observed. |
1 | Impact of enucleation for choroidal melanoma on the performance of vision-dependent activities. We report a functional outcome assessment of 71 patients who underwent enucleation for choroidal melanoma. Each was interviewed to evaluate his her self-reported ability to perform four vision-dependent activities--working, driving, reading, and television viewing--before enucleation and when interviewed. The interval between enucleation and the interview varied between 2 and 25 years. Eighty-seven percent (62/71) reported no change in their ability to perform these important vision-dependent tasks. At 15 years after enucleation, 90% (18/20) retained the ability to drive and 96% (25/26) retained the ability to read. These results are reassuring for those with choroidal melanoma who are faced with enucleation, because most of these patients seem likely to continue at a level of visual function comparable with their preenucleation status. |
5 | Outpatient management of burns in children. The majority of burn wound management can be performed on an outpatient basis by the primary care physician or emergency physician. The physician, however, needs to know when to refer the patient for surgical evaluation and must be reasonably certain that the family will be compliant with wound care and follow-up. Fire prevention counselling still remains one of the most important aspects of burn management. |
4 | Influence of prosthetic design on durability of the Liotta porcine valve in the mitral position. From March 1979 to December 1984, the Liotta low-profile porcine bioprosthesis was employed for mitral valve replacement in 71 patients to avoid potential left ventricle-prosthesis mismatch occasionally observed with the standard, high-profile, Hancock porcine xenograft. Follow-up of 61 operative survivors showed at 10 years an actuarial survival of 67% +/- 7%, freedom from thromboemboli of 96% +/- 2%, freedom from structural deterioration of 63% +/- 11% and freedom from all Liotta bioprosthesis-related complications of 53% +/- 10%. Complications related to excessive protrusion of the stent into the left ventricular cavity were eliminated with the Liotta bioprosthesis; the peculiar stent configuration, however, was responsible for an increased rate of structural deterioration requiring reoperation in 10 patients (2.8% +/- 0.9%/patient-year) at a mean interval of 76 +/- 18 months after mitral valve replacement (range, 45 to 106 months). Common findings in all explants were cusp prolapse, cusp tears, and commissural rupture related to various degrees of tissue calcification, constantly leading to severe prosthetic incompetence. As also shown experimentally, such structural changes have been attributed to increased systolic stresses on the closed cusps, favored by excessive reduction of the stent height. Our experience shows that the Liotta bioprosthesis used for mitral valve replacement does not provide any clear-cut advantage over standard porcine bioprostheses and that its long-term durability appears affected by the unique prosthetic design. |
4 | Magnitude and time course of extracellular potassium inhomogeneities during acute ischemia in pigs. Effect of verapamil. Prior studies have demonstrated the presence of inhomogeneities in myocardial [K+]e after serial 10-minute occlusions of the left anterior descending coronary artery in the pig, even within restricted locations of an ischemic zone. These inhomogeneities are thought to underlie the electrophysiological abnormalities responsible for lethal ventricular arrhythmias through reentrant and nonreentrant pathways, but a clear association has not been demonstrated. As a prerequisite to establishing this association, these studies were performed to establish measurement standards for [K+]e inhomogeneity, to quantify the magnitude and time course of these inhomogeneities, to determine whether the inhomogeneities are greater in the ischemic border where lethal ventricular arrhythmias are known to originate, and to assess the effect of a known antifibrillatory drug on [K+]e inhomogeneities. [K+]e (expressed as the change in potassium equilibrium potential, dEK [mV]) was measured in 15 preparations using an average of 17 closely spaced, critically calibrated K(+)-sensitive electrodes having stable response characteristics. A series of four 10-minute occlusions each separated by a 50-minute reperfusion period were performed in each study. In half of the studies, intravenous verapamil (0.2 mg/kg bolus followed by 0.0065 mg/kg/hr) was administered before the fourth occlusion. In nine studies (five control and four verapamil), electrodes were placed in the marginal ischemic zone (from 2 mm outside to 5 mm inside the visible cyanotic border). In six other studies (three control and three verapamil), electrodes were placed in the central ischemic zone (10-20 mm within the ischemic region). We determined that the standard deviation is the best measure of inhomogeneity and that 12 equivalent measurement sites are required to estimate it with a satisfactory degree of statistical confidence. We found that after 10 minutes of ischemia, mean dEK was 1.6 times greater in the central than in the marginal ischemic zone, whereas mean standard deviation at the same time was 1.5 times greater in the marginal than in the central ischemic zone. Verapamil reduced mean dEK and mean standard deviation in both ischemic zones for most of the occlusion by delaying the rise in [K+]e and the inhomogeneity of that rise by 3-5 minutes. Comparisons of mean dEK with mean standard deviation revealed a steep linear relation in the marginal zone and a curvilinear relation in the central zone where higher mean dEK values were not accompanied by higher values for mean standard deviation. Furthermore, we determined that these relations were not altered by verapamil.(ABSTRACT TRUNCATED AT 400 WORDS). |
5 | A placebo-controlled trial of maintenance therapy with fluconazole after treatment of cryptococcal meningitis in the acquired immunodeficiency syndrome. California Collaborative Treatment Group. BACKGROUND AND METHODS. In patients with the acquired immunodeficiency syndrome (AIDS), the rate of relapse after primary treatment for cryptococcal meningitis remains high. We conducted a controlled, double-blind trial to evaluate the efficacy of maintenance therapy with fluconazole. At entry into the study, all participants had sterile cultures of cerebrospinal fluid, blood, and urine after following a standardized course of therapy for culture-proved cryptococcal meningitis. The patients were randomly assigned to take either fluconazole or placebo as maintenance therapy. The dose of fluconazole was 100 mg daily in the first phase of study and 200 mg daily in the second phase. RESULTS. Of 84 patients initially enrolled, 16 (19 percent) were found to have silent, persistent infection on the basis of cultures that became positive after entry into the study; 7 other patients were lost to follow-up shortly after entry. Of the remaining 61 patients, 10 of 27 assigned to placebo (37 percent) and 1 of 34 assigned to fluconazole (3 percent) had a recurrence of cryptococcal infection at any site (difference in risk, 34 percent; 95 percent confidence interval, 15 to 53). Of the 11 recurrent infections, 7 were detected in urine obtained after prostatic massage. There were four recurrent meningeal infections in the patients taking placebo, but none in those taking fluconazole (mean duration of follow-up, 164 days) (P = 0.03). In multivariate analyses, the best predictors of recurrence-free survival were fluconazole treatment (P = 0.02; relative hazard, 13.2), a lower serum cryptococcal-antigen titer (P = 0.05; relative hazard, 1.2), and more prolonged primary therapy with flucytosine (P = 0.09; relative hazard, 1.1). Survival and toxicity were similar in the two maintenance-treatment groups. CONCLUSIONS. In patients with AIDS, silent persistent infection is common after clinically successful treatment for cryptococcal meningitis. Maintenance therapy with fluconazole is highly effective in preventing recurrent cryptococcal infection. |
4 | Spinal cord injury after subclavian flap aortoplasty. An experimental study in piglets. Paraplegia is a rare but much feared complication of corrective surgery for coarctation of the aorta. The problem was studied in 31 newborn pigs submitted to subclavian flap aortoplasty. The aortic cross-clamping time ranged from 9-25 min. Twenty-three piglets with clamping times 9-18 min were neurologically intact, whereas eight with aortic clamping for 18-25 min became paraplegic. The clinical implications for newborn children with symptomatic aortic coarctation are discussed with regard to these experimental findings. |
1 | Massive metastasis from squamous carcinoma of the tonsil. Squamous carcinomas of the oro-pharynx are associated with a high incidence of distant metastases at post-mortem. A case of a massive distant metastasis from a squamous cell carcinoma of the tonsil is presented. This occurred despite excellent local control. The pathology and the possible management implications are discussed. |
5 | Growth hormone deficiency in children has psychological and educational co-morbidity. Growth delay caused by growth hormone deficiency (GHD) is a condition presented with increased frequency to pediatricians. Recent evidence suggests these patients should be evaluated developmentally for behavioral and educational problems. Such assessment would assure a comprehensive approach to treatment and increase the likelihood of a satisfactory outcome in young adulthood. This article briefly reviews what is known about the behavioral and educational difficulties experienced by growth hormone deficient patients. Specific recommendations for educational assessment and anticipatory guidance are presented. |
3 | Motor dysfunction in HIV-infected patients without clinically detectable central-nervous deficit. Motor tests were performed in 50 HIV-infected patients in all stages according to the current CDC classification, but without any clinically evident central nervous system deficit, and the results compared with an age-matched control group. Patients were excluded from the study if there was alcohol or drug abuse, fever and/or opportunistic cerebral infection. The parameters tested were postural tremor of the outstretched hands, most rapid voluntary alternating index finger movements (MRAM) and rise time of most rapid index finger extensions (MRC). Whereas tremor peak frequencies did not differ significantly in the patients and controls, MRAM and rise times of MRCs showed significant slowing in the patient group. Morphologically, the motor test performance of the HIV-infected patients was similar to that of patients with manifest basal ganglia disease (Parkinson's, Huntington's and Wilson's diseases). MRI scans of all patients were normal. It is concluded that in HIV-infected patients there is a very early subclinical central nervous system affection, especially of the basal ganglia, which is detectable with appropriate, quantitative motor function tests. These functional abnormalities precede the structural alterations in the MRI scans. |
1 | De novo carcinoma of the lower urinary tract in renal allograft recipients. Immunocompetence has been postulated as an important defense against the progression of urothelial carcinoma. Three cases of de novo lower urinary tract carcinoma in renal transplant recipients demonstrated the potential for unusually rapid urothelial extension and invasion in chronically immunosuppressed patients. Two patients had a history of perineal condyloma acuminata; tumors from 1 of these harbored the genetic sequences of human papillomavirus type 6. One patient had multiple manifestations of cyclophosphamide-related urothelial injury, including bladder carcinoma. Treatment of 2 patients culminated in a radical operation during which the remaining native urinary system was resected completely, with sacrifice of the allograft kidney in 1 and diversion into an ileal conduit in 1. The remaining patient underwent urethrectomy and partial cystectomy with a sigmoid conduit. |
2 | Fibronectin-related substance located in the chief cells of human and rat gastric mucosa. A novel substance located in the chief cells of human and rat gastric mucosa, which was detected immunologically by either polyclonal or monoclonal antihuman fibronectin (FN) antibodies, is reported. All three polyclonal antihuman FN antibodies used in this study reacted immunohistologically exclusively with the chief cells. Monoclonal antibody against C-terminal peptide or cell binding peptide reacted clearly with the human chief cells, but monoclonal antibodies against FN N-terminal and midmolecule failed to react with the cells. Western blot analysis of the rat gastric mucosal extract with polyclonal antihuman FN antibody showed that this substance has a molecular weight of about 70,000 Da. Therefore, this substance appears to be a fragment containing the C-terminal peptide of whole molecule FN and thus in the present study is named FN-related substance (FNRS). In a further study with ethanol-induced ulcer model of the rat, the physiological significance of FNRS was examined. The FNRS decreased remarkably, in a dose-dependent manner, in the fundic mucosa of the rats that ingested ethanol. The FNRS appeared to be associated with development of mucosal damage and repair, subsequently playing, in part, an important role in the gastric mucosal protection mechanism. |
