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5 | Thoracoscopic carbon dioxide laser treatment of bullous emphysema. A new technique of thoracoscopic laser ablation of pulmonary bullae suitable for patients with multiple bullae and diffuse emphysema was developed and assessed in 22 patients. 20 of 22 patients survived. Pre-operative and postoperative functional evaluation is available for the 11 patients followed up for more than a month; at 1 to 3 months postoperatively there were increases in FVC (mean 2.0 litres pre-operatively to 2.7 litres postoperatively, p less than 0.001), in FEV1 (0.74 to 1.06 litres, p = 0.01), and in maximum exercise treadmill times (5.4 min to 8.0 min, p less than 0.01). Postoperative air leaks lasted a mean of 13 days and usually resolved spontaneously. Other complications were bleeding (1 patient) and unilateral acute lung injury (1 patient). These results suggest that selected patients with diffuse emphysema and pulmonary bullae may benefit from thoracoscopic carbon dioxide laser ablation. |
2 | Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Eighteen patients with active pancreatic ductal disruptions, including 14 with definable fluid collections, were treated with transpapillary pancreatic duct drains or stents. Twelve of these patients had undergone a previous percutaneous or surgical pancreatic drainage procedure or both, and 8 had long-term drainage tubes in chronic fistulous tracts. Transpapillary catheters could be placed across the ductal disruption or directly into the fluid collection in each case, and 16 of 18 patients had resolution of the disrupted pancreatic duct. Twelve of 14 fluid collections resolved. Complications were limited to mild exacerbation of pancreatitis symptoms in 2 patients and 2 patients who developed subsequent stent occlusion leading to recurrent pancreatitis (1 patient) or recurrent duct blowout with pseudocyst (1 patient). Nine patients had variably significant ductal changes attributable to pancreatic duct stents. At a median follow-up of 16 months, 7 patients ultimately required surgery for ongoing pancreatic pain or residual/recurrent fluid collection. The transpapillary treatment of ongoing pancreatic ductal disruption with or without fluid collection has the potential to obviate surgery in some patients, change an urgent surgical procedure into an elective one, or even assist the surgeon in the performance of intraoperative pancreatography. Further study of this technique appears warranted and must be placed into the perspective of current therapies. |
4 | Immediate and short-term cardiovascular effects of fosinopril, a new angiotensin-converting enzyme inhibitor, in patients with essential hypertension. Immediate and short-term cardiovascular effects of a new angiotensin-converting enzyme inhibitor, fosinopril, were assessed in 10 patients with mild to moderate essential hypertension. Administration of a 10 mg oral dose of fosinopril reduced mean arterial pressure (p less than 0.001) as a result of a 24% fall in total peripheral resistance (p less than 0.001). Short-term therapy (12 weeks) maintained the decrease in mean arterial pressure (p less than 0.05) by decreasing total peripheral resistance (p less than 0.01), without reflexive cardiac stimulation or expanding intravascular volume. Renal vascular resistance decreased (p less than 0.05) while renal blood flow, glomerular filtration rate and filtration fraction remained unchanged. The response pattern to mental, isometric and orthostatic stress was similarly unchanged. Left ventricular mass diminished by 11% (p less than 0.01); myocardial contractility was unaffected. Afterload was reduced (p less than 0.05), and velocity of circumferential fiber shortening and stroke volume increased (p less than 0.05). Thus, arterial pressure reduction produced by fosinopril was associated with improved systemic and renal hemodynamics and reduced left ventricular mass. |
5 | Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Spontaneous bacterial peritonitis is diagnosed when (a) the ascitic fluid culture is positive, (b) the ascitic fluid neutrophil count is greater than or equal to 250 cells/mm3 and (c) there is no evident intraabdominal surgically treatable source for infection. Few details are available regarding the variant of ascitic fluid infection in which the culture grows bacteria (pure growth of a single type of organism), but the neutrophil count is less than 250 cells/mm3. In this prospective study of 138 episodes of culture-positive spontaneously infected ascites detected in 105 patients, 44 (31.9%) were episodes of "monomicrobial nonneutrocytic bacterascites" compared with 94 (68.1%) episodes of spontaneous bacterial peritonitis. Seventeen patients had both types of infection. The infection-related mortality and hospitalization mortality were similar between the two groups. Patients with bacterascites appeared to have less severe liver disease. In 62% of bacterascites episodes in which a second paracentesis was performed before any treatment the fluid spontaneously became sterile without development of ascitic fluid neutrocytosis. Thirty-eight percent of patients with bacterascites (who underwent a second paracentesis before treatment was started) progressed to spontaneous bacterial peritonitis--sometimes within a few hours. The concentration of the chemoattractant C5a was not decreased in the ascitic fluid of the bacterascites patients; this excludes ascitic fluid C5a deficiency as the explanation of the lack of neutrocytosis. Monomicrobial nonneutrocytic bacterascites is a common variant of ascitic fluid infection that may resolve without treatment or may progress to spontaneous bacterial peritonitis. |
4 | Pulmonary function and cardiovascular risk factor relationships in black and in white young men and women. The CARDIA Study Pulmonary function is known to be related inversely to incidence of coronary heart disease, congestive heart failure, chronic obstructive lung disease, lung cancer, and death from all causes. Reasons for some of these associations are poorly understood. Relationships between cardiovascular disease risk factors and pulmonary function were examined in 5,115 18- to 30-year-old black and white male and female participants in the study of Coronary Artery Risk Development in Young Adults (CARDIA). Forced expiratory volume in 1 s adjusted for height (FEV1/Ht2) was significantly lower in smokers than nonsmokers and in persons who reported shortness of breath; FEV1/Ht2 was correlated positively with a history of strenuous physical activity, duration of exercise on the treadmill, and high-density lipoprotein cholesterol. It was associated negatively with skinfold thicknesses, serum triglycerides, fasting serum insulin, and the Cook Medley scale of hostility. The association between pulmonary function and heart disease risk may reflect associations with physical fitness, vigor, fatness, and lipid profiles, as well as with cigarette smoking. |
1 | Intraoperative electron beam radiation therapy for recurrent locally advanced rectal or rectosigmoid carcinoma. A multimodality approach of moderate-dose to high-dose preoperative radiation therapy, surgical resection, and intraoperative electron beam radiation therapy (IORT) has been used for patients with locally recurrent rectal or rectosigmoid carcinoma. The 5-year actuarial local control and disease-free survival for 30 patients undergoing this treatment program were 26% and 19%, respectively. The most important factor predicting a favorable outcome was complete resection with negative pathologic resection margins. The determinant local control and disease-free survival for 13 patients undergoing complete resection were 62% and 54%, respectively, whereas for 17 patients undergoing partial resection these figures were 18% and 6%, respectively. There did not appear to be a difference in local control or survival based on the original surgical resection (abdominoperineal resection versus low anterior resection). However, the likelihood of obtaining a complete resection after preoperative radiation therapy was higher in patients who had previously undergone a low anterior resection than patients undergoing prior abdominoperineal resection. For the 30 patients undergoing external beam irradiation, resection, and IORT, the most significant toxicities were soft tissue or sacral injury and pelvic neuropathy. Efforts to further improve local control are directed toward the concurrent use of chemotherapy (5-fluorouracil with and without leucovorin) as radiation dose modifiers during external beam irradiation and the use of additional postoperative radiation therapy. |
4 | Giant cell arteritis. A case with unusual neurologic manifestations and a normal sedimentation rate. Giant cell (temporal) arteritis is a serious inflammatory condition that can lead to blindness, stroke, or other adverse sequelae if not properly treated. An elevated erythrocyte sedimentation rate has traditionally been emphasized as a criterion for making this diagnosis. Delays in diagnosis and unnecessary testing may occur when a patient presents with a normal erythrocyte sedimentation rate and a clinical history consistent with this condition. We describe a patient with giant cell arteritis who presented with a normal erythrocyte sedimentation rate and who subsequently developed devastating central nervous system complications. |
5 | Morphological observations late (greater than 30 days) after clinically successful coronary balloon angioplasty. This report describes clinical, morphological, and histological findings late (1.6-24.1 months [average, 8.2 months]) after clinically successful coronary balloon angioplasty in 20 necropsied patients with coronary angioplasty restenosis. Clinical evidence of restenosis occurred in 14 (70%) of patients, including six patients with sudden coronary death. Of the 20 patients, 14 (70%) had cardiac causes of death and six (30%) had noncardiac causes of death. Two major subgroups of histological findings were observed: 1) intimal proliferation (60%) and 2) atherosclerotic plaques only. Of the eight sites with atherosclerotic plaques only, six were eccentric lesions and two were concentric lesions. No morphological evidence of previous angioplasty injury (cracks, breaks, or tears) was observed in the eight patients with atherosclerotic plaques only. Proposed mechanisms for the development of intimal proliferation involve the reaction of smooth muscle cells and platelets, whereas elastic recoil of overstretched eccentric or concentric atherosclerotic lesions represents the most likely explanation for the findings in the latter subgroup. On the basis of these morphological findings at angioplasty restenosis sites, specific treatment strategies for coronary artery balloon angioplasty restenosis are proposed. |
1 | Impaired production of tumor necrosis factor in breast cancer. Spontaneous and lipopolysaccharide (LPS)-induced production of tumor necrosis factor (TNF) by peripheral blood macrophages was investigated in breast cancer. Whereas spontaneous TNF production by macrophages derived from patients with breast cancer was comparable with the one found in healthy controls (P greater than 0.1), LPS-stimulated macrophages derived from patients in the disease-free interval as well as with metastatic breast cancer were found to produce significantly lower amounts of TNF, as compared with macrophages derived from healthy control individuals (P less than 0.0005). However, the production of TNF did not significantly differ between the two patient populations (P greater than 0.05). The impairment of LPS-induced TNF production did not depend upon such characteristics of the primary tumor as size, axillary lymph node and estrogen receptor status, or upon the fact of administration of adjuvant chemotherapy and, in patients with metastatic disease, hormone treatment. To further investigate cytokine production by macrophages, spontaneous and LPS-induced interleukin-1 (IL-1) production was investigated also. However, no difference was found between patients and controls concerning IL-1 generation. The authors thus conclude that LPS-induced TNF production was impaired in breast cancer independent of the presence of detectable metastatic disease, whereas IL-1 production remained unimpaired. |
5 | Evaluation and therapy of breakthrough bleeding in women using a triphasic oral contraceptive. This study was designed to investigate the incidence and pattern of breakthrough bleeding (BTB) in 1,259 women who were prescribed for the first time a triphasic oral contraceptive (OC, 7-7-7) and to evaluate a hypothesis of management for BTB persisting after three cycles. The new users were compared with a control group of 696 women who had used various OCs for at least 6 months. The incidence of BTB in the control group was 16.8% and in the new users was 24.9%, 17.5%, and 15.3% in the first 3 months, respectively. Breakthrough bleeding occurred late in the 7-7-7 package in 58% and early or midway through the package in 17% and 25%, respectively. We hypothesized that late-package BTB would improve if the patient was switched to a monophasic pill similar to the relatively estrogenic formulation of the beginning of the package and vice versa for early or midpackage BTB. Seventy women with BTB at 3 months were randomly given 0.5/35 or 1/35 for a further 3 months. Breakthrough bleeding was more likely (P less than 0.05) to improve in women switched to 1/35 compared with 0.5/35 regardless of where in the package BTB occurred. |
5 | The prevalence of Helicobacter pylori infection in the Peoples Republic of China. Meta-analysis on data from 16 (two volunteer and 14 endoscopic) studies ahs been performed to investigate the prevalence of Helicobacter pylori infection in the stomachs of individuals within the Peoples Republic of China. In this survey covering 2216 cases (89 volunteers and 2127 endoscopy patients), the incidence of H. pylori infection in 15- to 22-yr-old healthy volunteers, and in 13- to 88-yr-old symptomatic patients undergoing gastroscopy was 49.4% and 64.5%, respectively. The frequency of H. pylori infection in chronic gastritis (63.6%), gastric ulcer (71.9%), and duodenal ulcer disease (73.1%) differed significantly from that in histologically normal individuals (8.2%), confirming the relationship of H. pylori infection with those disease states. We found no significant association between H. pylori infection and symptoms. |