1 | Prostate cancer: transrectal ultrasound and pathology comparison. A preliminary study of outer gland (peripheral and central zones) and inner gland (transition zone) cancer. A study was conducted to compare results of transrectal ultrasound with pathologic findings on 116 patients who underwent radical prostatectomy for treatment of prostate cancer. In 96% (111 of 116), transrectal ultrasound guided biopsies of a hypoechoic lesion proved cancer; seven patients had known Stage A cancer; one patient had cancer detected by palpation and not detected by ultrasound. Cancers in the outer gland (peripheral and central zones) were compared with cancers in the inner gland (transition zone) by both ultrasound and pathology. Forty-eight percent (52 of 108) of cancers originating in the outer gland showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the outer gland were the prostatic capsule (38%), anterior fibromuscular stroma (5%), seminal vesicle (18%), the base of the gland at the neurovascular bundle (21%), and the apex (31%). Twenty-two percent (17 of 54) of cancers originating in the inner gland (transition zone) showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the inner gland were the anterior fibromuscular stroma (6%) and apex (11%). Both histologic and biologic differences between outer and inner gland cancers were found when tumor size was controlled. Gleason scores were significantly different for inner and outer gland cancers, with mean scores of 6.2 +/- 1.6 and 7.4 +/- 0.9, respectively. An odds ratio of 8.6 confirmed the increased risk of extraprostatic extension for outer gland cancer. Outer gland cancers showed increased aggressive behavior of both histologic and biologic nature. The difference in biologic aggressiveness of outer and inner gland cancers has definite implications for treatment options. Use of other diagnostic parameters, such as DNA ploidy, may help to determine which cancers to treat and when to treat them; this may have more relevance for cancers originating in the inner gland. Strategic transrectal ultrasound guided biopsy affords accurate tumor mapping and staging when modes of internal spread and escape of cancer from both outer and inner gland are known. Thus, transrectal ultrasound may be our "window of observation" through which additional research may explain the histologic and biologic discrepancies between outer and inner gland cancers. |
1 | Preoperative superselective arteriolar embolization: a new approach to enhance resectability of spinal tumors. The extent of surgical resection of spinal tumors is frequently limited by blood loss and technical difficulty associated with the vascularity of the tumors. We report here the use of superselective percutaneous arterial embolization to reduce the rate of blood loss at the time of surgical resection and enhance resectability. The types of tumors treated were metastatic renal carcinoma, metastatic thyroid carcinoma, metastatic melanoma, and giant cell tumor of the sacrum. Two of the patients required repeated embolization and surgery for recurrent symptoms. The estimated blood loss in seven of nine procedures performed on the six patients ranged from 300 to 800 ml, after which no transfusion was required. In two procedures, extensive resection of very large tumors resulted in larger losses of blood, and postoperative transfusion was necessary. No significant complications of embolization or surgery occurred. A key factor in our embolization technique is the use of microfibrillar collagen, which allows occlusion of tumor vessels as small as 20 microns and may prevent reconstitution of the embolized vessels by collateral flow. We conclude that preoperative arterial embolization enhances the resectability of a variety of spinal tumors by reducing intraoperative blood loss. This may provide an additional benefit by reducing the risk related to postoperative transfusion. By permitting a more aggressive surgical approach, the use of preoperative embolization also has the potential to improve outcome in patients with spinal tumors. |
5 | Association of anterior ectopic anus and partial absence of levator musculature in a woman with impaired defecation. Report of a case. A 25-year-old nulliparous woman with adult onset constipation and slight anterior displacement of the anus underwent pelvic magnetic resonance imaging and was diagnosed with congenital hemiabsence of the levator ani sling. Impaired defecation was confirmed by anorectal function studies and defecography demonstrated an anterior rectocele, perineal descent at the upper limit of normal, and partial obstruction of defecation, which appeared related to the levator sling abnormality. To our knowledge, this combination of findings has not been previously described as a cause of adult onset constipation. |
4 | Hemifacial spasm caused by a spontaneous dissecting aneurysm of the vertebral artery. Case report. The authors describe the first reported case of dissecting aneurysm presenting with hemifacial spasm. The patient was a 58-year-old woman with left hemifacial spasm of 2 years' duration. Cranial nerve examination was otherwise normal and no other clinical symptoms were observed. Vertebral angiography revealed a fusiform enlargement of the left vertebral artery and contrast medium remaining in the intramural false lumen in the venous phase. Microvascular decompression of the facial nerve with wrapping of the aneurysm resulted in complete relief of the hemifacial spasm. |
1 | History of cigarette smoking and risk of leukemia and myeloma: results from the Adventist health study. The risks of leukemia and myeloma associated with cigarette smoking were evaluated in a cohort study of 34,000 Seventh-day Adventists. Although Seventh-day Adventists do not smoke by church proscription, many are adult converts who smoked cigarettes prior to their baptism into the church. In comparison with those who never smoked, ex-smokers experience a relative risk of 2.00 (95% confidence interval = 1.01-3.95) for leukemia and 3.01 (95% confidence interval = 1.13-8.05) for myeloma. Risks increased in a dose-response fashion with increasing numbers of cigarettes smoked daily for both leukemia (trend P = .009) and myeloma (trend P = .005). Also, the risks of both leukemia and myeloma increased with the total duration of cigarette smoking. The cigarette smoking-leukemia relationship was strongest for myeloid leukemia, for which ex-smokers experienced a relative risk of 2.24 (95% confidence interval = 0.91-5.53). These data lend support to the hypothesis that cigarette smoke may induce malignant degeneration in bone marrow and its products. |
5 | Deep vein obstruction and leg swelling caused by femoral ganglion. We present a case of a rare ganglion cyst originating from the hip joint and compressing the common femoral vein producing signs and symptoms that mimicked a deep vein thrombosis. Excision of the mass promptly restored normal venous return. This condition has not been previously reported in the English-language medical literature. |
5 | Cyclophosphamide-induced hemorrhagic pyelitis and ureteritis associated with cystitis in marrow transplantation. A 29-year-old woman suffered fatal hemorrhagic pyelitis, ureteritis and cystitis after receiving 4,800 mg./m.2 cyclophosphamide in preparation for marrow transplantation despite intravenous hydration and a Foley catheter. Cyclophosphamide-induced urothelial damage is not limited to the bladder and upper tract monitoring also is necessary. |
3 | Flow cytometric DNA content of adenoid cystic carcinoma of submandibular gland. Correlation of histologic features and prognosis. Flow cytometric analysis of nuclear DNA content was performed in 26 adenoid cystic carcinomas of the submandibular gland using archived, paraffin-embedded tissues. The DNA content was compared with multiple histologic parameters and clinical course. Ten carcinomas (38%) were aneuploid and 16 (62%) diploid. Aneuploid carcinomas demonstrated a higher frequency of solid cytoarchitecture, lymph node metastases, and advanced clinical stage, as compared with diploid carcinomas. Other histologic features predicting aggressive clinical behavior also correlated with abnormal DNA content and included invasion of nerves larger than 0.25 mm and intravascular extension. Our data suggest that DNA content analysis can be an effective objective parameter in the clinicopathologic assessment of adenoid cystic carcinoma. |
4 | Torsades de pointes therapy with phenytoin. We present the case of a woman with myocardial infarction complicated by malignant ventricular arrhythmia and torsades de pointes. The torsades de pointes was refractory to conventional therapy but responsive to phenytoin. This case suggests the clinical usefulness of phenytoin for adjunct therapy of life-threatening ventricular arrhythmias when standard treatment modalities fail. |
4 | Evidence for abnormal Na+/H+ antiport activity detected by phosphorus nuclear magnetic resonance spectroscopy in exercising skeletal muscle of patients with essential hypertension. 1. Exercise-induced pH changes in skeletal muscle were studied in a group of eight subjects with essential hypertension by using 31P n.m.r. spectroscopy. 2. Leucocyte Na+/H+ antiport activity was measured in vitro in the same subjects using a pH-sensitive fluorescent dye. 3. Resting skeletal muscle pH and unstimulated leucocyte pH values were similar to those in control subjects, but increased Na+/H+ antiport activity was demonstrated in the leucocytes from hypertensive subjects by acid loading in vitro. Decreased skeletal muscle acidification and an increased rate of pH recovery was also demonstrated in vivo in these same patients during an acid load induced by isotonic exercise. 4. These findings suggest that the increased cellular Na+/H+ antiport activity, which has been demonstrated in vitro in essential hypertension, also affects the biochemical response of skeletal muscle to physiological levels of exercise. This strengthens the argument that increased Na+/H+ antiport activity in hypertension is a generalized and physiologically relevant cellular abnormality. |
5 | Intraosseous infusion of dobutamine and isoproterenol. Intraosseous infusion has been advocated as an emergency route in sick infants and children when intravenous access is not readily obtainable. Dobutamine hydrochloride and isoproterenol hydrochloride are useful emergency drugs that have not been studied when administered into the bone marrow. In a swine model, we compared the physiologic responses (heart rate, arterial pressure, and cardiac output) of dobutamine and isoproterenol infusions delivered intravenously and intraosseously during 20-minute intervals. We observed statistically significant effects of both dobutamine and isoproterenol delivered by the intraosseous route. In addition, the effects resulting from intraosseous infusion were statistically similar to those resulting from intravenous administration of these drugs. We conclude that the intraosseous infusion of dobutamine and isoproterenol is an effective and useful method for emergency administration of these medications. |
5 | Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer. In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy (AMPT, n = 77) has been compared with truncal vagotomy and pyloroplasty (TVP, n = 69) in 146 patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the TVP group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after AMPT (five) than TVP (two) (P = 0.29, n.s.). Dumping and diarrhoea were significantly commoner (P less than 0.001) after TVP, with 31 instances as opposed to eight with AMPT. The mean operating time was increased by 6 min when AMPT was performed rather than TVP. The results of this study have shown that AMPT is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure. |
2 | Pharmacology of pravadoline: a new analgesic agent. Pravadoline is a new chemical entity with analgesic activity in humans. This report describes the pharmacology of pravadoline and compares the activity of pravadoline with that of two major classes of analgesics, the opioids and the nonsteroidal anti-inflammatory drugs (NSAIDs). Like the NSAIDs, pravadoline inhibited the synthesis of prostaglandins (PGs) in mouse brain both in vitro (IC50, 4.9 microM) and ex vivo (ED50, 20 mg/kg p.o.) and displayed antinociceptive activity in rodents subjected to a variety of chemical, thermal and mechanical nociceptive stimuli. Administration of pravadoline prevented the writhing response induced by i.p. administration of acetylcholine (ED50, 41 mg/kg p.o.) or PGE2 (ED50, 24 mg/kg p.o.) and prolonged the response latency induced by tail immersion in hot water at a temperature of 55 degrees C (minimum effective dose, 100 mg/kg s.c.). In the rat, treatment with pravadoline prevented acetic acid-induced writhing (ED50, 15 mg/kg p.o.), brewer's yeast-induced hyperalgesia (Randall-Selitto test) (minimum effective dose, 1 mg/kg p.o.), the nociceptive response induced by paw flexion in the adjuvant-arthritic rat (ED50, 41 mg/kg p.o.) and bradykinin-induced head and forepaw flexion (ED50, 78 mg/kg, p.o.). The antinociceptive activity of pravadoline cannot be explained by an opioid mechanism, because pravadoline-induced antinociception was not antagonized by naloxone (1 mg/kg s.c.) and pravadoline did not bind to opioid receptors at concentrations up to 10 microM. However, like the opioid analgesics, pravadoline diminished the electrically induced twitch response of mouse vas deferens preparations, but, in contrast to opioids, this action of pravadoline was not attenuated by naloxone. The possibility is discussed that this effect of pravadoline upon isolated tissues may contribute to its antinociceptive activity. In contrast to NSAIDs, pravadoline was more potent ex vivo as an inhibitor of the formation of PGs in brain vs. stomach. In addition, pravadoline failed to produce gastrointestinal lesions when administered p.o. to rats or mice, and did not possess significant anti-inflammatory activity at antinociceptive doses. Also unlike NSAIDs, pravadoline inhibited rat gastrointestinal transit when administered at doses similar to those which were antinociceptive. The overall pharmacologic profile of pravadoline suggests that the compound may be capable of managing more diverse or more severe pain than is achieved by anti-inflammatory analgesics, without producing side effects commonly associated with either the opioid or the nonopioid analgesics. |
1 | Inhibition of invasion of invasive human bladder carcinoma cells by protein kinase C inhibitor staurosporine. To study the effect of the protein kinase C (PKC) inhibitor staurosporine on invasion, we selected the invasive human bladder carcinoma cell line EJ. Total PKC activity was more than twofold higher in the EJ cells than in RT4 cells (superficial human bladder carcinoma cells), which do not pass through an artificial basement membrane. There was more PKC activity in the cytosol than in the membrane of EJ cells. Staurosporine, at nontoxic concentrations, inhibited the invasion of EJ cells through an artificial basement membrane in a dose-dependent manner. Staurosporine caused a dose-dependent inhibition of cell motility but did not inhibit cell attachment. Staurosporine represents a new agent for the inhibition of tumor cell invasion and may prove useful in studying the mechanisms responsible for this phenomenon. |
5 | Association of umbilical venous with inferior vena cava blood flow velocities. The fetal cardiac and placental circulations are interconnected through the umbilical venous and arterial vasculature. We hypothesized that alterations in umbilical venous blood flow velocities are present in fetuses with abnormal umbilical arterial circulation, and further, that changes in inferior vena cava blood flow velocities occur with, and might explain, these variations in umbilical venous blood flow velocities. Umbilical venous and inferior vena cava blood flow velocities were examined in 15 normal fetuses and in 59 fetuses with abnormalities that included absent end-diastolic umbilical artery blood flow velocities (N = 21) or abnormal heart rates (N = 27). Inferior vena cava velocities were also analyzed in 11 other fetuses with anomalies or known growth or placental abnormalities who had abnormal umbilical venous blood flow velocities. In normal fetuses, variations in umbilical venous velocities occurred during fetal activity or with fetal breathing; however, no variation in velocity corresponded with heart rate. Eleven of 21 fetuses with absent end-diastolic velocities in the umbilical artery demonstrated decreases in umbilical venous velocities ("venous pulsations") during arterial diastole. Blood flow velocities in the reverse direction, from the right atrium into the inferior vena cava with atrial contraction, were significantly greater in these fetuses than in those without umbilical venous pulsations (27.5 +/- 14.9% and 7.5 +/- 5.7% of total forward flow velocity, respectively; P less than .001). Venous pulsations were also seen in fetuses with abnormally fast or slow heart rates; reverse flow with atrial contraction in the inferior vena cava was likewise greater than normal in these fetuses. |
2 | Oral contraception in disease states. Oral contraceptives are clearly contraindicated in patients with a history of thromboembolic disease, ischemic heart attack, or cerebral stroke. Patients requiring long-term anticoagulant treatment can be treated with gonadotropin-releasing hormone analogs to prevent ovulation, because ruptured follicles can cause massive intraperitoneal bleeding. Patients with essential hypertension and severe liver diseases should also discontinue treatment 4 weeks before major elective surgery. Migraine and diabetes mellitus are regarded as relative contraindications, depending on the individual situation. Long-term diseases, such as Crohn's disease, epilepsy, and sickle cell anemia, also require individualized consultation. |
5 | Full-thickness skin graft vaginoplasty for treatment of the stenotic or foreshortened vagina. Vaginal stenosis or foreshortening following surgery or radiation therapy can lead to dyspareunia. This report concerns the successful use of full-thickness skin grafts taken from the flank overlying the iliac crest to treat vaginal stenosis or foreshortening. The operation consists of incising the involved area and creating a space which will become the recipient site. An elliptical piece of full-thickness skin harvested from the area overlying the iliac crest is cleared of underlying fat, trimmed to fit the recipient site, and sutured in place. Vaginal packing is used to keep the graft against the recipient bed. Ten patients have been treated successfully with this technique, without significant complications or sequelae. Follow-up from 6 weeks to 42 months showed excellent postsurgical vaginal capacity in all patients. Similarly, excellent functional results were achieved in eight patients, with distinct improvement in the remaining two. This procedure is a useful addition to the gynecologic surgeon's armamentarium. |
1 | Acute promyelocytic leukemia: impact of hemorrhagic complications on response to induction chemotherapy and survival. From 1976 to 1989, 21 adult patients with previously untreated acute promyelocytic leukemia were seen at the University of Virginia Hospital. We reviewed their cases retrospectively to determine the impact of hemorrhagic complications and other factors on treatment outcome. We observed a complete remission rate of 35%; the median survival in complete responders was 15 months. Evidence of disseminated intravascular coagulation was found in 13 (62%) of the 21 cases at diagnosis. Fatal intracranial hemorrhage was the leading cause of death, occurring in eight (40%) of the 20 patients evaluated. Initial leukocyte count greater than 4.0 x 10(9)/L and platelet count less than 20 x 10(9)/L were significantly associated with an increased risk of intracranial hemorrhage. In patients with disseminated intravascular coagulation, the rate of intracranial hemorrhage was reduced by treatment with heparin. The high mortality of 40% (8/20) due to intracranial hemorrhage during induction was a major contributor to the low complete remission rate of 35% (7/20) in this series of consecutive unselected patients with newly diagnosed acute promyelocytic leukemia. |
5 | Effect of maintenance digoxin therapy on aerobic performance and exercise left ventricular function in mild to moderate heart failure due to coronary artery disease: a randomized, placebo-controlled, crossover trial. Despite 200 years of use, the ability of digitalis glycosides to improve exercise capacity in patients with congestive heart failure remains controversial, partly because of imprecise end points and suboptimal study design. Therefore, this question was examined in 10 ambulatory patients (8 men and 2 women) aged 46 to 70 years (mean 57.8) in sinus rhythm with mild to moderate chronic stable congestive heart failure due to coronary artery disease and systolic left ventricular dysfunction (ejection fraction 32 +/- 12). All underwent maximal treadmill exercise with respiratory gas analysis and upright cycle ergometry with gated radionuclide angiography after 4 weeks of digoxin or placebo therapy, administered in a randomized double-blind crossover protocol. Neither treadmill exercise duration (7.7 +/- 2.3 versus 7.3 +/- 2.7 min) nor peak oxygen consumption (18.7 +/- 3.7 versus 18.4 +/- 5.4 ml/kg per min) differed between digoxin and placebo regimens. However, the change in peak oxygen consumption induced by digoxin was inversely related to the peak oxygen consumption during placebo therapy (r = -0.64, p less than 0.05). At maximal treadmill effort, heart rate (138 +/- 16 versus 141 +/- 21 beats/min), oxygen pulse (10.3 +/- 2.1 versus 9.9 +/- 2.2 ml/beat), ventilation (40.3 +/- 10.6 versus 42.0 +/- 10.8 liters/min) and ventilatory equivalent (29.4 +/- 4.8 versus 31.5 +/- 6.8) did not differ between digoxin and placebo treatment, although systolic blood pressure was higher during digoxin therapy (163.0 +/- 23.1 versus 153.2 +/- 25.3 mm Hg, p less than 0.05). |
5 | Value of combined assessment of physical health and functional status in community-dwelling aged: a prospective study in Florence, Italy. A survey of the health and social conditions of a representative sample of 967 persons aged 60 years and older from the city of Florence, Italy, was undertaken in 1980. In 1987, a follow-up survey of this cohort was performed. There were 391 documented deaths, 408 survivors, and 168 individuals who could not be located. Functional ability at baseline was assessed using a World Health Organization 14-item scale. Indicators of physical health status included chronic disease status, number of drugs, physician visits, and days of hospitalization. After adjustment for age and sex, both functional ability and indicators of physical health status were found to be independent, statistically significant predictors of mortality. The results of this study further support the view that biomedical and functional assessment are both necessary for a comprehensive evaluation of the older population. |
1 | Emergent signs of cancer. Recognizing them early in the office or ER. Primary care physicians have a crucial role in recognition of potentially emergent conditions in patients with known or suspected cancer. This task presents a significant challenge because the initial manifestations of these conditions are usually nonspecific. In most cases, therapy is far more effective when diagnosis is made at the earliest possible point. Thus, physicians should become familiar with conditions commonly seen in cancer patients, such as superior vena cava syndrome, malignant pericardial effusion, spinal-epidural metastasis, and altered mentation from brain metastases, metabolic encephalopathy, or hypoglycemia. |
4 | A standard heparin nomogram for the management of heparin therapy. A nomogram for the adjustment of heparin dosage was developed to standardize heparin therapy and to reduce delays in achieving and maintaining a therapeutic activated partial thromboplastin time (APTT) result. Fifty consecutive patients with acute venous thromboembolism had their continuous intravenous heparin therapy adjusted according to this heparin nomogram. The effect of the nomogram on heparin therapy in these patients was compared with data from 53 historical control patients. The proportion of patients in the nomogram group who reached a therapeutic APTT at 24 hours after the start of heparin therapy was 66%, which increased to 81% at 48 hours. In contrast, 37% and 58% of the control patients reached a therapeutic APTT at 24 and 48 hours, respectively. The percentage of therapeutic APTT results of the total number of APTT determinations was greater in the nomogram patients than controls. The use of this heparin nomogram resulted in (1) achieving a therapeutic APTT at 24 and 48 hours in a large proportion of patients and (2) reduced periods of inadequate anticoagulation and overanticoagulation during heparin therapy. |
4 | Does isoflurane lead to a higher incidence of myocardial infarction and perioperative death than enflurane in coronary artery surgery? A clinical study of 1178 patients To examine if the choice of volatile agents influences cardiac outcome in coronary artery surgery, 1178 patients undergoing elective coronary artery bypass grafting without additional operations received enflurane (608) or isoflurane (570) as their primary anesthetics. The inspired concentration of volatile agent (administered with 50% nitrous oxide) was adjusted depending on the level of blood pressure at the discretion of the anesthesiologist. In addition to the volatile agent assigned, each patient received small doses of fentanyl at induction and before sternotomy (total 0.006-0.008 mg/kg). The groups did not differ in preoperative and surgical characteristics except for a more frequent history of renal dysfunction in patients given isoflurane. The rates of postoperative myocardial infarction, administration of positive inotropic agents at the time of weaning from cardiopulmonary bypass, and in-hospital deaths in the enflurane and isoflurane groups were 1.8% and 4.0% (P less than 0.05), 4.9% and 8.1% (P less than 0.05%), and 0.3% and 2.1% (P less than 0.01), respectively. Although the mechanism of the adverse effects of isoflurane could not be clarified in this study, these results demonstrate that the use of isoflurane could be inappropriate in patients undergoing coronary artery bypass grafting. |
1 | Effects of hypovolemia and transfusion on tumor growth in MCA-tumor-bearing rats. Pretransplant blood transfusion has been shown to significantly affect the outcome of renal transplantation. Evidence regarding the association of blood transfusions with growth or recurrence of solid tumors is still conflicting both in clinical and in experimental studies, although diminished survival has been suggested in several studies. To determine the influence of blood transfusions and hypovolemia, as separate or combined factors, on tumor growth, we evaluated the weight of a subcutaneously implanted sarcoma (methylcholanthrene-induced) in 35 rats. After reaching 1% tumor burden (day 0), the animals were separated into two groups: hypovolemia (shed volume, 15 ml/kg) or normovolemia. These groups were further divided according to resuscitation: OO (no resuscitation), BL (receiving syngeneic blood stored in citrate phosphate dextrose for 4 days, 15 ml/kg), SL (receiving 0.9% sodium chloride, 45 ml/kg). Tumor dimensions were determined daily by external measurement, and tumor weight was calculated. Hypovolemia exerted a significant influence on tumor growth, independent of the resuscitation modality. The rats that received blood transfusions showed an increased rate of tumor growth, compared to the animals that received saline solution or no treatment. No interaction was noted between the effects produced by hypovolemia and blood transfusion. We conclude that the hypovolemic event enhanced tumor growth independently of the resuscitation, and transfusion of citrate phosphate dextrose-blood stored for 4 days did influence tumor growth in this model. We suggest that the effect of blood transfusion in patients with cancer has to be redefined to account for the influence of possible hypovolemic events. |
5 | Evaluation of the results of oesophagectomy for oesophageal cancer. The long-term results of standard techniques of oesophagectomy were examined in 127 patients with squamous cell carcinoma of the oesophagus. A near-total oesophagectomy with a cervical anastomosis was performed in 93 patients and an oesophagogastrectomy with an intrathoracic anastomosis was carried out in 34 patients. One hundred and eight patients had a curative oesophagectomy and 19 patients had a palliative resection. Eight patients received radiotherapy to the tumour bed. There were 15 deaths in hospital and the overall 5-year survival rate including perioperative deaths was 13.2 per cent. Survival was adversely affected by incomplete excision of macroscopic tumour (P less than 0.001), positive regional lymph nodes (P less than 0.05) and distant lymphatic metastases (P less than 0.02). The 5-year survival rate of patients with tumour invasion beyond the oesophageal wall (T3) and negative nodes was 20 per cent. Postoperative irradiation had no effect on the survival of patients with gross residual tumour. Complete clearance of microscopic tumour was achieved in 50 per cent of patients with T3 tumours and this group did not benefit from adjuvant radiotherapy. Survival in patients undergoing curative oesophagectomy with residual microscopic tumour, however, was significantly improved by irradiation of the tumour bed (P less than 0.01). These results suggest that the survival of patients can be increased significantly by the excision of all gross tumour and by identification of those who will benefit from local radiotherapy. |