4 | The diagnosis and prognosis of autosomal dominant polycystic kidney disease. BACKGROUND. Autosomal dominant polycystic kidney disease is usually caused by a mutant gene at the PKD1 locus on the short arm of chromosome 16, but in about 4 percent of families with the disorder it is caused by unknown mutations elsewhere in the genome. The natural course of the disease in both genetic forms is not well characterized. METHODS. We studied 17 families with autosomal dominant polycystic kidney disease to compare presymptomatic diagnosis by ultrasonography with diagnosis by genetic-linkage studies and to relate clinical variation of the disease to whether the PKD1 mutation was implicated. RESULTS. In 10 families the disorder was found to cosegregate with polymorphic DNA markers flanking the PKD1 locus, in 2 families it did not, and in 5 families linkage could not be determined. In the 10 families with the PKD1 mutation, 46 percent of the members less than 30 years old who had a 50 percent risk of inheriting a mutation had renal cysts, as compared with 11 percent of the members of the two families without linkage (P less than 0.001). In the PKD1 families, all 67 diagnoses made by ultrasonography were confirmed by determination of the genotype as inferred from linkage. Forty of 48 members (83 percent) less than 30 years old who inherited the PKD1 mutation had renal cysts. All 27 members 30 years old or older who inherited the mutation had renal cysts, suggesting that the probability of a false negative diagnosis did not exceed 0.13 in this age group (P less than 0.05). The mean (+/- SE) age at the onset of end-stage renal disease among members of the PKD1 families was 56.7 +/- 1.9 years, as compared with 69.4 +/- 1.7 years among members with cysts in the families without linkage (P = 0.0025). Hypertension and renal impairment were less frequent and occurred later in the families without the PKD1 mutation. CONCLUSIONS. At present, in most persons with a 50 percent risk of autosomal dominant polycystic kidney disease, imaging techniques are the only mode of reaching a diagnosis before symptoms appear. In such persons a negative ultrasonographic study during early adult life indicates that the likelihood of inheriting a PKD1 mutation is small. In the few who inherit a non-PKD1 mutation for polycystic kidney disease, renal failure is likely to occur relatively late in life. |
4 | Electrocardiographic markers of ischemia during mental stress testing in postinfarction patients. Role of body surface mapping. In patients with coronary artery disease, radionuclide investigations have documented a high incidence of mental stress-induced myocardial ischemia in the absence of significant electrocardiographic changes and/or angina. To investigate the causes of the low electrocardiographic sensitivity, we recorded body surface maps during mental arithmetic in 22 normal volunteers and 37 postinfarction patients with residual exercise ischemia. Myocardial perfusion was studied with thallium-201 or technetium-99 (SESTAMIBI) planar scans. In 14 patients, body surface maps were also recorded during atrial pacing at the heart rate values achieved during mental stress. While taking the body surface maps, the area from J point to 80 msec after this point (ST-80) was analyzed by integral maps, difference maps, and departure maps (the difference between each patient's difference map and the mean difference map for normal subjects). The body surface mapping criteria for ischemia were a new negative area on the integral maps, a negative potential of more than 2 SD from mean normal values on the difference maps, and a negative departure index of more than 2. Scintigraphy showed asymptomatic myocardial hypoperfusion in 33 patients. Eight patients had significant ST segment depression. The ST-80 integral and difference maps identified 17 ischemic patients. Twenty-four patients presented abnormal departure maps. One patient presented ST depression and abnormal body surface maps without reversible tracer defect. In 14 of 14 patients, atrial pacing did not reproduce the body surface map abnormalities. The analyses of the other electrocardiographic variables showed that in patients with mental stress-induced perfusion defects, only changes of T apex-T offset (aT-eT) interval in Frank leads and changes of maximum negative potential value of aT-eT integral maps significantly differed from those of normal subjects. Our results confirm the low electrocardiographic sensitivity for detecting mental stress-induced myocardial hypoperfusion in postinfarction patients. ST analysis in the body surface map increases the information content of the electrocardiographic signal. T wave analysis appears to offer fewer diagnostic advantages. |
3 | Lateral medullary infarction: prognosis in an unselected series. We describe the acute and long-term prognosis in 43 patients with lateral medullary infarction (LMI) collected from a population-based stroke registry from 1982 to July 1988. Mean age was 63.9 years and median time of follow-up was 33 months. In the acute phase, 5 patients (11.6%) died from respiratory and cardiovascular complications and 2 new strokes occurred, both in the posterior circulation. During follow-up, recurrent vertebrobasilar territory strokes occurred in only 2 patients (a rate of 1.9% per year). The mechanisms of stroke were vertebral artery (VA) branch occlusion, causing a medial medullary syndrome, and basilar artery thrombosis propagating from a contralateral, distal VA stenosis. In the acute phase of LMI, respiratory and cardiovascular events, presumably caused by autonomic dysfunction related to the lateral medullary lesion, are the major hazards. Recurrent posterior circulation strokes were uncommon during follow-up. |
4 | Direct monitoring of capillary perfusion following normovolemic hemodilution in an experimental skin-flap model. The effects of normovolemic hemodilution on skin flap survival are studied in a recently developed skin-flap model (homozygous hairless mouse ear) in which nutritional capillary flow is monitored directly by means of intravital microscopy from the time of flap creation throughout the establishment of necrosis. Two diluting agents (dextran 60 and hydroxyethyl starch 200) are utilized. Our quantitative findings demonstrate that the amount of nonperfused tissue following flap creation in both the dextran (n = 23) and starch (n = 13) groups was significantly decreased as compared with controls (n = 19). Our qualitative observations suggest that improved hemorrheologic properties at the microcirculatory level are responsible for the observed decreased necrosis. Various mechanisms by which hemodilution may act to prevent necrosis are discussed. |
5 | The surgical pathologist's role in liver transplantation. Liver transplantation has become an option in treating a wide variety of diseases. The surgical pathologist, as a member of the transplantation team, is increasingly involved in the evaluation of allograft dysfunction. Interpretation of the liver allograft biopsy specimen requires integration of clinical history, biochemical data, and histologic patterns of a wide variety of lesions, including harvesting injury, vascular thrombosis, rejection, infection, and recurrent disease. This article reviews the varied histologic appearances of the more common forms of liver allograft injury, the contexts in which they arise, and their distinction from one another. |
2 | Nonsteroidal anti-inflammatory drugs and peptic ulcer disease. Evidence has accumulated that nonsteroidal anti-inflammatory drugs (NSAIDs) cause clinically important gastroduodenal ulcers. The pathogenesis, which involves the impairment of mucosal resistance to injury in an acid-peptic environment, is multifactorial and controversial. Ulcers caused by NSAIDs can occur either in mucosa inflamed because of infection with Helicobacter pylori or in histologically normal mucosa. The use of these drugs has been linked to an unexpectedly high incidence of ulcer complications, and a history of peptic ulcer disease is common in such cases. Nonsteroidal anti-inflammatory drugs thus appear both to exacerbate an underlying peptic diathesis and to cause de novo ulcers. The association between the use of these drugs and ulcer complications is supported by ulcer prevalence data from cross-sectional studies, and by data from case-controlled and cohort studies, and from randomized, experimental trials. Drug-induced gastric ulcers have been prevented by misoprostol, but not by H2 blocker therapy. Several therapies have been reported to promote ulcer healing despite continued use of NSAIDs, but adequate controlled trials have not been done. Small gastric and duodenal ulcers readily heal, whereas larger gastric ulcers require vigorous and prolonged therapy. The relative efficacies of various therapies in preventing ulcers, healing ulcers, or preventing complications remain to be established. |
5 | The Indian experience with hypertrophic pyloric stenosis. A study of 58 consecutive Indian infants operated for congenital hypertrophic pyloric stenosis revealed an accentuated male predominance in the incidence of the disease and far less preoperative hemetemesis as compared to that in their Western counterparts. 'Pyloric tumor' was palpable in 89% of cases. Only 34.5% of these infants were first born. Postoperative vomiting occurred in 13.8% of patients and wound sepsis was not encountered. Air contrast radiography confirmed the diagnosis in clinically doubtful cases. |
4 | Use of the variable-length intraluminal sutureless graft. From August 1987 to May 1988 we treated 4 patients with acute ascending aortic dissections with a variable-length intraluminal aortic prosthesis. This operation uses profound hypothermic circulatory arrest and represents a refinement of existing techniques. There was no mortality, and morbidity was minimal. Modifications of this technique can be used in performing proximal aortic root reconstruction with a composite valved conduit. The use of a variable-length intraluminal prosthesis and hypothermic circulatory arrest is illustrated. This is a safe and useful technique in select cases of acute ascending aortic dissection. |
3 | Localization of technetium-99m-glucarate in zones of acute cerebral injury. The potential structural similarity of technetium-99m-labeled glucaric acid (99mTc-glucarate) to that of fructose suggests that this agent may enter cells by a sugar transport system. Studies with LLC-PK1 cells demonstrated inhibition of 99mTc-glucarate uptake by fructose, confirming this potential relationship. Since anaerobic metabolism can use either glucose or fructose, we hypothesized that 99mTc-glucarate may concentrate in areas of acute ischemic injury. To test this hypothesis, 63 adult rats with middle cerebral artery (MCA) occlusion followed by reperfusion were injected with 99mTc-glucarate and in vivo and ex vivo images were acquired. Seven animals were also studied with 18FDG and high resolution PET imaging. The radionuclide images were compared to the results of triphenyl tetrazolium chloride (TTC) staining and conventional histopathology. Thirty-five rats had significant accumulation of 99mTc-glucarate and no TTC staining (indicating infarction) in the involved hemisphere. Of the remaining 28 rats with TTC staining (suggesting viability) of the involved hemisphere, 16 (57%) had 99mTc-glucarate accumulation. In the seven rats that were studied with both 99mTc-glucarate and 18FDG, 99mTc-glucarate accumulated at the center of the occluded MCA territory while 18FDG activity was decreased in this region. These results suggest that 99mTc-glucarate is a sensitive marker of acute severe cerebral injury, but its mechanism of localization is probably different from that of 18FDG. |
5 | Severity of cystic fibrosis in patients homozygous and heterozygous for delta F508 mutation. To assess the relation between genotype and severity of disease in cystic fibrosis (CF) the frequencies and extent of several features of its phenotypic expression were investigated in the 235 patients who attend the Danish CF Centre. 14 patients who attend irregularly and 3 who do not carry the delta F508 mutation at all were excluded. The case-reports of the remaining 218 patients (aged 4 months to 41 years) were carefully evaluated, and they were all analysed for the delta F508 mutation. 172 (79%) were homozygous for delta F508 and 46 (20%) were heterozygous. The mutation therefore occurs on 89% of the chromosomes analysed. There were no significant differences between the homozygous and heterozygous groups in the proportions with meconium ileus at birth, liver involvement, or chronic Pseudomonas aeruginosa infection. However, significantly more of the homozygous patients had onset of symptoms before the age of 6 months (p less than 0.025); they were significantly younger at diagnosis (p = 0.013) and centre referral (p = 0.006); they required greater pancreatic enzyme substitution (p = 0.0002) and had poorer lung function; and the calculated yearly incidence of chronic Ps aeruginosa infection and yearly mortality rates were greater than in heterozygous patients (p = 0.0001). |
5 | Studies of controlled reperfusion after ischemia. XX. Reperfusate composition: detrimental effects of initial asanguineous cardioplegic washout after acute coronary occlusion. This study tests whether initial asanguineous washout of potentially toxic substances that accumulate during ischemia improves recovery produced by blood cardioplegic reperfusion and evaluates the role of plasma versus whole blood cardioplegia. METHODS: Twenty-four dogs underwent 2 hours of occlusion of the left anterior descending coronary artery and 20 minutes of blood cardioplegic reperfusion on total vented bypass. In 13 dogs, a 5-minute infusion of either a crystalloid (n = 7) or plasma (n = 6) cardioplegic solution (containing the same pH, calcium potassium, and osmolarity as blood cardioplegia) was given immediately before reoxygenation with blood cardioplegia. Regional oxygen uptake and coronary vascular resistance were measured during controlled reperfusion, and segmental shortening (ultrasonic crystals), tissue water content, and histochemical damage (triphenyltetrazolium chloride stain) were assessed 1 hour after bypass was discontinued. RESULTS: Asanguineous cardioplegic washout before reoxygenation with blood cardioplegic solution resulted in a progressive (+42%) increase in coronary vascular resistances (from 123 to 176 units, p less than 0.05) and low oxygen utilization during 20 minutes of blood cardioplegic reperfusion (29 ml/100 gm, p less than 0.05); coronary vascular resistance remained low throughout blood cardioplegic reperfusion without washout (from 109 to 98 units), and oxygen utilization was 54 ml/100 gm (p less than 0.05). Neither plasma nor crystalloid washout restored substantial regional systolic shortening (3% systolic shortening versus 73% systolic shortening with blood cardioplegia), and asanguineous washout caused more myocardial edema (81.1% +/- 80.9% versus 79.5% water content, p less than 0.05) and produced extensive transmural triphenyltetrazolium chloride damage (48% +/- 41% versus 8% nonstaining in area at risk, p less than 0.05) than initial blood cardioplegic reperfusion. CONCLUSION: Asanguineous cardioplegic washout before blood cardioplegic reperfusion limits oxygen utilization during subsequent controlled reperfusion, restricts early recovery of systolic shortening, allows more myocardial edema, and produces extensive histochemical damage, which may be avoided by initial reoxygenation with blood cardioplegia. The red blood cells appear more important than the plasma components of blood cardioplegia. |
2 | Cigarette smoking, gastric acidity and peptic ulceration. What are the relationships? The influence of cigarette smoking on intragastric acidity was assessed in duodenal ulcer patients in symptomatic remission and in healthy volunteers in a retrospective study. Continuous 24-hr pH recordings in 150 nonsmokers and 174 smokers receiving placebo treatment were compared. Daytime intragastric acidity was higher in smokers with a median pH (interquartile range) of 1.56 (1.34-1.80) than in nonsmokers, who had a median pH of 1.70 (1.45-1.97) (P less than 0.001). There was no difference in 24-hr and nighttime median pH between the two groups. The small difference in daytime intragastric acidity in smokers and nonsmokers is unlikely to account for the increased prevalence of peptic ulcer disease in smokers. The analysis of smoking status in duodenal ulcer patients and healthy controls and males and females supports the general trend towards higher daytime acidity in smokers. Again, no differences in pH during the 24-hr or night period were found between the groups. The epidemiological and clinical correlation between smoking and duodenal ulcer disease is not adequately explained by increased intragastric acidity. |
5 | Reoperation for biliary strictures. Benign bile duct strictures most often follow intraoperative injury not recognized until later. The ideal reconstruction entails a mucosa-to-mucosa anastomosis without tension, usually with a stent tube to maintain patency in the immediate postoperative period. The mortality rate for reoperation and bile duct reconstruction in patients who are not cirrhotic is approximately 2%, and success rates average 85%. Prevention of operative injuries by the use of cholangiography, careful dissection, and removal of the gallbladder from the fundus downward is the best treatment. |
2 | High ethanol consumption as risk factor for intracerebral hemorrhage in young and middle-aged people. We examined the prevalence of high ethanol intake, hypertension, and other risk factors for intracerebral hemorrhage in a case-control study of 24 young and middle-aged patients with intracerebral hemorrhage. We recorded ethanol consumption, history of hypertension, liver disease, cigarette smoking, and mild or severe coagulation disorder in each case of intracerebral hemorrhage and in 48 control patients matched by sex and age. In univariate matched analyses, the frequencies of high ethanol intake (p = 0.009), hypertension (p = 0.05), and coagulation disorder (p = 0.05) were higher in the cases than in the controls. After controlling for possible confounding factors, we found that high ethanol intake and hypertension were the only independent risk factors for intracerebral hemorrhage (p = 0.02 and p = 0.05, respectively). The hemorrhagic lesion found in cases with a high ethanol intake tended to be located in the cerebral lobes (p = 0.01), contrasting with the typical basal ganglia location of hypertensive hematomas (p = 0.009). We conclude that chronic, high ethanol intake should be considered as an important risk factor for lobar hematomas in young and middle-aged people. |
4 | Dietary fats and oils in cardiac arrhythmia in rats. The effect of long-term feeding of various dietary fats and oils on cardiac arrhythmia was studied in an animal model of sudden cardiac death. After confirmation that a dietary supplement of saturated animal fat (SF) increased the animals' susceptibility to develop cardiac arrhythmia under ischemic stress whereas the polyunsaturated fatty acids of sunflower seed oil (SSO) reduced this susceptibility, we found that diets supplemented with either chemically refined palm oil (PO-I) or physically refined palm oil (PO-II) gave results that were generally intermediate in value between the SF and the SSO groups. However, during reperfusion of a previously ischemic heart, both PO-I- and PO-II-supplemented diets appeared to be as effective as SSO in reducing ventricular premature beats. In addition, the incidence of animals displaying severe ventricular fibrillation was much less after palm-oil feeding than it was after SF feeding. These preliminary results warrant further investigation of the potential antiarrhythmic effects of commercial palm oil. |
3 | Symptoms of Raynaud's syndrome in patients with fibromyalgia. A study utilizing the Nielsen test, digital photoplethysmography, and measurements of platelet alpha 2-adrenergic receptors. Twenty-nine female patients with fibromyalgia were questioned about symptoms of cold intolerance and Raynaud's syndrome; objective documentation of cold-induced vasospasm was obtained by a Nielsen test. Twelve patients (41%) had abnormal Nielsen test results, and 11 patients (38%) had elevated levels of platelet alpha 2-adrenergic receptors. There was a positive correlation between the percentage of change in finger systolic pressure on cooling (Nielsen test) and the number of alpha 2-adrenergic receptors. There was poor correlation between Raynaud's syndrome symptoms and an abnormal Nielsen test result. Digital photoplethysmography showed a normal waveform in 2 of 3 patients. We hypothesize that a subgroup of patients with fibromyalgia syndrome have an up-regulation of alpha 2-adrenergic receptors as a cause of their exaggerated reaction to cold. |
4 | The future of nephrology. The Cellular and Molecular Age of Nephrology has dawned and the future is remarkably exciting. The successful attack on the major causes of renal disease, including genetic diseases, glomerulonephritis, diabetes, vasculitis, acute renal failure, and hypertension, will necessitate improved knowledge about pathogenesis. This new knowledge will allow early detection and target-specific therapies, the array of which is only limited by our imagination. The challenge to be an active player in this exciting future as a physician-scientist in the field of nephrology is indeed a rare opportunity. |
5 | The Marinesco-Sjogren syndrome examined by computed tomography, magnetic resonance, and 18F-2-fluoro-2-deoxy-D-glucose and positron emission tomography. The Marinesco-Sjogren syndrome is an autosomal recessive degenerative disorder characterized by congenital cataracts, cerebellar ataxia, spasticity, mental deficiency, and skeletal abnormalities. We studied two adult siblings with Marinesco-Sjogren syndrome using anatomic and metabolic brain imaging techniques to characterize the pattern and nature of abnormalities in the brain. Computed tomographic and magnetic resonance imaging showed diffuse brain atrophy of mild to moderate degree, involving primarily the white matter of the cerebrum, cerebellum, brain stem, and cervical spinal cord. The pattern of atrophy resembled that seen in diffuse leukoencephalopathies. Measurements of local cerebral glucose metabolic rates with positron emission tomography revealed no statistically significant differences from normal control subjects in most regions, but metabolic rate was decreased in the thalamus in one patient. The findings support a diffuse white matter disorder in Marinesco-Sjogren syndrome. |
5 | How and why aztreonam works. Aztreonam is the first monocyclic beta-lactam antibiotic (monobactam) to be tested clinically. Its synthetic structure determines specific areas of activity, including enhanced activity against Pseudomonas species, exceptional activity against gram-negative bacteria, stability to beta-lactamases and lack of activity against gram-positive bacteria--all of which can be directly related to its chemical composition. Aztreonam has a high affinity for the protein-binding protein 3 (PBP-3) of aerobic gram-negative bacteria. Most of these organisms are inhibited and killed at low concentrations of the drug. Aztreonam binds poorly to PBP sites of the aerobic gram-positive and anaerobic bacteria and consequently has relatively poor inhibitory effects against these bacteria. In vitro, minimum inhibition concentration (MIC) values against almost all of the Enterobacteriaceae and against Neisseria and Haemophilus strains are typically below 1 microgram per milliliter. MIC values against Pseudomonas aeruginosa of 8 micrograms per milliliter are comparable with those of other antipseudomonal beta-lactams and the acylureidopenicillins. As combination therapy with amino-glycosides, aztreonam acts in synergy against P. aeruginosa, Acinetobacter and gentamicin-resistant gram-negative rods. Aztreonam is widely distributed in the body tissues and fluids, and the average elimination half-life is 1.7 hours. Intramuscular dosing results in peak serum levels in approximately one hour, while intravenous dosing results in peak levels within five minutes. After a 2 gram dose given intravenously, MIC90 values for most of the Enterobacteriaceae are exceeded for eight hours, and those for P. aeruginosa, for almost six hours. The steady-state volume of distribution is approximately 0.18 liter per kilogram. Concentrations above the MIC90 for most gram-negative bacteria are also present within bone, prostate and cerebrospinal fluid. Between 60 and 70 per cent of the drug is excreted unchanged in the urine, resulting in concentrations approximating 3,000 micrograms per milliliter two hours after a 1 gram dose given intravenously. Serum clearance of aztreonam is directly proportional to creatinine clearance. Dosage adjustment must, therefore, be made in the presence of reduced clearance. Dosing varies between 0.5 and 2.0 grams every six to 12 hours, depending on the severity of the infection. The characteristics of aztreonam suggest that it is a useful nonnephrotoxic drug for treatment of aerobic gram-negative infection. |
5 | A study of fatigue in systemic lupus erythematosus. Fifty-nine patients with systemic lupus erythematosus were evaluated by questionnaires, histories, physical examinations and routine laboratory studies in order to better understand their fatigue. The fatigue severity scale (scored from 1 to 7) was used to measure fatigue and yielded a mean score +/- SD of 4.6 +/- 1.5. Fifty-three percent of the patients reported that fatigue was their most disabling symptom. Although perceived as severe, the symptom of fatigue did not correlate significantly with any of the laboratory measures. However, there was a significant correlation between fatigue and the physician's rating of disease activity. Fatigue also correlated significantly with depression which accounted for 21% of the variation in fatigue scores. |
2 | Emergency laparoscopy. Unnecessary abdominal explorations in severely injured patients can be reduced by employing emergent or urgent laparoscopy in blunt abdominal trauma and the obscured, acute abdominal cases. In 150 blunt abdominal trauma cases, a mini-laparoscopy was used in the emergency room or the intensive care unit without major complications. In 56%, the findings were negative. In 19%, the laparoscopic findings were corroborated by surgery. In 25%, a minimal to moderate hemoperitoneum was found and the laparoscopic impression dictated close observation. Unnecessary exploration was avoided except in one case. In the elderly high-risk patient with a poor history, abdominal examination can be noninformative. Laparoscopy can detect acute appendicitis or organ perforation. In the young female, appendicitis can be differentiated from pelvic inflammatory disease. Laparoscopy is more accurate and gives a larger latitude for decision-making than lavage. It can also be useful in the obscured problematic abdominal case. |
2 | Kaposi's sarcoma of the colon in a young HIV-negative woman with Crohn's disease. We report a case of isolated colonic Kaposi's sarcoma in a 36-year-old HIV-negative woman with refractory Crohn's disease of the colon and perineum following 11 months' treatment with azathioprine. The clinical features of this case are quite different from those classically described in Kaposi's sarcoma. Among the known risk factors, iatrogenic immunosuppression would appear to be the most probable. |
5 | Carotid-esophageal fistula following a penetrating neck injury: case report. Carotid arterial injuries frequently are associated with injuries to adjacent structure of the neck, particularly the esophagus and trachea. Complications from these repairs are common and fistula formation is herein described between the carotid artery and esophageal repair. |
5 | Insulin-like growth factor I expression by tumors of neuroectodermal origin with the t(11;22) chromosomal translocation. A potential autocrine growth factor. Expression of insulin-like growth factor I (IGF-I) mRNA by some tumor cell lines of neuroectodermal origin has been described. To further explore the significance of IGF-I mRNA expression in these tumors, a more extensive analysis was performed. Most (9 of 10) neuroectodermal tumor cell lines with a t(11;22) translocation (primitive neuroectodermal tumor [PNET], Ewing's sarcoma, esthesioneuroblastoma) expressed IGF-I mRNA, whereas 0 of 15 cell lines without the translocation (PNET, neuroblastoma) expressed IGF-I. Furthermore, inasmuch as all neuroblastoma (12 of 12) cell lines examined expressed IGF-II RNA, the pattern of IGF expression could distinguish between these closely related tumors. CHP-100, a PNET cell line with the t(11;22) translocation, was shown to secrete both IGF-I protein and an IGF binding protein, IGFBP-2. This cell line also expressed the type I IGF receptor mRNA, and blockade of this receptor by a monoclonal antibody (alpha IR3) inhibited serum-free growth. These data demonstrate that IGF-I expression is a property of neuroectodermal tumors with a t(11;22) translocation and that interruption of an IGF-I autocrine loop inhibits the growth of these tumor cells. |