2 | Morphological study of cholesterol hepatolithiasis. Report of three cases. Three cases of pure cholesterol intrahepatic stones are compared morphologically to those of calcium bilirubinate stones. Cholesterol stones were found in the intrahepatic bile duct of the left lateral lobe in two cases and in both the left lateral and the right posterior lobe in one. Although the chronic inflammatory reaction and fibrous thickening of bile duct wall were similar in both types of hepatolithiasis, the proliferation of intrahepatic periductal glands and the production of mucin were rather mild, compared to that is the liner containing calcium bilirubinate stones. Multiple intramural cholesterol calculi and cholesterin granulomas (cholesterin crystals surrounded by foreign-body giant cells) were found within the cystically dilated small bile duct branches and/or conduits of periductal glands. The calculi and granulomas were characteristic for cholesterol hepatolithiasis. These findings suggest that the formation of the cholesterol stones differs from that of calcium bilirubinate stones; the perturbation of factors influencing cholesterol nucleation in the hepatic bile may be related to the changed microenvironment of the intrahepatic bile ducts, which is followed by the formation of cholesterol stones. |
4 | Coronary bypass grafting with totally calcified or acutely dissected ascending aorta. From August 1984 through November 1988, 10 of 2,658 patients undergoing coronary artery bypass grafting had ascending aortic disease that was not amenable to proximal anastomoses for coronary bypass grafting. This was due to a calcified aorta in 6 and acute aortic dissection in 4. There were 5 male and 5 female patients with a mean age of 71 years. Cannulation site was the femoral artery in 5, ascending aorta in 3, and aortic arch in 2. Profound hypothermia and ventricular fibrillation, with no cross-clamp or cardioplegia, was used in 9 patients, and circulatory arrest in 1. In 8 patients a single internal mammary artery was used as the total inflow with a saphenous vein graft brought off the internal mammary artery to one or more distal left-sided coronary vessels. Bilateral internal mammary arteries were used in 2 other patients. Operative mortality was zero. There was one perioperative myocardial infarction and one transient stroke without sequelae. All patients have done well from 1 to 6 years postoperatively. These data support the use of internal mammary arteries as single or bilateral proximal conduits for other venoarterial bypass grafts when the aorta is extensively diseased either by calcification or dissection. |
4 | Smooth muscle cell proliferation and restenosis after stand alone coronary excimer laser angioplasty It has been shown that coronary excimer laser angioplasty can remove atherosclerotic intracoronary tissue. Stand alone coronary excimer laser angioplasty was successfully performed in a 53 year old white man with 90% stenosis of the left anterior descending coronary artery and exertional angina (Canadian Cardiovascular Society class III). The lesion was reduced to a 30% residual stenosis with use of a 1.2 mm and subsequently a 1.8 mm diameter laser catheter. Early follow-up angiography 24 h later revealed persistent patency and unchanged lesion diameter of the target vessel. The patient was free of symptoms during the 2 month follow-up period, but died suddenly while playing in a tennis tournament 63 days after the procedure. Postmortem histologic examination revealed 80% restenosis at the lesion site without plaque disruption or thrombosis. Specific staining of the histologic specimen for smooth muscle cells using alpha-actin revealed significant smooth muscle cell proliferation at the site of coronary excimer laser angioplasty. However, most of the vessel narrowing appeared to be due to underlying fibrotic plaque as a result of insufficient tissue ablation. This was probably related to the size of the currently available catheters, which are too small to create a large channel. |
5 | Future needs for ERCP: incidence of conditions leading to bile duct obstruction and requirements for diagnostic and therapeutic biliary procedures. Although the development of endoscopic methods of treatment for biliary obstruction has proceeded rapidly in recent years, endoscopic retrograde cholangiopancreatographic (ERCP) services are patchily distributed. A recent survey by the British Society of Gastroenterology has shown that almost half the district general hospitals questioned did not have a sphincterotomy service available locally. To assess the level of provision required, two investigations have been undertaken. Firstly, an epidemiological study of bile duct obstruction has been carried out in the South Western Region. Secondly, the actual surgical and endoscopic workload in treating obstructive jaundice has been analysed in two health districts. Using present incidence and treatment rates at least 50 ERCPs per 100,000 of the population per year are estimated to be required in the future. Surgical treatment rates can be expected to fall as the number of therapeutic ERCPs increases. The implications of this estimate in equipment and staffing terms are discussed. |
5 | Long-term clinical results with the Ionescu-Shiley pericardial xenograft. From 1977 to 1987, 829 Ionescu-Shiley pericardial valves (Shiley, Inc., Irvine, Calif.) were implanted in 766 patients at the University of Ottawa Heart Institute. There were 476 patients who had aortic valve replacement, 234 who had mitral valve replacement, and 44 who had double valve replacement. The standard-profile design was used in 508 patients and the low-profile design in 321 patients. Follow-up was obtained for 97% of patients, with calculation of event-free probabilities. At 10 years the overall probability of freedom from structural failure was 48% +/- 7% after aortic valve replacement, 44% +/- 15% after mitral valve replacement, and 79% +/- 11% after double valve replacement. Although at 5 years the probability of failure was statistically lower with the low-profile design, this favorability was lost by 6 years. Freedom from structural failure was only 47% +/- 7% for the standard-profile valve at 10 years. Thus the probability of freedom from reoperation was only 46% +/- 7% after aortic valve replacement, 39% +/- 6% after mitral valve replacement, and 65% +/- 20% after double valve replacement at 10 years. Thromboembolism occurred in 69 patients, for a predicted freedom from this complication at 10 years of 79% +/- 3% after aortic, 73% +/- 7% after mitral, and 96% +/- 4% after double valve replacement. There were 31 cases of endocarditis. The 10-year predicted freedom from endocarditis, therefore, was 86% +/- 3% after aortic, 98% +/- 1% after mitral, and 97% +/- 1% after double valve replacement. A total of 221 operative and late deaths were recorded in this series. Prosthetic valve failure accounted for 27% of late deaths. The 10-year survival rates were estimated to be 56% +/- 5% (aortic valve replacement), 54% +/- 6% (mitral valve replacement), and 51% +/- 8% (double valve replacement). We concluded that the Ionescu-Shiley pericardial xenograft provides less than optimal clinical performance and its use has been discontinued. |
4 | Reversible cardiogenic shock due to chest tube compression of the right ventricle. A 62-year-old woman developed shock immediately after the insertion of a right-sided chest tube. A chest roentgenogram showed the chest tube to be overlying the heart and possibly compressing the right ventricle. An animal model was developed to replicate this clinical situation. Using a domestic goat model pulmonary artery, peripheral arterial catheters were inserted along with a right sided chest tube placed to suction. A second chest tube guided by a flexible fiberoptic bronchoscope placed within its lumen was positioned between the right ventricle and the sternum of the animals. Thirteen paired measurements in three goats (average of 4.3 measurements per animal) of cardiac output, heart rate, and mean arterial blood pressure were made at baseline and after chest tube placement over the right ventricle. The data were analyzed using a paired t test statistic. Compared with baseline measurements, there was a significant decrease in cardiac output (p less than 0.001) and mean arterial pressure (p less than 0.001) as well as an increase in heart rate (p = 0.0056) after placement of the chest tube across the right ventricle. We conclude that a misplaced chest tube compressing the right ventricle can impede cardiac output and lead to a low cardiac output state. Physicians inserting chest tubes in patients should be aware of this potential complication as it is easily treated by withdrawal of the chest tube. |
5 | Intrarectal ultrasonography in rectal cancer staging and in the evaluation of pelvic disease. Clinical uses of intrarectal ultrasound. Accurate preoperative staging of a rectal cancer patient may impact heavily on subsequent management. This study attempts to evaluate the accuracy of intrarectal ultrasonography (IRUS) in staging rectal cancers compared to clinical and pathologic examination. In addition the accuracy of IRUS was assessed in a group of patients with uncertain pelvic-perirectal disease after a negative physical examination. In a prospective manner, 52 cancer patients were staged with digital exam and IRUS. Accuracy rates were 48% and 83%, respectively, compared to pathologic evaluation in assessing wall penetration, and IRUS identified positive lymph nodes in 12 of 17 cases. In patients with pelvic disease, IRUS corresponded with pathologic diagnosis in 15 of 17 cases and revealed new information in 6 patients. Intrarectal ultrasonography appears to be the most accurate imaging technique for staging rectal cancers and demonstrates promise in the evaluation of perirectal-pelvic disease. |
5 | A new syndrome of congenital hypoparathyroidism, severe growth failure, and dysmorphic features. Twelve infants (six boys, six girls) with severe hypocalcaemic tetany or convulsions were seen over a three year period. Nine patients were symptomatic in the newborn period. Their hypocalcaemia was associated with hyperphosphataemia and very low concentrations of immunoreactive parathyroid hormone. None of the babies suffered from congenital cardiac disease. Cell mediated immunity, measured in five patients, was normal. There were no chromosomal abnormalities but all patients shared several dysmorphic features including deep set eyes, microcephaly, thin lips, beaked nose tip, external ear anomalies, micrognathia, and depressed nasal bridge. Mental retardation of varying degree was found in all patients. All had severe intrauterine and postnatal growth retardation. Four patients have died. The remaining eight patients are on treatments with vitamin D and calcium supplements with no change in their growth pattern. We believe that this association of congenital hypoparathyroidism with severe growth failure and dysmorphism represents a new syndrome. |
2 | Self-management of dietary compliance in coeliac disease by means of ELISA "home test" to detect gluten. To improve compliance with a gluten-free diet in coeliac disease a simple prototype test kit was developed to detect gluten in foods for use at home. The test is based on monoclonal antibodies to heat-stable gluten proteins which crossreact appropriately with barley and rye proteins. It is suitable for use with a wide range of raw or cooked foods. The food is extracted with dilute hydrochloric acid and 1 drop of the extract transferred to an antibody-coated tube; enzyme-labelled gluten detection antibody is added and after 3 min the tube is washed and colour developer is added. The reaction is stopped after 2 min, stabilising the blue colour. The home kit was compared with a quantitative laboratory kit, and the qualitative agreement was very good. The kit could distinguish foods with trace gluten contents (acceptable for a "gluten-free" diet) from those with a slightly higher but unacceptable gluten content. In a trial of the prototype kit by 47 coeliac disease patients of diverse ages and educational backgrounds, 93% of tests correctly identified foods as acceptable or unacceptable. |
5 | Lack of prognostic value of syncope in patients with Wolff-Parkinson-White syndrome Syncope in patients with Wolff-Parkinson-White syndrome may be considered a premonitory event heralding the future development of sudden death. Therefore, the clinical and electrophysiologic data of 101 patients with Wolff-Parkinson-White syndrome referred for invasive evaluation of known arrhythmias were reviewed to assess the incidence and clinical relevance of syncope. Thirty-six patients reported the occurrence of one or more syncopal episodes (group 1) and 65 patients had no syncope (group 2). These two groups did not differ significantly with regard to age, gender, incidence and characteristics of arrhythmia, clinical history, frequency of arrhythmic events and presence of associated cardiac disease. There were 10 patients in group 1 and 12 in group 2 who had ventricular fibrillation. There were no statistical differences between the two groups with respect to the effective refractory period of the right atrium, atrioventricular node, accessory pathway and right ventricle. Furthermore, no differences between the two groups were noted with respect to cycle length of circus movement tachycardia, mean heart rate during atrial fibrillation, and minimum RR interval during atrial fibrillation. In addition, the accessory pathway location was not significantly different between group 1 and group 2. The occurrence of syncope could not be predicted from any electrophysiologic finding and this symptom had a low sensitivity and specificity for recognition of dangerous rapid heart rates. Furthermore, the prognostic value of syncope was less accurate and predictive than the shortest RR interval during atrial fibrillation and the anterograde effective refractory period of the accessory pathway for aborted sudden death occurrence. |
3 | Cerebellar syndrome caused by isoniazid. Treatment of tuberculosis in a hemodialysis patient with isoniazid, rifampin, and pyrazinamide resulted in the development of acute cerebellar dysfunction. This resolved rapidly following the discontinuation of isoniazid and pyrazinamide, reinstitution of isoniazid at a lower dose, and addition of pyridoxine. We discuss why we believe this syndrome was caused by isoniazid. Patients with renal failure who undergo antituberculous therapy with isoniazid should receive supplemental pyridoxine to reduce the likelihood of isoniazid-related neurotoxicity. |