1 | Activation of Epstein-Barr virus latent genes protects human B cells from death by apoptosis. Epstein-Barr virus (EBV), a human herpesvirus, establishes a persistent asymptomatic infection of the circulating B-lymphocyte pool. The mechanism of virus persistence is not understood but, given the limited lifespan of most B cells in vivo, it seems most likely that EBV-infected cells must gain access to the long-lived memory B-cell pool. Here we show in an in vitro system that EBV, through expression of the full set of eight virus-coded 'latent' proteins, can protect human B cells from programmed cell death (apoptosis), the deletion mechanism which normally restricts entry into memory. We have found that EBV-positive Burkitt's lymphoma (BL) cell clones retaining the original tumour cell phenotype and expressing only one of the virus latent proteins, the nuclear antigen EBNA 1, are extremely sensitive to apoptosis; in this respect they resemble the tumour's normal cell of origin found in the germinal centres of lymphoid tissue. By contrast, isogenic BL cell clones which have activated expression of all eight EBV latent proteins are resistant to the induction of apoptosis. The EBV latent proteins should therefore be seen not just as activators of B-cell proliferation but, perhaps more importantly, as mediators of enhanced B-cell survival. |
1 | Bilateral breast cancer. A second primary breast cancer in the opposite breast can be either synchronous or metachronous. The majority are metachronous. A woman who has had breast cancer has a fivefold increase in risk for a second breast cancer. Additional risk factors include multifocal cancer, lobular carcinoma in situ, and an original cancer at an early age with long survival. Lobular carcinoma in situ is predominantly a marker for the subsequent development of a second primary breast cancer. The incidence of synchronous bilateral cancer is approximately 1% to 2% and that of metachronous cancer 5% to 6%. The cancer can be invasive or noninvasive. Mammography has increased the number of synchronous cancers found but not the overall incidence. The incidence of invasive cancer detected by random biopsy of the opposite breast is not high enough to justify routine adoption of this procedure. The remaining breast must be followed for the remainder of the patient's life by physical examination and annual mammography. The treatment of the secondary primary breast cancer should be that appropriate for the stage of the disease. The prognosis for the woman with a second primary breast cancer is quite favorable and is dependent on the stage of both the first and the second cancer. |
5 | Esophageal malignancies: is preoperative radiotherapy the way to go? During the period 1969 to 1988, 68 patients with esophageal malignancy were subjected to preoperative radiotherapy consisting of 30 Gy over 3 weeks followed by esophagectomy after a wait of 2 weeks. Sixty-two of 68 patients (91%) were followed up retrospectively (5-year survival rate, 17.2%; 10-year survival rate, 4.8%). Radiosensitivity of the tumor was graded by a radiation effect scoring method devised by us, and this was found to correlate with long-term prognosis (p = 0.05). Radiotherapy "sterilized" malignant involvement of adventitia and draining lymph nodes in 8 patients and thereby converted "palliative" into potentially "curative" resections with a mean survival of 57.2 months in this group of patients. Preoperative radiotherapy was found to increase the survival, decrease the incidence of residual tumor at the resected stump, reduce the incidence of local recurrence, and increase the resectability rate. |
4 | Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years BACKGROUND. Atrial septal defects have been surgically correctable for more than 30 years. The long-term survival rates among patients treated in the early era of cardiac surgery are poorly documented, but such data are of critical importance to the future medical care, employability, and insurability of these patients. METHODS. To determine the natural history of surgically corrected atrial septal defects, we studied all 123 patients who underwent repair of an isolated defect (ostium secundum or sinus venosus) at the Mayo Clinic between 1956 and 1960, 27 to 32 years after the procedure. The follow-up status of all patients was determined by written questionnaires and telephone interviews. Hospital records and death certificates were obtained if interim hospitalization or death had occurred. RESULTS. The overall 30-year actuarial survival rate among survivors of the perioperative period was 74 percent, as compared with 85 percent among controls matched for age and sex. The perioperative mortality was 3.3 percent (four deaths). Actuarial 27-year survival rates among patients in the younger two quartiles according to age at operation (less than or equal to 11 years and 12 to 24 years) were no different from rates among controls--97 percent and 93 percent, respectively. In the two older quartiles (25 to 41 years and greater than 41 years), 27-year survival rates were significantly less (P less than 0.001)--84 percent and 40 percent, respectively--than in controls (91 and 59 percent). Independent predictors of long-term survival according to multivariate analysis were age at operation (P less than 0.0001) and systolic pressure in the main pulmonary artery before operation (P less than 0.0027). When repair was performed in older patients, late cardiac failure, stroke, and atrial fibrillation were significantly more frequent. CONCLUSIONS. Among patients with surgically repaired atrial septal defects, those operated on before the age of 25 have an excellent prognosis, but older patients require careful, regular supervision. |
1 | Endothelin-like immunoreactivity in human breast cyst fluid. Immunoreactive endothelin has been detected in 21 of 43 samples of breast cyst fluid (21 cases; 3.5 +/- 0.6 pmol/l, mean +/- SEM. Other 22 cases; not detectable, less than 0.5 pmol/l). Fast protein liquid chromatographic analysis of the immunoreactive endothelin of pooled breast cyst fluid showed two immunoreactive peaks; one in the void volume and the other in the position of endothelin-1. It is probable that endothelin-1 is produced by the epithelial cells lining breast cysts, but significance of the presence of endothelin-1 in breast cyst fluid remains to be elucidated. |
5 | Evaluating tooth eruption on sealant efficacy. For patients aged 5 to 9 and 11 to 14, 100 occlusal surfaces on newly erupting permanent molars were treated with a self-curing pit and fissure sealant. All teeth were categorized according to stage of eruption and sealant thickness of the coating applied. After 36 months, 75 surfaces were examined for a final evaluation; 52 surfaces (70%) did not need retreatment. Of the 23 surfaces retreated as a result of sealant loss or marginal deterioration, 18 were retreated only once in the six recall evaluations. Those molars treated originally with the operculum covering the distal marginal ridge of the occlusal surface had twice the probability for retreatment as teeth not treated until the entire marginal ridge was exposed. The thickness of the sealant coating did not affect the early signs of sealant failure. |
1 | Prosthetic arthroplasty of the knee after resection of a sarcoma in the proximal end of the tibia. A report of sixteen cases. The results of a specific type of prosthetic reconstruction of the knee (total replacement arthroplasty) after resection of a sarcoma of the proximal part of the tibia in sixteen patients were retrospectively reviewed. The diagnosis was stage-IIB osteogenic sarcoma in nine patients, stage-IIB malignant fibrous histiocytoma in three patients, and stage-IB sarcoma of various types in four patients. The length of tibial resection ranged from 100 to 257 millimeters. Of the eleven patients who were available for functional examination (mean duration of follow-up, sixty-three months), three patients had an excellent result, seven had a good result, and one had a fair result. Of the five patients who were not available for functional testing, one who was doing well was lost to follow-up at eighty months, one had died of metastases at sixteen months, and three had had a secondary amputation for infection or for loosening of the prosthesis. |
5 | Prognostic indices for tumor relapse and tumor mortality in follicular thyroid carcinoma. To establish an objective basis for therapeutic decisions and follow-up programs in patients with follicular thyroid cancer, the authors developed a prognostic scoring system. The prognostic impact of nine clinical, histologic, and therapeutic parameters was quantified retrospectively based on a multivariate analysis covering 149 patients. The relative relapse risk in follicular thyroid cancer (RR) was 6.8-fold increased in the presence of a moderate when compared with a high degree of histologic tumor differentiation. The RR rose with increasing age of the patient at time of tumor diagnosis by a factor of 1.8 per 20 years. The RR was reduced by a factor of 4.3 after the performance of a neck dissection and by a factor of 2.3 after percutaneous radiation therapy of the neck. The relative mortality risk in follicular thyroid cancer (RM) rose in the absence of a tumor capsule by a factor of 10, in the presence of a moderate compared with a high degree of histologic tumor differentiation by a factor of 5.9, in the presence of distant metastases by a factor of 3.2, and with increasing age of the patient at the time of tumor diagnosis by a factor of 2.2 per 20 years. From these data prognostic indices denoting the individual risk for tumor relapse (IRR index) and tumor mortality (IMR index) were calculated. The indices categorize patients into low-risk, medium-risk, or high-risk groups with regard to tumor relapse and tumor-related death. Consequently, the IRR and IMR indices contribute to select patients with follicular thyroid cancer who need an aggressive form of treatment and an intensive follow-up program. The indices may also be used for risk stratification in prospective therapy trials. |
3 | Indwelling epidural catheters for pain control in gynecologic cancer patients. Seven patients with severe pain caused by an advanced, incurable gynecologic malignancy were treated with an indwelling epidural catheter connected to an implantable subcutaneous port through which morphine was infused. There were few major complications associated with insertion or maintenance of the system. The average usage was 60 days, although the system functioned continuously for 6 months in one patient. Pain distribution in these women ranged from the upper abdomen to the lower extremities. All patients, including one with liver metastases, reported good to excellent pain control with the epidural narcotics. Two subjects with upper abdominal pain occasionally required supplemental oral oxycodone, but the other five patients had adequate pain relief with the epidural system alone. The indwelling epidural system provides excellent analgesia for patients with advanced, incurable gynecologic cancer. |
3 | Multicenter long-term safety and efficacy study of vigabatrin for refractory complex partial seizures: an update. We followed 66 patients with refractory complex partial seizures and a favorable initial response to vigabatrin for 5 to 72 (median, 43) months. Thirty-seven patients discontinued vigabatrin for the following reasons: benefit-to-risk evaluation, 8; seizure breakthrough, 6; adverse events, 6; seizure breakthrough and adverse events, 5; moved or lost, 4; no longer eligible for study, 2; non-drug-related death, 2; narcotic abuse, 1; and patient request, three. There were no clinically significant abnormalities in laboratory studies including SMA 12, complete blood count, ECG, EEG, and visual evoked response testing, and no toxicity other than reversible, dose-dependent side effects. Based on this and other long-term data, clinical trials of vigabatrin have resumed in the United States and Canada. |
5 | Takayasu's disease with axillary, right coronary artery, and right internal mammary stenosis treated with angioplasty. A 47-year-old woman presented with progressive angina and failed medical therapy. After an unsuccessful attempt at angioplasty of a totally occluded right coronary artery, coronary artery bypass using the right internal mammary artery was performed. She presented 2 years later with stenosis in the mammary graft, right coronary artery, and axillary artery. These lesions were all treated with angioplasty. |
5 | Foreign bodies in the throat: a prospective study of 388 cases. We present the results of a prospective study of 388 patients presenting with a history of swallowing a foreign body. We indicate whether the patients' symptoms and signs were associated with a retained foreign body. While tenderness on palpation was an unreliable sign, pooling at indirect laryngoscopy invariably predicted a retained object. In many patients, initial careful examination of the oropharynx by casualty officers would have shown a retained fishbone in the tonsil or tongue and would have resulted in 16 per cent fewer radiographs and 17 per cent fewer referrals to the ENT department. Radiography only improved management in a small minority and 35 per cent of films were interpreted incorrectly by casualty officers. A follow-up barium swallow disclosed a pathological lesion in a significant proportion of patients with bolus obstruction, whether or not this was passed spontaneously. |
5 | Protamine transcript sharing among postmeiotic spermatids. Sharing of cytoplasmic constituents through intercellular bridges connecting postmeiotic spermatids can allow for functional equivalence of genetically nonequivalent spermatids. The technique of in situ hybridization was used to study postmeiotic distribution of transcripts from the mouse protamine 1 (Prm-1) gene among spermatids of mice with chromosomally unbalanced gametes. The Prm-1 gene is located on chromosome 16 and is expressed exclusively in haploid spermatids. Mice doubly heterozygous for two Robertsonian translocations involving chromosome 16 were used for the study of postmeiotic accumulation of transcripts of the Prm-1 gene in spermatogenic cells. The meiotic segregation pattern of chromosomal homologues in these mice produces some spermatids that are chromosomally unbalanced; some spermatids lack chromosome 16 while others have two. In situ hybridization with a cDNA probe for the Prm-1 gene transcript performed on both whole testis sections and spermatogenic cell suspensions showed that there was no statistical difference in distribution of grains over step-5 to step-10 spermatids from Robertsonian-translocation heterozygous mice and from control mice of normal karyotype. These results are consistent with sharing of transcripts of the Prm-1 gene among spermatids within a syncytium. |
4 | Distribution of angiographic vasospasm after subarachnoid hemorrhage: implications for diagnosis by transcranial Doppler ultrasonography. A study was undertaken to determine how frequently angiographic vasospasm occurs outside the normal access range of transcranial Doppler ultrasound in patients who have suffered a subarachnoid hemorrhage. Vasospasm located in the basal vessels is readily identifiable using transcranial Doppler ultrasound whereas spasm affecting the more distal, vertically oriented arteries is outside the standard detection range. It is therefore speculated that the sensitivity of the technique would be adversely affected by a high incidence of distal vasospasm. A total of 136 angiograms performed on 68 patients after a subarachnoid hemorrhage from anterior circulation aneurysms were reviewed to determine the typical distribution of vasospasm. Of the 40 cases that showed greater than or equal to 25% vessel narrowing, 50.0% had spasm restricted to the basal vessels, 42.5% had spasm involving both basal and distal segments, and 7.5% had spasm of the distal segments only. None of the patients with distal vasospasm alone developed delayed ischemic deficits. It is concluded that most patients with anterior circulation aneurysms who develop vasospasm will have involvement of the basal vessels, but a small number of patients may develop vasospasm only in distal vessels. |
1 | Cellular immune response toward human articular chondrocytes. T cell reactivities against chondrocyte and fibroblast membranes in destructive joint diseases. Articular cartilage is one of the major targets in destructive joint diseases in humans. We studied cellular immune reactions against cartilage cell-surface membranes, because it has recently been suggested that these represent possible antigenic structures, based upon the observation of autoantibodies with this specificity in certain joint diseases. A striking T cell reactivity toward chondrocyte membranes was found both in blood and synovial tissue from patients with rheumatoid arthritis. This reactivity was strongly dependent on the presence of monocytes and had all the characteristics of an antigen-driven process. Clonal analysis demonstrated high precursor frequencies in peripheral blood T cells that were reactive against chondrocyte membranes. This response to chondrocyte membranes greatly exceeded the T cell stimulation induced by membranes from other sources such as fibroblasts or epithelial cells. In contrast to patients with rheumatoid arthritis, individuals with osteoarthritis showed a strong peripheral blood and synovial fluid T cell response not only to chondrocyte membranes, but also to fibroblast membrane material. However, there was no reactivity to epithelial cell membranes. Normal donors generally did not show significant responses to any membrane preparation. These data indicate that there is a strong T cell reactivity toward chondrocyte membranes in destructive joint disorders, and this may significantly contribute to the pathogenetic processes that occur in these diseases. |
2 | Differential regulation of liver P-450III cytochromes in choline-deficient rats: implications for the erythromycin breath test as a parameter of liver function. Progressive liver fibrosis in rats develops when they are fed a diet deficient in choline. This diet also results in a pronounced and selective decrease in the liver microsomal content of a phase I drug-metabolizing enzyme belonging to the cytochrome P-450III gene family. Because P-450III cytochromes characteristically catalyze the N-demethylation of erythromycin, we believed that the production of breath CO2 from erythromycin would be dramatically reduced in choline-deficient rats. However, when 12 choline-deficient rats were compared with 9 control rats, the reduction in CO2 production from erythromycin (mean decrease 71%) was essentially identical to that from aminopyrine (mean decrease 69%), a substrate believed to be metabolized normally by the hepatocyte in fibrotic liver disease. Furthermore, we found that the relative erythromycin and aminopyrine demethylase activities were comparable when measured in vitro in liver microsomes prepared from the choline-deficient rats. To determine the molecular basis for the erythromycin demethylase activity in the choline-deficient rats, the liver microsomes were subjected to immunoblot analysis using a variety of polyclonal and monoclonal antibodies capable of distinguishing individual P-450III-related proteins. Our studies confirm that a major erythromycin demethylase belonging to the P-450III family, termed P-450p, was greatly reduced in the choline-deficient rat liver. However, the specific concentration of a second P-450p-related protein was essentially normal and that of a third P-450p-related protein was actually increased in the choline-deficient rat liver. |
5 | t(3;21)(q26;q22): a recurring chromosomal abnormality in therapy-related myelodysplastic syndrome and acute myeloid leukemia. We have identified an identical reciprocal translocation between the long arms of chromosomes 3 and 21 with breakpoints at bands 3q26 and 21q22, [t(3;21)(q26;q22)], in the malignant cells from five adult patients with therapy-related myelodysplastic syndrome (t-MDS) or acute myeloid leukemia (t-AML). Primary diagnoses were Hodgkin's disease in two patients and ovarian carcinoma, breast cancer, and polycythemia vera in one patient each. Patients had been treated with chemotherapy including an alkylating agent for their primary disease 1 to 18 years before the development of t-MDS or t-AML. We have not observed the t(3;21) in over 1,500 patients with a myelodysplastic syndrome or acute myeloid leukemia arising de novo or in over 1,000 patients with lymphoid malignancies. We have previously reported that the t(3;21) occurs in Philadelphia chromosome-positive chronic myelogenous leukemia (CML). Thus, the t(3;21) appears to be limited to t-MDS/t-AML and CML, both of which represent malignant disorders of an early hematopoietic precursor cell. These results provide a new focus for the study of therapy-related leukemia at the molecular level. |
5 | Human papillomavirus associated with poor healing of episiotomy repairs. A retrospective case-control investigation was conducted for risk factors in 47 parturients whose episiotomies dehisced in the immediate postpartum period. Data were extracted from the inpatient, outpatient, and pathology records of each of these 47 patients, as well as from the same records for each of the next two patients who delivered with the same type and degree of episiotomy. No difference between subjects and controls was found for age, parity, or medical history. Except for human papillomavirus (HPV), past or present history of sexually transmitted diseases was not a risk factor. However, active lesions, history thereof, or subsequent development of infection with HPV was found in 14 of 47 patients (29.8%) who had episiotomy breakdown, compared with 13 of 94 women (13.8%) who did not experience this complication, a statistically significant difference (P less than .023). Eleven subjects (23.4%) and nine controls (9.6%) gave a history of smoking during pregnancy, also a statistically significant difference (P less than .026). |
4 | Cor triatriatum: clinical presentation and surgical results in 12 patients. Twelve patients with cor triatriatum have been seen at our institution since 1979. The clinical presentation, diagnostic evaluation, and surgical results are outlined in this retrospective review. Operation is the treatment of choice for this rare congenital cardiac defect. One patient died 1 day before scheduled operation, and 2 patients died postoperatively, yielding a surgical mortality rate of 17% and an overall mortality rate of 25%. Resection of the obstructing atrial membrane was performed using hypothermic cardiopulmonary bypass in all cases. Left atriotomy was performed in 6 patients, and right atriotomy was performed in 7. The two postoperative deaths occurred in patients who had serious associated cardiac defects. Associated anomalies include atrial septal defect, persistent left superior vena cava, and partial anomalous pulmonary venous return. The postoperative course has been excellent in all 9 surviving patients; all remain asymptomatic. Cor triatriatum is amenable to surgical repair with excellent results when diagnosed early and when not complicated by other severe cardiac anomalies. |
2 | Clinical management of gastric cancer and concomitant esophagogastric varices. We report the late results of treatment of 13 consecutive patients with gastric cancer and concomitant esophagogastric varices. Of seven good-risk patients classified as Child's class A or B, gastrectomy together with selective shunt operation was performed in two, total gastrectomy with splenectomy in three, and distal partial gastrectomy with paraesophageal devascularization without splenectomy in one. The remaining patient with early gastric cancer underwent distal partial gastrectomy following repeated endoscopic injection sclerotherapy (EIS) for treatment of the esophageal varices. Although the majority of patients who underwent surgical repair of varices (i.e., shunt, splenectomy, or devascularization) died, total gastrectomy with splenectomy was the only procedure that led to control of the esophageal varices. Since partial gastrectomy combined with EIS limits the morbidity and mortality of an extensive resection and at the same time controls esophageal variceal bleeding, it is probably the procedure of choice for patients with a carcinoma in the lower two-thirds of the stomach. Concerning non-surgical cases, two patients were effectively treated using laser endoscopy and EIS, without the occurrence of variceal bleeding. The remaining four patients, given chemotherapy or irradiation for treatment of gastric carcinoma, died within 4 months with variceal bleeding or liver failure. For the poor-risk patients with evidence of severe liver dysfunction, laser treatment and EIS would be the treatment of choice. |
1 | Infiltration of the lower respiratory tract by helper/inducer T lymphocytes in HTLV-1-associated adult T-cell leukemia/lymphoma. The human T-cell lymphotropic virus type 1 (HTLV-1) is the causative agent of adult T-cell leukemia/lymphoma (ATLL), a disorder in which peripheral blood and multiple organs are infiltrated by malignantly transformed T lymphocytes. We investigated the nature of pulmonary disease in a patient with serologic evidence of HTLV-1 infection. In this case, endobronchial biopsy specimens showed infiltration of the bronchial mucosa by pleomorphic cells exhibiting a high degree of nuclear irregularity. These cells were morphologically identical in appearance to malignant cells found in peripheral blood and infiltrating the dermis, expressed the OKT4/Leu3 phenotype and the receptor for interleukin 2, and, by analogy to gene rearrangement studies on leukemic blood cells, were monoclonal in origin. However, in situ hybridization of endobronchial biopsy specimens with full-length HTLV-1 probes failed to detect retroviral RNA or proviral DNA. These studies indicate that T lymphocytic involvement of the lower respiratory tract in HTLV-1-associated ATLL is characterized by expression of a malignant phenotype despite the inability to document actual cellular infection with this retrovirus by a molecular hybridization technique. |
2 | Evaluation of the magnitude of gastro-oesophageal reflux in Barrett's oesophagus. A manometric study to determine the role of gastro-oesophageal reflux in Barrett's oesophagus was performed on 20 patients with Barrett's oesophagus and 53 patients with reflux oesophagitis without Barrett's oesophagus (25 with mild oesophagitis and 28 with severe oesophagitis). For the same reason, the 20 patients with Barrett's oesophagus also underwent 24 hour continuous oesophageal pH monitoring, and the results obtained were compared with those of 20 oesophagitis patients without Barrett's oesophagus (10 with mild oesophagitis and 10 with severe oesophagitis). The manometric results show that the motor changes found in the Barrett's group are specific but similar to the motor dysfunction associated with reflux oesophagitis. Motor anomalies are probably related more to the inflammatory process in the oesophageal wall than to the metaplastic changes themselves. The pH monitoring results show that while reflux in the Barrett's oesophagus patients was greater overall than in the oesophagitis group without Barrett's oesophagus, the changes are similar when the results are compared with the severe oesophagitis group. In conclusion there are other factors besides gastro-oesophageal reflux involved in the pathogenesis of Barrett's oesophagus. |
5 | Stair climbing as an exercise test to predict the postoperative complications of lung resection. Two years' experience. The results of a clinically performed preoperative stair climb was compared to the presence of postthoracotomy complications in the retrospective hospital record review of 54 adult men. The stair climb was a maximum of five flights (125 steps) performed at the patient's rate and terminated at his request. Pulmonary function measurements and facets of the stair climb physiology were also examined in reference to the presence, type, and severity of complications experienced. Most minor complications such as transient arrhythmias, atelectasis, and pneumonia were clearly not predicted by the stair climb performance. The ability to climb three flights preoperatively most clearly separated those patients having the longer postoperative intubation and hospital stay, greater frequency of complications, and cumulative complication score (p less than 0.005). This retrospective study did not have sufficient numbers of fatal cardiopulmonary complications to exclude the possibility that these may be predicted by the results of this simple test. |
5 | Clinical experience with the Nimbus pump. The Nimbus pump is an indwelling, electromagnetic powered left ventricular (LV) assist device inserted transfemorally. The inflow cannula (7 mm) is positioned across the aortic valve and the pump in the descending aorta. Indications for insertion include cardiogenic shock despite maximal medical support and PCWP greater than 18 mmHg, MAP less than 90 mmHg, and Cl less than 2 L/min/m2. Twelve patients underwent the attempt at surgical insertion of the Nimbus pump. Diagnoses included eight acute myocardial infarctions (AMI), two ischemic cardiomyopathy, one postpartum cardiomyopathy, and one transplanted heart rejection. Eight (67%) of twelve patients had successful insertion. One patient had peripheral vascular disease preventing passage, and three had femoral vessels too small for insertion (less than 7.5 Hagar dilator). Five patients with the diagnosis of AMI had successful insertion and three (60%) underwent sufficient LV recovery for removal of the device; the other two patients died of stroke and ventricular arrhythmias, respectively. Three patients with the diagnosis of cardiomyopathy had progression of the disease process, and their needs exceeded the capabilities of the pump and they died of multiorgan failure. The Nimbus pump is an attractive LV assist device because of its pumping capacity (3.5 L/min) and minor surgical procedure for insertion. However, its application is limited because of access route and size. The device appears to work well for patients in cardiogenic shock after AMI (60% recovery) but does not appear indicated for patients with cadiomyopathy. |