5 | Treatment of craniomaxillofacial fibrous dysplasia: how early and how extensive? Twenty-eight craniomaxillofacial fibrous dysplasia patients were treated as early as the symptoms occurred. The principles of surgical treatment were based on the zones of involvement: total excision of dysplastic bone of fronto-orbital, zygoma, and upper maxillary origin (zone 1) and bone reconstruction primarily; conservative excision on hair-bearing skull (zone 2), central cranial base (zone 3), and tooth-bearing bones (zone 4); and optic canal decompression on patients with orbital dysplasia and decreasing visual acuity. Patients were followed for 1 to 11 years (average 5.3 years). No recurrence or invasion of the fibrous dysplasia into the grafted bone was seen. One patient had orthognathic maxillary osteotomy on the reconstructed maxilla 6 years after initial reconstruction. Five of 19 patients with alveolar dysplasia had a recurrence and were reshaped. One patient had mandibular sagittal osteotomies to set back the prognathic, fibrous dysplasic mandible after three attempts at conservative shaving. Another patient with mandibular fibrous dysplasia had recurrence with pain and a hemimandibulectomy with successful immediate free vascularized iliac bone graft reconstruction. |
5 | Parathyroidectomy in chronic renal failure: a nine-year follow-up study. Seventy-three patients with chronic renal failure who underwent parathyroidectomy between March 1978 and April 1987 were reviewed. Thirty-four patients had undergone sub-total parathyroidectomy, and 39 patients had undergone total parathyroidectomy with parathyroid autograft into the forearm. Eight patients showed persistent hyperparathyroidism requiring a second surgical procedure. In all other patients there was highly statistical improvement in parathyroid hormone, total calcium, ionized calcium, alkaline phosphatase and a significant reduction in calcium x phosphate product. Histological evidence of osteitis fibrosa was present in 21 of 22 patients before surgery. Postoperatively, four showed complete resolution and improvement. Three patients developed histological evidence of osteomalacia during the study period. Only four of the 39 patients who underwent total parathyroidectomy with autograft had true recurrent hyperparathyroidism and only two of the 34 patients who underwent sub-total parathyroidectomy had recurrent disease, indicating that there is little to choose between the two techniques in the control of secondary hyperparathyroidism and its subsequent recurrence. In one patient with recurrence of hyperparathyroidism from a forearm parathyroid graft the histological picture was different from that of normal hyperplastic parathyroid tissue. Although it is probable that abnormal parathyroid tissue had been implanted there was no evidence of invasive growth into the forearm muscle. The most striking feature of long term follow-up was the difference in calcium x phosphate product in patients in whom vascular calcification increased compared to those patients with no change or regression of calcification. Mean calcium phosphate product in those patients with progressive vascular calcification was 4.93 for small and medium size vessels and 5.38 for large vessels compared to 4.10 for small and medium vessels and 4.09 for large vessels. In the former case the serum phosphate was 2.00 and 2.17 as compared to 1.75 or 1.73, suggesting that the aim in patients with end stage renal failure maintained by dialysis should be to control the serum phosphate concentration to 1.8 mmol or less and the calcium x phosphate product to less than 4.2. |
4 | Combined orthopedic and vascular injury in the lower extremities: indications for amputation. A retrospective review was undertaken to determine risk factors associated with amputation after open fractures of the lower extremity that were complicated by vascular injury. During an 11-year period ending in December 1987, we observed open fractures in 31 patients and injuries to the popliteal artery in 16 patients, to the tibial arteries in eight patients, to the femoral artery in five patients, and to the dorsal artery of the foot in two patients. Vascular repair was accomplished in 25 patients; 12 patients had primary end-to-end anastomosis, 12 patients had reverse saphenous vein grafts, and one patient had a bovine graft. Of these 25 patients, five patients required amputation because of infection and three patients required amputation because of continued ischemia. Three patients with irreparable damage had immediate amputation, and three patients without distal ischemia had vessel ligation only. The risk factors associated with amputation were shock on admission (10 of 19 patients [p less than 0.02]) and a crushed extremity (10 of 18 patients [p less than 0.01]). The overall amputation rate, which included three immediate amputations and eight late amputations, was 35.2%. The data suggest that limb salvage is possible in two thirds of patients with combined orthopedic and vascular injuries of the lower extremity, but a history of shock or crush injury with vascular compromise is an unfavorable prognostic sign. |
5 | Double-blind randomized trial of perioperative fibrinolytic enhancement for femoropopliteal bypass. Patients with rest pain or acute peripheral arterial thrombosis are known to have impaired endogenous fibrinolysis, which is associated with an increased risk of early vascular graft thrombosis. This risk is exacerbated by the fibrinolytic shutdown which is known to occur after major surgery. Stanozolol, which has been demonstrated to enhance endogenous fibrinolysis, was therefore used in an attempt to prevent this perioperative fibrinolytic shutdown and so enhance graft patency. Twenty-seven patients were randomized to receive either 50 mg stanozolol or placebo intramuscularly 24 h before operation, followed by a 6 week course of either 5 mg stanozolol or placebo orally, twice daily. On the second day after operation, 10-11 MBq of autologous 111indium-labelled platelets were injected, with scanning over the graft on the 3 following days. Despite using a large depot of stanozolol, significant effects, such as raised plasminogen (P less than 0.001), reduced fibrinogen (P less than 0.001) and reduced euglobulin lysis time (P less than 0.001), were not seen until the seventh day after operation, with maximum benefit at 6 weeks. This was reflected in the 111indium-labelled platelet deposition studies. The placebo group had a progressive increase in platelet deposition on all 3 days. In contrast, those receiving stanozolol showed a lower, static picture of deposition. However, these changes did not attain statistical significance. Three patients experienced early graft thrombosis, two in the placebo group and one in the stanozolol group. Only an incomplete inhibition of the perioperative fibrinolytic shutdown was achieved. Much longer preoperative courses are thus required to allow the maximum effect to be present at the most crucial time. At present, perioperative fibrinolytic enhancement does not appear to be a practical proposition, and we must await the development of new safer and more potent agents. |
1 | An immunohistochemical study of pi class glutathione S-transferase expression in normal human tissue. Glutathione S-transferases (GSTs), a family of isoenzymes that play an important role in protecting cells from cytotoxic and carcinogenic agents, can be separated by biochemical and immunologic characteristics into three distinct classes named alpha, mu, and pi. Previous studies have indicated that there is marked heterogeneity in the expression of different GST isoenzymes in different normal and malignant tissues. To better understand the regulation of the human pi class glutathione S-transferase isoenzyme (GST-pi), the tissue distribution of this protein wa studied by an immunohistochemical technique using an anti-GST-pi polyclonal antibody in normal paraffin-embedded human tissues. These studies indicate that there is a broad distribution of GST-pi in normal human tissues and establish a precise localization within the different organs studied. GST-pi was expressed predominantly in normal epithelial cells of the urinary, digestive, and respiratory tracts, suggesting a possible role for GST-pi in detoxication and elimination of toxic substances. Previous studies have indicated that GST-pi and the putative drug efflux pump P-glycoprotein are both overexpressed in multidrug-resistant human breast cancer cells and in xenobiotic resistant preneoplastic rat hyperplastic liver nodules. Results from this study indicate that there are also similarities between the normal tissue distribution GST-pi and that previously reported for mammalian P-glycoprotein, particularly in secretory epithelia. This finding suggests that these two gene products, which have been implicated in the development of resistance to cytotoxic drugs, may be coregulated in normal and malignant cells. |
5 | Application of a modified bioassay for monitoring serum teicoplanin and vancomycin in febrile neutropenic patients. Teicoplanin is a glycopeptide antibiotic with a mode of action and spectrum of activity similar to those of vancomycin. Its efficacy and tolerability as empiric therapy and its pharmacokinetic properties in neutropenic patients are being studied in a double-blinded, randomized trial in comparison with those of vancomycin. We report here a modified agar diffusion bioassay which is suitable for monitoring levels of either teicoplanin or vancomycin in serum during combination therapy with beta-lactams, aminoglycosides, and amphotericin B. Serum samples spiked with either teicoplanin or vancomycin gave reproducible results (mean coefficient of variation, 8.8%) regardless of the presence of tobramycin, amikacin, piperacillin, ceftazidime, amphotericin B, or their combinations. Among 25 patients who received teicoplanin at a dosing schedule of 6 mg/kg every 24 h intravenously, steady state was reached after 14.2 +/- 4.0 days, and 1-h peak and trough concentrations of teicoplanin in serum at steady state were 40.8 +/- 15.0 and 12.5 +/- 3.2 mg/liter, respectively. In contrast, among 25 patients who received vancomycin at a dosing schedule of 15 mg/kg every 12 h intravenously, steady state was reached by 24 h, and the 1-h peak and trough concentrations in serum were 37.5 +/- 15.6 and 8.3 +/- 3.8 mg/liter, respectively. The elimination half-lives for teicoplanin estimated by two separate approaches agreed closely with each other: 80.5 +/- 21.5 h by an accumulation model (M. Gilbaldi and D. Perrier, Pharmacokinetics, 2nd ed., p. 121, 1982) and 87.3 +/- 19.3 h as predicted from the degree of renal function (M. Rowland, Clin. Pharmacokinetic 18:184-209, 1990). These values were 14- to 15-fold higher than that for vancomycin (5.6 +/- 1.8 h). |
1 | A clinicopathologic study of the eyes in familial adenomatous polyposis with extracolonic manifestations (Gardner's syndrome). The eyes of a 51-year-old woman with familial adenomatous polyposis and extracolonic manifestations (Gardner's syndrome) were obtained postmortem and studied by light microscopy and by transmission and scanning electron microscopy. We found a generalized abnormality in melanogenesis of the retinal pigment epithelium and at least three types of pigmented lesions. The histologic findings in one type of lesion were consistent with congenital hypertrophy of the retinal pigment epithelium or benign pigmented nevus of the retinal pigment epithelium. The other two types of lesion were most consistent with hamartomatous malformations of the retinal pigment epithelium featuring cellular hypertrophy, hyperplasia, and rarely retinal invasion and formation of a minute mushroom-shaped tumor. These histopathologic findings indicate a generalized effect of the familial adenomatous polyposis gene on the retinal pigment epithelium. This oncogene, which is responsible for tumor formation in the gastrointestinal tract, soft tissues, bone, and other locations in patients with familial adenomatous polyposis, also leads to a generalized defect in melanogenesis and focal lesions of the retinal pigment epithelium. |
5 | Transfection and stable transformation of adult mouse Schwann cells with SV-40 large T antigen gene. Cultured Schwann cells derived from adult mouse dorsal root ganglia and peripheral nerves were transfected with a plasmid containing SV-40 large T antigen gene, and 25 colonies of stable transformants were obtained, one of which was expanded and recloned. This transfected cell line, designated MS1, expressed SV-40 large T antigen and showed continuous cell growth with a doubling time of 27 hours. The MS1 cells had distinct Schwann cell phenotypes such as S-100 protein, laminin, 2',3'-cyclic nucleotide 3'-phosphodiesterase and P0 protein, as shown by immunofluorescence microscopy. When MS1 cells were exposed to dibutyryl cyclic adenosine-3',5'-monophosphate (dbc AMP), they extended long bipolar processes two- to ten-fold longer than those of untreated MS1 cells and frequently formed whorl-like alignments similar to palisade formations or organoid patterns observed in human Schwannomas and neurofibromas. These results suggest that transformed Schwann cells can be a useful model for analyzing regulatory mechanisms of Schwann cells, neuron-Schwann cell interactions and experimental Schwann cell neoplasms in vitro. |
1 | Osteoblastoma of the spine. A review of 75 cases. Clinical and radiologic features of 75 cases of osteoblastoma of the spine were reviewed. In addition to pain, which was the most frequent complaint, 18 patients demonstrated objective neurologic deficit, while scoliosis was observed in 17 patients. Aspirin yielded pain relief in 13 patients. Pathologic fracture was not encountered. The radiologic and histologic characteristics of osteoblastoma of the spine are indistinguishable from those arising in other sites. The typical lesion exhibited a well-defined, geographic margin with a sclerotic, frequently lobulated border. Approximately one half of the cases were predominantly lucent, the remainder displaying varying degrees of matrix mineralization. Distribution of the osteoblastomas through the spinal axis was as follows: cervical-29, thoracic-16, lumbar-17, sacral-13. Other significant findings included posterior element involvement in 73 of 75 cases, and a striking male to female ratio of 2.5 to 1. |
1 | Kaposi's sarcoma involvement of the bone marrow. Kaposi's sarcoma (KS) is a predominantly cutaneous malignancy with several clinical variants. Extracutaneous sites of involvement are uncommon in all disease variants except epidemic KS (human immunodeficiency virus related) and the African lymphadenopathic variant. Extracutaneous KS usually involves the lymph nodes, gastrointestinal tract, and respiratory tract. The authors report the first description of a patient with classic KS to have bone marrow involvement. Two additional patients with KS variants and bone marrow involvement have been described. Bone marrow tumor invasion should be considered in patients with KS and hematologic abnormalities. |