5 | Persistent carcinoma in situ of the testis after chemotherapy for advanced testicular germ cell tumours. The chemosensitivity of testicular carcinoma in situ (CIS) was analysed in 25 testes excised 10 weeks to 4.5 years following platinum-based chemotherapy. CIS was present in 8 of the 23 evaluable cases (35%), in 5 of which the lesion coexisted with invasive germ cell tumour. It is concluded that CIS may persist or recur after chemotherapy. This has implications for occult presentation of metastatic germ cell tumours and also for the management of the contralateral testis in patients with testicular germ cell tumours. |
3 | Meningiomas mimicking cerebral schwannoma. A brain tumor with histological features reminiscent of schwannoma with underlying meningioangiomatosis was subjected to electron microscopic and immunohistochemical analysis, which confirmed the neoplasm as a meningioma. This prompted reexamination of a similar tumor, described in a previous publication as a cerebral schwannoma, with identical immunohistochemical techniques. The results obtained favored alteration of this diagnosis to that of meningioma. This experience has led the authors to recommend the use of immunohistochemistry techniques when evaluating unusual intracranial neoplasms. |
5 | Clinical experience with the Medtronic-Hall valve prosthesis. Medtronic-Hall valves were implanted during 204 procedures performed between 1982 and 1988. Mean population age was 54.4 years; 96% of patients were in New York Heart Association functional class III or greater. Emergency operations constituted 16% of the procedures. Rheumatic heart disease was the single most common indication for valve replacement. In 18% of patients, operation was performed to replace a previous prosthetic valve. The mean follow-up was 3.2 years. Overall operative mortality was 10.3%, the highest mortality being for double-valve replacements (24%). Valve-related mortality, by position, was 5.3% for aortic valves, 6.0% for mitral valves, and 4.0% for multiple-valve replacements. Actuarial 5-year freedom from events were: survival, 68%; thromboembolism, 90%; prosthetic valve endocarditis, 98%; paravalvular leak, 95%; and reoperation, 92%. Complications with the highest mortality were thromboembolism (36%) and endocarditis (33%). The complication rates in this series are high but the patients were more severely ill than in other reports, and operative survivors experienced a considerable improvement in New York Heart Association functional class. |
2 | Barium meals in the elderly--a quality reassurance. The consecutive double contrast barium meal examinations of 100 elderly patients (aged over 65 years) and a group of 33 younger adult patients were analysed by two observers for technical quality and pathological abnormalities. Technical quality declined with patient age, especially in those over 75 years, but was sufficient to enable diagnosis of abnormalities in 60% of the elderly group. It is concluded that, in the majority of elderly patients, the technical quality of double contrast barium meal examinations is sufficiently high to offer considerable diagnostic utility. |
5 | The electrocardiogram in chronic obstructive pulmonary disease. The electrocardiogram is often abnormal in patients who have chronic obstructive pulmonary disease. The most frequent abnormalities are a rightward P-wave axis (greater than or equal to 70 degrees) and a rightward QRS axis (greater than or equal to 90 degrees). In addition, low voltage in the limb leads, an S1S2S3 pattern, poor R-wave progression, a posterior-superior terminal QRS vector or other changes may be present. Transient atrial and ventricular dysrhythmias are common. Knowledge of the usual electrocardiographic manifestations of chronic obstructive pulmonary disease enables the clinician to recognize uncharacteristic abnormalities, which often represent the effects of superimposed illnesses or drug toxicity. |
1 | Immunotherapy. Neuroblastoma as a model. Combinations of aggressive therapy and radiotherapy directed at the primary tumor site as well as dose intensive chemotherapy against metastases can effectively induce complete remissions in patients with stage IV neuroblastomas. By virtue of its tumor specificity, the use of immunotherapy at the time when microscopic residual disease is present holds great promise in eradicating the tumors permanently. Monoclonal antibodies can accumulate selectively and at high concentrations in neuroblastomas. They have the potential of initiating complement activation and inflammation at the tumor site. Hematopoietic factors and cytokines can reinforce the body with tumoricidal leukocytes. Ex vivo activation of autologous white cells as well as arming by genetic manipulation can also produce tumor-seeking vehicles that may be therapeutically useful. As the knowledge of tumor and host immunobiology accumulates, the optimal combination of these approaches will become apparent. |
5 | Skin manifestations in congenital deficiency of leucocyte-adherence glycoproteins (CDLG). In congenital deficiency of leucocyte-adherence glycoproteins (CDLG) there is an immunodeficiency with impaired leucocyte function and cutaneous and extracutaneous infections occur. In more than 30% of cases the condition has a fatal course. We report the skin manifestations of three siblings with CDLG in which areas of skin necrosis occurred that resembled pyoderma gangrenosum. |
1 | Immunohistochemical demonstration of keratin in ameloblastoma as an indication of tumor differentiation. Keratin expression was studied immunohistochemically in 27 ameloblastomas using polyclonal antibody against wide-spectrum keratins (TTL) and monoclonal antibodies against lower- and higher-molecular-weight keratins (PKK1 and KL1), respectively, to clarify the tumor differentiation. Reactions with TTL and KL1 antibodies were generally positive in the stellate cells of the follicular or acanthomatous ameloblastomas. Cell nests of the basal cell type were positive for PKK1. On the other hand, the reactions with TTL or KL1 in the plexiform type were generally weak or absent. From these facts, it was concluded that the follicular, as well as acanthomatous, ameloblastoma is liable to undergo squamous differentiation, whereas the plexiform ameloblastoma remains in primitive stage of tumor differentiation. |
5 | Immune functions during treatment of growth hormone-deficient children with biosynthetic human growth hormone. Immune functions, including cell surface markers, interleukin-2 receptor levels and responses of lymphocytes to mitogenic stimulation were evaluated in seven growth hormone deficient children ages 4-15 years, during treatment with biosynthetically derived human growth hormone. Treatment resulted in a decrease in % B cells and in % T total cells and also decreases in most individual patients' mitogen responses and interleukin-2 receptor levels. Most of the changes noted were transient and similar to those previously demonstrated during pituitary-derived human growth hormone treatment. Although not resulting in overt clinical manifestations in our patients, we think that potential interactions between growth hormone and immune functions need to be considered by physicians treating children with growth hormone. |
4 | Quantitative echocardiographic analysis of global and regional left ventricular function: a problem revisited. We recorded two-dimensional echocardiograms simultaneously with the respiration measurements of 20 normal subjects and 20 patients with anterior myocardial infarction. The apical long-axis and four-chamber views were quantitatively analyzed. Measurement variability of global ejection fraction and regional ejection fraction of 100 regions was calculated during inspiration and at end-expiration for two observers. To minimize variability, the endocardial contour was redefined and traced with an improved computer-assisted tracing system. Variability (absolute mean difference) between two beats at end-expiration was significantly less than during inspiration (p less than 0.05): for ejection fraction the variability at end-expiration was 3.4% and the variability during inspiration was 6.4% (mean, 54%; SD, 7%); for regional ejection fraction the variability at end-expiration was 11.8% and the variability during inspiration was 21.5% (mean, 56%; SD, 15%). Intraobserver and interobserver variability values of one beat at end-expiration for ejection fraction were 3.1% and 3.8%, respectively, and 9.5% and 12.8%, respectively, for regional ejection fraction. Variability in patients with myocardial infarction was comparable. This method of recording respiration and analyzing left ventricular function at end-expiration, with a new contour definition and tracing system, provides a measurement variability that is considerably less than that reported in previous echocardiographic studies and that is comparable to angiographic methods. |
4 | Family history fails to identify many children with severe hypercholesterolemia. Optimal strategies for identifying children with hypercholesterolemia have not been established. Several groups have advocated that testing of serum cholesterol levels be limited to those children who have family histories of hyperlipidemia or premature coronary heart disease. We studied the ability of comprehensive family histories to identify children with hyperlipidemia in a group of 114 children (mean age, 8 +/- 4 years) who were referred for treatment of hypercholesterolemia. A positive family history was defined according to guidelines of the American Academy of Pediatrics. The mean fasting total cholesterol in the children was 5.74 +/- 1.42 mmol/L (222 mg/dL). Family history was negative for hypercholesterolemia or premature coronary heart disease in 22 (22%) of 100 children with total cholesterol levels greater than the 75th percentile for their ages, in 13 (18.3%) of 71 children with total cholesterol levels greater than the 95th percentile for their ages, and in four (11.8%) of 34 children with presumed heterozygous familial hypercholesterolemia. Of the 78 children who had both hypercholesterolemia and positive family histories, hyperlipidemia was reported in 72 families, whereas premature heart disease was reported in only 27. We conclude that in a population of children referred because of known hypercholesterolemia, a detailed family history not only fails to identify many children with mild hypercholesterolemia, but also fails to identify a significant proportion of children with markedly elevated cholesterol levels. Additionally, in families of children with hypercholesterolemia, a history of hyperlipidemia is more common than a history of premature heart disease. |
4 | Assessment of ventricular function with an ambulatory left ventricular function monitor. Changes in ventricular function caused by activities of daily living, including standing, walking, stair climbing, and mental stress, were evaluated using a radionuclide device that recorded left ventricular function on a beat-by-beat basis. The ambulatory monitor was positioned over the patient's left ventricle after a gated blood pool scan. Monitoring revealed a 10% increase of left ventricular ejection fraction from baseline to brisk walking, an 18% increase during stair climbing, and a 6% increase with mental stress. In some subjects, however, the increase in ejection fraction during mental stress exceeded that during exercise. |
5 | Morphological and histopathological aspects of aneurysms after patch aortoplasty for coarctation. Repair of coarctation of the aorta by synthetic patch grafting has been complicated by late aneurysm formation. These aneurysms differ macroscopically from atherosclerotic thoracic aortic dilatations. Specimens for microscopic examination were taken from 14 of 20 patients undergoing aneurysm resection. Histological analysis of the specimens showed medionecrosis in 13 patients of the specimens showed medionecrosis in 13 patients (93%), foreign body reaction in 11 patients (78%), and intimal thickening in 3 patients (21%). The three layers of the aortic wall could be identified in the aneurysms. On the basis of these results, we discuss the etiologic factors and pathogenetic mechanisms involved in the development of these aneurysms. |
5 | A clinical study of acute gastrointestinal hemorrhage associated with various shock states. Gastrointestinal hemorrhage from stress ulceration is a life-threatening complication in a critically ill patient. We retrospectively studied 471 patients admitted to the Department of Traumatology of our hospital who developed shock in their clinical course. Forty-two patients (8.9%) developed gastrointestinal hemorrhage, most within 1 wk (76.2%). The hemorrhage lesion usually was located in the corpus of the stomach. The mortality rate of the shock patients with gastrointestinal hemorrhage was 33.3% (14 of 42). Comparison of different types of shock showed that the incidence, severity, and mortality rates of gastrointestinal hemorrhage were significantly higher in septic shock patients than in hemorrhagic shock patients. These findings show the importance of preventive therapy against progression of early mucosal damage and development of gastrointestinal hemorrhage in shock patients, especially those with sepsis. |
1 | Expression of the human nephron differentiation molecules in renal cell carcinomas. The authors tested frozen sections from 28 renal cell carcinomas (RCC)--21 clear, 1 eosinophilic, 4 basophilic, and 2 spindle-shaped cell type--with monoclonal antibodies (MAb) reacting against cytokeratin, vimentin, CD24, CALLA/CD10, villin, CD26, and HLA class I and class II molecules. These molecules are markers of specific segments of the mature kidney, and their loss or acquisition reflects the different steps of human nephrogenesis. KI67 MAb was used to evaluate cell-proliferating activity. All RCC cases expressed cytokeratin. Coexpression of vimentin was observed in 21 of 28 cases. Whether of clear or chromophilic type, all tumoral cells strongly expressed CD24 molecule, present on primitive blastema cells. All clear-type RCCs expressed CALLA/CD10 and 60% were also villin positive; some were faintly positive for CD26. CALLA, villin, and CD26 were not detected in basophilic cell type. HLA class I molecules were variably expressed in almost all cases, but HLA class II were never detected on tumoral cells. Except for the spindle-shaped population, cell-proliferating activity was low. These results favor the hypothesis that RCCs derive from cells that have 'recovered' the different options of metanephric differentiation. Clear cells show evidence of maturation toward proximal type, while basophilic cells do not. It would be of interest to evaluate the usefulness of serum measurements of villin and/or CALLA as markers in clear cell-type RCC. |