5 | Electrophysiologic effects of exogenous phosphocreatine in cardiac tissue: potential antiarrhythmic actions. The cellular electrophysiologic effects of exogenous phosphocreatine (PCr) were analyzed to ascertain its purported antiarrhythmic properties during myocardial ischemia and reperfusion. Transmembrane potentials were recorded from isolated guinea pig papillary muscles and Purkinje fibers studied in vitro. Under control, normoxic conditions, 10 mmol/L PCr significantly increased the action potential duration (measured at 90% of repolarization) in ventricular muscle by 14.6 +/- 3.3 msec and the effective refractory period by 11.5 +/- 3.8 msec (both p less than 0.01). Under ischemic-like conditions (hypoxia, lactic acidosis, elevated [K+]o, zero substrate) PCr had no effect. Phosphocreatinine, a related compound that is not a direct substrate in the creatine kinase reaction, acted similarly to PCr suggesting that alterations induced by PCr did not involve a change in the energy state of cells. However, PCr reduced free [Ca2+]o by nearly 20%, and its electrical effects under normoxic conditions could be largely reversed by a concomitant 20% increase in [Ca2+]o. In Purkinje fibers superfused with low [K+]o-Tyrode's solution to elicit conditions of Ca2+ overload, delayed afterdepolarizations and triggered responses were reversibly inhibited by PCr. These data suggest that the antiarrhythmic effects of PCr in situ may involve prolongation of the effective refractory period in nonischemic tissue or attenuation of membrane changes elicited by Ca2+ overload in ischemic cells. The mechanism by which PCr produces these effects may be related in part to changes in extracellular Ca2+ composition. |
2 | Resolution of cirrhotic glomerulonephritis following successful liver transplantation. A 38-year-old man with liver failure due to Laennec's cirrhosis developed nephrotic range proteinuria and hematuria. Renal biopsy showed membranoproliferative glomerulonephritis with 2+ staining for IgA and complement consistent with cirrhotic glomerulonephritis. After orthotopic liver transplantation, proteinuria and hematuria rapidly resolved. This case indicates that glomerulonephritis associated with cirrhosis may be successfully treated with hepatic transplantation. Whether the improvement in glomerular abnormalities resulted from immunosuppression therapy or from restoration of normal hepatic function is unknown. |
1 | Usefulness of pulsed Doppler ultrasound in detection of angiographically evident recurrence of hepatocellular carcinoma after arterial embolization treatment. Because hepatocellular carcinoma treated by transcatheter arterial embolization often regains its size, routine follow-up is necessary. The usefulness of pulsed Doppler ultrasound for detection of this type of recurrence was compared with ultrasonography and computed tomography in 21 such hepatocellular carcinomas. Of 15 hepatocellular carcinomas diagnosed by angiography as showing recurrence, four were detected with ultrasonography and five were detected with computed tomography. Doppler signals were obtained in the peripheral portions corresponding to tumor vessels or stains on angiograms in 14 of these 15 hepatocellular carcinomas, but they were undetectable in six hepatocellular carcinomas with no recurrence. All signals disappeared after transcatheter arterial embolization. One false-negative hepatocellular carcinoma with pulsed Doppler ultrasound showed faint tumor stains on angiograms; these were also negative on ultrasonography and computed tomography. Pulsed Doppler ultrasound may be superior to ultrasonography and computed tomography as a routine procedure to detect the recurrence of hepatocellular carcinoma treated by transcatheter arterial embolization. |
3 | Unusual presentation of squamous cell carcinoma of the middle ear and mastoid. An unusual case of squamous cell carcinoma of the middle ear and mastoid in which syncope was a major presenting feature is reported. No such case has been reported in the literature. A possible explanation is offered. |
4 | Ultrasonic evaluation of early carotid atherosclerosis. We investigated the prevalence of carotid atherosclerosis, including mild early lesions, and its association with cervical bruits and various risk factors (age, male sex, hypertension, hyperlipidemia, diabetes mellitus, obesity, and cigarette smoking) in 232 consecutive Japanese patients. High-resolution real-time B-mode ultrasonography was performed to determine the extent of atherosclerosis, and it was quantified by using a scoring system. The prevalence of carotid atherosclerosis was 49%, 59%, and 41% in all 232 patients, the 100 symptomatic patients, and the 132 asymptomatic patients, respectively. Although carotid lesions were detected frequently (87%) in the 30 patients with cervical bruits, bruits were noted in only 30% of the 88 examined patients with carotid atherosclerosis. Independent risk factors for carotid atherosclerosis in these patients were found to be age, male sex, and hyperlipidemia; diabetes mellitus was a possible risk factor for carotid atherosclerosis. Our study did not show a close association between hypertension and carotid atherosclerosis, and this might be caused by the high prevalence of hypertension in our patients. Our findings suggest an increasing prevalence of carotid atherosclerosis in the Japanese, though this should be confirmed in a population-based study. Our study demonstrates the clinical usefulness of high-resolution B-mode ultrasonography for the evaluation of early carotid atherosclerosis. |
5 | The Maylard incision in gynecologic surgery The transverse muscle-splitting Maylard incision was used in 175 gynecologic patients who required pelvic-abdominal surgery. One hundred fifty-three patients (87%) had pelvic malignancy; other indications for operation included uterine myomas, endometriosis, tuboovarian abscess, and benign ovarian cysts. Exposure was excellent: 54% of patients underwent pelvic lymphadenectomy and 17% underwent paraaortic lymphadenectomy. Twelve patients (6.9%) had wound complications, but there was neither long-term morbidity nor mortality associated with the incision. Fifty-six patients (32%) received preoperative or postoperative pelvic radiation therapy with no detrimental effect on wound healing. The Maylard incision is cosmetic, strong, easily learned, and has an acceptable complication rate. Unless a vertical incision is indicated, the Maylard technique is preferred when optimal exposure and accessibility to the pelvis are required. |
4 | Apical segmental dysfunction in hypertrophic cardiomyopathy: subgroup with unique clinical features. A segmental wall motion abnormality is an unusual finding in patients with hypertrophic cardiomyopathy. To clarify its clinical significance, 48 patients with hypertrophic cardiomyopathy were analyzed. Eight patients (Group A) had apical segmental dysfunction; 40 (Group B) had normal wall motion. No patient in either group had coronary artery stenosis on selective coronary arteriography. In all patients in Group A, apical segmental dysfunction was revealed by left ventriculography; however, it could be detected by echocardiography in only two patients in Group A. Left ventricular hypertrophy by electrocardiogram (ECG) was more common in Group B (p less than 0.05). Abnormal Q waves were more frequently discovered in Group A (p less than 0.005) and were recognized predominantly in the lateral leads. On serial ECGs, a gradual development of abnormal Q waves was noted in six of eight patients in Group A. Malignant arrhythmias were more common in Group A (p less than 0.001). In two patients in Group A, left ventricular dilation and congestive heart failure developed during the follow-up period. Thus, the presence of a Q wave in the lateral leads on an ECG in patients with hypertrophic cardiomyopathy may indicate the presence of apical segmental dysfunction. Left ventriculography should be performed to examine the presence of this abnormality and 24 h ambulatory ECG monitoring should be done to detect malignant arrhythmias in patients who have abnormal Q waves in the lateral leads. Patients with this unique type of hypertrophic cardiomyopathy need careful follow-up evaluation. |
1 | Mucinous adenocarcinoma of the submandibular gland. A rare tumor not easily classifiable among published histologic categories for salivary gland tumors is reported. The neoplasm developed within the submandibular gland of a 78-year-old woman with invasion of the mandible and metastasis to regional lymph nodes. Histopathologically, cuboidal cells possessing clear cytoplasm and displaced round nuclei proliferated and exhibited an adenomatous pattern. Many cystic spaces surrounded by tumor cell strands were seen, mucus substance filled in the cystic spaces, and the tumor cells seemed mucus-secreting, but neither epidermoid cells nor papillary appearance could be observed. Electromicroscopically, numerous mucous droplets of low electron density were prominent in the cytoplasm, and the tumor cells had sparse irregular microvilli on the luminal surface. Mucin histochemistry, including paradoxical concanavalin A staining, revealed that the tumor cells contained neutral and acid mucins, and these were identified as class II and III mucosubstances. No other neoplastic lesion, except recurrent metastatic neck nodes, has been detected 6 years after the first examination, and it seems that the tumor is a rare primary mucinous adenocarcinoma of the submandibular gland. |
5 | Pain relief achieved by transcutaneous electrical nerve stimulation and/or vibratory stimulation in a case of painful legs and moving toes. A patient is described with painful legs and moving toes. The pain had been occurring for more than 15 years, and a variety of therapies had been attempted with only partial, if any, success. Only morphine had succeeded in relieving the pain, but it had to be discontinued to avoid tolerance and dependence. We devised a treatment consisting of transcutaneous electrical nerve stimulation (TENS), vibratory stimulation (VS), and a combination of the two methods (TENS + VS). TENS brought about partial pain relief, but was less effective than VS; dual stimulation (TENS + VS) led to complete alleviation of the pain. Four months later, the patient was applying dual stimulation himself at home and was thus able to maintain complete relief with 3 or 4 weekly sessions. We suggest that dual stimulation results in a large-scale recruitment of large-diameter afferent fibres and may thus set up a powerful inhibitory control of nociception in our patient. |
5 | Effect of nisoldipine on hemodynamic responses to defibrillation. Sequences of ventricular fibrillation-defibrillation cause transient hypertension; we hypothesized that this "adrenergic overshoot" might be blunted by the functional antiadrenergic effect of the calcium channel blocking drug nisoldipine, with a potentially beneficial reduction in myocardial oxygen requirements. However, other calcium channel blocking drugs have been shown to reduce shock success for defibrillation, a deleterious effect. Thus the purposes of this study were to assess the effect of nisoldipine on the hemodynamic responses to the sequences of ventricular fibrillation-defibrillation, and its effect on the energy requirements for defibrillation. In 16 dogs we administered intravenous nisoldipine (1 microgram/kg bolus followed by an infusion of 0.075 to 0.50 microgram/kg/min) to lower mean blood pressure 10% and 20% below baseline. Ventricular fibrillation was induced electrically, and shocks of varying energy levels (30, 50, and 100 joules) were administered to determine defibrillation energy requirements. Heart rates and blood pressures were recorded up to 3 minutes after each shock to determine hemodynamic responses. Measurements were made before nisoldipine administration and again at the two levels of drug-induced blood pressure decline. We found that the usual systolic blood pressure "overshoot" after defibrillation (typically maximum at 15 to 30 seconds after shocks) was significantly blunted after nisoldipine administration (p less than 0.05). Heart rate slowing after defibrillation (a cholinergic response) was not affected. Nisoldipine did not alter shock success rates, which varied from 12 +/- 7%SE at 30 joules to 68 +/- 12% at 100 joules. Thus nisoldipine blunted the "adrenergic overshoot" of systolic blood pressure following defibrillation, a potentially beneficial effect, without altering the energy requirements for transthoracic defibrillation. |
2 | Changes in anal canal sensation after childbirth. Obstetic trauma predisposes to faecal incontinence. Anal canal sensation is impaired in incontinent patients. To assess the effect of childbirth on anal canal sensation anal mucosal electrosensitivity was measured in 122 primiparous patients in the immediate postnatal period and in 74 at 6 months postpartum. There were 35 normal vaginal deliveries, 36 forceps deliveries, 20 ventouse extractions, ten vaginal breech deliveries and 21 caesarean sections. Sensation was impaired in the lower, mid and upper anal canal immediately after delivery in those patients who had a normal vaginal delivery or a forceps delivery when compared with controls or with those delivered by caesarean section. Women who had ventouse deliveries had impaired sensation immediately after delivery in the mid anal canal compared with controls and those undergoing caesarean section. By 6 months there were no differences between any group. Patients who sustained a division of the external anal sphincter at delivery had impaired sensation which persisted in the upper anal canal at 6 months. |
3 | Quantification of biomedical findings of chronic pain patients: development of an index of pathology. Difficulties in assessing and quantifying the biomedical signs and symptoms that may be related to patients' reports of pain are well recognized. Although there appears to be some consensus among physicians as to the potential utility of examination and diagnostic tests frequently used to evaluate chronic pain patients, little attention has been paid to the reliability of interpreting the results of these procedures. Moreover, the integration of biomedical findings to form a general index of pathology associated with chronic pain has been a difficult problem to solve because not all biomedical procedures used to evaluate pain patients are necessarily relevant or indicated for a specific patient. Two studies are presented that were designed to evaluate the reliability of 23 biomedical procedures commonly used to evaluate chronic pain patients and to determine if findings on these procedures can effectively be combined to form a reliable index of physical pathology. The results of study 1 suggest that 17 of the 23 procedures can be applied in clinical setting with acceptable levels of reliability. Study 2 provides evidence that an innovative weighted scoring approach, based on current medical consensus, can be used to produce a reliable, general index of pathology that is independent of the number of procedures used to evaluate patients. The utility of this quantification approach to biomedical findings for clinical and research purposes is discussed. |
5 | Sex reversal syndrome (XX male). Men who appear normal and live a normal life, may have a 46,XX karyotype and present with the typical features of infertility and end organ (testicular) failure. They are azoospermic and their small testicles show specific patterns on light and electron microscopy. Recent advances in genetics (1) favor the "X-Y interchange" theory to explain this phenomenon; (2) hypothesize about the roles of the H-Y antigen and testis determining factor (TDF) in determining "maleness"; and (3) allow mapping of the relative positions of H-Y and TDF loci on the Y chromosome. |
5 | Interruption of critical aortoiliac collateral circulation during nonvascular operations: a cause of acute limb-threatening ischemia. In patients with aortoiliac occlusive disease interruption of critical collaterals during another nonvascular or cardiac operation may threaten limb viability. This occurred in four patients whose limb-threatening ischemia was precipitated by radical cystectomy with bilateral hypogastric artery ligation, left colon resection, or coronary artery revascularizations by means of the internal mammary artery. Important collateral pathways, the interruption of which may account for this phenomenon, are detailed, and approaches are outlined for prevention and management of acute ischemia in this setting. |
4 | Propafenone treatment of symptomatic paroxysmal supraventricular arrhythmias. A randomized, placebo-controlled, crossover trial in patients tolerating oral therapy. OBJECTIVE: To test the hypothesis that propafenone, administered orally, prevents symptomatic paroxysmal supraventricular arrhythmias. DESIGN: a 6-month, open-label, dose-finding phase followed by a randomized, double-blind, placebo-controlled, crossover phase, with each treatment period lasting up to 60 days. SETTING: An outpatient clinic. PATIENTS: Thirty-three patients with either paroxysmal supraventricular tachycardia (n = 16) or paroxysmal atrial fibrillation (n = 17) were enrolled. Their arrhythmias were documented by electrocardiogram before enrollment. Twenty-three patients (14 with paroxysmal supraventricular tachycardia and 9 with paroxysmal atrial fibrillation) were randomized and the data obtained from these patients were used in the efficacy analysis. INTERVENTION: Propafenone (300 mg three times daily in 19 patients, 300 mg twice daily in 3 patients, and 150 mg twice daily in 1 patient) and matching placebo tablets were administered in a randomized sequence. MEASUREMENTS: Symptomatic arrhythmia was documented by telephone transmission of the electrocardiogram. MAIN RESULTS: The time to first recurrence was prolonged for the overall group of 23 patients while they received propafenone (P = 0.004). The recurrence rate of arrhythmia during treatment with propafenone was estimated to be approximately one fifth of the recurrence rate during treatment with placebo. CONCLUSIONS: Propafenone is effective in reducing symptomatic paroxysmal supraventricular arrhythmias. |
2 | The role of the mast cell in clinical gastrointestinal disease with special reference to systemic mastocytosis. The gastrointestinal tract is a rich source of mast cells with an enormous surface area that permits a high degree of interaction between the mast cell and intestinal luminal contents. The active metabolic products of the mast cell influence gastrointestinal secretion, absorption, and motility through paracrine effects of local mast cell degranulation and also cause systemic effects through the release of cellular products into the blood stream. Systemic mastocytosis influences physiologic function through the systemic effects of mast cell products released from focal (e.g., bone marrow) or wide spread increases in mast cell number. Local gastrointestinal proliferation of mast cells in response to recognized (e.g., gluten in celiac sprue) or obscure stimuli can alter gastrointestinal function and induce systemic symptoms. Celiac sprue, inflammatory bowel disease, and non-ulcer dyspepsia are three examples of gastrointestinal diseases in which mast cells can be implicated in the pathophysiology of the symptoms. |
1 | Chromogranin A storage and secretion: sensitivity and specificity for the diagnosis of pheochromocytoma. Chromogranin A, co-stored and co-released with catecholamines from adrenal medullary and sympathetic neuronal vesicles, is elevated in the plasma of patients with pheochromocytoma. The usefulness of the hormone in the differential diagnosis of hypertension is examined. An elevated level of chromogranin A had comparable diagnostic sensitivity (83%, 24/29) to, but greater diagnostic specificity (96%, 86/90) than the level of plasma catecholamines when subjects with pheochromocytoma (n = 29) were evaluated in comparison to several reference groups, including normotensive controls (n = 49), subjects with essential hypertension (n = 28), subjects with renovascular hypertension (n = 5), and subjects with primary aldosteronism (n = 3). Subjects with signs or symptoms suggesting pheochromocytoma, but in whom the diagnosis was ultimately ruled out (n = 5) had normal plasma levels of chromogranin A. A modest rise in chromogranin A in those with essential hypertension, and correlation of chromogranin A with diastolic blood pressure in normotensive patients and patients with essential hypertension did not impair the diagnostic usefulness of chromogranin A for pheochromocytoma. Renal failure was associated with an elevated plasma chromogranin A independently of blood pressure. Plasma chromogranin A correlated with tumor mass, tumor chromogranin A content, tumor norepinephrine content, and urinary vanillylmandelic acid excretion; it did not correlate with plasma or urinary catecholamines, nor with blood pressure in patients with pheochromocytoma. Plasma chromogranin A levels did not differ in subjects with pheochromocytoma when stratified by age, sex, tumor location, or tumor pathology. Several drugs used in the diagnosis or treatment of pheochromocytoma (clonidine, metoprolol, phentolamine, and tyramine) had little effect on plasma chromogranin A concentration. Within the pheochromocytoma, chromogranin A was localized along with catecholamines to the soluble core of chromaffin granules, where it accounted for 18 +/- 5% of vesicle soluble protein. We conclude that 1) chromogranin A emerges along with catecholamines from pheochromocytoma chromaffin granules; 2) plasma chromogranin A is a sensitive and specific diagnostic tool in evaluation of actual or suspected pheochromocytoma; 3) plasma chromogranin A predicts pheochromocytoma tumor size and overall catecholamine production; and 4) drugs commonly employed in the diagnosis or treatment of pheochromocytoma have little effect on plasma chromogranin A level, preserving the usefulness of chromogranin A in evaluating pheochromocytoma. Thus, measurement of chromogranin A provides a useful adjunct to the diagnosis of pheochromocytoma. |
5 | Analysis of DNA polymorphisms suggests that most de novo dup(21q) chromosomes in patients with Down syndrome are isochromosomes and not translocations. Down syndrome is rarely due to a de novo duplication of chromosome 21 [dup(21q)]. To investigate the origin of the dup(21q) and the nature of this chromosome, we used DNA polymorphisms in 10 families with Down syndrome due to de novo dup(21q). The origin of the extra chromosome 21q was maternal in six cases and paternal in four cases. Furthermore, the majority (eight of 10) of dup(21q) chromosomes were isochromosomes i(21q) (four were paternal in origin, and four were maternal in origin); however, in two of 10 families the dup(21q) chromosome appeared to be the result of a Robertsonian translocation t(21q;21q) (maternal in origin in both cases). |
5 | Diffuse axonal injury: analysis of 100 patients with radiological signs. One hundred patients with head injuries who showed diffuse axonal injury on computed tomographic scans are reported. Evaluation of the Glasgow Coma Score, pupillary signs, and computed tomographic findings on admission led to an improved ability to forecast outcomes. Our relatively good results as compared with other series, can be explained by the high proportion of children and by the liberal use of computed tomography to evaluate head injuries, thus revealing that concussion may sometimes be regarded as an early form of diffuse axonal injury. |
3 | Synchronous Hodgkin's disease and myelofibrosis terminating with granulocytic sarcoma and acute megakaryocytic leukemia. Our patient had stage IIIAI Hodgkin's disease with synchronous myelofibrosis and myeloid metaplasia. A slowly progressive myeloproliferative disease developed over 9 1/2 years and terminated in a painful osteolytic bone disease, spinal extradural granulocytic sarcoma and acute megakaryocytic leukemia. It is likely that this was a result of the myeloproliferative disease rather than a late complication from combination chemotherapy. Our case demonstrates the importance of a curative approach to Hodgkin's disease even in the face of a coexistent disease with a long or unknown natural history. |
1 | 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. |
1 | Postoperative follow-up of patients with early breast cancer. Patterns of care among clinical oncologists and a review of the literature. Eighty clinical oncologists in the southeastern United States were surveyed to determine their strategies for follow-up care after primary treatment of early-stage breast cancer. The frequency of use of the history and physical examination, complete blood count, liver function tests, carcinoembryonic antigen levels, chest x-ray, skeletal survey, bone scan, liver scan, and mammogram for observing hypothetical low- and high-risk patients was assessed. Yearly mammograms were recommended by more than 95% of respondents. History and physical examination were the modalities used most often, whereas periodic bone and liver scans were used only in a minority of patients. A review of the literature supported the strategy of the respondents in this survey and further underscored the cost-effectiveness of the history and physical examination in detecting recurrence during follow-up. Based on this survey and supporting literature, recommendations for reasonable yet cost-conscious follow-up are presented. |
1 | Ileal duplication cyst causing massive bleeding in a child. Intestinal duplication is a rare congenital anomaly; nonetheless, it comprises more than half of all alimentary duplication disorders. Our case report describes the hemorrhagic sequelae of this entity with surgical and pathologic findings. A review of anatomical classification, embryology, and natural history of duplication cyst follows; differentiating characteristics of duplication cyst versus Meckel's diverticulum are outlined. Intestinal duplication cyst should be considered in the differential diagnosis of GI bleeding, especially in children. |
1 | A randomized trial of the effect of three non-steroid anti-inflammatory agents in ameliorating cancer-induced fever. Paraneoplastic fever is well known, and is not an uncommon problem in daily practice. In an effort to ameliorate tumour-induced fever we randomized 48 patients to receive three different non-steroid anti-inflammatory drugs: Naproxen (500 mg d-1), Indomethacin (75 mg d-1) or Diclophenac sodium (75 mg d-1). All patients had solid tumours, and microbial infection had been excluded. All three drugs were equally effective in bringing the temperature down to normal for a period of 30-33 d. Naproxen had the most rapid effect. In cases of fever relapse with the first drug, when the other two drugs were given instead, both proved equally effective. No side-effects were observed. We conclude that Naproxen, Indomethacin and Diclophenac sodium are equally effective in ameliorating paraneoplastic fever. In relapse, a second drug given subsequently can be effective as well. |
3 | Pharmacology of recovery after stroke. Laboratory research during the past decade has begun to provide insights into the neurobiologic basis of functional recovery after brain injury. It is clear that drugs influencing specific neurotransmitters also can influence the recovery process. Some of these drugs may be beneficial, but others may be detrimental. Some of the difficulties in interpreting the results of these behavioral studies are reviewed, and potential mechanisms of drug effects are discussed. These types of studies are leading to an increased awareness of the potentially harmful effects of some drugs often given to stroke patients. Pharmacotherapy designed to enhance functional recovery after stroke may be possible in the future. |
5 | Long-time survival of a patient with glioblastoma and Turcot's syndrome. Case report. A rare case of Turcot's syndrome is reported in a long-time survivor of glioblastoma multiforme. The patient was treated for his tumor in 1976 with macroscopically complete surgical resection and radiotherapy consisting of 60 Gy to the tumor bed and 40 Gy to the whole brain. Five years later, in 1981, he developed adenocarcinoma of the colon Dukes Stage B which was successfully treated at another hospital by surgery alone. In 1990, he presented with multiple colon polyps and adenocarcinoma Dukes Stage A. For more than 15 years, the patient has been afflicted with cystic and conglobate acne. Possible mechanisms and treatment with 13-cis retinoic acid are discussed. |