5 | Tension pneumothorax secondary to a gastropleural fistula in a traumatic diaphragmatic hernia. We report a case of tension pneumothorax due to a gastropleural fistula resulting from perforation of the stomach in a traumatic diaphragmatic hernia. Awareness of perforation of strangulated stomach or bowel in a diaphragmatic hernia as a cause of pneumothorax, with or without tension physiology, in a patient with a history of trauma is important so that surgical repair can be undertaken without delay. |
4 | Tricuspid valve repair for tricuspid valve endocarditis: tricuspid valve "recycling". Tricuspid valve endocarditis traditionally has been treated with either valve excision or valve replacement. To avoid implantation of foreign material in an infected field, we have applied the principles of mitral valve repair to 4 patients with tricuspid valve endocarditis. On preoperative echocardiography, all patients had 3 to 4+ tricuspid regurgitation, evidence of progressive right ventricular enlargement, and mobile vegetations. In each case, up to three quarters of the anterior leaflet was excised en bloc with infected chordae and papillary muscle heads. Surgical procedures included standard quadrangular resection, conversion to a bicuspid valve, and pericardial patch replacement of the anterior leaflet with mobilization of basal chordae to replace resected marginal chordae. On postoperative echocardiography, tricuspid regurgitation and right ventricular dimensions were reduced in 2 of 4 patients in spite of loss of leaflet tissue. All excised valve tissue demonstrated bacteria on Gram stain or culture. Nonetheless, all repaired valves were successfully sterilized without recurrent infections. Tricuspid valve repair can allow eradication of infection with potential for improving valve competency in complicated tricuspid valve endocarditis. |
5 | Postoperative hypertension: a prospective, placebo-controlled, randomized, double-blind trial, with intravenous nicardipine hydrochloride. Nicardipine hydrochloride, a new calcium channel blocker for intravenous use, has been compared with placebo in a prospective, randomized, double-blind trial on postoperative hypertension. Of 175 patients who signed preoperative consent, 24 (13.7%) met entry criteria. Hypertension was significantly better controlled in nicardipine-treated patients compared with those receiving placebo (93% versus 30%, p less than 0.05). All the placebo failures were subsequently successfully treated with nicardipine. There were no significant complications in either group. The authors conclude that nicardipine HC1 is an effective, safe therapy for postoperative hypertension. Further studies are now indicated comparing it with other drugs currently used to treat this condition. |
4 | The leukocyte count: a predictor of hypertension. In an exploratory study of 1031 persons observed to progress from normotension to essential hypertension and 1031 matched subjects who remained normotensive, the initial leukocyte count (WBC) was found to be related to the development of hypertension, with risk increased 40% (95% confidence interval 12-82%) in persons in the highest as compared to the lowest quartile of WBC. This relationship proved to be largely independent of body mass index, body fat distribution, alcohol and tobacco consumption, and parental history of hypertension. An increased WBC may reflect greater sympathetic tone or may directly increase peripheral vascular resistance by impeding circulation through small blood vessels. If confirmed, this study adds another condition to the growing list for which the WBC is predictive. This simple, cheap test should be considered for inclusion in prospective epidemiological studies of many different diseases. |
4 | Elevated plasma beta-endorphin levels in patients with congestive heart failure Recent experimental studies show that the opioid system is important to the pathophysiology of cardiovascular impairment in congestive heart failure. Plasma beta-endorphin levels were measured in 37 patients with congestive heart failure and compared with those of 21 age- and gender-matched normal subjects. The relation of plasma beta-endorphin levels and cardiac function at rest and exercise capacity was assessed in 17 of the patients with dilated cardiomyopathy. Exercise capacity was determined by symptom-limited maximal treadmill exercise with expired gas analysis. Plasma beta-endorphin levels were elevated and correlated with the patients' New York Heart Association functional cardiac status (control: 14.0 +/- 4.4 pg/ml; class II: 17.9 +/- 3.6 pg/ml; class III: 28.3 +/- 8.8 pg/ml; class IV: 46.7 +/- 14.6 pg/ml, mean +/- SD). No relation was found between plasma beta-endorphin levels and left ventricular systolic performance as assessed by M-mode and Doppler echocardiography. Plasma beta-endorphin levels were negatively correlated with cardiac output determined by Doppler echocardiography and positively correlated with systemic vascular resistance (r = -0.733, r = 0.747, respectively, both p less than 0.001), but not correlated with calf blood flow as measured by a plethysmography. A good correlation was found between plasma beta-endorphin levels at rest and exercise capacity. The correlations with peak oxygen consumption, anaerobic threshold, and peak rate-pressure product were r = -0.721, -0.672, and -0.674, respectively (p less than 0.01). The data show that plasma beta-endorphin levels are elevated in patients with congestive heart failure and reflect, to some degree, the severity of the disease. |
1 | Lipiodol computerized tomography: how sensitive and specific is the technique in the diagnosis of hepatocellular carcinoma? Computerized tomography (CT) following the intra-arterial injection of Lipiodol (Lipiodol-CT) was performed on 60 patients suspected of having a hepatocellular carcinoma (HCC). Four main patterns of uptake of the Lipiodol within the liver were seen on CT. Of the 14 well circumscribed lesions with dense homogeneous uptake of Lipiodol, 13 were confirmed to be HCCs. Of the 25 lesions with dense patchy uptake of Lipiodol at the periphery and/or in the centre, 19 were confirmed to be HCCs. In 18 patients, in whom only ill defined faint patchy uptake of Lipiodol was present in the liver, or in whom no hepatic uptake was present at all, only one patient was found later to have an HCC. Of the three hypodense lesions in the liver with no Lipiodol uptake, one was found to be necrotic HCC, one a cholangiocarcinoma and one a regenerative nodule. In the diagnosis of HCC, Lipiodol-CT had an overall sensitivity of 97.1%, an accuracy of 88.3% and a specificity of 76.9%. Of the 34 patients with HCC, only 23 were solitary at diagnosis. The size of the HCCs ranged from 0.8 cm to 11 cm in diameter with the median size at 2.2 cm. Eleven of 34 HCCs (32.3%) were resectable. We conclude that, as part of a screening programme for high risk patients. Lipiodol-CT is useful in the early detection of HCCs. The technique also plays an important role in determining whether the tumour should be resected or managed with chemotherapy. By detecting HCCs while still small, the resectability rate can also be improved. |
4 | Coronary angioplasty requiring extraordinarily high balloon inflation pressure. Two cases are presented in which extraordinarily high balloon inflation pressures (20 and 17 atm) were required to successfully dilate a saphenous vein graft stenosis and a right coronary artery stenosis. The clinical application of high balloon inflation pressures and balloon selection is discussed. |
1 | Breast self-examination in relation to the occurrence of advanced breast cancer. Two hundred nine female enrollees of the Group Health Cooperative of Puget Sound who developed advanced-stage breast cancer during the period 1982-1988 were interviewed about their practice of breast self-examination (BSE), use of other breast cancer screening modalities, and medical and reproductive histories. Each subject's description of how she performed the examination was scored according to her mention of up to 10 recommended BSE techniques. A random sample of 433 women without advanced-stage breast cancer from the same population was interviewed for comparison. Relative to women not practicing BSE, the risk of advanced-stage breast cancer among BSE users was 1.15 (95% confidence interval, 0.73-1.81). Frequency of BSE did not differ between women with advanced-stage breast cancer and control subjects, whether in all subjects or in subgroups defined by age, use of mammography, or frequency of clinical breast examinations. While self-described proficiency in BSE was generally low in both case and control subjects, the small percentage of women reporting more thorough self-examinations, regardless of frequency, had about a 35% decrease in the occurrence of advanced-stage breast cancer compared to women who did not perform BSE. These results suggest that, while carefully performed BSE may avoid the development of some advanced-stage breast cancers, BSE as practiced by most Seattle-area women is of little or no benefit. |
3 | Genetic mapping of "Lubag" (X-linked dystonia-parkinsonism) in a Filipino kindred to the pericentromeric region of the X chromosome. "Lubag" is an X-linked disorder causing dystonia and parkinsonism that has only been described in families from the Philippines, principally from the island of Panay. We have established linkage between the disease phenotype "lubag" and DNA markers which span the Xp11.22-Xq21.3 region by using a large Filipino family with 8 affected men in three generations. These DNA markers define an interval of about 20 centimorgans in the pericentromeric region of the X chromosome as the most likely site of the disease locus XDPD (X-linked dystonia-parkinsonism). XDPD has a maximum multipoint log likelihood ratio score (Zmax) of about 4.6 over the interval from Xq12 to Xq21.31 (DXS159-DXYS1X). The co-occurrence of dystonia and parkinsonism in lubag and in other known disorders suggests there may be a common pathogenetic mechanism. Identification of the genetic defect in this family may provide an important clue toward understanding the pathogenesis and pathophysiology of both dystonia and parkinsonism. |
4 | Usefulness of labetalol in chronic atrial fibrillation. Beta-adrenergic blocking agents are useful in controlling excessive ventricular rate in chronic atrial fibrillation (AF) but often reduce exercise capacity. To investigate the advantage of labetalol--a unique beta blocker with alpha-blocking property--in chronic AF, 10 patients without underlying structural heart disease were studied with treadmill test, 12-minute walk and 24-hour ambulatory electrocardiographic monitoring. Patients were randomized and crossed over to receive 4 phases of treatment (placebo, digoxin, digoxin with half-dose labetalol, and full-dose labetalol). Exercise durations were 14.1 +/- 1.5, 14.2 +/- 1.5, 16.1 +/- 1.1 and 15.6 +/- 1.1 minutes, respectively, indicating that labetalol did not reduce exercise tolerance. Although digoxin had no advantage over placebo in controlling maximal heart rate (177 +/- 2 vs 175 +/- 3 beats/min), labetalol, both as monotherapy or as an adjunct to digoxin, was advantageous (156 +/- 4 vs 177 +/- 2 beats/min, p less than 0.01, and 154 +/- 4 vs 177 +/- 2 beats/min, p less than 0.01, respectively). The rate-pressure product was consistently lowered by labetalol at rest and during exercise. At peak exercise, the addition of labetalol to digoxin reduced the maximal rate-pressure product achieved from 30,900 +/- 1300 to 24,100 +/- 2,000 mm Hg/min (p less than 0.01) and the maximal rate-pressure product was lowest with full-dose labetalol (22,300 +/- 1,600 mm Hg/min). During submaximal exercise on treadmill or during the 12-minute walk, the combination of labetalol and digoxin produced the best heart rate control, whereas labetalol monotherapy was comparable to digoxin therapy. |
3 | Spinal instability secondary to metastatic cancer. Fifty-five patients with severe pain from spinal instability secondary to metastatic cancer were referred to Hope Hospital, none being judged to be in a terminal condition. One patient had too extensive disease for surgery so 54 were treated by 55 spinal stabilisations; 49 obtained complete relief of pain and two had partial relief. There were three failures. Twenty-eight of the patients had clinical evidence of spinal cord or cauda equina compression and were decompressed at the time of stabilisation. Of these, 20 had major recovery of neurological function. Patients with pre-operative evidence of extradural tumour had 'prophylactic' decompression at the time of stabilisation; none of these patients later developed signs of cord or cauda equina compression. The results suggest that alleviation of pain and restoration of mobility are best achieved by segmental spinal stabilisation; a few patients require a combined anterior and posterior stabilisation. Postoperative radiotherapy should be given whenever possible, and the causative tumour should be treated by endocrine or chemotherapy, as indicated. |
5 | Multiple gunshot wounds of the head: an anthropological view. A decomposed body was judged at the scene to have two gunshot wounds of the thorax and three of the head. Confirmed at autopsy, the condition of the remains precluded conclusions about the precise nature of the defects. Preparation and reconstruction of the skull disclosed seven large cranial defects and a series of fractures. This preparation allowed the application of well-known principles of gunshot wound analysis. Although the analysis of specific gunshot wound defects is well covered in the literature, there are few examples of the application of gunshot wound principles to complex wound cases. Three entrances and three exits were identified. A seventh defect resulted from bullet passage. Finally, the wounds were sequenced. |