1 | Expression of platelet-derived growth factors, transforming growth factors, and the ros gene in a variety of primary human brain tumors. Ribonucleic acid was isolated from a wide spectrum of central nervous system tumors to examine the expression of platelet-derived growth factors (PDGF) A and B, tumor growth factors (TGF-beta) 1 and 2, and ros messenger ribonucleic acid. Eight glioblastoma cell lines were examined as well as cell cultures from 22 tumor explants. The explants included 6 glioblastomas, 4 anaplastic astrocytomas, 5 astrocytomas, 3 ependymal tumors, 2 meningiomas, 1 medulloblastoma. and 1 ganglioglioma. For comparison, 2 nontumor glial cell cultures were included. The PDGF B-chain was expressed in 5 of 8 glioblastoma cell lines, 2 of 6 glioblastomas, and in 3 of 4 anaplastic astrocytoma explants. There was no PDGF B expression in 4 astrocytomas, 3 ependymomas of varying malignancy, in the remainder of the tumors, or in the nontumor glial cells. The PDGF A-chain was expressed in all of the tumors, with the exception of the malignant ependymoma and in both nontumor glial cell cultures. TGF-beta 1 was expressed in all of the tumors and in nontumor glial cells. The expression of TGF-beta 2 was expressed in many of the benign and malignant tumors and also in both nontumor glial cell cultures. The ros messenger ribonucleic acid was expressed in 1 of 5 glioblastoma cell lines and in 2 of 6 glioblastoma cell explants, but in none of the other tumors or in the nontumor glial cells. |
3 | Evaluation and treatment of mental disorders in patients with AIDS. Mental symptoms are common in patients with AIDS. Optimal management involves the identification and treatment of underlying mental disorders rather than symptomatic treatment alone. Organic mental disorders are very frequent in AIDS, particularly with seriously ill patients who are medical inpatients. There is a high priori probability that such common symptoms as agitation, irritability, and insomnia will be caused by an organic mental disorder. Psychopharmacology in the patient with AIDS requires considerable caution. Lower doses and careful surveillance for subtle neuropsychiatric side effects are necessary. Routine medical contact with a compassionate physician may be of inestimable value to the patient in coping with the fear and dread that surround the illness. |
5 | Methylation-sensitive sequence-specific DNA binding by the c-Myc basic region. The function of the c-Myc oncoprotein and its role in cell growth control is unclear. A basic region of c-Myc is structurally related to the basic motifs of helix-loop-helix (HLH) and leucine zipper proteins, which provide sequence-specific DNA binding function. The c-Myc basic region was tested for its ability to bind DNA by attaching it to the HLH dimerization interface of the E12 enhancer binding factor. Dimers of the chimeric protein, termed E6, specifically bound an E box element (GGCCACGTGACC) recognized by other HLH proteins in a manner dependent on the integrity of the c-Myc basic motif. Methylation of the core CpG in the E box recognition site specifically inhibited binding by E6, but not by two other HLH proteins. Expression of E6 (but not an E6 DNA binding mutant) suppressed the ability of c-myc to cooperate with H-ras in a rat embryo fibroblast transformation assay, suggesting that the DNA recognition specificity of E6 is related to that of c-Myc in vivo. |
1 | Cavernous hemangioma of the spinal cord: report of 2 unusual cases. We present 2 cases of spinal cord intramedullary cavernous hemangioma; 1 patient is the 1st reported case of multiple spinal cord lesions. Diagnosis is greatly enhanced by the use of MRI. |
5 | Postoperative complications in patients with disabling psychiatric illnesses or intellectual handicaps. A case-controlled, retrospective analysis. The purpose of this study was to quantitate the operative risk and costs encountered in the surgical treatment of institutionalized patients. Operative complications and duration of hospitalization for 200 institutionalized patients were compared with those in a control group of patients matched for age, sex, and type of operation drawn from the general hospital population. Postoperative complications occurred in 53 (26.5%) of the patients in the study group compared with 15 (7.5%) of the patients in the control group. Elective laparotomy was followed by a complication in 48% of institutionalized patients compared with 11.6% of matched controls. Emergency celiotomy carried a 75% complication rate in the study group. Atelectasis and pneumonia accounted for 50% of the postoperative complications and occurred with greatest frequency following intra-abdominal procedures. The median hospital stay for all institutionalized patients was 3 days more than for matched controls. A strategy for postoperative treatment is presented, with particular emphasis on prevention of pulmonary complications. |
4 | Vascular flow capacity of hindlimb skeletal muscles in spontaneously hypertensive rats. Total and regional skeletal muscle flows (radiolabeled microspheres) were determined in isolated maximally vasodilated hindquarters of spontaneously hypertensive rats (SHR) and age-matched (11-12 mo) normotensive Wistar-Kyoto rats (WKY) to assess the vascular flow capacity of the skeletal muscle vascular beds. Vascular flow capacity was estimated by measuring total hindquarters and regional muscle blood flows (under conditions of maximal vasodilation with papaverine or papaverine plus isoproterenol) over a wide range of perfusion pressures in WKY and SHR. Capillary exchange capacity was estimated by determining the capillary filtration coefficient. Isogravimetric capillary pressures and segmental vascular resistances were determined in each hindquarter. Isogravimetric flows and capillary pressures were not different between WKY and SHR. However, total and precapillary vascular resistances were significantly elevated in SHR, and postcapillary resistances were not different compared with WKY. Maximal capillary filtration coefficient values for the SHR group averaged 20% lower than WKY values, suggesting that hypertension was associated with a reduction in the microvascular surface area available for fluid exchange and, therefore, the capillary exchange capacity. Over the perfusion pressures studied, total hindquarters flows averaged 60% lower in SHR than in WKY. Flows to individual skeletal muscles averaged 76% lower in SHR than in WKY regardless of the muscle fiber type. Thus, modifications exist in the hindlimb skeletal muscle vasculature of SHR that reduces the capillary exchange capacity and limit the capacity of deliver flow at a given perfusion pressure gradient. |
2 | Macroscopic and microscopic gut lesions in seronegative spondyloarthropathies. A retrospective study by ileocolonoscopy and multiple biopsies was performed on 96 patients with seronegative spondylarthropathy, 17 patients with osteoarthritis (OA) and 19 patients with chronic abdominal discomfort. Under these conditions, inflammatory gut lesions were detected in 66.7% of the patients with spondyloarthropathy, 12.5% with OA and 15.8% with chronic abdominal discomfort. In 10 patients treated by sulfasalazine (Salazopyrine), pathologic lesions disappeared simultaneously with an improvement of the rheumatic conditions. comparison between patients treated and untreated with nonsteroidal inflammatory drugs (NSAID) demonstrated that NSAID did not enter into the etiopathology of the intestinal lesions. Our study therefore confirms the high incidence of inflammatory gut lesions among patients with spondylarthropathy which seems not to be related to NSAID therapy. |
4 | Percutaneous right brachial artery approach with 5F catheters for studying coronary artery disease. We prospectively studied 60 ischemic patients with 5F catheters (Pigtail and Amplatz) using the percutaneous right brachial artery approach (group I), in order to compare this technique with two groups of 100 patients each randomly studied by the femoral route with either 5F (group II) or 8F (group III) catheters (Pigtail and Judkins). The following parameters were analyzed: need to change the initially elected catheter diameter or/and artery approach; technical difficulty for obtaining LV, LCA, and RCA angiograms; total time of X-ray exposure; quality image of LV, LCA, and RCA angiograms; incidence of arterial puncture related hematomas or total arterial occlusion; and duration of local compression after sheath removal. There were no differences between 5F brachial and femoral approaches except for the arterial compression time (p less than 0.01) and the X-ray exposure time (p = 0.03) which were longer with the brachial approach. Whatever the route used, 5F showed a mild increase difficulty (brachial p = 0.001; femoral p = 0.01) and a mild decreased quality image for LCA (branchial p = 0.006; femoral p less than 0.05). Mild hematomas were more frequent with 8F catheters (p less than 0.05). The procedure could be completed by the elected first artery and type of catheter (5F or 8F) in 57/60 patients in group I, in 95/100 in group II, and in 96/100 in group III (nonsignificant differences). Thus, the percutaneous right brachial artery approach using 5F catheters is similar to the femoral artery approach with the same catheters. Although both of them showed a mild increased technical difficulty and a mild decreased quality image compared to 8F, mainly for LCA angiograms, they allowed complete and reliable angiograms reading and analysis. |
5 | Expression of P-glycoprotein in adult T-cell leukemia cells. We have examined the expression of P-glycoprotein (P-gp) in adult T-cell leukemia (ATL) samples from 25 patients. Based on immunoblotting with a monoclonal antibody against P-gp, C219, 8 of 20 ATL patients were P-gp positive at the initial presentation. All 6 patients at the relapsed stage were P-gp positive, and refractory to chemotherapy. The expression of MDR1 mRNA in P-gp-positive ATL cells was increased at the relapsed stage of one patient. P-gp of this patient was photolabeled with [3H]azidopine and the labeling was inhibited with nimodipine, vinblastine and progesterone. These results suggest that P-gp expressed in ATL cells from patients at relapsed stage has the same binding site(s) for the drugs as that in multidrug resistant cells, and is correlated with the refractory nature of the cells to chemotherapy. |
5 | Correlations between vertebral regional bone mineral density (rBMD) and whole bone fracture load. To assess the significance of regional quantitative computed tomography measurements of bone density with respect to mechanical strength in the human lumbar spine, 58 vertebrae (from 12 males, 10 females) were scanned in vitro with multiple-thin-slice quantitative computed tomography and then compressed to fracture. With computer graphics, 18 specific regions of physical density and 10 combination averages of density were identified within each vertebral body. To ensure the statistical independence of data, the individual vertebral specimens were assigned to one of three groups (T11-L1, L2-L3, or L4-L5). Use of best-subsets procedures resulted in regression models to predict fracture strength. These models used specific regional density values and often the age and sex of the donors. The correlation coefficients that resulted from the multiple regression models ranged from r = 0.88 to r = 0.95. When the density values were multiplied by the minimum cross-sectional area of the vertebral body, similar regional density averages were selected, and the predictive values were slightly improved (r = 0.94-0.97). The heterogeneity of the density samples (measured as standard deviation) in multiple regression fashion also produced strong correlation coefficients (r = 0.88-0.94). The bone density in an anterior cylinder of the midplane region, the location measured most often in quantitative computed tomography densitometry, was strongly correlated (r = 0.85) to fracture load for the T12-L1 group (N = 20), but was not significant for the other two groups of vertebrae. The cancellous bone density from the female data was not found to be significantly different from the male data set. |
1 | Evaluation of serum CA 125 as a tumor marker in non-small cell lung cancer. Serum CA 125 levels were evaluated in 130 healthy subjects and 133 patients with untreated pulmonary lesions. These were 33 patients with benign pulmonary conditions and 100 with lung cancer. The mean concentration of CA 125 was higher in patients with lung cancer (37 +/- 81 U/ml) than in those with nonmalignant disease (4.2 +/- 5.7 U/ml) (P less than 0.01). In the healthy control group CA 125 concentrations were significantly lower (0.63 +/- 1.5 U/ml) (P less than 0.001). In patients with lung cancer the concentration of this tumor marker was related to the tumor-node-metastasis (TNM) stage. At a cut-off value of 15 U/ml, CA 125 had a sensitivity of 44%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 65% with respect to healthy subjects; in patients with benign pulmonary conditions, these values were 44%, 94%, 94%, and 31%, respectively. At this cut-off value, a correlation between the respectability prognosis and the likelihood of survival 24 months posttreatment was observed. These findings suggest that CA 125 can be used as an adjunctive test in the management of patients with lung cancer patients. |
2 | Intracorporeal biliary lithotripsy. Most bile duct calculi can be removed with standard percutaneous or endoscopic techniques. Very large stones are the most common cause for failure. Intracorporeal lithotripsy, and EHL in particular, can be used safely in either the biliary tree or gallbladder to fragment these large stones and allow percutaneous removal or passage. Intracorporeal EHL requires direct vision to prevent damage to the bile duct mucosa. Intracorporeal laser lithotripsy may offer some safety advantages, but the laser requires much more expensive equipment than intracorporeal EHL. Additional studies are needed to determine the technique that is better in each circumstance. |
3 | Rediscovering tactile agnosia. Eighty-four patients with damage to various levels of the nervous system, ranging from the peripheral nerves to the cerebral cortex, underwent somesthetic assessment in order to determine the degree to which basic and complex perceptual and motor disorders affect tactile object recognition (TOR) and to determine whether TOR can be impaired in the absence of more basic sensorimotor imperception. The results suggest that (1) basic and intermediate disorders of somesthetic function impair TOR but are commensurately more severe for any given degree of TOR impairment in patients with peripheral lesions than in patients with cortical lesions; (2) neither hemiparesis nor hemianopia alone precludes normal TOR; (3) hemineglect contributes substantially to TOR impairment; (4) impairment of TOR can occur in the absence of more basic somesthetic dysfunction and constitutes tactile agnosia; (5) tactile agnosia is a subtle, nondisabling disorder that should be distinguished from the nonagnosic, severe and disabling disorder, astereognosis; and (6) tactile agnosia results from unilateral damage to parietotemporal cortices, possibly including the second somatosensory cortex, in either hemisphere. |
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