1 | Chemoprotective effects of recombinant human IL-1 alpha in cyclophosphamide-treated normal and tumor-bearing mice. Protection from acute toxicity, hematologic effects, development of late mortality, and enhanced therapeutic efficacy. In this study, recombinant human IL-1 alpha (rhIL-1 alpha) was used to protect normal and tumor-bearing BALB/c mice from the acute toxicity caused by lethal doses of cyclophosphamide (Cy) and 5-fluorouracil. Pretreatment of mice for 7 days with 10,000 U/day of rhIL-1 alpha protected 70 to 100% of mice from the acute death induced by lethal doses of both Cy (380 mg/kg) and 5-fluorouracil (250 mg/kg). In contrast, post-treatment of mice with single or multiple doses of rhIL-1 alpha was not chemoprotective. Pretreatment of mice with rhIL-1 alpha increased the acute LD90 of Cy from 380 mg/kg to greater than 500 mg/kg in normal mice, an LD90 dose-modifying effect of at least 1.25, was accompanied by a more rapid recovery from neutropenia and a less severe reduction in the number of bone marrow single lineage monocyte, myeloid, or myelomonocytic colonies. Some of the mice (10 to 50%) that were successfully protected by pretreatment with rhIL-1 alpha died after day 50. These mice consistently presented with extensive pulmonary inflammation and fibrosis at death. Mice bearing murine renal cancer (Renca) were also protected from the acute toxic effects of Cy (450 mg/kg) by pretreatment with rhIL-1 alpha. Renca-bearing mice pretreated with rhIL-1 alpha and either sublethal (300 mg/kg) or lethal (450 mg/kg) doses of Cy exhibited enhanced survival times over those of untreated Renca-bearing mice. Interestingly, the cause of death in Renca-bearing mice that ultimately failed treatment with rhIL-1 alpha plus 300 mg/kg Cy was recurrent tumor, whereas most mice treated with rhIL-1 alpha plus 450 mg/kg Cy had no detectable tumor, although several died from late pulmonary inflammation and fibrosis. Thus, the dose escalation of Cy in rhIL-1 alpha-pretreated mice results in greater antitumor effects of Cy. However, the dose escalation of some cytotoxic agents allowed by the use of myelostimulatory agents can result in late fatal complications not detected in acute toxicity testing. |
1 | Cystic hygroma: massive recurrence in adult life. Cystic hygroma is considered a disease of childhood. It may appear for the first time in adult life but recurrence by that stage is rare and may present difficulties in diagnosis due to previous treatment. The authors present a case where early pharmacological intervention may have prevented a potentially life threatening situation. The world literature is also reviewed. |
3 | Inconsistent response to divalproex sodium in hemichorea/hemiballism. We report 6 patients with hemichorea/hemiballism of vascular origin who were treated with divalproex sodium (Depakote). Four of 6 responded initially. Marked improvement was seen in 2 patients only and in 1 of these hemiballism recurred despite continuing therapy. Divalproex sodium is not uniformly effective in the treatment of hemichorea/hemiballism. |
5 | An extracorporeal perfusion system to bridge pediatric liver transplant candidates. An extracorporeal liver perfusion system was designed to maintain cadaver livers in an oxygenated, normothermic state for bridging procedures for hepatic transplantation. Nonpulsatile high flow and pulsatile low flow blood are supplied to the portal venous (PV) and hepatic arterial (HA) circulations. Controlled low blood flow (5-10 cc/kg [patient]/min) is exchanged between the high flow extracorporeal perfusion circuit (1 cc/g [liver]/min) and the patient. The system was evaluated in perfusions of fresh, excised pig livers (n = 5). The average oxygen consumption was 9 +/- 3 microliters/g/min, and bile production averaged 4.7 microliters/g/hr. Perfusion pressures and flows were normal in both the HA and PV circulations for about 4 hr. Pressures then gradually rose, especially in the HA circulation, causing flow to decrease, with subsequent mottling and discoloration of the liver. Red blood cell, platelet, and white blood cell counts fell continuously. Maintenance of liver function was assessed by clearance of an 80 mg taurocholic acid challenge. An average of 56% of injected acid was cleared from the perfused livers (n = 5) in the first half hour, compared with 90% and 25% for the in situ (n = 3) and unperfused (n = 3) control livers, respectively. The system consistently maintained livers in a moderately well functioning state through the first 4 hr of perfusion. Adequate support of animals with induced hepatic failure must now be demonstrated. |
5 | Clinical characteristics and coronary angiographic findings of patients with unstable angina, acute myocardial infarction, and survivors of sudden ischemic death occurring during and after sport. The clinical characteristics and coronary angiographic findings of 42 well-conditioned subjects with an acute ischemic event related to sport are reported. Five patients had unstable angina, 25 had acute myocardial infarction (AMI), and 12 were resuscitated victims of sudden ischemic death. Twenty-two events occurred during sport (group A) and 20 after sport (group B). There were two women and 40 men. The mean age was 46 years (range 25 to 65). Twelve out of 30 patients who smoked cigarettes had an adjunctive risk factor for coronary artery disease. Twelve others (28%) had no identifiable risk factor. Prodromal cardiac symptoms were detected in three patients (group A). Two patients had previous myocardial infarction (group B). Coronary angiography was performed acutely in 39 patients. The distribution of the ischemia-related coronary artery was comparable in both groups. The lesion morphology of 35 culprit coronary arteries was described as concentric in six patients and eccentric with regular borders (type I lesion) in 11 and irregular borders (type II lesion) in 18. Eccentric lesions consistent with ruptured plaques prevailed in both groups. Associated coronary artery disease was present in 10 patients. There was no relationship between the number of risk factors and the extent of diseased coronary arteries. Clinical characteristics and coronary angiographic findings of patients with unstable angina, AMI, and sudden death either during or after sport are similar and indicate a common pathogenesis. The probable mechanism of a coronary event related to sport is exercise-induced plaque rupture. In most instances such an event is unexpected and unpredictable. Identification of some subjects at risk is possible. |
4 | Prevalence of coronary heart disease in Scotland: Scottish Heart Health Study Data from 10,359 men and women aged 40-59 years from 22 districts in the Scottish Heart Health Study were used to describe the prevalence rates of coronary heart disease in Scotland in 1984-1986 and their relation to the geographical variation in mortality in these districts. Prevalence was measured by previous history, Rose chest pain questionnaire, and the Minnesota code of a 12 lead resting electrocardiogram. The prevalence of coronary heart disease in Scotland was high compared with studies from other countries that used the same standardised methods. A history of angina was more common in men (5.5%) than in women (3.9%), though in response to the Rose questionnaire 8.5% of women and 6.3% of men reported chest pain. A history of myocardial infarction was three times more common in men than women, as was a Q/QS pattern on the electrocardiogram. There were significant correlations between the different measures of coronary prevalence. District measures of angina correlated well with mortality from coronary heart disease, and these correlations tended to be stronger in women than in men. There was no significant correlation between mortality from coronary heart disease and measures of myocardial infarction. The study provides data on the prevalence of coronary heart disease in men and women that are valuable for the planning of cardiological services. |
2 | Peritoneal blastomycosis. Blastomycosis is a systemic fungal infection caused by Blastomyces dermatitidis. Involvement of the peritoneum is unusual, with only two previously reported cases that occurred in association with disseminated disease. A single case of histopathologically proven blastomycosis involving the peritoneum is presented, as well as a short overview of previously published cases on gastrointestinal and peritoneal blastomycosis. The case is unique in that chronic peritonitis was the only manifestation of disease. The diagnosis was made by laparoscopy. |
4 | Free protein S deficiency in a family with venous thrombosis. Inherited deficiencies of protein S, an inhibitor of the coagulation system, are now recognized as occurring at least twice as frequently as antithrombin III deficiency in patients with venous thrombosis. Protein S is present in plasma in a complexed form, which is inactive, and in a free or functional form. Free protein S combines with activated protein C to inhibit factors V and VIII. This report describes the evaluation of a family with recurrent deep venous thrombosis and superficial thrombophlebitis. Levels of antithrombin III and protein C as well as plasminogen were normal. The levels of total protein S, which includes the value for the free and complexed forms of protein S, were also normal. However, the free protein S levels were greatly reduced in all symptomatic members who were studied. This report illustrates the importance of obtaining measurement of free protein S levels in patients who are suspected of having inherited venous thrombotic disorders. |
5 | Pelvic pain and infections. Infectious etiologies of both acute and chronic pelvic pain are common and may involve multiple organ systems. In the evaluation of the acute pain, it is important to remember that rapidity of diagnosis is important because of the possibility of significant morbidity and even death if a condition is not attended to rapidly. In recent years, laparoscopic evaluation of the pelvis has provided a better understanding of the pathophysiology of some of these infections, as well as possible therapeutic maneuvers. The evaluation of chronic pelvic pain requires a thorough attempt at careful diagnosis with minds open to the possibility that other organ systems besides the genital tract may be involved. Laparoscopy also may be an important diagnostic and therapeutic tool in the evaluation of the sequelae of pelvic inflammation leading to chronic pelvic pain. All therapeutic modalities that are instituted on the basis of the diagnostic evaluation must take into consideration that a strong emotional component is generally associated with chronic pelvic pain. Such components must be addressed in order to achieve the best possible results for the patient. |
5 | Dependence among host response parameters used to diagnose urinary tract infection. The host-response parameters fever, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) are activated in concert by cytokines such as interleukin-6 (IL-6). Il-6 is secreted in response to Escherichia coli infection of the urinary tract. This study tested the hypothesis that the level of fever, CRP, and ESR is coregulated in individual patients. Body temperature, CRP, ESR, pyuria, and renal concentrating capacity were analyzed in 692 children with first-time urinary tract infections. The association of the parameters was evaluated by correlation and multiple regression analysis. The body temperature, CRP, and ESR were significantly correlated (r = .54, .58, and .58; P less than .001), and variation in CRP and ESR explained approximately 40% of the variation in fever. In contrast, the renal concentrating capacity and pyruia were weakly or not at all correlated with the febrile response (r = -.22; P less than .001), and less than 10% of the variation in renal concentrating capacity was explained by the other parameters. The results suggest that fever, CRP, and ESR describe the same aspect of the host response to UTI. |
5 | Laser placement in noncontact Nd:YAG cyclophotocoagulation. We treated 40 eyes of 40 patients by using noncontact transscleral Nd:YAG cyclophotocoagulation to determine whether treatment 1.5 or 3.0 mm posterior to the corneoscleral lumbus was preferable. Patients were randomly assigned to one of the treatment groups, and all other variables, including power, number, and distribution of laser applications, were kept constant. Six months postoperatively, those treated 1.5 mm posterior to the corneoscleral limbus had a lower intraocular pressure (P = .0047) than those treated 3.0 mm from the corneoscleral limbus. The 1.5-mm group also required fewer retreatment (P = .017) and had a slightly lower occurrence of visual acuity loss after this procedure. We believe it may be advantageous to locate the laser application approximately 1.5 mm posterior to the corneoscleral limbus, rather than further posteriorly, when performing noncontact transscleral Nd:YAG cyclophotocoagulation. |
5 | A preliminary report of arthroscopic findings following acute condylar trauma Standard therapy in orthopedics dictates that joints with suspected hemarthrosis be considered for irrigation or exploration, especially when immobilization is part of the treatment plan. In this preliminary report, 14 patients who had condylar/subcondylar fractures underwent superior joint space arthroscopy as part of the evaluation and treatment of their fractures. In all but two patients, blood was found in the superior joint space. Length of time from injury to time of examination correlated with the quantities of blood found. The severity and direction of the blow seemed to influence the findings in the joints. Synovial ecchymosis was a consistent finding. The disc appeared to be grossly intact and within the glenoid fossa in all cases, even when the condyle was grossly displaced. These findings raise questions about the role of direct disc injury as a source of postoperative temporomandibular joint (TMJ) symptoms, as well as about the practice of immobilization of fractures immediately after trauma. Further studies will be necessary to compare the treatment results in patients who have had arthroscopy versus those who have not. |
5 | Simultaneous or staged bilateral total knee replacements in rheumatoid arthritis. A prospective study. In a prospective study of 100 knee arthroplasties in patients with rheumatoid arthritis, simultaneous bilateral surgery was compared with staged bilateral replacements. All patients had improved function following their operations but those who had staged surgery only achieved maximum benefit after the second knee had been replaced. The complication rate was no greater for simultaneous surgery and we therefore advocate the method for those patients who require bilateral replacements. |
5 | Clonal deletion of V beta 14-bearing T cells in mice transgenic for mammary tumour virus. Autoreactive T lymphocytes are clonally deleted during maturation in the thymus. Deletion of T cells expressing particular receptor V beta elements is controlled by poorly defined autosomal dominant genes. A gene has now been identified by expression of transgenes in mice which causes deletion of V beta 14+ T cells. The gene lies in the open reading frame of the long terminal repeat of the mouse mammary tumour virus. |
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